ms 2 - hypothetical case hf

8/13/2019 MS 2 - Hypothetical Case HF

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Arellano University

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A Case Study on a Patient Diagnosed with Congestive Heart Failure

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By

DEGAMO, Dominique Excelsis J.


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I. INTRODUCTIONa) Definition of the Disease

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 HF, and it implies that patients with congestion

have HF. The Agency for Health Care Policy and Research (AHCPR) HF guidelines panel (1994)

defined HF 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 the body’s demands. The HF guideline panel used the term heart failure because

many patients with HF do not manifest pulmonary or systemic congestion. 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 life-longdiagnosis that is managed with lifestyle changes and medications to prevent acute congestive

episodes. CHF is usually an acute presentation of HF.

b) Cause or Risk Factors1. Cause

HF may result from a number of causes like cardiac compensatory mechanisms,

other dysfunctions and other disorders of the heart.Cardiac compensatory mechanisms (increases in heart rate, vasoconstriction, and

heart enlargement) occur to assist the struggling heart. These mechanisms are able to

compensate for the heart's inability to pump effectively and maintain sufficient blood flow to


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An elevation in afterload also may be caused by hypertension, valvular stenosis, or

hypertrophic cardiomyopathy. Myocardial dysfunction is most often caused by coronary artery

disease, cardiomyopathy, hypertension, or valvular disorders. Atherosclerosis of the coronaryarteries is the primary cause of HF.

Coronary artery disease is found in more than 60% of the patients with HF (Braunwald

et al., 2001). Ischemia causes myocardial dysfunction because of resulting hypoxia and acidosis

from the accumulation of lactic acid. Myocardial infarction causes focal heart muscle necrosis,

the death of heart muscle cells, and a loss of contractility; the extent of the infarctioncorrelates with the severity of HF. Revascularization of the coronary artery by a percutaneous

coronary intervention or by coronary artery bypass surgery may correct the underlying cause

so that HF is resolved.


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Several systemic conditions contribute to the development and severity of HF, including

increased metabolic rate (eg, fever, thyrotoxicosis), iron overload (eg, from hemochromatosis),

hypoxia, and anemia (serum hematocrit less than 25%). All of these conditions require anincrease in CO to satisfy the systemic oxygen demand. Hypoxia or anemia also may decrease

the supply of oxygen to the myocardium. Cardiac dysrhythmias may cause HF, or they may be

a result of HF; either way, the altered electrical stimulation impairs the myocardial contraction

and decreases the overall efficiency of myocardial function. Other factors, such as acidosis

(respiratory or metabolic), electrolyte abnormalities, and antiarrhythmic medications, can

worsen the myocardial dysfunction.

Other causes include: pulmonary embolism; chronic lung disease; hemorrhage andanemia; anesthesia and surgery; transfusions or infusions; increased body demands (fever,

infection, pregnancy, arteriovenous fistula); drug-induced; physical and emotional stress; and,

excessive sodium intake.

2. Risk FactorsGENETIC CONSIDERATIONS

HF is a complex disease combining the actions of several genes with environmental

factors. Many HF risk factors have genetic causes or are associated with genetic

predispositions. These include hypertrophic cardiomyopathy (HCM) and dilated

cardiomyopathy (DCM), coronary artery disease, myocardial infarction, and hypertension.

Genetic polymorphisms of the reninangiotensin-aldosterone system (RAAS) and sympathetic

system have also been associated with susceptibility to and/or mitigation of HF. Gene variants

in the alpha-2c adrenoceptor and the alpha-1 adrenoceptor have been associated with a

higher risk of HF among African Americans.

GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS

HF may occur at any age and in both genders as a result of congenital defects


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Left-sided heart failure (left ventricular failure) causes different manifestations than

right-sided heart failure (right ventricular failure). Chronic HF produces signs and symptoms of

failure of both ventricles. Although dysrhythmias (especially tachycardia’s, ventricular ectopicbeats, or atrioventricular [AV] and ventricular conduction defects) are common in HF, they

may also be a result of treatments used in HF (eg, side effect of digitalis).

LEFT-SIDED HEART FAILURE

Pulmonary congestion occurs when the left ventricle cannot pump the blood out of the


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Fluid that accumulated in the dependent extremities during the day begins to be

reabsorbed into the circulating blood volume when the person lies down. Because the

impaired left ventricle cannot eject the increased circulating blood volume, the pressure in thepulmonary circulation increases, causing further shifting of fluid into the alveoli. The fluid filled

alveoli cannot exchange oxygen and carbon dioxide. Without sufficient oxygen, the patient

experiences dyspnea and has difficulty getting an adequate amount of sleep.

The cough associated with left ventricular failure is initially dry and nonproductive.

Most often, patients complain of a dry hacking cough that may be mislabeled as asthma or

chronic obstructive pulmonary disease (COPD). The cough may become moist. Large quantities

of frothy sputum, which is sometimes pink (blood tinged), may be produced, usually indicatingsevere pulmonary congestion (pulmonary edema).

Adventitious breath sounds may be heard in various lobes of the lungs. Usually, bi-

basilar crackles that do not clear with coughing are detected in the early phase of left

ventricular failure. As the failure worsens and pulmonary congestion increases, crackles may

be auscultated throughout all lung fields. At this point, a decrease in oxygen saturation may

occur.

In addition to increased pulmonary pressures that cause decreased oxygenation, the

amount of blood ejected from the left ventricle may decrease, sometimes called forward

failure. The dominant feature in HF is inadequate tissue perfusion. The diminished CO has

widespread manifestations because not enough blood reaches all the tissues and organs (low

perfusion) to provide the necessary oxygen. The decrease in SV can also lead to stimulation of

the sympathetic nervous system, which further impedes perfusion to many organs.

Blood flow to the kidneys decreases, causing decreased perfusion and reduced urine

output (oliguria). Renal perfusion pressure falls, which results in the release of renin from the

kidney. Release of renin leads to aldosterone secretion. Aldosterone secretion causes sodiumand fluid retention, which further increases intravascular volume. However, when the patient

is sleeping, the cardiac workload is decreased, improving renal perfusion, which then leads to

frequent urination at night (nocturia)


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accommodate all the blood that normally returns to it from the venous circulation. The

increase in venous pressure leads to jugular vein distention (JVD).

The clinical manifestations that ensue include edema of the lower extremities(dependent edema), hepatomegaly (enlargement of the liver), distended jugular veins, ascites

(accumulation of fluid in the peritoneal cavity), weakness, anorexia and nausea, and

paradoxically, weight gain due to retention of fluid.

Edema usually affects the feet and ankles, worsening when the patient stands or

dangles the legs. The swelling decreases when the patient elevates the legs. The edema can

gradually progress up the legs and thighs and eventually into the external genitalia and lower

trunk. Edema in the abdomen, as evidenced by increased abdominal girth, may be the onlyedema present. Sacral edema is not uncommon for patients who are on bed rest, because the

sacral area is dependent. Pitting edema, in which indentations in the skin remain after even

slight compression with the fingertips (Fig. 30-2), is obvious only after retention of at least 4.5

kg (10 lb) of fluid (4.5 liters).

