TABLE OF CONTENTS

Table of Contents i
Acknowledgment ii

CHAPTER
I. Objectives page 2
II. Introduction page 4
III. Patient’s Profile page 6
i. Biographic Data page 6
ii. Clinical Data page 7
iii. Past Health History page 8
iv. Present Health History page 8
v. Family History with Genogram page 8
IV. Comprehensive Health Assessment page 10
V. Review of Anatomy and Physiology page 14
VI. Pathophysiology page 24
i. Definition of Diagnosis page 24
ii. Etiology page 26
iii. Symptomatology page 30
iv. Schematic Diagram page 34
v. Narrative page 37
VII. Course in the Ward/Treatment/Interventions page 40
i. Doctor’s Progress Notes page 40
ii. Laboratory/Diagnostic Examinations page 49
VIII. Pharmacologic Management (Drug Study) page 60
IX. Nursing Care Plan page 75
X. Discharge Plan page 92
XI. References page 96

i
 ACKNOWLEDGEMENT

This manuscript would not have been a success without the assistance of
these significant people.The group would like to express its heartfelt gratitude and
appreciation to the following individuals for their endless aid and support:

To God, our Father, all praises and glory to You. We went through a lot during
this unique experience, but it taught us to be mature enough in dealing with our
challenges, as well as how to be a better son and daughter to you. Thank you for
providing us with far more than we deserve.

To our ever loving, supportive and devoted parents, thank you for your
unwavering financial, emotional, and spiritual support. Despite the fact that it was the
most expensive, difficult, and hectic experience, you were always available when we
needed you;

To our Program Chair-Nursing, Christine M. Fiel. Phd, RN, MN, for allowing
us to witness this wonderful rotation in the midst of the pandemic This has been a
life-changing event for all of us;

To our RLE Supervisor, Kenneth M. Sabido, RN, MN, and our Clinical
Instructor, Daniel B. Garcia, Jr., RN, MSN, CHA, FPCHA, DCE, thank you for your
constant supervision and support;

To our patient and his family, thank you for your cooperation and for
entrusting us with our obligations as student nurses.

This has been a tremendous experience for us; it has shaped us into better,
more mature people. This would not be possible without your assistance.

1
 CHAPTER I

STATEMENT OF OBJECTIVES

Specific objective

Specifically, the group aims to attain the following objectives within the allotted time
given for the case study completion:

a) Provide an Introduction that will give an overview of the study;

b) Present accurate clinical information of the client, which will serve as the
baseline information. These would include personal and clinical information
such as health histories, nursing assessments, etc.;

c) Formulate a narrative health assessment including the findings that is

specific, measurable, attainable, realistic, and time-bounded;

d) Make a genogram that reflects both sides of the patient's family to trace and
locate possible hereditary diseases;

e) Identify the body system/s involved in the disease process and create a
review of anatomy and physiology;

f) Define the diagnosis of the patient's condition with a minimum of three

definitions;

2
g) Discuss the pathophysiology of the specific disease, including the correlating
predisposing and precipitating factors and its symptomatology to fill in with the
needed knowledge necessary to understand the disease process;

h) Rationalize the patient's medical management, which is reflected on the

doctor's order, diagnostic tests, and laboratory examinations to determine the
specific functions of the varied interventions;

i) Create nursing care plans and drug studies of medications given to the
patient; and

j) Render appropriate teachings to the client through discharge planning.

3
 CHAPTER II

INTRODUCTION

The only cardiovascular condition with rising hospitalization costs and a

persistent drain on health care spending is Congestive Heart Failure (CHF). As
people live longer, CHF is more common, with diastolic heart failure being more
common among the elderly. The first line of defense against coronary artery disease
is vigorous blood pressure management, which also plays a key role in risk factor
management. In Addition, health care providers from a variety of specialties will
come into contact with individuals who are at risk for heart failure as the population
ages and cardiovascular risk factors become more widespread. Application of
current guidelines and risk factor reduction through lifestyle adjustments are
essential for effective management of this population. The survival and quality of life
of patients with heart failure have significantly improved over the past generation
thanks to a combination of behavioral, pharmacological, device-based, and surgical
treatment modalities. The continual application of these guidelines and research into
cutting-edge treatment modalities are still essential in light of the rising prevalence of
heart failure. (Ramani & Uber, 2010).

A study conducted for risk behavior studies among a subgroup of older

Filipinos living in low-income communities in the Philippines, the study was able to
gain a better understanding of the heart health problems that afflict this population
and how to prevent them from enhancing the overall well-being of older Filipinos
nationwide. Congestive Heart Failure is the leading cause of death for Filipinos,
accounting for about 32% of all Filipino deaths. Hypertension is one of the significant
risk factors that are quite prevalent among Filipinos in both the USA and in the
Philippines and increases their risk of the disease (Cacciata et.al, 2021). In addition,
Davao city had the highest number of deaths by heart diseases in the Philippines'
Davao region, accounting for nearly 2.1 thousand out of over 6.2 thousand deaths

4
across the region last 2019. On the other hand, the city of Mati reported only 175
deaths from heart diseases in the same year (Statista Research Department, 2022).

In the study of (Tumanan-Mendoza et. Al, 2017), it was aforementioned that

the prevalence of hospitalization due to congestive heart failure (CHF) among adult
patients aged 19 years and above in the Philippines and its 17 regions in 2014. It
also determined the demographic profile of these patients, etiology and type of CHF,
comorbidities, duration of hospitalization and the overall in-hospital mortality rate.
There were 16 cases of heart failure for every 1000 Filipino patients admitted due to
a medical condition in 2014. Hypertension was possibly the most common etiologic
factor. Compared to western and Asia-Pacific countries, the local mortality rate was
relatively higher.

Moreover, four million adults in the Philippines are diagnosed with diabetes
and common comorbidities and complications with type 2 diabetes, including heart
diseases. More than 32% of those with type 2 diabetes have cardiovascular
complications, while more than 87% are either overweight or obese, according to the
data collected.

Locally, Dabwenyos should maintain their health and take care of their
kidneys because the city has had the third-highest number of renal disorders
nationwide since 2017. Each year, people with hypertension lose 2% of their
kidney's functionality, whereas people with diabetes lose 5% of their kidney's
functionality. The PhilHealth Circular 2021-0009 states that although a patient
typically receives hemodialysis treatment 90 days per year, the approved payment of
benefit claims has lately been According to the National Kidney and Transplant
Institute (NKTI), one Filipino develops chronic renal failure every hour or about 120
Filipinos per million population every year. Latest estimates show that around 2.3
million Filipinos have chronic kidney disease (CKD). In 2016, more than 36,000
patients were on dialysis treatment which reflects a 15 percent increase in the
number of patients in just one year (Dr Bad-ang, 2022).

5
 CHAPTER III

PATIENT'S PROFILE

This section contains the patient’s important health information to allow ease
of data retrieval as necessary. The patient’s complete profile includes the following
components: Biographic Data, Clinical Data, Past Health, Present Health History,
and Family History.

Biographic Data

The table below shows the patient’s most basic available information.

Name Patient P.C.

Age 70 years old

Birthday July 8, 1952

Gender Male

Status Married

Weight 85 kg

Height 167.6 cm

BMI 30.3 (Obese)

Nationality Filipino

Religion Born Again Christian

Occupation Retired

Table 1. Biographic Data

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Clinical Data

Clinical data includes information on determinants of health, health metrics, and

health status, as well as documentation of care delivery. These records are collected
for a variety of reasons and stored in a variety of databases throughout the
healthcare system.

● Chief of complaint: Exertional dyspnea

● Date of Admission: October 18, 2022
● Time of admission: 5:58 PM
● Mode of Arrival: Ambulatory
● Bed and Room no.: 516
● Attending Physician: Dr. Tan
● Diagnosis: Congestive heart failure secondary to coronary artery
disease functional capacity level II, bilateral pedal effusion, acute
kidney injury secondary to intrarenal azotemia probably top of
chronic kidney disease secondary to diabetes kidney disease.
● Vital signs:

Blood pressure 120/70 mmHg

Heart rate 65 bpm
Respiratory rate 28 cpm
Temperature 35.7 °C
O2 saturation 93% on room air
Table 2. Vital Signs

7
Past Health History:

Patient had a history of Diabetes Mellitus type II managed with insulin (toujeo)
26U for 20 years, Hypertension managed with Losartan 100mg for 3 years, Deep
Vein Thrombosis managed with Cilostazol 50mg and Clopidogrel 75mg, and
elevated creatinine managed with Aminoral 1 tab for 1 year. The patient had his
spinal cord compression repair surgery in 2017 at SPMC and Phacoemulsification
surgery in 2020 at Mission Mintal. The patient is a former smoker (20 packs per
year) and occasional alcoholic beverage drinker. Patient is allergic to the medication
Dapagliflozin under the brand name Forxiga.

Present Health History:

3 months prior to admission, the patient noted episodes of 2 pillow orthopnea

associated with exertional dyspnea, he noted that he can walk approximately >100m
and can still climb flights of stairs. No medication taken, no consultation was done. In
the interim, the patient had current symptoms but tolerated.

October 18, 2022, the patient had a consult with AP, still with exertional
dyspnea now noted to have shortened the distance that he is able to walk. No
cough, no fever. The patient had work up, noted with blood pressure elevation of
200/100 and elevated troponin I of 1.45 H thus advised admission. The patient is
awake, responsive, coherent. The patient has a globular abdomen and grade 2
pitting edema. Vital signs are the following: BP: 200/100, PR: 69, RR: 22, T: 36.6, O2
saturation: 99%.

Family Health History:

Family health history reveals positive for hypertension on the paternal side.
The maternal side reveals positive for hypertension and diabetes mellitus type II.

8
Genogram

Figure 1. Genogram

9
 CHAPTER IV

COMPREHENSIVE HEALTH ASSESSMENT

This part of the manuscript is dedicated to help in essential nursing function which provides foundation for quality
nursing care and intervention. Health assessment helps to identify and collect the normal, risk factors and any alterations
or health problems on the patient’s condition.

COMPREHENSIVE HEALTH ASSESSMENT

GUIDELINES NORMAL ASSESSMENT DAY 1 DAY 2 DAY 3

I. MENTAL STATUS

a) State of mental Alert, Conscious, and coherent N/A N/A Patient is alert, conscious, and
consciousness coherent
b) Orientation Oriented to person, time, place, N/A N/A Can recognize the people around
and event occurring him. Oriented to time, place,and
surroundings
c) Attention span Has attention span of 5 to 15 N/A N/A Has an attention span of at least
minutes and able to cooperate 5-8 minutes
d) Ability to understand Can comprehend things and N/A N/A Can understand instructions
understand situation properly

II. STATE OF SPECIAL SENSES

a) Auditory perception Able to hear clearly in both ears N/A N/A Can hear in both ears without
using any aids
b) Visual perception Able to see without the use of N/A N/A Patient can watch TV from a
any aids distance without any eyeglasses
c) Speech perception Able to speak spontaneously N/A N/A Can speak clearly but in low

10
 voice
d) Tactile perception Reactive to touch, and to hot or N/A N/A Patient is reactive during
cold sensation palpation of apical pulse
e) Olfactory perception Has good sense of smell N/A N/A Patient can distinguish odors

III. MOTOR ABILITY

a) Current mobility Ambulatory without any N/A N/A Patient is on complete bed rest
assistance
b) Posture Erect body posture on standing N/A N/A He was on lying position upon
and sitting observation
c) Range of joint Able to flex and raise upper and N/A N/A Can extend, flex, and raise his
motion lower extremities upper extremities
d) Muscle and nervous Good muscle strength and N/A N/A Can clench fist in a weak manner
status coordinated movement
e) Loss of extremities Has complete extremities N/A N/A No loss of extremities

IV. BODY TEMPERATURE

a) Range 36.5- 37. 5 degree celcius N/A N/A 34.7 - 35.7 degree celcius
V. RESPIRATORY STATUS
a) Character Clear breath sounds without N/A N/A Decreased breath sounds at left
extra effort in respiration. RR base + Minimal crackles at right
range of 16-20 cpm base. Patient uses accessory
muscles while breathing when in
discomfort with an RR range of
20-28 cpm. Patient experiences
SOB when lying and can be
relieved by positioning him in
semi-fowlers position
b) Use of respiratory No oxygen inhalation supplement N/A N/A Patient has oxygen inhalation via
aids nasal cannula at 2 liters per

11
 minute
c) Interference with No interference with respiration N/A N/A With oxygen administration noted
respiration
d) Abnormal No abnormal Opening N/A N/A No abnormal respiratory opening
respiratory opening

VI. CIRCULATORY STATUS

a) Characteristic of Regular, strong, and palpable N/A N/A Regular but weak to palpate
arterial pulse pulse
b) Apical-Radial pulse Has palpable pulse with a range N/A N/A Weak to palpate with a range of
of 60-100 bpm with rhythmic 60 - 65 bpm
beats
c) Intravenous fluids With intravenous fluid N/A N/A Without intravenous fluid

VII. NUTRITIONAL STATUS

a) Condition of Buccal Has pinkish buccal cavity with N/A N/A Intact gums, no lession noted,
Cavity enough misture, no lession, complete set of teeth
redness and swelling
b) Digestion of Food Has good appetite, able to N/A N/A Consumes all the food served
consume all food served
c) Weight Appropriate to his age = 193.4 lb N/A N/A 85 kg.
(84.72kg)

VIII. ELIMINATION STATUS

a) Bowel Defecates once a day N/A N/A Not able to defecate during the
shift
b) Bladder Can urinate freely N/A N/A Voids freely for at least 2 times
during the shift and urine is
slightly yellow in color
c) Abnormalities No abnormalities in elimination N/A N/A No abnormalities in elimination

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IX. FEMALE REPRODUCTIVE STATUS

a) Age of menarche N/A N/A N/A

b) Pattern of Menses N/A N/A N/A
c) Pregnancy N/A N/A N/A
d) Vaginal Discharge N/A N/A N/A
X. STATE OF SKIN AND APPENDAGES
a) Skin Has intact skin with good skin N/A N/A Skin is dry
turgor
b) Hair Fine and evenly distributed N/A N/A Hair is evenly distributed
c) Nails Well trimmed nails, pink nail N/A N/A Clean and well-trimmed nails with
beds, short and clean CRT of 2 seconds
d.) Mucosa Moist and clear N/A N/A Oral mucosa is moist
XI. STATE OF PHYSICAL HEALTH AND STATUS
a) Sleep/ Rest pattern Sleeps at least 6-8 hours a day N/A N/A Patient sleeps mostly during
admission
b) Presence of pain/ No presence of pain/discomfort N/A N/A Chest pain was noted. Slight
discomfort discomfort was noted due to
difficulty in breathing & shortness
of breath. Pain scale of 7/10
c) Use of supportive No supportive aids use N/A N/A Patient does not use any
aids supportive aids
XII. EMOTIONAL STATUS
a) Emotional reaction Responds appropriately to topics N/A N/A Can express his concerns very
and discomfort well when asked
b) Body Image Has good body image N/A N/A Has bipedal edema
c) Ability to relate to Can relate to others and N/A N/A Can socialize very well
others expresses good feelings
Table 3. Comprehensive Health Assessment

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 CHAPTER V

REVIEW OF ANATOMY AND PHYSIOLOGY

This section of the manuscript is dedicated to the review of Anatomy and Physiology
of the affected organ/system.

Cardiovascular System

Figure 2. Cardiovascular System (Vanputte et al., 2020).

The Circulatory System, also known as the Cardiovascular System, is in

charge of delivering oxygen and nutrients to all parts of the body. It also removes
waste from cells and organs so that the body can eliminate it. This system includes
the heart, blood and blood vessels which are the veins, arteries, and capillaries
(Martini et al., 2018).

