NURSING DIAGNOSIS: Impaired gas exchange

related to:
  1. decreased pulmonary blood flow associated with a reduction in systemic tissue perfusion resulting from the vasodilation, increased capillary permeability, and selective vasoconstriction that occur in response to release of inflammatory mediators;
  2. loss of effective lung surface associated with:
    1. atelectasis resulting from hypoventilation and the decrease in surfactant production that occurs when blood flow to the lungs is diminished
    2. accumulation of secretions in the lungs resulting from decreased mobility, poor cough effort, and an increased production of secretions if a respiratory tract infection is present
    3. accumulation of fluid in the lungs resulting from the generalized endothelial damage and increase in capillary permeability that occur with a systemic inflammatory response to severe infection.
Desired Outcome
The client will experience adequate O2/CO2 exchange as evidenced by:
  1. usual mental status
  2. unlabored respirations at 12 - 20/minute
  3. oximetry results within normal range
  4. blood gases within normal range.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of impaired gas exchange:
    1. restlessness, irritability
    2. confusion, somnolence
    3. tachypnea, dyspnea
    4. significant decrease in oximetry results
    5. decreased PaO2 and/or increased PaCO2
    6. central cyanosis (a late sign).
  2. Implement measures to improve gas exchange:
    1. perform actions to maintain adequate tissue perfusion (see Diagnosis 1, action b) in order to maintain adequate pulmonary blood flow
    2. place client in a semi- to high Fowler's position unless contraindicated
    3. instruct and assist client to change position, deep breathe, and cough at least every 2 hours
    4. assist with positive airway pressure techniques (e.g. IPPB, continuous positive airway pressure [CPAP], bilevel positive airway pressure [BiPAP], expiratory positive airway pressure [EPAP]) if ordered
    5. maintain activity restrictions as ordered; increase activity gradually as allowed and tolerated
    6. discourage smoking (the irritants in smoke increase mucus production, impair ciliary function, and can damage the bronchial and alveolar walls; the carbon monoxide decreases oxygen availability)
    7. administer antimicrobial agents as ordered to resolve the infectious process and control the systemic inflammatory response.
  3. Consult appropriate health care provider (e.g. respiratory therapist, physician) if signs and symptoms of impaired gas exchange persist or worsen.