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Tuesday, July 6, 2010

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


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