A Case Presentation of

Congestive Heart Failure

secondary to Coronary
Artery Disease

Objectives
At the end of this case study, the learner should
be able to:
Understand Congestive Heart Failure
Recognize its clinical signs and symptoms
Identify causative factors of the Heart Failure
Learn the medical and surgical management
Know perioperative care in meeting patients
needs

Congestive Heart Failure

Is the insufficiency of the cardiac output to supply the metabolic
needs of the peripheral tissue caused by insufficient pump.
The most common reason for hospitalization in adults >65 years
old.
Complications of CHF are Kidney damage or failure, Heart valve
problems, Liver damage and Stroke
Management of CHF:
Increase Cardiac Contractility Digitalis
Reduce Preload Diuretics and Rotating torniquet
Reduce Afterload Vasodilators and Rest

Classifications of Heart Failure

Classification

Symptoms

Stage A

High risk of heart failure but no

structural heart disease or
symptoms of heart failure

Stage B

Structural heart disease but no

symptoms of heart failure

Stage C

Structural heart disease and

symptoms of heart failure

Stage D

Refractory heart failure requiring

specialized interventions

2 Types of problems in congestive heart failure:

1. Systolic dysfunction occurs when the heart can't pump enough
blood to supply all the body's needs.
2. Diastolic dysfunction occurs when the heart cannot accept all
the blood being sent to it.

Etiology
o Damage to muscular wall (M.I)
o Cardiomyopathy
o Hypertesion
o Coronary Artery Disease
o Valvular Defects
o Infections

Signs and Symptoms:

Signs and Symptoms:

Anatomy and Physiology

Pathophysiology

Patients Profile
Name: R.M.G
Ward Rm: SMW (Special Monitoring Ward) Bed #4
Age: 61 y/o
Sex: Male
Civil status: Married
Birth place: Valenzuela city
Nationality: Filipino
Religion: Catholic
Adm. Date and Time: 9/5/14
Type of admission: SPECIAL MONITORING WARD BED#4
Physicians Diagnosis: COGENITAL HEART FAILURE
SECONDARY TO CORONARY ARTERY DISEASE.

Physical Examination
VITAL SIGNS: BP 130/80

PR :89

RR: 24 TEMP: 36

SKIN: (-) Rashes

HEENT: conjuctival erythema, + puffy eyelids
CHEST: SCE
HEART: dynamic precordium, AB 5th intercostal
LUNGS: (-) rales
ABDOMEN: globular, soft, everted umbilicus
GENITALIA: + swelling
RECTUM: N/A
EXTREMITIES: grade 2-3 bipedal edema
NEUROGICAL: GCS 15
ADMITTING DX: Congestive Heart Failure Secondary to
Coronary artery disease.

Patients History
Chief Complain: Edema
History of Present illness:
3 Months PTA, patient noted on and off SOB, 2 week PTA
noted bipedal edema. 1 week PTA noted puffy eyelids 2
days PTA consulted VMC, CXR ECG done.
Past Medical/Surgical History:
(-) HPN / Edema

