St. Augustine School of Nursing 2nd Floor, Banco Filipino Bldg. San Pedro St.

Davao City

A Case Study Presentation on Congestive Heart Failure n Partial fulfil!ent of the re"uire!ents in #PN 2$2

Presented to the Clinical nstructor of St. Augustine School of Nursing Davao City Branch

Su%!itted %y& Aloy, Charlie 'ay (. Ca!posano, (o)ena #. Arapan, *ia +enlthrod P. Castillones, *ary Alelie 'anine B.

,cto%er 2-$.

AC/N,0#1D+1*1N2

0e )ould li3e to than3 Al!ighty +od for guiding us and !a3ing this case study a success. 2his case presentation a%out Congestive Heart Failure )as !ade possi%le through the effort of our tea!. 2he topic )as very relevant since this has %een a 3iller disease co!!on in !ost people. 0e the group . of PN24$ )ould li3e to e5press our heartfelt gratitude and than3s to the people )ho have given their support in !a3ing this !anuscript a )onderful e5perience and to those people )ho %eca!e instru!ents in !a3ing this possi%le. 0e )ould li3e to than3 patient, for allo)ing us to have her as our su%6ect for our case study )hich she had %een very cooperative and open during our intervie). 0e )ould li3e to than3 the staff nurses of saac 2. (o%illo *e!orial Hospital for their 3indness and patience in assisting us in every e5posure that )e have. 2o our Clinical nstructor, for their advices, the 3no)ledge they i!parted to us, and the ti!e they taught us to %e !ore responsi%le in every aspect that )e do. 2han3 you so !uch Sir and *a7a!. 2o our parents, for their never4ending support, financially and e!otionally, than3 you so !uch8 2o our group !ates )ho had shared their 3no)ledge and ideas for the co!pletion of this case study, )ho )illingly helped us gather the necessary data and infor!ation needed for the co!plication, 2han3 you so !uch guys.

2o all )ho )ould %e a%le to read and research this case study, )e hope that )e are a%le to contri%ute so!e of the infor!ation regarding this illness. 0e hope this )ill help and lead you in one )ay or another.

2AB#1 ,F C,N21N2

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N2(,DBC2 ,N

Heart Failure often referred to as congestive heart failure CCHFD, is the ina%ility of the heart to pu!p sufficient %lood to !eet the needs of the tissues for o5ygen and nutrients. Ho)ever, the ter! CHF is !isleading, %ecause it indicates that patients !ust e5perience pul!onary or peripheral congestion to have HF, and it i!plies that patients )ith congestion have HF. 2he Agency for Health Care Policy and (esearch CAHCP(D HF guidelines panel C2-->D defined HF as a clinical syndro!e characteriEed %y signs and sy!pto!s of fluid overload or of inade"uate tissue perfusion.

Chttp&FF))).nl!.nih.govF!edlineplusFencyFarticleF---$:A.ht!D 2hese signs and sy!pto!s result )hen the heart is una%le to generate a C, sufficient to !eet the %ody7s de!ands. 2he HF guideline panel used the ter! heart failure %ecause !any patients )ith HF do not !anifest pul!onary or syste!ic congestion. 2he ter! HF is preferred and indicates !yocardial heart disease in )hich there is a pro%le! )ith contraction of the heart Csystolic dysfunctionD or filling of the heart Cdiastolic dysfunctionD and )hich !ay or !ay not cause pul!onary or syste!ic congestion. :

So!e cases of HF are reversi%le, depending on the cause. *ost often, HF is a life4 long diagnosis that is !anaged )ith lifestyle changes and !edications to prevent acute congestive episodes. CHF is usually an acute presentation of HF.

Chttp&FFen.)i3ipedia.orgF)i3iFHeartGfailureD Currently, Congestive Heart Failure continues to %e a !a6or pu%lic health pro%le! )orld)ide. t is the leading cause of !or%idity and !ortality in !ost developed countries. According to the A!erican Heart Association C2-$2D, appro5i!ately : !illion patients have heart failure and nearly ::-,--- ne) patients are diagnosed each year. n addition, nearly .--,--- patients die fro! heart failure yearly. Chttp&FF))).cdc.govFdhdspFdataGstatisticsFfactGsheetsFfsGheartGfailure.ht!D n the Philippines, cardiovascular diseases are the !ost co!!on causes of !ortality. According to the Depart!ent of Health C2-$2D, a%out ;;,-?- in a $--,--populations have died in the Philippines due to diseases of the heart. 2he aging of the population and the e!erging pande!ic of cardiovascular diseases in the developing nations of the )orld signal a rise in the incidence and prevalence of heart failure glo%ally and !agnify the i!portance of its prevention. Congestive Heart Failure is also the $st leading cause of death as of 2-$.. Chttp&FF))).healthcentral.co!Fheart4 .

diseaseFhFstatistics4of4congestive4heart4failure4in4the4philippines.ht!lD 2he prevention of heart failure is an urgent pu%lic health need )ith national and glo%al i!plications. 2his paper is a case report a%out *rs. @, ;2 years old, fe!ale, Filipino, hypertensive, no dia%etic, a post4!itral currently diagnosed )ith Congestive Heart Failure. ts purpose is to revie) the pathophysiology, pre4analytical factors, and

treat!ent in a congestive heart failure patient and identify possi%le reco!!endations for future nursing care. 2his case report is significant to our future nursing care %ecause it helps stress the i!portance of not only identification and treat!ent of patients )ith heart failure %ut also the i!portance of pro!oting a healthy lifestyle and preventive strategies to decrease the prevalence of heart failure in the general population. Also, it e5plores the need for a thorough case analysis of a client to deliver the %est nursing care. ,B'1C2 =1S

+eneral ,%6ective& At the end of the first se!ester, the group )ill %e e5pected to have ac"uired the 3no)ledge, s3ills, and attitudes funda!ental in dealing )ith the case of a client )ith Congestive Heart Failure.

Specific ,%6ective& dentify the client that )ould %e suita%le for our case study. 1sta%lish rapport to the client and fa!ily !e!%er. 2race the client7s health history involving the past and present illness. ,%tain the follo)ing data fro! the patient7s chart such as& o Past *edical History o History of Present llness o #a%oratory 15a!ination and (esults o Doctor7s ,rder ;

o Phar!acological !edication applied Discuss and illustrate the Anato!y H Physiology of the organ H the syste! affected %y such disease. dentify the etiology and sy!pto!atology )ith scientific %asis on Congestive Heart Failure. 2race and illustrate the pathophysiology of the disease. 2o interpret and illustrate the la%oratory e5a!ination results of our client. *a3e a drug study of the !edicines that the patient is ta3ing. For!ulate a nursing care plan for the patient. Construct a discharge planning and health teaching for the patient. 2o i!part !ore health teachings and reco!!endations to the client and to the significant other. 15plain the ideal and actual prognosis fro! the data collected, 2o evaluate this case study and its significance to nursing practice and nursing education.

PA2 1N2 DA2A

Na!e of Patient Age Address Se5 Birth date Birthplace Height 0eight Nationality Civil Status (eligion Socio4econo!ic status

& & & & & & & & & & & &

*rs. @ ;2 years old Puro3 2:, 2eacher7s =illage, Calinan, Davao City Fe!ale 'une 22, $<>$ Bohol, Philippines : Feet :- 3ilogra! Filipino 0ido)er (o!an Catholic *iddle4Class College Degree Holder

1ducational Bac3ground &

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,ccupation

&

2eacher CretiredD

C# N CA# DA2A

Hospital Ad!itting Date and 2i!e Ho) Ad!itted 0ardF(oo! and Bed Chief Co!pliant Attending Physician Provisional Diagnosis Final Diagnosis

& saac 2. (o%illo *e!orial Hospital & August $:, 2-$. I <&2- A! & Per )heelchair & St. Anne )ard, $$.D & Body !alaise & Dr. #icayan & Hypertensive Cardiovascular Disease & Congestive Heart Failure, Hypertensive Cardiovascular Disease

Date Discharge

& August $?, 2-$.

