199075883 case-pres-chf-with-hyperipidemia-and-uti

1. Get Homework/Assignment Done Homeworkping.com Homework Help https://www.homeworkping.com/ Research Paper help https://www.homeworkping.com/ Online Tutoring https://www.homeworkping.com/ click here for freelancing tutoring sites Mr. Osel Sherwin Melad Clinical Instructor, Medicine Ward Rotation (Lower Annex) College of Nursing Silliman University Dear Sir: We are Level III students of Silliman University College of Nursing and currently assigned for this 2nd semester duty in Medicine Ward Rotation at Negros Oriental Provincial Hospital, Lower Annex, in the 7-3 pm or 2-10 pm shift during Saturdays and Sundays. In this connection, we would like to apply for a case study on the case of Mrs. Lydia Rafales, a 63-yr. old resident of Looc, Dumaguete City, Negros Oriental. She was diagnosed with Congestive Heart Failure with hyperlipidemia and UTI.

2. We are interested in this case since this can further enrich our knowledge and improve our skills toward the care of this patient. In this way, we could further share our knowledge to all our classmates during the case presentation on Saturday March 25, 2006 at AVT II. We are hoping for your favorable response. Thank you very much and God Bless! Sincerely Yours, FRUSSELL V. ELTANAL BSN-III BERYL GRACE S. VINCOY BSN-III Acknowledgment: We would like to express our gratefulness… First of all to our Almighty God, for giving us the chance to have this kind of activity and for giving us the strength that we need,

3. To our teachers, for the concepts we have learned in the Medicine rotation, especially to Mr. Osel Sherwin Melad, who enriched us with their experiences and inspiration to thrive for excellence, To our clients, for their trust and accommodation, especially to Mrs. Lydia Rafales, for she is our very first client whom we chose for our case study, To our C.I. group for the spirit of unity and for never giving up despite of the problems we encountered, And to our loving parents and guardians who were there to support us financially and emotionally throughout the study, And for those who in one way or another have help in our case analysis, we are filled with happiness and gratitude for your immeasurable help. Thank You… TOPIC DESCRIPTION: The topic deals with the care of patient with a medical diagnosis of Congestive Heart Failure. This covers the psychosocial profile of the patient, which includes the demographic data with genogram, history of present illness, chief complaints, past medical history, anatomy and physiology of the affected systems, growth and development, physical assessment, pathophysiology of the disease, medical management, laboratory exams, pharmacology, nursing care plans, functional health patterns, two pertinent reading related to the topic and evaluation of the case study. CENTRAL OBJECTIVES:

4. At the end of the case analysis presentation, the learners shall improve their knowledge on the important concepts of caring with a patient who is diagnosed of having congestive heart failure, and shall also manifest positive attitudes and skills towards providing care to those patients including their family and significant others. SPECIFIC OBJECTIVES: Within our case study we will be able to: 1. Identify the demographic data of our patient including her genogram and ecomap 2. Review the anatomy and physiology of the affected systems 3. Trace and explain the pathophysiology of congestive heart failure 4. Utilize the nursing process with competence by making functional health patterns and nursing care plans for our patient 5. State the importance and the mechanism of actions of the medications given 6. Recognize the importance of laboratory exams 7. Utilize some medical management to give holistic care of our patient NURSING HISTORY Part I. Demographic Information  Name of patient: Rafales, Lydia  Civil Status: Married  Name of husband: Rafales, Teofilo  Sex: Female  Age: 63

5.  Address: Looc, Dumaguete City  Occupation: Vendor  Religion: Roman Catholic  Educational Attainment: Elementary Undergraduate  Nationality: Filipino  Room and Bed No.: FPA ward  Doctor(s) in charge: Dr. Joyce Maningo Date & Time of Admission: February 20, 2006 @ 11:10 am Chief Complaint(s): Dyspnea for one week Diagnosis: Congestive Heart Failure with hyperlipidemia and UTI General Impression of client (appearance upon first contact): • Received sitting on bed, appeared weak and restless, and oriented to environment. Responsive and answered questions coherently. IV line ifusing well @ right metacarpal vein @ KVO. O2 inhalation @ 2 L/min. T=37.6 C, P=73 bpm strong and regular, R=34 cpm shallow and effortless, BP=160/90 mmHg. Escolastico Duhaylungsod - 50 years old Gorgonia Duhaylungsod - died of cancer of the - 81 years old liver

6. Teofilo Rafales Lydia Rafales - 68 years old - 63 years old - non-smoker/non-alcoholic - CHF; hyperlipidemia; UTI drinker Richard Rebecca Rosalyn Rowena Remelyn Richel Rosemarie Rosa Rosa Mae 46 y/o 44 y/o 42 y/o 40 y/o 38 y/o 36 y/o 33 y/o 30 y/o 24 y/o Kidney failure cyst (operated) cyst asthma GENOGRAM ECOMAP Kauban sa Hospital Family Church: Dumaguete Cathedral

7. Lydia Rafales Organization 63 y/o Hospital Personnel/NOPH Neighborhood Market GROWTH AND DEVELOPMENT For many women and men in late adulthood life, sexuality has achieved a degree of stability. A sense of masculinity or femininity and comfortable patterns of behavior have been established. This increased security and identity can promote greater intimacy in sexual and social relationships. This may also be a time when adults allow themselves more freedom in exploring and satisfying sexual needs. Although menopause alters reproductive functioning, it does not physically inhibit sexual functioning. Generally, a woman with strong self image, positive sexual and social relationships, and knowledge regarding her body and menopause is likely to progress through this natural biologic stage without problems and remain sexually active and satisfied.

8. During midlife, men may begin to experience changes in sperm production, erectile power, achievement of orgasm, and sex drive, although these changes generally do not significantly alter reproductive or sexual functioning. Some men feel that these changes threaten their sexuality and “maleness” and may respond negatively. Other men feel these changes make sex more pleasurable and intimate and often respond positively. Actual sexual dysfunctions, as a result of physical and psychosocial changes, may arise at this time. Midlife is often a time when both men and women reexamine life goals, careers, accomplishments, value systems, and familial and social relationships. As a result, some people adapt, whereas others experience stress or a crisis. This reexamination can positively or negatively affect an individual’s and sexuality. According to Robert Havighurst, middle-adulthood is the time wherein men and women of this age adjust to aging of their parents, as well as having children to take care of. This is the reason why he labeled this as the “sandwich generation.” Moreover, he stated some developmental tasks that middle adults should accomplish, this includes: assisting teen-age children to become responsible adults; achieving adult social civic responsibility; reaching and maintaining satisfactory performance in one’s occupation (reach the peak of one’s career); relating to one’s spouse as a person; and, accepting and adjusting to physiologic changes of middle age. On the other hand, Erik Erickson stated that men and women under this stage should achieve a sense of generativity while avoiding self-absorption and stagnation. This means that a person may achieve a feeling of productivity, creativity as evidenced by reaching one’s previously established goals or he may feel unsuccessful because of his/her lack of accomplishments. Our client is 55 years old, she has five children and a husband. She admitted that she easily gets irritated even before she had her menopause. She also shared that she is stressed most of the time because she keeps on thinking about their family’s financial problem. She also admitted that she had some regrets of not finishing school, and that she is still wondering what would have happen to her if only she strived hard to graduate in college despite of their poverty. PHYSICAL ASSESSMENT GENERAL SURVEY VITAL SIGNS Sex: Female Temperature: 37.6 C Race: Filipino Pulse Rate: 73 bpm strong and regular

9. Age: 63 Respiratory Rate: 34 cpm shallow and regular Marital Status: Married BP: 160/90 mmHg Signs of Distress: Present Height: 4’9” Level of awareness: Conscious but restless Weight: 48 kls. Body type: normal and slim Posture: not erect Gait: coordinated Body movements: coordinated Hygiene and grooming: poor Dress/clothing: clean but not presentable Body and odor: no foul odor Mod and effect: irritable Speech: clear and understandable INTEGUMENTARY SYSTEM The client works excessively outside her house and her skin is exposed to heat due to her work as grilled pork or “tocino” vendor. Her skin color is same as before as claimed and there are no lesions. She has not experienced trauma with regards to her skin integrity. She doesn’t have food and drug allergies as claimed. She doesn’t also take vitamins and she takes a bath once a day. She uses bath soap and a shampoo. She also uses ointment whenever she feels pain. SKIN Color-dark brown Lesions-none Edema-none Scars-present on her legs and arms, but little only Mobility/turgor-slightly poor turgor and mobility Texture-not so smooth

10. Temperature-warm to touch NAILS She hasn’t experienced any trauma on her nails. She sometimes forgot to cut her nails and only cut it when she realized to do so. Fingernails: capillary refill at boundary (3 seconds) Color-slightly opaque, nail beds are not so visible Shape-convex and well-rounded Thickness-thick Angle-not approximately 160° HEAD The client hasn’t experienced any trauma in her head. She sometimes feels headache and dizziness as claimed. She has an experience of having dandruff. SCALP Presence of little dandruff noted No nits Scaliness noted HAIR The client basically is not using any wig. Her hair is washed by shampoo. She haven’t experienced a great loss of hair strands. Grayish in color Not evenly distributed Smooth Coarse Pliant

11. FACE Contour-round shape Symmetry-symmetrical Involuntary movement-none Edema-not noted Masses-not noted Scaliness noted around the cheek and just above the two eyebrows EYEBROWS Abundant, evenly distributed, no scaliness Masses not noted EYES Literate Conjunctiva and sclera - Pinkish, not swelling, no nodules palpated - Pupils (4 mm) equal in size, reactive to light and accommodation Extra ocular Movements - Can follow movements Eyelids - No masses palpated - Symmetrical movements of eyelids EARS

12. No deformities, appropriate size with the face and aligned with the lateral canthus of the eyes Symmetrical Cerumen noted with minimum amount Pinkish ear canal No drainage noted NOSE Symmetrical No deformity Size and shape is appropriate to her face No presence of tenderness and nodules Nasal mucosa is pink and moist Nasal septum is close to midline, thicker anteriorly than posteriorly SINUSES Not tender No masses and nodules palpated MOUTH Lips are ruddy pinkish, cracking of the lips noted No lumps and masses noted GUMS  With tight margin of gums, no bleeding, discoloration and growth

13. TEETH • With 15 teeth extracted, minimal dental caries noted • No abnormal shape and position • Yellow and with stains ROOF OF THE MOUTH/HARD PALATE • Whitish in color • Dome-shaped TONGUE • Dull red in color • Tongue can move with side to side • Floor of the mouth is highly vascular PHARYNX The uvula rise together with the soft palate when the patient says ”ahh” Enlargement of tonsils are not noted No ulcerations POSTERIOR AND ANTERIOR CHEST Health History: The client doesn’t smoke. She does have cough and increased secretions presently. Dyspnea noted and claimed. POSTERIOR CHEST Rate is not normal with 34 cycles per minute, regular Rhythm is regular

14. Depth-normal, not too shallow Effort-present Use of accessory muscle is noted Shape is elliptical with ribs sloping downward It is symmetrical Masses-absent Tenderness- absent Vibration is symmetrical Crackles noted over her lungs and dull sounds Vesicular sound in the upper posterior chest and the peripheral area, then in the middle part, presence of bronchovesicular sounds. Decreased breath sound noted ANTERIOR CHEST Rate is not normal with 34 cycles per minute, regular Rhythm is regular Depth is normal and not too shallow Effort is present Use of accessory muscle is present The ribs slope downward with symmetrical interspaces Absent of masses and tenderness Vibration is symmetrical Crackles sounds noted HEART The client has experienced body weakness and she cannot do her ADLs effectively because she gets easily tired and fatigue as claimed. She doesn’t smoke but she is exposed to smoke from grilling “tocino” everyday during those times. LOCATION

