Impaired Gas Exchange: Nursing Diagnosis and Comprehensive Care Plan

What is Impaired Gas Exchange?

Gas exchange is the essential process where oxygen moves from the alveoli in the lungs into the pulmonary capillaries, and carbon dioxide moves from the capillaries into the alveoli to be exhaled. This vital exchange occurs through diffusion, a passive process driven by concentration gradients across the alveolar-capillary barrier. Effective gas exchange relies on maintaining these concentration differences through adequate ventilation (airflow into and out of the alveoli) and perfusion (blood flow through the pulmonary capillaries).

Typically, a delicate balance exists between ventilation and perfusion, ensuring optimal gas exchange. However, various health conditions can disrupt this balance, leading to impaired gas exchange. Dead space refers to the volume of air inhaled that does not participate in gas exchange, representing ventilation without perfusion. Dead space results in a high ventilation/perfusion (V/Q) ratio, reducing alveolar ventilation and consequently decreasing PaO2 even in functional alveoli. The consequence of reduced PaO2 is hypoxemia (Powers & Dharmoon, 2023).

Conditions that alter or collapse alveoli, such as atelectasis, pneumonia, pulmonary edema, and acute respiratory distress syndrome, significantly impair ventilation. Other factors that can negatively impact gas exchange include high altitudes, hypoventilation, and reduced oxygen-carrying capacity of the blood due to decreased hemoglobin. It’s important to note that total pulmonary blood flow naturally decreases in older adults compared to younger individuals. Furthermore, obesity in patients with COPD and the general impact of excess fat mass on lung function increase the risk of hypoxia. Individuals who smoke, have pre-existing pulmonary conditions, experience prolonged immobility, or have undergone chest or upper abdominal surgeries are also at heightened risk for impaired gas exchange.

Pulse oximetry is a crucial non-invasive tool for continuous monitoring of oxygen saturation in patients at risk for impaired gas exchange, providing immediate feedback on their respiratory status.

Causes

Impaired gas exchange can stem from a variety of causes and related factors. Understanding these underlying issues is crucial for effective nursing intervention. Common causes include:

Ventilation-perfusion imbalance: Mismatches between airflow and blood flow in the lungs.
Hypoventilation: Inadequate alveolar ventilation due to weak respiratory muscles or ineffective breathing patterns.
Airway obstruction: Blockage of airways by mucus, foreign bodies, or other obstructions.
Decreased lung expansion: Conditions like atelectasis that limit the lungs’ ability to fully expand.
Alveolar-capillary membrane changes: Thickening or damage to the membrane, hindering diffusion.
Reduced hemoglobin levels: Anemia or other conditions affecting hemoglobin, impacting oxygen transport.
High metabolic demand: Increased oxygen consumption due to fever or physical exertion.
Smoking or pollutant exposure: Damage to lung tissue and airways from inhaled irritants.
Prolonged immobility: Shallow breathing and reduced lung expansion due to inactivity.
Altered chest wall mechanics: Obesity, musculoskeletal limitations, or deformities affecting chest wall movement.
Neuromuscular conditions: Diseases affecting respiratory muscle function (e.g., Guillain-Barré syndrome, myasthenia gravis).
Anxiety or emotional distress: Impacting respiratory rate and depth, potentially leading to hyperventilation or breath-holding.
High altitudes: Reduced atmospheric oxygen concentration.
Post-surgical impacts: Especially after chest or upper abdominal surgeries, pain and anesthesia can reduce respiratory effort.

Signs and Symptoms

Recognizing the signs and symptoms of impaired gas exchange is essential for prompt nursing intervention. Patients may exhibit a range of indicators, including:

Dyspnea: Labored or difficult breathing, often described as shortness of breath.
Cyanosis: Bluish discoloration of the skin, nail beds, or mucous membranes, indicating hypoxemia.
Tachypnea: Abnormally rapid breathing, often a compensatory mechanism for hypoxemia.
Use of accessory muscles: Visible use of neck and shoulder muscles to assist breathing, indicating increased respiratory effort.
Restlessness or agitation: Early signs of hypoxemia as the brain is highly sensitive to oxygen deprivation.
Confusion or altered mental status: Worsening hypoxemia can lead to cognitive impairment.
Decreased oxygen saturation levels (SpO2): Measured by pulse oximetry, values below 90% typically indicate hypoxemia.
Abnormal arterial blood gas (ABG) results: Hypoxemia (low PaO2) and hypercapnia (high PaCO2) are key indicators.
Fatigue or weakness: Reduced oxygen supply to muscles can cause fatigue and weakness.
Orthopnea: Difficulty breathing when lying flat, often relieved by sitting or standing.
Persistent cough: May be present with or without sputum production, depending on the underlying cause.
Nasal flaring: Widening of the nostrils during breathing, a sign of respiratory distress, especially in infants and children.
Wheezing or crackles on auscultation: Abnormal breath sounds indicating airway obstruction or fluid in the lungs.
Increased heart rate (tachycardia): The heart attempts to compensate for hypoxemia by pumping faster.
Pallor or pale skin: Can occur due to reduced oxygenated blood flow to the periphery.
Diminished breath sounds on auscultation: May indicate reduced airflow to a portion of the lung.
Changes in behavior: Irritability, anxiety, or other behavioral changes can be early indicators of hypoxemia.
Clubbing of fingers: Chronic hypoxemia can lead to the bulbous enlargement of fingertips and nail beds over time.

