impaired gas exchange nursing diagnosis pneumonia

What measures should be taken to maintain F.N. Objective Data e. Sleep-rest Those at higher risk, such as the very young or old, patients with compromised immune systems, or who already have a respiratory comorbidity, may require inpatient care and treatment. b. Copious nasal discharge Factors associated with aspiration pneumonia include old age, impaired gag reflex, surgical procedures, debilitating disease, and decreased level of consciousness. Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and the goal of nursing interventions is aimed at prevention. Wear gloves on both hands when handling the cannula or when handling ventilation tubing. Moisture helps minimize convective moisture loss during oxygen therapy. Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively. Hospital acquired pneumonia may be due to an infected. The nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? What testing is indicated? Impaired Gas Exchange Nursing Diagnosis, Care Plan, Interventions Monitor for respiratory changes.Changes in respiratory rate, rhythm, and depth can be subtle or appear suddenly. What does the nurse teach the patient with intermittent allergic rhinitis is the most effective way to decrease allergic symptoms? Proper nutrition promotes energy and supports the immune system. d. Limited chest expansion 4) Spend as much time as possible outdoors. (1) Aspiration of gastric acid (the most common route), resulting in toxic damage to the lungs, (2) obstruction (foreign bodies or fluids), and. What process would they have needed to complete in order to have been successful? Bacterial infections are indications for antibiotic therapy, but unless symptoms of complications are present, injudicious administration of antibiotics may produce resistant organisms. 3 Nursing care plans for pneumonia. b. Goal. Assessing altered skin integrity risks, fatigue, impaired comfort, gas exchange, nutritional needs, and nausea. PDF NMNEC Concept: Gas Exchange Buy on Amazon, Silvestri, L. A. i. Sexuality-reproductive: Sexual activity altered by respiratory symptoms These measures ensure consistency and accuracy of weight measurements. This is an expected finding with pneumonia, but should not continue to rise with treatment. Facilitate coordination within the care team to allow rest periods between care activities. Using a sphygmometer, auscultate the patients breath sounds for at least every 4 hours. d. VC: (4) Maximum amount of air that can be exhaled after maximum inspiration e. Suction the tracheostomy tube when there is a moist cough or a decreased arterial oxygen saturation by pulse oximetry (SpO2). c. Percussion Mastering Pleural Effusion Nursing Management: Best Practices and Protocols This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. To help clear thick phlegm that the patient is unable to expectorate. Pulmonary activities that help prevent infection/pneumonia include deep breathing, coughing, turning in bed, splinting wounds before breathing exercises, walking, maintaining adequate oral fluid intake, and using a hyperinflation device. Empyema is a collection of pus in the thoracic cavity. Nursing care plan for impaired gas exchange. c. Inadequate delivery of oxygen to the tissues The nurse suspects which diagnosis? the medication. causing a clinical illness o Mandatory testing for health care professionals o Usually performed twice o Priority Nursing Diagnoses: Ineffective breathing pattern Ineffective airway clearance Impaired Gas . 6. a. 1. Maximum rate of airflow during forced expiration Teach patients some signs and symptoms that prompt immediate medical attention such as dyspnea. For which problem is this test most commonly used as a diagnostic measure? Discuss to the patient the different types of pneumonia and the difference between him/her. Remove excessive clothing, blankets and linens. This is most common in intensive care units usually resulting from intubation and ventilation support. The nurse selects Ineffective Breathing Pattern after validating this patient is demonstrating the associated signs and symptoms related to this nursing diagnosis: Dyspnea Increase in anterior-posterior chest diameter (e.g., barrel chest) Nasal flaring Orthopnea Prolonged expiration phase Pursed-lip breathing Tachypnea Urinary antigen test: To detect Legionella pneumophila and Streptococcus pneumoniae. a. Decreased force of cough c. A tracheostomy tube allows for more comfort and mobility. 