Nursing Diagnosis: Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures secondary to CHF as evidenced by shortness of breath, SpO2 level of 85%, abnormal ABG results and crackles upon auscultation. Oxygenation and ventilation may need to be supported mechanically. Registered Nurse, Free Care Plans, Free NCLEX Review, Nurse Salary, and much more. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. Finally, on Friday, March 3, the IHS Markit Services PMI for February will be released. Monitor the oxygen saturation levels and blood gas (ABG) results. The most important part of the care plan is the content, as that is the foundation on which you will base your care. The formatting isnt always important, and care plan formatting may vary among different nursing schools or medical jobs. Impaired gas exchange r/t alveolar-capillary membrane changes AEB chest x-ray suggesting possible area of consolidation in the right lower lobe Acute Confusion r/t situational crisis AEB restlessness, irritability, and agitation. Overall, cigarette smoking is the most common irritant that causes COPD worldwide. Weight Mass Student - Answers for gizmo wieght and mass description. -Pts O2 Saturation will be between 90-100% as evidence by nursing documentation during hospitalization.-Pt will have clear sputum as evidence by nursing documentation by discharge. How do you develop a nursing care plan? position changes and turn Impaired gas exchange in COPD can cause symptoms like shortness of breath, coughing, and fatigue. Gas Exchange . Copyright 2022 SimpleNursing.com. 4. patient will have This can prevent airway collapse, Pillows to support elevated position and support for arms, Supportive therapy to decrease chest and abdominal discomfort and pain if present, Assistance with positive airway pressure techniques-CPAP, BiPAP, PEP device, Assure breathing deeply will not dislodge tubes or cause wound opening, Diuretics, bronchodilators, antibiotics, steroids, pain medications, anticoagulants. This process is called gas exchange. Assess the patients vital signs and characteristics of respirations at least every 4 hours. NurseTogether.com does not provide medical advice, diagnosis, or treatment. These capabilities provide timely, automated data measurement and control for service activities to accelerate response to market and operational change. Gas exchange happens in the alveoli in the lungs. Manage Settings (relevant medical orders, comfort Nursing diagnoses handbook: An evidence-based guide to planning care. Assessment Nursing Diagnosis Planning Interventions Rationale Evaluatio n Subjective data: "I cannot breath." as verbalized by the patient. It also leads to hypoxemia and hypercapnia. Objective data: >wheezing upon inspiration and expiration >Acute shortness of breath >dyspnea . Assist the physician to initiate intubation and mechanical ventilation of the patient, if required. 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 . Early recognition of signs and symptoms of impaired gas exchange allows for prompt intervention. s erm In 2 days, the patient will Patient verbalizes understanding of oxygen and other therapeutic interventions. Desired Outcome: The patient will demonstrate adequate oxygenation as evidenced by reaching the prescribed target oxygen saturation levels. Encourage the patient to cough to expectorate thick sputum. Administer anti-pyretics as prescribed for high fever. Nursing-Diagnosis: Impaired gas exchange related to the destruction of alveolar walls. IMPLEMENTATION Abnormal This can lead to a variety of symptoms, such as: Impaired gas exchange is also characterized by hypoxemia and hypercapnia. Upon physical assessment his breathing is shallow and labored, respiratory rate is 30 breaths per minute, heart rate 115 beats per minute, oxygen saturation 83% on room air, blood pressure 179/98 mm Hg, he has +4 pitting edema in bilateral lower extremities, and crackles are heard in his lung fields throughout. -The nurse will teach the patient 4 benefits of wearing a CPAP machine at home when she sleeps. To maintain adequate oxygen supply by delivering proper ventilation and oxygenation while allowing the lungs to heal. This limits This nursing diagnosis can be a serious health threat usually closely associated with other nursing diagnoses like ineffective breathing pattern or ineffective airway clearance. He reports over the past 3 days his shortness of breath, particularly with activity, has increased significantly. Pascoal LM, et al. Oxygen and carbon dioxide are exchanged across the alveolar-capillary barrier in a passive manner, depending on both gases concentrations. However, my patient had normal vital signs, no complaint of pain, and no lab test except a positive strep test. Kent BD, et al. Assess the patients vital signs, especially the respiratory rate and depth. 101.6, Skin feels hot on assessment, WBC 30,0000, chest x-ray shows possible bilaterally lower lobe pneumonia. (2021). Anti-pyretic drugs aim to reduce the bodys temperature levels. Pahal P, et al. Decrease in blood pressure to patients baseline (ideally <120/80), Improved contractility by decreasing excess fluid, improvement in breathing status, and stabilization of vital signs, Decreased oxygen saturation (83% at room air), Patients activity level will return to baseline. Injection Gone Wrong: Can You Spot The Mistakes? To optimise gas exchange, each sample will be collected after a 15-second breath hold . 