Which of the following actions is most appropriate in response to this? Rationale: Helps reduce fatigue during mealtime, and provides opportunity to increase total caloric intake. This causes CO2 to stay in the alveoli and not exhale out of the body as well as making it harder for O2 to enter into the alveoli. If loading fails, click here to try again. Rationale: Cyanosis may be peripheral (noted in nailbeds) or central (noted around lips/or earlobes). Which explanation should the nurse provide? }, author={Steve A Sahn}, journal={Clinical infectious diseases : an official publication of the Infectious Diseases Society of America}, year={2007}, … Avoid gas-producing foods and carbonated beverages. Encourage a rest period of 1 hr before and after meals. Monitor level of consciousness and mental status. Assess dietary habits, recent food intake. Deep suctioning may be required when cough is ineffective for expectoration of secretions. Rationale: Although patient may be nervous and feel the need for sedatives, these can depress respiratory drive and protective cough mechanisms. Participate in treatment regimen within level of ability/situation. Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Based on this information, he most likely has which of the following conditions? Benjamin GC. You have not finished your quiz. Rationale: Breath sounds may be faint because of decreased airflow or areas of consolidation. The actual cause of emphysema is unknown. Rationale: Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode. 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. Discuss importance of avoiding people with active respiratory infections. Recommend rinsing mouth with water and spitting, not swallowing, or use of spacer on mouthpiece of inhaled corticosteroids. Obtain sputum specimen by deep coughing or suctioning for Gram’s stain, culture and sensitivity. Stress need for routine influenza and pneumococcal vaccinations. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect. There is no cure but the symptoms can be treated and progression of the disease can be slowed. The client asks the nurse to explain the purpose of this breathing technique. The disease state is progressive. Even though it cannot be stopped it can be slowed with treatment. Instruct patient and SO in use of NIPPV as appropriate. Teach the patient pursed-lip and diaphragmatic breathing. Blood tests may also show if the infection has spread to your blood or you have signs of inflammation. Please wait while the activity loads. Air pollution is a risk factor for development of COPD, but it is not the most important risk factor. Rationale: Useful in evaluating the degree of respiratory distress or chronicity of the disease process. Generally, inhaled anticholinergic agents are the first-line therapy for emphysema, with the addition of betaadrenergic agonists added in a stepwise fashion. Why and how do we even use Nursing Care Plans? A nurse is assessing a male client with chronic airflow limitations and notes that the client has a “barrel chest.” The nurse interprets that this client has which of the following forms of chronic airflow limitations? (A client with emphysema may have an I:E ratio as high as 1:4.). Encourage deep-slow or pursed-lip breathing as individually needed or tolerated. Normally alveoli are little pouches of springy grapes, but patients with emphysema have misshapen pouches that are not springy. Stress proper handwashing (nurse and patient), and use gloves when handling or disposing of tissues, sputum containers. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system. Conserve the patient’s energy in every possible way. Increase fluid intake to 3000 mL per day within cardiac tolerance. Encourage abdominal or pursed-lip breathing exercises. etiology empyema stabbing gunshot wounds etc. 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. Which finding indicates that the drug is producing a therapeutic effect? X-ray or CT scan pictures are used to find signs of pneumonia or a lung abscess. Encourage the client to perform pursed lip breathing. Decreased respiratory excursion,resonance to hyperresonance, decreased breath sounds with prolonged expiration, normal or decreased fremitus, Impaired gas exchange related to destruction of alveolar walls. 