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Transcript of For Printing Grand Case Group1 (1)
A Case Study in Congestive Heart Failure
Presented To
The Faculty of the College of Nursing
University of Perpetual Help System DALTA
Alabang- Zapote Road, Las Pinas City
In Partial Fulfillment of the Requirements
In NCM 104 – RLE
Submitted By:
Abad, Maria Angelica S.Abangan, Daryl Rey A.
Abarca, Weena Czarina Mae PAgnir, Marc Kharis G.Alindogan, Angelica P.Arcilla, Rinald Franz R.Argosino, Caszandra G.
Arip, Sharmina B.Babasa, Carmen G.Bareno, Abigail R.Barrazona, Tricia S.
Mrs. Gracila Ucag-Decena, RN, MANClinical Instructor
February 2012
1
TABLE OF CONTENTS
I. Introduction 3
II. Patient’s profile 4
III. Genogram 5
IV. Nursing History 6
V. Physical Examination 9
VI. Diagnostic/Laboratory Examination 14
VII. Clinical Findings 16
VIII. Anatomy and Physiology/Pathophysiology 17
IX. Problem Prioritization 20
X. Nursing Diagnosis 20
XI. Nursing Care Plan 21
XII. Drug Study 29
XIII. Discharge Planning 34
XIV. Reference/Bibliography 36
2
I. INTRODUCTION
Patient R.C.S is admitted at the University of Perpetual Help Medical Center with a chief
complaint of Easy Fatigability. His admitting diagnosis is T/C CHF FC II, UTI HASCVD
Congestive heart failure (CHF) is a condition in which the heart's function as a pump is
inadequate to meet the body's needs. Signs and symptoms include fatigue, excess fluid in the
lungs and shortness of breath, constipation, dizziness, sore throat, neck pain and lower back pain,
along with headaches. Interventions on CHF would be such of lifestyle modifications, medicines
and heart transplant. On the other hand UTI or urinary tract infection is an infection caused by
pathogenic organisms such as bacteria, fungi, or parasites. In any of the structures that comprise
the urinary tract. Signs and symptoms include painful and burning urination, cloudy and strong-
smelling urine, pelvic pain for women and rectal pain on men. Treatment for thus include
antibiotic therapy.
We handled patient R.C.S during his second day at the hospital. We rendered nursing
interventions such as established rapport, assessed patient’s overall and current status,
regulatated and monitored intravenous fluid, due oral meds given, monitored intake and output,
we also rendered health teaching for the enhancement of his health condition, vital signs taken
and recorded, administered and monitored oxygen inhalation, performed physical assessment,
interviewed patient using Gordon’s Functional Health Pattern to provide baseline data.
Our purpose for accomplishing this case study is to provide further information to other
students as well as nurses that may also need this case study in the future. It will also improve the
quality of care rendered by nurses to patient. We also aim to prolong the lives of the patients.
Lastly, it sets us to learn, enhance and gain knowledge, as well as helps patients to understand
their current condition.
3
II. PATIENT’S PROFILE
Patient’s Name: R.C.S
Address: 31 Manggahan Burgos Street Laspinas City
Sex: Male
Civil Status: Widowed
Age: 79
Birthday: April 7, 1932
Occupation: Retired
Nationality: Filipino
Religion: Roman Catholic
Admission Date: January 30, 2012 Admission Time: 8:30 pm
Institution: University of Perpetual Help Dalta Medical Center
Physician: Dr. Rodriguez, Andrei Rhonel
Admitting Diagnosis: T/C CHF FC II, UTI HASCVD
Final Diagnosis: CHF FC II, UTI
Chief Complain: Easy Fatigability
4
III. GENOGRAM
5
GM GFGF
GG
GM
?? G
G GB Pt..
B
Legend: GM: Grandmother GF: Grandfather B: Boy G: Girl
: Hypertension : Diabetic : Deceased ?? : Unknown number
G
IV. NURSING HISTORY
Three days prior to admission, patient R.C.S. was noted to have occasional episodes of
easy fatigability with dyspnea. No other associated symptoms such as chest pain or fever noted.
No consultation were done and no medications were taken. Few hours prior to admission, patient
still with episodes of easy fatigability sought consult at Jonelta OPD, then was later transferred to
ER of University of Perpetual Help Dalta Medical Center and was advised for admissions. (+)
Angiogram (Feb 2011), (+) Inguinal Hernia (year unknown), (-) DM, (-) HPN, (-) Asthma.
Previous chronic smoker, occasional alcoholic beverage drinker.
Pt. has undergone Coronary angiography and left ventriculography at St. Luke’s Medical
Center last February 3, 2011 with an operative diagnosis of Atherosclerotic CAD mild dse
involving proximal and mid LAP, proximal to mid RCA. Patient RS tolerated the procedure well
and was hemodynamically stable all- throughout.
