Mindanao State University Buug

College of Health Sciences Ipil Extension

Sanito, Ipil, Zamboanga Sibugay
Name: Group B
Year/Section: BSN - IV
Date of Submission:
Clinical Instructor: Ms. Donnabelle Lumbatan RN

Score: ___________________

PHYSICAL ASSESSMENT TOOL

1.

PROFILE
Name: Norlyn Helar
Address: Poblacion, Titay, zamboanga Sibugay Province
Date of Admission: August 18, 2010 Time: 8:00pm
Arrived via: Wheelchair
Stretcher
Ambulatory
Admitting M.D.:
Dr. Ko
Source Providing Information:
Patient
Other: Husband

Age:32 yo
Sex: Female
Status: Married
Weight:
Height: 52
Temp:37.2
Pulse: 120
RR: 32
BP: 120/80

NURSING HISTORY
A. Chief Complain (Onset, Duration, Pt.s Perception):
Abdominal enlargement, abdominal pain radiating to the back x3 days, DOB x3days.
B. History of Present Illness (HPI) (Location, onset, character, intensity, duration, aggravation and alleviation, associated symptoms, previous treatment and results, social and
vocational responsibilities, affected diagnosis)
This is a case of Mrs. Noralane Helar, a 32 yo, female and a resident of Poblacion, Titay, Zamboanga Sibugay who was admitted for the second time at the Zamboanga
Sibugay Provincial Hospital last August 18, 2010 at around 8:00PM with the chief complains of Abdominal enlargement for 2 months, abdominal pain x3 days, DOB x 3 days. The
patients husband explained that his wife condition developed after she had a miscarriage last 2007. After the miscarriage, her wife would complain of abdominal pain from time to
time. Last 2009, her wife was hospitalized due to abdominal enlargement and abdominal pain radiating to her back. After spending more than a week at the hospital they were
referred to a hospital at Zamboanga City. She had undergone several diagnostic procedure but all with no result that may contribute to the identification of the cause of her
abdominal enlargement. The husband then decided to have her wife check by a quack doctor which promised that he could cure his wife, but after a few weeks with no sign of
progress left and did not returned. 3 days prior to admission the patient experience severe abdominal pain and DOB which led to their decision to seek medical attention.

2. Past Medical History

b. General State of Health: The patient prior to having her miscarriage was describe by the husband as a healthy person who only experiences minor illnesses such as cough
and colds which did not need prompt medical attention.
c. Childhood Illness: The patient only experienced cough and colds and sometimes fever during childhood as stated by the husband.
d. Adult Illness: The patient was hospitalized because of abdominal enlargement 1 year prior to admission.
e. Psychiatric Illness: The patient have no family history of any psychiatric illnesses.
f.

Accidents and Injuries: The patient did not experience accidents and injuries.

g. Surgeries: Patient had not undergone any surgeries.

h. Hospitalizations: The patient was hospitalized because of abdominal enlargement 1 year prior to admission.
D. Current Medical Status
a. Current Medications:
b. Allergies: The patient has no known allergies to food or drugs.
c. Tobacco (frequency, amount, duration): The patient is not an active smoker but her husband smokes making her a passive smoker.
d. Alcohol, drugs and related substance (frequency, amount, duration): The patient does not take alcoholic beverages
e. Diet: The patient had no diet restriction but her fluid intake was controlled, up to 800ml only for 24 hours.
f.

Screening Test: The patient was subject to several screening test which includes

g. Immunizations: The patient was not a fully immunized child and did not receive any immunization during admission.
h. Exercise and Leisure Activities: The patient is a housewife, her usual activities includes house cleaning, cooking and socializing with their neighbors..
i.

Sleep Patterns: The patient was restless because of difficulty of breathing and she is uncomfortable because of her abdominal enlargement and pain.

j.

Environmental Hazards: The patient is prone to fall because there was no side rail on the bed. The ward was also congested and the ventilation is poor making the patient
prone to nosocomial infection.

k. Use of Safety Measures: The patients husband sits beside his wife to watch her. Pillows were not used on her side.

E. Family History with Genogram

Acquired Diseases:
Hypercholestereloremia
Kidney Disease
Tuberculosis
Alcoholism
Drug addiction
Hypertension
Hepatitis A
B
C
Other (Please Specify)

x
x
x
x
x
x
x
x
x
x

Heredo-familial disease
Diabetes
Heart Disease
Hypertension
Stroke
Cancer
Arthritis
Rheuma
Allergies
Asthma
Epilepsy
Mental Illness
Other (Please specify)

x
x
x
x
x
x
x
x
x
x
x
x

Diagram (with legend)

Male

8 y.o

Patient

Female (deceased)

Female

32 y.o

Male (deceased)

58 y.o

Husband

7 y.o

60 y.o

37 y.o

F. Psychological History
a. Home Situation and Significant Others: The patient has good interpersonal relationship with her children and husband as reported by her husband.
b. Daily Life: The patient is a house wife a her daily activities are cleaning, cooking doing the laundry and socializing with their neighbors.
c. Important Experiences: The husband reported that the most significant experience that his wife could have encountered was when she had a miscarriage.
d. The Patients outlook: The patients husband reported that his wife had mentioned that she wants to recover from her sickness and live a normal life again.

NURSING ASSESSMENT
Name: Norlyn Helar
Chief Complain: Abdominal enlargement, abdominal pain radiating to the back x3 days, DOB x3days.
Impression/Diagnosis: congestive heart failure; ascites, anasarca
Date of Admission: 10 23 - 09 (11:00pm)
Diet: low fat low salt, fluid restriction 800cc for 24 hours
Type of Operation (if any): none
Normal Pattern
Before Hospitalization
Initial

Age: 32 y.o.

