Changes in behavior and mental status can be early signs of impaired gas exchange. If they cannot, sputum can be obtained via suctioning. 2. Sputum for Gram stain and culture and sensitivity tests: Sputum is obtained from the lower respiratory tract before starting antibiotic therapy to identify the causative organisms. One way to have a good prognosis and help fasten recovery is to comply with the prescribed treatment. Tuberculosis frequently presents with a dry cough. If the probe is intact at the site and perfusion is adequate, an ABG analysis will be ordered by the HCP to verify accuracy, and oxygen may be administered, depending on the patient's condition and the assessment of respiratory and cardiac status. Promote skin integrity.The skin is the bodys first barrier against infection. Nursing Diagnosis: Impaired Gas Exchange related to decreased lung compliance and altered level of consciousness as evidence by dyspnea on exertion, decreased oxygen content, decreased oxygen saturation, and increased PCO2. 2. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). b. A) 1, 2, 3, 4 Place the patient in a comfortable position. Viruses such as RSV (common cause in infants age 1 and below), flu and cold viruses can cause viral pneumonia, which is the second most common type of pneumonia. When admitting a female patient with a diagnosis of pulmonary embolism (PE), the nurse assesses for which risk factors? Retrieved February 9, 2022, from, Testing for Sepsis. She earned her BSN at Western Governors University. Maximum amount of air lungs can contain Environmental irritants such as flowers, dust, and strong perfume smell or any strong smelling substance will only worsen the patients condition. Hospital-Acquired Pneumonia (Nosocomial Pneumonia) and Ventilator-Associated Pneumonia: Overview, Pathophysiology, Etiology. c. Course crackles 1. b. An initial negative skin test should be repeated in 1 to 3 weeks and if the second test is negative, the individual can be considered uninfected. 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. d. VC Impaired Gas Exchange Assessment 1. As an Amazon Associate I earn from qualifying purchases. c. TLC: (2) Maximum amount of air lungs can contain c. Ventilation-perfusion scan St. Louis, MO: Elsevier. The nurse can also teach coughing and deep breathing exercises. e. Airway obstruction is likely if the exact steps are not followed to produce speech. b. c. a radical neck dissection that removes possible sites of metastasis. Awakening with dyspnea, wheezing, or cough. These values may be adequate for patients with chronic hypoxemia if no cardiac problems occur but will affect the patients' activity tolerance. 3.5 Acute Pain. The patient will also be able to demonstrate and verbalize understanding about the desired therapeutic regimen. Chronic hypoxemia Sputum samples can be cultured to appropriately treat the type of bacteria causing infection. She found a passion in the ER and has stayed in this department for 30 years. Teach the patient to use the incentive spirometer as advised by their attending physician. The other options contribute to other age-related changes. Lung consolidation with fluid or exudate Encourage fluid intake and nutrition.Hydration is vital to prevent dehydration and supports homeostasis. Impaired gas exchange 5. Obtain a sputum sample for culture.If the patient can cough, have them expectorate sputum for testing. c. TLC Assess lung sounds and vital signs.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. Coughing and difficulty of breathing may cause. 4. Report weight changes of 1-1.5 kg/day. Drug therapy is an alternative to avoidance of the allergens, but long-term use of decongestants can cause rebound nasal congestion. c. A negative skin test is followed by a negative chest x-ray. Assess lung sounds and vital signs. b. Filtration of air What is the first patient assessment the nurse should make? d. treatment with medication only if the pharyngitis does not resolve in 3 to 4 days. c. Airway obstruction Pneumonia will be one of the most frequent infections the nurse will encounter and treat. Base to apex To regulate the temperature of the environment and make it more comfortable for the patient. A 36-year-old patient with type 1 diabetes mellitus asks the nurse whether an influenza vaccine is necessary every year. Nursing Diagnosis: Ineffective Breathing Pattern related to decreased lung expansion secondary to pneumonia as evidenced by a respiratory rate of 22, usage of accessory muscles, and labored breathing. Saunders comprehensive review for the NCLEX-RN examination. Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and the goal of nursing interventions is aimed at prevention. a. treatment with antibiotics. The trachea connects the larynx and the bronchi. f. Cognitive-perceptual: Decreased cognitive function with restlessness, irritability. A relative increase in antibody titers indicates viral infection. 