Impaired gas exchange

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• assess respirations: note quality, rate, pattern, depth, and breathing effort. Both
rapid, shallow breathing patterns and hypoventilation affect gas exchange.
Shallow, "sighless" breathing patterns postsurgery (as a result of effect of
anesthesia, pain, and immobility) reduce lung volume and decrease
ventilation.

• Assess lung sounds, noting areas of decreased ventilation and the presence of
adventitious sounds.

• Assess for signs and symptoms of hypoxemia: tachycardia, restlessness,

diaphoresis, headache, lethargy, and confusion.

• Assess for signs and symptoms of atelectasis: diminished chest excursion,

limited diaphragm excursion, bronchial or tubular breath sounds, rales, tracheal shift
to affected side. Collapse of alveoli increases physiological shunting.

• Assess for signs or symptoms of pulmonary infarction: cough, hemoptysis,

pleuritic pain, consolidation, pleural effusion, bronchial breathing, pleural friction rub,
fever.

• Monitor vital signs. With initial hypoxia and hypercapnia, blood pressure
(BP), heart rate, and respiratory rate all rise. As the hypoxia and/or
hypercapnia becomes more severe, BP may drop, heart rate tends to
continue to be rapid with arrhythmias, and respiratory failure may ensue
with the patient unable to maintain the rapid respiratory rate.

• Assess for changes in orientation and behavior. Restlessness is an early sign

of hypoxia. Chronic hypoxemia may result in cognitive changes such as
memory changes.

• Monitor ABGs and note changes. Increasing PaCO2 and decreasing PaO2 are
signs of respiratory failure. As the patient begins to fail, the respiratory rate
will decrease and PaCO2 will begin to rise. Some patients, such as those with
COPD, have a significant decrease in pulmonary reserves, and any
physiological stress may result in acute respiratory failure.

• Use pulse oximetry to monitor oxygen saturation and pulse rate. Pulse
oximetry is a useful tool to detect changes in oxygenation. Oxygen
saturation should be maintained at 90% or greater. This tool can be
especially helpful in the outpatient or rehabilitation setting where patients
at risk for desaturation from chronic pulmonary diseases can monitor the
 effects of exercise or activity on their oxygen saturation levels. Home
oxygen therapy can then be prescribed as indicated. Patients should be
assessed for the need for oxygen both at rest and with activity. A higher
liter flow of oxygen is generally required for activity versus rest (e.g., 2 L at
rest, and 4 L with activity). Medicare guidelines for reimbursement for home
oxygen require a PaCO2 less than 58 and/or oxygen saturation of 88% or
less on room air. Oxygen delivery is then titrated to maintain an oxygen
saturation of 90% or greater.

• Assess skin color for development of cyanosis. For cyanosis to be present, 5 g

of hemoglobin must desaturate.

• Monitor chest x-ray reports. Chest x-rays may guide the etiological factors
of the impaired gas exchange. Keep in mind that radiographic studies of
lung water lag behind clinical presentation by 24 hours.

• Monitor effects of position changes on oxygenation (SaO2, ABGs, SVO2, and end-
tidal CO2). Putting the most congested lung areas in the dependent position
(where perfusion is greatest) potentiates ventilation and perfusion
imbalances.

• Assess patient’s ability to cough effectively to clear secretions. Note quantity,

color, and consistency of sputum. Retained secretions impair gas exchange.
Therapeutic Interventions

• Maintain oxygen administration device as ordered, attempting to maintain

oxygen saturation at 90% or greater. This provides for adequate oxygenation.

Avoid high concentration of oxygen in patients with COPD. Hypoxia stimulates the
drive to breathe in the chronic CO2 retainer patient. When applying oxygen,
close monitoring is imperative to prevent unsafe increases in the patient’s
PaO2, which could result in apnea.

NOTE: If the patient is allowed to eat, oxygen still must be given to the patient but
in a different manner (e.g., changing from mask to a nasal cannula). Eating is an
activity and more oxygen will be consumed than when the patient is at rest.
Immediately after the meal, the original oxygen delivery system should be
returned.

• For patients who should be ambulatory, provide extension tubing or portable

oxygen apparatus. These promote activity and facilitate more effective
ventilation.

• Position with proper body alignment for optimal respiratory excursion (if
tolerated, head of bed at 45 degrees). This promotes lung expansion and
improves air exchange.
• Routinely check the patient’s position so that he or she does not slide down in
bed. This would cause the abdomen to compress the diaphragm, which
would cause respiratory embarrassment.

• Position patient to facilitate ventilation/perfusion matching. Use upright, high-

Fowler’s position whenever possible. High-Fowler’s position allows for optimal
diaphragm excursion. When patient is positioned on side, the good side
should be down (e.g., lung with pulmonary embolus or atelectasis should be
up).

• Pace activities and schedule rest periods to prevent fatigue. Even simple
activities such as bathing during bed rest can cause fatigue and increase
oxygen consumption.

• Change patient’s position every 2 hours. This facilitates secretion movement

and drainage.

• Suction as needed. Suction clears secretions if the patient is unable to

effectively clear the airway.

• Encourage deep breathing, using incentive spirometer as indicated. This

reduces alveolar collapse.

• For postoperative patients, assist with splinting the chest. Splinting optimizes
deep breathing and coughing efforts.

• Encourage or assist with ambulation as indicated. This promotes lung

expansion, facilitates secretion clearance, and stimulates deep breathing.

• Provide reassurance and allay anxiety:

 Have an agreed-on method for the patient to call for assistance (e.g., call
light, bell).
 Stay with the patient during episodes of respiratory distress.

• Anticipate need for intubation and mechanical ventilation if patient is unable to

maintain adequate gas exchange. Early intubation and mechanical ventilation
are recommended to prevent full decompensation of the patient. Mechanical
ventilation provides supportive care to maintain adequate oxygenation and
ventilation to the patient. Treatment also needs to focus on the underlying
causal factor leading to respiratory failure.
 • Administer medications as prescribed. The type depends on the etiological
factors of the problem (e.g., antibiotics for pneumonia, bronchodilators for
COPD, anticoagulants/thrombolytics for pulmonary embolus, analgesics for
thoracic pain).
Education/Continuity of Care

• Explain the need to restrict and pace activities to decrease oxygen consumption
during the acute episode.

• Explain the type of oxygen therapy being used and why its maintenance is
important. Issues related to home oxygen use, storage, or precautions need
to be addressed.

• Teach the patient appropriate deep breathing and coughing techniques. These
facilitate adequate air exchange and secretion clearance.

• Assist patient in obtaining home nebulizer, as appropriate, and instruct in its use
in collaboration with respiratory therapist.

• Refer to home health services for nursing care or oxygen management as

appropriate.