Case study

Chronic heart failure exacerbation

Location: telemetry unit

History/Intervention: This pt. Is a 67 y/o male with ischemic cardiomayopathy and history
of chronic heart failure. He is a veteran, brought him to the emergency dept. He was
complaining of shortness of breath, especially at night and when walking, fatigue and
swelling in his ankle and feet. Physical examination revealed mild respiratory distress and
2+ dependent pitting edema. Serum creatinine level was 1.0. Upon questioning the pt.
About the events leading, up to this morning he stated that he did not take his water pill for
last five days because his wife’s ankles were swollen so he gave the pill to her. He also
admitted to being out of one of them heart pills but cannot remember which one. He states
he is on several heart medications. He has not brought any of his medication to the
emergency dept. With him.12 leads ECG revealed sinus tachycardia without ectopy. His
client radiography showed cardiomegaly with perihilar infiltrates. An ABG was drawn and the
results are pending. A saline lock was inserted into his right forearm and he was admitted to
the telemetry unit. He is allergic to Penicillins, Cephalosporins, Midazolam.

Nursing care
- Admit to telemetry unit
- Telemetry monitoring (notify health care provider if rate is <60 0r >120)
- Administer Oxygen 2-5 LPM nasal cannula to maintain pulse oximeter greater than 95%
9notify health care provider if <95%)
- Pulse oximeter q 4hr; incentive spirometry q4hrs
- VS q4hrs; apply sequential compression devices; I & O evet shift
- Low Na diet; fluid restriction 1000ml/day
- Daily weights; bathroom privileges
- Elect5rolytes, Blood glucose, BUN, creatinine, Mg level, CBC, Cardiac Enzymes,
Echocardiogram
- Digoxin 0.25 mg PO every day
- Captopril 6.25 PO every 6 hrs
- Metoprolol 12.5 mg PO every day
- Furosemide 40mg PO BID
- Potassium 2o mEq PO every day
- Docusate Na 60mg PO every day
- Saline flush every shift
- Nitroglycerine 0.4mg tablet SL q5mins x3min chest pain
- Morphine Sulfate 2mg IVP for unrelieved chest pain (notify health care provider)
Biographical data:

Name: Rene Aquende Age: 67 y/o

Address: Vista Verde Pasig

Date of birth: November 1, 1943 Gender: male

Religion:

Reason foe seeking health care/ chief complaint:

Shortness of breath. Hands and legs swollen.

Perception of health status:

Hypertensive

Previous illness/ Hospitalization/ Surgeries:

Hypertension

Family medical history:

Arthritis: none DM: none Mental Disorder: none

Cancer: none Heart Disease: none Hypertension:

Sickle cell anemia: none Chronic Lung Disease: none

CVA: none Kidney Disease: none

Immunization/ Exposure to communicable Disease:

Complete

Allergies:

Penicillin, cephalosporin, Midzolam

Home Medication/ Alternative Medicine:

Psychosocial History:
Alcohol use: occasionally
Tobacco: 1 pack/day
Caffeine intake: 1 cup/day
Gordon’s functional patterns
Pattern Before Hospitalization
Health perception Feel good
Nutritional metabolic Very fun eating meat
Elimination At least 2 times a day
Activity/ exercise Walking
Sleep-rest Easier when the television
is turn off
Cognitive/ perceptual Surgery that can be
undergo
Role/relationship
Sexuality/ reproductive Active
Coping/ stress tolerance Call friends, watching
television
Value/ beliefs Don’t do unto others what
others want do to you
Physical Assessment
Body Assessment
Ankle and feet Edema
During Hospitalization
Having shortness of
breath
Limited food intake
No idea
Walking
Easy
The expenses
Not active because of his
condition
Call friends, watching
television
Don’t do unto others what
others want do to you
Analysis
Edema due to not taking of
waterpills for five days.
 Diagnostic/ laboratory examinations

Lab Result Normal Value Analysis

CBC:
Wbc 11.9 5,000 - 10,000 /mm3 Slightly elevated
hgb 11.5 14-17 g/dl Low hemoglobin
hct 35.10% 42-52% Low hematocrit
platelet 250 200,000 - 500,000 Normal
/mm3

