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Este o urgen caracterizat prin instalarea rapid a uneidispnee severe:

Cardiogenic: prin creterea transudatului la nivelul alveoleipulmonare i interstiiului pulmonar, secundar creterii presiuniin atriul stng

Noncardiogenic: prin mecanism lezional alveolo-capilar pulmonar: toxic, septic, arsuri

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1. B!" C#$%"#CE: &oli coronariene '(# )orm sever *alvulopatii +ruptur de cordae, muci papilari,

endocardite, disecie aort/. #!(E C#0E: 0remie - emodializai (oxice 2 )um, gaze toxice 3eps #ltitudine

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"nsu)icien *3, cu incapacitateaacestuia de a pompa su)icientsnge n aort, ceea ce determinreducerea %C, creterea presiunii

n #3

i staz pulmonarretrograd Creterea presiunii idrostatice la

nivelul circulaiei pulmonaredetermin trecerea apei n

interstiiu, alveole, &ronii 2 aparetransudatul &rono-alveolar 3cade di)uziunea oxigenului la

nivel alveolo-capilar cu ipoxie

http://google.nucleusinc.com/enlargeexhibit.php?ID=9140http://hon.nucleusinc.com/enlargeexhibit.php?ID=9915

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#nxietate, )atiga&ilitate, senzaie de moarte iminent %ispnee sever, ortopnee, taipnee Cianoz (egumente umede, reci (use uscat n prima )az, apoi cu sput spumoas rozat+uneori

emoptoic, aerat, caracteristic (ul&urri neurologice determinate de ipoxie: o&nu&ilare,

stupoare, com

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'(# sau (# +semn ne)avora&il

(aicardie, puls alternant+semn ne)avora&il

$aluri crepitante mari 4n ploaie5 +respiraiezgomotoas, umed

0neori raluri +&ronospasm asociat

3u)luri cardiace:

http://www.google.ro/imgres?imgurl=http://www.medical-look.com/diseases_images/pulmonary_edema.jpg&imgrefurl=http://www.medical-look.com/Lung_diseases/Pulmonary_edema.html&usg=__dji3FvEdxUQ6O1uW2lkUPkxiEuQ=&h=326&w=400&sz=95&hl=ro&start=26&itbs=1&tbnid=NVZqgtrzhQQBIM:&tbnh=101&tbnw=124&prev=/images%3Fq%3Dpulmonary%2Boedema%26start%3D18%26hl%3Dro%26sa%3DN%26gbv%3D2%26ndsp%3D18%26tbs%3Disch:1http://www.google.ro/imgres?imgurl=http://www.medical-look.com/diseases_images/pulmonary_edema.jpg&imgrefurl=http://www.medical-look.com/Lung_diseases/Pulmonary_edema.html&usg=__dji3FvEdxUQ6O1uW2lkUPkxiEuQ=&h=326&w=400&sz=95&hl=ro&start=26&itbs=1&tbnid=NVZqgtrzhQQBIM:&tbnh=101&tbnw=124&prev=/images%3Fq%3Dpulmonary%2Boedema%26start%3D18%26hl%3Dro%26sa%3DN%26gbv%3D2%26ndsp%3D18%26tbs%3Disch:1

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1. EC6: "7# , iscemie sau modi)icri nespeci)ice

/. $x. toracic: Cardiomegalie

8. 7ar9eri &iologici: (n"

. Ecocardiogra)ie: ;E scazuta, '(.reexpansiune pulmonar &rusc +evacuare

intempestiv

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#ezare pacient n ortopnee #cces venos 7onitorizarea emodinamic i respiratorie

(ratament etiologic - antidot $eecili&rare volemic cu soluii cristaloide N0 %"0$E("CEJaccentueaz ipovolemia xigenoterapie: masc cu rezervor

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%in intoxica ii: - scoaterea din mediul toxic - antidot atunci cnd exist - ventila ia mecanic la nevoie

%e origine in)ec ioas:- oxigenoterapie - tonicardiace - corticoterapie

- anti&ioterapieCN($#"N%"C#(K 7$;"N#A

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%e cauze neurologice:- tratament simptomatic-Nu se mai practic: sngerarea a&undent

+8??-=??ml-diurez osmotic cu 7anitol i ;urosemid !a uremici:

-oxigenoterapie

-tonicardiace-dializ

CN($#"N%"C#(K 7$;"N#A

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"atrogen:-nu se mai practic: emisia de snge +8??-=??ml-)urosemid-doz ini ial /? -F? mg i.v.

!a neca i:

-oxigenoterapie cu ;i/ 1?? sau oxigeniper&ar

- "( cu *7 n )uncie de valoarea gazelor

arteriale- administrare de cristaloide pentru re)acereavolemiei, controlul (.#.

Contraindicate sunt diureticele i sngerareaA

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Hnsoit de un medic

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NEVOIAALTERAT

MANIFESTAREA DEDEPENDEN

PROBLEMA DEDEPENDEN

DIAGNOSTIC DENURSING

SURSA DEDIFICULTATE

Nevoia de a

respira si a aveao buna circulatie

%ispnee severa(aipneertopnee

(use, cianoza(egumente umede, reci

$$L/M@min

%ispneeCirculatie inadecvata

%i)icultate de arespire datorita

prezentei secretiilor

&structia cailorrespiratorii prin edem

alveolar si ipersecretie#nxietate

Nevoia de aelimina fluide

(ranspiratii reciEdeme

Eliminare inadecvatacalitativ

Edeme ale mem&relordatorita circulatiei

inadecvate

Edemul alveolar pulmonar

Nevoia de a se

misca si a avea obuna postura

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DIAGNOSTICUL DENURSING

OBIECTIVE INTERVENTII DE NURSING EVALUARE

DIFICULTATEA DE ARE!IRA DAT"RITA

!RE#ENTEI ECRETIIL"R

#meliorarea dispneii$educerea secretiilor &ronsice

-#sigurare ventilatie in camera-"i aspir secretiile si curat gura &olnavului

- #plic oxigenoterapie pe masca cu rezervor >-1?l@min

- #dministrez Nitroglicerina

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"nsu)icien a respiratorie acut impune

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de)iniia edemului pulmonar acut recunoaterea semnelor clinice ale edemului pulmonar acut aplicarea msurilor de urgen speci)ice $ecunoaterea complicaiilor