Nursing Care Plan

Nursing DiagnosisImpaired Gas Exchange r/t altered oxygen supply

Long Term GoalPatient will maintain optimal gas exchange

Short Term Goals / Outcomes:Patient will maintain normal arterial blood gas (ABGs).Patient will be awake and alert.Patient will demonstrate a normal depth, rate and pattern of respirations.

Interventions Rationale Evaluation

Assess respirations: quality, rate, pattern, depth and breathing effort.

Rapid, shallow breathing and hypoventilation affect gas exchange by affecting CO2 levels. Flaring of the nostrils, dyspnea, use of accessory muscles, tachypnea and /or apnea are all signs of severe distress that require immediate intervention.

Patient is free of signs of distress.ABGs show PaCO2 between 35-45Pts respirations are of a normal rate and depth.

Assess for life-threatening problems. (i.e. resp arrest, flail chest, sucking chest wound).

Absence of ventilation, asymmetric breath sounds, dyspnea with accessory muscle use, dullness on chest percussion and gross chest wall instability (i.e. flail chest or sucking chest wound) all require immediate attention.

Patient exhibits spontaneous breathing, no dyspnea, use of accessory muscles, resonance on percussion and no chest wall abnormalities.

Auscultate lung sounds. Also assess for the presence of jugular vein distention (JVD) or tracheal deviation.

Absence of lung sounds, JVD and / or tracheal deviation could signify a Pneumothorax or Hemothorax.

Patient’s lungs sounds are clear to auscultate throughout all lobes.

Assess for signs of hypoxemia.

Tachycardia, restlessness, diaphoresis, headache, lethargy and confusion are all signs of hypoxemia.

Patient is free of signs of hypoxia.

Monitor vital signs. Initially with hypoxia and hypercapnia blood pressure (BP), heart rate and respiratory rate all increase. As the condition becomes more severe BP may drop, heart rate continues to be rapid with arrhythmias and respiratory failure may ensue.

Patient is normotensive with heart rate 60 – 100 bpm and respiratory rate 10-20.

Assess for changes in orientation and behavior.

Restlessness is an early sign of hypoxia. Mentation gets worse as hypoxia increases due to lack of blood supply to the brain.

Patient is awake, alert and oriented X3.

Monitor ABGs. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure.

ABGs show PaCO2 between 35-45 and PaO2between 80 – 100.

Place the patient on continuous pulse oximetry.

Pulse oximetry is useful in detecting changes in oxygenation. Oxygen saturation should be maintained at 90% or greater.

SaO2 via pulse oximetry remains at 90 – 100%.

Assess skin color for development of cyanosis, especially

Lack of oxygen delivery to the tissues will result in cyanosis. Cyanosis needs treated immediately as it is a late development in hypoxia.

Patient is free of cyanosis.

circumoral cyanosis.

Provide supplemental oxygen, via 100% O2 non-rebreather mask.

Early supplemental oxygen is essential in all trauma patients since early mortality is associated with inadequate delivery of oxygenated blood to the brain and vital organs.

Patient is receiving 100% oxygen. SaO2 via pulse oximetry is 90 – 100%.

Prepare the patient for intubation.

Early intubation and mechanical ventilation are necessary to maintain adequate oxygenation and ventilation, prior to full decompensation of the patient.

Artificial airway is placed and maintained without complications.

Treat the underlying injuries with appropriate interventions.

Treatment needs to focus on the underlying problem that leads to the respiratory failure.

Appropriate injury specific treatment has been started.

If rib fractures exist:

1. Assess for paradoxical chest movements.

2. Provide adequate pain

3. relief.

Assess breath sounds.

Paradoxical movements accompanied by dyspnea and pain in the chest wall indicate flail chest. Flail chest is a life-threatening complication of rib fractures that requires mechanical ventilation and aggressive pulmonary care.Pain relief is essential to enhance coughing and deep breathing. Absence of bilateral breath sounds in the presence of a flail chest, indicates a pneumo/hemo thorax.

No paradoxical movements are noted.Patient reports pain as <3 on 0-10 scale.Bilateral breath sounds present in all lobes.

If Pneumothorax or Hemothorax exist:

1. obtain chest x-ray

2. prepare for insertion of a chest tube

If open Pneumothorax exists place a dressing that is taped on three sides for temporary management.

A chest x-ray confirms the presence of a Pneumothorax and / or Hemothorax.A chest tube decreases the thoracic pressure and re-inflates the lung tissue.

A three sided dressing gives the accumulated air a way to escape, thereby decreasing thoracic pressure and preventing a tension Pneumothorax. A chest tube must then be inserted.

Chest tube is placed and connected to 20cm wall suction with good tidaling and no air leak or SQ emphysema noted.

Three-sided dressing maintained. No further cardiopulmonary decompensation noted in patient.

Position patient with head of bed 45 degrees (if tolerated).

Promotes better lung expansion and improved gas exchange.

Patient’s rate and pattern are of normal depth and rate at 45 degree angle.

Assist patient with coughing and deep breathing techniques (positioning, incentive

Promotes alveolar expansion and prevents alveolar collapse.Splinting helps reduce pain and optimizes deep breathing and coughing efforts.

Patient is able to cough and deep breathe effectively.

spirometry, frequent position changes, splinting of the chest).

Suction patient as needed.

Suctioning aides to remove secretions from the airway and optimizes gas exchange.

Patient suctioned for moderate amount of thin yellow secretion. Lung sounds clear after suctioning.

Hyperoxygenate patient with 100% before and after suctioning. Keep suctioning to 10-15 seconds.

Prevents alteration in oxygenation during suctioning. Patient’s SaO2 remained >90% during suctioning.

Pace activities and provide rest periods to prevent fatigue.

Even simple activities, such as bathing, can increase oxygen consumption and cause fatigue.

No changes to cardiopulmonary status noted during activity.Patients SaO2 remains >90% during activities.