Auscultation of lung sounds is a fundamental nursing assessment technique to identify abnormal sounds like wheezing or crackles, which can indicate impaired gas exchange.

Nursing Care Plans and Management

Developing a comprehensive nursing care plan for patients with impaired gas exchange is paramount. The overarching goal is to optimize oxygenation and ensure adequate ventilation. Key components of the care plan include:

Assessment and Monitoring: Continuous monitoring of respiratory status, oxygen saturation, and ABGs.
Positioning and Airway Management: Utilizing optimal positioning to enhance lung expansion and maintaining a patent airway.
Medication and Treatment Administration: Administering prescribed medications such as bronchodilators, corticosteroids, or antibiotics, and oxygen therapy.
Fluid and Nutrition Management: Maintaining adequate hydration and nutritional support to optimize respiratory function.
Client Education and Support: Educating patients and families about the condition, treatment plan, and self-management strategies.
Collaboration and Referrals: Working with physicians, respiratory therapists, and other healthcare professionals to provide holistic care.

Nursing Problem Priorities

Prioritizing nursing problems is essential for efficient and effective care. For patients with impaired gas exchange, key nursing priorities include:

Inadequate oxygen perfusion: This is the highest priority as it directly threatens cellular function and survival. Interventions focus on maximizing oxygen delivery, monitoring oxygen saturation, and administering oxygen as needed.
Alteration in breathing patterns: Ineffective breathing patterns exacerbate impaired gas exchange. Monitoring for signs of respiratory distress and implementing interventions to promote effective breathing are critical.
Risk for respiratory failure: Severely impaired gas exchange can progress to respiratory failure, a life-threatening condition. Vigilant monitoring and proactive interventions are necessary to prevent this progression.
Relief from fear or anxiety: Dyspnea and hypoxemia can induce significant anxiety. Addressing emotional needs and providing reassurance are important aspects of care.
Client and caregiver education: Empowering patients and families with knowledge about the condition and its management enhances adherence to treatment and promotes better outcomes.

Nursing Assessment

A thorough nursing assessment is the cornerstone of care for patients with impaired gas exchange. Key assessment areas include:

Subjective Data: Gathering information from the patient about symptoms such as dyspnea, cough, sputum production (quantity, color, consistency), chest pain, wheezing, and hemoptysis (coughing up blood). Consider non-pulmonary conditions that may mimic respiratory symptoms.
Objective Data:
- Hypoxemia: Assess oxygen saturation via pulse oximetry; monitor for signs of hypoxia such as restlessness, confusion, cyanosis.
- Abnormal breathing pattern: Observe respiratory rate, depth, and rhythm; note any deviations from normal.
- Abnormal arterial blood gases: Review ABG results for hypoxemia (PaO2 < 80 mmHg), hypercapnia (PaCO2 > 45 mmHg), and acid-base imbalances.
- Restlessness: Observe for agitation, inability to sit still, or constant movement.
- Cyanosis: Inspect skin, nail beds, and mucous membranes for bluish discoloration.
- Dyspnea: Assess the patient’s subjective experience of breathing difficulty, using a dyspnea scale if appropriate.
- Cough: Characterize the cough (dry, productive, frequency, triggers).
- Nasal flaring: Observe for widening of nostrils with breathing.
- Hypercapnia: Monitor for signs like headache, dizziness, lethargy, disorientation.
- Hypoxia: Assess for tissue oxygen deficiency signs beyond hypoxemia, such as altered mental status, fatigue.
- Orthopnea: Ask if the patient experiences shortness of breath when lying flat and if it’s relieved by sitting up.
- Tachypnea: Count respiratory rate; a rate above 20 breaths per minute in adults is considered tachypnea.
- Use of accessory muscles: Observe for visible contraction of sternocleidomastoid, scalene, or abdominal muscles during breathing.

Nursing Diagnosis

Based on the assessment data, appropriate nursing diagnoses can be formulated. These diagnoses guide the development of the nursing care plan and provide a framework for interventions. Common nursing diagnoses for impaired gas exchange include:

Impaired Gas Exchange: This is the primary diagnosis when assessment findings clearly indicate a problem with oxygenation and carbon dioxide elimination. It is defined as excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.
Ineffective Breathing Pattern: This diagnosis is used when the patient’s respiratory rate, depth, or rhythm is altered, and ventilation is compromised.
Ineffective Airway Clearance: Applies when the patient is unable to clear secretions or obstructions from the airway, hindering gas exchange.
Activity Intolerance: May be diagnosed if impaired gas exchange limits the patient’s ability to perform activities of daily living due to dyspnea or fatigue.
Anxiety: Related to air hunger and difficulty breathing.
Fear: Related to the sensation of not being able to breathe and potential for respiratory distress.
Deficient Knowledge: Regarding the management of their respiratory condition and strategies to improve gas exchange.