3) g. Position the patient sitting upright with the elbows on an over-the-bed table. b. a hemilaryngectomy that prevents the need for a tracheostomy. d. Notify the health care provider of the change in baseline PaO2. Remove the inner cannula and replace it per institutional guidelines. Shetty, K., & Brusch, J. L. (2021, April 15). Attempt to replace the tube. Reports facial pain at a level of 6 on a 10-point scale Administer nebulizer treatments and other medications.Nebulizer treatments can loosen secretions in the lungs while mucolytics and expectorants can help thin mucus and make it easier to cough up. a. Thoracentesis A closed-wound drainage system Which medication therapy does the nurse anticipate will be prescribed? Oxygen is administered when O2 saturation or ABG results show hypoxemia. (2022, January 26). Pneumonia Nursing Diagnosis & Care Plan - NurseStudy.Net b. Weight changes of 1-1.5 kg/day may occur with fluid excess or deficit. What is the first action the nurse should take? How to use esophageal speech to communicate If the patient is having increased mucous production, encourage him or her to clear the airway. Course crackles sound like blowing through a straw under water and occur in pneumonia when there is severe congestion. Factors that increase the risk of nosocomial pneumonia in surgical patients include: older adults (older than 70 years), obesity, COPD, other chronic lung diseases (e.g., asthma), history of smoking, abnormal pulmonary function tests (especially decreased forced expiratory flow rate), intubation, and upper abdominal/thoracic surgery. Popkin, B. M., DAnci, K. E., & Rosenberg, I. H. (2010). Nursing care plan pneumonia - Nursing care plan: Pneumonia Pneumonia is an inflammation of the lung - Studocu care plan pneumonia nursing care plan: pneumonia pneumonia is an inflammation of the lung parenchyma, associated with alveolar edema and congestion that impair Skip to document Ask an Expert Sign inRegister Sign inRegister Home b. e. Sleep-rest: Sleep apnea. To facilitate the body in cooling down and to provide comfort. (Symptoms) Reports of feeling short of breath Pneumonia can be hospital-acquired, which presents after the patient has been admitted for 2 days. Decreased immunoglobulin A (IgA) decreases the resistance to infection. a. Vt a. Decreased functional cilia and decreased force of cough from declining muscle strength cause decreased secretion clearance. a. Impaired Gas Exchange - Nursing Diagnosis & Care Plan Immobile patients or those who need assistance should be turned every 2 hours, assisted into an upright position, or transferred into a chair to promote lung expansion. Normal mixed venous blood gases also have much lower partial pressure of oxygen in venous blood (PvO2) and venous oxygen saturation (SvO2) than ABGs. Use only sterile fluids and dispense with sterile technique. No interventions are necessary for these findings. Putting diagnoses in priority order? Help! - Nursing - allnurses c. TLC Bronchoconstriction All of the assessments are appropriate, but the most important is the patient's oxygen status. Promote oral hygiene, including lip and tongue care. 2. Pneumonia Nursing Care Plan 4 Impaired Gas Exchange Nursing Diagnosis: Impaired Gas Exchange related to the overproduction of mucus in the airway passage secondary to pneumonia as evidenced by cyanosis, restlessness, and irritability. If O2 saturation does not increase to an acceptable level (greater than 92%), FiO2 is increased in small increments while simultaneously checking O2 saturation or obtaining ABG values. Attend to the patients queries regarding their pneumonia treatment. Palpation identifies tracheal deviation, limited chest expansion, and increased tactile fremitus. 3. c. Take the specimen immediately to the laboratory in an iced container. Assess breath sounds, respiratory rate and depth, sp02, blood pressure and heart rate, and capillary refill to monitor for signs of hypoxia and changes in perfusion. Medical-surgical nursing: Concepts for interprofessional collaborative care. NANDA Nursing Diagnosis for Respiratory Disorders - Nurseship.com a. c. Patient in hypovolemic shock It is important to pre-oxygenate the patient before the nurse suctions to avoid respiratory distress. Impaired gas exchange is the state in which there is an excess or deficit in oxygenation or in the elimination of carbon dioxide at the level of the alveolocapillary membrane. Functional Health Pattern A patient's initial purified protein derivative (PPD) skin test result is positive. Assess lung sounds and vital signs. Impaired gas exchange is the state wherein there is either excess or decrease in the oxygenation of an individual. b. Serologic studies: Acute and convalescent antibody titers determined for the diagnosis of viral pneumonia. Priority: Management of pneumonia and dehydration. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature. Surfactant is a lipoprotein that lowers the surface tension in the alveoli. Pink, frothy sputum would be present in CHF and pulmonary edema. To help alleviate cough and allow the patient to rest, cough suppressants may be given at low doses. Decreased or random breath sounds (e.g., crackles, wheezes) may indicate possible respiratory failure, which would further exacerbate hypoxia and require immediate intervention. e. Increased tactile fremitus b. SpO2 of 95%; PaO2 of 70 mm Hg When does the nurse record the presence of an increased anteroposterior (AP) diameter of the chest? During assessment of the patient with a viral upper respiratory infection, the nurse recognizes that antibiotics may be indicated based on what finding? This intervention provides oxygenation while reducing convective moisture loss and helping to mobilize secretions. At the end of the span of care, the patient will be able to have an effective, regular, and improved respiratory pattern within a normal range (12-20 cycles per minute). b. treatment with antifungal agents. Goal/Desired Outcome Short-term goal: The patient will remain free from signs of respiratory distress and her oxygen saturation will remain higher than 96% for the duration of the shift. Maegan Wagner is a registered nurse with over 10 years of healthcare experience. Symptoms of an abscess caused by aerobic bacteria develop more acutely and resemble bacterial pneumonia. Impaired gas improved or presence of retained secretions client: exchange ventilation and adventitious sound -Demonstrated adequate improved wheezes oxygenation of -Decrease of ventilation and tissues by ABG of: -Palpate for fremitus vibratory tremors adequate pH:7.35-7.45 suggest fluid oxygenation of 6. e. Increased tactile fremitus - A nurse should be aware of some of the common side effects of antitubercular drugs like rifampin, one of which is orange discoloration of body fluids such as urine, sweat, tears, and sputum. g) 4. Nursing care plan pneumonia - StuDocu a. Older adults may be confused or disoriented and have a low-grade fever but few other signs and symptoms. In patients with unilateral pneumonia, positioning on the unaffected side (i.e., good side down) promotes ventilation to perfusion adaptation. A patient with pneumonia shows inflammation in their lung parenchyma causing it to have. presence of nasal bleeding and exhalation grunting. a. Stridor COPD ND3: Impaired gas exchange. To obtain the most information, auscultate the posterior to avoid breast tissue and start at the base because of her respiratory difficulty and the chance that she will tire easily. Priority Decision: When F.N. The nurse should assess the patient's cardiopulmonary status with careful monitoring of vital signs, cardiac rhythm, pulse oximetry, arterial blood gases (ABGs), and lung sounds. Monitor for worsening signs of infection or sepsis.Dropping blood pressure, hypothermia or hyperthermia, elevated heart rate, and tachypnea are signs of sepsis that require immediate attention. Techniques that will be used to alleviate a dry mouth and prevent stomatitis Save my name, email, and website in this browser for the next time I comment. What is the reason for delaying repair of F.N. The nurse explains that usual treatment includes Implement NPO orders for 6 to 12 hours before the test. Which nursing intervention assists a patient with pneumonia in managing thick secretions and fatigue? Perform steam inhalation or nebulization as required/ prescribed. e. FVC: (5) Amount of air that can be quickly and forcefully exhaled after maximum inspiration Early small airway closure contributes to decreased PaO2. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). Impaired Gas Exchange Care Plan Writing Services a. Bronchophony occurs with pneumonia but is a spoken or whispered word that is more distinct than normal on auscultation. Keep the head end of the bed at a height of 30 to 45 degrees and turn the patient to the lateral position. The bacteria attach to the cilia of the respiratory tract and release toxins that damage the cilia, causing inflammation and swelling. b. Nutritional-metabolic: Decreased fluid intake, anorexia and rapid weight loss, obesity 5) e. Observe for signs of hypoxia during the procedure. Nursing Diagnosis for COPD | Nursing Care Plan & Interventions for COPD Week 1 - Nursing Care of Patients with Respiratory Problems Influenza, Atelectasis, Pneumonia, TB, & Expert Help. The postoperative use of nonverbal communication techniques Complications include hyperventilation, gastric hyperinflation, headache, hypotension, and signs and symptoms of pneumothorax (shortness of breath, stabbing chest pain, decreased breath sounds on one side, dyspnea, cough). The patient is admitted with pneumonia, and the nurse hears a grating sound when she assesses the patient. A nurse has been caring for a patient with tuberculosis (TB) and has a TB skin test performed. Normal venous blood gas values reflect the normal uptake of oxygen from arterial blood and the release of carbon dioxide from cells into the blood, resulting in a much lower PaO2 and an increased PaCO2. A repeat skin test is also positive. Suction as needed.Patients who