Impaired gas exchange occurs when the vital process of oxygen and carbon dioxide exchange within the lung tissues is disrupted. This condition is a significant health concern and often intertwines with other nursing diagnoses such as ineffective breathing patterns or ineffective airway clearance. Understanding decreased oxygen saturation as a critical indicator of impaired gas exchange is paramount in nursing practice.
Causes (Related To) of Decreased Oxygen Saturation
Decreased oxygen saturation, a key indicator of impaired gas exchange, can stem from various conditions that compromise a patient’s airway, blood flow, or overall respiratory effectiveness. Recognizing these underlying causes is crucial for accurate nursing diagnosis and intervention. Here are some common factors contributing to decreased oxygen saturation:
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Airway Compromise: Obstructions in the airway, such as a foreign object lodging itself, can physically block airflow, leading to reduced oxygen intake and subsequently decreased oxygen saturation levels.
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Reduced Blood Flow: Conditions that impede blood flow can significantly impair gas exchange, resulting in decreased oxygen saturation. This can be linked to cardiac or pulmonary issues, including pulmonary embolism or heart failure. Furthermore, diseases affecting the blood’s capacity to carry oxygen can also contribute to this issue.
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Respiratory Effectiveness Issues: Chronic lung conditions like chronic obstructive pulmonary disease (COPD) directly impact respiratory effectiveness. Additionally, certain medications, notably opiates, can depress respiratory rate and depth, leading to ineffective respiration and decreased oxygen saturation.
Signs and Symptoms (As Evidenced By) of Decreased Oxygen Saturation
Decreased oxygen saturation, a critical sign in nursing diagnosis, manifests through a range of subjective and objective indicators. Recognizing these signs and symptoms is essential for prompt assessment and intervention.
Subjective Symptoms (Patient Reports)
- Dyspnea: Patients often report dyspnea, or shortness of breath, which is a primary subjective symptom indicating potential decreased oxygen saturation.
- Diaphoresis: Excessive sweating, or diaphoresis, can occur as the body attempts to compensate for reduced oxygen levels.
- Visual Disturbances: Changes in vision can be reported, reflecting the impact of decreased oxygen to the brain.
- Headaches: Headaches may arise due to altered blood gas levels associated with impaired gas exchange and decreased oxygen saturation.
Objective Signs (Nurse Assesses)
- Altered Respiratory Patterns: Changes in breathing patterns, such as rapid, shallow, or labored breathing, are objective signs assessed by nurses.
- Restlessness: Increased restlessness can be an early indicator of hypoxemia and decreased oxygen saturation.
- Lethargy: As oxygen saturation decreases, patients may exhibit lethargy or decreased responsiveness.
- Cyanosis: Bluish discoloration of the skin and mucous membranes (cyanosis) is a late and critical sign of significantly decreased oxygen saturation.
- Confusion: Cognitive changes, including confusion, can occur as the brain is deprived of adequate oxygen.
- Irritability: Patients may become unusually irritable due to physiological stress from decreased oxygen levels.
- Impending Sense of Doom: A feeling of impending doom or anxiety can sometimes accompany severe respiratory distress and decreased oxygen saturation.
- Abnormal Arterial Blood Gas (ABG) Values or Blood pH: Lab values, specifically ABG results showing abnormal oxygen and carbon dioxide levels or blood pH imbalances, objectively confirm impaired gas exchange.
- Vital Signs Changes:
- Increased Heart Rate: Tachycardia, or an elevated heart rate, is a common compensatory mechanism in response to decreased oxygen saturation.
- Decreased Oxygen Saturation: Measured via pulse oximetry, a reading below the normal range (typically <90%) directly indicates decreased oxygen saturation.
Expected Outcomes for Patients with Decreased Oxygen Saturation
When addressing decreased oxygen saturation as a nursing diagnosis, establishing clear and measurable expected outcomes is crucial for effective care planning. These outcomes serve as benchmarks for monitoring patient progress and the effectiveness of nursing interventions. Common goals and expected outcomes include:
- Relief of Dyspnea: The patient will report a noticeable reduction or complete relief from dyspnea, indicating improved respiratory function.
- Oxygen Saturation Above 90%: The patient will consistently maintain an oxygen saturation level of 90% or greater, demonstrating adequate oxygenation.
