Course Code NCM 104

Course Title HEART FAILURE (CONGESTIVE HEART FAILURE)

Level Offering 2ND Semester AY 2020-2021

Clinical area of assignment MEDICAL WARD
Date of Exposure FEBRUARY 8, 9 & 10, 2021
No. of hours 24 hours

DIZON, DEXIE
BSN3

F  Decreased cardiac output related to altered myocardial contractility/inotropic changes as evidenced by

irritability and body weakness.

D  Received patient lying on bed, “Nang hihina ako, madali ako mapagod at para kong lagi inaantok“
 Weak in appearance
 Always asleep but easily awakens
 Shallow respiration
 Slow movements noted
 Needs assistance upon changing positions
 Dyspnea noted
 Pallor noted
 VS taken as follows: RR of 30cpm; with a heart rate of 69 bpm; blood pressure of 80 X 60 mmHg.

A  Auscultated apical pulse;

 Assessed heart rate, and rhythm
 Inspect skin for pallor,cyanosis.
 Monitoredurine output, noting decreasing output and dark or concentrated urine
 Noted changes in sensorium.
 Provided quiet environment.
 Administered supplemental oxygen as indicated
 Administered diuretics as prescribed.

R  Patient was able to display vital signs within acceptable limits, dysrhythmias controlled and no
symptoms of failure.

Prepared by:
HILARIO A. SANGLAY
Clinical Instructor

Noted by:
GINA L. CASI, RN.Ph.D
Dean-CNC