A Case Study on the Concept of Oxygenation CONGESTIVE HEART FAILURE…

Question A Case Study on the Concept of Oxygenation CONGESTIVE HEART FAILURE… A Case Study on the Concept of OxygenationCONGESTIVE HEART FAILUREMrs. J.M., a 75 year old widow, noticed that she felt tired a lot lately stating, “Mabilis tsaka madalas na akong mahapo kahit konti lang ung ginagawa ko”. Her son even commented that his mother seemed to lack interest in usual activities and that she seemed to be a bit confused in her responses to everyday situation. He also noticed his mother has difficulty sleeping but feels better with 2 pillows at her head. Mrs. J.M. had developed a non-productive cough, so her son made an appointment with her healthcare provider. The nurse assessed Mrs. J.M. 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 her last check-up. Suspecting that Mrs. J.M. may be experiencing heart failure, the nurse consulted and referred her to a physician. The physician agreed with the nurse’s assessment and Mrs. J.M. was prescribed digoxin, furosemide (Lasix) and potassium chloride 40 mEqs (IV), Oxygen at 3Lpm via nasal canula to maintain O2 Saturation at above 93% As they were preparing documents for Mrs. J.M. to be admitted in the ward for further diagnosis and monitoring, the nurse gathers data for initial interview. Her son verbalized that his mother was diagnosed with Diabetes Mellitus Type II 15 years ago and hypertension 6 years ago. She 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 o BNP: 453pg/mL Troponin (+) o 2D Echo – waiting for results • BUN & Creatinine – within normal limits • CBC – RBC 4.8/ mcL o WBC- 9,000/ mcL  FORMAT FOR CASE ANALYSIS THROUGH CONCEPT MAPPINGINTRODUCTION AND OBJECTIVES PATHOPHYSIOLOGY AND MANAGEMENT B. Narrative Discussion III. DISCHARGE PLANNING IV. RELATED NURSING THEORY V. REVIEW OF RELATED STUDIES/LITERATURE VI. REFERENCES Note: This is a simplified schematic diagram of the disease process. This will vary according to the symptomatology (numbers and nature of signs and symptoms) For the above format, please be guided with the description of the parts of the case analysis. INTRODUCTION – shall include objectives, brief definition of the disease, statistical data (global, national, and local), and RT implications to education, practice, and research.ETIOLOGY – should indicate factors contributing to the condition or disease process of the patient DISEASE PROCESS – will indicate mode of entry (if applicable), organs involve or affected; described in diagram and narrative form the pathogenesis of a disease, the biological mechanism (or mechanisms) progress of disease showing its morphological features or that leads to the diseased state. SYMPTOMATOLOGY – can be multiple. Should include the positive and negative pertinent findings.Each sign and symptom should yield to a specific assessment/diagnostics and possibly management. DIAGNOSTICS/ LABORATORY CONFIRMATORY TEST – should be based on the signs and symptoms and the specific stage of disease process, and this will include a. Physical Assessment of the affected system. b. Medical Diagnostics may include IDEAL or potential diagnostic procedures. c. Nursing Diagnosis (NANDA) MANAGEMENT a. Medical – includes procedures ( ex. NGT, intubation, suctioning, BT,etc.) and drugs (including IV, parenteral feeding, ) b. Surgical – if there is c. Nursing – nursing interventions based on the formulated nursing diagnosis  PROGNOSIS The predicted outcome of a disease and the chance of recovery if treatment is applied and if no treatment has been initiated to the patient. DISCHARGE PLANNING / CP REHABILITATION – interdisciplinary approach to continuity of care and to include cardiopulmonary rehabilitation if applicable. REVIEW OF RELATED STUDIES/LITERATURES – journals or articles containing related literatures or studies from authentic source not later than 5 years from publication. REFERENCES – in APA format, not later than 5 years Health Science Science Nursing FUNDS NR224 Share QuestionEmailCopy link Comments (0)