I.

INTRODUCTION Congestive Heart Failure is a condition in which the hearts pumping ability becomes compromised and therefore cannot pump enough blood to the muscles, tissues, and organs of the body. The weakening of the hearts pumping ability causes blood and fluid to back up into the lungs, hence the congestive part of its name. It is one of the most life threatening conditions of all heart diseases.

According to the Philippines National Statistics Office, heart disease was found to be the leading cause of deaths in the Philippines as of 2009. In 2010, about 5 million Americans were diagnosed with Congestive Heart Failure. The American Heart

Association states that the risk of heart failure increases with age. Individuals age 40 years and older has a 20% chance of obtaining Congestive Heart Failure.

Heart failure may be categorized as (1) LVF versus RVF, (2) backward versus forward, (3) high output versus low output. In the case of the patient, she has a Left Ventricular Failure. Left ventricular failure causes either pulmonary congestion or a disturbance in the respiratory control mechanisms. The patient manifests rales, dyspnea, paroxysmal nocturnal dyspnea, orthopnea, pulmonary edema, which are all consistent with Left-sided Congestive Heart Failure. The cause of the patients condition resulted from interrelated factors such as Diabetes Mellitus Type II and Myocardial Infarction.

Out of the 86,241,697 people in the Philippines, 1,521,912 have Congestive Heart Failure. Congestive Heart Failure is the 6th leading cause of mortality in the Philippines, affecting males more often than females.

Gastritis (inflammation of the gastric or stomach mucosa) is a common GI problem. Gastritis maybe acute, lasting several hours to a few days, or chronic, resulting from repeated exposure to irritating agents or recurring episodes of acute gastritis.

Acute Gastritis is often caused by dietary indiscretion person eats food that is irritating, too highly seasoned, or contaminated with disease causing microorganisms. Other causes of acute gastritis include overuse of aspirin and other non-steroidal antiinflammatory drugs (NSAIDs),excessive alcohol intake, bile reflux, and radiation therapy. A more severe form of acute gastritis is cause by ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. Scarring can occur, resulting in pyloric stenosis or obstruction.

Acute gastritis also may develop in acute illness, especially when the patient has had major traumatic injuries; burns; severe infection; hepatic, renal, or respiratory failure; or major surgery. Gastritis maybe the first sign of an acute systemic infection. The client discussed in the case, client A, is a 63 year old male who was admitted Cagayan de Oro Medical Center. The client was chosen because his case of Congestive Heart Failure encompasses different pulmonary and systemic symptoms and complications, making this case interesting and challenging.

In this study, the nursing process during the course of the duty is discussed. The importance of a nurses knowledge, skills and attitude, in the management of this particularly chronically ill patient with multiple complications from a Coronary Artery Disease that progressed to Congestive Heart Failure, is emphasized. Insights to the disease process and the human response to the disease are taken, not just from the book, but from what is actually happening to the client.

Through this case study, a continuum of service that encompasses every level of care in a diversified system throughout the lifespan, regardless of the patients status, race, gender, age, ethics, religion, or sexual preference, is embraced. Successful nursing practice in a challenging health care world entails that each nurse, student or professional, deliver high quality, competent, effective, and collaborative care based not just on established nursing standards but on their humanity as well.

OBJECTIVES General: This study aims to develop knowledge, skills and attitudes towards nursing care management of client who developed a Congestive Heart Failure, Specifically, this aims to: OBJECTIVES OF THE STUDY General Objective: The main goal is to be able to present the case study of my chosen client that would provide a comprehensive discussion of disease and be able to come up with the appropriate nursing care and intervention to be given. Specific Objectives: In order to meet the general objective, I aim to:

establish rapport to the patient and the patients significant others, interpret the pertinent data gathered from the patient and her significant others, state the present health history of the patient, define the complete diagnosis of the patient, present the cephalocaudal assessment obtained from the patient, discuss the anatomy and physiology of the system involved in the patients disease, familiarize completely the etiology of the disease trace the pathophysiology of the patients disease, be aware of its signs and symptoms as well as its complications obtain and rationalize the doctors order, discuss the nature of the drugs given to the patient, present a specific, measurable, attainable, realistic and time-bounded nursing care plans for the client, Outline recommendations based on the case studys findings.

SCOPE AND LIMITATIONS OF THE STUDY This study is only limited to my patient, A., his health condition, the history of his present illness, the medical intervention and nursing care given to him. The care is limited to only 8 hours of clinical exposure which aimed for his betterment. Data were also limited to the patients chart and as well as the verbalizations of his significant others when I asked them relevant questions.

II. PATIENTS PROFILE

Name: Timtim, Alberto Sex: Male Birthday: January 5, 1950 Age: 63 years old Address: Molave, Zamboanga del Sur Religion: Roman Catholic Nationality: Filipino Occupation: Retired Carpenter Civil status: Married Educational Attainment: College Level Family Income: 15,000/month Wife: Name: Timtim, Leonora Age: 60 years old Occupation: Housewife Children: 2 Clinical/ Admitting Data Date of admission Time of admission Hospital/Institution Ward/Room Attending Physician Neonatal History Type of Previous Illness Diagnosis : Congestive Heart Failure, Cardiomegaly, Acute Gastritis : September 16, 2013 : 7:00 pm : Cagayan de Oro Medical Center : Medical Ward : Dr. Sandra Oliveros/ Dr. dela Serna : NSVD (Hilot) CHF - May 2009

III. CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS

Three months PTA, patient was admitted for 3 days at Pagadian City Hospital because of generalized body weakness. Then he sought another doctors advice 1 months after and again admitted at Ozamis City and he was found to have a Cardiomegaly. Then 3 days PTA, patient experienced due to chest pain and difficulty breathing. Someone advised them to seek advice from COMC so they decided to be admitted in the said hospital.

Heredo-Familial Disease Non diabetic and no known asthma.

Food and Drug allergy No known allergies

Spiritual History Patient A is a Roman Catholic and has a strong faith in our supreme being. He regularly attends mass every Friday and Sunday at Quiapo Church. He believes that God is always there for him and his family in times of problems and challenges.

Diet and Lifestyle Patient claimed to be non- picky eater; Patient A seldom eats meat and poultry. Patient said that he doesnt like the taste of pork. Patient always eats vegetables and fish. Patient consumes vegetables that are rich in fiber such as saluyot and he eats more rice. Patient has a good appetite. Patient complies with his do ctors order by avoiding foods that are restricted to him. Patient A voids approximately 4-6 times a day without experiencing pain during urination. He defecates once or twice a day and seldom experience constipation. He does it every 6 in the morning, thrice a week, for about an hour. He usually sleeps 5-6 hours a day. Patient sleeps at 9 or 10 in the evening and wakes up early in the morning, usually at 2 or 3am. He stated that there are episodes that he gets awaken from sleep because he experiences difficulty of breathing.

