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CONGESTIVE HEART
FAILURE
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I. Nursing History
1. Biographic Data
Name: Mr. X
Age: 53 years old
Address: Quezon City, Philippines
Sex: Male
Marital Status: Married
2. Chief Complaint
Cough
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3. Present Illness
2 weeks prior to admission:
The patient is with cough withwhitish sticky phlegm.
The patient had no other signsand symptoms like fever, chestpain, shortness of breath,difficulty of breathing,abdominal pain and numbness.
The patient had consulted and
the patient was given Cefalexine500mg 3x a day andDextometrophan 3x a day fortemporary relief
1 week prior to admission:
The patient had occurrence ofcough with whitish phlegmassociated with easy fatigability;2 3 pillow orthopnea anddecrease appetite. No fever, nochest pain, no nausea and
vomiting, no body weakness.
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4. Past History
The clients creatinine level was increased 2 3 years ago.Admitted due to decrease input and output 0 output and pedal
edema, cardiomyopathy 2 3 years ago. HCTZ 2500, Carvedilol
6.25 2x a day, on once a day Lanoxin 0.25 tab, Lasix 40 2x
a day, Coumadin 2.5mg once a day. Patient had DiabetesMellitus for 10 years, CBG every other day on insulin 2 3 years
ago.
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5. Personal and Social History
The client is a non smoker
The client consumed 2 3 bottles of beer in a week
The client is a previous dentist
Father: Congestive Heart Failure, Diabetes Mellitus Mother: Diabetes Mellitus
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Course in the wardJune 25, 2013
Client was endorsed and reviewed clients chart and noted allmedications as ordered.
Preparation of medications Acetylcysteine 600 mg/tablet once aday diluted in a half glass of water, Ketosterol 600 mg/tablet twice a
day [8:00am and 1:00pm], Levofloxacin 750 mg/tablet once a dayand Kalium durule thrice a day for three days given after meal[started on second day of admission (June 22, 2013)] and was givenas prescribed after the vital signs are taken.
The client had a diet of low salt and low fat. At 11:00am CompleteBlood Glucose Test (CBG) was taken as ordered with a result of 56
mg/dl. The attending physician ordered a retake of CBG reading for1:00pm. Vital signs are taken at 12:00nn.
The client had his CBG Test retake at 1:00pm with a result of 138mg/dl and Kalium durule was given after meal.
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June 26, 2013
The client was endorsed. Reviewed chart: discharge order noted.
Provided continuity of care given: vital signs taken and preparationof medications Acetylcysteine 600 mg/dl once a day diluted in a halfglass of water, Ketosterol 600 mg/tablet twice a day [8:00am and1:00pm], Levofloxacin 750 mg/tablet once a day, Kalium durulethrice a day for three days given after meal [started on second dayof admission (June 22, 2013)], Lanoxin 0.25 mg/tablet once a dayand Furosemide 40 mg/tablet every 12 hours taken orally withBlood Pressure precaution of 90/60 mmHg was given as prescribed.
Client was advised for discharged. Instructed client regarding his
home medications: Lactulose 120ml take 30cc every other day,Captopril 25 mg/tablet take tablet twice a day and he wasadvised to have a follow up check up after 1 week.
