MANAGEMANT OF CLIENTS WITH

”ATRIAL FIBRILATION IN RVR IN CHF, CAP-MR, COPD IN AE, HCVD,ARF 2 TO

CONGESTION”

BY CATHERINE NATAWIRARINDRY

FACULTY OF HEALTH
MASTER OF SCIENCE IN NURSING
SILLIMAN UNIVERSITY
2019

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 HEALTH HISTORY: ARF 2 TO CONGESTION, AF IN RVR IN CHF FV IV,
CAP-MR,COPD IN AE, HCVD

Today’s Date : February 18, 2019; 08.00 AM

A. BIOGRAPHICAL DATA
Patient Record
Name : Mr. Cadiz
Age : 75 year old
Date of birth : October 13, 1943
Gender : Male
Marital status : Married
Religion : Protestant
Nationality : Filipino
Occupation : Retired Policeman
Address :Poblacion, Negros Oriental
Addmission date : February 17, 2019

Historian record
Name : Mr. Lael
Date of birth : April 12, 1984
Age : 34 year old
Gender : Male
Address : Poblacion, Negros Oriental
Relationship with the patient : Son

B. CHIEF COMPLAINT
The family said, their father come to hospital because hard to breath.

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C. PRESENT ILLNESS
6 days PTA, patient noted onset of cough with whitish sputum. No consult was
done. 3 days PTA, patient had persistence of cough now with onset of dyspnea. He was
admitted at Bindoy District Hospital and was managed.

D. PAST HEALTH HISTORY

 Medical History
Family said, their father was admitted at Bindoy District Hospital February 11,
2019. 5 days PTA, onset of productive cough, yellowish sputum, no fever,
dyspnea, no consult done. 2 days PTA, persistence of above with associated
dyspnea this cough admission in a local hospital ODA, patient still has a
persistence of above cough referral to this institution.
 Surgical History
Family denies his father do any surgical.
 Allergies
Family said his father with egg and chicken
 Medications
Family said his doctor prescribed Doxofylline 400 mg/tab, Apixaban 5 mg/tab,
Eperisone Hcl 50 mg/tab, Candesartan 8 mg/tab, Spironolactone 25 mg/tab,
Furosemide 40 mg/tab, Tamsulosin 400 mg/tab.
 Communicable diseases
Family said their father has COPD and CAP-MR.
 Injuries and accidents
Family denies their father get any severe accident.
 Special needs
Family said his father felt weak, her daily need like take a bath, dressing, and
others need were helped by family member and nurse while in the hospital.
 Blood Transfusions
Family denies his father get any blood transfusions.
 Childhood illnesses
Family said they did not know about their father illness as a child.

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  Immunization
Family said they never asked their father about immunization

E. FAMILY HEALTH HISTORY

Mr. Lael denies their family has any history communicable disease, except his father
has COPD and CAP-MR. Mr. Cadiz diagnose had hypertension, congestive heart failure,
and acute renal failure. Mr. Lael said their family don’t have history of mental disorders,
drug addiction, kidney disease, HIV / AIDS, liver, heart failure, only his father had
history of heart failure, COPD, CAP-MR, ARF, AF.

F. SOCIAL HISTORY
 Alcohol use : Mr. Lael said his father like drank alcohol
 Tobacco use : Mr. Lael said his father used tobacco 35 pack for a year
 Drug use :Mr. Lael said his father never taken illegal drugs without
prescribed from his doctor.
 Work environment: Mr. Lael said his father was police retirement.
 Religion : Mr. Lael said their religion is protestant

G. HEALTH MAINTENANCE ACTIVITIES

 Health Perception and Health Management Pattern
Mr. Lael said healthy is very important for their family. Mr. Lael said if family
member get sick his family would go to the hospital or clinic. Mr. lael said his father
disease now because of his life style, his father like drunk, smoking, and eat fatty food
and because of old age.

 Nutritional-Metabolic Pattern
Mr. Lael said before sick his father like to consuming salty food and fat. When in the
hospital his father consume food 3 times a day from hospital, but when in SUCM
hospital doctor did not allow his father to eat, his father get nutrition only from infuse
and get some medication through NGT.
 Elimination Pattern

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 Mr.Lael said his father don’t has problem during defecation, but his father did not
defecate about two days because his father didn’t eat and get nutrition from infusion
only.

 Activity-Exercise Pattern
SELF CARE ABILITY 0 1 2 3 4
Eating and drinking 
Toileting 
Dressing 
Mobility in bed 
Moving 
Ambulation / ROM 
Mr. Lael said during hospitalized all his father daily activities were helped by the
nurse and family member, because his father use ventilator and weak to move from
bed.
 Sleep-Rest Pattern
Mr. Lael said at home his father can sleep 6-7 hours per day, but since in the hospital
his father always sleep.
 Cognitive-Perceptual Pattern
Mr. lael said his father unconscious because the medication and his diseases.
 Self-Perception—Self-Concept Pattern
Mr. Lael said his father was a hardworking, but after sick he just stay in hospital.
 Roles-Relationships Pattern
Mr. Lael said when at home his father had good relations and communication with
neighbors or with their member family.
 Values-Beliefs Pattern
Mr. Lael said his father is Protestant. Mr. Lael said before sick his father was actively
participating in religious activities, but since in the hospital he cannot go to the church.

H. Physical Examination (Head Toe To)

a) General condition
 Gasgow Coma Scale currently : E= 2, M=2, V= 2, total 6 Somnolence
 General response before : Sleepiness, weak.

