Chf-revised.docx

I. INTRODUCTION

A. OVERVIEW Heart failure, sometimes referred to as congestive heart failure, is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. Heart failure is a clinical syndrome characterized by signs and symptoms of fluid overload or inadequate tissue perfusion. The underlying mechanism of the heart failure involves impaired contractile properties of the heart (systolic dysfunction) or filling of the heart (diastolic) that leads to a lowerthan-normal cardiac output. The low cardiac output can lead to compensatory mechanisms that cause increased workload on the heart and eventual resistance to filling of the heart. Heart failure is a life-long diagnosis managed with lifestyle changes and medications to prevent acute congestive episodes. Congestive heart failure is usually an acute presentation of heart failure. Common underlying conditions include

coronary

atherosclerosis

(primary

cause),

valvular

disease,

cardiomyopathy, inflammatory or degenerative muscle disease, and arterial

1

I. INTRODUCTION

hypertension. A number of systemic factors can contribute to the development and severity of cardiac failure. Increased metabolic rate (fever, thyrotoxicosis), hypoxia, and anemia require an increased cardiac output to satisfy systemic oxygen demand. Dysrhythmia decreased the efficiency of myocardial function. Source: Johnson, Joyce Young. Handbook for Brunner & Suddarth’s Textbook of Medical – Surgical Nursing, Eleventh Edition. Lippincott Williams & Wilkins.

Clinical Manifestations 

Symptoms of inadequate tissue perfusion



Diminished cardiac output with accompanying dizziness, confusion, fatigue, exercise or heat intolerance, cool extremities, and oliguria



Congestion of tissues



Increased pulmonary venous pressure (pulmonary edema) manifested by cough and shortness of breath



Dysrhytmia may indicate heart failure or may be noted as a result of the treatment for heart failure.



Increased systemic venous pressure, as evidenced by generalized peripheral edema and weight gain

Left-Sided Heart Failure Most often precedes right-sided heart failure Backward Failure 

Pulmonary congestion; cough; fatigability; tachycardia with an S3 heart sound; anxiety; restlessness

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I. INTRODUCTION



Dyspnea on exertion (DOE), orthopnea, paroxysmal nocturnal dyspnea (PND)



Cough may be dry and nonproductive but is most often moist.



Bibasilar crackles advancing to crackles in all lung fields



Large quantities of frothy sputum, which is sometimes pink (blood tinged)

Forward Failure Tachycardia, weak, thread pulse, anxiety, oliguria and nocturia, altered digestion, ashen, pale, cool and clammy skin Right-Sided Heart Failure 

Congestion of the viscera and peripheral tissues



Edema of lower extremities (dependent edema), usually pitting edema, weight gain, hepatomegaly



Distended neck veins, (jugular vein distention), ascites, anorexia, and nausea



Nocturia and weakness

Source: Johnson, Joyce Young. Handbook for Brunner & Suddarth’s Textbook of Medical – Surgical Nursing, Eleventh Edition. Lippincott Williams & Wilkins.

3

I. INTRODUCTION

B. STATISTICAL DATA Local The prevalence rate was 1.6% or 1648 cases of CHF for every 100 000 patient claims for medical conditions in 2014. The mean age was 52.6±15.1 years. There was no sex predilection. Only 22.67% of the hospitalization claims for CHF listed possible specific etiologies, the most common of which was hypertensive heart disease (86.7%). There were more cases of systolic compared to diastolic heart failure. The mean length of hospital stay was 5.9 days (+8.2) days (median 4 days), with an overall in-hospital mortality rate of 8.2%. There were 16 cases of heart failure for every 1000 Filipino patients admitted due to a medical condition in 2014. Hypertension was possibly the most common etiologic factor. Compared to western and Asia-Pacific countries, the local mortality rate was relatively higher. Source: http://pubmedcentralcanada.ca/pmcc/articles/PMC5372042/

International The number of adults living with heart failure increased from about 5.7 million (2009-2012) to about 6.5 million (2011-2014), according to the American Heart Association’s 2017 Heart Disease and Stroke Statistics Update. Based on the latest statistics, the number of people diagnosed with heart failure, which means the heart is too weak to pump blood throughout the body, is projected to rise by 46 percent by 2030, resulting in more than 8 million people adults with heart failure. According to experts, there are several reasons for the

4

I. INTRODUCTION

rise in heart failure, that can be attributed to medical advances, because more people are surviving heart attacks which means they face higher heart failure risk afterward, said Paul Muntner, Ph.D., a member of the statistical update’s writing panel and a professor and vice chair in the Department of Epidemiology at the University of Alabama at Birmingham. But the aging of America and other health problems are also major contributors.

C. SCOPE AND LIMITATION On the 1st March of 2018, student nurses were assigned at Laguna Medical Center, Santa Cruz, Laguna, Medical Ward from 6 am to 3 pm shift under the supervision of Ma’am Ma. Janice M. Bernardo, MAN, MSN. The patient was received lying in bed, with IV Heplock & Foley Catheter. The assigned student nurses includes head-to-toe assessment, monitoring and recording of vital signs, IV regulation, charting the patient’s data and nurse’s management, and providing health teachings are part of their duty. After the patient’s confinement, the assigned student nurses decided to conduct a phone call instead of home visit due to the worsening condition of the patient. A phone call was carried out for further health history & assessment and also to grasp the patient’s progress last April 21, 2018. During the phone call, the assigned student nurses clarify their intentions and motives, they also asked the wife of the patient to permit them to ask questions, and as a result, they had willingly participated all throughout the interview.

5

I. INTRODUCTION

D. BACKGROUND OF THE STUDY This case study aims to identify patient’s problems and health needs in order to promote the general health of the patient by providing proper interventions through the application of nursing process. This case was chosen by the student nurses for them to practice their skills in formulating and implementing a nursing care plan, in conducting a thorough assessment to help in managing the patient's case and also to develop their sense of teamwork as they execute their case study with the help of the concepts in Medical Surgical course, Human Anatomy and Physiology and other science related studies.

General Objective: At the end of the case presentation the nursing students from BSN III-A will be able to gain knowledge and comprehend their case even more, and also to further understand and gain extensive knowledge form the case. Specific Objectives: 

The student will be able to enumerate the predisposing and precipitating factors that contribute to Congestive Heart Failure.



Provide a thorough assessment and data gathering that could help and a significant factor in formulating a nursing care plan.



State and identify the appropriate nursing diagnosis and make interventions.

6

I. INTRODUCTION



Provide specific and suitable health teachings to promote awareness.



Plan appropriate nursing care intervention.



To implement plan of care.



To formulate an individualized nursing care plan.



Provide health teaching to the patient or to the significant others.



Determine the effectiveness of every plan and the outcome for the health education provided.

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II. PATIENT’S PROFILE

Case No.:

166345

Patient’s Name:

Hil

Address:

Calauan, Laguna

Gender:

Male

Birthday:

July 22, 1992

Age:

25 years old

Nationality:

Filipino

Civil Status:

Married

Allergies:

No known allergies

Admitting Time:

12:10 PM

Admitting Date:

February 23, 2018

Admitting Diagnosis:

t/c CHF

Principal Diagnosis:

CHF

Admitting Physician:

Aileen M. Abadier, MD

Chief Complaint:

Generalized Edema

III. PATIENT’S HISTORY

A. Present History Prior to admission, Patient Hil was experiencing progressive generalized edema for the last 5 months. Upon admission, the patient was also accompanied by difficulty in breathing, dizziness, and fatigue besides the generalized edema. First the edema was only on lower peripheries but as the day goes by, the edema evolves also on upper extremities. The patient also experiences paroxysmal nocturnal dyspnea (PND), orthopnea, and cough during the last 5 months. The patient also realized that there’s an increase in the girth of his abdomen. At times, the patient also experiences nausea and vomiting. To relieve the symptoms of what the patient is enduring, the patient took medication such as Robitussin (guaifenesin). The patient also apply or inhale Vicks when the nausea and vomiting attacks. Before the day of hospitalization, February 22, 2018, prior to sleeping the patient experiences difficulty of breathing but was relieved later on and then at the middle of the night, the patient were awaken due to shortness of breath. At the morning, the patient and his family was beginning to be anxious and worried because of the edema on his face. During the hospitalization last March 1, 2018, the patient was handled by one of the Group 2 students and was physical assessed and was taken vital signs. For the 8 am, the vital signs were BP=140/80, T=36.2, P= 96 bpm, R= 20cpm. The patient was experiencing shortness of breath with shallow breathing, so the patient was administrated with Oxygen via Nasal Cannula at 3 liters per minute as

III. PATIENT’S HISTORY

ordered by the doctor. At 12 pm, the patient's blood pressure is 120/100, P= 79 bpm, R= 22 cpm, T= 36.2. The intake measured was 450 ml and output calibrated was 150 ml. At the second handling of the patient last March 7, 2018, the assigned student nurse was able to talk to the patient with a good mood. At the lunch, the patient’s irritability came back. The patient at that time was able to sit by himself but even though he has the endurance to do it, a facial grimacing can be seen due to the illness. The difficulty in breathing subsided but there was still an irregularity in his intake and output. The intake measured was 250 ml and output calibrated was 100 ml. The patient’s vital sings in the morning was BP = 130/100, P = 95, T= 36.4, R = 26. At the afternoon, BP = 120/90, P = 110, R = 24, and T = 37. B. Past History General: Patient Hil was already exposed in alcohol and cigarettes when he was only 13 years old. At 18 years old, the patient was starting to have elevated blood pressure, ranging from 130/90 – 140/80. Infectious Diseases: Before Hospitalization

During Hospitalization

Common colds, cough, fever, measles, mumps, chicken pox

Allergy: No known allergies

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III. PATIENT’S HISTORY

Transfusions: None Hospitalizations, Operations, Injuries: No past hospitalization, operation, or injury.

