A Caselet on

CONGESTIVE HEART FAILURE

___________________________________________________________

Presented to:

Vicky Palomero, RN

In partial Fulfillment of the Requirements In NCM RLE

Submitted by:

Cherrybelle Love Guidoga

January 2012

INTRODUCTION
Heart failure, often referred to as congestive heart failure (CHF), is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. However, the term CHF is misleading, because it indicates that patients must experience pulmonary or peripheral congestion to have heart failure, and it implies that patients with congestions have heart failure. The Agency for Health Care Policy and Research (AHCPR) HF guidelines panel (1994) defined heart failure as a clinical syndrome characterized by signs and symptoms of fluid overload or of inadequate tissue perfusion. These signs and symptoms result when the heart is unable to generate a CO sufficient to meet bodys demands. The HF guideline panel used the term heart failure because many patients with HF do not manifest pulmonary or systemic congestions. The term HF is preferred and indicates myocardial heart disease in which there is a problem with contraction of the heart (systolic dysfunction) or filling of the heart (diastolic dysfunction) and which may or may not cause pulmonary or systemic congestion. Some cases of HF are reversible, depending on the cause. Most often, HF is a lifelong diagnosis that is managed with lifestyle changes and medications to prevent acute congestive episodes. CHF is usually an acute presentation of heart failure. Currently, congestive heart failure or heart failure continues to be a major public health problem worldwide. It is the leading cause of morbidity and mortality in most developed countries. According to the American Heart Association (2001), approximately 5 million patients have heart failure and nearly 550,000 new patients are diagnosed each year. In addition, nearly 300,000 patients die from heart failure yearly. In the Philippines, cardiovascular diseases are the most common causes of mortality. According to the Department of Health (2005), about 77,060 in a 100, 000 populations have died in the Philippines due to diseases of the heart. The aging of the population and the emerging pandemic of cardiovascular diseases in the developing nations of the world signal a rise in the incidence and prevalence of heart failure globally and magnify the importance of its prevention. The prevention of heart failure is an urgent public health need with national and global implications.

In our one week exposure at Pesante Sr. Memorial Hospital, I handled patients who had diseases and complications involving mainly the heart. But what captured my attention was our selected patients situation. I became more interested to her diagnosis and I wanted to know more about the disease. And I cannot deny the fact that diseases affecting the heart continuously grow in number especially among elder client. And as health advocates, I should be aware about the disease, its development, how it is developed, and what are the appropriate nursing plans to be done in order to meet the clients needs. This case report is significant to my future nursing care because it helps stress the importance of not only identification and treatment of patients with heart failure but also the importance of promoting a healthy lifestyle and preventive strategies to decrease the prevalence of heart failure in the general population. Also, it explores the need for a thorough case analysis of a client to deliver the best nursing care and provides sufficient information about Congestive Heart Failure. Perhaps this is the reason why I chose this case study.

OBJECTIVES
General Objective:
Within our five-days duty exposure at Pesante Sr. Memorial Hospital, I will be able to create a Case Study concerning a patients state of health and all the aspects that contribute to and affect his/her condition. Specific Objectives: We aim to: 1. Acquire pertinent data of the client which a relevant to the case study
2. Determine the current health history basing from the signs and

symptoms and other manifestations of alteration in health conditions

3. Present the physical assessment in a cephalocaudal manner; 4. Discuss the body systems involved as well as its normal functioning 5. Trace the pathophysiology of the disease process both in narrative

discussion and schematic diagram;

6. Discuss

each of the drugs administered including their action,

indication, side effects and the nursing responsibilities in giving the medications;

7. Present

the

actual

laboratory

examinations

done

and

their

interpretations and our nursing responsibilities for the recognition of the diagnosis;
8. Formulate at least 2 nursing care plans that are actual and feasible in a

nursing approach, in order to alleviate the health condition of the client and lessen the risk of other probable injury;
9. Generate a discharge plan and prognosis for the continuous health

care even at home;

10. Enumerate the different sources including books and websites for the

reference of the scientific and medical facts found in this case study.

PATIENTS DATA

Name: Age: Sex: Civil Status: Religion: Citizenship:

Patient X 61 years old Female Married Roman Catholic Filipino

Attending Physician: Dr. Tanudtanud Dr. Evelyn Pesante Superioridad Date of Admmission: Time of Admission: Chief Complaint: fatigue Admitting Diagnosis: Congestive Heart Failure January 31, 2012 9:30AM shortness of breath, dizziness and

Diet:

