LEARNING ACTIVITIES (Clinical Simulation/ Exploration and Application)

Case No. 1

Mrs. Bunker, age 79, is admitted with a diagnosis of heart failure exacerbation. She reports a 2-day
history of increasing fatigue and shortness of breath, and weight gain of 3 pounds. Home medications
include lisinopril (Zestril®) 20 mg daily, carvedilol (Coreg®) 12.5 mg BID, furosemide (Lasix®) 20 mg daily,
and atorvastatin (Lipitor®) 40 mg daily. On assessment, Mrs. Bunker has labored respirations and a
respiratory rate of 28 breaths per minute. The nurse hears crackles throughout both lungs on
auscultation and notes 3+ pitting edema in the lower extremities.

Answer questions 1-5 with RATIONALE.

1. As the nurse on duty, what should you include in Mrs. Bunker’s initial care?

I would schedule periods of rest throughout the day. Fatigue is a cardinal symptom of heart failure and
Mrs. Bunker has reported increased fatigue. Scheduling periodic periods of rest is helpful in managing
fatigue. Positioning the patient with her legs elevated during an acute exacerbation may worsen
symptoms by returning fluid to the circulation and increasing preload. Activity should be reduced during
an acute exacerbation. Fluids should be restricted, not increased, during an acute exacerbation with
signs of fluid overload.

2. Mrs. Bunker puts on her call light and says, “I need help!” you assessed her with increased respiratory
rate and dyspnea, and coughing pink, frothy spu- tum. The nurse-in-charge notifies the Rapid Response
Team (RRT). What is most important for you to do while waiting for the RRT?

I would assess Mrs. Bunker’s vital signs and oxygen saturation. Mrs. Bunker is experiencing symptoms of
pulmonary edema. Positioning her in high-Fowler's position will improve lung expansion and
oxygenation; positioning the legs dependent will decrease venous return to the heart and decrease pre-
load. Although further assessment (lung sounds and vital signs) may be done, positioning the patient to
improve symptoms is more important. While beta blockers are important therapy for heart failure, they
are contraindicated in patients who have pulmonary edema.

3. At 9:00 a.m. on the second day after admission, Mrs. Bunker’s blood pressure is 110/70 mm Hg and
her heart rate is 56 beats per minute. Her scheduled medications include carvedilol, furosemide, and
sacubi- tril/valsartan (Entresto®). How should you manage the scheduled medications?

I would dminister all scheduled medications. The blood pressure is within normal limits. The heart rate is
slightly below the normal range at 56 bpm and beta blockers such as carvedilol may cause bradycardia.
However, the blood pressure is being maintained and beta blocker therapy is important for patients who
have heart failure; the carvedilol should be administered.

4. Mrs. Bunker’s condition has improved and discharge is anticipated. What topics should you include in
the discharge teaching?

I’m going to include medication management, daily weights, decreased sodium intake, and regular
exercise. Patients with heart failure should be educated about weighing themselves daily, reducing
sodium intake, managing their medications, and getting regular exercise.

5. Mrs. Bunker’s discharge orders include continuing sacubitril/valsartan 49 mg/51 mg twice daily, as
well as all previous home medications. Which home medication should the nurse discuss with the
prescriber?

Sacubitril/valsartan should not be given within 36 hours of the patient receiving an ACEI (e.g., lisinopril)
or an ARB.

6. Discuss the Anatomy and Physiology of the affected system.

The cardiovascular system is sometimes called the circulatory system. It consists of the heart, which is a
muscular pumping device, and a closed system of vessels called arteries, veins, and capillaries. As the
name implies, blood contained in the circulatory system is pumped by the heart around a closed circuit
of vessels as it passes again and again through the various "circulations" of the body.

The Heart
The heart is enclosed by a sac known as the pericardium. There are three layers of tissues that form
the heart wall. The outer layer of the heart wall is the epicardium, the middle layer is the
myocardium, and the inner layer is the endocardium. The internal cavity of the heart is divided into
four chambers:

 Right atrium
 Right ventricle
 Left atrium
 Left ventricle

The two atria are thin-walled chambers that receive blood from the veins. The two ventricles are
thick-walled chambers that forcefully pump blood out of the heart. Differences in thickness of the
heart chamber walls are due to variations in the amount of myocardium present, which reflects the
amount of force each chamber is required to generate.

The right atrium receives deoxygenated blood from systemic veins; the left atrium receives
oxygenated blood from the pulmonary veins.