Family History
NONE
Personal Social History:
Smoker
Alcohol drinker

Diagnostic Tests
Serum Test
September 9, 2014
TEST

RESULT

UNIT

REFERENCES

NORMAL VALUE

14.57

mmol/L

high

2.50 6.50

CREATININE

154.2

mmol/L

high

58.0 -127

SODIUM

131.60

mmol/L

low

135.0 148.0

POTASSIUM

4.83

mmol/L

CHLORIDE

98.10

mmol/L

BUN

3.50 -5.30

98.00 107.00

Diagnostic Tests: Abnormal Findings

TEST NAME

RESULT

UNIT

REFERENCES

NORMAL VALUES

BUN

14.57

mmol/L

high

2.50 6.50

CREATININE

154.2

mmol/L

high

58.0 -127

SODIUM

131.60

mmol/L

low

135.0 148.0

HEMOGLOBIN

162

g/L

high

125-160

HEMATOCRIT

0.518

g/L

high

0.380-0.500

GLUCOSE

3.68

mmol/L

low

5.05-6.45

HDL

0.5

mmol/L

low

0.90-1.50

TOTAL PROTEIN

61.6

g/L

low

62.0-85.0

URINE: BACTERIA

few

UTZ

Minimal bilateral
effusion. ascites

Gordons 11 Functional Health Pattern

1.Health perception /health management
Patient is a 62-year-old, male, married. Diagnose with congestive
heart failure secondary to coronary artery disease. He cannot
describe thoroughly about his condition due to unconsciousness.
2. Nutritional metabolic
Before
Patient has complete meals ( breakfast, lunch and dinner) and
has usually fluid intake of 8-12 glasses /day.
Now
Hes on a diet of low fat, low salt. And limits fluids 1L/day. With
all needs attended. With PNSS inserted.
3. Elimination
BLADDER:
Before
He can void 4-5x a day without any pain felt.
Now
He wears a diaper that is soaked weighing 800 gms (800ml)
at the end of the shift.

4. Activity/ exercise
Before
He has no work due to his age. And always stay at their
house and make fun to his family and to his
grandson/granddaughter.
Now
He is on bed over a long period of time.
5. Cognitive- perception
Before
He is a college graduate of a school they did not
mention. According to the significant others, he has no
deficit to his sensory perception (hearing and sight)and
hes able to read and write.
Now
He is experiencing difficulty of breathing due to his
condition. And he cannot talk since he was admitted
because he is stroke. And he is still unconscious

6. Sleep- Rest
Before
He has a good sleep- wake cycle. He usually sleeps at 9 pm and
awakes at 6-7 am to help her family in their house work.
Now
He has sleep disturbance due to always experiencing difficulty of
breathing.\
7. Self perception/ Self concept
According to the significant others, the patient is a good father
and husband to his wife. He is very dedicated to his work before
when he is still strong. He sometimes smoke and drink alcohol but
not all the time.
8. Role-Relationship
Communication:
Before
According to significant others, before his speech is clear. And
he can speak Tagalog and English.
Now
He cannot communicate due to his condition. He just nod
when nurses, doctors and his relatives talk to him.

9. Sexuality reproductive
According to the significant others, he has a wife with 6
siblings.
10. Coping /stress tolerance
According to the significant others, that whenever he
has a problem, he shares it to his family member in order
to solve it.
11 .Value Belief
According to the significant others, patient is a Catholic
since birth. He did not change into any religion.

Course in the Ward

September 5, 2014
Doctors Notes

Admit to SMW
Monitor VS q2
LSLF diet
Limit fluid 1L a day
Heplock
Labs: CXR ECG
CBC- BUN CREA PT, PTT
HGT TPAG FBS
Furosemide 20mg IV q6 BP
>110/70
Spironolactone 50g 1tab OD
Rosuvastatin 20g 1tab OD
Trimetazidine 35g 1tab BID
Clopidogrel75g 1 Tab OD
I & O every shift

Nurses Notes
Admitted 62 - year-old male
diagnose with congestive
heart failure
received patient from ER
accompanied by relative and
nurse on duty
With heplock intact
With foley cath connected to
urine bag with o2 support
via nasal cannula
Elevated blood pressure
Labs requested
Meds given
Place a low salt low fat diet
Limit fluids 1L/day
BP : 130/80

September 6, 2014
Doctors Notes

Nurses Notes

Decrease furosemide to q8
Decrease VS every 4 hour

Fluid volume excess

On bed with heplock
With o2 support via nasal
cannula
With foley cath connected to
urine bag
Ordered to limit fluid to 1L
per day
Diuretic given with BP
VS taken
Advise significant other to
assist with ADL

