I.

INTRODUCTION According to the National Statistic Office, Cardiovascular Disease is still the leading cause of death in the country, currently affecting 77,000 out of 100,000 population, this fact has driven us to discuss a case about cardiovascular disease, thus we chose the case of a 54 year old female client, diagnosed of Congestive Heart Failure IV, Secondary to Coronary Artery Disease, as it holds vast amount knowledge that we future nurses, can learn from. This case will be the pathway to higher knowledge and the key to work efficiently when tackling this kind of disease. By definition, the term "heart failure" is globally defined as the state in which the heart is unable to pump blood at a rate adequate for satisfying the requirements of the tissue with function parameters remaining within normal limits. And according to The New York Heart Association, There are four classifications of heart failure which are; Class I: no limitation is experienced in any activities, there are no symptoms from ordinary activities; Class II: slight, mild limitation of activity, the patient is comfortable at rest or with mild exertion; Class III: marked limitation of any activity, the patient is comfortable only at rest; and Class IV: any physical activity brings on discomfort and symptoms occur at rest. By number, as of 2009 Congestive Heart Failure is present in 2 percent of people ages 40 59 years old, more than 5 percent of people ages 60 69 years old and 10 percent of people ages 70 and older (WHO). Here in the Philippines, out of the 86 million populations, 1.5 million have Congestive Heart Failure and it is the 6th leading cause of heart disease in the Philippines, affecting males more often than females. Causes of CHF are the following: Coronary Artery Disease, including angina and heart attack, is the most common underlying cause of Congestive Heart Failure. People who have a heart attack are at high risk of developing Congestive Heart Failure. Most people with heart failure also experience uncontrolled high blood pressure in the past, and about one out of every three people with heart failure also has suffered from diabetes. The particular symptoms that an individual experiences are determined by which side of the heart is involved in the heart failure. For example, the left atrium receives oxygenated blood from the lungs and passes it onto the left ventricles, which pumps it to the rest of the body. When the left side isnt pumping efficiently, blood
1

backs up in the vessels of the lungs, and sometimes fluid is forced out of the lung vessels and into the breathing space themselves. This pulmonary congestion causes shortness of breath. The other major symptoms of left - sided heart failure are fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and the sputum production that comes from pulmonary congestion. Right - sided heart failure, on the other hand is a condition in which fluids move back into the veins that empty into the right side of the heart. Pressure then builds up in the liver and veins in the legs. Liver may become enlarge and swelling may occur, as well as edema. Diagnostic procedures commonly use to support the clinical diagnosis of CHF are: Echocardiography, Chest X Ray, and Electrocardiogram (ECG/EKG). This case study is about a 54 year old female client, currently diagnosed of Congestive Heart Failure IV, Secondary to Coronary Artery Disease, whom we handled last December 7, 2011 up to December 8, 2011 at Tondo Medical Center, Medical ward 2 -10 pm shift.

II. OBJECTIVES

General Objective: Currently, Heart Disease is the leading cause of mortality here in our country. Its because of the lifestyle, knowledge deficit and other risk factors that cause this disease. So we, BSNIV Section 12 of Arellano University College of Nursing, aims to enhance our knowledge with regards to the clients general health and disease condition. This also seeks to assimilate the students skills through application of nursing interventions and medical management. Furthermore, this case presentation intends to improve our attitude by conveying open mindedness and utilizing therapeutic communication all throughout the activity, and lastly we want to emphasize that we future nurses should be familiar with this case , because we are the instruments in helping the country lessen the morbidity and mortality rate on heart problems. Specific Objectives: At the end of the presentation the students will be able to: Discuss a brief introduction about Congestive Heart Failure IV, Secondary to Coronary Artery Disease together with the clinical manifestations. Select a theoretical framework for the study in relation to a nursing approach applied to our client. Discuss the clients demographic and health history with its Gordons Eleven Functional Health Patterns. Interpret the abnormal findings of the physical assessment and compare it to the normal results which will help in analyzing the disease process. Correlate the different laboratory tests and results done to the client with its interpretation. Discuss the normal Anatomy and Physiology of the heart. Explain the Pathophysiology of Congestive Heart Failure IV, Secondary to Coronary Artery Disease.
3

Enumerate the signs, symptoms and complications of our client. Identify Nursing Problems related to the situation of the client. Implement necessary interventions, in relation to our clients condition. Discuss the drugs that had been prescribed and used by the client. Discuss the appropriate discharge plan for the client.

III. THEORETICAL FOUNDATION LYDIA HALLS THEORY CARE, CORE, CURE

Lydia Halls model for nursing provides a framework to encourage open communication between patients and nurses. The model has three interrelated circles that represent medical and clinical management nurses to the client. Care This is the part of the model reserved for nurses, and focused on performing that noble task of nurturing the patients, meaning the component of this model is the motherly care provided by nurses, which may include, but is not limited to provision of comfort measures, provision of patient teaching activities and helping the patient meet their needs where help is needed. Cure The second aspect of the nursing process is shared with medicine and is labeled as the cure. Hall comments on the two ways that this medical aspect of nursing may be viewed; it may be viewed as the nurse assisting the doctor by assuming medical tasks or functions. The other view of this aspect of nursing is to see the nurse helping the patient through his or her medical, surgical, and rehabilitative care in the role of comforter and nurturer.

Core The third are that nursing shares with all of the helping professions is that of using relationships for therapeutic effect the core. This area emphasizes the social, emotional, spiritual, and intellectual needs of the patient in relation to family, institution, community and the world. Knowledge foundational to the core was based on the social sciences and therapeutic use of self. Through the closeness offered by the provision of intimate bodily care, the patient will feel comfortable enough to explore with the nurse who she is, where she is, where she wants to go and will take or refuse help in getting there the patient will make amazingly rapid progress towards recovery and
5

rehabilitation. Hall believed that through this process, the patient would emerge as a whole person.

For the Care Model, since her heart failure was classified as Class IV, meaning even at rest she was developing signs and symptoms of cardiopulmonary insufficiency, manifested by shortness of breath, restlessness and easy fatigability; thus eventually forcing our client to limit her activity. In that case, she was unable to perform her activities of daily living. As nurses, we assisted our client to achieve her optimum level of function and to perform her daily activities specially her hygienic practices, like bathing in which we applied the principle of bed bath. We also provided our client a commode, which she can use whenever she feels like urinating or defecating. In that manner we are providing our client an environment of comfort. It is also our responsibility to conduct health teaching, so we advised our client to avoid activities that will aggravate her condition, such as blowing of the nose hard and doing Valsalva maneuver. Furthermore, we promoted open communication by encouraging our client to express her thoughts, fears and concerns about her health thus, resulting in decreasing her anxiety.

In terms of Cure Model, since her condition was severely affecting her, we provided our client both medical and supportive management. Firstly, in the medical management, we made sure that she was able to take her medications at the right time, with the right dose. We also assisted in administering oxygen, regulating intravenous fluids and insertion of contraptions as ordered by the physician. Secondly, is the

supportive management, in which we made sure that we were able to assess the client frequently, thus indentifying possible problems that our client may encounter during the illness process.

In Core Model, our main goal during that time was to alleviate the anxiety and the distress that she experienced, as manifested by irritability and restlessness. As nurses, we used ourselves therapeutically, by rendering touch and tender loving care technique

coupled with therapeutic communication. In that manner, we effectively helped our client cope in her present condition.

