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CHAPTER 1 INTRODUCTION

Congestive heart failure (CHF), presently known as left-sided heart failure, is a condition in which the heart can't pump enough blood to the body's other organs. Because the two ventricles of the heart represent two separate pumping system, it is possible for one to fail by itself for a short period. Most heart failure begins with failure of the left ventricle and progresses to failure of both ventricles. Typical causes of CHF include hypertensive, coronary artery, and valvular disease involving the mitral or aortic valve. Decreased tissue perfusion from poor cardiac output and pulmonary congestion from increased pressure in the pulmonary vessels indicate CHF. The initial symptoms of CHF, such as swelling of the ankles, seems so minor that patients may not seek treatment until significant heart damage has already been done. A number of different conventional treatments may be prescribed. These include medications such as diuretics and invasive procedures such as a balloon angioplasty with coronary stenting. (Ignatavicius, 2006) CHF is a risk factor for the development of pleural effusion. Pleural effusion is when fluid accumulates between the thin, transparent membrane covering the lungs and the membrane that lines the inner surface of the chest wall. Normally, the pleurae are silky smooth, allowing the lungs to slide easily along the chest wall when the individual breathes in and out. But when the pleurae around the lungs become inflamed (called pleurisy), fluid can accumulate and may become infected (called empyema). (http://www.wellness.com) Pleuritic chest pain, chest pressure, dyspnea, and cough are the most common symptoms of pleural effusion. Pain may occur with little fluid

formation as the symptom is related to the intense inflammation of the pleural surfaces. Atelectasis may occur. (http://www.nlhep.org) Atelectasis is a condition in which all or part of a lung becomes airless and collapses. A common cause of atelectasis is a blockage of one of the tubes (bronchi) that branch off from the trachea (windpipe) and lead to the lung tissue. The blockage may be caused by something inside the bronchus, such as a plug of mucus, a tumor, or an inhaled foreign object (such as a coin, piece of food, or a toy). Alternatively, the bronchus may be blocked by something pressing from the outside, such as a tumor or enlarged lymph nodes. Blockage from the outside can also occur if the pleural space (the space outside of the lung but inside of the chest) contains a large amount of fluid (pleural effusion) or air (pneumothorax). The only symptom a person with atelectasis may feel is shortness of breath. Symptoms may also reflect the disorder that caused atelectasis (for example, chest pain due to an injury) or a disorder that results from atelectasis (for example, chest pain with deep breathing, due to pneumonia). Treatment of atelectasis may involve making sure deep breathing occurs, relieving airway blockages, or both. Sometimes blockages can be relieved when a patient's airway is suctioned by a health care practitioner. (http://www.merck.com) According to the World Health Organization, more than 22 million people worldwide suffer from congestive heart failure. In the Philippines, out of the 86,241,697 people, 1,521,912 have CHF. It is the 6th leading cause of mortality in the Philippines. (http://www.slideshare.net) Chronic, or irreversible, kidney disease is a progressive reduction of functioning renal tissue such that the remaining kidney mass can no longer maintain the bodys

internal environment. It can develop insidiously over a period of many years, or can occur as a result of a bout of renal failure from which the person fails to recover. The end result for the person with renal failure is either uremia or death, treatment by dialysis and/or transplant. (Ignatavicius, 2006) The causes of chronic kidney disease are numerous. The most common causes of CKD are diabetic nephropathy, hypertension, and glomerulonephritis. Together, these cause approximately 75% of all adult cases. Certain geographic areas have a high incidence of HIV nephropathy. Systemic diseases, such as diabetes mellitus, hypertension, lupus erythematosus, polyarteritis, and sickle cell disease may also produce renal failure. (Ignatavicius, 2006) The pathogenesis of chronic renal failure portrays slow deterioration and destruction of renal nephrons with progressive loss of their normal function. As the total glomerular filtration rate falls and clearance is reduced, the serum urea nitrogen and creatinine levels rise. Remaining functioning nephrons hypertrophy as they are required to filter a larger load of solutes. One of the consequences of this is that the kidneys lose their ability to concentrate urine adequately. In an attempt to continue excreting the solutes, a large volume of dilute urine is passed, making the person susceptible to fluid depletion. The tubules gradually lose their ability to reabsorb electrolytes. Occasionally, this can result in salt-wasting, in which the urine contains very large amounts of sodium, which leads to more polyuria. Thus, the body becomes unable to rid itself of water, salt, and other waste products through the kidneys. (Ignatavicius, 2006) One of the most common extrarenal diseases affecting the kidney is diabetes mellitus. Diabetic nephropathy, a progressive process, frequently leads to renal failure.