Developmental Task Erik Eriksons Psychosocial Theory of Development Erik Erikson adapts and expands Freud Theory of development to include the entire life span, believing that people continue to develop throughout life. He believed in the massive influence of culture on behavior and placed more emphasis on the external world such as depression and was according to his theory, each stage signals a task that must be achieved. The resolution of task can be complete, partial, and successful. He believes that the greater the task achievements that healthier the personality of the person, failure to achieve a task influences the persons ability to achieved the next tasks. Erikson emphasizes that people must change and adapt their behavior to maintain control over their lives. According to him, personality development is influenced by biologic, psychological, environmental, and social factors throughout the life cycle.

Late Adulthood: 55 or 65 to Death

Ego Development Outcome: Ego Integrity vs. Despair Basic Strengths: Wisdom

Erikson felt that much of life is preparing for the middle adulthood stage and the last stage is recovering from it. Perhaps that is because as older adults we can often look back on our lives with happiness and are content, feeling fulfilled with a deep sense that life has meaning and we've made a contribution to life, a feeling Erikson calls integrity. Our strength comes from a wisdom that the world is very large and we now have a detached concern for the whole of life, accepting death as the completion of life. On the other hand, some adults may reach this stage and despair at their experiences and perceived failures. They may fear death as they struggle to find a purpose to their lives, wondering "Was the trip worth it?" Alternatively, they may feel they have all the answers (not unlike going back to adolescence) and end with a strong dogmatism that only their view has been correct.

Analysis: Patient A achieved the developmental task because he was able to perform well as a part of his family. He was able to teach and care for his children as they continue to grow. He feels fulfilled and contented on what he has done and understand the things happening to him. He was aware of her condition and he accepts it. Thus, Ego integrity developed. a. Physical Development Patient A physical development belongs to a late adult age. She weighs 65 kilograms and stands 56 tall. By merely looking at the patients physicality, he was actually lean in appearance. In terms of perception in health functioning, patient A considered herself as well fitted and is conscious and aware of her present condition. b. Psychosocial Development Patient A is strong. Even if theres problem, the family remained strong and has cooperation in each member of the family. He was contented on her life; he felt happiness in taking care of his children and grandchildren. c. Cognitive Development Patient A makes decisions on his own but makes sure to still consult his family. As he recalls the memories before, he was the third child of their parents. But he decided to separate from her parents as well as her siblings. According to him, theyve learned to live in their own at a young age. Analysis: Based from experiences expressed by patient A, it may be presumed that his personality features molded during his early married life. He focused on that part of his life and he developed every virtues and attitudes in that part of her life. d. Moral and Spiritual Development The patient is a Roman Catholic and he believes that GOD exists. He always goes to church every Sunday and Friday he always prays the rosary. Analysis: His decision is highly affected by his religion and faith. He often prays for guidance before he makes her decision.

IV. ANATOMY & PHYSIOLOGY and PATHOPHYSIOLOGY

Figure 1-2 Anatomical Structure of the Heart Heart The heart is shaped like a blunt cone and is approximately the size of a closed fist. It is located in the thoracic cavity between the two pleural cavities, which surround the lungs. The heart, trachea, esophagus, and associated structures form a midline partition, the mediastinum. Functions: 1. Generating blood pressure 2. Routing blood 3. Ensuring one-way blood flow 4. Regulating blood supply Right side of the Heart: Right Atrium- the first chamber which receives deoxygenated blood from the body through the inferior and superior venacava. Right Ventricle- it pumps the blood into the lungs which exchange of oxygen and carbon dioxide occurs.

Left side of the Heart: Left Atrium- the first chamber which receives highly oxygenated blood from the lungs through the Pulmonary Veins. Left Ventricle- the strongest of the heart's pumps. Its thicker muscles need to perform contractions powerful enough to force the blood to all parts of the body. The Valves Tricuspid Valve-regulates blood flow between the right atrium and the right ventricle Pulmonary Valve-opens to allow blood to flow from the right ventricle to the lungs Mitral Valve-regulates blood flow between the left atrium and the left ventricle Aortic Valve-allows blood to flow from the left ventricle to the ascending aorta The Hearts Electrical System Superior vena cava- is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the head and upper body feed into the superior vena cava, which empties into the right atrium of the heart Inferior vena cava-is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the legs and lower torso feed into the inferior vena cava, which empties into the right atrium of the heart. Aorta-is the largest single blood vessel in the body. It is approximately the diameter of your thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts of the body.

Layers: Epicardium - also called visceral pericardium -a thin serous membrane forming the smooth outer surface of the heart Myocardium -thick middle layer of the heart

-is composed of cardiac muscle cells and is responsible for contractions of the heart chambers. Endocardium -which consist of simple squamous epithelium over a layer of connective tissue.

SYSTEMIC AND PULMONARY CIRCULATION

Figure 1-3 Systemic and Pulmonary Circulation

In the systemic circulation, arteries bring oxygenated blood to the tissues of the body. The pulmonary circulation (for arterial blood sent to the lungs) is excluded from this definition. As blood circulates through the body, oxygen diffuses from the blood into cells surrounding the capillaries, and carbon dioxide diffuses into the blood from the capillary cells. Veins bring deoxygenated blood back to the heart.
The function of the GI tract The function of the GI tract is to carry out the digestive processes within the body. Large food molecules are metabolised into small, soluble molecules that can be absorbed into the blood stream and lymphatic system and incorporated into cells. Digestion occurs both mechanically by physical means, such as chewing, peristalsis and churning movements of the stomach and small intestine, and chemically through enzyme-mediated metabolic reactions. General structure of the GI tract The GI tract or alimentary canal forms a continuous tube from the mouth to the anus, therefore, food is not actually inside the body until it has been metabolised and absorbed

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into the bloodstream. The wall of the GI tract is permeable to digested food molecules but impermeable to some potentially harmful organisms and other foreign particles, which remain outside the body. The GI tract wall comprises four basic tissues surrounding the lumen:

Inner mucosa Submucosa Muscle layer Outer serosa

(secretion, absorption, protection)

(support, blood supply, nerves controlling secretion) (circular constriction, longitudinal contraction, nerves controlling motility) (secretes lubricating fluid)

The inner mucosa The mucosa is the innermost layer of the digestive tract, and its surface comes into direct contact with food particles in the GI tract. It is responsible for absorption of digested food. The mucosa lubricates solid contents to facilitate their movement along the digestive tract, and it contains glands and cells that produce digestive juices and mucus. It provides a degree of protection to the outer layers against harmful substances and pathogens present in the gut lumen. Some muscle fibres (the muscularis mucosa) are also present. The submucosa The submucosa lies under and around the mucosal layer. It consists of tough, fibrous tissues and acts as a supporting structure for the GI tract. The submucosa carries the major blood vessels into which digested food molecules are absorbed. It also contains the main lymph vessels of the GI tract, and the Meissner's plexus a network of nerves that control digestive and hormonal secretions. The muscle layer The muscle layer is composed of two layers of smooth muscle an inner layer of circular muscle fibres (which narrow the lumen when contracted) and an outer layer of longitudinal muscle fibres (which shorten and widen the lumen). The stomach has an additional internal layer of oblique muscles. Contractions of these muscles help to mechanically break down and mix food with digestive juices, and move food along the GI tract using peristalsis. The major nerve supply of the GI tract, known as the myenteric or Auerbachs plexus, is also contained in the muscle layer. It makes sensory connections through the layers, as well as along the length of the GI tract to control motility. The outer serosa The serosa, the outermost layer, is only found covering the abdominal digestive organs, and is an extension of the peritoneum, which lines the wall of the peritoneal cavity. In areas of the GI tract that lack epithelium, for example the oesophagus, this layer is known as the

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adventitia. The peritoneum itself is a membrane that holds the organs of the GI tract in place in the abdomen and encloses the vessels associated with absorption from the stomach and intestine. The serosa secretes a watery lubricant that allows parts of the gut to move smoothly over each other without friction.

