Scenario

An 86 year old female comes into the ER. Pt states she has been extremely short of breath for the past 12 hours and
you note she is only about to state 2-3 words before she stops and has to breathe again. You note she is using her
accessory muscles to help her breathe. Collecting health history is difficult. Pt came in on her home oxygen tank and
you note the oxygen setting is on 4 Liters. The pt states her normal oxygen setting is 2 L but since she has became
short of breath she increased it to 4 liters but says it hasn’t helped and that is why she come to the ER. Pt breathing
is fast and irregular (especially on activity and exertion). You hook the patient up to cardiac monitor and find her
oxygen saturation to be 85%, HR 112, BP 150/86, and RR 36. Lungs sounds are diminished and hard to hear. Chest
X-ray shows hyper-inflated lungs with flatten diaphragm correlating with COPD. ABGS show PCO2 60, pH 7.25, PO2
50, O2 Sat 85%.
Nursing Diagnosis:
Ineffective Breathing Pattern related to hypoxia as evidence by shortness of breath with activity, use of accessory
muscles, O2 saturation of 85%, and abnormal ABGS.
Subjective Data:
Pt states she has been extremely short of breath for the past 12 hours, pt states her normal oxygen setting is 2 L but
since she has became short of breath she increased it to 4 liters but says it hasn’t helped and that is why she come to
the ER.
Objective Data:
You note she is only about to state 2-3 words before she stops and has to breathe again. You note she is using her
accessory muscles to help her breathe. Collecting health history is difficult. Pt came in on her home oxygen tank and
you note the oxygen setting is on 4 Liters. The Pt breathing is fast and irregular (especially on activity and
exertion). You hook the patient up to cardiac monitor and find her oxygen saturation to be 85%, HR 112, BP 150/86,
and RR 36. Lungs sounds are diminished and hard to hear. Chest X-ray shows hyper-inflated lungs with flatten
diaphragm correlating with COPD. ABGS show PCO2 60, pH 7.25, PO2 50, O2 Sat 85%
Nursing Outcomes:
-Pt oxygen saturation will be 90-100% throughout hospitalization.-Pt respiratory rate will be 12-20 breaths per minute
throughout hospitalization
-Pt will demonstrate two breathing techniques to use during dyspneic episodes within 12 hours.
-Pt will verbalized two ways on how to prevent COPD exacerbation.

Nursing Interventions:
The nurse will place the pt on bipap per md order and assess patient’s oxygen saturation every 30 minutes.-The
nurse will assess pt respiratory rate every 30 minutes within the first 8 hours and then every 4 hours when the
patients respiratory rate is 12-20 breaths per minute during hospitalization.
-The nurse will verbalized and demonstrate to the patient 4 breathing techniques to use during dyspneic episodes
within 6 hours of the hospitalization.
-The nurse will verbalize four ways on how to prevent COPD exacerbation to the patient within 12 hours of
hospitalization.
https://www.registerednursern.com/nursing-care-plan-diagnosis-and-interventions-for-ineffective-breathing-pattern-
dyspnea-respiratory-distress-syndrome-hyoxia-acute-respiratory-failure-hypoxemia-and-respiratory-illness/

Impaired Gas Exchange

Impaired Gas Exchange: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary

membrane.

Gas is exchanged between the alveoli and the pulmonary capillaries via diffusion. Diffusion of oxygen and carbon

dioxide occurs passively, according to their concentration differences across the alveolar-capillary barrier. These

concentration differences must be maintained by ventilation (air flow) of the alveoli and perfusion (blood flow) of the

pulmonary capillaries.

A balance between the two normally exists but certain conditions can alter this balance, resulting in Impaired Gas

Exchange. Dead space is the volume of a breath that does not participate in gas exchange. It is ventilation without

perfusion.
Conditions that cause changes or collapse of the alveoli (e.g., atelectasis, pneumonia, pulmonary edema, and
acute respiratory distress syndrome) impair ventilation. High altitudes, hypoventilation, and altered oxygen-carrying
capacity of the blood from reduced hemoglobin are other factors that affect gas exchange. The total pulmonary blood
flow in older patients is lower than in young subjects. Obesity in COPD and the impact of excessive fat mass on lung
function put patients at greater risk for hypoxia. Smokers and patients suffering from pulmonary problems, prolonged
period of immobility, chest or upper abdominal incisions are also at risk for Impaired Gas Exchange.
Related Factors

Here are some factors that may be related to Impaired Gas Exchange:

