Nursing Interventions for Impaired Gas Exchange

Definition Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane. Defining Characteristics Abnormal arterial blood gases; abnormal arterial pH; abnormal breathing pattern; abnormal skin color; confusion; decrease in carbon dioxide (CO ) level; diaphoresis; dyspnea; headache on awakening; hypercapnia; hypoxemia; hypoxia; irritability; nasal flaring; restlessness, somnolence; tachycardia; visual disturbances 2 Related Factors To be developed Associated Condition Alveolar-capillary membrane changes; ventilation-perfusion imbalance NOC (Nursing Outcomes Classification) Suggested NOC Outcomes Respiratory Status: Gas Exchange, Ventilation Example NOC Outcome with Indicators Achieves appropriate Respiratory Status: Gas Exchange as evidenced by the following indicators: Cognitive status/Partial pressure of oxygen/Partial pressure of carbon dioxide/Arterial pH/Oxygen saturation. (Rate each indicator of Respiratory Status: Gas Exchange: 1 = severe deviation from normal range, 2 = substantial deviation from normal range, 3 = moderate deviation from normal range, 4 = mild deviation from normal range, 5 = no deviation from normal range [see Section I].) Client Outcomes Client Will (Specify Time Frame) • Demonstrate improved ventilation and adequate oxygenation as evidenced by blood gas levels within normal parameters for that client • Maintain clear lung fields and remain free of signs of respiratory distress • Verbalize understanding of oxygen supplementation and other therapeutic interventions NIC (Nursing Interventions Classification) Suggested NIC Interventions Acid-Base Management; Airway Management Example NIC Activities—Acid-Base Management Monitor for symptoms of respiratory failure (e.g., low Pa O and elevated PaCO levels and respiratory muscle fatigue); Monitor determinants of tissue oxygen delivery (e.g., PaO , SaO , and hemoglobin levels, and cardiac output) if available 2 2 Nursing Interventions and Rationales 2 2 • Monitor respiratory rate, depth, and ease of respiration. Watch for use of accessory muscles and nasal flaring. Normal respiratory rate is 14 to 16 breaths per minute in the adult (Bickley & Szilagyi, 2017). When the respiratory rate exceeds 30 breaths per minute, along with other physiological measures, a significant cardiovascular or respiratory alteration exists. • Auscultate breath sounds every 1 to 2 hours. The presence of crackles and wheezes may alert the nurse to airway obstruction, which may lead to or exacerbate existing hypoxia. In severe exacerbations of chronic obstructive pulmonary disease (COPD), lung sounds may be diminished or distant with air trapping (Bickley & Szilagyi, 2017). • The nurse should consider respiratory rate, work of breathing, and lung sounds along with PaO2 values, arterial oxygen saturation (SaO2), oxygen saturation continuously using pulse oximetry (SpO2), patient tidal volume, and minute ventilation. Presence of dyspnea, asynchronous chest and abdominal movements, accessory muscles, and agitation indicate potential oxygenation problems (Barton, Vanderspank-Wright, & Shea, 2016). • Monitor the client's behavior and mental status for the onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. Changes in behavior and mental status can be early signs of impaired gas exchange. In the late stages the client becomes lethargic and somnolent (Lee, 2017). ▴ Monitor oxygen saturation continuously using pulse oximetry (SpO2) (Lee, 2017). Note blood gas results as available. An oxygen saturation of less than 88% (normal is 95%– 100%) or a partial pressure of oxygen of less than 55 mm Hg (normal is 80–100 mm Hg) indicates significant oxygenation problems (Bein et al, 2016; Siela & Kidd, 2017). Pulse oximetry is useful for tracking and/or adjusting supplemental oxygen therapy for clients with COPD (GOLD, 2017). • Monitor venous oxygen saturation to determine an index of oxygen balance to reflect between oxygen delivery and oxygen consumption (Dirks, 2017). • Measurements of oxygenation supply in the macrocirculation include those made upstream from the tissue level. The parameters measured are arterial partial pressure of oxygen (PaO2), arterial oxygen content (CaO2), arterial oxygen saturation (SaO2) determined on the basis of arterial blood gas (ABG) analysis and pulse oximetry (SpO2), and ratio of PaO2 to fraction of inspired oxygen (FiO2) or the PF ratio. Measurements of oxygenation or oxygen extraction or consumption in the macrocirculation made downstream from tissues