$-

$$

$2

H1A#2H H S2,(J

Past health history *rs. @ )as %orn on 'une 22, $<>$ at Bohol regional hospital via nor!al spontaneous vaginal delivery and she )as the first child and the only child in the fa!ily of *r. Serapio H *rs. 1pedia. ,ur patient had received full i!!uniEation since %irth until adulthood and during her infanthood she had never %een hospitaliEed )hen she had an illness such as cough, cold and severe a%do!inal pain instead her !other used to treat !ild condition. %y her%al !edicine or %rought her to a faith healer *rs. @ %elonged to !iddle socioecono!ic fa!ily. *rs.@ )as ad!itted at saac 2. (o%illo *e!orial Hospital last 'une $2, 2-$$ )ith a finding of congestive health failure and on 'une 2;, 2-$$ *rs.@@@ )as discharged fro! the saac 2. (o%illo *e!orial Hospital for the first t)o days *rs.@@@ )as a%le to ta3e his !edication prescri%ed %ut due to old age or !e!ory gap pro%le!, he did not a%le to continue ta3ing her !aintenance !edication.

Present health history According to her caregiver, on August $>, 2-$. they had their fiesta festival cele%ration. 2here are lots of co)or3er in her house. n the evening, *rs. @ co!plaint of shortness of %reathing. Her caregiver decided to ta3e her to the nearest hospital )hich is saac 2. (o%illo *e!orial Hospital on August $:, 2-$. at e5actly <&2-a!.

$.

Fa!ily health history *rs. @ )as our !ain su%6ect in this case presentation. 2heir fa!ily7s lineage revealed. n fact his health condition )as pro%a%ly ac"uired fro! his fa!ily. As )e e5plored our patient7s fa!ily health history, )e had o%tained this data. As )e Starts, )e start on his father. He father7s na!e is Serapio, he )as suffering fro! hypertensive attac3ed. Her grand!other )as Sefirina, )ho )as a hypertensive person. Her grandfather )as 'uanito, )ho is a dia%etic person. Her %rother7s na!e )as 'uanito 'r, is also a dia%etic person. Her sister na!e )as (inita and also a dia%etic person. Her !other7s na!e )as 1pedia, )ho )as an asth!atic person. Her grand!other )as 1l!ina, )ho )as a hypertensive person. Her grandfather )as Cer%olo, )ho )as suffering heart failure. Her sister na!e )as Sirina, )ho )as an asth!atic person. Her %rother na!e )as Cedro, )ho )as an asth!atic and hypertensive person. #ina )as her sister, )ho )as a dia%etic person.

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D1F N 2 ,N ,F D A+N,S S

2he purpose of the heart is to pu!p %lood to the %ody in order to nourish it. Heart failure doesnKt !ean that the heart has stopped )or3ing, %ut that it 6ust isnKt a%le to pu!p enough %lood to !eet the needs of the %ody. 2his !ay happen )hen the heart !uscle itself is )ea3er than nor!al or )hen there is a defect in the heart that prevents %lood fro! getting out into the circulation. 0hen the heart does not circulate %lood nor!ally, the 3idneys receive less %lood and filter less fluid out of the circulation into the urine. 2he e5tra fluid in the circulation %uilds up in the lungs, the liver, around the eyes, and so!eti!es in the legs. 2his is called fluid LcongestionL and for this reason doctors call this Lcongestive heart failure. ,lder children )ith congestive heart failure !ay %e tired and have pro%le!s 3eeping up )ith their friends on the playground, )hile infants )ith congestive heart failure usually have sy!pto!s during feeding including s)eating, fast %reathing and fatigue. n addition, these infants !ay not gain )eight )ell. Fluid !ay also %uild up in the rest of the %ody, causing s)elling of the feet, the legs or around the eyes. Chttp&FF))).!ydr.co!.auFcongestive4heart4failureD Heart failure, so!eti!es 3no)n as congestive heart failure CCHFD, occurs )hen your heart !uscle doesnKt pu!p %lood as )ell as it should. Conditions such as narro)ed arteries in your heart Ccoronary artery diseaseD or high %lood pressure gradually leave your heart too )ea3 pu!p efficiently. Not all conditions that lead to heart failure can %e reversed, %ut treat!ents can i!prove the signs and sy!pto!s of heart failure and help you live longer. #ifestyle changes, such as e5ercising, reducing salt in your diet, !anaging stress and especially losing )eight, can i!prove your "uality of life. 2he

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%est )ay to prevent heart failure is to control conditions that cause heart failure, such as coronary artery disease, high %lood pressure, dia%etes or o%esity.

Chttp&FF))).!ayoclinic.co!FhealthFheart4failureFDS---?$D Congestive heart failure, ina%ility of the heart to 3eep up )ith the de!ands on it, )ith failure of the heart to pu!p %lood )ith nor!al efficiency. 0hen this occurs, the heart is una%le to provide ade"uate %lood flo) to other organs, such as the %rain, liver, and 3idneys. A%%reviated CHF. CHF !ay %e due to failure of the right or left ventricle, or %oth. 2he sy!pto!s can include shortness of %reath CdyspneaD, asth!a due to the heart Ccardiac asth!aD, pooling of %lood CstasisD in the general %ody Csyste!icD circulation or in the liverKs CportalD circulation, s)elling Cede!aD, %lueness or dus3iness CcyanosisD, and enlarge!ent ChypertrophyD of the heart. 2he !any causes of CHF include coronary artery disease leading to heart attac3s and heart !uscle C!yocardiu!D )ea3nessM pri!ary heart !uscle )ea3ness fro! viral infections or to5ins, such as prolonged alcohol e5posure heart valve disease causing heart !uscle )ea3ness due to too !uch lea3ing of %lood or causing heart !uscle stiffness fro! a %loc3ed valve, hyperthyroidis!M and high %lood pressure. Chttp&FF))).hop3ins!edicine.orgFheartGvascularGinstituteFconditionsGtreat!entsFconditi onsFcongestiveGheartGfailure.ht!lD

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D1=1#,P*1N2A# 2H1,(J Fro! e5a!ining the changes in your o)n life span you can see that critical tas3s arise at certain ti!es in our lives. *astery of these tas3s is satisfying and encourages us to go on to ne) challenges. Difficulty )ith the! slo)s progress to)ard future acco!plish!ents and goals. As a !echanis! for understanding the changes that occur during the life span. (o%ert Havighurst Stage deal tas3 #ate Adulthood Decreasing physical C?: and a%oveD activities for good health

'ustification 2he condition of our patient, )ho has ede!a, and i!%alance, she and her care giver decided to reduce so!e activities )ho can !a3e her tired, li3e attending so!e far se!inars

1valuation Not achieved

Ad6usting for lifestyle and reduce inco!e.

in church. Patient )as a retired teacher, a little change on her lifestyle and inco!e

Achieved

2he satisfactory of life style or living in the society.

Patient is satisfied )ith her life even though she has %een living alone for several years no).

Achieved

PHJS CA# ASS1SS*1N2 $;

Date& August $:, 2-$. P* +eneral Survey&

2i!e& :&--

Patient )as ad!itted at saac 2. (o%illo *e!orial Hospital. (oo! N$$.D. Patient sitting on the %ed, a)a3ed, coherent and conscious, )ithout =F. =ital sign Blood pressure 2e!perature Pulse rate (espiratory rate $>-F<- !!Hg .: O C ;. %p! 2; cp! Height & : ft. 0eight& >: 3g nterpretation& 2he client7s pulse rate is nor!al )hich is the only vital sign that is nor!al a!ong the other, such as the te!perature is decrease, the respiratory rate is slightly elevated and the %lood pressure is %orderline. ntegu!entary& Pale color of the s3in )as noted )ith a%sence of %ruises or %edsores. Pitting ede!a noted at her upper and lo)er e5tre!ities. Ho)ever loss of elasticity of the s3in )as noted, s3in )as slightly cold )ith senile s3in. S3in turgor )as not assessed. Head S3ull shape )as nor!ocephalic, the hair is %lac3 and )ith no dandruff, lesions or laceration.

Face 2here7s s)elling noted at left side of the 6ugular vein. 2he distance of the eye%ro)s )ere e"ually aligned and raised. 2here7s no lesion or laceration noted. 1yes $A

2he pupils are %lac3 and e"ually round in shape and sluggish reactive to light. 2here7s no lesion or discharges noted. Patient is near sighted and is using eye glasses )ith a grade she could not re!e!%er. 1ars 2he ears )as e"ual in siEe, there7s no !asses. S)elling, redness or discharges and even any foreign o%6ect. 2here7s no pain noted. 2he patient cannot hear clearly nor!al )hat the nurse vocaliEe nor!ally. Nose 2here are no lesions, s)elling or redness noted. No discharges or pain. Difficulty of %reathing noted )ith the o5ygen inhalation of 24. #p! via nasal cannula. *outh 2he lips are pale, and dry )ith no lesions or sores noted. 2here )ere no lesion or s)elling noted in the tongue. And a%sence of infla!!ation of tonsils.

