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Heart failure (HF) is generally defined as inability of the heart to supply


sufficient blood flow to meet the body's needs. It has various diagnostic criteria,
and the term á  is often incorrectly used to describe other cardiac-
related illnesses, such as myocardial infarction (heart attack) or cardiac arrest.

Common causes of heart failure include myocardial infarction (heart attacks) and
other forms of ischemic heart disease, hypertension,valvular heart disease,
and cardiomyopathy. Heart failure can cause a number of symptoms
including shortness of breath (typically worse when lying flat, which is
called orthopnea), coughing, chronic venous congestion, ankle swelling,
and exercise intolerance. Heart failure is often undiagnosed due to a lack of a
universally agreed definition and challenges in definitive diagnosis. Treatment
commonly consists of lifestyle measures (such as decreased salt intake) and
medications, and sometimes devices or even surgery.

Heart failure is a common, costly, disabling, and potentially deadly


condition. In developing countries, around 2% of adults suffer from heart failure,
but in those over the age of 65, this increases to 6±10%.
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èackward failure of the right ventricle leads to congestion of systemic
capillaries. This generates excess fluid accumulation in the body. This causes
swelling under the skin (termed peripheral edema or anasarca) and usually
affects the dependent parts of the body first (causing foot and ankle swelling in
people who are standing up, and sacral edema in people who are predominantly
lying down). Nocturia (frequent nighttime urination) may occur when fluid from
the legs is returned to the bloodstream while lying down at night. In progressively
severe cases, ascites (fluid accumulation in the abdominal cavity causing
swelling) and hepatomegaly (enlargement of the liver) may develop. Significant
liver congestion may result in impaired liver function, and jaundice and
even coagulopathy (problems of decreased blood clotting) may occur.
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The objective of the study is to give quality-nursing care to assigned
patient and impart knowledge based on the nursing process and critical thinking
skills. This care study aims to guide the student nurses in providing client-
centered nursing care while applying critical thinking in all phases of nursing care
from assessment to evaluation.

This study is directed towards health maintenance and rehabilitation. èy


utilizing the skills and knowledge, the client is being protected from any
complications and potential severity of the disease condition. Thereby, rendering
proper interventions and nursing actions could certainly alleviate the client¶s
health problem.

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The primary concern of the study is health maintenance and detection of


actual and potential health problem that prevent the disease of the patient.

Nevertheless, the client¶s history of present illness including family history


is being scrutinized to detect any possible health problem or knowledge deficit
regarding family care.

Moreover, information and details regarding the patient¶s disease such as


pathophysiology, precipitating and predisposing factors, clinical
manifestations/signs and symptoms are being considered before intervening with
the client¶s condition. Nonetheless, health teachings are given to client as part of
the discharge plan. Proper nursing intervention and health teachings are given to
be able to provide quality-nursing care. Furthermore, the limitation of the study
lies on the time given to do study.

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# : Olaer, Amada
 : 83 years old
 ): Male
   : September 26 1926
 |  * Tagoloan CDOC
  !* Plain Housewife

|: Married
 ! * Filipino
! #!* Patient
   !* Jehovah¶s witness
 *| San Vicente village, Casinglot Tagoloan Misamis
Oriental

"   "|'+ "%|


 || #  !: August 14, 2010
 # || #  !: 11:45 AM
 ! !|'  !: Dr. Casino M.
 |#  !: Tachypnea and Nocturnal Orthopnea
#  !| ! : èipedal Edema

 #  * 36.2°C
' | *| | | 91 bpm
   !| * 30 cpm
|'  *| 140/70 mmHg

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The patient name Amada Olaer presently residing at San Vicente
village, Casinglot Tagoloan Misamis Oriental. He has 5 children and some
of his children currently living in the other city. Was diagnosed with Heart
Disease and conducted Uterine myomectomy last September 2009

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A 83 years old women currently residing at San Vicente village,


Casinglot Tagoloan Misamis Oriental admitted at Cagayan De Oro
Medical Center with Edema on èoth Legs and Tachypnea.

