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8/11/2019 Chf Case Studty(Draft)
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Introduction:
For the purpose of privacy and confidentiality, the real name of the patient in this Case Study is withheld and she will refe rred to as
Patient X
Patient X is a 98 years old female who was currently residing at San Miguel, Tarlac City. Patient X was admitted at the Central Luzon
Doctors Hospital last July 6, 2014 at 10:40pm with a chief complaint of difficulty of breathing.
Background Knowledge
Congestive Heart Failure describes the inability or failure of the heart to adequately meet the needs of organs and tissues for oxygen and
nutrients. This decrease in cardiac output, the amount of blood that the heart pumps, is not adequate to circulate the blood returning to the heart
from the body and lungs, causing fluid (mainly water) to leak from capillary blood vessels. This leads to the symptoms that may includeshortness
of breath,weakness,and swelling.
What Causes Congestive Heart Failure?
There may be many potential reasons for a patient to develop heart failure. It may be due to structural damage to the heart, inability of the
heart to squeeze properly, medications or drugs that affect heart function, lung disease, and other underlying medical diseases. More than one
cause may be present at the same time.
http://www.medicinenet.com/shortness_of_breath/symptoms.htmhttp://www.medicinenet.com/shortness_of_breath/symptoms.htmhttp://www.medicinenet.com/weakness/symptoms.htmhttp://www.medicinenet.com/weakness/symptoms.htmhttp://www.medicinenet.com/shortness_of_breath/symptoms.htmhttp://www.medicinenet.com/shortness_of_breath/symptoms.htm8/11/2019 Chf Case Studty(Draft)
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Risk Factors
Congestive heart failure is often a consequence of atherosclerotic heart disease and therefore the risk factors are the same: poorly
controlled high blood pressure, high cholesterol, diabetes,smoking,and family history.Heart valve diseasebecomes a risk factor as the patient
ages. (ww.medicinenet.com)
Congestive Heart Failure Symptoms
The hallmark symptom of left heart failure is shortness of breath or dyspnea (dys=abnormal + pnea= breathing). This may occur while at
rest, with activity or exertion, while lying flat (orthopnea), or may awaken a patient fromsleep (paroxysmal nocturnal dyspnea). The shortness of
breath may be due to fluid (water, mainly) accumulation in the lungs or the inability of the heart to be efficient enough to pump blood to the
organs of the body when called upon in times of exertion orstress.Chest pain or angina may be associated, especially if the underlying cause of
the failure is atherosclerotic heart disease. (www.medicinenet.com)
http://www.medicinenet.com/smoking_and_quitting_smoking/article.htmhttp://www.medicinenet.com/heart_valve_disease/article.htmhttp://www.medicinenet.com/sleep/article.htmhttp://www.medicinenet.com/stress/article.htmhttp://www.medicinenet.com/chest_pain/article.htmhttp://www.medicinenet.com/chest_pain/article.htmhttp://www.medicinenet.com/stress/article.htmhttp://www.medicinenet.com/sleep/article.htmhttp://www.medicinenet.com/heart_valve_disease/article.htmhttp://www.medicinenet.com/smoking_and_quitting_smoking/article.htm8/11/2019 Chf Case Studty(Draft)
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When to Call the Doctor
The Doctor should be called if there are signs and symptoms of congestive heart failure and any of these situations:
Symptoms ofsudden heart failure,such as:o Severe shortness of breath (trouble getting a breath even when resting).o Suddenly getting an irregular heartbeat that lasts for a while, or getting a very fast heartbeat along
withdizziness,nausea,orfainting.
o Foamy, pink mucus with a cough and shortness of breath.o Chest pain or pressure, or a strange feeling in the chest.o Sweating.o Shortness of breath.o Nausea or vomiting.o Pain, pressure, or a strange feeling in the back, neck, jaw, or upper belly, or in one or both shoulders or arms.o Lightheadedness or sudden weakness.o A fast orirregular heartbeat.