Hepatomegaly and tenderness in the right upper quadrant of the abdomen result from

venous engorgement of the liver. The increased pressure may interfere with the liver’s ability

to perform (secondary liver dysfunction). As hepatic dysfunction progresses, pressure within

the portal vessels may rise enough to force fluid into the abdominal cavity, a condition known

as ascites. This collection of fluid in the abdominal cavity may increase pressure on the

stomach and intestines and cause gastrointestinal distress. Hepatomegaly may also increase

pressure on the diaphragm, causing respiratory distress.

Anorexia (loss of appetite) and nausea or abdominal pain results from the venous

engorgement and venous stasis within the abdominal organs. The weakness that accompanies

right-sided HF results from reduced CO, impaired circulation, and inadequate removal of

catabolic waste products from the tissues.

d) Epidemiology or StatisticsU I S A S


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PHILIPPINES

In the Philippines, HF is the fastest-growing cardiac disorder and it affects 2% of the

population. Almost 1 million hospital admissions occur each year for acute decompensated HF,and the rehospitalization rates during the 6 months following discharge are as much as 50%. In

spite of recent advances in the treatment of HF, the 5-year estimated mortality rate is almost

50% (Department of Health, 2005).

e) Assessment HighlightsHISTORY

Patients with HF typically have a history of a precipitating factor such as myocardialinfarction, recent open heart surgery, dysrhythmias, or hypertension. Symptoms vary based on

the type and severity of failure. Ask patients if they have experienced any of the following:

anxiety, irritability, fatigue, weakness, lethargy, mild shortness of breath with exertion or at

rest, orthopnea that requires two or more pillows to sleep, nocturnal dyspnea, cough with

frothy sputum, nocturia, weight gain, anorexia, or nausea and vomiting. Take a complete

medication history, and determine if the patient has been on any dietary restrictions.

Determine if the patient regularly participates in a planned exercise program.The New York Heart Association has developed a commonly used classification system

that links the relationship between symptoms and the amount of effort required to provoke

the symptoms.


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veins may become engorged and distended. If the pulsations in the jugular veins are visible 4.5

cm or more above the sternal notch with the patient at a 45-degree angle, jugular venous

distension is present. The liver may also become engorged, and pressure on the abdomenincreases pressure in the jugular veins, causing a rise in the top of the blood column.

This positive finding for HF is known as hepatojugular reflux (HJR). The patient may also

have peripheral edema in the ankles and feet, in the sacral area, or throughout the body.

Ascites may occur as a result of passive liver congestion.

With auscultation, inspiratory crackles or expiratory wheezes (a result of pulmonary

edema in left-sided failure) are heard in the patient’s lungs. The patient’s vital signs may

demonstrate tachypnea or tachycardia, which occur in an attempt to compensate for thehypoxia and decreased CO. Gallop rhythms such as an S3 or an S4, while considered a normal

finding in children and young adults, are considered pathological in the presence of HF and

occur as a result of early rapid ventricular filling and increased resistance to ventricular filling

after atrial contraction, respectively. Murmurs may also be present if the origin of the failure is

a stenotic or incompetent valve.

PSYCHOSOCIAL

Note that experts have found that the physiological measures of HF (such as ejection

fraction) do not always predict how active, vigorous, or positive a patient feels about his or her

health; rather, a person’s view of health is based on many factors such as social support, level

of activity, and outlook on life.

f) Diagnostic Procedures


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ANGIOTENSIN-CONVERTING ENZYME INHIBITORS. ACE inhibitors (ACE-Is) have a pivotal role in

the management of HF due to systolic dysfunction. They have been found to relieve the signsand symptoms of HF and significantly decrease mortality and morbidity (when used to treat a

symptomatic patient) by inhibiting neurohormonal activation (CONSENSUS Trial Study Group,

1987; SOLVD Investigators, 1992). Available as oral and intravenous medications, ACE-Is

promote vasodilation and dieresis by decreasing afterload and preload. By doing so, they

decrease the workload of the heart.

Vasodilation reduces resistance to left ventricular ejection of blood, diminishing the

heart’s workload and improving ventricular emptying. In promoting diuresis, ACE -Is decreasethe secretion of aldosterone, a hormone that causes the kidneys to retain sodium. ACE-Is

stimulate the kidneys to excrete sodium and fluid (while retaining potassium), thereby

reducing left ventricular filling pressure and decreasing pulmonary congestion.

ACE-Is may be the first medication prescribed for patients in mild failure—patients with

fatigue or dyspnea on exertion but without signs of fluid overload and pulmonary congestion.

Results from studies (Clement et al., 2000; NETWORK Investigators, 1998) to identify the

specific dose to achieve this effect are equivocal, although one large study showed significant

reductions in death and hospitalization with higher doses (Packer et al., 1999). However, it is

recommended to start at a low dose and increase every 2 weeks until the optimal dose is

achieved and the patient is hemodynamically stable. The final maintenance dose depends on

the patient’s blood pressure, fluid status, renal status, and degree of cardiac failure.

Patients receiving ACE-I therapy are monitored for hypotension, hypovolemia,

hyponatremia, and alterations in renal function, especially if they are also receiving diuretics.

Because ACE-Is cause the kidneys to retain potassium, the patient who is also receiving

a diuretic may not need to take oral potassium supplements. However, patients receivingpotassiumsparing diuretics (which do not cause potassium loss with diuresis) must be carefully

monitored for hyperkalemia. ACE-Is may be discontinued if the potassium remains above 5.0

mEq/L or if the serum creatinine is 3 0 mg/dL and continues to increase Other side effects of


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systemic vascular resistance and left ventricular afterload. It has also been shown to help avoid

the development of nitrate tolerance. As with ARBs, this combination of medications is usually

used when patients are not able to tolerate ACE-Is.

BETA-BLOCKERS. When used with ACE-Is, beta-blockers, such as carvedilol (Coreg), metoprolol

(Lopressor, Toprol), or bisoprolol (Zebeta), have been found to reduce mortality and morbidity

in NYHA class II or III HF patients by reducing the cytotoxic effects from the constant stimulation

of the sympathetic nervous system (Beta-Blocker Evaluation of Survival Trial [BEST]

Investigators, 2001; CIBIS-II Investigators and Committees, 1999; MERIT, 1999; Packer et al.,

1996; Packer et al., 2001). These agents have also been recommended for patients withasymptomatic systolic dysfunction, such as after acute myocardial infarction or

revascularization to prevent the onset of symptoms of HF.

However, beta-blockers may also produce many side effects, including exacerbation of

HF. The side effects are most common in the initial few weeks of treatment. The most frequent

side effects are dizziness, hypotension, and bradycardia. Because of the side effects,

betablockers are initiated only after stabilizing the patient and ensuring a euvolemic (normal

volume) state. They are titrated slowly (every 2 weeks), with close monitoring at each increase

in dose. If the patient develops symptoms during the titration phase, treatment options include

increasing the diuretic, reducing the dose of ACE-I, or decreasing the dose of the beta-blocker.

