Case-Study-On-Pulmonary Edema

A Case Study on
CARDIOGENIC PULMONARY EDEMA
In Partial Fulfillment of the Requirements in

RT 125 Clinical Education 1
ADULT INTENSIVE RESPIRATORY CARE

ROTATION
Submitted to:
LLOYD L. DEOCADES, RTRP
Clinical Instructor
Submitted by:
GHIAN CARLO M. ALBOS
MELLEN GRACE R. ANTONIANO
SHANAIA LIV M. ASISEO
SANDRA GRACE R. DELA CRUZ
ANNE LARISSE R. LORENZO
LUTHER JAMES P. OLACO
BSRT 4A
Group 3
August 9, 2022
TABLE OF CONTENTS
Introduction 5
Objectives 7
General Objectives 7
Specific Objectives 7
Definition Of Diagnosis 9
Patient History 11
Past Health History 11
Present Health History 11
Genogram 12
Genogram Narrative 13
Assessment 14
Physical 14
General Appearance 14
Vital Signs 14
Glasgow Coma Scale 14
Level Of Consciousness 14
Head 14
Eyes 15
Nose 15
Mouth 15
Neck 15
Chest 15
Abdomen 15
Skin 16
Upper And Lower Extremities 16
Developmental Task 16
Havighurst's Developmental Tasks Theory 16
Erik Erikson’s Stages Of Psychosocial Development 19
Anatomy And Physiology 23
Cardiovascular System 23
Heart 23
Blood Vessels 23
Arteries 24
Veins 24
Capillaries 24
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Respiratory System 24
Upper Airways 24
Nose 25
Oral Cavity 25
Pharynx 25
Larynx 25
Lower Airways 25
Trachea 26
Bronchi And Bronchioles 26
Alveolar Ducts 26
Alveoli 26
Lung Interstitium 27
Lymphatic System 27
Pulmonary Vasculature 28
Oncotic Pressure 28
Hydrostatic Pressure 29
Frank-Starling Law (Starling’s Law) 29
Pathophysiology 30
Factors 30
Diagram 33
Narrative 35
Diagnostics 37
Pulse Oximetry 37
Arterial Blood Gas Analysis 37
Radiography 38
Echocardiography 39
Brain-Type Natriuretic Peptide (Bnp) Testing 40
Pulmonary Arterial Catheter 40
Blood Urea Nitrogen Test 42
Serum Electrolyte Test 43
Drug Study 44
Aceon 44
Aldactazide 47
Coreg 50
Roxanol 52
GoNitro 55
Viagra 58
3
Samsca 59
Simdax 62
Natrecor 64
Nitropress 66
Symjepi 69
RT Management 70
Respiratory Therapy Care Plan 72
Respiratory Therapy Care Plan 1 72
Pulmonary Rehabilitation 91
Prognosis 95
References 96
4
INTRODUCTION
The Bachelor of Science in Respiratory Therapy (BSRT) is an intensive ten-month

clinical rotation accumulating a total of 1,600 hours. Five clinical areas are expected to
be mastered by the interns which include the Adult Intensive Respiratory Care (AIRC).
The AIRC clinical area concludes to a total of 450 hours which include an exposure to
this specific field and focuses on topics such as airway management, cardiopulmonary
resuscitation, mechanical ventilation, and cardiopulmonary monitoring (Commission on
Higher Education, 2017). To further understand the roles, knowledge, and skills of a
respiratory therapist under this rotation, the interns intend to investigate a patient with a
case of cardiogenic pulmonary edema.
According to Iqbal & Gupta (2022), pulmonary edema refers to the accumulation
of excessive fluid in the alveolar walls and alveolar spaces of the lungs. It can be a life-
threatening condition in some patients with high mortality and requires immediate
assessment and management. Pulmonary edema can however be brought by non-
cardiogenic or cardiogenic reasons. Cardiogenic means a condition that arises due to
conditions or complications that are caused by the heart. Therefore, cardiogenic
pulmonary edema is a pulmonary edema caused by a heart-related condition.
As mentioned earlier, cardiogenic pulmonary edema is defined as pulmonary

edema due to increased capillary hydrostatic pressure secondary to elevated pulmonary
venous pressure. Cardiogenic pulmonary edema reflects the accumulation of fluid with a
low-protein content in the lung interstitium and alveoli as a result of cardiac dysfunction
(Sovari, A.A., 2022). Cardiogenic pulmonary edema affects people with heart conditions,
especially heart failure. About 6 million American adults have heart failure.
An estimated 80% of people with heart failure have pulmonary edema (Cleveland
Clinic, 2022). Heart failure is the worsening of heart failure symptoms to the point that the
patient requires intensification of therapy and intravenous treatment. Heart failure can be
dramatic and rapid in onset and can cause complications such as flash pulmonary edema
or more gradual with the worsening of symptoms over time until a critical point of
decompensation is reached (King, K.C., & Goldstein, S., 2022).
This case study will present cardiogenic pulmonary edema as a complication to a

patient having congestive heart failure. The diagnosis will be supported by environmental
factors and family history. Respiratory care diagnostics and plans will also be presented
in this study along with a proposed treatment, management, and care plan designed for
the patient of concern. With this presentation, the interns hope to be able to gain adequate
information and in-depth understanding about the disease as well as apply their
knowledge and skills to hopefully alleviate the patient’s conditions. They will also be able
5
to find areas that may be in need of improvement that may need further discussion in
future studies. This case may also serve as a reference guide for other respiratory therapy
student interns as well as clinical instructors who intend to discuss this disease to
respiratory therapy students.
6
OBJECTIVES
General Objectives
Within the 4 weeks under the Adult Intensive Respiratory Care (AIRC) rotation in
Southern Philippines Medical Center, the third group of the Bachelor of Science in
Respiratory Therapy interns will be able to hone their knowledge and apply the skills and
theories they have learned to improved the patient’s health status as well as be able to
create a comprehensive and detailed manuscript of the patient’s condition which is the
Cardiogenic Pulmonary Edema.
Specific Objectives
To achieve their goal, the respiratory therapy interns specifically will be able to:
a. To be able to create a comprehensive and detailed case study that is

