congestive heart failure case press

8/22/2019 Congestive Heart Failure Case Press

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CONGESTIVE HEART

FAILURE


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I. Nursing History

1. Biographic Data

Name: Mr. X

Age: 53 years old

Address: Quezon City, Philippines

Sex: Male

Marital Status: Married

2. Chief Complaint

Cough


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3. Present Illness

2 weeks prior to admission:

The patient is with cough withwhitish sticky phlegm.

The patient had no other signsand symptoms like fever, chestpain, shortness of breath,difficulty of breathing,abdominal pain and numbness.

The patient had consulted and

the patient was given Cefalexine500mg 3x a day andDextometrophan 3x a day fortemporary relief

1 week prior to admission:

The patient had occurrence ofcough with whitish phlegmassociated with easy fatigability;2 3 pillow orthopnea anddecrease appetite. No fever, nochest pain, no nausea and

vomiting, no body weakness.


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4. Past History

The clients creatinine level was increased 2 3 years ago.Admitted due to decrease input and output 0 output and pedal

edema, cardiomyopathy 2 3 years ago. HCTZ 2500, Carvedilol

6.25 2x a day, on once a day Lanoxin 0.25 tab, Lasix 40 2x

a day, Coumadin 2.5mg once a day. Patient had DiabetesMellitus for 10 years, CBG every other day on insulin 2 3 years

ago.


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5. Personal and Social History

The client is a non smoker

The client consumed 2 3 bottles of beer in a week

The client is a previous dentist

Father: Congestive Heart Failure, Diabetes Mellitus Mother: Diabetes Mellitus


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Course in the wardJune 25, 2013

Client was endorsed and reviewed clients chart and noted allmedications as ordered.

Preparation of medications Acetylcysteine 600 mg/tablet once aday diluted in a half glass of water, Ketosterol 600 mg/tablet twice a

day [8:00am and 1:00pm], Levofloxacin 750 mg/tablet once a dayand Kalium durule thrice a day for three days given after meal[started on second day of admission (June 22, 2013)] and was givenas prescribed after the vital signs are taken.

The client had a diet of low salt and low fat. At 11:00am CompleteBlood Glucose Test (CBG) was taken as ordered with a result of 56

mg/dl. The attending physician ordered a retake of CBG reading for1:00pm. Vital signs are taken at 12:00nn.

The client had his CBG Test retake at 1:00pm with a result of 138mg/dl and Kalium durule was given after meal.


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June 26, 2013

The client was endorsed. Reviewed chart: discharge order noted.

Provided continuity of care given: vital signs taken and preparationof medications Acetylcysteine 600 mg/dl once a day diluted in a halfglass of water, Ketosterol 600 mg/tablet twice a day [8:00am and1:00pm], Levofloxacin 750 mg/tablet once a day, Kalium durulethrice a day for three days given after meal [started on second dayof admission (June 22, 2013)], Lanoxin 0.25 mg/tablet once a dayand Furosemide 40 mg/tablet every 12 hours taken orally withBlood Pressure precaution of 90/60 mmHg was given as prescribed.

Client was advised for discharged. Instructed client regarding his

home medications: Lactulose 120ml take 30cc every other day,Captopril 25 mg/tablet take tablet twice a day and he wasadvised to have a follow up check up after 1 week.


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II. Conceptual Framework


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III. Physical Assesment

VITAL SIGNS RESULTS

June 25, 2013

Blood Pressure 120/90 mmHg

Temperature 35.1oC

Respiratory Rate 24 breaths per minute

Pulse Rate 80 beats per minute


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Head to Toe Assesment

ACTUAL

ASSESSMENT

NORMAL

ASSESSMENT

ANALYSIS and

INTERPRETATION

HEAD

FACE

Eyes pale color of sclera white color of sclera decrease oxygen in

the blood flow

yellowish color of

conjunctiva

white color of

conjunctiva

jaundice due to

hemolysis of Red

Blood Cells

Lips pale in color depends on the colorof race

inadequateoxygenation

Neck distended jugular vein no distention of

jugular vein

indirect indicator of

pressure in the right

atrium


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THORAX and

ABDOMEN

LUNGS

Breath sounds crackles/rales upon

auscultation

bronchovesicular

breath sound

pulmonary congestion

or pulmonary edema

Abdomen wide abdominal

distention

(105cm./41inches)

