Respiratory system
Pathophysiology Nursing Assessment Analysis Plans Hints
Pneumonia:
Inflammation of
lower respiratory
tractCaused by
infectious
... [Show More] agents
Organisms reach
the lungs in 3
methods:
1.Aspiration
2. Inhalation
3.Hematogenous
spread Pneumonia
is classified
according to
causitive agent
1.Bacterial (gram
pos and neg)
2.Viral
3.Fungal
4.Chemical
Pneumonia may
be community
acquired or
nosomcomial
High risk groups include
1.Debilitated by lung secretions
2.Cigarette smokers
3. Immoblie
4. Imunosuppressed
5.Expereincing a
depressed gag
reflex
6. Sedated
7.Experiencing
neuromusclar
disorders
A.Tachypnea: shallow
respirations with use of
accessory muscles.
B.Abrupt onset of fever
with shaking and chills
(not reliable in O/A)
C.Productive cough with pleuritic pain
D.Rapid bounding pulse
E. In older adults sx include:
1.Confusion
2.Lethargy
3.Anorexia
4.Rapid respiratory
rate
F.Pain and dullness to
percussion over the
affected lung area
G.Bronchial breaht sounds/crackles
H.Chest radiography
indication of inflitrates
with consolidation or
pleural effusions
I.Elevated white blood cell coung
J.ABG of hypoxemia
K.On pulse oximetry a
drop in O2 satruation (>
90 and ideally 95)
A. Impaired gas exchange related to…
B. Ineffective airway celarance related to…
C.Activity intolerance related to…
D.Risk for deficient fluid volume related to….
E. Ineffective breathing
pattern related to…
A.Assess suptum for
volume, color,
consistency and
clarity.
B.Assist client to
cough
productivelyby:
1.deep breathing
care every 2
hours (many
use incentive
spiometer)
2.Using
humidity to
loosen
sevretions
(may be
oxylgenerate
d)
3.Suctioning
airway if
necessary
C.Assess lung sounds
before and after
coughing
D.Assess rate, depth,
and pattern of
respirations
regularly (normal
adultrate 16 to 20
breaths/min)
E.Monitor Abg's (pO2
> 80mm2; Pco2
< 45mm hg)
F.Monitor O2
saturation with
pulseoximetry
(ideally > 95%)
G.Assess skin color
H.Assess mental
status,
restlessness, and
irritability
I.Administer o2 as prescribed
J.Monitor
temperature regularly
K.Provide
adequate rest
periods,
including
uniterrupted
sleep.
L.Encourage at risk
groups to annual
pneumonia and
influenza (flu)
immuniziations.
High risk for pneumonia
Any person who has an
altered level of
consciousness, has
depressed or absent gag
and cough reflexes or is
susceptible to aspirating
orophayngeal secretions,
including alcoholics,
anesthesized, those with a
brain injury and those ina
state of drug overdose and
stroke victims are at high
risk
When feeding-- raise the
head of the bed and
position the client on his or
her side and not on the
back.
Bronchial brath sounds
are heard over areas of
density or consolidation.
Sound waves are easily
transmitted over
consolidated tissues.
Hydration
Enables liquefication of
mucous trapped in the
bronchioles and alveoli,
facilitating expectoration Is
essential for client
experiencing fever
Is important because 300 to
400 mL of fluid is lostdaily
by the lugns through
evaporation.
Irritably and restlessnes are
early signs of cerebral
hypoxia; the cleint's brain is
not recieiing enough ofO2.
Pneumonia Preventaives
Older adults: flue shots;
pneumonia,
immunizations; avoiding
soucres of infection and
indoor pollutants (dust,
smoke and aerosols); no
smoking.
Immunosuppressed and
debilitated persons:
infection avoidance, [Show Less]