Grand Case Chf Final Na Final Na Final Na True

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Perpetual Help College of Manila 1240 V. Concepcion St. Sampaloc, Manila College of Nursing A Case Study on: Congestive Heart Failure Presented to the faculty of Perpetual Help College of manila In partial fulfillment of the requirements for Nursing Care Management (NCM) 204 Related Learning Experiences 1 st semester of S.Y. 2010-2011 Submitted by Section E – Group 1

Transcript of Grand Case Chf Final Na Final Na Final Na True

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Perpetual Help College of Manila1240 V. Concepcion St. Sampaloc, Manila

College of Nursing

A Case Study on:

Congestive Heart Failure

Presented to the faculty of

Perpetual Help College of manila

In partial fulfillment

of the requirements for

Nursing Care Management (NCM) 204

Related Learning Experiences

1st semester of S.Y. 2010-2011

Submitted by

Section E – Group 1

OBJECTIVES

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General:

This study aims to develop knowledge, skills and attitudes towards nursing care

management of client who developed a Congestive Heart Failure due to Type II Diabetes

Mellitus.

Specifically, this aims to:

To identify the precipitating factors regarding the pathogenesis of the disease

being manifested by the client

To enumerate clinical manifestations of the diseases manifested by the client

To discuss the pathophysiology of Left-Sided Congestive Heart Failure.

To demonstrate the appropriate approach used in dealing with clients with

Congestive Heart Failure.

To perform dependent and independent interventions, being done to the client

appropriately and with care.

To perform comprehensive nursing care and interventions with competence and

confidence in rendering care to clients with Congestive Heart Failure.

To establish rapport to client and family/significant others.

To encourage family/significant others to cooperate in the interventions that are

being performed to the client.

To collaborate with all the health team to promote efficient care to the client.

INTRODUCTION

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Congestive heart failure is a physiologic state in which the heart cannot pump enough

blood to meet the metabolic needs of the body (determined as oxygen consumption). Heart

failure results from changes in systolic or diastolic function of the left ventricle. The heart

fails when, because of intrinsic disease or structural defects, it cannot handle a normal blood

volume or, in the absence of disease cannot tolerate a sudden expansion in blood volume

(e.g.., during exercise).

The main causes of Congestive Heart Failure are as follows: Coronary Artery Disease,

Untreated High Blood Pressure, Faulty heart valves, Cardiomyopathy, Lung disease,

Diabetes, Infections, Alcoholism and some Toxic Drugs. The Non-Modifiable risk factors are

age, gender, race, family history, personal history. The Modifiable risk factors are smoking,

high blood pressure, anemia and diabetes.

Heart failure may be categorized as (1) LVF versus RVF, (2) backward versus forward, (3)

high output versus low output. In the case of the patient, she has a Left Ventricular Failure.

Left ventricular failure causes either pulmonary congestion or a disturbance in the

respiratory control mechanisms. The patient manifests rales, dyspnea, paroxysmal nocturnal

dyspnea, orthopnea, pulmonary edema, which are all consistent with Left-sided Congestive

Heart Failure. The cause of the patient’s condition resulted from interrelated factors such as

Diabetes Mellitus Type II and Myocardial Infarction.

Out of the 86,241,697 people in the Philippines, 1,521,912 have Congestive Heart Failure.

Congestive Heart Failure is the 6th leading cause of mortality in the Philippines, affecting

males more often than females.

According to World Health Organization, more than 22 million people worldwide suffer

from Congestive Heart Failure. In the United States, congestive heart failure (CHF) was the

underlying cause of death for approximately 38,000 persons in 2007; of those deaths,

approximately 92% were among persons aged greater than or equal to 65 years.

We chose this case because we find it challenging. The disease is one of the most

common causes of mortality rate in our country. This study will give us more knowledge and

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skills improving our nursing care management in patients with such disease and so we will

be confident to help for the betterment in providing health care in the future.

DEMOGRAPHIC DATA

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Client's Name: Patient LB

Age: 65years old

Birthdate: November 18, 1945

Sex: Female

Address: Sampaloc Manila

Province: Jolo, Sulu

Height: 5’3”

Weight: 46 kilograms

Civil Status: Widow

Religion: Roman Catholic

Nationality: Filipino

Race: Asian

Language: Tagalog and English

Occupation: Housewife

Educational Attainment: College Undergraduate

Date of Admission: August 26, 2010 / 6:12 PM

Attening Physician: Dr. Bartolome

Chief Complaint: Difficulty of Breathing, Chest pain

Admitting Diagnosis: Hypertensive Cardiovascular Disease; Congestive

Heart Failure Secondary to Diabetes Mellitus Type II; Hyperuricemia; Anemia

Final Diagnosis: IHD, HCVD,CHF, CKD

History of Present Illness

One month prior to admission patient LB was hospitalize at Ospital ng Sampaloc at

around 11:30pm. According to her she was admitted because of hypertension, chest pain

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and difficulty of breathing. She had been confined for 3 days. According to the patient, she

was diagnosed with Myocardial Infarction. Her medication was given by Dr. Ocampo as

follows: Aldactone 400mg/tab OD, Captopril 25mg/tab BID and Imdur 40mg/tab OD. After

hospitalization, the pain and dyspnea subsides. Then the doctor ordered her for discharge.

When the patient was doing the laundry she started experiencing difficulty of

breathing and chest pain after which she lost consciousness. She was immediately brought

to the hospital by her son. Patient LB was admitted at the ER of Ospital ng Sampaloc on

August 26, 2010 at 6:12 PM with a chief complaint of difficulty of breathing and chest pain.

Upon arrival at the Emergency Room, the client was conscious already. The physician

assessed the status of the patient, then he noted (+) chest pain, (+)tachypnea, (+)dyspnea,

(+)bradycardia, and (+)hypertension. The physician instructed the patient to undergo

different diagnostic procedures such as ECG and various laboratory exams like Serum

Electrolytes and Cardiac Enzymes test. Her admitting diagnosis is HYPERTENSIVE

CARDIOVASCULAR DISEASE; CONGESTIVE HEART FAILURE SECONDARY TO DIABETES

MELLITUS II. The physician referred the patient to Medical/Surgical Ward and gave doctor’s

orders such as NGT insertion, IV insertion, Foley Catheter Insertion, NPO instructed, Vital

Signs Monitoring, initial oxygen via face mask (5 L/min). Medications ordered by the

physician during admission are the following Aldactone OD, Captopril 25 mg/tab for HPN,

Imdur 30mg/tab OD, Clonidine 35mg/tab OD, Diltiazem 125mg OD.

Past Health History

The patient was hospitalized in the year 1977 when she gave birth to her last child

here in manila. She was confined at the hospital for two days. She experience Measles when

she was 6 years old and had Chicken Fox when she was 12 years old.

Family Health History

GENOGRAM

DM

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LEGEND:

CHF - Congestive Heart Failure

DM - Diabetes Mellitus

MI - Myocardial Infarction

HPN - Hypertension

Px - Patient

- Male

- Female

- Deceased

Lifestyle

Patient LB seldom eats meat and poultry. Patient said that she doesn’t like the taste of

pork. Patient always eats vegetables and fish. Patient consumes vegetables that are rich in

fiber such as ‘saluyot’ and she eats more rice. Patient has a good appetite. Patient complies

with her doctor’s order by avoiding foods that are restricted to her. Patient LB voids

Px CHF,

DM, MI, HPN

MIIHPM, MI

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approximately 10-12 times a day without experiencing pain during urination. She defecates

once or twice a day and seldom experience constipation. She does it every 6 in the morning,

thrice a week, for about an hour. She usually sleeps 5-6 hours a day. Patient sleeps at 9 or

10 in the evening and wakes up early in the morning, usually at 2 or 3am. She stated that

there are episodes that she gets awaken from sleep because she experiences difficulty of

breathing. Patient naps in the afternoon because she feels sleepy every afternoon.

Spiritual History

Patient LB is a Roman Catholic and has a strong faith in our supreme being. She

regularly attends mass every Friday and Sunday at Quiapo Church. She believes that God is

always there for her and his family in times of problems and challenges.

Sexual History

Being a widow, the patient has no more sexual activity for almost 15 years now. But

when she was younger she and her husband make love 2 to 3 times a week.