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II. Conceptual Framework
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III. Physical Assesment
VITAL SIGNS RESULTS
June 25, 2013
Blood Pressure 120/90 mmHg
Temperature 35.1oC
Respiratory Rate 24 breaths per minute
Pulse Rate 80 beats per minute
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Head to Toe Assesment
ACTUAL
ASSESSMENT
NORMAL
ASSESSMENT
ANALYSIS and
INTERPRETATION
HEAD
FACE
Eyes pale color of sclera white color of sclera decrease oxygen in
the blood flow
yellowish color of
conjunctiva
white color of
conjunctiva
jaundice due to
hemolysis of Red
Blood Cells
Lips pale in color depends on the colorof race
inadequateoxygenation
Neck distended jugular vein no distention of
jugular vein
indirect indicator of
pressure in the right
atrium
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THORAX and
ABDOMEN
LUNGS
Breath sounds crackles/rales upon
auscultation
bronchovesicular
breath sound
pulmonary congestion
or pulmonary edema
Abdomen wide abdominal
distention
(105cm./41inches)
depends on body mass
index
fluid accumulation in
the abdominal cavity
due to heart failure
UPPER
EXTREMITIES
Palms both palms are pallor pinkish in color inadequate
oxygenationNail beds both hands nail bed
are cyanotic in color
pinkish in color inadequate
oxygenation
LOWER
EXTREMITIES
Feet grade 2 pitting edema
on both feet
no pitting edema venous insufficiency
in lower extremity
Soles pallor on both soles Pinkish in color inadequate
oxygenation
GENERAL SURVEY:
o Body weaknesso Easily fatigue
SKIN:
o Dark brown in coloro Dry, cold, clammy skino Grade 2 pitting edema on both feeto Poor skin turgor
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IV. Laboratory/Diagnostic Exams
ECG RESULT (June 22, 2013)
Interpretation:
Sinus Rhythm
Right Axis Deviation
Bi-Atrial Enlargement
Incomplete Right Bundle Branch Block
Non Specific T Wave Changes
Persistent Postero-Basal Forces
2 DIMENSIONAL ECHOCARDIOGRAM AND COLOR FLOW REPORT
Interpretation: Color Flow Doppler Study
Mitral regurgitation, moderate
Tricuspid regurgitation, moderate
Pulmonic regurgitation
Calculated pulmonary artery pressure by pulmonary acceleration time (74msec), Pulomonary Hypertension, mild
Conclusion:
Dilated left ventricular dimension with left ventricular global hypokinesia
Widened E-point septal separation with low flow configuration of mitral valve leaflets indicative of left ventricular dysfunction
Depressed left ventricular ejection fraction = 28% by Simpson and 26% by Cubed method
Rheologic stasis noted in left ventricular cavity
Dilated left atrial dimension without evidence of thrombus
Dilated right atrial and right ventricular dimensions
Normal man pulmonary artery and aortic root dimensions
Mitral valve, tricuspid valve, aortic valve and pulmonic valve are normal
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Blood Glucose chart
DEPARTMENT OF RADIOLOGY
Section of Ultrasound
TOTAL ABDOMINAL ULTRASOUND
Impression:
Cholelithiasis.
Normal sonogram of the liver, pancreas, spleen, kidneys and urinary bladder.
Prostate gland enlargement with concretions.
DATE RESULT REFERENCE VALUE ANALYSIS
June 23, 2013
(11:30am)
269 mg/dl 80120 mg/dl Increased blood
sugar level
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Department of Pathology
Section of hematology
TEST RESULTS REFERENCE
VALUES
ANALYSIS
CBC with PLATELET
COUNT
Red Cell Count
MCV 96.5 (high) 80.096.0 Indicate to
classify anemiasMCH 34.6 (high) 27.533.2
MCHC 0.359 (high) 0.322
0.355DIFFERENTIAL
COUNT
Lymphocytes 0.41 (high) 0.250.35 Indicates
infection
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Hematology Section
Coagulation
PROTHROMBIN TIME RESULTS REFERENCE
VALUE
ANALYSIS
June 22,
2013
June 25,
2013
Patient 16.5 sec. 37.9 sec. 1014 sec. Prolong clotting
to occur
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Department of pathology
