Perpetual Help College of Manila1240 V. Concepcion St. Sampaloc, Manila
College of Nursing
A Case Study on:
Congestive Heart Failure
Presented to the faculty of
Perpetual Help College of manila
In partial fulfillment
of the requirements for
Nursing Care Management (NCM) 204
Related Learning Experiences
1st semester of S.Y. 2010-2011
Submitted by
Section E – Group 1
OBJECTIVES
General:
This study aims to develop knowledge, skills and attitudes towards nursing care
management of client who developed a Congestive Heart Failure due to Type II Diabetes
Mellitus.
Specifically, this aims to:
To identify the precipitating factors regarding the pathogenesis of the disease
being manifested by the client
To enumerate clinical manifestations of the diseases manifested by the client
To discuss the pathophysiology of Left-Sided Congestive Heart Failure.
To demonstrate the appropriate approach used in dealing with clients with
Congestive Heart Failure.
To perform dependent and independent interventions, being done to the client
appropriately and with care.
To perform comprehensive nursing care and interventions with competence and
confidence in rendering care to clients with Congestive Heart Failure.
To establish rapport to client and family/significant others.
To encourage family/significant others to cooperate in the interventions that are
being performed to the client.
To collaborate with all the health team to promote efficient care to the client.
INTRODUCTION
Congestive heart failure is a physiologic state in which the heart cannot pump enough
blood to meet the metabolic needs of the body (determined as oxygen consumption). Heart
failure results from changes in systolic or diastolic function of the left ventricle. The heart
fails when, because of intrinsic disease or structural defects, it cannot handle a normal blood
volume or, in the absence of disease cannot tolerate a sudden expansion in blood volume
(e.g.., during exercise).
The main causes of Congestive Heart Failure are as follows: Coronary Artery Disease,
Untreated High Blood Pressure, Faulty heart valves, Cardiomyopathy, Lung disease,
Diabetes, Infections, Alcoholism and some Toxic Drugs. The Non-Modifiable risk factors are
age, gender, race, family history, personal history. The Modifiable risk factors are smoking,
high blood pressure, anemia and diabetes.
Heart failure may be categorized as (1) LVF versus RVF, (2) backward versus forward, (3)
high output versus low output. In the case of the patient, she has a Left Ventricular Failure.
Left ventricular failure causes either pulmonary congestion or a disturbance in the
respiratory control mechanisms. The patient manifests rales, dyspnea, paroxysmal nocturnal
dyspnea, orthopnea, pulmonary edema, which are all consistent with Left-sided Congestive
Heart Failure. The cause of the patient’s condition resulted from interrelated factors such as
Diabetes Mellitus Type II and Myocardial Infarction.
Out of the 86,241,697 people in the Philippines, 1,521,912 have Congestive Heart Failure.
Congestive Heart Failure is the 6th leading cause of mortality in the Philippines, affecting
males more often than females.
According to World Health Organization, more than 22 million people worldwide suffer
from Congestive Heart Failure. In the United States, congestive heart failure (CHF) was the
underlying cause of death for approximately 38,000 persons in 2007; of those deaths,
approximately 92% were among persons aged greater than or equal to 65 years.
We chose this case because we find it challenging. The disease is one of the most
common causes of mortality rate in our country. This study will give us more knowledge and
skills improving our nursing care management in patients with such disease and so we will
be confident to help for the betterment in providing health care in the future.
DEMOGRAPHIC DATA
Client's Name: Patient LB
Age: 65years old
Birthdate: November 18, 1945
Sex: Female
Address: Sampaloc Manila
Province: Jolo, Sulu
Height: 5’3”
Weight: 46 kilograms
Civil Status: Widow
Religion: Roman Catholic
Nationality: Filipino
Race: Asian
Language: Tagalog and English
Occupation: Housewife
Educational Attainment: College Undergraduate
Date of Admission: August 26, 2010 / 6:12 PM
Attening Physician: Dr. Bartolome
Chief Complaint: Difficulty of Breathing, Chest pain
Admitting Diagnosis: Hypertensive Cardiovascular Disease; Congestive
Heart Failure Secondary to Diabetes Mellitus Type II; Hyperuricemia; Anemia
Final Diagnosis: IHD, HCVD,CHF, CKD
History of Present Illness
One month prior to admission patient LB was hospitalize at Ospital ng Sampaloc at
around 11:30pm. According to her she was admitted because of hypertension, chest pain
and difficulty of breathing. She had been confined for 3 days. According to the patient, she
was diagnosed with Myocardial Infarction. Her medication was given by Dr. Ocampo as
follows: Aldactone 400mg/tab OD, Captopril 25mg/tab BID and Imdur 40mg/tab OD. After
hospitalization, the pain and dyspnea subsides. Then the doctor ordered her for discharge.
When the patient was doing the laundry she started experiencing difficulty of
breathing and chest pain after which she lost consciousness. She was immediately brought
to the hospital by her son. Patient LB was admitted at the ER of Ospital ng Sampaloc on
August 26, 2010 at 6:12 PM with a chief complaint of difficulty of breathing and chest pain.
Upon arrival at the Emergency Room, the client was conscious already. The physician
assessed the status of the patient, then he noted (+) chest pain, (+)tachypnea, (+)dyspnea,
(+)bradycardia, and (+)hypertension. The physician instructed the patient to undergo
different diagnostic procedures such as ECG and various laboratory exams like Serum
Electrolytes and Cardiac Enzymes test. Her admitting diagnosis is HYPERTENSIVE
CARDIOVASCULAR DISEASE; CONGESTIVE HEART FAILURE SECONDARY TO DIABETES
MELLITUS II. The physician referred the patient to Medical/Surgical Ward and gave doctor’s
orders such as NGT insertion, IV insertion, Foley Catheter Insertion, NPO instructed, Vital
Signs Monitoring, initial oxygen via face mask (5 L/min). Medications ordered by the
physician during admission are the following Aldactone OD, Captopril 25 mg/tab for HPN,
Imdur 30mg/tab OD, Clonidine 35mg/tab OD, Diltiazem 125mg OD.
Past Health History
The patient was hospitalized in the year 1977 when she gave birth to her last child
here in manila. She was confined at the hospital for two days. She experience Measles when
she was 6 years old and had Chicken Fox when she was 12 years old.
Family Health History
GENOGRAM
DM
LEGEND:
CHF - Congestive Heart Failure
DM - Diabetes Mellitus
MI - Myocardial Infarction
HPN - Hypertension
Px - Patient
- Male
- Female
- Deceased
Lifestyle
Patient LB seldom eats meat and poultry. Patient said that she doesn’t like the taste of
pork. Patient always eats vegetables and fish. Patient consumes vegetables that are rich in
fiber such as ‘saluyot’ and she eats more rice. Patient has a good appetite. Patient complies
with her doctor’s order by avoiding foods that are restricted to her. Patient LB voids
Px CHF,
DM, MI, HPN
MIIHPM, MI
approximately 10-12 times a day without experiencing pain during urination. She defecates
once or twice a day and seldom experience constipation. She does it every 6 in the morning,
thrice a week, for about an hour. She usually sleeps 5-6 hours a day. Patient sleeps at 9 or
10 in the evening and wakes up early in the morning, usually at 2 or 3am. She stated that
there are episodes that she gets awaken from sleep because she experiences difficulty of
breathing. Patient naps in the afternoon because she feels sleepy every afternoon.
Spiritual History
Patient LB is a Roman Catholic and has a strong faith in our supreme being. She
regularly attends mass every Friday and Sunday at Quiapo Church. She believes that God is
always there for her and his family in times of problems and challenges.
Sexual History
Being a widow, the patient has no more sexual activity for almost 15 years now. But
when she was younger she and her husband make love 2 to 3 times a week.
Developmental Task
Erik Erikson’s Psychosocial Theory of Development
Erik Erikson adapts and expands Freud Theory of development to include the entire life span, believing that
people continue to develop throughout life. He believed in the massive influence of culture on behavior and placed
more emphasis on the external world such as depression and was according to his theory, each stage signals a task
that must be achieved. The resolution of task can be complete, partial, and successful. He believes that the greater
the task achievements that healthier the personality of the person, failure to achieve a task influences the person’s
ability to achieved the next tasks. Erikson emphasizes that people must change and adapt their behavior to
maintain control over their lives. According to him, personality development is influenced by biologic,
psychological, environmental, and social factors throughout the life cycle.