Developmental Task

Erik Erikson’s Psychosocial Theory of Development

Erik Erikson adapts and expands Freud Theory of development to include the entire life span, believing that

people continue to develop throughout life. He believed in the massive influence of culture on behavior and placed

more emphasis on the external world such as depression and was according to his theory, each stage signals a task

that must be achieved. The resolution of task can be complete, partial, and successful. He believes that the greater

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the task achievements that healthier the personality of the person, failure to achieve a task influences the person’s

ability to achieved the next tasks. Erikson emphasizes that people must change and adapt their behavior to

maintain control over their lives. According to him, personality development is influenced by biologic,

psychological, environmental, and social factors throughout the life cycle.

Late Adulthood: 55 or 65 to Death

Ego Development Outcome: Ego Integrity vs. Despair

Basic Strengths: Wisdom

Erikson felt that much of life is preparing for the middle adulthood stage and the last stage is recovering from it.

Perhaps that is because as older adults we can often look back on our lives with happiness and are content, feeling

fulfilled with a deep sense that life has meaning and we've made a contribution to life, a feeling Erikson

calls integrity. Our strength comes from a wisdom that the world is very large and we now have a detached

concern for the whole of life, accepting death as the completion of life.

On the other hand, some adults may reach this stage and despair at their experiences and perceived failures. They

may fear death as they struggle to find a purpose to their lives, wondering "Was the trip worth it?" Alternatively,

they may feel they have all the answers (not unlike going back to adolescence) and end with a strong dogmatism

that only their view has been correct.

Analysis:

Patient LB achieved the developmental task because she was able to perform well as a part of her family.

She was able to teach and care for her children as they continue to grow. She feels fulfilled and contented on what

she has done and understand the things happening to her. She was aware of her condition and she accepts it. Thus,

Ego integrity developed.

a. Physical Development

Patient LB’s physical development belongs to a late adult age. She weighs 46 kilograms and stands 5’3” tall.

By merely looking at the patient’s physicality, she was actually lean in appearance. In terms of perception in health

functioning, patient LB considered herself as well fitted and is conscious and aware of her present condition.

b. Psychosocial Development

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Patient LB is strong. Even if there’s problem, the family remained strong and has cooperation in each

member of the family. She was contented on her life; she felt happiness in taking care of her children and

grandchildren.

c. Cognitive Development

Patient LB makes decisions on her own but makes sure to still consult her family. As she recalls the

memories before, she was the third child of their parents. But she decided to separate from her parents as well as

her siblings. According to her, they’ve learned to live in their own at a young age. Now that she has her own family,

she makes sure that she provides everything they needed with the help of her second husband.

Analysis:

Based from experiences expressed by patient LB, it may be presumed that her personality features molded

during her early married life. She focused on that part of her life and she developed every virtues and attitudes in

that part of her life.

d. Moral and Spiritual Development

The patient is a Roman Catholic and she believes that GOD exists. She always goes to church every Sunday and

Friday she always pray the rosary.

Analysis:

Her decision is highly affected by her religion and faith. She often prays for guidance before she makes her

decision.

ANATOMY AND PHYSIOLOGY

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Figure 1-2 Anatomical Structure of the Heart

Heart

The heart is shaped like a blunt cone and is approximately the size of a closed fist.

It is located in the thoracic cavity between the two pleural cavities, which surround the

lungs.

The heart, trachea, esophagus, and associated structures form a midline partition, the

mediastinum.

Functions:

1. Generating blood pressure

2. Routing blood

3. Ensuring one-way blood flow

4. Regulating blood supply

Right side of the Heart:

Right Atrium- the first chamber which receives deoxygenated blood from the body through

the inferior and superior venacava.

Right Ventricle- it pumps the blood into the lungs which exchange of oxygen and

carbon dioxide occurs.

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Left side of the Heart:

LeftAtrium- the first chamber which receives highly oxygenated blood from the lungs

through the Pulmonary Veins.

Left Ventricle- the strongest of the heart's pumps. Its thicker musclesneed to perform

contractions powerful enough to force the blood toall parts of the body.

The Valves

Tricuspid Valve-regulates blood flow between the right atrium and the right ventricle

Pulmonary Valve-opens to allow blood to flow from the right ventricle to the lungs

Mitral Valve-regulates blood flow between the left atrium and the left ventricle

Aortic Valve-allows blood to flow from the left ventricle to the ascending aorta

The Hearts Electrical System

Superior vena cava- is one of the two main veins

bringing de-oxygenated blood from the body to the heart.

Veins from the head and upper body feed into the superior

vena cava, which empties into the right atrium of the heart

Inferior vena cava-is one of the two main veins bringing

de-oxygenated blood from the body to the heart. Veins from

the legs and lower torso feed into the inferior vena cava,

which empties into the right atrium of the heart.

Aorta-is the largest single blood vessel in the body. It is approximately the diameter of your

thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts of

the body.

Layers:

Epicardium - also called visceral pericardium

-a thin serous membrane forming the smooth outer surface of the heart

Myocardium -thick middle layer of the heart

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-is composed of cardiac muscle cells and is responsible for contractions of the heart

chambers.

Endocardium -which consist of simple squamous epithelium over a layer of connective

tissue.

SYSTEMIC AND PULMONARY CIRCULATION

Figure 1-3 Systemic and Pulmonary Circulation

In the systemic circulation, arteries bring oxygenated blood to the tissues of the body.

The pulmonary circulation (for arterial blood sent to the lungs) is excluded from this

definition. As blood circulates through the body, oxygen diffuses from the blood into cells

surrounding the capillaries, and carbon dioxide diffuses into the blood from the capillary

cells. Veins bring deoxygenated blood back to the heart.

PATHOPHYSIOLOGY OF CONGESTIVE HEART FAILURELEFT-SIDED

(Book Base)

Causes:-Myocardial infarction-Prolong hypertension-Aortic Stenosis –Insufficiency-Mitral Stenosis – Insufficientcy

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PATHOPHYSIOLOGY OF CONGESTIVE HEART FAILURELEFT-SIDED

(Client Base)

Reduced Myocardial ContractilityIncreased Cardiac Workload

Decreased Diastolic FilingObstruction of Left Arial Emptying

Left-Sided Congestive Heart Failure

Blood drums back into the pulmonary capillary bed

Decreased Stroke Volume

Pressure of blood into the pulmonary capillary bed increases

Fluid shift into the intra and inter-alveolar spaces

Pulmonary Edema

Decreased Tissue Perfussion

Increase Cellular Hypoxia Decrease blood flow to the kidneys

Signs and Symptoms of LSCHFRAAS Stimulation

Vasoconstriction & Rearbsorption of Sodium and Water

Increase ECG Volume

Increase total blood volumeIncrease Systemic Blood pressure

Dyspnea Paroxysmal Nocturnal Dyspnea Orthopnea Rales/ Crackles Moist Cough Blood Tinged Frothy Sputum Wheezing/ Cardiac Asthma Dizziness Fatigue Weakness Anorexia Hypokalemia Polycythemia S3 & S4 heart sounds

Modifiable factor:

Lifestyle

Non-Modifiable factor:

Myocardial infarctionDiabetes Mellitus

AgeHeredity

Hypertension

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REVIEW OF SYSTEMS

August 30, 2010

SYSTEMS SUBJECTIVE CUESIntegumentary System “Wala naman ako problema sa balat,

ganito lang talaga ang balat pag tumanda na” as verbalized by the patient.

Respiratory System “Mabilis ang paghinga ko, parang kinakapos kaya nahihirapan ako sa paghinga” as verbalized by thepatient.

Increased workload

Enlargement of left ventricle

DyspneaParoxysmal nocturnal dyspneaOrthopneaFatigueRales/crackles

Reduced myocardial contractility

Blood drums backInto the pulmonary

capillary bed

Pressure of blood into the pulmonary capillary bed

increases

Fluid shift into the intra and inter-alveolar spaces

Pulmonary edema

LEGEND:

Sign and symptoms

Congestive Heart failure

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“Parang nalulunod ako, hindi ako makahinga ng maayos” as verbalized by the patient.

“Gusto ko ng mataas na unan, itaas nyo ang higaan ko dito sa may likuran ko” as verbalized by the patient.

“Hinahabol ko ang paghinga ko kasi nauubusan ako” as verbalized by the patient

“Bumibilis ang paghinga ko pag sumasakit ang dibdib ko” as verbalized by the patient.

“Irerate ko ang sakit sa 7 out of 10” as verbalized by the patient.