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PATHOPHYSIOLOGY OF CONGESTIVE HEART FAILURE LEFT-SIDED

(Book Base)
Causes: -Myocardial infarction -Prolong hypertension -Aortic Stenosis Insufficiency -Mitral Stenosis Insufficientcy

Reduced Myocardial Contractility Increased Cardiac Workload Decreased Diastolic Filing Obstruction of Left Arial Emptying

Left-Sided Congestive Heart Failure

Blood drums back into the pulmonary capillary bed

Decreased Stroke Volume

Pressure of blood into the pulmonary capillary bed increases

Decreased Tissue Perfussion

Fluid shift into the intra and inter-alveolar spaces

Increase Cellular Hypoxia Decrease blood flow to the kidneys

Pulmonary Edema Signs and Symptoms of LSCHF

RAAS Stimulation

Vasoconstriction & Rearbsorption of Sodium and Water Dyspnea Paroxysmal Nocturnal Dyspnea Orthopnea Rales/ Crackles Moist Cough Blood Tinged Frothy Sputum Wheezing/ Cardiac Asthma Dizziness Fatigue Weakness Anorexia Hypokalemia Polycythemia S3 & S4 heart sounds

Increase ECG Volume

Increase total blood volume Increase Systemic Blood pressure

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PATHOPHYSIOLOGY OF CONGESTIVE HEART FAILURE LEFT-SIDED (Actual Pathophysiology of our patient) Precipitating Factor: Sedentary Lifestyle (smoking, drinking alcoholic beverages) Predisposing Factor: Advancing Age (63 years old) Heredity Hypertension

Decreased elasticity of blood vessels and formation of plaques on blood vessels Narrowing of the blood vessels Necrosis and scarring of the vascular endothelium Impediment of blood flow to the body Increased workload of the heart

Dilatation of the ventricles

Increase in preload

Increased stretching of the myocardial muscle

Ineffective cardiac muscle contraction and increase O2 demand of cardiac

Decreased contraction in cardiac muscle

Decreased cardiac output and systemic perfusion

Conitnued neurohormonal stimulation

Cardiac remodelling

Increased stroke volume and decreased cardiac output 14

Inadequate Tissue Perfusion

Increased Wall tension

PALLOR

Decreased blood flow to the kidneys

Decreased perfusion in the coronary arteries

Increased pulmonary pressure

Separation of mitral valve leaflets

Kidneys produce hormones

Deprivation of cardiac muscle cells of nutrients needed for survival

FATIGUE & WEAKNESS

Increased pulmonary pressure

Salt and water retention Normal balance between oxygen and supply and demand is disrupted

Impaired left ventricular relaxation

EDEMA

ISCHEMIA

Increased diastolic pressure exceeding hydrostatic & osmotic pressure in pulmonary capillaries

Conversion of aerobic metabolism to anaerobic metabolism Causes reduced contractility Decreased adenosine

Increased capillary pressure in the lungs

Decreases the hearts ability

Increased lactic acid production

Fluid shifts from the circulating blood into the interstitium, bronchioles, bronchi & alveoli

BRADYCARDIA

Irritation of myocardial cells PULMONARY CONGESTION CHEST PAIN Decreased lung expansion Fluid trapped in pulmonary trees DYSPNEA BILATERAL CRACKLES

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V. MEDICAL MANAGEMENT a. Doctors Order Date & Time Doctors Order Rationale September 16, >Please admit under the service of Dr. To provide management 2012 dela Serna fitted for patient

>Secure consent to care

To provide understanding in the part of the client including significant others for any medical, surgical, and nursing intervention and also for legal documentation purposes

>TPR q shift

To monitor the Vital signs of patient for any untoward complications

>Low salt diet

It may affect the blood pressure of the patient. To check or evaluate any deviation from normal in blood count; To check for what type of blood the patient has for possible blood transfusion; To check for blood sugar level The sodium levels are measured to detect whether there's the right balance of sodium and liquid in the blood to carry out those functions. Potassium is is essential to regulate how the heart beats. Potassium levels that are too high or too low can increase the risk of an abnormal heartbeat (also called arrhythmias) To check for the electrical activity of the heart It is a projection radiograph of the chest used to diagnose conditions

>Laboratory:

CBC

Hgt

Na K

ECG CXR PA

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Creatinine

affecting the chest, its contents, and nearby structures. It is an indicator of the renal function; SGPT and SGOT assists in differentiating whether the jaundice requires surgical treatment, as in case of obstructive jaundice due to gall bladder stones; It is a measure of how well the kidneys are working. It maintains fluid volumes in balance between the space inside and outside the blood vessels. Lactated Ringer's contains electrolytes, substances necessary for cell functioning It used to treat high blood pressure (hypertension). Lowering high blood pressure helps prevent strokes, heart attacks, and kidney problem. Captopril is an ACE inhibitor and works by relaxing blood vessels so that blood can flow more easily This medication is used to treat the symptoms of too much stomach acid such as stomach upset, heartburn, and acid indigestion For continuity of care

SGPT

BUN

>Start IVF of PLR 1L @ 20gtts KVO rate

>Give Captopril 25mg

>Alligost (Maalox) 2tabs now then TID

>Continue other medications ISMN 50mg 1-0-0 Losartan + HCIZ 100/12 1-0-1/2

To treat high blood pressure and reduce the risk of stroke in certain people with heart disease This promotes sodium and water excretion while conserving potassium. Clopidogrel helps prevent platelet aggregations or

Spirolactone (Aldoctone) 25mg

Clopidogrel 75mg 0-1-0

17

>BP q 4

blood clots which can lead to vascular ischemic events. For BP monitoring, to check if there is a difference in the BP To monitor and determine fluid retention For further patients thorough assessment and management Doctors assessment patient of

>I & O q shift

>please inform AP of his admission September 17, 2013 12:30pm Seen and examined patient

>No fruit/ fruit juices in the diet

Usually in CHF, kidneys do not work well and

>Hold Aldactone >Domperidon (motilium) 1tab TID >Evaluated total calcium, phosphorus, urea, crea, albumin SGPT in old test > Limit PO fluid to 600ml/day >I & O q shift >Thank you for referral

To stop diuresis To improve mobility peristaltic

To avoid fluid overload Monitoring fluid balance

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b. LABORATORY RESULTS Hematology It is a series of screening test, which consist of Hemoglobin and Hematocrit. It is used routinely to screen for, to help diagnose and to monitor variety of condition. It provides a complete evaluation of all formed elements of the blood. It can supply a great deal of information necessary to diagnosed hematopoetic system and helps to evaluate the strategies and prognosis of certain disease.

