I.

Patient s profile

Name: Mateo, Florentina Galinato Gender: Female Age: 76 y/o Status: Widow Add: 131 Brooks Point BC Birthplace: Taguidin, Ilocos Sur Religion: Protestant Nationality: Fil Education: Grade 3 Primary Language: Ilokano Date of admission: 1/5/12 4:15p Condition upon arrival: ambulatory Admitting physician: Dr. Jason Bacani Attending Physician: Dr. Nelia Bacay Ward: 316 1 Admitting Diagnosis: coronary artery diseas in congestive heart failure: new York heart association (NYHA) class II-III; hypertension; r/o dyslipidemia, diabetes mellitus and hyperuricemia Chief complaint: Easy fatigability, difficulty of breathing

II.

Comprehensive Assessment

Into ER, a 76 y/o female, ambulatory, accompanied by daughter came in due to difficulty of breathing and easy fatigability. Six months prior to admission, patient experienced easy fatigability that prompted her to seek consultation to Dr. Bacay in SLU-HSH. She was diagnosed to have congestive heart failure and was prescribed to take Diltiazem. She has known hypertensive history, year unrecalled from which she was first diagnosed. Patient claimed that she is not compliant to drug therapy due to financial constraint. Patient experienced persistent worsening of symptoms such as slight limitation of activities of daily living; fatigue during physical activity and difficulty of breathing. She sought consultation to Dr. Bacay and was advised to continue taking the said medication. 2 weeks prior to admission, patient observed having ankle edema on both ankles. She decided to seek for consultation hence admitted in this said institution. Upon physical assessment, the patient is calm and coherent with poor eye contact. Respiration is 21 cycles per minute, deep and regular in rhythm. The lungs were auscultated and revealed fine crackles in both lung fields and heard during the end of inspiration and not cleared during coughing. There were no wheezing noted. The heart was also auscultated for S3 and S4 heart sound, there were no extra heart sounds appreciated. Jugular vein distention was also not noted. Assessing for dependent parts, the patient has significant 2+ pitting bipedal edema on both ankles. Diagnostic tests were done. Sputum test dated 1-6-12 gram shows gram stain smear with occasion gram positive cocci in signles with occasional gram negative bacilli. Complete blood count confirms normal data for white blood cell, red blood cell, platelet, neutrophils and segmenters. Albumin level is decreased with a value of 30.4 g/l (N= 39.7-49.4). Fasting blood sugar result was 5.90 mmol/L which is slightly elevated from the normal range of 4.11-5.89. uric acid is also increased with a value of 7.7mg/dl (N=2.4-5.7) thus hyperuricemia is being ruled out. The patient was ordered with low purine, diabetic diet @1500 kcal/day and that simple sugars are excluded. On the other hand, lipid profile shows an elevated LDL with a value of 2.36 (N= 2.59-3.34). In addition to that the patient is on low fat, low cholesterol diet. 2D-Echo was deferred by Dr. Bacay.

A. Pathophy B. List of actual problems

1. Ineffective airway clearance r/t retained secretions in the tracheobronchial tree .> the patient reported of having dyspnea during exertion and even at rest. Upon ausculatation, there are fine crackles noted on both lung fields. The patient was also noted to have productive cough associated with sputum production characterized as yellowish in color and thick in consistency. The patient is also hooked to oxygen 4-5lpm per nasal cannula. this is the first priority for the patient because it involves the airway. This is supported by Maslow s hierarchy of needs wherein oxygenation is the most basic need for survival. If there is a blockage along the airway or impaired function of the alveoli, oxygen could not be delivered effectively. In addition, one of the 14 basic needs of every individual is to breathe normally according to Virginia Henderson 2. Ineffective tissue perfusion r/t interruption of blood flow > Since the heart cannot effectively pump blood out of the ventricle, the blood volume and pressure in the left atrium increases causing backflow to the pulmonary tissues. The patient manifests easy fatigability and activity intolerance. Dizziness also results from the decreased cardiac output. this is the second priority in the nursing care because the cardiopulmonary system is compromised. According to Maslow s hierarchy of needs, oxygentation is a basic need. In this case, oxygenation is deprived to vital organs such as the heart and brain causing ineffective perfusion 3. Excess fluid volume r/t sodium and water retention  The patient manifests 2+ pitting bipedal edema on both ankles indicating fluid retention. Upon auscultating for lung sounds, there are fine crackles on both lung fields. The patient is on strict KVO as ordered. Intake and output status is also monitored accurately. This is the third priority for the patient since there is fluid imbalance. According to faye abdellah s 21 nursing problems, every individual must maintained fluid and electrolyte balance. In this case, the patient intake must be monitored strictly to prevent complications from occurring such as pulmonary edema or cardiac tamponade 4. Activity intolerance and fatigue r/t imbalance between oxygen supply and demand bec of dec CO  The patient having heart failure have little or no cardiac reserve to meet increased oxygen demands. The patient depend on her daughter for activities of daily living such as toileting. The patient also complained of having difficulty of breathing and fatigue. There were no associated chestpains or palpitations. As the disease progresses and cardiac function is further compromised, activity intolerance increased. This is the fourth priority as stated by abdellah that optimal activity is basic to all individuals. Because, the patient has low cardiac outout and inability to participate in activities, self care may be affected. 5. Noncompliance r/t lack of knowledge  The patient stated that she is not very compliant to medication due to financial constraint. She was prescribed of Diltiazem six months ago but she stopped taking the said medication which resulted to the worsening of her condition. The patient also claimed of lack of knowledge when it comes to lifestyle changes including medication and diet. This is included in the prioritization since noncompliance can contribute to the worsening of the disease. In line with this is the theory of Goal attainment theory by King, the

nurse and patient share information about their perception in a given situation. The nurse can provide health education that may promote adherence to treatment regimen. This is to ensure adequate understanding and at the same time there is feedback coming from the patient.

