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A Case Study on a Patient Diagnosed with Congestive Heart Failure
___________________________________________ Presented to the Faculty In Partial Fulfillment Of the Requirements in Related Learning Experience (Eversley Childs Sanitarium-Medical Ward) ___________________________________________ Presented by TANGCALAGAN, Kent C. TONZO, Hope Glysdi TUMAMUT, Yvenette Kris UY, Justin Earl VILLAMIL, Molly YBAÑEZ, Ma. Doreen BSN-III Block 8 __________________________________________ Presented to Aeda Mae Siao, RN Clinical Instructor __________________________________________ April 19-23; 26-30, 2010
INTRODUCTION a) Definition of the Disease Heart Failure often referred to as congestive heart failure (CHF), is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. However, the term CHF is misleading, because it indicates that patients must experience pulmonary or peripheral congestion to have HF, and it implies that patients with congestion have HF. The Agency for Health Care Policy and Research (AHCPR) HF guidelines panel (1994) defined HF as a clinical syndrome characterized by signs and symptoms of fluid overload or of inadequate tissue perfusion. These signs and symptoms result when the heart is unable to generate a CO sufficient to meet the body’s demands. The HF guideline panel used the term heart failure because many patients with HF do not manifest pulmonary or systemic congestion. The term HF is preferred and indicates myocardial heart disease in which there is a problem with contraction of the heart (systolic dysfunction) or filling of the heart (diastolic dysfunction) and which may or may not cause pulmonary or systemic congestion. Some cases of HF are reversible, depending on the cause. Most often, HF is a life-long diagnosis that is managed with lifestyle changes and medications to prevent acute congestive episodes. CHF is usually an acute presentation of HF. b) Cause or Risk Factors 1. Cause HF may result from a number of causes like cardiac compensatory mechanisms, other dysfunctions and other disorders of the heart. Cardiac compensatory mechanisms (increases in heart rate, vasoconstriction, and heart enlargement) occur to assist the struggling heart.These mechanisms are able to compensate for the heart's inability to pump effectively and maintain sufficient blood flow to organs and tissue at rest. Physiologic stressors that increase the workload of the heart (exercise, infection) may cause these mechanisms to fail and precipitate the clinical syndrome associated with a failing heart (elevated ventricular/atrial pressures, sodium and water retention, decreased CO, circulatory and pulmonary congestion). The compensatory mechanisms may hasten the onset of failure because they increase afterload and cardiac work. Two types of dysfunction may exist with heart failure (see Figure 13-5). Systolic failure: poor contractility of the myocardium resulting in decreased CO and a resulting increase in the systemic vascular resistance. The increased SVR causes an increase in the afterload (the force the left ventricle must overcome in order to eject the volume of blood). Diastolic failure: stiff myocardium, which impairs the ability of the left ventricle to fill up with blood. This causes an increase in pressure in the left atrium and pulmonary vasculature causing the pulmonary signs of heart failure. It may also be caused by disorders of heart muscle resulting in decreased contractile properties of the heart. Elevated preload can be caused by incompetent valves, renal failure, volume overload, or a congenital left-to-right shunt. Elevated afterload occurs when the ventricles have to generate higher pressures
in order to overcome impedance and eject their volume. This disorder may also be referred to as an abnormal pressure load. An elevation in afterload also may be caused by hypertension, valvular stenosis, or hypertrophic cardiomyopathy. Myocardial dysfunction is most often caused by coronary artery disease, cardiomyopathy, hypertension, or valvular disorders. Atherosclerosis of the coronary arteries is the primary cause of HF.
Coronary artery disease is found in more than 60% of the patients with HF (Braunwald et al., 2001). Ischemia causes myocardial dysfunction because of resulting hypoxia and acidosis from the accumulation of lactic acid. Myocardial infarction causes focal heart muscle necrosis, the death of heart muscle cells, and a loss of contractility; the extent of the infarction correlates with the severity of HF. Revascularization of the coronary artery by a percutaneous coronary intervention or by coronary artery bypass surgery may correct the underlying cause so that HF is resolved. Cardiomyopathy is a disease of the myocardium. There are three types: dilated, hypertrophic, and restrictive Dilated cardiomyopathy, the most common type of cardiomyopathy, causes diffuse cellular necrosis, leading to decreased contractility (systolic failure). Dilated cardiomyopathy can be idiopathic (unknown cause), or it can result from an inflammatory process, such as myocarditis, from pregnancy, or from a cytotoxic agent, such as alcohol or adriamycin. Hypertrophic cardiomyopathy and restrictive cardiomyopathy lead to decreased
Valvular heart disease is also a cause of HF. pregnancy. All of these conditions require an increase in CO to satisfy the systemic oxygen demand. Usually. Other factors. iron overload (eg. These include hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM). valve disease. Compared with the general U. Risk Factors GENETIC CONSIDERATIONS HF is a complex disease combining the actions of several genes with environmental factors. the incidence and prevalence of HF are higher in African Americans. either way. anesthesia and surgery. Other causes include: pulmonary embolism. the altered electrical stimulation impairs the myocardial contraction and decreases the overall efficiency of myocardial function. coronary artery disease. and. and hypertension. thyrotoxicosis). hypoxia. from hemochromatosis). cardiomyopathy and HF may resolve after the end of pregnancy or with the cessation of alcohol ingestion. including increased metabolic rate (eg. AND LIFE SPAN CONSIDERATIONS HF may occur at any age and in both genders as a result of congenital defects. Hypoxia or anemia also may decrease the supply of oxygen to the myocardium. However. increased body demands (fever. Elderly people. HF due to cardiomyopathy becomes chronic. Gene variants in the alpha-2c adrenoceptor and the alpha-1 adrenoceptor have been associated with a higher risk of HF among African Americans. The valves ensure that blood flows in one direction. or valve disease. and Native Americans. this can be considered a compensatory mechanism because it increases contractility. or they may be a result of HF. and anemia (serum hematocrit less than 25%). fever. As compared with whites. leading to diastolic HF. coronary artery disease. transfusions or infusions. recent immigrants from . 2. can worsen the myocardial dysfunction. Systemic or pulmonary hypertension increases afterload (resistance to ejection). such as acidosis (respiratory or metabolic). Several systemic conditions contribute to the development and severity of HF. electrolyte abnormalities. GENDER. myocardial infarction. the hypertrophy may impair the heart’s ability to fill properly during diastole. infection. myocardial infarction. however.Page |4 distensibility and ventricular filling (diastolic failure). which increases the workload of the heart and leads to hypertrophy of myocardial muscle fibers. hypertension. are much more prone to the condition because of chronic hypertension. coronary artery disease. Hispanic/Latinos. However. physical and emotional stress. hemorrhage and anemia. Genetic polymorphisms of the reninangiotensinaldosterone system (RAAS) and sympathetic system have also been associated with susceptibility to and/or mitigation of HF. excessive sodium intake. blood has increasing difficulty moving forward. arteriovenous fistula). ETHNIC/RACIAL. increasing pressure within the heart and increasing cardiac workload. and antiarrhythmic medications. drug-induced. all of which occur more frequently in the elderly population. With valvular dysfunction. population. Many HF risk factors have genetic causes or are associated with genetic predispositions. chronic lung disease. Cardiac dysrhythmias may cause HF. chronic ischemia.S. or autoimmune disorders.
CAD. diabetes. c) Signs and Symptoms The clinical manifestations produced by the different types of HF (systolic.. side effect of digitalis). family history. Although men and women have similar rates of HF. smoking. The signs and symptoms of HF are most often described in terms of the effect on the ventricles. diastolic. or both) are similar (Chart 30-2) and therefore do not assist in differentiating the types of HF. women tend to have the condition later in life than men. hyperlipidemia. Although dysrhythmias (especially tachycardias. they may also be a result of treatments used in HF (eg. alcohol consumption. or atrioventricular [AV] and ventricular conduction defects) are common in HF. and. OTHER RISK FACTORS Other risk factors include: hypertension. Chronic HF produces signs and symptoms of failure of both ventricles. Left-sided heart failure (left ventricular failure) causes different manifestations than right-sided heart failure (right ventricular failure).Page |5 nonindustrialized nations and the former Soviet republics have a higher prevalence of HF as well. LEFT-SIDED HEART FAILURE . use of cardiotoxic drugs. ventricular ectopic beats.
difficulty in breathing when lying flat. Patients with orthopnea usually prefer not to lie flat. may be produced. At this point. pulmonary crackles. crackles may be auscultated throughout all lung fields. Adventitious breath sounds may be heard in various lobes of the lungs. which is sometimes pink (blood tinged). forcing fluid from the pulmonary capillaries into the pulmonary tissues and alveoli. patients complain of a dry hacking cough that may be mislabeled as asthma or chronic obstructive pulmonary disease (COPD). may be precipitated by minimal to moderate activity (dyspnea on exertion [DOE]). cough. the amount of blood ejected from the left ventricle may decrease. or shortness of breath. Usually. the pressure in the pulmonary circulation increases. causing decreased perfusion and reduced urine output (oliguria). An extra heart sound. which impairs gas exchange. The diminished CO has widespread manifestations because not enough blood reaches all the tissues and organs (low perfusion) to provide the necessary oxygen. which further impedes perfusion to many organs. The decrease in SV can also lead to stimulation of the sympathetic nervous system. Release of renin leads to aldosterone secretion. which decreases blood flow from the left atrium into the left ventricle during diastole. Without sufficient oxygen. sometimes called forward failure. a decrease in oxygen saturation may occur. S3. Large quantities of frothy sputum. The fluid filled alveoli cannot exchange oxygen and carbon dioxide.Page |6 Pulmonary congestion occurs when the left ventricle cannot pump the blood out of the ventricle to the body. Blood flow to the kidneys decreases. The patient may report orthopnea. Aldosterone secretion causes . They may need pillows to prop themselves up in bed. or they may sit in a chair and even sleep sitting up. As the failure worsens and pulmonary congestion increases. The increased left ventricular end-diastolic blood volume increases the left ventricular end-diastolic pressure. In addition to increased pulmonary pressures that cause decreased oxygenation. The dominant feature in HF is inadequate tissue perfusion. Some patients have sudden attacks of orthopnea at night. the patient experiences dyspnea and has difficulty getting an adequate amount of sleep. Pulmonary venous blood volume and pressure rise. causing further shifting of fluid into the alveoli. Because the impaired left ventricle cannot eject the increased circulating blood volume. and lowerthan-normal oxygen saturation levels. Most often. a condition known as paroxysmal nocturnal dyspnea (PND). dyspnea also can occur at rest. usually indicating severe pulmonary congestion (pulmonary edema). may be detected on auscultation. Fluid that accumulated in the dependent extremities during the day begins to be reabsorbed into the circulating blood volume when the person lies down. bi-basilar crackles that do not clear with coughing are detected in the early phase of left ventricular failure. Dyspnea. The blood volume and pressure in the left atrium increases. The cough associated with left ventricular failure is initially dry and nonproductive. The cough may become moist. which decreases blood flow from the pulmonary vessels. These effects of left ventricular failure have been referred to as backward failure. which results in the release of renin from the kidney. The clinical manifestations of pulmonary venous congestion include dyspnea. Renal perfusion pressure falls.
The swelling decreases when the patient elevates the legs. The clinical manifestations that ensue include edema of the lower extremities (dependent edema). This collection of fluid in the abdominal cavity may increase pressure on the stomach and intestines and cause gastrointestinal distress. Decreased brain perfusion causes dizziness. . a condition known as ascites. As hepatic dysfunction progresses. is obvious only after retention of at least 4. congestion of the viscera and the peripheral tissues predominates. in which indentations in the skin remain after even slight compression with the fingertips (Fig. Hepatomegaly may also increase pressure on the diaphragm. Decreased CO causes other symptoms. The pulses become weak and thready. Edema in the abdomen. hepatomegaly (enlargement of the liver). coughing. distended jugular veins. Stimulation of the sympathetic system also causes the peripheral blood vessels to constrict. as evidenced by increased abdominal girth. and paradoxically. confusion. 30-2). RIGHT-SIDED HEART FAILURE When the right ventricle fails. anorexia and nausea. Sacral edema is not uncommon for patients who are on bed rest. because the sacral area is dependent. which then leads to frequent urination at night (nocturia).5 kg (10 lb) of fluid (4. The increase in venous pressure leads to jugular vein distention (JVD). and the patient is easily fatigued and has decreased activity tolerance. The weakness that accompanies right-sided HF results from reduced CO. so the skin appears pale or ashen and feels cool and clammy.Page |7 sodium and fluid retention. improving renal perfusion. pressure within the portal vessels may rise enough to force fluid into the abdominal cavity. restlessness. weakness. Hepatomegaly and tenderness in the right upper quadrant of the abdomen result from venous engorgement of the liver. ascites (accumulation of fluid in the peritoneal cavity). when the patient is sleeping. may be the only edema present. impaired circulation. The edema can gradually progress up the legs and thighs and eventually into the external genitalia and lower trunk. Pitting edema. The decrease in the ejected ventricular volume causes the sympathetic nervous system to increase the heart rate (tachycardia). Edema usually affects the feet and ankles. causing respiratory distress. As anxiety increases. Anorexia (loss of appetite) and nausea or abdominal pain results from the venous engorgement and venous stasis within the abdominal organs.5 liters). the cardiac workload is decreased. lightheadedness. Without adequate CO. Decreased gastrointestinal perfusion causes altered digestion. which further increases intravascular volume. This occurs because the right side of the heart cannot eject blood and cannot accommodate all the blood that normally returns to it from the venous circulation. worsening when the patient stands or dangles the legs. Fatigue also results from the increased energy expended in breathing and the insomnia that results from respiratory distress. and anxiety due to decreased oxygenation and blood flow. often causing the patient to complain of palpitations. and nocturia. the body cannot respond to increased energy demands. weight gain due to retention of fluid. so does dyspnea. enhancing anxiety and creating a vicious cycle. However. The increased pressure may interfere with the liver’s ability to perform (secondary liver dysfunction). and inadequate removal of catabolic waste products from the tissues.
