Perpetual Help College of Manila 1240 V. Concepcion St.

Sampaloc, Manila College of Nursing

A Case Study on: Congestive Heart Failure

Presented to the faculty of Perpetual Help College of manila

In partial fulfillment of the requirements for Nursing Care Management (NCM) 204 Related Learning Experiences 1st semester of S.Y. 2010-2011

Submitted by Section E – Group 1

OBJECTIVES
General: This study aims to develop knowledge, skills and attitudes towards nursing care management of client who developed a Congestive Heart Failure due to Type II Diabetes Mellitus.

Specifically, this aims to: • To identify the precipitating factors regarding the pathogenesis of the disease being manifested by the client • • • To enumerate clinical manifestations of the diseases manifested by the client To discuss the pathophysiology of Left-Sided Congestive Heart Failure. To demonstrate the appropriate approach used in dealing with clients with Congestive Heart Failure. • To perform dependent and independent interventions, being done to the client appropriately and with care. • To perform comprehensive nursing care and interventions with competence and confidence in rendering care to clients with Congestive Heart Failure. • • To establish rapport to client and family/significant others. To encourage family/significant others to cooperate in the interventions that are being performed to the client. • To collaborate with all the health team to promote efficient care to the client.

INTRODUCTION
Congestive heart failure is a physiologic state in which the heart cannot pump enough blood to meet the metabolic needs of the body (determined as oxygen consumption). Heart failure results from changes in systolic or diastolic function of the left ventricle. The heart fails when, because of intrinsic disease or structural defects, it cannot handle a normal blood volume or, in the absence of disease cannot tolerate a sudden expansion in blood volume (e.g.., during exercise). The main causes of Congestive Heart Failure are as follows: Coronary Artery Disease, Untreated High Blood Pressure, Faulty heart valves, Cardiomyopathy, Lung disease, Diabetes, Infections, Alcoholism and some Toxic Drugs. The Non-Modifiable risk factors are age, gender, race, family history, personal history. The Modifiable risk factors are smoking, high blood pressure, anemia and diabetes. Heart failure may be categorized as (1) LVF versus RVF, (2) backward versus forward, (3) high output versus low output. In the case of the patient, she has a Left Ventricular Failure. Left ventricular failure causes either pulmonary congestion or a disturbance in the respiratory control mechanisms. The patient manifests rales, dyspnea, paroxysmal nocturnal dyspnea, orthopnea, pulmonary edema, which are all consistent with Leftsided Congestive Heart Failure. The cause of the patient’s condition resulted from interrelated factors such as Diabetes Mellitus Type II and Myocardial Infarction. Out of the 86,241,697 people in the Philippines, 1,521,912 have Congestive Heart Failure. Congestive Heart Failure is the 6th leading cause of mortality in the Philippines, affecting males more often than females. According to World Health Organization, more than 22 million people worldwide suffer from Congestive Heart Failure. In the United States, congestive heart failure (CHF) was the underlying cause of death for approximately 38,000 persons in 2007; of those

deaths, approximately 92% were among persons aged greater than or equal to 65 years. We chose this case because we find it challenging. The disease is one of the most common causes of mortality rate in our country. This study will give us more knowledge and skills improving our nursing care management in patients with such disease and so we will be confident to help for the betterment in providing health care in the future.

Hyperuricemia. Anemia Final Diagnosis: IHD. 1945 Sex: Female Address: Sampaloc Manila Province: Jolo. Bartolome Chief Complaint: Difficulty of Breathing. CKD . Congestive Heart Failure Secondary to Diabetes Mellitus Type II. HCVD.DEMOGRAPHIC DATA Client's Name: Patient LB Age: 65years old Birthdate: November 18.CHF. Sulu Height: 5’3” Weight: 46 kilograms Civil Status: Widow Religion: Roman Catholic Nationality: Filipino Race: Asian Language: Tagalog and English Occupation: Housewife Educational Attainment: College Undergraduate Date of Admission: August 26. Chest pain Admitting Diagnosis: Hypertensive Cardiovascular Disease. 2010 / 6:12 PM Attening Physician: Dr.

When the patient was doing the laundry she started experiencing difficulty of breathing and chest pain after which she lost consciousness. (+)bradycardia. According to her she was admitted because of hypertension. Diltiazem 125mg OD. (+)tachypnea. Foley Catheter Insertion. Ocampo as follows: Aldactone 400mg/tab OD. initial oxygen via face mask (5 L/min). The physician instructed the patient to undergo different diagnostic procedures such as ECG and various laboratory exams like Serum Electrolytes and Cardiac Enzymes test. Imdur 30mg/tab OD. the client was conscious already. Captopril 25 mg/tab for HPN. The physician assessed the status of the patient. Her medication was given by Dr. After hospitalization. CONGESTIVE HEART FAILURE SECONDARY TO DIABETES MELLITUS II. She had been confined for 3 days. she was diagnosed with Myocardial Infarction. Patient LB was admitted at the ER of Ospital ng Sampaloc on August 26. Then the doctor ordered her for discharge. IV insertion. NPO instructed. 2010 at 6:12 PM with a chief complaint of difficulty of breathing and chest pain. Medications ordered by the physician during admission are the following Aldactone OD. Her admitting diagnosis is HYPERTENSIVE CARDIOVASCULAR DISEASE. Upon arrival at the Emergency Room. According to the patient. then he noted (+) chest pain. . Vital Signs Monitoring. and (+)hypertension. chest pain and difficulty of breathing. Captopril 25mg/tab BID and Imdur 40mg/tab OD. Clonidine 35mg/tab OD. She was immediately brought to the hospital by her son. the pain and dyspnea subsides.History of Present Illness One month prior to admission patient LB was hospitalize at Ospital ng Sampaloc at around 11:30pm. The physician referred the patient to Medical/Surgical Ward and gave doctor’s orders such as NGT insertion. (+)dyspnea.