6
V. GORDON’S FUNCTIONAL HEALTH ASSESSMENT
1. Health Perception
Patient R.C.S describes health as having enough energy. The reason of his health care visit is easy fatigability. He manages his condition through having adequate rest. He takes medications for his illness. Patient R.C.S. seeks health advice from a resident doctor and follows the doctor’s advice for the betterment of his health condition. Patient R.S. used to smoke and drink alcohol when he was teenager.
2. Nutritional Metabolic Patterns
Patient R.C.S. usually follows a soft diet meal such as soup and vegetables, and also observes a LFLS diet. He sometimes eats rice and meat. He also takes supplements like Centrum, a multivitamins that helps him to boost his immune system. He usually drinks water about 1 to 2 liters before, but currently limited to 500 ml per day. He sometimes experiences difficulty in swallowing when eating rice and meat while in the hospital. He has no allergy to any foods. He also has dental problems and wears dentures.
3. Elimination Pattern
Patient R.C.S. voids 5 to 6 times a day. He stated that sometimes he feels pain when urinating. The color is amber yellow. He has a bowel movement every other day. His feces are hard and color brown. He also experienced having a urinary catheter because of pain in the prostate and difficulty in urinating. He also used laxatives or suppositories before.
4. Activity Exercise Pattern
Patient R.C.S. has easy fatigability and minimal participation on the house hold chores. He used to do some light exercises. He verbalized that he often sits in front of the TV. He has a problem in ambulating due to pedal edema and pain. When he has no illness, he can do things on his own but with assistance most of the time.
5. Sleep Pattern
Patient R.C.S. usually sleeps at night around 8 to 9 o’clock and wake up at 8 o’clock in the morning. He usually takes 30 minutes to fall asleep and states that he feels like “nalulunod”. He also stated that most of the time, he is “naaalimpungatan”.
6. Cognitive – Perceptual Pattern
Patient R.C.S is able to write and read. He has hearing difficulties. He also has eye problem and uses glasses when reading. His last eyexam was a year ago. He feels chest pain sometimes.
7
7. Role Relationship Pattern
Patient R.C.S. lives with his daughter and grandchildren. His wife passed away due to liver cancer. The one that supports him financially and provides his needs are his children. His family is important to him. He said that they haven’t had any conflict in their family.
8. Coping/ Stress Tolerance
Patient R.C.S. has major changes in his life the past two years, especially when he had undergone through a Coronary Angiography Left Ventriculography. When he has problems the one that he talked to is his children. He is always relaxed at home. He used to take alcohol or smoke tobacco whenever he has problem before.
9. Value Belief Pattern
Patient R.C.S. had accomplished many things in life and thanks God for this life. He wants his grandchildren to finish their studies. And he always prays to God to give him good health in order for him to live longer and so he can spend more time with his family. He stated that his religion is important.]
10. Self-Esteem, Self-Concept, Self-Perception Pattern
Patient R.C.S describes himself as family-oriented person. He loves his family the most. He also states that he has many friends. At present, he is concerned about how will he be able to cope up with his current health condition. He also states that he is already contented with the way his life is right now in terms of his children’s conditions.
8
VI. PHYSICAL EXAMINATION
Date done: January 31, 2012Parts Techniques Used Normal Findings Actual Findings Analysis
General Survey
Body Built Inspection Proportionate Thin Due to Lack of appetite
Posture and Gait Inspection Relaxed and Erect Relaxed and Erect Normal
Hygiene and Grooming
Inspection Clean and neat Clean and neat Normal
Body Odor Inspection No odor No odor Normal
Signs of distress Interview; Inspection No distress No distress Normal
Affect or Mood Interview; Inspection Cooperative Cooperative Normal
Speech Interview Understandable Understandable Normal
Emotional state Observation Happy Happy Normal
Vital Signs
Temperature Inspection Axillary 35.5 degrees Celsius
Normal
Pulse Rate Palpation 60-100bpm: Radial 79 beats/min: Regular
Normal
Respiratory Rate Inspection 12-20cpm 29 cpm: regular Due to CHF
Blood Pressure Inspection 120/80mmHg 90/70 mmHg: Sitting
Due to the inability of the heart to pump sufficient blood around the bod,y a complication of CHF
Skin and Nails
Color Inspection Based on Race Brown Normal
9
Symmetry of Color Inspection Uniform Uniform Normal