Take a complete medication history. the rate of coronary artery disease is decreasing and just the opposite is true for HF. irritability. PHILIPPINES In the Philippines. mild shortness of breath with exertion or at rest. dysrhythmias. In spite of recent advances in the treatment of HF. lethargy. The New York Heart Association has developed a commonly used classification system that links the relationship between symptoms and the amount of effort required to provoke the symptoms. 2001). recent open heart surgery. and the rehospitalization rates during the 6 months following discharge are as much as 50%. nocturia. Determine if the patient regularly participates in a planned exercise program.Page |8 d) Epidemiology or Statistics UNITED STATES As with coronary artery disease. the economic burden caused by HF is estimated to be more than 23 billion dollars in direct and indirect costs and is expected to increase (American Heart Association. or hypertension. Many hospitalizations could be prevented by improved and appropriate outpatient care. Symptoms vary based on the type and severity of failure. the rates are 3. nocturnal dyspnea. for non-Hispanic blacks. weight gain. anorexia. e) Assessment Highlights HISTORY Patients with HF typically have a history of a precipitating factor such as myocardial infarction. The prevalence rate of HF among non-Hispanic whites 20 years of age or older is 2. with more than one-half million new cases diagnosed each year (American Heart Association. However. the incidence of HF increases with age.1%. The rate of readmission to the hospital remains staggeringly high. The rise in the incidence of HF reflects the increased number of elderly and improvements in treatment of HF resulting in increased survival rates. respectively (American Heart Association. orthopnea that requires two or more pillows to sleep. or nausea and vomiting. HF is the most common reason for hospitalization of people older than age 65 and the second most common reason for visits to a physician’s office.3% for men and 1. cough with frothy sputum. 2001). fatigue. and determine if the patient has been on any dietary restrictions. However. Nearly 5 million people in the United States have HF. Almost 1 million hospital admissions occur each year for acute decompensated HF. the 5-year estimated mortality rate is almost 50% (Department of Health. Ask patients if they have experienced any of the following: anxiety. 2001). . HF is the fastest-growing cardiac disorder and it affects 2% of the population.5% and 3. 2005).5% for women. weakness.
in the sacral area. This positive finding for HF is known as hepatojugular reflux (HJR). jugular venous distension is present. or positive a patient feels about his or her health. respectively. inspiratory crackles or expiratory wheezes (a result of pulmonary edema in left-sided failure) are heard in the patient’s lungs. the jugular veins may become engorged and distended. or irritability caused by hypoxia. cool. Ascites may occur as a result of passive liver congestion. Gallop rhythms such as an S3 or an S4. and pressure on the abdomen increases pressure in the jugular veins. The patient’s vital signs may demonstrate tachypnea or tachycardia. The liver may also become engorged. while considered a normal finding in children and young adults. are considered pathological in the presence of HF and occur as a result of early rapid ventricular filling and increased resistance to ventricular filling after atrial contraction. and outlook on life.5 cm or more above the sternal notch with the patient at a 45degree angle. The patient may also have peripheral edema in the ankles and feet. rather. or throughout the body. anxiety. With auscultation. level of activity. Murmurs may also be present if the origin of the failure is a stenotic or incompetent valve. which occur in an attempt to compensate for the hypoxia and decreased CO. Pale or cyanotic. If the pulsations in the jugular veins are visible 4. a person’s view of health is based on many factors such as social support. vigorous.Page |9 PHYSICAL EXAMINATION Observe the patient for mental confusion. PSYCHOSOCIAL Note that experts have found that the physiological measures of HF (such as ejection fraction) do not always predict how active. clammy skin is a result of poor perfusion. causing a rise in the top of the blood column. f) Diagnostic Procedures . In rightsided HF.
Medications are prescribed based on the patient’s type and severity of HF. and smoking. alcohol. and recommending avoidance of excessive fluid intake. involving the use of left ventricular and biventricular pacing. including mechanical assist devices and transplantation. which normally depolarizes the right and left bundle . Some patients may need supplemental oxygen therapy only during activity. monitoring daily weights and other signs of fluid retention. innovative therapies. may be considered. Oxygen therapy is based on the degree of pulmonary congestion and resulting hypoxia. coronary artery revascularization with percutaneous transluminal coronary angioplasty (PTCA) or bypass surgery may be considered. Left bundle branch block (LBBB) is frequently found in patients with systolic dysfunction. is a treatment for HF with electrical conduction defects. If the patient’s condition is unresponsive to advanced aggressive medical therapy. encouraging regular exercise. MEDICAL MANAGEMENT Managing the patient with HF includes providing general counseling and education about sodium restriction. and.P a g e | 10 g) Management The basic objectives in treating patients with HF are the following: eliminate or reduce any etiologic contributory factors. LBBB occurs when the electrical impulse. reduce the workload on the heart by reducing afterload and preload. such as atrial fibrillation or excessive alcohol ingestion. Others may require hospitalization and endotracheal intubation. If the patient has underlying coronary artery disease. especially those that may be reversible. Cardiac resynchronization.
diminishing the heart’s workload and improving ventricular emptying.. ACE-Is promote vasodilation and dieresis by decreasing afterload and preload. If the patient is unable to continue an ACE inhibitor (eg. provides synchronized electrical stimulation to the heart. although one large study showed significant reductions in death and hospitalization with higher doses (Packer et al. In one study. they decrease the workload of the heart. renal status.5 mEq/L or above). ACE-Is may be the first medication prescribed for patients in mild failure—patients with fatigue or dyspnea on exertion but without signs of fluid overload and pulmonary congestion. Use of a pacing device (eg.. Results from studies (Clement et al. which can lead to further decreased ejection fraction (Gerber et al. fluid status. specific beta-blockers decrease mortality and morbidity if added to the initial medications. compared with 38% of placebo patients (Abraham. However. ACE-Is decrease the secretion of aldosterone. Digitalis is added to ACE inhibitors if the symptoms continue. Medications for diastolic failure depend on the underlying condition. 2002). PHARMACOLOGICAL MANAGEMENT Several medications are indicated for systolic HF. because of development of renal impairment as evidenced by elevated serum creatinine or persistent serum potassium levels of 5. By doing so. Spironolactone. In promoting diuresis. thereby reducing left ventricular filling pressure and decreasing pulmonary congestion. They have been found to relieve the signs and symptoms of HF and significantly decrease mortality and morbidity (when used to treat a symptomatic patient) by inhibiting neurohormonal activation (CONSENSUS Trial Study Group. SOLVD Investigators. A diuretic is added if signs of fluid overload develop. Although previously contraindicated in HF. it is recommended to start at a low dose and increase every 2 weeks until the optimal dose is achieved and the patient is hemodynamically stable. The dyssynchronous electrical stimulation of the ventricles causes the right ventricle to contract before the left ventricle. 2000. and degree of cardiac failure. 1987. 1992). including NYHA functional class and global assessment. 1999). NETWORK Investigators. ACEIs stimulate the kidneys to excrete sodium and fluid (while retaining potassium). If the patient is in mild systolic failure. Vasodilation reduces resistance to left ventricular ejection of blood. 2001). Medtronic InSync). a hormone that causes the kidneys to retain sodium. a weak diuretic may also be added for persistent symptoms. 29). such as hypertension (see Chap. The final maintenance dose depends on the patient’s blood pressure. depolarizes the right bundle branch but not the left bundle branch. 32) or valvular dysfunction (see Chap. an angiotensin II receptor blocker (ARB) or hydralazine and isosorbide dinitrate are considered as part of the treatment plan. Available as oral and intravenous medications. with leads placed on the inner wall of the right atrium and right ventricle and on the outer wall of the left ventricle. an ACE inhibitor usually is prescribed.. 1998) to identify the specific dose to achieve this effect are equivocal. 63% of the patients who had received these devices showed improvement in clinical status. ACE inhibitors (ACEIs) have a pivotal role in the management of HF due to systolic dysfunction. ANGIOTENSIN-CONVERTING ENZYME INHIBITORS. .P a g e | 11 branches at the same time.
As with ARBs. hyperkalemic and hypovolemic states must be corrected. Adjusting the dose or type of diuretic in response to the patient’s blood pressure and renal function may allow for continued increases in the dosage of ACE-Is.P a g e | 12 Patients receiving ACE-I therapy are monitored for hypotension. 1999. When used with ACE-Is.0 mEq/L or if the serum creatinine is 3. ACE-Is and ARBs also have similar side effects: hyperkalemia. peak.0 mg/dL and continues to increase. ARBs are usually prescribed when patients are not able to tolerate ACE-Is. especially if they are also receiving diuretics. such as carvedilol (Coreg). 1996. Table 30-3 identifies several types of ACEIs and their pharmacokinetics. ACE-Is may be discontinued if the potassium remains above 5. losartan [Cozaar]) have a similar hemodynamic effect as ACE-Is: lowered blood pressure and lowered systemic vascular resistance. Hypotension is most likely to develop from ACE-I therapy in patients older than age 75 and in those with a systolic blood pressure of 100 mm Hg or less. and duration of the medication. the patient who is also receiving a diuretic may not need to take oral potassium supplements. hypovolemia. Nitrates (eg. It has also been shown to help avoid the development of nitrate tolerance. the cough indicates angioedema. metoprolol (Lopressor. Other side effects of ACE-Is include a dry. ANGIOTENSIN II RECEPTOR BLOCKERS (ARBS). BETA-BLOCKERS. Packer et al. A combination of hydralazine (Apresoline) and isosorbide dinitrate (Dilatrate-SR. 2001). or bisoprolol (Zebeta). Packer et al. isosorbide dinitrate) cause venous dilation. However. which reduces the amount of blood return to the heart and lowers preload. the cough could also indicate a worsening of ventricular function and failure. Isordil. Whereas ACE-Is block the conversion of angiotensin I to angiotensin II.. patients receiving potassiumsparing diuretics (which do not cause potassium loss with diuresis) must be carefully monitored for hyperkalemia. or severe cardiac failure. Before the initiation of the ACE-I. the ACE-I must be stopped immediately. MERIT. Sorbitrate) may be another alternative for patients who cannot take ACE-Is. ARBs (eg. HYDRALAZINE AND ISOSORBIDE DINITRATE. and renal dysfunction. an increased level of potassium in the blood. hyponatremia. Toprol).. Hydralazine lowers systemic vascular resistance and left ventricular afterload. have been found to reduce mortality and morbidity in NYHA class II or III HF patients by reducing the cytotoxic effects from the constant stimulation of the sympathetic nervous system (Beta-Blocker Evaluation of Survival Trial [BEST] Investigators. persistent cough that may not respond to cough suppressants. such as after acute . These agents have also been recommended for patients with asymptomatic systolic dysfunction. Rarely. ARBs block the effects of angiotensin II at the angiotensin II receptor. 2001. a serum sodium level of less than 135 mEq/L. Although their action is different than that of ACE-Is. this combination of medications is usually used when patients are not able to tolerate ACE-Is. 1999. beta-blockers. hypotension. Because ACE-Is cause the kidneys to retain potassium. If angioedema affects the oropharyngeal area and impairs breathing. When to observe for these effects and for how long depends on the onset. CIBIS-II Investigators and Committees. and alterations in renal function. However.
inhibit sodium and chloride reabsorption mainly in the ascending loop of Henle. is recommended for patients with well-controlled. An important nursing role during titration is educating the patient about the potential worsening of symptoms during the early phase of treatment. Patients with signs and symptoms of fluid overload should be started on a diuretic. one that primarily blocks the beta-adrenergic receptor sites in the heart). Diuretics are medications used to increase the rate of urine production and the removal of excess extracellular fluid from the body. such as metolazone (Mykrox. Toprol). The side effects are most common in the initial few weeks of treatment. including exacerbation of HF. It is very important that nurses provide support to patients going through this symptom-provoking phase of treatment. these patients need to be monitored closely for increased asthma symptoms. such as metoprolol (Lopressor. If the patient develops symptoms during the titration phase. and bradycardia. Zaroxolyn). The most frequent side effects are dizziness. beta-blockers may also produce many side effects. inhibit sodium and chloride reabsorption mainly in the early distal tubules. To minimize these side effects. and potassium-sparing diuretics. However. loop. Because beta-blockade can cause bronchiole constriction. staggering the administration of the beta-blocker with the ACEI is recommended. such as furosemide (Lasix). reducing the dose of ACE-I. Thiazide diuretics. They are titrated slowly (every 2 weeks). or decreasing the dose of the beta-blocker. a beta1-selective beta-blocker (ie. Because of the side effects. Of the types of diuretics prescribed for patients with edema from HF. betablockers are initiated only after stabilizing the patient and ensuring a euvolemic (normal volume) state. Any type of beta-blocker is contraindicated in patients with severe or uncontrolled asthma. They also increase potassium and bicarbonate excretion. hypotension. mild to moderate asthma. three are most common: thiazide. treatment options include increasing the diuretic. However. These medications are classified according to their site of action in the kidney and their effects on renal electrolyte excretion and reabsorption.P a g e | 13 myocardial infarction or revascularization to prevent the onset of symptoms of HF. and that improvement may take several weeks. DIURETICS. with close monitoring at each increase in dose. a thiazide for those with mild symptoms or a loop diuretic for patients with more severe symptoms or with renal insufficiency . Loop diuretics.