Valves of the Heart

Pumps need a set of valves to keep the fluid flowing in one direction and the heart is no exception.
The heart has two types of valves that keep the blood flowing in the correct direction. The valves
between the atria and ventricles are called atrioventricular valves (also called cuspid valves), while
those at the bases of the large vessels leaving the ventricles are called semilunar valves.

The right atrioventricular valve is the tricuspid valve. The left atrioventricular valve is the bicuspid, or
mitral, valve. The valve between the right ventricle and pulmonary trunk is the pulmonary semilunar
valve. The valve between the left ventricle and the aorta is the aortic semilunar valve.

When the ventricles contract, atrioventricular valves close to prevent blood from flowing back into
the atria. When the ventricles relax, semilunar valves close to prevent blood from flowing back into
the ventricles.
Pathway of Blood through the Heart

While it is convenient to describe the flow of blood through the right side of the heart and then
through the left side, it is important to realize that both atria contract at the same time and both
ventricles contract at the same time. The heart works as two pumps, one on the right and one on the
left, working simultaneously. Blood flows from the right atrium to the right ventricle, and then is
pumped to the lungs to receive oxygen. From the lungs, the blood flows to the left atrium, then to the
left ventricle. From there it is pumped to the systemic circulation.

Blood Supply to the Myocardium

The myocardium of the heart wall is a working muscle that needs a continuous supply of oxygen and
nutrients to function with efficiency. For this reason, cardiac muscle has an extensive network of
blood vessels to bring oxygen to the contracting cells and to remove waste products.

The right and left coronary arteries, branches of the ascending aorta, supply blood to the walls of the
myocardium. After blood passes through the capillaries in the myocardium, it enters a system of
cardiac (coronary) veins. Most of the cardiac veins drain into the coronary sinus, which opens into the
right atrium.

Blood Vessels

Blood vessels are the channels or conduits through which blood is distributed to body tissues. The
vessels make up two closed systems of tubes that begin and end at the heart. One system, the
pulmonary vessels, transports blood from the right ventricle to the lungs and back to the left atrium.
The other system, the systemic vessels, carries blood from the left ventricle to the tissues in all parts
of the body and then returns the blood to the right atrium. Based on their structure and function,
blood vessels are classified as either arteries, capillaries, or veins. 
 Arteries

Arteries carry blood away from the heart.

Pulmonary arteries transport blood that has a
low oxygen content from the right ventricle to
the lungs. Systemic arteries transport
oxygenated blood from the left ventricle to the
body tissues. Blood is pumped from the
ventricles into large elastic arteries that branch
repeatedly into smaller and smaller arteries until
the branching results in microscopic arteries called arterioles. The arterioles play a key role in regulating
blood flow into the tissue capillaries. About 10 percent of the total blood volume is in the systemic
arterial system at any given time.

The wall of an artery consists of three layers. The innermost layer, the tunica intima (or just intima),
contains simple squamous epithelium, basement membrane and connective tissues. The epithelium is
in direct contact with the blood flow. The middle layer, the tunica media, is primarily smooth muscle
and is usually the thickest layer. It not only provides support for the vessel but also changes vessel
diameter to regulate blood flow and blood pressure. The outermost layer, which attaches the vessel
to the surrounding tissue, is the tunica externa or tunica adventitia. This layer is connective tissue
with varying amounts of elastic and collagenous fibers. The connective tissue in this layer is quite
dense where it is adjacent to the tunic media, but it changes to loose connective tissue near the
periphery of the vessel.

Veins

Veins carry blood toward the heart. After blood passes through the capillaries, it enters the smallest
veins, called venules. From the venules, it flows into progressively larger and larger veins until it
reaches the heart. In the pulmonary circuit, the pulmonary veins transport blood from the lungs to
the left atrium of the heart. This blood has a high oxygen content because it has just been oxygenated
in the lungs. Systemic veins transport blood from the body tissue to the right atrium of the heart. This
blood has a reduced oxygen content because the oxygen has been used for metabolic activities in the
tissue cells.

The walls of veins have the same three

layers as the arteries. Although all the
layers are present, there is less smooth
muscle and connective tissue. This makes
the walls of veins thinner than those of
arteries, which is related to the fact that
blood in the veins has less pressure than
in the arteries. Because the walls of the veins are thinner and less rigid than arteries, veins can hold
more blood. Almost 70 percent of the total blood volume is in the veins at any given time. Medium
and large veins have venous valves, similar to the semilunar valves associated with the heart, that
help keep the blood flowing toward the heart. Venous valves are especially important in the arms and
legs, where they prevent the backflow of blood in response to the pull of gravity.

