Skip to main content

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

Popular posts from this blog

Ineffective Breastfeeding Nursing Interventions and Rationales

Nursing Interventions and Rationales Refer to care plan for Effective Breastfeeding 1. Assess for presence/absence of related factors or conditions that would preclude breastfeeding. Some conditions (e.g. certain maternal drugs, maternal HIV-positive status, infant galactosemia) may preclude breastfeeding, in which case the infant needs to be started on a safe alternative method of feeding (Riordan, Auerbach, 2000; Lawrence, 2000). 2. Assess breast and nipple structure. Normal nipple and breast structure or early detection and treatment of abnormalities with continuing support are important for successful breastfeeding (Vogel, Hutchison, Mitchell, 1999). 3. Evaluate and record the mother's ability to position, give cues, and help the infant latch on. Correct positioning and getting the infant to latch on is critical for getting breastfeeding off to a good start and contributes to breastfeeding success (Duffy, Percival, Kershaw, 1997; Brandt, Andrews, Kvale, 1998)

NANDA Ineffective Health Maintenance

NANDA Definition: The inability to identify, manage, or seek out help to maintain health Defining Characteristics: History of lack of health-seeking behavior;  reported or observed lack of equipment, financial, and/or other resources;  reported or observed impairment of personal support systems;  expressed interest in improving health behaviors;  demonstrated lack of knowledge regarding basic health practices;  demonstrated lack of adaptive behaviors to internal and external environmental changes;  reported or observed inability to take responsibility for meeting basic health practices in any or all functional pattern areas Related Factors: Disabled family coping, perceptual-cognitive impairment (complete or partial lack of gross or fine motor skills);  lack of or significant alteration in communication skills (written, verbal, or gestural);  unachieved developmental tasks;  lack of material resources;  dysfunctional grieving;  disabling spiritual distress;  inabi

Intracranial Tumor - Nursing Diagnosis and Interventions

Assessment for Brain Tumor (Intracranial Tumor) Focal neurological disorders. In the frontal lobe, occurred personality disorders, affective disorders, the motor system dysfunction, seizures, aphasia. Precentral gyrus can be found on Jacksonian seizures. In the occipital lobe, visual disturbances, and headache. Temporal lobe can occur auditory hallucinations, visual or gustatory and psychomotor seizures, aphasia. In the parietal lobe can be found the inability to distinguish left – right, sensory deficit (contralateral). Increased ICT: lethargy, decreased HR, decreased level of consciousness, papilledema, projectile vomiting, seizures, changes in breathing patterns, changes in vital signs. Mental. Personality changes, depression, decreased memory and ability to make decisions. Pituitary dysfunction. Cushing’s syndrome, acromegaly, giantisme, hypopituitarism. Pain. Persistent headache. Seizure activity. Fluid status. Nausea and vomiting, decreased urine output, dry muc