The patient is observed for the effectiveness of digitalis therapy: lessening dyspnea and orthopnea. A key concern associated with digitalis therapy is digitalis toxicity. 1997). patient age. It improves contractility. weight loss. <2 g/day). nifedipine (Adalat. but they do not prolong life. 1998). or symptoms. Procardia). Serum creatinine and potassium levels are monitored frequently (eg. The serum potassium level is measured at intervals because diuresis may have caused hypokalemia. and increase in activity tolerance. They may be used to improve symptoms especially in patients with . 1993). It has been found to be effective in reducing mortality and morbidity in NYHA class III and IV HF patients when added to ACE-Is. dihydropyridine calcium channel blockers.. The medication increases the force of myocardial contraction and slows conduction through the AV node. are contraindicated in patients with systolic dysfunction. and pharma cokinetic properties. Tiazac).P a g e | 14 (Brater. increasing left ventricular output. decrease in pulmonary crackles on auscultation. although they may be used in patients with diastolic dysfunction. it is effective in decreasing the symptoms of systolic HF and in increasing the patient’s ability to perform activities of daily living (Digitalis Investigation Group. and ototoxicity. so digitalis toxicity may occur. and renal function. renal function. Table 30-4 lists commonly used diuretics. and renal and hepatic function. relief of peripheral edema. CALCIUM CHANNEL BLOCKERS. First-generation calcium channel blockers. Dosages depend on the indications. electrolyte and fluid balance. The most commonly prescribed form of digitalis for patients with HF is digoxin (Lanoxin). DIGITALIS. Careful patient monitoring and dose adjustments are necessary to balance the effectiveness with the side effects of therapy. Serum digoxin levels are obtained once each year or more frequently if there have been changes in the patient’s medications. Spironolactone (Aldactone) is a potassium-sparing diuretic that inhibits sodium reabsorption in the late distal tubule and collecting duct. within the first week and then every 4 weeks) when this medication is first administered. and digoxin. avoidance of excessive fluid intake (<2 quarts/day). Verelan). The effect of a given dose of medication depends on the state of the myocardium. Side effects of diuretics include electrolyte imbalances. It also has been shown to significantly decrease hospitalization rates and emergency room visits for NYHA class II and III HF patients (Uretsky et al. and a lowsodium diet (eg. Amlodipine (Norvasc) and felodipine (Plendil). Chart 30-3 summarizes the actions and uses of digitalis along with the nursing surveillance required when it is administered. hyperuricemia (causing gout). symptomatic hypotension (especially with overdiuresis). dosages. Although digitalis does not decrease the mortality rate. Dilacor. clinical signs and symptoms. Both types of diuretics may be used for those in severe HF and unresponsive to a single diuretic. which removes fluid and relieves edema. and diltiazem (Cardizem. cause vasodilation. These medications may not be necessary if the patient responds to activity recommendations. Diuretics greatly improve the patient’s symptoms. reducing systemic vascular resistance. Isoptin. loop diuretics. such as verapamil (Calan. The medication also enhances diuresis. The effect of digitalis is enhanced in the presence of hypokalemia.
especially if the patient has a history of an embolic event or atrial fibrillation or mural thrombus is present. NUTRITIONAL MANAGEMENT . such as ibuprophen (Aleve. use of decongestants should be avoided. Advil. They can increase systemic vascular resistance and decrease renal perfusion. Nonsteroidal anti-inflammatory drugs (NSAIDs). OTHER MEDICATIONS.P a g e | 15 nonischemic cardiomyopathy. 2000). especially in the elderly. For similar reasons. Anticoagulants may be prescribed. Other medications such as antianginal medications may be given to treat the underlying cause of HF. Motrin) should be avoided (Page & Henry. although they have no effect on mortality.
Nursing actions to evaluate therapeutic effectiveness include the following: • Keeping an intake and output record to identify a negative balance (more output than input) • Weighing the patient daily at the same time and on the same scale. a cardiac transplant may be considered if other measures fail. and cultural food patterns. A balance needs to be achieved between the ability of the patient to alter the diet and the amount of medications that are prescribed. this recommendation reduces fluid retention and the symptoms of peripheral and pulmonary congestion. IABP is used with caution because there are several possible complications. It is the balance of these effects that determines the type and dosage of pharmacologic therapy. or coronary artery bypass surgery to improve oxygen flow to the myocardium. thrombolytic therapy. percutaneous transluminal coronary angioplasty. It involves a balloon catheter placed in the descending aorta that inflates during diastole and deflates during systole. Finally. monitoring for a 2. This is generally used as a bridge to surgery or in cardiogenic shock after acute myocardial infarction. directional coronary atherectomy. usually in the morning after urination. is generally under 60 years of age. Corrective surgery may also be warranted if the elevated afterload is caused by a stenotic valve. Another measure that may be taken to reduce afterload is an intraaortic balloon pump (IABP). h) Nursing Responsibilities and Preventive Measures The nurse is responsible for administering the medications and for assessing their beneficial and detrimental effects to the patient. ischemic changes in the legs. dislikes. if there is no history of other pulmonary diseases. and migration of the balloon up or down the aorta. and is psychologically stable. SURGICAL MANAGEMENT If the elevated preload is caused by valvular regurgitation.P a g e | 16 A low-sodium (≤2 to 3 g/day) diet and avoidance of excessive amounts of fluid are usually recommended. Although it has not been shown to affect the mortality rate. and if the patient does not smoke or use alcohol. if all other organ systems are viable. which would decrease the need for the heart to pump that volume.to 3-lb gain in a day or 5-lb gain in week • Auscultating lung sounds at least daily to detect an increase or decrease in pulmonary crackles • Determining the degree of JVD • Identifying and evaluating the severity of dependent edema . including dissection of the aortoiliac arteries. OTHER MEASURES Other measures the physician may use include supplemental oxygen. The balloon augments filling of the coronary arteries during diastole and decreases afterload during systole. the patient may require corrective surgery. The purpose of sodium restriction is to decrease the amount of circulating volume. placement of a coronary stent. Any change in diet needs to be done with consideration of good nutrition as well as the patient’s likes.
decreases work of respiratory muscles and oxygen utilization. Offer careful explanations and answers to the patient's questions. reduces BP. IMPROVING OXYGENATION Raise head of bed 8 to 10 inches (20 to 30 cm) reduces venous return to heart and lungs. Provide bedside commode to reduce work of getting to bathroom and for defecation. recumbency promotes diuresis by improving renal perfusion. orthopnea. and dyspnea on exertion) and evaluating changes • MAINTAINING ADEQUATE CARDIAC OUTPUT Place patient at physical and emotional rest to reduce work of heart. Monitor for premature ventricular beats. decrease in crackles. Use markings for comparative assessment over time and among different care providers. Auscultate heart sounds frequently and monitor cardiac rhythm. Position the patient every 2 hours (or encourage the patient to change position frequently) to help prevent atelectasis and pneumonia. alleviates pulmonary congestion. paroxysmal nocturnal dyspnea. Note alternating strong and weak pulsations (pulsus alternans). increases heart reserve. and lumbosacral area supported with pillows. Provide rest in semi-recumbent position or in armchair in airconditioned environment that reduces work of heart. Note presence of S3 or S4 gallop (S3 gallop is a significant indicator of heart failure). and poor capillary refill of nail beds. relief of peripheral edema). Observe for signs and symptoms of reduced peripheral tissue perfusion: cool temperature of skin. head and arms resting on an over-the-bed table. and speeds the heart. improves efficiency of heart contraction. Evaluate frequently for progression of left-sided heart failure. Take frequent BP readings. elevates arterial pressure. Encourage deep-breathing exercises every 1 to 2 hours to avoid atelectasis. which can cause myocardial ischemia and decrease perfusion to vital organs. Auscultate lung fields at least every 4 hours for crackles and wheezes in dependent lung fields (fluid accumulates in areas affected by gravity). Provide for psychological rest since emotional stress produces vasoconstriction. . as well as monitoring for postural hypotension and making sure that the patient does not become hypotensive from dehydration • Examining skin turgor and mucous membranes for signs of dehydration • Assessing symptoms of fluid overload (eg. Watch for sudden unexpected hypotension. facial pallor. Sit orthopneic patient on side of bed with feet supported by a chair. Note narrowing of pulse pressure. Observe for increased rate of respirations (could be indicative of falling arterial pH). Monitor clinical response of patient with respect to relief of symptoms (lessening dyspnea and orthopnea. Promote physical comfort. the level on the patient's back where adventitious breath sounds are heard. Observe for Cheyne-Stokes respirations (may occur in elderly patients because of a decrease in cerebral perfusion stimulating a neurogenic response).P a g e | 17 Monitoring pulse rate and blood pressure. Avoid situations that tend to promote anxiety and agitation. Support lower arms with pillows to eliminate pull of their weight on shoulder muscles. Observe for lowering of systolic pressure. Mark with ink that does not easily rub off.
Small. or humid weather. if you are unable to do so. The nurse and patient can collaborate to develop a schedule that promotes pacing and prioritization of activities. the person can carry the objects up the stairs all at once. vital signs and oxygen saturation level are monitored before. The nurse helps the patient to identify peak and low periods of energy and plan energy-consuming activities for peak periods. pain. the person can carry cleaning supplies around in a basket or backpack rather than walk back and forth to obtain the items. Heart rate should return to . Administer oxygen as directed. Prolonged bed rest. phlebothrombosis. The patient’s response to activities needs to be monitored. cold. they also promote decreased activity tolerance. and immediately after an activity to identify whether they are within the desired range. decrease the intensity of activity. objects that need to be taken upstairs can be put in a basket at the bottom of the stairs throughout the day. The patient then should be advised to increase the duration of the activity. one to four times per day. and methods of adjusting an activity to ensure pacing but still accomplish the task are discussed. Otherwise. Vegetables can be chopped or peeled while sitting at the kitchen table rather than standing at the kitchen counter. before increasing the intensity of the activity (Meyer. Because some patients may be severely debilitated. such as pressure ulcers (especially in edematous patients). 2001). For example. • Avoid performing physical activities outside in extreme hot. during. the patient should be given the following safety guidelines: • Begin with a few minutes of warm-up activities. 2001). Before undertaking physical activity. Likewise. and pulmonary embolism. • End with cool-down activities and a cool-down period.P a g e | 18 Offer small. At the end of the day. If the patient is hospitalized. Pacing and prioritizing activities help maintain the patient’s energy to allow participation in regular physical activity. a total of 30 minutes of physical activity three to five times each week should be encouraged (Georgiou et al. • Stop the activity if severe shortness of breath. PROMOTING ACTIVITY TOLERANCE Although prolonged bed rest and even short periods of recumbency promote diuresis by improving renal perfusion. which may be selfimposed. Barriers to performing an activity are identified. or dizziness develops. they may need to perform physical activities only 3 to 5 minutes at a time. should be avoided because of the deconditioning effects and hazards. the person may prepare the meals for the entire day in the morning. For example. • Wait 2 hours after eating a meal before performing the physical activity. An acute event that causes severe symptoms or that requires hospitalization indicates the need for initial bed rest. • Ensure that you are able to talk during the physical activity.. frequent meals decrease the amount of energy needed for digestion while providing adequate nutrition. then the frequency. frequent feedings to avoid excessive gastric filling and abdominal distention with subsequent elevation of diaphragm that causes decrease in lung capacity. The schedule should alternate activities with periods of rest and avoid having two significant energy-consuming activities occur on the same day or in immediate succession.
and leg exercises may help to prevent skin injury. Oral diuretics should be administered early in the morning so that diuresis does not interfere with the patient’s nighttime rest. pulmonary congestion is alleviated. and interpersonal contact. Discussing the timing of medication administration is especially important for patients. or the patient may sit in a comfortable armchair. The lower arms are supported with pillows to eliminate the fatigue caused by the constant pull of their weight on the shoulder muscles.P a g e | 19 baseline within 3 minutes. the amount of fluid needs to be monitored closely. Because decreased circulation in edematous areas increases the risk of skin injury. especially for HF patients with recent myocardial infarction. who may have urinary urgency or incontinence. The nurse monitors the patient’s fluid status closely— auscultating the lungs. the nurse assesses for skin breakdown and institutes preventive measures. MANAGING FLUID VOLUME Patients with severe HF may receive intravenous diuretic therapy. processed. If the patient is receiving intravenous fluids. short-term and long-term goals can be developed to gradually increase the intensity.to 10-inch] blocks may be used). the head and arms resting on an overbed table.to 30-cm [8. positioning the patient in an armchair is advantageous. duration. In this position. regular encouragement. A single dose of a diuretic may cause the patient to excrete a large volume of fluid shortly after administration. the head of the bed may be elevated (20. double-concentrating to decrease the fluid volume administered). If the diet includes fluid restriction. monitoring daily body weights. but patients with less severe symptoms may receive oral diuretic medication (see Table 30-4 for a summary of common diuretics). the nurse can assist the patient to plan the fluid intake throughout the day while respecting the patient’s dietary preferences. and the lumbosacral spine supported by a pillow. positioning to avoid pressure. or increased anxiety. and assisting the patient to adhere to a low-sodium diet by reading food labels and avoiding high-sodium foods such as canned. CONTROLLING ANXIETY . because this position favors the shift of fluid away from the lungs. the venous return to the heart (preload) is reduced. The number of pillows may be increased. recent open-heart surgery. the use of elastic compression stockings. A supervised program may also benefit those who need the structured environment. The nurse positions the patient or teaches the patient how to assume a position that shifts fluid away from the heart. significant educational support. Referral to a cardiac rehabilitation program may be needed. and impingement of the liver on the diaphragm is minimized. The patient who can breathe only in the upright position may sit on the side of the bed with the feet supported on a chair. the degree of fatigue felt after the activity can be used as assessment of the response. If pulmonary congestion is present. such as elderly people. and convenience foods (Chart 30-4). and the physician or pharmacist can be consulted about the possibility of maximizing the amount of medication in the same amount of intravenous fluid (eg. Frequent changes of position. If the patient is at home. If the patient tolerates the activity. and frequency of activity.