The heart is a mediastinal structure that acts as the body’s pumping station,
by which it pumps blood to the lungs and to the systemic arteries. In the anatomical
position, the heart is obliquely positioned, with its anatomical base pointing
posterolaterally to the right and the apex of the heart directed anterior inferior to the
left. The right cardiac chambers account for most of the anterior or sternocostal
surface of the heart. However, the walls of both ventricles constitute the inferior or

14
diaphragmatic surface. Also, it is surrounded by a pericardium, a sac composed of
the outer and inner layers. Pericardial space, on the other hand, delicately protects
and cushions the heart by having pericardial fluid lubricate its inner layers (Martini et
al., 2018).

In addition, the wall of the heart has three layers, namely: (1) Epicardium, the
heart's outermost layer, a visceral layer that attaches to the myocardium of the heart.
(2) Myocardium is the middle layer of the heart that is made up of cardiac muscle
fiber. It manages the power needed to transport the oxygen pumped by the heart to
the rest of the organs. (3) Endocardium, the innermost layer of the heart. This layer
outlines the inner heart chambers, covers heart valves, and is running alongside the
endothelium of large blood vessels (Martini et al., 2018).

Further, the blood flow is pumped by the heart's four major vessels. These are
as follows: (1) Aorta, transports blood away from the left ventricle via the main trunk
of the systemic artery system. (2) Superior and inferior vena cava deliver blood
from the head and chest area to the heart, while the inferior vena cava returns blood
from the lower body regions to the heart. (3) Pulmonary artery, responsible for
transporting blood from the right ventricle to the lungs. (4) Pulmonary veins, there
are four of them, two on the left and two on the right, and they all transport
oxygenated blood to the left atrium from the left and right lungs, correspondingly
(Martini et al., 2018).

Furthermore, the heart is made up of four chambers namely: (1) Right atrium,
which receives non-oxygenated blood from the superior vena cava and inferior vena
cava and pumps it through the tricuspid valve to the right ventricle. (2) Right
ventricle is responsible for pumping the blood through the pulmonary valve to the
lungs, where it becomes oxygenated. (3) Left atrium receives oxygenated blood
from the lungs and pumps it through the mitral valve to the left ventricle. (4) Left
ventricle pumps oxygen-rich blood through the aortic valve to the aorta and the rest
of the body (Martini et al., 2018).

15
 Lungs

Figure 3. The Lungs (Vanputte et al., 2020).

The lungs are the foundational organs of the respiratory system, whose most
basic function is to facilitate gas exchange from the environment into the
bloodstream. The lungs are pyramid-shaped, paired organs that are connected to the
trachea by the right and left bronchi; on the inferior surface. The trachea is a tube-like
structure within the neck and upper chest. It transports air to and from the lungs when
a person breathes (Sendić, 2022).

Each lung is composed of smaller units called lobes. Fissures separate these
lobes from each other. The right lung consists of three lobes: the superior, middle,
and inferior lobes. The left lung consists of two lobes: the superior and inferior
lobes. A bronchopulmonary segment is a division of a lobe, and each lobe houses
multiple bronchopulmonary segments. Each segment receives air from its tertiary
bronchus and is supplied with blood by its artery. Further, inside the lungs are
bronchi—tubes that run from the trachea into each lung. The bronchi branch off into
smaller tubes called bronchioles which help air reach the alveoli, which are tiny air
sacs in each lung. The alveoli are where the lungs and the blood exchange oxygen
and carbon dioxide during the process of breathing in and breathing out. Pulmonary
surfactant is essential for life as it lines the alveoli to lower surface tension, thereby
preventing atelectasis, a complete or partial collapse of the entire lung or area (lobe)

16
of the lung, during breathing. Pulmonary surfactant is a complex mixture of specific
lipids, proteins, and carbohydrates, which is produced in the lungs by type II alveolar
epithelial cells. The surfactant mixture is an essential group of molecules to support
air breathing (Sendić, 2022).

KIDNEYS

Figure 4. The Kidneys (Vanputte et al., 2020).

The kidneys are located on either side of the vertebral column, between
vertebrae T12 and L3. The left kidney lies slightly superior to the right kidney. The
kidneys are vital organs responsible for clearing waste products, salts, and water
from the body (Vanputte et al., 2020).

External Structures of the Kidney

There are two kidneys, one on each side of the spinal column. They are
approximately 11 cm long, 5–6 cm wide and 3–4 cm thick. They are said to be
bean‐shaped organs, where the outer border is convex; the inner border is known as
the hilum, and it is here that the renal arteries, renal veins, nerves, and the ureters
enter and leave the kidneys. The renal artery carries blood to the kidneys; and once
the blood is filtered, the renal vein takes the blood away. The right kidney is in

17
contact with the liver’s large right lobe, and hence the right kidney is approximately
2−4 cm lower than the left kidney (Vanputte et al., 2020).

Covering and supporting the kidneys are three layers: (1) renal fascia, is the
outer layer and consists of a thin layer of connective tissue that anchors the kidneys
to the abdominal wall and the surrounding tissues. The middle layer is called (2) the
adipose tissue and surrounds the capsule. It cushions the kidneys from trauma. The
inner layer is called (3) the renal capsule. It consists of a layer of smooth connective
tissue that is continuous with the outer layer of the ureter. The renal capsule protects
the kidneys from trauma and maintains their shape (Vanputte et al., 2020).

Internal Structures of the Kidney

There are three distinct regions inside the kidney: (1) The renal cortex is the
outermost part of the kidney. The renal column is the medullary extension of the
renal cortex. The renal cortex is reddish in color and has a granular appearance,
which is due to the capillaries and the structures of the nephron. (2) The medulla is
lighter in color and has an abundance of blood vessels and tubules of the nephrons.
The medulla consists of approximately 8–12 renal pyramids. The renal pyramids,
also called Malpighian pyramids, are cone‐shaped sections of the kidneys. The
wider portion of the cone faces the renal cortex, while the narrow end points
internally, and this section is called the renal papilla. Urine formed by the nephrons
flows into cup‐like structures, called calyces, via papillary ducts. Each kidney
contains approximately 8–18 minor calyces and two or three major calyces. The
minor calyces receive urine from the renal papilla, which conveys the urine to the
major calyces. The major calyces unite to form (3) the renal pelvis, which then
conveys urine to the bladder. The renal pelvis forms the expanded upper portion of
the ureter, which is funnel‐shaped and it is the region where two or three calyces
converge (Vanputte et al., 2020).

18
 Nephron

These are small structures and they form the functional units of the kidney.
Two types of nephrons found in the kidney are cortical nephrons and
juxtamedullary nephrons. Each kidney has about 1.25 million nephrons, with a
combined length of about 145 km (85 miles). The nephron consists of a glomerulus
and a renal tubule. The glomerulus is the main filtering unit of the kidney. It is formed
by a capillary network between an afferent arteriole and an efferent arteriole. There
are approximately over 1 million nephrons per kidney, and it is in these structures
where urine is formed. The nephrons: (1) Filter blood; (2) Perform selective
reabsorption; (3) Excrete unwanted waste products from the filtered blood .

The nephron is part of the homeostatic mechanism of the body. This system
helps regulate the amount of water, salts, glucose, urea, and other minerals in the
body. The nephron is a filtration system located in the kidney and is responsible for
the reabsorption of water and salts (Martini et al., 2018).

The nephron is divided into several sections:(1) Bowman’s capsule, also

known as the glomerular capsule. Bowman’s capsule is a cup‐like sac and is the
first portion of the nephron. It performs the first step in the filtration of blood to form
urine. (2) Proximal convoluted tubule, from Bowman’s capsule, the filtrate drains
into the proximal convoluted tubule. The surface of the epithelial cells of this segment
of the nephron is covered with densely packed microvilli. The microvilli increase the
surface area of the cells, thus facilitating their resorptive function. It absorbs salt,
water, glucose, amino acids, potassium, urea, phosphate, and citrate; and helps to
manage the pH level of the blood. (3) Loop of Henle, the proximal convoluted tubule
then bends into a loop called the loop of Henle. The main function of the loop of
Henle is to generate a concentration gradient that creates a region of a high
concentration of sodium in the medulla of the kidney. (4) Distal convoluted tubule,
the thick ascending portion of the loop of Henle leads into the DCT. It’s an important
site for the active secretion of ions and acids, regulation of calcium ions, selective

19
reabsorption of water, and regulation of pH level. (5) The collecting ducts, the
collecting duct system, is the last part of the nephron and participates in electrolyte
and fluid balance through reabsorption and excretion, processes regulated by the
hormones aldosterone and vasopressin. From here the filtrate, now called urine,
drains into the renal pelvis. This is the stage where sodium and water are finally
reabsorbed (Martini et al., 2018).

Glomerular Filtration

Filtration is the process in which blood pressure forces plasma and dissolved
material out of capillaries. In glomerular filtration, blood pressure forces plasma,
dissolved substances, and small proteins out of the glomeruli and into Bowman’s
capsules. This fluid is no longer plasma but is called the renal filtrate (Martini et al.,
2018).

The blood cells and larger proteins are too large to be forced out of the
glomeruli, so they remain in the blood. Waste products are dissolved in blood plasma,
so they pass into the renal filtrate. Useful materials such as nutrients and minerals
are also dissolved in plasma and are also present in the renal filtrate (Martini et al.,
2018).

The glomerular filtration rate is the amount of renal filtrate formed by the
kidneys in 1 minute and averages 100 to 125 mL per minute. GFR may be altered if
the rate of blood flow through the kidney changes. If blood flow increases, the GFR
increases, and more filtrate is formed. If blood flow decreases, the GFR decreases,
less filtrate is formed, and urinary output decreases (Martini et al., 2018).

20
 Enzymes, Hormones, and Cells

Angiotensin and aldosterone

As the blood volume and blood pressure decrease, the juxtaglomerular cells
secrete a hormone called renin. Renin is an enzyme that helps control your blood
pressure and maintain healthy levels of sodium and potassium in your body. Renin
acts on a plasma protein called angiotensinogen and converts it into angiotensin I.
Angiotensinogen is produced by the hepatocytes of the liver. Angiotensin I is
transported by the blood to the lungs. In the lung capillaries, there are enzymes
called angiotensin-converting enzymes. ACE is predominantly found in the lung
capillaries, but this enzyme is also found throughout the body. ACE converts
angiotensin I into angiotensin II. Angiotensin II causes the muscular walls of small
arteries or also known as arterioles to constrict, increasing blood pressure.
Angiotensin II also triggers the release of the hormone aldosterone from the adrenal
glands and vasopressin, an antidiuretic hormone from the pituitary gland. Aldosterone
and vasopressin cause the kidneys to retain sodium. Aldosterone also causes the
kidneys to excrete potassium. The increased sodium causes water to be retained,
thus increasing blood volume and blood pressure (Manual, 2022).

Production of aldosterone in the zona glomerulosa of the adrenal cortex is

regulated by the renin-angiotensin system. The renin-angiotensin-aldosterone
system is a well-known regulator of blood pressure and a determinant of target-organ
damage. It controls fluid and electrolyte balance through coordinated effects on the
heart, blood vessels, and kidneys. Angiotensin II is the main effector of the
renin-angiotensin-aldosterone system and exerts its vasoconstrictor effect
predominantly on the post-glomerular arterioles, thereby increasing the glomerular
hydraulic pressure and the ultrafiltration of plasma proteins, effects that may
contribute to the onset and progression of chronic renal damage. AII may also directly
contribute to accelerated renal damage by sustaining cell growth, inflammation, and
fibrosis. Interventions that inhibit the activity of the RAAS are renoprotective and may

21
slow or even halt the progression of chronic nephropathies. ACE inhibitors and
angiotensin II receptor antagonists can be used in combination to maximize RAAS
inhibition and more effectively reduce proteinuria and GFR decline in diabetic and
nondiabetic renal disease (Remuzzi et al., 2021).

Erythropoietin

Erythropoietin (EPO) is a glycoprotein hormone that is naturally produced by

the peritubular cells of the kidney. The supply of this hormone is adequately
maintained by the body in order to stimulate red blood cell production. Simply, EPO
helps make red blood cells. Having more red blood cells raises hemoglobin levels.
Red blood cells include the protein hemoglobin, which aids in the blood's ability to
deliver oxygen throughout the body.

Patients with end-stage renal disease or chronic kidney disease are typically
prescribed ESAs. These individuals typically have lower hemoglobin levels which
result in the inability to manufacture enough erythropoietin because there is damage
to the kidneys and limited EPO production by the peritubular cells. Also, this hormone
is secreted whenever the blood oxygen level decreases. With more RBCs in
circulation, the oxygen-carrying capacity of the blood is greater, and the hypoxic state
may be corrected. Anemia is one of the most debilitating consequences of renal
failure, one that hemodialysis cannot reverse. Diseased kidneys stop producing
erythropoietin, a natural stimulus for RBC production. Erythropoietin can be produced
by genetic engineering and is available for hemodialysis patients (Remuzzi et al.,
2021).

Immune Cells

Included also in the disease process are the immune cells like the
macrophages and fat-laden macrophages called foam cells. Renal macrophages
(RMs) are myeloid cells residing in renal tissue that fulfill specific renal functions

22
including homeostasis, immune surveillance, and repair (Liu et al., 2020). In a state of
hypertension, which is considered one of the common causes of Chronic Kidney
Disease, these macrophages slip into the damaged glomerulus and start secreting
growth factors. These growth factors include the Transforming Growth Factor Beta 1.
Transforming growth factor-β (TGF-β) is a profibrotic cytokine found in chronic
renal diseases, which initiates and modulates a variety of pathophysiological
processes (Loeffler & Wolf, 2013). These growth factors cause the mesangial cells, or
the specialized cells in the kidney, to regress back to their more immature cell state
known as mesoangioblasts.

23
 CHAPTER VI

PATHOPHYSIOLOGY

i. Definition of Diagnosis

In accordance with Tinsley (2018), congestive heart failure, often known as

heart failure, is a condition where the heart muscle is unable to pump blood as
efficiently as it should. Shortness of breath is frequently brought on by this because
blood frequently backs up and fluid can accumulate in the lungs. The heart eventually
becomes too weak or stiff to fill and pump blood adequately as a result of several
cardiac disorders, such as coronary artery disease (coronary artery disease) or
excessive blood pressure. With the right care, heart failure symptoms and indications
can be reduced, and some patients may even live longer. Your quality of life can be
improved by making lifestyle changes including decreasing weight, getting more
exercise, cutting back on salt (sodium) in your diet, and managing stress. Heart
failure, however, poses a risk to life. Tinsley also aforementioned that this condition
deteriorates over time. In fact, there are four phases of cardiac failure (Stage A, B, C
and D). From "high risk of developing heart failure" to "advanced heart failure," there
are various stages. You progress to the next stage of heart failure as your heart
muscle pumps less blood to your organs as heart failure worsens. Since you cannot
advance through the stages of heart failure backward, the aim of treatment is to stop
you from doing so or to stop the course of your heart failure.

Moreover, heart failure does not imply that the heart is no longer beating.
Instead, it indicates that the heart performs less effectively than usual. Blood
pressure in the heart rises and blood flow through the heart and body is slowed down
due to a number of potential reasons. As a result, the heart is unable to pump the
body's requirements for oxygen and nourishment. The heart's chambers may react by
expanding to accommodate more blood to pump through the body or by stiffening

24
and thickening. This keeps the blood flowing, but with time, the heart muscle walls
may deteriorate and lose their ability to pump as effectively. Furthermore, the body
may begin to retain fluid (water) and salt as a result of the kidneys' reaction. The
body becomes clogged if fluid accumulates in the limbs, legs, ankles, feet, lungs, or
other organs. The condition is referred to as congestive heart failure. Heart failure
may now be treated in more ways than ever before. The first steps involve stringent
management of your drugs and way of life, along with continuous monitoring. As the
condition worsens, specialists in the treatment of heart failure may be able to provide
more cutting-edge options (Merschel, 2019).

