(CHF)

A. Definition

Heart failure (HF) or Congestive Heart Failure (CHF) is a physiologic state in which
the heart cannot pump enough blood to meet the metabolic needs of the body. Heart
failure results from changes in the systolic or diastolic function of the left ventricle. The
heart fails when, because of intrinsic disease or structural it cannot handle a normal
blood volume or, in absence of disease, cannot tolerate a sudden expansion in blood
volume. Heart failure isa progressive and chronic condition that is managed by
significant lifestyle changes and adjunct medical therapy to improve quality of life. Heart
failure is caused from a variety of cardiovascular conditions such as
chronic hypertension, coronary artery disease, and valvular disease.
Heart failure is not a disease itself, instead, the term refers to a clinical syndrome
characterized by manifestations of volume overload, inadequate tissue perfusion, and
poor exercise tolerance. Whatever the cause, pump failure results in hypoperfusion of
tissues, followed by pulmonary and systemic venous congestion.

B. Clinical Manifestations

The signs and symptoms of heart failure are defined based on which ventricle
is affected — left-sided heart failure causes a different set of manifestations than right-
sided heart failure.

Left-Sided Heart Failure

 Dyspnea on exertion
 Pulmonary congestion
 Cough that is initially dry and nonproductive
 Frothy sputum that is sometimes blood-tinged
 Inadequate tissue perfusion
 Weak, thready pulse
 Fatigue

Right-Sided Heart Failure

 Congestion of the viscera and peripheral tissues
 Edema of the lower extremities
 Because heart failure causes vascular congestion, it is often called congestive
heart failure, although most cardiac specialist no longer uses this term. Other terms
used to denote heart failure include chronic heart failure, cardiac decompensation,
cardiac insufficiency, and ventricular failure.

C. Nursing Diagnosis

1. Decreased Cardiac Output: Inadequate blood pumped by the heart to meet

metabolic demands of the body.
Related factors:
 Altered myocardial contractility/inotropic changes
 Alterations in rate, rhythm, electrical conduction
 Structural changes (e.g., valvular defects, ventricular aneurysm)
 Poor cardiac reserve
 Side effects of medication
 Generalized weakness.

Defining Characteristics
 Increased heart rate (tachycardia), dysrhythmias, ECG changes
 Changes in BP (hypotension/hypertension)
 Extra heart sounds (S3, S4)
 Decreased urine output
 Diminished peripheral pulses
 Cool, ashen skin; diaphoresis
 Orthopnea, crackles, JVD, liver engorgement, edema
 Chest pain

Desired Outcomes
 Patient will demonstrate adequate cardiac output as evidenced by vital
signs within acceptable limits, dysrhythmias absent/controlled, and no
symptoms of failure (e.g., hemodynamic parameters within acceptable
limits, urinary output adequate).

 Patient will report decreased episodes of dyspnea, angina.

 Patient will participate in activities that reduce cardiac workload.
 D. Nursing Interventions

Nursing Interventions Rationale

Nursing Assessment

Tachycardia is usually present (even at rest) to

compensate for decreased ventricular
contractility. Premature atrial contractions (PACs),
paroxysmal atrial tachycardia (PAT), PVCs,
multifocal atrial tachycardia (MAT), and atrial
fibrillation (AF) are common dysrhythmias
Auscultate apical pulse, assess heart rate, rhythm. associated with HF, although others may also
Document dysrhythmia if telemetry is available. occur.

Note: Intractable ventricular dysrhythmias

unresponsive to medication suggest ventricular
aneurysm.

S1 and S2 may be weak because of diminished

pumping action. Gallop rhythms are common
Note heart sounds. (S3and S4), produced as blood flows into
noncompliant chambers. Murmurs may reflect
valvular incompetence.
Decreased cardiac output may be reflected in
diminished radial, popliteal, dorsalis pedis, and
Palpate peripheral pulses. post tibial pulses. Pulses may be fleeting or
irregular to palpation, and pulsus alternans (strong
beat alternating with weak beat) may be present.
In early, moderate, or chronic HF, BP may be
elevated because of increased SVR. In advanced
Monitor BP. HF, the body may no longer be able to
compensate, and profound hypotension may
occur.
Nursing Interventions Rationale

