Sample of Nursing Care Plan for Impaired Gas Exchange - Nursing Diagnosis for Impaired Gas Exchange
Definition of Impaired Gas Exchange
- Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane
Defining Characteristics of Impaired Gas Exchange
- Abnormal pH and arterial blood gases levels
- Abnormal respiratory rate, rhythm, and depth
- Confusion
- Cyanosis
- Diaphoresis
- Dyspnea
- Headache upon awakening
- Hypoxia and hypoxemia
- Increased or decreased carbon
- dioxide levels
- Irritability/Restlessness
- Nasal flaring
- Pale, dusky skin
- Tachycardia
Related Factors of Impaired Gas Exchange
- Alveolar-capillary membrane changes
- Ventilation–perfusion changes
Assessment Focus | Nursing Diagnosis for Impaired Gas Exchange
Nursing Care Plan for Impaired Gas Exchange | Assessment Focus; Expected Outcomes; Suggested NOC Outcomes
Assessment Focus of Impaired Gas Exchange
- Activity/exercise
- Cardiac function
- Neurocognition
- Respiratory function
Expected Outcomes of Impaired Gas Exchange
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 | Nursing Diagnosis for Impaired Gas Exchange
Gas Exchange: Ventilation; Respiratory Statue: Gas Exchange; Vital Signs
Nursing Interventions of Impaired Gas Exchange | Nursing Diagnosis for Impaired Gas Exchange
Nursing Diagnosis for Impaired Gas Exchange | Nursing Interventions of Impaired Gas Exchange and Rationales; Suggested NIC Interventions
Nursing Interventions of Impaired Gas Exchange and Rationales
- 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.
- 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, as ordered.
- 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.
- Teach and demonstrate correct breathing and coughing techniques 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 inhaling 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.
- 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 demand.
- 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 information that can be referred to when needed.
Suggested NIC Interventions| Nursing Diagnosis for Impaired Gas Exchange
Acid–Base Management; Airway Management; Airway suctioning; Anxiety Reduction; Energy Management; Exercise Promotion; Fluid Management
This is a sample of Nursing Diagnosis for Impaired Gas Exchange.
