00030 Impaired gas exchange

Domain 3: elimination and exchange
Class 4: respiratory function
Diagnostic Code: 00030
Nanda label: deterioration of gas exchange
Diagnostic focus: gas exchange
Approved 1980 • Revised 1996, 1998, 2017, 2020 • Evidence level 3.3

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « deterioration of gas exchange »  is defined as: excess or deficit in oxygenation and/or elimination of carbon dioxide.

Definite characteristics

  • Abnormal arterial pH
  • Abnormal skin color
  • Alteration of deep breathing
  • Respiratory rhythm alteration
  • Bradypnea
  • Confusion
  • Decrease in carbon dioxide level
  • Diaphoresis
  • Sopor
  • Cephalea when awakening
  • Hypercapnia
  • hypoxemia
  • Hypoxia
  • Irritable mood
  • Nasal flutter
  • Psychomotor agitation
  • Tachycardia
  • Tachypnea
  • Visual disorders

Related factors

  • Ineffective cleaning of the airways
  • Ineffective respiratory pattern
  • Pain

Risk population

  • Premature infants

Associated problems

  • Changes in the alveolo-channel membrane
  • asthma
  • General anesthesia
  • heart disease
  • Imbalance ventilation-perfusion

Suggestions of use

  • This label should be used with caution. The reduction of the passage of gases between the pulmonary alveoli and the vascular system can be discovered only through a diagnostic test requested by a doctor: blood gas analysis. A patient could have most of the defining characteristics without actually suffering a deterioration in the alveolar gas exchange. It is better to use a diagnostic statement that describes oxygen -related problems, so that nursing personnel can diagnose and treat independently (for example, activity intolerance). If the suggested alternative diagnoses are treated, which are stated below, the deterioration of the gas exchange should improve. If the patient is at risk of deterioration of the gas exchange, the proper collaboration problem should be noted (for example, possible complication of thrombophlebitis: pulmonary piston). See the suggestions of use for ineffective cleaning of the respiratory tract, ineffective respiratory pattern and dysfunctional response to the weaning of the respirator.
  • The deterioration of gaseous exchange can be associated with several medical diagnoses. For example, functional lung tissue reduction can be secondary to chronic pneumopathy, pneumonia, thoracotomy, atelectasis, acute respiratory insufficiency syndrome Diaphragmatic mass and hernia. In addition, the reduction of blood supply to the lungs can occur secondary to pulmonary hypertension, pulmonary embolism, congestive heart failure, acute respiratory insufficiency syndrome and anemia.

Suggested alternative diagnostics

  • Activity, intolerance to
  • Ineffective respiratory pattern
  • Dysfunctional ventilatory response to weaning (DVWR)
  • Spontaneous ventilation, deterioration of the
  • Respiratory routes, ineffective cleaning of the

NOC Results

  • Respiratory status: Gaseous exchange: Alveolar exchange of C02 and 0 2 to maintain gase concentrations in blood pressure
  • Tissue perfusion: pulmonary: adequacy of blood flow through the pulmonary vasculature to perfuse the units of the alveoli-channels
  • Response to assisted breathing: adults: alveolar exchange and tissue perfusion are supported by assisted breathing
  • Vital signs: degree in which temperature, pulse, breathing and blood pressure are within normal limits

Evaluation objectives and criteria

Examples with the terms noc

  • The deterioration of gas exchange is resolved, as evidenced by an allergic reaction without risks: systemic, electrolytic balance and acid-base, response to assisted breathing: adults, the respiratory state: gaseous exchange, the respiratory state: ventilation, pulmonary tissue perfusion and vital signs
  • The respiratory state: gas exchange is not compromised, as evidenced by the following indicators (specify from 1 to 5: severe, substantial, moderate, light or none):
    • Cognitive state Pa02, Paco, arterial pH and saturation of 02 C02 exhaled
  • The respiratory state: gas exchange is not compromised, as evidenced by the following indicators (specify from 1 to 5: severe, substantial, moderate, light or none):
    • Dyspnea at rest
    • Dyspnea with exercise
    • Consultation, cyanosis and drowsiness
  • The respiratory state: ventilation is not at risk, as evidenced by the following indicators (specifying 1 to 5: seriously, substantially, moderately, slightly or not compromised):
    • Respiratory rate
    • Respiratory rhythm
    • Depth of inspiration
    • Air expulsion
    • Dyspnea at rest
    • Auscultation of respiratory sounds