Male Patient . MI. She experience Measles when she was 6 years old and had Chicken Fox when she was 12 years old. Family Health History GENOGRAM DM HPM. HPN LEGEND: CHF DM MI HPN Px Congestive Heart Failure Diabetes Mellitus Myocardial Infarction Hypertension . MI MII Px CHF. She was confined at the hospital for two days. DM.Past Health History The patient was hospitalized in the year 1977 when she gave birth to her last child here in manila.

. Patient complies with her doctor’s order by avoiding foods that are restricted to her. Patient naps in the afternoon because she feels sleepy every afternoon. She defecates once or twice a day and seldom experience constipation. Spiritual History Patient LB is a Roman Catholic and has a strong faith in our supreme being. But when she was younger she and her husband make love 2 to 3 times a week. She believes that God is always there for her and his family in times of problems and challenges. Patient said that she doesn’t like the taste of pork. Patient always eats vegetables and fish. She stated that there are episodes that she gets awaken from sleep because she experiences difficulty of breathing. Patient consumes vegetables that are rich in fiber such as ‘saluyot’ and she eats more rice.Deceased Lifestyle Patient LB seldom eats meat and poultry. Patient has a good appetite. She regularly attends mass every Friday and Sunday at Quiapo Church.Female . the patient has no more sexual activity for almost 15 years now. Sexual History Being a widow. She does it every 6 in the morning. Patient sleeps at 9 or 10 in the evening and wakes up early in the morning. thrice a week.. Patient LB voids approximately 10-12 times a day without experiencing pain during urination. usually at 2 or 3am. She usually sleeps 5-6 hours a day. for about an hour.

and social factors throughout the life cycle. a feeling Erikson calls integrity. failure to achieve a task influences the person’s ability to achieved the next tasks. Late Adulthood: 55 or 65 to Death Ego Development Outcome: Ego Integrity vs.Developmental Task Erik Erikson’s Psychosocial Theory of Development Erik Erikson adapts and expands Freud Theory of development to include the entire life span. believing that people continue to develop throughout life. personality development is influenced by biologic. The resolution of task can be complete. environmental. According to him. Perhaps that is because as older adults we can often look back on our lives with happiness and are content. . He believed in the massive influence of culture on behavior and placed more emphasis on the external world such as depression and was according to his theory. psychological. and successful. Erikson emphasizes that people must change and adapt their behavior to maintain control over their lives. each stage signals a task that must be achieved. Despair Basic Strengths: Wisdom Erikson felt that much of life is preparing for the middle adulthood stage and the last stage is recovering from it. feeling fulfilled with a deep sense that life has meaning and we've made a contribution to life. He believes that the greater the task achievements that healthier the personality of the person. partial.

Thus. patient LB considered herself as well fitted and is conscious and aware of her present condition. She was able to teach and care for her children as they continue to grow. Analysis: Patient LB achieved the developmental task because she was able to perform well as a part of her family.Our strength comes from a wisdom that the world is very large and we now have a detached concern for the whole of life. She weighs 46 kilograms and stands 5’3” tall. They may fear death as they struggle to find a purpose to their lives. Physical Development Patient LB’s physical development belongs to a late adult age. She feels fulfilled and contented on what she has done and understand the things happening to her. On the other hand. she was actually lean in appearance. a. According to her. c. she felt happiness in taking care of her children and grandchildren. the family remained strong and has cooperation in each member of the family. But she decided to separate from her parents as well as her siblings. By merely looking at the patient’s physicality. Ego integrity developed. In terms of perception in health functioning. some adults may reach this stage and despair at their experiences and perceived failures. b. Even if there’s problem. they may feel they have all the answers (not unlike going back to adolescence) and end with a strong dogmatism that only their view has been correct. Psychosocial Development Patient LB is strong. she was the third child of their parents. they’ve . She was aware of her condition and she accepts it. Cognitive Development Patient LB makes decisions on her own but makes sure to still consult her family. accepting death as the completion of life. As she recalls the memories before. wondering "Was the trip worth it?" Alternatively. She was contented on her life.

She always goes to church every Sunday and Friday she always pray the rosary. it may be presumed that her personality features molded during her early married life. She focused on that part of her life and she developed every virtues and attitudes in that part of her life. Analysis: Based from experiences expressed by patient LB. She often prays for guidance before she makes her decision.learned to live in their own at a young age. she makes sure that she provides everything they needed with the help of her second husband. Moral and Spiritual Development The patient is a Roman Catholic and she believes that GOD exists. Now that she has her own family. d. ANATOMY AND PHYSIOLOGY Figure 1-2 Anatomical Structure of the Heart . Analysis: Her decision is highly affected by her religion and faith.

