Nursing Diagnosis

Impaired Gas Exchange

NANDA-I Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the
alveolar-capillary membrane
By the process of diffusion, the exchange of oxygen and carbon dioxide occurs in the alveolarcapillary membrane area. The relationship between ventilation (air flow) and perfusion (blood
flow) affects the efficiency of the gas exchange. Normally there is a balance between ventilation
and perfusion; however, certain conditions can offset this balance, resulting in impaired gas
exchange. Altered blood flow from a pulmonary embolus, or decreased cardiac output or shock
can cause ventilation without perfusion. Conditions that cause changes or collapse of the alveoli
(e.g., atelectasis, pneumonia, pulmonary edema, and adult respiratory distress syndrome) impair
ventilation. Other factors affecting gas exchange include high altitudes, hypoventilation, and
altered oxygen-carrying capacity of the blood from reduced hemoglobin. Older patients have a
decrease in pulmonary blood flow and diffusion as well as reduced ventilation in the dependent
regions of the lung where perfusion is greatest. Chronic conditions such as chronic obstructive
pulmonary disease (COPD) put these patients at greater risk for hypoxia. Other patients at risk
for impaired gas exchange include those with a history of smoking or pulmonary problems,
obesity, prolonged periods of immobility, and chest or upper abdominal incisions.
Common Related Factors
Alveolar-capillary membrane changes
Ventilation-perfusion imbalance
Altered oxygen supply
Altered oxygen-carrying capacity of blood
Defining Characteristics
Confusion
Somnolence
Restlessness
Irritability

Common Expected Outcomes

Patient maintains optimal gas exchange as evidenced by arterial blood gases (ABGs) within the
patient's usual range, alert responsive mentation or no further reduction in level of consciousness,
relaxed breathing, and baseline heart rate for patient.
NOC Outcomes

Respiratory Status
Gas Exchange

NIC Interventions

Respiratory Monitoring; Oxygen Therapy; Airway Management

Inability to move secretions

Hypoxia/hypoxemia

Dyspnea

Abnormal arterial blood gases

Abnormal breathing (rate, depth, rhythm)

Tachycardia

Abnormal skin color (pale, dusky)

Ongoing Assessment
Assess respirations, noting quality, rate, rhythm, depth, and breathing effort.
Patients will adapt their breathing patterns over time to facilitate gas exchange. Both rapid,
shallow breathing patterns and hypoventilation affect gas exchange. Shallow, "sighless"
breathing patterns after surgery (as a result of the effect of anesthesia, pain, and immobility)
reduce lung volume and decrease ventilation. Hypoxia is associated with signs of increased
breathing effort.
Assess lung sounds, noting areas of decreased ventilation and the presence of adventitious
sounds.
Changes in lung sounds may reveal the etiology of impaired gas exchange.
Assess for tachycardia, restlessness, irritability, diaphoresis, headache, visual disturbances, and
confusion.
These are early nonpulmonary signs of hypoxia; lethargy and somnolence are late signs.
Cognitive changes may occur with chronic hypoxia.
Assess for signs and symptoms of atelectasis: diminished chest excursion, limited diaphragm
excursion, bronchial or tubular breath sounds, crackles, tracheal shift to affected side.
Collapse of alveoli increases shunting (perfusion without ventilation), resulting in hypoxemia.
Assess for signs and symptoms of pulmonary infarction: cough, hemoptysis, pleuritic pain,
consolidation, pleural effusion, bronchial breath sounds, pleural friction rub, fever.
Hypoxia results from increased dead space ventilation (ventilation without perfusion) and reflex
bronchoconstriction in areas adjacent to the infarct.
Monitor vital signs.
With initial hypoxia and hypercapnia, blood pressure (BP), heart rate, and respiratory rate all
increase. As the hypoxia and/or hypercapnia becomes severe, BP and heart rate decrease, and
dysrhythmias may occur. Respiratory failure may ensue when the patient is unable to maintain
the rapid respiratory rate.
Assess for headache, dizziness, lethargy, reduced ability to follow instructions, disorientation,
coma.
These are signs of hypercapnia.
Monitor ABGs, and note changes.

Increasing PaCO2 and decreasing PaO2 are signs of hypoxemia and respiratory acidosis. As the
patient's condition deteriorates, the respiratory rate will decrease and PaCO2 will begin to
increase. Some patients, such as those with COPD, have a significant decrease in pulmonary
reserves, and additional physiological stress may result in acute respiratory failure.
Use pulse oximetry to monitor oxygen saturation.
Pulse oximetry is a useful tool to detect changes in oxygenation. Oxygen saturation should be
maintained at 90% or greater.
Assess nutritional status.
Obesity may restrict downward movement of the diaphragm, increasing the risk for atelectasis,
hypoventilation, and respiratory infections. Work of breathing is increased in severe obesity due
to the excessive weight of the chest wall. Hypercapnia and hypoxia result. Malnutrition may
reduce respiratory mass and strength, affecting muscle function.
Monitor hemoglobin levels.
Low levels reduce the uptake of oxygen at the alveolar-capillary membrane and oxygen delivery
to the tissues.
Assess skin, nail beds, and mucous membranes for pallor or cyanosis.
Cool, pale skin may be secondary to a compensatory vasoconstrictive response to hypoxemia. As
oxygenation and perfusion become impaired, peripheral tissues become cyanotic. For cyanosis to
be present, 5 g of hemoglobin must be desaturated.
Monitor chest x-ray reports.
Chest x-ray studies reveal the etiological factors of the impaired gas exchange. Keep in mind that
radiographic studies of lung water lag behind clinical presentation by 24 hours.
Monitor effects of position changes on oxygenation (ABGs, SVO2, and pulse oximetry).
Putting the most compromised lung areas in the dependent position (where perfusion is greatest)
potentiates ventilation and perfusion imbalances.
Assess the patient's ability to cough effectively to clear secretions. Note quantity, color, and
consistency of sputum.
Retained secretions impair gas exchange.
Evaluate hydration status.
Gas exchange may be impaired by overhydration (in conditions such as heart failure). In
conditions associated with increased sputum production (e.g., pneumonia, COPD), insufficient
hydration may reduce the ability to clear secretions.
Assess use of herbal remedies (e.g., licorice and hyssop to promote expectoration, goldenseal for
pneumonia, hawthorn for heart failure).
Drug interactions with prescribed drugs and contraindications need to be evaluated (e.g., licorice
should not be used by patients on digitalis preparations and those with hypertension; sodium loss
and retention of water and potassium may occur with long-term use of high doses).

