Impaired gas exchange occurs due to alveolar-capillary membrane changes, such as fluid shifts and fluid collection into interstitial space and alveoli. Although inadequately treated -hemolytic streptococcal infections may lead to rheumatic heart disease or glomerulonephritis, antibiotic treatment is not recommended until strep infections are definitely diagnosed with culture or antigen tests. A nurse has been caring for a patient with tuberculosis (TB) and has a TB skin test performed. Respiratory distress requires immediate medical intervention. Being aware of the patient's condition, what approach should the nurse use to assess the patient's lungs (select all that apply)? What action should the nurse take? f. Cognitive-perceptual: Decreased cognitive function with restlessness, irritability. The patient will also be able to reach maximum lung expansion with proper ventilation to keep up with the demands of the body. Pleural friction rub occurs with pneumonia and is a grating or creaking sound. The patient receives 1 point for each criterion: confusion (compared to baseline); BUN greater than 20 mg/dL; respiratory rate greater than or equal to 30 breaths/min; systolic BP of less than 90 mm Hg; and age greater than or equal to 65 yrs. Administer antibiotics.A diagnosis of pneumonia will warrant antibiotic treatment. The patient will also be able to demonstrate and verbalize understanding about the desired therapeutic regimen. The postoperative use of nonverbal communication techniques When obtaining a health history from a patient with possible cancer of the mouth, what would the nurse expect the patient to report? If he or she can not do it, then provide a suction machine always at the bedside. RR 24 "You should get the inactivated influenza vaccine that is injected every year." At the end of the span of care, the patient will be able to have an effective, regular, and improved respiratory pattern within a normal range (12-20 cycles per minute). d. An ET tube is more likely to lead to lower respiratory tract infection. Nursing diagnosis Related factors Defining characteristics Examples of this type of nursing diagnosis include: Decreased cardiac output Chronic functional constipation Impaired gas exchange Problem-focused nursing diagnoses are typically based on signs and symptoms present in the patient. Obtain the supplies that will be used. Nursing Diagnosis: Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures secondary to CHF as evidenced by shortness of breath, A bronchoscopy requires NPO status for 6 to 12 hours before the test, and invasive tests (e.g., bronchoscopy, mediastinoscopy, biopsies) require informed consent that the HCP should obtain from the patient. This work is the product of the b. Epiglottis What is the best response by the nurse? Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by shortness of breath, low SPO2, and bacteria found in sputum culture. Decreased immunoglobulin A (IgA) decreases the resistance to infection. Factors that increase the risk of nosocomial pneumonia in surgical patients include: older adults (older than 70 years), obesity, COPD, other chronic lung diseases (e.g., asthma), history of smoking, abnormal pulmonary function tests (especially decreased forced expiratory flow rate), intubation, and upper abdominal/thoracic surgery. d. Pleural friction rub d. A tracheostomy tube and mechanical ventilation, What should the nurse include in discharge teaching for the patient with a total laryngectomy? Patients with compromised immune systems such as those with COPD, HIV, or autoimmune diseases should be educated on the risk and how to protect themselves. These interventions help ensure that the patient has the appropriate knowledge and is able to perform these activities. symptoms. If abnormal, the lungs are not oxygenating adequately causing poor perfusion of the tissues. c. There is equal but diminished movement of the 2 sides of the chest. a. SpO2 of 92%; PaO2 of 65 mm Hg It involves the inflammation of the air sacs called alveoli. c. Use cromolyn nasal spray prophylactically year-round. 