A Case Study in Congestive Heart Failure

Presented To

The Faculty of the College of Nursing

University of Perpetual Help System DALTA

Alabang- Zapote Road, Las Pinas City

In Partial Fulfillment of the Requirements

In NCM 104 – RLE

Submitted By:

Abad, Maria Angelica S.Abangan, Daryl Rey A.

Abarca, Weena Czarina Mae PAgnir, Marc Kharis G.Alindogan, Angelica P.Arcilla, Rinald Franz R.Argosino, Caszandra G.

Arip, Sharmina B.Babasa, Carmen G.Bareno, Abigail R.Barrazona, Tricia S.

Mrs. Gracila Ucag-Decena, RN, MANClinical Instructor

February 2012

1

TABLE OF CONTENTS

I. Introduction 3

II. Patient’s profile 4

III. Genogram 5

IV. Nursing History 6

V. Physical Examination 9

VI. Diagnostic/Laboratory Examination 14

VII. Clinical Findings 16

VIII. Anatomy and Physiology/Pathophysiology 17

IX. Problem Prioritization 20

X. Nursing Diagnosis 20

XI. Nursing Care Plan 21

XII. Drug Study 29

XIII. Discharge Planning 34

XIV. Reference/Bibliography 36

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I. INTRODUCTION

Patient R.C.S is admitted at the University of Perpetual Help Medical Center with a chief

complaint of Easy Fatigability. His admitting diagnosis is T/C CHF FC II, UTI HASCVD

Congestive heart failure (CHF) is a condition in which the heart's function as a pump is

inadequate to meet the body's needs. Signs and symptoms include fatigue, excess fluid in the

lungs and shortness of breath, constipation, dizziness, sore throat, neck pain and lower back pain,

along with headaches. Interventions on CHF would be such of lifestyle modifications, medicines

and heart transplant. On the other hand UTI or urinary tract infection is an infection caused by

pathogenic organisms such as bacteria, fungi, or parasites. In any of the structures that comprise

the urinary tract. Signs and symptoms include painful and burning urination, cloudy and strong-

smelling urine, pelvic pain for women and rectal pain on men. Treatment for thus include

antibiotic therapy.

We handled patient R.C.S during his second day at the hospital. We rendered nursing

interventions such as established rapport, assessed patient’s overall and current status,

regulatated and monitored intravenous fluid, due oral meds given, monitored intake and output,

we also rendered health teaching for the enhancement of his health condition, vital signs taken

and recorded, administered and monitored oxygen inhalation, performed physical assessment,

interviewed patient using Gordon’s Functional Health Pattern to provide baseline data.

Our purpose for accomplishing this case study is to provide further information to other

students as well as nurses that may also need this case study in the future. It will also improve the

quality of care rendered by nurses to patient. We also aim to prolong the lives of the patients.

Lastly, it sets us to learn, enhance and gain knowledge, as well as helps patients to understand

their current condition.

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II. PATIENT’S PROFILE

Patient’s Name:                     R.C.S

Address:                                         31 Manggahan Burgos Street Laspinas City

Sex:                                         Male

Civil Status:                            Widowed

Age:                                        79

Birthday:                                 April 7, 1932

Occupation:                            Retired

Nationality:                             Filipino

Religion:                                  Roman Catholic

Admission Date:                     January 30, 2012 Admission Time:                     8:30 pm

Institution:                              University of Perpetual Help Dalta Medical Center

Physician: Dr. Rodriguez, Andrei Rhonel

Admitting Diagnosis:              T/C CHF FC II, UTI HASCVD

Final Diagnosis:                     CHF FC II, UTI

Chief Complain:                      Easy Fatigability

4

III. GENOGRAM

5

GM GFGF

GG

GM

?? G

G GB Pt..

B

Legend: GM: Grandmother        GF: Grandfather               B: Boy                                  G: Girl                              

          : Hypertension                           : Diabetic                           : Deceased    ?? :   Unknown number

G

IV. NURSING HISTORY

Three days prior to admission, patient R.C.S. was noted to have occasional episodes of

easy fatigability with dyspnea. No other associated symptoms such as chest pain or fever noted.

No consultation were done and no medications were taken. Few hours prior to admission, patient

still with episodes of easy fatigability sought consult at Jonelta OPD, then was later transferred to

ER of University of Perpetual Help Dalta Medical Center and was advised for admissions. (+)

Angiogram (Feb 2011), (+) Inguinal Hernia (year unknown), (-) DM, (-) HPN, (-) Asthma.

Previous chronic smoker, occasional alcoholic beverage drinker.

Pt. has undergone Coronary angiography and left ventriculography at St. Luke’s Medical

Center last February 3, 2011 with an operative diagnosis of Atherosclerotic CAD mild dse

involving proximal and mid LAP, proximal to mid RCA. Patient RS tolerated the procedure well

and was hemodynamically stable all- throughout.