particularly if health care providers and family members behave in maternalistic or paternalistic ways. they are likely to be restless and anxious and feel overwhelmed by breathlessness. Other contributing factors may include misinformation. and increasing the frequency and significance of those opportunities over time. After the patient is comfortable. providing encouragement while identifying the patient’s . Contributing factors may include lack of knowledge and lack of opportunities to make decisions. Taking time to listen actively to patients often encourages them to express their concerns and ask questions. When the patient exhibits anxiety. and increased heart rate. This sympathetic response increases the amount of work that the heart has to do. and confident manner and maintain eye contact. When necessary. which may prevent adequate rest. the degree of anxiety decreases. brief directions for an activity. In cases of confusion and anxiety reactions that affect the patient’s safety. and the quality of sleep improves. Oxygen may be administered during an acute event to diminish the work of breathing and to increase the patient’s comfort. Promoting physical comfort. the nurse should also state specific. lack of information. elevated arterial pressure. and resistance inevitably increases the cardiac workload. causing the patient to react to sedativehypnotic medications with confusion and increased anxiety. calm. hospital policies may promote standardization and limit the patient’s ability to make decisions (eg. the patient’s cardiac work also is decreased. take medications. These symptoms tend to intensify at night. what time to have meals. Emotional stress stimulates the sympathetic nervous system. The nurse assesses for factors contributing to a sense of powerlessness and intervenes accordingly. leading to toxicity. Hepatic congestion may slow the liver’s metabolism of medication. To help decrease the patient’s anxiety. MINIMIZING POWERLESSNESS Patients need to recognize that they are not helpless and that they can influence the direction of their lives and the outcomes of treatment. Restraints are likely to be resisted. the nurse takes steps to promote physical comfort and psychological support. prepare for bed). By decreasing anxiety. Cerebral hypoxia with superimposed carbon dioxide retention may be a problem in HF.P a g e | 20 Because patients in HF have difficulty maintaining adequate oxygenation. and teaching the patient to perform relaxation techniques and to avoid anxietytriggering situations may relax the patient. Other strategies include providing the patient with decision-making opportunities. If the patient is hospitalized. which causes vasoconstriction. the nurse should speak in a slow. The patient who insists on getting out of bed at night can be seated comfortably in an armchair. providing accurate information. a family member’s presence provides reassurance. or poor nutritional status. Lack of sleep may increase anxiety. The nurse explains how to use relaxation techniques and assists the patient to identify factors that contribute to anxiety. the use of restraints should be avoided. Sedative-hypnotic medications must be administered with caution. such as when activities are to occur or where objects are to be placed. the nurse can begin teaching ways to control anxiety and to avoid anxiety-provoking situations. As cerebral and systemic circulation improves. In many cases.
Hypokalemia poses new problems for the patient with HF because it markedly weakens cardiac contractions. Signs are weak pulse. faint heart sounds. Patients are advised to consult their physician or pharmacist before including grapefruit in their diet. volume depletion from excessive urination. thready pulse. orange or tomato juice. there are 393 mg of sodium in 1 g (1000 mg) of salt. potatoes.” and the quantity should be indicated in milligrams. beets. prohibition of food from home. It is important to remember that serum potassium levels do not always indicate the total amount of potassium within the body. and prunes (dried plums). Periodic assessment of the patient’s electrolyte levels will alert health team members to hypokalemia. and watermelon are good dietary sources of potassium. fatigue. The sources of sodium should be specified in describing the regimen. spinach. especially with the use of ACE-Is or ARBs and spironolactone. potassium depletion). and life expectancy increases. Grapefruit (fresh and juice) is a good dietary source of potassium but has serious drug–food interactions. Serum levels are assessed frequently when the patient starts diuretic therapy and then usually every 3 to 12 months. including salt substitutes. and hyponatremia. Hyperkalemia may also occur. malaise. the nurse advises the patient to avoid the above products. Dried apricots. unnecessary hospitalizations decrease. Prolonged diuretic therapy may also produce hyponatremia (deficiency of sodium in the blood). muscle flabbiness. and a rapid. raisins. An oral potassium supplement (potassium chloride) may also be prescribed for patients receiving diuretic medications. peaches. Low levels of potassium may also indicate a low level of magnesium. Patients and . MONITORING AND MANAGING POTENTIAL COMPLICATIONS Profuse and repeated diuresis can lead to hypokalemia (ie. and generalized weakness. the nurse advises patients to increase their dietary intake of potassium. Other problems associated with diuretic administration are hyperuricemia (excessive uric acid in the blood). PROMOTING HOME AND COMMUNITY-BASED CARE The nurse provides patient education and involves the patient in implementing the therapeutic regimen to promote understanding and adherence to the plan. and assisting the patient to differentiate between factors that can be controlled and those that cannot. hypomagnesemia. squash. muscle cramps and twitching. When the patient understands or believes that the diagnosis of HF can be successfully managed with lifestyle changes and medications. If the patient is at risk for hyperkalemia. the nurse may want to review hospital policies and standards that tend to promote powerlessness and advocate for their elimination or change (eg.P a g e | 21 progress. which results in apprehension. limited visiting hours. hypotension. In some cases. Salt is not 100% sodium. hypokalemia can lead to digitalis toxicity. Digitalis toxicity and hypokalemia increase the likelihood of dangerous dysrhythmias (see Chart 30-3). and hyperglycemia. recurrences of acute HF lessen. diminished deep tendon reflexes. required wearing of hospital gowns). rather than simply saying “low-salt” or “saltfree. which can add to the risk for dysrhythmias. figs. bananas. To reduce the risk for hypokalemia. weakness. In patients receiving digoxin.
A summary of teaching points for the patient with HF is presented in Chart 30-5. perform and record daily weights. not just what the physician or other health care team members think is needed. maintain a low-sodium diet. restricting sodium intake. engage in routine physical activity.P a g e | 22 their families need to be taught to follow the medication regimen as prescribed. but they also need to understand the possible outcomes of those decisions. avoiding excess fluids. interventions that may promote adherence include teaching to ensure accurate understanding. preventing infection with influenza and pneumococcal immunizations. the nurse needs to convey that monitoring symptoms and daily weights. . avoiding noxious agents (eg. Patients and their families need to be informed that the progression of the disease is influenced in part by choices made about health care and the decisions about following the treatment plan. and participating in regular exercise all aid in preventing exacerbations of HF. Although noncompliance is not well understood. They also need to be informed that health care providers are there to assist them in reaching their health care goals. The nurse should be aware of cultural factors and adapt the teaching plan accordingly. Ultimately. The patient and family members are supported and encouraged to ask questions so that information can be clarified and understanding enhanced. alcohol. and recognize symptoms that indicate worsening HF. tobacco). Patients and family members need to make the decisions about the treatment plan. The treatment plan then will be based on what the patient wants.
2. and. skills and attitude on the disease process of Congestive Heart Failure generally on the body. Verbalize feelings and thoughts of his present condition. OBJECTIVES a) General After 1-3 hours of case presentation in the medical ward. Know the possible causes of the disorder. e) Make a comprehensive nursing care plan and its intervention. Cooperate on management prepared by the student nurse. c) Review the anatomy and physiology of the integumentary system. Nurse-Centered Objectives Upon completion of this case study. Understand awareness of his disorder. deliver specific interventions needed to treat the disease. the Guest should be able to: Establish rapport and trusting relationship with the student nurse. h) Apply the learned self-care measures to improve well-being. Give information about self. f) Impart knowledge to the patient regarding on his condition g) Evaluate patient’s response towards rendered care given by the student nurse.Patient-Centered Objectives Upon a) b) c) d) e) f) g) completion of this case study. anticipate and provide effective nursing care.P a g e | 23 II. the student nurse should be able to: a) Make a thorough assessment about the patient’s personal history. Learn and understand why such laboratory examinations are being done. b) Specific 1. the students will be able to develop and apply specific knowledge. family and past experiences. family background and lifestyle b) Cite factors that contribute to the patient’s condition. . d) Explain the histopathology and pathogenesis of Congestive Heart Failure.
the patient experienced symptoms of shortness of breath. Mandaue City was assessed last April 23. 2010. Upon her 2nd child. The patient was diagnosed with Eclampsia with a BP of 180/120mmHg which was her usual BP measurement for her current illness. the patient was unable to comply the necessary medications and decided to stay at home for care. TT1.9. Patient is currently having 3 children. Patient MR manifested symptoms of on and off moderate grade fever. Patient MR is in the Genital phase. since she has a heart problem. The ego in the genital stage is well- . Anti Hepa-B 1. 2 and 3. 2010 at around 12:00 a.P a g e | 24 III. Patient is already living with her own family. married.m via Taxi accompanied by her eldest son with admitting complaints of shortness of breath. Patient claimed to be sexually active. d) Developmental History According to Sigmund Freud Psychosexual Stage. 3. Admitting V/S is as follows: T-37. headache and fatigue. BP200/160. and the basic task for the individual is the detachment from the parents. On April 17. 33 years old. she ate less on restricted foods high in cholesterol. She's under the care of Dr. c) History of Present Illness Prior to admission the patient was experiencing dizziness. Health History a) Client Profile A case of Patient MR. PR-92. Patient is neither a smoker nor an alcoholic beverage drinker. OPV 1. She has no known allergies to drug as well as to foods. she was admitted to the hospital last year 2001 for 4 days in Eversley Child's Sanitarium under unrecalled doctor and was diagnosed with Pre-eclampsia. DPT 1. This stage represents the major portion of life. 2 and 3. Patient MR was then adviced by the doctor not to have another child but then was not followed since she had her 3rd child in the year 2007 and was confined for 3 consecutive days in Vicente Sotto Memorial Medical Center under the Service of unrecalled Doctor. Two days prior to admission. Lagora. Filipino citizen. Patient was transferred to the Female Medical Ward at 4:10 am of the same day. female. 2. Due to lack of financial support. the energy is expressed with adult sexuality. In this stage the focus on the genitals. a Roman Catholic. 4 and 5. housewife and presently living in Paknaan. but. 2 and 3. 2010 by 4:30am at the Evvesley Childs Sanitarium (Female Medical ward). dizziness and fatigue. b) Past Medical History Patient disclosed that she has received the following immunizations: BCG 1 and 2. Patient claimed to be hypertensive but not diabetic or asthmatic. and gradually coughing episodes were noted. She was only able to remember Nefidipine as her medication. She then sought for medical assistance in Mandaue District and had a BP of 200/160mmHg. RR-25. She was also unable to recall the specific medications she took that time. Client was admitted last April 19.
Patient MR disposes their garbage through garbage trucks which collects their trash during Mondays and Thursdays. Rules of law are important for maintaining a society. They use plastic bags and old barrels for garbage containers. According to kohlberg's Theory of Moral Development. and so uses secondary process thinking. Socially-valued work and disciplines are expressions of generativity as well as contributing to society and helping future generations. Stagnation wherein it concerns of establishing and guiding the next generation. hardwork and nurturing as important values on being a mother and a wife to her family. Patient MR is in the Postconventional Morality wherein people begin to account for the differing values.a sense of productivity and accomplishment. patient belongs to the 4th stage of "Individuative-Reflective" faith (usually mid-twenties to late thirties) a stage of angst and struggle. but members of the society should agree upon these standards. she can still manage to talk to some friends and mingle with her neighbors from time to time. they have electricity and have their own water source. Patient MR expressed symbolic gratification that includes the formation of love relationships and families. She expressed her faith to God that despite her situation and that she still believes that God will heal her from her illness. Patient is already raising a family and verbalized her hopes on working towards the betterment of society. The patient took personal responsibility for her beliefs and feelings. Patient MR has a quiet type of personality but though such. and beliefs of other people. . a sense of generativity. Patient considers values of honesty. She together with her family with three children are living in a rented house and lot nearby the street side which is made out of mixed materials. They have one dog and a cat as their pet. which allows symbolic gratification. opinions. a dining area and a living room. or acceptance of responsibilities associated with adulthood.P a g e | 25 developed. In Fowler's stages of faith development. In Erik Erikson's psychosocial Stages of development. They have two bedrooms. Patient MR also has no problems with going to Church and to the market which is only 2km away from their house. e) Environmental History Patient MR is currently residing in Paknaan Mandaue City Cebu. Their toilet is a manual flush type. Patient MR belongs to Generativity vs. The patient claimed that there is no difficulty in seeking healthcare because of the distance from the health center is not that far approximately 5km.
She had recently experienced a 5-8 lb weight gain as a result of her CHF. vegetables and meat. Her urine was clear and yellow. She reported urinating three to four times daily with no difficulty and no recent change in her urinary pattern. lunch and dinner is composed of rice. sometimes twice. She can consume 7-9 glasses a day. She stated that she did not take vitamin supplements because they are expensive. and reported moving her bowels daily. She scaled her health 6 out of 10. Her perception of her health was in sync with reality. During admission. the patient’s usual diet from breakfast. She was visibly weak. During admission. Her past medical history was concise as presented previously. She reported during on her 24-hour diet recall that she had been eating a cup of coffee and bread for breakfast. Health Perception/ Health Management Patient MR defines health as “panglawas”. She was fully continent with experience profuse sweating. She had no enteral feeding or NG tube. Her diet restrictions were low sodium and low fat because of her CHF and cardiac history. side dish of fish in varied preparation. She was 5’6” and 165 pounds. She wanted to see a health care provider each time she feels ill but not realized due to financial restraints. Marjorie Gordon’s Functional Health Patterns 1. She denied changes in this pattern. with an intake total of 200 mL and an output total of 500 mL in the entire shift. Patient’s current dietary status is DAT. She once practiced drinking “mangagaw” when she experience fever. She was not well educated about her CHF and the dietary restrictions it imposed. drinking 1-2 cups of coffee daily and along with two 5-7 glasses of water. and her IV was 500mL D5W running at 10ggts/min. the patient was fully functional in the elimination pattern. She had a bowel movement the day of our interview. Nutritional/ Metabolic PTA. and her abdomen was soft with active bowel sounds in all four quadrants. and was unable to perform all of her ADL’s without assistance. She was aware of the fact that she was “pretty sick” when she came in to the hospital. 3. . She exercised by walking or swimming daily and was very careful about what she ate. She was not well oriented with knowledgeable and medications of her disease.P a g e | 26 IV. Elimination Prior to admission. Her fluid balance was improving. Her prescribed diet was a cardiac diet. She was very independent and did not like to be waited on. She reported adequate fluid intake. She was not aware of the effects of an increase in sodium and fat intake to her CHF. and a cup of rice and a vegetable soup for dinner. a cup of rice and fish for lunch. patient experiences 1-2 bowel movements per day and usually voids 4-5 times a day with estimates 200ml per urination. She did not report any changes in appetite or difficulty chewing but have difficulty swallowing. 2. She reported experiencing occasional nausea and loose stools.
