CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED COMPLICATIONS (ACUTE RENAL FAILURE)

8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED

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I. PATIENTS PROFILE

Name: Mr. A. R.

Age: 73

Sex: Male

Civil Status: Married

Religion: Roman Catholic

Address: Brgy. Manlocboc Aguilar, Pangasinan

Occupation: Farmer

II. CHIEF COMPLAINTS

The patient was experiencing Difficulty of Breathing (DOB) characterized by a heavy object on top of

his left chest with a scale of 7 over 10 as 10 being the highest. .

III. HISTORY OF PRESENT ILLNESS

Present condition started one hour prior to admission, patient is watching news at their home and

experienced sudden difficulty of breathing, as verbalize by the significant others and the patient stated

this kasla adda naka patong ditoy barukong ko su nga marigatan nak a aganges to the S.O. And he adds

that the client has a history of asthma and they think that it was the cause of difficulty of breathing.

Before it was mild and can relieve through rest but this time it was the time the client was not able to

tolerate the complaint so the family immediately refer it to the hospital.

IV. PAST MEDICAL HISTORY

The client is 73 years old, he suffers from asthma, and had his check ups only when severe

asthma attacks and was prescribed a medicine such as ventolin and salbutamol at the very young age but

despite of his condition he began to smoke five (5) sticks/day at the age of 20 and the S.O. claims that the

client used to drink occasionally. He loves to eat fatty foods and drink coffee 2 cups a day and doesnt

follow any special diet.

Year 2007 when the client first confined at a primary hospital in their town Aguilar, Mr. A. R.

was admitted and confined for more than a week because of difficulty in breathing and increased blood

pressure. They were advised to undergo ECG and Chest X-ray in Dagupan Doctors Villaflor Memorial

Hospital. The result was seen and interpreted by the cardiologist and was found out that Mr. A. R. has

enlargement of the heart. From then on, Mr. A.R visits his cardiologist twice a month and takes his

medicines as maintenance for his BP and heart religiously.

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V. SOCIAL AND ENVIRONMENTAL HISTORY

The client is a farmer, he started to work in their own rice field at the age of 18 and stop tending

their rice field at the age of 50. Basing from Ericksons developmental tasks theory, he is on late

adulthood. .According to the S.O. the client drinks occasionally and began to smoke five (5) sticks/day at

the age of 20.

Their house is well ventilated and was sited along the national road although it is expose to

smokes from vehicles which triggers his asthma.

VI. FAMILY HISTORY

The patients father was deceased by natural death. The mother was deceased with a history of

asthma and hypertension. They had 6 siblings; our patient was the 4

th

child. The first and second childwas deceased with an illness of hypertension. The 3rd and 5th child have no known illness inherited from

the parents and the last child is suffering from asthma. According to the S.O., other relatives from the

mother side are asthmatic and hypertensive and some relatives were past away with the same health

problem.

VII. PHYSICAL EXAMINATION

1. GENERAL SURVEY

The client is weak in appearance, with an ongoing IVF of D5NM 1L, conscious, was not able

to speak due to tracheostomy, needs assistance in moving, with a mechanical ventilator and with

NGT inserted at the right nostril. He can response to pain through withdrawing his left foot.

2. HEAD, EYES, EARS, NOSE, THROAT

a. HEAD

The clients head is symmetrical and no fracture observed.

b. EYES

The client cant able to open his left eyelid; his right pupil is dilated and reactive to light

at 2-3 mm. No tender mass upon palpation, lacrimal discharges were absent. Patient can only see

object place on his right and in front of him.

c. EARS

Ears are symmetrical, smooth in texture and are in the same color. No discharges were

noted. Patient responds to slow and loud instruction. Sense of hearing bilaterally is tested thru

watch ticking into the ear and hearing is intact as a result.

d. NOSE

Olfactory status was not properly assessed since test of each nostril separately was not

possible due to the presence of nasogastric tube on client right nostril. Small lesion noted around

the site where NGT was inserted.

e. THROAT

The throat was not proper assessed since the client has underlying tracheostomy.

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3. RESPIRATORY SYSTEM

Client breathes thru the help of mechanical ventilator on this following set up: FiO2:

30% TV: 450 BUR: 12 PF: 40

Rales or crackling sound is heard on inspiration upon auscultation on the left lung field. Oral

mucosa and lips are pale, no clubbing of finger nails noted. Thick yellowish, tenacious secretion

is evident upon suctioning. ABG study reveals: Metabolic Alkalosis Compensated - Ph = 7.5

PCO2 = 41.1 PO2 = 64.3 HCO3 = 32.2 B.E = 9.3 TCO2

= 33.5 O2Sat. = 84.1

4. CARDIOVASCULAR SYSTEM

The patients blood pressure ranges from 120/60 up to 160/60 mmHg at the left arm while

on lying position. Heart beat is irregular during periods of exertion and anxiety. ECG tracing

reveals occasional PVC and tachycardia. Heart murmurs are audible. Extremities are warm to

touch and peripheral pulses are present and palpable. Hemoglobin and hematocrit values are

relatively low. Jugular vein distention is present and all pulses are weak upon palpation.

5. GASTROINTESTINAL SYSTEM

The clients mean of feeding is through NGT due to the presence of tracheostomy,

enlargement of the abdomen noted.

6. GENITO-URINARY SYSTEM

The client eliminates via diaper and condom catheter. His urine output ranges from 500-

1000ml for 8hrs and has bowel movement twice a day with semi-solid and tarry stool. No bladder

distention upon assessment at the hypogastric region.

7. MASCULO- SKELETAL SYSTEM

The client is on complete bed rest without bathroom privileges and need assistance in

moving. Tingling sensation was noted upon asking the client to squeeze an examiners hands and

push his feet against a resistance. Client is not able to perform flexion, extension, abduction and

adduction independently because when he was instructed to stretch his upper and lower

extremities to and fro he was not able to do it by himself, thus he needs support in doing such.

8. INTEGUMENTARY SYSTEM

The client is slightly cyanotic in nail beds, with pale oral mucosa and palpebral

conjunctiva. Skin is dry and warm to touch. No lesion cracks and bruises noted. The client has ashort, dry gray hair. No dandruff and parasites observed. Nails are clean and well trimmed.

9. NERVOUS SYSTEM

Orientation of three areas (time, place and date) was limited due to his condition. Verbal

response is finite but thru gestures, facial expression as his way of interaction it was known that

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he is aware where he is, understand simple to complex instruction, able to write and read. It is

evident that intellectual development is appropriate on his age.

