IMPAIRED GAS EXCHANGE NURSING OUTCOMES CLASSIFICATIONS, NURSING ASSESSMENTS AND RATIONALE, NURSING INTERVENTIONS CLASSIFICATION AND RATIONALE, AND CLIENT/FAMILY TEACHING AND DISCHARGE PLANNING.

IMPAIRED GAS EXCHANGE

IMPAIRED GAS EXCHANGE NURSING OUTCOMES CLASSIFICATIONS, NURSING ASSESSMENTS AND RATIONALE, NURSING INTERVENTIONS CLASSIFICATION AND RATIONALE, AND CLIENT/FAMILY TEACHING AND DISCHARGE PLANNING.

NANDA-I

Definition

This article is focused on expounding on impaired gas exchange nursing classifications, nursing assessments and rationale, nursing interventions classification and rationale, and client/family teaching and discharge planning.

What is impaired gas exchange?

Impaired gas exchange refers to excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane. Gas is exchanged between the alveoli and the pulmonary capillaries via diffusion. Diffusion of oxygen and carbon dioxide occurs passively, according to their concentration differences across the alveolar-capillary barrier. These concentration differences must be maintained by ventilation (air flow) of the alveoli and perfusion (blood flow) of the pulmonary capillaries.

IMPAIRED GAS EXCHANGE NURSING OUTCOMES CLASSIFICATIONS, NURSING ASSESSMENTS AND RATIONALE, NURSING INTERVENTIONS CLASSIFICATION AND RATIONALE, AND CLIENT/FAMILY TEACHING AND DISCHARGE PLANNING.
What is impaired gas exchange?

Conditions that cause changes or collapse of the alveoli (e.g., atelectasis, pneumonia, pulmonary edema, and acute respiratory distress syndrome) impair ventilation. High altitudes, hypoventilation, and altered oxygen-carrying capacity of the blood from reduced hemoglobin are other factors that affect gas exchange. The total pulmonary blood flow in older patients is lower than in young subjects. Obesity in COPD and the impact of excessive fat mass on lung function put patients at greater risk for hypoxia. Smokers and patients suffering from pulmonary problems, prolonged periods of immobility, chest or upper abdominal incisions are also at risk for Impaired Gas Exchange.

Signs and symptoms of impaired gas exchange

What are the signs and symptoms of impaired gas exchange?

Abnormal arterial blood gases;   abnormal arterial pH;   abnormal breathing pattern; abnormal skin color;   confusion; decrease in carbon dioxide (CO2) level; diaphoresis; dyspnea; headache on awakening; hypercapnia; hypoxemia; hypoxia; irritability; nasal flaring; restlessness, somnolence; tachycardia; visual disturbances.

Associated conditions of impaired gas exchange

What are the associated conditions of impaired gas exchange?

Alveolar-capillary membrane changes; ventilation-perfusion imbalance

Alveolar-capillary membrane changes; ventilation-perfusion imbalance

Alveolar-capillary membrane changes and ventilation-perfusion imbalance (decreased oxygen-carrying capacity of blood, altered oxygen supply, alveolar-capillary membrane changes) possibly evidenced by dyspnea with exertion, tachypnea, changes in mentation, irritability, tachycardia, hypoxia, hypercapnia.

NURSING OUTCOMES CLASSIFICATION (NOC) OF IMPAIRED GAS EXCHANGE

NOC

What are the common goals and expected outcomes for Impaired Gas Exchange?

  • Patient maintains optimal gas exchange as evidenced by usual mental status, unlabored respirations at 12-20 per minute, oximetry results within normal range, blood gases within normal range, and baseline HR for the patient.
  • Patient maintains clear lung fields and remains free of signs of respiratory distress.
  • Patient verbalizes understanding of oxygen and other therapeutic interventions.
  • Patient participates in procedures to optimize oxygenation and in management regimen within the level of capability/condition.
  • Patient manifests resolution or absence of symptoms of respiratory distress.

NURSING ASSESSMENT AND RATIONALE FOR IMPAIRED GAS EXCHANGE

What are the assessments and rationales for impaired gas exchange?

The patient’s general appearance may give clues to respiratory status. Observing the individual’s responses to activity are cue points in performing an assessment related to Impaired Gas Exchange.