15. S1 (BELOW) – located at LMCL (Left midclavicular line) - below the nipple at the 5th ICS - with 97 beats per minute strong and irregular S2 (UPPER) – located at the right sternal border at the 2nd ICS - with 97 bpm strong and irregular S1 (UPPER) – at the left sternal border at the 2nd ICS - normal and regular on its sound and rhtythm ANATOMY AND PHYSIOLOGY Cardiovascular System: The Heart ANATOMY OF THE HEART Location and Size The size and weight of the heart give few hints of its incredible strength. Approximately the size of a person’s fist, the hollow, come-shaped heart weighs less than a pound. The heart is located within the bony thorax and is flanked on each side by the lungs. Its more pointed apex is directed toward the left hip and

16. rests on the diaphragm, approximately at the level of the fifth intercostals space. It’s broader posterosuperior aspect, or base, from which the great vessels of the body emerge, points toward the right shoulder and lies beneath the second rib. Coverings and Wall The heart is enclosed by a double sac of serous, the pericardium. The visceral pericardium, tightly hugs the external surface of the heart and is actually part of the heart wall. It is continuous at the base with the loosely applied parietal pericardium, which is reinforced on its superficial face by dense connective tissue. This fibrous layer helps protect the heart and anchors it to surroundings structures, such as the diaphragm and the sternum. A slippery lubricating fluid (serous fluid) is produced by the serous pericardial membranes. This fluid allows the heart to beat easily in a relatively frictionless environment as the pericardial layers slide smoothly across each other. The heart walls are composed of three layers: the outer epicardium, the myocardium, and the innermost endocardium. The myocardium consists of thick bundles of cardiac muscle twisted and whorled into ringlike arrangements. It is the layer that actually contracts. The myocardium is reinforced internally by a dense, fibrous connective tissue network called the “skeleton of the heart.” The endocardium is a thin, glistening sheet of endothelium that lines the heart chambers. It is continuous with the linings of the blood vessels leaving and entering the heart. Chambers and Associated Great Vessels The heart has four hollow chambers or cavities – two atria and two ventricles. Each of these chambers is lined with endocardium, which helps blood flow smoothly through the heart. The superior atria are primarily receiving chambers. As a rule, they are not important in the pumping activity of the heart. Blood flows into the atria under low pressure from the veins of the body and then continues on to fill the ventricles. The inferior thick-walled ventricles are the discharging chambers, or actual pumps of the heart. When they contract, blood is propelled out of the heart and into the circulation. The heart is somewhat twisted; the right ventricle forms most of its anterior surface; the left ventricle forms its apex. The septum the divides the heart longitudinally is reffered to as the interventricular or interatrial septum, depending on which chamber it divide and separates. Although it is a single organ, the heart functions as a double pump. The right side works as the pulmonary circuit pump. It receives relatively oxygen-poor blood from the veins of the body through the large superior and inferior venae cavae and pumps it out through the pulmonary trunk. The pulmonary trunk splits into the right and left pulmonary arteries, which carry blood to the lungs, where oxygen is picked up and carbon dioxide is unloaded. Oxygen-rich blood drains from the lungs and is returned to the left side of the heart through the four pulmonary veins. The circulation just described from the right side of the heart to the lungs and back to the left side of the heart, is called the pulmonary circulation. Its only function is to carry blood to the lungs for gas exchange and then return it to the heart. Blood returned to the left side of the heart is pumped out of the heart into the aorta from which the systematic arteries branch to supply essentially all body tissues. Oxygen-poor blood circulates from the tissues back to the right atrium via the systematic veins, which empty their cargo into either the superior or inferior vena cava. This second circuit, from the left side of the heart through the body tissues and the back to the right side of the heart, is called the systematic circulation.

17. It supplies oxygen-and nutrient-rich blood to all body organs. Because the left ventricle is the systematic pump that pumps blood over a much longer pathway through the body, its walls are substantially thicker than those of the right ventricle, and it is a much powerful pump. Valves The heart is equipped with four valves, which allow blood to flow in only one direction through the heart chambers- from the atria, the ventricles and out the great arteries leaving the heart. The atrioventricular, or AV valves are located between the atrial ventricular chambers on each side. The AV valves prevent backflow into the atria when the ventricles contract. The left AV valve- the bicuspid, or mitral, valve-consists of two cusps, or flaps, of endocardium. The right AV valve, the tricuspid valve, has three cusps. Tiny white cords, the chordae tendineae-literally, “heart strings”-anchor the cusps to the walls of the ventricles. When the heart is relaxed and blood is passively filling its chambers, the AV valve flaps hang limply into the ventricles. As the ventricles contract, they press on the blood in their chambers, and the intraventricular pressure (pressure inside the ventricles) begins to rise. This causes the AV- valve flaps to be forced upward, closing the valves. At this point the chordae tendineae are working to anchor the flaps in a closed position. If the flaps were unanchored, they would blow upward into the atria like an umbrella being turned inside out by a gusty wind. In this manner, the AV valves prevent backflow into the atria when the ventricles are contracting. The second set of valves, the semilunar valves, guards the bases of the two large arteries leaving the ventricular chambers. Thus they are known as the pulmonary and aortic semilunar valves. Each semilunar valve has three cusps that fit tightly together when the valves are closed. When the ventricles arecontracting and forcing blood out of the heart, the cusps are forced open flattened against the walls of the arteries by the tremendous force of rushing blood. Then when the ventricles relax, the blood begins to flow backward toward the heart, and the cusps fill with blood, closing the valves. This prevents arterial blood from reentering the heart. Each set of valves operates at a different time. The AV valves are open during heart relaxation and closed when the ventricles are contracting. The semilunar valves are closed during heart relaxation and are forced open when the ventricles contract. As they open and close in response to pressure changes in the heart, the valves force blood to continually move forward on its journey through the heart. Cardiac Circulation Although the heart chambers are bathed with blood almost continuously, the blood contained in the heart does not nourish the myocardium. The blood supply that oxygenates and nourishes the heart is provided by the right and left coronary arteries branch from the base of the aorta and encircle the heart in the atrioventricular groove at the junction of the atria and ventricles. The coronary arteries and their branches (the anterior interventricular and circumflex arteries on the left, and the posterior interventricular and marginal arteries on the right) are compressed when the ventricles are contracting and fill when the heart is relaxed. The myocardium is drained by several cardiac veins, which empty into an enlarged vessel on the backside of the heart called the coronary sinus. The coronary sinus, in turn, empties into the right atrium. When the heart beats at a very rapid rate, the myocardium may receive an inadequate blood supply because the relaxation periods (when the blood is able to flow to the heart tissue) are shortened.

18. PHYSIOLOGY OF THE HEART As the heart beats or contracts, the blood makes continuous round trips---in and out of the heart, through the rest of the body, and then back to the heart--- only to be sent out again. The amount of work that a heart does is almost too incredible to believe. In one day, it pushes the body’s supply of 6 quarts or so of blood through the blood vessels over 1000 times, meaning that it actually pumps about 6000 quarts of blood in a single day. Conduction System of the Heart Cardiac muscle cells can and do contract spontaneously and independently, even if all nervous connections are severed. Moreover, these spontaneous contractions occur in a regular and continuous way. Although cardiac muscles can beat independently, the muscle cells in different areas of the heart have different rhythms. The atrial cells beat about 60 times per minute, but the ventricular cells contract much more slowly (20-40/min). Therefore, without some type of unifying control system, the heart would be an uncoordinated and inefficient pump. Two types of controlling systems act to regulate heart activity. One of these involves the nerves of the autonomic nervous system that act like “brakes” and “accelerators” to increase or decrease the heart rate depending on which division is activated. The second system is the intrinsic conduction system, or nodal system, that is built into the heart tissue. The intrinsic conduction system is composed of a special tissue nowhere else in the body; it is much like a cross between muscle and nervous tissue. This system causes heart muscle depolarization in only one direction—from the atria to the ventricles. In addition, it enforces a contraction rate of approximately 75 beats per minute on the heart; thus, the heart beats as coordinated unit. One of the most important parts of the intrinsic conduction system is a cresent-shaped node of tissue called the sinoatrial (SA)node, located in the right atrium. Other components include the atrioventricular (AV)node at the junction of the atria and ventricles, the atrioventricular(AV) bundle (bundle of His) and the right and left bundle branches located in the interventricular septum, and finally the Purkinje fibers, which spread within the muscle of the ventricle walls. Because the SA node has the highest rate of depolarization in the whole system, it starts each heart beat and sets the pace for the whole heart. Consequently, the SA node is often called the pacemaker. Cardiac Cycle And Heart Sounds In a healthy heart, the atria contract simultaneously. Then as they start to relax, contraction of the ventricles begins. Systole and diastole mean heart contraction and relaxation respectively. The term cardiac cycle refers to the events of one complete heartbeat, during which both atria and ventricles contract and then relax. The normal cardiac cycle is about 0.8 second.

19. When using stethoscope, you can hear two distinct sounds during each cardiac cycle. These heart sounds are often described by two sylaables, “lub” and “dup”, ans the sequence is lub-dup, pause, and so on. The first heart sound (lub) is caused by closing of AV valves. The second sound, (dup) occurs when the semilunar valves close at the end of systole. The first heart sound is longer and louder than the second heart sound, which tends to be short and sahrp. Blood flows silently as long as the flow is smooth and uninterrupted. If it strikes obstructions, its flows become turbulent and generate sounds, such as heart murmurs, that can e heard with a stethoscope. Cardiac Output Cardiac output is the amount of blood pumped out by each side of the heart (actually each ventricle) in one minute. It is the product of the heart rate (HR) and the stroke volume (SV). Stroke volume is the volume of blood pumped out by a ventricle with each heartbeat. In general, stroke volume increases as the force of ventricular contraction increases. Since the normal adult volume is about 1500 ml, the entire blood supply passes through the body once each minute. Cardiac output varies with the demands of the body. It rises when the stroke volume is increased or the heart betas faster or both; it drops when either or both of these factors decrease. Regulation of Stroke Volume A healthy heart pumps out about 60% of the blood that enters it. As noted above, this is approximately 70 ml (about 2 ounces) with each heartbeat. According to Starling’s law of the heart, the critical factor controlling strike volume is how much the cardiac muscle cells are stretched just before they contract. The more they are stretched, the stronger the contraction will be. The important factor stretching the heart muscle is venous return, the amount of blood entering the heart and distending its ventricles. If one side of the heart suddenly begins to pump more blood than the other, the increased venous to the opposite ventricle will force it to pump out an equal amount, thus preventing back up of blood in the circulation. Anything that increase the volume or speed of venous return also increases stroke volume and force of contraction. For example, a slow heartbeat allows more time for the ventricles to fill. Exercise speeds venous return because it results in increased heart rate and force. The enhanced squeezing action of active skeletal muscles on the veins returning blood to the heart, the so called muscular pump, also plays a major role in increasing the venous return. On the other hand, low venous return such as might result from severe blood loss or an extremely rapid heart rate, decreases stroke volume causing the heart to beat less forcefully. Regulation of the Heart Rate In healthy people, stroke volume tends to be relatively constant. However, when blood volume drops suddenly or when the heart has been seriously weakened, stroke volume declines, and cardiac output is maintained by a faster heartbeat. Although heart contraction does not depend on the nervous system, its rate can be changed temporarily by the automatic nerves. Indeed, the most important external influence on heart rate is the activity of the autonomic nervous system. Heart rate is also modified by various chemicals,hormones, and ions.