- Vital Signs Within Normal Limits: The patient’s vital signs, including heart rate, respiratory rate, and blood pressure, will stabilize and remain within normal ranges for their age and condition.
- Improved Ventilation Signs and Symptoms: The patient will exhibit objective signs and symptoms of improved ventilation, such as ease of breathing, clear breath sounds, and reduced use of accessory muscles.
- Arterial Blood Gas (ABG) Levels Within Normal Limits: ABG analysis will demonstrate values within the normal physiological range, confirming effective gas exchange at a cellular level.
- Normal Lung Findings on Imaging Scans: Chest X-rays or other imaging scans will show normal lung findings, indicating resolution of underlying pulmonary issues contributing to decreased oxygen saturation.
Nursing Assessment for Decreased Oxygen Saturation
A thorough nursing assessment is the cornerstone of managing decreased oxygen saturation as a nursing diagnosis. This involves systematic data collection to understand the patient’s respiratory status and guide appropriate interventions.
1. Monitor Vital Signs: Regular monitoring of vital signs is paramount. Initially, blood pressure and pulse rate may increase in response to hypoxemia/hypercapnia, but they can subsequently decrease as gas exchange worsens. Continuous monitoring reveals trends in respiratory rate and oxygen saturation, crucial indicators of the severity of impaired gas exchange.
2. Continuous Pulse Oximetry: Applying a continuous pulse oximeter is a non-invasive and rapid method to assess oxygen saturation levels. It provides real-time data, enabling close observation of oxygen levels and the effectiveness of interventions aimed at improving oxygenation.
3. Respiratory Status Assessment: A comprehensive respiratory assessment involves observing the lungs for signs of altered ventilation, evaluating the rate, depth, and quality of respirations, and noting the use of accessory muscles. Increased breathing effort is a significant indicator of hypoxia. Variations from normal breathing patterns may signal compromised oxygen levels.
4. Auscultate Lung Sounds: Auscultation of lung sounds is essential to identify adventitious breath sounds that may indicate impaired gas exchange due to alveolar collapse or fluid accumulation. Adventitious sounds include:
- Wheezing
- Crackles
- Stridor
- Rhonchi
- Pleural friction rub
5. Cardiovascular Status Assessment: Given the interconnectedness of respiratory and cardiovascular systems, assessing cardiovascular status is vital. Heart conditions and blood disorders can directly affect blood oxygen levels and contribute to impaired gas exchange. Monitor for alterations in blood pressure, cardiac rhythm, and heart rate. Hypoxemia can induce dysrhythmias and fluctuations in blood pressure and heart rate.
6. Assess Anxiety, Mentation, and Behavior: Neurological assessments are crucial as reduced cerebral perfusion, a consequence of decreased oxygen saturation, manifests as changes in cognition and behavior. Anxiety can further impede oxygen flow to the brain by inducing vasoconstriction. Assess for confusion, restlessness, and changes in behavior.
7. Obtain Blood Sample for ABG Analysis: Arterial blood gas (ABG) analysis is a definitive diagnostic tool. Monitoring ABG and hemoglobin levels helps determine the presence and extent of inadequate oxygen and carbon dioxide exchange, identifying conditions like hypoxemia, respiratory acidosis, and respiratory failure.
8. Prepare Patient for Imaging Scans: Various chest imaging studies are valuable in diagnosing the underlying cause of impaired gas exchange:
- Chest X-ray
- Chest computed tomography (CT)
- CT angiogram
- Ventilation-perfusion (VQ scan)
9. Perform Pulmonary Function Tests (PFTs): Pulmonary Function Tests (PFTs) offer direct measurements of lung volumes, bronchodilator response, and diffusion capacity. PFTs are instrumental in diagnosing lung diseases and guiding treatment strategies.
Nursing Interventions for Decreased Oxygen Saturation
Nursing interventions are crucial in managing decreased oxygen saturation and improving patient outcomes. These actions are aimed at addressing the underlying causes and supporting respiratory function.
1. Maintain Patent Airway: Ensuring a patent airway is the priority. Techniques include:
- Proper suctioning techniques to clear secretions.
- Head tilt and jaw thrust maneuver to open the airway in unconscious patients.
- Placement of endotracheal tube or tracheostomy for advanced airway management.
- Use of positive pressure ventilation (CPAP or BiPAP) to support breathing.
