impaired gas exchange nursing diagnosis pneumonia

b. a. If the patient is having increased mucous production, encourage him or her to clear the airway. e. FVC Tylenol) administered. Discussion Questions - Conditions that increase the risk for aspiration include a decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and insertion of nasogastric (NG) tubes with or without enteral feeding. 2. This also increases the risk for aspiration pneumonia. 2. Assess for mental status changes. In addition, have the patient upright and leaning forward to prevent swallowing blood. d. Limited chest expansion A pulmonary angiogram outlines the pulmonary vasculature and is useful to diagnose obstructions or pathologic conditions of the pulmonary vessels, such as a pulmonary embolus. It can be obtained by coughing, aspiration, transtracheal aspiration, bronchoscopy or open lung biopsy. Nursing Diagnosis & Care Plan for Impaired Gas Exchange - Tutorsploit 4. Concept Map-AHI - Concept Mapping Nursing diagnosis: Impaired gas b. It is very important to take and record the patients respiratory assessment to make it a basis if there are any abnormal findings in the future. Attempt to replace the tube. Impaired gas exchange is a nursing diagnosis for a patient suffering current or future problems with oxygen/carbon dioxide balance (unknown, 2012). With severe pneumonia, the patient needs a higher level of care than general medical-surgical. When taking care of a patient with pneumonia, it is important to ensure the environment is well ventilated, conducive for good rest, and accessible when the patient needs assistance or help. Smoking does not directly affect filtration of air, the cough reflex, or reflex bronchoconstriction, but it does impair the respiratory defense mechanism provided by alveolar macrophages. Maximum amount of air that can be exhaled after maximum inspiration e. Observe for signs of hypoxia during the procedure. Weight changes of 1-1.5 kg/day may occur with fluid excess or deficit. d. Assess the patient's swallowing ability. Examine sputum for volume, odor, color, and consistency; document findings. 8. Associated with altered oxygenation and alveolar-capillary membrane changes resulting from the inflammatory process and exudate in the lungs. c. A negative skin test is followed by a negative chest x-ray. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). During a follow-up visit one week after starting the medication, the patient tells the nurse, "In the last week, my urine turned orange, and I am very worried about it." Select all that apply. Suction the mouth or the oral airway as needed. 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. Assist the patient with position changes every 2 hours. Assess the need for hyperinflation therapy. d. Positron emission tomography (PET) scan. e. Sleep-rest g. Position the patient sitting upright with the elbows on an over-the-bed table. 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. Our website services and content are for informational purposes only. If they cannot, sputum can be obtained via suctioning. However, it is highly unlikely that TB has spread to the liver. b. treatment with antifungal agents. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. The palms are placed against the chest wall to assess tactile fremitus. After the intervention, the patients airway is free of incidental breath sounds. Wheezing is a sign of airway obstruction that requires immediate intervention to ensure effective gas exchange. Bronchoconstriction Bronchoconstriction Ensure that the patient verbalizes knowledge of these activities and their reasons and returns demonstrations appropriately. St. Louis, MO: Elsevier. Appendix N3: Nursing Diagnoses Grouped by Diseases/Disorders COPD ND3: Impaired gas exchange. This position provides comfort, promotes descent of the diaphragm, maximizes inspiration, and decreases work of breathing. Identify the ability of the patient to perform self-care and do activities of daily living. 1. Impaired Gas Exchange - Nursing Diagnosis & Care Plan Atrial Fibrillation Nursing Diagnosis and Nursing Care Plan, Readiness for Enhanced Coping Nursing Diagnosis and Nursing Care Plans, Cystic Fibrosis Nursing Diagnosis Care Plan - NurseStudy.Net. e. Posterior then anterior Always maintain sterility or aseptic techniques when performing any invasive procedure. The postoperative use of nonverbal communication techniques a. Undergo weekly immunotherapy. Document the results in the patient's record. d. Avoid any changes in oxygen intervention for 15 minutes following the procedure. This is an expected finding with pneumonia, but should not continue to rise with treatment. 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 . arrives in the postanesthesia care unit (PACU) following surgery, what priority assessments should the nurse make in the immediate postoperative period? Impaired gas exchange is a nursing diagnosis that describes the inability of your body to oxygenate blood adequately. g. FEV1 c. Remove the inner cannula if the patient shows signs of airway obstruction. The alcohol intake of the patient is within normal limits, so it is not correct to say that alcohol may have damaged the liver. Pneumonia causing increased pus and mucus in the alveoli will interfere with gas exchange and oxygenation. c. Turbinates A) Teaching the patient how to cough effectively and. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. 2) d. Direct the family members to the waiting room. b. Bacterial pneumonias affect all or part of one lobe of the lung, whereas viral pneumonias occur diffusely throughout the lung. Assess lung sounds and vital signs. d. An electrolarynx placed in the mouth. NANDA Nursing diagnosis for Pneumonia Pneumonia ND1: Ineffective airway clearance. 1. a. Verify breath sounds in all fields. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. It is important to acknowledge their limited information about the disease process and start educating him/her from there. a. Acid-fast stains and cultures: To rule out tuberculosis. A closed-wound drainage system Nursing Diagnosis and Care Plans for COPD | Med-Health.net Discharging the patient is unsafe. A) Admit the patient to the intensive care unit. d. Pleural friction rub Instruct patients who are unable to cough effectively in a cascade cough. c. Persistent swelling of the neck and face 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. b. The nurse determines effective discharge teaching for a patient with pneumonia when the patient makes which statement? Impaired gas exchange diagnosis was present in 42.6% of the children in the first assessment. Because antibody production in response to infection with the tuberculosis (TB) bacillus may not be sufficient to produce a reaction to TB skin testing immediately after infection, 2-step testing is recommended for individuals likely to be tested often, such as health care professionals. What Are Some Nursing Diagnosis for COPD? (2020, June 15). 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 Nursing care plan pneumonia - StuDocu The bacteria may enter the blood stream and cause, Trouble sleeping. b. Oxygen is administered when O2 saturation or ABG results show hypoxemia. Sepsis Alliance. a. treatment with antibiotics. Popkin, B. M., DAnci, K. E., & Rosenberg, I. H. (2010). Impaired Gas Exchange Nursing Diagnosis - New Scholars Hub g. Fine crackles An indicator of inadequate fluid volume is a urine output of less than 30 ml/hr for 2 consecutive hours. b. RV b. Pinch the soft part of the nose. Allow 90 minutes for. Direct pressure on the entire soft lower portion of the nose against the nasal septum for 10 to 15 minutes is indicated for epistaxis. Avoid environmental irritants inside the patients room. Lung consolidation with fluid or exudate Auscultate breath sounds at least every 2 to 4 hours or as the patients condition dictates. Monitor cuff pressure every 8 hours. Has been NPO since midnight in preparation for surgery Excess CO2 does not increase the amount of hydrogen ions available in the body but does combine with the hydrogen of water to form an acid. Amount of air exhaled in first second of forced vital capacity Patients who are weak or lack a cough reflex may not be able to do so. b. SpO2 of 95%; PaO2 of 70 mm Hg b. Decreased immunoglobulin A (IgA) decreases the resistance to infection. While the nurse is feeding a patient, the patient appears to choke on the food. 2) It is a highly contagious respiratory tract infection. Base to apex Aspiration precautions include maintaining a 30-degree elevation of the HOB, turning the patient onto his or her side rather than back, and using continuous rather than bolus feeding when the patient is enteral. 3) Sleep alone. Symptoms Altered consciousness Anxiety Changes in arterial blood gases (ABGs) Chest Tightness Coughing, with yellow sticky sputum Impaired gas exchange 5. 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. 3 the nursing process diagnosis - SlideShare Bilateral ecchymosis of eyes (raccoon eyes) c. Have the patient hyperextend the neck. Advise individuals who smoke to stop smoking, especially during the preoperative and postoperative periods. c. Lateral sequence How does the nurse respond? Volcanic eruptions and other natural events result in air pollution. All of the assessments are appropriate, but the most important is the patient's oxygen status. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Encourage the patient to see their medical attending physician for approval and safe treatment. These practices further reduce the risk of contamination. Are there any collaborative problems? c. Mucociliary clearance Priority Decision: The nurse receives an evening report on a patient who underwent posterior nasal packing for epistaxis earlier in the day. 3. a. Esophageal speech Types of Nursing Diagnoses There are 4 types of nursing diagnoses. c. Empyema Select all that apply. d. Pulmonary embolism Supplemental oxygen will help in the increased demand of the body and will lower the risk of having respiratory distress and low oxygen perfusion in the body. Assess lab values.An elevated white blood count is indicative of infection. 