Respiratory acidosis, an elevation in the PaCO2 level, is caused by hypoventilation with resultant excess carbonic acid. Acidosis can be due to or associated with primary defects in lung function or changes in normal respiratory pattern. The disorder may be acute or chronic.
Nursing Care Plan
Impaired Gas Exchange
May be related to
- Ventilation perfusion imbalance (altered oxygen-carrying capacity of blood, altered oxygen supply, alveolar-capillary membrane changes, or altered blood flow)
Possibly evidenced by
- Dyspnea with exertion, tachypnea
- Changes in mentation, irritability
- Hypoxia, hypercapnia
- Demonstrate improved ventilation and adequate oxygenation of tissues as evidenced by ABGs within patient’s acceptable limits and absence of symptoms of respiratory distress.
- Verbalize understanding of causative factors and appropriate interventions.
- Participate in treatment regimen within level of ability/situation.
|Monitor respiratory rate, depth, and effort.||Alveolar hypoventilation and associated hypoxemia lead to respiratory distress or failure.|
|Auscultate breath sounds.||Identifies areas of decreased ventilation (atelectasis) or airway obstruction and changes as patient deteriorates or improves, reflecting effectiveness of treatment, dictating therapy needs.|
|Note declining level of consciousness.||Signals severe acidotic state, which requires immediate attention. Note: In recovery, sensorium clears slowly because hydrogen ions are slow to cross the blood-brain barrier and clear from cerebrospinal fluid and brain cells.|
|Monitor heart rate and rhythm.||Tachycardia develops early because the sympathetic nervous system is stimulated, resulting in the release of catecholamines, epinephrine, and norepinephrine, in an attempt to increase oxygen delivery to the tissues. Dysrhythmias that may occur are due to hypoxia (myocardial ischemia) and electrolyte imbalances.|
|Note skin color, temperature, moisture.||Diaphoresis, pallor, cool or clammy skin are late changes associated with severe or advancing hypoxemia.|
|Encourage and assist with deep-breathing exercises, turning, and coughing. Suction as necessary. Provide airway adjunct as indicated. Place in semi-Fowler’s position.||These measures improve lung ventilation and reduce or prevent airway obstruction associated with accumulation of mucus.|
|Restrict use of hypnotic sedatives or tranquilizers.||In the presence of hypoventilation, respiratory depression and CO2 narcosis may develop.|
|Discuss cause of chronic condition (when known) and appropriate interventions and self-care activities.||Promotes participation in therapeutic regimen, and may reduce recurrence of disorder.|
|Assist with identification or treatment of underlying cause.||Treatment of disorder is directed at improving alveolar ventilation. Addressing the primary condition (oversedation, lung and respiratory system trauma, pulmonary edema, aspiration) promotes correction of the acid-base disorder.|
|Monitor and graph serial ABGs, pulse oximetry readings; Hb, serum electrolyte levels.||Evaluates therapy need and effectiveness. Note: Bedside pulse oximetry monitoring is used to show early changes in oxygenation before other signs or symptoms are observed.|
|Administer oxygen as indicated. Increase respiratory rate or tidal volume of ventilator, if used.||Prevents and corrects hypoxemia and respiratory failure. Note: Must be used with caution in presence of emphysema because respiratory depression or failure may result.|
|Assist with ventilatory aids: IPPB in conjunction with bronchodilators. Monitor peak flow pressure.||Increases lung expansion and opens airways to improve ventilation, preventing respiratory failure.|
|Maintain hydration (IV/PO) and provide humidification.||Assists in correction of acidity and thinning and mobilization of respiratory secretions.|
|Provide appropriate chest physiotherapy, including postural drainage and breathing exercises.||Aids in clearing secretions, which improves ventilation, allowing excess CO2 to be eliminated.|
|Administer IV solutions such as lactated Ringer’s solution or 0.6 M solution of sodium lactate.||May be useful in nonemergency situations to help control acidosis, until underlying respiratory problem can be corrected.|
|Administer medications as indicated:|
|Naloxone hydrochloride (Narcan)||May be useful in arousing patient and stimulating respiratory function in presence of drug overdose and sedation, or acidosis resulting from cardiac arrest.|
|Sodium bicarbonate (NaHCO3)||May be given in small IV doses in emergency situations to quickly correct acidosis if pH is less than 7.25 and hyperkalemia coexists. Note: Rebound alkalosis or tetany may occur.|
|Potassium chloride (KCl)||Replaces potassium that shifts out of cells during acidotic state. Correction of the acidosis may cause a relative serum hypokalemia as potassium shifts back into cells. Potassium imbalance can impair neuromuscular or respiratory function, causing generalized muscle weakness and cardiac dysrhythmias.|
|Bronchodilators||Helps open constricted airways to improve gas exchange.|
|Provide low-carbohydrate, high-fat diet (Pulmocare feedings), if indicated.||Helps reduce CO2 production and improves respiratory muscle function and metabolic homeostasis.|
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other nursing care plans related to endocrine system and metabolism disorders:
- Acid-Base Balance
- – Respiratory Acidosis Nursing Care Plan
- – Respiratory Alkalosis Nursing Care Plan
- – Metabolic Acidosis Nursing Care Plan
- – Metabolic Alkalosis Nursing Care Plan
- Addison’s Disease | 3 Care Plans
- Cushing’s Disease | 6 Care Plans
- Diabetes Mellitus Type 1 (Juvenile Diabetes) | 4 Care Plans
- Diabetes Mellitus Type 2 | 17 Care Plans
- Diabetic Ketoacidosis (DKA) and Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) | 4 Care Plans
- Eating Disorders: Anorexia & Bulimia Nervosa | 7 Care Plans
- Fluid and Electrolyte Imbalances | 10 Care Plans
- – Fluid Balance: Hypervolemia & Hypovolemia
- – Potassium (K) Imbalances: Hyperkalemia and Hypokalemia
- – Sodium (Na) Imbalances: Hypernatremia and Hyponatremia
- – Magnesium (Mg) Imbalances: Hypermagnesemia and Hypomagnesemia
- – Calcium (Ca) Imbalances: Hypercalcemia and Hypocalcemia
- Gestational Diabetes Mellitus | 4 Care Plans
- Hyperthyroidism | 7 Care Plans
- Hypothyroidism | 3 Care Plans
- Obesity | 4 Care Plans
- Thyroidectomy | 5 Care Plans