Soft Diet

HEALTH HISTORY
a) Client Profile A case of Patient X, 61 years old, female, married, Filipino citizen, a Roman Catholic, and housewife. Client was admitted last January 31, 2012 at around 9:30 a.m via jeepney accompanied by her eldest son with admitting complaints of shortness of breath, dizziness and fatigue. Admitting V/S is as follows: T-37.5; PR-92; RR-25; BP140/100. She's under the care of Dr. Tanudtanud and Dr. Evelyn Pesante Superioridad. Patient claimed to be hypertensive but not diabetic or asthmatic. Patient is neither a smoker nor an alcoholic beverage drinker. She has no known allergies to drug as well as to foods; but, since she has a heart problem, she ate less on restricted foods high in cholesterol. b) History of Present Illness Prior to admission the patient was experiencing dizziness, headache and fatigue. Due to lack of financial support, the patient was unable to comply the necessary medications and decided to stay at home for care. Two days prior to admission, the patient experienced symptoms of shortness of breath. On January 28, 2012, Patient X manifested

symptoms of on and off moderate grade fever, and gradually coughing episodes were noted.

PHYSICAL ASSESSMENT
General Physical Survey I. Appearance and behavior 1. Age,sex,race: 61 years old, female, Asian 2. Body build: medium stature with sufficient amount of subcutaneous fat with body weakness noted 3. Posture: relaxed, with shoulders back, and both feet stable 4. Hygiene and grooming: skin, nails clean and trimmed with good hygiene 5. Dress: Patient is appropriate dressed, clothes were cleaned 6. Odor of body and breath: no foul body and breath odor 7. Signs of distress: persistent non-productive coughing noted and difficulty of breathing 8. Apparent State of Health: Patient appears weak 9. Speech: Patient has understandable speech at moderate pace

10. Attitude: with cooperative attitude and behavior 11. Thought Process: Has logical sequence and sense of reality of thought VITAL SIGNS: T- 36.9C RR- 26 bpm PR- 87 bpm CR- 89 bpm BP- 110/90 mmHg HEIGHT and WEIGHT: Weight: 72 kilograms Height: 53

Review of systems:

A. Integument: Patients skin appears light to dark brown in color with slightly lightercolored palms, nails beds, and lips; with smooth and soft skin, slightly cool to touch and dry; with good skin turgor; no swelling, or edema noted. B. Neurologic Patient is oriented to place, person, time. Pupils are equally reactive to light. Equal strength of lower extremities, left upper arm slightly weak with chest tube attached. Clear, audible speech, responsive to verbal commands and can differentiate taste. C. Musculoskeletal Patient has normal ROM of extremities and but slight weakness of left upper extremety noted; verbalized slight pain on left part of the chest. D. Respiratory Patient has even pattern of respiration with frequent coughing exercises; decreased breath sounds heard upon auscultation of left lung, crackles sounds heard upon auscultation of right lung; productive cough noted and has difficulty of breathing.

E.Cardiovascular Patient has weak regular apical pulse with cardiac rate of 89bpm, and radial pulse of 87 bpm. There is edema noted on the lower extremities and skin is slightly cool but dry to touch. F.Gastrointestinal Patient has moist oral mucosa. With normal bowel sounds. Weight did not increase nor decrease from admission. No episodes of nausea and vomiting. Passes soft yellowish stool once a day, every day.

ANATOMY AND PHYSIOLOGY

Your heart is located under the ribcage in the center of your chest between your right and left lungs. Its muscular walls beat, or contract, pumping blood continuously to all parts of your body. The size of your heart can vary depending on your age, size, and the condition of your heart. A normal, healthy, adult heart most often is the size of an average clenched adult fist. Some diseases of the heart can cause it to become larger.

The Exterior of the Heart

Below is a picture of the outside of a normal, healthy, human heart. Heart Exterior

The illustration shows the front surface of a heart, including the coronary arteries and major blood vessels. The heart is the muscle in the lower half of the picture. The heart has four chambers. The right and left atria (AY-tree-uh) are shown in purple. The right and left ventricles are shown in red. Some of the main blood vesselsarteries and veinsthat make up your blood circulatory system are directly connected to the heart. The ventricle on the right side of your heart pumps blood from your heart to your lungs. When you breathe air in, oxygen passes from your lungs through your blood vessels and into your blood. Carbon dioxide, a waste product, is passed from your blood through blood vessels to your lungs and is removed from your body when you breathe out. The left atrium receives oxygen-rich blood from your lungs. The pumping action of your left ventricle sends this oxygen-rich blood through the aorta (a main artery) to the rest of your body. The Right Side of Your Heart The superior and inferior vena cava are in blue to the left of the heart muscle as you look at the picture. These veins are the largest veins in your body. After your body's organs and tissues have used the oxygen in your blood, the vena cava carries the oxygen-poor blood back to the right atrium of your heart. The superior vena cava carries oxygen-poor blood from the upper parts of your body, including your head, chest, arms, and neck. The inferior vena cava carries oxygen- poor blood from the lower parts of your body. The oxygen-poor blood from the vena cava flows into your heart's right atrium and hen on to the right ventricle. From the right ventricle, the blood is pumped through the pulmonary arteries (in blue in the center of the picture) to your lungs. There, through many small, thin blood vessels called capillaries, the blood picks up more oxygen. The oxygen-rich blood passes from your lungs back to your heart through the pulmonary veins (in red to the left of the right atrium in the picture) The Left Side of Your Heart Oxygen-rich blood from your lungs passes through the pulmonary veins (in red to the right of the left atrium in the picture). It enters the left atrium and is pumped into the left ventricle. From the left ventricle, the oxygen-rich blood is pumped to the rest of your body through the aorta. Like all of your organs, your heart needs blood rich with oxygen. This oxygen is