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V. GORDON’S FUNCTIONAL HEALTH ASSESSMENT

1. Health Perception

Patient R.C.S describes health as having enough energy. The reason of his health care visit is easy fatigability. He manages his condition through having adequate rest. He takes medications for his illness. Patient R.C.S. seeks health advice from a resident doctor and follows the doctor’s advice for the betterment of his health condition. Patient R.S. used to smoke and drink alcohol when he was teenager.

2. Nutritional Metabolic Patterns

Patient R.C.S. usually follows a soft diet meal such as soup and vegetables, and also observes a LFLS diet. He sometimes eats rice and meat. He also takes supplements like Centrum, a multivitamins that helps him to boost his immune system. He usually drinks water about 1 to 2 liters before, but currently limited to 500 ml per day. He sometimes experiences difficulty in swallowing when eating rice and meat while in the hospital. He has no allergy to any foods. He also has dental problems and wears dentures.

3. Elimination Pattern

Patient R.C.S. voids 5 to 6 times a day. He stated that sometimes he feels pain when urinating. The color is amber yellow. He has a bowel movement every other day. His feces are hard and color brown. He also experienced having a urinary catheter because of pain in the prostate and difficulty in urinating. He also used laxatives or suppositories before.

4. Activity Exercise Pattern

Patient R.C.S. has easy fatigability and minimal participation on the house hold chores. He used to do some light exercises. He verbalized that he often sits in front of the TV. He has a problem in ambulating due to pedal edema and pain. When he has no illness, he can do things on his own but with assistance most of the time.

5. Sleep Pattern

Patient R.C.S. usually sleeps at night around 8 to 9 o’clock and wake up at 8 o’clock in the morning. He usually takes 30 minutes to fall asleep and states that he feels like “nalulunod”. He also stated that most of the time, he is “naaalimpungatan”.

6. Cognitive – Perceptual Pattern

Patient R.C.S is able to write and read. He has hearing difficulties. He also has eye problem and uses glasses when reading. His last eyexam was a year ago. He feels chest pain sometimes.

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7. Role Relationship Pattern

Patient R.C.S. lives with his daughter and grandchildren. His wife passed away due to liver cancer. The one that supports him financially and provides his needs are his children. His family is important to him. He said that they haven’t had any conflict in their family.

8. Coping/ Stress Tolerance

Patient R.C.S. has major changes in his life the past two years, especially when he had undergone through a Coronary Angiography Left Ventriculography. When he has problems the one that he talked to is his children. He is always relaxed at home. He used to take alcohol or smoke tobacco whenever he has problem before.

9. Value Belief Pattern

Patient R.C.S. had accomplished many things in life and thanks God for this life. He wants his grandchildren to finish their studies. And he always prays to God to give him good health in order for him to live longer and so he can spend more time with his family. He stated that his religion is important.]

10. Self-Esteem, Self-Concept, Self-Perception Pattern

Patient R.C.S describes himself as family-oriented person. He loves his family the most. He also states that he has many friends. At present, he is concerned about how will he be able to cope up with his current health condition. He also states that he is already contented with the way his life is right now in terms of his children’s conditions.

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VI. PHYSICAL EXAMINATION

Date done: January 31, 2012Parts Techniques Used Normal Findings Actual Findings Analysis

General Survey

Body Built Inspection Proportionate Thin Due to Lack of appetite

Posture and Gait Inspection Relaxed and Erect Relaxed and Erect Normal

Hygiene and Grooming

Inspection Clean and neat Clean and neat Normal

Body Odor Inspection No odor No odor Normal

Signs of distress Interview; Inspection No distress No distress Normal

Affect or Mood Interview; Inspection Cooperative Cooperative Normal

Speech Interview Understandable Understandable Normal

Emotional state Observation Happy Happy Normal

Vital Signs

Temperature Inspection Axillary 35.5 degrees Celsius

Normal

Pulse Rate Palpation 60-100bpm: Radial 79 beats/min: Regular

Normal

Respiratory Rate Inspection 12-20cpm 29 cpm: regular Due to CHF

Blood Pressure Inspection 120/80mmHg 90/70 mmHg: Sitting

Due to the inability of the heart to pump sufficient blood around the bod,y a complication of CHF

Skin and Nails

Color Inspection Based on Race Brown Normal

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Symmetry of Color Inspection Uniform Uniform Normal

Edema Inspection; Palpation No edema Grade 2 pitting edema

Due to CHF

Skin Lesion Inspection Smooth Smooth; Flat Nevi Normal

Moisture Inspection Moist Dry Decrease skin elasticity

Skin Turgor Palpation upon pinching

Good Poor Excess Fluid Volume

Nail Curvature Inspection Convex 160 degrees

Convex 160 degrees

Normal

Texture Inspection Smooth Smooth Normal

Nail bed color Inspection Pink and Clear Pink and Clear Normal

Surrounding Tissue Inspection Intact Intact Normal

Capillary Refill Blanch Test Less than 4 seconds

6 seconds Decreased tissue perfusion

Head

Distribution Inspection Even Uneven Due to aging

Thickness Inspection Thick Thin Due to aging

Texture and Oiliness

Inspection Silky Silky Normal

Infestations Inspection No Infestations No infestation Normal

Body Hair Inspection Sparse Leg hair Sparse leg hair Normal

Size and Shape Inspection Normocephalic Normocephalic Normal

Contour Inspection; Palpation Smooth Smooth Normal

Facial Features Inspection Symmetrical Symmetrical Normal

Eyes

Eyebrows Inspection Even distribution Even distribution Normal

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Eye Lashes Inspection Even distribution Even distribution Normal