During the interview and assessment using GCS, client obtained a score of GCS 9 which

means client is lethargic. (EO: 4 V:1 M:4)

VIII. DIAGNOSTIC

DATE August 12,2009

DIAGNOSTIC

PROCEDURE

Chest AP

DESCRIPTION X rays are a form of radiation that can penetrate the body and produce an image

on an x-ray film. Another name for x ray is radiograph.

Consist of two views, the frontal view (referred to as posterioranterior or PA)and the lateral (side) view. It is preferred that the patient stand for this exam,

particularly when studying collection of fluid in the lungs.

PURPOSE Used to evaluate organs and structures within the chest for symptoms of

diseases. Chest x-ray include views of the lungs, heart, small portion of the GIT,

thyroid gland and the bones of the chest

IMPLICATIONS OF

THE FINDINGS

o There is a confluentdensity in the right peracardiac area and in the

right middle lung field.

- Indicates abnormal accumulation of fluid in the pericardiac area

and right middle lung which is to be consider as pneumonia.

o There is an irregular foreign body in the left midhemithorax.

- It may be an artifact or a bullet fragment.

o The heart is moderately enlarged. Aorta is atheromatous.

- Theres a fatty deposits on the inner walls of the aorta. This

narrows the passageway, and can become mineralized and

hardened.

- An enlarged heart may be caused by a thickening of the heart

muscle because of increased workload.o Blunted right costophrenic sulcus.

- It may be due to minimal pleural effusion.

DATE August 15,2009

DIAGNOSTIC

PROCEDURE

Chest AP

DESCRIPTION X rays are a form of radiation that can penetrate the body and produce an

image on an x-ray film. Another name for x ray is radiograph.

Consist of two views, the frontal view (referred to as posterioranterior or

PA) and the lateral (side) view. It is preferred that the patient stand for this

exam, particularly when studying collection of fluid in the lungs.

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thyroid gland and the bones of the chest area.

IMPLICATIONS OF

THE FINDINGS

o Follow-up examination after 3 days shows significant clearing of the

pneumonia in the right lung.

- Infiltrate has been cleared.

o The heart is enlarged to the same degree with LAE and LVE. There is

no pulmonary congestion.

- An enlarged heart may be caused by a thickening of the heartmuscle because of increased workload.

DATE August 17,2009

DIAGNOSTIC

PROCEDURE

Chest AP







diseases. Chest x-ray include views of the lungs, heart, small portion of the GIT,thyroid gland and the bones of the chest area.

IMPLICATIONS OF

THE FINDINGS

o Follow-up examination 2 days after the last study shows essentially the

same findings. The cardiac shadow is enlarged with apparent flask-

shaped configuration.

- May be due to the presence ofpericardial effusion is now considered.

o The lungs are hypoventilated. (Peak Flow increased to 30% on August 18,

2009).

- Due to reduced lung function. The body's carbon dioxide levelrises, which results in too little oxygen in the blood.

DATE Aug.25, 2009

DIAGNOSTIC

PROCEDURE

Chest AP








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IMPLICATIONS OF

THE FINDINGS

o Follow-up study since 17 August shows minimal haziness of the right

perihilar region wherein pneumonitis cannot be excluded. Clinical

correlation is recommended.

- Haziness likely represents layering of pleural effusion.o An endotracheal tube is still seen with its tip at the level of T3-T4.

- To ensure proper placement of the ET tube.

o There is cardiomegaly. Aorta is minimally tortuous and calcified.

- An enlarged heart may be caused by a thickening of the heart

muscle because of increased workload.

- The aorta has an irregular shape, contorted, and can affect blood

flow coming out of the heart and to the body tissues.

- Aorta is stiff due to calcium deposits in the artery wall which is

known as atherosclerosis. Aortic calcification is more common in

older patients and those with cardiovascular disease and high

cholesterol.

o Right hemidiaphragm appears elevated.

- May be due to atelectasis (lung collapse).

o The right costophrenic sulcus is blunt.

- To rule out minimal right pleural fluid and/or thickening.

o An opaque foreign body is noted in the left lower hemithorax

superimposed on the left cardiac shadow to be correlated clinically

- Presence of foreign body in the left lower hemithorax.

DATE Sept. 1, 2009

DIAGNOSTIC

PROCEDURE

Chest AP









IMPLICATIONS OF

THE FINDINGS

o Follow-up examination since August 25, 2009 now shows a tracheostomy

tube in place of the ET.

o Linear strands in the left lung base.

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- May be due to subsegmental atelectasis.

o The heart shadow is enlarged. Aorta is atheromatous.

- Theres a fatty deposits on the inner walls of the aorta. Thisnarrows the passageway, and can become mineralized and

hardened.- An enlarged heart may be caused by a thickening of the heartmuscle because of increased workload.

o There is a bulge in the right hilar area.

- May be due to prominent pulmonary artery.

o Elevated diaphragm. Minimal pleural effusion in the right is not ruled-

out.

- Still theres an excess fluid accumulation in the pleural cavity.

DATE Aug.19, 2009

DIAGNOSTIC

PROCEDURE

2D ECHO

DESCRIPTIONBased on detection of echoes produce by a beam of ultrasound passes

transmitted in to the heart.

PURPOSE Used for imaging the living heart

IMPLICATIONS OF

THE FINDINGS

o Eccentric left ventricular hypertrophy with multi segmental wall

motion.

- Abnormality consistent with coronary artery disease with post

myocardial infarction with depressed systolic function (EF 30-

35%).

o Dilated left atrium.

- Dilated left atrium may be due to mitral regurgitation.

o Aortic sclerosis with mild aortic regurgitation.

- Theres a calcification and thickening of an aortic valve in the

absence of obstruction of ventricular outflow but the valve doesn't

close properly, and blood can leak backward through it.

o Mild mitral regurgitation.

o Left ventricular thrombus noted.

- Left ventricular thrombus is the complications of myocardial

infarction (MI). Left ventricular thrombus is the major source

of embolic stroke after ST segment elevation myocardial

infarction.

DATE Aug.22-Sept.1, 2009

DIAGNOSTIC

PROCEDURE

CBC

DESCRIPTIONIs a series of test used to evaluate the composition and concentration of the

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cellular components of blood.

PURPOSE As a preoperative test to ensure both adequate oxygen carrying capacity and

hemostasis.

