Chronic Obstructive Pulmonary Disease

Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur
ISO 9001:2008 GRADUATE SCHOOL
DISTURBANCES IN GAS EXCHNAGE

Reported by: CHRISTELLE KAY G. ASIS
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Chronic obstructive pulmonary disease (COPD) is a chronic condition in which there is a
slow, progressive obstruction of airflow into or out of the lungs.
Signs and Symptoms
o cough,
o chest discomfort,
o shortness of breath, and
o wheezing.
Progressive or more serious symptoms may include:
o respiratory distress,
o tachypnea,
o cyanosis,
o use of accessory respiratory muscles,
o peripheral edema,
o hyperinflation,
o chronic wheezing,
o abnormal lung sounds,
o prolonged expiration,
o elevated jugular venous pulse, and
o cyanosis.
Risk Factors
The primary cause of chronic obstructive pulmonary disease is cigarette smoking and/or
exposure to tobacco smoke. Other causes include air pollution, infectious diseases, and
genetic conditions. The risk factors of COPD is increased by smoking tobacco,
secondhand smoke, air pollution, alpha-1 antitrypsin deficiency and a few other
conditions. Chronic bronchitis, emphysema, asthma, and infectious diseases can
contribute to the development of chronic obstructive pulmonary disease.
The stages of chronic obstructive pulmonary disease range from stage I to stage IV. As
the stage number increases, the disease progressively becomes worse; stage IV is also
known as "end stage" chronic obstructive pulmonary disease.
Diagnostic Tests/Procedures
The diagnosis of this COPD is by taking the patient's breathing history and exposure to
irritants such as cigarette smoking or other agents. A pulmonologist usually determines
the stage of COPD by their FEV1 level.
Management
 The treatment for this health condition includes avoiding any of the risks and causes
of COPD such as cigarette smoke or toxic fumes, medications, or in a small number
of patients, lung surgery or lung transplant.
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 Medical treatments for COPD include medications to stop smoking,

various bronchodilators, anticholinergics, steroids, and enzyme inhibitors.
 Other therapies for this health condition may include antibiotics, mucolytic agents,
oxygen, endurance exercises, and yoga.
 Surgery for COPD may include bullectomy, lung volume reduction, or lung transplant.
 The prognosis and life expectancy for individuals with chronic obstructive pulmonary
disease ranges from good to poor, depending on the person's COPD stage, with a
decreasing outlook as the stages progress toward stage IV.
 Individuals with COPD should contact their health-care professional before treating
themselves with home remedies (for example, vitamins, antioxidants, omega-3 fatty
acids).
 Prevention or lowering the risk factors for chronic obstructive pulmonary disease
includes avoiding the causes and irritants (for example, smoking) or vaccines that
protect the lungs from infection (for example, the flu and pneumococcal vaccines).
 Depending upon the stage of chronic obstructive pulmonary disease, other doctors
besides the patient's primary care physician may be involved and may include
pulmonologists, lung surgeons, and/or other professionals such as pulmonary
rehabilitation specialists and other team members.
 Individuals should contact their doctors about COPD if they experience any of the
signs or symptoms of COPD.
BRONCHIAL ASTHMA
Asthma is a complex clinical syndrome of chronic airway inflammation characterized by
recurrent, reversible, airway obstruction. Airway inflammation also leads to airway
hyperreactivity, which causes airways to narrow in response to various stimuli.
Risk Factors
Asthma is a common chronic condition, affecting approximately 8%-10% of Americans,

or an estimated 23 million Americans as of 2008. Asthma remains a leading cause of
missed work days. It is responsible for 1.5 million emergency department visits annually
and up to 500,000 hospitalizations. Over 3,300 Americans die annually from asthma.
Furthermore, as is the case with other allergic conditions, such as eczema (atopic
dermatitis), hay fever (allergic rhinitis), and food allergies, the prevalence of asthma
appears to be on the rise.
Asthma vs. COPD: What are the differences?
 Asthma is characterized by reversible airway narrowing, whereas COPD (chronic

obstructive pulmonary disease) typically has fixed airway narrowing.
 Some symptoms of COPD are similar to asthma, including wheezing, shortness of
breath, and cough.
 The cough in COPD can be more productive of mucus than asthma, and patients with
severe COPD may need oxygen supplementation.
 COPD is very often a result of cigarette smoke exposure, either direct or secondhand,
although severe asthma can evolve to COPD over time.
 Medications used to treat COPD include inhaled corticosteroids, bronchodilators,
inhaled corticosteroid/bronchodilator combinations, long-acting muscarinic
antagonists, and oral steroids.
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 There is a newly described syndrome called asthma/COPD overlap syndrome that

displays characteristics of both asthma and COPD. This is an area of medicine that
needs further study.
Asthma results from complex interactions between an

individual's inherited genetic makeup and their
interactions with the environment. The factors that
cause a genetically predisposed individual to
become asthmatic are poorly understood. The
following are risk factors for asthma:
 Family history of allergic conditions

 Personal history of hay fever (allergic rhinitis)
 Viral respiratory illness, such as respiratory syncytial virus (RSV), during childhood
 Exposure to cigarette smoke
 Obesity
 Lower socioeconomic status
What are the different types of asthma?
The many potential triggers of asthma largely explain the different ways in which asthma
can present. In most cases, the disease starts in early childhood from 2-6 years of age.
In this age group, the cause of asthma is often linked to exposure to allergens, such as
dust mites, tobacco smoke, and viral respiratory infections. In very young children, less
than 2 years of age, asthma can be difficult to diagnose with certainty. Wheezing at this
age often follows a viral infection and might disappear later, without ever leading to
asthma. Asthma, however, can develop again in adulthood. Adult-onset asthma occurs
more often in women, mostly middle-aged, and frequently follows a respiratory tract
infection. The triggers in this group are usually nonallergic in nature.
Types: allergic (extrinsic) and nonallergic (intrinsic) asthma
Your doctor may refer to asthma as being "extrinsic" or "intrinsic." A better understanding
of the nature of asthma can help explain the differences between them. Extrinsic, or
allergic asthma, is more common and typically develops in childhood. Approximately
70%-80% of children with asthma also have documented allergies. Typically, there is a
family history of allergies. Additionally, other allergic conditions, such as nasal allergies
or eczema, are often also present. Allergic asthma often goes into remission in early
adulthood. However, in many cases, the asthma reappears later.
Intrinsic asthma represents a small amount of all cases. It usually develops after the age
of 30 and is not typically associated with allergies. Women are more frequently affected
and many cases seem to follow a respiratory tract infection. Obesity also appears to be
a risk factor for this type of asthma. Intrinsic asthma can be difficult to treat and symptoms
are often chronic and year-round.
Signs and Symptoms
The classic signs and symptoms of asthma are shortness of breath, cough (often worse
at night), and wheezing (high-pitched whistling sound produced by turbulent airflow
through narrow airways, typically with exhalation). Many patients also report chest
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tightness. It is important to note that these symptoms are episodic, and individuals with
asthma can go long periods of time without any symptoms.
Common triggers for asthmatic symptoms include exposure to allergens (pets, dust mites,
cockroach, molds, and pollens), exercise, and viral infections. Tobacco use or exposure
to secondhand smoke complicates asthma management.
Many of the symptoms and signs of asthma are nonspecific and can be seen in other
conditions as well. Symptoms that might suggest conditions other than asthma include
new symptom onset in older age, the presence of associated symptoms (such as chest
discomfort, lightheadedness, palpitations, and fatigue), and lack of response to
appropriate medications for asthma.
The physical exam in asthma is often completely normal. Occasionally, wheezing is

present. In an asthma exacerbation, the respiratory rate increases, the heart rate
increases, and the work of respiration increases. Individuals often require accessory
muscles to breathe, and breath sounds can be diminished. It is important to note that the
blood oxygen level typically remains fairly normal even in the midst of a significant asthma
exacerbation. Low blood oxygen level is therefore concerning for impending respiratory
failure.
Diagnostic tests
The diagnosis of asthma begins with a detailed history and physical examination.
Primary-care providers are familiar with the diagnosis of asthma, but specialists such as
allergists or pulmonologists may be involved. A typical history is an individual with a family
history of allergic conditions or a personal history of allergic rhinitis who
experiences coughing, wheezing, and difficulty breathing, especially with exercise or
during the night. There may also be a propensity toward bronchitis or respiratory
infections. In addition to a typical history, improvement with a trial of appropriate
medications is very suggestive of asthma.
In addition to the history and exam, the following are diagnostic procedures that can be
used to help with the diagnosis of asthma:
 Lung function testing with spirometry: This test measures lung function as the patient
breathes into a tube. If lung function improves significantly following the administration
of a bronchodilator, such as albuterol, this essentially confirms the diagnosis of asthma.
It is important to note, however, that normal lung function testing does not rule out the
possibility of asthma.
 Measurement of exhaled nitric oxide (FeNO): This can be performed by a quick and
relatively simple breathing maneuver, similar to spirometry. Elevated levels of exhaled
nitric oxide are suggestive of "allergic" inflammation seen in conditions such as asthma.
 Skin testing for common aeroallergens: The presence of sensitivities to environmental
allergies increases the likelihood of asthma. Of note, skin testing is generally more
useful than blood work (in vitro testing) for environmental allergies. Testing for food
allergies is not indicated in the diagnosis of asthma.
 Other potential but less commonly used tests include provocation testing such as a
methacholine challenge, which tests for airway hyperresponsiveness.
Hyperresponsiveness is the tendency of the breathing tubes to constrict or narrow in
response to irritants. A negative methacholine challenge makes asthma much less
likely. Specialists sometimes also measure sputum eosinophils, another marker for
"allergic" inflammation seen in asthma. Chest imaging may show hyperinflation, but is
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often normal in asthma. Tests to rule out other conditions, such as cardiac testing, may
also be indicated in certain cases.
 Blood testing can sometimes help differentiate between different types of asthma.
Helpful blood tests include checking for the level of allergic antibody (IgE) or
specialized white blood cells called eosinophils, which are often associated with allergic
or extrinsic asthma.
Management
As per widely used guidelines, the treatment goals for asthma are to:
 adequately control symptoms,

 minimize the risk of future exacerbations,
 maintain normal lung function,
 maintain normal activity levels, and
 use the least amount of medication possible with the least amount of potential side
effects.
Inhaled corticosteroids (ICS) are the most effective anti-inflammatory agents available for
the chronic treatment of asthma and are first-line therapy per most asthma guidelines. It
is well recognized that ICS are very effective in decreasing the risk of asthma
exacerbations. Furthermore, the combination of a long-acting bronchodilator (LABA) and
an ICS has a significant additional beneficial effect on improving asthma control.
The most commonly used asthma medications include the following:
 Short-acting bronchodilators (albuterol [Proventil, Ventolin, ProAir, ProAir RespiClick,