Nursing Goals

Setting realistic and measurable goals is essential for evaluating the effectiveness of the nursing care plan. Common goals for patients with impaired gas exchange include:

Maintain optimal gas exchange: As evidenced by:
- Alert and oriented mental status.
- Unlabored respirations at a rate of 12-20 breaths per minute.
- Oxygen saturation (SpO2) within the normal range for the patient (typically ≥ 94% or as specified by physician order).
- Arterial blood gases within normal limits for the patient’s condition.
- Heart rate within the patient’s baseline range.
Maintain clear lung fields: Absence of adventitious breath sounds (wheezes, crackles) on auscultation.
Verbalize understanding of oxygen therapy and other therapeutic interventions: Patient can explain the purpose and proper use of oxygen and other treatments.
Participate in procedures to optimize oxygenation: Patient actively engages in deep breathing exercises, positioning, and other interventions within their capabilities.
Demonstrate resolution or absence of symptoms of respiratory distress: Absence or significant reduction in dyspnea, cyanosis, restlessness, and other signs of respiratory compromise.

Nursing Interventions and Actions

Nursing interventions are designed to address the identified nursing diagnoses and achieve the established goals. Interventions for impaired gas exchange are categorized to focus on key aspects of care:

1. Improving Oxygen Perfusion

Assessment of Oxygen Saturation

Monitor oxygen saturation continuously using pulse oximetry.
Pulse oximetry is a non-invasive, readily available tool for early detection of changes in oxygenation. A SpO2 below 90% generally indicates hypoxemia and necessitates further assessment and intervention.

Monitor for signs and symptoms of atelectasis: bronchial or tubular breath sounds, crackles, diminished chest excursion, limited diaphragm excursion, and tracheal shift to the affected side.
Atelectasis, or alveolar collapse, impairs ventilation and gas exchange. These assessment findings suggest areas of lung collapse. Low ventilation-perfusion states, termed shunt-producing disorders, occur when perfusion exceeds ventilation, causing blood to bypass alveoli without gas exchange. This is seen in conditions like pneumonia, atelectasis, tumors, or mucus plugs.

Observe nail beds and skin for cyanosis, paying close attention to the tongue and oral mucous membranes.
Central cyanosis of the tongue and oral mucosa is a critical sign of severe hypoxia and requires immediate medical attention (Pahal et al., 2021). Peripheral cyanosis in extremities may be less indicative of severe hypoxia. Cyanosis becomes visible when at least 5g/dL of hemoglobin is unoxygenated.

Monitor the patient’s behavior and mental status for restlessness, agitation, confusion, and (in late stages) extreme lethargy.
Changes in mental status are sensitive indicators of impaired gas exchange, particularly hypoxia. Neurological manifestations of moderate hypoxia include restlessness, headache, and confusion. Severe hypoxia can lead to altered mentation, coma, and potentially death if not promptly corrected (Bhutta et al., 2022).

Observe for signs and symptoms of pulmonary infarction: bronchial breath sounds, consolidation, cough, fever, hemoptysis, pleural effusion, pleuritic pain, and pleural friction rub.
Pulmonary infarction (lung tissue death due to blocked blood supply) results in increased dead space and reflex bronchoconstriction, leading to hypoxia (ventilation without perfusion). These signs and symptoms are also characteristic of other disorders like pulmonary emboli and cardiogenic shock.

Note blood gas (ABG) results and changes.
ABG analysis is crucial for assessing oxygenation (PaO2), carbon dioxide elimination (PaCO2), and acid-base balance. Increasing PaCO2 and decreasing PaO2 indicate respiratory acidosis and hypoxemia. Deteriorating respiratory status is often reflected in a decreasing respiratory rate and increasing PaCO2. ABG studies provide valuable data on lung function and ventilation.

Monitor the effects of position changes on oxygenation (ABG and pulse oximetry).
Positioning can significantly impact ventilation and perfusion. Placing the most compromised lung area in a dependent position (lower) can worsen ventilation-perfusion imbalances. Regional lung and chest wall compliance varies with position due to gravity and anatomical factors (Guerin et al., 2020).

Check hemoglobin levels.
Low hemoglobin levels reduce the blood’s oxygen-carrying capacity, leading to anemic hypoxia. Adequate hemoglobin is essential for oxygen uptake at the alveolar-capillary membrane and oxygen delivery to tissues (Pittman, 2011).

Assess venous oxygen saturation (SvO2) as indicated.
Venous blood gas (VBG) studies provide additional information on oxygen delivery and consumption by tissues. SvO2 reflects the balance between oxygen utilization and oxygen return to the heart. VBG analysis is useful in guiding therapy for postoperative patients at risk for hemodynamic instability or those with septic shock.

Assess for signs of obstructive sleep apnea (OSA).
Undiagnosed OSA may be identified during hospitalization. Signs include snoring, pauses in breathing during sleep, and unrefreshing sleep. OSA leads to intermittent apnea and hypoxia due to airway obstruction during sleep (Hoyord, 2019).

Arrange for nocturnal trend oximetry.
This test monitors oxyhemoglobin saturation overnight, providing data on nocturnal oxygenation. It’s used to assess the need for nighttime oxygen supplementation (Bhutta et al., 2022).

Assist the patient during the six-minute walk test.
This test evaluates oxyhemoglobin saturation response to exercise and the distance walked in six minutes. It helps in titrating oxygen supplementation and assessing therapy response (Bhutta et al., 2022).

Optimal Client Positioning

Regularly check the patient’s position to prevent slumping in bed.
Slumped positioning compresses the diaphragm, restricting lung expansion. Elastic pressures of the chest wall and respiratory system are more positive in the supine position compared to upright, and abdominal pressure is a key factor (Mezidi & Guerin, 2018).