“Sumasakit ang dibdib ko, parang pinipiga” as verbalized by the patient.

“Hindi ako makatulog ng maayos, nagigising ako dahil nahihirapan akong huminga” as verbalized by the patient.

Cardiovascular System “Mataas ang BP ko, highblood kasi ako.” as verbalized by the patient.

“Yung sakit parang lumalakad sa kanang bahagi ng dibdib ko” as verbalized by the patient

Gastrointestinal System “Wala naman masakit sa tyan ko, pag lang madudumi ako” as verbalized by the patient.

“Hindi ako makakaen ng maayos dahil mapait ang panlasa ko” as verbalized by the patient.

Genitourinary System “Wala naman masakit pag umiihi ako. ” as the patient.

Musculoskeletal System “Wla naman masakit s mga kasukasuan ko, wla din ako rayuma” as verbalized by the patient.

Neurologic system “Nanghihina lang ako, pero kaya kong maglakad mag isa at hindi ako nahihirapang bumalanse” as verbalized by the patient.

Endocrine system “Di ko nga alam na may diabetes ako e, sinabi lang ng doctor meron na daw ako.” as verbalized by the patient.

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Results from an increase left ventricular and left atrial pressures, which cause excessive accumulation of fluid in interstitial and alveolar spaces. Pulmonary artery pressures will also be elevated. Treat with vasodilators and ACE inhibitors to decrease afterload

Early sign of left ventricular failure that is the result of a compensatory effort to increase cardiac output. Tachycardia will continue at increasing rates if left ventricular failure persists. Treat with digitalis to increase the heart’s contractility and rate.

CLINICAL PATHWAY

Left sided CHF Ride Sided CHF

No

No

No

Yes

Yes

Yes Can you hear bibasilar crackles on auscultation of lungs?

Very Specific sign of right ventricular failure, resulting from increased venous pressure. This increased pressure will also be reflected in increased central venous pressure. Treat with diuretics to decrease blood volume and decrease venous pressure

Is jugular venous distention present?

Is the heart rate over 100 beats/min?

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Early finding in left ventricular failure but will persist as failure progresses. It occurs as the left ventricle becomes less compliant.

This occurs because the left ventricle dilates in order to increase ventricular contraction and emptying.

Results from reduced perfusion to the kidneys when renal perfusion is reduced, the blood urea nitrogen rises but the creatinine level in unaaffected

Figure 1-1 Clinical Manifestations of Left sided and Right Sided CHF

Physical AssessmentAugust 30, 2010

Vital Signs

T: 36.2°

RR: 26 breaths/min

PR: 111 beats/min

Height: 5’3”

Weight: 46kg

Bp: 140/90 mmHg

BMI: 17.88

No

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes Can you hear an S3 or summation gallop when you auscultate the heart?

Is the point of maximal impulse enlarged or shifted laterally to the left?

Is there a parasternal heave?

Is the blood urea nitrogen increased while the creatinine is normal?

Is ascites present?

Is the liver enlarged?

Is the hepatojugular reflex is present?

Is there a measurable weight gain in a short period?

This occurs because the right ventricle dilates in order to increase ventricular contraction and emptying.

Results from fluid accumulation in the abdomen.

Hepatomegaly is due to congestion of the liver with venous blood

Results from the inability of the right ventricle to handle the increase in pressure and venous return.

Results from fluid retention

Treat with diuretics to decrease blood volume and venous pressure

Yes

No

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Analysis: According to Black, a BMI of less than 18.5 is categorized underweight for less than

desirable weigh for height.(Medical surgical Nursing by Black)

General Survey:

We received patient awake on bed in high-fowlers position. Conscious and coherent.

With IVF of PNSS 1LXKVO located at left metacarpal vein, intact and infusing well. With Foley

catheter connected on a urine bag containing 1200ml. With oxygen tank at bedside and is

being used when needed. The patient wears dress suitable for the temperature. Pale looking

and body weakness noted.

BODY PART and

ASSESSMENT

TECHNIQUE NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

SkinSkin color

Uniformity of skin color

Assess edema

Skin lesions

Inspection

Inspection

InspectionPalpation

InspectionPalpation

Varies from light to deep brown; from ruddy pink

to light pink; from yellow overtones

to olive

Generally uniform except in areas exposed to the sun; areas of

lighter pigmentation in

dark skinned people

No edema

Freckles; some birthmarks, no

abrasion or other lesions

Deep Brown color

Uniform in color except in areas exposed

to sunlight

No edema

No lesions or abrasions

According to KOZIER skin color varies from

race. Asian people have a deep brown

color. (Fundamentals of Nursing p.540)

According to KOZIER some areas have

lighter pigmentation such as palms, lips,

nail beds in dark skinned people.

(Fundamentals of Nursing p.538)

According to KOZIER a normal skin doesn’t show swollen, shiny,

taut, and tends to blanch the skin color.

(Fundamentals of Nursing p.3535)

According to KOZIER skin lesions are those that appear initially in

response to some change in the external

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Skin moisture

Skin temperature

Skin turgor

Inspection

Palpation

Palpation

Moisture in skin folds and the

Axillae

Uniform; within normal range of

temperature

When pinched, skin springs back to previous state

Dryness and flaky

Cold, clammy skin

The skin moves back slowly

on internal environment of the

skin. (Fundamentals of Nursing p.539)

According to KOZIER the skin is dry and

flaky because sebaceous and sweat glands are less active

in elderly.Excessive Dryness

indicate dehydration(Fundamentals of

Nursing p.539)

According to D’Amico and Barbarito localized coolness results from decreased circulation due to vasoconstriction or occlusion which may occur from peripheral arterial insufficiency.

According to KOZIER in elders, The skin takes longer to return to its natural shape after

being pinched between the thumb

and finger.Due to the normal loss

of peripheral skin turgor in elders

(Fundamentals of Nursing p.540)

Hair

Hair Color

Evenness of growth over

the scalp

Inspection

Inspection

Asian race hair color are black

Evenly distributed hair

Hair patches in grayish color.

Evenly distributed hair over the scalp

According to D’Amico and Barbarito, In elders, graying

patches in hair color is normal, it is due to aging process. (An

Introduction to Health & Physical Assessment in Nursing pp. 890. 1st

Edition)

According to D’Amico and Barbarito, the amount of hair varies with age, gender, and overall health. Healthy hair is evenly distributed (An

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Hair thickness of thinness

Hair texture and oiliness

Presence of infections or infestations

Amount of body hair

Inspection

Inspection

InspectionPalpation

Inspect

Thick hair

Silky, resilient hair

No infection or infestations

Variable

Thick hair

Rigid; Oily; Dry hair;

Disheveled

No visible infestations

and infection

Variable

Introduction to Health and Physical Assessment in Nursing p. 206)

According to D’Amico and Barbarito, Hair

maybe thick and thin or fine and may

appear straight, wary and curly (An

Introduction to Health and Physical

Assessment in Nursing p. 206)

According to D’Amico and Barbarito,

Disheveled hair indicates lack of care.

(An Introduction to Health & Physical

Assessment in Nursing pp. 890. 1st Edition)

According to KOZIER a normal hair has no sores, lice & nits. (Fundamentals of Nursing pp.541)

According to KOZIER because abnormal hairiness indicates

hirtuism. (Fundamentals of

Nursing p.541)Nails

Fingernail plate

Fingernail and toenail texture

Fingernail and

Inspect

Inspect

Inspect

Convex curvature; angle

of nail plate about 160°

Smooth texture

Dark-skinned

Convex curvature

Rough texture

Pallor in color

According to KOZIER the nail plate is

normally colorless and a convex curve. The

angle between the nail and the nail bed is

normally 160 degrees. (Fundamentals of

Nursing p.542)

According to KOZIER in elders, the nails grow more slowly, thick and rough. (Fundamentals

of Nursing p.542)

According to KOZIER

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toenail bed color

Tissues surrounding

nails

Blanch test of capillary refill.

Inspect

Test

clients may have brown or black pigmentation in

longitudinal streaks

Intact epidermis

Prompt return of pink or usual

color generally less than 2

seconds

Intact epidermis

Slow capillary refill of about 4

sec.

pallor may reflect poor arterial circulation (Fundamentals of

Nursing p.542)

According to KOZIER the tissue surrounding the nails is normally

intact epidermis. (Fundamentals of

Nursing p.542)

According to KOZIER slow rate of capillary

refill may indicate circulatory problems.

