CONGESTIVE HEART FAILURE

I. Nursing History
1. Biographic Data Name: Mr. X Age: 53 years old Address: Quezon City, Philippines Sex: Male Marital Status: Married 2. Chief Complaint Cough

3. Present Illness

2 weeks prior to admission: The patient is with cough with whitish sticky phlegm. 1 week prior to admission: The patient had occurrence of cough with whitish phlegm associated with easy fatigability; 2 3 pillow orthopnea and decrease appetite. No fever, no chest pain, no nausea and vomiting, no body weakness.

The patient had no other signs and symptoms like fever, chest pain, shortness of breath, difficulty of breathing, abdominal pain and numbness.
The patient had consulted and the patient was given Cefalexine 500mg 3x a day and Dextometrophan 3x a day for temporary relief

4. Past History
The clients creatinine level was increased 2 3 years ago. Admitted due to decrease input and output 0 output and pedal edema, cardiomyopathy 2 3 years ago. HCTZ 2500, Carvedilol 6.25 2x a day, on once a day Lanoxin 0.25 tab, Lasix 40 2x a day, Coumadin 2.5mg once a day. Patient had Diabetes Mellitus for 10 years, CBG every other day on insulin 2 3 years ago.

5. Personal and Social History

The client is a non smoker The client consumed 2 3 bottles of beer in a week The client is a previous dentist Father: Congestive Heart Failure, Diabetes Mellitus Mother: Diabetes Mellitus

Course in the ward

June 25, 2013

Client was endorsed and reviewed clients chart and noted all medications as ordered. Preparation of medications Acetylcysteine 600 mg/tablet once a day diluted in a half glass of water, Ketosterol 600 mg/tablet twice a day [8:00am and 1:00pm], Levofloxacin 750 mg/tablet once a day and Kalium durule thrice a day for three days given after meal [started on second day of admission (June 22, 2013)] and was given as prescribed after the vital signs are taken. The client had a diet of low salt and low fat. At 11:00am Complete Blood Glucose Test (CBG) was taken as ordered with a result of 56 mg/dl. The attending physician ordered a retake of CBG reading for 1:00pm. Vital signs are taken at 12:00nn. The client had his CBG Test retake at 1:00pm with a result of 138 mg/dl and Kalium durule was given after meal.

June 26, 2013 The client was endorsed. Reviewed chart: discharge order noted. Provided continuity of care given: vital signs taken and preparation of medications Acetylcysteine 600 mg/dl once a day diluted in a half glass of water, Ketosterol 600 mg/tablet twice a day [8:00am and 1:00pm], Levofloxacin 750 mg/tablet once a day, Kalium durule thrice a day for three days given after meal [started on second day of admission (June 22, 2013)], Lanoxin 0.25 mg/tablet once a day and Furosemide 40 mg/tablet every 12 hours taken orally with Blood Pressure precaution of 90/60 mmHg was given as prescribed. Client was advised for discharged. Instructed client regarding his home medications: Lactulose 120ml take 30cc every other day, Captopril 25 mg/tablet take tablet twice a day and he was advised to have a follow up check up after 1 week.

II. Conceptual Framework

III. Physical Assesment

VITAL SIGNS RESULTS June 25, 2013 Blood Pressure Temperature Respiratory Rate Pulse Rate 120/90 mmHg 35.1oC 24 breaths per minute 80 beats per minute

Head to Toe Assesment

ACTUAL ASSESSMENT HEAD FACE Eyes NORMAL ASSESSMENT ANALYSIS and INTERPRETATION

pale color of sclera

yellowish color of conjunctiva

white color of sclera

white color of conjunctiva depends on the color of race no distention of jugular vein

Lips

pale in color

Neck

distended jugular vein

decrease oxygen in the blood flow jaundice due to hemolysis of Red Blood Cells inadequate oxygenation indirect indicator of pressure in the right atrium

