Case Complete

7/30/2019 Case Complete

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Pamantasan ng Cauyao

Katapatan Homes, Brgy. Banay-banay, Cabuyao, Laguna

COLEGE OF NURSING

A CASE STUDYon

CONGESTIVE HEART FAILURE, CHRONIC KIDNEY DISEASE, ANEMIA, PLEURAL EFFUSION

In Partial Fulfillment

Of the Course

RLE 106

Submitted to:

Minerva Sanchez, RN RM MAN

Submitted by:Abo-Abo, Jamie Joyce Darlene

Dela Cruz, RachaneeOa, Cherry Anne

Palomares, KrishnaVerzola, Jeri Mei

RLE 106 GROUP II-B

Mon. Wed. 02:00 pm- 10:00 pm


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INTRODUCTION

BACKGROUND OF STUDY


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The group chose the case Chronic Kidney Disease with complications of Anemia, Congestive Heart Failure and

Pleural Effusion since we are dealing with alteration of endocrine and renal disorders in NCM 106 lecture. We are willing

to do this case to challenge our minds in analyzing the problem, enhancing and gaining new knowledge that may bring

new leanings for the members of the group.

GOAL OF THE STUDY

After this case study, we will be able to know more about chronic Kidney Disease including its causes, prevention

and treatments in the occurrence of this disease.

OBJECTIVES:

To explain the meaning of Chronic Kidney Disease and how it come up to its complications.

To trace the Pathophysiology behind the occurrence of CKD.

To enumerate the different signs and symptoms of CKD.

To formulate and apply nursing care plans by utilizing the nursing process.

To learn new clinical skills as well as to sharpen our minds in the management of patient with CKD.

OVERVIEW OF THE DISEASE: CHRONIC KIDNEY DISEASE


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Chronic kidney disease is the slow loss of kidney function over time. The main function of the kidneys is to remove wastes

and excess water from the body. Chronic kidney disease (CKD) slowly gets worse over time. In the early stages, there may be

no symptoms. The loss of function usually takes months or years to occur. It may be so slow that symptoms do not appear until

kidney function is less than one-tenth of normal.

SCENARIO:

Kidney diseases, especially End Stage Renal Disease (ESRD), are already the 7th leading cause of death among the

Filipinos. One Filipino develops chronic renal failure every hour or about 120 Filipinos per million populations per year. More than

5,000 Filipino patients are presently undergoing dialysis and approximately 1.1 million people worldwide are on renal replacement

therapy. Reliable estimates reveal that the number of these patients will double in 2010. (National Kidney and transplant institute)

RISK FATORS FOR CKD

Although chronic kidney disease sometimes results from primary diseases of the kidneys themselves, the major causes are diabetes

and high blood pressure.

Type 1 and type 2 diabetes mellitus cause a condition called diabetic nephropathy, which is the leading cause of kidneydisease in the United States.

High blood pressure (hypertension), if not controlled, can damage the kidneys over time.

Glomerulonephritis is the inflammation and damage of the filtration system of the kidneys, which can cause kidney failure.Post infectious conditions and lupus are among the many causes of glomerulonephritis.

Polycystic kidney disease is an example of a hereditary cause of chronic kidney disease wherein both kidneys have multiplecysts.

Use of analgesics regularly over long durations of time can cause analgesic nephropathy, another cause of kidney disease.Certain other medications can also damage the kidneys.

Clogging and hardening of the arteries (atherosclerosis) leading to the kidneys causes a condition called ischemic

nephropathy, which is another cause of progressive kidney damage.

Obstruction of the flow of urine by stones, an enlarged prostate, strictures (narrowing), or cancers may also cause kidneydisease.

Other causes of chronic kidney disease include HIV infection, disease, heroin, amyloidosis, stones, chronic, and certaincancers.

Effects and symptoms of chronic kidney disease include:

need to urinate frequently, especially at night (nocturia);
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swelling of the legs and puffiness around the eyes (fluid retention);

high blood pressure;

fatigue and weakness (from anemia or accumulation of waste products in the body);

loss of appetite, nausea and vomiting;

itching, easy bruising, and pale skin (from anemia);

shortness of breath from fluid accumulation in the lungs;

headaches, numbness in the feet or hands (peripheral neuropathy), disturbed sleep, altered mental status(encephalopathy from the accumulation of waste products or uremic poisons), and restless legs syndrome;

chest pain due to pericarditis (inflammation around the heart);

bleeding (due to poor blood clotting);

bone pain and fractures; and

Decreased sexual interest and erectile dysfunction.

DIAGNOSTIC TEST

1. A urinalysis may show protein or other changes. These changes may appear 6 months to 10 or more years before symptoms

appear. Tests that check how well the kidneys are working include:

Creatinine clearance Creatinine levels

BUN

2. Chronic kidney disease changes the results of several other tests. Every patient needs to have the following checked

regularly, as often as every 2 - 3 months when kidney disease gets worse:

Albumin

Calcium

Cholesterol

Complete blood count (CBC) Electrolytes

Magnesium

Phosphorous

Potassium

Sodium

3. Causes of chronic kidney disease may be seen on:
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Abdominal CT scan

Abdominal MRI

Abdominal ultrasound

Kidney biopsy

Kidney scan

Kidney ultrasound

4. This disease may also change the results of the following tests:

Erythropoietin

PTH

Bone density test

Vitamin D

COMPLICATIONS

Anemia

Bleeding from the stomach or intestines

Bone, joint, and muscle pain

Changes in blood sugar

Damage to nerves of the legs and arms (peripheral neuropathy)