depends on body mass

index

fluid accumulation in

the abdominal cavity

due to heart failure

UPPER

EXTREMITIES

Palms both palms are pallor pinkish in color inadequate

oxygenationNail beds both hands nail bed

are cyanotic in color

pinkish in color inadequate

oxygenation

LOWER

EXTREMITIES

Feet grade 2 pitting edema

on both feet

no pitting edema venous insufficiency

in lower extremity

Soles pallor on both soles Pinkish in color inadequate

oxygenation

GENERAL SURVEY:

o Body weaknesso Easily fatigue

SKIN:

o Dark brown in coloro Dry, cold, clammy skino Grade 2 pitting edema on both feeto Poor skin turgor


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IV. Laboratory/Diagnostic Exams

ECG RESULT (June 22, 2013)

Interpretation:

Sinus Rhythm

Right Axis Deviation

Bi-Atrial Enlargement

Incomplete Right Bundle Branch Block

Non Specific T Wave Changes

Persistent Postero-Basal Forces

2 DIMENSIONAL ECHOCARDIOGRAM AND COLOR FLOW REPORT

Interpretation: Color Flow Doppler Study

Mitral regurgitation, moderate

Tricuspid regurgitation, moderate

Pulmonic regurgitation

Calculated pulmonary artery pressure by pulmonary acceleration time (74msec), Pulomonary Hypertension, mild

Conclusion:

Dilated left ventricular dimension with left ventricular global hypokinesia

Widened E-point septal separation with low flow configuration of mitral valve leaflets indicative of left ventricular dysfunction

Depressed left ventricular ejection fraction = 28% by Simpson and 26% by Cubed method

Rheologic stasis noted in left ventricular cavity

Dilated left atrial dimension without evidence of thrombus

Dilated right atrial and right ventricular dimensions

Normal man pulmonary artery and aortic root dimensions

Mitral valve, tricuspid valve, aortic valve and pulmonic valve are normal


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Blood Glucose chart

DEPARTMENT OF RADIOLOGY

Section of Ultrasound

TOTAL ABDOMINAL ULTRASOUND

Impression:

Cholelithiasis.

Normal sonogram of the liver, pancreas, spleen, kidneys and urinary bladder.

Prostate gland enlargement with concretions.

DATE RESULT REFERENCE VALUE ANALYSIS

June 23, 2013

(11:30am)

269 mg/dl 80120 mg/dl Increased blood

sugar level


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Department of Pathology

Section of hematology

TEST RESULTS REFERENCE

VALUES

ANALYSIS

CBC with PLATELET

COUNT

Red Cell Count

MCV 96.5 (high) 80.096.0 Indicate to

classify anemiasMCH 34.6 (high) 27.533.2

MCHC 0.359 (high) 0.322

0.355DIFFERENTIAL

COUNT

Lymphocytes 0.41 (high) 0.250.35 Indicates

infection


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Hematology Section

Coagulation

PROTHROMBIN TIME RESULTS REFERENCE

VALUE

ANALYSIS

June 22,

2013

June 25,

2013

Patient 16.5 sec. 37.9 sec. 1014 sec. Prolong clotting

to occur


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Department of pathology

Section of clinical chemistryTEST RESULT REFERENCE

VALUE

INTERPRETATION ANALYSIS

June

22,

2013

June

24,

2013

Glucose 116 mg/dl (high) 74 106 Abnormal Increased

blood glucose

level

Urea 64

mg/dl(high)

50

mg/dl(high)

9 20 Abnormal

Creatinine 2.3

mg/dl

(high)

1.9

mg/dl

(high)

0.66 1.25 Abnormal Renal

insufficiency

Uric Acid 15.0 mg/dl

(high)