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. How does the nurse assess the patient's chest expansion? Assess the patients vital signs and characteristics of respirations at least every 4 hours. b. Repeat the ABGs within an hour to validate the findings. Productive cough (viral pneumonia may present as dry cough at first). This can be due to a compromised respiratory system or due to lung disease. Asthma: 7 Nursing Diagnosis About It | New Health Advisor Pulse oximetry is inaccurate if the probe is loose, if there is low perfusion, or when skin color is dark. a. Stridor 1# Priority Nursing Diagnosis. To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. Doing activities at the same time will only increase the demands of oxygen in the body, and patients with pneumonia cannot tolerate it. Nursing Diagnosis 1: Risk for fluid volume deficit related to increased fluid losses secondary to diarrhea and decreased fluid intake; Nursing Diagnosis 2: Impaired gas exchange related to pneumonia and decreased oxygen saturation levels; 2. Health perception-health management Problems of Oxygenation: Ventilation (Lewis Med-Surg Section 6) - Quizlet Subjective Data The home health nurse provides which instruction for a patient being treated for pneumonia? 5) e. Observe for signs of hypoxia during the procedure. 4) Recent abdominal surgery. Desired Outcome: At the end of the span of care, the patient will be able to understand the transmission, disease process, and available treatments for pneumonia. d) 8. Pneumonia Nursing Diagnosis & Care Plan - NurseStudy.Net As such, here are the signs and symptoms that demonstrate the presence of impaired gas exchange. Here are 11 nursing diagnoses common to pneumonia nursing care plans (NCP). Which instructions does the nurse provide for the patient? Start asking what they know about the disease and further discuss it with the patient. See Table 25.8 for more thorough descriptions of these sounds and their possible etiologies and significance. These interventions help ensure that the patient has the appropriate knowledge and is able to perform these activities. Arrange the tasks of the patient when providing care to him/her. The treatment and medication should be prescribed by the attending physician and do not take meds that are not prescribed to prevent unnecessary drug interaction. Elevate the head of the bed and assist the patient to assume semi-Fowlers position. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). b. To increase the oxygen level and achieve an SpO2 value of at least 96%. c. Explain the test before the patient signs the informed consent form. c. Use cromolyn nasal spray prophylactically year-round. 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. 1. 3) Treatment usually includes macrolide antibiotics. Hospital-Acquired Pneumonia (Nosocomial Pneumonia) and Ventilator-Associated Pneumonia: Overview, Pathophysiology, Etiology. If a patient is immobile they must be repositioned every 2 hours to maintain skin integrity. What is included in the nursing care of the patient with a cuffed tracheostomy tube? How to use esophageal speech to communicate Oral hygiene moisturizes dehydrated tissues and mucous membranes in patients with fluid deficit. Use the antibiotic to treat the bacterial pneumonia, which is the underlying cause of the patients hyperthermia. Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively. b. Stop feeding when the patient is lying flat. b. b. These symptoms are very crucial and the patient must be given immediate care and intervention to avoid hypoxia. Assess the patients vital signs at least every 4 hours. a. impaired Gas Exchange may be related to decreased oxygen-carrying capacity of blood, reduced RBC life span, abnormal RBC structure, increased blood viscosity, predisposition to bacterial pneumonia/pulmonary infarcts, possibly evidenced by dyspnea, use of accessory muscles, cyanosis/signs of hypoxia, tachycardia, changes in mentation, and . d. Small airway closure earlier in expiration This is most common in intensive care units usually resulting from intubation and ventilation support. She has worked in Medical-Surgical, Telemetry, ICU and the ER. d. Comparison of patient's current vital signs with normal vital signs. c. Take the specimen immediately to the laboratory in an iced container. A third type is pneumonia in immunocompromised individuals. Match the following pulmonary capacities and function tests with their descriptions. It is important to let the patient know the pros of taking an accurate dosage and the right timing of medication for fast recovery. - According to the Expanded CURB-65 scale, which is used as a supplement to clinical judgment to determine the severity of pneumonia, the patient's score is a 5; placement in the intensive care unit is recommended. Report significant findings. 8. e. Suction the tracheostomy tube when there is a moist cough or a decreased arterial oxygen saturation by pulse oximetry (SpO2). Use of accessory respiratory muscles (scalene, sternocleidomastoid, external intercostal muscles), decreased chest expansion due to pleural pain, dullness when tapping on affected (consolidated) areas. Order stat ABGs to confirm the SpO2 with a SaO2. The immunity will not protect for several years, as new strains of influenza may develop each year. d. A tracheostomy tube and mechanical ventilation, What should the nurse include in discharge teaching for the patient with a total laryngectomy? Assisting the patient in moderate-high backrest will facilitate better lung expansion thus they can breathe better and would feel comfortable. Viruses such as RSV (common cause in infants age 1 and below), flu and cold viruses can cause viral pneumonia, which is the second most common type of pneumonia. If the patient is enteral fed, recommend continuous rather than bolus feeding. 