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Pamantasan ng Cauyao
Katapatan Homes, Brgy. Banay-banay, Cabuyao, Laguna
COLEGE OF NURSING
A CASE STUDYon
CONGESTIVE HEART FAILURE, CHRONIC KIDNEY DISEASE, ANEMIA, PLEURAL EFFUSION
In Partial Fulfillment
Of the Course
RLE 106
Submitted to:
Minerva Sanchez, RN RM MAN
Submitted by:Abo-Abo, Jamie Joyce Darlene
Dela Cruz, RachaneeOa, Cherry Anne
Palomares, KrishnaVerzola, Jeri Mei
RLE 106 GROUP II-B
Mon. Wed. 02:00 pm- 10:00 pm
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INTRODUCTION
BACKGROUND OF STUDY
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The group chose the case Chronic Kidney Disease with complications of Anemia, Congestive Heart Failure and
Pleural Effusion since we are dealing with alteration of endocrine and renal disorders in NCM 106 lecture. We are willing
to do this case to challenge our minds in analyzing the problem, enhancing and gaining new knowledge that may bring
new leanings for the members of the group.
GOAL OF THE STUDY
After this case study, we will be able to know more about chronic Kidney Disease including its causes, prevention
and treatments in the occurrence of this disease.
OBJECTIVES:
To explain the meaning of Chronic Kidney Disease and how it come up to its complications.
To trace the Pathophysiology behind the occurrence of CKD.
To enumerate the different signs and symptoms of CKD.
To formulate and apply nursing care plans by utilizing the nursing process.
To learn new clinical skills as well as to sharpen our minds in the management of patient with CKD.
OVERVIEW OF THE DISEASE: CHRONIC KIDNEY DISEASE
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Chronic kidney disease is the slow loss of kidney function over time. The main function of the kidneys is to remove wastes
and excess water from the body. Chronic kidney disease (CKD) slowly gets worse over time. In the early stages, there may be
no symptoms. The loss of function usually takes months or years to occur. It may be so slow that symptoms do not appear until
kidney function is less than one-tenth of normal.
SCENARIO:
Kidney diseases, especially End Stage Renal Disease (ESRD), are already the 7th leading cause of death among the
Filipinos. One Filipino develops chronic renal failure every hour or about 120 Filipinos per million populations per year. More than
5,000 Filipino patients are presently undergoing dialysis and approximately 1.1 million people worldwide are on renal replacement
therapy. Reliable estimates reveal that the number of these patients will double in 2010. (National Kidney and transplant institute)
RISK FATORS FOR CKD
Although chronic kidney disease sometimes results from primary diseases of the kidneys themselves, the major causes are diabetes
and high blood pressure.
Type 1 and type 2 diabetes mellitus cause a condition called diabetic nephropathy, which is the leading cause of kidneydisease in the United States.
High blood pressure (hypertension), if not controlled, can damage the kidneys over time.
Glomerulonephritis is the inflammation and damage of the filtration system of the kidneys, which can cause kidney failure.Post infectious conditions and lupus are among the many causes of glomerulonephritis.
Polycystic kidney disease is an example of a hereditary cause of chronic kidney disease wherein both kidneys have multiplecysts.
Use of analgesics regularly over long durations of time can cause analgesic nephropathy, another cause of kidney disease.Certain other medications can also damage the kidneys.
Clogging and hardening of the arteries (atherosclerosis) leading to the kidneys causes a condition called ischemic
nephropathy, which is another cause of progressive kidney damage.
Obstruction of the flow of urine by stones, an enlarged prostate, strictures (narrowing), or cancers may also cause kidneydisease.
Other causes of chronic kidney disease include HIV infection, disease, heroin, amyloidosis, stones, chronic, and certaincancers.
Effects and symptoms of chronic kidney disease include:
need to urinate frequently, especially at night (nocturia);
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swelling of the legs and puffiness around the eyes (fluid retention);
high blood pressure;
fatigue and weakness (from anemia or accumulation of waste products in the body);
loss of appetite, nausea and vomiting;
itching, easy bruising, and pale skin (from anemia);
shortness of breath from fluid accumulation in the lungs;
headaches, numbness in the feet or hands (peripheral neuropathy), disturbed sleep, altered mental status(encephalopathy from the accumulation of waste products or uremic poisons), and restless legs syndrome;
chest pain due to pericarditis (inflammation around the heart);
bleeding (due to poor blood clotting);
bone pain and fractures; and
Decreased sexual interest and erectile dysfunction.
DIAGNOSTIC TEST
1. A urinalysis may show protein or other changes. These changes may appear 6 months to 10 or more years before symptoms
appear. Tests that check how well the kidneys are working include:
Creatinine clearance Creatinine levels
BUN
2. Chronic kidney disease changes the results of several other tests. Every patient needs to have the following checked
regularly, as often as every 2 - 3 months when kidney disease gets worse:
Albumin
Calcium
Cholesterol
Complete blood count (CBC) Electrolytes
Magnesium
Phosphorous
Potassium
Sodium
3. Causes of chronic kidney disease may be seen on:
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Abdominal CT scan
Abdominal MRI
Abdominal ultrasound
Kidney biopsy
Kidney scan
Kidney ultrasound
4. This disease may also change the results of the following tests:
Erythropoietin
PTH
Bone density test
Vitamin D
COMPLICATIONS
Anemia
Bleeding from the stomach or intestines
Bone, joint, and muscle pain
Changes in blood sugar
Damage to nerves of the legs and arms (peripheral neuropathy)
Dementia
Fluid buildup around the lungs (pleural effusion)
Heart and blood vessel complications
o Congestive heart failure
o Coronary artery disease
o High blood pressure
o Pericarditis
o Stroke
High phosphorous levels
High potassium levels
Hyperparathyroidism
Increased risk of infections
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Liver damage or failure
Malnutrition
Miscarriages and infertility
Seizures
Swelling (edema)
Weakening of the bones and increased risk of fractures
http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000404/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A001488/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A001191/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A003200/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A003103/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000404/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A001488/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A001191/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A003200/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A003103/7/30/2019 Case Complete
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OVERVIEW OF THE DISEASE: CONGESTIVE HEART FAILURE WITH HYPERTENSION
Hypertension, or commonly known as high blood pressure, is a medical condition wherein the blood pressure of an individual isrecurrently elevated. Hypertension is an important contributor to morbidity and mortality from cardiovascular disease. It is a anindependent risk factor for stroke, myocardial infarction, renal failure, congestive heart failure, progressive atherosclerosis, dementia,coronary artery disease and peripheral vascular disease. Hypertension affects approximately 50 million individuals in the UnitedStates and approximately 1 billion individuals worldwide.