supplied through the coronary arteries as blood is pumped out of your heart's left ventricle. Your coronary arteries are located on your heart's surface at the beginning of the aorta. Your coronary arteries (shown in red in the drawing) carry oxygen-rich blood to all parts of your heart.

The Interior of the Heart

Below is a picture of the inside of a normal, healthy, human heart Heart Interior

The illustration shows a cross-section of a healthy heart and its inside structures. The blue arrow shows the direction in which oxygen-poor blood flows from the body tothe lungs. The red arrow shows the direction in which oxygen-rich blood flows fromthe lungs to the rest of the body. The Septum The right and left sides of your heart are divided by an internal wall of tissue calledthe septum. The area of the septum that divides the atria (the two upper chambers of your heart) is called the atrial or interatrial septum.The area of the septum that divides the ventricles (the two lower chambers of your heart) is called the ventricular or interventricular septum. Heart Chambers The picture shows the inside of your heart and how it's divided into four chambers. The two upper chambers of your heart are called atria. The atria receive and collect blood. The two lower chambers of your heart are called ventricles. The ventricles pump blood out of your heart into the circulatory system to other parts of your body. Heart Valves The picture shows your heart's four valves. Shown counterclockwise in the picture, the valves include the aortic valve, the tricuspid valve, the pulmonary valve, and the mitral valve.

Blood Flow The arrows in the drawing show the direction that blood flows through your heart. The light blue arrows show that blood enters the right atrium of your heart from the superior and inferior vena cava. From the right atrium, blood is pumped into the right ventricle. From the right ventricle, blood is pumped to your lungs through the pulmonary arteries. The light red arrows show the oxygen-rich blood coming in from your lungs through the pulmonary veins into your heart's left atrium. From the left atrium, the blood is pumped into the left ventricle. The left ventricle pumps the blood to the rest of your body through the aorta. For the heart to work properly, your blood must flow in only one direction. Your heart's valves make this possible. Both of your heart's ventricles have an "in" (inlet) valve from the atria and an "out" (outlet) valve leading to your arteries. Healthy valves open and close in very exact coordination with the pumping action of your heart's atria and ventricles. Each valve has a set of flaps called leaflets or cusps that seal or open the valves. This allows pumped blood to pass through the chambers and into your arteries without backing up or flowing backward.

Heart Contraction and Blood Flow

Heartbeat Almost everyone has heard the real or recorded sound of a heartbeat. When your heart beats, it makes a "lub-DUB" sound. Between the time you hear "lub" and "DUB," blood is pumped through your heart and circulatory system. A heartbeat may seem like a simple, repeated event, but it's a complex series of very precise and coordinated events that take place inside and around your heart. Each side of your heart uses an inlet valve to help move blood between the atrium and ventricle. The tricuspid valve does this between the right atrium and ventricle. The mitral valve does this between the left atrium and ventricle. The "lub" is the sound of the tricuspid and mitral valves closing. Each of your heart's ventricles has an outlet valve. The right ventricle uses the pulmonary valve to help move blood into the pulmonary arteries. The left ventricle uses the aortic valve to do the same for the aorta. The "DUB" is the sound of the aortic and pulmonary valves closing. Each heartbeat has two basic parts: diastole, or relaxation, and atrial and ventricular systole (SIS-toe-lee), or contraction. During diastole, the atria and ventricles of your heart relax and begin to fill with blood. At the end of diastole, your heart's atria contract (atrial systole) and pump blood into the ventricles. The atria then begin to relax. Next, your heart's ventricles contract (ventricular systole) and pump blood out of your heart. Pumping Action Your heart uses its four valves to ensure your blood flows only in one direction. Healthy valves open and close in coordination with the pumping action of your heart's atria and ventricles. Each valve has a set of flaps called leaflets or cusps. These seal or open the valves. This allows pumped blood to pass through the chambers and into your blood vessels without backing up or flowing back ward. Oxygen-poor blood from the vena cava fills your heart's right atrium. The atrium contracts (atrial systole). The tricuspid valve located between the right atrium and ventricle opens for a short time and then shuts. This allows blood to enter into the right ventricle without flowing back into the right atrium. When your heart's right ventricle fills with blood, it contracts (ventricular systole).The pulmonary valve located between your right ventricle and pulmonary artery opens and closes quickly. This allows