September 7, 2014
Doctors Notes

Nurses Notes

Increase Furosemide 20 mg
q6
Whole abdominal utz

Fluid volume excess

On bed with heplock
With o2 support via nasal
cannula
With foley cath connected to
urine bag
Ordered to limit fluid to 1L
per day
Diuretic given with BP
VS taken
Advise significant other to
assist with ADL

September 8, 2014
Doctors Notes

Nurses Notes

Repeat CXR
Ceftriaxone 2g IV q12
(-)ANST

To continuity of care
On bed conscious, with
heplock
Checked safety and
comfortability
O2 inhalation via nasal
cannula
Seen and examined by Dra.
Aguilla with order made and
come out needs attached for
whole abdomen Ultrasound
(UTZ) On 9/9/14 at 1 p.m
Maintained and encouraged
deep breathing and
relaxation technique.
Noted still within episode of
difficulty of breathing
endorsed to next shift.

September 9, 2014
Doctors Notes

Paracetamol 1 ampule every 4

hours ANST(-) Temp: 38.5 C
Paracetamol TIV 1 tab every 4
hour ,T: 37.8 C

Nurses Notes

Ineffective breathing pattern

On bed , tachypnic concerns.
Vital sign taken
Kept at o2 support, Temp. 38.6

September 10, 2014

Doctors Notes

Decrease furosemide 20 gram

IV every 8 hours x 1 day, then
reassess

Nurses Notes

On bed, conscious, slightly

dyspnic, with o2 support via
nasal cannula at 2pm.
Promote rest and maintained on
high back rest, encourage deep
breathing exercise.
Still with o2 support via nasal
cannula.
Reported of difficulty of
breathing mild to moderate to
next shift.

September 11, 2014

Doctors Notes

Nurses Notes

Continue Furosemide 20mg

IV q8
Refer labs once available

On bed, conscious, with

heplock inserted, not to
distress.
Checked safety and
comfortability
Oral meds recorded

September 12, 2014

Doctors Notes

Nurses Notes

Shift IV Furosemide to 40mg Continuing of care

Vital signs taken, oral meds
tab BID
VS every shift
given
Cefixime 200mf cap BID
Put side rails up for the
Bladder training x 2 cycles
patients safety

September 13, 2014

Doctors Notes

Nurses Notes

Shift Furosemide IV to 40
mg tabs BID
Decrease VS to every shift
Shift ceftriaxone to cefixime
200 mg caps

On bed with body weakness,

with o2 support via nasal
cannula
Vital sign taken, kept
patients comfortable
Medication given,
encouraged in deep
breathing exercise

September 14, 2014

Doctors Notes

Nurses Notes

MGH
Follow up check-up after 1
week

Rounds made by Dr. Aguilla

with may go home ordered
Meds given & instructed
Advise follow up check- up
after 1 week

Drug Study

DRUG CLASS

ACTION

INDICATION

CONTRAINDICATION

ADVERSE
EFFECT

NURSING
INTERVENTION

PARACETAMOL
(Antipyretic,
Nonopiod)

Acts directly on
heat-regulating
center to cause
vasodilation and
sweating

Temporary
reduction of fever,
back and muscle
aches

Allergy to
acetaminophen
u/c impaired
hepatic, chronic
alcoholism

Headache,
Shake well before
Dyspnea, hepatic use give drug with
toxicity and failure food
DC if
hypersensitivity
occurs

Ceftriazone
3rd generation
cephalosporin

Inhibits synthesis
of bacterial
cellwall causing
celldeath.