She was functional in this health pattern. symmetrical breaths. 6. Her capillary refill was less than 3 seconds and her extremities were warm and pink. She had a limited range of motion and her tone and strength were symmetrical in all extremities. Risk for falls is the main nursing diagnosis in this health pattern due to fatigue. She reported occasional difficulty with her short term memory. O2 was placed through nasal cannula regulated at 4 L. She had a steady gait. Patient sometimes have short naps in the afternoon. tingling or pain in her extremities. She was at some risk for impaired short term memory related to her age. patient complains about her low stamina. During admission.P a g e | 27 4. Her ADL includes washing clothes. things like word and name recall. Client usually wakes at 6am. Activity/ Exercise Prior to admission. Client’s problemof the very small number of hours of sleep is due to nocturnal paroxysmal dyspnea. The client has difficulty to follow the pen placed . patient has an approximately 3-4 hours of sleep. and palpitations related to her CHF. she reported sleeping about 4 hours per night and feeling well rested during the day. She reported feeling shortness of breath. She had fine inspiratory and expiratory crackles posteriorly througout. As a past time she watches television with her children during late afternoon. She reported don’t have sufficient energy to perform activities due to fatigue. She did not report any numbness. Her respiratory rate was 28 with normal. She can’t tolerate strenuous activities. Cognitive/ Perceptual Patient can decode simple instructions such as advising her to change her position or clothes. doing household chores and cleaning the backyard. and her BP was 119/59. She reported exercising daily by walking or swimming. She said that the easiest way for her to learn things is to do them herself and she did not like being waited on. She did exhibit lethargy and irritability and during night times due to SOB and nocturnal paroxysmal dyspnea. She needed assistance with her ADL’s and to keep herself well groomed. 5. Her diagnosis in this area is risk for disturbed sleep pattern related to difficulty falling asleep at night. Patient was weak and needs assistive devices. She had no real visual difficulties other than wearing glasses and no hearing problems. and doing her household chores. She had +2 strength radial pulses and +1 strength pedal pulses. Her apical pulse was 70 and irregular due to a-fib. She reported having occasional difficulty falling asleep for which she sometimes used milk as sleeping aid. Client is not able to read the text of the calendar and writings from chart half a meter away. She took occasional naps after her walk or during soap operas in the afternoon. Sleep/ Rest PTA. fatigue. During admission.
7. hot (rubbed hand) or cold (mineral water bottle) objects and location of touch in the distinct parts of the body. salt.o. and that sexual intercourse had been limited for a while due to dypnea during strenuous activity. Her children and grandchildren had been challenging for her recently. Sexuality/ Reproductive Client has an obstetric history of G3P3. Her primary language was “Bisaya” and she had a high school degree. alcohol). She can reply appropriately to questions during conversation. she was powerless or had lost hope. She stated the feeling of emptiness sometimes. Client has an irregular menstrual cycle with menses appearing once in two-three months. Client demonstrates nonverbal communication congruent to verbal communication. . She described herself as determined and stubborn and said she liked to do things herself and ask for help if she needed it. consents that she never performed it. Client experienced sexual contact with husband at the age of 22 y. whispered pectoriloquy. She can read and write as verbalized by SO. Client relays messages with consistency and exhibit agreement and disagreement of statements. Client is able to taste familiar flavors (sugar. Client can’t hear whispers a foot away and can’t hear distinct conversation 2 meters away. She verbalizes that sexual activity should be in the context of marriage. with her husband. Client has difficulty distinguishing smell (perfume. Client verbalizes no history of sexually related illnesses or problems is currently in UTI. She uses 3-4 napkin pads per day. vinegar) as verbalized. She had excellent eye contact and conversational skills. She said she felt angry/annoyed when she was not in control and experienced occasional heart palpitations when she felt anxious or fearful. The client is not aware of the importance of self breast examination. She stated that her sexual relationship with her husband was satisfying. Client expresses no concern. Client expresses that she can learn better through visual aids and experience. and she reported feeling depressed when she couldn’t help them out with their various issues in life. iced tea. She said that her recent illness had not changed her self image and that it had only motivated her to get better. Client has a clear but weak speech. abuse or problems regarding illness and sexual patterns. The client uses contraceptives such as pills from 2005-2008. and. 8. Client is unable to hear and comprehend sentences during the test. Thelarche began at 10 years of age. Menarche was experienced during 13 years of age.P a g e | 28 in the six cardinal gazes and sometimes have involuntary movements. The client speaks of single partner sexual contact to date. Client is dependent in the decision-making process. She was noted menarche at the age of 13. Self-Perception/ Self-Concept Her recent job is a factory worker. She currently was retired. Client can distinguish blunt and sharp areas at the bottom of the pen. She said that she sometimes feels weak.
. She was married and lived with her husband. and they had three daughters. She said that she turns to her older daughter for support. She was not afraid to point out when she felt something was not right or could be improved. She reported that they had no financial concerns. Role-Relationship Pattern She was fully functional in this pattern. She was very assertive and noticed everything that went on during her hospital stay.P a g e | 29 9.
P a g e | 30 Three Generation Genogram .
Coping and Stress Tolerance Her family situation and illness was the major stressor in her life. She said that she felt relaxed when she have someone to share to. She said that she just tries “to get through it. She was Catholic and stated that her religion was important to her. Values and Belief Patient was fully functional in this health pattern as well. her diagnosis is readiness for enhanced family coping related to the situation with her mother and children as evidenced by desire to solve their problems. 11. Every time she experiences decision making process. Her source of strength is her family and God. .” She reported relieving stress by going for a walk or talking to her daughter and friends. she consults her husband as her second opinion. she said.P a g e | 31 10. Patient sees respect as the most important value in life. she gets the things she wants from life. “magkasakit ang tanang taw”. When I asked her about her beliefs about health and illness. In this area. She said that in general. She practiced by praying and reading the bible.
RR – 28 cpm Head Head is rounded with smooth skull contour. Cornea is transparent.P a g e | 32 V. Conjunctiva is transparent. Patient blinks when the cornea is touched.38 C. curled slightly outward. firm. smooth. Eyelashes are equally distributed. Physical Assessment GENERAL APPEARANCE: Patient seen lying on bed. with venoclysis of # 3 D5 Water. and with smooth texture. coherent. PR – 98 bpm. and upper and lower borders of cornea are slightly covered. Light reflection appears at symmetric spots in both eyes. Facial movements are symmetric. Lacrimal gland has no edema and no tenderness. No tenderness noted and lesions are absent. Buccal mucosa is uniform in pink color. shiny and smooth. firm and not tender. Palpebral conjunctiva is shiny. moist. Both ears can hear normal voice tones. Facial feature is symmetric. slightly rough and with . Tongue is centrally located. capillaries are evident. Iris is flat and round. Facial sinuses are not tender. Pinna recoils after it is folded. Cerumen is wet and brown in color. Gums have no retractions. responsive. Nasal septum is intact and in midline. Patient can see objects in the periphery. moist. symmetrically aligned. no discharge or flaring. smooth texture. palpebral fissures equal in size and symmetric nasolabial folds. soft. well outlined. absence of discharge. round. Position is symmetric. The mucosa of the nasal cavities is pink with clear watery discharge. alert. glistening and elastic texture. and sclera is white. BP – 180/90. afebrile. infusing well at right hand with the following vital signs: T. and no discoloration. Hair is evenly distributed. smooth and pink in color. moist. Mouth and Oropharynx Lips are uniform in pink color. soft. yellowish and shiny tooth enamel. moves equally. The patient has 25 teeth with smooth. Lids close symmetrically. moves in unison with parallel alignment. When lids open. Lesions are absent. Nose Symmetric and straight. Pupils are black in color. pink in color. Eyes Hair in eyebrow is evenly distributed. contain air and light up equally. and smooth. Nodules and masses are absent. Auricles are mobile. Skin are intact on eyelids. Tympanic membrane is pearly gray in color and semitransparent. moist and pink in color. Both eyes are coordinated. no visible sclera above corneas. contour is symmetrical and has the ability to purse lips. Ears Color is the same as the face. Air moves freely as the patient breath through the nares. awake. black in color. skin is intact. equal in size.
muscles at rest are atonic (lacking firm). no discharge. Bse of the tongue is smooth with prominent veins. Patient has slow. Upon palpation. Bladder is not palpable. Thorax and Lungs Patient has barrel chest. No contractures were noted on the tendons and muscles. S3 is present. uniform in color. Posterior thorax has intact skin and has uniform temperature. Jugular veins are absent. When limbs were elevated. Salivary glands has the same color with the buccal mucosa and floor of the mouth. rounded. and no evidence of enlargement of liver or spleen. Pulsations are present on the tricuspid area. Expansion on posterior chest is evident. Nodes are not palpable on the entire neck. Movement of the abdomen while breathing is symmetric. Upon palpation. Abdomen Skin is unblemished on the abdomen. The contour of abdomen with reference to the foot is symmetric. Head movement is coordinated with smooth motion without discomfort.P a g e | 33 thin whitish coating. Gag reflex is present. coordinated . Crackles and wheezing heard upon auscultation on the chest. intensity is increased. Skin color is pink. Oropharynx is pink and has a smooth posterior wall. tricuspid and apical. no tenderness was noted with consistent tension. Heart Pulsations are absent on the aortic and pulmonic areas. Tonsils are pink and smooth. Upon auscultation of the heart on the aortic. veins collapse. Peripheral Vascular System Pulse volumes on periphery are symmetric. No edema was noted. Liver is not palpable and border feels smooth. no tenderness and masses are absent. Rapid breathing is noted and use of accessory muscles when breathing. Spinal alignment is vertical. Skin texture is resilient and moist. Musculoskeletal System Muscle size is equal on both sides of the body. Cough is productive. Neck Neck muscles are equal in size and head is centered. Pulsations are decreased. Chest wall is intact. Carotid arteries have also symmetric pulse volumes. Skin temperature is not excessively warm or cold. Uvula is light pink and smooth. Hard palate is lighter pink and has more irregular texture. Tongue moves freely without tenderness. Gland ascends upon telling the patient to swallow but is not visible. pulmonic. Thyroid gland is not visible upon inspection. Limbs are not tender and symmetric in size. Trachea is centrally placed in midline of the neck with space equal on both sides.
no tenderness. Patient communicates in a an average page with proper choice of words. Snellen chart was not used in the assessment. CRANIAL NERVE FUNCTION Cranial Nerve I Patient is able to identify the smell of alcohol and perfume. Thought Process Patient can recall three digit numbers that was asked to repeat. She can still recall the things she has done within the day. Awareness Patient is oriented to time. the date and names of family members. Patient can still recall information given earlier such as the name of the student nurse. swelling or nodules upon palpation.P a g e | 34 movements. Patient was asked of the time of the day. She can be able to perform simple mathematical calculations and problem solving. place. Cranial Nerve IV . Joints have no swelling. Patient is able to answer questions that need simple abstract thinking. She can respond to questions simultaneously. Patient has sound judgment and can be able to express her decisions and interests. and person by tactful questioning. alert and responds to verbal stimuli. Cranial Nerve II Patient can see the periphery when one eye is covered. Upon palpation of the bone. Communicating Process Patient is able to use verbal and nonverbal communication such as facial expression and hand gestures. Cranial Nerve III Patient can follow the six ocular movements and pupil reaction when light has been used in testing for PERRLA. She is able to use appropriate affect and mood and able to use appropriate words when communicating. MENTAL STATUS Level of Consciousness Patient is awake. Patient can able to comprehend questions and directions. Speaks clearly and uses appropriate words. Bones have no deformities. tenderness or swelling was not noted.
She can also identify sweet and sour taste. Cranial Nerve XI Head can extend to front. Alternating blunt and sharp ends over client’s forehead showed positive result. Patient is able to discriminate between sharp and dull sensation. Patient was able to squeeze fingers. back and sides. Cranial Nerve VII Patient is able to perform facial expression as assessed. Cranial Nerve V Patient’s blink reflex is positive through the use of cotton in touching the sclera. Cranial Nerve XII Patient can move tongue from side to side and can protrude it.P a g e | 35 Patient is positive to six ocular movements. Vibration on vocal chord is felt upon palpation. finger to fingers and fingers to thumb. finger to nose and to nurse’s fingers. CEREBELLAR / MOTOR FUNCTION Assessment on gross motor function is deferred. SENSORY FUNCTION Patient is able to react on light and touch sensation. Patient can recognize objects being placed on hands. Swallowing is also present. alternating supine and pronation of hand on lap. make fist. . She can able to determine one poin and two point objects being used. Patient can shrug shoulder against resistance from hand. Patient can also discriminate between hot and cold temperature. Cranial Nerve IX Swallowing ability is present and gag reflex. She can also identify numbers and letters written on palm. Cranial Nerve VIII Patient is able to hear words that were spoken to her and can hear audible sounds through the use of alternative device in assessing hearing of the patient. Cranial Nerve VI Eyes equally move. Cranial Nerve X Client’s speech has no hoarseness. able to perform finger to nose test. Patient is able to move her tongue freely side to side and up to down. eyeballs move laterally.
P a g e | 36 .
