Question

After 1 month in the NICU, he noticed that he felt tired a lot lately stating, “Mabilis tsaka madalas na akong mahapo kahit konti lang ung ginagawa ko”. His son even commented that his father seemed to lack interest in usual activities and that he seemed to be a bit confused in his responses to everyday situation. He also noticed his father has difficulty sleeping but feels better with 2 pillows at his head. The nurse assessed JC and noted crackles in both bases of her lungs, a lower than normal blood pressure and slight tachycardia (based on previous consults), and a slight weight gain in seven (7) months since his last check-up. Suspecting that JC may be experiencing heart failure, the nurse consulted and referred him to a physician. The physician agreedwith the nurse’s assessment and JC was prescribed digoxin, furosemide (Lasix) and potassium chloride 40 mEqs (IV), Oxygen at 3Lpm via nasal canula to maintain O2 Saturation at above 93%. His son verbalized that his mother was diagnosed with Diabetes Mellitus Type II 15 years ago and hypertension 6 years ago. He was then prescribed Metformin 500mg/ tab twice a day and Captopril 25 mg/ tab once a day. Physical Examination reveals:
Vital signs:
• BP: 110/ 70
• T: 36.8 degrees Centigrade
• PR: 89 BPM
• RR: 25 BPM
• Weight: 76 kg.
• GCS: E- 4; V- 4; M- 6 (disoriented) 14/15
• Crackles at the base of the lungs
• (+) S4 sounds
• Bipedal Edema grade 2+
• Muscle strength of 3/5 on both lower extremities
• Physician diagnosed patient with Class III Heart Failure
DIAGNOSTIC TESTS
• Cardiac markers
• BNP: 453pg/mL Troponin (+)
• 2D Echo – waiting for results
• BUN & Creatinine – within normal limits
• CBC - RBC 4.8/ mcL
• WBC- 9,000/ mcL
• Platelet count- 320,000/ mcL
• Sodium- 139 mEq
• Potassium- 2.9 mEq
• FBS- 7 mmol/L
• HbAIC- 6.5 %
• Lipid profile, Uric acid- within normal range
• Chest Xray – Cardiomegaly with right and left ventricular hypertrophy, fluid in lower lung fields.
During his stay, diagnostic examination work up was performed and with the following orders and treatments:
• Vital signs every 4 hours
• Strict Intake and output
• Weigh patient daily pre-breakfast, post-void
• IVF of PNSS 1 L to run on KVO
Medications:
• KCl 40mEq IV (incorporated to 1 L of PNSS) run for 24 hours
• Digoxin 0.25 microgram one a day
• Furosemide (Lasix) 40 mgIV every 8 hours
• Metformin 500mg/ tab twice a day and
• Captopril 25 mg/ tab once a day.
• Oxygen maintained at 3 LPM via nasal canula
• Nebulization of Normal saline every 12 hours
• Chest physiotherapy
• Complete bedrest without bathroom privileges
• Capillary blood glucose (CBG) monitoring daily
• Diet: Low salt, low fat

Ordered treatment and procedures:
• CBC, Sodium, Potassium
• IVF shifted to heparin/ saline lock
• Oxygen at 1LPM via nasal canula (well tolerated)
• Maintained on low salt, low fat, with banana
• Up and about, with minimal bathroom privileges (with assistance)
• Prepare discharge summary

Guide questions:
1. Provide 5 nursing responsibilities related to the laboratory and diagnostic examination including the procedures and medications?
2. What are the treatments and procedures performed during the course of Hospitalization? Provide the rationale.
3. List 5 medication classifications and the rationale for using each. (Drug Study Format)
4. Identify at least three (3) priority nursing problems and formulate 3 nursing care
plans with appropriate objective and evaluation of care. (with Scientific Rationale on the Nursing Diagnosis and Rationale on the Interventions)
5. Enumerate 5 appropriate discharge plan and health teaching for your patient. Provide the rationale.
6. Research on readings or journal of current issues related to the case mentioned and provide your reflection. Cite your references.

Answer 1

1.NURSING RESPONSIBILIES

• Monitoring of vital signs for a patient with heart failure and the likely findin2gs
• Life style modification for the patient
• Diet modification for the patient
• Administration of medications and oxygen therapy
• Coordination of the diagnostic examinations for efficient clinical management of the patient with heart failure
• Provision of counseling and health education to the patient and family
• Applications of ethical principles in caring for the patient with heart failure

2. TREATMENT AND PROCEDURE USED DURING HOSPITALIZATION

TREATMENT

• KCl 40 mEq IV for 24 hours
• Digoxin 0.25mg once a day
• Furosemide 40 mg IV every 8 hours
• Metformin 500 mg /tab twice a day
• Captopril 25 mg/tab once a day
• oxygen maintained at 3 LPM via nasal canula
• Nebulization of normal saline every 12 hours
• Chest physiotherapy
• Complete bedrest without bathroom privileges
• Capillary blood glucose monitoring daily
• Diet: low salt, low fat9

PROCEDURES

• Cardiac markers
• BNP: 453 pg/mL troponin(+)
• 2D echo
• BUN and creatinine
• CBC-RBC 4.8/mcL
• WBC -9000/mcL
• platelet count-320,000/mcL
• Sodium-139mEq
• Pottasium-2.9mEq
• FBS-7mmol/L
• HbA1C-6.5%
• Lipid profile, uric acid
• Chest xray

3.MEDICATION CLASSIFICATIONS

1.Digitalis , such as digoxine

• To improve contractions of the heart muscles and cardiac output

2.Diuretics, such as furosemide

• To enhance the elimination of excess fluid from the body abd by so doing to prevent systemic edema such as pulmonary edema.

3. Angiotensin converting enzyme inhibitors

• eg: lisinopril, enalapril
• These type of medications prevent the conversion of angiotensin l to angiotensin ll from the juxtra glomerulo apparatus of the kidneys.

4.Cardioselective beta blockers

• eg: metoprolol, proponolol

5. Calcium channel blockers

• eg; amlodipine, nifedipine

6. Angiotensin receptor blockers

• eg: telmisartan, valsartan

4. NURSING INTERVENTIONS AND RATIONALE

• Palpate peripheral pulse- decreased cardiac output may be reflected in diminished radial, popliteal, dorsalis pedis and post tibial pulses. pulses may be fleeting or irregular to palpation and pulsus alternans may be present
• Monitor BP- In early ,moderate, or chronic heart failure, BP may be elevated because of increased SVR. In advanced HF, the body may no longer be able to compensate and profound hypotension may occur.
• Monitor urine output, noting decreasing output and concentrated urine- Kidneys respond to reduced cardiac output by retaining water and sodium. Urine output is usually decreased during the day because of fluid shifts into tissues but may be increased at night because fluid returns to circulation when patient is recumbent

NURSING PLANS

• Decreased cardiac output
• Activity intolerance
• Excess fluid volume
• Risk for impaired gas exchange
• Risk for impaired skin integrity
• Deficient knowledge
• Acute pain
• Ineffective tissue perfusion
• Hyperthermia
• Ineffective breathing pattern
• Ineffective airway clearance
• Impaired gas exchange
• Ftigue