Nursing Diagnosis Ineffective airway clearance r/t retained secretions in the tracheobronchial tree S> nahihirapan akong huminga. Pag nakahiga para akong nalulunod O> with initial vital signs of T= 37, Pr= 92, BP= 110/90

Explanation of the problem Accumulated fluid in the alveoli and airway interferes with ventilation of the lungs. The problem happens when the left ventricle cannot effectively pump blood out of the ventricle into the aorta and the systemic circulation.

Objectives

Interventions done in the ER Dx: 1. Assess respiratory status including rate, effort, use of accessory muscles, sputum characteristic, lung sounds and skin color

Rationale

Expected outcome

>useful in evaluating the degree of respiratory distress and presence of pulmonary congestion indicating need for further intervention

>RR of 21 cpm, deep, regular >SPO2 of 81-82% at room air >calm and coherent with poor eye contact >prefers semifowler s position >with productive cough, able to expectorate phlegm characterized as yellowish in color and thick in consistency >(-) use of accessory muscles >(-) retractions >with nasal flaring >with diminished breath sounds on both lung fields >with fine crackles on both lung fields upon auscultation >on O2 inhalataion at 4-5LPM via nasal cannula >on D5LRS 1L x strict KVO

The blood volume and pressure increases at the left atrium decreasing blood flow from the pulmonary vessels. Fluid from the pulmonary capillaries enters the pulmonary tissues and alveoli causing pulmonary interstitial edema and impaired gas exchange

2. oxygen saturation as indicated,

> Oxygen saturation levels provide a measure of gas exchange and tissue perfusion.

Tx: 1. Elevate head of bed to 30 degrees, semifowler s position 2. Administer oxygen 4-5 LPM/NC as ordered 3. Administer salbutamol nebulization as ordered >reduces oxygen consumption/demands and promotes maximal lung inflation

>supplemental oxygen promotes gas exchange

>promotes bronchodilation of the airway, relieving dyspnea and improves airway exchange >fluid restriction is monitored strictly to prevent fluid accumulation and pulmonary congestion

4. Assist in IV insertion of PLRS iL x strict KVO as ordered; regulated accordingly 5. Assist in CBC extraction

>for assessing levels of RBC, WBC, Hgb, Hct &

platelet count 6. Ensure airway patency >a patent airway is vital for pulmonary function and gas exchange

Edx: 1. encourage frequent position changes 2. encourage coughing exercises and deep breathing exercises

>helps prevent atelectasis and pneumonia

>coughing moves secretions from smaller airways to larger airways

Nursing Diagnosis Ineffective tissue perfusion r/t interruption of blood

Explanation of the problem As the heart fails as a pump, stroke volume and tissue perfusion

Objectives

Interventions done in the ER Dx: 3. monitor vital signs and

Rationale

Expected outcome

>decreased cardiac output stimulates the

flow S> madali akong mapagod tapos madalas rin akong mahilo >no reports on chestpains and palpitations O> with initial vital signs of T= 37, Pr= 92, RR=21, BP= 110/90 >weighing 47kg; >no murmurs appreciated >no skip beats noted >full and equal peripheral pulses >no diaphoresis noted >1-2 capillary refill >skin turgor of 1-2 seconds goes back immediately >no jugular vein distention seen >no bruit upon auscultation >2+ pitting bipedal edema on both ankles

decrease. As left ventricular function fails, cardiac output fails. Pressures in the left ventricle and atrium increase as the amount of blood remaining in the ventricle after systole increases. These increased pressures impair filling, causing congestion and increased pressures in the pulmonary vascular system

oxygen saturation as indicated,

SNS to increase heart rate in an attempt to restore cardiac output. Oxygen saturation levels provide a measure of gas exchange and tissue perfusion. >ventricular gallo (s3) is an early sign of heart failure; atrial gallop (S4) may also be present. Crackles are often heard in the lung bases, increasing crackles, dyspnea and shortness of breath indicate worsening of failure >to assess the electrical activity of the heart and to note for any arrythmias or any irregularities >weight is an objective measure if fluid status

4. auscultate heart and breath sounds

5. perform 12lead ECG as ordered, privacy provided 6. obtain weight

Tx 1. administer oxygen 4-5 LPM/NC as ordered >this improves oxygenation of the blood, decreasing the effects of hypoxia and ischemia >furosemide is a diuretic used to decrease the cardiac workload and edema > to reduce the workload of breathing;

2. prepare furosemide IV as ordered

3. elevate the head of bed to 30 degrees 4. provide bedpan at bedside 5. ensure safety by raising siderails and instructing the watcher to stay with the patient Edx: 1. educate the patient to rise

>anticipate the need for voiding due to the side effect of diuretic >to prevent any falls

>furosemide can cause orthostatic

slowly from sitting or reclining position 2. educate to include food rich in potassium such as bananas to be added to the diet

hypotension

>furosemide can cause a loss in potassium through excretion.

3. reinforce health education with regards to therapeutic regimen

>health teaching in line with management of hypertension will promote compliance/adherence to the part of the patient >understanding fosters compliance with the prescribed diet

4. discuss the importance for sodium restriction