016- Dark Yellow Cloudy 1. Hodgkin’s disease and metastasis A decrease implies no significant interpretation A decrease implies no significant interpretation Within normal range Withn normal range Straw to dark yellow Clear Newborns: 11.8 x 84 % /L A decrease implies anemia. chronic myelocytic leukemia.52 0.4 /L /L 5-10 x /L 40-74 % 0.006 Adults: 1. Significant Laboratory Findings and Diagnostic Procedures Diagnostic or Laboratory Procedure Date Ordered and Date Results were released Normal Range Patient’s Results Male Female Analysis and Interpretation of Results HEMATOLOGY Hemoglobin 04-2010 140180 g/L 120160 g/L 117 g/L Hematocrit 04-2010 04-2010 RBC WBC 04-2010 Differential Count Neutrophils 04-2010 0.47 g/L g/L 4.02 Infants: 1. hay fever.030 Normal Result Turbity implies kidney infection An increase implies nephritic syndrome .420. parasitic infections.35 g/L 4.P a g e | 37 VI.0021. recent hemorrhage and fluid retention A decrease implies anemia and hemodilution A decreaseimplies anemia and fluid overload of >24 hours Within normal range Lymphocyt es Monocyte 04-2010 04-2010 19-48 % 12 % 3-9 % 2% Eosinophil 04-2010 Basophil 04-2010 URINE CHEMISTRY Color 04-2010 Appearance 04-2010 Specific 04-20Gravity 10 0-7 % 0-2 % 2% 0% An increase implies asthma.1 5.74.4 /L 8.26.370.
Fine granular. Waxy casts Small amounts Small amounts None Negative 2-4 /hpf 10-12 /hpf Coarsely granular. An increase implies trauma or tumors Normal result Glucose RBC WBC Casts Negative 0 /hpf 0-2 /hpf 0-2 0-5 /hpf /hpf Hyaline.0 (++) Within normal range Presence implies proteinuria.6-6. 1-2 /hpf Amorphous Materials Epithelial Cells Bacteria 04-2010 04-2010 04-2010 Few Few Many Normal result Normal result Presence implies GUT infection or contamination of external genitalia Other Procedures: X-ray 04/20/10 Conclusion: Bilateral Pleural Effusion predominantly at the left.5 None 5. coarse.022 4.P a g e | 38 pH Protein 04-2010 04-2010 04-2010 04-2010 04-2010 04-2010 1. RBC. Electrocardiograph 04/20/10 10 mm/ mV 25 mm/s HF:DF HR=112 bpm . WBC. renal failure or myeloma Normal result Within maximum normal range.
Marjorie Gordon’s Functional health Patterns Summary of Significant Findings ACTUAL NURSING DIAGNOSES Activity intolerance related to imbalance between oxygen supply and demand Anxiety related to breathlessness and restlessness from inadequate oxygenation Powerlessness related to inability to perform role responsibilities secondary to chronic illness and hospitalization.P a g e | 39 VII. POTENTIAL/ RISK NURSING DIAGNOSES b. Laboratory and Impaired gas Diagnostic Tests exchange related to alveolar edema due to elevated ventricular pressure secondary to pleural effusion . Physical Assessment Ineffective airway clearance related to presence of tracheobronchial obstruction Decreased Cardiac Output related to impaired contractility and increased preload and afterload. FINDINGS a. Excess fluid volume related to excess fluid or sodium intake and retention of fluid secondary to heart failure and its medical therapy c.
Anatomy and Physiology THE HEART THE HEART WALLS .P a g e | 40 VIII.
P a g e | 41 THE HEART CHAMBERS AND VALVES THE CONDUCTION SYSTEM OF THE HEART .
• Base – broad superior portion of the heart which is the point of attachment for the great vessels • Apex – inferior end that tapers to a blunt point immediately above the diaphragm The adult heart is about 9 cm wide at the base. 13 cm from base to apex and 6 cm from anterior to posterior at its thickest point – roughly size of one’s fist. Its weight is 300 g. between the lungs and deep to the sternum. .P a g e | 42 THE CIRCULATORY SYSTEM The Heart The heart is located in the thoracic cavity in the mediastinum. • Pericardium – a double-walled sac that encloses the heart Parts: .Parietal Pericardium – outer wall with thick superficial fibrous layer and thin serous layer.
while the left ventricle forms the apex and inferoposterior aspect.walled receiving chambers for blood returning to the heart by way of the great veins.P a g e | 43 . • Myocardium – the layer between the epicardium and the endocardium.Visceral Pericardium – covers the heart surface. The Chambers • Right and Left Atria – the thin. • Right and Left Ventricles – the pumps that eject blood into the arteries And keep it flowing around the body. It is a simple squamous endothelium overlying a thin areolar tissue layer. • Endocardium – lines the interior of the heart chambers. Each atrium has a small earlike extension called auricle that slightly increases its volume. The right ventricle constitutes most of the anterior aspect of the heart. The Heart Wall • Epicardium – serous membrane on the heart surface consisting of squamous epithelium overlying a thin layer of adipose tissue. It is where the largest branch of coronary blood vessel travel through.extends obliquely down the heart from the coronary sulcus toward the apex at the back Thin flaccid walls that are exhibited by the atria: Interatrial Septum – separates both atria Intraventricular Septum – much more vesicular The Valves Atrioventricular (AV) Valves – regulate the openings between the atria and the ventricles Semilunar Valves – regulate the flow of blood from the ventricles into the great arteries Pulmonary Valve – controls the opening from the right ventricle into the pulmonary trunk Aortic Valve . Sulci (grooves) – boundaries on the surface of the four chambers of the heart Namely: Coronary Sulcus – encircles the heart near the base and separates the atria above the ventricles below. It covers the valve surfaces and is continuous with the endothelium of the blood vessels. Anterior Intraventricular Sulcus – extends obliquely down the heart from the coronary sulcus toward the apex at the front Posterior Intraventricular Sulcus .controls the opening from the left ventricle into the aorta Blood Flow through the Chambers . It is the thickest and performs the work of the heart.
and the inferior vena cava draining the abdominal cavity and lower limbs. The oxygen-enriched blood returns by way of several veins which converge to form four pulmonary veins by the time they reach heart. Blood in the aorta flows to every organ in the body. "Isovolumic ventricular contraction" it is when the ventricles begin to contract. and expels blood through the aortic valve into the ascending aorta. This artery ascends from the heart front of the heart and branches into the right and left pulmonary arteries.the fibrous skeleton acts as an insulator to prevent currents from getting to the ventricle by another route. AV valves open and blood flows from atrium to the ventricle. as well as the semilunar valves and there is no change in volume. neck. Atrioventricular Node – acts as an electrical gateway to the ventricles. These four empty into the left atrium. Heart Rate . which lead to the respective lungs. Cardiac cycle is the term referring to all or any of the events related to the flow or blood pressure that occurs from the beginning of one heartbeat to the beginning of the next. Ventricles are empty. the AV valve closes and blood is forced through the pulmonary valve into the pulmonary trunk. "Atrial systole" when atria is contracting. Second. When the right ventricle contracts. Sinoatrial Node – the pacemaker of the heart that initiates each heartbeat and determines the heart rate. 2. this blood unloads its carbon dioxide and picks up a load of oxygen. no blood is entering the ventricles. Pressure decreases. 4. Blood in the right atrium flows through the right AV valve and into the right ventricle. AV valves close. the AV Valves open and the whole heart is relaxed. Blood flows from there past the left valve into the left ventricle. upper limbs and thoracic cavity. "Late diastole" which is when the semilunar valves close. 4. the superior vena cava draining the head.the frequency of the cardiac cycle Five Stages of 'beat' of the heart: 1. Atrioventricular Bundle – forks into the right and left bundle branches.P a g e | 44 Blood returns to the heart through the two large veins. ventricles stop contracting and begin to relax. 3. They form more elaborate networks in the left ventricle than in the right. The left ventricle contracts at the same time as the right. In the lungs. 5. and returning to the heart via the vena cavae. The Conduction System 1. unloading some of its O2 from the tissues. Purkinje Fibers – distribute the electrical excitation to the myocytes of the ventricles. 2. "Isovolumic ventricular relaxation". they are still contracting and the semilunar valves are open. semilunars are shut because blood in the aorta is pushing them shut. which enter the interventricular septum and descend toward the apex. "ventricular ejection". 3. .
the blood pressure increases and decreases. which is the product of stroke volume and heart rate. which are long chains of sarcomeres. Each myocyte contains myofibrils. the contractile units of the cell. This applies equally to both left and right ventricles of the heart. They arise from myoblasts. It is calculated by subtracting the volume of blood in the ventricle at the end of a beat (called end-systolic volume) from the volume of blood just prior to the beat (called end-diastolic volume). Under normal circumstances. Myocyte (also known as a muscle cell) is the type of cell found in muscles. These two stroke volumes are generally equal. Because stroke volume decreases in certain conditions and disease states. . Stroke volume (SV) is the volume of blood pumped from one ventricle of the heart with each beat. each cycle takes approximately one second. The cardiac cycle is coordinated by a series of electrical impulses that are produced by specialized heart cells found within the sino-atrial node and the atrioventricular node.P a g e | 45 Throughout the cardiac cycle. both approximately 70 ml in a healthy 70-kg man. Stroke volume is an important determinant of cardiac output. The cardiac muscle is composed of myocytes which initiate their own contraction without help of external nerves (with the exception of modifying the heart rate due to metabolic demand). stroke volume itself correlates with cardiac function.
apical impulse is hypertrophy Increased Increased displaced laterally polymorphisms of S4 catecholamine preload Paroxysmal the release nocturnal Increased pulmonary breathing reninangiotensincapillary pressure Increased Increased Increased aldosterone system ventricular heart rate contraction of (RAAS) and Pulmonary Air in lungs volume sarcomeres edema replaced by blood/ sympathetic system Increased strokeinterstitial fluid have also been Small airway Rales volume Stimulates associated with juxta. Fatigue *hyperlipidemia orthopnea * diabetes Fluid retention Normal Decreased Sweating during the day O2 in perfusion at *CAD venous night LIFESTYLE Nocturia blood *smoking Skin appears dusky *alcohol consumption Right-sided HF *Use of cardiotoxic drugs ENVIRONMENT .P a g e | 46 IX. coronary adrenergic depression of Decreased Diastolic the artery disease.perfusion of fusion of pooling in the heart to supply perfusion *Elderly people triction the heart the extremities appropriate during the day OTHERS cerebrum and abdomen amounts of blood to *hypertension Ischemia Confusion skeletal muscles Shortness of breath.obstruction wheezing Increased endsusceptibility to capillary I diastolic pressure and/or mitigation of receptors Reflex shallow HF and rapid Left-sided HF * Gene variants in breathing the alpha-2c Reduction in vital capacity Restrictive physiology Air trapping adrenoceptor and the alpha-1 Work of breathing increases adrenoceptor RACE Respiratory Dyspnea * African Americans muscle fatigue * Hispanic/Latinos Ventilation/ Perfusion mismatch * Native Americans *Soviet Republics Peripheral Decreased Underper-Reduced blood Inability of the Reduced renal AGE vascons. stroke volume support of respiratory dysfunction ventricular center myocardial Decreased function infarction. Pathophsiology (Left Sided Heart Failure) AGENT HOST GENES Inappropriate Restricted Decreased *Genetic methods placed filling on myocyte Myocyte predisposition on on the heart the heart contractility loss hypertrophic cardiomyopathy Decreased Decreased Increased (HCM) and dilated Systolic WHEN SLEEPING elastic stiffness of the relaxation dysfunction cardiomyopathy Reduced Nocturnal recoil ventricle (DCM). and cardiac output Increased left Rapid filling in hypertension ventricular endearly diastole * Genetic diastolic pressure S3.
ascites. myocardial infarction.P a g e | 47 Pathophsiology (Right Sided Heart Failure) HOST GENES *Genetic predisposition on hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM). dependent edema Distention of liver capsule RUQ pain dyspnea Right-Sided HF . and hypertension * Genetic polymorphisms of the reninangiotensinaldosterone system (RAAS) and sympathetic system have also been associated with susceptibility to and/or mitigation of HF * Gene variants in the alpha-2c adrenoceptor and the alpha-1 adrenoceptor RACE * African Americans * Hispanic/Latinos * Native Americans *Soviet Republics AGE *Elderly people OTHERS *hypertension *hyperlipidemia * diabetes *CAD LIFESTYLE *smoking *alcohol consumption *Use of cardiotoxic drugs ENVIRONMENT AGENT Pulmonary HTN Cor Pulmonale Right Ventricular Pressure > Left Ventricular Pressure Interventricular septum bows to the left Prevent efficient filling of the left ventricle Pulmonary congestion Partial obstruction of the left ventricular outflow Left-Sided HF Increased Destruction of Hypoxia-induced Sequela to Right afterload on the pulmonary vasoconstriction of thepulmonary ventricular right ventricle capillary bed pulmonary arteries disease ischemia Systolic dysfunction Decreased stroke volume Decreased cardiac output Decreased ventricular function Decreased Decreased Increased elastic stiffness of the relaxation recoil ventricle Diastolic dysfunction Increased right ventricular enddiastole pressure Congestion of hepatic veins hypertrophy Increased Increased Increased catecholamine preload right-sided release Increased atrial pressure pressure Increased ventricular volume Increased Increased Accumulation Expansion of Impinge heart rate contraction of the liver normal of fluid in the sarcomeres diaphragmsystemic matic Increased stroke venous function circulation volume Venous congestion Anasarca. coronary artery disease.
as indicated I: to maintain airway 5. R: Auscultate breath sounds.P a g e | 48 X. The patient may report orthopnea. R: Monitor vital signs and cardiac rhythm I: for baseline data and monitoring 2. or shortness of breath. difficulty in breathing when lying flat.as verbalized by the patient Objective cue: >restlessness >irritability >diaphoresis >bilateral crackles that do not clear with cough >pale skin color Scientific Analysis: Dyspnea. R: Encourage frequent position changes and deepbreathing/coughing exercises. the objectives were partially met. Nursing Care Plans DATE ACTIVE PROBLEM Impaired gas exchange related to alveolar edema due to elevated ventricular pressures Subjective cue: “Maglisod jud ko'g ginhawa”. R: Encourage adequate rest and EVALUATION Desired Outcome: After 8 hours of nursing intervention. R: Elevate head of bed. may be precipitated by minimal to moderate activity (dyspnea on exertion [DOE]). Patients with NURSING INTERVENTIONS Independent: 1. dyspnea also can occur at rest. R:Note character and effectiveness of cough mechanism I: ability to clear airways of secretions 4. Use incentive spirometer. the patient was able to demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within patient's normal limits and absence of symptoms of respiratory distress Actual Outcome: After 8 hours of nursing intervention. as indicated I: promotes chest expansion and drainage of secretions 6. provide adjuncts and suction. R: Maintain adequate I/O I: for mobilization of secretions 7. chest physiotherapy. I: notes areas of decreased/adventitious breath sounds 3. The patient was able to improved ventilation and oxygenation of tissues as evidenced by patient breathing without using much of the accessory muscle April 22. 2010 .
