NR 324 Week 2 Altered Gas Exchange

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Chamberlain University

NR-324 Adult Health I

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Date

Nursing Care: Altered Gas Exchange

Altered gas exchange involves impaired oxygenation and carbon dioxide elimination due to various health conditions. Nursing care for individuals with altered gas exchange requires a comprehensive understanding of the underlying pathophysiology and tailored assessments and interventions. Diseases that often contribute to this condition include cardiac disorders (e.g., coronary artery disease, heart failure), pulmonary illnesses (e.g., COPD, pneumonia), and renal dysfunctions (e.g., chronic kidney disease).

Assessment of Altered Gas Exchange

When evaluating a client with impaired gas exchange, a thorough assessment should be conducted. This includes examining past and current health conditions, procedures, medications, lifestyle choices, and clinical signs.

Assessment Data	Examples	Rationale
Past Medical History	Heart failure, COPD, liver/kidney disease, pregnancy	These conditions can compromise lung function or alter perfusion, impeding gas exchange.
Procedures	Surgery, chest procedures	Surgeries and procedures may limit lung expansion or increase infection risk, thus affecting oxygenation.
Medications	IV fluids, sedatives, allergens	These can cause fluid overload or bronchoconstriction, reducing respiratory function.
Lifestyle	Smoking, obesity, diet	Chemical inhalants impair lung tissue; obesity restricts diaphragm movement; high-sodium diets may cause fluid retention.
Vital Signs	RR, O2 saturation	Tachypnea and decreased saturation may signal hypoxia.
Respiratory Exam	Abnormal lung sounds, asymmetry	Indicators of fluid, infection, or reduced airflow.
Labs	ABGs, lactate, CO2 levels	ABGs provide precise insight into oxygenation and ventilation status.
Imaging	CT, V/Q scan, X-ray	These tests confirm structural or perfusion-related lung abnormalities.

Systematic Nursing Interventions for Altered Gas Exchange

Interventions are guided by patient symptoms and diagnostic data. These actions aim to optimize oxygenation and address the root cause of impairment.

System	Nursing Actions	Rationale
Neurological	Monitor mental status	Changes like confusion or drowsiness may reflect hypoxia.
Respiratory	Elevate HOB, assess lung sounds, encourage breathing exercises	These promote lung expansion and mobilize secretions.
Cardiovascular	Monitor BP and HR	Gas exchange issues may activate sympathetic responses or indicate sepsis.
Gastrointestinal	Auscultate heart sounds, measure abdominal girth	Detects fluid overload or diaphragmatic restriction.
Genitourinary	Monitor I\&O	Identifies fluid imbalances that could impair gas exchange.

Nursing Interventions and Treatment Strategies

Nurses play a critical role in delivering immediate interventions and supporting medical treatments to improve gas exchange.

Oxygen Therapy: Provides direct support to improve oxygenation levels. Devices range from nasal cannulas to high-flow systems, each delivering specific FiO2 levels.

Device	Flow Rate (L/min)	Oxygen Concentration
Nasal cannula	1-6	24%-44%
Simple face mask	6-12	35%-50%
Partial/non-rebreather	10-15	60%-90%
Venturi mask	2-15	24%-60%
High-flow nasal cannula	Up to 60	Up to 100%

Procedures: Thoracentesis and chest tube insertions may be required to remove fluid impeding lung function.
Ventilation: If spontaneous breathing is inadequate, mechanical ventilation or manual devices like bag-valve masks are necessary.

Medications for Gas Exchange Impairment

Drug Class	Indication	Considerations
Diuretics	Pulmonary congestion	Monitor BP, electrolytes
Antibiotics	Bacterial infection	Ensure culture collection pre-administration
Bronchodilators	Asthma, COPD	May raise HR and BP
Steroids	Inflammation	Watch for side effects
Antifungals	Fungal infections	Often long-term therapy
Anticholinergics	COPD	Risk of toxicity
Bicarbonate	Acidosis	Monitor ABGs

Diagnostic Evaluation

Arterial blood gas analysis remains the gold standard for evaluating gas exchange efficiency. ABG results guide clinical decisions, revealing whether the disturbance is respiratory or metabolic and whether compensation is occurring.

Pneumonia and Gas Exchange

Pneumonia is a common cause of altered gas exchange. It involves inflammation of the lung tissue, often from infection, and is frequently accompanied by fluid-filled alveoli, which block oxygenation.

Clinical Signs of Pneumonia

General: Fatigue, anxiety, confusion (especially in older adults)
Physical: Fever, chills, chest pain, cough, shortness of breath, wheezing, and decreased SpO2

Risk Factors and Assessment

Category	Examples	Explanation
Medical History	COPD, asthma, sinusitis	Pre-existing conditions reduce pulmonary resilience
Procedures	Surgery	Post-op immobility increases pneumonia risk
Medications	Immunosuppressants	Reduce ability to fight infections
Lifestyle	Smoking, vaping	Damages mucociliary clearance and alveoli

Types of Pneumonia

Aspiration: Inhalation of gastric contents; avoid by assessing swallowing.
Hospital-acquired: Onset 48+ hours after admission; prevent with aseptic technique.
Community-acquired: Acquired outside hospitals; promote hygiene and vaccinations.