IMPLICATIONS OF

THE FINDINGS

WBC:

The WBC was relatively high due to pneumonia, as shown by the

graph; there was a slight drop on August 27 probably as result of

aggressive antibiotic regimen implemented on the patient. Apparently due

to long-term use of Mechanical Ventilator and the insertion of ET tube,

VAP was considered as the cause of the steady rise of WBC.

- A high count indicates not a specific disease by itself but indicates

infection, systemic illness, inflammation, allergy and leukemia, too

much of mental stress also increases the count of the white blood cells

in the body. Also, once the count of white blood cell is on the higherside, the risk of cardiovascular mortality also increases.

RBC:

- Low RBC counts are indicative of anemia and anemia can have many

causes, with our patient causes includes vitamin and iron deficiencies

andacute bleeding. Replacement of this component (RBC) is necessary

to increase the oxygen carrying capacity of blood.

HEMOGLOBIN:

- A low hemoglobin count indicates a low red blood cell count referred toas anemia. Hemoglobin levels can be resurrected by following a

balanced diet.

HEMATOCRIT:

- A low hematocrit is referred to as being anemic. An anemic person has

fewer or smaller than normal red blood cells. A low hematocrit,

combined with other abnormal blood tests, confirms the diagnosis.

DATE Aug.12-Sept 2, 2009

DIAGNOSTIC

PROCEDURE

Serum electrolytes

DESCRIPTIONAre positively and negatively charged molecules called ions, that are found

within the body cell and extracellular fluids including blood plasma.These ions

are measured to assess renal, endocrine and acid base function.

PURPOSE To measure the concentration of electrolytes are needed for both the diagnosis

and management of renal endocrine acid base balance and many concentration.

IMPLICATIONS OFTHE FINDINGS

Sodium:- Low blood sodium (hyponatremia) occurs when you have an

abnormally low amount of sodium in your blood or when you have an

excess of water in your blood. Low blood sodium is common in older

adults, especially those who are hospitalized or living in long term care

facilities

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Chloride:

- Hypochloremia is decreased serum chloride level and is usually related

to excess losses of chloride ion through the GI tract, kidneys, or

sweating. Hypochloremic clients are at risk for alkalosis and may

experience muscle twiyching,tremors or tetany.

- If you are dehydrated, your chloride level is increased and . if you are

overhydrated, your chloride level is decreased

Potassium:

Hyperkalemia

- Is a potassium excess or a serum potassium level greater than 5.3

meq/L. Hyperkalemia is less common than hypokalemia and rarely

occurs in clients with normal renal function. It is however, more

dangerous than hypokalemia and can lead to cardiac arrest.

Hypokalemia

- Is a potassium deficit or a serum potassium level of less than 3.4 meq/L.

DATE Aug. 23 and Sept 24, 2009

DIAGNOSTIC

PROCEDURE

BUN

DESCRIPTIONMeasure amount of nitrogen in the blood that comes from the waste product

urea.

PURPOSE It is done to see how well the kidneys are working.

IMPLICATIONS OF

THE FINDINGS

- A BUN test is done to see how well your kidneys are working. If your

kidneys are not able to remove urea from the blood normally, your

BUN level rises.

- Heart failure, dehydration, or a diet high in protein can also make your

BUN level higher.

DATE Aug.20 -Sept.1, 2009

DIAGNOSTIC

PROCEDURE

Creatinine

DESCRIPTIONImportant compound produced by the body, it combines with phosphorus to

make high energy phosphate compared in the body

PURPOSE Use to diagnose impaired kidney function and to determine renal damage

IMPLICATIONS OF

THE FINDINGS

- High creatinine occurs with sudden (acute) kidney failure, which may

be caused by conditions such as shock or severe dehydration.

- As the kidneys become impaired for any reason, the creatinine level inthe blood will rise due to poor clearance by the kidneys. Abnormally

high levels of creatinine thus warn of possible malfunction or failure of

the kidneys.

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IX. MEDICAL DIAGNOSIS

CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY

DISEASE- MYOCARDIAL INFARCTION

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X. Comprehensive Pathophysiology

ETIOLOGY OF CONGES HEART FAILURESECONDARY to CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION

and RELATED COMPLICATIONS (ACUTE RENAL FAILURE)

old myocardial infarction

left atrial pressure

rupture of chordae tendeneae LEFT-SIDED HEART FAILURE

mitral valve regurgitationaortic valve regurgitation/stenosis

Blood dams back into stroke volume enlargement of the chambersthe pulmonary capillary bed of the heart

Pressure of blood into tissue perfusionthe pulmonary capillary altered normal

bed increases ( dyspnea ) electrical pathway

cellular blood flow to

PULMONARY EDEMA hypoxia the kidneys ARRHYTHMIAS

prolonged renal ischemia

ACUTE TUBULAR NECROSIS/ACUTE RENAL FAILURE

l

Failure of kidneys inability of the excretion of Na reabsorptionto produce kidneys to nitrogenous in tubules

erythropoietin metabolize wastesVit. D

Anemiahypocalcemia uremia water

retention

edema/ascites

Azotemia Stomatitis and GI renal encephalopathy accumulationbleeding of wastes

on skin

CNS changes

coffee-ground NGT aspirate lethargy pruritus

11 force of RVcontraction

residual blood ofthe RV at the timeof diastole

RV

preload

blood backflowsfrom RV to RA

Coronary ArteryDisease

Pulmonary EdemaSigns and Symptoms:Dyspneaparoxysmal nocturnalorthopnearales / crackles / wheezesmoist coughblood-tinged frothy sputumdizzinesssyncopefatigueweaknessanorexiaclubbing fingers

pulses alternansS3 and S4 heart sounds

pulmonary vascularresistance

RV contraction

force of RVcontraction

RV Hypoxia

RV oxygen demand

RIGHT SIDED HEARTFAILURE

heart damageventricular overload

ventricular contraction

myocardial contractility cardiac workload diastolic filling

Hyperventilation, headache, cyanosis,dizziness, Fatigue, drowsiness,

unconsciousness, paresthesias, tingling

Tingling

Risk Factors:HypercholesterolemiMen (>45 years old)Women (>55 years old)Cigarette smokingAlcoholismDiabetes mellitusObesity

Physical inability sodium intakeHereditary

Predisposing Factors:HypertensionCAD

Fatigue , weakness, fainting,

breathlessness, palpitations, dizziness,

headache, tinnitus, difficulty sleeping,

difficulty concentrating, palecomplexion, tachycardia

Palpitations, tachycardia, irregularheartbeat, anxiety, weakness,

dizziness, lightheadedness, faintingor nearly fainting, sweating,

shortness of breath, chest pain

Hypotension , pulses weak,Diarrhea, abdominal pain,Nausea/vomiting, muscle

spasms, anxiety


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RA pressure

RA preload

blood backflows fromRA to systemic

circulation venous pressureJVD

fluid moves into theinterstitial space

due to retention offluid

(07/23/08

Peripheral edema

Signs and Symptoms:

liver congestion, ascites,weakness, weight gaindue to retention of fluid


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XI. TREATMENT AND MANAGEMENT

a. Drug study

TRADE AND GENERIC

NAME

CLASSIFICATION MECHANISM OF

ACTION

SIDE EFFECTS NURSING INTERVENTIONS

Trade Name:

Furoscan

Generic name:

Furosemide

diuretics A potent loop diuretic

that inhibits sodiumand chloride

reabsorbtion at theproximal and distal

tubules and theascending loop of

Henle.