blood to enter into your pulmonary arteries without flowing back into the right ventricle. This is important because the right ventricle begins to refill with more blood through the tricuspid valve. Blood travels through the pulmonary arteries to your lungs to pick up oxygen. Oxygen-rich blood returns from the lungs to your heart's left atrium through the pulmonary veins. As your heart's left atrium fills with blood, it contracts. This event also is called atrial systole. The mitral valve located between the left atrium and left ventricle opens and closes quickly. This allows blood to pass from the left atrium into the left ventricle without flowing backward. As the left ventricle fills with blood, it contracts. This event also is called ventricular systole. The aortic valve located between the left ventricle and aorta opens and closes quickly. This allows blood to flow into the aorta. The aorta is the main artery that carries blood from your heart to the rest of your body. The aortic valve closes quickly to prevent blood from flowing back into the left ventricle, which is already filling up with new blood.

Circulation and Blood Vessels

Your heart and blood vessels make up your overall blood circulatory system. Your blood circulatory system is made up of four subsystems. Arterial Circulation Arterial circulation is the part of your overall blood circulatory system that involves arteries, like the aorta and pulmonary arteries. Arteries are blood vessels that carry blood away from your heart. Healthy arteries are strong and elastic. They become narrow between beats of the heart, and they help keep your blood pressure consistent. This helps blood circulate efficiently through your body. Arteries branch into smaller blood vessels called arterioles. Arteries and arterioles have strong, flexible walls that allow them to adjust the amount and rate of blood flowing to various parts of your body. Venous Circulation Venous circulation is the part of your overall blood circulatory system that involves veins, like the vena cava and pulmonary veins. Veins are blood vessels that carry blood to your heart. Veins have thinner walls than arteries. Veins can widen as the amount of blood passing through them increases. Capillary Circulation Capillary circulation is the part of your overall blood circulatory system where oxygen, nutrients, and waste pass between your blood and parts of your body. Capillaries connect the arterial and venous circulatory subsystems. Capillaries are very small blood vessels. The importance of capillaries lies in their very thin walls. Unlike arteries and veins, capillary walls are thin enough that oxygen and nutrients in your blood can pass through the walls to the parts of your body that need them to work normally. Capillaries' thin walls also allow waste products like carbon dioxide to pass from your body's organs and tissues into the blood, where it's taken away to your lungs. Pulmonary Circulation Pulmonary circulation is the movement of blood from the heart to the lungs and back to the heart again. Pulmonary circulation includes both arterial and venous circulation. Blood without oxygen is pumped to the lungs from the heart (arterial circulation).Oxygen-rich blood moves from the lungs to the heart through the pulmonary veins (venous circulation).Pulmonary

circulation also includes capillary circulation. Oxygen you breathe in from the air passes through your lungs into your blood through the many capillaries in the lungs. Oxygen-rich blood moves through your pulmonary veins to the left side of your heart and out of the aorta to the rest of your body. Capillaries in the lungs also remove carbon dioxide from your blood so that your lungs can breathe the carbon dioxide out into the air.

VI. PATHOPHYSIOLOGY
PREDISPOSING FACTOR -Age - Race - Hereditary ETIOLOGY PRECIPITATING FACTOR - High cholesterol level - Secondary Life Style - Obesity

-Myocardial Infarction -Hypertension -Aortic stenos is insufficiency -Mitral stenos is

Reduced myocardial contractility Increases cardiac workload Decreased diastolic filling Obstructions of left atrial emptying

Left atrial pressure Bloods dams back into the pulmonary capillary bed

Left sided CHF

Pressure at the pulmonary capillary bed

Stroke volume decreases

Tissue perfusion decreases

Bloods flow to the kidneys RAAS stimulation

Pulmonary edema

Cellular hypoxia

Vasoconstriction and reabsorption of Na and water

ECF volume

S/S
Total blood volume Systemic BP

Sign and Symptoms Symptoms are dependent on two factors. The first is based on the side of the heart, right or left, that is involved. The second factor is based on the type of failure, either diastolic or systolic. Symptoms and presentation may be indistinguishable making diagnosis impossible based on symptoms. Left side of the heart pumps blood from the lungs to the organs, failure to do so leads to congestion of the lung veins and symptoms that reflect this, as well as reduced supply of blood to the tissues. The predominant respiratory symptom is shortness of breath on exertion (dyspnea) or in severe cases at rest - and easy fatigueability. Orthopnea is increasing breathlessness on reclining, often measured in the number of pillows required to lie comfortably. Paroxysmal nocturnal dyspnea is a nighttime attack of severe breathlessness, usually several hours after going to sleep. Poor circulation to the body leads to dizziness, confusion and diaphoresis and cool extremities at rest. Predominant left-sided clinical signs are tachypnea and increased work of breathing (signs of respiratory distress not specific to heart failure), rales or crackles, which suggests the development of pulmonary edema, dullness of the lung fields to percussion and diminished breath sounds at the bases of the lung, which suggests the development of a pleural effusion (fluid collection in the pleural cavity) that is transudative in nature, and cyanosis which suggests hypoxemia, caused by the decreased rate of diffusion of oxygen from fluid-filled alveoli to the pulmonary capillaries.

