ms 2 - hypothetical case hf
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Arellano University
___________________________________________
A Case Study on a Patient Diagnosed with Congestive Heart Failure
___________________________________________
By
DEGAMO, Dominique Excelsis J.
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I. INTRODUCTIONa) Definition of the Disease
Heart Failure often referred to as congestive heart failure (CHF), is the inability of the
heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients.
However, the term CHF is misleading, because it indicates that patients must experience
pulmonary or peripheral congestion to have HF, and it implies that patients with congestion
have HF. The Agency for Health Care Policy and Research (AHCPR) HF guidelines panel (1994)
defined HF as a clinical syndrome characterized by signs and symptoms of fluid overload or of
inadequate tissue perfusion.These signs and symptoms result when the heart is unable to generate a CO sufficient
to meet the body’s demands. The HF guideline panel used the term heart failure because
many patients with HF do not manifest pulmonary or systemic congestion. The term HF is
preferred and indicates myocardial heart disease in which there is a problem with contraction
of the heart (systolic dysfunction) or filling of the heart (diastolic dysfunction) and which may
or may not cause pulmonary or systemic congestion.
Some cases of HF are reversible, depending on the cause. Most often, HF is a life-longdiagnosis that is managed with lifestyle changes and medications to prevent acute congestive
episodes. CHF is usually an acute presentation of HF.
b) Cause or Risk Factors1. Cause
HF may result from a number of causes like cardiac compensatory mechanisms,
other dysfunctions and other disorders of the heart.Cardiac compensatory mechanisms (increases in heart rate, vasoconstriction, and
heart enlargement) occur to assist the struggling heart. These mechanisms are able to
compensate for the heart's inability to pump effectively and maintain sufficient blood flow to
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An elevation in afterload also may be caused by hypertension, valvular stenosis, or
hypertrophic cardiomyopathy. Myocardial dysfunction is most often caused by coronary artery
disease, cardiomyopathy, hypertension, or valvular disorders. Atherosclerosis of the coronaryarteries is the primary cause of HF.
Coronary artery disease is found in more than 60% of the patients with HF (Braunwald
et al., 2001). Ischemia causes myocardial dysfunction because of resulting hypoxia and acidosis
from the accumulation of lactic acid. Myocardial infarction causes focal heart muscle necrosis,
the death of heart muscle cells, and a loss of contractility; the extent of the infarctioncorrelates with the severity of HF. Revascularization of the coronary artery by a percutaneous
coronary intervention or by coronary artery bypass surgery may correct the underlying cause
so that HF is resolved.
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Several systemic conditions contribute to the development and severity of HF, including
increased metabolic rate (eg, fever, thyrotoxicosis), iron overload (eg, from hemochromatosis),
hypoxia, and anemia (serum hematocrit less than 25%). All of these conditions require anincrease in CO to satisfy the systemic oxygen demand. Hypoxia or anemia also may decrease
the supply of oxygen to the myocardium. Cardiac dysrhythmias may cause HF, or they may be
a result of HF; either way, the altered electrical stimulation impairs the myocardial contraction
and decreases the overall efficiency of myocardial function. Other factors, such as acidosis
(respiratory or metabolic), electrolyte abnormalities, and antiarrhythmic medications, can
worsen the myocardial dysfunction.
Other causes include: pulmonary embolism; chronic lung disease; hemorrhage andanemia; anesthesia and surgery; transfusions or infusions; increased body demands (fever,
infection, pregnancy, arteriovenous fistula); drug-induced; physical and emotional stress; and,
excessive sodium intake.
2. Risk FactorsGENETIC CONSIDERATIONS
HF is a complex disease combining the actions of several genes with environmental
factors. Many HF risk factors have genetic causes or are associated with genetic
predispositions. These include hypertrophic cardiomyopathy (HCM) and dilated
cardiomyopathy (DCM), coronary artery disease, myocardial infarction, and hypertension.
Genetic polymorphisms of the reninangiotensin-aldosterone system (RAAS) and sympathetic
system have also been associated with susceptibility to and/or mitigation of HF. Gene variants
in the alpha-2c adrenoceptor and the alpha-1 adrenoceptor have been associated with a
higher risk of HF among African Americans.
GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS
HF may occur at any age and in both genders as a result of congenital defects
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Left-sided heart failure (left ventricular failure) causes different manifestations than
right-sided heart failure (right ventricular failure). Chronic HF produces signs and symptoms of
failure of both ventricles. Although dysrhythmias (especially tachycardia’s, ventricular ectopicbeats, or atrioventricular [AV] and ventricular conduction defects) are common in HF, they
may also be a result of treatments used in HF (eg, side effect of digitalis).
LEFT-SIDED HEART FAILURE
Pulmonary congestion occurs when the left ventricle cannot pump the blood out of the
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Fluid that accumulated in the dependent extremities during the day begins to be
reabsorbed into the circulating blood volume when the person lies down. Because the
impaired left ventricle cannot eject the increased circulating blood volume, the pressure in thepulmonary circulation increases, causing further shifting of fluid into the alveoli. The fluid filled
alveoli cannot exchange oxygen and carbon dioxide. Without sufficient oxygen, the patient
experiences dyspnea and has difficulty getting an adequate amount of sleep.
The cough associated with left ventricular failure is initially dry and nonproductive.
Most often, patients complain of a dry hacking cough that may be mislabeled as asthma or
chronic obstructive pulmonary disease (COPD). The cough may become moist. Large quantities
of frothy sputum, which is sometimes pink (blood tinged), may be produced, usually indicatingsevere pulmonary congestion (pulmonary edema).
Adventitious breath sounds may be heard in various lobes of the lungs. Usually, bi-
basilar crackles that do not clear with coughing are detected in the early phase of left
ventricular failure. As the failure worsens and pulmonary congestion increases, crackles may
be auscultated throughout all lung fields. At this point, a decrease in oxygen saturation may
occur.
In addition to increased pulmonary pressures that cause decreased oxygenation, the
amount of blood ejected from the left ventricle may decrease, sometimes called forward
failure. The dominant feature in HF is inadequate tissue perfusion. The diminished CO has
widespread manifestations because not enough blood reaches all the tissues and organs (low
perfusion) to provide the necessary oxygen. The decrease in SV can also lead to stimulation of
the sympathetic nervous system, which further impedes perfusion to many organs.
Blood flow to the kidneys decreases, causing decreased perfusion and reduced urine
output (oliguria). Renal perfusion pressure falls, which results in the release of renin from the
kidney. Release of renin leads to aldosterone secretion. Aldosterone secretion causes sodiumand fluid retention, which further increases intravascular volume. However, when the patient
is sleeping, the cardiac workload is decreased, improving renal perfusion, which then leads to
frequent urination at night (nocturia)
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accommodate all the blood that normally returns to it from the venous circulation. The
increase in venous pressure leads to jugular vein distention (JVD).
The clinical manifestations that ensue include edema of the lower extremities(dependent edema), hepatomegaly (enlargement of the liver), distended jugular veins, ascites
(accumulation of fluid in the peritoneal cavity), weakness, anorexia and nausea, and
paradoxically, weight gain due to retention of fluid.