Dementia

Fluid buildup around the lungs (pleural effusion)

Heart and blood vessel complications

o Congestive heart failure

o Coronary artery disease

o High blood pressure

o Pericarditis

o Stroke

High phosphorous levels

High potassium levels

Hyperparathyroidism

Increased risk of infections
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Liver damage or failure

Malnutrition

Miscarriages and infertility

Seizures

Swelling (edema)

Weakening of the bones and increased risk of fractures
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OVERVIEW OF THE DISEASE: CONGESTIVE HEART FAILURE WITH HYPERTENSION

Hypertension, or commonly known as high blood pressure, is a medical condition wherein the blood pressure of an individual isrecurrently elevated. Hypertension is an important contributor to morbidity and mortality from cardiovascular disease. It is a anindependent risk factor for stroke, myocardial infarction, renal failure, congestive heart failure, progressive atherosclerosis, dementia,coronary artery disease and peripheral vascular disease. Hypertension affects approximately 50 million individuals in the UnitedStates and approximately 1 billion individuals worldwide.

SCENARIO:

As the population ages, the prevalence of hypertension will increase even further broad and effective preventive measuresare implemented (1). In the Philippines, 9.6M are hypertensive and 15.4M are predisposed to be hypertensive among adults, 20years and over (2). Unfortunately, half of those who has hypertension are not aware that they have the condition, only 13.1% of themhas been treated and 19.3 % has been controlled (3). Since hypertension may be present in an individual in years without noticeablesymptoms, it is otherwise known as The Silent Assassin (4), In the Philippines, for over 5 years, hypertension ranks as the fifthleading cause of morbidity (5).

This implies that hypertension is a chronic problem or condition of the country and perhaps not much has been done on itscontrol and prevention. Prolonged and uncontrolled hypertension is very dangerous. Unhealthy lifestyles which include cigarettesmoking, unmanaged stress, salty food consumption, physical inactivity, or being overweight are the common modifiable risk factorsto having hypertension. Non modifiable factors include genetic predisposition to hypertension and other disease condition likediabetes, heart and kidney disease, high cholesterol level, or stroke and an increasing age.Hypertension in its earlier stage is manageable. The simplest way of controlling high blood pressure is through lifestyle modificationby having healthy diet and regular exercise.

Congestive heart failure is defined as the state in which the heart is unable to pump blood at a rate adequate for satisfyingthe requirements of the tissues with function parameters remaining within normal limits usually accompanied by effort intolerancefluid retention, and reduced longevity.

The most severe manifestation of CHF, pulmonary edema, develops when this imbalance causes an increase in lung fluidsecondary to leakage from pulmonary capillaries into the interstitium and alveoli of the lung.


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CASE ABSTRACT

Patient X is 64 year old woman was rushed in the emergency room of Panlalawigang

Pagamutan ng Laguna at around 6:00pm last June 16, 2012 with the chief complaint of

difficulty of breathing, orthopnea and chest pain. associated with nausea and vomiting. Shewas then advised by Dra. Menendez to be admitted with strict observation in the intensive

care unit. Upon assessment, patient X was noted with bipedal edema and seen with nose

bleeding that is when she was referred to ENT and advised with nasal packing, Paranasal

Sinus CT scan and x-ray in the paranasal sinus and advised to be taken with laboratory

studies including Hematology, Complete Blood Count, ECG and chest Xray. By then, the

attending Physician ordered, Losartan 50 mg, Furosemide 20mg/tab OD and was hooked

with 1L PNSS KVO.


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HEALTH HISTORY


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HEALTH HISTORY

Patient: X

Birthday: September 1,1947

Age: 64 years old

Address: San Antonio, SPC

Religion: Catholic

Sex: female

Nationality: Filipino

Civil status: Married

Rank in the Family: Grandmother Admission Date and Time: 06-16-2012; 7:40 pm

Attending Physician: Dr. Menendez

Admission Diagnosis: CHF / Chronic Kidney Disease, Anemia

Source of History: Patient & Daughter

Reliability of Historian: Reliable

Chief Complaint: DOB

HISTORY OF PRESSENT ILLNESS

A day prior to admission, the patient experienced difficulty of breathing and sought to bring him to PPL , SPC hospital. In the

ER seen ( + )nose bleeding, the attending physician immediately requested nasal packing and series of laboratory tests to verify the

illness of the patient and brought to ICU unit. Upon interview with the patient and her daughter, we had found out that it was her

second time in hospitalization in the ICU unit with the same complain and she also has a chronic heart failure for almost 10 years


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together with anemia and hypertension but later found out that she also has a chronic kidney disease and elevated blood sugar

level upon her present hospitalization .In the Chest X ray found out that she has a mild pleural effusion and scheduled for CTT

insertion and it was inserted on the right 5 th ICS midaxillary line last June 20, 2012 collected 900ml pinkish pleural fluid and repeat

chest x-ray ordered after removal of CTT on last June 24, 2012 9:10am by Dr. Isberto, accidentally another finding come on with mild

pleural effusion on the left ling but the patient refuse to have another CTT insertion and sign a waiver. Patient X is for blood

transfusion after the relieved of her DOB. The pleural fluids are examined to the laboratory for culture and sensitivity and cell block

for further diagnosis but patient has still with bipedal edema.

PAST HEALTH HISTORY

Two months ago, the patient had been hospitalized because of the same complaint of DOB.