Nec3 2here )ere no #aceration, tenderness or s)elling on the nec3. 2hyroid )as not enlarge upon palpation. 2here7s no pro%le! in turning to left, right and hyper e5tending of nec3. Chest and #ungs (espiratory rate of 2; cp!, difficulty of %reathing noted )ith the o5ygen inhalation of 24. #p! via cannula. Harsh %reath sounds noted, and indication of accu!ulation of phleg!.

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Heart Apical heart )as noted and presence of a heart !ur!ur upon auscultation noted )ith a point of !a5i!al i!pulses at :th intercostal space left !idclavicular line, ho)ever patients has a cardiac rate of ;. %p!. A%do!en 2he a%do!en )as flat and free fro! any lesion, ulceration )ith nor!oactive %o)el sound. 2here are no !asses, laceration, nodules and irregularities noted upon palpation. Ho)ever a%sent of a%do!inal rigidity and distension )as not noted upon percussion. +enitourinary A nor!al e5cretion of yello) urine )as noted )ith urine output of $>-cc in four hours. No other discharges and disco!fort upon urination according to the patient.

1li!ination Pattern Stool )as dar3 %ro)n and no present of %lood noted, and patient defecates : ti!es in a )ee3. 2here are no other a%nor!alities co!plain %y the patient. Neurologic Syste! Patient can o%ey ver%al co!!and. ho)ever she can tal3 in slo) lo) voice due to s)elling in the left side of the face in !andi%le area. 1ye ,pening C1D > P Spontaneous . P ,pening speech 2 P ,pening to pain $ P eyes opening =er%al (esponse C=D : P Oriented > P Confuse . P nappropriate )ords 2 P nco!prehensi%le *otor (esponse C*D ? P Obey commands : P #ocaliEe to pain > P )ithdra)s to pain . P a%nor!al fle5ion

2-

(eaction P right and left P S4Sluggish SiEe P .!! Cright and leftD

sounds $ P No ver%al response

2 4 15tensor response

$ P No response Hand grip& (ight P a%sent #eft P a%sent #eg !ove!ent & (ight P a%sent #eft P a%sent 2otal Q 1 R = R * $: Q > R : R ?

Cranial Nerve Function $st ,lfactory Present of o5ygen inhalation via canal cannula at 2; cp!. Patient can ela%orate either it7s a strong adore or not, such as cotton %alls )et )ith alcohol and )ater. 2nd ,ptic Nerve Patient )as near sightedness due to her age %ut she preferred to use eye glasses )hen she read letters. Ho)ever )e find out that she cannot see far o%6ect. 0e tested it %y using %all pen o%6ect. 2$

.rd ,cculo!otor Nerve n assess!ent !ove!ent of pupils are Noted. And sluggish reactive to light )ith her %oth pupils. >th 2rochlear Nerve Bpon assess!ent the constriction of pupils )as noted )ith the siEe of .!! dia!eter. :th 2rige!inal 2here7s no difficulties of che)ing noted. And the %oth side of the chee3s are good in sensation can identify either rough or s!ooth. ?th A%ducens Nerve 2he patient pupils are e"ual around and %lac3 and reactive to light. ;th Facial Nerve 0hen )e as3ed her to close her eyes, to s!ile and to fro)n there7s no a%nor!alities noted. Ho)ever sensation of the chee3s and forehead )as good. Ath Acoustic Nerve Bpon assess!ent she follo)ed actions li3e close her eyes %ut she loses her %alance. n fact she cannot stand and )al3 due to her ede!a in %oth side of the legs. <th +lossopharyngeal Nerve and $-th =agus Nerve Speech of the patient )as not so clear due to s)elling in the left side of the face in !andi%le area. $$th Spinal Accessory Nerve 2here )as no difficulty of turning her head fro! left to right. And there7s no other difficulties noted.

22

$2thHypoglossal Nerve 2he patient )as a%le to !ove her tongue fro! left to right and up)ard. the sense of taste )as good.

ANA2,*J AND PHJS ,#,+J

2.

2he Heart s a hollo) !uscular organ, appro5i!ately the siEe of its o)nerKs fist t is positioned in the centre of the chest area, %et)een the lungs and is divided in four 2>

cha!%ers. 2he heart %eats appro5i!ately $--,--- ti!es every day in order to supply our cells )ith o5ygen rich %lood and pu!ps a%out 2,--- gallons of %lood through its cha!%ers on a daily %asis. Four cha!%ers $. #eft atriu! 4 t receives o5ygenated %lood fro! the pul!onary veins, and pu!ps it into the left ventricle. 2. #eft ventricle4 (eceives o5ygenated %lood fro! the left atriu! via the !itral valve, and pu!ps it into the aorta via the aortic valve. .. (ight atriu! 4 (eceives deo5ygenated %lood fro! the superior and inferior vena cava and the coronary sinus, and pu!ps it into the right ventricle through the tricuspid valve. >. (ight ventricle 4 (eceives deo5ygenated %lood fro! the right atriu! via the tricuspid valve, and pu!ps it into the pul!onary artery via the pul!onary valve and pul!onary trun3. 2he right and left sides of the heart are divided %y a !uscular )all called the septu!. 2he septu! prevents deo5ygenated and o5ygenated %lood fro! !i5ing together. *etaphorically spea3ing, the house is your heart and the pipes are the %lood vessels that are found throughout our %odies. Blood is pu!ped fro! the heart around all parts of the %ody through a co!ple5 transport syste!. 2he Superior vena cava is a large vein carrying deo5ygenated %lood into the heart, the superior vena cava Ccarrying %lood fro! the head, ar!s, and upper %odyD, )hile the nferior vena cava is a large vein carrying deo5ygenated %lood into the heart., the inferior vena cava Ccarrying %lood fro! the lo)er %odyD.

2:

2he Pul!onary vein is a vein carrying o5ygenated %lood fro! the lungs to the left atriu! of the heart and the pul!onary artery is a the artery carrying %lood fro! the right ventricle of the heart to the lungs for o5ygenation 2he !itral valve lies %et)een the left atriu! and left ventricle preventing %lood fro! lea3ing %ac3 into the left atriu! during e6ection CsystoleD. 2he nor!al !itral valve opens )hen the left ventricle rela5es CdiastoleD allo)ing %lood fro! the left atriu! to fill the deco!pressed left ventricle. 0hen the left ventricle contracts CsystoleD, the increase in pressure )ithin the ventricle causes the valve to close, preventing %lood fro! lea3ing into the left atriu!. 2he aortic valve lies %et)een the left ventricular cha!%er and aorta, preventing %lood fro! lea3ing %ac3 into the left ventricle after it has %een e6ected into the circulation. 2he purpose of the valve is to close )hen the ventricle pu!ps %lood into the pul!orary arteries that lead to the lungs. 2he tricuspid valve is located on the right side of the heart %et)een the right atriu! and ventricle. t prevents the %ac3 flo) of %lood as it is pu!ped fro! the right atriu! to the right ventricle. 2he Aorta is the largest artery in the %ody. Arteries are vessels that carry %lood a)ay fro! the heart. 2he aorta arises fro! the left ventricle of the heart, for!s an arch, and then e5tends do)n to the a%do!en, )here it %ranches off into t)o s!aller arteries. 2he heart has . !uscles na!ely the 1picardiu!, the !yocardiu! and the pericardiu!. 2he epicardiu!is the outer protective layer of the heart. t is co!posed of connective tissue covered %y epitheliu!. 2he epicardiu! is also 3no)n as the visceral

2?