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  Respiration rate currently : 24 times per minute
 Pulse rate currently : 119 times per minute
 O2 saturation : 100 %
 SaO2 :98%
 Temperature : 36,5o C
 Blood pressure : 95/65 mmHg
 Weigh now : - kg
 Weigh before sick :- kg
 High :- cm

b) Skin
 Inspection
 Color :Pale
 Lesions : yes
 Scarring : none
 Blisters : none
 Pallor : yes

 Palpation
 Moisture : dry
 Temperature : warm
 Tenderness : nontender
 Texture : smooth, and roughness at her feet
 Turgor : elastic
 Edema : no pitting edema

c) Head and Hair

 Inspection
 Color : gray
 Distribution : there is no alopecia

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  Lesions : none
 Hair loss : there is hair loss
 scalp : shiny, intact, no lesions or masses

 Palpation
 Texture : thick
 Masses : none
 Depressions : none
 Tenderness : none

d) Nails
 Inspection
 Color : white
 Shape and Configuration: smoot and slightly rounded
 Cleanliness of nails : clean
 Capillary refill : less than 3 seconds

 Palpation
 Texture : firm
 Masses : none
 Lesions : none
 Pain : none

e) Eyes
 Inspection
 Visual acuiy :-
 Visual fields :-
 Eyelids, eyebrowsm eyelashes : symmetriccal with no droping, infections, and no
tumors of the lids
 Swelling or edema : none

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  Lesions : none
 Inflammation : none
 Color blind : none
 Ptosis : none
 Redness : none
 Cardinal field of Gaze : both eyes can move smoothly and symmetrically
 Conjunctiva : no swelling, no injection, no exudate, no lesion, no
foreign bodies, the color pink.
 Sclera : white
 Cornea : cloudiness.
 Iris : smooth and without apparent vascularity
 Pupil : black, round, equal diameter, ranging 2 mm, constrict
briskly to derect and consensual light.
 Use visual aids : none

 Palpation
 Masses : none
 Pain : none

f) Ears
 Inspection
 Shape : Symmetrical, no redness, no deformities, no nodules.
 Lesions : none
 Inflammation : none
 Cleanliness of outside ear : clean
 Cleanliness of the ear hole : clean
 Tympanic membrane : Pearly grey, no abnormalities
 Watch test :-
 Voice-whisper test :-
 Weber test :-

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  Rinne test :-

 Palpation
 Auricle : No pain, no tenderness
 Mastoid tip : No tenderness
 Masses : none

g) Nose and Sinuses

 Inspection
 Shape : Sharp, symmetrically in the midline of face,
 Inflammation : none
 Patency : no patent
 Bleeding : none
 Swelling : none
 Blockage or congestion : breath through ventilator mechanic
 Drainage : there’s discharge secretions
 In sense of smell :

 Palpation
 Pain : none
 Masses : none
 Tumor : none

 Percussion
 Pain : none
 sinuses resonant : yes

h) Mouth
 Inspection
 breath : smell musty

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  lips : dry, lesions
 Lips color : pale
 bleeding : none
 swelling : none
 Tongue : cannot moves freely because use E.T.
 Mucosa : white
 Dental hygiene : Dirty and smelling
 Cavity : yes
 Gums : No redness, no swelling, bleeding, no retraction from the
teeth, no discoloration
 Teeth : Have 32 teeth, the color is white to yellow, and there
some caries.
 Cleanliness of the tongue : dirty
 Throat : exudate, and decrease gag reflex.

 Palpation
 Consistency : soft
 Tenderness : none
 Nodules : none
 Masses : none
 Lumps : none
 Lesions : none

i) Throat and Neck

 Inspection
 the muscles of the neck: Symmetrical in the middle of the head
 Enlargement : No enlargement of parotid glands.
 Growth : none
 scars : none

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  palpation
 Masses : none
 Tanderness : none
 swelling : none
 inflammation : none
 Lymph nodes : not visible

 Auscultationn
 Bruits : none

j) Chest and lungs

 Inspection
 Color : The color is dark like the other skin color, areolar and
nipples are darker in pigmentation.
 size : small
 tenderness : none
 quality : dull
 redness : none
 swelling : none
 dimpling : none
 niple retraction : none
 trauma : none
 masses : none
 Discharge : none
 Contour : Convex, without flattening, retractions, dimpling
 Thickening and edema : none
 Superficial vascular : Diffuse and symmetrical

 palpation
 elicit pain : none

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  lesions : none
 Masses : none
 Enlargement of breast : none

k) Respiratory
 Inspection
 Respiration rate : 17 per minutes
 pattern : regular
 depth :Normal respiration, there is no hypoventilation or
hyperventilation
 audibility : can hear audible breathing
 mode of breathing : Inhale and exhale through the ventilator mechanic
 retraction : absent
 symetry of chest wall : symmetric
 crecless : yes, on all lung field
 Tracheal position : on the middle
 Dyspnea : yes
 cough : yes

 Auscultation
 Breath sounds : reonchi

 Palpation
 Pulsation : none
 Masses : none
 Thoracic tenderness : none
 Crepitus : none
 Thoracic expansion : decreased

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  Percussion
 Thoracic percussion : dullness

l) Heart
 Inspection
 Aortic area : The pulsations not visible
 Pulmonic area : The pulsations not visible
 Mid precordial area : The pulsations not visible
 Tricuspid area : The pulsations not visible
 Mitral area : The pulsations not visible
 Inspection of the jugular venous pressure : The jugular veins are most distended
when the patient is flat, absent when the head of the bed is at a 90o angle.
 Inspection of the hepatojugular reflux : This pressure not elicit any change in the
jugular veins.
 Inspection and palpation of peripheral perfusion: No ulceration.
 Homan’s sign test : there is no complaints of calf pain when this evaluated.
 Manual compression : cannot feel the impulse.
 Retrograde filling, or trendelenburg test: the veins fill from below the occlusion
and within 35 seconds, and no additional filling.

