Impaired Gas Exchange Definition: Excess or lack of oxygenation and or removal of carbon dioxide in the alveolar capillary membrane.
Defining characteristics:
- Impaired vision
- Reduction in CO2
- Tachycardia
- Hypercapnia
- Fatigue
- Somnolence
- Irritability
- Hypoxia
- Confusion
- Dyspnoe
- Nasal pharyngeal
- Normal blood gas analyzer
- Cyanosis
- Abnormal skin color (white, black)
- Hypoxemia
- Hypercarbia
- Headache when waking
- Abnormal breathing frequency and depth
Related factors:
- Ventilation perfusion imbalance
- Alveolar-capillary membrane changes
NOC:
- Respiratory Status: Gas exchange
- Respiratory Status: Ventilation
- Vital Sign Status
Results Criteria:
- Demonstrate improved ventilation and adequate oxygenation
- Maintain cleanliness of the lungs and free of signs of respiratory distress
- Demonstrate effective cough and breath sounds are clean, no cyanosis and dyspnea (capable of removing the sputum, was able to breathe easily, no pursed lips)
- Vital signs within normal range
NIC:
1. Airway Management
- Open the airway, using chin lift technique or jaw thrust if necessary
- Position the patient to maximize ventilation
- Identification of patients need the installation of an artificial airway device
- Replace the mayo if necessary
- Perform chest physiotherapy if necessary
- Remove secretions by coughing or suctioning
- Auscultation of breath sounds, record the presence of additional noise
- Do the suction on the mayo
- Give bronchodilators if necessary
- Give your humidifier
- Adjust fluid intake to optimize the balance
- Monitor respiration and oxygen status
2. Respiratory Monitoring
- Monitor on average, the depth, rhythm and respiratory effort
- Note the movement of the chest, observe the symmetry, the use of additional muscle, supraclavicular and intercostal muscle retraction
- Monitor breath sounds, such as snoring
- Monitor breathing patterns: bradipena, takipenia, Kussmaul, hyperventilation, Cheyne stokes, Biot
- Note the location of the trachea
- Diagfragma monitor muscle fatigue (paradoxical movement)
- Auscultation of breath sounds, noting areas of decreased / no ventilation and additional sound
- Determine the need for suction by mengauskultasi crakles and ronkhi main airway
- Auscultation of lung sounds after the action for the results.