pericardiu!. 2he *yocardiu! is a !uscular !iddle layer )all of the heart. t is co!posed of spontaneously contracting cardiac !uscle fi%ers )hich allo) the heart to contract. 2he endocardiu! is the inner layer of the heart that is continuous )ith the inner lining of blood vessels. Arteries are vessels )hich transports %lood a)ay fro! the heart. 2he arteries %ranch repeatedly to for! arterioles Cs!all arteriesD, the s!allest and thinnest %ranches of arteries. 2he function of the arteries is to carry %lood fro! the heart to all organs, )ith the e5ception of the pul!onary arteries )hich carry deo5ygenated %lood to the lungs, all arteries carry o5ygenated %lood. Arteries and veins are connected %y %lood capillaries, !icroscopically s!all tu%es )hich for! a net)or3, the capillary %ed in different tissues. 2he %lood capillaries are so s!all that red %lood corpuscles can only !ove in a single file through it. 2he e5change of all su%stances ta3es place in these capillaries. 2hese functions includes that the capillaries allo)s for gaseous e5change to ta3e place %et)een the capillaries and the tissue fluidsM nutrients diffuse fro! the capillaries into the tissue fluids and )aste products such as car%on dio5ide and nitrogen. 2he =eins are vessels )hich transports %lood to the heart. Fro! the capillaries the %lood drains into very s!all veins called venules, )hich unite into larger veins along )hich the %lood returns to the heart. 2he !ain functions includes carrying of deo5ygenated %lood fro! the organs and tissues %ac3 to the heartM the pul!onary veins carry o5ygenated %lood fro! the lungs to the left atriu!M veins also carry )aste products a)ay fro! the organs and tissues, )hile the veins associated )ith the s!all intestine carry digested food via the liver to the inferior vena cava.

2;

2he heart%eats are triggered and regulated %y the conducting syste!, a net)or3 of specialiEed !uscle cells that for! an independent electrical syste! in the heart !uscles. 2hese cells are connected %y channels that pass che!ically caused electrical i!pulses.

NA((A2 =1 PA2H,PHJS ,#,+J

n addition, inco!plete closure of the aortic valve also results in increased preload as the left ventricle is forced to pu!p the entire diastolic volu!e

received fro! the left atriu! and the volu!e fro! the aorta. ncreased afterload occurs as there is increased pressure for the heart to generate the !ove!ent of the increased

2A

volu!e fro! the left ventricle into the aorta. 2he increased volu!e )or3 causes increased pressure for the left ventricle to pu!p !ore %lood. As the )or3load increases, the )alls of the cha!%er gro) thic3er, losing their elasticity and eventually !ay lead to the failure of the heart to pu!p )ith as !uch force as a healthy heart. Systolic dysfunction or failure is evident leading to altered syste!ic perfusion and decrease in end4systolic volu!e. A decrease in end4systolic volu!e causesa decrease in cardiac output )hich also contri%utes to the decrease perfusion of tissues inthe %ody. 2his includes increase in sy!pathetic activity, activation of the renin4angiotensin aldosterone path)ay and eventual decrease in o5ygen supply in tissues. 15plains that increased activity of the sy!pathetic nervous syste! or the renin4 angiotensin4aldosterone syste! C(AASD.2he purpose of this initialresponse is to increase heart rate and contractility and support the failing !yocardiu! Sy!pathetic sti!ulation causes peripheral vasoconstriction. Peripheral vasoconstriction !ay cause capillary endothelial da!age.Decreased o5ygen supply in tissues is detri!ental %ecause if o5ygen delivery to cells is insufficient for the de!and, prolonged co!pensatory !echanis!s can lead to cell death. As there is decreased o5ygen supply to, %rain, gastrointestinal tract and liver. Decreased perfusion to the tissues and eventual decrease in o5ygen supply causesi ncreased !yocardial )or3load as it atte!pts to co!pensate for the reduction CS!eltEer H Bare, 2-$-D. 1ventually, co!pensatory !echanis!s fail and even the !yocardiu! e5periences a decrease in o5ygen supply CPorth, 2--;D. 2his decreases o5ygen supply tothe %rain and induces decreased o5ygen supply in the %lood. 0hen this happens, the

2<

heart !uscle !ust use alternative, less efficient for!s of fuel so that it can perfor! its function of pu!ping %lood to the %ody or co!!only called anaero%ic !eta%olis! CPorth, 2--;D.

SCH1*A2 C D A+(A*

.-

.$

.2

..

.>

SJ*P2,*A2,#,+J

S +NS AND SJ*2,*S

P(1S1N2

'BS2 F CA2 ,N

Because of the viscosity of the %lood that !a3es the %lood Dyspnea vessels narro)ed and leads to increase of %lood pressure and it caused to increase of )or3load of the heart and the person e5perienced difficulty of %reathing. Acco!panied %y ane!ia, %ecause of the loss rupture in Pallor (BC causes degradation of intracellular protein, particularly he!oglo%in.

Pain

neffective peripheral tissue perfusion %ecause of the inade"uate delivery of rich %lood to the %ody tissues. Body !alaise is vague feeling of disco!fort this !ay

Body 0ea3ness

present as a result of the sign and sy!pto!s of the disease and )ar! acco!!odation during our assess!ent and intervie).

Fatigue

(elated sleep deprivation, not a%le to sleep )ell due to irritation and pain lo)er e5tre!ities.

.:

#AB,(A2,(J (1SB#2

2est FBS

(esult >.$<

Nor!al range ..A<4:A..!!olF#

'ustification FBS S $-- !gFdl C:.? !!olFlD Q nor!al fasting %lood sugarM

FBS $--4$2: !gFdl C:.?4?.< !!olFlD Q F+ Ci!paired fasting glucoseDM

FBS T $2? !gFdl C;.- !!olFlD Q provisional diagnosis of dia%etes

2otal Cholesterol

?.>-

S:.2-!!olF#

*rs. @@@ diet )as high in cholesterol, )hich also lead hi! to suffer fro! a Congestive Heart Failure, %ecause one of the precipitating factor of CHF is %eing hypercholesterole!ia )here in the pla"ue accu!ulate the %lood vessels for!ing a clot, and leading to

2riglycerides

$.$;

S2..!!olU#

atherosclerosis. High triglyceride levels !ay %e due to&

Cirrhosis or liver da!age Diet lo) in protein and high in car%ohydrates

Hypothyroidis! Cunderactive thyroidD

.?

Nephrotic syndro!e Ca 3idney disorderD

Poorly controlled dia%etes

#o) triglyceride levels !ay %e due to&

#o) fat diet Hyperthyroidis! Coveractive thyroidD

*ala%sorption syndro!e Cconditions in )hich the s!all intestine does not a%sor% fats )ellD

HD#

-.<A

-.<-4$.>:!!olF#

*alnutrition 2hose )ith highest C,pti!alD total HD#

particle concentrations H lo)est rates of #D# >.AA Bp to ..<!!oF# cardiovascular disease events ncrease of the #o) density lipoprotein or Bad cholesterol Build up in the )alls of arteries and for! a pla"ue causing the arteries to narro) and can lead to poor tissue perfusion. As a !atter of fact *rs. @@@ suffering fro! a Congestive Heart Failure. D A+N,S2 C 21S2

Chest @4ray .;

A result i!age that helps the doctors to see the underlying condition not 6ust on the lungs %ut as )ell as on the heart failed.

A chest @4ray result of *rs. @

(adiographic (esult HaEy densities are noted in %oth lo)er lungs fields )ith ho!ogeneous opacities o%scuring %oth %ases. 2here is enlarge!ent )ith the left atrial and left ventricular configuration. Central vasculature is pro!inent. Calcifications are noted in the aortic 3no%. 2he rest of the included structures appear unre!ar3a%le. *P(1SS ,N& PN1B*,N A B,2H #,01( #BN+S 0 2H B #A21(A# * N *A# F#B D. #1F2 S D1D CA(D ,*1+A#J 0 2H PB#*BNA(J C,N+1S2 ,N A2H1(,*A2,BS A,(2A. #eft ventricular cardio!egaly is the enlarge!ent of the left ventricle due to irregular. 2achycardia contractions that serve as co!pensation to !aintain sufficiency supply of %lood throughout the syste!.

Blood test

.A

2hese can7t %e diagnosis )hether so!eone has have a stro3e, %ut they can provide i!portant infor!ation, such us ho) "uic3ly %lood clots, cholesterol levels, or )hether so!eone has dia%etes P all of )hich increases the chances of having a stro3e.

Bltrasound 2his uses ultrasound )aves to sho) )hether %lood vessels are %loc3ed or a%nor!al.