2. Administer Oxygen Therapy as Ordered: Oxygen therapy is a primary intervention to increase oxygen levels and combat hypoxia and hypoxemia. Nurses may administer 2-6 liters per minute of oxygen via nasal cannula in emergency situations. However, it’s crucial to note that patients with COPD require careful oxygen administration to maintain SaO2 between 88-92% and avoid high concentrations.
3. Prepare for Possible Intubation and Mechanical Ventilation: In cases of severe respiratory distress, mechanical ventilation may be necessary. Prepare for potential intubation and ensure a crash cart is readily available at the bedside. Collaborate closely with respiratory therapists regarding mechanical ventilator management.
4. Administer Medications as Ordered: Medications are prescribed based on the etiology of impaired gas exchange. Common medications include:
- Bronchodilators to open airways.
- Steroids to reduce inflammation.
- Mucolytics to thin secretions.
5. Position Patient Comfortably: Patient positioning significantly impacts respiratory function. Repositioning every two hours or according to facility policy is recommended to promote optimal lung expansion, drainage, and secretion movement. Beneficial positions include:
- Semi-Fowler’s position
- High Fowler’s (sitting) position
- Orthopneic position
- Tripod position
- Trendelenburg position (specifically for hypovolemic shock).
6. Treat Underlying Cause: Addressing the root cause of decreased oxygen saturation is paramount for long-term management. Underlying causes can be acute or chronic and include:
- Asthma
- Chronic obstructive pulmonary disease (COPD)
- Lung infection (pneumonia)
- Pneumothorax
- Pulmonary edema
- Pulmonary embolism
- Low hemoglobin levels
- Heart defects
- Cardiac conditions like heart failure
7. Replace Fluids with Caution: Fluid management requires careful consideration as both fluid overload and dehydration can negatively impact gas exchange. Administer fluids cautiously, especially in patients with heart failure or pulmonary edema. Conversely, adequate hydration can help liquefy secretions, facilitating mobilization and expectoration.
8. Manage Anxiety and Respiratory Depression: Address factors that exacerbate impaired gas exchange, such as anxiety and respiratory depression. If respiratory depression is opioid-induced, administer reversal agents like naloxone.
9. Instruct Patient in Breathing and Coughing Techniques: Educate patients on therapeutic breathing and coughing exercises. Proper techniques enhance oxygenation and air exchange and aid in mobilizing secretions, particularly in conditions like atelectasis.
10. Refer to Pulmonary Rehabilitation: For patients with chronic respiratory conditions, pulmonary rehabilitation programs can be highly beneficial. Assess patient willingness and provide referrals as appropriate.
11. Collaborate with Respiratory Therapist: Respiratory therapists are integral to the care team. Collaborate closely with them to optimize respiratory interventions and ventilator management. They continuously monitor ABGs and adjust ventilator settings as needed.
Nursing Care Plans for Decreased Oxygen Saturation
Nursing care plans are essential tools for structuring and prioritizing care for patients with decreased oxygen saturation. They provide a framework for both short-term and long-term goals.
Care Plan #1
Diagnostic Statement:
Impaired gas exchange related to alveolar-capillary membrane changes secondary to COPD as evidenced by oxygen saturation 79%, heart rate 112 bpm, and patient reports of dyspnea.
Expected Outcomes:
- Patient will achieve oxygen saturation >90% within 1 hour of nursing interventions.
- Patient will demonstrate stable vital signs within normal limits within 4 hours of nursing intervention.
- Patient will exhibit ABG findings within normal limits by the end of the shift.
- Patient will show improving breath sounds or diminishing adventitious sounds by the end of the shift.
Assessment:
1. Auscultate Lung Sounds: Assess for lung sounds indicative of atelectasis, as alveolar collapse can cause hypoxemia.
2. Monitor Vital Signs: Check vital signs every 15 minutes to detect changes in heart rate and blood pressure. Initially, these may rise due to hypoxemia/hypercapnia, then decrease as impairment worsens.
3. Monitor Oxygen Saturation: Use continuous pulse oximetry to track oxygen saturation trends.
4. Obtain ABG: Arterial blood gas analysis is the most reliable indicator of COPD exacerbation severity and treatment efficacy.
