Assessment Rationales
Assess respiratory rate, depth, and Rapid and shallow breathing patterns and
effort, including the use of accessory hypoventilation affect gas exchange. Increased
muscles, nasal flaring, and abnormal respiratory rate, use of accessory muscles, nasal
breathing patterns. flaring, abdominal breathing, and a look of panic in
the patient’s eyes may be seen with hypoxia.
Assess the lungs for areas of Any irregularity of breath sounds may disclose the
decreased ventilation and auscultate cause of impaired gas exchange. Presence of
presence of adventitious sounds. crackles and wheezes may alert the nurse to an
airway obstruction, which may lead to or exacerbate
existing hypoxia. Diminished breath sounds are
linked with poor ventilation.
Monitor patient’s behavior and Changes in behavior and mental status can be early
mental status for onset of signs of impaired gas exchange. Cognitive changes
restlessness, agitation, confusion, and may occur with chronic hypoxia.
(in the late stages) extreme lethargy.
Monitor for signs and symptoms of Collapse of alveoli increases shunting (perfusion
atelectasis: bronchial or tubular without ventilation), resulting in hypoxemia.
breath sounds, crackles, diminished
chest excursion, limited diaphragm
excursion, and tracheal shift to
affected side.
Observe for signs and symptoms of Increased dead space and reflex bronchoconstriction
pulmonary infarction: bronchial in areas adjacent to the infarct result to hypoxia
breath sounds, consolidation, cough, (ventilation without perfusion).
fever, hemoptysis, pleural effusion,
pleuritic pain, and pleural friction
rub.
Monitor for alteration in BP and HR. BP, HR, and respiratory rate all increase with initial
hypoxia and hypercapnia. However, when both
conditions become severe, BP and HR decrease, and
dysrhythmias may occur.
Observe for nail beds, cyanosis in Central cyanosis of tongue and oral mucosa is
skin; especially note color of tongue indicative of serious hypoxia and is a medical
and oral mucous membranes. emergency. Peripheral cyanosis in extremities may
or may not be serious
Assess for headaches, dizziness, These are signs of hypercapnia.
lethargy, reduced ability to follow
instructions, disorientation, and
coma.
Monitor oxygen saturation Pulse oximetry is a useful tool to detect changes in
continuously, using pulse oximeter. oxygenation. An oxygen saturation of <90% (normal:
95% to 100%) or a partial pressure of oxygen of <80
(normal: 80 to 100) indicates significant oxygenation
problems.
Note blood gas (ABG) results as Increasing PaCO2 and decreasing PaO2 are signs of
available and note changes. 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 COPD, have a significant
decrease in pulmonary reserves, and additional
physiological stress may result in acute respiratory
failure.
Monitor the effects of position Putting the most compromised lung areas in the
changes on oxygenation (ABGs, dependent position (where perfusion is greatest)
venous oxygen saturation [SvO2], and potentiates ventilation and perfusion imbalances.
pulse oximetry.
Consider the patient’s nutritional Certain conditions affect lung expansion. Obesity
status. 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. Malnutrition may also
reduce respiratory mass and strength, affecting
muscle function.
Check on Hgb levels. Low levels reduce the uptake of oxygen at the
alveolar-capillary membrane and oxygen delivery to
the tissues.
Monitor chest x-ray reports. Chest x-ray studies reveal the etiological factors of
the impaired gas exchange.
Assess the patient’s ability to cough Retained secretions weaken gas exchange.
out secretions. Take note of the
quantity, color, and consistency of the
sputum.
Evaluate the patient’s hydration Overhydration may impair gas exchange in patients
status. with heart failure. Insufficient hydration, on the other
hand, may reduce the ability to clear secretions in
patients with pneumonia and COPD.