Laboratory Results: Hematology LABORATORY AND DIAGNOSTIC EXAMINATIONS

Date September 16, 2013 WBC Lab. Test Hematology Significant or Results/Findings Actual Result 4.4 Normal values A low leukocyte count may be due to the clients antibiotic medication which was prescribed to treat previous UTI. A slight increase of monocytes may indicate a stress response to a chronic inflammation or a chronic disease state (in this case, CHF) Low hemoglobin level which can result in anemia may be caused by several reasons.

5-10 x 109/L

0.56 Neutrophils 0.35

0.51-0.67

0.21-0.35

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Date September 16, 2013

Lab. Test Blood Chemistry Lymphocytes BUN

Actual Result

Normal values

Significant or Results/Findings A high level of BUN shows that there is a Proteinuria is often seen in CHF and it may decrease in renal perfusion which is often the cause the loss of erythropoietin in the urine. case with congestive heart failure. ACE inhibitor therapy may interfere with both erythropoietin in transport the A decrease in HDL leadsproductions to decreased of cholesterol away from the arteries leading kidney and erythropoietin activity in the to further accumulation of cholesterol in the lumen bone marrow. Decreased renal perfusion beds.may Thiscause furtheradamages the already decrease in hemoglobin level atherosclerotic vessels, which contributes to by theperfusion reductionto of the production inadequate heart. of erythropoietin in the kidney. Low level of sodium may be due to the diuretic therapy of the patient or dueresult to increased A low hematocrit may from an activity of arginine vasopressin (AVP) that occurs in or increased plasma volume (hemodilution) CHF. from AVP reduced increases free-water reabsorption in red blood cell volume. the renal collecting ducts, increasing blood Hemodilution is common in CHF patients. volume and diluting plasma sodium concentrations. Nursing Responsibilities: level Maintain aseptic An elevated of BUA maytechnique due to thein doing decrease in renal excretion of uric proper acid that is procedures. Perform caused by decrease renal perfusion that often handwashing. accompanies CHF. Nutrition of the client should be ensured as this will strengthen his immunity. Nursing Responsibilities: Enhance rest to lower bodys Ensure adequate fluid intake within oxygen restrictions (<requirements. 1L/day) Strictly monitor fluid intake and output. Administer O2 as needed Observe for outward manifestation of fluid and electrolyte imbalances especially hyponatremia Advice client to avoid fried foods but instead to consume foods prepared by boiling or steaming. Explain to the client the benefits of food rich in omega-3 fatty acids like tilapia and catfish Ensure adequate dietary sodium intake by consuming meals on time.

0.09

0.02 0.08

Monocytes Cholesterol 123 Creatinine Hemoglobin 211 150-400 x 109/L 130-180gm/dl

HDL

Platelet LDL count

Glucose 37 Hematocrit Triglycerides 39-54%

BUA

Na

20

10.0

2.5 6.4 mmol/L

3.6

5.2 mmol/L

100.4

35.4 150.3 mol/L

0.55

0.7 2.2 mmol/L

2.926

1.7 4.6

4.15

3.8 6 mmol/L

0.62

0.4 1.8

0.58

0.14 0.41

128.5

135 148mmol/L

3.54

3.4 5.3mmol/L

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RADIOLOGY Chest X ray A chest x ray is a procedure used to evaluate organs and structures within the chest for symptoms of disease. Chest x rays include views of the lungs, heart, and small portions of the gastrointestinal tract, thyroid gland and the bones of the chest area. X rays are a form of radiation that can penetrate the body and produce an image on an xray film.

CHEST PHYSICAL ASSESSMENT RESULTS: Lungs are clear. Heart is enlarged. Aorta is lertous. Diaphragm sulci are intact. IMPRESSION: Cardiomegaly Anleromatous Aorta Analysis: Patient A developed cardiomegaly due to Congestive Heart Failure.

SONOGRAPHY Ultrasound Abdominal ultrasound is an imaging procedure used to examine the internal organs of the abdomen, including the liver, gallbladder, spleen, pancreas, and kidneys. The blood vessels that lead to some of these organs can also be looked at with ultrasound.

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SONOGRAPHIC RESULTS: REQUEST: Whole Abdomen Liver: The liver is normal in size, shape & echo pattern No discrete mass or dilated Intrahepatic duct seen Impression: Normal study of the Liver.

Gallbladder:

Wall is not thickened No Intraluminal echogenicitis seen

Impression:

Normal study of the Gallbladder

Common Duct: Impression:

The common duct measured 0.4cm It is normal in caliber

Pancreas:

The pancreas is normal in size, shape & echo pattern No discrete mass lesion seen

Impression:

Normal study of the Pancreas

Spleen:

The spleen is normal in size & echo pattern No discrete mass lesion or calcification seen

Impression:

Normal study of the Spleen

Kidneys: measured 7.3x

The right kidney measured 6.3 x 3.1cm while the left kidney

4.1cm Both kidney appears small with diffusely increase parenchymal echogenicity No lithiasis or hydronephrosis seen Impression: Chronic nephropathy, bilateral.

Urinary Bladder:

Urinary Bladder was not adequately distended.

Analysis: Patient A has Cardiomegaly which can be caused by a number of different conditions, including diseases of the heart muscle or heart valves, high blood pressure, arrhythmias, and pulmonary hypertension. Cardiomegaly can also sometimes

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accompany longstanding anemia. Also Chronic Nephropathy, a renal disease that can lead to cardiovascular disease and pericarditis.

ELECTROCARDIOGRAPHY ECG Sep. 4, 2010 9:30pm Actual Findings

PR Int.: P/QRS/T Int (MS): QT/QTC Int. (MS): P/QRS/T Axis (Deg):

271 118, 96, 182 434, 446 71,52

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C. DRUG STUDY Drug/Classification/Dose, Route, and Frequency

Indication

Mechanism of Action

Adverse Reaction

Nursing Responsibilities Be alert for early signs of hepatotoxicity (though low and thought to be a hypersensitivity reaction): jaundice (dark urine, pruritus, yellow sclera and skin) Be aware that even if symptomatic relief is provided by ranitidine, this should not be interpreted as absence of gastric malignancy Lab tests: Periodic liver functions. Monitor creatinine clearance if renal dysfunction is present or suspected. When clearance is <50 mL/min, manufacturer recommends reduction of the dose to 150 mg once q24 hours with cautious and gradual reduction of the interval to q12 hours or less, if necessary. Monitor BP during periods of diuresis and through period of dosage adjustment Monitor for S&S of hypokalemia Monitor I&O ratio and pattern Avoid replacing fluid losses with large amounts of water Lab tests: Obtain frequent blood count, serum and urine electrolytes, CO2, BUN, blood sugar, and uric acid values during first few months of therapy and periodically thereafter. 25

Zantac (Ranitidine)/ H2receptor Antagonist/ 50 mg IV every 8 hours

Prevention and treatment of stress-induced upper GI bleeding in critically ill patients

Potent anti-ulcer drug that competitively and reversibly inhibits histamine action at H2receptor sites on parietal cells, thus blocking gastric acid secretion. Indirectly reduces pepsin secretion but appears to have minimal effect on fasting and postprandial serum gastrin concentrations or secretion of gastric intrinsic factor or mucus

Change in the amount of urine produced Dark urine Fever, chills, or sore throat Hallucinations Epigastric pain Unusual bruising or bleeding Jaundice

Lasix (Furosemide)/ Loop Diuretic/ 40mg IV every 8 hours

Edema associated with CHF

Inhibit reabsorption of sodium and water in the ascending limb of the loop of Henle.

