Nursing Diagnosis: Risk for Impaired Gas Exchange related to alveolar-capillary membrane changes such as fluid collection and shifts into interstitial space or alveoli
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Gas Exchange
Demonstrate adequate ventilation and oxygenation of tissues by ABG values and oximetry within client’s normal ranges and be free of symptoms of respiratory distress.
Participate in treatment regimen within level of ability and situation.
Nursing Care Plan Intervention with Rationale:
1. Auscultate breath sounds, noting crackles and wheezes.
Rationale: Reveals presence of pulmonary congestion or collection of secretions, indicating need for further intervention.
2. Instruct client in effective coughing and deep breathing.
Rationale: Clears airways and facilitates oxygen delivery.
3. Encourage frequent position changes.
Rationale: Helps prevent atelectasis and pneumonia.
4. Maintain chair rest and bedrest in a semi-Fowler’s position, with head of bed elevated 20 to 30 degrees. Support arms with pillows.
Rationale: Reduces oxygen consumption and demands and promotes maximal lung inflation.
5. Monitor and graph serial ABG values and pulse oximetry.
Rationale: Hypoxemia can be severe during pulmonary edema. Compensatory changes are usually present in chronic HF.
6. Administer supplemental oxygen, as indicated.
Rationale: Increases alveolar oxygen concentration, which may correct or reduce tissue hypoxemia.
7. Administer medications, as indicated, such as the following: Diuretics, for example, furosemide (Lasix) Bronchodilators, for example, aminophylline
Rationale: Reduce alveolar congestion, enhancing gas exchange. Increase oxygen delivery by dilating small airways and exert mild diuretic effect to aid in reducing pulmonary congestion.
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