Pallor is indicative of diminished peripheral

perfusion secondary to inadequate cardiac output,
vasoconstriction, and anemia. Cyanosis may
Inspect skin for pallor, cyanosis.
develop in refractory HF. Dependent areas are
often blue or mottled as venous congestion
increases.
Kidneys respond to reduced cardiac output by
retaining water and sodium. Urine output is
Monitor urine output, noting decreasing output usually decreased during the day because of fluid
and concentrated urine. shifts into tissues but may be increased at night
because fluid returns to circulation when patient is
recumbent.
Note changes in sensorium: lethargy, confusion, May indicate inadequate cerebral perfusion
disorientation, anxiety, and depression. secondary to decreased cardiac output.
Allows detection of left-sided heart failure that
may occur with chronic renal failure patients due
Assess for abnormal heart and lung sounds.
to fluid volume excess as the diseased kidneys are
unable to excrete water.
Patients with renal failure are most often
hypertensive, which is attributable to excess fluid
Monitor blood pressure and pulse.
and the initiation of the renin-angiotensin
mechanism.
The accumulation of waste products in the
bloodstream impairs oxygen transport and intake
Assess mental status and level of consciousness.
by cerebral tissues, which may manifest itself as
confusion, lethargy, and altered consciousness.
Decreased perfusion and oxygenation of tissues
secondary to anemia and pump ineffectiveness
Assess patient’s skin temperature and peripheral
may lead to decreased in temperature and
pulses.
peripheral pulses that are diminished and difficult
to palpate.
Results of the test provide clues to the status of
Monitor results of laboratory and diagnostic tests.
the disease and response to treatments.
Nursing Interventions Rationale

Provides information regarding the heart’s ability

Monitor oxygen saturation and ABGs.
to perfuse distal tissues with oxygenated blood
Therapeutic Interventions
Makes more oxygen available for gas exchange,
Give oxygen as indicated by patient symptoms,
assisting to alleviate signs of hypoxia and
oxygen saturation and ABGs.
subsequent activity intolerance.
Implement strategies to treat fluid and electrolyte Decreases the risk for development of cardiac
imbalances. output due to imbalances.
Administer cardiac glycoside agents, as ordered, Digitalis has a positive isotropic effect on the
for signs of left sided failure, and monitor for myocardium that strengthens contractility, thus
toxicity. improving cardiac output.
Encourage periods of rest and assist with all Reduces cardiac workload and minimizes
activities. myocardial oxygen consumption.
Assist the patient in assuming a high Fowler’s Allows for better chest expansion, thereby
position. improving pulmonary capacity.
Teach patient the pathophysiology of disease, Provides the patient with needed information for
medications management of disease and for compliance.
Reposition patient every 2 hours To prevent occurrence of bed sores
Instruct patient to get adequate bed rest
To promote relaxation to the body
and sleep
To ensure safety and reduce risk for fallsthat may
Instruct the SO not to leave the client unattended
lead to injury
Physical rest should be maintained during acute or
Encourage rest, semirecumbent in bed or chair. refractory HF to improve efficiency of cardiac
Assist with physical care as indicated. contraction and to decrease myocardial oxygen
demand/ consumption and workload.
Provide quiet environment: explain
Psychological rest helps reduce emotional stress,
therapeutic management, help patient avoid
which can produce vasoconstriction, elevating BP
stressful situations, listen and respond to
and increasing heart rate.
expressions of feelings.
Provide bedside commode. Have patient avoid Commode use decreases work of getting to
activities eliciting a vasovagal response (straining bathroom or struggling to use bedpan. Vasovagal
Nursing Interventions Rationale

during defecation, holding breath during position maneuver causes vagal stimulation followed by
changes). rebound tachycardia, which further compromises
cardiac function.
Elevate legs, avoiding pressure under knee.
Decreases venous stasis, and may reduce
Encourage active and passive exercises. Increase
incidence of thrombus or embolus formation.
activity as tolerated.
Check for calf tenderness, diminished pedal Reduced cardiac output, venous pooling, and
pulses, swelling, local redness, or pallor of enforced bed rest increases risk
extremity. of thrombophlebitis.
Incidence of toxicity is high (20%) because of
Withhold digitalis preparation as indicated, and narrow margin between therapeutic and toxic
notify physician if marked changes occur in cardiac ranges. Digoxinmay have to be discontinued in the
rate or rhythm or signs of digitalis toxicity occur. presence of toxic drug levels, a slow heart rate, or
low potassium level.
Increases available oxygen for myocardial uptake
Administer supplemental oxygen as indicated.
to combat effects of hypoxia.
Administer medications as indicated:
Diuretics, in conjunction with restriction of dietary
sodium and fluids, often lead to clinical
improvement in patients with stages I and II HF. In
general, type and dosage of diuretic depend on
 Diuretics: furosemide (Lasix), ethacrynic
cause and degree of HF and state of renal
acid (Edecrin), bumetanide (Bumex),
function. Preload reduction is most useful in
spironolactone (Aldactone).
treating patients with a relatively normal cardiac
output accompanied by congestive symptoms.
Loop diuretics block chloride reabsorption, thus
interfering with the reabsorption of sodium and
water.
 Vasodilators: nitrates (Nitro-Dur, Vasodilators are the mainstay of treatment in HF
Isordil); and are used to increase cardiac output, reducing
 arterial dilators: hydralazine circulating volume (venodilators) and decreasing
(Apresoline); SVR, thereby reducing ventricular workload. Note:
 combination drugs: prazosin Parenteral vasodilators (Nitroprusside) are
Nursing Interventions Rationale