Edema usually affects the feet and ankles, worsening when the patient stands or
dangles the legs. The swelling decreases when the patient elevates the legs. The edema can
gradually progress up the legs and thighs and eventually into the external genitalia and lower
trunk. Edema in the abdomen, as evidenced by increased abdominal girth, may be the onlyedema present. Sacral edema is not uncommon for patients who are on bed rest, because the
sacral area is dependent. Pitting edema, in which indentations in the skin remain after even
slight compression with the fingertips (Fig. 30-2), is obvious only after retention of at least 4.5
kg (10 lb) of fluid (4.5 liters).
Hepatomegaly and tenderness in the right upper quadrant of the abdomen result from
venous engorgement of the liver. The increased pressure may interfere with the liver’s ability
to perform (secondary liver dysfunction). As hepatic dysfunction progresses, pressure within
the portal vessels may rise enough to force fluid into the abdominal cavity, a condition known
as ascites. This collection of fluid in the abdominal cavity may increase pressure on the
stomach and intestines and cause gastrointestinal distress. Hepatomegaly may also increase
pressure on the diaphragm, causing respiratory distress.
Anorexia (loss of appetite) and nausea or abdominal pain results from the venous
engorgement and venous stasis within the abdominal organs. The weakness that accompanies
right-sided HF results from reduced CO, impaired circulation, and inadequate removal of
catabolic waste products from the tissues.
d) Epidemiology or StatisticsU I S A S
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PHILIPPINES
In the Philippines, HF is the fastest-growing cardiac disorder and it affects 2% of the
population. Almost 1 million hospital admissions occur each year for acute decompensated HF,and the rehospitalization rates during the 6 months following discharge are as much as 50%. In
spite of recent advances in the treatment of HF, the 5-year estimated mortality rate is almost
50% (Department of Health, 2005).
e) Assessment HighlightsHISTORY
Patients with HF typically have a history of a precipitating factor such as myocardialinfarction, recent open heart surgery, dysrhythmias, or hypertension. Symptoms vary based on
the type and severity of failure. Ask patients if they have experienced any of the following:
anxiety, irritability, fatigue, weakness, lethargy, mild shortness of breath with exertion or at
rest, orthopnea that requires two or more pillows to sleep, nocturnal dyspnea, cough with
frothy sputum, nocturia, weight gain, anorexia, or nausea and vomiting. Take a complete
medication history, and determine if the patient has been on any dietary restrictions.
Determine if the patient regularly participates in a planned exercise program.The New York Heart Association has developed a commonly used classification system
that links the relationship between symptoms and the amount of effort required to provoke
the symptoms.
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veins may become engorged and distended. If the pulsations in the jugular veins are visible 4.5
cm or more above the sternal notch with the patient at a 45-degree angle, jugular venous
distension is present. The liver may also become engorged, and pressure on the abdomenincreases pressure in the jugular veins, causing a rise in the top of the blood column.
This positive finding for HF is known as hepatojugular reflux (HJR). The patient may also
have peripheral edema in the ankles and feet, in the sacral area, or throughout the body.
Ascites may occur as a result of passive liver congestion.
With auscultation, inspiratory crackles or expiratory wheezes (a result of pulmonary
edema in left-sided failure) are heard in the patient’s lungs. The patient’s vital signs may
demonstrate tachypnea or tachycardia, which occur in an attempt to compensate for thehypoxia and decreased CO. Gallop rhythms such as an S3 or an S4, while considered a normal
finding in children and young adults, are considered pathological in the presence of HF and
occur as a result of early rapid ventricular filling and increased resistance to ventricular filling
after atrial contraction, respectively. Murmurs may also be present if the origin of the failure is
a stenotic or incompetent valve.
PSYCHOSOCIAL
Note that experts have found that the physiological measures of HF (such as ejection
fraction) do not always predict how active, vigorous, or positive a patient feels about his or her
health; rather, a person’s view of health is based on many factors such as social support, level
of activity, and outlook on life.
f) Diagnostic Procedures
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ANGIOTENSIN-CONVERTING ENZYME INHIBITORS. ACE inhibitors (ACE-Is) have a pivotal role in
the management of HF due to systolic dysfunction. They have been found to relieve the signsand symptoms of HF and significantly decrease mortality and morbidity (when used to treat a
symptomatic patient) by inhibiting neurohormonal activation (CONSENSUS Trial Study Group,
1987; SOLVD Investigators, 1992). Available as oral and intravenous medications, ACE-Is
promote vasodilation and dieresis by decreasing afterload and preload. By doing so, they
decrease the workload of the heart.
Vasodilation reduces resistance to left ventricular ejection of blood, diminishing the
heart’s workload and improving ventricular emptying. In promoting diuresis, ACE -Is decreasethe secretion of aldosterone, a hormone that causes the kidneys to retain sodium. ACE-Is
stimulate the kidneys to excrete sodium and fluid (while retaining potassium), thereby
reducing left ventricular filling pressure and decreasing pulmonary congestion.
ACE-Is may be the first medication prescribed for patients in mild failure—patients with
fatigue or dyspnea on exertion but without signs of fluid overload and pulmonary congestion.
Results from studies (Clement et al., 2000; NETWORK Investigators, 1998) to identify the
specific dose to achieve this effect are equivocal, although one large study showed significant
reductions in death and hospitalization with higher doses (Packer et al., 1999). However, it is
recommended to start at a low dose and increase every 2 weeks until the optimal dose is
achieved and the patient is hemodynamically stable. The final maintenance dose depends on
the patient’s blood pressure, fluid status, renal status, and degree of cardiac failure.
Patients receiving ACE-I therapy are monitored for hypotension, hypovolemia,
hyponatremia, and alterations in renal function, especially if they are also receiving diuretics.
Because ACE-Is cause the kidneys to retain potassium, the patient who is also receiving
a diuretic may not need to take oral potassium supplements. However, patients receivingpotassiumsparing diuretics (which do not cause potassium loss with diuresis) must be carefully
monitored for hyperkalemia. ACE-Is may be discontinued if the potassium remains above 5.0
mEq/L or if the serum creatinine is 3 0 mg/dL and continues to increase Other side effects of
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systemic vascular resistance and left ventricular afterload. It has also been shown to help avoid
the development of nitrate tolerance. As with ARBs, this combination of medications is usually
used when patients are not able to tolerate ACE-Is.
BETA-BLOCKERS. When used with ACE-Is, beta-blockers, such as carvedilol (Coreg), metoprolol
(Lopressor, Toprol), or bisoprolol (Zebeta), have been found to reduce mortality and morbidity
in NYHA class II or III HF patients by reducing the cytotoxic effects from the constant stimulation
of the sympathetic nervous system (Beta-Blocker Evaluation of Survival Trial [BEST]
Investigators, 2001; CIBIS-II Investigators and Committees, 1999; MERIT, 1999; Packer et al.,
1996; Packer et al., 2001). These agents have also been recommended for patients withasymptomatic systolic dysfunction, such as after acute myocardial infarction or
revascularization to prevent the onset of symptoms of HF.
However, beta-blockers may also produce many side effects, including exacerbation of
HF. The side effects are most common in the initial few weeks of treatment. The most frequent
side effects are dizziness, hypotension, and bradycardia. Because of the side effects,
betablockers are initiated only after stabilizing the patient and ensuring a euvolemic (normal
volume) state. They are titrated slowly (every 2 weeks), with close monitoring at each increase
in dose. If the patient develops symptoms during the titration phase, treatment options include
increasing the diuretic, reducing the dose of ACE-I, or decreasing the dose of the beta-blocker.