C. Family History

Narrative: According to the patient, they have history of heart diseases. For the patient's family history, hypertension and MI runs in the family. For the siblings

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III. PATIENT’S HISTORY

of the patient, there is no presence of heart diseases except for the patient, diagnosed with CHF.

D. Developmental History Erik Erikson's Psychosocial Development Stage 6: = 18 – 40 y/o – “Intimacy vs. Isolation” Description: Stage six of the Erikson stages is very apparent for young adults who are in their 30s. People at this stage become worried about finding the right partner and fear that if they fail to do so, they may have to spend the rest of their lives alone. The patient was married at 20 years old and has children of 3. The patient’s wife supports him to the fullest. The wife always visits and the one who’s takes care of the patient. The patient told the students that he was very lucky to have his wife and assists him back to health. The patient has no problem with the relationship with his wife. The patient’s wife spends most of her time to aid her husband. The children also lessen the patient’s enduring symptoms which makes the patient slightly improve his emotional and psychological well-being. E. Socioeconomic The patient is living in the house with his family. When he was younger,

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III. PATIENT’S HISTORY

he had work. He assists in the carpenters in a construction site in his town. Thus the patient was influenced in drinking alcohol and smoking cigarettes. Before the hospitalization, the patient was working as a carpenter of making houses near he lives. The wife of the patient handles their small sari-sari store. The business that they are handling is where they also get from all the expenses they need to support the patient’s needs. According to the wife, during and after the hospitalization the patient becomes very picky in food. So they need to spend a lot to satisfy the requests of her husband even though sometimes they are near to scarcity. F. Psychological The patient was always sleeping and hardly to move due to his condition. The patient responds occasionally. The wife said that sometimes you will not have the interest to talk to him because due to snobbish behavior and he became very irritable. Sometimes when the wife tries to have a conversation with him, the patient will shrew at her telling that why she has that tone of voice. The daughter also said that when the patient endures pain as verbalized by the patient, he becomes very irritable and disoriented to the point that you can no longer talk to him.

G. Socio-cultural During his younger days, the patient spends a lot of time working and studying if he must. He was always drinking liquors and smoking cigarettes with

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III. PATIENT’S HISTORY

his co-workers and classmates. After the stroke, he stopped hanging out with his co-workers and friends; he also stopped drinking and smoking. H. Spiritual The family is affiliated to Roman Catholic. According to the patient’s wife, their family attends to church regularly, every Sunday, and always prays and asks for God's guidance. After the hospitalization, the patient believes that God has still purpose for him. I.

Nutrition

BEFORE

DURING

AFTER

The patient likes eating

During hospitalization,

After hospitalization, the

salty and fatty food like

the patient eats 3 times a

patient has increased

fried chicken and any

day, he regularly eats

appetite, he likes eating

meat dishes. When

porridge. His intake was

porridge, goto, and

vegetables are only in the

450 ml (February 28,

always like having extra

entrée, he always

2018) and 250 ml (March

rice. He drinks water 6 –

requests for some meat.

7, 2018)

7 glasses per day.

The patient also likes eating lots of rice, or any high in carbohydrates. Before the hospitalization, the patient was having a hard time eating due to his

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III. PATIENT’S HISTORY

generalized edema.

J. Elimination BEFORE

DURING

AFTER

URINATION Before the

During the

After the hospitalization,

hospitalization, according

hospitalization, the

the patient regularly

to him, regularly voids 5

patient was in diaper and

changes diaper for 2 – 3

times a day.

Foley Catheter, the

times a day.

output calibrated was 150 ml (February 28, 2018) and 100 ml (March 7, 2018) DEFECATION Before the

During the

After the hospitalization,

hospitalization, the

hospitalization, the

the patient on his diapers

patient defecates 1 to 2

patient on his diapers

defecated 2 – 3 times a

times a day with

defecates 0 to 1 times a

day with unknown

unknown consistency.

day.

consistency.

K. Exercise BEFORE

DURING

AFTER

Before the hospitalization

During hospitalization,

After hospitalization, the

and the appearance of

the patient stops his daily

patient tries to stretch his

manifestations, the

routine exercise due to

limbs every morning.

patient regularly walks

his illness.

before going to work.

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III. PATIENT’S HISTORY

L. Hygiene BEFORE

DURING

Before hospitalization,

During hospitalization,

the patient usually takes a

the patient’s wife

bath once and brushes his

provides hygienic care

teeth twice every day.

for him with the help of

And during at night

the assigned student

before sleeping, he cleans

nurse by changing

himself and changes his

clothes.

AFTER After hospitalization, the wife of the patient assists the patient to the bathroom and for brushing his teeth; the wife will hand over a small basin with water and his toothbrush with toothpaste.

clothes to provide comfort.

M. Sleep & Rest BEFORE

DURING

AFTER

Before hospitalization,

During hospitalization,

After hospitalization, the

the patient sleeps normal.

the patient sleeps most of

patient had difficulty of

The patient sleeps at 9

the time but awakes due

sleeping because the

pm and wakes at 6 or 7

to dyspnea.

patient feels any time he

am for his work.

will die due to his dyspnea.

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IV. DIET PLAN

DIET PLAN Wt. = 74 kg Ht. = 5 feet 7 inch = 170.18 cm BMI = 74/(1.70)2 = 25.55 DBW = 170.18 – 100 = 70.18 kg = 70.18 – 7.02 (10% of 70.18) =63.16 or 63 kg/s NDAP = 112 lbs + 7(4) = 112+28 = 140 lbs/2.2 = 63.6 kg TEA = 64 kg x 27.5 = 1760 kcal CHO = 65% = 0.65 x 1760 = 1144 kcal/4 = 290g CHON = 20% = 0.20 x 1760 = 352 kcal/4 = 90g FATS = 15% = 0.15 x 1760 = 264 kcal/9 = 30g SAMPLE CALCULATION Diet Prescription: 1760 FOOD

NO. EXCHANGES 2

CHO (g) 3

Veg., List I-A Veg., List 1 3 I-B Fruit, List 3 30 II Milk, List 1 12 III Sugar List 7 35 VII Partial Sum = 83 290 (prescribed CHO) - 83 (partial sum of CHO) 207/23 = 9 no. of rice exchanges

CHON (g) 1

FAT (g)

1

ENERGY (kcal) 16 16 120

8

5

125 140

IV. DIET PLAN

Rice, List IV

9

207

18

Partial Sum = 90 (prescribed CHON) - 28 62/8 = 8 no. meat exchanges Meat, List 6 Va Meat, List 2 Vb Partial Sum = 30 (prescribed fat) - 23 7/5 = 1 no. of fat exchanges Fat, List 1 VI TOTAL 290

28

Breakfast -

-

-

Apple (65g) Oatmeal (1/2 cup) (2 tsp sugar) Boiled Chicken’s Egg (1 pc) Bear Brand Sachet Low Fat Milk (250 g)

AM Snack -

48

6

246

16

12

172

23

92

Lunch

Orange - Sitaw at Juice (2 Kalabasa tsp)  Sitaw - Ham (1/2 cup) Sandwhic  Squash h (1/2 cup)  Pan de - Buttered American Shrimp o (2  Shrimp slice) “Sugpo”  Ham (1 (50g) slice)  Butter (2 tsp) - Rice (160 g) - Biko (40 g) - Banana “lakatan” (80g)

900

5

45

28

1780

PM Snack -

Binatog (1/2 cup) Coffee (2 tsp sugar)

Dinner     -

-

Chicken Curry Carrots (1/2 cup) Potato (390 cups) Chicken Breast (90g) Corn Oil (3 tsp) Rice (80g) Ice Cream, regular (90g) Fruit Cocktail (1/4 cup)

V. PHYSICAL ASSESSMENT

PHYSICAL ASSESSMENT Assessment Method Integumentary Skin Inspection

Findings

Implications

With dry appearance

Dry skin on the lower part of the legs because of pressure from inside the tissue. Reference: https://medicaldictionary.thefreedictionary.com/oe dema

Cold, clammy skin

Over-activity of the sympathetic nervous system. This leads to narrowing of arteries and excessive stimulation of sweat glands. This means that less blood flow to the skin makes them cold and clammy at the time when the excessive stimulation to the sweat glands makes the skin wet. Reference: https://medicaldictionary.thefreedictionary.com/oe dema

Nails

Inspection

With pale appearance of

nail beds, capillary refill time of 3 seconds.