(Minipress); reserved for patients with severe HF or those

unable to take oral medications.
 ACE inhibitors: benazepril (Lotensin), ACE inhibitors represent first-line therapy to
captopril (Capoten), lisinopril (Prinivil), control heart failure by decreasing ventricular
enalapril (Vasotec), quinapril (Accupril), filling pressures and SVR while increasing cardiac
ramipril (Altace), moexipril (Univasc). output with little or no change in BP and heart
rate.
 Angiotensin II receptor Antihypertensive and cardioprotective effects are
antagonists: eprosartan (Teveten), attributable to selective blockade of
irbesartan (Avapro), valsartan (Diovan); AT1(angiotensin II) receptors and angiotensin II
synthesis.
Increases force of myocardial contraction when
diminished contractility is the cause of HF, and
 Digoxin (Lanoxin) slows heart rate by decreasing conduction velocity
and prolonging refractory period of the
atrioventricular (AV) junction to increase cardiac
efficiency /output.
These medications are useful for short-term
treatment of HF unresponsive to cardiac
 Inotropic agents: amrinone (Inocor),
glycosides, vasodilators, and diuretics in order to
milrinone (Primacor), vesnarinone
increase myocardial contractility and produce
(Arkin-Z);
vasodilation. Positive inotropic properties have
reduced mortality rates 50% and improved quality
of life.
 Beta-adrenergic receptor
Useful in the treatment of HF by blocking the
antagonists: carvedilol (Coreg),
cardiac effects of chronic adrenergic stimulation.
bisoprolol (Zebeta), metoprolol
Many patients experience improved activity
(Lopressor);
tolerance and ejection fraction.

Decreases vascular resistance and venous return,

reducing myocardial workload, especially when
 Morphine sulfate.
pulmonary congestion is present. Allays anxiety
and breaks the feedback cycle of anxiety to
catecholamine release to anxiety.
Nursing Interventions Rationale

 Antianxiety agents and sedatives. Promote rest, reducing oxygen demand and
myocardial workload.
May be used prophylactically to prevent thrombus
 Anticoagulants: low-dose heparin, and embolus formation in presence of risk factors
warfarin (Coumadin). such as venous stasis, enforced bed rest, cardiac
dysrhythmias, and history of previous thrombotic
episodes.
Because of existing elevated left ventricular
pressure, patient may not tolerate increased fluid
Administer IV solutions, restricting total amount as
volume (preload). Patients with HF also excrete
indicated. Avoid saline solutions.
less sodium, which causes fluid retention and
increases myocardial workload.
Fluid shifts and use of diuretics can alter
Monitor and replace electrolytes. electrolytes (especially potassium and chloride),
which affect cardiac rhythm and contractility.
ST segment depression and T wave flattening can
develop because of increased myocardial oxygen
Monitor serial ECG and chest x-raychanges. demand, even if no coronary artery disease is
present. Chest x-ray may show enlarged heart and
changes of pulmonary congestion.
Cardiac index, preload, afterload, contractility, and
cardiac work can be measured noninvasively by
Measure cardiac output and other functional
using thoracic electrical bioimpedance (TEB)
parameters as indicated.
technique. Useful in determining effectiveness of
therapeutic interventions and response to activity.
Monitor laboratory studies:
 BUN, creatinine. Elevation of BUN or creatinine
reflects kidney hypoperfusion.
May be elevated because of liver congestion and
 Liver function studies (AST, LDH).
indicate need for smaller dosages of medications
that are detoxified by the liver.
 Prothrombin time (PT), activated partial Measures changes in coagulation processes or
thromboplastin time (aPTT) coagulation effectiveness of anticoagulant therapy.
Nursing Interventions Rationale

studies.