Pupils Inspection PERRLA PERRLA Normal

Conjunctiva Inspection Pinkish Pale Decreased tissue perfusion

Visual Acquity Inspection Able to read Able to read with glasses

Due to impaired visual acuity

Ears

Ear Canal Inspection Dry cerumen Normal

Pinna Inspection Uniform color with skin

Uniform color; Symmetrical

Normal

Hearing Acquity Inspection Intact Poor hearing Due to aging

Nose

Symmetry Inspection Symmetrical Symmetrical Normal

Nasal Cavity Inspection Septum in midline Septum in midline Normal

Sinus Tenderness Inspection Not tender Not tender Normal

Pharynx

Uvula Inspection In midline In midline Normal

Tonsils Inspection Pink and smooth Pink and smooth Normal

Gag Reflex Inspection Intact Intact Normal

Mouth

Lips Inspection; Palpation Soft and Symmetrical

Dry and symmetrical

Normal

Teeth Inspection Complete and shiny white

Dentures Due to aging

Tongue Inspection Midline Midline Normal

Palate Inspection Light pink and smooth

Light Pink and smooth

Normal

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Neck

Muscle Inspection Equal in size Equal in size Normal

Movement Inspection Coordinated Coordinated Normal

Range of Motion Inspection Full Full Normal

Lymph Nodes Palpation Not palpable Not palpable Normal

Carotid Pulse Palpation Symmetric Pulse Symmetric Pulse Normal

Jugular Veins Inspection Not visible Not visible Normal

Chest and Lungs

Breathing Pattern Inspection; Auscultation

Quiet; Regular; Effortless

Use of accessory muscle

Accumulation of fluid in the pleural space

Shape and Symmetry

Inspection Symmetrical Symmetrical Normal

Spinal Alignment Inspection; Palpation Aligned Aligned Normal

Skin Inspection Smooth Smooth Normal

Breath Sounds Auscultation Clear Crackles Accumulation of fluid in the pleural space

Breast size and shape

Inspection Rounded Rounded Normal

Areola Inspection Rounded Rounded Normal

Nipples Inspection Round; Symmetric Round; Symmetric Normal

Heart

Precordium Auscultation Pulsation Pulsation Normal

Heart Sounds Auscultation S1 louder at S2 at Base

S3 Due to CHF

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Abdomen

Skin Integrity Inspection Unblemished Unblemished Normal

Contour Inspection Rounded Rounded Normal

Bowel Sounds Auscultation Normoactive Normoactive Normal

Back Extremities

Muscle Size Inspection Equal Equal Normal

Muscle tone Inspection Firm Firm Normal

Muscle Strength Inspection Equal Unequal Due to aging

Bones Inspection Tenderness Tenderness Normal

Range of Motion Inspection Full Limited Due to weakness

VII. DIAGNOSTIC LABORATORY EXAMINATION

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University of Perpetual Help DALTA Medical Alabang-Zapote Road Pamplona III, Las Pinas

Laboratory/Diagnostic Department

Name: R.S Patient No. 9BAge:79 y/o A.P: Tabang, AntonioSex: Male

DATE and

TIME

EXAMINATION RESULTS NORMAL VALUE

UNIT INTERPRETATION

1/30/12

2:12 PM

CBCRBC 3.24 4.5-6 X10^12/L Anemia

Hematocrit 0.34 0.40-0.54 L Risk for fluid volume excess

Hemoglobin 114 120-160 g/L AnemiaWBC 7.1 4.5-10 X10^9/L Normal

Stabs/Bands - 0.00-0.05 - NormalSegmenters 0.66 0.50-0.70 - Normal

Lymphocytes 0.10 0.20-0.40 % Active infection or immunodeficiency

Basophils - 0.00-0.01 % NormalMonocytes .10 0.00-0.07 % Bacterial infectionEosinophils 0.03 0.00-0.05 % Normal