SCENARIO:
As the population ages, the prevalence of hypertension will increase even further broad and effective preventive measuresare implemented (1). In the Philippines, 9.6M are hypertensive and 15.4M are predisposed to be hypertensive among adults, 20years and over (2). Unfortunately, half of those who has hypertension are not aware that they have the condition, only 13.1% of themhas been treated and 19.3 % has been controlled (3). Since hypertension may be present in an individual in years without noticeablesymptoms, it is otherwise known as The Silent Assassin (4), In the Philippines, for over 5 years, hypertension ranks as the fifthleading cause of morbidity (5).
This implies that hypertension is a chronic problem or condition of the country and perhaps not much has been done on itscontrol and prevention. Prolonged and uncontrolled hypertension is very dangerous. Unhealthy lifestyles which include cigarettesmoking, unmanaged stress, salty food consumption, physical inactivity, or being overweight are the common modifiable risk factorsto having hypertension. Non modifiable factors include genetic predisposition to hypertension and other disease condition likediabetes, heart and kidney disease, high cholesterol level, or stroke and an increasing age.Hypertension in its earlier stage is manageable. The simplest way of controlling high blood pressure is through lifestyle modificationby having healthy diet and regular exercise.
Congestive heart failure is defined as the state in which the heart is unable to pump blood at a rate adequate for satisfyingthe requirements of the tissues with function parameters remaining within normal limits usually accompanied by effort intolerancefluid retention, and reduced longevity.
The most severe manifestation of CHF, pulmonary edema, develops when this imbalance causes an increase in lung fluidsecondary to leakage from pulmonary capillaries into the interstitium and alveoli of the lung.
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CASE ABSTRACT
Patient X is 64 year old woman was rushed in the emergency room of Panlalawigang
Pagamutan ng Laguna at around 6:00pm last June 16, 2012 with the chief complaint of
difficulty of breathing, orthopnea and chest pain. associated with nausea and vomiting. Shewas then advised by Dra. Menendez to be admitted with strict observation in the intensive
care unit. Upon assessment, patient X was noted with bipedal edema and seen with nose
bleeding that is when she was referred to ENT and advised with nasal packing, Paranasal
Sinus CT scan and x-ray in the paranasal sinus and advised to be taken with laboratory
studies including Hematology, Complete Blood Count, ECG and chest Xray. By then, the
attending Physician ordered, Losartan 50 mg, Furosemide 20mg/tab OD and was hooked
with 1L PNSS KVO.
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HEALTH HISTORY
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HEALTH HISTORY
Patient: X
Birthday: September 1,1947
Age: 64 years old
Address: San Antonio, SPC
Religion: Catholic
Sex: female
Nationality: Filipino
Civil status: Married
Rank in the Family: Grandmother Admission Date and Time: 06-16-2012; 7:40 pm
Attending Physician: Dr. Menendez
Admission Diagnosis: CHF / Chronic Kidney Disease, Anemia
Source of History: Patient & Daughter
Reliability of Historian: Reliable
Chief Complaint: DOB
HISTORY OF PRESSENT ILLNESS
A day prior to admission, the patient experienced difficulty of breathing and sought to bring him to PPL , SPC hospital. In the
ER seen ( + )nose bleeding, the attending physician immediately requested nasal packing and series of laboratory tests to verify the
illness of the patient and brought to ICU unit. Upon interview with the patient and her daughter, we had found out that it was her
second time in hospitalization in the ICU unit with the same complain and she also has a chronic heart failure for almost 10 years
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together with anemia and hypertension but later found out that she also has a chronic kidney disease and elevated blood sugar
level upon her present hospitalization .In the Chest X ray found out that she has a mild pleural effusion and scheduled for CTT
insertion and it was inserted on the right 5 th ICS midaxillary line last June 20, 2012 collected 900ml pinkish pleural fluid and repeat
chest x-ray ordered after removal of CTT on last June 24, 2012 9:10am by Dr. Isberto, accidentally another finding come on with mild
pleural effusion on the left ling but the patient refuse to have another CTT insertion and sign a waiver. Patient X is for blood
transfusion after the relieved of her DOB. The pleural fluids are examined to the laboratory for culture and sensitivity and cell block
for further diagnosis but patient has still with bipedal edema.
PAST HEALTH HISTORY
Two months ago, the patient had been hospitalized because of the same complaint of DOB.
FAMILY HEALTH HISTORY
Upon interview, she has 7 children of which has no known diseases .Her mother has also a heart disease and elevated blood
pressure. No allergy to any foods and medicines.
SOCIO-ECONOMIC STATUS
Their family has a simple life. The family lives in a concrete house. They have electricity and good ventilation. They also
have an adequate living space. She is living separately with her sons and daughters who provide her daily needs. She is living with
her 3 grandchildren.