 Palpation
 Aorta area : No pulsations, no thrills, heaves can palpated
 Pulmonic area : No pulsations, no thrills, heaves can palpated
 Mid precordial area : No pulsations, no thrills, heaves can palpated
 Tricuspid area : No pulsations, no thrills, heaves can felt
 Mitral area : No thrills, no heaves
 Epitrochlear node : The epitrochlear node is not palpable

 Auscultation
 Heart rhymes : irregular rhymes

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  Heart sound : disting heart sound, PMI located at 5th ICS, MCL on
the left
 Percussion
 sound : dull

m)Gastrointestinal
 Inspection
 Symmetry : flat
 Pigmentation and color : no abnormal color finding around the abdomen.
 Scars : No abdominal scars present
 Masses or nodules : no masses or nodules are present
 Pulsation : No strong abdominal pulsations are observed

 Auscultation
 Bowel sound : normative bowel sound, the sound 12 times per minute.
 Vascular sound : No bruits sound.
 Venous Hum : none
 Friction Rubs : none

 Percussion
 Abdominal :Tympanic
 Liver Span : 6 cm
 Liver descent : dullness
 Spleen : dullness
 Stomach : tympanic
 Kidney : no tenderness
 Liver : no tenderness
 Bladder : dull

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  Palpation
 Light palpation : smooth with consistent softness
 Abdominal muscle guarding : absent during expiration
 Deep palpation : No enlargement, no masses, no bulges, no swelling.
 Hook method : Liver cannot palpable
 Spleen : Not palpable
 Kidneys : Not palpable
 Bladder : sooth and round
 Inguinal Lymph nodes : no tender
 Pain : none
 Masses : none

n) Urinary and defecation

 Urine color : yellow
 Frequency of urine : 800 ml per 12 hours
 Pain while urinating : none
 Hematuria : none
 Burning sensation when urinating : none
 feelings of dissatisfaction while urinating : none
 Frequency of defecation: cannot defecation 2 days
 Pain during defecation : none

o) Musculoskeletal
 Inspection
 Posture : Symmetrical, no abnormalities
 Structure defect : none
 Muscle size and shape : No involuntary movement
 edema : None

 palpation

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  Muscle tone : Feel smooth and firm, no pain.
 Joints : The external joint contour feel smooth, strong, and firm.
No swelling, no pain, no tenderness, no warmth, no nodules, no deformity, no
tactile detection, no grating, no popping.
 Muscle strength :

Right left

5/5 5/5

5/5 5/5

p) Neurological
 Mental status
 Posture and movement: patient look unconscious, sleepiness
 Personal hygiene: patient clean, well groomed.
 Facial expression: facial expressions appropriate to the content of the
conversation and should be symmetrical.
 Affect: patient always sleep every time
 Communication: when stimulated pain the patient only moans and the words are
not clear

 Level of Consciousness
 GCS : sleepiness, GCS score: 6
 Sensory Assessment
 Pain: the patient localizes pain

 Cortical sensation
 Vibration sense: none
 Stereogenosis: none
 Graphesthesia: none
 Two-point discrimination: none
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 Nerve function
 Olfactory nerve I : not tested
 Optic nerve II, III : No visual field defect
 Nerve III, IV, VI : intact EOMS
 .Nerve V, VII : intent corneal reflex, no facial asymmetry
 Acoustic nerve VIII : intact hearing
 Glossopharyngeal Nerve IX and Vagus Nerve X : Gag reflex (+)
 Spinal accessory Nerve XI : symmetrical shoulder
 Hypoglossal Nerve XII : no tongue deviation

 Motoric system :
 Muscle strength :

Right left

5/5 5/5

5/5 5/5

 Sensory System:
 Muscle strength :
Right left

100% 100%

100% 100%

 Pathological Reflex
 Glabellar: not presence
 Clonus: no sustained clonus
 Babinski: a negative babinski reflex

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 q) Female Reproductive
 Inspection
 patient use urin chateter
 Palpation
 pain : none
 masses : none
 tumor : none

r) Nutrition
 frecuancy of eat :3 times a day before sick,now is NPO
 anorexia : yes
 dysphagia : none
 weigh before sick :-
 weigh after sick :-
 height :-
 body mass index :-

I. Laboratory data

Date: 02/18/19
Hematology
Conventional units Reference range
Sodium 142.90 mEq/L 135-145
Potassium 6.00 mEq/L 3.6-5.0
SGPT/ALT 182.00 U/L 21-72

Date: 02/18/19 Normal range

Complate blood count
Hemoglobin 11.90 gm% 13-16
Hematocrit 37.00% 42-50
White Blood Cell 12750/cumm 4500-11000
 Segmenters 41% 55-70
 Band 19
 Lymphocyte 12% 20-35

