Universidad de Manila

UNIVERSIDAD DE MANILA (City College of Manila) College of Nursing
In Partial Fulfillment of the Requirements in Medical-Surgical Nursing Related Learning Experience
A case of a client with ACUTE PULMONARY CONGESTION

OSPITAL NG SAMPALOC Medical-Surgical Ward
Submitted by:
Ilejay, Miriam T. Junio, Ma. Teresa S. Kalaw, Gemilyn T. Linsangan, Nica Rose M. Luna, Maribeth Baby T. Maloloy-on, Janine D. Montalvo, Marie Jodel H. Narciso, Ronel S. Salvatus, Reymel O. Group 3 Nr-31
January 12, 2011
Table of Contents: Contents CHAPTER I A. Introduction B. Objectives C. Definition of Terms Page Number
CHAPTER II A. B. C. D. Nursing Health History Gordons Functional Health Pattern Review of Systems Physical Assessment
CHAPTER III A. Anatomy and Physiology B. Pathophysiology with schematic diagram
CHAPTER IV A. Diagnostic and Laboratory Procedures B. Drug Study
CHAPTER V A. List of Nursing Diagnosis B. Nursing Care Plan C. Course in the Ward
CHAPTER VI A. Evaluation B. Conclusion C. Discharge Plan Bibliography
I.
Introduction
The client name was Mrs. L. aged 72 years old, female. She was admitted last January 01
2011 at 9:30pm in the emergency room of the Ospital ng Sampaloc, located at 677 Gen. Geronimo St. cor. Carola St., Sampaloc, Manila 1008, together with her daughter. She was admitted to the emergency room due to her chest pain and difficulty of breathing. She was brought to the hospital conscious and diaphoretic. Her skin color is cyanotic. She had distress and crackles can be heard. Upon admission, her diagnosis was acute pulmonary congestion to consider acute coronary syndrome. Until January 02 2011, she was transferred from emergency room to medical-surgical ward at room 503B.
In normal lungs, a continuous stream of fluid flows from the capillary bed to the alveolar interstitial. In pulmonary congestion, an x-ray will clearly show fluid build-up in the lungs and upper airway obstruction. Pulmonary congestion is the abnormal accumulation of liquid in the lungs, usually related to an inflammation or congestive heart failure.
Pulmonary congestion makes the air sacs in the lungs water logged. It also impedes the exchange of air, making breathing difficult. A person with pulmonary congestion can suffocate due to the increasing fluid and then may suffer heart failure, which can lead to death. The loss of air space can cause cardiac arrest. Difficulty of breathing and severe pain in the chest when coughing makes it more strenuous for the individual to expel the mucus from the bronchial tubes. If the effort to expel the liquid by cough fails, the mucus may obstruct the airway that carry the air to the lungs, which can consequently leads to the heart attack.
In addition, it can also be a complication of heart attack, leaking or narrowed heart valves such as mitral or aortic valves, or any disease of the heart that either result in weakening and/or suffering of the heart muscle also known as cardiomyopathy. The failing heart transmits its increased pressure to the lung veins. As pressure in the lung veins rises, fluid is flushed into the air spaces or alveoli. This fluid then becomes a barrier to the normal oxygen exchange, resulting in the shortness of breath. It can also be caused by direct lung injury from toxins including heat and poisonous gas, sever infection, or an excess of body fluids as seen in the kidney failure.
The group had chosen this particular disease condition due to the curiosity and interest regarding to the current situation of the patient. They do believe that taking this opportunity would challenge them and they thought that it is a best experience to take for the group to test how the condition works in patient in reality. Through a thorough and actual observation to the said disease their knowledge upon the case would make them further understand and achieved a best type of learning. This is also a good opportunity to train their skill in doing and giving the actual, direct and potential care to the patient in order to sharpen their skill as a future nurses. Moreover, the readers of this study will acquire more knowledge and skills that might help them in further study in the near future.
II.
OBJECTIVES
General objectives This study was formulated from the client whose having a diagnosis of acute pulmonary congestion to consider acute coronary syndrome that focuses on assessing, intervention, medical management, and many more. Moreover, this aim is to provide and conduct a thorough study in order to understand and to know more about the disease condition by he means of taking this opportunity, we would like to make use of it to master our intellectual and practical skill in regards to the disease.
Specific Objectives: 1. To gather a comprehensive, complete and reliable patients profile which includes the past and present history of illness, socio-demographic data and other elative data that are needed in the study. 2. To thoroughly assess the clients condition in order to formulate a good foundation of base line data regarding to the disease. 3. To grasp the facts that lies behind the laboratory findings and the following diagnostic procedure done upon the clients condition demand. 4. To rightly interpret the results behind the laboratory findings and diagnostic procedures done upon the needs of the client. 5. To provide the priority nursing problems which are present to the client during and after the admission and treatment.
6. To conduct and provide best and applicable intervention and care needed by the client. 7. To provide appropriate health teaching in order to achieve the optimum health of the client. 8. To test and evaluate the effectiveness of the intervention and management into the client.
III.
PATIENTS HEALTH HISTORY
A. Initial Data Chief Complaint Date of Admission Time of Admission Mode of Admission Ward General Appearance Difficulty of breathing and chest pain January 1, 2011 9:30 pm Wheelchair borne Medical/Surgical ward The patient was conscious upon the endorsement to the ER but appeared in distress because he experienced difficulty breathing and chest pain. She was assisted by her daughter. Admitting Diagnosis Acute Pulmonary Congestion
B. Demographic Data Patient Name Address Age Date of Birth Sex Occupation Nationality Mrs. L Sampaloc, Manila 72 February 11, 1938 Female Dressmaker Filipino
Marital Status Religion Weight Height Body Mass Index
Married Roman Catholic 62 kgs 157.48 cm 25.001 kg/m2 Formula: BMI = weight (kg)/ height2 = 62 kgs/ (1.5748)2 = 25.001 kg/m2
Usual source of health Care Source and Reliability of Information
Ospital ng Sampaloc Client- (4 = very reliable) Clients Daughter-
C. Chief Complaint
Client stated hirap na hirap akong huminga at sumasakit pa ung dibbid ko..
D. History of Present Illness
1960- The client was diagnosed with Type II Diabetes Mellitus, however the hospital and exact course of treatment were failed to identify by that client. 1970- The client become aware of her elevated blood pressure (140/110mm hg) from consultation to a friend who practice
blood pressure taking. However, she failed to seek for medical attention and continue to live with same lifestyle. 2005- She suffered from mild stroke and was admitted to Ospital ng Sampaloc and stayed for 1 week. At this period, the client was also diagnosed with CAD (Coronary Arterial Disease) and was managed while she was in the hospital. The exact course of treatment ( medication and medical treatment ) were unavailable and failed to identify by the client. The client do --- to adhere with the treatment (for \cad and hypertension)and continue to eat salty, fatty and sweet foods. Her Diabetes Mellitus is still unmanaged. January 1, 2011 (3 hours prior to admission) - The client complaint of pinching pain and difficulty to have a calm sleep. 1 hour before admission- the client complained on a sudden onset of difficulty in breathing and an intermittent pinching pain. Her relatives herself brought her to Ospital ng Sampaloc and were diagnosed as Acute
pulmonary congestion.
E. Past Medical History Medical History 2005: Mild Stroke and CAD- Mrs. L was diagnosed to have Mild Stroke at Ospital ng Sampaloc. She was then, admitted to the hospital but the whole course of treatment were failed to identified.
2011: The client experienced chest pain and difficulty of breathing, the client was admitted to Ospital ng Sampaloc and was given medical treatment. Surgical History Allergies Client denies to have any form of surgery Client verbalized that she had not experienced allergies on medications and food Injuries/ Accidents Immunizations She did not experience any major accidents Client admitted that she received complete immunizations during her childhood Blood Transfusions The client had not undergone blood transfusions.
F. Family History
Legend Female
Liver Disease
Male
Complications of Aging
Dead A&W Alive and well

