Nursing Diagnosis & Care Plan for Impaired Gas Exchange- A Student’s Guide
Introduction
Impaired gas exchange is a very serious condition. It occurs when there is an interruption in the transfer of oxygen from the respiratory system to the bloodstream due to ineffective breathing, lung disease, or other problems. The patient may experience lethargy and shortness of breath, as well as a bluish tinge around their mouth.
This blog post will focus on how nurses can diagnose impaired gas exchange and the care plan to help those with this condition, and is meant for nursing students. As you read, keep in mind that our top writers are ready to help in case you get stuck or cannot complete your nursing assignment due to other reasons such as a busy schedule. All you need to is place an order with us!
Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students, for learning purposes only, and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.
What is Gas Exchange?
Gas exchange is how oxygen and carbon dioxide are transferred between an organism’s blood and its environment.
What is Impaired Gas Exchange?
Impaired gas exchange is a condition that occurs when there is an insufficient amount of oxygen in the blood. This can occur for various reasons, including but not limited to: lung disease, heart failure, and pneumonia.
Anatomy of the Respiratory System
The respiratory system is composed of the nose, pharynx, larynx, trachea, bronchi, and lungs. It is an organ involved in gas exchange through breathing; therefore, it relies on a smooth passage of air from the upper respiratory tract to the lower respiratory tract within the lungs.
The primary function of this organ is to provide a medium for aerobic respiration. When oxygen and carbon dioxide (CO2) exchange occurs in the lungs, it is called the gas exchange. This process occurs within the alveoli that are present in the lungs. The respiratory system allows gaseous components to pass into and out of the body through inhalation and exhalation.
It is essential for the smooth flow of blood and oxygen into the body and carbon dioxide out of the body.
Causes & Risk Factors of Impaired Gas Exchange
The most common cause of this condition is poor oxygen levels. This can be due to a compromised respiratory system or due to lung disease. Other risk factors include:
Age
The elderly are particularly at risk, and therefore healthcare workers must pay close attention to them.
Smoking/tobacco use
Smoking damages the lungs and other areas of the body, which can lead to impaired gas exchange
Kidney disease
This can result in fluid buildup in the lungs, which makes breathing harder
Trauma to the chest
A person may have been injured while playing sports or riding a bike, which could cause damage to their lungs.
Cardiovascular disease
People who have the cardiovascular disease may be at risk for impaired gas exchange.
Signs & Symptoms of Impaired Gas Exchange
The signs and symptoms of impaired gas exchange include:
- A bluish color to their lips or nail beds indicates altered oxygen supply
- Lightheadedness
- Feelings of extreme exhaustion
- Wheezing/ breath sounds
- Rapid breathing or difficulty breathing (each breath may seem very shallow)
- Vomiting/nausea – this often occurs when the CO2 (carbon dioxide) levels in the blood rise or if there is a large amount of fluid in their lungs
- Loss of consciousness – this is very serious and requires immediate action
Nursing Diagnosis for Impaired Gas Exchange
The nursing diagnoses that are associated with impaired gas exchange include:
Nursing Diagnosis-Airway clearance
Airway clearance is the nursing diagnosis that describes this condition. It occurs when there is an interruption in the transfer of oxygen from the respiratory system to the bloodstream due to ineffective breathing, lung disease, or other problems. The patient will experience lethargy and shortness of breath as well as a bluish tinge around their mouth.
Nursing Diagnosis -Infection
Patients with impaired gas exchange are at a greater risk for infection because they have difficulty breathing and generally spend more time in bed.
Nursing Diagnosis -Injury
This is another nursing diagnosis that is associated with impaired gas exchange. It occurs when there is an interruption in the transfer of oxygen from the respiratory system to the bloodstream due to ineffective breathing, lung disease, or other problems.
Nursing Diagnosis -Activity intolerance
Having difficulty breathing can make it difficult for a person to get around, leading to less aerobics and possible weight gain.
Fatigue
Fatigue due to poor oxygen levels, the patient will be fatigued most of the time and will feel extreme exhaustion.
Pain
Pain is associated with lung disease or respiratory system damage.
Pulse Oximetry Aids in Diagnosing Impaired Gas Exchange
One of the ways that a person’s gas exchange can be tested is by using pulse oximetry. This is where a small device will measure a patient’s oxygen levels and heart rate. This information will then be displayed on the monitor hooked up, which allows doctors to observe the changes in a patient’s vitals over time.
Chest X-ray
A chest X-ray is the best way to tell if a patient has impaired gas exchange. Chest X-rays will allow the healthcare worker to see if there is fluid build in the lungs, which would indicate impaired gas exchange.