FUNCTIONAL HEALTH PERCEPTION
A. Health Perception and Health Management Pattern
Patient XY detailed that she had usual colds associated with fever and cough when she was young and was relieved
by herbal medicines from the quack doctors in the barrio. Due to lack of finances, they were not able to maintain proper
nutrition and medications needed by a child before and added up the fact that, they were to lack of opportunities to see a
health professional that can modify things that is needed to perform a healthy lifestyle and can prevent diseases like what she
had now.
BEFORE ADMISSION DURING ADMISSION
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B. NUTRITION-METABOLICPATTERN
Prior to admission, the patients daily diet is fish,meat, pork and beef with salt or soy sauce andsometimes he eats soup of vegetable mixedwith rice. He drinks a lot of water.
Prior to surgery, he was NPO for about 6-8 hrs.After 2-3 days, he again eats up salty foods, suchas French fries with salts poured on it andtogether with coke.
C. ELIMINATION PATTERN A day prior to admission, the patient has nodifficulty in defecating. But sometimes sheexperience urine retention
During the confinement, he defecates once a daywith close monitoring on his urine due to timesshe doesnt have urine output or insufficient.
D. SLEEP-REST PATTERN The patient usually sleeps at around 8:00 pm atawakes at 6:30 am.
During confinement, she has disturbed sleepingpattern due to vital signs monitoring every hourand of her DOB.
E. ACTIVITY-EXERCISEPATTERN
The patient walks in her backyard for exercise During confinement, she does range of motionexercises.
ACTIVITY-EXERCISE PATTERN
CODE:
LEVEL 0 full self careLEVEL1 requires use of equipment or deviceLEVEL 2 requires assistance or supervision from another personLEVEL 3 - requires assistance or supervision from another person or deviceLEVEL 4 - is dependent and does not participate
PRIOR UPON PRIOR UPONFEEDING 0 2 GROOMING 0 2BATHING 0 2 GENERAL MOBILITY 0 2TOILETING 0 2 COOKING 0 3BED MOBILITY 0 2 HOME MAINTENANCE 1 3
DRESSING 0 2 SHOPPING 2 4
F. Cognitive and Perceptual Pattern
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She has sometimes experiencing dementia, but during our interview on the following days she is oriented to time, place and
person.
G. Self perception and Self Concept Pattern
Patient XY stated that shes not yet feeling good during her hospital stay and the only thing that made her worry is her
grandchildren, because she didnt know whos in charge in taking care of the children while shes in the hospital.
H. Coping stress tolerance Pattern
Patient XY explained that problems can be easily handled when you dont think of it that much. Shes not taking too much
pressure in handling problems with the help of her children. She can easily manage stress because of her grandchildren.
I. Value Belief Pattern
Shes regularly attending mass every Sunday in their chapel and according to her; God is very good because she is still there
for her, taking care of her especially with her current situation.
ERIK ERIKSONS STAGES OF DEVELOPMENT
Erikson believed that the more success an individual has at each developmental stage, the healthier the personality of the
individual. Failure to complete the any developmental stage influences the persons ability to improve in the next level. These
developmental stages can be viewed as series of crises.
According to his 8th Stage of Development which is the Maturity or Integrity Versus Despair, the persons task is to accept his
own worth as an individual, the uniqueness of ones own life and acceptance of death. As observed to our 64 year old patient, this
task was achieved as evidenced by her attitude towards life and the fact that whatever happens to her shes ready, but the only thing
that made a matter is the thought that she wasnt able to prevent certain diseases. But all in all, her deep faith to God helps her to
achieve her developmental task.
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PHYSICAL ASSESSMENT
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PHYSICAL ASSESSMENT
A. General Survey June 20,2012
Received patient lying in bed with IVF of PNRS 1L for KVO. She is in pain and irritable and upon observation patient X
looks pale and weak with shortness of breath, (+) bipedal edema, (+) hypertension, with nasal cannula, O2 regulated at
8L/min, bag and with CTT inserted on her 5 th ICS midaxilliary line connected to One way bottle. Foley catheter connected to
urine.
Vital Signs (upon assessment June 20, 2012 @ 7pm)
TEMPERATURE( Celsius)
PULSE(beats/min)
RESPIRATORY RATE( breaths/min)
BLOOD PRESSURE(mm/hg)
HGT RESULT
36.2 70bpm 18bpm 140/90 138mg/dL
VITAL SIGNS MONITORING RECORD
JUNE 18, 2012 2 -10 PM
TIME TEMPERATURE( Celsius)
PULSE(beats/min)
