impaired gas exchange

Megan Kassel
Med/Surg Nursing Diagnosis: Impaired gas exchange r/t ventilation-perfusion imbalance aeb oxygen saturation of 91%
Long-Term Goal: Patient will maintain optimal gas exchange.
Outcome Criteria
One outcome criteria for each intervention. Number each one.
Interventions
Label each as assess/monitor/independent/ dependent/teaching/collaboration Rationale
Answers why, how, what your interventions will help solve, prevent,
Or lesson the stated problem specific to each patient.
Evaluation
Evaluate the patient outcome, NOT the intervention
1. Pt’s lung sounds will be clear to auscultation as assessed q4h.
1. Ind: Auscultate lung sounds q4h
1. This patient has COPD, with a 50 pack year smoking history. She no longer smokes, but the effects of COPD are still present. Cigarette smoking has an irritating effect on the cells causing hyperplasia (increase in proliferation), including the goblet cells; which results in an increased production of mucus. This hyperplasia reduces the airway diameter and increases the difficulty in clearing these secretions. Smoking also produces abnormal dilation of the distal air space with destruction of the alveolar walls. Auscultation aids in assessing the movement of air through the tracheobronchial tree, and detects mucus or obstructed airways. Wheezing or decreased breath sounds are usually present in this disease. Also if mucus production is increased, crackles or rhonchi might be evident, because of the inability to bring up secretions effectively. In this patient decreased breath sounds in the bases was noted on auscultation, and on admission she had crackles. Auscultating the lung fields is important in assessing for worsening of gas exchange, so interventions can be implemented to improve gas exchange (respiratory therapy, O2, CPT, CXR). P&P, Lewis
1. M; Pt’s lung sounds were clear to auscultation as monitored q4h, with decreased sounds in the bases.
2. Pt’s HR will remain between 60-100 bpm, BP between 120-139/80-89 mm Hg, RR between 12-20 breaths/min, O2 sat 95-100% as assessed q4h.
2.Ind: Monitor VS q8h
2. Gas exchange abnormalities result in hypoxemia and hypercapnia as the disease worsens. Initially BP, HR, and RR increase in the presence of hypoxia and hypercapnia. As they become severe, BP and HR decrease, and dysrhythmias may occur. Respiratory failure may follow when the patient is unable to maintain a rapid RR. Increasing PaCO2, and decreasing PaO2 are also signs of respiratory failure. COPD causes a significant decrease lung volume. Hypoxia is something that we want to reverse as soon as possible, so it doesn’t become more severe and lead to tissue damage. Monitoring VS is important to catch early signs. Lewis, NCP
2. P; Pt’s VS on 11/21 were: Pulse 58, BP 142/60, RR 16, O2 98% on 3L.

3. Pt will remain alert and oriented as monitored q4h.

3. Ind: Monitor for changes in LOC q4h

3. A change in LOC; such as unexplained apprehension, restlessness/irritability, and confusion/lethargy; as early signs of inadequate oxygenation. Late signs are unexplained confusion/lethargy, combativeness, and coma. Catching the early signs of change in LOC is imperative in preventing permanent brain damage from decreased oxygen to the brain. This occurs when oxygen saturation is decreased; maintaining an oxygen saturation above 95% ensures this. Lewis