  1. Assess respiratory rate, depth, and effort, including the use of accessory muscles, nasal flaring, and abnormal breathing patterns.
    Rapid and shallow breathing patterns and hypoventilation affect gas exchange (Gosselink & Stam, 2005). Increased respiratory rate, use of accessory muscles, nasal flaring, abdominal breathing, and a look of panic in the patient’s eyes may be seen with hypoxia.
  2. Assess the lungs for areas of decreased ventilation and auscultate presence of adventitious sounds.
    Any irregularity of breath sounds may disclose the cause of impaired gas exchange. The presence of crackles and wheezes may alert the nurse to airway obstruction, leading to or exacerbating existing hypoxia. Diminished breath sounds are linked with poor ventilation.
  3. Monitor patient’s behavior and mental status for the onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy.
    Changes in behavior and mental status can be early signs of impaired gas exchange. Restlessness, which may be triggered by conditions that change the respiratory state, presented high specificity in a determination study conducted by Pascoal (2015). Cognitive changes may occur with chronic hypoxia.
  4. Monitor for signs and symptoms of atelectasis: bronchial or tubular breath sounds, crackles, diminished chest excursion, limited diaphragm excursion, and tracheal shift to the affected side.
    The collapse of alveoli increases shunting (perfusion without ventilation), resulting in hypoxemia. Hypoxemia was the defining characteristic that presented high specificity to determine impaired gas exchange (Pascoal et al., 2015).
  5. Observe for signs and symptoms of pulmonary infarction: bronchial breath sounds, consolidation, cough, fever, hemoptysis, pleural effusion, pleuritic pain, and pleural friction rub.
    Increased dead space and reflex bronchoconstriction in areas adjacent to the infarct result in hypoxia (ventilation without perfusion).
  6. Monitor for alteration in BP and HR.
    BP, HR, and respiratory rate all increase with initial hypoxia and hypercapnia. However, when both conditions become severe, BP and HR decrease and dysrhythmias may occur.
  7. Observe for nail beds, cyanosis in the skin; especially note the color of the tongue and oral mucous membranes.
    Central cyanosis of the tongue and oral mucosa indicates severe hypoxia and is a medical emergency (Pahal et al., 2021). Peripheral cyanosis in extremities may or may not be serious.
  8. Monitor for signs of hypercapnia.
    Hypercapnia is the buildup of carbon dioxide in the bloodstream. Signs of hypercapnia include headaches, dizziness, lethargy, reduced ability to follow instructions, disorientation, and coma.
  9. Monitor oxygen saturation continuously, using a pulse oximeter.
    Pulse oximetry is a useful tool to detect changes in oxygenation. An oxygen saturation of <90% (normal: 95% to 100%) or a partial pressure of oxygen of <80 (normal: 80 to 100) indicates significant oxygenation problems.
  10. Note blood gas (ABG) results as available and note changes.
    Increasing PaCO2 and decreasing PaO2 are signs of respiratory acidosis and hypoxemia. As the patient’s condition deteriorates, the respiratory rate will decrease, and PaCO2 will increase. Some patients, such as those with COPD, have a significant decrease in pulmonary reserves, and additional physiological stress may result in acute respiratory failure.
  11. Monitor the effects of position changes on oxygenation (ABGs, venous oxygen saturation [SvO2], and pulse oximetry.
    Putting the most compromised lung areas in the dependent position (where perfusion is greatest) potentiates ventilation and perfusion imbalances.
  12. Consider the patient’s nutritional status.
    Certain conditions affect lung expansion. Obesity may restrict the downward movement of the diaphragm, increasing the risk for atelectasis, hypoventilation, and respiratory infections. Labored breathing is present in severe obesity as a result of excessive weight of the chest wall. Malnutrition may also reduce respiratory mass and strength, affecting muscle function.
  13. Check on Hgb levels.
    Low levels reduce the uptake of oxygen at the alveolar-capillary membrane and oxygen delivery to the tissues.
  14. Monitor chest x-ray reports.
    Chest x-ray studies reveal the etiological factors of the impaired gas exchange.
  15. Assess the patient’s ability to cough out secretions. Take note of the quantity, color, and consistency of the sputum.
    Retained secretions weaken gas exchange.
  16. Evaluate the patient’s hydration status.
    Overhydration may impair gas exchange in patients with heart failure. On the other hand, insufficient hydration may reduce the ability to clear secretions in patients with pneumonia and COPD.
NURSING INTERVENTIONS CLASSIFICATION AND RATIONALES FOR IMPAIRED GAS EXCHANGE
IMPAIRED GAS EXCHANGE NURSING OUTCOMES CLASSIFICATIONS, NURSING ASSESMENTS AND RATIONALE, NURSING INTERVENTIONS CLASSIFICATION AND RATIONALE, AND CLIENT/FAMILY TEACHING AND DISCHARGE PLANNING.
What are the nursing interventions and rationales for normal care of impaired gas exchange?