2 8 Nursing diagnosis for pneumonia. c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. c. Decreased chest wall compliance She found a passion in the ER and has stayed in this department for 30 years. c. Place the patient in high Fowler's position. c. Patient in hypovolemic shock c. a radical neck dissection that removes possible sites of metastasis. Monitor oximetry values; report O2 saturation of 92% or less. c. Wheezes c. SpO2 of 90%; PaO2 of 60 mm Hg The nurse is caring for a patient who experiences shortness of breath, severe productive cough, and fever. Impaired Gas Exchange is a NANDA nursing diagnosis that is used for conditions where there is an alteration in the balance between the exchange of gases in the lungs. impaired gas exchange nursing care plan scribd. The patient must have enough rest so that the body will not be exhausted and avoid an increase in the oxygen demand. The width of the chest is equal to the depth of the chest. 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 A patient with pneumonia shows inflammation in their lung parenchyma causing it to have. What measures should be taken to maintain F.N. c. Airway obstruction Match the descriptions or possible causes with the appropriate abnormal assessment findings. Monitor ABGs and oxygen saturation.Decreasing sp02 signifies hypoxia. - 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. 3.3 Risk for Infection. With acute bronchitis, clear sputum is often present, although some patients have purulent sputum. Educating him/her to use the incentive spirometer will encourage him/her to exercise deep inspiration that will help get more oxygen in the lungs and prevent hypoxia. Rest lowers the oxygen demand of a patient whose reserves are likely to be limited. Immunocompromised people are more susceptible to fungal pneumonia than healthy individuals. Allow the patient to have enough bed rest and avoid strenuous activities. Trend and rate of development of the hyperkalemia Saunders comprehensive review for the NCLEX-RN examination. Hospital associated Nosocomial pneumonias, Pneumonia in the immunocompromised individual, Risk for Infection (nosocomial pneumonia), Impaired Gas Exchange due to pneumonic condition, 5 Nursing care plans for anemia | Anemia nursing interventions, 5 Nursing diagnosis of pneumonia and care plans, Nursing Care Plans Stroke with Nursing Diagnosis. What is the reason for delaying repair of F.N. Learning to apply information through a return demonstration is more helpful than verbal instruction alone. 3. f. A physician performs the first tracheostomy tube change 2 days after the tracheostomy. Use only sterile fluids and dispense with sterile technique. a. Stridor If the patient is complaining about the difficulty of breathing, provide supplemental oxygen as ordered. 6. A less severe form of bacterial pneumonia is called walking or atypical pneumonia, in which the symptoms are very mild and the infected person can do his/her activities of daily living as normal. a. TB What do these findings indicate? Nursing Diagnosis: Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures secondary to CHF as evidenced by shortness of breath, 2/21/2019 Compiled by C Settley 10. Nursing Care Plan (NCP) for Impaired Gas Exchange | NRSNG Nursing Course Impaired gas exchange is a risk nursing diagnosis for pneumonia. Respiratory distress requires immediate medical intervention. Decreased or random breath sounds (e.g., crackles, wheezes) may indicate possible respiratory failure, which would further exacerbate hypoxia and require immediate intervention. 2. of . c. Check the position of the probe on the finger or earlobe. Air trapping Gas exchange is the passage of oxygen and carbon dioxide in opposite directions across the alveolocapillary membrane (Miller-Keane, 2003). b. Nursing Management of COVID-19 | EveryNurse.org The position of the oximeter should also be assessed. Decreased functional cilia and decreased force of cough from declining muscle strength cause decreased secretion clearance. d. Testing causes a 10-mm red, indurated area at the injection site. The nurse identifies which factor that places a patient at risk for aspiration pneumonia? Select all that apply. Impaired gas exchange is a condition that occurs when there is an insufficient amount of oxygen in the blood. Tachycardia (resting heart rate [HR] more than 100 bpm). Periorbital and facial edema reduced by about half since second hospital day "You should get the inactivated influenza vaccine that is injected every year." Coarse crackling sounds are a sign that the patient is coughing. d. Assess arterial blood gases every 8 hours. f. Cognitive-perceptual A) 1, 2, 3, 4 Which instructions does the nurse provide to the patient to minimize exposure to close contacts and household members? Pulmonary embolism does not manifest in this way, and assessing for it is not required in this case. a. 6. The greatest chance for a pneumothorax