 Altered oxygen supply

 Altered oxygen-carrying capacity of blood

 Alveolar-capillary membrane changes

 Ventilation-perfusion imbalance

Related to excessive or thick secretions secondary to:

 Allergy

 Cardiac or pulmonary disease

 Exposure to noxious chemical

 Infection

 Inflammation Smoking

Related to immobility, stasis of secretions, and ineffective cough secondary to:

 Central nervous system (CNS) depression/head trauma

 Cerebrovascular accident (stroke)

 Guillain-Barre syndrome

 Multiple sclerosis

 Myasthenia gravis

 Quadriplegia

Treatment Related

 Anesthesia (general or spinal)

 Sedating or paralytic effects of medications, drugs, or chemicals

 Suppressed cough reflex

 Tracheostomy

Situational (Personal, Environmental)

Related to immobility secondary to:

 Anxiety

 Cognitive impairment

 Fatigue

 Fear

 Pain

 Perception

 Surgery

 Trauma
Related to extremely high or low humidity

 For infants, related to placement on stomach for sleep

 Exposure to cold, laughing, crying, allergens, smoke

Defining Characteristics

Impaired Gas Exchange is characterized by the following signs and symptoms:

 Abnormal arterial blood gasses

 Abnormal arterial pH

 Abnormal breathing (rate, depth, rhythm)

 Confusion

 Cyanosis (in neonates only)

 Decreased carbon dioxide

 Diaphoresis

 Dyspnea

 Elevated BP

 Headache upon awakening

 Hypercapnea

 Hypoxia

 Hypoxemia

 Irritability

 Nasal flaring

 Pallor

 Restlessness

 Somnolence

 Tachycardia

 Visual disturbances

Goals and Outcomes

The following are the common goals and expected outcomes for Impaired Gas Exchange.

 Patient maintains optimal gas exchange as evidenced by usual mental status, unlabored respirations at

12-20 per minute, oximetry results within normal range, blood gases within normal range, and baseline

HR for patient.

 Patient maintains clear lung fields and remains free of signs of respiratory distress.

 Patient verbalizes understanding of oxygen and other therapeutic interventions.

  Patient participates in procedures to optimize oxygenation and in management regimen within level of

capability/condition.

 Patient manifests resolution or absence of symptoms of respiratory distress.

Nursing Assessment

The patient’s general appearance may give clues to respiratory status. Observing the individual’s responses to

activity are cue points in performing an assessment related to Impaired Gas Exchange.
Assessment Rationales

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

Nursing Interventions

The following are the therapeutic nursing interventions for Impaired Gas Exchange:
Interventions Rationales

Position patient with head of bed elevated, in a
semi-Fowler’s position (head of bed at 45 degrees
when supine) as tolerated.
Regularly check the patient’s position so that he or
she does not slump down in bed.
If patient has unilateral lung disease, position the
patient properly to promote ventilation-perfusion.
Turn the patient every 2 hours. Monitor mixed
venous oxygen saturation closely after turning. If it
drops below 10% or fails to return to baseline
promptly, turn the patient back into a supine
position and evaluate oxygen status.
Encourage or assist with ambulation as per
physician’s order.
If patient is obese or has ascites, consider
positioning in reverse Trendelenburg position at 45
degrees for periods as tolerated.
Consider positioning the patient prone with upper
thorax and pelvis supported, allowing the
abdomen to protrude. Monitor oxygen saturation,
and turn back if desaturation occurs. Do not put in
prone position if patient has multisystem trauma.
If patient is acutely dyspneic, consider having
patient lean forward over a bedside table, if
tolerated.
Maintain an oxygen administration device as
ordered, attempting to maintain oxygen saturation
at 90% or greater.
Upright position or semi-Fowler’s position allows increased thoracic
capacity, full descent of diaphragm, and increased lung expansion
preventing the abdominal contents from crowding.
Slumped positioning causes the abdomen to compress the diaphragm
and limits full lung expansion.
Gravity and hydrostatic pressure cause the dependent lung to become
better ventilated and perfused, which increases oxygenation. When the
patient is positioned on the side, the good side should be down (e.g., lung
with pulmonary embolus or atelectasis should be up). However, when
conditions like lung hemorrhage and abscess is present, the affected lung
should be placed downward to prevent drainage to the healthy lung.
Turning is important to prevent complications of immobility, but in critically
ill patients with low hemoglobin levels or decreased cardiac output,
turning on either side can result in desaturation.
Ambulation facilitates lung expansion, secretion clearance, and stimulates
deep breathing.
Trendelenburg position at 45 degrees results in increased tidal volumes
and decreased respiratory rates.
Partial pressure of arterial oxygen has been shown to increase in the
prone position, possibly because of greater contraction of the diaphragm
and increased function of ventral lung regions. Prone positioning
improves hypoxemia significantly.
Leaning forward can help decrease dyspnea, possibly because gastric
pressure allows better contraction of the diaphragm.
Supplemental oxygen may be required to maintain PaO2 at an acceptable
level.

