CHF, HPN and CAP

8/3/2019 CHF, HPN and CAP

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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


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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


3/17

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, andHaemophilus 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.


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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 howto 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


5/17

Increased renal

absorption of sodium

and water Increase of Renin-

Angiotensin-

Aldosterone

activity (kidneys)

Dysfunction of Vascular

endothelium that leads to

decrease vasodilation

Increase sympathetic

nervous system

activity related toIncrease Fluid

volume

Hypertrophy

STRESS

Functional

Constrictions

Constriction

of veins

Increase

PreloadIncrease

Contractility

CARDIAC

OUTPUT

Increases Heart PERIPHERAL

RESISTANCE Increases

Ineffective Autoregulation

HYPERTENSION

Nephrons tend to

react on sympathetic

response of the bodyNormal Elastic Function of blood vessels


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Presence of Cardiovascular Disease

(Atherosclerosis of coronary arteries, cardiomayopathy valvular

disorders coronar arter disease

Hypertension

(Elevated Blood Pressure

Ventricular Overload

Decrease Ventricular Contraction

Stimulate release of epinephrine

and norepinephrine

Tachycardia

M ocardial H ertro h

Decrease Ventricular Filling

Stimulates Renin-Angiotensin-

Aldosterone System for sodium and

water retention

Decrease Renal Perfusion

Decrease CARDIAC OUTPUT

Increase Osmotic Pressure

Fluid Overload

EdemaInvading Organisms:

(Staphylococcus Pneumoniae)

Enters the small blood vessels in the

lungs(Capillaries)

Capillaries become leaky and protein

rich fluid seeps in the alveoliCause Oxygen Deprivation

Mucus production and leaky

capillaries may linge the mucus

with bloodAlveoli fill further with fluid and debris

Consolidation occurs

(Hollow air)

Solidification of spaces within the

lung due to quantities fluid debris

Infection of Alveolar walls and

Parenchyma of the lings


7/17


8/17

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


9/17

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 4 Grooming 4

Bathing 4 General Mobility 4

Toileting 5 Cooking 4

Bed mobility 5 Home Maintenance 4


10/17

Dressing 5 Shopping 4

Mr. B.

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. Hestated,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


11/17

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


12/17

ENERIC

NAME

BRAND

NAME

ACTION DRUG INTERACTION ADVERSE EFFECT NURSING CONSIDE

osemide

mg IV

then 40

V q 8-

heck

Lasix, Delone,

Detu

e

A "water pill"(diuretic) thatincreases the amountof urine you make,which causes yourbody to get rid ofexcess water.Lowering high bloodpressure helpsprevent strokes,heart attacks, andkidney problems.

It also reducesswelling/fluidretention (edema)and can help toimprove symptomssuch as troublebreathing.

blocking theabsorption of sodium,chloride, and waterfrom the filtered fluidin the kidney tubules,causing a profoundincrease in theoutput of urine(diuresis)

Congestive

heart failure,

liver disease,

or kidney

disease.

Hypertension

Drugs that can affecthearing/balance (e.g.,aminoglycoside antibioticssuch as gentamicin,tobramycin), amphotericinB, cholestyramine,cisplatin, colestipol,corticosteroids(e.g., prednisone), digoxin,lithium, nonsteroidal anti-inflammatorydrugs (NSAIDs suchas ibuprofen, indomethacin), large doses of aspirinand aspirin-like drugs

(salicylates), sucralfate.

Dizziness, light-headedness, headache,blurred vision, loss ofappetite, stomachupset, diarrhea,or constipation

serious symptomsof dehydration or mineralloss: muscle cramps orweakness, confusion,severe dizziness,drowsiness, unusual drymouth or thirst, nausea orvomiting, fast/irregularheartbeat, unusualdecrease in the amount ofurine, fainting, seizures

Before using thismedication ask fomedical history, esof: kidney disease,disease, untreatedimbalance (e.g., sopotassium), gout,

Avoid prolonged suexposure, tanning or sunlamps

Laboratory and/or tests (e.g., kidney liver function testsacid, cholesterol le

blood mineral leveas potassium,) shoperformed periodicmonitor your progcheck for side effe

Have your blood pchecked regularly taking this medica

oglyceri

ACLU L

6

Nitrostat,

Nitr

oqui

ck,

Nitr

olin

gual,

Nitr

o-

Dur,

Mini

tran,

Nitr

o-

Bid

and

Nitr

al

Patch

Preferentially dilatesblood vessels thatsupply the areas ofthe heart wherethere is not enoughoxygen therebydelivering oxygen tothe heart tissue thatneeds it most.