For unilateral lung disease, position the patient to promote ventilation-perfusion.
Gravity and hydrostatic pressure improve ventilation and perfusion in the dependent lung. The “good lung down” position is generally recommended (e.g., in cases of pulmonary embolus or atelectasis, the affected lung should be positioned upwards). However, in conditions like lung hemorrhage or abscess, the affected lung should be positioned downward to prevent drainage into the healthy lung (Lanks, 2022).

Turn the patient every two hours. Monitor mixed venous oxygen saturation closely after turning. If it drops below 10% or fails to return to baseline promptly, return the patient to supine position and reassess oxygen status.
Turning prevents complications of immobility, but in critically ill patients, it can cause desaturation, especially with low hemoglobin or decreased cardiac output. Functional residual capacity decreases in the supine position (Mezidi & Guerin, 2018).

Consider prone positioning with upper thorax and pelvis supported, allowing the abdomen to protrude. Monitor oxygen saturation and revert to supine if desaturation occurs. Avoid prone position in multisystem trauma patients.
Prone positioning can improve arterial oxygenation, possibly due to improved diaphragm contraction and function of ventral lung regions. It enhances hypoxemia in ARDS patients by promoting more even gas-tissue distribution and homogenous lung stress and strain (Guerin et al., 2020).

Support the patient with pillows or cushions for comfort and proper alignment. Use positioning aids for immobile patients.
Proper alignment prevents muscle fatigue and respiratory effort, improving breathing efficiency and oxygenation. Positioning aids like wedges and rolled blankets provide support, maintain alignment, and promote lung expansion.

Instruct the patient on positioning for chest physiotherapy.
Chest physiotherapy, including postural drainage, uses gravity to aid in removing bronchial secretions. Different positions facilitate drainage from different lung lobes. Lower and middle lobes drain better with the head down, while upper lobes drain better with the head up. Secretions are then removed by coughing or suctioning.

Consider special positioning devices.
Continuous lateral rotation beds or prone positioning devices may optimize oxygenation in some patients. Lateral rotation is thought to improve secretion drainage and increase functional residual capacity by increasing critical opening pressure to the dependent lung (Goldhill et al., 2020).

Oxygen Therapy

Maintain prescribed oxygen administration device to keep oxygen saturation at 90% or greater.
Supplemental oxygen is often necessary to maintain adequate PaO2. Oxygen transport depends on cardiac output, arterial oxygen content, hemoglobin concentration, and metabolic needs.

Avoid high oxygen concentrations in COPD patients unless specifically ordered.
In COPD patients with chronic carbon dioxide retention, hypoxia is the primary respiratory drive. High oxygen concentrations can suppress this drive, leading to apnea. Close monitoring is crucial to prevent unsafe PaO2 increases. Maintain SpO2 between 90% and 93% using the lowest effective oxygen flow.

Provide oxygen during meals for patients who are allowed to eat, switching from mask to nasal cannula if appropriate.
Oxygen demand increases with activity. Nasal cannulas allow eating, talking, and coughing without interrupting oxygen flow. Return to the original delivery system immediately after meals. Nasal cannulas can cause nasal and pharyngeal mucosa irritation and drying.

Administer humidified oxygen via appropriate device (nasal cannula or face mask) as ordered. Monitor for hypoventilation, indicated by increased somnolence, after initiating or increasing oxygen therapy.
Humidification prevents drying of mucous membranes. Patients with chronic lung disease may rely on hypoxic drive to breathe and may hypoventilate with oxygen therapy. Oxygen toxicity (from >50% oxygen for >24 hours) can damage the alveolar-capillary membrane, leading to pulmonary edema and cell death.

For ambulatory patients, use extension tubing or portable oxygen apparatus.
These measures improve exercise tolerance by maintaining oxygen levels during activity. Oxygen concentrators are portable and cost-effective for home use, delivering 1-10 liters/minute.

Schedule nursing care to allow for rest and minimize fatigue.
Hypoxic patients have limited reserves. Inappropriate activity can worsen hypoxia. COPD patients often have decreased exercise tolerance, especially in the morning due to overnight secretion accumulation. Plan self-care activities and determine optimal times for them.

Assess indicators of oxygen therapy effectiveness.
Oxygen is a medication and requires a provider’s prescription (except in emergencies). Monitor for indicators of inadequate oxygenation such as confusion, restlessness, lethargy, diaphoresis, pallor, tachycardia, tachypnea, and hypertension.

Monitor for signs of oxygen toxicity.
Oxygen toxicity can occur with high oxygen concentrations (>50%) for extended periods (>24 hours). Symptoms resemble acute respiratory distress syndrome: substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates on chest X-rays.

Consider gerontologic factors when assessing oxygen delivery efficacy.
The respiratory system changes with aging. Older adults may have increased chest rigidity, increased respiratory rate, decreased PaO2, and reduced lung expansion, increasing their risk for aspiration and infection.

Treatment for Hypercapnia

Monitor for signs of hypercapnia.
Hypercapnia (CO2 buildup in the blood) symptoms include headache, dizziness, lethargy, impaired cognitive function, disorientation, and coma. Sudden hypercapnia can cause increased pulse and respiratory rate and elevated blood pressure. PaCO2 > 60 mm Hg causes cerebrovascular vasodilation and increased cerebral blood flow (Guerra, 2022).