IV. NURSING HISTORY

A. Biographical Data:

Clients Name/Initial: TP Address: Yellowbell St., Navotas City Gender: Female Date of Birth: February 22, 1957 Place of Birth: Samar, Leyte Age: 54 years old Nationality: Filipino Religion: Roman Catholic Source of Referral: OPD Medicine Department of Tondo Medical Center Source of Health Assistance: Tondo Medical Center Emergency Contact: sister Date of Admission: December 5, 2011 Medical Diagnosis: Congestive Heart Failure IV, Secondary to Coronary Artery Disease
B. Chief Complaint:

Nahihirapan akong huminga at naninikip ang dibdib ko, as verbalized by the client.
7

C. History of Present illness TP is a 54 year old female client who came in to the Emergency Department of Tondo Medical Center last December 5, 2011 at exactly 9 in the morning. She complained of difficulty of breathing and chest pain, which started 2 hours prior to admission. One week prior to admission, the client experienced shortness of breath, light headedness and easy fatigability, although relieved by rest. This was accompanied by chest pain, which she described as squeezing like pain, which radiated to her left shoulder, with a pain scale of 4/10, lasting for 3 minutes, intermittently and was aggravated by exertion. She managed it by taking sublingual Nitroglycerin as prescribed by her physician during her hospitalization last 2009. Also the client complained of sleep disturbances, in which she will wake up in the middle of her sleep because she feels like drowning. The above signs and symptoms persisted which prompted her to seek consult in the OPD Medicine Department of Tondo Medical Center. The physician advised her to have some rest and avoid strenuous activity that will aggravate her condition, and was prescribed of Isosorbide Dinitrate for her chest pain. She was also advised to undergo laboratory examinations/tests specifically Chest X Ray to confirm her condition and to return once results were completed. However, the client didnt comply due to financial constraints. Two days prior to admission, the chest pain increases from 4/10 to 7/10, however still relieved by sublingual Nitroglycerin and rest. Until the morning of December 5, 2011 at exactly 7am ( two hours prior to admission ), while the client was preparing foods for their carinderia, she experienced difficulty of breathing and chest pain, which she characterized as chest tightness over the substernal area, radiating to her left shoulder and back, with a pain scale of 8/10. Unfortunately, she ran out of Nitroglycerin to manage the pain. Instead she lay down and took some rest. But to no avail, the above signs and symptoms persisted, thus prompting our client to be rushed at Tondo Medical Center and was subsequently admitted.

D. Past Health History In 1997, she was diagnosed to have Hypertension, Stage 1. She was given unrecalled antihypertensive medications which were regularly taken for 2 years. However on the later years medications were only taken when she experienced dizziness and light-headedness. In 2009, she was admitted at Tondo Medical Center for five (5) days because of sharp, stabbing chest pain. Impression then was Coronary Artery Disease by ECG. The following medications were prescribed: Simvastatin, Propanolol, Verapamil, Captopril and Nitroglycerin. Lifestyle modification was advised. On that same year (2009), she was also diagnosed to have Pulmonary Tuberculosis I by AFB smear and Chest X- ray. She was treated with Izoniazid, Rifampicin, Pyrazinamide and Ethambutol for 2 months for the intensive phase;and Izoniazid and Rifampicin for 4 months for the maintenance phase. Sputum examination revealed negative result after 6 months of anti - TB regimen. Also the client claimed to us that she already contracted childhood illnessess such as Measles and Chickenpox in which it was treated by home remedies. In addition to that, the client was also taking over the counter drugs such as Paracetamol if she has fever. When she was 16 years old she suffered from a minor fall accident, manifested by minor bruises. Immunization was not complete. The client could not recall what vaccines were given. However, she has a BCG scar on her right deltoid. There was no history of surgery, allergy to food/drugs nor special needs.

E. Family Health History

Family Member

Diabetes Mellitus

Cancer

Heart Disease

Asthma

Hypertension

Sister

None

None

None

None

Hypertensive

Eldest brother

Diabetic (type II)

None

None

None

Hypertensive

Father

Diabetic

None

Heart Disease (unrecalled diagnosis)

None

Hypertensive

Mother

None

None

Heart Disease (unrecalled diagnosis)

None

Hypertensive

F. Social History Our client is 54 year old, living with her sister in a bungalow type of house with one room, kitchen and a bathroom with manual type of flush. She and her sister own an eatery near their house. The source of their electricity is MERALCO and their water supply is from NAWASA. Their house is near the public road, market and different institutions, as well as Tondo Medical Center. She doesnt smoke, drink alcoholic beverages nor use prohibited drugs. The client and her husband separated 10 years
10

ago. They have three children who are college degree holders and are currently employed. Though they have their own families they still support their mothers medications and hospitalization. The client has a good relationship with her children as well as her sister and grandchildren. The last travel history of the client was in March, 2011 at Samar, Leyte. Our client is a high school graduate.

G. Obstetric History Menarche: 11 years old Obstetric score: G3 P3 T3 P0 A0 L3 Menopause: 50 years old. Past pregnancy history:

Year of pregnancy

Gender of baby

Type of Delivery Normal

Complication

1981

Female

Spontaneous delivery Normal

None

1983

Female

Spontaneous delivery Normal

None

1987

Male

Spontaneous delivery

None

11

V. ANATOMY AND PHYSIOLOGY HEART The human heart is a cone shaped, hollow, muscular organ located in the mediastinum between the lungs. It is about the size of an adult fist. The heart rest on the diaphragm, tilting forward and to the left, in the clients chest. Each beat of the heart pumps about 60cc or ml of blood or 5L/min. During the strenuous activity, the heart can double the amount of blood pumped to meet the increased oxygen needs of the peripheral tissue. The heart is encapsulated by a protective covering called the Pericardium. Cardiac muscle tissue is

composed of three layers: Epicardium, Myocardium and Endocardium. The myocardium, the middle layer is composed of striated muscle fibers interlaced into bundles. This middle layer is responsible for contractile force of the heart. The innermost layer which is the endocardium is composed of endothelial tissue, which is responsible for the inside lining of the heart.

CHAMBERS OF THE HEART A muscular wall which is called the septum separates the heart into two halves: the Right and the Left. Each half has an upper chamber which is termed as the Atrium and a lower chamber, the Ventricle. The RIGHT side, which is composed of the Right Atrium (RA) and Right Ventricle (RV). The right atrium receives deoxygenated venous blood (venous return) from all peripheral tissue by way of the superior vena cava and the inferior vena cava and also from the heart muscle by way of the coronary sinus. Most of this venous return flows passively from the RA, through the opened Tricuspid Valve then into the RV during ventricular diastole or filling. When there are blood remains to the RA after
12

ventricular diastole, it is being propelled into the RV during the atrial systole or contraction.The right ventricle is a flat muscular pump located behind the sternum. The RV generates enough pressure, about 25 mmHg to close the tricuspid valve, open the pulmonic valve, and propel blood into the pulmonary artery and the lungs. The LEFT side, after blood is reoxygenated in the lungs, it flows freely from the four pulmonary veins into the Left Atrium (LA). Blood then flows through an opened mitral valve into the Left Ventricle (LV). When the LV is almost full, the LA contracts, pumping the remaining blood volume into the LV. With the systolic contraction the LV generates enough pressure, approximately 120 mmHg to close the mitral valve and open the aortic valve. Blood is then propelled into the aorta and into the systemic circulation. The LV is the largest and most muscular chamber of the heart. Its wall is two to three times the thickness of the right ventricular wall. CORONARY ARTERIES The heart receives blood to meet its metabolic needs through the coronary artery system. The blood leaving the LV exits through the aorta, the bodys main artery. Two coronary arteries, referred to as the "left" and "right" coronary arteries, emerge from the beginning of the aorta, near the top of the heart. The initial segment of the left coronary artery is called the left main coronary. This blood vessel is approximately the width of a soda straw and is less than an inch long. It branches into two slightly smaller arteries: the left anterior descending coronary artery and the left circumflex coronary artery. The left anterior descending coronary artery is embedded in the surface of the front side of the heart. The left circumflex coronary artery circles around the left side of the heart and is embedded in the surface of the back of the heart. Just like branches on a tree, the coronary arteries branch into progressively smaller vessels. The larger vessels travel along the surface of the heart; however, the smaller branches penetrate the heart

13

muscle. The smallest branches, called capillaries, are so narrow that the red blood cells must travel in single file. In the capillaries, the red blood cells provide oxygen and nutrients to the cardiac muscle tissue and bond with carbon dioxide and other metabolic waste products, taking them away from the heart for disposal through the lungs, kidneys and liver. When cholesterol plaque accumulates to the point of blocking the flow of blood through a coronary artery, the cardiac muscle tissue fed by the coronary artery beyond the point of the blockage is deprived of oxygen and nutrients. This area of cardiac muscle tissue ceases to function properly. The condition when a coronary artery becomes blocked causing damage to the cardiac muscle tissue it serves is called a myocardial infarction or heart attack. REGULATION OF HEARTS FUNCTION a. INTRINSIC REGULATION Refers to the mechanism contained within the heart itself. The force of contraction produced by cardiac muscle is related to the degree of stretch of cardiac muscle fibers. The amount of blood in the ventricles at the end of ventricular diastole determines the degree to which the cardiac muscle fibers are stretched. Venous return is the amount of blood that returns to the heart, and the degree in which the ventricular walls are stretched at the end if diastole is called preload. If venous return increases, the heart fills to a greater volume and stretches the cardiac muscle fiber, producing an increase in preload. In response to the increased preload, cardiac muscle fiber contract with a greater force resulting to increase CO. As venous return increases, preload will also increases, resulting to an increase in CO. As venous return decreases, preload will also decrease, thus CO will also decrease. This relationship of the preload and the stroke volume is called Starlings Law of the heart.

