College of Nursing

CONGESTIVE HEART FAILURE

Presented to:
Ms. Alyssa Ashley Malag

Presented by:
Elegado, Joana D. Estoque, Jhomar A. Guzman, Charlayne Joyce G.

PATIENT ASSESSMENT DATA BASE A. GENERAL DATA

Patients Name: MMM Address: Philippines Age: 49 y/o Sex: Male Birth Date: April 4, 1962 Rank in the family: Father Nationality: Filipino Civil Status: Married Date of Admission: December 12, 2011 Order of admission: Transfer to medical ward, TPR every shift, DIAGNOSTICS: FBS, BUN, Creatinine, THERAPEUTICS: monitor V/S every shift and IFC Attending physician: Dr. Leal

B. C.

CHIEF COMPLAINT
Mr. M complaints of difficulty of breathing.

HISTORY OF PRESENT ILLNESS

Present condition started 2 months prior to admission wherein patient noticed swelling of the feet accompanied by difficulty of breathing. No consult was done. No medications taken. One month prior to admission, difficulty of breathing persisted. Also, there was worsening of the swelling of the lower extremity from the feet to above the knee. No consult was done. No medications taken. Two weeks prior to admission, patient now had generalized edema accompanied by difficulty of breathing and oliguria. Still no consult was done. No medication taken. Worsening of difficulty of breathing prompted patient to seek/consult in this institution and was subsequently admitted.

D.

PAST HEALTH HISTORY/STATUS

During his childhood, the most common illnesses that he encountered were fever, cough and colds. He completed all his immunizations. He claimed to be hospitalized 3 years ago with diagnosis of Rheumatic heart disease and hypertension. Maintenance medications were given rarely, Aspirin, Captopril, and Digoxin but poor compliance and he was lost to follow up. Moreover, he has known allergies to any inhalants, injectants, and ingestants.

E.

FAMILY ASSESSMENT
NAME RELATION AGE SEX OCCUPATION EDUCATIONAL ATTAINMENT Elementary Undergraduate High school Graduate

MMM

Patient

49

Construction Worker

JM

Son

19

F. SYSTEMS REVIEW 1.) HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN

Clients Perception of Health: Patient perceives health as Naragsak ti ritnak nu malusog ak. Clients Perception about Illness: In contrast to health, she perceives illness as Narigat ti biyag nu adda ti sakit. Health Maintenance and Habits: In maintaining his health, he eats green leafy vegetables and fruits and walking every morning serves as his exercise. Compliance with prescribed medications and treatment: He actively participates/cooperates with his treatment and takes medication on time. 2.) NUTRITIONAL METABOLIC PATTERN: The smell and appearance of the food can trigger the clients appetite. His usual diet is high in carbohydrates, protein. He eats 3 times a day with 3-4 cups of rice. He drinks 1L of water per day and he consumes 1 glass of juice per day. 3.) ELIMINATION PATTERN During his hospitalization, the patient defecates once a day. His stool is usually brown and foul-smelling with formed consistency and he does not use any laxative. He has intact Intra Folley catheter. 4.) ACTIVITY- EXERCISE PATTERN- Self care ability 0 - Feeding II - Dressing 0 - Bathing 0 - Bed mobility II - Grooming II - Toileting II - Home maintenance II - Cooking _____others

Legend: 0- Full Care I- Requires use of assistance II- Requires assistance and supervisions by others III- Requires assistance or supervisions from another and equipment and devices IV Dependent, doesnt participate 5.) COGNITIVE PERCEPTUAL PATTERN The patient does not have any abnormalities in hearing and doesnt use eyeglasses when reading. He has normal sensory perception. He stated that he has difficulty in learning. 6.) SLEEP- REST PATTERN During his hospitalization, he doesnt experience any sleeping problems. Usually, he sleeps 10 hours per day: 7 hours at night and 3 hours of nap during the day. He only closes his eyes until he falls asleep. 7.) SELF- PERCEPTION AND SELF- CONCEPT PATTERN The patient feels disappointed and at the same time worried because he doesnt know where to get money for his hospitalization. In describing his health he stated, Haan unay naragsak ta hanak nga napigsa. He also stated that hes strength and weakness is his children.

8.) ROLE- RELATIONSHIP PATTERN

He has great relationship with his children and significant others. Even if sometimes he received financial support from his children, he believes that he could also work because he doesnt want to become a burden to his family.