Monitor ABG or VBG analysis results.
Arterial or venous blood gas analysis is vital for evaluating pH, serum CO2, and serum HCO3. Anion gap calculation can help differentiate metabolic from respiratory acidosis (Guerra, 2022).

Monitor respiratory rate, depth, and effort.
Frequent respiratory assessment allows early detection of changes in breathing patterns and effort. In hypercapnia, assess for respiratory distress signs like increased rate, shallow breaths, or accessory muscle use.

Instruct on incentive spirometry.
Spirometry assesses lung function. Forced expiratory volume in one second and forced vital capacity help determine if hypoventilation is restrictive or obstructive. Air trapping suggests COPD or asthma (Guerra, 2022).

Instruct patient to maintain upright position or elevate head of bed.
Upright positioning promotes optimal lung expansion and ventilation by allowing the diaphragm to function effectively and reducing chest pressure.

Encourage deep breathing exercises.
COPD patients often have shallow, rapid, and inefficient breathing. Diaphragmatic breathing, with practice, can reduce respiratory rate, increase alveolar ventilation, and improve air expulsion. Pursed-lip breathing slows expiration, prevents small airway collapse, and helps control breathing rate and depth.

Administer prescribed bronchodilators.
Bronchodilators relax airway smooth muscles, dilate bronchioles, and improve airflow, facilitating better ventilation and gas exchange in hypercapnia.

Assist with noninvasive ventilatory support as indicated.
Noninvasive ventilation (NIV), usually positive-pressure ventilation via tight-fitting mask, reduces the need for intubation, lowers complication rates, and reduces care costs. NIV is also used long-term for chronic hypercapnic respiratory failure in COPD (Csoma et al., 2022).

Assist with endotracheal ventilation and mechanical ventilation as appropriate.
BiPAP, CPAP, and intubation with mechanical ventilation support oxygenation and CO2 removal. Mechanical ventilation, while invasive, offers better control of respiratory rate, tidal volume, FiO2, and pressure support (Guerra, 2022).

2. Promoting Effective Breathing Patterns

Effective breathing is crucial for adequate ventilation and oxygenation, ensuring efficient gas exchange. In conditions like COPD, pneumonia, or asthma, interventions to support and enhance respiratory function are essential.

Assessment of Respirations and Pulmonary Function

Assess respiratory rate, depth, and effort, including accessory muscle use, nasal flaring, and abnormal breathing patterns.
Hypoxia can present acutely with dyspnea and tachypnea or chronically with exertional dyspnea. Stridor indicates upper airway obstruction. Chronic presentation often includes dyspnea on exertion. Hypoxia signs include increased respiratory rate, accessory muscle use, nasal flaring, abdominal breathing, and a panicked look (Bhutta et al., 2022).

Assess lungs for decreased ventilation areas and adventitious sounds.
Irregular breath sounds can reveal the cause of impaired gas exchange. Crackles and wheezes suggest airway obstruction exacerbating hypoxia. Diminished sounds indicate poor ventilation. Listen to two full inspirations and expirations at each location for accurate sound interpretation.

Monitor for alterations in blood pressure (BP) and heart rate (HR).
Initially, BP, HR, and respiratory rate increase with hypoxia and hypercapnia. However, in severe cases, BP and HR decrease, and dysrhythmias may occur. Tachycardia can result from severe hypoxia as the body attempts to deliver sufficient oxygen to tissues (Bhutta et al., 2022).

Assess for chest pain.
Chest pain or discomfort may occur with pneumonia, pulmonary infarction, pleurisy, or bronchogenic carcinoma. Assess pain quality, intensity, radiation, precipitating factors, and relationship to position and respiratory phases.

Assess risk factors contributing to ineffective breathing pattern.
Smoking history (including secondhand smoke exposure) is crucial as many lung disorders are linked to tobacco smoke. Socioeconomic factors may predispose certain groups to higher lung disease burdens. Poverty increases the risk of severe asthma exacerbations, hospitalizations, and death.

Breathing and Coughing Techniques

Assess patient’s ability to cough out secretions. Note sputum quantity, color, and consistency.
Retained secretions impair gas exchange. Coughing is a protective reflex against secretion accumulation or foreign body inhalation. Cough reflex may be impaired by respiratory muscle weakness, paralysis, prolonged inactivity, nasogastric tube, or depressed brain medullary center function.

Client Positioning

Position patient with head of bed elevated, in semi-Fowler’s position (45 degrees) if tolerated.
Upright or semi-Fowler’s position increases thoracic capacity, diaphragm descent, and lung expansion, preventing abdominal contents from crowding. In ARDS, upright position (45 degrees trunk elevation and

For obese or ascites patients, consider reverse Trendelenburg position at 45 degrees as tolerated.
Reverse Trendelenburg at 45 degrees increases tidal volumes and decreases respiratory rate. In patients with BMI > 35 kg/m², a 70-degree sitting position reduces expiratory flow limitation, auto-PEEP, and plateau pressure compared to supine (Mezidi & Guerin, 2018).