Prolonged capillary refill time indicates compromised arterial perfusion. Reference:Brunner & Suddarth’s Textbook of Medical Surgical Nursing 13th Edition, Chapter 25, p667.

If your fingernail beds are looking a little ghostly, you may have anemia, a blood disorder characterized by a low red blood cell count. “Anemia resulting from low levels of iron can lead to inadequate oxygen in the blood, which causes the skin and tissues to become pale, particularly the tissues under

19

V. PHYSICAL ASSESSMENT

the nails Reference: https://www.shape.com/lifestyle/bea uty-style/7-things-your-nails-cantell-you-about-your-health

Eyes and Vision Eyelids Inspection

Puffy eyes

Heart problems can contribute to “Bags under the eyes.” And puffy eyes may actually be the first sign of a medical problem. That’s because puffy eyes often become more noticeable with any condition that causes fluid retention. Reference: https://www.youtube.com/watch?v= bn0s576wX8w

Palpebral conjunctiva

Inspection

Pale

Paleness is due to inadequate circulation of oxygens. Decreased perfusion and vasoconstriction Reference:Brunner & Suddarth’s Textbook of Medical Surgical Nursing 13th Edition, Chapter 60 p.1759 and Unit 7, p.902

Mouth and Oropharynx

Inspection

With dry lips

Causes of chapping and cracking in the corners of the lips is due difficulty of breathing and inadequate supply of blood. Reference: Live Strong (2015) Retrieved From http://www.healthline.com/health/ pneumonia

Neck

Inspection

Jugular Vein distention

Increased venous pressure leads to jugular venous distention and increased capillary hydrostatic pressure throughout the venous system.

20

V. PHYSICAL ASSESSMENT

Reference:Brunner & Suddarth’s Textbook of Medical Surgical Nursing 13th Edition, Chapter 29, p799.

Chest and Lungs Heart

Auscultation

Palpation

With Cardiac Rate of 128 bpm, Irregular rapid heartbeats, tachyarrythmia (atrial fibrillation)

Radial Pulse of 96 bpm Auscultation

Atrial fibrillation is an uncoordinated artrial electrical activation that causes a rapid, disorganized, and uncoordinated twitching of atrial musculature. Reference:Brunner & Suddarth’s Textbook of Medical Surgical Nursing 13th Edition, Chapter 26, p703.

Pulse deficit is a clinical sign wherein, one is able to find a difference in count between heart beat (Apical beat or Heart sounds) and peripheral pulse. This occurs even as the heart is contracting, the pulse is not reaching the periphery. Reference: https://drsvenkatesan.com/2008/08/ 13/what-is-pulse-deficit-what-isthe-mechanism-of-pulse-deficitwhere-does-it-occur/

Respiratory Tract

Respiratory rate of 26 cpm

The shortness of breath may be accompanied by fatigue or a sensation of smothering or sternal compression. In the later stages of left ventricular failure, the pulmonary circulation remains congested, and dyspnea occurs with mild exertion. Moreover, the patient may develop orthopnea or paroxysmal nocturnal dyspnea.

21

V. PHYSICAL ASSESSMENT

Reference: https://www.ncbi.nlm.nih.gov/books /NBK213/

With adventitious breath sounds of rales

Abdomen

Inspection

Abdominal distention – abdominal girth of 103 cm.

Pulmonary edema secondary to left-sided congestive heart failure can also cause rales

Reference: https://www.practicalclinicalskills.c om/rales

Portal hypertension and the resulting increase in capillary pressure and obstruction of venous blood flow through the liver are contributing factors.

Reference:Brunner & Suddarth’s Textbook of Medical Surgical Nursing 13th Edition, Chapter 20, p475.

Lower extremities

Inspection

Presence of edema both legs, graded 3+ 6mm

Peripheral edema is a common finding in patients with CHF and peripheral vascular diseases. Such as deep vein thrombosis and chronic venous insufficiency. Reference:Brunner & Suddarth’s Textbook of Medical Surgical Nursing 13th Edition, Chapter 60, p1765.

Presence of ulcer both legs

Because of changes in peripheral nerves, infection begin and if left untreated may lead to ulceration. Ulceration unresponsive to treatment are leading cause of diabetic foot and amputation. Reference:Brunner & Suddarth’s

22

V. PHYSICAL ASSESSMENT

Textbook of Medical Surgical Nursing 13th Edition, Chapter 60, p1765.

Mental Status Level of Consciousness

Inspection

Aware and alert. (March 1, 2018)

Awareness is the ability to directly know and perceive, to feel, or to be cognizant of events. More broadly, it is the state or quality of being conscious of something. Alertness is the state of active attention by high sensory awareness such as being watchful and prompt to meet danger or emergency. Retrieved from:www.psychologydictionary.co m

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VI. ANATOMY AND PHYSIOLOGY

The cardiovascular system consists of the heart, which is an anatomical pump, with its intricate conduits (arteries, veins, and capillaries) that traverse the whole human body carrying blood. The blood contains oxygen, nutrients, wastes, and immune and other functional cells that help provide for homeostasis and basic functions of human cells and organs. The pumping action of the heart usually maintains a balance between cardiac output and venous return. Cardiac output (CO) is the amount of blood pumped out by each ventricle in one minute. The normal adult blood volume is 5 liters and it usually passes through the heart once a minute. The cardiac cycle refers to events that occur during one heart beat and is split into ventricular systole (contraction/ejection phase) and diastole (relaxation/filling phase). A normal heart rate is approximately 60 - 100bpm, and

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VI. ANATOMY AND PHYSIOLOGY

the cardiac cycle spreads over 0.8 seconds. The heart sounds transmitted are due to closing of heart valves, and abnormal heart sounds, called murmurs, usually represent valve incompetency or abnormalities. Blood is transported through the whole body by a continuum of blood vessels. Arteries are blood vessels that transport blood away from the heart, and veins transport the blood back to the heart. Capillaries carry blood to tissue cells and are the exchange sites of nutrients, gases, wastes, etc. The heart is a muscular organ weighing between 250-350 grams located obliquely in the mediastinum. It functions as a pump supplying blood to the body and accepting it in return for transmission to the pulmonary circuit for gas exchange. The heart contains 4 chambers that essentially make up 2 sides of 2 chamber (atrium and ventricle) circuits; the left side chambers supply the systemic circulation, and the right side chambers supply the pulmonary circulation. The chambers of each side are separated by an atrioventricular valve (A-V valve). The left-sided chambers are separated by the mitral (bicuspid) valve, and right-sided chambers are divided by the tricuspid valve. Blood flows through the heart in only one direction enforced by a valvular system that regulates opening and closure of valves based on pressure gradients.

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VI. ANATOMY AND PHYSIOLOGY

The systemic circuit originates in the left side of the heart and functions by receiving oxygen-laden blood into the left atrium from the lungs and flows one way down into the left ventricle via the mitral valve. From the left ventricle, oxygen rich blood is pumped to all organs of the human body through the aortic semilunar valve.

26

VII. PATHOPHYSIOLOGY

PRECIPITATING FACTORS: PRE-DISPOSING FACTORS: 

Family history of hypertension



Chronic Hypertension



Early exposure to smoking (Age 13)



Early alcohol consumption, 3-6 bottles/week (Age 13)



Increased fatty food intake

Thick ventricles and stiff heart muscles

Blood back up

Decreased cardiac output and stroke volume Increased heart rate (110 bpm) 

Pulmonary edema (dyspnea with RR of 26cpm)



Peripheral edema (bipedal grd.3 6mm and ascites of 104cm)





Bipedal pitting edema grd. 3 (6mm)

RAAS Activation

Sodium and Fluid retention



Sodium level (132 meq/L)



Anasarca

Volume overload

From right ventricle to vena cava

From left ventricle to the lungs

Ascites (104cm abdml girth)

27

VII. PATHOPHYSIOLOGY





Bipedal pitting edema grd. 3 (6mm)

Decreased blood flow to the lungs

Decreased blood flow to the body

Peripheral edema/ jugular vein distention

Pulmonary edema ()

Ascites (104cm)





Adventitious breath sound (rales)

Weak pulse/dyspnea

Dyspnea (26cpm)

CONGESTIVE HEART FAILURE

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VII. PATHOPHYSIOLOGY

29

VII. PATHOPHYSIOLOGY

30

VIII. DIAGNOSTIC PROCEDURES Blood Chemistry 3 –Febuary 26, 2018 PARAMETER White Blood Cell

NORMAL 4-10 (x10^9/L)

RESULT 11.7

INTERPRETATION HIGH

IMPLICATION An increased count (leukocystosis) commonly signals infection, such as an abscess. Source: Nurse’s Quick Check, Diagnostic Tests, Lippincott Williams & Wilkins, 2006 Since the patient also has ulcerations on his lower limbs.