14

b. EXTRINSIC REGULATION Refers to the mechanism external to the heart, such as either hormonal or nervous regulation. Nervous influences are carried through the autonomic nervous system. Both sympathetic and parasympathetic nerve fiber innervates the heart. Sympathetic stimulation causes the heart rate and stroke volume to increase, whereas parasympathetic stimulation causes heart rate and stroke volume to decrease. The Baroreceptor, plays an important role in regulating the function of the heart. Barorecptors are stretch receptors that monitor blood pressure in the aorta and in the wall of the internal carotid arteries, which carry blood to the brain. Changes in blood pressure result in changes in the stretch of the walls of these blood vessels. Thus, changes in the blood pressure cause changes in the frequency of action potentials produced by the baroreceptors. The action potential is transmitted along the nerve fibers from the stretch receptors to the medulla oblongata of the brain. Within the medulla oblongata is a cardioregulatory center, which receives and integrates action potential from the baroreceptors, also the cardioregulatory mechanism influences sympathetic stimulation of the adrenal gland. The Chemoreceptors are located at the carotid and aortic body, main function of this is to monitor oxygen level in the blood as well as the carbon dioxide level. They send action potentials along the sensory nerve fibers to the medulla oblongata. When the blood level decreases, carbon dioxide increase, the chemoreceptors increased frequency of action potential and activates the chemoreceptor reflex. In response, the vasomotor and the cardiovascular centers decreases parasympathetic and increases sympathetic nervous system which increases HR and vasoconstriction.

15

VI. PATHOPHYSIOLOGY
Precipitating factors Predisposing factors

Family history of heart disease

Recent diagnosis of Coronary Artery Disease last 2009

Age: 54 years old

Diet: High intake of foods rich in cholesterol

Hypertensive since 1997

Injury to the arterial wall (tunica intima)

Menopause

Promotes LDL and platelet to assimilate in the injured part

Estrogen level decreases

Inability to maintain cholesterol level in the blood Plaque begins to form as well as platelets in the injured area

Blood cholesterol level increases (6.3mmol/L) and LDL (2.40 mmol/L) Results to partial thrombus formation

Sluggish blood flow results

16

Decrease oxygenated blood and nutrents supply in the myocardium area

Ischemia results

Anaerobic metabolism, and increases lactic acid production and secretion in the myocardial area.

Blood pressure decreases therefore, little blood will pass the aorta

Decrease Cardiac Ouput and Stroke Volume Experiencing easy fatigability

Decrease myocardial contractility

Myocardial muscles are and become less functional

Chest tightness like pain that radiates to her left shoulder and back, and with a pain scale of 8/10

Registered on pressoreceptor/baroreceptors in w/c its stimulates the sympathetic nervous system to increase HR, and promoting peripheral vasoconstriction,

Point of maximal impulse is now displaced in the 6th ICSMCL

Paleness of the skin, nail, and conjunctiva. Also capillary refill last for 4 seconds, cool and clammy skin, easy Fatigability and irregular bowel movements

Increase Blood pressure, and Cardiac output, results

Increase venous return to the heart results

Left ventricular hypertrophy results

Enlargement of the heart shown in the Chest XRay

Preload increases

Heart fills greater volume and stretches the cardiac muscle fibers Due to hypertrophy, LV cannot pump out blood efficiently to supply the systemic circulation

This causes cardiac muscle fibers to contract with a greater force

Stroke volume increase, thus resulting to increase in Cardiac 17 output and venous return

Blood pooling in the LV occurs

S3 gallop sound

Decrease blood pressure and Cardiac oputput Renin Angiotensin Aldosterone system stimulates adrenal cortext to release aldosterone, thus attracting water

Increase pressure in the LV results to back flow of blood to the LA to the pulmonary capillaries

Pulmonary congestion appear in the chest x - ray

Decrease blood flow to the kidney Decrease secretion of erythropoetin

Pulmonary Edema

Decrease tactile fremitus

Fluid interferes with oxygen carbon dioxide exchange

Crackles

On exertion

Dyspnea

Edema on the dependent part (lower extremities) however this only occurs at day, as the client sleeps or lies down, the fluid will then goes back to the lungs

Blood volume increases

Decreased level of HCT 0.33%

RBC level decreases as well as hemoglobin (4.6 and 11.3 mg/dl) respectively

intercostals muscle retraction

Paroxysmal nocturnal dypnea

18

VII. GORDONS 11 FUNCTIONAL HEALTH PATTERN

Pattern

Before Hospitalization

During Hospitalization

Analysis

Health Perception Health Management Pattern

She claimed that she was diagnosed to have Hypertension, Stage 1 in 1997. For 2 years, she was able to take unrecalled antihypertensive medications, however on the later years medications were only taken when she experienced dizziness and light headedness. Also in relation to her hypertension, her physician advised her to have a monthly monitoring of her Blood pressure and lifestyle modification, but the client didnt comply because she perceives that she is healthy. Years gone by until last 2009, she was rushed to the Tondo Medical Center Emergency

According to the client, her health is progressing well. She was able to follow her treatment regimen given by her health care provider. Also she promises to herself that she will take care of her health by following all the health teaching and complying to all medication that was given to her.

According to Murray and Zentner, the ability of a client to adopt and maintain healthy behaviour depends on the clients perception of her current health status and her level of knowledge regarding the effect of the behaviours and how to maintain this behaviour. The client must identify the behaviours to be maintained or change. In relation to or client, she perceives that she is still healthy even though, she was diagnosed of Hypertension, her physician advised her about strict compliance to her medications and avoid stress and lifestyle modification, however she didnt comply. In that manner, our client shows ineffective health maintenance, and because of this, her condition get worsen as it complicates to Coronary Artery Disease and Congestive Heart Failure.

19

Department because of chest pain, and the impression was Coronary Artery Disease. Her physician advised her again of lifestyle modification and strict compliance to her medication, however because of financial problem, she was unable to follow her physician advised.

Nutritional and Metabolic Pattern.

Our client food preferences are the following: During breakfast, she eats pandesal and drink 1 cup of coffee. During Lunch and Dinner, she eats foods like papaitan, ihaw ihaw, pritong manok at isda, foods that they also served in their carinderia. She consumes 7 8 glasses of water per day. Her weight was 153 lbs (70kg), standing 53 (63inches). Body Mass Index was 27.1. No

During her 3rd hospital day, the client was on low fat, and low sodium diet. She eats fruits and bread, consuming 2 3 glasses of water per day. Her weight decreases form 153 to 150 lbs. Body Mass Index was 26.5

As what our data says, before our clients diet further aggravates her present condition, eating too much food high in cholesterol and sodium is bad specifically for the heart, which is according to the fundamentals of nursing by Kozier. Too much cholesterol in the circulation can lead to cholesterol plaque deposit (atherosclerosis) that will narrow the lumen thus results to Coronary Artery Disease. During her hospitalization, her weight decreases, this is due to the diuretics she was taking and her diet modification.

20

Elimination Pattern

Bowel: Usually defecates once a day without experiencing discomforts/difficulty, usually morning or afternoon. Stool brown in color and is well-formed. Bladder: Voids 3 4 times a day although she claimed that her urine output was not that to many as compare to her pre - illness state. Urine color is clear.

Bowel: The patient has irregular bowel movement with difficulty passing it. Usually once every 2 days or sometimes 3 days as what she claimed

During her hospitalization our client experienced irregular bowel movement and According to Joyce Black, many factors can contribute on what our client was experiencing, one of these were decreased mobility; which leads to decreased peristaltic movement. In relation to our client, Bladder: Voids 6 times during the her CHF was categorized to 4 which shift. Amber yellow in color. Without means, severely compromised, that difficulty in voiding. even at rest she experienced signs and symptoms of the disease, thats why one of the management is bed rest to conserve energy and oxygen. In addition to that, since there is decreased in cardiac output, tendency is that blood that supplying the gastro intestinal tract specifically the large intestine was deprive of oxygenated blood, thus leading to decreased peristaltic movement. In Terms of her voiding pattern, before her hospitalization the client voids 3 4 times a day, even though she drinks a lot of fluids, her urine output was not that many as compare to her pre illness state, and according to Workman and Ignatavicius, Congestive Heart Failure, is the state
21

in which heart is unable to pump out blood effectively. In that manner there is decrease in cardiac output therefore, decreasing also her urine output. However, because of medications like Digoxin( increases contractility of the heart), diuretics like furosemide and aldactone, her urine output during her hospital stay was markedly increase as compare to her pre hospitalization.