THORAX and ABDOMEN LUNGS Breath sounds Abdomen

crackles/rales upon auscultation wide abdominal distention (105cm./41inches)

bronchovesicular breath sound depends on body mass index

pulmonary congestion or pulmonary edema fluid accumulation in the abdominal cavity due to heart failure

UPPER EXTREMITIES Palms Nail beds LOWER EXTREMITIES Feet Soles

both palms are pallor both hands nail bed are cyanotic in color

pinkish in color pinkish in color

inadequate oxygenation inadequate oxygenation

GENERAL SURVEY: o Body weakness o Easily fatigue SKIN: o o o o

grade 2 pitting edema on both feet pallor on both soles

no pitting edema Pinkish in color

venous insufficiency in lower extremity inadequate oxygenation

Dark brown in color Dry, cold, clammy skin Grade 2 pitting edema on both feet Poor skin turgor

IV. Laboratory/Diagnostic Exams

ECG RESULT (June 22, 2013) Interpretation: Sinus Rhythm Right Axis Deviation Bi-Atrial Enlargement Incomplete Right Bundle Branch Block Non Specific T Wave Changes Persistent Postero-Basal Forces 2 DIMENSIONAL ECHOCARDIOGRAM AND COLOR FLOW REPORT Interpretation: Color Flow Doppler Study Mitral regurgitation, moderate Tricuspid regurgitation, moderate Pulmonic regurgitation Calculated pulmonary artery pressure by pulmonary acceleration time (74msec), Pulomonary Hypertension, mild Conclusion: Dilated left ventricular dimension with left ventricular global hypokinesia Widened E-point septal separation with low flow configuration of mitral valve leaflets indicative of left ventricular dysfunction Depressed left ventricular ejection fraction = 28% by Simpson and 26% by Cubed method Rheologic stasis noted in left ventricular cavity Dilated left atrial dimension without evidence of thrombus Dilated right atrial and right ventricular dimensions Normal man pulmonary artery and aortic root dimensions Mitral valve, tricuspid valve, aortic valve and pulmonic valve are normal

Blood Glucose chart

DATE June 23, 2013 (11:30am) RESULT 269 mg/dl REFERENCE VALUE 80 120 mg/dl ANALYSIS Increased blood sugar level

DEPARTMENT OF RADIOLOGY Section of Ultrasound TOTAL ABDOMINAL ULTRASOUND Impression: Cholelithiasis. Normal sonogram of the liver, pancreas, spleen, kidneys and urinary bladder. Prostate gland enlargement with concretions.

Department of Pathology Section of hematology

TEST CBC with PLATELET COUNT Red Cell Count MCV MCH MCHC DIFFERENTIAL COUNT Lymphocytes RESULTS REFERENCE VALUES ANALYSIS

96.5 (high) 34.6 (high) 0.359 (high)

80.0 96.0 27.5 33.2 0.322 0.355

Indicate to classify anemias

0.41 (high)

0.25 0.35

Indicates infection

Hematology Section Coagulation

PROTHROMBIN TIME RESULTS June 22, 2013 16.5 sec. June 25, 2013 37.9 sec. REFERENCE VALUE ANALYSIS

Patient

10 14 sec.

Prolong clotting to occur

Department of pathology Section of clinical chemistry

TEST RESULT June June 22, 24, 2013 2013 116 mg/dl (high) REFERENCE VALUE INTERPRETATION ANALYSIS

Glucose

74 106

Abnormal

Increased blood glucose level

Urea

Creatinine

Uric Acid

64 50 mg/dl mg/dl (high) (high) 2.3 1.9 mg/dl mg/dl (high) (high) 15.0 mg/dl (high) 185 mg/dl (high)

9 20

Abnormal

0.66 1.25

Abnormal

Renal insufficiency Decrease renal tissue perfusion Increase cholesterol level in blood