Hematuria Hyponatremia Hypochloremic alkalosis Hypokalemia Melena Ototoxicity Pancreatitis Xanthopsia

Plavix (Clopidogrel)/ Thrombolytic Agent/ 75mg Oral OD

Reduction of atherosclerotic events(MI, stroke, vascular death)

Inhibits platelet aggregation by irreversibly inhibiting the adenosine diphosphate (ADP) pathway for platelet activation

Severe neutropenia Hematuria Melena Purpura Hematemesis Rash

May be administered with or without food Provide small, frequent meals if GI upset occurs Provide comfort measures and arrange for analgesics if headache occurs Periodic measurement of bleeding time and platelet function is needed Should be administered on an empty stomach (Administer on an empty stomach hour before meals.). Monitor effectiveness of drug in relieving angina Note: Chronic administration of large doses may produce tolerance and thus decrease effectiveness of nitrate preparation Make position changes slowly, particularly from recumbent to upright posture, and dangle feet and ankles before walking Keep a record of anginal attacks and the number of sublingual tablets required to provide relief. Should be administered with food Check blood pressure before initiation of therapy and at regular intervals throughout therapy Monitor daily I&O and check for edema.

Isordil (ISDN)/ Nitrate Vasodilator/ 60mg Oral OD

Treatment of chronic congestive heart failure. Prophylactic management of Angina Pectoris

Aldactone (Spironolactone)/ Potassium-sparing Diuretic/ 25mg Oral BID

Management of CHF. Counteract potassium lost caused by other diuretics

Stimulation of intracellular cystic- GMP results in vascular smooth muscle relaxation of both arterial and venous vasculature. Increased venous pooling decreases ventricular pressure (pre-load) and arterial dilatation decreases arterial resistance (afterload). Therefore this reduces cardiac oxygen demand by decreasing left ventricular pressure and systematic vascular resistance by dilating arteries Spironolactone acts on the distal renal tubules as a competitive antagonist of aldosterone. It increases the excretion of sodium chloride and water while conserving potassium and hydrogen ions.

Headaches Flushing Orthostatic hypotension Dizziness Palpitations Weakness

Gynaecomastia Drowsiness Headache Hyponatremia Tachycardia Hypotension Oliguria Loss of libido

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Impotence

Observe for and report immediately the onset of mental changes, lethargy, or stupor in patients with liver disease Lab tests: Monitor serum electrolytes (sodium and potassium) especially during early therapy; monitor digoxin level when used concurrently. Should be administered one hour before meals. Dosage must be individualized. Monitor BP closely following the first dose Advise bed rest and BP monitoring for the first 3 h after the initial dose Lab tests: Establish baseline urinary protein levels before initiation of therapy and check at monthly intervals for the first 8 months of treatment and then periodically thereafter Monitor for blood pressure, ECG, pulse frequently during dose adjustments Monitor for intake and output ratios and daily weight. Assess for signs and symptoms of CHF Assess for signs and symptoms of Hypotension Instruct patient to have a low fat low sodium diet regimen Assess for signs of angioedema Monitor BUN and serum creatinine levels Monitor for signs of hyperkalemia

Capoten (Captopril)/ ACEinhibitor/ 25mg Oral BID

Management of CHF

Lowers blood pressure by specific inhibition of the angiotensin-converting enzyme (ACE). This interrupts conversion sequences initiated by renin that lead to formation of angiotensin II, a potent endogenous vasoconstrictor.

Arthralgia Hypotension Dizziness Fainting Hyperkalemia Neutropenia

Losartan (Cozaar) Management to Hypertension

It blocks vasoconstrictor Fatigue and aldosterone producing Hypotension effects of angiotensin II at Bradycardia receptor sites, including vascular smooth muscle and the adrenal glands

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Aluminum Hydorxide, Mangesium Hydroxide (Maalox)

Symptomatic relief of hyperacidity

Dissolves in acidic gastric secretions, releasing anions that partially neutralize gastric hydrochloric acid. Also elevates gastric pH, inhibiting the action of pepsin.

Constipation Diarrhea Edema Hypermagnesemia Hypophosphatemia Osteomalacia Osteoporosis

Motilium (Domperidone)

It facilitates gastric emptying and decreases small bowel transit time by increasing esophageal and gastric peristalsis and by lowering esophageal sphincter pressure. Indications: The relief of nausea and vomiting, epigastric sense of fullness, upper abdominal discomfort and regurgitation of gastric contents

Immune System Disorder: Very rare; Allergic reaction Endocrine disorder: Rare; increased prolactin levels Nervous system disorders: Very rare; extrapyramidal side effects. Gastro-intestinal disorders: Rare gastrointestinal disorders including very rare transient intestinal cramps

Monitor long-term use of high doses if patient is on sodium-restricted diet. Assess for GI bleeding Watch for constipation Tell patient to take drug 1hour after meals and at bedtime. Caution patient not to take drug within 1 to 2hours of anti-infectives. Advise patient to take drug with water or fruit juice. Instruct patient to report signs and symptoms of GI bleeding and hypophosphatemia (appetite loss, malaise, muscle weakness). Recommend increased fiber and fluid intake and regular physical activity to help ease constipation 1. Take this medication by mouth as prescribed usually 30 minutes before meals and at bedtime 2. Monitor for persistence of nausea and vomiting to evaluate the effectiveness of the drug. 3. Monitor for signs of abdominal discomfort such as epigastric pain or abdominal fullness. 4. Monitor vital signs to determine signs of dehydration 5. Perform oral care 7. Tell client to limit intake of alcoholic beverages. 8. Tell patient that she may get dizzy or drowsy with this drug, tell her not to sit or stand quickly. 9. Tell patient to keep away from the sun because this can make her more sensitive to the sun. 28

VI. NURSING ASSESSMENT Name of Patient: Timtim, Alberto Temp: 36.6 PR: 78bpm NURSING SYSTEM REVIEW CHART RR: 20cpm BP: Height: 54 140/90mmHg ft. Weight: 65kg Date: September 17, 2013