Right Sided Congestive Heart Failure PREDISPOSING FACTOR -Age - Race - Hereditary - LSCHF - Pulmonary Embolism - Right ventricular infarction - Congenital septal defects ETIOLOGY PRECIPITATING FACTOR - High cholesterol level - Secondary Life Style - Obesity

Reduced myocardial contractility Increases cardiac workload Decreased diastolic filling Contraction of right sided atrial filling Obstruction of right atrial emptying Increase right atrial pressure Right sided CHF

Blood drains back from RV to RA

Increased pressure in the s/s: veins Neck vein engorgement hepatomegaly Portal hypertension ascites Peripheral edema

DISCHARGED PLANNING
I. MEDICATION
o

Instruct watcher to give the medication at the exact time, dose, route and frequency. Rationale- to prevent the formation of the drug resistance when wrong medications are given and to attain therapeutic effect of the drug.

o Explain the purpose of each medication Rationale- this will provide information to the client as to why she needs to take the prescribed medication because of its action and indication.
o

Explain to the watcher the indication and possible side effects brought by each of the drug. Rationale- to give awareness to the patient about the purpose of the drugs; it will also prevent panic to the patient when side effects are experience.

Instruct the watcher to give drugs that are only prescribed by the physician
Rationale- non-prescribed drugs may have made an

antagonistic or synergistic effect if taken with other drugs. o Instruct to take meals before taking the medications, unless it is contraindicated
Rationale- to decrease the risk of hypoglycemic shock. o

Instruct the watcher that when adverse effect are noted consult the physician immediately Rationale- to prevent any complication that will arise.

II. EXERCISE
o

Instruct the patient to have adequate exercise as tolerated and advise family to assist patient in performing light exercise. Massages are also encouraged Rationale- for proper blood circulation

III. TREATMENT
o

Instruct the patient and family to maintain prescribed medication regularly as ordered by the physician Rationale- to have a pace recovery

Let the watcher and the family know that they should maintain conductive practices to hasten recovery Rationale- to promote healing and recovery

o Instruct regular consultation to the physician Rationale- to monitor progress and help to evaluate the effectiveness ot the therapy. IV. HYGIENE
o

Inform the patient of the advantages of always keeping the body clean. Include the family in the health teaching and advise them to facilitate patients hygienic activities. Rationale- to promote cleanliness, comfort, and prevent infections.

V. OUT PATIENT REFERRAL

o

Instruct the patient to follow the physicians order or when to consult for check-up Rationale- to enable the physician to evaluate the patients condition and monitor the patients progress after medical intervention.

o Inform to seek medical care immediately if adverse reactions of the drugs occur Rationale- to prevent exacerbation of illness.
o

Advise the family to observe for signs of clients discomfort Rationale- to render appropriate intervention

VI. DIET o Inform the family that the client must have/receive adequate nutrition Rationale- this promotes the clients wellness and maximizes his physical recovery.
o

Avoid skipping meals, instead, eat on time with strict aspiration precaution

 Rationale- this helps in meeting the daily nutritional

requirements of the body and decrease the risk of aspiration pneumonia

PROGNOSIS
DETERMINA NTS DURATION OF ILLNES ONSET OF ILLNESS PRECIPITATI NG FACTOR WILLINGNES S TO TAKE MEDICINES FAMILY SUPPORT POO R (1) FAIR (2) GOO D (3) JUSTIFICATION Signs of the disease manifested 2 months prior to admission. And 7 days after admission, the patient manifests a better condition The onset of illness cannot be properly identified but signs and symptoms started 2 months prior to admission and 7 days ago, patient was admitted for proper management. Possible precipitating factor is patients eat foods which is high in cholesterol and not doing exercise. The patient is willing to take his medications. The familys support is very evident. They are willing to comply with the treatment regimen and are capable of providing the financial support necessary.

Respective numerical values Rating: Poor =1.0-1.6 Good= 2.4-3.0 Computation: Fair= 1.7-2.3

Formula: rate x frequency Poor: 1x0=1 Fair: 2 x 1 = 0 Good:3 x 4 = 12 13 / 5 (# of determinants) = 2.6

(GOOD!) With the use of the criteria presented above, our patients general prognosis is GOOD with a result of 2.6. Patient X has a poor score for the precipitation factor because of her life style such as eating high fat foods and not doing exercise. He has no fair prognosis. Patient was given a good prognosis on the duration of illness, onset of illness, willingness to take medicines, and family support. Above all, the patient will hopefully recover as early as possible following the recommended treatment regimen given to her.