Chemistry:
Na 137 136 -145 mEq/l Normal
K 3.6 3.5 - 5.0 mEq/l Normal
Cl 100 95 - 107 mEq/L Normal
CO2 24 20-29 mEq/L Normal
Glucose 118 100 -125 mg/dl Normal
BUN 6 7 - 20 mg/dl Below normal
Creatinine 1.2 0.5 - 1.1 mg/dl Slightly elevated
Magnesium 1.6 1.5-2.5 mEq/L Normal
Cardiac enzymes
Cpk 86 38–174 Normal
cpkmb 0.00% 0% to 6% of total CPK Normal
troponin 0.1 Less than 0.2 mcg/L Normal
Anatomy and physiology
 Pathophysiology of the disease

Heart failure

Activation sympathetic
decreased renal
circulatory reflexes
blod flow

Compensated Heart Failure

increase heart rate, cardiac contractility

salt and water retention 
and peripheral vascular resistance
increased
vascular volume 
 improved cardiac reserve
increased stroke volume via
Frank starling mechanism

Decompensated Heart Failure

Decreased diastolic
overfilling of the ventricles and
Filling time
circulation  decreased stroke
decreased stroke volume
volume and development of the increase after load 
peripheral and pulmonary edema
increase pressure work

MANAGEMENT
Acute decompensation
In acute decompensated heart failure (ADHF), the immediate goal is to re-establish adequate
perfusion and oxygen delivery to end organs. This entails ensuring that airway, breathing, and
circulation are adequate. Immediated treatments usually involve some combination of
vasodilators such as nitroglycerin, diuretics such as furosemide, and possibly non invasive
positive pressure ventilation (NIPPV)
Chronic management
The goal is to prevent the development of acute decompensated heart failure, to counteract the
deleterious effects of cardiac remodeling, and to minimize the symptoms that the patient suffers.
First-line therapy for all heart failure patients is angiotensin-converting enzyme (ACE)
inhibition. ACE inhibitors (i.e., enalapril, captopril, lisinopril, ramipril) improve survival and
quality of life in heart failure patients, and have been shown to reduce mortality in patients with
left ventricular dysfunction in numerous randomized trials.[35][36] In addition to pharmacologic
agents (oral loop diuretics, beta-blockers, ACE inhibitors or angiotensin receptor blockers,
vasodilators, and in severe cardiomyopathyaldosterone receptor antagonists), behavioral
modification should be pursued, specifically with regards to dietary guidelines regarding salt and
fluid intake. Exercise should be encouraged as tolerated, as sufficient conditioning can
significantly improve quality-of-life.
In patients with severe cardiomyopathy, implantation of an automatic implantable cardioverter
defibrillator(AICD) should be considered. A select population will also probably benefit
from ventricular resynchronization.
In select cases, cardiac transplantation can be considered. While this may resolve the problems
associated with heart failure, the patient generally must remain on an immunosuppressive
regimen to prevent rejection, which has its own significant downsides
Palliative care and hospice
Without transplantation, heart failure caused by ischemic heart disease is not reversible, and
cardiac function typically deteriorates with time. (In particular, diastolic function worsens as a
function of age even in individuals without ischemic heart disease.)

Risk factors
Be aware that certain factors may cause symptoms of heart failure to get worse. Some of these factors are:
high salt foods or beverages
medications that cause salt and water to be retained
fast heart rhythms
a cold or the flu
excessive fluid intake

