Nursing Diagnosis for Thrombophlebitis | Impaired Gas Exchange

Nursing diagnosis: impaired gas exchange related to altered blood flow to alveoli or to major portions of the lung; alveolar-capillary membrane changes—atelectasis, airway or alveolar collapse, pulmonary edema or effusion, excessive secretions or active bleeding

Possibly evidenced by

Profound dyspnea, restlessness, apprehension, somnolence, cyanosis

Changes in arterial blood gases (ABGs) or pulse oximetry, such as hypoxemia and hypercapnia

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Gas Exchange

Demonstrate adequate ventilation and oxygenation by ABGs within client’s normal range.

Report or display resolution or absence of symptoms of respiratory distress.

Nursing care plan intervention with rationale:

1. Note respiratory rate and depth and work of breathing, such as use of accessory muscles or nasal flaring and pursed-lip breathing.

Rationale: Tachypnea and dyspnea accompany pulmonary obstruction. Dyspnea and increased work of breathing may be first or only sign of subacute PE. Severe respiratory distress and

failure accompanies moderate to severe loss of functional lung units.

2. Auscultate lungs for areas of decreased and absent breath sounds and the presence of adventitious sounds, such as crackles.

Rationale: Nonventilated areas may be identified by absence of breath sounds. Crackles occur in fluid-filled tissues and airways or may reflect cardiac decompensation.

3. Observe for generalized duskiness and cyanosis in “warm tissues,” such as earlobes, lips, tongue, and buccal membranes.

Rationale: Indicative of systemic hypoxemia.

4. Monitor vital signs. Note changes in cardiac rhythm.

Rationale: Tachycardia, tachypnea, and changes in BP are associated with advancing hypoxemia and acidosis. Rhythm alterations and extra heart sounds may reflect increased cardiac workload

related to worsening ventilation imbalance.

5. Assess level of consciousness and evaluate mentation changes.

Rationale: Systemic hypoxemia may be demonstrated initially by restlessness and irritability, then by progressively decreased mentation.

6. Assess activity tolerance, such as reports of weakness and fatigue, vital sign changes, or increased dyspnea during exertion. Encourage rest periods, and limit activities to

client tolerance.

Rationale: These parameters assist in determining client response to resumed activities and ability to participate in self-care.

7. Institute measures to restore or maintain patent airways, such as deep-breathing exercises, coughing, and suctioning.

Rationale: Plugged or collapsed airways reduce number of functional alveoli, negatively affecting gas exchange.

8. Elevate head of bed as client tolerates.

Rationale: Promotes maximal chest expansion, making it easier to breathe and enhancing physiological and psychological comfort.

9. Assist with frequent changes of position, and get client out of bed to ambulate as tolerated.

Rationale: Turning and ambulation enhance aeration of different lung segments, thereby improving oxygen diffusion.

10. Monitor frequently, and arrange for someone to stay with client, as indicated.

Rationale: Provides assurance that changes in condition will be noted and that assistance is readily available.