MAKATI MEDICAL CENTER College of Nursing

A clinical Abstract of a patient with Atrial Fibrillation and Congestive Heart Failure

Submitted by: Ramos, Princess Mizzah S.

Submitted to: Maria Elisa Jimenez

January 19, 2012

CLIENT PRESENTATION This is a case of patient R.F.L, a 32 year old female, born on the 11th of November 1980 and is currently residing in Makati City. She is a Roman Filipino Catholic and is living with her parents, works as a call center agent. She was brought to the Emergency Department of a tertiary hospital in Makati ast January 3, 2011 with a chief complaint of decreasing urinary output. Patient is a known case of Rheumatic Heart Disease (2000) maintained with medication. She is diagnosed with atrial fibrillation, congestive heart failure. On December 30, 2011, patient noted the development of edema which started around her ankles and within a day reached up to her thighs, refraining her from going to work due to limited mobility. On December 31, 2011, patient sought consult at a satellite clinic of Medical City, where she was advised to just continue on with her medication and to seek medical advice again after 2-3 days if without improvement. Hence admission. Review of systems reveals that patient has body weakness, afebrile, no dizziness nor headache, no nausea/vomiting or diarrhea. She experiences shortness of breath, no chest pain. Gastrointestinal, urinary, genital, peripheral vascular, musculoskeletal and neuro/psychiatric assessment shows no significant findings. Past medical history reveals that patient was confined a number of times due to RHD last August 2008 & 2011 at a tertiary hospital in Makati. She is currently on the following medications: Digoxin 25mg, Aspirin 80mg, Furosemide 40mg three times a week if without symptoms, Spirinolactone + Aldactone 50mg and Coversyl 25mg. Patient has no allergies.

Family history reveals that the grandfather of the patients mother has diabetes. However there is no history of hypertension, coronary artery disease, asthma and cancer. Personal history reveals that patient smoked 5 sticks of cigarette per day for a few months but stopped upon being diagnosed with rheumatic heart disease, occasionally drinks but lately has refrained. She denies illicit drug use and does not engage in physical activities. Socio- economic history reveals that she works as a call center agent, sources of support is herself and family. Patient seems to accept her current condition, does not have leisure activities Upon physical examination, patient looks cathetic, hooked to nasal cannula at 2lpm, globular abdomen with foley catheter inserted, bulging eyes, slightly pale palpebral conjunctiva and slightly yellowish. Supple, distended neck veins while reclined at approximately 45 degrees. No scars or masses noted, breath sounds are slightly decreased on the right and both lung bases. Upon cardiovascular auscultation: dynamic precordium, heart rate of 38 beats per minute, irregular, (+) heaves, palpable thrills. Apex displaced to 6th intercostals space anterior to mid axillary line, (+) systolic murmur heard best at apex. Globular abdomen, normoactive bowel sounds, hepatomegaly (liver edge palpated from left midclavicular area sloping across the midline to below the umbilicus on the right), no edema. Client was limited to 1 liter fluid intake per day and has a diet of low salt, low fat. The student nurse was able to take care of the patient from the 4th to the 6th of January 2011 during the morning (0600H-1400H) shift. Student nurse introduced herself to the patient so as to establish rapport and informed her of the activities to be done during the shift. Initial vital signs for 0800H was taken with the following results: 100/70 mmHg, 30cpm, 36.7 C, 38bpm, 0/10 PS. Bedside nurse was made aware that the patient was tachypneic (30 cpm) and bradycardic