Health teachings
Examine your lifestyle and habits. Healthy habits help to reduce your chance of illness. Eating to
optimize your health by limiting salt and fluid intake, including both activity and rest into your daily
routines and other habits are wise choices to adopt and can help you manage Heart Failure.
• Low sodium diet Limit the amount of sodium (salt) you eat. Salt is like a sponge, it keeps extra
fluid in your body. Your heart has to work harder to pump this extra fluid. By decreasing your intake
of salt, you can help your body lose the extra fluid. Tips for reducing salt intake are provided in your
patient education booklet.
• Monitor fluid intake With CHF, you may retain fluid in your body. To help avoid this, you may
need to limit the amount of fluid you drink during the day.
• Weigh yourself regularly Fluid build-up in your body shows on your scale as weight gain. A
sudden weight gain when you have been eating normally may be an early sign of fluid build-up. If
your weight increases more than 2 pounds (1 kg) in 2 days, or 5 pounds (3 kg) in a single week, call
your nurse or doctor.
 • Know about alcohol If you drink alcohol, you may have to severely reduce your intake or you may
have to abstain from alcohol completely, since alcohol impairs heart function. It is recommended that
you drink no more than one standard drink per day.
• Be smoke free Smoking, or exposure to second-hand smoke, makes the heart work harder and
decreases the amount of oxygen carried in the blood. Nicotine injures the lining of the arteries and
increases the build up of fat deposits in that area.
• Balance activity It is important to balance your daily activities with rest periods to help control your
symptoms. Some people find if they are too active one day, they are very tired for the next few days.
Taking rest periods during the day is helpful. Consider it as a “catch up” time for your heart.
Participate in regular physical activity. Regular physical activity may help you to feel better and make
your daily activities easier. A healthcare team member can advise you about the right kind and
amount of activity for you.
• Balance demands of work You may have concerns about whether you are able to continue to work
full-time or part-time outside the home. This will depend on your symptoms and the type of job you
have. Financial concerns or retraining possibilities may also be on your mind. If you are a
homemaker, you may also need to take time off. Ask family members, friends and neighbours for
help. Talk to your healthcare team about the concerns and challenges you face in this area.
• Intimate relations You and your partner may experience anxiety about sexual activity. This is very
common. Intercourse with your partner is not as hard on your heart as you may think. Research shows
that sexual activity takes about the same energy as walking up two flights of stairs or walking briskly.
Foreplay is a good warm-up for the increased activity of intercourse. This may be a time when you
desire sex less. Some reasons for this may be medications you are taking, fatigue or stress. It may be
helpful if you and your partner discuss this with your doctor or healthcare team.
• Manage stress well Stress is often a productive part of everyday life. But when stress becomes
“distress”, it makes your heart work harder. Although stress cannot be eliminated, it can be managed:
Ψ Learn what triggers stress for you
Ψ Learn to recognize your symptoms when stressed
Ψ Set aside time to relax every day
Ψ Try relaxation techniques and stress management programs
Ψ Get support from family and friends
Ψ Talk about your challenges
Ψ Regular physical activity is a great stress management tool
Ψ Seek professional help if stress becomes too overwhelming
• Share your feelings When you were diagnosed with heart failure, you may have felt shock,
anger, fear, anxiety, loss, or sadness. This is to be expected. Your family and friends may have
felt the same way. Sharing your feelings with each other is one way of coping with the changes
that are happening. You will need each other for support as you start to look ahead to the future.
Hypertension

Alternative Names: High blood pressure; HBP; Blood pressure - high

Definition of Hypertension:

Hypertension is the term used to describe high blood pressure.

Blood pressure readings are measured in millimeters of mercury (mmHg) and

usually given as two numbers. For example, 120 over 80 (written as 120/80 mmHg).

• The top number is your systolic pressure, the pressure created when your
heart beats. It is considered high if it is consistently over 140.
• The bottom number is your diastolic pressure, the pressure inside blood
vessels when the heart is at rest. It is considered high if it is consistently over
90.

Either or both of these numbers may be too high.

Blood pressure

Pre-hypertension is when your systolic blood pressure is between 120 and 139 or
your diastolic blood pressure is between 80 and 89 on multiple readings. If you have
pre-hypertension, you are more likely to develop high blood pressure.

Risk factors:

Blood pressure measurements are the result of the force of the blood produced by
the heart and the size and condition of the arteries.

Many factors can affect blood pressure, including:

• How much water and salt you have in your body

• The condition of your kidneys, nervous system, or blood vessels
• The levels of different body hormones

High blood pressure can affect all types of people. You have a higher risk of high
blood pressure if you have a family history of the disease. High blood pressure is
more common in African Americans than Caucasians. Smoking, obesity, and
diabetes are all risk factors for hypertension.

Most of the time, no cause is identified. This is called essential hypertension.

High blood pressure that results from a specific condition, habit, or medication is
called secondary hypertension. Too much salt in your diet can lead to high blood
pressure. Secondary hypertension may also be due to:
 • Adrenal gland tumor
• Alcohol abuse
• Anxiety and stress
• Arteriosclerosis
• Birth control pills
• Coarctation of the aorta
• Cocaine use
• Cushing syndrome
• Diabetes
• Kidney disease, including:
o Glomerulonephritis (inflammation of kidneys)
o Kidney failure
o Renal artery stenosis
o Renal vascular obstruction or narrowing
• Medications
o Appetite suppressants
o Certain cold medications
o Corticosteroids
o Migraine medications
• Hemolytic-uremic syndrome
• Henoch-Schonlein purpura
• Obesity
• Pain
• Periarteritis nodosa
• Pheochromocytoma
• Pregnancy (called gestational hypertension)
• Primary hyperaldosteronism
• Renal artery stenosis
• Retroperitoneal fibrosis
• Wilms' tumor

