Scolio,Heart Failure

7/29/2019 Scolio,Heart Failure

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Ryan Oneil A. Lomeda SCOLIOSIS 1/19/12BSN 4A2

Assessment Nursing Diagnosis Sci. Explanation Planning Nursing Intervention Rationale Evaluation

Subjective Data:Masakit yung likod konagsimula etodalawang araw ng

nakakalipas nungnatulog ako sa sofa,as stated

Objective Data:

14 y/o

5/10 pain scaleon lower back

Left shoulder ishigher thanright

Obvious S-shaped spine

X-ray revealed

a lateralcurvature oflumbar spine

Acute Pain related tostructural changes

secondary toscoliosis aeb 5/10pain scale on lowerback, left shoulder is

higher than right ,obvious S-shaped

spine, x-ray revealeda lateral curvature of

lumbar spine

Predisposing Factors:GeneticsSex: Female

Age: 14 y/o

Carrying books on herright side

Prolonged improperpositioning

Spine progressivelybends to one side tocompensate for thedeficit

Ligaments surroundingthe vertebral joints getstretched and tightenaccording to positionusually maintained(Right)S/sx:

Left shoulder ishigher thanright

Spine rotated slightlyon its axisS/Sx:

Obvious S-shaped spine

X-ray revealeda lateral

curvature oflumbar spine

Ribs rotates as well

Discharge Outcome:Upon discharge, theclient will be able toreport pain is relieved

aeb:a. Pain scale 0/10

b. Use of correctivedevice to alleviate pain

Short Term Goal:After 8 hours of nursingintervention, the clientwill:a. Participate intreatment regimen toalleviate pain

b. Demonstrate use ofrelaxation skills anddiversional activities

c. Verbalize non-pharmacologicalmethods to providerelief

d. Pain scale of 3/10from 5/10

Independent:

Re-assess vital signsespecially pain anddetermine the

causative /contributing factors ofthe presentingproblem

Accept clientsdescription of pain.

Acknowledge thepain experience andconvey acceptance ofclients response topain

Provide comfortmeasures ( touch,repositioning, use ofwarm/cold compress)

Encourage use ofrelaxation techniquesand diversionalactivities (focusedbreathing, watchingTV, imaging)

Encourage adequaterest periods

Pain is the fifth vitalsign and usuallyalters the vital

signs. Re-assessingdetermines theneed to modifyinterventions set

Pain is a subjectiveexperience andcannot be felt byothers and toestablishappropriatetreatment planspecific toindividual situation

Promotes non-pharmacologicalpain management

Distracts theattention from painfelt and reducetension. Promotesnon-pharmacologicalpain management

Prevents fatigueand overexhaustion

Short Term Goal:After 8 hours of nursingintervention, the client:a. Participated in treatmen

regimen to alleviate painaeb:-Proper positioning-Adequate rest periodbetween activities-Correct usage ofMilwaukee Brace-Intake of Tramadol 50 mg

b. Demonstrated use ofrelaxation skills anddiversional activities aeb:-Deep breathing exercise-Watching TV-Guided Imagery

c. Verbalized non-pharmacological methodsto provide relief aeb:-Usage of Milwaukee Brac-Proper positioning-Adequate rest periodbetween activities

d. Verbalized pain scale of3/10 from 5/10 aeb:-Intake of Tramadol 50 mg-Proper positioning-Adequate rest period

between activities

Goal Fully Achieved>Terminate Nursing Care


2/12

Acute PainS/sx:

5/10 pain scaleon lower back

Reference:

Pathophysiology for theHealth Professions 3rd

ed. by Gould, p. 1245

Prepare the child forimmobilizationprocedure byshowing materials tobe used andprocedure in age-appropriate terms

Provide opportunityfor the child toexpress fears andask questions aboutdeformity and bracewear

Instruct the child toassess the skin underand around the bracefrequently for signs ofskin breakdown

Instruct the patient toexamine brace dailyfor signs of looseningor breakage

Instruct patient towear cotton shirtunder brace to avoidrubbing

Bracing is used tohalt the progressionof the curve.