CNS: vertigo, headache,

dizziness, weakness,restlessness.

CV: orthostatic hypotensionGI: abdominal discomfort and

pain, diarrhea, anorexia, nausea,constipation, pancreatitis

HEMATOLOGIC: anemia,METABOLIC: dehydration,

hypokalemia, fluid andelectrolyte imbalance, including

dilutional hyponatremia,hypocalcemia, and

hypomagnesemia,hyperglycemiaand impaired

glucose tolerance

Monitor fluid intake and output

and electrolyte, BUN, andcarbon dioxide frequently.

Watch for signs ofhypokalemia, such as muscle

weakness and cramps. Monitor elderly patients, who

are especially susceptible toexcessive diuresis, because

circulatory collapse andthrombo-embolic complication

are possible.

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TRADE AND

GENERIC NAME


ACTION

SIDE EFFECTS NURSING

INTERVENTIONS

Trade Name:Lanoxin

Generic name:Digoxin

Anti-arrythmic Inhibits sodiumpotassium activated

adenosinetriphosphatase,

thereby promotingmovement of calcium

from extra cellular tointra cellular

cytoplasm and strengthening myocardial

contraction. Also actson CNS to enhance

vagal tone, slowingconduction through

the SA Node to AVnodes and providing

an anti arrhythmiceffect.

CNS: Fatigue, generalizedmuscle weakness, agitation,

hallucination, headache, malaise,dizziness, vertigo, stupor,

paresthesia.CV: arrhythmias

EENT:blurred vision, lightflashes, photophobia, diplopia

GI: anorexia, nausea, vomiting,diarrhea.

Before giving loading dose ,obtain base line data (heart rate

and rhythm, blood pressure,and electrolytes) and ask

patient about use of cardiacglycocides within the previous

2 to 3 weeks.

Before giving drug , take

apical-radial pulse for 1 minute.Record and notify the

prescriber of significant(sudden increase or decrease in

pulse rate, pulse deficit,irregular beats and particularly,

regularization of a previouslyirregular rhythm). If this occur,

check blood pressure andobtain a 12 lead ECG.

Toxic effects on the heartmaybe life-threatening and

require immediate attention.

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TRADE AND GENERIC

NAME


ACTION

SIDE EFECTS NURSING

INTERVENTIONS

Trade Name:Dobutrex

200mg/250ml

Generic name:

Dobutamine

hydrochloride

Adrenergic Directly stimulatesbeta1 receptors of

heart to increasemyocardial

contractility andstroke volume. At

therapeutic dosages,drug decreases

peripheral vascularresistance (afterload),

reduces ventricularfilling

pressure( preload),and may facilitate

AV node conduction .

CNS: HeadacheCV: Increase heart rate,

hypertension, pvcs , angina.Palpitation. hypotension

GI: nausea/ vomitingRespiratory: shortness of

breath, asthmatic episodes

Monitor potassium levelcarefully. Take corrective

action before hypocalemiaoccurs.

Monitor digoxin level.Therapeutic level ranges from

0.8-2 mg per ml. obtain bloodfor digoxin level at least 6-8

hrs after last oral dose,preferably just before next

scheduled dose.

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TRADE NAME AND

GENERIC NAME

CLASSIFICATION

MECHANISM OF

ACTION


Trade Name:lLgnonex

Generic Name:

Lidocaine hydrochloride

Anti-arrythmic A class IB antiarrhythmic that

decreases thedepodalization,

automaticity, andexcitability in the

ventricles during thediastolic phase by

direct action on thetissues, especially the

purkinje network.

CNS: ligthheadedness,confusion, tremor, lethargy,

restlessness, anxiety, seizures.CV: Hypotension,

bradycardia, new or worsencardiac arrythmias, cardiac

arrest.GI: vomiting

Respiratory: Respiratorydepression and arrest.

Give IM injections in thedeltoid muscle only.

Monitor isoenzymes when usingIM drug for suspected M.I.

lidocaine will show a sevenfoldincrease in C and K level. Such an

increase originates in the skeletalmuscle, not the heart.

Monitor drug level. Therapeuticlevels are 2-5 mcg per ml.

Monitor patients response,especially blood pressure and

electrolytes, BUN, and creatininelevels .notify prescriber promptly

if abnormalities develop.

If arrhythmias worsen or ECG

changes (for example, QRScomplex widens or P.R interval

substantially prolongs), stopinfusion and notify physician.

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TRADE NAME

AND GENERIC

NAME


ACTION


Trade Name:Xylocaine

Generic Name:

Gentamicine sulfate

Aminoglyciside Inhibits proteinsynthesis by binding

directly to the 30Sribosomal subunit.

Usually bactericidal.

CNS: seizure, dizziness,headache, encelopathy,

confusionCV: hypotension

GU: nephrotoxicity, possibleincrease in urinary excretion

of casts.Respiratory: apnea

GI: vomiting, nauseaHematologic: leucopenia,

thrombocytopenia,agranulocytosis

Musculoskeletal: muscletwitching, myasthenia

gravis-like syndrome

Obtain specimen for culture andsensitivity test before giving first dose

period. Therapy may begin whileawaiting results.

Evaluate patients hearing before andduring therapy. Notify physician if

patient complains of tinnitus, vertigo, orhearing lost.

Weigh patient and review renalfunction studies before therapy begins.

Obtain blood for peak gentamicinlevel one hour after IM injection for 30

minutes after IV infusion finishes; fortrough levels, draw blood just before

next dose. Dont collect blood in aheparinized tube; heparin is

incompatible with amino glycosides

Monitor renal function: urine output,specific gravity, urinalysis, BUN and

creatinine clearance. Report toprescriber evidence of declining renal

function.