Symptoms:

Most of the time, there are no symptoms. Symptoms that may occur include:

• Chest pain
• Confusion
• Ear noise or buzzing
• Irregular heartbeat
• Nosebleed
• Tiredness
• Vision changes

If you have a severe headache or any of the symptoms above, see your doctor right
away. These may be signs of a complication or dangerously high blood pressure
called malignant hypertension.
Priority Nursing Diagnosis:

• Record most recent blood pressure reading

• Record previous blood pressure reading
• Get the average systolic (top number) and diastolic (bottom number)
reading?
• blood pressure increased changes

Other tests may be done to look for blood in the urine or heart failure. Your doctor
will look for signs of complications to your heart, kidneys, eyes, and other organs in
your body.

These tests may include:

Chem-20 or Metabolic panel - comprehensive; Chem-20; SMA20; Sequential multi-

channel analysis with computer-20; SMAC20; Metabolic panel 20

Definition of Comprehensive metabolic panel:

A comprehensive metabolic panel is a group of chemical tests performed on the

blood serum (the part of blood that doesn't contain cells).

These tests include total cholesterol, total protein, and various electrolytes.
Electrolytes in the body include sodium, potassium, chlorine, and many others.

The rest of the tests measure chemicals that reflect liver and kidney function.

1. Echocardiogram
2. Urinalysis
3. Ultrasound of the kidneys

Management

The goal of treatment is to reduce blood pressure so that you have a lower risk of
complications.

Medical

There are many different medicines that can be used to treat high blood pressure,
including:

• Alpha blockers
• Angiotensin-converting enzyme (ACE) inhibitors
• Angiotensin receptor blockers (ARBs)
• Beta-blockers
 • Calcium channel blockers
• Central alpha agonists
• Diuretics
• Renin inhibitors, including aliskiren (Tekturna)
• Vasodilators

Your doctor may also tell you to exercise, lose weight, and follow a healthier diet. If
you have pre-hypertension, your doctor will recommend the same lifestyle changes
to bring your blood pressure down to a normal range.

Often, a single blood pressure drug may not be enough to control your blood
pressure, and you may need to take two or more drugs. It is very important that you
take the medications prescribed to you. If you have side effects, your health care
provider can substitute a different medication.

Expectations (prognosis):

Most of the time, high blood pressure can be controlled with medicine and lifestyle
changes.

Complications

• Aortic dissection
• Blood vessel damage (arteriosclerosis)
• Brain damage
• Congestive heart failure
• Kidney damage
• Kidney failure
• Heart attack
• Hypertensive heart disease
• Stroke
• Vision loss

Prevention:

Adults over 18 should have their blood pressure checked routinely.

Lifestyle changes may help control your blood pressure:

• Lose weight if you are overweight. Excess weight adds to strain on the heart.
In some cases, weight loss may be the only treatment needed.
• Exercise regularly. If possible, exercise for 30 minutes on most days.
• Eat a diet rich in fruits, vegetables, and low-fat dairy products while reducing
total and saturated fat intake (the DASH diet is one way of achieving this kind
of dietary plan).
• Avoid smoking. (Nicotine withdrawal)
• If you have diabetes, keep your blood sugar under control.
• Do not consume more than 1 or 2 alcoholic drinks per day.
• Try to manage your stress.
• Monitoring blood pressure
• Untreated hypertension
• Lifestyle changes
• DASH diet(Dietary Approaches to Stop Hypertension)
• High blood pressure tests
• Exercise can lower blood pressure
• Blood pressure check
• Blood pressure
Pathophysiology of Hyperten
Ischemic cardiomyopathy

Alternative Names: Ischemic heart disease; Cardiomyopathy - ischemic

Definition of Ischemic cardiomyopathy:

Ischemic cardiomyopathy is a term that doctors use to describe patients who

have congestive heart failure due to coronary artery disease.

"Ischemic" means that an organ (such as the heart) is not getting enough
blood and oxygen. "Cardio" means heart and "myopathy" means muscle-
related disease.