Capillaries

Capillaries, the smallest and most numerous of the blood vessels, form the connection between the
vessels that carry blood away from the heart (arteries) and the vessels that return blood to the heart
(veins). The primary function of capillaries is the exchange of materials between the blood and tissue
cells.

Capillary distribution varies with the metabolic activity of body tissues. Tissues such as skeletal
muscle, liver, and kidney have extensive capillary networks because they are metabolically active and
require an abundant supply of oxygen and nutrients. Other tissues, such as connective tissue, have a
less abundant supply of capillaries. The epidermis of the skin and the lens and cornea of the eye
completely lack a capillary network. About 5 percent of the total blood volume is in the systemic
capillaries at any given time. Another 10 percent is in the lungs.

Smooth muscle cells in the arterioles where they branch to form capillaries regulate blood flow from
the arterioles into the capillaries.

Role of the Capillaries

In addition to forming the connection between the arteries and veins, capillaries have a vital role in
the exchange of gases, nutrients, and metabolic waste products between the blood and the tissue
cells. Substances pass through the capillaries wall by diffusion, filtration, and osmosis. Oxygen and
carbon dioxide move across the capillary wall by diffusion. Fluid movement across a capillary wall is
determined by a combination of hydrostatic and osmotic pressure. The net result of the capillary
microcirculation created by hydrostatic and osmotic pressure is that substances leave the blood at
one end of the capillary and return at the other end.

7. Outline the Pathophysiology of the disease

Causes:
Myocarditis
Ventricular aneurysm
Cardiac temponade

Tachycardia Fluid overload

Ventricular dilatation

Myocardial hypertrophy Water reabsorption

Decrease cardiac output

Increase ADH

Decrease renal perfusion

Increase Osmotic pressure

Increase sodium retention

NAME: Bunker AGE: 79 years old CIVIL STATUS: EDUCATIONAL
ATTAINMENT:

DIAGNOSIS:

DRUG NAME MODE OF INDICATIONS CONTRAINDICAT SIDE EFFECTS NURSING

ACTION OINS INTERVENTIONS

Generic Causes Adjunctive Contraindicated CNS: When an using in

Name: decreased treatment in patients dizziness, acute MI, give
lisinopril productio (with hypersensitive to headache, patient the
n of diuretics and ACE inhibitors fatigue, appropriate and
angiotensi cardiac and in those with paresthesia. standard
Brand Name: n II and glycosides) a history of recommended
Zestril suppressio for heart angioedema CV: nasal treatment such as
n of the failure related to congestion thrombolytics,
renin- Adults: previous aspirin, and beta
Pharmacologi angiotensi initially, 5mg treatment with EENT: blockers.
cal Class: n- P.O. daily; ACE inhibitors orthostatic
ACE aldosteron increased as hypotention, Although ACE
inhibitors e system. needed to Warning: Use hypotention, inhibitors reduce
maximum of during pregnancy chest pain. BP in all races, BP
20 mg (40 mg can cause injury reductions is less
for Zestril) and death to the GI: diarrhea, in blacks taking an
Route: P.O daily developing fetus. nausea, ACE inhibitor
P.O. When pregnancy dyspnea. alone. Black
Adjust-a- is detected, stop patient should
dose; if drug as soon as GU: impaired take drug with a
sodium level possible. renal thiazide diuretic
is less than function, for a more
130 mEq, Use cautiously in impotence. favorable
serum patients with response.
creatinine impaired renal Metabolic:
greater than 3 function; adjust hyperkalemia Monitor WBC
mg/Dl, OR dosage. with deferential
CrCl less than Skin: rash counts before
30 therap, every 2
Ml/minute, Other: weeks for first
start angioedema three months of
treatment at therapy, and
2.5 mg daily. periodically
thereafter.
 Look alike-sound
alike: don’t
confuse lisonopril
with fisonopril or
Leoresal. Don’t
confuse Zestril
with Zostrix, Zetia,
Zebeta, or Zyrtec.

