IV.

Course of confinement:

This is the case of Mrs. Blank who was confined at La Union Medical Center in Agoo,

La Union with the chief complaint of difficulty of breathing and Excessive Cough. She was then

diagnosed of Severe Heart Disease upon admission.

Mrs. Blank was admitted to the ED(Emergency Department) at 11:30 pm last July 17,

2010 with complaints of DOB and initial vital signs of BP=110/70, mmHg PR=60 beats/min,

RR= 24 cycles per minute, Temp=36.8 °C. Initial treatments were administration of oxygen

regulated at 3 L/min per nasal cannula, IFC insertion, chest X-Ray, ECG monitoring and an

order of a first IV fluid D5W1L x KVO(Strict). Chest X-ray revealed the presence of

Cardiomegaly with pulmonary congestion. The patient was later given a nursing diagnosis of

Ineffective airway clearance related to retained secretions in the tracheo-bronchial tree.

DAY 1 – 07/18/10

The patient’s nursing management during this day includes decreasing forceful coughing

episodes and providing adequate oxygen supply. Nursing interventions done were to maintain O 2

inhalation, regulating of IVF as ordered, giving due medications. Diagnostic interventions were

reviewing of charts, monitoring the input and output and assessing the level of consciousness and

circulatory status of the patient. Educative interventions done were encouraging the patient to

verbalize discomfort.

Medications Diagnoses Diagnostic Therapeutic Educative

Salbutamol Ineffective airway Reviewing encouraging the

nebulization x 3 doses clearance related to of charts, patient to
q 20 mins then 4o retained secretions in characterizi verbalize
the tracheo-bronchial ng of headache and
tree phlegm, dizziness
monitoring And for
of vital significant others
signs to provide rest
especially opportunity,
Furosemide 40 mg IV q Fluid Volume BP and RR, advising patient to
12o(with BP excess related to auscultating stand slowly to
precaution) accumulation of the breath prevent dizziness
fluid in the pleural, sounds,
pericardial and monitoring
the input Advise patient to
interstitial space;
and output take high
pulmonary
and potassium diet
capillaries
assessing and supplement
Digoxin .75 mg IV now Decrease cardiac the level of Provide rest Encourage patient
– may give 25 mg IV output related to consciousne and decrease to eat potassium-
after 4o for CR > 100 altered stroke ss and stress to rich foods
BPM volume circulatory decrease CR
status of the
patient

DAY 2 – 07/19/10

The patient’s nursing management during this day includes decreasing forceful coughing

episodes and providing adequate oxygen supply. Doctor’s orders were to continue medications

prescribed, decrease Furosemide dosage to OD, decrease Digoxin dosage to .25 mg OD and start

Captopril medication. Nursing interventions were helping on performance of activities of daily

living, providing safety and security, monitoring of vital signs and regulating of IVF as ordered,

providing rest opportunity and maintaining head of bed elevated high fowler’s position.

Diagnostic interventions were reviewing of charts, characterizing of phlegm, monitoring of vital

signs, auscultating the breath sounds, noting for any verbal or/and non-verbal cues for

discomfort, monitoring the input and output and assessing the level of consciousness and

circulatory status of the patient. Educative interventions done were deep breathing exercise, huff

cough demonstration to decrease irritation during episodes of cough, encouraging the patient to

verbalize discomfort, needs and concerns and for significant others to provide rest opportunity,

and advising her to have an adequate rest.

