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Nursing Diagnosis for Rheumatic Heart Disease Risk for Impaired Gas Exchange

Risk for Impaired Gas Exchange related to the accumulation of blood in the lungs due to increased atrial filling

Goal: risk for impaired gas does not occur

Expected outcomes:

Demonstrating adequate ventilation and oxygenation of the tissue, indicated by blood gas analysis / oximetry in the normal range and free of symptoms of respiratory distress.
Participate in a treatment program within the ability / situation.


Intervention and rationale:

1. Auscultation of breath sounds, note: crackles, mengii.
2. Instruct the patient to cough effectively, breathing deeply.
3. Maintain a semi-Fowler position, chock the hand with a pillow if possible
4. Collaboration in the provision of supplemental oxygen as indicated.
5. Collaboration for the examination of blood gas analysis.
6. Collaboration for the administration of diuretics.
7. Collaboration for the administration of bronchodilator drugs.

Rational:

1. Stating pulmonary congestion / collecting secretions indicate the need for further intervention.
2. Clearing the airway and facilitate the flow of oxygen.
3. Lowering the oxygen consumption / needs and enhance maximum lung expansion.
4. Increasing alveolar oxygen concentration, which can improve / lower tissue hypoxemia.
5. Can be severe hypoxemia during pulmonary edema.
6. Lowers alveolar congestion, improve gas exchange.
7. Increasing the flow of oxygen to dilate small airways and emit a mild diuretic effect to reduce pulmonary congestion.

Risk for Impaired Gas Exchange - Nursing Diagnosis for Rheumatic Heart Disease
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