Heart failure is a chronic disorder in which your heart is unable to continuously

pump blood efficiently enough to satisfy your body's demands. Exercise, medication,
and maybe surgery are all part of the course of treatment for heart failure. How well
you take care of yourself is one of the aspects that affects your attitude. Heart failure,
also known as congestive heart failure, is a chronic illness that deteriorates over time.
Heart failure, despite the name suggesting otherwise, is the inability of the heart to
pump blood as effectively as it should. Your organs may suffer harm when your
heart's pumping capacity is reduced, and fluid may build up in your lungs. Your heart
can't pump enough blood around your body, which results in congestive heart failure.
Other regions of your body begin to accumulate as a result, most frequently your
lungs and lower extremities (feet/legs). In actuality, about 6 million Americans suffer
from heart failure, and more than 870,000 new cases are discovered every year.
Congestive heart failure is the most common reason for hospitalization in adults over
65 (Cassoobhoy, 2020).

25
ii. Etiology

This section is dedicated to the etiology of the patient's current condition which
will help us identify the predisposing and precipitating factors that contributed to the
development of the condition

ETIOLOGY PRESENT JUSTIFICATION

(Predisposing/Precipitating)

PREDISPOSING:

Genes ✓ Hypertension tends to run in

- Hypertension families. Individuals whose parents
- Diabetes II have hypertension have an elevated
risk of developing the condition,
particularly if both parents are
affected (National Library of
Medicine, 2019).

Gender ✓ Men are almost twice as likely to

- Male develop type 2 diabetes as women.
Being overweight or obesity is
considered a primary risk factor for
diabetes. However, obesity rates are
similar between men and women in
the U.S. This suggests that the
relationship between sex, weight,
and diabetes may be more nuanced
(Meisser, 2021).

Age ✓ The risk of developing diabetes

increases with age. Hypertension is
- 70 years old a highly prevalent condition with
numerous health risks, and the
incidence of hypertension is greatest
among older adults (Rev, 2016).

Diabetes ✓ Diabetes is a disease that creates

high glucose levels in the blood.

26

High Blood Pressure ✓ High blood pressure escalates
- BP: 200/100 mmHg
Heart Attack ✓ If you’ve previously had heart
Coronary Artery Disease ✓ Coronary arteries help circulate the
Heart Valve Disease X Heart valve disease occurs when
27
Typically, your pancreas should
create insulin to regulate your blood
sugar levels, but when this hormone
is lacking, it eventually leads to high
blood sugar. Diabetes also
contributes to hardening and
narrowing the arteries, constricting
blood flow and increasing your risk
of developing heart failure (Modern
Heart and Vascular, 2022).
tension in the body’s arteries, which
carry blood to and from the heart.
People who have hypertension can
also be in danger of developing
congestive heart failure (Modern
Heart and Vascular, 2022).
attacks, you also have a higher
chance of developing congestive
heart failure. Each heart attack
weakens the heart muscle, which
could put you in danger of
developing other heart conditions. A
deficient heart cannot function the
way it needs to, supplying blood and
oxygen to organs (Modern Heart
and Vascular, 2022).
blood back to the heart. With
coronary artery disease, the walls of
the heart’s artery accumulate
built-up cholesterol, which creates
plaque. Over time, accumulated
cholesterol plaque prevents blood
flow and increases the risk of
developing future heart failure
(Modern Heart and Vascular, 2022).
one or more of the valves in your
heart don’t work properly. In these
cases, the heart has to work harder
 to pump blood throughout the body,
which can potentially lead to heart
failure (Modern Heart and Vascular,
2022).

Irregular Heartbeats X When your heart beats irregularly,

your heart becomes weakened.
Sometimes this can lead to heart
failure (Modern Heart and Vascular,
2022).

Congenital Heart Disease X Congenital heart disease refers to

birth defects with the heart’s
structure or the way it works. These
defects can lead to other heart
problems later on, all of which can
weaken the heart and prevent it from
pumping enough blood to the body.
This, in turn, can lead to heart failure
(Modern Heart and Vascular, 2022).

Sleep Apnea X With sleep apnea, a person’s

breathing stops and starts frequently
during sleep, leading to low oxygen
levels. These drops in oxygen cause
your heart to beat faster, which
weakens the heart. In addition,
oxygen level drops also weaken the
blood vessels. All of these problems
can contribute to heart failure
(Modern Heart and Vascular, 2022).

Ethnicity X Though anyone can develop

congestive heart failure, some
ethnicities have a higher risk. For
example, African Americans have a
30% higher risk of dying from heart
disease than Caucasians. Based on
your ethnicity, you may also be more
vulnerable to high blood pressure
(Modern Heart and Vascular, 2022).

28
PRECIPITATING:

Former 20 pack year smoker ✓ The effects of cigarette smoking on

blood pressure are complex, with
evidence that smoking increases
blood pressure acutely and
increases the risk of renovascular,
malignant, and masked
hypertension (Appel, 2022).

Obese ✓ Obesity, a condition related to

excess fat adiposity, is associated
with an increased risk for
dyslipidemia, diabetes, and
hypertension which are independent
and major risk factors for CVD
(Tecla, 2018).

Obesity is a risk factor for coronary

artery disease (CAD), which results
from cholesterol plaque buildup in
the arteries of the heart (Jin, 2013).

Viruses X Some viruses can weaken the

cardiovascular system, eventually
leading to heart failure (Fletcher,
2022).

Alcohol Abuse X Heavy alcohol consumption over

long periods can severely harm your
physical and mental health. If you
misuse alcohol, you can put yourself
at risk of organ failure, brain damage
and even some forms of cancer. You
may also experience psychological
disorders such as depression and
anxiety, which can adversely affect
your heart (Modern Heart and
Vascular, 2022).
Table 4. Etiology

Presented table shows the predisposing and precipitating factors that the
patient possesses. According to the patient’s family history, the client's mother was

29
hypertensive and diabetic. On the other hand, his father was also hypertensive which
makes it a predisposing factor for client to have hypertension and diabetes. Thus, the
patient was more at risk for developing CHF.Aging can weaken and stiffen your heart.
People 65 years or older have a higher risk of heart failure. Older adults are also
more likely to have other health conditions that cause heart failure. Moreover,
long-term health conditions such as coronary artery disease, heart attack, Heart valve
disease, sleep apnea, chronic kidney disease, increases risk for developing CHF.

Precipitating factors that clients possess include former 20 pack year smoking
which increases blood pressure acutely and increases the risk of renovascular,
malignant, and masked hypertension. Thus, increases the risk of having CHF. In
addition, patient was obese which increases the chance of developing diabetes
putting the patient at higher risk of having CHF.

iii. Symptomatology

SIGNS/ SYMPTOMS PRESENT JUSTIFICATION

DIABETES MELLITUS

Dry skin ✓ One of the most common

diabetes-related skin symptoms and a
sign of elevated glucose levels is
dryness, (American Diabetes
Association, 2022).

Elevated glucose level ✓ Diabetic patients may have overly high

blood sugar levels, which can result in
a variety of health issues, including
kidney disease (Fletcher, 2022).

Fatigue ✓ People with diabetes commonly

30
 experience persistent fatigue. Causes
of fatigue can include high or low blood
sugar levels, being overweight,
(Fletcher, 2022).

CHRONIC KIDNEY DISEASE

Elevated creatinine ✓ High creatinine levels typically signify

(343.6 μmol) that the kidneys are not functioning
properly. Possible causes of this
dysfunction include kidney infection
glomerulonephritis, kidney stones
and, kidney failure

Grade 2 pitting edema ✓ Water retention due to a loss of GFR

leading to sodium and fluid retention.
Fluid moves into the extravascular
space, due to increased hydrostatic
pressure, causing pitting edema in the
lower extremity, (Lancet, 2012)

Elevated BUN ✓ Normal BUN levels vary, but high

(57.0 mg/dL) levels in blood sample usually means
that kidneys are not working normally.
It can be a sign of kidney disease or
failure (Cleveland Clinic, 2022).

Hematuria X Underlying conditions producing

hematuria, like diabetes, can be
associated with progressive decline in
kidney function in the setting of CKD,
(Orlandi et. Al., 2018).

HYPERTENSION

Episodes of Dizziness ✓ High blood pressure and dizziness are

often associated because a person
with uncontrolled hypertension may
present with dizziness (Fletcher,
2022).

31
Elevated blood pressure ✓ Having blood pressure measures
consistently above normal may result
in a diagnosis of high blood pressure
(or hypertension). The higher your
blood pressure levels, the more risk
you have for other health problems,
such as heart disease, heart attack,
and stroke, (CDC, 2021)

CORONARY ARTERY DISEASE – CONGESTIVE HEART FAILURE

Chest pain ✓ Angina, or chest pain and discomfort,

is the most common symptom of CAD.
Angina can happen when too much
plaque builds up inside arteries,
causing them to narrow. Narrowed
arteries can cause chest pain because
they can block blood flow to your heart
muscle and the rest of your body,
(CDC, 2022).

✓ Exertional dyspnoea is among the

Dyspnea on exertion and
use of accessory muscle
dominant symptoms in patients with
chronic heart failure and progresses
relentlessly as the disease advances,
leading to reduced ability to function
and engage in activities of daily living,
(Dubé, 2016).

Orthopnea ✓ Orthopnea usually happens because

the heart is not strong enough to pump
out all the blood sent from lungs. Heart
disease, cardiomyopathy, high blood
pressure, and other problems can
cause this weakness (Fletcher, 2022).

SOB while talking and ✓ Decreased cardiac output causes

increase heart workload to provide
enough blood, which requires a lot of
effort to talk considering heart pumps
ineffectively (Fletcher, 2022).

32
 Pulmonary crackles ✓ Pulmonary congestion may cause
crackling sounds in lungs. People with
congestive heart failure (CHF) often
have pulmonary congestion (Fletcher,
2022).

Elevated Pro-BNP ✓ Pro-BNP levels elevated in patients

with cardiac disease due to myocardial
stress and volume overload (Novack,
2022).

Elevated troponin 1 ✓ Elevated troponin I is diagnostic for

myocardial injury. Coronary artery
disease (CAD) has been well known to
cause the elevation of troponin I
(Yang, 2017).
Table 5. Symptomatology

Upon admission, the signs and symptoms of diabetes presented in the table
were present in the patient. Dry skin, fatigue and elevated blood glucose are all
common signs and symptoms of diabetes mellitus. Patient was also diagnosed with
chronic kidney disease which causes the elevation of creatinine (343.6 μmol) in which
the normal result ranges between 62 - 102 μmol , BUN (57.0 mg/dL) with a normal
result that ranges between 6 - 24 mg/dL and grade 1 pitting edema. Client also
manifested an uncontrollable hypertension that causes episodes of dizziness and
elevated blood pressure. Overtime, these diseases exacerbate leading to congestive
heart failure.

Upon auscultation, pulmonary crackles were heard which were caused by

pulmonary congestion from congestive heart failure or CHF. Moreover, laboratory test
results revealed an elevated Pro-BNP. Pro-BNP levels elevated in patients with
cardiac disease due to myocardial stress and volume overload, (Novack, 2022). In
addition, elevated troponin 1 was also noted. Elevated troponin I is diagnostic for
myocardial injury. Coronary artery disease (CAD) has been well known to cause the
elevation of troponin I (Yang, 2017).

33
iv. Schematic Diagram

34
35
Figure 5. Schematic Diagram

36
v. Narrative

Congestive heart failure, often known as heart failure, is a chronic condition

that becomes worse over time. The inability of your heart to constantly pump blood
effectively enough to meet your body's needs is known as heart failure. Treatment
options for heart failure may include exercise, medication, and even surgery. Despite
what the term would imply, heart failure refers to the heart's inability to pump blood as
efficiently as it could. When your heart's ability to pump blood is diminished, your
organs might be damaged, and fluid could accumulate in your lungs. To permit more
blood to pump through the body, the heart's chambers may enlarge in response, or
they may harden and thicken. This maintains blood flow, but with time, the heart
muscle walls could degenerate and stop pumping as efficiently. The response of the
kidneys may also cause the body to start retaining fluid (water) and salt. If fluid builds
up in the limbs, legs, ankles, feet, lungs, or other organs, the body gets clogged.
(Cassoobhoy, 2020).

The client's mother was hypertensive and diabetic, according to the patient's
family history. His father, on the other hand, was also hypertensive, making it a risk
factor for the patient to develop hypertension and diabetes. Furthermore, Meisser
(2021) noted that males are about twice as likely as women to get type 2 diabetes. In
addition, the chance of having diabetes rises with age. Given that the patient is
already 70 years old, hypertension is a common disorder with multiple health
hazards, and the prevalence of hypertension is highest in older persons (Rev, 2016).
The patient displayed the signs and symptoms of diabetes. Diabetes mellitus is
characterized by dry skin, tiredness, and increased blood glucose levels. During
auscultation, pulmonary crackles were detected, which were produced by pulmonary
congestion induced by congestive heart failure or CHF. Furthermore, testing findings
indicated an increased Pro-BNP. Because of myocardial stress and volume overload,
pro-BNP levels rise in individuals with heart illness (Novack, 2022).

In accordance with the study of Atta & Toth-Manikowski (2015), the most
common cause of chronic kidney disease is diabetes mellitus type 2 followed by

37
hypertension that are both uncontrolled. In the case of diabetes mellitus type 2, the
main problem is insulin resistance since the ability of insulin to bind to special
receptors on the cell surface is diminished. The body’s natural response to restore
the normal functioning of taking up glucose by the cells is through the excessive
production of insulin by the pancreas which eventually continues its cycles and
increases the level of glucose in the blood. The process by which glucose attaches to
proteins is called enzymatic glycosylation which eventually leads to tissue damage.
The natural response of the body from tissue damage is the activation of
pro-inflammatory molecules that can be overstimulated that causes inflammation of
efferent arteriole which leads to thickening of the walls of the artery caused by build
of the substances released during the pro-inflammatory process. Blockage of blood
flow will lead to reduced blood perfusion to the kidney causing reduced oxygen
supply to the nephrons. Mesangial cells are activated which secretes transforming
growth factor beta 1 that causes the mesangial cells to return to their normal state
which then stimulates the production of extracellular matrix which is deposited around
the walls of the glomerulus leading to glomerulosclerosis. Reduced blood flow to the
kidney will eventually lead to a decrease in glomerular filtration rate of the kidneys.
On the other hand, uncontrolled hypertension can progress to myocardial infarction
due to the restriction of blood flow to coronary artery which is caused by the formation
of plaques that are formed around the walls of the arteries from the damaged
endothelial cells which causes inflammation that will further activate the inflammatory
cells to destroy and ingest particles of low density lipoprotein that can be transported
into the arterial wall.

Cong Wang et al., (2019) stated that patients with acute myocardial infarction
can develop acute kidney injury as its complication. Ischemia causes the renal
arteries to abruptly constrict which leads to hypoperfusion of the kidneys from a
sudden decline in blood volume which at the same time causes reduced blood supply
to the kidney.

In the study of Chi-yuan & Raymond (2017) they reported that chronic kidney
disease can also be caused by untreated acute kidney injury that results from

38
continuous decline in renal function which causes prolonged ischemia that can further
damage the normal functioning of the kidney to perform its primary function which is
the ability to filter waste products.