Causes, incidence, and risk factors:

Ischemic cardiomyopathy results when the arteries that bring blood and
oxygen to the heart are blocked. There may be a buildup of cholesterol and
other substances, called plaque, in the arteries that bring oxygen to heart
muscle tissue. Over time, the heart muscle does not work well, and it is more
difficult for the heart to fill and release blood.

Ischemic cardiomyopathy is a common cause of congestive heart failure.

Patients with this condition may at one time have had a heart attack, angina,
or unstable angina. A few patients may not have noticed any previous
symptoms.

Ischemic cardiomyopathy is the most common type of cardiomyopathy in the

United States. It affects approximately 1 out of 100 people, most often
middle-aged to elderly men.

Risks Factors

• Diabetes
• High blood pressure
• High cholesterol
• High fat diet
• Obesity
• Personal or family history of heart attack, angina, unstable angina,
atherosclerosis, or other coronary artery diseases
• Smoking
Signs and Symptoms:

Patients with ischemic cardiomyopathy usually have symptoms of angina

and heart failure.

Symptoms of angina include:

• Chest pain that occurs behind the breastbone or slightly to the left of
it. It may feel like tightness, heavy pressure, squeezing, or crushing
pain. The pain may spread to the neck, jaw, back, shoulder, or arm.
• A feeling of indigestion or heartburn
• Dizziness or light-headedness
• Nausea, vomiting, and cold sweats
• Sensation of feeling the heart beat (palpitations)
• Shortness of breath
• Unexplained tiredness after activity (more common in women)

Symptoms of heart failure usually develop slowly over time. However,

sometimes symptoms start very suddenly and are severe. Common
symptoms include:

• Shortness of breath, especially with activity

• Shortness of breath that occurs after lying down for a while
• Cough
• Fatigue, weakness, faintness
• Swelling of the abdomen (in adults)
• Loss of appetite
• Swelling of feet and ankles (in adults)
• Pulse may feel irregular or rapid, or there may be a sensation of feeling
the heart beat (palpitations)

Signs and tests:

The physical examination may be normal, or it may reveal signs of fluid

buildup:

• "Crackles" in the lungs

• Elevated pressure in the neck vein
• Enlarged liver
• Extra heart sounds
• Leg swelling

There may be other signs of heart failure.

This condition is usually diagnosed only if a test shows that the pumping
function of the heart is too low. This is called a decreased ejection fraction. A
normal ejection fraction is around 55 - 65%. Most patients with this disorder
have ejection fractions much less than this.

Tests used to measure ejection fraction include:

1. ECG- An electrocardiogram (ECG) is a test that records the electrical

activity of the heart.

See also:

• Holter monitoring- A Holter monitor is a machine that continuously records

the heart's rhythms. The monitor is usually worn for 24 - 48 hours during
normal activity.
• Stress test- An exercise stress test is a screening tool to test the effect of
exercise on your heart. It provides an overall look at the health of your heart.

2. Echocardiogram- An echocardiogram is a test that uses sound waves to

create a moving picture of the heart. The picture is much more detailed than
a plain x-ray image and involves no radiation exposure.
3. Gated SPECT
4. MRI of chest
5. Ventriculogram performed during a cardiac catheterization

Biopsy of the heart is needed in rare cases to rule out other disorders.

Lab tests that may be used to rule out other disorders and assess the
condition of the heart include:

• Blood chemistries
• Cardiac biochemical markers (CK-MB, troponin)
• CBC
• Coronary risk profile

Treatment:

The goal of treatment is to relieve symptoms and treat the cause of the
condition. If symptoms are severe, you may need to stay in the hospital.

A cardiac catheterization will be done to see if you can have bypass surgery
or a balloon procedure (angioplasty). These treatments can improve blood
flow to the damaged or weakened heart muscle.

The overall treatment of cardiomyopathies is focused on treating heart

failure.

Drugs and treatments that may be used include:

 • ACE inhibitors such as captopril, enalapril, lisinopril, and ramipril
• Angiotensin receptor blockers (ARBs) such as losartan and candesartan
• Diuretics, including thiazide, loop diuretics, and potassium-sparing
diuretics
• Digitalis glycosides
• Beta-blockers such as carvedilol and metoprolol
• Drugs that dilate blood vessels (vasodilators)

Some people may benefit from the following heart devices:

• Single or dual chamber pacemaker

• Biventricular pacemaker
• Implantable cardioverter-defibrillator
• Left ventricular assist device (LVAD)

A low-salt diet may be prescribed for adults. Fluid may be restricted in some
cases. You can usually continue your regular activities, if you are able.