Nursing Care Plan for Impaired Gas Exchange Patients
-Keep the patient’s head elevated at all times.
-Maintain a fluid intake of approximately 30-40 cc/kg/day (fluids should contain glucose, amino acids, and essential fatty acids). This will keep mucous membranes moist for easier breathing and reduce damage to the respiratory system.
-Maintain bowel regularity by using stool softeners or laxatives to keep the airways free of mucus buildup.
-Keep the patient away from people with infections that could spread to them, such as colds and flu.
-Keep the patient away from secondhand tobacco smoke.
-Allow the patient to rest when needed.
-Ensure that there is a call system in place and that the staff is aware of any changes in the patient’s condition or if they develop fever or chills.
-Inform other members of your team so care can be provided at all times.
-Keep the room temperature between 18-20 degrees Celsius, and ensure the patient is warm enough that they do not shiver or get cold.
-Turn on humidifiers in the patient’s room if too dry of an environment is present to decrease cracks in the mucous membranes and allow easier breathing.
-Please check the patient’s oxygen saturation levels, pulse oximetry, and respiratory rate every 2 hours or more frequently if needed.
-If the patient is experiencing pain, administer analgesics to relieve them of any pain they are experiencing.
-If the patient has a chest infection, administer antibiotics as prescribed by your physician to correct this issue. -If the patient is dehydrated, provide oral rehydration therapy. This can include fluids (like Gatorade) high in electrolytes, which replace what is lost when a person has diarrhea or vomiting.
-Keep secretions moistened with water as directed by the physician’s orders. -Administer bronchodilators or steroids as prescribed by your physician to relieve breathing difficulties and other respiratory issues.
-Check the patient’s skin color, lips, nailbeds, and mucous membranes frequently to ensure adequate oxygenation for the patient’s safety.
-Monitor vital signs like heart rate, respiratory rate, and blood pressure throughout the shift to ensure that abnormalities do not develop with the patient’s condition.
-Position the bed at an angle of 45 degrees to facilitate adequate oxygen flow in and out of the lungs.
Standing Orders – Chest Pain or Shortness of Breath (Shortness of Breath)
If you notice any signs or symptoms, please report them immediately. These include:
-Sweating and pale color of the skin (from lack of oxygen and blood flow). -If the patient begins breathing rapidly, stops with pauses, or is irregular. This is a sign that the patient has lost control over body functions such as heartbeat or breathing. If this occurs, immediately call for help and administer CPR if needed.
-If you notice chest pain in your patient, give oxygen to relieve this pain.
-If the patient has been coughing up mucus, administer cough suppressants as directed by your physician.
-Report any change in mental statuses such as confusion or delirium. This is a sign of respiratory distress and can result in death if not treated quickly. If this occurs, immediately call for help and administer oxygen as needed and CPR if needed.
-Report any change in sleeping or breathing patterns, or if the patient experiences a decreased appetite or is not eating. This can also be a sign of respiratory distress, so report it immediately to your team members, other staff on duty, and your physician’s office.
Impaired Gas Exchange Nursing Interventions
Nursing interventions to promote gas exchange:
-Monitor vital signs such as temperature, heart rate, respiratory rate, and pulse oximetry (measures amount of oxygen in the blood) every 4 hours or more frequently if needed.
-Assess the patient’s respiratory status, performing pulmonary function tests, and observing for fever or chills, which can signal an infection or other condition that may require additional treatment to resolve.
Assess the patient’s oxygen saturation and arterial blood gas levels, heart rate, respiratory rate, and lung sounds throughout the shift to ensure adequate respiration for optimal patient safety.
-Monitor patient’s skin color, lips, nail beds, and mucous membranes. It should be noted that if the patient’s skin is blue or purplish-blue, low oxygen saturation levels are present.
-Administer medications such as bronchodilators to open airways, albuterol for asthma, or steroids for allergic reactions.
-Administer oxygen as per the physician’s orders.
-Provide rest periods for the patient to help prevent complications.
-Elevate the head of the bed to facilitate adequate oxygen flow in and out of the lungs. Position it to about 45 degrees, which will make breathing easier.
-Maintain a patent airway to prevent gagging/choking from secretions. Provide care as needed for the patient’s comfort and safety, including skincare and catheter care.
-Administer oxygen by face mask or nasal cannula to relieve dyspnea (shortness of breath). -Position patient in semi-Fowler’s position. Prepare for an emergency, such as suctioning the airways, mouth-to-mouth, and/or CPR if needed to promote patient safety until help arrives.
Standing Orders – Hypoxemia or Low Blood Oxygen (Hypoxemia)
If you notice any signs or symptoms, please report them immediately. These include:
-Cold, clammy, and pale skin (from lack of oxygen and blood flow).