An important nursing role during titration is educating the patient about the potential
worsening of symptoms during the early phase of treatment, and that improvement may take
several weeks. It is very important that nurses provide support to patients going through this
symptom-provoking phase of treatment. Because beta-blockade can cause bronchiole
constriction, a beta1-selective beta-blocker (ie, one that primarily blocks the beta-adrenergic
receptor sites in the heart), such as metoprolol (Lopressor, Toprol), is recommended forpatients with well-controlled, mild to moderate asthma. However, these patients need to be
monitored closely for increased asthma symptoms. Any type of beta-blocker is contraindicated
in patients with severe or uncontrolled asthma
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DIURETICS. Diuretics are medications used to increase the rate of urine production and the
removal of excess extracellular fluid from the body. Of the types of diuretics prescribed for
patients with edema from HF, three are most common: thiazide, loop, and potassium-sparingdiuretics. These medications are classified according to their site of action in the kidney and
their effects on renal electrolyte excretion and reabsorption. Thiazide diuretics, such as
metolazone (Mykrox, Zaroxolyn), inhibit sodium and chloride reabsorption mainly in the early
distal tubules. They also increase potassium and bicarbonate excretion. Loop diuretics, such as
furosemide (Lasix), inhibit sodium and chloride reabsorption mainly in the ascending loop of
Henle. Patients with signs and symptoms of fluid overload should be started on a diuretic, a
thiazide for those with mild symptoms or a loop diuretic for patients with more severesymptoms or with renal insufficiency (Brater, 1998). Both types of diuretics may be used for
those in severe HF and unresponsive to a single diuretic. These medications may not be
necessary if the patient responds to activity recommendations, avoidance of excessive fluid
intake (
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obtained once each year or more frequently if there have been c hanges in the patient’s
medications, renal function, or symptoms.
CALCIUM CHANNEL BLOCKERS. First-generation calcium channel blockers, such as verapamil
(Calan, Isoptin, Verelan), nifedipine (Adalat, Procardia), and diltiazem (Cardizem, Dilacor,
Tiazac), are contraindicated in patients with systolic dysfunction, although they may be used in
patients with diastolic dysfunction. Amlodipine (Norvasc) and felodipine (Plendil),
dihydropyridine calcium channel blockers, cause vasodilation, reducing systemic vascular
resistance. They may be used to improve symptoms especially in patients with nonischemic
cardiomyopathy, although they have no effect on mortality.
OTHER MEDICATIONS. Anticoagulants may be prescribed, especially if the patient has a history
of an embolic event or atrial fibrillation or mural thrombus is present. Other medications such
as antianginal medications may be given to treat the underlying cause of HF. Nonsteroidal anti-
inflammatory drugs (NSAIDs), such as ibuprophen (Aleve, Advil, Motrin) should be avoided
(Page & Henry, 2000). They can increase systemic vascular resistance and decrease renal
perfusion, especially in the elderly. For similar reasons, use of decongestants should be
avoided.
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recommendation reduces fluid retention and the symptoms of peripheral and pulmonary
congestion. The purpose of sodium restriction is to decrease the amount of circulating volume,
which would decrease the need for the heart to pump that volume. A balance needs to beachieved between the ability of the patient to alter the diet and the amount of medications
that are prescribed. Any change in diet needs to be done with consideration of good nutrition
as well as the patient’s likes, dislikes, and cultural food patterns.
SURGICAL MANAGEMENT
If the elevated preload is caused by valvular regurgitation, the patient may require
corrective surgery. Corrective surgery may also be warranted if the elevated afterload iscaused by a stenotic valve. Another measure that may be taken to reduce afterload is an intra-
aortic balloon pump (IABP). This is generally used as a bridge to surgery or in cardiogenic shock
after acute myocardial infarction. It involves a balloon catheter placed in the descending aorta
that inflates during diastole and deflates during systole. The balloon augments filling of the
coronary arteries during diastole and decreases afterload during systole. IABP is used with
caution because there are several possible complications, including dissection of the aortoiliac
arteries, ischemic changes in the legs, and migration of the balloon up or down the aorta.
Trans-Myocardial Revascularization (TMR) Patients with severe coronary artery disease
and angina, who are not amenable to balloon dilatation or coronary artery bypass grafting, may
meet the criteria for trans-myocardial revascularization (TMR).
This procedure, which can be done by itself or in combination with conventional
coronary bypass surgery, consists of the creation of channels through the heart muscle. As
these channels heal, they stimulate the creation of new small vessels or capillaries by a process
known as angiogenesis. While the resolution of the angina may take weeks to a few months,
surgical scars and the length of hospitalization may be minimized, especially in cases in which
no other procedures are performed.
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According to an abstract presented at the American Heart Association's 2005 Scientific
Sessions, LVADs reduced the risk of death in end-stage heart failure patients by 50 percent at
six and 12 months and extended the average life span from 3.1 months to more than 10months.
Pacemaker (a.k.a. Artificial Pacemaker) A small device that has wires which are implanted in
the heart tissue to send electrical impulses that help the heart beat in a regular rhythm. The
device is powered by a battery.
Implantable Cardiovascular Defibrillator (ICD) A device that has wires which are implanted into
the heart tissue and can deliver electrical shocks, detect the rhythm of the heart and
sometimes "pace" the heart's rhythms, as needed.
Implantable Medical Devices Pacemakers and Implantable Cardioverter Defibrillators (ICDs) are
used to treat arrhythmias — a condition of heart rhythm problems that occurs when the
electrical impulses that coordinate your heartbeats don't function properly, causing your heart
to beat too fast, too slow or irregularly. The Left Ventricular Assist Device (LVAD) helps maintain
the pumping ability of your heart.
OTHER MEASURES
Other measures the physician may use include supplemental oxygen, thrombolytic
therapy, percutaneous transluminal coronary angioplasty, directional coronary atherectomy,
placement of a coronary stent, or coronary artery bypass surgery to improve oxygen flow to
the myocardium. Finally, a cardiac transplant may be considered if other measures fail, if all
other organ systems are viable, if there is no history of other pulmonary diseases, and if thepatient does not smoke or use alcohol, is generally under 60 years of age, and is
psychologically stable.
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Monitoring pulse rate and blood pressure, as well as monitoring for posturalhypotension and making sure that the patient does not become hypotensive from
dehydration Examining skin turgor and mucous membranes for signs of dehydration Assessing symptoms of fluid overload (eg, orthopnea, paroxysmal nocturnal dyspnea,
and dyspnea on exertion) and evaluating changes
MAINTAINING ADEQUATE CARDIAC OUTPUT
Place patient at physical and emotional rest to reduce work of heart. Provide rest
in semi-recumbent position or in armchair in air-conditioned environment that reduces workof heart, increases heart reserve, reduces BP, decreases work of respiratory muscles and
oxygen utilization, improves efficiency of heart contraction; recumbency promotes diuresis by
improving renal perfusion. Provide bedside commode to reduce work of getting to bathroom
and for defecation. Provide for psychological rest since emotional stress produces
vasoconstriction, elevates arterial pressure, and speeds the heart. Promote physical comfort.