FAMILY HEALTH HISTORY

Upon interview, she has 7 children of which has no known diseases .Her mother has also a heart disease and elevated blood

pressure. No allergy to any foods and medicines.

SOCIO-ECONOMIC STATUS

Their family has a simple life. The family lives in a concrete house. They have electricity and good ventilation. They also

have an adequate living space. She is living separately with her sons and daughters who provide her daily needs. She is living with

her 3 grandchildren.

FUNCTIONAL HEALTH PERCEPTION

A. Health Perception and Health Management Pattern

Patient XY detailed that she had usual colds associated with fever and cough when she was young and was relieved

by herbal medicines from the quack doctors in the barrio. Due to lack of finances, they were not able to maintain proper

nutrition and medications needed by a child before and added up the fact that, they were to lack of opportunities to see a

health professional that can modify things that is needed to perform a healthy lifestyle and can prevent diseases like what she

had now.

BEFORE ADMISSION DURING ADMISSION


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B. NUTRITION-METABOLICPATTERN

Prior to admission, the patients daily diet is fish,meat, pork and beef with salt or soy sauce andsometimes he eats soup of vegetable mixedwith rice. He drinks a lot of water.

Prior to surgery, he was NPO for about 6-8 hrs.After 2-3 days, he again eats up salty foods, suchas French fries with salts poured on it andtogether with coke.

C. ELIMINATION PATTERN A day prior to admission, the patient has nodifficulty in defecating. But sometimes sheexperience urine retention

During the confinement, he defecates once a daywith close monitoring on his urine due to timesshe doesnt have urine output or insufficient.

D. SLEEP-REST PATTERN The patient usually sleeps at around 8:00 pm atawakes at 6:30 am.

During confinement, she has disturbed sleepingpattern due to vital signs monitoring every hourand of her DOB.

E. ACTIVITY-EXERCISEPATTERN

The patient walks in her backyard for exercise During confinement, she does range of motionexercises.

ACTIVITY-EXERCISE PATTERN

CODE:

LEVEL 0 full self careLEVEL1 requires use of equipment or deviceLEVEL 2 requires assistance or supervision from another personLEVEL 3 - requires assistance or supervision from another person or deviceLEVEL 4 - is dependent and does not participate

PRIOR UPON PRIOR UPONFEEDING 0 2 GROOMING 0 2BATHING 0 2 GENERAL MOBILITY 0 2TOILETING 0 2 COOKING 0 3BED MOBILITY 0 2 HOME MAINTENANCE 1 3

DRESSING 0 2 SHOPPING 2 4

F. Cognitive and Perceptual Pattern


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She has sometimes experiencing dementia, but during our interview on the following days she is oriented to time, place and

person.

G. Self perception and Self Concept Pattern

Patient XY stated that shes not yet feeling good during her hospital stay and the only thing that made her worry is her

grandchildren, because she didnt know whos in charge in taking care of the children while shes in the hospital.

H. Coping stress tolerance Pattern

Patient XY explained that problems can be easily handled when you dont think of it that much. Shes not taking too much

pressure in handling problems with the help of her children. She can easily manage stress because of her grandchildren.

I. Value Belief Pattern

Shes regularly attending mass every Sunday in their chapel and according to her; God is very good because she is still there

for her, taking care of her especially with her current situation.

ERIK ERIKSONS STAGES OF DEVELOPMENT

Erikson believed that the more success an individual has at each developmental stage, the healthier the personality of the

individual. Failure to complete the any developmental stage influences the persons ability to improve in the next level. These

developmental stages can be viewed as series of crises.

According to his 8th Stage of Development which is the Maturity or Integrity Versus Despair, the persons task is to accept his

own worth as an individual, the uniqueness of ones own life and acceptance of death. As observed to our 64 year old patient, this

task was achieved as evidenced by her attitude towards life and the fact that whatever happens to her shes ready, but the only thing

that made a matter is the thought that she wasnt able to prevent certain diseases. But all in all, her deep faith to God helps her to

achieve her developmental task.


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PHYSICAL ASSESSMENT


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PHYSICAL ASSESSMENT

A. General Survey June 20,2012

Received patient lying in bed with IVF of PNRS 1L for KVO. She is in pain and irritable and upon observation patient X

looks pale and weak with shortness of breath, (+) bipedal edema, (+) hypertension, with nasal cannula, O2 regulated at

8L/min, bag and with CTT inserted on her 5 th ICS midaxilliary line connected to One way bottle. Foley catheter connected to

urine.

Vital Signs (upon assessment June 20, 2012 @ 7pm)

TEMPERATURE( Celsius)

PULSE(beats/min)

RESPIRATORY RATE( breaths/min)

BLOOD PRESSURE(mm/hg)

HGT RESULT

36.2 70bpm 18bpm 140/90 138mg/dL

VITAL SIGNS MONITORING RECORD

JUNE 18, 2012 2 -10 PM

TIME TEMPERATURE( Celsius)

PULSE(beats/min)

RESPIRATORYRATE

( breaths/min)

BLOODPRESSURE

(mm/hg)

O2 SATURATION(%)

3pm 36.4 68 20 140/60 97

4pm 36.6 71 22 130/80 97

5pm 36.6 70 21 110/70 98


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6pm 36.3 67 19 120/90 97

7pm 36.3 71 18 110/70 97

8pm 36.3 72 18 110/70 97

9pm 36.3 73 19 120/90 97

10pm 36.0 73 19 120/90 97

JUNE 20, 2012 2-10 PM


PULSE(beats/min)

RESPIRATORYRATE

( breaths/min)

BLOODPRESSURE

(mm/hg)