centered around cardiogenic pulmonary edema.
b. Find a patient with distinct conditions that relate to cardiogenic pulmonary

edema.
c. Establish patient and their immediate family member’s trust to gain

cooperation during the assessment and interview.
d. Collect significant data about the patient from the patient directly and/or
from their immediate family members which can be used as the foundation
of the case study.
e. Expound the patient's case through the manuscript supported by relevant

statistics, articles, journals, and findings related to RT education, research,
and practice.
f. Create general and specific objectives that are specific, measurable,

attainable, realistic, and time-bounded.
g. Define the patient’s diseases with supporting references.
h. Present a detailed patient data which includes biographical data, clinical

data, past and present health history, and tracing the patient’s genogram
i. Perform a cephalocaudal assessment to assess any abnormalities that may

be present in the patient following the inspection, palpation, percussion, and
auscultation method.
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j. Identify the patient’s developmental tasks using the Havighurst's
Developmental Task Theory and Erik Erikson’s Theory.
k. Discuss the anatomy and physiology of the involved organ systems in the
patient;s condition.
l. Generate the pathophysiology of the patient’s condition including its risk

factors, etiology, disease process, symptoms, diagnostics, treatments, and
outcomes through a detailed diagram and narrative.
m. Determine the diagnostic tests which can be used to confirm the patient’s
condition explaining the purpose of each test and presenting the patient’s
result to each test
n. Enumerate the medication/s that are or can be prescribed to the patient.
o. Formulate at least three (3) respiratory therapy care plans focused on

improving the patient’s status.
p. Design a pulmonary rehabilitation plan can be integrated to the patient when

they are discharged from the clinical setting that can help them improve
their condition.
q. Formulate the patient’s prognosis by discussing the outcome of the patient's

condition upon admission and after receiving treatment.
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DEFINITION OF DIAGNOSIS
In this section, the readers will be able to read the definition of Cardiogenic
pulmonary edema which will give readers basic background and help understand the
underlying principles of the said disease. The following includes various ways to describe
Cardiogenic pulmonary Edema:
Pulmonary edema is defined as a condition where there is movement of fluid from

the pulmonary vascular to the interstitial and pulmonary alveoli. In pulmonary edema
there is an accumulation of serous fluid or serosanguinous in the interstitial space and
alveoli of the lung making gas exchange not possible (Soenarta et al., 2018).
As stated above, Cardiogenic pulmonary edema is mainly referred to as the

buildup of extra fluid with a low-protein content in the lungs as a result of cardiac
dysfunction that can be life-threatening mostly to patients with a history of heart failure.
This is typically caused by heart failure and results from blood building up and pressure
increasing on the left side of the heart. In addition to making it harder to breathe, cardiac
edema can cause organ damage due to insufficient oxygen (Pinto & Garan, 2022).
The initial events in Cardiogenic pulmonary edema involve hemodynamic

pulmonary congestion with high capillary pressures. This causes increased fluid transfer
out of capillaries into the interstitium and alveolar spaces. High capillary hydrostatic
pressures can also cause barrier disruption which increases permeability and fluid
transfer into the interstitium and alveoli. Fluid in alveoli alters surfactant function and
increases surface tension. This can lead to more edema formation and to atelectasis with
impaired gas exchange (Dobbe et al., 2019). Moreover, the said increase in hydrostatic
pressure in the pulmonary capillaries also leads to an increase in transvascular filtration.
When the interstitial pressure of the lung is greater than the intrapleural pressure, the fluid
moves towards the visceral pleura which causes pleural effusions. If the endothelial
capillary permeability remains normal, the edema fluid leaving the circulation has a low
protein content (Soenarta et al., 2018).
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PERSONAL DATA
Any details that could directly identify the patient fall under this section. The
personal data stated below are the biographical and clinical information, which are
gathered with full consent for this case study.
Biographical Data
Personal Name : Patient Yu

Age : 65
Sex : Female
Race : South East Asian
Nationality : Filipino
Date of Birth : July 27, 1957
Height : 5'5” (65 inches)
Weight : 85 kg (136.687lbs.)
BMI : 31.2 (Obese Class I)
Civil Status : Married
Occupation : Chef
Religion : Roman Catholic
Home Address : Bangkal, Davao City
Clinical Data
Chief Complaint : Shortness of breath on exertion, dizziness, chest

pains, and pink, frothy secretions
Admitting Diagnosis: Cardiogenic Pulmonary Edema
Admission Date : August 01, 2022
Time Admitted : 9:00 pm
Place of Admission : San Pedro Hospital, Guzman St., Davao City
Mode of Admission : Per wheelchair
Room Number : Adult ICU 1, Room #8
Attending Physician : Benny Bilang, RTRP, MD
Final Diagnosis : Cardiogenic Pulmonary Edema
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PATIENT HISTORY
Past Health History
Patient Yu is a Filipino born on July 27, 1957 and is the third born in a family with
three children. Throughout her childhood, she received full immunization including BCG,
DPT, OPV and Hepatitis B vaccines. Patient Yu was diagnosed with asthma when she
was 15 years old. This condition was completely treated after 3 months of treatment. At
16 years old she was interested in how to learn to swim and it made her productive during
the summer days. The doctor advised her to continue swimming because it is one of the
best exercises for asthma because it builds the respiratory muscles. She was also
hospitalized at age 40 for obesity (type 1) and hypertension. She was hospitalized with
nosebleeds, irregular heart rhythms, buzzing in the ears and remained in the hospital for
a night. Patient Yu is monitored until the blood pressure is back to normal. After her
release, she was advised to rest for a week and after that Patient Yu was advised to
increase her physical activity, maintain a healthy weight and monitor her blood pressure
from time to time or else her health might deteriorate.
Present Health History
Patient Yu is currently a 65-year-old mother who is working as a chef on a self-