Avoid situations that tend to promote anxiety and agitation. Offer careful explanations and
answers to the patient's questions.
Evaluate frequently for progression of left-sided heart failure. Take frequent BP
readings. Observe for lowering of systolic pressure. Note narrowing of pulse pressure. Note
alternating strong and weak pulsations (pulsus alternans). Auscultate heart sounds frequently
and monitor cardiac rhythm. Note presence of S3 or S4 gallop (S3 gallop is a significant indicator
of heart failure). Monitor for premature ventricular beats.
Observe for signs and symptoms of reduced peripheral tissue perfusion: cool
temperature of skin, facial pallor, and poor capillary refill of nail beds. Monitor clinical
response of patient with respect to relief of symptoms (lessening dyspnea and orthopnea,decrease in crackles, relief of peripheral edema). Watch for sudden unexpected hypotension,
which can cause myocardial ischemia and decrease perfusion to vital organs.
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Offer small, frequent feedings to avoid excessive gastric filling and abdominal
distention with subsequent elevation of diaphragm that causes decrease in lung capacity.
Administer oxygen as directed.
PROMOTING ACTIVITY TOLERANCE
Although prolonged bed rest and even short periods of recumbency promote diuresis
by improving renal perfusion, they also promote decreased activity tolerance. Prolonged bed
rest, which may be selfimposed, should be avoided because of the deconditioning effects and
hazards, such as pressure ulcers (especially in edematous patients), phlebothrombosis, and
pulmonary embolism. An acute event that causes severe symptoms or that requireshospitalization indicates the need for initial bed rest. Otherwise, a total of 30 minutes of
physical activity three to five times each week should be encouraged (Georgiou et al., 2001).
The nurse and patient can collaborate to develop a schedule that promotes pacing and
prioritization of activities. The schedule should alternate activities with periods of rest and
avoid having two significant energy-consuming activities occur on the same day or in
immediate succession. Before undertaking physical activity, the patient should be given the
following safety guidelines:
Begin with a few minutes of warm-up activities. Avoid performing physical activities outside in extreme hot, cold, or humid weather. Ensure that you are able to talk during the physical activity; if you are unable to do so,
decrease the intensity of activity.
Wait 2 hours after eating a meal before performing the physical activity. Stop the activity if severe shortness of breath, pain, or dizziness develops. End with cool-down activities and a cool-down period.Because some patients may be severely debilitated, they may need to perform physical
activities only 3 to 5 minutes at a time, one to four times per day. The patient then should be
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activity to identify whether they are within the desired range. Heart rate should return to
baseline within 3 minutes. If the patient is at home, the degree of fatigue felt after the activity
can be used as assessment of the response. If the patient tolerates the activity, short-term andlong-term goals can be developed to gradually increase the intensity, duration, and frequency
of activity.
Referral to a cardiac rehabilitation program may be needed, especially for HF patients
with recent myocardial infarction, recent open-heart surgery, or increased anxiety. A
supervised program may also benefit those who need the structured environment, significant
educational support, regular encouragement, and interpersonal contact.
MANAGING FLUID VOLUME
Patients with severe HF may receive intravenous diuretic therapy, but patients with
less severe symptoms may receive oral diuretic medication (see Table 30-4 for a summary of
common diuretics). Oral diuretics should be administered early in the morning so that diuresis
does not interfere with the patient’s nighttime rest. Discussing the timing of medication
administration is especially important for patients, such as elderly people, who may have
urinary urgency or incontinence. A single dose of a diuretic may cause the patient to excrete a
large volume of fluid shortly after administration.
The nurse monitors the patient’s fluid status closely—auscultating the lungs,
monitoring daily body weights, and assisting the patient to adhere to a low-sodium diet by
reading food labels and avoiding high-sodium foods such as canned, processed, and
convenience foods (Chart 30-4). If the diet includes fluid restriction, the nurse can assist the
patient to plan the fluid intake throughout the day while respecting the patient’ s dietary
preferences. If the patient is receiving intravenous fluids, the amount of fluid needs to be
monitored closely, and the physician or pharmacist can be consulted about the possibility ofmaximizing the amount of medication in the same amount of intravenous fluid (eg, double-
concentrating to decrease the fluid volume administered).
The nurse positions the patient or teaches the patient how to assume a position that
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CONTROLLING ANXIETY
Because patients in HF have difficulty maintaining adequate oxygenation, they are
likely to be restless and anxious and feel overwhelmed by breathlessness. These symptomstend to intensify at night. Emotional stress stimulates the sympathetic nervous system, which
causes vasoconstriction, elevated arterial pressure, and increased heart rate. This sympathetic
response increases the amount of work that the heart has to do. By decreasing anxiety, the
patient’s cardiac work also is decreased. Oxygen may be administered during an acute event to
diminish the work of breathing and to increase the patient’s comfort.
When the patient exhibits anxiety, the nurse takes steps to promote physical comfort
and psychological support. In many cases, a family member’s presence provides reassurance.To help decrease the patient’s anxiety, the nurse should speak in a slow, calm, and confident
manner and maintain eye contact. When necessary, the nurse should also state specific, brief
directions for an activity.
After the patient is comfortable, the nurse can begin teaching ways to control anxiety
and to avoid anxiety-provoking situations. The nurse explains how to use relaxation techniques
and assists the patient to identify factors that contribute to anxiety. Lack of sleep may increase
anxiety, which may prevent adequate rest. Other contributing factors may include
misinformation, lack of information, or poor nutritional status. Promoting physical comfort,
providing accurate information, and teaching the patient to perform relaxation techniques and
to avoid anxiety triggering situations may relax the patient.
Cerebral hypoxia with superimposed carbon dioxide retention may be a problem in HF,
causing the patient to react to sedative-hypnotic medications with confusion and increased
anxiety. Hepatic congestion may slow the liver’s metabolism of medication, leading to toxicity.
Sedative-hypnotic medications must be administered with caution.
In cases of confusion and anxiety reactions that affect the patient’s safety, the use ofrestraints should be avoided. Restraints are likely to be resisted, and resistance inevitably
increases the cardiac workload. The patient who insists on getting out of bed at night can be
seated comfortably in an armchair As cerebral and systemic circulation improves the degree
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nurse may want to review hospital policies and standards that tend to promote powerlessness
and advocate for their elimination or change (eg, limited visiting hours, prohibition of food
from home, required wearing of hospital gowns).
MONITORING AND MANAGING POTENTIAL COMPLICATIONS
Profuse and repeated diuresis can lead to hypokalemia (ie, potassium depletion). Signs
are weak pulse, faint heart sounds, hypotension, muscle flabbiness, diminished deep tendon
reflexes, and generalized weakness. Hypokalemia poses new problems for the patient with HF
because it markedly weakens cardiac contractions. In patients receiving digoxin, hypokalemia
can lead to digitalis toxicity. Digitalis toxicity and hypokalemia increase the likelihood of
dangerous dysrhythmias (see Chart 30-3). Low levels of potassium may also indicate a low
level of magnesium, which can add to the risk for dysrhythmias. Hyperkalemia may also occur,
especially with the use of ACE-Is or ARBs and spironolactone.