RESPIRATORYRATE
( breaths/min)
BLOODPRESSURE
(mm/hg)
O2 SATURATION(%)
3pm 36.4 68 20 140/60 97
4pm 36.6 71 22 130/80 97
5pm 36.6 70 21 110/70 98
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6pm 36.3 67 19 120/90 97
7pm 36.3 71 18 110/70 97
8pm 36.3 72 18 110/70 97
9pm 36.3 73 19 120/90 97
10pm 36.0 73 19 120/90 97
JUNE 20, 2012 2-10 PM
TIME TEMPERATURE( Celsius)
PULSE(beats/min)
RESPIRATORYRATE
( breaths/min)
BLOODPRESSURE
(mm/hg)
O2 SATURATION(%)
3pm 35.5 70 19 130/80 99
4pm OR OR OR OR OR
5pm 35.5 70 18 120/80 98
5:15pm 35.7 71 20 130/70 97
5:30pm 37.7 70 18 110/80 99
5:45pm 35.9 70 19 120/70 97
6pm 35.9 71 18 140/80 98
7pm 36.2 70 18 140/90 99
8pm 36.2 72 19 130/80 97
9pm 36.2 72 21 140/80 98
10pm 36.2 73 16 140/80 96
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JUNE 25 , 2012 2-10PM
TIME TEMPERATURE( Celsius)
PULSE(beats/min)
RESPIRATORYRATE
( breaths/min)
BLOODPRESSURE
(mm/hg)
O2 SATURATION(%)
3pm 36.1 58 20 140/60 97
4pm 36.0 70 20 120/80 98
5pm 36.7 80 20 120/70 99
6pm 36.1 80 24 130/80 99
7pm 36.1 70 20 110/80 98
8pm 36.4 81 19 130/80 99
9pm 36.3 80 21 130/70 97
10pm 36.3 81 20 130/70 98
JUNE 26, 2012 2-10PM
TIME TEMPERATURE( Celsius)
PULSE(beats/min)
RESPIRATORYRATE
( breaths/min)
BLOODPRESSURE
(mm/hg)
O2 SATURATION(%)
3pm 36.1 81 20 150/80 99
4pm 36.3 78 20 150/80 97
5pm 36.2 79 21 150/80 99
6pm 36.3 80 21 150/80 95
7pm 36.2 79 22 160/80 99
8pm 36.4 81 22 160/80 98
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9pm 36.0 78 23 150/80 97
10pm 36.0 77 22 150/70 98
RANDOM BLOOD SUGAR (HGT) MONITORING RECORD every 6 hours - JUNE 16 21, 2012
Upon Admission June 16, 2012 = 253 mg/dl
JUNE 17,
2012
RESULT
(mg/dl)
JUNE
18, 2012
RESULT
(mg/dl)
JUNE
19, 2012
RESULT
(mg/dl)
JUNE
20, 2012
RESULT
(mg/dl)
JUNE
21, 2012
RESULT
(mg/dl)
6AM 175 12MN 161 12MN 146 12MN 135 12MN --
12NN 162 6AM 156 6AM 141 6AM 144 6AM 152
6PM 167 12PM 145 12PM -- 12PM -- 12PM 146
-- -- 6PM 141 6PM 135 6PM 138 6PM 146
INTAKE AND OUTPUT MONITORING RECORD
DATE SHIFT ORAL INTAKE (cc) IV (cc) URINE OUTPUT (cc)
JUNE 18, 2012 6-2 70 50 160
2-10 170 68 200
10-6 80 85 205
DATE SHIFT ORAL INTAKE (cc) IV (cc) URINE OUTPUT (cc)
JUNE 19, 2012 6 -2 180 145 248
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2-10 150 60 295
10-6 90 85 130
DATE SHIFT ORAL INTAKE (cc) IV (cc) URINE OUTPUT (cc)
JUNE 20, 2012 6-2 290 60 255
2-10 133 171 220
10-6 90 115 255
DATE SHIFT ORAL INTAKE (cc) IV (cc) URINE OUTPUT (cc)
JUNE 21, 2012 6-2 270 70 200
2-10 300 120 260
10-6 20 85 70
DATE SHIFT ORAL INTAKE (cc) IV (cc) URINE OUTPUT (cc)
JUNE 22, 2012 6-2 75 180 20
2-10 240 100 33
10-6 80 50 130
DATE SHIFT ORAL INTAKE (cc) IV (cc) URINE OUTPUT (cc)
JUNE 23, 2012 6-2 90 20 30
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2-10 150 110 100
10-6 120 145 120
DATE SHIFT ORAL INTAKE (cc) IV (cc) URINE OUTPUT (cc)
JUNE 24, 2012 6-2 220 10 280
2-10 200 60 380
10-6 90 110 200
DATE SHIFT ORAL INTAKE (cc) IV (cc) URINE OUTPUT (cc)
JUNE 25, 2012 6-2 450 100 300
2-10 400 90 350
10-6 90 75 165
DATE SHIFT ORAL INTAKE (cc) IV (cc) URINE OUTPUT (cc)
JUNE 26, 2012 6-2 330 60 47
2-10 270 60 205
10-6 110 70 300
JUNE 27, 2012 6-2 390 120 135
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PLEURAL FLUIDS OUTPUT MONITORING RECORD
JUNE 20 23, 2012
JUNE 20, 2012
Thoracostomy obtained
AMOUNT
800cc
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Thoracentesis obtained 4cc
JUNE 21, 2012
2-10 pm 0
10-6am 70cc
JUNE 22, 2012
6- 2pm 0
2 10pm 50cc
JUNE 23, 2012
6-2pm 0
2-10pm 50cc
B. INTEGUMENT
Skin: Patient X has a light brown complexion. Her skin is smooth and dry with poor skin turgor, wrinkled appearancedue to her age.
Mucous Membrane: Patient X has pale lips. Theres a sign of dryness
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Nails: Her fingernails and toenails are short and dirty, capillary refill (4-5 seconds)
Hair: Patients X hair is evenly distributed with gray colored hair; and theres no presence of dandruff and lice, with ashort haircut.
HEET
Head: Upon inspection, she has a round and symmetrical skull. No nodules and tenderness.
Eyes: Patient Xs eyebrow is fairly distributed; eyelashes are slightly short and curl. Her eyes are black in color andPale conjunctiva, no noted discharge.
Ears: Smooth and soft to touch, its color is the same as her color of the skin. No presence of any discharge, she canrecognize to any sound. Symmetrical upon inspection, and auricle aligned with outer canthus of eye. Ears also recoil.
Nose: Smooth to touch, no presence of any discharge and deformities. She can recognize good and bad smell.
Mouth/Throat/Pharynx/Teeth: Upon assessment, patients lips are pale in color, symmetry and contour, no notedsores and gums.
Face: Pale looking skin, symmetrical in both sides.
Neck/Lymp Nodes: No noted lesions, no palpable lymph nodes.