3. Outcomes are influenced by the age of the patient, the extent of the disease process, the underlying disease, and the pathogen involved. Assess the ability and effectiveness of cough.Pneumonia infection causes inflammation and increased sputum production. Aspiration pneumonia is a nonbacterial (anaerobic) cause of hospital-associated pneumonia that results from aspiration of gastric contents. b. Cuff pressure monitoring is not required. A combination of excess CO2 and H2O results in carbonic acid, which lowers the pH of cerebrospinal fluid and stimulates an increase in the respiratory rate. d. VC: (4) Maximum amount of air that can be exhaled after maximum inspiration Weight changes of 1-1.5 kg/day may occur with fluid excess or deficit. 4. Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively. Objective Data: >Tachypnea RR: 33 breaths per min >Dyspnea >Peripehral Cyanosis Rationale An infection triggers alveolar inflammation and edema. Impaired Gas Exchange Thisnursing diagnosis for asthma relates to the decreased amount of air that is exchanged during inspiration and expiration. Consider imperceptible losses if the patient is diaphoretic and tachypneic. b. a hemilaryngectomy that prevents the need for a tracheostomy. - A nurse should be aware of some of the common side effects of antitubercular drugs like rifampin, one of which is orange discoloration of body fluids such as urine, sweat, tears, and sputum. Discharging the patient is unsafe. A 73-year-old patient has an SpO2 of 70%. 4) Cough suppressants and antihistamines should not be used. Immunocompromised people are more susceptible to fungal pneumonia than healthy individuals. Patient who is anesthetized a. Stridor 6) Minimize time on public transportation. b. Nutritional-metabolic The most common causes of community-acquired pneumonia (CAP) is S. pneumoniae followed by Klebsiella pneumoniae, Haemophilus influenzae, and Pseudomonas aeruginosa. Pinch the soft part of the nose. The nurse will gather the supplies as soon as the order to do a thoracentesis is given. The manifestations of viral, fungal, and bacterial infections are similar, and appearance is not diagnostic except when the white, irregular patches on the oropharynx suggest that candidiasis is present. Atelectasis a. Vt c. Terminal structures of the respiratory tract Implement NPO orders for 6 to 12 hours before the test. c. Explain the test before the patient signs the informed consent form. Medscape Reference. b. treatment with antifungal agents. Remove the inner cannula and replace it per institutional guidelines. c. Terminal structures of the respiratory tract e. Increased tactile fremitus g) 4. Volcanic eruptions and other natural events result in air pollution. Air trapping The nurse provides care for a patient with a suspected lung abscess and expects which assessment finding? Samples for ABGs must be iced to keep the gases dissolved in the blood (unless the specimen is to be analyzed in <1 minute) and taken directly to the laboratory. Treatment for pneumonia needs to be complied with completely to ensure a good prognosis and improve health. 6. A patient with pneumonia is at high risk of getting fatigued and overexertion because of the increased need for oxygen demands in the body. d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube. In patients with unilateral pneumonia, positioning on the unaffected side (i.e., good side down) promotes ventilation to perfusion adaptation. To avoid the formation of a mucus plug, suction it as needed. (n.d.). What do these findings indicate? Medical-surgical nursing: Concepts for interprofessional collaborative care. Impaired cardiac output 3. Urinary antigen test: To detect Legionella pneumophila and Streptococcus pneumoniae. Assist the patient with position changes every 2 hours. b. Administer the prescribed antibiotic and anti-pyretic medications. For which problem is this test most commonly used as a diagnostic measure? To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. Has been NPO since midnight in preparation for surgery Are there any collaborative problems? Course crackles sound like blowing through a straw under water and occur in pneumonia when there is severe congestion. What measures should be taken to maintain F.N. 5. c. Remove the inner cannula if the patient shows signs of airway obstruction. Encourage rest and limit exertion.Patients may not be able to tolerate too much activity. Use of accessory respiratory muscles (scalene, sternocleidomastoid, external intercostal muscles), decreased chest expansion due to pleural pain, dullness when tapping on affected (consolidated) areas. d. Parietal pleura. c. Ventilation-perfusion scan The nurse identifies which factor that places a patient at risk for aspiration pneumonia? Keep the head end of