Congenital Heart Disease
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| Assessment data (subjective and objective findings relevant to THIS diagnosis) | Goals / expected outcomes | Nursing intervention | Rationale | Evaluation |
|---|---|---|---|---|
| Patient exhibits cyanosis, reports fatigue on exertion, shows decreased SpO2 levels (below 92%), tachypnea, and possible clubbing of fingers. | Patient will maintain adequate oxygenation with SpO2 above 92% and demonstrate reduced signs of cyanosis within 24 hours. | Monitor respiratory rate, depth, and effort every 2 hours. | Early detection of respiratory distress allows timely intervention to prevent hypoxia. | Respiratory parameters remain stable or improve, indicating effective gas exchange. |
| Assess oxygen saturation continuously using pulse oximetry. | Provides objective measurement of oxygenation status and guides oxygen therapy. | SpO2 readings remain within target range, showing improved oxygenation. | ||
| Position patient in semi-Fowler’s or Fowler’s position to facilitate lung expansion. | Improves ventilation and reduces work of breathing by maximizing lung capacity. | Patient tolerates position with decreased respiratory effort and improved oxygenation. | ||
| Encourage and assist with deep breathing and coughing exercises. | Promotes alveolar expansion and clearance of secretions to improve gas exchange. | Patient performs exercises regularly with improved breath sounds and oxygenation. | ||
| Administer supplemental oxygen as prescribed and monitor response. | Increases oxygen availability to tissues and relieves hypoxia. | Oxygen therapy results in improved SpO2 and decreased cyanosis. |
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