http://www.webmd.com/hw-popup/sudden-heart-failurehttp://www.webmd.com/brain/tc/dizziness-lightheadedness-and-vertigo-topic-overviewhttp://www.webmd.com/digestive-disorders/digestive-diseases-nausea-vomitinghttp://www.webmd.com/brain/understanding-fainting-basicshttp://www.webmd.com/pain-management/guide/whats-causing-my-chest-painhttp://www.webmd.com/skin-problems-and-treatments/hyperhidrosis2http://www.webmd.com/heart-disease/guide/what-causes-heart-palpitationshttp://www.webmd.com/heart-disease/guide/what-causes-heart-palpitationshttp://www.webmd.com/skin-problems-and-treatments/hyperhidrosis2http://www.webmd.com/pain-management/guide/whats-causing-my-chest-painhttp://www.webmd.com/brain/understanding-fainting-basicshttp://www.webmd.com/digestive-disorders/digestive-diseases-nausea-vomitinghttp://www.webmd.com/brain/tc/dizziness-lightheadedness-and-vertigo-topic-overviewhttp://www.webmd.com/hw-popup/sudden-heart-failure8/11/2019 Chf Case Studty(Draft)
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Nursing Process
A. Nursing health history
A. Demographic Data
Name: Patient X
Address: San Miguel, Tarlac City
Gender: FemaleAge: 98 yrs. Old
Birthdate: August 9, 1915Religion: Catholic
Date of admission: july 6, 2014 / 10:40pm
Attending Doctor: Conrado R. Genilo III MDAdmitting Doctor: Maricis C. Lopez MD
B. Chief complaint
Patient X was brought to the hospital and seek medical attention due to the chief complaint of difficulty of breathing
C. History of present illness
1 day prior to admission the patient manifest difficulty of breathing and easy fatigability with edema at both low extremities.
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Review of System
General Appearance
Weight loss Weight gain Anorexia Fatigue
Weakness Night sweats Generalized jaundice
Note: the patient has weak in appearance
Skin
Itch Bruising Rash Bleeding
Lesions Blister Ecchymoses Burns Drainage
Note: No abnormalities in skin found
Ears
Pain Discharge Tinnitus
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Hearing loss
Note: the patient has slightly hearing loss due to aging
Nose
Obstruction Epistaxis Discharges
Note: no abnormalities in skin found
Throat & Mouth
Sore throat Bleeding gums Tooth Ache
Tooth Decay
Note: No abnormalities in throat and mouth
Chest
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Cough Hemoptysis Wheeze Pain in Respiration
Dyspnea Sputum Rales
Note: the patient is unable to expel sputum, suctioning performed. Dyspnea and rales is the symptoms of CHF.
CVS
Chest pain Palpitation Dyspnea Edema
Orthopnea Others__________
Note: Chest pain, Palpitation and Edema because of congestion
GIT
Intolerance Heartburn Nausea Jaundice
Vomiting Pain Bleeding Excessive Gas
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Constipation Change in BM Melena
Note: no abnormalities in GIT found
Genito Urinary
Dysuria Nocturia Retension Polyuria
Dribbling Hematuria Flank Pain Tea colored urine Oliguria
Note: patient experience Oliguria and tea colored urine due to concentration.
Neuro
Headaches Dizziness Memory Loss Fainting Numbness Tingling
Seizures
Paresis Paralysis
Others: ________________
Notes: patient has memory loss due to aging.
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Anatomy and Physiology
To understand what occurs in heart failure, it is useful to be familiar with the anatomy of the heart and how it works. Theheart is composed of two independent pumping systems, one on the right side, and the other on the left. Each has two
chambers, an atrium and a ventricle. The ventricles are the major pumps in the heart.
The external structures of the heart include the ventricles, atria, arteries, and veins. Arteries carry blood away from the heart while
veins carry blood into the heart. The vessels colored blue indicate the transport of blood with relatively low content of oxygen and
high content of carbon dioxide. The vessels colored red indicate the transport of blood with relatively high content of oxygen and low
content of carbon dioxide.
The Right Side of the Heart
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The right system receives blood from the veins of the whole body. This is "used" blood, which is poor in oxygen and rich incarbon dioxide.
The right atrium is the first chamber that receives blood. The chamber expands as its muscles relax to fill with blood that has returned from the body. The blood enters a second muscular chamber called the right ventricle. The right ventricle is one of the heart's two major pumps. Its function is to pump the blood into the lungs. The lungs restore oxygen to the blood and exchange it with carbon dioxide, which is exhaled.
The Left Side of the Heart
The left system receives blood from the lungs. This blood is now oxygen rich.