9.) COPING- STRESS TOLERANCE PATTERN

The patient perceives stress and problems in life as parigat ti pinagbiyag. Whenever he has problem, he goes to the canteen and drinks alcohol.

10.) VALUE- BELIEF PATTERN He is a Roman Catholic and he believes having faith in God will help us surpass all the trials or problems in life. G. HEREDO- FAMILIAL ILLNESS
Maternal side: Hypertension Paternal side: No known illness

II. PERSONAL/SOCIAL HISTORY A. Habits: a. Caffeine: 1 cup of coffee. b. Smoking: The patient doesnt smoke. c. Alcohol: He drinks 1 bottle of beer if he desires. d. Tea: He doesnt drink tea. e. Drugs: He doesnt take prohibited drugs. B. Lifestyle: If he has no work, he goes to the canteen and drinks alcohol. C. Social Affiliation: The patient is actively participating activities in the community. D. Rank in the family: He is a fathe of 3 children. E. Travel (within 6 months): The patient didnt travel to far places prior to admission. F. Educational Attainment: Elementary UnderGraduate.

VIII. LABOLATORY Type of Examination: BLOOD CHEMISTRY

RESULT

NORMAL VALUE

SIGNIFICANCE

BUN Creatinine

21.67 mg/dL 247.52 umol/L

8-22mg/dL 53-106 umol/L

Normal Marked damage to functioning nephrons

RESULT

NORMAL VALUE

SIGNIFICANCE

Fasting Blood Sugar RBS Cholesterol Triglyceride HDL LDL

5.41 mmol/L 7.43 4.07 mmol/L 0.66 62 83.96mg/dL

3.9-6.1 mmol/L

Normal

4-6.5mmol/L 0.08-0.2g/L >40mg/dL <180mg/dL

Normal A sign of metabolic syndrome. Normal Normal

IX. DRUG STUDY Generic Name: Atorvastatin Brand Name: Lipitor Dosage: 10mg/tab , OD Drug Classification: HMG CoA reductase inhibitors, or "statins." Indication: Adjunct to diet to treat elevated serum triglyceride levels

Mechanism of Action Reduces blood levels of triglycerides a nd slightly increases levels of HDLcholesterol.

Side Effects Weakness Dizziness Abdominal pain Constipation

Contraindication Contraindicated in patients hypertensive to the drug and in those with active liver disease or conditions linked with unexplained persistent increases in transaminase levels

Adverse Effect Peripheral edema UTI Myalgia bronchitis

Nursing Consideration Administer drug without regard to food, but at same time each day. Ensure that patient has tried cholesterollowering diet regimen for 36 mo before beginning therapy.

Generic Name: Furosemide Brand Name:Lasix Dosage: 40mg/IVP, every 6 hours Drug Classification: Loop Diuretic Indication: Indicated in adults and pediatric patients for the treatment of edema associated with congestive heart failure, cirrhosis of the liver, and renal disease

Mechanism of Action Enhances excretion of sodium, chloride, potassium by direct action at ascending limb of loop of Henle and produces a diuretic effect.

Side Effects
Diarrhea Constipation stomach pain

Contraindication Lasix (furosemide) is contraindicated in patients with anuria and in patients with a history of hypersensitivity to furosemide.

Adverse Effect dry mouth thirst nausea vomiting hearing loss

Nursing Consideration Before using this medication, tell your doctor if you have kidney disease, liver disease, gout, lupus, diabetes, or an allergy to sulfa drugs. Blood will need to be tested on a regular basis.

headache dizziness

Generic name: Enalapril Maleat Brand name: Vasotec Dosage: 20mg/tab, OD Drug classification: Angiotensin converting enzyme inhibitor Indication: Indicated for the treatment of hypertension

Mechanism of action Angiotensinconverting enzyme inhibitors reduce the activity of the reninangiotensinaldosterone system.

Side effect Dizziness Headache Vertigo Cough

Contraindications contraindicated in patients who are hypersensitive to this product and in patients with a history of angioedema relate d to previous treatment with an angiotensin converting enzyme inhibitor and in patients with hereditary or idiopathic angioed ema

Adverse effect Pneumonia Bronchitis UTI Angina pectoris

Nursing considerations Enalapril can be taken with or without food. Blood pressure will need to be checked on a regular basis. Store enalapril at room temperature away from moisture and heat.