Nursing Problem: Impaired Gas Exchange Nursing Diagnosis: Impaired gas exchange related to altered oxygen carrying capacity

of the blood secondary to anemia as manifested by dyspnea, RR of 24 breaths per minute, restlessness, nasal flaring, use of accessory muscles when breathing, cyanosis of distal extremities, hemoglobin levels of 107, RBC levels of 3.82and ABG results of moderate hypoxemia and paO2 level of 72.2. Nursing Inference: Hemoglobin and RBCs are important components of the blood that is important in gas exchange in the alveolar level. RBCs are the blood cells that contain hemoglobin which in turn is responsible in carrying oxygen and when these reach low levels, such as in cases of bleeding and anemia, the result is a deficit in oxygenation as reflected in changes in ABG results. When there is oxygen deficit, the body compensates by increasing the respiratory rate in an attempt to take more oxygen into the system. However, this increased respiratory rate also results into rapid elimination of carbon dioxide at the alveoli-capillary level and consequently a rapid excretion of CO2 from the body which is also detrimental such that it causes respiratory alkalosis. Nursing Goal: After 2 hours of rendering series of nursing interventions, the client will be able to demonstrate improved ventilation and achieve adequate oxygenation as will be manifested by absence of dyspnea, RR within normal range, absence of restlessness, absence of nasal flaring, non-use of accessory muscles during breathing, normal color of distal extremities, hemoglobin and RBC levels within normal range, and normal paO2 levels. Nursing Interventions: Intervention 1. Elevate head of bed /position client appropriately 2. Change position of patient frequently and encourage deep breathing exercises 3. Encourage use of cupped hands when breathing 4. Provide supplemental oxygen

Rationale To maintain patent airway

Promotes optimal expansion and drainage of secretions To prevent over excretion of carbon dioxide that may result to alkalosis To provide adequate amount of oxygen to meet the bodys needs 5. Maintain adequate intake and output For mobilization of secretions 6. Encourage adequate rest and limit activities Helps limit oxygen consumption within client tolerance; provide calm/restful environment Nursing Goal: After 2 hours of rendering series of nursing interventions, the client was able to demonstrate improved ventilation and achieve adequate oxygenation as manifested by absence of dyspnea, RR of 20 breaths per minute, absence of restlessness, absence of nasal flaring, non-use of accessory muscles during breathing, pinkish color of distal extremities, hemoglobin and RBC levels within normal range, and normal paO2 levels.