Nursing 211

N211: Health Differences Across the Lifespan I families about risk factors that include preventive measures. Encourage at risk groups to get annual pneumonia and influenza immunizations. Bronchial breath sounds are heard over areas of density or consolidation. Sound waves are easily transmitted over consolidated tissue. Hydration enables liquefication of mucus trapped in the bronchioles and alveoli, facilitating expectoration. Hydration is essential for clients experiencing fever. Hydration is important because 300 to 400ml of fluid is lost daily by the lungs through evaporation. Irritability and restlessness are early signs of cerebral hypoxia. Pneumonia Preventatives In older clients, encourage flu shots and pneumonia immunization; avoiding sources of infection and indoor pollutants (dust, smoke, and aerosols). Immunosuppressed and debilitated clients need to avoid infections, have sensible nutrition, adequate intake and balance rest with activity. Comatose and immobile clients need to have the head of the bed elevated to feed and for two hours after feeding. Interventions also include frequent turning and repositioning. Cancer of the Larynx is when a neoplasm occurs in the larynx, typically squamous cell in origin. Contributing factors are prolonged use of alcohol and tobacco, vocal straining, chronic laryngitis, family predisposition, industrial exposure to carcinogens and nutritional deficiencies. Men are affected eight times more often than women. Diagnosis occurs between the ages of 55 and 70. The earliest sign is hoarseness or a change in vocal quality. Nursing Assessment Includes assessing for hoarseness, pain with swallowing, dysphagia, dyspnea, cough, hemoptysis, weight loss, neck pain radiating to the ear, enlarged cervical nodes and halitosis. The tongue and the mouth often appear white, gray, dark brown or black and may appear patchy. Diagnostics Include magnetic resonance imaging (MRI), direct laryngoscopy, and radiographs of the head, neck and chest and computed tomography (CT) scan of the neck and biopsy. Nursing Diagnosis • Anxiety related to… • Ineffective airway clearance related to… • Impaired verbal communication related to… • Ineffective breathing pattern related to…


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