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Heart failure with preserved ejection fraction (HFpEF) with Cellulitis at…
Heart failure with preserved ejection fraction (HFpEF) with Cellulitis at left forearm
General Information
Diagnosis
Heart failure with preserved ejection fraction (HFpEF) with Cellulitis at left forearm and surgical site
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Chief complain
There was bleeding at the Pace maker and there was redness on the left arm, pain, swelling, redness, heat, 1 week before coming to the hospital.
- Thai male, Age 83 year old
- Date of admission in the hospital: 25 September 2020, Time 14.30 min.
- ward: Critical Care Unit 9/1
Present illness
-1 week before going to the hospital There is bleeding at the Pace maker and there is redness on the left arm, pain, swelling, redness, heat, and pain. The patient denies a concussion accident. Enough to do daily activities Panting a little Does not hurt angina
-1 day before coming to the hospital There was still a little bit of bleeding at the Pace maker and there was redness on the left arm, pain, swelling, redness, more heat, more movement and more pain.
past illness
- Diabetes Mellitus (DM) approximately 45 years of age, 5 years later it was found to be Hypertension (HT), Benign Prostatic Hyperplasia (BPH), Chronic Kidney Disease (not dialysis).
- Refuse to use medicine, decoction set, medicine pot, bolus pot
- refuse to smoke
- Reject drug allergy, food allergy
- Used to drink alcohol, started drinking since the age of 20 years, drinking a bottle a day every day And quit drinking at the age of 70
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General appearance
The first 83-year-old Thai male patient Good level of consciousness.
- Head and Face: Symmetry,normal shape ,no mass and lesions.
- Hair/Scalp: white color,normal distribution,no scalp dry,no lesion.
- Eyes: Normal eye movement, - No ptosis, no Squint, Conjunctiva mild pale, Pupil round and equal diameter 3 mm. Rt = Lt , RTL Both eyes
- Ear: Normal hearing, xternal ears no mass,no lesion ,both ears canal normal , no abrasion or inflammation
- Nose: External configuration normal ,mucous membrane pink . Turbinate not enlarged, not injected , no discharge. Septum not deviated.
- Mouth: Buccal mucous membrane pink, no cyanosis Oropharyx not injected, no dental
- Neck: No stiffness of neck, Trachea in midline,No engorgement of neck vein.
- Chest: Normal chest contour, there is a surgical wound, put a pacemaker on the left chest wall, covered with Gauze pad, no bleeding.
- Abdomen: Normal abdomen contour , no distension ,no bulging,no superficial vein dilatation, no surgical scar, Bowel sound 4-6 / min . No tenderness, rebound tenderness
- Arm: left arm is swollen, red when touched, the patient will cry for pain,
: right arm is labeled on heparin lock. Able to move normally.
- Leg: right leg on heparin lock, moving nnormally
: left leg moving normally The skin is not cold, the feet do not have a wound.
- The first Vital sign received (28/09/2020, Time 07.30 min)
-Temperature 36.8 ° C
-Heart rate 95 bpm.
-Respiratory rate 20 bpm.
-Blood Pressure 132/62 mmHg.
-O2 Sat 98%.
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Nursing diagnosis
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2.Volume Overload Due to loss of kidney function to filter. Causing congestion of waste products in the body
- Follow-up of laboratory examination results, including BUN, Cr, GFR (CKD-EP)
- Measure vital signs every 4 hours.
- Observe the symptoms of panting, unable to lie down and assess the swelling.
- Take diuretic Lasix 250 mg v drip in 6 hr according to doctor's treatment plan
- View and recommend relatives to restrict salty foods, such as those containing salt, fish sauce, soy sauce, fermented foods, etc.
- Record water in-out every 8 hours and observe urine on the carriage. Should be more than 200 ml.
- There is a chance that the body's tissues are not getting enough oxygen. Due to ineffective gas exchange
- Set the head position 30 degrees high.
- Evaluate the level of consciousness continuously every 4 hours.
- Record and track vital signs every 4 hours.
- Assess the skin appearance, humidity, coldness and color.
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5.Low cardiac output Due to the compression performance of the heart muscle decreases from the presence of atrial fibrillation.
6..Record V/S, O2sat q 1 hr. to assess BP, HR if BP < 90/60 mmHg. HR> 120, < 60 bpm Give a notify doctor.
- Assess the symptoms If symptoms chest pain occur, immediately notify the doctor.
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- Assess the signs and symptoms of perfusion insufficiency: decreased consciousness, confusion, agitation, sobriety, cyanosis, cold, capillary refill >3 Second, the distal pulse light, fast Less urine output 0.5-1 cc/kg/hr.
3.Take care and observe volume overload from low cardiac output such as edema, dyspnea, orthopnea, lung: crepitation.
- Bed rest care to reduce O2 consumption of the heart muscle.
7.Lasix 120 mg iv according to treatment plan and monitor for side effects such as hypokalemia restrict fluid 1,000 cc / day, retrict Na <2 g / day.record I / O keep -ve balance
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