Pamantasan ng Lungsod ng Pasig Alcalde Jose St.

, Kapasigan, Pasig City COLLEGE OF NURSING

Case Presentation (Medicine Ward)

Submitted by: Jhune Emmanuel S. Villegas BSN III Nightingale

Submitted to: Professor Elena Mabini

Introduction

Congestive Heart failure Inability of the heart to keep up with the demands on it and, specifically, failure of the heart to pump blood with normal efficiency may be due to failure of the right or left or both ventricles This can include shortness of breath (dyspnea), cardiac asthma, pooling of blood (stasis) in the systemic circulation or in the liver's circulation, swelling (edema), cyanosis, and enlargement of the heart as signs and symptoms

Hypertension Generally defined as a persistent elevation of systolic a persistent elevation of systolic blood pressure of 140mm of Hg or blood pressure of 140mm of Hg or above and diastolic pressure of above and diastolic pressure of 90mm of Hg or above. Blood pressure is determined by the amount of blood your heart pumps and the amount of resistance to blood flow in your arteries. The more blood your heart pumps and the narrower your arteries, the higher your blood pressure. Persistent hypertension is one of the risk factors for strokes, heart attacks, heart failure and arterial aneurysm, and is a leading cause of chronic kidney failure

Uncontrolled and prolonged elevation of blood pressure can lead to a variety of changes in the myocardial structure, coronary vasculature, and conduction system of the heart. These changes can lead to the development of left ventricular hypertrophy, coronary artery disease, various conduction system diseases, and systolic and diastolic dysfunction of the myocardium, which manifest clinically as angina or myocardial infarction, cardiac arrhythmias, and congestive heart failure. Thus, hypertensive cardiovascular disease is a term applied generally to heart diseases, such as LVH, coronary artery disease, cardiac arrhythmias, and CHF, caused by direct or indirect effects of elevated BP. Although these diseases generally develop in response to

chronically elevated BP, marked and acute elevation of BP can also lead to accentuation of an underlying predisposition to any of the symptoms traditionally associated with chronic hypertension

Community-Acquired Pneumonia It occurs outside of hospitals and other health care settings. Most people get CAP by breathing in germs (especially while sleeping) that live in the mouth, nose, or throat. It is the most common type of pneumonia. Most cases occur during the winter. About 4 million people get this form of pneumonia each year. About 1 out of every 5 people who has CAP needs to be treated in a hospital. most common causes of CAP differ depending on a person's age, but they include Streptococcus pneumoniae, viruses, the atypical bacteria, and Haemophilus influenzae

Nursing Theory THEORETICAL FRAMEWORK NOLA PENDERS THEORY: HEALTH PROMOTION MODEL

The health promotion model is a competence- or approach-oriented model in which the motivational source for behavior change is based in the individuals subjective value of the changethat is, how our client perceives the benefits of changing the given health behavior.

The importance of an individuals unique personal factors or characteristics and experiences will depend on the target behavior for health promotion. Prior related behavior includes previous experience, knowledge, and skill in health-promoting actions.

Individuals who made a habit of a previous health-promoting behavior and received a positive benefit as a result will engage in future health-promoting behaviors.

In contrast, a person with a history of barriers to achieving the behavior remembers the hurdles, which creates a negative effect.

Nurse can assist by focusing on the positive benefits of the behavior, teaching them how to overcome the hurdles and providing positive feedback for their successes.

Our interventions usually focus on factors that can be modified. We also focus on factors that cannot be changed, such as family history. Like our client who has a family history of hypertension, he may neglect self-care practices.

He may do this out of fear or just feeling that with his family history, it is inevitable that he also had hypertension. Nurses should recognize this and direct more support and information to this especially offer more hope for a cure.

Health-promoting behavior is directed toward attaining positive health outcomes for the client. Health-promoting behaviors should result in improved health, enhanced functional ability, and better quality of life at all stages of development.

To promote the health of our client, plan of activities is necessary for implementation. It includes diet modification specifically Low Salt Low Fat Diet, deep breathing exercise for pain management and coughing exercise,frequent positioning and elevation of bed for improvement of ventilation.

As a nurse, one must reinforce clients personal and family health-promoting behaviors. And by assisting them to develop and choose health-promoting options.

