Impaired Gas Exchange

5 Impaired Gas Exchange Nursing Care Plans

Impaired Gas Exchange NCLEX Review Care Plans

5 Nursing Care Plans on Impaired Gas Exchange

Impaired Gas Exchange is a NANDA nursing diagnosis that is used for conditions where there is an alteration in the balance between the exchange of gases in the lungs.

The process of gas exchange, called diffusion, happens between the alveoli and the pulmonary capillaries. Oxygen and carbon dioxide are exchanged across the alveolar-capillary barrier in a passive manner, depending on both gases’ concentrations.

The differences in gas concentration are balanced by both the perfusion or blood flow in the pulmonary capillaries and the ventilation or the airflow in the alveoli. When ventilation occurs but perfusion fails, the imbalance and impairment of gas exchange occur.

Signs and Symptoms of Impaired Gas Exchange

  • Nasal flaring
  • Dyspnea or difficulty of breathing
  • Headache that occurs upon waking up
  • Skin pallor
  • Diaphoresis or too much sweating
  • Visual disturbances
  • Abnormal arterial blood gases (ABG) results – hypoxia and/or hypercapnia
  • Low saturation levels
  • Abnormal respiratory rate, depth, and rhythm
  • Restlessness and irritability
  • Cyanosis – bluish discoloration of the skin especially in neonates
  • Tachycardia
  • Somnolence

Causes and Risk Factors of Impaired Gas Exchange

  • Medical conditions that involve the collapse or alteration in the alveoli – including pneumonia, acute respiratory distress syndrome (ARDS), and pulmonary edema
  • Living in high altitudes
  • Medical conditions that cause reduced hemoglobin levels – including bleeding disorders, lung cancer, and ongoing chemotherapy for cancer
  • Age – the total pulmonary blood flow in older people is lower than younger ones
  • Obesity – excessive fat mass affects lung function and increases the risk for hypoxia
  • Smoking
  • Prolonged immobility – as in trauma patients and those with neuromuscular disorders
  • Patients who have undergone chest or upper abdominal surgery

Nursing Care Plans for Impaired Gas Exchange

Nursing Care Plan 1

Emphysema

Nursing Diagnosis: Impaired Gas Exchange related to altered oxygen supply secondary to emphysema as evidenced by shortness of breath, wheeze upon auscultation, phlegm, oxygen saturation of 82%, restlessness, and reduced activity tolerance

Desired Outcome: The patient will demonstrate adequate oxygenation as evidenced by reaching the prescribed target oxygen saturation levels.

InterventionsRationales
Assess the patient’s vital signs, especially the respiratory rate and depth. Auscultate the lungs and monitor for wheezing or other abnormal breath sounds.To create a baseline set of observations for the emphysema patient, and to monitor any changes in the vital signs as the patient receives medical treatment.
Monitor the color of skin and mucous membrane.Peripheral cyanosis (bluish discoloration of the skin, ear lobes, or nail beds) may be evident with hypoxemia. Central cyanosis involving the mucosa may indicate further reduction of oxygen levels.
Encourage the patient to cough to expectorate thick sputum. Suction as needed.Impaired small airways experience impaired gas exchange primarily due to thick, tenacious mucoid secretions. The patient may be unable to cough the phlegm, therefore deep suctioning may be required.
Provide humidified oxygen as prescribed.To reduce the risk of drying out the lungs.
Reposition the patient by elevating the head of the bed and encouraging him/her to sit on an upright position. Encourage pursed lip breathing and deep breathing exercises.To improve the delivery of oxygen in the airways and to reduce shortness of breath and risk for airway collapse.
Refer the patient to a chest physiotherapist.To enable to patient to receive more information and specialized care in the removal of thick lung secretions and enabling of improved gas exchange.

Nursing Care Plan 2

Congestive Heart Failure

Nursing Diagnosis: Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures secondary to CHF as evidenced by shortness of breath, SpO2 level of 85%, abnormal ABG results and crackles upon auscultation.

Desired Outcome: The patient will have improved oxygenation and will not show any signs of respiratory distress.

InterventionsRationales
Assess the patient’s vital signs and characteristics of respirations at least every 4 hours.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment.
Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.To increase the oxygen level and achieve an SpO2 value within the target range.
Administer medications as prescribed.Diuretics are prescribed to reduce the alveolar congestion. Bronchodilators increase the delivery of oxygen by means of improving the dilation of small airways.
Encourage small but frequent meals.  To avoid abdominal distention and diaphragm elevation which can lead to a decrease in lung capacity.
Elevate the head of the bed to 20 – 30 degrees. Assist the patient to assume semi-Fowler’s position.Head elevation and semi-Fowler’s position help improve the expansion of the lungs, enabling the patient to breathe more effectively.

Nursing Care Plan 3

Acute Respiratory Distress Syndrome (ARDS)

Nursing Diagnosis: Impaired Gas Exchange related to chest trauma secondary to ARDS as evidenced by shortness of breath, fast and labored breathing, cyanosis of skin, rapid pulse, oxygen saturation of 78%, restlessness, and reduced activity tolerance

Desired Outcome: The patient will demonstrate adequate oxygenation as evidenced by an oxygen saturation within the target range set by the physician as well as normalized ABG levels.