Edema Inspection; Palpation No edema Grade 2 pitting edema
Due to CHF
Skin Lesion Inspection Smooth Smooth; Flat Nevi Normal
Moisture Inspection Moist Dry Decrease skin elasticity
Skin Turgor Palpation upon pinching
Good Poor Excess Fluid Volume
Nail Curvature Inspection Convex 160 degrees
Convex 160 degrees
Normal
Texture Inspection Smooth Smooth Normal
Nail bed color Inspection Pink and Clear Pink and Clear Normal
Surrounding Tissue Inspection Intact Intact Normal
Capillary Refill Blanch Test Less than 4 seconds
6 seconds Decreased tissue perfusion
Head
Distribution Inspection Even Uneven Due to aging
Thickness Inspection Thick Thin Due to aging
Texture and Oiliness
Inspection Silky Silky Normal
Infestations Inspection No Infestations No infestation Normal
Body Hair Inspection Sparse Leg hair Sparse leg hair Normal
Size and Shape Inspection Normocephalic Normocephalic Normal
Contour Inspection; Palpation Smooth Smooth Normal
Facial Features Inspection Symmetrical Symmetrical Normal
Eyes
Eyebrows Inspection Even distribution Even distribution Normal
10
Eye Lashes Inspection Even distribution Even distribution Normal
Pupils Inspection PERRLA PERRLA Normal
Conjunctiva Inspection Pinkish Pale Decreased tissue perfusion
Visual Acquity Inspection Able to read Able to read with glasses
Due to impaired visual acuity
Ears
Ear Canal Inspection Dry cerumen Normal
Pinna Inspection Uniform color with skin
Uniform color; Symmetrical
Normal
Hearing Acquity Inspection Intact Poor hearing Due to aging
Nose
Symmetry Inspection Symmetrical Symmetrical Normal
Nasal Cavity Inspection Septum in midline Septum in midline Normal
Sinus Tenderness Inspection Not tender Not tender Normal
Pharynx
Uvula Inspection In midline In midline Normal
Tonsils Inspection Pink and smooth Pink and smooth Normal
Gag Reflex Inspection Intact Intact Normal
Mouth
Lips Inspection; Palpation Soft and Symmetrical
Dry and symmetrical
Normal
Teeth Inspection Complete and shiny white
Dentures Due to aging
Tongue Inspection Midline Midline Normal
Palate Inspection Light pink and smooth
Light Pink and smooth
Normal
11
Neck
Muscle Inspection Equal in size Equal in size Normal
Movement Inspection Coordinated Coordinated Normal
Range of Motion Inspection Full Full Normal
Lymph Nodes Palpation Not palpable Not palpable Normal
Carotid Pulse Palpation Symmetric Pulse Symmetric Pulse Normal
Jugular Veins Inspection Not visible Not visible Normal
Chest and Lungs
Breathing Pattern Inspection; Auscultation
Quiet; Regular; Effortless
Use of accessory muscle
Accumulation of fluid in the pleural space
Shape and Symmetry
Inspection Symmetrical Symmetrical Normal
Spinal Alignment Inspection; Palpation Aligned Aligned Normal
Skin Inspection Smooth Smooth Normal
Breath Sounds Auscultation Clear Crackles Accumulation of fluid in the pleural space
Breast size and shape
Inspection Rounded Rounded Normal
Areola Inspection Rounded Rounded Normal
Nipples Inspection Round; Symmetric Round; Symmetric Normal
Heart
Precordium Auscultation Pulsation Pulsation Normal
Heart Sounds Auscultation S1 louder at S2 at Base
S3 Due to CHF
12
Abdomen
Skin Integrity Inspection Unblemished Unblemished Normal
Contour Inspection Rounded Rounded Normal
Bowel Sounds Auscultation Normoactive Normoactive Normal
Back Extremities
Muscle Size Inspection Equal Equal Normal
Muscle tone Inspection Firm Firm Normal
Muscle Strength Inspection Equal Unequal Due to aging
Bones Inspection Tenderness Tenderness Normal
Range of Motion Inspection Full Limited Due to weakness
VII. DIAGNOSTIC LABORATORY EXAMINATION
13
University of Perpetual Help DALTA Medical Alabang-Zapote Road Pamplona III, Las Pinas
Laboratory/Diagnostic Department
Name: R.S Patient No. 9BAge:79 y/o A.P: Tabang, AntonioSex: Male
DATE and
TIME
EXAMINATION RESULTS NORMAL VALUE
UNIT INTERPRETATION
1/30/12
2:12 PM
CBCRBC 3.24 4.5-6 X10^12/L Anemia
Hematocrit 0.34 0.40-0.54 L Risk for fluid volume excess
Hemoglobin 114 120-160 g/L AnemiaWBC 7.1 4.5-10 X10^9/L Normal
Stabs/Bands - 0.00-0.05 - NormalSegmenters 0.66 0.50-0.70 - Normal
Lymphocytes 0.10 0.20-0.40 % Active infection or immunodeficiency
Basophils - 0.00-0.01 % NormalMonocytes .10 0.00-0.07 % Bacterial infectionEosinophils 0.03 0.00-0.05 % Normal
Platelet count 162 150-400 x10^9/L Normal2:49 PM
BUN 10.2 3.2-7.1 mmol/L Renal problemCreatinine 88 58-110 mmol/L Normal
Mg .94 0.7-1.0 mmol/L NormalK 3.6 3.5-5 mmol/|L NormalNa 132 137-145 mmol/L r/t Fluid Volume
excess4:01 PM
Color Yellow Yellow - NormalTransparency Turbid Clear - Risk for infection
pH 6 5-7 - NormalProtein +1 none - ProteinuriaGlucose - none - Normal
Spec. Gravity 1.025 1.010-1.025 - NormalRBC 0-3HPF None - Risk for infection
Pus cell 15-20HPF None - Risk for in fectionEpithelial Few Absence or