Sex: Female

Inclusive Dates of Care:, August 17, 2010

Clinical Appraisal
Day 1

1.ACTIVITIES REST
A. Activities

The patients daily activities are house hold

The patient was in CBR w/o
chores which include doing the laundry, cooking BRP.
and cleaning. She sleeps at around 9pm and
wakes at around 6am. She has adequate rest as
reported by her husband.

B. Rest

C. Sleeping Pattern

2. NUTRITIONAL
METABOLIC PATTERN

Patients typical food intakes are fried fish,

vegetables, occasionally pork and beef meat
A. Typical Intake (food, fluid) and rice. She takes 3 meals a day and does not
take alcoholic beverages. Her weight was not
B. Diet
monitored at home.
C. Weight
D. Medications/Supplement

The patient had no diet restriction

but her fluid intake was restricted to
only 800cc for 24 hours. Her weight
was also not taken during
admission.

Day 2

3. ELIMINATION PATTERN
A. Urine (frequency, color,
transparency)

B. Bowel (frequency, color,

transparency)

Urine bright yellow in color, transparent, 3 to 4 x

a day

The patient did not void during the

shift.

Soft well formed,

The patient did not defecate during

the shift.

The patient have verbalize wanting to recover

from her illness and be able to live a normal life
again as reported by her husband.

The patient was with her husband

and served as her emotional support
system.

4. EGO INTEGRITY
A. Perception of Self
B. Coping Mechanism

C. Support System

D. Mood/Affect
5. NEURO SENSORY
A. Mental State

B. Conditions of 5 senses
(sight, hearing, smell,
taste, touch)
6. OXYGENATION

The patients mental state prior to admission was The patient appeared weak but was
that of an average person and the condition of
in good mental condition. She was
the 5 senses were intact.
oriented to place and was able to
answer to questions asked.
The condition of 5 senses were all
intact.

A. Vital Signs

Vital signs were not monitored before

admission.
120

Pulse Rate
Heart Rate

120/80

Blood Pressure
B. Lung Sounds

Lung sounds were not assessed prior to

admission.

Lung sounds was not assessed

during the shift.

C. History of Respiratory
Problems

No respiratory problems reported.

The patient has difficulty of

breathing.

Prior to admission the patient experienced

reoccurring abdominal pain aggravated by
ambulation and work. Intensity was moderate.

The patient experienced severe

abdominal pain with a pain score of
9 out of 10.

The patient when in pain takes a rest and did

not use any OTC drugs to alleviate the pain.

The patient is in HBR.

7. PAIN COMFORT
A. Pain (location, onset,
character, intensity,
duration, associated
aggravation)

B. Comfort Measures /
Alleviation
C. Medications

8. HYGIENE AND ACTIVITIES The patient is a house wife and her activities of
OF DAILY LIVING
daily living includes doing the laundry, cooking
and cleaning the house. She takes a bath once
a day.

The patient was in CBR w/o BRP.

Sexuality Reproductive
Pattern
A. Female (Menarche,
Menstrual Cycle, Civil
Status, Number of
Children)
B. Male (Circumcision, Civil
Status, Number of
Children)

The patient is married with a GTPAL of

G=3 P=2 T=2 A=1 L=2. She had a menarche
when she was 13 yo.

The patient is married with a GTPAL

of
G=3 P=2 T=2 A=1 L=2. She had a
menarche when she was 13 yo.

Review of System
Weight: ?
Height: 32
General Condition

Temp: 37.2C
PR: 120 bpm
RR: 32 cpm
BP: 120/80 mmHg
Patient received lying on bed, very weak, with #1 IVF D5LR with 990 cc level left regulated @ 10 gtts/min (KVO) hooked on the left arm. With
urinary catheter attach to Foley bag.
Patient is conscious, oriented to person, date, place and time.
Periorbital on both eyes noted.
Facial grimace noted. Enlarged abdomen noted.
Poor grooming and poor hygiene noted.

Integumentary

Patients skin color is brown and dry. Moist skin folds and no axillary hair noted. Edema noted on both lower extremities. No scar noted.
Head - Hair is fine, black, thin and evenly distributed. No flakes and dirt on the scalp noted.
Patients nail is convex in curvature, light pink in color and capillary refill time is 2 sec. Dirty finger nails noted. Poor skin turgor noted.

HEENT

H - Head is symmetrical. Symmetrical facial movements noted. Periorbital edema noted on both eyes. Head circumference is 52cm.
E - Outer canthus of the eyes is aligned with the ears.
Hairs in the eyebrows are evenly distributed with intact skin. No discharges noted. Pupil dilated and constricted when assessed. Pupil enlarge,
round, rective to light and accommodation (PERRLA). Patient blinked when cornea was touched. No discharges noted.
E - Auricle is aligned with the outer cantus of the eye. Symmetrical, firm and not tender.
Pinna recoils after it was folded. No discharges noted.
N - Hair is fairly distributed to both nares and no discharges noted.
Patient is having mechanical concentrator with 3L/min to consume.
T - Dry and lesions on the lips noted.

Respiratory

Patients RR: 32 cpm which is above the normal range, there is tachypnea.
Patient is having mechanical concentrator with 3L/min to consume.
Difficulty of breathing noted, used of accessory muscles noted during inhalation.

Cardiovascular

Patients PR: 120 bpm which is above the normal range, there is tachycardia.
Peripheral pulses present and palpable assessed on the brachial, radial, ulnar and carotid artery. Pulse strength is 3+. Capillary refill time is 2
seconds.

Gastrointestinal

Patient is under NPO. The patients abdomen enlarge. Abnormal bowel sound heard upon auscultation (7-8 bowel sound per minute).
Tenderness on the abdomen noted upon palpation.
Dry and lesions on the lips noted.