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). The nurse assesses the oxygen flow rate to ensure that it does not exceed: Oxygen is used cautiously and should not exceed 2 L/min. Pleural empyema is usually caused by pneumonia. Although PPEs are relatively common, empyema (i.e., the accumulation of pus in the pleural space) is less common… NURSING DIAGNOSIS OF PATIENT WITH EMPYEMA 1. A male client with emphysema becomes restless and confused. 5 Steps to Writing a (kick ass) Nursing Care Plan, Dear Other Guys, Stop Scamming Nursing Students, The S.O.C.K. Nursing Diagnosis: Acute Pain related to inflammation and swelling of the pleura secondary to pleural effusion, as evidenced by sudden and severe chest pain, pain rating of 10 out of 10 on pain scale, guarding sign on the chest, irritability, worsening pain upon inhalation. Rationale: These activities promote mobilization and expectoration of secretions to reduce risk of developing pulmonary infection. Support groups or home visits may be desired or needed to provide assistance, emotional support, and respite care. Treatment is directed at improving ventilation, decreasing work of breathing and preventing infection. Having excess weight on the patient decreases the space for the lungs to expand. Nursing Diagnosis. Good luck! Keep environmental pollution to a minimum such as dust, smoke, and feather pillows, according to individual situation. Any items you have not completed will be marked incorrect. Chen W, Lin YC, Liang SJ, Tu CY, Chen HJ, Hang LW. Rationale: Tachypnea is usually present to some degree and may be pronounced on admission or during stress or concurrent acute infectious process. Supporting arms and legs with table, pillows, and so on helps reduce muscle fatigue and can aid chest expansion. Which of the following types of lung cancer is the most prevalent carcinoma of the lung for both men and women? Once you are finished, click the button below. Lack of information/unfamiliarity with information resources, Inaccurate follow-through of instructions. An X-ray can only identify empyema when there is a specific amount of fluid in the pleural cavity, however. Our hottest nursing game is out now in the App Store. Emphysema is the enlargement and destruction of the alveolar, bronchial, and bronchiolar tissue with resultant loss of recoil, air trapping, thoracic overdistention, sputum accumulation, and loss of diaphragmatic muscle tone. Maintaining a patent airway is a priority. Apply a compression dressing to the area. Assess and monitor respirations and breath sounds, noting rate and sounds (tachypnea, stridor, crackles, wheezes). Rationale: NIPPV may be used at night or periodically during day to decrease CO. What principle are they based on? Nurse Murphy administers albuterol (Proventil), as prescribed, to a client with emphysema. Risk factors for the development of emphysema include cigarette smoking, living or working in a highly polluted area, and a family history of pulmonary disease. Chronic dilatation of a bronchus or bronchi. Review importance of breathing exercises, effective cough, frequent position changes, and adequate fluid intake. Rationale: These patients and their SOs may experience anxiety, depression, and other reactions as they deal with a chronic disease that has an impact on their desired lifestyle. Rationale: Noxious tastes, smells, and sights are prime deterrents to appetite and can produce nausea and vomiting with increased respiratory difficulty. In most instances, the sample can be obtained at the time of chest drain insertion. Stress importance of oral care and dental hygiene. (Picmonic), 00.01 Nursing Care Plans Course Introduction, 01.03 Using Nursing Care Plans in Clinicals, Nursing Care Plan for Atrial Fibrillation (AFib), Nursing Care Plan for Congenital Heart Defects, Nursing Care Plan for Congestive Heart Failure (CHF), Nursing Care Plan for Gestational Hypertension, Preeclampsia, Eclampsia, Nursing Care Plan for Heart Valve Disorders, Nursing Care Plan for Myocardial Infarction (MI), Nursing Care Plan for