Impaired Gas Exchange

Assessment
Subjective:
nahihirapan akong
huminga as verbalized
by the patient

Objective:
Pale in appearance
(+) use of accessory
muscles when
breathing
Tachypnea
VS as follows:
T: 38C
CR: 89
RR: 30bpm
BP: 110/60

Planning
After 6 hours of nursing
interventions the patient will
demonstrate ease in
breathing and will normalize
oxygen saturation level

Intervention

Scientific Rationale

Assess respiratory rate, depth, and ease.

Suction airway as indicated, using sterile

technique andobserving safety precautions,
e.g., mask, protectiveeyewear

Demonstrate and encourage pursed-lip

breathing during exhalation, especially for
patients with fibrosis or parenchymal
destruction.

Promote bedrest or limit activity and assist

with self-care activities as necessary.

Observe color of skin, mucous membranes,

and nailbeds, noting presence of peripheral
cyanosis (nail beds)

Elevate head and encourage frequent position

changes, deep breathing, and effective
coughing.

Monitor serial ABGs and pulse oximetry.

Provide supplemental oxygen as appropriate.

Assess anxiety level and encourage

verbalization of feelings and concerns
regarding complication of HIV

Manifestations of respiratory distress are

dependent on/and indicative of the degree of
lung involvement and underlying general health
status.
Assists in clearing the ventilatory passages,
therebyfacilitating gas exchange and
preventing respiratorycomplications
Creates resistance against outflowing air to
prevent collapse or narrowing of the airways,
thereby helping distribute air throughout the
lungs and relieve or reduce shortness of
breath.
Reducing oxygen consumption and demand
during periods of respiratory compromise may
reduce severity of symptoms.
Cyanosis of nail beds may represent
vasoconstriction or the bodys response to
fever/chills
These measures promote maximum chest
expansion, mobilize secretions and improve
ventilation.
Decreased oxygen content (PaO2) and/or
saturation or increased PaCO2 indicate need
for intervention or change in therapeutic
regimen.
Oxygen is administered by the method that
provides appropriate delivery within the
patients tolerance.
Anxiety is a manifestation of psychological
concerns and physiological responses to
hypoxia. This can reduce the psychological
component, thereby decreasing oxygen
demand and adverse physiological responses.

Evaluation
After 6 hours of
nursing
interventions the
patient has
demonstrated
ease in breathing
with RR of 20bpm
and has oxygen
saturation level of
96%