Few- Normal
14
Bacteria M. Thread Few
Absence or few
- Normal
8:40 PMSGPT 29 21-72 U/L Normal
1/31/12
11:27 AM
FBS 5.58 4.10-5.9 mmol/L NormalCholesterol 3.39 0-5.2 mmol/L Normal
HD Lipoprotein 0.85 0-1.55 mmol/L NormalLD Lipoprotein 2.3 0-3.9 mmol/L Normal
Triglyceride .59 0-1.69 mmol/L NormalAlbumin 34 35-50 g/L Inflammation
2/4/12
1:43 PMK 4.2 3.5-5 mmol/L Normal
Examination: Chest X-ray Portable
Date: 1/30/2012
Interpretation: - Cardiomegaly, biventricular pattern
- Atheromatus Aorta
- Minimal Pleural effusion, Thickening, Left
Examination: QRS Morphology
Date: 1/30/2012
Interpretation: Inferior Myocardial Infarction and Anterior Myocardial Infarction, AGE undetermined
Examination: Chest Decubitus Portable
Date: 1/31/2012
Interpretation: (-) for pleural effusion
15
VIII. CLINICAL FINDINGS
Clinical Findings: Congestive Heart Failure
Signs and Symptoms:
Dyspnea
Tachycardia
Pedal edema
Fatigue
Pleural effusion
Nasal Flaring
Jugular venous distention
Crackles
Chest pain
Use of accessory muscle
Hypotension
Patient experienced some the above signs and symptoms of Congestive Heart Failure
which are listed above. Use of accessory muscle, Crackles, Nasal flaring, Pedal edema, and
Hypotension is evident. Chest pain and fatigue are the subjective cues verbalized by the patient.
16
IX. ANATOMY AND PHYSIOLOGY
The heart is a muscular structure with four chambers and four valves. The upper chambers,
which are filling chambers, are called the left and right atria. The lower chambers, which are
pumping chambers, are called the left and right ventricle.
Heart valves lie at the exit of each of the four heart chambers and maintain one-way blood flow
through the heart. The four heart valves make sure that blood always flows freely in a forward
direction and that there is no backward leakage.
The tricuspid valve regulates blood flow between the right atrium and right ventricle.
17
The pulmonic valve controls blood flow from the right ventricle into the pulmonary arteries,
which carry blood to the lungs to pick up oxygen.
The mitral valve lies between the left atrium and the left ventricle. It prevents blood from leaking
back into the left atrium during left ventricular contraction.
The aortic valve lies between the left ventricle and the aorta (the largest artery in the body). It
opens the way for oxygen-rich blood to pass from the left ventricle into the aorta, where it is
delivered to the rest of the body.
Blood flow through the heart
The "left" side of the heart controls the flow of oxygen-rich blood from the lungs to the entire
body. The "right" side of the heart controls the flow of oxygen-poor blood from the veins in the
body to the lungs.
Blood flows from the right and left atria into the ventricles through the open tricuspid and mitral
valves, respectively; when the ventricles are full, the mitral and tricuspid valves close. This
prevents blood from flowing backward into the atria while the ventricles contract.
As the ventricles begin to contract, the pulmonic and aortic valves are forced open and blood is
pumped out of the ventricles through the open valves into the pulmonary artery toward the lungs,
and into the aorta, to the body.
When the ventricles finish contracting and begin to relax, the aortic and pulmonic valves close.
These valves prevent blood from flowing back into the ventricles. This cycle is repeated over and
over, causing blood to flow continuously to the heart, lungs and body.
18
Pathophysiology
19
Non- Modifiable factors:
Age: 79 years old, Family history of Hypertension
Modifiable factors:
Sedentary lifestyle, smoker, alcohol drinker, high carbohydrate high fat diet
Accumulation of fatty streak in the intima of arterial wall
Decreased oxygenation of myocardium
X. PROBLEM PRIORITIZATION
1. Impaired Gas Exchange
2. Decreased Cardiac Output
3. Excess Fluid Volume
4. Risk for Injury
5. Risk for Non-compliance
20
Ischemia in the myocardium
Increased Anti-diuretic hormone
Fluid Overload
Chronic tissue congestion
Reduced myocardial contractility
Fluid RetentionIncreased Osmotic Pressure
Increased Cardiac Workload
Decreased Renal Perfusion
Sodium Retention
Decreased Cardiac output
Enlargement of the heart
Proliferation of bacteria in the Urinary tract
Urinary Retention
Urinary Tract Infection
Congestive Heart Failure
Edema
Destruction of capillaries
Impaired peripheral circulation
Hypotension
Increased preload and afterload
XI. NURSING DIAGNOSIS
A. Actual Problem
1. Impaired gas exchange related to ventilation perfusion imbalance as manifested by with oxygen of 3-
4L/min via nasal cannula,(+) Crackles @ Left lungs, (+) Nasal Flaring, Tachypneic with the RR of
29cpm, (+) Retraction, Cold clammy skin, BP of 90/70, and capillary refill (6 sec.)
