PRIORITY 2: Impaired Gas Exchange Related to excessive or thick secretions tree secondary to pneumonia

Assessment Explanation of the Objectives Interventions Rationale Criteria Actual

Problem Evaluation
Cues: > Impaired Gas STO: Assess respiratory rate, Rapid and shallow breathing STO Partially
Exchange: Excess or depth, and effort, patterns and hypoventilation Fully met if After 16 met,
Nursing deficit in oxygenation >After 16 hour of nursing including affect gas exchange. Increased hours of nursing patient’s
diagnosis : and/or carbon dioxide interventions the client will use of accessory respiratory rate, use of accessory intervention the oxygen
Impaired Gas elimination at the be able to maintain airway muscles, muscles, nasal flaring, abdominal patient will have clear saturation
Exchange alveolar-capillary patency by having nasal flaring, and breathing, and a look of panic in breath sounds and is between
Related to membrane. clear breath sounds and abnormal the patient’s eyes may be seen normal range in 90-91%
have a normal range of Breathing patterns. with hypoxia. Oxygen saturation and she
excessive or
Gas is exchanged SPo2 (93% and above) (93% and above) still has
thick secretions between the alveoli Any irregularity of breath sounds Partially met if the crackles on
tree secondary to and the pulmonary >After 8 hours of nursing may disclose the cause of patients oxygen her lower
pneumonia capillaries via interventions, Patient impaired gas exchange. saturation increases lung fields
diffusion. Diffusion of manifests resolution or Assess the lungs for Presence of crackles and to 90% to 92% or
S oxygen and carbon absence of symptoms of areas wheezes may alert the nurse to increases from any
> “Nahihirapan dioxide occurs respiratory distress. Such of decreased ventilation an airway obstruction, which may range higher than
pa rin syang passively, according as difficulty in breathing, and auscultatepresence lead to or exacerbate existing former SPo2
huminga kaya to their concentration Shortness in breath, and of adventitious sounds. hypoxia. Diminished breath Not met if the
ganyan lagi ang differences across the crackles on the lung fields sounds are linked with poor patients SPo2
posisyon nya” alveolar-capillary upon auscultation ventilation. decreased or
barrier. These remained the same
O concentration >After 5 minutes of nursing Not met,
> On O2 differences must be interventions patient would Changes in behavior and mental STO 2 the patient
inhalation at maintained by identify the importance of status can be early signs of Fully met if after 8 is feeling
7LMP via ventilation (air flow) of DBE and coughing impaired gas exchange. hours of nursing DOB or
Facemask the alveoli and exercises and perform DBE Monitor patient’s behavior Cognitive changes may occur interventions the SOB and
>RR of 25, perfusion (blood flow) and atleast 2-3 coughing and mental status with chronic hypoxia. patient will not still has
shallow of the pulmonary exercises for onset of restlessness, experience secretions
>SPo2: 87% capillaries. agitation, confusion, and DOB,SOB or in the
>Has episodes (in the late stages) Collapse of alveoli increases presence of tracheobro
of productive > A balance between >After 5 minutes of nursing extreme shunting (perfusion without secretions In the nchial tree
Cough the two normally interventions the patient will lethargy. ventilation), resulting in tracheobronchial tree
>Crackles heard exists but certain verbalize understanding of hypoxemia. Partially met if the
upon conditions can alter oxygen and 3 other Monitor for signs and patient will feel 1 of
auscultation on this balance, resulting therapeutic interventions. symptoms of atelectasis: the respiratory
PRIORITY 2: Impaired Gas Exchange Related to excessive or thick secretions tree secondary to pneumonia