An important nursing role during titration is educating the patient about the potential

worsening of symptoms during the early phase of treatment, and that improvement may take

several weeks. It is very important that nurses provide support to patients going through this

symptom-provoking phase of treatment. Because beta-blockade can cause bronchiole

constriction, a beta1-selective beta-blocker (ie, one that primarily blocks the beta-adrenergic

receptor sites in the heart), such as metoprolol (Lopressor, Toprol), is recommended forpatients with well-controlled, mild to moderate asthma. However, these patients need to be

monitored closely for increased asthma symptoms. Any type of beta-blocker is contraindicated

in patients with severe or uncontrolled asthma


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DIURETICS. Diuretics are medications used to increase the rate of urine production and the

removal of excess extracellular fluid from the body. Of the types of diuretics prescribed for

patients with edema from HF, three are most common: thiazide, loop, and potassium-sparingdiuretics. These medications are classified according to their site of action in the kidney and

their effects on renal electrolyte excretion and reabsorption. Thiazide diuretics, such as

metolazone (Mykrox, Zaroxolyn), inhibit sodium and chloride reabsorption mainly in the early

distal tubules. They also increase potassium and bicarbonate excretion. Loop diuretics, such as

furosemide (Lasix), inhibit sodium and chloride reabsorption mainly in the ascending loop of

Henle. Patients with signs and symptoms of fluid overload should be started on a diuretic, a

thiazide for those with mild symptoms or a loop diuretic for patients with more severesymptoms or with renal insufficiency (Brater, 1998). Both types of diuretics may be used for

those in severe HF and unresponsive to a single diuretic. These medications may not be

necessary if the patient responds to activity recommendations, avoidance of excessive fluid

intake (


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obtained once each year or more frequently if there have been c hanges in the patient’s

medications, renal function, or symptoms.

CALCIUM CHANNEL BLOCKERS. First-generation calcium channel blockers, such as verapamil

(Calan, Isoptin, Verelan), nifedipine (Adalat, Procardia), and diltiazem (Cardizem, Dilacor,

Tiazac), are contraindicated in patients with systolic dysfunction, although they may be used in

patients with diastolic dysfunction. Amlodipine (Norvasc) and felodipine (Plendil),

dihydropyridine calcium channel blockers, cause vasodilation, reducing systemic vascular

resistance. They may be used to improve symptoms especially in patients with nonischemic

cardiomyopathy, although they have no effect on mortality.

OTHER MEDICATIONS. Anticoagulants may be prescribed, especially if the patient has a history

of an embolic event or atrial fibrillation or mural thrombus is present. Other medications such

as antianginal medications may be given to treat the underlying cause of HF. Nonsteroidal anti-

inflammatory drugs (NSAIDs), such as ibuprophen (Aleve, Advil, Motrin) should be avoided

(Page & Henry, 2000). They can increase systemic vascular resistance and decrease renal

perfusion, especially in the elderly. For similar reasons, use of decongestants should be

avoided.


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recommendation reduces fluid retention and the symptoms of peripheral and pulmonary

congestion. The purpose of sodium restriction is to decrease the amount of circulating volume,

which would decrease the need for the heart to pump that volume. A balance needs to beachieved between the ability of the patient to alter the diet and the amount of medications

that are prescribed. Any change in diet needs to be done with consideration of good nutrition

as well as the patient’s likes, dislikes, and cultural food patterns.

SURGICAL MANAGEMENT

If the elevated preload is caused by valvular regurgitation, the patient may require

corrective surgery. Corrective surgery may also be warranted if the elevated afterload iscaused by a stenotic valve. Another measure that may be taken to reduce afterload is an intra-

aortic balloon pump (IABP). This is generally used as a bridge to surgery or in cardiogenic shock

after acute myocardial infarction. It involves a balloon catheter placed in the descending aorta

that inflates during diastole and deflates during systole. The balloon augments filling of the

coronary arteries during diastole and decreases afterload during systole. IABP is used with

caution because there are several possible complications, including dissection of the aortoiliac

arteries, ischemic changes in the legs, and migration of the balloon up or down the aorta.

Trans-Myocardial Revascularization (TMR) Patients with severe coronary artery disease

and angina, who are not amenable to balloon dilatation or coronary artery bypass grafting, may

meet the criteria for trans-myocardial revascularization (TMR).

This procedure, which can be done by itself or in combination with conventional

coronary bypass surgery, consists of the creation of channels through the heart muscle. As

these channels heal, they stimulate the creation of new small vessels or capillaries by a process

known as angiogenesis. While the resolution of the angina may take weeks to a few months,

surgical scars and the length of hospitalization may be minimized, especially in cases in which

no other procedures are performed.


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According to an abstract presented at the American Heart Association's 2005 Scientific

Sessions, LVADs reduced the risk of death in end-stage heart failure patients by 50 percent at

six and 12 months and extended the average life span from 3.1 months to more than 10months.

Pacemaker (a.k.a. Artificial Pacemaker) A small device that has wires which are implanted in

the heart tissue to send electrical impulses that help the heart beat in a regular rhythm. The

device is powered by a battery.

Implantable Cardiovascular Defibrillator (ICD) A device that has wires which are implanted into

the heart tissue and can deliver electrical shocks, detect the rhythm of the heart and

sometimes "pace" the heart's rhythms, as needed.

Implantable Medical Devices Pacemakers and Implantable Cardioverter Defibrillators (ICDs) are

used to treat arrhythmias — a condition of heart rhythm problems that occurs when the

electrical impulses that coordinate your heartbeats don't function properly, causing your heart

to beat too fast, too slow or irregularly. The Left Ventricular Assist Device (LVAD) helps maintain

the pumping ability of your heart.

OTHER MEASURES

Other measures the physician may use include supplemental oxygen, thrombolytic

therapy, percutaneous transluminal coronary angioplasty, directional coronary atherectomy,

placement of a coronary stent, or coronary artery bypass surgery to improve oxygen flow to

the myocardium. Finally, a cardiac transplant may be considered if other measures fail, if all

other organ systems are viable, if there is no history of other pulmonary diseases, and if thepatient does not smoke or use alcohol, is generally under 60 years of age, and is

psychologically stable.


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Monitoring pulse rate and blood pressure, as well as monitoring for posturalhypotension and making sure that the patient does not become hypotensive from

dehydration Examining skin turgor and mucous membranes for signs of dehydration Assessing symptoms of fluid overload (eg, orthopnea, paroxysmal nocturnal dyspnea,

and dyspnea on exertion) and evaluating changes

MAINTAINING ADEQUATE CARDIAC OUTPUT

Place patient at physical and emotional rest to reduce work of heart. Provide rest

in semi-recumbent position or in armchair in air-conditioned environment that reduces workof heart, increases heart reserve, reduces BP, decreases work of respiratory muscles and

oxygen utilization, improves efficiency of heart contraction; recumbency promotes diuresis by

improving renal perfusion. Provide bedside commode to reduce work of getting to bathroom

and for defecation. Provide for psychological rest since emotional stress produces

vasoconstriction, elevates arterial pressure, and speeds the heart. Promote physical comfort.