EENT []impaired []blind []pain vision []reddened []drainage []gums []hard hearing []deaf []burning []edema []lesion []teeth Assess eyes, ears, nose, throat for any abnormalities [x]no problem RESPIRATORY []asymmetric []tachypnea []apnea [x]cough []rales []barrel chest []bradypnea []shallow []rhonchi [x]sputum []diminished []dyspnea [x]wheezing []orthopnea []labored []pain []cyanotic Assess respiration, rate, rhythm, depth, pattern, breath sounds, comfort []no problem CARDIOVASCULAR []arrhythmia []tachycardia []numbness []diminished []edema []fatigue pulses []irregular []bradycardia []murmur []tingling []absent pulses []pain Assess heart sound, rate, rhythm, pulse, blood pressure, circulation, fluid retention, comfort []no problem GASTROINTESTINAL TRACT []obese []distention []mass []dysphagia []rigidity []pain Assess abdomen, bowel habits, swallowing, bowel sound, comfort [x]no problem GENITO-URINARY & GYNE []pain []urine color []bleeding []hematuria []discharges []nocturia Assess urine frequency, control, color, odor, comfort, gyne bleeding, discharges []no problem NEURO []paralysis []stuporous []unsteady []seizures []lethargic []comatose []vertigo []tremors []confused []vision []grip

Facial Grimace Chest Pain: 6/10 CARDIOMEGALY Abdominal Pain: 6/10 Guarding BP: 140/90mmHg Skin warm to touch Untrimmed nails Recent change weight & apetite in

(pail nailbeds) Generalized weakness Untrimmed nails body

Assess motor function, sensation, Loc, strength, grip, gait, coordination, orientation, speech [ x]no problem MUSCULOSKELETAL & SKIN []appliance []stiffness []itching [x]hot []petechiae []drainage []prosthesis []swelling []lesion []cool []poor turgor []deformity []wound []rash []skin color []flushed []atrophy []pain (back) [x]pale []diaphoretic []moist Assess mobility, motion, gait, alignment, joint, function, skin color, texture, turgor, integrity []no problem

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NURSING ASSESSMENT II SUBJECTIVE DATA OBJECTIVE DATA COMMUNICATION Comments:Wala []Glasses []Languages []Hearing Loss man pud hinuon, []Contact Lens []Hearing Aide []Visual Changes okay raman, Pupil L: R:3m []Speech difficulties size 3mm m [x]Denied Reaction: Pupil Equally Round Reacting to Light Accomodation - PERRLA OXYGENATION Comments: Wala Respiration [x]Regular []Irregular []Dyspnea man siya gi-ubo, Describe: Wheezing is noted upon []Smoking History ok raman pero auscultation. may time na hindi []Cough maayos paghinga []Sputum niya R: Full Chest expansion symmetric to Left Lung []Denied CIRCULATION [x]Chest Pain [x]Numbness of extremities [x]Denied NUTRITION Diet Low Salt Diet [x]Recent change in weight and appetite []Swallowing Difficulty []Denied ELIMINATION Usual bowel pattern Once a day Constipation Remedy Comments: Sumasakit man dibdib ko nasa may 6/10 L: Full Chest expansion symmetric to Right Lung Heart Rhythm [x]Regular []Irregular Ankle Edema : No Ankle Edema Noted Pulse Car Rad AP Fem* R 74bpm 76bpm 78 NO L 75bpm 74bpm 78 NO Comments []Dentures [x]None Complete Incomplete Upper [] [] Lower [] []

Comments: Nagamay siya gamay pero di man sobra gyud, naa napud mga bawal sa iya nga pagkaon Urinary frequency 4 X DAY []Urgency []Dysuria

[]Hematuria Urine color, Date of last BM []Incontinence consistency, odor September 14, []Polyuria 2013 No foley bag catheter Diarrhea Character []Foley in place attached to urobag. []Denied MANAGEMENT OF HEALTH AND Briefly describe patients ability to follow ILLNESS treatments (diets, medications, etc.) Patient is diligent of his diet, medications and treatment. Medications were properly consumed. [x]Alcohol []Denied N/A []SBE Last Pap Smear: Not Applicable LMP: N/A

Comments: The client has not yet voided upon waking up in the morning and his bowel sounds are not clearly heard.

Bowel Sounds : hypoactive Abdominal Distention []Yes [x]No

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SUBJECTIVE DATA SKIN INTEGRITY Comments: Wala []Dry Wala naman ako []Itching problema sa balat, [x]Denied ganito lang talaga ang balat pag tumanda na

OBJECTIVE DATA [x]Dry []Cold [] Pale []Flushed [x]Warm []Moist []Cyanotic Rashes, ulcers, decubitus (describe size, location, drainage, color, odor There are no rashes ulcers, decubitus seen. LOC & Orientation: Patient is conscious and is oriented of time and place Gait: []Walker []Cane []Steady []Unsteady []Sensory & motor losses in face and extremities: No sensory and motor losses in the face and extremities ROM Limitations:No ROM limitations except for hand with IV catheter [x]Facial Grimace [x]Guarding []Other signs of pain: Facial grmace & guarding seen when patient is coughing.

ACTIVITY & Comments: SLEEP Nakatulog ako ng []Convulsion maayos pero may []Dizziness oras na nagigising []Limited Motion of ako, Joints Limitation in ability to [x]Ambulate []Bathe self []Denied COMFORT/SLEEP/AWAKE [x]Pain (location, Comments:Sakit frequency & remedy ako tiyan, labi na []Nocturia magtindog ko []Sleep Difficulty mukalit lang siya []Denied sakit, 5/10

COPING Occupation Retired Carpenter Members of household : 5 Most supportive person: Leonora Cinco

Observed non-verbal behavior : There are no observed non-verbal behavior to patient. Person and phone number that can be reached at any time Client refuse to give

SPECIAL PATIENT INFORMATION 65kg Daily Weight ___N/A___PT/OT___________ 140/90mmHg BP q Shift ___N/A____ Irradiation __N/A__ Neuro VS ___N/A___ Urine Test __N/A_____ CVP/SG Reading ___N/A_____24 hour urine collection
Date Ordered September 12, 2013 Diagnostic/Laboratory Exams Complete Blood Count* Hgt Creatinine Na, K, BUN SGPT Date Done September 16, 2013 Date Ordered September 16, 2013 September 17, 2013 IV Fluids/Bood #1 PLR #2 PLR Date Disc September 17, 2013

September 17, 2013

*Refer to Results in the Diagnostic Exams Page

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VII. NURSING MANAGEMENT PROGRESS NOTES September 17, 2013 FIRST DAY (ASSESSMENT) I had my assessment, Wednesday at 1:00 in the afternoon at Polymedic General Hospital, CDOC with my patient Yu, Klint Robin Y. Upon arrival, patient was sleeping in his bed. I had done my head to toe assessment and assessed patients health status through inspection, auscultation, palpation and percussion. Assessment findings included: patient has occasional productive cough and is suffering from hyperthermia. I also determined the patients diet (Diet as Tolerated) and we found out that since he has fever, there is already recent change in appetite as well as hi s weight. Vital signs are within normal range. Significant others expressed that he always sleep and very weak since admission, he cant answer my questions. He just woke up when I have something to ask then goes back to sleep directly. With the assessment presented, I prioritized problems and planned interventions based on the existing problems manifested by the patient. Interventions planned were focused on relieving pain and providing comfort to the patient. The following were the interventions rendered and health teachings given: 1. Obtained and recorded vital signs. 2. Monitored blood pressure. 3. Encouraged to express feelings regarding feelings toward body weakness 4. Instructed to avoid gastric irritant foods. 5. Encouraged adequate rest periods 6. Encouraged to do deep breathing exercise during onset of pain 7. Encouraged to do diversional activities like listening to music. 8. Placed patient to comfortable position. 9. Emphasized compliance of prescribed medications. 10. Emphasized to limit fluid intake. 11. Keep back always dry.