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Amada Olaer 83 year old presently living at San Vicente village,
Casinglot Tagoloan Misamis Oriental come to Cagayan De Oro Medical
Center at 11:45 in the morning complaining of Edema on èoth Legs and
Tachypnea.
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Infancy and early age
 Learning to talk
 Learning to take solid foods
 Learning to walk
Middle childhood
 Learning to get along with age mates
 èuilding wholesome attitudes toward oneself as growing organism
 Developing attitudes toward social groups and institutions.
Adolescence
 Achieving new and more mature relations with age mates of both
sexes
 Achieving a masculine or feminine social role.
 Selecting and preparing for an occupation
Middle age
 Achieving adult civic and social responsibility
 Developing adult leisure time activities
 Adjusting to aging parents
Later Maturity
 Achieving to decreasing physical strength and health
 Adjusting to retirement and reduce income
 Establishing satisfactory physical living arrangements.

èasing on this theory, Mr. Ricatcho belongs to the later maturity stage wherein
he has achieving physical strength and health.
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Oral èirth to 1 year mouth is the center of pleasure


Anal 2 ± 3 years anus and rectum are the center of pleasure
Phallic 4 ± 5 years the genitals are the center of pleasure
Latency 6 ± 12 years energy is directed to physical activities
0 ! | 12|3| | | ! | |  | | ! !||
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èasing on this theory, Mrs. Olaer belongs to the genital stage wherein he
has already encourage separation from parents achievement of independence
and decision making.
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Infancy èirth ± 18 months Trust vs. Mistrust
Early Childhood 18 months ± 3 years Autonomy vs. Shame & Doubt
Late Childhood 3 ± 5 years Initiative vs. Guilt
School Age 6 ± 12 years Industry vs. Inferiority
Adolescence 12 ± 20 years Identity vs. Role Confusion
Young Adulthood 18 ± 25 years Intimacy vs. Isolation
Adulthood 25 ± 65 years Generativity vs. Stagnation
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èasing on this theory, Mrs. Olaer belongs to maturity. Which involves the
acceptance of worth and uniqueness of one own self.
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Sensorimotor Phase èirth to 2 years


Pre-conceptual Phase 2 ± 3 years
Intuitive Thought Phase 4 ± 6 years
Concrete Operations Phase 7 ± 11 years
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èasing on this theory, Mr. Olaer belongs to the Formal operational stage in which
he has solved previously encountered problems in a logical manner and has
used rational thinking. These include financial problems and also with regards to
his health.

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The heart is a hallow organ, positioned left of the center in the chest cavity within
the pericardial cavity. The base of the heart is located superiorly, and the apex is
directed downward and leftward and formed by the lateral tip of the left ventricle.

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Unoxygenated blood from the venous system empties into the right atrium via the
superior and inferior vena cava coronary sinus. When sufficient amount of blood
fills the atrium, blood begins to flow from the right atrium through the tricuspid
valve into the right ventricle. When sufficient amount of blood fills the right
ventricle, the tricuspid valve closes, creating high pressure in the right ventricle.
The ventricle contracts and forces blood and through the pulmonary artery via
the pulmonic valve. At the lungs, oxygen is acquired and oxygenated blood is
transported to the left atrium via the pulmonary veins. As blood fills the left
atrium, blood begins to pour into the left ventricle through the mitral valve closes
tightly, creating strong pressure in the left ventricle. The left ventricle contracts
and opens the aortic valve sending blood to the systemic circulation via the aorta.

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!  |  |occurs when the right ventricle is unable to pump blood
into the pulmonary circulation. Less blood is oxygenated and
pressure increases in the right atrium and systemic venous
circulation, which results in edema of the extremities.
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Family History Obesity
Age Excess Alcohol Consumption
High Salt intake Smoking
Low Potassium Intake Stress
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(|%|    "%|
5|3|8:|3|;<|
8:00 pm
ƒ Please admit under the service
± For further management and
Dr. Casino M.
treatment of condition
ƒ Secure consent to care
± For legality purposes.
ƒ Diet: Soft diet and low fat. low
salt diet. ± To provide easy digestion of food
without experiencing pain upon
digestion
ƒ Start IVF Plain NSS 1L @ KVO ± To provide access for intravenous
rate medications.
ƒ Labs:
 CèC now
± To screen the patient¶s blood
component and to detect any
abnormalities. This also serves as a
baseline data to evaluate
effectiveness of blood transfusions.
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Complete èlood Count
Hematocrit 35.3 (37-47 vol %) ± Anemia
Hemoglobin 12.4 (11-15 gms %) ± Anemia
White èlood Cells 15,000 (5000-1000/mm3) ± Normal
Platelet Count 134,000 (150,000-350,000/mm3) infection
Differential Count
Lymphocytes 18 (25-55%) ± infection
Monocytes - (2-4 %) ± Normal
Eosinophils 1 (1-3%) ± Normal