3. M; pt remained alert and oriented to person, place, time, and situation as monitored q4h, indicating adequate gas exchange.
4. Pt’s skin will be warm and pink, nail beds and mucus membranes will be free from cyanosis as assessed q4h.
4. Ind: Assess skin, nail beds, and mucus membranes q4h
4. As oxygenation is impaired, perfusion becomes impaired, due to the decreased oxygen in the blood. This leads to peripheral tissue becoming cyanotic (blue discoloration from desaturated Hgb in capillaries). The skin also becomes cool and clammy. Central cyanosis (tongue, soft palate, and conjunctiva), and peripheral cyanosis (extremities, nail beds, and ear lobes), are late signs of hypoxia. This pt has a decreased O2 saturation on RA indicating decreased gas exchange that could cause this cyanosis. P&P, Lewis
4. M; pt’s skin was warm and pink, and nail beds and m.m. free from cyanosis as assessed q4h.
5. Pt will show no labored breathing and O2 sat >95% with HOB at least 30 degrees while supine
5. Ind: Maintain HOB at 30 degrees while supine throughout hospital stay.
5. Maintaining the HOB at least at 30 degrees up to 45 degrees facilitates breathing by maintain abdominal organs away from the diaphragm. This allows for better contraction and expansion of diaphragm allowing for better lung expansion leading to increase in alveolar gas exchange. This helps decrease the work of breathing to maintain better oxygen exchange. 102 class notes
5. P; Pt displayed some labored breathing in afternoon with bed at 30 degrees, O2 sat at 97% on 3L
6. Pt will use incentive spirometer to expand lungs qh while awake.
6. Ind: Encourage use of incentive spirometer qh while awake
6. The use of an incentive spirometer encourages voluntary deep breathing, while also providing visual feedback to the pt. Through slow inhalation the lungs are able to maximally inflate and sustain inflation in all lobes of the lungs promoting gas exchange. Ensuring the patient is using the device correctly is important to get the full effect. This patient would benefit from this because of the increased time lying in bed to prevent atelectasis and improve gas exchange.
6. U; Pt did not use incentive spirometer throughout the day.
7. Pt will complete ADL’s without worsening SOB and fatigue as monitored qshift.
7. Ind: Pace care and ADL’s qshift.
7. A pt’s ADL’s (bathing, toileting, ambulating), increase the amount of oxygen consumption. Planning to go at a slower pace to not overwork the pt is important so there oxygen saturation doesn’t decrease to a dangerous level, (<95%). The pt should also know to continue this while at home to avoid becoming hypoxic. The use of oxygen in this pt while completing ADL’s will help keep oxygen saturation at an acceptable level.
7. M; pt completed ADL’s without worsening SOB or fatigue as monitored qshift.

8. Pt chest xray will be negative for evidence of impaired gas exchange as assessed per MD order

8. Dep: Obtain order for CXR and assess results per MD order

8. Chest x-rays help reveal etiological factors of impaired gas exchange. This pt’s CXR showed mild pulmonary vascular congestion with mild cardiomegaly, no infiltrate, and hyperinflation. The absence of a pulmonary infiltrate shows there isn’t any abnormal fluid in the lungs which would mean the pt might have pneumonia. But there was hyperinflation noted, this correlates with the COPD. Air gets trapped in the lungs and they overinflate. As more alveoli become over distended, increasing amount of air gets trapped. Being aware of this hyperinflation aids in helping the doctor and the nurse come up with interventions to help the pt with easier breathing. Nursing interventions such as pursed lip breathing, incentive spirometer, and other breathing exercises can be implemented, because of this knowledge. Lewis

8. U; pt’s CXR showed hyperinflation on admission. A repeat CXR had not been ordered.
9. Pt’s lung sounds will be clear as assessed q4h.
9. Dep: Administer furosemide 20 mg tab PO once a day
9. Furosemide is a loop diuretic, used to mobilize edematous fluids, and reduce blood pressure (decreasing preload). The action of this drug is inhibiting the reabsorption Na and Cl from the loop of Henle and distal tubule. It increases renal excretion of H2O, Na, Cl, Mg, and Ca. The movement of this extra fluids helps decrease both fluid in the lungs and in the extremities. With decreased fluid in the lungs will be better able to expand and increase gas exchange. Davis, Lewis
9. M; pt displayed clear lung sounds as assessed q4h.
10. Pt’s respirations will be easy and unlabored with a rate of 12-20 breaths/min as assessed after dose daily.
10. Dep: Administer Tudorza aerosol powder inhaler q12h
10. Tudorza is an anticholinergic that inhibits the M3 receptors in bronchial smooth muscle. The therapeutic effect of this drug is bronchodilation with lessened symptoms of COPD. This is not for acute use but for long term maintenance. Pt is on Spiriva at home this is also an anticholinergic. This improves lung function, improves quality of life, and decreases number of exacerbations and hospitalizations. Having this maintenance drug is important in the management of COPD. Davis, Lewis
10. P; pt had some labored breathing in afternoon, with a respiratory rate of 16 breaths/min.
11. Pt will display no wheezing or SOB as monitored after each dose PRN.
11. Dep: Administer Xopnex nebulizer for SOB or wheezing PRN
11. Xopnex is a bronchodilator used as a short term control of bronchospasm. This drug is relatively selective for beta-2 (pulmonary receptors). This bronchodilator is used prn when the pt experiences severe SOB or wheezing to help open up the airways to keep oxygen saturation up and prevent obstruction. Having both a long term and short acting drug to prevent bronchospasm is important in the COPD pt. Davis
11. M; pt was without any worsening of SOB or wheezing as assessed q4h.