owned business. She was diagnosed with Left-side Congestive Heart Failure 2 years ago
when she was hospitalized for complaining about having shortness of breath related to
feeling like drowning, dizziness, disorientation, fatigue, and an abnormal increase in
weight. She was hospitalized for a month before being discharged and was given a
prescription of vasodilators and diuretics as maintenance for her condition that,
unfortunately, she was not committed to due to her busy schedule. She was also advised
to change her diet and include exercise to combat further disease progression and
complications yet her busy schedule has not allowed her to do so. She has no history of
alcohol or drug abuse. A month ago, she complained about difficulty of breathing
whenever she moved and was having a cough with no secretions. One week after her
initial complaint, she has started to gain weight abnormally again despite admitting that
she has not changed her diet and was also easily fatigued and was also having occasional
chest pains. Three days ago, she has stated that her chest pains have worsened, was
constantly disoriented with her surroundings, fatigued even when doing simple tasks such
as walking on a flat surface, and is now coughing with pink, frothy secretions. She was
abruptly brought to the ER by her husband for admission.
Upon initial assessment, the patient exhibited tachypnea through nasal flaring,
pursed-lip breathing, and use of accessory muscles in both inspiration and expiration.
Cyanosis was observable around the patient’s lips. Crackles were heard upon
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auscultation on both lung bases. Upon checking the ABG, result she has Uncompensated
Respiratory Acidosis with uncorrected hypoxemia and for the Chest X-ray result, there is
symmetrical area shadowing in the central region of both lungs, left heart enlargement
with congestion in the pulmonary veins and bilateral small to moderate sized pleural
effusions. She was placed initially on supplementary oxygen at 10L/min via a venturi
mask and had a SpO2 reading of 54% however, after confirming her diagnosis she was
switched to a continuous positive airway pressure (CPAP) at 6 cm H2O with 70% FiO2.
Genogram
Figure 1. Genogram of Patient Yu
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Genogram Narrative
On the paternal side, the patient’s grandfather died at the age of 84 while her
grandmother died at the age of 75. Both grandparents died of old age. Her grandfather
was diagnosed with hypertension, but this was never identified as his primary cause of
death. Her father is an only child diagnosed with hypertension and obesity and taking oral
medications for his hypertension as prescribed.
On the maternal side, the patient’s grandfather died at the age of 75 due to
cardiogenic pulmonary edema secondary to his unattended congestive heart failure. Her
grandmother died at 49 due to hypertension but also had obesity. The patient’s uncle
passed away when he was 64 years old due to complications from cardiogenic pulmonary
edema secondary to his congestive heart failure and hypertension. His other uncle who
is 67 years old has obesity. Her mother is known to have hypertension and diabetes and
is taking prescribed medication regularly to maintain both.
The patient also has two siblings. Her older sister is 69 years old diagnosed with
obesity, hypertension and diabetes and is taking medications prescribed to maintain her
hypertension and diabetes. Her older brother who is 67 years old has congestive heart
failure and hypertension and is taking medication to maintain both but is also obese.
FInally, Patient Yu, who is 65 years old, is diagnosed with obesity, hypertension, and
congestive heart failure which lead to cardiogenic pulmonary edema. In relation to this,
the patient’s cardiogenic pulmonary edema has a genetic influence.
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ASSESSMENT
Physical
General appearance
The patient is in obvious respiratory distress per her paleness and signs of
cyanosis as shown in her lips. The patient is also observed to be confused when
asked and appears to be sweating excessively.
Vital Signs
RESULTS NORMAL VALUES
Blood Pressure: 150/90 120/80 mmHg

Heart Rate: 110 bpm 60-100 bpm
Respiratory Rate: 30/min 12-20/min
Temperature: 37.4OC 36.5OC - 37.5OC
O2 Saturation: 54% 95-100% (normal), 88-92% (COPD)
Glasgow Coma Scale
Eye Opening 4 (spontaneous)

Verbal Response 4 (confused but can answer)
Motor Response 6 (obeys command)
____________________________
GCS score: 14 (mild head injury)
Level of Consciousness
The patient’s level of consciousness is described to be awake. The patient

is confused when asked with questions but responds immediately. Patient is
deemed to be awake but confused.
Head
Upon inspection the head is round, no lumps, hair is evenly distributed, no

infestation. Upon palpation there are no tenderness and bumps.
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Eyes
Upon inspection eyes are symmetrical, no discharges, anicteric sclera,

pupils are equally round reactive to light and accommodation (3mm). Eyelids in
normal position with no abnormal widening or ptosis. Upon palpation there is no
swelling or redness over lacrimal gland and has a pink palpebral conjunctiva
Nose
Upon inspection the nasal septum is in the middle, there is nasal flaring, no
discharges, inferior and middle turbinates dark pink, moist and free of lesions.
Upon palpation there is no tenderness in the frontal and maxillary sinuses.
Mouth
Upon inspection the patient is having pursed lips and blue discoloration, a
sign of cyanosis. The gums are pale without redness or swelling and frenulum is
in the midline. Pink frothy sputum remnants have been observed. Patient was
placed on oxygen therapy via venturi mask at 10L/min then to CPAP at 6cm H2O.
Neck
Upon inspection there is a sign of a raised jugular vein and use of accessory
muscles but no masses observed. Upon palpation there is no lymph node
enlargement.
Chest
Upon inspection the patient has an increased anteroposterior chest

diameter and use of accessory muscles during inspiration and expiration, there are
no lesions and masses. Upon palpation there is a decrease in tactile fremitus and
vocal fremitus. Upon percussion there is a hyperresonant note. Upon auscultation,
diminished breath sounds were heard, wheezing and crackles were also heard.
Abdomen
Upon inspection there are no distention, lesions and abrasions. Umbilicus

is in midline and recessed with no bulging. There is tenderness in the right upper
quadrant (location of the liver) with light palpation.
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Skin
Upon inspection there are no lesions and excoriation noted, no abrasions,

there is skin paleness and cyanosis is noted. Upon inspection, the skin is cold in
the extremities.
Upper and Lower Extremities
Upon inspection, digital clubbing is present and the lower extremities exhibit
peripheral edema and there is tenderness upon palpation.
Developmental Task
Havighurst's Developmental Tasks Theory
TASK MET/UNMET RATIONALE
Infancy & early childhood