Medications Diagnoses Diagnostic Therapeutic Educative

Salbutamol Ineffective airway reviewing of encouraging the

nebulization x 3 doses clearance related to charts, patient to
q 20 mins then 4o retained secretions in characterizi verbalize
the tracheo-bronchial ng of headache and
tree phlegm, dizziness
Auscultate and for significant
breath others to provide
sounds rest opportunity,
before and
Furosemide 40 mg IV Fluid Volume after advising patient to
OD(with BP excess related to administrati stand slowly to
precaution) accumulation of on, prevent dizziness
fluid in the pleural, monitoring
pericardial and of vital
signs Advise patient to
interstitial space;
especially take high
pulmonary
BP and RR, potassium diet
capillaries
auscultating and supplement
Digoxin 25 mg IV OD Decrease cardiac the breath Provide rest Encourage patient
for CR > 100 BPM output related to sounds, and decrease to eat potassium-
altered stroke monitoring stress to rich foods
volume the input decrease CR
Captopril 25 mg ½ tab (HYPERTENSION) and output Encourage patient
OD (watch out for and to slowly rise
hypotension) assessing from bed to
the level of prevent
consciousne orthostatic
ss and hypotension
circulatory
status of the
patient

DAY 3 – 07/20/10

The patient’s nursing management during this day includes was still on decreasing

forceful coughing episodes and providing adequate oxygen supply. Doctor’s order includes to

undergo 2D echo, to start Gentamycin medication and to continue medications. The patient can

now tolerate intermittent weaning of oxygen administration. Nursing interventions were helping

on performance of activities of daily living, providing safety and security, monitoring of vital

signs and regulating of IVF as ordered, providing rest opportunity and maintaining head of bed

elevated high fowler’s position. Diagnostic interventions were reviewing of charts,

characterizing of phlegm, monitoring of vital signs, auscultating the breath sounds, noting for

any verbal or/and non-verbal cues for discomfort, monitoring the input and output and assessing

the level of consciousness and circulatory status of the patient. It also includes the re-evaluation

of effective deep breathing exercise and huff cough demonstration. Educative interventions done

were to encourage performance of deep breathing exercise and huff coughing, encouraging the

patient to verbalize discomfort, needs and concerns and for significant others to provide rest

opportunity, and advising her to have an adequate rest.

Medications Diagnoses Diagnostic Therapeutic Educative

Salbutamol Ineffective airway reviewing of encouraging the

nebulization x 3 doses clearance related to charts, patient to
q 20 mins then 4o retained secretions in characterizi verbalize
the tracheo-bronchial ng of headache and
tree phlegm, dizziness
Auscultate and for significant
breath others to provide
sounds rest opportunity,
before and
Furosemide 40 mg IV Fluid Volume after advising patient to
OD(with BP excess related to administrati stand slowly to
precaution) accumulation of on, prevent dizziness
fluid in the pleural, monitoring
pericardial and of vital
Advise patient to
interstitial space; signs
take high
pulmonary especially
potassium diet
capillaries BP and RR,
and supplement
auscultating
Digoxin 25 mg IV OD Decrease cardiac the breath Provide rest Encourage patient
for CR > 100 BPM output related to sounds, and decrease to eat potassium-
altered stroke monitoring stress to rich foods
volume the input decrease CR
Captopril 25 mg ½ tab (HYPERTENSION) and output Encourage patient
OD (watch out for and to slowly rise
hypotension) assessing from bed to
the level of prevent
consciousne orthostatic
ss and hypotension
Gentamycin 80 mg IV Ineffective airway circulatory Encourage patient
q 8o clearance related to status of the to report adverse
retained secretions in patient reactions such as
the tracheo-bronchial dizziness, vertigo,
tree(for infection) ringing in the ears
and numbness

DAY 4 07/21/10

The patient’s nursing management during this day includes was still on decreasing

forceful coughing episodes and providing adequate oxygen supply. Doctor’s order was to

continue medications. Nursing interventions were helping on performance of activities of daily

living, providing safety and security, monitoring of vital signs and regulating of IVF as ordered,

providing rest opportunity and maintaining head of bed elevated high fowler’s position.

Diagnostic interventions were reviewing of charts, characterizing of phlegm, monitoring of vital

signs, auscultating the breath sounds, noting for any verbal or/and non-verbal cues for

discomfort, monitoring the input and output and assessing the level of consciousness and

circulatory status of the patient. It also includes the re-evaluation of effective deep breathing

exercise and huff cough demonstration. Educative interventions done were to encourage

performance of deep breathing exercise and huff coughing, encouraging the patient to verbalize

discomfort, needs and concerns and for significant others to provide rest opportunity, and

advising her to have an adequate rest.