20. During times of physical or emotional stress, the nerves of the sympathetic division of the autonomic nervous system stimulate the SA and AV nodes and the cardiac muscle itself. As a result, the heart beats more rapidly. This is familiar phenomenon to anyone who has ever been frightened or has had run to catch a bus. As fast as the heart pumps under ordinary conditions, it really speeds up when special demand are placed on it. Since a faster blood flow increases the rate at which fresh blood reaches body cells, more oxygen and glucose are made available to them during periods of stress. When demand declines, the heart adjusts. Parasympathetic nerves, primarily the vagus nerves, slow and steady the heart, giving it more time to rest during noncrisis times. Various hormones and ions can have a dramatic effect on heart activity. Epinephrine, which mimics the effect of the sympathetic nerves, and thyroxine both increase heart rate. Electrolyte imbalances pose a real threat to the heart. For example, reduced levels of ionic calcium in the blood depress the heart; whereas hypercalcemia causes such prolonged contractions that the heart may stop entirely. Excesses or lack of needed ions such as sodium and potassium also modify heart activity. A deficit of potassium ions in the blood, for example, causes the heart to beat feebly, and abnormal heart rhythms appear. The pumping action of the healthy heart maintains a balance between cardiac output and venous return. But the pumping efficiency of the heart is depressed so that the circulation is inadequate to meet tissue needs, congestive heart failure (CHF) occurs. Because the heart is a double pump, each side can fail independently of the other. If the left heart fails, pulmonary congestion occurs. The right side of the heart continues to propel blood to the lungs, but the left side is unable to eject the running blood into the systemic circulation. As blood vessels within the lungs become swollen with blood, the pressure within them increases,and fluid leaks from the circulation into the lung tissue, causing pulmonary edema. If untreated, the person suffocates. If the right side of the heart fails, peripheral congestion occurs as blood backs up in the circulation. Edema is most noticeable in the distal parts of the body: The feet, ankles, and fingers become swollen and puffy. Failure of one side of the heart puts a greater strain on the opposite side, and eventually the whole heart fails. Congestive Heart Failure (left-sided heart failure) Congestive heart failure is a syndrome rather than a disease, heart failure occurs when the heart cannot pump enough blood to meet the body’s metabolic needs. Heart failure results in intravascular and interstitial volume overload and poor tissue perfusion. An individual with heart failure experiences reduced exercise tolerance, a reduced quality of life, and a shortened life span. Etiology The pumping action of the heart is not able to meet the body’s demand for blood, resulting in inadequate perfusion. Some of the causes of the heart failure are hypertension; CAD, MI, chronic obstructive pulmonary disease (COPD), cardiac valve damage, arrythmias (dysrhythmias), and cardiomyopathy. The causes of the heart failure can be divided into three subgroups: (1) abnormal loading conditions, (2) abnormal muscle function, and (3) conditions or diseases that precipitate or exacerbate heart failure. 1. Abnormal Loading Conditions-

21. Venous return stretches the heart and improves contractility. When the heart is overloaded with blood, excessive stretch and decreased contraction occurs. Overload develops because blood does not leave the ventricles during contraction. Preload refers to the stretch of the ventricular myocardial fibers just before the ventricular contraction. The load or the stretch placed on the ventricular fibers corresponds to the end-diastolic ventricular volume and pressure. Preload is determined by the condition of the heart valves (especially the mitral valve), blood volume, ventricular wall compliance, and venous tone. Increased preload usually increases contractility and stretch due to the filling pressures from venous return and previous volume. Afterload corresponds to the amount of tension that the heart must generate to overcome systemic pressure and allow adequate ventricular emptying. In other words, afterload indicates how “hard” the heart must pump to force blood into the circulation. 2. Abnormal Muscle Function There are certain conditions that directly interfere with myocardial contractility. Intrinsic conditions are inherent in the cardiac muscle and include MI; myocarditis, an inflammation of the myocardium associated with viral, bacterial, fungal, or parasitic diseases or toxic chemical injury; cardiomyopathy, and ventricular aneurysm. Such disorders impair the contractile function of the myocardial fibrils, which reduces ventricular emptying and stroke volume. 3. Conditions that Precipitate or Exacerbate Heart Failure • Physical or Emotional Stress – strenuous physical exercise and strong emotions (fear, excitement, anxiety) increase sympathetic nervous tone and catecholamine release. This increases myocardial work by increasing heart rate, myocardial contractility, and blood pressure. • Dysrythmias – Cardiac dysrhythmias, most notably tachycardia (rapid heart rate), are the most common factors precipitating heart failure. A rapid heartbeat shortens the time for ventricular filling (diastole), which in turn reduces cardiac output and decreases myocardial perfusion. In addition, the workload and oxygen requirements of the myocardium increases. • Infections – any systemic infection increases the oxygen demands of the body tissues. The heart must keep with these demands. Fever and hypoxemia, which occur in some pulmonary infections, further tax the ailing heart and may precipitate failure. • Anemia - reduction in the oxygen – carrying capacity of the blood, as in anemia, necessitates increased cardiac output to meet the body’s need for oxygen. Whereas a normal heart may adjust to the increased workload, a compromised heart cannot, and failure ensues.

22. • Thyroid disorders – thyrotoxicosis, associated with hyperthyroidism, augments the metabolic needs of the body, accelerating heart rate and the workload of the heart. If the thyroxicosis is untreated, heart failure may occur. In hypothyroidism, the thyroid produces an inadequate amount of thyroxine (thyroid hormone). This can indirectly lead to heart failure by predisposing the client to coronary artherosclerosis. • Pregnancy – heart failure ranks high among cause of death during pregnancy. Pregnancy increases the metabolic needs of the body, thereby increasing the workload of the heart. Pregnant women with rheumatic valvular disease are particularly prone to heart failure. Signs and Symptoms Early Clinical Manifestations of Left-Sided Heart Failure • Dyspnea caused by pulmonary congestion • Orthopenia or orthopnea as blood is redistributed from legs to the central circulation when the patient lies down at night

23. • Paroxysmal nocturnal dyspnea due to the reabsorption of the interstitial fluid when lying down and reduced sympathetic stimulation with sleeping • Fatigue associated with reduced oxygenation and an inability to increase cardiac output in response to physical activity Later Clinical Manifestations of Left-Sided Heart Failure • Crackles due to pulmonary congestion • Hemoptysis resulting from bleeding veins in the bronchial system caused by venous distention • Patient of maximal impulse displaced toward the left anterior axillary line caused by left ventricular hypertrophy • Tachycardia due to sympathetic stimulation • S3 caused by rapid ventricular filling • S4 resulting from atrial contraction against a noncompliant ventricle • Cool, pale skin resulting from peripheral vasoconstriction • Restlessness and confusion due to reduced cardiac output EVALUATION Thank God, we’ve done for it… After long hard days of making this valuable paper, at last we found justice. Making a case analysis paper is not an easy task, but is a fulfilling experience. We have gone at this far because we were able to use the Nursing Process that has been taught unto us by our beloved faculty of the College of Nursing in Silliman

24. University. First, we used thoroughly the proper assessment that has to be done during the contact with our client. We used the Gordon’s Functional Health Patterns, our effective communication skills and by using our senses to critically observed the client’s responses. By then, we gathered all the information and cues we had assessed and immediately planned our care. We put our plan into action. We would like to extend our thanks to our C.I. Mr. Osel Sherwin Melad that despite of the hectic schedule we’ve been facing, he is always there to support and guide us. Thanks for the group conferences and ward class that broadens our knowledge about laboratory and diagnostic exams, nature of some diseases and how it can be intervened. It is such an honor to present to you our case, CHF, and we are thanking each and everyone for by this event we had able to provide a quality care to our patient. This event not only taught us how to be vigilant in giving care but it made also an impact unto our side and that is, to learn to value time and individual’s importance. PHARMACOLOGY 1. furosemide (fur oh' se mide) Apo-Furosemide (CAN), Furoside (CAN), Lasix, Myrosemide (CAN) Pregnancy Category C

25. Drug class Loop diuretic Therapeutic actions Inhibits the reabsorption of sodium and chloride from the ascending limb of the loop of Henle, leading to a sodium-rich diuresis. Indications  Oral, IV: Edema associated with CHF, cirrhosis, renal disease  IV: Acute pulmonary edema  Oral: Hypertension Contraindications and cautions  Contraindicated with allergy to furosemide, sulfonamides; allergy to tartrazine (in oral solution); anuria, severe renal failure; hepatic coma; pregnancy; lactation.  Use cautiously with SLE, gout, diabetes mellitus. Available forms Tablets—20, 40, 80 mg; oral solution—10 mg/mL, 40 mg/5 mL; injection—10 mg/mL Dosages ADULTS  Edema: Initially, 20–80 mg/day PO as a single dose. If needed, a second dose may be given in 6–8 hr. If response is unsatisfactory, dose may be increased in 20- to 40-mg increments at 6- to 8-hr intervals. Up to 600 mg/day may be given. Intermittent dosage schedule (2–4 consecutive days/wk) is preferred for maintenance, or 20–40 mg IM or IV (slow IV injection over 1–2 min). May increase dose in increments of 20 mg in 2 hr. High-dose therapy should be given as infusion at rate not exceeding 4 mg/min.  Acute pulmonary edema: 40 mg IV over 1–2 min. May be increased to 80 mg IV given over 1–2 min if response is unsatisfactory after 1 hr.  Hypertension: 40 mg bid PO. If needed, additional antihypertensive agents may be added. PEDIATRIC PATIENTS Avoid use in premature infants: stimulates PGE2 synthesis and may increase incidence of patent ductus arteriosus and complicate respiratory distress syndrome.  Edema: Initially, 2 mg/kg/day PO. If needed, increase by 1–2 mg/kg in 6–8 hr. Do not exceed 6 mg/kg. Adjust maintenance dose to lowest effective level.

