republic of the philippines tarlac state university college of nursing

Republic of the PhilippinesTarlac State University

College of NursingLucinda CampusA.Y.: 2009-20010

Case Study

of

CONGESTIVE HEARTFAILURE

Submitted by:Castanar, Aimelyn C.

Coquia, Benjamin III S.Cortez, Christian Jay B.

Dumlao, Jennifer M.Gabriel, Rutzki S.Justo, Jonalyn V.

Mamucod, Madel S.Marcos, Shierly Luz D.Natividad, Manuelito A.

Group B3

1

TABLE OF CONTENTS

I. Introduction…………………………………………………………………1II. Nursing Process……………………………………………………………..3

A. Assessment1. Personal Data……………………………………………………32. History of Past Illness…………………………………………...63. History of Present Illness………………………………………..64. Physical Assessment

i. 13 Areas of Assessment……………………………………..65. Diagnostic and Laboratory Procedures……………………...….176. Anatomy and Physiology……………………………………….227. Pathophysiology

i. Book Based…………………………………………………24ii. Client Based………………………………………………...25

B. Planning1. Nursing Care Plan………………………………………………26

C. Implementation1. Medical Management…………………………………………...342. Drug Study……………………………………………………...383. Diet……………………………………………………………...434. Activity or Exercise……………………………………………..455. Surgical Management…………………………………………...486. SOAPIE…………………………………………………………50

D. Evaluation1. Patient’s Daily Program in the Hospital………………………...572. Discharge Planning……………………………………………...58

III. Conclusion…………………………………………………………………..59IV. Recommendation……………………………………………………………59V. Bibliography………………………………………………………………...60

2

ACKNOWLEDGEMENT

We would like to extend our deepest gratitude to our Almighty God, for giving us the wisdom, strength, guidance and intellect that we need for the fulfillment of this case study.

We would also want to sincerely express our unending gratitude to Miss. Abilain Tuazon, RN for continuous guidance and support that she had rendered to us. Also to the clinical instructors who inspired us in doing this study. We couldn’t have done this far if we haven’t been equipped with the knowledge and the learning they shared.

To all members of the group for being cooperative and responsible to finish this case study. Thanks guys!

GROUP B3

3

I. INTRODUCTION

Congestive heart failure (CHF) also called heart failure is a complex syndrome in which the hearts pumping functions becomes insufficient to meet the needs of the vital organs and tissues of the body. CHF can result from any structural and functional cardiac disorder that impairs the ability of the heart to effectively contract and relax.

Although CHF is due to the failure of the heart to adequately pump out enough blood, there can be many different causes. Most often it occurs because the heart has been damaged, either by high blood pressure, previous heart attacks, or direct damage to the heart muscle. CHF can also occur when there is damage to the valves within the heart or with scarring the pericardium.

There are four forms of heart failure. First, when the blood backs up from the right side of the heart it is called right-sided heart failure. The symptoms of this typically start with swelling of the legs and ankles that gets worse when the person stands and improves when she lays down. If the blood backs up from the left side of the heart it is called left-sided heart failure. It can cause shortness of breath and coughing especially during exercise such as walking up stairs or when lying down flat in bed. A systolic heart failure can be cause by heart attacks; in this condition the heart pumping action is reduced or weakened. While in diastolic heart failure, the heart can contract normally but is stiff or less compliant when it is relaxing and filling with blood.

Congestive heart failure is graded by severity and symptoms.An accurate and early diagnosis is essential to target appropriate therapy and improve

patient outcome. There is no single diagnostic test for CHF and it is largely a clinical diagnosis base on history and physical examination. Clinical diagnosis of CHF is difficult due to non-specific symptoms and physical signs so laboratory test are also rendered such as CBC (complete blood count) and BNP (brain natriuretic peptide). Patients also undergo Chest X-ray, ECG and CT scan.

The treatments for heart failure have improved dramatically over the last five to ten years. Treatment is aimed at stabilizing the condition and treating the symptoms. In dealing with patients with CHF it is important to know what causes the heart failure to reverse that if possible. Most patients can be managed to the point where they have few symptoms but this often requires that they take five or more medications per day to help the heart recover.

Congestive heart failure is a major chronic disease for older adults, accounting for about 260,000 deaths a year. Based on American Heart Association, person aged 40 years and older has a one of five chances of developing heart failure. 80% of men and 70% of women under age of 65 are diagnosed with CHF and will die within five to ten years. (www.americanheart.org/presenter)

According to World Health Organization, more than 22 millions of people worldwide are suffering from CHF. In United States, there are about 5 millions of Americans who are having CHF and it is more common among African American than whites. Here in the Philippines, the prevalence extrapolations for Congestive Heart Failure are about 1.5 millions. (www.cureresearch.com/c/congestive_heart_failure/stats-country.htm).

As our group go on with our weekly duty at the Tarlac Provincial Hospital, the group handled patient with Congestive Heart Failure. So, as nursing students, we decided to study this kind of case. The reason of studying this case is to enhance and broaden our knowledge about the

4

http://www.cureresearch.com/c/congestive_heart_failure/stats-country.htm

disorder. And also, to share our knowledge to the patients who are suffering from this condition and in those who are at high risk to render primary prevention and simple interventions of the disorder.

It is of fundamental importance that case studies are to be performed in the nursing profession; it is where understanding of the disease’ description, pathophysiology and etiology that satisfactorily contribute to the formation of proper holistic management to the patient is being learned.

Thorough exploration and completion of case studies provides nurses a systematic way of looking events analyzing information regarding certain medical condition. It expands medical knowledge and expertise in the nurses’ part.

The primary significance of the study is to stimulate the mind and awareness of the patient as well as the family members to properly acquire enough knowledge and correct information in dealing and recognizing such kind of disease. To make also the health team to be more aware about the status of our health care system where they can analyze and apply towards themselves and others in fulfilling good health condition.

Through this study, the people will know and be aware about what Congestive Heart Failure means when it comes to our health by educating them the importance of this condition. Case study is specially designed to provide information in which both the patient and the student nurse benefits from it. With this, we, as student nurses will be able to provide appropriate nursing interventions that would help in restoring the wellness of the patient in accordance to his or her condition. This is primarily essential because it enhances the student’ skills, knowledge and attitude in the practice of the nursing process. It provides broader understanding about the condition chosen through research and actual observation as it is a training ground and practice in developing learned skills in the assessment and management of the disease.

This can serve as an instrument for the future reference of the next nursing students of the school. To share the book based and actual clinical management of the disease and may be used as a base line for more advance and depth study in accordance to the changing society.

Objectives:Comprehensive understanding about the condition will formulate a good perception and

information to both patients and nurse in dealing and exploring such kind of disease. These objectives will help to attain such benefits in knowledge and skills to identify patient with Congestive Heart Failure.

General Enhance understanding regarding Congestive Heart Failure and together factual data and current trends in regards to the condition

Specific Establish rapport with the client thus enhancing communication skills and to be able to gather pertinent information to the client and significant others. To identify the types and stages of Congestive Heart Failure. Know and apply corresponding intervention regarding the patient’s condition.

5

Evaluate effectiveness of the nursing intervention rendered.

Perform continuous physical assessment in order to gather pertinent information in the disease condition.

II. Nursing Process:

A. ASSESSMENT

1. Personal Dataa. Demographic Data:

Name : Mrs. AAge : 55 y/oSex : femaleCivil status : marriedOccupation : farmerReligious affiliation : Roman CatholicRole Position : HousewifeAddress : Maliwalo, Tarlac CityPlace of Birth : Maliwalo, Tarlac CityNationality : FilipinoUsual source of Medication : noneChief Complaint : chest pain, headacheDiagnosis : CHF IIIDate of Admission : January 28, 2009

b. Environmental status

According to Mrs. A, their house is a mix of wood and concrete which is consists of 3 bedrooms. Their house is located near their farm and irrigation at Maliwalo, Tarlac City wherein they have their television and radio. Their source of water was coming from a forced pump, not potable. The drainage according to her is open. They usually dump and burn their waste, because she said that there were no garbage collectors going to their place.