Intra-abdominal
infections caused
by E.coli,
Klebsiella
pneumoniae

Contraindicated
with allergy to
cephalosporins or
penicillins. Use
cautiously with
renal failure,
lactation,
pregnancy

Pain
Induration
Phlebitis
Rash
Diarrhea
Thrombocytosis
Leucopenia
Glossitis
Respiratory
superinfections

Assess patient for

signs and
symptoms of
infection before
and during the
treatment

Aldactone
Spironolactone
Potassiumsparing
diuretic

Completely blocks
the effects of
aldosterone in the
renal tubule,
causing loss of
sodium and water
and retention of
potassium

Primary
hyperaldosteronis
m, adjunctive
therapy in the
therapy in the
treatment of
edema associated
with CHF,
nephritic
syndrome, hepatic
cirrhosis,
treatment of

Acute renal
insufficiency,
progressive renal
failure,
hyperkalemia, and
anuria. Clients
receiving
potassium
supplements,
amiloride or
triamterene

Dizziness,
headache,
drowsiness, rash,
cramping,
diarrhea,
hyperkalemia,
hirsutism,
gynecomastia,
deepening of the
voice, irregular
menses

Instruct client not

to drive/operate
machinery until
drug effects are
realized may
cause drowsiness
or uneasy gait.

DRUG CLASS

ACTION

INDICATION

Rosuvastatin
calcium
Crestor

Lowering high
cholesterol and
triglycerides in
certain patient.
It also
increases highdensity
lipoprotein
cholesterol
levels.

an adjunct to
diet in the
treatment of
elevated total
cholesterol,
mixed
dyslipidemia,
atherosclerosis

Vastarel MR
Trimetazidine
dihydrochlori
de

acts by directly
counteracting
all the major
metabolic
disorders
occurring
within the
ischemic cell.

Long treatment
of coronary
insufficiency,
angina
pectoris.

ADVERSE
EFFECT
hypersensitivity Nausea,
, impaired
dyspepsia,
hepatic
diarrhea,
function,
constipation,
alcoholism,
vomiting,
renal
rhinitis,
impairment,
sinusitis,
advanced age, cough,
hypothyroidism dyspnea,
pneumonia
CONTRAINDICATION

Do not take
Rare cases of
Vastarel MR if
GI disorders.
you are allergic
to any of the
constituents.
This drug is
generally not
recommended
during breast
feeding

NURSING
INTERVENTION

- Monitor
patient closely
for signs of
muscle injury,
especially
higher doses
- Provide
comfort
measures to
deal with
headache,
muscle
cramps, or
nausea
use cautiously
in patients with
heart failure or
hypertension
and in elderly
patients.

DRUG CLASS

ACTION

INDICATION

CONTRAINDIC
ATION

Clopidogrel
75 mg 1 tab
PO OD

Anti-platelet
agents Platelet
aggregation
inhibitors

Reduction of
atherosclerotic
events in
patients at risk
for such events
including recent
MI, acute
coronary
syndrome
stroke, or
peripheral
vascular
disease.

Use Cautiously
in:
Patients at risk
for bleeding.
History of GI
bleeding/ulcer
disease Severe
hepatic
impairment

Betamethasone
dipropionate
>Corticosteroid
(long acting)
>Glucocorticoid
>Hormone

Betamethasone
is a synthetic
(man-made)
corticosteroid
that is used
topically (on the
skin).

Ulcerative
Hypersensitivity
colitis, acute
Systemic fungal
exacerbations of or acute
MS, and
infections
palliation in
some leukemias
and lymphomas
Trichinosis with
neurologic or
myocardial
involvement

ADVERSE
EFFECT
(CNS)
Headache,
dizziness, and
myasthenia.
(GI) N & V and
incontinence.
( CV)
Hypotension.
(SKIN) Flushing
pallor sweating
and increased
perspiration

Acne, cracking
and stinging of
the skin;
dryness;
excessive hair
growth;
inflamed hair
follicles; itching;
skin irritation

NSG
INTERVENTIO
N
Assess patient
for symptoms of
stroke,
peripheral
vascular
disease, or MI
periodically
during therapy

Give daily dose

before 9 AM to
mimic normal
peak
corticosteroid
blood levels.
Increase dosage
when patient is
subject to
stress.

ASSESSMENT

DIAGNOSIS

PLANNING

Subjective:
Nanghihina
ako, dalhin
niyo na ako
sa hospital.
as verbalized
by the
patient.