Kidney Cancer
A&W
Stroke, Client L. Cerbrovascular accident
A&W
G. Social History Alcohol Use The client denies to drink ant form of alcohol beverages Drug Use The client stated that hindi peo pag mga gmot para sa sakit ko.. iniinom ko Tobacco Use Client verbalized that she is not into smoking Sexual Practice The client admitted that she is not sexually active anymore.
H. Home Environment
Physical environment
The client stated that they own a 2-storey house made of wood and cement. She is living with her son, and daughter and her daughters family. She has her own mini space for her dressmaking shop. The house has a good ventilation and lighting. There water source is from MWSS and they drink water from refilled water station. Garbage is collected every morning by a trash collector.
Psychosocial environment
Hindi na ako gaanong lumalabas, pero ung anak ko, sa barangay ngtratarbaho
Hobbies/Leisure/Activities
Client verbalized that before she usually watch television and take a nap.
Education
The client stated that graduate lang ako ng high school
Economic Status
The client stated tha sapat lng ang kinikita namen para sa pangaraw-araw pero pag may ibang gastusin na, hirap na kame
Roles/Relationships
The client stated that she has a good relationship with her family. ok naman kame lahat sa bahay, tsaka Masaya naman kami na samasama. As stated by the client.
Characteristic Patterns of Daily Living
Before, the client can perform the activities of daily living well. She can also help in the needs of their family by making dress and selling it. Now that she is ill, the client ADL is partially assisted. She is usually in bed rest and with bathroom privileges and performs morning routine assisted by his daughter. After that she takes a nap and eats her lunch and takes her medications. Again take a rest and wakes up, to eat merienda, sometimes she had difficulty of sleeping but she manages to just take a nap until dinner.
I. Health Maintenance Activities Sleep According to the client before she sleeps at around 8:00pm and wake up at around 5:00 am Now that she is ill she usually take a rest and lie down. Diet The client stated that she always eat three times a day prior to confinement. y The client preferred eating almost all
delicacies of food. Now, that the client is ill, The clients diet was low salt, low fat.
Exercise
The client was not engage in any strenuous or heavy physical activity before. The client has no regular exercise, and spent her whole day in sewing clothes or resting. During hospitalization, the client was confined in bed. The client performs ROM exercises.
Elimination
Client stated that her defecation pattern was once every two days. The client said that she urinates frequently prior to confinement but wasnt sure about the exact frequency. Now that the client is ill, she defecates every day with a semiformed stool.
IV.
PHYSICAL ASSESSMENT
Performed: January 04, 2011 8:00am Name: Mrs. L. Age: 72 years old Sex: Female General appearance: The group received their patient asleep lying flat on bed together with her relative. Mrs. L. has an I.V fluid insertion in her right hand and a foley catheter attached to a calibrated urine bag. The patient is clean. Her weight is 72kg and a height of 5 ft 2. Vital Signs: 8:00A.M TEMPERATURE RESPIRATORY RATE PULSE RATE BLOOD PRESSURE 35.1C 30 bpm 79 bpm 130/100 mmhg
Head to toe Assessment: During Skin the inspection, the clients skin was
characterized of having a brown sagging skin. There are no sign of paleness and edema. She had a scar in her anterior left foot due to healed wound. The clients has a short dry hair and dyed into brown
Hair and Scalp
color. When it comes to the inspection of her scalp there was no presence of dandruff nor lice. The color of the clients nail bed is pink. She has a short
Nails
and dirty nails. Her nails in the foot were manicured into pink. She has normal capillary refill of < 3secs. After doing inspection to the neck of the client, We
Neck
found out that the neck has no presence of swelling and soreness. The neck is symmetric. There were no pain felt when she moves her neck. Upon palpation, the spinous process of the cervical vertebrae and supraclavicular fosae, there are no swelling, nodules and tenderness found. Moreover the clients can perform the ROM of her neck. There were no granting sound heard. Swelling of lymph node and tenderness apparent. The respiratory rates of the patient were 30 breaths per
Thorax and Lungs
minute. There were no masses or scars into the clients chest. Her chest wall are symmetric. Both sides of chest wall were smooth, warm and dry to palpate. There were crackles heard. The clients breathing pattern is tachypnic. Then the clients lung area elicited resonant sound while in the bony area, we heard a dull sound. The clients cardiac rate is 79 bpm while her blood
Heart
pressure is 130/100 mmhg which is above normal. The heart beat is regular. She had undergone radiology last January 02, 2011 its findings tell that her aorta is dilated. The patient had experienced a pinching pain in the middle of her chest. The abdomen of the client is flat and in a domed
Abdomen
shape. There are no bumps, bulges or masses noted. The umbilicus is located in the middle of the abdomen and it is inverted. The skin of the abdomen of the client is smooth and uniform in color. Borborygmous sound are present, her bowel movements are normal and there is no presence of constipation. The clients extremities is symmetric.The skin is
Extremities
smooth and brown in color, the same color with other body parts. The anterior left foot of the client has a big
scar. The muscles are intact and she can able to move her extremities. Upon assessment, the client has urinary incontinence Genitourinary and there is a Foley catheter inserted to the urinary meatus which was attached to a calibrated urine bag. The color of her urine is yellow and its transparency is turbid. There were no vaginal discharges noted. The patients skull is smooth and symmetric in Skull and Face contour. There are no lesion or tenderness noted in her face. Facial asymmetry is noted. The client has a cataract on her right eye. She had a Eyes blurred vision. Light gray colored pupil noted. No signs of inflammation and excessive tearing present. The clients ears are symmetrically aligned. The color Ears of her auricles is brown same as the color of her skin. There are no presence of lesion and discharge. She cant hear clearly. The color of the clients nose appears to be same color Nose of her face and skin. The nasal septum was positioned in the midline and the nostrils are patent. There are no signs of discharges and flaring in her nose.
The lips of the patient are dry and cracks are visible. Mouth and Oropharynx Her uvula is in the midline presence of white patches on the tongue noted. There are no signs of lesion, inflammation or nodules apparent. Her gums are pink and her tonsil is normal foul odor in the mouth is present. The client is able to swallow and her gag reflex is present. The client was conscious and coherent. The client Neurological Assessment didnt felt dizzy. Her reflexes are normal and her sensation can easily responds. Glassgow Coma Scale Eye Response: Verbal Response: Motor Response: Total Score: 4 5 5 14
General
The client stated, Ang laki ng ipinayat ko ngayon. The client stated, Nanghihina ang katawan ko. The client s daughter stated, Madali na siya mapagod dahil sa kanyang kondisyon ngayon. The client s daughter stated, Oo, pinapawisan siya tuwing gabi The client s daughter stated, Hindi siya nilalagnat. The client stated, Kinamot at nagsugat ang aking paa when she was asked about what happened to the big scar on her left foot. The client stated, wala when she was asked if she has pruritis and rashes. The client s daughter stated, wala siyang pasa. Head: The client stated, Hindi ako nahihilo at hindi masakit and ulo ko. The client s daughter stated, wala siyang bukol sa ulo. Eyes: The client stated, May katarata ang kanan kong mata. At nanlalabo na din ang kaliwa kong mata. The client stated, Hindi when she was asked if she is using eyeglasses. The client stated, Hindi when she asked if she feel dry on her eyes. Ears: The client stated, Oo malakas pa ang pandinig ko when asked if she has the ability to hear. The client stated, Hindi when she was asked if her ears are painful. The client s daughter stated, wala when she was asked if the patient s ear has discharges. Nose: The client stated, Nakakahinga naman ako ng maluwag. The client s daughter stated, hindi dumugo ilong niya. The client stated, Wala when she was asked if she has an allergy. Throat: the client stated, Hindi when she was asked if there is difficulty in swallowing or painful. The client stated, Nakapustiso na lang ako ngayon. The client stated, Wala when she was asked if she has bleeding gum and mouth sores. The client stated, Hindi when she was asked if she
Skin
Head, Eyes, Ears, Nose, Throat (HEENT)
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary Musculoskeletal
Neurologic
Hematologic Endocrine
has difficulty in breathing. The client stated, Minsan lang when she was asked if she was having chest pain. The client s daughter stated, Hindi siya makahinga kaya dinala naming siya dito. The client s daughter stated, Hindi siya inuubo. The client s daughter stated, Sinugod din siya dito dahil biglang sumakit ang kanyang dibdib. The client s daughter stated, Hindi ito ang unang beses na dinala siya ditto sa hospital dahil sumakit ang dibdib niya. The client stated, Mahilig akong kumain ng matatami, maaalat at mamantikang pagkain. The client stated, Madami ako kung kumain noon. The client s daughter stated, Wala naman bakas ng dugo ang kanyang dumi at ihi. The client stated, Hindi ako araw-araw dumudumi bago ako ma-ospital. The client s daughter stated, Wala siyang ulcer. The client stated, Wala naman masakit sa akin kapag umiihi. The client stated, Hindi when she was asked if she have painful sensation to her bone and joints. The client s daughter stated, Kailangan ko pa siyang alalayan pag kikilos sa kama. The client stated, kayak o naman bumangon mag-isa, pero minsan nahihirapan ako. The client stated, Oo when she was asked if she has muscle weakness. The client s daughter stated, nakakaalala pa naman siya kahit sa ganyan niyang kondisyon. The client s daughter stated, Wala naman pagkakataon may dumugo sa kanya. The client stated, May diabetes din ako.
V.
REVIEW OF SYSTEM
General
The client stated, Ang laki ng ipinayat ko ngayon. The client stated, Nanghihina ang katawan ko. The client s daughter stated, Madali na siya mapagod dahil sa kanyang kondisyon ngayon. The client s daughter stated, Oo, pinapawisan siya tuwing gabi The client s daughter stated, Hindi siya nilalagnat. The client stated, Kinamot at nagsugat ang aking paa when she was asked about what happened to the big scar on her left foot. The client stated, wala when she was asked if she has pruritis and rashes. The client s daughter stated, wala siyang pasa. Head: The client stated, Hindi ako nahihilo at hindi masakit and ulo ko. The client s daughter stated, wala siyang bukol sa ulo. Eyes: The client stated, May katarata ang kanan kong mata. At nanlalabo na din ang kaliwa kong mata. The client stated, Hindi when she was asked if she is using eyeglasses. The client stated, Hindi when she asked if she feel dry on her eyes. Ears: The client stated, Oo malakas pa ang pandinig ko when asked if she has the ability to hear. The client stated, Hindi when she was asked if her ears are painful. The client s daughter stated, wala when she was asked if the patient s ear has discharges. Nose: The client stated, Nakakahinga naman ako ng maluwag. The client s daughter stated, walang pagdudugo sa kanyang ilong. The client stated, Wala when she was asked if she has an allergy. Throat: the client stated, Hindi when she was asked if there is pain or difficulty when swallow. The client stated, Nakapustiso ako dalawang taon ang nakalipas.
Skin
Head, Eyes, Ears, Nose, Throat (HEENT)
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary Musculoskeletal
Neurologic
Hematologic Endocrine
The client stated, Wala when she was asked if she has bleeding gum and mouth sores. The client stated, Hindi when she was asked if she has difficulty in breathing. The client stated, Minsan lang when she was asked if she was having chest pain. The client s daughter stated, Hindi siya makahinga kaya dinala naming siya dito. The client s daughter stated, Hindi siya inuubo. The client s daughter stated, Sinugod din siya dito dahil biglang sumakit ang kanyang dibdib. Hindi ito ang unang beses na sumakit ang dibdib niya. The client stated, Mahilig akong kumain ng matatami, maaalat at mamantikang pagkain. The client stated, Madami ako kung kumain noon. The client s daughter stated, Wala naman bakas ng dugo ang kanyang dumi at ihi. The client stated, Hindi ako araw-araw dumudumi bago ako ma-ospital. The client s daughter stated, Wala siyang ulcer. The client stated, Wala namang sumasakit kapag ako y umiihi umiihi. The client stated, Hindi when she was asked if she have painful sensation to her bone and joints. The client s daughter stated, Kailangan ko pa siyang alalayan pag kikilos sa kama. The client stated, kayak o naman bumangon mag-isa, pero minsan nahihirapan ako. The client stated, Oo when she was asked if she has muscle weakness. The client stated, Hindi , when she was asked if she has backache . The client s daughter stated, nakakaalala pa naman siya kahit sa ganyan niyang kondisyon. The client s daughter stated, Wala naman pagkakataon may dumugo sa kanya. The client stated, May diabetes din ako.