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orthopnea usually prefer not to lie flat. They may need pillows to prop themselves up in bed, or they may sit in a chair and even sleep sitting up. Some patients have sudden attacks of orthopnea at night, a condition known as paroxysmal nocturnal dyspnea (PND). The cough associated with left ventricular failure is initially dry and nonproductive. Most often, patients complain of a dry hacking cough that may be mislabeled as asthma or chronic obstructive pulmonary disease (COPD). The cough may become moist. Large quantities of frothy sputum, which is sometimes pink (blood tinged), may be produced, usually indicating severe pulmonary congestion (pulmonary edema). Adventitious breath sounds may be heard in various lobes of the lungs. Usually, bi-basilar crackles that do not clear with coughing are detected in the early phase of left ventricular
limit activities to within client tolerance. I: Promote calm/restful environment helps limit oxygen need/consumption 8. R: Keep environment allergen/pollutant free I: to reduce irritant effect of dust and chemicals on airway 9. R: Provide psychological support, active-listen questions/concerns I: to reduce anxiety Dependent: 1. R: Administer medications, as indicated I: to treat underlying conditions Source: Source: Sparks, S and Taylor, C, Nursing Diagnosis Reference Manual 3rd edition; Springhouse Corporation, Pennsylvannia
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failure. As the failure worsens and pulmonary congestion increases, crackles may be auscultated throughout all lung fields. At this point, a decrease in oxygen saturation may occur (Wolkenstein, 2000). April 22, 2010 Decreased Cardiac Output related to impaired contractility and increased preload and afterload. Subjective cue: “Sige ra jud kog pangluspad”,as verbalized by the patient Objective cue: >restlessness >irritability >diaphoresis >pale skin color Scientific Analysis: In addition to increased pulmonary pressures that cause decreased oxygenation, the amount of blood ejected from the left ventricle may decrease, Independent: 1. R: Place patient at physical and emotional rest I: to reduce work of heart. 2. R: Provide rest in semi-recumbent position or in armchair in airconditioned environment I: that reduces work of heart, increases heart reserve, reduces BP, decreases work of respiratory muscles and oxygen utilization, improves efficiency of heart contraction; recumbency promotes diuresis by improving renal perfusion 3. R:Provide bedside commode I: to reduce work of getting to bathroom and for defecation. 4. R: Provide for psychological rest since emotional stress produces vasoconstriction. I:elevates arterial pressure, and Desired Outcome: After 8 hours of nursing intervention, the patient was able to demonstrate improved cardiac output within normal levels of preload and afterload. Actual Outcome: After 8 hours of nursing intervention, the objectives were partially met. The patient was able to initiate actions to increase cardiac output but symptoms persisted.
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sometimes called forward failure. The dominant feature in HF is inadequate tissue perfusion. The diminished CO has widespread manifestations because not enough blood reaches all the tissues and organs (low perfusion) to provide the necessary oxygen. The decrease in SV can also lead to stimulation of the sympathetic nervous system, which further impedes perfusion to many organs. Blood flow to the kidneys decreases, causing decreased perfusion and reduced urine output (oliguria). Renal perfusion pressure falls, which results in the release of renin from the kidney. Release of renin leads to aldosterone secretion. Aldosterone secretion causes sodium and fluid retention, which further increases intravascular volume. However, when the patient is sleeping, the cardiac workload is decreased, improving renal perfusion, which then leads to frequent urination at night (nocturia). Decreased CO causes other
speeds the heart. 5. R: Promote physical comfort. Avoid situations that tend to promote anxiety and agitation. Offer careful explanations and answers to the patient's questions. I: Decreases anxiety 6. R: Take frequent BP readings. Observe for lowering of systolic pressure. Note narrowing of pulse pressure. Note alternating strong and weak pulsations (pulsus alternans). Auscultate heart sounds frequently and monitor cardiac rhythm. Note presence of S3 or S4 gallop (S3 gallop is a significant indicator of heart failure). Monitor for premature ventricular beats. I: Evaluates for progression of leftsided heart failure. Source: Source: Sparks, S and Taylor, C, Nursing Diagnosis Reference Manual 3rd edition; Springhouse Corporation, Pennsylvannia
and anxiety due to decreased oxygenation and blood flow.(Wolkenstein. Stimulation of the sympathetic system also causes the peripheral blood vessels to constrict. 2000). as verbalized by the patient Objective cue: >Adventitious breath Independent: 1. confusion. vital signs within patient's normal limits. As anxiety increases. R: Compare current weight admission and/or previously stated weight I: provides a comparative baseline 2. Decreased gastrointestinal perfusion causes altered digestion. and free signs of edema Actual Outcome: After 8 hours of nursing intervention. Decreased brain perfusion causes dizziness. stable weight. April 22. so does dyspnea. so the skin appears pale or ashen and feels cool and clammy. restlessness.P a g e | 52 symptoms. R: Measure abdominal girth for changes that I: may indicate increasing fluid retention/edema Desired Outcome: After 8 hours of nursing intervention. 2010 Excess fluid volume related to excess fluid or NA intake and retention of fluid secondary to Heart failure and its medical therapy Subjective cue: “puno kaayo akong gibati. lightheadedness. R: Auscultate breath sounds I: for presence of crackles and congestion 3. enhancing anxiety and creating a vicious cycle. the patient was able to stabilize fluid volume as evidenced by balance I/O. the objectives .”.
change position frequently I: to reduce tissue pressure and risk for skin breakdown 7.g.P a g e | 53 sounds(crackles) >changes in respiratory pattern >Dyspnea >Restless >Pulmonary congestion Scientific Analysis: Fluid that accumulated in the dependent extremities during the day begins to be reabsorbed into the circulating blood volume when the person lies down. 2000). BP. The fluid filled alveoli cannot exchange oxygen and carbon dioxide. causing further shifting of fluid into the alveoli. as appropriate I: to facilitate movement of diaphragm. R: Restrict sodium and fluid intake. the pressure in the pulmonary circulation increases. The patient was able to have a normal vital signs of T-37. thus improving respiratory effort Dependent: 1. R: Place in semi-Fowler's position. as indicated I: for nutritional therapy Source: Source: Sparks. (Wolkenstein. R: Observe skin and mucous membranes I: for presence of decubitus/ulceration 6. R: Administer medications (e.110/70 mmHG .1 c. 4. the patient experiences dyspnea and has difficulty getting an adequate amount of sleep. S and were partially met. Without sufficient oxygen. R: Assess neuromuscular reflexes I: to evaluate for presence of electrolyte imbalances such as hypernatremia 5. R: Elevate edematous extremities.diuretics) I: To treat underlying conditions Collaborative: 1. Because the impaired left ventricle cannot eject the increased circulating blood volume. P-77 bpm R-19 cpm.
Nursing Diagnosis Reference Manual 3rd edition. Actual Outcome: . I: Instruct and help patient to alternative periods of rest and activity. C. * Patient states understanding of the need to increase activity level gradually. Objective: . R: To help increase the activity level. R: Improves physical and psychosocial well-being. 6.” as verbalized by the patient. Pennsylvannia Independent: 1.generalized weakness . Desired Outcomes: After 8 hours of nursing interventions. blood is Taylor. 4. being sure to include activities the patient considers essential. * Patient demonstrates skill in conserving energy while carrying out daily activities to tolerance level. * Patient explains illness and connects symptoms of activity intolerance with deficit in oxygen supply or use.P a g e | 54 April 23. * Patient states desire to increase activity level. I: Identify activities the patient considers desirable and meaningful. 2010 Activity intolerance related to imbalance between oxygen supply and demand Cues and Objectives Subjective: “dali ra ko makutasan. R: Participation in planning helps ensure patient compliance. I: Identify and minimize factors that decrease the patient’s exercise tolerance.limited range of motion . 5. 2. * Patient states satisfaction with each new level of activity attained. I: Monitor physiological responses to increased activity. I: Encourage patient to help plan activity progression. dili ko kasugakod ug dugay ug bug-at nga trabaho. Springhouse Corporation. To compensate. the heart is unable to pump the amount of blood required to meet all of the body’s needs.short term performance of an activity Scientific Analysis: As heart failure becomes more severe. R: To enhance their positive impact. R: To reduce the body’s organ demand and prevent fatigue. * Blood pressure and pulse and respiratory rates remain within prescribed limits during activity. 3. I: Discuss with the patient the need for activity.
Nursing Diagnosis Reference Manual 3rd edition. people with heart failure often feel weak (especially in their arms and legs). 8. Springhouse Corporation. R: These measures reduce cellular metabolism and oxygen demand. R: Participation in planning encourages patient satisfaction and compliance. including the arms and legs. . climbing stairs or carrying groceries R: To ensure return to normal a few minutes after exercising. Source: Source: Sparks. formulate a plan with the patient and caregivers that will enable the patient either to continue functioning at maximum activity intolerance or to gradually increase the tolerance. 10. I: Teach patient exercises for increasing strength and endurance. The: *Patient stated understanding of the need to perform daily activities. R: Improves breathing and gradually increase activity level. I: Teach patient how to conserve energy while performing activities of daily living. the objectives were partially met.P a g e | 55 diverted away from less-crucial areas. 7. tired and have difficulty performing ordinary activities such as walking. *Patient demonstrated conservation of energy while performing activities. S and Taylor. I: Support and encourage activity to patient’s level of tolerance. I: Before discharge. C. As a result. 9. to supply the heart and brain. R: Helps patient develop level of tolerance. Afer 8 hours of nursing intervenions.
I: Suction as needed. .use of accessory muscles when breathing . and deep breath every 2 to 4 hours. *Patient’s arterial blood gas values are within normal limits. the objectives were partially met. unless contraindicated.tachypnea with RR of 28 Scientific Analysis: Mucus is produced at all times by the membranes lining the air passages. Objective: . I: Encourage fluids (atleast 3. R: To help prevent pooling of secretions and to maintain airway patency. R: To facilitate chest expansion and Desired Outcome: After 8 hours of nursing interventions. The: *Patient verbalized understanding on coughing techniques * Patient increased fluid volume to 3 to 4 liters per day. and to ventilate basilar lung fields.shortness of breath . I: Help patient turn. * Patient clears airway using controlled coughing techniques. * Patient expectorates sputum. 4. R: To ensure adequate hydration and loosen secretions. I: Mobilize patient to full capabilities. 2010 Ineffective airway clearance related to presence of tracheobronchial obstruction Cues and Evidences: Subjective: “maglisod ko ug ginhawa nya huot ako dughan.P a g e | 56 Pennsylvannia April 23. * Patient drinks 3 to 4 liters of fluid daily. R: To stimulate cough and airways. The inflammation and increased in secretions block the airways making it difficult for the person Independent: 1. 3.dyspnea .000 mL daily). I: Place patient in Fowler’s position and support upper extremities. 6. especially postural drainage. Be alert for progression of airway clearance. *Patient understands necessity of adequate hydration Actual Outcome: After 8 hours of nursing interventions. cough. R: To aid breathing and chest expansion.” as verbalized by the patient. R: To detect early signs of compromise. excess mucus is produced and it will retain in tracheobronchial tree. 2. *Patient performs chest physiotherapy. I: Assess respiratory status at least every for hours or according to establishment standards. 5. When the membranes are irritated or inflamed.
R: To prevent spreading infection. Springhouse Corporation. I: Perform postural drainage. 10. Encourage lateral. 8. I: Monitor and document sputum characteristics every shift. 2000). and upright positions as much as possible. sitting. cough reflex will be stimulated. C. I: Provide tissues and paper bags for hygienic sputum disposal. R: To enhance mobilization of of secretions that interferes with oxygenation. Pennsylvannia .P a g e | 57 to maintain a patent airway. R: To enhance lung expansion and ventilation. R: To gauge therapy’s effectiveness. prone. 7. 9. I: Avoid supine position for extended periods. Nursing Diagnosis Reference Manual 3rd edition. In order to expel excessive secretions. and vibration every 4 hours or as ordered. Source: Sparks. percussion. An increased in RR will also be expected as a compensatory mechanism of the body due to obstructed airways (Wolkenstein. S and Taylor. ventilation.
gonorrhea. otitis media. paresthesias GI: nausea. reducing or eliminating infection. diarrhea. flatulence.letharg y. • Inspect IM and IV injection sites frequently for signs of phlebitis. penicillins. sinusitis. urinary tract infections. Name of medication or drugs Cefuroxime 750mg IVTT Drug Study indications/reasons for administrating the drugs Side effects. Determine history of hypersensitivity reactions to cephalosporins. skin and soft tissue infections. before therapy is initiated.vomiting . abdominal pain. particularly to drugs. . dizziness. pharyngitis/tonsillitis. GU: nephrotoxicity Hematologic: bone marrow depression Hypersensitivi ty: ranging from rash to fever to anaphylaxis. Although pseudomembranous colitis. meningitis. and is used for surgical prophylaxis. and history of allergies. lower respiratory tract infections.P a g e | 58 XI. Report any significant changes. Effectively treats bone and joint infections.anorexi a. • Report onset of loose stools or diarrhea. serum sickness reaction • Nursing Interventions It is effective for the treatment of penicillinase-producing Neisseria gonorrhoea (PPNG). adverse reactions a nurse note for CNS: headache. bronchitis. • Monitor I&O rates and pattern: Especially important in severely ill patients receiving high doses.
