Ryan Oneil A.

Lomeda BSN 4A2 Assessment Subjective Data: Masakit yung likod ko nagsimula eto dalawang araw ng nakakalipas nung natulog ako sa sofa, as stated Objective Data: 14 y/o 5/10 pain scale on lower back Left shoulder is higher than right Obvious Sshaped spine X-ray revealed a lateral curvature of lumbar spine

SCOLIOSIS Nursing Diagnosis Acute Pain related to structural changes secondary to scoliosis aeb 5/10 pain scale on lower back, left shoulder is higher than right , obvious S-shaped spine, x-ray revealed a lateral curvature of lumbar spine Sci. Explanation Predisposing Factors: Genetics Sex: Female Age: 14 y/o Carrying books on her right side Prolonged improper positioning Spine progressively bends to one side to compensate for the deficit Ligaments surrounding the vertebral joints get stretched and tighten according to position usually maintained (Right) S/sx: Left shoulder is higher than right Spine rotated slightly on its axis S/Sx: Obvious Sshaped spine X-ray revealed a lateral curvature of lumbar spine Ribs rotates as well Planning Discharge Outcome: Upon discharge, the client will be able to report pain is relieved aeb: a. Pain scale 0/10 b. Use of corrective device to alleviate pain Short Term Goal: After 8 hours of nursing intervention, the client will: a. Participate in treatment regimen to alleviate pain b. Demonstrate use of relaxation skills and diversional activities c. Verbalize nonpharmacological methods to provide relief d. Pain scale of 3/10 from 5/10 Nursing Intervention Independent: Re-assess vital signs especially pain and determine the causative / contributing factors of the presenting problem Accept clients description of pain. Acknowledge the pain experience and convey acceptance of clients response to pain Rationale Pain is the fifth vital sign and usually alters the vital signs. Reassessing determines the need to modify interventions set Pain is a subjective experience and cannot be felt by others and to establish appropriate treatment plan specific to individual situation Promotes nonpharmacological pain management

1/19/12 Evaluation Short Term Goal: After 8 hours of nursing intervention, the client: a. Participated in treatment regimen to alleviate pain aeb: -Proper positioning -Adequate rest period between activities -Correct usage of Milwaukee Brace -Intake of Tramadol 50 mg b. Demonstrated use of relaxation skills and diversional activities aeb: -Deep breathing exercise -Watching TV -Guided Imagery c. Verbalized nonpharmacological methods to provide relief aeb: -Usage of Milwaukee Brace -Proper positioning -Adequate rest period between activities d. Verbalized pain scale of 3/10 from 5/10 aeb: -Intake of Tramadol 50 mg -Proper positioning -Adequate rest period between activities Goal Fully Achieved >Terminate Nursing Care

Provide comfort measures ( touch, repositioning, use of warm/cold compress) Encourage use of relaxation techniques and diversional activities (focused breathing, watching TV, imaging) Encourage adequate rest periods

Distracts the attention from pain felt and reduce tension. Promotes nonpharmacological pain management Prevents fatigue and over exhaustion

Acute Pain S/sx: 5/10 pain scale on lower back Reference: Pathophysiology for the Health Professions 3rd ed. by Gould, p. 1245

Prepare the child for immobilization procedure by showing materials to be used and procedure in ageappropriate terms Provide opportunity for the child to express fears and ask questions about deformity and brace wear

Plan Bracing is used to halt the progression of the curve. Discharge Outcome: Upon discharge, the client reported pain is relieved aeb: a. Pain scale 0/10 -Intake of Tramadol 50 mg -Proper positioning -Adequate rest period between activities b. Used of corrective device to correct deformity -Correct usage of Milwaukee Brace 23 hour/day -Demonstrated how to apply Milwaukee Brace Goal Fully Achieved >Terminate Nursing Care Plan

Bracing is used to halt the progression of the curve. Airing out the concern of the child and providing answers will increase the compliance to the regimen Braces touching the skin surfaces can causing skin excoriation and discomfort Brace should be fit and exert adequate compression and traction to correct curvature Braces should be worn over a T-shirt to prevent the plastic pads from touching the skin surfaces and causing skin excoriation