O2 SATURATION(%)

3pm 35.5 70 19 130/80 99

4pm OR OR OR OR OR

5pm 35.5 70 18 120/80 98

5:15pm 35.7 71 20 130/70 97

5:30pm 37.7 70 18 110/80 99

5:45pm 35.9 70 19 120/70 97

6pm 35.9 71 18 140/80 98

7pm 36.2 70 18 140/90 99

8pm 36.2 72 19 130/80 97

9pm 36.2 72 21 140/80 98

10pm 36.2 73 16 140/80 96


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JUNE 25 , 2012 2-10PM


PULSE(beats/min)

RESPIRATORYRATE

( breaths/min)

BLOODPRESSURE

(mm/hg)

O2 SATURATION(%)

3pm 36.1 58 20 140/60 97

4pm 36.0 70 20 120/80 98

5pm 36.7 80 20 120/70 99

6pm 36.1 80 24 130/80 99

7pm 36.1 70 20 110/80 98

8pm 36.4 81 19 130/80 99

9pm 36.3 80 21 130/70 97

10pm 36.3 81 20 130/70 98

JUNE 26, 2012 2-10PM


PULSE(beats/min)

RESPIRATORYRATE

( breaths/min)

BLOODPRESSURE

(mm/hg)

O2 SATURATION(%)

3pm 36.1 81 20 150/80 99

4pm 36.3 78 20 150/80 97

5pm 36.2 79 21 150/80 99

6pm 36.3 80 21 150/80 95

7pm 36.2 79 22 160/80 99

8pm 36.4 81 22 160/80 98


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9pm 36.0 78 23 150/80 97

10pm 36.0 77 22 150/70 98

RANDOM BLOOD SUGAR (HGT) MONITORING RECORD every 6 hours - JUNE 16 21, 2012

Upon Admission June 16, 2012 = 253 mg/dl

JUNE 17,

2012

RESULT

(mg/dl)

JUNE

18, 2012

RESULT

(mg/dl)

JUNE

19, 2012

RESULT

(mg/dl)

JUNE

20, 2012

RESULT

(mg/dl)

JUNE

21, 2012

RESULT

(mg/dl)

6AM 175 12MN 161 12MN 146 12MN 135 12MN --

12NN 162 6AM 156 6AM 141 6AM 144 6AM 152

6PM 167 12PM 145 12PM -- 12PM -- 12PM 146

-- -- 6PM 141 6PM 135 6PM 138 6PM 146

INTAKE AND OUTPUT MONITORING RECORD

DATE SHIFT ORAL INTAKE (cc) IV (cc) URINE OUTPUT (cc)

JUNE 18, 2012 6-2 70 50 160

2-10 170 68 200

10-6 80 85 205


JUNE 19, 2012 6 -2 180 145 248


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2-10 150 60 295

10-6 90 85 130


JUNE 20, 2012 6-2 290 60 255

2-10 133 171 220

10-6 90 115 255


JUNE 21, 2012 6-2 270 70 200

2-10 300 120 260

10-6 20 85 70


JUNE 22, 2012 6-2 75 180 20

2-10 240 100 33

10-6 80 50 130


JUNE 23, 2012 6-2 90 20 30


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2-10 150 110 100

10-6 120 145 120


JUNE 24, 2012 6-2 220 10 280

2-10 200 60 380

10-6 90 110 200


JUNE 25, 2012 6-2 450 100 300

2-10 400 90 350

10-6 90 75 165


JUNE 26, 2012 6-2 330 60 47

2-10 270 60 205

10-6 110 70 300

JUNE 27, 2012 6-2 390 120 135


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PLEURAL FLUIDS OUTPUT MONITORING RECORD

JUNE 20 23, 2012

JUNE 20, 2012

Thoracostomy obtained

AMOUNT

800cc


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Thoracentesis obtained 4cc

JUNE 21, 2012

2-10 pm 0

10-6am 70cc

JUNE 22, 2012

6- 2pm 0

2 10pm 50cc

JUNE 23, 2012

6-2pm 0

2-10pm 50cc

B. INTEGUMENT

Skin: Patient X has a light brown complexion. Her skin is smooth and dry with poor skin turgor, wrinkled appearancedue to her age.

Mucous Membrane: Patient X has pale lips. Theres a sign of dryness


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Nails: Her fingernails and toenails are short and dirty, capillary refill (4-5 seconds)

Hair: Patients X hair is evenly distributed with gray colored hair; and theres no presence of dandruff and lice, with ashort haircut.

HEET

Head: Upon inspection, she has a round and symmetrical skull. No nodules and tenderness.

Eyes: Patient Xs eyebrow is fairly distributed; eyelashes are slightly short and curl. Her eyes are black in color andPale conjunctiva, no noted discharge.

Ears: Smooth and soft to touch, its color is the same as her color of the skin. No presence of any discharge, she canrecognize to any sound. Symmetrical upon inspection, and auricle aligned with outer canthus of eye. Ears also recoil.

Nose: Smooth to touch, no presence of any discharge and deformities. She can recognize good and bad smell.

Mouth/Throat/Pharynx/Teeth: Upon assessment, patients lips are pale in color, symmetry and contour, no notedsores and gums.

Face: Pale looking skin, symmetrical in both sides.

Neck/Lymp Nodes: No noted lesions, no palpable lymph nodes.

PULMONARY


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She has a CTT inserted on her Right 5th ICS midaxilliary line. Patient X experience difficulty in breathing with shortness ofbreath.