Activity and exercise Pattern

According to our client, when the signs and symptoms of CHF was not that evident, she usually do household chores and cook for their calinderia. When she has a free time, she loves to walk around to her neighbours and mingle with them. However when signs and symptoms of CHF were severely compromising her, that even at rest she develops signs and symptoms like easy fatigability and dyspnea, she

The client was on complete bed rest. She is still suffering from easy fatigability due to the present condition that limits her to move around, although the client claimed that she can still feed herself and do hygienic practices with minimal assistance.

According to Pender, exercise stimulates an increased production of endorphins which promotes sense of well being. In relation to our client, when signs and symptoms were not that evident, she used to do lots of things like doing house hold chores and cooking for their eatery, however when sign and symptoms were progressing, she cannot perform her usual activities, forcing her to rest more. In that manner our clients shows decreased in her sense of well

22

refrained activity.

from

strenuous

being.

Sleep and rest Pattern

She usually sleeps 6- 8 hours a day. Sleeping at around 10PM and waking up at around 5 or 6 in the morning to cook for their calinderia and do household chores. However, when signs and symptoms were evident, that was the time she experienced difficulty in getting sleep, as she told us that when she lie down, she feels like drowning. In order for her to get a sleep without feeling of distress, she usually use 3 4 pillows, The client was able to read and write, and doesnt experienced alteration in her visual and hearing. She also claimed that she can communicate well without any difficulty and can comprehend well. She can speak Tagalog and Waray.

The client claimed that she finds it difficult to sleep during her first night in the hospital because she has not yet adapted to the environment. However during the second day, she has been able to well although still using 3 pillows.

Before her confinement and during her hospitalization, our client used to experience paroxysmal nocturnal dyspnea during night in which causes her sleep disturbances and according to Kozier, illness that causes physical distress can result in sleeping problems.

Cognitive Perceptual Pattern

The client was conscious, and There is no difference before and coherent still no complaints in her during hospitalization. visual function and hearing and can understand well.

23

Self Perception and Self Concept Pattern

She is a friendly person; she loves to socialize with her friends in their neighbourhood. She wants to have good health and live his life to the fullest

Her condition made her realize her that she is not that healthy. She was reminiscing her regrets in life. She thinks that it is too late to change because of her condition, although our client states that she is still positive and optimistic about her condition.

Before hospitalization our client looks herself as healthy individual who is friendly and loves to entertain her friends and neighbour but because of her confinement and condition, our client realizes that she is no longer healthy and can die anytime, according to Kozier Events or situations may change the level of self concept over time. Illness and trauma can also affect the selfconcept.

Roles /Relationship Pattern

The client has a close family relationship especially to her sister, children and grandchildren. However, she was separated to her husband 10 years ago, the client told us that, her husband was stubborn, lazy and alcoholic, thats why she decided to be separated.

The client tells us that she misses her family especially her sister, although her sister usually visits her. She also told us that she wants to go home as soon as possible.

As what our client says, she used to be with her sister everyday because of their job as a carinderia vendor, but due to her confinement and illness, she cannot be with her sister.

24

Sexuality/ Reproductive Pattern

Client is now on her menopausal years; her menarche was when she was 11 years old. She has 3 grown up children. She claimed that in the past when she and her husband were still together they used to practice natural family planning.

Since her Congestive Heart failure As our data says, our client was was categorized to class IV meaning separated, she doesnt practice any even at rest she was developing sexual activity for the past 10 years. signs and symptoms of cardiopulmonary insufficiency, thats why she doesnt think about her sexual life, instead, she thinks about her health and how to improve it.

The client stated that when Coping Stress Tolerance she was experiencing stress in the past, she managed it by Pattern doing household chores, and through working.

The client told us that her confinement brought her stress and according to her, she is still very optimistic and positive that she can handle this thing out.

As what our client told us. During her confinement and due to her condition she was on stress but she stated that she is very positive that she can still handle things out; in that manner our client has effective coping mechanism. Because of her hospitalization, the client wasnt able to go to the church but able to pray inside her room. She is optimistic that God will help her to recover and live long.

Value/Belief

Patient is a Roman According to the patient, Catholic. According to the she follows therapeutic client, she goes to Sunday regimen and has a strong mass with her family. faith to God whom she believes will help her recover soon. Also the client expressed that her only wish is to see her grandchildren growing up. She does not fear death but wishes that she will live longer. She claimed that her religion helps her to get through her condition
25

REVIEW OF SYSTEMS Head ,Eyes, Ears, Nose, Mouth, and Throat (HEENT) Cardiovascular Respiratory Gastrointestinal No dizziness No blurring of vision No difficulty of swallowing No nausea and vomiting. Light headedness Chest pain that radiates to her shoulder and back Easy fatigability Productive Cough with whitish phlegm Orthopnea Uses 3 pillows to sleep. Shortness of breath Paroxysmal Nocturnal Dyspnea No constipation No diarrhea No nausea and vomiting. No abdominal pain

26

 Genitourinary

No frequency No discomfort No dysuria

VIII. Physical Assessment (12/08/11) was done on the 3rd hospital day. General Survey: The client was on sitting position, with Heplock placed in her left hand, intact. Conscious and coherent, oriented to time and place. She stands 53 (63Inches) and weighs 150lbs (68kg) with a BMI of 26.5. Poor grooming with no deformities noted.
Vital Signs: Temperature: 36.1C Pulse Rate: 86bpm Respiratory Rate: 26cpm

Blood Pressure: 140/90mmHg SKIN

Body Parts

Actual Findings Brown in color, no lesions,

Analysis

Nursing Alert Cold and clammy skin, is indicative of

Skin (Inspection and Palpation)

Abnormal
27

no palpable mass. Normal skin turgor, cold and clammy.

Ineffective tissue perfusion. This is due to the stimulation of the sympathetic nervous system which causes vasoconstriction and decreases blood supply to the periphery. HEAD

Head skull was round, (normocephalic and symmetric with frontal, Head Skull (Inspection and Palpation) parietal and occipital prominence) smooth skull contour, uniform consistency and absence of masses. Hair was black in color, not Hair (Inspection) evenly distributed, thin, and not silky. Normal Document Normal Document

Facial features are

28

Face (Inspection)

Symmetrical, equal in size and free of lesions. Facial expression matches emotion. Cranial nerve 7 is functioning well. Eyes were symmetrically aligned and without This is indicative of ineffective tissue perfusion. It is due to the failure of the left ventricle to pump out blood to the Abnormal systemic circulation, resulting to decrease CO and BP. In that manner, the blood that passes to the aorta is not enough, therefore the baroreceptors in the aorta, detected it and passes impulses to the medulla oblongata and sympathetic nervous system, which will promote increase in HR and promotes peripheral vasoconstriction as a compensatory mechanism. External Ears; symmetrical and auricle was aligned with Normal Document

Eyes (Inspection)

protruding or appearing sunken. Pupils are equally round and reactive to light/ accommodation; pale palpebral conjunctiva. Cranial nerves 2, 3, 4, 6, are functioning well.

Ears( Inspection)

the outer canthus, free of

29

Normal

Document

lesions, and no tenderness. Good hearing acuity and normal cranial nerve 8.

Color same as face, symmetrical nares, nasal septum in the middle, no Nose (Inspection) discharges nor lesions, however we noted nasal flaring upon inhalation. Abnormal

This is indicative of difficulty of breathing due to pulmonary edema, in which her alveoli is congested with fluids, thus impairing the exchange between oxygen and carbon dioxide. Therefore, our client is at risk to develop respiratory acidosis. In that manner we positioned our client in high fowlers to ease her breathing. We administered oxygen 2- 3 LPM as ordered via nasal cannula.

Mouth/lips was pale in appearance, able to purse Mouth/Lips (Inspection) lips. Tongue in central position, move freely and no tenderness. Gums were pale in color. Abnormal

It denotes that our client has poor perfusion or anemia. This is brought about by the vasoconstriction promoted by the sympathetic nervous system as a compensatory mechanism, which impairs perfusion to some peripheral and major organs.

30

Kidney is one of the organs that is greatly affected if vasoconstriction occurs. This vasoconstriction can cause decrease blood flow to the kidney resulting to decrease secretion of erythropoetin that will be released by the kidney to become an RBC. No palpable cervical lymph Neck (Inspection and Palpation) nodes. Thyroid gland in midline, smooth, firm and non tender. Gland ascends during swallowing. No distension of the jugular vein. Presence of supraclavicular retraction. THORAX No lesions. Symmetrical expansion with intercostals Lungs (Inspection,Palpation, Percussion and Auscultation) muscle retraction. Decrease tactile fremitus. Crackles Abnormal Presence of crackles over the base of the lungs indicates that there is fluid accumulation. Her left ventricle cannot pump out blood to the Abnormal. Supraclavicular retraction is indicative of difficulty of breathing which is brought about by pulmonary edema.

