IMPAIRED GAS EXCHANGE
Excess or deﬁcit in oxygenation and/or carbon dioxide elimination
at the alveolar-capillary membrane
• Abnormal pH and arterial
• Headache upon awakening
blood gases levels
• Hypoxia and hypoxemia
• Abnormal respiratory rate,
• Increased or decreased carbon
rhythm, and depth
• Nasal ﬂaring
• Pale, dusky skin
• Alveolar-capillary membrane changes
• Ventilation–perfusion changes
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Cardiac function
• Respiratory function
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
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.
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,
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
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
Marklew, A. (2006, January–February). Body positioning and its effect on
oxygenation—A literature review. Nursing in Critical Care, 11(1), 16–22.