3.5 8.51

Abnormal

Triglycerides

0 150

Abnormal

Direct HDL Globulin A/G Ratio Potassium

19 mg/dl (low) 4.7 g/dl (high) 0.6 (low) 3.43 mmol/L (low)

40 60 2.5 3.5 1.5 3.5 3.5 5.1

Abnormal Abnormal Abnormal Abnormal

Decrease pumping of the heart

Electrolytes
TEST RESULT June 22, 2013 1.08 REFERENCE VALUE 1.10 1.40 mmol/L INTERPRETATION ANALYSIS Ionized Calcium Abnormal Decrease contractility of heart muscle

TEST

RESULT June 22, 2013

UNIT

REFERENCE VALUE

INTERPRETATION

ANALY SIS

Routine Chemistry Glycosylated Hemoglobin (HbA1c)

8.0

4.3 6.4

Abnormal

Uncontro lled Diabetes Mellitus (3 months)

URINALYSIS SECTION OF CLINICAL MICROSCOPY

MACROSCOPIC Color Transparency RESULT Dark Yellow Hazy REFERENCE VALUE Yellow Clear INTERPR ETATION Abnormal Abnormal ANALYSI S Concentrate d Insufficient glomelular filtration Renal damage Renal damage

Reaction Albumin Urobilinogen

6.0 +1 1.0 mg/dl

7.0 Negative Negative

Abnormal Abnormal Abnormal

Microscopic
RESULT RBC Bacteria 12 Few REFERENCE VALUE 02 None INTERPRETATION Abnormal Abnormal ANALYSIS

DEPARTMENT OF RADIOLOGY Roentgenological Findings Impression: Left ventricular enlargement

RESPIRATORY THERAPY UNIT Arterial Blood Gas (ABG) Determination

pH pC02 p02 HC03 BE Sa02 tC02

RESULT 7.52 25.4 136.7 20.4 (-) 0.7 99.0 21.2

REFERENCE VALUE 7.35 7.45 35 45mmHg 80 100 mmHg 22 -26 mEq/L 2 95 100% 21 27 mmol/L

ANALYSIS

V. Drug Study

VI. Anatomy and Physiology

VII. Pathophysiology

VIII. Prioritized List of Nursing Problems

IX. Nursing Care Plan

X. Discharge Plan
Medications
Captopril 25 mg/tab. Trimetazidine (vastarel MR) 35 mg/tab. Humulin- N Coumadin 2.5 mg/tab. Lanoxin 0.25 mg/tab. Lactulose 120 ml/ bottle. Ketosterol 600 mg/tab. Ferrous Sulfate Calcium Gluconate 500 mg/tab. Furosemide 40 mg/tab. Take tab. 2x a day. Take 1 tab. 2 x a day Inject 4 units, SC @ A.M.; & 4 units SC @ P.M. Take 1 tablet every other day. Take 1 tablet every other day Take 30 cc 1 x a day. Hold for BM > 3 x day. Take 1 tablet 2 x a day. Take 1 tablet 2x a day Take 1 tablet 1 x a day. Take 1 tablet 1 x a day

Exercise/Activities

Gradually resume activities of daily living.

Treatment
Health Teaching OPD Follow- Up

Care of Attending Physician

Encourage proper diet with exercise. Limit fluids to 1 L per day.

After 1 week Laboratory Work Ups (OPD) PT Na & K BUN Crea CBC with Plt BUA

Diet

Low Salt, Low Fat

Sexuality/ Resume spiritual Spiritual: activity.

Adviser: Mr. Xavier Acuar RN, US-RN,MAN

Group 1: Arapol, Nikki M. Corpuz Richard Erikson Flores, Russelle Lowelle B. Gutierrez, Ailyn O. Ilao, Roldan O. Moreno, Ma. Kristina M. Sabatin, John Amadeus R. Simpao, Michael Vincent S. Thornton, Louzaldy Earl D. Villanueva, Mark Jason Wi, Lynn Joy

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