2. Decreased Cardiac Output r/t as manifested by, Pitting Edema on the right foot. (10 sec) Grade is
2+, Weakness,Cold clammy skin,Capillary refill (6 sec.), Dizziness, Lethargy, BP of
90/70mmhg
3. Excess fluid volume related to water retention secondary to CHF as manifested by pitting edema on
the right foot. (10 sec) Grade is 2+, (+)Crackles @ Left lung, RR of 29cpm, BP of 90/70mmHg
B. Potential Problem
1. Risk for injury r/t altered mobility as manifested by (+) weakness, Ambulatory w/ assistance, Blurred
Vision, BP: 90/70, w/ O2 administration via cannula
2. Risk for non-compliance secondary to knowledge deficit as manifested by (+) confusion on present
condition. And frequent asking of question
21
XII. NURSING CARE PLANA. Actual
Assessment Diagnosis Planning Selected Intervention
Implemented Intervention
Rationale
Subjective: “Nahirapan akong huminga pag wala nitong oxygen.”
-Fatigue
Objective:
With oxygen of 3-4L/min via nasal cannula
(+) Crackles @ Left lung
(+) Nasal Flaring
Tachypneic with the RR of 29cpm
(+) Retraction Cold clammy
skin BP of 90/70 Capillary refill
(6 sec.)
Impaired gas exchange related to ventilation perfusion imbalance as manifested by with oxygen of 3-4L/min via nasal cannula,(+) Crackles @ Left lungs, (+) Nasal Flaring, Tachypneic with the RR of 29cpm, (+) Retraction, Cold clammy skin, BP of 90/70, and capillary refill (6 sec.)
After 6 hours of Nursing interventions the patient will be able to:
Participate in the treatment regimen such as breathing exercises.
Demonstrate improved ventilation without the presence of nasal flaring and retraction.
Respiratory rate will decrease to normal range (12-20 cpm)
Establish rapport
Assess vital signs
Monitor and regulate IV fluid
Monitor I/O
Observe skin color & nailbeds.
Auscultate breath sounds
Elevate head and the feet
Established rapport
Monitored and recorded vital signs
Monitored and regulated IV fluids
Monitored I/O
Observed skin color & nailbeds.
Auscultated breath sounds
Elevated head and the feet
Encouraged frequent
To gain trusting relationship with the patient.
Predicator of fluid balance that should be client’s usual range in healthy status
To ensure accurate fluid status and to avoid further complications that may result to fluid overload
To ensure accurate fluid status
To identify of there is a presence of vasoconstriction
To determine ascertain status and to note progress
To provide airway and venous return
To promote lung
Encourage frequent position changes and deep breathing exercises
Provided oxygen at lowest concentration as indicated
Encourage the patient to maintain adequate I/O
Promote adequate rest periods
Encourage the patient to do deep breathing exercises
Keep dry back and loosen clothing
Assist with self-care needs and ambulation
position changes and deep breathing exercises
Monitored the oxygen level of the patient
Encouraged the patient to maintain adequate I/O
Promoted adequate rest periods
Encouraged the patient to do deep breathing exercises
(Notimplemented)
(Not implemented)
expansion
To provide sufficient ventilation
To avoid further complications that may result to fluid overload
To prevent fatigue to decrease demand in oxygen
To maximize effort in breathing
To promote comfort and adequate ventilation
To provide safeness
Assessment Diagnosis Planning Selected Intervention
Implemented Intervention
Rationale
Subjective:“medyo nanghihina ako” as verbalized by the client
Objective: Pitting Edema
on the right foot. (10 sec) Grade is 2+
Weakness Cold clammy
skin Capillary refill
(6 sec.) Dizziness Lethargy BP of
90/70mmhg
Decreased Cardiac Output r/t altered preload and afterload as manifested by, Pitting Edema on the right foot. (10 sec) Grade is 2+, Weakness,Cold clammy skin,Capillary refill (6 sec.), Dizziness, Lethargy, BP of 90/70mmhg
At the end of 6 hours nursing intervention the client will manifest a BP within normal range (120/80 mmhg)
establish rapport
assessment of client’s overall condition
provide comfort measures
provide safety measures
VS taking
provide health teaching about the ff.:
> medications > adequate rest > diet
established rapport
rendered morning care
assessed client’s health status
VS taken and recorded
provided comfort measures such as:
> positioning client in a trendelenburg
reinforced safety and security measures
e.g. raised side rails up.
for client’s cooperation
for client’s comfort and hygiene
to determine changes on client’s condition
for baseline data
for clients comfort and to increase blood flow
for client’s assistance
to prevent injury
Assessment Diagnosis Planning Selected Intervention Implemented Rationale
Intervention
Objective:
Pitting Edema on the right foot. (10 sec) Grade is 2+
(+)Crackles @ Left lung
RR of 29cpm
BP of 90/70mmHg
Excess fluid volume related to water retention secondary to CHF as manifested by pitting edema on the right foot. (10 sec) Grade is 2+, (+)Crackles @ Left lung, RR of 29cpm, BP of 90/70mmHg
After 6 hours of Nursing interventions the patient will be able to:
Demonstrate adequate fluid balance AEB absence of crackles and decreasing edema
Verbalize understanding of fluid restrictions
Establish rapport
Assess vital signs
Monitor and regulate IV fluid
Monitor I/O
Auscultate breath sounds
Elevate head (patient is dyspneic) elevate affected foot with one pillow.