They also have domesticated animals such as dogs, and chickens, and one Carabao that they are using at their farm.

c. Lifestyle

Mrs. A is a farmer, and according to her it serves as her form of exercise whenever she goes to their farm. The client denies any vices such as smoking cigarette, alcohol drinking, and even drug abuse. She usually has a cup of coffee in the morning. When it comes to her type of

6

diet, she is fond of eating vegetables, fish and meat. The client also added that she likes eating fatty and salty foods, such as chicharon.

She entertains her self by watching TV whenever she has free time, and even going to the houses of her relatives just near their house to make a chat with them. The client usually sleeps at around 9pm and wakes up early in the morning at 5am.

d. Social Status

The patient spends her free time bonding with her husband, children and her grandchildren. She said that they have a intact and good family relationship. But whenever some issues or problem arises, they handle it by talking about it in a calm and respectful manner and it is just normal. She also has a good relationship among with her neighbors, that most of them are also their relatives.

e. Psychologic Status

Having a problem is just normal according to her. But for her, you should not mind your problem for it not to become a problem. She usually spoke her self up whenever they have a conflict among with her family members to express her feelings, but sometimes she also want to leave in their house to avoid the conflict to get worsen.

7

Aging Aging Aging Aging

Aging Aging Aging Aging Aging Aging Aging Aging

A&G A&G DM A&G A&G A&G A&G A&G A&G CHF A&G A&GLEGEND: FEMALE A&G - ALIVE & WELL DECEASED CHF-congestive heart failure MALE

DECEASED POINT TO Pt. FAMILY HISTORY OF HEALTH AND ILLNESS

8

85 80

75 60

62647880 7076

58 60

59

62

70

8080

60

65

4951

55

66

53

68

72

74

2. History of Past Illness

According to Mrs. A, she had her immunization when she was a child, but couldn’t remember what those vaccines were for. She also remembered a contagion of mumps and chickenpox, when she was in elementary. She revealed that she’s got an excessive fondness for sweets, that’s why when she reached 30 years old she was diagnosed with DM. Jokingly, she added that she can even compare their brgy. Health center to a wet market, and she being the “suki”, for the numerous time she frequently at that place due to her high blood pressure.

Then last January 28, 2009, she experienced difficulty of breathing, pain in her nape as well as body weakness, and she vomited twice. It was then she decided that her case was beyond the brgy. Health center control anymore, and so seeks treatment in ER department in Tarlac Provincial Hospital. The physician told her that she was hypertensive with a blood pressure of 160/110, and was admitted that same day. She was supposed to stay for days only, yet her blood pressure plummeted to 200/110 that caused her stroke and paralyzed her left arm.

Oh sabi sa present nya 2nd confinement nya na, kaya dapat nasa history of past nya kung anu ngyari nung 1st confinement nya….eheh., comment lang poh…

3. History of Present Illness

The patient stated that from her admission last January 28, 2009 until July 21, 2009, she didn’t felt any different thing that can alarm her. She also stated that she was able to follow or comprehend with the doctor’s advised.

Until 2 days prior to admission, Mrs. A felt difficulty of breathing and chest pain, but it doesn’t put her in high alarm. 1 day prior to admission she still felt difficulty of breathing. Then hours prior to admission while she was preparing to have her sleep, she felt chest pain together with difficulty of breathing and for this time its accompanied with headache, so her family brought her to TPH-E.R wherein the doctor decided to admit her in the hospital and that caused her 2nd confinement.

4. Physical Assessment

13 AREAS OF ASSESSMENT

SOCIAL STATUS

Mrs. A is a 55 years old wife of Mr. X. They were married for about 36 years. They have 10 children and she said that because they were old enough, they allow their elder children regarding decision making. They are a extended type of family wherein some of their grandchildren are living with them. According to her, she never experienced any intimate family violence and no known conflicts within their family. Although there are some misunderstandings, but as she said, they always try to solve it in a good manner. They live at and their house was located in a compound area and most of their neighbors are their relatives. Whenever she feels stress, she just takes rest and sleep or sometimes watches television.

9

According to her she usually set aside her problems and not taking it seriously. Her hobbies are planting vegetables in their farm with her husband, cleaning their house, washing clothes and sometimes chatting with their neighbors. She denies membership of any social organization but sometimes just attending barangay assembly if she had available time. They are Roman Catholic, and are often attends holy Mass with her family. She denied any drug abuse and was not fond of smoking nor drinking alcohol.

Standard and NormsSocial status is the determinant of patient’s response to the things he encounters and how

he treats or how he deals with other person. Social status of the patient is also a determinant of many factors that can affect the patient’s health. Getting social history is included if the patient is an alcoholic or drug and tobacco user. Alcohol can interfere with normal body metabolism and normal body function, drugs can affects the clients normal body function (Health Assessment by Zator, Estes 2006)

InterpretationBased on the assessment, the patient has a good relationship with her family and to her

neighbors which is an indication of good social stability. She does her responsibility as a good wife to her husband and responsible mother to her children as well as to her grandchildren. She was able to cope or handle any social conflicts. She has a good spiritual status and no known determinant factors that affects her body function.

MENTAL STATUS

Posture and Movements

Mrs. A is comfortably positioned flat on bed. She usually complains chest pain and right sided body weakness.( bat sabi sa past illness left arm tapos paralyze pa tapos sakin right sided weakness naman?) She was able to do her activities but with assistance. Her facial expressions are appropriate with her feelings and mood of conversation. The patient is sometimes stiff due to the weakness she experience because of her condition. She usually moves slowly and carefully with assistance. She wears loose and light clothing appropriate for his condition. She is not well groomed with uncombed hair and has clean but untrimmed nails and pale in appearance.

Level of consciousness

Mrs. A is aware about her condition, she is oriented where she is and was able to recognized people around her. She was able to respond with the questions given to her with an appropriate answer and eye to eye contact was established during the conversation.

Mood

Upon assessing Mrs. A she cooperates attentively with appropriate mood. She talks with us calmly with low voice and answers our questions appropriately.

10

Thought Process and Perception

Mrs. A has the ability to express her thoughts and feelings. She was able to answer our questions appropriately and sometimes she also asked questions related on the topics being discussed to her and shares to us her ideas, opinions and experiences in life. Cognitive Abilities

Mrs. A shown awareness to about his present condition, about the treatment and surgical procedure he undergone. He is aware regarding the people around him and the time and place where he is. He is also able to recall significant events in his life.

Standard and NormsThe patient should appear relaxed with the appropriate amount of concern for the

assessment. He should exhibit erect posture, a smooth gait symmetrical body movement. The patient should be clean and well groomed and should wear appropriate clothing for age, weather and socioeconomic status. Facial expression should be appropriate to the content of the conversation and should be symmetrical. The patient should b able to produce spontaneous, coherent speech. The patient should have an effortless flow with normal inflections, volume, pitch, articulation, rate and rhythm. The patient should be able to respond or answer questions appropriately. (Health Assessment by Mary Elle Zator Estes,2006)

InterpretationMrs. A has a normal mental status wherein she responds well and can answer our

questions appropriately. She is also aware about the time and the place where she was. Based on the data gathered she possessed good appearance, thought processes, and was conscious at the time of monitoring. She also interacts attentively upon assessment and interview with appropriate mood. But due to her condition, her movements were sometimes limited and thus she needs assistance to attain her needs.