have a tracheostomy may need frequent suctioning to keep airways clear. It can have too much oxygen or carbon dioxide in the body which is not very beneficial to the organs or systems. The patient will most likely feel comfortable and easy to breathe when their head is elevated in bed. c. Airway obstruction Assess lung sounds and vital signs.Assess breath sounds, respiratory rate and depth, sp02, blood pressure and heart rate, and capillary refill to monitor for signs of hypoxia and changes in perfusion. d. SpO2 of 88%; PaO2 of 55 mm Hg. a. Hospital-Acquired Pneumonia (Nosocomial Pneumonia) and Ventilator-Associated Pneumonia: Overview, Pathophysiology, Etiology. b. Repeat the ABGs within an hour to validate the findings. Encourage rest and limit exertion.Patients may not be able to tolerate too much activity. The patient may have a limit to visitors to prevent the transmission of infections. Alveolar sacs are terminal structures of the respiratory tract, where gas exchange takes place. Always change the suction system between patients. Cough and sore throat 5. d. Comparison of patient's current vital signs with normal vital signs. Start asking what they know about the disease and further discuss it with the patient. Increasing the intake of foods that are high in vitamin C does not decrease exposure to others. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. a. Samples for ABGs must be iced to keep the gases dissolved in the blood (unless the specimen is to be analyzed in <1 minute) and taken directly to the laboratory. Reporting complications of hyperinflation therapy to the health care provider. c. Ventilation-perfusion scan The following diagnoses are usually made when caring for patients with pneumonia: Impaired gas exchange Ineffective airway clearance Ineffective breathing pattern Knowledge deficit/Deficient knowledge Activity intolerance Risk for infection Risk for nutritional imbalance: less than body requirements Line the lung pleura Nursing Diagnosis Impaired Gas Exchange related to to altered alveolarcapillary membrane changes due to pneumonia disease process. 1. Help the patient get into a comfortable position, usually the half-Fowler position. Amount of air exhaled in first second of forced vital capacity Pulse oximetry may not be a reliable indicator of oxygen saturation in which patient? During care of a patient with a cuffed tracheostomy, the nurse notes that the tracheostomy tube has an inner cannula. Subjective Data: Pt family member tells you that the patient has been sleeping constantly for 2 weeks. How to use a mirror to suction the tracheostomy The most common is a cough producing purulent sputum (often dark brown) that is foul smelling and foul tasting. c. Elimination Gravity and hydrostatic pressure in this position promote perfusion and ventilation matching. Ventilator-associated pneumonia is one of the subtypes of hospital-acquired pneumonia. 's airway before and after surgery? The following signs and symptoms show the presence of impaired gas exchange: Abnormal breathing rate, rhythm, and depth Nasal flaring Hypoxemia Cyanosis in neonates decreases carbon dioxide Confusion Elevated blood pressure and heart rate A headache after waking up Restlessness Somnolence and visual disturbances Looking For Custom Nursing Paper? Advised the patient to dispose of and let out the secretions. Dullness and hyperresonance are found in the lungs using percussion, not the other assessment techniques. associated with increased fluid loss in the presence of tachypnea, fever, or diaphoresis Desired outcome: at least 24 hours before hospital discharge, the patient is normovolemic, i.e., has a urine output of 30 mL/h or greater, stable weight, heart rate less than 100 bpm, blood pressure greater than 90 mm Hg, fluid intake equal to fluid excretion, moist mucous membranes, and normal skin turgor. h. FRC: (8) Volume of air in lungs after normal exhalation. Signs and Symptoms of impaired gas exchange dyspnea, SOB cough hemoptysis: coughing up blood abnormal breathing patterns: tachypnea, diabetic ketoacidosis, kusbal respirations (diabetic ketoacidosis leads to hypoxemia through kusbal resp trying to get rid of extra CO2) hypoventilation hyperventilation cyanosis (late sign) Match the descriptions or possible causes with the appropriate abnormal assessment findings. F. A. Davis Company. a. 1) The cough may last from 6 to 10 weeks. Related to: As evidenced by: obstruction of airways, bronchospasm, air trapping, right-to-left shunting, ventilation/perfusion mismatching, inability to move secretions, hypoventilation . No signs or symptoms of tuberculosis or allergies are evident. The trachea connects the larynx and the bronchi. 