Diagnostic Tools for Pneumonia

Chest X-ray: Confirms lung consolidation.
ABGs: Reveals hypoxemia.
Sputum C\&S: Identifies the pathogen.
CBC, blood cultures: Detect infection and sepsis.
Electrolytes: Check for dehydration.

Pneumonia Treatment and Nursing Care

Treatment often includes antibiotics (e.g., penicillin, cephalosporins), bronchodilators (e.g., albuterol, ipratropium), and corticosteroids.

Nursing Interventions

Monitor for neurologic changes, vital sign fluctuations, and oxygenation trends.
Administer prescribed medications.
Position client in high-Fowler’s position.
Encourage fluid intake and nutritional support.
Perform chest physiotherapy.
Collaborate with respiratory, nutrition, and rehabilitation specialists.

CURB-65 Scale

Letter	Meaning	Clinical Implication
C	Confusion	Indicates hypoxia
U	Urea >19	Possible renal dysfunction
R	RR >30	Poor gas exchange
B	BP <90/60	Suggests sepsis
65	Age >65	High risk for complications

Vaccination and Prevention

Encourage immunizations (e.g., PCV13, PPSV23, influenza)
Promote hand hygiene and smoking cessation
Avoid crowded places during outbreaks

Interprofessional Collaboration

Body System	Nursing Action	Rationale
Neurological	Monitor LOC	Indicates hypoxemia and cognitive impairment
Respiratory	Monitor RR, reposition, administer O2 and medications	Improves ventilation and symptom relief
Cardiovascular	Monitor BP and HR	Detects sepsis or hemodynamic instability

Vaccine Administration Considerations

When administering common vaccines such as influenza and SARS-CoV-2, nurses must assess the client’s current health condition. Vaccines can typically be given even if the individual presents with a mild cold. However, administration should be avoided in clients who are experiencing fever, chills, or a severe cold. Nurses should educate the client about the importance of vaccination and possible physiological reactions post-injection. Prior to administration, vital signs must be recorded, and the vaccine should be administered intramuscularly. Post-vaccination monitoring for at least 15 minutes is essential to observe for reactions such as redness, swelling, fever, or chills. Equipment for treating anaphylactic reactions, including epinephrine and airway support, should always be readily available.

Chronic Obstructive Pulmonary Disease (COPD)

Introduction to COPD

COPD is a progressive and irreversible pulmonary disorder characterized by chronic inflammation and obstructed airflow. It results from long-term exposure to environmental pollutants, smoking, and in some cases, genetic factors such as alpha-1 antitrypsin deficiency. Nurses must understand the disease’s underlying pathophysiology to effectively support gas exchange in affected clients. Since COPD contributes to increased pulmonary vascular pressure, it can worsen or cause other conditions.

Clinical Presentation of COPD

Clients with COPD often exhibit the following symptoms:

Persistent cough
Increased mucus production
Shortness of breath (dyspnea)
Chest tightness
Fatigue

Long-term complications can include heart disease and lung cancer. Emphysema and chronic bronchitis are primary contributors. COPD most commonly affects middle-aged and older adults. Periodic exacerbations, often triggered by infections or environmental factors, may persist for several days.

Airway Condition	Characteristics
Healthy Airway	Smooth mucus, normal lumen, intact alveoli
Unhealthy Airway	Excess mucus, inflammation, alveolar damage

Health History and Risk Factors

Comprehensive health history is crucial for identifying modifiable and non-modifiable risk factors associated with COPD.

Category	Example Factors	Rationale
Non-Modifiable	Age, genetic predisposition	Age and genetic disorders reduce lung elasticity and increase gas exchange anomalies
Medical History	Lung trauma, bronchitis, asthma	Recurrent infections damage alveoli and reduce airway clearance
Lifestyle Factors	Smoking, pollutants, occupational hazards	Environmental exposure can lead to chronic lung damage

Diagnostic Testing for COPD

Diagnostic Test	Purpose
Spirometry	Assesses lung function and severity
Chest X-ray	Identifies structural changes such as hyperinflation
Serum Alpha-1 Antitrypsin	Detects genetic predisposition
Arterial Blood Gases (ABGs)	Evaluates respiratory compensation
6-Minute Walk Test	Assesses functional exercise capacity and oxygen levels
COPD Assessment Test (CAT)	Measures symptoms and health impact