May be necessary to correct bradydysrhythmias

 Prepare for insertion and maintenance
unresponsive to drug intervention, which can
of pacemaker, if indicated.
aggravate congestive failure and/or produce
pulmonary edema.
Prepare for surgery as indicated:
Heart failure due to ventricular aneurysm or
valvular dysfunction may require aneurysmectomy
 Valve replacement, angioplasty,
or valve replacement to improve myocardial
coronary artery bypass grafting (CABG).
contractility/ function. Revascularization of
cardiac muscle by CABG may be done to improve
cardiac function.
Cardiomyoplasty, an experimental procedure in
which the latissimus dorsi muscle is wrapped
around the heart and electrically stimulated to
 Cardiomyoplasty.
contract with each heartbeat, may be done to
augment ventricular function while the patient is
awaiting cardiac transplantation or when
transplantation is not an option.
Other new surgical techniques include
transmyocardial revascularization (percutaneous
 Transmyocardial revascularization. [PTMR]) using CO2 laser technology, in which a
laser is used to create multiple 1-mm diameter
channels in viable but underperfused cardiac
muscle.
An intra-aortic balloon pump (IABP) may be
inserted as a temporary support to the failing
heart in the critically ill patient with potentially
Assist with mechanical circulatory support system, reversible HF. A battery-powered ventricular assist
such as IABP or VAD, when indicated. device (VAD) may also be used, positioned
between the cardiac apex and the descending
thoracic or abdominal aorta. This device receives
blood from the left ventricle (LV) and ejects it into
Nursing Interventions Rationale

the systemic circulation, often allowing patient to

resume a nearly normal lifestyle while awaiting
heart transplantation. With end-stage HF, cardiac
transplantation may be indicated.

2. Activity Intolerance: Insufficient physiologic or physiological energy to endure or

complete required or desired activity.

Related Factors
 Imbalance between oxygen supply/demand
 Generalized weakness
 Prolonged bed rest/immobility

Defining Characteristics
 Weakness, fatigue
 Changes in vital signs, presence of dysrhythmias
 Dyspnea
 Pallor, diaphoresis

Desired Outcomes
 Participate in desired activities; meet own self-care needs.
 Achieve measurable increase in activity tolerance, evidenced by reduced
fatigue and weakness and by vital signs within acceptable limits during
activity.

Nursing Interventions Rationale

Nursing Assessment

Check vital signs before and immediately after

Orthostatic hypotension can occur with activity
activity, especially if patient is receiving
because of medication effect (vasodilation), fluid
vasodilators, diuretics, or beta-blockers.
shifts (diuresis), or compromised cardiac pumping
Nursing Interventions Rationale

function.

Compromised myocardium and/or inability to

Document cardiopulmonary response to activity. increase stroke volume during activity may cause
Note tachycardia, dysrhythmias, dyspnea, an immediate increase in heart rate and oxygen
diaphoresis, pallor. demands, thereby aggravating weakness and
fatigue.

Fatigue is a side effect of some medications (beta-

Assess for other causes of fatigue (treatments, blockers, tranquilizers, and sedatives). Pain and
pain, medications). stressful regimens also extract energy and produce
fatigue.

To note for any abnormalities and deformities

Assess patient’s general condition
present within the body

Therapeutic Interventions

May denote increasing cardiac decompensation

Evaluate accelerating activity intolerance.
rather than overactivity.

Provide assistance with self-care activities as Meets patient’s personal care needs without
indicated. Intersperse activity periods with rest undue myocardial stress and excessive oxygen
periods. demand.

Strengthens and improves cardiac function under

stress, if cardiac dysfunction is not irreversible.
Implement graded cardiac rehabilitation program.
Gradual increase in activity avoids excessive
myocardial workload and oxygen consumption.

Assist patient with ROM exercises. Check regularly To prevent deep vein thrombosis due to vascular
for calf pain and tenderness. congestion.

Adjust client’s daily activities and reduce intensity Prevents straininga nd overexertion which may
Nursing Interventions Rationale

of level. Discontinue activities that cause aggravate symptoms

undesired psychological changes

Instruct client in unfamiliar activities and in

Conserves energy and promote safety
alternate ways of conserve energy

Encourage patient to have adequate bed rest

Relaxes the body and promotes comfort
and sleep

Provide the patient with a calm and quiet

Provides relaxation
environment

Assist the client in ambulation Prevents risk for falls that could lead to injury

Note presence of factors that could contribute to Fatigue affects both the client’s actual and
fatigue perceived ability to participate in activities

Ascertain client’s ability to stand and move about

Determines current status and needs associated
and degree of assistance needed or use of
with participation in needed or desired activities
equipment

Give client information that provides evidence of

Sustains motivation of client
daily or weekly progress

Encourage the client to maintain a positive

Enhances sense of well being
attitude

Assist the client in a semi-fowlers position Promotes easy breathing

Elevate the head of the bed Maintains an open airway

Prevents injuries
Assist the client in learning and demonstrating
Nursing Interventions Rationale

appropriate safety measures

Instruct the SO not to leave the client unattended Avoids risk for falls

Provide client with a positive atmosphere Helps minimize frustration and rechannel energy

Instruct the SO to monitor response of patient to

Indicates need to alter activity level
an activity and recognize the signs and symptoms

3. Acute Pain: Unpleasant sensory and emotional experience arising from actual or
potential tissue damage or described in terms of such damage; sudden or slow
onset of any intensity from mild to severe with anticipated or predictable end
and a duration of <6 months.

