Nursing care plans for Impaired Gas Exchange is used when there is an excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane to a patient.
By the process of diffusion the exchange of oxygen and carbon dioxide occurs in the alveolar-capillary membrane area. The relationship between ventilation (airflow) 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 [ARDS]) impair ventilation. Other factors affecting gas exchange include high altitudes, hypoventilation, and altered oxygen-carrying capacity of the blood from reduced hemoglobin. Elderly 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.
- Allergic response
- Altered level of consciousness
- Decrease lung compliance
- Excessive or thick secretions
- Neuromuscular impairment
- Loss of lung elasticity
- Prolonged immobility
- Surgery (chest or upper abdominal incisions)
As evidenced by:
- Dyspnea on exertion (DOE)
- Lethargy and fatigue
- Inability to move secretions
- Decreased oxygen content, decreased oxygen saturation, increased PCO?
- Pursed lip breathing with prolonged expiratory phase
- Increased anteroposterior chest diameter, if chronic
- Increased pulmonary vascular resistance (increased pulmonary artery/right ventricular pressure)
Plan & Outcome:
The patient will demonstrate optimal gas exchange as permitted by clinical condition:
- Absence of cyanosis
- ABG’s are within acceptable limits.
- Alert responsive mentation or no further reduction in mental status.
ON GOING ASSESSMENT
- Assess respirations: note quality, rate, rhythm, depth, and breathing effort. 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 & the presence of adventitious sounds. Changes in lung sounds may reveal the etiology of impaired gas exchange.
- Assess for tachycardia, restlessness, diaphoresis, headache, visual disturbances, and confusion. There are early nonpulmonary signs of hypoxia; lethargy, and somnolence are late signs.
- Monitor ital signs. With initial hypoxia and hypercapnia, BP, heart rate, and respiratory rate all increase. As the hypoxia and/or hypercapnia becomes severe, BP and HR decrease, & arrhythmias 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 ABG’s that deviate from patient’s baseline. Increasing PaCO2 & decreasing PaO2 are signs of respiratory failure. As the patient’s condition deteriorates, the respiratory rate will decrease & PaCO2 will begin to increase. Some patients, such as those with COPD, have a significant decrease in pulmonary reserves, & additional physiological stress may result in acute respiratory failure.
- Use pulse oximetry to monitor O2 saturation & PR. O2 saturation should be maintained at 90 % or greater.
- Assess nutritional status. Malnutrition may reduce respiratory mass & strength, affecting muscle function. Obesity may restrict downward movement of the diaphragm, increasing the risk for atelectasis, hypoventilation & respiratory infections. Work of breathing is increased in severe obesity (excessive weight of chest wall).
- Monitor hemoglobin – low levels reduce the uptake of O? at the alveolar capillary membrane & oxygen delivery to the tissues.
- Assess skin color for the development of cyanosis. Cool, pale skin may be secondary to a compensatory vasoconstrictive response to hypoxemia.
- Monitor chest x-ray reports.
- Monitor effects of positon changes on oxygenation (ABGs, SVO2, & pulse oximetry).
- Assess patient’s ability to cough effectively to clear secretions. Note quantity, color, & consistency of sputum.
- Evaluate hydration status. Gas exchange may be impaired by overhydration (e.g., heart failure). In conditions associated with increased sputum production (e.g., pneumonia, COPD) insufficient hydration may be reduce the ability to clear secretions.
- Maintain O2 administration as ordered. Avoid high concentration of O2 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 the patient but in a different manner (e.g., changing from mask to a nasal cannula).
- Position the patient with proper body alignment for optimal respiratory excursion (if tolerated, HOB at 45° when supine).
- Routinely check the patient’s position so that he/she does not slide down in bed. This would cause the abdomen to compress the diaphragm which would cause respiratory embarrassment.
- Position the patient to facilitate ventilation-perfusion matching when a side-lying position is used. (e.g., lung with pulmonary embolus or atelectasis should be up & good side should be down, lung haemorrhage or abscess – affected lung placed downward to avoid drainage to healthy lung)
- Pace activities & schedule rest periods to prevent fatigue. Assist with ADLs.
- Change the patient’s position every 2 hours. This facilitates secretion movement & drainage & decreases atelectasis.
- Suction as needed.
- Encourage deep breathing, using incentive spirometer as ordered.
- For postoperative patients, assist with splinting the chest. Splinting optimizes deep breathing & coughing efforts.
- Encourage or assist with ambulation as indicated – to promote lung expansion, facilitate secretion clearance, & stimulates deep breathing.
- Provide reassurance and allay anxiety: Stay with patient during episodes of respiratory distress, facilitate use of relaxation measures (meditation, imagery, prayer, music)
- Anticipate need for intubation & mechanical ventilation if the patient is unable to maintain adequate gas exchange.
- Administer medications as prescribed. This type depends on the etiological factors of the problem (e.g., antibiotics for pneumonia, bronchodilators for COPD, anticoagulants & thrombolytics for pulmonary embolus, analgesics for thoracic pain).
EDUCATION / CONTINUITY OF CARE
- Explain the need to restrict & pace activities to decrease oxygen consumption during the acute episode. This reduces fatigue & dyspnea.
- Explain the type of oxygen therapy being used & 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 appropriate breathing and coughing techniques. These facilitate adequate air exchange and secretion clearance.
- Teach the patient safe and effective use of a nebulizer (home nebulizer). A nebulizer provides humidification that enhances clearance of secretions & may be used to deliver mucolytics and bronchodilators.
- Instruct about medications: indications, dosage, frequency, side-effects, & administration requirements. Include review of metered dose inhalers if applicable. Knowledge promotes safe & effective medication administration.
- Teach the patient or caregivers the signs of early respiratory compromise & their appropriate management. Early detection & treatment may reduce emergency department visits, hospitalizations, & mortality.
- Discuss the need for lifestyle modifications such as the following:
- Smoking cessation
- Avoidance of persons with respiratory infections.
- Need for influenza and pneumococcal vaccines for older adults and patients with lung and other chronic diseases.
- Weight loss if applicable
- Avoidance of allergens (respiratory irritants)
- For chronic respiratory disorders, refer for pulmonary rehabilitation.
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