Impaired Gas Exchange | Nursing Care Plan for Respiratory Alkalosis

Nursing diagnosis: impaired Gas Exchange related to ventilation-perfusion imbalance, such as altered oxygen supply, altered blood flow, altered oxygen-carrying capacity of blood,

alveolar-capillary membrane changes

Possibly evidenced by

Dyspnea, tachypnea

Changes in mentation

Hypocapnia, tachycardia

Hypoxia

Desired Outcomes/Evaluation Criteria—Client Will

Electrolyte and Acid-Base Balance

Demonstrate improved ventilation and adequate oxygenation of tissue as evidenced by ABGs within client’s acceptable limits and absence of symptoms of respiratory distress.

Verbalize understanding of causative factors and appropriate interventions.

Participate in treatment regimen within level of ability or situation.

Nursing intervention with rationale:

1. Monitor respiratory rate, depth, and effort; ascertain cause of hyperventilation if possible, for example, anxiety, pain, and improper ventilator settings.

Rationale: Identifies alterations from usual breathing pattern and influences choice of intervention.

2. Assess level of awareness and cognition. Note neuromuscular status—strength, tone, reflexes, sensation, and presence of tremors.

Rationale: Decreased mentation (mild to severe) and tetany or seizures may occur when alkalosis is severe due to shifts in calcium.

3. Instruct and encourage client to breathe slowly and deeply. Speak in a low, calm tone of voice. Provide safe environment.

Rationale: May help reassure and calm the agitated client, thereby aiding the reduction of respiratory rate. Assists client to regain control. Note: Clients with hyperventilation syndrome as a cause of their respiratory alkalosis may particularly benefit from reassurance and client education in breathing techniques.

4. Demonstrate appropriate breathing patterns, if appropriate, and assist with respiratory aids, such as rebreathing mask or bag.

Rationale: Decreasing the rate of respirations can halt the “blowing off” of CO2, elevating PaCO2 level and normalizing pH.

5. Provide comfort measures; encourage use of meditation and visualization. Use tepid sponge bath or cool cloths.

Rationale: Promotes relaxation and reduces stress. Control and reduction of fever reduces potential for seizures and helps reduce respiration rate.

6. Provide safety and seizure precautions, such as bed in low position, padded side rails, frequent observation.

Rationale: Changes in mentation and CNS and neuromuscular hyperirritability may result in client harm, especially if tetany or convulsions occur.

7. Discuss cause of condition, if known, and appropriate interventions and self-care activities.

Rationale: Promotes participation in therapeutic regimen and may reduce recurrence of disorder.

8. Assist with identification and treatment of underlying cause.

Rationale: Respiratory alkalosis is a complication, not an isolated occurrence and rarely requires emergent treatment (unless pH is greater than 7.5); thus, correction of alkalosis is undertaken by addressing the primary condition, such as hyperventilation of panic attack, organ failure, severe anemia, and drug effect. Because respiratory alkalosis usually occurs in

response to some stimulus, treatment is unsuccessful unless the stimulus is controlled.

9. Monitor and graph serial ABGs and pulse oximetry.

Rationale: Identifies therapy needs and effectiveness. Note: Rapid correction of PaCO2 in individual with chronic respiratory alkalosis (has a lower serum bicarbonate) may cause metabolic acidosis to develop.

10. Monitor serum potassium and replace, as indicated.

Rationale: Hypokalemia may occur as potassium is lost via urine or shifted into the cell in exchange for hydrogen in an attempt to correct alkalosis.

Impaired Gas Exchange | Nursing Care Plan for Respiratory Acidosis

Nursing diagnosis: impaired gas exchange related to ventilation perfusion imbalance—altered oxygen-carrying capacity of blood, altered oxygen supply, alveolar-capillary membrane

changes, or altered blood flow

Possibly evidenced by

Dyspnea with exertion, tachypnea

Changes in mentation, irritability

Tachycardia

Hypoxia, hypercapnia

Desired Outcomes/Evaluation Criteria—Client Will

Electrolyte and Acid-Base Balance

Demonstrate improved ventilation and adequate oxygenation of tissues as evidenced by ABGs within client’s acceptable limits

and absence of symptoms of respiratory distress.

Knowledge: Disease Process

Verbalize understanding of causative factors and appropriate interventions.

Participate in treatment regimen within level of ability or situation.

Nursing care plan intervention

1. Monitor respiratory rate, depth, and effort.

Rationale: Alveolar hypoventilation and associated hypoxemia lead to respiratory failure.

2. Auscultate breath sounds.

Rationale: Identifies area(s) of decreased ventilation, such as atelectasis, or airway obstruction and changes as client deteriorates or improves, reflecting effectiveness of treatment and dictating therapy needs.

3. Note declining level of awareness or consciousness.

Rationale: Signals severe acidotic state, which requires immediate attention. Note: In recovery, sensorium clears slowly because hydrogen ions are slow to cross the blood-brain barrier and

clear from cerebrospinal fluid (CSF) and brain cells.