To reduce the risk for hypokalemia, the nurse advises patients to increase their dietary
intake of potassium. Dried apricots, bananas, beets, figs, orange or tomato juice, peaches, and
prunes (dried plums), potatoes, raisins, spinach, squash, and watermelon are good dietary
sources of potassium. An oral potassium supplement (potassium chloride) may also be
prescribed for patients receiving diuretic medications. If the patient is at risk for hyperkalemia,the nurse advises the patient to avoid the above products, including salt substitutes.
Grapefruit (fresh and juice) is a good dietary source of potassium but has serious drug –
food interactions. Patients are advised to consult their physician or pharmacist before
including grapefruit in their diet.
Periodic assessment of the patient’s electrolyte levels will alert health team members
to hypokalemia, hypomagnesemia, and hyponatremia. Serum levels are assessed frequently
when the patient starts diuretic therapy and then usually every 3 to 12 months. It is importantto remember that serum potassium levels do not always indicate the total amount of
potassium within the body.
Prolonged diuretic therapy may also produce hyponatremia (deficiency of sodium in
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Although noncompliance is not well understood, interventions that may promote
adherence include teaching to ensure accurate understanding. A summary of teaching points
for the patient with HF is presented in Chart 30-5.The patient and family members are supported and encouraged to ask questions so
that information can be clarified and understanding enhanced. The nurse should be aware of
cultural factors and adapt the teaching plan accordingly.. They also need to be informed that
health care providers are there to assist them in reaching their health care goals. Patients and
family members need to make the decisions about the treatment plan, but they also need to
understand the possible outcomes of those decisions. The treatment plan then will be based
on what the patient wants, not just what the physician or other health care team members
think is needed. Ultimately, the nurse needs to convey that monitoring symptoms and daily
weights, restricting sodium intake, avoiding excess fluids, preventing infection with influenza
and pneumococcal immunizations, avoiding noxious agents (eg, alcohol, tobacco), and
participating in regular exercise all aid in preventing exacerbations of HF.
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II. OBJECTIVESi) General
After 1-3 hours of case presentation in the medical ward, the students will be able todevelop and apply specific knowledge, skills and attitude on the disease process of
Congestive Heart Failure generally on the body; anticipate and provide effective nursing
care; and, deliver specific interventions needed to treat the disease.
j) Specific1. Nurse-Centered Objectives
Upon completion of this case study, the student nurse should be able to:
a) Make a thorough assessment about the patient’s personal history, familybackground and lifestyle
b) Cite factors that contribute to the patient’s condition. c) Review the anatomy and physiology of the integumentary system.d) Explain the histopathology and pathogenesis of Congestive Heart Failure.e) Make a comprehensive nursing care plan and its intervention.f) Impart knowledge to the patient regarding on his conditiong) Evaluate patient’s response towards rendered care given by the student nurse.
2.
Patient-Centered Objectives
Upon completion of this case study, the Guest should be able to:
) bl h d l h h h d
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II. Health Historya) Client ProfileA case of Patient MR, 33 years old, female, married, Filipino citizen, a Roman Catholic,
housewife and presently living in Paknaan, Mandaue City was assessed last April 23, 2010 by
4:30am at the Evvesley Childs Sanitarium (Female Medical ward). Client was admitted last April
19, 2010 at around 12:00 a.m via Taxi accompanied by her eldest son with admitting
complaints of shortness of breath, dizziness and fatigue. Admitting V/S is as follows: T-37.9;
PR-92; RR-25; BP-200/160. She's under the care of Dr. Lagora. Patient was transferred to theFemale Medical Ward at 4:10 am of the same day. Patient claimed to be hypertensive but not
diabetic or asthmatic. Patient is neither a smoker nor an alcoholic beverage drinker. She has
no known allergies to drug as well as to foods; but, since she has a heart problem, she ate less
on restricted foods high in cholesterol.
b) Past Medical HistoryPatient disclosed that she has received the following immunizations: BCG 1 and 2, DPT
1, 2 and 3, OPV 1, 2 and 3, Anti Hepa-B 1, 2 and 3, TT1, 2, 3, 4 and 5. Patient is currently having
3 children. Upon her 2nd child, she was admitted to the hospital last year 2001 for 4 days in
Eversley Child's Sanitarium under unrecalled doctor and was diagnosed with Pre-eclampsia.
She was also unable to recall the specific medications she took that time. Patient MR was then
adviced by the doctor not to have another child but then was not followed since she had her
3rd child in the year 2007 and was confined for 3 consecutive days in Vicente Sotto Memorial
Medical Center under the Service of unrecalled Doctor. The patient was diagnosed with
Eclampsia with a BP of 180/120mmHg which was her usual BP measurement for her current
illness. She was only able to remember Nefidipine as her medication.
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sexually active. The ego in the genital stage is well-developed, and so uses secondary process
thinking, which allows symbolic gratification. Patient MR expressed symbolic gratification that
includes the formation of love relationships and families, or acceptance of responsibilities
associated with adulthood.
In Erik Erikson's psychosocial Stages of development, Patient MR belongs to Generativity
vs. Stagnation wherein it concerns of establishing and guiding the next generation. Socially-
valued work and disciplines are expressions of generativity as well as contributing to society
and helping future generations. Patient is already raising a family and verbalized her hopes on
working towards the betterment of society, a sense of generativity- a sense of productivity andaccomplishment.
According to kohlberg's Theory of Moral Development, Patient MR is in the
Postconventional Morality wherein people begin to account for the differing values, opinions,
and beliefs of other people. Rules of law are important for maintaining a society, but members
of the society should agree upon these standards. Patient considers values of honesty,
hardwork and nurturing as important values on being a mother and a wife to her family.
In Fowler's stages of faith development, patient belongs to the 4th stage of
"Individuative-Reflective" faith (usually mid-twenties to late thirties) a stage of angst and
struggle. The patient took personal responsibility for her beliefs and feelings. She expressed
her faith to God that despite her situation and that she still believes that God will heal her
from her illness.
e) Environmental HistoryPatient MR is currently residing in Paknaan Mandaue City Cebu. She together with her
family with three children are living in a rented house and lot nearby the street side which is
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III. Physical AssessmentGENERAL APPEARANCE:
Patient seen lying on bed, awake, alert, responsive, coherent, afebrile, with venoclysis of # 3 D5
Water, infusing well at right hand with the following vital signs: T- 38 C, BP – 180/90, PR – 98 bpm, RR –
28 cpm.
IV. Significant Laboratory Findings and Diagnostic Procedures
Diagnostic or
Laboratory
Procedure
Date
Ordered and
Date Results
were
released
Normal Range
Patient’s Results Analysis and Interpretation of ResultsMale Female
HEMATOLOGY
Hemoglobin 04-20-10 140-180
g/L
120-160
g/L
117 g/L A decrease implies anemia,
recent hemorrhage and fluidretention
Hematocrit 04-20-10 0.42-
0.52 g/L
0.37-
0.47 g/L
0.35 g/L A decrease implies anemia
and hemo dilution
RBC 04-20-10 4.7-6.1
/L
4.2-5.4
/L
4.4 /L A decrease implies anemia
and fluid overload of >24
hoursWBC 04-20-10 5-10 x /L 8.8 x /L Within normal range
Differential Count
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Appearance 04-20-10 Clear Cloudy Turbity implies kidney
infection
Specific
Gravity
04-20-10 Newborns: 1-1.02
Infants: 1.002-
1.006
Adults: 1.016-
1.022
1.030 An increase implies nephritic
syndrome
pH 04-20-10 4.6-6.5 5.0 Within normal range
Protein 04-20-10 None (++) Presence implies proteinuria,renal failure or myeloma
Glucose 04-20-10 Negative Negative Normal result
RBC 04-20-10 0 /hpf 0-2 /hpf 2-4 /hpf Within maximum normal
range.