Nursing Interventions for COPD

System	Nursing Action	Rationale
Neurological	Monitor consciousness	Identifies hypoxemia-induced mental status changes
Respiratory	Assess rate, pattern, and lung sounds; use high-Fowler’s position	Optimizes lung expansion and gas exchange
	Encourage pursed-lip breathing and rest periods	Reduces air trapping and fatigue
	Administer bronchodilators, steroids, and oxygen as prescribed	Enhances ventilation and reduces inflammation
	Perform chest physiotherapy and promote coughing	Aids in secretion clearance
Immunologic	Administer vaccines (influenza, COVID-19, pneumococcal)	Prevents complications from infections
Nutritional	Encourage protein-rich diet and hydration	Supports immune response and mucus clearance
Cardiovascular	Monitor vitals and assess for arrhythmias	Detects cardiovascular complications from pulmonary hypertension

Asthma

Overview of Asthma

Asthma is a chronic respiratory condition characterized by airway hyperresponsiveness and inflammation. Unlike COPD, asthma is usually reversible with proper treatment. Triggers include allergens, exercise, cold air, and gastroesophageal reflux. Nurses should identify and manage these triggers through comprehensive history-taking and physical examination.

Risk Category	Examples	Rationale
Medical History	Eczema, GERD, allergies, frequent infections	Suggests systemic inflammatory or allergic response contributing to asthma
Lifestyle Factors	Smoking, cold air, occupational exposure	Inhaled irritants promote inflammation and bronchospasm

Nursing Interventions for Asthma

System	Nursing Action	Rationale
Neurological	Assess mental status	Hypoxia can lead to cognitive dysfunction
Respiratory	Monitor breathing patterns, lung sounds, and use semi-Fowler’s position	Enhances gas exchange and reduces dyspnea
	Eliminate allergens and cold air exposure	Minimizes exacerbation risks
	Encourage fluid intake and deep breathing exercises	Loosens mucus and supports secretion clearance
	Educate on peak flow meter usage	Promotes self-monitoring and timely medication usage
	Provide rescue inhaler and initiate oxygen therapy if necessary	Prevents respiratory failure

Diagnostic Tests for Asthma

Test	Purpose
Spirometry	Measures reversible airflow obstruction
Chest X-ray	Rules out other pulmonary disorders
Peak Expiratory Flow Rate	Determines asthma control level
Allergy Testing & Serum IgE	Identifies allergic triggers
Serum Eosinophil Count	Diagnoses eosinophilic asthma

Asthma Medications

Class	Mechanism of Action	Nursing Considerations
Beta Agonists	Stimulates beta-2 receptors for bronchodilation	Monitor for tachycardia and proper inhaler technique
Leukotriene Inhibitors	Reduces leukotriene-mediated inflammation	Watch for mood changes and anxiety
Methylxanthines	Improves diaphragm movement and bronchodilation	Monitor toxicity symptoms such as nausea and arrhythmias
Corticosteroids	Reduces airway inflammation	Inhaled forms preferred; systemic forms have more side effects
Antihistamines	Blocks histamine response	Effective for allergic asthma; monitor for sedation
IgE Blockers	Inhibits allergen-mediated mast cell activation	Used in severe persistent asthma; administered subcutaneously
Anticholinergics	Blocks muscarinic receptors for bronchodilation	Often used as maintenance therapy

Severe Asthma (Status Asthmaticus)

Status asthmaticus is a medical emergency where typical asthma treatments fail to relieve symptoms. Nurses must be prepared to secure the airway, provide emergency oxygen support, and monitor the client continuously. Emergency equipment should be readily available and in working condition.

Asthma Inhaler and Nebulizer Education

Proper medication delivery is essential. Clients should be trained on using metered dose inhalers (MDIs), dry powder inhalers (DPIs), and nebulizers correctly. Use of spacers with MDIs is encouraged to ensure better drug delivery. Cleaning protocols for each device should be taught to prevent infection and ensure device longevity.

Peak Flow Meter Education

Clients should be taught how to use a peak flow meter to monitor airway function. This helps them track symptom severity and take timely action based on their personal asthma action plan. The meter provides results in liters per minute and is critical in managing exacerbations.

Oxygen-Induced Hypercapnia in COPD

Clients with severe COPD should use supplemental oxygen cautiously. Over-oxygenation can lead to carbon dioxide retention, worsening respiratory acidosis. Maintaining oxygen saturation between 88% and 92% is ideal for these individuals. Indicators of severe COPD include a fixed FEV1 of less than 49%, chronic oxygen use, and GOLD stage 3 or 4 classification.

Cor Pulmonale

Prolonged hypoxia from COPD can lead to right-sided heart failure, known as cor pulmonale. This condition results from increased pulmonary artery pressure and right ventricular overload. Signs include jugular vein distension, peripheral edema, and atrial arrhythmias. Diuretics are often needed to manage fluid overload.

References

American Lung Association. (2023). Chronic Obstructive Pulmonary Disease (COPD). https://www.lung.org/lung-health-diseases/lung-disease-lookup/copd

Centers for Disease Control and Prevention. (2023). Influenza (flu) vaccine. https://www.cdc.gov/flu/prevent/index.html

Global Initiative for Asthma (GINA). (2024). Global Strategy for Asthma Management and Prevention. https://ginasthma.org