Impaired Gas Exchange

Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary

membrane.

Related Factors

 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

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

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.

INTERVENTIONS RATIONALE
Upright position or semi-Fowler’s position allows
Position patient with head of bed elevated, in a semi-
increased thoracic capacity, full descent of diaphragm,
Fowler’s position (head of bed at 45 degrees when
and increased lung expansion preventing the abdominal
supine) as tolerated.
contents from crowding.
Regularly check the patient’s position so that he or she Slumped positioning causes the abdomen to compress
does not slump down in bed. the diaphragm and limits full lung expansion.
If patient has unilateral lung disease, position the Gravity and hydrostatic pressure cause the dependent
patient properly to promote ventilation-perfusion. 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.
Turn the patient every 2 hours. Monitor mixed venous
Turning is important to prevent complications of
oxygen saturation closely after turning. If it drops
immobility, but in critically ill patients with low
below 10% or fails to return to baseline promptly, turn
hemoglobin levels or decreased cardiac output, turning
the patient back into a supine position and evaluate
on either side can result in desaturation.
oxygen status.
Encourage or assist with ambulation as per physician’s Ambulation facilitates lung expansion, secretion
order. clearance, and stimulates deep breathing.
If patient is obese or has ascites, consider positioning Trendelenburg position at 45 degrees results in
in reverse Trendelenburg position at 45 degrees for increased tidal volumes and decreased respiratory
periods as tolerated. rates.
Consider positioning the patient prone with upper Partial pressure of arterial oxygen has been shown to
thorax and pelvis supported, allowing the abdomen to increase in the prone position, possibly because of
protrude. Monitor oxygen saturation, and turn back if greater contraction of the diaphragm and increased
desaturation occurs. Do not put in prone position if function of ventral lung regions. Prone positioning
patient has multisystem trauma. improves hypoxemia significantly.
Leaning forward can help decrease dyspnea, possibly
If patient is acutely dyspneic, consider having patient
because gastric pressure allows better contraction of
lean forward over a bedside table, if tolerated.
the diaphragm.
Maintain an oxygen administration device as ordered,
Supplemental oxygen may be required to maintain
attempting to maintain oxygen saturation at 90% or
PaO2  at an acceptable level.
greater.
Hypoxia stimulates the drive to breathe in the patient
 Avoid a high concentration of oxygen in who chronically retains carbon dioxide. When
patients with COPD unless ordered. 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 different More oxygen will be consumed during the activity.
manner (changing from mask to a nasal The original oxygen delivery system should be
cannula). returned immediately after every meal.

Administer humidified oxygen through appropriate

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

Impaired Spontaneous Ventilation: Decreased energy reserves results in an individual’s

inability to maintain breathing adequate to support life.
May be related to

 Acute respiratory failure

 Metabolic factors
 Respiratory muscle fatigue
Possibly evidenced by

 Adventitious breath sounds

 Apnea
 Apprehension
 Arterial ph less than 7.35
 Decreased tidal volume
 Decreased oxygen saturation (Sao2 <90%)
 Decreased Pao2 level (>50 to 60 mm Hg)
 Diminished lung sounds
  Dyspnea
 Forced vital capacity less than 10 mL/kg
 Increased Paco2 level (50 to 60 mm Hg or higher)
 Increased or decreased respiratory rate
 Inability to maintain airway (emesis, depressed gag, depressed cough).
 Restlessness
Desired Outcomes

 Client will maintain spontaneous gas exchange resulting in reduced dyspnea, normal

oxygen saturation, normal arterial blood gases (ABGs) within client parameters.
 Client will demonstrate an absence of complications from the mechanical ventilation.

INTERVENTIONS RATIONALE
Therapeutic interventions prior to intubation:
 Maintain the client’s airway. Use the oral An artificial airway is used to prevent the tongue from
or nasal airway as needed. occluding the oropharynx.
This position promotes oxygenation via maximum
 Maintain client in a High- chest expansion and is implemented during events of
Fowler’s position as tolerated. Frequently respiratory distress. Do not let the client slide down;
check the position. this causes the abdomen to compress the diaphragm,
which could cause respiratory change.
 Encourage deep breathing and coughing Deep breathing facilitates oxygenation. A deep cough
exercises. is effective in clearing mucus out of the lungs.
 Use nasotracheal suction as needed if
coughing and deep breathing are not Suctioning is needed to clients who are unable to
useful. remove secretions from the airway by coughing.

