Impaired Gas Exchange - Asthma Nursing Diagnosis and Interventions

Nursing Care Plan for Asthma

Nursing Diagnosis : Impaired Gas Exchange related to changes in capillary membrane - alveolar

Goal :
Clients are able to :

• Respiratory Status: Ventilation.
• Respiratory status : Airway patency.
• Vital sign status.

Outcomes :

• Demonstrate effective cough and breath sounds were clean, no cyanosis and dyspnea (able to produce a sputum sample, is able to breathe easy, no pursed lips)
• Showed a patent airway (the client does not feel suffocated, the rhythm of breath, respiratory frequency in the normal range, no abnormal breath sounds)
• Vital signs within normal range (blood pressure, pulse, respiration).

NIC :

Airway Management

• Open the airway , use techniques jaw thrust or chin lift if necessary.
• Position the patient to maximize ventilation.
• Identification of the patient's need for installation of an artificial airway.
• Attach mayo if necessary.
• Perform chest physiotherapy if necessary.
• Remove secretions by coughing or suctioning.
• Auscultation of breath sounds, note the presence of additional noise.
• Perform suction on orofaringeal airway.
• Give a humidifier.
• Set intake to optimize fluid balance.
• Monitor respiration and O2 status.

Oxygen Therapy

• Clean the mouth, nose and trachea.
• Maintain a patent airway.
• Set oxygenation equipment.
• Monitor the flow of oxygen.
• Maintain the position of the patient.
• Observe for signs of hypoventilation.
• Monitor the presence of the oxygenation of the patient's anxiety.

Monitoring vital signs

• Monitor BP , pulse , temperature , and RR .
• Note the fluctuations in blood pressure .
• Monitor VS when the patient is lying down , sitting , or standing .
• Auscultation of blood pressure in both arms and compare .
• Monitor BP , pulse , RR , before , during , and after activity .
• Monitor the quality of the pulse .
• Monitor respiratory rate and rhythm .
• Monitor lung sounds .
• Monitor abnormal breathing pattern .
• Monitor temperature , color , and moisture.
• Monitor peripheral cyanosis .
• Monitor the presence of Cushing's triad ( widened pulse pressure , bradycardia , increased systolic ) .
• Identify the cause of vital sign changes