Ascertain precipitating factors when possible. Rate, quality, and depth of respirations; vital signs, Physical findings: Dyspnea, cyanosis, decreased muscle mass, cough, increased anteroposterior chest diameter, and use of accessory muscles during respiration; characteristics of sputum, Activity tolerance, ability to perform self-care, Signs and symptoms of infection; response to pharmacologic therapy, response to oxygen therapy. Rationale: Oxygen delivery may be improved by upright position and breathing exercises to decrease airway collapse, dyspnea, and work of breathing. Note:  Pulse oximetry readings detect changes in saturation as they are happening, helping to identify trends before patient is symptomatic. PLUS, we are going to give you examples of Nursing Care Plans for all the major body systems and some of the most common disease processes. Encourage expectoration of sputum; suction when indicated. Rationale: Breath sounds may be faint because of decreased airflow or areas of consolidation. In a client with emphysema, albuterol is used as a bronchodilator. People who have emphysema are often thin with wasted musculature. Rationale: Monitoring disease process allows for alterations in therapeutic regimen to meet changing needs and may help prevent complications. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. It would not be the device of choice to provide high oxygen concentration. Rationale: Reduces potential for exposure to infectious illnesses such as upper respiratory infection (URI). Increase fluid intake to 3000 mL per day within cardiac tolerance. Pleural empyema is usually caused by pneumonia. Encourage the client to perform pursed lip breathing. Bronchodilators: Anticholinergic agents such as atropine sulfate, ipratropium bromide are used in reversal of bronchoconstriction. Note presence and degree of dyspnea as for reports of “air hunger,” restlessness, anxiety, respiratory distress, use of accessory muscles. If you do, you’ll retain a great deal for current use, as well as, for the exam. Assess and record respiratory rate, depth. Maintaining a patent airway is a priority. Rationale: Restlessness and anxiety are common manifestations of hypoxia. Review importance of breathing exercises, effective cough, frequent position changes, and adequate fluid intake. Nutrition: imbalanced, less than body requirements, Medication side effects; anorexia, nausea/vomiting, Weight loss; loss of muscle mass, poor muscle tone, Reported altered taste sensation; aversion to eating, lack of interest in food. The inhalation of environmental air pollutants in the #1 cause of emphysema cases. Aspiration pneumonia, lung abscess and empyema. Provide information and encourage participation in support groups (American Lung Association, public health department). Explain and reinforce explanations of individual disease process. Streptococcus pneumoniae accounts for … Give frequent oral care, remove expectorated secretions promptly, provide specific container for disposal of secretions and tissues. Rationale: Cessation of smoking may slow or halt progression of COPD. Impaired urinary elimination related to urinary calculi. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3682248/, http://www.mayoclinic.org/diseases-conditions/emphysema/symptoms-causes/dxc-20317007, https://www.khanacademy.org/science/health-and-medicine/respiratory-system-diseases/emphysema/v/emphysema-pathophysiology, http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/emphysema/?referrer=https://www.google.com/, That Time I Dropped Out of Nursing School. Rationale: Tachycardia, dysrhythmias, and changes in BP can reflect effect of systemic hypoxemia on cardiac function. A fine needle aspiration of pleural fluid, obtained … Choose the letter of the correct answer. A male client with emphysema becomes restless and confused. Note inspiratory and expiratory ratio. Rationale: Pursed-lip and abdominal or diaphragmatic breathing exercises strengthen muscles of respiration, help minimize collapse of small airways, and provide the individual with means to control dyspnea. Have patient resume activity gradually and increase as individually tolerated. Note: Recent research supports use of prone position to increase Pao. Review oxygen requirements and dosage for patient who is discharged on supplemental oxygen. Recommend eating small, frequent meals, including high-protein, high-density foods. Nurse Murphy administers albuterol (Proventil), as prescribed, to a client with emphysema. Rationale: Reduces localized immunosuppressive effect of drug and risk of oral candidiasis. Rationale: Odorous, yellow, or greenish secretions suggest the presence of pulmonary infection. A nurse is caring for a male client with emphysema who is receiving oxygen. when you move on the step #3 of the nursing process, your goals and nursing interventions will be specifically aimed at those actual symptoms. Instruct the patient to report any signs and symptoms of infection to the primary healthcare provider. Increased production of secretions; retained secretions; thick, viscous secretions, Changes in depth/rate of respirations, use of accessory muscles, Abnormal breath sounds, e.g., wheezes, rhonchi, crackles, Cough (persistent), with/without sputum production. 3. Rationale: Fever may be present because of infection or dehydration. If you leave this page, your progress will be lost. General conditioning exercises increase activity tolerance, muscle strength, and sense of well-being. Monitor visitors; provide masks as indicated. Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? 276-8. Display progressive weight gain toward goal as appropriate. Supporting arms and legs with table, pillows, and so on helps reduce muscle fatigue and can aid chest expansion. Impaired Gas Exchange; May be related to. Teach the patient about the disease and its implications for lifestyle changes, such as avoidance of cigarette smoke and other irritants, activity alterations, and any necessary occupational changes. Stress need for routine influenza and pneumococcal vaccinations. Encourage a healthy weight Early stages of emphysema: overweight Late stages of emphysema: underweight. Curr Opin Pulm Med. The Venturi mask provides low levels of supplemental oxygen. Exposure to lung irritants in the air: smoke, air pollutants, chemicals, dust, etc. Discuss safe use of oxygen and refer to supplier as indicated. 