Impaired Gas Exchange

Published on Monday October 12th , 2009

Impaired
Gas Exchange

(_)Actual (_)
Potential

Related
To:
[Check
those that apply]
(_)
Anesthesia
(_) Allergic response
(_) Altered level of consciousness

(_) Anxiety
(_) Aspiration
(_) Decreased lung compliance
(_) Edema of tonsils, adenoids, sinuses
(_) Excessive or thick secretions
(_) Fear

(_) Immobility
(_) Improper
positioning

 (_)
Infection
(_) Loss of lung elasticity
(_) Medication
(_) Neuromuscular impairment

(_) Obstruction
(_) Pain
(_) Smoking
(_) Surgery
(_) Other:_____________________________
____________________________________

____________________________________

 

As
evidenced by:
[Check
those that apply]
Major:

(Must be
present)		 (_)
Dyspnea on exertion.
Minor:

(May be
present)		 (_)
Tendency to assume a three-point position (bending
forward while supporting self by placing one hand on each
knee).
(_) Pursed lip breathing with prolonged expiratory phase.
(_) Increased anteroposterior chest diameter, if chronic.

(_) Lethargy and fatigue.
(_) Increased pulmonary vascular resistance (increased
pulmonary artery/right ventricular pressure).
(_) Decreased oxygen content, decreased oxygen
saturation, increased PCO2.
(_) Cyanosis.

 

Date &
Sign.		 Plan and Outcome
[Check
those that apply]		 Target
Date:		 Nursing Interventions
[Check
those that apply]		 Date
Achieved:
  The
patient will:

(_)
Demonstrate optimal gas exchange as permitted by clinical
condition A.E.B.:

  • absence of
    cyanosis
  • ABG’s are within
    acceptable limits.

(_) Other:

 

   (_)
Assess color, respiratory rate and depth, effort, rythm
q___.

(_) Check
for breath sounds q___.

(_) Report ABG’s that
deviate from patient’s baseline.

(_) Position to
facilitate optimum breathing patterns:

  • HOB elevated ___
    deg.
  • turn q____ hrs.
  • other:

(_) Cough and deep
breath.

(_) Suction q___ hrs.

(_) Increase actibity
as tolerated to facilitate diaphragm excursion. eg:
________________________
________________________

(_) Encourage fluid
intake to decrease viscosity of secretions (when
indicated).

(_) Explore with
patient potential etiological factors contributing to
impaired gas exchange and provide appropriate health
teaching. (Discharge Plan)

(_)
Other:________________
________________________
________________________
________________________

 

  

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature