Impaired gas exchange?

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OK, I am very new to this- but I am going to give it my best shot.

I had a 59 year old female patient-

DX- bilateral lower ext. cellulitis(from fungal infection), COPD, DM, Morbid Obesity (unsure of weight- couldn't be weighed at hospital, and had not been weighed accurately in a few years)

Receiving 160 units of 70/30 insulin in the am, and 90 units at hs, as well as coverage with sliding scale, also receiving albuterol and atrovent updrafts, solumedrol 80 IVP, lasix 80 po, ancef 1gram IVPB, advair, zocor, and synthroid. Coumadin was on hold for elevated INR. She also received several ointments to areas of lower ext. that had been Incised by the doc, and debrided (Fungal growths, and really interesting)

Anyway- she had SOB with casual conversation that was worsened with any activity. Lung sounds clear, but diminished in lower lobes. O2 going at 5L per n/c, and respirations @ 26 with HOB up, O2 sat 93-95%. Edema, 2 and 3 plus to lower ext. (PITTING) Required coverage with regular insulin for FSBS of 319 at 1130 accucheck.

Urinary output adequate- BUN and Creatinine slightly elevated, WBC slightly elevated, but going down, Potassium WNL, no ABG's on chart.

She attempted to turn and position herself, and help with her care, she was pleasant, and anxious to learn.

Now- I want to go with this-Impaired Gas Exchange related to alveolar-capillary membrane changes-

can you tell me if I am headed the right way?

Any help would be greatly appreciated, and thanks!!

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Specializes in Utilization Management.

Impaired Gas Exchange really should only be used if the patient has had ABGs drawn. Activity Intolerance would be a feasible nursing diagnosis since you said she became SOB with conversation, worsening with activity.

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I thought so too, but when I asked my instructor about it, she said that I had to focus my nursing diagnosis towards the ABC's and that she would not accept activity intolerance for this patient- she even went so far as to suggest impaired gas exchange. :banghead:

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Specializes in Utilization Management.

Hmmm...Well, if she suggested it then use it...but there's no objective data to support impaired gas exchange if ABGs weren't drawn.

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So, you are saying that this does not fit-

Impaired gas exchange r/t alveolar-capillary membrane changes, secondary to COPD, AEB dyspnea, tachypnea, and diminished breath sounds in bilateral lower lung fields.

I forgot to mention that her repirations were 26 at rest.

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Specializes in Utilization Management.

I'm just saying that the way I was taught, abnormal ABGs are necessary in order to use Impaired Gas Exchange as a nursing diagnosis. Drawing blood gases is the only way I know of to objectively show that there really is impaired gas exchange. Maybe someone else will jump in and help us out lol...:)

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OK, I kind of agree with you on the ABG's. How about this - Ineffective breathing pattern r/t obesity, secondary to COPD, AEB dyspnea and tachypnea.

OR

Ineffective airway clearance r/t retained secretions, secondary to COPD, AEB dyspnea, absent cough, and diminished breath sounds

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Specializes in Utilization Management.

Maybe...Ineffective Breathing Pattern related to COPD AEB changes in RR and pattern from baseline, dyspnea, and tachypnea. I'm hesitant about using COPD in the second part, though, as it is a medical diagnosis. You would need to know what the patient's baseline is as far as RR and pattern and include those figures.

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Any other comments, ideas, thoughts would be greatly appreciated. And thanks for the comments/help I have received thus far.

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OK, this is what I came up with -

Impaired gas exchange r/t alveolar-capillary membrane changes and retained secretions, secondary to COPD, AEB dyspnea, tachypnea, orthopnea, diminished breath sounds in lower lung fields and absence of cough.

Any ideas for a short term and long term goal?

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It is difficult for me to come up with goals- don't know why, but especially in this case- as I have no ABG's

I guess I could go with -short term goal- Will exhibit adequate improvement of shortness of breath, with return to normal baseline respiratory rate and depth within 48 hours. (We have to have an exact time frame)

Then- Long term goal- maybe

will exhibit movement of air in lower lung fields, with effective cough mechanism within 5 days

or

adequate oxygenation/ventilation AEB O2 sat of 95% or greater

Any thoughts? Please help!!

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