Late Adulthood: 55 or 65 to Death
Ego Development Outcome: Ego Integrity vs. Despair
Basic Strengths: Wisdom
Erikson felt that much of life is preparing for the middle adulthood stage and the last stage is recovering from it.
Perhaps that is because as older adults we can often look back on our lives with happiness and are content, feeling
fulfilled with a deep sense that life has meaning and we've made a contribution to life, a feeling Erikson
calls integrity. Our strength comes from a wisdom that the world is very large and we now have a detached
concern for the whole of life, accepting death as the completion of life.
On the other hand, some adults may reach this stage and despair at their experiences and perceived failures. They
may fear death as they struggle to find a purpose to their lives, wondering "Was the trip worth it?" Alternatively,
they may feel they have all the answers (not unlike going back to adolescence) and end with a strong dogmatism
that only their view has been correct.
Analysis:
Patient LB achieved the developmental task because she was able to perform well as a part of her family.
She was able to teach and care for her children as they continue to grow. She feels fulfilled and contented on what
she has done and understand the things happening to her. She was aware of her condition and she accepts it. Thus,
Ego integrity developed.
a. Physical Development
Patient LB’s physical development belongs to a late adult age. She weighs 46 kilograms and stands 5’3” tall.
By merely looking at the patient’s physicality, she was actually lean in appearance. In terms of perception in health
functioning, patient LB considered herself as well fitted and is conscious and aware of her present condition.
b. Psychosocial Development
Patient LB is strong. Even if there’s problem, the family remained strong and has cooperation in each
member of the family. She was contented on her life; she felt happiness in taking care of her children and
grandchildren.
c. Cognitive Development
Patient LB makes decisions on her own but makes sure to still consult her family. As she recalls the
memories before, she was the third child of their parents. But she decided to separate from her parents as well as
her siblings. According to her, they’ve learned to live in their own at a young age. Now that she has her own family,
she makes sure that she provides everything they needed with the help of her second husband.
Analysis:
Based from experiences expressed by patient LB, it may be presumed that her personality features molded
during her early married life. She focused on that part of her life and she developed every virtues and attitudes in
that part of her life.
d. Moral and Spiritual Development
The patient is a Roman Catholic and she believes that GOD exists. She always goes to church every Sunday and
Friday she always pray the rosary.
Analysis:
Her decision is highly affected by her religion and faith. She often prays for guidance before she makes her
decision.
ANATOMY AND PHYSIOLOGY
Figure 1-2 Anatomical Structure of the Heart
Heart
The heart is shaped like a blunt cone and is approximately the size of a closed fist.
It is located in the thoracic cavity between the two pleural cavities, which surround the
lungs.
The heart, trachea, esophagus, and associated structures form a midline partition, the
mediastinum.
Functions:
1. Generating blood pressure
2. Routing blood
3. Ensuring one-way blood flow
4. Regulating blood supply
Right side of the Heart:
Right Atrium- the first chamber which receives deoxygenated blood from the body through
the inferior and superior venacava.
Right Ventricle- it pumps the blood into the lungs which exchange of oxygen and
carbon dioxide occurs.
Left side of the Heart:
LeftAtrium- the first chamber which receives highly oxygenated blood from the lungs
through the Pulmonary Veins.
Left Ventricle- the strongest of the heart's pumps. Its thicker musclesneed to perform
contractions powerful enough to force the blood toall parts of the body.
The Valves
Tricuspid Valve-regulates blood flow between the right atrium and the right ventricle
Pulmonary Valve-opens to allow blood to flow from the right ventricle to the lungs
Mitral Valve-regulates blood flow between the left atrium and the left ventricle
Aortic Valve-allows blood to flow from the left ventricle to the ascending aorta
The Hearts Electrical System
Superior vena cava- is one of the two main veins
bringing de-oxygenated blood from the body to the heart.
Veins from the head and upper body feed into the superior
vena cava, which empties into the right atrium of the heart
Inferior vena cava-is one of the two main veins bringing
de-oxygenated blood from the body to the heart. Veins from
the legs and lower torso feed into the inferior vena cava,
which empties into the right atrium of the heart.
Aorta-is the largest single blood vessel in the body. It is approximately the diameter of your
thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts of
the body.
Layers:
Epicardium - also called visceral pericardium
-a thin serous membrane forming the smooth outer surface of the heart
Myocardium -thick middle layer of the heart
-is composed of cardiac muscle cells and is responsible for contractions of the heart
chambers.
Endocardium -which consist of simple squamous epithelium over a layer of connective
tissue.
SYSTEMIC AND PULMONARY CIRCULATION
Figure 1-3 Systemic and Pulmonary Circulation
In the systemic circulation, arteries bring oxygenated blood to the tissues of the body.
The pulmonary circulation (for arterial blood sent to the lungs) is excluded from this
definition. As blood circulates through the body, oxygen diffuses from the blood into cells
surrounding the capillaries, and carbon dioxide diffuses into the blood from the capillary
cells. Veins bring deoxygenated blood back to the heart.
PATHOPHYSIOLOGY OF CONGESTIVE HEART FAILURELEFT-SIDED
(Book Base)
Causes:-Myocardial infarction-Prolong hypertension-Aortic Stenosis –Insufficiency-Mitral Stenosis – Insufficientcy
PATHOPHYSIOLOGY OF CONGESTIVE HEART FAILURELEFT-SIDED
(Client Base)
Reduced Myocardial ContractilityIncreased Cardiac Workload
Decreased Diastolic FilingObstruction of Left Arial Emptying
Left-Sided Congestive Heart Failure
Blood drums back into the pulmonary capillary bed
Decreased Stroke Volume
Pressure of blood into the pulmonary capillary bed increases
Fluid shift into the intra and inter-alveolar spaces
Pulmonary Edema
Decreased Tissue Perfussion
Increase Cellular Hypoxia Decrease blood flow to the kidneys
Signs and Symptoms of LSCHFRAAS Stimulation
Vasoconstriction & Rearbsorption of Sodium and Water
Increase ECG Volume
Increase total blood volumeIncrease Systemic Blood pressure
Dyspnea Paroxysmal Nocturnal Dyspnea Orthopnea Rales/ Crackles Moist Cough Blood Tinged Frothy Sputum Wheezing/ Cardiac Asthma Dizziness Fatigue Weakness Anorexia Hypokalemia Polycythemia S3 & S4 heart sounds
Modifiable factor:
Lifestyle
Non-Modifiable factor:
Myocardial infarctionDiabetes Mellitus
AgeHeredity
Hypertension
REVIEW OF SYSTEMS
August 30, 2010
SYSTEMS SUBJECTIVE CUESIntegumentary System “Wala naman ako problema sa balat,
ganito lang talaga ang balat pag tumanda na” as verbalized by the patient.
Respiratory System “Mabilis ang paghinga ko, parang kinakapos kaya nahihirapan ako sa paghinga” as verbalized by thepatient.
Increased workload
Enlargement of left ventricle
DyspneaParoxysmal nocturnal dyspneaOrthopneaFatigueRales/crackles
Reduced myocardial contractility
Blood drums backInto the pulmonary
capillary bed
Pressure of blood into the pulmonary capillary bed
increases
Fluid shift into the intra and inter-alveolar spaces
Pulmonary edema
LEGEND:
Sign and symptoms
Congestive Heart failure
“Parang nalulunod ako, hindi ako makahinga ng maayos” as verbalized by the patient.
“Gusto ko ng mataas na unan, itaas nyo ang higaan ko dito sa may likuran ko” as verbalized by the patient.
“Hinahabol ko ang paghinga ko kasi nauubusan ako” as verbalized by the patient
“Bumibilis ang paghinga ko pag sumasakit ang dibdib ko” as verbalized by the patient.
“Irerate ko ang sakit sa 7 out of 10” as verbalized by the patient.
“Sumasakit ang dibdib ko, parang pinipiga” as verbalized by the patient.
“Hindi ako makatulog ng maayos, nagigising ako dahil nahihirapan akong huminga” as verbalized by the patient.
Cardiovascular System “Mataas ang BP ko, highblood kasi ako.” as verbalized by the patient.
