Perpetual Help College of Manila

1240 V. Concepcion St. Sampaloc, Manila

College of Nursing

A Case Study on:

Congestive Heart Failure

Presented to the faculty of

Perpetual Help College of manila

In partial fulfillment

of the requirements for

Nursing Care Management (NCM) 204

Related Learning Experiences

1st semester of S.Y. 2010-2011

Submitted by

Section E – Group 1
 OBJECTIVES

General:

This study aims to develop knowledge, skills and attitudes towards nursing care

management of client who developed a Congestive Heart Failure due to Type II Diabetes

Mellitus.

Specifically, this aims to:

• To identify the precipitating factors regarding the pathogenesis of the disease

being manifested by the client

• To enumerate clinical manifestations of the diseases manifested by the client

• To discuss the pathophysiology of Left-Sided Congestive Heart Failure.

• To demonstrate the appropriate approach used in dealing with clients with

Congestive Heart Failure.

• To perform dependent and independent interventions, being done to the client

appropriately and with care.

• To perform comprehensive nursing care and interventions with competence

and confidence in rendering care to clients with Congestive Heart Failure.

• To establish rapport to client and family/significant others.

• To encourage family/significant others to cooperate in the interventions that

are being performed to the client.

• To collaborate with all the health team to promote efficient care to the client.
 INTRODUCTION

Congestive heart failure is a physiologic state in which the heart cannot pump

enough blood to meet the metabolic needs of the body (determined as oxygen

consumption). Heart failure results from changes in systolic or diastolic function of the

left ventricle. The heart fails when, because of intrinsic disease or structural defects, it

cannot handle a normal blood volume or, in the absence of disease cannot tolerate a

sudden expansion in blood volume (e.g.., during exercise).

The main causes of Congestive Heart Failure are as follows: Coronary Artery

Disease, Untreated High Blood Pressure, Faulty heart valves, Cardiomyopathy, Lung

disease, Diabetes, Infections, Alcoholism and some Toxic Drugs. The Non-Modifiable risk

factors are age, gender, race, family history, personal history. The Modifiable risk factors

are smoking, high blood pressure, anemia and diabetes.

Heart failure may be categorized as (1) LVF versus RVF, (2) backward versus forward,

(3) high output versus low output. In the case of the patient, she has a Left Ventricular

Failure. Left ventricular failure causes either pulmonary congestion or a disturbance in

the respiratory control mechanisms. The patient manifests rales, dyspnea, paroxysmal

nocturnal dyspnea, orthopnea, pulmonary edema, which are all consistent with Left-

sided Congestive Heart Failure. The cause of the patient’s condition resulted from

interrelated factors such as Diabetes Mellitus Type II and Myocardial Infarction.

Out of the 86,241,697 people in the Philippines, 1,521,912 have Congestive Heart

Failure. Congestive Heart Failure is the 6th leading cause of mortality in the Philippines,

affecting males more often than females.

According to World Health Organization, more than 22 million people worldwide

suffer from Congestive Heart Failure. In the United States, congestive heart failure (CHF)

was the underlying cause of death for approximately 38,000 persons in 2007; of those
deaths, approximately 92% were among persons aged greater than or equal to 65

years.

We chose this case because we find it challenging. The disease is one of the most

common causes of mortality rate in our country. This study will give us more knowledge

and skills improving our nursing care management in patients with such disease and so

we will be confident to help for the betterment in providing health care in the future.
 DEMOGRAPHIC DATA

Client's Name: Patient LB

Age: 65years old

Birthdate: November 18, 1945

Sex: Female

Address: Sampaloc Manila

Province: Jolo, Sulu

Height: 5’3”

Weight: 46 kilograms

Civil Status: Widow

Religion: Roman Catholic

Nationality: Filipino

Race: Asian

Language: Tagalog and English

Occupation: Housewife

Educational Attainment: College Undergraduate

Date of Admission: August 26, 2010 / 6:12 PM

Attening Physician: Dr. Bartolome

Chief Complaint: Difficulty of Breathing, Chest pain

Admitting Diagnosis: Hypertensive Cardiovascular Disease; Congestive

Heart Failure Secondary to Diabetes Mellitus Type II; Hyperuricemia; Anemia

Final Diagnosis: IHD, HCVD,CHF, CKD

History of Present Illness

One month prior to admission patient LB was hospitalize at Ospital ng Sampaloc

at around 11:30pm. According to her she was admitted because of hypertension, chest

pain and difficulty of breathing. She had been confined for 3 days. According to the

patient, she was diagnosed with Myocardial Infarction. Her medication was given by Dr.

Ocampo as follows: Aldactone 400mg/tab OD, Captopril 25mg/tab BID and Imdur

40mg/tab OD. After hospitalization, the pain and dyspnea subsides. Then the doctor

ordered her for discharge.

When the patient was doing the laundry she started experiencing difficulty of

breathing and chest pain after which she lost consciousness. She was immediately

brought to the hospital by her son. Patient LB was admitted at the ER of Ospital ng

Sampaloc on August 26, 2010 at 6:12 PM with a chief complaint of difficulty of breathing

and chest pain. Upon arrival at the Emergency Room, the client was conscious already.