DRUG NAME MODE OF INDICATIONS CONTRAINDICAT SIDE EFFECTS NURSING

ACTION OINS INTERVENTIONS

Generic Inhibits In patients Contraindicated CNS: Patient should

Name: HMG-CoA with clinically in patients headache, follow a standard
atorvastatin reductase, evident hypersensitive to asthenia, cholesterol-
an early coronary drug and in those insomnia. lowering diet
(and rate artery disease with active liver CV: before and during
limiting) (CAD), to disease or peripheral therapy.
Brand Name: step in reduce the unexplained edema
Lipitor cholestero risk of persistent EENT: Before treatment,
l nonfatal MI, elevations of pharyngitis, asses patient for
Pharmacologi biosenthes fatal and non- transaminase rhinitis, underlying causes
cal Class: is. fatal strokes, levels. sinusitis, for
Lipid- angina, heart nasopharyngi hypercholesterole
Lowering failure, and Contraindicated tis. mia and obtain
Agents, revasculariza in pregnant and GI: abdominal baseline lipid
Statins; tion breastfeeding pain, profile. Obtain
HMG-CoA procedures. woman and in constipation, periodic LFT
Reductase women of diarrhea, results and lipid
Inhibitors To reduce the childbearing age. dyspepsia, levels before
risk of MI flatulence, starting treatment
stroke in Use cautiously in nausea. and 6 and 12
Route: patients with patients with GU: UTI weeks after
P.O. type 2 hepatic Musculoskele initiation, or after
diabetes and impairment or tal: an increase in
multiple risk heavy alcohol rhabdomyoly dosage and
factors for use. sis, arthritis, periodically
CAD but who arthralgia, thereafter.
don’t yet Withold or stop myalgia,
have the drug in patients at extremity Watch for signs of
disease. risk for renal pain. myositis.
failure caused by Resoiratory:
rhabdomylysis bronchitis Look alike-sound
resulting from Skin: rash alike: don’t
trauma; in Other: confuse
serious, acute allergic atorvastatin with
conditions that reactions, atomoxetine.
suggest flulike Don’t confuse
myopathy; and in syndrome, Lipitor with
major surgery, infection. Loniten, Levatol,
severe acute or Zyrtec.
infection,
hypotension,
uncontrolled
seizures, or
severe metabolic,
endocrine and
electrolyte
disorder.
DRUG NAME MODE OF INDICATIONS CONTRAINDICAT SIDE EFFECTS NURSING
ACTION OINS INTERVENTION
S

Generic Non Hypertensio Hypersensitivity; Bradycardia, AV

Name: selective n, alone or severe chronic block, angina  WARNING:
carvedelol beta blocker with other heart failure, pectoris, Do not
with alpha oral drugs, bronchial hypervolemia, discontinue
blocking especially asthma or leucopenia, drug
Brand activity diuretics related hypotension, abruptly
Name: bronchospastic peripheral after
Coreg Carvedilol Treatment of conditions; edema, allergy, chronic
causes mild to severe hepatic malaise, fluid therapy
vasodilation severe CHF impairment. overload, (hypersensi
Pharmacolo by blocking of ischemic Patients with melena, tivity to
gical Class: the activity or NYHA class IV periodontitis, catecholami
Alpha- of α- cardiomyopa cardiac failure, hyperuricemia, nes may
nonselective blockers, thic origin 2nd or 3rd ° AV hyponatremia, have
beta blokers mainly at with digitalis, block, sick sinus increased developed,
alpha-1 diuretics, syndrome alkaline causing
receptors. It ACE (unless a phosphatase, exacerbatio
Route: exerts inhibitors permanent glycosuria, n of angina,
P.O. antihyperten pacemaker is in prothrombin MI, and
sive effect Left place), time, SGPT and ventricular
partly by ventricular cardiogenic SGOT levels, arrhythmias
reducing dysfunction shock or severe purpura, ); taper drug
total (LVD) after bradycardia. somnolence, gradually
peripheral MI Lactation. impotence, over 2 wk
resistance albuminuria, with
and hypokinesia, monitoring.
vasodilation. Unlabeled nervousness,
It is used in uses: Angina sleep disorder,
patients with (25–50 mg skin reaction,
renal bid) tinnitus, dry Consult with
impairment, mouth, anemia, physician
NIDDM or sweating, fatigue, about
IDDM arthralgia, withdrawing
aggravation, drug if
dizziness. patient is to
Diarrhea, nausea, undergo
vomiting, surgery
insomnia, (withdrawal
hypercholesterol is
emia, weight controversia
gain, abnormal l).
vision, rhinitis,
pharyngitis and
hypertriglyceride Give with
mia. food to
decrease
orthostatic
hypotension
and adverse
effects.

Monitor for
orthostatic
hypotension
and provide
safety
precautions.

Monitor
diabetic
patient
closely;
drug may
mask
hypoglycem
ia or worsen
hyperglyce
mia.