31

appreciated over the base of both lung fields.

circulation, therefore pooling of the blood and back flow to the pulmonary circulation occurs resulting to pulmonary edema. This condition impairs the exchange of oxygen and carbon dioxide in the lungs. Intercostals muscle retraction is indicative that the client is experiencing difficulty of breathing. We positioned our client in high fowlers and administered oxygen as ordered.

Point of maximal impulse (PMI) was displaced to the Heart (Auscultation and Palpation) 6th intercostal space mid axillary line. Irregular rhythm with S3 gallop noted on the 5th intercostal space midclavicular line. Abnormal

S3 heart sound It is the gallop sound heard during rapid ventricular filling due to failure of left ventricle on ejecting blood into the system during systole. This may denote that there is an increase in volume of blood in the left ventricle. It shows that the clients left ventricle is not functioning well.

32

Displaced point of maximal impulse This may indicate that the heart is enlarged. Normally point of maximal impulse is located at the 5th Intercostal space mid clavicular line.

ABDOMEN No lesions, flabby abdomen. Normoactive bowel sound. No organomegaly, negative Abdomen (IAPP) fluid wave, no tenderness. Normal Document

33

EXTREMETIES No deformities on both upper and lower extremities. +2 pitting edema noted on Extremities
(Inspection /Palpation)

Since the left ventricle cannot pump out oxygenated blood to the systemic circulation, the blood pressure Abnormal decreases. We know that the major organ responsible for the regulation of the blood pressure is the beanshaped kidney. The kidney will then detect decrease blood pressure, resulting in the stimulation of the Renin Angiotension Aldosterone System ,causing an increase retention of sodium and water, to compensate for the decrease blood pressure. This condition may cause edema.

both lower extremities.

Nails with convex curvature, smooth in texture. Capillary refill of 4 seconds Nail (Inspection/Palpation) Abnormal

Decrease in blood pressure and cardiac output will lead to stimulation of sympathetic nervous system, resulting to constriction of peripheral

34

organs.

35

IX. Laboratory Data Chest X Ray result (12/05/11) Lungs are filled with fluids, pulmonary vessels are slightly accentuated. Heart is

enlarged with left ventricular form Impression: Cardiomegaly with diffuse pulmonary infiltrate consistent with

Pulmonary Edema HEMATOLOGY (12/06/11) 1st hospital day.

COMPLETE BLOOD COUNT

Normal Values

(12/06/11)

Analysis/ Interpretation

Nursing Alert

HEMOGLOBIN

14 18g/dl

11.3g/dl

Decreased (Abnormal)

HEMATOCRIT

0.37 0.45%

0.33%

Decreased (Abnormal)

Hemoglobin is the major substance in RBC, and its level indicates the bloods ability to carry oxygen throughout the body. Therefore, decrease level of Hemoglobin may indicate that our clients RBC has inability to carry oxygen, thus resulting our client to be at risk to develop hypoxia and hypoxemia. Hematocit means the percentage of oxygen in the RBC. The hemodilution denotes two things; the pulmonary congestion and the increase blood volume made by

36

WBC

5-10 x 10^9/l

11.6

Increased (Abnormal)

RBC

5.0 6.4

4.6

Decreased (Abnormal)

the kidney to compensate for the decrease BP and CO. This condition resulted to fluid volume excess and ineffective breathing pattern. Increase WBC is indicative of infection. Since her left ventricle cannot pump out blood efficiently to the circulation, tendency is that, there will be an increase pressure in the left ventricle causing back flow of blood in the pulmonary circulation. The alveoli may be filled with water. This moist environment is a good medium for bacteria/ microorganisms; making our client at risk to develop respiratory infection like Pneumonia. This happens because of decreased in CO and BP brought about by the impaired left ventricle. Since the blood passing the aorta is insufficient or not enough, the baroreceptors detect it and stimulate the sympathetic nervous system to increase HR and to promote vasoconstriction. This

37

vasoconstriction greatly impaired the blood flow going to the bean- shaped organ leading to decrease erythropoietin secretion. Kidney is responsible for the regulation of BP. Any decrease in BP will lead to the stimulation of adrenal gland to retain more salt and water thus, increasing the blood volume as a compensatory mechanism. EOSINOPHILS 0.02 % 0.04% 0.50% 0.70% 0.20% 0.40% 0.02% 0.05% 0.03 Normal None

NEUTROPHILS/SEG MENTERS LYMPHOCYTES MONOCYTES

0.53

Normal

None

0.33 0.05

Normal Normal

None None

Clotting Factor

Result

Reference Range 150-450 73 127% 0.88 1.21

38

Analysis

Nursing Alert

PLATELET COUNT

185

Normal

None

% ACTIVITY

80.3

Normal

None

INR

1.14

Normal

None

APTT

37.4

30.4 41.2

Normal

None

Serum and Electrolytes Nursing Alert RANGE RESULT (12/06/11) RESULT (12/12/11) ANALYSIS 1st hospital day (12/06/11) - Increased (Abnormal)

SODIUM

136 145 mmol/L

146 mmol/L

135 mmol/L

7th hospital day(12/12/11) Normal

POTASSIUM

3.5 5.1 mmol/L

3.8 mmol/L

3.8 mmol/L

Normal

The result of her Sodium last December 06, 2011 was brought about by her diet prior to hospitalization; and also it is due to the compensatory mechanism that the kidney has made. In that manner our client developed edema, especially to the lower extremities. However, because of her diet modification and medications prescribed, her Sodium level became normal. Still need to evaluate potassium level, since the client was on digoxin therapy. We must maintain her potassium to a normal level. Decrease in potassium can potentiate digoxin

39

toxicity. URINALYSIS (12/07/11) - 2nd hospital day RESULT

COLOR

LIGHT

TRANSPARENCY

CLEAR

SUGAR

NEGATIVE

PROTEIN

NEGATIVE

PH SPECIFIC GRAVITY

6.0 1.010 02 13

WBC

RBC

EPITHELIAL CELL

OCCASIONAL

CRYSTAL

NONE

AMORPHOUS URATE

OCCASIONAL

LIPOLIPIDS AND TRIGYCERIDES (12/06/11) 1st hospital day

40

NORMAL VALUES

RESULTS (12/06/11)

RESULTS (12/12/11)

ANALYSIS 1st hospital day (12/06/11) Increased (Abnormal) 7th hospital day(12/12/11) Normal

Nursing Alert Cholesterol level last December 06, 2011 was elevated. This is due to her diet of foods high in cholesterol. In addition to that, since she is 54 yo, menopause plays a major role in maintaining cholesterol level in the blood. Therefore, high intake of cholesterol and decrease estrogen level, can lead to Coronary Artery Disease or Myocardial Infarction. However, because of diet modification and medications prescribed to her, Cholesterol level became normal. None

CHOLESTEROL

1.3 5.2

6.3mmol/L

4.9mmol/L

TRIGLYCERIDES

0.17 1.70

1.15mmol/L

1.57 mmol/L

Normal

HDL CHOLESTEROL

1.04 1.55

1.05mmol/L

1.08 mmol/L

Normal (GOOD Cholesterol) 1st hospital day (12/06/11) Increased

None

LDL

1.89

2.40mmol/L

1.89

LDL level last December 06, 2011 was elevated. This is

41

(Abnormal)

7th hospital day(12/12/11) Normal

due to her diet of foods high in Cholesterol. In addition to that, she is 54yo,and menopause plays a major role in maintaining cholesterol level in the blood. Therefore high intake of cholesterol and decrease estrogen level, can lead to Coronary Artery Disease or Myocardial Infarction. However, because of diet modification and medications prescribed to her, LDL level became normal.

