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학습 자료 둘러보기 →A report of sudden onset severe shortness of breath in a patient with chronic heart failure is a critical sign of acute decompensated heart failure and potential pulmonary edema. This directly compromises the Breathing component of the ABC framework, making it the highest priority.
Immediate nursing actions include assessing oxygen saturation, breath sounds (for crackles), and vital signs. Administer oxygen to maintain SpO2 above 92%, position the patient upright, and prepare for interventions like diuretics and non-invasive ventilation.
An acute change in baseline is a red flag. A patient with acute pulmonary edema can deteriorate rapidly to respiratory failure. Do not delay assessment for other tasks; this is a life-threatening emergency.
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