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Medical Dx FSCC Clinical Tool: Medical Diagnosis

Student_________________ Clients Initials_______ Clinical Week_______

Pathology of Disease: Describe the pathology related to your patients medical diagnosis. Include textbook signs and symptoms

Congestive heart failure is the inability of the heart to circulate blood effectively enough to meet the bodys metabolic needs. Heart failure
may affect the left or right ventricle, though often it affects the left side first. It may result from impaired ejection of blood from the heart
during systole or from impaired relaxation of the heart during diastole. About 400,000 people in the United States are diagnosed each year
with heart failure, and 10% to 20% die of the disease annually. The prognosis for patients with heart failure depends on the ejection
fraction, that is, the proportion of blood in the ventricle that is propelled from the heart during each contraction. Congestive heart failure
may result from myocardial infarction, myocardial ischemia, arrhythmias, heart valve lesions, congenital malformation of heart or vessels,
constrictive pericarditis, cardiomyopathies, renal failure, and fluid overload, thyrotoxicosis, and severe anemia. Congestive heart failure is
a chronic, long term condition that gradually becomes worse over time. The disease is easily diagnosed with a chest x-ray, which shows an
enlarged heart and pulmonary edema, and elevated levels (>100) of brain natriuretic peptide (BNP). Early symptoms include: labored
breathing, orthopnea, nocturia, and exertional fatigue. Later stage symptoms include: fatigue, pitting edema, dyspnea, ascites, below
normal O2 saturation, confusion, anxiety, crackles, wheeze, cough w/frothy pink or white sputum, enlarged spleen and liver, decreased
urine output, jugular vein distention (JVD), dilated pupils, cyanosis, cool skin, weak pulse, and decreased blood pressure.

Sources include: The American Heart Association, http://www.americanheart.org ,


Davis, F. A., Tabers Cyclopedic Medical Dictionary, 20th Edition
Jarvis, Carolyn, Physical Examination & Health Assessment, 4th Edition

Textbook Picture Client Presentation


Signs and Symptoms: Early symptoms Signs and Symptoms: The client is 90 years old, with a history of hypertension, and a brain
include: labored breathing, orthopnea, natriuretic peptide (BNP) of 268. This patient was admitted to the nursing home after being
nocturia, and exertional fatigue. Later displaced from Gulfport, Mississippi, by hurricane Katrina. The client does not have a long
stage symptoms include: fatigue, pitting history to derive information from.
edema, dyspnea, ascites, below normal O2
saturation, confusion, anxiety, crackles,
wheeze, cough w/frothy pink or white
sputum, enlarged spleen and liver,
decreased urine output, jugular vein
distention (JVD), dilated pupils, cyanosis, Medical Management including medications, diagnostic tests & surgery: The client is
cool skin, weak pulse, and decreased blood allergic to ace inhibitors, so the physician has prescribed Metoprolol 25 mg BID. The client
pressure. had a complete CBC, Blood gas workup, BUN, Creatinine, Na, K, Cl, Ca on September 14,
2005.
Medical Management including
medications, diagnostic tests & surgery:
Medications include: diuretics, afterload,
reducers (e.g., angiotensin-converting
enzyme inhibitors), and agents that
improve the contractility of the heart (e.g., Prognosis: Client is taking medications to reduce and maintain her diagnosis. She does not
digoxin, dobutamine) are often combined live an unhealthy lifestyle, doesnt smoke, and is given a diet appropriate for her health
in the acute and chronic treatment of heart condition.
failure. Other drugs that have shown to be
effective are nesiritide, nitrates,
hydralazine, and some beta blockers.
Diagnostic tests include: a chest x-ray, 24
hour ECG monitoring (Holter),
Electrocardiography, Cardiac enzymes,
Chest x-ray, Blood gases, Potassium,
Serum lipids, Echocardiogram, Nuclear
imaging, MUGA, Cardiac catheterization
w/angiography, and check levels of brain
natriuretic peptide (BNP), if >100, suggests
CHF.
Surgeries include: Valve heart
replacement surgery in patients with
valvular heart disease. Cardiac transplant
can be used in advanced heart failure.
Prognosis: Congestive heart disease is not
a curable disease, and may require frequent
hospitalizations. Effective treatment
requires client to quit smoking, maintain a
sensible exercise regime, and start eating a
low-fat, low-sodium, and low-cholesterol
diet, and regular check-ups w/physician.

Nursing Care: Monitor clients blood Nursing Care: Monitor clients blood pressure and pulse, weigh client daily, administer
pressure, pulse rate, and administer prescribed medications, maintain healthy diet, help client with mobility and exercise.
prescribed medications, teach patient to
make healthier lifestyle choices such as:
quit smoking, exercise, stress reduction,
low-fat diet choices, low-cholesterol diet
choices, lower salt intake.

How does your client compare to what is considered usual medical/nursing interventions?

My client is being well cared for by the nursing home staff and physicians. Medications are administered daily; eats a well-balanced diet,
and is made as comfortable as possible. The clients blood pressure, pulse rate, and weight are not monitored as often as the medication
nursing indications indicate.