Angiogra! A doctor inserts a catheter into a %lood vessels and in6ects an @4ray dye. 2he @4ray )ill then reveal )hether there is a%nor!alities %lood flo) in the vessel.

1lectrocardiogra! C1C+D 2his give a snapshot of the heart7s electrical activity, !easuring its regularly. So!e heart irregularities can lead to the creation of %lood clots, )hich can travel to the %rain.

1chocardiogra! Bltrasound )aves are captured on videotape to give a vie) of ho) the heart !uscles are functioning and the %lood is flo)ing through the heart. C24scan is used to produce a .4D i!age of the head, sho)ing %lood vessels, %ones, %rains and soft tissue. *( scan4 2his uses !agnetic fields to %riefly after )ater !olecules in the %rain. t result in a !ore detailed .4D i!age of the head. Can catch a%nor!alities that are too s!all or in a location the C2 can7t see. 2i!eFDate Doctors7s ,rder (ationale

.<

August $:, 2-$. <&.- A*

Ad!it patient to )ard,

#et the patient to choose a roo! )here she can %e co!forta%le to rest and afforda%le.

#o) salt and sodiu! diet,

#o) control

salt

diet high

helps %lood

pressure Cede!eD, lo) sodiu! diet is re"uired for nor!al !uscle never and

function, co!!unication %lood pressure.

=ital sign every >hour,

2o !onitor the physical condition of the patient and o%tain %aseline data especially the vital sign, every >hours.

=F of PNSS $# at /=,,

Plain

nor!al

saline

solution is a sterile,

>-

nonpyrogenic

solution

for fluid and electrolyte replenish!ent.

#a%oratory& $. co!plete count, 2. urine analysis, .. chest @4ray, >. 1lectrocardiogra! %lood

#a%oratory& CCBCD %lood e5a!ination is i!portant to deter!ine the %lood a%nor!alities C15.

nfection, platelet elevationD factors that causes the

patient illness, )hile Curine analysisD deter!ined the

renal function, present of %acteria, glucose, %lood and pus Cchest @4rayD is a test that uses a s!all a!ount of radiation to create an i!age of the structures )ithin the chest including the heart, lungs, %lood vessels and %ones. deter!ined a%nor!alities of C1C+D )ill the heart

>$

conductions syste!.

*edication& Furose!ide >-!g $ta% once a day,

Furose!ide !edication

is )hich

a is

used in hypercalcae!ia, hypertension, ede!a

and treating decreased urine production.

#osartan :-!g $ta% once a day,

#osartan is used for treating hypertension,

reducing the ris3 of stro3e in patients )ith hypertension, and left ventricular hypertrophy Cover !uscleD, people develop and )ith heart treating dia%etic C3idney

nephropathy diseaseD. !dur ?-!g $ ta% once a day,

!dur in preventive and long ter! treat!ent of angina pectorisFpost

>2

!yocardial C* D angina.

infection

#ano5in

-.2:!g

$ta%

Digo5in is used for !ild to !oderate congestive heart failure and for treating heart an a%nor!al called

once a day,

rhyth!

arterial fi%rillayion.

Carvedilol ?.2:!g $ta% once a day,

Carvedilol is used to treat congestive heart failure, %lood i!prove control pressure, high and

survival

follo)ing a heart attac3.

Clopidogrel ;-!g $ta% once a day,

Clopidogrel is used to help %lood prevent clots in har!ful fro! people

developing

)ho have had a recent heart attac3, a stro3e, or

>.

severe re"uiring

chest

pain

hospitaliEation. *onitor input and output, 2o !onitor the )ater input to our %ody and to !onitor renal output, urine color and identify renal a%nor!alities.

$$&2: P*

Atara5 2:!g $ta% once a day,

Hydro5yEine is used for the relief of pruritus CitchingD various conditions. caused %y

allergic

August $?, 2-$. ;&:- A*

Add NaC# $ta% three ti!es a day,

Sodiu! chloride is used in !edical treat!ents such as = infusions and catheter flushes.

August $?, 2-$. $$&.- A*

Ho!e !edication& $. Furose!ide >-!g $ta% once a day,

Ho!e

!edication

is

given to continue the treat!ent of the patient

>>

2. #osartan

:-!g

in her ho!e.

$ta% once a day, .. !dur ?-!g $ta% once a day, >. #ano5in -.2:!g

$ta% once a day, :. Carvedilol ?.2:!g $ta% once a day, ?. Clopidogrel ;-!g $ta% once a day.

>:

Date ,rdered August .-, 2-$.

+eneric Na!e

Brand Na!e

Classification

(oute and Dosage (oute&

*echanis! of Action #osartan is an oral !edication that %elongs to a

ndication 2reat!ent of hypertension M in heart failure and

Contraindicati on Breast4 feeding, renal artery stenosis, hyper3ale!ia. hyper4 sensitive to other sulfona!ide4 derived drugs.

Side 1ffects and Adverse (eaction Side effects& $.

Nursing (esponsi%iliti es 0ashed

#osartan CoEaar Anti4

infla!!atory ,ral

hands %efore and Diarrhea, *uscle cra!p, DiEEiness, nso!nia, and Nasal congestion. 2. Chec3ed after giving the drugs.

Dosage& class of drugs :-!g

called angiotensin !yocardial receptor %loc3ers CA(BsD. infarction. t !ay %e used alone or in co!%ination )ith other antihypertensi ve agents.

for the doctor7s order.

Adverse effects&

..

,%served

the $- rights !paired renal function and rarely, rash, angioede!a. >. Assess upon giving the drugs.

patient7s %lood pressure %efore starting >? theraphy.

>;

Date ,rdere d August $:, 2-$.

+eneric Na!e Hydro5yEine

Brand Na!e Atara 5

Classification

(oute and Dosage

*echanis! of Action Hydro5yEine is an antihista!ine

ndication Bseful in the

Contraindication Clinical data in hu!an %eings

Side 1ffects and Adverse (eaction Side effects&

Nursing (esponsi%ilit ies >0ashed hands %efore

Antihista!ine (oute& ,ral

!anage!ent are inade"uate of pruritus to esta%lish safety in early

2iredness, DiEEiness, Sleepiness,

and after giving the !edication.

Dosage& )ith 2:!g

anticholinergic due to CdryingD and sedative properties that is used to treat allergic reactions. 2he %ody releases hista!ine during several types of allergic allergic conditions such as chronic

pregnancy. Bntil Distur%ed such data are availa%le, hydro5yEine is coordination, Drying and thic3ening of oral, (espiratory secretion, Sto!ach Hydro5yEine is contraindicated for patients )ho have sho)n a previous hypersensitivity to it. *yalgia, *yositis, VAssess Adverse effects& distress. >,%served the patient7s $- rights upon giving the !edication. > Chec3ed for the doctor7s order.

urticaria and contraindicated atopic and contact der!atoses, and in hista!ine4 !ediated in early pregnancy.

reactions and44 pruritus. to a lesser >A e5tent44during so!e viral

><

Date ,rdered August $:, 2-$.

(oute Classification and Dosage Carvedilol Carvid Beta %loc3ers (oute& +eneric Na!e Brand Na!e ,ral

*echanis! of Action Bsed treating

ndication

Contraindication Bronchial asth!a, chronic in %ronchitis, pul!onary

Side 1ffects and Adverse (eaction Side 1ffects&

Nursing (esponsi%ilities V hands 0ashed %efore

for 1ssential hypertension or

high %lood alone Dosage& pressure ?.2:!g and Congestive Heart Failure.

Diarrhea,

dro)siness, and after giving

co!%ination

lightheadednesstiredness the !edication.

)ith other anti4 e!physe!a, hypersensitives, allergic rhinitis, Adverse effects& of V Chec3ed for the DiEEiness, headache and order. sinus tiredness, sho)ed pulse doctor7s

congestive heart s)elling failure, Angina laryngeal pectoris, idiopathic !ucosa,

node syndro!e, rate or gastrointestinal V ,%served the CSAD C+ D upset or flu4li3e patient7s $upon the

cardio!yopathy. sinoatrial

%loc3, 2nd and sy!pto!s and %reathing rights .rd degree pro%le!s. giving

atrioventricular CA=D %loc3, too slo) heart rate, !yocardial infarctin,severe :liver dysfunction,

!edication.