“Yung sakit parang lumalakad sa kanang bahagi ng dibdib ko” as verbalized by the patient
Gastrointestinal System “Wala naman masakit sa tyan ko, pag lang madudumi ako” as verbalized by the patient.
“Hindi ako makakaen ng maayos dahil mapait ang panlasa ko” as verbalized by the patient.
Genitourinary System “Wala naman masakit pag umiihi ako. ” as the patient.
Musculoskeletal System “Wla naman masakit s mga kasukasuan ko, wla din ako rayuma” as verbalized by the patient.
Neurologic system “Nanghihina lang ako, pero kaya kong maglakad mag isa at hindi ako nahihirapang bumalanse” as verbalized by the patient.
Endocrine system “Di ko nga alam na may diabetes ako e, sinabi lang ng doctor meron na daw ako.” as verbalized by the patient.
Results from an increase left ventricular and left atrial pressures, which cause excessive accumulation of fluid in interstitial and alveolar spaces. Pulmonary artery pressures will also be elevated. Treat with vasodilators and ACE inhibitors to decrease afterload
Early sign of left ventricular failure that is the result of a compensatory effort to increase cardiac output. Tachycardia will continue at increasing rates if left ventricular failure persists. Treat with digitalis to increase the heart’s contractility and rate.
CLINICAL PATHWAY
Left sided CHF Ride Sided CHF
No
No
No
Yes
Yes
Yes Can you hear bibasilar crackles on auscultation of lungs?
Very Specific sign of right ventricular failure, resulting from increased venous pressure. This increased pressure will also be reflected in increased central venous pressure. Treat with diuretics to decrease blood volume and decrease venous pressure
Is jugular venous distention present?
Is the heart rate over 100 beats/min?
Early finding in left ventricular failure but will persist as failure progresses. It occurs as the left ventricle becomes less compliant.
This occurs because the left ventricle dilates in order to increase ventricular contraction and emptying.
Results from reduced perfusion to the kidneys when renal perfusion is reduced, the blood urea nitrogen rises but the creatinine level in unaaffected
Figure 1-1 Clinical Manifestations of Left sided and Right Sided CHF
Physical AssessmentAugust 30, 2010
Vital Signs
T: 36.2°
RR: 26 breaths/min
PR: 111 beats/min
Height: 5’3”
Weight: 46kg
Bp: 140/90 mmHg
BMI: 17.88
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes Can you hear an S3 or summation gallop when you auscultate the heart?
Is the point of maximal impulse enlarged or shifted laterally to the left?
Is there a parasternal heave?
Is the blood urea nitrogen increased while the creatinine is normal?
Is ascites present?
Is the liver enlarged?
Is the hepatojugular reflex is present?
Is there a measurable weight gain in a short period?
This occurs because the right ventricle dilates in order to increase ventricular contraction and emptying.
Results from fluid accumulation in the abdomen.
Hepatomegaly is due to congestion of the liver with venous blood
Results from the inability of the right ventricle to handle the increase in pressure and venous return.
Results from fluid retention
Treat with diuretics to decrease blood volume and venous pressure
Yes
No
Analysis: According to Black, a BMI of less than 18.5 is categorized underweight for less than
desirable weigh for height.(Medical surgical Nursing by Black)
General Survey:
We received patient awake on bed in high-fowlers position. Conscious and coherent.
With IVF of PNSS 1LXKVO located at left metacarpal vein, intact and infusing well. With Foley
catheter connected on a urine bag containing 1200ml. With oxygen tank at bedside and is
being used when needed. The patient wears dress suitable for the temperature. Pale looking
and body weakness noted.
BODY PART and
ASSESSMENT
TECHNIQUE NORMAL FINDINGS
ACTUAL FINDINGS
ANALYSIS
SkinSkin color
Uniformity of skin color
Assess edema
Skin lesions
Inspection
Inspection
InspectionPalpation
InspectionPalpation
Varies from light to deep brown; from ruddy pink
to light pink; from yellow overtones
to olive
Generally uniform except in areas exposed to the sun; areas of
lighter pigmentation in
dark skinned people
No edema
Freckles; some birthmarks, no
abrasion or other lesions
Deep Brown color
Uniform in color except in areas exposed
to sunlight
No edema
No lesions or abrasions
According to KOZIER skin color varies from
race. Asian people have a deep brown
color. (Fundamentals of Nursing p.540)
According to KOZIER some areas have
lighter pigmentation such as palms, lips,
nail beds in dark skinned people.
(Fundamentals of Nursing p.538)
According to KOZIER a normal skin doesn’t show swollen, shiny,
taut, and tends to blanch the skin color.
(Fundamentals of Nursing p.3535)
According to KOZIER skin lesions are those that appear initially in
response to some change in the external
Skin moisture
Skin temperature
Skin turgor
Inspection
Palpation
Palpation
Moisture in skin folds and the
Axillae
Uniform; within normal range of
temperature
When pinched, skin springs back to previous state
Dryness and flaky
Cold, clammy skin
The skin moves back slowly
on internal environment of the
skin. (Fundamentals of Nursing p.539)
According to KOZIER the skin is dry and
flaky because sebaceous and sweat glands are less active
in elderly.Excessive Dryness
indicate dehydration(Fundamentals of
Nursing p.539)
According to D’Amico and Barbarito localized coolness results from decreased circulation due to vasoconstriction or occlusion which may occur from peripheral arterial insufficiency.
According to KOZIER in elders, The skin takes longer to return to its natural shape after
being pinched between the thumb
and finger.Due to the normal loss
of peripheral skin turgor in elders
(Fundamentals of Nursing p.540)
Hair
Hair Color
Evenness of growth over
the scalp
Inspection
Inspection
Asian race hair color are black
Evenly distributed hair
Hair patches in grayish color.
Evenly distributed hair over the scalp
According to D’Amico and Barbarito, In elders, graying
patches in hair color is normal, it is due to aging process. (An
Introduction to Health & Physical Assessment in Nursing pp. 890. 1st
Edition)
According to D’Amico and Barbarito, the amount of hair varies with age, gender, and overall health. Healthy hair is evenly distributed (An
Hair thickness of thinness
Hair texture and oiliness
Presence of infections or infestations
Amount of body hair
Inspection
Inspection
InspectionPalpation
Inspect
Thick hair
Silky, resilient hair
No infection or infestations
Variable
Thick hair
Rigid; Oily; Dry hair;
Disheveled
No visible infestations
and infection
Variable
Introduction to Health and Physical Assessment in Nursing p. 206)
According to D’Amico and Barbarito, Hair
maybe thick and thin or fine and may
appear straight, wary and curly (An
Introduction to Health and Physical
Assessment in Nursing p. 206)
According to D’Amico and Barbarito,
Disheveled hair indicates lack of care.
(An Introduction to Health & Physical
Assessment in Nursing pp. 890. 1st Edition)
According to KOZIER a normal hair has no sores, lice & nits. (Fundamentals of Nursing pp.541)
According to KOZIER because abnormal hairiness indicates
hirtuism. (Fundamentals of
Nursing p.541)Nails
Fingernail plate
Fingernail and toenail texture
Fingernail and
Inspect
Inspect
Inspect
Convex curvature; angle
of nail plate about 160°
Smooth texture
Dark-skinned
Convex curvature
Rough texture
Pallor in color
According to KOZIER the nail plate is
normally colorless and a convex curve. The
angle between the nail and the nail bed is
normally 160 degrees. (Fundamentals of
Nursing p.542)
According to KOZIER in elders, the nails grow more slowly, thick and rough. (Fundamentals
of Nursing p.542)
According to KOZIER
toenail bed color
Tissues surrounding
nails
Blanch test of capillary refill.
Inspect
Test
clients may have brown or black pigmentation in
longitudinal streaks
Intact epidermis
Prompt return of pink or usual
color generally less than 2
seconds
Intact epidermis
Slow capillary refill of about 4
sec.
pallor may reflect poor arterial circulation (Fundamentals of
Nursing p.542)
According to KOZIER the tissue surrounding the nails is normally
intact epidermis. (Fundamentals of
Nursing p.542)
According to KOZIER slow rate of capillary
refill may indicate circulatory problems.