Maxair, Xopenex]) provide quick relief and can be used in conjunction for exercise-
induced symptoms.
 Inhaled steroids (budesonide [Pulmicort Turbuhaler, Pulmicort Respules], fluticasone
[Flovent, Arnuity Ellipta], beclomethasone [Qvar], mometasone [Asmanex],
ciclesonide [Alvesco], flunisolide [Aerobid, Aerospan]) are first-line anti-inflammatory
therapy.
 Long-acting bronchodilators (salmeterol [Serevent], formoterol [Foradil], vilanterol) can
be added to ICS as additive therapy. LABAs should never be used alone for the
treatment of asthma.
 Leukotriene modifiers (montelukast [Singulair], zafirlukast [Accolate], zileuton [Zyflo])
can also serve as anti-inflammatory agents.
 Anticholinergic agents (ipratropium [Atrovent, Atrovent HFA], tiotropium [Spiriva],
umeclidinium [Incruse Ellipta]) can help decrease sputum production.
 Anti-IgE treatment (omalizumab [Xolair]) can be used in allergic asthma.
 Anti-IL5 treatment (mepolizumab [Nucala], reslizumab [Cinqair]) can be used in
eosinophilic asthma.
 Chromones (cromolyn [Intal, Opticrom, Gastrocrom], nedocromil [Alocril]) stabilize
mast cells (allergic cells) but are rarely used in clinical practice.
 Theophylline (Respbid, Slo-Bid, Theo-24) also helps with bronchodilation (opening the
airways) but is rarely used in clinical practice due to an unfavorable side-effect profile.
 Systemic steroids (prednisone [Deltasone, Liquid Pred], prednisolone [Flo-
Pred, Pediapred, Orapred, Orapred ODT], methylprednisolone [Medrol, Depo-
Medrol, Solu-Medrol], dexamethasone [DexPak]) are potent anti-inflammatory agents
that are routinely used to treat asthma exacerbations but pose numerous unwanted
side effects if used repeatedly or chronically.
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 Numerous additional monoclonal antibodies are also currently being studied and will
likely be available within the next couple of years.
 Immunotherapy or allergy shots have been shown to decrease medication reliance in
allergic asthma.
 There are no home remedies that have proven benefit for asthma.
There is often concern about potential long-term side effects of inhaled corticosteroids.
Numerous studies have repeatedly shown that even long-term use of inhaled
corticosteroids has very few if any sustained, clinically significant side effects, including
changes in bone health, growth, or weight. However, the goal always remains to treat all
individuals with the least amount of medication that is effective. Patients with asthma
should be routinely reassessed for any appropriate changes to their medical regimen.
Asthma medications can be administered via inhalers either with or without a spacer or
nebulized solution. It is important to note that if an individual has proper technique with
an inhaler, the amount of medication deposited in the lungs is no different than that when
using a nebulized solution. When prescribing asthma medications, it is essential to
provide the appropriate teaching on proper delivery technique.
Smoking cessation and/or minimizing exposure to secondhand smoke are critical when
treating asthma. Treating concurrent conditions such as allergic rhinitis
and gastroesophageal reflux disease (GERD) may also improve asthma
control. Vaccinations such as the annual influenza vaccination
and pneumonia vaccination are also indicated.
Although the vast majority of individuals with asthma are treated as outpatients, treatment
of severe exacerbations can require management in the emergency department or
inpatient hospitalization. These individuals typically require use of supplemental oxygen,
early administration of systemic steroids, and frequent or even continuous administration
of bronchodilators via a nebulized solution. Individuals at high risk for poor asthma
outcomes are referred to a specialist (pulmonologist or allergist). The following factors
should prompt consideration or referral:
 History of ICU admission or multiple hospitalizations for asthma

 History of multiple visits to the emergency department for asthma
 History of frequent use of systemic steroids for asthma
 Ongoing symptoms despite the use of appropriate medications
 Significant allergies contributing to poorly controlled asthma
What is an asthma action plan?
Patient education is a critical component in the successful management of asthma. An

asthma action plan provides an individual with specific directions for daily asthma
management and for adjusting medications in response to increasing symptoms or
decreasing lung function, as usually measured by a peak flow meter.
What is the prognosis for asthma?
The prognosis for asthma is generally favorable. Children experience complete remission
more often than adults. Although adults with asthma experience a greater rate of loss in
their lung function as compared to age-controlled counterparts, this decline is usually not
as severe as seen in other conditions, such as chronic obstructive pulmonary
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disease (COPD) or emphysema. Asthma in the absence of other comorbidities does not
appear to shorten life expectancy. Risk factors for poor prognosis from asthma include
 a history of hospitalizations, especially ICU admissions or intubation,

