Impaired gas exchange is when there is a disruption of the oxygen and carbon dioxide exchange in the lung tissues. This nursing diagnosis can be a serious health threat usually closely associated with other nursing diagnoses like ineffective breathing pattern or ineffective airway clearance.
In this article:
- Causes (Related to)
- Signs and Symptoms (As evidenced by)
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Causes (Related to)
Impaired gas exchange can result from any condition that compromises a patient’s airway, blood flow, or respiratory effectiveness. The following are common causes of impaired gas exchange:
- Airway compromise can be caused by a physical blockage, such as a foreign body lodged in the airway.
- Reductions in blood flow resulting in impaired gas exchange can be related to cardiac or pulmonary problems such as a pulmonary embolism or heart failure. Diseases that affect the ability for blood to carry oxygen can also result in impaired gas exchange.
- Respiratory effectiveness can be affected by chronic conditions that affect the lungs like chronic obstructive pulmonary disorder. Certain drugs, including opiates, can depress a patient’s respiratory rate and depth resulting in impaired gas exchange as well.
Signs and Symptoms (As evidenced by)
Impaired gas exchange can manifest with a variety of signs and symptoms. In a physical assessment, a patient with impaired gas exchange may present with one or more of the following:
Subjective: (Patient reports)
Objective: (Nurse assesses)
- Altered respiratory patterns
- Restlessness
- Lethargy
- Cyanosis
- Confusion
- Irritability
- Impending sense of doom
- Lab values
- Abnormal arterial blood gas values or blood pH
- Vital signs changes
- Increased heart rate
- Decreased oxygen saturation
Expected Outcomes
The following are the common nursing care planning goals and expected outcomes for impaired gas exchange:
- Patient will report relief of dyspnea.
- Patient will have an oxygen saturation of greater than 90%.
- Patient will manifest vital signs within normal limits.
- Patient will present signs and symptoms of improved ventilation.
- Patient will demonstrate arterial blood gas (ABG) levels within normal limits.
- Patient will have imaging scans with normal lung findings.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. The following section will cover subjective and objective data related to impaired gas exchange.
1. Monitor the vital signs.
Blood pressure and pulse rate first increase with the severity of hypoxemia/hypercapnia but later fall as the impairment to gas exchange worsens. It can reveal respiratory rate and oxygen saturation alterations as gas exchange continuously impairs.
2. Attach a continuous pulse oximeter to the patient.
A pulse oximeter is a quick assessment that determines the oxygen saturation level. Close observation of the patient’s oxygen level and assessment of treatments are accessible by a continuous pulse oximeter.
3. Assess the respiratory status.
Examine the lungs for altered ventilation, the rate and quality of respirations, and the use of the accessory muscles. Increased breathing effort indicates hypoxia. Variations in breathing patterns may be a sign of altered oxygen levels.
4. Auscultate the lung sounds.
Hypoxemia may arise from alveolar collapse. Impaired gas exchange is manifested by the presence of adventitious breath sounds, such as:
- Wheezing
- Crackles
- Stridor
- Rhonchi
- Pleural friction rub
5. Assess the cardiovascular status.
Heart problems and blood conditions may affect the oxygen levels in the blood, causing impaired gas exchange. Track alterations in blood pressure, cardiac rhythm, or heart rate. In addition to severe dysrhythmias, hypoxemia can alter blood pressure and heart rate.
6. Assess for anxiety, mentation, and behavior.
Reduced cerebral perfusion is reflected in changes in cognition and behavior. Anxiety alters the flow of oxygen to the brain by inducing vasoconstriction.
7. Obtain a blood sample.
Monitor the arterial blood gas (ABG) and hemoglobin levels to determine the presence of inadequate oxygen and carbon dioxide, causing respiratory alterations (such as hypoxemia, respiratory acidosis, and respiratory failure).
8. Prepare the patient for imaging scans.
The following imaging tests of the chest help determine the cause behind the compromised gas exchange:
- Chest X-ray
- Chest computed tomography (CT)
- CT angiogram
- Ventilation-perfusion (VQ scan)
9. Perform PFT.
The Pulmonary Function Test (PFT) directly measures lung volumes, bronchodilator response, and diffusion capacity. It can aid in diagnosing and directing lung disease treatment.