WARNING:
Monitor
patient for any
sign of hepatic
impairment
(pruritus, dark
urine or stools,
anorexia,
jaundice,
pain);
 DRUG NAME MODE OF INDICATION CONTRAINDICATOI SIDE EFFECTS NURSING
ACTION S NS INTERVENTIONS

Generic Name: Inhibit Edema due Anuria; hepatic low blood Assess patient’s
furosemide reabsorptio to cardiac, coma & precoma; pressure, nderlying
n of sodium hepatic & severe condition before
Brand Name: and water renal hypokalemia &/or Dehydration starting
Lasix in the disease, hyponatremia; and theraphy.
ascending burns; mild hypovolemia w/ or electrolyte
limb of the to w/o hypotension. depletion Monitor for renal
Pharmacologic loop of moderate Hypersensitivity to (for example, cardiac,neurologi
al Class: Henle by HTN, sulfonamides. sodium, c, GI
Diuretics interfering hypertensiv potassium). manifestations
with the e crisis, of hypokalemia.
Route: chloride acute heart jaundice,
IV push binding site failure, Monitor for CNS,
of the reduced ringing in the GI,
1Na+, 1K+, urinary ears cardiovascular,
2Cl- output due (tinnitus), integumentarym
cotransport to gestoses, neurologic
system. chronic sensitivity to manifestations
Loop renal light of jypocalcemia,
diuretics failure, (photophobia
increase nephrotic ), Monitor for CNS,
the rate of syndrome. hyperactive
delivery of rash, reflexes,
tubular depressed
fluid and pancreatitis, cardiac
electrolytes output,nausea,
to the nausea, vomiting,
distal sites tachycardia
of diarrhea,
hydrogen Assess fluid
and abdominal volume
potassium pain, and status(urine,colo
ion dizziness. r, quality and
secretion, specific gravity)
while Increased
plasma blood sugar Assess patient
volume and uric acid tinnitus, or pain
contraction levels
increases
aldosteron
e
 production.
The
increased
delivery
and high
aldosteron
e levels
promote
sodium
reabsorptio
n at the
distal
tubules,
thus
increasing
the loss of
potassium
and
hydrogen
ions.

9. Have at least 5 NCPs for Mrs. Bunker. Arrange it according to the level of priority.

Assesment Diagnosis Planning Implementatio Rationale Evaluation

n
Subjective: Decreased cardiac • 1. Auscultate 2. Tachycardia  After
“kapoy akong output related to apical pulse, is usually nursing
gibati” Altered myocardial Short Term: assess heart present (even intervention
contractility/inotrop After 3-4 rate, rhythm. at rest) to
s, the
ic changes. hours of Document compensate for
patient shall
 nursing dysrhythmia if decreased have
Objective: interventions telemetry is ventricular participated
 Pale , the patient available. contractility. in activities
conjunctiv will Premature
that reduce
a, nail participate in atrial
the
activities contractions
beds, and workload of
that reduce (PACs),
buccal the heart.
the workload paroxysmal
mucosa of the heart. atrial
• Long tachycardia After 2-3 days
 irregul Term: After (PAT), PVCs, of nursing
ar rhythm 2-3 days of multifocal atrial interventions,
of pulse nursing tachycardia the patient
interventions (MAT), and shall have been
 bradyc , the patient atrial fibrillation able to display
ardia will be able (AF) are hemodynamic
to display common stability
 genera hemodynami dysrhythmias
lized c stability. associated with
weakness 2. Note heart HF, although
sounds. others may also
occur.

2. S1 and S2 may
be weak
because of
diminished
pumping
action. Gallop
rhythms are
common (S3and
S4), produced
as blood flows
into
3. Palpate noncompliant
peripheral chambers.
pulses. Murmurs may
reflect valvular
incompetence.

3. Decreased
cardiac output
may be
reflected in
diminished
radial,
popliteal,
dorsalis pedis,
 and post tibial
pulses. Pulses
may be fleeting
4. Monitor BP. or irregular to
palpation, and
pulsus
alternans
(strong beat
alternating with
weak beat) may
be present.

4. In early,
moderate, or
chronic HF, BP
may be
5. Inspect skin elevated
for pallor, because of
cyanosis. increased SVR.
In advanced HF,
the body may
no longer be
able to
compensate,
and profound
hypotension
may occur.

5. Pallor is
indicative of
diminished
peripheral
perfusion
secondary to
inadequate
6. Monitor cardiac output,
urine output, vasoconstrictio
noting n, and anemia.
decreasing Cyanosis may
output and develop in
concentrated refractory HF.
urine. Dependent
areas are often
blue or mottled
as venous
congestion
increases.
 6. Kidneys
respond to
reduced cardiac
output by
retaining water
7. Note and sodium.
changes in Urine output is
sensorium: usually
lethargy, decreased
confusion, during the day
disorientation, because of fluid
anxiety, and shifts into
depression. tissues but may
be increased at
8. Assess for night because
abnormal fluid returns to
heart and lung circulation
sounds. when patient is
recumbent.