Risk for Dysfunctional Ventilatory Weaning Response

Risk factors may include:
- Sleep disturbance
- Limited or insufficient energy stores
- Pain or discomfort
- Adverse environment, such as inadequate monitoring or support
- Client-perceived inability to wean; decreased motivation
- History of extended weaning

Possibly evidenced by: presence of signs and symptoms establishes an actual diagnosis

Desired Outcomes:
- The patient will actively participate in the weaning process.
- Reestablish independent respiration with ABGs within acceptable range and free of signs
of respiratory failure.
- Demonstrate increased tolerance for activity and participate in self-care within level of
ability.
 INTERVENTIONS RATIONALE
1. Assess physical factors involved in weaning as Rationale: The heart has to work harder to meet
follows: Stable heart rate/rhythm, blood pressure (BP), increased energy needs associated with weaning.
and clear breath sounds. Physician may defer weaning if tachycardia,
pulmonary crackles, or hypertension are present.
2. Explain weaning techniques, for example, Assists client to prepare for weaning process, helps
spontaneous breathing trial (SBT), T-piece, pressure limit fear of unknown, promotes cooperation, and
support ventilation (PSV), and spontaneous enhances likelihood of a successful outcome. Note:
intermittent maximal ventilation (SIMV). Discuss
individual plan and expectations.
3. Provide undisturbed rest and sleep periods. Avoid Maximizes energy for weaning process; limits fatigue
stressful procedures or situations and nonessential and oxygen consumption. Note: It takes approximately
activities. 12 to 14 hours of respiratory rest to rejuvenate tired
respiratory muscles.
4. Evaluate and document client’s progress. Note Indicators that client may require slower weaning and
restlessness; changes in BP, heart rate, and respiratory an opportunity to stabilize, or may need to stop
rate; use of accessory muscles; dis coordinated program.
breathing with ventilator; increased concentration on
breathing (mild dysfunction); client’s concerns about
possible machine malfunction; inability to cooperate or
respond to coaching; and color changes.

5. Recognize and provide encouragement for client’s Positive feedback provides reassurance and support for
efforts. continuation of weaning process.
6. Monitor cardiopulmonary response to activity. Excessive oxygen consumption and demand increases
the possibility of failure.
7. Consult with dietitian and nutritional support team Reduction of carbohydrates and fats may be required to
for adjustments in composition of diet. prevent excessive production of CO2, which could
8. Monitor CBC, serum albumin and prealbumin, alter respiratory drive.
transferrin, total iron-binding capacity, and
electrolytes, especially potassium, calcium, and
phosphorus.
9. Review chest x-ray and ABGs. Chest x-rays should show clear lungs or marked
improvement in pulmonary congestion or infiltrates.
ABGs should document satisfactory oxygenation on an
FiO2 of 40% or less.

Decreased Cardiac Output: Inadequate blood pumped by the heart to meet the metabolic

demands of the body.

Related Factors

Here are some factors that may be related to Decreased Cardiac Output:

 Alteration in heart rate, rhythm, and conduction

 Cardiac muscle disease
 Decreased oxygenation
 Impaired contractility
 Increased afterload
 Increased or decreased ventricular filling (preload)
Defining Characteristics
The nursing diagnosis Decreased Cardiac Output is characterized by the following signs and
symptoms:

 Abnormal heart sounds (S3, S4)

 Angina
 Anxiety, restlessness
 Change in level of consciousness
 Crackles, dyspnea, orthopnea, tachypnea
 Decreased activity tolerance/fatigue
 Decreased cardiac output
 Decreased peripheral pulses; cold, clammy skin/poor capillary refill
 Decreased venous and arterial oxygen saturation
 Dysrhythmias
 Ejection fraction less than 40%
 Hypotension
 Increased central venous pressure (CVP)
 Increased pulmonary artery pressure (PAP)
 Tachycardia
 Weight gain, edema, decreased urine output

Goals and Outcomes

The following are the common goals and expected outcomes for the nursing
diagnosis Decreased Cardiac Output:

 Patient demonstrates adequate cardiac output as evidenced by blood pressure and

pulse rate and rhythm within normal parameters for patient; strong peripheral pulses;
and an ability to tolerate activity without symptoms of dyspnea, syncope, or
chest pain.
 Patient exhibits warm, dry skin, eupnea with absence of pulmonary crackles.
 Patient remains free of side effects from the medications used to achieve adequate
cardiac output.
 Patient explains actions and precautions to take for cardiac disease.