 Avoid a high concentration of oxygen
in patients with COPD unless
ordered.
Hypoxia stimulates the drive to breathe in the patient who chronically
retains carbon dioxide. When administering oxygen, close monitoring is
imperative to prevent unsafe increases in the patient’s PaO2 which could
result in apnea.

 If the patient is permitted to eat,

provide oxygen to the patient but in a More oxygen will be consumed during the activity. The original oxygen
delivery system should be returned immediately after every meal.
different manner (changing from

mask to a nasal cannula).

Administer humidified oxygen through appropriate A patient with chronic lung disease may need a hypoxic drive to breathe
 device (e.g., nasal cannula or face mask per
physician’s order); watch for onset of
hypoventilation as evidenced by increased
somnolence after initiating or increasing oxygen
therapy.
For patients who should be ambulatory, provide
extension tubing or a portable oxygen apparatus.
Help patient deep breathe and perform controlled
coughing. Have patient inhale deeply, hold breath
for several seconds, and cough two to three times
with mouth open while tightening the upper
abdominal muscles as tolerated.
Encourage slow deep breathing using an incentive
spirometer as indicated.
Suction as necessary.
For postoperative patients, assist with splinting the
chest.
Provide reassurance and reduce anxiety.
Pace activities and schedule rest periods to
prevent fatigue. Assist with ADLs.
Administer medications as prescribed.
Monitor the effects of sedation and analgesics on
patient’s respiratory pattern; use judiciously.
Consider the need for intubation and mechanical
ventilation.
Schedule nursing care to provide rest and
minimize fatigue.
Assess the home environment for irritants that
impair gas exchange. Help the patient to adjust
home environment as necessary (e.g., installing
air filter to decrease presence of dust).
Instruct patient to limit exposure to persons with
respiratory infections.
Instruct family in complications of disease and
importance of maintaining medical regimen,
including when to call physician.
Support family of patient with chronic illness.
and may hypoventilate during oxygen therapy.
These measures may improve exercise tolerance by maintaining
adequate oxygen levels during activity.
This technique can help increase sputum clearance and decrease cough
spasms. Controlled coughing uses the diaphragmatic muscles, making
the cough more forceful and effective.
These technique promotes deep inspiration, which increases oxygenation
and prevents atelectasis.
Suction clears secretions if the patient is not capable of effectively
clearing the airway. Airway obstruction blocks ventilation that impairs gas
exchange.
Splinting optimizes deep breathing and coughing efforts.
Anxiety increases dyspnea, respiratory rate, and work of breathing.
Activities will increase oxygen consumption and should be planned so the
patient does not become hypoxic.
The type depends on the etiological factors of the problem
(e.g., antibiotics for pneumonia, bronchodilators for
COPD, anticoagulants and thrombolytics for pulmonary embolus,
analgesics for thoracic pain).
Both analgesics and medications that cause sedation can depress
respiration at times. However, these medications can be very helpful for
decreasing the sympathetic nervous system discharge that accompanies
hypoxia.
Early intubation and mechanical ventilation are recommended to prevent
full decompensation of the patient. Mechanical ventilation provides
supportive care to maintain adequate oxygenation and ventilation.
The hypoxic patient has limited reserves; inappropriate activity can
increase hypoxia.
Irritants in the environment decrease the patient’s effectiveness in
accessing oxygen during breathing.
This is to reduce the potential spread of droplets between patients.
Knowledge of the family about the disease is very important to prevent
further complications.
Severely compromised respiratory functioning causes fear and anxiety in
patients and their families. Reassurance from the nurse can be helpful.

See Also

You may also like the following posts and nursing diagnoses:

 Nursing Diagnosis: The Complete List – archive of different nursing diagnoses with their definition,

related factors, goals and nursing interventions with rationale.

 The Ultimate Guide to Nursing Diagnosis – learn how to formulate nursing diagnoses correctly in this

easy-to-follow guide!
  1,000+ Nursing Care Plans List – the ultimate database of nursing care plans for different diseases

and conditions! Get the complete list!