8. May indicate
inadequate
cerebral
perfusion
secondary to
decreased
cardiac output.
9. Monitor
blood pressure
and pulse. 8. Allows
detection of
left-sided heart
failure that may
occur with
chronic renal
failure patients
due to fluid
volume excess
as the diseased
10. Assess kidneys are
mental status unable to
and level of excrete water.
consciousness.
9. Patients with
renal failure are
most often
hypertensive,
which is
attributable to
excess fluid and
the initiation of
the renin-
angiotensin
mechanism.

10. The
accumulation
of waste
products in the
bloodstream
impairs oxygen
transport and
intake by
cerebral
tissues, which
may manifest
itself as
confusion,
lethargy, and
altered
consciousness.
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Activity After 8 hrs 1. Check vital 1. Orthostatic Goal

“dali rako kapoyon intolerance of nursing signs before and hypotension can attained.
kapoy kog lihok” related to intervention immediately occur with
Imbalance the patient after activity, activity because
between will be able especially if of medication
oxygen to achieve patient is effect
supply/deman measurable receiving (vasodilation),
d increase in vasodilators, fluid shifts
activity diuretics, or (diuresis), or
tolerance, beta-blockers. compromised
Objective: evidenced cardiac pumping
 Weakness, by reduced function.
fatigue fatigue and
 Changes in weakness 2. Document 2.Compromised
vital signs, and by vital cardiopulmonary myocardium
presence of signs within response to and/or inability
dysrhythmias acceptable activity. Note to increase
 Dyspnea limits tachycardia, stroke volume
 Pallor, during dysrhythmias, during activity
diaphoresis activity. dyspnea, may cause an
 With VS diaphoresis, immediate
taken as pallor. increase in heart
follows: rate and oxygen
T: 36.5 demands,
P: 66 bpm thereby
R: 16 cpm aggravating
BP: weakness and
120/80 fatigue.
mmHg
3. Fatigue is a
3. Assess for side effect of
other causes of some
fatigue medications
(treatments, (beta-blockers,
pain, tranquilizers,
medications). and sedatives).
Pain and
stressful
regimens also
extract energy
and produce
fatigue.
 4. To note for
4. Assess any
patient’s general abnormalities
condition and deformities
present within
the body

5. Evaluate 5. May denote

accelerating increasing
activity cardiac
intolerance. decompensation
rather than
overactivity.

6. Provide 6. Meets
assistance with patient’s
self-care personal care
activities as needs without
indicated. undue
Intersperse myocardial
activity periods stress and
with rest excessive
periods. oxygen demand.

7. Strengthens
7. Implement and improves
graded cardiac cardiac function
rehabilitation under stress, if
program cardiac
dysfunction is
not irreversible.
Gradual
increase in
activity avoids
excessive
myocardial
workload and
oxygen
consumption.

8. To prevent
8. Assist patient deep vein
with ROM thrombosis due
exercises. Check to vascular
regularly for calf congestion.
pain and
tenderness. 9. Prevents
9. Adjust client’s straininga nd
 daily activities overexertion
and reduce which may
intensity of aggravate
level. symptoms
Discontinue
activities that
cause undesired
psychological
changes
10. Conserves
10. Instruct energy and
client in promote safety
unfamiliar
activities and in
alternate ways
of conserve
energy

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Excess fluid intake After 8hrs of 1. Monitor 1. Urine output Goal was
“Nanambok jod ko ja related to reduced nursing urine output, may be scanty met.
murag lain ahung glomerular intervention, noting and
dughan” filtration rate the patient amount and concentrated
(decreased cardiac will be able to color, as well (especially
output)/increased demonstrate as time of day during the day)
antidiuretic stabilized when diuresis because of
hormone (ADH) fluid volume occurs. reduced renal
production, and with balanced perfusion.
Objective: sodium/water intake and Recumbency
 Orthopnea, retention. output, favors diuresis;
S3 heart breath therefore, urine
sound sounds output may be
 Oliguria, clear/clearing, increased at
edema, JVD, vital signs night and/or
positive within during bed rest.
hepatojugula acceptable
r reflex range, stable 2. Monitor 2. Diuretic
 Weight gain weight, and and calculate therapy may
 Hypertension absence of 24-hour result in
 Respiratory edema. intake and sudden
distress, output (I&O) increase in fluid
abnormal balance. loss (circulating
 breath hypovolemia),
sounds even though
 With VS edema or
taken as ascites
follows: remains.
3. Maintain
T: 36.5 chair or bed 3. Recumbency
P: 66 bpm rest in semi- increases
R: 16 cpm Fowler’s glomerular
BP: 120/80 position filtration and
mmHg during acute decreases
phase. production of
ADH, thereby
enhancing
diuresis.