Genitourinary

Patient has urinary catheter attach to Foley bag with 200cc of urine. With pubic hair noted.

Excretory

The patients has urinary catheter attach to foley bag with 200cc of urine characterized with amber color of urine.
Patient was not able to defecate.

Endocrine

Weight of the patient was not able to obtain. Height is 54.

No tenderness or lumps in the neck noted upon palpation.
Moist in skin folds and without axilla hair noted.

Musculoskeletal

Patient was very weak, spine is vertically aligned, no masses and lesion, no deformities, equal size on both sides of the body, no contractures
noted. No tremors noted.
Muscle wasting on both upper extremities noted while edematous on both lower extremities noted .
Flaccidity (decrease muscle tone) noted. Restlessness noted.

Neurological

The patient is in the low level of consciousness, appears very weak, and lethargic.
Mental state is stable, oriented to person, date, place and time, but still patient answer question that were asked.

Reproductive

Patient is 32year old, married.

G3T2P2A1L2.
Pubic hair was fairly distributed and edematous noted. No discharges noted.

ANATOMY AND PHYSIOLOGY

Cardiovascular System
Heart - is the organ that helps supply blood and oxygen to all parts of the body.
Heart Wall
Epicardium - the outer layer of the wall of the heart.
Myocardium - the muscular middle layer of the wall of the heart.
Endocardium - the inner layer of the heart.
4 Chambers of the Heart
Right Atrium
The right atrium receives de-oxygenated blood from the body through the superior vena cava (head and upper body)
and inferior vena cava (legs and lower torso).
Right Ventricle
The right ventricle receives de-oxygenated blood as the right atrium contracts.
Left Atrium
The left atrium receives oxygenated blood from the lungs through the pulmonary vein. As the contraction triggered by
the sinoatrial node progresses through the atria, the blood passes through the mitral valve into the left ventricle.
Left Ventricle
The left ventricle receives oxygenated blood as the left atrium contracts. The blood passes through the mitral valve into the left ventricle. The aortic valve leading into the aorta is closed, allowing the
ventricle to fill with blood. Once the ventricles are full, they contract.
Valves of the Heart
Tricuspid Valve
The tricuspid valve separates the right atrium from the right ventricle. It opens to allow the de-oxygenated blood collected in the right atrium to flow into the right ventricle. It closes as the right
ventricle contracts, preventing blood from returning to the right atrium; thereby, forcing it to exit through the pulmonary valve into the pulmonary artery.

Mitral Value
The mitral valve separates the left atrium from the left ventricle. It opens to allow the oxygenated blood collected in the left atrium to flow into the left ventricle. It closes as the left ventricle contracts,
preventing blood from returning to the left atrium; thereby, forcing it to exit through the aortic valve into the aorta.
Pulmonary Valve
The pulmonary valve separates the right ventricle from the pulmonary artery. As the ventricles contract, it opens to allow the de-oxygenated blood collected in the right ventricle to flow to the lungs. It
closes as the ventricles relax, preventing blood from returning to the heart.
Aortic Valve
The aortic valve separates the left ventricle from the aorta. As the ventricles contract, it opens to allow the oxygenated blood collected in the left ventricle to flow throughout the body. It closes as the
ventricles relax, preventing blood from returning to the heart.
Superior Vena Cava
The superior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the head and upper body feed into the superior vena cava, which empties
into the right atrium of the heart.
Inferior Vena Cava
The inferior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the legs and lower torso feed into the inferior vena cava, which empties into
the right atrium of the heart.

Aorta
The aorta is the largest single blood vessel in the body. It is approximately the diameter of your thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts of the body.
Pulmonary Artery
The pulmonary artery is the vessel transporting de-oxygenated blood from the right ventricle to the lungs. A common misconception is that all arteries carry oxygen-rich blood. It is more appropriate to
classify arteries as vessels carrying blood away from the heart.
Pulmonary Vein

The pulmonary vein is the vessel transporting oxygen-rich blood from the lungs to the left atrium. A common misconception is that all veins carry de-oxygenated blood. It is more appropriate to
classify veins as vessels carrying blood to the heart.
Papillary Muscles
The papillary muscles attach to the lower portion of the interior wall of the ventricles. They connect to the chordae tendineae, which attach to the tricuspid valve in the right ventricle and the mitral
valve in the left ventricle. The contraction of the papillary muscles opens these valves. When the papillary muscles relax, the valves close.
Chordae Tendineae
The chordae tendineae are tendons linking the papillary muscles to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. As the papillary muscles contract and relax, the
chordae tendineae transmit the resulting increase and decrease in tension to the respective valves, causing them to open and close.
Heart Anatomy: Cardiac Cycle
The Cardiac Cycle is the sequence of events that occurs when the heart beats. Below are the two phases of the cardiac cycle:

Diastole Phase - the heart ventricles are relaxed and the heart fills with blood.

Systole Phase - the ventricles contract and pump blood to the arteries.
Peritoneum
The peritoneum is the serous membrane that forms the lining of the abdominal cavity or the .It covers most of the intra-abdominal organs

Layers

The outer layer, called the parietal peritoneum, is attached to the abdominal wall.
The inner layer, the visceral peritoneum, is wrapped around the internal organs that are located inside the intraperitoneal cavity.
The potential space between these two layers is the peritoneal cavity; it is filled with a small amount (about 50 ml) of slippery serous fluid that allows the two layers to slide freely over each
other.
The term mesentery is often used to refer to a double layer of visceral peritoneum. There are often blood vessels, nerves, and other structures between these layers. The space between
these two layers is technically outside of the peritoneal sac, and thus not in the peritoneal cavity.

