Nursing diagnosis – IMPAIRED GAS EXCHANGE

IMPAIRED  GAS  EXCHANGE

DEFINITION

Excess or deficit in oxygenation and/or carbon dioxide elimination

at the alveolar-capillary membrane

DEFINING CHARACTERISTICS

• Abnormal pH and arterial

• Headache upon awakening

blood gases levels

• Hypoxia and hypoxemia

• Abnormal respiratory rate,

• Increased or decreased carbon

rhythm, and depth

dioxide levels

• Confusion

• Irritability/Restlessness

• Cyanosis

• Nasal flaring

• Diaphoresis

• Pale, dusky skin

• Dyspnea

• Tachycardia

RELATED FACTORS

• Alveolar-capillary membrane changes

• Ventilation–perfusion changes

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Neurocognition

• Cardiac function

• Respiratory function

EXPECTED OUTCOMES

The patient will

• Carry out ADLs without weakness or fatigue.

• Maintain normal Hb and HCT levels.

• Express feelings of comfort in maintaining air exchange.

• Cough effectively and expectorate sputum.

• Be free from adventitious breath sounds.

• Perform relaxation techniques every 4 hr.

• Use correct bronchial hygiene.

SUGGESTED NOC OUTCOMES

Gas Exchange: Ventilation; Respiratory Statue: Gas Exchange; Vital

Signs

INTERVENTIONS AND RATIONALES

Determine: Monitor respiratory status; rate and depth of breaths;

chest expansion; accessory muscle use; cough and amount and color

of sputum; and auscultation of breath sounds every 4 hr to detect

early signs of respiratory failure.

Monitor vital signs, arterial blood gases, and Hb levels to detect

changes in gas exchange.

Report signs of fluid overload or dehydration immediately. This

can lead to changes in acid-base balance and affect respiratory status.

Perform: Elevate head 30 to facilitate lung expansion and prevent

atalectasis. Assist with ADLs as needed to decrease tissue oxygen.

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Perform bronchial hygiene as ordered (e.g., coughing, percussing,

postural drainage, and suctioning) to promote drainage and keep

airways clear. Administer bronchodilators, antibiotics, and steroids,

as ordered.

Record intake and output every 8 hr to monitor fluid balance.
Auscultate lungs every 4 hr and report abnormalities to detect

decreased or adventitious breath sounds.

Orient patient to the environment, that is, use of call bell, side

rails, and bed positioning controls. Place side rails up and bed

position down when the patient is in bed. Place personal items

within the patient’s reach. Assist patient when he or she is getting

out of bed in case of dizziness. These measures prevent risk of

falling. Move patient slowly to avoid hypostatic hypotension. Post

a notice where it can be seen that the patient is at risk for falling.

Inform: Teach and demonstrate correct breathing and coughing tech-

niques such as diaphragmatic or abdominal breathing and have

patient return demonstration to ensure patient understands proper

technique and promote effective coughing and deep breathing.

Teach patient correct way of using inhalers. Remind patient about

mouth care after each dose. Failure to clean the mouth after inhal-

ing can cause candidiasis in the throat.

Review all medications with patient and family and list side

effects for each to ensure that the patient recognizes side effects and

reports them to the physician.

Encourage relaxation techniques to reduce oxygen demand.

Attend: Encourage patient to express feelings. Attentive listening

helps build a trusting relationship.

Encourage family members to stay with the patient, especially

during times of anxiety to promote relaxation which reduces oxygen

demand.

Manage: Request for a case manager to make a home visit to help

prepare family for the patient’s return to a safe environment.

Refer patient to community resources and offer written informa-

tion that can be referred to when needed.

SUGGESTED NIC INTERVENTIONS

Acid–Base Management; Airway Management; Airway suctioning;

Anxiety Reduction; Energy Management; Exercise Promotion; Fluid

Management

Reference

Marklew, A. (2006, January–February). Body positioning and its effect on

oxygenation—A literature review. Nursing in Critical Care, 11(1), 16–22.

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