- Physiological damage to the alveoli
- Circulatory compromise
- Lack of oxygen supply
- Insufficient availability of blood (carrier of oxygen)
Subjective Data: patient’s feelings, perceptions, and concerns. (Symptoms)
- Reports of feeling short of breath
- Expresses feelings of being tired and weak
Objective Data: assessment, diagnostic tests, and lab values. (Signs)
- Oxygen saturation below 90%
- Abnormal lung sounds
- Tripod position
- Anxious appearance
- Irritability, restlessness, confusion
- Abnormal vital signs: Increased heart rate above baseline; Increased respiratory rate above baseline;
- Altered characteristics of respirations: rate, rhythm, and depth
- Dyspnea (difficulty breathing)
- Altered skin color: pallor; cyanosis; dusky
- Abnormal chest x-ray
- Abnormal blood gas value
- Anemia: Decreased hemoglobin and hematocrit
- Past medical history reveals respiratory comorbidities such as COPD and asthma
- The patient will demonstrate adequate oxygenation with ABGs within normal limits
- The patient will have vital signs that are within the patient’s normal range
- The patient will have clear lung sounds
- The patient will deny any difficulty breathing
- The patient will be free of any signs of respiratory distress
- The patient will demonstrate an intact mentation
|Assess the characteristics of respirations. Note |
Use of accessory muscles
These indicators show the severity of respiratory distress. Factors such as pain, immobility, and sedation can affect breathing patterns and cause shallow breaths. This leads to reduced lung volume and decreased gas exchange. Hypoxia often goes along with prolonged increased work of breathing.
|Monitor oxygen saturation continuously. |
Consistent monitoring allows for better tracking of a trend. A slow decline in oxygen saturation might get missed with only spot-checking oxygen saturation. Increased oxygen demand and decreased oxygen saturation indicate a compromise in oxygenation.
|Auscultate lung sounds at least every 2 to 4 hours. Listen for adventitious breath sounds. |
Patients with respiratory problems may have wheezes, crackles, or sound diminished. Changes or worsening in these lung sounds may indicate a decline in ventilation. Often lung sounds contribute to disclosing the source of poor ventilation.
|Assess the ability to cough and clear secretions. Note characteristics of sputum. |
The pooling of secretions in the respiratory tract affects gas exchange. Sputum may be sampled to rule out an infectious process.
|Assess for cyanosis. |
Note the color of the tongue and oral mucous membranes. Blue discoloration of the tongue and oral membranes may indicate central cyanosis, a medical emergency. This condition means that tissues and organs are deprived of adequate amounts of oxygen.
|Assess the patient’s mentation. |
Irritability, restlessness, and confusion can be early signs of hypoxia, whereas late signs are lethargy and somnolence. Deterioration in cognition may be a sign of decreased oxygenation of the brain and other organs.
|Assess the patient’s mental makeup and level of stress and anxiety. |
Stress and anxiety can function as a catalyst in worsening breathing. Anxiety over the inability to breathe makes breathing worse and therefore exacerbates impaired gas exchange.
|Monitor ABGs frequently. |
Blood gases provide information about gas exchange. Abnormal blood gases could cause an acidotic or alkalotic state. An increase in Paco2 and a decrease in Pao2 might indicate respiratory acidosis and hypoxemia. Hypoxemia is a low oxygen level in the blood. If oxygen levels in the blood are low, supply for the brain and other organs are affected.
|Assess the patient’s nutritional status. |
Prolonged increased work of breathing requires a large amount of calories. Patients with chronic respiratory conditions use a lot of energy. Achieving an ideal BMI is crucial because obesity might need a lot of energy to use the diaphragm and accessory muscles. In contrast, malnutrition and underweight may lead to loss of muscle mass. With this loss, breathing muscles could be affected and weakened, leading possibly to respiratory failure.
|Review chest x-rays. |
Imaging can often provide information about the etiology of the impaired gas exchange and monitor a trend of the disease process.
|Check Hemoglobin (Hbg) levels. |
Hemoglobin carries oxygen within the blood. If Hbg levels are low, there is a decreased capacity to carry oxygen to the tissues.
|Monitor WBCs. |
An increased white count can be an indication of infectious disease.
|Monitor the effects of medications. |
Medications such as sedatives, pain medications, and other drugs might affect the brain’s ventilatory response. This could lead to carbon dioxide retention impeding adequate oxygenation.