 Medications Diagnoses Diagnostic Therapeutic Educative

Salbutamol Ineffective airway reviewing of encouraging the

nebulization x 3 doses clearance related to charts, patient to
q 20 mins then 4o retained secretions in characterizi verbalize
the tracheo-bronchial ng of headache and
tree phlegm, dizziness
Auscultate and for significant
breath others to provide
sounds rest opportunity,
before and
Furosemide 40 mg IV Fluid Volume after advising patient to
OD(with BP excess related to administrati stand slowly to
precaution) accumulation of on, prevent dizziness
fluid in the pleural, monitoring
pericardial and of vital
signs Advise patient to
interstitial space;
especially take high
pulmonary
BP and RR, potassium diet
capillaries
auscultating and supplement
Digoxin 25 mg IV OD Decrease cardiac the breath Provide rest Encourage patient
for CR > 100 BPM output related to sounds, and decrease to eat potassium-
altered stroke monitoring stress to rich foods
volume the input decrease CR
Captopril 25 mg ½ tab (HYPERTENSION) and output Encourage patient
OD (watch out for and to slowly rise
hypotension) assessing from bed to
the level of prevent
consciousne orthostatic
ss and hypotension
Gentamycin 80 mg IV Ineffective airway circulatory Encourage patient
q 8o clearance related to status of the to report adverse
retained secretions in patient reactions such as
the tracheo-bronchial dizziness, vertigo,
tree(for infection) ringing in the ears
and numbness
Prioritization:

1. Ineffective Airway Clearance related to retained secretions in the tracheo-bronchial tree

This problem is under the physiologic need in the Maslow’s hierarchy of needs.
The problem is a vital one that needs to be addressed immediately. Oxygen is
vital to life and decreased of such may impair bodily functions and will aggravate
or even predispose further heart problem.
2. Decreased Cardiac Output related to decreased left ventricular contractility

This problem is also under the physiologic need but third on ABC prioritization.
The problem must be addressed as second because if there will be no O2 there will
be no essence of the heart. The Heart will pump nothing because there is no
Oxygen.
3. Fluid Volume Excess related to accumulation of fluid in the pleural and interstitial space;
pulmonary capillaries

The problem is under the physiologic need in the Maslow’s hierarchy of needs.
The problem is under the Fluids in the OFFTERASS after the ABC’s. This
problem can affect the well being of the patient specifically congesting the patient
and may lead to multiple organ failure if not addressed immediately. Addressing
the above problems may also decrease or alleviate the severity of the problem.
4. Ineffective Tissue Perfusion related to decrease circulating oxygen

The problem is also under the physiologic need and must be prioritized even
before the problem under fluids but the justification on this prioritization lies on
what to treat first. If the problem like ineffective airway clearance, decreased
cardiac output and fluid volume excess is treated first, the underlying condition
would not precipitate thus it should be placed after the said problems.
5. Activity Intolerance related to decreased ability of the heart to perfuse blood

The problem is under the physiologic need in the Maslow’s Hierarchy of needs
which is next to the above physiologic need. Addressing the above or proceeding
problems may treat the activity intolerance of the patient.
6. Sleep Deprivation related to difficulty of breathing when lying

The problem is also in the physiologic need but the problem has just started or
starting to manifest. Addressing the above problems will treat the condition.
7. Risk for Imbalanced Nutrition related to lack of appetite

The problem is a physiologic need but it is just a potential problem of which,

actual problems should be addressed first before this specific problem. Even if the
weight is decreased, it is within normal range. Addressing the actual problems
above may prevent the occurrence of this condition.
.
Problem: Congestive Heart Failure
Nursing Diagnosis: Fluid Volume Excess related to accumulation of fluid in the pleural and interstitial space; pulmonary capillaries
Goal: After 2 days of nursing intervention the patient will manifest improved fluid volume
Objectives:
LTO: After 3 days of nursing interventions, the patient will,
• Maintain stable weight accurately
• Maintain stable and normal vital signs
• Manifest decreased grade of edema, from grade II to I
• Maintain appropriate fluid intake
STO: after 8 hours of nursing intervention, the patient will,
• Demonstrate behaviors to monitor fluid status accurately
• Demonstrate behaviors to prevent aggravation of fluid volume excess
• Verbalize compliance to appropriate dietary or fluid intake
• Demonstrate behaviors to treat fluid volume excess.
CUES Explanation of the problem Intervention Rationale Evaluation

