Date

October 01, 2009

Lab Test
Hemoglobin Hematocrit WBC Platelet

Normal Value
11 - 16 g/dL 37 - 47 % 4.5 - 11 10g/L 150-450 10g/L

Patients Values
15.5 (Normal) 47.3 (H) 6.39 (Normal) 176 (Normal)

Significance
No alteration to the normal value of the results The increase number of hematocrit is due to low oxygen level in the blood No alteration to the normal value of the results No alteration to the normal value of the results

Nursing Care
Informed patients watcher to provide the patient with nutritious foods. Advice patient to increase food intake rich in vitamin B12 Informed patients watcher to provide the patient with nutritious foods. Informed patients watcher to provide the patient with nutritious foods.

Generic Name/ Trade Name/ Form of Medication

Date Ordered

Classific a-tion

Dosage And Frequen cy

Mechanism Of Action

Indication

Contraindication

Adverse Reaction

Nursing Responsiblity

Lanoxin (Digoxin) Tablet

October 01, 2009

Cardiac Drug Antiarryth -mic Inotropic

0.25mg 1 Tab OD 6AM

Digoxin increases Cardiac Failure the strength and accompanied by vigor of heart atrial contraction and is fibrillation; useful in the management of treatment of heart chronic cardiac failure. It inhibits failure where the activity of an systolic ezyme that dysfunction or controls ventricular movement of dilatation is calcium, sodium dominant; and potassium management of into heart certain muscles. Calcium supraventricucontrols the force Lar arrythmias, of contraction, particularly inhibiting ATPase chronic atrial increases calcium flatter and in heart muscle fibrillation. and therefore increases the force of heart

In patients with hypersensitivi ty to the drug or any of its components and in those with Digoxin induced toxicities, ventricular fibrillation or ventricular tachycardia unless by heart failure. Used to patient with MI.

CNS: Agitation, Dizziness, Fatigue, Generalized muscle weakness, hallucinations, headache, malaise, paresthesia, vertigo CV: Arrythmias, heart failure, EENT: Blurred vision, myopia, light flashes, photophobia, GI: Anorexia, diarrhea, nausea and vomiting

>Before loading dose, obtain baseline heart rate and rhythm, blood pressure and electrolyte levels. >Instruct patient and care giver about drug action, dosage regimen, pulse taking, reportable signs and follow-up plans. > Instruct patient not to substitute 1 brand of digoxin for another. > Intruct patient to eat K reach food.

contractions. Spironolactone (Aldactone) Tablet Octiober 01, 2009 Diuretic 25 mg Tab OD 6 AM Specific pharmacologic antagonist of aldosterone, acting primarily through competitive binding of receptors at the aldosteronedependent Na-K exchange site in the distal convoluted renal tubule. It causes increased amounts of Na and water to be excreted, while K is retained. It acts both as a diuretic and as an antihypertensiv e drug by this mechanism. Aldactone is indicated to patients having hyperaldosteron ism, edema, congestive heart failure, cirrhosis of the liver, nephritic syndrome, hypertension, hypokalemia Aldactone is contraindicate d for patients with anuria, acute renal insufficiency, significant impairment of renal excretory function, or hyperkalemia. GI: Gastric bleeding, ulceration, gastritis, diarrhea, cramping, nausea & vomiting GU: impotence CNS: Confusion, ataxia, headache, drowsiness, lethargy Metabolic: dehydration,hyp erkalemia, hyponatremia, mild acidosis > Monitor vital signs as well as intake and output > to prevent serious hyperkalemia, warn patient not to eat large amounts of potassium containign salt substitutes > Tell patient to take drug with meals

Cefuroxime (Zegen) Capsule

Octiober 01, 2009

Cephalosporin

500 mg 1 Tab BID 8-8

Inhibits cellwall synthesis, promoting osmotic instability; usually bactericidal. Hinders or kills susceptible bacteria, including many gram-positive organisms and enteric gramnegative bacilli.

Treatment of bone & joint infections, bronchitis (& other lower resp tract infections), gonorrhea, meningitis, otitis media, peritonitis, pharyngitis, sinusitis, skin infections, surgical infections & UTI.

Known allergy to cephalosporin s.

Thrombophlebit is. Pruritus, urticaria, diarrhea, nausea, pseudomembra nous colitis. Decrease in Hb & hematocrit, transient increase in liver enzymes, elevation in serum creatinine & BUN. Possibly seizure & angioedema.

>Advice the patient to take meals before taking the medication >Tell the patient to report adverse reaction >Advice the patient to increase fluid intake

Nursing Problem: Shortness of Breath

Date Identified: October 2, 2009

Date Evaluated: October 2, 2009

Assessmen Diagnosi t s
SUBJECTIVE Naglisud ko ug ginhawa,murag mawad-an gyud ko ug hangin as verbalized by the patient. Impaired Gas Exchange related to decreased tissue perfusion

Inferenc e
Heart failure refers to the inability of the heart to maintain cardiac output sufficient to meet the bodys metabolic needs or if adequate cardiac output can only be achieved with elevated filling pressures. This definition also includes the inability of the heart

Planning
After 8 hours of duty patient will be able to demonstrate adequate ventilation and be free of symptoms of respiratory distress.

Interventi on
Independent Instruct patient ineffective coughing, deep breathing. Encourage frequent position changes. Maintain chair/bedrest, with head of bed elevated 2030 degrees, semiFowlers position. Support arms with pillows. Collaborative

Rationale
Clears airways and facilitates oxygen delivery.

Evaluatio n
Goal Unmet Patient was not able to demonstrate adequate ventilation and symptoms of respiratory distress are still present.

Helps prevent atelectasis and pneumonia.