PATHOPHYSIOLOGY
(Right-sided Heart Failure)
Causes: Stenosis or regurgitation of the tricuspid and pulmonic valves; right ventricular infarction; cardiomyopathy; persistent left sided heart failure; pulmonary embolus; pulmonary
HPN
blood dams back from right
ventricle to the right atrium

increase venous pressure

increase permeability

osmotically active substances

leak into interstitial spaces

S/s: edema;weakness;
wt. gain

decrease Cardiac output

S/s: Jugular vein distention,

increase venous
pressure

hepatic vein distention

causing liver dysfunction

increase pressure in the

portal circulation

Increase pressure forces fluid

into the abdominal cavity

congestion of the GI tract may interfere

with digestion and absorption of
nutrients

decrease
renal
perfusion
Renin- angiotensinAldosterone system is
stimulated

S/s:hepatomegaly;RUQ
pain ;respiratory distress
vasoconstriction
S/s: ascites; increase abdominal
S/s : anorexia;
abdominal
discomfort

Na and fluid
retention; thirst

increase BP,
preload,afterload

vasodilation
and diuresis

ANP release

aldosteron
e release

increase workload

Fluid Volume
excess

MEDICAL MANAGEMENT OF HEART FAILURE

IDEAL
A. Medications
1. Digitalis therapy
Cardiac glycosides such as digoxin (lanoxin), crystodigin (digitoxin) are the
commonly used drugs. A key concern associated with digitalis therapy is digitalis
toxicity. Antidote for digitalis toxicity is Digoxin Immune Fab (Digibind).
2. Diuretic therapy
To promote excretion of edema fluid and help to sustain cardiac output and tissue
perfusion by reducing preload. Of the types of diuretics prescribed for patients with
edema from HF, three are most common: thiazide, loop, and potassium-sparing
diuretics.
3. Vasodilators
To decrease afterload by decreasing resistance ventricular emptying. Most
commonly used drugs are Hydralazine (Apresoline), Captopril (Capoten).
4. Beta adrenergic blockers
Beta-blockers and angiotensin-converting enzyme inhibitors should be used to
control hypertension or protect the heart. Metoprolol (Lopressor, Toprol), or
bisoprolol(Zebeta) are the commonly used drugs.
B. Paracentesis
Removal of fluid (ascites) from the peritoneal
Cavity through a small surgical incision or puncture made through the abdominal wall
under sterile conditions.
C. Oxygen therapy
D. IVF Administration
E. Urinary Catheterization
F. DIET
Sodium restriction (2-3 g/day)
Avoidance of excess fluid intake

Furosemide 40 mg IVT OD
Cefuroxime 250 mg IVT every 8 hrs
D5LR 1L @ KVO
Oxygen inhalation 3L/min
Foley bag catheter inserted
Moderate high back rest
Complete bed rest without bathroom privilege
Low fat, low salt diet
fluid limited to 800cc in 24 hr

G. Activity
Balanced program of activity and rest
ACTUAL
August 17, 2010
Lanoxin 0.25 mg 1 tab OD

SURGICAL MANAGEMENT

Valvuloplasty
- a procedure in which a small balloon is inserted and inflated to stretch and open a narrowed
(stenosed) heart valve.
Valves are doors or gates that are present in the heart. Depending on their location, they can
be aortic, pulmonary, mitral, and tricuspid valves. These valves control the flow of blood to and
from the heart. When these valves become narrow (stenosis) due to hardening and calcium
deposits =Valvuloplasty performed.
Indications of Valvuloplasty
Mitral valve stenosis
Pulmonary valve stenosis
Older or debilitated patients with aortic stenosis
Children with congenital aortic stenosis.
Complications:
bleeding at the catheter insertion site
blood clot or damage to the blood vessel at the insertion site
infection at the catheter insertion site
cardiac dysrhythmias/arrhythmias (abnormal heart rhythms)
embolism
Responsibilities:
Ensure that there is a sign consent. (that gives permission to do the procedure).
Assess if patient is allergic or sensitive to medications, contrast dyes, iodine, shellfish
or latex.
If the mother is pregnant, notify immediately the physician. Because radiation
exposure may lead to birth defects.
Ensure patient is NPO for atleast 6 hours.
Assess patient if he/she has history of bleeding disorders or if patient is taking any
anticoagulant medications, aspirin, or any medications that can affect blood clotting. (it
is necessary for you to stop some of the medications prior to procedure.
Empty patients bladder before the procedure.
An IV line will be started prior to procedure. (for any injection of mediactions).

Commissurotomy
- is a special form of valvuloplasty.
- used when the leaflets of the valve become stiff and actually fuse together at the
base.
Fused leaflets commissures
2 Types of Commissurotomy
1.Closed Commissurotomy
-the valve is not directly visualized.
-do not require cardiopulmonary bypass.
-the surgeons finger or a dilator is used to break open the commissure.
-a midsternal incision is made.
2. Open Commissurotomy
-are performed with direct visualization of the valve.
-Cardiopulmonary bypass is initiated.
-Median sternotomy or left thoracic incision is made.
-A finger, scalpel, balloon, or dilator may be used to open the commissures.
Annuloplasty
is a technique aimed at repairing the fibrous tissue at the base of the heart valves (the
annulus).
-

Annuloplasty ring
A ring is used to correct a problem andprovide support for the valve,

VALVE REPLACEMENT
General anesthesia and cardiopulmonary bypass are used for all valve replacements

median sternotomy is performed

leaflets and other valve structures such as the chordae and papillary muscles, are
removed