EMOTIONAL STATUS

The patient always supports her emotional needs. She can freely express her emotions, whenever she feels sad, angry and has courage to face her problems and find time searching for possible solution. The patient has an optimistic view of life, which reflects in her attitude in the hospital. The patient looks positively that her condition will improve and she will be out of the hospital soon.

Standard and NormsEmotional wellness is the ability to manage stress and to express emotions appropriately.

It involves the ability to recognize, accept and express feelings, and to accept one’s limitations. (Fundamentals Of Nursing, Kozier, pg 173.) Normal coping pattern or emotions stability could include acceptance of the problem, adjustment to it, expressing of self-perception and self-control of emotions, probable temporary use of defense mechanism and support system (Fundamentals of Nursing by Kozier). Carrying out emotional feelings through words and facial expressions are normal signs of present physical condition (Nursing Fundamentals by Daniels)

11

InterpretationThe patient has the ability to convey her emotions and feelings to her family. She can

appreciate simple things. The patient is expressive in her emotions that can help in developing holistically with a strong emotional status, she can handle unexpected circumstances and was able to adapt to whatever problem she may have.

SENSORY PERCEPTION

Sense of SightDuring our interview to our patient, she complained of blurred vision and we have to

move closely to see our face. Other than that, her external eyes were symmetrical in shape and size, have no lesion and no bleeding found. Her sclera is whitish in color with some small superficial vessels; her whole conjunctiva appeared white with few small blood vessels. The patient can raise both eyelids asymmetrically. Her pupils are black and round.

Standard and NormsThe normal visual acuity is 20/20. There should be no presence of lesions or any

perforation in the eye of the patient. (Health Assessment by Mary Elle Zator Estes,2006)

Sense of SmellThe patient’s nose is on the midline, it is symmetrically in shape and the nostrils are

intact. She was able to distinguished different odor like alcohol, perfume or cologne and different scent of fruits provided like orange.

Standard and NormsPatient must be able to identify different smell; nose should be at the midline position,

free from lesions and intact nostrils. (Health Assessment by Mary Elle Zator Estes,2006)

Sense of HearingOur group performed a hearing test in order to check if the patient had a good sense of

hearing by whispering words about 3 inches away from the ear and asked her to repeat the words that were spoken to her to check if she really heard the words. The patient was able to answer questions correctly that means her hearing ability is good. No bleeding, wounds, or lesions are found on her external ear.

Standard and NormsPatient should hear whispered words or watch tick test and ear must free from lesions and

masses. (Health Assessment by Mary Elle Zator Estes,2006)

Sense of TasteTongue and oral cavities are symmetrical and no lesions or abnormalities were found.

The patient was able to determine taste of salty, sweet, sour, and bitter taste.

12

Standard and NormsPatient should be able to sense the different kind of tastes like sweet, bitter, sour, and

salty. (Health Assessment by Mary Elle Zator Estes,2006)

Pain SensationThe patient is able to response with the pain sensation when we pinched her skin. And

she was able to determine if the object is sharp or not and can able to determined if the object is smooth or rough. (kala ko ba paralyze un left o right arm nya? Nakakaramdam sya ng pain sa paralyze part ng body nya?...ehehen)

Standard and NormsIdentifies correct object, identifies correct number and identifies correct direction of body

part is move. (Nurse Handbook of Heath Assessment by J.R Weber,2004)

InterpretationRegarding the patient’s sense of perception, there is no problem found except with her

sense of sight because of her blurred vision. (eh pano un sa paralyze nya? Ammmh., un sinasabi ko kanina ay?) It only means that his visual acuity is not in normal. Other than that, she already possesses normal perception in other areas.

MOTOR STABILITY

Mrs. A during our duty at the hospital, we observed that her condition makes her bedridden and depends on her children’s assistance. She cannot ambulate by herself. She also complains discomfort because of her upper extremities’ numbness and right or left body weakness. She is not comfortable about her condition because of the medical procedures given to her such as the oxygen therapy that is connected to her nares and the IV fluids inserted to her. She moves slowly in changing her position when she sleeps and rest.

Standard and NormsWalking is initiated in one smooth, rhythmic fashion. The patient remains erect and

balanced during all stages of gait. The lower limbs are able to bear full body weight during standing and ambulation. The patient should be able to transfer easily to various positions. Gaits as well as other body movements should be smooth and effortless. All body parts should have control, purposeful movement. (Fundamentals of Nursing, Kozier; Physical Examination and Health Assessment, Estes)

InterpretationThe patient has impaired mobility due to the numbness and weakness on the left or right

side of her body extremities. She has difficulty moving and performing her activities of daily living wherein she is dependent to the one who is taking care of her. Being unable to ambulate and not able to perform the activities of daily living (ADL’s) alone shows that the client’s condition extremely affects her mobility which may further deviate the normal muscle tone and motor movements of the body if not prevented

13

BODY TEMPERATURE

Date Time Route Temperature Interpretation

07-27-096pm10pm

Axillary36.5˚C36.7˚C

NormalNormal

07-28-096pm10pm


NormalNormal

07-29-096pm10pm


NormalNormal

07-30-096pm10pm


NormalNormal

07-31-096pm10pm


NormalNormal

Standard and Norms

Route for Body Temp. Measurement Average Normal RangeOral 37.0˚C / 38.6˚F 36.0˚ - 38.0˚C / 96.8˚ – 100.4˚F

Rectal0.4˚C / 0.7˚F higher than oral 36.7˚ – 38.0˚C / 98.0˚ - 100˚F

Axillary0.6˚C / 1.0˚F lower than oral 35.4˚ - 37.4˚C / 95.8 – 99.4˚F

TympanicCalibrated to oral/rectal scale See oral / rectal

Reference:Estes, Mary Elen Zator. (2006) Health Assessment and Physical Examination (3rd Edition

RESPIRATORY STATUS

Date Time Respiratory Rate Interpretation

07-27-096pm10pm

3224

TachypneicTachypneic

14

07-28-096pm10pm

2228


07-29-096pm10pm

2028

NormalTachypneic

07-30-096pm10pm

2221


07-31-096pm10pm

1819

NormalNormal

Standard and NormsIn a resting adult, the normal respiratory rate is12- 20 bpm, normal respirations are

regular. The normal depth of inspiration is non-exaggerated and effortless. The healthy adults’ thorax rises and falls in unison in the respiratory cycle. The patient’s respiratory cycle can be heard by the unaided ear a few centimeters away from the patient’s nose and mouth. A healthy adult breathes comfortably in a supine position, prone or upright position and most patient inhale and exhale through the nose. No pulsation of masses, thoracic tenderness and crepitus should be present. (Fundamentals of Nursing 7th Edition by Kozier, Erb, Berman).

Analysis:

The patient’s respiratory status was tachypneic in a few days and when she was admitted. She was experienced difficulty breathing due insufficient oxygen supply. (sana madagdagan pa to’)

CIRCULATORY STATUS

DATE TIME BP PRJuly 27, 2009 6:00 pm 150/110 100

10:00pm 140/80 98July 28, 2009 6:00 pm 150/100 87

10:00pm 160/100 80July 29, 2009 6:00 pm 140/100 76

10:00pm 130/90 80

15

July 30. 2009 6:00pm10:00pm

110/90130/90

8983

July 31, 2009 6:00pm10:00pm

150/80140/80

8788

The patients capillary refill returns back to normal color within 2-3 seconds.