The physician assessed the status of the patient, then he noted (+) chest pain,

(+)tachypnea, (+)dyspnea, (+)bradycardia, and (+)hypertension. The physician

instructed the patient to undergo different diagnostic procedures such as ECG and

various laboratory exams like Serum Electrolytes and Cardiac Enzymes test. Her

admitting diagnosis is HYPERTENSIVE CARDIOVASCULAR DISEASE; CONGESTIVE HEART

FAILURE SECONDARY TO DIABETES MELLITUS II. The physician referred the patient to

Medical/Surgical Ward and gave doctor’s orders such as NGT insertion, IV insertion,

Foley Catheter Insertion, NPO instructed, Vital Signs Monitoring, initial oxygen via face

mask (5 L/min). Medications ordered by the physician during admission are the following

Aldactone OD, Captopril 25 mg/tab for HPN, Imdur 30mg/tab OD, Clonidine 35mg/tab

OD, Diltiazem 125mg OD.

Past Health History

The patient was hospitalized in the year 1977 when she gave birth to her last

child here in manila. She was confined at the hospital for two days. She experience

Measles when she was 6 years old and had Chicken Fox when she was 12 years old.

Family Health History

GENOGRAM
DM

HPM,
MII
MI

Px CHF,

DM, MI,
HPN

LEGEND:

CHF - Congestive Heart Failure

DM - Diabetes Mellitus

MI - Myocardial Infarction

HPN - Hypertension

Px - Patient

- Male
 - Female

- Deceased

Lifestyle

Patient LB seldom eats meat and poultry. Patient said that she doesn’t like the

taste of pork. Patient always eats vegetables and fish. Patient consumes vegetables that

are rich in fiber such as ‘saluyot’ and she eats more rice. Patient has a good appetite.

Patient complies with her doctor’s order by avoiding foods that are restricted to her.

Patient LB voids approximately 10-12 times a day without experiencing pain during

urination. She defecates once or twice a day and seldom experience constipation. She

does it every 6 in the morning, thrice a week, for about an hour. She usually sleeps 5-6

hours a day. Patient sleeps at 9 or 10 in the evening and wakes up early in the morning,

usually at 2 or 3am. She stated that there are episodes that she gets awaken from sleep

because she experiences difficulty of breathing. Patient naps in the afternoon because

she feels sleepy every afternoon.

Spiritual History

Patient LB is a Roman Catholic and has a strong faith in our supreme being. She

regularly attends mass every Friday and Sunday at Quiapo Church. She believes that

God is always there for her and his family in times of problems and challenges.

Sexual History

Being a widow, the patient has no more sexual activity for almost 15 years now.

But when she was younger she and her husband make love 2 to 3 times a week.
Developmental Task

Erik Erikson’s Psychosocial Theory of Development

Erik Erikson adapts and expands Freud Theory of development to include the

entire life span, believing that people continue to develop throughout life. He believed in

the massive influence of culture on behavior and placed more emphasis on the external

world such as depression and was according to his theory, each stage signals a task that

must be achieved. The resolution of task can be complete, partial, and successful. He

believes that the greater the task achievements that healthier the personality of the

person, failure to achieve a task influences the person’s ability to achieved the next

tasks. Erikson emphasizes that people must change and adapt their behavior to

maintain control over their lives. According to him, personality development is

influenced by biologic, psychological, environmental, and social factors throughout the

life cycle.

Late Adulthood: 55 or 65 to Death

Ego Development Outcome: Ego Integrity vs. Despair

Basic Strengths: Wisdom

Erikson felt that much of life is preparing for the middle adulthood stage and the last

stage is recovering from it. Perhaps that is because as older adults we can often look

back on our lives with happiness and are content, feeling fulfilled with a deep sense that

life has meaning and we've made a contribution to life, a feeling Erikson calls integrity.
Our strength comes from a wisdom that the world is very large and we now have a

detached concern for the whole of life, accepting death as the completion of life.

On the other hand, some adults may reach this stage and despair at their experiences

and perceived failures. They may fear death as they struggle to find a purpose to their

lives, wondering "Was the trip worth it?" Alternatively, they may feel they have all the

answers (not unlike going back to adolescence) and end with a strong dogmatism that

only their view has been correct.

Analysis:

Patient LB achieved the developmental task because she was able to perform well

as a part of her family. She was able to teach and care for her children as they continue

to grow. She feels fulfilled and contented on what she has done and understand the

things happening to her. She was aware of her condition and she accepts it. Thus, Ego

integrity developed.

a. Physical Development

Patient LB’s physical development belongs to a late adult age. She weighs 46

kilograms and stands 5’3” tall. By merely looking at the patient’s physicality, she was

actually lean in appearance. In terms of perception in health functioning, patient LB

considered herself as well fitted and is conscious and aware of her present condition.

b. Psychosocial Development

Patient LB is strong. Even if there’s problem, the family remained strong and has

cooperation in each member of the family. She was contented on her life; she felt

happiness in taking care of her children and grandchildren.

c. Cognitive Development

Patient LB makes decisions on her own but makes sure to still consult her family.

As she recalls the memories before, she was the third child of their parents. But she

decided to separate from her parents as well as her siblings. According to her, they’ve
learned to live in their own at a young age. Now that she has her own family, she makes

sure that she provides everything they needed with the help of her second husband.

Analysis:

Based from experiences expressed by patient LB, it may be presumed that her

personality features molded during her early married life. She focused on that part of

her life and she developed every virtues and attitudes in that part of her life.

d. Moral and Spiritual Development

The patient is a Roman Catholic and she believes that GOD exists. She always goes to

church every Sunday and Friday she always pray the rosary.

Analysis:

Her decision is highly affected by her religion and faith. She often prays for

guidance before she makes her decision.