Avoid situations that tend to promote anxiety and agitation. Offer careful explanations and

answers to the patient's questions.

Evaluate frequently for progression of left-sided heart failure. Take frequent BP

readings. Observe for lowering of systolic pressure. Note narrowing of pulse pressure. Note

alternating strong and weak pulsations (pulsus alternans). Auscultate heart sounds frequently

and monitor cardiac rhythm. Note presence of S3 or S4 gallop (S3 gallop is a significant indicator

of heart failure). Monitor for premature ventricular beats.

Observe for signs and symptoms of reduced peripheral tissue perfusion: cool

temperature of skin, facial pallor, and poor capillary refill of nail beds. Monitor clinical

response of patient with respect to relief of symptoms (lessening dyspnea and orthopnea,decrease in crackles, relief of peripheral edema). Watch for sudden unexpected hypotension,

which can cause myocardial ischemia and decrease perfusion to vital organs.


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Offer small, frequent feedings to avoid excessive gastric filling and abdominal

distention with subsequent elevation of diaphragm that causes decrease in lung capacity.

Administer oxygen as directed.

PROMOTING ACTIVITY TOLERANCE

Although prolonged bed rest and even short periods of recumbency promote diuresis

by improving renal perfusion, they also promote decreased activity tolerance. Prolonged bed

rest, which may be selfimposed, should be avoided because of the deconditioning effects and

hazards, such as pressure ulcers (especially in edematous patients), phlebothrombosis, and

pulmonary embolism. An acute event that causes severe symptoms or that requireshospitalization indicates the need for initial bed rest. Otherwise, a total of 30 minutes of

physical activity three to five times each week should be encouraged (Georgiou et al., 2001).

The nurse and patient can collaborate to develop a schedule that promotes pacing and

prioritization of activities. The schedule should alternate activities with periods of rest and

avoid having two significant energy-consuming activities occur on the same day or in

immediate succession. Before undertaking physical activity, the patient should be given the

following safety guidelines:

Begin with a few minutes of warm-up activities. Avoid performing physical activities outside in extreme hot, cold, or humid weather. Ensure that you are able to talk during the physical activity; if you are unable to do so,

decrease the intensity of activity.

Wait 2 hours after eating a meal before performing the physical activity. Stop the activity if severe shortness of breath, pain, or dizziness develops. End with cool-down activities and a cool-down period.Because some patients may be severely debilitated, they may need to perform physical

activities only 3 to 5 minutes at a time, one to four times per day. The patient then should be


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activity to identify whether they are within the desired range. Heart rate should return to

baseline within 3 minutes. If the patient is at home, the degree of fatigue felt after the activity

can be used as assessment of the response. If the patient tolerates the activity, short-term andlong-term goals can be developed to gradually increase the intensity, duration, and frequency

of activity.

Referral to a cardiac rehabilitation program may be needed, especially for HF patients

with recent myocardial infarction, recent open-heart surgery, or increased anxiety. A

supervised program may also benefit those who need the structured environment, significant

educational support, regular encouragement, and interpersonal contact.

MANAGING FLUID VOLUME

Patients with severe HF may receive intravenous diuretic therapy, but patients with

less severe symptoms may receive oral diuretic medication (see Table 30-4 for a summary of

common diuretics). Oral diuretics should be administered early in the morning so that diuresis

does not interfere with the patient’s nighttime rest. Discussing the timing of medication

administration is especially important for patients, such as elderly people, who may have

urinary urgency or incontinence. A single dose of a diuretic may cause the patient to excrete a

large volume of fluid shortly after administration.

The nurse monitors the patient’s fluid status closely—auscultating the lungs,

monitoring daily body weights, and assisting the patient to adhere to a low-sodium diet by

reading food labels and avoiding high-sodium foods such as canned, processed, and

convenience foods (Chart 30-4). If the diet includes fluid restriction, the nurse can assist the

patient to plan the fluid intake throughout the day while respecting the patient’ s dietary

preferences. If the patient is receiving intravenous fluids, the amount of fluid needs to be

monitored closely, and the physician or pharmacist can be consulted about the possibility ofmaximizing the amount of medication in the same amount of intravenous fluid (eg, double-

concentrating to decrease the fluid volume administered).

The nurse positions the patient or teaches the patient how to assume a position that


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CONTROLLING ANXIETY

Because patients in HF have difficulty maintaining adequate oxygenation, they are

likely to be restless and anxious and feel overwhelmed by breathlessness. These symptomstend to intensify at night. Emotional stress stimulates the sympathetic nervous system, which

causes vasoconstriction, elevated arterial pressure, and increased heart rate. This sympathetic

response increases the amount of work that the heart has to do. By decreasing anxiety, the

patient’s cardiac work also is decreased. Oxygen may be administered during an acute event to

diminish the work of breathing and to increase the patient’s comfort.

When the patient exhibits anxiety, the nurse takes steps to promote physical comfort

and psychological support. In many cases, a family member’s presence provides reassurance.To help decrease the patient’s anxiety, the nurse should speak in a slow, calm, and confident

manner and maintain eye contact. When necessary, the nurse should also state specific, brief

directions for an activity.

After the patient is comfortable, the nurse can begin teaching ways to control anxiety

and to avoid anxiety-provoking situations. The nurse explains how to use relaxation techniques

and assists the patient to identify factors that contribute to anxiety. Lack of sleep may increase

anxiety, which may prevent adequate rest. Other contributing factors may include

misinformation, lack of information, or poor nutritional status. Promoting physical comfort,

providing accurate information, and teaching the patient to perform relaxation techniques and

to avoid anxiety triggering situations may relax the patient.

Cerebral hypoxia with superimposed carbon dioxide retention may be a problem in HF,

causing the patient to react to sedative-hypnotic medications with confusion and increased

anxiety. Hepatic congestion may slow the liver’s metabolism of medication, leading to toxicity.

Sedative-hypnotic medications must be administered with caution.

In cases of confusion and anxiety reactions that affect the patient’s safety, the use ofrestraints should be avoided. Restraints are likely to be resisted, and resistance inevitably

increases the cardiac workload. The patient who insists on getting out of bed at night can be

seated comfortably in an armchair As cerebral and systemic circulation improves the degree


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nurse may want to review hospital policies and standards that tend to promote powerlessness

and advocate for their elimination or change (eg, limited visiting hours, prohibition of food

from home, required wearing of hospital gowns).

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Profuse and repeated diuresis can lead to hypokalemia (ie, potassium depletion). Signs

are weak pulse, faint heart sounds, hypotension, muscle flabbiness, diminished deep tendon

reflexes, and generalized weakness. Hypokalemia poses new problems for the patient with HF

because it markedly weakens cardiac contractions. In patients receiving digoxin, hypokalemia

can lead to digitalis toxicity. Digitalis toxicity and hypokalemia increase the likelihood of

dangerous dysrhythmias (see Chart 30-3). Low levels of potassium may also indicate a low

level of magnesium, which can add to the risk for dysrhythmias. Hyperkalemia may also occur,

especially with the use of ACE-Is or ARBs and spironolactone.