 What is a Nursing Care Plan? 9 Steps on How to Write a Care Plan – learn how to write an excellent

care plan. We explain the concepts and walk you through the steps.

Other Nursing Diagnoses

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 Activity Intolerance

 Acute Confusion

 Acute Pain

 Anxiety

 Caregiver Role Strain

 Constipation

 Chronic Pain

 Decreased Cardiac Output

 Deficient Fluid Volume

 Deficient Knowledge

 Diarrhea

 Disturbed Body Image

 Disturbed Thought Processes

 Excess Fluid Volume

 Fatigue

 Fear

 Hopelessness

 Hyperthermia

 Hypothermia

 Imbalanced Nutrition: Less Than Body Requirements

 Imbalanced Nutrition: More Than Body Requirements

 Impaired Gas Exchange

 Impaired Oral Mucous Membrane

 Impaired Physical Mobility

 Impaired Swallowing

 Impaired Tissue (Skin) Integrity

 Impaired Urinary Elimination

 - Functional Urinary Incontinence

 - Reflex Urinary Incontinence

 - Stress Urinary Incontinence

 - Urge Urinary Incontinence

 Impaired Verbal Communication

 Ineffective Airway Clearance

 Ineffective Breathing Pattern

 Ineffective Coping

 Ineffective Therapeutic Regimen Management

 Ineffective Tissue Perfusion

 Latex Allergy Response

 Powerlessness

 Rape Trauma Syndrome

 Risk for Aspiration

 Risk for Bleeding

 Risk for Falls

 Risk for Infection

 Risk for Injury

 Risk for Unstable Blood Glucose Level

 Self-Care Deficit

 Urinary Retention
Risk for Aspiration: At risk for entry of gastrointestinal secretions, oropharyngeal secretion, solids, or fluids into

tracheobronchial passages.

Aspiration is breathing in a foreign object such as foods or liquids into the trachea and lungs and happens when

protective reflexes are reduced or jeopardized. An infection that develops after an entry of food, liquid, or vomit into

the lungs can result in aspiration pneumonia. Inhaling chemical fumes or breathing in and choking on certain

chemicals, even small amounts of gastric acids can damage lung tissue, resulting in chemical pneumonitis. Many

household and industrial chemicals can produce both an acute and a chronic form of inflammation in the lungs which

can place patients at risk for aspiration. Acute conditions, like postanesthesia effects from surgery or diagnostic tests,

happen predominantly in the acute care setting. Chronic conditions, like altered consciousness from head

injury, spinal cord injury, neuromuscular weakness, hemiplegia, and dysphagia from stroke, use of tube feedings for

nutrition, and artificial airway devices such as tracheostomies, may be experienced in the home, rehabilitative, or

hospital setting.

Prevention is the main goal when caring for patients at risk for aspiration. Evidence shows that one of the principal

precautionary measures for aspiration is placing at-risk patients in a semirecumbent position. Other measures include

compensating for absent reflexes, assessing feeding tube placement, identifying delayed stomach emptying, and

managing effects of prolonged intubation.

Risk Factors

Here are some factors that may be related to Risk for Aspiration:

 Advanced age

 Anesthesia or medication administration

 Decreased gastrointestinal motility

 Delayed gastric emptying

 Depressed cough or gag reflex

 Drug or alcohol intoxication

 Facial, oral, or neck surgery or trauma

 Impaired swallowing

 Increased gastric residual

 Presence of gastrointestinal tubes

 Presence of tracheostomy or endotracheal tube

 Reduced level of consciousness

 Seizure activity

 Situations hindering elevation of upper body

 Tube feedings

 Wired jaws

Goals and Outcomes

The following are the common goals and expected outcomes for Risk for Aspiration:

 Patient is free of signs of aspiration and the risk of aspiration is decreased.

 Patient expectorates clear secretions and is free of aspiration.

 Patient maintains a patent airway with normal breath sounds.

 Patient swallows and digests oral, nasogastric, or gastric feeding without aspiration.

Nursing Assessment

Assessment is required in order to distinguish possible problems that may have lead to aspiration as well as name

any episode that may occur during nursing care.

