Impaired Gas Exchange

ASSESSMENT Irritability Pallor on face and fingers on both extremities V/S: T – 36.5 ºC P – 129 bpm R – 58 breaths/min Lab tests: Hb – 68 gm/L HCT – 0.23% RBC – 2.91 x 1012/L

DIAGNOSIS Impaired Gas Exchange related to low RBC count as evidenced by pallor on the face and fingers, and dyspnea

PLANNING General: - To facilitate the maintenance of oxygen to all body cells

INTERVENTION Independent:

RATIONALE

Assess patient’s respirations: Rate, rhythm, depth and and breathing effort

This will serve as indicators of respiratory function and assess the therapy needed by the patient

After 1 day of effective nursing interventions the patient will be able to:

Monitor vital signs, note for changes in cardiac rhythm

Hypoxia is associated with signs of increased breathing effort

1. Display laboratory values within acceptable range

Recommend quiet atmosphere and bed rest if indicated

This enhances rest to lower body’s oxygen requirements and reduces strain on the heart and lungs .

Recommend mother to stimulate the baby to cry once in a while

Enhances lung expansion to maximize oxygenation for cellular uptake.

2. Manifest glow on the face and return of color on the fingers

Collaborative: Monitor Hb levels

Low Hb levels reduce the uptake of oxygen at the alveolar capillary membrane and oxygen delivery to tissues

Administer packed RBCs or exchange transfusions as indicated

This increases number of oxygen-carrying cells, improve circulation. PRBCs are used because they are less likely to create circulatory overload

Administer meds as indicated: - Ferlin i ml BID -Folic Acid 5 mg i tab BID -Fortum 270 mg IV q2H NST

Drug therapy helps to increase haemoglobin levels and promote maximum potential of wellness

EVALUATION After the whole stay of the patient in the ICU, patient was able to achieved: Increase hemoglobin level after blood transfusion Return of pinkish color on both hands and face