In conclusion, the progression of chronic kidney disease affects the ability of

the kidneys to perform its vital functions. The renin angiotensin aldosterone system is
stimulated by the disease process causing the buildup of waste products and fluid
since the ability of the kidneys to maintain fluid and electrolyte balance gradually
declines which leads to fluid volume overload. Excessive fluid in the circulation
causes an increase in the workload of the heart which can eventually weaken the
heart muscle leading to congestive heart failure.

39
 CHAPTER VII

COURSE IN THE WARD/ TREATMENT/ INTERVENTIONS

Medical Management

This section of the manuscript is dedicated to the chronological presentation of the Doctor's Progress Notes. This is
a part from the Medical Management section of the Course in the Ward/ Treatment/ Interventions.

DOCTOR’S PROGRESS NOTES

DATE DOCTORS ORDER

October 18, 2022 - Please carry out admitting orders

8:00 pm - Secure consent to care
- Facilitate pending laboratory test
Physical examination - Will inform Aps of their Admission
- Refer
Vital signs:
MEDS:
BP :120/60
- Give Aspirin 80 mg tab 4 tabs now then 1 tab OD
CR: 69 - Shift furosemide 40mg IV now then q 12 w/ BP
precaution
RR: 22
- Enoxoparin 0.8 mg SQ OD
T: 36.6 - Carvedilol 6.25mg tab 1 tab BID hold if w/ heart rate
< 60 bpm
02 sat 99% at room air - Trimetazidine 35 mg 1 tab BID
- Refer

40
CBG: 150mg/dI

Height: 167.6 cm

Weight: 85kg

Awake, responsive, coherent, NIRD AS, PPC, PERRLA,

moist oral mucosa

NO NVE

ECE, decreased BS left base, + minimal crackles right

base

AP, Distinct s1 and s2, no murmurs Globular abdomen,

NABS, soft, no tenderness,

tympanitic on all quadrants

Full pulses, grade 2 pitting edema

Labs:

ECG: Non specific ST T wave changes

Trop 1 1.42 H

UA L.yellow Hazy Gluc ++++ Alb +++ Ph 6.0 SG 1.015

Pus 0-2 RBC 8-10

Cbc Hgb 128 Wbc 8.3 Hct 0.39 Plt 294 Seg 61.9 Lymp

27 Mono 6.5 Eos 4.2 Baso 0.4

41
Crea 243.6

SUA 570

K 4.6 Na 137 ALT 18.7 RBS 17.79 HBA1C 9.8

ABG PH 7.362 PCO2 40.5 PO2 79 HCO3 22.5 B.E -2.9

TCO2 24 SAO2 95

NORMAL ACID BASE BALANCE WITH MILD

HYPOXEMIA

CXR: lung fields are clear Heart is enlarged with left

ventricular configuration Impression: Left Ventricular

Cardiomegaly with atherosclerotic aorta

Impression:

NSTEMI Killip //

HCVD, LVH, SR, FC III CKD G4A3 sec to DKD HPN stage
2 - uncontrolled DM type 2- controlled

MEDS:
October 18, 2022
- Give Aspirin 80 mg tab 4 tabs now then 1 tab OD
8:15 pm - Shift furosemide 40mg IV now then q 12 w/ BP
precaution
- Enoxoparin 0.8 mg SQ OD
- Carvedilol 6.25mg tab 1 tab BID hold if w/ heart rate
< 60 bpm

42
 - Trimetazidine 35 mg 1 tab BID
- Refer

October 18, 2022

8:30 pm - Hook to Cardiac Monitor
- Please monitor I & O at Bedside
- BP precaution
- Refer accordingly

- Repeat ECG 12 L NOW

October 18, 2022 - Refer
10:00 pm

- CHEST PAIN
- DOB (Difficulty of Breathing)

October 18, 2022 - Repeat Trop I

- Start trimag tab 1 tab BID x 3 days
11:00 pm - Facilitate 2D ECHO w/ droplets studies tomorrow
- Refer
BP: 110/60

PR: 69

RR: 18

T: 36.8

O2 Sat 99% at 2 Lpm via NC

Asleep, comfortable

43
No complaint

October 19, 2022 - May transfer to room

- Refer
3:55 am

BP :110/60

PR: 65

RR: 16

T 36.2

RT PCR Negative

- Complaint of chest pain

- Difficulty of Breathing
- Able to sleep comfortably

October 19, 2022 - Complete bed rest for now

- May use urinal
5:20 am - Facilitate 2D ECHO W/ DS, USD of W/ prostate (pre
& post void scan)
BP :110/60 - Continue other present management
- Refer
PR: 65

RR: 16

T 36.2

O2 Sat 100%

44
Receiving notes:

- Chest pain
- Dyspnea
- Desaturation

Awake, comfortable, NIRD as BPC

ECE, minimal bibasal crackles

AD OHS regular rhythm

Flabby, soft nontender, abdomen

Full pulses, art bipedal edema

October 19, 2022 - D/C Cardiac monitoring

- Include S. Albumin on todays blood extraction
10:00 am - Insulin glargine 22 units OD SQ
- Clomidine 75mg/tab q 12 h
EF- 61%

CBG:209-219

BP- 120/80

PR: 60

RR: 16

T: 36 C

O2 Sat 98%

45
(-) fever

(-) chest pain

(-) abdominal pain

(-) episodes of dizziness

(+)exertional dyspnea

ECE, Fine crackles

Flabby, soft, non tender abdomen

Full pulses

GCS 15

October 19, 2022

11:40 am

NEPHRO

Patient is awake, noted SOB while talking no chest pain

Fine crackles, Bibasal lung field, no wheezing

46
DHS, (-) MURMUR

Soft, Non-tender & non- distended abdomen

(+) Grade 1- Bipedal edema

Latest Labs:

USD :Bilateral parenchymal disease ; Urocystitis

October 19. 2022

2:06 pm - Carvedilol to 6.5 mg OD

Acute NSTEMI KI, CVI, PAD

October 19, 2022 - Continue meds & management

- Follow-up 2D-ECHO official result
3:30 pm - Follow-up S. Albumin
- Refer for unusualities
CBG: - Provide I & O monitoring sheet at bedside
209-219-276

Patients is comfortable

(+) back pain

47
(-)fever

(-) nausea / vomiting

(-) dysuria

(-) hematuria

(-) hypogastric tenderness

(-) chest pain

(-) hypotension

(-) desaturation

October 19, 2022 - Give Kl pre dinner

6:20 PM

10/19/2022 - Limit to <1L/day

- May include S. albumin to Bind test tom
6:40 pm

Plan: Urologist possible cystocomy ICT urogram Tlc

cardiorenal syndrome type 1 and type 2 on top of CKD sec
to DMN

SGLT2- May shot 2 weeks

48
Table 6. Doctor’s Progress Notes

LABORATORY / DIAGNOSTIC EXAMINATIONS

Exam taken: October 19, 2022; 8:07AM

Procedure: Ultrasound Whole Abdomen

The liver is normal in size and configuration. The parenchymal echo pattern is homogeneous. However, there is
mild diffuse increase in parenchymal echogenicity, relative to spleen parenchyma. Coarse calcific densities noted at the
lateral segment of the left lobe. Intrahepatic ducts are not dilated. The gallbladder is distended to physiologic size. The
wall is smooth and not thickened. There are no intraluminal echoes seen. The widest anteroposterior diameter of the
common duct is 0.4cm. No pericholecystic unusualities. The pancreas and spleen are normal in size and configuration
with no focal lesion or calcification seen. The abdominal aorta and para-aortic areas are partially obscured by overlying
gas artifacts. Both kidneys are normal in size. There is cystic focus in the inferior pole of the right kidney measuring
1.7cm. The prostate is normal in size with no ascites.

IMPRESSION:

Normal size liver with mild fatty infiltration. Coarse calcific densities in the left lobe noted (residual foci from previous
infection).
Diffuse bilateral renal parenchymal disease
UROCYSTITIS
Ultrasonically normal gallbladder, pancreas, spleen, and prostate gland.

49
No ascites.

Exam taken: October 19, 2022; 2:54 AM

Procedure: COVID RT-PCR

Test Result: NEGATIVE

INTERPRETATION OF RESULT WHEN APPROPRIATE

FINAL RESULT INTERPRETATION

SARS-CoV-2 POSITIVE The 2019 novel coronavirus (SARS-CoV-2)

target nucleic acids are detected.

SARS-CoV-2 PRESUMPTIVE POSITIVE The 2019 novel coronavirus (SARS-CoV-2)

nucleic may be present.

50
 SARS-CoV-2 NEGATIVE The 2019 novel coronavirus (SARS-CoV-2)
target nucleic acids are not detected.

Table 7. Covid RT-PCR Result

Exam taken: October 18, 2022; 6:40PM

PROCEDURE PURPOSE NORMAL RANGE RESULT

51
 Coagulation Test A coagulation factor test is PT Control
9.00 - 13.00 sec 13.0 sec
used to find out if you have
a problem with any of your Percent Activity
70.00 - 200.00% 133.0%
clotting factors that may
cause too little or too much Protime
10.00 - 14.00 sec 10.0 sec
blood clotting.
INR
0.00 - 1.20 0.86
Coagulation factor tests are
also used to monitor people APTT
22.60 - 35.00 sec 33.9 sec
who have a known problem
with clotting factors or who Control
23.50 - 36.40 36.0 sec
take medicine called blood
thinners to lower the risk of
blood clots.

Table 8. Coagulation Test Result

Exam taken: October 18, 2022; 6:40PM

PROCEDURE PURPOSE NORMAL RESULT CLINICAL

RANGE SIGNIFICANCE

52
 Pro-BNP A B-type natriuretic 0.00 - 450.00 3,038.6 (H) This suggests that the
peptide (BNP) test ng/L patient’s heart has to
gives your provider work harder to pump
information about how blood, thus this makes
your heart is working. more BNP. Higher
This blood test levels of BNP can be
measures the levels of an indication of heart
a protein called BNP failure.
in your bloodstream.

Table 9. Pro-BNP Result

Exam taken: October 18, 2022; 1:50PM

PROCEDURE PURPOSE NORMAL RESULT CLINICAL

53
 RANGE SIGNIFICANCE

Cardiac An enzyme marker test Troponin I 1.43 (H) High (elevated) levels of
Biomarker Test is a blood test to 0.00 - 0.30 cardiac enzymes can be
measure specific ug/mL a sign of a myocardial
biological markers infarction or injury.
(biomarkers) in your
blood. Cardiac enzymes
are also called cardiac
biomarkers. This is to
screen for heart damage
and other problems,
diagnose heart
conditions that cause
symptoms such as chest
pain, angina and
shortness of breath.

Table 10. Cardiac Biomarker Test Result

Exam taken: October 18, 2022; 1:50PM

54
 PROCEDURE PURPOSE NORMAL RANGE RESULT CLINICAL
SIGNIFICANCE

Comprehensi A comprehensive Crea Increased level of

ve Metabolic
metabolic panel (CMP) is 62 - 102 μmol 343.6 μmol creatinine is a sign of poor
Panel (CMP)
a test that measures 14 kidney function related to
different substances in its disease process, CKD.
your blood. It provides
important information
about your body's BUN 57.0 mg/dL Increased level of BUN
chemical balance and 6 - 24 mg/dL generally indicates that a
metabolism. Metabolism is patient’s kidney isn’t
the process of how the working well. It is also an
body uses food and Potassium 4.6 mmol/L indicator for CHF.
energy. Abnormal levels of 3.6 - 5.2 mmol/L
any of these substances
or combination of them Sodium 137.0 mmol/L
can be a sign of a serious 136 - 145 mmol/L
health problem.

Table 11. Comprehensive Metabolic Panel Test Result

Exam taken: October 18, 2022; 1:44PM

55
 PROCEDURE PURPOSE PHYSICAL/CHEMICA MICROSCOPIC FINDING
L EXAMINATION

Urinalysis A urinalysis (also known Color - Light Yellow Pus Cells - 0-2
as a urine test) is a test
Appearance - Hazy RBC - 8-10
that examines the visual,
Glucose - ++++ Epithelial Cells - Few
chemical and microscopic
aspects of your urine. It Albumin - +++ Mucous Threads - Few
can include a variety of
pH - 6.0 Bacteria - Few
tests that detect and
Specific Gravity -
measure various
1.015
compounds that pass
Blood - 150
through your urine using a
single sample of urine. Ketones - Negative

Bilirubin - Negative

Urobilinogen - Normal

Leukocyte - Negative

Nitrite - Negative
Table 12. Urinalysis Microscopic Finding

56
Exam taken: October 18, 2022; 1:50PM

PROCEDURE PURPOSE NORMAL RANGE RESULT CLINICAL SIGNIFICANCE

CBC (Complete CBC

Blood Count) The CBC indicates
with the counts of white Hemoglobin
Differential blood cells, red blood 110.00 - 150.00 g/L 128
Leukocyte cells, and platelets. It
RBC Count
Count also includes the 4.00 - 5.50 10^12/L 4.5
concentration of
hemoglobin and WBC Count
hematocrit. It also 5.00 - 10.00 10^9/L 8.3
evaluates your overall
health and detects a Hematocrit
variety of diseases 0.37 - 0.45 L/L 0.39
and conditions, such
as infections, anemia, Platelet count
140.00 - 440 10^9/L 294
and leukemia. A CBC
test with differential Differential Count
measures the number
of each type of these Segmenters
white blood cells. 55.00 - 65.00% 61.9

Lymphocytes
35.00 - 45.00% 27.0 (L) Low levels of lymphocytes
suggest the presence of
Monocytes infection.
6.00 - 12.00% 6.5

Eosinophils
2.00 - 4.00% 4.2 (H) Elevated levels of

57
 eosinophils suggest mild
Basophils allergic reaction or drug
0.00 - 2.00% 0.4 sensitivity.

Red Cell Indices

MCV
80.00 - 96.10 fL 87.0

MCH
27.50 - 33.20 pg 28.4

MCHC
318.00 - 354.00 g/L 328

RDW-CV
11.50 - 14.50% 14.3

MPV
7.20 - 11.10 fL 7.9
Table 13. Complete Blood Count with Differential Leukocyte Count Result

Exam taken: October 18, 2022; 7:30PM

58
 PROCEDURE PURPOSE NORMAL RANGE RESULT IMPRESSION

Arterial Blood An arterial blood gas pH NORMAL ACID BASE

Gas Test (ABG) test measures 7.35 - 7.45 7.36 BALANCE WITH MILD
oxygen and carbon HYPOXEMIA
dioxide levels in your pCo2
blood. It also 35 - 45 mmHg 40.5
measures your
body’s acid-base pO2
(pH) level, which is 80 - 100 mmHg 79
usually in balance
when you’re healthy. HCO3
You may get this test 21 -28 mmol/L 22.5
if you’re in the
hospital or if you B.E
have a serious injury (-2) (+2) -2.9
or illness.
TCO2
The test gives your 23 - 30 24
doctor clues about
how well your lungs, SaO2
heart, and kidneys 95 - 100 94
are working. You’ll
probably get other
tests along with it.
Table 14. Arterial Blood Gas Test Result

Exam taken: October 17, 2022; 2:31 PM

59
Procedure: Electrocardiogram

ECG Diagnosis: Sinus rhythm nonspecific, T wave abnormality

Procedure: Capillary Blood Glucose

DATE TIME RESULTS

10/18/2022 11PM 209 mg/dL

5AM 219 mg/dL

11AM 276 mg/dL

10/19/2022 5PM 253 mg/dL

Table 15. Capillary Blood Glucose Test Result

CHAPTER VIII

60
 Pharmacologic Management (Drug Study)

Nurses should collaborate with the patient to determine the need for and use of medicine, as well as the patient's
understanding of the medication and how to take it. As a vital aspect of treatment, nurses should properly explain drug
regimens and why a medicine has been prescribed. The pharmacologic management section of this paper can be found
here.