Bracing is used tohalt the progressionof the curve. Airingout the concern ofthe child andproviding answerswill increase thecompliance to theregimen

Braces touching theskin surfaces cancausing skinexcoriation and

discomfort

Brace should be fitand exert adequatecompression andtraction to correctcurvature

Braces should beworn over a T-shirtto prevent theplastic pads fromtouching the skin

surfaces andcausing skinexcoriation

Plan

Discharge Outcome:Upon discharge, the clientreported pain is relievedaeb:a. Pain scale 0/10

-Intake of Tramadol 50 mg-Proper positioning-Adequate rest periodbetween activities

b. Used of corrective devicto correct deformity-Correct usage ofMilwaukee Brace 23hour/day-Demonstrated how toapply Milwaukee Brace

Goal Fully Achieved>Terminate Nursing Care

Plan


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Instruct about whichprevious activitiescan be continued inthe brace

Inform patient thatMilwaukee brace isworn 23 hours a day

Teach mother andpatient how to applythe braces

Collaborative:

Administermedications asordered: Tramadol 50mg q 8

Notify Physician ifregimens areinadequate to meetpain control andcorrection

Refer patient to an

The Milwaukeebrace should beworn for 23 hours aday and can beremoved forparticipation inschool activitiesand to promote thecorrection ofcurvation andprevent furtherprogress

The brace can betaken off whentaking a bath but nomore than 1 hour topromote thecorrection ofcurvation andprevent furtherprogress

Brace should be fitand exert adequatecompression andtraction to correctcurvature

To maintainacceptable levelof pain.

To maintainacceptable levelof pain.

Frequent follow-up


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Orthopedic Doctor are necessary tocheck the fit of thedevice

Reference:Maternal and Childby Pillitteri vol. 2 p.1627


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Ryan Oneil A. Lomeda LEFT-SIDED HEART FAILURE PULMONARY EDEMA & CAP 1/13/12BSN 4A2


Subjective Data:Nahihirapan akonghuminga at masakitang dibdib ko, madaliakong mapagod atnagigising ako tuwingmedaling araw, asstated

Objective Data:

66 year old female

Vital Signs:HR = 90RR = 22T = 37.5BP = 130-140/90

Dyspnea on exertionwith ordinaryphysical activity

mild to moderatechest pains

easy fatigability

ParosysmalNocturnal Dyspnea

(+) Orthopnea

Cardiac Asthma withCheyne-StrokesRespiration

S3 gallop on heartsounds

cough

runny nose

(+) DM 2

(+) CAD

ST-Elevated Anterior

Fluid volume excessrelated to impairedcardiac contractility

secondary tomyocardial infarctionaeb dyspnea, chest

pain, easy fatigability,orthopnea, cheyne

stroke respiration, S3gallop, cough

Discharge Outcome:Upon discharge, theclient will be able tomaintain fluid volume ata normal level aeb:a. individually adequateurine output

b. stable vital signs

c. absence of cough

d. absence ofadventitious breathsounds

e. absence of extraheart sound

Short Term Goal:After 8 hours of nursingintervention, the clientwill:a.Verbalizeunderstanding ofcausative factors andpurpose of treatmentregimen

b. Demonstrate at least3 behaviors to monitorand correct fluid excess

c. Demonstrate lifestylechanges to promotecardiac health

Independent:

Re-assess vitalsigns and determine

the causative /contributing factors ofthe presenting problem

Auscultatebreath sounds and notefor presence ofadventitious breathsounds

Auscultate hearttones for extra heartsounds and murmur

Evaluate level ofconsciousness

Restrict fluidintake to 2-2.5L/dayand sodium intake

Monitor I/Oaccurately, calculate 24hour fluid balance

Establishes abaseline data todetermine the needto modifyinterventions set

To note if there ispresence ofadventitious breathsounds indicatingfluids in the lungs

To note if there ispresence of extraheart sounds ormurmur indicating of

myocardial injury

Increase blood in thelungs impairs thetissue perfusion andcauses respiratoryacidosis causingchanges insensorium

To decrease theamount of circulatingblood volumewater

Measures adequatefluid intake andretention in the body

Short Term Goal:After 8 hours of nursingintervention, the client:a.Verbalizedunderstanding of causativfactors and purpose oftreatment regimen aeb:> Knowing thecomplications> Knowing the prevention> Knowing the treatments

b. Demonstrated 4interventions to monitor ancorrect fluid excess-Monitor input and output-Fluid intake restriction to 2.5L/day

-Sodium diet restriction-Proper positioning semfowlers position

c. Demonstrated lifestylechanges to promote cardiahealth aeb:-increased bed rest, restperiods in betweenactivities-decreased stress or stimu-Fluid intake restriction to 2.5L/day-Sodium diet restriction