Nursing Interventions
Nursing interventions and care are essential for the patient’s recovery from impaired gas exchange. In the following section, you’ll learn about possible nursing interventions for a patient with impaired gas exchange.
1. Maintain patent airway.
Ensure the upper airways remain open by:
- Proper suctioning techniques
- Head tilt and jaw thrust maneuver
- Placement of endotracheal tube or tracheostomy
- Use of positive pressure ventilation (such as CPAP or BiPAP)
2. Administer oxygen therapy as ordered.
Nurses can administer 2-6 liters per minute of oxygen through a nasal cannula during emergencies. Oxygen therapy can increase the oxygen levels, preventing hypoxia and hypoxemia. Patients with COPD should avoid high concentrations of oxygen. For patients with COPD, nurses should aim to maintain Sa02 between 88-92%.
3. Prepare for possible intubation and mechanical ventilation.
Ventilation and oxygenation can require mechanical assistance. Ensure a crash cart at the bedside for possible intubation. Coordinate with the respiratory therapist for the use of a mechanical ventilator.
4. Administer medications as ordered.
Medications are ordered based on the cause of the impaired gas exchange. The following medications are used to open the airways and maintain their patency, such as:
- Bronchodilators
- Steroids
- Mucolytics
5. Place the patient comfortably.
Reposition the patient every two hours or as per the facility’s policy. It encourages optimal lung expansion, drainage, and secretion movement. The patient may be placed in the following positions:
- Semi-Fowler’s position
- High Fowler’s (sitting) position
- Orthopneic position
- Tripod position
- Trendelenberg position (for patients with hypovolemic shock)
6. Treat the underlying cause.
The root cause of poor gas exchange determines the course of treatment. The reason may be an acute or chronic condition, such as:
- Asthma
- Chronic obstructive pulmonary disease (COPD)
- Lung infection (pneumonia)
- Pneumothorax
- Fluid in the lungs (pulmonary edema)
- Blood clot in the lungs (pulmonary embolism)
- Low hemoglobin levels
- Heart defects
- Cardiac condition (such as heart failure)
7. Replace the fluids with caution.
Fluids may cause or may help impaired gas exchange. Administer fluids with caution to patients with heart conditions (such as heart failure) or those with fluid in the lungs. Encouraging increased fluids can liquify the secretion and help mobilize and expel them quickly.
8. Manage anxiety and respiratory depression.
If impaired gas exchange is related to respiratory depression, carry out the recommended reversal agents. Reversal medications such as naloxone will lessen the respiratory depression brought on by opioids.
9. Ask the patient to demonstrate breathing and coughing techniques.
Teach the patient how to use breathing and coughing exercises for therapeutic purposes. Using the proper breathing and coughing methods helps promote oxygenation and air exchange while mobilizing secretions, particularly if the patient has atelectasis.
10. Refer the patient to pulmonary rehabilitation.
Determine whether the patient is willing to recommend pulmonary rehabilitation. Pulmonary rehabilitation can help patients with long-term respiratory conditions.
11. Collaborate with the respiratory therapist.
Respiratory therapists may recommend the appropriate intervention for the patient. They monitor the patient’s arterial blood gas and adjust the mechanical ventilator accordingly.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section you will find nursing care plan examples for impaired gas exchange.
Care Plan #1
Diagnostic statement:
Impaired gas exchange related to alveolar-capillary membrane changes secondary to COPD as evidenced by oxygen saturation 79%, heart rate 112 bpm, and patient reports of dyspnea.
Expected outcomes:
- Patient will have oxygen saturation of greater than 90% within 1 hour of nursing interventions.
- Patient will manifest stable vital signs within normal limits within 4 hours of nursing intervention.
- Patient will demonstrate ABG findings within normal limits at the end of the shift.
- Patient will reveal improving breath sounds or diminishing adventitious sounds at the end of the shift.