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TRADE NAME AND

GENERIC NAME


ACTION


Trade name:

Toprol

Generic name:Metoprolol succinate

antihypertensive Unknown. A selective

beta blocker thatselectively blocks

beta1- adrenergicreceptors; decreases

cardiac output,peripheral resistance,

and cardiac oxygenconsumption; and

depresses renninsecretion.

CNS: fatigue, dizziness,

headache, depressionCV: hypotension, bradycardia,

heart failure, AV blockRespiratory: dyspnea

GI: diarrhea, nausea

Always check patients

apical pulse rate when beforegiving drug. If its slower than

60bpm. Withhold drug and callphysician immediately.

Monitor blood pressurefrequently; metropolol masks

common signs and symptomsof shock.

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b. IV Fluids

COMPONENT CLASSIFICATION EFFECTS/ USES SIGNIFICANCE

D5W ISOTONICo Used to supply water and calories to

the body

o Adult I.V. solution to keep vein open

o Vehicle for mixing medications for

I.V. delivery for all age groups.o May be a primary adult I.V. fluid for

medical emergencies

o Provides calories for some metabolic

needs.

o Supplies body water for hydration

o Spares body protein by providing

carbohydrate for metabolism.o Capable of producing diuresis depending

on clinical state of the patient.


D5NM ISOTONICo For long-term parenteral nutrition in

acute and chronic renal insufficiencyand in haemofiltration and peritoneal

and haemodialysis.

o Provides water and electrolytes with

carbohydrate calories for replacementof acute extracellular fluid losses

without disturbing normal electrolyterelationships

o For replacement of acute extracellular

fluid losses without disturbing normalelectrolyte relationships.

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Dextrose D 50% HYPERTONICo Is used in emergency care to treat

hypoglycemia and to manage coma ofunknown origin.

o Primary carbohydrate fuel used in the

body.

COMPONENT CLASSIFICATIO

N

EFFECTS/ USES SIGNIFICANCE

PNSS contains 154 mEq/L

of Na+ and Cl.

ISOTONICo Used to replace fluids in dehydration

o Used frequently in intravenous drips

(IVs) for patients who cannot take

fluids orally and have developed orare in danger of developing

dehydration or hypovolemia

o Used to replace fluids in dehydration,

go with blood transfusions,hyponatremia, and burn victims, it is

isotonic,( same osmolarity as our bodyfluids

o Replacement & maintenance of fluid &

electrolytes.

o Restores the blood volume rapidly.

o The first fluid used when hypovolemia is

severe enough to threaten the adequacy of

blood circulation and has long beenbelieved to be the safest fluid to give

quickly in large volumes.

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XII. NURSING DIAGNOSIS

ACTUAL PROBLEM 1:IMPAIRED GAS EXCHANGE RELATED TO VENTILATION PERFUSION IMBALANCE AS MANIFESTED BY INCREASE IN CARDIAC RATEAND RESPIRATION, RESTLESSNESS, AND SHORTNESS OF BREATH.

ASESSSMENT EXPLANATION

OF THE

PROBLEM

PLANNING NSG.

INTERVENTION

RATIONALE EVALUATION

OBJECTIVE:

Increased

cardiac rate(PR- 160 bpm)

Restlessness/changes in

mentation

Shortness of

breath

Increased

respiratory rate(RR=32per min)

The rise inpulmonary, venous

and capillary

pressureprecipitates

movement of fluidfrom the capillaries

in to theinterstitium and

alveolar spaces.Excessive

interstitial fluidaccumulation

prevents theexchange of gas

back and forthbetween alveoli

and blood.

STO:

After 24 hrs of

nursingintervention, the

patientssymptoms of

respiratorydistress will be

lessened

INDEPENDENT

Auscultated breath

sounds noting crackles,wheezes.

Assessed respiratoryrate, depth and ease; use

of accessory muscles.

Instructed patient in

effective deep breathing.

Reveals presence of pulmonary

congestion/ collection ofsecretions indicating need for

further intervention.

Hypoventilation (pleuritic pain/abdominal distention), pleural

effusion/ alveolar edema, and

incomplete airway clearance(general weakness/ fatigue and

pain) impair gas exchange,resulting in respiratory

insufficiency/ distress.Manifestations are dependent on

degree of lung involvement and

underlying pulmonary generalhealth status.

Clears airway and facilitates

oxygen delivery.

STO met.

Ventilation and

oxygenation isadequate for

individual needs.

Patient

demonstratesease of breathing

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NURSING

DIAGNOSIS:

IMPAIRED GAS

EXCHANGERELATED TO

VENTILATIONPERFUSION

IMBALANCE AS

MANIFESTED BYINCREASE INCARDIAC RATE

ANDRESPIRATION,

RESTLESSNESS,AND SHORTNESS

OF BREATH.

Encourage frequent

position changes.

Maintained bed rest in

Semi-Fowlers position.

Observed color of skin,

mucus membranes,

nailbeds, noting presenceof peripheral (nailbeds)

cyanosis.

Assessed mentalstatus.

>Monitored heart rate/

rhythm.

Monitored bodytemperature, as

indicated. Providedcomfort measures to

reduce fever and chills,

e.g.,addition/ removal ofbed covers/ blankets,

comfortable roomtemperature, tepid or cool

water sponges.

Reduces oxygen consumption/demands and promotes maximal

lung inflation.

Cyanosis of nailbeds may

indicate vasoconstriction or bodyresponse to fever/ chills.

Restlessness, irritaion,confusion may reflect

hypoxemia/ decreased cerebraloxygenation.

Tachycardia is usually presentas a result of fever/ dehydration

but may represent a response tohypoxemia.

High fever (common inpneumonia) greatly increases

metabolic demands and oxygenconsumption, and alters

oxyhemoglobin curve reducingcellular oxygenation.

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Maintained bed rest.

Elevated head andencourage frequent

position changes anddeep breathing.

Assessed level ofanxiety, stayed with

patient.

Observed for

deterioration in condition,noting decrease in BP,

copious amount of pink/

bloody secretion, pallor,cyanosis, change in level

of consciousness, severeDOB, restlessness.

COLLABORATIVE

Monitored serial ABGs.

Prevents over exhaustion andreduces oxygen consumption/

demands and energy needs to

facilitate resolution of infection.

These measures promotemaximal inspiration, enhance

expectoration of secretions toimprove ventilation.