ANATOMY AND PHYSIOLOGY

Figure 1-2 Anatomical Structure of the Heart

Heart

• The heart is shaped like a blunt cone and is approximately the size of a closed

fist.

• It is located in the thoracic cavity between the two pleural cavities, which

surround the lungs.

• The heart, trachea, esophagus, and associated structures form a midline partition,

the mediastinum.

Functions:

1. Generating blood pressure

2. Routing blood

3. Ensuring one-way blood flow

4. Regulating blood supply

Right side of the Heart:

• Right Atrium- the first chamber which receives deoxygenated blood from the body

through the inferior and superior venacava.

• Right Ventricle- it pumps the blood into the lungs which exchange of oxygen and

carbon dioxide occurs.

Left side of the Heart:

• LeftAtrium- the first chamber which receives highly oxygenated blood from the

lungs through the Pulmonary Veins.

• Left Ventricle- the strongest of the heart's pumps. Its thicker musclesneed to

perform contractions powerful enough to force the blood toall parts of the body.

The Valves

• Tricuspid Valve-regulates blood flow between the right atrium and the right

ventricle

• Pulmonary Valve-opens to allow blood to flow from the right ventricle to the lungs

• Mitral Valve-regulates blood flow between the left atrium and the left ventricle

• Aortic Valve-allows blood to flow from the left ventricle to the ascending aorta

The Hearts Electrical System

• 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-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-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.

Layers:

• Epicardium - also called visceral pericardium

-a thin serous membrane forming the smooth outer surface of the heart

• Myocardium -thick middle layer of the heart

 -is composed of cardiac muscle cells and is responsible for contractions of the

heart chambers.

• Endocardium -which consist of simple squamous epithelium over a layer of

connective tissue.

SYSTEMIC AND PULMONARY CIRCULATION

Figure 1-3 Systemic and Pulmonary Circulation

In the systemic circulation, arteries bring oxygenated blood to the tissues of the

body. The pulmonary circulation (for arterial blood sent to the lungs) is excluded from

this definition. As blood circulates through the body, oxygen diffuses from the blood into

cells surrounding the capillaries, and carbon dioxide diffuses into the blood from the

capillary cells. Veins bring deoxygenated blood back to the heart.

PATHOPHYSIOLOGY OF CONGESTIVE HEART FAILURE

LEFT-SIDED
(Book Base)

Causes:
-Myocardial infarction
-Prolong hypertension
-Aortic Stenosis –Insufficiency
-Mitral Stenosis – Insufficientcy
 Reduced Myocardial Contractility
Increased Cardiac Workload
Decreased Diastolic Filing
Obstruction of Left Arial Emptying

Left-Sided Congestive Heart Failure

Blood drums back into the Decreased Stroke

pulmonary capillary bed Volume

Pressure of blood into the Decreased Tissue

pulmonary capillary bed Perfussion
increases
Fluid shift into the intra
and inter-alveolar spaces
Increase Cellular Decrease blood flow to
Hypoxia the kidneys
Pulmonary Edema

Signs and Symptoms of

RAAS Stimulation
LSCHF

• Dyspnea Vasoconstriction &

• Paroxysmal Rearbsorption of Sodium and
Nocturnal Dyspnea Water
• Orthopnea
• Rales/ Crackles Increase ECG Volume
• Moist Cough
• Blood Tinged Frothy
Increase total blood volume
Sputum
Increase Systemic Blood
• Wheezing/ Cardiac
pressure
Asthma
• Dizziness
• Fatigue
• Weakness
• Anorexia
• Hypokalemia

PATHOPHYSIOLOGY OF CONGESTIVE HEART FAILURE

LEFT-SIDED
(Client Base)

Non-Modifiable factor:
Modifiable factor:
Myocardial infarction
Lifestyle Diabetes Mellitus
Age
Heredity
Hypertension
 Enlargement of left ventricle

Increased workload

Reduced myocardial
contractility

Blood drums back

Into the pulmonary
capillary bed

Pressure of blood into

the pulmonary
capillary bed
increases

Fluid shift into the intra

and inter-alveolar

Pulmonary edema
Dyspnea
Paroxysmal
Congestive Heart failure nocturnal dyspnea
Orthopnea
Fatigue
Rales/crackles
LEGEND:

Sign and
symptoms

REVIEW OF SYSTEMS

August 30, 2010

SYSTEMS SUBJECTIVE CUES

Integumentary System “Wala naman ako problema sa balat,
ganito lang talaga ang balat pag
tumanda na” as verbalized by the
patient.
 Respiratory System “Mabilis ang paghinga ko, parang
kinakapos kaya nahihirapan ako sa
paghinga” as verbalized by the
patient.

“Parang nalulunod ako, hindi ako makahinga

ng maayos” as verbalized by the patient.

“Gusto ko ng mataas na unan, itaas nyo ang

higaan ko dito sa may likuran ko” as
verbalized by the patient.

“Hinahabol ko ang paghinga ko kasi

nauubusan ako” as verbalized by the patient

“Bumibilis ang paghinga ko pag sumasakit

ang dibdib ko” as verbalized by the patient.

“Irerate ko ang sakit sa 7 out of 10” as

verbalized by the patient.

“Sumasakit ang dibdib ko, parang

pinipiga” as verbalized by the patient.

“Hindi ako makatulog ng maayos,

nagigising ako dahil nahihirapan akong
huminga” as verbalized by the patient.