PULMONARY
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She has a CTT inserted on her Right 5th ICS midaxilliary line. Patient X experience difficulty in breathing with shortness ofbreath.
CARDIOVASULAR
Upon auscultation, he has a normal heart sound and normal heart rate and regular rhythm.
ABDOMEN
No nodes palpable.
MUSCULOSKELETAL
(+) bipedal edema.
NEUROLOGIC
Upon assessment, Patient X was very irritable and just focusing on his pain being felt last june 20, 2012.
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ANATOMY AND PHYSIOLOGY
URINARY SYSTEM
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Kidneys
Each kidney is behind the peritoneum and surrounded by a renal capsule and adipose tissue.
The kidney is divided into an outer cortex and an inner medulla.
Each renal pyramid has a base located at the boundary between the cortex and medulla, and the tip extends toward thecenter of the kidney and is surrounded by a calyx.
Calyces are extensions of the renal pelvis, which is the expanded end of the ureter within the renal sinus.
The functional unit of the kidney is the nephron. The parts of the nephron are the renal corpuscle, the proximal tubule, the
loop of Henle and the distal tubule.
The filtration membrane is formed by the glomerular capillaries, the basement membrane and the podocytes of Bowmans
capsule.
Arteries and Veins
Renal arteries give rise to branches that lead to afferent arterioles.
Afferent arterioles supply the glomeruli.
Efferent arterioles carry blood from the glomeruli to the pertibular capillaries.
Blood from the pertibular capillaries flows to the renal veins.
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Ureters, Urinary Bladder and Urethra
Each ureter carries urine from renal pelvis to the urinary bladder.
The urethra carries urine from the urinary bladder to the outside of the body.
The ureters and urinary bladder are lined with transitional epithelium and have smooth muscle on their walls.
The external urinary sphincter regulates the flow of urine through the urethra.
Functions of the Urinary System
The kidneys excrete waste products.
The kidneys control blood volume by regulating the volume of urine produced.
The kidneys help regulate the concentration of major ions in the body fluids.
The kidneys help regulate pH of the body fluids
The kidneys regulate the concentration of red blood cells in the blood.
The kidneys participate, with the skin and liver, in Vitamin D synthesis.
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CARDIOVASCULAR SYSTEM
The cardiovascular system can be thought of as the transport system of the body. This system has three main components:the heart, the blood vessel and the blood itself. The heart is the system's pump and the blood vessels are like the delivery routes.Blood can be thought of as a fluid which contains the oxygen and nutrients the body needs and carries the wastes which need to beremoved. The following information describes the structure and function of the heart and the cardiovascular system as a whole.
Function and Location of the HeartThe heart's job is to pump blood around the body. The heart is located in between the two lungs. It lies left of the middle of the chest.
Structure of the HeartThe heart is a muscle about the size of a fist, and is roughly cone-shaped. It is about 12cm long, 9cm across the broadest point andabout 6cm thick. The pericardium is a fibrous covering which wraps around the whole heart. It holds the heart in place but allows it tomove as it beats. The wall of the heart itself is made up of a special type of muscle called cardiac muscle.
Chambers of the Heart
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The heart has two sides, the right side and the left side. The heart has four chambers. The left and right side each have twochambers, a top chamber and a bottom chamber. The two top chambers are known as the left and right atria (singular: atrium). Theatria receive blood from different sources. The left atrium receives blood from the lungs and the right atrium receives blood from therest of the body. The bottom two chambers are known as the left and right ventricles. The ventricles pump blood out to different partsof the body. The right ventricle pumps blood to the lungs while the left ventricle pumps out blood to the rest of the body. Theventricles have much thicker walls than the atria which allows them to perform more work by pumping out blood to the whole body.
Blood VesselsBlood Vessel are tubes which carry blood. Veins are blood vessels which carry blood from the body back to the heart. Arteries areblood vessels which carry blood from the heart to the body. There are also microscopic blood vessels which connect arteries andveins together called capillaries. There are a few main blood vessels which connect to different chambers of the heart. The aorta isthe largest artery in our body. The left ventricle pumps blood into the aorta which then carries it to the rest of the body throughsmaller arteries. The pulmonary trunk is the large artery which the right ventricle pumps into. It splits into pulmonary arteries whichtake the blood to the lungs. The pulmonary veins take blood from the lungs to the left atrium. All the other veins in our body drain intothe inferior vena cava (IVC) or the superior vena cava (SVC). These two large veins then take the blood from the rest of the body intothe right atrium.
Valves
Valves are fibrous flaps of tissue found between the heart chambers and in the blood vessels. They are rather like gates whichprevent blood from flowing in the wrong direction. They are found in a number of places. Valves between the atria and ventricles areknown as the right and left atrioventricular valves, otherwise known as the tricuspid and mitral valves respectively. Valves betweenthe ventricles and the great arteries are known as the semilunar valves. The aortic valve is found at the base of the aorta, while thepulmonary valve is found the base of the pulmonary trunk. There are also many valves found in veins throughout the body. However,there are no valves found in any of the other arteries besides the aorta and pulmonary trunk.
SYSTEMIC AND CORONARY CIRCULATION
Pulmonary circulation beginswith the right heart.
It is here that the oxygenated blood
from the venous system enters the rightatrium through two large veins, thesuperior and inferior vena cava.
Blood is transported to the lungs viathe pulmonary atery and itsbranches.
Oxygen rich blood returns to the leftatrium through cerebral pulmonary
veins.
With systemic circulation blood ispumped out of the left ventricle
through the aorta and major branches tosupply all of the body tissues.
Coronary circulation, on the otherhand, supplies the heart with its own
network of vessels.
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PATHOPHYSIOLOGY
The left and right coronary arteriesoriginate at the base of the aorta and
branch out to encircled the
myocardium.
