Nursing Diagnosis: Impaired Gas exchange Application of NANDA, NOC, NIC

Nursing Diagnosis: Impaired Gas exchange
Betty J. Ackley

NANDA Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane

Defining Characteristics: Visual disturbances; decreased carbon dioxide; dyspnea; abnormal arterial blood gases; hypoxia; irritability; somnolence; restlessness; hypercapnia; tachycardia; cyanosis (in neonates only); abnormal skin color (pale, dusky); hypoxemia; hypercarbia; headache on awakening; abnormal rate, rhythm, depth of breathing; diaphoresis; abnormal arterial pH; nasal flaring

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         Respiratory Status: Gas Exchange

·         Respiratory Status: Ventilation

·         Tissue Perfusion: Pulmonary

·         Vital Signs Status

·         Electrolyte and Acid-Base Balance

Client Outcomes

·         Demonstrates improved ventilation and adequate oxygenation as evidenced by blood gases within client's normal parameters

·         Maintains clear lung fields and remains free of signs of respiratory distress

·         Verbalizes understanding of oxygen and other therapeutic interventions

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Airway Management

·         Oxygen Therapy

·         Respiratory Monitoring

·         Acid-Base Management

Nursing Interventions and Rationales

·         Monitor respiratory rate, depth, and effort, including use of accessory muscles, nasal flaring, and abnormal breathing patterns. Increased respiratory rate, use of accessory muscles, nasal flaring, abdominal breathing, and a look of panic in the client's eyes may be seen with hypoxia.

·         Auscultate breath sounds q __ h(rs). Presence of crackles and wheezes may alert the nurse to an airway obstruction, which may lead to or exacerbate existing hypoxia.

·         Monitor client's behavior and mental status for onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. Changes in behavior and mental status can be early signs of impaired gas exchange (Misasi, Keyes, 1994). In late stages the client becomes lethargic, somnolent, and then comatose (Pierson, 2000).

·         Monitor oxygen saturation continuously, using pulse oximeter. Note blood gas results as available. An oxygen saturation of <90% (normal: 95% to 100%) or a partial pressure of oxygen of <80 (normal: 80 to 100) indicates significant oxygenation problems.

·         Observe for cyanosis in skin; especially note color of tongue and oral mucous membranes. Central cyanosis of tongue and oral mucosa is indicative of serious hypoxia and is a medical emergency. Peripheral cyanosis in extremities may or may not be serious (Carpenter, 1993).

·         If client is acutely dyspneic, coach the client to slow respiratory rate using touch on the shoulder, demonstrating slower respirations while making eye contact with the client, and communicating in a calm, supportive fashion. Anxiety can exacerbate dyspnea, causing the client to enter into a dyspneic panic state (Gift, Moore, Soeken, 1992; Bruera et al, 2000). The nurse's presence, reassurance, and help in controlling the client's breathing can be very beneficial (Truesdell, 2000).

·         Demonstrate and encourage the client to use pursed-lip breathing. Pursed-lip breathing results in increased use of intercostal muscles, decreased respiratory rate, increased tidal volume, and improved oxygen saturation levels (Breslin, 1992). Pursed-lip breathing can result in increased exercise performance (Casciarai et al, 1981), and it empowers the client to self-manage dyspnic incidences (Truesdell, 2000).

·         Position client with head of bed elevated, in a semi-Fowler's position as tolerated. Semi-Fowler's position allows increased lung expansion because the abdominal contents are not crowding the lungs.

·         If client has unilateral lung disease, alternate semi-Fowler's position with lateral position (with a 10- to 15-degree elevation and "good lung down" for 60 to 90 minutes). This method is contraindicated for clients with a pulmonary abscess or hemorrhage or interstitial emphysema. Gravity and hydrostatic pressure cause the dependent lung to become better ventilated and perfused, which increases oxygenation (Lasater-Erhard, 1995; Yeaw, 1992).

·         If client has a bilateral lung disease, position in either a semi-Fowler's or side-lying position, which increases oxygenation as indicated by pulse oximetry (or if client has pulmonary catheter, venous oxygen saturation). Turn client every 2 hours. Monitor mixed venous oxygen saturation closely after turning. If it drops below 10% or fails to return to baseline promptly, turn the client back into a supine position and evaluate oxygen status. Turning is important to prevent complications of immobility, but in critically ill clients with low hemoglobin levels or decreased cardiac output, turning on either side can result in desaturation (Winslow, 1992). Critically ill clients should be turned carefully and watched closely (Gawlinksi, Dracup, 1998).