Weigh the patient regularly
Measure abdominal girth
Established rapport
Monitored and recorded vital signs
Monitored and regulated IV fluids
Monitored I/O
Auscultated breath sounds
Elevated head and foot
(Not implemented)
(Not
To gain trusting relationship with the patient.
Predicator of fluid balance that should be client’s usual range in healthy status
To ensure accurate fluid status and to avoid further complications that may result to fluid overload
To ensure accurate fluid status
To determine ascertain status and to note progress
To provide airway and to help the fluids move out to the extremities
Body weight is a sensitive indicator of fluid balance.
To know if fluid retention is present
implemented)
Assessment Diagnosis Planning Selected Intervention
Implemented Intervention Rationale
Subjective:“mabilis lang ako mapagod saka hirap na gumalaw parang matutumba” as verbalized by the client.
Objective: (+) weakness Ambulatory w/
assistance Blurred Vision BP: 90/70 w/ O2
administration via cannula
Risk for injury r/t altered mobility as manifested by (+) weakness, Ambulatory w/ assistance, Blurred Vision, BP: 90/70, w/ O2 administration via cannula
After 6 hours of nursing intervention the client will be able to be free from any injury such as fall.
Establish rapport
Monitor and regulate IVF
Monitor and record vital signs.
Identify contributing factors
Provide comfort
measures.
Maintain quiet and calm environment
Monitor environment for unsafe conditions.
Reinforce LSLF diet
Encourage to have adequate periods of rest.
Discuss w/
Established rapport
Monitored and regulated IVF
Monitored and recorded vital signs.
Identified contributing factors
Provide comfort measures
Maintained quiet and calm environment.
Monitored environment for unsafe conditions.
Reinforced LSLF diet
Encouraged to have adequate periods of rest.
to gain trust and confidence of the patient.
for good hydration status
Provides a baseline data.
to know different factors that may affect the client’s situation.
to self enhancement
to provide rest
to prevent factors that may harm the client.
to avoid any complications
To prevent fatigue.
Promotes early detection
family the importance of early detection and reporting of changes in condition or any unusual sign and symptoms
Discuss importance of self-monitoring of condition or emotions (fatigue, anger, irritability)
Instruct patient to call for assistance as needed.
Instruct to always have companion
(Not Implemented)
(Not Implemented)
Instructed patient to call for assistance as needed.
Instructed to always have companion.
of developing complications.
for the client to be aware that it can contribute to occurrence of injury
to ensure safety
to ensure safety
Assessment Diagnosis Planning Selected Intervention Implemented Intervention Rationale
Subjective: Risk for non- At the end of Establish rapport Established rapport. To gain patient’s trust.
“Hindi ko alam kung ano itong sakit ko sa puso, at kung bakit.” as verbalized by the patient.
Objective:
(+) confusion on present condition.
frequent asking of question.
compliance secondary to knowledge deficit as manifested by (+) confusion on present condition. And frequent asking of question.
45 minutes of health teaching the patient will be able to:
understand disease process, treatment and medication schedule.
remember the health teaching conducted with the guidance of his SO.
Render morning care and comfort measures S/A changing of linens and gown.
VS taking and monitoring.
Assess knowledge of the patient regarding his present status.
Conduct health teaching regarding safety precautions.
Conduct health teaching regarding definition of disease, signs and symptoms.
Discuss to the client together with his SO the drugs and its drug action.
Emphasize strict compliance with prescribed diet.
Emphasize to decrease fluid intake.
Rendered morning care and comfort measures S/A changing of linens and gown.
VS taken and monitored.
Assessed knowledge of the patient regarding his present status.
Conducted health teaching regarding safety precautions.
Conducted health teaching regarding definition of disease, signs and symptom.
Discussed to the client together with his SO the drugs and its drug action.
Emphasized strict compliance with prescribed diet.
Emphasized to decrease fluid intake.
To provide comfort.
To establish baseline data.
To know what to teach and explain to the client.
To prevent injury.
Used layman’s term in health teaching to prevent confusion.
To know what are the expected side effects of the drugs and to take extra precaution.
This will help to improve client’s condition.
Since the client has CHF.
XIII. DRUG STUDYGeneric Name Brand Name Mechanism of
ActionContraindications Dosage Effects and
Adverse EffectNursing
Responsibilities
Furosemide Diumide, Diuspec, Frusema, Furide, Pharmix, and Pisamor
Furosemide is a potent diuretic (water pill) that is used to eliminate water and salt from the body.
patients with anuria or who are hypersensitive to the drug.
The recommended adult daily dose of furosemide ranges from 20 mg to 200 mg. Once the effective single dose has been determined, it may be taken 1 to 3 times a day.