The oxygen-rich blood returns through veins coming from the lungs (pulmonary veins) to the heart. It is received from the lungs in the left atrium, the first chamber on the left side. Here, it moves to the left ventricle, a powerful muscular chamber that pumps the blood back out to the body. The left ventricle is the strongest of the heart's pumps. Its thicker muscles need to perform contractions powerful enough to
force the blood to all parts of the body. This strong contraction produces systolic blood pressure (the first and higher number in blood pressure measurement). The
lower number (diastolic blood pressure) is measured when the left ventricle relaxes to refill with blood between beats. Blood leaves the heart through the ascending aorta, the major artery that feeds blood to the entire body.
The Valves
Valves are muscular flaps that open and close so blood will flow in the right direction. There are four valves in the heart:
The tricuspid regulates blood flow between the right atrium and the right ventricle. The pulmonary valve opens to allow blood to flow from the right ventricle to the lungs. The mitral valve regulates blood flow between the left atrium and the left ventricle. The aortic valve allows blood to flow from the left ventricle to the ascending aorta.
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Pathophysiology
Left Sided Congestive Heart Failure
Pathophysiology
Causes
o Myocardial Infarctiono Hypertensiono Aortic stenos is insufficiencyo Mitral stenos is insufficiency
Reduced myocardial contractility
Increases cardiac workload
Decreased diastolic filling
Left atrial pressureLeft sided CHFBloods dams back intothe pulmonary
capillary bedStroke volume decreases
Pressure at the
pulmonary capillary bedTissue perfusion
decreases
Cellular h oxiaPulmonar edema
Bloods flow to the kidneys
RAAS stimulation
Vasoconstriction and
reabsorption of Na and water
ECF volume
S/S
Total blood volume
Systemic BP
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DRUG STUDY
Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities
Clopidogre
1 bisulfate
Anti platelet
Drug
75mg
1 tab
OD
Inhibits platelet
aggregation by
inhibiting binding
of adenosipine
diphosphate to its
platelet receptor
and subsequent
ADP- mediative
activation ofglycoprotein
complex
Lactation Active
pathological
bleeding such as
peptic ulcer or
intracranial
hemorrhage.
GI bleeding, purpura,
bruising,
hematoma,
epistaxis,
hematuria,
eye bleeding
(mainly conjunctiva),
intracranial bleeding,
GI disturbances,
diarrhea, rash,
pruritus
-Assess for any active bleeding
as with ulcers or intracranial
bleeding
-take exactly as directed, may
take without regard to food.
Food will lessen chance of
stomach upset
-report any unusual bruising or
bleeding; advise all providers
of prescribed therapy
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Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities
Lasix Loop diuretic 1 amp
IVP
q8
Inhibits sodium and
chloride
reabsorption at the
proximal tubules,
distal tubules and
ascending tubules
loop of henle
leading to excretion
of water together
with sodium,
chloride and
potassium diuretic,
antihypertensive.
Hypersensitivity
to sulfonylureas
anuria
Orthostatic
hypotension,
thrombophlebitis,
chronic aortitis,
vertigo,headache,
dizziness, paresthesia,
restlessness, fever
photosensitivity,
urticarial, pruritis
necrotizing angitis
-monitor the blood pressure,
fluid intake and output,
electrolytes: potassium,
sodium, calcium, magnesium,
glucose, uric acid and BUN
-monitor neurologic
manifestation of hypokalemia,
hypomagnesemia,
hyponatremia, hyperchloremia
-monitor intake and output
-assess patient for tinnitus,
hearing loss, ear pain
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Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities
Ranitidine Histamine H2
Receptor
blocking drug
50mg
IV
q12
Competitively
inhibits gastric acid
secretion by
blocking the effect
of histamine H2
receptors both
daytime and
nocturnal basal
gastric acid
secretion, as well as
food and
pentagastrin
-simulated gastric
acid are inhibited
Hypersensitivity
History of acute
Porphyria
Long term therapy
Cardiac arrhythmias,
bradycardia, headache,
fatigue, dizziness,
hallucination,
depression, insomnia
-use caution in presence of
renal hepatic impairment
-assess potential for
interactions with other
pharmacological agents patient
may be taking
- assess knowledge/ teach
patient appropriate use,possible side effects/
appropriate interventions, and
adverse symptoms to repot
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Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities
Rosuvastatin
calcium
Anti-
hyperlipidemic
20 mg 1
tab OD
A fungal metabolite
that inhibits the
enzyme (HGM-
CoA) that catalyzes
the first step in the
cholesterol
synthesis pathway,
resulting in a
decrease
In serum
cholesterol, serum
LDLs (associated
with increased risk
of coronary artery
disease) and either
an increase or no
change in serum
HDLs (associated
with decreased)
hypersensitivity,
impaired hepatic
function,
alcoholism, renal
impairment,
advanced age,
hypothyroidism
Nausea, dyspepsia,
diarrhea, constipation,
vomiting, rhinitis,
sinusitis, cough,
dyspnea, pneumonia
-Arrange for proper
consultation about need for
diet and exercise changes
-Administer drug at bed time
-Monitor patient closely for
signs of muscle injury,
especially higher doses
-Provide comfort measures to
deal with headache, muscle
cramps, or nausea
-Offer support and
encouragement to deal with
disease, diet, drug therapy, and
follow-up care.
