Impaired Gas Exchange — Pneumonia

Nursing Diagnosis: Gas Exchange, impaired

May be related to

• Alveolar-capillary membrane changes (inflammatory effects)
• Altered oxygen-carrying capacity of blood/release at cellular level (fever, shifting oxyhemoglobin curve)
• Altered delivery of oxygen (hypoventilation)

Possibly evidenced by

• Dyspnea, cyanosis
• Tachycardia
• Restlessness/changes in mentation
• Hypoxia

Desired Outcomes

• Demonstrate improved ventilation and oxygenation of tissues by ABGs within patient’s acceptable range and absence of symptoms of respiratory distress.
• Participate in actions to maximize oxygenation.

Nursing Interventions	Rationale
Assess respiratory rate, depth, and ease.	Manifestations of respiratory distress are dependent on/and indicative of the degree of lung involvement and underlying general health status.
Observe color of skin, mucous membranes, and nailbeds, noting presence of peripheral cyanosis (nailbeds) or central cyanosis (circumoral).	Cyanosis of nailbeds may represent vasoconstriction or the body’s response to fever/chills; however, cyanosis of earlobes, mucous membranes, and skin around the mouth (“warm membranes”) is indicative of systemic hypoxemia.
Assess mental status.	Restlessness, irritation, confusion, and somnolence may reflect hypoxemia/ decreased cerebral oxygenation.
Monitor heart rate/rhythm.	Tachycardia is usually present as a result of fever/dehydration but may represent a response to hypoxemia.
Monitor body temperature, as indicated. Assist with comfort measures to reduce fever and chills, e.g., addition/removal of bedcovers, comfortable room temperature, tepid or cool water sponge bath.	High fever (common in bacterial pneumonia and influenza) greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation.
Maintain bedrest. Encourage use of relaxation techniques and diversional activities.	Prevents overexhaustion and reduces oxygen consumption/demands to facilitate resolution of infection.
Elevate head and encourage frequent position changes, deep breathing, and effective coughing.	These measures promote maximal inspiration, enhance expectoration of secretions to improve ventilation.
Assess level of anxiety. Encourage verbalization of concerns/feelings. Answer questions honestly. Visit frequently, arrange for SO/visitors to stay with patient as indicated.	Anxiety is a manifestation of psychological concerns and physiological responses to hypoxia. Providing reassurance and enhancing sense of security can reduce the psychological component, thereby decreasing oxygen demand and adverse physiological responses.
Observe for deterioration in condition, noting hypotension, copious amounts of pink/bloody sputum, pallor, cyanosis, change in level of consciousness, severe dyspnea, restlessness.	Shock and pulmonary edema are the most common causes of death in pneumonia and require immediate medical intervention.
Monitor ABGs, pulse oximetry.	Follows progress of disease process and facilitates alterations in pulmonary therapy.
Administer oxygen therapy by appropriate means, e.g., nasal prongs, mask, Venturi mask.	The purpose of oxygen therapy is to maintain Pao2 above 60 mm Hg. Oxygen is administered by the method that provides appropriate delivery within the patient’s tolerance.