12. Pt’s BNP will be less than 100 pg/mL by discharge.

12. Dep: Obtain order for BNP and monitor results per MD order

12. Dyspnea is a sign in both COPD and HF. With COPD dyspnea is progressive and usually occurs with exertion, and is present every day. And in the late stages pt’s can experience dyspnea even at rest. Similar to HF, dyspnea can occur with mild exertion or at rest. Small amounts of BNP are stored within the granules in the ventricles. The release of BNP is triggered by increased pressure (especially the left ventricle). BNP levels have shown to be significantly increased in HF. Obtaining a BNP can help distinguish whether the dyspnea is a respiratory or a cardiac cause. If the BNP is increased you know it is more of a cardiac cause. The pt has a history of both COPD and HF, her BNP on admission was 841; indicating more of a cardiac cause for the dyspnea. Lewis

12. P; Pt’s BNP went from 841 to 312 before discharge. Plan is ongoing.
13. Pt will receive oxygen 2L NC to keep oxygen saturation between 95-100%.
13. Dep: Administer O2 at 2-6 L/min via NC to keep sats above 95%
13. Gas exchange at the alveolar level may be compromised due to copious secretions, the inflammatory process, or low Hgb levels. With this pt the inflammatory process from COPD and increased workload of heart was the most likely cause. Low flow O2 has been shown to increase quality of life, prolong life and help relieve pulmonary hypertension, decrease polycythemia, increase LOR by decreasing hypoxia, and increase exercise intolerance. The O2 should be kept on to keep O2 sats above 95%. 102 notes
13. M; pt’s O2 was 97% on 3 L/min NC.
14. Pt will demonstrate and verbalize purpose of pursed lip breathing by discharge.
14. Teach pursed lip breathing while in hospital
14. Inability to expire air is a main characteristic of COPD. As the peripheral airways become obstructed, air is progressively trapped during expiration. The residual air, combined with the loss of elastic recoil, makes passive expiration of air difficult and air is trapped in the lungs. Pursed lip breathing prolongs exhalation, thereby preventing bronchiolar collapse and air trapping. Decreasing the CO2 retention. Teaching techniques to improve gas exchange that can be done anywhere is an easy way to give the pt more control over their breathing. Lewis
14. M; pt demonstrated pursed lip breathing by discharge.
15. Pt will have order for O2 therapy at home before discharge.
15. Collaborate with MD for O2 at home before discharge
15. Improved survival occurs in pt’s with COPD who receive long- term O2 therapy to treat hypoxemia. The improved prognosis occurs from the prevention of progression of the disease. This long term therapy also has benefits such as improved mental acuity, lung mechanics, sleep, and exercise tolerance. This pt had a decreased oxygen saturation on RA, she could easily become hypoxic. Having both COPD and HF leaves her at a greater risk. Having the O2 therapy at home will prevent her from becoming hypoxemic, and allow her to carry out her ADL’s without becoming SOB. Lewis
15. M; pt had an order for O2 therapy at home at discharge.