Nursing Interventions Rationale

Nursing Assessment

Assess patient pain for intensity using a pain rating To identify intensity, precipitating factors and
scale, for location and for precipitating factors. location to assist in accurate diagnosis.

The vasodilator nitroglycerin enhances blood flow

Administer or assist with self-administration of to the myocardium. It reduces the amount of
vasodilators, as ordered. blood returning to the heart, decreasing preload
which in turn decreases the workload of the heart.

Assessing response determines effectiveness of

Assess the response to medications every 5
medication and whether further interventions are
minutes
required.
Nursing Interventions Rationale

To provide non pharmacological pain

Provide comfort measures.
management.

A quiet environment reduces the energy demands

Establish a quiet environment.
on the patient.

Elevation improves chest expansion and

Elevate head of bed.
oxygenation.

Tachycardia and elevated blood pressure usually

Monitor vital signs, especially pulse and blood occur with angina and reflect compensatory
pressure, every 5 minutes until pain subsides. mechanisms secondary to sympathetic nervous
system stimulation.

Anginal pain is often precipitated by emotional

Teach patient relaxation techniques and how to
stress that can be relieved non-pharmacological
use them to reduce stress.
measures such as relaxation.

In some case, the chest pain may be more serious

Teach the patient how to distinguish between
than stable angina. The patient needs to
angina pain and signs and symptoms of myocardial
understand the differences in order to seek
infarction.
emergency care in a timely fashion.

Hypertension
A. Definition

Hypertension is the term used to describe high blood pressure. Hypertension is

repeatedly elevated blood pressure exceeding 140 over 90 mmHg. It is categorized
as primary or essential (approximately 90% of all cases) or secondary, which occurs as a
result of an identifiable, sometimes correctable pathological condition, such as renal
disease or primary aldosteronism pathological condition, such as renal disease or
primary aldosteronism.

B. Nursing Diagnosis

 Cardiac Output, risk for decreased

C. Risk factors may include

 Increased vascular resistance, vasoconstriction

 Myocardial ischemia
 Ventricular hypertrophy/rigidity

D. Possibly evidenced by

 Not applicable. Existence of signs and symptoms establishes an actual nursing

diagnosis.

E. Desired Outcomes

 Participate in activities that reduce BP/cardiac workload.

 Maintain BP within individually acceptable range.
 Demonstrate stable cardiac rhythm and rate within patient’s normal range.
 Participate in activities that will prevent stress (stress management, balanced
activities and rest plan).

Dengue Fever

A. Definition

 Dengue fever is an acute febrile disease caused by infection with one of the
serotypes of dengue virus. It is a mosquito-born disease caused by genus Aedes.
  Dengue is also known as Breakbone Fever, Hemorrhagic Fever, Dandy Fever,
Infectious Thrombocytopenic Purpura.
 Dengue hemorrhagic fever is a fatal manifestation of dengue virus that manifest
with bleeding diathesis and hypovolemic shock.
 These viruses are related to the viruses that cause the West Nile infection and yellow
fever.

B. Pathophysiology

The pathophysiology of dengue hemorrhagic fever include:

 Initial phase. The initial phase of DHF is similar to that of dengue fever and other
febrile viral illnesses. The virus is deposited in the skin by the vector, within few days
viremia occurs, lasting until the 5th day for the symptoms to show.
 Hemorrhagic symptoms. Shortly after the fever breaks or sometimes within 24 hours
before, signs of plasma leakage appear along with the development of hemorrhagic
symptoms.
 Vascular leakage. Vascular leakage in these patients results in hemoconcentration
and serous effusions and can lead to circulatory collapse.
 Progression. If left untreated, DHF most likely progresses to dengue shock syndrome.

C. Etiology

The etiologic agent and vector of dengue:

 Flavivirus. It is caused by infection of one of the four serotypes of dengue virus,

which is a Flavivirus, a genus of single-stranded nonsegmented RNA virus.

 Aedes aegypti. Dengue virus is transmitted by day-biting mosquitoes of the genus

Aedes that breeds in stagnant water. It has white dots at the base of its wings, with
white bands on the legs.
 Incubation period. It has an incubation period of three to ten days.

D. Clinical Manifestations

Symptoms, which usually begin 4 to 6 days after infection and may last to up to 10 days,
include:
  High fever. Sudden high fever occurs as a result of the infection.