CARDIOVASULAR

Upon auscultation, he has a normal heart sound and normal heart rate and regular rhythm.

ABDOMEN

No nodes palpable.

MUSCULOSKELETAL

(+) bipedal edema.

NEUROLOGIC

Upon assessment, Patient X was very irritable and just focusing on his pain being felt last june 20, 2012.


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ANATOMY AND PHYSIOLOGY

URINARY SYSTEM


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Kidneys

Each kidney is behind the peritoneum and surrounded by a renal capsule and adipose tissue.

The kidney is divided into an outer cortex and an inner medulla.

Each renal pyramid has a base located at the boundary between the cortex and medulla, and the tip extends toward thecenter of the kidney and is surrounded by a calyx.

Calyces are extensions of the renal pelvis, which is the expanded end of the ureter within the renal sinus.

The functional unit of the kidney is the nephron. The parts of the nephron are the renal corpuscle, the proximal tubule, the

loop of Henle and the distal tubule.

The filtration membrane is formed by the glomerular capillaries, the basement membrane and the podocytes of Bowmans

capsule.

Arteries and Veins

Renal arteries give rise to branches that lead to afferent arterioles.

Afferent arterioles supply the glomeruli.

Efferent arterioles carry blood from the glomeruli to the pertibular capillaries.

Blood from the pertibular capillaries flows to the renal veins.


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Ureters, Urinary Bladder and Urethra

Each ureter carries urine from renal pelvis to the urinary bladder.

The urethra carries urine from the urinary bladder to the outside of the body.

The ureters and urinary bladder are lined with transitional epithelium and have smooth muscle on their walls.

The external urinary sphincter regulates the flow of urine through the urethra.

Functions of the Urinary System

The kidneys excrete waste products.

The kidneys control blood volume by regulating the volume of urine produced.

The kidneys help regulate the concentration of major ions in the body fluids.

The kidneys help regulate pH of the body fluids

The kidneys regulate the concentration of red blood cells in the blood.

The kidneys participate, with the skin and liver, in Vitamin D synthesis.


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CARDIOVASCULAR SYSTEM

The cardiovascular system can be thought of as the transport system of the body. This system has three main components:the heart, the blood vessel and the blood itself. The heart is the system's pump and the blood vessels are like the delivery routes.Blood can be thought of as a fluid which contains the oxygen and nutrients the body needs and carries the wastes which need to beremoved. The following information describes the structure and function of the heart and the cardiovascular system as a whole.

Function and Location of the HeartThe heart's job is to pump blood around the body. The heart is located in between the two lungs. It lies left of the middle of the chest.

Structure of the HeartThe heart is a muscle about the size of a fist, and is roughly cone-shaped. It is about 12cm long, 9cm across the broadest point andabout 6cm thick. The pericardium is a fibrous covering which wraps around the whole heart. It holds the heart in place but allows it tomove as it beats. The wall of the heart itself is made up of a special type of muscle called cardiac muscle.

Chambers of the Heart
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The heart has two sides, the right side and the left side. The heart has four chambers. The left and right side each have twochambers, a top chamber and a bottom chamber. The two top chambers are known as the left and right atria (singular: atrium). Theatria receive blood from different sources. The left atrium receives blood from the lungs and the right atrium receives blood from therest of the body. The bottom two chambers are known as the left and right ventricles. The ventricles pump blood out to different partsof the body. The right ventricle pumps blood to the lungs while the left ventricle pumps out blood to the rest of the body. Theventricles have much thicker walls than the atria which allows them to perform more work by pumping out blood to the whole body.

Blood VesselsBlood Vessel are tubes which carry blood. Veins are blood vessels which carry blood from the body back to the heart. Arteries areblood vessels which carry blood from the heart to the body. There are also microscopic blood vessels which connect arteries andveins together called capillaries. There are a few main blood vessels which connect to different chambers of the heart. The aorta isthe largest artery in our body. The left ventricle pumps blood into the aorta which then carries it to the rest of the body throughsmaller arteries. The pulmonary trunk is the large artery which the right ventricle pumps into. It splits into pulmonary arteries whichtake the blood to the lungs. The pulmonary veins take blood from the lungs to the left atrium. All the other veins in our body drain intothe inferior vena cava (IVC) or the superior vena cava (SVC). These two large veins then take the blood from the rest of the body intothe right atrium.

Valves

Valves are fibrous flaps of tissue found between the heart chambers and in the blood vessels. They are rather like gates whichprevent blood from flowing in the wrong direction. They are found in a number of places. Valves between the atria and ventricles areknown as the right and left atrioventricular valves, otherwise known as the tricuspid and mitral valves respectively. Valves betweenthe ventricles and the great arteries are known as the semilunar valves. The aortic valve is found at the base of the aorta, while thepulmonary valve is found the base of the pulmonary trunk. There are also many valves found in veins throughout the body. However,there are no valves found in any of the other arteries besides the aorta and pulmonary trunk.

SYSTEMIC AND CORONARY CIRCULATION

Pulmonary circulation beginswith the right heart.

It is here that the oxygenated blood

from the venous system enters the rightatrium through two large veins, thesuperior and inferior vena cava.

Blood is transported to the lungs viathe pulmonary atery and itsbranches.

Oxygen rich blood returns to the leftatrium through cerebral pulmonary

veins.

With systemic circulation blood ispumped out of the left ventricle

through the aorta and major branches tosupply all of the body tissues.