If you smoke or drink alcohol excessively, stop doing so. These habits
increase stress on the heart.

You may be asked to monitor your body weight daily. Weight gain of 3 or
more pounds over 1 or 2 days may indicate fluid buildup (in adults).

A heart transplant may be recommended for patients who have failed all the
standard treatments and still have very severe symptoms. Recently,
implantable, artificial heart pumps have been developed. However, very few
patients are able to undergo either of these advanced treatments.

Expectations (prognosis):

This is a very serious disorder. It is a chronic illness that usually gets worse
over time. Infection and other stress on your body from other medical
illnesses will also cause symptoms to get worse.

It is very important to discuss your situation with your doctor to ensure that
you can improve it as much as possible. You can control symptoms of heart
failure and angina with medication, lifestyle changes, and by treating any
underlying disorder.

Complications:

• Arrhythmias, including lethal arrhythmias

 • Cardiogenic shock

Prevention:

The best way to prevent ischemic cardiomyopathy is to avoid getting heart

disease.

• Stop smoking
• Eat a healthy diet
• Maintain a healthy weight
• Exercise as much as possible
• Avoid excessive drinking
• See your doctor to control blood pressure, cholesterol, and diabetes

Pathophysiology of Ischemic Cardiomyopathy

Nursing care plan
Assessme Diagnosi Planning Nursing Rationale Evaluation
nt s intervention
Subjectiv Decreas After 30 to - Monitor BP. - Comparison After 30 to
e: ed 60 Measure in both of pressures 60
-difficulty cardiac minutes of arms/thighs three provides a minutes of
of output nursing times, 3-5 min more complete nursing
breathing interventio apart while picture of interventio
-dizziness n the patient is at rest, vascular n the
- patient then sitting, then involvement/sc patient
headache will be standing for initial ope of would be
able to: evaluation. Use problem. able to:
Objective correct cuff size Severe
: - and accurate hypertension is -
-edema participate technique. classified in the participate
in adult as a in
BP- activities diastolic activities
160/100 that pressure that
T-36.8 reduce BP/ elevation to reduce BP/
cardiac 110 mm Hg; cardiac
workload. progressive workload.
-maintain diastolic -maintain
BP within readings above BP within
individuall 120 mm Hg are individuall
y - Note presence, considered first y
acceptabl quality of central accelerated, acceptable
e range. and peripheral then malignant range.
- pulses. (very severe). -
demonstra demonstra
te stable - Bounding te stable
cardiac carotid, cardiac
rhythm jugular, radial, rhythm
and rate and femoral and rate
within pulses may be within
patient’s observed/palpa patient’s
normal ted. Pulses in normal
range. the legs/feet range.
may be
diminished,
-Maintain activity reflecting
restrictions, e.g., effects of
bedrest/chair vasoconstrictio
rest; schedule n (increased
periods of systemic
uninterrupted vascular
rest; assist resistance
patient with self- [SVR]) and
care activities as venous
needed. congestion.
- Reduces
- Administer physical stress
 medications as and tension
indicated: that affect
Thiazide blood pressure
diuretics, e.g., and the course
chlorothiazide of
(Diuril); hypertension.
hydrochlorothiazi
de
(Esidrix/HydroDIU
RIL); - Diuretics are
bendroflumethiaz considered
ide (Naturetin); first-line
indapamide medications for
(Lozol); uncomplicated
metolazone stage I or II
(Diulo); hypertension
quinethazone and may be
(Hydromox); used alone or
in association
with other
drugs (such as
beta-blockers)
to reduce BP in
patients with
relatively
normal renal
function. These
diuretics
potentiate the
effects of other
antihypertensiv
e agents as
well, by
limiting fluid
retention, and
may reduce
the incidence
of strokes and
heart failure.

Assessme Diagnosis Planning Nursing Rationale Evaluation

nt intervention
Risk for After 1 hour -define and -provide basis After 1 hour
Subjective: prone of nursing state the understandin of nursing
-feeling of behavior intervention limits of g elevations intervention
dizziness related to the patient desired BP. of BP, and the patient
lack of will Explain clarifies would
Objective: knowledg verbalize hypertensio misconceptio verbalize the
-vital signs e about the n, and its ns and also understandi
taken the understandi effect on the understandin ng of the
disease. ng of the heart, blood g that high BP disease
BP- disease vessels, can exist process and
160/100 process and kidney, and without treatment
T-36.8 treatment brain. symptom or regimen.
regimen. even when
feeling well.