Instruct the child to assess the skin under and around the brace frequently for signs of skin breakdown Instruct the patient to examine brace daily for signs of loosening or breakage Instruct patient to wear cotton shirt under brace to avoid rubbing

Instruct about which previous activities can be continued in the brace

The Milwaukee brace should be worn for 23 hours a day and can be removed for participation in school activities and to promote the correction of curvation and prevent further progress The brace can be taken off when taking a bath but no more than 1 hour to promote the correction of curvation and prevent further progress Brace should be fit and exert adequate compression and traction to correct curvature To maintain acceptable level of pain. To maintain acceptable level of pain.

Inform patient that Milwaukee brace is worn 23 hours a day

Teach mother and patient how to apply the braces

Collaborative: Administer medications as ordered: Tramadol 50 mg q 8 Notify Physician if regimens are inadequate to meet pain control and correction Refer patient to an

Frequent follow-up

Orthopedic Doctor

are necessary to check the fit of the device Reference: Maternal and Child by Pillitteri vol. 2 p. 1627

Ryan Oneil A. Lomeda BSN 4A2 Assessment Subjective Data: Nahihirapan akong huminga at masakit ang dibdib ko, madali akong mapagod at nagigising ako tuwing medaling araw, as stated Objective Data: 66 year old female Vital Signs: HR = 90 RR = 22 T = 37.5 BP = 130-140/90 Dyspnea on exertion with ordinary physical activity mild to moderate chest pains easy fatigability Parosysmal Nocturnal Dyspnea (+) Orthopnea Cardiac Asthma with Cheyne-Strokes Respiration S3 gallop on heart sounds cough runny nose (+) DM 2 (+) CAD ST-Elevated Anterior

LEFT-SIDED HEART FAILURE PULMONARY EDEMA & CAP Nursing Diagnosis Fluid volume excess related to impaired cardiac contractility secondary to myocardial infarction aeb dyspnea, chest pain, easy fatigability, orthopnea, cheyne stroke respiration, S3 gallop, cough Sci. Explanation Planning Discharge Outcome: Upon discharge, the client will be able to maintain fluid volume at a normal level aeb: a. individually adequate urine output b. stable vital signs c. absence of cough d. absence of adventitious breath sounds e. absence of extra heart sound Short Term Goal: After 8 hours of nursing intervention, the client will: a. Verbalize understanding of causative factors and purpose of treatment regimen b. Demonstrate at least 3 behaviors to monitor and correct fluid excess c. Demonstrate lifestyle changes to promote cardiac health Nursing Intervention Independent: Re-assess vital signs and determine the causative / contributing factors of the presenting problem Auscultate breath sounds and note for presence of adventitious breath sounds Auscultate heart tones for extra heart sounds and murmur Rationale Establishes a baseline data to determine the need to modify interventions set To note if there is presence of adventitious breath sounds indicating fluids in the lungs To note if there is presence of extra heart sounds or murmur indicating of myocardial injury Increase blood in the lungs impairs the tissue perfusion and causes respiratory acidosis causing changes in sensorium To decrease the amount of circulating blood volume water Measures adequate fluid intake and retention in the body

1/13/12 Evaluation Short Term Goal: After 8 hours of nursing intervention, the client: a. Verbalized understanding of causative factors and purpose of treatment regimen aeb: > Knowing the complications > Knowing the preventions > Knowing the treatments b. Demonstrated 4 interventions to monitor and correct fluid excess -Monitor input and output -Fluid intake restriction to 22.5L/day -Sodium diet restriction -Proper positioning semifowlers position c. Demonstrated lifestyle changes to promote cardiac health aeb: -increased bed rest, rest periods in between activities -decreased stress or stimuli -Fluid intake restriction to 22.5L/day -Sodium diet restriction Goal Fully Achieved >Terminate Nursing Care Plan