Sutures are placed around the annulus and then into the valve prosthesis

Postoperative complications:
-bleeding
-thromboembolism
- Infection
-congestive
-heart failure
- hypertension
-dysrhythmias
-hemolysis
-mechanical obstruction of the valve
Types of Valve Prostheses:
MECHANICAL VALVES
Indicated:
Renal failure, hypercalcemia, endocarditis, or sepsis and requires valve replacement
Complication:
Thromboemboli
TISSUE OR BIOLOGIC VALVES
a.) Xenografts are tissue valves (eg, bioprostheses, heterografts);
most are from pigs (porcine)
b.) Homografts, or allografts (ie, human valves), areobtained from cadaver tissue donations
c.) Autografts (ie, autologous valves) are obtained by
excising the patients own pulmonic valve and a portion of the
pulmonary artery for use as the aortic valve
Heart Transplantation
Indications :

Cardiomyopathy
Ischemic heart disease
Valvular disease
Rejection of previously transplanted hearts, and congenital heart disease

TYPES:
A.) Orthotopic transplantation
-most common surgical procedure for cardiac transplantation

-The recipients heart is removed, and the donor heart is implanted at the vena cava and
pulmonary veins.
B.) Heterotopic transplantation
-less commonly performed
-donor heart is placed to the right and slightly anterior to the recipients heart; the
recipients heart is not removed
CORONARY BYPASS GRAFTING

Surgery creates new routes around narrowed and blocked arteries, allowing sufficient
blood flow to deliver oxygen and nutrients to the heart muscle

Saphenous vein from the leg - most commonly used vessel

Cardiac catheterization with angiography (coronary arteriography) is the most accurate

test to detect coronary artery narrowing.
CORONARY BYPASS GRAFTING
Procedure:
-Surgeon makes an incision down the middle of the chest and then saws through the
breastbone (sternum)
-Heart is cooled with iced salt water, while a preservative solution is injected into the heart
arteries.
-Plastic tubes are placed in the right atrium to channel venous blood out of the body for
passage through a plastic sheeting (membrane oxygenator) in the heart lung machine
CORONARY BYPASS GRAFTING
-The main aorta is clamped off (cross clamped) during CABG surgery to maintain a bloodless
field and to allow bypasses to be connected to the aorta.
-At the end of surgery, the sternum is wired together with stainless steel and the chest incision
is sewn closed
-Plastic tubes (chest tubes) are left in place

NURSING MANAGEMENT
IDEAL
Providing Oxygenation

administer oxygen therapy per nasal cannula at 2-6L/min as ordered

evaluate arterial blood gas analysis results

maintain semi-fowlers or high fowlers position to maximize oxygenation by promoting

greater lung expansion
Promoting Rest and Activity

bed rest or limited activity may be necessary during the acute phase

provide an overbed table close to the patient to allow resting the head and arms

the arms may be supported on pillows to reduce the pull on the shoulder musle

administer Diazepam (Valium) 2-10mg. 3 to 4 times a day as ordered

gradual ambulation is encouraged

activities should progress through dangling, sitting up in chair and then walking in
increased distances

assess for signs of activity intolerance

Decreasing Anxiety

identifying feelings and concerns related to these feelings

identify strengths that can be used for coping

learn what can be done to decrease anxiety

Facilitating Fluid Balance

control sodium intake

administer diuretics and digitalis as prescribed

monitor input and output and vital signs

frequent small feedings, minimize exertion and reduce gastrointesitinal blood

requirements

restrict sodium intake

Promoting Elimination

advise the clients to avoid straining at defecation which involves valsalva maneuver

administer laxative as ordered

encourage use of bedside commode

Facilitating Learning

teach the client and his family about the disorder and self care

monitor s/s of recurring CHF

avoid fatigue, balance rest with activity

observe prescribed sodium restriction

eat small, frequent meals rather than 3 large meals a day

take prescribed medications at regular basis

observed ollow-up care as directed

If pulmonary edema occurs in the client

place in high-fowlers position, with legs slightly lowered to facilitate breathing and to
reduce preload

morphine sulfate 10 15 mg/IV As ordered

oxygen therapy at 40% to 70% by nasal cannula or face mask

Aminophylline / IV as ordered

Diuretic therapy

Vasodilators

Monitor serum potassium

ACTUAL

Providing Skin Care

edematous skin is poorly nourished and susceptible to pressure sores

change position at frequent intervals

assess the sacral area regularly

use protective devices to prevent pressure sores

Promoting Nutrition

provide bland, low-calorie, low-residue with vitamin supplement during the acute
phase

HBR

monitor input and output every shift

monitor vital signs every shift

regulated IVF at prescribed rate

bedside care

insertion of urinary catheter with UB

with oxygen via nasal cannula as ordered

fluid restriction to 800cc for 24 hours

procedure) regarding monitoring for bleeding or excess drainage

from puncture site, avoiding heavy lifting or straining, changing
position slowly, and monitoring for fever.
Assisting with a Paracentesis
Preprocedure
1. Prepare the patient by providing the necessary information and
instructions about the procedure and by offering reassurance.
2. Instruct the patient to void.
3. Gather appropriate sterile equipment and collection receptacles.
4. Place patient in upright position on edge of bed with feet supported
on stool, or place in chair. Fowlers position should be
used for the patient confined to bed.
5. Place sphygmomanometer cuff around patients arm to allow
monitoring of blood pressure during the procedure.
Procedure
1. The physician, using aseptic technique, inserts the trocar through a
puncture wound below the umbilicus. The fluid drains from the
abdomen through a drainage tube into a container.
2. Help the patient maintain position throughout procedure.
3. Measure and record blood pressure at frequent intervals from the
beginning of the procedure.
4. Monitor the patient closely for signs of vascular collapse: pallor,
increased pulse rate, or decreased blood pressure.
Postprocedure
1. Return patient to bed or to a comfortable sitting position.
2. Measure, describe, and record the fluid collected.
3. Label samples of fluid and send to laboratory.
4. Continue to monitor vital signs every 15 minutes for 1 hour,
every 30 minutes over 2 hours, then every hour over 2 hours and
then every 4 hours. Monitor temperature after procedure and
every 4 hours.
5. Assess for hypovolemia, electrolyte loss, changes in mental status,
and encephalopathy.
6. Check puncture site when taking vital signs for bleeding and
leakage.
7. Provide patient education (especially if patient is discharged after