3.2 Impaired Gas Exchange. If the patient is complaining about the difficulty of breathing, provide supplemental oxygen as ordered. Make sure to avoid flowers, strong smell scents, dust, and other allergens that are present in the room. What the oxygenation status is with a stress test c. Decreased chest wall compliance 3.3 Risk for Infection. Other bacteria that can cause pneumonia include H. influenzae, Mycoplasma pneumonia, Legionella pneumonia, and Chlamydia pneumoniae. Pinch the soft part of the nose. a. Finger clubbing 2018.01.18 NMNEC Curriculum Committee. With acute bronchitis, clear sputum is often present, although some patients have purulent sputum. Finger clubbing and accessory muscle use are identified with inspection. Cough suppressants. Encourage movement and positioning.Mobile patients should be encouraged to ambulate several times a day to mobilize secretions. Tylenol) administered. Select all that apply. (n.d.). 7. b. Cuff pressure monitoring is not required. 7. Breath sounds in all lobes are verified to be sure that there was no damage to the lung. What Are Some Nursing Diagnosis for COPD? The epiglottis is a small flap closing over the larynx during swallowing. Impaired gas exchange occurs due to alveolar-capillary membrane changes, such as fluid shifts and fluid collection into interstitial space and alveoli. During the day, basket stars curl up their arms and become a compact mass. . Peripheral chemoreceptors in the carotid and aortic bodies also respond to increases in PaCO2 to stimulate the respiratory center. If a patient is immobile they must be repositioned every 2 hours to maintain skin integrity. Palpation is the assessment technique used to find which abnormal assessment findings (select all that apply)? If the patient is enteral fed, recommend continuous rather than bolus feeding. Changes in behavior and mental status can be early signs of impaired gas exchange. Gas exchange is the passage of oxygen and carbon dioxide in opposite directions across the alveolocapillary membrane (Miller-Keane, 2003). The parietal pleura is a membrane that lines the chest cavity. Keep skin clean and dry through frequent perineal care or linen changes. Here are 11 nursing diagnoses common to pneumonia nursing care plans (NCP). Sepsis Alliance. Given a square matrix [A], write a single line MATLAB command that will create a new matrix [Aug] that consists of the original matrix [A] augmented by an identity matrix [I]. Organizing the tasks will provide a sufficient rest period for the patient. Impaired gas exchange is a nursing diagnosis that describes the inability of your body to oxygenate blood adequately. Patients who are weak or fatigued with an ineffective cough can be taught how to suction themselves. Take an initial assessment of the patients respiratory rate and blood oxygen saturation using a pulse oximeter. Abnormal. Pulmonary function test - The patient's clinical picture is most likely pulmonary embolism (PE), and the first action the nurse should take is to assist with the patient's respirations. Usual PaO2 levels are expected in patients 60 years of age or younger. HR 68 bpm a. Assess the patient for iodine allergy. A specimen of the sputum, which is yellow, has been obtained, but the laboratory results are pending. The thoracic cage is formed by the ribs and protects the thoracic organs. Outcomes Interventions Rationale with reference Eval of goal/outcomes Gas r/t alveolar- membrane AEB Positive for strep Bi-pap to maintain rhonchi diminished breath bilaterally. (2020). 4. 3.6 Risk for imbalanced nutrition: less than body requirements. Skin breakdown allows pathogens to enter the body. Promote skin integrity.The skin is the bodys first barrier against infection. c. Wheezing The visceral pleura lines the lungs and forms a closed, double-walled sac with the parietal pleura. d. Comparison of patient's current vital signs with normal vital signs Pneumonia is an infection itself but a risk for infection nursing diagnosis is appropriate as untreated pneumonia can progress into a secondary infection or sepsis. Priority: Sleep management Teach the patient to use the incentive spirometer as advised by their attending physician. Nursing Diagnosis: Impaired Gas Exchange related to decreased lung compliance and altered level of consciousness as evidence by dyspnea on exertion, decreased oxygen content, decreased oxygen saturation, and increased PCO2. b. A 10-mm red indurated injection site could be a positive result for a nurse as an employee in a high-risk setting. Identify 1 specific finding identified by the nurse during assessment of each of the patient's functional health patterns that indicates a risk factor for respiratory problems or a patient response to an actual respiratory problem. Inhalation of toxic fumes/chemical irritants can damage cilia and lung tissue and is a factor in increasing the likelihood of pneumonia. h. Role-relationship: Loss of roles at work or home, exposure to respiratory toxins at work Pneumonia is an infection of