3.5 8.51 Abnormal Decrease

renal tissue

perfusion

Triglycerides 185 mg/dl (high) 0 150 Abnormal Increase

cholesterollevel in blood

Direct HDL 19 mg/dl (low) 40 60 Abnormal

Globulin 4.7 g/dl (high) 2.5 3.5 Abnormal

A/G Ratio 0.6 (low) 1.5 3.5 Abnormal

Potassium 3.43 mmol/L

(low)

3.5 5.1 Abnormal Decrease

pumping of

the heart


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ElectrolytesTEST RESULT REFERENCE

VALUE


June 22, 2013

Ionized

Calcium

1.08 1.101.40 mmol/L Abnormal Decrease

contractility

of heart

muscle

TEST RESULT UNIT REFERENCE

VALUE

INTERPRETATION ANALY

SIS

June 22,

2013

Routine

Chemistry

GlycosylatedHemoglobin

(HbA1c)

8.0 % 4.3

6.4 Abnormal Uncontrolled

Diabetes

Mellitus

(3

months)


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URINALYSIS

SECTION OF CLINICAL MICROSCOPY

Microscopic

MACROSCOPIC RESULT REFERENCEVALUE

INTERPRETATION

ANALYSIS

Color Dark Yellow Yellow Abnormal Concentrate

d

Transparency Hazy Clear Abnormal Insufficient

glomelular

filtration

Reaction 6.0 7.0 Abnormal

Albumin +1 Negative Abnormal Renal

damage

Urobilinogen 1.0 mg/dl Negative Abnormal Renal

damage

RESULT REFERENCE

VALUE


RBC 12 02 Abnormal

Bacteria Few None Abnormal


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DEPARTMENT OF RADIOLOGY

Roentgenological FindingsImpression:

Left ventricular enlargement


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RESPIRATORY THERAPY UNIT

Arterial Blood Gas (ABG) Determination

RESULT REFERENCE VALUE ANALYSIS

pH 7.52 7.357.45

pC02 25.4 3545mmHg

p02 136.7 80100 mmHg

HC03 20.4 22 -26 mEq/L

BE (-) 0.7 2

Sa02 99.0 95100%

tC02 21.2 2127 mmol/L


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V. Drug Study


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VI. Anatomy and Physiology


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VII. Pathophysiology


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VIII. Prioritized List of Nursing

Problems


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IX. Nursing Care Plan


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X. Discharge Plan

Captopril 25 mg/tab. Take tab. 2x a day.

Trimetazidine (vastarel MR) 35 mg/tab. Take 1 tab. 2 x a day

Humulin- N Inject 4 units, SC @ A.M.; & 4 units SC @ P.M.

Coumadin 2.5 mg/tab. Take 1 tablet every other day.

Lanoxin 0.25 mg/tab. Take 1 tablet every other day

Lactulose 120 ml/ bottle. Take 30 cc 1 x a day. Hold for BM > 3 x day.

Ketosterol 600 mg/tab. Take 1 tablet 2 x a day.

Ferrous Sulfate Take 1 tablet 2x a day

Calcium Gluconate 500 mg/tab. Take 1 tablet 1 x a day.Furosemide 40 mg/tab. Take 1 tablet 1 x a day

Medications

Gradually resume activities of daily living.Exercise/Activities


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Care of Attending PhysicianTreatment

Encourage proper diet with exercise.

Limit fluids to 1 L per day.

HealthTeaching

After 1 week

Laboratory Work Ups (OPD)

PT

Na & K

BUN

Crea

CBC with Plt

BUA

OPDFollow- Up


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Low Salt, Low FatDiet

Resume spiritualactivity.Sexuality/Spiritual:


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Adviser:Mr. Xavier Acuar RN, US-RN,MAN

Group 1:Arapol, Nikki M.

Corpuz Richard Erikson

Flores, Russelle Lowelle B.

Gutierrez, Ailyn O.

Ilao, Roldan O.

Moreno, Ma. Kristina M.

Sabatin, John Amadeus R.

Simpao, Michael Vincent S.

Thornton, Louzaldy Earl D.Villanueva, Mark Jason

Wi, Lynn Joy


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