Section of clinical chemistryTEST RESULT REFERENCE
VALUE
INTERPRETATION ANALYSIS
June
22,
2013
June
24,
2013
Glucose 116 mg/dl (high) 74 106 Abnormal Increased
blood glucose
level
Urea 64
mg/dl(high)
50
mg/dl(high)
9 20 Abnormal
Creatinine 2.3
mg/dl
(high)
1.9
mg/dl
(high)
0.66 1.25 Abnormal Renal
insufficiency
Uric Acid 15.0 mg/dl
(high)
3.5 8.51 Abnormal Decrease
renal tissue
perfusion
Triglycerides 185 mg/dl (high) 0 150 Abnormal Increase
cholesterollevel in blood
Direct HDL 19 mg/dl (low) 40 60 Abnormal
Globulin 4.7 g/dl (high) 2.5 3.5 Abnormal
A/G Ratio 0.6 (low) 1.5 3.5 Abnormal
Potassium 3.43 mmol/L
(low)
3.5 5.1 Abnormal Decrease
pumping of
the heart
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ElectrolytesTEST RESULT REFERENCE
VALUE
INTERPRETATION ANALYSIS
June 22, 2013
Ionized
Calcium
1.08 1.101.40 mmol/L Abnormal Decrease
contractility
of heart
muscle
TEST RESULT UNIT REFERENCE
VALUE
INTERPRETATION ANALY
SIS
June 22,
2013
Routine
Chemistry
GlycosylatedHemoglobin
(HbA1c)
8.0 % 4.3
6.4 Abnormal Uncontrolled
Diabetes
Mellitus
(3
months)
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URINALYSIS
SECTION OF CLINICAL MICROSCOPY
Microscopic
MACROSCOPIC RESULT REFERENCEVALUE
INTERPRETATION
ANALYSIS
Color Dark Yellow Yellow Abnormal Concentrate
d
Transparency Hazy Clear Abnormal Insufficient
glomelular
filtration
Reaction 6.0 7.0 Abnormal
Albumin +1 Negative Abnormal Renal
damage
Urobilinogen 1.0 mg/dl Negative Abnormal Renal
damage
RESULT REFERENCE
VALUE
INTERPRETATION ANALYSIS
RBC 12 02 Abnormal
Bacteria Few None Abnormal
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DEPARTMENT OF RADIOLOGY
Roentgenological FindingsImpression:
Left ventricular enlargement
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RESPIRATORY THERAPY UNIT
Arterial Blood Gas (ABG) Determination
RESULT REFERENCE VALUE ANALYSIS
pH 7.52 7.357.45
pC02 25.4 3545mmHg
p02 136.7 80100 mmHg
HC03 20.4 22 -26 mEq/L
BE (-) 0.7 2
Sa02 99.0 95100%
tC02 21.2 2127 mmol/L
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V. Drug Study
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VI. Anatomy and Physiology
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VII. Pathophysiology
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VIII. Prioritized List of Nursing
Problems
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IX. Nursing Care Plan
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X. Discharge Plan
Captopril 25 mg/tab. Take tab. 2x a day.
Trimetazidine (vastarel MR) 35 mg/tab. Take 1 tab. 2 x a day
Humulin- N Inject 4 units, SC @ A.M.; & 4 units SC @ P.M.
Coumadin 2.5 mg/tab. Take 1 tablet every other day.
Lanoxin 0.25 mg/tab. Take 1 tablet every other day
Lactulose 120 ml/ bottle. Take 30 cc 1 x a day. Hold for BM > 3 x day.
Ketosterol 600 mg/tab. Take 1 tablet 2 x a day.
Ferrous Sulfate Take 1 tablet 2x a day
Calcium Gluconate 500 mg/tab. Take 1 tablet 1 x a day.Furosemide 40 mg/tab. Take 1 tablet 1 x a day
Medications
Gradually resume activities of daily living.Exercise/Activities
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Care of Attending PhysicianTreatment
Encourage proper diet with exercise.
Limit fluids to 1 L per day.
HealthTeaching
After 1 week
Laboratory Work Ups (OPD)
PT
Na & K
BUN
Crea
CBC with Plt
BUA
OPDFollow- Up
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Low Salt, Low FatDiet
Resume spiritualactivity.Sexuality/Spiritual:
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Adviser:Mr. Xavier Acuar RN, US-RN,MAN
Group 1:Arapol, Nikki M.
Corpuz Richard Erikson
Flores, Russelle Lowelle B.
Gutierrez, Ailyn O.
Ilao, Roldan O.
Moreno, Ma. Kristina M.
Sabatin, John Amadeus R.
Simpao, Michael Vincent S.
Thornton, Louzaldy Earl D.Villanueva, Mark Jason
Wi, Lynn Joy
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