Thrombophlebitis / Deep Vein Thrombosis (DVT), Nursing Care Plan for Cleft Lip / Cleft Palate, Nursing Care Plan for Infective Conjunctivitis / Pink Eye, Nursing Care Plan for Otitis Media / Acute Otitis Media (AOM), Nursing Care Plan for Constipation / Encopresis, Nursing Care Plan for Diverticulosis / Diverticulitis, Nursing Care Plan for Eating Disorders (Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder), Nursing Care Plan for Gastroesophageal Reflux Disease (GERD), Nursing Care Plan for Hyperemesis Gravidarum, Nursing Care Plan for Inflammatory Bowel Disease (Ulcerative Colitis / Crohn’s Disease), Nursing Care Plan for Peptic Ulcer Disease (PUD), Nursing Care Plan for Vomiting / Diarrhea, Nursing Care Plan for GI (Gastrointestinal) Bleed, Nursing Care Plan for Acute Kidney Injury, Nursing Care Plan for Benign Prostatic Hyperplasia (BPH), Nursing Care Plan for Chronic Kidney Disease, Nursing Care Plan for Enuresis / Bedwetting, Nursing Care Plan for Urinary Tract Infection (UTI), Nursing Care Plan for Acquired Immune Deficiency Syndrome (AIDS), Nursing Care Plan for Disseminated Intravascular Coagulation (DIC), Nursing Care Plan for Dehydration & Fever, Nursing Care Plan for Herpes Zoster – Shingles, Nursing Care Plan for Lymphoma (Hodgkin’s, Non-Hodgkin’s), Nursing Care Plan for Skin cancer – Melanoma, Basal Cell Carcinoma, Squamous Cell Carcinoma, Nursing Care Plan for Varicella / Chickenpox, Nursing Care Plan for Burn Injury (First, Second, Third degree), Nursing Care Plan for Eczema (Infantile or Childhood) / Atopic Dermatitis, Nursing Care Plan for Pressure Ulcer / Decubitus Ulcer (Pressure Injury), Nursing Care Plan for Alcohol Withdrawal Syndrome / Delirium Tremens, Nursing Care Plan for Alzheimer’s Disease, Nursing Care Plan for Autism Spectrum Disorder, Nursing Care Plan for Dissociative Disorders, Nursing Care Plan for Generalized Anxiety Disorder, Nursing Care Plan for Mood Disorders (Major Depressive Disorder, Bipolar Disorder), Nursing Care Plan for Personality Disorders, Nursing Care Plan for Post-Traumatic Stress Disorder (PTSD), Nursing Care Plan for Somatic Symptom Disorder (SSD), Nursing Care Plan for Suicidal Behavior Disorder, Nursing Care Plan for Addison’s Disease (Primary Adrenal Insufficiency), Nursing Care Plan for Diabetic Ketoacidosis (DKA), Nursing Care Plan for Diabetes Mellitus (DM), Nursing Care Plan for Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS), Nursing Care Plan for Myasthenia Gravis (MG), Nursing Care Plan for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), Nursing Care Plan for Systemic Lupus Erythematosus (SLE), Nursing Care Plan for Cerebral Palsy (CP), Nursing Care Plan for Increased Intracranial Pressure (ICP), Nursing Care Plan for Multiple Sclerosis (MS), Nursing Care Plan for Neural Tube Defect, Spina Bifida, Nursing Care Plan for Parkinson’s Disease, Nursing Care Plan for Abortion, Spontaneous Abortion, Miscarriage, Nursing Care Plan for Abruptio Placentae / Placental abruption, Nursing Care Plan for Bronchiolitis / Respiratory Syncytial Virus (RSV), Nursing Care Plan for Fetal Alcohol Syndrome (FAS), Nursing Care Plan for Hyperbilirubinemia of the Newborn / Infant Jaundice / Neonatal Hyperbilirubinemia, Nursing Care Plan for Meconium Aspiration, Nursing Care Plan for Pediculosis Capitis / Head Lice, Nursing Care Plan for Premature Rupture of Membranes (PROM) / Preterm Premature Rupture of Membranes (PPROM), Nursing Care Plan for Phenylketonuria (PKU), Nursing Care Plan for Postpartum Hemorrhage (PPH), Nursing Care Plan for Preterm Labor / Premature Labor, Nursing Care Plan for Acute Respiratory Distress Syndrome, Nursing Care Plan for Asthma / Childhood Asthma, Nursing Care Plan for Bronchoscopy (Procedure), Nursing Care Plan for Chronic Obstructive Pulmonary Disease (COPD), Nursing Care Plan for Pertussis / Whooping Cough, Nursing Care Plan for Pneumothorax/Hemothorax, Nursing Care Plan for Respiratory Failure, Nursing Care Plan for Restrictive Lung Diseases, Nursing Care Plan for Thoracentesis (Procedure), Nursing Care Plan for Gout / Gouty Arthritis, Nursing Care Plan for Rheumatoid Arthritis (RA). 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