• The heart. • Right Ventricle. Functions: 1.it pumps the blood into the lungs which exchange of oxygen and carbon dioxide occurs.the first chamber which receives highly oxygenated blood from the lungs through the Pulmonary Veins. 4. 3. . the mediastinum. Left side of the Heart: • LeftAtrium.Heart • fist. Generating blood pressure Routing blood Ensuring one-way blood flow Regulating blood supply Right side of the Heart: • Right Atrium. and associated structures form a midline partition. 2. trachea.the first chamber which receives deoxygenated blood from the body through the inferior and superior venacava. esophagus. • It is located in the thoracic cavity between the two pleural cavities. which The heart is shaped like a blunt cone and is approximately the size of a closed surround the lungs.

the strongest of the heart's pumps. It is approximately the diameter of your thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts of the body. Veins from the legs and lower torso feed into the inferior vena cava. The Valves • Tricuspid Valve-regulates blood flow between the right atrium and the right ventricle • • • Pulmonary Valve-opens to allow blood to flow from the right ventricle to the lungs Mitral Valve-regulates blood flow between the left atrium and the left ventricle Aortic Valve-allows blood to flow from the left ventricle to the ascending aorta The Hearts Electrical System • Superior vena cava.also called visceral pericardium -a thin serous membrane forming the smooth outer surface of the heart • Myocardium -thick middle layer of the heart . Layers: • Epicardium . • Aorta-is the largest single blood vessel in the body. Veins from the head and upper body feed into the superior vena cava. Its thicker musclesneed to perform contractions powerful enough to force the blood toall parts of the body.• Left Ventricle. which empties into the right atrium of the heart.is one of the two main veins bringing de-oxygenated blood from the body to the heart. which empties into the right atrium of the heart • Inferior vena cava-is one of the two main veins bringing de-oxygenated blood from the body to the heart.

Veins bring deoxygenated blood back to the heart. PATHOPHYSIOLOGY OF CONGESTIVE HEART FAILURE LEFT-SIDED (Book Base) Causes: -Myocardial infarction -Prolong hypertension -Aortic Stenosis –Insufficiency -Mitral Stenosis – Insufficientcy . and carbon dioxide diffuses into the blood from the capillary cells. • Endocardium -which consist of simple squamous epithelium over a layer of connective tissue. As blood circulates through the body. oxygen diffuses from the blood into cells surrounding the capillaries.-is composed of cardiac muscle cells and is responsible for contractions of the heart chambers. arteries bring oxygenated blood to the tissues of the body. The pulmonary circulation (for arterial blood sent to the lungs) is excluded from this definition. SYSTEMIC AND PULMONARY CIRCULATION Figure 1-3 Systemic and Pulmonary Circulation In the systemic circulation.

Reduced Myocardial Contractility Increased Cardiac Workload Decreased Diastolic Filing Obstruction of Left Arial Emptying Left-Sided Congestive Heart Failure Blood drums back into the pulmonary capillary bed Pressure of blood into the pulmonary capillary bed increases Fluid shift into the intra and inter-alveolar spaces Pulmonary Edema Increase Cellular Hypoxia Decreased Stroke Volume Decreased Tissue Perfussion Decrease blood flow to the kidneys Signs and Symptoms of LSCHF • Dyspnea • Paroxysmal Nocturnal Dyspnea • Orthopnea • Rales/ Crackles • Moist Cough • Blood Tinged Frothy Sputum • Wheezing/ Cardiac Asthma • Dizziness • Fatigue • Weakness • Anorexia • Hypokalemia RAAS Stimulation Vasoconstriction & Rearbsorption of Sodium and Water Increase ECG Volume Increase total blood volume Increase Systemic Blood pressure PATHOPHYSIOLOGY OF CONGESTIVE HEART FAILURE LEFT-SIDED (Client Base) Modifiable factor: Lifestyle Non-Modifiable factor: Myocardial infarction Diabetes Mellitus Age Heredity Hypertension .

2010 SYSTEMS Integumentary System SUBJECTIVE CUES “Wala naman ako problema sa balat. .Enlargement of left ventricle Increased workload Reduced myocardial contractility Blood drums back Into the pulmonary capillary bed Pressure of blood into the pulmonary capillary bed increases Fluid shift into the intra and inter-alveolar Pulmonary edema Congestive Heart failure LEGEND: Sign and symptoms Dyspnea Paroxysmal nocturnal dyspnea Orthopnea Fatigue Rales/crackles REVIEW OF SYSTEMS August 30. ganito lang talaga ang balat pag tumanda na” as verbalized by the patient.