For acute dyspnea, have patient lean forward over bedside table if tolerated.
Leaning forward can decrease dyspnea, possibly by reducing gastric pressure on the diaphragm. The orthopneic position (tripod position) involves sitting and leaning forward with arms propped on an overbed table or knees. Elevate head of bed to 90 degrees and place a table with pillows across the bed. Pillows behind the lower back can increase comfort and support (Arps, 2017).

Pulmonary Function Testing

Consider pulmonary function tests (PFTs).
PFTs are used for chronic respiratory disorders to aid diagnosis, assess function and dysfunction extent, therapy response, and as screening in hazardous industries. They assess breathing mechanics, diffusion, and gas exchange.

Instruct patient on measuring peak flow rate.
Patients with respiratory symptoms may undergo complete diagnostic evaluation, even with “normal” PFT results. Teach patients to measure peak flow rate (maximal expiratory flow) at home using a spirometer to monitor therapy progress and adjust medications based on guidelines.

Encourage slow deep breathing using incentive spirometer as indicated.
Incentive spirometry promotes deep inspiration, increasing oxygenation and preventing atelectasis. Volume-type spirometry requires a deep breath through the mouthpiece, pausing at peak inflation, then exhaling. Flow-type spirometers have movable balls lifted by breath force, indicating inhaled air volume and flow by ball height and duration.

Administer medications as prescribed.
Medication type depends on the etiology: antibiotics for pneumonia, bronchodilators for COPD, anticoagulants, thrombolytics for pulmonary embolus, and analgesics for thoracic pain.

Instruct patient on proper positioning during PFTs.
Proper positioning ensures optimal ventilation during testing. Spirometry is usually performed sitting, but supine measurement may be needed for neuromuscular disorders (Ponce, 2022).

Assist in measuring lung volumes.
Lung volume measurement detects effort-independent lung volume changes, especially when functional vital capacity is reduced on spirometry. Gas dilution and body plethysmography methods are used. Body plethysmography is the gold standard (Ponce, 2022).

Assess patient’s respiratory muscle pressure.
Respiratory muscle strength is assessed with maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP). MIP indicates diaphragm and inspiratory muscle strength, MEP indicates abdominal and expiratory muscle strength. MEP < 60 cm H20 predicts weak cough and secretion clearance difficulty (Ponce, 2022).

Emphasize informing healthcare staff of illness or cardiopulmonary disorder before testing.
PFTs are generally safe. Contraindications include acute coronary syndrome, ruptured aneurysms, and surgical wound dehiscence. Bronchoprovocation testing is contraindicated in patients with recent myocardial infarction, unstable heart disease, or stroke (within 3 months). Acute illness may yield suboptimal results (Ponce, 2022).

3. Reducing the Risk of Respiratory Infection or Failure

Impaired gas exchange increases the risk of respiratory failure by disrupting oxygen and carbon dioxide exchange. Timely management of underlying causes is crucial to prevent or treat respiratory failure and restore adequate gas exchange.

Identification of Worsening Respiratory Symptoms

Monitor chest X-ray reports.
Chest X-rays reveal causes of impaired gas exchange. Normal lung tissue is radiolucent. Densities from fluid, tumors, foreign bodies, and other pathologies are detectable via X-ray. Chest X-rays may reveal extensive lung pathology even in the absence of symptoms.

Closely monitor patient’s ABG results.
Acute respiratory failure is defined by PaO2 < 60 mm Hg, PaCO2 > 50 mm Hg, and arterial pH < 7.35.

Assess for respiratory failure symptoms.
COPD patients are at risk for respiratory insufficiency, infections, and exacerbations, increasing the risk of acute and chronic respiratory failure. Asterixis may indicate severe hypercapnia. Hypoxemia and acidosis can cause tachycardia and arrhythmias. Dyspnea often accompanies respiratory failure (Kaynar & Sharma, 2020).

Monitor for nosocomial infections.
Nosocomial infections (pneumonia, UTIs, catheter-related sepsis) are common complications of respiratory failure, especially with mechanical devices. Nosocomial pneumonia has a high incidence and significant mortality (Kaynar & Sharma, 2020).

Identify PaO2:FiO2 ratio as indicated.
This ratio measures hypoxia severity. Normal PaO2/FiO2 ratio is 300-500 mm Hg. Ratio < 300 indicates abnormal gas exchange, < 200 mm Hg indicates severe hypoxemia. PaO2/FiO2 ratio is primarily used to define ARDS severity (Bhutta et al., 2022).

For Patients with Mechanical Ventilation and Endotracheal Intubation

Consider need for intubation and mechanical ventilation.
Early intubation and mechanical ventilation are recommended to prevent full decompensation. Mechanical ventilation supports oxygenation and ventilation. Endotracheal intubation and mechanical ventilation are indicated in respiratory failure or compromised airway, evidenced by decreasing PaO2, increasing PaCO2, and persistent acidosis.

Suction as necessary.
Suction clears secretions if the patient cannot effectively clear the airway. Obstruction impairs ventilation and gas exchange. In mechanically ventilated patients, in-line suction catheters allow rapid suction, minimize cross-contamination, decrease hypoxemia, sustain PEEP, and reduce anxiety (associated with suctioning).

Monitor sedation and analgesic effects on respiratory pattern; use judiciously.
Analgesics and sedatives can depress respiration but can also reduce sympathetic nervous system discharge associated with hypoxia. Monitor vital signs and hemodynamic instability, reporting changes to the provider as they may indicate ineffective mechanical ventilation or excessive sedation/analgesia.