Interventions:
1. Initiate Oxygen Therapy: Administer 2-6 liters/minute of oxygen via nasal cannula as ordered. Supplemental oxygen supports oxygen saturation. Avoid high concentrations in COPD patients. Consult a respiratory therapist if >6 liters is needed to maintain saturation.
2. Support Pulmonary Rehabilitation: Assess patient willingness to participate in pulmonary rehabilitation, which benefits patients with chronic respiratory disorders.
3. Refer to Respiratory Therapist: For chronic conditions like COPD, respiratory therapist involvement is crucial for ongoing monitoring and pulmonary rehabilitation support.
Care Plan #2
Diagnostic Statement:
Impaired gas exchange related to decreased ventilation secondary to opioid use as evidenced by respiratory rate of 6 respirations per minute, oxygen saturation 70%, and extreme lethargy.
Expected Outcomes:
- Patient will achieve oxygen saturation >90% within 1 hour of nursing interventions.
- Patient will manifest respiratory rate >8 breaths per minute within 4 hours of nursing intervention.
- Patient will demonstrate ABG findings within normal limits by the end of the shift.
- Patient will show improving breath sounds or diminishing adventitious sounds by the end of the shift.
- Patient will present alert, conscious, and oriented mentation within 4 hours of nursing intervention.
Assessment:
1. Assess Lungs for Decreased Ventilation: Poor ventilation is associated with diminished breath sounds, ABG alterations, and low oxygen saturation. Monitor for significant changes and act promptly as respiratory depression can be fatal.
2. Note Adventitious Lung Sounds: Breath sounds help identify the cause of impaired gas exchange. Auscultate in a quiet environment using a stethoscope. Normal sounds are bronchial, bronchovesicular, and vesicular.
3. Assess Mentation Changes: Altered mentation indicates decreased brain oxygenation. Note any sedation use, which can reduce respiratory effort.
Interventions:
1. Administer Reversal Agent: For opioid-induced respiratory depression, use naloxone. Multiple doses may be needed depending on severity.
2. Anticipate Intubation and Mechanical Ventilation: Early intervention is key to prevent decompensation. Mechanical ventilation may be required for oxygenation and ventilation support.
3. Collaborate with Respiratory Therapist: Respiratory therapists manage patients on mechanical ventilation and can recommend appropriate interventions.
4. Manage Airway: Ensure a clear airway. Suction secretions as needed. Utilize airway management tools like nasopharyngeal airway (NPA), oropharyngeal airway (OPA), endotracheal tube, tracheostomy, laryngeal mask airway, or Combitube.
Care Plan #3
Diagnostic Statement:
Impaired gas exchange related to ventilation perfusion imbalance secondary to hypovolemic shock as evidenced by cyanosis, heart rate 162 bpm, and oxygen saturation 76%.
Expected Outcomes:
- Patient will verbalize controlled anxiety by the end of the shift.
- Patient will achieve oxygen saturation >90% within 1 hour of nursing interventions.
- Patient will manifest heart rate within normal limits within 4 hours of nursing intervention.
- Patient will present alert, conscious, and oriented mentation within 4 hours of nursing intervention.
- Patient will perform activities without assistance by the end of the shift.
- Patient will manifest PFT within normal limits by the end of the shift.
Assessment:
1. Assess Level of Consciousness/Activity Level: Increased agitation and restlessness are signs of decreased brain perfusion. Observe activity level and alertness.
2. Assess Anxiety: Hypoxic patients can be anxious and irritable. Severe anxiety can lead to hypo- or hyperventilation, reducing blood flow to vital organs.
3. Note Medications: Review medications, as sedatives and anxiolytics can increase respiratory depression risk.
4. Perform Pulmonary Function Test: PFTs can provide detailed information about lung function and capacity.
Interventions:
1. Provide Reassurance: Anxiety can worsen respiratory distress. Reassurance can help reduce respiratory rate and breathing difficulty.
2. Trendelenburg Position (if tolerated): This position can improve blood flow to vital organs by placing the head, lungs, and vital organs in a dependent position.
3. Prepare to Administer Fluid Bolus: Fluid resuscitation addresses hypovolemic shock, improving oxygenation status by restoring fluid loss.
Care Plan #4
Diagnostic Statement:
Impaired gas exchange related to altered oxygen-carrying capacity of blood secondary to sickle cell anemia as evidenced by irritability, dusky skin color, and oxygen saturation 84%.