4. Monitor heart rate and rhythm.

Rationale: Tachycardia develops early because the sympathetic nervous system is stimulated, resulting in the release of catecholamines, epinephrine, and norepinephrine in an attempt

to increase oxygen delivery to the tissues. Dysrhythmias that may occur are due to hypoxia (myocardial ischemia) and electrolyte imbalances.

5. Note skin color, temperature, and moisture.

Rationale: Diaphoresis, pallor, and cool, clammy skin are late changes associated with severe or advancing hypoxemia.

6. Encourage and assist with deep-breathing exercises, turning, and coughing. Suction as necessary. Provide airway adjunct as indicated. Place in semi-Fowler’s position.

Rationale: These measures improve lung ventilation and reduce or prevent airway obstruction associated with accumulation of mucus.

7. Restrict use of hypnotic sedatives or tranquilizers.

Rationale: In the presence of hypoventilation, respiratory depression and CO2 narcosis may develop.

8. Discuss cause of chronic condition, when known, and appropriate interventions and self-care activities.

Rationale: Promotes participation in therapeutic regimen and may reduce recurrence of disorder.

9. Assist with identification and treatment of underlying cause.

Rationale: Treatment of disorder is directed at improving alveolar ventilation. Multiple team management, including physicians, pulmonologist and respiratory therapists, or neurologists, may be required to address the underlying condition, such as oversedation, brain trauma, COPD, pulmonary edema, aspiration, and promote correction of the acid-base disorder.

10. Monitor and graph serial ABGs and pulse oximetry readings.

Rationale: Evaluates therapy needs and effectiveness. Note: Pulse oximetry monitoring is used to monitor and show early changes in oxygenation, which can occur before other signs or

symptoms are observed.

Imbalanced Nutrition: Less than Body Requirements | Nursing Care Plan for Tuberculosis

Nursing diagnosis: imbalanced Nutrition: Less than Body Requirements related to fatigue; frequent cough and sputum production; dyspnea; anorexia; insufficient financial resources

Possibly evidenced by

Weight 10% to 20% below ideal for frame and height

Reported lack of interest in food, altered taste sensation

Poor muscle tone

Desired Outcomes/Evaluation Criteria—Client Will

Nutritional Status

Demonstrate progressive weight gain toward goal with normalization of laboratory values and be free of signs of malnutrition.

Initiate behaviors or lifestyle changes to regain and to maintain appropriate weight.

Nursing intervention with rationale:

1. Document client’s nutritional status on admission, noting skin turgor, current weight and degree of weight loss, integrity of oral mucosa, ability to swallow, presence of bowel tones,

and history of nausea, vomiting, or diarrhea.

Rationale: Useful in defining extent of problem and appropriate choice of interventions.

2. Ascertain client’s usual dietary pattern and likes and dislikes.

Rationale: Helps to identify specific needs or strengths. Consideration of individual preferences may improve dietary intake.

3. Monitor intake and ouput (I&O) and weight periodically.

Rationale: Useful in measuring effectiveness of nutritional and fluid support.

4. Investigate anorexia, nausea, and vomiting. Note possible correlation to medications. Monitor frequency, volume, and consistency of stools.

Rationale: Affects dietary choices and can identify areas for problem-solving to enhance intake of nutrients.

5. Encourage and provide for frequent rest periods.

Rationale: Helps conserve energy, especially when metabolic requirements are increased by fever.

6. Provide oral care before and after respiratory treatments.

Rationale: Reduces bad taste left from sputum or medications used for respiratory treatments that can stimulate the vomiting center.

7. Encourage small, frequent meals with foods high in protein and carbohydrates.

Rationale: Maximizes nutrient intake without undue energy expenditure from eating large meals.

8. Encourage SO to bring foods from home and to share meals with client unless contraindicated.

Rationale: Creates a more normal social environment during mealtime and helps meet personal and cultural preferences.

9. Refer to dietitian for adjustments in dietary composition.

Rationale: Provides assistance in planning a diet with nutrients adequate to meet client’s metabolic requirements, dietary preferences, and financial resources postdischarge.

10. Consult with respiratory therapy to schedule treatments 1 to 2 hours before or after meals.

Rationale: May help reduce the incidence of nausea and vomiting associated with medications or the effects of respiratory treatments on a full stomach.

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Ajou University, School of Medicine
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- The

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.

Ineffective Airway Clearance | Nursing Care Plan for Tuberculosis

Nursing diagnosis: ineffective airway clearance related to thick, viscous, or bloody secretions; fatigue, poor cough effort; tracheal or pharyngeal edema

Possibly evidenced by

Abnormal respiratory rate, rhythm, depth

Abnormal breath sounds—rhonchi, wheezes, stridor

Dyspnea

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Airway Patency

Maintain patent airway.

Expectorate secretions without assistance.

Demonstrate behaviors to improve or maintain airway clearance.

Participate in treatment regimen, within the level of ability and situation.

Identify potential complications and initiate appropriate actions.

