Impaired Gas Exchange | Nursing Care Plan for Lung Cancer

Nursing diagnosis: impaired gas exchange related to removal of lung tissue; altered oxygen supply—hypoventilation; decreased oxygen-carrying capacity of blood—blood loss

Possibly evidenced by

Dyspnea

Restlessness

Changes in mentation

Hypoxemia and hypercapnia

Cyanosis

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Gas Exchange

Demonstrate improved ventilation and adequate oxygenation of tissues by arterial blood gases (ABGs) within client’s normal range.

Be free of symptoms of respiratory distress.

Nursing intervention with rationale:

1. Note respiratory rate, depth, and ease of respirations. Observe for use of accessory muscles, pursed-lip breathing, or changes in skin or mucous membrane color, such as pallor and cyanosis.

Rationale: Respirations may be increased as a result of pain or as an initial compensatory mechanism to accommodate for loss of lung tissue. However, increased work of breathing and cyanosis may indicate increasing oxygen consumption and energy expenditures or reduced respiratory reserve, for example, in an elderly client or extensive COPD.

2. Auscultate lungs for air movement and abnormal breath sounds.

Rationale: Consolidation and lack of air movement on operative side are normal in the client who has had a pneumonectomy; however, a client who has had a lobectomy should demonstrate normal airflow in remaining lobes.

3. Investigate restlessness and changes in mentation and level of consciousness.

Rationale: May indicate increased hypoxia or complications such as mediastinal shift in a client who has had a pneumonectomy when accompanied by tachypnea, tachycardia, and tracheal

deviation.

4. Assess client response to activity. Encourage rest periods, limiting activities to client tolerance.

Rationale: Increased oxygen consumption and demand and stress of surgery may result in increased dyspnea and changes in vital signs with activity; however, early mobilization is desired to help prevent pulmonary complications and to obtain and maintain respiratory and circulatory efficiency. Adequate rest balanced with activity can prevent respiratory compromise.

5. Note development of fever.

Rationale: Fever within the first 24 hours after surgery is frequently due to atelectasis. Temperature elevation within postoperative day 5 to 10 usually indicates an infection, such as wound or systemic.

6. Maintain patent airway by positioning, suctioning, and use of airway adjuncts.

Rationale: Airway obstruction impedes ventilation, impairing gas exchange.

7. Reposition frequently, placing client in sitting and supine to side positions.

Rationale: Maximizes lung expansion and drainage of secretions.

8. Avoid positioning client with a pneumonectomy on the operative side; instead, favor the “good lung down” position.

Rationale: Research shows that positioning clients following lung surgery with their “good lung down” maximizes oxygenation by using gravity to enhance blood flow to the healthy lung, thus creating the best possible match between ventilation and perfusion.

9. Encourage and assist with deep-breathing exercises and pursed-lip breathing, as appropriate.

Rationale: Promotes maximal ventilation and oxygenation and reduces or prevents atelectasis.

10. Administer supplemental oxygen via nasal cannula, partial rebreathing mask, or high-humidity face mask, as indicated.

Rationale: Maximizes available oxygen, especially while ventilation is reduced because of anesthetic, depression, or pain, and during period of compensatory physiological shift of

circulation to remaining functional alveolar units.