Anxiety is a manifestation ofpsychologic concerns as well as

physiologic response to hypoxia.Providing reassurance,

enhancing sense of security canreduce the psychologic

component, thereby decreasing

oxygen demand and adversephysiologic response

Shock and pulmonary edema

are the most common causes ofdeath in pneumonia and require

immediate medical intervention.

May show severe hypoxemiaduring acute pulmonary edema

or reveal compensatory changes

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Administered

supplemental oxygen as

indicated.

Administered

medications as indicated.- Diuretics

- Bronchodilators

in chronic CHF.

Increases alveolar oxygen

concentration and may enhance

arterial oxygenation to correct/reduce tissue hypoxemia.

Reduces alveolar congestion,

enhancing gas exchange.

Increases oxygen delivery by

dilating small airways and exertsmild diuretic effect to aid in

reducing pulmonary congestion.

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ACTUAL PROBLEM 2:DECREASED CARDIAC OUTPUT RELATED TO ALTERED HEART RATE/RHYTHM AS EVIDENCED BY INCREASED HEARTRATE/DYSRRYTHMIAS, CHANGES IN BLOOD PRESSURE, EXTRA HEART SOUNDS AND DECREASED URINE OUTPUT.

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26

ASSESSMENT EXPLANATION OF

THE PROBLEM

PLANNING NSG.

INTERVENTION


OBJECTIVE:

Increased heart

rate (PR- 160

bpm)

Decreased urineoutput

200 cc/ day

Diminished

peripheral pulses

Cool skin,

excessivesweating

breathes betterwhen in upright

position, cracklesnoted

jugular veindistension, edema

NURSINGDIAGNOSIS:

DECREASED

CARDIAC OUTPUTRELATED TO

ALTERED HEART

RATE/RHYTHM ASEVIDENCED BYINCREASED

HEART RATE /DYSRRYTHMIAS,

CHANGES IN

BLOODPRESSURE,

EXTRA HEARTSOUNDS AND

DECREASED

URINE OUTPUT.

When failure first begins,

the left ventricle fails toeject its full quota of

blood. At this point, the

compensatorymechanisms of

sympathetic nervoussystem activation

(tachycardia, dilation andhypertrophy) occur. When

this mechanism fail, theamount of blood

remaining in the leftventricle t the end of

diastole increases thisincrease in residual blood

in turn decreases theventricles capacity to

receive blood from theleft atrium. The left

atrium having to work

harder to eject blooddilates and hypertrophies.

It is unable to receive thefull amount of incoming

blood from the pulmonary

vein and left atrialpressure increases. The

workload of themyocardium greatly

increases with abnormalloading of the

ventricles. While an

increase in preloadusually precipitates anincrease in myocardial

contractility (Starlingslaw), filling pressures may

rise beyond thecapabilities of the

normally compliant heart.Suddenly or overtime,

this expansion in preloadlessens the force and

efficiency of ventricular

STO:

After 24 hrs. ofnursing

intervention, the

pt. will be able todisplay vital

signs withinacceptable limits,

absence ofirregular heart

rhythm orcontrolled

episodes of DOB.

INDEPENDENT

Assessed, monitored

and recorded heart

rate and rhythm.

Palpated peripheral

pulses.

Monitored blood

pressure.

Inspected skin forpallor, cyanosis, and

excessive sweating.

Monitored urine

output, notedfluctuations of/

decreasing output anddark/ concentrated

urine

Assessed level of

consciousness.

Tachycardia is usually

present even at rest to

compensate for decreased LVcontractility. PVCs, PACs, and

AF are common dysrrythmiasassociated with CHF, although

others may also occur.

Decreased cardiac output

may be reflected in diminishedradial, popliteal, dorsalis pedis

and posttibial pulses. Pulses

may be fleeting or irregular topalpation, and pulsus alternans(strong beat alternating with

weak beat) may be present.

In early, moderate or chronic

CHF, BP may be elevated dueto increased SVR. In advanced

CHF, the body may no longerbe able to compensate and

profound/ irreversible

hypotension may occur.

Indicative of diminishedperipheral perfusion secondary

to decreased /inadequatecardiac output. Cyanosis may

develop in refractory CHF.

Dependent areas are often blue

or mottled as venouscongestion increases.

Kidneys respond to reduce

cardiac output by retainingwater and sodium.

May indicate inadequate

cerebral perfusion secondary to

The goal met

since the vital

signs of the clientis within normal

range, absenceof irregular heart

rhythm orcontrolled and

episodes of DOB

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ACTUAL PROBLEM No. 3 : EXCESS FLUID VOLUME RELATED TO COMPROMISED REGULATORY MECHANISM AND SODIUM RETENTION AS MANIFESTEDBY DECREASE URINE OUTPUT, EDEMA, JUGULAR VEIN DISTENTION AND INCREASED BLOOD PRESSURE

ASSESSMENT EXPLANATION

OF THE

PROBLEM

PLANNING NSG.

INTERVENTION


OBJECTIVE:

Decreased urineoutput

(200 cc/ day)

Edema, jugularvein distention

Increased bloodpressure

(BP=160/90)

Respiratory

distress, abnormalbreath sounds

breathes wellwhen in upright

position

As cardiac output falls,decrease renal blood

flow causes oliguria. Ifrenal artery pressure

falls, lowered

glomerular filtrationincreases retention of

sodium and water. Inresponse to a

continued productionin renal blood flow, the

rennin- angiogenesis-aldosteron mechanism

activates. The adrenalcortex released

aldosteron, promotesfurther retention of

sodium and water by

the renal tubule thisresults in anexpansion in blood

volume of up to 30%

and edema. As the

STO:

After 24 hrs ofnursing

intervention, the

patient willdemonstrate

stabilized fluidvolume with

balanced intakeand output, breath

sounds clearing,vital signs within

acceptable range,edema reduced.

INDEPENDENT

Monitored urine output,noting amount and color.

Monitored/ calculated 24-hour intake and output

balance.

Maintained bed rest insemi-Fowlers position.

Assessed for distendedneck and peripheral

vessels. Inspected

dependent body areas foredema with/without pitting;

Urine output may bescanty and concentrated.

Diuretic therapy mayresult in sudden/

excessive fluid loss(hypovolemia) even

though edema/ ascitisremains.

Recumbency increasesglomerular filtration and

decreases production ofADH, thereby enhancing

diuresis.

Excessive fluidretention may be

manifested by venous

engorgement and edemaformation. Peripheral

STO met since the

patients:

serum electrolytes

are within normal

limits.