Other examples

The patient will be able to:

  • Present a pulmonary function within normal limits
  • Have a symmetric chest expansion
  • Describe the home care plan
  • Do not breathe with pursed lips
  • Do not suffer lack of breath or orthopnea
  • Do not use breathing accessory muscles

NIC Interventions

  • Ventilation assistance: improve a spontaneous respiratory pattern
  • optimal that maximizes oxygen exchange and carbon dioxide in the lungs
  • Embolia care: pulmonary: limitation of complications for a patient suffering, or runs risk of lung circulation
  • Laboratory data interpretation: Critical analysis of patient laboratory data to help make medical decisions
  • Anaphylactic management: Improvement of adequate ventilation and tissue perfusion of a person with an allergic reaction (antigen-antibody) severe
  • Electrolyte management: Improvement of electrolytic balance and prevention of complications that result from abnormal or unwanted serum electrolytes concentrations
  • Management of respiratory tract: facilitation of the permeability of the respiratory tract
  • Asthma management: identification, treatment and prevention of inflammation or constriction reactions in respiratory tract passages
  • Balance-base balance: Improvement of acid-base balance and prevention of complications resulting from the acid-base imbalance
  • Acid-base balance management: Respiratory acidosis: balance improvement
  • acid-base and prevention of complications resulting from serum PC02 concentrations above the desired
  • Balance Management-Base: Respiratory alkalosis: Improvement of acid-base balance and prevention of complications resulting from serum pc02 concentrations lower than desired
  • Monitoring of vital signs: Collection and analysis of cardiovascular, respiratory data and body temperature to determine and prevent complications
  • Oxygen therapy: Oxygen administration and surveillance of its effectiveness
  • Hemodynamic regulation: optimization of heart rate, preload, postcard and contractility
  • Assisted breathing: use of an artificial device to help the patient breathe
  • Respiratory surveillance: Collection and analysis of patient data to guarantee the permeability of the respiratory tract and the appropriate gas exchange

Nursing Activities

Nursing activities for this diagnosis focus on the gaseous exchange in the alveolo-chapila membrane. However, efforts to facilitate ventilation can improve oxygen availability. Other interventions focus on related factors (for example, reduction in anxiety and pain management).

Valuations

  • Evaluate pulmonary sounds, frequency, depth and respiratory effort, and sputum production as indicators of the effective use of the support equipment
  • Monitor the saturation of O, with the pulse oximeter
  • Monitor the results of arterial gases (for example, low pao concentrations, and high of PAC02 suggest respiratory deterioration)
  • Monitor electrolyte concentrations
  • Monitor mental state (for example, level of consciousness, restlessness and confusion)
  • Increase the frequency of surveillance when the patient is seen sleepy
  • Observe if there is cyanosis, especially oral mucous membranes
  • (NIC) Management of respiratory tract:
    • Identify if the patient needs, or may need, the insertion of a respiratory path
    • Auscultar the respiratory sounds taking note of the reduced or absent breathing areas and the presence of anomalous sounds
    • Monitor the respiratory and oxygenation state, as required
  • (NIC) Hemodynamic regulation:
    • Auscultate cardiac sounds
    • Monitor and record the heart rate, rhythm and pulses
    • Monitor the presence of peripheral edema, distension of the jugular vein and cardiac sounds S3 and S4
    • Monitor the operation of the pacemaker, if applicable

