pneumonia.pdf - ACTIVE LEARNING TEMPLATE System Disorder...

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Unformatted text preview: ACTIVE LEARNING TEMPLATE: System Disorder STUDENT NAME______________________________________ Pneumonia DISORDER/DISEASE PROCESS___________________________________________________________ REVIEW MODULE CHAPTER__17 __________ Alterations in Health (Diagnosis) Ineffective Airway Clearance Pathophysiology Related to Client Problem Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. Health Promotion and Disease Prevention Start an Evidence-Based Pneumonia Quality Improvement Program, and educate the poor community. ASSESSMENT SAFETY CONSIDERATIONS Risk Factors Expected Findings Smoking; smoke inhalation; second-hand smoke, Airway spasm; retained secretions; excessive mucus; secretions in bronchi; exudate in alveoli;Neuromuscular dysfunction; hyperplasia of bronchial walls; chronic obstructive pulmonary disease; infection; asthma; allergic airways Laboratory Tests Dyspnea; diminished breath sounds; orthopnea; adventitious breath sounds (crackles, wheezes); cough, ineffective or absent; sputum production; cyanosis; difficulty vocalizing; wide-eyed; changes in respiratory rate and rhythm, restlessness Diagnostic Procedures -CBC- elevated(may not be present in older adults) -ABGs- Hypoxemia (decreased PaO2 <80mm Hg) -Blood culture- To rule out organisms in the blood -Serum electrolytes- To identify causes of dehydration -Chest X-ray -Pulse oximetry- usually less than expected reference range PATIENT-CENTERED CARE Nursing Care Patient will maintain clear, open airways as evidence by normal breath sounds, normal rate and depth of respirations, and ability to effectively cough up secretions after treatments and deep breaths. Patient will demonstrate increased air exchange. Anxiety, Cognitive impairment, Fatigue, Fear, Pain Perception, Surgery, Trauma Risk for Falls, skin brake down, incontinence dermatitis, and Altered mental status related to low oxygenation Complications Medications Antibiotics Corticosteroids Bronchodilators Client Education Teach about Influenza and Pneumococcal vaccines. A cool mist humidifier may help breathing at home. Antibiotic medication compliances. Bacteria in the bloodstream (bacteremia) Fluid accumulation around the lungs (pleural effusion). Fluid replacement Therapeutic Procedures Administer humidified oxygen. Chest PT, two hour repositioning, incentive spirometer, ACTIVE LEARNING TEMPLATES Antipyretic NSAIDS Interprofessional Care Home health nursing to monitor for medication compliance and nutrition status. Dietitian for meal planning and nutritional needs. Social working for medication assistance and home health care. Lung abscess. An abscess occurs if pus forms in a cavity in the lung. Therapeutic Procedure  A11 ...
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