TPR SHEET

Hours 10apm 2pm

Day 1 (December 12, 2012) Assessment Temperature Pulse Rate Respiratory Rate 36.6 36.4 78bpm 72bpm 20cpm 18cpm

Blood Pressure 140/90mmHg 150/100mmHg

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A. IDEAL NURSING MANAGEMENT Nursing Diagnosis Nursing Interventions 1. Monitored urine output, noted amount and color Rationale - scanty and concentrated urine output signals reduced renal perfusion - evaluates effect of diuretic therapy and assesses fluid retention or loss - recumbency increases glomerular filtration and decreases production of ADH, thereby enhancing diuresis - involving client in therapy regimen may enhance sense of control and cooperation with restrictions

Excess Fluid Volume r/t sodium and water retention 2 detrimental compensatory mechanism (decreased renal perfusion, activation of reninangiotensin-aldosterone system) as a response to decreased cardiac output of heart failure

2. Monitored intake and output for the shift

3. Maintained on bed rest in semi-Fowlers position

4. Established at most 330cc fluid intake per 8 hours. Informed client of <1L fluid restriction. Instructed client to record own intake and output 5. Weighed daily

- documents changes in/resolution of edema or monitors development of excessive fluid shifts/ weight loss - monitors signs of excessive fluid volume and retention of 10 lb of fluid for pitting edema - monitors signs of pulmonary congestion

6. Assessed for JVD and inspected edema (pitting/nonpitting) daily

7. Auscultated breath sounds daily

8. Assessed bowel sounds and noted complaints of abdominal distention 9. Measured abdominal girth

- monitors signs of visceral congestion that alters GI function - monitors development of ascites - monitors sign of venous congestion, hepatomegaly causing alteration in liver function - monitors signs of hypo/hyperkalemia and hyponatremia due to diuretic therapy and sudden fluid shifts

10. Palpated abdomen and noted complaints of RUQ pain

11. Monitored for lethargy, hypotension and muscle cramping/twitching

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12. Administered furosemide and spironolactone as prescribed.

- increase rate removal & sodium/chloride reabsorption

of fluid prevent

Nursing Diagnosis

Nursing Interventions 1. Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors. 2. Administer or assist with self-administration of vasodilators, as ordered.

Rationale 1. To identify intensity, precipitating factors and location to assist in accurate diagnosis.

Acute pain related to CHF

3. Assess the response to medications every 5 minutes

2. The vasodilator nitroglycerin enhances blood flow to the myocardium. It reduces the amount of blood returning to the heart, decreasing preload which in turn decreases the workload of the heart. 3. Assessing response determines effectiveness of medication and whether further interventions are required. 4. To provide nonpharmacological pain management. 5. A quiet environment reduces the energy demands on the patient. 6. Elevation improves chest expansion and oxygenation. 7. Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation. 8. Anginal pain is often precipitated by emotional stress that can be relieved non-pharmacological measures such as relaxation. 9. In some case, the chest pain may be more serious than stable angina. The patient needs to understand the differences in order to seek emergency care in a timely fashion

4. Provide comfort measures. 5. Establish a quiet environment. 6. Elevate head of bed.

7. Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides. 8. Teach patient relaxation techniques and how to use them to reduce stress. 9. Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction

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Nursing Diagnosis

Nursing Interventions 1. Assess for abnormal heart and lung sounds.

Rationale

Decreased Cardiac Output

2.

3.

4.

5.

6.

7.

8.

1. Allows detection of leftsided heart failure that may occur with chronic renal failure patients due to fluid volume excess as the diseased kidneys are unable to excrete water. Monitor blood pressure 2. Patients with renal failure and pulse. are most often hypertensive, which is attributable to excess fluid and the initiation of the rennin-angiotensin mechanism. 3. The accumulation of Assess mental status and waste products in the level of consciousness. bloodstream impairs oxygen transport and intake by cerebral tissues, which may manifest itself as confusion, lethargy, and altered consciousness. 4. Decreased perfusion and Assess patients skin oxygenation of tissues temperature and secondary to anemia and peripheral pulses. pump ineffectiveness may lead to decreased in temperature and peripheral pulses that are diminished and difficult to palpate. Monitor results of 5. Results of the test provide laboratory and diagnostic clues to the status of the tests. disease and response to treatments. Monitor oxygen 6. Provides information saturation and ABGs. regarding the hearts ability to perfuse distal tissues with oxygenated blood Give oxygen as indicated 7. Makes more oxygen by patient symptoms, available for gas oxygen saturation and exchange, assisting to ABGs. alleviate signs of hypoxia and subsequent activity intolerance. 8. Decreases the risk for Implement strategies to development of cardiac treat fluid and electrolyte output due to imbalances imbalances. .

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9. Administer cardiac 9. Digitalis has a positive glycoside agents, as isotropic effect on the ordered, for signs of left myocardium that sided failure, and monitor strengthens contractility, for toxicity. thus improving cardiac output. 10. Encourage periods of rest 10. Reduces cardiac workload and assist with all and minimizes myocardial activities. oxygen consumption. 11. Allows for better chest 11. Assist the patient in expansion, thereby assuming a high Fowlers improving pulmonary position. capacity. 12. Provides the patient with 12. Teach patient the needed information for pathophysiology of management of disease disease, medications and for compliance. 13. Reposition patient every 13. To prevent occurrence of 2 hours bed sores 14. Instruct patient to get 14. To promote relaxation to adequate bed rest and the body sleep 15. To ensure safety and 15. Instruct the SO not to reduce risk for falls that leave the client may lead to injury unattended

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B. ACTUAL NURSING MANAGEMENT S O

Sakit ang akung tiyan, gahapdus pud. Pain as claimed with pain scale of 6 out of 10 o facial grimaces o guarding o restless

Acute Pain related to inflammation of the lining of the stomach

Long term: After 1 day of nursing intervention, patient will continuously report alleviation of pain with pain scale of 1. Short term: After 4 hours of nursing interventions, the patient will report a decreased or alleviated pain scale from 6/10 5/10 and below.

Encouraged deep breathing exercise during onset of pain. Provided quiet environment, calm activities. Encouraged to do diversional activities such as listening to music. Provided comfort measures such as backrub, changes of position Promoted adequate rest period Administered medication as prescribed.

The patient reported a pain scale of 4/10.