occurs with a thoracentesis because of the possibility of lung tissue injury during this procedure. Impaired Gas Exchange; May be related to. high-pitched and inspiratory crackles (rales) that are amplified by coughing or heard only after coughing. f. Airflow around the tube and through the window allows speech when the cuff is deflated and the plug is inserted. a. b. i. Sexuality-reproductive: Sexual activity altered by respiratory symptoms A repeat skin test is also positive. Immunotherapy may be indicated if specific allergens are identified and cannot be avoided. Teach patients some signs and symptoms that prompt immediate medical attention such as dyspnea. This is needed to help the patient conserve his or her energy and also effective relaxation when the patient feels anxious and having a hard time concentrating and breathing. In healthy individuals, pneumonia is not usually life-threatening and does not require hospitalization. f. Use of accessory muscles. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? a. Number the following actions in the order the nurse should complete them. a. Generally, two types of pneumonia are distinguished: community-acquired and hospital-associated (nosocomial). What is a nursing diagnosis for impaired gas exchange? Put the index fingers on either side of the trachea. The 150 mL of air is dead space in the trachea and bronchi. When inflamed, the air sacs may produce fluid or pus which can cause productive cough and difficulty breathing. Pneumonia can be mild but can also be fatal if left untreated. Related to: As evidenced by: obstruction of airways, bronchospasm, air trapping, right-to-left shunting, ventilation/perfusion mismatching, inability to move secretions, hypoventilation . Select all that apply. Retrieved February 9, 2022, from https://www.sepsis.org/sepsis-basics/testing-for-sepsis/, Yang, Fang1#; Yang, Yi1#; Zeng, Lingchan2; Chen, Yiwei1; Zeng, Gucheng1 Nutrition Metabolism and Infections, Infectious Microbes & Diseases: September 2021 Volume 3 Issue 3 p 134-141 doi: 10.1097/IM9.0000000000000061 (Pneumonia: Symptoms, Treatment, Causes & Prevention, 2020). Stridor is identified with auscultation. These values may be adequate for patients with chronic hypoxemia if no cardiac problems occur but will affect the patients' activity tolerance. Priority: Management of pneumonia and dehydration. Assessment findings include a new onset of confusion, a respiratory rate of 42 breaths/minute, a blood urea nitrogen (BUN) of 24 mg/dL, and a BP of 80/50 mm Hg. c. Place the thumbs at the midline of the lower chest. Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by shortness of breath, low SPO2, and bacteria found in sputum culture. 3. Let the patient do a return demonstration when giving lectures about medication and therapeutic regimens. Skin breakdown allows pathogens to enter the body. d. Apply an ice pack to the back of the neck. It may also cause hepatitis. 1. Start oxygen administration by nasal cannula at 2 L/min. An SpO2 of 88% and a PaO2 of 55 mm Hg indicate inadequate oxygenation and are the criteria for continuous oxygen therapy (see Table 25.10). c. a throat culture or rapid strep antigen test. Functional Health Pattern Dont forget to include some emergency contact numbers just in case there is an emergency. through the second week after the onset of symptoms. These techniques mentioned will greatly help the patient to avoid respiratory distress and assist the body to take in oxygen and avoid hypoxia. Fever and vomiting are not manifestations of a lung abscess. Nigel wishes to use the PES format for Mr. Hannigan's nursing diagnoses. Peripheral chemoreceptors in the carotid and aortic bodies also respond to increases in PaCO2 to stimulate the respiratory center. The cough with pertussis may last from 6 to 10 weeks. Administer the prescribed antibiotic and anti-pyretic medications. Teach the importance of complying with the prescribed treatment and medication. d. Notify the health care provider of the change in baseline PaO2. It reduces the pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse. 's nasal packing is removed in 24 hours, and he is to be discharged. A) 2, 3, 4, 5, 6 However, here are some potential NANDA nursing diagnoses that may be applicable: Impaired gas exchange related to decreased lung expansion and ventilation-perfusion imbalance; . Oximetry: May reveal decreased O2 saturation (92% or less). Encourage coughing up of phlegm. Impaired Gas Exchange Nursing Diagnosis & Care Plans - NurseStudy.Net Which age-related changes in the respiratory system cause decreased secretion clearance (select all that apply)? - Patients with sputum smear-positive TB are considered infectious for the first 2 weeks after starting treatment. Frequent suctioning increases risk of trauma and cross-contamination. For best yield, blood cultures should be obtained before antibiotics are administered. This intervention decreases pain during coughing, thereby promoting a more effective cough. Line the lung pleura Nursing diagnosis: Deficient knowledge about the disease process and treatment of pneumonia related to lack of information as evidenced by failure to comply with treatment.

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