 ! | #  |
Potassium 3.39 (135-147Meq/L) ± low potassium
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furosemide 08/14/10 Loop 40mg/O Inhibits the This is for Geriatric dehydration, Caution Patient to
reabsorption hypochlorem
Diuretics D/Per Patient¶s patients may change positions
of sodium and ia,
Orem chloride retention have hypokalemia slowly to minimize
from the loop ,
of fluid and increased risk orthostatic
of Henle and hypomagnes
distal renal for of side effects emia, hypotension Instruct
tubule. hyponatremi
congestive especially patient to consult
Increases a,
renal heart hypotension of hypovolemia health care
excretion of , metabolic
failure. Electrolyte professionals
water, sodium, alkalosis
chloride, imbalance at regarding diet
magnesium,
Usual dose
hydrogen, and
calcium.May
have renal
and peripheral
vasodilatory
effects.Effectiv
eness
persists in
impaired renal
function.
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Trimetazidin 08/14/10 Hydroxyzin 35 actions may This is for ‡Contraindicate ‡CNS:Drowsin ‡Use cautiously
be due to with
e e pamoate mg/èID/P the patients d with allergy to ess, involuntar uncomplicated
suppression of
dihydrochlori er Orem subcorticalare oxygenatio hydroxyzine, y motor vomiting in
as of the CNS; children (may
de n pregnancy, activity, contribute to
has clinically
lactation including Reye's syndrome
demonstrated and blood or unfavorably
antihistaminic, tremor and
pressure influence its
analgesic, seizures outcome;
antispasmodic extrapyramidal
‡GI: Dry mouth
,antiemetic, effects
‡Hypersensitivi
mild may obscure
antisecretory, ty: Wheezing, diagnosis of
and Reye's
dyspnea, syndrome).
bronchodilator
activity chest
tightness
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Losartan 08/14/10 Angiotensin ½ tab Selectively This is Contraindicat ‡CNS: Head Use cautiously with
ed with ache,dizzin hepatic or renal
potassium II receptor 50 blocks the intended for
dysfunction,
blocker binding of hypersensitivi ess, syncop
mg/OD/ the patient¶s hypovolemia
ty to losartan, e, insomnia
(ARè) Per angiotensin II Hypertension pregnancy ‡CV:Hypot
Antihyperten to specific
Orem (use during ension
sive tissue the ‡Dermatolo
receptors second or gic: Rash,
found in the third trimester urticaria,
vascular can cause pruritus,
smooth injury or even alopecia,
muscle and death to the dry skin
adrenal gland; fetus), ‡GI: Diarrhe
lactation. a,
this action
abdominal
blocks the
pain,
vasoconstricti
nausea, con
on effect of stipation,
the renin- dry mouth
angiotensin ‡Respiratory
system as well : URI
as the release symptoms,
of aldosterone cough,
leading to sinus
decreasedblo disorders
‡Other: èac
od pressure.
k pain,
fever, gout,
muscle
weakness
, | 0|&%-| |%, %9|$ |

# : Olaer, Amada  : 08-14-10


 # : 36.2ºC '* 91bpm ': 140/90mmhg Height: 5¶3´ 9 : 110 lbs
: 30cpm
 * Place an [X] in the area of abnormality. Comment at the
space provided. Indicate the location of the problem in the figure using [X].
Impaired Vision
V  
     
      