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S O

Gakapoyan ko ug dali Restlessness Greater need for sleep and rest Weakness and fatigue

A P

Excessive Fluid volume r/t decreased cardiac output Short term: After 8 hours of nursing intervention, the patient will verbalize understanding of causative factors and demonstrate behaviors to resolve excess fluid volume. Long term: After 3-4 days of nursing intervention, the patient will demonstrate adequate fluid balanced AEB output equal to exceeding intake, clearing breath sounds, and decreasing edema

1. Auscultate breath sounds q 2hr and pm for the presence of crackles and monitor for frothy sputum production 2. Assess for presence of peripheral edema. Do not elevate legs if the client is dyspneic. 3. Follow low-sodium diet and/or fluid restriction 4. Encourage or provide oral care q 2. 5. Obtain patient history to ascertain the probable cause of the fluid disturbance. 6. Monitor for distended neck veins and ascites 7. Evaluate urine output in response to diuretic therapy.

Goal is met after 8 hours of nursing intervention, patient has higher fluid intake than output.

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S O

Galain lage ako dughan murag gasakit usahay Pain Scale of 6-7/10 Facial Grimace

A P

Acute Pain related to CHF Short Term: After 3-4 hours of nursing interventions, the patients pain will decrease from 67to 3 as verbalized by the patient. Long Term: After 2-3 days of nursing interventions, the patient will demonstrate activities and behaviors that will prevent the recurrence of pain.

1. Assessed patient pain for intensity using a pain rating scale, for location and for precipitating factors. 2. Assessed the response to medications every 5 minutes 3. Provided comfort measures such as listening to music. 4. Established a quiet environment. 5. Elevated head of bed. 6. Monitored vital signs especially pulse and blood pressure, every 5 minutes until pain subsides. 7. Taught patient relaxation techniques and how to use them to reduce stress. After 4 hours of nursing interventions, the patient demonstrated behaviors to alleviate pain and he reported pain scale of 5.

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S O

No subjective cues with pale conjunctiva, nail beds and buccal mucosa irregular rhythm of pulse bradycardia pulse rate of 34 beats/min generalized weakness

Decreased cardiac output r/t altered heart rate and rhythm AEB bradycardia

Short Term: After 3-4 hours of nursing interventions, the patient will participate in activities that reduce the workload of the heart. Long Term: After 2-3 days of nursing interventions, the patient will be able to display hemodynamic stability.

1. 2. 3. 4. 5. 6. 7. 8. 9.

Assessed for abnormal heart and lung sounds. Monitored blood pressure and pulse. Assessed mental status and level of consciousness. Assessed patients skin temperature and peripheral pulses. Monitored results of laboratory and diagnostic tests. Encouraged periods of rest and assisted with all activities. Assist the patient in assuming a high Fowlers position. Repositioned patient every 2 hours Instructed patient to get adequate bed rest and sleep

Short Term: After 3-4 hours, the patient has participated in activities that reduce the workload of the heart. Long Term: After 2-3 days of nursing interventions, the patient has been able to display hemodynamic stability.

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VIII. REFERRAL AND FOLLOW-UP HEALTH TEACHINGS MEDICATION Client was reminded of the name and purpose of prescribed drugs; and was instructed to take medications as prescribed and reminded him of the consequences of not doing so, which is exacerbation of his condition. Instructed to take his home medications: Isordil (ISDN) 60mg/PO/OD Captopril 75mg/PO/OD

EXERCISE

Encouraged client to stay as active as he can; a mild exercise regimen was suggested (helps decrease symptoms and improve heart function). Stretching in the morning and active ROM exercises was recommended.

Walking around the house or outside with friends once a day for 15-30 minutes if tolerated was advised. Heavy lifting and strenuous activities should be avoided. Rest in between any activity and to rest when tired (or experiencing shortness of breath) was emphasized.

. Taught the importance of proper personal hygiene and hand washing Encouraged to schedule rest periods and sleep periods. TREATMENT If symptoms for Bronchitis persist esp. patient has also Asthma, have nebulisation with 1neb per use. Explained the purpose and importance of a follow-up check-up. Return 3 days after discharged to Dr. Sandra Oliveros clinic at COMC, Room 214 at 10:00am. OUTPATIENT (check-up) Advised the client and the caregiver to seek consult in the nearest health care facility when any signs of complications occur: fever, chills, pain or feeling of fullness in the chest, restlessness, decrease in the amount of urine and frequency of urination, rapid respirations, bloody sputum, palpitations and warmth pain numbness tingling on extremities.

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Instructed the client to limit intake of sodium by avoiding canned and processed goods, cheese, seasonings, sauces and condiments; also to refrain adding too much salt to foods when cooking.

DIET

Encouraged recommended dietary restrictions: a lowfat, low-cholesterol diet to avoid the risk for any advanced heart problems. (Recommended foods: high fiber food items like green leafy vegetables and whole wheat bread. Foods to be avoided: fats like butter, coconut oil, fried food, cakes, ice creams, ham, bacon, yolk of egg, red meat, organ meats, crab, shrimps, cheese, cream)

Instructed client to not skip meals, to eat in small, frequent feedings and to rest before, after and even while eating so as not to cause sudden increases in the workload of the heart.

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IX.

EVALUATION

At the end of the study, we were able to attain the goal that we have set from the start of his study. Thorough gathering of data by means of physical assessment were met and through the gathered data we were able to identify some health problems and able to skillfully formulate nursing care plan that we applied to our patient in actual. By means of reviewing, discussing and elaborating the affected anatomy and physiology of the body enabled me to create interventions that could alleviate pain and any discomfort experienced by the patient. With the help of the patient a nd his significant others cooperation, we were able to explore part of the patients personality that also helped me increasing interventions appropriate for him. Through the interventions I imparted there was a progress in patients health status such as regained his activity of daily living.

We also imparted health teachings not only the patient but to for him to impart for his family as well, in order to lower the risk of having this kind of condition. Choosing the right diet was also elaborated for him to be aware of the precise choice of foods and nutrition right for preventing the disease like avoiding food that is salty, fatty and especially those highly seasoned foods which always pertained to the food we were eating, we should still be conscious with our health especially if we want to live longer. Avoid that life threatening disease which not only shorten our life but caused us some financial problem too.

Lastly, We were also grateful for having the opportunity to have the case study for she not only gain knowledge but also enhanced my skills in the field of nursing by means of planning interventions and rendering care to the patient. We are hoping that the readers would be more conscious and be more careful in taking of their health to prevent conditions to persist.

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X.

DOCUMENTATION

BIBLIOGRAPHY

BOOKS
Smeltzer, Susann and Brenda Bare. Textbook of Medical Surgical Nursing 9th edition. Published J.B Lippincott Company. Lippincott Williams and Wilkins. Nursing drug Handbook. A Wolter's Klawer business 27th edition. Kozier, B.E, Gleonora, K, Blais, J.M Wilkinson (2001) Fundamentals of Nursing. 5th edition. JB Lippincott Company. Philadelpia. Pages 759 & 1227

ELECTRONIC LINKS Congestive Heart Failure. http://nurseslabs.com/congestive-heart-failure-av-block-nursing-care-plans/ Congestive Heart Failure Diagnosis. http://nursing-care-plan.blogspot.com/2011/12/nursing-diagnosis-and-interventionsfor.html

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