42

X. Drug Study

Drug Name

Classification

Mechanism of Action

Indication

Contraindication

Side Effects/Adverse Effects

Nursing Alert

Generic Name: Furosemide

Loop diuretic

Brand Name: Apo-Furosemide Furoside Lasix

Inhibits reabsorption of sodium and chloride at proximal and distal tubule and in the loop of Henle

Pulmonary edema; edema in CHF,

Hypersensitivity to sulfonamides, anuria,

CNS: Headache, fatigue, weakness, paresthesias CV: Hypotension

Assess : For any contraindication prior to administration of the drug. Weight, I&O everyday to determine fluid loss, effect of drug may be decreased if used everyday Electrolytes (K, Na, Cl); include BUN, blood sugar, CBC, serum creatinine, blood pH, ABGs, uric acid, calcium, magnesium

hypovolemia, electrolyte depletion ELECT: Hypokalemia, hypochloremic alkalosis, hypomagnesemia, hyperuricemia, hypocalccemia, hyponatremia, metabolic alkalosis ENDO: Hyperglycmeia GI: Nausea, diarrhea, dry mouth, vomiting, anorexia, cramps, oral, gastric
43

Dosage: 20mg/tab

Frequency: BID

irritations, pancreatitis GU: Polyuria, renal failure, glycosuria HEMA: Thrombocytopenia , agranulocytosis, leucopenia, neutropenia, anemia INTEG: Rash, pruritus, purpura, Stevens-Johnson syndrome, sweating, photosensitivity, urticaria

V/S specially blood pressure for hypotension prior to administration Give with food to avoid gastroinestinal upset, preferably with breakfast (to prevent nocturia).

Teach patient/family: To discuss the need for a high-potassium diet or potassium replacement with prescriber To rise slowly from lying or sitting position; orthostatic hypotension may occur To recognize adverse reactions that may occur: muscle cramps, weakness, nausea, dizziness

44

Regarding entire regimen, including exercise, diet, stress relief for hypertension To take with food or milk for GI symptoms To take early in day to prevent sleeplessness

45

Drug Name

Classification

Mechanism of Action

Indication

Contraindication

Side Effects/Adverse Effects

Nursing Considerations

Generic Name: Spironolactone

Potassiumsparing diuretic

Brand Name: Aldactone, Novospiroton

Competes with aldosterone at receptor sites in distal tubule, resulting in excretion of sodium chloride, water, retention of potassium, phosphate

Edema of CHF, diureticinduced hypokalemi a

Hypersensitivity, anuria, severe renal disease, hyperkalemia,

CNS: Headache, drowsiness, GI: cramps, bleeding, gastritis, vomiting, anorexia, nausea INTEG: Rash, pruritus, urticaria

Assess: For any contraindication specially hyperkalemia before administration of the drug. Give with food to avoid gastroinestinal upset, preferably with breakfast (to prevent nocturia).

Dosage: 25mg/tab HEMA: Agranulocytosis Frequency: OD ELECT: Hyeprcholoremic metabolic acidosis, hyperkalemia, hyponatremia

Electrolytes: Na, Cl, K, BUN, serum creatinine, ABGs, CBC

Weight, I&O everyday to determine fluid loss; effect of drug may be decreased if used every day; ECG periodically (long term

46

therapy) Hydration: skin turgor, thirst, dry mucous membranes V/S specially blood pressure for hypotension.

Teach patient/family: To notify prescriber of cramps, diarrhea, lethargy, thirst, headache, skin rash, Notify the physician if you experience digoxin toxicity.

47

Drug Name

Classification

Mechanism of Action

Indication

Contraindication

Side Effects/Adverse Effects

Nursing Alert

Generic Name: Digoxin

Cardiac Glycoside

Brand Name: Lanoxin

Dosage: 250mg/ml/amp amp

Frequency: OD

Inhibits the Congestive sodiumheart potassium failure ATPase, which makes more calcium available for contractile proteins, resulting in increased cardiac output; increases force of contraction (+inotropic effect); decreases heart rate (chronotropic effect); decreases AV conduction speed

Hypersensitivity to digitalis, ventricular fibrillation, ventricular tachycardia,

CNS: Headache, drowsiness, fatigue.

Assess: For any contraindication prior to administration Cardiac Rhythm using the apical pulse for 1 min before giving drug; if pulse <60 in adult or <90 in an infant, take again in 1 hr; if <60 in adult, withhold the medication and call prescriber; note rate, rhythm, character; monitor ECG continuously during parenteral loading dose

CV: Dysrhythmias, hypotension, bradycardia,

EENT: Blurred vision, yellowgreen halos, photophobia, diplopia

GI: Nausea, vomiting, anorexia, abdominal pain, diarrhea

48

Electrolytes: K, Na, Cl, Mg, Ca; renal function studies: BUN, Creatinine; blood studies: ALT, AST, Bilirubin, Hct, Hgb before initiating treatment and periodically thereafter I&O ratio, daily weights; monitor turgor, lung sounds, edema

Monitor drug levels (therapeutic level 0.52ng/ml), best time to monitor blood for therapeutic level is 6 8 hours after administration or prior to administration, also assess for any sign and symptoms of toxicity such as: Vomiting Anorexia Nausea

49

Diarrhea Abdominal pain Vision(yellow green halos)

Make sure to have digibind (antidote for toxicity) in the bedside Cardiac status: apical pulse, character, rate, rhythm

Teach patient/family: Not to stop abruptly; teach all aspects of drug, to take exactly as ordered; how to monitor heart rate To avoid OTC medications, since adverse drug interactions may occur; do not take antacid at the same time To notify prescriber of loss of appetite, lower stomach pain, diarrhea, weakness, drowsiness,

50

headache, blurred or yellow vision, rash, depression, toxicity Not to break, crush, or chew caps To report shortness of breath, difficulty of breathing, weight gain, edema, persistent cough Eat foods high in potassium such as banana and watermelon.

51

Drug Name

Classification

Mechanism of Action

Indication

Contraindicati on

Side Effects/Adverse Effects CNS: Headache, Dizziness, tremors, malaise, fatigue, GI: Nausea, vomiting, diarrhea, abdominal pain, anorexia, constipation, hepatotoxicity CV: Hypotension, bradycardia, INTEG: Rash, photosensitivity, blue-gray skin discoloration, spontaneous ecchymosis, toxic epidermal necrolysis ENDO: Hyperthyroidism or hypothyroidism

Nursing Alert

Generic Name: Amiodarone Brand Name: Cordarone Pacerone Dosage: 250mg Frequency: BID

Antidysrhythmi Prolongs duration c (Class III) of action potential and effective refractory period, noncompetitive - and adrenergic inhibition; increases PR and QT intervals, decreases sinus rate, decreases peripheral vascular resistance

Severe ventricular tachycardia, supraventricu lar tachycardia, atrial fibrillation, ventricular fibrillation not controlled by first-line agents, cardiac arrest

Pregnancy (D), lactation, 2nd-, 3rd-degree AV block, bradycardia, severe sinus node dysfunction, neonates, infants

Assess: Assess for any contraindication prior to medication administration Liver function studies: AST, ALT, bilirubin, creatinine if patient is on longterm therapy

Blood studies: CBC, Hct, Hgb, PT, if patient is on longterm therapy

Allergic reactions: rash, urticaria,; if these occur, drug may have to be discontinued; patients with asthma, nasal polyps,

52

RESP: Pulmonary fibrosis, pulmonary inflammation, ARDS; gasping syndrome if used in neonates

allergies: severe allergic reaction may occurs. Ototoxicity: tinnitus, ringing, roaring in ears; audiometric testing needed before, after longterm therapy Visual changes: blurring, halos; corneal, retinal damage Edema in feet, ankle, legs Pain: location, duration, type, intensity, prior to dose Musculoskeletal status: ROM prior to dose Fever; length of time and related symptoms

53

Teach patient/family: To report any symptoms of hepatotoxicity, renal toxicity, visual changes, ototoxicity, allergic reactions, bleeding (long-term therapy) To take with 8 oz H2O and sit upright for hr after dose

To read label on the other OTC drugs; may contain aspirin or salicylates That the therapeutic response takes 2 wks (arthritis); give hr before planned exercise To avoid alcohol ingestion; GI bleeding may occur The patients who

54

have allergies,

Drug Name

Classification

Mechanism of Action

Indication

Contraindication

Side Effects/Adverse Effects

Nursing Alert

Generic Name: SulbactamAmpicillin

Broadspectrum antiinfective

Brand Name: Unasyn

Dosage: 750mg IV

Interferes with cell Pneumonia Hypersensitivity wall replication of to penicillins, susceptible organisms; the ampicillin, or cell wall, rendered sulbactam osmotically unstable, swells, bursts from osmotic pressure; combination extends spectrum of activity by lactamase inhibition

HEMA: Anemia, Assess: increased bleeding Assess for any time, bone marrow contraindication depression, subsequent to granulocytopenia administration GI: Nausea, vomiting, diarrhea, increased AST, ALT, abdominal pain, gastritis, stomatitis, glossitis,