Goal Fully Achieved>Terminate Nursing CarPlan


6/12

Wall MyocardialInfarction

Heart Failure stage C

ECG= CardiomegalyLeft VentricularHypertrophyOld Anterior-Septal

Wall MI V1-V3. CHEST PA=

CardiomegalyAtheroscleroticAorta withsignificantpulmonarycongestion

(+) Interstitial Edemawith loss of pulmonarymarkings(+) Kerley A & B Lineswith subpleural fluid

ECHO-CARDIOGRAPHICFINDING= DilatedCardiomyopathy,with Coronary

Artery Disease,Left VentricularSystolicDysfunction(Segmental), withmoderate RightVentricularDysfunction andDepressedEjection Fraction Lside

Place patient ina semi-fowlers position

Weigh patientdaily on a regular

schedule

Provide a quiteand peacefulenvironment anddecrease stimulus

Encourage 30mins. Of light physicalexercise, as tolerated

Inform patientregarding medicationsto be taken: effect,dosage, frequency,route, adverse effects,routine laboratorymonitoring

Reinforce topatient the need forheart transplant

Inform patientregarding surgery

Collaborative:

Establish an IV

Facilitates venousreturn

Evaluates theeffectiveness ofdiuretic therapy

To decrease cardiacload, oxygenconsumption and riskfor decomposition

Maintains regularphysical activities andprevent contractures

Educate the client tobe known ofpharmacologicregimens

Educate the client tobe known of the needfor surgery

Educate the client tobe known ofoutcomes regardingcondition

To support steadyrehydration overtime

Discharge Outcome:Upon discharge, the clientwas able to maintain fluidvolume at a normal levelaeb:a. individually adequateurine output:-30cc/hour

b. stable vital signsHR = 80RR = 20T = 36.5BP = 130/90

c. absence of cough

d. absence of adventitiousbreath sounds

e. absence of extra heart

sound

Goal Fully Achieved>Terminate Nursing CarPlan


7/12

line of 0.9 NaCl, asordered by thephysician.

Administer O2therapy via O2 cannula@ 2-4LPM

Administerprescribed medications:

ACE inhibitors(captopril)

Vasodilator(Nitroglycerin)

Beta blockers(metropolol)

Spironolactone(aldosterone)

Digitalis (digoxin)

Calsium ChannelBlocker

Lipid-Reductase(simvastatin)

O2 therapy is givento supply anadequate amount ofO2 in the body

Decreases after loadand preload

Decreases BP andpreload by dilatingthe coronary artery

Blocks adrenergicsite receptor causingdecrease HR andcontractility

Inhibits sodium

reabsorption in thedistal tubule andcollecting ducts

Improves cardiaccontractility

Prevents calcium ionto enter the smoothmuscle causingrelaxation anddilation of muscle

Reduces cholesterol

level

Collaboratesintervention to


8/12

Refer to otherhealthcareprofessionals: dietitian,surgeon, cardiologist

improve health andclients well-being

Reference:Medical SurgicalNursing 12th ed byBrunner andSuddarth pp. 829-837


9/12

Ryan Oneil A. Lomeda RIGHT-SIDED HEART FAILURE HYPERTESION 1/14/12BSN 4A2


Subjective Data:Mabilis akong mapagodngayon, tsakanadagdagan ang akingtimbang at may manas paako, as stated

Objective Data:

50 year old male

Vital Signs:HR = 98RR = 22T = 37BP = 140/100

Hypertensive

Non-compliant

Eddematous lower

extremities easy fatigability

weight gain from 86 lbsto 100 lbs

(+) DM 2

Easy satiety

Hepato-splenomegaly

Elevated jugular venouspressure

Ascites

ECG= Cardiomegalyand Right VentricularHypertrophy

CHEST PA=

CardiomegalyAtherosclerotic Aorta withno pulmonary congestion

Fluid volume excessrelated to ineffective

right ventricularpump secondary tohypertension aeb

dyspnea, chest pain,easy fatigability,

orthopnea, cheynestroke respiration, S3

gallop, cough

Discharge Outcome:Upon discharge, theclient will be able to:a. eliminate or reduceany etiologic

b. maintain fluid volumeat a normal level aeb:-individually adequateurine output-stable vital signs-absence of peripheraledema