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  Epsinophil 0% 1-4
 Monocyte 28% 1-6
 Basophil 0% 0.00-1.00
Platelet Count 134 T/cumm 150-400
Red Blood Cell 4.1 M/cumm 4.6-6.2
Mean Corpuscular Vol 91 fL 80-96
Mean Corpuscular Hgb 29.2 pg 27-31
Mean Corps Hgb Conc 32.2% 33-36

Date: 02/18/19 Normal Range

Blood Gas
Fio2 45.00
Hgb 14.50
Site Brachial
Specimen Arterial
pH 7.10 7.35-7.45
PCO2 74.20 mmHg 35-45
PO2 168.00 mmHg 80-105
Bicarbonate 22.90 mEq/L 22-26
Total CO2 25.20 mEq/L 23-27
Base excess -7.00 mEq/L -2 to +3
O2 SAT 98.70 % 95-98

Date: 02/18/19 Conventional Units Normal range

Hematology
Creatinin Serum 2.50 mg/dL 0.7-1.4

Date: 02/18/19
Conventional units Reference range
Troponin T 50-100 ng/mL <50
Acute myocardial infarction possible; repeat the test to detect rising Troponin T levels in the
context of clinical assessment according to guidelines; search for differential diagnosis and other
cause of Tropinin T elevation.

Date: 02/18/19
Conventional units Reference range
Troponin I – HS Quanti 130.0000 pg/mL <= 34.2

Date: 02/18/19
Conventional units Reference range
PRO-BNP >9000pg/mL PRO-BNP
Acute CHF Unlikely: 300 pg/mL
Acute CHF less likely, consider alternative causes:

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50 years= 300-400 pg/mL
50-75 years= 300-900 pg/mL
75 years= 300-1800 pg/mL
Acute CHF likely:
50 years= 450 pg/mL
50-75 years= 900 pg/mL
75 years=1800pg/mL

 Gram Stain
Specimen type : Endotracheal Aspirate
PMN/PUS CELLS : more than 25 per low power field
Epithelial : less than 25 per low power field
Impression : no organisms seens

J. Medication
September 10, 2018
1. Apixaban (ELIQUIS) 5 mg FC tablet (1 tablet b.i.d) not given (anticoagulant)
2. Ca Polystyrene sulfonate (KALIMATE) 3 G sachet powder for oral suspension(1
sachet Q 4 h) (hyperkalemia drug)
3. Candesartan cilexetil (CANDEZ)8mg tablet (1 tablet O.D) (vasodilation mostly
arteriole, excretion of sodium and water and retention of potassium (through effects on
the kidney))
4. Dextrose (D50 water) 500 mg/MI, 50 mll plastic ampule (Intravenous injectio, 1
polypump Q 4 h)
5. Digoxin (Lanoxin) 250 mcg/tablet (oral, 1 tablet O.D) (increased force of myocardial
contraction)
6. Furosemide (LASIX) 20 mg, 2 ml ampul (40 mg Q 8 H) (High ceilling loop diuretic)
7. Hydrocortisone Na Succinate (SOLUCORTEF) 100 mg, 2 ml powder for injection (1
vial Q 8 H) (prevent inflammation, suppress airway mucus production, and promote
responsiveness of beta2 receptors in the bronchial tree)
8. Pantoprazole (PANTOPRAZ) 40 mg vil, powder for injection (40 mg O.D) (reduce
gastric acid secretion)
9. Ipratropium, Salbutamol (DUAVENT) 500 mcg/2.5 Per 2.5 mL Pulmoneb (1 nebule Q
6 H) (bronchodilation)

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 10. Piperacilin Na+ Tazobactam Na (PIPTAZ) 2 G/250 Mg vial (2.25 grams Q 8
H)(antibiotic)
11. Sodium bicarbonate (SUPRACID) 650 mg tablet (oral 1 tablet t.d.s)
12. Midoozolam 2.5 mg IV TT given x 2 doses
13. Morphine 4 mg IVTT
14. Calcuium gluc i amp very slow IVTT
15. Kalimate i tab sachet in 50 cc H20 Q 4x 3 doses via NGT

K. Nursing diagnosis
1. Ineffective Airway clearance related to chronic obstructive pulmonary disease
2. Ineffective Tissue perfusion (specify type): cerebral, renal, cardiopulmonary, GI, peripheral
related to hypoventilation; impaired transport of oxygen across alveolar and/or capillary
membrane
3. Excess Fluid volume related to Compromised regulatory mechanism
4. Infection related to immunologic disorder.