Platelet count 162 150-400 x10^9/L Normal2:49 PM

BUN 10.2 3.2-7.1 mmol/L Renal problemCreatinine 88 58-110 mmol/L Normal

Mg .94 0.7-1.0 mmol/L NormalK 3.6 3.5-5 mmol/|L NormalNa 132 137-145 mmol/L r/t Fluid Volume

excess4:01 PM

Color Yellow Yellow - NormalTransparency Turbid Clear - Risk for infection

pH 6 5-7 - NormalProtein +1 none - ProteinuriaGlucose - none - Normal

Spec. Gravity 1.025 1.010-1.025 - NormalRBC 0-3HPF None - Risk for infection

Pus cell 15-20HPF None - Risk for in fectionEpithelial Few Absence or

Few- Normal

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Bacteria M. Thread Few

Absence or few

- Normal

8:40 PMSGPT 29 21-72 U/L Normal

1/31/12

11:27 AM

FBS 5.58 4.10-5.9 mmol/L NormalCholesterol 3.39 0-5.2 mmol/L Normal

HD Lipoprotein 0.85 0-1.55 mmol/L NormalLD Lipoprotein 2.3 0-3.9 mmol/L Normal

Triglyceride .59 0-1.69 mmol/L NormalAlbumin 34 35-50 g/L Inflammation

2/4/12

1:43 PMK 4.2 3.5-5 mmol/L Normal

Examination: Chest X-ray Portable

Date: 1/30/2012

Interpretation: - Cardiomegaly, biventricular pattern

- Atheromatus Aorta

- Minimal Pleural effusion, Thickening, Left

Examination: QRS Morphology

Date: 1/30/2012

Interpretation: Inferior Myocardial Infarction and Anterior Myocardial Infarction, AGE undetermined

Examination: Chest Decubitus Portable

Date: 1/31/2012

Interpretation: (-) for pleural effusion

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VIII. CLINICAL FINDINGS

Clinical Findings: Congestive Heart Failure

Signs and Symptoms:

Dyspnea

Tachycardia

Pedal edema

Fatigue

Pleural effusion

Nasal Flaring

Jugular venous distention

Crackles

Chest pain

Use of accessory muscle

Hypotension

Patient experienced some the above signs and symptoms of Congestive Heart Failure

which are listed above. Use of accessory muscle, Crackles, Nasal flaring, Pedal edema, and

Hypotension is evident. Chest pain and fatigue are the subjective cues verbalized by the patient.

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IX. ANATOMY AND PHYSIOLOGY

The heart is a muscular structure with four chambers and four valves. The upper chambers,

which are filling chambers, are called the left and right atria. The lower chambers, which are

pumping chambers, are called the left and right ventricle.

Heart valves lie at the exit of each of the four heart chambers and maintain one-way blood flow

through the heart. The four heart valves make sure that blood always flows freely in a forward

direction and that there is no backward leakage.

The tricuspid valve regulates blood flow between the right atrium and right ventricle.

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The pulmonic valve controls blood flow from the right ventricle into the pulmonary arteries,

which carry blood to the lungs to pick up oxygen.

The mitral valve lies between the left atrium and the left ventricle. It prevents blood from leaking

back into the left atrium during left ventricular contraction.

The aortic valve lies between the left ventricle and the aorta (the largest artery in the body). It

opens the way for oxygen-rich blood to pass from the left ventricle into the aorta, where it is

delivered to the rest of the body.

Blood flow through the heart

The "left" side of the heart controls the flow of oxygen-rich blood from the lungs to the entire

body. The "right" side of the heart controls the flow of oxygen-poor blood from the veins in the

body to the lungs.

Blood flows from the right and left atria into the ventricles through the open tricuspid and mitral

valves, respectively; when the ventricles are full, the mitral and tricuspid valves close. This

prevents blood from flowing backward into the atria while the ventricles contract.

As the ventricles begin to contract, the pulmonic and aortic valves are forced open and blood is

pumped out of the ventricles through the open valves into the pulmonary artery toward the lungs,

and into the aorta, to the body.

When the ventricles finish contracting and begin to relax, the aortic and pulmonic valves close.

These valves prevent blood from flowing back into the ventricles. This cycle is repeated over and

over, causing blood to flow continuously to the heart, lungs and body.

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Pathophysiology

19

Non- Modifiable factors:

Age: 79 years old, Family history of Hypertension

Modifiable factors:

Sedentary lifestyle, smoker, alcohol drinker, high carbohydrate high fat diet

Accumulation of fatty streak in the intima of arterial wall

Decreased oxygenation of myocardium

X. PROBLEM PRIORITIZATION

1. Impaired Gas Exchange

2. Decreased Cardiac Output

3. Excess Fluid Volume

4. Risk for Injury

5. Risk for Non-compliance

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Ischemia in the myocardium

Increased Anti-diuretic hormone

Fluid Overload

Chronic tissue congestion

Reduced myocardial contractility

Fluid RetentionIncreased Osmotic Pressure

Increased Cardiac Workload

Decreased Renal Perfusion

Sodium Retention

Decreased Cardiac output

Enlargement of the heart

Proliferation of bacteria in the Urinary tract

Urinary Retention

Urinary Tract Infection

Congestive Heart Failure

Edema

Destruction of capillaries

Impaired peripheral circulation

Hypotension

Increased preload and afterload

XI. NURSING DIAGNOSIS

A. Actual Problem

1. Impaired gas exchange related to ventilation perfusion imbalance as manifested by with oxygen of 3-

4L/min via nasal cannula,(+) Crackles @ Left lungs, (+) Nasal Flaring, Tachypneic with the RR of

29cpm, (+) Retraction, Cold clammy skin, BP of 90/70, and capillary refill (6 sec.)