Coronary circulation, on the otherhand, supplies the heart with its own

network of vessels.
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PATHOPHYSIOLOGY

The left and right coronary arteriesoriginate at the base of the aorta and

branch out to encircled the

myocardium.


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LABORATORY


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LABORATORY RESULTS

Hematology

(06/22/12)

Result Normal Values Clinical Significance

Hemoglobin 73g/L 110-165g/L Decrease in various anemias,

pregnancy, severe or

prolonged hemorrhage, and

with excessive fluid intake

Hematocrit .23cu/L 0.35-0.50cu/L Decrease in severe anemias,

anemia of pregnancy, acute

massive blood loss

WBC 3.9q/l 5.0-10.0x9/L Decrease in disease-fightingcells (leukocytes) circulating in

your blood.


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Urinalysis

(6/18/12)

Result Clinical Significance

MACROSCOPIC FINDINGS

Color Yellow Within normal values

Transparency slight turbid Within normal values

Specific Gravity 1.010 Within normal values

Reaction Acidic (6.0)

Albumin + Increased level of albumin

indicates albuminuria

Sugar - Within normal values

Ketones - Within normal values

Bilirubin - Within normal values

Urobilinogen - Within normal values

Nitrite - Within normal values

Blood trace Indicates slight hemoglobinuria

Leukocytes + Slight escape of WBC is an

indicative of slight infection.

Ascorbic Acid - Within normal values

MICROSCOPIC FINDINGS

Pus cells 20-30/hpf Indicates infection


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RBC 5-10/hpf Slight escape of RBC indicates

hematuria

Bacteria + Indicates bacteriuria

Epithelial cells few Indicates slight escape of epithelial cells

Crystals A. urates + Presence of urine crystals.

Blood Chemistry

(06/18/12)

Result Normal Values Clinical Significance

Fasting Blood Sugar 142.7mg/dl 80-110mg/dl An increase in glucose level in

the blood

Cholesterol 242.6mg/dl 150-200mg/dl An increased number of fat

deposits in the vascular walls.

Triglycerides 161.8mg/dl < 150 mg/dL Increase level of fat deposits in

the arterial and vascular walls.

BUN 53.5mg/dl 10-20mg/dl Increasing levels suggest

condition that assess kidney

function.

Creatinine 5.2mg/dl 0.7-1.4mg/dl Increasing levels suggest


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condition that assess kidney

function.

Uric Acid 10.5mgs/ 3.5-8.5 mg/dL Increased that may indicate

high concentration purine

waste staying on the blood.

HDL-chol.F 52.7mg/dl 35-85mg/dl Within normal levels

LDL-Chol. 157.5mgs/dl 60-160 mg/dl Within normal levels

ECG INTERPRETATION

DATE SUGGESTION INTERPRETATION

6-14-12 Tachyarryrthmias, high lateral wall

ischemia

Any disturbance of the heart rhythm in

which the heart rate is abnormallyincreased.

6-18-12 Diffuse Myocardial Ischemia A loss of oxygen to the heart muscle

caused by blockage of the coronary

arteries or their branches.


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DRUG STUDY


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DRUG NAME THERAPEUTICACTION

INDICATION CONTRAINDICATION ADVERSE EFFECT NURSINGCONSIDERATION

Generic NameFurosemide

Brand Name:Lasix

Classification:Loop diuretic

Inhibits thereabsorption ofsodium andchloride from theproximal and

distal renaltubules and theloop of Henle,leading to asodium-richdiuresis.

EdemaassociatedwithCHFrenal

disease(oral, IV)

Contraindicatedwith allergy tofurosemide,sulfonamides;

allergy to tartrazine(in oral solution);electrolytedepletion; anuria,severe renalfailure; hepaticcoma; pregnancy;lactation.

CNS: Dizziness,vertigo, paresthesias,xanthopsia,weakness, headache,drowsiness, fatigue,

blurred vision, tinnitus,irreversible hearingloss

CV: Orthostatichypotension, volumedepletion, cardiacarrhythmias,thrombophlebitis

SKIN:

Photosensitivity, rash,pruritus, urticaria,purpura, exfoliativedermatitis, erythemamultiforme

GI: Nausea, anorexia,vomiting, oral andgastric irritation,constipation, diarrhea,acute pancreatitis,jaundice

GU: Polyuria,nocturia, glycosuria,urinary bladder spasm

HEMA: Leukopenia,anemia,thrombocytopenia

Administer withfood or milk toprevent GI upset.

Reduce dosage if

given with otherantihypertensives;readjust dosagegradually as BPresponds.

Give early in theday so thatincreased urinationwill not disturbsleep.

Avoid IV use if oraluse is at allpossible.

Do not expose tolight, may discolortablets or solution;do not usediscolored drug orsolutions.

Measure and

record weight tomonitor fluidchanges.

Arrange to monitorserum electrolytes,hydration, liverfunction.


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Arrange forpotassium-rich dietor supplementalpotassium asneeded.



Generic Name:Nitroglycerin

Brand Names:Deponit patch

Drug class:

Antianginals

A nitrate thatreduces cardiacoxygen demandby decreasing leftventricular enddiastolic pressure(preload) and, to

a lesser extent,systemic vascularresistance(afterload).

To preventanginaattacks

Contraindicated topatients with earlyMI, severe anemia,increased ICP,angle closureglaucoma,orthostatichypotension, andallergy toadhesives.

CNS: Headache,dizziness, weakness

CV: Orthostatichypotension,tachycardia, flushing,palpitations

SKIN: cutaneousvasodilation

GI: Nausea andvomiting

Closely monitorVital signs duringinfusion,particularly bloodpressure.