Standard and NormsNormal blood pressure varies with age. As a person ages, blood pressure generally

increases. The normal blood pressure of an adult is 120/80 mmHg. Normally baroreceptors (Receptors that are located in the walls of most of the great arteries that sense hypotension and initiate reflex vasoconstriction and tachycardia to bring the blood pressure back to normal) help a patient to maintain a normal blood pressure when changing from supine from a sitting or standing position. Processes increasing cardiac output, such as exercise, will normally increase blood pressure. Pulse pressure is normally 30 – 40 mmHg. Normal pulse rate also varies with age. The normal pulse rate of an adult is 60 – 100 BPM. The heart rate normally increases during periods of exertion. Normal pulse rhythm is regular with equal intervals between each beat. The pulse volume is normally the same with each pulse beat. A normal pulse volume can be felt with a moderate amount of pressure of the fingers and obliterated with greater pressure. Capillary refill is an indicator of peripheral circulation. Normal capillary refill may also vary with age, but the color should not return to normal within 2 -3 seconds. (Health Assessment by Mary Elle Zator Estes)

Analysis:Based on the standard and norms the patient is hypertensive. She has a normal pulse rate

capillary refill. Sana madagdagan…ehehe

NUTRITIONAL STATUS

The patient weighs 55 kg and 5’1” in height. The patient was on low fat low salt diet. She was given an IV fluid of D5LRS to maintain fluid and electrolytes balance in her body. According to the her, she ate nutritious food such as fruits and vegetables. During her younger years, she verbalize that that she is fond of eating sweet foods like chocolates. She eats three times a day and drink fluids 8-10 glasses of water.

BMI=weight in kg Height in m2

=51 kg

5’1” =51 kg

(1.5494)2

= 51 kg

2.4

16

= 21.25

Standard and NormsNormal human being usually eats 3 times per day and a fluid intake of 8 - 10 glasses of

water. Nutrients must be taken equally according to their standards. There should be no problem regarding food and drug allergies and anything associated with nutrition. Nutritional of patient is a good determinant of a possible heart condition. Nutrition can be a prevention and treatment for some diseases. Normal body mass index is 20 – 25, less than 20 is associated with heart problem, and in some people more than 27 indicates higher risk for developing heart problems. (Fundamentals of Nursing 7th Edition by Kozier, Erb, Berman)

BMI <16 malnourished16-19 underweight20-25 normal26-30 overweight31-40 moderately to severely obese>40 morbidly obese

Interpretation The patient is in normal weight. With regards to patient nutritional status it appears that

she is able to meet her nutritional needs. Low fat low salt diet can help the client to reduce the intake of fats in her body.

ELIMINATION STATUSDuring our duty in the Medicine Charity Ward in Tarlac Provincial Hospital, our patient

told us that she was able to urinate about five times a day, the amount of every urination is about 200 – 250 cc with a urine color of yellow to light yellow depending on the fluids and liquids being consumed. The patient denies of pain upon urination, blood in the urine and this was proven through our daily monitoring. She can defecate at least once a day and it was characterized as dark brown and sometimes light brown stool and no feeling of pain during defecation.

Standard and NormsElimination of the waste products of digestion from the body is essential to healthy

people who have had a bowel movement once a day for 75 years can view as a missing 1 day as a serious problem. Normal feces are made of about 75% of water and 25% solid materials. They are soft but formed. Feces were normally brown, chiefly due to the presence of stercobilin and urobilin, which are derived from bilirubin. An adult usually forms 7 – 10 liters of flatus in the large intestines every 24 hours. Urine elimination should be at least 30 – 50ml per hour when a normal person was urinated and the normal bowel movement is 1 – 2 times per day. (Fundamentals of Nursing 7 th Edition by Kozier, Erb, Berman and Nutrition 2005 by 2nd Edition by Alex B. Abalos)

Interpretation

17

With regards to the patient’s elimination status, it appears that her urine output is in normal ranges and has a normal bowel movement.

REPRODUCTIVE STATUS

Mrs__ has 10 children. She is happily married to her husband. Living and enjoying her life with her family. Any contraceptives used wala daw ba? Any operation regarding sa repro system nya wala din?

Standard and NormsSex has been defined as one of the basic physiologic need according to Maslow’s

Hierarchy of needs. It is therefore, sex is an essential part for the well being of a person. An average normal individual should have a nature reproductive status in order to meet or attain sexual satisfaction. A number of changes take place during the middle years. At 40, most adult can function as effectively as they did in their 20s. However, during ages 40-65 many physical changes take place. Both men and women experience decreasing hormonal production, caussing the climacteric, usually called menopause in women. These events often affect the individual’s sexual self-concept, body image, and sexual identity. (Fundamentals of Nursing 7th Edition by Kozier, Erb, Berman)

InterpretationThe patient’s reproductive status is normal with regards of having children. But due to

her age and medical condition she is now experiencing a decline in interest regarding on sexual activity.

STATE OF PHYSICAL REST AND COMFORT

While in the hospital the patient stated that she can’t have her complete sleep due to chest pain and due to noisy environment. She told us that in the hospital, the first 3 days of her confinement she was able to sleep for just 5 hours at night because of the pain. At the daytime she stated that she want to sleep to gain strength but she can’t have a good sleep, so she just take rest.

Standard and NormsThe sleep wake cycle is very important to young adults they usually have an active

lifestyle, and are thought to have required 7-8 hours of sleep each night but may do well on less. (Fundamentals of Nursing 7th Edition by Kozier, Erb, Berman and Nutrition 2005 by 2nd Edition by Alex B. Abalos)

Interpretation The patient’s state of physical rest and sleep was disturbed while she is in the hospital

due to environmental factor and the chest pain she’s bearing.

STATE OF SKIN APPENDAGES

18

Patient’s skin is intact. No lesion, mass, lump is found. The pt.’s skin is brown in complexion and no discoloration found. Her hair is well distributed all over the body. There is no hair in her face. Her scalp is white in colour, no dandruff or lesion or palpable mass noted. There is no infestation observed. Her fingers are complete both in upper and lower extremities. Her nails are intact and not pale in appearance. There is no clubbing of fingernails noted. Standard and Norms

Normally, the skin is uniform whitish pink or brown color, defending on the patient race. Exposure to sunlight results increased pigmentation of an exposed area. Normally, there are no areas of bleeding. No skin lesions should be present except for freckles, birthmarks or moles, which may be flat or elevated. The skin is dry with minimum of perspiration. Moisture also varies with changes in environment, muscular activity, and body temp. stress and activity levels. Skin surface temp. should be warm and equal bilaterally. Skin surface should be non tender. It should be smooth, even and firm except where there is significant hair growth. When the skin is released, it should returns to its original contour rapidly. Edema should no be present. Terminal hair is found in the eyebrows, eyelashes and scalp, and in the axilla and pubic areas after puberty. Males may experience a certain degree of normal balding and may also develop terminal facial and chest hair. The scalp should be pale white to pink in light skinned individuals and light brown in dark skinned individuals. There should be no signs of infestations or lesions. Dandruff may be present. Hair may feel thin, straight course, thick or curly. It should be shiny and resilient when traction is applied and should no come out in clumps in your hands. Normally, the nails have a pink cast in light skinned individuals and are dark brown in dark skinned individuals. It should be smooth and slightly rounded or flat. Curve nails are normal variant. Nail thickness should be uniform throughout, with no brittle edges. The angle of the nail bed should be approximately 160 degrees. It should be firm on palpation. (Health Assessment by Mary Elle Zator Estes)

Interpretation Client’s state of skin appendages are normal.