Cardiovascular System “Mataas ang BP ko, highblood kasi ako.”

as verbalized by the patient.

“Yung sakit parang lumalakad sa kanang

bahagi ng dibdib ko” as verbalized by the
patient

Gastrointestinal System “Wala naman masakit sa tyan ko, pag

lang madudumi ako” as verbalized by the
patient.

“Hindi ako makakaen ng maayos dahil

mapait ang panlasa ko” as verbalized by the
patient.

Genitourinary System “Wala naman masakit pag umiihi ako. ”

as the patient.
Musculoskeletal System “Wla naman masakit s mga kasukasuan
ko, wla din ako rayuma” as verbalized by
the patient.
Neurologic system “Nanghihina lang ako, pero kaya kong
maglakad mag isa at hindi ako
nahihirapang bumalanse” as verbalized
by the patient.
 Endocrine system “Di ko nga alam na may diabetes ako e,
sinabi lang ng doctor meron na daw
ako.” as verbalized by the patient.

CLINICAL PATHWAY

Left sided CHF Ride

Sided CHF
Results from an increase left Yes No
Can you hear bibasilar
ventricular and left atrial crackles on auscultation of
pressures, which cause lungs?
excessive accumulation of fluid
in interstitial and alveolar
spaces. Pulmonary artery
pressures will also be elevated.
Treat with vasodilators and ACE

Early sign of left ventricular
failure that is the result of a
compensatory effort to increase
cardiac output. Tachycardia will
continue at increasing rates if
left ventricular failure persists.
Treat with digitalis to increase
the heart’s contractility and rate.
Early finding in left ventricular
failure but will persist as failure
progresses. It occurs as the left
ventricle becomes less
compliant.
This occurs because the left
ventricle dilates in order to
increase ventricular contraction
and emptying.
Results from reduced perfusion
to the kidneys when renal
perfusion is reduced, the blood
urea nitrogen rises but the
creatinine level in unaaffected
Figure 1-1 Clinical Manifestations of Left sided and Right Sided CHF
Physical Assessment
Vital Signs
T: 36.2°
RR: 26 breaths/min
No
Is jugular venous distention
present?
Yes
Is the heart rate over 100
beats/min?
Yes Can you hear an S3 or
summation gallop when you
auscultate the heart?
Yes Is the point of maximal
impulse enlarged or shifted
laterally to the left?
No
Is there a parasternal heave?
Yes Is the blood urea nitrogen
increased while the creatinine
is normal?
No
Is ascites present?
No
Is the liver enlarged?
No
Is the hepatojugular reflex is
present?
Is there a measurable weight
gain in a short period?
August 30, 2010
Very Specific sign of right
Yes ventricular failure, resulting
from increased venous
pressure. This increased
No pressure will also be
reflected in increased
central venous pressure.
Treat with diuretics to
decrease blood volume and
No
No
Yes
This occurs because the
right ventricle dilates in
order to increase ventricular
No
contraction and emptying.
Yes
Results from fluid
accumulation in the
abdomen.
Yes
Hepatomegaly is due to
congestion of the liver with
venous blood
Yes
Results from the inability of
the right ventricle to handle
the increase in pressure and
venous return.
Yes
Results from fluid retention
Treat with diuretics to
decrease blood volume and
PR: 111 beats/min

Height: 5’3”

Weight: 46kg

Bp: 140/90 mmHg

BMI: 17.88

Analysis: According to Black, a BMI of less than 18.5 is categorized underweight for less

than desirable weigh for height.(Medical surgical Nursing by Black)

General Survey:

We received patient awake on bed in high-fowlers position. Conscious and

coherent. With IVF of PNSS 1LXKVO located at left metacarpal vein, intact and infusing

well. With Foley catheter connected on a urine bag containing 1200ml. With oxygen tank

at bedside and is being used when needed. The patient wears dress suitable for the

temperature. Pale looking and body weakness noted.

 BODY PART TECHNIQUE NORMAL ACTUAL ANALYSIS
and FINDINGS FINDINGS
ASSESSMENT
Skin
Skin color Inspection Varies from light Deep Brown According to KOZIER
to deep brown; color skin color varies from
from ruddy pink race. Asian people
to light pink; from have a deep brown
yellow overtones color. (Fundamentals
to olive of Nursing p.540)

Uniformity of Inspection Uniform in According to KOZIER

skin color Generally uniform color except in some areas have
except in areas areas exposed lighter pigmentation
exposed to the to sunlight such as palms, lips,
sun; areas of nail beds in dark
lighter skinned people.
pigmentation in (Fundamentals of
dark skinned Nursing p.538)
people

Assess edema Inspection No edema

Palpation According to KOZIER a
normal skin doesn’t
No edema show swollen, shiny,
taut, and tends to
blanch the skin color.
(Fundamentals of
Nursing p.3535)

Skin lesions Inspection No lesions or

Palpation abrasions
According to KOZIER
Freckles; some skin lesions are those
birthmarks, no that appear initially in
abrasion or other response to some
lesions change in the external
on internal
environment of the
skin. (Fundamentals of
Skin moisture Inspection Dryness and Nursing p.539)
flaky

Moisture in skin According to KOZIER

folds and the the skin is dry and
Axillae flaky because
sebaceous and sweat
glands are less active
in elderly.
Excessive Dryness
indicate dehydration
(Fundamentals of
Skin Palpation Cold, clammy Nursing p.539)
temperature skin

Uniform; within According to D’Amico

normal range of and Barbarito localized
temperature coolness results from
decreased circulation
due to vasoconstriction
Skin turgor Palpation The skin moves or occlusion which may
back slowly occur from peripheral
arterial insufficiency.

