Risk for Impaired Gas Exchange | Nursing Diagnosis for Lymphoma

Nursing diagnosis: risk for impaired Gas Exchange

Risk factors may include
Altered oxygen-carrying capacity of blood
Tracheobronchial obstruction—enlarged mediastinal nodes and airway edema (HL and NHL), superior vena cava syndrome (NHL)

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

Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Ventilation
Maintain a normal, effective respiratory pattern, free of dyspnea, cyanosis, or other signs of respiratory distress, and arterial blood gases (ABGs) within normal limits (WNL).

Nursing intervention with rationale:
1. Assess and monitor respiratory rate, depth, and rhythm. Note reports of dyspnea or use of accessory muscles, nasal flaring, and altered chest excursion.
Rationale: Changes such as tachypnea, dyspnea, and use of accessory muscles, may indicate progression of respiratory involvement requiring prompt intervention.

2. Place client in position of comfort, usually with head of bed elevated or sitting upright, leaning forward with weight supported on arms, and feet dangling.
Rationale: Maximizes lung expansion, decreases work of breathing, and reduces risk of aspiration.

3. Reposition and assist with turning periodically.
Rationale: Promotes aeration of all lung segments and mobilizes secretions.

4. Instruct in and assist with deep-breathing techniques and pursed-lip or abdominal diaphragmatic breathing, if indicated.
Rationale: Helps promote gas diffusion and expansion of small airways. Provides client with some control over respiration, helping to reduce anxiety.

5. Evaluate skin color, noting pallor or development of cyanosis, particularly in nailbeds, ear lobes, and lips.
Rationale: Proliferation of WBCs and anemia can reduce oxygen-carrying capacity of the blood, leading to hypoxemia.

6. Assess respiratory response to activity. Note reports of dyspnea and increased fatigue. Schedule rest periods between activities.
Rationale: Decreased cellular oxygenation reduces activity tolerance. Rest reduces oxygen demands and minimizes fatigue and dyspnea.

7. Encourage energy-saving techniques, such as rest periods before and after meals, use of shower chair, and sitting for care.
Rationale: Aids in reducing fatigue and dyspnea and conserves energy for cellular regeneration and respiratory function.

8. Promote bedrest and provide care as indicated during acute or prolonged exacerbation.
Rationale: Worsening respiratory involvement and hypoxia may necessitate cessation of activity to prevent more serious respiratory compromise.

9. Encourage expression of feelings. Acknowledge reality of situation and normality of feelings.
Rationale: Anxiety increases oxygen demand, and hypoxemia potentiates respiratory distress or cardiac symptoms, which in turn escalates anxiety.

10. Provide calm, quiet environment.
Rationale: Promotes relaxation, conserving energy and reducing oxygen demand.