4. Line the lung pleura Look for and report urine output less than 30 ml/hr or 0.5 ml/kg/hr. 1) b. a. Suction the tracheostomy. The patient will also be able to reach maximum lung expansion with proper ventilation to keep up with the demands of the body. The turbinates in the nose warm and moisturize inhaled air. To care for the tracheostomy appropriately, what should the nurse do? b. Symptoms of an abscess caused by aerobic bacteria develop more acutely and resemble bacterial pneumonia. All of the assessments are appropriate, but the most important is the patient's oxygen status. Position the patient to be comfortable (usually in the half-Fowler position). Priority Decision: The nurse receives an evening report on a patient who underwent posterior nasal packing for epistaxis earlier in the day. Promote fluid intake (at least 2.5 L/day in unrestricted patients). Surfactant is a lipoprotein that lowers the surface tension in the alveoli. Which medication therapy does the nurse anticipate will be prescribed? Amount of air exhaled in first second of forced vital capacity b. Stridor The type of antibiotic is determined after a sputum culture result is obtained and the specific type of bacteria is known. a. Monitor oximetry values; report O2 saturation of 92% or less. With acute bronchitis, clear sputum is often present, although some patients have purulent sputum. If there is airway obstruction this will only block and cause problems in gas exchange. The patient needs to be able to effectively remove these secretions to maintain a patent airway. b. 3. The nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? Use of accessory respiratory muscles (scalene, sternocleidomastoid, external intercostal muscles), decreased chest expansion due to pleural pain, dullness when tapping on affected (consolidated) areas. There is a prominent protrusion of the sternum. Teach the patient some useful relaxation techniques and diversional activities such as proper deep breathing exercises. The syringe used to obtain the specimen is rinsed with heparin before the specimen is taken and pressure is applied to the arterial puncture site for 5 minutes after obtaining the specimen. The patient has been diagnosed with an early vocal cord cancer. The patient will have improved gas exchange. Assess the patients knowledge about Pneumonia. b. This is most common in intensive care units usually resulting from intubation and ventilation support. NANDA Nursing diagnosis for Pneumonia Pneumonia ND1: Ineffective airway clearance. 5. It reduces the pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse. Provide tracheostomy care every 24 hours. Auscultate breath sounds at least every 2 to 4 hours or as the patients condition dictates. Allow the patient to have enough bed rest and avoid strenuous activities. 1. Cough suppressants. b. Finger clubbing a. Assess the patients vital signs at least every 4 hours. c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Order stat ABGs to confirm the SpO2 with a SaO2. Assess the patients vital signs and characteristics of respirations at least every 4 hours. a. Deflate the cuff, then remove and suction the inner cannula. Poor peripheral perfusion that occurs with hypovolemia or other conditions that cause peripheral vasoconstriction will cause inaccurate pulse oximetry, and ABGs may have to be used to monitor oxygenation status and ventilation status in these patients. b. Cyanosis Reporting complications of hyperinflation therapy to the health care provider. Saline instillation can cause bacteria to shift to the lower lung areas, increasing the risk of inflammation and invasion of sterile tissues. What is an advantage of a tracheostomy over an endotracheal (ET) tube for long-term management of an upper airway obstruction? Impaired gas exchange is a nursing diagnosis that describes the inability of your body to oxygenate blood adequately. c. Terminal structures of the respiratory tract Pulse oximetry may not be a reliable indicator of oxygen saturation in which patient? A patient's ABGs include a PaO2 of 88 mm Hg and a PaCO2 of 38 mm Hg, and mixed venous blood gases include a partial pressure of oxygen in venous blood (PvO2) of 40 mm Hg and partial pressure of carbon dioxide in venous blood (PvCO2) of 46 mm Hg. The alcohol intake of the patient is within normal limits, so it is not correct to say that alcohol may have damaged the liver. The assessment findings include a temperature of 98.4F (36.9C), BP 130/88 mm Hg, respirations 36 breaths/min, and an oxygen saturation reading of 91% on room air. Arterial blood gas (ABG) values: May vary depending on extent of pulmonary involvement or other coexisting conditions. d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube. Streptococcus pneumoniae is the causative agent for most of the cases of adult community-acquired pneumonia. The nurse is providing postoperative care for a patient three days after a total knee arthroplasty. c. Perform mouth care every 12 hours. Facilitate coordination within the care team to allow rest periods between care activities. d. Comparison of patient's current vital signs with normal vital signs. Watch for signs and symptoms of respiratory distress and report them promptly. Rest lowers the oxygen demand of a patient whose reserves are likely to be limited. The nurse must understand how to monitor for worsening infection, complications, and the rationales for treatment. Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by shortness of breath, low SPO2, and bacteria found in sputum culture. 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. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). b. a. If O2 saturation does not increase to an acceptable level (greater than 92%), FiO2 is increased in small increments while simultaneously checking O2 saturation or obtaining ABG values. Ventilation-perfusion scans and positron emission tomography (PET) scans involve injections, but no manipulation of the respiratory tract is involved. Expresses concern about his facial appearance Nutrition reviews, 68(8), 439458. CH. The cuff passively fills with air. Lung abscess. 7) c. Send labeled specimen containers to the laboratory. 56 Skip to document Ask an Expert Sign inRegister Sign inRegister Home d. Self-help groups and community resources for patients with cancer of the larynx, When assessing the patient on return to the surgical unit following a total laryngectomy and radical neck dissection, what would the nurse expect to find? c. Lateral sequence After which diagnostic study should the nurse observe the patient for symptoms of a pneumothorax? Night sweats Normal mixed venous blood gases also have much lower partial pressure of oxygen in venous blood (PvO2) and venous oxygen saturation (SvO2) than ABGs. d. Pulmonary embolism. An SpO2 of 88% and a PaO2 of 55 mm Hg indicate inadequate oxygenation and are the criteria for continuous oxygen therapy (see Table 25.10). Decreased functional cilia 3. 2 8 Nursing diagnosis for pneumonia. The nurse explains that usual treatment includes Exercise and activity help mobilize secretions to facilitate airway clearance. Nursing Diagnosis 1: Risk for fluid volume deficit related to increased fluid losses secondary to diarrhea and decreased fluid intake; Nursing Diagnosis 2: Impaired gas exchange related to pneumonia and decreased oxygen saturation levels; 2. b. What other assessment should the nurse consider before making a judgment about the adequacy of the patient's oxygenation? Which actions prevent the dislodgement of a tracheostomy tube in the first 3 days after its placement (select all that apply)? d. Parietal pleura. Smoking further increases the risk of developing pneumonia and should be avoided. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. Assessing altered skin integrity risks, fatigue, impaired comfort, gas exchange, nutritional needs, and nausea. Assess intake and output (I&O). Also called nosocomial pneumonia, this type of pneumonia originates from being admitted in the hospital. To determine the tracheal position, the nurse places the index fingers on either side of the trachea just above the suprasternal notch and gently presses backward. d. Patient can speak with an attached air source with the cuff inflated. a. b. RV: (7) Amount of air remaining in lungs after forced expiration How does the nurse assess the patient's chest expansion? Impaired Gas Exchange Nursing Diagnosis & Care Plan Related Factors Physiological damage to the alveoli Circulatory compromise Lack of oxygen supply Insufficient availability of blood (carrier of oxygen) Subjective Data: patient's feelings, perceptions, and concerns. Preventing the spread of coronavirus infection to the patient's family members, community, and healthcare providers. Air trapping Monitor cuff pressure every 8 hours. Stridor is identified with auscultation. Fever reducers and pain relievers. a. General physical assessment findingsof pneumonia. deep inspiratory crackles (rales) caused by respiratory secretions, and circumoral cyanosis (a late finding). The home health nurse provides which instruction for a patient being treated for pneumonia? 4) f. Instruct the patient not to talk during the procedure. The bacteria causing hospital-acquired pneumonia may be antibiotic-resistant, rendering this disease more difficult to treat than community-acquired pneumonia. CASE STUDY: Rhinoplasty Pinch the soft part of the nose. 3. Which action does the nurse take next? The most common. Gas exchange is the passage of oxygen and carbon dioxide in opposite directions across the alveolocapillary membrane (Miller-Keane, 2003). f. Airflow around the tube and through the window allows speech when the cuff is deflated and the plug is inserted. The immunity will not protect for several years, as new strains of influenza may develop each year. 7. Impaired gas exchange occurs due to alveolar-capillary membrane changes, such as fluid shifts and fluid collection into interstitial space and alveoli. Older adults may be confused or disoriented and have a low-grade fever but few other signs and symptoms. d) 8. Chronic hypoxemia A) 2, 3, 4, 5, 6 Atrial Fibrillation Nursing Diagnosis and Nursing Care Plan, Readiness for Enhanced Coping Nursing Diagnosis and Nursing Care Plans, Cystic Fibrosis Nursing Diagnosis Care Plan - NurseStudy.Net. d. Testing causes a 10-mm red, indurated area at the injection site. A third type is pneumonia in immunocompromised individuals. Since the patient is manifesting impaired gas exchange, one of the good indications that the oxygen absorption inside the body is not improving is through the skin changes, nail bed discoloration, and mucous production.