To reduce the risk for hypokalemia, the nurse advises patients to increase their dietary

intake of potassium. Dried apricots, bananas, beets, figs, orange or tomato juice, peaches, and

prunes (dried plums), potatoes, raisins, spinach, squash, and watermelon are good dietary

sources of potassium. An oral potassium supplement (potassium chloride) may also be

prescribed for patients receiving diuretic medications. If the patient is at risk for hyperkalemia,the nurse advises the patient to avoid the above products, including salt substitutes.

Grapefruit (fresh and juice) is a good dietary source of potassium but has serious drug –

food interactions. Patients are advised to consult their physician or pharmacist before

including grapefruit in their diet.

Periodic assessment of the patient’s electrolyte levels will alert health team members

to hypokalemia, hypomagnesemia, and hyponatremia. Serum levels are assessed frequently

when the patient starts diuretic therapy and then usually every 3 to 12 months. It is importantto remember that serum potassium levels do not always indicate the total amount of

potassium within the body.

Prolonged diuretic therapy may also produce hyponatremia (deficiency of sodium in


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Although noncompliance is not well understood, interventions that may promote

adherence include teaching to ensure accurate understanding. A summary of teaching points

for the patient with HF is presented in Chart 30-5.The patient and family members are supported and encouraged to ask questions so

that information can be clarified and understanding enhanced. The nurse should be aware of

cultural factors and adapt the teaching plan accordingly.. They also need to be informed that

health care providers are there to assist them in reaching their health care goals. Patients and

family members need to make the decisions about the treatment plan, but they also need to

understand the possible outcomes of those decisions. The treatment plan then will be based

on what the patient wants, not just what the physician or other health care team members

think is needed. Ultimately, the nurse needs to convey that monitoring symptoms and daily

weights, restricting sodium intake, avoiding excess fluids, preventing infection with influenza

and pneumococcal immunizations, avoiding noxious agents (eg, alcohol, tobacco), and

participating in regular exercise all aid in preventing exacerbations of HF.


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II. OBJECTIVESi) General

After 1-3 hours of case presentation in the medical ward, the students will be able todevelop and apply specific knowledge, skills and attitude on the disease process of

Congestive Heart Failure generally on the body; anticipate and provide effective nursing

care; and, deliver specific interventions needed to treat the disease.

j) Specific1. Nurse-Centered Objectives

Upon completion of this case study, the student nurse should be able to:

a) Make a thorough assessment about the patient’s personal history, familybackground and lifestyle

b) Cite factors that contribute to the patient’s condition. c) Review the anatomy and physiology of the integumentary system.d) Explain the histopathology and pathogenesis of Congestive Heart Failure.e) Make a comprehensive nursing care plan and its intervention.f) Impart knowledge to the patient regarding on his conditiong) Evaluate patient’s response towards rendered care given by the student nurse.

2.

Patient-Centered Objectives

Upon completion of this case study, the Guest should be able to:

) bl h d l h h h d


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II. Health Historya) Client ProfileA case of Patient MR, 33 years old, female, married, Filipino citizen, a Roman Catholic,

housewife and presently living in Paknaan, Mandaue City was assessed last April 23, 2010 by

4:30am at the Evvesley Childs Sanitarium (Female Medical ward). Client was admitted last April

19, 2010 at around 12:00 a.m via Taxi accompanied by her eldest son with admitting

complaints of shortness of breath, dizziness and fatigue. Admitting V/S is as follows: T-37.9;

PR-92; RR-25; BP-200/160. She's under the care of Dr. Lagora. Patient was transferred to theFemale Medical Ward at 4:10 am of the same day. 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) Past Medical HistoryPatient disclosed that she has received the following immunizations: BCG 1 and 2, DPT

1, 2 and 3, OPV 1, 2 and 3, Anti Hepa-B 1, 2 and 3, TT1, 2, 3, 4 and 5. Patient is currently having

3 children. Upon her 2nd child, she was admitted to the hospital last year 2001 for 4 days in

Eversley Child's Sanitarium under unrecalled doctor and was diagnosed with Pre-eclampsia.

She was also unable to recall the specific medications she took that time. Patient MR was then

adviced by the doctor not to have another child but then was not followed since she had her

3rd child in the year 2007 and was confined for 3 consecutive days in Vicente Sotto Memorial

Medical Center under the Service of unrecalled Doctor. The patient was diagnosed with

Eclampsia with a BP of 180/120mmHg which was her usual BP measurement for her current

illness. She was only able to remember Nefidipine as her medication.


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sexually active. The ego in the genital stage is well-developed, and so uses secondary process

thinking, which allows symbolic gratification. Patient MR expressed symbolic gratification that

includes the formation of love relationships and families, or acceptance of responsibilities

associated with adulthood.

In Erik Erikson's psychosocial Stages of development, Patient MR belongs to Generativity

vs. Stagnation wherein it concerns of establishing and guiding the next generation. Socially-

valued work and disciplines are expressions of generativity as well as contributing to society

and helping future generations. Patient is already raising a family and verbalized her hopes on

working towards the betterment of society, a sense of generativity- a sense of productivity andaccomplishment.

According to kohlberg's Theory of Moral Development, Patient MR is in the

Postconventional Morality wherein people begin to account for the differing values, opinions,

and beliefs of other people. Rules of law are important for maintaining a society, but members

of the society should agree upon these standards. Patient considers values of honesty,

hardwork and nurturing as important values on being a mother and a wife to her family.

In Fowler's stages of faith development, patient belongs to the 4th stage of

"Individuative-Reflective" faith (usually mid-twenties to late thirties) a stage of angst and

struggle. The patient took personal responsibility for her beliefs and feelings. She expressed

her faith to God that despite her situation and that she still believes that God will heal her

from her illness.

e) Environmental HistoryPatient MR is currently residing in Paknaan Mandaue City Cebu. She together with her

family with three children are living in a rented house and lot nearby the street side which is


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III. Physical AssessmentGENERAL APPEARANCE:

Patient seen lying on bed, awake, alert, responsive, coherent, afebrile, with venoclysis of # 3 D5

Water, infusing well at right hand with the following vital signs: T- 38 C, BP – 180/90, PR – 98 bpm, RR –

28 cpm.

IV. Significant Laboratory Findings and Diagnostic Procedures

Diagnostic or

Laboratory

Procedure

Date

Ordered and

Date Results

were

released

Normal Range

Patient’s Results Analysis and Interpretation of ResultsMale Female

HEMATOLOGY

Hemoglobin 04-20-10 140-180

g/L

120-160

g/L

117 g/L A decrease implies anemia,

recent hemorrhage and fluidretention

Hematocrit 04-20-10 0.42-

0.52 g/L

0.37-

0.47 g/L

0.35 g/L A decrease implies anemia

and hemo dilution

RBC 04-20-10 4.7-6.1

/L

4.2-5.4

/L

4.4 /L A decrease implies anemia

and fluid overload of >24

hoursWBC 04-20-10 5-10 x /L 8.8 x /L Within normal range

Differential Count


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Appearance 04-20-10 Clear Cloudy Turbity implies kidney

infection

Specific

Gravity

04-20-10 Newborns: 1-1.02

Infants: 1.002-

1.006

Adults: 1.016-

1.022

1.030 An increase implies nephritic

syndrome

pH 04-20-10 4.6-6.5 5.0 Within normal range

Protein 04-20-10 None (++) Presence implies proteinuria,renal failure or myeloma

Glucose 04-20-10 Negative Negative Normal result

RBC 04-20-10 0 /hpf 0-2 /hpf 2-4 /hpf Within maximum normal

range.