When pinched, According to KOZIER in

 LABORATORY RESULTS

Hematology

It is a series of screening test, which consist of Hemoglobin and Hematocrit. It is

used routinely to screen for, to help diagnose and to monitor variety of condition. It

provides a complete evaluation of all formed elements of the blood. It can supply a great

deal of information necessary to diagnosed hematopoetic system and helps to evaluate

the strategies and prognosis of certain disease.

Laboratory Results: Hematology

August 25, 2010

LABORATORY RESULT NORMAL INTERPRETATION ANALYSIS

EXAM VALUES
Hemoglobin 9.1 Female -Patient LB has low Hemoglobin is the

12-14 g/dl hemoglobin level protein molecule

which indicates within red blood cells

anemia and lack of that carries oxygen

oxygen. and gives blood its

red color. The

amount of oxygen in

the body tissues

depends on how
 much hemoglobin is

in the red cells.

Without enough

hemoglobin, the

tissues lack oxygen,

and the heart and

lungs must work

harder to try to

compensate.

(Medical – Surgical

Nursing 7th edition by

Joyce M. Black pp.

2262)
Hct 0.27 0.37-0.47 -Patient LB has low Hematocrit is a

hematocrit level compound measure

which indicates of red Blood cell

anemia. number and size. A

decrease in the

number or size of red

cells also decreases

the amount of space

they occupy,

resulting in low

hematocrit. (Medical

– Surgical Nursing 7th

edition by Joyce M.

Black pp. 2263)

WBC 11.5 4.8-10.8 x 10 -Patient LB has high White blood cells

WBC count which which also called

indicates infection leukocytes, defend

and tissue necrosis the body against

infection. They form

in the bone marrow

and consist of
 several different

types and sub-types.

A high WBC count

often means that an

infection is present in

the body. (Medical –

Surgical Nursing 7th

edition by Joyce M.

Black pp. 2263)

Segmenters 80 60-70% -Patient LB has high Increased in

percentage of neutrophils,

segmenters indicates basophils,

inflammatory disease eosinophils and

or response, tissue monocytes may be

necrosis (myocardial due to acute

infarction), basophils coronary syndrome,

for hemolytic anemias bacterial infection

and bacterial and sometimes

infection. Leukemia. (Medical –

Surgical Nursing 7th

edition by Joyce M.

Black pp. 2263)

Lymphocyte 20 30-40% -Patient LB has low Lymphocytes are the

percentage of primary components

lymphocytes indicates of the body's

a very high risk of immune system.

infection especially They are the source

viral infection. of serum

immunoglobulins and

of cellular immune

response. As a result,

they play an

important role in

immunologic
 reactions. All

lymphocytes are

produced in the bone

marrow. Sometimes

drugs can be a factor

to a decreased

lymphocyte counts

such as

corticosteroids and

immunosuppressive

drugs. (Medical –

Surgical Nursing 7th

edition by Joyce M.

Black pp. 2263)

Analysis:

Based on the results taken, the hemoglobin and hematocrit of the patient appears

to be low due to her anemic condition. While the WBC and Segmenter count of the

patient appears to be high, this indicates infection. Lastly, Lymphocytes count suggests

a very high risk of infection.

CHEMISTRY

August 26, 2010

LABORATORY RESULT NORMAL Interpretation Analysis

EXAM VALUES
FBS 12.84 4.2-6.4 mmol/L Increase An increase
in FBS level
which
indicates
hyperglycemi
a, and a sign
of diabetes. .
(Medical –
Surgical
Nursing 7th
 edition by
Joyce M.
Black pp.
2263)
Cholesterol 3.07 3.8-6.7 mmol/L Within Normal
Range
Uric Acid 9.3 2.5-8.0 mg/dL Increase In humans,
uric acid is
the major
end product
of purine
catabolism in
the absence
of urate
oxidase.
Increase in
Uric acid
levels result
in
hyperuricemi
a. (Medical –
Surgical
Nursing 7th
edition by
Joyce M.
Black pp. 90)

August 25, 2010

LABORATORY RESULT NORMAL Interpretatio Analysis

EXAM VALUES n
Sodium 131.2 135-148 Decrease Accourding
mmol/L to Black and
Hawks
decrease
level of
sodium
indicates
possible
malabsorptio
n
(Medical-
Surgical
Nursing, 7th
Edition Vol. 1
pp 782)
Potassium 6.9 3.5-5.3 mmol/L Increase According to
Black and
Hawks,
increased
potassium
indicates
hyperkalimia
(Medical-
Surgical
Nursing, 7th
Edition Vol. 1
pp 782)

August 27, 2010

 LABORATORY RESULT NORMAL INTERPRETAIO ANALYSIS
EXAM VALUES N
Potassium 7.55 3.5-5.3 Increase According to
mmol/L Black and
Hawks,
increased
potassium
indicates
hyperkalimi
a (Medical-
Surgical
Nursing, 7th
Edition Vol.
1 pp 782)
Triglycerine 2.39 0.68-1.9 Increase High level of
mmol/L triglycerine
indicates
high level of
sugar,
alcohol and
calories
associated
with
diabetes,
kidney
disease and
liver disease
((Medical-
Surgical
Nursing, 7th
Edition Vol.
1 pp 782))

