Impaired Gas Exchange related to pulmonary congestion secondary change in alveolar capillary membrane and fluid retention interstisiil.
Goal:
Maintain adequate ventilation and oxygenation in
Action :
Rational :
Read More :
Nursing Care Plan for Cardiac Decompensation
Goal:
Maintain adequate ventilation and oxygenation in
Action :
- Assess the respiratory work (frequency, rhythm, sound and depth)
- Provide additional Oxygenation 6 liters / minute
- Monitor saturation (oximetry) PH, BE, HCO3
- Correction of acid-base balance
- Give a position that allows clients improve lung expansion. (Semi-Fowler)
- Prevent atelectasis by exercising effective coughing and deep breathing
- Perform fluid balance
- Limit fluid intake
- Eavluasi radiographic pulmonary congestion through
Rational :
- To determine the effectiveness of gas exchange function.
- To increase the concentration of oxygen in the gas exchange process.
- To determine the level of oxygenation in tissues as a result of the adequacy of gas exchange process.
- Prevent acidosis which can aggravate respiratory function.
- Enhance lung expansion
- Heavy congestion will worsen perukaran process gas so the impact on the onset of hypoxia.
- Increases contractility of heart muscle that can decimate Odem thus prevents the onset of gas exchange impairment.
Read More :
Nursing Care Plan for Cardiac Decompensation