-If the patient’s breathing has become fast or irregular, with periods where it is not recognized, or they stop breathing altogether. If this occurs, immediately call for help and administer CPR if needed.
-If you notice chest pain in your patient, give oxygen to relieve this pain.
-If the patient has been coughing up mucus, administer cough suppressants as directed by your physician.
-Report any change in mental statuses such as confusion or delirium. This is a sign of respiratory distress and can result in death if not treated quickly. If this occurs, immediately call for help and administer oxygen as needed and CPR if needed.
-Report any change in sleeping or breathing patterns, or if the patient experiences a decreased appetite or is not eating. This can also be a sign of respiratory distress, so report it immediately to your team members, other staff on duty, and your physician’s office.
-Keep emergency equipment, such as a suction catheter and oxygen tubing, at the bedside.
-Initiate frequent position changes to promote gas exchange for patients on mechanical ventilation (breathing machine).
Standing Orders – Asthma Care Plan (Asthma)
If you notice any signs or symptoms, please report them immediately. These include:
-A feeling that the breathing is restricted as if a weight was on your chest.
-If you experience any physical signs like increased heart rate and the rapid shallow breathing of short gasped breaths.
-A whistling sound/ breath sounds when breathing out accompanied by wheezing with each breath (wheeze).
-If your asthma symptoms worsen, you should call for help immediately and administer albuterol as ordered by the health care provider.
-Consider using your bronchodilator, which is an inhaler to open airways. You can also take an oral steroid if needed once approved by the health care provider.
-Stay on top of your asthma medications.
-Walk around during your rest period even if you do not feel like it. Reduction in inactivity can lead to respiratory distress and possible complications due to lack of oxygen.
Nursing Interventions Directed Towards Patient Comfort and Safety
-Assisting the patient with exercises to enhance breathing and lung efficiency. This can include using the incentive spirometer, which increases air capacity by strengthening the respiratory muscles.
– Administering medications as prescribed during the nursing shift.
Non-pharmacological interventions
-Encourage smoking cessation – nicotine is a bronchodilator that opens airways. It also causes fluid buildup in the lungs and inhibits proper blood flow to the heart.
– Provide relaxation techniques such as deep breathing, massage therapy, or guided imagery to help the patient relax and reduce the stress that may contribute to their symptoms.
– Provide restriction/elimination diets for patients who suffer from asthma and bronchitis due to inflammation of the airways. These foods include foods that are spicy, fried, or contain preservatives. They may also restrict dairy, egg, and wheat products.
Nursing Interventions that are directed towards the caregiver
Please provide information about the disease process to family members and caretakers and encourage them to provide adequate rest for the patient. This allows for decreased anxiety and frustration in the patient, which is important in recovering from their condition.
– Educate the patient on ways to avoid fatigue, such as recommending short walks and proper rest periods during the day.
Complications for Impaired Gas Exchange
The patient may experience the following complications:
-Pneumonia: a condition in which an infection of the lungs causes inflammation or tissue damage. If not treated, this can cause fluid accumulation and strain on the heart leading to cardiac arrest.
– Chronic Obstructive Pulmonary Disease (COPD): this is a progressive lung disease that causes airflow blockage to the lungs. This can be caused by smoking, allergies, and/or exposure to harmful chemicals such as smoke from a fire or inhaling asbestos.
– Asthma: more than half of those who develop asthma will have symptoms into adulthood. Aside from physical characteristics, there are no distinguishing features between children and adults who have asthma.
– Heart Failure: affects approximately 2 million people in the United States and is one of the most common causes of hospitalization among older people. It occurs if the heart muscle or its valves become damaged. The heart then cannot pump blood as well as it should.
You may also be interested in Comprehensive Nursing Diagnosis for Heart Failure
Summary
A patient with impaired gas exchange may experience shortness of breath and difficulty breathing due to an inability to oxygenate the blood. This is a condition where there is not enough oxygen for the body’s cells, organs, tissues, and systems needed for survival.
Signs and symptoms include hypoxemia (low levels of oxygen in the blood), dyspnea (shortness of breath), tachypnea (rapid breathing), and rapid heart rate.
It may be caused by infections, such as pneumonia or COPD, allergies, anemia, or other diseases that diminish the oxygen-carrying capacity of the blood.
The nursing interventions for this condition concern assessment and treatment of the patient regarding their hypoxemia, as well as relieving anxiety and/or stress that the patient may experience. Treatment can include medications, breathing exercises, and dietary modifications.
The caregiver is also the main focus in this condition because they are responsible for assisting the patient in staying calm and composed during their recovery period.