Assessment Rationales

Assess level of consciousness. The primary risk factor of aspiration is decreased level of consciousness.
Monitor respiratory rate, depth, and effort. Note
Signs of aspiration should be identified as soon as possible to prevent
any signs of aspiration such as dyspnea, cough,
further aspiration and to initiate treatment that can be life-saving.
cyanosis, wheezing, or fever.
Evaluate swallowing ability by assessing for the
following:

 Coughing, choking, throat clearing,

gurgling or “wet” voice during or after Impaired swallowing increases the risk for aspiration. There remains a
need for valid and easy-to-use methods to screen for aspiration risk.
swallowing

 Residual food in mouth after eating

 Regurgitation of food or fluid through

the nares
Review results of swallowing studies as ordered.
Assess for presence of nausea or vomiting.
Observe for food particles in tracheal secretions in
patients with tracheostomies.
Auscultate bowel sounds to assess for
gastrointestinal motility.
Assess pulmonary status for clinical evidence of
aspiration. Auscultate breath sounds noting for
crackles and rhonchi. Monitor chest x-ray films as
ordered.
Monitor the effectiveness of the cuff in patients
with endotracheal or tracheostomy tubes.
In patients with nasogastric (NG) or gastrostomy tubes:
 Check placement before feeding,
using tube markings, x-ray study
For high-risk patients, performance of a videofluoroscopic swallowing
study may be indicated to determine the nature and extent of any
swallowing abnormality.
Nausea or vomiting places patients at great risk for aspiration, especially if
the level of consciousness is compromised. Antiemetics may be required
to prevent aspiration of regurgitated gastric contents.
Food should never be present in the tracheobronchial passages. It
signifies aspirated material.
Reduced gastrointestinal motility increases the risk of aspiration as fluids
and food build up in the stomach. Further, elderly patients have a
decrease in esophageal motility, which delays esophageal emptying.
When combined with the weaker gag reflex of older patients, aspiration is
at higher risk.
Aspiration of small amounts can happen with sudden onset of respiratory
distress or without coughing particularly in patients with diminished levels
of consciousness. Pulmonary infiltrates on chest x-ray films indicate some
level of aspiration has already occurred.
An ineffective cuff can increase the risk of aspiration. Work together with
the respiratory therapist, as necessary, to verify cuff pressure.
A displaced tube may erroneously deliver tube feeding into the airway.
Chest x-ray verification of accurate tube placement is most reliable.
Gastric aspirate is usually green, brown, clear, or colorless, with a pH
between 1 and 5.
 (most accurate), pH of gastric fluid,

and color of aspirate as guides.

 Test sputum with glucose oxidase Significant amounts of glucose in sputum may be indicative of aspiration.
reagent strips.

 Check residuals before feeding, or

every 4 hours if feeding is
continuous. Hold feedings if amount
of residuals is large, and notify the
physician.
Assess the patient and family for willingness and
cognitive ability to learn and cope with swallowing,
feeding, and related disorders.
Large amounts of residuals indicate delayed gastric emptying and can
cause distention of the stomach, leading to reflux emesis. The amount of
residuals may vary depending on the volume and rate of infusion;
however, the evaluation can be unreliable. Feedings are often held if
residual volume is greater than 50% of the amount to be delivered in 1
hour.
Food and feeding habits may be strongly tied to family cultural values.
Acknowledgment and/or adjustment to cultural values can facilitate
compliance and successful family coping.

Nursing Interventions

The following are the therapeutic nursing interventions for Risk for Aspiration:
Interventions Rationales

