Cardiac Decompensation is a condition of congestive heart failure in which the heart is unable to ensure adequate cellular perfusion in all parts of the body without assistance. Causes may include myocardial infarction, increased workload, infection, toxins, or defective heart valves.
Nursing Diagnosis Nursing Care Plan Cardiac Decompensation
Impaired Gas Exchange related to pulmonary congestion, secondary to changes in alveolar capillary membrane and interstitial fluid retention.
Definition : Impaired Gas Exchange
Circumstances where an individual has decreased course of gas (O2 and CO2) that an actual or risk of lung alveoli and the vascular system.
Circumstances where an individual has decreased course of gas (O2 and CO2) that an actual or risk of lung alveoli and the vascular system.
Goal :
- Maintain ventilation and oxygenation are adequate,
- Normal blood pH,
- PO 2 80-100 mmHg,
- PCO2 35-45 mm Hg,
- HCO3 -3 - 1.2
Nursing Interventions :
- Assess the respiratory work (frequency, rhythm, sound and depth)
- Provide additional oxygenation
- Monitor saturation (oximetry) PH, BE, HCO3
- Correction of acid-base balance
- Give a position that allows clients improve lung expansion. (Semi-Fowler)
- Prevent atelectasis with the train effective coughing and deep breathing
- Perform fluid balance
- Limit fluid intake
- Eavluasi radiographic pulmonary congestion through
