Nursing diagnosis: impaired gas exchange related to decreased oxygen-carrying capacity of the blood, reduced RBC life span or premature destruction, abnormal RBC structure, sensitivity to low oxygen tension due to strenuous exercise, increase in altitude, increased blood viscosity—occlusions created by sickled cells packing together within the capillaries, pulmonary congestion—impairment of surface phagocytosis, predisposition to bacterial pneumonia, pulmonary infarcts
Possibly evidenced by
Dyspnea, use of accessory muscles
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Gas Exchange
Demonstrate improved ventilation and oxygenation as evidenced by respiratory rate within normal limits, absence of cyanosis, use of accessory muscles, and clear breath sounds.
Participate in ADLs without weakness and fatigue.
Display improved or normal pulmonary function tests.
Nursing intervention with rationale:
1. Monitor respiratory rate and depth, use of accessory muscles, and areas of cyanosis.
Rationale: Indicators of adequacy of respiratory function or degree of compromise and therapy needs and effectiveness.
2. Auscultate breath sounds, noting presence or absence, and adventitious sounds.
Rationale: Development of atelectasis and stasis of secretions can impair gas exchange.
3. Monitor vital signs; note changes in cardiac rhythm.
Rationale: Changes in vital signs and development of dysrhythmias reflect effects of hypoxia on cardiovascular system.
4. Investigate reports of chest pain and increasing fatigue. Observe for signs of increased fever, cough, and adventitious breath sounds.
Rationale: Reflective of developing acute chest syndrome, which increases the workload of the heart and oxygen demand.
5. Assess LOC and mentation regularly.
Rationale: Brain tissue is very sensitive to decreases in oxygen, and changes in mentation may be an early indicator of developing hypoxia.
6. Evaluate activity tolerance; limit activities to those within client’s tolerance or place client on bedrest. Assist with ADLs and mobility, as needed.
7. Assist in turning, coughing, and deep-breathing exercises.
Rationale: Promotes optimal chest expansion, mobilization of secretions, and aeration of all lung fields; reduces risk of stasis of secretions and pneumonia.
8. Encourage client to alternate periods of rest and activity. Schedule rest periods, as indicated.
Rationale: Protects from excessive fatigue and reduces oxygen demands and degree of hypoxia.
9. Demonstrate and encourage use of relaxation techniques, such as guided imagery and visualization.
Rationale: Relaxation decreases muscle tension and anxiety and, hence, the metabolic demand for oxygen.
10. Promote adequate fluid intake, such as 2 to 3 L/day within cardiac tolerance.
Rationale: Sufficient hydration is necessary to provide for mobilization of secretions and to prevent hyperviscosity of blood with associated capillary occlusion.