WBC 04-20-10 0-2 /hpf 0-5 /hpf 10-12 /hpf An increase implies trauma or

tumors

Casts 04-20-10 Hyaline, coarse.

Fine granular.

RBC, WBC.

Waxy casts

Coarsely

granular.

1-2 /hpf

Normal result

Amorphous

Materials

04-20-10 Small amounts Few Normal result

Epithelial Cells 04-20-10 Small amounts Few Normal result

Bacteria 04-20-10 None Many Presence implies GUT

infection or contamination of


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VI. Anatomy and PhysiologyTHE HEART

THE HEART WALLS


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THE HEART CHAMBERS AND VALVES

THE CONDUCTION SYSTEM OF THE HEART


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THE CIRCULATORY SYSTEM


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Pathophysiology (Left Sided Heart Failure)

MYOCARDIAL DYSFUNCTION

Increased Left

Atrial Pressure

blood dams back

into the pulmonary

capillary

PULMONAR

Y EDEMA

Signs & Symptoms: Dyspnea

PND

Crackles

Wheezing

Dizziness

Weakness

S3 sound

LSCHF decreased CO

decreased systemic BP

decreased tissue

RAAS

stimulation Activation of

Baroreceptor


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Pathophysiology (Right Sided Heart Failure)

Vasoconstriction increased

afterload

increased BP

increased HR

ventricular

remodeling


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VIII. Nursing Care PlansACTIVE PROBLEM NURSING INTERVENTIONS EVALUATION

Impaired gas exchange related to alveolar

edema due to elevated ventricular

pressures

Subjective cue:

“Maglisod jud ko'g ginhawa”(nahihirapan

talaga akong huminga), as verbalized by

the patient

Objective cue:

>restlessness

>irritability

>diaphoresis

>bilateral crackles that do not clear with

cough

>pale skin color

Scientific Analysis:

Dyspnea, or shortness of breath, may

be precipitated by minimal to moderate

activity (dyspnea on exertion *DOE+);

dyspnea also can occur at rest. The

patient may report orthopnea, difficulty

in breathing when lying flat. Patients with

Independent:

1. R: Monitor vital signs and cardiac rhythm

I: for baseline data and monitoring

2. R: Auscultate breath sounds,

I: notes areas of decreased/adventitious

breath sounds

3. R:Note character and effectiveness of

cough mechanism

I: ability to clear airways of secretions

4. R: Elevate head of bed, provide adjuncts

and suction, as indicated

I: to maintain airway

5. R: Encourage frequent position changes

and deep-breathing/coughing exercises. Use

incentive spirometer, chest physiotherapy, as

indicated

I: promotes chest expansion and drainage of

secretions

6. R: Maintain adequate I/O

I: for mobilization of secretions

7. R: Encourage adequate rest and limit

activities to within client tolerance.

I: Promote calm/restful environment

helps limit oxygen need/consumption

Desired Outcome:

After 8 hours of nursing intervention,

the patient was able to demonstrate

improved ventilation and adequate

oxygenation of tissues by ABGs within

patient's normal limits and absence of

symptoms of respiratory distress

Actual Outcome:


the objectives were 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


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orthopnea usually prefer not to lie flat.

They may need pillows to prop

themselves up in bed, or they may sit in a

chair and even sleep sitting up. Some

patients have sudden attacks of

orthopnea at night, a condition known as

paroxysmal nocturnal dyspnea (PND).

8. R: Keep environment allergen/pollutant

free

I: to reduce irritant effect of dust and

chemicals on airway

9. R: Provide psychological support, active-

listen questions/concerns

I: to reduce anxiety

Dependent:

1. R: Administer medications, as indicated

I: to treat underlying conditions

Source: Source: Sparks, S and Taylor, C,Nursing Diagnosis Reference Manual 3

rd

edition; Springhouse Corporation,

Pennsylvannia

Decreased Cardiac Output related to

impaired contractility and increased

preload and afterload.

Subjective cue:

“Sige ra jud kog pangluspad” (lage nlang

akong maputla),as verbalized by the

patient

Independent:

1. R: Place patient at physical and emotional

rest

I: to reduce work of heart. 2. R: Provide rest in semi-recumbent position

or in armchair in air-conditioned environment

I: that reduces work of heart, increases heart

reserve, reduces BP, decreases work of

respiratory muscles and oxygen utilization,

improves efficiency of heart contraction;

Desired Outcome:


the patient was able to demonstrate

improved cardiac output withinnormal levels of preload and afterload.

Actual Outcome:


the objectives were partially met. The

patient was able to initiate actions to


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Objective cue:

>restlessness

>irritability

>diaphoresis

>pale skin color


In addition to increased pulmonary

pressures that cause decreased

oxygenation, the amount of blood ejected

from the left ventricle may decrease,

sometimes called forward failure. The

dominant feature in HF is inadequatetissue perfusion. The diminished CO has

widespread manifestations because not

enough blood reaches all the tissues and

organs (low perfusion) to provide the

necessary oxygen. The decrease in SV can

also lead to stimulation of the

sympathetic nervous system, which

further impedes perfusion to many

organs. (Wolkenstein, 2000).

recumbency promotes diuresis by improving

renal perfusion

3. R:Provide bedside commode

I: to reduce work of getting to bathroom and

for defecation.

4. R: Provide for psychological rest since

emotional stress produces vasoconstriction.

I:elevates arterial pressure, and speeds the

heart.

5. R: Promote physical comfort. Avoid

situations that tend to promote anxiety and

agitation. Offer careful explanations and

answers to the patient's questions. I: Decreases anxiety

6. R: Take frequent BP readings. Observe for

lowering of systolic pressure. Note narrowing

of pulse pressure. Note alternating strong and

weak pulsations (pulsus alternans). Auscultate

heart sounds frequently and monitor cardiac

rhythm. Note presence of S3 or S4 gallop (S3

gallop is a significant indicator of heart

failure). Monitor for premature ventricular

beats.

I: Evaluates for progression of left-sided heart

failure.

Source: Source: Sparks, S and Taylor, C,

increase cardiac output but symptoms

persisted.


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cannot eject the increased circulating

blood volume, the pressure in the

pulmonary circulation increases, causing

further shifting of fluid into the alveoli.

The fluid filled alveoli cannot exchange

oxygen and carbon dioxide. Without

sufficient oxygen, the patient experiences

dyspnea and has difficulty getting an

adequate amount of sleep. (Wolkenstein,

2000).