26.  Pulmonary edema: 1 mg/kg IV or IM. May increase by 1 mg/kg in 2 hr until the desired effect is seen. Do not exceed 6 mg/kg. PATIENTS WITH RENAL IMPAIRMENT Up to 4 g/day has been tolerated. IV bolus injection should not exceed 1 g/day given over 30 min. Pharmacokinetics Route Onset Peak Duration Oral 60 min 60–120 min 6–8 hr IV, IM 5 min 30 min 2 hr Metabolism: Hepatic; T1/2: 30–60 min Distribution: Crosses placenta; enters breast milk Excretion: Urine, feces IV facts Preparation: Store at room temperature; exposure to light may slightly discolor solution. Infusion: Inject directly or into tubing of actively running IV; inject slowly over 1–2 min. Incompatibilities: Do not mix with acidic solutions. Isotonic saline, lactated Ringer's injection, and 5% dextrose injection may be used after pH has been adjusted (if necessary); precipitates form with gentamicin, netilimicin, milrinone in 5% dextrose, 0.9% sodium chloride. Adverse effects  CNS: Dizziness, vertigo, paresthesias, xanthopsia, weakness, headache, drowsiness, fatigue, blurred vision, tinnitus, irreversible hearing loss  CV: Orthostatic hypotension, volume depletion, cardiac arrhythmias, thrombophlebitis  Dermatologic: Photosensitivity, rash, pruritus, urticaria, purpura, exfoliative dermatitis, erythema multiforme  GI: Nausea, anorexia, vomiting, oral and gastric irritation, constipation, diarrhea, acute pancreatitis, jaundice  GU: Polyuria, nocturia, glycosuria, urinary bladder spasm  Hematologic: Leukopenia, anemia, thrombocytopenia, fluid and electrolyte imbalances  Other: Muscle cramps and muscle spasms Interactions

27. Drug-drug  Increased risk of cardiac arrhythmias with digitalis glycosides (due to electrolyte imbalance)  Increased risk of ototoxicity with aminoglycoside antibiotics, cisplatin  Decreased absorption of furosemide with phenytoin  Decreased natriuretic and antihypertensive effects with indomethacin, ibuprofen, other NSAIDs  Decreased GI absorption with charcoal  May reduce effect of insulin or oral antidiabetic agents because blood glucose levels can become elevated Nursing considerations CLINICAL ALERT! Name confusion has occurred between furosemide and torsemide; use extreme caution. Assessment  History: Allergy to furosemide, sulfonamides, tartrazine; electrolyte depletion anuria, severe renal failure; hepatic coma; SLE; gout; diabetes mellitus; lactation, pregnancy  Physical: Skin color, lesions, edema; orientation, reflexes, hearing; pulses, baseline ECG, BP, orthostatic BP, perfusion; R, pattern, adventitious sounds; liver evaluation, bowel sounds; urinary output patterns; CBC, serum electrolytes (including calcium), blood sugar, liver and renal function tests, uric acid, urinalysis, weight Interventions  Administer with food or milk to prevent GI upset.  Reduce dosage if given with other antihypertensives; readjust dosage gradually as BP responds.  Give early in the day so that increased urination will not disturb sleep.  Avoid IV use if oral use is at all possible.  Do not mix parenteral solution with highly acidic solutions with pH below 3.5.  Do not expose to light, may discolor tablets or solution; do not use discolored drug or solutions.  Discard diluted solution after 24 hr.  Refrigerate oral solution.  Measure and record weight to monitor fluid changes.

28.  Arrange to monitor serum electrolytes, hydration, liver function.  Arrange for potassium-rich diet or supplemental potassium as needed. Teaching points  Record intermittent therapy on a calendar or dated envelopes. When possible, take the drug early so increased urination will not disturb sleep. Take with food or meals to prevent GI upset.  Weigh yourself on a regular basis, at the same time and in the same clothing, and record the weight on your calendar.  These side effects may occur: Increased volume and frequency of urination; dizziness, feeling faint on arising, drowsiness (avoid rapid position changes; hazardous activities, like driving; and consumption of alcohol); sensitivity to sunlight (use sunglasses, wear protective clothing, or use a sunscreen); increased thirst (suck on sugarless lozenges; use frequent mouth care); loss of body potassium (a potassium-rich diet or potassium supplement will be needed).  Report loss or gain of more than 3 lb in 1 day, swelling in your ankles or fingers, unusual bleeding or bruising, dizziness, trembling, numbness, fatigue, muscle weakness or cramps. Adverse effects in Italic are most common; those in Bold are life-threatening. 2. digoxin (di jox' in) Digitek, Lanoxicaps, Lanoxin, Novo-Digoxin (CAN) Pregnancy Category C Drug classes Cardiac glycoside Cardiotonic Therapeutic actions Increases intracellular calcium and allows more calcium to enter the myocardial cell during depolarization via a sodium–potassium pump mechanism; this increases force of contraction (positive inotropic effect), increases renal perfusion (seen as diuretic effect in patients with CHF), decreases heart rate (negative chronotropic effect), and decreases AV node conduction velocity.

29. Indications  CHF  Atrial fibrillation Contraindications and cautions  Contraindicated with allergy to digitalis preparations, ventricular tachycardia, ventricular fibrillation, heart block, sick sinus syndrome, IHSS, acute MI, renal insufficiency and electrolyte abnormalities (decreased K+ , decreased Mg++ , increased Ca++ ).  Use cautiously with pregnancy and lactation. Available forms Lanoxicaps capsules—0.05, 0.1, 0.2 mg; tablets—0.125, 0.25, mg, elixir—0.05 mg/mL; injection—0.25 mg/mL; pediatric injection—0.1 mg/mL Dosages Patient response is quite variable. Evaluate patient carefully to determine the appropriate dose. ADULTS Loading dose, 0.75–1.25 mg PO or 0.125–0.25 mg IV. Maintenance dose, 0.125–0.25 mg/day PO. Lanoxicaps capsules 0.4–0.6 mg PO; maintenance dose: 0.5–0.1 mg/day PO. PEDIATRIC PATIENTS  Loading dose: Oral (mcg/kg) IV (mcg/kg) Premature 20–30 15–25 Neonate 25–35 20–30 1–24 mo 35–60 30–50 2–5 yr 30–40 25–35 5–10 yr 20–35 15–30 > 10 yr 10–15 8–12 Maintenance dose, 25%–35% of loading dose in divided daily doses. Usually 0.125–0.5 mg/day PO. GERIATRIC PATIENTS WITH IMPAIRED RENAL FUNCTION

30. Creatinine Clearance (mL/min) Dose 10–25 0.125 mg/day 26–49 0.1875 mg/day 50–79 0.25 mg/day Pharmacokinetics Route Onset Peak Duration Oral 30–120 min 2–6 hr 6–8 days IV 5–30 min 1–5 hr 4–5 days Metabolism: Some hepatic; T1/2: 30–40 hr Distribution: May cross placenta; enters breast milk Excretion: Largely unchanged in the urine IV facts Preparation: Give undiluted or diluted in fourfold or greater volume of sterile water for injection, 0.9% sodium chloride injection, 5% dextrose injection, or lactated Ringer's injection. Use diluted product promptly. Do not use if solution contains precipitates. Infusion: Inject slowly over 5 min or longer. Incompatibility: Do not mix with dobutamine. Adverse effects  CNS: Headache, weakness, drowsiness, visual disturbances, mental status change  CV: Arrhythmias  GI: GI upset, anorexia Interactions Drug-drug  Increased therapeutic and toxic effects of digoxin with thioamines, verapamil, amiodarone, quinidine, quinine, erythromycin, cyclosporine (a decrease in digoxin dosage may be necessary to prevent toxicity; when the interacting drug is discontinued, an increase in the digoxin dosage may be necessary)

31.  Increased incidence of cardiac arrhythmias with potassium-losing (loop and thiazide) diuretics  Increased absorption or increased bioavailability of oral digoxin, leading to increased effects with tetracyclines, erythromycin  Decreased therapeutic effects with thyroid hormones, metoclopramide, penicillamine  Decreased absorption of oral digoxin if taken with cholestyramine, charcoal, colestipol, antineoplastic agents (bleomycin, cyclophosphamide, methotrexate)  Increased or decreased effects of oral digoxin (adjust the dose of digoxin during concomitant therapy) with oral aminoglycosides Drug-alternative therapy  Increased risk of digoxin toxicity if taken with ginseng, hawthorn, or licorice therapy  Decreased absorption with psyllium  Decreased serum levels with St. John's wort Nursing considerations Assessment  History: Allergy to digitalis preparations, ventricular tachycardia, ventricular fibrillation, heart block, sick sinus syndrome, IHSS, acute MI, renal insufficiency, decreased K+ , decreased Mg++ increased Ca++  Physical: Weight; orientation, affect, reflexes, vision; P, BP, baseline ECG, cardiac auscultation, peripheral pulses, peripheral perfusion, edema; R, adventitious sounds; abdominal percussion, bowel sounds, liver evaluation; urinary output; electrolyte levels, liver and renal function tests Interventions  Monitor apical pulse for 1 min before administering; hold dose if pulse < 60 in adult or < 90 in infant; retake pulse in 1 hr. If adult pulse remains < 60 or infant < 90, hold drug and notify prescriber. Note any change from baseline rhythm or rate.  Take care to differentiate Lanoxicaps from Lanoxin; dosage is very different  Check dosage and preparation carefully.  Avoid IM injections, which may be very painful.  Follow diluting instructions carefully, and use diluted solution promptly.  Avoid giving with meals; this will delay absorption.  Have emergency equipment ready; have K+ salts, lidocaine, phenytoin, atropine, cardiac monitor on standby in case toxicity develops.  Monitor for therapeutic drug levels: 0.5–2 ng/mL.

32. Teaching points  Do not stop taking this drug without notifying your health care provider.  Take pulse at the same time each day, and record it on a calendar (normal pulse for you is___); call your health care provider if your pulse rate falls below ____.  Weigh yourself every other day with the same clothing and at the same time. Record this on the calendar.  Wear or carry a medical alert tag stating that you are using this drug.  Have regular medical checkups, which may include blood tests, to evaluate the effects and dosage of this drug.  Report unusually slow pulse, irregular pulse, rapid weight gain, loss of appetite, nausea, vomiting, blurred or "yellow" vision, unusual tiredness and weakness, swelling of the ankles, legs or fingers, difficulty breathing. Adverse effects in Italic are most common; those in Bold are life-threatening. 3. captopril (kap' toe pril) Apo-Capto (CAN), Capoten, Gen-Captopril (CAN), Novo-Captopril (CAN), Nu-Capto (CAN) Pregnancy Category C (first trimester) Pregnancy Category D (second, third trimesters) Drug classes Angiotensin-converting enzyme (ACE) inhibitor Antihypertensive Therapeutic actions Blocks ACE from converting angiotensin I to angiotensin II, a powerful vasoconstrictor, leading to decreased blood pressure, decreased aldosterone secretion, a small increase in serum potassium levels, and sodium and fluid loss; increased prostaglandin synthesis also may be involved in the antihypertensive action. Indications  Treatment of hypertension alone or in combination with thiazide-type diuretics  Treatment of CHF in patients unresponsive to conventional therapy; used with diuretics and digitalis  Treatment of diabetic nephropathy

33.  Treatment of left ventricular dysfunction after MI  Unlabeled uses: Management of hypertensive crises; treatment of rheumatoid arthritis; diagnosis of anatomic renal artery stenosis, hypertension related to scleroderma renal crisis; diagnosis of primary aldosteronism, idiopathic edema; Bartter's syndrome; Raynaud's syndrome Contraindications and cautions  Contraindicated with allergy to captopril, history of angiodema.  Use cautiously with impaired renal function; CHF; salt or volume depletion, lactation, pregnancy. Available forms Tablets—12.5, 25, 50, 100 mg Dosages ADULTS  Hypertension: 25 mg PO bid or tid; if satisfactory response is not noted within 1–2 wk, increase dosage to 50 mg bid–tid; usual range is 25–150 mg bid–tid PO with a mild thiazide diuretic. Do not exceed 450 mg/day.  CHF: 6.25–12.5 mg PO tid in patients who may be salt or volume depleted. Usual initial dose, 25 mg PO tid; maintenance dose, 50–100 mg PO tid. Do not exceed 450 mg/day. Use in conjunction with diuretic and digitalis therapy.  Left ventricular dysfunction after MI: 50 mg PO tid, starting as early as 3 days post MI. Initial dose of 6.25 mg, then 12.5 mg tid, increasing slowly to 50 mg tid.  Diabetic nephropathy: 25 mg PO tid. PEDIATRIC PATIENTS Safety and efficacy not established. GERIATRIC PATIENTS AND PATIENTS WITH RENAL IMPAIRMENT Excretion is reduced in renal failure; use smaller initial dose; adjust at smaller doses with 1- to 2-wk intervals between increases; slowly adjust to smallest effective dose. Use a loop diuretic with renal dysfunction. Pharmacokinetics Route Onset Peak Oral 15 min 30–90 min Metabolism: T1/2: 2 hr

