Administer the prescribed antibiotics for bacterial pneumonia. To improve the delivery of oxygen in the airways and to reduce shortness of breath and risk for airway collapse. Herdman, T., Kamitsuru, S. & Lopes, C. (2021). This website provides entertainment value only, not medical advice or nursing protocols. Altered Vital signs. acute respiratory distress syndrome (ARDS), Hydronephrosis Nursing Diagnosis and Care Plan, Psychosocial Nursing Diagnosis and Nursing Care Plan, Abnormal arterial blood gases (ABG) results hypoxia and/or hypercapnia, Abnormal respiratory rate, depth, and rhythm, Cyanosis bluish discoloration of the skin especially in neonates, Medical conditions that involve the collapse or alteration in the alveoli including, Medical conditions that cause reduced hemoglobin levels including bleeding disorders, lung cancer, and ongoing chemotherapy for, Age the total pulmonary blood flow in older people is lower than younger ones, Prolonged immobility as in trauma patients and those with neuromuscular disorders, Patients who have undergone chest or upper abdominal surgery. Nursing Diagnosis: Impaired gas exchange related to ventilation perfusion imbalance secondary to hypovolemic shock as evidenced by cyanosis, heart rate 162 bpm, and oxygen saturation 76%. This can be due to a compromised respiratory system or due to [] Because some food may cause patient to retain more fluid than others. Impaired gas exchange Increased work of breathing Increased airway resistance Alveolar hyperplasia . Lab values and vital signs can also point to potential impaired gas exchange. 3 part Actual Problem It is vital to monitor patients admitted with congestive heart failure closely. Having certain other health conditions is also associated with a poorer COPD outlook. Some mechanisms behind impaired gas exchange in COPD can include one or a combination of the following: When gas exchange is impaired, you cannot effectively get enough oxygen or rid your body of carbon dioxide. 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. Learn more. -Pts ABGs will be within normal limits with 24 hours of hospital stay.-Pt will be verbalize the understanding of smoking cessation and how it relates to COPD. (Symptoms) Verbalizes difficulty breathing Complains of feeling fatigued Reports a long history of tobacco use Reports having a cold for several weeks Objective Data: assessment, diagnostic tests, and lab values. For post-pneumonectomy patients, position the patient with good lung down, which means positioning on the non-operative side. This can result in hypoventilation and stasis of secretions with subsequent impaired gas exchange, Prevent complications such as collapsed airway, Provide information about disease/prognosis, therapy needs, and prevention of recurrences, 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, 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. Our experts continually monitor the health and wellness space, and we update our articles when new information becomes available. 2. SUPPORTING Respiratory acidosis and hypoxemia are evidenced by increasing PaCO2 and decreasing PaO2. All rights reserved. -The nurse will teach the patient 3 signs and symptoms that indicate PCO2 level may be high and when to contact her md. Provide reassurance and assess for increased. (2011). Reports of sudden extreme dyspnea/air hunger, Head and bed elevation 20-30 degrees, semi-Fowlers position to reduce oxygen consumption and to promote maximal lung inflation, Engaging client in therapy regimen as it may enhance sense of control and cooperation with restrictions, Gradual increase in activity as allowed and tolerated. This book continues to stand out in the field for its strategic approach, solid research base, comprehensive range of topics, even-handed examination of oral and written channels, and focus on managerial, not entry-level, competencies. If you would like to change your settings or withdraw consent at any time, the link to do so is in our privacy policy accessible from our home page.. The patient is excessively sleepy and falls asleep easily even with stimuli. 2. COPD is a group of lung conditions that make it hard to breathe. What are nursing care plans? Lab and Diagnostic work shows: WBC 30,000 and chest x-ray preliminary results show possible bilateral lower lobe pneumonia. To increase the oxygen level and achieve an SpO2 value within the target range. To improve the delivery of oxygen in the airways and to reduce shortness of breath and risk for airway collapse. 