Page 7 - PNEUMONIA NURSING CARE PLAN
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IMPAIRED GAS EXCHANGE
Impaired Gas Exchange related to retained secretions and inflammatory pulmonary.
Related Factors
• Alveolar-capillary membrane changes (inflammatory effects)
• Altered oxygen-carrying capacity of blood/release at cellular level (fever, shifting oxyhemoglobin curve)
• Altered delivery of oxygen (hypoventilation)
• Collection of mucus in airways
• Inflammation of airways and alveoli
• Fluid-filled alveoli
Assessment
• Dyspnea, Tachypnea
• Pale, dusky, skin color
• Cyanosis
• Tachycardia
• Restlessness, irritability, changes in mentation
• Hypoxemia
• Hypotension
• Disorientation
Goals and outcomes
• Patient will demonstrate improved ventilation and oxygenation of tissues by ABGs within patient’s acceptable
range and absence of symptoms of respiratory distress.
• Patient will maintain optimal gas exchange.
• Patient will participate in actions to maximize oxygenation.
Nursing Interventions and Rationales
Nursing Interventions Rationale
Assessment
Manifestations of respiratory distress are
dependent on/and indicative of the degree of lung
involvement and underlying general health status
as patients will adapt their breathing patterns to
Assess respirations: note quality, rate,
rhythm, depth, use of accessory muscles, facilitate effective gas exchange.
ease, and position assumed for easy
breathing. Rapid, shallow breathing patterns and
hypoventilation directly affects gas exchange.
Hypoxia is associated with signs of increased
breathing effort. Tripod positioning is an evidence
of significant dyspnea.
As oxygenation and perfusion become impaired,
Observe color of skin, mucous membranes, peripheral tissues become cyanotic. Cyanosis of
and nail beds, noting presence of peripheral
nail beds may represent vasoconstriction or the
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