2. Decreased Cardiac Output r/t as manifested by, Pitting Edema on the right foot. (10 sec) Grade is

2+, Weakness,Cold clammy skin,Capillary refill (6 sec.), Dizziness, Lethargy, BP of

90/70mmhg

3. Excess fluid volume related to water retention secondary to CHF as manifested by pitting edema on

the right foot. (10 sec) Grade is 2+, (+)Crackles @ Left lung, RR of 29cpm, BP of 90/70mmHg

B. Potential Problem

1. Risk for injury r/t altered mobility as manifested by (+) weakness, Ambulatory w/ assistance, Blurred

Vision, BP: 90/70, w/ O2 administration via cannula

2. Risk for non-compliance secondary to knowledge deficit as manifested by (+) confusion on present

condition. And frequent asking of question

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XII. NURSING CARE PLANA. Actual

Assessment Diagnosis Planning Selected Intervention

Implemented Intervention

Rationale

Subjective: “Nahirapan akong huminga pag wala nitong oxygen.”

-Fatigue

Objective:

With oxygen of 3-4L/min via nasal cannula

(+) Crackles @ Left lung

(+) Nasal Flaring

Tachypneic with the RR of 29cpm

(+) Retraction Cold clammy

skin BP of 90/70 Capillary refill

(6 sec.)

Impaired gas exchange related to ventilation perfusion imbalance as manifested by with oxygen of 3-4L/min via nasal cannula,(+) Crackles @ Left lungs, (+) Nasal Flaring, Tachypneic with the RR of 29cpm, (+) Retraction, Cold clammy skin, BP of 90/70, and capillary refill (6 sec.)

After 6 hours of Nursing interventions the patient will be able to:

Participate in the treatment regimen such as breathing exercises.

Demonstrate improved ventilation without the presence of nasal flaring and retraction.

Respiratory rate will decrease to normal range (12-20 cpm)

Establish rapport

Assess vital signs

Monitor and regulate IV fluid

Monitor I/O

Observe skin color & nailbeds.

Auscultate breath sounds

Elevate head and the feet

Established rapport

Monitored and recorded vital signs

Monitored and regulated IV fluids

Monitored I/O

Observed skin color & nailbeds.

Auscultated breath sounds

Elevated head and the feet

Encouraged frequent

To gain trusting relationship with the patient.

Predicator of fluid balance that should be client’s usual range in healthy status

To ensure accurate fluid status and to avoid further complications that may result to fluid overload

To ensure accurate fluid status

To identify of there is a presence of vasoconstriction

To determine ascertain status and to note progress

To provide airway and venous return

To promote lung

Encourage frequent position changes and deep breathing exercises

Provided oxygen at lowest concentration as indicated

Encourage the patient to maintain adequate I/O

Promote adequate rest periods

Encourage the patient to do deep breathing exercises

Keep dry back and loosen clothing

Assist with self-care needs and ambulation

position changes and deep breathing exercises

Monitored the oxygen level of the patient

Encouraged the patient to maintain adequate I/O

Promoted adequate rest periods

Encouraged the patient to do deep breathing exercises

(Notimplemented)

(Not implemented)

expansion

To provide sufficient ventilation

To avoid further complications that may result to fluid overload

To prevent fatigue to decrease demand in oxygen

To maximize effort in breathing

To promote comfort and adequate ventilation

To provide safeness

Assessment Diagnosis Planning Selected Intervention

Implemented Intervention

Rationale

Subjective:“medyo nanghihina ako” as verbalized by the client

Objective: Pitting Edema

on the right foot. (10 sec) Grade is 2+

Weakness Cold clammy

skin Capillary refill

(6 sec.) Dizziness Lethargy BP of

90/70mmhg

Decreased Cardiac Output r/t altered preload and afterload as manifested by, Pitting Edema on the right foot. (10 sec) Grade is 2+, Weakness,Cold clammy skin,Capillary refill (6 sec.), Dizziness, Lethargy, BP of 90/70mmhg

At the end of 6 hours nursing intervention the client will manifest a BP within normal range (120/80 mmhg)

establish rapport

assessment of client’s overall condition

provide comfort measures

provide safety measures

VS taking

provide health teaching about the ff.:

> medications > adequate rest > diet

established rapport

rendered morning care

assessed client’s health status

VS taken and recorded

provided comfort measures such as:

> positioning client in a trendelenburg

reinforced safety and security measures

e.g. raised side rails up.

for client’s cooperation

for client’s comfort and hygiene

to determine changes on client’s condition

for baseline data

for clients comfort and to increase blood flow

for client’s assistance

to prevent injury

Assessment Diagnosis Planning Selected Intervention Implemented Rationale

Intervention

Objective:

Pitting Edema on the right foot. (10 sec) Grade is 2+

(+)Crackles @ Left lung

RR of 29cpm

BP of 90/70mmHg

Excess fluid volume related to water retention secondary to CHF as manifested by pitting edema on the right foot. (10 sec) Grade is 2+, (+)Crackles @ Left lung, RR of 29cpm, BP of 90/70mmHg

After 6 hours of Nursing interventions the patient will be able to:

Demonstrate adequate fluid balance AEB absence of crackles and decreasing edema

Verbalize understanding of fluid restrictions

Establish rapport

Assess vital signs

Monitor and regulate IV fluid

Monitor I/O

Auscultate breath sounds

Elevate head (patient is dyspneic) elevate affected foot with one pillow.