DIAGNOSTIC TESTS
CHEST X-RAY = obtain to determine the size, contour and position of the heart
ELECTROCARDIOGRAM = recording of the electrical activity of the heart. Lead 12 is the most commonly used to diagnose dysrhythmias, conduction abnormalities, enlarged heart chambers,
myocardial ischemia or infarction, high or low calcium and potassium level.
COMPLETE BLOOD COUNT = indentifies the total number of white blood, red blood cell, platelet count, hemoglobin and hematocrit.
TEST

INCREASE

5,000-10,000/cumm

Infection, inflammation, leukemia, parasitic infestation

WHITE BLOOD CELL

RED BLOOD CELL

Polycythemia vera, dehydration, COPD

DECREASE
Bone marrow depression, tissue damage, viral infection,
autoimmune diseases, malignancies, malnutrition, alcoholism,
severe infection
Anemias, hemodilution

4.25.4 million/cumm
PLATELET COUNT

Polycythemia vera, splenectomy, fractures, metastatic cancer

Polycythemia, chronic lung disease

Anemias, bone marrow

depression, DIC, ecclampsia,
hepatitis,
Anemia

Polycythemia, dehydration

Anemia, hemodilution, leukemia

150,000450,000/cumm
HEMOGLOBIN
1216 g/dL
HEMATOCRIT
3646%

ECHOCARDIOGRAPHY = noninvasive ultrasound test that is used to examine the size, shape and motion of cardiac structures. It is a particularly useful tool for diagnosing pericardial effusions,
determining the etiology of heart murmurs, evaluating the function of prosthetic heart valves, determining chamber size, and evaluating ventricular wall motion.
POSITRON EMISSION TOMOGRAPHY = used to diagnose cardiac dysfunction. PET provides more specific information about myocardial perfusion and viability than does or thallium scanning.
CARDIAC CATHETERIZATION = is an invasive diagnostic procedure in which radiopaque arterial and venous catheters are introduced into selected blood vessels of the right and left sides of the
heart. It is also used to measures the pressure and oxygen saturation in the four (4) chambers of the heart.

SUMMARY OF INTRAVENOUS FLUID

DATE AND TIME STARTED

INTRAVENOUS FLUID

DROP RATE

HOURS TO RUN

DATE AND TIME CONSUMED

August 17, 2010 @7:50 pm

Generic and Brand

Name,
Classification

Recommended
and Prescribed
dosage, Route of
Administration

D5W

Mechanism of Action

10 gtts/min (KVO)

Indication

Contraindication

25 hours

Adverse Reactions

August 18, 2010 @ 8:50 pm

The IV fluid was not able to consume
because the patient died.

Nursing Responsibilities

G: Cefuroxime

Interferes with
bacterial cell wall
synthesis by inhibiting
the final step in the
cross-linking of
peptidoglycan strands.
Peptidoglycan makes
the cell membrane
rigid and protective.
Without it, bacterial
cells rupture and die.

B: Ceftin
C: Antibiotic (2nd
generation
cephalosporins)

Generic and Brand

Name,
Classification

Recommended and
Prescribed dosage,
Route of
Administration

Mechanism of Action

>pharyngitis and tonsillitis

>acute otitis media
>impetigo
>sinusitis
>uncomplicated UTI
>bacterial meningitis

Indication

>hypersensitivity to
cephalosporins and
their components.

Contraindication

>chills,fever,headache,s
eizure
>hearing loss, oral
candidiasis
>abdominal
cramps,diarrhea,hepato
megaly,nausea and
vomiting
>elevated BUN level,
nephrotoxicity, renal
failure
>eosinophilia,hemolytic
anemia,neutropenia,thr
ombocytopenia,unusual
bleding
>arthralgia
>dyspnea
>ecchymosis,erythema,
pruritus, rash, StevensJohnson syndrome
>injection site
edema,pain and
redness

>obtain C and S test and results,

before giving the drug
>administer IV injection over 3 to5
minutes
>monitor IV site for extravasation &
phlebitis
>monitor px for allergic reactions
>asses bowel pattern daily
>asses sign of blood dyscrasia such
as pharyngitis, eccymhosis,bleeding
and arthralgia
>monitor PT and bleeding time, as
ordered
>encourage px to take drugs with
meals or after meals
>instruct px to immediately report to
prescriber severe diarrhea

Adverse Reactions

Nursing Responsibilities

G: Furosemide
B: Lasix
C: Loop diuretic,
anti-hypertensive

Inhibits sodium and

water reabsorption in
the Loop of Henle and
increases urine
formation. As the bodys
plasma volume
decreases,aldosterone
production increases,
which promotes sodium
reabsorption and the
loss of potassium and
hydrogen ions. This
also increases the
excretion of calcium,
magnesium,
bicarbonate,
ammonium, and
phosphate. By reducing
intracellular and
extracellular fluid
volume, the drug
reduces BP and
decreases cardiac
output. Overtime,
cardiac output returns to
normal.