RECOMMENDATION
We recommend the following to the Mr. X and his family to perform the following to prevent complications of disease and further management. We recommend them: 1. To follow the Doctors order. 2. To religiously follow the schedule for taking his medications.
3. To have follow up check-ups to assess the usefulness of the medical

treatment and to prevent occurrence of further complications. 4. To perform light exercises to promote physical fitness.
5. To avoid stress and teach some management such as massage,

therapeutic touch, silence etc to handle it.

6. To avoid high-sodium foods, limit intake of saturated fat, trans fat and

cholesterol.
7. To avoid highly seasoned foods such as coffee, tea, cola and alcohol. 8. The patient with his family should be teach in assessing for skin

breakdown when at home, and institute preventive measures such as frequent changes of position, positioning to avoid pressure, elastic pressure stockings and leg exercises 9. To consult immediately to health personnel if there is any unsualities felt or observed

BIBLIOGRAPHY

Book references:
Brunner & Suddarths Textbook of Medical-Surgical Nursing 10th Edition Authors: Suzanne C. Smeltzer, RN, EdD, FAAN Brenda G. Bare, RN, MSN The Essentials of Anatomy and Physiology 5th Edition Author: Elaine N. Marieb Fundamentals of Nursing 7th Edition, Fundamentals of Nursing 7th Edition Clinical Handbook Authors: Barbara Kozier Glenora Erb Audrey Berman Shirlee Snyder Physical Assessment Manual of NDU-College of Health Sciences Nurses Pocket Guide 11th Edition Authors: Marilynn E. Doenges Mary Frances Moorhouse Alice C. Murr Drug Information Handbook for Nursing Authors: Beatrice B. Turkoski, RN, PhD Brenda R. Lance, RN, MSN John E. Janosik, PharmD Nursing 2007 Drug Handbook Lippincott Williams and Wilkins PPDs Nursing Drug Guide 2007 Edition Malan Press Inc. Mosbys Pocket dictionary of Medicine, Nursing and Health Professions 5th Edition

Weblinks:
http://www.mims.com

http://www.nursingcrib.com
http://www.merck.com/

LABORATORY STUDIES
A. Hematology (February 01, 2010)

DETERMINATIO N WBC RBC HGB HCT PLT

ACTUAL VALUE 42.3 4.2 112 0.35 442

NORMAL VALUE 4 10 3.8 5.8 110 160 0.36 0.5 100 300

UNITS 109/L 1012/ L g/L

INTERPRETATION Above normal range Within normal range Within normal range Below normal range

CLINICAL SIGNIFICANCE May indicate Infection, Inflammation, Trauma There are enough RBC to carry hemoglobin There are enough hemoglobin to carry O2 to the body cells and tissues May indicate Hemorrhage, Anemia, Hyperthyroidism, Dietary deficiency May indicate Malignant Disorder, Polycythemia, Rheumatoid Arthritis, Iron Deficiency Anemia Mai indicate Iron deficiency Anemia There are enough adequate circulating hematocrit There are enough hematocrit concentration in the blood A decrease implies no significant interpretation There are enough monocytes to defend the body from infections May indicate Leukemia, Sepsis, Immunodeficiency diseases

Nursing responsibilities BEFORE: Determine patient understands of purpose of procedure and method you will use. Determine if special conditions need to be met before specimen collection. Assess patient for possible risks associated with venipuncture: anticoagulant therapy, low platelet count, bleeding disorders Determine patients ability to cooperate with procedures Assess patient for contraindicated sites for venipuncture: presence of IV fluids, hematoma ,at potential site Review history of care providers order for type of test. DURING: Verify patients identity by using at least two forms of identifiers, neither of which is the patients room number. Verify the type of procedure with the patient AFTER Reinspect venipuncture site Determine if patient remains anxious or fearful.

109/L

Above normal range Below normal range Within normal range Within normal range Within normal range Below normal range Within normal range Below normal range

MCV MCH MCHC RDW-SD LYM% MXD% NEUT%

83.2 26.5 319 46.3 18.5 8.70 25.60

86 100 26 31 310 370 37 50 20 40 3 10 45 77

fl pg g/L % % % %

 Check Laboratory report for test results Discuss the results to the patient together with the doctor

A. Urinalysis

DETERMINANT S Color Reaction Appearance Specific Gravity Chemical Characteristics: Sugar Albumin Microscopic Findings: Pus cells RBC

ACTUAL VALUE Yellow Acidic Clear 1.030

NORMAL VALUE Straw to Yellow Acidic Clear 1.005-1.030

INTERPRETATIO N Within normal range Within normal range Within normal range Within normal range

CLINICAL SIGNIFICANCE

NURSING RESPONSIBILITIES

A normal description of the Before: physical characteristics of Explain the procedure to the pt. and how urine A normal reaction of urine he can cooperate. with relation to pH Provide privacy. Physical manifestation that urine does not have macro During: filtrates Concentration of solutes in Instruct the pt. on how to get urine the urine or concentrations of samples (it should be midstream/ sterile ions are at normal levels. technique). Tell the pt. that the procedure is painless.

