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A 6-year-old girl is brought to the emergency department by her parents. The child appeared pale, dyspnic, edematous, pulse of 115 bpm, respirations of 38, and oxygen saturation of 80. Apical heart rate displaced down and laterally. Lungs have harsh rhonchi and rales on auscultation. A diagnosis of Congestive heart failure is made. What is the first priority intervention the nurse should do?

Explanation

•The child is showing signs of poor oxygenation and perfusion. Administering oxygen will enhance the body's supply without increasing demand. This is the priority nursing action in order to reduce tissue damage due to hypoxia.

•If the child has dyspnea, hypoxemia, or cyanosis, supplemental oxygen via hood, mask or nasal prongs is usually necessary.

•Administration of drugs as ordered to strengthen heart action and diuretics reduce fluid overload.

•Continuous cardiac monitoring provides objective evidence of cardiac function.

•Arterial blood gases and pulse oximetry provide information of tissue oxygenation.

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