Therapeutic Interventions
Position the patient with proper body alignment for optimal respiratory excursion (if tolerated,
head of bed at 45 degrees when supine).
Upright position allows for increased thoracic capacity and full descent of diaphragm, preventing
the abdominal contents from crowding the lungs and preventing their full expansion.
Routinely check the patient's position so that he or she does not slump down in bed.

Slumped positioning causes the abdomen to compress the diaphragm and limits full lung
expansion.
Position the patient to facilitate ventilation-perfusion matching when a side-lying position is
used.
When the patient is positioned on the side, the good side should be down (e.g., lung with
pulmonary embolus or atelectasis should be up). When lung hemorrhage or abscess is present,
the affected lung should be placed downward to avoid drainage to the healthy lung.
Change the patient's position every 2 hours.
Repositioning facilitates secretion movement and drainage and decreases atelectasis.
Encourage or assist with ambulation as indicated.
Ambulation promotes lung expansion, facilitates secretion clearance, and stimulates deep
breathing.
Maintain oxygen administration device as ordered, attempting to maintain oxygen saturation at
90% or greater.
Supplemental oxygen may be required to maintain PO2 at an acceptable level.
Avoid high concentration of oxygen in patients with COPD unless ordered.
Hypoxia stimulates the drive to breathe in the chronic CO2 retainer patient. When applying
oxygen, close monitoring is imperative to prevent unsafe increases in the patient's PaO2, which
could result in apnea.
If the patient is allowed to eat, give oxygen to the patient but in a different manner (e.g.,
changing from mask to a nasal cannula).
Eating is an activity, and more oxygen will be consumed than when the patient is at rest.
Immediately after the meal, the original oxygen delivery system should be returned.
For patients who should be ambulatory, provide extension tubing or portable oxygen apparatus.
These measures may improve exercise tolerance by maintaining adequate oxygen levels during
activity.
Encourage slow deep breathing, using incentive spirometer as indicated.
This therapy reduces tachypnea and alveolar collapse.
For postoperative patients, assist with splinting the chest.
Splinting optimizes deep breathing and coughing efforts.
Assist with coughing or suction as needed.
Excessive suctioning can interfere with gas exchange in the bronchopulmonary tree. Suctioning
removes secretions to maintain a patent airway, thereby enhancing oxygenation.
Provide reassurance, and allay anxiety.
Anxiety increases dyspnea, respiratory rate, and work of breathing.
Pace activities and schedule rest periods to prevent fatigue. Assist with activities of daily living.
Activities will increase oxygen consumption and should be planned so the patient does not
become hypoxic.
Administer medications as prescribed.
The type depends on the etiological factors of the problem (e.g., antibiotics for pneumonia,
bronchodilators for COPD, anticoagulants and thrombolytics for pulmonary embolus, analgesics
for thoracic pain).
Anticipate need for intubation and mechanical ventilation.
Early intubation and mechanical ventilation are recommended to prevent full decompensation of
the patient. Mechanical ventilation provides supportive care to maintain adequate oxygenation
and ventilation to the patient.

Education/Continuity of Care
Explain the need to restrict and pace activities to decrease oxygen consumption during the acute
episode.
Energy conservation reduces fatigue and dyspnea.
Teach the patient appropriate breathing and coughing techniques.
These techniques facilitate adequate air exchange and secretion clearance.
Instruct about medications: indications, dosage, frequency, side effects, and administration
requirements. Include review of metered-dose inhalers if applicable.
Knowledge promotes safe and effective medication administration.
Explain the type of oxygen therapy being used and why its maintenance is important.
Issues related to home oxygen use, storage, or precautions need to be addressed for safe and
effective treatment.
Teach the patient or caregivers the signs of early respiratory compromise and their appropriate
management.
Early detection and treatment may reduce emergency department visits, hospitalizations, and
mortality. Such instruction prevents delays in seeking help in life-threatening situations.
Refer to home health services for nursing care or oxygen management as appropriate.
Referral facilitates continuation of needed services.
For chronic respiratory disorders, refer for pulmonary rehabilitation.
Rehabilitation training decreases dyspnea and fatigue, and it increases exercise capacity and
perception of control over condition.