(Fundamentals of Nursing p.542)
HeadSize, shape,
and symmetry
Nodules, masses and depression
Facial features
Edema and hollowness
Symmetry of
Inspect
Inspect
Inspect
Inspect
Inspect
Rounded; Normocephalic
Smooth, uniform consistency; absence of
nodules and masses
Symmetric; symmetric facial
movements
No visible for sunken eyes; no
edema
Symmetric facial
Rounded; Normocephalic
No masses, no signs of
depression; no nodules
Symmetrically aligned; no
increase facial hair
No edema; no sunken eyes
Symmetric facial
According to KOZIER normal head size is
referred to as Normocephalic.
(Fundamentals of Nursingp.544)
According to KOZIER normal skull is free
from Sebaceous cysts; a local deformities
from trauma(Fundamentals
of Nursing p.544)
According to KOZIER normal facial feature
doesn’t have and increase facial hair,
thinning of eyebrows, asymmetric features,
exopthalmos, myxedema facies and
moon face. (Fundamentals of
Nursing p.545)
According to KOZIER any disorders can cause a change in facial condition.
(Fundamentals of Nursing p.540)
facial movements
movements movementsAccording to D’
Amarico and Barbarito Cranial nerve III, IV,
and VI control movement of the eye.
Cranial nerve VII controls movement of
the face (An Introduction to Health
and Physical assessment in Nursing
p.248)
Eyes and VisionExternal Eye
Eyebrows
Eyelashes
Eyelids
Bulbar conjunctiva
Palpebral conjunctiva
Inspect
Inspect
Inspect
Inspect
Inspect
Hair evenly distributed; skin
intact; symmetrically aligned; equal
movement
Equally distributed;
curled slightly outward
Skin intact; no discharge; no discoloration;
Lids close symmetrically;
bilateral blinking;
Transparent; capillaries sometimes
evident; sclera appears white (yellowish in dark-skinned
clients)
Shiny; smooth; pink
Hair evenly distributed;
equal alignment and movement of
eyebrows
Equally distributed and curled outward
Skin intact; no discharge; no discoloration;
lids close symmetrically;
bilateral blinking
Transparent; no lesions; evidence of capillaries
Pale conjuntiva
According to KOZIER normal eyebrow shows no loss of hair, scaling
and flakiness of the skin. (Fundamentals of
Nursing p.549)
According to KOZIER normal eyelash is curled outward to
protect the inner eye. (Fundamentals of
Nursing p.547)
According to KOZIER normal eyelids have no
discharge, redness, swelling, flaking; lids
close at the same time in frequent blinking.
(Fundamentals of Nursing p.548)
According to KOZIER normal bulbar
conjunctiva shows free of lesions, and no
evidence of discoloration.
(Fundamentals of Nursing p.548)
According to Taylor’s paleness often results from an inadequate
amount of circulating blood or hemoglobin, causing inadequate oxygenation of the
body tissues.(fundamentals of
Lacrimal sac and
nasolacrimal duct
Cornea
Anterior Chamber
Pupils
Visual AcuityNear Vision/
Distance Vision
InspectPalpate
Inspect
Inspect
Inspect
Test
Snellen’s Chart
No edema or tearing
Transparent; shiny; smooth;
iris is visible
Transparent; no shadows of light
on iris
Black in color; equal in size;
round; smooth; iris flat and round
Able to read print
Normal vision is 20/20; at the 20ft
the client can read the line
numbered 20.
No evidence of tearing; no
edema
Transparent and shiny;
smooth; iris is visible; Arcus senilis is also
visible
Transparent; not cloudy; no
visible of shallow shadows
Black in color; equal in size;
round in shape; no bulging or
iris
Able to read small print in
near distance
20/80
Nursing p.573 )
According to KOZIER normal lacrimal sac
and nasolacrimal duct shows no swelling or
tenderness over lacrimal gland.
(Fundamentals of Nursing p.549)
According to KOZIER in older people, a thin, grayish white ring around the margin
(arcus senilis) may be evident.
(Fundamentals of Nursing p.554)
According to KOZIER normal anterior
chamber show no visible of shallow
shadows because if this is present, it
indicates Glaucoma. (Fundamentals of
Nursing p.550)
According to KOZIER pupils are normally black, round, and
smooth in borders. Cloudy pupils are often
indicates Cataract. (Fundamentals of
Nursing p.547)
According to KOZIER visual acuity decreases as the lens of the eye
ages and becomes more opaque and loses elasticity.
(Fundamentals of Nursing p.554)
According to Taylor’s the larger the
denominator, the poorer the
vision(Fundamentals of Nursing 5th Edition p.
579)
Ears and Hearing
Auricles and Pinna
External Ear Canal
Inspect
Palpate
Inspect
Color same as facial skin;
symmetrical; auricle aligned
with outer canthus of the
eye
Mobile, firm, no tenderness; pinna recoils after it is
folded
Dry cerumen, sticky; no discharge
Color same as facial skin;
symmetrically aligned; in line
with outer canthus,
Appear to be increase in
size.
Mobile, firm, no tenderness;
pinna recoils to its previous
state
No discharge; dry cerumen
According to KOZIER in elders, The pinna
increase in both width and length, and the earlobe elongates. (Fundamentals of
Nursing p.559)
According to KOZIER normal pinna appears no lesions, flaky, scaly
skin, no tenderness because if there is
tenderness it indicates inflammation or
infection of external ear. (Fundamentals of
Nursing p.556)
According to KOZIER In elders, earwax is drier.
(Fundamentals of Nursing p.559)
Gross Hearing Acuity Test
Client’s response to normal voice
tones
Test Normal voice tones audible
Normal voice tones audible
but with a confused behavior
According to KOZIER in elders, conversation can be distorted and
result in what appears to be inappropriate or
confused behavior (Fundamentals of
Nursing p.559)
Nose and SinusesExternal Nose
Nasal septum
Inspect
Palpate
Inspect
Symmetric and straight; no discharge or
flaring; uniform in color
Not tender; No lesions
Nasal septum Intact and in the
midline
Symmetrically aligned and straight; No discharge or flaring; same color as facial
color
No tenderness and no lesions
Nasal septum intact and in the midline
According to KOZIER normal external nose
is symmetrically aligned with a normal
size, no discharge from nares and no presence
of lesions and free from tenderness. (Fundamentals of
Nursing p.560)
According to KOZIER no septum deviated to the right or to the left.
(Fundamentals of
Maxillary and Frontal sinuses
Palpate
No tenderness
No tenderness
Nursing p.561)
According to KOZIER normal maxillary and
frontal sinuses have no signs of any tenderness.
(Fundamentals of Nursing p.561)
Mouth and Oropharynx
Outer Lips
Inner lips andBuccal mucosa
Teeth and Gums
Inspect
inspect
Inspect
Inspect
Uniform pink color; soft; moist; smooth texture
Uniform pink color; Moist; smooth; soft;
glistening; elastic texture
32 adult teeth; smooth; white shiny tooth enamel
Pallor and dry
Pallor
24 permanent teeth; some have black discoloration of the enamel
Pale gums
According to KOZIER in elders, the oral
mucosa may be drier than that of younger persons because of decreased salivary
gland activity. (Fundamentals of
Nursing p.566)According to Taylor’s pallor often results from an inadequate
amount of circulating blood or hemoglobin, causing inadequate oxygenation of the
body tissue. (Fundamental’s of
Nursing p.573)
According to Taylor’s pallor often results from an inadequate amount of circulating blood or hemoglobin, causing inadequate oxygenation of the body tissue. (Fundamental’s of Nursing p.573
According to KOZIER tooth loss occurs as a
result of dental problem; The teeth may show a sign of staining, erosion,
chipping, and abrasion due to loss of dentin
(Fundamentals of
Tongue
Tongue movement
Base of the tongue
Floor of the mouth
Hard and soft palate
Inspect
Inspect
Pink gums; moist; firm texture to
gums; no retraction of
gums
Central position; pink in color; moist; slightly
rough; no lesions; raised papillae
Moves freely; no tenderness
Smooth tongue base with
prominent veins
No masses; no nodules
Light pink, smooth, soft
palateLighter pink hard
palate, more irregular texture
Central position; no lesions
Moves freely; no tenderness
No swelling; no ulceration; with
presence of veins
No masses; no nodules
Soft and hard palate have
same color; no irritations
Nursing p.566)
According to Taylor’s paleness often results from an inadequate
amount of circulating blood of Hgb, causing
inadequate oxygenation of the
body tissue.(Fundamentals of Nursing 5th Edition
p.573)
According to KOZIER a normal tongue is
centrally aligned and a presence of papillae. A
dry tongue indicate fluid deficit
(Fundamentals of Nursing p.564)
According to KOZIER normal tongue
movement shows no restricted mobility. (Fundamentals of
Nursing p.564)
According to KOZIER normal base of the tongue shows no
swelling and ulceration.
