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Assessment Diagnosis Planning Intervention Rationale Evaluation
Assessment Diagnosis Planning Intervention Rationale Evaluation
Assessment Diagnosis Planning Intervention Rationale Evaluation
Auscultate heart
sounds; note
rate, rhythm, The new onset of
presence of S3, a gallop rhythm,
S4, and lung tachycardia, and
sounds. fine crackles in
lung bases can
indicate onset of
heart failure. If
patient develops
pulmonary
edema, there will
be coarse crackles
on inspiration an
d severe dyspnea.