Peripheral pulses arepalpable.

Peripheral edemanot present

Skin appearshydrated.

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NURSINGDIAGNOSIS:

EXCESS FLUIDVOLUME RELATED

TO COMPROMISEDREGULATORY

MECHANISM ANDSODIUM RETENTION

AS MANIFESTED BY

DECREASE URINEOUTPUT, EDEMA,JUGULAR VEIN

DISTENTION ANDINCREASED BLOOD

PRESSURE

sodium concentration

in the extracellularfluid increases, the

osmotic pressure of

the plasma alsoincreases. The

hypothalamusresponse to the higher

osmotic pressure byreleasing ADH from

posterior pituitary.

This promotes renaltubular reabsorption of

water

noted presence of

generalized body edema(anasarca).

Changed position

frequently. Elevated feet.Inspected skin surface,

kept dry and providedpadding as indicated.

Auscultated breath

sounds, noting decreasedand/or adventitious sounds,

e.g., crackles, wheezes.

Investigated suddenextreme DOB air hunger,

sitting straight up,

sensation of suffocation,feelings of panic.

edema begins in feet/

ankles (or dependentareas), and ascends as

failure worsens. Pitting

edema is generallyobvious only after

retention of at least 10 lbof fluid.

Edema formation,

slowed circulation,

altered nutritional intakeand prolonged

immobility/ bed rest arecumulative stressors

affecting skin integritywhich require close

supervision andpreventive interventions.

Fluid volume excessoften leads to pulmonary

congestion. Symptoms ofpulmonary edema may

reflect left acute heartfailure.

May indicatedevelopment of

complications

(pulmonary edema/embolus) and differsfrom othopnea and

paroxysmal nocturnaldyspnea in that it

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Monitored bloodpressure.

Provided small, frequenteasily digestible meals.

Noted increased lethargy,hypotension, muscle

cramping.

COLLABORATIVE

Administered medications

as indicated:

- Diuretics

develops much more

rapidly and requiresimmediate intervention.

Hypertension suggestsfluid volume excess and

may reflect developing/increasing pulmonary

congestion, heart failure.

Reduced gastric

motility can adverselyaffect digestion and

absorption. Smallfrequent meals may

enhance digestion/prevent abdominal

discomfort.

Signs of potassium

and sodium deficits thatmay occur due to fluid

shifts and diuretictherapy.

Increases rate of urineflow and may inhibit

reabsorption of sodium/

chloride in the renaltubules.

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- Potassium supplements

Maintained fluid/ sodium

restrictions as indicated.

Monitored chest x-ray.

Potassium wasting is acommon side effect of

diuretic therapy which

can adversely affectcardiac function.

Reduces total bodywater/ prevents fluid re-

accumulation.

Reveals changes

indicative of increased/resolution of pulmonary

congestion.

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POTENTIAL PROBLEM NO. 1: RISK FOR IMPAIRED SKIN INTEGRITY RELATED TO PROLONGED PHYSICAL IMMOBILIZATION.

ASSESSMENT EXPLANATION

OF THE

PROBLEM

PLANNING NSG. INTERVENTION RATIONALE EVALUATION

OBJECTIVE:

Bed ridden

With limited

mobility

Weak inappearance

Needassistance

when moving

NURSINGDIAGNOSIS:

RISK FOR IMPAIRED

SKIN INTEGRITYRELATED TO

PROLONGED

PHYSICALIMMOBILIZATION.

Immobilityimpedes

circulation and

diminishes thesupply ofnutrients to

specific areas, asa result skin

breakdown andformation of

pressure ulcerscan occur. The

skin can atrophyas a result of

prolongedimmobility. Shifts

in body fluidsbetween the fluid

compartmentscan affect the

consistency and

health of thedermis and

subcutaneous

tissues in the

STO:

After 8 hours ofnursing

intervention, thepatient will

demonstrate

behaviors ortechniques to

prevent skinbreakdown and

ulceration.

LTO:

After 2-3 days of

nursingintervention, the

patient will preventthe occurrence of

skin ulcers.

INDEPENDENT

Assess skin daily. Note

color, turgor, circulation and

sensation. Describe lesionand observed changes.

Maintain good skinhygiene, e.g. wash

thoroughly, pat drycarefully, and massage with

lotion or appropriate creamas indicated.

Reposition frequently.

Protect bony prominenceswith pillows.

Massage bony surfacesespecially that patient issedentary in bed.

Establishes baseline

with which changes in

status can be compared,and appropriateinterventions instituted.

Maintaining clean, dryskin provides a barrier to

infection. Patting skin dryinstead of rubbing reduces

risk of dermal trauma todry/ fragile skin.

Massaging increasescirculation to the skin and

promotes comfort.

Reduces stress on

pressure points andpossibility of ulceration/

decubiti.

Increase circulation toall skin areas limitingtissue ischemia/ effects of

cellular hypoxia.

STO:

After 8 hours ofnursing interventions,

goal met if the clientdemonstrate behaviors

or techniques to

prevent skinbreakdown and

ulceration.

LTO:

After 2- 3 days of

nursing interventions,LTO met if the patient

will display noulceration and

maintains skinintegrity.

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dependent partsof the body,eventually

causing a gradual

loss in skinelasticity.

Assist with active orpassive range of motion

exercises.

Maintain clean, dry,

wrinkle-free linen.

Cleanse perianal area.

Remove stool with waterand soap and mineral oil.

Avoid use of toilet paper.Apply protective creams,

e.g. zinc oxide.

COLLABORATIVE

Use protective devices,

e.g., egg-crate, heel/elbowprotectors, and pillows as

indicated.

Promotes circulation;prevents stasis.

Skin friction caused by

wet or wrinkled sheetsleads to irritation and

potentiates infection.

Prevents maceration

caused by diarrhea andkeeps perianal lesions dry.

Note: Use of toilet papermay abrade lesions.

Avoids skin breakdown

by preventing/ reducingpressure against skin

surfaces.

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POTENTIAL PROBLEM NO. 2: RISK FOR ASPIRATION RELATED TO PRESENCE OF TRACHEOSTOMY.

ASSESSMENT Explanation of

the problem

PLANNING NSG. INTERVENTION RATIONALE EVALUATION

OBJECTIVES:

impairedswallowing

presence of

tracheostomy aggressivenessto lie down after

NGT feeding

NURSING

DIAGNOSIS:

RISK FORASPIRATION

RELATED TOPRESENCE OF

TRACHEOSTOMY

Client was not able

to swallow and so

tracheostomy wasdone. Client is at

risk of aspiration

due to the presenceof tracheostomy

because theres apossibility for entry

of gastrointestinalsecretions,

oropharyngealsecretions, or solids

or fluids intotracheobronchial

passages.

