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NCLEX & CGFNS Practice Questions
Impaired Gas Exchange
  • Actual
  • Risk for (Potential)

Related To: [Check those that apply]

  • Altered O2 supply
  • Alveolar-capillary membrane changes
  • Altered blood flow
  • Altered oxygen-carrying capacity of blood

As evidenced by: [Check those that apply]

  • Confusion
  • Somnolence
  • Restlessness
  • Irritability
  • Cyanosis
  • Inability to move secretions
  • Hypercapnia
  • Hypoxia
  • Dsypnea
  • Nasal Flaring

Patient’s Diagnosis: –
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Objective/Expected Outcome;The patient will:

  • maintains optimal gas exchange as evidenced by: normal ABGs, alert responsive mentation, and no further reduction in mental status.
  • Others

Note: you need to indicate time frame/target as objective must be measurable.

Nursing Interventions Scientific Rationale
Assess respirations: note quality, rate, pattern, depth, and breathing effort. Both rapid, shallow breathing patterns and hypoventilation affect gas exchange.
Assess for signs and symptoms of atelectasis: diminished chest excursion, limited diaphragm excursion, bronchial or tubular breath sounds, rales, tracheal shift to affected side. Collapse of alveoli increases physiological shunting.
Monitor vital signs. With initial hypoxia and hypercapnia, blood pressure (BP), heart rate, and respiratory rate all rise.
Assess for changes in orientation and behavior. Restlessness is an early sign of hypoxia. Chronic hypoxemia may result in cognitive changes, such as memory changes.
Monitor arterial blood gases (ABGs) and note changes. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure.
Use pulse oximetry to monitor O2 saturation and pulse rate continuously. Pulse oximetry is a useful tool to detect changes in oxygenation. O2 saturation should be maintained at 90% or greater.
Assess skin color for development of cyanosis. For cyanosis to be present, 5 gm of hemoglobin must desaturate.
Monitor chest x-ray reports. Chest x-rays may guide the etiologic factors of the impaired gas exchange.
Assess patient's ability to cough effectively to clear secretions. Note quantity, color, and consistency of sputum. Retained secretions impair gas exchange.
Maintain oxygen administration device as ordered, attempting to maintain O2 saturation at 90% or greater. To provide for adequate oxygenation.
Position with proper body alignment for optimal respiratory excursion (if tolerated, head of bed at 45 degrees). This promotes lung expansion and improves air exchange.
Change patient's position every 2 hours. This facilitates secretion movement and drainage.
Suction as needed. To clear secretions if the patient is unable to effectively clear the airway.
Encourage deep breathing, using incentive spirometer as indicated. To reduce alveolar collapse.
Encourage or assist with ambulation as indicated. To promote lung expansion, facilitate secretion clearance, and stimulate deep breathing.

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