Heartbreaker Age: 52 years old Ward: Andrew Hall 1
Chief Complaint: abdominal pain Diagnosis: Aortic Stenosis, Cardiomegaly, CHF , Ac!te "idney n#!ry secondary to sc$emic %ep$ropat$y wit$ Complicated &' Cues Diagnosis Rationale Objectives Nursing Intervention Rationale Evaluation Subjective (%amamanas an akon mga tiil), as *erbali+ed by t$e patient. (,agan naabat ako $in b!gat ngan t!bigon tak tiyan) as *erbali+ed by t$e patient. Objective -ascites: present abdominal girt$./0) 1pre$ospitali+ation. (2 -bipedal edema 32 -weig$t gain 4rom 50kgs. 'o 52 kgs. -blood press!re. 1/0670nnHg 1n .120680mmHg2 -#!g!lar *ein distention o4 5cm -Hg.115g69 1n.1/0- 175g692 -Ht.0.:5 1n.0./2- 0.502 - Hypokalemia . :.28mmol 1%.:.5-5.: mmol692 -proteins.3333 -creatinine .15/.25 !mol69 1normal.71- 115!mol692 -,&%6; .17.08 ;<cess 4l!id *ol!me related to red!ced glomer!lar 4iltration rate as e*idenced by ascites and bipedal edema. ;<cess 4l!id *ol!me is de4ined as increased isotonic 4l!id retention. %!rsing =iagnosis Handbook: A g!ided to planning care 7 t$
ed. ,y Ackley > 9adwig p. 5/0 4 t$e $eart becomes se*erely damaged, no amo!nt o4 compensation, eit$er by sympat$etic ner*o!s re4le< or by 4l!id retention, can make t$e e<cessi*ely weakened $eart p!mp a normal cardiac o!tp!t. As a conse?!ence, t$e cardiac o!tp!t cannot rise $ig$ eno!g$ to make t$e kidneys e<crete normal ?!antities o4 4l!id. '$ere4ore, 4l!id contin!es to be retained, t$e person de*elops more and more edema. Short !erm "oal A4ter 5 $o!rs o4 n!rsing inter*ention, client will demonstrate !nderstanding o4 related 4actors as mani4ested by: @erbali+e !nderstanding o4 dietary and 4l!id restrictions. =emonstrat e be$a*iors to monitor 4l!id stat!s.
#ong !erm "oal
A4ter 1 week o4 n!rsing inter*ention, client will demonstrate stabili+ed 4l!id *ol!me as e*idenced by: =emonstrat e balanced >A. Absence6de crease o4 edema. =emonstrat e stable lab res!lts. Independent Monitor !rine o!tp!t, noting amo!nt, color and time o4 day di!resis occ!rs Maintain c$air or bed rest in semi-FowlerBs position d!ring ac!te p$ase ;stablis$ 4l!id intake sc$ed!le i4 restrictedC incorporate be*erage pre4erences i4 possible. Di*e 4re?!ent mo!t$ care6ice c$ips as part o4 4l!id allotment Eeig$ed daily at same time o4 day, on same scale, wit$ same e?!ipment and clot$ing. Assess skin t!rgor. &rine o!tp!t may be scanty and concentrated 1d!ring t$e day2 w$ic$ res!lted 4rom red!ced renal per4!sion. &rine o!tp!t may be increased at nig$t6d!ring bed rest beca!se o4 rec!mbent position. Fec!mbent position increases DFF and decreases prod!ction o4 A=H w$ic$ en$ances di!resisC impro*es respiratory e44ort n*ol*ing patient in t$erapy regimen may en$ance sense o4 control and cooperation wit$ restrictions. Fed!ce discom4ort o4 4l!id restrictions. =aily body weig$t is best monitor o4 4l!id stat!s. A weig$t gain o4 more t$an 0.5 kg6day s!ggests 4l!id retention. Skin t!rgor re4lects ade?!ate $ydration "oals full$ met A4ter 5 $o!rs o4 n!rsing inter*ention, client demonstrated !nderstanding o4 related 4actors as mani4ested by: 4ollowing dietary and 4l!id restrictions ca!tio!sly monitored 4l!id intake and o!tp!t metic!lo!sly "oals partiall$ met A4ter : days o4 n!rsing inter*ention, client GatientBs edema decreased to grade 1. %o increase o4 abdominal girt$ noted. demonstrated stable lab res!lts mmol69 1n.2.5-8.: mmol692 - Additional =iagnosis: Ac!te kidney in#!ry secondary to isc$emic nep$ropat$y secondary to CHF, complicated &' - Final diagnosis: se*ere aortic stenosis, cardiomegaly, CHF ascites Medical G$ysiology 11 t$ ;dition, D!yton > Hall p.251 Monitored $eart rate 1HF2, ,G Fecorded acc!rate intake and o!tp!t 1>A2. C$ange position 4re?!entlyC ele*ate 4eet w$en sitting. nspect skin integrity, keep dry and pro*ide padding as indicated A!sc!ltate breat$ so!nds noting ad*entitio!s ,S. %ote presence o4 dyspnea, tac$ypnea, ort$opnea, G%= or persistent co!g$ Fecommend ele*ating lower e<tremities "eeps linen dry and 4ree o4 wrinkles ;nco!rage amb!lation n*asi*e monitoring may be needed 4or assessing intra*asc!lar *ol!me, especially in pts. wit$ poor cardiac 4!nction. Acc!rate >A are necessary 4or determining renal 4!nction and 4l!id replacement needs and red!cing risk o4 4l!id o*erload. ;dema 4ormation, slowed circ!lation and prolonged immobility are stressors t$at a44ect skin integrity t$at will re?!ire pre*enti*e inter*entions. ;<cess 4l!id *ol!me o4ten leads to p!lmonary congestion. Fespiratory symptoms may $a*e slower onset b!t more di44ic!lt to re*erse. ;n$ances *eno!s ret!rn and red!ces edema 4ormation in t$e lower e<tremities. Moist!re predisposes to skin breakdown Gromote circ!lation Collaborative Administer di!retics as ordered: F!rosemide 1loop di!retic2 /0mg 2 @ now t$en ? 12 $o!rs Aldactone 1potassi!m-sparing di!retic, aldosterone antagonist2 25mg 1 tab A= Maintain 4l!id6sodi!m restrictions as ordered Monitor ser!m alb!min and electrolytes n$ibits t$e reabsorption o4 sodi!m and c$loride 4rom t$e ascending limb o4 t$e loop o4 Henle, leading to a sodi!m-ric$ di!resis. ,locks t$e e44ects o4 aldosterone in t$e renal t!b!le, ca!sing loss o4 sodi!m and water retention o4 potassi!m Fed!ces total 4l!id *ol!me in t$e body and pre*ent 4l!id reacc!m!lation. =ecreased ser!m alb!min a44ects plasma colloid osmotic press!re, res!lting in edema 4ormation.
NCP Ineffective Airway Clearance Related To The Accumulation of Secretions As Evidence by Decrease in Respiratory Rate and NGT and ET Tube Attached and Crackles at The Left Base of The Lungs