19

5. Diagnostic and Laboratory Procedures

Diagnostic/LaboratoryProcedures

Date Ordered Indications/ Purposes Results Normal Values

Analysis andInterpretation

Hematology WBC

RBC

Hgb

Hct

Lym

July 24, 2009 The CBC is used for the following purposes:•as a preoperative test to ensure both adequate oxygen carrying capacity and homeostasis.•to identify persons who may have an infection.•to diagnose anemia.•to identify acute and chronic illness, bleeding tendencies, and white blood cell disorders such as leukemia.•to monitor treatment for anemia and other blood diseases.

6/L

3.12

87.0g/L

272g/L

30.1%L

4.1-10.9

4.20-6.30

120-180 g/L

370-510g/L

?

Within normal values.

Decreased level of RBC indicated hemorrhage.

Decreased

Decreased level of Hct indicated hemorrhage

?

Nursing ResponsibilitiesBefore:

1. Check for the doctor’s order.2. Discuss the importance of the procedure.3. Explain to the client how to participate to the procedure.

After:1. Apply pressure on the site for 5-10 minutes after the procedure.2. Have the patient take a rest after the procedure.3. Encourage patient to eat foods rich in iron such as beans, green leafy vegetables and meats.

20

HEMATOLOGY NORMAL VALUES

RESULT INTERPRETATION

07-25-09

FBS3.9 – 6.1 mmol/L

BUN2.9 – 8.2 mmol/L

13.70 Above normal level

CREATENIN 53 – 106 mmol/L


SODIUM 136 – 142 mmol/L

127.4 Within normal level

POTASSIUM 3.8 – 5.0 mmol/L


CHLORIDE 95 – 103 meq/L


HEMATOLOGY NORMAL VALUES

RESULT INTERPRETATION

07-27-09FBS 3.9 – 6.1

mmol/L5.09 Within normal level

CHOLESTEROL3.88 – 6.47 mmol/L


TRIGLYCERIDE 0.11 – 2.15 mmol/L


HDL30 – 75 mmol/L


LDL 66 – 178 mmol/L


21

Nursing Responsibilities

Before:1. Check for the doctor’s order.2. Discuss the importance of the procedure.3. Explain to the client how to participate to the procedure.

After:1. Apply pressure on the site for 5-10 minutes after the procedure.2. Have the patient take a rest after the procedure.

22

Diagnostic/LaboratoryProcedures

Date Ordered Indications/ Purposes Results Normal Values Analysis andInterpretation

Serum Electrolytes>Sodium

>Potassium

>Chloride

July 28, 2009 To determine electrolyte and acid-base imbalances. 132.0mmol/L

5.06mmol/L

103mmol/L

136-142mmol/L

3.8-5.0mmol/L

95-103mmol/L

decreased

slightly increased

within normal values

Nursing ResponsibilitiesBefore:

1. Check for the doctor’s order.2. Discuss the importance of the procedure.3. Explain to the client how to participate to the procedure.

After:1. Apply pressure on the site for 5-10 minutes after the procedure.2. Have the patient take a rest after the procedure.3. Instruct patient to increase fluid intake

6. Anatomy and Physiology

The heart is located under the ribcage in the center of the chest between the right and left lung. It’s shaped like an upside-down pear. The size of the heart can vary depending on age, size, or the condition of the heart. A normal, healthy, adult heart most often is the size of an average clenched adult fist. Some diseases of the heart can cause it to become larger.

The essential function of the heart is to pump blood to various parts of the body. The mammalian heart has four chambers: right and left atria and right and left ventricles. The two atria act as collecting reservoirs for blood returning to the heart while the two ventricles act as pumps to eject the blood to the body. As in any pumping system, the heart comes complete with valves to prevent the back flow of blood. Deoxygenated blood returns to the heart via the major veins (superior and inferior vena cava), enters the right atrium, passes into the right ventricle, and from there is ejected to the pulmonary artery on the way to the lungs. Oxygenated blood returning from the lungs enters the left atrium via the pulmonary veins, passes into the left ventricle, and is then ejected to the aorta.

The pumping action of the heart starts with the simultaneous contraction of the two atria. This contraction serves to give an added push to get the blood into the ventricles at the end of the slow-filling portion of the pumping cycle called "diastole." Shortly after that, the ventricles contract, marking the beginning of "systole." The aortic and pulmonary valves open and blood is forcibly ejected from the ventricles, while the mitral and tricuspid valves close to prevent backflow. At the same time, the atria start to fill with blood again. After a while, the ventricles relax, the aortic and pulmonary valves close, and the mitral and tricuspid valves open and the ventricles start to fill with blood again, marking the end of systole and the beginning of diastole. It should be noted that even though equal volumes are ejected from the right and the left heart, the left ventricle generates a much higher pressure than does the right ventricle.

PATHOPHYSIOLOGY BOOK BASED

PATHOPHYSIOLOGY CLIENT BASED

Nursing Care Plan # 1

ASSESSMENT PLANNING INTERVENTION EVALUATIONS> “Nahihirapan ako huminga” as verbalized by the patient.

O > with body weakness

pale looking with exertional dyspnea right sided weakness RR: 32; tachypneic

Nursing Diagnosis: Impaired gas exchange r/t excessive fluid in alveoli

Scientific Explanation: Because the impaired left ventricle cannot eject increase circulating blood volume, the pressure in the pulmonary circulation increased, causing further shifting of fluid into the alveoli. The fluid filled alveoli cannot exchange oxygen and carbon dioxide. Without sufficient oxygen, the patient experience dyspnea and has difficulty getting enough sleep.

Within 3-4 hrs of proper nursing intervention, the patient will demonstrate improved ventilation and adequate oxygenation and remain free from signs of respiratory distress.

>Monitor respiratory rate, depth, and effort including use of accessory muscle, nasal flaring, and abnormal breathing pattern.

R: ↑RR use of accessory muscle, normal flaring, and abnormal breathing may be seen with hypoxia.

>Auscultate breath sounds every 1-2 hrs.

R: The presence of crackles and wheezes may alert the nurse to airway obstruction which may lead to or exacerbate existing hypoxia.

>Observe for cyanosis of the skin especially color of the tongue and oral mucous membranes.

R: to prevent any sings of hypoxia

>Turn patient every 2 hrs.

After 3-4 hrs of proper nursing intervention, the patient will demonstrate improved ventilation and adequate oxygenation and remain free from signs of respiratory distress.

R: to prevent immobility and bedsores.

>Help patient deep breathe and perform controlled coughing.

R: to help ↑ sputum clearance and ↓ cough spasms.

>Administer humidified oxygen through an appropriate device (e.g. cannula).

R: to promote oxygen supplement

>Provide rest and minimize fatigue

R: to promote relaxation

>↓ NA and ↓ fatty foods, ↑ fiber

>Emphasize the importance of nutritious food like vegetables and fruits such as oranges and mangoes rich in Vit. C.

R: for faster recover


Assessment Diagnosis Planning Intervention with Rationale EvaluationS: ØO:> conscious> weak in appearance> decreased body movement>with ongoing IVF of LRS @ 600 cc level regulated @ 15 gtts/min via left hand infusing well.

> Risk for aspiration r/t impaired swallowing.

> Within the shift the pt. will maintain gastric feeding without aspiration.

> Monitor vital signs, especially respiratory rate.R: It can be an indication of aspiration> Feed the client in upright position.> To avoid aspiration>Have an assistant in feeding the client.> To prevent unnecessary incident and to ensure client’s safety.>Feed the client with small serving of food.> To avoid choking the client.> Keep head of bed elevated when feeding and for at least an hour afterwards.R: To decrease risk for aspiration.> Have suction machine available when feeding.R: Pt. with aspiration needs immediate suctioning.> Ensure comfort and safety.R: To maintain the pt. in good condition.

