1. The patient was experiencing impaired gas exchange and difficulty breathing due to impaired perfusion to the myocardium from left ventricular failure.
2. Nursing interventions included elevating the head of the bed, encouraging deep breathing exercises, listening to breath sounds, and assisting with procedures to improve oxygenation and ventilation.
3. The goal was for the patient to demonstrate improved breathing, oxygenation, and understanding of their condition within 8 hours.
1. The patient was experiencing impaired gas exchange and difficulty breathing due to impaired perfusion to the myocardium from left ventricular failure.
2. Nursing interventions included elevating the head of the bed, encouraging deep breathing exercises, listening to breath sounds, and assisting with procedures to improve oxygenation and ventilation.
3. The goal was for the patient to demonstrate improved breathing, oxygenation, and understanding of their condition within 8 hours.
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1. The patient was experiencing impaired gas exchange and difficulty breathing due to impaired perfusion to the myocardium from left ventricular failure.
2. Nursing interventions included elevating the head of the bed, encouraging deep breathing exercises, listening to breath sounds, and assisting with procedures to improve oxygenation and ventilation.
3. The goal was for the patient to demonstrate improved breathing, oxygenation, and understanding of their condition within 8 hours.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online from Scribd
CRITERIA Impaired gas Perfusion to the After 8 hours of Goal – met S- exchange r/t myocardium is often nursing intervention when patient “nahihirapang ventilation impaired with left the patient will be Independent: was able to huminga ang perfusion ventricular failure, able to: demonstrate aking anak” imbalance. and especially with 1. Elevated head of bed/ 1. To maintain airway improved as verbalized cardiac hypertrophy. 1. Demonstrate position client ( Deonges; 2006: ventilation and by the As the amount of improved appropriately, provide P267) adequate patients blood ejected from ventilation airway adjuncts and oxygenation of mother. the left ventricle and adequate suction as indicated. tissues by HBGs diminishes, oxygenation within clients hypostatic pressure of tissues by 2.Encouraged frequent normal limits builds in the HBGs within deep breathing/ coughing 2. Promotes optimal pulmonary venous clients normal exercises. chest expansion and system and results in limits drainage of O- Patient is fluid-filled alveoli secretions. restless. Rate, and pulmonary 2. Participate in (Deonges;2006:P26 rhythm and congestion. treatment 3. auscultated breath 8) depth of (Ignatavicius; 2006: regimen(e.g, sounds noting crakles, breathing is p753) breathing wheezes 3. Reveals presence abnormal. exercises, of pulmonary Nasal flaring effective congestion/ collection was noted. coughing, use of secretion, of oxygen) Collaborative: indicating need for V/S: within level of further intervention. BP: 130/100 ability/situatio 1. Assisted with (Deonges;2006: mmHg n. procedures as individually P268) T: 36.6 ˚C indicated ( e.g., P: 160 bpm 3. Verbalize transfusion, phlebotomy, R: 60 cpm understanding bronchoscopy 1. to improve of causative respiratory function/ factors and oxygen-carrying appropriate capacity intervention. (Deonges;2006:P268)