34. Distribution: Crosses placenta; enters breast milk Excretion: Urine Adverse effects  CV: Tachycardia, angina pectoris, MI, Raynaud's syndrome, CHF, hypotension in salt- or volume-depleted patients  Dermatologic: Rash, pruritus, pemphigoid-like reaction, scalded mouth sensation, exfoliative dermatitis, photosensitivity, alopecia  GI: Gastric irritation, aphthous ulcers, peptic ulcers, dysgeusia, cholestatic jaundice, hepatocellular injury, anorexia, constipation  GU: Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, urinary frequency  Hematologic: Neutropenia, agranulocytosis, thrombocytopenia, hemolytic anemia, pancytopenia  Other: Cough, malaise, dry mouth, lymphadenopathy Interactions Drug-drug  Increased risk of hypersensitivity reactions with allopurinol  Decreased antihypertensive effects with indomethacin  Increased captopril effects with probenecid Drug-food  Decreased absorption of captopril with food Drug-lab test  False-positive test for urine acetone Nursing considerations Assessment  History: Allergy to captopril, history of angioedema, impaired renal function, CHF, salt or volume depletion, pregnancy, lactation  Physical: Skin color, lesions, turgor; T; P, BP, peripheral perfusion; mucous membranes, bowel sounds, liver evaluation; urinalysis, renal and liver function tests, CBC and differential Interventions  Administer 1 hr before or 2 hr after meals.

35.  Alert surgeon and mark patient's chart with notice that captopril is being taken; the angiotensin II formation subsequent to compensatory renin release during surgery will be blocked; hypotension may be reversed with volume expansion.  Monitor patient closely for fall in BP secondary to reduction in fluid volume (excessive perspiration and dehydration, vomiting, diarrhea); excessive hypotension may occur.  Reduce dosage in patients with impaired renal function. Teaching points  Take drug 1 hr before or 2 hr after meals; do not take with food. Do not stop without consulting your health care provider.  Be careful of drop in blood pressure (occurs most often with diarrhea, sweating, vomiting, dehydration); if light-headedness or dizziness occurs, consult your health care provider.  Avoid over-the-counter medications, especially cough, cold, allergy medications that may contain ingredients that will interact with ACE inhibitors. Consult your health care provider.  These side effects may occur: GI upset, loss of appetite, change in taste perception (limited effects, will pass); mouth sores (perform frequent mouth care); rash; fast heart rate; dizziness, light-headedness (usually passes after the first few days; change position slowly, and limit your activities to those that do not require alertness and precision).  Report mouth sores; sore throat, fever, chills; swelling of the hands, feet; irregular heartbeat, chest pains; swelling of the face, eyes, lips, tongue, difficulty breathing. Adverse effects in Italic are most common; those in Bold are life-threatening. 4. clindamycin (klin da mye' sin) clindamycin hydrochloride Oral: Cleocin, Cleocin Suppository, Dalacin C (CAN) clindamycin palmitate hydrochloride Oral:

36. Cleocin Pediatric clindamycin phosphate Oral, parenteral, topical dermatologic solution for acne, vaginal preparation: Cleocin Phosphate, Cleocin T, Cleocin Vaginal Ovules, Clinda-Derm (CAN), Dalacin C (CAN) Pregnancy Category B Drug class Lincosamide antibiotic Therapeutic actions Inhibits protein synthesis in susceptible bacteria, causing cell death. Indications  Systemic administration: Serious infections caused by susceptible strains of anaerobes, streptococci, staphylococci, pneumococci; reserve use for penicillin- allergic patients or when penicillin is inappropriate; less toxic antibiotics (erythromycin) should be considered  Parenteral: Treatment of septicemia caused by staphylococci, streptococci; acute hematogenous osteomyelitis; adjunct to surgical treatment of chronic bone and joint infections due to susceptible organisms; do not use to treat meningitis; does not cross the blood–brain barrier.  Topical dermatologic solution: Treatment of acne vulgaris  Vaginal preparation: Treatment of bacterial vaginosis Contraindications and cautions Systemic administration  Contraindicated with allergy to clindamycin, history of asthma or other allergies, tartrazine (in 75- and 150-mg capsules); hepatic or renal dysfunction; lactation.  Use cautiously in newborns and infants due to benzyl alcohol content; associated with gasping syndrome. Topical dermatologic solution, vaginal preparation  Contraindicated with allergy to clindamycin or lincomycin.  Use cautiously with history of regional enteritis or ulcerative colitis; history of antibiotic-associated colitis.

37. Available forms Capsules—75, 150, 300 mg; granules for oral solution—75 mg/5 mL; injection—150 mg/mL; topical gel—10 mg; topical lotion—10 mg; topical solution—10 mg; vaginal cream—2%; vaginal suppository—100 mg Dosages ADULTS Oral 150–300 mg q 6 hr, up to 300–450 mg q 6 hr in more severe infections. Parenteral 600–2,700 mg/day in two to four equal doses; up to 4.8 g/day IV or IM may be used for life-threatening situations. Vaginal One applicator (100 mg clindamycin phosphate) intravaginally, preferably at hs for 7 consecutive days; or insert vaginal suppository, preferably at hs for 7 consecutive days, 3 days for Cleocin Vaginal Ovules. Topical Apply a thin film to affected area bid. PEDIATRIC PATIENTS Oral For clindamycin HCl, 8–20 mg/kg/day in three or four equal doses. For clindamycin palmitate HCl, 8–25 mg/kg/day in three or four equal doses; for children weighing < 10 kg, use 37.5 mg tid as the minimum dose. Parenteral Neonates: 15–20 mg/kg/day in three or four equal doses. > 1 mo: 15–40 mg/kg/day in three or four equal doses or 300 mg/m2 /day to 400 mg/m2 /day; in severe infections, give 300 mg/day regardless of weight. GERIATRIC PATIENTS OR PATIENTS WITH RENAL FAILURE Reduce dose, and monitor patient's serum levels carefully. Pharmacokinetics Route Onset Peak Duration Oral Varies 1–2 hr 8–12 hr IM 20–30 min 1–3 hr 8–12 hr IV Immediate Minutes 8–12 hr Topical Minimal systemic

38. absorption Metabolism: Hepatic; T1/2: 2–3 hr Distribution: Crosses placenta; enters breast milk Excretion: Urine and feces IV facts Preparation: Store unreconstituted product at room temperature. Reconstitute by adding 75 mL of water to 100-mL bottle of palmitate in two portions. Shake well; do not refrigerate reconstituted solution. Reconstituted solution is stable for 2 wk at room temperature. Dilute reconstituted solution to a concentration of 300 mg/50 mL or more of diluent using 0.9% sodium chloride injection, 5% dextrose injection, or lactated Ringer's solution. Solution is stable for 16 days at room temperature. Infusion: Do not administer more than 1,200 mg in a single 1-hr infusion. Infusion rates: 300 mg in 50 mL diluent, 10 min; 600 mg in 50 mL diluent, 20 min; 900 mg in 50–100 mL diluent, 30 min; 1,200 mg in 100 mL diluent, 40 min. Incompatibilities: Do not mix with calcium gluconate, ampicillin, phenytoin, barbiturates, aminophylline, and magnesium sulfate. May be mixed with sodium chloride, dextrose, calcium, potassium, vitamin B complex, kanamycin, gentamicin, penicillin, carbencillin. Incompatible in syringe with tobramycin. Adverse effects Systemic administration  CV: Hypotension, cardiac arrest (with rapid IV infusion)  GI: Severe colitis, including pseudomembranous colitis, nausea, vomiting, diarrhea, abdominal pain, esophagitis, anorexia, jaundice, liver function changes  Hematologic: Neutropenia, leukopenia, agranulocytosis, eosinophilia  Hypersensitivity: Rashes, urticaria to anaphylactoid reactions  Local: Pain following injection, induration and sterile abscess after IM injection, thrombophlebitis after IV use Topical dermatologic solution  CNS: Fatigue, headache  Dermatologic: Contact dermatitis, dryness, gram-negative folliculitis  GI: Pseudomembranous colitis, diarrhea, bloody diarrhea; abdominal pain, sore throat  GU: Urinary frequency Vaginal preparation  GU: Cervicitis, vaginitis, vulvar irritation

39. Interactions Systemic administration Drug-drug  Increased neuromuscular blockade with neuromuscular blocking agents  Decreased GI absorption with kaolin, aluminum salts Nursing considerations Assessment  History: Allergy to clindamycin, history of asthma or other allergies, allergy to tartrazine (in 75- and 150-mg capsules); hepatic or renal dysfunction; lactation; history of regional enteritis or ulcerative colitis; history of antibiotic associated colitis  Physical: Site of infection or acne; skin color, lesions; BP; R, adventitious sounds; bowel sounds, output, liver evaluation; complete blood count, renal and liver function tests Interventions Systemic administration  Culture infection before therapy.  Administer oral drug with a full glass of water or with food to prevent esophageal irritation.  Do not give IM injections of more than 600 mg; inject deep into large muscle to avoid serious problems.  Do not use for minor bacterial or viral infections.  Monitor renal and liver function tests, and blood counts with prolonged therapy. Topical dermatologic administration  Keep solution away from eyes, mouth and abraded skin or mucous membranes; alcohol base will cause stinging. Shake well before use.  Keep cool tap water available to bathe eye, mucous membranes, abraded skin inadvertently contacted by drug solution. Vaginal preparation  Give intravaginally, preferably at hs. Teaching points Systemic administration  Take oral drug with a full glass of water or with food.  Take full prescribed course of oral drug. Do not stop taking without notifying health care provider.