L. Nursing Intervention

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No Diagnose Objectives and Nursing Intervention Rational
Criteria for
Results
1 Diagnose: Ineffective Nursing  Monitor respiratory patterns,  A normal respiratory
Airway clearance related Outcome including rate, depth, and rate for an adult
to chronic obstructive Classification: effort. without dyspnea is 12 to
pulmonary disease  Respiratory 20. With secretions in
status: the airway, the
ventilation respiratory rate will
Subjective data:  Respiratory increase.
- The family said, Status: Airway  Normal blood gas
their father come Patency  Monitor blood gas values and values are a PO2 of 80
to hospital because  Respiratory pulse oxygen saturation levels to 100 mm Hg and a
hard to breath. Status: Gas as available. PCO2 of 35 to 45 mm
- Family said, their Exchange Hg. An oxygen
father was  Aspiration saturation of less than
admitted at Control 90% indicates problems
Bindoy District with oxygenation.
Hospital February After nursing Hypoxemia can result
11, 2019, 5 days action for 3 x 24 from ventilation-
PTA, onset of hours the patient perfusion mismatches
productive cough shows the secondary to
and dypsnea. effectiveness of respiratory secretions.
the airway as  Position client to optimize  An upright position
Objective data: evidenced by the respiration (e.g., head of bed allows for maximal air
 Vital signs: criteria of the elevated 45 degrees and exchange and lung
- GCS currently : results: repositioned at least every 2 expansion; lying flat
E= 2, M=2, V= 2, hours). causes abdominal organs
total 6  Demonstrates to shift toward the chest,
- General response effective which crowds the lungs
before: Sleepiness, coughing and and makes it more
weak. clear breath difficult to breathe.
- RR currently: 24 sounds; is Studies have shown that
times per minute free of in mechanically
- PR currently: 119 cyanosis and ventilated clients
times per minute dyspnea receiving enteral
- O2 saturation: 100  Maintains a feedings, there is a
% patent airway decreased incidence of
- SaO2: 98% at all times nosocomial pneumonia if
- Temperature: 36,  Relates the client is positioned at
o methods to a 45-degree
5 C
- BP: 95/65 mmHg enhance semirecumbent position
 BGAs: pH 7.30 secretion as opposed to a supine
(normal range 7.35- removal position (Torres, Serra-

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 7.45), PCO2 40.10  Relates the
mmHg(35-45),
bicarbonate 19.70
Eq/L(22-26)
(Respiratory acidosis a
half compensate).
 Use ventilator mechanic
 Patient loss of
consciousness  Identifies
 Orthopenea
 Use respiratory aids
muscles
Battles, Ros, 1992;
significance Drakulovic et al, 1999).
of changes in  Assist with clearing secretions  Help remove secretions;
sputum to from pharynx by offering and after to maintain
include color, tissues and gentle suction of adequate oxygenation
character, the oral pharynx if necessary.
amount, and  Normal sputum is clear
odor  Observe sputum, noting color, or gray and minimal;
odor, and volume. abnormal sputum is
and avoids green, yellow, or
specific bloody; malodorous;
factors and often copious.
that inhibit
effective  Research is promising on
airway  Provide oral care every 4 the use of chlorhexidine
clearance hours. Oral care freshens the oral rinses after oral care
mouth after respiratory to reduce bacteria, and
secretions have been possibly reduce the
expectorated. incidence of nosocomial
pneumonia
 Assess nutritional status  Clients with decreased
oxygenation have little
energy to use for eating
and will avoid meals.
Malnutrition significantly
affects the aerobic
capacity of muscle and
exercise tolerance in
clients with chronic
obstructive pulmonary
disease (COPD). When
nutritional status is
clearly improved, it is
accompanied by
improvements in strength
of the respiratory muscles
and, in some studies,
increased distance of
walking
 Fluids help minimize
 Ensure adequate hydration mucosal drying and
within cardiac and renal maximize ciliary action to
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 reserves. move secretions. Some
Dextrose (D50 water) clients cannot tolerate
500 mg/MI, 50 ml increased fluids because
plastic ampule of underlying disease.
(Intravenous injectio,
1 polypump Q 4 h)

 Administer medications  Watch for side effects

bronchodilators or inhaled such as tachycardia or
steroids as ordered. anxiety with
Hydrocortisone Na bronchodilators,
Succinate inflamed pharynx with
(SOLUCORTEF) 100 inhaled steroids.
mg, 2 ml powder for Bronchodilators
injection (1 vial Q 8 decrease airway
H) resistance secondary to
Ipratropium, bronchoconstriction.
Salbutamol
(DUAVENT) 500
mcg/2.5 Per 2.5 mL
Pulmoneb (1 nebule Q
6 H)

2 Diagnose: Ineffective Nursing Cerebral perfusion:  New onset of these

Tissue perfusion (specify Outcome  Monitor neurological neurological symptoms
type): cerebral, renal, Classification: status can signify a stroke. If
cardiopulmonary, GI,  Good caused by a thrombus
peripheral related to circulation and the client receives
hypoventilation; impaired Status treatment within 3
transport of oxygen across  Cardiac Pump hours, a stroke can often
alveolar and/or capillary Effectiveness: be reversed.
membrane Tissue  Monitor vital signs  Abnormal vital signs are
Perfusion: symptoms of abnormal
Subjective data: Cardiac neurological status.
- Family said his father  Tissue
felt weak, her daily Perfusion:  Monitor BGAs, pupil
need like take a bath, Cerebral size, sharpness,  if there is one or more of
dressing, and others  Tissue symmetry and reaction these test is abnormal it
need were helped by Perfusion: indicates a problem with
family member and Peripheral neurological status.
nurse while in the  Fluid Balance
hospital.  Hydration Peripheral perfusion
- Mr. Lael said during  Urinary  Note skin color and feel  Skin pallor or mottling,

