Nursing Diagnosis Impaired Gas exchange

Nursing Diagnosis Impaired Gas exchange Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

Visual disturbances, decreased carbon dioxide, dyspnea, abnormal arterial blood gases, hypoxia, irritability, somnolence, restlessness, hypercapnia, tachycardia, cyanosis, abnormal skin color, hypoxemia, hypercarbia, headache on awakening, abnormal rate rhythm depth of breathing, diaphoresis, abnormal arterial pH, abnormal nasal flaring

Nursing Outcomes

Respiratory Status: Gas Exchange
Respiratory Status: Ventilation
Tissue Perfusion: Pulmonary
Vital Signs Status
Electrolyte and Acid-Base Balance

Client Outcomes

Demonstrates improved ventilation and adequate oxygenation as evidenced by blood gases within client's normal parameters
Maintains clear lung fields and remains free of signs of respiratory distress
Verbalizes understanding of oxygen and other therapeutic interventions

Nursing Interventions

Airway Management
Oxygen Therapy
Respiratory Monitoring
Acid-Base Management
Monitor respiratory Auscultate breath sounds, rate, depth, and effort, including use of accessory muscles, nasal flaring, and abnormal breathing patterns, oxygen saturation using pulse oximeter. Note blood gas results as available continuously
Monitor client's behavior and mental status for onset of restlessness, agitation, confusion, and extreme lethargy.
Observe for cyanosis sign
coach the client to slow respiratory rate, Demonstrate and encourage the client to use pursed-lip breathing
Position client with head of bed elevated, in a semi-Fowler's position, If client has unilateral lung disease, alternate semi-Fowler's position with lateral position. If client has a bilateral lung disease, position in either a semi-Fowler's or side-lying position
Administer oxygen
If chronic pulmonary disease is interfering with quality of life, refer client for pulmonary rehabilitation.
Encourage client to stop smoking