Next Anatomy and physiology dko mahanap eh

Nephrons tend to react on sympathetic response of the body STRESS Increased renal absorption of sodium and water Increase sympathetic nervous system activity related to dysfunction

Normal Elastic Function of blood vessels

Increase Fluid volume

Constriction of veins

Increase of ReninAngiotensinAldosterone activity (kidneys)

Dysfunction of Vascular endothelium that leads to decrease vasodilation

Increase Preload CARDIAC OUTPUT Increases (Heart)

Increase Contractility

Hypertrophy

Functional Constrictions

PERIPHERAL RESISTANCE Increases

Ineffective Autoregulation

HYPERTENSION Elevation of Blood Pressure

Presence of Cardiovascular Disease (Atherosclerosis of coronary arteries, cardiomayopathy valvular disorders,coronary artery disease) Hypertension (Elevated Blood Pressure)

Ventricular Overload

Decrease Ventricular Contraction

Stimulate release of epinephrine and norepinephrine

Decrease Renal Perfusion

Stimulates Renin-AngiotensinAldosterone System for sodium and water retention

Tachycardia Myocardial Hypertrophy Increase Osmotic Pressure Decrease Ventricular Filling

Decrease CARDIAC OUTPUT Invading Organisms: (Staphylococcus Pneumoniae) Capillaries small blood vesselsprotein Enters the become leaky and in the Cause fluid seeps in the alveoli rich Oxygen Deprivation lungs(Capillaries)

Fluid Overload Edema

Mucus productionoccurs Solidification Alveolar walls and Infection of of spaces within the Consolidation and leaky capillariesto quantities fluid debris may linge the mucus lung due further of the lings AlveoliParenchymawith fluid and debris fill (Hollow air) with blood

Nursing Health History Biographical Data 1. Patient X 2. Bayabas St., Napico, Manggahan, Pasig City 3. 49 years old 4. Male 5. Filipino 6. Married 7. Company worker 8. Roman Catholic 9. Office loan as source of health finances Chief Complaint: Client verbalizes, Nalulunod ako, Di ako makatulog. He stated that he was unable to sleep for three consecutive days prior to admission because of shortness of breath. Presence of fever for three days and cough with yellowish phlegm. HEALTH HISTORY A. History of Present Illness Mr. B is known of having hypertension 5 years ago but not taking any maintenance drug. He was admitted to ER last July 18, 2010 due to difficulty of breathing. He has cough with yellowish phelgm and with (+) crackle and SCE. B. Past History Mr. B had childhood illnesses like chickepox, measles,mumps when he ws young. He has no known allegies to food, drugs, animals, insects or environmental agents. He had a gunshot accident before. He has previous hospitalization last 2000 due to peptic ulcer disease. C. Past History of Illness Mr. B stated that in his family, there was none of the diseasa conditions similar with other patients of the hospitals. His family history was only about asthma with her wife and hypertension from his dad. Her two chikdren also asthma, the eldest and youngest.

PAIN ASSESSMENT

The client stated that prior to confinement he experiened some pain. It was pain during coughing under the diaphram and upper abdomen. And when cough is prevented from doing so, it became more worst pain. He rated it 7 out of 10 and to relieve the pain he usually position himself prone.

FUNCTIONAL HEALTH PATTERN 1. Health Perception and Health Management Pattern According to Mr. B, he is feeling well even though he is not yet for discharge and they are still waiting for more clarified reason of being healthily discharge. He said it is easy to follow the instructions that his doctors and nurses may tell him. He thinks that his codition right now is brought about by overworking and lack of proper food choices. He has stop smoking since 2000 after he was hospitalized of having peptic ulcer disease.

2. Nutrition and Metabolic Pattern Mr. B said that before, his typical type of foods are galunggong and pinakbet but because he is working, the typical foods he eats are chickens, porks, beef and oily foods. He also said thateating too much fatty foods might be one of the reason why he became a CHF patient. He also loose weight in 1 months , because before, he weighs 92 kilograms and now, its only 76.2 kilograms. He has two decaying teeth but he doesnt want it to be removed for it is not aching anyway.

3. Elimination Pattern Mr. B said that he has none of eliminating problems as well as urinating. He described it as normal frequent urination.

4. Activity-Exercise Pattern Perceived ability for: Feeding Bathing Toileting Bed mobility 4 4 5 5 Grooming General Mobility Cooking Home Maintenance 4 4 4 4

Dressing Mr. B.

Shopping

5. Sleep- Rest Pattern Mr. B said that there is difficulty for him to sleep due to cough he still have. He also said that he takes siesta by 1pm to 6pm. And for him, to relieve the diffucultly hes in, he use to change position from supine to sitting and to prone.

6. Cognitive-Perceptual Pattern He has no colorblindness experiencing as well as hearing impairment. He also said that he learns more easily when the topic is beng lactured to him and he take notes of those informations and listens actively. Aside from that, Mr. B didnt say anything.

7. Self- Perception and Self- Concept Pattern Mr. B, described himselfes Dati malakas ako, di naman ako nahahapo, ngayon lagi na ko nahahapo. Para akong nalulunod,hinahingal agad ako. The client states that he feels less capable of doing things he usually do. Especially those tasks hes doing at work. He missed his job he said; he wants to be discharge early so that he can go back to work and have the assignment in their working places.