Assess

sy!pto!s and record %aseline %efore during and

:$

Date ,rdered August $:, 2-$.

+eneric Na!e

Brand (oute and *echanis! Classification Na!e Dosage of Action Antiplatelet

ndication

Contraindication Hypersensitivity

Side 1ffects and Adverse (eaction Side effects&

Nursing (esponsi%ilities V0ashed hands %efore and after

Clopidogrel Plavi5

(oute&P., Antiplatelet (eduction of Dosage& ;:!g Conce a dayD drugs are treat heart attac3, stro3es. (is3 reduction and peripheral artery disease.

atherosclerotic severe liver events C!yocardial infarction,or vascular deathD in patients )ith i!pair!ent. Active pathological %leeding. i.e. peptic ulcer and intracranial Adverse effects& Diarrhea A%do!inal pain ndigestion or heart%urn

giving the !edication. V Chec3ed for the doctor7s order. V,%served the patient7s $- rights upon giving the drug VAssess sy!pto!s

atherosclerosis he!orrhage. docu!ented %y recent stro3e, !yocardial infarction or esta%lished peripheral arterial disease. :2 2reat!ent of patient7s Pregnancy and lactation.

+. %leeding, and record %aseline purpura, %ruising, he!aturia, eye%leeding, intracranial %leeding, +. distur%ances, diarrhea, %efore and during treat!ent.V*onitor signs of %leedingM he!oglo%in and he!atocrit periodically V *onitor liver function

:.

Date ,rdered August $:, 2-$.

+eneric Na!e Sodiu! Chloride CNaClD

Brand Na!e Nor!al Saline Flush

Classification

(oute and Dosage (oute& ,ral

*echanis! of Action 4(eplaces and !aintains

ndication

Contraindication

Side 1ffects and Adverse (eaction Side effects&

Nursing (esponsi%ilities V0ashed hands %efore

1lectrolyte replace!ent

15tracellular volu!e depletion fluid and electrolytes replace!ent, opthal!ic for the te!porary relief of corneal ede!a, eye dryness, nasal !oisturiEes, dry and crusted stuffy nostrils due t allergy,colds,over use of antihista!inic decongestants.

V Hypersensitivity to any of its co!ponents, lactation and sports people.

An5iety, chest pain, severe chills, confusion, coughing,

and after giving the !edication

Dosage& $ta% C.5 a dayD

sodiu! and chloride level )hich are essential ions necessary in nor!al cellular.

VChec3ed for the doctor7s order

V 1ffects on a%ility to drive and use !achines

diEEiness, feeling of heat. V,%served the patient7s $- rights Adverse effects& upon giving the

VHypernatre!ia,h ypo3ale!ia,acido sis,dia%etes !ellitus. Headache, pul!onary ede!a, %ac3 pain, diarrhea, nu!%ness,

!edication

V*onitored the eletrolytes levels VAssess patient7s fluid status V,%tain %aseline sodiu! and chloride levels %efore starting

:>

!uscle t)itching,

Date ,rdered August $:, 2-$.

+eneric Na!e sosor%ideF *ononitrate

Brand Na!e !dur

Classific ation Anti4 Angina Drugs

(oute and Dosage (oute& ,ral

*echanis! of Action ,ral e5tended release

ndication

Contraindication

Side 1ffects and Adverse (eaction Side 1ffects&

Nursing (esponsi%ilities V 0ashed hands %efore and after

2reat!ent of severe congestive heart failure CCHFD in co!%ination )ith cardiac glycosides,

Acute *yocardial nfarction C* D )ith lo) filling pressures e5ceot in ntensive Care Bnit C CBD )ith continous he!odyna!ic !onitoringM left heart failure )ith lo) filling pressures.

Headache DiEEiness #ightheadache Nausea

giving the drug.

Dosage& ?-!g

for!ulation S*N, the !a6or active !eta%olite of isosor%ide

VChec3ed for the doctor7s order.

Adverse 1ffects&

V,%served the $- rights upon giving the

dinitrateM !ost diuretics, of the clinical activity of the dinitrate is attri%uted to the !ononitrate. Angiotensin Converting 1nEy!es CAC1D inhi%itors,arteri al vasodilators, pul!onary hypertension.

ncreased heart rate CtachycardiaD. Decreased heart rate C%radycardiaD Hypotension, =o!iting,

!edication.

VAssessed for pain, duration, ti!e started, activity %eing perfor!ed, character intensity.

::

:?

Date ,rdered Septe!%er $:, 2-$.

+eneric Na!e Digo5in

Brand Na!e #ano5in

Classification Antidysrhyth !ic

(oute and Dosage (oute& ,ral

*echanis! of Action ncreases the strength and vigor of heart

ndication Chronic cardiac failure )ith atrial fi%rillation ventricular dilatation,supra ventricular arrhyth!ias.

Contraindication nter!ittent co!plete heart %loc3 or 2nd degree atrioventricular %loc3 especially )ith history of stro3e P ada! attac3M )olff4 par3inson4)hite syndro!e, hypertrophic o%structive cardio!yopathyM hypersensitivity.

Side 1ffects and Nursing Adverse (esponsi%ilities (eaction Side effects& V0ashed hands %efore and aftr Nausea, vo!iting, Headache, diEEiness, s3in rashes, and !ental changes. giving the !edication. VChec3ed for the doctor7s order. V,%served the patient7s $Adverse effects& rights upon giving the drug Anore5ia, +astrointestinal distur%ances, central nervous syste! effects, atrial tachycardia and VAssess sy!pto!s and record %aseline %efore and during treat!ent. V,%tain patient7s history of underlying

Dosage& -.2:!gFta %

contractions and is useful in the treat!ent of heart failure.

:;

gyneco!astia.

NB(S N+ CA(1 P#AN $D Decreased Cardiac ,utput Date Cues Su%6ective& August $?, 2-$. I.p! Pattern Nursing Diagnosis (ationale Nursing 1valuation

Activity P Decreased Cardiac Patient !ust ,utput rFt Altered Be co!pletely Stro3e =olu!e. Bed rest and !onitor o5ygen inhalation.

ntervention Assess potential At the end of Ahr for developing span of care, the pt )ill& Display he!odyna!i c sta%ility De!onstrate decreased episodes dyspnea. De!onstrate an increase of

/apoy a3ong la)as og 15ercise 3alipnungon 3ayo 3o 3ahinga. Cfati"ue,diEEeness and Feeling %reathlessnessD 3o,dli Pattern.

shoc3 states. (evie) la% data 1valuate reports evidence client and of

the

e5tre!e fatigue, intolerance ,%6ective& 1de!a 0eight +ain :A Diet of the for

activity, sudden or )t progressive gain,

patient lo) salt

Dyspnea Cla!!y s3in S3in color

lo) fat !ust eat fruits and vegeta%les no oily foods for the recovery of the patient

s)elling

of

in

activity

e5tre!eties, and progressive S,B to assess of for poor

tolerance. =er%aliEe 3no)ledge of the process, individual ris3 factors, and plan. Participate in activities that reduce the dse

changes& pallor Cough (estlessness

signs

ventricular function andFor

co!plete rest .

%ed

i!pending cardiac failure. (evie) signs of i!pending shoc3, decreased cognition unsta%le su%nor!al and or noting

drin3ing !ore )ater for the dehydration !ust not occur.

)or3load of the heart dentify signs of

lo) cardiac

:<

BP. Deter!ine including cognitive status /eep client on %ed or chair rest in position of co!fort. decrease consu!ption and ris3 of C2o ,2

deco!pensation, =S alter and activities, see3 help

appropriately.

deco!positionD Ad!inister high4flo) via !as3Fventilator, ?,2

as indicated. C2o increase availa%le cardiac functionFtissue perfusionD *onitor fre"uently. =S C2o ,2 for

note response to activitiesD

2D Fatigue Date Cues Pattern Nursing Diagnosis ?$ (ationale Nursing ntervention 1valuation

Su%6ective& August $?, 2-$. I.p!