Nursing interventions and rationales for normal care of impaired gas exchange

What are the nursing interventions and rationales for normal care of impaired gas exchange?

  1. Monitor respiratory rate, depth, and ease of respiration. Watch for use of accessory muscles and nasal flaring. Normal respiratory rate is 14 to 16 breaths per minute in the adult (Bickley & Szilagyi, 2017). When the respiratory rate exceeds 30 breaths per minute, along with other physiological measures, a significant cardiovascular or respiratory alteration exists.
  2. Auscultate breath sounds every 1 to 2 hours. The presence of crackles and wheezes may alert the nurse to airway obstruction, which may lead to or exacerbate existing hypoxia. In severe exacerbations of chronic obstructive pulmonary disease (COPD), lung sounds may be diminished or distant with air trapping (Bickley & Szilagyi, 2017).
  3. The nurse should consider respiratory rate, work of breathing, and lung sounds along with PaO2 values, arterial oxygen saturation (SaO2), oxygen saturation continuously using pulse oximetry (SpO2), patient tidal volume, and minute ventilation. The presence of dyspnea, asynchronous chest and abdominal movements, accessory muscles, and agitation indicate potential oxygenation problems (Barton, Vanderspank-Wright, & Shea, 2016).
  4. Monitor the client’s behavior and mental status for the onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. Changes in behavior and mental status can be early signs of impaired gas exchange. In the late stages, the client becomes lethargic and somnolent (Lee, 2017).
  5. Monitor oxygen saturation continuously using pulse oximetry (SpO2) (Lee, 2017). Note blood gas results as available. Oxygen saturation of less than 88% (normal is 95%– 100%) or partial pressure of oxygen of less than 55 mm Hg (normal is 80–100 mm Hg) indicates significant oxygenation problems (Bein et al, 2016; Siela & Kidd, 2017). Pulse oximetry is useful for tracking and/or adjusting supplemental oxygen therapy for clients with COPD (GOLD, 2017).
  6. Monitor venous oxygen saturation to determine an index of oxygen balance to reflect between oxygen delivery and oxygen consumption (Dirks, 2017).
  7. Measurements of oxygenation supply in the macrocirculation include those made upstream from the tissue level. The parameters measured are arterial partial pressure of oxygen (PaO2), arterial oxygen content (CaO2), arterial oxygen saturation (SaO2) determined on the basis of arterial blood gas (ABG) analysis and pulse oximetry (SpO2), and ratio of PaO2 to fraction of inspired oxygen (FiO2) or the PF ratio. Measurements of oxygenation or oxygen extraction or consumption in the macrocirculation made downstream from tissues include tissue oxygen consumption, mixed venous oxygen saturation (SvO2) or central venous oxygen saturation (ScvO2), and blood levels of lactate (Siela & Kidd, 2017).
  8. Observe for cyanosis of the skin, and especially note the color of the tongue and oral mucous membranes. EB: In central cyanosis, both the skin and mucous membranes are affected because of seriously impaired pulmonary function from unventilated or underventilated alveoli. Peripheral cyanosis (skin only) usually indicates vasoconstriction or obstruction to blood flow (Loscalzo, 2016). Central cyanosis of the tongue and oral mucosa is indicative of serious hypoxia and is a medical emergency. Peripheral cyanosis in the extremities may be caused by activation of the central nervous system or exposure to cold and may or may not be serious (Bickley & Szilagyi, 2017).
  9. Position the client in a semirecumbent position with the head of the bed at a 30- to 45- degree angle to decrease the aspiration of gastric, oral, and nasal secretions (Grap, 2009; Siela, 2010; American Association of Critical Care Nurses, 2016, 2017; Vollman, Dickinson, & Powers, 2017). Evidence shows that mechanically ventilated clients have a decreased incidence of aspiration pneumonia if the client is placed in a 30- to 45-degree semirecumbent position as opposed to a supine position.
  10. If the client has unilateral lung disease, position with the head of the bed at 30 to 45 degrees with “good lung down” in a side-lying position and affected lung up (Barton, Vanderspank-Wright, & Shea, 2016).