(Fundamentals of Nursing p.542)

HeadSize, shape,

and symmetry

Nodules, masses and depression

Facial features

Edema and hollowness

Symmetry of

Inspect

Inspect

Inspect

Inspect

Inspect

Rounded; Normocephalic

Smooth, uniform consistency; absence of

nodules and masses

Symmetric; symmetric facial

movements

No visible for sunken eyes; no

edema

Symmetric facial

Rounded; Normocephalic

No masses, no signs of

depression; no nodules

Symmetrically aligned; no

increase facial hair

No edema; no sunken eyes

Symmetric facial

According to KOZIER normal head size is

referred to as Normocephalic.

(Fundamentals of Nursingp.544)

According to KOZIER normal skull is free

from Sebaceous cysts; a local deformities

from trauma(Fundamentals

of Nursing p.544)

According to KOZIER normal facial feature

doesn’t have and increase facial hair,

thinning of eyebrows, asymmetric features,

exopthalmos, myxedema facies and

moon face. (Fundamentals of

Nursing p.545)

According to KOZIER any disorders can cause a change in facial condition.

(Fundamentals of Nursing p.540)

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facial movements

movements movementsAccording to D’

Amarico and Barbarito Cranial nerve III, IV,

and VI control movement of the eye.

Cranial nerve VII controls movement of

the face (An Introduction to Health

and Physical assessment in Nursing

p.248)

Eyes and VisionExternal Eye

Eyebrows

Eyelashes

Eyelids

Bulbar conjunctiva

Palpebral conjunctiva

Inspect

Inspect

Inspect

Inspect

Inspect

Hair evenly distributed; skin

intact; symmetrically aligned; equal

movement

Equally distributed;

curled slightly outward

Skin intact; no discharge; no discoloration;

Lids close symmetrically;

bilateral blinking;

Transparent; capillaries sometimes

evident; sclera appears white (yellowish in dark-skinned

clients)

Shiny; smooth; pink

Hair evenly distributed;

equal alignment and movement of

eyebrows

Equally distributed and curled outward

Skin intact; no discharge; no discoloration;

lids close symmetrically;

bilateral blinking

Transparent; no lesions; evidence of capillaries

Pale conjuntiva

According to KOZIER normal eyebrow shows no loss of hair, scaling

and flakiness of the skin. (Fundamentals of

Nursing p.549)

According to KOZIER normal eyelash is curled outward to

protect the inner eye. (Fundamentals of

Nursing p.547)

According to KOZIER normal eyelids have no

discharge, redness, swelling, flaking; lids

close at the same time in frequent blinking.

(Fundamentals of Nursing p.548)

According to KOZIER normal bulbar

conjunctiva shows free of lesions, and no

evidence of discoloration.

(Fundamentals of Nursing p.548)

According to Taylor’s paleness often results from an inadequate

amount of circulating blood or hemoglobin, causing inadequate oxygenation of the

body tissues.(fundamentals of

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Lacrimal sac and

nasolacrimal duct

Cornea

Anterior Chamber

Pupils

Visual AcuityNear Vision/

Distance Vision

InspectPalpate

Inspect

Inspect

Inspect

Test

Snellen’s Chart

No edema or tearing

Transparent; shiny; smooth;

iris is visible

Transparent; no shadows of light

on iris

Black in color; equal in size;

round; smooth; iris flat and round

Able to read print

Normal vision is 20/20; at the 20ft

the client can read the line

numbered 20.

No evidence of tearing; no

edema

Transparent and shiny;

smooth; iris is visible; Arcus senilis is also

visible

Transparent; not cloudy; no

visible of shallow shadows

Black in color; equal in size;

round in shape; no bulging or

iris

Able to read small print in

near distance

20/80

Nursing p.573 )

According to KOZIER normal lacrimal sac

and nasolacrimal duct shows no swelling or

tenderness over lacrimal gland.

(Fundamentals of Nursing p.549)

According to KOZIER in older people, a thin, grayish white ring around the margin

(arcus senilis) may be evident.

(Fundamentals of Nursing p.554)

According to KOZIER normal anterior

chamber show no visible of shallow

shadows because if this is present, it

indicates Glaucoma. (Fundamentals of

Nursing p.550)

According to KOZIER pupils are normally black, round, and

smooth in borders. Cloudy pupils are often

indicates Cataract. (Fundamentals of

Nursing p.547)

According to KOZIER visual acuity decreases as the lens of the eye

ages and becomes more opaque and loses elasticity.

(Fundamentals of Nursing p.554)

According to Taylor’s the larger the

denominator, the poorer the

vision(Fundamentals of Nursing 5th Edition p.

579)

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Ears and Hearing

Auricles and Pinna

External Ear Canal

Inspect

Palpate

Inspect

Color same as facial skin;

symmetrical; auricle aligned

with outer canthus of the

eye

Mobile, firm, no tenderness; pinna recoils after it is

folded

Dry cerumen, sticky; no discharge

Color same as facial skin;

symmetrically aligned; in line

with outer canthus,

Appear to be increase in

size.

Mobile, firm, no tenderness;

pinna recoils to its previous

state

No discharge; dry cerumen

According to KOZIER in elders, The pinna

increase in both width and length, and the earlobe elongates. (Fundamentals of

Nursing p.559)

According to KOZIER normal pinna appears no lesions, flaky, scaly

skin, no tenderness because if there is

tenderness it indicates inflammation or

infection of external ear. (Fundamentals of

Nursing p.556)

According to KOZIER In elders, earwax is drier.

(Fundamentals of Nursing p.559)

Gross Hearing Acuity Test

Client’s response to normal voice

tones

Test Normal voice tones audible

Normal voice tones audible

but with a confused behavior

According to KOZIER in elders, conversation can be distorted and

result in what appears to be inappropriate or

confused behavior (Fundamentals of

Nursing p.559)

Nose and SinusesExternal Nose

Nasal septum

Inspect

Palpate

Inspect

Symmetric and straight; no discharge or

flaring; uniform in color

Not tender; No lesions

Nasal septum Intact and in the

midline

Symmetrically aligned and straight; No discharge or flaring; same color as facial

color

No tenderness and no lesions

Nasal septum intact and in the midline

According to KOZIER normal external nose

is symmetrically aligned with a normal

size, no discharge from nares and no presence

of lesions and free from tenderness. (Fundamentals of

Nursing p.560)

According to KOZIER no septum deviated to the right or to the left.

(Fundamentals of

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Maxillary and Frontal sinuses

Palpate

No tenderness

No tenderness

Nursing p.561)

According to KOZIER normal maxillary and

frontal sinuses have no signs of any tenderness.

(Fundamentals of Nursing p.561)

Mouth and Oropharynx

Outer Lips

Inner lips andBuccal mucosa

Teeth and Gums

Inspect

inspect

Inspect

Inspect

Uniform pink color; soft; moist; smooth texture

Uniform pink color; Moist; smooth; soft;

glistening; elastic texture

32 adult teeth; smooth; white shiny tooth enamel

Pallor and dry

Pallor

24 permanent teeth; some have black discoloration of the enamel

Pale gums

According to KOZIER in elders, the oral

mucosa may be drier than that of younger persons because of decreased salivary

gland activity. (Fundamentals of

Nursing p.566)According to Taylor’s pallor often results from an inadequate

amount of circulating blood or hemoglobin, causing inadequate oxygenation of the

body tissue. (Fundamental’s of

Nursing p.573)

According to Taylor’s pallor often results from an inadequate amount of circulating blood or hemoglobin, causing inadequate oxygenation of the body tissue. (Fundamental’s of Nursing p.573

According to KOZIER tooth loss occurs as a

result of dental problem; The teeth may show a sign of staining, erosion,

chipping, and abrasion due to loss of dentin

(Fundamentals of

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Tongue

Tongue movement

Base of the tongue

Floor of the mouth

Hard and soft palate

Inspect

Inspect

Pink gums; moist; firm texture to

gums; no retraction of

gums

Central position; pink in color; moist; slightly

rough; no lesions; raised papillae

Moves freely; no tenderness

Smooth tongue base with

prominent veins

No masses; no nodules

Light pink, smooth, soft

palateLighter pink hard

palate, more irregular texture

Central position; no lesions

Moves freely; no tenderness

No swelling; no ulceration; with

presence of veins

No masses; no nodules

Soft and hard palate have

same color; no irritations

Nursing p.566)

According to Taylor’s paleness often results from an inadequate

amount of circulating blood of Hgb, causing

inadequate oxygenation of the

body tissue.(Fundamentals of Nursing 5th Edition

p.573)

According to KOZIER a normal tongue is

centrally aligned and a presence of papillae. A

dry tongue indicate fluid deficit

(Fundamentals of Nursing p.564)

According to KOZIER normal tongue

movement shows no restricted mobility. (Fundamentals of

Nursing p.564)

According to KOZIER normal base of the tongue shows no

swelling and ulceration.