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LABORATORY
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LABORATORY RESULTS
Hematology
(06/22/12)
Result Normal Values Clinical Significance
Hemoglobin 73g/L 110-165g/L Decrease in various anemias,
pregnancy, severe or
prolonged hemorrhage, and
with excessive fluid intake
Hematocrit .23cu/L 0.35-0.50cu/L Decrease in severe anemias,
anemia of pregnancy, acute
massive blood loss
WBC 3.9q/l 5.0-10.0x9/L Decrease in disease-fightingcells (leukocytes) circulating in
your blood.
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Urinalysis
(6/18/12)
Result Clinical Significance
MACROSCOPIC FINDINGS
Color Yellow Within normal values
Transparency slight turbid Within normal values
Specific Gravity 1.010 Within normal values
Reaction Acidic (6.0)
Albumin + Increased level of albumin
indicates albuminuria
Sugar - Within normal values
Ketones - Within normal values
Bilirubin - Within normal values
Urobilinogen - Within normal values
Nitrite - Within normal values
Blood trace Indicates slight hemoglobinuria
Leukocytes + Slight escape of WBC is an
indicative of slight infection.
Ascorbic Acid - Within normal values
MICROSCOPIC FINDINGS
Pus cells 20-30/hpf Indicates infection
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RBC 5-10/hpf Slight escape of RBC indicates
hematuria
Bacteria + Indicates bacteriuria
Epithelial cells few Indicates slight escape of epithelial cells
Crystals A. urates + Presence of urine crystals.
Blood Chemistry
(06/18/12)
Result Normal Values Clinical Significance
Fasting Blood Sugar 142.7mg/dl 80-110mg/dl An increase in glucose level in
the blood
Cholesterol 242.6mg/dl 150-200mg/dl An increased number of fat
deposits in the vascular walls.
Triglycerides 161.8mg/dl < 150 mg/dL Increase level of fat deposits in
the arterial and vascular walls.
BUN 53.5mg/dl 10-20mg/dl Increasing levels suggest
condition that assess kidney
function.
Creatinine 5.2mg/dl 0.7-1.4mg/dl Increasing levels suggest
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condition that assess kidney
function.
Uric Acid 10.5mgs/ 3.5-8.5 mg/dL Increased that may indicate
high concentration purine
waste staying on the blood.
HDL-chol.F 52.7mg/dl 35-85mg/dl Within normal levels
LDL-Chol. 157.5mgs/dl 60-160 mg/dl Within normal levels
ECG INTERPRETATION
DATE SUGGESTION INTERPRETATION
6-14-12 Tachyarryrthmias, high lateral wall
ischemia
Any disturbance of the heart rhythm in
which the heart rate is abnormallyincreased.
6-18-12 Diffuse Myocardial Ischemia A loss of oxygen to the heart muscle
caused by blockage of the coronary
arteries or their branches.
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DRUG STUDY
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DRUG NAME THERAPEUTICACTION
INDICATION CONTRAINDICATION ADVERSE EFFECT NURSINGCONSIDERATION
Generic NameFurosemide
Brand Name:Lasix
Classification:Loop diuretic
Inhibits thereabsorption ofsodium andchloride from theproximal and
distal renaltubules and theloop of Henle,leading to asodium-richdiuresis.
EdemaassociatedwithCHFrenal
disease(oral, IV)
Contraindicatedwith allergy tofurosemide,sulfonamides;
allergy to tartrazine(in oral solution);electrolytedepletion; anuria,severe renalfailure; hepaticcoma; pregnancy;lactation.
CNS: Dizziness,vertigo, paresthesias,xanthopsia,weakness, headache,drowsiness, fatigue,
blurred vision, tinnitus,irreversible hearingloss
CV: Orthostatichypotension, volumedepletion, cardiacarrhythmias,thrombophlebitis
SKIN:
Photosensitivity, rash,pruritus, urticaria,purpura, exfoliativedermatitis, erythemamultiforme
GI: Nausea, anorexia,vomiting, oral andgastric irritation,constipation, diarrhea,acute pancreatitis,jaundice
GU: Polyuria,nocturia, glycosuria,urinary bladder spasm
HEMA: Leukopenia,anemia,thrombocytopenia
Administer withfood or milk toprevent GI upset.
Reduce dosage if
given with otherantihypertensives;readjust dosagegradually as BPresponds.
Give early in theday so thatincreased urinationwill not disturbsleep.
Avoid IV use if oraluse is at allpossible.
Do not expose tolight, may discolortablets or solution;do not usediscolored drug orsolutions.
Measure and
record weight tomonitor fluidchanges.
Arrange to monitorserum electrolytes,hydration, liverfunction.
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Arrange forpotassium-rich dietor supplementalpotassium asneeded.
DRUG NAME THERAPEUTICACTION
INDICATION CONTRAINDICATION ADVERSE EFFECT NURSINGCONSIDERATION
Generic Name:Nitroglycerin
Brand Names:Deponit patch
Drug class:
Antianginals
A nitrate thatreduces cardiacoxygen demandby decreasing leftventricular enddiastolic pressure(preload) and, to
a lesser extent,systemic vascularresistance(afterload).
To preventanginaattacks
Contraindicated topatients with earlyMI, severe anemia,increased ICP,angle closureglaucoma,orthostatichypotension, andallergy toadhesives.
CNS: Headache,dizziness, weakness
CV: Orthostatichypotension,tachycardia, flushing,palpitations
SKIN: cutaneousvasodilation
GI: Nausea andvomiting
Closely monitorVital signs duringinfusion,particularly bloodpressure.
Removetransdermal patchbeforedefibrillation.
Advise patient notto stop drugabruptly.