VI.
Gordons Typology of Health Patterns
Typology/Pattern
Patient Activity (before hospitalization)
Patient Activity (during hospitalization) y The client views herself to be unhealthy because first she is confined in a hospital and second, shes been suffering from the manifestations of her condition. y The client is aware and understands the medical diagnosis.
Health Perception/ Health Management
y The client views herself to be healthy when she was still young and during her teenage years. The client said that she can do just about everything during these period and very seldom got ill. y The clients perception about her health changed in 2005 when she suffered from Diabetes Mellitus and experienced its symptoms. y The client has been taking self-prescribed medications everytime she feel ill. She only consult to doctors or professional health practitioners if she felt that the conditions worsen. The client admitted though that she also patronize faith and traditional healers. y The client said the she never
used illegal drugs, smoke a cigarette and drink alcohol. y The client verbalized that she always give importance to her health Nutritional/Metabolic y The client stated that she always eat three times a day prior to confinement. y The client preferred eating almost all delicacies of food. y Client stated that her defecation pattern was once every two days. y The client said that she urinates frequently prior to confinement but wasnt sure about the exact frequency. Activity/ Exercise y The client was not engage in any strenuous or heavy physical activity before. y The client has no regular exercise, and spent her whole day in sewing clothes or resting. Sleep/ Rest y The client sleeps early in the evening at around 8pm and wake up by 6am. y The client sleeps late at around 10-12 midnights and identify no specific reason for this condition. y The client has an average of one defecation every day with a semi-formed stool. y The client has a Foley catheter attached to a urine bag with an output of 20cc/hr. y During hospitalization, the client was confined in bed. The client performs ROM exercises. y The clients diet was low salt, low fat.. y There are no restrictions on her fluid intake and a 500cc D5W is currently infused.
Elimination
y The client now prefers to rest. Cognitive/ Perceptual y The clients daughter claimed that her mother has a normal cognition and perception through things. y The client is oriented with the three spheres of cognition (time, space and person) during the tract of duty. y The client knows the time and reacts appropriately. y Recent and remote memory intact. y The client has been aware with her condition y The client stated that she maintained a good relationship with the people around her, especially to her family. y Expresses concern about her condition and wishes for a speedy recovery. Role/ Relationship y The client stated that she maintained a good relationship with the people around her, especially to her family. When she got ill, her daughter was the one helping her to do her duties. Sexuality/ Reproduction y The client revealed that she is not sexuality active anymore. Coping/ Stress Tolerance y The client stated that her mechanism to cope stress is through resting, watching television programs, and listening to radio. y The client revealed that she is not sexuality active anymore. y Resting and talking to her daughter is her only mechanism to relieve stress.
Self-Perception/ Self-Concept
Values/ Beliefs
y The client is a Roman Catholic and stated that she believes in the existence of a Supreme Being. The client stated that she always attend to masses, except if she ill.
y The client is a Roman Catholic and stated that she believes in the existence of a Supreme Being. Because of her current condition, the client fails to attend masses.
VII.
ANATOMY AND PHYSIOLOGY The cardiovascular system consists of the heart, which is a muscular pumping
organ, a closed system of blood vessels called arteries, veins, and capillaries, and lymphatic vessels. Blood contained in the cardiovascular system is pumped by the heart alternately through the systemic and pulmonary circulations. The circulation of blood allows for delivery of oxygen, nutrients, hormones, etc. to tissues of the body, and removal of carbon dioxide and other metabolic waste products. The gas exchange between ambient air and blood in the pulmonary circulation occurs in the alveolar walls of the lungs. The lymphatic vessels drain excess interstitial fluid, and transport lymph and chyle. PARTS:
I. Arch of The Aorta The aorta is the largest artery in the body. It extends upward from the left ventricle of the heart, arches over the heart to the left, and descends just in front of the spinal column. The first portion of the aorta is the "ascending aorta," which branches into the "arch of the aorta." Three major arteries originate from the aortic arch: the "brachiocephalic artery," which supplies blood to the brain and head; the left common carotid artery and the left subclavian artery. II. Brachial Artery/Vein The brachial artery stems from the axillary artery and moves along the humerus (upper arm bone) down to the elbow. It gives rise to the "deep brachial artery" that curves around the back of the humerus to supply blood to the triceps muscles. Shorter branches
pass into various other muscles on the front of the upper arm, and others descend down each side of the elbow to join arteries in the forearms. The corresponding brachial vein will parallel the artery on its trip back to the heart. III. Bronchus The bronchus is the air passage into the lungs. Each lung has one main bronchus, which begins at the end of the trachea or windpipe. The bronchus divides into smaller branches known as segmental bronchi, which then divide into bronchioles. (See "Bronchial Bulbs") IV. Carotid Arteries The carotid arteries are the four principal arteries of the neck and head. They have two specialized regions: the carotid sinus, which monitors the blood pressure, and the carotid body, which monitors the oxygen content in the blood and helps regulate breathing. The internal carotid arteries enter the skull to supply the brain and eyes. At the base of the brain, the two internal carotids and the basilar artery join to form a ring of blood vessels called the "circle of Willis." The external carotid arteries have several branches which supply the tissues of the face, scalp, mouth and jaws. V. The Heart The heart is a pumping system which intakes deoxygenated blood through the veins, delivering it to the lungs for oxygenation and then pumping it into the various arteries to be transmitted to where it is needed throughout the body for energy. The heart is about the size of a fist but delivers a more powerful punch. Luckily for us, it contains a buffer zone to decrease its force or we would be shaken by every beat. This buffer zone also protects the heart from outside injury and keeps it from scraping against the chest wall. In
some instances, nightmares can seem so real that the heart will pound in fear. In one study, the heart rate of the sleeper was timed at 150 beats per minute. Myth has it that the heart is the seat of the emotions, but it is, instead, a pump to circulate the blood throughout the body and only contributes to the emotions by sending oxygenated blood to our brain cells; so, if you want to gain someone's affection, you may have to ask Cupid to shoot them through the head rather than the heart. An arrow through the heart (or through the head, for that matter) would stop all bodily functions. The Medical Dictionary reports that the heart beats more than 2.5 billion times in an average lifetime. Isn't that "thumping"? VI. Inferior Vena Cava The inferior vena cava is a large vein ascending through the abdomen. It collects blood from the hepatic veins, the lumbar veins, gonadal veins, renal veins, and phrenic veins. These vessels usually drain regions that are supplied by arteries with corresponding names. The inferior vena cava enters the heart through the right atrium. VII. Intermediate Antebrachial Vein
The intermediate antebrachial vein drains blood from dorsum of thumb and the elbow VIII. Internal Iliac Artery The abdominal aorta divides to form the "common iliac arteries" in the lower abdomen, and these vessels supply blood to the pelvic organs, gluteral region, and legs. Each common iliac artery descends a short distance and divides into an internal and an external branch. The internal iliac artery divides into many smaller branches to supply the various pelvic muscles and tissue structures, as well as the gluteal muscles (buttocks) and the external genitalia. Some of the important branches of this vessel include: (1)
iliolumbar artery to the ilium (hipbone) and muscles of the back; (2) superior and inferior gluteal arteries to the muscles of the buttocks, pelvic muscles, and the skin of the buttocks; (3) internal pudendal artery to the alimentary canal, external genitalia, and hip joint; (4) the superior and inferior vesical arteries to the urinary bladder and, in males, the prostate gland; (5) middle rectal artery to the rectum; and (6) uterine artery to the uterus and vagina in females. IX. Iliac Vein In the pelvic region, blood is carried away from organs of the reproductive, urinary, and digestive systems by vessels leading to the "internal iliac veins." These veins have many interconnections that form a network (called "plexuses") in the region of the rectum, urinary bladder, and prostate gland (in the male) or uterus and vagina (in the female). The internal iliac veins come from deep in the pelvic region and rise to the lower portion of the abdomen, where they join with the right and left "external iliac veins" and form the "common iliac veins." These, in turn, merge to produce the "inferior vena cava" at the level of the fifth lumbar vertebra. X. Jugular Veins There are jugular veins on each side of the neck, which return the deoxygenated blood from the head to the heart. The jugular vein lies deep inside the neck and is seldom injured XI. Lateral Femoral Circumflex Artery/Vein The deep femoral artery supplies much of the musculature in the front and middle compartments of the thigh. Some of its vessels penetrate through the muscles to the back compartment and contribute to the supply of the hamstrings. The "lateral femoral
circumflex artery" arises from the side of the deep femoral artery and passes behind the sartorius and rectus femoris muscles, where it divides into three branches: the ascending, transverse, and descending branches. The "ascending branch" passes over to the side of the hip, and joins a network with the end branches of the superior gluteal and deep iliac circumflex arteries. The "descending branch" courses downward behind the rectus femoris, and one long branch descends as far as the knee, where it joins an aspect of the popliteal artery. It is accompanied by a branch of the femoral nerves. The "transverse branch" is the smallest branch, but it is often absent. It winds around the femur and connects a network of vessels and nerves on back of the thigh. The corresponding veins parallel the paths of the arteries of the same name. XII. Genicular Artery
The genicular arteries (inferior and superior) supply the knee joint and the skin of the upper and media leg. XIII. Pulmonary Artery/Vein When the muscular wall of the right ventricle contacts, the blood inside the heart chamber is put under more pressure, and the tricuspid valve closes. As a result, the only exit is through the "pulmonary trunk," which divides to form the right and left "pulmonary arteries." At the base of this trunk is a "pulmonary semilunar valve" that is made up of three leaflets or cusps. This valve opens when the right ventricle contracts. When the right ventricular muscles relax, blood starts back up the pulmonary trunk, causing the valve to close to prevent the flow from returning into the ventricular chamber. The pulmonary vein travels parallel to the pulmonary artery as it carries the blood back up to the heart.