(Fundamentals of Nursing p.564)

According to KOZIER normal floor of the mouth shows no swelling and no

nodules. (Fundamentals of

Nursing p.564)

According to KOZIER normal hard and soft palate does not show

any discoloration, irritations, and bony growths (exostoses)

growing from the hard palate. (Fundamentals

of Nursing p.565)

Uvula Inspect Positioned in midline of soft

palate

Positioned in midline of soft

palate

According to KOZIER normal uvula

positioned at midline

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Tonsils Inspect Pink and smooth; no discharge

Pink and smooth; no

discharge; no lesions

with no deviation to one side, immobility

may indicate damage to trigeminal nerve or

vagus nerve. (Fundamentals of

Nursing p.565)

According to KOZIER normal tonsils are

pink, smooth in texture, no redness, no

swelling, and no presence of lesions.(Fundamentals of

Nursing p.565)

NeckNeck muscles

Head movement

Lymph nodes

Trachea

Thyroid Gland

Inspect

Observe

Palpate

Palpate

Inspect

Muscles equal in size; head centered

Coordinated, smooth

movements with no discomfort

Not palpable

Central placement in

midline of neck; spaces are equal

in both sides

Not visible on

Equal in size; head centered

Coordinated; no discomfort

Not palpable

In midline placement of neck; spaces

are equal

Not visible

According to D’Amico and Barbarito the neck muscles equal in both

sides and head centered. (An

Introduction to Health & Physical Assessment in Nursing pp. 249 1st

Edition)

According to D’Amico and Barbarito, there

should be no pain and no limitation of movement. (An

Introduction to Health & Physical Assessment in Nursing pp. 249 1st

Edition)

According to Taylors the lymph nodes are

generally not palpable, if palpable, they should be small,

mobile, smooth & not tender. (Fundamentals

of Nursing pp.584)

According to Taylors the trachea is normally

midline at the suprasternal notch, is palpated for alignment

& position. (Fundamentals of Nursing Taylors 5th

Edition pp. 583)

According to Taylors

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inspection the thyroid gland is normally not palpable.

It should have no enlargement, masses

& nodules. (Fundamentals of Nursing Taylors 5th

Edition pp. 583)

Thorax and Lungs

Posterior thorax

Posterior thorax

Posterior thorax

(for respiratory excursion)

Posterior thorax

(for tactile fremitus)

Posterior thorax

Inspect

Palpate

Respiratory excursion

Palpate

Percuss

Auscultate

Symmetrically equal both sides

Chest wall intact; no tenderness; no

masses

Full and symmetric chest

expansion

Bilateral symmetry of

tactile fremitus; fremitus is heard most clearly at the apex of the

lungs

Resonate, except over scapula

Vesicular and bronchovesicular

Symmetrically equal in size

and shape both sides

No lumps or bulges; no tenderness

Full and symmetric

chest expansion

Tactile fremitus equal

Resonate

Bronchovesicular sound

According to Taylors the color should be

even & consistent with the color of the

patient’s face. The shape or contour

should have a downward equal slope

at the rib cage. The chest should be

symmetric w/ the transverse diameter

greater than the anteroposterior

diameter (Fundamentals of Nursing Taylors 5th

Edition pp. 586)

According to Taylors The skin of posterior

thorax should be warm & should not be

tender; Free from masses.

(Fundamentals of Nursing Taylors 5th

Edition pp.586)

According to Taylors, The Thorax should

expand symmetrically. (Fundamentals of Nursing Taylors 5th

Edition pp. 586

According to Taylors, equal bilateral mild vibratory sensations

are palpated. (Fundamentals of Nursing Taylors

According to Taylors, The sound is hollow, loud, and low in pitch

& of long duration. (Fundamentals of Nursing Taylors 5th

Edition pp. 586)

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Anterior Thorax

Trachea

InspectPalpate

Auscultate

breath sounds

Breathing pattern is quiet, rhythmic

and effortless respirations; No

chest pain

Bronchial and tubular breath

sounds

Shortness and Difficulty of breathing;

High pitch and soft

According to D’ Amico and Barbarico are

medium in loudness and pitch. (An

introduction to Health and Physical

Assessment in Nursing pp.377)

According to Black dyspnea and

orthopnea often occur in left sided CHF due

to Increase distribution of blood to the

pulmonary circulation/preload. (Medical - Surgical Nursing p. 1655)

According to Black fine crackles a discontinue,

non musical, high pitch. Soft and brief associated with left

CHF. During inspiration, the resulting vibration in the airway causes a

discrete, sharp sound of very short duration

(Medical - Surgical Nursing p. 1654)

Cardiovascular

Heart Inspect

Auscultate

No pulsation; no lift or heave

S1: Usually heard at all sites,

usually louder at apical area

S2: Usually heard at al sites.

Usually louder at base of the heart

Systole: silent interval; slightly shorter duration than diastole at

normal heart rate

No pulsation; no lift or heave

Increase intensity;

Presence of S4 and S3;

summation gallop; Cardiac

Murmurs.

According to Kozier indicates enlargement and over activity of left ventricle (Fundamentals of Nursing p.583)

According to Black due to increased pressure

beyond the valve. Higher closing

pressure occur and resulting in a louder A2 (the closing sound of

aortic valve). The combined presence of

S3 and S4 produce summation gallop (S7)

because the left ventricle becomes less compliant. (Medical -

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Carotid artery

Jugular Veins

Palpate

Inspect

(60-90 bpm)

Diastole: silent interval, slightly longer duration than systole at

normal heart rate

Symmetric pulse volumes; full

pulsations

Veins not visible

Increase pulse volume

Veins visible

Surgical Nursing p. 1654)

According to Black due to increase distribution of blood in pulmonary circulation (Medical - Surgical Nursing p.

1655)

According to D’Amico and Barbarito the

jugular veins are not normally visible when the client sits upright. The external jugular vein is located over

the sternocleidomastoid

muscle. (An Introduction to Health & Physical Assessment in Nursing pp. 453 1st

Edition)

AbdomenAbdomen

Abdominal contour

Abdominal movements

Inspect

Inspect

Inspect

Unblemished skin; uniform

color

Flat, rounded (convex), or scaphoid; no evidence of

enlargement of liver or spleen;

symmetric contour

Skin uniform in color

Flat, rounded; no evidence of enlargement of liver or spleen; symmetric in

contour

Symmetric movements

According to Taylor’s normally the skin color may be slightly lighter

than exposed area. (Fundamentals of Nursing p. 596)

According to Taylor’s abdomen should be evenly rounded or symmetric without visible peristalsis.

There should be no evidence of

enlargement of liver or spleen. (Fundamentals

of Nursing p. 596)

According to D’Amico

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Abdomen for bowel sounds

Liver

Auscultate

Percuss

Palpate

Symmetric movement of respiration;

visible peristalsis; aortic pulsations at epigastric area

Audible bowel sounds; absence of arterial bruits;

absence of friction rub

No evidence of enlargement of

liver

No tenderness

caused by respiration;

aortic pulsations at

epigastric area

Audible bowel sounds;

absence of arterial bruits;

absence of peritoneal friction rub

No evidence of enlargement

No tenderness

and Barbarito, movements can

include pulsations or peristalsic waves.(An Introduction to Health & Physical Assessment in Nursing pp. 530 1st

Edition)

According to D’Amico and Barbarito the

normal bowel sounds are irregular, gurgling, and high pitch sound.