Hemoglobin

130 – 180 (g/L)

118

LOW

A low hemoglobin count may be a sign of a disease or condition which needs medical attention, because it could lead to inadequate oxygenation of the vital organs. Reference: http://www.md-health.com/Low-Hemoglobin.html

Segmented Neutrophils

Lymphocytes

55-65 (%)

25-35 (%)

89.9

4.2

HIGH

LOW

Since the patient has right sided heart failure, it now affects the systemic circulation of blood in the different systems of the body that would lead to impairment of some of the vital organs. The presence of mature, hypersegmented neutrophils that have more nuclear segments than normal indicate hepatic disease. Source: Nurse’s Quick Check, Diagnostic Tests, Lippincott Williams & Wilkins, 2006 The patient has ascites and according to the patient’s ultrasound of liver (February 26, 2018), the patient has contracted liver with hepatocellular change. Low lymphocyte count (LLC) is a common finding during the systemic inflammatory response, and clinical and

31

VIII. DIAGNOSTIC PROCEDURES

animal studies suggest that LCC plays a putative role in accelerated atherosclerosis. For instance, there is recent evidence that LLC is associated with worse outcomes in patients with heart failure, chronic ischemic heart disease and acute coronary syndromes. Reference: https://www.ncbi.nlm.nih.gov/pubmed/21671854 Since LLC is associated with heart diseases, and the patient was diagnosed with CHF. February 26, 2018 PARAMETER

Sodium

NORMAL VALUE

RESULT

135-145 mEq/L

132

INTERPRETATION

LOW

IMPLICATION

A low sodium level in the blood may result from excess water or fluid in the body, diluting the normal amount of sodium so that the concentration appears low. This type of hyponatraemia can be the result of chronic conditions such as kidney failure (when excess fluid cannot be efficiently excreted) and congestive heart failure, in which excess fluid accumulates in the body. SIADH (syndrome of inappropriate anti-diuretic hormone) is a disease whereby the body produces too much anti-diuretic hormone (ADH), resulting in retention of water in the body. Reference: https://www.webmd.boots.com/a-to-z-guides/hyponatraemia

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VIII. DIAGNOSTIC PROCEDURES

Potassium

3.5-5.3 mEq/L

3.0

LOW

Dehydration, diarrhoea, excessive sweating (hyperhidrosis) and laxative abuse are common causes of low potassium levels. It may also be caused by a lack of potassium in the diet; however, this is uncommon. Other causes include medicines that affect the amount of potassium in the body, such as diuretics, also known as water pills. Reference: https://www.webmd.boots.com/a-to-z-guides/low-potassium-hypokalaemia

Creatinine

0.50-1.70

1.94

HIGH

Elevated creatinine level signifies impaired kidney function or kidney disease. As the kidneys become impaired for any reason, the creatinine level in the blood will rise due to poor clearance of creatinine by the kidneys. Abnormally high levels of creatinine thus warn of possible malfunction or failure of the kidneys. Reference: https://www.medicinenet.com/creatinine_blood_test/article.htm

Blood Urea Nitrogen (BUN)

8.0-25.0

20.73

LOW

Low blood urea nitrogen counts can be caused by liver problems, malnutrition, not eating enough protein, or overhydration. Reference: https://www.healthline.com/health/blood-urea-nitrogen-test

33

VIII. DIAGNOSTIC PROCEDURES

Febuary 24, 2018

PROCEDURE Electrocardiogram (ECG)

FINDINGS Atrial Fibrillation

IMPLICATION Typically characterized by left ventricular dilation and subsequent systolic dysfunction, this disorder can be caused by both atrial and ventricular arrhythmias, most commonly chronic atrial fibrillation. Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC305772 1/

Febuary 26, 2018

PROCEDURE Electrocardiogram (ECG)

FINDINGS Rhythm: Tachyarhythmia

IMPLICATION Heart failure associated with tachyarrhythmias can very often be reversed by dealing with the underlying tachyarrhythmia. Typically characterized by left ventricular dilation and subsequent systolic dysfunction, this disorder can be caused by both atrial and ventricular arrhythmias. In tachycardia-induced heart failure the patient's often debilitating symptoms can be ameliorated. Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC305772 1/

34

VIII. DIAGNOSTIC PROCEDURES

February 26, 2018 PROCEDURE ULTRASOUND

FINDINGS Contracted liver with hepatocellular change

Dilated intrahepatic duct

IMPLICATION Since the patient has heart failure and the patient’s heart cannot pump enough blood throughout the body, there is an inadequacy in the oxygen carried by the blood. Thus the liver cannot function appropriately and can lead to impairment. Biliary obstruction caused by small simple cysts is very rare. We present a case of biliary dilatation caused by a simple cyst with a 4-cm diameter. Biliary obstruction caused by a simple cyst is very rare,1– 4 and dilatation of the intrahepatic bile duct in association with tumor lesions usually indicates malignancy. Reference:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4254236/

Massive ascites

Ascites is defined as the accumulation of fluid in the peritoneal cavity. It is a common clinical finding, with various extraperitoneal and peritoneal causes, but it most often results from liver cirrhosis. Reference: Brunner &Suddarth’s Textbook of Medical Surgical Nursing 13th Edition, Chapter 49, p1336

Reactive cholecystitis

Inflammation of the gallbladder which can be acute or chronic.

35

VIII. DIAGNOSTIC PROCEDURES

Corticomedulary junction distinct

The corticomedullary junction of the kidney is seen here, with the cortex in which can be seen a medullary ray (renal column) extending to the medulla.

Distended bowel

Distended bowel syndrome is a condition in which the abdomen becomes enlarged.

Reference: https://healthfully.com/distended-bowel-syndrome-5070987.html

36

IX. MEDICAL MANAGEMENT DOCTOR’S ORDER

DATE 

9/27/17



Pls. admit to med

INTERPRETATION 

4:15 pm

Hospital policy designates the exact procedure that should be followed when admitting the patient to the holding area or

PR- 102

opening room suite. Admission will help to

O₂ Sat- 95

monitor the client’s condition. The admitting

BP- 110/70

procedure is continued with reassessment of

SPO₂ 98%

the patient and allowanced of time for last

HR- 95

minutes question. (references: medical-surgical

HGT- 53

nursing 5th edition by Lewis, Heitkemper and Dirksen Chapter 17, pages 380)



TPR q shift



The recording of temperature, pulse rate, and respiratory rate part of physical examination. Acute changes and tends over time are documented and unexpected changes and values that deviate significantly from a patient’s normal values are brought to the attention of the patient’s primary health care provider. (references: brunner and Suddarth’s textbook and medical-surgical nursing 13th edition by Janice L. Hinkle and Kerry H. Cheever chapter 5 page 67)

 

Secure consent

Informed consent is the patient’s autonomous decision about whether to undergo a procedure. Before signing the consent, the risk and benefit of the procedure must be explained in terms he patient could easily understand. This is to prepare patient psychologically and the health workers from battery. (references: maternal and child health

37

IX. MEDICAL MANAGEMENT nursing 6th edition by Adele Pilliteri chapter 24, page 658 and Brunner and Suddarth’s textbook of medcal surgical nursing 13th edition by Janice L. Hinkle and Kerry H. Cheever chapter 27 page 406)

 

Oxygen administration is a treatment that delivers oxygen gas to breathe. Oxygen

0₂ administration 2-4

therapy may be prescribed when there is

lpm

a condition that causes the blood oxgen levels to be too low. (references: https://www.nhlbi.nih.gov/hea;th/healthtopics/topics/oxt)



Following a low salt and low fat diet helps keep blood pressure and swelling



(edema) under control. It can also make

Low salt and low fat

breathing easier if there is a heart failure. (references: https://www.wedmd.com/heartdisease/heart -failure/lowsalt/sodium-eating)



CBC – a complete blood count test gives important information about the kinds and numbers of cells in the



LABS;



CBC

blood,especially RBC, WBC, and platelets. Source: http://www.webmd.com/a-toz-guides/complete-blood-count-cbc#1



Several simple urine tests are often doneby nurses on the nursing units. These include tests for specific gravity,

38

IX. MEDICAL MANAGEMENT pH, and the presence of abnormal 

constituents such as glucose, ketones,

UA

protein, and occult blood. Source: Kozier &Erb’s Fundamentals of Nursing 9th edition Unit 8 pg. 808-825



Help find the cause of common symptoms such as a cough, shortness of breath, or chest pain. Find lung conditions such as pneumonia, lung



cancer, COPD, collapsed lung

CXR PA,

(pneumothorax) or cystic fibrosis and monitor treatment for this conditions. Source: www.webmd.com/heart-disease/cheastx-ray