Expected Outcomes:
- Patient will achieve oxygen saturation >90% within 1 hour of nursing interventions.
- Patient will manifest skin color within normal limits within 4 hours of nursing intervention.
- Patient will demonstrate hemoglobin levels within normal limits by the end of the shift.
Assessment:
1. Note Hypoxia Signs: Assess respirations for rate, quality, and accessory muscle use. Increased effort indicates hypoxia. Changes in breathing patterns signal oxygenation changes.
2. Attach Cardiac Monitor: Monitor vital signs, especially heart rate, blood pressure, and cardiac rhythm. Hypoxemia can cause heart rate and blood pressure changes and dysrhythmias.
3. Check Hemoglobin Levels: Patients with sickle cell disease have compromised gas exchange due to decreased blood oxygen and hemoglobin.
Interventions:
1. Reposition Patient Every Two Hours: Frequent repositioning aids lung drainage and secretion movement, promotes comfort, and reduces breathing effort.
2. Educate on Breathing/Coughing Techniques: Teach therapeutic techniques to mobilize secretions and enhance air exchange and oxygenation.
3. Prevent Stroke: Assess stroke risk, which is elevated in sickle cell anemia. Blood transfusion may be ordered to reduce stroke risk.
4. Consider Stem Cell Transplant: Stem cell transplant is the only curative treatment for sickle cell anemia, replacing impaired bone marrow with healthy donor marrow.
Care Plan #5
Diagnostic Statement:
Impaired gas exchange related to pulmonary fluid buildup secondary to acute respiratory distress syndrome (ARDS) as evidenced by restlessness and nasal flaring.
Expected Outcomes:
- Patient will demonstrate improved oxygenation as evidenced by a PaO₂/FiO₂ ratio of 300 mmHg or greater.
- Patient will tolerate prone positioning for at least 12 hours per day to improve oxygenation.
Assessment:
1. Obtain Chest X-ray: X-ray findings depend on ARDS stage. May be normal initially but will show fluid buildup in alveolar and interstitial spaces in the exudative phase.
2. Perform Neurological Assessment: Monitor mental status for confusion, agitation, or decreased LOC, indicating poor brain oxygenation.
3. Monitor Work of Breathing: Observe for nasal flaring and other signs of increased breathing effort, like accessory muscle use.
4. Monitor PaO₂/FiO₂ Ratio: This ratio assesses ARDS severity. Normal is 400-500 mmHg; a decreasing ratio indicates worsening ARDS.
Interventions:
1. Address Underlying Cause: ARDS causes are diverse (inflammatory, infectious, traumatic, vascular). Interventions may include antibiotics, diuretics, steroids, mechanical ventilation, etc.
2. Prone Positioning: Prone positioning (patient on stomach) improves ventilation and perfusion by reducing lung pressure.
3. Conservative Fluid Management: Fluid restriction in some ARDS cases can improve oxygenation and facilitate earlier ventilator weaning. Excess fluids can impair gas exchange.
4. Trial Noninvasive Ventilation: Before intubation, consider noninvasive positive-pressure ventilation, which may be sufficient to improve oxygenation and avoid ventilation-acquired pneumonia.
References
- Bhutta, B. S., Alghoula, F., & Berim, I. (2022, August 9). Hypoxia – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved November 2023, from https://www.ncbi.nlm.nih.gov/books/NBK482316/
- Doenges, Marilynn E., et al. Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care. F.A. Davis, 2005.
- Gulanick, Meg, and Judith L. Myers. Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier/Mosby, 2014.
- Harman, E. M. (2024, July 10). Acute Respiratory Distress Syndrome (ARDS) Treatment & Management. Medscape. https://emedicine.medscape.com/article/165139-treatment#showall
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (Eds.). (2024). NANDA-I International Nursing Diagnoses: Definitions and Classification, 2024-2026. Thieme. 10.1055/b000000928
- Hypoxia: Causes, symptoms, tests, diagnosis & treatment. (2022, December 5). Cleveland Clinic. Retrieved November 2023, from https://my.clevelandclinic.org/health/diseases/23063-hypoxia
- Sheard, S., Rao, P., & Devaraj, A. (2012, April). Imaging of Acute Respiratory Distress Syndrome. Respiratory Care. https://rc.rcjournal.com/content/57/4/607
