NCP Heart Failure - Risk for Impaired Skin Integrity

Nursing Diagnosis Risk for impaired skin integrity> related to pitting edema.

Expected outcomes:
clients can demonstrate behaviors / techniques to prevent skin damage.
Maintaining the integrity of the skin.

Interventions:

1. Change position often in bed / chair, assistive range of motion exercises passive / active.
2. Provide frequent skin care, minimizing the moisture / excretion.
3. Check narrow shoes / sandals and change as needed.
4. Monitor skin, bone protrusion noted, edema, impaired circulation area / pigmentation or overweight / underweight.
5. Massage the area red or white.

Rational:

1. Improving circulation / lowering an area that interfere with blood flow.
2. Too dry or moist skin damage and accelerating damage.
3. Dependent edema can cause the shoe is too narrow, increasing the risk of stress and damage to the skin on the feet.
4. Lowering the pressure on the skin, improve circulation.
5. Skin disorders are at risk due to the peripheral circulation, physical immobilization and impaired nutritional status. Increase blood flow, minimizing tissue hypoxia.

Source :

http://list-nanda-nursing-diagnosis.blogspot.com/2013/01/risk-for-impaired-skin-integrity-ncp.html

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.