(Fundamentals of Nursing p.564)
According to KOZIER normal floor of the mouth shows no swelling and no
nodules. (Fundamentals of
Nursing p.564)
According to KOZIER normal hard and soft palate does not show
any discoloration, irritations, and bony growths (exostoses)
growing from the hard palate. (Fundamentals
of Nursing p.565)
Uvula Inspect Positioned in midline of soft
palate
Positioned in midline of soft
palate
According to KOZIER normal uvula
positioned at midline
Tonsils Inspect Pink and smooth; no discharge
Pink and smooth; no
discharge; no lesions
with no deviation to one side, immobility
may indicate damage to trigeminal nerve or
vagus nerve. (Fundamentals of
Nursing p.565)
According to KOZIER normal tonsils are
pink, smooth in texture, no redness, no
swelling, and no presence of lesions.(Fundamentals of
Nursing p.565)
NeckNeck muscles
Head movement
Lymph nodes
Trachea
Thyroid Gland
Inspect
Observe
Palpate
Palpate
Inspect
Muscles equal in size; head centered
Coordinated, smooth
movements with no discomfort
Not palpable
Central placement in
midline of neck; spaces are equal
in both sides
Not visible on
Equal in size; head centered
Coordinated; no discomfort
Not palpable
In midline placement of neck; spaces
are equal
Not visible
According to D’Amico and Barbarito the neck muscles equal in both
sides and head centered. (An
Introduction to Health & Physical Assessment in Nursing pp. 249 1st
Edition)
According to D’Amico and Barbarito, there
should be no pain and no limitation of movement. (An
Introduction to Health & Physical Assessment in Nursing pp. 249 1st
Edition)
According to Taylors the lymph nodes are
generally not palpable, if palpable, they should be small,
mobile, smooth & not tender. (Fundamentals
of Nursing pp.584)
According to Taylors the trachea is normally
midline at the suprasternal notch, is palpated for alignment
& position. (Fundamentals of Nursing Taylors 5th
Edition pp. 583)
According to Taylors
inspection the thyroid gland is normally not palpable.
It should have no enlargement, masses
& nodules. (Fundamentals of Nursing Taylors 5th
Edition pp. 583)
Thorax and Lungs
Posterior thorax
Posterior thorax
Posterior thorax
(for respiratory excursion)
Posterior thorax
(for tactile fremitus)
Posterior thorax
Inspect
Palpate
Respiratory excursion
Palpate
Percuss
Auscultate
Symmetrically equal both sides
Chest wall intact; no tenderness; no
masses
Full and symmetric chest
expansion
Bilateral symmetry of
tactile fremitus; fremitus is heard most clearly at the apex of the
lungs
Resonate, except over scapula
Vesicular and bronchovesicular
Symmetrically equal in size
and shape both sides
No lumps or bulges; no tenderness
Full and symmetric
chest expansion
Tactile fremitus equal
Resonate
Bronchovesicular sound
According to Taylors the color should be
even & consistent with the color of the
patient’s face. The shape or contour
should have a downward equal slope
at the rib cage. The chest should be
symmetric w/ the transverse diameter
greater than the anteroposterior
diameter (Fundamentals of Nursing Taylors 5th
Edition pp. 586)
According to Taylors The skin of posterior
thorax should be warm & should not be
tender; Free from masses.
(Fundamentals of Nursing Taylors 5th
Edition pp.586)
According to Taylors, The Thorax should
expand symmetrically. (Fundamentals of Nursing Taylors 5th
Edition pp. 586
According to Taylors, equal bilateral mild vibratory sensations
are palpated. (Fundamentals of Nursing Taylors
According to Taylors, The sound is hollow, loud, and low in pitch
& of long duration. (Fundamentals of Nursing Taylors 5th
Edition pp. 586)
Anterior Thorax
Trachea
InspectPalpate
Auscultate
breath sounds
Breathing pattern is quiet, rhythmic
and effortless respirations; No
chest pain
Bronchial and tubular breath
sounds
Shortness and Difficulty of breathing;
High pitch and soft
According to D’ Amico and Barbarico are
medium in loudness and pitch. (An
introduction to Health and Physical
Assessment in Nursing pp.377)
According to Black dyspnea and
orthopnea often occur in left sided CHF due
to Increase distribution of blood to the
pulmonary circulation/preload. (Medical - Surgical Nursing p. 1655)
According to Black fine crackles a discontinue,
non musical, high pitch. Soft and brief associated with left
CHF. During inspiration, the resulting vibration in the airway causes a
discrete, sharp sound of very short duration
(Medical - Surgical Nursing p. 1654)
Cardiovascular
Heart Inspect
Auscultate
No pulsation; no lift or heave
S1: Usually heard at all sites,
usually louder at apical area
S2: Usually heard at al sites.
Usually louder at base of the heart
Systole: silent interval; slightly shorter duration than diastole at
normal heart rate
No pulsation; no lift or heave
Increase intensity;
Presence of S4 and S3;
summation gallop; Cardiac
Murmurs.
According to Kozier indicates enlargement and over activity of left ventricle (Fundamentals of Nursing p.583)
According to Black due to increased pressure
beyond the valve. Higher closing
pressure occur and resulting in a louder A2 (the closing sound of
aortic valve). The combined presence of
S3 and S4 produce summation gallop (S7)
because the left ventricle becomes less compliant. (Medical -
Carotid artery
Jugular Veins
Palpate
Inspect
(60-90 bpm)
Diastole: silent interval, slightly longer duration than systole at
normal heart rate
Symmetric pulse volumes; full
pulsations
Veins not visible
Increase pulse volume
Veins visible
Surgical Nursing p. 1654)
According to Black due to increase distribution of blood in pulmonary circulation (Medical - Surgical Nursing p.
1655)
According to D’Amico and Barbarito the
jugular veins are not normally visible when the client sits upright. The external jugular vein is located over
the sternocleidomastoid
muscle. (An Introduction to Health & Physical Assessment in Nursing pp. 453 1st
Edition)
AbdomenAbdomen
Abdominal contour
Abdominal movements
Inspect
Inspect
Inspect
Unblemished skin; uniform
color
Flat, rounded (convex), or scaphoid; no evidence of
enlargement of liver or spleen;
symmetric contour
Skin uniform in color
Flat, rounded; no evidence of enlargement of liver or spleen; symmetric in
contour
Symmetric movements
According to Taylor’s normally the skin color may be slightly lighter
than exposed area. (Fundamentals of Nursing p. 596)
According to Taylor’s abdomen should be evenly rounded or symmetric without visible peristalsis.
There should be no evidence of
enlargement of liver or spleen. (Fundamentals
of Nursing p. 596)
According to D’Amico
Abdomen for bowel sounds
Liver
Auscultate
Percuss
Palpate
Symmetric movement of respiration;
visible peristalsis; aortic pulsations at epigastric area
Audible bowel sounds; absence of arterial bruits;
absence of friction rub
No evidence of enlargement of
liver
No tenderness
caused by respiration;
aortic pulsations at
epigastric area
Audible bowel sounds;
absence of arterial bruits;
absence of peritoneal friction rub
No evidence of enlargement
No tenderness
and Barbarito, movements can
include pulsations or peristalsic waves.(An Introduction to Health & Physical Assessment in Nursing pp. 530 1st
Edition)
According to D’Amico and Barbarito the
normal bowel sounds are irregular, gurgling, and high pitch sound.
