NURSING CARE PLAN: Impaired Gas Exchange related to decreased Oxygen carrying capacity of blood

MEDICAL DIAGNOSIS: Obstructive jaundice, etiology to be determined; to be confirmed, cholecystic carcinoma

Diagnosis & Explanation of Actual
Goals and Objectives Interventions Rationale Evaluation Criteria
Assessment Data The Problem Criteria
Nursing Diagnosis: Biliary Goal: Patient maintains optimal STO:
obstruction of gas exchange 1. Assess respiratory rate, 1. Rapid and shallow Goal met with the following
Impaired Gas Exchange related to
depth, and effort, including breathing patterns and criteria if:
decreased Oxygen carrying the essential
use of accessory muscles, hypoventilation affect gas After 8 hours of nursing
flow of bile to STO:
capacity of blood nasal flaring, and abnormal exchange. Increased intervention the patient will
the intestines After 8 hours of nursing be able to:
breathing patterns of the respiratory rate, use of
result to increase intervention the patient will be patient with obstructive accessory muscles, nasal
intrabiliary able to: 1. Verbalize understanding
jaundice. flaring, abdominal of causative factors and
Subjective Cues pressure causes breathing, and a look of appropriate intervention.
“Nahihirapan din siya huminga” intrahepatic bile 1. Verbalize understanding panic in the patient’s eyes
2. Participate in treatment
As verbalized by live-in partner. ducts to of causative factors and may be seen with hypoxia. regimen(e.g, breathing
progressively appropriate exercises, effective
dilate from bile intervention. coughing, use of oxygen)
Objective Cues within level of
engorgement. 2. Participate in treatment 2. Assess the lungs for areas of 2. Any irregularity of breath ability/situation
>episodes of DOB regimen(e.g, breathing decreased ventilation and sounds may disclose the
>Shallowness of breath auscultate presence of cause of impaired gas
This leads to exercises, effective Goal partially met if:
adventitious sounds as the exchange. Presence of
>tachypneic damage to cell coughing, use of After 8 hours of nursing
client may develop crackles and wheezes may intervention the patient will
>clubbed thumbnails wall surrounding, oxygen) within level of pneumonia during hospital alert the nurse to an airway be able to:
damaging the ability/situation. stay. obstruction, which may
VITAL SIGNS (4/20/18) liver (organ with lead to or exacerbate 1. Verbalize understanding
the principle LTO: existing hypoxia. of causative factors and
Vital Value N appropriate intervention
function of iron After 72 hours of nursing Diminished breath sounds
sign are linked with poor
homeostasis). intervention the patient will be Goal not met if:
RR 23 cpm 12-20 able to: ventilation.
SpO2 90% 95-100 Without After 8 hours of nursing
Temp 37.5C 36.5- enough iron, the 1. Demonstrate improved intervention the patient was
3. Monitor patient’s behavior 3. Changes in behavior and NOT be able to:
37.5 body’s red blood ventilation and and mental status for onset mental status can be early
PR 87 bpm 60-100 cells cannot carry adequate oxygenation of restlessness, signs of impaired gas 1. Verbalize understanding
BP 120/80 <120/80 oxygen. of tissues by Hgb’s agitation, confusion, and (in exchange. Cognitive of causative factors and
within client’s normal the late stages) extreme changes may occur with appropriate intervention.
2. Participate in treatment
ABG (04/09/18) limits lethargy in the patient with chronic hypoxia.
regimen(e.g, breathing
obstructive jaundice. exercises, effective
pH 7.56 7.35-7.45
coughing, use of oxygen)
PaO2 78% 80%-100% Source: 4. Monitor for signs and 4. Collapse of alveoli within level of
PaCO2 53 35-45 Smeltzer, S. C. O., symptoms of atelectasis: increases shunting ability/situation
HCO3 38 22-26 Hinkle, J. L. ., bronchial or tubular breath (perfusion without
Cheever, K. H. ., sounds, crackles, diminished
Partially compensated metabolic & Bare, B. G.. chest excursion, ventilation), resulting in
(2010). Brunner limited diaphragmexcursion, hypoxemia. LTO:
alkalosis; moderately hypoxic
& Suddarth's and tracheal shift to
textbook of affected side.
CBC (04/09/18) Goal met with the following
Hgb 109 140-180 medical-surgical criteria if:
5. Observe for signs and 5. Increased dead space and
Hct 0.31 0.40 – 0.54 nursing (12th symptoms of pulmonary reflex bronchoconstriction After 72 hours of nursing
ed.).Preoperative infarction: bronchial breath in areas adjacent to the intervention the patient will
Nursing be able to:
sounds, infarct result to hypoxia
Management consolidation, cough, fever, (ventilation without 1. Demonstrate improved
(pp. 399-414) hemoptysis, pleural perfusion). ventilation and adequate
Philadelphia: effusion, pleuritic pain, and oxygenation of tissues by
Wolters Kluwer pleural friction rub. Hgb’s within client’s
Health/Lippincott normal limits
Williams & 6. Monitor for alteration in BP 6. BP, HR, and respiratory
and HR. rate all increase with initial Goal partially met if:
Wilkins
hypoxia and hypercapnia.
However, when both After 72 hours of nursing
intervention the patient will
conditions become severe,
be able to:
BP and HR decrease, and
dysrhythmias may occur. 1. Demonstrate improved
ventilation and adequate
oxygenation of tissues by
7. Observe for nail beds, Hgb’s however not
cyanosis in skin; especially 7. Central cyanosis of tongue within client’s normal
note color of tongue and and oral mucosa is limits
oral mucous membranes. indicative of serious
hypoxia and is a medical Goal not met if:
emergency. Peripheral
cyanosis in extremities may After 72 hours of nursing
or may not be serious intervention the patient will
be able to:
8. Assess for headaches, 8. These are signs of
dizziness, lethargy, reduced hypercapnia. 1. Demonstrate unchanged
and unimproved
ability to follow instructions,
ventilation and
disorientation, and coma. inadequate oxygenation
of tissues by Hgb’s.
2. Experience pulmonary
9. Monitor oxygen saturation 9. Pulse oximetry is a useful complications such as
continuously, using pulse tool to detect changes in pneumonia
oximeter. oxygenation. An oxygen
saturation of <90%
(normal: 95% to 100%) or a
partial pressure of oxygen

