Nursing Diagnosis: Impaired Gas Exchange

Related Factors:

Altered oxygen supply Alveolar-capillary membrane changes Altered blood flow Altered oxygen-carrying capacity of blood

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

Respiratory Status

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

Respiratory Monitoring

Ongoing Assessment

Assess respirations: note quality, rate, pattern, depth, and breathing effort.--Both rapid, shallow breathing patterns and hypoventilation affect gas exchange. Shallow, "sighless" breathing patterns postsurgery (as a result of effect of anesthesia, pain, and immobility) reduce lung volume and decrease ventilation. Assess lung sounds, noting areas of decreased ventilation and the presence of adventitious sounds. Assess for signs and symptoms of hypoxemia: tachycardia, restlessness, diaphoresis, headache, lethargy, and confusion. Monitor vital signs.--With initial hypoxia and hypercapnia, blood pressure (BP), heart rate, and respiratory rate all rise. As the hypoxia and/or hypercapnia becomes more severe, BP may drop, heart rate tends to continue to be rapid with arrhythmias, and respiratory failure may ensue with the patient unable to maintain the rapid respiratory rate. Use pulse oximetry to monitor oxygen saturation and pulse rate.--Pulse oximetry is a useful tool to detect changes in oxygenation. Oxygen saturation should be maintained at 90% or greater. This tool can be especially helpful in the outpatient or rehabilitation setting where patients at risk for desaturation from chronic pulmonary diseases can monitor the effects of exercise

or activity on their oxygen saturation levels. Home oxygen therapy can then be prescribed as indicated. Patients should be assessed for the need for oxygen both at rest and with activity. A higher liter flow of oxygen is generally required for activity versus rest (e.g., 2 L at rest, and 4 L with activity). Medicare guidelines for reimbursement for home oxygen require a PaCO2 less than 58 and/or oxygen saturation of 88% or less on room air. Oxygen delivery is then titrated to maintain an oxygen saturation of 90% or greater. Assess patients ability to cough effectively to clear secretions. Note quantity, color, and consistency of sputum.--Retained secretions impair gas exchange.

Therapeutic Interventions

Position with proper body alignment for optimal respiratory excursion (if tolerated, head of bed at 45 degrees).--This promotes lung expansion and improves air exchange. Position patient to facilitate ventilation/perfusion matching. Use upright, high-Fowlers position whenever possible.--High-Fowlers position allows for optimal diaphragm excursion. When patient is positioned on side, the good side should be down (e.g., lung with pulmonary embolus or atelectasis should be up). Pace activities and schedule rest periods to prevent fatigue.-Even simple activities such as bathing during bed rest can cause fatigue and increase oxygen consumption. Encourage deep breathing, using incentive spirometer as indicated.--This reduces alveolar collapse. For postoperative patients, assist with splinting the chest.-Splinting optimizes deep breathing and coughing efforts. Encourage or assist with ambulation as indicated.--This promotes lung expansion, facilitates secretion clearance, and stimulates deep breathing. Provide reassurance and allay anxiety: Have an agreed-on method for the patient to call for assistance (e.g., call light, bell). Stay with the patient during episodes of respiratory distress.

Education/Continuity of Care

Teach the patient appropriate deep breathing and coughing techniques.--These facilitate adequate air exchange and secretion clearance.