> Within the shift the pt. will maintain gastric feeding without aspiration as evidenced by respiratory rate in expected range.

Nursing Care Plan # 3Assessment Planning Interventions Rationale Evaluations

S> “parang may sapot ang nakikita ko” as verbalized by the pt.

O> Frequently

blinking Move closely to

see us clearly Unable to read

news paper from 12 inches away

Frequently rubbing her eyes

A>disturbed sensory perception r/t altered sensory perception

associated with impaired vision

After 1hr of appropriate nursing interventions the client will verbalize of gaining knowledge to

improve vision

Discuss interventions avoiding aggravating the problem like avoiding watching television in close distance and avoiding reading in dim light

Advise eating vegetables like squash and carrots

Encourage to wear correctional glasses with proper visual acuity given by an ophthalmologist

Advise to avoid

To prevent aggravation of the disease

Vegetables like squash and carrots contains vitamin A that helps in gaining good eye sight

Eyes glasses with proper acuity given by a ophthalmologist can help in gaining good eye sight

Frequently

After 1hr of appropriate nursing interventions the client will verbalize gaining knowledge to improve her vision as manifested by understanding the interventions that are given.

frequently rubbing her eyes.

Advise to keep lights on when doing ADL

rubbing eyes sometimes can cause of infection

Adequacy of light can improve visualization

Nursing Care Plan # 4Assessment Planning Interventions Rationale Evaluations

S> “halos di ako makagalaw” as verbalized by the pt.

O> C O2

inhalation via nasal cannula @ 3lpm

Difficulty turning observed

Weak in appearance

Needs assistance when sitting

Inability to perform ADL like urinating noted

A> Impaired physical mobility r/t decreased strength

After 4hr of appropriate nursing interventions the client will verbalize feeling of increase strength and ability to move.

Demonstrate relaxation techniques such as back rubbing and massaging

Render range of motion technique

Discuss how to use assistive devices such as walker, to increase mobility

Increase independence in doing ADL

Limit potential uncomfortable movements that requires energy

To promote relaxation for gaining adequate rest

To promote muscle contractions

Assistive devices such as walker helps client in ambulation

To encourage self efficacy

To save energy

After 4hr of appropriate nursing interventions the client will verbalized feeling of increase strength and ability to move.


C. Implementationi. Medical Management

I. IVF, BT, NGT, Nebu, TPN, OxygenMedical Management/

TreatmentDate Ordered/

PerformedDate Changed/ Date

Continued

General Description Inidcation/ Purposes Client Reaction to Treatment

D5LR 1L regulated @ 30 gtts/min.

Date ordered:July 24, 2009

Date performed:July 24, 2009

An isotonic solution but provides free water when dextrose is

metabolized.

It expands intracellular and extracellular fluid

volumes..

None

NURSING RESPONSIBILITIES

Before:1. Inspect each container. Read the label. Ensure solution is the one ordered and is with in the expiration date.2. Invert container and carefully inspect the solution in good light for cloudiness, haze, or particulate matter. Any container which is suspect should not be used.3. Use only if solution is clear and container and seal are intact.

After:1. Watch for infection at the site of injection, venous thrombosis or phlebitis extending from the site of injection, extravasation and hypervolemia.2. Symptoms may result from an excess or deficit of one or more of the ions present in the solution; therefore, frequent monitoring of electrolytes levels is essential.3. Monitor the regulation of the IVF.4. Check for any signs of any infiltration complication in the IV site.

ii. Drugs

Name of Drug

Date ordered-Date GivenDate Changed

Route of Administration and DosageFrequency of Administration

General Action

Indication Client response to medicine with actual S/E

Generic Name:Furosemide

Brand Name:Furoside

Therapeutic Classification:> Diuretic> Anti-hypertensive

>Inhibits sodium and chloride re-absorption at proximal and distal tubules and ascending loop of Henle.

> Heart Failure

No unusual response noted.


1. Assess patient’s underlying condition before the therapy.2. Be alert for adverse reaction and drug interaction. 3. Assess patient’s and family’s knowledge of drug therapy.4. Advise patient to stand slowly to prevent dizziness, not to drink alcohol and to minimize strenuous activity.

Name of Drug

Date ordered-Date GivenDate Changed


General Action


Generic Name:Morphine Sulfate

Brand Name:Morphine H.P

Therapeutic Classification:> Analgesic

> Binds with opioid receptors in CNs, altering both perception of and emotional response to pain through unknown mechanism.

> Severe pain No unusual response noted.


1. Assess patient’s pain before therapy and regularly thereafter to monitor drug’s effectiveness.2. Assess patient’s and family’s knowledge of drug therapy.3. Morphine is drug of choice in relieving pain of M.I. it may cause transient decrease in blood pressure.4. Warn patient about getting out of bed or walking around without assistance.5. Tell patient to report continued pain and not to increase dose independently.

Name of Drug Date ordered-Date GivenDate Changed


General Action


Generic Name:Metoclopramide Hydrochloride

Brand Name:Pramin

Therapeutic Classification:> Anit-emetic> G.I stimulant.

> Stimulates motility of upper G.I tract by inc4easing lower esophageal sphincter tone. Blocks dopamine receptors at chemoreceptor trigger zone.

> To prevent or reduce nausea and vomiting.



1. Assess patient’s pain before therapy and regularly thereafter to monitor drug’s effectiveness.2. Assess patient’s and family’s knowledge of drug therapy.3. Instruct patient not to drink alcohol during therapy.4. Advise patient to avoid activities requiring alertness for 2 hours after taking each dose.

Name of Date Route of General Indication Client

Drug ordered-Date GivenDate Changed

Administration and DosageFrequency of Administration

Action response to medicine with actual S/E

Generic Name:Omeprazole

Brand Name:Losec

Therapeutic Classification:> Proton –pump inhibitor

>Inhibits acid (proton) pump and binds to hydrogen-potassium adenosine triphosphate on secretory surface of gastric parietal cells to block formation of gastric acid.

> Heartburn on 2 or more days per week



1. Assess patient’s pain before therapy and regularly thereafter to monitor drug’s effectiveness.2. Assess patient’s and family’s knowledge of drug therapy.3. Be alert for adverse effect. 4. If G.I reaction occurs, monitor patient’s hydration.5. Explain the importance of taking the drug exactly as prescribed.

Name of Drug Date ordered-Date GivenDate Changed


General Action Indication Client response to medicine with actual S/E

Generic Name:Digoxin

Brand Name:Lanoxin

Therapeutic Classification:> Anti-aarhythmic> Inotropic

>inhibits sodium potassium activated adenosine triphosphate, thereby promoting movement of calcium from extracellular to intracellular cytoplasm and strengthening myocardial contraction. Also acts on CNS to enhance vagal tone, slowing conduction through SA and AV nodes and providing antiaarhtymic effect.

> Heart failure



1. Obtain pt.’s underlying condition before starting the therapy.2. Monitor effectiveness by taking apical pulse for full 1 minute before giving a dose.3. Look for adverse reaction and drug interaction.4. Assess patient’s and family’s knowledge of drug therapy.5. Monitor potassium level carefully.6. Tell pt. not to change one brand from another.7. Advise patient to eat potassium rich food.





Generic Name:Ciprofloxacin

Brand Name:Ciproxin

Therapeutic Classification:> anti-biotic

> Unknown. Bactericidal effects may result from inhibition of bacterial DNA gyrase and prevention of replication of susceptible bacteria.

> No unusual response noted.


1. Assess patient’s infection before therapy and regularly throughout. 2. Before giving the first dose, obtain specimen for culture and sensitivity test.3. Observe for adverse reaction and report immediately.4. Advise patient to take plenty of water during the therapy.5. Warn patient to avoid hazardous tasks that requires alertness, such as driving.

