Nursing diagnosis: risk for impaired Gas Exchange
Risk factors may include
Altered blood flow; blood or fat emboli
Alveolar and capillary membrane changes—interstitial, pulmonary edema, congestion
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Gas Exchange
Maintain adequate respiratory function, as evidenced by absence of dyspnea or cyanosis; respiratory rate and arterial blood gases (ABGs) are within client’s normal range.
Nursing intervention with rationale:
1. Monitor respiratory rate and effort. Note stridor, use of accessory muscles, retractions, and development of central cyanosis.
Rationale: Tachypnea, dyspnea, and changes in mentation are early signs of respiratory insufficiency and may be the only indicator of developing pulmonary emboli in the early stage. Remaining signs and symptoms reflect advanced respiratory distress and impending failure.
2. Auscultate breath sounds, noting development of unequal, hyperresonant sounds; also note presence of crackles, rhonchi, or wheezes and inspiratory crowing or croupy sounds.
Rationale: Changes in or presence of adventitious breath sounds reflects developing respiratory complications—atelectasis, pneumonia, emboli, or acute respiratory distress syndrome (ARDS). Inspiratory crowing reflects upper airway edema and is suggestive of fat emboli.
3. Handle injured tissues and bones gently, especially during first several days.
Rationale: This may prevent the development of fat emboli associated with fractures, especially of the long bones and pelvis, occasionally seen in the first 12 to 72 hours post injury.
4. Instruct and assist with deep-breathing and coughing exercises. Reposition frequently.
Rationale: Promotes alveolar ventilation and perfusion. Repositioning promotes drainage of secretions and decreases congestion in dependent lung areas.
5. Note increasing restlessness, confusion, lethargy, or stupor.
Rationale: Impaired gas exchange or presence of pulmonary emboli can cause deterioration in client’s level of consciousness as hypoxemia and acidosis develop.
6. Observe sputum for signs of blood.
Rationale: Hemoptysis may occur with pulmonary emboli.
7. Inspect skin for petechiae above nipple line, in axilla, spreading to abdomen or trunk, buccal mucosa and hard palate, and conjunctival sacs and retina.
Rationale: This is the most characteristic sign of fat emboli, which may appear within 2 to 3 days after injury.
8. Instruct in, and encourage regular use of, incentive spirometry.
Rationale: Maximizes ventilation and minimizes atelectasis.
9. Administer supplemental oxygen, if indicated.
Rationale: Increases available O2 for optimal tissue oxygenation.
10. Administer medications, as indicated, for example: Low-molecular-weight heparin or heparinoids, such as enoxaparin (Lovenox), dalteparin (Fragmin), or fondaparinux (Arixtra)
Rationale: Used for prevention of thromboembolic phenomena, including deep vein thrombosis and pulmonary emboli.