Which assessment finding in a patient with impaired gas exchange is most useful?

The nursing care of clients who have Altered gas exchange involves the understanding of the pathophysiology of the disease process or injury that causes the disruption to the oxygenation of the body. Altered gas exchange can be caused by many disease processes affecting oxygenation in the body such as heart diseases (coronary artery disease, myocardial infarction, inflammatory and structural heart disorders), respiratory diseases (upper and lower respiratory tract disorders, chronic obstructive pulmonary disease [COPD]), and renal disorders (acute kidney injury, chronic kidney disease, nephrotic syndrome, glomerulonephritis). As a nurse, looking for cues, and acting on those findings will help to manage clients who have altered gas exchange.

Though sputum can be collected any time of day, the best time to collect sputum is in the morning because after a night of sleep it is more likely to have a large amount of sputum available. Sputum for gram stain and culture and sensitivity will determine what type of bacteria may be causing an altered gas exchange will help better direct treatment to improve this issue.

Administration of albuterol via nebulization and prednisone PO: Assessing the client by listening to lung sounds before and after the medication administration, respiratory rate and oxygen saturation are vital to being able to evaluate the effects of the medication. Albuterol will help the immediate symptoms, while prednisone will take time to reduce inflammation. Oxygen is not needed to administer nebulizer therapy and may or may not be administered depending upon prescriptions.

Gas exchange meds: Albuterol, prednisone, and oxygen are medications that will improve gas exchange. Albuterol dilates the airways to allow for more surface area to perform gas exchange. prednisone reduced inflammatory response in the lungs, allowing for more gas exchange. Oxygen increases the amount of inhaled gas to increase gas exchange. Rivaroxaban and aspirin decrease blood clotting, atorvastatin decreases cholesterol, and famotidine reduces stomach acid. None of these affect gas exchange.

In caring for a client with altered gas exchange, it is important to look at their history, medications they are on, social and lifestyle

factors, and procedures or surgeries that could impact their health. In addition, physical assessment findings can lead to additional cues indicating an alteration in gas exchange.

Assessment Data Examples Rationale

Past Medical History/ History of Present Illness

Heart failure, valvular disorders, dysrhythmias, respiratory infections, chronic obstructive pulmonary disease (COPD), kidney disease, liver disease, pregnancy

These are clinical conditions may affec exchange by reducing the ability of the function correctly, or by causing an imp carbon dioxide to leave the alveoli, or enter the alveoli. This can be caused t lung swelling (pulmonary edema), decrea ability of the lung to expand, or the ina the blood to freely flow and exchange the capillary beds of the lungs.

Procedures Recent surgery, respiratory procedures, pulmonary surgeries

Anesthesia and prolonged immobility decrease lung function and increase th lung infection, inflammation, and decreas inflation. In addition, procedures inclu tube insertions, pulmonary surgery ma impact gas exchange.

Medications IV fluids, sedatives, allergic reactions

Fluids can cause overload or electrolyt imbalances that may affect gas exchan medications can cause decreased respi which decrease gas exchange. Allergi to medications can cause bronchocons limit gas exchange.

Lifestyle/Social Recreational chemical inhalation, diet, obesity

Cigarette or any type of vape/drug inh cause lung damage leading to decrease exchange. Obesity can cause resistance diaphragm or sleep apnea which leads gas exchange. High sodium diet can ca hypertension and the potential for fluid leading to poor gas exchange.

mellitus type I , emphysema and was admitted in the

hospital last month due to pneumonia.

The vital signs are temp 99 degrees Fahrenheit, RR 27 breaths/

minute , HR 105 beats per minute , BP 150/80 mm

Hg and 88% oxygen saturation in room air.

Answer: Shortness of breath, confusion, and chronic emphysema all suggest an alteration in gas exchange. Abnormal respiratory rate and low oxygen saturation also suggest altered gas exchange. Blood pressure, increased pulse, and lower extremity edema suggest altered fluid balance. Diabetes does not cause altered gas exchange except during diabetic ketoacidosis (which there is no indication of here). The client's pneumonia resolved during last hospitalization. The patient being pale and diaphoretic suggest altered cardiac output. Based on the data collected from the History and Physical assessment of your client including the past medical and surgical history, procedures, lifestyle and medications (over the counter or prescribed), you will assess the client using head to toe assessment and look at the laboratory and radiology test results.

The interprofessional care of the altered gas exchange may be different based on the etiology and some of the assessment findings. There are generally things that nurses can do to treat altered gas exchange regardless of the etiology. This includes actions that improve gas exchange, and further assessment that may involve focusing on and treating an underlying cause.

Here are some considerations in caring for someone with suspected altered gas exchange:

System Nursing Actions/Assessment Rationale

Neurological System

Monitor neurological function and level of consciousness

Changes in gas exchange can cause mental status such as confusion, let

System Nursing Actions/Assessment Rationale

drowsiness, stupor or coma.

Respiratory System

Elevate the head of the bed (45- degrees/semi to high fowler’s position)

This will expand the lungs by takin off the diagphragm and forcing any the lungs towards the bottom so mo area is available for gas exchange.

Monitor respiratory rate, breathing pattern and oxygen saturation.

Change in respiratory rate, breathin and oxygenation can suggest the nee further action.

Assess for adventitious lung sounds (crackles, rales, stridor or absent etc).

This may help clarify the cause of alteration in gas exchange, and can used to evaluate results before and nursing actions

Encourage deep/purse lip breathing exercises, ambulation, active/passive ROM and use of incentive spirometer.