XIV. Lungs (An Overview) Air, which is inhaled through the mouth and nasal passages, travels through the windpipe or "trachea" into two main air passages. These divide into smaller branches which separate into even smaller "twigs" like an upside-down tree. The respiratory system is mainly contained in two lungs. The little air sacs at the end of the twigs comprise the fruit of the tree, and through its thin walls gasses pass into and out of the blood. The right lung is made up of three compartments, each of which contain a branch and each of which stems off into smaller "twigs," which hold the air sacs (or "fruit" of the tree) that process the oxygen in the air to be released into the blood and expel carbon dioxide, which is exhaled through the nose and mouth. The left lung cavity contains only two sections (each with its own branches, twigs and fruit) and encloses the heart, which processes the oxygenated blood and returns deoxygenated blood into the lungs for exhalation. Breathing is an automatic process which comes from the brain stem and is so strong a force that the involuntary reflexes will not allow us to stop breathing for any length of time. The passageways in the respiratory system are lined with various types of epithelia to prepare the air properly for utilization and with hair-like fibers called cilia that move in a wave-like motion to sweep debris out of the lungs for expulsion. The women in ancient Greece and Rome wore corsets of linen to restrain their figures. The female waistline has been moved up and down over the passage of time, but this became a real health hazard when whalebone corsets came into use during the last part of the 19th and early part of the 20th centuries, because they constricted the vital organs in the body especially those of the respiratory and digestive systems. Women with "wasp-like" waists
fainted so often that those who were well-off purchased "fainting" couches; and when a woman "swooned," the cry, "Cut her laces!" often allowed her enough air to recover. XV. Posterior Tibial Artery
At its lower end, the popliteal artery below the knee divides into the anterior and the posterior tibial arteries. The posterior tibial artery, the larger of the two popliteal branches, descends beneath the calf muscle and divides into branches to supply blood to the skin, muscles, and other tissues of the lower leg along the way. Some of these join the nerve networks behind the knee and around the ankle. The largest branch of the posterior tibial artery is the "peroneal artery," which travels down along the fibula (lower leg bone) and contributes to the nerve network around the ankle. XVI. Radial Artery/Vein Within the elbow, the brachial artery divides into an ulnar and a radial artery. The radial artery, a true continuation of the brachial artery, travels down the radial side of the forearm to the wrist. As it nears the wrist, it rises close to the surface and is a convenient vessel for taking the pulse. At the wrist, branches of the ulnar and radial arteries join to form a network of vessels, which supply the structures in the wrist, hand and fingers. The corresponding radial vein will parallel the artery as it travels back to the heart. XVII. Retromandibular Vein The retromandibular vein is a tributary of the internal and external jugular veins, which run up the neck into the facial veins.
XVIII. Brachiocephalic Artery/Vein
The brachiocephalic artery supplies blood to the tissues of the brain and the head. It is the first branch of the aortic arch and rises up to a point near the junction of the sternum (breast bone) and the right clavicle (collarbone). At this point, it divides, giving rise to the "common carotid artery," which carries blood to the right side of the neck and head, and the right "subclavian artery," which leads to the right arm. Branches of the subclavian artery supply blood to parts of the shoulder, neck and head. The brachiocephalic vein takes blood from these sites back to the heart from the subclavian vein. XIX. Ulnar Artery/Vein Within the elbow, the brachial artery divides into an ulnar and a radial artery. The ulnar artery leads down the ulnar side of the forearm to the wrist. Some of the branches supply blood to the area around the elbow-joint, while others supply the flexor and extensor muscles in the lower arm. At the wrist, branches of the ulnar and radial arteries join to form a network of vessels, which supply the structures in the wrist, hand and fingers. The corresponding ulnar vein will parallel the brachial artery on its way back to the heart. XX. Veins
Internally, the heart is divided into four hollow chambers, two on the left and two on the right. The upper chambers, called "atria," have relatively thin walls and receive blood returning through the veins. The lower chamber, the "ventricles," force blood out of the heart into the arteries to be carried back to the various sites throughout the body. Veins are responsible for returning blood to the heart after exchanges of gases, nutrients, and wastes have been made between the blood and the body cells. Veins begin when capillaries merge into venules, the venules into small veins, and the small veins merge
into larger ones. They are harder to follow than the arteries, because these vessels are interconnected with irregular networks, so that many small unnamed venules may join to form a larger vein. On the other hand, larger veins typically parallel the courses taken by named arteries, and the veins are often given the same name as the companion arteries. The veins from all parts of the body (except from the lungs back to the heart) converge into two major paths that lead to the right atrium of the heart. These veins are the "superior vena cava" and the "inferior vena cava."
CARDIOVASCULAR SYSTEM ROLE
Pulmonary circulation The Pulmonary circulation is the portion of the cardiovascular system which transports oxygen-depleted blood away from the heart, to the lungs, and returns oxygenated blood back to the heart. Oxygen deprived blood from the vena cava enters the right atrium of the heart and flows through the tricuspid valve into the right ventricle, from which it is pumped through the pulmonary semilunar valve into the pulmonary arteries which go to the lungs. Pulmonary veins return the now oxygen-rich blood to the heart, where it enters the left atrium before flowing through themitral valve into the left ventricle. Then, oxygen-rich blood from the left ventricle is pumped out via the aorta, and on to the rest of the body. Systemic circulation The systemic circulation carries oxygenated blood from the heart to peripheral tissues, and then returns the deoxygenated blood to the heart. Blood pumped out of the left ventricle of the heart enters the aorta, a large elastic artery, which distributes the blood to its many branches, including large elastic arteries, medium-sized muscular arteries and small arteries (arterioles). Healthy arteries are strong and elastic. They narrow between beats of the heart, which helps to keep the blood pressure consistent. This helps blood circulate efficiently
through the body. Arteries and arterioles have strong, flexible walls that allow them to adjust to the amount and rate of blood flowing to different parts of the body. Arterioles supply blood to capillaries, where oxygen, nutrients, and waste pass between the blood and body tissues. Capillaries are very small blood vessels that connect the arterial and venous vessels. The importance of capillaries lies in their very thin walls. Unlike arteries and veins, capillary walls are thin enough that oxygen and nutrients in the blood can pass through the walls to the parts of the body that need them to function normally. Capillaries' thin walls also allow waste products like carbon dioxide to pass from the body's organs and tissues into the blood, where it's taken away to the lungs. Veins of the systemic circulation drain capillaries and carry deoxygenated blood back to the right atrium of the heart. Veins have thinner walls than arteries and can increase in width as the amount of blood passing through them increases. Coronary circulation The coronary circulatory system provides a blood supply to the heart. As it provides oxygenated blood to the heart, it is by definition a part of the systemic circulatory system.
VIII. LABORATORY AND DIAGNOSTIC PROCEDURE A. Urinalysis The urinalysis is the most important initial study in the evaluation of the patient suspected of having a UTI. A negative urinalysis makes the diagnosis of UTI unlikely. A simple midstream sample voided into a sterile container is sufficient and the more difficult and elaborate clean-caught midstream urine has not been found to be superior.
If the urine sample cannot be examined within 10 -15 minutes of obtaining it, it must be refrigerated. Uncentrifuged urine can be examined with a microscope (immersion lens) under a cover slip. The finding of bacteria by this method has a 90% correlation with the culture of > 1 million bacteria/ mL. In women the finding of greater than 7 white cells per high power field is suggestive of infection while the absence of this finding makes this diagnosis unlikely. In men the presence of any number of white cells should be considered abnormal. If urine has been centrifuged, pyuria is significant only if there are more than ten white cells per high power field. The presence of white cell casts in centrifuged urine is an important indicator of pyelonephritis.
Simple midstream sample into a clean container is sufficient More than 7 WBC/ high power field is diagnostic Any number of WBC in men is significant WBC casts suggest pyelonephritis.
January 2, 2011 EXAMINATION MADE Color Transparency White blood cells Red blood cells VALUES OBTAINED yellow NORMAL VALUES Amber yellow Normal Infection Infection Normal INTERPRETATION
Slightly turbid Clear 40-50 0-1 05 per hpf 02 per hpf
B. Complete Blood Count
The complete blood count (CBC) is a common blood test that evaluates the three major types of cells in the blood: red blood cells, white blood cells, and platelets.
The CBC is used as a broad screening test to check for such disorders as anemia, infection, and many other diseases. It is actually a panel of tests that examines different parts of the blood and includes the following:
White blood cell (WBC) count is a count of the actual number of white blood cells per volume of blood. Both increases and decreases can be significant.
White blood cell differential looks at the types of white blood cells present. There are five different types of white blood cells, each with its own function in protecting us from
infection. The differential classifies a person's white blood cells into each type: neutrophils (also known as segs, PMNs, granulocytes, grans), lymphocytes, monocytes, eosinophils, and basophils.
y
Red blood cell (RBC) count is a count of the actual number of red blood cells per volume of blood. Both increases and decreases can point to abnormal conditions.
y y
Hemoglobin measures the amount of oxygen-carrying protein in the blood. Hematocrit measures the percentage of red blood cells in a given volume of whole blood.
The platelet count is the number of platelets in a given volume of blood. Both increases and decreases can point to abnormal conditions of excess bleeding or clotting. Mean platelet volume (MPV) is a machine-calculated measurement of the average size of your platelets. New platelets are larger, and an increased MPV occurs when increased numbers of platelets are being produced. MPV gives your doctor information about platelet production in your bone marrow.
Mean corpuscular volume (MCV) is a measurement of the average size of your RBCs. The MCV is elevated when your RBCs are larger than normal (macrocytic), for example in anemia caused by vitamin B12 deficiency. When the MCV is decreased, your RBCs are smaller than normal (microcytic) as is seen in iron deficiency anemia or thalassemias.
Mean corpuscular hemoglobin (MCH) is a calculation of the average amount of oxygen-carrying hemoglobin inside a red blood cell. Macrocytic RBCs are large so tend to have a higher MCH, while microcytic red cells would have a lower value.
Mean corpuscular hemoglobin concentration (MCHC) is a calculation of the average concentration of hemoglobin inside a red cell. Decreased MCHC values (hypochromia)
are seen in conditions where the hemoglobin is abnormally diluted inside the red cells, such as in iron deficiency anemia and in thalassemia. Increased MCHC values (hyperchromia) are seen in conditions where the hemoglobin is abnormally concentrated inside the red cells, such as in burn patients and hereditary spherocytosis, a relatively rare congenital disorder.
y
Red cell distribution width (RDW) is a calculation of the variation in the size of your RBCs. In some anemias, such as pernicious anemia, the amount of variation (anisocytosis) in RBC size (along with variation in shape poikilocytosis) causes an increase in the RDW. The CBC test is considered a safe procedure. However, as with many medical tests, there
are some problems that can occur with having blood drawn:
y y y
fainting or feeling lightheaded hematoma (blood accumulating under the skin causing a lump or a bruise) pain associated with multiple punctures to locate a vein
COMPLETE BLOOD COUNT January 2, 2011 EXAMINATION MADE WBC Count Monocyte Hemoglobin Hematocrit Platelet VALUES OBTAINED 11.3 2.8 13.6 0.41 258 NORMAL VALUES 4.8-10.8 0-7 12-16 g/L 37-47 150-400 o Normal Normal q Normal INTERPRETATION
C. CLINICAL CHEMISTRY Received: January 2, 2011 Negative Troponin T Comment: Pre-extracted blood was received by our laboratory Released: January 2, 2011 ( 7:03 p.m.)