(38bpm). Breath sounds were decreased on both lung bases, shallow breaths and altered chest excursion were noted. Patient verbalized medyo hirap ako huminga. Latest hematology laboratory results are as follows: HGB (L) 10.10 g/dL, Hct (L) 30.90%, RBC (L) 4.21x10^6/uL, WBC (L) 3.40% x10^3/uL.With the above stated objective and subjective cues, Ineffective breathing pattern related to decreased breath sounds on both lung bases as evidenced by respiratory rate of 30cpm Ineffective cardiopulmonary tissue perfusion related to decreased hemoglobin concentration as evidenced by low hemoglobin count of 10.10 g/dL nursing problem was identified. The goal for this problem was to improve breathing pattern and improve cardiopulmonary tissue perfusion. The following nursing interventions were done: established rapport with patient, vital signs taken and recorded,noting changes in blood pressure, heart rate and respirations, auscultated chest,taking note of adventitious breath sounds, noted rate and depth of respirations, identify changes related to systemic and/or peripheral alterations in circulation (change in sensorium,vital sign changes,pain, change in skin appearance,temperature), assess extremities, noting skin texture or presence of edema, elevated head of bed, placed patient to preferred position of comfort, encouraged slower/deeper respirations, cautioned client to avoid activities that increase cardiac workload, use of pursed lip technique, elevated lower extremities, placed pillow under patients legs, instructed patient to take adequate rest periods after performing breathing exercises, discussed relationship of smoking to respiratory function, kept side rails elevated, placed call light within patients reach. After verbalization of discomfort regarding difficulty in breathing, altered heart rhythm and tachypnea (30cpm) and bradypnea (38bpm) being present, positivie palpable thrills, heaves, systolic murmur heard best at apex and distended neck veins upon physical assessment, Decreased cardiac output related to altered heart rhythm (atrial fibrillation) as evidenced

by tachypnea (30cpm) and bradypnea ( 38bpm) nursing diagnosis was formed. Same nursing interventions was done to meet the goal which is to improve cardiopulmonary tissue perfusion. Taking into consideration that the patient has problems in oxygenation and cardiopulmonary perfusion, the nursing problem Risk for activity intolerance related to altered heart rhythm (atrial fibrillation) was formed. The following nursing interventions were done to meet the goal: Vital signs taken and recorded,noting changes in bloodpressure, heart rate and respirations, asked patient about usual level of energy, encouraged patient to perform passive exercises, discussed with patient the relationship of her condition to inability to perform desired activities, instructed client to verbalize the need for assist/assistive devices when needed, encouraged patient to take adequate rest periods, provided quiet environment,place call light within patients reach. List of Problems: 1. Ineffective breathing pattern related to decreased breath sounds on both lung bases as evidenced by respiratory rate of 30cpm 2. Ineffective cardiopulmonary tissue perfusion related to decreased hemoglobin concentration as evidenced by low hemoglobin count of 10.10 g/dL 3. Decreased cardiac output related to altered heart rhythm (atrial fibrillation) as evidenced by tachypnea (30cpm) and bradypnea ( 38bpm) 4. Risk for activity intolerance related to altered heart rhythm (atrial fibrillation)

Psychosocial and Spiritual The patient has no psychosocial and/or spiritual problems. She was easy to get along with and was willing to cooperate with the interventions being done to her.

Summary of Interventions Diagnostic Examinations o Hematology o Clinical Chemistry o Complete blood count o X-ray o Urinalysis

Surgical Interventions The patient did not undergo any type of surgery Independent Nursing Actions Established rapport with patient Vital signs taken and recorded,noting changes in bloodpressure, heart rate and respirations Auscultated chest,taking note of adventitious breath sounds, noted rate and depth of respirations Elevated head of bed, placed patient to preferred position of comfort Encouraged slower/deeper respirations, use of pursed lip technique.

Instructed patient to take adequate rest periods after performing breathing exercises Discussed relationship of smoking to respiratory function Kept side rails elevated, placed call light within patients reach

Placed client in semi-Fowlers position Elevated lower extremities, placed pillow under patients legs Reminded client that she can only consume 1 liter of fluids in a day Educated client about her low salt, low fat diet Encouraged client to change positions slowly and dangle legs before standing

Asked patient about usual level of energy Encouraged patient to perform passive exercises Discussed with patient the relationship of her condition to inability to perform desired activities Instructed client to verbalize the need for assist/assistive devices when needed

Evaluation