Evaluate level of consciousness

Restrict fluid intake to 2-2.5L/day and sodium intake

Monitor I/O accurately, calculate 24 hour fluid balance

Wall Myocardial Infarction Heart Failure stage C ECG= Cardiomegaly Left Ventricular Hypertrophy Old Anterior-Septal Wall MI V1-V3. CHEST PA= Cardiomegaly Atherosclerotic Aorta with significant pulmonary congestion (+) Interstitial Edema with loss of pulmonary markings (+) Kerley A & B Lines with subpleural fluid ECHOCARDIOGRAPHIC FINDING= Dilated Cardiomyopathy, with Coronary Artery Disease, Left Ventricular Systolic Dysfunction (Segmental), with moderate Right Ventricular Dysfunction and Depressed Ejection Fraction L side

Place patient in a semi-fowlers position Weigh patient daily on a regular schedule Provide a quite and peaceful environment and decrease stimulus

Facilitates venous return Evaluates the effectiveness of diuretic therapy To decrease cardiac load, oxygen consumption and risk for decomposition Maintains regular physical activities and prevent contractures Educate the client to be known of pharmacologic regimens

Discharge Outcome: Upon discharge, the client was able to maintain fluid volume at a normal level aeb: a. individually adequate urine output: -30cc/hour b. stable vital signs HR = 80 RR = 20 T = 36.5 BP = 130/90 c. absence of cough d. absence of adventitious breath sounds e. absence of extra heart sound Goal Fully Achieved >Terminate Nursing Care Plan

Encourage 30 mins. Of light physical exercise, as tolerated Inform patient regarding medications to be taken: effect, dosage, frequency, route, adverse effects, routine laboratory monitoring Reinforce to patient the need for heart transplant Inform patient regarding surgery

Educate the client to be known of the need for surgery Educate the client to be known of outcomes regarding condition To support steady rehydration overtime

Collaborative: Establish an IV

line of 0.9 NaCl, as ordered by the physician.

Administer O2 therapy via O2 cannula @ 2-4LPM Administer prescribed medications: ACE inhibitors (captopril) Vasodilator (Nitroglycerin) Beta blockers (metropolol)

O2 therapy is given to supply an adequate amount of O2 in the body

Decreases after load and preload Decreases BP and preload by dilating the coronary artery Blocks adrenergic site receptor causing decrease HR and contractility Inhibits sodium reabsorption in the distal tubule and collecting ducts Improves cardiac contractility

Spironolactone (aldosterone)

Digitalis (digoxin) Calsium Channel Blocker

Prevents calcium ion to enter the smooth muscle causing relaxation and dilation of muscle Reduces cholesterol level

Lipid-Reductase (simvastatin)

Collaborates intervention to

 Refer to other healthcare professionals: dietitian, surgeon, cardiologist

improve health and clients well-being Reference: Medical Surgical Nursing 12th ed by Brunner and Suddarth pp. 829-837

Ryan Oneil A. Lomeda BSN 4A2 Assessment Subjective Data: Mabilis akong mapagod ngayon, tsaka nadagdagan ang aking timbang at may manas pa ako, as stated Objective Data: 50 year old male Vital Signs: HR = 98 RR = 22 T = 37 BP = 140/100 Hypertensive Non-compliant Eddematous lower extremities easy fatigability weight gain from 86 lbs to 100 lbs (+) DM 2 Easy satiety Hepato-splenomegaly Elevated jugular venous pressure Ascites ECG= Cardiomegaly and Right Ventricular Hypertrophy CHEST PA= Cardiomegaly Atherosclerotic Aorta with no pulmonary congestion

RIGHT-SIDED HEART FAILURE HYPERTESION Nursing Diagnosis Fluid volume excess related to ineffective right ventricular pump secondary to hypertension aeb dyspnea, chest pain, easy fatigability, orthopnea, cheyne stroke respiration, S3 gallop, cough Sci. Explanation Planning Discharge Outcome: Upon discharge, the client will be able to: a. eliminate or reduce any etiologic b. maintain fluid volume at a normal level aeb: -individually adequate urine output -stable vital signs -absence of peripheral edema Short Term Goal: After 8 hours of nursing intervention, the client will: a. Verbalize understanding of causative factors and purpose of treatment regimen b. Demonstrate at least 3 behaviors to monitor and correct fluid excess c. Demonstrate lifestyle changes to promote cardiac health Nursing Intervention Independent: Re-assess vital signs and determine the causative / contributing factors of the presenting problem Auscultate heart tones for extra heart sounds and murmur Rationale Establishes a baseline data to determine the need to modify interventions set

