Risk for Impaired Gas Exchange

risk for impaired gas exchange care note

Introduction/Pathophysiology [1,2]

Presence of pulmonary congestion, pulmonary edema and collection of secretions can all result in impaired gas exchange. Impaired gas exchange occurs due to alveolar-capillary membrane changes, such as fluid shifts and fluid collection into interstitial space and alveoli. This leads to excess or deficit of oxygen at the alveolar capillary membrane with impaired carbon dioxide elimination. Often, metabolic compensatory changes occur, however during pulmonary edema, hypoxemia can be severe and may require immediate interventions. Early recognition of signs and symptoms of impaired gas exchange allows for prompt intervention. Using the nursing risk for impaired gas exchange care note can help alleviate clients’ symptoms of impaired gas exchange and prevent life-threatening complications.

Causes[1,2]

  • Heart failure
  • Pulmonary edema
  • Pulmonary congestion
  • COPD
  • Smoking
  • Fibrosis

Symptoms[1,2]

Subjective (client may report)

  • shortness of breath
  • difficulty breathing
  • headache upon awakening

Objective[1,2]: 

  • decreased CO2
  • tachycardia
  • hypercapnia
  • restlessness
  • somnolence
  • irritability
  • confusion
  • hypoxia
  • dyspnea
  • cyanosis (neonates only)
  • abnormal arterial blood gases
  • abnormal skin color-pale, dusky
  • abnormal heart rate and rhythm
  • changes in depth of breathing
  • diaphoresis
  • nasal flaring
  • low partial pressure of oxygen in arterial blood
  • low pulse oximetry

Risk factors[1,2]:

  • Heart failure
  • Infections
  • Ventilation and perfusion imbalance
  • Asthma
  • COPD
  • Emphysema
  • Neuromuscular conditions that cause fixation or weakening of the diaphragm

Intervention[1]

Assessment[1,2]

Collect client history, including risk factors and symptoms (objective and subjective data)

Cardiac Function:

  • Blood pressure
  • Heart rate

Respiratory function

  • Shortness of breath
  • Cough
  • Pulmonary x-ray
  • Increased sputum production

Neurologic/Sensory function

  • Altered mental status
  • Irritability
  • Restlessness
  • Somnolence

Visual appearance/labs

  • Skin color
  • Oximetry
  • Acid-base labs

Impaired Gas exchange Nursing Diagnosis[1,2]

Assessment of impaired gas exchange

  • Assess pulse oximetry
  • Assess cardiac function such as blood pressure and heart rate
  • Asses arterial blood gasses
  • Assess electrolytes blood pH
  • Assess use of central nervous system depressants
  • Inspect dependent body areas for edema with and without pitting
    • Pitting edema is generally obvious only after 10lbs weight gain

Rationale: 

  • Pulmonary edema may develop more rapidly, and immediate intervention is necessary
  • Use of central nervous system depressants may cause depression of respiratory center and cough reflex. This can result in hypoventilation and stasis of secretions with subsequent impaired gas exchange

Planning[1,2]

  • Prevent complications such as collapsed airway
  • Provide information about disease/prognosis, therapy needs, and prevention of recurrences
  • Client education

Risk for impaired gas exchange care note

Perform:

  • Auscultate breath sounds, noting crackles and wheezes
  • Measures to facilitate removal of pulmonary secretions such as suction, postural drainage, percussion and vibration
  • Consultation with appropriate health care providers if signs and symptoms worsen

Provide:

  • Instructions on copying such as effective coughing, deep breathing
    • Diaphragmatic breathing technique to promote greater movement of the diaphragm and decreased use of accessory muscles
    • pursed lip-breathing technique to cause mild resistance to exhalation, which creates positive pressure in airways. This can prevent airway collapse
  • Pillows to support elevated position and support for arms
  • Chest Physiotherapy
  • Supportive therapy to decrease chest and abdominal discomfort and pain if present
  • Assistance with positive airway pressure techniques-CPAP, BiPAP, PEP device
  • Support to decrease fear and anxiety
    • Assure breathing deeply will not dislodge tubes or cause wound opening

Administer:

  • Supplemental oxygen as indicated
  • Diuretics, bronchodilators, antibiotics, steroids, pain medications, anticoagulants

Monitor:

  • ABG’s
  • Blood pH
  • Pulse oximetry
    • In clients with abnormal cardiac index, research suggests pulse oximeter measurements may exceed actual oxygen saturation by up to 7%.
  • Reports of sudden extreme dyspnea/air hunger
  • Cognitive level
  • Blood pressure
  • Chest X-ray
  • WBC

Encourage:

  • Frequent position changes
    • Helps prevent atelectasis and pneumonia
    • Mobilized secretions
    • Aids lung expansion
  • Head and bed elevation 20-30 degrees, semi-Fowler’s position to reduce oxygen consumption and to promote maximal lung inflation
  • Use of spirometry every 1 to 2 hours
  • Engaging client in therapy regimen as it may enhance sense of control and cooperation with restrictions
  • Client to discontinue smoking
  • Gradual increase in activity as allowed and tolerated

Goals and Outcomes[1,2]

  • Client demonstrates adequate ventilation and oxygenation of tissue evidenced by ABGs and oximetry.
  • Client is free of symptoms of respiratory distress
  • Clients oximetry is within normal range
  • Client participates in treatment regimen within level of ability and situation
  • stabilized fluid volume with balanced intake and output
  • Breath sounds are clear
  • Vital signs within acceptable range

Post intervention evaluation/monitoring [1]

Monitor[1,2]

  • Cardiac rate and BP
  • ABGs
  • Oximetry
  • Unlabored respirations at 12-20 breaths/min
  • Electrolytes: sudden fluid shifts may lead to sodium and potassium imbalance/deficiency
  • Mental status

Future goals [1]

  • Absence of dyspnea
  • Normal depth and rate of respiration
  • Initiate supportive medication therapy
  • maintain healthy diet and weight goal

Prevention[1,2]

  • Discourage smoking
  • Adherence to medications

Supplemental material

Client case

Client is recovering from a bypass surgery 3 days ago and is currently admitted in the ICU. Client mentions that he is starting to experience shortness of breath and has a hard time taking a deep breath Client states he feels lightheaded while in bed and has a constant headache. Client has history of MI x 2, dyslipidemia and asthma

Questions: 

Based on the client case, what are the symptoms predictive of excess fluid volume?

Answer: SOB, difficulty breathing, lightheadedness, headache

When treating clients with impaired gas exchange, providers should avoid administration of:

  1. diuretics
  2. central nervous system depressants
  3. steroids
  4. anticoagulants

Preferred bed position to support lung function in clients with impaired gas exchange is

  1. legs elevated
  2. head and neck elevated 20-30 degrees
  3. arms supported
  4. prone position
  5. a and b
  6. b and c
  7. c and d

Clients with impaired gas exchange are at risk of

  1. Pulmonary edema
  2. Pulmonary congestion
  3. Altered mental status
  4. Increased heart rate
  5. All of the above

List at least 3 tips for preventing impaired gas exchange

  1. Stop smoking
  2. Promote cough and sputum clearing
  3. Engage in diaphragmatic and pursed lip breathing techniques
  4. Use medications as instructed
  5. Change bed positions often

References:

  1. Doenges, Marilynn E., et al. Nursing Care Plans: Guidelines for Individualizing Client Care. F.A. Davis, 2006.
  2. Haugen, Nancy, et al. Ulrich & Canale’s Nursing Care Planning Guides: Prioritization, Delegation, and Critical Reasoning. Elsevier, 2020.