101.6. Desired Outcome: Within 1 hours of nursing interventions, the patient will have improved ventilation and gas exchange as evidenced by oxygen saturation within normal range, and respiratory rate greater than 8. Seventy-seven-year . Impaired gas exchange is a disruption of the oxygen and carbon dioxide exchange in the lung tissues. NANDA label (Doenges) Learn how your comment data is processed. Assess the patients vital signs, especially the respiratory rate and depth. Wow, I give up! According to the Centers for Disease Control and Prevention (CDC), about 15.7 million people in the United States, or about 6.4 percent of the population, have COPD, making it the fourth leading cause of death in the United States in 2018. It is a collection of fluid in the pleural space of the lungs. When this happens, its hard to provide your body with enough oxygen to support daily activities and to remove enough carbon dioxide a condition called hypercapnia. RECOGNIZE/ANALYZE CUES 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%. PATIENTS CONDITION AND These conditions are progressive, which means that they can get worse over time. What is the disease process causing This topic is now closed to further replies. We strive for 100% accuracy, but nursing procedures and state laws are constantly changing. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. Excess.. Mucous production . We and our partners use data for Personalised ads and content, ad and content measurement, audience insights and product development. Care Plans are often developed in different formats. MAKE A CHANGE IN THE Congestive heart failure is a chronic condition that can progress over time. This is because COPD is associated with progressive damage to the alveoli and airways. -Pt will be provided with a CPAP machine to take home that meets her expectations. Pursed lip breathing and deep breathing exercises also prevents atelectasis or lung collapse. It can lead to an inadequate amount of blood pumping out of the heart. EVALUATE PATIENT Encourage adequate When collecting primary subjective data, which is an appropriate source for the nurse to use? Bipap ordered with the following settings Ipap 20, Epap 8, Oxygen Percentage 30%, Rate 12. If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Nursing care plans: Diagnoses, interventions, & outcomes. breath sounds are Patient exhibited dyspnea on ambulation from stretcher to bed. 2. A non-cardiogenic process brought on by injury to the lung or a cardiogenic process brought on by an inability to remove enough blood from the lungs must be identified for appropriate treatment. such as monitor, assess, observe or (2011). Ackley, B.J., Ladwig, G.B., Flynn-Makic, M.B., Martinez-Kratz, M.R., & Zanotti, M. (2020). Monitor vital signs for oxygen saturation and changes in heart rate, blood pressure, or cardiac rhythm. Diseases that affect the ability for blood to carry oxygen can also result in impaired gas exchange. Powers KA, et al. Subjective Data: "no smoking history, for three weeks prior to admission increasing difficulty with cough with thick white sputum, shortness of breath, and syncope associated with asthma. are impacted by 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 . How is impaired gas exchange and COPD diagnosed? 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. Breath sounds Buy on Amazon, Gulanick, M., & Myers, J. L. (2017). Clinical, physiologic, and radiographic factors contributing to development of hypoxemia in moderate to severe COPD: A cohort study. These conditions impact the lungs in different ways. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing Diagnosis: Impaired gas exchange related to alveolar-capillary membrane changes secondary to COPD as evidenced by oxygen saturation 79%, heart rate 112 bpm, and patient reports of dyspnea. Treatment for hypercapnia involves noninvasive ventilation therapy, often called BiPAP, which is the name of a brand of ventilation therapy machine. 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. intervention), TAKE ACTION Feelings of anxiousness can increase respiratory rate and cause difficulty breathing and should be avoided if possible. 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. SATISFY THE OUTCOME Encourage the patient to cough to expectorate phlegm. Nursing Diagnosis: Impaired gas exchange related to decreased ventilation secondary to opioid use as evidenced by respiratory rate of 6 respirations per minute, oxygen saturation 70%, and extreme lethargy. -Pt will list 3 signs and symptoms of high PCO2 level and when to notify her doctor. This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions. See our full, Important Disclosure: Please keep in mind that these care plans are listed for, Click to share on Facebook (Opens in new window), Click to share on Twitter (Opens in new window), Click to share on Pinterest (Opens in new window), Click to share on Reddit (Opens in new window), Click to share on LinkedIn (Opens in new window), Click to share on WhatsApp (Opens in new window), Click to share on Pocket (Opens in new window), Click to share on Telegram (Opens in new window), Click to share on Skype (Opens in new window), IV Drug Use Complications & Dangers: (Endocarditis, Infection, Infectious Diseases). Which action by the nurse is the most appropriate? During this process, oxygen enters the bloodstream while carbon dioxide is removed. This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. Gas exchange is the process where carbon dioxide, a waste gas, is exchanged in the lungs for fresh oxygen. She received her RN license in 1997. This website provides entertainment value only, not medical advice or nursing protocols. C. Patient will have Abnormal objective data BP:140/80mmHg PR: 102bpm RR:24cpm T:37.7C Use of accessory muscles, restless and irritable Three-part diagnostic statement Impaired gas exchange related to hypoxia as evidenced by the use of accessory muscles, respiratory rate of 24 cpm and BP of 140/80. 