(An Introduction to Health & Physical

Assessment in Nursing pp. 532 1st Edition)

According to D’Amico and Barbarito, upon percussion there are no dullness below the costal margin (liver enlargement). (An

Introduction to Health & Physical Assessment in Nursing pp. 536 1st

Edition)According to Taylor’s sounds are dull over

the liver. (Fundamentals of

Nursing 5th edition p. 596)

According to Taylor’s the abdomen is soft, relaxed and free of

tenderness.(Fundamentals of Nursing p. 596)

Genitalia

Female genitalia

Inspection Foley Catheter connected to

urine bag. Intact; no sign of infection. Urine Bag container:

1200cc

Upper Extremities

Left Upper Inspect Skin is uniform; Skin is uniform; According to D’Amico

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Arm

Right Upper Arm

Left Lower Arm

Right Lower Arm

Fingers

Fingernail

Inspect

Inspect

Inspect

Inspect

Test (capillary refill)

No tenderness; no lesions; no masses; no

edema

Skin is uniform; No tenderness; no lesions; no masses; no

edema

Skin is uniform; No tenderness; no lesions; no masses; no

edema

Skin is uniform; No tenderness; no lesions; no masses; no

edema

No clubbing fingernails

Capillary refill at 2 sec

No tenderness; no lesions; no masses; no

edema

Skin is uniform; No tenderness; no lesions; no masses; no

edema

With IVF PNSS 1L x KVO

located at left metacarpal

vein and infusing well

Skin is uniform; No tenderness; no lesions; no masses; no

edema

No clubbing fingernails

Delay Capillary Refill at 4sec

and Barbarito the skin color should match the skin tone of the rest of

the body.(An Introduction to Health & Physical Assessment in Nursing pp.493 1st

Edition)

According to D’Amico and Barbarito the skin is uniform and should

be free from tenderness & edema.

(An Introduction to Health & Physical

Assessment in Nursing pp. 493 1st Edition)

Supplying extra water to a dehydrated

patient or supplying the daily water and

salt needs ("maintenance" needs)

of a patient who is unable to take them

by mouth.

According to D’Amico and Barbarito the skin is uniform and should

be free from tenderness & edema.

(An Introduction to Health & Physical

Assessment in Nursing pp. 493 1st Edition)

According to clubbed fingernails are due to diseases of the heart or lung. Almost any type of lung disease can lead to clubbed fingernails

(Fundamentals of Nursing p.542)

According to Kozier slow rate of capillary

refill may indicate circulatory problems.

(Fundamentals of Nursing p.542)

Lower Extremities

Left Thigh Inspect Similar in color; equal to the right

Similar in color; equal to the

According to D’Amico and Barbarito the skin

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Right Thigh

Left Leg

Right Leg

Toenails

Inspect

Inspect

Inspect

Inspect

thigh; no edema; no swelling; no

tenderness

Similar in color; equal to the left thigh; no edema; no swelling; no

tenderness

Similar in color; no edema; no swelling; no tenderness

Similar in color; no edema; no swelling; no tenderness

Clean; Capillary refill at 2 sec

right thigh; no edema; no swelling; no tenderness

Similar in color; equal to the left thigh; no edema; no swelling; no tenderness

Similar in color; no edema; no swelling; no tenderness

Similar in color; no edema; no swelling; no tenderness

Clean; capillary refill is slower

than the normal range.

(4seconds)

is uniform and should be free from

tenderness & edema.(An Introduction to Health & Physical

Assessment in Nursing pp. 493 1st Edition)

According to D’Amico and Barbarito the skin is uniform and should

be free from tenderness & edema.

(An Introduction to Health & Physical

Assessment in Nursing pp. 493 1st Edition)

According to D’Amico and Barbarito the skin is uniform and should

be free from tenderness & edema.

(An Introduction to Health & Physical

Assessment in Nursing pp. 493 1st Edition)

According to D’Amico and Barbarito the skin is uniform and should

be free from tenderness & edema.

(An Introduction to Health & Physical

Assessment in Nursing pp. 493 1st Edition)

According to Kozier slow rate of capillary

refill may indicate circulatory problems.

(Fundamentals of Nursing p.542)

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LABORATORY RESULTS

Hematology

It is a series of screening test, which consist of Hemoglobin and Hematocrit. It is used

routinely to screen for, to help diagnose and to monitor variety of condition. It provides a

complete evaluation of all formed elements of the blood. It can supply a great deal of

information necessary to diagnosed hematopoetic system and helps to evaluate the

strategies and prognosis of certain disease.

Laboratory Results: Hematology

August 25, 2010

LABORATORY

EXAM

RESULT NORMAL

VALUES

INTERPRETATION ANALYSIS

Hemoglobin 9.1 Female

12-14 g/dl

-Patient LB has low

hemoglobin level

which indicates

anemia and lack of

oxygen.

Hemoglobin is the

protein molecule

within red blood cells

that carries oxygen

and gives blood its

red color. The

amount of oxygen in

the body tissues

depends on how

much hemoglobin is

in the red cells.

Without enough

hemoglobin, the

tissues lack oxygen,

and the heart and

Page 36: Grand Case Chf Final Na Final Na Final Na True

lungs must work

harder to try to

compensate.

(Medical – Surgical

Nursing 7th edition by

Joyce M. Black pp.

2262)

Hct 0.27 0.37-0.47 -Patient LB has low

hematocrit level

which indicates

anemia.

Hematocrit is a

compound measure

of red Blood cell

number and size. A

decrease in the

number or size of red

cells also decreases

the amount of space

they occupy,

resulting in low

hematocrit. (Medical

– Surgical Nursing 7th

edition by Joyce M.

Black pp. 2263)

WBC 11.5 4.8-10.8 x 10 -Patient LB has high

WBC count which

indicates infection

and tissue necrosis

White blood cells

which also called

leukocytes, defend

the body against

infection. They form

in the bone marrow

and consist of

several different

types and sub-types.

A high WBC count

often means that an

infection is present

in the body. (Medical

Page 37: Grand Case Chf Final Na Final Na Final Na True

– Surgical Nursing 7th

edition by Joyce M.

Black pp. 2263)

Segmenters 80 60-70% -Patient LB has high

percentage of

segmenters indicates

inflammatory disease

or response, tissue

necrosis (myocardial

infarction), basophils

for hemolytic anemias

and bacterial

infection.

Increased in

neutrophils,

basophils,

eosinophils and

monocytes may be

due to acute

coronary syndrome,

bacterial infection

and sometimes

Leukemia. (Medical –

Surgical Nursing 7th

edition by Joyce M.

Black pp. 2263)

Lymphocyte 20 30-40% -Patient LB has low

percentage of

lymphocytes indicates

a very high risk of

infection especially

viral infection.

Lymphocytes are the

primary components

of the body's

immune system.

They are the source

of serum

immunoglobulins

and of cellular

immune response.

As a result, they play

an important role in

immunologic

reactions. All

lymphocytes are

produced in the bone

marrow. Sometimes

drugs can be a factor

to a decreased

Page 38: Grand Case Chf Final Na Final Na Final Na True

lymphocyte counts

such as

corticosteroids and

immunosuppressive

drugs. (Medical –

Surgical Nursing 7th

edition by Joyce M.

Black pp. 2263)

Analysis:

Based on the results taken, the hemoglobin and hematocrit of the patient appears to

be low due to her anemic condition. While the WBC and Segmenter count of the patient

appears to be high, this indicates infection. Lastly, Lymphocytes count suggests a very high

risk of infection.

CHEMISTRY

August 26, 2010

LABORATORY EXAM

RESULT NORMAL VALUES

Interpretation Analysis

FBS 12.84 4.2-6.4 mmol/L Increase An increase in FBS level which indicates hyperglycemia, and a sign of diabetes. . (Medical – Surgical Nursing 7th edition by Joyce M. Black pp. 2263)

Cholesterol 3.07 3.8-6.7 mmol/L Within Normal Range

Uric Acid 9.3 2.5-8.0 mg/dL Increase In humans, uric acid is the major

end product of purine

catabolism in the absence

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of urate oxidase.

Increase in Uric acid

levels result in

hyperuricemia. (Medical –

Surgical Nursing 7th

edition by Joyce M.