10. Note client’s blood gas 10. Increasing PaCO2 and
(ABG) results as available
and note changes.
11. Monitor the effects of 11. Putting the most
position changes on
oxygenation (ABGs, venous
oxygen saturation [SvO2],
and pulse oximetry.
12. Consider the patient’s 12. Certain conditions affect
nutritional status.
of <80 (normal: 80 to 100)
indicates significant
oxygenation problems.
decreasing PaO2are signs of
respiratory acidosis and
hypoxemia. As the
patient’s condition
deteriorates, the
respiratory rate will
decrease and PaCO2 will
begin to increase. Some
patients, such as those
with obstructive juandice,
have a significant decrease
in pulmonary reserves, and
additional
physiological stress may
result in acute respiratory
failure.
compromised lung areas in
the dependent position
(where perfusion is
greatest) potentiates
ventilation and perfusion
imbalances.
lung expansion.
Obstructive jaundice may
restrict downward
movement of
the diaphragm, increasing
the risk for atelectasis,
hypoventilation, and
respiratory infections.
Labored breathing is
present in severe obesity
as a result of excessive
weight of the chest wall.

13. Check on Hgb levels.
14. Monitor chest x-ray reports. 14. Chest x-ray studies reveal
15. Assess the patient’s ability
to cough out secretions.
Take note of the quantity,
color, and consistency of
the sputum.
16. Position patient with head
of bed elevated, in a semi-
Fowler’s position (head of
bed at 45 degrees
when supine) as tolerated.
17. Regularly check the
patient’s position so that he
or she does not slump down
in bed.
18. If patient has unilateral lung 18. Gravity and hydrostatic
disease, position the patient
properly to promote
ventilation-perfusion.
Malnutrition may also
reduce respiratory mass
and strength,
affecting muscle function.
13. Low levels reduce the
uptake of oxygen at the
alveolar-capillary
membrane and
oxygen delivery to the
tissues.
the etiological factors of
the impaired gas exchange.
15. Retained secretions
weaken gas exchange.
16. Upright position or semi-
Fowler’s position allows
increased thoracic
capacity, full descent
of diaphragm, and
increased lung expansion
preventing the abdominal
contents from crowding.
17. Slumped positioning causes
the abdomen to compress
the diaphragmand limits
full lung expansion.
pressure cause the
dependent lung to become
better ventilated and
perfused, which increases
oxygenation. When the