D. RADIOLOGY REPORT Date: January 02, 2011 Follow film when compared to the other done Dec. 22, 2010 shows lesser degree of cardiomegaly. Aorta is dilated.
IX.
PATHOPHYSIOLOGY
Modifiable factors
Non- modifiable Factors
diet and increase carbohydrates low in micronutrients sedentary lifestyle
Age Gender
Free blood glucose is high in the blood
Insulin levels increase in blood stream
Decrease sensitivity of tissue to insulin
Cell become resistant to insulin
Inability to transport glucose to cell
Increase Blood Viscosity
Blood glucose in the blood remains high
Affect the lens of the eye
Mobilization of fat to be a source of glucose
Blurring of vision
Some fats remain free lipids in the blood Fats are eventually accumulated to vessel walls Atherosclerosis
Some fats are converted to glucose
The lens goes cloudy
Cataract
Hypertension
Disruption of coronary artery
Distensibility of the left ventricle Platelet activation Myocardial relaxation
Impaired Ventricular filling Activation of coagulation cascade
Congestive Heart Failure
Endothelial vasoconstriction
Thrombus formation
Left ventricular fails
Embolisation
Blood dams back from left atrium to lungs
Occlusion/ Obstruction
Increase intravascular hydrostatic pressure
Acute Coronary Syndrome
Modifiable factors Fluid from the blood is forced out to the interstitium (edema fluid)
- High blood pressure - High cholesterol intake - History of stroke - Type II Diabetes mellitus Signs and Symptoms
Edema fluid leaks into alveolar space
chest pain diaphoresis nausea vomiting shortness of breath difficulty of breathing Atypical sensation palpitations
Acute Pulmonary Congestion
X.
Medical Management
A.
Bladder Training Bladder training is a way of learning to manage urinary incontinence. It is generally used
for stress incontinence, urge incontinence or a combination of the 2 types (mixed incontinence). Stress incontinence is when urine leaks because of sudden pressure on your lower stomach muscles, such as when you cough, laugh, lift something or exercise. Urge incontinence is when the need to urinate comes on so fast that you can't get to a toilet in time. It can help to: lengthen the amount of time between bathroom trips, increase the amount of urine your bladder can hold and improve your control over the urge to urinate. B. Diagnostic Procedures The diagnostic procedure is a method or technique used to identify or to see the nature of disease or disorder. It is also used to figure out what kind of disease is present. This is followed in making a medical diagnosis and this excludes procedures which are primarily carried out on specimens in a laboratory. C. High Back Rest Position (Fowlers position) It is a standard patient position. It is used to relax tension of the abdominal muscles, allowing for improved breathing in immobile patients, and to increase comfort during eating and other activities. It is also used in postpartum women to improve uterine drainage. The patient is placed in a semi-upright sitting position (45-60 degrees) and may have knees either bent or straight.
D.
Health Teaching It is the way of giving knowledge to the client regarding the condition of the disease. This involves the discussion about the facts of the disease, its causes and risk factors. Most of the time the main goal of this method was to provide knowledge to the clients in order to help his/her in managing and intervention of his/her condition to achieve the optimum level of health.
E.
Insertion of Foley Catheter Foley catheter is a thin, sterile tube inserted into your bladder to drain urine. Because it
can be left in place in the bladder for a period of time, it is also called an indwelling catheter. It is held in place with a balloon at the end, which is filled with sterile water to hold it in place. The urine drains into a bag and can then be taken from an outlet device to be drained. Laboratory tests can be conducted on your urine to look for infection, blood, muscle breakdown, crystals, electrolytes, and kidney function. The procedure to insert a catheter is called catheterization. A Foley catheter is used with many disorders, procedures, or problems such as these: Retention of urine leading to urinary hesitancy, straining to urinate, decrease in size and force of the urinary stream, interruption of urinary stream, and sensation of incomplete emptying; Obstruction of the urethra by an anatomical condition that makes it difficult for you to urinate: prostate hypertrophy, prostate cancer, or narrowing of the urethra; Urine output monitoring in a critically ill or injured person; Collection of a sterile urine specimen for diagnostic purposes; Nerverelated bladder dysfunction, such as after spinal trauma and many more. A catheter can be inserted regularly to assist with urination. F. Intravenous Therapy
Intravenous therapy or IV therapy is the giving of substances directly into a vein. Therapies administered intravenously are often called specialty pharmaceuticals. It is commonly referred to as a drip because many systems of administration employ a drip chamber, which prevents air entering the blood stream (air embolism) and allows an estimate of flow rate. It may be used to correct electrolyte imbalances, to deliver medications, for blood transfusion or as fluid replacement to correct, for example, dehydration. Compared with other routes of administration, the intravenous route is the fastest way to deliver fluids and medications throughout the body. Some medications, as well as blood transfusions and lethal injections, can only be given intravenously. G. Low Salt diet
Sodium is an essential mineral or micronutrient which along with potassium helps to regulate the body's fluid balance. Unlike other minerals, sodium alias salt has a recognizable and popular taste, and is widely added to snack foods and other processed foods. Your body needs salt, which contains sodium, to work properly. Sodium helps your body control your blood pressure, blood volume, muscles and nerves, and more. But, too much sodium in your diet can be bad for you. For most people, dietary sodium comes from salt that is in or added to their food. If you have high blood pressure or heart failure, your doctor may advise you to limit how much salt you eat every day. Even people with normal blood pressure will have lower (and healthier) blood pressure if they lower how much salt they eat. Dietary sodium is measured in milligrams (mg), and your doctor may tell you to eat no more than 2,300 mg a day when you have these conditions. For some people, 1,500 mg a day is an even better goal. H. Low fat diet
A low-fat diet as the name implies is a diet that consists of little fat, especially saturated fat and cholesterol, which is thought to lead to increased blood cholesterol levels and heart attack. It is important to know that dietary fat is needed for good health, as fats supply energy and fatty acids, in addition to supplying fat-soluble vitamins like A, D, E, and K. this diet were implemented to reduce the plaque formation among blood vessel and decreases the amount of blood cholesterol level thus decreasing the possibility to acquire heart attack. I. Oxygen Therapy It is the administration of oxygen as a medical intervention, which can be for a variety of purposes in both chronic and acute patient care. Oxygen is essential for cell metabolism, and in turn, tissue oxygenation is essential for all normal physiological functions. High blood and tissue levels of oxygen can be helpful or damaging; depending on circumstances and oxygen therapy should be used to benefit the patient by increasing the supply of oxygen to the lungs and thereby increasing the availability of oxygen to the body tissues, especially when the patient is suffering from hypoxia and/or hypoxemia. It is indicated to used as a medical treatment in both chronic and acute cases, and can be used in hospital, pre-hospital or entirely out of hospital, dependant on the needs of the patient and the views of the medical professional advising, use in chronic conditions like A common use of supplementary oxygen is in patients with chronic obstructive pulmonary disease (COPD); Use in acute conditions for example oxygen is widely used in emergency medicine, both in hospital and by emergency medical services or advanced first aiders, In the pre-hospital environment, high flow oxygen is definitively indicated for use in resuscitation, major trauma, anaphylaxis, major hemorrhage, shock, active convulsions and hypothermia. It may also be indicated for any other patient where their injury or illness has caused hypoxemia, although in this case oxygen flow should be moderated to achieve target
oxygen saturation levels, based on pulse oximetry and lastly for personal use, high concentration oxygen is used as home therapy to abort cluster headache attacks, due to its vasoconstrictive effects.
J.
Pharmacotheraphy It is the treatment of disease through the administration of drugs. As such, it is considered
part of the larger category of therapy. Pharmacists are experts in pharmacotherapy and are responsible for ensuring the safe, appropriate, and economical use of medicines. As pharmacotherapy specialists, pharmacists have responsibility for direct patient care, often functioning as a member of a multidisciplinary team, and acting as the primary source of drugrelated information for other healthcare professionals.
XI.
y
DRUG STUDY
Drugs administered upon the admission to the Emergency Room
Date Started: January 1, 2011
DRUG NAME
CLASSI-FICATION
DOSAGE, TIME, FREQUENCY
MECHANISM OF ACTION
INDICATION
CONTRA INDICATIONS AND CAUTION
ADVERSE EFFECTS
NURSING CONSIDERATIONS
Furosemide (Lasix)
Loop Diuretics
40 mg. IV., TID q8
Inhibits sodium and chloride reabsorption at the proximal and distal tubules and in the ascending loop of Henle.
This drug was given to patient due to pulmonary edema and hypertension of 160/110 mmHg
Patient has no contraindication to drug.
Patient exhibits weakness and hypotension. Other possible adverse effects are: CNS: dizziness, vertigo, paresthesias, xanthopsia CV: thrombophlebitis Dermatologic: photosensitivity, rash, pruritus, urticaria GI: nausea, anorexia, vomiting, constipation, oral and gastric
y y
Possible contraindications are: y y Hypersensitivity Anuria
y y y
Use cautiously with: y y y Gout Diabetes Mellitus Systemic lupus erythematosus
Monitor weight, BP and PR Monitor fluid, I & O, electrolyte, BUN and CO2 levels frequently WOF: signs of hypokalemia Monitor uric acid levels Monitor glucose levels especially in DM clients Instruct patient about a highpotassium diet. Foods rich in potassium include citrus fruits, tomatoes, and bananas.
irritation GU: urinary bladder spasm, nocturia Hematologic: leukopenia, anemia, thrombocytopenia, hyperglycemia, hyperuricemia Others: muscle cramps and muscle spasm
XXI. Drugs administered upon the admission to the Emergency Room
DRUG NAME
CLASSIFICATION
MECHANISM OF ACTION
INDICATION
CONTRA INDICATIONS AND CAUTION Patient has no contraindication to drug.
ADVERSE EFFECTS
Losartan
y y
Antihypertensive Adrenergic-receptor Blocker
100 mg 1 tab, P.O., OD
Selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland; this action blocks the vasoconstriction effect of the rennin-angiotensin system as well as the release of aldosterone leading to decreased BP.
This drug was given to patient due to hypertension and to reduce the risk of CVA.
Patient exhibits weakness, headache, and hypotension. Other possible adverse effects are: CNS: dizziness, syncope, insomia Dermatologic: rash, urticaria, pruritus, alopecia, dry skin GI: diarrhea, abdominal pain, nausea, constipation, dry mouth Respiration: cough Others: back pain, gout
Possible contraindications are: y y Hypersensitivity Pregnancy (use during 2nd & 3rd trimester can cause injury or even death to the fetus) Lactation
Administer without regard to meals. Monitor client closely in any situation that may lead to a decrease in BP secondary to reduction in fluid volume
Use cautiously with: y y Hepatic & renal impairment Hypovolemia
Started: January 3, 2011
DRUG NAME
CLASSI-FICATION
MECHANISM OF ACTION
INDICATION
ADVERSE EFFECTS
Isosorbide mononitrate
y y y
Antianginal Nitrate vasodilator
60mg tab, P.O., OD
Relaxes vascular smooth muscle with a resultant decrease in venous return and decrease in arterial BP, which reduces left ventricular workload and decreases myocardial oxygen consumption.
This drug was given since the patient exhibits chest pain.
Patient exhibits weakness. Other possible adverse effects are:
Possible contraindications are: y y y y Allergy to nitrates Severe anemia Head trauma Cerebral hemorrhage
Use cautiously with: y y y y Pregnancy Lactation Acute MI Heart failure
y CNS: restlessness, vertigo, dizziness, fainting y CV: tachycardia, retrosternal discomfort, y palpitations, hypotension, syncope, collapse, rebound hypertension GI: nausea, vomiting, diarrhea,
Give sublingual preparations under the tongue or in the buccal pouch; discourage client from swallowing Create a nitratefree period to minimize tolerance Give oral preparations on an empty stomach Assess orthostatic hypotension, blood pressure at baseline and during treatment
abdominal pain, ulcer