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Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities
Kalium
durule
electrolytic
and water
balance agent
1 tab
TIDPrincipal
intracellular cation;
essential for
maintenance of
intracellular
isotonicity,
transmission of
nerve impulses,
contraction ofcardiac, skeletal,
and smooth
muscles,
maintenance of
normal kidney
function, and for
enzyme activity.
Plays a prominent
role in both
formation and
correction of
imbalances in acid
base metabolism.
Severe renal
impairment; severe
hemolytic
reactions; untreated
Addisons disease;
crush syndrome;
early postoperative
oliguria (except
during GIdrainage);
adynamic ileus;
acute dehydration;
heat cramps,
hyperkalemia,
patients receiving
potassium-sparing
diuretics, digitalis
intoxication with
AV conduction
disturbance.
Nausea, vomiting,
diarrhea, abdominal
distension.
Pain, mental confusion,
irritability, listlessness,
paresthesias of
extremities, muscle
weaknessand heaviness
of limbs, difficulty inswallowing, flaccid
paralysis.
Oliguria, anuria.
Hyperkalemia
-Monitor I&O ratio and pattern
in patients receiving the
parenteral drug. If oliguria
occurs, stop infusion promptly
and notify physician.
-Monitor for and report signs
of GI ulceration (esophageal or
epigastric pain or
hematemesis).
-Monitor patients receiving
parenteral potassium closely
with cardiac monitor. Irregular
heartbeat is usually the earliest
clinical indication of
hyperkalemia.
-Be alert for potassium
intoxication (hyperkalemia, see
S&S, Appendix F); may result
from any therapeutic dosage,
and the patient may be
asymptomatic.
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Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities
Cordarone Anti-
arrhythmics
200mg
1 tab
TID
Effects result from
blockade of
potassium
chloride leading to
a prolongation
potential duration.
-Contraindicated
In patients
hypersensitivity
to drug or iodine.
-Those with
cardiogenic shock,
second or third
degree AV block,
severe SA node
disease resulting
in bradycardia
unless an artificialpacemaker is
present, and in
those for whom
bradycardia has
caused syncope.
CNS : fatigue, malaise,
tremor, peripheral
neuropathy, ataxia,
paresthesia, insomnia,
sleep disturnbances,
headache.
CV: hypotension,
bradycardia,
arrhythmias, heart
failure, heart block,
sinus arrest, edema.
EENT: visual
disturbances, optic
neuropathy, or
neuritis resulting in
visual impairment,
abnormal smell.
GI : Nausea, vomiting,
abnormal taste,
anorexia,constipation,
abdominal pain.
Hematologic :
coagulation
abnormalities
Hepatic : hepatic
-Monitor blood pressure and
heart rate and rhythm
frequently.
-Perform continuous ECG
monitoring when starting or
changing doses. Notify
prescriber or significant
change in assessment result.
-Watch carefully for
pulmonary toxicity.
-Watch for evidence ofpneumonitis, exertional
dyspnea, non productive
cough, and pleuritic chest
pain.
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failure , hepatic
dysfunction
Metabolic :
hypothyroidism,
hyperthyroidism.
Respiratory : acute
respiratory isease
distress syndrome,
SEVERE PULMONARY
TOXICITY.
SKIN :
photosensitivity, solar
dermatitis, blue gray
skin.
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Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities
Lactulose Contraindicated
in patients on a
low galactose
diet.
1tbsp
HSProduces an
osmotic effect in
colon ; resultingdistention
promotes
peristalsis. Also
decrease
ammonia,
probably as a
result of bacterial
degradation,
which lowers the
pH of colon
contents.