Activity

P Fatigue Sleep Deprivation.

rFt Perfor! activities of

dentify presence At the end of physical andFor of Ahr span psychological conditions of care, the pt )ill&

0alay 3usog a3ong 15ercise la)as og dli 3aau 3o Pattern. 3a pronounce og !ga )ords. =er%aliEation of an

daily living and participate in

desired activities at level of a%ility Participate reco!!ended treat!ent progra!. in

Note age, gender, (eport and develop!ental stage Ascertain client7s i!proved sense energy dentify of of

unre!itting or over)hel!ing lac3 of energy

%elief a%out )hat %asis is causing

the fatigue and individual

fatigue ,%6ective& Dro)sy #ac3 of energy ?2 Deter!ine presenceFdeg ree of sleep distur%ances Assess evaluate status =S

to areas fluid control. and

of

cardiopul!onary

Do not give

%y o%taining patientFS, descriptions of fatigue As3 client to rate fatigue scaleD C$4 $and its

response activity. Deter!ine presenceFdegree of distur%ances o%taining patientFS, descriptions of

to hard e5ercise it can the affect

sleep condition %y of patient li3e)ise you si!ple e5ercise. a the

effects on a%ility to participate in desired activities. .D Activity ntolerance Date Cues Su%6ective& Pattern Activity Nursing Diagnosis P Activity ?. +oal of

ntervention Note

1valuation client At the end of

,%6ectives dentify presence

Per!ente August $?, 2-$. I.p!

lang

3o 15ercise

ntolerance +eneraliEed 0ea3ness.

rFt of andFor

physical

reports )ea3ness, fatigue, difficulty acco!plishing

of Ahr span of care, the pt pain, )ill& (eport i!proved sense of energy. dentify %asis fatigue and individua l areas of control. Perfor! activities of

3apoyon, dali pa 6ud Pattern. 3o !asu3o !o 3alit lang 3o !asu3o )alay hinungdan og ta!ad na pud 3o !ag storya 3ana gud !ag storya. =er%al report of fatigueF)ea3n ess =er%aliEes e5ertional disco!fort =er%aliEes no desire andFor

psychological conditions.

Bnderstanding the patient

tas3s, inso!nia Assess

andFor

attitude due to her disease and age.

cardiopul!onary response to

physical activity, including %efore, =S during,

and after activityM note accelerating fatigue. ?>

lac3 of interest in activity

Ascertain a%ility to stand and

of

daily

living and participat e desired activities at level in

!ove a%out, and degree assistance ,%6ective& A%nor!al H( or response activity. Pallor BP to *onitor the necessary or use of e"uip!ent to deter!ine current status and needs associated participation neededFdesired activities Ane!ia is the cause of pallor ?: Assess e!otional and psychological of

%lood pressure of the patient For o%taining

of a%ility

)ith Participate in in reco!!ended treat!ent progra!.

%asis and refer unusualities in

the nurse station.

lo) in red %lood cells in the %ody so !ust stress co!plete rest reco!!ended. the patient not %e and %ed is

factors affecting the situation Note related such effects interactions !edications. as treat!ent4 factors, side and of current

>D Decreased Cardiac ,utput Date Cues Su%6ective& August 2-$. Pattern Nursing Diagnosis (ationale Nursing 1valuation

Activity P Decreased Cardiac Patient !ust ,utput rFt Altered Be co!pletely Stro3e =olu!e. ?? Bed rest and

ntervention Assess potential At the end of Ahr for developing span of care, the pt )ill&

$?, /apoy a3ong la)as og 15ercise 3alipnungon 3o,dli Pattern.

shoc3 states.

I.p!

3ayo 3o 3ahinga. Cfati"ue,diEEeness and Feeling %reathlessnessD

!onitor o5ygen inhalation.

the

(evie) la% data 1valuate reports evidence client and of

Display he!odyna!i c sta%ility

De!onstrate decreased episodes dyspnea. of

e5tre!e fatigue, intolerance ,%6ective& 1de!a 0eight +ain Dyspnea Cla!!y s3in S3in color Diet of the for

activity, sudden or )t s)elling progressive gain, of

De!onstrate an in increase activity

patient lo) salt lo) fat !ust eat fruits and vegeta%les no oily foods for the recovery of the patient

e5tre!eties, and progressive S,B to assess of for poor

tolerance. =er%aliEe 3no)ledge of the process, individual dse

changes& pallor Cough (estlessness

signs

ventricular function andFor

?;

co!plete rest .

%ed

i!pending cardiac failure. (evie) signs of i!pending shoc3, decreased cognition unsta%le su%nor!al BP. Deter!ine including cognitive status /eep client on %ed or chair rest in position of and or noting

ris3 factors, and plan. Participate in activities that reduce the

drin3ing !ore )ater for the dehydration !ust not occur.

)or3load of the heart dentify signs of

lo) cardiac deco!pensation, =S alter and activities, see3 help

appropriately.

?A

co!fort. decrease consu!ption and ris3

C2o ,2

of

deco!positionD Ad!inister high4flo) via !as3Fventilator, as indicated. C2o increase availa%le cardiac functionFtissue perfusionD ?< *onitor =S ,2 for ,2

fre"uently.

C2o

note response to activitiesD

Fatigue Date Cues Su%6ective& August 2-$. I.p! $?, Pattern Activity Nursing Diagnosis P Fatigue Sleep Deprivation. (ationale rFt Perfor! activities of Nursing ntervention 1valuation

dentify presence At the end of andFor psychological conditions physical of span care, pt )ill& age, (eport and i!proved Ahr of the

0alay 3usog a3ong 15ercise la)as og dli 3aau 3o Pattern. 3ah pronounce of !ga )ords. =er%aliEation of an

daily living and participate in

desired activities at level of a%ility Participate ;in

Note gender,

unre!itting or over)hel!ing lac3 of energy

reco!!ended treat!ent progra!.

develop!ental stage Ascertain client7s a%out causing

sense energy dentify

of

%elief %asis )hat is fatigue the and

of

,%6ective& Dro)sy #ac3 of energy

Deter!ine presenceFdeg ree of sleep distur%ances %y o%taining patientFS, descriptions of fatigue

fatigue Assess evaluate status =S

individual to areas fluid control. and Do not of

cardiopul!onary response activity. Deter!ine presenceFdegree of

to give hard e5ercise it can affect the

As3 client to rate fatigue ;$ C$4 $-

sleep condition

scaleD

and

its

distur%ances o%taining patientFS, descriptions of

%y of patient

the

effects on a%ility to participate in desired activities.

li3e)ise you si!ple e5ercise. a

;2

:D Activity ntolerance Date Cues Su%6ective& Per!ente August 2-$. I.p! la! Pattern Activity 3o 15ercise Nursing Diagnosis P Activity +oal of ,%6ectives dentify of ntervention 1valuation

Note client reports At the end of of fatigue, difficulty acco!plishing tas3s, andFor )ea3ness, Ahr span of pain, care, the pt )ill& (eport i!proved sense of energy. dentify %asis fatigue and of

ntolerance rFt presence +eneraliEed 0ea3ness.

$?, 3apoyon,dali padyud Pattern. 3o !asu3o !o 3alit lang 3o !su3o )alay hinungdan og ta!ad napud 3o !ag istorya 3ana gud !ag istorya. =er%al of fatigueF)ea3n ess report

physical andFor psychological conditions.

Bnderstanding the patient

inso!nia Assess cardiopul!onary response to physical activity, including

attitude due to her disease and age.

=S %efore, during, ;.

=er%aliEes e5ertional disco!fort

and after activityM note fatigue. Ascertain a%ility to stand and !ove accelerating

individua l areas of control. Perfor! activities of daily

=er%aliEes no desire andFor

lac3 of interest in activity

a%out, and degree of assistance necessary or use of e"uip!ent to deter!ine current status and needs )ith in

living and participat e desired activities at level in

,%6ective& A%nor!al H( or BP response to activity. Pallor *onitor the

associated participation neededFdesired activities Assess and

%lood pressure of the patient For o%taining

of a%ility e!otional Participate in

%asis and refer ;>

psychological reco!!ended

unusualities the station.

in

factors affecting the treat!ent current situation Note treat!ent4 progra!.

nurse

Ane!ia is the cause of pallor lo) in red %lood cells in the %ody so the patient !ust stress co!plete rest reco!!ended. not %e and %ed is

related factors, such as side effects and interactions !edications. of

;:

D SCHA(+1 P#ANN N+

*.1.2.H.,.D

Discharge planning is the process %y )hich the patient is assisted to develop a plan of care for ongoing !aintenance and i!prove!ent of health care, even after he or she !ay %e discharged fro! the acute care hospital.