Black pp. 90)

August 25, 2010

LABORATORY EXAM

RESULT NORMAL VALUES

Interpretation

Analysis

Sodium 131.2 135-148 mmol/L

Decrease Accourding to Black and

Hawks decrease level of sodium

indicates possible

malabsorption

(Medical- Surgical

Nursing, 7th

Edition Vol. 1 pp 782)

Potassium 6.9 3.5-5.3 mmol/L Increase According to Black and

Hawks, increased potassium indicates

hyperkalimia (Medical- Surgical

Nursing, 7th

Edition Vol. 1 pp 782)

August 27, 2010

LABORATORY EXAM

RESULT NORMAL VALUES

INTERPRETAION

ANALYSIS

Potassium 7.55 3.5-5.3 mmol/L

Increase According to Black and

Hawks, increased potassium indicates

hyperkalimia (Medical-

Surgical Nursing, 7th

Edition Vol. 1 pp 782)

Triglycerine 2.39 0.68-1.9 Increase High level of

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mmol/L triglycerine indicates

high level of sugar,

alcohol and calories

associated with

diabetes, kidney

disease and liver disease

((Medical- Surgical

Nursing, 7th

Edition Vol. 1 pp 782))

August 29, 2010

LABORATORY EXAM

RESULT NORMAL VALUES

Interpretation

Analysis

Potassium 7.6 3.5-5.3 mmol/L Increase Patient LB has an

increased in potassium

level, it indicates

hyperkalemia,

dehydration, acute or chronic kidney failure,

diabetes or infection. (Medical- Surgical

Nursing, 7th

Edition Vol. 1 pp 782)

August 30,

2010

LABORATORY EXAM

RESULT NORMAL VALUES

Interpretation Analysis

Creatinine 739 50-70 umoL/L Increase High level of creatinine indicates a

disease that affects the

kidney (Medical- Surgical

Nursing, 7th

Edition Vol. 1 pp 782)

Potassium 6.7 3.5-5.3 umoL/L Increase Increased potassium

level indicate hyperkalemi

a.(Medical- Surgical

Nursing, 7th

Edition Vol. 1 pp 782)

Page 41: Grand Case Chf Final Na Final Na Final Na True

August 28, 2010

ARTERIAL BLOOD GAS

Analyte Normal Values Results Interpretation & Analysis

pH 7.35-7.45 7.30 AcidosisPCo2 35-45 40 NHCo3 22-26 17 AcidosisPO2 80-100 75

Analysis:

Metabolic Acidosis

Troponin Test

August 26, 2010

LABORATORY EXAM

RESULT NORMAL VALUES

Interpretation Analysis

Troponin T (-) (-) Troponin is negative

She/He can still have the narrowings in the heart tubes that have not totally

blocked. (Medical- Surgical

Nursing, 7th

Edition Vol. 1

Page 42: Grand Case Chf Final Na Final Na Final Na True

pp 782)

RADIOLOGY

Chest X – ray

A chest x ray is a procedure used to evaluate organs and structures within the chest

for symptoms of disease. Chest x rays include views of the lungs, heart, and small portions

of the gastrointestinal tract, thyroid gland and the bones of the chest area. X rays are a form

of radiation that can penetrate the body and produce an image on an x-ray film.

CHEST PHYSICAL ASSESSMENT –

RESULTS: Lungs are clear.

Heart is enlarged.

Aorta is lertous.

Diaphragm sulci are intact.

IMPRESSION: Cardiomegaly

Anleromatous Aorta

Analysis:

Patient LB developed cardiomegaly due to Congestive Heart Failure.

SONOGRAPHYUltrasound

Abdominal ultrasound is an imaging procedure used to examine the internal organs of the

abdomen, including the liver, gallbladder, spleen, pancreas, and kidneys. The blood vessels

that lead to some of these organs can also be looked at with ultrasound.

SONOGRAPHIC RESULTS:REQUEST: Whole Abdomen

Liver: The liver is normal in size, shape & echo pattern

No discrete mass or dilated Intrahepatic duct seen

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Impression: Normal study of the Liver.

Gallbladder: Wall is not thickened

No Intraluminal echogenicitis seen

Impression: Normal study of the Gallbladder

Common Duct: The common duct measured 0.4cm

Impression: It is normal in caliber

Pancreas: The pancreas is normal in size, shape & echo pattern

No discrete mass lesion seen

Impression: Normal study of the Pancreas

Spleen: The spleen is normal in size & echo pattern

No discrete mass lesion or calcification seen

Impression: Normal study of the Spleen

Kidneys: The right kidney measured 6.3 x 3.1cm while the left kidney

measured 7.3x

4.1cm

Both kidney appears small with diffusely increase

parenchymal echogenicity

No lithiasis or hydronephrosis seen

Impression: Chronic nephropathy, bilateral.

Urinary Bladder: Urinary Bladder was not adequately distended.

Analysis:

Patient LB has Cardiomegaly which can be caused by a number of different conditions,

including diseases of the heart muscle or heart valves, high blood pressure, arrhythmias,

and pulmonary hypertension. Cardiomegaly can also sometimes accompany

longstanding anemia. Also Chronic Nephropathy, a renal disease that can lead to

cardiovascular disease and pericarditis.

ELECTROCARDIOGRAPHY

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ECG Sep. 4, 2010

9:30pm

Actual Findings

PR Int.: 271

P/QRS/T Int (MS): 118, 96, 182

QT/QTC Int. (MS): 434, 446

P/QRS/T Axis (Deg): 71,52

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MANAGEMENT

I. MEDICAL MANAGEMENT

-DOCTOR’S ORDER

August 26, 2010

7:15pm

Patient LB admitted to MS ward. Dr. Bartolome gave orders of diabetes drugs -

1800kcal/ day to begin in 30 meals & strict aspiration precaution. Dr. Bartolome request for

CBC, Blood type, Na K, HGB, ECG, BUN, Creatinine and 2d Doppler. He ordered PNSS 1L x

16°, ISMN 30mg/ tab OD, Cefoxitin 2g/50 ml IV every 6 hours. He also ordered intermediate

insulin 15 Units, Clonidine 5mcg. tab for BP 130/100, Diphenhydramine 1cap- 5 and to

prepare 2 units PRBC to be transfuse. Other medications ordered; Allopurinol 300mg/tab OD,

Simvastatin 20mg/tab OD in PRN, Ranitidine 50mg Q8 TID, Lactulose syrup 30ml OD. Other

orders; Monitor Vital signs Q2, to be refer and record, monitor Input and Output every shift

to be refer and record and “Monitor CBG”.

7:30pm

Refer of CBG in 255mm/hr.

11:10pm

Patient LB’s blood pressure arise at 160/120, Dr. Bartolome ordered Furosemide

40mg. For chest pain, D50 50cc + 10”u” x 15 x 3 doses. He also ordered diet of no fruits/

juices. For hyperkalemia, he ordered nebulization of salbutamol every 8°. Patient LB hook to

cardiac monitor.

August 27, 2010

1:25am

Patient LB’s heart rate arises to 120bpm and have (+) crackles. Dr. Bartolome ordered

Furosemide 40mg, Isoket drip 15mgtts/hr and Lanoxin 0.125mg slow IV. Monitor vital sign,

input and output Q1 and record. For insertion of Foley catheter and connect to urine bag.

Other medication: Morphine 2mg via IV. For withhold intermediate insulin in the morning.

6:00am

Progress Note: CBG-96mg/dl

10:30am

IVF to follow: PNSS 1L x 16°

Isoket to consume

7:15pm

IVF to follow: PNSS 1L x 16°

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August 28, 2010

8:00 am

Dr. Bartolome ordered for a repeat ECG and IVF to follow: PNSS 1L x 16°

5:00pm

Patient has serum potassium of 7.55; ECG peak at T. waves. Dr. Bartolome ordered

calcium gluconate 1 ampule slow IV push, D50, NaCl 8”u” Q6 for 3 doses and after he then

ordered repeat serum Sodium and potassium.

August 29, 2010

7:45am

Dr. Bartolome ordered diet as no fruits. For medication; hold ranitidine and

omeprazole 20mg/tab OD.

2:45pm

IVF of D5050 1 vial +8”u” on D5w to run for 6° for 3 doses.

6:15pm

Continue IVF of PNSS 1L x 16°

August 30, 2010

10:35am

Dr. Bartolome request for Sodium and Potassium and a followed up laboratory results.

3:25pm

Dr. Bartolome ask a service of nephro for evaluation of laboratory results. He ordered

Calcium gluconate 1 ampule slow IV push now, D5050 1vial + 8 “u” of insulin q6 x 3 doses,

MaHCo3 1tab TID, IVF to follow PNSS 1L x 16°

August 31, 2010

7:15am

Continue followed up nephro referral and continue medications ordered by Dr.

Bartolome.

