About
Accumulation of fluid in the lungs, usually as a result of fluid overload or Congestive Heart Failure.
Assess
Lung sounds, history of cardiac problems, recent fluid overload, respirations, pulse oximetry, vital signs.
Complications
Respiratory or cardiac arrest- start CPR.
End stage congestive heart failure
Diagnosis
- Fluid volume excess related to retention of sodium and water
- Decreased cardiac output related to impaired heart function
- Impaired gas exchange related to excessive fluid in the lungs and alveoli
- Activity intolerance related to dyspnea and chronic disease state
Goals
- The client will have adequate oxygenation.
- The client will identify symptoms that may necessitate a change in treatment protocol.
- The client will have clear breath sounds upon auscultation.
Interventions
- Assess lung sounds, vital signs, and pulse oximetry.
- Monitor intake and output, monitor daily weights ( a 2.2 pound weight gain = 1 liter of fluid gain).
- Implement fluid restrictions as ordered.
- Administer diuretics, as ordered.
- Administer other cardiac drugs to manage cardiac disease ( cardiac glycosides, antihypertensives, nitrates, etc).
- Teach client to monitor for signs of worsening; increase in daily weights, increase in shortness of breath, orthopnea, nocturia, etc).
- Teach the client to maintain a low sodium diet.
- Monitor for signs/ symptoms of complications.
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