• Do not self-medicate children for pain more than 5 d without consulting a physician. backache and period pains.g. One advantage of paracetamol over aspirin and NSAIDs is that it doesn't irritate the stomach or causing it to bleed. Skin rashes.5° C (103° F). or recurrent fever. For this reason. overdosing and chronic use can cause liver damage and other toxic effects. cold and flu remedies. Paracetamol is often included in cough. Patient & Family Education • Do not take other medications (e. Side effects are rare with paracetamol when it is taken at the recommended doses. muscle and joint pain.P a g e | 59 Paracetamol 500mg 1 tab q 8h for fever To relieve mild to moderate pain due to things such as headache. It is also used to bring down a high temperature. even with moderate acetaminophen doses.. blood disorders and acute inflammation of the pancreas have occasionally occurred in people taking the drug on a regular basis for a long time. especially in individuals with poor nutrition. cold preparations) containing acetaminophen without medical advice. . potential Side effects of aspirin and Assessment & Drug Effects • Monitor for S&S of: hepatotoxicity. fever over 39. • Do not give children more than 5 doses in 24 h unless prescribed by physician. paracetamol can be given to children after vaccinations to prevent postimmunisation pyrexia (high temperature). • Do not use for fever persisting longer than 3 d.
vomiting. hyperglycemia. Excessive diuresis can result in dehydration and hypovolemia. hyponatremia hypokalemia. . Monitor BP during periods of diuresis and through period of dosage adjustment. dehydration. Sudden death from cardiac arrest has been reported. Report symptoms to physician. constipation. Sudden alteration in fluid and electrolyte balance may precipitate significant adverse reactions. acute hypotensive episodes. elevated BUN. Exact mode of action not clearly defined. hypomagnesemia. dizziness with excessive diuresis. particularly in meningitis. Weigh patient daily under standard conditions. blood sugar. cirrhosis of liver. Has been used concomitantly with mannitol for treatment of severe cerebral edema. circulatory collapse. including nephrotic syndrome. oral and gastric burning. diarrhea. and uric acid values during first few months of therapy and periodically thereafter. CO2. and for treatment of hypercalcemia. and kidney disease. Monitor I&O ratio and pattern. Metabolic: Hypovolemia. BUN. glycosuria. closely monitor BP and vital signs. GI: Nausea. alone or in combination with other antihypertensive agents. Monitor for S&S of hypokalemia. Report decrease or unusual increase in output.P a g e | 60 NSAIDs. Furosemide 80mg IVTT actions: Rapid-acting potent sulfonamide "loop" diuretic and antihypertensive with pharmacologic effects and uses almost identical to those of ethacrynic acid. hypocalcemia (tetany). CV: Postural hypotension. decreases renal vascular resistance and may increase renal blood flow Treatment of edema associated with CHF. hyperuricemia. Observe older adults closely during period of brisk diuresis. Drug may cause hyperglycemia. anorexia. Assessment & Drug Effects • • • • • • • Observe patients receiving parenteral drug carefully. and hypotension. Lab tests: Obtain frequent blood count. Monitor urine and blood glucose & HbA1C closely in diabetics and patients with decompensated hepatic cirrhosis. serum and urine electrolytes. circulatory collapse. hypochloremia metabolic alkalosis. May be used for management of hypertension.
leukopenia. blurred vision. exfoliative dermatitis. necrotizing angiitis (vasculitis). Body as a Whole: Increased perspiration. Skin: Pruritus. acute pancreatitis. urinary frequency. porphyria cutanea tarde. irreversible renal failure. jaundice. purpura. agranulocytosis (rare). aplastic anemia. thrombocytopenic purpura.P a g e | 61 abdominal cramping. feeling of fullness in ears. . Urogenital: Allergic interstitial nephritis. hearing loss (rarely permanent). vertigo. paresthesias. Special Senses: Tinnitus. activation of SLE. photosensitivity. urticaria. Hematologic: Anemia.
Salbutamol 1 neb q6 To relieve bronchospasm associated with acute or Assessment & Drug Effects Body as a Whole: . pain at IM injection site. weakness.P a g e | 62 muscle spasms. thrombophlebitis.
CNS stimulation. vomiting. anxiety. Also used to prevent exercise-induced bronchospasm. convulsions. which may interfere with precision handwork. weakness. Monitor for: S&S of fine tremor in fingers. Essential hypertension. and pulse oximetry. dilated pupils. bradycardia. GI • ducate patient to avoid hazardous activity such as driving until response to drug is known. and vascular supply to skeletal muscles) than on beta1 (heart) receptors. nervousness. GI symptoms. excitement.P a g e | 63 actions: Synthetic sympathomimetic amine and moderately selective beta2adrenergic agonist with comparatively long action. Hypersensitivity reaction. Special Senses: Blurred vision. GI: Nausea. reflex tachycardia. (hyperactivity. tachycardia. Acts more prominently on beta2 receptors (particularly smooth muscles of bronchi. bronchitis. Minimal or no effect on alpha-adrenergic receptors. particularly in children 2–6 y. . Aldozide 1 tab BID chronic asthma. hoarseness. hypotension. insomnia). if drug-induced insomnia is a problem. CV: Palpitation. edema and ascites of Gynecoma stia. or other reversible obstructive airway diseases. hallucinations. nervousness. uterus. Lab tests: Periodic ABGs. Consult physician about giving last albuterol dose several hours before bedtime. Report promptly to physician. pulmonary functions. Other: Muscle cramps. CNS: Tremor. • • • • Monitor therapeutic effectiveness which is indicated by significant subjective improvement in pulmonary function within 60–90 min after drug administration. hypertension. headache. Inhibits histamine release by mast cells. restlessness.
fever. mental confusion.P a g e | 64 Mechanism of Action: : competes with aldosterone for receptor sites in the distal renal tubules. idiopathic edema symptoms . lethargy. acute pancreatiti s. pruritus. muscle spasm. headache and thrombocy topenia. increasing sodium chloride and water excretion while conserving potassium and hydrogen ions. liver cirrhosis. leukopeni a. cutaneous eruptions. paresthesi a. weakness. ataxia • • Take with meals or milk. serum electrolytes (K. may block the effect of aldosterone on arteriolar smooth muscle as well CHF. Na) and renal function . jaundice. nephritic syndrome. avoid excessive ingestion of food high in potassium or use of salt substitutes Diuretic effect may be delayed 2-3 days and maximum hypertensive may be delayed 2-3weeks. agranuloc ytosis. orthostati c hypertensi on. monitor I and O ratios and daily weight. BP.
Refer to drug instructions for each. Discharge Plan Outcome Identification Nursing Interventions Patients need to understand the purpose. .Instruct patient to plan exercises on a regular basis each day. I .Advice patient that prolonged strenuous exercise may require increased food at bedtime to avoid nocturnal hypoglycemia.Assess patient’s understanding of exercise regimen.Advise patient to assess blood glucose level before and after strenuous exercise.Evaluate the patient’s level of understanding on the instructions given about the medications METHODS Medication Exercise and Environme nt Regularly scheduled.Remind and instruct the parent on home medication instructions . and improves cardiovascular fitness. E . and possible side effects of all medication orders and instructions to be given prescribed medications. moderate exercise performed for at least 30 minutes most days of the week promotes the utilization of carbohydrates.P a g e | 65 XII. . route. A . A . − Instruct patient to avoid exercise whenever blood glucose . I .Explain the importance of exercise: Caloric expenditure for energy in exercise Carryover of enhanced metabolic rate and efficient food utilization .Assess patient and SO’s ability to understand regarding home dosage. • • . enhances the action of insulin.Encourage patient to eat a carbohydrate snack before exercising to avoid hypoglycemia. assists with weight control.
Assess patient’s will or degree to decrease/ cease smoking.Patients need to know when to notify the physician and increase testing during times of illness. − − − Encouraged so to maintain quiet environment Encouraged so to maintain patient surrounding clean Encouraged so to provide patient proper hygiene E .Assess for the patient’s ability to do self-care the name of a smoking cessation program or . You follow the same . In addition.Check the response to the interventions and actions performed Health Teaching and If the patient continues to smoke. encourage patients to stop smoking. Patient should contact health care provider if levels remain elevated. Instructed the patient to right information or advice by the physician Instructed the patient to follow right time & medication − Because of the atherosclerotic changes that occur. A . − Stress the importance of close attention to even minor skin injuries. a support group. I .Assess if the patient is continually sticking to V/S monitoring schedules and treatment regimen. provide A . Treatment Teach patients the appropriate technique for testing blood and urine and how to interpret the results.Evaluate patient’s level of understanding on the information given and degree of awareness on the importance of good sanitation and proper exercise. teach patients to avoid crossing their legs when sitting and to begin a regular exercise program.P a g e | 66 levels exceed 250 mg/day and urine ketones are present. − E .
Evaluate progress of health condition.Evaluate patient’s level of understanding on the instructions given and information open to her.Evaluate responses to wellness plan and action performed .Assess for signs and symptoms .Instruct patient to watch for timing of food and not to eat more .Discuss concerns with parent to identify underlying issues − Identify health behaviors/habits that may interfere to improve patient’s health status Instructed patient to do other way of personal hygiene like proper hand washing. A . Remind for follow-up schedule. I . tooth brushing after eating and taking a bath everyday − E . Call if appropriate. and pregnancy. stress.Assess foods in compliance to given diet -Assess patient’s preference of food I . growth periods. Diet Emphasize the importance of adjusting diet during illness.Instruct patient/ SO to refer immediately to physician if health condition worsens − − Instructed the patient to express every time of discomfort Encourage patient to side to side position E .P a g e | 67 Hygiene protocol for drinking to avoid other diseases. A . Out Patient follow-up and Observatio n Note any referrals to social services.Assess the understanding of the parent as to the possible reason for follow-up visit I .
Avoid salt whenever possible. Do not fry foods. High in calories. • Avoid adding calories with butter or cream sauces.Teach how to calculate caloric intake. Eat raw fruits and vegetables or steam vegetables to retain fiber. soy sauce. Limit use of foods with hidden sodium content (eg.P a g e | 68 than necessary. and vegetables. pickled foods. Carbohydrates should be varied to include fruits. processed meats). . . fats contribute to weight gain in type 2 diabetes mellitus (DM). • Protein selections that are lean will help reduce fat and cholesterol intake. proteins. . Encourage patients to avoid alcohol . cheese. . • Do not season foods with salt or salt-containing spices. skim off fat from stews or other prepared dishes.Use alcohol only in moderation. crackers. bouillon). gravies. • Use salt-containing condiments sparingly (ketchup. or boil foods and discard fat. and fats. broil.Prepare foods to retain vitamins and minerals and reduce fats.Each meal should consist of a balance of carbohydrates. Bake. and bacon. • Fats should be used sparingly with <10% of total calories derived from saturated fats. • Trim all visible fat from meat. starches. fat back. • • • • • .
etc.Evaluate emotional. psychosocial and spiritual progress. • • . • • Limit diet: soda intake to 2 L/day.Use alternative nonnutritive. or 1. A . 12 oz beer. E .Evaluate patient’s level of understanding and degree of awareness about strict implementation of the diet. noncaloric sweeteners in moderation. Spiritual Provide emotional and spiritual support.Assess patient’s readiness to be involved in such activities .Strengthen patient’s relationship with God by letting him participate religious activities: Sunday Mass. Avoid frequent use of foods and beverages with concentrated sucrose. Prayer Meetings.5 oz distilled liquor = 1 alcohol serving). E – Evaluate patient’s desire for spiritual growth . .Encourage patient to attend Sunday Masses if Catholic .P a g e | 69 Do not omit food from meal plan in exchange for alcohol. Limit intake to 1-2 drinks per week (4 oz dry wine.Assess for barriers to practice religious beliefs I . Rosary.
McPhee. Vishwanath R Linggapa. 8th Edition.A. Bibliography Amnesi. Sandra M. Pathophysiology of Disease: An Introduction to Clinical Medicine. Philadelphia: F. 2008. Nettina. Davis Company. Susan A Johnson.. . Stamford. Pennsylvania: F. Sandra M. Diseases and Disorders: A Nurses. and et. Doenges. 2nd Edition. Lippincott Manual of Nursing Practice. Connecticut: Appleton & Lange. and Elizabeth Jacqueline Mills. Therapeutic Manual 3rd Edition. 1997. Chicago: Lippincott Williams & Wilkins. Stephen J. PPD's Nursing Drug Guide. Davis Company. Mary Frances Moorhouse. and Jack D Lange. Sommers.P a g e | 70 XIII.A. Lippincott Williams & Wilkins. Marilyn S. 2008. Marilynn. and Alice Murr. al. and Theresa A Beery. 2006. 2009. William F Ganong. Brunner& Suddarth's Medical-Surgical Nursing 10th Edition.. Pasig: Medicomm Pacific. Inc. 11th edition. Nurse's Pocket Guide. 2007.
P a g e | 71 XIV. Appropriate nursing interventions are needed to be carried on in order to help the patient alleviate symptoms and regain the health status. Learning Insights Upon conducting the case study on congestive heart failure. I was able to learn to identify the problems being encountered by patients and therefore. *** . Through this case study. I have learned another aspect in the field of Medical Surgical Nursing. diagnostic procedures on identifying the disease. its treatment procedures including medical regimen and developing nursing care plans has helped me understood the details and necessary information about the disease. the symptoms. Studying about the disease process itself from factors affecting it. pathophysiology. being able to prioritize them and address then accordingly.
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