Dependent:

1. R: Administer medications (e.g.diuretics)

I: To treat underlying conditions

Collaborative:

1. R: Restrict sodium and fluid intake, as

indicated

I: for nutritional therapy


Nursing Diagnosis Reference Manual 3rd

edition; Springhouse Corporation,Pennsylvannia

Activity intolerance related to imbalance

between oxygen supply and demand

Cues and Objectives

Subjective:

“dali ra ko makutasan, dili ko kasugakod

ug dugay ug bug-at nga trabaho,” as

verbalized by the patient.

Independent:

1. I: Discuss with the patient the need for

activity.

R: Improves physical and psychosocial well-

being.

2. I: Identify activities the patient considers

desirable and meaningful.

R: To enhance their positive impact.

3. I: Encourage patient to help plan activity

progression, being sure to include activities

the patient considers essential.

R: Participation in planning helps ensure

patient compliance.

Desired Outcomes:

After 8 hours of nursing interventions,

* Patient states desire to increase

activity level.

* Patient states understanding of the

need to increase activity level

gradually.

* Blood pressure and pulse and

respiratory rates remain within

prescribed limits during activity.

* Patient states satisfaction with each

new level of activity attained.

* Patient demonstrates skill in


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Objective:

- generalized weakness

- limited range of motion

- short term performance of an activity


As heart failure becomes more severe,

the heart is unable to pump the amount

of blood required to meet all of the

body’s needs. To compensate, blood is

diverted away from less-crucial areas,

including the arms and legs, to supply the

heart and brain. As a result, people withheart failure often feel weak (especially in

their arms and legs), tired and have

difficulty performing ordinary activities

such as walking, climbing stairs or

carrying groceries

4. I: Instruct and help patient to alternative

periods of rest and activity.

R: To reduce the body’s organ demand and

prevent fatigue.

5. I: Identify and minimize factors that

decrease the patient’s exercise tolerance.

R: To help increase the activity level.

6. I: Monitor physiological responses to

increased activity.

R: To ensure return to normal a few minutes

after exercising.

7. I: Teach patient how to conserve energy

while performing activities of daily living.R: These measures reduce cellular

metabolism and oxygen demand.

8. I: Teach patient exercises for increasing

strength and endurance.

R: Improves breathing and gradually increase

activity level.

9. I: Support and encourage activity to

patient’s level of tolerance.

R: Helps patient develop level of tolerance.

10. I: Before discharge, formulate a plan with

the patient and caregivers that will enable the

patient either to continue functioning at

maximum activity intolerance or to gradually

increase the tolerance.

conserving energy while carrying out

daily activities to tolerance level.

* Patient explains illness and connects

symptoms of activity intolerance with

deficit in oxygen supply or use.

Actual Outcome:


the objectives were partially met. The:

*Patient stated understanding of the

need to perform daily activities.

*Patient demonstrated conservation

of energy while performing activities.


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R: Participation in planning encourages

patient satisfaction and compliance.


Nursing Diagnosis Reference Manual 3rd edition; Springhouse Corporation,

Pennsylvannia

Ineffective airway clearance related to

presence of tracheobronchial obstruction

Cues and Evidences:

Subjective:“maglisod ko ug ginhawa nya huot ako

dughan,” (nahihirapan talaga akong

huminga masikip ang aking dibdib) as

verbalized by the patient.

Objective:

- shortness of breath

- dyspnea

- use of accessory muscles when

breathing

- tachypnea with RR of 28


Mucus is produced at all times by the

Independent:

1. I: Assess respiratory status at least every

for hours or according to establishment

standards.

R: To detect early signs of compromise.2. I: Place patient in Fowler’s position and

support upper extremities.

R: To aid breathing and chest expansion, and

to ventilate basilar lung fields.

3. I: Help patient turn, cough, and deep

breath every 2 to 4 hours.

R: To help prevent pooling of secretions and

to maintain airway patency.

4. I: Suction as needed. Be alert for

progression of airway clearance.

R: To stimulate cough and airways.

5. I: Encourage fluids (atleast 3,000 mL daily).

R: To ensure adequate hydration and loosen

secretions, unless contraindicated.

Desired Outcome:


* Patient clears airway using

controlled coughing techniques.

* Patient expectorates sputum.* Patient drinks 3 to 4 liters of fluid

daily.

Patient’s arterial blood gas values are

within normal limits.

*Patient performs chest

physiotherapy, especially postural

drainage.

*Patient understands necessity of

adequate hydration

Actual Outcome:


the objectives were partially met. The:


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membranes lining the air passages. When

the membranes are irritated or inflamed,

excess mucus is produced and it will

retain in tracheobronchial tree. The

inflammation and increased in secretionsblock the airways making it difficult for

the person to maintain a patent airway.

In order to expel excessive secretions,

cough reflex will be stimulated. An

increased in RR will also be expected as a

compensatory mechanism of the body

due to obstructed airways (Wolkenstein,

2000).

6. I: Mobilize patient to full capabilities.

R: To facilitate chest expansion and

ventilation.

7. I: Perform postural drainage, percussion,

and vibration every 4 hours or as ordered.R: To enhance mobilization of of secretions

that interferes with oxygenation.

8. I: Avoid supine position for extended

periods. Encourage lateral, sitting, prone, and

upright positions as much as possible.

R: To enhance lung expansion and ventilation.

9. I: Provide tissues and paper bags for

hygienic sputum disposal.R: To prevent spreading infection.

10. I: Monitor and document sputum

characteristics every shift.

R: To gauge therapy’s effectiveness.

Source: Sparks, S and Taylor, C, Nursing

Diagnosis Reference Manual 3rd

edition;

Springhouse Corporation, Pennsylvannia

*Patient verbalized understanding on

coughing techniques

* Patient increased fluid volume to 3

to 4 liters per day.


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IX. Drug StudyName of

medication or

drugs

indications/reasons for

administrating the drugs

Side effects, adverse reactions

a nurse note for Nursing Interventions

Cefuroxime 750mg

IVTT It is effective for the

treatment of penicillinase-

producing Neisseria

gonorrhoea (PPNG).

Effectively treats bone and

joint infections, bronchitis,

meningitis, gonorrhea,

otitis media,

pharyngitis/tonsillitis,sinusitis, lower respiratory

tract infections, skin and

soft tissue infections,

urinary tract infections,

and is used for surgical

prophylaxis, reducing or

eliminating infection.

CNS: headache,

dizziness,lethargy,

paresthesias

GI: nausea,vomiting,

diarrhea,anorexia, abdominal

pain, flatulence,

GU: nephrotoxicity

Hematologic: bone marrow

depression

Hypersensitivity: ranging from

rash to fever to anaphylaxis,

serum sickness reaction

Determine history of hypersensitivity reactionsto cephalosporins, penicillins, and history of

allergies, particularly to drugs, before therapy is

initiated.

Inspect IM and IV injection sites frequently forsigns of phlebitis.

Report onset of loose stools or diarrhea.Although pseudomembranous colitis.

Monitor I&O rates and pattern: Especiallyimportant in severely ill patients receiving high

doses. Report any significant changes.


