Nursing Diagnosis: Hyperthermia related to the disease process of bacterial pneumonia as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, and profuse sweating. Try to use words that can be understood by normal people. The body needs more oxygen since it is trying to fight the virus or bacteria causing pneumonia. Subjective Data Advised the patient to dispose of and let out the secretions. c. Drainage on the nasal dressing Amount of air remaining in lungs after forced expiration Nursing care plan for impaired gas exchange. Collaboration: In planning the care for a patient with a tracheostomy who has been stable and is to be discharged later in the day, the registered nurse (RN) may delegate which interventions to the licensed practical/vocational nurse (LPN/VN) (select all that apply)? Arrange the tasks of the patient when providing care to him/her. d. Ventilate the patient with a manual resuscitation bag until the health care provider arrives. Nursing Diagnosis: Impaired Gas Exchange related to the overproduction of mucus in the airway passage secondary to pneumonia as evidenced by cyanosis, restlessness, and irritability. Mixed venous blood gases are used when patients are hemodynamically unstable to evaluate the amount of oxygen delivered to the tissue and the amount of oxygen consumed by the tissues. A patient develops epistaxis after removal of a nasogastric tube. If there are some questions or clarifications when it comes to their medicines, make sure to find time to explain to him/her so that this will ensure compliance with the treatment. impaired Gas Exchange may be related to decreased oxygen-carrying capacity of blood, reduced RBC life span, abnormal RBC structure, increased blood viscosity, predisposition to bacterial pneumonia/pulmonary infarcts, possibly evidenced by dyspnea, use of accessory muscles, cyanosis/signs of hypoxia, tachycardia, changes in mentation, and . Decreased compliance contributes to barrel chest appearance. What is the reason for delaying repair of F.N. e. Sleep-rest This examination detects the presence of random breath sounds (e.g., crackles, wheezes). As such, here are the signs and symptoms that demonstrate the presence of impaired gas exchange. Administer oxygen.Supplemental oxygen may be needed to support oxygenation and to maintain sp02 levels. Discuss to him/her the different pros and cons of complying with the treatment regimen. Which action does the nurse take next? c. Terminal structures of the respiratory tract Nursing diagnoses handbook: An evidence-based guide to planning care. d. Avoid any changes in oxygen intervention for 15 minutes following the procedure. e. Increased tactile fremitus a. c. Explain the test before the patient signs the informed consent form. Nurses also play a role in preventing pneumonia through education. After the intervention, the patients airway is free of incidental breath sounds. Guillain-Barr syndrome, illicit drug use, and recent abdominal surgery do not put the patient at an increased risk for aspiration pneumonia. Encourage plenty of rest without interruption in a calm environment, and space out activities such as bathing or therapy to limit oxygen consumption. Priority: Sleep management Allow 90 minutes for. 3.6 Risk for imbalanced nutrition: less than body requirements. Start oxygen administration by nasal cannula at 2 L/min. Primary care, with acute or intensive care hospitalization due to complications. An indicator of inadequate fluid volume is a urine output of less than 30 ml/hr for 2 consecutive hours. It involves the inflammation of the air sacs called alveoli.

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