1. CLOPIDOGREL

CLASSIFICATION/ CONTRAINDICATIONS ADVERSE EFFECTS

DRUG NAME INDICATION NURSING RESPONSIBILITY
MECHANISM OF
ACTION

CLASSIFICATION: Prevent heart Patients with ● Hallucination ● Monitor platelet count

attacks and active ● Hypotension periodically for early
Antiplatelet drug strokes in pathological ● Constipation detection of
persons with bleeding ● Hemorrhage thrombocytopenia
MECHANISM OF heart disease ● Monitor for allergic
ACTION: , recent Hypersensitivit reactions especially at the
stroke, or y to Clopidogrel beginning of the
Figure 6. Clopidogrel Works by reducing blood treatment.
(MIMS, 2017). the ability of the circulation ● Observe for signs and
platelets to stick disease symptoms of hepatic
BRAND NAME: together and insufficiency during
reduces the risk of clopidogrel therapy.
Plavix clots forming ● Advise patients that it may
take longer than usual to
GENERIC NAME: REFERENCE: stop bleeding and to
Wilkins, W. L. &. refrain from activities in
Clopidogrel (2021). which trauma and
Nursing2022 Drug bleeding may occur.
DOSAGE: Handbook (Nursing ● Instruct the patient to

61
 Drug Handbook) notify the prescriber if
75 mg/tab (Forty-Second, unusual bleeding occurs.
North American).
ROUTE: LWW.

PO

FREQUENCY:

OD
Table 16. Drug Study of Clopidogrel

2. LINAGLIPTIN

CLASSIFICATION/ CONTRAINDICATIONS ADVERSE EFFECTS

DRUG NAME INDICATION NURSING RESPONSIBILITY
MECHANISM OF ACTION

CLASSIFICATION: Indicated as an Contraindicate CNS: Headache ● Monitor HbA1c and fasting

adjunct to diet d to patients blood glucose levels
Antidiabetics and exercise to hypersensitive EENT: periodically.
improve to the drug and Nasopharyngitis ● Monitor patient for signs
MECHANISM OF glycemic control its and symptoms of
ACTION: in adults with components. GI: Diarrhea hypoglycemia (anxiety,
type-2 diabetes. confusion, diaphoresis,
Inhibits DPP-4, an Metabolic: tachycardia, paresthesia)
enzyme that rapidly hypoglycemia ● Monitor patient for signs
Figure 7: Tradjenta inactivates incretin and symptoms of
(MIMS, 2022). hormones, which Musculoskeletal: hyperglycemia (excess
play a part in the Arthralgia, Back thirst, excess urination)
BRAND NAME: body’s regulation of pain, Myalgia ● Monitor patient for signs
glucose. and symptoms of
Tradjenta RESP: Cough, URI pancreatitis (persistent,
REFERENCE: severe abdominal pain,

62
GENERIC: Kluwer, W. (2018). which may radiate to the
Nursing 2022 Drug back, and vomiting)
Linagliptin Handbook. Wolters
Kluwer Medical. Patient Teaching:
DOSAGE:
● Inform patients of the
5mg potential risks and benefits
of linagliptin and of
ROUTE: alternative modes of
therapy.
Oral ● Instruct patients to take
drugs only as pre- scribed.
If a dose is missed, advise
the patient not to double
the next dose.
● Explain to the patient the
importance of proper diet.
regular physical activity,
and periodic blood
glucose monitoring.
● Teach patients to
recognize and manage
hypoglycemia and
hyperglycemia.
● Teach patient signs and
symptoms of pancreatitis
and to immediately
contact prescriber if they
occur.
Table 17. Drug Study of Linagliptin

3. CLONIDINE

63
 CLASSIFICATION/ CONTRAINDICATIONS ADVERSE EFFECTS
DRUG NAME INDICATION NURSING RESPONSIBILITY
MECHANISM OF ACTION

CLASSIFICATION: Renal Hypersensitive CNS: drowsiness, ● Drug may given to lower

Hypertension to the drug dizziness, sedition, BP rapidly in some
Therapeutic class: weakness, fatigue, hypersensitive
Antihypertensives Use malaise, agitation, emergencies
cautiously in depression ● Monitor BP and pulse rate
Pharmacologic patients with frequently. Dosage is
class: Centrally severe CV: Bradycardia, usually adjusted to patients
acting alpha coronary severe rebound BP and tolerance
Figure 8: agonists insufficiency, HTN, or thostatic ● Dont crush, break, or allow
Clonidine, (Patron conduction hypotension patient to chew
Analysis, 2021) MECHANISM OF disturbances, extended-release tablets.
ACTION: recent MI, GI: constipation, dry ● Elderly patients may be
BRAND NAME: cerebrovascula mouth, nausea, more sensitive than
Unknown. Thought r disease, vomiting. anorexia younger ones to drug’s
Catapres to stimulate alpha 2 chronic renal hyposensitive effects.
receptors and inhibit failure, or GU: urine retention, ● observe patient for
GENERIC: the central impaired liver erectile dysfunction tolerance to drug’s
vasomotor centers, function therapeutic effects, which
Clonidine decreasing Metabolic: Weight may require increased
sympathetic outflow Gain dosage
DOSAGE: to the heart, kidneys, ● don't stop drug before
and peripheral Skin: pruritis, surgery
150mg 1 Tab vasculature and dermatitis with ● don't confuse clodinine
lowering peripheral transdermal patch, with clonazepam,
ROUTE: vascular resistance, rash clozapine, Klonopin,
BP, and HR quinidine, or clomiphene
PO Other: loss of libido
REFERENCE: Patient Teaching:
FREQUENCY: Kluwer, W. (2022).
Nursing 2022 Drug ● instruct patient to take drug
Handbook. Wolters exactly as prescribed
Q12
Kluwer Medical.

64
 ● advised patient that
stopping drug abruptly may
cause severe rebound
HTN: dosage must be
reduced gradually over 2 to
4 days, as instructed by
prescriber.
● Tell patient to take the last
dose immediately before
bedtime
● Caution patient that drug
may cause drowsiness but
that this adverse effect
usually diminishes over 4
to 6 weeks
● Inform patients that
dizziness upon standing
can be minimized by rising
slowly form a sitting or
lying position and avoid
sudden position changes.
Table 18. Drug Study of Clonidine

4. TRIMETAZIDINE

65
 DRUG NAME CLASSIFICATION/ INDICATION ADVERSE EFFECTS NURSING RESPONSIBILITY
MECHANISM OF ACTION CONTRAINDICATIONS

CLASSIFICATION: Stable Angina Parkinson's Significant: ● Should be taken with

Anti-Anginal Drugs disease, New-onset or food with a full glass of
parkinsonian worsening of water
MECHANISM OF symptoms, parkinsonian ● Monitor Renal Function
ACTION: restless leg symptoms (e.g. ● Encourage patient to
Vasodilators work by syndrome, akinesia, hypertonia, continue efforts at
relaxing the smooth tremors, and tremor). smoking cesation
Figure 9:
muscle of arteries other related CV: Rarely, ● provide safety measures
Trimetazidine
and veins, which let’s movement palpitations, if lethargy occurs
(RiteMed, 2017)
blood flow freely. It disorders. extrasystoles,
inhibits fatty acid Severe renal tachycardia. Patient Teaching:
BRAND NAME:
metabolism and impairment GI: Nausea,
RiteMed
stimulates the vomiting, abdominal ● This drug may cause
metabolism of pain, diarrhoea, drowsiness or dizziness,
GENERIC:
glucose. It helps the dyspepsia. if affected, do not drive or
Trimetazidine
body use oxygen, General: Asthenia. operate machinery
which relieves chest CNS: Headache,
DOSAGE:
pain caused by dizziness.
35mg 1 Tab
blocked blood
vessels. Skin: Rash, urticaria,
ROUTE:
pruritus.
PO
REFERENCE:
MIMS. (2022). Trimetazidine: Vascular: Rarely,
FREQUENCY: Indication, Dosage, Side
Effect, Precaution | MIMS arterial hypotension,
BID
Philippines. orthostatic
Www.mims.com. hypotension,
https://www.mims.com/philip
pines/drug/info/trimetazidine flushing.
?mtype=generic

Table 19. Drug Study of Trimetazidine

66
 5. ATORVASTATIN

DRUG NAME CLASSIFICATION/ INDICATION CONTRAINDIC ADVERSE EFFECTS NURSING RESPONSIBILITY

MECHANISM OF ACTION ATIONS

CLASSIFICATION: Atorvastatin is Hypersensiti ● joint pain ● Assess for allergies to

HMG-CoA reductase indicated, in vity to ● stuffy nose HMG-CoA reductase
inhibitor combination with atorvastatin. ● sore throat inhibitors
dietary Active liver ● diarrhea ● Assess for signs of
modifications, to disease or ● pain arms or muscle weakness or pain
MECHANISM OF prevent unexplained legs ● Monitor for EKG changes
ACTION: cardiovascular transaminas ● For muscle pain,
Figure 10: Lipitor events in patients e elevation. administer pain
(MIMS, 2022a) It works by slowing the with cardiac risk medications as ordered
production of factors and/or ● Assess for changes in
BRAND NAME: cholesterol in the body abnormal lipid concentration, alertness,
to decrease the profiles. and vision
Lipitor amount of cholesterol It may be used as a
that may build up on preventive agent for
GENERIC: the walls of the non-fatal
arteries and block myocardial
Atorvastatin blood flow to the heart, infarction, fatal and
brain, and other parts non-fatal stroke,
DOSAGE: of the body revascularization
procedures,
10mg REFERENCE: hospitalization for
Kizior, R. J., Hodgson, B. congestive heart
ROUTE: B., Hodgson, K. J., failure and angina
&amp; Witmer, J. B. in patients with
PO (2016). Saunders coronary heart
nursing drug handbook
disease.
FREQUENCY: 2016. Elsevier.
OD
Table 20. Drug Study of Atorvastatin

67
 6. ASPIRIN

CLASSIFICATION/ CONTRAINDICATIONS ADVERSE EFFECTS

DRUG NAME INDICATION NURSING RESPONSIBILITY
MECHANISM OF ACTION

CLASSIFICATION: For primary Contraindicate CNS: agitation, ● Advise patient on a

prevention of d in patients cerebral edema, low-salt diet that 1 tablet
Anticoagulant thromboembolic hypersensitive coma, confusion, of buffered aspirin
disorders and to drug and in dizziness, contains 553 mg of
MECHANISM OF cardiovascular those with headache, lethargy, sodium.
ACTION: events NSAID-induced seizures, subdural ● Advise patient to take
sensitivity or intracranial drug with food, milk,
Figure 11: Aspirin Thought to produce reactions, hem-orrhage. antacid, or large glass of
(Bayer, 2022) analgesia and exert G6PD water to reduce Gl
its anti-inflammatory deficiency, or CV: arrhythmias, reactions.
BRAND NAME: effect by inhibiting bleeding hypotension, ● Tell patient not to crush or
prostaglandin and disorders, such tachycardia. chew enteric-coated or
Bayer Aspirin other substances as hemophilia, extended-release forms
that sensitize pain von Willebrand EENT: tinnitus, but to swallow them
GENERIC: receptors. Drug may disease, hearing loss. whole.
relieve fever through telangiectasia, ● Advise patient to take
Aspirin central action in the bleeding Gl: nausea, GI extended-release
hypothalamic ulcers, and bleeding, dyspepsia, capsules at same time
heat-regulating hemorrhagic GI dis-tress, occult each day.
DOSAGE: center. In low doses, states. bleeding. ● Warn patient not to drink
drug also appears to pancreatitis, alcohol 2 hours before or
80MG/1TAB interfere with clotting Use vomiting. 1 hour after taking
by keeping a cautiously in extended-release capsule
ROUTE: platelet-aggregating patients with GI Hematologic: and not to take extra
substance from lesions, prolonged bleeding capsule to make up for a
PO forming. impaired renal time, leukopenia, missed dose.
REFERENCE: function, throm-bocytopenia, ● Remind patient taking
FREQUENCY: Kluwer, W. (2022). hypoprothrombi coagulopathy, DIC. drug for a chronic
Nursing2022: Drug ne-mia, vitamin condition not to stop drug

68
OD Handbook K deficiency, Hepatic: hepatitis. without first discussing
thrombocytope with prescriber.
nia, or Metabolic: ● Instruct patient to discard
thrombotic dehydration, aspirin tablets that have a
thrombocytope hyper-kalemia, strong vinegar-like odor.
nic purpura. hyperglycemia; ● Tell patient to consult
hypoglycemia, prescriber if giving drug to
Avoid use in metabolic acidosis, children for longer than 5
patients with respiratory days or adults for longer
severe hepatic alka-losis. than 10 days.
impairment or ● Advise patient receiving
history of active Skin: rash, bruising, prolonged treatment with
peptic ulcer urticaria, hives. large doses of aspirin to
disease. Other: angioedema, watch for small, round,
Reye syndrome, red pinprick spots;
hypersensitivity bleeding gums; and signs
reactions. of GI bleeding; advise
patient to drink plenty of
fluids.Encourage use of a
soft-bristled toothbrush.
Table 21. Drug Study of Aspirin

69
 7. CARVEDILOL

CLASSIFICATION/ CONTRAINDICATIONS ADVERSE EFFECTS

DRUG NAME INDICATION NURSING RESPONSIBILITY
MECHANISM OF ACTION

CLASSIFICATION: Carvedilol is a Carvedilol Body as a whole: ● Monitor for therapeutic

Beta-adrenergic non-selective (COREG) is increased sweating, effectiveness which is
blocking agents adrenergic contraindicated fatigue, chest pain, indicated by lessening of
(Beta blockers) blocker in patients who pain, arthralgia signs and symptoms of
indicated for the has: congestive heart failure
MECHANISM OF chronic therapy CV: bradycardia. and improved blood
ACTION: of heart failure ● History of hypotension, pressure control.
Carvedilol is used with reduced serious hypertension, AV ● Hold medication if HR
for treating high ejection hypersensit block/heart block <60bpm as ordered by the
blood pressure and fraction, ivity angina physician.
Figure 12: congestive heart hypertension, reaction ● Use cautiously for the
Carvedilol (Unilab, failure. It is related to and left (Stevens-J GI: diarrhea, patient as the patient is
2022) labetalol ventricular ohnson nausea, abdominal, diabetic.
(Normodyne, dysfunction syndrome, pain, vomiting ● Monitor lab test results.
BRAND NAME: Trandate). Carvedilol following angioedem Monitor liver function tests
blocks receptors of myocardial a, RESP: sinusitis, periodically; at first sign of
Carvid the adrenergic infarction. anaphylaxi bronchitis hepatic toxicity, stop drug
nervous system, the s) administration and notify
GENERIC: system of nerves in ● Pulmonary Hematologic: physician.
which adrenalin edema thrombocytopenia ● Monitor for worsening of
Carvedilol (epinephrine) is ● Cardiogeni symptoms in patients with
active. Nerves from c shock Metabolic: peripheral vascular
DOSAGE: the adrenergic ● Bradycardi hyperglycemia, disorder.
system enter the a, heart weight increase, ● Monitor digoxin levels with
6.25 mg/tab heart and release an block or gout concurrent use; plasma
adrenergic chemical sick sinus digoxin concentration may
ROUTE: (norepinephrine) that syndrome CNS: dizziness, increase.
attaches to (unless a headache,
PO