Name of Drug

Date ordered-Date

GivenDate

Changed

Route of Administration

and DosageFrequency of

Administration

General Action Indication Client response to medicine

with actual S/E

Generic Name:

Losartan Potassium

Brand Name:Cozaar

Therapeutic Classification:

> Anti-hypertensive

>Inhibits vasoconstricting

and aldosterone-

secreting effects of angiotensin

II by selectively blocking

binding of angiotensin II to receptor site in many tissues,

including vascular

somooth muscle and adrenal

glands.

> Hypertension> To reduce risk of stroke

in patients with

hypertension.

No unusual response

noted.


1. Assess patient’s blood pressure before starting therapy and regularly thereafter to monitor drug’s effectiveness.2. Regularly assess creatinine and BUN levels to check kidney function.3. Be alert for adverse reaction.4. Tel patient to avoid sodium substitutes because they may contain potassium, which can cause hyperkalemia.

Name of Drug Date ordered- Route of General Action Indication Client

Date GivenDate Changed


response to medicine with actual S/E

Generic Name:Isosorbide Dinitrate

Brand Name:Isordil

Therapeutic Classification:> Anti-anginal> Vasodilator

>may reduce cardiac oxygen demand by decreasing left ventricular end diastolic pressure (preload) and, to a lesser extent, systemic vascular resistance (after load). May increase blood flow through collateral coronary vessels.

> Adjunctive treatment of heart failure



1. Assess patient’s angina before starting therapy and regularly thereafter.2. Monitor blood pressure, heart rate and rhythm.3. Assess pt.’s and family’s knowledge of drug therapy and be alert for adverse reaction.4. Tell patient to take drug as prescribed and to keep it accessible at all times.5. Tell patient to avoid alcohol consumption during therapy.6. Instruct patient to keep the drug in a cool place, in tightly closed container, away from light.





Generic Name:Simvatatin

Brand Name:Zocor

Therapeutic Classification:> Anti-hyperlipemic

> Inhibits HMG-CoA reductase. This enzyme is early (and rate-limiting) step in synthetic pathway of cholesterol.

> To reduce risk of CAD mortality



1. Obtain history of pt’s LDL and total cholesterol levels.2. Be alert for adverse reaction.3. Assess pt.’s dietary fat intake.4. Tell pt. to take drug with evening meal to enhance absorption and cholesterol biosynthesis.5. Tell pt. to report any adverse reaction, particularly muscle aches and pains.

iii. DietTYPE OF DIET DATE ORDERED, GENERAL INDICATION/S, SPECIFIC FOODS CLINT RESPONSE

DATE STARTED,DATE CHANGED

DESCRIPTION PURPOSE/S TAKEN AND/OR REACTION TO THE DIET

Low Fat Date ordered:July 27, 2009

Date Started:July 27, 2009

Diet that prescribes a specific level of fat for patients whose condition requires a small amount of fat fraction.

To prevent aggravation of accumulation of fats

Lean or grilled meat and fish

The patient eat the served food and understands the benefits of the diet in his condition.Diet tolerated

Low Salt Date ordered:July 27, 2009

Date Started: July 27, 2009

The patient tries to eat and accept the served food and understands the benefits of the diet in his condition.Diet tolerated

Diabetic diet Date ordered:July 27, 2009

Date Started: , July 27, 2009

The patient tries to eat and accept the served food and understands the benefits of the diet in his condition.Diet tolerated

NURSING RESPONSIBILITIESBefore:

1. Emphasize the importance of the diet2. Discuss the food sources included in the diet.3. Explain to the client the purpose of the diet. After:1. Assess the client’s response to the diet.2. Assess the client’s understanding about the diet.

iv. Activity or ExerciseTYPES OF EXERCISE DATE ORDERED, DATE

STARTED, DATE GENERAL DESCRIPTION INDICATIO/S, PURPOSE/S CLIENT’S

RESPONSE/REACTION TO

CHANGED. THE ACTIVITY/EXERCISE

Deep Breathing Exercises

Range of Motion Exercise

Date ordered:

Date Started: ,

Date Changed:

Date ordered:Date Started: ,

Date Changed:

Deep breathing is a relaxation technique that can be self-taught. Deep breathing releases tension from the body and clear the mind, improving both physical and mental wellness.

We tend to breathe shallowly or even hold our hold our breath when we are feeling anxious

Maximum possible movement for a joint. Normal muscle strength for complete voluntary range of motion.

Breathing exercises can be used to optimize gas exchange, promote lung expansion, minimize atelectasis, decrease dyspnea, and promote secretion removal especially after prolonged inactivity.

Strengthens muscle to prevent muscle atrophy or weakness among patients who mostly confined on bed.

Promotes blood circulation.

Participate willingly in the activity.

Patient verbalizes alleviated pain sensationand serves as an effective relaxation technique.

Understands and appreciates the benefits of the exercise

Participate willingly in the activity.

Understands and appreciates the benefits of the exercise

NURSING RESPONSIBILITIES:

DEEP BREATHING EXERCISE

BEFORE:1. Explain the procedure to gain patients cooperation.2. Discuss the benefits of the exercise

DURING:1. Help the client perform deep breathing exercise.2. Advise to rest between activities.

AFTER:1. Encourage to perform exercise at last 1 hour before every meal.2. Encourage verbalization of increased comfort.

RANGE OF MOTION EXERCISEBEFORE:1. Explain the procedure to gain patients cooperation.2. Discuss the benefits of the exercise

DURING:1. Help the client perform deep breathing exercise.2. Advise to rest between activities.3. Ensure the patient’s safety.

AFTER:1. Encourage to perform active ROM exercise at last 1 hour before every meal.2. Encourage verbalization of any pain after the activity3. Encourage verbalization of increased comfort.

SOAPIE # 1

S> “Nahihirapan ako huminga” as verbalized by the patient.

O > with body weakness

pale looking with exertional dyspnea right sided weakness RR: 32; tachypneic

A> Impaired gas exchange r/t excessive fluid in alveoli

P> Within 3-4 hrs of proper nursing intervention, the patient will demonstrate improved ventilation and adequate oxygenation and remain free from signs of respiratory distress.

I> Monitor respiratory rate, depth, and effort including use of accessory muscle, nasal flaring, and abnormal breathing pattern.

>Auscultate breath sounds every 1-2 hrs.

>Observe for cyanosis of the skin especially color of the tongue and oral mucous membranes.

>Turn patient every 2 hrs.

>Help patient deep breathe and perform controlled coughing.

>Administer humidified oxygen through an appropriate device (e.g. cannula).

>Provide rest and minimize fatigue

>↓ NA and ↓ fatty foods, ↑ fiber

>Emphasize the importance of nutritious food like vegetables and fruits such as oranges and mangoes rich in Vit. C.

E> After 3-4 hrs of proper nursing intervention, the patient will demonstrate improved ventilation and adequate oxygenation and remain free from signs of respiratory distress.

SOAPIE # 2

S: Ø

O: > Conscious> Weak in appearance> Decreased body movement> With ongoing IVF of LRS @ 600 cc level regulated @ 15 gtts/min via left hand infusing well.

A: Risk for aspiration r/t impaired swallowing.

P: Within the shift the pt. will maintain gastric feeding without aspiration.

I: Monitor vital signs, especially respiratory rate.

Feed the client in upright position

Have an assistant in feeding the client

Feed the client with small serving of food.

Keep head of bed elevated when feeding and for at least an hour afterwards.

Have suction machine available when feeding.

Ensure comfort and safety.

E: > Within the shift the pt. will maintain gastric feeding without aspiration as evidenced by respiratory rate in expected range.