24
 hospitalized all his
father daily activities
were helped by the
nurse and family
member, because his
father use ventilator
and weak to move
from bed.
- Mr. lael said his father
unconscious because
the medication and his
diseases.
Objective data:
 Vital signs:
- GCS currently :
E= 2, M=2, V= 2,
total 6
- General response
before: Sleepiness,
weak.
- RR currently: 24
times per minute
- PR currently: 119
times per minute
- O2 saturation: 100
% treatment
- SaO2: 98%
- Temperature: 36,
5o C
- BP: 95/65 mmHg
 BGAs: pH 7.30
(normal range 7.35-
7.45), PCO2 40.10
mmHg(35-45),
bicarbonate 19.70
Eq/L(22-26)
(Respiratory acidosis a
half compensate).
 Patient loss of
consciousness
 SGPT/ALT 182.00
U/L (normal range 21-
Elimination temperature of the skin. cool or cold skin
temperature, or an
After nursing absent pulse can signal
action for 3 x 24 arterial obstruction,
hours the patient which is an emergency
shows the that requires immediate
effectiveness of intervention. Rubor
the tissue (reddish-blue color
perfusion by the accompanied by
criteria of the dependency) indicates
results: dilated or damaged
 Demonstrates vessels. Brownish
adequate tissue discoloration of skin
perfusion as indicates chronic venous
evidenced by insufficiency
palpable  Check capillary refill.  Nail beds usually return
peripheral to a pinkish color within
pulses, warm 3 seconds after nail bed
and dry skin, compression.
adequate
urinary output,  Note skin texture and the  Thin, shiny, dry skin
and the presence of hair, ulcers, or with hair loss; brittle
absence of gangrenous areas on the legs nails; and gangrene or
respiratory or feet. ulcerations on toes and
distress anterior surfaces of feet
 Verbalizes are seen in clients with
knowledge of arterial insufficiency. If
ulcerations are on the
regimen, side of the leg, they are
including usually venous (Bates,
appropriate Bickley, Hoekelman,
exercise and 1998).
medications  Measure circumference
and their  Note presence of edema of ankles and calf at the
actions and in extremities and rate it same time each day in
possible side on a four-point scale. the early morning.
effects
 Identifies Cardiovascular perfusion:  The new onset of a
changes in  Listen to heart sounds; note gallop rhythm,
lifestyle that rate, rhythm, presence of S3, tachycardia, and fine
are needed to S4, and lung sounds (noting crackles in lung bases
increase tissue presence of crackles). can indicate onset of
perfusion heart failure (Janowski,
1996). If client develops
25
 72),
 Potassium 6.00 mEq/L
(normal range 3.6-5.0)
 Creatinine serum 2.50
mg/dL (normal range  Observe for confusion,
0,7-1.4) restlessness, agitation,
 Troponin T 50-100 dizziness.
mg/L (normal range
<50)  Observe for chest pain or
 PRO-BNP > 9000 discomfort; note location,
pg/mL (normal range radiation, severity, quality,
for 75 years 1800 duration, associated
pg/mL) manifestations such as
 Troponin I-HS Quanti nausea, and precipitating and
130.0000 pg/mL relieving factors.
(normal range <= 34.2)
 ECG impression: atrial
fibrilation
 anorexia and use NGT  Give medications within
defined parameters to
 fatique
maintain contractility,
 Orthopnea
preload, and afterload per
 skin dry
physician's order.
Apixaban (ELIQUIS) 5
mg FC tablet (1 tablet
b.i.d) not given
(anticoagulant)
Digoxin (Lanoxin) 250
mcg/tablet (oral, 1
tablet O.D)
Ca Polystyrene
sulfonate (KALIMATE)
3 G sachet powder for
oral suspension(1 sachet
Q 4 h)
Candesartan cilexetil
(CANDEZ)8mg tablet
(1 tablet O.D)
Furosemide (LASIX)
20 mg, 2 ml ampul (40
mg Q 8 H)
 Watch laboratory data
closely, especially arterial
blood gases and
pulmonary edema, there
will be coarse crackles
on inspiration and
severe dyspnea
 Central nervous system
disturbances may be
noted with decreased
cardiac output.
 Chest pain/discomfort is
generally indicative of
an inadequate blood
supply to the heart,
which can compromise
cardiac output. Clients
with heart failure can
continue to have chest
pain with angina or can
infarct.
 By following
parameters, the nurse
ensures maintenance of
a delicate balance of
medications that
stimulate the heart to
increase contractility,
maintaining adequate
perfusion of the body.
 Client may be receiving
cardiac glycosides and
the potential for toxicity
is greater with
26
 electrolytes, including
potassium.
 The elderly have
 Observe for side effects
from cardiac medications.
 In clients with
 Closely monitor fluid
intake including IV lines.
Maintain fluid restriction if
ordered.
 Monitor intake and output. 
If client is acutely ill,
measure hourly urine
output and note decreases
in output.
 Routine blood work can
Renal perfusion:
 Monitor lab work such as
complete blood count,
sodium level, and serum
creatinine.
hypokalemia;
hypokalemia is common
in heart clients because
of diuretic use.
difficulty with
metabolism and
excretion of medications
due to decreased
function of the liver and
kidneys; therefore toxic
side effects are more
common.
decreased cardiac
output, poorly
functioning
ventricles may not
tolerate increased
fluid volumes.
Decreased cardiac
output results in
decreased perfusion
of the kidneys, with a
resulting decrease in
urine output.
provide insight into the
etiology of heart failure
and extent of
decompensation. A low
serum sodium level
often is observed with
advanced heart failure
and can be a poor
prognostic sign.(Hurst)
Serum creatinine levels
will elevate in clients
with severe heart failure
because of decreased
perfusion to the kidneys.
Creatinine may also
elevate because of ACE
inhibitors
27
3 Excess Fluid volume Electrolyte and  Monitor location and  Heart failure and renal
Acid-Base Balance
related to Compromised extent of edema; use a failure are usually
 Fluid Balance
millimeter tape in the associated with dependent
regulatory mechanism  Hydration
After nursing action same area at the same edema because of
Subjective data:
for 3 x 24 hours the time each day to measure increased hydrostatic
-Mr. Lael said his father
patient shows there edema in extremities. pressure; dependent
cannot eat because advice is no excess fluid edema will cause swelling
from the doctor volume balance by in the legs and feet of
the criteria of the ambulatory clients and the
Objective data:
results:
 Vital signs: pre-sacral region of clients
 Remains free of
on bed rest. Dependent
- GCS currently : edema,
effusion, weight edema was found to
E= 2, M=2, V= 2, appropriate for demonstrate the greatest
total 6 client
sensitivity as a defining
 Maintains clear
- General response characteristic for excess
lung sounds;
before: Sleepiness, no evidence of fluid volume. Generalized
dyspnea or edema (e.g., in the upper
weak.
orthopnea
extremities and eyelids) is
- RR currently: 24  Maintains urine
output within associated with decreased
times per minute
500 ml of oncotic pressure as a
- PR currently: 119 intake and result of nephrotic
normal urine
times per minute syndrome. Measuring the
osmolality and
- O2 saturation: 100 specific gravity extremity with a

