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Impaired Gas Exchange

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