(Birth till 6 years old) According to the patient, she
apparently began to crawl, walk
At this stage, the child learns
and talk quite early in childhood.
to crawl, walk, eat solids, talk
By the age of 3, she was
and be potty trained. The
already potty trained and was
child also learns sex
able to urinate or defecate
differences and also learns to MET
without adult assistance. She
read. They are also
learned the difference of sexes
beginning to form concepts
and began to read at a similar
and learn their mother
time. She was also able to use
tongue in order to express
words to express herself by the
their emotions and describe
age of 4.
physical surroundings.
Middle childhood (6-12

years old) Patient stated that, as a child,
she was physically active and
During this stage, the child enjoyed playing outdoor games
leans to be physically active MET with her neighbors. She
and participate in games, mentions that her parents had
they also learn to get along instilled into her the values that
with age mates and make they lived by, but also gave her
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friends. Wholesome attitudes the freedom to develop her own
begin to form towards values and different attitudes.
oneself as a growing and
curious human. It is also
during this stage that the
child develops their
conscience and values. The
child develops personal
independence and different
attitudes toward different
social groups.
Adolescence (13 to 18
years old)
During this stage, they start At this stage, patient was an

developing their social role active student leader at the
and accepting one’s institution she studied at and
physique. They also develop also beginning planning for her
emotional independence future. At the age of 17, patient
MET began her own small business
towards other adults. At this
stage, they also prepare for in order to save her own money.
future plans and acquire a
set of values fit for them.
Socially responsible behavior
also begins and grows. They
are also tasked to select
Early adulthood (19 to 30

years old)
At this point, they begin to Patient graduated from college

select a mate and learn to by this stage and at the age of
live with a partner. This is 25 got married. According to the
when most begin to settle MET patient, her small business
down and start a family of bloomed and she also worked a
their own. Occupation also corporate job. At the age of 29,
becomes a priority and taking she had her first and only child.
on more social responsibility.
Finding a group to develop
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relationships with is also part
of this stage.
Middle age (30 to 60 years

old)
During this period, adults are

fully developed and start Patient was able to take care of
assisting their children to and raise her child with proper
become socially responsible. guidance up to early adulthood.
Achieving and maintaining She is still happily married and
satisfactory results in one’s MET is financially stable. She also
occupation is achieved, so as participated in leisure time
to grow as a professional. activities whenever she had the
Leisure time activities are time.
also developed. Adults also
relate themselves to their
spouse as an individual,
while also accepting and
adjusting to the physiological
changes in middle age.
Later maturity (60 years old

and older)
The patient’s health is
deteriorating as evidence of her
hypertension and diagnosis of
During this stage, physical congestive heart failure. She
strength and health begin to also has obesity which further
deteriorate and they begin affects her health. However,
adjusting to retirement and MET
she still continues to work on
reduced income. They reach her successful restaurant
a point where they adjust to business, attending to her
the death of their spouse. family's needs, and participating
They begin to adopt and in the betterment of her
adapt to social roles in a community.
flexible manner.
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Establishment of satisfactory
and comfortable physical
living arrangements is also a
task at this final stage.
Erik Erikson’s Stages of Psychosocial Development
TASK MET/UNMET RATIONALE
Trust vs Mistrust (0 to 1
1⁄2)
During this stage, infants are

uncertain about their The patient was well raised by
surroundings, and rely on her parents. She mentioned,
their primary caregiver for based on the story of her late
security and consistency of MET mother, that she was very clingy
care. If the care is consistent and dependent on her mother.
and reliable, infants develop She would only calm down
a sense of trust which they when her mother was present
will carry onto other with her.
relationships along the line,
and they will also develop a
sense of security.
Autonomy vs Shame (1 ½ According to the patient and

to 3 years old) what she remembers, she was
a very active child and always
The child is physically wanted to choose her own
developing and is becoming MET
outfits or eat using utensils
more active. At this stage, without the assistance of others.
the child begins discovering She enjoyed coloring and
that they have many different drawing at this stage.
skills and abilities. This
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includes picking and putting
on clothes, playing with
different toys, trying different
food, etc. These skills
illustrate the child’s growing
sense of autonomy and the
curiosity kicks in.
Initiative vs Guilt (3 to 5
years old)
At this stage, the child

regularly interacts with other
children their age, especially
at school. A vital part of this
Patient stated that she enjoyed
stage is play time, as it
playing outside with her
allows the child to explore
neighbors and made friends
their own skills through MET with every child she could see.
initiating activities and
They enjoyed running around
participating in games.
and going on adventures
Children begin to use their
together.
imagination when playing. If
given the opportunity to
explore, a child develops a
sense of initiative and
security in their ability to
make friends and make their
own decisions.
Industry vs Inferiority (5 to
At this stage, the patient
12 years old)
excelled at reading, writing and
At this stage, children begin even basic sums. She also
MET
learning to read and write in enjoys drawing. As a child, she
their mother tongue, to do was active and was often seen
sums and to do things on at the playground during recess
their own. An important role break.
is held by teachers as they
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help guide and teach children
specific skills. The child’s
peer group gains significance
and becomes a source of the
child’s self-esteem. This
gives them a chance to
develop a sense of
acceptance.
Identity vs Confusion (12

to 18 years old) Patient was active in school
organizations at this stage and
Adolescents search for a even started her own small
sense of self and personal MET
business, with the plan of being
identity. During this stage, able to save her own money.
they desire the ability to
explore their personal values,
beliefs and goals
Intimacy vs Isolation (18 to

40 years) During this stage, patient was
able to build long- term
Major conflict centers on MET
relationships with people she
developing intimate, loving trusted, such as with her
and secure relationships with spouse.
other people
Generativity vs Stagnation
(40 to 65 years old)
Patient is currently at this stage
During this stage, adults and has managed to raise her
strive to create and nurture MET child well, despite having a
things that will last. An chronic illness. She is also
example would be parenting active in her community and
children or contributing a takes part in leisure activities.
positive impact that brings
benefit to others.
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Contributing to society and
taking part in activities that
benefit future generations are
vital at this stage.
Ego integrity vs Despair