August 29, 2010

LABORATORY RESULT NORMAL Interpretatio Analysis

EXAM VALUES n
Potassium 7.6 3.5-5.3 mmol/L Increase Patient LB
has an
increased in
potassium
level, it
indicates
hyperkalemi
a,
dehydration,
acute or
chronic
kidney
failure,
diabetes or
infection.
(Medical-
Surgical
Nursing, 7th
Edition Vol. 1
 pp 782)

August 30, 2010

LABORATORY RESULT NORMAL Interpretation Analysis

EXAM VALUES
Creatinine 739 50-70 umoL/L Increase High level of
creatinine
indicates a
disease that
affects the
kidney
(Medical-
Surgical
Nursing, 7th
Edition Vol. 1
pp 782)
Potassium 6.7 3.5-5.3 umoL/L Increase Increased
potassium
level indicate
hyperkalemi
a.
(Medical-
Surgical
Nursing, 7th
Edition Vol. 1
pp 782)
August 28, 2010

ARTERIAL BLOOD GAS

Analyte Normal Values Results Interpretation &

Analysis
pH 7.35-7.45 7.30 Acidosis
PCo2 35-45 40 N
HCo3 22-26 17 Acidosis
PO2 80-100 75

Analysis:

Metabolic Acidosis

Troponin Test

August 26, 2010

LABORATORY RESULT NORMAL Interpretation Analysis

EXAM VALUES
Troponin T (-) (-) Troponin is She/He can
negative still have the
narrowings
in the heart
tubes that
have not
totally
blocked.
(Medical-
Surgical
Nursing, 7th
Edition Vol. 1
pp 782)

RADIOLOGY

Chest X – ray
A chest x ray is a procedure used to evaluate organs and structures within the
chest for symptoms of disease. Chest x rays include views of the lungs, heart, and small
portions of the gastrointestinal tract, thyroid gland and the bones of the chest area. X
rays are a form of radiation that can penetrate the body and produce an image on an x-
ray film.
CHEST PHYSICAL ASSESSMENT –

RESULTS: Lungs are clear.

Heart is enlarged.

Aorta is lertous.

Diaphragm sulci are intact.

IMPRESSION: Cardiomegaly

Anleromatous Aorta

Analysis:

Patient LB developed cardiomegaly due to Congestive Heart Failure.

SONOGRAPHY
Ultrasound

Abdominal ultrasound is an imaging procedure used to examine the internal organs of

the abdomen, including the liver, gallbladder, spleen, pancreas, and kidneys. The blood

vessels that lead to some of these organs can also be looked at with ultrasound.

SONOGRAPHIC RESULTS:
REQUEST: Whole Abdomen
Liver: The liver is normal in size, shape & echo pattern
No discrete mass or dilated Intrahepatic duct seen
Impression: Normal study of the Liver.

Gallbladder: Wall is not thickened

No Intraluminal echogenicitis seen
Impression: Normal study of the Gallbladder

Common Duct: The common duct measured 0.4cm

Impression: It is normal in caliber

Pancreas: The pancreas is normal in size, shape & echo pattern

No discrete mass lesion seen
Impression: Normal study of the Pancreas
 Spleen: The spleen is normal in size & echo pattern
No discrete mass lesion or calcification seen
Impression: Normal study of the Spleen

Kidneys: The right kidney measured 6.3 x 3.1cm while the left kidney
measured 7.3x
4.1cm
Both kidney appears small with diffusely increase
parenchymal echogenicity
No lithiasis or hydronephrosis seen
Impression: Chronic nephropathy, bilateral.

Urinary Bladder: Urinary Bladder was not adequately distended.

Analysis:

Patient LB has Cardiomegaly which can be caused by a number of different

conditions, including diseases of the heart muscle or heart valves, high blood

pressure, arrhythmias, and pulmonary hypertension. Cardiomegaly can also sometimes

accompany longstanding anemia. Also Chronic Nephropathy, a renal disease that can

lead to cardiovascular disease and pericarditis.

ELECTROCARDIOGRAPHY

ECG Sep. 4, 2010

9:30pm

Actual Findings

PR Int.: 271

P/QRS/T Int (MS): 118, 96, 182

QT/QTC Int. (MS): 434, 446

P/QRS/T Axis (Deg): 71,52

 MANAGEMENT

I. MEDICAL MANAGEMENT
-DOCTOR’S ORDER
August 26, 2010
7:15pm
Patient LB admitted to MS ward. Dr. Bartolome gave orders of diabetes drugs -
1800kcal/ day to begin in 30 meals & strict aspiration precaution. Dr. Bartolome request
for CBC, Blood type, Na K, HGB, ECG, BUN, Creatinine and 2d Doppler. He ordered PNSS
1L x 16°, ISMN 30mg/ tab OD, Cefoxitin 2g/50 ml IV every 6 hours. He also ordered
intermediate insulin 15 Units, Clonidine 5mcg. tab for BP 130/100, Diphenhydramine
1cap- 5 and to prepare 2 units PRBC to be transfuse. Other medications ordered;
Allopurinol 300mg/tab OD, Simvastatin 20mg/tab OD in PRN, Ranitidine 50mg Q8 TID,
Lactulose syrup 30ml OD. Other orders; Monitor Vital signs Q2, to be refer and record,
monitor Input and Output every shift to be refer and record and “Monitor CBG”.
7:30pm
Refer of CBG in 255mm/hr.
11:10pm
Patient LB’s blood pressure arise at 160/120, Dr. Bartolome ordered Furosemide
40mg. For chest pain, D50 50cc + 10”u” x 15 x 3 doses. He also ordered diet of no
fruits/ juices. For hyperkalemia, he ordered nebulization of salbutamol every 8°. Patient
LB hook to cardiac monitor.

