Rationale: Malnutrition can affect general well-being and lower resistance to infection. When you complete this course, you will be able to write and implement powerful and effective Nursing Care Plans. Assess and monitor respirations and breath sounds, noting rate and sounds (tachypnea, stridor, crackles, wheezes). Assess dietary habits, recent food intake. The catheter is an inexpensive device that provides a variable fraction of inspired oxygen and may cause gastric distention. Parapneumonic effusion (PPE; i.e., pleural fluid that results from pneumonia or lung abscess) is the most common cause of an exudative pleural effusion. Nursing Diagnosis. 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. Recommend eating small, frequent meals, including high-protein, high-density foods. Impaired urinary elimination related to urinary calculi. Which finding indicates that the drug is producing a therapeutic effect? COPD Pathochart Adult respiratory distress syndrome (ARDS). 2. Patient education is vital to long-term management. Rationale: Noxious tastes, smells, and sights are prime deterrents to appetite and can produce nausea and vomiting with increased respiratory difficulty. Once diagnosed with emphysema, the disease state is constant. What step should nurse Jasmine take next? Administer supplemental oxygen during meals as indicated. NCLEX® and NCLEX-RN® are Registered Trademarks of the NCSBN, HESI® is a registered trademark of Elsevier Inc., TEAS® and Test of Essential Academic Skills™ are registered trademarks of Assessment Technologies Institute, CCRN® is a Registered trademark of the AACN; all of which are unaffiliated with, not endorsed by, not sponsored by, and not associated with NRSNG, LLC or TazKai, LLC and its affiliates in any way. Explain and reinforce explanations of individual disease process. A face tent provides a fairly accurate fraction of inspired oxygen, but is bulky and uncomfortable. Encourage balance between activity and rest. Discuss safe use of oxygen and refer to supplier as indicated. Scattered moist crackles may indicate interstitial fluid or cardiac decompensation. Decreased cardiac output related to heart failure secondary to hypocalcemia. Worsening ABGs accompanied by confusion/ somnolence are indicative of cerebral dysfunction due to hypoxemia. 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. Rationale: Can produce abdominal distension, which hampers abdominal breathing and diaphragmatic movement and can increase dyspnea. Altered oxygen supply (obstruction of airways by secretions, bronchospasm; air-trapping) Alveoli destruction; Alveolar-capillary membrane changes; Possibly evidenced by. Chen W, Lin YC, Liang SJ, Tu CY, Chen HJ, Hang LW. Provide information about activity limitations and alternating activities with rest periods to prevent fatigue; ways to conserve energy during activities (pulling instead of pushing, sitting instead of standing while performing tasks); use of pursed-lip breathing, side-lying position, and possible need for supplemental oxygen during sexual activity. Rationale: Restlessness and anxiety are common manifestations of hypoxia. Other Drug Therapy: Bronchodilators, which are used for prevention and maintenance therapy, can be administered as aerosols or oral medications. Intervention: Demonstrate technique for using a metered-dose inhaler (MDI), such as how to hold it, taking 2–5 min between puffs, cleaning the inhaler. You have not finished your quiz. 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. Streptococcus pneumoniae accounts for … Presence of wheezes may indicate bronchospasm or retained secretions. Rationale: Reduces risk of misuse (too little or too much) and resultant complications. Rationale: Some degree of bronchospasm is present with obstructions in airway and may or may not be manifested in adventitious breath sounds such as scattered, moist crackles (bronchitis); faint sounds, with expiratory wheezes (emphysema); or absent breath sounds (severe asthma). 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: Useful in evaluating the degree of respiratory distress or chronicity of the disease process. Patient will report pain is decreased or controlled. Increase fluid intake to 3000 mL per day within cardiac tolerance. Encourage the patient to use controlled coughing to clear secretions that might have collected in the lungs during sleep. Place patients who are experiencing dyspnea in a high Fowler position to improve lung expansion. Altered oxygen supply (obstruction of airways by secretions, bronchospasm; air-trapping), Abnormal ABG values (hypoxia and hypercapnia). The only person who is educated is the one who has learned how to learn and change. Rationale: Decreases dyspnea and increases energy for eating, enhancing intake. Impaired Gas Exchange; May be related to. Withdrawal of fluid from the pleural space provides material for a culture and sensitivity test of the organism and helps the infection resolve. Treatment of infection (antimicrobial therapy at the first sign of respiratory infection). Parapneumonic effusions are predominately exudative and occur in as many as 50-70% of patients admitted with a complicated pneumonia. In addition, many COPD patients habitually eat poorly, even though respiratory insufficiency creates a hypermetabolic state with increased caloric needs. Explain necessary dietary adjustments to the patient and family. 2. Incorrect. A person with emphysema will not exhibit noticeable symptoms. Emphysema, Asthma and Chronic Bronchitis are disease under COPD. 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