 frequent reliance on systemic steroids,
 significant medical comorbidities.
The airway narrowing in asthma may become fixed over time and can resemble COPD
or emphysema. The other main complication of asthma is due to side effects from oral
steroid use, which can include bone loss (osteoporosis), weight gain, and glucose
intolerance.
Is it possible to prevent asthma?
With the increasing prevalence of asthma, numerous studies have looked for risk factors
and ways to potentially prevent asthma. It has been shown that individuals living on farms
are protected against wheezing, asthma, and even environmental allergies. The role of
air pollution has been questioned in both the increased incidence of asthma and in
regards to asthma exacerbations.
Climate change is also being studied as a factor in the increased incidence of asthma.
Maternal smoking during pregnancy is a risk factor for asthma and poor outcomes.
Tobacco smoke is also a significant risk factor for the development and progression of
asthma. Treatment of environmental allergies with allergen immunotherapy,
or allergy shots, has been shown to decrease a child's risk of developing asthma. The
development of asthma is ultimately a complex process influenced by many
environmental and genetic factors, and currently there is no proven way to decrease an
individual's risk of developing asthma.
CYSTIC FIBROSIS
 Cystic fibrosis (CF) is an inherited disease that affects the secretory glands, including
the mucus and sweat glands. Cystic fibrosis mostly affects the lungs,
pancreas, liver, intestines, sinuses, and sex organs.
 CF is due to a mutation in the CF gene on chromosome 7. The CF gene encodes a
protein known as the cystic fibrosis transmembrane regulator (CFTR). The abnormal
CFTR protein in patients with CF leads to disruption of chloride channels on the cells.
 CF is characterized by the production of abnormal mucus that is excessively thick and
sticky. The abnormal mucus leads to blockages within the lungs and airways. This
leads to repeated, serious lung infections that can damage the lungs.
 Lung function often starts to decline in early childhood in people who have cystic
fibrosis. Over time, permanent damage to the lungs can cause severe breathing
problems.
 The thick, sticky mucus also can block tubes, or ducts, in the pancreas. As a result,
the digestive enzymes from the pancreas can't reach the small intestine, causing
impaired absorption of fats and proteins. This can cause vitamin deficiency and
malnutrition.
 Due to the defect in chloride channels, CF fibrosis also causes the sweat to become
very salty.
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 Every person inherits two CFTR genes -- one from each parent. CF is inherited in an
autosomal recessive manner; children who inherit a faulty gene from each parent will
have cystic fibrosis.
 Children who inherit one faulty gene and one normal gene will be "CF carriers." Cystic
fibrosis carriers usually have no symptoms of cystic fibrosis, but they can pass the
faulty gene on to their children.
 About 30,000 people in the United States have cystic fibrosis. It is one of the most
common inherited diseases among Caucasians. About 1,000 new cases of cystic
fibrosis are diagnosed each year.
 The symptoms of cystic fibrosis vary from person to person and over time.
 Doctors diagnose cystic fibrosis based on the results from various tests. The most
commonly used test is a sweat chloride test, which measures the concentration of
chloride in sweat. Direct genetic testing to identify the CF mutation is also used. Most
U.S. States screen newborns for cystic fibrosis.
 Cystic fibrosis has no cure. However, treatments have greatly improved in recent
years. Treatment may include nutritional and respiratory therapies,
medicines, exercise, and more. Early treatment for cystic fibrosis can improve both
quality of life and lifespan.
 As treatments for cystic fibrosis continue to improve, so does life expectancy for those
who have the disease. Today, some people who have cystic fibrosis are living into
their forties, fifties, and older.
EMPHYSEMA
 Emphysema is a destructive disease of the lung in which the alveoli (small sacs) that
promote oxygen exchange between the air and the bloodstream are destroyed.
 Smoking is the primary cause of emphysema, which makes it a preventable illness.
 There are also less common genetic causes of emphysema including alpha-1
antitrypsin deficiency.
 The primary symptom of emphysema is shortness of breath. It is a progressive
complaint by affected individuals, worsening over time. Early in the disease, shortness
of breath may occur with exercise and activity but symptoms gradually worsen and
may occur at rest.
 Diagnosis of emphysema is based upon history, physical examination, and pulmonary
function studies.
 Once present, emphysema is not curable, but its symptoms are controllable.
 Medication regimens are available to preserve function for daily activities and quality
of life for an individual with emphysema.
 Oxygen supplementation may be required for a person with emphysema.
 Exercise training and education are essential components of emphysema therapy and
pulmonary rehabilitation.
 Surgical options for individuals with emphysema have been developed and but are
not expected to be available for widespread use.
 Emphysema does not affect quantity of life, but rather quality of life. There are no
studies that can predict life-expectancy in individuals with emphysema.
SARCOIDOSIS
 Sarcoidosis is a disease that causes inflammation of body tissues.
 The cause of sarcoidosis is not known.
 Sarcoidosis commonly affects the lungs and skin.
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 Diagnosis is suggested by the patient's medical history, routine tests, a physical

examination, and a chest X-ray.
 Many patients with sarcoidosis require no treatment.
 For more severe disease, cortisone-related medications are used. Other treatments
are considered, as above, depending on what areas of the body are affected and to
what degree.
Nursing Care Plan