Keep suction machine available when feeding high-risk patients.
If aspiration does occur, suction immediately.
Inform the physician or other health care provider instantly of
noted decrease in cough/gag reflexes or difficulty in swallowing.
Keep head of bed elevated when feeding and for at least a half
hour afterward.
Position patients with a decreased level of consciousness on
their side.
Supervise or aid the patient with oral intake. Never give oral
fluids to a comatose patient.
Provide foods with consistency that the patient can swallow. Use
thickening agents if recommended by a speech pathologist or
dietician.
Allow the patient to chew thoroughly and eat slowly during
meals.
Note new onset of abdominal distention or increased rigidity of
abdomen.
For patients with reduced cognitive abilities, eliminate distracting
stimuli during mealtimes. Tell the patient not to talk while eating.
During enteral feedings, position patient with head of bed
elevated 30 to 40 degrees; maintain for 30 to 45 minutes after
feeding.
Place medication and food on the strong side of the mouth when
unilateral weakness or paresis is present.
Offer liquids after food is eaten.
A patient with aspiration needs immediate suctioning and
will need further lifesaving interventions such as intubation.
Early intervention protects the patient’s airway and prevents
aspiration. Anyone identified as being at high risk for
aspiration should be kept NPO (nothing by mouth) until
further evaluation is completed.
Maintaining a sitting position after meals may help decrease
aspiration pneumonia in the elderly.
This positioning (rescue positioning) decreases the risk for
aspiration by promoting the drainage of secretions out of the
mouth instead of down the pharynx, where they could be
aspirated.
Supervision helps identify abnormalities early and allows
implementation of strategies for safe swallowing.
Withholding fluids and foods as needed prevents aspiration.
Thickened semisolid foods such as pudding and hot cereal
are most easily swallowed and less likely to be aspirated.
Liquids and thin foods (e.g., creamed soups) are most
difficult for patients with dysphagia.
Well-masticated food is easier to swallow, food cut into
small pieces may also be easier to swallow.
Abdominal distention or rigidity can be associated with
paralytic or mechanical obstruction and an increased
likelihood of vomiting and aspiration.
Concentration must be focused on chewing and swallowing.
There is a higher risk for the airway to be opened when
talking and eating at the same time.
Keeping patient’s head elevated helps keep food in stomach
and decreases incidence of aspiration
Careful food placement promotes chewing and successful
swallowing.
Ingesting food and fluids together increases swallowing
difficulties.
 Place whole or crushed pills in soft foods (e.g., custard). Verify
with a pharmacist which pills should not be crushed.
Stop continual feeding temporarily when turning or moving
patient.
Provide oral care before and after meals.
In patients with artificial airways:
 Perform oral suctioning as needed.
 Brush teeth twice a day, and swab mouth with
sponge applicators every 2 to 4 hours between
brushing.
In patients with NG or gastrostomy tubes:
 If ordered by physician, put several drops of blue
or green food coloring in tube feeding to help
indicate aspiration. In addition, test the glucose in
tracheobronchial secretions to detect aspiration of
enteral feedings.
 Elevate the head of bed to 30 to 45 degrees while
feeding the patient and for 30 to 45 minutes
afterward if feeding is intermittent. Turn off the
feeding before lowering the head of bed. Patients
with continuous feedings should be in an upright
position.
Consult a speech pathologist, as appropriate.
For patients at high risk for aspiration, obtain complete
information from the discharging institution regarding institutional
management.
Establish emergency and contingency plans for care of patient.
Educate the patient and family the need for proper positioning.
Instruct in signs and symptoms of aspiration.
Demonstrate on suctioning techniques to prevent accumulation
of secretions in the oral cavity.
Refer the patient to a home health nurse, rehabilitation
specialist, or occupational therapist as indicated.
See Also
You may also like the following posts and nursing diagnoses:
Mixing pills with food helps reduce risk for aspiration.
When turning or moving a patient, it is difficult to keep the
head elevated to prevent regurgitation and possible
aspiration.
Oral care before meals reduces bacterial counts in the oral
cavity. Oral care after eating removes residual food that
could be aspirated at a later time.
Suctioning reduces the volume of oropharyngeal secretions
and reduces aspiration risk.
Oral care reduces the risk for ventilator-associated
pneumonia by decreasing the number of microorganisms in
aspirated oropharyngeal secretions.
Colored secretions suctioned or coughed from the
respiratory tract indicate aspiration.
Upright positioning reduces aspiration by decreasing reflux
of gastric contents.
A speech pathologist can be consulted to perform a
dysphagia assessment that helps determine the need for
videofluoroscopy or modified barium swallow and to
establish specific techniques to prevent aspiration in
patients with impaired swallowing.
Continuity of care can prevent unnecessary stress for the
patient and family and can facilitate successful management
in the home setting.
Clinical safety of patient between visits is a primary goal of
home care nursing.
Upright positioning decreases the risk for aspiration.
Information helps in appropriate assessment of high-risk
situations and determination of when to call for further
evaluation.
Respiratory aspiration requires prompt action to maintain
the airway and promote effective breathing and gas
exchange.
Use of consultants may be required to ensure outcomes are
achieved.
  Nursing Diagnosis: The Complete List – archive of different nursing diagnoses with their definition,

related factors, goals and nursing interventions with rationale.

 The Ultimate Guide to Nursing Diagnosis – learn how to formulate nursing diagnoses correctly in this

easy-to-follow guide!

 1,000+ Nursing Care Plans List – the ultimate database of nursing care plans for different diseases

and conditions! Get the complete list!