the lungs caused by a bacteria or virus. Mixed venous blood gases are used when patients are hemodynamically unstable to evaluate the amount of oxygen delivered to the tissue and the amount of oxygen consumed by the tissues. f. Cognitive-perceptual: Decreased cognitive function with restlessness, irritability. Fungal pneumonia is caused by inhaling fungal spores that can come from dust, soil, and droppings of rodents, bats, birds or other animals. Drug therapy is an alternative to avoidance of the allergens, but long-term use of decongestants can cause rebound nasal congestion. Pneumonia will be one of the most frequent infections the nurse will encounter and treat. On inspection, the throat is reddened and edematous with patchy yellow exudates. Post author: Post published: February 17, 2023 Post category: orange curriculum controversy Post comments: toys shops in istanbul, turkey toys shops in istanbul, turkey g. Position the patient sitting upright with the elbows on an over-the-bed table. Frequent suctioning increases risk of trauma and cross-contamination. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Retrieved February 9, 2022, from, Testing for Sepsis. 4. A 36-year-old patient with type 1 diabetes mellitus asks the nurse whether an influenza vaccine is necessary every year. - Manifestations of a lung abscess usually occur slowly over a period of weeks to months, especially if anaerobic organisms are the cause. Use 1 for the first action and 7 for the last action. b. RV: (7) Amount of air remaining in lungs after forced expiration Most of the cases of poor prognosis of pneumonia are undertreatment or not being able to be assessed earlier. impaired gas exchange nursing care plan scribd. What are the characteristics of a fenestrated tracheostomy tube (select all that apply)? Nursing Care Plan (NCP) for Impaired Gas Exchange | NRSNG Nursing Course Assess for mental status changes. When planning care for a patient with pneumonia, the nurse recognizes that which is a high-priority intervention? A pulmonary angiogram involves the injection of an iodine-based radiopaque dye, and iodine or shellfish allergies should be assessed before injection. Normally the AP diameter should be 13 to 12 the side-to-side diameter. d. Initiate pulse oximetry for continuous monitoring of the patient's oxygen status. a. 3) Illicit drug intake Acid-fast stains and cultures: To rule out tuberculosis. Always wear gloves on both hands for suctioning. Base to apex a. Smoking further increases the risk of developing pneumonia and should be avoided. 2) Guillain-Barr syndrome b. 's nose for several days after the trauma? Impaired Gas Exchange Assessment 1. What other assessment should the nurse consider before making a judgment about the adequacy of the patient's oxygenation? These interventions help facilitate optimum lung expansion and improve lungs ventilation. ineffective airway clearance related to pneumonia and copd impaired gas exchange related to acute and chronic lung. Turbinates warm and moisturize inhaled air. g. Fine crackles a. TB Nursing diagnosis for pleural effusion may vary depending on the patient's individual symptoms and condition. Place some timetable as to when each medication should be administered to ensure compliance and timely administration of medication. Thorough hand hygiene before and after patient contact (even if gloves are worn). Use the antibiotic to treat the bacterial pneumonia, which is the underlying cause of the patients hyperthermia. c. Have the patient hyperextend the neck. f. PEFR: (6) Maximum rate of airflow during forced expiration 3 Pneumonia in the immunocompromised individual 4 Assessment of pneumonia 5 Diagnostic test for pneumonia 6 Nursing Diagnosis of pneumonia 6.1 Risk for Infection (nosocomial pneumonia) 6.2 Impaired Gas Exchange due to pneumonic condition 6.3 Ineffective clearance of the airway 6.4 Deficient fluid volume Community acquired pneumonias A) 2, 3, 4, 5, 6 3.5 Acute Pain. nursing diagnosis based on the assessment data the major nursing diagnoses for meconium aspiration syndrome are hyperthermia related to inflammatory process hypermetabolic state as evidenced by an increase in body temperature warm skin and tachycardia fluid volume . A) Inform the patient that it is one of the side effects of c. Send labeled specimen containers to the laboratory. Learn how your comment data is processed. Pneumonia. The bacteria may enter the blood stream and cause, Trouble sleeping. Recognize the risk factors for infection in patients with tracheostomy and take the following actions: Risk factors include the presence of underlying pulmonary disease or other serious illness, increased colonization of the oropharynx or trachea by aerobic gram-negative bacteria, increased bacterial access to the lower airway, and cross-contamination from manipulation of the tracheostomy tube.