pero kaya kong maglakad mag isa at hindi ako nahihirapang bumalanse” as verbalized by the patient. “Gusto ko ng mataas na unan. “Hindi ako makatulog ng maayos. “Parang nalulunod ako. “Nanghihina lang ako. “Wla naman masakit s mga kasukasuan ko. Genitourinary System Musculoskeletal System Neurologic system “Wala naman masakit pag umiihi ako. pag lang madudumi ako” as verbalized by the patient. “Yung sakit parang lumalakad sa kanang bahagi ng dibdib ko” as verbalized by the patient Gastrointestinal System “Wala naman masakit sa tyan ko. “Hindi ako makakaen ng maayos dahil mapait ang panlasa ko” as verbalized by the patient. ” as the patient. “Sumasakit ang dibdib ko. parang kinakapos kaya nahihirapan ako sa paghinga” as verbalized by the patient. parang pinipiga” as verbalized by the patient. “Irerate ko ang sakit sa 7 out of 10” as verbalized by the patient. itaas nyo ang higaan ko dito sa may likuran ko” as verbalized by the patient.Respiratory System “Mabilis ang paghinga ko. Cardiovascular System “Mataas ang BP ko. highblood kasi ako. . wla din ako rayuma” as verbalized by the patient. “Hinahabol ko ang paghinga ko kasi nauubusan ako” as verbalized by the patient “Bumibilis ang paghinga ko pag sumasakit ang dibdib ko” as verbalized by the patient. hindi ako makahinga ng maayos” as verbalized by the patient. nagigising ako dahil nahihirapan akong huminga” as verbalized by the patient.” as verbalized by the patient.

Pulmonary artery pressures will also be elevated. CLINICAL PATHWAY Left sided CHF Sided CHF Results from an increase left ventricular and left atrial pressures. sinabi lang ng doctor meron na daw ako. which cause excessive accumulation of fluid in interstitial and alveolar spaces.Endocrine system “Di ko nga alam na may diabetes ako e.” as verbalized by the patient. Treat with vasodilators and ACE Ride Yes No Can you hear bibasilar crackles on auscultation of lungs? .

Results from fluid retention Yes Is there a measurable weight gain in a short period? Figure 1-1 Clinical Manifestations of Left sided and Right Sided CHF Treat with diuretics to decrease blood volume and Physical Assessment Vital Signs T: 36. No Is the liver enlarged? Yes Hepatomegaly is due to congestion of the liver with venous blood No Is the hepatojugular reflex is present? Yes Results from the inability of the right ventricle to handle the increase in pressure and venous return. Treat with digitalis to increase the heart’s contractility and rate. the blood urea nitrogen rises but the creatinine level in unaaffected This occurs because the right ventricle dilates in order to increase ventricular contraction and emptying. Results from fluid accumulation in the abdomen. resulting from increased venous pressure. Tachycardia will continue at increasing rates if left ventricular failure persists. Treat with diuretics to decrease blood volume and Yes Can you hear an S3 or summation gallop when you auscultate the heart? Is the point of maximal impulse enlarged or shifted laterally to the left? No Yes No No Yes No Is there a parasternal heave? Is the blood urea nitrogen increased while the creatinine is normal? Is ascites present? Yes No Yes Results from reduced perfusion to the kidneys when renal perfusion is reduced.No Yes Early sign of left ventricular failure that is the result of a compensatory effort to increase cardiac output. 2010 . Is jugular venous distention present? Is the heart rate over 100 beats/min? Yes No Very Specific sign of right ventricular failure.2° RR: 26 breaths/min August 30. This increased pressure will also be reflected in increased central venous pressure. Early finding in left ventricular failure but will persist as failure progresses. It occurs as the left ventricle becomes less compliant. This occurs because the left ventricle dilates in order to increase ventricular contraction and emptying.

(Medical surgical Nursing by Black) General Survey: We received patient awake on bed in high-fowlers position. Conscious and coherent. The patient wears dress suitable for the temperature.PR: 111 beats/min Height: 5’3” Weight: 46kg Bp: 140/90 mmHg BMI: 17. intact and infusing well.88 Analysis: According to Black. With oxygen tank at bedside and is being used when needed. .5 is categorized underweight for less than desirable weigh for height. With Foley catheter connected on a urine bag containing 1200ml. Pale looking and body weakness noted. With IVF of PNSS 1LXKVO located at left metacarpal vein. a BMI of less than 18.

(Fundamentals of Nursing p.BODY PART and ASSESSMENT Skin Skin color TECHNIQUE NORMAL FINDINGS Varies from light to deep brown. (Fundamentals of Nursing p. clammy skin Uniform. Excessive Dryness indicate dehydration (Fundamentals of Nursing p. According to D’Amico and Barbarito localized coolness results from decreased circulation due to vasoconstriction or occlusion which may occur from peripheral arterial insufficiency. no abrasion or other lesions Skin lesions Inspection Palpation Skin moisture Inspection Moisture in skin folds and the Axillae Dryness and flaky According to KOZIER skin lesions are those that appear initially in response to some change in the external on internal environment of the skin. lips. Asian people have a deep brown color. from ruddy pink to light pink. within normal range of temperature Skin turgor Palpation The skin moves back slowly When pinched. some birthmarks. According to KOZIER in . from yellow overtones to olive Generally uniform except in areas exposed to the sun. and tends to blanch the skin color. (Fundamentals of Nursing p.538) Uniformity of skin color Inspection Uniform in color except in areas exposed to sunlight Assess edema Inspection Palpation No edema No edema According to KOZIER a normal skin doesn’t show swollen.539) Skin temperature Palpation Cold. shiny. nail beds in dark skinned people. (Fundamentals of Nursing p.539) According to KOZIER the skin is dry and flaky because sebaceous and sweat glands are less active in elderly. taut.540) According to KOZIER some areas have lighter pigmentation such as palms.3535) No lesions or abrasions Freckles. areas of lighter pigmentation in dark skinned people ACTUAL FINDINGS Deep Brown color ANALYSIS Inspection According to KOZIER skin color varies from race.