INTERVENTIONS RATIONALE
Record intake and output. If patient is acutely ill,
Reduced cardiac output results in reduced perfusion of
measure hourly urine output and note decreases in
the kidneys, with a resulting decrease in urine output.
output.
For patients with increased preload, limit fluids and Fluid restriction decreases extracellular fluid volume
sodium as ordered. and reduces demands on the heart.
In patients with decreased cardiac output, poorly
Closely monitor fluid intake including IV lines.
functioning ventricles may not tolerate increased fluid
Maintain fluid restriction if ordered.
volumes.
Auscultate heart sounds; note rate, rhythm, presence of The new onset of a gallop rhythm, tachycardia, and
 fine crackles in lung bases can indicate onset of heart
failure. If patient develops pulmonary edema, there
S3, S4, and lung sounds.
will be coarse crackles on inspiration and severe
dyspnea.
Closely monitor for symptoms of heart failure and
decreased cardiac output, including diminished quality
of peripheral pulses, cold and clammy skin and
As these symptoms of heart failure progress, cardiac
extremities, increased respiratory rate, presence of
output declines.
paroxysmal nocturnal dyspnea or orthopnea, increased
heart rate, neck vein distention, decreased level of
consciousness, and presence of edema.
Chest pain/discomfort is generally suggestive of an
Note chest pain. Identify location, radiation, severity, inadequate blood supply to the heart, which can
quality, duration, associated manifestations such compromise cardiac output. Patients with heart failure
as nausea, and precipitating and relieving factors. can continue to have chest pain with angina or can
reinfarct.
If chest pain is present, have patient lie down, monitor
These actions can increase oxygen delivery to the
cardiac rhythm, give oxygen, run a strip, medicate for
coronary arteries and improve patient prognosis.
pain, and notify the physician.
Place on cardiac monitor; monitor for dysrhythmias,
Atrial fibrillation is common in heart failure.
especially atrial fibrillation.
Patient may be receiving cardiac glycosides and the
Examine laboratory data, especially arterial blood potential for toxicity is greater with hypokalemia;
gases and electrolytes, including potassium. hypokalemia is common in heart patients because of
diuretic use.
Routine blood work can provide insight into the
etiology of heart failure and extent of decompensation.
A low serum sodium level often is observed with
Monitor laboratory tests such as complete blood count, advanced heart failure and can be a poor prognostic
sodium level, and serum creatinine. sign. Serum creatinine levels will elevate in patients
with severe heart failure because of decreased
perfusion to the kidneys. Creatinine may also elevate
because of ACE inhibitors.
Depending on etiological factors, common medications
Administer medications as prescribed, noting side include digitalis therapy, diuretics, vasodilator therapy,
effects and toxicity. antidysrhythmics, angiotensin-converting enzyme
inhibitors, and inotropic agents.
EKG can reveal previous MI, or evidence of left
ventricular hypertrophy, indicating aortic stenosis or
chronic systemic hypertension. Xray may provide
Review results of ECG and chest Xray.
information on pulmonary edema, pleural effusions, or
enlarged cardiac silhouette found in dilated
cardiomyopathy or large pericardial effusion.
Maintain adequate ventilation and perfusion as in the
following:
 Position patient in semi-Fowler’s to high- Upright position is recommended to reduce preload
Fowler’s. and ventricular filling when fluid overload is the cause.
 Place patient in supine position For hypovolemia, supine positioning increases venous
return and promotes diuresis.
The failing heart may not be able to respond to
 Administer oxygen therapy as prescribed. increased oxygen demands. Oxygen saturation need to
be greater than 90%.
During acute events, ensure patient remains on bed rest In severe heart failure, restriction of activity often
or maintains activity level that does not compromise facilitates temporary recompensation.
 cardiac output.
Monitor blood pressure, pulse, and condition before It is necessary for the nurse to assess how well the
administering cardiac medications such as angiotensin patient is tolerating current medications before
converting enzyme (ACE) inhibitors, digoxin, administering cardiac medications; do not hold
and beta-blockers such as carvedilol. Notify physician medications without physician input. The physician
if heart rate or blood pressure is low before holding may decide to have medications administered even
medications. though the blood pressure or pulse rate has lowered.
Decreased activity can cause constipation. Straining
Monitor bowel function. Provide stool softeners as
when defecating that results in the Valsalva maneuver
ordered. Tell patient to avoid straining when
can lead to dysrhythmia, decreased cardiac function,
defecating.
and sometimes death.
Getting out of bed to use a commode or urinal does not
stress the heart any more than staying in bed to toilet.
Advise patient to use a commode or urinal for toileting
In addition, getting the patient out of bed minimizes
and avoid use of a bedpan.
complications of immobility and is often preferred by
the patient.
Apply music therapy to decrease anxiety and improve Music has been shown to reduce heart rate, blood
cardiac function. pressure, anxiety, and cardiac complications.
Associate patient to heart failure program or cardiac
A thoroughly monitored exercise program can improve
rehabilitation program for education, evaluation, and
both functional capacity, and left ventricular function.
guided support to increase activity and rebuild life.
Educate family and patient about the disease process,
complications of disease process, information on Early recognition of symptoms facilitates early
medications, need for weighing daily, and when it is problem solving and prompt treatment.
appropriate to call doctor.
Aid family adapt daily living patterns to establish life
Transition to the home setting can cause risk factors
changes that will maintain improved cardiac
such as inappropriate diet to reemerge.
functioning in the patient.
Smoking cessation advice and counsel given by nurses
Explain importance of smoking cessation and
can be effective, and should be available to patients to
avoidance of alcohol intake.
help stop smoking.
Psychoeducational programs including information on
Educate patient the need for and how to incorporate stress management and health education have been
lifestyle changes. shown to reduce long term mortality and recurrence of
myocardial infarction in heart patients.

Ineffective Tissue Perfusion: Decrease in oxygen, resulting in failure to nourish tissues at

capillary level.