Approximately 25% of people with end-stage renal disease have diabetes mellitus. Researchers estimate that 50-60% of people with insulin-dependent diabetes mellitus (IDDM, or type 1) will develop end-stage renal disease within 15 to 20 years of beginning insulin therapy. (Ignatavicius, 2006) Several pathlologic changes lead to renal failure in people with diabetes mellitus. The most frequent is a characteristic intercapillary glomerulosclerosis, or scarring of the capillary loops. Progressive microangiopathy, nephrosclerosis, affects the afferent and efferent arterioles and eventually causes scarring of the glomerulus, tubules, and interstitium. (Ignatavicius, 2006) Renal failure may be initially identified when the person is undergoing evaluation for recurrent insulin reactions. Sometimes, the sclerotic process can be prevented or slowed before proteinuria occurs by: carefully controlling the diabetes abd hypertension, appropriately adjusting insulin therapy, treating neurogenic bladder dysfunction, and preventing urinary tract infections. However, the person inevitably develops the symptomatic phase about five years after the appearance of significant proteinuria, regardless of the degree of diabetic control. (Ignatavicius, 2006) The goal of therapy is to slow down or halt the otherwise relentless progression of CKD to stage 5. Control of blood pressure and treatment of the original disease, whenever feasible, are the broad principles of management. Generally, angiotensin converting enzyme inhibitors or angiotensin II receptor antagonists are used as they have been found to slow the progression of CKD to stage 5. Although the use of ACE inhibitors and ARBs represents the current standard of care for patients with CKD, patients progressively lose kidney function while on these medications, which reported a

decrease over time in estimated glomerular filtration rate in patients treated by these conventional methods. (Ignatavicius, 2006)

Purpose of the Study The case study aims to utilize the nursing process in presenting the nursing care plan of a young adult who was diagnosed to have Schizophrenia. Specifically, this study aims to determine the following: 1. 2. 3. 4. Identify factors that led to the development of the problem. Analyze the relationship of factors leading to the development of the problem. Discuss relevant interventions that were utilized to resolve the problem. Explain the clients response towards the interventions given.

Significance of the Study This study is made for the benefit of the following people: To the significant others, this study will provide them with details of what their family member went thru providing them with understanding of the disease process and more knowledge and competency on how to properly care and support for the patient. To the researcher, that this study may serve as a partial basis for the provision of appropriate nursing care and interventions for the client through better comprehension of the clients problems and needs. To the health care team, this study serves as a document of the efficiency of nursing care rendered to the client.

To the clinical instructor, this study will serve as a criterion for evaluation of the nursing students in the implementation of the individualized care given to the client and to serve as a reference in enhancing their teaching skills through analysis and appraisal of similar cases encountered by the students. To the future researchers, this study should serve as a reference for research and to guide then in the formation of a more comprehensive nursing care plan of a patient with a similar condition.

Scope and Limitations This study utilized a Retrospective A approach wherein the client was handled by the researcher, and medical records were reviewed for validation of data. This study was conducted at the 7th Floor-Circular of Makati Medical Center. The scope of the study is the care of a client with Congestive Heart Failure. The focus of the study is the utilization of nursing process and core competencies in the standards of nursing in the provision of comprehensive nursing care of a client with complex problems. The study covers the history of the clients illness up to the time that the patient was handled by the researcher for 8 hours each day on February 1,2, and 3, 2010. Data collection method includes clients interview, observation and medical records. Data were obtained using the Nursing History Form and Physical assessment. The researchers only handled S.E.G. for only three days. The plan of care formulated is only applicable during the period of study.

Background of the Study This is a case study on the care of S.E.G., an 85 year old female diagnosed with CKD, Pleural effusion, and Atelectasis. The study was conducted at Makati Medical Center, an institution which offers a wide variety of health services for promotion of health, prevention and treatment of diseases and has a broad diversity of specializations. It aspires to be an internationally known medical center dedicated to excellence in providing quality health care. Its mission is to provide first-class health care services through a collaborative effort of highly competent health care team as well as the technical and management staff, which are supported by well developed research and training programs facilitated by state-ofthe-art professional equipment and specialized tools. The study was mainly done at the Medical-Surgical ward located at the 7th floor circular of Makati Medical Center during the pm shift (1400H-2200H) from February 13, 2010. The 7th circular ward provides care to medical-surgical patients from admission until the discharge from the institution. It provides total quality health care with its staff: the physicians, the staff nurses, nursing aides and clerks; and up-to-date facilities. The student nurses assigned in the 7th circular ward have different tasks like rendering pm care, monitoring vital signs, feeding via nasogastric or gastrostomy tube, suctioning, and monitoring integrating the nursing process in providing quality health care. The student nurses were well guided by their clinical instructor as well as their preceptors in the performance of these tasks.

The case was chosen by the researchers because they believe that this will serve as an opportunity for them to learn and at the same time enhance their skills in utilizing the nursing care process in handling patients with complex problems. Furthermore, the researchers believe that the case will provide them opportunity to learn more about the disease, its pathophysiology, and the proper nursing care to render to patients with the certain kind of disease.