Weigh the patient regularly

Measure abdominal girth

Established rapport

Monitored and recorded vital signs

Monitored and regulated IV fluids

Monitored I/O

Auscultated breath sounds

Elevated head and foot

(Not implemented)

(Not

To gain trusting relationship with the patient.

Predicator of fluid balance that should be client’s usual range in healthy status

To ensure accurate fluid status and to avoid further complications that may result to fluid overload

To ensure accurate fluid status

To determine ascertain status and to note progress

To provide airway and to help the fluids move out to the extremities

Body weight is a sensitive indicator of fluid balance.

To know if fluid retention is present

implemented)

Assessment Diagnosis Planning Selected Intervention

Implemented Intervention Rationale

Subjective:“mabilis lang ako mapagod saka hirap na gumalaw parang matutumba” as verbalized by the client.

Objective: (+) weakness Ambulatory w/

assistance Blurred Vision BP: 90/70 w/ O2

administration via cannula

Risk for injury r/t altered mobility as manifested by (+) weakness, Ambulatory w/ assistance, Blurred Vision, BP: 90/70, w/ O2 administration via cannula

After 6 hours of nursing intervention the client will be able to be free from any injury such as fall.

Establish rapport

Monitor and regulate IVF

Monitor and record vital signs.

Identify contributing factors

Provide comfort

measures.

Maintain quiet and calm environment

Monitor environment for unsafe conditions.

Reinforce LSLF diet

Encourage to have adequate periods of rest.

Discuss w/

Established rapport

Monitored and regulated IVF

Monitored and recorded vital signs.

Identified contributing factors

Provide comfort measures

Maintained quiet and calm environment.

Monitored environment for unsafe conditions.

Reinforced LSLF diet

Encouraged to have adequate periods of rest.

to gain trust and confidence of the patient.

for good hydration status

Provides a baseline data.

to know different factors that may affect the client’s situation.

to self enhancement

to provide rest

to prevent factors that may harm the client.

to avoid any complications

To prevent fatigue.

Promotes early detection

family the importance of early detection and reporting of changes in condition or any unusual sign and symptoms

Discuss importance of self-monitoring of condition or emotions (fatigue, anger, irritability)

Instruct patient to call for assistance as needed.

Instruct to always have companion

(Not Implemented)

(Not Implemented)

Instructed patient to call for assistance as needed.

Instructed to always have companion.

of developing complications.

for the client to be aware that it can contribute to occurrence of injury

to ensure safety

to ensure safety

Assessment Diagnosis Planning Selected Intervention Implemented Intervention Rationale

Subjective: Risk for non- At the end of Establish rapport Established rapport. To gain patient’s trust.

“Hindi ko alam kung ano itong sakit ko sa puso, at kung bakit.” as verbalized by the patient.

Objective:

(+) confusion on present condition.

frequent asking of question.

compliance secondary to knowledge deficit as manifested by (+) confusion on present condition. And frequent asking of question.

45 minutes of health teaching the patient will be able to:

understand disease process, treatment and medication schedule.

remember the health teaching conducted with the guidance of his SO.

Render morning care and comfort measures S/A changing of linens and gown.

VS taking and monitoring.

Assess knowledge of the patient regarding his present status.

Conduct health teaching regarding safety precautions.

Conduct health teaching regarding definition of disease, signs and symptoms.

Discuss to the client together with his SO the drugs and its drug action.

Emphasize strict compliance with prescribed diet.

Emphasize to decrease fluid intake.

Rendered morning care and comfort measures S/A changing of linens and gown.

VS taken and monitored.

Assessed knowledge of the patient regarding his present status.

Conducted health teaching regarding safety precautions.

Conducted health teaching regarding definition of disease, signs and symptom.

Discussed to the client together with his SO the drugs and its drug action.

Emphasized strict compliance with prescribed diet.

Emphasized to decrease fluid intake.

To provide comfort.

To establish baseline data.

To know what to teach and explain to the client.

To prevent injury.

Used layman’s term in health teaching to prevent confusion.

To know what are the expected side effects of the drugs and to take extra precaution.

This will help to improve client’s condition.

Since the client has CHF.

XIII. DRUG STUDYGeneric Name Brand Name Mechanism of

ActionContraindications Dosage Effects and

Adverse EffectNursing

Responsibilities

Furosemide Diumide, Diuspec, Frusema, Furide, Pharmix, and Pisamor

Furosemide is a potent diuretic (water pill) that is used to eliminate water and salt from the body.

patients with anuria or who are hypersensitive to the drug.

The recommended adult daily dose of furosemide ranges from 20 mg to 200 mg. Once the effective single dose has been determined, it may be taken 1 to 3 times a day.