Negative Negative

Negative Negative

Within range

normal May indicate patient is negative for Diabetes Mellitus May indicate efficient filtration of glumeruli.

After: Bring the urine samples in the laboratory.

Within normal range

4-5/hpf 1-3

0-2/hpf 0-2

Above normal range Above normal range

May indicate infection of the urinary tract May indicate infection of the urinary tract

NURSING CARE PLAN Cues Subjective: Nanghihina ako at medyo nahihirapan akong huminga as patient verbalize. Objective: Difficulty in breathing restlessness irritability diaphoresis pale skin color Need Physiologic need Nursing diagnosis Decreased cardiac output related to altered afterload and contractility of the heart secondary to congestive heart failure OUTCOME IDENTIFICATION / OBJECTIVE After 4 hours ineffective nursing interventions, patient will display hemodynamic stability and participate in activities that reduce workload of the heart. NURSING INTERVENTION/RATIONALE Establish rapport - To gain trust and cooperation IVF check and regulated - Serves as baseline of the condition of the patient. Auscultate apical pulse; asses heart rate, rhythm. - Tachycardia is usually present, even at rest, to compensate for decreased ventricular contractility. Inspect skin for pallor, cyanosis and temperature. - Pallor is indicative of diminished peripheral perfusion secondary to inadequate cardiac output, vasoconstriction, and anemia. Cyanosis indicates vasoconstriction. Monitor urine output. - Urine output may decrease during the day because of fluid shifts in the tissues. Oliguria can also reflect decreased renal perfusion Elevate legs, avoiding pressure under knee. Encourage active /passive exercises - Decreases venous stasis, and may reduce incidence of thrombus or embolus formation Provide quiet, restful environment - Psychological rest can help reduce emotional stress that could increase workload of the heart. Instruct to eat Small Frequent Feedings - To decrease circulatory load. Administer supplemental oxygen as indicated EVALUATION

Goal met, patient was display hemodynamic stability as evidence by BP-110/80mmhg, has adequate of urine output of 3 times within 8 hours shift. And was able to participate in activities that reduce workload of the heart such as maintaining bed rest and free from stress.

edema on both
feet

decreased
peripheral pulse

Vital signs:
RR -24 bpm HR-109 bpm

Increases available oxygen form myocardial uptake to combat effects of hypoxia or ischemia

NURSING CARE PLAN Cues Need Nursing diagnosis OUTCOME IDENTIFICATION / OBJECTIVE NURSING INTERVENTION/RATIONALE EVALUATION

Subjective: Medyo nahihirapan akong huminga as patient verbalize. Objective: Difficulty in breathing restlessness irritability diaphoresis pale skin color

Physiologic need

Impaired gas exchange r/t altered oxygen supply as evidence by dyspnea secondary to CHF

After 8 hrs of holistic nursing care the pt. will be able to demonstrate improve ventilation and adequate oxygenation of tissues by ABGs oximetry and to be free from symptoms of respiratory distress.

used of accessory
muscles

decreased
peripheral pulse

Vital signs:
RR -24 bpm HR-109 bpm

Establish rapport - To gain trust and cooperation IVF check and regulated - Serves as baseline of the condition of the patient. Monitor V/S especially respiratory rate - To evaluate degree of compromise Auscultate breath sounds, note areas of decreased/ adventitious breath sounds. - To ascertain status and note progress or complications Auscultate breath sounds, noting crackles, wheezes - Reveals presence of pulmonary congestion/collection of secretions, indicating need for further intervention. Elevate HOB or change position every 2 hours as necessary - To maximize respiratory effort and maintain airway Encourage client to increase oral fluid intake. - To help liquefy secretions Encouraged frequent deep breathing/ coughing exercises - Promotes optimal chest expansion and drainage of secretions Administer supplemental oxygen as indicated - Increases alveolar oxygen concentration, which may correct/reduce tissue hypoxemia. Monitor/graph serial ABGs, pulse oximetry. - Hypoxemia can be severe during pulmonary edema. Compensatory changes are usually present in chronic HF.

Partially met. The patient was able to improved ventilation and oxygenation of tissues as evidenced by patient breathing without using much of the accessory muscle and free from respiratory distress.

