Heartbreaker Age: 52 years old Ward: Andrew Hall 1
Chief Complaint: abdominal pain Diagnosis: Aortic Stenosis, Cardiomegaly, CHF , Ac!te "idney n#!ry secondary to sc$emic %ep$ropat$y wit$ Complicated &' Cues Diagnosis Rationale Objectives Nursing Intervention Rationale Evaluation Subjective (%amamanas an akon mga tiil), as *erbali+ed by t$e patient. (,agan naabat ako $in b!gat ngan t!bigon tak tiyan) as *erbali+ed by t$e patient. Objective -ascites: present abdominal girt$./0) 1pre$ospitali+ation. (2 -bipedal edema 32 -weig$t gain 4rom 50kgs. 'o 52 kgs. -blood press!re. 1/0670nnHg 1n .120680mmHg2 -#!g!lar *ein distention o4 5cm -Hg.115g69 1n.1/0- 175g692 -Ht.0.:5 1n.0./2- 0.502 - Hypokalemia . :.28mmol 1%.:.5-5.: mmol692 -proteins.3333 -creatinine .15/.25 !mol69 1normal.71- 115!mol692 -,&%6; .17.08 ;<cess 4l!id *ol!me related to red!ced glomer!lar 4iltration rate as e*idenced by ascites and bipedal edema. ;<cess 4l!id *ol!me is de4ined as increased isotonic 4l!id retention. %!rsing =iagnosis Handbook: A g!ided to planning care 7 t$
ed. ,y Ackley > 9adwig p. 5/0 4 t$e $eart becomes se*erely damaged, no amo!nt o4 compensation, eit$er by sympat$etic ner*o!s re4le< or by 4l!id retention, can make t$e e<cessi*ely weakened $eart p!mp a normal cardiac o!tp!t. As a conse?!ence, t$e cardiac o!tp!t cannot rise $ig$ eno!g$ to make t$e kidneys e<crete normal ?!antities o4 4l!id. '$ere4ore, 4l!id contin!es to be retained, t$e person de*elops more and more edema. Short !erm "oal A4ter 5 $o!rs o4 n!rsing inter*ention, client will demonstrate !nderstanding o4 related 4actors as mani4ested by: @erbali+e !nderstanding o4 dietary and 4l!id restrictions. =emonstrat e be$a*iors to monitor 4l!id stat!s.
#ong !erm "oal
A4ter 1 week o4 n!rsing inter*ention, client will demonstrate stabili+ed 4l!id *ol!me as e*idenced by: =emonstrat e balanced >A. Absence6de crease o4 edema. =emonstrat e stable lab res!lts. Independent Monitor !rine o!tp!t, noting amo!nt, color and time o4 day di!resis occ!rs Maintain c$air or bed rest in semi-FowlerBs position d!ring ac!te p$ase ;stablis$ 4l!id intake sc$ed!le i4 restrictedC incorporate be*erage pre4erences i4 possible. Di*e 4re?!ent mo!t$ care6ice c$ips as part o4 4l!id allotment Eeig$ed daily at same time o4 day, on same scale, wit$ same e?!ipment and clot$ing. Assess skin t!rgor. &rine o!tp!t may be scanty and concentrated 1d!ring t$e day2 w$ic$ res!lted 4rom red!ced renal per4!sion. &rine o!tp!t may be increased at nig$t6d!ring bed rest beca!se o4 rec!mbent position. Fec!mbent position increases DFF and decreases prod!ction o4 A=H w$ic$ en$ances di!resisC impro*es respiratory e44ort n*ol*ing patient in t$erapy regimen may en$ance sense o4 control and cooperation wit$ restrictions. Fed!ce discom4ort o4 4l!id restrictions. =aily body weig$t is best monitor o4 4l!id stat!s. A weig$t gain o4 more t$an 0.5 kg6day s!ggests 4l!id retention. Skin t!rgor re4lects ade?!ate $ydration "oals full$ met A4ter 5 $o!rs o4 n!rsing inter*ention, client demonstrated !nderstanding o4 related 4actors as mani4ested by: 4ollowing dietary and 4l!id restrictions ca!tio!sly monitored 4l!id intake and o!tp!t metic!lo!sly "oals partiall$ met A4ter : days o4 n!rsing inter*ention, client GatientBs edema decreased to grade 1. %o increase o4 abdominal girt$ noted. demonstrated stable lab res!lts mmol69 1n.2.5-8.: mmol692 - Additional =iagnosis: Ac!te kidney in#!ry secondary to isc$emic nep$ropat$y secondary to CHF, complicated &' - Final diagnosis: se*ere aortic stenosis, cardiomegaly, CHF ascites Medical G$ysiology 11 t$ ;dition, D!yton > Hall p.251 Monitored $eart rate 1HF2, ,G Fecorded acc!rate intake and o!tp!t 1>A2. C$ange position 4re?!entlyC ele*ate 4eet w$en sitting. nspect skin integrity, keep dry and pro*ide padding as indicated A!sc!ltate breat$ so!nds noting ad*entitio!s ,S. %ote presence o4 dyspnea, tac$ypnea, ort$opnea, G%= or persistent co!g$ Fecommend ele*ating lower e<tremities "eeps linen dry and 4ree o4 wrinkles ;nco!rage amb!lation n*asi*e monitoring may be needed 4or assessing intra*asc!lar *ol!me, especially in pts. wit$ poor cardiac 4!nction. Acc!rate >A are necessary 4or determining renal 4!nction and 4l!id replacement needs and red!cing risk o4 4l!id o*erload. ;dema 4ormation, slowed circ!lation and prolonged immobility are stressors t$at a44ect skin integrity t$at will re?!ire pre*enti*e inter*entions. ;<cess 4l!id *ol!me o4ten leads to p!lmonary congestion. Fespiratory symptoms may $a*e slower onset b!t more di44ic!lt to re*erse. ;n$ances *eno!s ret!rn and red!ces edema 4ormation in t$e lower e<tremities. Moist!re predisposes to skin breakdown Gromote circ!lation Collaborative Administer di!retics as ordered: F!rosemide 1loop di!retic2 /0mg 2 @ now t$en ? 12 $o!rs Aldactone 1potassi!m-sparing di!retic, aldosterone antagonist2 25mg 1 tab A= Maintain 4l!id6sodi!m restrictions as ordered Monitor ser!m alb!min and electrolytes n$ibits t$e reabsorption o4 sodi!m and c$loride 4rom t$e ascending limb o4 t$e loop o4 Henle, leading to a sodi!m-ric$ di!resis. ,locks t$e e44ects o4 aldosterone in t$e renal t!b!le, ca!sing loss o4 sodi!m and water retention o4 potassi!m Fed!ces total 4l!id *ol!me in t$e body and pre*ent 4l!id reacc!m!lation. =ecreased ser!m alb!min a44ects plasma colloid osmotic press!re, res!lting in edema 4ormation.