-these risk
factors have
-assist the been shown
patient in to contribute
identifying to
modifiable hypertension.
risk factors
like diet high
in sodium,
saturated -lack of
fats and cooperation is
cholesterol. common
reason for
-reinforce failure of
the antihypertensi
importance ve therapy.
of adhering
to treatment
regimen and -decreases
keeping peripheral
follow up various
appointment pooling that
s. may be
potentiated
-suggest by
frequent vasodilators
position and
changes, leg prolonged
exercises sitting or
when lying standing.
down.

-caffeine is a
cardiac
stimulant and
-encourage may
patient to adversely
decrease or affect cardiac
eliminate function.
caffeine like
in tea,
coffee, cola
 and
chocolates.

assessmen diagnosis planning Nursing rationale Evaluation

t interventio
n
Subjective: Ineffective after 30 -determine -that would
-the patient breathing minutes of presence of Cause
verbalize pattern nursing factors/physi breathing
nahihirapan secondary intervention cal patterns.
akong to fatigue the patient conditions
huminga will able to as noted in
(difficulty of breath related
breathing) easily. factors. -for
manageme
Objective: -administer nt of
-altered oxygen at underlying
chest lowest pulmonary
excursion concentratio condition,
-vital signs n indicated respiratory
taken and distress, or
prescribed cyanosis.
BP-160/100 respiratory
T-36.8 medications. -to promote
[hysiologica
-Elevate l/
HOB and/or psychologic
have client al ease of
sit up in maximal
chair, as inspiration.
appropriate.

Assessmen diagnosis planning Nursing Rationale Evaluation

t interventio
n
Subjective Activity Not -fatigue
: intoleranc presence of affects both
-the patient e related factors client’s
verbalize of to contributing actual and
fatigue/ generalize to fatigue. perceived
weakness. d ability to
-difficulty of weakness participate
breathing activities.

Objective: -evaluate -provides

-vital signs client’s comparativ
taken actual and e baseline
perceived and
BP-160/100 limitations/ provides
T-36.8 degree of information
deficit in about
light of needed
usual education/
status. intervention
s regarding
quality of
life.

-note client Symptoms

reports of may be
weakness, result of/or
fatigue, contribute
pain, to
difficulty intolerance
accomplishi of activity.
ng tasks,
and/or
insomnia.

Drug study:
Brand Name Mechanism of dosage indication contraindication Side effects Nsg responsibilities
action

furosemide inhibits the 40mg 1. edema Never use with Most common; do not confuse
reabsorption of associated ethacrynic acids. jaundice , tinnitus, lasix with lanoxin (
sodium and with CFC, Anuria , hearing a cardiac
chloride in the nephritic hypersensitivity to impairment , glycoside).
proximal and distal syndrome, drug, severe renal hypotension, 1. Give 2-4 days
tubules as well as hepatic desease associated water/electrolyte per week.
the ascending loop cirrhosis, and with azotemia and depletion, 2.food decreases
of henle; this results as cites. oliguria, hepatic pancreatitis, bioavailability of
in the exretion of 2.Iv for acute coma associated abdominal pain, furosemide and
sodium chloride, pulmonary with electrolyte dizziness, anemia. ultimately the
and to a lesser edema. depletion. degree of diuretics.
degree, potassium Lactation.
and bicarbonate
ions. The resulting
urine is more acid.

Brand Name Mechanism of dosage indication contraindication Side effects

action

furosemide inhibits the 40mg 1. edema associated with Never use with Most common;
reabsorption of CFC, nephritic syndrome, ethacrynic acids. Anuria ,jaundice , tinnitus,
sodium and hepatic cirrhosis, and as hypersensitivity to drug, hearing impairment ,
chloride in the cites. severe renal desease hypotension,
proximal and 2.Iv for acute pulmonary associated with azotemia water/electrolyte
distal tubules as edema. and oliguria, hepatic depletion,
well as the coma associated with pancreatitis,
ascending loop of electrolyte depletion. abdominal pain,
henle; this results Lactation. dizziness, anemia.
in the exretion of
sodium chloride,
and to a lesser
degree, potassium
and bicarbonate