1/14/12 Evaluation Short Term Goal: After 8 hours of nursing intervention, the client: a. Verbalized understanding of causative factors and purpose of treatment regimen aeb: > Knowing the complications > Knowing the preventions > Knowing the treatments b. Demonstrated 5 interventions to monitor and correct fluid excess -Daily weight -Monitor input and output -Fluid intake restriction to 22.5L/day -Sodium diet restriction -Proper positioning semifowlers position c. Demonstrated lifestyle changes to promote cardiac health aeb: -compliance with medications prescribed -increased bed rest, rest periods in between activities -decreased stress or stimuli -Fluid intake restriction to 22.5L/day -Sodium diet restriction

To note if there is presence of extra heart sounds or murmur indicating of myocardial injury Decreased circulation in edematous areas are at risk for pressure ulcer and skin breakdown Measures adequate fluid intake and retention in the body Evaluates the effectiveness of diuretic therapy To prevent fluid accumulation since sodium attracts water Helps prevent pressure ulcer and increases venous return

Assess for skin breakdown

Monitor I/O accurately, calculate 24 hour fluid balance

Weigh patient daily on a regular schedule

Encourage 30 mins. of light physical

 ECHOCARDIOGRAHIC FINDING= Dilated Cardiomyopathy Coronary Artery Disease Right Ventricular Dysfunction moderate Left Ventricular Dysfunction Depressed Ejection Fraction R side

exercise especially the legs or edematous areas, as tolerated Restrict fluid intake to 2-2.5L/day and sodium intake Measure jugular vein distention

To decrease the amount of circulating blood volume Stagnation of blood leads to venous system engorgement and increase CVP Facilitates venous return Venous return is reduced, and pressure on diaphragm is relieved Positioning avoids pressure ulcer and skin breakdown To decrease cardiac load, oxygen consumption and risk for decomposition Educate the client to be known of pharmacologic regimens

Goal Fully Achieved >Terminate Nursing Care Plan Discharge Outcome: Upon discharge, the client was able to a. eliminate or reduce any etiologic b. maintain fluid volume at a normal level aeb: -individually adequate urine output > 30cc/hour -stable vital signs > HR = 80 > RR = 20 > T = 36.5 > BP = 130/90 -absence of peripheral edema > Regained normal weight= 86 lbs > non-tender RUQ > non-edematous lower extremities Goal Fully Achieved >Terminate Nursing Care Plan

Place patient in a semi-fowlers position Elevate edematous areas (legs) or support with pillow

Frequently change the position of the patient Provide a quite and peaceful environment and decrease stimulus

Inform patient regarding medications to be taken: effect, dosage, frequency, route, adverse effects,

To support steady

routine laboratory monitoring Collaborative: Establish an IV line of 0.9 NaCl, as ordered by the physician. Administer O2 therapy via O2 cannula @ 2-4LPM Administer prescribed medications: ACE inhibitors (captopril) Vasodilator (Nitroglycerin) Beta blockers (metropolol)

rehydration overtime O2 therapy is given to supply an adequate amount of O2 in the body

Decreases after load and preload Decreases BP and preload by dilating the coronary artery Blocks adrenergic site receptor causing decrease HR and contractility Inhibits sodium reabsorption in the distal tubule and collecting ducts Improves cardiac contractility Prevents calcium ion to enter the smooth muscle causing relaxation and dilation of muscle Reduces cholesterol level

Spironolactone (aldosterone)

Digitalis (digoxin) Calsium Channel Blocker

Lipid-Reductase (simvastatin) Refer to other healthcare professionals: dietitian, cardiologist

Collaborates intervention to improve health and clients well-being Reference: Medical Surgical Nursing 12th ed by Brunner and Suddarth pp. 829-837