Impaired Gas Exchange

Assessment Subjective: “Mabilis ang kanyang paghinga” as stated. Objective: -RR: 28 cpm -PR: 102 bpm -wheezes upon auscultation -with pulse oxymeter  -with mechanical mechanical ventilator 

Nursing Diagnosis Impaired Gas Exchange related to altered oxygen supply (obstruction of  airways by secretion) as evidenced by wheezes upon auscultation

Scientific Explanation Entry of noxious particles or gases to the lungs ↓ Release of  mediators ↓ Abnormal inflammation of the lungs ↓ Chronic inflammation ↓ Scar tissue formation ↓ Narrowing of  airway lumen ↓ Airflow limitations ↓ Impaired gas exchange ↓ wheezes

Reference: Pathophysiology

Planning Discharge Outcome: After 3 days of  nursing intervention the client: -Manifest absence of wheezes upon auscultation -Attain normal breathing pattern of 20 cpm

Short-term outcome: After 2 hours of nursing intervention the client: -Demonstrate improved ventilation and adequate oxygenation of  tissues by ABG of: pH:7.35-7.45 paCO2: 3545mmHg

Intervention

Rationale

Independent:

Evaluation Discharge Outcome ACHIEVED: After 3 days of  nursing intervention the client: -Manifested absence of  wheezes upon auscultation - Attained normal breathing pattern of 20 cpm

-Monitor skin and mucous membrane color 

-Duskiness and central cyanosis indicate advanced hypoxemia

-Elevate head of the bed, assist patient to assume position to ease work of  breathing

-Oxygen delivery may be improved by upright suctioning

-Suction when needed

-Suctioning is required when cough is ineffective for expectoration of secretions Short-term outcome -Presence of  ACHIEVED: wheezes may After 2 hours indicate of nursing bronchospasm/ intervention the retained secretions client: -Demonstrated improved -Decrease of  ventilation and vibratory tremors adequate suggest fluid oxygenation of  collection or air  tissues by ABG of: tapping pH:7.35-7.45

-Auscultate breath sounds, noting areas of decreased air-flow or presence of  adventitious sound

-Palpate for fremitus

by Gold, 4th edition p.345

paO2: 8095mmHg -Decrease respiratory rate from 28cpm to 13 cpm

-Provide quiet environment to allow the patient to relax

-External stimuli may prevent relaxation or inhibit sleep

Collaborative: -Monitor pulse oximetry and ABGs -Administer  antianxiety, sedative, or narcotic agents as indicated(e.g.morhine )

-to identify if  hypoxia is present -to reduce dyspnea by controlling the anxiety and restlessness -use as aid in treatment

-Hooked to mechanical ventilator  Reference: Nursing care Plan by Marilyn Doenges, 7th edition p.124-125

paCO2: 3545mmHg paO2: 8095mmHg -decreased respiratory rate from 28cpm to 13 cpm