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.
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
Pathophysiologic
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)
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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.
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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
Rapid and shallow breathing

patterns and hypoventilation
affect gas exchange.
Assess respiratory rate, depth, and effort, including Increased respiratory rate,
use of accessory muscles, nasal flaring, and use of accessory muscles,
abnormal breathing patterns. 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
Assess the lungs for areas of decreased ventilation
alert the nurse to an airway
and auscultate presence of adventitious sounds.
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
Monitor patient’s behavior and mental status for
signs of impaired gas
onset of restlessness, agitation, confusion, and (in
exchange. Cognitive
the late stages) extreme lethargy.
changes may occur with
chronic hypoxia.
Monitor for signs and symptoms of atelectasis: Collapse of alveoli increases

bronchial or tubular breath sounds, crackles, shunting (perfusion without
diminished chest excursion, limited diaphragm ventilation), resulting in
excursion, and tracheal shift to affected side. hypoxemia.
Increased dead space and

Observe for signs and symptoms of pulmonary
reflex bronchoconstriction in
infarction: bronchial breath sounds, consolidation,
areas adjacent to the infarct
cough, fever, hemoptysis, pleural effusion, pleuritic
result to hypoxia (ventilation
pain, and pleural friction rub.
without perfusion).
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BP, HR, and respiratory rate

all increase with initial
hypoxia and hypercapnia.
Monitor for alteration in BP and HR. 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
Observe for nail beds, cyanosis in skin; especially
medical emergency.
note color of tongue and oral mucous membranes.
Peripheral cyanosis in
extremities may or may not
be serious
Assess for headaches, dizziness, lethargy, reduced

These are signs of
ability to follow instructions, disorientation, and
hypercapnia.
coma.
Pulse oximetry is a useful

tool to detect changes in
oxygenation. An oxygen
saturation of <90% (normal:
Monitor oxygen saturation continuously, using
95% to 100%) or a partial
pulse oximeter.
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
Note blood gas (ABG) results as available and note
increase. Some patients,
changes.
such as those with COPD,
have a significant decrease
in pulmonary reserves, and
additional
physiological stress may
result in acute respiratory
failure.
Monitor the effects of position changes on Putting the most

oxygenation (ABGs, venous oxygen saturation compromised lung areas in
[SvO2], and pulse oximetry. the dependent position
(where perfusion is greatest)
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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.
Consider the patient’s nutritional status.
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
Check on Hgb levels. alveolar-capillary membrane
and oxygen delivery to the
tissues.
Chest x-ray studies reveal

Monitor chest x-ray reports. the etiological factors of the
impaired gas exchange.
Assess the patient’s ability to cough out secretions.

Retained secretions weaken
Take note of the quantity, color, and consistency of
gas exchange.
the sputum.
Overhydration may impair

gas exchange in patients
with heart failure. Insufficient
Evaluate the patient’s hydration status. 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
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Upright position or semi-Fowler’s position allows

Position patient with head of bed elevated,
increased thoracic capacity, full descent of
in a semi-Fowler’s position (head of bed at
diaphragm, and increased lung expansion
45 degrees when supine) as tolerated.
preventing the abdominal contents from crowding.
Regularly check the patient’s position so Slumped positioning causes the abdomen to
that he or she does not slump down in compress the diaphragm and limits full lung
bed. 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
If patient has unilateral lung disease,
should be down (e.g., lung with
position the patient properly to promote
pulmonary embolus or atelectasis should be up).
ventilation-perfusion.
However, when conditions like lung hemorrhage
and abscess is present, the affected lung should
be placed downward to prevent drainage to the
healthy lung.
Turn the patient every 2 hours. Monitor

mixed venous oxygen saturation closely Turning is important to prevent complications of
after turning. If it drops below 10% or fails immobility, but in critically ill patients with low
to return to baseline promptly, turn the hemoglobin levels or decreased cardiac output,
patient back into a supine position and turning on either side can result in desaturation.
evaluate oxygen status.
Encourage or assist with ambulation as Ambulation facilitates lung expansion, secretion

per physician’s order. clearance, and stimulates deep breathing.
If patient is obese or has ascites, consider

Trendelenburg position at 45 degrees results in
positioning in reverse Trendelenburg
increased tidal volumes and decreased respiratory
position at 45 degrees for periods as
rates.
tolerated.
Consider positioning the patient prone with

Partial pressure of arterial oxygen has been shown
upper thorax and pelvis supported,
to increase in the prone position, possibly because
allowing the abdomen to protrude. Monitor
of greater contraction of the diaphragm and
oxygen saturation, and turn back if
increased function of ventral lung regions. Prone
desaturation occurs. Do not put in prone
positioning improves hypoxemia significantly.
position if patient has multisystem trauma.
If patient is acutely dyspneic, consider Leaning forward can help decrease dyspnea,
having patient lean forward over a bedside possibly because gastric pressure allows better
table, if tolerated. contraction of the diaphragm.
14
Maintain an oxygen administration device

