Possibly evidenced by
Inability to move secretions
Abnormal ABGs—hypoxia and hypercapnia
Changes in vital signs
Reduced tolerance for activity
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Gas Exchange
Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within client’s normal range and be free of symptoms of respiratory distress.
Participate in treatment regimen within level of ability and situation.
Nursing care plan intervention with rationale:
1. Assess respiratory rate and depth. Note use of accessory muscles, pursed-lip breathing, and inability to speak or converse.
Rationale: Useful in evaluating the degree of respiratory distress and chronicity of the disease process.
2. Elevate head of bed and assist client to assume position to ease work of breathing. Include periods of time in prone position as tolerated. Encourage deep, slow or pursed-lip breathing as individually needed and tolerated.
Rationale: Oxygen delivery may be improved by upright position and breathing exercises to decrease airway collapse, dyspnea, and work of breathing. Note: Recent research supports use
of prone position to increase PaO2.
3. Assess and routinely monitor skin and mucous membrane color.
Rationale: Cyanosis may be peripheral (noted in nailbeds) or central (noted around lips or earlobes). Duskiness and central cyanosis indicate advanced hypoxemia.
4. Encourage expectoration of sputum; suction when indicated.
Rationale: Thick, tenacious, copious secretions are a major source of impaired gas exchange in small airways. Deep suctioning may be required when cough is ineffective for expectoration
5. Auscultate breath sounds, noting areas of decreased airflow and adventitious sounds.
Rationale: Breath sounds may be faint because of decreased airflow or areas of consolidation. Presence of wheezes may indicate bronchospasm or retained secretions. Scattered, moist crackles may indicate interstitial fluid or cardiac decompensation.
6. Palpate chest for fremitus.
Rationale: Decrease of vibratory tremors suggests fluid collection or airtrapping.
7. Monitor level of consciousness and mental status. Investigate changes.
Rationale: Restlessness and anxiety are common manifestations of hypoxia. Worsening ABGs accompanied by confusion and somnolence are indicative of cerebral dysfunction due to
8. Evaluate level of activity tolerance. Provide calm, quiet environment. Limit client’s activity or encourage bedrest or chair rest during acute phase. Have client resume activity gradually and increase as individually tolerated.
Rationale: During severe, acute, or refractory respiratory distress, client may be totally unable to perform basic self-care activities because of hypoxemia and dyspnea. Rest interspersed with
care activities remains an important part of treatment regimen. An exercise program is aimed at improving aerobic capacity and functional performance, increasing endurance and strength without causing severe dyspnea, and can enhance sense of well-being.
9. Evaluate sleep patterns, note reports of difficulties and whether client feels well rested. Provide quiet environment and group care and monitoring activities to allow periods of uninterrupted sleep. Limit stimulants such as caffeine. Encourage position of comfort.
Rationale: Multiple external stimuli and presence of dyspnea and hypoxemia may prevent relaxation and inhibit sleep.
10. Monitor vital signs and cardiac rhythm.
Rationale: Tachycardia, dysrhythmias, and changes in BP can reflect effect of systemic hypoxemia on cardiac function.