 Severe headaches. Severe headaches also torment the patient.

 Damage to lymph and blood vessels. As the virus slowly spreads, even the lymph
and blood vessels are affected.
 Bleeding. Bleeding from the nose and gums is a characteristic of DHF.
 Enlargement of the liver. The dengue virus could also penetrate the liver, causing
fatal damage.
 Circulatory system failure. The circulatory system ultimately fails eventually if the
disease is not treated promptly.

E. Complications

Dengue cases may be not adequately recognized in the United States, and as a result,
many cases often end up with complications.

 Dengue shock syndrome. Common symptoms in impending shock include abdominal

pain, vomiting, and restlessness.

F. Assessment and Diagnostic Findings

Laboratory criteria for the diagnosis of dengue virus may include 1 of the following:

 Dengue virus isolation. Isolation of the dengue virus from serum, plasma,
leukocytes, or autopsy samples.
 Immunoglobulin titers. Demonstration of a fourfold or greater change in reciprocal
immunoglobulin or IgM antibody titers to one or more dengue virus antigens in
paired serum samples.
 Immunohistochemistry. Demonstration of the dengue virus antigen in autopsy
tissue via immunohistochemistry or immunofluorescence.
 Polymerase chain reaction. Detection of viral genomic sequences in autopsy tissue,
serum, or cerebrospinal fluid samples via PCR.
 Complete blood count. In DHF, there may be presence of increases hematocrit level
secondary to plasma extravasation and/or third-space fluid loss.
 Decreased platelet count. This test confirms dengue.
 Guaiac test. Guaiac testing for occult blood in the stool should be performed on all
patients suspected with dengue virus infection.
G. Nursing Diagnosis

Based on the assessment data, the major nursing diagnoses for a patient with DHF are:

 Risk for bleeding related to possible impaired liver function.

 Deficient fluid volume related to vascular leakage.
 Pain related to abdominal pain and severe headaches.
 Risk for ineffective tissue perfusion related to failure of the circulatory system.
 Risk for shock related to dysfunction in the circulatory system.

H. Nursing Care Planning and Goals

The goals in a patient with DHF are:

 Be free of signs of bleeding.

 Display laboratory results within normal range for individuals.
 Maintain fluid volume at a functional level.
 Report pain is relieved or controlled.
 Follow prescribed pharmacologic regimen.
 Demonstrate adequate tissue perfusion.
 Display hemodynamic stability.
 Be afebrile and free from other signs of infection.

I. Nursing Interventions

Nursing interventions appropriate for a patient with DHF include:

 Blood pressure monitoring. Measure blood pressure as indicated.

 Monitoring pain. Note client report of pain in specific areas, whether pain is
increasing, diffused, or localized.
 Vascular access. Maintain patency of vascular access for fluid administration or blood
replacement as indicated.
 Medication regimen. There must be a periodic review of the medication regimen of
the client to identify medications that might exacerbate bleeding problems.
 Fluid replacement. Establish 24-hour fluid replacement needs.
 Managing nose bleeds. Elevate position of the patient and apply ice bag to the bridge
of the nose and to the forehead.
 Trendelenburg position. Place the patient in Trendelenburg position to restore blood
volume to the head.
J. Evaluation

A successful nursing care plan has achieved the following:

 Absence of signs of bleeding.

 Displayed laboratory results within normal range for individuals.
 Maintained fluid volume at a functional level.
 Reported pain is relieved or controlled.
 Followed prescribed pharmacologic regimen.
 Demonstrated adequate tissue perfusion.
 Displayed hemodynamic stability.
 Afebrile and free from other signs of infection.
 Diabetes Mellitus

A. Definition

Diabetes mellitus (DM) is a chronic disease characterized by insufficient production

of insulin in the pancreas or when the body cannot efficiently use the insulin it produces.
This leads to an increased concentration of glucose in the bloodstream (hyperglycemia). It is
characterized by disturbances in carbohydrate, protein, and fat metabolism.

Sustained hyperglycemia has been shown to affect almost all tissues in the body and is
associated with significant complications of multiple organ systems, including the eyes, nerves,
kidneys, and blood vessels.

B. Nursing Care Plans for Diabetes Mellitus

Nursing care planning goals for patients with diabetes include effective treatment to
normalize blood glucose and decrease complications using insulin replacement, balanced
diet, and exercise. The nurse should stress the importance of complying with the prescribed
treatment program. Tailor your teaching to the patient’s needs, abilities, and developmental
stage. Stress the effect of blood glucose control on long-term health.