Assessment:
1. Listen to the lung sounds.
Assess for lung sounds for indications of atelectasis. The collapse of the alveoli can cause hypoxemia.
2. Monitor the vital signs.
Check vital signs every 15 minutes and assess for changes in heart rate and blood pressure. As hypoxemia/hypercapnia progresses, heart rate and blood pressure rise at first and then decrease as the gas exchange impairment becomes more severe.
3. Monitor the oxygen saturation.
Use a continuous pulse oximeter to monitor oxygen saturation.
4. Obtain ABG.
The most reliable indicator of the degree and acuteness of a disease exacerbation is arterial blood gas (ABG) analysis. It evaluates Chronic obstructive pulmonary disease (COPD) progression or the efficacy of the treatment.
Interventions:
1. Hook the patient to oxygen therapy.
Administer 2-6 liters per minute of oxygen through a nasal cannula as ordered. Supplemental oxygen can help maintain oxygen saturation at a normal level. Avoid high concentrations of oxygen for patients with COPD. If the patient requires more oxygen than 6 liters to maintain oxygen saturation, a respiratory therapist should be consulted.
2. Support the patient throughout the pulmonary rehabilitation.
Assess the patient’s willingness to refer to pulmonary rehabilitation. Patients who suffer from chronic respiratory disorders can benefit from pulmonary rehabilitation training.
3. Refer the patient to a respiratory therapist.
COPD is a chronic lung disease that requires monitoring by a respiratory therapist. They can help the patient throughout the pulmonary rehabilitation.
Care Plan #2
Diagnostic statement:
Impaired gas exchange related to decreased ventilation secondary to opioid use as evidenced by respiratory rate of 6 respirations per minute, oxygen saturation 70%, and extreme lethargy.
Expected outcomes:.
- Patient will have oxygen saturation of greater than 90% within 1 hour of nursing interventions.
- Patient will manifest a respiratory rate greater than 8 breaths per minute within 4 hours of nursing intervention.
- Patient will demonstrate ABG findings within normal limits at the end of the shift.
- Patient will reveal improving breath sounds or diminishing adventitious sounds at the end of the shift.
- Patient will present alert, conscious, and oriented mentation within 4 hours of nursing intervention.
Assessment:
1. Assess the lungs for decreased ventilation.
Poor ventilation is associated with diminished breath sounds, alterations in ABG, and oxygen saturation. Note any significant changes and immediately act as impaired gas exchange due to respiratory depression can be fatal.
2. Note the adventitious lung sounds.
Breath sounds can help determine or confirm the cause of impaired gas exchange. Place the patient in a quiet environment and use a stethoscope to auscultate for the breath sounds. Normal findings are bronchial, bronchovesicular, and vesicular sounds.
3. Assess for changes in mentation.
Alterations in mentation indicate decreased oxygen in the brain. Note the use of sedation, which can decrease the respiratory effort.
Interventions:
1. Provide a reversal agent for respiratory depression.
Naloxone should be used for respiratory depression caused by opiods. Depending on the severity of the respiratory depression, several doses may be necessary.
2. Anticipate the need for intubation and mechanical ventilation.
Early intervention is recommended to prevent total decompensation. Oxygenation and ventilation may need to be supported mechanically.
3. Work with a respiratory therapist.
Respiratory therapists monitor the patient with mechanical ventilation. They can discuss and recommend appropriate interventions to the healthcare provider.
4. Manage the airway.
Ensure that the airway is clear of obstructions. Suction the secretions as needed. Use airway management tools, such as:
- Nasopharyngeal airway (NPA)
- Oropharyngeal airway (OPA)
- Endotracheal tube
- Tracheostomy
- Laryngeal mask airway
- Combitude
Care Plan #3
Diagnostic statement:
Impaired gas exchange related to ventilation perfusion imbalance secondary to hypovolemic shock as evidenced by cyanosis, heart rate 162 bpm, and oxygen saturation 76%.
Expected outcomes:
- Patient will verbalize controlled anxiety at the end of the shift.
- Patient will have oxygen saturation of greater than 90% within 1 hour of nursing interventions.