GU: dysuria, impotence, urinary frequency
DRUG NAME
CLASSIFICATION
MECHANISM OF ACTION
INDICATION
ADVERSE EFFECTS
Omeprazole
y y
Antisecretory Proton-pump inhibitor
20mg 1 tab, P.O., OD
Gastric acidpump inhibitor: suppresses gastric acid secretion by specific inhibition of the hydrogenpotassium ATPase enzyme system at the secretory surface of the gastric parietal cells.
Omeprazole treats ulcer and heartburn which the patient may possibly developed.
Patient exhibits weakness and hypotension. Other possible adverse effects are:
y y
Possible contraindications are: y Hypersensitivity
Use cautiously with: y y Pregnancy Lactation
CNS: y headache, dizziness, vertigo, insomnia, anxiety, paresthesias GI: diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth Respiration: cough,
Administer drug before meals Administer antacids with, if needed. Have regular medical followup visit Report severe headache, worsening of symptoms, fever and chills.
epistaxis
Dermatologic: rash, inflammation, urticaria, pruritus, alopecia, dry skin
DRUG NAME
CLASSIFICATION
MECHANISM OF ACTION
INDICATION
ADVERSE EFFECTS
Clopidogrel
y y
Antiplatelet ADP receptor antagonist
75 mg. 1 tab, P.O., OD
Inhibits platelet aggregation by blocking ADP receptors on platelets, preventing clumping of platelets.
Clopidogrel treats acute coronary syndrome which was the patient s to considered diagnosis.
Patient exhibits weakness, hypertension, and headache. Other possible adverse effects are:
Possible contraindications are: y y Allergy to clopidogrel Active pathological bleeding (peptic ulcer, intracranial hemorrhage) Lactation
Use cautiously with: y y y Recent surgery Hepatic impairment Pregnancy
CNS: dizziness, y syncope, flushing CV: edema Dermatologic: y rash, pruritus