70
 receptors on the pacemaker paresthesia Patient Teaching:
FREQUENCY: heart's muscle and is in place) Educate the patient and the
stimulates the ● Severe family about the following
BID muscle to beat more hepatic things:
rapidly and impairment ● Do not abruptly
forcefully. By ● Asthma or discontinue taking this
blocking the other drug.
receptors, carvedilol bronchosp ● The patient may
reduces the heart's astic experience dizziness or
rate and force of disorders faintness, as a risk of
contraction and orthostatic hypotension.
thereby reduces the It is also ● Do not engage in
work of the heart. contraindicated hazardous activities
for patients while experiencing
REFERENCE: who have dizziness.
Omudhome, O. drank / are ● If you have diabetes,
(2018, November 5). taking the drug may increase
Carvedilol (Coreg): beverages or the effects of
Side Effects, Uses & medications hypoglycemic drugs
Dosage. that might and mask sign and
MedicineNet. contain alcohol. symptoms of
Retrieved hypoglycemia.
September 4, 2022,
from
https://www.medicin
enet.com/carvedilol/
article.htm#what_are
_the_uses_for_carv
edilol

Table 22. Drug Study of Carvedilol

71
 8. ENOXAPARINE

DRUG NAME CLASSIFICATION/ INDICATION CONTRAINDICATIONS ADVERSE EFFECTS NURSING

MECHANISM OF RESPONSIBILITY
ACTION

CLASSIFICATION: Pulmonary Hypersensitivity CNS: ● Check and verify with

Embolism to drug, heparin, confusion,severe doctor’s order.
Therapeutic class: Deep vein pork products, pain ● Observe 10 rights of
Anticoagulants thrombosis benzyl alcohol CV: edema medication
Figure 13: Patients with peripheral edema administration.
Enoxaparine Pharmacologic history of GI: nausea, diarrhea ● Establish rapport to the
(Lovenox, 2022) class: immune-mediat Hematologic: patient and to the
Low-molecular-weigh ed HIT within thrombocytopenia, watcher inside the
BRAND NAME: t heparins past 100 days haemorrhage, room.
or in the bleeding ● Inform the patient’s
Lovenox MECHANISM OF presence of complications watcher about the
ACTION: circulating RESP: dyspnea common side effects to
GENERIC NAME: Accelerates formation antibodies Skin:hematoma, provide assurance.
of antithrombin III erythema ● Urge the watcher to
Enoxaparine –thrombin complex report all the adverse
and deactivates SIDE EFFECTS reactions and to
DOSAGE: thrombin, preventing
● Mild irritation immediately.
conversio n of
0.8 mg fibrinogen to fribrin.
● Pain ● In administering the
Drug has a higher ● Bruising drug, with patient lying
ROUTE: antifactor-Xa-to-antifac ● Redness, and down, give by deep
tor-Iia activity ration swelling at the subcutaneous injection,
Subcutaneously than heparin injection site alternating doses by left
● Fatigue and right anterolateral
FREQUENCY: REFERENCE: ● Fever and posterolateral
Kluwer, W. (2022). abdominal walls.
OD Nursing 2022 Drug
Handbook. Wolters
Table 23. Drug Study of Enoxaparine
72
 9. LEVAMLODIPINE

CLASSIFICATION/ CONTRAINDICATIONS ADVERSE EFFECTS

DRUG NAME INDICATION NURSING RESPONSIBILITY
MECHANISM OF ACTION

CLASSIFICATION: Hypertension ● Hypotension ● Orthostatic ● Obtain baseline data of heart

● Hypovolemi hypotension rate and blood pressure.
Calcium channel a ● Bradycardia Withhold medication if heart
blockers ● Hyperkalemi ● Hypoglycemia rate is below 60 bpm and
a ● Hypervolemia blood pressure less than
Figure 14: MECHANISM OF 90/60 mmHg
Levamlodipine ACTION: SIDE EFFECTS: ● Monitor blood glucose as
(Adppharma, 2022) ● Dizziness prescribed by the physician
Block calcium ● Drowsiness to check for hypoglycemia
BRAND NAME: channel in the ● Lightheaded ● Monitor lab results and
vascular smooth ness promptly refer for presence
Asomex muscle to promote ● Fatigue of electrolyte imbalances
vasodilation. It ● Inform patient that if
GENERIC: decreases blood dizziness persists, report to
pressure and bedside nurse to provide
Levamlodipine relaxes blood vessel prompt management
in order to increase ● Raise side rails to ensure
DOSAGE: supply of oxygen safety of the patient
and blood to the ● Warn patient that abruptly
2.5 mg circulation discontinuing the drug can
cause rebound hypertension
ROUTE: REFERENCE: ● Advise patient to avoid foods
Kizior, R. et al. (2016). high in cholesterol such as
PO Saunders Nursing fast foods
Drug Handbook 2016. ● Encourage patient to
Elsevier increase intake of fruits and
FREQUENCY:
vegetables.
OD
Table 24. Drug Study of Levamlodipine
73
 10. FUROSEMIDE

CLASSIFICATION/ CONTRAINDICATIONS ADVERSE EFFECTS

DRUG NAME INDICATION NURSING RESPONSIBILITY
MECHANISM OF ACTION

CLASSIFICATION: Indicated to: ● Anuria CNS: Headache, For Congestive Heart Failure
● Hypovolemi fatigue,
Functional Class.: ● Pulmonary a weakness, ● Assess fluid volume status:
Loop Diuretic edema vertigo, I&O ratios and record, count
● edema in paresthesias or weigh diapers as
Chemical Class.: CHF appropriate, weight,
Sulfonamide ● nephrotic CV: Orthostatic distended red veins, crackles
Figure 14: derivative syndrome hypotension, in lung, color, quality, and
Furosemide ● ascites, chest pain, ECG specific gravity of urine, skin
(Adppharma, 2022) MECHANISM OF ● hepatic changes, turgor, adequacy of pulses,
ACTION: disease circulatory moist mucous membranes,
BRAND NAME: ● hypertension collapse bilateral lung sounds,
Acts on the peripheral pitting edema;
Lasix ascending loop of EENT: Loss of dehydration symptoms of
Henle in the kidney, hearing, ear pain, decreasing output, thirst,
GENERIC: inhibiting tinnitus, hypotension, dry mouth and
reabsorption of blurred vision mucous membranes should
Furosemide electrolytes sodium be reported.
and chloride, ELECT:
DOSAGE: causing excretion of Hypokalemia, ● Monitor electrolytes:
sodium, calcium, hypochloremic potassium, sodium, chloride,
40 mg magnesium, alkalosis, magnesium; also include
chloride, hypomagnesemi BUN, blood pH, ABGs, uric
ROUTE: water, and some a, hyperuricemia, acid, CBC, blood glucose.
potassium; hypocalcemia,
IV decreases hyponatremia, For Hypertension
reabsorption of metabolic
FREQUENCY: sodium and chloride alkalosis ● Assess B/P before and during
and increases therapy lying, standing, and

74
OD excretion of ENDO: sitting as appropriate;
potassium in the Hyperglycemia orthostatic hypotension can
distal tubule of the occur rapidly.
kidney; responsible GI: Nausea,
for slight diarrhea, dry Patient/family education
antihypertensive mouth, vomiting,
effect and peripheral anorexia, ● Teach patient to take the
vasodilatation cramps, oral or medication early in the day to
(Kizior, et al., 2016). gastric irritations, prevent nocturia.
pancreatitis
● Instruct the patient to take
REFERENCE: GU: Polyuria, with food or milk if GI
renal failure, symptoms of nausea and
Kizior, R. et al. (2016). glycosuria, anorexia occur.
Saunders Nursing bladder spasms
Drug Handbook 2016. ● Teach patient to maintain a
Elsevier Red = Life record of weight on a weekly
Threatening basis and notify physician of
weight loss of .5 lb

Table 25. Drug Study of Furosemide

75
 CHAPTER IX

NURSING MANAGEMENT

This section contains the following: Nursing Care Plan and Discharge Planning

i. Nursing Care Plan

A nursing care plan (NCP) is a systematic process that involves accurately identifying current needs as well as
recognizing possible needs or dangers. Nurses, their patients, and other healthcare workers can communicate through
care plans to obtain better health outcomes. The quality and consistency of patient care would suffer if the nursing care
planning procedure was not in place.

PROBLEM SCIENTIFIC GOALS/ NURSING RATIONALE EVALUATION

BASIS OBJECTIVES INTERVENTIONS

Excess Fluid Within 6 hours of October 19, 2022;

October 19, Volume as nursing care and INDEPENDENT: 9:00 PM
2022; 3:00 PM evidenced by intervention, the
grade 2 bilateral patient will be able 1. Monitor the patient’s 1. Urine output may be “GOAL MET”
Subjective: pitting pedal to have decreased urine output, and scanty and concentrated,
edema fluid volume as take note of the especially during the day
“Tingala mi ani amount and color, because of reduced After 6 hours of
secondary to evidenced by the
niya kay nikalit disease following expected as well as the time renal nursing care and
perfusion.
lang ug process. outcomes: of day when diuresis Recumbency favors
intervention, the
panghupong occurs. diuresis; therefore, urine
patient was
iyang tiil, unya Scientific Basis: 1. The patient will output may be increased somehow able to
hapo pirmente be able to at night and/or during
iyang bed rest. have decreased
Heart failure (HF) stabilize fluid fluid volume as
paminaw. or Congestive volume as
Ingon lagi ang 2. Monitor, take note 2. Diuretic therapy may evidenced by the

76
doctor tungod Heart Failure evidenced by: and calculate the result in a sudden following
daw ni saiyang (CHF) is a patient’s 24-hour increase in fluid loss,
outcomes:
heart ug physiologic state a. Balanced input intake and output even though edema or
kidney kay in which the and output (I&O) balance. ascites remain.
1. The patient was
connected ra heart cannot (I&O)
lagi daw.” as pump enough b. Vital signs 3. Monitor BP and 3. Hypertension and able to
verbalized by blood to meet the within normal central venous elevated CVP suggest demonstrate a
the patient’s body’s metabolic values. pressure. fluid volume excess and stabilize fluid
wife. needs following c. Decrease of may reflect developing volume with
any structural or patient’s weight pulmonary congestion
and HF. balanced input
functional and output, but
impairment of 2. The patient will
needs for
Objective: ventricular filling be able to 4. Assess for 4. Excessive fluid retention
or ejection of express feelings distended neck and may be manifested by further
VS: blood (Vera, of comfort and peripheral vessels. venous engorgement observation and
BP:200/100; 2022). Heart better breathing Inspect dependent and edema formation. evaluation as
PR: 65bpm; failure results and will be body areas for Peripheral edema begins
evidenced by:
RR 28; T: 35.7; from changes in manifested by edema and check in feet and ankles and
SpO2: 93% the systolic or better respiratory for pitting. Also note ascends as failure
with O2 diastolic function rate and O2 the presence of worsens. Pitting edema a. Input of:
inhalation generalized body is generally obvious only 210mL and
of the left saturation;
ventricle, and it is edema. after retention of at least Output of:
Weight: 85 kg 10 lb of fluid. Increased 650mL
a progressive 3. The patient will
and chronic verbalize vascular congestion b. Vital signs are
Input: 0 ml eventually results in
condition understanding of within normal
managed by individual dietary systemic tissue edema.
Output: 400 values; BP:
ml significant and fluid
5. Note complaints of 5. Visceral congestion can 110/70, PR:
lifestyle changes modifications
and adjunct and restrictions. anorexia, nausea, alter intestinal function. 60, RR: 16, T:
medical therapy abdominal 34.7, SpO2:
(+) grade 2
to improve distension, and 99% with
bilateral pitting
quality of life. constipation. oxygen
pedal edema
Heart failure is supplementati
caused by

77
various 6. Assess 6. Expression of feelings on
cardiovascular understanding and may decrease anxiety,
c. Decreased
conditions such encourage which is an energy drain
verbalization of that can contribute to the patient's
as chronic
feelings regarding feelings of fatigue, and weight from
hypertension,
coronary artery limitations. this is to confirm the 85kg to 83kg.
disease, and patient’s cooperation
valvular disease. towards the therapy. 2. The patient
With patients DEPENDENT: express feelings
with heart failure, of comfort and
manifestation of 7. Administer 7. To reduce congestion
medications such as and edema if heart better breathing
fluid excess is a
Diuretics failure is the cause of and there is
classic symptom
because as the (Furosemide). fluid overload. notable
heart starts to alleviation of the
fail, the renal respiratory rate
perfusion falls. 8. Maintain the 8. Recumbency increases
(23cpm) and O2
The kidneys patient’s chair or glomerular filtration and
bed rest in decreases the saturation
respond by (95%);
increasing the semi-Fowler’s production of ADH
production of position during an (Antidiuretic hormone),
renin, leading to acute phase. thereby enhancing 3. The patient was
more aldosterone diuresis. able to
production, which verbalize
is consequently 9. Establish a fluid 9. Involving patients in the
understanding
followed by intake schedule as therapeutic regimen may
fluids are medically enhance a sense of of individual
sodium and
restricted to 1 L, control and cooperation dietary and fluid
water retention.
Arginine incorporating with restrictions. modifications
vasopressin is beverage and restrictions.
also released preferences when
further enhancing possible. Give the
fluid retention patient frequent
and stimulating mouth care and ice

78
thirst. The chips can be part of
activation of the the fluid allotment.
renin–angiotensi
n–aldosterone 10. Weigh the patient 10. Document the changes
and arginine daily, and compare in edema in response to
vasopressin previous therapy because
systems maintain measurements. diuretics can result in
cardiac preload excessive fluid shifts and
which produces weight loss and
more fluid, and bodyweight is a sensitive
afterload, thereby indicator of fluid balance,
maintaining the and an increase
homeostasis of indicates fluid volume
the excess.
cardiovascular
system but at a 11. Investigate reports 11. This may cause
cost of increased of sudden extreme complications that it
systemic venous dyspnea and air develops much more
pressure. hunger, need to sit rapidly and requires
straight up, a immediate intervention.
Reference: sensation of
suffocation, feelings
Khan, Y. H., of panic, or
Sarriff, A., & impending doom.
Malhi, T. H.
(2019, July 21). 12. Follow a low-sodium 12. A diet low in sodium can
NCBI - Chronic diet and/or fluid help lessen fluid
Kidney Disease, restriction. retention, and fluid
Fluid Overload restriction is used as a
and Diuretics: A way to avoid overloading
Complicated your heart.
Triangle. NCBI.
Retrieved 13. Encourage or 13. The client senses thirst
September 12, provide oral care. because the body

79
 2022, from senses dehydration. Oral
https://www.ncbi. care can alleviate the
nlm.nih.gov/pmc/ sensation without an
articles/PMC495 increase in fluid intake.
6320/
14. Encourage rest and 14. Proper rest lessens the
Vera, M. B. provide quiet room risk of increased blood
(2022b, July 8). pressure.
Excess Fluid COLLABORATIVE:
Volume in Heart
Failure. 15. Consult dietician as 15. To develop a dietary plan
Nurseslabs. needed and identify food to be
Retrieved limited or omitted.
September 4,
2022, from 16. Endorse the 16. This is a vital component
https://nurseslab patient's needs and for a continuous and
s.com/heart-failur restrictions to the successful intervention
e-nursing-care-pl next shift. and therapy.
ans/3/

Table 26. Excess Fluid Volume as evidenced by grade 2 bilateral pitting pedal edema secondary to disease process.

