3. Impaired gas exchange
related to: airway obstruction by secretions, spasm of the bronchus.
Nursing Diagnosis : Impaired Gas Exchange
related to: airway obstruction by secretions, spasm of the bronchus.
Nursing Diagnosis : Impaired Gas Exchange
Goal: Demonstrate improved ventilation and adequate oxygenation of tissues with blood gas analysis in the normal range and free of symptoms of respiratory distress.
Nursing Interventions - Impaired Gas Exchange related to Bronchitis:
a. Assess the frequency, depth of breathing. Note the use of accessory muscles, mouth breathing, inability to speak / talk.
R / useful in the evaluation of the degree of respiratory distress and / or chronic disease process.
b. Elevate head of bed, help patients to choose a position that is easy to breathe. Encourage deep breath or breathing lips slowly as needed / individual tolerance.
R / oxygen delivery can be improved by a high seating position and breathing exercises to reduce airway collapse, dyspnea, and breath work.
c. Provide appropriate bronchodilator required. Can be administered orally, IV, rectal, or inhaled. Give oral bronchodilators or IV at the time interspersed with the action nebulizer, metered dose inhalers to extend the effectiveness of the drug. Observation of side effects: tachycardia, dysrhythmias, CNS excitation, nausea and vomiting.
R / Bronchodilators dilate the airway and helps fight the bronchial mucosal edema and muscular spasm. Because side effects can occur in this action, carefully adjusted doses for each patient, according to tolerance and clinical response.
d. Evaluate the effectiveness of the actions nebulizer, metered dose inhalers. Assess decrease shortness of breath, wheezing or crackles drop, looseness secretion, decreased anxiety. Make sure that the action is given before meals to prevent nausea and to reduce the fatigue that accompanies feeding activity.
R / Combining medication with a nebulizer aerosolized bronchodilator commonly used to control bronchoconstriction. Providing appropriate actions will reduce its effectiveness. Aerolisation ease bronchial clearance, help control the inflammatory process, and improve the function of ventilation.
e. Instruct and encourage the patient on diaphragmatic breathing and effective coughing.
R / techniques improve ventilation by opening the airway and clearing the airway of sputum. Improvement of gas exchange.
f. Provide supplemental oxygen in accordance with the indications of blood gas analysis results and patient tolerance.
R / can fix / prevent worsening hypoxia.
Nursing Interventions - Impaired Gas Exchange related to Bronchitis:
a. Assess the frequency, depth of breathing. Note the use of accessory muscles, mouth breathing, inability to speak / talk.
R / useful in the evaluation of the degree of respiratory distress and / or chronic disease process.
b. Elevate head of bed, help patients to choose a position that is easy to breathe. Encourage deep breath or breathing lips slowly as needed / individual tolerance.
R / oxygen delivery can be improved by a high seating position and breathing exercises to reduce airway collapse, dyspnea, and breath work.
c. Provide appropriate bronchodilator required. Can be administered orally, IV, rectal, or inhaled. Give oral bronchodilators or IV at the time interspersed with the action nebulizer, metered dose inhalers to extend the effectiveness of the drug. Observation of side effects: tachycardia, dysrhythmias, CNS excitation, nausea and vomiting.
R / Bronchodilators dilate the airway and helps fight the bronchial mucosal edema and muscular spasm. Because side effects can occur in this action, carefully adjusted doses for each patient, according to tolerance and clinical response.
d. Evaluate the effectiveness of the actions nebulizer, metered dose inhalers. Assess decrease shortness of breath, wheezing or crackles drop, looseness secretion, decreased anxiety. Make sure that the action is given before meals to prevent nausea and to reduce the fatigue that accompanies feeding activity.
R / Combining medication with a nebulizer aerosolized bronchodilator commonly used to control bronchoconstriction. Providing appropriate actions will reduce its effectiveness. Aerolisation ease bronchial clearance, help control the inflammatory process, and improve the function of ventilation.
e. Instruct and encourage the patient on diaphragmatic breathing and effective coughing.
R / techniques improve ventilation by opening the airway and clearing the airway of sputum. Improvement of gas exchange.
f. Provide supplemental oxygen in accordance with the indications of blood gas analysis results and patient tolerance.
R / can fix / prevent worsening hypoxia.
| 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.:
(_) 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:
(_) 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:________________
________________________ ________________________ ________________________ |
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