The amount of oxygen in the body tissues depends on how .1 RESULT NORMAL VALUES Female 12-14 g/dl INTERPRETATION -Patient LB has low hemoglobin level which indicates anemia and lack of oxygen. Laboratory Results: Hematology August 25. It can supply a great deal of information necessary to diagnosed hematopoetic system and helps to evaluate the strategies and prognosis of certain disease. It provides a complete evaluation of all formed elements of the blood.LABORATORY RESULTS Hematology It is a series of screening test. 2010 LABORATORY EXAM Hemoglobin 9. to help diagnose and to monitor variety of condition. which consist of Hemoglobin and Hematocrit. ANALYSIS Hemoglobin is the protein molecule within red blood cells that carries oxygen and gives blood its red color. It is used routinely to screen for.

resulting in low hematocrit. Black pp.8-10.much hemoglobin is in the red cells. Hct 0. 2263) White blood cells which also called leukocytes.8 x 10 -Patient LB has high WBC count which indicates infection and tissue necrosis Black pp.27 0. defend the body against infection. the tissues lack oxygen. A decrease in the number or size of red cells also decreases the amount of space they occupy. WBC 11. They form in the bone marrow and consist of . 2262) Hematocrit is a compound measure of red Blood cell number and size.37-0.47 -Patient LB has low hematocrit level which indicates anemia. (Medical – Surgical Nursing 7th edition by Joyce M. (Medical – Surgical Nursing 7th edition by Joyce M. and the heart and lungs must work harder to try to compensate. Without enough hemoglobin.5 4.

Black pp. Black pp. Lymphocyte 20 30-40% -Patient LB has low percentage of lymphocytes indicates a very high risk of infection especially viral infection. eosinophils and monocytes may be due to acute coronary syndrome. 2263) Lymphocytes are the primary components of the body's immune system. 2263) Increased in neutrophils. basophils. Segmenters 80 60-70% -Patient LB has high percentage of segmenters indicates inflammatory disease or response. (Medical – Surgical Nursing 7th edition by Joyce M. As a result. A high WBC count often means that an infection is present in the body. (Medical – Surgical Nursing 7th edition by Joyce M. basophils for hemolytic anemias and bacterial infection.several different types and sub-types. tissue necrosis (myocardial infarction). They are the source of serum immunoglobulins and of cellular immune response. bacterial infection and sometimes Leukemia. they play an important role in immunologic .

CHEMISTRY August 26. and a sign of diabetes. . (Medical – Surgical Nursing 7th edition by Joyce M. While the WBC and Segmenter count of the patient appears to be high.4 mmol/L Interpretation Increase Analysis An increase in FBS level which indicates hyperglycemi a. this indicates infection. 2010 LABORATORY EXAM FBS RESULT 12.84 NORMAL VALUES 4. (Medical – Surgical Nursing 7th . the hemoglobin and hematocrit of the patient appears to be low due to her anemic condition. Lastly. Lymphocytes count suggests a very high risk of infection.2-6.reactions. Black pp. Sometimes drugs can be a factor to a decreased lymphocyte counts such as corticosteroids and immunosuppressive drugs. 2263) Analysis: Based on the results taken. All lymphocytes are produced in the bone marrow.

9 3. 1 pp 782) According to Black and Hawks. 7th Edition Vol. Increase in Uric acid levels result in hyperuricemi a.3 3. 1 pp 782) Potassium 6. (Medical – Surgical Nursing 7th edition by Joyce M. Black pp. 2010 . Black pp.5-8.0 mg/dL Within Normal Range Increase In humans. uric acid is the major end product of purine catabolism in the absence of urate oxidase.07 9.2 NORMAL VALUES 135-148 mmol/L Interpretatio n Decrease Analysis Accourding to Black and Hawks decrease level of sodium indicates possible malabsorptio n (MedicalSurgical Nursing. 90) August 25.8-6.edition by Joyce M.3 mmol/L Increase August 27. increased potassium indicates hyperkalimia (MedicalSurgical Nursing. 7th Edition Vol. 2010 LABORATORY EXAM Sodium RESULT 131. 2263) Cholesterol Uric Acid 3.7 mmol/L 2.5-5.

dehydration. it indicates hyperkalemi a. 7th Edition Vol. 1 pp 782)) Triglycerine 2.LABORATORY EXAM Potassium RESULT 7. diabetes or infection.6 NORMAL VALUES 3.3 mmol/L INTERPRETAIO N Increase ANALYSIS According to Black and Hawks. kidney disease and liver disease ((MedicalSurgical Nursing.9 mmol/L Increase August 29.55 NORMAL VALUES 3.5-5. 1 pp 782) High level of triglycerine indicates high level of sugar.39 0. (MedicalSurgical Nursing.5-5.3 mmol/L Interpretatio n Increase Analysis Patient LB has an increased in potassium level. alcohol and calories associated with diabetes. 7th Edition Vol. 2010 LABORATORY EXAM Potassium RESULT 7.68-1. acute or chronic kidney failure. 1 . 7th Edition Vol. increased potassium indicates hyperkalimi a (MedicalSurgical Nursing.