the lung fields in Impaired Gas bronchial or tubular breath distress but 2-3 would
>expectorates Exchange. Dead sounds, crackles, be alleviated
whitish phlegm space is the volume diminished chest Not met if the patient
>nasal flaring of a breath that does LTO: excursion, limited still experience all of
>use of not participate in gas > After 3 days of nursing diaphragm excursion, and BP, HR, and respiratory rate all her respiratory
accessory exchange. It is interventions Patient tracheal shift to affected increase with initial hypoxia and distress/ there is no
muscles ventilation without maintains optimal gas side hypercapnia. However, when improvement on Not met.
>no chest perfusion. exchange as evidenced by both conditions become severe, health
indrawing usual mental status, Monitor for alteration in BP and HR decrease, and
>Pale unlabored respirations at BP and HR. dysrhythmias may occur. STO 3
12-20 per minute, oximetry Fully met if after 5
Conditions that cause results within normal range, Central cyanosis of tongue and minutes of health
changes or collapse blood gases within normal oral mucosa is indicative of teaching the patient
of the alveoli (e.g., range, and baseline HR for serious hypoxia and is a medical will perform DBE and
atelectasis, patient. emergency. Peripheral cyanosis identify 3 coughing
pneumonia, Observe for nail beds, in extremities may or may not be exercises Not met
pulmonary edema, cyanosis in skin; serious Partially met if the because
and acute respiratory especially note color of patient will perform patient is
distress syndrome) tongue and oral mucous These are signs of hypercapnia. DBE and identify 1-2 unable to
impair ventilation. membranes. coughing exercises identify
High altitudes, Not met if the patient techniques
hypoventilation, and does not do DBE and due to her
altered oxygen- not identify any age
carrying capacity of Assess for headaches, coughing exercise constraints
the blood from dizziness, lethargy, Pulse oximetry is a useful tool to and still not
reduced hemoglobin reduced ability to follow detect changes in oxygenation. STO 4 feeling
are other factors that instructions, An oxygen saturation of <90% Fully met if the well.
affect gas exchange. disorientation, and coma. (normal: 95% to 100%) or a partial patient verbalizes
The total pulmonary pressure of oxygen of <80 understand of oxygen
blood flow in older Monitor oxygen saturation (normal: 80 to 100) indicates and 3 therapeutic
patients is lower than continuously, using pulse significant oxygenation problems. interventions Partially
in young subjects. oximeter. Partially met if the met,
Obesity in COPD and patient identifies 1-2 patient
the impact of Retained secretions weaken gas therapeutic shows
excessive fat mass on exchange. interventions and usual
lung function put does not verbalize mental
PRIORITY 2: Impaired Gas Exchange Related to excessive or thick secretions tree secondary to pneumonia

patients at greater understanding of status, has

risk for hypoxia. oxygen or vice versa unlabored
Smokers and patients Assess the patient’s Not met if the patient respiration
suffering from ability to cough out Overhydration may impair gas does not verbalize but at 24-27
pulmonary problems, secretions. Take note of exchange in patients with heart understanding of per minute
prolonged period of the quantity, color, and failure. Insufficient hydration, on oxygen and does not and her
immobility, chest or consistency of the the other hand, may reduce the identify any oximetry
upper abdominal sputum. ability to clear secretions in therapeutic results are
incisions are also at patients with pneumonia and interventions still below
risk for Impaired Gas Evaluate the patient’s COPD. normal
Exchange. hydration status. LTO: ranges
Upright position or semi-Fowler ’s Fully met if after 3 And her
position allows increased thoracic days of nursing heart rate
>Pneumonia is an
capacity, full descent of interventions Patient is 78
infection in one or
diaphragm, and increased lung maintains optimal (normal)
both lungs. It can be
expansion preventing the gas exchange as
caused by bacteria,
abdominal contents from evidenced by usual
viruses, or fungi.
Position patient with head crowding. mental status,
Bacterial pneumonia
of bed elevated, in a unlabored
is the most common
semi-Fowler’s position Turning is important to prevent respirations at 12-20
type in adults.
(head of bed at 45 complications of immobility, but in per minute, oximetry
degrees when supine) as critically ill patients with low results within normal
>Pneumonia causes tolerated. hemoglobin levels or decreased range, blood gases
inflammation in the air cardiac output, turning on either within normal range,
sacs in your lungs, side can result in desaturation. and baseline HR for
which are called patient.
alveoli. The alveoli fill Turn the patient every 2
with fluid or pus, hours. Monitor mixed Partially met if the
making it difficult to venous oxygen saturation patient
breathe. closely after turning. If it experienences
drops below 10% or fails Ambulation facilitates lung unlabored
>Normally the lungs to return to baseline expansion, secretion clearance, respirations but has
are free from promptly, turn the patient and stimulates deep breathing. abnormal oxygen
secretions. back into a supine saturation levels and
Pneumonia bacteria position and evaluate These technique promotes deep the HR of the patient
oxygen status. inspiration, which increases is high or vice versa
PRIORITY 2: Impaired Gas Exchange Related to excessive or thick secretions tree secondary to pneumonia

are invading the lung oxygenation and prevents (one factor improved)
parenchymathus, Encourage or assist with atelectasis. Not met if the patient
producing ambulation as per did not improve at all.
inflammatory process. physician’s order. Activities will increase oxygen
And these responses consumption and should be
leading to filling of the Encourage slow deep planned so the patient does not
alveolar sacs with breathing using an become hypoxic.
exudates leading to incentive spirometer as
consolidation. The indicated.
airway is narrowed
thus wheezes is being Pace activities and
heard. DOB in some schedule rest periods to
cases prevent fatigue. Assist
with ADLs.

References:

Nurseslabs (n.d.) Impaired Gas Exchange, Retrieved on 10/16/18 from https://nurseslabs.com/impaired-gas-exchange/

Scribd (n.d.) NCP Impaired Gas Exchange, Retrieved on 10/16/18, from https://www.scribd.com/doc/35779302/NCP-Impaired-Gas-Exchange