(An Introduction to Health & Physical
Assessment in Nursing pp. 532 1st Edition)
According to D’Amico and Barbarito, upon percussion there are no dullness below the costal margin (liver enlargement). (An
Introduction to Health & Physical Assessment in Nursing pp. 536 1st
Edition)According to Taylor’s sounds are dull over
the liver. (Fundamentals of
Nursing 5th edition p. 596)
According to Taylor’s the abdomen is soft, relaxed and free of
tenderness.(Fundamentals of Nursing p. 596)
Genitalia
Female genitalia
Inspection Foley Catheter connected to
urine bag. Intact; no sign of infection. Urine Bag container:
1200cc
Upper Extremities
Left Upper Inspect Skin is uniform; Skin is uniform; According to D’Amico
Arm
Right Upper Arm
Left Lower Arm
Right Lower Arm
Fingers
Fingernail
Inspect
Inspect
Inspect
Inspect
Test (capillary refill)
No tenderness; no lesions; no masses; no
edema
Skin is uniform; No tenderness; no lesions; no masses; no
edema
Skin is uniform; No tenderness; no lesions; no masses; no
edema
Skin is uniform; No tenderness; no lesions; no masses; no
edema
No clubbing fingernails
Capillary refill at 2 sec
No tenderness; no lesions; no masses; no
edema
Skin is uniform; No tenderness; no lesions; no masses; no
edema
With IVF PNSS 1L x KVO
located at left metacarpal
vein and infusing well
Skin is uniform; No tenderness; no lesions; no masses; no
edema
No clubbing fingernails
Delay Capillary Refill at 4sec
and Barbarito the skin color should match the skin tone of the rest of
the body.(An Introduction to Health & Physical Assessment in Nursing pp.493 1st
Edition)
According to D’Amico and Barbarito the skin is uniform and should
be free from tenderness & edema.
(An Introduction to Health & Physical
Assessment in Nursing pp. 493 1st Edition)
Supplying extra water to a dehydrated
patient or supplying the daily water and
salt needs ("maintenance" needs)
of a patient who is unable to take them
by mouth.
According to D’Amico and Barbarito the skin is uniform and should
be free from tenderness & edema.
(An Introduction to Health & Physical
Assessment in Nursing pp. 493 1st Edition)
According to clubbed fingernails are due to diseases of the heart or lung. Almost any type of lung disease can lead to clubbed fingernails
(Fundamentals of Nursing p.542)
According to Kozier slow rate of capillary
refill may indicate circulatory problems.
(Fundamentals of Nursing p.542)
Lower Extremities
Left Thigh Inspect Similar in color; equal to the right
Similar in color; equal to the
According to D’Amico and Barbarito the skin
Right Thigh
Left Leg
Right Leg
Toenails
Inspect
Inspect
Inspect
Inspect
thigh; no edema; no swelling; no
tenderness
Similar in color; equal to the left thigh; no edema; no swelling; no
tenderness
Similar in color; no edema; no swelling; no tenderness
Similar in color; no edema; no swelling; no tenderness
Clean; Capillary refill at 2 sec
right thigh; no edema; no swelling; no tenderness
Similar in color; equal to the left thigh; no edema; no swelling; no tenderness
Similar in color; no edema; no swelling; no tenderness
Similar in color; no edema; no swelling; no tenderness
Clean; capillary refill is slower
than the normal range.
(4seconds)
is uniform and should be free from
tenderness & edema.(An Introduction to Health & Physical
Assessment in Nursing pp. 493 1st Edition)
According to D’Amico and Barbarito the skin is uniform and should
be free from tenderness & edema.
(An Introduction to Health & Physical
Assessment in Nursing pp. 493 1st Edition)
According to D’Amico and Barbarito the skin is uniform and should
be free from tenderness & edema.
(An Introduction to Health & Physical
Assessment in Nursing pp. 493 1st Edition)
According to D’Amico and Barbarito the skin is uniform and should
be free from tenderness & edema.
(An Introduction to Health & Physical
Assessment in Nursing pp. 493 1st Edition)
According to Kozier slow rate of capillary
refill may indicate circulatory problems.
(Fundamentals of Nursing p.542)
LABORATORY RESULTS
Hematology
It is a series of screening test, which consist of Hemoglobin and Hematocrit. It is used
routinely to screen for, to help diagnose and to monitor variety of condition. It provides a
complete evaluation of all formed elements of the blood. It can supply a great deal of
information necessary to diagnosed hematopoetic system and helps to evaluate the
strategies and prognosis of certain disease.
Laboratory Results: Hematology
August 25, 2010
LABORATORY
EXAM
RESULT NORMAL
VALUES
INTERPRETATION ANALYSIS
Hemoglobin 9.1 Female
12-14 g/dl
-Patient LB has low
hemoglobin level
which indicates
anemia and lack of
oxygen.
Hemoglobin is the
protein molecule
within red blood cells
that carries oxygen
and gives blood its
red color. The
amount of oxygen in
the body tissues
depends on how
much hemoglobin is
in the red cells.
Without enough
hemoglobin, the
tissues lack oxygen,
and the heart and
lungs must work
harder to try to
compensate.
(Medical – Surgical
Nursing 7th edition by
Joyce M. Black pp.
2262)
Hct 0.27 0.37-0.47 -Patient LB has low
hematocrit level
which indicates
anemia.
Hematocrit is a
compound measure
of red Blood cell
number and size. A
decrease in the
number or size of red
cells also decreases
the amount of space
they occupy,
resulting in low
hematocrit. (Medical
– Surgical Nursing 7th
edition by Joyce M.
Black pp. 2263)
WBC 11.5 4.8-10.8 x 10 -Patient LB has high
WBC count which
indicates infection
and tissue necrosis
White blood cells
which also called
leukocytes, defend
the body against
infection. They form
in the bone marrow
and consist of
several different
types and sub-types.
A high WBC count
often means that an
infection is present
in the body. (Medical
– Surgical Nursing 7th
edition by Joyce M.
Black pp. 2263)
Segmenters 80 60-70% -Patient LB has high
percentage of
segmenters indicates
inflammatory disease
or response, tissue
necrosis (myocardial
infarction), basophils
for hemolytic anemias
and bacterial
infection.
Increased in
neutrophils,
basophils,
eosinophils and
monocytes may be
due to acute
coronary syndrome,
bacterial infection
and sometimes
Leukemia. (Medical –
Surgical Nursing 7th
edition by Joyce M.
Black pp. 2263)
Lymphocyte 20 30-40% -Patient LB has low
percentage of
lymphocytes indicates
a very high risk of
infection especially
viral infection.
Lymphocytes are the
primary components
of the body's
immune system.
They are the source
of serum
immunoglobulins
and of cellular
immune response.
As a result, they play
an important role in
immunologic
reactions. All
lymphocytes are
produced in the bone
marrow. Sometimes
drugs can be a factor
to a decreased
lymphocyte counts
such as
corticosteroids and
immunosuppressive
drugs. (Medical –
Surgical Nursing 7th
edition by Joyce M.
Black pp. 2263)
Analysis:
Based on the results taken, the hemoglobin and hematocrit of the patient appears to
be low due to her anemic condition. While the WBC and Segmenter count of the patient
appears to be high, this indicates infection. Lastly, Lymphocytes count suggests a very high
risk of infection.
CHEMISTRY
August 26, 2010
LABORATORY EXAM
RESULT NORMAL VALUES
Interpretation Analysis
FBS 12.84 4.2-6.4 mmol/L Increase An increase in FBS level which indicates hyperglycemia, and a sign of diabetes. . (Medical – Surgical Nursing 7th edition by Joyce M. Black pp. 2263)
Cholesterol 3.07 3.8-6.7 mmol/L Within Normal Range
Uric Acid 9.3 2.5-8.0 mg/dL Increase In humans, uric acid is the major
end product of purine
catabolism in the absence
of urate oxidase.
Increase in Uric acid
levels result in
hyperuricemia. (Medical –
Surgical Nursing 7th
edition by Joyce M.