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). To create a baseline set of observations for the ARDS patient, and to monitor any changes in the vital signs as the patient receives medical treatment. Learn more. (Symptoms) Reports of feeling short of breath EKG Rhythms | ECG Heart Rhythms Explained - Comprehensive NCLEX Review, Simple Anatomy Quiz Most Nurses Get WRONG! This will reduce hypoxemia resulting in improved oxygen saturation and reduce dyspnea. To stabilize vital signs and maintain adequate oxygen saturation prior to transfer from ED to the hospital unit. Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Cardiovascular System Complains of chest pain that is worse when coughing. Hypoxic patients can become anxious and irritable. 2023 nurseship.com. Close monitoring of types of food and drinks is also important. Fluid is constantly being added and reabsorbed by capillaries and lymph vessels in the pleura. -The nurse will teach the patient 3 signs and symptoms that indicate PCO2 level may be high and when to contact her md. demonstrating, performing treatments, Overall, treatment for COPD with impaired gas exchange focuses on reducing symptoms and slowing disease progression. An individual can have right-sided or left-sided heart failure as well as systolic or diastolic heart failure. Some of our partners may process your data as a part of their legitimate business interest without asking for consent. VS: HR 85, BP 130/82, Temp 98.6, RR irregular 19. St. Louis, MO: Elsevier. COPD, and by extension the impaired gas exchange associated with it, is caused by long-term exposure to environmental irritants. Some hospitals may havethe information displayed in digital format, or use pre-made templates. required for EACH NCLEX Review Care Plan for Ineffective Gas Exchange, Ineffective Airway Clearance, Pneumonia, COPD, Emphysema, & Common Cold The free nursing care plan example below includes the following conditions: Ineffective Gas Exchange, Ineffective Airway Clearance, Pneumonia, COPD, Emphysema, & Common Cold. thefabulousmrst 22 Posts Specializes in NICU. I was going to go with ineffective gas exchange, impaired swallowing, risk for infection ( he was on an infectious disease floor) and knowledge deficit. Impaired gas exchange occurs due to alveolar-capillary membrane changes, such as fluid shifts and fluid collection into interstitial space and alveoli. UNIVERSITY OF SOUTH ALABAMA To increase activity level to patients baseline prior to discharge. -Pt will be free from any facial and mouth breakdown frombipap machine. Continue with Recommended Cookies. Vital Signs: BP 120/80, HR 80, O2 Sat 87% on room air, Temp. You note when the patient is asleep she has apneic episodes where her oxygen saturation will decrease to 82%. A 2016 study found that, of 678 participants with COPD, 46 (7 percent) developed hypoxemia. Pt states she has been coughing up greenish to brownish sputum that is thick. Planning C. Implementation D. Diagnosis 4. Pt states she has felt bad since Monday and today is Friday. Otherwise, scroll down to view this completed care plan. The patient is on 3L nasal cannula with oxygen saturation of 88%. By accessing any content on this site or its related media channels, you agree never to hold us liable for damages, harm, loss, or misinformation. Patient reports shortness of breath and difficulty breathing. Interventions Follow guidelines as per facility for patients who are high risk for falls. ncbi.nlm.nih.gov/pmc/articles/PMC4230177/, nhs.uk/conditions/chronic-obstructive-pulmonary-disease-copd/, nhlbi.nih.gov/health-topics/how-lungs-work, ncbi.nlm.nih.gov/pmc/articles/PMC3107696/, onlinelibrary.wiley.com/doi/full/10.1111/resp.12619, ncbi.nlm.nih.gov/pmc/articles/PMC4547073/, bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-016-0331-0, COPD: How a 5-Question Screening Tool Can Help Diagnose Condition, 5 Ways to Keep Your Lungs Healthy and Strong, FEV1 and COPD: How to Interpret Your Results. Buy on Amazon, Silvestri, L. A. (2014). (2015). The subjective evaluation of itch showed a continuous decrease in itching scores throughout the course of the study compared to baseline. Frequent repositioning promotes drainage and movement of lung secretions. 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. expansion and Impaired Gas Exchange Diagnoses: Chronic Bronchitis (COPD) Problem Identified: Impaired Gas exchange Nursing Diagnoses: Impaired Gas Exchange r/t altered oxygen supplyobstruction. In doing this, it will help to remove additional fluid thereby improving his oxygen and breathing capability further. (2016). In CHF, the heart is either unable to contract completely or fill completely during relaxation. Reversal agents will diminish the respiratory depression caused by opiates. These are the tiny air sacs in your lungs where gas exchange occurs. In people with COPD, gas exchange is often impaired. Do not treat a patient based on this care plan. What are the risk factors for developing impaired gas exchange and COPD? 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. The health and flexibility of your airways and alveoli are vital in promoting effective gas exchange. Care Plans are often developed in different formats. Airway compromise can be caused by a physical blockage, such as a foreign body lodged in the airway. The patients lab work reveals an elevated BNP level of 954pg/mL and a chest x-ray shows pulmonary congestion.