Republic of the Philippines COLLEGE OF NURSING Bicol University Legazpi City

A CASE STUDY
(ATHEROSCLEROSIS)
Submitted by: GROUP 3, 9, 5, 11

INTRODUCTION

OBJECTIVES
General Objective: Specific Objective: Skills: Attitude: Nurse-Centered Objectives: Client-Centered Objectives:

Demographic Profile
Client s Name: L. L. Age: 66 years old Address: P#2 Salvacion, Daraga, Albay Civil Status: Married Sex: Female Nationality: Filipino Religion: Roman Catholic Date of admission: January 9, 2012 Time of admission: 9:35 PM Chief complaint: Bipedal Edema One Week PTC Admitting diagnosis: ATHEROSCLEROSIS HEART DISEASE, CAD in AF, CHF, FC III with CPC of the Liver Physical Findings: (+) hepatomegaly, (-) HTN and (-) DM (+) bipedal fitting edema Grade III (+) congestion of lungs (+) diastolic murmur, (+) weak vein engorgement One week had history of bipedal edema associated with difficulty of breathing (+) orthopnea (2 pillows) (-) cough, (-) fever, (-) abdominal pain (+) decrease urine output, (+) loss of appetite

Present History A case of L.L, 69 years of age from P#2 Salvacion, Daraga, Albay, admitted at

BRTTH with a chief complain of Bipedal Edema. One week prior to admission, the patient had onset of progressive bipedal edema associated with difficulty of breathing, (+) 2 pillows orthopnea, (-) cough, (-) fever, (-) abdominal pain, (+) loss of appetite, and decreased urine output, condition tolerated. Past History Patient is a known case of Heart Disease with a maintenance medication of Furosemide 20mg, 1 tablet, Monday, Wednesday, Friday; Spironolactone

25mg, 1 tablet, Tuesday, Thursday, Saturday, Sunday; Trinetazidine 35mg, 1 tablet, BID with good compliance of medication. Previously, patient was admitted last February 2011 due to CAD with CHF with CPC with 2D echo (-) PTB. unrecalled. During that time, he has (-) HTN, (-) Dm and

Development History

Anatomy and Physiology

Pathophysiology Diagnostic Evaluation/ Lab Exams

Urinalysis Macroscopic Color Transparency Specific Gravity Microscopic RBC Pus Cells Epithelial Cells Amorphous Urates Bacterial Cells Crystals Urates Phosphate Calcium Coxalate Others

Dark yellow turbid 1.025

Reaction 5.0 Chemical Tests negative Sugar A. Albumin positive Special Tests B. Foams test Ketone Pregnancy test Analysis and Interpretation: Laboratory results revealed that there is sugar present. High level of protein in predictor of renal disease progression.

1-3 / HPF 5-10 / IPF Few Few Plenty

presence of albumin in the blood and no urine indicates protein losses, a strong

Hematology WBC RBC HGB Result 5.5 5.58 152 Normal 4.8-10.8x10^9 /L 4.7-6.1x10^12 /L 130-170 g/L Analysis Normal Result was normal. Result was normal.

HCT Platelet Count Neutrophil Lymphocytes

0.49 130 68 32

0.40-0.52 150-400x10^9/ul 40-70% 19-48%

Result was normal. Result was normal. Result was normal.

Test

Result

Unit

Normal values

Analysis and Interpretation

Creatinine

341 high 5.8 low

umol/L

71

133

Potassium

mmol/L

3.65

5.20

Result was above normal thus showing inability of the kidney to excrete nitrogenous waste. Result was normal.

Doppler Study VALVE

MAX VEL M/SEC

PEAK GRAD mmhg

AORTIC MITRAL TRICUSPID PULMONIC PA PRESSURE

B=0.63 E=1.35 E=0.49

A=1.09 A=0.72 A=0.33

B=2

A=5

E=7 A=2 E=1 A=0 2

0.72 68

Mode and 2d Echocardiography

Dilated left ventricle with severe hypokinesia of the basal segments of the anterior left ventricular free wall and interventricular septum, which becomes akinetic from mid to apex. There is likewise hypokinesia of the basal segments of the inferoposterior left ventricular free wall and lateral left ventricular free wall which becomes severely hypokinetic from mid to apex. Dilated LA

Dilated RV Normal RA, main PA and aortic root dimensions. Thickened MV leaflets with low flow configuration and widened E-point septal separation. Thickened aortic valve cusps with no restrictions of motion. Structurally normal tricuspid valve and pulmonic valve.

Color Flow and Doppler Study

Abnormal color flow display noted across the mitral valve, tricuspid valve and pulmonic valve.

Color Flow and Doppler Study

Dilated LV with segmental wall motion abnormality indicative of coronary artery disease with severe left ventricular dysfunction. Dilated left atrium. Dilated right ventricle. Severe tricuspid regurgitation. Moderate pulmonary htn with pulmonic regurgitation. Echocardiographic Data Taken last February 2011 Dimension PT Normal FXN (cm) LV(ed) LV(es) RV(ed) LA(es) RA(es) AORTA PA IVS(ed) IVS(es) LVPW(ed) LVPW(es) 7.1 6.4 4.0 4.1 3.6 2.7 2.9 1.1 1.4 0.9 1.2 (0.8-1.1) (2.2-4.0) (3.0-3.5) (3.5-4.5) (3.0-3.9) (3.0-3.5) (0.8-1.1) EPSS 2.3 EF % FS % 21% 10% (55.0-77.0) (28.0-42.0) (0.5-1.5) (<=1.0) (<=195) (<=600) (4.5-5.0) LVEDV LVVESV STROKE VOL

PT

Normal

364 209 55

(91-125)

Analysis and Interpretation:

Medical Treatment and Evaluation Treatment

Date 01/9/12 Order Intravenous Fluid Insertion of D5W to run at KVO rate. I and O every shift This measures how much fluids are taken and how much has been excreted. This also indicates any problem in the kidneys. Vital signs are done every one hour to monitor the clients well being such as temperature which is indicative of hyperthermia. Also to monitor the blood pressure for possible elevation. Too fat and salts may overwork the kidneys. Rationale

01/9/12

01/9/12 Monitor Vital Signs every 1 hour

01/9/12 Low Salt, Low Fat Diet

01/9/12 01/9/12

Bed Rest 12 Hour ECG

Medical Management
a. b. c. d. e. f. g. h. Dopamine Drip 200mg Furosemide 20mg IV every 8 hours, BP > 90/60 HNDB 250mg Digoxin 0.2 mg/tab OD Spironolactone 25mg tablet CaCO3 500mg/tablet TID NaHCO3 650mg/tab TID AGA 80mg/tab OD PC

Drug Study Surgical Management Nursing Care Plan Discharge Plan

Medication Exercise Treatment Health Teaching Observable Signs and Symptoms Diet Spirituality/ Sex

REFERENCES

Doctors Orders

1-9-12 patient admitted Pca to Medical Ward secure consent for admission and mangament monitor V/S every 1 hour I and O every shift bed rest low salt, low fat diet IVF d5W 500 and KVO Report for: a. 12 hour ECG b. CBG c. CxRay d. CBC e. Na, K, Ca, Mg, Creatinine f. Urinalysis