Impaired Gas Exchange

AssessmentPlanningInterventionScientific RationaleEvaluation

Subjective:nahihirapan akong huminga as verbalized by the patient

Objective:Pale in appearance(+) use of accessory muscles when breathingTachypneaVS as follows:T: 38CCR: 89RR: 30bpmBP: 110/60 After 6 hours of nursing interventions the patient will demonstrate ease in breathing and will normalize oxygen saturation level

Assess respiratory rate, depth, and ease.

Suction airway as indicated, using sterile technique andobserving safety precautions, e.g., mask, protectiveeyewear

Demonstrate and encourage pursed-lip breathing during exhalation, especially for patients with fibrosis or parenchymal destruction.

Promote bedrest or limit activity and assist with self-care activities as necessary.

Observe color of skin, mucous membranes, and nailbeds, noting presence of peripheral cyanosis (nail beds)

Elevate head and encourage frequent position changes, deep breathing, and effective coughing.

Monitor serial ABGs and pulse oximetry.

Provide supplemental oxygen as appropriate.

Assess anxiety level and encourage verbalization of feelings and concerns regarding complication of HIV

Manifestations of respiratory distress are dependent on/and indicative of the degree of lung involvement and underlying general health status. Assists in clearing the ventilatory passages, therebyfacilitating gas exchange and preventing respiratorycomplications Creates resistance against outflowing air to prevent collapse or narrowing of the airways, thereby helping distribute air throughout the lungs and relieve or reduce shortness of breath. Reducing oxygen consumption and demand during periods of respiratory compromise may reduce severity of symptoms. Cyanosis of nail beds may represent vasoconstriction or the bodys response to fever/chills These measures promote maximum chest expansion, mobilize secretions and improve ventilation. Decreased oxygen content (PaO2) and/or saturation or increased PaCO2 indicate need for intervention or change in therapeutic regimen. Oxygen is administered by the method that provides appropriate delivery within the patients tolerance. Anxiety is a manifestation of psychological concerns and physiological responses to hypoxia. This can reduce the psychological component, thereby decreasing oxygen demand and adverse physiological responses.

After 6 hours of nursing interventions the patient has demonstrated ease in breathing with RR of 20bpm and has oxygen saturation level of 96%