WEEK 2 : Nursing care plan for pneumonia

Question 1

Name all the nursing diagnosis that undergoes the nursing care plan for pneumonia

Answer 1

impaired gas exchange
ineffective breathing
ineffective airway clearance
acute pain

Question 2

recall that these are nursing diagnosis when it comes to pneumonia patient

impaired gas exchange
ineffective breathing

give the rationale for them

Answer 2

1)Impaired gas exchange-n (related to fluid and exudate
accumulation at the capillary-alveolar membrane as evidenced
by decreased breath sounds, abnormal arterial blood gas levels,
abnormal chest x-ray, restlessness, and confusion)

2) related to fatigue, respiratory
muscle fatigue as evidenced by dyspnea, tachypnea, nasal
flaring, altered chest excursion

Question 3

would this be a true rationale for these following :
ineffective airway clearance
acute pain

related to excessive mucus,
retained secretions as evidenced by ineffective cough, excessive
sputum, adventitious breath sounds, dyspnea

acute pain related to biological injury agent as evidenced by
positioning to ease pain, protective behaviour, change in
physiological parameter

Answer 3

true

Question 4

how should we monitor for resp monitoring?

Answer 4

asculate breath sounds ( any adventitious lung sounds )

monitor rate rhythym depth and effort to respirations to determine resp status

monitor for restlessness, air hunger, and anxiety

monitor pt’s ability to cough effectevly to promote secretion removal

monitor resp secretion to detect purulent sputum or hemptysis

Question 5

would this be true or false? and where does this fall under to?

Administer supplemental O2 as ordered to promote adequate
oxygenation.
* Set up O2 equipment and administer through a humidified
system to prevent drying of the respiratory tract.
* Monitor the effectiveness of O2 therapy (e.g., pulse oximetry,
ABGs) to evaluate patient response to therapy.
* Monitor for skin breakdown from friction of O2 device.
* Monitor patient’s anxiety related to need for O2 therapy to
provide explanations and reassurance.
* Periodically check O2 delivery device to ensure that the
prescribed concentration is being delivered.

Answer 5

yes this is true

Question 6

is it okay to encourage the pt to monitor their own pain to intervene appropriately to allow independence and prepare for discharge
?

Answer 6

yes this is true

Question 7

what type of non pharmacological techniques are we teaching the pt when it comes to acute pain

Answer 7

relaxation, guided imagery, music theraphy, distraction, and massage )

Question 8

true or false? Use pain control measures before pain becomes severe
because mild to moderate pain is controlled more quickly.

Answer 8

yes this is true

Question 9

would this be true or false? Medicate before an activity to increase participation, but
evaluate the hazard of sedation to help minimize pain that will be experienced?

Answer 9

true

Question 10

is this true or false? Position to minimize respiratory efforts (i.e., elevate the head
of the bed and provide overbed table for patient to lean on) to
reduce work of breathing and oxygen needs

Answer 10

yes this is true