Impaired Gas Exchange | Nursing Care Plan for Pancreatitis

Nursing diagnosis: impaired gas exchange related to Pain, with splinting of respirations; upper abdominal distention and elevated diaphragm; pleural effusion, Alveolar or capillary membrane changes—interstitial edema, pulmonary congestion

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

Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Ventilation
Maintain adequate ventilation with respiratory rate and rhythm normal for client, breath sounds clear, and free of dyspnea or
shortness of breath.
Respiratory Status: Gas Exchange
Display arterial blood gases (ABGs) within client’s normal range.

Nursing intervention with rationale:
1. Evaluate respiratory rate and depth. Note respiratory effort; for example, presence of dyspnea, use of accessory muscles, and nasal flaring.
Rationale: Client responses are variable. Rate and effort may be increased by pain, accumulation of secretions, or abdominal distention. Respiratory depression can occur with use of opioid analgesics. Early recognition and treatment of abnormal ventilation may prevent complications.

2. Auscultate breath sounds. Note areas of diminished or absent breath sounds and presence of adventitious sounds, such as rhonchi or crackles.
Rationale: Loss of active breath sounds in an area of previous ventilation may reflect atelectasis. Crackles or rhonchi may be indicative of fluid accumulation due to interstitial edema, pulmonary congestion, or infection.

3. Encourage client participation and responsibility for deepbreathing exercises, use of adjuncts, and coughing, as indicated. Reposition frequently.
Rationale: Stimulates respiratory function and lung expansion. Effective in preventing and resolving pulmonary congestion.

4. Reinforce splinting of abdomen with pillows during deep breathing or coughing.
Rationale: May enhance effectiveness of cough effort.

5. Note increasing restlessness, confusion, and lethargy.
Rationale: May indicate impaired gas exchange and possible ARDS, requiring prompt evaluation and intervention.

6. Monitor and graph serial ABGs and pulse oximetry, and review chest x-ray reports.
Rationale: Decreasing oxygen level or saturation and increasing PaCO2 and changes in chest x-rays suggest developing complications requiring further evaluation and treatment.

7. Administer supplemental oxygen O2, if indicated.
Rationale: Increases available O2 for tissue and organ function. Note: Inability to maintain adequate oxygenation indicates need for more aggressive therapy or mechanical ventilation.