40.  These side effects may occur: Nausea, vomiting (eat small, frequent meals); superinfections in the mouth, vagina (use frequent hygiene measures; request treatment if severe).  Report severe or watery diarrhea, abdominal pain, inflamed mouth or vagina, skin rash or lesions. Topical dermatologic administration  Apply thin film of acne solution to affected area twice daily, being careful to avoid eyes, mucous membranes, abraded skin; if solution contacts one of these areas, flush with copious amounts of cool water.  Report abdominal pain, diarrhea. Vaginal preparation  Use vaginal preparation for 7 or 3 consecutive days, preferably at bedtime. Refrain from sexual intercourse during treatment with this product.  Report vaginal irritation, itching; diarrhea, no improvement in complaint being treated. Adverse effects in Italic are most common; those in Bold are life threatening. 5. Generic name: Simvastatin (Synvinolin) Brand name: Lipex, Zocor Mechanism of action: Inhibits HMG-CoA reductase, which is an early (and rate-limiting) step in cholesterol biosynthesis. Indications:  To reduce risk of death from CV disease and CV events in proteins at high-risk for coronary events  To reduce total and LDL cholesterol levels in patients with homozygous familial hypercholesterolemia Contraindications:  Contraindicated in patients hyper sensitive to drug and in those with active liver disease or conditions that cause unexplained persistent elevations of transaminase levels. Also, contraindicated in pregnant and breast-feeding women of childbearing potential. Adverse reactions/side effects: CNS: headache, asthenia GI: abdominal pain, constipation, diarrhea, dyspepsia, flatulence, nausea, vomiting Respiratory: upper respiratory tract infection 6. Generic name: Roxithromycin

41. Brand name: Macrol Indications: upper and lower respiratory tract, skin and soft tissue and GUT infections (excluding gonoaxcal infections) and otitis media. Contraindications: allergy to other macrolides. Concomitant therapy with ergot alkaloid vasoconstrictors. Adverse reactions:  Dizziness; epigastric pain, nausea, vomiting, diarrhea 7. Generic name: cefixime Brand name: zefral Indication:  Bronchitis, secondary infections of chronic respiratory tract diseases, pneumonia Contraindications:  History of shock. Hypersensitivity Adverse reactions:  Shock, hypersensitivity reactions, dermatogenic effects; 61 disturbances

42. USUAL PATTERN INITIAL APPRAISAL ONGOING APPRAISAL ONGOING APPRAISAL 1. Health Perception Health Management  Generally health is not so good for the past year  Client experiences colds, fever and flue recurrently with 2-3 mos. Gap  She takes OTC drugs as a remedy to these conditions like biogesic  Also takes oregano to help ease the common colds. She uses 7 leaves of it and drinks 3 glasses from the extract of oregano  She also visits a physician every now and then for check-up of some health problems she experiences  Sahe is a non-smoker and not an alcoholic drinker  She verbalized “maglisod ko ug pagtuman sa isulti sa doctor nako kay wala man pod mi kwarta”  Verbalized that her health as of now is “daot na”  Verbalized “kapoy kayo akong lawas”  She wishes to get well soon  V/S 5pm T: 36.70 C PR: 74 bpm, strong and regular RR: 34 cpm, shallow and regular BP: 160/90 mmhg  Lab results: Blood chemistry ♦ BUN------------------ 24mg/dl ♦ Creatinine------------ 0.94mg% ♦ FBS------------------- 86mg/dl ♦ Uric Acid------------ 6.5mg/dl ♦ Cholesterol----------151 mg/dl  Verbalized “maayo-ayo na akong paminaw”  V/S 3pm T: 37.4 degrees Celsius PR: 85 bpm, strong and regular RR: 31 cpm, deep and regular BP: 150/80 mmhg  Medications: same with additional Aldazide  IVF plain NSS at KVO right metacarpal vein  Oxygen Inhalation at 1L/min.  V/S 8pm T: 37.4 degrees Celsius PR: 80 bpm, strong and regular RR: 31 cpm, deep and regular BP: 170/80 mmhg  Verbalized “maayo-ayo na akong paminaw”  V/S 3pm T: 37.4 degrees Celsius PR: 85 bpm, strong and regular RR: 31 cpm, deep and regular BP: 150/80 mmhg  Medications: same  IVF plain NSS at KVO right metacarpal vein  Oxygen Inhalation off

43. ♦ Triglyceride----------81mg/dl ♦ Chol-HDL-----------30 mg/dl ♦ LDL -----------------104 mg/dl Urinalysis  Color----------------yellow  Transpaerncy------clear  Sp.Gravity---------1.010  Glucose-------------Neg.  Protein--------------trace  pH-------------------6.0 Microscopic Examination  Pus cells------------10-15/hpf  RBC-----------------0-2  Epithelial cells-----moderate Clinical Examination  Na+-----------------136mEq/l  K+------------------4.0mEq/L CBC  Hemoglobin------13.8gm%  Hematocrit-------42.1%  WBC--------------6,100/cumm  Seg---------------80%  Neutrophils-----  Lymphocytes--15%  Eosinophils----1%  Monocytes-----3%

44. 2. Nutritional Metabolic Pattern  For breakfast: Milk (2-3 glasses), 2 pieces of bread and rice (1 ½ cup) for her viand she will have any of the following: vegetables, sardines, “inon-onan”, and “ginamos”  For lunch: she will have “law-oy”, vegetables and consumes 1 ½ cup of rice  For supper: she usally eats noodles and “inon-onan” and consumes 1 ½ cup of rice  She drinks 6 glasses of water daily  Also drinks 2 cups of coffee  Platelet count----330,000 Medications  Furosemide 20g OD  Digoxin 0.25mg ½ tab O.D. P.O.  Captopril 25 mg ½ tab O.D. P.O.  Clindamycin 300 mg q 6 hrs. IVTT  Cefuroxime 1 g q 8 hrs. IVTT  Simvastatin 20 mg 1 tab BID P.O.  Cefixime 200mg 1 tab BID P.O.  Roxithromycin 300 mg O.D. P.O.  IVTT Plain NSS at KVO left metacarpal vein  Oxygen inhalation at 2L/min.  Her diet is low fat and low salt diet  Verbalized “ wala kayo ko gana sa pagkaon”  Consumes ¾ of her share for meal  Meal consists of beef stew and fish  Abrasion from scratching is seen on her left forearm  Client reported that it is itchy  Skin has poor skin turgor and  Her diet is still low fat and low salt  Verbalized “ wala kayo ko gana sa pagkaon”  Verbalized “ wala kayo nahurot akong kan-on kay gahi man”  Drank 750 ml of water  Lunch consists: 1 cup of rice, I piece fried chicken, isda (inon-onan)- consumed half of her share for meal  Supper: ½ rice was consumed, I piece of fish, soup of beef stew (1/2 cup), consumed “2x”2 meat of beef  Red spots were seen on her forearm  Her diet is still low fat and low salt  Verbalized “ wala kayo nahurot akong kan-on kay gahi man”  Breakfast: consumed ½ cup, I piece hotdog, 1 piece of grilled fish, I banana, 1 cup of rice  Drank 350 ml of water  Normal skin color and temperature  Red spots were seen on her forearm from scratching. Client reported that it is itchy  Moderately good capillary refill  Skin has poor skin turgor and

45.  Her favorite food is fish and has moderately good appetite  She is advised by the physician not to eat foods rich in purines because of her arthrtitis 3. Elimination Pattern  Defecates 3-4 times a day  Character of stool is not formed. Verbalized “basa-basa gamay”; yellowish in color  Reported to experience moderate pain on gastric region when she defecates  Urinates 6 times aday and reported very minimal pain  Characteristics of urine is yellowish in color and is about ½ glass or 120 ml  Perspiration is moderate 4. Activity exercise Pattern  Does household chores as a housewife  She sells tocino either raw or grilled  She gets enough rest but not enough energy for her daily activities  She seldoms spend time for leisure mobility  Capillary refill: 3-4 sec.  Verbalized “Katol akong panit, dayong akong kaloy maona samad”  Red spots were seen on her forearm from scratching. Client reported that it is itchy  skin color is slightly pale  Defecated twice. Character of stool is not formed, yellowish in color and small in amount  Still experiences moderate pain on gastric region when she defecates  Urinated 6 times, and amount is 120 ml/ urination; very minimal pain during urination  Has minimal perspiration  Claimed to have difficulty breathing  Appeared weak and lethargic  Hair is not fixed well, hygiene is from scratching. Client reported that it is itchy  Moderately good capillary refill  Skin has poor skin turgor and mobility  Defecated twice. Character of stool is not formed, yellowish in color and small in amount  Still experiences moderate pain on gastric region when she defecates  Urinated 6 times, and amount is 120 ml/ urination; no pain during urination  Has minimal perspiration  Claimed to have difficulty breathing  Still appeared weak and lethargic  Hair is not fixed well, hygiene is poor  Has not yet taken a bath  Appeared restless  Stays in bed most of the time  Movement is minimal mobility  wound on left leg seen from scratching  defecated twice (slightly formed, yellowish in color and small in amount  still experiences moderate pain on gastric region when she defecates  urinated 6 times (1/2 cup/urination)  Participated in tolerable desired activities  Met own self-care needs with minimum assistance from other person  Improved posture  decreased Labored breathing  decreased use of accessory muscles

46. activities  She enjoys chatting with her neighbors  She does not perform any exercise  Perceived ability for the following: Bathing: 2 cooking: 2 Toileting: 2 Home maintenance: 2 Dressing: 2 shopping: 2 Grooming: 2 bed mobility: 2 Feeding: 2 General Mobility: 2  Claimed to have difficulty breathing  Claimed that often times she does the household with assistance 5. Sleep- Rest Pattern  Sleeps from 8pm and wakes at 4am  Has enough rest  No difficulty in getting herself to sleep  Does not take drugs or other medium in order for her to sleep  Uses 2 pillows  Can sleep with lights on poor  Has not yet taken a bath  Appeared restless  Stays in bed most of the time  Movement is minimal  barely converse with her watchers  posture is bent  bed in semi-fowler’s position  perceived ability for the following  feeding :2  bathing : 2  toileting : 2  bed mobility : 2  dressing : 2  grooming : 2  general mobility : 2  sleeps at 8pm and wakes t 4pm  reported to have difficulty getting enough rest because of the need to wake up when medical personnel  Still barely converse with her watchers  posture is bent  bed in semi-fowler’s position  perceived ability for the following  feeding 2  bathing : 2  toileting : 2  bed mobility : 2  dressing : 2  grooming : 2  general mobility : 2  sleeps at 8pm and wakes t 4pm  reported to have difficulty getting enough rest because of the need to wake up when medical personnel perform their interventions  no difficulty or problems with patients adjacent to her  can sleep with lights on  appeared rested but still lethargic  Hair is not fixed well, hygiene is poor  Still has not yet taken a bath but had sponge bath by her daughter  Stays in bed most of the time  Movement is still minimal  Converse now with her watchers  posture has slightly improved: minimized use of 3 point position  bed in semi-fowler’s position  perceived ability for the following  feeding 2  bathing : 2  toileting : 2  bed mobility : 2  dressing : 2  grooming : 2  general mobility : 2  sleeps at 8pm and wakes t 4pm  yawning was Absent  sleepy eyes was Absent  no difficulty or problems with patients adjacent to her  can sleep with lights on  sleeps with 2 pillows propped under

47. 6. Cognitive Perceptual Pattern  Has no problems in hearing and visualizing  Does not use eyeglasses or reading glasses  Being forgetful sometimes  Whenever she feels weakness of her body, she will just rest  Educational attainment is grade five  She speaks bisaya 7. Self Perception Self Concept Pattern  Client claimed that her children makes her angry when they disobey her  She ignores the things that will make her angry  She feels good about herself and contended 8. Role Relationship Pattern  Lived with her husband, 2 perform their interventions  yawning noted  sleepy eyes  no difficulty or problems with patients adjacent to her  Frequent yawning observed  can sleep with lights on  sleeps with 2 pillows propped under her head  blankets keep her comfortable  client verbalized the following:  “wala raman pod ko problema sa pandungog ug panan-aw”  “dili raman ko magamit ug antipara  “usahay malimot ko sa ubang butang”  Provide coherent answers to questions  Oriented to environment and is aware of self but is lethargic  Verbalized the following:  “gulang nako, wala nay paglaum na mobalik sa akong pagkabatan- on”  “’naa nakoy dagahang sakit”  sleeps with 2 pillows propped under her head  blankets keep her comfortable  still has no problem in hearing and visualizing  Provide coherent answers to questions  Oriented to environment and is aware of self but is lethargic  Responsive to stimuli  She hasn’t regretted anything  She is satisfied of the life she had  Feels incapable of doing things on her own because of her condition  Feels dependent to others for her needs her head  blankets keep her comfortable Provide coherent answers to questions Oriented to environment and is aware of self but is lethargic Responsive to stimuli She claimed that due to her condition, she can no longer do her usual task She wishes to be cured form her condition Feels incapable of doing things on her own because of her condition Feels dependent to others for her needs