Black pp. 90)
August 25, 2010
LABORATORY EXAM
RESULT NORMAL VALUES
Interpretation
Analysis
Sodium 131.2 135-148 mmol/L
Decrease Accourding to Black and
Hawks decrease level of sodium
indicates possible
malabsorption
(Medical- Surgical
Nursing, 7th
Edition Vol. 1 pp 782)
Potassium 6.9 3.5-5.3 mmol/L Increase According to Black and
Hawks, increased potassium indicates
hyperkalimia (Medical- Surgical
Nursing, 7th
Edition Vol. 1 pp 782)
August 27, 2010
LABORATORY EXAM
RESULT NORMAL VALUES
INTERPRETAION
ANALYSIS
Potassium 7.55 3.5-5.3 mmol/L
Increase According to Black and
Hawks, increased potassium indicates
hyperkalimia (Medical-
Surgical Nursing, 7th
Edition Vol. 1 pp 782)
Triglycerine 2.39 0.68-1.9 Increase High level of
mmol/L triglycerine indicates
high level of sugar,
alcohol and calories
associated with
diabetes, kidney
disease and liver disease
((Medical- Surgical
Nursing, 7th
Edition Vol. 1 pp 782))
August 29, 2010
LABORATORY EXAM
RESULT NORMAL VALUES
Interpretation
Analysis
Potassium 7.6 3.5-5.3 mmol/L Increase Patient LB has an
increased in potassium
level, it indicates
hyperkalemia,
dehydration, acute or chronic kidney failure,
diabetes or infection. (Medical- Surgical
Nursing, 7th
Edition Vol. 1 pp 782)
August 30,
2010
LABORATORY EXAM
RESULT NORMAL VALUES
Interpretation Analysis
Creatinine 739 50-70 umoL/L Increase High level of creatinine indicates a
disease that affects the
kidney (Medical- Surgical
Nursing, 7th
Edition Vol. 1 pp 782)
Potassium 6.7 3.5-5.3 umoL/L Increase Increased potassium
level indicate hyperkalemi
a.(Medical- Surgical
Nursing, 7th
Edition Vol. 1 pp 782)
August 28, 2010
ARTERIAL BLOOD GAS
Analyte Normal Values Results Interpretation & Analysis
pH 7.35-7.45 7.30 AcidosisPCo2 35-45 40 NHCo3 22-26 17 AcidosisPO2 80-100 75
Analysis:
Metabolic Acidosis
Troponin Test
August 26, 2010
LABORATORY EXAM
RESULT NORMAL VALUES
Interpretation Analysis
Troponin T (-) (-) Troponin is negative
She/He can still have the narrowings in the heart tubes that have not totally
blocked. (Medical- Surgical
Nursing, 7th
Edition Vol. 1
pp 782)
RADIOLOGY
Chest X – ray
A chest x ray is a procedure used to evaluate organs and structures within the chest
for symptoms of disease. Chest x rays include views of the lungs, heart, and small portions
of the gastrointestinal tract, thyroid gland and the bones of the chest area. X rays are a form
of radiation that can penetrate the body and produce an image on an x-ray film.
CHEST PHYSICAL ASSESSMENT –
RESULTS: Lungs are clear.
Heart is enlarged.
Aorta is lertous.
Diaphragm sulci are intact.
IMPRESSION: Cardiomegaly
Anleromatous Aorta
Analysis:
Patient LB developed cardiomegaly due to Congestive Heart Failure.
SONOGRAPHYUltrasound
Abdominal ultrasound is an imaging procedure used to examine the internal organs of the
abdomen, including the liver, gallbladder, spleen, pancreas, and kidneys. The blood vessels
that lead to some of these organs can also be looked at with ultrasound.
SONOGRAPHIC RESULTS:REQUEST: Whole Abdomen
Liver: The liver is normal in size, shape & echo pattern
No discrete mass or dilated Intrahepatic duct seen
Impression: Normal study of the Liver.
Gallbladder: Wall is not thickened
No Intraluminal echogenicitis seen
Impression: Normal study of the Gallbladder
Common Duct: The common duct measured 0.4cm
Impression: It is normal in caliber
Pancreas: The pancreas is normal in size, shape & echo pattern
No discrete mass lesion seen
Impression: Normal study of the Pancreas
Spleen: The spleen is normal in size & echo pattern
No discrete mass lesion or calcification seen
Impression: Normal study of the Spleen
Kidneys: The right kidney measured 6.3 x 3.1cm while the left kidney
measured 7.3x
4.1cm
Both kidney appears small with diffusely increase
parenchymal echogenicity
No lithiasis or hydronephrosis seen
Impression: Chronic nephropathy, bilateral.
Urinary Bladder: Urinary Bladder was not adequately distended.
Analysis:
Patient LB has Cardiomegaly which can be caused by a number of different conditions,
including diseases of the heart muscle or heart valves, high blood pressure, arrhythmias,
and pulmonary hypertension. Cardiomegaly can also sometimes accompany
longstanding anemia. Also Chronic Nephropathy, a renal disease that can lead to
cardiovascular disease and pericarditis.
ELECTROCARDIOGRAPHY
ECG Sep. 4, 2010
9:30pm
Actual Findings
PR Int.: 271
P/QRS/T Int (MS): 118, 96, 182
QT/QTC Int. (MS): 434, 446
P/QRS/T Axis (Deg): 71,52
MANAGEMENT
I. MEDICAL MANAGEMENT
-DOCTOR’S ORDER
August 26, 2010
7:15pm
Patient LB admitted to MS ward. Dr. Bartolome gave orders of diabetes drugs -
1800kcal/ day to begin in 30 meals & strict aspiration precaution. Dr. Bartolome request for
CBC, Blood type, Na K, HGB, ECG, BUN, Creatinine and 2d Doppler. He ordered PNSS 1L x
16°, ISMN 30mg/ tab OD, Cefoxitin 2g/50 ml IV every 6 hours. He also ordered intermediate
insulin 15 Units, Clonidine 5mcg. tab for BP 130/100, Diphenhydramine 1cap- 5 and to
prepare 2 units PRBC to be transfuse. Other medications ordered; Allopurinol 300mg/tab OD,
Simvastatin 20mg/tab OD in PRN, Ranitidine 50mg Q8 TID, Lactulose syrup 30ml OD. Other
orders; Monitor Vital signs Q2, to be refer and record, monitor Input and Output every shift
to be refer and record and “Monitor CBG”.
7:30pm
Refer of CBG in 255mm/hr.
11:10pm
Patient LB’s blood pressure arise at 160/120, Dr. Bartolome ordered Furosemide
40mg. For chest pain, D50 50cc + 10”u” x 15 x 3 doses. He also ordered diet of no fruits/
juices. For hyperkalemia, he ordered nebulization of salbutamol every 8°. Patient LB hook to
cardiac monitor.
August 27, 2010
1:25am
Patient LB’s heart rate arises to 120bpm and have (+) crackles. Dr. Bartolome ordered
Furosemide 40mg, Isoket drip 15mgtts/hr and Lanoxin 0.125mg slow IV. Monitor vital sign,
input and output Q1 and record. For insertion of Foley catheter and connect to urine bag.
Other medication: Morphine 2mg via IV. For withhold intermediate insulin in the morning.
6:00am
Progress Note: CBG-96mg/dl
10:30am
IVF to follow: PNSS 1L x 16°
Isoket to consume
7:15pm
IVF to follow: PNSS 1L x 16°
August 28, 2010
8:00 am
Dr. Bartolome ordered for a repeat ECG and IVF to follow: PNSS 1L x 16°
5:00pm
Patient has serum potassium of 7.55; ECG peak at T. waves. Dr. Bartolome ordered
calcium gluconate 1 ampule slow IV push, D50, NaCl 8”u” Q6 for 3 doses and after he then
ordered repeat serum Sodium and potassium.
August 29, 2010
7:45am
Dr. Bartolome ordered diet as no fruits. For medication; hold ranitidine and
omeprazole 20mg/tab OD.
2:45pm
IVF of D5050 1 vial +8”u” on D5w to run for 6° for 3 doses.
6:15pm
Continue IVF of PNSS 1L x 16°
August 30, 2010
10:35am
Dr. Bartolome request for Sodium and Potassium and a followed up laboratory results.
3:25pm
Dr. Bartolome ask a service of nephro for evaluation of laboratory results. He ordered
Calcium gluconate 1 ampule slow IV push now, D5050 1vial + 8 “u” of insulin q6 x 3 doses,
MaHCo3 1tab TID, IVF to follow PNSS 1L x 16°
August 31, 2010
7:15am
Continue followed up nephro referral and continue medications ordered by Dr.
Bartolome.
11:00am
Continue IVF PNSS 1L x16°
September 01, 2010
8:00am
Dr. Bartolome ordered repeat serum potassium and a request for creatinine. Continue
IVF to follow D5.03 Nacl 500cc x KVO; Continue medication.