These are techniques used to expan lungs, slow a client's breathing, and some comfort for shortness of brea

Report new abnormal findings or changes to health care provider

This facilitates the need for further medication, or other therapies that identify and treat underlying causes gas exchange.

The interprofessional care below focuses on cardiovascular system. Altered gas exchange can cause some changes in the cardiovascular system because it can affect the oxygen levels in the blood. Oxygen is vital for the body to function.

cannula, mask, or other device is often done initially and as part of the treatment in patients with gas exchange problems.

Chest Procedures= Several things can cause an altered gas exchange. Sometimes it is constriction of the lung from inflating (blood, fluid or infection in the plueral space). When this occurs, a thoracentesis (putting a needle or tube in the chest to drain the fluid) is performed. Often the nurse will assist in the procedure and may need to monitor chest tubes that are inserted to continually drain fluid.

Ventilation= While oxygen can be administered when there is altered gas exchange, problems with ventilation may stop the oxygen from getting to the alveoli. When this occurs artifical ventilation is done. A bag-valve-mask is one device that ventilates the lungs, a mechanical ventilator is another.

Medication= Many times, medications are given to reduce the problems that are causing altered gas exchange. Here are some medications that are used to improve gas exchange in select conditions:

Medication Class

Pathophysiologic problem Considerations

Diuretics Fluid overload Monitor electrolytes and blood pressure

Antibiotics Bacterial respiratory infection

Check for allergies to antibiotics

Bronchodilators Asthma Can cause tachycardia and high blood pressure

Medication Class

Pathophysiologic problem Considerations

Steroids Lung inflammation Long term side effects can be common

Antifungals Fungal lung infection

Usually requires prolonged treatment

Anticholinergics Chronic obstructive pulmonary disease

Can lead to anticholinergic toxicity

Bicarbonate Acidosis (respiratory or metabolic)

Monitor arterial blood gasses frequently

Oxygen therapy is used to supply poor oxygenation in the lungs. Administration of oxygen is based on respiratory assessment and arterial blood gas results. There are different delivery devices for oxygen that have different concentration of oxygen.

Delivery Device

Liters per minute Oxygen concentration

Nasal cannula 1 to 6 LPM 24 to 44%

Simple face mask 6 to 12 LPM 35 to 50%

Partial and non- breather masks

10 to 15 LPM

60 to 90%

instructions before use is essential. Here are some things to remember about chest tubes:

 Monitor fluid drainage frequently, and if it is excessive, the healthcare provider should be notified  Most chest tube systems should be stored below the level of insertion  Many chest tube systems are closed systems and should not be drained  Insertion site of the tube should be kept clean with dressing changed per hospital policy Usually, an occlusive dressing with a thick cream (like Vaseline soaked gauze) is used to ensure there is no leakage around the tube  While a chest tube is usually stitched in place, it is still important to protect the tube from unintentional removal

One of the most important functions associated with gas exchange is ventilation. The process of breathing moves oxygen into the lungs while expelling carbon dioxide, a biproduct of cellular metabolism.

Ensuring ventilation is the highest

priority in all patients at all times.

Ventilation

When a client is not breathing, then gas exchange does not occur. In these cases, they need to be artificially ventilated until the reason they are not breathing is solved. Initially a bag-valve-mask is used to emergently ventilate. After this, an endotracheal tube may be used to protect the client's airway, and directly deliver oxygen and air to their lungs using a mechanical ventilator. Here are some things to remember if you are caring for a patient who has an endotracheal tube in place:

 The endotracheal tube is the client's current lifeline to the world

 It is essential that the placement and location of that tube is kept safe  Safety measures usually done include taking and securing the tube at the exact position it has been placed in the nose or mouth  Continuous monitoring of the patient to ensure the airway remains intact and the equipment (ventilator) is working properly  If needed, client should be restrained for their own safety  Ensure to follow hospital policy regarding restraints  Always have a bag-valve-mask available in case an endotracheal tube is unintentionally removed  Always have a way to call for assistance if a situation arises that you cannot leave the room because you are protecting the client's airway  Endotracheal tubes are always secured with tape or a specialized holder. There are markings to indicate how far the tube was inserted. In most cases, clients will need to be restrained and/or sedated while the endotracheal tube is in. A bag-valve-mask should always be available in a room where a patient has an endotracheal tube. While signs of normal ventilation ensure the airway is clear, other assessment findings are used to ensure normal gas exchange.

The best measurement of gas exchange is the arterial blood gas (ABG) laboratory test. A person specially trained in drawing from an artery can include a physician, respiratory therapist, or other health care professional.

After an ABG is drawn, it is important to monitor the site the lab was obtained from to ensure bleeding doesn't occur. Because of the high pressure in an artery, there can be substantial blood loss in a short period of time. Usually, a pressure dressing is used. This tight bandage ensures hemostasis while NOT being tight enough to cut off circulation.

Results of ABGs, especially in urgent or emergent conditions, can often be back within a matter of minutes. Based on the results, the patient can be alkalotic, normal, or acidotic. In addition, the cause can be identified as respiratory or metabolic. There is sometimes evidence of partial or complete compensation

(including oxygen), performing procedures like intravenous insertions, foley catheter insertions, or complex dressing changes. Making decisions based on their assessments and educating patients on medications or other complex topics.

When in doubt, consult the board of nursing in the state you are in for clarification.

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