Impaired Gas Exchange

Saturday, October 1, 2011 ·
Impaired gas exchange

DEFINITIONS:
Excess and deficiency of oxygen and / or elimination of carbon dioxide in the capillary-alveolar membrane

PURPOSE:
Addressing the problem of gas exchange impairment

CRITERIA:
No increase in respiratory work
There is no use of accessory muscles / retractions and asymmetrical chest expansion
Ronchi / crackles reduced s.d. disappear
Blood Gas Analysis within normal limits
Vital signs within normal limits

Impaired Gas Exchange NURSING DIAGNOSIS:

Impaired gas exchange related to

  • Anesthesia
  • Allergic response
  • Altered level of consciousness
  • Anxiety
  • Aspiration
  • Obstruction
  • Decrease lung compliance
  • Excessive or thick secretions
  • Neuromuscular impairment
  • Infection
  • Loss of lung elasticity
  • Prolonged immobility
  • Surgery (chest or upper abdominal incisions)
  • Medication


EVIDENCED BY:

  • Dyspnea on Exertion (DOE)
  • Confusion
  • Restlessness
  • Irritability
  • Lethargy and fatigue
  • Inability to move secretions
  • Decreased oxygen content, oxygen saturation Decreased, 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)
  • Hypercapnia
  • Hypoxia
  • Cyanosis


Impaired Gas Exchange CARE PLAN AND Outcome:

  • The patient Will demonstrate the 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.


Impaired Gas Exchange NURSING Interventions:

  • Assess respiratory status periodically, noted a change in the levels of hypoxia
  • Auscultation of lung sounds periodically, note the quality of breath sounds, wheezing, expiratory lengthening and observation symmetry chest movement
  • Assess presence of cyanosis
  • Auscultation of heart rhythm and sound
  • Help clients to rest in peace keeping environment
  • Position the client in comfortable position (Fowler or semi-Fowler)
  • Teach and motivate clients to do pernapasanmulut / lips (pursed lip)
  • Monitor fluid intake and output balance
  • Monitor oxygen saturation (Pulse Oximetri if any)
  • Monitor kepatenan hose WSD
  • Monitor output WSD
  • Replace the bottle properly WSD


HEALTH EDUCATION:

  • Explain the use of ancillary equipment properly (oxygen, suctioning, spirometers, inhalers, and intermittent pressure breathing / IPPB)
  • Teach relaxation techniques breathing in
  • Teach effective coughing techniques


Act of collaboration:

  • Keep an eye / limit peroral and parenteral fluid administration
  • Monitor ventilator
  • Observation Fi O2
  • Ensure adequate oxygen humidity
  • Monitor levels of PO and PCO
  • Perform blood gas analysis
  • Lung X-ray monitor on a regular basis
  • Provide appropriate medical therapy program