·         If client is obese or has ascites, consider positioning client in reverse Trendelenburg position at 45 degrees for periods as tolerated. A study demonstrated that use of the reverse Trendelenburg position at 45 degrees resulted in increased tidal volumes and decreased respiratory rates in a group of intubated clients with obesity, abdominal distention, and ascites (Burns et al, 1994; Winslow, 1996).

·         Consider positioning the client prone with upper thorax and pelvis supported, allowing the abdomen to protrude. Monitor oxygen saturation, and turn back if desaturation occurs. Do not put in prone position if client has multisystem trauma. Partial pressure of arterial oxygen has been shown to increase in the prone position, possibly because of greater contraction of the diaphragm and increased function of ventral lung regions (Douglas et al, 1977; Lasater-Erhard, 1995; Curley, 1999). Prone positioining improves hypoxemia significantly (Dupont et al, 2000). In one study clients with multisystem trauma had serious iatrogenic injuries with prone positioning, including wound dehiscence, chest wall pressure necrosis, and a cardiac arrest (Offner et al, 2000).

·         If client is acutely dyspnic, consider having client lean forward over a bedside table, if tolerated. Leaning forward can help decrease dyspnea, possibly because gastric pressure allows better contraction of the diaphragm (Celli, 1998). The tripid position can be helpful during times of dypnea (Dunn, 2001).

·         Help client deep breathe and perform controlled coughing. Have client inhale deeply, hold breath for several seconds, and cough two to three times with mouth open while tightening the upper abdominal muscles as tolerated. This technique can help increase sputum clearance and decrease cough spasms (Celli, 1998). Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective

NOTE: If client has excessive fluid in respiratory system, see interventions for Ineffective Airway clearance.

·         Monitor the effects of sedation and analgesics on client's respiratory pattern; use judiciously. Both analgesics and medications that cause sedation can depress respiration at times. However, these medications can be very helpful for decreasing the sympathetic nervous system discharge that accompanies hypoxia.

·         Schedule nursing care to provide rest and minimize fatigue. The hypoxic client has limited reserves; inappropriate activity can increase hypoxia.

·         Administer humidified oxygen through appropriate device (e.g., nasal cannula or face mask per physician's order); watch for onset of hypoventilation as evidenced by increased somnolence after initiating or increasing oxygen therapy. A client with chronic lung disease client may need a hypoxic drive to breathe and may hypoventilate during oxygen therapy.

·         Provide adequate fluids to liquefy secretions within the client's cardiac and renal reserve. If client is severely debilitated from chronic respiratory disease, consider use of a wheeled walker to help in ambulation.

·         Use of a wheeled walker has been shown to result in significant decrease in disability, hypoxemia, and breathlessness during a 6-minute walk test (Honeyman, Barr, Stubbing, 1996).

·         Monitor nutritional status. Refer client for a dietary consult if needed. Many clients with emphysema are malnourished. Improved nutrition can help improve inspiratory muscle function (Meeks et al, 1999).

·         If chronic pulmonary disease is interfering with quality of life, refer client for pulmonary rehabilitation. Pulmonary rehabilitation programs that include desensitization to dyspnea and guided mastery with monitored exercise are preferable. Pulmonary rehabilitation has been shown to improve exercise capacity, ability to walk, and sense of well-being (Fishman, 1994; American Thoracic Society, 1999; Janssens, 2000). The processes of desensitization and guided mastery for control of dyspnea have helped clients learn to be in control of their condition and have increased the amount of activity they can tolerate (Carrieri-Kohlman et al, 1993).

·         Refer client to pulmonary rehabilitation team if client has chronic respiratory disease. This team is multidisciplinary, and working together can help increase exercise capacity, decrease dyspnea, improve quality of life, and decrease admissions to the hospital (Celli, 1998).

NOTE: If client becomes ventilator-dependent, see care plan for Impaired spontaneous Ventilation.

Geriatric

·         Use central nervous system depressants carefully to avoid decreasing respiration rate. An elderly client is prone to respiratory depression.

·         Maintain low-flow oxygen therapy. An elderly client is susceptible to oxygen-induced respiratory depression.

·         Encourage client to stop smoking. There are substantial health benefits for elderly clients who stop smoking (Foyt, 1992).

Home Care Interventions

·         Assess the home environment for irritants that impair gas exchange. Help the client to adjust home environment as necessary (e.g., installing air filter to decrease presence of dust).

·         Refer client to occupational therapy as necessary to assist with adapting to home environment and energy conservation.

·         Assist client with identifying and avoiding situations that exacerbate impairment of gas exchange (e.g., stress-related situations, proximity to noxious gas fumes such as chlorine bleach). Irritants in the environment decrease the client's effectiveness in accessing oxygen during breathing.