>reduce edema
>hypersensitivity to
>manage mild to moderate
furosemide, sulfonamide
HPN, as adjunct to treat
or their components.
acute pulmonary edema and
hypertensive crisis

DRUG STUDY

>dizziness,fever,headache,p
aresthesia, restlessness,
vertigo,weakness
>orthostatic HPN, shock,
thromboembolism
>blurred vision,
ototoxicity,stomatitis,tinnitus
>hyperglycemia
>abdominal cramps,
anorexia, constipation,
diarrhea, indigestion,
nausea & vomiting
>bladder spasms, glycosuria
>agranulocytosis,
anemia,azotemia, hemolytic
anemia, leuopenia,
thrombocytopenia
>muscle spasms
>erythema mutiforme,
exfoliative dermatitits.
jaundice, photosensitivity,
pruritus, purpura, rash,
urticaria

>cautious to pxs with hepatic

cirrhosis
>obtain weight before and
periodically during therapy to
monitor fluid loss
>administer drug slowly IV over
1 to 2 minutes to prevent
ototoxicity
>monitor BP and hepatic and
renal function as well as BUN
>expect to discontinue
furosemide at maximum dosage
if oliguria persists for more than
24 hours
>encourage px to notify
prescriber if adverse reactions
occur such as hearing loss,
vertigo, or ringing, buzzing or
sense of fullness in ears
>encourage px to take drugs
with meals or after meals
>emphasize the importance of
weight and diet control,
especially limiting sodium intake
>instruct px to take drug at the
same time each day to maintain
therapeutic effects.

GENERIC NAME
BRAND NAME
CLASSIFICATION

PRESCRIBED,
RECOMMENDED
DOSAGE, FREQUENCY AND
ROUTE OF ADMINISTRATION

Digoxin (di-jox-in)

Prescribed: 0.25 mg O.D. tab

Lanoxin

Recommended:
0.125-0.25 mg; tab

Classification:
Therapeutic:
antiarrhythmics,
inotropics
Pharmacologic:
digitalis glycosides

MECHANISM OF
ACTION

INDICATION

CONTRAINDICATION

ADVERSE REACTION

NURSING
RESPONSIBILITIES

Increases the force

ofmyocardial
contraction.
Prolongs refractory
period of the AV
node. Decreases
conduction through
the SA and AV
nodes.

Treatment of CHF.
Tachyarrhythmias:
Atrial fi brillation
and atrial flutter
(slows ventricular
rate), Paroxysmal
atrial tachycardia.

Hypersensitivity;
Uncontrolled ventricular
arrhythmias; AV block;
Idiopathic
hypertrophic subaortic
stenosis; Constrictive
pericarditis; Known
alcohol intolerance
(TOPICAL/LOCAL).
(elixir only).

CNS: fatigue, headache,

weakness. EENT: blurred
vision, yellow or green vision.
CV: AR RHYTHMIAS,
bradycardia, ECG changes,
A-V block, S-A block. GI:
anorexia, nausea, vomiting,
diarrhea. Endo:
gynecomastia. Hemat:
thrombocytopenia.Metab:
electrolyte imbalances with
dioxin toxicity.

Monitor blood pressure

periodically in patients
receiving IV digoxin.
Observe IV site for
redness or infiltration;
extravasation can lead to
tissue irritation and
sloughing.
Monitor intake and output
ratios and daily weights.
Assess for peripheral
edema, and auscultate
lungs for rales/crackles
throughout therapy.
Before administering initial
loading dose, determine
whether patient has taken
any digitalis preparations
in the preceding 23 wk.

Therapeutic Effects:
Increased cardiac
output (positive
inotropic effect) and
slowing of the
heart rate (negative
chronotropic effect).

NURSING CARE PLAN

CUES
S:
Dii jud makalakaw akung
asawa, as verbalized by the
husband.
O:
At 9:00 pm, received px lying
on bed, weak and with O2
inhalation via nasal cannula
regulated at 3 L/min with
newly hooked D5LR 1L at
KVO, hooked on the left arm,
infusing well.
>afebrile
>body malaise noted
>difficulty of turning noted
>edema at lower extremities
noted
>difficulty of breathing noted
> abdominal pain with pain
score of 9 in a scale of 0-10
( 0-no pain,10-excruciating
pain)
>muscle wasting on both arms
noted
>abdominal enlargement
noted
>protrusion on umbilical area
noted
>scaly skin at lower
extremities noted
>excessive sweating noted
>V/S
T 37.2 degree Celcius
P 120 bpm
R 32 cpm
BP 120/80 mmHg

NURSING DIAGNOSIS
Activity Intolerance r/t
imbalance between oxygen
supply and demand.

OBJECTIVES
Within my 8 of duty, px will be
able to identified technique to
enhance activity tolerance.

INTERVENTIONS
>monitor V/S every 4 hours.

RATIONALE
>to establish baseline data

>regulate IVF at KVO.

> to prevent cardiac overload.

>note presence of factors

>fatigue affects both the px

contributing to fatigue ( acute

actual and perceived ability to

or chronic illness, heart failure)

participate in activities.

> Alter or modify patients

activities.

>to prevent overexertion

>plan care to carefully balance

rest period with activity

>to reduce fatigue

>increase exercise/ activity

levels gradually
>assist px in activities such as

>to conserve energy

self-care or when turning.

>promote comfort measure

>to protect px from injury.

and provide relief for pain

> plan for maximal activity

>to enhance ability to

within the pxs ability.

participate in activities
>to promote the idea of need

>encourage px to maintain

for progressive activity.

positive attitude and suggest

use of relaxation technique.

>to enhance sense of wellbeing.

NURSING CARE PLAN

EVALUATION
After 8 of duty, patient was
able to identified technique to
enhance activity tolerance
such as balance rest period
with activity and
maintain positive attitude.