Objective: -Restlessness -Chest pain Shallow,labored breathing -Orthopnea -Vital Signs taken as follows: T: 37C PR: 84bpm

Reduces oxygen consumption/demand s and promotes Maximal lung inflation.

R: 26cpm BP: 130/90 mmHg

to clear venous return, resulting in vascular congestion and a secondary drop in cardiac output. Heart failure commonly leads to pulmonary congestion and or peripheral edema, at which point it can be called a Congestive Heart Failure.

Administer supplemental oxygen as indicated. Administer medications as indicated: Aldactone

Increases alveolar oxygen concentration, which may Correct/reduce tissue hypoxemia. Reduces alveolar congestion, enhancing gas exchange.

Nursing Problem: Chest Pain

Date Identified: October 2, 2009

Date Evaluated: October 2, 2009

Assessmen t
SUBJECTIVE DATA: Sakit akong dughan if muginhawa ko ug kana pod kong naa ko buhaton nga manginahanglan ug kusog as verbalized by the patient. OBJECTIVE DATA: -Chest Pain -Orthopnea -Tachycardia -Restlessness -Vital signs taken as follows T: 37C PR: 84bpm R: 26cpm BP: 130/90

Diagnos is
Decreased Cardiac Output related to altered myocardial contractility and/or structural changes

Inferenc e
Heart failure refers to the inability of the heart to maintain cardiac output sufficient to meet the bodys metabolic needs or if adequate cardiac output can only be achieved with elevated filling pressures. This definition also includes the inability of

Plannin g
After 8 hours of duty patient will be able to display vital signs within acceptable limits, report decreased episodes of dyspnea, angina. Participate in activities that reduce cardiac workload.

Interventi on
Independent Auscultate apical pulse; assess heart rate, rhythm (document dysrhythmia if telemetry available). Monitor BP.

Rationale
Tachycardia is usually present (even at rest) to compensate for decreased ventricular contractility.

Evaluation

Goal Partially Met Patient was able to participate in activities that reduce cardiac workload but was not able to display vital In early, moderate, or signs within chronic HF, BP may acceptable be elevated limits and report because of increased decreased SVR. In advanced HF, episodes of the body may dyspnea,angina no longer be able to . compensate, and profound/irreversible hypotension may occur. Physical rest should be maintained during acute or refractory HF to

Encourage rest, semirecumbent in bed or chair. Assist

mmHg

the heart to clear venous return, resulting in vascular congestion and a secondary drop in cardiac output. Heart failure commonly leads to pulmonary congestion and or peripheral edema, at which point it can be called a Congestive Heart Failure.

with physical care as indicated.

improve efficiency of cardiac contraction and to decrease myocardial oxygen demand/consumption and workload. Psychological rest helps reduce emotional stress, which can produce vasoconstriction, elevating BP and increasing heart rate/work.

Provide quiet environment; explain medical/nursing management; help patient avoid stressful situations; listen/respond to expressions of feelings/fears. Collaborative Administer supplemental oxygen as indicated.

Increases available oxygen for myocardial uptake to combat effects of hypoxia/ischemia.

Nursing Problem: Unable to tolerate physical activities

Date Identified: October 2, 2009

Date Evaluated: October 2, 2009

Assessmen Diagnosis Inference t

SUBJECTIVE Kapoyan ko magtindog or bisan maglakaw lang sa palibot,luya lang gyud kayo ko kadto kausa nakuyapan gyud ko as verbalized by the patient. OBJECTIVE -Fatigue -Weakness -Restlessness -Fainting episodes -Vital signs taken as Activity Intolerance related to imbalance between oxygen supply and demand Heart failure refers to the inability of the heart to maintain cardiac output sufficient to meet the bodys metabolic needs or if adequate cardiac output can only be achieved with elevated filling pressures. This definition also includes

Planning
After 8 hours of duty patient will be able to participate in desired activities; meet own self-care needs and achieve measurable increase in activity tolerance, evidenced by reduced fatigue and weakness

Intervention
Independent Check vital signs before and immediately after activity, especially if patient is receiving vasodilators, diuretics, or beta-blockers. Document cardiopulmonary response to activity. Note tachycardia, dysrhythmias, dyspnea, diaphoresis, pallor.

Rationale
Orthostatic hypotension can occur with activity because of medication effect (vasodilation), fluid shifts (diuresis), or compromised cardiac pumping function. Compromised myocardium/inability to increase stroke volume during activity may cause an immediate increase in heart rate and oxygen demands, thereby aggravating weakness and fatigue.

Evaluation
Goal Partially Met Patient was able to participate in desired activities but didnt achieve an increase in activity tolerance.

follows T: 37C PR: 84bpm R: 26cpm BP: 130/90 mmHg

the inability of the heart to clear venous return, resulting in vascular congestion and a secondary drop in cardiac output. Heart failure commonly leads to pulmonary congestion and or peripheral edema, at which point it can be called a Congestive Heart Failure.

Assess for other precipitators/causes of fatigue, e.g., treatments, pain, medications.

Fatigue is a side effect of some medications (e.g., betablockers, tranquilizers, and sedatives). Pain and stressful regimens also extract energy and produce fatigue.

Evaluate accelerating activity intolerance.

May denote increasing cardiac decompensation rather than overactivity. Meets patients personal care needs without undue myocardial stress/excessive oxygen demand. Strengthens and improves cardiac function under stress, if cardiac dysfunction is not irreversible.

Provide assistance with self-care activities as indicated. Intersperse activity periods with rest periods.

Collaborative

Implement graded cardiac Gradual increase rehabilitation/activity in activity avoids program. excessive myocardial workload and oxygen consumption.