48. children and 3 grandchildren  Claimed to have no problems in the family  If ever there are problems, it is discussed by the family  Claimed to have good relationship with her neighbors  sometimes expressed her emotions and inner feelings to her neighbor 9. Sexually Reproductive Pattern  has 9 children; 8 girls and 1 boy  claimed to have a happy family  doesn’t used any contraceptives  is not sexually active anymore  practices improper washing of vagina  18 years of marriage  Menarche: 15 years old  Menopausal: 40 years old 10. Coping Stress Tolerance  Claimed that she easily gets tense  Major change in her life is the deterioration of her health  She solves problems by praying to God 11. Value Belief Pattern  Dependent on the pension of her husband for financial resources  Not able to do usual task  Daughter and husband are present as watchers  Not able to do usual task  Able to talk and laugh but lmited  Verbalized that “naguol sila sa akong pagkahospial ka yang kwarta na ibayad  Only 2 of her children is with her out of 9  No problems with her reproductive system  Verbalized “kapoy na mag-ing-ana (referring to sexual activity)  Shares her problems to student nurses and family  She was accompanied by her husband all the time  There was no problem in their family that was difficult to solve  The same daughter was seen yesterday on her side as a watcher  No reproductive problems  No sexual concerns  Rests on bed whenever she is tired  Her husband is very supportive to her needs She was assisted by her daughter and husband in doing desired activities  The same daughter was seen yesterday on her side as a watcher  No reproductive problems  No sexual concerns  Client verbalized “ mag-ampo ko kung magu-ol” Shares her problems to student nurses and family  Rests on bed whenever she is tired

49.  A roman catholic  Claimed to be highly spiritual  Values her family and relationship with other people  Rest’s in Sim’s position whenever she is tired  Family is supportive to her needs  Verbalizes that she commits to God her condition  Prays to God for her problems to be solved  Values her family so much and relationships with other people  Continues to pray and values her life and self-worth  Able to deal others with respect  Continues to pray and values her life and self-worth  Able to deal others with respect CUES/EVIDENCES NURSINGDIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

50. Subjective ♦ Coffee drinker as claimed ♦ Verbalized “ maglisod ko ug ginhawa” Objective ♦ 63 years old ♦ Admitted with medical diagnosis of CHF 20 ASHD; UTI; hyperlipidemia ♦ Oxygen 2 L/min ♦ IVF Plain NSS at KVO rate ♦ V/S T: 36.70 C PR: 74 bpm, strong and regular RR: 34 cpm, shallow and regular BP: 160/90 mmhg ♦ Labored breathing noted ♦ Use of accessory muscles in breathing ♦ Body weakness noted 2. Decreased cardiac output related to heart failure Within our care, our client will have an increase in cardiac output as evidenced by: • V/S within normal range T: 36.50 C-37.50 C PR: 60-100 bpm RR: 16-20 cpm BP:100-140/60-90mmhg • Regular cardiac rhythm • decrease Labored breathing • decrease abnormal lung sounds • urine output of 1,500ml/24 hrs. and characteristics remains normal • decrease use of accessory muscles • decrease body weakness Independent: • Monitor V/S q 4 hrs. • Assess BP for hypertension and RR for tachypnea • monitor lung sounds for adventitious sounds such as crackles and for presence of coughing • monitor intake and output and analyze findings . note color and amount of urine • Assess for change in mental status • Assess peripheral → provides baseline data → hypertension may be caused by chronic vasoconstriction or may indicate fear or anxiety, and increased RR may indicate fatigue or increased pulmonary congestion → this indicates a further decrease in cardiac output and possibility of developing pulmonary edema → if intake exceeds output, the client is at risk for fluid overload and may not be able to clear fluids because of decompensating heart. Dark, concentrated urine and oliguria may reflect a decrease in renal perfusion → may indicate decreased cerebral perfusion or hypoxia → decreased strength of After, our client had an increase in cardiac output as evidenced by: • 2 V/S were within normal range T: 37.4 degrees Celsius PR: 85 bpm, strong and regular RR: 31 cpm, deep and regular BP: 150/80 mmhg • Regular cardiac rhythm • decreased Labored breathing • decreased abnormal lung sounds • urine output of 1,500ml/24 hrs. and characteristics remains normal: not met- 600ml • decreased use of accessory muscles •decreased body

51. ♦ Limited talk ♦ Presence of crackles upon auscultation pulses for strength and peripheral pulses is CUES/EVIDENCES NURSINGDIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION ♦ Capillary refill is 3-4 secs. ♦ Senile turgor and poor mobility ♦ Color of urine is yellowish; amount is quality Provide Health Teachings often found in clients with decreased cardiac output, and a further decrease in baseline may indicate cardiac failure weakness

52. 600 ml o Encourage psychological and physical rest o Encourage client to eat as ordered and rest afterwards o Encourage to do deep breathing and coughing exercises o Instruct client to quit drinking coffee and other drinks that contain caffeine o Encourage client to ambulate Collaborative o Administer prescribed medication as ordered  Increased physical or mental strain can increase myocardial and oxygen demands  Prevents complications and enables client preserve energy  Promotes oxygenation in the body and to clear airway  This maybe a factor of a decreased cardiac output  Promote proper circulation of blood  Promotes therapeutic effect to client and enables us to know the current respond to medication CUES/EVIDENCES NURSINGDIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION Subjective ♦ Verbalized “kapoy kayo akong lawas” 3. Activity intolerance related to imbalance between oxygen supply and demand secondary Within our care, our client will achieve an increase in activity tolerance as evidenced Independent: • Monitor V/S before and immediately after  Significant changes in V/S can occur with compromised cardiac After our care, our client achieved an increase in activity tolerance as evidenced by:

53. ♦ Verbalized “ maglisod ko ug ginhawa” Objective ♦ 63 years old ♦ Admitted with medical diagnosis of CHF 20 ASHD; UTI; hyperlipidemia ♦ V/S T: 36.70 C PR: 74 bpm, strong and regular RR: 34 cpm, shallow and regular BP: 160/90 mmhg ♦ Oxygen 2 L/min ♦ IVF Plain NSS at KVO rate ♦ Appeared weak and lethargic ♦ Hair is not fixed ♦ Smell is not so pleasant ♦ Appear restless ♦ Stays in bed most of the time in a low semi-fowler’s position; faces on one to disease condition by: • V/S are within normal range T: 36.50 C-37.50 C PR: 60-100 bpm RR: 16-20 cpm BP:100-140/60-90mmhg • Reduced weakness and fatigue • Participation in tolerable desired activities • Meeting own self-care needs with minimum assistance • Improved posture activity or receiving medication • Monitor client’s response to activities. Note for dyspnea, diaphoresis, pallor and tachycardia • Monitor client’s oxygen supply • Perform procedures with proper spacing • Provide assistance with self- care activities as indicated • Schedule rest periods with client Provide Health Teachings o Instruct client to avoid activities that needs pumping function and medication effect  Compromised cardiac pumping can cause immediate increase in heart rate and oxygen demands therefore by aggravating weakness and fatigue  Assess if client’s oxygen supply is enough for her oxygen demands  Clustering activities increases oxygen and may cause fatigue and weakness  Client will be able to meet personal care needs without undue myocardial stress  Rest periods help alleviate fatigue and decrease workload  Activities that needs more supply than the body can supply can • 2 V/S are within normal range T: 37.4 degrees Celsius PR: 85 bpm, strong and regular RR: 31 cpm, deep and regular BP: 150/80 mmhg • Reduced weakness and fatigue • Participated in tolerable desired activities • Met own self-care needs with minimum assistance • posture has slightly improved: minimized use of 3 point posit

54. more oxygen supply CUES/EVIDENCES NURSINGDIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION side propped with 2 pillows ♦ Barely converse with her watchers ♦ Posture is bent when she sits ♦ Moderate perspiration ♦ Perceived ability for the following: Feeding: 2 Bathing: 2 Toileting: 2 Dressing: 2 Grooming: 2 General Mobility: 2 Client needs assistance from another person o Instruct client to report any problems with activity intolerance like difficulty in breathing, pallor and weakness o Encourage client to participate in activities beneficial to her health within tolerable level cause fatigue and weakness  Immediate interventions can be done to compensate with client’s needs  Promotes cooperation and easiness in performing activities with client. It also promotes good relationship with persons involved with the activities

55. CUES/EVIDENCES NURSINGDIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION Subjective ♦ Verbalized“ maglisod ko ug ginhawa” ♦ Verbalized “kapoy kayo akong lawas” Objective ♦ 63 years old ♦ Admitted with medical diagnosis of CHF 20 ASHD; UTI; hyperlipidemia ♦ V/S T: 36.70 C PR: 74 bpm, strong and regular RR: 34 cpm, shallow and regular BP: 160/90 mmhg ♦ Oxygen 2 L/min ♦ IVF Plain NSS at KVO rate ♦ Appeared weak and lethargic 1. Ineffective breathing pattern related to imbalance between oxygen supply and demand Within our care, our client shall have improved effective respiratory pattern as evidenced by: • V/S are within normal range: T: 36.50 C-37.50 C PR: 60-100 bpm RR: 16-20 cpm BP:100-140/60-90mmhg • Reduced weakness, fatigue and restlessness • Improved breathing by minimal use of accessory muscles Independent: • Monitor V/S before and immediately after activity or receiving medication • Monitor client’s capillary refill • Monitor client’s response to activities. Note for dyspnea, diaphoresis, pallor and tachycardia • Maintain client’s position in semi- fowler’s Provide Health Teachings • Instruct client to avoid activities that needs more oxygen supply  Significant changes in V/S can occur with compromised cardiac pumping function and medication effect  To assess the status of clients’ oxygenation  Compromised cardiac pumping function can cause immediate increase in heart rate and oxygen demands thereby aggravating weakness and fatigue  Elevation of patient’s head is beneficial to patient’s breathing pattern Activities that needs more supply than the body can supply can cause fatigue and weakness After our care, our client had improved effective respiratory pattern as evidenced by: • 2 V/S are within normal range: T: 36.50 C-37.50 C PR: 60-100 bpm RR: 16-20 cpm BP:100-140/60-90mmhg • Reduced weakness, fatigue and restlessness • Improved breathing by minimal use of accessory muscles