2004 Jul. Intervention: To increase inspiratory muscle strength and endurance, the client may need to learn inspiratory resistive breathing. Causes/Risk Factors Presence of bacterial pneumonia or lung abscess Penetrating chest trauma Hematogenous infection of the pleural space Iatrogenic causes (after thoracic surgery or thoracentesis) 4. Differentiate acute episode from exacerbation of chronic dyspnea. Regular use of the peak flow meter may reduce the severity of the attack because of earlier intervention. Rationale: To identify intensity, precipitating factors and location to assist in accurate diagnosis. Although PPEs are relatively common, empyema (i.e., the accumulation of pus in the pleural space) is less common… Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Rationale: Cyanosis may be peripheral (noted in nailbeds) or central (noted around lips/or earlobes). Rationale: Decreases anxiety and can lead to improved participation in treatment plan. Teach the patient pursed-lip and diaphragmatic breathing. Also, the writing of questions sets up a perfect stage for exam-studying later. Furthermore, it has not been determined how to choose patients who can be treated with thoracoscopy versus … Provide a detailed plan of care and baseline physical assessment to home care nurse as needed on discharge from acute care. A client with COPD has developed malnutrition and weight loss since his diagnosis 8 years ago. Ascertain understanding of individual nutritional needs. Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within patient’s normal range and be free of symptoms of respiratory distress. If you're not a subscriber, you can: You can read the full text of this article if you:-- Select an option -- Log In > Buy This Article > Become a Subscriber > Get Content & Permissions > Antibiotics are ordered if a secondary infection develops. Bronchodilators and metered-dose inhalers (aerosol therapy, dispensing particles in fine mist). Select all that apply. These lead to increased anteroposterior diameter, referred to as “barrel chest.” The client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion. Apply a compression dressing to the area. Because of this extensive smoking history and symptoms the client most likely has chronic obstructive bronchitis. Arrange for return demonstrations of equipment used by the patient and family. Discuss importance of medical follow-up care, periodic chest x-rays, sputum cultures. Rationale: Reduces risk of misuse (too little or too much) and resultant complications. Rationale: Diminished or hypoactive bowel sounds may reflect decreased gastric motility and constipation (common complication) related to limited fluid intake, poor food choices, decreased activity, and hypoxemia. Fluids during meals can increase gastric distension and pressure on the diaphragm. Identify relationship of current signs/symptoms to the disease process and correlate these with causative factors. Provide frequent small feedings. This lesson is part of the NURSING.com Nursing Student Academy. Provide quiet environment, group care or monitoring activities to allow periods of uninterrupted sleep; limit stimulants such as caffeine; encourage position of comfort. Bronchodilators: Beta2-adrenergic agents such as( inhaled beta2-adrenergic agonists by metered-dose inhaler (MDI) such as albuterol, metaproterenol, or terbutaline )are used in reversal of bronchoconstriction, Systemic corticosteroids such as methylprednisolone IV; prednisone PO is used to decrease inflammatory response and improve airflow in some patients for a few days during acute exacerbations. Verbalize understanding of condition/disease process and treatment. Of the following oxygen administration devices, which has the advantage of providing high oxygen concentration? Encourage balance between activity and rest. Rationale: Decreases bacterial growth in the mouth, which can lead to pulmonary infections. Which of the following actions is most appropriate in response to this? N2 - This case study provides a discussion of the diagnosis, management and comprehensive plan of care for empyema in children for the advanced practice registered nurse (APRN) working in primary care. Tests: Blood tests are used to find the bacteria or fungi causing your empyema. Which of the following is the most important risk factor for development of Chronic Obstructive Pulmonary Disease? As a preventive measure, influenza and pneumonia vaccines are administered. Rationale: NIPPV may be used at night or periodically during day to decrease CO. Maintain airway patency with breath sounds clear/clearing. The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. PPE may be the consequence of either community-acquired or nosocomial pneumonia. Recommend avoidance of sedative antianxiety agents unless specifically prescribed or approved by physician treating respiratory condition. Nursing Diagnosis: Ineffective gas exchange related to thick secretions as evidence by O2 saturation of 87% on room air, complaints of shortness of breath, and coughing up greenish to brown sputum. Pipe, cigar and other types of tobacco smoking are also risk factors. Caused by an infection that spreads from the lung and leads to an accumulation of pus in the pleural space, the infected fluid can build up to a quantity of a pint or more, which puts pressure on the lungs, causing shortness of breath and pain. The nurse notes shortness of breath and tachypnea. In most instances, the sample can be obtained at the time of chest drain insertion. Maternal and Child Health Nursing (NCLEX Exams), Medical and Surgical Nursing (NCLEX Exams), Pharmacology and Drug Calculation (NCLEX Exams), Abdominal Aortic Aneurysm Nursing Care Plan & Management. Initiate necessary lifestyle changes and participate in treatment regimen. How do they fit in with what I already know? Which finding indicates that the drug is producing a therapeutic effect? In this guide are pneumonia nursing care plans and nursing diagnosis, nursing interventions and nursing assessment for pneumonia.Nursing interventions for pneumonia and care plan goals for patients with pneumonia include measures to assist in effective coughing, maintain a patent airway, decreasing viscosity and tenaciousness of secretions, and assist in … Deep suctioning may be required when cough is ineffective for expectoration of secretions. Encourage abdominal or pursed-lip breathing exercises. Verbalize understanding of individual causative/risk factors. The pleural space is between your lungs and the inside of your chest cavity. Presence of wheezes may indicate bronchospasm or retained secretions. Parapneumonic effusions are predominately exudative and occur in as many as 50-70% of patients admitted with a complicated pneumonia. Monitor level of consciousness and mental status. Inadequate primary defenses (decreased ciliary action, stasis of secretions), Inadequate acquired immunity (tissue destruction, increased environmental exposure). Why and how do we even use Nursing Care Plans? Promotes environmental and physical safety. Observe color, character, odor of sputum. For more information, visit www.nursing.com/cornell. Rationale: These environmental factors can induce or aggravate bronchial irritation, leading to increased secretion production and airway blockage.
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