Adult Health HESI Study Guide: Updated Guide Solution

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Respiratory system Pathophysiology Nursing Assessment Analysis Plans Hints Pneumonia: Inflammation of lower respiratory tractCaused by infectious 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 More]

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