56. ♦ Bed is in semi- fowler’s position and faces on one side ♦ labored breathing ♦ Uses accessory muscles ♦ Barely converse with her watchers CUES EVIDENCES Subjective  sleeps at 8pm and wakes t 4pm  sleep is interrrupted  reported to have difficulty getting enough rest because of the need to wake up when medical personnel perform their interventions  no difficulty or problems with patients adjacent to her  can sleep with lights on  sleeps with 2 pillows propped under her head NURSING DX 6. Disturbed Sleeping Pattern related to hospital routines OBJECTIVES Within our care, our client will be free from S/S of disturbed sleeping pattern as evidenced by: • V/S are within normal range: T: 36.50 C-37.50 C PR: 60-100 bpm RR: 16-20 cpm BP:100-140/60- 90mmhg • Client will verbalized good, sound sleep • Absence of yawning • Absence of sleepy eyes o Instruct client to report any problems with activity intolerance like difficulty in breathing, pallor and weakness INTERVENTIONS Independent • Monitor V/S q 4 hrs. • Monitor S/S of disturbed sleeping pattern • Assess level of consciousness • Encourage client to drink warm liquid before sleeping if not contraindicated • Perform back rub • Provide rest and  Immediate interventions can be done to compensate with client’s needs RATIONALE - to be able to assess significant changes in the client’s V/S which may indicate S/S of disturbed sleeping pattern - evaluate improvements of client’s sleeping pattern - evaluate improvements of client’s sleeping pattern -this promotes sleep -this will help client fall asleep - this will help client fall asleep EVALUATION Within our care, our client was free from S/S of disturbed sleeping pattern as evidenced by: • 2 V/S are within normal range: T: 36.50 C-37.50 C PR: 60-100 bpm RR: 16-20 cpm BP:100-140/60- 90mmhg • Client verbalized good, sound sleep • yawning was Absent • sleepy eyes was Absent

57.  blankets keep her comfortable Objective  Appeared weak and lethargic  sleepy eyes  Appeared restless  Stays in bed most of the time  Frequent yawning observed  V/S 5pm T: 36.70 C PR: 74 bpm, strong and regular RR: 34 cpm, shallow and regular BP: 160/90 mmhg • barely converse with her watchers • Improved level of consciousness relaxation techniques • Health Teachings • Advise patient to limit intake of caffeine prior to bed time • Offer reading materials • Environmental manipulation Collaborative • Administer medication as ordered - this delays sleep -this can help client fall asleep -a comfortable environment help client fall asleep -administering medication can induce sleep • Improved level of consciousness:not met- client still appear lethargic

58. CUES/EVIDENCE S Subjective ♦ 63 years old ♦ Admitted with medical diagnosis of CHF 20 ASHD; UTI; hyperlipidemia ♦ V/S NURSING DX 4. Ineffective tissue perfusion related to decreased blood flow secondary to disease condition OBJECTIVES Within our care, our client will demonstrate improved tissue perfusion as evidenced by: • V/S are within normal range: • V/S are within normal range: T: 36.50 C-37.50 C PR: 60-100 bpm RR: 16-20 cpm BP:100-140/60- INTERVENTIONS Independent: • Monitor V/S q 4 hrs. • Monitor client’s capillary refill RATIONALE  Significant changes in V/S can occur with compromised cardiac pumping function and medication effect  To assess the status of clients’ oxygenation  Decreased blood flow to the can cause significant changes in client’s skin EVALUATION After our care, our client demonstrated improved tissue perfusion as evidenced by: • 2 of the 4 V/S are within normal range: • V/S are within normal range: T: 36.50 C-37.50 C PR: 60-100 bpm RR: 16-20 cpm BP:100-140/60- 90mmhg

59. T: 36.70 C PR: 74 bpm, strong and regular RR: 34 cpm, shallow and regular BP: 160/90 mmhg ♦ Oxygen 2 L/min ♦ IVF Plain NSS at KVO rate ♦ skin color is slightly pale ♦ Skin temp. is warm ♦ Capillary refill is 3-4 secs. ♦ Senile turgor and poor mobility ♦ Bed is in semi- fowler’s position and faces on one side ♦ labored breathing ♦ Uses accessory muscles 90mmhg • Normal skin color and temperature • Improved capillary refill • Absence of diminished peripheral pulses • Absence of pallor and cyanosis • Inspect for skin color and temperature changes • Maintain client’s position in semi- fowler’s Provide Health Teachings • Instruct client to have bed rest • Instruct client to report any problems related to ineffective tissue perfusion conditions  Elevation of patient’s head is beneficial to patient’s breathing pattern  Limitation of activity can help minimize risk of complications  Immediate interventions can be done to compensate with client’s needs • Normal skin color and temperature • Improved capillary refill: Moderately good capillary refill-3 sec • diminished peripheral pulses was absent • pallor and cyanosis was absent

60. CUES/EVIDENCES NURSING Dx OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

61. Subjective: - verbalized, “kapoy na kaayo” - verbalized, “gulang na ko, luya na ang akong lawas” Objective:  perceived ability for the following  feeding :2  bathing : 2  toileting : 2  bed mobility : 2  dressing : 2  grooming : 2  general mobility : 2 - v/s 5 pm T: 36.70 C PR: 74 bpm, strong and regular RR: 34 cpm, shallow and regular BP: 160/90 mmhg - Appeared weak and lethargic - Hair is not fixed well, Self-care deficit r/t activity intolerance Within our care, the patient will be able to safely perform self-care activities to her maximum ability as evidenced by:  Client will perform simple self-care activities (self- combing, brushing teeth, bathing, etc.) that will not make her tired.  Client will display activities with minimal assistance.  Vital signs within normal range: T: 36.5-37.50 C PR: 60-100 bpm, strong and regular RR: 16-20 cpm, shallow and regular BP: 100-140/60-90 mmHg  Assess vital signs q 4 hrs.  Encourage patient to go to the bathroom to void instead of using bedpan as tolerated.  Encourage patient to do self care activities with minimal assistance such as combing the hair, brushing the teeth, taking a bath, etc. as tolerated.  Ensure that all equipment needed in performing self- care activities are close to patient.  Educated the client on the  To establish baseline data  To foster independence if able to perform the activity alone.  To promote independence and self-esteem.  To conserve energy.  To increase the willingness of the patient in doing self-care After our care, the patient was able to perform self care activities to her maximum ability as evidenced by:  Client performed simple activities such as combing her hair and taking a bath.  Client displayed activities with minimal assistance.  2 v/s within normal range not met T: 37.4 degrees Celsius PR: 85 bpm, strong and regular RR: 31 cpm, deep and regular BP: 150/80 mmHg

62.  Black, J.M., et. al. Medical Surgical Nursing 6th ed. 2001. The Curtis Center Independnce Square West Philadelphia, Pennsylvania 19106  Black ,J.M., Jacobs E. M. Medical-Surgical Nursing 5th ed. 1997. The Curtis Center Independnce Square West Philadelphia, Pennsylvania 19106  Bullock, B.L., Rosendahl, P.P., Pathophysiology 3rd ed. 1992. Lippincott Company 227 East Washington Square, Philadelphia, Pennsylvania 19106  Health and Home November-December 2000  Lemone, P. et.al. Medical-Surgical Nursing.1996. Addison-Wesley Nursing. A division of the Benjamin/Cunnings Publishing Company Inc.  McAnce K.L., Huether S. E. Pathohysiology 2nd ed 1994. Mosby-Year Book Inc. 11830 Westline Industrial Drive, St. Louis, Missouri 63146

63.  McAnce K.L., Huether S. E. Pathohysiology 3rd ed 1998. Mosby-Year Book Inc. 11830 Westline Industrial Drive, St. Louis, Missouri 63146  Porth C. M, Pathophysiology. 4th ed.1994. Lippincott Company 227 East Washington Square, Philadelphia, Pennsylvania 19106  Smeltzer Medical Surgical Nursing 8th ed.1996. Lippincott Company 227 East Washington Square, Philadelphia, Pennsylvania 19106  www.lejacq.com

64. At the end of our case analysis presentation the learners had improved knowledge on the important concepts of caring with a patient who is diagnosed of having congestive heart failure, and manifested positive attitudes and skills towards providing care to those patients including their family and significant others. Within our case study we were able to attain following: identify the demographic data of our patient including her genogram and ecomap, reviewed the anatomy and physiology of the affected systems, traced and explained the pathophysiology of CHF, utilized the nursing process with competence by making functional health patterns and nursing care plans for our patient, stated the importance and the mechanism of actions of the medications given, recognized the importance of lab exams and were able to utilize some medical management to give holistic care of our patient.

65. You Can Survive Heart Attack Even When Alone Let’s say it’s 6:15pm and you’re driving home (alone of course), after unusually hard day on the job. You’re really tired, upset and frustrated. Suddenly you start experiencing severe pain in your chest that starts to radiate out into your arm and up into your jaw. You are only about 5 miles from the hospital nearest your home; unfortunately you don’t know you’ll be able to make it that far. Date Laboratory and Diagnostic Result Normal Values Implications February 20, 2006 Blood chemistry BUN------------------ 24mg/dl Creatinine------------ 0.94mg% FBS------------------- 86mg/dl Uric Acid------------ 6.5mg/dl Cholesterol----------151 mg/dl Triglyceride----------81mg/dl Chol-HDL-----------30 mg/dl LDL -----------------104 mg/dl Urinalysis Color----------------yellow Transpaerncy------clear Sp.Gravity---------1.010 Glucose-------------Neg. Protein--------------trace pH-------------------6.0 Microscopic Examination Pus cells------------10-15/hpf RBC-----------------0-2 Epithelial cells-----moderate Clinical Examination Na+-----------------136mEq/l K+------------------4.0mEq/L CBC Hemoglobin------13.8gm% Hematocrit-------42.1% WBC--------------6,100/cumm Seg---------------80% Neutrophils----- Lymphocytes--15% Eosinophils----1% Monocytes-----3% Platelet count----330,000 Blood chemistry BUN---------------8-23mg/dl Creatinine---------0.5-1.2mg% FBS----------------60-110mg/dl Uric acid----------2.4-5.7mg% Cholesterol-------< 200mg/dl Triglyceride------40-150mg/dl Chol-HDL--------30-80mg/dl LDL -------------60-180mg/dl Urinalysis Color---------straw-deep amber Transparency----clear Sp.Gravity-------1.010-1-1.025 Glucose-----------(-) Protein------------(-) pH-----------------4.6-8 Microscopic Examination Pus cells----------0-5/hpf RBC---------------0-2 Epithelial cells---moderate Clinical Examination Na+----------------136mEq/l K+-----------------4.0mEq/L CBC Hemoglobin------13.8gm% Hematocrit-------42.1% WBC--------------6,100/cumm Seg---------------80% Neutrophils-----55-70% Lymphocytes---15% Eosinophils-----1% Monocytes------3% Platelet count------330,000 Increase in BUN may indicate renal failur Creatinine is the most accurate measure of A FBS level over 140 mg for 2-3 times in Normal examination of urine is useful in s urinary tract as well as for the diagnosis a Hemoglobin, which transports oxygen, is indicate anemia, recent hemorrhage and fl A low hct suggests anemia massive blood Measures a number of WBCs in a microli infection and inflammation as well as in m Decreased may mean bone marrow depres hepatitis, influenza, measles, mumps, rube storage diseases, deficiency of folic acid o Increase in lymphocytes may mean infecti Eosinophils are responsible for allergic re Promote coagulation by supplying phosph hemostatic plug for vascular injuries. Dec RBCs

66. What can you do? You’ve been trained in CPR but the guy that taught the course neglected to tell you to perform it on yourself. Without help, the person whose heart stops beating properly and who begins to faint, has only about 10 sec. left before losing consciousness. However, these victims can help themselves by coughing repeated and very vigorously. A deep breath should be taken before each cough, and the cough must be deep and prolonged, as when producing sputum from deep inside the chest. A breath and cough must be repeated about every 2 sec. without let up until help arrives, or until the heart is felt to be beating normally again. Deep breaths get oxygen into the lungs and coughing movements squeeze the heart and keep the blood circulating. The squeezing pressure on the hart attack victims can get to a hospital.

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