Care-plan on Congestive Heart Failure Essay

General Data, Health History, and Review of Systems (10 Points)

Biographical Data

Patient G.W. is a retired industry worker who worked for 39 years for the same company that manufactures automobiles. He does not have a college degree but finished high school. He is married and the wife is still alive. They have two grown children and four teenage grandchildren. Both of his parents are deceased, but he has two living siblings.

Chief Complaint

This encompassed tiredness, difficulty in breathing and inability to climb stairs without having to sit down and rest.

History of Present Illness (Detailed)

The onset of the symptoms was two weeks ago but he has never experienced them before. The dyspnea is located in the chest and lasts as long as the patient is engaged in some form of physical activity, however mild. The dyspnea is characteristically suffocating and is aggravated by physical activity. Sitting upright or lying propped up on pillows make it better. The dyspnea is more resent at night when lying supine, but also during the day when walking. On a scale of 1-10, the patient rates its severity as 6. Care-plan on Congestive Heart Failure Essay

Past Medical/Surgical and Injury History

He has a history of COPD for the past ten years and has also been admitted with community-acquired pneumonia twice. Underwent bilateral tubal ligation at age 35 and inguinal hernia repair in 2005. No history of injuries.

Socio-cultural History (alcohol, tobacco, drugs, ADLs, marital status, children, religion, culture, ethnic group, and education)

He smoked a packet of cigarettes daily for thirty years before being forced to quit after diagnosis with COPD. He is a social drinker of the occasional glass of wine or bottle of beer over the weekends. No history of drug abuse, married with two children and Hispanic by ethnicity. He is a Catholic Christian with a high school certificate but no college education. He is very proud of his Mexican culture as a son of immigrants and could still perform his activities of daily living (ADLs) unaided up to the time he started having the current symptoms a fortnight ago. Care-plan on Congestive Heart Failure Essay

Spiritual Well-Being

He is sufficiently spiritual and attends church every Sunday.

Family History of Illness

Both of his parents died of complications arising from heart disease.

Immunization History

As far as he can remember, he was given all the immunizations he needed as a child. In adulthood, he has received the flu vaccine only.

Developmental Stage in Life

According to Erik Erikson, he is at the developmental stage of ego integrity vs. despair (McLeod, 2018).

Description of Procedures (Surgeries) Performed this Admission

None has been done so far. Care-plan on Congestive Heart Failure Essay

Review of Systems – brief history of each system and use abbreviated format, not complete sentences

General: No fever, chills, or weight loss. Admits fatigue and weakness.

Psychiatric: Denies anxiety or depression.

Skin, hair, and nails: No itching, skin rash, or hair loss.

Lymph nodes: Denies splenectomy. Denies palpable nodes.

HEENT (head, eyes, ears, nose, mouth, throat): Denies loss of vision, double vision, or blurred vision. No sneezing, nasal congestion, or rhinorrhea. Denies sore throat or hearing loss.

Neck: Denies feeling any nodes.

Blood: Denies bleeding or ease of bruising.

Breasts: Denies feeling any masses.

Cardiovascular: Reports pedal edema, chest pain, and palpitations.

Respiratory: Reports shortness of breath wheezing, and coughing.

GI: Reports swelling of the abdomen (ascites), nausea, and loss of appetite. Care-plan on Congestive Heart Failure Essay

GU: Reports increased frequency of micturition at night.

Musculoskeletal: Denies any muscle pain or weakness.

Neurologic: Denies dizziness, weakness, headache, paralysis, numbness, or a change in bladder and bowel control.

Endocrine: Denies heat intolerance, excessive sweating, or excessive thirst.

Section II

In this section, the student must address a description of the disease process including etiology, pathophysiology, signs and symptoms and standard treatment including medication, surgery, etc. (This section should be used to describe the textbook explanation of the disease and compare it with the patient’s picture of his/her disease condition. (5 Points)

Pathophysiology of Disease Process (Points 10)

Congestive heart failure (CHF) results from pathological conditions such as hypertension, intravascular fluid overload, reduced effectiveness of the myocardium or heart muscle, or increased peripheral demand for blood. Due to any of these factors, the heart muscle is not able to effectively pump blood and the blood therefore pools in the heart and flows backwards impacting the normal cardiorespiratory physiology. The backflow of blood floods the lungs with fluid causing pulmonary edema and compromised gaseous exchange making the patient breathless and exercise intolerant (Hammer & McPhee, 2018). Care-plan on Congestive Heart Failure Essay

Classic Signs and Symptoms of Disease Process (5 Points)

The classic signs and symptoms of CHF include edema of the legs and feet, shortness of breath, weakness and fatigue, tachycardia/ palpitations, ascites, intolerance of physical activity, wheezing, coughing pink blood-stained sputum, weight gain, increased nocturnal micturition, and chest pain (Hammer & McPhee, 2018).

Section III

Physical Assessment (15 Points)

Physical Assessment:

Vital Signs (T, P, R, BP, SPO2): T=37.3°C, P=100 b/m, R=25/m, BP=140/95 mmHg, SpO2=92% (off supplemental oxygen), BMI=34.2 kg/m2.

General Appearance: Clean-shaven, well kempt, but looks overweight or obese.

Psychiatric: No unusual behaviors, no flight of ideas, no hallucinations, and no tics.

HEENT: Normocephalic atraumatic, no yellowing of the sclera, no erythema, no otorrhea, intact tympanium, pupils equal, round, and reactive to light and accommodation (PERRLA).

Neck: Nuchal rigidity absent with no lymphadenopathy. Good motion range.

Breasts and Lymph Nodes: No masses or nodes.

Pulmonary: Wheezing, rales/ crackles, and crepitations are audible on auscultation. Care-plan on Congestive Heart Failure Essay

Cardiovascular: S3 with gallop sounds audible.

Skin and Nails: No visible rash or fungal infection of the nails.

Abdomen: Muffed but audible bowel sounds present. Distended, soft, but no guarding or rebound tenderness.

Genitourinary: No lesions or abnormal discharges.

Pelvic and Rectal: No lesions or piles.

Extremities: No coldness and no palor.

Musculoskeletal: Normal muscle strength. Abnormal gait absent.

Neurological (DTR’s, reflex grading, cranial nerve evaluation): Cranial nerves intact as well as DTRs.

__________________________________________________

Incisions: No incisions present.

Drains: No drains present.

Diet/Nutrition: A low-salt. Low sodium diet rich in fresh fruits and vegetables.

IVs: Milrinone IV therapy.