Instruct patient to limit exposure to persons with respiratory infections.
This reduces droplet spread. Patients with impaired gas exchange often have weakened immune systems, increasing susceptibility to respiratory infections, which can worsen respiratory function.

Place patient in semi-Fowler’s position.
After tracheostomy for mechanical ventilation and stable vital signs, semi-Fowler’s position facilitates ventilation, promotes drainage, minimizes edema, and prevents suture line strain.

Ensure endotracheal/tracheostomy tube cuff pressure is within normal parameters.
Cuff inflation is needed for mechanical ventilation or aspiration risk. Maintain lowest possible cuff pressure (20-25 mm Hg) for adequate tidal volumes and aspiration prevention. Monitor cuff pressure every 8 hours using a handheld pressure gauge on the pilot balloon.

Adjust ventilator settings as appropriate and indicated.
Adjust ventilator for patient comfort and synchrony. Appropriate volume ventilator settings result in satisfactory ABGs and minimal cardiovascular compromise. Review manufacturer’s instructions before initiating mechanical ventilation.

Implement care bundle interventions for mechanically ventilated patients.
Evidence-based VAP bundles improve outcomes. Key elements include head-of-bed elevation (30-45 degrees), daily “sedation vacations” and readiness-to-extubate assessments, peptic ulcer prophylaxis, deep venous thrombosis prophylaxis, and daily oral care with chlorhexidine (0.12% oral rinses).

Perform tracheostomy care routinely.
Patients with endotracheal or tracheostomy tubes lack upper airway defenses and are often immunocompromised. Tracheostomy care is performed at least every 8 hours (more frequently if needed) due to infection risk.

Perform oral hygiene frequently.
Frequent oral hygiene is essential as the oral cavity is a primary source of lung contamination in intubated patients. NG tube presence also increases aspiration risk, leading to nosocomial pneumonia.

4. Providing Relief from Anxiety

Air hunger, or the urge to breathe, can be triggered by increased respiratory drive or reduced ventilation, causing anxiety, fear, and frustration (Banzett et al., 2021).

Assessment of Anxiety Level

Assess anxiety level in patients with dyspnea or air hunger.
Anxiety is common in COPD patients. Tools like the Hospital Anxiety and Depression Scale (HADS), Beck Anxiety Inventory, and Spielberger State-Trait Anxiety Inventory are used (Yohannes et al., 2017).

Observe patient for anxiety cues.
Observe body language, behavior (restlessness, fidgeting, pacing, tense expressions), and verbal cues (fear, worry, anxious statements). Patients may be reluctant to admit anxiety, but physical signs may reveal it.

Monitor changes in respiratory symptoms.
Dyspnea and anxiety are often linked. Respiratory distress can worsen anxiety. Assess respiratory status to identify physical factors exacerbating anxiety, like increased breathing effort or distress signs (nasal flaring, retractions).

Monitor vital signs.
Monitor heart rate, blood pressure, and oxygen saturation for objective anxiety indicators. Anxiety can activate the sympathetic nervous system, increasing heart rate and blood pressure. Oxygen saturation changes during dyspnea may indicate anxiety.

Pulmonary Rehabilitation

Introduce pulmonary rehabilitation to patient and caregivers.
Pulmonary rehabilitation alleviates symptoms and optimizes function. Goals include symptom reduction, improved quality of life, and increased physical and emotional participation in daily activities. Breathing exercises, retraining, and exercise programs improve function. PR reduces anxiety and dyspnea in COPD patients in short-term follow-up (Yohannes et al., 2017).

Assist patient with breathing exercises.
Nurses educate patients and families and facilitate physical therapy for breathing retraining. Diaphragmatic breathing reduces respiratory rate and increases alveolar ventilation. Pursed-lip breathing slows expiration, prevents airway collapse, controls breathing rate/depth, and promotes relaxation, helping manage dyspnea and panic.

Arrange for weekly pulmonary rehabilitation program attendance.
Intensive 3-week PR programs (6 hours/day, 5 days/week) significantly reduce dyspnea and anxiety, improving exercise capacity and quality of life. Anxiety symptom improvement is related to perceived dyspnea at rest. However, this program may not suit moderate-to-severe COPD patients (Yohannes et al., 2017).

Instruct patient about activity pacing.
COPD patients have decreased exercise tolerance, especially in the morning. Plan self-care activities and determine optimal times for bathing, dressing, and other daily activities.

Promote physical conditioning techniques.
Exercise training benefits COPD patients of all grades. Techniques include breathing exercises and general exercises for energy conservation and ventilation improvement. Graded exercises and conditioning programs (treadmills, stationary bikes, measured walks) improve symptoms, work capacity, and exercise tolerance.

Provide nutritional counseling as appropriate.
Nutritional status impacts symptom severity, disability, and prognosis. Assess caloric needs and counsel on meal planning and supplementation. Monitor weight and intervene as needed.

Promote coping measures to reduce anxiety and depression.
Breathing difficulties induce anxiety, depression, and behavioral changes. Shortness of breath and fatigue can cause irritability and panic. Educate and support spouses/families as caregiver role in end-stage COPD is challenging.

