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Risk for Impaired Gas Exchange related to Congestive Heart Failure

Nursing Diagnosis: Risk for Impaired Gas Exchange related to changes in alveolar capillary membrane due to a buildup of fluid in the lung cavity

Purpose:

After nursing actions on the client, with the expected outcomes:
Looks adequate ventilation and oxygenation of the tissues in which normal limits, and free from symptoms of respiratory distress.
Participate in treatment.

Interventions:
  • Auscultation breath sounds, note the wheezing.
  • Teach the client to cough effectively and breathe deeply.
  • Adjust the position of sleeping with the head elevated 200-300, semi-Fowler, put a pillow on the elbow.
  • Give medications as indicated.
  • Provide oxygen as needed.
Rational:
  • Indicate the presence of congestive lung / collection secretion.
  • Clearing the airway and facilitate the exchange of oxygen.
  • Reducing the need for oxygen and improve lung development to the fullest.
  • Increasing the concentration of oxygen alveoli, which may reduce tissue hypoxemia.
  • Bronchodilator, increase oxygen intake by widening the airway and commercialize a diuretic effect on the reduction of pulmonary failure.

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