Nursing Interventions for Impaired Gas Exchange
|Administer oxygen as ordered to maintain oxygen saturation above 90%. |
Supplemental oxygen improves gas exchange and oxygen saturation. The patient may need a nasal cannula or other devices such as a venturi mask or opti-flow to maintain an oxygen saturation above 90%.
|Assist the patient in an upright (30 to 45 degrees) position as their condition allows. |
A proper body alignment allows for adequate lung expansion and movement of respiratory muscles to support the lungs.
|Adjust the position frequently. |
Patients might tire quickly because of increased work of breathing. Frequent adjustment helps maintain a correct body alignment for easier ventilation and gas exchange. The nurse may use pillows and other devices to keep the patient comfortable and positioned correctly.
|Encourage frequent pulmonary toiletry. |
Cough and deep breathing exercises
Use of incentive spirometry
Use of a flutter valve to loosen secretions.
Using these devices helps with ventilation and prevents atelectasis. The flutter valve helps break up mucus and secretions.
|Provide small frequent meals and add supplements. |
Small meals require less energy to consume, and supplements might help patients who do not meet their required daily calorie intake.
|Encourage the patient to ambulate as tolerated. |
Ambulation helps with lung expansion and promotes deep breathing.
|Provide reassurance if the patient is anxious. |
Calming words can help reduce anxiety and decrease the work of breathing. This can decrease oxygen demand and improve gas exchange.
|Provide rest periods between ADLs and pace activities. |
Frequent rest periods may be helpful to prevent increased oxygen demand.
|Consider a rotoprone bed or mattresses with a percussion function. |
Proning and percussion help loosen secretions and remove them from the respiratory system allowing for more surface area on the alveoli. More surface area allows for better gas exchange.
|Administer medications as ordered. |
Medications depend on the etiology of the disease process. Antibiotics may be used for infections, diuretics for fluid accumulation. The treatment plan is very dependent on the condition that is being treated.
|Offer home health services if the patient has chronic lung disease and needs assistance at home. |
These services help maintain care at home and reduce the need for hospitalizations.
For the Critical Care Patient
|Anticipate the need for intubation if noninvasive oxygen delivery methods fail to maintain adequate ventilation. |
Mechanical ventilation is often needed to achieve adequate gas exchange.
|Turn and reposition the patient every 2 hours. |
Frequent positioning helps prevent the pooling of secretions in the lungs and prevents alveoli from collapsing.
|Keep the head of the bed elevated at least 30 degrees at all times. |
Intubated patients have a decreased ability to manage their secretions. Keeping the head elevated helps move secretions and prevents compromising the airway.
|Suction the airway as needed. |
Clearing the airway from secretions helps improve ventilation and, therefore, gas exchange.
Patient Teaching and Continuity of Care
|Educate about energy conserving techniques. The primary care physician may consult occupational therapy to adjust to new situations. |
Prioritization and spacing activities help conserve energy. Another essential part of saving energy is making use of resources. Encourage the patient to have family and caregivers help with more demanding activities.
|Teach about coughing and deep breathing methods. |
Exercises such as pursed-lip breathing and using the tripod position aid in clearing secretions and increasing lung expansion, helping facilitate gas exchange.
|Explain to the patient and family about the type of oxygen therapy used at home. |
Knowledge about the use, troubleshooting, precautions, and storage of the oxygen delivery system promotes safety.
|Explain to the family and caregiver early signs of decreased oxygenation and interventions to take. |
Early recognition and intervention can make a big difference in the patient’s outcome. Taking action may reduce the number of hospital visits and emergencies.
|Educate about smoking cessation and provide resources such as outpatient facilities that can help. The primary health care provider can prescribe medications that reduce withdrawal symptoms. |
Smoking causes damage to the lungs and impairs adequate gas exchange.
|Teach about the correct use of medications.|
Possible side effects
Use of metered-dose inhaler
Safe and correct use of medications ensures the best possible patient outcome. It is most beneficial for the patient if the drug is used as intended and ordered.
More Care Plans:
Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook (10th ed). Maryland Heights: Mosby Elsevier.
Gulanick, M., & Myers, J. (2014). Nursing care plans (8th ed.). Elsevier.
Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing (8th ed.). Elsevier.