CUES
S:
Nanghupong ang duha ka tiil
sa akong asawa , as
verbalized by the husband.
O:
At 9:00 pm, received px lying
on bed, weak and with O2
inhalation via nasal cannula
regulated at 3 L/min with
newly hooked D5LR 1L at
KVO, hooked on the left arm,
infusing well.
>afebrile
>edema at lower extremities
noted
>body malaise noted
> abdominal pain with pain
score of 9 in a scale of 0-10
( 0-no pain,10-excruciating
pain)
>muscle wasting on both arms
noted
>abdominal enlargement
noted
>protrusion on umbilical area
noted
>poor skin turgor noted
>scaly skin at lower
extremities noted
>capillary refill time 2 seconds
noted
>V/S
T 37.2 degree Celcius
P 120 bpm
R 32 cpm
BP 120/80 mmHg

NURSING DIAGNOSIS
Excess Fluid Volume related
to sodium and water retention

OBJECTIVES

INTERVENTIONS
>monitor v/s every 4
Within my 8 of duty, the px will > regulate IVF @ KVO.
be able to verbalize
>measure abdominal girth of
understanding of individual
the px.
dietary/fluid restriction.
>asses neuromuscular
reflexes
>record intake and output
accurately.
>weight px daily on a regular
schedule.
>restrict fluid and sodium
intake as indicated.
>elevate edematous
extremities of the px, change
position frequently.
>place px in semi-fowlers
position.
> Caution px/SO to avoid
added salt in food and foods
with high sodium content.
>suggest intervention such as
frequent oral care or use of lip
balm.
>stress need for mobility
and/or frequent position
changes.

RATIONALE
>to establish baseline data
> to prevent cardiac overload.
>to monitor changes that may
indicate increasing fluid
retention or edema.
>to evaluate for presence of
electrolyte imbalances such as
hypernatremia.
>to monitor lose large volume
of fluid after a single dose of
diuretic when used.
> to determine the
effectiveness of diuretic
therapy.
> to prevent further edema.
>to reduce tissue pressure
and risk of skin breakdown.
>to facilitate movement of
diaphragm thus improving
respiratory effort.
>to avoid or control edema.
>to reduce discomfort of fluid
restriction.
>prevent stasis and reduce
risk of tissue injury.

EVALUATION
After my 8 of duty, SO was
able to verbalize
understanding of individual
dietary/fluid restriction such as
eating low sodium food and
limiting fluid intake.

CUES
S:
Maglisud jud siyag ginhawa, as
verbalized by the husband.
O:
At 9:00 pm, received px lying on
bed, weak and with O2 inhalation
via nasal cannula regulated at 3
L/min with newly hooked D5LR 1L
at KVO, hooked on the left arm,
infusing well.
>afebrile
>difficulty of breathing noted
>restlessness noted
>tachycardia noted
>abdominal enlargement noted
>protrusion on umbilical area noted
>body malaise noted
>difficulty of turning noted
>edema at lower extremities noted
> abdominal pain with pain score of
9 in a scale of 0-10 ( 0-no pain,10excruciating pain)
>muscle wasting on both arms
noted
>poor skin turgor noted
>capillary refill time 2 seconds
noted
>scaly skin at lower extremities
noted
>V/S
T 37.2 degree Celcius
P 120 bpm
R 32 cpm
BP 120/80 mmHg

NURSING DIAGNOSIS
Decreased Cardiac
Output related to
impaired contractility and
increased preload and
afterload.

NURSING CARE PLAN

OBJECTIVES
INTERVENTIONS
>monitor v/s every 4
Within my 8 of duty, the px will >regulate IVF @ KVO.
be able maintain cardiac
>evaluate client report of
output.
extreme fatigue, intolerance of
activity, sudden or progressive
weight gain, swelling of
extremities and progressive
shortness of breath.
>assess urine output hourly or
periodically, noting total fluid
balance.
> Place patient at physical and
emotional rest.
>keep client on bed/position
px in semi-fowlers position
>administer high-flow oxygen
via oxygen mask or cannula
>schedule activities and
assessments.
>decrease environmental
stimuli.
>encourages client to breath
in/out during activities that
increase risk for valsalva
effect.
>administer analgesics as
prescribed.

DISCHARGE PLAN

RATIONALE
>to establish baseline data
>to prevent cardiac overload.
>to assess for signs of poor
ventricular function and/or
impending cardiac failure.

>to allow for timely alterations

in therapeutic regimen.
> to the reduce work of heart.
>decreases oxygen
consumption and risk of
decomposition.
>to increase oxygen available
for cardiac function/tissue
perfusion.
>to maximize sleep periods.
>to promote adequate rest.
>to prevent changes in cardiac
pressures and/or impede
blood flow.
>to promote comfort or rest

EVALUATION
After my 8 of duty, the px was
able to maintain cardiac output
such as decreased episodes
of dyspnea and demonstrate
an increase in activity
intolerance.

Patients name:
Condition upon discharge:

Date of discharge:
Nature: Home per request () Discharged against medical advice ()

I.MEDICATIONS
Instruct the patient to take medications at prescribed dosage.
Instruct the patient to keep medications in room temperature to ensure effectiveness.
Instruct the patient to be familiar with the medications and make a list of medication to be taken.
II.EXERCISE
Instruct the patient to change position every two hours to prevent complications associated with immobility such ass pressure ulcer.
Teach the S.O. how to provide passive ROM exercise.
Give the benefits of exercise such as promoting blood circulation.
III.DIET
Instruct the patient to avoid fatty and salty foods.
Instruct the patient to limit fluid intake.
Instruct the patient to avoid alcohol intake.
IV.HEALTH TEACHING
Instruct the patient to change position every two hours to prevent complications associated with immobility such as pressure ulcer.
Educate the patient and the S.O. about the management if there is edema such as limiting fluid intake and dangling the feet to promote venous return .
Instruct the patient to weigh self daily.
V.SCHEDULE FOR NEXT VISIT
Instruct the patient to see the doctor immediately if symptoms such as generalized edema and difficulty of breathing occurs.
Visit the physician on the arrange date for follow up medication taken is taking actions.
Visit the physician for the next visit as order.