 BUN/CREAT,

Deterioration in renal function is manifested by rises in the blood urea nitrogen (BUN) and creatinine values. Sources: Barbara K. Timby and Nacy E. Smith’s Medical and Surgical Nursing 10th edition Unit 19 pg. 909



Na⁺ , K⁺



an electrolyte test is used to identify problems with body’s (salt) balance. Electrolyte testing may be carried out as a part of routine blood test, called U+Es. (references:http://www.webmd.boots.com/a-to-zguidestesting-sodium-potassium-and-more)

39

IX. MEDICAL MANAGEMENT  

FBS

It measures the amount of glucose in the blood to test for diabetes or prediabetes. Typical fasting time at least 8 hours. (references:https://www.webmd.com/cholesterolmanagemnet/fasting -blood-tests)



 ECG,

Electrocardiograhy (ECG) is the graphic recording of the electrical currents generated by the heart muscle. Sources: Barbara K. Timby and Nacy E. Smith’s Medical and Surgical Nursing 10th edition Unit 6 pg. 310



Doppler Scan of both



A Doppler ultrasound is a test that uses high frequency sound waves to measure

legs

the amount of blood flow through the arteries and veins, usually those that supply blood to arms and legs. (references: https://www.healthline.com/dopplerultrasound-exam-of-an-arm-or-leg)



 Start PNSS 1 L × KVO

It is a source of water and electrolytes, it should be used with great care with congestive heart failure which there exists edema with sodium retention. (references: http://webcache.googleusercontent.com/Normal_ saline_solution.html)

40

IX. MEDICAL MANAGEMENT 

Burinex1 tab OD



To inhibit sodium and chloride reabsorption in the ascending loop of Henle (Sources: Jones &Barlett learning;2011 Nurse’s Drug handbook Tenth Edition)



Trimetazidine 35 BID



Indicated for angina pectoris (Sources: Jones &Barlett learning;2011 Nurse’s Drug handbook Tenth Edition)



Clopidogrel 75 OD



To reduce thrombolytic events in patients with atherosclerosis documented by recent stroke, MI, or peripheral arterial disease.(Sources: Jones &Barlett learning;2011 Nurse’s Drug handbook Tenth Edition)

 

Indicated for organic and functional chronic diseases of the lower limbs;

Daflon 500 g

heavy legs (Sources: Jones &Barlett learning;2011 Nurse’s Drug handbook Tenth Edition)



 Monitor BP/CR/HGT

To acquire baseline, to aid in assessment of the cardiovascular system and to aid in diagnosis of the disease. (references: https://www.nursingtimes.net/clinical/aarchive/as sessmentskills.article)

 8:49 am



Indicated in the treatment of insulin

Stat D50-50 Fast Drip

hypoglycemia to restore blood glucose

1 vial as ordered by

levels.

41

IX. MEDICAL MANAGEMENT 9:15 am

Dr. Pestacio thru

(references:https://drugs.com/pro/dextrose-

HGT- 15O mg/dl

phone call

50.html)



9/28/17



1:20 am

hypoglycaemia to restore blood glucose

D50-50 FD as side

levels.(references:https://drugs.com/pro/dextros

drip hold

e-50.html)

(+) seizure Hct- 50 mg/dl



T- 36.4 C O₂Sat 98



levels.(references:https://drugs.com/pro/dextros e-50.html)





Indicated in the treatment of insulin hypoglycaemia to restore blood glucose

Give another D50-50 to as SLPE

2:20 AM

Indicated in the treatment of insulin

Ff. up labs

The purpose of the following up laboratories is to determine the patient’s

Hct- 79 mg/dl

outcomes in relation to the desired goals

4 am- 90/70

of therapy.

5am- 59 mg/dl

(references:http://www.cpmc.org/learning/labtest

(+) allergy to all

s.html)

antibiotics  

It measures the amount of glucose in the

Monitor Hgt q 6 Hs

blood to test for diabetes or prediabetes.

and q shift

(references:https://www.webmd.com/cholesterolmanagemnet/fasting -blood-tests)\

 

Stat Ceftriaxone 1 gm

It is used to prevent or treat certain infections caused by bacteria. (references:http://chealth.canoe.com/drug/getdru

q 12 (ANST)

g/ceftriaxone)

42

IX. MEDICAL MANAGEMENT 

Patients receive medications appropriate to their clinical needs, in doses that meet

9:00 AM



Cont. other meds

their own individual requirements, for an

Hgt- 48 mg/dl

adequate period of time.

(+) DM- meds

(references:httpapps.who.int/medicinedocs/en/d/J

1:05 aft Hgt 107

h3011e/1.html)

mg/dl O₂ Sat 96% 

Med Hx DM- prasions



Check-up done here

Daily dressing of

promote healing

wound

(references:http://health.canoe.com/drugchangin g-dressing)

at PPL BP- 160/100



Multiple drug allergies not known

To keep clean and dry at all times to



to informant

hypoglycaemia to restore blood glucose

Hook 2 vials D50-

levels. (references:

50 as side drip

https://drugs.com/pro/dextrose-50.html)

 

Indicated in the treatment of insulin

Intravenous Fluids restore tissue perfusion by optimizing intravascular

IVF TF: D5NSS 1

volume, supporting the pumping action

L + D50-50 I vial

of the heart and improving the

× KVO

competence of the vascular system. Sources: Brunner and Suddarth’s Textbook Nursing Chapter 15 pg. 301

 

This position allows for improved breathing due to chest expansion and

Moderate high

oxygenation.

back rest

(references:http://www.nursefrontier.com -position-definition/explanation) 

To treat various conditions such as

43

IX. MEDICAL MANAGEMENT 

Hydrocortisone

arthritis,severe allergies, blood

250 mg IV now

diseases,breathing problems, and skin diseases.(references: Jones &Barlett learning;2011 Nurse’s Drug handbook Tenth Edition)

 

Treatment and prevention for angina pectoris.(references:nursingcrib.com/drug-

Isoket 10 mg +

guides/)

D5W 90 ml via soluset × 10 mgtts/min Crea 1.94



 Transfer to ICU

Require for close observation and monitoring.

K- 3 U

(references:http://cpmc.org/learning/documents/i cu-ws.html)

CXR- severe cardiomegaly r/o Pneumonia

 

(+) Pneumonia

To prevent ischemic complications of

Enoxaparin 40 RU

unstable angina.(references: Jones &Barlett

Sc q 12

learning;2011 Nurse’s Drug handbook Tenth

(+) low first wound

Edition)

4:45 pm Hgt- 43 mg/dl

 

IVF to follow

Intravenous Fluids restore tissue perfusion by optimizing intravascular volume, supporting the pumping action of the heart and improving the competence of the vascular system. Sources: Brunner and Suddarth’s Textbook Nursing Chapter 15 pg. 301



Start PNSS 1 Liter + 40 mg KCL ×



It is a source of water and electrolytes, it should be used with great care with

44

IX. MEDICAL MANAGEMENT KVO

congestive heart failure which there exists edema with sodium retention. (references: http://webcache.googleusercontent.com/Normal_ saline_solution.html)



KCL 600 g 1 Tab



To prevent hypokalemia (references: Jones &Barlett learning;2011

BID c meals × 3

Nurse’s Drug handbook Tenth Edition)

days then repeat serum ,

 

D/C Daflon

Discontinuation of such medications involves optimising all treatments to achieve individual care goals. (references: http://www.bmj.com/content/349/bmj.g7013)

 

Indicated in the treatment of insulin

D50-50 2 vials as

hypoglycemia to restore blood glucose

side drip, now then

levels.

uptHgt after 1 hour

(references:https://drugs.com/pro/dextrose50.html)



RptHgt at 9pm



It measures the amount of glucose in the

6:30 pm

blood to test for diabetes or prediabetes.

Hgt- 112 mg/dl

(references:https://www.webmd.com/cholesterolmanagemnet/fasting -blood-tests)

9pm Hgt- 37 mg/dl



Give another 2 vials D50-50 as side drip now then another 2 vials



Indicated in the treatment of insulin hypoglycaemia to restore blood glucose levels. (references:https://drugs.com/pro/dextrose-

45

IX. MEDICAL MANAGEMENT 50.html)

after 1 hour  2 am

D50-50 2 vials as



Indicated in the treatment of insulin hypoglycaemia to restore blood glucose

side drip

Hgt- 41 mg/dl

levels.

(+) hypokalemia

(references:https://drugs.com/pro/dextrose50.html

(+) basal rales (+) wheezes (+) infected wound



severe

IVF TF: D5NSS 1 Liter+ D50-50 vial



It is a source of water and electrolytes, it should be used with great care with

× KVO

congestive heart failure which there exists edema with sodium retention. (references: http://webcache.googleusercontent.com/Normal_ saline_solution.html)



Furosemide 20 mg TIV q 12



To inhibit sodium and chloride reabsorption.(references: Jones &Barlett learning;2011 Nurse’s Drug handbook Tenth Edition)

 7:20 am

Hook 3 D50-50 1 vial now



Indicated in the treatment of insulin

BP- 130/80

hypoglycaemia to restore blood glucose

O2sat 97%

levels.