%  Maintains millimeter tape is more

normal central
- SaO2: 98% accurate than using the 1
venous
pressure, to 4 scale.
- Temperature:
pulmonary  Monitor lung sounds for
 Pulmonary edema results
36,5o C capillary wedge crackles, monitor
from excessive shifting of
- BP: 95/65 mmHg pressure, respirations for effort, and
cardiac output, fluid from the vascular
 BGAs: pH 7.30 and vital signs determine the presence
space into the pulmonary
and severity of orthopnea.
(normal range 7.35- interstitial space and

7.45), PCO2 40.10 alveoli. Pulmonary edema

can interfere with the
mmHg(35-45),
oxygen-carbon dioxide
bicarbonate 19.70
exchange at the alveolar-
Eq/L(22-26)
capillary membrane
(Respiratory acidosis a (Metheny, 2000), resulting
half compensate). in dyspnea and orthopnea

28
 Patient loss of  With head of bed elevated
consciousness 30 to 45 degrees, monitor
jugular veins for distention
 SGPT/ALT 182.00
in the upright position;
U/L (normal range 21-
assess for positive
72),
hepatojugular reflex.
 Potassium 6.00 mEq/L
(normal range 3.6-5.0)  Monitor central venous
 Creatinine serum 2.50 pressure, mean arterial
mg/dL (normal range pressure, pulmonary
artery pressure,
0,7-1.4)
pulmonary capillary wedge
 WBC 12750 /cumm
pressure, and cardiac
(normal range 4500-
output; note and report
11000), Monocytes trends indicating
28% (normal range1-6), increasing pressures over
esinophil 0% (normal time.
range 1-4), Lymphocyte
12% (normal range 20-
 Monitor vital signs; note
35), segmentera 41%
decreasing blood pressure,
(normal range 55-70)
tachycardia, and
 anorexia and use NGT tachypnea. Monitor for
 fatique gallop rhythms. If signs of
heart failure are present,
 Dypsnea
see nursing care plan for
 Orthopnea
Decreased Cardiac output.
 skin dry
 Monitor serum osmolality,
 Cannot defecate 2 days serum sodium, blood urea
 diet: NPO nitrogen (BUN)/creatinine
 Oliguria, ratio, and hematocrit for
decreases.
 Urine: 400 ml a day
 Monitor intake and output;
note trends reflecting
decreasing urine output in
relation to fluid intake.
 Increased intravascular
volume results in jugular
vein distention, even in a
client in the upright
position, and also a
positive hepatojugular
reflex.
 Increased vascular volume
with decreased cardiac
contractility increases
intravascular pressures,
which are reflected in
hemodynamic parameters.
Over time, this increased
pressure can result in
uncompensated heart
failure.
 Heart failure results in
decreased cardiac output
and decreased blood
pressure. Tissue hypoxia
stimulates increased heart
and respiratory rates.

These are all measures of
concentration and will
decrease (except in the
presence of renal failure)
with increased
intravascular volume. In
clients with renal failure
the BUN will increase
because of decreased
renal excretion.
 Accurately measuring
intake and output is very
important for the client
with fluid volume overload
29
 Administer prescribed  Therapeutic responses to
diuretics as appropriate diuretic therapy include

Ca Polystyrene natriuresis, diuresis,

elimination of edema,
sulfonate
vasodilation, reduction of
(KALIMATE) 3 G cardiac filling pressures,
sachet powder for decreased renal

oral suspension(1 vasculature resistance,

and increased renal blood
sachet Q 4 h).
flow. The blood pressure
Candesartan reduction in response to
cilexetil ACE inhibitors is greater in

(CANDEZ)8mg the presence of sodium

depletion and diuretic
tablet (1 tablet O.D)
therapy. The incidence of
Furosemide electrolyte and metabolic
(LASIX) 20 mg, 2 imbalances ranges from

ml ampul (40 mg Q 14% to Maintain the rate

of all IV infusions carefully
8 H).
60%; the most common is
Calcuium gluc i amp hypokalemia.
very slow IVTT
Kalimate i tab
sachet in 50 cc H20
Q 4x 3 doses via
NGT
 Fluid restriction may
 Maintain the rate of all IV
decrease intravascular
infusions carefully.
volume and myocardial
Dextrose (D50
workload. Overzealous
water) 500 mg/MI, fluid restriction should not
50 mll plastic be used because
hypovolemia can worsen
ampule (Intravenous
heart failure. In one
injectio, 1 polypump
study, instituting fluid
Q 4 h) restriction, distributing
fluids over a 24-hour