Related Factors

- Decreased hemoglobin concentration in blood

- Enzyme poisoning
- Exchange problems
- Hypervolemia
- Hypoventilation
- Hypovolemia
- Impaired transport of oxygen across alveolar and/or capillary membrane
- Interruption of arterial flow
- Interruption of venous flow
- Mechanical reduction of venous and/or arterial blood flow
 - Mismatch of ventilation with blood flow

Defining Characteristics
Cardiopulmonary

 Abnormal arterial blood gases

 Altered respiratory rate outside of acceptable parameters
 Bronchospasms
 Capillary refill >3 seconds
 Chest pain
 Chest retraction
 Dyspnea
 Dysrhythmias
 Nasal flaring
 Sense of “impending doom”
 Use of accessory muscles
Cerebral

 Altered mental status

 Behavioral changes
 Changes in motor response
 Changes in pupillary reactions
 Difficult in swallowing
 Extremity weakness or paralysis
 Speech abnormalities
Gastrointestinal

 Abdominal distention
 Abdominal pain or tenderness
 Hypoactive or absent bowel sounds
 Nausea
Peripheral

 Altered sensations
 Altered skin characteristics (hair, nails, moisture)
 Cold extremities
 Dependent, blue, or purple skin color
 Diminished arterial pulsations
 Edema
 Positive Homan’s sign
 Skin discolorations
 Skin temperature changes
 Skin color pale on elevation, color does not return on lowering the leg
 Slow healing of lesions
  Weak or absent pulses
Renal

 Altered blood pressure outside of acceptable parameters

 Elevation in BUN/creatinine ratio
 Hematuria
 Oliguria or anuria

Goals and Outcomes

 Patient identifies factors that improve circulation.

 Patient identifies necessary lifestyle changes.
 Patient exhibits growing tolerance to activity.
 Patient shows no further worsening/repetition of deficits.
 Patient engages in behaviors or actions to improve tissue perfusion.
 Patient maintains maximum tissue perfusion to vital organs, as evidenced by warm
and dry skin, present and strong peripheral pulses, vitals within patient’s normal
range, balanced I&O, absence edema, normal ABGs, alert LOC, and absence of chest
pain.
 Patient verbalizes or demonstrates normal sensations and movement as appropriate.
 Patient states when to contact physician or health-care professional

INTERVENTIONS RATIONALE
A variety of tests are available depending on the cause
of the impaired tissue perfusion. Angiograms, Doppler
Submit patient to diagnostic testing as indicated. flow studies, segmental limb pressure measurement
such as ankle-brachial index (ABI), and vascular stress
testing are examples of these tests.
Sufficient fluid intake maintains adequate filling
Check for optimal fluid balance. Administer IV
pressures and optimizes cardiac output needed for
fluids as ordered.
tissue perfusion.
Reduce renal perfusion may take place due to vascular
Note urine output.
occlusion.
Maintain optimal cardiac output. This ensures adequate perfusion of vital organs.
Consider the need for potential embolectomy, These facilitate perfusion when interference to blood
heparinization, vasodilator therapy, thrombolytic flow transpires or when perfusion has gone down to
therapy, and fluid rescue. such a serious level leading to ischemic damage.
Ineffective Tissue Perfusion: Cardiovascular
Administer nitroglycerin (NTG) sublingually for
This enhances myocardial perfusion.
complaints of angina.
Maintain oxygen therapy as ordered. To enhance myocardial perfusion.
Ineffective Tissue Perfusion: Cerebral
When patient experiences dizziness due to
orthostatic hypotension when getting up, educate
methods to decrease dizziness, such as remaining
Orthostatic hypotension results in temporary decreased
seated for several minutes before standing, flexing feet
cerebral perfusion.
upward several times while seated, rising slowly,
sitting down immediately if feeling dizzy, and trying to
have someone present when standing.
 Review trend in level of consciousness (LOC) and
Check mental status; perform a neurological possibility for increased ICP and is helpful in deciding
examination. location, extent and development/resolution or central
nervous system (CNS) damage.
If ICP is increased, elevate head of bed 30 to 45 This promotes venous outflow from brain and helps
degrees. reduce pressure.
Avoid measures that may trigger increased ICP such
as coughing, vomiting, straining at stool, neck in These will further reduce cerebral blood flow.
flexion, head flat, or bearing down.
These reduce risk of seizure which may result from
Administer anticonvulsants as needed.
cerebral edema or ischemia.
Control environmental temperature as necessary. Fever may be a sign of damage to hypothalamus. Fever
Perform tepid sponge bath when fever occurs. and shivering can further increase ICP.
Evaluate eye opening. Establishes arousal ability or level of consciousness.
Measures overall awareness and capacity to react to
external stimuli, and best signifies condition of
consciousness in the patient whose eyes are closed due
to trauma or who is aphasic. Consciousness and
involuntary movement are incorporated if patient can
Evaluate motor reaction to simple commands, noting
both take hold of and let go of the tester’s hand or
purposeful and nonpurposeful movement. Document
grasp two fingers on command. Purposeful movement
limb movement and note right and left sides
can comprise of grimacing or withdrawing from
individually.
painful stimuli. Other movements (posturing and
abnormal flexion of extremities) usually specify
disperse cortical damage. Absence of spontaneous
movement on one side of the body signifies damage to
the motor tracts in the opposite cerebral hemisphere.
Measures appropriateness of speech content and level
of consciousness. If minimum damage has taken place
in the cerebral cortex, patient may be stimulated by
Evaluate verbal reaction. Observe if patient is oriented verbal stimuli but may show drowsy or uncooperative.
to person, place and time; or is confused; uses More broad damage to the cerebral cortex may be
inappropriate words or phrases that make little sense. manifested by slow reaction to commands, lapsing
into sleep when not aroused, disorientation, and stupor.
Injury to midbrain , pons, and medulla is evidenced by
lack of appropriate reactions to stimuli.
Provide rest periods between care activities and Constant activity can further increase ICP by creating a
prevent duration of procedures. cumulative stimulant effect.
Decreased cerebral blood flow or cerebral edema may
Reorient to environment as needed.
result in changes in the LOC.
Ineffective Tissue Perfusion: Peripheral
Gently repositioning patient from a supine to
sitting/standing position can reduce the risk for
Assist with position changes. orthostatic BP changes. Older patients are more
susceptible to such drops of pressure with position
changes.
Exercise prevents venous stasis and further circulatory
Promote active/passive ROM exercises.
compromise.
Administer medications as prescribed to treat These medications facilitate perfusion for most causes
underlying problem. Note the response. of impairment.
 Antiplatelets/anticoagulants These reduce blood viscosity and coagulation.
 Peripheral vasodilators These enhance arterial dilation and improve peripheral
blood flow.
 Antihypertensives These reduce systemic vascular resistance and optimize
 cardiac output and perfusion.
 Inotropes These improve cardiac output.
This saturates circulating hemoglobin and augments
Provide oxygen therapy as necessary. the efficiency of blood that is reaching the ischemic
tissues.
Position patient properly in a semi-Fowler’s to high- Upright positioning promotes improved alveolar gas
Fowler’s as tolerated. exchange.

Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients insufficient to meet

metabolic needs.

Related Factors

Here are some factors that may be related to Imbalanced Nutrition: Less Than Body
Requirements:

- Inability to absorb or metabolize foods

- Inability to digest foods
- Inability to ingest foods
- Inability to procure adequate amounts of food
- Increased metabolic needs caused by disease process or therapy
- Knowledge deficit
- Unwillingness to eat

Related to increased caloric requirements and difficulty in ingesting sufficient calories

secondary to:

 AIDS
 Burns (post acute phase)
 Cancer
 Chemical dependence
 Gastrointestinal complications/deformities
 Infection
 Preterm infants
 Trauma
Related to  dysphagia  secondary to:

 Amyotrophic lateral sclerosis

 Cerebral palsy
 Cerebrovascular accident (CVA)
 Cleft lip/palate
 Möbius syndrome
  Muscular dystrophy
 Neuromuscular disorders
 Parkinson’s disease
Related to decreased absorption of nutrients secondary to:

 Crohn’s disease
 Cystic fibrosis
 Lactose intolerance
 Necrotizing enterocolitis

Related to decreased desire to eat secondary to altered level of consciousness

Related to self-induced vomiting, physical exercise in excess of caloric intake, or refusal to eat
secondary to anorexia nervosa
Related to reluctance to eat for  fear  of poisoning secondary to paranoid behavior
Related to anorexia nervosa and excessive physical agitation secondary to bipolar disorder
Related to anorexia and diarrhea secondary to protozoal infection
Related to vomiting, anorexia, and impaired digestion secondary to pancreatitis
Related to anorexia, impaired protein and fat metabolism, and impaired storage of vitamins
secondary to cirrhosis
Related to anorexia, vomiting, and impaired digestion secondary to GI malformation or
necrotizing enterocolitis
Related to anorexia secondary to gastroesophageal reflux

Treatment Related
Related to protein and vitamin requirements for wound healing and decreased intake secondary
to:

 Medications (chemotherapy)
 Radiation therapy
 Surgery
 Surgical reconstruction of mouth
 Wired jaw
Related to inadequate absorption as a medication side effect of:

 Antacid
 Colchicine
 Neomycin
 para-Aminosalicylic acid
 Pyrimethamine
Related to decreased oral intake, mouth discomfort, nausea, and vomiting secondary to:

 Chemotherapy
 Oral trauma
 Radiation therapy
 Tonsillectomy
Related to inadequate absorption as a medication side effect of:

 Antacid
 Antibiotics (Clotrimazole, Rifampicin)
 Antiepileptics
 Antihypertensives (nifedipine, spironolactone)
 Antineoplastic drugs
 Antiretroviral drugs (ritonavir, saquinavir)
 Colchicine
 Dexamethasone
 Herbal medicines: Kava kava
 Neomycin
 Pyrimethamine
 St, John’s wort (hyperforin)
Situational (Personal, Environmental)
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Related to decreased desire to eat secondary to:

 Allergies
 Anorexia
 Depression
 Nausea and vomiting
 Social isolation
 Stress
Related to inability to procure food (physical limitation or financial or transportation problems)
Related to inability to chew (damaged or missing teeth, ill-fitting dentures)
Related to  diarrhea
Maturational
Infant/Child
Related to inadequate intake secondary to:

 Inadequate production stimulation of breast milk

 Lack of emotional/sensory
 Lack of knowledge of caregiver
Related to malabsorption, dietary restrictions, and anorexia secondary to:

 Celiac disease
 Cystic fibrosis
 GI malformation
 Gastroesophageal reflux
 Lactose intolerance
 Necrotizing enterocolitis
Related to sucking difficulties (infant) and  dysphagia  secondary to:

 Cerebral palsy
  Cleft lip and palate
 Neurologic impairment
Related to inadequate sucking, fatigue, and dyspnea secondary to:

 Congenital heart disease

 Developmental delay
 Hyperbilirubinemia
 Prematurity
 Respiratory distress syndrome
 Viral syndrome

Defining Characteristics

Imbalanced Nutrition: Less Than Body Requirements is characterized by the following signs and
symptoms:

- Abdominal pain with or without pathology

- Actual or potential metabolic needs in excess of intake with weight loss
- Capillary fragility
- Decreased serum albumin
- Decreased serum transferrin or iron-binding capacity
- Diarrhea and/or steatorrhea
- Documented inadequate caloric intake
- Dry, brittle, hair easily plucked from scalp
- Excessive hair loss
- Hyperactive bowel sounds
- Loss of subcutaneous tissue
- Loss of weight or without adequate caloric intake
- Mental irritability or confusion
- Muscle weakness and tenderness
- Pale, dry skin
- Paresthesias
- Poor muscle tone
- Red, swollen oral mucous membranes
- Sunken fontanel in infant
- The individual who is not NPO reports or is found to have food intake less than the
recommended daily allowance (RDA) with or without weight loss
- Triceps skinfold, mid-arm circumference, and mid-arm muscle circumference less than
60% standard measurement
- Weight 10% to 20% below ideal body weight and height

Goals and Outcomes

The following are the common goals and expected outcomes for Imbalanced Nutrition: Less
Than Body Requirements.
 - Patient presents understanding of significance of nutrition to healing process and general
health.
- Patient or caregiver verbalizes and demonstrates selection of foods or meals that will
accomplish a termination of weight loss.
- Patient demonstrates behaviors, lifestyle changes to recover and/or keep appropriate
weight.
- Patient displays nutritional ingestion sufficient to meet metabolic needs as manifested by
stable weight or muscle-mass measurements, positive nitrogen balance, tissue
regeneration and exhibits improved energy level.
- Patient shows no signs of malnutrition.
- Patient takes adequate amount of calories or nutrients.
- Patient maintains weight or displays weight gain on the way to preferred goal, with
normalization of laboratory values.
- Patient weighs within 10% of ideal body weight (IBW).

INTERVENTIONS RATIONALE
Experts like a dietician can determine nitrogen balance
as a measure of the nutritional status of the patient. A
Ascertain healthy body weight for age and height.
negative nitrogen balance may mean protein
Refer to a dietitian for complete nutrition assessment
malnutrition. The dietician can also determine the
and methods for nutritional support.
patient’s daily requirements of specific nutrients to
promote sufficient nutritional intake.
Patients may lose concern in addressing this dilemma
Set appropriate short-term and long-term goals.
without realistic short-term goals.
A pleasing atmosphere helps in decreasing stress and is
Provide a pleasant environment.
more favorable to eating.
Elevating the head of bed 30 degrees aids in
Promote proper positioning.
swallowing and reduces risk for aspiration with eating.
Oral hygiene has a positive effect on appetite and on
the taste of food. Dentures need to be clean,
Provide good oral hygiene and dentition.
fit comfortably, and be in the patient’s mouth to
encourage eating.
Nursing assistance with activities of daily living
If patient lacks strength, schedule rest periods before (ADLs) will conserve the patient’s energy for activities
meals and open packages and cut up food for patient. the patient values. Patients who take longer than one
hour to complete a meal may require assistance.
Attention to the social perspectives of eating is
Provide companionship during mealtime.
important in both hospital and home settings.
Consider the use of seasoning for patients with changes Seasoning may improve the flavor of the foods and
in their sense of taste; if not contraindicated. attract eating.
Consider six small nutrient-dense meals instead of
Eating small, frequent meals lessens the feeling of
three larger meals daily to lessen the feeling of
fullness and decreases the stimulus to vomit.
fullness.
For patients with physical impairments, refer to an Special devices may be provided by an expert that can
occupational therapist for adaptive devices. help patients feed themselves.
Adjustments of the thickness and consistency of foods
For patients with impaired swallowing, coordinate with
to improve nutritional intake may be provided by a
a speech therapist for evaluation and instruction.
speech therapist.
Determine time of day when the patient’s appetite is at Patients with liver disease often have their largest
peak. Offer highest calorie meal at that time. appetite at breakfast time.
Encourage family members to bring food from home to Patients with specific ethnic or religious preferences or
the hospital. restrictions may not consider foods from the hospital.
 Offer high protein supplements based on individual Such supplements can be used to increase calories and
needs and capabilities. protein without conflict with voluntary food intake.
Energy supplementation has been shown to produce
Offer liquid energy supplements. weight gain and reduce falls in frail elderly living in
the community.
These beverages will decrease hunger and lead to early
Discourage caffeinated or carbonated beverages.
satiety.
Keep a high index of suspicion of malnutrition as a Impaired immunity is a critical adjunct factor in
causative factor in infections. malnutrition-associated infections in all age groups.
Metabolism and utilization of nutrients are improved
Encourage exercise.
by activity.
Nutritional support may be recommended for patients
who are unable to maintain nutritional intake by the
Consider the possible need for enteral or parenteral
oral route. If gastrointestinal tract is functioning well,
nutritional support with the patient, family, and
enteral tube feedings are indicated. For those who
caregiver, as appropriate.
cannot tolerate enteral feedings, parenteral nutrition is
recommended.
Validate the patient’s feelings regarding the impact of Validation lets the patient know that the nurse has
current lifestyle, finances, and transportation on ability heard and understands what was said, and it promotes
to obtain nutritious food. the nurse-patient relationship.
Once discharged, help the patient and family identify
Change is difficult. Multiple changes may be
area to change that will make the greatest contribution
overwhelming.
to improved nutrition.
Accepting the patient’s or family’s preferences shows
Adapt modification to their current practices.
respect for their culture.