Supplemental oxygen may be required to maintain
as ordered, attempting to maintain oxygen
PaO2 at an acceptable level.
saturation at 90% or greater.
 Avoid a high concentration of Hypoxia stimulates the drive to breathe in the

patient who chronically retains carbon dioxide.
oxygen in patients with COPD When administering oxygen, close monitoring is
unless ordered. 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 More oxygen will be consumed during the activity.
The original oxygen delivery system should be
in a different manner (changing
returned immediately after every meal.
from mask to a nasal cannula).
Administer humidified oxygen through

appropriate device (e.g., nasal cannula or
A patient with chronic lung disease may need a
face mask per physician’s order); watch
hypoxic drive to breathe and may hypoventilate
for onset of hypoventilation as evidenced
during oxygen therapy.
by increased somnolence after initiating or
increasing oxygen therapy.
For patients who should be ambulatory, These measures may improve exercise tolerance
provide extension tubing or a portable by maintaining adequate oxygen levels during
oxygen apparatus. activity.
Help patient deep breathe and perform
controlled coughing. Have patient inhale This technique can help increase sputum
deeply, hold breath for several seconds, clearance and decrease cough spasms. Controlled
and cough two to three times with mouth coughing uses the diaphragmatic muscles, making
open while tightening the upper abdominal the cough more forceful and effective.
muscles as tolerated.
Encourage slow deep breathing using an These technique promotes deep inspiration, which
incentive spirometer as indicated. increases oxygenation and prevents atelectasis.
Suction clears secretions if the patient is not
capable of effectively clearing the airway. Airway
Suction as necessary.
obstruction blocks ventilation that impairs gas
exchange.
For postoperative patients, assist with Splinting optimizes deep breathing and coughing
splinting the chest. efforts.
Anxiety increases dyspnea, respiratory rate, and
Provide reassurance and reduce anxiety.
work of breathing.
Activities will increase oxygen consumption and
Pace activities and schedule rest periods
should be planned so the patient does not become
to prevent fatigue. Assist with ADLs.
hypoxic.
The type depends on the etiological factors of the
problem (e.g., antibioticsfor pneumonia,
Administer medications as prescribed. bronchodilators for COPD, anticoagulants and
thrombolytics for pulmonary embolus, analgesics
for thoracic pain).
15
Both analgesics and medications that cause

sedation can depress respiration at times.
Monitor the effects of sedation and
However, these medications can be very helpful
analgesics on patient’s respiratory pattern;
for decreasing the sympathetic nervous system
use judiciously.
discharge that accompanies hypoxia.
Early intubation and mechanical ventilation are

recommended to prevent full decompensation of
Consider the need for intubation the patient. Mechanical ventilation provides
and mechanical ventilation. supportive care to maintain adequate oxygenation
and ventilation.
Schedule nursing care to provide rest and The hypoxic patient has limited reserves;
minimize fatigue. inappropriate activity can increase hypoxia.
Assess the home environment for irritants
that impair gas exchange. Help the patient Irritants in the environment decrease the patient’s
to adjust home environment as necessary effectiveness in accessing oxygen during
(e.g., installing air filter to decrease breathing.
presence of dust).
Instruct patient to limit exposure to This is to reduce the potential spread of droplets
persons with respiratory infections. between patients.
Instruct family in complications of disease
Knowledge of the family about the disease is very
and importance of maintaining medical
important to prevent further complications.
regimen, including when to call physician.
Severely compromised respiratory functioning
Support family of patient with chronic causes fear and anxiety in patients and their
illness. families. Reassurance from the nurse can be
helpful.
16
Table of Contents
Title Pages
CHRONIC OBSTRUCTIVE PULMONARY DISEASE ..................................................... 1

BRONCHIAL ASTHMA ................................................................................................... 2
CYSTIC FIBROSIS ......................................................................................................... 7
EMPHYSEMA ................................................................................................................. 8
SARCOIDOSIS ............................................................................................................... 8
17

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DISTURBANCES IN GAS EXCHNAGE