Decreased
cardiac output
r/t altered heart
rate and
rhythm.

After series (23 days) of

nursing
interventions,
the patients
cardiac output
will be in its
normal limits;
BP, peripheral
pulses strong
and equal with
adequate
capillary refill
time and
decrease
frequency or
absence of
dysrhythmias.

Objective:
Weaknes
s
Irregular
rhythm of
pulse
Pale
conjuncti
va and
nail beds
Paleness
dystrhyth
mia

NURSING
INTERVENTIONS
1.

2.

3.
4.

5.

6.

Review signs of
impending
failure/shock, nothing
vital signs, invasive
hemodynamic
parameters, breath
sounds, heart tones,
and urinary output.
Assess patients skin
temperature;
evaluate quality and
equality of pulses as
indicated.
Monitor cardiac
rhythm continuously.
Note response to
activity and promote
adequate rest by
decreasing stimuli,
providing quiet
environment,
schedule activities
and assessments.
Give oxygen as
indicated by patients
symptoms, oxygen
saturation and ABGs.
Provide for diet
restrictions with
frequent small feeding
or easily digested meal
and provide fluid as
indicated. (may need to
consider electrolyte
replacement)

RATIONALE
1.

2.

3.
4.

5.

6.

Note presence of
pulsus paradoxus,
reflecting cardiac
tamponade.
Decreased cardiac
output results in
diminished
weak/thready pulses.
Irregularities suggest
dysrhythmias which
may require further
evaluation or
monitoring.
To note effectiveness
of medication/
devices.
To maximize sleep
periods. Overexertion
increases oxygen
consumption/
demand.
Increase amount of
oxygen available for
myocardial uptake,
reducing ischemia and
resultant cellular
irritation/
dysrhythmias.
To maintain adequate
nutrition and fluid
balance.

EVALUATION
After 2-3 days
of nursing
interventions,
the patient
display
hemodynamic
stability; w/
normal cardiac
output, strong
and equal
peripheral
pulses,
absence of
dysrhythmias
and the
patient
appeared
relax.

ASSESSMENT
Subjective:
Hindi ako
gaanong
makagalaw,
parang ang bigat
sa pakiramdam.
as verbalized by
the patient.
Objective:

Limited ROM

Abnormal
pulse and
rhythm

Generalized
weakness

(+) DOB

DIAGNOSIS
Activity
intolerance r/t
imbalance
oxygen supply
and demand
as evidenced
by limited
ROM,
generalize
weakness and
DOB.

PLANNING
After series (2- 1.
3 days) of
nursing
interventions,
the patient will
report
measurable
increase in
activity
2.
intolerance w/
HR and BP
within its
normal limits,
and skin
warm, pink
and dry.
3.

4.

5.

6.

NURSING
INTERVENTIONS
Encourage rest
(bed/chair) initially.
Thereafter, limit
activity on basis of
pain/ adverse
cardiac response.
Provide non-stress
divertional activities.
Adjust client daily
activities and reduce
intensity of level.
Instruct patient to
avoid increasing
abdominal pressure.
(ex. Straining during
defecation) give
stool softener as
indicated.
Review signs and
symptoms reflecting
intolerance of
present activity
levels.
Provide positive
atmosphere, calm
and quiet
environment, while
acknowledging
difficulty of the
situation for the
client.
Promote comfort
measures and
provide for relief of
pain.
Assist the client in
position, elevate

RATIONALE
1.

2.

3.

4.
5.
6.

Reduces myocardial
workload/ oxygen
consumption, reducing
risk of complication.
Activities that required
holding the breath and
bearing down (valsalva
maneuver) can result in
bradycardia
(temporarily reduced
cardiac output) and
rebound tachycardiaw/
elevated blood
pressure.
Palpitations, pulse
irregularities,
development of chest
pain, or dyspnea may
indicate need for
changes in exercise
regimen or medication.
Helps minimize
frustration, rechannel
energy.
To enhance ability to
participate in activities.
Allows better chest
expansion and reduce
risk for orthostatic
hypotension.