(P) seizure

(references:https://drugs.com/pro/dextrose50.html

RR- 27



May give glucose

9/29/17

H2O of non

8:15 am

fatmilk mix c



Energy is required for the normal functioning of the organs in the body.

46

IX. MEDICAL MANAGEMENT glucose

These energy mostly came from sugars(glucose). (references:http://www.caninsulin.com/Glucosemetabolism.asp)



9:35 am Hgt- 37 mg/dl



Electrocardiograhy (ECG) is the graphic recording of the electrical currents

Rpt ECG now v. o

generated by the heart muscle. Sources:

Dra. Melendez

Barbara K. Timby and Nacy E. Smith’s Medical and Surgical Nursing 10th edition Unit 6 pg. 310



 NTG patch over

To prevent chronic angina attacks, acute angina pectoris ; to prevent or minimize

ACW

angina attacks before stressful events.(references: Jones &Barlett learning;2011 Nurse’s Drug handbook Tenth Edition)

 9/29/17

Akosi Obed Edum M.

A do-not-resuscitate order, or DNR order, is a medical order written by a

baybayonanak ng

doctor. It instructs health care providers

pasyentenasi Johnny M.

not to do cardiopulmonary resuscitation

Baybayon

(CPR) if a patient’s breathing stops or if

aynagdesisyonna wag ng

the patient’s heart stops beating.

ipa CPR ang pasyente

(references:

kung sakalingtumigil ang

https://medlineplus.gov/encypatientinstructions/0

paghinga o pagtigil ng

00473.htm)

tibok ng puso.

Signed by Obed Edum U. Baybayon 

To control bouts of increase seizure

47

IX. MEDICAL MANAGEMENT (P) Seizure

activity. (references: Jones &Barlett 

May give

learning;2011 Nurse’s Drug handbook Tenth

160/100

diazepam 5 mg IV

Edition)

O2sat -98%

prn in seizure

10:30 am

10:40 am Hgt 58



Indicated in the treatment of insulin hypoglycaemia to restore blood glucose

mg/dl 

levels.

May give 2 vials

(references:https://drugs.com/pro/dextrose-

D50-50 now

50.html)



Indicated in the treatment of insulin hypoglycaemia to restore blood glucose

1:30 pm Hgt- 110 mg/dl



levels. Give 3 vials of

(references:https://drugs.com/pro/dextrose-

D50-50 now

50.html)



It is ordered diet as tolerated when the gastrointestinal tract is tolerating food

3:30 pm Hgt- 49 mg/dl

and is ready for advancement to the next 

May have diet as

stage.

tolerated

(references:https://www.livestrong.comarticle/wh at-is-the-meaning-of-diet-as-tolerated/)



angina pectoris ; to prevent or minimize

5:40 pm 

angina attacks before stressful

NTG over anterior

events.(references: Jones &Barlett

chest wall once

learning;2011 Nurse’s Drug handbook Tenth

daily

9/30/17

To prevent chronic angina attacks, acute

Edition)



Indicated in the treatment of insulin hypoglycaemia to restore blood glucose

48

IX. MEDICAL MANAGEMENT 12mn



Hgt- 90 mg/dl

Give D50-50 2

levels.

vials TIV SD now

(references:https://drugs.com/pro/dextrose50.html)

9/30/17 54 mg/dl

(+) Episodes of

 

hypoglycaemia

Indicated in the treatment of insulin hypoglycaemia to restore blood glucose

Give 2 vials D50-

levels.

50 as side drip

(references:https://drugs.com/pro/dextrose-

(+) min Pleural

50.html)

effusion, (+) rales (+) di KCL supplem,



 Daily wound care

To keep clean and dry at all times to promote healing

diEnoxoparin, AMI

(references:http://health.canoe.com/drugchangin

(+) multiple

g-dressing)

allergies including 

betadine 

Patients receive medications appropriate to their clinical needs, in doses that meet

Continue med

their own individual requirements, for an adequate period of time. (references:httpapps.who.int/medicinedocs/en/d/J h3011e/1.html)

 

an electrolyte test is used to identify problems with body’s (salt) balance.

Repeat Serum

Electrolyte testing may be carried out as

Na/K

a part of routine blood test, called U+Es. (references:http://www.webmd.boots.com/a-to-zguidestesting-sodium-potassium-and-more)



 Relay episode of hypoglycaemia

low blood glucose or hypoglycaemia is one of the most common problems associated with diabetes, in particular,

49

IX. MEDICAL MANAGEMENT insulin treatment. (references:http://www.joslin.org/info/)



9/30/17 

(references: Jones &Barlett learning;2011

NaCl I tab BID × 3

Nurse’s Drug handbook Tenth Edition)

days



10/1/17 7:25 am



To prevent hypokalemia

Patients receive medications appropriate to their clinical needs, in doses that meet

Cont. Meds

their own individual requirements, for an adequate period of time. (references:httpapps.who.int/medicinedocs/en/d/J h3011e/1.html)

 

IVF TF D5NSS

Intravenous Fluids restore tissue perfusion by optimizing intravascular volume, supporting the pumping action of the heart and improving the competence of the vascular system. Sources: Brunner and Suddarth’s Textbook Nursing Chapter 15 pg. 301

 

ˇO2 to 2 lpm

Oxygen administration is a treatment that delivers oxygen gas to breathe. Oxygen therapy may be prescribed when there is a condition that causes the blood

50

IX. MEDICAL MANAGEMENT oxgenlevels to be too low. (references: https://www.nhlbi.nih.gov/hea;th/healthtopics/topics/oxt)



10/2/17 5:30 am



Electrocardiograhy (ECG) is the graphic recording of the electrical currents

Rpt ECG

generated by the heart muscle. Sources:

(-) DOB/ Chest

Barbara K. Timby and Nacy E. Smith’s Medical

pain

and Surgical Nursing 10th edition Unit 6 pg. 310

Bipedal edema

 10/3/17 5:50 pm



Intravenous Fluids restore tissue perfusion by optimizing intravascular

Shift IVF to NSS 1

volume, supporting the pumping action

L

of the heart and improving the competence of the vascular system. Sources: Brunner and Suddarth’s Textbook Nursing Chapter 15 pg. 301



10/4/17 

Patients receive medications appropriate to their clinical needs, in doses that meet

Cont. Meds

their own individual requirements, for an adequate period of time. (references:httpapps.who.int/medicinedocs/en/d/J h3011e/1.html)

 



Patient may continue treatment at home



Indicated for angina pectoris

MGH

Home meds

(Sources: Jones &Barlett learning;2011 Nurse’s

-trimetazidine 35

Drug handbook Tenth Edition)

BID 

To reduce thrombolytic events in patients

51

IX. MEDICAL MANAGEMENT -clopidogrel 75

with atherosclerosis documented by

OD

recent stroke, MI, or peripheral arterial disease.(Sources: Jones &Barlett learning;2011 Nurse’s Drug handbook Tenth Edition)



Indicated for organic and functional chronic diseases of the lower limbs; heavy legs (Sources: Jones &Barlett

-Daflon 500 mg

learning;2011 Nurse’s Drug handbook Tenth

tab TID

Edition)



Used to treat or prevent vitamin deficiency due to poor diet, certain illnesses.

- Vit B complex

(references:https:www.webmd.com/drugs/2/drug

OD

s-3387/vitamins-b-complex-oral/details)



Management and prophylaxis of angina pectoris; adjunct in CHF.

- Montra 30 g 1

(references:http://www.mims.com/philippines/dru

tab

g/info/montra)

52

X. DRUG STUDY NAME OF DRUG Generic Name: Losartan Brand Name: Cozaar Classification: Angiotensin II receptor blocker

DOSAGE 50 mg tab q6° Frequency: every 6 hours Route: Per Orem Onset: unknown Peak: 1 hour Duration: unknown

INDICATION/ CONTRAINDICATION Indication: Heart failure in patients with current or prior symptoms. Since the patient has elevated BP = 130/100. Contraindications:  Contraindicated in patients hypersensitive to drug. Breastfeeding isn’t recommended during losartan therapy.  Use cautiously in patients with impaired renal or hepatic function.

MODE OF ACTION Inhibits vasoconstrictive and aldosterone secreting action angiotensin II receptor on the surface of vasocular smooth muscle and other tissue each use.

ADVERSE REACTION CNS:dizziness, asthenia, fatigue, headache, insomnia. CV:edema, chest pain. EENT: nasal congestion, sinusitis, pharyngitis, sinus disorder. GI:abdominal pain, nausea, diarrhea, dyspepsia. GU:UTI METABOLIC:hyperkalemia, hypoglycemia, hyponatremia, weight gain. MUSCULOSKELETAL: Muscle cramps, myalgia, back or leg pain. RESPIRATORY: cough, upper respiratory tract infection.