80
 PROBLEM SCIENTIFIC GOALS/ NURSING RATIONALE EVALUATION
BASIS OBJECTIVES INTERVENTIONS

October 19, After 8 hours of INDEPENDENT October 19, 2022

2022; Ineffective nursing care and @ 10:00 P.M
2:00 P.M tissue perfusion intervention the 1. Assess cardiac and 1. This assessment
related to patient will be circulatory status. establishes a “Goal partially
Subjective: decrease in able to improve baseline and detects met”
oxygen in the tissue perfusion: changes that may
The watcher blood as indicate a change in After 8 hours of
reported that evidence by a. No alteration cardiac output or nursing care
the feet and mild hypoxemia in Level of perfusion. and intervention
ankles of the consciousne the patient was
patient Scientific Basis: ss 2. Provide a quiet 2. A quiet environment able to improve
suddenly swells b. Chest pain environment. reduces the energy tissue
Ineffective tissue will be demands on the perfusion:
perfusion refers relieved patient.
Objective: to a lack of c. Edema will a. GCS score
oxygenated diminish 3. Monitor the color, 3. Color of extremities of 15
● (+) Pale blood flow to d. Display vital temperature, and should be usual for b. Chest pain
palpebral specific areas of signs within sensation of all ethnicity. Pallor, was
conjunctiva the body. Due to acceptable extremities. cyanosis, or mottled relieved
● (+) Chest decreased limits skin color indicate a c. Edema is
pain cardiac output, blockage in still noted
● ABG result there is perfusion to the d. Display vital
shows mild decreased extremity. signs within
hypoxemia preload and acceptable
● SOB is stroke volume. limits
noted Thus, there is 4. Note the severity of 4. The severity of
decreased blood extremity edema. edema shows how Vital signs:
pumped out from far advanced venous
Vital signs: the heart. A stasis is. This BP: 110/70;
BP: 200/100; decrease in assessment and PR: 60 bpm;
PR: 65bpm; stroke volume checking extremity RR: 16;

81
RR: 28; decreases circumference T: 34.7;
T: 35.7; perfusion should be done daily SpO2: 100% with
SpO2: 93% with throughout the at the same time to O2 inhalation
O2 inhalation body (Wagner, monitor a trend.
2022).
5. Monitor hemoglobin 5. The lower the
frequently. oxygen saturation is,
the lower is the
Reference: affinity for
hemoglobin,
Study.com | Take meaning oxygen
Online Courses. uptake will be
Earn College reduced. That
Credit. Research results in less
Schools, oxygen circulating in
Degrees & the body.
Careers. (n.d.).
https://study.com/ 6. Measure capillary 6. To determine
academy/lesson/i refill. adequacy of systemic
neffective-tissue- circulation.
perfusion-definiti
on-risk.html 7. Upright or
7. Position patient with semi-Fowler’s position
head of the bed allows increased
elevated, in a thoracic capacity, total
semi-Fowler’s position descent of the
as tolerated. diaphragm, and
increased lung
expansion preventing
the abdominal
contents from
crowding.

8. Note blood gas (ABG) 8. Increasing PaCO2 and

82
 results as available decreasing PaO2 are
and note changes. signs of respiratory
acidosis and
hypoxemia.

9. Encourage slow deep 9. This technique

breathing using an promotes deep
incentive spirometer inspiration, which
as indicated. increases oxygenation
and prevents
atelectasis.

DEPENDENT:

10. Check for optimal fluid 10. Sufficient fluid intake

balance. Administer IV maintains adequate
fluids as ordered. filling pressures and
optimizes cardiac
output needed for
tissue perfusion.

11. Maintain an oxygen 11. Supplemental oxygen

administration device
as ordered, attempting
to maintain oxygen
saturation at 90% or
greater.
may be required to
maintain PaO2 at an
acceptable level.

12. Administer 12. To improve patient

medications as prognosis.
ordered by the
physician.

83
 COLLABORATIVE:

13. Collaborate with the 13. To maximize systemic

physicians, nurses, or circulation and organ
other health care perfusion.
providers in treatment
of underlying
conditions.

14. Refer to dieticians. 14. For a well-balanced

low saturated-fat,
low-cholesterol diet
and other
modifications as
indicated.
Table 27. Ineffective tissue perfusion related to decreased cardiac output as evidence by bipedal edema

84
 PROBLEM SCIENTIFIC GOALS/ NURSING RATIONALE EVALUATION
BASIS OBJECTIVES INTERVENTIONS

November 22, After 8 hours of INDEPENDENT: November 22,

2022; Decreased nursing 2022;
10:00 A.M. Cardiac Output assessment and 1. Monitor and document 1. It is done to help you 6:00 P.M.
related to altered intervention, the vitals signs especially evaluate if there are
Subjective: preload, heart patient will be able O2 stat. any abnormalities “GOAL
rate/rhythm as to demonstrate based on previous PARTIALLY
“Tingala mi ani evidence by adequate cardiac data. MET”
niya kay nikalit bipedal edema, output as
lang ug chest pain and manifested by: 2. Maintain adequate 2. When questioning with After 8 hours of
panghupong ECG change ventilation and empathy while nursing
iyang tiil, unya A. Display perfusion as Position reserving any form of assessment and
hapo pirmente Scientific Basis: hemodynamic patient in judgment allows the intervention, and
iyang paminaw. stability (e.g., semi-Fowler’s to patient's parents to the patient will be
Ingon lagi ang Decreased blood pressure, high-Fowler’s. express freely their able to:
doctor tungod Cardiac output is cardiac output, frustrations and
daw ni saiyang inadequate blood urinary output, disappointment
heart ug kidney pumped by the peripheral regarding negative
heart to meet the pulse) as A. The patient's
kay connected feelings, needs, or
metabolic demand indicated by hemodynamic
ra lagi daw.” as skills.
of the body. vital signs stability and
verbalized by
(Herdman, H., within normal 3. Educate the patient 3. It is done to help you vital signs was
the patient’s
Kamitsuru, range. within normal
wife. about his condition evaluate if there are
S.,2018) Altered range but the
and explain about the any abnormalities
heart rate/rhythm Normal Vitals: pt is still under
Objective: intervention done. based on previous
and preload as pt monitoring.
data.
● (+) Chest expriencing ● BP: 200/100
pain with bipedal edema mmHg 4. Teach patients and 4. A variety of tests are
slight chest pain with ● Temp: their guardian to available depending on B. The
36.5C-37.2C patient
discomfort slight discomfort recognize the signs the case of the pt.
● RR: 12-20 bpm was able to
● (+) Dyspnea and with ECG and symptoms that report no
on exertion impression of ● HR: 60-100 need to be reported to

85
● O2 Sinus Rhythm bpm the nurse. further
inhalation Nonspecific T ● O2 Stat: episodes of
via nasal wave abnormality. 95%-100% 5. Elevate legs, avoiding 5. In patients with dyspnea.
cannula Altered preload as pressure under the decreased cardiac
● (+) Bipedal pt experiencing knee or in a position output, poorly
edema fluid retention as comfortable to the functioning ventricles
● (+) Pale fluids leak out into B. Report/demonst patient. may not tolerate C. The patient
palpebral intracellular space rate decreased increased fluid edema wasn’t
conjunctiva as preload episodes of volumes. diminished
increased and dyspnea. DEPENDENT: and it still
Vital signs: venous return monitoring.
inhibited. (Wound 6. Closely monitor fluid 6. These actions can
BP: 200/100; Care,2019) Pt with intake, including IV increase oxygen
C. The patient will
PR: 65bpm; altered heart rate/ lines. Maintain fluid delivery to the
stabilize and D. The patient
RR: 28; rhythm can restriction if ordered. coronary arteries and
the patient verbalizes the
T: 35.7; experience sick improve patient
edema will comfort of
SpO2: 93% sinus syndrome, prognosis.
diminish. being able to
as the sinus node
breath through
Labs: is responsible for 7. Administer cardiac 7. An upright position is
the nasal
setting the pace of medications and recommended to
cannula.
ECG Dx: the heart. If the D. The patient will diuretics as promote chest
Sinus Rhythm sinus node does verbalize the prescribed. expansion.Also to
Nonspecific T not work properly, comfort of using reduce preload and
wave the heart rate may the ventricular filling when
abnormality alternate between administered fluid overload is the
too O2. cause.
slow/bradycardia
and too 8. As chest pain is 8. The failing heart may
fast/tachycardia. present, have the not be able to respond
Sick sinus patient lie down, to increased oxygen
syndrome can be monitor cardiac demands. Oxygen
caused by rhythm, give oxygen, saturation needs to be
scarring near the medicate for pain, and greater than 90%
sinus node that's notify the physician.

86
 slowing, disrupting
or blocking the 9. Maintain oxygen 9. This promotes
travel of impulses. therapy as ordered. cooperation and
This is most understanding about
common among his condition.
older adults, as
our pt (Releford COLLABORATIVE:
,2022)
10. Submit patients to 10. Early assessment
diagnostic testing as facilitates immediate
Reference: indicated. treatment.

Releford, B.
(2022, February
21). Edema in
Chronic Wounds |
Risk Factors |
Diagnosis and
Treatment. The
Wound Pros.
https://www.thewo
undpros.com/post/
edema-in-chronic-
wounds-risk-factor
s-diagnosis-and-tr
eatment

Table 28. Decreased Cardiac Output related to altered preload, heart rate/rhythm as evidence by bipedal edema, chest pain
and ECG change

87
 PROBLEM SCIENTIFIC GOALS/ NURSING RATIONALE EVALUATION
BASIS OBJECTIVES INTERVENTIONS

November 22, Impaired gas After 8 hours of Independent: November 22,

2022; exchange treatment period, 2022:
10:00 A.M. related to the patient will be 1. Assess breathing 1. Aids to provide a 06:00 P.M.
altered alveolar able to atain pattern, respiratory basis for evaluating
Subjective: and capillary improved rate, and pulse rate adequacy of “FULLY MET”
exchange ventilation and every 4 hours. ventilation and the
Patient reported secondary to oxygenation status: presence of dyspnea. After 8 hours of
shortness of Congestive treatment period,
breath while Heart Failure a. Will exhibit no 2. Check oxygen 2. Aids to detect any the patient was able
talking and rapid and saturation level every changes in oxygen to atain improved
difficulty of shallow breaths 4 hours by the use of levels of the blood. ventilation and
breathing upon Scientific Basis: by absence of pulse oximeter oxygenation status:
exertion. nasal flaring
Congestive heart 3. Inspect nasal mucosa 3. Presence of nasal a. Patient
Objective: failure develops b. Will provide for nasal flaring flaring occurs in manifested
when the heart is diminish response to ineffective ease of
● Shortness of unable to adventitious ventilation. breathing by
breath while adequately pump breath sounds 4. Perform lung 4. Adventitious breath absence of
talking blood containing auscultation for the sounds indicate an nasal flaring
● Exertional oxygen and c. Will demonstrate presence of underlying cause
Dyspnea nutrients to improve comfort adventitious sounds which should be b. Absence of fine
● Fatigue tissues and vital and breathing investigated for further crackles
● Tachypnea organs and as a pattern while investigation.
● Fine result, fluid shifts talking 5. Assess skin and 5. To identify presence c. Demonstrate
crackles in into the interstitial mucous membrane of cyanosis and pallor ease of
bilateral space and fluid d. Will be able to for its color which is an indicator breathing while
basal accumulates in perform basic for inadequate talking
membrane the alveoli. activities without ventilation
Inadequate difficulty of d. No complaints
Vital Signs: exchange of breathing 6. Position the patient in 6. To promote full chest of shortness of
● BP: oxygenation in i. Eating semi-fowler's position expansion which breath with

88
 200/100; the ii. Going to helps to alleviate exertion;
● PR: 65bpm; alveolar-capillary the difficulty of breathing patient was
● RR: 28; membrane bathroom 7. Assist patient on 7. This technique can able to:
● T: 35.7; causes the iii. Talking deep breathing and help increase sputum i. Eat
● SpO2: 93% patient to present perform controlled clearance and ii. Go to the
clinical coughing. Have the decrease cough bathroom
manifestation of patient inhale deeply, spasms. Controlled iii. Talk
difficulty of hold breath for coughing uses the
breathing. several seconds, and diaphragmatic
cough two to three muscles, making the
Reference: times with mouth cough more forceful
Berman, A., open while tightening and effective.
Synder, S., & the upper abdominal
Frandsen, G. muscles as tolerated.
(2016). Kozier & 8. Suction as 8. Suction clears
Erb’s necessary. secretions if the
Fundamentals of patient is not capable
Nursing: of effectively clearing
Concepts, the airway.
practices, and 9. Pace activities and 9. Activities will increase
process. (10th schedule rest periods oxygen consumption
ed.). Pearson to prevent fatigue. and should be
Education Inc. Assist with ADLs planned, so the
patient does not
Dependent: become hypoxic.

10. Administer 10. To delivery low

supplemental oxygen concentration of
via nasal cannula @2 oxygen for clients
L/min as prescribed requiring support due
by the physician to inadequate
oxygenation or
ventilation.
Table 29. Impaired gas exchange related to altered alveolar and capillary exchange secondary to Congestive Heart Failure
89
 PROBLEM SCIENTIFIC GOALS/ NURSING RATIONALE EVALUATION
BASIS OBJECTIVES INTERVENTIONS

November 22, Activity After an 8 hour INDEPENDENT: November 22,

2022; intolerance span of care, 2022:
10:00 A.M. related to patient will report 1. Monitor vital 1. To obtain baseline data. 06:00 P.M.
imbalance measurable signs.
Subjective: between oxygen increase in activity “FULLY MET”
supply/demand tolerance as 2. Observe 2. During physical activity, the
Patient secondary to evidenced by: cardiopulmonary nurse can keep an eye on After an 8 hour
expresses CHF as response to the patient's heart rate, span of care,
fatigue evidenced by a. The patient will activity. oxygen saturation, and patient reported
dyspnea with be able to use cardiac rhythm. Blood measurable
Objective: exertion, chest identified pressure fluctuations, increase in activity
pain and techniques to tachycardia, and EKG tolerance as
● Exertional elevated Blood enhance alterations can all indicate evidenced by:
Dyspnea pressure and tolerance; overexertion and aid in the
● Fatigue RR formulation of the best a. The patient was
● Tachypnea b. The patient will course of action (Wagner, be able to use
● Edema demonstrate a 2022). identified
● Chest Pain Scientific Basis: decrease in techniques to
physiological 3. Provide a calm 3. Anxiety and restlessness enhance
Vital Signs: Activity signs of environment. might develop from tolerance;
● BP: intolerance can intolerance; and dyspnea brought on by HF.
200/100; be described as Give the patient access to b. The patient
● PR: 65bpm; insufficient c. The patient will a calm, dimly lit area that is demonstrated a
● RR: 28; physiological or be able to free of distractions and decrease in
● T: 35.7; psychological identify clutter. Encourage the physiological
● SpO2: 93% energy to alternative ways patient to breathe slowly signs of
complete to maintain and deliberately, and offer intolerance; and
required or desired activity them emotional support so
desired daily level. they can feel in control c. The patient was
activities. Activity (Wagner, 2022). able to identify
intolerance is a alternative ways

90
common side 4. Ascertain the 4. To determine current to maintain
effect of heart client’s ability to status and needs desired activity
failure and can stand and move associated with level.
be related to about the degree participation in
generalized of assistance needed/desired activities
weakness and necessary or use (Doenges et. al., 2019).
difficulty resting of equipment.
and sleeping
(Berman, Synder, 5. Encourage 5. Provide toiletries at the
& Frandsen, participation. bedside so the patient can
2016). brush their teeth or comb
their hair. Have the patient
assist with turning
themselves in bed
Reference: (Wagner, 2022).
Berman, A.,
Synder, S., & 6. Provide 6. Meets patient’s personal
Frandsen, G. assistance with care needs without undue
(2016). Kozier & self-care myocardial
Erb’s activities as stress/excessive oxygen
Fundamentals of indicated. demand.
Nursing: Intersperse
Concepts, activity periods
practices, and with rest periods.
process. (10th
ed.). Pearson 7. Teach methods 7. Group tasks together, sit
Education Inc. to conserve when possible when
energy. performing ADLs, plan rest
periods, promote restful
sleep, do not rush
activities, and avoid
activities in hot or cold
temperatures, (Wagner,
2022).