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[)] impaired vision [ ] blind Ear ± Hard of hearing
[ ] pain reddened [ ] drainage
[ ] gums [)] hard of hearing [)] deaf Tachypnea
[ ] burning [ ] edema [ ] lesion teeth
Assess eyes, ears, nose throat
For abnormality [ ] no problem
%'   *|
[ ] asymmetric [)] tachypnea [ ] barrel chest
[ ] apnea [ ] rales [ ] cough Poor Skin
[ ] bradypnea [)] shallow [ ] rhonchi turgor
[ ] sputum [ ] diminished [ ] dyspnea
[] orthopnea [ ] labored [ ] wheezing
[] pain [ ] cyanotic
Assess resp. rate, rhythm, pulse blood
breath sounds, comfort [ x] no problem
0  %  "| *|
[ ] obese [|] distention [ ] mass
[ ] dysphagia [ ] rigidity [ ] pain
V  
     
      

Assess abdomen, bowel habits, swallowing


bowel sounds, comfort [ ] no problem
0%   &| |0&%*|
[ ] pain [ ] urine color [ ] vaginal bleeding
[ ] hematuria [ ] discharge [ ] nocturia
assess urine frequency, control, color, odor, comfort
%*|
[ ]|paralysis [ ] stuporous [ ] unsteady [ ] seizures
[ ] lethargic [ ] comatose [|] vertigo [ ] tremors
[ ] confused [ ] vision [ ] grip
assess motor, function, sensation, LOC, strength Edema on èoth Legs
grip, gait, coordination, speech [ ] no problem
-".%"% "| |. *|
[ ] appliance [ ] stiffness [ ] itching [ ] petechiae
[ ] hot [ ] drainage [ ] prosthesis[)] swelling [)] edema
[ ] lesion [)] poor turgor [ ] cool [ ] flushed [)] fatique
[ ] atrophy [)] pain [ ] ecchymosis [ ] diaphoretic/moist
assess mobility, motion, gait, alignment, joint function
skin color, texture, turgor, integrity [x] no problem
7% ,%| 7% ,%|
Comments: ³dili na paka 'Glasses 'Languages
kita akong isa ka mata ug 'Contact Lens 'Hearing Aid
--   *|
dili na kayo ko pka R 4mm L 4mm
||||'Hearing loss
dungog´as verbalized by Pupil Size 4mm 'speech difficulties
' Visual changes
the patient. Reaction Pupils not reactive to light
'Denied
accommodation.
=&0%  | Comments: Resp. 'Regular ' irregular
||||'Dyspnea ³Gapanigarilyo ako sa Describe: èreathing cycle is not normal.
'Smoking history bata pa ako´as
None verbalized by the patient R Right lung is symmetric with the left lung
'Cough L Left lung is symmetric with the right lung
'Sputum
'Denied
 "  | Comments: ³Dili ako Heart Rhythm 'regular 'irregular
||||'Chest pain maka tindog kay Ankle Edema ankle edema not seen
'Leg pain gahubag ako paa´as Pulse Car. Rad. DP Fem*
'Numbness of verbalized by the patient. R 72 + 76 + +
Extremities L 72 + 76 + +
'Denied Comments: all pulse are palpable
*If applicable
  | 'Dentures 'None
Diet: Soft diet and low fat diet
'N 'V Comments: ³Mahurot Full Partial With patient
Character man sad ang akong Upper '| | '| | '
'Recent change in pagkaon´as verbalized by
weight, appetite the patient. Lower '| | '| | '
'Swallowing difficulty .
'Denied *Dental caries on upper left molar teeth.
| Comments: Normal èowel sounds: Normal
%" -   | 'Urinary frequency èowel Movement Abdominal distention
Usual bowel pattern ³3 times a day´ present 'yes 'no
³Every other day´ 'Urgency
Urine* (color,
'Constipation 'Dysuria
'Hematuria
consistency, odor)
remedy
'Incontinence Urine color is yellow
³None´
'Date of last èM 'Polyuria *if they are in place?
08-14-10 'Foley in place
'Diarrhea character 'Denied

