Nursing Diagnosis Long Term Goal

Impaired Gas Exchange r/t altered oxygen supply Patient 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, Rapid, shallow breathing and hypoventilation affect gas exchange by affecting Patient is free of signs of distress.
pattern, depth and breathing effort. CO2 levels. Flaring of the nostrils, dyspnea, use of accessory muscles, ABGs show PaCO2 between 35-45
tachypnea and /or apnea are all signs of severe distress that require immediate Pts respirations are of a normal rate and depth.
intervention.
Assess for life-threatening Absence of ventilation, asymmetric breath sounds, dyspnea with accessory Patient exhibits spontaneous breathing, no dyspnea, use
problems. (i.e. resp arrest, flail muscle use, dullness on chest percussion and gross chest wall instability (i.e. of accessory muscles, resonance on percussion and no
chest, sucking chest wound). flail chest or sucking chest wound) all require immediate attention. chest wall abnormalities.
Auscultate lung sounds. Also Absence of lung sounds, JVD and / or tracheal deviation could signify a Patient’s lungs sounds are clear to auscultate throughout
assess for the presence of jugular Pneumothorax or Hemothorax. all lobes.
vein distention (JVD) or tracheal
deviation.
Assess for signs of hypoxemia. Tachycardia, restlessness, diaphoresis, headache, lethargy and confusion are all Patient is free of signs of hypoxia.
signs of hypoxemia.
Monitor vital signs. Initially with hypoxia and hypercapnia blood pressure (BP), heart rate and Patient is normotensive with heart rate 60 – 100 bpm and
respiratory rate all increase. As the condition becomes more severe BP may respiratory rate 10-20.
drop, heart rate continues to be rapid with arrhythmias and respiratory failure
may ensue.
Assess for changes in orientation Restlessness is an early sign of hypoxia. Mentation gets worse as hypoxia Patient is awake, alert and oriented X3.
and behavior.
Monitor ABGs.
Place the patient on continuous
pulse oximetry.
Assess skin color for development
of cyanosis, especially circumoral
cyanosis.
Provide supplemental oxygen, via
100% O2 non-rebreather mask.
Prepare the patient for intubation.
Treat the underlying injuries with
appropriate interventions.
If rib fractures exist:
1. Assess for paradoxical
chest movements.
2. Provide adequate pain
3. relief.
Assess breath sounds.
If Pneumothorax or Hemothorax
exist:
increases due to lack of blood supply to the brain.
Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. ABGs show PaCO2 between 35-45 and PaO2 between 80
– 100.
Pulse oximetry is useful in detecting changes in oxygenation. Oxygen SaO2 via pulse oximetry remains at 90 – 100%.
saturation should be maintained at 90% or greater.
Lack of oxygen delivery to the tissues will result in cyanosis. Cyanosis needs Patient is free of cyanosis.
treated immediately as it is a late development in hypoxia.
Early supplemental oxygen is essential in all trauma patients since early Patient is receiving 100% oxygen. SaO2 via pulse
mortality is associated with inadequate delivery of oxygenated blood to the oximetry is 90 – 100%.
brain and vital organs.
Early intubation and mechanical ventilation are necessary to maintain adequate Artificial airway is placed and maintained without
oxygenation and ventilation, prior to full decompensation of the patient. complications.
Treatment needs to focus on the underlying problem that leads to the Appropriate injury specific treatment has been started.
respiratory failure.
Paradoxical movements accompanied by dyspnea and pain in the chest wall No paradoxical movements are noted.
indicate flail chest. Flail chest is a life-threatening complication of rib fractures Patient reports pain as <3 on 0-10 scale.
that requires mechanical ventilation and aggressive pulmonary care. Bilateral breath sounds present in all lobes.
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.
 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.
Position patient with head of bed
45 degrees (if tolerated).
Assist patient with coughing and
deep breathing techniques
(positioning, incentive spirometry,
frequent position changes, splinting
of the chest).
Suction patient as needed.
Hyperoxygenate patient with 100% Prevents alteration in oxygenation during suctioning.
before and after suctioning. Keep
suctioning to 10-15 seconds.
Pace activities and provide rest
periods to prevent fatigue.
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.
Promotes better lung expansion and improved gas exchange.
Promotes alveolar expansion and prevents alveolar collapse.
Splinting helps reduce pain and optimizes deep breathing and coughing efforts.
Suctioning aides to remove secretions from the airway and optimizes gas
exchange.
Even simple activities, such as bathing, can increase oxygen consumption and
cause fatigue.
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.
Patient’s rate and pattern are of normal depth and rate at
45 degree angle.
Patient is able to cough and deep breathe effectively.
Patient suctioned for moderate amount of thin yellow
secretion. Lung sounds clear after suctioning.
Patient’s SaO2 remained >90% during suctioning.
No changes to cardiopulmonary status noted during
activity.
Patients SaO2 remains >90% during activities.