Common side effects of furosemide include low blood pressure, dehydration and electrolyte depletion (for example, sodium, potassium)
Increased blood sugar and uric acid levels also may occur.
Observe patients receiving parenteral drug carefully; closely monitor blood pressure and vital signs. Sudden death from cardiac event has been reported
ASA(Acetylsalicylic acid)
Aspirin, Arthritis Foundation Safety Coated Aspirin, Bayer Aspirin, Bayer Children's Aspirin, Ecotrin
Aspirin is a nonsteroidal antiinflammatory drug (NSAID) effective in treating fever, pain, and inflammation in the body. It also prevents blood clots (i.e., is antithrombotic).
People with kidney disease, hyperuricemia, or gout should not take aspirin because it inhibits the kidneys' ability to excrete uric acid, and thus may exacerbate these conditions
Adults: 325 to 500 mg P.O.q3 hrs, or 325 to 650 mg P.O. q4 hrs, or 650 to 1000 mg P.O q 6 hrs, to maximum dosage of 4,000 mg/day.
The most common side effects of aspirin involve the gastrointestinal system and ringing in the ears.
Tell patient to report ototoxicity symptoms, unusual bleeding and bruising
Tell patient not to take other over-the-counter preparations containing aspirin
Captopril Capoten Captopril is an oral drug and a member of a class of drugs
ACE inhibitors, including captopril, can be harmful to
Acute Hypertension
A dry, persistent cough has been reported commonly
Do not use salt substitutes containing
called angiotensin converting enzyme (ACE) inhibitors. ACE inhibitors are used for treating high blood pressure, heart failure, and for preventing kidney failure due to high blood pressure and diabetes.
the fetus and should not be taken by pregnant women.
12.5-25 mg PO; may repeat PRN
Hypertension
25-150 mg PO BID/TID
CHF
6.25-12.5 mg PO TID in conjunction with cardiac glycoside and diuretic therapy
Diabetic Nephropathy
25 mg PO TID
with the use of captopril and other ACE inhibitors.
Other side effects include abdominal pain, constipation, diarrhea, rash, dizziness, fatigue, headache, loss of taste, loss of appetite, nausea, vomiting, fainting and numbness or tingling in the hands or feet.
potassium.
Use two forms of birth control including hormonal and barrier methods.
Avoid NSAIDs; may be present in OTC preparations.
Ciprofloxacin Cipro, Cipro XR, Proquin XR
Ciprofloxacin Ciprofloxacin stops the multiplication of bacteria by inhibiting the reproduction and repair of their genetic material (DNA).
Ciprofloxacin is contraindicated in persons with a history of hypersensitivity to ciprofloxacin, any member of the quinolone class of antimicrobial agents, or any of the product components.
500-750mg PO every 12 hr
The most frequent side effects of ciprofloxacin include nausea, vomiting, diarrhea, abdominal pain, rash, headache, and restlessness.
Rare allergic reactions have been described, such as
If an antacid is needed, take it at least 2 hours before or after dose
Drink plenty of fluids while your taking this drug
hives and anaphylaxis (shock).
Omeprazole omeprazole/sodium bicarbonate, Prilosec, Zegerid
Omeprazole is in a class of drugs called proton pump inhibitors (PPI) that block the production of acid by the stomach.
Are contraindicated in patients with known hypersensitivity to any component of the formulation.
20 mg to 40 mg once daily. Tablets should be taken at least 1 hour before a meal.
The most common side effects are diarrhea, nausea, vomiting, headaches, rash and dizziness. Nervousness, abnormal heartbeat, muscle pain, weakness, leg cramps, and water retention occur infrequently.
assess patient routinely for epigastric or abdominal pain.
give medication on time and at right dose.
inform about possible side effect of the drug.
Trimetazidine Vastarel MR, Vastarel 20 mg, Vastarel LM, Vastarel LP, Preductal MR, Flavedon MR, Flavedon 20 mg, Cardaptan, Idaptan, Carvidon MR and Trizedon MR, vestar
Affects myocardial substrate utilization by inhibitrng fatty acid oxidation and shifting ATP production with less 02 consumption from FFA to glucose oxidation
Hypersensitivity, pregnancy, breast-feeding (nursing mothers should stop breast-feeding).
Ischaemic heart disease (angina pectoris, sequelae of infarction) Hypersensitivity.
Adults: 20mg thrice daily after meals.
Children: Not recommended.
Feeling Dazed And Extreme Fatigue
abscess, disseminated intravascular coagulation, dysphonia.
u se c au t i ous ly i n pa t i en t s w i th hea r t f a i l u r e o r hype r t ens ion and i n e l de r l y patients.