Contraindicated in
patients on a low
galactose diet.
Abdominal cramps,
belching, diarrhea,
flatulence, gaseous
distension. Nausea,
vomiting.
-To minimize sweet taste,
dilute with water or fruit
juice or give with food.
-Prepare enema by adding
200g (300ml) to 700 ml of
water or normal saline
solution.
-Monitor mental status
-Replace fluid intake.
-Inform patient aboutadverse reactions and tell
him to notify prescriber if
reactions become
bothersome or if diarrhea
occurs.
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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
Objective:Patient
manifested:
Generalized
weakness
(+) DOB
Easy fatigability After nursing
intervention the
patient will able to
show strength and
energy
1. Assess vital
signs.
2. Determine
presence ordegree of
sleep
disturbances.
3. Obtain clientdescriptions
of fatigue.
4. Ask client torate fatigue.
5. Planinterventions
to allowindividually
adequate rest
periods.
6.Assist with
self-care
needs and
ambulation.
7. Avoidexposure to
temperature
and humidity
extremes
8. Instruct clientin ways to
monitor
responses to
1. To evaluate
fluid status
and
cardiopulmonary
response to
activity.
2. Fatigue canbe a
consequence
of sleep
deprivation.
3. To assist inevaluating
impact onclients life.
4. To
determine
degree of
fatigability.
5. To maximizeparticipation.
6. To conserve
energy for
other tasks.
7. Has negativeimpact on
energy level.
8. Indicate the
need to alter
activity level
9. To promote
For further
management
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activity and
significant
signs or
symptoms.
9. Promote
overall healthmeasures
10.Providesupplemental
oxygen, as
indicated.
11.Assist clientto identify
appropriate
coping
behaviors.
energy
10.Presence ofhypoxemia
reduces
oxygen
available forcellular
uptakes and
contributes
to fatigue.
11.Promote
sense of
control and
improves
self-esteem.
Assessment Diagnosis Planning Intervention Rationale Evaluation
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Subjective:
Objective:Patient
manifested:
productive
cough
yellowish in
color
presence of
rales upon
auscultation
(+) DOB
Impaired Gas
exchange
After nursing
intervention the
will able to breath
w/o oxygen
therapy, and
decrease secretion
production.
1. Monitor and
record vital
signs
2. Observe colorof skin,
mucous
membranes
and nail beds,
noting
presence of
peripheral
cyanosis.
3. Elevate head
of bed and
encourage
frequent
position
changes.
4. Keep back dry.
5. Promoteadequate restperiods
6. Changeposition q 2
hrs.
7. Keepenvironment
allergen free
8. Suction
secretions
PRN9. Administer
oxygen
therapy as
ordered.
1. To obtain
baseline data
2. Cyanosis of
nail beds
may
represent
vasoconstric
tion or the
bodys
response to
fever/ chills
3. To promotemaximal
inspiration,
enhance
expectoratio
n of
secretions in
order to
improveventilation
4. To avoid
coughing
5. Rest will
prevent
fatigue and
decrease
oxygen
demands for
metabolic
demands6. To promote
drainage of
secretions
7. To reduce
irritant
effects on
airways
8. To clear
For further
evaluation and
management
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airway when
secretions
are blocking
the airway.
9. O2 therapy is
indicated toincrease
oxygen
saturation
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Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:(none)
Objective:Patient
manifested:
Edema on
extremities
( 6mm)
DOB
Excess Fluid
Volume
-After nursing
intervention the
patient will be
able to decrease
difficulty of
breathing.
-patients edema
will decrease from
(6mm) to 0.
-
1. Establish rapport
2. Monitor and recordVS
3. Assess patientsgeneral condition
4. Monitor I&O every 4hours
5. Assess for presenceof peripheral edema.
Do not elevate legs if
the client is dyspnic.
6. Follow low-sodium
diet and/or fluid
restriction
7. Encourage orprovide oral care q2
8. Monitor for
distended neck veins
and ascites
9. Evaluate urineoutput in response
to diuretic therapy.
10.Assess the need foran indwelling
urinary catheter.
11.Institute/instructpatient regarding
fluid restrictions as
appropriate.