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Paracetamol 500mg

1 tab q 8h for fever

To relieve mild to moderate

pain due to things such as

headache, muscle and joint

pain, backache and period

pains. It is also used to

bring down a high

temperature. For this

reason, paracetamol can

be given to children after

vaccinations to prevent

post-immunisation pyrexia

(high temperature).

Paracetamol is often

included in cough, cold andflu remedies.

Side effects are rare with

paracetamol when it is taken

at the recommended doses.

Skin rashes, blood disorders

and acute inflammation of the

pancreas have occasionally

occurred in people taking the

drug on a regular basis for a

long time. One advantage of

paracetamol over aspirin and

NSAIDs is that it doesn't

irritate the stomach or causing

it to bleed, potential Side

effects of aspirin and NSAIDs.

Assessment & Drug Effects

Monitor for S&S of: hepatotoxicity, even withmoderate acetaminophen doses, especially in

individuals with poor nutrition.

Patient & Family Education

Do not take other medications (e.g., coldpreparations) containing acetaminophen

without medical advice; overdosing and chronic

use can cause liver damage and other toxic

effects.

Do not self -medicate children for pain morethan 5 d without consulting a physician.

Do not use for fever persisting longer than 3 d,fever over 39.5° C (103° F), or recurrent fever.

Do not give children more than 5 doses in 24 hunless prescribed by physician.


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photosensitivity, porphyria

cutanea tarde, necrotizing

angiitis (vasculitis).

Body as a Whole: Increased

perspiration; paresthesias;

activation of SLE, muscle

spasms, weakness;

thrombophlebitis, pain at IM

injection site.

Salbutamol 1 neb q

6

Actions:

Synthetic

sympathomimetic

amine and

moderately

selective beta2-

adrenergic agonist

with comparatively

long action. Acts

more prominently

on beta2 receptors

(particularly

smooth muscles of

bronchi, uterus,

and vascular supply

To relieve bronchospasm

associated with acute or

chronic asthma, bronchitis,

or other reversibleobstructive airway

diseases. Also used to

prevent exercise-induced

bronchospasm.

Body as a Whole:

Hypersensitivity reaction.

CNS: Tremor, anxiety,

nervousness, restlessness,convulsions, weakness,

headache, hallucinations.

CV: Palpitation, hypertension,

hypotension, bradycardia,

reflex tachycardia. Special

Senses: Blurred vision, dilated

pupils.

GI: Nausea, vomiting. Other:

Muscle cramps, hoarseness.

Assessment & Drug Effects

Monitor therapeutic effectiveness which isindicated by significant subjective improvementin pulmonary function within 60–90 min after

drug administration.

Monitor for: S&S of fine tremor in fingers,which may interfere with precision handwork;

CNS stimulation, particularly in children 2–6 y,

(hyperactivity, excitement, nervousness,

insomnia), tachycardia, GI symptoms. Report

promptly to physician.

Lab tests: Periodic ABGs, pulmonary functions,and pulse oximetry.

Consult physician about giving last albuteroldose several hours before bedtime, if drug-

induced insomnia is a problem.


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to skeletal muscles)

than on beta1

(heart) receptors.

Minimal or no

effect on alpha-adrenergic

receptors. Inhibits

histamine release

by mast cells.

Aldozide 1 tab BID

Mechanism of

Action: : competes

with aldosteronefor receptor sites

in the distal renal

tubules, increasing

sodium chloride

and water

excretion while

conserving

potassium and

hydrogen ions,may block the

effect of

aldosterone on

arteriolar smooth

muscle as well

Essential hypertension,

edema and ascites of CHF,

liver cirrhosis, nephritic

syndrome, idiopathic

edema

Gynecomastia, GI symptoms,

lethargy, headache and

thrombocytopenia,

leukopenia, agranulocytosis,

cutaneous eruptions, pruritus,mental confusion, paresthesia,

acute pancreatitis, jaundice,

orthostatic hypertension,

muscle spasm, weakness,

fever, ataxia

educate patient to avoid hazardous activity such asdriving until response to drug is known.

Take with meals or milk; avoid excessive ingestionof food high in potassium or use of salt substitutes

Diuretic effect may be delayed 2-3 days andmaximum hypertensive may be delayed 2-3weeks;

monitor I and O ratios and daily weight, BP, serum

electrolytes (K, Na) and renal function


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X. Discharge PlanMETHODS Outcome Identification Nursing Interventions

Medication Patients need to understand the purpose,

dosage, route, and possible side effects of allprescribed medications.

A - Assess patient and SO’s ability to understand regarding home

medication orders and instructions to be given

I - Remind and instruct the parent on home medication instructions

- Refer to drug instructions for each.

E - Evaluate the patient’s level of understanding on the instructions given

about the medications

Exercise and

Environment

Regularly scheduled, moderate exercise

performed for at least 30 minutes most days ofthe week promotes the utilization of

carbohydrates, assists with weight control,

enhances the action of insulin, and improves

cardiovascular fitness.

A - Assess patient’s understanding of exercise regimen.

I - Explain the importance of exercise:

Caloric expenditure for energy in exercise Carryover of enhanced metabolic rate and efficient food utilization

- Advise patient to assess blood glucose level before and after strenuous

exercise.

- Instruct patient to plan exercises on a regular basis each day.

- Encourage patient to eat a carbohydrate snack before exercising to

avoid hypoglycemia.

- Advice patient that prolonged strenuous exercise may require

increased food at bedtime to avoid nocturnal hypoglycemia.

Instruct patient to avoid exercise whenever blood glucose levelsexceed 250 mg/day and urine ketones are present. Patient should


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contact health care provider if levels remain elevated.

Encouraged so to maintain quiet environment Encouraged so to maintain patient surrounding clean Encouraged so to provide patient proper hygiene

E - Evaluate patient’s level of understanding on the information given and

degree of awareness on the importance of good sanitation and proper

exercise.

Treatment Teach patients the appropriate technique for

testing blood and urine and how to interpret

the results.

Stress the importance of close attention to even

minor skin injuries.

Because of the atherosclerotic changes that

occur, encourage patients to stop smoking.

A - Assess if the patient is continually sticking to V/S monitoring schedules

and treatment regimen.

I - Patients need to know when to notify the physician and increase

testing during times of illness.

In addition, teach patients to avoid crossing their legs when sitting andto begin a regular exercise program.

Instructed the patient to right information or advice by the physician Instructed the patient to follow right time & medicationE - Check the response to the interventions and actions performed

Health

Teaching and

Hygiene

If the patient continues to smoke, provide the

name of a smoking cessation program or a

support group. You follow the same protocol for

drinking to avoid other diseases.

A - Assess for the patient’s ability to do self -care

- Assess patient’s will or degree to decrease/ cease smoking.

I - Discuss concerns with parent to identify underlying issues


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Encourage patients to avoid alcohol - Teach how to calculate caloric intake.

- Each meal should consist of a balance of carbohydrates, proteins, and

fats.

Carbohydrates should be varied to include fruits, starches, andvegetables.

Protein selections that are lean will help reduce fat and cholesterolintake.

Fats should be used sparingly with


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ms 2 - hypothetical case hf

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