Nursing intervention with rationale:

1. Assess respiratory function, such as breath sounds, rate, rhythm, and depth, and use of accessory muscles.

Rationale: Diminished breath sounds may reflect atelectasis. Rhonchi and wheezes indicate accumulation of secretions and inability to clear airways, which may lead to use of accessory

muscles and increased work of breathing.

2. Note ability to expectorate mucus and cough effectively; document character and amount of sputum and presence of hemoptysis.

Rationale: Expectoration may be difficult when secretions are very thick as a result of infection or inadequate hydration. Bloodtinged or frankly bloody sputum results from tissue breakdown in the lungs and may require further evaluation and intervention.

3. Place client in semi- or high-Fowler’s position. Assist client with coughing and deep-breathing exercises.

Rationale: Positioning helps maximize lung expansion and decreases respiratory effort. Maximal ventilation may open atelectatic areas and promote movement of secretions into larger

airways for expectoration.

4. Clear secretions from mouth and trachea; suction as necessary.

Rationale: Prevents obstruction and aspiration. Suctioning may be necessary if client is unable to expectorate secretions.

5. Maintain fluid intake of at least 2,500 mL/day unless contraindicated.

Rationale: High fluid intake helps thin secretions, making them easier to expectorate.

6. Humidify inspired oxygen.

Rationale: Prevents drying of mucous membranes and helps thin secretions.

7. Administer medications, as indicated, for example: Mucolytic agents, such as acetylcysteine (Mucomyst)

Rationale: Reduces the thickness and stickiness of pulmonary secretions to facilitate clearance.

8. Bronchodilators, such as oxtriphylline (Choledyl) and theophylline (Theo-Dur)

Rationale: Increases lumen size of the tracheobronchial tree, thus decreasing resistance to airflow and improving oxygen delivery.

9. Corticosteroids (prednisone)

Rationale: May be useful in the presence of extensive involvement with profound hypoxemia and when inflammatory response is life-threatening.

10. Be prepared for and assist with emergency intubation.

Rationale: Intubation may be necessary in rare cases of bronchogenic TB accompanied by laryngeal edema or acute pulmonary bleeding.

Risk for Infection | Nursing Care Plan for Tuberculosis

Risk factors may include

Inadequate primary defenses, decreased ciliary action and stasis of secretions

Tissue destruction, extension of infection

Lowered resistance, suppressed inflammatory process

Malnutrition

Environmental exposure

Insufficient knowledge to avoid exposure to pathogens

Possibly evidenced by

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

Desired Outcomes/Evaluation Criteria—Client Will

Risk Control

Identify interventions to prevent or reduce risk of spread of infection.

Demonstrate techniques and initiate lifestyle changes to promote safe environment.

Nursing care plan intervention with rationale:

1. Review pathology of disease—active or inactive phases, dissemination of infection through bronchi to adjacent tissues or via bloodstream and lymphatic system—and potential

spread of infection via airborne droplet during coughing, sneezing, spitting, talking, laughing, and singing.

Rationale: Helps client realize and accept necessity of adhering to medication regimen to prevent reactivation and complications. Understanding of how the disease is passed and awareness of transmission possibilities help client and significant other (SO) take steps to prevent infection of others.

2. Identify others at risk, such as household members, close associates, and friends.

Rationale: Those exposed may require a course of drug therapy to prevent development of infection.

3. Instruct client to cough, sneeze, and expectorate into tissue and to refrain from spitting. Review proper disposal of tissue and good hand-washing techniques. Request return

demonstration.

Rationale: Behaviors necessary to prevent spread of infection.

4. Review necessity of infection control measures, such as temporary respiratory isolation.

Rationale: May help client understand need for protecting others while acknowledging client’s sense of isolation and social stigma associated with communicable diseases. Note: AFB can

pass through standard masks; therefore, particulate respirators are required.

5. Monitor temperature, as indicated.

Rationale: Febrile reactions are indicators of continuing presence of infection.

6. Identify individual risk factors for reactivation of tuberculosis, such as lowered resistance associated with alcoholism, malnutrition, intestinal bypass surgery, use of immunosuppressant

drugs, presence of diabetes mellitus or cancer, or postpartum.

Rationale: Knowledge about these factors helps client alter lifestyle and avoid or reduce incidence of exacerbation.

7. Stress importance of uninterrupted drug therapy. Evaluate client’s potential for cooperation.

Rationale: Contagious period may last only 2 to 3 days after initiation of drug regimen, but in the presence of cavitation or moderately advanced disease, risk of spread of infection may

continue up to 3 months. Compliance with multidrug regimens for prolonged periods is difficult; therefore, DOT should be considered.

8. Review importance of follow-up and periodic reculturing of sputum for the duration of therapy.

Rationale: Aids in monitoring the effects of medications and client’s response to therapy.

9. Encourage selection and ingestion of well-balanced meals. Provide frequent small “snacks” in place of large meals as appropriate.

Rationale: Presence of anorexia or preexisting malnutrition lowers resistance to infectious process and impairs healing. Small snacks may enhance overall intake.