- Patient will manifest heart rate within normal limits within 4 hours of nursing intervention.
- Patient will present alert, conscious, and oriented mentation within 4 hours of nursing intervention.
- Patient will perform activities without assistance at the end of the shift.
- Patient will manifest PFT within normal limits at the end of the shift.
Assessment:
1. Assess for changes in the level of consciousness or activity level.
Increased agitation and restlessness are signs of decreased brain perfusion. Observe the patient’s activity level and alertness.
2. Assess for increased anxiety.
Hypoxic patients can become anxious and irritable. Severe anxiety can cause hypo- or hyperventilation, resulting in decreased blood flow to the vital organs.
3. Note the medications taken.
Review the medications taken by the patient. Sedatives and anxiolytics can increase the risk of respiratory depression, resulting in impaired gas exchange.
4. Perform pulmonary function test.
There are two ways to perform PFT. Depending on the results that healthcare provider needs, these two approaches may be combined and utilized to conduct distinct tests.
Interventions:
1. Provide reassurance.
Feelings of anxiousness can increase respiratory rate and cause difficulty breathing and should be avoided if possible.
2. Place the patient in the Trendelenburg position if tolerated.
Trendelenburg position places the head, lungs, and vital organs in a dependent position, increasing blood flow and perfusion.
3. Prepare to administer fluid bolus as ordered.
Fluid resuscitation will treat the underlying cause of the impaired gas exchange and improve oxygenation status. Restore the fluid loss in hypovolemic shock.
Care Plan #4
Diagnostic statement:
Impaired gas exchange related to altered oxygen-carrying capacity of blood secondary to sickle cell anemia as evidenced by irritability, dusky skin color, and oxygen saturation 84%.
Expected outcomes:
- Patient will have oxygen saturation of greater than 90% within 1 hour of nursing interventions.
- Patient will manifest skin color within normal limits within 4 hours of nursing intervention.
- Patient will demonstrate hemoglobin levels within normal limits at the end of the shift.
Assessment:
1. Note the presence of hypoxia.
Assess respirations for rate and quality, as well as the use of accessory muscles.Increased breathing effort is a sign of hypoxia. Changes in breathing patterns can indicate changes in oxygenation status.
2. Attach the patient to a cardiac monitor.
Monitor vital signs and note changes in heart rate, blood pressure, or cardiac rhythm. Hypoxemia can cause heart rate and blood pressure changes and dangerous dysrhythmias.
3. Check hemoglobin levels.
Patients with sickle cell disease have a compromised gas exchange due to decreased blood oxygen and hemoglobin (oxygen-carrier).
Interventions:
1. Change the patient’s position every two hours.
Frequent repositioning promotes drainage and movement of lung secretions. It promotes comfort and lessens breathing effort.
2. Educate the patient on how to perform therapeutic breathing and coughing techniques.
Appropriate breathing and coughing techniques mobilize secretions and increase air exchange and oxygenation.
3. Prevent stroke.
Stroke risk assessment necessitates measurement of the blood flow in the brain. Transfuse blood as ordered to lower the risk of stroke.
4. Consider stem cell transplant.
The only treatment available for sickle cell anemia is a stem cell transplant. Bone marrow transplant entails using healthy bone marrow from a donor to replace the bone marrow impaired by sickle cell anemia.
References
- Bhutta, B. S., Alghoula, F., & Berim, I. (2022, August 9). Hypoxia – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved November 2023, from https://www.ncbi.nlm.nih.gov/books/NBK482316/
- Doenges, Marilynn E., et al. Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care. F.A. Davis, 2005.
- Gulanick, Meg, and Judith L. Myers. Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier/Mosby, 2014.
- Herdman, T. Heather, and Shigemi Kamitsuru. Nursing Diagnoses: Definitions and Classification 2018-2020. Thieme, 2018.
- Hypoxia: Causes, symptoms, tests, diagnosis & treatment. (2022, December 5). Cleveland Clinic. Retrieved November 2023, from https://my.clevelandclinic.org/health/diseases/23063-hypoxia