Removetransdermal patchbeforedefibrillation.

Advise patient notto stop drugabruptly.

DRUG NAME THERAPEUTIC

ACTION

INDICATION CONTRAINDICATION ADVERSE EFFECT NURSING

CONSIDERATIONGeneric Name:Acetaminophen

Brand Names:Biogesic

Drug class:Nonopioid

Thought toproduceanalgesia byblocking painimpulses byinhibitingsynthesis ofprostaglandin in

Mild painand fever

Contraindicated topatients withhypersensitivity todrug.

HEMA: hemolyticanemia, neutropenia,leukopenia,pancytopenia

HEPATIC:jaundice

METAB:

Advise patient thatdrug is only forshort-term use.

Do not to use formarked fever(temperaturehigher than 103.1


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analgesics andantipyretics

the CentralNervous System(CNS) or of othersubstances thatsensitize painreceptors tostimulation.

hypoglycemia

SKIN: rash, urticaria

F [39.5 C]), feverpersisting-longerthan 3 days, orrecurrent feverunless directed by prescriber.

High doses orunsupervisedlong-term use cancause liverdamage.



Generic Name:

Acetaminophen

Brand Names:Biogesic

Drug class:Nonopioidanalgesics andantipyretics

Thought to

produceanalgesia byblocking painimpulses byinhibitingsynthesis ofprostaglandin inthe CentralNervous System(CNS) or of othersubstances that

sensitize painreceptors tostimulation.

Mild painand fever

Contraindicated topatients withhypersensitivity todrug.

HEMA: hemolytic

anemia, neutropenia,leukopenia,pancytopenia

HEPATIC:jaundice

METAB:hypoglycemia

SKIN: rash, urticaria

Advise patient thatdrug is only forshort-term use.

Do not to use formarked fever(temperaturehigher than 103.1F [39.5 C]), feverpersisting-longerthan 3 days, orrecurrent feverunless directed by prescriber.

High doses orunsupervisedlong-term use cancause liverdamage.


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GenericName:Ceftriaxone

Brand Names:Rocephin

Drug class:AntimicrobialandAntiparasitic

Inhibits bacterialcell wallsynthesis,

rendering cellwall osmoticallyunstable, leadingto cell deathreceptors tostimulation.

Treatment ofLRIT(e.g.pneumonia,) skin andsoft tissueinfections

Hypersensitivity tocephalosporinsand penicillins,lidocaine or anyother localanaestheticproduct of theamide type.

CNS:Fever, headache,dizziness

CV: Phlebitis

GI: Diarrhea

GU: Genital pruritus,candidiasis

Ask the patient ifshe is allergic topenicillins and

cephalosporins Instruct patient to

take medication asprescribed for thelength of timeordered even if hefeels better.

Teach patient toreport sore throat,bruising, bleedingand joint pain.

Advise patient towatch out forperineal itching,fever, malaise,redness, pain,swelling, rashdiarrhea

Instruct the patientto discomfort in theIV insertion line.



Generic Name:Telmisartan

Brand Names:Micardis

Blocksvasoconstrictingand aldosteronesecreting effectsof angiotensin IIby selective

Hypertension

Hypersensitivity todrug and itscomponent.

CNS:Pain, fatigue,headache, dizziness

CV: chest pain,hypertension,

Monitor patient forhypotension afterstarting drug.

Monitor bloodpressure, closely.

Tell patient that


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Drug class:Antihypertensive

blocking thebinding ofangiotensin II othe angiotensin Ireceptor in manytissues, such asvascular smooth

muscle and theadrenal gland.

peripheral edema

EENT: pharyngitis,sinusitis

GU: UTI

RESPI: cough,URTI

drug should betaken with regardmeals.


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Generic Name:Ketorolac

Brand Names:Toradol

Drug class:NSAIDS

Inhibitsprostaglandinsynthesis,producing

peripherallymediatedanalgesia

Short termmanagement of pain

(not toexceed 5days totalfor allroutescombined)

Hypersensitivity todrug and itscomponent.

CNS: drowsiness,abnormal thinking,dizziness, euphoria,headache

RESP: asthma,dyspnea

CV: edema, pallor,vasodilation

GI: GI Bleeding,abnormal taste,diarrhea, dry mouth,

dyspepsia, GI pain,nausea

GU: oliguria, renaltoxicity, urinaryfrequency

Assess forrhinitis, asthma,and urticaria.

Assess pain(note type,location, andintensity) prior toand 1-2 hrfollowingadministration.

Caution patientto avoidconcurrent use

of alcohol,aspirin, NSAIDs,acetaminophen,or other OTCmedicationswithoutconsulting healthcareprofessional.

Advise patient to

consult visualdisturbances,tinnitus, weightgain, edema,black stools,persistentheadache, orinfluenza-likesyndromes(chills, fever,

muscles aches,pain) occur.


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46/53

NURSING CARE PLAN

Assessment Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective:

Hindi ko alamkung bakit akominamanas asverbalized by thepatient.

Objective:

Bipedal Edema(piting edema) - +2

Excess fluidvolume r/t reduceglomerularfiltration rate.

After nursingintervention thepatient willstabilized fluidvolume. Asevidenced by freesigns of edema.

Independent:

Assessneuromuscularreflexes.

Review laboratorydata (Hb/Hct) proteins,elcetrolytes, urinespecific gravity, chest x-

To evaluate forpresence ofelectrolytesimbalances such ashyper.

To evaluate degreeof fluid and electrolyteimbalance andresponse to therapies.