WBC 04-20-10 0-2 /hpf 0-5 /hpf 10-12 /hpf An increase implies trauma or
tumors
Casts 04-20-10 Hyaline, coarse.
Fine granular.
RBC, WBC.
Waxy casts
Coarsely
granular.
1-2 /hpf
Normal result
Amorphous
Materials
04-20-10 Small amounts Few Normal result
Epithelial Cells 04-20-10 Small amounts Few Normal result
Bacteria 04-20-10 None Many Presence implies GUT
infection or contamination of
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VI. Anatomy and PhysiologyTHE HEART
THE HEART WALLS
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THE HEART CHAMBERS AND VALVES
THE CONDUCTION SYSTEM OF THE HEART
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THE CIRCULATORY SYSTEM
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Pathophysiology (Left Sided Heart Failure)
MYOCARDIAL DYSFUNCTION
Increased Left
Atrial Pressure
blood dams back
into the pulmonary
capillary
PULMONAR
Y EDEMA
Signs & Symptoms: Dyspnea
PND
Crackles
Wheezing
Dizziness
Weakness
S3 sound
LSCHF decreased CO
decreased systemic BP
decreased tissue
RAAS
stimulation Activation of
Baroreceptor
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Pathophysiology (Right Sided Heart Failure)
Vasoconstriction increased
afterload
increased BP
increased HR
ventricular
remodeling
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VIII. Nursing Care PlansACTIVE PROBLEM NURSING INTERVENTIONS EVALUATION
Impaired gas exchange related to alveolar
edema due to elevated ventricular
pressures
Subjective cue:
“Maglisod jud ko'g ginhawa”(nahihirapan
talaga akong huminga), as verbalized by
the patient
Objective cue:
>restlessness
>irritability
>diaphoresis
>bilateral crackles that do not clear with
cough
>pale skin color
Scientific Analysis:
Dyspnea, or shortness of breath, may
be precipitated by minimal to moderate
activity (dyspnea on exertion *DOE+);
dyspnea also can occur at rest. The
patient may report orthopnea, difficulty
in breathing when lying flat. Patients with
Independent:
1. R: Monitor vital signs and cardiac rhythm
I: for baseline data and monitoring
2. R: Auscultate breath sounds,
I: notes areas of decreased/adventitious
breath sounds
3. R:Note character and effectiveness of
cough mechanism
I: ability to clear airways of secretions
4. R: Elevate head of bed, provide adjuncts
and suction, as indicated
I: to maintain airway
5. R: Encourage frequent position changes
and deep-breathing/coughing exercises. Use
incentive spirometer, chest physiotherapy, as
indicated
I: promotes chest expansion and drainage of
secretions
6. R: Maintain adequate I/O
I: for mobilization of secretions
7. R: Encourage adequate rest and limit
activities to within client tolerance.
I: Promote calm/restful environment
helps limit oxygen need/consumption
Desired Outcome:
After 8 hours of nursing intervention,
the patient was able to demonstrate
improved ventilation and adequate
oxygenation of tissues by ABGs within
patient's normal limits and absence of
symptoms of respiratory distress
Actual Outcome:
After 8 hours of nursing intervention,
the objectives were partially met. The
patient was able to improved
ventilation and
oxygenation of tissues as evidenced by
patient breathing without using much
of the accessory muscle
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orthopnea usually prefer not to lie flat.
They may need pillows to prop
themselves up in bed, or they may sit in a
chair and even sleep sitting up. Some
patients have sudden attacks of
orthopnea at night, a condition known as
paroxysmal nocturnal dyspnea (PND).
8. R: Keep environment allergen/pollutant
free
I: to reduce irritant effect of dust and
chemicals on airway
9. R: Provide psychological support, active-
listen questions/concerns
I: to reduce anxiety
Dependent:
1. R: Administer medications, as indicated
I: to treat underlying conditions
Source: Source: Sparks, S and Taylor, C,Nursing Diagnosis Reference Manual 3
rd
edition; Springhouse Corporation,
Pennsylvannia
Decreased Cardiac Output related to
impaired contractility and increased
preload and afterload.
Subjective cue:
“Sige ra jud kog pangluspad” (lage nlang
akong maputla),as verbalized by the
patient
Independent:
1. R: Place patient at physical and emotional
rest
I: to reduce work of heart. 2. R: Provide rest in semi-recumbent position
or in armchair in air-conditioned environment
I: that reduces work of heart, increases heart
reserve, reduces BP, decreases work of
respiratory muscles and oxygen utilization,
improves efficiency of heart contraction;
Desired Outcome:
After 8 hours of nursing intervention,
the patient was able to demonstrate
improved cardiac output withinnormal levels of preload and afterload.
Actual Outcome:
After 8 hours of nursing intervention,
the objectives were partially met. The
patient was able to initiate actions to
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Objective cue:
>restlessness
>irritability
>diaphoresis
>pale skin color
Scientific Analysis:
In addition to increased pulmonary
pressures that cause decreased
oxygenation, the amount of blood ejected
from the left ventricle may decrease,
sometimes called forward failure. The
dominant feature in HF is inadequatetissue perfusion. The diminished CO has
widespread manifestations because not
enough blood reaches all the tissues and
organs (low perfusion) to provide the
necessary oxygen. The decrease in SV can
also lead to stimulation of the
sympathetic nervous system, which
further impedes perfusion to many
organs. (Wolkenstein, 2000).
recumbency promotes diuresis by improving
renal perfusion
3. R:Provide bedside commode
I: to reduce work of getting to bathroom and
for defecation.
4. R: Provide for psychological rest since
emotional stress produces vasoconstriction.
I:elevates arterial pressure, and speeds the
heart.
5. R: Promote physical comfort. Avoid
situations that tend to promote anxiety and
agitation. Offer careful explanations and
answers to the patient's questions. I: Decreases anxiety
6. R: Take frequent BP readings. Observe for
lowering of systolic pressure. Note narrowing
of pulse pressure. Note alternating strong and
weak pulsations (pulsus alternans). Auscultate
heart sounds frequently and monitor cardiac
rhythm. Note presence of S3 or S4 gallop (S3
gallop is a significant indicator of heart
failure). Monitor for premature ventricular
beats.
I: Evaluates for progression of left-sided heart
failure.
Source: Source: Sparks, S and Taylor, C,
increase cardiac output but symptoms
persisted.
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cannot eject the increased circulating
blood volume, the pressure in the
pulmonary circulation increases, causing
further shifting of fluid into the alveoli.
The fluid filled alveoli cannot exchange
oxygen and carbon dioxide. Without
sufficient oxygen, the patient experiences
dyspnea and has difficulty getting an
adequate amount of sleep. (Wolkenstein,
2000).
Dependent:
1. R: Administer medications (e.g.diuretics)
I: To treat underlying conditions
Collaborative:
1. R: Restrict sodium and fluid intake, as
indicated
I: for nutritional therapy
Source: Source: Sparks, S and Taylor, C,
Nursing Diagnosis Reference Manual 3rd
edition; Springhouse Corporation,Pennsylvannia
Activity intolerance related to imbalance
between oxygen supply and demand
Cues and Objectives
Subjective:
“dali ra ko makutasan, dili ko kasugakod
ug dugay ug bug-at nga trabaho,” as
verbalized by the patient.
Independent:
1. I: Discuss with the patient the need for
activity.
R: Improves physical and psychosocial well-
being.
2. I: Identify activities the patient considers
desirable and meaningful.
R: To enhance their positive impact.
3. I: Encourage patient to help plan activity
progression, being sure to include activities
the patient considers essential.
R: Participation in planning helps ensure
patient compliance.
Desired Outcomes:
After 8 hours of nursing interventions,
* Patient states desire to increase
activity level.
* Patient states understanding of the
need to increase activity level
gradually.
* Blood pressure and pulse and
respiratory rates remain within
prescribed limits during activity.
* Patient states satisfaction with each
new level of activity attained.
* Patient demonstrates skill in
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Objective:
- generalized weakness
- limited range of motion
- short term performance of an activity
Scientific Analysis:
As heart failure becomes more severe,
the heart is unable to pump the amount
of blood required to meet all of the
body’s needs. To compensate, blood is
diverted away from less-crucial areas,
including the arms and legs, to supply the
heart and brain. As a result, people withheart failure often feel weak (especially in
their arms and legs), tired and have
difficulty performing ordinary activities
such as walking, climbing stairs or
carrying groceries
4. I: Instruct and help patient to alternative
periods of rest and activity.
R: To reduce the body’s organ demand and
prevent fatigue.
5. I: Identify and minimize factors that
decrease the patient’s exercise tolerance.
R: To help increase the activity level.
6. I: Monitor physiological responses to
increased activity.
R: To ensure return to normal a few minutes
after exercising.
7. I: Teach patient how to conserve energy
while performing activities of daily living.R: These measures reduce cellular
metabolism and oxygen demand.
8. I: Teach patient exercises for increasing
strength and endurance.
R: Improves breathing and gradually increase
activity level.
9. I: Support and encourage activity to
patient’s level of tolerance.
R: Helps patient develop level of tolerance.
10. I: Before discharge, formulate a plan with
the patient and caregivers that will enable the
patient either to continue functioning at
maximum activity intolerance or to gradually
increase the tolerance.
conserving energy while carrying out
daily activities to tolerance level.
* Patient explains illness and connects
symptoms of activity intolerance with
deficit in oxygen supply or use.
Actual Outcome:
After 8 hours of nursing interventions,
the objectives were partially met. The:
*Patient stated understanding of the
need to perform daily activities.
*Patient demonstrated conservation
of energy while performing activities.
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R: Participation in planning encourages
patient satisfaction and compliance.
Source: Source: Sparks, S and Taylor, C,
Nursing Diagnosis Reference Manual 3rd edition; Springhouse Corporation,
Pennsylvannia
Ineffective airway clearance related to
presence of tracheobronchial obstruction
Cues and Evidences:
Subjective:“maglisod ko ug ginhawa nya huot ako
dughan,” (nahihirapan talaga akong
huminga masikip ang aking dibdib) as
verbalized by the patient.
Objective:
- shortness of breath
- dyspnea
- use of accessory muscles when
breathing
- tachypnea with RR of 28
Scientific Analysis:
Mucus is produced at all times by the
Independent:
1. I: Assess respiratory status at least every
for hours or according to establishment
standards.
R: To detect early signs of compromise.2. I: Place patient in Fowler’s position and
support upper extremities.
R: To aid breathing and chest expansion, and
to ventilate basilar lung fields.
3. I: Help patient turn, cough, and deep
breath every 2 to 4 hours.
R: To help prevent pooling of secretions and
to maintain airway patency.
4. I: Suction as needed. Be alert for
progression of airway clearance.
R: To stimulate cough and airways.
5. I: Encourage fluids (atleast 3,000 mL daily).
R: To ensure adequate hydration and loosen
secretions, unless contraindicated.
Desired Outcome:
After 8 hours of nursing interventions,
* Patient clears airway using
controlled coughing techniques.
* Patient expectorates sputum.* Patient drinks 3 to 4 liters of fluid
daily.
Patient’s arterial blood gas values are
within normal limits.
*Patient performs chest
physiotherapy, especially postural
drainage.
*Patient understands necessity of
adequate hydration
Actual Outcome:
After 8 hours of nursing interventions,
the objectives were partially met. The:
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membranes lining the air passages. When
the membranes are irritated or inflamed,
excess mucus is produced and it will
retain in tracheobronchial tree. The
inflammation and increased in secretionsblock the airways making it difficult for
the person to maintain a patent airway.
In order to expel excessive secretions,
cough reflex will be stimulated. An
increased in RR will also be expected as a
compensatory mechanism of the body
due to obstructed airways (Wolkenstein,
2000).
6. I: Mobilize patient to full capabilities.
R: To facilitate chest expansion and
ventilation.
7. I: Perform postural drainage, percussion,
and vibration every 4 hours or as ordered.R: To enhance mobilization of of secretions
that interferes with oxygenation.
8. I: Avoid supine position for extended
periods. Encourage lateral, sitting, prone, and
upright positions as much as possible.
R: To enhance lung expansion and ventilation.
9. I: Provide tissues and paper bags for
hygienic sputum disposal.R: To prevent spreading infection.
10. I: Monitor and document sputum
characteristics every shift.
R: To gauge therapy’s effectiveness.
Source: Sparks, S and Taylor, C, Nursing
Diagnosis Reference Manual 3rd
edition;
Springhouse Corporation, Pennsylvannia
*Patient verbalized understanding on
coughing techniques
* Patient increased fluid volume to 3
to 4 liters per day.
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IX. Drug StudyName of
medication or
drugs
indications/reasons for
administrating the drugs
Side effects, adverse reactions
a nurse note for Nursing Interventions
Cefuroxime 750mg
IVTT It is effective for the
treatment of penicillinase-
producing Neisseria
gonorrhoea (PPNG).
Effectively treats bone and
joint infections, bronchitis,
meningitis, gonorrhea,
otitis media,
pharyngitis/tonsillitis,sinusitis, lower respiratory
tract infections, skin and
soft tissue infections,
urinary tract infections,
and is used for surgical
prophylaxis, reducing or
eliminating infection.
CNS: headache,
dizziness,lethargy,
paresthesias
GI: nausea,vomiting,
diarrhea,anorexia, abdominal
pain, flatulence,
GU: nephrotoxicity
Hematologic: bone marrow
depression
Hypersensitivity: ranging from
rash to fever to anaphylaxis,
serum sickness reaction
Determine history of hypersensitivity reactionsto cephalosporins, penicillins, and history of
allergies, particularly to drugs, before therapy is
initiated.
Inspect IM and IV injection sites frequently forsigns of phlebitis.
Report onset of loose stools or diarrhea.Although pseudomembranous colitis.
