Nursing 211

N211: Health Differences Across the Lifespan I spread. Pneumonia is generally classified according to the causative agent. Pneumonia may be community acquired or nosocomial (hospital/agency acquired). High risk groups include individuals who are debilitated by accumulated lung secretions, cigarette smokers, immobile, immunosuppressed, experiencing a depressed gag reflex, sedated or experiencing neuromuscular disorders. Nursing Assessment Includes tachypnea, shallow respirations, abrupt onset of fever with shaking chills, productive cough with pleuritic pain, rapid bounding pulse, chills, crackles, rhonchi, pleural friction rub on auscultation, SOB, dyspnea, tachypnea, use of accessory muscles, sputum production. In older adults’ symptoms include confusion, lethargy, anorexia and rapid respiratory rate. Diagnostics Chest x-ray shows pulmonary infiltrates with consolidation or pleural effusion, elevated white blood cell count, arterial blood gases indicate hypoxemia, sputum study to identify specific organism. On pulse oximetry, a drop-in oxygen saturation is seen. Any client who has an altered level of consciousness, has depressed or absent gag and cough reflexes, or is susceptible to aspirating oropharyngeal secretions, including alcoholics, anesthetized clients, those with brain injury, those in a state of drug overdose, and stroke victims, is at high risk. When feeding, raise the head of the bed and position the client on his or her side, not on the back. Nursing Diagnosis • Impaired gas exchange related to diminished ventilation secondary to inflammation and infection of distal air space • Ineffective airway clearance related to pain, positioning, fatigue, and thick secretions • Activity intolerance related to… • Ineffective breathing pattern related to pain with respirations • Risk for deficient fluid volume related to… Nursing Interventions Include monitoring for dehydration due to insensible water loss secondary to fever, monitor respiratory status to detect early signs of compromise. Assess sputum for volume, color, consistency and clarity. Assist client to cough productively by deep breathing every two hours (may use incentive spirometer), using humidity to loosen secretions and suction airway as necessary. Provide fluids up to 3L/day unless contraindicated, which will help to liquefy secretions. Assess lung sounds before and after coughing. Assess rate, depth and pattern on respirations. Monitor ABGs (PO2 >80mm Hg, PCO2 <45mm Hg. Monitor oxygen saturation with pulse oximetry, assess skin color, assess mental status, restlessness and irritability. Administer oxygen as prescribed. Monitor temperature regularly. Provide adequate rest periods, including uninterrupted sleep. Teach high risk clients and their


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