 What is a Nursing Care Plan? 9 Steps on How to Write a Care Plan – learn how to write an excellent

care plan. We explain the concepts and walk you through the steps.

Other Nursing Diagnoses

 Activity Intolerance

 Acute Confusion

 Acute Pain

 Anxiety

 Caregiver Role Strain

 Constipation

 Chronic Pain

 Decreased Cardiac Output

 Deficient Fluid Volume

 Deficient Knowledge

 Diarrhea

 Disturbed Body Image

 Disturbed Thought Processes

 Excess Fluid Volume

 Fatigue

 Fear

 Hopelessness

 Hyperthermia

 Hypothermia

 Imbalanced Nutrition: Less Than Body Requirements

 Imbalanced Nutrition: More Than Body Requirements

 Impaired Gas Exchange

 Impaired Oral Mucous Membrane

 Impaired Physical Mobility

 Impaired Swallowing

 Impaired Tissue (Skin) Integrity

 Impaired Urinary Elimination

 - Functional Urinary Incontinence

 - Reflex Urinary Incontinence

  - Stress Urinary Incontinence

 - Urge Urinary Incontinence

 Impaired Verbal Communication

 Ineffective Airway Clearance

 Ineffective Breathing Pattern

 Ineffective Coping

 Ineffective Therapeutic Regimen Management

 Ineffective Tissue Perfusion

 Latex Allergy Response

 Powerlessness

 Rape Trauma Syndrome

 Risk for Aspiration

 Risk for Bleeding

 Risk for Falls

 Risk for Infection

 Risk for Injury

 Risk for Unstable Blood Glucose Level

 Self-Care Deficit

 Urinary Retention
Nursing Care Plan, Diagnosis, Interventions Risk For Aspiration, Impaired Swallowing, Ineffective
Swallowing, Difficulty Swallowing, Dysphagia, Peg Tube Feeding, and Difficulty chewing.

Scenario:
An 86 year old female is being transferred to your unit. In report, you received that she has a PEG Tube with

feedings that include Jevity 1.2 cal at 75 cc/hr. The PEG tube was placed three days ago and yesterday was

when the feedings were started. The nurse tells you the patient’s residuals have been less than 10 ccs and

that the patient is tolerating the feeding very well. The patient is to be kept nothing by mouth (NPO) due to her

speech evaluation showing “silent aspiration”. Mouth care is to be performed every 4 hours along with lip care.

The patient is aphasic and has advanced stage of Alzheimer’s disease. The patients last chest x ray shows

“resolving pneumonia in left lower lobe”.

Nursing Diagnosis:
Risk for aspiration related to tube feeding as evidence by patient having peg tube with feedings and speech
evaluation showing silent aspiration.
Subjective Data:
The nurse tells you the patient’s residuals have been less than 10 ccs and that the patient is tolerating the feeding
very well.
Objective Data:
In report, you received that she has a PEG Tube with feedings that include Jevity 1.2 cal at 75 cc/hr. The PEG tube
was placed three days ago and yesterday was when the feedings were started. The patient is to be keep nothing by
mouth (NPO) due to her speech evaluation showing “silent aspiration”. Mouth care is to be performed every 4 hours
along with lip care. The patient is aphasic and has advanced stage of Alzheimer’s disease. The patients last chest x
ray shows “resolving pneumonia in left lower lobe”.
Nursing Outcomes:
-Pt’s head of bed will be greater than or equal to 30′ degrees during the hospitalization.-Pt’s mouth will be clean
and free from any debris or mucous build-up during hospitalization.
-Pt will tolerate tube feedings well by having less than 30 cc of residual throughout hospitalization.
Nursing Interventions:
-The nurse will verbalize and demonstrate to the family and staff about how to keep the head of the greater than 30′
degrees and the importance of doing so every shift.-The nurse will assess for head of the bed placement every shift.
-The nurse will provide mouth and lip care to the patient every four hours through out the hospitalization.
-The nurse will check the patients peg tube residual and document residual amounts every shift.
Pathophysiology
Essentially, at its most basic level, respiratory failure is inadequate gas exchange. Not enough oxygen is being
exchanged in your lungs, and therefore it’s not getting into circulation.
There are three main types:

 Type I is low levels of oxygen in the blood (hypoxia) – also called hypoxemic respiratory failure
 Type II is hypoxia with high levels of carbon dioxide (hypercapnia) – also called hypercapnic respiratory
failure
o High levels of carbon dioxide result when your lungs can get rid of it (breathe out) and it begins to
build up
 Type III is also called perioperative respiratory failure is basically when patients get atelectasis after general
anesthesia or shock
o Type III is a subset of Type I
Your body desperately needs oxygenated blood to function. Therefore, if you’re not getting good gas exchange in the
lungs and oxygenating your blood, your organs will suffer.