·         Instruct client to limit exposure to persons with respiratory infections.

·         Instruct family in complications of disease and importance of maintaining medical regimen, including when to call physician.

·         Assess nutritional status. Instruct client to eat several small meals daily and to use dietary supplements as necessary. Clients with decreased oxygenation have little energy to use for eating and will avoid meals. Malnutrition significantly affects the aerobic capacity of muscle and exercise tolerance in clients with chronic obstructive pulmonary disease (COPD) (Palange et al, 1995). When nutritional status is clearly improved, it is accompanied by improvements in strength of the respiratory muscles and, in some studies, increased distance of walking (Larson, Leidy, 1998).

·         Refer client for home health aide services as necessary to assist with activities of daily living (ADLs). Clients with decreased oxygenation have decreased energy to carry out personal and role activities.

·         Assess family role changes and coping ability. Refer client to medical social services as appropriate for assistance in adjusting to chronic illness. Inability to maintain pre-illness level of social involvement leads to frustration and anger in the client and may create a threat to the family unit. In one study, clients with chronic lung problems were described as negative, helpless, confused, and socially obstreperous by their family members (Leidy, Traver, 1996).

·         Refer to outpatient pulmonary rehabilitation program, or a home-based training program for COPD. Outpatient rehabilitation programs can achieve worthwhile benefits, including decreased perception of dypnea, increased walking distance, and less fatigue, with benefits that persist for a period of 2 years (Glell R et al, 2000). A simple home-based program of exercise training can achieve improvement in exercise tolerance, dyspnea, and quality of life for COPD patients (Hernandez et al, 2000). In mild COPD, a weight-training program was shown to result in increased strength and increased exercise tolerance (Clark et al, 2000).

·         Support family of client with chronic illness. Severely compromised respiratory functioning causes fear and anxiety in clients and their families. Reassurance from the nurse can be helpful.

Client/Family Teaching

·         Teach client these techniques to use during acute dypneic episodes:

o Pursed-lip breathing and controlled diaphragmatic breathing: Have client watch pulse oximetry to note improvement in oxygenation with breathing techniques. Controlled breathing techniques can help control anxiety and decrease panic and dyspnea (Celli, 1998; Dunn, 2001).

o Progressive muscle relaxation with or without guided imagery. Progressive relaxation eases the workload of muscles that are not being used to breathe, reducing the body's oxygen requirement (Dunn, 2001).

o Assistive breathing technique: Fold arms just below ribcage and push into belly while exhaling, then release during inhalation; repeat process until breathing becomes more controlled. This technique can help push the diaphragm up and force out the trapped air that was causing the feeling of pressure (Dunn, 2001).

·         Instruct client to keep home temperature above 68ø F and to avoid cold weather. Cold air temperatures cause constriction of the blood vessels and increased moisture, impairing the client's ability to absorb oxygen.

·         Teach clients to keep humidity levels in their homes between 40% and 50%, using a humidifier or dehumidifier as needed. Both high humidity and low humidity can affect the ability of the COPD client to breathe comfortably (Dunn, 2001).

·         Teach client energy conservation techniques and the importance of alternating rest periods with activity. See nursing interventions for Fatigue.

·         Teach the importance of not smoking. Be aggressive in approach, and ask client to set a date for smoking cessation. Recommend nicotine replacement therapy (nicotine patch or gum). Refer client to smoking cessation programs. Encourage clients who relapse to keep trying to quit. All health care clinicians should be aggressive in helping smokers quit (Agency for Health Care Policy Research, 1996).

·         Instruct family regarding home oxygen therapy if ordered (e.g., delivery system, liter flow, safety precautions). If need for oxygen is chronic, encourage use of a portable system. Explain advantages of transtracheal oxygen delivery systems. Encourage client to use oxygen as ordered. Clients with portable oxygen therapy spent more time outside and walked futher than people with fixed delivery systems (Vergeret, Brambilla, Mounier, 1989). Clients with transtracheal oxygen delivery systems were more independent than those with fixed delivery systems and had increased morale (Bloom et al, 1989; Larson, Leidy, 1998). Clients who used oxygen for longer periods had decreased mortality (Pierson, 2000).

·         Teach client relaxation therapy techniques to help reduce stress responses and panic attacks resulting from dyspnea. Relaxation therapy includes progressive muscle relaxation, autogenic techniques, visualization, and diaphragmatic breathing. This therapy can help to modify the symptoms of dyspnea and help the client deal with feelings associated with the chronic disease (Jerman, Haggerty, 1993).