  11. If the client is acutely dyspneic, consider having the client lean forward over a bedside table, resting elbows on the table if tolerated. Leaning forward can help decrease dyspnea, possibly because gastric pressure allows better contraction of the diaphragm (Langer et al, 2009; Mahler, 2014). This is called the tripod position and is used during times of distress, including when walking, leaning forward on the walker.
  12. Help the client deep breathe and perform controlled coughing. Have the client inhale deeply, hold their breath for several seconds, and cough two or three times with the mouth open while tightening the upper abdominal muscles as tolerated. Controlled coughing uses the diaphragmatic muscles, which makes the cough more forceful and effective. If the client has excessive fluid in the respiratory system, see the interventions for Ineffective Airway clearance.
  13. Monitor the effects of sedation and analgesics on the client’s respiratory pattern; use judiciously (Barton, Vanderspank-Wright, & Shea, 2016). Both analgesics and medications that cause sedation can depress respiration at times. However, these medications can be very helpful for decreasing the sympathetic nervous system discharge that accompanies hypoxia (Spruit et al, 2013).
  14. Schedule nursing care to provide rest and minimize fatigue. The hypoxic client has limited reserves; inappropriate activity can increase hypoxia (Spruit et al, 2013).
  15. Administer humidified oxygen through an appropriate device (e.g., nasal cannula or Venturi mask per the health care provider’s order); aim for an oxygen (O2) saturation level of 90% or above. Oxygen should be titrated to target an SpO2 of 94% to 98%, except with carbon monoxide poisoning (100% oxygen), acute respiratory distress syndrome (ARDS) (88%–95%), those at risk for hypercapnia (88%–92%), and premature infants (88%– 94%) (Blakeman, 2013). Watch for the onset of hypoventilation as evidenced by increased somnolence. There is a fine line between ideal and excessive oxygen therapy; increasing somnolence is caused by retention of CO2 leading to CO2 narcosis (Wong & Elliott, 2009). Promote oxygen therapy during a COPD exacerbation. Supplemental oxygen should be titrated to improve the client’s hypoxemia with a target of 88% to 92% (GOLD, 2017).
  16. Once oxygen is started, ABGs should be checked 30 to 60 minutes later to ensure satisfactory oxygenation without CO2 retention or acidosis (GOLD, 2017). EBN: Use of high-flow nasal cannula oxygen therapy may improve gas exchange and oxygenation in acute hypoxemic respiratory failure (Lenglet et al, 2012; Sztrymf et al, 2012; Rittayamai, Tscheikuna, & Rujiwit, 2014; Siela & Kidd, 2017).
  17. Supplemental oxygen can cause toxicity and should be administered at the lowest level that achieves an arterial saturation appropriate for a given patient (Budinger & Mutlu, 2013; Helmerhorst et al, 2015). Conservative oxygen strategies that target a goal of 88% to 92% SpO2 levels in patients receiving invasive mechanical ventilation appear justified (Panwar et al, 2016).
  18. Assess nutritional status including serum albumin level and body mass index (BMI). Malnourishment in a client with COPD has a negative effect on the course of the disease; it can result in loss of muscle mass in the respiratory muscles, including the diaphragm, which can lead to respiratory failure (GOLD, 2017).
  19. Assist the client to eat small meals frequently and use dietary supplements as necessary. Engage dietary issues by evaluating and creating an optimal nutrition plan. For some clients, drinking 30 mL of a supplement every hour while awake can be helpful.
  20. If the client is severely debilitated from chronic respiratory disease, consider the use of a wheeled walker to help in ambulation.
  21. Watch for signs of psychological distress including anxiety, agitation, and insomnia.
  22. Refer the COPD client to a pulmonary rehabilitation program. Pulmonary rehabilitation is now considered a standard of care for the client with COPD (Nici et al, 2009; Spruit et al, 2013; GOLD, 2017)

