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.

Impaired Gas Exchange | Nursing Diagnosis for Sickle Cell Crisis

Nursing diagnosis: impaired gas exchange related to decreased oxygen-carrying capacity of the blood, reduced RBC life span or premature destruction, abnormal RBC structure, sensitivity to low oxygen tension due to strenuous exercise, increase in altitude, increased blood viscosity—occlusions created by sickled cells packing together within the capillaries, pulmonary congestion—impairment of surface phagocytosis, predisposition to bacterial pneumonia, pulmonary infarcts

Possibly evidenced by
Dyspnea, use of accessory muscles
Restlessness, confusion
Tachycardia
Cyanosis (hypoxia)

Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Gas Exchange
Demonstrate improved ventilation and oxygenation as evidenced by respiratory rate within normal limits, absence of cyanosis, use of accessory muscles, and clear breath sounds.
Participate in ADLs without weakness and fatigue.
Display improved or normal pulmonary function tests.

Nursing intervention with rationale:
1. Monitor respiratory rate and depth, use of accessory muscles, and areas of cyanosis.
Rationale: Indicators of adequacy of respiratory function or degree of compromise and therapy needs and effectiveness.

2. Auscultate breath sounds, noting presence or absence, and adventitious sounds.
Rationale: Development of atelectasis and stasis of secretions can impair gas exchange.

3. Monitor vital signs; note changes in cardiac rhythm.
Rationale: Changes in vital signs and development of dysrhythmias reflect effects of hypoxia on cardiovascular system.

4. Investigate reports of chest pain and increasing fatigue. Observe for signs of increased fever, cough, and adventitious breath sounds.
Rationale: Reflective of developing acute chest syndrome, which increases the workload of the heart and oxygen demand.

5. Assess LOC and mentation regularly.
Rationale: Brain tissue is very sensitive to decreases in oxygen, and changes in mentation may be an early indicator of developing hypoxia.

Ventilation Assistance

6. Evaluate activity tolerance; limit activities to those within client’s tolerance or place client on bedrest. Assist with ADLs and mobility, as needed.
Rationale:

7. Assist in turning, coughing, and deep-breathing exercises.
Rationale: Promotes optimal chest expansion, mobilization of secretions, and aeration of all lung fields; reduces risk of stasis of secretions and pneumonia.

8. Encourage client to alternate periods of rest and activity. Schedule rest periods, as indicated.
Rationale: Protects from excessive fatigue and reduces oxygen demands and degree of hypoxia.

9. Demonstrate and encourage use of relaxation techniques, such as guided imagery and visualization.
Rationale: Relaxation decreases muscle tension and anxiety and, hence, the metabolic demand for oxygen.

10. Promote adequate fluid intake, such as 2 to 3 L/day within cardiac tolerance.
Rationale: Sufficient hydration is necessary to provide for mobilization of secretions and to prevent hyperviscosity of blood with associated capillary occlusion.

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.

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.

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.

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.

Nursing Diagnosis for Pneumonia | Impaired Gas Exchange

Nursing diagnosis: impaired gas exchange related to alveolar-capillary membrane changes—inflammatory effects; altered oxygen-carrying capacity of blood or release at cellular level—fever, shifting oxyhemoglobin curve; altered delivery of oxygen—hypoventilation

Possibly evidenced by

Dyspnea, cyanosis

Tachycardia

Restlessness and changes in mentation

Hypoxia

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Gas Exchange

Demonstrate improved ventilation and oxygenation of tissues by ABGs within client’s acceptable range and absence of symptoms of respiratory distress.

Participate in actions to maximize oxygenation.

Nursing intervention with rationale:

1. Assess respiratory rate, depth, and ease.

Rationale: Manifestations of respiratory distress are dependent on, and indicative of, the degree of lung involvement and underlying general health status.

2. Observe color of skin, mucous membranes, and nailbeds, noting presence of peripheral cyanosis (nailbeds) or central cyanosis (circumoral).

Rationale: Cyanosis of nailbeds may represent vasoconstriction or the body’s response to fever or chills; however, cyanosis of earlobes, mucous membranes, and skin around the mouth (“warm membranes”) is indicative of systemic hypoxemia.

3. Assess mental status.

Rationale: Restlessness, irritation, confusion, and somnolence may reflect hypoxemia or decreased cerebral oxygenation.

4. Monitor heart rate and rhythm.

Rationale: Tachycardia is usually present as a result of fever and dehydration, but may represent a response to hypoxemia.

5. Monitor body temperature, as indicated. Assist with comfort measures to reduce fever and chills, such as addition or removal of bedcovers, comfortable room temperature, and tepid or cool water sponge bath.

Rationale: High fever, common in bacterial pneumonia and influenza, greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation.

6. Maintain bedrest. Encourage use of relaxation techniques and diversional activities.

Rationale: Prevents exhaustion and reduces oxygen consumption and demands to facilitate resolution of infection.

7. Elevate head and encourage frequent position changes, deep breathing, and effective coughing.

Rationale: These measures promote maximal inspiration and enhance expectoration of secretions to improve ventilation.

8. Assess level of anxiety. Encourage verbalization of concerns and feelings. Answer questions honestly. Visit frequently and arrange for significant other (SO) and visitors to stay

with client as indicated.

Rationale: Anxiety is a manifestation of psychological concerns and physiological responses to hypoxia. Providing reassurance and enhancing sense of security can reduce the psychological

component, thereby decreasing oxygen demand and adverse physiological responses.