EVALUATION
After 2-3 days
of nursing
interventions,
the patient
progressive
increase in
tolerance and
participating in
activities for
his wellness
and increase
strength of his
extremities w/
good color of
skin.

ASSESSMENT

DIAGNOSIS

PLANNING

NURSING
INTERVENTIONS
Subjective:
Ineffective
After series
1. Observe breathing
Hindi ako
breathing
(2-3 days) of
pattern for SOB,
makahinga,
pattern r/t
nursing
nasal flaring,
sumisikip at
fatigue and
interventions,
pursed-lip
parang may
decreased lung the patients
breathing or
nakadagan sa expansion
respiratory
prolonged
dibdib ko. as secondary to
pattern will be
expiratory phase.
verbalized by CHF
effective
2. Position the
the patient.
without
patient in optimal
causing
body alignment in
Objective:
fatigue.
semi-fowlers
Weaknes
position for
s
breathing.
Productiv
3. Assess for
e cough
concomitant pain/
Dyspnea
discomfort.
Pursed4. Suction airways as
lip
needed.
breathing
5. Encourage slower/
Abnormal
deeper
pulse
respirations, used
rate and
of pursed-lip
rhythm
technique, and so
Pale
on.
Difficulty
6. Instruct to avoid
vocalizin
overeating/ gasg
forming foods.
7. Assist patient to
use relaxation
technique.
8. Encourage client
to develop a plan
for smoking
cessation.
9. Encourage

RATIONALE
1.

2.

3.
4.
5.
6.
7.

8.
9.

Presence of nasal
flaring and use of
accessory muscles
of respirations may
occur in response
to ineffective
ventilation.
To open or
maintain open
airway/ to
maximize lung
ventilation.
That may
restrict/limit
respiratory effort.
To clear secretions.
To assist client in
taking control of
the situation.
May cause
abdominal
distension.
To reduce stress/
decrease tension
level, to enhance
sense of well
being.
To promote
wellness
To limit fatigue and
enhance comfort.

EVALUATION
After 2-3 days of
nursing
interventions, the
patient improve
his breathing
pattern,
maximizing
respiratory effort
with good posture
and effective use
of accessory
muscle without
causing fatigue.

ASSESSMENT

DIAGNOSIS

PLANNING

Subjective:
bago naming
siya dalhin sa
hospital,
nanlalambot at
nanghihina siya
at masakit daw
ang dibdib nya.
as verbalized by
the relative.

Ineffective
tissue
perfusion r/t
decreased
cardiac output

After series
(2-3 days) of
nursing
interventions,
the patient
will
demonstrate
behaviors to
improve
circulation,
increased
perfusion as
individually
appropriate
and no pain.

Objective:
(+) chest
pain
Pain scale of
7/10
(+) DOB
Mouth
breathing
Weakness
Pale
(+) edema
on lower
extremities

NURSING
INTERVENTIONS
1. Assess the
response to
medication every
5 minutes.
2. Provide quiet,
restful
atmosphere.
3. Provide oxygen
and monitor
oxygen saturation
via pulse
oximetry as
ordered.
4. Elevate head of
bed.
5. Teach patient
relaxation
techniques and
how to use them.
6. Encourage
adequate rest
period.
Reposition the
patient every 2
hours.
7. Encourage client
to quit smoking,
join stop-smoking
programs.
8. Provide for diet
restrictions. (ex.
Reduction of
cholesterol and
triglycerides, high
or low in protein,

RATIONALE
1.
2.
3.

4.

5.

6.
7.

8.

