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