After nursingintervention---patient hadstabilized fluidvolume asevidenced byslight edema +1.


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Restlessness V/S taken asfollow:T: 37.8 CPR: 86RR: 24BP: 140/90

Urine Output

ray & osmolality /sodium secretion.

Evaluate edematousextremeties, changeportion frequently.

Set an appropriate rateof fluid intake/infusionthroughout 24hrsperiod.

Collaborative: Administermedication, diuretics.

To reduce tissuepressure and risk ofskin breakdown.

To prevent

peaks/valleys in fluidlevel.

To eliminate thewater and salt in thebody.

Assessment Diagnosis Planning NursingIntervention

Rationale Evaluation

Subjective:

Nahihirapan akonghuminga as verbalized

by the patient.

Objective:

DOB

O2 Sat (96%)

Restlessness

V/S: 140/90o RR: 24

Ineffectivebreathingpattern r/t flueraleffusion

accumulation offluid in thelungs.

After nursingintervention thepatient willestablish

normaleffectiverespiratorypattern.

Independent:Determinepresence offactors/physical

conditions.

Auscultate thechest.

Elevate HOB or

To know what causesthe breathingimpairments.

To evaluate presencecharacter of breathsounds secretions.

To promote physiologicalease of maximalinspiration.

After nursingintervention thepatient wasestablished

normal /effectiverespiratorypattern.


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o PR: 86

o Temp: 37.8 C

carry in an uprightposition.

Provide use ofadjuncts such asincentive spirometer.

Administer oxygenat lowestconcentrationindicated andprescribedrespiratorymedication.

Monitor pulseoximetry as

indicated.

To facilitate deeperrespiratory effort.

For management ofunderlying pulmonary

condition.

To verifymaintenance/improvement in O2 SAT.

Assessment Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective:

Kakaunti lang angnakakain ko kasi

hindi sapat angkita ng mga anakko as verbalizedby the patient.

Objective:Capillary Refill(+3)Body Weakness

Nutrition:imbalanced,less than bodyrequirements r/tinability to ingest or

absorb nutrientsbecause of economicfactors.

After nursingintervention thepatient willverbalize

understanding ofcausative factorswhen known andnecessaryinterventions.

Independent:

Ascertainunderstanding of

individual nutritionalneeds

Discuss eating habits,including foodpreferences,intolerances/aversions.

Assess weight, age,

To determine whatinformation to

provide patient/SO.

To appeal topatientslikes/desires

Provide

After nursingintervention thepatient wasverbalized

understanding ofcausative factorswhen known andnecessaryinterventions.


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Poor muscle tonePale

body built/strength,activity/ rest level, andsoft forth Consult dietician/nutritional team asindicated

Encourage patients tochoose foods that areappealing.

Collaborative: Review medicalregimen and provideinformation/ assistanceas necessary.

comparative baseline

To implementinterdisciplinary teammanagement

To stimulateappetite.

To prevent othercomplication.

Assessment Nursing

Diagnosis

Planning Nursing

Interventions

Rationale Evaluation

Subjective:

Tumataas ang

presyon ko. as

verbalized by the

patient.

Objectives:

Restlessness

Decrease

cardiac output r/tincrease

systemic

vasoconstriction.

Short Term:

After nursing

intervention the

patient will

demonstrate

increase in

activity tolerance.

Independent:

Monitor in trends

heart rate and

blood pressure

especially noting

hypertension. Be

aware of specific

systolic and

Tachycardia is a

common response

to discomfort and

inadequate

blood/fluid

replacement.

Sustained

After nursing

interventions thepatient was

demonstrate an

increase in

activity tolerance

and was

participated in

activities that


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Conscious and

Coherent

V/S: BP140/90

-RR-26

PR- 85,

TEMP 37.8 C

Long Term:

After nursing

intervention

patient will

participate inactivities that

minimize or

enhance cardiac

function.

diastolic limits

defined for

patients.

Records skin

temperature, color

and quality/

equality of

peripheral pulses.

Monitor I&O and

fluid balance.

Schedule

uninterrupted

rest/sleep periods.

Assists with self

care activities as

needed.

Monitor graded

activity program.

Note patient

response, v/s

before/during

activity.

tachycardia

increase cardiac

workload and can

decrease cardiac

output.

Warm pink skin and

strong equal pulses

are general

indicators of

adequate cardiac

output.

Useful in

determining fluid

needs or

identifyingexcesses which

can compromise

cardiac output or

O2 consumption.

Prevent fatigue/

over exhaustion

and excessive

cardio vascular

stress.

Regular exercise

stimulates

circulation/

cardiovascular tone

and promotes well

maximize and

enhance cardiac

output.


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Collaborative:

Measure cardiac

output and other

functional

parameters asindicated.

Administer

electrolytes and

medication as

indicated e.g.:

diuretics, anti-

coagulant.

Review serial

ECGs

Administer

supplemental

oxygen as

being.

Useful in evaluating

response totherapeutic

interventions and

identifying needs

for more

aggressive/

emergency care.

Patients needs are

variable, depending

on type of surgery,patients response

to surgical,

intervention and

pre existing

condition. E.g.: type

of heart failure.

Most frequent done

to follow the

progress in

normalization of

electrical

conduction pattern

to identify

complications.

Promotes maximal


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appropriate. oxygenation which

can reduce cardiac

workload and aid in

resolving

myocardial

ischemia and

dysrhythmias.


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DISCHARGE PLAN

and

PROGNOSIS

Documents

Case Complete