GI: nausea, Gi distress, constipation, diarrhea, GI bleed
Provide frequent small meals if GI upset occurs Provide comfort measures and arrange for analgesics if headache occurs. Assess for symptoms of stroke, MI during treatmet Take drug with meals
DRUG NAME
CLASSIFICATION
MECHANISM OF ACTION
INDICATION
ADVERSE EFFECTS
Ciprofloxacin
y y
Antibacterial Fluoroquinolone
500 mg., 1 tab, P.O., BID
Bactericidal; interferes with DNA replication in susceptible bacteria preventing cell reproduction.
This drug was given as treament for possible urinary tract infection that the patient may have due to uninary catheterization.
Patient exhibits weakness, headache and hypotension. Other possible adverse effects are:
Possible contraindications are: y Allergy to ciprofloxacin and other fluoroquinolones Pregnancy Lactation
y y
Use cautiously with: y y Renal impairment Seizures
CNS: dizziness, insomnia, fatigue, blurred vision, y hallucinations, ataxia, nightmares y CV: arrythmias, EENT: dry y eye, eye pain, keratopathy GI: nausea, vomiting, dry mouth diarrhea,
Arrange for culture & sensitivity tests before beginning therapy Continue therapy for 2 days after signs & symptoms of infection are gone Ensure that client is well hydrated Give antacids at least 2 hrs. after dosing Encourage client to complete full course of therapy
abdominal pain
GU: renal failure
DRUG NAME
CLASSIFICATION
MECHANISM OF ACTION
INDICATION
ADVERSE EFFECTS
Simvastatin
y y
Antihyperlipidemic HMG-CoA inhibitor
40 mg. Tab, P.O., OD
Inhibits HMGCoA reductase, the enzymes that catalyzes the first step in the cholesterol synthesis pathway, resulting in a decrease in serum cholesterol, serum LDLs, and either an increase or no change in serum HDLs.
Patient was given simvastatin to reduce the risk of coronary disease and to prevent hypercholesterolemia.
Patient exhibits headache. Other possible adverse effects are:
Possible contraindications are: y y y y y Allergy to simvastatin Active liver disease Persistent elevation of serum tranaminases Pregnancy Lactation
Use cautiously with: y y Impared hepatic and renal function cataracts
CNS: y asthenia, sleep disturbances GI: flatulence, diarrhea, abdominal pain, cramps, y constipation, nausea, dyspepsia, liver failure, heartburn Respiration: sinusitis, pharyngitis
Ensure that client has tried a cholesterollowering diet regimen for 3-6 mo before beginning therapy Give in evening; highest rates of cholesterol synthesis are between midnight and 5 am Arrange for regular followup during longterm therapy. Consider reducing dose if cholesterol falls below target.
y y
Monitor bowel pattern daily Monitor triglycerides, cholesterol baseline throughout treatment
DRUG NAME
CLASSI-FICATION
MECHANISM OF ACTION
INDICATION
ADVERSE EFFECTS
Aspirin
y y y y y y y
Analgesic Anti-inflammatory Antiplatelet Antipyretic NSAIDS Salicylate Antirheumatic
80 mg. Tab, P.O. OD
Exhibits antipyretic, antiinflammatory and analgesic effects. The antipyretic effect is due to an action on the hypothalamus, resulting in heat loss by vasodilation of peripheral blood vessels. Antiinflammatory effects are mediated by a decrease in prostaglandin synthesis. It also decreases platelet aggregation.
This drug was given to patient due to chest pain.
Patient has no contraindication to drug. Possible contraindications are: y y y y y Allergy to salicylates or NSAIDs Allergy to tartrazines Blood coagulation deficiency Bleeding ulcers Hemophilia
No adverse effects seen on patient. Other possible adverse effects are: GI: dyspepsia, heartburn, anorexia, nausea, epigastric discomfort, potentiation of peptic ulcer Allergic: Bronchospasm, asthma-like symptoms, anaphylaxis, skin rashes, urticaria Hematologic: prolongation of bleeding time, thrombocytopenia, leucopenia, Other: Thirst, fever, dimness of vision
Use cautiously with: y Impaired renal function y Peptic ulcer disease y Pregnancy y Lactation
Give drug with food or after meals if GI upset occurs Do not use aspirin that has a strong vinegar-like odor Do not crush or chew entericcoated tablets. Assess pain and limitation of movement; note type, location, and intensity before and at the peak after administration.
DRUG NAME
CLASSIFICATION
MECHANISM OF ACTION
INDICATION
ADVERSE EFFECTS
Diltiazem
y y y
Antianginal Antihypertensive Calcium channel blocker
30 mg. P.O., TID
Inhibits calcium transport into myocardial smooth muscle cells. Systemic and coronary vasodilation.
Diltiazem was given to patient since she exhibits chest pain and hypertension.
Patient has no contraindication to drug. Possible contraindications are: y y y y Allergy to diltiazem Impaired hepatic function Severe hypertension Cardiogenic shock
Patient exhibits headache and hypotension. Other possible adverse effects are:
y y y
CNS: fatigue, lightheadedness, dizziness CV: arrhythmias, bradycardia, palpitations GI: nausea, hepatic injury, reflux Dermatologic: Flushing, rash
Monitor BP and pulse before therapy, during titration and therapy Monitor I&O and weight Assess for CHF Monitor cardiac rhythm regularly during stabilization of dosage. Do not cut, crush, or chew drug. Report irregular heart beat, shortness of breath, swelling of the hands or feet, constipation.
DRUG NAME
CLASSIFICATION
MECHANISM OF ACTION
INDICATION
ADVERSE EFFECTS
Spironolactone (Aldactone)
y y
Antihypertensive Potassium-sparing Diuretics
20 mg P.O. BID
Competitively blocks the effects of aldosterone in the renal tubule, causing loss of sodium and water and retention of potassium.
This drug was given to patient due to hypertension of 130/80 mm Hg.
Patient exhibits headache, and fatigue Other possible adverse effects are: CNS: dizziness, drowsiness, ataxia, confusion Dermatologic: rash, urticaria GI: cramping, diarrhea, dry mouth, vomiting GU: impotence, amenorrhea Hematologic: hyperkalemia, hyponatremia Others: hirsutism,
Possible contraindications are:
y y y y
Allergy to aldactone Hyperkalemia Renal disease Anuria
y y
Use cautiously with: y y Pregnancy Lactation
Educate patient to avoid hazardous activity such as driving until response to drug is known. Take with meals or milk Avoid excessive ingestion of food high in potassium or use of salt substitutes Diuretic effect may be delayed 2-3 days and maximum hypertensive may be delayed 2-3weeks Monitor I and O ratios and daily weight, BP,
gynecomasia, deepens of the voice.
serum electrolytes (K, Na) and renal function Give daily doses early so that increased urination does not interfere with sleep.
XII.
NURSING CARE PLAN
cues
Nursing diagnosis Disturbed sleeping pattern related to shortness of breathe
Inference
Planning
Nursing Intervention y Identified the presence of factors that could contribute to insomnia such as environment and aging. Arranged care to provide for uninterrupted periods for rest especially allowing for longer periods of sleep at night when possible. Do as much as possible without waking the client y
Rationale
evaluation
Subjective: Nahihirapan akong makatulog sa gabi as verbalized by the client. Objective: Objective: -Dark circles under eyes -Restlessness -Irritability -Dozing -Yawning -Difficulty in arousal
Inability of the heart to function to meet the needs of the body
After 8 hours of continuous nursing intervention the client will be able to improved Increased sleeping cardiac pattern as workload evidenced by : y Rested Hypertrophy appearanc of e, myocardial verbalizati muscle( on of cardiomegaly feeling rested, )diminished and function in improvem LV and ent in pooling of sleep the blood in pattern. the ventricle Backflow of the blood to
To identify causative and contributing factors
Goal met: After 8hours of nursing intervention the client achieved improved sleeping pattern as evidenced by: y Reported Rested appearance, verbalization of feeling rested, and improvement in sleep pattern.
To assist client to establish optimal sleep and rest pattern
LA and to the lungs Presence of blood in the lungs Difficulty in breathing Nocturnal dyspnea Disturbed sleeping pattern.
Instruct the client to follow bedtime rituals Instruct client to elevate head with pillows.
To promote relaxation
Elevating the head of the client reduce pulmonary congestion and nocturnal dyspnea
Provide quiet environment and comfort measures in preparation for sleep such as arranging all the personal materials in particular manners. Instruct client to decreased fluid intake before bed
To promote uninterrupted rest for optimal sleep enhancement
To prevent
time y Administered medication as ordered by the physician Provided oxygen as ordered.
overload
Bronchodilators are use to relax smooth muscle of breathing
y Oxygen therapy are use to maintain gas exchange
Cues
Nursing diagnosis Ineffective tissue perfusion related to vasoconstriction of blood vessels.
Inference
Planning
Nursing Intervention
Rationale
Evaluation
Subjective: Nahihilo ako as verbalized by the client. Objective: v/s BP:140/100 PR:72 RR:30 TEMP:35.1 use of accessory muscle in breathing
Increased cardiac output that injures the endothelial cells of the arteries and the action of prostaglandins. Vasoconstriction occurs and blood pressure increases.
After 8 hours of continues nursing intervention the client blood pressure will decrease from 140/ 100mmHg to 120/80mmHg.
Monitored blood Sodium pressure tends every to be 4hours. excreted Instructed to at a faster have enough rate. rest on semi fowlers To reduce edema that position. may Instructed to activate renin eat low fat angiotensin and low salt aldosterone diet. system. Administered To control antithe hypertensive BP and to drug as avoid ordered. other complication s.
To know the base line of BP
After 8hours of nursing intervention the clients blood pressure was decreased from 140/100mmHg to 120/90mmHg.
Assessment
Nursing Diagnosis Self-care deficit related to impaired mobility status as manifested by activity intolerance.
Inferences
Planning
Nursing Intervention Rationale y y
evaluation
hindi ko man lang masuklay ang buhok ko at malinis ang sarili ko As verbalized by the client. Objective: The client appeared: y Inability to feed self independe ntly y Inability to dress self independe ntly y Inability to bathe and groom self independe ntly y Inability
Due to condition resulting body weakness unable to perform activities daily living.
After 1 hour of continuous nursing intervention the client will be able to perform selfcare activity within level of own ability.
Determine individual strength and skills of a client.
Make appropriate technique that will facilitate teaching to develop plan of care appropriate to individual situation.
After 8hours of continuous nursing intervention the client safely performs (to maximum ability) self-care activities.
y y Plan a time for listening to the client concern
To discover barriers to participation in regimen and to work on problem solutions.
Allow sufficient time for dressing and undressing, since the task may be tiring, painful, and difficult. Plan for person to
to perform toileting tasks independe ntly Inability to transfer from bed to wheelchai r Inability to ambulate independe ntly
learn and demonstrate one part of an activity before progressing further. y Nurture individualized attributes such as humor, positive attitude, faith, and hope. y To enhance sense of wellbeing
Assessment
Nursing diagnosis Activity intolerance related to immobility
Inference
Planning
Nursing intervention y Assess ability to stand and movement and degree of assisted needed
Rationale y
evaluation
Subjective: nahihirapanakongk umiloslalonakapagb umabangonakoas verbalized by the client. Objective: v/s: BP- 130/100mmhg PR- 72 bpm RR-30 bpm TempThe client appeared: y Verbal report of fatigue or weakness y Inability to begin or perform activity y Abnormal heart rate or blood pressure (BP) response to activity y Exertional discomfort or
Due to condition resulting body weakness unable to perform activities daily living.
After 8 hours of continuous nursing intervention the client will use identified techniques to enhance activity tolerance.
Adjust activities or discontinu e activities that precipitate the clients condition. Teach methods that facilitate conservati on of energy such as
After 8 hours of continuous nursing interventio n the client was able to use identified technique to enhanced activity tolerance To prevent as overexertio evidenced by: n. y Client verbal izes and To uses conserve energ energy and yavoid extra conse consumptio rvatio n of n oxygen. techni To determine current status and needs associated with participatio n in desired activities.
dyspnea
having 3 minutes of rest during performin g activities. y Assist client in learning and demonstra ting appropriat e safety measures. Encourag e client to maintain positive attitude, suggest use of relaxation technique s such as visualizati on.
ques. y
To prevent injuries.
To enhance sense of well-being.
Cues
Inference Nursing Diagnosis Myocardial Regurgitation Backflow of blood LA Return of blood to pulmonary capillary bed. Increase hydrostatic pressure in pulmonary vessels. Fluid shifting from intravascular to alveoli. Pulmonary congestion.
Planning
Nursing Intervention
Rationale
Evaluation
Subjective: nakakaramada m ako ng paghirap sa paghinga as verbalized by the client. Objective: The client appeared: y Confusion y Somnolence y Restlessnes s y Irritability y Inability to move secretions
Impaired gas exchange related to pulmonary congestion as manifeste d by increased respiratory rate.
After 8 hours of continous nursing intervention the client will demonstrate improvement of ventilation as evidenced by: y Decreas ed in rerpirato ry rate Decreas ed crackles Client appear relaxed
Identified prescence of factors that could contribute to inpaired gas exchange such as aging and environment Monitor vital signs.
To identified the causative and contributing factors
Monitoring vital signs reflect the client status. y
Goal met. After 8 hours of nursing intervention the client demonstrat e improvemed ventilation as evidence by: Reported decreased in RR Decreased crackles upon auscultation Client
y y y Observed restlessness and anxiety
These are the common signs of hypoxia
y y Signs of
and comfort able
Auscultated the lungs for the sound of crackles y
cracles indicate accumulatio n of fluid in the lungs
appear relaxed and comfortable.
Position client appropriately such as elevation of the head at least 15 degree.
Positioning the client appropriatel y helps to promote maximal expansion of the lungs which enables breath effectively and improves opening of the airway.
Encourage deep breathing exercise
Encourage adequate rest and limit activities Provide oxygen as ordered
To breathe easier and to avoid respiratory distress To limit oxygen consumptio n Oxygen administrati on provides supplement al oxygenation in the body
XIII. DISCHARGE PLAN
MEDICATION- instructs the client to take the following medication: Furosemide (LASIX) 40 mg to be taken once a day. Furosemide will make the client urinate more often and the client may get dehydrated easily. The client must follow the doctors instructions about using potassium supplements like aldactone that can cause loss of sodium and water and retention of potassium. Since furosemide has a diuretic effect, the client must avoid becoming dehydrated by drinking lots of water. And this medication makes the client more sensitive to the sun, so encouraged the client to avoid prolonged exposure to the sun. Isosorbide mononitrate (IMDUR) 30 mg to be taken once a day, since the drug prepared by 60 mg the tablet should be cut into half to arrive at 30 mg dosage per day. It used to prevent chest pain or angina in patients with a certain heart condition. Also, advice client to take maintenance drugs such as calcium channel blocker and antihypertensive drugs. EXERCISE- an underlying heart condition may necessitate changing activities to those with less physically demanding or emotionally stressful responsibilities. The client should limit extraneous activities that will aggravate her condition. And encourage the client to perform simple activities like walking. TREATMENT-treatment includes: placing the client into sitting position, oxygen, assisted or mechanical ventilation (if available). To help the client breath better, she is placed in a sitting position, the goal of treatment is to reduce the amount of fluid in the lungs, improve gas exchange and heart function and where possible to correct the underlying disease.
HEALTH TEACHING- encourage the client to limit intake of salty and fatty foods, increase intake of potassium since the client is taking furosemide medication. The client must drink lots of water but limit some beverages like soft drinks and coffee. The client must also avoid duties that need large physical activities. And lastly, encourage client to have regular checkups. OUT-PATIENT- encourage client to have a regular follow-up exams to monitor progress. Regular checkup or consultations will increase the clients awareness about her health condition. DIET-low sodium diet may advice to the client and an increase in potassium like eating banana as well as increase intake of water because she taking diuretic medication. The client must avoid fatty foods because it may aggravate her condition. And fats may end up as atheromatous plaque that may end up in the formation of blockages. SPIRITUAL- encourage the client to attend the mass if she is in good condition and tell her that only God knows the end of all things and only God can provide not only physical but also emotional and spiritual strength to help her overcome difficulties in her life.