4. Involving
4. Establish patient in
fluid intake therapy
schedule if regimen may
fluids are enhance sense
medically of control and
restricted, cooperation
incorporating with
beverage restrictions.
preferences
when
possible. Give
frequent
mouth care.
Ice chips can
be part of
fluid
allotment.

5. Weigh
daily. 5. Documents
Frequently changes edema
monitor blood in response to
urea nitrogen, therapy. A gain
creatinine, of 5 lb
and serum represents
potassium, approximately
sodium, 2 L of fluid.
chloride, and Conversely,
magnesium diuretics can
levels. result in
excessive fluid
 shifts and
6. Assess for weight loss.
distended
neck and 6. Excessive
peripheral fluid retention
vessels. may be
Inspect manifested by
dependent venous
body areas for engorgement
edema (check and edema
for pitting); formation.
note presence Peripheral
of generalized edema begins
body edema in feet and
(anasarca). ankles (or
dependent
areas) and
ascends as
failure worsens.
Pitting edema is
generally
obvious only
after retention
of at least 10 lb
of fluid.
Increased
vascular
congestion
(associated
with RHF)
eventually
results in
systemic tissue
7. Auscultate edema.
breath
sounds, 7. Excess fluid
noting volume often
decreased leads to
and/or pulmonary
adventitious congestion.
sounds Symptoms of
(crackles, pulmonary
wheezes). edema may
Note presence reflect acute
of increased left-sided HF.
dyspnea, RHF’s
tachypnea, respiratory
orthopnea, symptoms
paroxysmal (dyspnea,
nocturnal cough,
dyspnea, orthopnea)
persistent may have
cough. slower onset
but are more
difficult to
8. Investigate reverse.
reports of
sudden 8. May indicate
extreme development of
dyspnea and complications
air hunger, (pulmonary
need to sit edema and/or
straight up, embolus) and
sensation of differs from
suffocation, orthopnea
feelings of paroxysmal
panic or nocturnal
impending dyspnea in that
doom. it develops
much more
rapidly and
requires
immediate
9. Monitor BP intervention.
and central
venous 9. Hypertension
pressure and elevated
(CVP) CVP suggest
fluid volume
excess and may
reflect
developing
pulmonary
10. Assess congestion, HF.
bowel sounds.
Note 10. Visceral
complaints of congestion
anorexia, (occurring in
nausea, progressive HF)
abdominal can alter
distension, intestinal
constipation. function.
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute Pain After 8hrs of 1. Introduce self- 1. To gain patient’s After 8hrs of
‘’sakit ahung nursing establishing trust nursing
dughan ja galisod intervention, rapport intervention,
kog ginhaswa” the patient the patient
will be able to 2. Assess patient 2. To identify was able to
demonstrate pain for intensity intensity, demonstrate
activities and using a pain rating precipitating factors activities
Objective: behaviors that scale, for location and location to and
 Difficulty of will prevent and for assist in accurate behaviors
breathing the precipitating diagnosis. that will
 Chest pain recurrence of factors. prevent the
 Restlessness pain. recurrence
 With VS 3. Administer or 3. The vasodilator of pain.
taken as assist with self- nitroglycerin
follows: administration of enhances blood flow
vasodilators, as to the myocardium.
T: 36.5 ordered. It reduces the
P: 66 amount of blood
bpm returning to the
R: 16 heart, decreasing
cpm preload which in
BP: turn decreases the
120/80 workload of the
mmHg heart.