DRUG NAME THERAPEUTIC
ACTION
INDICATION CONTRAINDICATION ADVERSE EFFECT NURSING
CONSIDERATIONGeneric Name:Acetaminophen
Brand Names:Biogesic
Drug class:Nonopioid
Thought toproduceanalgesia byblocking painimpulses byinhibitingsynthesis ofprostaglandin in
Mild painand fever
Contraindicated topatients withhypersensitivity todrug.
HEMA: hemolyticanemia, neutropenia,leukopenia,pancytopenia
HEPATIC:jaundice
METAB:
Advise patient thatdrug is only forshort-term use.
Do not to use formarked fever(temperaturehigher than 103.1
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analgesics andantipyretics
the CentralNervous System(CNS) or of othersubstances thatsensitize painreceptors tostimulation.
hypoglycemia
SKIN: rash, urticaria
F [39.5 C]), feverpersisting-longerthan 3 days, orrecurrent feverunless directed by prescriber.
High doses orunsupervisedlong-term use cancause liverdamage.
DRUG NAME THERAPEUTICACTION
INDICATION CONTRAINDICATION ADVERSE EFFECT NURSINGCONSIDERATION
Generic Name:
Acetaminophen
Brand Names:Biogesic
Drug class:Nonopioidanalgesics andantipyretics
Thought to
produceanalgesia byblocking painimpulses byinhibitingsynthesis ofprostaglandin inthe CentralNervous System(CNS) or of othersubstances that
sensitize painreceptors tostimulation.
Mild painand fever
Contraindicated topatients withhypersensitivity todrug.
HEMA: hemolytic
anemia, neutropenia,leukopenia,pancytopenia
HEPATIC:jaundice
METAB:hypoglycemia
SKIN: rash, urticaria
Advise patient thatdrug is only forshort-term use.
Do not to use formarked fever(temperaturehigher than 103.1F [39.5 C]), feverpersisting-longerthan 3 days, orrecurrent feverunless directed by prescriber.
High doses orunsupervisedlong-term use cancause liverdamage.
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DRUG NAME THERAPEUTICACTION
INDICATION CONTRAINDICATION ADVERSE EFFECT NURSINGCONSIDERATION
GenericName:Ceftriaxone
Brand Names:Rocephin
Drug class:AntimicrobialandAntiparasitic
Inhibits bacterialcell wallsynthesis,
rendering cellwall osmoticallyunstable, leadingto cell deathreceptors tostimulation.
Treatment ofLRIT(e.g.pneumonia,) skin andsoft tissueinfections
Hypersensitivity tocephalosporinsand penicillins,lidocaine or anyother localanaestheticproduct of theamide type.
CNS:Fever, headache,dizziness
CV: Phlebitis
GI: Diarrhea
GU: Genital pruritus,candidiasis
Ask the patient ifshe is allergic topenicillins and
cephalosporins Instruct patient to
take medication asprescribed for thelength of timeordered even if hefeels better.
Teach patient toreport sore throat,bruising, bleedingand joint pain.
Advise patient towatch out forperineal itching,fever, malaise,redness, pain,swelling, rashdiarrhea
Instruct the patientto discomfort in theIV insertion line.
DRUG NAME THERAPEUTICACTION
INDICATION CONTRAINDICATION ADVERSE EFFECT NURSINGCONSIDERATION
Generic Name:Telmisartan
Brand Names:Micardis
Blocksvasoconstrictingand aldosteronesecreting effectsof angiotensin IIby selective
Hypertension
Hypersensitivity todrug and itscomponent.
CNS:Pain, fatigue,headache, dizziness
CV: chest pain,hypertension,
Monitor patient forhypotension afterstarting drug.
Monitor bloodpressure, closely.
Tell patient that
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Drug class:Antihypertensive
blocking thebinding ofangiotensin II othe angiotensin Ireceptor in manytissues, such asvascular smooth
muscle and theadrenal gland.
peripheral edema
EENT: pharyngitis,sinusitis
GU: UTI
RESPI: cough,URTI
drug should betaken with regardmeals.
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DRUG NAME THERAPEUTICACTION
INDICATION CONTRAINDICATION ADVERSE EFFECT NURSINGCONSIDERATION
Generic Name:Ketorolac
Brand Names:Toradol
Drug class:NSAIDS
Inhibitsprostaglandinsynthesis,producing
peripherallymediatedanalgesia
Short termmanagement of pain
(not toexceed 5days totalfor allroutescombined)
Hypersensitivity todrug and itscomponent.
CNS: drowsiness,abnormal thinking,dizziness, euphoria,headache
RESP: asthma,dyspnea
CV: edema, pallor,vasodilation
GI: GI Bleeding,abnormal taste,diarrhea, dry mouth,
dyspepsia, GI pain,nausea
GU: oliguria, renaltoxicity, urinaryfrequency
Assess forrhinitis, asthma,and urticaria.
Assess pain(note type,location, andintensity) prior toand 1-2 hrfollowingadministration.
Caution patientto avoidconcurrent use
of alcohol,aspirin, NSAIDs,acetaminophen,or other OTCmedicationswithoutconsulting healthcareprofessional.
Advise patient to
consult visualdisturbances,tinnitus, weightgain, edema,black stools,persistentheadache, orinfluenza-likesyndromes(chills, fever,
muscles aches,pain) occur.
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NURSING CARE PLAN
Assessment Diagnosis Planning Nursing Intervention Rationale Evaluation
Subjective:
Hindi ko alamkung bakit akominamanas asverbalized by thepatient.
Objective:
Bipedal Edema(piting edema) - +2
Excess fluidvolume r/t reduceglomerularfiltration rate.
After nursingintervention thepatient willstabilized fluidvolume. Asevidenced by freesigns of edema.
Independent:
Assessneuromuscularreflexes.