Etiology
Many situations and/or conditions can result in respiratory failure. Trauma, medication (oversedation, for example),
various disease processes (COPD, asthma, PE, pneumonia), damage to the actual lungs/surrounding tissue/spinal
cord or nerves supporting the lungs/brain, and inhalation injuries are the major ones.

Desired Outome
Restore oxygen levels of blood as appropriate and remove excess carbon dioxide

Respiratory failure Nursing Care Plan

Subjective Data:

 Feeling SOB
 Respiratory distress
 Confusion
 Lethargy
Objective Data:

 Hypoxia
 Hypercapnia
 Blue skin, lips, nail beds, etc.
 Arrhythmias
 Increased RR
 Decreased RR
 Increased breathing workload
 Low Sp02
 Decreasing level of consciousness

Nursing Interventions and Rationales:

1. Maintain patent airway

o Some patients with trauma or neurological injury may require frequent suctioning and/or
oropharyngeal airway/nasopharyngeal airway/intubation to ensure adequate oxygen delivery
2. Obtain and evaluate labs (ABG)
o This will reveal the level of decompensation as well as if interventions are effective
3. Complete a full respiratory assessment to detect changes or further decompensation as early as possible,
and notify MD as indicated
o Enables quicker interventions and may change them (for example, wheezing noted on auscultation
would potentially indicate steroids and a breathing treatment, while crackles could require
suctioning, repositioning, and potential fluid restriction)
4. Provide supplemental oxygen as appropriate
o Supplemental oxygen will ideally increase their oxygen levels. (Use caution with COPD patients, as
they cannot breathe out the CO2 adequately, so over-oxygenation is a concern, and they also may
have a lower baseline SpO2 level)
5. Ensure patient is in optimal position to decrease work of breathing
o Sitting up in bed to enable appropriate lung expansion allows for adequate inspiration and
expiration, which facilitates better gas exchange (if clinically appropriate to be sitting up)
6. Prepare for rapid sequence intubation, if necessary
o Helpful to be prepared, as this can progress quickly. Know where the necessary meds and
equipment are and how to get ahold of assistive personnel.
7. Remove any negative/distracting stimuli: turn the TV off, encourage family members to be calm
o When patients are anxious or cannot focus it can increase their work of breathing and exacerbate
the issue. Promote a calming environment so all the patient has to worry about is breathing.
8. Prevent ventilator acquired pneumonia (VAP) if patient is intubated
o If the patient becomes intubated, prevent this major further complication
9. Provide oral care
o If a patient is intubated or receiving oxygen via nasal cannula/face mask or tent, or other method of
delivery, oral care is essential to protect mucous membrane and prevent infection
10. Cluster care
o Decreases oxygen demands if patient’s rest can be maximized
11. Promote appropriate nutrition
o Malnourishment is common with chronic lung disease, and appropriate nutrition provides the
patient support for healing
12. Assist to treat underlying cause. If the patient has pneumonia, administering antibiotics is essential to
healing, if the patient has a PE, administer appropriate blood thinners, if the patient has asthma, you’re
auscultating lungs sounds before and after to evaluate effectiveness.
o The underlying cause must be treated and routinely reevaluated for the patient to progress.
13. Monitor for conditions that can increase the oxygen demands (fever, anemia)
o Frequently other things are going on, so make sure you’re being diligent in addressing them to give
the patient the best opportunity to maximize their gas exchange (treat the fever, administer blood
products, etc.)
14. Prevent aspiration pneumonia in patients who cannot maintain their own airway
o Hypoxia can cause lethargy and a decreasing LOC; should they aspirate on their own secretions
this will put them at a significantly increased risk for aspiration pneumonia, which would further
impair gas exchange and respiratory failure
15. Manage secretions
o Tough to allow appropriate gas exchange in a patient if they cannot handle their own secretions
and are using effort to cough/clear their airway, or if it is getting down into their trachea.
16. Assess ability to swallow safely post-intubation
o Vocal cords may be irritated and have edema if a patient has been intubated and if give oral intake
too quickly too early, patients can easily aspirate. Many facilities require patients to wait 12-24 hrs
post intubation to resume regular oral intake as well as a swallow evaluation.