Patient and family education

  • Explain the proper use of the auxiliary equipment (oxygen, aspiration, spirometer, intermittent positive pressure breathing or PPI)
  • Teach the patient with breathing and relaxation techniques
  • Explain to the patient and family the reasons for applying low flow oxygen and other treatments
  • Inform the patient and the family that is prohibited smoking
  • (NIC) Management of respiratory tract:
    • Teach how effectively cough
    • Teach the patient how to use the prescribed inhalers, as appropriate

Collaboration activities

  • Consult with the doctor about the future needs of the blood or abg arterial gas test, and the use of auxiliary equipment, as indicated by a change in the patient’s state
  • Communicate changes in correlated evaluation data (for example, patient sensory state, respiratory sounds, respiratory pattern, arterial gases, sputum, effect of medications)
  • Manage prescription medications (for example, sodium bicarbonate) to maintain acid-base balance
  • Prepare the patient for assisted breathing, if necessary
  • (NIC) Management of respiratory tract:
    • Administer air or humidified oxygen, as appropriate
    • Administer bronchodilators, as required
    • Administer treatments with aerosol, as appropriate
    • Administer treatments with ultrasonic nebulizer, if necessary
  • (NIC) Hemodynamic regulation: Manage antiarrhythmic medications, as needed

Others

  • Inform the patient before starting the planned procedures, to reduce anxiety and increase the feeling of control
  • Reassure the patient during irregular breathing periods or anxiety
  • Offer frequent oral hygiene
  • Apply measures to reduce oxygen consumption (for example, fever control and pain, reduction of anguish)
  • If oxygen is prescribed to patients with chronic respiratory problems, closely monitor oxygen flow and breaths, by the risk of respiratory depression caused by oxygen
  • Establish a care plan for a patient in a mechanical fan, which could include:
    • Ensure proper oxygen administration by reporting abnormal values ??in arterial gases, set an ambú bag to the source of oxygen to the head and hyperoxigening it before aspiration
    • Ensure an effective respiratory pattern when evaluating synchronization and the possible need for sedation
    • Maintain the permeability of the respiratory tract aspiring the patient and maintaining an endotracheal tube or a replacement to the header
    • Monitor any complication (for example, pneumotorax, unilateral aeration)
    • Check the correct placement of the endotracheal tube
  • (NIC) Management of respiratory tract:
    • Place the patient to maximize the possibility of ventilation
    • Place the patient in a posture that reduces dyspnea
    • Insert an oral or nasopharyngeal respiratory path, as appropriate
    • Eliminate secretions to foster cough or aspiration
    • Promote the process of slow and deep breathing, change of position and coughing
    • Help with the use of an incentive spirometer, if applicable
    • Perform thoracic physiotherapy, as appropriate
  • (NIC) Hemodynamic regulation:
    • Raise the head of the bed, if required
    • Place in trendelenburg, if applicable

At home

  • Evaluate the possible sources of allergens and passive smoking
  • Help the patient recognize and avoid situations that cause respiratory problems (for example, use of domestic cleaners and solvents, stressful factors)
  • Emphasize the family that nobody should smoke at home
  • Channel to smoking programs, if necessary
  • Encourage the family to install an air filter at home
  • Instruct the patient and his family about the home assistance plan, for example medicines, activity, auxiliary equipment, signs and symptoms that can communicate and community resources
  • Maintain the temperature of the home above 20 ° C (68 ° F)
  • Channel to health aid and household cleaning services to preserve energy
  • Evaluate the electrical safety (for example, landing) of the respiratory equipment
  • If a domestic respirator is used, notify the police, firefighters and service provider

Older people

  • Carefully monitor breaths when depressants of the central nervous system are used. The metabolism of the drugs changes with age and the elderly are susceptible to respiratory depression
  • If oxygen is prescribed, low flow must be used to avoid respiratory depression caused by oxygen