Post on 10-Apr-2018
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
1/41
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
2/41
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.
2
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
3/41
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.
3
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
4/41
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
4
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
5/41
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.
5
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
6/41
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 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
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 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
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,
6
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
7/41
thyroid gland and the bones of the chest area.
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
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 area.
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.
7
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
8/41
- 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
8
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
9/41
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
9
http://www.buzzle.com/articles/balanced-diet/http://www.buzzle.com/articles/balanced-diet/8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
10/41
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.
10
http://www.webmd.com/hw-popup/heart-failure-8021http://www.webmd.com/hw-popup/dehydrationhttp://www.webmd.com/hw-popup/heart-failure-8021http://www.webmd.com/hw-popup/dehydration8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
11/41
IX. MEDICAL DIAGNOSIS
CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY
DISEASE- MYOCARDIAL INFARCTION
11
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
12/41
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
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
13/41
12
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
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
14/41
13
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
15/41
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.
13
13
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
16/41
TRADE AND
GENERIC NAME
CLASSIFICATION MECHANISM OF
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.
14
14
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
17/41
TRADE AND GENERIC
NAME
CLASSIFICATION MECHANISM OF
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.
15
15
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
18/41
TRADE NAME AND
GENERIC NAME
CLASSIFICATION
MECHANISM OF
ACTION
SIDE EFFECTS NURSING INTERVENTIONS
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.
16
16
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
19/41
TRADE NAME
AND GENERIC
NAME
CLASSIFICATION MECHANISM OF
ACTION
SIDE EFFECTS NURSING INTERVENTIONS
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.
17
17
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
20/41
TRADE NAME AND
GENERIC NAME
CLASSIFICATION MECHANISM OF
ACTION
SIDE EFFECTS NURSING INTERVENTIONS
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.
18
18
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
21/41
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.
COMPONENT CLASSIFICATION EFFECTS/ USES SIGNIFICANCE
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.
19
19
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
22/41
COMPONENT CLASSIFICATION EFFECTS/ USES SIGNIFICANCE
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.
20
20
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
23/41
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
21
21
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
24/41
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.
22
22
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
25/41
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
23
23
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
26/41
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.
24
24
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
27/41
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.
25
25
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
28/41
26
ASSESSMENT EXPLANATION OF
THE PROBLEM
PLANNING NSG.
INTERVENTION
RATIONALE EVALUATION
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
26
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
29/41
27
27
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
30/41
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
RATIONALE EVALUATION
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.
28
28
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
31/41
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
29
29
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
32/41
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.
30
30
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
33/41
- 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.
31
31
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
34/41
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.
32
32
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
35/41
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.
33
33
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
36/41
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
34
34
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
37/41
Ascertain that feeding
tube is in correct position.Measure residuals at
appropriate period
Prevents overfeedingand risk of aspiration
35
35
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
38/41
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:
37
37
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
39/41
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
38
38
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
40/41
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?
39
39
8/8/2019 CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION AND RELATED
41/41
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