include tissue oxygen consumption, mixed venous oxygen saturation (SvO2) or central venous oxygen saturation (ScvO2), and blood levels of lactate (Siela & Kidd, 2017). • Observe for cyanosis of the skin, and especially note color of the tongue and oral mucous membranes. EB: In central cyanosis both the skin and mucous membranes are affected because of seriously impaired pulmonary function from unventilated or underventilated alveoli. Peripheral cyanosis (skin only) usually indicates vasoconstriction or obstruction to blood flow (Loscalzo, 2016). Central cyanosis of the tongue and oral mucosa is indicative of serious hypoxia and is a medical emergency. Peripheral cyanosis in the extremities may be caused by activation of the central nervous system or exposure to cold and may or may not be serious (Bickley & Szilagyi, 2017). • Position the client in a semirecumbent position with the head of the bed at a 30- to 45degree angle to decrease the aspiration of gastric, oral, and nasal secretions (Grap, 2009; Siela, 2010; American Association of Critical Care Nurses, 2016, 2017; Vollman, Dickinson, & Powers, 2017). Evidence shows that mechanically ventilated clients have a decreased incidence of aspiration pneumonia if the client is placed in a 30- to 45-degree semirecumbent position as opposed to a supine position. • If the client has unilateral lung disease, position with head of bed at 30 to 45 degrees with “good lung down” in a side-lying position and affected lung up (Barton, Vanderspank-Wright, & Shea, 2016). ▴ If the client is acutely dyspneic, consider having the client lean forward over a bedside table, resting elbows on the table if tolerated. Leaning forward can help decrease dyspnea, possibly because gastric pressure allows better contraction of the diaphragm (Langer et al, 2009; Mahler, 2014). This is called the tripod position and is used during times of distress, including when walking, leaning forward on the walker. • Help the client deep breathe and perform controlled coughing. Have the client inhale deeply, hold the breath for several seconds, and cough two or three times with the mouth open while tightening the upper abdominal muscles as tolerated. Controlled coughing uses the diaphragmatic muscles, which makes the cough more forceful and effective. If the client has excessive fluid in the respiratory system, see the interventions for Ineffective Airway clearance. ▴ Monitor the effects of sedation and analgesics on the client's respiratory pattern; use judiciously (Barton, Vanderspank-Wright, & Shea, 2016). Both analgesics and medications that cause sedation can depress respiration at times. However, these medications can be very helpful for decreasing the sympathetic nervous system discharge that accompanies hypoxia (Spruit et al, 2013). • Schedule nursing care to provide rest and minimize fatigue. The hypoxic client has limited reserves; inappropriate activity can increase hypoxia (Spruit et al, 2013). ▴ Administer humidified oxygen through an appropriate device (e.g., nasal cannula or Venturi mask per the health care provider's order); aim for an oxygen (O2) saturation level of 90% or above. Oxygen should be titrated to target an SpO2 of 94% to 98%, except with carbon monoxide poisoning (100% oxygen), acute respiratory distress syndrome (ARDS) (88%–95%), those at risk for hypercapnia (88%–92%), and premature infants (88%– 94%) (Blakeman, 2013). Watch for onset of hypoventilation as evidenced by increased somnolence. There is a fine line between ideal and excessive oxygen therapy; increasing somnolence is caused by retention of CO2 leading to CO2 narcosis (Wong & Elliott, 2009). Promote oxygen therapy during a COPD exacerbation. Supplemental oxygen should be titrated to improve the client's hypoxemia with a target of 88% to 92% (GOLD, 2017). • Once oxygen is started, ABGs should be checked 30 to 60 minutes later to ensure satisfactory oxygenation without CO2 retention or acidosis (GOLD, 2017). EBN: Use of high-flow nasal cannula oxygen therapy may improve gas exchange and oxygenation in acute hypoxemic respiratory failure (Lenglet et al, 2012; Sztrymf et al, 2012; Rittayamai, Tscheikuna, & Rujiwit, 2014; Siela & Kidd, 2017). • Supplemental oxygen can cause toxicity and should be administered at the lowest level that achieves an arterial saturation appropriate for a given patient (Budinger & Mutlu, 2013; Helmerhorst et al, 2015). Conservative oxygen strategies that target a goal of 88% to 92% SpO2 levels in patients receiving invasive mechanical