-0|+|$% "$|D| ""%| èriefly describe the patient¶s ability to follow


||||'Alcohol 'Denied treatments (diet, meds, etc.) for chronic health
(Amount, frequency) problems (if present).
Drinks if there is occation
'SèE Last Pap smear N/A The Patient directly follows the treatment and
4¨| N/A
LMP: take prescribed medication.
7% ,%| 7% ,%|
. | %0 &*| Comments: ³Naa lay |||||'› || '| | '|
gapanubo nga itom ± itom |||||' 
| | '  |
|||||'Dry
sa ako panit´as verbalized |||||' | | '|
'Itching
by the patient.    |
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 |  | || |
'Other |   |
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'Denied |
 , &B +%&| Comments: ³sakit ug
'LOC and orientation: Conscious to time and
'Convulsion maglisud ko ug lakaw´, date.
'Dizziness as verbalized by the
'Limited motion ofpatient.
Gait: |||||'walker 'cane 'other
joints
Limitation in ability to
'Steady 'unsteady
'Ambulate
'Sensory and motor losses in face or
'èathe self
extremities: None
'Other
'ROM limitations: Lower extremities can¶t
'Denied
move simultaneously.
| 'Facial grimace
-+B"%%'B9 .%|
'Guarding
'Pain 'Other signs of pain: No other
Comments: ³dili kaau ako
(location, makatulog sa gabie´ as Signs of pain observed
frequency, 'Side rail release from signed (60+years)
verbalized by the patient.
remedies)
'Nocturia
'Sleep difficulties
'Denied

' 0| Observed non-verbal behavior: Patient seen


Occupation: Plain Housewife weak
Members of household: 5 members The person and her phone number that can be
reached any time: none
Most supportive person: son

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||110 lbs Daily Weight none PT/OT
140/90mmHg èP q Shift none Irradiation
_none__________ Neuro VS yes Urine Test ________
none CVP/SG. Reading yes 24h urine collection
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08-14-10 Complete èlood Count 08-14-09 08-14-10 #1 D5NSS 1L 08-14-10
@ KVO rate
08-14-10 #2 D5NSS
1L@KVO rate

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When blood flow through the renal artery is decreased, the baroreceptor reflex is
stimulated and rennin is released into the bloodstream. Renin interacts with
angiotensinogen to produce angiotensi I. When angiotensin I contacts ACE, it is
converted to angiotensin II, a potent vasoconstrictor. Angiotensin II increases arterial
vasoconstriction, promote release of norepinephrine from sympathetic nerve endings,
and stimulates the adrenal medulla to secrete aldosterone, which enhances sodium
and water absorption. Stimulation of the rennin-angiotensin system causes plasma
volume to expand and preload to increase.

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1. ‡Establish rapport 1. ‡To gain patient¶s trust and
2. ‡Monitor and record VS cooperation ‡To obtain baseline
3. ‡Assess patient¶s general condition data
4. ‡Monitor I&O every 4 hours 2. ‡To determine what approach to
5. ‡Weigh patient daily and compare to use in treatment
previous weights 3. ‡I&O balance reflects fluid status
6. .‡Auscultate breath sounds q 2hr and 4. ‡èody weight is a sensitive
pm for the presence of crackles and indicator of fluid balance and an
monitor for frothy sputum production increase indicates fluid volume
7. ‡Assess for presence of peripheral excess.
edema. Do not elevate legs if the 5. ‡When increased pulmonary
client is dyspneic. capillary hydrostatic pressure
8. ‡Follow low-sodium diet and/or fluid exceeds oncotic pressure, fluid
restriction moves within the alveolar septum
9. ‡Encourage or provide oral care q2 and is evidenced by the
probable cause of the fluid auscultation of crackles. Frothy,
disturbance. pink-tinged sputum is an indicator
10. ‡Monitor for distended neck veins that the client is developing
and ascites pulmonary edema
11. ‡Evaluate urine output in response to 6. ‡Decreased systemic blood
diuretic therapy. pressure to stimulation of
12. ‡Assess the need for an indwelling aldosterone, which causes
urinary catheter. increased renal tubular absorption
13. ‡Institute/instruct patient regarding of sodium Low-sodium diet helps
fluid restrictions as appropriate. prevent increased sodium
retention, which decreases water
retention. Fluid restriction may be
used to decrease fluid intake,
hence decreasing fluid volume
excess.
7. ‡The client senses thirst because
the body senses dehydration. Oral
care can alleviate the sensation
without an increase in fluid intake.
8. ‡Heart failure causes venous
congestion, resulting in increased
capillary pressure. When
hydrostatis pressure exceeds
interstitial pressure, fluids leak out
of ht ecpaillaries and present as
edema in the legs, and sacrum.
Elevation of legs increases venous
return to the heart.
9. ‡May include increased fluids or
sodium intake, or compromised
regulatory mechanisms.
10. ‡Inidicates fluid overload
11. ‡Focus is on monitoring the
response to the diuretics, rather
than the actual amount voided
12. ‡Treatment focuses on diuresis of
excess fluid.
13. ‡This helps reduce extracellular
volume