SOAPIE # 3

S> “parang may sapot ang nakikita ko” as verbalized by the pt.

O> • Frequently blinking• Move closely to see us clearly• Unable to read news paper from 12 inches away• Frequently rubbing her eyes

A> disturbed sensory perception r/t altered sensory perception associated with impaired vision

P> After 1hr of appropriate nursing interventions the client will verbalize of gaining knowledge to improve vision.

I>• Discussed interventions avoiding aggravating the problem like avoiding watching

television in close distance and avoiding reading in dim light• Advised eating vegetables like squash and carrots• Encouraged to wear correctional glasses with proper visual acuity given by an

ophthalmologist• Advised to avoid frequently rubbing her eyes• Advised to keep lights on when doing ADL

E> After 1hr of appropriate nursing interventions the client verbalized gaining knowledge to improve her vision as manifested by understanding the interventions that are given.

SOAPIE # 4

S> “halos di ako makagalaw” as verbalized by the pt.

O> • c O2 inhalation via nasal cannula @ 3lpm• Difficulty turning observed• Weak in appearance• Needs assistance when sitting• Inability to perform ADL like urinating noted

A> Impaired physical mobility r/t decreased strength

P> After 4hr of appropriate nursing interventions the client will verbalize feeling of increase strength and ability to move.

I>• Demonstrated relaxation techniques such as back rubbing and massaging• Rendered range of motion technique• Discussed how to use assistive devices such as walker, to increase mobility• Increased independence in doing ADL • instructed to limit potential uncomfortable movements that requires energy

E> After 4hr of appropriate nursing interventions the client verbalized feeling of increased strength and ability to move.

SOAPIE # 5

D. EVALUATION1. Patient’s daily program in the hospital

Daily program 1st Day(July 27, 2009)

2nd Day(July 28, 2009)

3rd Day(July 29 2009)

4th Day (July 30, 2009)

5th Day (July 31, 2009)

Nursing Problems

1. Impaired gas exchange r/t excessive fluid in alveoli

2. Risk for aspiration r/t impaired swallowing.

3. disturbed sensory perception r/t altered sensory perception associated with impaired vision

4. Impaired physical mobility r/t decreased strength

check

check

check

check

check

Temperature:

6pm-37.5 °C10 pm-36.7 °C

Respiratory Rate:

6pm-32 cpm10 pm-24 cpm Pulse Rate:

6pm-103bpm10 pm-100bpm Blood Pressure:

6pm-150/110mmHg10 pm-140/80mmHg

Temperature:

6pm-36.4 °C10 pm-36.4 °C

Respiratory Rate:

6pm22 cpm10 pm-28 cpm Pulse Rate:


6pm-150/100mmHg10 pm-160/100mmHg

Temperature:

6pm-36.4 °C10 pm-36.2 °C

Respiratory Rate:



6pm-140/100mmHg10 pm-160/90mmHg

Temperature:

6pm-37 °C10 pm-36 °C

Respiratory Rate:



6pm-110/90 mmHg10 pm-130/90 mmHg

Temperature:

8am- 37 °C10am- 36.9 °C

Respiratory Rate:

8am- 18cpm10am-19cpm Pulse Rate:

8am- 87bpm10am-88bpm Blood Pressure:

8am- 150/80mmHg10am-140/80mmHg

Diagnostic & Lab. Procedures

For 12 LECG 12 LECGFor troponin TFor serum electrolyte

For troponin T For troponin T For 2 d echo

Medical and Surgical Mgt.

Vital signs monitoring D5W





Drugs SimvatatinIsosorbide DinitrateLosartan Potassium

SimvatatinIsosorbide DinitrateLosartan Potassium



Losartan

Amlodipine

CiprofloxacinDigoxinOmeprazoleMetoclopramide HydrochlorideMorphine SulfateFurosemide




Furosemide

Digoxin

Metformide Simvastatin Cemeprazole

ISMN

Ammo acid + mineral cap

Diet Low saltLow fatDiabetic diet

Low saltLow fatDiabetic diet




Exercise Deep breathing ExerciseRange of motion

Deep breathing ExerciseRange of motion




Discharge Planning

i. General condition of the patient upon discharge

It was July 31, 2009, when a patient was discharge. The patient was able to sit on bed without assistance sure ka ditto girl?. She can able to tolerate food on the tray. She has no already experienced difficulty of breathing huh? Nawindang ata ako?ehehe . She verbalized that she never felt chest pain.

ii METHOD

M> Losartan 50mg once a day

>Amlodipine 5mg once a day before bedtime

>Furosemide 40mg twice a day

>Digoxin 0.25mg once a day

>Metformide 500mg three times a day after meals

>Simvastatin 40mg once a day after meal

>Cemeprazole 20mg twice a day after meals

>ISMN 60mg twice a day

>Ammo acid + mineral cap three times a day

E>Activities of daily living with assistance

>Deep breathing exercise

T>Ø

H> encourage to continue ↑ protein diet, ↓fat and sodium diet

>Encourage to continue taking the prescribed medicines

>Encourage to resume ADL

>Instruct to get enough rest and relaxation technique

>Avoid strenous activities that promotes easy fatigue

>Emphasize the importance of nutritious food like vegetables and fruits such as oranges

>Lessen fluid intake

O>Follow up checkup after one week

>Still for 2D echo

D>↓fat, ↓Sodium, ↑ fiber

III. CONCLUSION

Discipline is one of the major factors needed by the patient with congestive heart failure She must be able to know on how to tolerate his foods particularly the limitations of fats and cholesterol intake. Proper balance nutrition and regular exercise is a good practice for the alleviation and minimal occurrence of this kind of disease.

As we work this kind of study, the group gained wide knowledge and understanding about CHF, the problems related to this condition and the different management that should be prioritized in order for us to have positive outcomes in nursing problems. Good nurse-patient relationship was also established as we conduct this study. This study helps us to identify measures to prevent complications of the disease and also for them to have understanding about this condition and to practice independent implementation for this kind of disease

IV. RECOMMENDATION

As nursing students, gaining an adequate knowledge about our patient’s condition is a must to be able to give appropriate managements. So our recommendations to our patient are to maintain proper diet that is high in fiber and low salt-low fat diet, limiting fluids for at least 1 litter a day may be helpful to prevent aggravation of disease. Patient should always be practice regular intake of her medication and must always restrict any strenuous activities that cause stress and fatigue. Any abnormalities or adverse effects should report to the physician immediately. Patient should also practice independence to promote sense of well-being but with strict injury precaution due to her right side body weakness.

V. BIBLIOGRAPHY

BOOKS:

Ackley, Betty J. and Ladwig, Gail B., Nursing Diagnosis Handbook, 7th Edition, 2006.Estes Zator, Mary Ellen. Health Assessment and Physical Examination, 3rd Edition, 2006.Ignativicius and Workman. Medical- Surgical Nursing, Collaborative and Critical Thinking Vol. 1 and 2, 2004.Kozier, Erb, Berman, Synder. Fundamentals of Nursing, Concepts, Process and Practice, 7th

Edition, 2004.Lippicott, Williams and Wilkins. Springhouse Nurse’s Drug Guide, 2007.Mosby’s Pocket Dictionary of Medicine, Nursing and Health Professions.Smeltzer, Suzanne C. and Bare, Brenda G., Medical- Surgical Nursing, Vol. 2 10th Edition, 2004.Website http://www.umm.edu/ency/article/000274.htm http://emedicine.medscape.com/article/172216-overview

http://emedicine.medscape.com/article/172216-overview

http://www.umm.edu/ency/article/000274.htm

republic of the philippines tarlac state university college of nursing

Documents