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. Oxygenation and ventilation may need to be supported mechanically. Acute exacerbations of this chronic condition can also be very common especially if an individual is not following or is unaware of the appropriate guidelines and recommendations. Buy on Amazon. Assess the patients vital signs, especially the respiratory rate and depth. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. Objectives:Noninvasive assessment of pulmonary gas exchange in preterm infants with and without bronchopulmonary dysplasia to grade disease severity and to identify determinants of impaired gas exchange. ASSESSEMENT What are the risk factors for developing impaired gas exchange and COPD? The patient is excessively sleepy and falls asleep easily even with stimuli. Pahal P, et al. In addition to her hospital and trauma center experience, Shelly has also worked in post-acute, long-term, and outpatient settings. Hypoxemia and impaired CO 2 clearance are characteristics of acute respiratory distress syndrome (ARDS) (1-3).Abundant literature has explored the mechanisms of gas exchange abnormalities in ARDS. ABGs were collected and the patients pCO2 74, pH 7.24, P02 55, HCO3 33.2. All vital signs To increase oxygen saturation 92% prior to transfer from ED and admission to hospital floor unit, To decrease excess fluid by 10 pounds by discharge to return patient to baseline dry weight. The formatting isnt always important, and care plan formatting may vary among different nursing schools or medical jobs. Etiology The most common cause for this condition is poor oxygen levels. To view the purposes they believe they have legitimate interest for, or to object to this data processing use the vendor list link below. Respiratory System Crackles in all lung fields Diminished Impaired gas exchange related to smoking as evidenced by dyspnea, crackles all lung fields, and oxygen . Nursing Diagnosis: Impaired gas exchange related to altered oxygen-carrying capacity of blood secondary to sickle cell anemia as evidenced by irritability, dusky skin color, and oxygen saturation 84%. Smoking when you have COPD can make your condition worse and can contribute to an increased impairment in gas exchange. AEB: -Pt will be provided with a CPAP machine to take home that meets her expectations. optimal chest 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. Lung disease can lead to severe abnormalities in blood gas composition.Because of the differences in oxygen and carbon dioxide transport, impaired oxygen exchange is far more common than impaired carbon dioxide exchange. Desired Outcome: The patient will demonstrate adequate oxygenation as evidenced by reaching the prescribed target oxygen saturation and ABG levels. The free nursing care plan example below includes the following conditions: Ineffective Gas Exchange, Ineffective Airway Clearance, Pneumonia, COPD, Emphysema, & Common Cold. Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. The patient has labored, tachypneic, breathing. The following diagnoses are usually made when caring for patients with pneumonia: Impaired gas exchange Ineffective airway clearance Ineffective breathing pattern Knowledge deficit/Deficient knowledge Activity intolerance Risk for infection Risk for nutritional imbalance: less than body requirements are impacted by decreased Suction as needed. Decreased cardiac output related to altered contractility as evidenced by tachycardia, hypertension, orthopnea, edema, abnormal lab work, and reduced EF. Effective chest drainage helps the remaining lung segments to re-expand successfully. Pt family member tells you that the patient has been sleeping constantly for 2 weeks. The last echocardiogram in the patients chart (completed 3 months prior) showed an Ejection Fraction (EF) of 40%. NY Times Paywall - Case Analysis with questions and their answers. Desired Outcome: Within 2 hours of nursing interventions, the patient will demonstrate improved gas exchange as evidenced by heart rate and oxygen saturation within normal range. If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. In some individuals, such as those with chronic obstructive pulmonary disease (COPD), gas exchange can become impaired. Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. At the same time as oxygen is moving into the blood, carbon dioxide moves from the blood into the alveoli. Copyright 2022 SimpleNursing.com. Kent BD, et al. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. Hemodynamic Monitoring (Normal Values| Purpose|Hemodynamic Instability), Sample Nursing Care Plan for Preeclampsia |scenario|NCP with rationales, 19 NANDA Nursing Diagnosis for Fracture |Nursing Priorities & Management, 25 NANDA Nursing Diagnosis for Breast Cancer, 5 Stages of Bone Healing Process |Fracture classification |5 Ps, 9 NANDA nursing diagnosis for Cellulitis |Management |Patho |Pt education, 20 NANDA nursing diagnosis for Chronic Kidney Disease (CKD), Administer supplemental oxygen therapy with continuous oxygen saturation monitoring, Supplemental oxygen will increase alveolar oxygen concentration, Rest will reduce the bodys oxygen demands and consumption, Position patient into Semi-Fowlers position, Positioning will allow for maximal lung expansion and inflation, Administer medications as ordered (diuretics), Diuretics will pull off excess fluid within the body thereby reducing congestion, The fluid restriction will prevent additional fluid accumulation, I&O monitoring will allow for assessment of progress made with the administration of diuretics and fluid restriction, Oxygen therapy will increase the available oxygen in the body for the myocardium and correct hypoxia, Administer antihypertensive medication as ordered, Antihypertensive medications will reduce the patients elevated blood pressure thereby reducing the additional stress on the heart, Administer medications as ordered (diuretics, ACE, and ARBs), Diuretics will decrease excess fluid and stress on the cardiac muscle, I&O should be monitored closely to successfully and accurately record the progress of treatment, Maintain chair/bedrest in semi-Fowlers position. The main assessment findings the nurse should be aware of for this patient begin with his vital signs, all of which are listed are abnormal. Breath sounds can help determine or confirm the cause of impaired gas exchange. impaired Gas Exchange may be related to decreased oxygen-carrying capacity of blood, reduced RBC life span, abnormal RBC structure, increased blood viscosity, predisposition to bacterial pneumonia/pulmonary infarcts, possibly evidenced by dyspnea, use of accessory muscles, cyanosis/signs of hypoxia, tachycardia, changes in mentation, and . 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. Skidmore-Roth Publications. MAKE A CHANGE IN THE Nursing care plans: Diagnoses, interventions, & outcomes. All Rights Reserved. Manage Settings Objective/Goal: To improve gas exchange . Suction as needed. When collecting primary subjective data, which is an appropriate source for the nurse to use? RECOGNIZE CUES He is also now using 3 pillows to sleep at night instead of his usual 1 pillow, and he has experienced a 10-pound weight gain in 3 days. Increased breathing effort is a sign of hypoxia. Congestive heart failure is a chronic condition that can progress over time. This is Subjective Data: 1. This is referred to as Impaired Gas Exchange. NURSING DIAGNOSIS Objective and subjective data collection Vitals: R-54, H-128, T-37.4 (axillary), BP-91/64, MAP-62, O 2-94% Other objective data: Wt 9.6 kg, Ht 76.5 cm, apical strong and regular, nail beds pink . To limit activity to decrease oxygen demand while also increasing oxygen supply. During this process, oxygen enters the bloodstream while carbon dioxide is removed. Impaired gas exchange in COPD can cause symptoms like shortness of breath, coughing, and fatigue. Participants expire into a GaSampler test kit (QuinTron, Milwaukee, WI [QT] 00892,) and 30cc of breath will be extracted from the sample holding bag with a leur-lock syringe (QT02741) with 1-way stopcock (QT01727-V). On assessment, patients skin feels hot to touch despite the patient stating she feels chilled. These conditions are progressive, which means that they can get worse over time. Please read our disclaimer. Ineffective gas exchange related to thick secretions as evidence by O2 saturation of 87% on room air, complaints of shortness of breath, and coughing up greenish to brown sputum. When you breathe out, the lungs deflate, pushing carbon dioxide up through your airways where it exits your body through your nose and mouth. As an Amazon Associate I earn from qualifying purchases. Patient exhibited dyspnea on ambulation from stretcher to bed. Assist the physician to initiate intubation and mechanical ventilation of the patient, if required. Collect client history, including risk factors and symptoms (objective and subjective data), Client is recovering from a bypass surgery 3 days ago and is currently admitted in the ICU. Objective data: >wheezing upon inspiration and expiration >Acute shortness of breath >dyspnea . Your lungs are vital for providing your body with fresh oxygen while ridding it of carbon dioxide. To avoid abdominal distention and diaphragm elevation which can lead to a decrease in lung capacity. years, immobility, Ongoing ASSESSMENTS: (verbs He has a known history of hypertension and heart failure. Early intervention is recommended to prevent total decompensation.