Blood studies: WBC, RBC, Hct, Hgb, bleeding time Renal studies: urinalysis, protein, blood, BUN, creatinine

Frequency: q8

GU: Oliguria, proteinuria, Teach patient/family: hematuria, vaginitis, To report moniliasis, superinfection: vaginal glomerulonephritis, itching, loose, fouldysuria smelling stools, black furry tongue
55

To report immediately presudomembranous colitis: fever, diarrhea with pus, blood, or mucus; may occur up to 4 wks after treatment

56

Drug Name

Classification

Mechanism of Action

Indication

Contraindication

Side Effects/Adverse Effects

Nursing Alert

Generic Name: Enoxaparin

Anticoagulant Antithrombotic

Brand Name: Lovenox

Dosage: 4000 U

Prevents conversion of fibrinogen to fibrin and prothrombin to thrombin by enhancing inhibitory effects of antithrombin III; produces higher ration of anti-factor Xa to IIa

Prevention of deepvein thrombosis, pulmonary emboli in hip

Hypersensitivity to GI: Nausea this drug, heparin, or pork; hemophilia, leukemia with bleeding, peptic ulcer disease thrombocytopenic purpura, heparin-induced thrombocytopenia HEMA: Hypochromic anemia, thrombocytopenia, bleeding

Assess: For any contraindication prior to administration Blood studies (Hct, CBC, coagulation studies, platelets, occult blood in stools, if platelet level is 100,000/mm3 with hold the drug

INTEG: Ecchymosis

Frequency: BID

For bleeding: gums, petechiae, ecchymosis, black tarry stools, hematuria; notify prescriber

Teach patient/family:
57

To use soft-bristle toothbrush to avoid bleeding gums, to use electric razor To report any signs of bleeding: gums, under skin, urine, stools

To avoid OTC drugs containing aspirin

58

Drug Name

Classification

Mechanism of Action

Indication

Contraindication

Side Effects/Adverse Effects

Nursing Alert

Generic Name: Isosorbide Dinitrate

Anti-anginal Vasodilator

Brand Name: Apo-ISDN ISDN

Decreases preload, afterload, which is responsible for decreasing left ventricular-enddiastolic pressure, systemic vascular resistance and reducing cardiac O2 demand

Chronic stable angina pectoris.

Hypersensitivity to this drug or nitrates, severe anemia, increased intracranial pressure, cerebral hemorrhage, acute MI

CV: Postural hypotension, tachycardia, collapse, syncope

Assess: For any contraindication prior to administration B/P, pulse, respirations during beginning therapy

GI: Nausea, vomiting

INTEG: Pallor, sweating, rash

Dosage: 5mg tab

Frequency: OD

CNS: Vascular headache, flushing, dizziness, weakness, faintness Teach patient/family: Make position changes slowly, particularly from recumbent to upright posture, to avoid orthostatic hypotension
59

Headache, lightheadedness, decreased B/P; may indicate a need for decreased dosage

Lie down at the first

indication of lightheadedness or faintness. To leave tabs in original container To avoid hazardous activities if dizziness occurs

The importance of complying with complete medical regimen To make position changes slowly to prevent orthostatic hypotension

Not to crush, chew sus rel caps, SL tabs

60

Drug Name

Classification

Mechanism of Action

Indication

Contraindication

Side Effects/Adverse Effects

Nursing Alert

Generic Name: Simvastatin Brand Name: Zocor Dosage: 10 mg Frequency: OD HS

Lipid-lowering agents

Inhibit an enzyme 3-hyrdorxy-3methyglutarylcoe nzyme A (HMGCoA) reductase, which is responsible for catalyzing an early step in the synthesis of cholesterol.

Adjunct to dietary therapy in the manageme nt of primary hyperchole sterolemia and mixed dyslipidemi a. Reduction of lipids/chole ssterol reduces the risk of MI and stroke sequelae and decreases the need for bypass procedures /angioplast
61

Hypersensitivity. Cross-sensitivity among agents may occur, acute hypotension,

CNS: Dizziness, headache, EENT: blurred vision GI: Abdominal cramps, flatus, heartburn, altered taste, dyspepsia, elevated liver enzymes, nausea, pancreatitis GU: Impotence DERM: Rashes, pruritus

Assess: Assess for any allergy or contraindication prior to administration of medication Obtain dietary history, especially with regard to fat consumption. Give in the evening; highest rates of cholesterol synthesis are between midnight and 5 AM. Lab Test consideration: Evaluate serum cholesterol and triglyceride levels before initiating, after 4-6 weeks of therapy, and periodically thereafter.

Monitor liver function test, including AST, before, at 6-12 weeks after initiation of therapy or after dose elevation, and then every 6 months. If AST levels increase to 3 times normal, simvastatin should be discontinued, May also cause increase alkaline phosphatase and bilirrubin levels.

Teach patient/family: Instruct patient to take medication as directed and not to skip doses or double up on missed doses. Advise patient to avoid drinking more that 1qt/day of grapefruit juice during therapy. Medication helps control but does not cure elevated serum cholesterol levels.

62

Advise patient that this medication should be used in conjunction with diet restrictions (fat, cholesterol, carbohydrates, and alcohol), exercise. Instruct patient to notify health care professional if unexplained muscle pain, tenderness, or weakness occurs, especially if accompanied by fever or malaise. Emphasize the importance of follow-up exams to determine effectiveness and to monitor for side effects.

63

XI. NURSING CARE PLANS

Cues

Nursing Diagnosis
Ineffective Breathing Pattern related to increased pulmonary congestion.

Rationale

Expected Outcomes

Nursing Intervention

Rationale

Evaluation

Subjective Data: Nahihirapan akong huminga, as verbalized by the client. Objective Data: Restlessness V/S: RR 30CPM Flaring of Ala nasi Intercostal retraction Decrease tactile fremitus

We prioritized this nursing problem for the reason that breathing is affected and according to Maslows Hierarchy of Needs breathing (oxygen) is one of our physiologic needs, and also difficulty of breathing was the first problem that our client experienced during our shift, so we immediately attended to it. Inference Analysis: Left Ventricle cannot pump out blood effectively, blood pooling occurs resulting to too much pressure in the LV that will lead to back flowing of blood to the pulmonary circulation specifically to the pulmonary capillary, hence causes to fluid filled alveoli that resulted to pulmonary congestion.

Short Term Goal: After 4 to 6 hours of nursing intervention, the client will verbalize relief in difficulty of breathing by manifesting, decrease in restlessness and RR will decrease from 26CPM to 23CPM.

Positioned client on high fowlers position.

To maximize oxygenation by promoting greater lung expansion. To supplement enough oxygen.

Administered oxygen via nasal cannula at the rate of 2 3 LPM.

After 5 hours of effective nursing intervention the clients difficulty of breathing was relieved as manifested by, decrease in restlessness and decreased RR of 23CPM

Crackles, base of the lungs Laboratory:

CXR result = Cardiomegaly with diffuse pulmonary infiltrate consistent with Pulmonary Edema

Long Term Goal: After 3 to 5 days of nursing intervention the client will verbalize absence of difficulty of breathing manifested by absence of restlessness, nasal flaring, intercostal muscle retraction, and RR will remain between 12 20
64

Encouraged adequate rest and limit activities within the clients tolerance

To prevent fatigue and to conserve oxygen and energy supply.

Encouraged frequent position changes and deep breathing exercise.

To promote optimum lung expansion.

After 6 days of effective nursing intervention the client was able to maintain absence of difficulty of breathing as manifested by, absence of restlessness, nasal flaring, intercostal muscle retraction.. Also the client,s RR was maintained at 1220 CPM

CPM

Administered Spironolactione and Furosemide as prescribed by the physician

These are diuretics which eliminate excessive fluids in her lungs which relieve pulmonary congestion

. For evaluation purposes

Monitor vital signs frequently

65

Cues

Nursing Diagnosis

Rationale

Expected Outcomes

Nursing Intervention

Rationale

Evaluation

Subjective Data: Bigla bigla nalang sumasakit ang dibdib ko, as verbalized by the client.

Acute Pain related to decrease oxygen in the myocardial cells

We selected this nursing problem because it is a potential or maybe an indication of tissue damage. However, we didnt make it as our

Short Term Goal: After 10 to 15 minutes of nursing intervention, the clients chest pain will subside from the pain scale of 8 down to 2 - 4 as manifested by absence of guarding behaviour, restlessness, and irritability

Administered oxygen via nasal cannula at the rate of 2 3 LPM.