8. Sexuality- Reproductive Pattern Mr. B, admitted that he is sexually active only with his wife and they use contraceptives.

9. Role- Relationship Pattern He descibed his role as a fullfiling one for he said, he was the only breadwinner of the family. But now that he was in the hospital, he was uncapable to find job and give income to his family. He stated,Kapag nakareover ako, babalik ako sa trabaho.

10. Stress- Tolerance Pattern He said that his primary stressors are his daughters. Because if he ask for favors, his daughters take some more time before dong it and he also said that his children were hardheaded and very

noisy. But he always think that he was highblood so he usually rejects the emotion of being angry. He want to calm down himself to prevent elevated blood pressure that he might have.

11. Value- Beliefs Pattern He said that the most important things for him were enough income to support his childrens studies as well as his family for everyday trials. His family were all Roman Catholics but they usually listens to Ely Soriano. He said, it is important to have faith cause it is where he takes his strength to go on and keep on struggling. The client believes that God will always be beside us. He is a God-fearing person. And according to him, religion is very important.

Next P.E wala ako eh dko na mahanap Tapos NCP dko din mahanap NCP nito eh

GENERIC NAME Furosemide 40 mg IV now then 40 mg IV q 8BP check

BRAND NAME Lasix, Delone, Detu e

ACTION

DRUG INTERACTION Drug study Congestive heart failure, liver disease, or kidney disease. Hypertension

ADVERSE EFFECT

NURSING CONSIDERATION

A "water pill"
(diuretic) that increases the amount of urine you make, which causes your body to get rid of excess water. Lowering high blood pressure helps prevent strokes, heart attacks, and kidney problems. It also reduces swelling/fluid retention (edema) and can help to improve symptoms such as trouble breathing. blocking the absorption of sodium, chloride, and water from the filtered fluid in the kidney tubules, causing a profound increase in the output of urine (diuresis) blood vessels that supply the areas of the heart where there is not enough oxygen thereby delivering oxygen to the heart tissue that needs it most. Used in the management of angina pectoris (heart pain).

Drugs that can affect

hearing/balance (e.g., aminoglycoside antibiotics such as gentamicin, tobramycin), amphotericin B, cholestyramine, cisplatin, colestipol, corticosteroids (e.g., prednisone), digoxin, lithium, nonsteroidal antiinflammatory drugs (NSAIDs such as ibuprofen, indomethacin ), large doses of aspirin and aspirin-like drugs (salicylates), sucralfate.

Dizziness, lightheadedness, headache, blurred vision, loss of appetite, stomach upset, diarrhea, or constipation serious symptoms of dehydration or mineral loss: muscle cramps or weakness, confusion, severe dizziness, drowsiness, unusual dry mouth or thirst, nausea or vomiting, fast/irregular heartbeat, unusual decrease in the amount of urine, fainting, seizures

Before using this

medication ask for medical history, especially of: kidney disease, liver disease, untreated mineral imbalance (e.g., sodium, potassium), gout, lupus Avoid prolonged sun exposure, tanning booths or sunlamps Laboratory and/or medical tests (e.g., kidney and liver function tests, uric acid, cholesterol levels, blood mineral levels such as potassium,) should be performed periodically to monitor your progress or check for side effects Have your blood pressure checked regularly while taking this medication

Nitroglyceri n 5g ACLU L x 16

Nitrostat, Nitr oqui ck, Nitr olin gual, Nitr oDur, Mini tran, Nitr oBid and Nitr al Patc h

Preferentially dilates

congestive heart failure associate d with myocardial infarction (heart attack) and high blood pressure

Some antidepressants;

some antipsychotics, quinidine (Quin aglute, Quinidex), procainamide(Pr onestyl, Procan-SR, Procanbid), benzodiazepine s such as diazepam (Valium) or opiates(morphine) Patients receiving nitroglycerin should be advised to drink alcoholic beverages with caution. Sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra) exaggerate the blood pressure lowering effects of nitroglycerin Ergot alkaloids can oppose the vasodilatory actions of nitroglycerin and may cause angina.

Persistent,

throbbing headache, flushing of the head and neck can occur with nitroglycerin therapy as can an increase in heart rate or palpitations, dizziness or weakness.

Before using this medication tell your doctor your medical history especially of: heart problems, head injury or surgery, glaucoma, thyroid conditions, anemia, alcohol usage, allergies (especially allergies to drugs or adhesives).