DRUG STUDY
Date Classifica tion Bronchodila tors Gener ic Name S A L B U T A M O L S U L F A T E Bran d Nam e V E N T O L I N Mechanism of Action Relaxes bronchial, uterine and vascular smooth muscle by stimulating beta2 receptors. Indication and Contraindication INDICATION: To prevent or treat bronchospasm in patients with reversible obstructive airway disease To prevent exerciseinduced bronchospasm CONTRAINDICATION: Contraindicated in patients hypersensitive to drug or its ingredients. Use cautiously in patients with CV disorders (including coronary insufficiency and hypertension), hyperthyroidism, or diabetes mellitus and those who are unusually responsive to adrenergic. Actual Dose 1neb q8 Side Effects Nursing Responsibilities Observed 10Rs in giving medication. Ventolin HFA is a newer version of the Ventolin metered-dose inhaler (MID) for asthma and other obstructive lungs diseases. Ventolin HFA uses the propellant hydrofluoroalkane as an alternative to chlorofluorocarbon s to propel the medication Warn patient about possibility of paradoxical bronchospasm. Tell to stop the drugs immediately if it occurs. Tell the patient to wash the inhaler with warm water, soapy water after using. Signat ure Studen t Signatu re CI

1/31/1 2

CNS: tremor, nervousness, dizziness, insomnia, headache, hyperactivity, weakness, CNS stimulation, malaise. CV: tachycardia, palpitation, hypertension EENT: dry and irritated nose and throat with inhaled form, nasal congestion, epistaxis, hoarseness. GI: Heartburn, nausea, vomiting, anorexia, bad taste, increased appetite. Metabolic: hypokalemia Musculoskeletal: muscle cramps Respiratory: Bronchospasm, cough, wheezing, dyspnea, bronchitis, increase sputum

DRUG STUDY Date Classifica tion Cephalospo rin Generic Name Cefuroxi me Bran d Nam e C E F T I N Mechanism of Action Second generation cephalosporin that inhibits cell-wall synthesis promoting osmotic instability; usually bactericidal. Indication and Contraindication INDICATION: Effective in treating meningitis & septicemia & for cardiothoracic procedures & surgical prophylaxis. CONTRAINDICATIO N: Contraindicated in paitents hypersensitive to drug or other cephalosporin. Use cautiously is patient hypersensitive to penicillin because of possibility of cross-sensitivity with other betalactam antibiotics. Use cautiously in breastfeeding Actual Dose Side Effects Nursing Responsibilities Observe 10 Rs in giving medication. Before administration ask patient if he as allergic to penicillin or cephalosporin. Tell patient to take drugs as prescribed, even after he feels better. Instruct patient to notify prescriber about rash or evidence of super infection. Advise patient receiving drug IV to report discomfort at IV Signat ure Studen t Signatu re CI

1/31/1 2

500mg 1cap BID

CV: phlebitis, & thromboplhebi tis GI :pseudo membranous Colitis, nausea, anorexia, vomiting, diarrhea. Hematologic: Transient neutropenia, Eosinophilia, Hemolytic anemia, thrombocytop enia. Other: anaphylaxis.

women & in patients with history of colitis or renal insufficiency.

insertion site.

DRUG STUDY Date Classifica tion Gener ic Name Bran d Nam Mechanism of Action Indication and Contraindication Actual Dose Side Effects Nursing Responsibilities Signat ure Studen Signatu re CI

e 1/31/1 2 Diuretics F U R O S E M I D E L A S I X A potent loop diuretic that inhibit sodium and chloride reabsorption at the proximal and distal tubules and the ascending loop of Henle Indication: Acute pulmonary edema, edema, hypertension Contraindication: Contraindicated to patients hypersensitivity to drug and in those with anuria Use cautiously in patients with hepatic cirrhosis and in those allergic to sulfonamidfes. Use furosemide during pregnancy only if potential benefits to mother clearly out weight risks to fetus. CNS: vertigo, headache, dizziness, paresthesia, weakness, restlessness,fever. CV: orthostatic, hypotension; thrombophlebitis with I.V administration EENT: transient deafness, blurred or yellowed vision GI: abdominal discomfort and pain, diarrhea, anorexia, nausea, vomiting, constipation Hepatic: Hepatic Dysfunction Metabolic: volume depletion and dehydration, asymptomatic hyperuricemia, impaired glucose intolerance, hypokalemia, hypochloremic alkalosis, fluids and electrolyte imbalance Musculoskeletal: muscle spasm Skin: dermatitis, purpura, photosensitivity, transient pain at I.V injection site Observe 10 Rs in giving medication. Monitor weight, blood pressure, and pulse rate routinely with long term use and during rapid dieresis. Furosemide can lead to profound and electrolyte depletion. Monitor fluid intake and output and electrolyte, BUN, and carbon dioxide level frequently. Watch for signs of hypokalemia such as muscle weakness and cramps Advise patient to immediately report ringing ears, severe abdominal pain, or soar throat and fever which may indicate furosemide toxicity.