Review laboratorydata (Hb/Hct) proteins,elcetrolytes, urinespecific gravity, chest x-
To evaluate forpresence ofelectrolytesimbalances such ashyper.
To evaluate degreeof fluid and electrolyteimbalance andresponse to therapies.
After nursingintervention---patient hadstabilized fluidvolume asevidenced byslight edema +1.
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Restlessness V/S taken asfollow:T: 37.8 CPR: 86RR: 24BP: 140/90
Urine Output
ray & osmolality /sodium secretion.
Evaluate edematousextremeties, changeportion frequently.
Set an appropriate rateof fluid intake/infusionthroughout 24hrsperiod.
Collaborative: Administermedication, diuretics.
To reduce tissuepressure and risk ofskin breakdown.
To prevent
peaks/valleys in fluidlevel.
To eliminate thewater and salt in thebody.
Assessment Diagnosis Planning NursingIntervention
Rationale Evaluation
Subjective:
Nahihirapan akonghuminga as verbalized
by the patient.
Objective:
DOB
O2 Sat (96%)
Restlessness
V/S: 140/90o RR: 24
Ineffectivebreathingpattern r/t flueraleffusion
accumulation offluid in thelungs.
After nursingintervention thepatient willestablish
normaleffectiverespiratorypattern.
Independent:Determinepresence offactors/physical
conditions.
Auscultate thechest.
Elevate HOB or
To know what causesthe breathingimpairments.
To evaluate presencecharacter of breathsounds secretions.
To promote physiologicalease of maximalinspiration.
After nursingintervention thepatient wasestablished
normal /effectiverespiratorypattern.
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o PR: 86
o Temp: 37.8 C
carry in an uprightposition.
Provide use ofadjuncts such asincentive spirometer.
Administer oxygenat lowestconcentrationindicated andprescribedrespiratorymedication.
Monitor pulseoximetry as
indicated.
To facilitate deeperrespiratory effort.
For management ofunderlying pulmonary
condition.
To verifymaintenance/improvement in O2 SAT.
Assessment Diagnosis Planning Nursing Intervention Rationale Evaluation
Subjective:
Kakaunti lang angnakakain ko kasi
hindi sapat angkita ng mga anakko as verbalizedby the patient.
Objective:Capillary Refill(+3)Body Weakness
Nutrition:imbalanced,less than bodyrequirements r/tinability to ingest or
absorb nutrientsbecause of economicfactors.
After nursingintervention thepatient willverbalize
understanding ofcausative factorswhen known andnecessaryinterventions.
Independent:
Ascertainunderstanding of
individual nutritionalneeds
Discuss eating habits,including foodpreferences,intolerances/aversions.
Assess weight, age,
To determine whatinformation to
provide patient/SO.
To appeal topatientslikes/desires
Provide
After nursingintervention thepatient wasverbalized
understanding ofcausative factorswhen known andnecessaryinterventions.
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Poor muscle tonePale
body built/strength,activity/ rest level, andsoft forth Consult dietician/nutritional team asindicated
Encourage patients tochoose foods that areappealing.
Collaborative: Review medicalregimen and provideinformation/ assistanceas necessary.
comparative baseline
To implementinterdisciplinary teammanagement
To stimulateappetite.
To prevent othercomplication.
Assessment Nursing
Diagnosis
Planning Nursing
Interventions
Rationale Evaluation
Subjective:
Tumataas ang
presyon ko. as
verbalized by the
patient.
Objectives:
Restlessness
Decrease
cardiac output r/tincrease
systemic
vasoconstriction.
Short Term:
After nursing
intervention the
patient will
demonstrate
increase in
activity tolerance.
Independent:
Monitor in trends
heart rate and
blood pressure
especially noting
hypertension. Be
aware of specific
systolic and
Tachycardia is a
common response
to discomfort and
inadequate
blood/fluid
replacement.
Sustained
After nursing
interventions thepatient was
demonstrate an
increase in
activity tolerance
and was
participated in
activities that
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Conscious and
Coherent
V/S: BP140/90
-RR-26
PR- 85,
TEMP 37.8 C
Long Term:
After nursing
intervention
patient will
participate inactivities that
minimize or
enhance cardiac
function.
diastolic limits
defined for
patients.
Records skin
temperature, color
and quality/
equality of
peripheral pulses.
Monitor I&O and
fluid balance.
Schedule
uninterrupted
rest/sleep periods.
Assists with self
care activities as
needed.
Monitor graded
activity program.
Note patient
response, v/s
before/during
activity.
tachycardia
increase cardiac
workload and can
decrease cardiac
output.
Warm pink skin and
strong equal pulses
are general
indicators of
adequate cardiac
output.
Useful in
determining fluid
needs or
identifyingexcesses which
can compromise
cardiac output or
O2 consumption.
Prevent fatigue/
over exhaustion
and excessive
cardio vascular
stress.
Regular exercise
stimulates
circulation/
cardiovascular tone
and promotes well
maximize and
enhance cardiac
output.
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Collaborative:
Measure cardiac
output and other
functional
parameters asindicated.
Administer
electrolytes and
medication as
indicated e.g.:
diuretics, anti-
coagulant.
Review serial
ECGs
Administer
supplemental
oxygen as
being.
Useful in evaluating
response totherapeutic
interventions and
identifying needs
for more
aggressive/
emergency care.
Patients needs are
variable, depending
on type of surgery,patients response
to surgical,
intervention and
pre existing
condition. E.g.: type
of heart failure.
Most frequent done
to follow the
progress in
normalization of
electrical
conduction pattern
to identify
complications.
Promotes maximal
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appropriate. oxygenation which
can reduce cardiac
workload and aid in
resolving
myocardial
ischemia and
dysrhythmias.
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DISCHARGE PLAN
and
PROGNOSIS