Fluid Volume Deficit (also known as Deficient Fluid Volume) is defined as decreased

intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone
without change in sodium. 

Related Factors
Here are some factors or etiology for the nursing diagnosis Fluid Volume Deficient that you can
use as your “related to” (R/T) in your nursing care plan:

- Active fluid loss (abnormal drainage or bleeding, diarrhea, diuresis)

- Electrolyte and acid-base imbalances
- Failure of regulatory mechanisms
- Fluid shifts (edema or effusion)
- Inadequate fluid intake
- Increased metabolic rate (fever, infection)

Defining Characteristics

- Alterations in mental state

- Concentrated urine
- Decreased skin turgor
- Decreased urine output (less than 30mL/hr)
- Decreased venous filling pressures (preload)
- Dry mucous membranes
 - Hemoconcentration
- Hypotension/orthostasis
- Sudden weight loss
- Tachycardia/weak, rapid HR
- Thirst
- Weakness

Goals and Outcomes

The following are the common goals and expected outcomes for Deficient Fluid Volume:

- Patient is normovolemic as evidenced by systolic BP greater than or equal to 90 mm HG

(or patient’s baseline), absence of orthostasis, HR 60 to 100 beats/min, urine output
greater than 30 mL/hr and normal skin turgor.
- Patient demonstrates lifestyle changes to avoid progression of dehydration.
- Patient verbalizes awareness of causative factors and behaviors essential to correct fluid
deficit.
- Patient explains measures that can be taken to treat or prevent fluid volume loss.
- Patient describes symptoms that indicate the need to consult with health care provider.

INTERVENTIONS RATIONALE
Oral fluid replacement is indicated for mild fluid
deficit and is a cost-effective method for replacement
treatment. Older patients have a decreased sense of
thirst and may need ongoing reminders to drink. Being
Urge the patient to drink prescribed amount of fluid.
creative in slecting fluid sources (e.g., flavored gelatin,
frozen juice bars, sports drink) can facilitate fluid
replacement. Oral hydrating solutions (e.g.,
Rehydralyte) can be considered as needed.
Aid the patient if he or she is unable to eat without
Dehydrated patients may be weak and unable to meet
assistance, and encourage the family or SO to assist
prescribed intake independently.
with feedings, as necessary.
If patient can tolerate oral fluids, give what oral fluids
Most elderly patients may have reduced sense of thirst
patient prefers. Provide fluid and straw at bedside
and may require continuing reminders to drink.
within easy reach. Provide fresh water and a straw.
Fluid deficit can cause a dry, sticky mouth. Attention
Emphasize importance of oral hygiene. to mouth care promotes interest in drinking and
reduces discomfort of dry mucous membranes.
Provide comfortable environment by covering patient Drop situations where patient can experience
with light sheets. overheating to prevent further fluid loss.
Plan daily activities. Planning conserves patient’s energy.
For more severe hypovolemia: 
Parenteral fluid replacement is indicated to prevent or
Insert and IV catheter to have IV access.
treat hypovolemic complications.
Administer parenteral fluids as prescribed. Consider Fluids are necessary to maintain hydration status.
the need for an IV fluid challenge with immediate Determination of the type and amount of fluid to be
infusion of fluids for patients with abnormal vital replaced and infusion rates will vary depending on
signs. clinical status.
Blood transfusions may be required to correct fluid loss
Administer blood products as prescribed.
from active gastrointestinal bleeding.
Maintain IV flow rate. Stop or delay the infusion if Most susceptible to fluid overload are elderly patients
signs of fluid overload transpire, refer to physician and require immediate attention.
 respectively.
A central venous line allows fluids to be infused
Assist the physician with insertion of central venous centrally and for monitoring of CVP and fluid status.
line and arterial line, as indicated. An arterial line allows for the continuous monitoring of
BP.
Fluid losses from diarrhea should be concomitantly
Provide measures to prevent excessive electrolyte loss
treated with antidiarrheal medications, as prescribed.
(e.g., resting the GI tract, administering antipyretics as
Antipyretics can decrease fever and fluid losses from
ordered by the physician).
diaphoresis.
Begin to advance the diet in volume and composition Addition of fluid-rich foods can enhance continued
once ongoing fluid losses have stopped. interest in eating.
Patient may have restricted oral intake in an attempt to
Encourage to drink bountiful amounts of fluid as control urinary symptoms, reducing homeostatic
tolerated or based on individual needs. reserves and increasing risk of dehydration or
hypovolemia.
Educate patient about possible cause and effect of fluid Enough knowledge aids the patient to take part in his
losses or decreased fluid intake. or her plan of care.
Patient needs to understand the value of drinking extra
Enumerate interventions to prevent or minimize future
fluid during bouts of diarrhea, fever, and other
episodes of dehydration.
conditions causing fluid deficits.
Emphasize the relevance of maintaining proper Increasing the patient’s knowledge level will assist in
nutrition and hydration. preventing and managing the problem.
Teach family members how to monitor output in the An accurate measure of fluid intake and output is an
home. Instruct them to monitor both intake and output. important indicator of patient’s fluid status.
Refer patient to home health nurse or private nurse in Continuity of care is facilitated through the use of
able to assist patient, as appropriate. community resources.
Some complications of deficient fluid volume cannot
Identify an emergency plan, including when to ask for be reversed in the home and are life-threatening.
help. Patients progressing toward hypovolemic shock will
need emergency care.