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The heat fails to pump enough blood to meet the metabolic needs of the body. The
blood flow that supplies the heart is also decreased thus decrease in cardiac
output occurs, blood then is insufficient and making it difficult to circulate the blood to all
parts of the body thus may cause altered heart rate and rhythm, weakness and paleness

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1. ‡Assess for abnormal heart 1. ‡Allows detection of left-sided heart
and lung sounds. failure that may occur with chronic
2. ‡Monitor blood pressure and renal failure patients due to fluid
pulse. volume excess as the diseased
3. ‡Assess mental status and kidneys are unable to excrete water.
level of consciousness 2. ‡Patients with renal failure are most
4. ‡Assess patient¶s skin often hypertensive, which is
temperature and peripheral attributable to excess fluid and the
pulses. initiation of the rennin-angiotensin
5. ‡Monitor results of laboratory mechanism
and diagnostic tests. 3. ‡The accumulation of waste products
6. ‡Monitor oxygen saturation and in the bloodstream impairs oxygen
AèGs. transport and intake by cerebral
7. ‡Give oxygen as indicated by tissues, which may manifest itself as
patient symptoms, oxygen confusion, lethargy, and altered
saturation and AèGs. consciousness.
8. ‡Implement strategies to treat 4. ‡Decreased perfusion and
fluid and electrolyte oxygenation of tissues secondary to
imbalances. anemia and pump ineffectiveness
9. ‡Administer cardiac glycoside may lead to decreased in
agents, as ordered, for signs of temperature and peripheral pulses
left sided failure, and monitor that are diminished difficult to
for toxicity. palpate.
10. ‡Encourage periods of rest and 5. ‡Results of the test provide clues to
assist with all activities. the status of the disease and
11. ‡Assist the patient in assuming response to treatments.
a high Fowler¶s position. 6. ‡Provides information regarding the
12. ‡Teach patient the heart¶s ability to perfuse distal tissues
pathophysiology of disease, with oxygenated blood
medications 7. ‡Makes more oxygen available for
13. ‡Reposition patient every 2 gas exchange, assisting to alleviate
hours signs of hypoxia and subsequent
14. ‡Instruct patient to get activity intolerance.
adequate bed rest and sleep 8. ‡Decreases the risk for development
15. ‡Instruct the SO not to leave of cardiac output due to imbalances.
the client unattended 9. ‡Digitalis has a positive isotropic
effect on the myocardium that
strengthens contractility, thus
improving cardiac output.
10. ‡Reduces cardiac workload and
minimizes myocardial oxygen
consumption.
11. ‡Allows for better chest expansion,
thereby improving pulmonary
capacity.
12. ‡Provides the patient with needed
information for management of
disease and for compliance.
13. ‡To prevent occurrence of bed sores
14. ‡To promote relaxation to the body
15. ‡To ensure safety and reduce risk for fall
may lead to injury

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In ischemic heart disease, atherosclerosis develops in the coronary arteries, causing
them to become narrowed or blocked. When a coronary artery is blocked, blood flow
to the area of the heart supplied by that artery is reduced. If the remaining blood flow
is inadequate to meet the oxygen demands of the heart, the area may become
ischemic and injured and myocardial infarction may result. Neural pain receptors are
stimulated by local mechanical stress resulting from abnormal myocardial contraction.

