About
Failure of the right ventricle causing systemic congestion and edema in the periphery.
Assess
Loss of appetite, JVD, peripheral edema, hepatomegaly, enlarged spleen, weight gain, blood pressure abnormalities, nausea
Complications
Multisystem organ failure, end stage disease
Diagnosis
- Impaired gas exchange related to pulmonary congestion
- Decreased cardiac output related to pump failure of ventricle
- Activity intolerance related to oxygen supply/ demand imbalances
- Excess fluid volume related to mechanical factors
Goals
- The client will remain free from injury.
- The client will maintain acceptable fluid balance.
- The client will identify symptoms that may necessitate a change in treatment protocol.
Interventions
- Monitor vitals, pulse oximetry, Intakes/ outputs, daily weights, circulation, edema, breath sounds frequently.
- Implement fluid restrictions as ordered.
- Administer diuretics, as ordered.
- Administer other drugs to manage cardiac disease ( cardiac glycosides, antihypertensives, nitrates, etc.).
- Teach client medication side-effects, rationale, and adverse reactions.
- Teach client activities to prevent post-operative complications including coughing and deep breathing, early ambulation.
- Teach client to monitor for signs of worsening; increase in daily weights, increase in peripheral edema, shortness of breath, orthopnea, nocturia, etc.
- Monitor for signs/ symptoms of complications.
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