[Quality Assurance] Nursing Process for Pneumonia in ICU

[Quality Assurance] Nursing Process for Pneumonia in ICU - 60p, 3 Diagnoses

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1. Ineffective airway clearance

The patient is experiencing accumulated bronchial secretions and decreased consciousness, which can lead to ineffective airway clearance. Suction can be used to remove the secretions and alleviate respiratory distress, as well as prevent aspiration. Once the ineffective airway clearance is resolved, the risk of aspiration will be lower.
2. Hyperthermia

The patient is experiencing a fever response due to bronchial inflammation and fungal infection. Monitoring vital signs, managing fluid balance, and administering antipyretic medications can help control the fever and prevent complications.
3. Impaired skin integrity

The patient has an open wound on the sacral area due to prolonged immobility and elevated blood glucose levels, which can delay wound healing. Wound care, pressure relief, and nutritional support are essential to promote skin integrity and wound healing.

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1. Ineffective airway clearance

Ineffective airway clearance is a serious medical condition that can have significant consequences if not properly managed. It occurs when the body is unable to effectively clear secretions or foreign material from the airways, leading to respiratory distress and potential complications. This can be caused by a variety of factors, including respiratory muscle weakness, neurological impairment, or excessive mucus production. Effective treatment typically involves a combination of airway clearance techniques, such as chest physiotherapy, suctioning, and the use of mechanical devices to assist with breathing. Careful monitoring and management by healthcare professionals is essential to ensure the patient's airway remains clear and they are able to maintain adequate oxygenation. Early recognition and prompt intervention are key to preventing further deterioration and improving patient outcomes.
2. Hyperthermia

Hyperthermia is a medical condition characterized by an abnormally high body temperature, typically above 40°C (104°F). It can be caused by a variety of factors, including exposure to high environmental temperatures, strenuous physical activity, certain medications, or underlying medical conditions. Hyperthermia can be a serious and potentially life-threatening condition, as it can lead to organ damage, neurological impairment, and even death if not properly managed. Treatment typically involves lowering the body temperature through cooling measures, such as immersion in cool water, the use of fans or air conditioning, and the administration of antipyretic medications. Careful monitoring and supportive care are essential to ensure the patient's temperature is brought down safely and to address any underlying causes. Early recognition and prompt intervention are crucial to prevent further complications and improve patient outcomes.
3. Impaired skin integrity

Impaired skin integrity is a condition in which the skin's protective barrier is compromised, leading to an increased risk of infection, tissue damage, and other complications. This can be caused by a variety of factors, including pressure ulcers, burns, wounds, or underlying medical conditions that affect the skin's ability to heal and regenerate. Effective management of impaired skin integrity typically involves a multifaceted approach, including wound care, the use of protective dressings, and addressing any underlying causes. Careful monitoring and assessment by healthcare professionals is essential to ensure the skin is healing properly and to prevent further deterioration. Early recognition and prompt intervention are key to promoting skin health, reducing the risk of complications, and improving patient outcomes.