1. To gain
patients trust
and
cooperation2. To obtain
baseline data
3. To determine
what
approach to
use in
treatment
4. I&O balance
reflects fluid
status
5. Decreasedsystemic
blood
pressure to
stimulation of
aldosterone,
which causes
increased
renal tubular
absorption of
sodium Low-
sodium diet
helps prevent
increased
sodium
retention,
which
decreases
water
retention.
For further
management and
evaluation
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Fluid
restriction
may be used
to decrease
fluid intake,
hencedecreasing
fluid volume
excess.
6. The clientsenses thirst
because the
body senses
dehydration.
Oral care can
alleviate the
sensationwithout an
increase in
fluid intake.
7. Heart failure
causes venous
congestion,
resulting in
increased
capillary
pressure.
When
hydrostatis
pressure
exceeds
interstitial
pressure,
fluids leak out
of ht
ecpaillaries
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and present
as edema in
the legs, and
sacrum.
Elevation of
legs increasesvenous return
to the heart.
8. Inidicates
fluid overload
9. Focus is on
monitoring
the response
to the
diuretics,
rather than
the actualamount
voided
10.Treatmentfocuses on
diuresis of
excess fluid.
11.This helpsreduce
extracellular
volume.
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Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:(none)
Objective:Patient
manifested:
Edema on
extremities
(grade 6)
DOB
Excess Fluid
Volume
-After nursing
intervention the
patient will be
able to decreasedifficulty of
breathing.
-patients edema
will decrease from
( grade 6) to 0.
-
12.Establish rapport13.Monitor and record
VS
14.Assess patients
general condition
15.Monitor I&O every 4
hours
16.Assess for presence
of peripheral edema.
Do not elevate legs if
the client is dyspnic.
17.Follow low-sodiumdiet and/or fluid
restriction
18.Encourage orprovide oral care q219.Monitor for
distended neck veins
and ascites
20.Evaluate urine
output in response
to diuretic therapy.
21.Assess the need for
an indwelling
urinary catheter.
22.Institute/instructpatient regarding
fluid restrictions as
appropriate.
12.To gainpatients trust
and
cooperation
13.To obtainbaseline data
14.To determinewhat
approach to
use in
treatment
15.I&O balancereflects fluid
status
16.Decreasedsystemicblood
pressure to
stimulation of
aldosterone,
which causes
increased
renal tubular
absorption of
sodium Low-
sodium diethelps prevent
increased
sodium
retention,
which
decreases
water
retention.
For further
management and
evaluation
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Fluid
restriction
may be used
to decrease
fluid intake,
hencedecreasing
fluid volume
excess.
17.The clientsenses thirst
because the
body senses
dehydration.
Oral care can
alleviate the
sensationwithout an
increase in
fluid intake.
18.Heart failure
causes venous
congestion,
resulting in
increased
capillary
pressure.
When
hydrostatis
pressure
exceeds
interstitial
pressure,
fluids leak out
of ht
ecpaillaries
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and present
as edema in
the legs, and
sacrum.
Elevation of
legs increasesvenous return
to the heart.
19.Inidicates
fluid overload
20.Focus is on
monitoring
the response
to the
diuretics,
rather than
the actualamount
voided
21.Treatmentfocuses on
diuresis of
excess fluid.
22.This helpsreduce
extracellular
volume.
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Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:
PainObjective:Patient
manifested:
(+) DOB
with a rate of
6 out of 10
with
complaints of
chest painunprovoked
Acute Pain The patient will
verbalize decrease
of pain.
1. Assess
patient pain
for intensity
using a painrating scale,
for location
and for
precipitating
factors.
2. Provide
comfort
measures.
3. Establish aquiet
environment.
4. Elevate head
of bed.
5. Monitor vital
signs,
especially
pulse and
blood
pressure,
every 5
minutes until
pain
subsides.
6. Teachpatient
relaxation
techniques
and how to
use them to
1. To identify
intensity,
precipitating
factors andlocation to
assist in
accurate
diagnosis.
2. To providenonpharmacolo
gical pain
management.
3. A quietenvironment
reduces theenergy demands
on the patient.
4. Elevationimproves chest
expansion and
oxygenation.
5. Tachycardia and
elevated blood
pressure usually
occur with
angina and
reflect
compensatory
mechanisms
secondary to
sympathetic
nervous system
stimulation.
6. Anginal pain is
For further
management and
evaluation.
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reduce
stress.
often
precipitated by
emotional stress
that can be
relieved non-
pharmacologicalmeasures such
as relaxation.
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