(65 years old and beyond)
Patient continues to manage
During this stage, adults MET her successful restaurant
contemplate their business while also giving back
accomplishments and to her community.
develop integrity if seen as
having lived a successful life.
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ANATOMY AND PHYSIOLOGY
Cardiovascular System
The cardiovascular
system is a collection of
organs, mainly consisting of
the heart, veins, and arteries,
that collects, delivers, pumps,
and returns oxygen to and
from the lungs to the different
parts of the body (Rodriguez,
2017). Other than delivering
oxygen, it also plays a huge
role in delivering nutrients and
hormones to the different parts
of the body as well as
collecting waste from
metabolic processes, such as
Carbon dioxide, for excretion in the body (Cleveland Clinic, 2021). It is an essential
component of the body that must be kept in check and must remain healthy as it is critical
for the overall health, function, and survival of the other different organ systems, muscles,
and tissues.
Heart
The heart is a four-chambered muscular organ approximately the size of a

fist. It is positioned in the mid-mediastinum of the chest, behind the sternum. It is
the primary organ responsible for pumping the blood throughout the body
(Cleveland Clinic, 2021). Due to this fact, the heart pumps the blood through
closed vessels to every tissue within the body which carries nutrients and oxygen,
as well as collecting waste to all cells in the body(Kohli, P., 2021).
Blood Vessels
It is a closed system where blood passes through to deliver oxygen,

nutrients, and hormones as well as collect wastes from metabolic processes that
occur on the different parts of the body (Kohli, P., 2021). It is composed of different
arteries, veins, and capillaries which are all connected to the heart which serves
as the main pumping mechanism that pushes the blood.
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Arteries
A blood vessel that carries oxygenated blood coming from the lungs away
from the heart. An exception to this is the pulmonary artery where it carries
deoxygenated blood or Carbon-dioxide rich blood from the heart to the
lungs instead.
Veins
A blood vessel that carries deoxygenated blood toward the heart. An

exception to this is the pulmonary vein where it carries oxygenated blood
from the lungs to the heart.
Capillaries
Considered as the smallest blood vessel, it is the main blood vessel that
branches from the artery and veins. It is where interaction between the cells
and the blood vessel occur to deliver blood, nutrients, and hormones and
collect wastes.
Respiratory System
The respiratory system is the primary

organ system involved in breathing, where the
body exchanges oxygen and carbon dioxide
(Ratini, M., 2021). The respiratory system is
the network of organs and tissues that help a
person breathe. It includes the airways, lungs
and blood vessels. The muscles that power
the lungs are also part of the respiratory
system. These parts work together to move
oxygen throughout the body and clean out
waste gasses like carbon dioxide (Cleveland
Clinic, 2020).
Upper Airways
The upper airways are composed of the nose, oral cavity, pharynx, and
larynx. The primary functions of the upper airways are of the following (1) to act as
a conductor of air, (2) humidifying and warming or cooling the inspired air, (3)
preventing foreign objects from entering the tracheobronchial tree, and (4) has an
important role in providing speech and smell (Des Jardins, 2020).
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Nose
It is the primary opening through which air enters and leaves the
body to the lungs. The primary functions of the nose are to filter, humidify,
and condition (warm or cool) inspired air. The nose is also important as the
site for the sense of smell and to generate resonance in phonation.
Oral Cavity
The oral cavity is considered an accessory respiratory passage. As

mentioned previously, the nose is the primary opening through which air
enters and leaves the body. However, in some cases such as strenuous
activities or when the patient is having problems breathing, mouth-breathing
is apparent as a way to supplement the increased need of air.
Pharynx
After the inspired air passes through the nasal cavity, it enters the
pharynx or commonly known as the throat. It is a muscular funnel that
extends from the posterior end of the nasal cavity to the superior end of the
esophagus and larynx The pharynx is divided into three parts: nasopharynx,
oropharynx, and laryngopharynx
Larynx
The larynx, or the voice box, is located between the base of the
tongue and the upper end of the trachea. It is composed of nine cartilages
which are the three single cartilages: thyroid, cricoid, and epiglottis plus the
three paired cartilages namely the: arytenoid, corniculate, and cuneiform
cartilages. It acts as a passageway of air between the pharynx and trachea,
a protective mechanism against aspiration of solids and liquids, and
generates sound for speech
Lower Airways
The airways of the tracheobronchial tree extend from the larynx down
to the airways participating in the gas exchange. These airways become
progressively narrower, shorter, and more numerous as they branch
throughout the lungs. The first 19 generations are known as conducting
airways because they transport gas from the upper airway to the lower
airways but do not participate in gas exchange unlike the succeeding
generations 20-28 which are part of the respiratory zone.
25
Trachea
Known as Generation 0, the trachea is a 5-inch-long tube made of

C-shaped hyaline cartilage rings lined with pseudostratified ciliated
columnar epithelium. It connects the larynx to the bronchi and allows air to
pass through the neck and into the thorax.
Bronchi and Bronchioles
At the base of the trachea, the last cartilaginous ring that forms the
bifurcation for the two bronchi is called the carina. It is an important
landmark that is used to identify where the trachea branches off into the left
and right main stem bronchi (Generation 1). This then continues to branch
off into Lobar Bronchi (Generation 2), Segmental Bronchi (Generation 3),
Subsegmental Bronchi (Generation 4-9), Bronchioles (Generation 10-15),
Terminal Bronchioles (16-19) which are all part of the conducting zone, and
the Respiratory Bronchioles (Generation 20-23) which is now part of the
respiratory zone.
Alveolar Ducts
Known as Generation 24-27, these are tiny ducts that connect the
respiratory bronchioles to alveolar sacs, each of which contains a collection
of alveoli. Alveolar ducts function to collect and direct the oxygen entering
the alveoli and the carbon dioxide exiting the lungs. The pressure of the
oxygen in these ducts maintains the pressure of the air in the alveoli.
Alveoli
Known as Generation 28, termed as the functional units of gas

exchange is where the bulk of gas exchange occurs between the lungs and
the cardiovascular system specifically in the alveolar-capillary membrane.
There are approximately 300 million alveoli between 75 and 300 μm in
diameter, and small pulmonary capillaries cover about 85 to 95 percent of
the alveoli. This arrangement provides an average surface area of 70 m 2
available for gas exchange.
26
Lung Interstitium
The lung interstitium