Activity Intolerance: Insufficient physiologic or psychological energy to endure or complete

required or desired daily activities.

Related Factors

Any factors that compromise effective oxygen transport or physical conditioning or create
excessive energy demands that surpass the patient’s physical and psychological abilities can
cause activity intolerance. Here are some factors that may be related to Activity Intolerance:

- Generalized weakness
- Imbalance between oxygen supply and demand
- Deconditioning secondary to prolonged immobilization and pain
- Sedentary lifestyle
- Increased metabolic demands
- Inadequate energy sources
- Inactivity secondary to assistive equipment
- Increased metabolic demands
- Compromised oxygen transport
- Pain
 - Medication side effects
- Imposed activity restriction
- Depression or lack of motivation

Defining Characteristics

Activity Intolerance is characterized by an altered physiologic response to activity including the

following signs and symptoms:
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Common

- Generalized weakness
- Deconditioned state
- Sedentary lifestyle
- Depression
- Lack of motivation
- Prolonged bed rest
- Insufficient sleep
- Imposed activity restriction
- Imbalanced oxygen supply and demand
- Pain
Pulse

- Weak pulse
- Change in rhythm
- Excessively increased
Respiratory

- Exertional dyspnea
- Shortness of breath
- Excessively increased or decreased RR
Blood Pressure

- Abnormal blood pressure response to activity

- Failure to increase BP with activity

Goals and Outcomes

The nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and
assist the patient with maintaining a satisfactory quality of life. The following are the common
goals and expected outcomes for Activity Intolerance.

- Patient will exhibit tolerance during physical activity as evidenced by a normal

fluctuation of vital signs during physical activity.
- Patient will identify factors that aggravate activity intolerance.
- Patient will report the ability to perform required activities of daily living.
 - Patient will verbalize and use energy-conservation techniques.
- Patient will identify methods to reduce activity intolerance.
- Patient will maintain blood pressure within normal limits 3 minutes after activity.

INTERVENTIONS RATIONALE
Establish guidelines and goals of activity with the Motivation and cooperation are enhanced if the patient
patient and/or SO. participates in goal setting.
Coordinated efforts are more meaningful and effective
Evaluate the need for additional help at home.
in assisting the patient in conserving energy.
Have the patient perform the activity more slowly, in a
longer time with more rest or pauses, or with assistance Helps in increasing the tolerance for the activity.
if necessary.
Gradually increase activity with active range-of-motion
Gradual progression of the activity prevents
exercises in bed, increasing to sitting and then
overexertion.
standing.
Dangle the legs from the bed side for 10 to 15 minutes. Prevents orthostatic hypotension.
Refrain from performing nonessential activities or Patient with limited activity tolerance need to prioritize
procedures. important taks first.
Assisting the patient with ADLs allows conservation of
energy. Carefully balance provision of
Assist with ADLs while avoiding patient dependency. assistance; facilitating progressive endurance will
ultimately enhance the patient’s activity tolerance and
self-esteem.
Use of commode requires less energy expenditure than
Provide bedside commode as indicated.
using a bedpan or ambulating to the bathroom.
Encourage physical activity consistent with the Helps promote a sense of autonomy while being
patient’s energy levels. realistic about capabilities.
Activities should be planned ahead to coincide with the
Instruct patient to plan activities for times when they
patient’s peak energy level. If the goal is too low,
have the most energy.
negotiate.
This helps the patient to cope. Acknowledgment that
Encourage verbalization of feelings regarding
living with activity intolerance is both physically and
limitations.
emotionally difficult.
Exercise maintains muscle strength, joint ROM, and
Encourage active ROM exercises. Encourage the exercise tolerance. Physical inactive patients need to
patient to participate in planning activities that improve functional capacity through repetitive
gradually build endurance. exercises over a long period of time. Strength training
is valuable in enhancing endurance of many ADLs.
Patient may be fearful of overexertion and potential
Provide emotional support and positive attitude
damage to the heart. Appropriate supervision during
regarding abilities.
early efforts can enhance confidence.
Appropriate aids will enable the patient to achieve
Provide the patient with the adaptive equipment needed
optimal independence for self-care and reduce energy
for completing ADLs.
consumption during activity.
Teach the patient and/or SO to recognize signs of Knowledge promotes awareness to prevent
physical overactivity or overexertion. the complication of overexertion.