Providing Interventions for Anxiety Relief

Provide reassurance and reduce anxiety.
Anxiety increases dyspnea, respiratory rate, and breathing effort. Reassurance alleviates distress and promotes calm. Trust in the nurse’s expertise and cooperation with the care plan are enhanced by reassurance.

Support family of chronically ill patients.
Severe respiratory compromise causes fear and anxiety in patients and families. Nurse reassurance is helpful, fostering a positive therapeutic relationship and open communication about symptoms and concerns.

Encourage verbalization of feelings for patient and caregivers.
Dyspnea and anxiety cause emotional turmoil and psychological burden. Verbalizing feelings provides emotional release and validation.

Provide therapeutic communication.
Therapeutic communication creates a calming, supportive environment and helps patients understand their condition, promoting trust.

Promote relaxation techniques (deep breathing, guided imagery).
Relaxation techniques reduce anxiety and improve coping with dyspnea. Deep breathing regulates breathing, reduces distress, and increases oxygenation. Guided imagery distracts and promotes calmness.

Encourage patient to assume position of comfort during dyspnea.
Comfortable positions (upright, leaning forward, pillows for support) reduce breathing effort, open chest, and improve ventilation.

Refer for cognitive behavioral therapy (CBT) if indicated.
CBT combines behavioral and cognitive therapy to address thought patterns inducing worry, anxiety, and depression. CBT, in individual or group sessions, addresses current problems and involves collaboration between therapist and patient (Yohannes et al., 2017).

5. Client and Caregiver Education

Set short- and long-term client education goals with patient and caregivers.
Client education involves setting realistic goals. For mild COPD, goals are to increase exercise tolerance and prevent pulmonary function decline. For severe COPD, goals are to preserve function and relieve symptoms. Plan and share treatment goals with the patient.

Consider patient’s nutritional status.
Obesity restricts diaphragm movement, increasing risks of atelectasis, hypoventilation, and respiratory infections. Malnutrition reduces respiratory mass and strength. COPD patients often have difficulty maintaining weight. Monitor weight and intervene as needed.

Evaluate patient’s hydration status.
Overhydration impairs gas exchange in heart failure. Dehydration impairs secretion clearance in pneumonia and COPD. Adequate hydration loosens secretions, facilitating expulsion.

Assess home environment for irritants. Help adjust home environment (e.g., air filter).
Irritants reduce oxygen access. Assess patient’s triggers (air pollution, temperature extremes, humidity, strong smells) to establish avoidance or treatment plans.

Encourage or assist with ambulation as indicated.
Ambulation facilitates lung expansion and secretion clearance. COPD patients experience progressive activity intolerance. Educate on pacing activities and using supportive devices to decrease energy expenditure. Walking aids may improve activity levels.

Help patient deep breathe and perform controlled coughing. Inhale deeply, hold breath, cough 2-3 times with mouth open while tightening abdominal muscles.
This technique increases sputum clearance and decreases cough spasms. Controlled coughing uses diaphragmatic muscles for a more forceful cough. Diaphragmatic breathing reduces respiratory rate and increases alveolar ventilation. Pursed-lip breathing slows expiration and prevents airway collapse.

For postoperative patients, assist with chest splinting.
Splinting optimizes deep breathing and coughing by minimizing pain. Analgesics also help facilitate more effective coughing.

Pace activities and schedule rest periods to prevent fatigue. Assist with ADLs.
Activities increase oxygen consumption. Plan activities and rest to prevent hypoxia. Space out interventions to decrease oxygen demand.

Instruct family on disease complications and medical regimen, including when to call the provider.
Family knowledge is crucial for preventing complications. Instruct them to report infection signs (fever, sputum changes), and worsening symptoms (chest tightness, dyspnea, fatigue).

Provide information about self-management programs during discharge teaching.
Self-Management Program of Activity, Coping, and Education (SPACE) with structured exercise reduces dyspnea. Health management programs with education, smoking cessation, exercise encouragement, rehabilitation instruction, and psychological counseling improve outcomes (Yohannes et al., 2017).

Refer patient to community-based or transitional care facilities/managers.
Referral for home, community-based, or transitional care enables assessment of the home environment, physical and psychological status, regimen adherence, and coping ability. Home visits reinforce rehabilitation program information and activities, and allow demonstration of medication/oxygen administration and exercises.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care This book is valuable for its evidence-based approach to nursing interventions. It uses a three-step system for client assessment, nursing diagnosis, and care planning, including step-by-step instructions for care implementation and outcome evaluation, fostering diagnostic reasoning and critical thinking skills.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
This resource includes over two hundred care plans based on the latest evidence-based guidelines, featuring new ICNP diagnoses, care plans on LGBTQ health issues, and electrolyte and acid-base balance.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
A quick-reference tool for identifying correct diagnoses and efficient care planning. The sixteenth edition features the most recent nursing diagnoses and interventions, with an alphabetized listing covering over 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
This manual helps plan, individualize, and document care for over 800 diseases and disorders. It provides subjective and objective data, sample clinical applications, prioritized actions/interventions with rationales, documentation sections, and more for each diagnosis.

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
This ebook includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health, focusing on interprofessional “patient problems” to improve patient communication.

References

Recommended sources, interesting articles, and references about management of patients with gas exchange problems to further your reading.

Facebook Email Copy Print Buffer Pinterest Share