Risk for Impaired Gas Exchange | Nursing Care Plan for Tuberculosis

Risk factors may include

Decrease in effective lung surface, atelectasis

Destruction of alveolar-capillary membrane

Thick, viscous secretions

Bronchial edema

Possibly evidenced by

(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Gas Exchange

Report absence of or decreased dyspnea.

Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within acceptable ranges.

Be free of symptoms of respiratory distress.

Nursing intervention with rationale:

1. Assess for dyspnea (using 0 to 10 scale), tachypnea, abnormal breath sounds, increased respiratory effort, limited chest wall expansion, and fatigue.

Rationale: Pulmonary TB can cause a wide range of effects in the lungs, ranging from a small patch of bronchopneumonia to diffuse intense inflammation, caseous necrosis, pleural effusion, and extensive fibrosis. Respiratory effects can range from mild dyspnea to profound respiratory distress. Note: Using a scale to evaluate dyspnea helps clarify degree of difficulty and changes in condition.

2. Evaluate change in level of mentation. Note cyanosis or change in skin color, including mucous membranes and nailbeds.

Rationale: Accumulation of secretions and airway compromise can impair oxygenation of vital organs and tissues.

3. Demonstrate and encourage pursed-lip breathing during exhalation, especially for clients with fibrosis or parenchymal destruction.

Rationale: Creates resistance against outflowing air to prevent collapse of the airways, thereby helping to distribute air throughout the lungs and relieve or reduce shortness of breath.

4. Promote bedrest, or limit activity and assist with self-care activities as necessary.

Rationale: Reducing oxygen consumption and demand during periods of respiratory compromise may reduce severity of symptoms.

5. Monitor serial ABGs and pulse oximetry.

Rationale: Decreased oxygen content (PaO2) and saturation or increased PaCO2 indicate need for change in therapeutic regimen.

6. Provide supplemental oxygen as appropriate.

Rationale: Aids in correcting the hypoxemia that may occur secondary to decreased ventilation and diminished alveolar lung surface.