Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
TL Pneumonia
Nursing of the adult with pneumonia (HESI)
| Question | Answer |
|---|---|
| Define pneumonia. | Inflammation of the lower respiratory tract |
| Pneumonia is often classified by the causative agents. Name some agents that can cause pneumonia. | Bacteria, Viral, Fungal (rare), and Chemical |
| Give three ways in which causative organisms can reach the lungs. | Aspiration, inhalation, hematogenous spread |
| List 7 conditions that increase risk for contracting pneumonia (DD II SS N). | Debilitated by accumulated lung secretions, smokers, immobile, immunosuppressed, depressed gag reflex, sedated, neuromuscular disorders |
| What will an chest radiograph show if the patient has pneumonia? | indication of infiltrates with consolidation or pleural effusion |
| What would the nurse expect to find on assessment of a patient with pneumonia? | tachypnea, shallow respirations, accessory muscle, fever/shaking/chills, cough with pleuritic pain, rapid bounding pulse, pain/dullness to percussion over affected lung area, bronchial breath sounds, crackles, high WBC, ABG=hypoxemia, low O2 sat |
| Fever and chills is not a reliable indicator of pneumonia in the elderly. What symptoms might the nurse expect to find in the elderly client with pneumonia? | confusion, lethargy, anorexia, rapid respiratory rate |
| Explain the ill effects of fever on the body. | Fever can cause dehydration, increased metabolism, and increased oxygen demand |
| Name some individuals who would be at increased risk for pneumonia due to altered LOC, gag/cough reflex, or increased risk for aspiration (So BAAD). | Stroke, Brain injured, Alcoholics, Anesthetized, Drug overdose |
| What should the nurse do when feeding a person who is at risk for aspiration? | raise the head of the bed and position the client on his side, not on the back |
| Give 4 applicable nursing diagnoses for the patient with pneumonia. | Ineffective airway clearance, Impaired gas exchange, Activity intolerance, Risk for deficient fluid volume |
| What assessments are pertinent to the patient with pneumonia? | sputum for volume, color, consistency, and clarity; lung sounds before and after coughing; respirations- rate, depth, pattern; pulse;ABGs; O2 saturation; Skin color; mental status – restlessness, irritability; temperature |
| What are the normal values for ABGs? | PH – 7.35 to 7.45; Po2 - 80%-100%; PaCo2 35-45mmHg; HCO3 22-26mEq/L |
| What is the normal rate of respirations? | 16-20 breaths per minute |
| What should the O2 saturation be? | Above 90%, ideally above 95% |
| What nursing interventions help the client with pneumonia to clear lung secretions? | Encourage deep breathing Q 2 hours/incentive spirometer; use humidity and encourage fluids up to 3 L/day (unless contraindicated) to loosen secretions |
| What interventions other than assessments and encouraging productive cough does the nurse provide to the client with pneumonia? | administer O2 as prescribed, administer antibiotics, provide adequate rest periods and uninterrupted sleep |
| What can the nurse do to prevent pneumonia? | Teach high-risk patients/families risk factors and preventative measures; encourage high risk groups to get annual pneumonia/flu immunization; elevate the head of bed when feeding comatose/immobile persons; teach to avoid infection sources; no smoking |
| What kind of breath sounds would the nurse expect to hear over areas of consolidation in the client with pneumonia? | bronchial breath sounds |
| Why are bronchial breath sounds heard over areas of consolidation or density? | Sound waves are easily transmitted over consolidated tissue |
| Why is hydration such a concern for the patient with pneumonia? | facilitates expectoration of mucous from alveoli and bronchioles; to hydrate fevered client; 300 – 400mL are lost daily through the lungs |
Created by:
Perseverandovercome
Popular Nursing sets