C. Risk for Unstable Blood Glucose

Risk for Unstable Blood Glucose: At risk for variation of blood glucose levels from the
normal range that may compromise health. Risk factors:

 Inadequate blood glucose monitoring

 Lack of adherence to diabetes management
 Medication management
 Deficient knowledge of diabetes management
 Developmental level
 Lack of acceptance of diagnosis
 Stress
 Sedentary activity level
 Insulin deficiency or excess
Nursing Interventions Rationale

Hyperglycemia results when there is an

inadequate amount of insulin to glucose.
Excess glucose in the blood creates an
Assess for signs of hyperglycemia. osmotic effect that results in increased thirst,
hunger, and increased urination. The patient
may also report nonspecific symptoms
of fatigue and blurred vision.

Blood glucose should be between 140 to 180

Assess blood glucose level before meals and at
mg/dL. Non-intensive care patients should be
bedtime.
maintained at pre-meal levels <140 mg/dL.

This is a measure of blood glucose over the

Monitor patient’s HbA1c-glycosylated hemoglobin. previous 2 to 3 months. A level of 6.5% to 7%
is desirable.

Assess for anxiety, tremors, and slurring of speech. These are signs of hypoglycemia and D50 is
Treat hypoglycemia with 50% dextrose. treatment for it.

Assess feet for temperature, pulses, color, and To monitor peripheral perfusion and
sensation. neuropathy.

Nonadherence to dietary guidelines can result

Assess the patient’s current knowledge and
in hyperglycemia. An individualized diet plan
understanding about the prescribed diet.
is recommended.

Physical activity helps lower blood glucose

levels. Regular exercise is a core part of
Assess the pattern of physical activity.
diabetes management and reduces risk for
cardiovascular complications.
 A patient with type 2 DM who uses insulin as
part of the treatment plan is at increased risk
for hypoglycemia. Manifestations of
hypoglycemia may vary among individuals but
are consistent in the same individual. The
Monitor for signs of hypoglycemia. signs are the result of both increased
adrenergic activity and decreased
glucose delivery to the brain, therefore, the
patient may experienced tachycardia,
diaphoresis, dizziness, headache, fatigue, and
visual changes.

Adherence to the therapeutic regimen

promotes tissue perfusion. Keeping glucose in
Administer basal and prandial insulin.
the normal range slows progression of
microvascular disease.

Blood glucose is monitored before meals and

Teach patient how to perform home glucose
at bedtime. Glucose values are used to adjust
monitoring.
insulin doses.

Hypertension is commonly associated with

Report BP of more than 160 mm Hg (systolic). diabetes. Control of BP prevents coronary
Administer hypertensive as prescribed. artery disease, stroke, retinopathy, and
nephropathy.

Instruct patient to avoid heating pads and always to Patients have decreased sensation in
wear shoes when walking. the extremities due to peripheral neuropathy.

Renal failure causes creatinine >1.5 mg/dL.

Monitor urine albumin to serum creatinine for renal
Microalbuminuria is the first sign of diabetic
failure.
nephropathy.

Instruct patient to take oral hypoglycemic medications as directed:

Stimulates insulin secretion by the pancreas.

 Sulfonylureas: glipizide (Glucotrol),
They also enhance cell receptor sensitivity to
 glyburide (DiaBeta), glimepiride(Amaryl). insulin and decrease the liver synthesis of
glucose from amino acids and stored
glycogen.
 Meglitinides: repaglinide (Prandin)
Stimulates insulin secretion by the pancreas.

These drugs decrease the amount of glucose

 Biguanides: metformin (Glucophage) produced by the liver and improve insulin
sensitivity. They enhance muscle cell receptor
sensitivity to insulin.
 Phenylalanine derivatives:nateglinide Stimulates rapid insulin secretion to reduce
(Starlix) the increases in blood glucose that occur soon
after eating.
 Alpha-glucosidase inhibitors:acarbose
Delays the absorption of glucose into the
(Precose), miglitol (Glyset).
blood from the intestine.

 Thiazolidinediones: pioglitazone (Actos),

Drugs decrease insulin resistance in
rosiglitazone (Avandia)
peripheral tissues.

 Incretin modifier: sitagliptin phosphate

Increases insulin secretion and
(Januvia)
decreases glucagon secretion.

Instruct patient to take insulin as directed

Have an onset of action within 15 minutes of
 Rapid-acting insulin analogs: lispro insulin
administration. The duration of action is 2 to
(Humalog), insulin aspart
3 hours for Humalog and 3 to 5 hours for
aspart.
Has an onset of action within 30 minutes of
 Short-acting insulin: regular
administration; duration of action is 4 to 8
hours.
 Intermediate-acting insulin: neutral
Onset of action for the intermediate-acting is
protamine Hagedorn (NPH), insulin zinc
one hour after administration; duration of
suspension (Lente)
action is 18 to 26 hours.