1 pp 782) Potassium 6. 1 pp 782) Increased potassium level indicate hyperkalemi a.pp 782) August 30. 7th Edition Vol.5-5. (MedicalSurgical Nursing.3 umoL/L Increase . 7th Edition Vol.7 3. 2010 LABORATORY EXAM Creatinine RESULT 739 NORMAL VALUES 50-70 umoL/L Interpretation Increase Analysis High level of creatinine indicates a disease that affects the kidney (MedicalSurgical Nursing.

1 pp 782) RADIOLOGY Chest X – ray A chest x ray is a procedure used to evaluate organs and structures within the chest for symptoms of disease. and small portions of the gastrointestinal tract. 2010 ARTERIAL BLOOD GAS Analyte pH PCo2 HCo3 PO2 Analysis: Metabolic Acidosis Normal Values 7.45 35-45 22-26 80-100 Results 7. X rays are a form of radiation that can penetrate the body and produce an image on an xray film. thyroid gland and the bones of the chest area.30 40 17 75 Interpretation & Analysis Acidosis N Acidosis Troponin Test August 26. (MedicalSurgical Nursing. . heart. 7th Edition Vol. 2010 LABORATORY EXAM Troponin T RESULT (-) NORMAL VALUES (-) Interpretation Troponin is negative Analysis She/He can still have the narrowings in the heart tubes that have not totally blocked. Chest x rays include views of the lungs.August 28.35-7.

CHEST PHYSICAL ASSESSMENT – RESULTS: Lungs are clear. Aorta is lertous. spleen. SONOGRAPHIC RESULTS: REQUEST: Whole Abdomen Liver: Impression: Gallbladder: Impression: Common Duct: Impression: Pancreas: Impression: The liver is normal in size. pancreas. IMPRESSION: Cardiomegaly Anleromatous Aorta Analysis: Patient LB developed cardiomegaly due to Congestive Heart Failure. Wall is not thickened No Intraluminal echogenicitis seen Normal study of the Gallbladder The common duct measured 0. shape & echo pattern No discrete mass lesion seen Normal study of the Pancreas . Diaphragm sulci are intact. and kidneys. The blood vessels that lead to some of these organs can also be looked at with ultrasound. SONOGRAPHY Ultrasound Abdominal ultrasound is an imaging procedure used to examine the internal organs of the abdomen.4cm It is normal in caliber The pancreas is normal in size. gallbladder. including the liver. Heart is enlarged. shape & echo pattern No discrete mass or dilated Intrahepatic duct seen Normal study of the Liver.

4. a renal disease that can lead to cardiovascular disease and pericarditis.3x 4.1cm The spleen is normal in size & echo pattern No discrete mass lesion or calcification seen Normal study of the Spleen The right kidney measured 6. arrhythmias. Urinary Bladder: Urinary Bladder was not adequately distended. bilateral. 182 434. Cardiomegaly can also sometimes accompany longstanding anemia. 2010 9:30pm Actual Findings PR Int. high blood pressure. Also Chronic Nephropathy. 96. including diseases of the heart muscle or heart valves.1cm while the left kidney Both kidney appears small with diffusely increase parenchymal echogenicity No lithiasis or hydronephrosis seen Impression: Chronic nephropathy. (MS): P/QRS/T Axis (Deg): 271 118. and pulmonary hypertension. ELECTROCARDIOGRAPHY ECG Sep.52 .: P/QRS/T Int (MS): QT/QTC Int. 446 71.Spleen: Impression: Kidneys: measured 7.3 x 3. Analysis: Patient LB has Cardiomegaly which can be caused by a number of different conditions.

input and output Q1 and record. Isoket drip 15mgtts/hr and Lanoxin 0. Ranitidine 50mg Q8 TID. For hyperkalemia. 6:00am Progress Note: CBG-96mg/dl 10:30am IVF to follow: PNSS 1L x 16° Isoket to consume 7:15pm . For withhold intermediate insulin in the morning. 11:10pm Patient LB’s blood pressure arise at 160/120. he ordered nebulization of salbutamol every 8°. Monitor Vital signs Q2. to be refer and record. Dr. Bartolome request for CBC. Dr. August 27.5 and to prepare 2 units PRBC to be transfuse. ECG. 2010 1:25am Patient LB’s heart rate arises to 120bpm and have (+) crackles. 7:30pm Refer of CBG in 255mm/hr.125mg slow IV. Cefoxitin 2g/50 ml IV every 6 hours. Other orders. Creatinine and 2d Doppler. HGB. Diphenhydramine 1cap. Patient LB hook to cardiac monitor. Other medications ordered. Other medication: Morphine 2mg via IV. ISMN 30mg/ tab OD. Bartolome gave orders of diabetes drugs 1800kcal/ day to begin in 30 meals & strict aspiration precaution. For chest pain. Blood type. Dr. BUN. Na K. Monitor vital sign. Bartolome ordered Furosemide 40mg.MANAGEMENT I. Allopurinol 300mg/tab OD. Bartolome ordered Furosemide 40mg. MEDICAL MANAGEMENT -DOCTOR’S ORDER August 26. tab for BP 130/100. D50 50cc + 10”u” x 15 x 3 doses. 2010 7:15pm Patient LB admitted to MS ward. For insertion of Foley catheter and connect to urine bag. He also ordered intermediate insulin 15 Units. He ordered PNSS 1L x 16°. Lactulose syrup 30ml OD. Clonidine 5mcg. He also ordered diet of no fruits/ juices. Simvastatin 20mg/tab OD in PRN. monitor Input and Output every shift to be refer and record and “Monitor CBG”. Dr.

