The nurse assesses an adult client with the nursing diagnosis of "impaired gas exchange.". Which assessment data does the nurse use to determine if the client's plan of care is effective?
1. SaO2 of 88%
2. Pink nail beds
3. Asymmetrical excursion
4. Intercostal retractions present
2
2. Nail beds are pink from adequate oxygenation unless the vessels vasoconstrict from another unrelated factor such as cold body temperature.
1. SaO2 at 88% is inadequate, representative of impaired gas exchange, and represents a PaO2 much less than 80 mm Hg (the lower limit for the partial pressure of oxygen in arterial blood).
3. Asymmetrical excursion of the chest or diaphragm is abnormal and affects gas ex-change by inadequate ventilation.
4. Intercostal retractions indicate increased work of breathing from hypoxia and imply that the exchange of gases is inadequate; the client is starved for oxygen and works hard to increase blood oxygenation.
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