August 27, 2010

1:25am
Patient LB’s heart rate arises to 120bpm and have (+) crackles. Dr. Bartolome
ordered Furosemide 40mg, Isoket drip 15mgtts/hr and Lanoxin 0.125mg slow IV. Monitor
vital sign, input and output Q1 and record. For insertion of Foley catheter and connect to
urine bag. Other medication: Morphine 2mg via IV. For withhold intermediate insulin in
the morning.
6:00am
Progress Note: CBG-96mg/dl
10:30am
IVF to follow: PNSS 1L x 16°
Isoket to consume
7:15pm
 IVF to follow: PNSS 1L x 16°

August 28, 2010

8:00 am
Dr. Bartolome ordered for a repeat ECG and IVF to follow: PNSS 1L x 16°
5:00pm
Patient has serum potassium of 7.55; ECG peak at T. waves. Dr. Bartolome
ordered calcium gluconate 1 ampule slow IV push, D50, NaCl 8”u” Q6 for 3 doses and
after he then ordered repeat serum Sodium and potassium.

August 29, 2010

7:45am
Dr. Bartolome ordered diet as no fruits. For medication; hold ranitidine and
omeprazole 20mg/tab OD.
2:45pm
IVF of D5050 1 vial +8”u” on D5w to run for 6° for 3 doses.
6:15pm
Continue IVF of PNSS 1L x 16°

August 30, 2010

10:35am
Dr. Bartolome request for Sodium and Potassium and a followed up laboratory
results.
3:25pm
Dr. Bartolome ask a service of nephro for evaluation of laboratory results. He
ordered Calcium gluconate 1 ampule slow IV push now, D5050 1vial + 8 “u” of insulin q6
x 3 doses, MaHCo3 1tab TID, IVF to follow PNSS 1L x 16°

August 31, 2010

7:15am
Continue followed up nephro referral and continue medications ordered by Dr.
Bartolome.
11:00am
Continue IVF PNSS 1L x16°

September 01, 2010

8:00am
Dr. Bartolome ordered repeat serum potassium and a request for creatinine.
Continue IVF to follow D5.03 Nacl 500cc x KVO; Continue medication.
12:00nn
 Limit oral intake to 1.5 L/day
 Maintain current IVF PNSS x 10ml/ hr
 Consume present IVF and shift to heplock
 Diet:
- 1800 kcal/ day, 40g CHON of high biologic value (no pork and beef), 2g Na
- 800mg, phosphorus diet, no fruits in diet
- Monitor I & O quantitatively and record pls.
 Diagnostics:
ABG:
- Relay labs today: creatinine 1 Ca, K 2D echo with Doppler once stable
Allopurinol 100mg 1 tab OD
- Hold captopril
- No ACE/ ARBS, no NSAIDS
- Start carvedilol 6.25mg/ tab, BID
- Hold furosemide
- Ciprofloxacin 500mg/ tab BID
- Adjust meds for ECC (estimated creatinine clearance)
- Refer for urine output <30ml/hr
- Erythropoietin 4000 “u” 8Q 2x/ week
- Refer accordingly
Progress Notes:
 History and Physical Examination received
 Awaiting laboratory results
 AKL 2° UTI on top of CKD 2° DM nephropathy cardiorenal syndrome
 Hyperkalemia probably 2° CKD, drug induced
 Hyperuricemia
 Will await labs today if patient’s hyperkalimia remains unintractable
 Advise patient’s to start hemodialysis
September 02, 2010
8:00am
IVF to follow PNSS 1Lx10cc/hr
September 03, 2010
11:50am
Shift IVF to heplock
6:30pm
For repeat potassium and creatinine. Continue medication.
11:20pm
Dr. Bartolome ordered IVF PNSS 1L x KVO, D50 50 cc + 10 “u” x 3 doses q 1°.
Progress Note: Potassium of 6.64

September 04, 2010

2:00am
Patient LB hook IVF PNSS x KVO with side drip of D50 50cc +10 “u” as ordered by
Dr. Bartolome, shift to heplock
11:30am
Progress Note: Hgt 287 mg/ dl
07:00pm
Patient LB for ECG, repeat sodium and potassium, IVF to follow PNSS x KVO

September 05, 2010

7:05am
Continue IVF PNSS x KVO
2:30am
For repeat CBC

September 06, 2010

6:10am
Dr. Bartolome ordered Amlodipine 5mg 1tab OD and to consume IVF of PNSS x
KVO & shifted to heplock. He ordered to transfer 2 units PRBC to consume. IVF to follow
PNSS 1L x 16°
Progress Note: Bp: 140/70 160/90
6:10pm
Progress Note: HGT of 7.4
7:30am
 For hemodialysis once with temporary access and inform the Dr. Bartolome.
Hemodialysis preparation and 2 ½ hour every 8 150ml/ mi, and QID 300ml/ min
Progress Note: Discuss the need for hemodialysis with the children. Indication of
uremia, intractable hyperkalimea

September 07, 2010

7:00am
Dr. Bartolome ordered D50 50cc +10 “u” x 3doses
Progress Note: Potassium of 9.74
8:00am
Continue IVF PNSS 1L x KVO. Patient LB for possible transfer to tertiary hospital
for dialysis.