To know the
effectiveness of the
medications.
Conserves energy/
lowers tissue oxygen
demand.
Increase amount of
oxygen available for
myocardial uptake,
reducing ischemia
and resultant cellular
irritation or
dysrhythmias.
To take advantage of
gravity decreasing
pressure on the
diaphragm and
enhancing ventilation
to different lung
segments.
To reduce stress/
decrease tension
level, to enhance
sense of well being.
To prevent fatigue
and to enhance
comfort.
Smoking cause
vasoconstriction and
May further
compromise
perfusion.
To maintain adequate
nutrition and to
promote wellness.

EVALUATION
After 2-3 days
of nursing
interventions,
the patient
circulation was
improve with
good
perfusion, pain
scale 7/10 to
0/10 no pain
and
discomfort,
and the patient
appeared
relax.

ASSESSMENT DIAGNOSIS
Subjective:
Nahihirapan
akong
huminga,
parang may
sagabal sa
lalamunan
ko. as
verbalized
by the
patient.
Objective:
(+) DOB
Difficulty
vocalizin
g
Cough
Changes
in
respirato
ry rate
and
rhythm
Pale
conjuncti
va and
nail beds

Ineffective
airway
clearance r/t
retained
secretions as
evidenced by
presence of
rales/crackles
sounds upon
auscultation

PLANNING
After series
(2-3 days) of
nursing
interventions,
the patient
will be able to
establish and
improve
airway
clearance as
evidenced by
absence of
signs of
respiratory
distress,
reduction of
congestion w/
breath sounds
clear and
improved RR.

1.

2.

3.
4.
5.
6.
7.

8.
9.

NURSING
INTERVENTIONS
Monitor respirations
and breath sounds,
noting rate and
sounds.
Position head midline
with flexion
appropriate for age or
condition.
Auscultate breath
sounds and assess air
movement.
Encourage deep
breathing and coughing
exercises.
Elevate head of bed/
change position every
2 hours and PRN.
Observe for signs/
symptoms of infection.
Instruct patient to have
adequate rest periods
and limit activities to
level of activity
intolerance.
Support reduction/
cessation of smoking.
Administer oxygen
therapy and other
medication as ordered.

RATIONALE
1.
2.

3.
4.
5.

6.
7.
8.
9.

Provides a basis for

evaluating adequacy
of ventilation.
To open or maintain
open airway in at
rest or compromised
individual.
To ascertain status
and note progress.
Breathing exercises
help maximize
ventilation.
To take advantage of
gravity decreasing
pressure on the
diaphragm and
enhancing drainage
of/ ventilation to
different lung
segments.
To identify infectious
process/ promote
timely intervention.
Prevents/ lessens
fatigue.
To mobilize
secretion.
Deliver low to
moderate levels of
oxygen to relieve
hypoxia.

EVALUATION
After 2-3 days
of nursing
interventions,
the patient
improve his
airway
clearance w/
absence of
rales and
crackle sounds,
absence of
respiratory
distress and
good RR.

Discharge Planning
MEDICATION
Advice/instruct the client to continue medication that are
prescribed by the physician andtheir actions. Instruct the
patient or the significant others for any
observable alterations on the patient condition.
EXERCISE
Instruct the patient to perform leg exercise as tolerated
such as walking to facilitate mobilization on lower
extremities.
THERAPY
Instruct the patient to continue medication. Also, activities
of daily living and self-caretraining are important to
encourage maintenance of hygiene.

 HEALTH TEACHING
Encourage the patient to increase fluid intake
Encourage the patient to eat foods rich in vitamins and
minerals/ nutritious food
Encourage the patient to avoid salty and fatty foods
Encourage the patient to have enough rest
OUT-PATIENT CARE
Instruct the client to come back for follow-up check-up as
scheduled by the attending physician.
DIET
Advised the patient to a Diet as Tolerated but preferably
avoiding saltyand fatty foods
SPIRITUAL/ SEXUAL ADVICE
Encourage the patient learn to accept responsibility for
their own physical, emotional,mental, and spiritual healing.