9. Observe for deterioration in condition, noting hypotension, copious amounts of pink or bloody sputum, pallor, cyanosis, change in level of consciousness, severe

dyspnea, and restlessness.

Rationale: Shock and pulmonary edema are the most common causes of death in pneumonia and require immediate medical intervention.

Nursing Diagnosis for COPD and Asthma | Impaired Gas Exchange

Nursing diagnosis: impaired gas exchange related to altered oxygen supply—obstruction of airways by secretions, bronchospasm, air-trapping; alveoli destruction.

Possibly evidenced by

Dyspnea

Confusion, restlessness

Inability to move secretions

Abnormal ABGs—hypoxia and hypercapnia

Changes in vital signs

Reduced tolerance for activity

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Gas Exchange

Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within client’s normal range and be free of symptoms of respiratory distress.

Participate in treatment regimen within level of ability and situation.

Nursing care plan intervention with rationale:

1. Assess respiratory rate and depth. Note use of accessory muscles, pursed-lip breathing, and inability to speak or converse.

Rationale: Useful in evaluating the degree of respiratory distress and chronicity of the disease process.

2. Elevate head of bed and assist client to assume position to ease work of breathing. Include periods of time in prone position as tolerated. Encourage deep, slow or pursed-lip breathing as individually needed and tolerated.

Rationale: Oxygen delivery may be improved by upright position and breathing exercises to decrease airway collapse, dyspnea, and work of breathing. Note: Recent research supports use

of prone position to increase PaO2.

3. Assess and routinely monitor skin and mucous membrane color.

Rationale: Cyanosis may be peripheral (noted in nailbeds) or central (noted around lips or earlobes). Duskiness and central cyanosis indicate advanced hypoxemia.

4. Encourage expectoration of sputum; suction when indicated.

Rationale: Thick, tenacious, copious secretions are a major source of impaired gas exchange in small airways. Deep suctioning may be required when cough is ineffective for expectoration

of secretions.

5. Auscultate breath sounds, noting areas of decreased airflow and adventitious sounds.

Rationale: Breath sounds may be faint because of decreased airflow or areas of consolidation. Presence of wheezes may indicate bronchospasm or retained secretions. Scattered, moist crackles may indicate interstitial fluid or cardiac decompensation.

6. Palpate chest for fremitus.

Rationale: Decrease of vibratory tremors suggests fluid collection or airtrapping.

7. Monitor level of consciousness and mental status. Investigate changes.

Rationale: Restlessness and anxiety are common manifestations of hypoxia. Worsening ABGs accompanied by confusion and somnolence are indicative of cerebral dysfunction due to

hypoxemia.

8. Evaluate level of activity tolerance. Provide calm, quiet environment. Limit client’s activity or encourage bedrest or chair rest during acute phase. Have client resume activity gradually and increase as individually tolerated.

Rationale: During severe, acute, or refractory respiratory distress, client may be totally unable to perform basic self-care activities because of hypoxemia and dyspnea. Rest interspersed with

care activities remains an important part of treatment regimen. An exercise program is aimed at improving aerobic capacity and functional performance, increasing endurance and strength without causing severe dyspnea, and can enhance sense of well-being.

9. Evaluate sleep patterns, note reports of difficulties and whether client feels well rested. Provide quiet environment and group care and monitoring activities to allow periods of uninterrupted sleep. Limit stimulants such as caffeine. Encourage position of comfort.

Rationale: Multiple external stimuli and presence of dyspnea and hypoxemia may prevent relaxation and inhibit sleep.

10. Monitor vital signs and cardiac rhythm.

Rationale: Tachycardia, dysrhythmias, and changes in BP can reflect effect of systemic hypoxemia on cardiac function.

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.

Nursing Diagnosis for Heart Failure: Risk for Impaired Gas Exchange

Nursing Diagnosis: Risk for Impaired Gas Exchange related to alveolar-capillary membrane changes such as fluid collection and shifts into interstitial space or alveoli

Possibly evidenced by

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

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Gas Exchange

Demonstrate adequate ventilation and oxygenation of tissues by ABG values and oximetry within client’s normal ranges and be free of symptoms of respiratory distress.

Participate in treatment regimen within level of ability and situation.

Nursing Care Plan Intervention with Rationale:

1. Auscultate breath sounds, noting crackles and wheezes.

Rationale: Reveals presence of pulmonary congestion or collection of secretions, indicating need for further intervention.

2. Instruct client in effective coughing and deep breathing.

Rationale: Clears airways and facilitates oxygen delivery.

3. Encourage frequent position changes.

Rationale: Helps prevent atelectasis and pneumonia.

4. Maintain chair rest and bedrest in a semi-Fowler’s position, with head of bed elevated 20 to 30 degrees. Support arms with pillows.

Rationale: Reduces oxygen consumption and demands and promotes maximal lung inflation.

5. Monitor and graph serial ABG values and pulse oximetry.

Rationale: Hypoxemia can be severe during pulmonary edema. Compensatory changes are usually present in chronic HF.

6. Administer supplemental oxygen, as indicated.

Rationale: Increases alveolar oxygen concentration, which may correct or reduce tissue hypoxemia.

7. Administer medications, as indicated, such as the following: Diuretics, for example, furosemide (Lasix) Bronchodilators, for example, aminophylline

Rationale: Reduce alveolar congestion, enhancing gas exchange. Increase oxygen delivery by dilating small airways and exert mild diuretic effect to aid in reducing pulmonary congestion.

Other possible Nursing Diagnosis for Heart Failure:

Excess Fluid Volume

Activity Intolerance

Risk for Chronic Pain

Decreased Cardiac Output