*1D CA2 ,N #ano5in, !dur, Carvedilol, Clopidogrel, Furose!ide, #osartan and Atara5. (ationale& t !ust %e ta3en once a day for easily to %e treated. (e!ind patient to 3eep a)ay fro! s3ipping !edication. (ationale& n order to have effective effect of the drugs. +ive details a%out the disadvantages if !edications are not ta3en. (ationale& So that the patient itself )ill %e a)are the conse"uences if she )ill not going to ta3e the !edication. 1ncourage patient to ta3e proper dosage. (ationale& 2o avoid drug overdose as )ell as for the adverse effect for the particular drugs. 1ducate patient the side effects and adverse effects reactions of the prescri%e !edication. (ationale& So that the patient )ill %e a)are for the nor!al side effect of the drugs, and )hat are the adverse effects of the drug. ;?

 Advise patient to notify physician if there any anusualities of side effects )hile ta3ing the prescri%e !edication. (ationale& 2o see3 !edication advised i!!ediately and to avoid further co!plication.

1@1(C S1 1ncourage to have an ade"uate rest and sleep for fast recovery. (ationale& (est and sleep is the %est rela5ation to our %ody as )ell as to our !ind, for the fast recovery of the patient health condition. 1ncourage patient to do passive range of !otion e5ercise, unless contraindication to do so. (ationale& (ange of !otion e5ercise involving the upper and lo)er e5tre!ities )ill pro!otes good tissue perfusion and a good %lood flo). Discuss )ith the patient to !aintain their surroundings clean. (ationale& 1nviron!ent is the greatest factor of cleanliness so it is very i!portant to !aintain the surroundings clean.

2(1A2*1N2 Advise the client and significant others of their involve!ent in the treat!ent can lead to control of the disease and can prevent co!plication. (ationale& Fa!ily support encourages the client to)ard a %etter #ife in the process of treat!ent and this allo) s in the process treat!ent.

;;

 2each fa!ily a%out the need of assistance in so!e aspectM ho)ever, it should %e specify not to e5aggerate to provision of health. (ationale& 2o ensure the! to support the clients as recovery process and at the sa!e ti!e to pro!ote independence. Stress the i!portance of follo)4up e5a!ination and treat!ent %ecause of physical status. (ationale& 2o have an idea on )hat possi%le outco!e )ill co!e if she stop seeing her doctor. 2his also helps !otivate the patient to %e %ac3 her )ellness fro! his disease.

HJ+ 1NC1 nstruct the client a%out proper hand )ashing.

(ationale& According to the 0H,, hand )ashing is the single !ost effective )ay of preventing spread of infection. nstruct the fa!ily to !aintain proper hygience of the patient.

(ationale& 2o pro!ote cleanliness co!fort and prevent ac"uiring infections.

,B2 PA2 1N2 ,(D1(S 15plain and encourage the need to have regular chec3 up. (ationale& 2o chec3 the condition of the patient and the effectiveness of the !edications given to the patient. 1ncourage the patient to return on the days of schedule chec3 up %y the physician. (ationale& 2o follo) the physicians order and to !onitor and evaluate the condition of the patient. ;A

nstruct the patient to co!ply the !edication a ho!e and follo) the schedule in ta3ing the !edication.

(ationale& 2o i!prove the patient health condition through follo)ing the treat!ent regi!en given to the patient.

D 12 1ncourage the patient to choose plenty of fresh fruits and vegeta%les. (ationale& 1ating foods especially high fi%er is i!portant %ecause they contain only s!all a!ount of salt. 1ncourage to the patient to follo) the doctor7s orderM #o) salt and #o) fat diet. (ationale& Fat or cholesterol is the reason )hy the %lood vessels %eca!e narro)ed, and #o) salt is the reason )hy our patient e5perience ede!a. 1ncourage patient to include high4fi%er foods in her diet. (ationale& Fi%er is the indigesti%le part of plant food that helps !ove food along the digestive tract, controls %lood sugar levels, and !ay reduce the level of cholesterol in the %lood.

;<

P(,+N,S S Criteria Poor Fair Duration of illness *rs. @@@ already suffered fro! a hypertensive last 'une $2, 2-$$ and ad!itted at Southern Philippines *edical Center for : days, %y the help of the %y !edication the doctor, that her +ood 'ustification

prescri%ed

hypertensive )as treated and last August $:, 2-$. *rs. J )as ad!itted at saac 2. (o%illo

*e!orial Hospital %ecause she has ,nset of illness Congestive Heart Failure. *rs. @@@ already a)are that he had Congestive Heart Failure for a long ti!e, ho)ever she a%le to !aintain her !aintenance

!edication so that the doctor advised her to !aintain !edication in order to ta3e the !aintenance !edication daily.

A-

Predisposing Factors

*rs. @55 had a three predisposing factors )hich are gender, age and hereditary, she )as already ;2 years old and having a Congestive Heart Failure, further!ore fe!ale are

Precipitating Factors

!ostly high ris3 of having a race. ,ur patient had precipitating factor )hich is hypertension.

0illingness to ta3e !edicationFco!pliance to treat!ent regi!ent

*rs. @@@ and even her cousins are follo)ing all the treat!ent regi!en given to her !ost especially for the !aintenance !edication that

Age

prescri%ed %y the doctor. *rs. @@@ is already ;2 years old of aged. 2his is one of at high ris3 of having a Congestive Heart

1nviron!ent

Failure. ,ur patient

is

affected

%y

environ!ental stressor as sti!ulus is pollution.

A$

Fa!ily Support

,ur patient has no fa!ily !e!%er %ecause her hus%and7s died of hypertensive and they don7t have children, %ut her cousins is helping her to ta3er her !edication.

+eneral Prognosis (ating +ood Fair Poor 2otal (anges Poor& $.- P $.? Fair& $.; P 2.. +ood& 2.> P ..0eight . 2 $ Nu!%er $ > . 0eight @ nu!%er . A . 2otal -.> $.$ -.> $.<

As )e evaluate our patient prognosis, the overall result is fair, this !ean that, the patient a%ility to recover in relation to her health condition is :-W, %ut if the patient )ill co!ply )ith the instruction and !edications given %y the physician it )ill prevent fro! further co!plication.

(1F1(1NC1

,nline (eference& A2

http&FF))).nl!.nih.govF!edlineplusFencyFarticleF---$:A.ht! http&FFen.)i3ipedia.orgF)i3iFHeartGfailure
http://www.mydr.com.au/congestive-heart-failure

http&FF))).!ayoclinic.co!FhealthFheart4failureFDS---?$ http&FF))).hop3ins!edicine.orgFheartGvascularGinstituteFconditionsGtreat!entsFconditio nsFcongestiveGheartGfailure.ht!l http&FF))).enotes.co!FtopicsF%lood4vessels http&FF))).%otany.u)c.ac.EaFsciGedFgrade$-F!anphysFvessel.ht! http&FF))).!edicinenet.co!FclonaEepa!Farticle.ht! http&FFhealthyliving.aEcentral.co!Frationale4lo)4sodiu!4diet4$A?$..ht!l http&FF!edical4dictionary.thefreedictionary.co!Fvenoclysis http&FF))).para!edicine.co!Fp!cFNor!alGSalineGSolution.ht!l http&FF!y.clevelandclinic.orgFi!aging4instituteFi!aging4servicesF54ray4hic4chest454 ray.asp5 http&FF))).un!.eduFXdpay!entFdo)FN>2>DFpagesF+uide2oDischargePlanning.pdf http&FF))).!edicalne)stoday.co!FarticlesF$A$$>2.php http&FF))).!edicinenet.co!FcongenitalGheartGdiseaseFarticle.ht! http&FF!edicine.acade!ic.ruF$;<<FCongenital

Boo3s& *eria! 0e%ster7s *edical Dictionary PPD7s Nursing Drug +uide 2nd 1dition A.

Ber!an, Snyder, /oEier, 1r%, et al., Fundamentals of Nursing 1ight 1dition =olu!e ,ne Concepts, Process, and Practice *ailyn 1. Doenges, *ary Frances *oorhouse and Alice C. *urr, Nurses Pocket Guide $2 1dition diagnosis, prioritiEed ntervention, and rationales

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