12:00nn
Limit oral intake to 1.5 L/day
Maintain current IVF PNSS x 10ml/ hr
Consume present IVF and shift to heplock
Diet:
- 1800 kcal/ day, 40g CHON of high biologic value (no pork and beef), 2g Na
- 800mg, phosphorus diet, no fruits in diet
- Monitor I & O quantitatively and record pls.
Diagnostics:
ABG:
- Relay labs today: creatinine 1 Ca, K 2D echo with Doppler once stable
Allopurinol 100mg 1 tab OD
- Hold captopril
- No ACE/ ARBS, no NSAIDS
- Start carvedilol 6.25mg/ tab, BID
- Hold furosemide
- Ciprofloxacin 500mg/ tab BID
- Adjust meds for ECC (estimated creatinine clearance)
- Refer for urine output <30ml/hr
- Erythropoietin 4000 “u” 8Q 2x/ week
- Refer accordingly
Progress Notes:
History and Physical Examination received
Awaiting laboratory results
AKL 2° UTI on top of CKD 2° DM nephropathy cardiorenal syndrome
Hyperkalemia probably 2° CKD, drug induced
Hyperuricemia
Will await labs today if patient’s hyperkalimia remains unintractable
Advise patient’s to start hemodialysis
September 02, 2010
8:00am
IVF to follow PNSS 1Lx10cc/hr
September 03, 2010
11:50am
Shift IVF to heplock
6:30pm
For repeat potassium and creatinine. Continue medication.
11:20pm
Dr. Bartolome ordered IVF PNSS 1L x KVO, D50 50 cc + 10 “u” x 3 doses q 1°.
Progress Note: Potassium of 6.64
September 04, 2010
2:00am
Patient LB hook IVF PNSS x KVO with side drip of D50 50cc +10 “u” as ordered by Dr.
Bartolome, shift to heplock
11:30am
Progress Note: Hgt 287 mg/ dl
07:00pm
Patient LB for ECG, repeat sodium and potassium, IVF to follow PNSS x KVO
September 05, 2010
7:05am
Continue IVF PNSS x KVO
2:30am
For repeat CBC
September 06, 2010
6:10am
Dr. Bartolome ordered Amlodipine 5mg 1tab OD and to consume IVF of PNSS x KVO &
shifted to heplock. He ordered to transfer 2 units PRBC to consume. IVF to follow PNSS 1L x
16°
Progress Note: Bp: 140/70 160/90
6:10pm
Progress Note: HGT of 7.4
7:30am
For hemodialysis once with temporary access and inform the Dr. Bartolome.
Hemodialysis preparation and 2 ½ hour every 8 150ml/ mi, and QID 300ml/ min
Progress Note: Discuss the need for hemodialysis with the children. Indication of
uremia, intractable hyperkalimea
September 07, 2010
7:00am
Dr. Bartolome ordered D50 50cc +10 “u” x 3doses
Progress Note: Potassium of 9.74
8:00am
Continue IVF PNSS 1L x KVO. Patient LB for possible transfer to tertiary hospital for
dialysis.
September 08, 2010
8:30am
IVF to follow PNSS 1L x KVO
September 09, 2010
7:00am
Nephro notes
Recommendations:
- Ciprofloxacin to 500g OD per orem
- May remove Foley catheter
- Limit oral fluid intake to ≤ 1L/ day
Diet 1800 kcal/ day
- 20g of Na/ day
- 80mg of Phosphorus/ day
- 50g of CHON of high biologic value
- Diabetic and low fat, low purine diet
*refer for dietician for further instruction
- MGH after blood transfusion of 1 “u” of PRBC, properly type and crossmatch
Progress Notes: Bp 120/ 80 140/80
(-) edema
10:15am
Additional order and hold insulin temporarily
01:00pm
For CT Scan
Progress Note: 160/80
September 10, 2010
8:00am
Repeat CBC 6° prior to Blood Transfussion.
8:30pm
1 unit PRBC secure properly type and Crossmatch, With continue IVF to consume then
disconnect. Dr. Bartolome ordered MGH anytime. Continue medication and advise to follow
up after dialysis.
Progress Note: hgb: 89, hct:0.26
II. NURSING CARE AND MANAGEMENT
a. Assessment/Interventions: Monitor vital signs/oxygenation/Neuro status (report changes in heart and
respiratory rate/patterns as well as changes in LOC). Daily weight (a 2.2 kg weight increase over a 1 day period is considered
significant). Breath sounds (monitor for increased crackles, rhonchi or pulmonary
congestion).
Capillary refill (if greater than 3 seconds, assess for signs of peripheral edema).
The presence of jugular vein distention (jugular vein distention can be a sign of worsening right sided heart failure).
The presence of hepatomegaly (also a sign of worsening right sided heart failure).
The presence of ascites (also a sign of worsening right sided heart failure). EKG changes Evaluate electrolyte levels (sodium, potassium and creatinine) Digoxin levels (if patient taking Digoxin) Pain level (degree, quality, source, location, onset and relieving factors) Intake and Output (monitor effects of diuretic therapy and observe for signs
and symptoms of either fluid overload or deficit) Assess degree of discomfort associated with activity (provide a proper
rest/activity balance. Group nursing interventions when appropriate). Monitor for restless, anxious behavior and promote self care participation. Maintain adequate bowel function (stool softeners such as Colace should be
ordered to prevent constipation).
b. Patient Teaching: The following patient/family education should be provided prior to discharge
andshould also be reiterated at post discharge office visits: Discharge medication regimens Diet (low sodium) Fluid restrictions Activities of daily living Exercise Smoking cessation/avoidance Available community resources/referrals The importance of making and keeping Dr.’s appointments Avoiding infection (flu/pneumovax vaccines) Self monitoring (when to report symptoms or changes such as shortness of
breath, dyspnea, changes in weight [greater than 2.2 lbs over 1-2 days], pedal edema, blood pressure changes, nausea or fatigue).
DISCHARGE PLANNING
M >Remind client to take furosemide, Catapres, Isordil, amlodepine, ISMN, and sucralfate
as prescribed.
>Instruct the relative to follow medication regimen.
E >Encourage the relative to do some exercises like a passive range of motion in
affected and unaffected parts of the body of the client.
T > Educate & instruct the family to monitor the blood pressure and pulse rate before
administering medication.
>Emphasize patient education with intense instruction regarding compliance with
dietary restrictions and medical therapy.
>Require patients to promptly follow up with their primary care physician or
cardiologist.
H >Inform the relative the importance of proper hygiene of the patient from head to toe.
>Educate and instruct the relatives on what proper food to give.
O >Inform the family of the patient to have a regular check-up for the continuity of
treatment.
>Instruct the family of the patient to monitor if there is any sudden change to the
patient and report immediately.
D >Instruct the relative to feed the client on time with nutrition food that is low in
sodium, low in cholesterol, low in fat and give citrus fruits, moderate in fluid intake and
increase fiber diet to improve health.
>Follow the diet prescribed by the doctor.
EVALUATION
The nursing interventions given to the patient has become helpful. Her
pulmonary signs and symptoms were treated. With the latest diagnostic exam done,
the chest x-ray was found clear. But the patient, due to renal impairment as
complication of her CHF and DM II is arranged to undergo hemodialysis.
RECOMMENDATION
Watch out for blood cholesterol because too much cholesterol may cause fatty
deposits to form in arteries—impeding blood flow and increasing the risk for complications,
and limit sodium rich food intake. Lifestyle changes are recommended—including the
nutritional diet such as limiting fats—specially saturated fats, eating fiber rich foods, fish—
rich in omega 3 fatty acids which is good for the heart, and fresh fruits and vegetables,
which contains antioxidants, and vitamins and minerals that help prevent everyday wear and
tear of coronary arteries. Exercise regularly to help make the heart stronger and lower down
blood pressure. Stop smoking or avoid exposure to second hand smoking. Restrain from
drinking alcoholic beverages. Rest in bed until breathing is easier and feel stronger. Then,
slowly return to your normal activities. Get at least 7 hours of rest each night and take naps
when feeling tired. Avoid being stress. Drink medications as prescribed such as diuretics and
heart medications