BACHELOR OF SCIENCE IN NURSING:

INTENSIVE NURSING PRACTICUM

RLE LCP MODULE RLE LCP UNIT WEEK

CONGESTIVE HEART FAILURE

 Read course and laboratory unit objectives

 Read study guide prior to class attendance
 Read required learning resources; refer to course unit terminologies
for jargons
 Participate in weekly discussion board (Canvas)
 Answer and submit course unit tasks

At the end of this unit, the students are expected to:

1. Apply the nursing process in the care of groups of clients with congestive heart failure:
a. Assess the client’s total health condition and resources.
b. Formulate nursing diagnoses based on the given scenario.
c. Develop a plan of care for individuals with acute congestive heart failure.
d. Implement a plan of care applying the appropriate principles, guidelines, and steps in
administering care to clients with congestive heart failure.
e. Evaluate the outcomes(s) of care post in clients with congestive heart failure.
2. Demonstrate competencies of a beginning staff nurse, nurse leader, and researcher.
3. Promote personal and professional growth by showing independence in performing varied
tasks and responsibilities.
Skills laboratory equipment and materials
To facilitate the practice of students’ nursing skills, the following rules must be implemented:
1. The use of the Nursing Skills laboratory equipment and materials appropriate of the given
case scenario are allowed.
2. Use resources from the required readings.
3. Students must perform the tasks in the worksheet at a given period.
Key Areas of
Competency
Responsibility
1. Safe and Demonstrates knowledge
Quality Nursing about the clients’ health status
Care and set priorities in nursing
care based on clients’ needs
Provides sound decision
making in the care of
individual/ family considering
their beliefs and Values
Promotes safety, comfort, and
privacy
Administers medications and
other health therapeutics
safely (accurately and
correctly)
2. Management Organizes workload to
of Resources facilitate client care.
Utilizes resources to support
client care by ensuring proper
functioning of equipment
3. Health Develops health education
Education plan based on assessed
learning needs
4. Legal Adheres to practices in
Responsibility accordance with the nursing
law, institutional policies and
Expected Performance and Criteria
Identifies the client’s health status in
determining the interventions for client’s with
Congestive Heart Failure
Gathers and analyzes data relevant to the
client’s health condition in deciding laboratory
procedures for correctly diagnosing
Congestive Heart Failure
Maintains a safe environment and performs
individualized nursing care, procedures and
protocols to attain safety, comfort and privacy
in all aspects of care all the time.
Conforms to the 10Rs of medication
administration and health therapeutics
Identifies nursing tasks and performs them
based on priorities.
Finishes tasks on time.
Observes appropriate protocols and
institutional policies.
Ensures availability, completeness, and
functionality of equipment and nurse’s
paraphernalia relevant to the performance of
procedures relevant to Congestive Heart
Failure
Implements applicable age-appropriate health
education activities to the client based on
needs assessment
Acts and performs nursing tasks related to
procedures in accordance with established
norms of conduct expected of a nurse and an
 Key Areas of
Competency Expected Performance and Criteria
Responsibility
protocols, and other relevant OLFU student as well as with the other
legislation. relevant legislation.
5. Ethico-moral Adheres to Code of Ethics of Maintain the privacy and confidentiality of
responsibility Nurses and respect rights of client’s information.
the client and other individuals
Accepts responsibility and accountability on
involved in the care of the the decisions made relating to the client’s
client. care.
6. Personal and Project a professional image Performs nursing tasks according to
Professional of the nurse professional standards.
Development Demonstrates good manners and right
conduct at all times.
Observes proper grooming and hygiene.
Adapts to changes willingly by being open to
new strategies or approaches relevant to the
care of client’s with Congestive Heart Failure
7. Quality Identifies and reports Identifies and reports inadequacies and
Improvement variances and recommends problem(s) encountered in the care of clients
appropriate solutions. with Congestive Heart failure
Recommends practical and appropriate
solutions.
8. Research Enhances competency level in Specifies researchable problems related to the
the utilization of different care of clients with Congestive Heart failure
forms of data gathering and and preventing complications.
principles of assessment and Gather, analyze, and interpret relevant data.
nursing care.
Analyzes and interprets data, Utilizes findings in research in the provision of
disseminate findings and CHF-related measures and client care.
apply recommend actions.
9. Records Maintains accurate and Records outcome of client care.
Management updated documentation of Submits legible, accurate and updated
client care observing legal documentation and/or information regarding
imperatives in documentation the client care.
and record keeping.
10. Communicatio Identifies verbal and non- Interprets and validates client’s body language
n verbal cues and facial expressions
Uses appropriate information Utilizes appropriate means and/or channels of
technology to facilitate communication to support the delivery of care
communication. to clients with Myocardial infarction
11. Collaboration Collaborates plan of care with Respects the role of other members of the
and Teamwork the other health care team health care team in administering procedures
members. and care to the client.
Refers the client to the appropriate allied
health team partners.
This is a case of a 65 year old female with a 10 year history of hypertension and diabetes. She
is taking Micardis 40 mg in the morning and Amlodipine 5 mg at night for hypertension. For
diabetes she is being given Janumet 100mg/1g 2x a day and Gliclazide 60 mg OD before
breakfast. The daughter reported poor compliance with medications.
The patient was brought to the emergency room due to difficult of breathing. Condition started
2 days PTA when the patient had easy fatigability going to the comfort room. She started
taking all her medications again but she did not seek consult. Symptom persisted until she
would have difficulty of breathing when getting out of bed.
In the emergency room BP 180/100 HR 110/min RR 35/min O2 sat 93%, Temp 36.8, patient is
pale, diaphoretic and in severe respiratory distress. (+) edema up to the knees area, (+)
crackles from lower to mid portion of the lungs.
In the emergency room, the client was given O2 per canula at 4-5lpm. IVF was initiated. The
doctor ordered for Furosemide 40 mg IV stat. CXR was done in the emergency room showing
pulmonary edema and heart enlargement

Complete the following activities to provide high quality, individualized care to the patient
1. From the data provided, formulate a nursing diagnosis and a care plan to be
implemented in the emergency room to this client.
2. What are other significant data that you need to be gathered in this client?
3. What do you think are the other diagnostic tests that will be ordered for this client and
their possible findings?

The client’s creatinine and serum potassium were elevated, she was referred to a nephrologist
for possible dialysis.
Make a pathophysiology on how kidney failure happens to a client with acute congestive heart
failure.
 .
Disposition Procedures & Meds Patient Survey Situation Unit Information

Adapted from PreMIS (https://ncems.org)

Patient Care Report Narratives
Time: C:

Date: H:

A:

R:

T:

_________________ ________ _____________________ _______________

Patient Received By Date Drv/Medic Certification & Number
_________ ________________________ _________________
Date Medic 1 Certification &
Number
_________ ________________________ _________________
Date Medic 2 Certification &
Number

(Evaluation Tool – refer to the given rubrics)

Date Completed:
Date Submitted:

1. Hinkle, J. and Cheever, K. (2017). Brunner & Suddharth’s Textbook of Medical-Surgical

Nursing, 14th ed. USA: Wolters Kluwe

2. Ignatavicius, D. and Workman, L. Medical-Surgical Nursing, 9th Edition

3. Mc Cance (2012) Pathophysiology, Eighth edition, Elsevier