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;
loss of effective lung surface associated with:
atelectasis resulting from hypoventilation and the decrease in surfactant production that occurs when blood flow to the lungs is diminished
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
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.
The client will experience adequate O2/CO2 exchange as evidenced by:
usual mental status
unlabored respirations at 12 - 20/minute
oximetry results within normal range
blood gases within normal range.
Nursing Actions and Selected Purposes/Rationales
Assess for and report signs and symptoms of impaired gas exchange:
significant decrease in oximetry results
decreased PaO2 and/or increased PaCO2
central cyanosis (a late sign).
Implement measures to improve gas exchange:
perform actions to maintain adequate tissue perfusion (see Diagnosis 1, action b) in order to maintain adequate pulmonary blood flow
place client in a semi- to high Fowler's position unless contraindicated
instruct and assist client to change position, deep breathe, and cough at least every 2 hours