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1. ‡Assess patient pain for intensity 1. ‡To identify intensity,
using a pain rating scale, for precipitating factors and
location and for precipitating location to assist in accurate
factors. diagnosis.
2. ‡Administer or assist with self 2. ‡The vasodilator nitroglycerin
administration of vasodilators, as enhances blood flow to the
ordered. myocardium. It reduces the
3. ‡Assess the response to amount of blood returning to
medications every 5 minutes the heart, decreasing preload
4. ‡Provide comfort measures which in turn decreases the
5. .‡Establish a quiet environment workload of the heart.
6. .‡Elevate head of bed 3. ‡Assessing Response
7. ‡Monitor vital signs, especially determines effectiveness of
pulse and blood pressure, every 5 medication and whether further
minutes until pain subsides. interventions are required.
8. ‡Teach patient relaxation 4. ‡To provide non
techniques and how to use them to pharmacological pain
reduce stress. management.
9. ‡Teach the patient how to 5. ‡A quiet environment reduces
distinguish between angina pain the energy demands on the
and signs and symptoms of patient.
myocardial infarction. 6. ‡Elevation improves chest
expansion and oxygenation
7. .‡Tachycardia and elevated
blood pressure usually occur
with angina and reflect
compensatory mechanisms
secondary to sympathetic
nervous system stimulation.
8. ‡Anginal pain is often
precipitated by emotional stress
that can be relieved non-
pharmacological measures
such as relaxation.
9. ‡In some case, the chest pain
may be more serious than
stable angina. The patient
needs to
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³Dili ko ganahan mag lihok - lihok´ as verbalize the patient.


S
ƒ Cold and clammy skin on both feet
O
ƒ Fatigue
ƒ èody weakness
Activity intolerance related to compromised oxygen transport secondary
A
to congestive heart failure.
Long term: The Patient will have absence of difficulty in breathing in 3-4
P
days
Short term: After 24 hrs the patient will have increase activity level
INDEPENDENT:
I
1. Assessed capillary refill in both upper and lower extremities
2. Monitored V/S obtain baseline O2 saturation
3. Assessed cardiopulmonary response of client During, before and
after
4. Encouraged Coughing exercise.
5. Advised clients to avoid cold places.
Goal met after 24 hrs of nursing intervention the patient will have
E
increase activity level.
|
³Gahubag ako duha ka tiil´ as verbalized by the patient.
S
ƒ Edema on both extremities
O
ƒ Crackles heard on both lung fields
Excessive fluid volume related to decrease cardiac output and sodium &
A
water retention secondary to CHF.
Long term : After 3-4 days of Nursing intervention patient will
P demonstrate adequate fluid balance output
Short term : after 3-4 hrs of interventions the patient has verbalize
understanding of causative factors and demonstrate behaviors to resolve
excess fluid.
INDEPENDENT:
1. Established rapport
2. Monitored and record V/S
3. Auscultated breath sounds q 2hr and pm for the presence of crackles
and monitor for frothy sputum production.
4. Monitored for distended neck veins and ascites
I 5. Assessed for presence of peripheral edema. Do not elevate legs if the
client is dyspneic.
6. Assessed the need for an indwelling urinary catheter.

DEPENDENT
7. Administered medication prior activity as needed for pain relief.
8. Administered medication for excessive fluid retention and CHF.
After 30 minute, the patient was able to verbalize the importance
E
intervention.

³Sakit kayo ako tiil´ as verbalized the patient.


S
ƒ Edema on both extremities
O
ƒ Facial grimace(+6)
èipedal Edema
A
Short Term:
After 3-4 hours of nursing interventions, the patient¶s pain will decrease
P from 7 to 3 as verbalized by the patient.
Long Term:
After 2-3 days of nursing interventions, the patient will demonstrate
activities and behaviors that will prevent the recurrence of pain.
INDEPENDENT:
1. Assessed patient pain for intensity using a pain rating scale, for
location and for precipitating factors.
2. Administered or assist with self administration of vasodilators, as
ordered.
3. Assessed the response to medications every 5 minutes
4. Provided comfort measures
5. .Established a quiet environment
I
6. .Elevated head of bed
7. Monitored vital signs, especially pulse and blood pressure, every 5
minutes until pain subsides.
8. Taught patient relaxation techniques and how to use them to
reduce stress.
9. Taught the patient how to distinguish between angina pain and
signs and symptoms of myocardial infarction.