Common side effects of furosemide include low blood pressure, dehydration and electrolyte depletion (for example, sodium, potassium)

Increased blood sugar and uric acid levels also may occur.

Observe patients receiving parenteral drug carefully; closely monitor blood pressure and vital signs. Sudden death from cardiac event has been reported

ASA(Acetylsalicylic acid)

Aspirin, Arthritis Foundation Safety Coated Aspirin, Bayer Aspirin, Bayer Children's Aspirin, Ecotrin

Aspirin is a nonsteroidal antiinflammatory drug (NSAID) effective in treating fever, pain, and inflammation in the body. It also prevents blood clots (i.e., is antithrombotic).

People with kidney disease, hyperuricemia, or gout should not take aspirin because it inhibits the kidneys' ability to excrete uric acid, and thus may exacerbate these conditions

Adults: 325 to 500 mg P.O.q3 hrs, or 325 to 650 mg P.O. q4 hrs, or 650 to 1000 mg P.O q 6 hrs, to maximum dosage of 4,000 mg/day.

The most common side effects of aspirin involve the gastrointestinal system and ringing in the ears.

Tell patient to report ototoxicity symptoms, unusual bleeding and bruising

Tell patient not to take other over-the-counter preparations containing aspirin

Captopril Capoten Captopril is an oral drug and a member of a class of drugs

ACE inhibitors, including captopril, can be harmful to

Acute Hypertension

A dry, persistent cough has been reported commonly

Do not use salt substitutes containing

called angiotensin converting enzyme (ACE) inhibitors. ACE inhibitors are used for treating high blood pressure, heart failure, and for preventing kidney failure due to high blood pressure and diabetes.

the fetus and should not be taken by pregnant women.

12.5-25 mg PO; may repeat PRN

Hypertension

25-150 mg PO BID/TID

CHF

6.25-12.5 mg PO TID in conjunction with cardiac glycoside and diuretic therapy

Diabetic Nephropathy

25 mg PO TID

with the use of captopril and other ACE inhibitors.

Other side effects include abdominal pain, constipation, diarrhea, rash, dizziness, fatigue, headache, loss of taste, loss of appetite, nausea, vomiting, fainting and numbness or tingling in the hands or feet.

potassium.

Use two forms of birth control including hormonal and barrier methods.

Avoid NSAIDs; may be present in OTC preparations.

Ciprofloxacin Cipro, Cipro XR, Proquin XR

Ciprofloxacin Ciprofloxacin stops the multiplication of bacteria by inhibiting the reproduction and repair of their genetic material (DNA).

Ciprofloxacin is contraindicated in persons with a history of hypersensitivity to ciprofloxacin, any member of the quinolone class of antimicrobial agents, or any of the product components.

500-750mg PO every 12 hr

The most frequent side effects of ciprofloxacin include nausea, vomiting, diarrhea, abdominal pain, rash, headache, and restlessness.

Rare allergic reactions have been described, such as

If an antacid is needed, take it at least 2 hours before or after dose

Drink plenty of fluids while your taking this drug

hives and anaphylaxis (shock).

Omeprazole omeprazole/sodium bicarbonate, Prilosec, Zegerid

Omeprazole is in a class of drugs called proton pump inhibitors (PPI) that block the production of acid by the stomach.

Are contraindicated in patients with known hypersensitivity to any component of the formulation.

20 mg to 40 mg once daily. Tablets should be taken at least 1 hour before a meal.

The most common side effects are diarrhea, nausea, vomiting, headaches, rash and dizziness. Nervousness, abnormal heartbeat, muscle pain, weakness, leg cramps, and water retention occur infrequently.

assess patient routinely for epigastric or abdominal pain.

give medication on time and at right dose.

inform about possible side effect of the drug.

Trimetazidine Vastarel MR, Vastarel 20 mg, Vastarel LM, Vastarel LP, Preductal MR, Flavedon MR, Flavedon 20 mg, Cardaptan, Idaptan, Carvidon MR and Trizedon MR, vestar

Affects myocardial substrate utilization by inhibitrng fatty acid oxidation and shifting ATP production with less 02 consumption from FFA to glucose oxidation

Hypersensitivity, pregnancy, breast-feeding (nursing mothers should stop breast-feeding).

Ischaemic heart disease (angina pectoris, sequelae of infarction) Hypersensitivity.

Adults: 20mg thrice daily after meals.

Children: Not recommended.

Feeling Dazed And Extreme Fatigue

abscess, disseminated intravascular coagulation, dysphonia.

u se c au t i ous ly i n pa t i en t s w i th hea r t f a i l u r e o r hype r t ens ion and i n e l de r l y  patients.