After 10 minutes of
This saturates circulating hemoglobin and increases the effectiveness of blood that is reaching the ischemic tissues. Isosorbide Dinitrate was administered; this drug dilates the coronary arteries, thus supplying it with enough oxygenated blood. effective nursing intervention and complying with the provided comfort measures and prescribed regimen, the clients chest pain subsided from the pain scale of 8/10 to 2/10.

Objective data: Precipitati ng factor: strenuous activity Quality: squeezing like pain. Location: substernal Radiation: radiating from left shoulder and back Severity: Pain scale: 8/10; score

top most priority, though it needs direct attention because it does not require immediate attention compared to impaired gas exchange which is our top priority. And also for the reason

Administered Isosorbide Dinitrate 5mg/tab OD as prescribed

Long Term Goal: After 3 to 4 days of nursing intervention, the client will exhibit absence of pain(0/10) Encouraged proper deep breathing exercise.

To remain calm and relax, reduce anxiety

After 4 days of effective nursing

that chest pain might be precipitated by impaired gas exchange, because of the decrease oxygen supply to the heart

Positioned the client on high fowlers

To maximize lung expansion, thus increasing oxygen intake.

intervention the client manifested maintenance of absence of pain(0/10) by complying to the therapeutic regimen

66

and comfort measures To distract her

muscles Timing: started every time she experience difficulty of breathing, and usually lasting for not more than 5 minutes. (tissues/cells). Hence, we need to treat first impaired gas exchange.

Inference Analysis: CHF can precipitate chest pain because of decreased coronary

Encouraged listening to music, read books, magazines, newspaper and conversing to her family guardian, visitor, or to his fellow patient as she feels mild to moderate chest pain.

attention regarding the chest pain and to reduce the anxiety and distress shes experiencing.

we provided her

Promoted calm and restful environment.

Facial grimace Restlessne ss Irritability Diaphoretic

perfusion from decreased CO and increased myocardial work.

To promote rest to the client, in order to conserve energy and lower tissue oxygen demand .as well as to divert the attention of the client about her chest pain.

V/S T 36.1 PR 86 RR 26 BP 140/90

Encouraged adequate rest/sleep and limit activities within the clients tolerance.

To prevent fatigue that aggravates the chest pain and to conserve oxygen and energy supply.

67

Cues

Nursing Diagnosis

Rationale

Expected Outcomes

Nursing Intervention

Rationale

Evaluation

Subjective Data: Medyo namumutla ang balat ko as verbalized by the client. Objective Data: Pallor cool and clammy skin

Ineffective Tissue Perfusion related to inadequate blood supply to the body (cells/tissues).

We consider this health problem as our least priority though it is a significant sign of progressing CHF as it indicates inadequate blood supply to the system it doesnt need immediate attention

Short Term Goal: After 1 3 days of nursing intervention the client will manifest improved circulation as manifested by decrease in paleness of the skin, easy fatigability, and capillary refill of 6 secs down to 2 4 secs. Long Term Goal: After 1 - 2 weeks of nursing intervention, the

Elevated head on bed (semifowlers position).

To promote good circulation of the blood into the system. This saturates circulating hemoglobin and increases the effectiveness of blood that is reaching the ischemic tissues.

After 2 days of effective nursing intervention the client

Administered oxygen via nasal cannula at the rate of 2 -3 LPM as ordered.

verbalized improved circulation as manifested by decrease in paleness of the skin and easy fatigability as well as her capillary refill is now normal (2seconds)

capillary refill lasting for> 4 seconds

compared to the first two nursing problems of our

Encouraged breathing exercise

deep To promote optimal lung expansion for good ventilation and perfusion as well as elimination of carbon dioxide.

Easy Fatigability

client.

After 1 week of effective nursing intervention the client

V/S: BP = 140/90 HR = 86 Laboratory: Hgb =

Inference Analysis: It is due to left ventricular failure from which stroke volume decreases

client will manifest effective perfusion and will show absence of signs and symptoms of Encouraged, quite and restful environment To promote rest to the client, in order to conserve energy and lower tissue oxygen demands.

show effective perfusion as manifested by absence of paleness ,

68

11.3g/dl Hct = 0.33%

which leads to stimulation of sympathetic nervous system that further impedes perfusion to organs and tissues by constricting peripheral blood vessels.

ineffective tissue perfusion such as pallor, cool and clammy skin, easy fatigability, capillary refill will decrease from 4 seconds to 2 seconds, and laboratory values and VS will return to normal. Administer Digoxin 250mg/ml/amp amp, OD as prescribed by the physician. Provided small frequent meals /foods and fluids. To reduce gastrointestinal blood supply, thus avoiding or preventing any aggravation of her condition.

easy fatigability, +2 edema in the lower extremities, capillary refill will decrease from 4 seconds to 2 seconds. Laboratory values and VS l returned to normal.

Administered Isosorbide Dinitrate 5mg/tab OD as prescribed

The rationale of administering Digoxin is to increase CO thereby increasing also the blood supply to the systemic circulation. Isosorbide Dinitrate was administered; this is because this drug dilates the arteries, thus supplying the body with enough oxygenated blood.

69

XII. DISCHARGE PLAN

Medication:
Review medication regimen Label all medications according to dosage, route and frequency ( Furosemide, Sprinolactone, Digitalis, Enoxaparin, Isosorbide Dinitrate and Simvastatin) Give written instruction to all medications especially to digitalis and diuretics. a. Digitalis therapy: Teaches the client to assess first her heart rate using her apical pulse which is located below her nipple for 1 full minute, if her PR is <60BPM or >120BPM, withhold the drug, wait again for 1hr then take PR if it is >60BPM or <120BPM administer it, if not call her physician immediately Also Advised her to eat foods high in potassium specifically banana, to increase potassium level, because decrease in potassium level potentiates digitalis toxicity Advised client to report any signs and symptoms of digitalis toxicity such as Vomiting, Anorexia, Nausea, Diarrhea, Abdominal pain and yellow green halos, immediately to her healthcare provider Also advised client that if she will experience any toxic effect of digitalis, 1st thing to do is call your health care provider after which drink orange juice to increase potassium level, thus preventing excessive depletion of her potassium level. Also advised client to have Digibind along with her in case of toxicity

70

b. Diuretic therapy: Furosemide Make sure to always assess signs and symptoms of hypokalemia (muscle cramps, weakness, and nausea) in relation to Digitalis therapy because decrease in potassium level potentiates toxicity. Also advised client to eat foods high in potassium such as avocado, banana, orange, and melon. Advised to take the drug, early in the morning or in the afternoon to prevent sleep pattern disturbance related to nocturia.

Exercise:
Advised client to avoid any strenuos activity, because it may aggravate her condition; however may start gradual ambulation to prevent risk for venous thrombosis. Advised client to position herself leaning forward or semi fowlers, if she experience dyspnea. Advised to increase walking and other activities gradually, provided they do not cause fatigue and dyspnea.

Treatment:
Advised client to adhere to the medical regimen given to her. Also advised client to avoid any stress, because stress causes anxiety. This anxiety increases breathlessness which may be perceived by the client as an increase in the severity of heart failure.

71

Health education:
Teach client about the sign and symptoms of recurrence or complications such as Right sided heart failure, and cardiac arrest Watch for: a. Weight gain report weight gain of more than 2 3 lbs in a few days b. Swelling of ankles, feet, jugular vein and abdomen c. Persistent chest pain

Outpatient:
Emphasized to the client the importance of follow up check up for continuos recovery of her condition.

Diet:
Advised client to decrease intake of sodium, however she needs to avoid fatty foods completely Provided list of foods with low residue and with vitamins supplement Advised to have small but frequent feeding

Spiritual:
Encouraged client to have a firm belief and faith in God

72

XIII. Bibliography

Physiology and Anatomy, by Greishelmer Wiedeman Essential of Human Anatomy And Physiology 7thed, by Elaine N. Marieb Saunders Nursing Drug Handbook,2007 DPDs 8th edition Nurses Pocket Guide 9th ed. Porth, C.M (2005) Pathophysiology Gould, B.E. Pathophysiology for the health professions 3rd edition. White Lois (2005) Foundation of Nursing, 2nd Edtion Daniels, R. Et al (2010) Nursing Fundamentals Caring and clinical decision making 2nd edition. Spratto, G.R. et al (2005) PDR Nurses Drug Handbook 2005 edition. Loebl, S. Et al (1994) The Nurses Drug Handbook 7th edition. Doenges, M.E. et al (2006) Nursing Care Plans Guidelines for individualizing client care across the life span

73

74