STO:

After 8 hours ofnursing intervention,

the client will

experience noaspiration as

evidenced bynoiseless

respirations; clearbreath sounds,

clear, odorlesssecretions

LTO:

After 24 hours of

nursing intervention,patients risk of

aspiration isdecreased as a

result of ongoingassessment and

daily intervention.

Independent:

Auscultate lung sounds

frequently

Observe for neck and

facial edema

Monitor level ofconsciousness

Avoid keeping clientsupine or flat when on

mechanical ventilation(especially when also

receiving enteral feedings).

Assess for residual foodin mouth after eating

To determine

presence ofsecretions/silent

aspiration

Client with neck

opening, tracheal/bronchial injury is at

particular risk for airwayobstruction and inability

to handle secretions.

A decreased level of

consciousness is a primerisk factor for aspiration.

Supine positioning andenteral feedings have

been shown to beindependent risk factors

for the development ofaspiration pneumonia

Pockets of food can beeasily aspirated at a latertime.

STO:

Goal met if after 8hours of nursing

intervention, the client

will experience noaspiration as

evidenced by noiselessrespirations; clear

breath sounds, clear,odorless secretions

LTO:

Goal met if after 24

hours of nursingintervention, patients

risk of aspiration isdecreased

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Ascertain that feeding

tube is in correct position.Measure residuals at

appropriate period

Prevents overfeedingand risk of aspiration

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XIII. DISCHARGE PLAN

CRITERIA HEALTH TEACHINGS

a. Diet Limit the amount of sodium (salt) in your diet to less than

2,000 mg. each dayo Dont add salt while youre cooking or at the table .o Avoid processed foods like lunch meats and canned

soups .

o Check food labels for sodium content.

o Talk with your doctor or a dietitian before using saltsubstitutes.

o Ask your doctor how much liquid you can drink each

day. You may have to limit the amount of liquidsyou drink.

o Eat a balanced diet that is low in fats and cholesterol.

b. Activities Weigh yourself every morning after you go to the bathroom.

Use the same scale and weigh yourself in the same type ofclothing each day.

Plan rest periods during the day to allow your heart to regain

strength for the next activity. Once your symptoms begin to go away, start light exercise

walking or chair exercises to help strengthen muscles. (Do

not exercise when you have severe symptoms). If you feel tired, have chest pain or are short of breath,

immediately stop what you are doing and rest. Put your feet up every few hours to avoid swelling in your legsand ankles.

Get enough rest at night.

Do not smoke!

c. Medications Take all your medications as prescribed by your doctor.

Keep a list of your medications with you at all times.

If you have questions or concerns, call your doctor

o Do not stop or change the dose of any of your

medications without first talking with your doctor.o Do not take any new medications including

vitamins, over-the-counter medications or herbal

remedies without first talking with your doctor.

XIV. Conclusions and Recommendations:

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The case is focused on the importance of precipitating factors that could lead to

complicated diseases.

The group recommends that during any health teachings, they should emphasize

on the importance of seeking medical advice when feeling not good. With these,

complicated diseases should be minimized or prevented as well.

Furthermore, the group would like to emphasis to these nurses that proper health

teaching to the client with the same situation and those similar needs. Health teachings

are very important for the patient and his significant others for them to understand and

realize that cooperation is very important in the prevention of disease and improvement

of his status

XV. List of References

1. Books

a.) Pathophysiology by Catherine Paradiso (2nd edition)

b.) Medical surgical nursing by Luckmann and Sorensen ( 3rd edition)

c.) Understanding Pathophysiology by Sue E. Huether and Kathryn L. McCance

(2nd edition)

d.) Nurses Pocket Guide by Doenges (11th edition)

e.) Drug hand book by Lippincott

f.) Anatomy and Physiology by Tortora

g.) Anatomy and Physiology by Seeley, et al.

h.) Fundamentals of Nursing by Kozier,

2. Websites

a. http://www.bannerhealth.com/NR/rdonlyres/8AF826C6-6BCD-4246-8DB8-8919D3E3CCDC/18039/DischargeCHF.pdf

b. http://www.imedix.com/congestive_heart_failure

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XVI. APPENDICES

A) Interview Guide

University of the CordillerasCollege of Nursing

CASE PRESENTATION FORMATSY 2009-2010

I. General Profile/Information-name, age, sex, marital status occupation, address,

religion

II. Chief Complaint/s- main complaint of the patient why s/he seek consultation and

hence, admitted.

III. History of present illness (seek the interviewer guide)

a. Complaint/s

b. Duration

c. Domain/ localization

d. Progression

e. Character

f. Relation to physiological function- what is the effect of posture? Are

symptoms worse when the patient is walking/ lying?

Note: Interview guide (Holloway,2004) to expound the HPI

. 1. Statement of the general health before illness. how have you been feeling

before the problem started?

2. Date of onset. When did this start?

3. Characteristics at onset. what was this like when this started?

4. Severity of symptoms. how would you rate the pain on a scale of 1-10, with 1

being the worst?

5. Course since onset. How often does the attack or the pain occur? ( once only,

daily, intermittently, continuously) and and have the symptoms changed since

the first attack?

6. Associated s/s. Have you noticed any other changes in your health or the way

you feel?

7. Aggravating or relieving factors. Is there anything that seems to make you

feel better or worse? Do you feel better or worse at certain times of the day?

8. Effect on activities. Has this stop you from going to work or kept you awake?

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9. Treatments tried and results. have you ever taken any medications or tried any

treatments? If so, what happened when you took the medication or after the

treatment?

In addition it is helpful to ask :

What do you think caused this problem? The patient may actually know the

cause but hesitate to reveal it for numerous reasons; for example, s/he may

have feelings of guilt regarding the cause of illness.

Is anyone else in the household sick?

IV. Past medical history ( Narrative form)

V. Social and environmental history (Narrative form)

VI. Family history (Narrative form)

VII. Physical examination

VIII. Diagnostics

IX. Medical diagnosis- final or principal diagnosis

X. Comprehensive Pathophysiology and Management

XI. Treatment and Management

XII. Nursing Diagnosis

XIII. Discharge Plan

XIV. Conclusions and Recommendations

XV. List of References

XVI. Appendices

40

Documents

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