3:25pm Dr. 2010 7:45am Dr. MaHCo3 1tab TID. IVF to follow PNSS 1L x 16° August 31. Dr. 2010 . He ordered Calcium gluconate 1 ampule slow IV push now. hold ranitidine and omeprazole 20mg/tab OD. 2010 8:00 am Dr. waves. August 29. 2010 7:15am Continue followed up nephro referral and continue medications ordered by Dr. Bartolome. Bartolome request for Sodium and Potassium and a followed up laboratory results. Bartolome ordered for a repeat ECG and IVF to follow: PNSS 1L x 16° 5:00pm Patient has serum potassium of 7.IVF to follow: PNSS 1L x 16° August 28. 6:15pm Continue IVF of PNSS 1L x 16° August 30. For medication. 11:00am Continue IVF PNSS 1L x16° September 01. Bartolome ordered diet as no fruits. D5050 1vial + 8 “u” of insulin q6 x 3 doses.55. 2010 10:35am Dr. NaCl 8”u” Q6 for 3 doses and after he then ordered repeat serum Sodium and potassium. D50. 2:45pm IVF of D5050 1 vial +8”u” on D5w to run for 6° for 3 doses. ECG peak at T. Bartolome ordered calcium gluconate 1 ampule slow IV push. Bartolome ask a service of nephro for evaluation of laboratory results.

 Diagnostics: ABG: Relay labs today: creatinine 1 Ca. drug induced  Hyperuricemia  Will await labs today if patient’s hyperkalimia remains unintractable  Advise patient’s to start hemodialysis September 02. Continue medication. 2010 8:00am IVF to follow PNSS 1Lx10cc/hr . Bartolome ordered repeat serum potassium and a request for creatinine. K 2D echo with Doppler once stable Hold captopril No ACE/ ARBS. phosphorus diet.03 Nacl 500cc x KVO. no NSAIDS Start carvedilol 6. no fruits in diet Monitor I & O quantitatively and record pls. 12:00nn  Limit oral intake to 1.8:00am Dr. BID Hold furosemide Ciprofloxacin 500mg/ tab BID Adjust meds for ECC (estimated creatinine clearance) Refer for urine output <30ml/hr Erythropoietin 4000 “u” 8Q 2x/ week Refer accordingly Allopurinol 100mg 1 tab OD Progress Notes:  History and Physical Examination received  Awaiting laboratory results  AKL 2° UTI on top of CKD 2° DM nephropathy cardiorenal syndrome  Hyperkalemia probably 2° CKD. Continue IVF to follow D5. 40g CHON of high biologic value (no pork and beef).25mg/ tab.5 L/day  Maintain current IVF PNSS x 10ml/ hr  Consume present IVF and shift to heplock  Diet: 1800 kcal/ day. 2g Na 800mg.

He ordered to transfer 2 units PRBC to consume. D50 50 cc + 10 “u” x 3 doses q 1°. 2010 6:10am Dr. Bartolome ordered Amlodipine 5mg 1tab OD and to consume IVF of PNSS x KVO & shifted to heplock. 11:20pm Dr. IVF to follow PNSS 1L x 16° Progress Note: Bp: 140/70 160/90 6:10pm Progress Note: HGT of 7. Progress Note: Potassium of 6. shift to heplock 11:30am Progress Note: Hgt 287 mg/ dl 07:00pm Patient LB for ECG.64 September 04. 2010 7:05am Continue IVF PNSS x KVO 2:30am For repeat CBC September 06. 2010 2:00am Patient LB hook IVF PNSS x KVO with side drip of D50 50cc +10 “u” as ordered by Dr. Bartolome ordered IVF PNSS 1L x KVO. Continue medication. IVF to follow PNSS x KVO September 05. repeat sodium and potassium.September 03. 2010 11:50am Shift IVF to heplock 6:30pm For repeat potassium and creatinine.4 7:30am . Bartolome.

