Page 6 - Altered Obstructive Nursing Care

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Impaired Gas Exchange

Related to

• Altered oxygen supply (obstruction of airways by secretions, bronchospasm; air-trapping)
• Alveoli destruction
• Alveolar-capillary membrane changes

Outcomes

• Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within patient’s
normal range and be free of symptoms of respiratory distress.
• Participate in treatment regimen within the level of ability/situation.

Nursing Interventions Rationale

Nursing Assessment

Assess and record respiratory rate, depth. Note Useful in evaluating the degree of respiratory
the use of accessory muscles, pursed-lip distress or chronicity of the disease process.
breathing, inability to speak or converse.

Cyanosis may be peripheral (noted
Assess and routinely monitor skin and mucous in nail beds) or central (noted around lips/or
membrane color. earlobes). Duskiness and central cyanosis
indicate advanced hypoxemia.

Restlessness, agitation, and anxiety are
common manifestations of hypoxia.
Monitor changes in the level of consciousness Worsening ABGs accompanied by confusion/
and mental status.
somnolence are indicative of cerebral
dysfunction due to hypoxemia.

Tachycardia, dysrhythmias, and changes in BP
Monitor vital signs and cardiac rhythm. can reflect the effect of systemic hypoxemia on
cardiac function.

Breath sounds may be faint because of
decreased airflow or areas of consolidation.
Auscultate breath sounds, noting areas of Presence of wheezes may indicate
decreased airflow and adventitious sounds. bronchospasm or retained secretions.
Scattered moist crackles may indicate
interstitial fluid or cardiac decompensation.

A decrease of vibratory tremors suggests fluid
Palpate for fremitus.
collection or air-trapping.

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