Domain 3. Elimination and exchange
Class 4. Respiratory function
Diagnostic Code: 00030
Nanda label: Impaired gas exchange
Diagnostic focus: Gas exchange
Nursing diagnosis impaired gas exchange is a clinical nursing diagnosis used by certified and registered nurses to accurately discern and identify patients suffering from an inability or difficulty of transporting oxygen needed for cellular and tissue function. The diagnosis incorporates a variety of factors such as patient history and medical records, laboratory results, and patient complaints to confirm a diagnosis.
NANDA Nursing Diagnosis Definition
The NANDA definition for nursing diagnosis impaired gas exchange states that “the patient is unable to transport and saturate tissues with the required amounts of oxygen. This can result in symptoms including dyspnea, tachycardia, tachypnea, and fatigue.”
The defining characteristics of nursing diagnosis impaired gas exchange consist of both subjective and objective observations. Subjectively, a patient may complain of dyspnea, fatigue, rapid pulse, and chest pain. Objectively, a healthcare provider may observe signs such as cyanois, increased respiratory rate, and decreased heart rate variability.
There are a number of factors which can contribute or induce the condition of impaired gas exchange. These include abnormal lung function, cardiac dysrhythmias, pulmonary exposure to hazardous gasses, inadequate oxygen intake, and infection of the lungs or airways.
Explanation: All of these conditions can interfere with the ability of the patient’s lungs to transport and saturate tissues with necessary levels of oxygen, leading to an inhancement in diagnosis of impaired gas exchange.
At Risk Population
Patients who are at higher risk for nursing diagnosis of impaired gas exchange include elderly individuals, persons who smoke cigarettes, and those with weakened immune systems or chronic lung diseases.
Explanation: Elderly patients often have age-related physiological alterations which can impair oxygenation, smokers often have lung damage which can effect gas exchange, and weakened immune systems or chronic lung conditions make it more difficult for patients to adequately pull oxygen into the bloodstream.
There are a variety of conditions which can be linked to nursing diagnosis of impaired gas exchange, such as hypoxia, pulmonary edema, left ventricular failure, and chronic obstructive pulmonary disease (COPD).
Explanation: Hypoxia is when there is an actually decreased level of oxygen in the blood, pulmonary edema indicates fluid in the alveoli, left ventricular failure impairs the heart’s functioning, and COPD often results in inflammation and tissue damage in the lungs.
Nursing diagnosis impaired gas exchange can be used to assess the possibility of oxygen deprivation in a patient. It is important to note that this diagnosis does not indicate etiology; it is only used to identify patients who are exhibiting symptoms of oxygen deprivation, which then need to be further assessed and treated.
Suggested Alternative NANDA Nursing Diagnoses
Alternative NANDA nursing diagnoses that might be related to nursing diagnosis impaired gas exchange include: cardiopulmonary dysfunction, dyspnea, ineffective breathing pattern, oxygenation, inadequate tissue perfusion, and hyperventilation.
Explanation: These all refer to conditions which are either directly or indirectly related to impaired gas exchange, and the presenting symptoms. All of them require further assessment to determine if they could be contributing to the patient’s current condition.
It is important to remember that the nursing diagnosis impaired gas exchange is used to identify patients who are exhibiting symptoms of oxygen deprivation. When assessing a patient for this condition, it is important to take into account the patient history and any possible contributing factors that could causing the condition. In addition, it is important to be aware of the relative risks associated with any potential treatments for this condition.
When considering possible NOC outcomes for nursing diagnosis impaired gas exchange, here is a list of suggested options: cardiovascular status, respiratory status, ventilation/perfusion, oxygenation, level of consciousness, and tissue integrity.
Explanation: Cardiovascular status and respiratory status refer to the patient’s heart and lung functioning respectively, while ventilation/perfusion examines the exchanges of oxygen and carbon dioxide. Oxygenation refers to the amount of oxygen actually in the body, and level of consciousness looks at the patient’s overall awareness. Lastly, tissue integrity evaluates the health and integrity of the cells and tissues throughout the body.
Evaluation Objectives and Criteria
When evaluating a patient’s condition for nursing diagnosis impaired gas exchange, there are a number of criteria which must be taken into consideration. They include arterial blood gas readings, pulse oximetry readings, signs of respiratory distress, and symptoms of dyspnea.
When considering potential interventions to support a diagnosis of impaired gas exchange, here is a list of suggested NIC interventions: assess oxygen levels, maintain SpO2 at target levels, administer oxygen, monitor cardiac rhythms, and confirm adequate ventilation.
Explanation: Assessing oxygen levels gives important information on how much oxygen is reaching the tissues, maintaining SpO2 at target levels helps to keep optimal levels of oxygen in the system, administering oxygen helps to increase the level of oxygen available, monitoring cardiac rhythms helps to detect any irregularities or dysrhythmias, and confirming adequate ventilation helps to ensure oxygen exchange is occurring.
In order to support nursing diagnosis impaired gas exchange, there are a number of nursing activities which should be done. This includes monitoring vital signs, monitoring arterial blood gases and pulse oximetry, providing supplemental oxygen as needed, encouraging deep breathing exercises, and using incentive spirometry to improve lung functioning.
Nursing diagnosis impaired gas exchange is an important diagnosis for identifying and monitoring patients with oxygen deprivation. It is important for healthcare professionals to understand the causes and contributing factors, as well as the NANDA definition and defining characteristics associated with this condition. When nursing diagnosis impaired gas exchange is present, nurses should use appropriate nursing interventions and activities to maximize patient comfort and optimize oxygen delivery.
- What is nursing diagnosis impaired gas exchange?
Nursing diagnosis impaired gas exchange is a clinical diagnosis used by nurses to identify patients with oxygen deprivation.
- What are the causes of nursing diagnosis impaired gas exchange?
Causes of nursing diagnosis impaired gas exchange can include abnormal lung function, cardiac dysrhythmias, hazardous exposures, inadequate oxygen intake, and infection.
- Who is at risk for nursing diagnosis impaired gas exchange?
Patients at higher risk for nursing diagnosis of impaired gas exchange include elderly individuals, smokers, and those with weakened immune systems or other chronic lung conditions.
- What types of conditions are associated with nursing diagnosis impaired gas exchange?
Associated conditions with nursing diagnosis impaired gas exchange include hypoxia, pulmonary edema, left ventricular failure, and chronic obstructive pulmonary disease (COPD).
- What types of nursing activities should be done for nursing diagnosis impaired gas exchange?
Nursing activities for nursing diagnosis impaired gas exchange include monitoring vital signs, arterial blood gases, and pulse oximetry, providing supplemental oxygen, and performing deep breathing exercises and incentive spirometry.