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NCP Impaired Gas Exchange — Heart Failure (CHF)

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NURSING DIAGNOSISRisk factors may include

  • Alveolar-capillary membrane changes, e.g., fluid collection/shifts into interstitial space/alveoli

Possibly evidenced by

  • [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes
Respiratory Status: Gas Exchange (NOC)

  • Demonstrate adequate ventilation and oxygenation of tissues by ABGs/oximetry within patient’s normal ranges and free of symptoms of respiratory distress.
  • Participate in treatment regimen within level of ability/situation.

Nursing Interventions & Rationale

Nursing Interventions Rationale
 Auscultate breath sounds, noting crackles, wheezes.  Reveals presence of pulmonary congestion/collection of secretions, indicating need for further intervention.
 Instruct patient in effective coughing, deep breathing.  Clears airways and facilitates oxygen delivery.
 Encourage frequent position changes.  Helps prevent atelectasis and pneumonia.
 Maintain chair/bedrest, with head of bed elevated 20–30 degrees, semi-Fowler’s position. Support arms with pillows.  Reduces oxygen consumption/demands and promotes maximal lung inflation.
 Monitor/graph serial ABGs, pulse oximetry.  Hypoxemia can be severe during pulmonary edema. Compensatory changes are usually present in chronic HF. Note: In patients with abnormal cardiac index, research suggests pulse oximeter measurements may exceed actual oxygen saturation by up to 7%.
 Administer supplemental oxygen as indicated.  Increases alveolar oxygen concentration, which may correct/reduce tissue hypoxemia.
Administer medications as indicated:
Diuretics, e.g., furosemide (Lasix)Bronchodilators, e.g., aminophylline
Reduces alveolar congestion, enhancing gas exchange.
Increases oxygen delivery by dilating small airways, and exerts mild diuretic effect to aid in reducing pulmonary congestion.