Nursing Diagnosis: Impaired Gas Exchange
Definition of Impaired Gas Exchange
- Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveoli-capillary membrane [This may be an entity of its own, but also may be an end result of other pathology with an interrelatedness between airway clearance and/or breathing pattern problems.]
Related Factors of Ineffective Breathing Pattern | Nursing Care Plan for Ineffective Breathing Pattern
- Ventilation perfusion imbalance [as in: altered blood flow (e.g., pulmonary embolus, increased vascular resistance), vasospasm, heart failure, hypovolemic shock]
- Alveolar-capillary membrane changes [e.g., acute respiratory distress syndrome; chronic conditions, such as restrictive/obstructive lung disease, pneumoconiosis, asbestosis/silicosis]
- [Altered oxygen supply (e.g., altitude sickness)]
- [Altered oxygen-carrying capacity of blood (e.g., sickle cell/other anemia, carbon monoxide poisoning)]
Defining Characteristics of Impaired Gas Exchange | Nursing Care Plan for Impaired Gas Exchange
SUBJECTIVE
- Dyspnea
- Visual disturbances
- Headache upon awakening
- [Sense of impending doom]
OBJECTIVE
- Confusion [decreased mental acuity]
- Restlessness; irritability; [agitation]
- Somnolence; [lethargy]
- Abnormal ABGs/arterial pH; hypoxia/hypoxemia; hypercapnia;
- hypercarbia; decreased carbon dioxide
- Cyanosis (in neonates only); abnormal skin color (e.g., pale, dusky)
- Abnormal breathing (e.g., rate, rhythm, depth); nasal flaring
- Tachycardia; [development of dysrhythmias]
- Diaphoresis
- [Polycythemia]
Desired Outcomes/Evaluation Criteria—Client Will:
- Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within client’s normal limits and absence of symptoms of respiratory distress (as noted in Defining Characteristics).
- Verbalize understanding of causative factors and appropriate interventions.
- Participate in treatment regimen (e.g., breathing exercises, effective coughing, use of oxygen) within level of ability/situation.
Nursing Interventions for Impaired Gas Exchange | Nursing Care Plan for Impaired Gas Exchange
NURSING PRIORITY NO. 1. To assess causative/contributing factors:
- Note presence of factors listed in Related Factors. Refer to NDs ineffective Airway Clearance; ineffective Breathing Pattern, as appropriate.
NURSING PRIORITY NO. 2. To evaluate degree of compromise:
- Note respiratory rate, depth, use of accessory muscles, pursed-lip breathing; and areas of pallor/cyanosis; for example, peripheral (nailbeds) versus central (circumoral) or general duskiness.
- Auscultate breath sounds, note areas of decreased/adventitious breath sounds as well as fremitus.
- Note character and effectiveness of cough mechanism (e.g, ability to clear airways of secretions).
- Assess level of consciousness and mentation changes. Note somnolence, restlessness, reports of headache on arising.
- Monitor vital signs and cardiac rhythm.
- Evaluate pulse oximetry to determine oxygenation; evaluate lung volumes and forced vital capacity to assess for respiratory insufficiency.
- Review other pertinent laboratory data (e.g., ABGs, CBC); chest x-rays.
- Assess energy level and activity tolerance.
- Note effect of illness on self-esteem/body image.
Nursing Care Plan for Impaired Gas Exchange
NURSING PRIORITY NO. 3. To correct/improve existing deficiencies:
- Elevate head of bed/position client appropriately, provide airway adjuncts and suction, as indicated, to maintain airway.
- Encourage frequent position changes and deep-breathing/coughing exercises. Use incentive spirometer, chest physiotherapy, IPPB, and so forth, as indicated. Promotes optimal chest expansion and drainage of secretions.
- Provide supplemental oxygen at lowest concentration indicated by laboratory results and client symptoms/situation.
- Monitor for carbon dioxide narcosis (e.g., change in level of consciousness, changes in O2 and CO2 blood gas levels, flushing, decreased respiratory rate, headaches), which may occur in client receiving long-term oxygen therapy.
- Maintain adequate I/O for mobilization of secretions, but avoid fluid overload.
- Use sedation judiciously to avoid depressant effects on respiratory functioning.
- Ensure availability of proper emergency equipment, including ET/trach set and suction catheters appropriate for age and size of infant/child/adult.
- Avoid use of face mask in elderly emaciated client.
- Encourage adequate rest and limit activities to within client tolerance. Promote calm/restful environment. Helps limit oxygen needs/consumption.
- Provide psychological support, active-listen questions/concerns to reduce anxiety.
- Administer medications, as indicated (e.g., inhaled and systemic glucocorticosteroids, antibiotics, bronchodilators, methylxanthines, expectorants), to treat underlying conditions.
- Monitor/instruct client in therapeutic and adverse effects as well as interactions of drug therapy.
- Minimize blood loss from procedures (e.g., tests, hemodialysis) to limit adverse affects of anemia.
- Assist with procedures as individually indicated (e.g., transfusion, phlebotomy, bronchoscopy) to improve respiratory function/oxygen-carrying capacity.
- Monitor/adjust ventilator settings (e.g., FIO2, tidal volume, inspiratory/expiratory ratio, sigh, positive end-expiratory pressure [PEEP]), as indicated, when mechanical support is being used.
- Keep environment allergen/pollutant free to reduce irritant effect of dust and chemicals on airways.
Nursing Care Plan for Impaired Gas Exchange
NURSING PRIORITY NO. 4. To promote wellness (Teaching/Discharge Considerations):
- Review risk factors, particularly environmental/employment related, to promote prevention/management of risk.
- Discuss implications of smoking related to the illness/ condition.
- Encourage client and SO(s) to stop smoking, attend cessation programs, as necessary, to reduce health risks and/or prevent further decline in lung function.
- Discuss reasons for allergy testing when indicated. Review individual drug regimen and ways of dealing with side effects.
- Instruct in the use of relaxation, stress-reduction techniques, as appropriate.
- Reinforce need for adequate rest, while encouraging activity and exercise (e.g., upper and lower extremity endurance/strength training and flexibility) to decrease dyspnea and improve quality of life.
- Emphasize the importance of nutrition in improving stamina and reducing the work of breathing.
- Review oxygen-conserving techniques (e.g., sitting instead of standing to perform tasks; eating small meals; performing slower, purposeful movements).
- Review job description/work activities to identify need for job modifications/vocational rehabilitation.
- Discuss home oxygen therapy and safety measures, as indicated, when home oxygen implemented.
- Identify specific supplier for supplemental oxygen/necessary respiratory devices, as well as other individually appropriate resources, such as home care agencies, Meals on Wheels, and so on, to facilitate independence.
Documentation Focus | Nursing Care Plan for Impaired Gas Exchange
ASSESSMENT/REASSESSMENT | Nursing Care Plan for Impaired Gas Exchange
- Assessment findings, including respiratory rate, character of breath sounds; frequency, amount, and appearance of secretions; presence of cyanosis; laboratory findings; and mentation level.
- Conditions that may interfere with oxygen supply.
PLANNING | Nursing Care Plan for Impaired Gas Exchange