Short Term Goal:After 8 hours of nursingintervention, the clientwill:

a.Verbalizeunderstanding ofcausative factors andpurpose of treatmentregimen

b. Demonstrate at least3 behaviors to monitorand correct fluid excess

c. Demonstrate lifestylechanges to promotecardiac health

Independent:

Re-assess vitalsigns and determinethe causative /contributing factors ofthe presenting problem

Auscultate hearttones for extra heartsounds and murmur

Assess for skinbreakdown

Monitor I/Oaccurately, calculate 24hour fluid balance

Weigh patientdaily on a regularschedule

Encourage 30mins. of light physical

Establishes abaseline data todetermine the needto modifyinterventions set

To note if there ispresence of extraheart sounds ormurmur indicating ofmyocardial injury

Decreased circulationin edematous areasare at risk forpressure ulcer and

skin breakdown

Measures adequatefluid intake andretention in the body

Evaluates theeffectiveness ofdiuretic therapyTo prevent fluidaccumulation sincesodium attracts water

Helps prevent

pressure ulcer andincreases venousreturn

Short Term Goal:After 8 hours of nursingintervention, the client:a.Verbalizedunderstanding of causafactors and purpose oftreatment regimen aeb> Knowing thecomplications> Knowing the prevent> Knowing the treatme

b. Demonstrated 5interventions to monitorcorrect fluid excess-Daily weight-Monitor input and outp-Fluid intake restriction

2.5L/day-Sodium diet restriction-Proper positioning sefowlers position

c. Demonstrated lifestychanges to promote cahealth aeb:-compliance withmedications prescribed-increased bed rest, resperiods in betweenactivities-decreased stress or sti

-Fluid intake restriction 2.5L/day-Sodium diet restriction


10/12

ECHOCARDIOGRAHICFINDING=Dilated CardiomyopathyCoronary Artery DiseaseRight VentricularDysfunction moderateLeft VentricularDysfunctionDepressed EjectionFraction R side

exercise especially thelegs or edematousareas, as tolerated

Restrict fluidintake to 2-2.5L/dayand sodium intake

Measure jugularvein distention

Place patient ina semi-fowlers position

Elevateedematous areas (legs)or support with pillow

Frequentlychange the position ofthe patient

Provide a quiteand peacefulenvironment anddecrease stimulus

Inform patientregarding medicationsto be taken: effect,dosage, frequency,route, adverse effects,

To decrease theamount of circulatingblood volume

Stagnation of bloodleads to venous

system engorgementand increase CVP

Facilitates venousreturn

Venous return isreduced, andpressure ondiaphragm is relieved

Positioning avoidspressure ulcer and

skin breakdown

To decrease cardiacload, oxygenconsumption and riskfor decomposition

Educate the client tobe known ofpharmacologicregimens

To support steady

Goal Fully Achieved>Terminate Nursing CPlan

Discharge Outcome:Upon discharge, the cliewas able toa. eliminate or reduce a

etiologic

b. maintain fluid volumea normal level aeb:-individually adequate uoutput> 30cc/hour

-stable vital signs> HR = 80> RR = 20> T = 36.5> BP = 130/90

-absence of peripheraledema> Regained normal wei86 lbs> non-tender RUQ> non-edematous loweextremities

Goal Fully Achieved>Terminate Nursing CPlan


11/12

routine laboratorymonitoring

Collaborative:

Establish an IVline of 0.9 NaCl, asordered by thephysician.

Administer O2therapy via O2 cannula@ 2-4LPM

Administerprescribed medications:

ACE inhibitors(captopril)

Vasodilator(Nitroglycerin)

Beta blockers(metropolol)

Spironolactone(aldosterone)

Digitalis (digoxin)

Calsium ChannelBlocker

rehydration overtime

O2 therapy is givento supply anadequate amount ofO2 in the body

Decreases after loadand preload

Decreases BP andpreload by dilatingthe coronary artery

Blocks adrenergicsite receptor causingdecrease HR andcontractility

Inhibits sodiumreabsorption in thedistal tubule andcollecting ducts

Improves cardiaccontractility

Prevents calcium ionto enter the smoothmuscle causingrelaxation anddilation of muscle

Reduces cholesterollevel


12/12

Lipid-Reductase(simvastatin)

Refer to otherhealthcare

professionals: dietitian,cardiologist

Collaboratesintervention toimprove health andclients well-being

Reference:Medical SurgicalNursing 12th ed by

Brunner andSuddarth pp. 829-837

Scolio,Heart Failure

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