Used in themanagementof angina pectoris(heart pain).

congestive heart

failure associate

d

with myocardial

infarction (heartattack) and high

blood pressure

Some antidepressants;some anti-psychotics, quinidine (Quinaglute,Quinidex), procainamide(Pronestyl, Procan-SR,Procanbid), benzodiazepines suchas diazepam (Valium) oropiates(morphine)

Patients receivingnitroglycerin should beadvised to drink alcoholicbeverages with caution.

Sildenafil (Viagra), tadalafil(Cialis)and vardenafil (Levitra)exaggerate the bloodpressure lowering effectsof nitroglycerin

Ergot alkaloids can opposethe vasodilatory actions ofnitroglycerin and maycause angina.

Persistent,throbbing headache,flushing of the head andneck can occur withnitroglycerin therapy ascan an increase in heartrate or palpitations,dizziness or weakness.

Before using this med

tell your doctor your m

history especially of:

problems, head injury

surgery, glaucoma, thconditions, anemia, a

usage, allergies (espe

allergies to drugs or

adhesives).

Drug study


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LABORATORY RESULTS

Serum TestJuly 18, 2010

SERUM RESULTS NORMAL INDICATIONS

Glucose 6.11 mmol/L 4.16-6.11 mmol/L Normal range

HDL 0.6 mmol/L 1.0- 1.6 mmol/L considered acoronary heart

disease risk factorindependent of thelevel of totalcholesterol

LDL 4.00 mmol/L 0.00-3.36 mmol/L Associated with arterialartherosclerosis

Serum Test

July 18, 2010

SERUM RESULTS NORMAL INDICATIONS

Urea 3.4 mmol/L 3.2-7.1 mmol/L Normal range

Crea 72.0 mmol/L 58.0-110 mmol/L Normal range

Na 137.0 mmol/L 137.0- 145 mmol/L Cardiac failure,Diuretics abuse

K 3.5 mmol/L 3.6- 5.0 mmol/L Associated withcorticosteroids &

diuretics, drugs that maycause hypokalemia
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14/17

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

QMMC with Dx: PUD; (+)HPN with (-)maintenace

medication;(-)DM, BA, PTB;(-)FDA ;previous cigarette

smoker D/C 2000,Alcoholic

Secure consentfor admission

EMERGENCY ROOM: 07-18-10(6:30am)Admitted a 49 y/o married male filipino client

CC: DIFFICULTY OF BREATHING

ASSESSMENT FINDINGS

Easy FatigabilityDOB (+)HPN (+) Fever(+) Crackles lower base with

occasional wheezes; SCE

Chest Pain

Given

Calcibloc prn

Given O2 at

4Lpm Via NCCombivent ml +

PNSS 2cc x 3 doses c

15 mins interval, thenq 2o

LABORATORIES:

CBC, APC, Na, K,

BUN, Creatinine,CXR-PA, HDL,LDL

Hooked to

PNSS 1Llx 12o

Results:

Urea: 3.4 mmol/L;Crea:72.0mmmol/L;

Na:137.0mmol(LO);K:3.5 mmol/L(LO)

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

NPO

Temporarily

Referral to Male Medicine Ward

WORKIND DIAGNOSIS:CAP MR, HAS CVD

MALE MEDICINE WARD 07-18-10(4pm)

Transfer via stretcher

Shift IVF to

D5W 500cc x

KVOon LSLF

Diet

Give Furosemide 40mg TIV now-

Check BP

Hold

Nebulization for15 mins, 60mg

tab PO now

On LSLF Diet Moderate HBRWith O2 2-3 Lpm via NC

With on going

IVF PNSS 1L x

KVO at fulllevel

SF 2DECHO with

DS-request , AU,

FBS, TC, TG, HDL,LDLT: 38. 9

oC

Paracetamol

1amp TIVPerform TSB by relativeT: 37.4oC

MALE MEDICINE WARD 07-19-10(6am)S/E by Dr. Duro

with orders carried

out Diet:LSLF with SAP

IVF: PNSS 1L

x KVO at900cc level

ADMITTING DIAGNOSIS:CHF 2o HPNCVD; CAP LR

Conscious &

Coherent at HBR

BP: 150/120RR: 36 breaths

T: 36.7oCCR: 108 bp

Medications:

Clarithromycin 500 mg/cap

Losartan 100mg/tabCefuroxime sodium 750mg TIVChest Pain Applied Nitroglycerinpatch

SF 2DECHO with

DS, UA, FBS, TC,HDL,LDL,

Continue O2support 3Lpm

via NC

Results:

LDL: 4.00mmol/L(HI)

HDL: 0.6mmol/L(LO)GLUCOSE:6.11mmol/L(HI)

A

A
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15/17

END OF DUTY


16/17

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 necessaryinterventions like deep breathing exercise, coughing exercise as well as diet management for the client.


17/17

CHF, HPN and CAP

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