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Case study Congestive Heart failure, B10FF4F4-D90C-4689-BD6C-A20574132D61…
Case study
Congestive Heart failure
Nursing Diagnosis
1.With hypothyroidism due to the inefficient of he Tricuspid valve.
Evaluate the patient's Volume Overload, such as pitting edema . Weight gain, Dyspnea , Orthopnea, enlarged liver.
Evaluate whether intake / output is balanced.
Take care to limit the amount of water in each day must be less than 1000ml / day.
4.Give diuretics according to doctor's treatment plan Lasix (40mg) 1x2 po PC morning, noon.
Advise patients not to eat out of the hospital and avoid foods high in salty and sodium.
6.Follow Echo results.
Risk of Hypoxia due to reduced O2 gas exchange efficiency.
1.Evaluat e Hypoxia such as respiratory rate, pulse, fingernail color, toes Skin lining Pale green appearance Because of dypsnea, Skin lining Pale green appearance indicates O2 depletion.
2.Fowler'sposition 30c
3.on O2 cannula 5 lpm according to the treatment plan.
4.bed rest
5.Teaches effective coughing
6.Vital Sign every 4 hours
Depletion of daily routine due to world pathology, leaky heart valves.
1.) Evaluate the daily routine of patients with ADL and Motor Power.
2.) Plan to assist in the daily routine of the patient.
3.) Prepare equipment for tooth brushing, toothpaste, basin with water Wipe the patient And prepare clothes, bed sheets, change for patients every morning
4.) Arrange the equipment Or drinking water near the patient
5.) Reduce stimuli If you have to do various activities at the same time
The risk of bleeding easily, difficult to stop from having blood clotting disorders.
Take care to cut nails short. It is advisable not for the patient not to peel or scratch the skin as hard as possible to cause injuries.
Recommend fruits that are high in vitamin C, such as oranges, guava.
In case of nosebleeds Let the patient lie down, squeeze the nose, breathe through the mouth, and place the ice pack on the forehead.
To draw blood, every time you need to press until the bleeding stops, take 5 minutes. Must be clean and dry
Continuously follow up on Lab platelet results.
Evaluate, monitor, and observe bleeding easily and difficult to stop by observing internal bleeding such as blood spots on the skin, scurvy, bloody urine. External bleeding, such as bleeding in the brain Observation of symptoms of lethargy, confusion, gastrointestinal bleeding Vomiting blood Bloody stools.
Anxious about current illnesses
Explain to patients and relatives about health problems, and explain possible risks to the patient and include the doctor's course of treatment.
Give opportunity for patients and relatives to inquire on the question of doubt and to vent their feelings.
Ensure that patients are assisted in performing daily activities.
Take care of the environment to be clean and tidy and set nursing activities that can be done at the same time.
Encourage encouragement and positive energy for patients and relatives.
1.Assess anxiety By observing facial behavior Patient posture Or from the depression assessment.
6.There may be complications due to hypokalemia.
Observe the symptoms of fatigue, weakness, heartburn, nausea, vomiting, flatulence.
Record vital signs every 2–4 hours.
Make the patient to rest in bed for activities. As needed Beware of accidents
Advise relatives to provide the patient with fruits that are high in potassium, such as bananas, grapes.
Record the input and output. Since patients are given diuretics, they can lead to loss of potassium in their urine.
Administer drug treatment according to doctor's treatment plan, KCL 30ml oral x 1dose.
Follow-up Electrolytes Electrocardiogram.
7.There is anemia due to a decrease in heart performance.
1) Evaluate and observe any abnormal symptoms indicating anemia, such as asthma, fatigue.
2) Vital signs are measured to assess anemia that can cause oxygen depletion.
3) Take care of rest and determine activities that can be performed according to the severity of the anemia. To reduce the need for oxygen in the body
4) Ensure that they get foods that are essential for red blood cell formation, such as iron, protein, vitamin C, foliamine, and soft and easily digestible food.
5) Follow up on laboratory results Hct, Hb values
Pathology
Patient 62 years old have heart valve conditions
Tricuspid valve
Blood from Rt.ventricle go back Rt.atrium,flow back Superior and inferior vena cava
Decreased blood supply to the lungs
Blood to the heart and lungs left atrium,
left ventricle lower
Cardiac output lower
The blood supply to various part of the body
is reduced
Congestive heart failure
Hypoxia
Hypervolemia