Nursing interventions and rationales for critical care of impaired gas exchange

What are the nursing interventions and rationales for critical care of impaired gas exchange?

  1. Assess and monitor oxygen indices such as the PF ratio (FiO2:PO2) and venous oxygen saturation/oxygen consumption (SvO2 or ScvO2) (Headley & Giuliano, 2011; Dirks, 2017; Siela & Kidd, 2017; Lough, 2018).
  2. Turn the client every 2 hours. Monitor mixed venous oxygen saturation closely after turning. If it drops below 10% or fails to return to baseline promptly, turn the client back into the supine position and evaluate oxygen status. If the client does not tolerate turning, consider the use of a kinetic bed that rotates the client from side to side in a turn of at least 40 degrees (St. Clair & MacDermott, 2017).
  3. If the client has ARDS with difficulty maintaining oxygenation, then consider positioning the client prone with the upper thorax and pelvis supported. Monitor oxygen saturation and turn the client back to supine position if desaturation occurs. EB: Oxygenation levels have been shown to improve in the prone position, probably because of decreased shunting and better perfusion of the lungs (Gattinoni et al, 2013; Drahnak & Custer, 2015; Barton, Vanderspank-Wright, & Shea, 2016; Bein et al, 2016; Vollman, Dickinson, & Powers, 2017; Vollman, Sole, Quinn, 2017). Prone ventilation significantly reduced mortality in clients with severe acute hypoxemic respiratory failure, but not in clients with less severe hypoxemia (Sud et al, 2010; Gattinoni et al, 2013). A PaO2 lower than 150 mm Hg measured on at least 5 cm H2O positive end-expiratory pressure (PEEP) is a recommended threshold for the application of proning (Gattinoni et al, 2013). Note: If the client becomes ventilator-dependent, see the care plan for impaired spontaneous Ventilation.
  4. High levels of PEEP likely improve oxygenation and gas exchange (Suzumura et al, 2014; Barton, Vanderspank-Wright, & Shea, 2016).

Nursing interventions and rationales for geriatric care of impaired gas exchange

What are the nursing interventions and rationales for geriatric care of impaired gas exchange?

  1. Use central nervous system depressants and other sedating agents carefully to avoid decreasing respiration effort (rate and depth of breathing).
  2. Maintain appropriate levels of supplemental oxygen therapy for clients with impaired gas exchange and hypoxemia (GOLD, 2017).

Nursing interventions and rationales for home care of impaired gas exchange

What are the nursing interventions and rationales for home care of impaired gas exchange?

  1. Work with the client to determine what strategies are most helpful during times of dyspnea. Educate and empower the client to self-manage the disease associated with impaired gas exchange. EBN/EB: A study found that use of oxygen, self-use of medication, and getting some fresh air were most helpful in dealing with dyspnea (Thomas, 2009). Evidence-based reviews have found that self-management offers COPD clients effective options for managing the illness, leading to more positive outcomes (Spruit et al, 2013; GOLD, 2017)
  2. Collaborate with health care providers regarding long-term oxygen administration for chronic respiratory failure clients with severe resting hypoxemia. Administer long-term oxygen therapy greater than 15 hours daily for PO2 less than 55 or SaO2 at or below 88% (GOLD, 2017).
  3. Assess the home environment for irritants that impair gas exchange. Help the client adjust the home environment as necessary (e.g., install an air filter to decrease the level of dust).
  4. Refer the client to occupational therapy as necessary to assist the client in adapting to the home and environment and in energy conservation (GOLD, 2017).
  5. Assist the client with identifying and avoiding situations that exacerbate impairment of gas exchange (e.g., stress-related situations, exposure to pollution of any kind, proximity to noxious gas fumes such as chlorine bleach). Irritants in the environment decrease the client’s effectiveness in accessing oxygen during breathing.
  6. Refer to GOLD guidelines for the management of home care and indications of hospital admission criteria (GOLD, 2017).
  7. Instruct the client to keep the home temperature above 68°F (20°C) and to avoid cold weather. Cold air temperatures cause constriction of the blood vessels, which impairs the client’s ability to absorb oxygen (Bickley & Szilagyi, 2017).
  8. Instruct the client to limit exposure to persons with respiratory infections. Viruses, bacteria, and environmental pollutants are the main causes of exacerbations of COPD (GOLD, 2017).
  9. Instruct the family on the complications of the disease and the importance of maintaining the medical regimen, including when to call a health care provider.
  10. Refer the client for home health aide services as necessary for assistance with activities of daily living. Clients with decreased oxygenation have decreased energy to perform personal and role-related activities
  11. When respiratory procedures are implemented, explain equipment and procedures to family members and provide needed emotional support. Family members assuming responsibility for respiratory monitoring often find this stressful (Langer et al, 2009).
  12. When electrically-based equipment for respiratory support is implemented, evaluate home environment for electrical safety, proper grounding, and so on. Ensure that notification is sent to the local utility company, the emergency medical team, and police and fire departments. Notification is important to provide for priority service.
CLIENT/FAMILY TEACHING AND DISCHARGE PLANNING OF IMPAIRED GAS EXCHANGE
IMPAIRED GAS EXCHANGE NURSING OUTCOMES CLASSIFICATIONS, NURSING ASSESMENTS AND RATIONALE, NURSING INTERVENTIONS CLASSIFICATION AND RATIONALE, AND CLIENT/FAMILY TEACHING AND DISCHARGE PLANNING.
What are the client/family teachings and discharge plans for impaired gas exchange?