Subjectives: The patient is diagnosed of Dx:

• “Dakkel kannu cardiomegaly and valvular heart • Monitor vital • Accumulation of fluid in
iti pusok imbaga disease. If there is cardiomegaly, signs different compartments can
ni doctor” there is an increase pressure in affect the functioning of
• “ adda iti nasakit the left ventricle that may cause different organs that is
ditoy barukong regurgitation of blood to the left reflected by monitoring the
ko” atrium. Then it goes to the right vital signs especially BP
Objectives: and left pulmonary vein until in and PR. It is also important
• Grade II edema the pulmonary capillaries. to determine these before
noted bipedally Valvular heart Disease the administration of some
• X-ray revealed (especially mitral regurgitation) medications like Lasix
pulmonary facilitates backflow of blood. In • Note and grade • Can be a baseline data for
congestion CHF, third spacing happens the presence of the severity of fluid volume
• X-ray revealed causing accumulation of fluid to edema excess or use to evaluate
cardiomegaly the pericardial space. (extremities and effectiveness of drug
• Crackles noted face) therapy
• Observe for the • Presence of such may
 on both middle presence of indicate the presence of
and lower lobes heaves or lifts heart disease
• Dullness noted on the left
upon percussion anterior chest
of anterior chest • Note patient’s • Information given helps the
• Murmur noted dietary regimen nurse to assess for possible
upon aggravating factors of fluid
auscultation of volume excess
the PMI(point • Monitor I and O • To evaluate if there’s
of Maximal adequate elimination of
Impulse) fluid or if fluid intake is
• In O2 inhalation controlled
at 2 LPM per • Weigh patient • To evaluate if there’s
nasal cannula daily retention of fluid in the
• Prefers to be in body
high fowler’s • Auscultate lung • Presence of crackles may
position fields for detect the presence and
• Weight is 51 crackles accumulation of fluid inside
kgs the lungs
• Vital signs: • Percuss lung • Presence of such indicates
BP: 110/70 mmHg fields for pulmonary congestion
RR: 26 CPM dullness
T: 36.2oC Tx:
PR: 64 BPM • Set an • To prevent peaks/valleys in
appropriate rate fluid level and thirst
of fluid intake
throughout 24
hour period
(1L/day)
• Place patient in • To facilitate movement of
a high fowler’s diaphragm, thus improving
position as respiratory effort
appropriate.
 • Maintain O2 • To promote oxygenation of
inhalation as the blood despite of the
ordered respiratory and cardiac
problem
• Promote • To reduce workload of the
patient’s rest heart and lungs
• Maintain • To facilitate elimination of
intactness and excessive fluid in the body
presence of IFC
Ed:
• Educate the • To encourage compliance
patient about with the treatment being
the disease rendered
process
• Instruct patient • To reduce discomfort of
to perform oral drying the mucous
care, chewing membrane from fluid
gum or hard restrictions
• Discuss • To promote compliance of
importance of the patient
fluid restrictions
• Stress to the • To prevent stasis and reduce
patient the need risk of tissue injury
for mobility
and/or frequent
position change
• Instruct patient • To promote independence,
to weigh herself awareness and self-care of
before taking the patient
first meal in the
morning
• Instruct patient • To prevent too much water
on low salt diet reabsorption in the kidney
• Instruct patient • These signs indicate fluid
to report if she retention that may
can’t urinate or aggravates her condition
if there’s
decrease in
urination
• Instruct patient • To prevent aggravation of
to limit fluid CHF
intake to 1L/day