NURSING RESPONSIBILITIES  Monitor the patients BP closely to evaluate effectiveness of therapy.  Monitor patients who are also taking diuretics for symptomatic hypotension.  Regularly assess the patients renal function (via creatinine and BUN levels).  Patients with severe heart failure whose renal function depends on the angiotensinaldosterone system may develop acute renal failure during therapy.

53

X. DRUG STUDY Close monitor patient’s BP, renal function, and potassium levels, especially during first few weeks of therapy and after dosage adjustments. Reference: Wolters Kluwer; 2016 Nursing Drug Handbook 36th Edition

NAME OF DRUG Generic Name:Furosemide Brand Name: Lasix Classification: Loop Diuretics

DOSAGE 40 mg IV q 6 Frequency: Q 6 hours Route: Intravenous Onset:Within 5 minutes Peak:30 minutes

INDICATION/ CONTRAINDICATION Indication: Generalized Edema associated with Congestive Heart Failure Generalized edema of pitting edema, grade 3, 6 mm. Contraindication: Contraindicated in patients hypersensitive to drug and in those with anuria.

MODE OF ACTION Inhibits sodium and chloride reabsorption at the proximal and distal tubules and the ascending loop of Henle.

ADVERSE REACTION

NURSING RESPONSIBILITIES CNS:vertigo, headache, dizziness,  Consider 10 paresthesia, weakness, restlessness, Golden fever Rights of CV:orthostatic hypotension, administering thrombophlebitis, with IV medication administration  Monitor EENT:transient deafness, blurred or weight, BP, yellowed vision, tinnitus and pulse rate GI:abdominal discomfort and pain, routinely with diarrhea, anorexia, nausea, long-term use vomiting, constipation, pancreatitis  If oliguria or GU:azotemia, nocturia, polyuria, azotemia frequent urination, oliguria develops or HEMATOLOGIC:agranulocytosis, increases,

54

X. DRUG STUDY Duration:2 hours

aplastic anemia, leukopenia, thrombocytopenia, anemia HEPATIC:hepatic dysfunction, jaundice METABOLIC:volume depletion and dehydration, asymptomatic hyperuricemia, impaired glucose tolerance, hypokalemia, hypochloremic alkalosis, hyperglycemia, dilutional hyponatremia, hypocalcemia, hypomagnesemia MUSCULOSKELETAL:muscle spasm SKIN:dermatitis, purpura, photosensitivity reactions, transient pain at I.M. injection site, toxic epidermal necrolysis, Stevens Johnson syndrome, erythema multiforme





drug may need to be stopped Monitor fluid intake and output and electrolyte, BUN, and carbon dioxide levels frequently Watch for signs of hypokalemia, such as muscle weakness and cramps



Reference: Jones & Bartlett Learning; 2011 Nurse’s Drug Handbook Tenth Edition

NAME OF DRUG Generic Name: Isosorbide mononitrate Brand Name:Imdur

DOSAGE 30 mg Tab OD Frequency:Once a day

INDICATION/ CONTRAINDICATION Indications: Reduces preload and afterload; as well as myocardial oxygen demand; also lowers blood pressure

MODE OF ACTION Thought to reduce cardiac oxygen demand by decreasing preload and afterload. Drug

ADVERSE REACTION CNS:headaches, dizziness, weakness. CV:orthostatic hypotension, tachycardia,

NURSING RESPONSIBILITIES  Monitor BP and heart rate and intensity and duration of drug

55

X. DRUG STUDY Route:Oral Classification: antianginals

Since the patient has elevated BP = 130/100

Onset:½-4 hours

Contraindication:  Contraindicated in patients with Duration:6-12 hypersensitivity or hours idiosyncrasy to nitrates and in those with severe hypotension, angle closure glaucoma, increased intracranial pressure, shock, or acute MI with low left ventricular filling pressure.  Use cautiously in patients with blood volume depletion (such as from diuretic therapy) or mild hypotension. Reference: Wolters Kluwer; 2016 Nursing Drug Handbook 36th Edition Peak:unknown

also may increase blood flow through the collateral coronary vessels.

palpitations, ankle edema, flushing, fainting. GI:nausea, vomiting. EENT:sublingual burning. SKIN:cutaneous vasodilation, rash.



response. Drug may cause headaches, especially at beginning of therapy, but tolerance usually develops. Treat headache with aspirin or acetaminophe n.

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X. DRUG STUDY NAME OF DRUG Generic Name: albuterol

DOSAGE 1 pra nebulizer q12

Brand Name: Salbutamol

Frequency:every 12 hours

Classification: Bronchodilators

Route:Inhalantion Onset:5-15 mins. Peak:30-120 min. Duration:2-6 hours

INDICATION/ CONTRAINDICATION Indications: To improve pulmonary function, especially in those with AO. Symptomatic relief of pulmonary congestion related to congestive heart failure Contraindication:  Contraindicated in patients with hypersensitivity to drug or its ingredients.  Use cautiously in patients with CV disorders (including coronary insufficiency and hypertenstion), hyperthyroidism, or diabetes mellitus and in those who are unusually responsive to adrenergics.  Use extendedrelease tablets cautiously in

MODE OF ACTION Relaxes bronchial, uterine, and vascular smooth muscle by stimulating beta₂ receptors.

ADVERSE REACTION CNS:tremor, nervousness, headache, insomnia, dizziness, weakness, CNS stimulation, malaise. CV:tachycardia, palpitations, hypertension, chest pain, lymphadenopathy. GI:nausea, vomiting. EENT:conjunctivitis, otitis media; dry and irritated nose and throat with inhaled form; nasal congestion; epistaxis; hoarness; pharyngitis, rhinitis. RESPIRATORY: bronchospasm, cough, wheezing, dyspnea, bronchitis, increased sputum.

NURSING RESPONSIBILITIES  Monitor patient for effectiveness.  Avoid contact of inhalation drug with eyes.  Do not increase in number or frequency without physician’s advice.

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X. DRUG STUDY patients with GI narrowing.

Reference: Wolters Kluwer; 2016 Nursing Drug Handbook 36th Edition

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XI. NURSING CARE PLAN PROBLEM PRIORITIZATION PROBLEM PRIORITIZATION

1. Ineffective breathing pattern r/t decreased lung expansion and pulmonary congestion secondary to congestive heart failure. Fluid volume excess r/t low albumin level 15 g/L secondary to congestive heart failure

2. Ineffective tissue perfusion related to Impaired transport of oxygen across alveolar and capillary membrane

3. Ineffective breathing pattern r/t decreased lung expansion and pulmonary congestion secondary to congestive heart failure.

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XI. NURSING CARE PLAN 1. Ineffective breathing pattern r/t decreased lung expansion and pulmonary congestion secondary to congestive heart failure. Fluid volume excess r/t low albumin level 15 g/L secondary to congestive heart failure

ASSESSMENT

DIAGNOSIS

PLANNING

Subjective: “Napansin ko na lumalaki ang tiyan ko” as verbalized

Fluid volume excess r/t. low albumin level 15 g/L secondary to congestive heart failure

After nursing interventions, patient will demonstrate stabilized fluid volume and decrease edema and abdominal girth.

Objective:     



Pallor Weak in appearance Abdominal distention noted Abdominal girth of 104 cm Bipedal edema with grade 3 6mm Irritability

IMPLEMENTATIO N  Monitor vital sign 







Established baseline data



Reflects circulating volume status, developing fluid shifts, and in response to therapy



BP elevations are usually associated with fluid volume excess



Indicative of pulmonary congestion/edema

Measure intake and output

Monitor BP

Assess respiratory status

RATIONALE

EVALUATION 

After nursing interventions, patient demonstrated stabilized fluid volume and decreased edema and abdominal girth

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XI. NURSING CARE PLAN  

noted RR of 26 bpm Abdominal girth of 104 cm









Reflects accumulation of fluid (ascites)



Decreases sensation of thirst, especially when fluid intake is restricted



Sodium may be restricted to minimize fluid retention in extra vascular spaces. Fluid restriction may be necessary to prevent dilutional hyponatremia



Used with caution to control edema and ascites, block effect

Monitor abdominal girth

Provide occasional ice chips if NPO

Restrict sodium and fluids as ordered

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XI. NURSING CARE PLAN 

Administer medications as indicated:  Diuretics (Furosemide)

of aldosterone, and increase water excretion while sparing potassium.