corresponds to an anatomic space
interposed between alveolar
membranes of the alveolar
epithelial lining cells and the
endothelial cells of the interstitial
capillaries (Shah M.R., et al., 2019).
It is composed of the alveolar
epithelium, pulmonary capillary
endothelium, basement membrane,
perivascular and perilymphatic tissues.
Lymphatic System
The lymphatic system consists of

two semi-independent parts: (1) a
meandering network of lymphatic vessels
and (2) various lymphoid tissues and
organs scattered throughout the body. The
lymphatic vessels transport fluids that have
escaped from the blood back to the
cardiovascular system. The lymphoid
tissues and organs house phagocytic cells
and lymphocytes, which play essential roles
in body defense and resistance to disease
(Marieb, E.N, & Keller, S.M., 2018). The
lymphatic system has many functions. Its
key functions include (1) maintains fluid
levels in the body, (2) absorbs fats from the digestive tract, (3) protects the body against
foreign invaders, and (4) transports and removes waste products and abnormal cells from
the lymph (Cleveland Clinic, 2020).
27
Pulmonary Vasculature
The cardiovascular system

and the pulmonary system work
together to deliver oxygen, an
essential element for survival, and
the excretion of carbon dioxide, a
waste product of cellular
metabolism. This is a cyclic
process and involves two different
systems which are the pulmonary
circulation and the systemic
circulation. First, the systemic
circulation has blood that is rich in
oxygen courtesy to being in the
lungs where gas exchange occurs
removing the carbon dioxide and
replacing it with oxygen. It is then
sent back to the heart via the
pulmonary vein entering the left
atrium, passing through the mitral
valve towards the left ventricle passing through the aortic valve then aorta towards the
systemic circulation. Oxygen-rich blood now passes through different arteries, then
towards capillaries where interaction between different cells takes place wherein oxygen
and other nutrients, hormones are transferred and waste products such as carbon dioxide
are taken. This now goes back to the veins where it goes to different organs that filter the
blood removing its waste. Venous blood re-enters the heart either though the superior or
inferior vena cava entering the right atrium passing through the tricuspid valve towards
the right ventricle then being pumped through the pulmonary valve and vein towards the
lungs where carbon dioxide is excreted and oxygen binds to the blood and the cycled
repeats (Marieb, E.N, & Keller, S.M., 2018).
Oncotic Pressure
Oncotic pressure, or colloid osmotic-pressure, is a form of osmotic pressure

induced by the proteins, notably albumin, in a blood vessel's plasma (blood/liquid) that
causes a pull on fluid back into the capillary. Participating colloids displace water
molecules, thus creating a relative water molecule deficit with water molecules moving
back into the circulatory system within the lower venous pressure end of capillaries
(Moman, R.N., et al., 2021).
28
Hydrostatic Pressure
It is the opposite of what an oncotic pressure does. The force of hydrostatic

pressure means that as blood moves along the capillary, fluid moves out through its pores
and into the interstitial space. This movement means that the pressure exerted by the
blood will become lower, as the blood moves along the capillary, from the arterial to the
venous end.
Frank-Starling Law (Starling’s Law)
The Frank-Starling law states that the force or tension developed in a muscle fiber
depends on the extent to which the fiber is stretched. In a clinical situation, when
increased quantities of blood flow into the heart (increasing preload), the walls of the heart
stretch (Marieb, E.N, & Keller, S.M., 2018). In a normal lung, the extravasation of fluid
from the capillaries into the alveoli is matched by the lymphatic system's ability to drain
the lung water. Imbalances in the Starling forces cause pulmonary edema and occur
primarily from a high hydrostatic pressure in cardiogenic pulmonary edema (Katz, J., et
al., 2019).
29
PATHOPHYSIOLOGY
Factors
PREDISPOSING FACTORS
FACTORS PRESENT/ABSENT RATIONALE
Common age for Cardiogenic

Pulmonary Edema (CPE) is usually at
around the age of 65 years old and
Age PRESENT
above as it is usually a secondary
condition caused by Congestive Heart
Failure (CHF) (Des Jardins, 2017).
Males are typically affected more than

females as men have a higher
incidence of acquiring heart failures
Sex ABSENT
such as CHF wherein it is the common
leading cause to be diagnosed with
CPE (Iqbal, M.A. & Gupta, M., 2022).
PRECIPITATING FACTORS
FACTORS PRESENT/ABSENT RATIONALE
Choose healthy meals and snacks

to help prevent heart disease and
Having a its complications. Eating lots of
healthy and ABSENT foods high in saturated fat and
nutritious diet trans fat may contribute to heart
disease (Centers for Disease
Control and Prevention, 2020).
ABSENT Alcohol can raise blood pressure.

Drinking
Men should have no more than 2
30
alcohol drinks per day, and women no
more than 1 drink per day.
Exercise can help strengthen the

heart and improve how oxygen
circulates through the body. It can
help spur the growth of new cells
to mend weakened muscles and
spur the growth of blood vessels in
Regular
ABSENT people with heart failure to prevent
exercise
further complications such as
heart-related pulmonary edema
People with heart failure will need
to discuss an exercise program
with a healthcare professional
(Bell, A.M., 2022).
The most common cause of cardiac

pulmonary edema is left sided
heart failure—commonly called as

congestive heart
Congestive
PRESENT failure (CHF). As the left side of the
Heart Failure
heart fails to pump the blood to the
body it is instead backed up into the
lungs where it leaks into the alveolar
spaces accumulating the fluid in it
(Sovari, A.A., 2020).
Over time, the arteries that supply

blood to the heart muscle can
become narrow from fatty deposits
Obesity PRESENT (plaques) such as in cases of obesity
patients. A slow narrowing of the
coronary arteries can weaken the left
ventricle (Mayo Clinic., 2020).
31
Untreated or uncontrolled high blood
Hypertension PRESENT pressure can enlarge the heart (Mayo
Clinic., 2020).
32
Diagram
33
34
Figure 2. Pathophysiology of Cardiogenic Pulmonary Edema
Narrative
Cardiogenic pulmonary edema is usually a complication brought about by