What are the client/family teachings and discharge plans for impaired gas exchange?

  1. Teach the client how to perform pursed-lip breathing and inspiratory muscle training, and how to use the tripod position. Have the client watch the pulse oximeter to note improvement in oxygenation with these breathing techniques. CEB: Pursed lip breathing results in increased use of intercostal muscles, decreased respiratory rate, and improved oxygen saturation levels (Mahler, 2014). Pursed-lip breathing may relieve dyspnea in advanced COPD (Mahler, 2014). A systematic review found that inspiratory muscle training was effective in increasing endurance of the client and decreasing dyspnea (Langer et al, 2009). Inspiratory muscle training likely improves breathlessness during exercise and/or with activities of daily living in patients with COPD and congestive heart failure (CHF) who exhibit inspiratory muscle weakness (Mahler, 2014).
  2. Teach the client energy conservation techniques and the importance of alternating rest periods with activity. See nursing interventions for Fatigue.
  3. Teach the importance of not smoking. Refer to smoking cessation programs, and encourage clients who relapse to keep trying to quit. Ensure that clients receive appropriate medications to support smoking cessation from the primary health care provider. EB: Patients should be referred to a comprehensive smoking cessation program, incorporating behavior change techniques that focus on enhancing patient motivation and confidence, patient education, and pharmacological and non-pharmacological interventions (GOLD, 2017).
  4. Instruct the family regarding home oxygen therapy if ordered (e.g., delivery system, liter flow, safety precautions). Long-term oxygen therapy can improve survival, exercise ability, sleep, and ability to think in hypoxemic clients. Client education improves compliance with prescribed use of oxygen (GOLD, 2017)
  5. Teach the client the need to receive a yearly influenza vaccine. Receiving a yearly influenza vaccine is helpful to prevent exacerbations of COPD (GOLD, 2017).
  6. Teach the client relaxation techniques to help reduce stress responses and panic attacks resulting from dyspnea. EB: Relaxation therapy can help reduce dyspnea and anxiety (Langer et al, 2009). Teach the client to use music, along with a rest period, to decrease dyspnea and anxiety (Mahler, 2014; Loscalzo, 2016).

EXAMPLES

NOC with indicators Example

NOC (Respiratory Status):

Gas Exchange, Ventilation.

Achieves   appropriate Respiratory   Status:   Gas   Exchange as   evidenced   by   the   following   indicators:   Cognitive

status/Partial pressure of oxygen/Partial pressure of carbon dioxide/Arterial pH/Oxygen saturation. (Rate each indicator

of Respiratory Status: Gas Exchange: 1 = severe deviation from normal range, 2 = substantial deviation from normal

range, 3 = moderate deviation from normal range, 4 = mild deviation from normal range, 5 = no deviation from normal

range [see Section I].

Achieves   appropriate Respiratory   Status:   Gas   Exchange as   evidenced   by   the   following   indicators:   Cognitive

status/Partial pressure of oxygen/Partial pressure of carbon dioxide/Arterial pH/Oxygen saturation. (Rate each indicator

of Respiratory Status: Gas Exchange: 1 = severe deviation from normal range, 2 = substantial deviation from normal

range, 3 = moderate deviation from normal range, 4 = mild deviation from normal range, 5 = no deviation from normal

range [see Section I].

Achieves appropriate respiratory status

Gas exchange as evidenced by the following indicators: Cognitive status/Partial pressure of oxygen/Partial pressure of carbon dioxide/ Arterial pH/Oxygen saturation.

Rating of each indicator respiratory status

Gas exchange 1: severe deviation from normal range, 2 = substantial deviation from normal range, 3 = moderate deviation from normal range, 4 = mild deviation from normal range, 5 = no deviation from normal range.

NIC Interventions Example

Example of NIC Activity —Acid-Base Management

  1. Monitor for symptoms of respiratory failure (e.g., low PaO2 and elevated PaCO2 levels and respiratory muscle fatigue)
  2. Monitor determinants of tissue oxygen delivery (e.g., PaO2, SaO2, and hemoglobin levels, and cardiac output) if available

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IMPAIRED GAS EXCHANGE NURSING OUTCOMES CLASSIFICATIONS, NURSING ASSESMENTS AND RATIONALE, NURSING INTERVENTIONS CLASSIFICATION AND RATIONALE, AND CLIENT/FAMILY TEACHING AND DISCHARGE PLANNING.

 

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