Impaired Gas Exchange

Assessment

Subjective:
His wife estimated
that he was
unconscious, with
open eyes and
jerking movements,
for
approximately 10
minutes
Objective:
- Syncope
- Edema
- Functional Left
ventricular outflow
obstruction
exacerbated by
afterload reduction
- Diuresis
- Presence of
ejection murmur
- Crackles in lungs
- Elevated BUN

Diagnosis
Ineffective Tissue
Perfusion related to
decrease in peripheral
blood circulation

Nursing Intervention

Independent:
1. Assess for signs of decreased tissue
perfusion.
2. Review laboratory data (ABGs, BUN,
creatinine, electrolytes, international
normalized ratio, and prothrombin time)
3. Check respirations and absence of work of
breathing.
4. Use pulse oximetry to monitor oxygen
saturation and pulse rate.
5. Check Hgb levels
6. Check for pallor, cyanosis, mottling, cool or
clammy skin. Assess quality of every pulse.
7. Check for optimal fluid balance.
8. Note urine output.
9. Maintain optimal cardiac output.
10.
When patient experiences dizziness due
to orthostatic hypotension when getting up,
educate methods to decrease dizziness, such
as remaining seated for several minutes
before standing, flexing feet upward several
times while seated, rising slowly, sitting down
immediately if feeling dizzy, and trying to
have someone present when standing.

11.
Assist with position changes.
12.
Elevate edematous legs as ordered and
ensure that there is no pressure under the
knee.