2010 7:00am  Nephro notes Recommendations: Ciprofloxacin to 500g OD per orem May remove Foley catheter Limit oral fluid intake to ≤ 1L/ day 20g of Na/ day 80mg of Phosphorus/ day 50g of CHON of high biologic value Diabetic and low fat. properly type and Diet 1800 kcal/ day . Bartolome ordered D50 50cc +10 “u” x 3doses Progress Note: Potassium of 9.74 8:00am Continue IVF PNSS 1L x KVO. and QID 300ml/ min Progress Note: Discuss the need for hemodialysis with the children. low purine diet *refer for dietician for further instruction crossmatch Progress Notes: Bp 120/ 80 140/80 (-) edema 10:15am Additional order and hold insulin temporarily MGH after blood transfusion of 1 “u” of PRBC.For hemodialysis once with temporary access and inform the Dr. Bartolome. 2010 7:00am Dr. Hemodialysis preparation and 2 ½ hour every 8 150ml/ mi. 2010 8:30am IVF to follow PNSS 1L x KVO September 09. September 08. Patient LB for possible transfer to tertiary hospital for dialysis. intractable hyperkalimea September 07. Indication of uremia.

With continue IVF to consume then disconnect.01:00pm For CT Scan Progress Note: 160/80 September 10. 2010 8:00am Repeat CBC 6° prior to Blood Transfussion. Dr. hct:0. Bartolome ordered MGH anytime. Progress Note: hgb: 89. Continue medication and advise to follow up after dialysis.26 . 8:30pm 1 unit PRBC secure properly type and Crossmatch.

Group nursing interventions when appropriate). Assessment/Interventions: • Monitor vital signs/oxygenation/Neuro status (report changes in heart and respiratory rate/patterns as well as changes in LOC). • Monitor for restless. • Daily weight (a 2. location. quality.2 kg weight increase over a 1 day period is considered significant). b.’s appointments • Avoiding infection (flu/pneumovax vaccines) . • Maintain adequate bowel function (stool softeners such as Colace should be ordered to prevent constipation). • Capillary refill (if greater than 3 seconds. NURSING CARE AND MANAGEMENT a. anxious behavior and promote self care participation. • Breath sounds (monitor for increased crackles. rhonchi or pulmonary congestion). Patient Teaching: The following patient/family education should be provided prior to discharge and should also be reiterated at post discharge office visits: • Discharge medication regimens • Diet (low sodium) • Fluid restrictions • Activities of daily living • Exercise • Smoking cessation/avoidance • Available community resources/referrals • The importance of making and keeping Dr. • The presence of ascites (also a sign of worsening right sided heart failure).II. assess for signs of peripheral edema). onset and relieving factors) • Intake and Output (monitor effects of diuretic therapy and observe for signs and symptoms of either fluid overload or deficit) • Assess degree of discomfort associated with activity (provide a proper rest/activity balance. • EKG changes • Evaluate electrolyte levels (sodium. potassium and creatinine) • Digoxin levels (if patient taking Digoxin) • Pain level (degree. • The presence of hepatomegaly (also a sign of worsening right sided heart failure). source. • The presence of jugular vein distention (jugular vein distention can be a sign of worsening right sided heart failure).

amlodepine. DISCHARGE PLANNING M >Remind client to take furosemide. >Require patients to promptly follow up with their primary care physician or cardiologist. >Emphasize patient education with intense instruction regarding compliance with dietary restrictions and medical therapy. nausea or fatigue). Isordil.• Self monitoring (when to report symptoms or changes such as shortness of breath. ISMN.2 lbs over 1-2 days]. changes in weight [greater than 2. O >Inform the family of the patient to have a regular check-up for the continuity of treatment. blood pressure changes. and sucralfate as prescribed. >Educate and instruct the relatives on what proper food to give. T > Educate & instruct the family to monitor the blood pressure and pulse rate before administering medication. pedal edema. H >Inform the relative the importance of proper hygiene of the patient from head to toe. >Instruct the family of the patient to monitor if there is any sudden change to the patient and report immediately. Catapres. dyspnea. E >Encourage the relative to do some exercises like a passive range of motion in affected and unaffected parts of the body of the client. >Instruct the relative to follow medication regimen. .

But the patient. and vitamins and minerals that help prevent everyday wear and tear of coronary arteries. low in cholesterol. slowly return to your normal activities. fish—rich in omega 3 fatty acids which is good for the heart. moderate in fluid intake and increase fiber diet to improve health. Then. RECOMMENDATION Watch out for blood cholesterol because too much cholesterol may cause fatty deposits to form in arteries—impeding blood flow and increasing the risk for complications. Get at least 7 hours of rest each night and take naps when feeling tired. Rest in bed until breathing is easier and feel stronger. eating fiber rich foods. EVALUATION The nursing interventions given to the patient has become helpful. and limit sodium rich food intake. Exercise regularly to help make the heart stronger and lower down blood pressure. >Follow the diet prescribed by the doctor. which contains antioxidants. Restrain from drinking alcoholic beverages. the chest x-ray was found clear. low in fat and give citrus fruits. Drink medications as prescribed such as diuretics and heart medications .D >Instruct the relative to feed the client on time with nutrition food that is low in sodium. Avoid being stress. With the latest diagnostic exam done. and fresh fruits and vegetables. Lifestyle changes are recommended— including the nutritional diet such as limiting fats—specially saturated fats. Stop smoking or avoid exposure to second hand smoking. due to renal impairment as complication of her CHF and DM II is arranged to undergo hemodialysis. Her pulmonary signs and symptoms were treated.

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