 Intermediate and rapid: 70% NPH/30% Premixed concentration has an onset of

regular. action similar to that of rapid-acting insulin
and a duration of action similar to that of
 intermediate-acting insulin.
Have an onset of one hour after
 Long-acting insulin: Ultralente, insulin
administration. Duration of action is 36
glargine (Lantus)
hours for Ultralente is 36 hours and for
glargine is at least 24 hours.
Instruct the patient on the proper preparation and administration of insulin.
Absorption of insulin is more consistent when
insulin is always injected in the same
anatomical site. Absorption if fastest in the
 Injection procedures.
abdomen, followed by the arms, thighs, and
buttocks. It is recommended by the American
Diabetes Association to administer insulin into
the subcutaneous tissue of the abdomen.
 Rotation of injection within one anatomical Injection of insulin in the same site over time
site. will result in lipoatrophy and lipohypertrophy
with reduced insulin absorption.
Insulin should be refrigerated at 2º to 8º C
(36º to 46º F). Unopened vials may be stored
 Storage of insulin. until their expiration date. To prevent
irritation from “cold insulin,” vials may be
stored at temperatures of 15º to 30ºC (59º to
86ºF) for 1 month. Opened
 Angina Pectoris

A. Definition
Angina pectoris is a clinical syndrome usually characterized by episodes or paroxysms of
pain or pressure in the anterior chest. The cause is insufficient coronary blood flow, resulting in
a decreased oxygen supply when there is increased myocardial demand for oxygen in response
to physical exertion or emotional stress.

B. Classification
There are five (5) classifications or types of angina.

 Stable angina. There is predictable and consistent pain that occurs on exertion and is
relieved by rest and/or nitroglycerin.
 Unstable angina. The symptoms increase in frequency and severity and may not be
relieved with rest or nitroglycerin.
 Intractable or refractory angina. There is severe incapacitating chest pain.
 Variant angina. There is pain at rest, with reversible ST-segment elevation and
thought to be caused by coronary artery vasospasm.
 Silent ischemia. There is objective evidence of ischemia but patient reports no pain.

C. Pathophysiology
Angina is usually caused by atherosclerotic disease.

 Almost invariably, angina is associated with a significant obstruction of at least one

major coronary artery.
 Oxygen demands not met. Normally, the myocardium extracts a large amount of
oxygen from the coronary circulation to meet its continuous demands.
 Increased demand. When there is an increase in demand, flow through the coronary
arteries needs to be increased.
 Ischemia. When there is blockage in a coronary artery, flow cannot be increased, and
ischemia results which may lead to necrosis or myocardial infarction.
 Schematic Diagram for Angina Pectoris via Scribd.

D. Clinical Manifestations

The severity of symptoms of angina is based on the magnitude of the precipitating

activity and its effect on activities of daily living.
  Chest pain. The pain is often felt deep in the chest behind the sternum and may
radiate to the neck, jaw, and shoulders.
 Numbness. A feeling of weakness or numbness in the arms, wrists and hands.
 Shortness of breath. An increase in oxygen demand could cause shortness of breath.
 Pallor. Inadequate blood supply to peripheral tissues cause pallor.

E. Nursing Assessment
In assessing the patient with angina, the nurse may ask regarding the following:

 Location of pain.
 Characteristics of pain.
 Health history.
 Pain scale.
 Onset of pain.
 Cause of pain.
 Measures that relieve pain.
 Other symptoms that occur with pain.

F. Nursing Diagnosis
Based on the assessment data, major nursing diagnosis may include:

 Ineffective cardiac tissue perfusion secondary to CAD as evidenced by chest pain or

other prodromal symptoms.
 Death anxiety related to cardiac symptoms.
 Deficient knowledge about the underlying disease and methods for avoiding
complication
 Noncompliance, ineffective management of therapeutic regimen related to failure
to accept necessary lifestyle changes.

G. Nursing Interventions
Nursing interventions for a patient with angina pectoris include:

 Treating angina. The nurse should instruct the patient to stop all activities and sit or
rest in bed in a semi-Fowler’s position when they experience angina, and administer
nitroglycerin sublingually.
 Reducing anxiety. Exploring implications that the diagnosis has for the patient and
providing information about the illness, its treatment, and methods of preventing its
progression are important nursing interventions.
 Preventing pain. The nurse reviews the assessment findings, identifies the level of
activity that causes the patient’s pain, and plans the patient’s activities accordingly.
 Decreasing oxygen demand. Balancing activity and rest is an important aspect of the
educational plan for the patient and family.