2. Ineffective tissue perfusion related to impaired transport of oxygen across alveolar and capillary membrane ASSESSMENT

DIAGNOSIS

PLANNING

Subjective: “Objectives:  Capillary refill of time 3 second  Dyspnea  Dysrhythmi as (Tachyarhyt hmia)  Bipedal edema with grade 3

Ineffective tissue perfusion related to Impaired transport of oxygen across alveolar and capillary membrane

After nursing intervention patient will identifies factors that improves circulation

IMPLEMENTATI ON  Assess for sign of decreased tissue perfusion



Assess for probable

RATIONALE 

Particular cluster of sign and symptoms occur with differing causes. Evaluation provides a baseline for future comparison



Early detection of the source facilitates quick,

EVALUATION After nursing intervention patient identifies factors that improves circulation

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XI. NURSING CARE PLAN      

6mm Pale in appearance Weak in appearance Abdominal distended Abdominal girth of 104 cm Irritable BP 140/80 RR 26 PR 110

contributing factors related to temporarily impair arterial blood flow.

effective management



Check respirations and absence of work of breathing

Cardiac pump malfunction and ischemic pain may result in distress



For baseline data



Monitor V/S





Record Blood pressure

Stable Blood pressure is needed to keep sufficient tissue perfusion.



Nonexistence of peripheral pulses must be reported or managed immediately systemic



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XI. NURSING CARE PLAN 





vasoconstriction resulting from reduced cardiac output may be manifested by diminished skin

Check for pallor. Assess quality of every pulse



Gently reposition patient from from a supine to sitting or standing position can reduce the risk orthostatic Bp.



Because of poor tissue perfusion it can be develop to the patient



With arterial in

Assist with position changes

Monitor for development of gangrene, venous ulceration

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XI. NURSING CARE PLAN 

Do not elevate legs above the level of the heart



Encourage smoking cessation



Educate patient about lifestyle that could improve tissue perfusion

suffiency, leg elevation deceases arterial blood supply to the legs



Smoking tobacco is also associated with catecholamines release resulting in vasoconstriction and decreased tissue perfusion



These measure reduce venous compression venous stasis and arterial vasoconstriction

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XI. NURSING CARE PLAN 3. Ineffective breathing pattern r/t decreased lung expansion and pulmonary congestion secondary to congestive heart failure ASSESSMENT Subjective: “Nahihirapan akong huminga” as verbalized Objectives:  Dyspnea  Tachypne a with RR of 26, irregular,s hallow breathing  Weak in appearanc e  Irritability noted  Pallor

DIAGNOSIS

PLANNING 

Ineffective breathing pattern r/t decreased lung expansion and pulmonary congestion secondary to congestive heart failure

After an hour of nursing intervention, the client will be relieve from dyspnea and breathing pattern will return to normal.

IMPLEMENTATIO N  





RATIONALE

EVALUATION 

Monitor V/S

Monitor respiratory rate, rhythm and depth

Auscultate breath sounds, noting crackles, wheezes and rhonchi



For baseline data



Rapid shallow respirations/dys pnea may be present because of hypoxia or fluid accumulation in the abdomen



Indicates developing complications and increasing risk of infection



Changes in

Investigate changes in LOC

After an hour of nursing intervention, the client be relieved from dyspnea and breathing pattern return to normal

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XI. NURSING CARE PLAN 



mentation may reflect hypoxemia and respiratory failure

Keep head of bed elevated. Position on sides 

Facilitates breathing by reducing pressure on the diaphragm



Aids in lung expansion and mobilizing secretions



May be necessary to treat/prevent hypoxia

Encourage frequent repositioning and deepbreathing exercises



Provide supplemental O 2 as order



Administer medications such as Albuterol

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XI. NURSING CARE PLAN 

To improve pulmonary function, especially in those with AO. Since the patient has CHF.

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XII. RECOMMENDATION

To the co-students: This study will help you to fully understand how Congestive Heart Failure occurs, what are the symptoms and management to be given to patient with this type ofdisease. You will also learn what are the risk factors that affect the progression of the disease. This will serve as your guide in presenting case presentations in your future career.

To the faculty members: This study will help you to regain your knowledge and also refreshes your idea about Congestive Heart Failure. This may be helpful in teaching lessons of the faculty members especially those who handled a topic that is related to Cardiovascular function. They hope that this would be a great help to all of you.

To their beloved readers: To their beloved readers who are concerned about Congestive Heart Failure. This study will serve as guide for you to fully understand how it occurs, because all the contents of this study were focused on the said disease. Diet, medication and other health management to prevent progression of the disease are also included.

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XIII. SUMMARY OF DISCHARGE Medication 

Taking all of the prescribed medications. Medications must be continued according to the doctor’s instruction. 1. trimetazidine 35 mg 2× a day 6 am , 6 pm 2. clopidogrel 75 mg OD 7 am with meals 3. Daflon 500 mg 1 tab 3× a day 6 am, 12nn, 6 pm 4. Vit B complex OD 6 am 5. Montra 30 mg 1 tab 7 am with meals

Exercise 

Provide patient with Passive Range of Motion.

Treatment 

No treatment

Health Teaching 

Emphasized to the patient’s relative the importance patient’s personal hygiene.



Maintaining safe environment for the patient.



Eating low salt and low fat foods; following a low salt and low fat diet helps keep blood pressure and swelling (edema) under control. It can also make breathing easier if there is a heart failure.



For Doppler scan of both legs



Regular monitoring blood sugar

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XIII. SUMMARY OF DISCHARGE Out-Patient Department 

Time and date of consultation: Follow-up after 1 week, October 18, 2017, Dr. Pestacio

Spiritual Advise the family to never lose her hope, and keep his faith despite of what happen

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XIV. BIBLIOGRAPHY

Book References: 

Barbara K. Timby and Nacy E. Smith’s Medical and Surgical Nursing 10th edition Unit 19 pg. 909



Brunner & Suddarth’s Textbook of Medical Surgical Nursing 13th Edition, Chapter 20, p475



Brunner & Suddarth’s Textbook of Medical Surgical Nursing 13th Edition, Chapter 25, p667



Brunner & Suddarth’s Textbook of Medical Surgical Nursing 13th Edition, Chapter 60 p.1759 and Unit 7, p.902



Brunner & Suddarth’s Textbook of Medical Surgical Nursing 13th Edition, Chapter 25, p655



Brunner & Suddarth’s Textbook of Medical Surgical Nursing 13th Edition, Unit 3, p250



Brunner & Suddarth’s Textbook of Medical Surgical Nursing 13th Edition, Chapter 60, p1765



Brunner and Suddarth’s textbook and medical-surgical nursing 13th edition by Janice L. Hinkle and Kerry H. Cheever chapter 5 page 67

  

Je Abarra, Laboratory Values and Interpretation-A Nurse’s Ultimate Guide, http://www.nursebuff.com/l aboratory-values-fornurses Jones & Bartlett Learning; 2011 Nurse’s Drug Handbook Tenth Edition Kozier & Erb’s Fundamentals of Nursing 9th edition Unit 8 pg. 808-825



Maternal and Child Health Nursing 6th edition by Adele Pilliteri chapter 24, page 658 and Brunner and Suddarth’s textbook of medcal surgical nursing 13th edition by Janice L. Hinkle and Kerry H. Cheever chapter 27 page 406

72

XIV. BIBLIOGRAPHY

Medical-Surgical nursing 5th edition by Lewis, Heitkemper and Dirksen Chapter 17, pages 380 Electronic References: 

http://chealth.canoe.com/drug/getdrug/ceftriaxone



http://cpmc.org/learning/documents/icu-ws.html



http://cpmc.org/learning/documents/icu-ws.html



http://health.canoe.com/drugchanging-dressing



http://health.canoe.com/drugchanging-dressing



http://webcache.googleusercontent.com/Normal_saline_solution.html



http://webcache.googleusercontent.com/Normal_saline_solution.html



http://www.bmj.com/content/349/bmj.g7013



http://www.bmj.com/content/349/bmj.g7013



http://www.caninsulin.com/Glucose-metabolism.asp



http://www.caninsulin.com/Glucose-metabolism.asp



http://www.cpmc.org/learning/labtests.html



http://www.nursefrontier.com-position-definition/explanation



http://www.webmd.boots.com/a-to-z-guidestesting-sodium-potassium-andmore



httpapps.who.int/medicinedocs/en/d/Jh3011e/1.html



https://drugs.com/pro/dextrose-50.html



https://medlineplus.gov/encypatientinstructions/000473.htm



https://www.healthline.com/doppler-ultrasound-exam-of-an-arm-or-leg



https://www.livestrong.comarticle/what-is-the-meaning-of-diet-as-tolerated



https://www.nursingtimes.net/clinical/aarchive/assessmentskills.article



https://www.nursingtimes.net/clinical/aarchive/assessmentskills.article



https://www.webmd.com/cholesterol-managemnet/fasting -blood-tests



https://www.webmd.com/cholesterol-managemnet/fasting -blood-tests



nursingcrib.com/drug-guides



nursingcrib.com/drug-guides

73

XIV. BIBLIOGRAPHY



httpapps.who.int/medicinedocs/en/d/Jh3011e/1.html



http://www.webmd.boots.com/a-to-z-guidestesting-sodium-potassium-andmore



http://www.joslin.org/info/

www.nurseslabs.com

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