4. Assess the 4. Assessing

response to response
medications every determines
5 minutes effectiveness of
medication and
whether further
interventions are
required.
5. Provide comfort
measures. 5. To provide non
pharmacological
pain management.
6. Establish a quiet
environment. 6. A quiet
environment
reduces the energy
demands on the
patient.
7. Elevate head of
bed. 7. Elevation
improves chest
expansion and
oxygenation.
8. Monitor vital
signs, especially 8. Tachycardia and
pulse and blood elevated blood
pressure, every 5 pressure usually
minutes until pain occur with angina
subsides. and reflect
compensatory
mechanisms
secondary to
sympathetic
nervous system
9. Teach patient stimulation.
relaxation
techniques and 9. Anginal pain is
how to use them often precipitated
to reduce stress. by emotional stress
that can be relieved
non-
pharmacological
10. Teach the measures such as
patient how to relaxation.
distinguish
between angina 10. In some case,
pain and signs and the chest pain may
symptoms of be more serious
myocardial than stable angina.
infarction. The patient needs to
understand the
differences in order
to seek emergency
care in a timely
fashion.
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Powerlessness After 4hrs of 1. Assess for factors Identifying the Goal was
“feeling naho related to nursing contributing to a related factors with met.
wana koy gamit chronic illness intervention sense of powerlessness can
dires kalibutan” and the patient powerlessness. benefit in
hospitalizations will be able to recognizing
recognize potential causes
means to and building a
Objective: control over collaborative plan
(-) facial personal 2. Assess for feelings of care.
expression situation. of apathy,
hopelessness, and 2. These moods
Not listening to depression. may be an element
everyone around of powerlessness.
3. Evaluate the
(+) signs of patient’s decision-
depression making competence. 3. Powerlessness is
the feeling that one
 With VS has lost the implicit
taken as power to control
follows: their own interests.
T: 36.5
P: 66 bpm 4. Know 4. It is necessary
R: 16 cpm situations/interactions for healthcare
BP: 120/80 that may add to the providers to
mmHg patient’s sense of recognize the
powerlessness. patient’s right to
refuse certain
procedures. Some
routines are done
on patients without
their consent
fostering a sense of
powerlessness.

5. Appraise the impact 5. Individuals may

of powerlessness on seem as though
the patient’s physical they are powerless
condition (e.g., to establish basic
appearance, oral aspects of life and
intake, hygiene, sleep self-care activities.
habits).
6. Assess the role of 6. The dilemma
illness plays in the about events,
patient’s sense of duration, and
powerlessness. course of illness,
prognosis, and
dependence on
others for guidance
and treatments can
contribute to
powerlessness.

7. Evaluate the results 7. A patient facing

of the information powerlessness may
given on the patient’s overlook
feelings and behavior. information. Too
much information
may overwhelm
the patient and add
to feelings of
powerlessness. A
patient simply
experiencing a
knowledge deficit
may be mobilized
to act in his or her
own best interest
after information is
presented and
options are
explored. The act
of providing
information about
heart failure may
strengthen a
patient’s sense of
independence.

8. Listen actively to 8. This approach

patient often. creates a
supportive
environment and
sends a message of
caring.

9. Encourage patient 9. This will aid

to identify strengths. patient to
recognize inner
strengths.
 10. Provide patient
with decision-making 10. This approach
opportunities with enhances patient’s
increasing frequency independence.
and significance.

10. FDAR

Day-1

Focus- Heart failure exacerbation

Data- Receive patient sitting on bed with heplock on right arm

Conscious and coherent

Respiratory rate: 25 cpm

BP: 130/90mmHg

Body malaise

DOB

Cold Clammy extremities

Action- Established rapport and introduced self

V/S taken and recorded

Provided bed side care

Health Teaching:

Proper position

Administration of diuretic drugs

Provide rest period

Placed patient into sitting position

Response- Adhere to self- care regimen

Day-2

Focus- Fatigue

Data- Received client sitting on bed with heplock

 Conscious and coherent

Irritable

Weakness noted

Slow flexes and responses

Poor concentration

V/S taken as follows:

T- 37.5°C

PR- 100 bpm

RR- 20 cpm

BP- 130/90 mmHg

Action- Established rapport and introduced self

V/S taken and recorded

Placed in position of comfort

Provided rest periods

Bedside care done

Assisted in self care activities

Promoted relaxation

Response- Seen client sitting in bed with no complaint of discomfort

Day-3

Focus- Hyperthermia

Data- Received client sitting on bed with heplock

Temperature @38.5°C

Concious and coherent

Red and dry skin

Fast and deep breathing

Strong pulse

V/S taken as follows:

T- 38.5°C
 PR- 99 bpm

RR- 19 cpm

BP- 140/80 mmHg

Action- Established rapport and introduced self

V/S taken and recorded

TSB done

Placed in position of comfort

Provided rest periods

Bedside care done

Assisted in self care activities

Promoted relaxation

Medication given

Response- Seen client sitting in bed with temperature of 37.5°C

Day-4

Focus: continuity of care

Data: Receive patient on bed sitting (semi fowlers position)

Conscious and coherent

Body weakness

Blood pressure: 140/80

Respiratory rate: 24bpm

Action: greeted and established rapport

V/S taken and recorded

Provided bed side care

Assisted in self-care activities,

monitored for unusual findings

Response: seen patient lying on bed relieve from discomfort