ventilation appear justified (Panwar et al, 2016). • Assess nutritional status including serum albumin level and body mass index (BMI). Malnourishment in a client with COPD has a negative effect on the course of the disease; it can result in loss of muscle mass in the respiratory muscles, including the diaphragm, which can lead to respiratory failure (GOLD, 2017). ▴ Assist the client to eat small meals frequently and use dietary supplements as necessary. Engage dietary issues by evaluating and creating an optimal nutrition plan. For some clients, drinking 30 mL of a supplement every hour while awake can be helpful. • If the client is severely debilitated from chronic respiratory disease, consider the use of a wheeled walker to help in ambulation. ▴ Watch for signs of psychological distress including anxiety, agitation, and insomnia. ▴ Refer the COPD client to a pulmonary rehabilitation program. Pulmonary rehabilitation is now considered a standard of care for the client with COPD (Nici et al, 2009; Spruit et al, 2013; GOLD, 2017). Critical Care ▴ Assess and monitor oxygen indices such as the PF ratio (FiO2:PO2) and venous oxygen saturation/oxygen consumption (SvO2 or ScvO2) (Headley & Giuliano, 2011; Dirks, 2017; Siela & Kidd, 2017; Lough, 2018). ▴ Turn the client every 2 hours. Monitor mixed venous oxygen saturation closely after turning. If it drops below 10% or fails to return to baseline promptly, turn the client back into the supine position and evaluate oxygen status. If the client does not tolerate turning, consider use of a kinetic bed that rotates the client from side to side in a turn of at least 40 degrees (St. Clair & MacDermott, 2017). ▴ If the client has ARDS with difficulty maintaining oxygenation, then consider positioning the client prone with the upper thorax and pelvis supported. Monitor oxygen saturation and turn the client back to supine position if desaturation occurs. EB: Oxygenation levels have been shown to improve in the prone position, probably because of decreased shunting and better perfusion of the lungs (Gattinoni et al, 2013; Drahnak & Custer, 2015; Barton, Vanderspank-Wright, & Shea, 2016; Bein et al, 2016; Vollman, Dickinson, & Powers, 2017; Vollman, Sole, Quinn, 2017). Prone ventilation significantly reduced mortality in clients with severe acute hypoxemic respiratory failure, but not in clients with less severe hypoxemia (Sud et al, 2010; Gattinoni et al, 2013). A PaO2 lower than 150 mm Hg measured on at least 5 cm H2O positive end-expiratory pressure (PEEP) is a recommended threshold for the application of proning (Gattinoni et al, 2013). Note: If the client becomes ventilator dependent, see the care plan for Impaired spontaneous Ventilation. ▴ High levels of PEEP likely improve oxygenation and gas exchange (Suzumura et al, 2014; Barton, Vanderspank-Wright, & Shea, 2016). Geriatric ▴ Use central nervous system depressants and other sedating agents carefully to avoid decreasing respiration effort (rate and depth of breathing). ▴ Maintain appropriate levels of supplemental oxygen therapy for clients with impaired gas exchange and hypoxemia (GOLD, 2017). Home Care • Work with the client to determine what strategies are most helpful during times of dyspnea. Educate and empower the client to self-manage the disease associated with impaired gas exchange. EBN/EB: A study found that use of oxygen, self-use of medication, and getting some fresh air were most helpful in dealing with dyspnea (Thomas, 2009). Evidence-based reviews have found that self-management offers COPD clients effective options for managing the illness, leading to more positive outcomes (Spruit et al, 2013; GOLD, 2017). • Collaborate with health care providers regarding long-term oxygen administration for chronic respiratory failure clients with severe resting hypoxemia. Administer long-term oxygen therapy greater than 15 hours daily for PO2 less than 55 or SaO2 at or below 88% (GOLD, 2017). • Assess the home environment for irritants that impair gas exchange. Help the client adjust the home environment as necessary (e.g., install an air filter to decrease the level of dust). ▴ Refer the client to occupational therapy as necessary to assist the client in adapting to the home and environment and in energy conservation (GOLD, 2017). • Assist the client with identifying and avoiding situations that exacerbate impairment of gas exchange (e.g., stress-related situations, exposure to pollution of any kind, proximity to noxious gas fumes such as chlorine