September 08, 2010

8:30am
IVF to follow PNSS 1L x KVO

September 09, 2010

7:00am
 Nephro notes
Recommendations:
- Ciprofloxacin to 500g OD per orem
- May remove Foley catheter
- Limit oral fluid intake to ≤ 1L/ day
Diet 1800 kcal/ day
- 20g of Na/ day
- 80mg of Phosphorus/ day
- 50g of CHON of high biologic value
- Diabetic and low fat, low purine diet
*refer for dietician for further instruction
- MGH after blood transfusion of 1 “u” of PRBC, properly type and
crossmatch
Progress Notes: Bp 120/ 80 140/80
(-) edema
10:15am
Additional order and hold insulin temporarily
01:00pm
For CT Scan
Progress Note: 160/80

September 10, 2010

8:00am
Repeat CBC 6° prior to Blood Transfussion.
8:30pm
1 unit PRBC secure properly type and Crossmatch, With continue IVF to consume
then disconnect. Dr. Bartolome ordered MGH anytime. Continue medication and advise
to follow up after dialysis.
Progress Note: hgb: 89, hct:0.26
II. NURSING CARE AND MANAGEMENT
a. Assessment/Interventions:
• Monitor vital signs/oxygenation/Neuro status (report changes in heart
and respiratory rate/patterns as well as changes in LOC).
• Daily weight (a 2.2 kg weight increase over a 1 day period is considered
significant).
• Breath sounds (monitor for increased crackles, rhonchi or pulmonary
congestion).
• Capillary refill (if greater than 3 seconds, assess for signs of peripheral
edema).
• The presence of jugular vein distention (jugular vein distention can be a
sign of worsening right sided heart failure).
• The presence of hepatomegaly (also a sign of worsening right sided
heart failure).
• The presence of ascites (also a sign of worsening right sided heart
failure).
• EKG changes
• Evaluate electrolyte levels (sodium, potassium and creatinine)
• Digoxin levels (if patient taking Digoxin)
• Pain level (degree, quality, source, location, onset and relieving factors)
• Intake and Output (monitor effects of diuretic therapy and observe for
signs and symptoms of either fluid overload or deficit)
• Assess degree of discomfort associated with activity (provide a proper
rest/activity balance. Group nursing interventions when appropriate).
• Monitor for restless, anxious behavior and promote self care
participation.
• Maintain adequate bowel function (stool softeners such as Colace should
be ordered to prevent constipation).

b. Patient Teaching:
The following patient/family education should be provided prior to
discharge and
should also be reiterated at post discharge office visits:
• Discharge medication regimens
• Diet (low sodium)
• Fluid restrictions
• Activities of daily living
• Exercise
• Smoking cessation/avoidance
• Available community resources/referrals
• The importance of making and keeping Dr.’s appointments
• Avoiding infection (flu/pneumovax vaccines)
 • Self monitoring (when to report symptoms or changes such as shortness
of breath, dyspnea, changes in weight [greater than 2.2 lbs over 1-2
days], pedal edema, blood pressure changes, nausea or fatigue).

DISCHARGE PLANNING

M >Remind client to take furosemide, Catapres, Isordil, amlodepine, ISMN, and sucralfate as

prescribed.

>Instruct the relative to follow medication regimen.

E >Encourage the relative to do some exercises like a passive range of motion in affected

and unaffected parts of the body of the client.

T > Educate & instruct the family to monitor the blood pressure and pulse rate before

administering medication.

>Emphasize patient education with intense instruction regarding compliance with dietary

restrictions and medical therapy.

>Require patients to promptly follow up with their primary care physician or cardiologist.

H >Inform the relative the importance of proper hygiene of the patient from head to toe.

>Educate and instruct the relatives on what proper food to give.

O >Inform the family of the patient to have a regular check-up for the continuity of

treatment.

>Instruct the family of the patient to monitor if there is any sudden change to the patient

and report immediately.

D >Instruct the relative to feed the client on time with nutrition food that is low in sodium,

low in cholesterol, low in fat and give citrus fruits, moderate in fluid intake and increase

fiber diet to improve health.

>Follow the diet prescribed by the doctor.

EVALUATION

The nursing interventions given to the patient has become helpful. Her pulmonary

signs and symptoms were treated. With the latest diagnostic exam done, the chest x-ray

was found clear. But the patient, due to renal impairment as complication of her CHF and

DM II is arranged to undergo hemodialysis.

RECOMMENDATION

Watch out for blood cholesterol because too much cholesterol may cause fatty

deposits to form in arteries—impeding blood flow and increasing the risk for

complications, and limit sodium rich food intake. Lifestyle changes are recommended—

including the nutritional diet such as limiting fats—specially saturated fats, eating fiber

rich foods, fish—rich in omega 3 fatty acids which is good for the heart, and fresh fruits

and vegetables, which contains antioxidants, and vitamins and minerals that help

prevent everyday wear and tear of coronary arteries. Exercise regularly to help make

the heart stronger and lower down blood pressure. Stop smoking or avoid exposure to

second hand smoking. Restrain from drinking alcoholic beverages. Rest in bed until

breathing is easier and feel stronger. Then, slowly return to your normal activities. Get

at least 7 hours of rest each night and take naps when feeling tired. Avoid being stress.

Drink medications as prescribed such as diuretics and heart medications