91
 8. Determine the 8. To provide a baseline for
client’s current comparison and an
activity level and opportunity to track
physical changes (Doenges et. al,
condition with 2019).
observation.

DEPENDENT:

9. Provide 9. Patients with decreased

supplemental activity tolerance may
oxygen therapy become short of breath
as needed. with activity and require
additional oxygen therapy
in order to maintain
appropriate oxygen
saturation levels.

10. Use portable 10. May determine the use of

pulse oximetry to supplemental oxygen to
assess for help compensate for the
oxygen increased oxygen
desaturation demands during physical
during activity. activity.

.
Table 30. Activity intolerance related to imbalance between oxygen supply/demand secondary to CHF as evidenced by
dyspnea with exertion, chest pain and elevated Blood pressure and RR.

92
 CHAPTER X

DISCHARGE PLAN

Medication

1. Instruct the patient to continue taking his medication as prescribed by the

physician.
2. Emphasize the route of administration, the frequency, and the dosage.
3. Educate the side effects of each drug that may occur after administration.
Give contact details of the physician or the hospital to the patient’s
spouse/guardian that they can call immediate response.

Exercise

1. Encourage the patient to start slowly and gradually in his exercise like
walking. Walk only when tolerated. If planning to do it outdoors, avoid
doing it when it is too hot or humid as extreme temperature can interfere
with circulation.
2. When in complete bed rest or patient cannot tolerate more movement,
instruct and demonstrate to the patient’s family to perform ROM (Range of
motion) exercise to the patient in order to reduce stiffness of the body.
3. Instruct and demonstrate to the patient to do the proper Pursed Lip
Breathing by starting breathing in through nose and breath out through the
mouth with pursed lips. Explain to the patient that it helps to keep airways
open longer so that it can remove the air that is trapped in their lungs by
slowing down their breathing rate and relieving shortness of breath.

93
Treatment

1. Discuss to the patient that he must comply with the physician treatment
provided after discharge.
2. Educate how treatment will be performed and continued at home. Tell the
patient and patient’s spouse/guardian to follow the directions of the doctor
or any other healthcare practitioner.
3. Explain the purpose of any provided treatment.
4. Demonstrate and let the patient also perform how treatment will be done
in the correct way.
5. Advice the patient to monitor weight and glucose level.
6. Encourage the patient to have his full cooperation with the given treatment
to obtain optimum health.

Hygiene

1. Educate the patient to have proper hygiene not only on himself but also in
his surroundings. Fresh air, pure water, efficient drainage, cleanliness, or
sanitation, and sunlight can be good in improving health conditions. It will
also help prevent further complications.
2. Encourage the patient's self-hygiene within his capabilities.
3. Instruct the patient's family to a bed bath and dental care if the patient is
on total bed rest.

Out-Patient (Check Up)

1. Remind the patient and family about the date when and where to have a
follow up check up.
2. Advice that the physician’s order must be kept in mind to prevent further
complications.

94
 3. Educate also the family about the health teaching that is given to patients.
It is for them to monitor the patient’s status. In order to report the status to
the physician.

Diet

1. Educate the patient about the importance and purpose of his prescribed
diet.
2. Encourage them to consult a registered dietitian. They can help in making
a meal plan that is right for them. Most people with kidney disease need to
limit salt (sodium), fluids, and protein. Some also have to limit potassium
and phosphorus.
3. Encourage the patient to eat healthy foods such as vegetables and fresh
fruits.
4. Educate the patient about fluid intake to prevent overload fluid in the body.
Discuss that fluid overload may lead to shortness of breath, increased
swelling, and/or weight gain.
5. Strictly limit sweets and desserts such as cookies, cakes, candies, and
pastries.
6. Advised to eat more protein such as eggs, fish, chicken and legumes to
help balance the blood sugar level
7. If the patient has a hard time eating enough, talk to your doctor or dietitian
about ways to add calories to your diet.
8. Educate patients that diet may change as the disease changes. See your
doctor for regular testing. And work with a dietitian to change diet as
needed.

95
Spirituality

1. Encourage the patient and the spouse/guardian to engage in what they

believe religiously. Strengthening faith, especially adjusting with their new
challenge in life would encourage them to be strong.
2. Encourage them to visit their churches as this can be the time to
strengthen their bond as family together with the God/Allah they believe.
3. Praying can also be their way of coping with the challenge that they face.

96
 CHAPTER XI

REFERENCES

Adams, H. (2017). Chronic Kidney Disease (CKD). Retrieved from

https://www.cdc.gov/diabetes/managing/diabetes-kidney-disease.html
Adppharma. (2022). Asomex 2.5mg & 5mg. ADP Pharma.
https://www.adppharma.com/product/asomex-2-5mg-5mg/
Appel, L., (2022). Smoking and hypertension. Retrieved from
https://www.uptodate.com/contents/smoking-and-hypertension#H4036205
542,
Bayer. (2022). Heart Health: Heart Attack & Stroke Information | Bayer
Aspirin. Www.bayeraspirin.com. https://www.bayeraspirin.com/
Cacciata, M. C., Alvarado, I., Jose, M. M., & Evangelista, L. S. (2021,
August 20). Health determinants and risk factors for coronary artery
disease among older Filipinos in rural communities. European journal of
cardiovascular nursing. Retrieved November 20, 2022, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8324596/#:~:text=Coronary
%20artery%20disease%20is%20the,increases%20their%20risk%20of%2
0CAD.
Cassoobhoy, A. (2020). High Blood Pressure and Heart Failure. Retrieved
from
https://www.webmd.com/heart-disease/heart-failure/blood-pressure-heart-f
ailure#:~:text=If%20you%20have%20heart%20failure,risk%20factor%20fo
r%20heart%20failure.
Centers for disease control and prevention, (2021). Coronary Artery
Disease. Retrieved from
https://www.cdc.gov/heartdisease/coronary_ad.htm#:~:text=Angina
Cole, J. B., & Florez, J. C. (2020). Genetics of diabetes mellitus and
diabetes complications. Nature Reviews. Nephrology, 16(7).
https://doi.org/10.1038/s41581-020-0278-5

97
Cudis, C. (2021, May 7). Diabetes among top killer diseases in PH.
Www.pna.gov.ph. https://www.pna.gov.ph/articles/1139440
Define_me. (n.d.). Retrieved November 20, 2022, from
https://www.kireports.org/article/S2468-0249(19)31251-3/fulltext#:~:text=T
he%20incidence%20rate%20of%20AKI,overall%20mortality%20rate%20o
f%204.8%25.
Dubé, p., et. al., (2016). Exertional dyspnoea in chronic heart failure: the
role of the lung and respiratory mechanical factors. Retrieved from
https://err.ersjournals.com/content/25/141/317#:~:text=Exertional%20dysp
noea
Fletcher, J., (2022) why does diabetes cause fatigue. Retrieved from
https://www.medicalnewstoday.com/articles/323398.
Hsu, R. K., & Hsu, C. (2016). The Role of Acute Kidney Injury in Chronic
Kidney Disease. Seminars in Nephrology, 36(4), 283–292.
https://doi.org/10.1016/j.semnephrol.2016.05.005
Huizen, J., (2021). What to know about dyspnea on exertion. Retrieved
from https://www.medicalnewstoday.com/articles/dyspnea-on-exertion
Hypertension in older adults: Assessment ... - wiley online library. (n.d.).
Retrieved November 20, 2022, from
https://onlinelibrary.wiley.com/doi/full/10.1002/clc.23303
Jin, J., (2013) Obesity and the Heart. Retrieved from
https://jamanetwork.com/journals/jama/fullarticle
Jonny, J., Hasyim, M., Angelia, V., Jahya, A. N., Hilman, L. P.,
Kusumaningrum, V. F., & Srisawat, N. (2020, May 20). Incidence of acute
kidney injury and use of renal replacement therapy in Intensive Care Unit
Patients in Indonesia - BMC nephrology. BioMed Central. Retrieved
November 20, 2022, from
https://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-020-01849
-y

98
Kenny, H. C., & Abel, E. D. (2019). Heart Failure in Type 2 Diabetes
Mellitus. Circulation Research, 124(1), 121–141.
https://doi.org/10.1161/circresaha.118.311371
Khan, Y. H., Sarriff, A., Adnan, A. S., Khan, A. H., & Mallhi, T. H. (2016).
Chronic Kidney Disease, Fluid Overload and Diuretics: A Complicated
Triangle. PLOS ONE, 11(7), e0159335.
https://doi.org/10.1371/journal.pone.0159335
Lancet, (2012). CHRONIC KIDNEY DISEASE (CKD). Retrieved from
http://www.pathophys.org/ckd/
Liu, F., Dai, S., Feng, D., Qin, Z., Peng, X., Sakamuri, S. S. V. P., Ren, M.,
Huang, L., Cheng, M., Mohammad, K. E., Qu, P., Chen, Y., Zhao, C., Zhu,
F., Liang, S., Aktas, B. H., Yang, X., Wang, H., Katakam, P. V. G., & Busija,
D. W. (2020). Distinct fate, dynamics and niches of renal macrophages of
bone marrow or embryonic origins. Nature Communications, 11(1).
https://doi.org/10.1038/s41467-020-16158-z
Loeffler, I., & Wolf, G. (2013). Transforming growth factor- and the
progression of renal disease. Nephrology Dialysis Transplantation,
29(suppl 1), i37–i45. https://doi.org/10.1093/ndt/gft267
Lovenox. (2022). Lovenox® for Anticoagulant Therapy. Home.
https://www.lovenox.com/enoxaparin-sodium
Malik, A., Brito, D., Vaqar, S., & Chhabra, L. (2022, September 19).
Congestive heart failure. National Library of Medicine; StatPearls
Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430873/
Manual, M. (2022). Figure: Regulating Blood Pressure: The
Renin-Angiotensin-Aldosterone System. MSD Manual Consumer Version.
https://www.msdmanuals.com/home/multimedia/figure/regulating-blood-pr
essure-the-renin-angiotensin-aldosterone-system
Martini, F., Nath, J. L., & Bartholomew, E. F. (2018). Fundamentals of
anatomy & physiology (11th ed.). Pearson Education Limited.

99
Meissner, M., (2021) How diabetes affects men vs. women. Retrieved
from
https://www.medicalnewstoday.com/articles/diabetes-affects-men-women#
Mellejor, L. Tracking system for high-risk kidney patients launched in
Davao. Retrieved November 17, 2022, from
https://www.pna.gov.ph/articles/1038456
Mendoza, J. A., Lasco, G., Renedo, A., Palileo-Villanueva, L., Seguin, M.,
Palafox, B., Amit, A. M. L., Pepito, V., McKee, M., & Balabanova, D. (2021,
November 17). (de)constructing 'therapeutic itineraries' of hypertension
care: A qualitative study in the Philippines. Social Science & Medicine.
Retrieved November 20, 2022, from
https://www.sciencedirect.com/science/article/pii/S0277953621009023
Merschel, M. (2019). The connection between diabetes, kidney disease
and high blood pressure. Retrieved from
https://www.heart.org/en/news/2020/11/03/the-connection-between-diabet
es-kidney-disease-and-high-blood-pressure
MIMS. (2022a). Lipitor Dosage & Drug Information | MIMS Philippines.
Www.mims.com. https://www.mims.com/philippines/drug/info/lipitor
MIMS. (2022b). Trajenta Dosage & Drug Information | MIMS Philippines.
Www.mims.com. https://www.mims.com/philippines/drug/info/trajenta
MIMSOnline Team, C. B. (2017). Platogrix Full Prescribing Information,
Dosage & Side Effects | MIMS Indonesia. Platogrix Full Prescribing
Information, Dosage & Side Effects | MIMS Indonesia. Retrieved
November 18, 2022, from
https://www.mims.com/indonesia/drug/info/platogrix?type=full
National Library of Medicine (2019). Hypertension. Retrieved from.
https://medlineplus.gov/genetics/condition/hypertension/
Novack, M., (2022). Natriuretic Peptide B Type Test. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK556136/,
Orlandi, P. et. al (2018). Hematuria as a risk factor for progression of
chronic kidney disease and death: findings from the Chronic Renal

100
Insufficiency Cohort (CRIC) Study. Retrieved from
https://bmcnephrol.biomedcentral.com/articles/
Patron Analysis. (2021, May 17). Catapres (Generic Clonidine) -
Prescriptiongiant. Prescriptiongiant.
https://prescriptiongiant.com/product/catapres-generic-clonidine
Published by Statista Research Department, & 26, O. (2022, October 26).
Philippines: Number of deaths from heart diseases in Davao Region by
location. Statista. Retrieved November 20, 2022, from
https://www.statista.com/statistics/1121840/heart-disease-cases-davao-re
gion-by-province-philippines/
Remuzzi, G., Perico, N., Macia, M., & Ruggenenti, P. (2021). The role of
renin-angiotensin-aldosterone system in the progression of chronic kidney
disease. Kidney International, 68(S57–S65), S57–S65.
https://doi.org/10.1111/j.1523-1755.2005.09911.x
Rev, R., (2016). Hypertension and Aging. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4768730/,
RiteMed. (2017). Heart Conditions | RM TRIMETAZIDINE 35 MG TAB.
Ritemed.com.ph.
https://www.ritemed.com.ph/products/rm-trimetazidine-35-mg-tab
Sendić, G. (2022). Respiratory system. Kenhub.
https://www.kenhub.com/en/library/anatomy/the-respiratory-system
Shahjehan, R. D., & Bhutta, B. S. (2022, August 9). Coronary Artery
Disease. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK564304/
Shao, C., Wang, J., Tian, J., & Tang, Y.-da. (1970, January 1). Coronary
artery disease: From mechanism to clinical practice. SpringerLink.
Retrieved November 20, 2022, from
https://link.springer.com/chapter/10.1007/978-981-15-2517-9_1
Tecla, T., et. al., (2018). Obesity and risk for hypertension and diabetes
among Kenyan adults Results from a national survey. Retrieved from

101
https://journals.lww.com/md-journal/Fulltext/2021/10080/Obesity_and_risk
_for_hypertension_and_diabetes.
Tinsley, G. (2018). Symptoms, causes, and treatment of chronic kidney
disease (CKD). Retrieved from
https://www.medicalnewstoday.com/articles/172179
Torborg, L. (2018). Mayo Clinic Q and A: Heart disease and kidney
disease — what’s the connection? Retrieved from
https://newsnetwork.mayoclinic.org/discussion/mayo-clinic-q-and-a-heart-
disease-and-kidney-disease-whats-the-connection/
Tumanan-Mendoza BA;Mendoza VL;Bermudez-Delos Santos
AA;Punzalan FE;Pestaño NS;Natividad RB;Shiu LA;Macabeo R; (n.d.).
Epidemiologic burden of hospitalisation for congestive heart failure among
adults aged ≥19 years in the Philippines. Heart Asia. Retrieved November
20, 2022, from https://pubmed.ncbi.nlm.nih.gov/28405229/
Unilab. (2022). Carvedilol. Unilab.com.ph.
https://www.unilab.com.ph/products/carvid
Van Buren, P. N., & Toto, R. (2011). Hypertension in Diabetic
Nephropathy: Epidemiology, Mechanisms, and Management. Advances in
Chronic Kidney Disease, 18(1), 28–41.
https://doi.org/10.1053/j.ackd.2010.10.003
Vanputte, C. L. (2017). Seeley’s anatomy & physiology (11th ed.).
Mcgraw-Hill Education.
Vera, M. (2019, August 21). Heart failure nursing care plans: 15 nursing
diagnosis - nurseslabs - page 3. Nurseslabs.
https://nurseslabs.com/heart-failure-nursing-care-plans/3/
Yang C. et. al., (2017). Retrospective cause analysis of troponin I
elevation in non-CAD patients. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5604657

102