After 30minutes, the patient was able to verbalized understanding of


E
causative factors when known and necessary intervention.
=|$% "$|% $ 0|
|

ƒ Aspirin ± helps to lower the risk of heart attack


ƒ èeta-blockers - are agents that block the action of these
stimulating hormones on the beta receptors of the
body's tissues, metoprolol (Toprol XL)
-%   |
ƒ ACE Inhibitors - these medications block the formation
of angiotensin II, a hormone with many potentially
adverse effects on the heart and circulation in patients
with heart failure. losartan (Cozaar),
ƒ èe sure any exercise is paced and balanced w/ rest
ƒ Avoid encouraging isometric exercise such as involve in
straining muscles
%=% %|
ƒ Don¶t let the patients exercise outdoors when it is too
cold, Hot or Humid-High humidity may cause the patient
tired more quickly
ƒ Oxygen through a tube in the nose or face
maskNitroglycerin under the tongue Pain medicines (
% -%| Morphine or meperidine )
ƒ Angioplasty
ƒ atherectomy
 ƒ Call the physician for further referral Approach the staff
'  %@ nurses if sudden physiological disturbance or changes
/ A| occurs.
ƒ Low Sodium intake high potassium intake Less Fat
 %|
Fewer calories More fiber
=|%+% "| |+""9'|

Our further Y    includes monitoring of changes in vital signs,


assessment of effectiveness of treatment regimen, and the advice regarding
the importance of adequate bed rest.
Our further
   includes instructions of dietary modification,
compliance with treatment regimen, and patient¶s participation through
reporting of adverse effects of medications to her physician. The patient was
also instructed to have a regular check-up at Cagayan De Oro Medical Center
in order to monitor her current condition.

|
= |%, "  |

At the end of the 2 days of caring to Mrs. Olaer I was able to identify
potential problems and specific nursing interventions were provided. With the
help of health teachings and other interventions, Mrs. Olaer was able to learn
how to recognize signs and symptoms and other risk factors of her condition.
She was able to verbalized the importance of taking her medication. She had
also recognized the importance of compliance to treatment regimen in order to
manage her condition.
= | " 0 '$&|

NURSING CARE PLANS. Guidelines for individualizing patient care by


Marilynn E. Doenges, Mary Frances Moorhouse, and Alice C. Murr. 4th Edition

NURSE¶S POCKET GUIDE. Diagnoses, Prioritized Interventions, and


Rationales by Marilynn E. Doenges , Mary Frances Moorhouse, and Alice C.
Murr,

ANATOMY AND PHYSIOLOGY. Compilation of lecture notes by Mr. Denise O.


Orong, PTRP and Daisy Colleen Young Mercado, RN, RM, MAN
|
NURSES DRUG GUIDE by: èillie Anne Wilson, Carolyn S. Tan
TAèLE OF CONTENT

I. INTRODUCTION
Overview of the Study
Objectives of the Study
Scope and Limitations
II. Health History
A. Profile of patient
è. Family and Personal
Health History
C. History of Present Illness
D. Chief Complaint
III. DEVELOPMENTAL DATA
IV. ANATOMY AND PHYSIOLOGY
V. PATHOPHYSIOLOGY
VI. DOCTOR¶S ORDER
Laboratory Results
Drug Study
VII. NURSING SYSTEM REVIEW CHART
VIII. NURSING MANAGEMENT
Ideal Nursing Management
Actual Nursing Management
IX. HEALTH TEACHINGS
X. EVALUATION
XI. REFERRALS AND FOLLOW-UP
XII. èIèLIOGRAPHY
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-6;18;8|
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a a a 

 a  a|
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#  |:
èaygan, Alleson John A. SNLDCU
èSN-3
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Mrs. Chedy Gapultos , RN
Clinical Instructor

September 1, 2010
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