11:00am

Continue IVF PNSS 1L x16°

September 01, 2010

8:00am

Dr. Bartolome ordered repeat serum potassium and a request for creatinine. Continue

IVF to follow D5.03 Nacl 500cc x KVO; Continue medication.

12:00nn

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Limit oral intake to 1.5 L/day

Maintain current IVF PNSS x 10ml/ hr

Consume present IVF and shift to heplock

Diet:

- 1800 kcal/ day, 40g CHON of high biologic value (no pork and beef), 2g Na

- 800mg, phosphorus diet, no fruits in diet

- Monitor I & O quantitatively and record pls.

Diagnostics:

ABG:

- Relay labs today: creatinine 1 Ca, K 2D echo with Doppler once stable

Allopurinol 100mg 1 tab OD

- Hold captopril

- No ACE/ ARBS, no NSAIDS

- Start carvedilol 6.25mg/ tab, BID

- Hold furosemide

- Ciprofloxacin 500mg/ tab BID

- Adjust meds for ECC (estimated creatinine clearance)

- Refer for urine output <30ml/hr

- Erythropoietin 4000 “u” 8Q 2x/ week

- Refer accordingly

Progress Notes:

History and Physical Examination received

Awaiting laboratory results

AKL 2° UTI on top of CKD 2° DM nephropathy cardiorenal syndrome

Hyperkalemia probably 2° CKD, drug induced

Hyperuricemia

Will await labs today if patient’s hyperkalimia remains unintractable

Advise patient’s to start hemodialysis

September 02, 2010

8:00am

IVF to follow PNSS 1Lx10cc/hr

September 03, 2010

11:50am

Shift IVF to heplock

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6:30pm

For repeat potassium and creatinine. Continue medication.

11:20pm

Dr. Bartolome ordered IVF PNSS 1L x KVO, D50 50 cc + 10 “u” x 3 doses q 1°.

Progress Note: Potassium of 6.64

September 04, 2010

2:00am

Patient LB hook IVF PNSS x KVO with side drip of D50 50cc +10 “u” as ordered by Dr.

Bartolome, shift to heplock

11:30am

Progress Note: Hgt 287 mg/ dl

07:00pm

Patient LB for ECG, repeat sodium and potassium, IVF to follow PNSS x KVO

September 05, 2010

7:05am

Continue IVF PNSS x KVO

2:30am

For repeat CBC

September 06, 2010

6:10am

Dr. Bartolome ordered Amlodipine 5mg 1tab OD and to consume IVF of PNSS x KVO &

shifted to heplock. He ordered to transfer 2 units PRBC to consume. IVF to follow PNSS 1L x

16°

Progress Note: Bp: 140/70 160/90

6:10pm

Progress Note: HGT of 7.4

7:30am

For hemodialysis once with temporary access and inform the Dr. Bartolome.

Hemodialysis preparation and 2 ½ hour every 8 150ml/ mi, and QID 300ml/ min

Progress Note: Discuss the need for hemodialysis with the children. Indication of

uremia, intractable hyperkalimea

September 07, 2010

7:00am

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Dr. Bartolome ordered D50 50cc +10 “u” x 3doses

Progress Note: Potassium of 9.74

8:00am

Continue IVF PNSS 1L x KVO. Patient LB for possible transfer to tertiary hospital for

dialysis.

September 08, 2010

8:30am

IVF to follow PNSS 1L x KVO

September 09, 2010

7:00am

Nephro notes

Recommendations:

- Ciprofloxacin to 500g OD per orem

- May remove Foley catheter

- Limit oral fluid intake to ≤ 1L/ day

Diet 1800 kcal/ day

- 20g of Na/ day

- 80mg of Phosphorus/ day

- 50g of CHON of high biologic value

- Diabetic and low fat, low purine diet

*refer for dietician for further instruction

- MGH after blood transfusion of 1 “u” of PRBC, properly type and crossmatch

Progress Notes: Bp 120/ 80 140/80

(-) edema

10:15am

Additional order and hold insulin temporarily

01:00pm

For CT Scan

Progress Note: 160/80

September 10, 2010

8:00am

Repeat CBC 6° prior to Blood Transfussion.

8:30pm

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1 unit PRBC secure properly type and Crossmatch, With continue IVF to consume then

disconnect. Dr. Bartolome ordered MGH anytime. Continue medication and advise to follow

up after dialysis.

Progress Note: hgb: 89, hct:0.26

II. NURSING CARE AND MANAGEMENT

a. Assessment/Interventions: Monitor vital signs/oxygenation/Neuro status (report changes in heart and

respiratory rate/patterns as well as changes in LOC). Daily weight (a 2.2 kg weight increase over a 1 day period is considered

significant). Breath sounds (monitor for increased crackles, rhonchi or pulmonary

congestion).

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Capillary refill (if greater than 3 seconds, assess for signs of peripheral edema).

The presence of jugular vein distention (jugular vein distention can be a sign of worsening right sided heart failure).

The presence of hepatomegaly (also a sign of worsening right sided heart failure).

The presence of ascites (also a sign of worsening right sided heart failure). EKG changes Evaluate electrolyte levels (sodium, potassium and creatinine) Digoxin levels (if patient taking Digoxin) Pain level (degree, quality, source, location, onset and relieving factors) Intake and Output (monitor effects of diuretic therapy and observe for signs

and symptoms of either fluid overload or deficit) Assess degree of discomfort associated with activity (provide a proper

rest/activity balance. Group nursing interventions when appropriate). Monitor for restless, anxious behavior and promote self care participation. Maintain adequate bowel function (stool softeners such as Colace should be

ordered to prevent constipation).

b. Patient Teaching: The following patient/family education should be provided prior to discharge

andshould also be reiterated at post discharge office visits: Discharge medication regimens Diet (low sodium) Fluid restrictions Activities of daily living Exercise Smoking cessation/avoidance Available community resources/referrals The importance of making and keeping Dr.’s appointments Avoiding infection (flu/pneumovax vaccines) Self monitoring (when to report symptoms or changes such as shortness of

breath, dyspnea, changes in weight [greater than 2.2 lbs over 1-2 days], pedal edema, blood pressure changes, nausea or fatigue).

DISCHARGE PLANNING

M >Remind client to take furosemide, Catapres, Isordil, amlodepine, ISMN, and sucralfate

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as prescribed.

>Instruct the relative to follow medication regimen.

E >Encourage the relative to do some exercises like a passive range of motion in

affected and unaffected parts of the body of the client.

T > Educate & instruct the family to monitor the blood pressure and pulse rate before

administering medication.

>Emphasize patient education with intense instruction regarding compliance with

dietary restrictions and medical therapy.

>Require patients to promptly follow up with their primary care physician or

cardiologist.

H >Inform the relative the importance of proper hygiene of the patient from head to toe.

>Educate and instruct the relatives on what proper food to give.

O >Inform the family of the patient to have a regular check-up for the continuity of

treatment.

>Instruct the family of the patient to monitor if there is any sudden change to the

patient and report immediately.

D >Instruct the relative to feed the client on time with nutrition food that is low in

sodium, low in cholesterol, low in fat and give citrus fruits, moderate in fluid intake and

increase fiber diet to improve health.

>Follow the diet prescribed by the doctor.

EVALUATION

The nursing interventions given to the patient has become helpful. Her

pulmonary signs and symptoms were treated. With the latest diagnostic exam done,

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the chest x-ray was found clear. But the patient, due to renal impairment as

complication of her CHF and DM II is arranged to undergo hemodialysis.

RECOMMENDATION

Watch out for blood cholesterol because too much cholesterol may cause fatty

deposits to form in arteries—impeding blood flow and increasing the risk for complications,

and limit sodium rich food intake. Lifestyle changes are recommended—including the

nutritional diet such as limiting fats—specially saturated fats, eating fiber rich foods, fish—

rich in omega 3 fatty acids which is good for the heart, and fresh fruits and vegetables,

which contains antioxidants, and vitamins and minerals that help prevent everyday wear and

tear of coronary arteries. Exercise regularly to help make the heart stronger and lower down

blood pressure. Stop smoking or avoid exposure to second hand smoking. Restrain from

drinking alcoholic beverages. Rest in bed until breathing is easier and feel stronger. Then,

slowly return to your normal activities. Get at least 7 hours of rest each night and take naps

when feeling tired. Avoid being stress. Drink medications as prescribed such as diuretics and

heart medications