Feel Like You Don’t Belong in Nursing School? Normal skin color. Initiate necessary lifestyle changes and participate in treatment regimen. Monitor level of consciousness and mental status. Which of the following is the most important risk factor for development of Chronic Obstructive Pulmonary Disease? Good luck! Rationale: Done to identify causative organism and susceptibility to various antimicrobials. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Why and how do we even use Nursing Care Plans? 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. Review importance of breathing exercises, effective cough, frequent position changes, and adequate fluid intake. for prolonged periods of time and with repeated exposure. Treatment of infection (antimicrobial therapy at the first sign of respiratory infection). An exercise program is aimed at increasing endurance and strength without causing severe dyspnea and can enhance sense of well-being. Explain and reinforce explanations of individual disease process. Rationale: Malnutrition can affect general well-being and lower resistance to infection. Oxygenation in low concentrations for severe hypoxemia. Rationale: Useful in evaluating the degree of respiratory distress or chronicity of the disease process. Please help. 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. Dyspnea; Abnormal breathing; Confusion, restlessness; Inability to move secretions; Abnormal ABG values (hypoxia and … Rationale: Reduces potential for exposure to infectious illnesses such as upper respiratory infection (URI). Recent advances in parapneumonic effusion and empyema. Report the finding to the physician immediately. Rationale: Helps reduce fatigue during mealtime, and provides opportunity to increase total caloric intake. Obtain sputum specimen by deep coughing or suctioning for Gram’s stain, culture and sensitivity. The nurse notes shortness of breath and tachypnea. Identify interventions to prevent/reduce risk of infection. Avoid gas-producing foods and carbonated beverages. Encourage deep-slow or pursed-lip breathing as individually needed or tolerated. In most instances, the sample can be obtained at the time of chest drain insertion. The client asks the nurse to explain the purpose of this breathing technique. Because of this extensive smoking history and symptoms the client most likely has chronic obstructive bronchitis. Which of the following actions is most appropriate in response to this? Teach the patient pursed-lip and diaphragmatic breathing. People who have emphysema are often thin with wasted musculature. Outcomes: Patients were able to demonstrate: Lung sounds clean. Ineffective breathing pattern related to the disease condition (empyema) evidenced by dyspnea and pleural pain. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema and cyanotic nail beds. How do they fit in with what I already know? Rationale: Peak flow level can drop before patient exhibits any signs and symptoms of asthma during the “first time” after exposure to a trigger. Respirations may be shallow and rapid, with prolonged expiration in comparison to inspiration. Encourage the patient to plan rest periods around his or her activities, conserving as much energy as possible. Announcement!! All references to such names or trademarks not owned by NRSNG, LLC or TazKai, LLC are solely for identification purposes and not an indication of affiliation. Notice that in these nursing diagnosis statements that the information after the "as evidenced by" are always your patient's actual symptoms that you obtained during your assessment. Stress importance of oral care and dental hygiene. 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. Provide information and encourage participation in support groups (American Lung Association, public health department). The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. Refer for evaluation of home care if indicated. Several tests are used to make the diagnosis. Rationale: Having this knowledge can enable patient to make informed choices or decisions to reduce dyspnea, maximize activity level, perform most desired activities, and prevent complications. To avoid infection, screen visitors for contagious diseases and instruct the patient to avoid crowds. The only person who is educated is the one who has learned how to learn and change. Note degree of difficulty with eating. Rationale: NIPPV may be used at night or periodically during day to decrease CO. A disease that results in a common clinical outcome of reversible airflow obstruction. Nursing Diagnosis. 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