congestive heart failure along with other conditions such as hypertension and obesity.
The left ventricle fails to pump blood efficiently and effectively due to a reduced ventricular
ejection fraction caused by an imbalance in the Starling forces. This results in a
congestion in the left ventricle and back to left atrium and pulmonary blood vessels
resulting in a build up of fluid volume and pressure to these areas. This initially improves
blood gas exchange as there is more blood available. However, over time, the elevated
capillary hydrostatic pressure and volume pushes the blood into the interstitial spaces of
the lungs. Increased left atrial pressure due to the dysfunctional left ventricle increases
pulmonary venous pressure and pressure in the lung microvasculature, resulting in
pulmonary edema. As it continues to fill up the lungs, specifically the lung interstitium, it
will eventually reach its limits (above 500 mL) and will occupy the alveoli as well. As a
result, the alveoli, instead of being filled with air, is filled with blood. This evidently impairs
35
gas exchange which causes a severe case of hypoxemia and hypoxia, dyspnea, and
reduced lung volumes.
Diagnostic tests usually include a (1) simple pulse oximetry or a may intricate (2)
arterial blood gas analysis to measure the oxygen saturation in the blood as well
determine pH levels where patients are usually academic, (3) radiography and
ultrasonography are helpful diagnostics in in distinguishing CPE from other pulmonary
causes of severe dyspnea, (4) Brain-type natriuretic peptide testing which is useful in
differentiating heart failure from pulmonary causes of dyspnea, (5) echocardiography can
be used to evaluate LV systolic and diastolic function, as well as valvular function, and to
assess for pericardial disease, (6) pulmonary arterial catheter can measure the
pulmonary capillary wedge pressure or PCWP.
Treatment can be done with (1) oxygen therapy via noninvasive methods such as
CPAP and BiPAP to supplement the increased need of oxygen, (2) mechanical ventilation
and intubation when patients remain hypoxic despite maximal noninvasive supplemental
oxygenation, (3) ECMO for critical patients that has now required blood to be cleaned and
re-oxygenated by a machine, and (4) cardiac transplant to solve the root cause of the
pulmonary edema in the first place.
Medications usually used are vasodilators such as ARBS and ACE inhibitors to
widen the blood vessels in the body and diuretics to help the patient push more fluids out
of their body. Other drugs include afterload reducers which can reduce the effects of the
edema.
If treatments and medications are addressed, this can reduce the risks of having
further complications such as respiratory fatigue and failure, severe peripheral edema
and ascites, hypertensive crisis, obstructive sleep apnea, infections from the pooling
secretions, and most especially avoiding death. However, if the condition is not treated,
patients may have complications such as arrhythmias, thromboembolism, cardiogenic
shock, pericarditis, renal and respiratory failure which could ultimately lead to death.
36
DIAGNOSTICS
Pulse Oximetry
Pulse oximetry is a painless, noninvasive method of measuring the saturation of

oxygen in a person’s blood. Oxygen saturation is a crucial measure of how well the lungs
are working. Most pulse oximeters are accurate to within 2% to 4% of the actual blood
oxygen saturation level. This means that a pulse oximeter reading may be anywhere from
2% to 4% higher or lower than the actual oxygen level in arterial blood (Yale Medicine,
2019). Pulse oximetry can also be used to initially assess the health of the person for
conditions that can affect blood oxygen levels such as in heart failure (John Hopkins
Medicine, 2021).
Patient Name: Patient Yu

Pulse Oximetry Date: August 1, 2021 at 9pm
Patient Name Pulse Oximetry Results Normal Range
Patient Yu 54% 95-100%
Interpretation: Hypoxemia due to pulmonary edema and decreased oxygenated

blood circulation
Arterial Blood Gas Analysis
An arterial blood gas (ABG) test is a blood test that requires a sample from an
artery in the body to measure the levels of oxygen and carbon dioxide in the blood. The
test also checks the balance of acids and bases, known as the pH balance, in the blood
(Cleveland Clinic, 2022). Many diseases are evaluated using an ABG, including acute
respiratory distress syndrome (ARDS), severe sepsis, septic shock, hypovolemic shock,
diabetic ketoacidosis, renal tubular acidosis, acute respiratory failure, heart failure,
cardiac arrest, asthma, and inborn errors of metabolism (Castro, D., et al., 2021).

ABG Test Date: August 1, 2021 taken at 9:00 pm
ABG Criteria Results Normal Values
pH 7.24 7.34-7.45
37
PaO2 55 mmHg 80-100 mmHg
(patient in supplemental oxygen
therapy via nasal CPAP at 6 cm
H2O at admission)
PaCO2 65 mmHg 35-45 mmHg
HCO3 25 mmHg 22-26 mmHg
SaO2 54 % 95-100%
Interpretation: Uncompensated Respiratory Acidosis with uncorrected
hypoxemia
Radiography
Chest radiography is helpful in distinguishing cardiogenic pulmonary edema (CPE)

from other pulmonary causes of severe dyspnea. Patients with heart-related diseases
may potentially show an enlarged heart, inverted blood flow, kerley lines, edema, and
bilateral and symmetrical effusions. It is, however, somewhat limited in patients with CPE
of abrupt onset, because the classic radiographic abnormalities may not appear for as
long as 12 hours after dyspnea begins (Sovari, A.A, 2020).

Chest Radiography: August 1, 2021
Findings: There is symmetrical area shadowing in the central region of both

lungs, left heart enlargement with congestion in the pulmonary veins and
bilateral small to moderate sized pleural effusions.
38
Ultrasonography
Ultrasound (also called sonography or ultrasonography) is a noninvasive imaging

test. An ultrasound picture is called a sonogram. Ultrasound uses high-frequency sound
waves to create real-time pictures or video of internal organs or other soft tissues, such
as blood vessels (Cleveland Clinic, 2022). In cases in which there is a moderate to high
pretest probability of acute CPE, ultrasonography can be useful in strengthening a
working diagnosis. Findings of B-lines on ultrasonography have been reported to have a
sensitivity of 94.1% and a specificity of 92.4% for acute CPE (Sovari, A.A, 2020).