Carvedilol Coreg, Carvil Dilatrend Coronis Eucardic Carloc
carvedilol, may greatly accentuate the effects of carvedilol and cause a steep decline in
Patients with severe hepatic impairment
Hypertension: 6.25 mg PO bid; maintain for 7–14 days, then increase to 12.5 mg PO bid
The most common side effects of carvedilol are dizziness, edema (fluid
Consult with physician about withdrawing drug if patient is to undergo surgery
blood pressure and/or heart rate.
if needed to control BP. Do not exceed 50 mg/day.CHF: Monitor patient very closely, individualize dose based on patient response. Initial dose, 3.125 mg PO bid for 2 wk, may then be increased to 6.25 mg PO bid. Maximum dose, 25 mg PO bid in patients < 85 kg or 50 mg PO bid in patients > 85 kg.
accumulation), decreased heart rate, diarrhea and postural hypotension (a rapid decrease in blood pressure when going from the seated to the standing position that causes lightheadedness and/or fainting).
Other common side effects of carvedilol are irregular heart rhythm, and abnormalities of vision.
(withdrawal is controversial).
Monitor for orthostatic hypotension and provide safety precautions.
Kalium durule Potassium chloride
replace potassium and maintain potassium level
use cautiously with patient with cardiac disease and renal impairment
The usual dietary intake of potassium by the average adult is 50 to 100 mEq per day
Nausea and vomiting, abdominal pain
Arrhythmias, heart block, hypotension cardiac arrest hyperkalemia respiratory paralysis
Make sure the powder are completely dissolve before giving
Simvastatin Zocor Like lovastatin, Hypersensitivity to The usual dose The most common Instruct patient to
simvastatin is a anticholesterol
HMG-CoA reductase inhibitors. Liver diseases. Pregnancy and nursing period.
ranges from 5 to 80 milligrams (mg) taken once daily. The recommended starting dose is 20 to 40 mg once a day
side effects of simvastatin are headache, nausea, vomiting, diarrhea, abdominal pain, muscle pain, and abnormal liver tests.
The most serious potential side effects are liver damage and muscle inflammation or breakdown.
report severe GI upset, changes in vision, unusual bleeding or bruising, dark urine or light-colored stools, fever, muscle pain, or soreness.
Always check for presence of rashes.
Motilium Domperidone Domperidone elevates serum prolactin concentrations
Known history of breast cancer, Prolactinoma (a pituitary tumor which releases prolactin)
Adults and adolescents (over 12 years and weighing 35 kg or more)
1 to 2 of the 10mg tablets three to four times per day with a maximum daily dose of 80 mg.
Possible Motilium side effects include dizziness, drowsiness, headache, insomnia, irritability or agitation, nervousness and twitching.
Before using this medication Conditions affecting use, especially: Sensitivity to domperidone
Obtaining medical attention if fainting, dizziness, irregular heartbeat or pulse
XIV. DISCHARGE PLANNING
Upon discharge, R.C.S with the support of significant others will adhere the following instruction:
Medications:
Mofloxacin 400mg/ tab OD
Captopril 25mg/tab ½ tab 2x a day
Aldactone 50mg/tab 1tab OD
Furosemide 40mg/tab 2x a day
ASA 80mg/tab 1tab OD after lunch
Clopidogrel 75mg/tab 1tab OD
Simvastatin 40mg 1tab OD before time
Digoxin 0.25mg 1tab OD
Trimetazidine 35mg/tab 1tab 2x a day
Exercise:
The best way to control congestive heart failure and to help prolong your life
is diet and exercise. You can perform inside the comfort of your home like:
Stretching
yoga
dangling of feet
moving of arm and shoulder at full range,
Deep breathing exercise
coughing exercise
Brisk walking
Treatment:
Take medication as ordered
Physical therapy
Oxygen therapy
Proper Diet
Health Teaching:
Limit your daily salt (sodium) intake to 2000 mg or less.
Fluids may need to be limited to 2000 ml (2L) per day.
Check your weight daily. If you gain 5 or more pounds (2kg) in 1to 3 days contact your
doctor.
Eat heart healthy, less processed foods that are low fat and high fiber.
If you’re overweight, try to lose 5 to 10% of your present weight.
Be active each day. Walking is great – aim for 30 minutes each day!
Limit alcohol consumption.
Avoid smoking.
Outpatient Appointment:
After 5 days on feb 10, 2012 (1-3pm) at Jonelta OPD with Serum K results.
Diet:
Follow a low fat and low salt diet
Eat nutritious food like fish, vegetables and fruits
Spiritual:
Continue reading the Holy Bible as he desires
Join Bible groups and fellowship
Attend Sunday Mass as he desires
XV. REFERENCE/BIBLIOGRAPHY
Books:
Doenges, Marilyn E., et. al. Nurse’s Pocket Guide. F. A. Davis Company. Philadelphia, 2010
Kozier, Barbara, et. al. Kozier & Erb’s Fundamentals in Nursing Volume Two. Pearson
Education South Asia PTE. LTD. Philippines, 2008.
Moyet, Lynda Juall C., et. al. Handbook of Nursing Diagnosis. C&E Publishing, Inc. Philippines,
2009.
Smeltzer, Suzanne C., et. al. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing.
Wolters Kluwer / Lippincott Williams & Wilkins. Philippines, 2010.