bleach). Irritants in the environment decrease the client's effectiveness in accessing oxygen during breathing. • Refer to GOLD guidelines for management of home care and indications of hospital admission criteria (GOLD, 2017). • Instruct the client to keep the home temperature above 68°F (20°C) and to avoid cold weather. Cold air temperatures cause constriction of the blood vessels, which impairs the client's ability to absorb oxygen (Bickley & Szilagyi, 2017). • Instruct the client to limit exposure to persons with respiratory infections. Viruses, bacteria, and environmental pollutants are the main causes of exacerbations of COPD (GOLD, 2017). • Instruct the family in the complications of the disease and the importance of maintaining the medical regimen, including when to call a health care provider. ▴ Refer the client for home health aide services as necessary for assistance with activities of daily living. Clients with decreased oxygenation have decreased energy to perform personal and role-related activities. • When respiratory procedures are implemented, explain equipment and procedures to family members and provide needed emotional support. Family members assuming responsibility for respiratory monitoring often find this stressful (Langer et al, 2009). • When electrically based equipment for respiratory support is implemented, evaluate home environment for electrical safety, proper grounding, and so on. Ensure that notification is sent to the local utility company, the emergency medical team, and police and fire departments. Notification is important to provide for priority service. ▴ Assess family role changes and coping ability. Refer the client to medical social services as appropriate for assistance in adjusting to chronic illness. CEB: Inability to maintain the level of social involvement experienced before illness leads to frustration and anger in the client and may create a threat to the family unit (Langer et al, 2009). • Support the family of the client with chronic illness. Severely compromised respiratory functioning causes fear and anxiety in clients and their families. Reassurance from the nurse can be helpful (Rose et al, 2014). Client/Family Teaching and Discharge Planning • Teach the client how to perform pursed-lip breathing and inspiratory muscle training, and how to use the tripod position. Have the client watch the pulse oximeter to note improvement in oxygenation with these breathing techniques. CEB: Pursed lip breathing results in increased use of intercostal muscles, decreased respiratory rate, and improved oxygen saturation levels (Mahler, 2014). Pursed-lip breathing may relieve dyspnea in advanced COPD (Mahler, 2014). A systematic review found that inspiratory muscle training was effective in increasing endurance of the client and decreasing dyspnea (Langer et al, 2009). Inspiratory muscle training likely improves breathlessness during exercise and/or with activities of daily living in patients with COPD and congestive heart failure (CHF) who exhibit inspiratory muscle weakness (Mahler, 2014). • Teach the client energy conservation techniques and the importance of alternating rest periods with activity. See nursing interventions for Fatigue. ▴ Teach the importance of not smoking. Refer to smoking cessation programs, and encourage clients who relapse to keep trying to quit. Ensure that clients receive appropriate medications to support smoking cessation from the primary health care provider. EB: Patients should be referred to a comprehensive smoking cessation program, incorporating behavior change techniques that focus on enhancing patient motivation and confidence, patient education, and pharmacological and nonpharmacological interventions (GOLD, 2017). ▴ Instruct the family regarding home oxygen therapy if ordered (e.g., delivery system, liter flow, safety precautions). Long-term oxygen therapy can improve survival, exercise ability, sleep, and ability to think in hypoxemic clients. Client education improves compliance with prescribed use of oxygen (GOLD, 2017). ▴ Teach the client the need to receive a yearly influenza vaccine. Receiving a yearly influenza vaccine is helpful to prevent exacerbations of COPD (GOLD, 2017). • Teach the client relaxation techniques to help reduce stress responses and panic attacks resulting from dyspnea. EB: Relaxation therapy can help reduce dyspnea and anxiety (Langer et al, 2009). • Teach the client to use music, along with a rest period, to decrease dyspnea and anxiety (Mahler, 2014; Loscalzo, 2016).