InterventionsRationales
Assess the patient’s vital signs, especially the respiratory rate and depth. Auscultate the lungs and monitor for wheezing or other abnormal breath sounds.To create a baseline set of observations for the ARDS patient, and to monitor any changes in the vital signs as the patient receives medical treatment.
Monitor the color of skin and mucous membrane.Peripheral cyanosis (bluish discoloration of the skin, ear lobes, or nail beds) may be evident with hypoxemia. Central cyanosis involving the mucosa may indicate further reduction of oxygen levels.
Monitor blood chemistry and arterial blood gases (ABG levels).Respiratory acidosis and hypoxemia are evidenced by increasing PaCO2 and decreasing PaO2. Decreasing oxygen saturation levels mean hypoxia.
Assist the physician to initiate intubation and mechanical ventilation of the patient, if required.To maintain adequate oxygen supply by delivering proper ventilation and oxygenation while allowing the lungs to heal.
Reposition the patient by elevating the head of the bed and encouraging him/her to sit on an upright position. Encourage pursed lip breathing and deep breathing exercises.To improve the delivery of oxygen in the airways and to reduce shortness of breath and risk for airway collapse.
Refer the patient to a chest physiotherapist.To enable to patient to receive more information and specialized care in the removal of thick lung secretions and enabling of improved gas exchange.

Nursing Care Plan 4

Pneumonia

Nursing Diagnosis: Impaired Gas Exchange related to pus and fluid-filled alveoli secondary to pneumonia as evidenced by shortness of breath, skin pallor, cyanosis, wheeze upon auscultation, phlegm, oxygen saturation of 80%, hypotension, tachycardia, restlessness, and reduced activity tolerance

Desired Outcome: The patient will demonstrate adequate oxygenation as evidenced by reaching the prescribed target oxygen saturation and ABG levels.

InterventionsRationales
Assess the patient’s vital signs, especially the respiratory rate and depth. Auscultate the lungs and monitor for wheezing or other abnormal breath sounds.To create a baseline set of observations for the emphysema patient, and to monitor any changes in the vital signs as the patient receives medical treatment.
Monitor the color of skin and mucous membrane.Peripheral cyanosis (bluish discoloration of the skin, ear lobes, or nail beds) may be evident with hypoxemia. Central cyanosis involving the mucosa may indicate further reduction of oxygen levels.
Administer the prescribed antibiotics for bacterial pneumonia.To treat the underlying cause of the exudate-filled alveoli and inflammation in the lungs.
Encourage the patient to cough to expectorate phlegm. Suction as needed.Impaired small airways experience impaired gas exchange primarily due to thick, tenacious mucoid secretions. The patient may be unable to cough the phlegm, therefore deep suctioning may be required.
Monitor body temperature. Administer anti-pyretics as prescribed for high fever.High fever in pneumonia poses a risk for higher metabolic demands, alteration in cellular oxygenation, and higher oxygen consumption. Anti-pyretic drugs aim to reduce the body’s temperature levels.
Provide humidified oxygen as prescribed.To reduce the risk of drying out the lungs.
Reposition the patient by elevating the head of the bed and encouraging him/her to sit on an upright position. Encourage pursed lip breathing and deep breathing exercises.To improve the delivery of oxygen in the airways and to reduce shortness of breath and risk for airway collapse.
Monitor the oxygen saturation levels and blood gas (ABG) results.Respiratory acidosis and hypoxemia are evidenced by increasing PaCO2 and decreasing PaO2. Decreasing oxygen saturation levels mean hypoxia.

Nursing Care Plan 5

Lung Cancer

Nursing Diagnosis: Impaired Gas Exchange related to altered oxygen supply secondary to lung cancer as evidenced by shortness of breath, wheeze upon auscultation, hypercapnia, cyanosis of the lips, oxygen saturation of 80%, restlessness, and changes in mentation 

Desired Outcome: The patient will demonstrate adequate oxygenation as evidenced by improved arterial blood gases (ABG) results.

InterventionsRationales
Assess the patient’s vital signs, especially the respiratory rate and depth.To create a baseline set of observations for the emphysema patient, and to monitor any changes in the vital signs as the patient receives medical treatment.
Auscultate the lungs and monitor for abnormal breath sounds.Lung cancer patients who have undergone respiratory surgical procedures may show a difference in breath sounds upon auscultation: Post-pneumonectomy – the operative side will show lack of air movement and consolidationPost-lobectomy – the remaining lobes will demonstrate normal airflow
Monitor the patient’s level of consciousness and changes in mentation.Post-pneumonectomy patients with tachypnea, tracheal deviation, and/or tachycardia may be experiencing mediastinal shift or severe hypoxia after the surgery.
Monitor the blood gas (ABG) results.Respiratory acidosis and hypoxemia are evidenced by increasing PaCO2 and decreasing PaO2.
Monitor the color of skin and mucous membrane.Peripheral cyanosis (bluish discoloration of the skin, ear lobes, or nail beds) may be evident with hypoxemia. Central cyanosis involving the mucosa may indicate further reduction of oxygen levels.
Encourage the patient to cough to expectorate any sputum. Suction as needed.Impaired small airways experience impaired gas exchange primarily due to thick, tenacious mucoid secretions. The patient may be unable to cough the phlegm, therefore deep suctioning may be required.
Provide humidified oxygen as prescribed.To reduce the risk of drying out the lungs.
Reposition the patient by elevating the head of the bed and encouraging him/her to sit on an upright sitting position or side-lying positions. Encourage pursed lip breathing and deep breathing exercises.To improve the delivery of oxygen in the airways and to reduce shortness of breath and risk for airway collapse. Ventilation is improved if the airway remains patent through frequent positioning. Lung expansion is also achieved in doing these nursing interventions. Pursed lip breathing and deep breathing exercises also prevents atelectasis or lung collapse.
For post-pneumonectomy patients, position the patient with “good lung down”, which means positioning on the non-operative side. Never position him/her on the operative side.Good lung down position helps the patient achieve maximum oxygenation and enhanced blood flow to the remaining lung.
Monitor the chest drainage system of post-lobectomy or lung resection patient.Effective chest drainage helps the remaining lung segments to re-expand successfully.
Refer the patient to a chest physiotherapist.To enable to patient to receive more information and specialized care in enabling of improved gas exchange.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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