About
Enlargement of the right ventricle of the heart due to chronic lung disease, leads to right ventricular failure.
Assess
Dyspnea, chest discomfort, pain pressure, Jugular venous distention, activity intolerance, abnormal heart and/ or lung sounds, crackles, rhonchi, hypoxia, anxiety, restless, confusion.
Complications
Respiratory or cardiac arrest- start CPR.
End stage congestive heart failure
Diagnosis
- Impaired gas exchange related to pulmonary congestion
- Decreased cardiac output related to pulmonary/ cardiac alterations
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).
- Teach client to monitor for signs of worsening; increase in daily weights, increase in shortness of breath, orthopnea, nocturia, etc.
- Administer diuretics, as ordered.
- Administer oxygen as ordered.
- Monitor for signs/ symptoms of complications.
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