19. Turn the patient every 2 19. Turning is important to
hours. Monitor mixed
venous oxygen saturation
closely after turning. If it
drops below 10% or fails to
return to baseline promptly,
turn the patient back into
a supineposition and
evaluate oxygen status.
20. Encourage or assist with 20. Ambulation facilitates lung
ambulation as per
physician’s order.
21. Consider positioning the 21. Partial pressure of arterial
patient pronewith upper
thorax and pelvis
supported, allowing the
abdomen to protrude.
Monitor oxygen saturation,
and turn back if
desaturation occurs. Do not
put in prone position if
patient has multisystem
trauma.
22. If the patient is permitted to 22. More oxygen will be
eat, provide oxygen to the
patient but in a different
manner (changing from
mask to a nasal cannula).
patient is positioned on the
side, the good side should
be down (e.g., lung with
pulmonary embolus or
atelectasis should be up).
However, when conditions
like lung hemorrhage and
abscess is present, the
affected lung should be
placed downward to
prevent drainage to the
healthy lung.
prevent complications of
immobility, but in critically
ill patients with
low hemoglobin levels
or decreased cardiac
output, turning on either
side can result in
desaturation.
expansion, secretion
clearance, and stimulates
deep breathing.
oxygen has been shown to
increase in
the proneposition, possibly
because of greater
contraction of
the diaphragm and
increased function of
ventral lung regions. Prone
positioning improves
hypoxemia significantly.
consumed during the
activity. The original
oxygen delivery system
should be returned

23. When patient is able to be
ambulatory, provide
extension tubing or a
portable oxygen apparatus
24. Help patient deep breath
and perform controlled
coughing. Have patient
inhale deeply, hold breath
for several seconds, and
cough two to three times
with mouth open while
tightening the upper
abdominal muscles as
tolerated.
25. Encourage slow deep
breathing using an
incentive spirometer as
indicated.
26. For postoperative patients,
assist with splinting the
chest.
27. Provide reassurance and
reduce anxiety.
28. Pace activities and schedule 28. Activities will increase
rest periods to
prevent fatigue. Assist with
ADLs.
29. Administer medications as
prescribed.
immediately after every
meal.
23. These measures may
improve exercise tolerance
by maintaining adequate
oxygen levels during
activity.
24. This technique can help
increase sputum clearance
and decrease cough
spasms. Controlled
coughing uses the
diaphragmatic muscles,
making the cough more
forceful and effective.
25. These technique promotes
deep inspiration, which
increases oxygenation and
prevents atelectasis.
26. Splinting optimizes deep
breathing and coughing
efforts.
27. Anxiety increases dyspnea,
respiratory rate, and work
of breathing.
oxygen consumption and
should be planned so the
patient does not become
hypoxic.
29. The type depends on the
etiological factors of the
problem (e.g., antibioticsfor
pneumonia, bronchodilators
for COPD, anticoagulants
and thrombolytics for

30. Monitor the effects of
sedation and analgesics on
patient’s respiratory
pattern; use judiciously.
31. Consider the need for
intubation and mechanical
ventilation.
32. Schedule nursing care to
provide rest and
minimize fatigue.
33. Assess the home
environment for irritants
that impair gas exchange.
Help the patient to adjust
home environment as
necessary (e.g., installing air
filter to decrease presence
of dust).
34. Instruct patient to limit
exposure to persons with
respiratory infections.
35. Instruct family in
complications of disease
and importance of
pulmonary embolus,
analgesics for thoracic pain).
30. 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.
31. 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.
32. The hypoxic patient has
limited reserves;
inappropriate activity can
increase hypoxia.
33. Irritants in the environment
decrease the patient’s
effectiveness in accessing
oxygen during breathing.
34. This is to reduce the
potential spread of droplets
between patients.
35. Knowledge of the family
about the disease is very
 maintaining medical
regimen, including when to
call physician.
36. Support family of patient
with chronic illness.
Kozier, B., Erb, G., Berman,
A., Snyder, S. J., Bouchal, D.
S. R. et al. (2014).
Fundamentals of Canadian
nursing: Concepts, process,
and practice (3rd ed.).
Toronto: Pearson. (ISBN
978-0133249781)
Klopp, A. (2002). Nursing
care plans nursing
diagnosis & intervention
(5th ed.). Philadelphia, PA:
FA Davis Company.
important to prevent
further complications.
36. Severely compromised
respiratory functioning
causes fear and anxiety in
patients and their families.
Reassurance from the nurse
can be helpful.
Doenges, M., Moorhouse,
M., & Murr, A. (2009).
Nursing care plans:
Guidelines for
individualizing client care
across the life span (8th
ed.). Philadelphia, PA: FA
Davis Company.
Klopp, A. (2002). Nursing
care plans nursing
diagnosis & intervention
(5th ed.). Philadelphia, PA:
FA Davis Company.
Kozier, B., Erb, G., Berman,
A., Snyder, S. J., Bouchal, D.
S. R. et al. (2014).
Fundamentals of Canadian
nursing: Concepts, process,
and practice (3rd ed.).
Toronto: Pearson. (ISBN
978-0133249781)