Monitor I&O rates and pattern: Especiallyimportant in severely ill patients receiving high
doses. Report any significant changes.
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Paracetamol 500mg
1 tab q 8h for fever
To relieve mild to moderate
pain due to things such as
headache, muscle and joint
pain, backache and period
pains. It is also used to
bring down a high
temperature. For this
reason, paracetamol can
be given to children after
vaccinations to prevent
post-immunisation pyrexia
(high temperature).
Paracetamol is often
included in cough, cold andflu remedies.
Side effects are rare with
paracetamol when it is taken
at the recommended doses.
Skin rashes, blood disorders
and acute inflammation of the
pancreas have occasionally
occurred in people taking the
drug on a regular basis for a
long time. One advantage of
paracetamol over aspirin and
NSAIDs is that it doesn't
irritate the stomach or causing
it to bleed, potential Side
effects of aspirin and NSAIDs.
Assessment & Drug Effects
Monitor for S&S of: hepatotoxicity, even withmoderate acetaminophen doses, especially in
individuals with poor nutrition.
Patient & Family Education
Do not take other medications (e.g., coldpreparations) containing acetaminophen
without medical advice; overdosing and chronic
use can cause liver damage and other toxic
effects.
Do not self -medicate children for pain morethan 5 d without consulting a physician.
Do not use for fever persisting longer than 3 d,fever over 39.5° C (103° F), or recurrent fever.
Do not give children more than 5 doses in 24 hunless prescribed by physician.
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photosensitivity, porphyria
cutanea tarde, necrotizing
angiitis (vasculitis).
Body as a Whole: Increased
perspiration; paresthesias;
activation of SLE, muscle
spasms, weakness;
thrombophlebitis, pain at IM
injection site.
Salbutamol 1 neb q
6
Actions:
Synthetic
sympathomimetic
amine and
moderately
selective beta2-
adrenergic agonist
with comparatively
long action. Acts
more prominently
on beta2 receptors
(particularly
smooth muscles of
bronchi, uterus,
and vascular supply
To relieve bronchospasm
associated with acute or
chronic asthma, bronchitis,
or other reversibleobstructive airway
diseases. Also used to
prevent exercise-induced
bronchospasm.
Body as a Whole:
Hypersensitivity reaction.
CNS: Tremor, anxiety,
nervousness, restlessness,convulsions, weakness,
headache, hallucinations.
CV: Palpitation, hypertension,
hypotension, bradycardia,
reflex tachycardia. Special
Senses: Blurred vision, dilated
pupils.
GI: Nausea, vomiting. Other:
Muscle cramps, hoarseness.
Assessment & Drug Effects
Monitor therapeutic effectiveness which isindicated by significant subjective improvementin pulmonary function within 60–90 min after
drug administration.
Monitor for: S&S of fine tremor in fingers,which may interfere with precision handwork;
CNS stimulation, particularly in children 2–6 y,
(hyperactivity, excitement, nervousness,
insomnia), tachycardia, GI symptoms. Report
promptly to physician.
Lab tests: Periodic ABGs, pulmonary functions,and pulse oximetry.
Consult physician about giving last albuteroldose several hours before bedtime, if drug-
induced insomnia is a problem.
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to skeletal muscles)
than on beta1
(heart) receptors.
Minimal or no
effect on alpha-adrenergic
receptors. Inhibits
histamine release
by mast cells.
Aldozide 1 tab BID
Mechanism of
Action: : competes
with aldosteronefor receptor sites
in the distal renal
tubules, increasing
sodium chloride
and water
excretion while
conserving
potassium and
hydrogen ions,may block the
effect of
aldosterone on
arteriolar smooth
muscle as well
Essential hypertension,
edema and ascites of CHF,
liver cirrhosis, nephritic
syndrome, idiopathic
edema
Gynecomastia, GI symptoms,
lethargy, headache and
thrombocytopenia,
leukopenia, agranulocytosis,
cutaneous eruptions, pruritus,mental confusion, paresthesia,
acute pancreatitis, jaundice,
orthostatic hypertension,
muscle spasm, weakness,
fever, ataxia
educate patient to avoid hazardous activity such asdriving until response to drug is known.
Take with meals or milk; avoid excessive ingestionof food high in potassium or use of salt substitutes
Diuretic effect may be delayed 2-3 days andmaximum hypertensive may be delayed 2-3weeks;
monitor I and O ratios and daily weight, BP, serum
electrolytes (K, Na) and renal function
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X. Discharge PlanMETHODS Outcome Identification Nursing Interventions
Medication Patients need to understand the purpose,
dosage, route, and possible side effects of allprescribed medications.
A - Assess patient and SO’s ability to understand regarding home
medication orders and instructions to be given
I - Remind and instruct the parent on home medication instructions
- Refer to drug instructions for each.
E - Evaluate the patient’s level of understanding on the instructions given
about the medications
Exercise and
Environment
Regularly scheduled, moderate exercise
performed for at least 30 minutes most days ofthe week promotes the utilization of
carbohydrates, assists with weight control,
enhances the action of insulin, and improves
cardiovascular fitness.
A - Assess patient’s understanding of exercise regimen.
I - Explain the importance of exercise:
Caloric expenditure for energy in exercise Carryover of enhanced metabolic rate and efficient food utilization
- Advise patient to assess blood glucose level before and after strenuous
exercise.
- Instruct patient to plan exercises on a regular basis each day.
- Encourage patient to eat a carbohydrate snack before exercising to
avoid hypoglycemia.
- Advice patient that prolonged strenuous exercise may require
increased food at bedtime to avoid nocturnal hypoglycemia.
Instruct patient to avoid exercise whenever blood glucose levelsexceed 250 mg/day and urine ketones are present. Patient should
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contact health care provider if levels remain elevated.
Encouraged so to maintain quiet environment Encouraged so to maintain patient surrounding clean Encouraged so to provide patient proper hygiene
E - Evaluate patient’s level of understanding on the information given and
degree of awareness on the importance of good sanitation and proper
exercise.
Treatment Teach patients the appropriate technique for
testing blood and urine and how to interpret
the results.
Stress the importance of close attention to even
minor skin injuries.
Because of the atherosclerotic changes that
occur, encourage patients to stop smoking.
A - Assess if the patient is continually sticking to V/S monitoring schedules
and treatment regimen.
I - Patients need to know when to notify the physician and increase
testing during times of illness.
In addition, teach patients to avoid crossing their legs when sitting andto begin a regular exercise program.
Instructed the patient to right information or advice by the physician Instructed the patient to follow right time & medicationE - Check the response to the interventions and actions performed
Health
Teaching and
Hygiene
If the patient continues to smoke, provide the
name of a smoking cessation program or a
support group. You follow the same protocol for
drinking to avoid other diseases.
A - Assess for the patient’s ability to do self -care
- Assess patient’s will or degree to decrease/ cease smoking.
I - Discuss concerns with parent to identify underlying issues
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Encourage patients to avoid alcohol - Teach how to calculate caloric intake.
- Each meal should consist of a balance of carbohydrates, proteins, and
fats.
Carbohydrates should be varied to include fruits, starches, andvegetables.
Protein selections that are lean will help reduce fat and cholesterolintake.
Fats should be used sparingly with
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