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UNIVERSIDAD DE MANILA (City College of Manila) College of Nursing

In Partial Fulfillment of the Requirements in Medical-Surgical Nursing Related Learning Experience

A case of a client with ACUTE PULMONARY CONGESTION

January 12, 2011

CHAPTER III A. Anatomy and Physiology B. Pathophysiology with schematic diagram

CHAPTER IV A. Diagnostic and Laboratory Procedures B. Drug Study

CHAPTER VI A. Evaluation B. Conclusion C. Discharge Plan Bibliography

PATIENTS HEALTH HISTORY

Marital Status Religion Weight Height Body Mass Index

Usual source of health Care Source and Reliability of Information

Ospital ng Sampaloc Client- (4 = very reliable) Clients Daughter-

D. History of Present Illness

Dead A&W Alive and well

Stroke, Client L. Cerbrovascular accident

The client stated that graduate lang ako ng high school

Characteristic Patterns of Daily Living

Hair and Scalp

Thorax and Lungs

Head, Eyes, Ears, Nose, Throat (HEENT)

Head, Eyes, Ears, Nose, Throat (HEENT)

Gordons Typology of Health Patterns

Patient Activity (before hospitalization)

Health Perception/ Health Management

XVIII. Brachiocephalic Artery/Vein

CARDIOVASCULAR SYSTEM ROLE

Slightly turbid Clear 40-50 0-1 05 per hpf 02 per hpf

B. Complete Blood Count

Non- modifiable Factors

diet and increase carbohydrates low in micronutrients sedentary lifestyle

Free blood glucose is high in the blood

Insulin levels increase in blood stream

Decrease sensitivity of tissue to insulin

Cell become resistant to insulin

Inability to transport glucose to cell

Increase Blood Viscosity

Blood glucose in the blood remains high

Affect the lens of the eye

Mobilization of fat to be a source of glucose

Some fats are converted to glucose

The lens goes cloudy

Disruption of coronary artery

Distensibility of the left ventricle Platelet activation Myocardial relaxation

Impaired Ventricular filling Activation of coagulation cascade

Congestive Heart Failure

Left ventricular fails

Blood dams back from left atrium to lungs

Increase intravascular hydrostatic pressure

Acute Coronary Syndrome

Edema fluid leaks into alveolar space

Acute Pulmonary Congestion

Date Started: January 1, 2011

DOSAGE, TIME, FREQUENCY

CONTRA INDICATIONS AND CAUTION

40 mg. IV., TID q8

Patient has no contraindication to drug.

Possible contraindications are: y y Hypersensitivity Anuria

Use cautiously with: y y y Gout Diabetes Mellitus Systemic lupus erythematosus

Date Started: January 1, 2011

XXI. Drugs administered upon the admission to the Emergency Room

DOSAGE, TIME, FREQUENCY

CONTRA INDICATIONS AND CAUTION Patient has no contraindication to drug.

Antihypertensive Adrenergic-receptor Blocker

100 mg 1 tab, P.O., OD

To know the base line of BP