the bed at a height of 30 to 45 degrees and turn the patient to the lateral position. Deficient knowledge (patient, family) regarding condition, treatment, and self-care strategies (Including information about home management of COPD) 7. Amount of air remaining in lungs after forced expiration presence of nasal bleeding and exhalation grunting. Please follow your facilities guidelines, policies, and procedures. Smoking further increases the risk of developing pneumonia and should be avoided. c. Mucociliary clearance Assess breath sounds, respiratory rate and depth, sp02, blood pressure and heart rate, and capillary refill to monitor for signs of hypoxia and changes in perfusion. A patient who is being treated at home for pneumonia reports fatigue to the home health nurse. With severe pneumonia, the patient needs a higher level of care than general medical-surgical. Saunders comprehensive review for the NCLEX-RN examination. Suction secretions as needed. Skin breakdown allows pathogens to enter the body. A less severe form of bacterial pneumonia is called walking or atypical pneumonia, in which the symptoms are very mild and the infected person can do his/her activities of daily living as normal. Sputum samples can be cultured to appropriately treat the type of bacteria causing infection. Normal mixed venous blood gases also have much lower partial pressure of oxygen in venous blood (PvO2) and venous oxygen saturation (SvO2) than ABGs. 1. Findings may show hypoxemia (PaO2 less than 80 mm Hg) and hypocarbia (PaCO2 less than 32-35 mm Hg) with resultant respiratory alkalosis (pH greater than 7.45) in the absence of underlying pulmonary disease. a. Maximum amount of air that can be exhaled after maximum inspiration 4) Spend as much time as possible outdoors. The nurse determines effective discharge teaching for a patient with pneumonia when the patient makes which statement? f. A physician performs the first tracheostomy tube change 2 days after the tracheostomy. 1. Chest x-ray examination: To confirm presence of pneumonia (i.e., infiltrate appearing on the film). 3. c. Tracheal deviation a. Apex to base a. Stridor Cough and sore throat A pulmonary angiogram outlines the pulmonary vasculature and is useful to diagnose obstructions or pathologic conditions of the pulmonary vessels, such as a pulmonary embolus. A significant increase in oxygen demand to maintain O2 saturation greater than 92% should be reported immediately. d. Ventilate the patient with a manual resuscitation bag until the health care provider arrives. Fungal pneumonia is caused by inhaling fungal spores that can come from dust, soil, and droppings of rodents, bats, birds or other animals. 1) SpO2 of 85% 2) PaCO2 of 65 mm Hg 3) Thick yellow mucus expectorant 4) Respiratory rate of 24 breaths/minute 5) Dullness to percussion over the affected area Click the card to flip 3. Tachycardia (resting heart rate [HR] more than 100 bpm). Turbinates warm and moisturize inhaled air. St. Louis, MO: Elsevier. Provide tracheostomy care. (2020, June 15). f. Cognitive-perceptual c. Take the specimen immediately to the laboratory in an iced container. 5. Advised the patient to dispose of and let out the secretions. c. Inadequate delivery of oxygen to the tissues a. The nurse should assess the patient's cardiopulmonary status with careful monitoring of vital signs, cardiac rhythm, pulse oximetry, arterial blood gases (ABGs), and lung sounds. 1. The patient is admitted with pneumonia, and the nurse hears a grating sound when she assesses the patient. Bronchoconstriction Associated with the presence of tracheobronchial secretions that occur with infection Desired outcomes: The patient demonstrates an effective cough. Decreased force of cough - The patient's clinical picture is most likely pulmonary embolism (PE), and the first action the nurse should take is to assist with the patient's respirations. It is important to let the patient know the pros of taking an accurate dosage and the right timing of medication for fast recovery. What is the reason for delaying repair of F.N. Cough, sore throat, low-grade elevated temperature, myalgia, and purulent nasal drainage at the end of a cold are common symptoms of viral rhinitis and influenza. No interventions are necessary for these findings. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? This assessment monitors the trend in fluid volume.
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