Course Code NCM 104

Course Title HEART FAILURE (CONGESTIVE HEART FAILURE)

Level Offering 2ND Semester AY 2020-2021

Clinical area of assignment MEDICAL WARD
Date of Exposure FEBRUARY 8, 9 & 10, 2021
No. of hours 24 hours

DIZON, DEXIE
BSN3

F  Activity intolerance related to imbalance between myocardial oxygen supply and demand as
manifested by body weakness.

D  Received patient lying on bed, “Nang hihina ako, madali ako mapagod at para kong lagi inaantok“
 Weak in appearance
 Always asleep but easily awakens
 Shallow respiration
 Slow movements noted
 Needs assistance upon changing positions
 Dyspnea noted
 Pallor noted
 VS taken as follows: RR of 30cpm; with a heart rate of 69 bpm; blood pressure of 80 X 60 mmHg.

A  Monitored heart rate, rhythm, respirations and blood pressure for abnormalities. Notify physician of
significant changes in VS.
 Assessed usual daily activities of patient vs. Tolerated activities during complain of patient
 Assessed muscle strength
 Assessed laboratory results
 Observed for and documented skin integrity several times a day.
 Provided assistance to patient when moving
 Facilitated log rolling every 2 hours
 Performed active range of motion intermittently
 Regulated IVF at ordered rate
 Interacted with patient
 Made a schedule for nursing time to provide for uninterrupted rest periods
 Discussed with patient the need for gradual activity increase and resumption
 Encouraged/ Explained to patient to adhere to advised treatment
 Advised to avoid abrupt standing and moving
 Encouraged the use of Bed pan for urinating until tolerance to walking resumes

R  Patient was able to increase and achieve desired activity level, progressively, with no intolerance
symptoms noted, such as respiratory compromise as evidenced by activity participation.

Prepared by:
HILARIO A. SANGLAY
Clinical Instructor

Noted by:
GINA L. CASI, RN.Ph.D
Dean-CNC