Carvedilol Coreg, Carvil Dilatrend Coronis Eucardic Carloc

carvedilol, may greatly accentuate the effects of carvedilol and cause a steep decline in

Patients with severe hepatic impairment

Hypertension: 6.25 mg PO bid; maintain for 7–14 days, then increase to 12.5 mg PO bid

The most common side effects of carvedilol are dizziness, edema (fluid

Consult with physician about withdrawing drug if patient is to undergo surgery

blood pressure and/or heart rate.

if needed to control BP. Do not exceed 50 mg/day.CHF: Monitor patient very closely, individualize dose based on patient response. Initial dose, 3.125 mg PO bid for 2 wk, may then be increased to 6.25 mg PO bid. Maximum dose, 25 mg PO bid in patients < 85 kg or 50 mg PO bid in patients > 85 kg.

accumulation), decreased heart rate, diarrhea and postural hypotension (a rapid decrease in blood pressure when going from the seated to the standing position that causes lightheadedness and/or fainting).

Other common side effects of carvedilol are irregular heart rhythm, and abnormalities of vision.

(withdrawal is controversial).

Monitor for orthostatic hypotension and provide safety precautions.

Kalium durule Potassium chloride

replace potassium and maintain potassium level

use cautiously with patient with cardiac disease and renal impairment

The usual dietary intake of potassium by the average adult is 50 to 100 mEq per day

Nausea and vomiting, abdominal pain

Arrhythmias, heart block, hypotension cardiac arrest hyperkalemia respiratory paralysis

Make sure the powder are completely dissolve before giving

Simvastatin Zocor Like lovastatin, Hypersensitivity to The usual dose The most common Instruct patient to

simvastatin is a anticholesterol

HMG-CoA reductase inhibitors. Liver diseases. Pregnancy and nursing period.

ranges from 5 to 80 milligrams (mg) taken once daily. The recommended starting dose is 20 to 40 mg once a day

side effects of simvastatin are headache, nausea, vomiting, diarrhea, abdominal pain, muscle pain, and abnormal liver tests.

The most serious potential side effects are liver damage and muscle inflammation or breakdown.

report severe GI upset, changes in vision, unusual bleeding or bruising, dark urine or light-colored stools, fever, muscle pain, or soreness.

Always check for presence of rashes.

Motilium Domperidone Domperidone elevates serum prolactin concentrations

Known history of breast cancer, Prolactinoma (a pituitary tumor which releases prolactin)

Adults and adolescents (over 12 years and weighing 35 kg or more)

1 to 2 of the 10mg tablets three to four times per day with a maximum daily dose of 80 mg.

Possible Motilium side effects include dizziness, drowsiness, headache, insomnia, irritability or agitation, nervousness and twitching.

Before using this medication Conditions affecting use, especially: Sensitivity to domperidone

Obtaining medical attention if fainting, dizziness, irregular heartbeat or pulse

XIV. DISCHARGE PLANNING

Upon discharge, R.C.S with the support of significant others will adhere the following instruction:

Medications:

Mofloxacin 400mg/ tab OD

Captopril 25mg/tab ½ tab 2x a day

Aldactone 50mg/tab 1tab OD

Furosemide 40mg/tab 2x a day

ASA 80mg/tab 1tab OD after lunch

Clopidogrel 75mg/tab 1tab OD

Simvastatin 40mg 1tab OD before time

Digoxin 0.25mg 1tab OD

Trimetazidine 35mg/tab 1tab 2x a day

Exercise:

The best way to control congestive heart failure and to help prolong your life

is diet and exercise. You can perform inside the comfort of your home like:

Stretching

yoga

dangling of feet

moving of arm and shoulder at full range,

Deep breathing exercise

coughing exercise

Brisk walking

Treatment:

Take medication as ordered

Physical therapy

Oxygen therapy

Proper Diet

Health Teaching:

Limit your daily salt (sodium) intake to 2000 mg or less.

Fluids may need to be limited to 2000 ml (2L) per day.

Check your weight daily. If you gain 5 or more pounds (2kg) in 1to 3 days contact your

doctor.

Eat heart healthy, less processed foods that are low fat and high fiber.

If you’re overweight, try to lose 5 to 10% of your present weight.

Be active each day. Walking is great – aim for 30 minutes each day!

Limit alcohol consumption.

Avoid smoking.

Outpatient Appointment:

After 5 days on feb 10, 2012 (1-3pm) at Jonelta OPD with Serum K results.

Diet:

Follow a low fat and low salt diet

Eat nutritious food like fish, vegetables and fruits

Spiritual:

Continue reading the Holy Bible as he desires

Join Bible groups and fellowship

Attend Sunday Mass as he desires

 

XV. REFERENCE/BIBLIOGRAPHY

Books:

Doenges, Marilyn E., et. al. Nurse’s Pocket Guide. F. A. Davis Company. Philadelphia, 2010

Kozier, Barbara, et. al. Kozier & Erb’s Fundamentals in Nursing Volume Two. Pearson

Education South Asia PTE. LTD. Philippines, 2008.

Moyet, Lynda Juall C., et. al. Handbook of Nursing Diagnosis. C&E Publishing, Inc. Philippines,

2009.

Smeltzer, Suzanne C., et. al. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing.

Wolters Kluwer / Lippincott Williams & Wilkins. Philippines, 2010.