LABORATORY RESULTS Serum Test July 18, 2010 SERUM Glucose HDL RESULTS 6.11 mmol/L 0.6 mmol/L NORMAL 4.16-6.11 mmol/L 1.0- 1.6 mmol/L INDICATIONS Normal range considered a coronary heart disease risk factor independent of the level of total cholesterol Associated with arterial artherosclerosis

LDL

4.00 mmol/L

0.00-3.36 mmol/L

Serum Test July 18, 2010 SERUM Urea Crea Na K RESULTS 3.4 mmol/L 72.0 mmol/L 137.0 mmol/L 3.5 mmol/L NORMAL 3.2-7.1 mmol/L 58.0-110 mmol/L 137.0- 145 mmol/L 3.6- 5.0 mmol/L INDICATIONS Normal range Normal range Cardiac failure, Diuretics abuse Associated with corticosteroids & diuretics, drugs that may cause hypokalemia

Course in the ward

PRESENT HISTORY: 3 days PTA,the patient has(+)Cough with productive with yellowish phlegm;(+)Fever; (+)Easy fatigability. Took self medications with paracetamol, Cefalexin, Salbutamol,and Guiafenessin PAST HISTORY The patient has(+)Previous Hospitalization (Year2000) at QMMC with Dx: PUD; (+)HPN with (-)maintenace medication;(-)DM, BA, PTB;(-)FDA ;previous cigarette smoker D/C 2000,Alcoholic

EMERGENCY ROOM: 07-18-10(6:30am) Admitted a 49 y/o married male filipino client CC: DIFFICULTY OF BREATHING Secure consent for admission

ASSESSMENT FINDINGS

(+) Crackles lower base with occasional wheezes; SCE

DOB

Easy Fatigability NPO Temporarily LABORATORIES: CBC, APC, Na, K, BUN, Creatinine, CXR-PA, HDL,LDL

(+)HPN

(+) Fever

Chest Pain

Hold Nebulization for 15 mins, 60mg tab PO now

Combivent ml + PNSS 2cc x 3 doses c 15 mins interval, then q 2o

Given Calcibloc prn

Hooked to PNSS 1Llx 12o

Given O2 at 4Lpm Via NC

MEDICATIONS: Cefuroxime 1.5 g (-)ANST TIV now then 250 mg TIV prn Clarithrimycin 500mg if needed then BID Paracetamol 300g TIV

BP: 250/190 mmHg P: 107 bpm T: 38.5oC RR: 32 breaths

Results: Urea: 3.4 mmol/L; Crea:72.0mmmol/L; Na:137.0mmol(LO); K:3.5 mmol/L(LO)

on LSLF Diet

Shift IVF to D5W 500cc x KVO

Give Furosemide 40mg TIV nowCheck BP

Referral to Male Medicine Ward

Results: Medications: With 2 Continue Oon going SF 2DECHO with BP: 150/120 S/E by Dr. Duro LDL: 4.00mmol/L(HI) Clarithromycin 500 mg/cap IVF: PNSS 1L IVF PNSS 1L Conscious & x SF 2DECHO with support 3Lpm HDL: 0.6mmol/L(LO) DS-request breaths Paracetamol RR: MALE with orders carried MEDICINE WARD 07-18-10(4pm) MALE MEDICINE WARD 07-19-10(6am) Losartan 100mg/tab 36 o, AU, Applied Nitroglycerin x KVO at at HBR KVO at full Coherent WORKIND DIAGNOSIS: DS, UA, FBS, TC, Chest Pain Perform TSBADMITTING DIAGNOSIS: TIV Diet: o via NC FBS, TC, TG, HDL, 1amp T: 36.7 C by relative Transfer via stretcherpatch out CVD o GLUCOSE:6.11mmol/L(HI) via NC sodium On Moderate HBR HPNCVD; CAPT: 38.level CAP MR, Lpm CHF 2 LR With O2 2-3HAS 900cc 9oCefuroxime LDL 750mg TIV T: LSLF Diet level LSLF with SAP C HDL,LDL, 37.4 C CR: 108 bp

END OF DUTY

EVALUATION

During the interview, nurse fined it hard to gather data that are necessary in their study. The patient was 49years old but having difficulty speaking due to cough. Even though there was a barrier on gathering information, the nurse was able to gather needed information because they had also interviewed the clients wife and daughter.

The doctors orders were all put into action by the nurse in charge just like the order for a 2DECHO. Other than that, there were some other laboratory tests that were undertaken by the client for further monitoring. There were many medications that were given to the client for different purposes like Furosemide, Clarithromycin, Losartan, and others.

Overall, the nurse thought t all of the interventions made by all health care providers were effective after the prescription to continue his medications. The nurse was able to implement necessary interventions like deep breathing exercise, coughing exercise as well as diet management for the client.