30
 period, and using a fluid
restriction when the client
had hyponatremia all had
high intervention content
validity scores for the fluid
management intervention
label (Cullen, 1992).
Client involvement in
planning will enhance
participation in the
necessary fluid restriction.
 Monitor daily weight for
 Body weight changes
sudden increases; use
reflect changes in body
same scale and type of
fluid volume. Clinically it is
clothing at same time
extremely important to
each day, preferably
get an accurate body
before breakfast. Body
weight of a client with
weight changes reflect
fluid imbalance
changes in body fluid
volume. Clinically it is
extremely important to
get an accurate body
weight of a client with
fluid imbalance

4 Diagnose: Infection Nursing Outcome  Observe and report  With the onset of infection
Classification: signs of infection such
related to immunologic the immune system is
as redness, warmth,
 Immune Status discharge, and activated and signs of
disorder.
 Knowledge: increased body
infection appear.
Infection control temperature.

 Risk control  Laboratory values are

Subjective data:
correlated with client's
- Family said, their After nursing action
 Note and report history and physical
for 3 x 24 hours the
father was admitted patient does not laboratory values examination to provide a
(white blood cell count
at Bindoy District experience infection
and differential, serum global view of the client's
with the results
protein, serum immune function and
Hospital February criteria:
albumin, and cultures).
nutritional status and
11, 2019. 5 days  Clients are free of develop an appropriate
signs and
PTA, onset of symptoms of plan of care for the
infection diagnosis.
productive cough,  Demonstrate
ability to prevent  Preventive skin

31
 yellowish sputum, infection assessment protocol,
 The leukocyte including documentation,
no fever, dyspnea. count is within  Assess skin for color,
normal limits moisture, texture, and assists in the prevention
- Family said their  Demonstrate turgor (elasticity). of skin breakdown. Intact
healthy living Keep accurate, ongoing
father has COPD documentation of skin is nature's first line of
behavior
and CAP-MR  Gastrointestinal, changes. defense against
genitourinary microorganisms entering
Objective data: conditions are
within normal the body.
 Gram Stain limits.  Immune function is
- Specimen type:  vital signs on
normal range affected by protein intake
Endotracheal (especially arginine); the
 Encourage a balanced balance between omega-6
Aspirate diet, emphasizing
proteins to feed the and omega-3 fatty acid
- PMN/PUS CELL:
immune system. intake; and adequate
more than 25 per amounts of vitamins A, C,
low power field and E and the minerals
zinc and iron. A deficiency
- Epithelial: less
of these nutrients puts the
than 25 per low
client at an increased risk
power field of infection
- Impression: no  Hospital-acquired
organisms seens pneumonia is the second
most common nosocomial
 WBC 12750 /cumm
infection but has the
(normal range 4500-
highest mortality (30%)
11000), Monocytes  Use strategies to and morbidity rates. The
prevent nosocomial
28% (normal range1-6), strategies listed are used
pneumonia: assess
esinophil 0% (normal lung sounds, sputum, to prevent nosocomial
and redness or
range 1-4), Lymphocyte pneumonia (Tasota et al,
drainage around stoma
sites; use sterile water 1998).Once treatment for
12% (normal range 20- rather than tap water
pneumonia has begun, it
35), segmentera 41% for mouth care of
immunosuppressed must continue for 48 to 72
(normal range 55-70) clients use sterile
hours, the minimum time
technique when
 Hemoglobin 11.90 suctioning; suction to evaluate a clinical
secretions above
gm% (normal range response.
tracheal tube before
suctioning; drain
13-16) accumulated
condensation in
 Hematocrit 37.00% ventilator tubing into a
(Normal range 42-50) fluid trap or other
collection device before

32
 temperature: 36,5oC repositioning the
client; assess patency
and placement of
nasogastric tubes;
elevate the head of the
client to (30° to  Fluid intake helps thin
prevent gastric reflux
of organisms in the secretions and replace
lung; institute feeding fluid lost during fever
as soon as possible;
assess for signs of  Standard Precautions are
feeding intolerance—no
based on the likely routes
bowel sounds,
abdominal distension, of transmission of
increased residual,
pathogens.
emesis.
 Encourage fluid intake.  Clients are most at risk for
cross-infection during bag
changing and emptying
 Follow Transmission-  Hygienic care is important
Based Precautions for
airborne-, droplet-, to prevent infection in at-
and contact- risk clients.
transmitted
microorganisms.  antibiotics is to suppress or
 Use careful technique
when changing and
stop the development of
emptying urinary harmful bacteria or
catheter bags; avoid
cross-contamination. microorganisms inside the
 Ensure client's
appropriate hygienic body
care with hand
washing; bathing; and
hair, nail, and perineal
care performed by
either nurse or client.
Hygienic care
 Administer prescribed
antibiotics as
appropriate

Piperacilin Na+
Tazobactam Na
(PIPTAZ) 2 G/250
Mg vial (2.25
grams Q 8 H)

References

33
 Huether, S. E., McCance, K. L. (2006). Phathophysiology; The Biologic Basis for
Diseases in Adulths and Children. 5th ed. St. Louis: Mosby, Inc.
 Workman, Ignatavicius. (2010). “Medical-Surgical Nursing: Patient-Centered
Collaborative Care”. United States of America: SAUNDERS Elsevier

34