Ultrasonography Test Date: August 1, 2021
Findings: Multiple B-lines in one intercostal space. B-line predominance

indicates interstitial syndrome, which is usually related to interstitial edema.
Echocardiography
Echocardiography uses ultrasound waves to produce an image of the heart, the

heart valves, and the great vessels. It helps assess heart wall thickness like in
hypertrophy or atrophy cases. It can be used to assess systolic function as well as
diastolic filling patterns of the left ventricle, which can help in the assessment of left
ventricular hypertrophy, hypertrophic or restrictive cardiomyopathy, severe heart failure,
and constrictive pericarditis (Cascino, T. & Shea, M., 2021).
39
Echocardiography Test Date: August 1, 2021
Findings: Echocardiography results shows an enlarged left ventricle which

explains pulmonary edema present with the patient
Brain-type Natriuretic Peptide (BNP) Testing
Natriuretic peptides are substances made by the heart. Two main types of these
substances are brain natriuretic peptide (BNP) and N-terminal pro b-type natriuretic
peptide (NT-proBNP). Normally, only small levels of BNP and NT-proBNP are found in
the bloodstream. High levels can mean that the heart is not pumping as much blood as
the body requires. When this happens, it can be due to congestive heart failure (Medline
Plus, 2021). Values above 100 pg/mL in a BNP test is an indicative sign of heart failure.
However, heart failure medications, including beta blockers, ACE inhibitors and diuretics,
can lower BNP levels in the blood. If the patient is taking these drugs to treat heart failure,
BNP test results may be lower than if they are not taking them. Levels can also be lower
if the patient has obesity or kidney failure (Cleveland Clinic, 2022).

BNP Test Date: August 1, 2021
Patient Name BNP Result Normal Range
Patient Yu 150 pg/mL <100 pg/mL

Interpretation: Patients results are above 100 pg/mL, Confirms her previous
diagnosis of congestive heart failure
Pulmonary Arterial Catheter
Pulmonary artery catheterization is a diagnostic procedure in which an
40
intravascular catheter is inserted through a central vein, such as the femoral, jugular,
antecubital or brachial vein, to connect to the right side of the heart and advance towards
the pulmonary artery. Pulmonary artery catheterization remains an excellent tool for the
assessment of patients with pulmonary hypertension, cardiogenic shock, or unexplained
dyspnea (Ziccardi, M.R., & Khalid, N., 2022). In patients with chronic pulmonary capillary
hypertension, capillary wedge pressures exceeding 30 mm Hg are required to overcome
the pumping capacity of the lymphatics and produce pulmonary edema (Sovari, A.A,
2020).

PCWP Test Date: August 1, 2021
Patient Name PCWP Result Normal PCWP
Patient Yu 40 mmHg <30 mmHg
Interpretation: Patient’s PCWP value is higher than normal indicative of a

heart failure that can lead to further complications when not managed
properly.
Electrocardiogram
An electrocardiogram (ECG) records the electrical signals in the heart. It's a

common and painless test used to quickly detect heart problems and monitor the heart's
health. An electrocardiogram is a painless, noninvasive way to help diagnose many
common heart problems. A health care provider might use an electrocardiogram to
determine or detect irregular heart rhythms or if there is a blocked or narrowed artery that
is causing chest pain. ECG is usually recommended for patients that are experiencing
chest pain, dizziness, heart palpitations, rapid pulse, shortness of breath, weakness,
fatigue, and decline in ability to exercise (Mayo Clinic, 2022). Abnormalities in any of the
segments may indicate heart problems that can cause further complications.

ECG Test Date: August 1, 2021
41
Interpretation: Evident prolongation on QRS interval is a sign of ventricular
failure which can cause complications such as pulmonary edema
Blood Urea Nitrogen Test
A BUN, or blood urea nitrogen test, can provide important information about a
patient’s kidney function. The main job of the kidneys is to waste and extra fluid removal
from the body. If the patient has kidney disease or a disease that causes kidney
malfunction, this waste material can build up in the blood. Over time, this may lead to
serious health problems, including high blood pressure, anemia, and heart disease.

BUN Test Date: August 1, 2021
Patient Name BUN Test Result Normal BUN Range
Patient Yu 26 mg/dL 6-24 mg/dl
Interpretation: Patient’s BUN result is higher than normal which can indicate
a potential kidney failure to occur
42
Serum Electrolyte Test
Electrolytes are electrically charged minerals that help control the amount of fluids
and the balance of acids and bases in the body. They also help control muscle and nerve
activity, heart rhythm, and other important functions. An electrolyte panel, also known as
a serum electrolyte test, is a blood test that measures levels of the body's main
electrolytes (Medline Plus, 2021).

Serum ElectrolyteTest Date: August 1, 2021
Electrolyte Patient Result Normal Range Classification
Sodium 120 mEq/L 136-145 mEq/L Hyponatremia
Potassium 2.5 mEq/L 3-5 mEq/L Hypokalemia
Calcium 4 mEq/L 4.5 to 5.25 mEq/L Hypocalcemia
Magnesium 1.2 mEq/L 1.7 to 1.4 mEq/L Hypomagnesemia
Chloride 115 mEq/L 98 to 106 mEq/L Hyperchloremia
Phosphorus 15 mEq/L 1.2-12.3 mEq/L Hyperphosphatemia
Interpretation: All patient’s serum electrolytes are not within the normal range
indicative of current abnormal status of the patient
43
DRUG STUDY
Brand name: Aceon

Generic name: Perindopril
Drug Classification: Angiotensin-
converting enzyme inhibitors
Mode of Action
ACE inhibitors such as perindopril prevent the body from creating a hormone
known as angiotensin II. Since angiotensin II is an enzyme that narrows the blood vessels
and releases hormones that can raise blood pressure, ACE inhibitors do this by blocking
(inhibiting) a chemical called angiotensin-converting enzyme where it can now reduce the
levels angiotensin 2 in the body. This widens the blood vessels and helps to reduce the
amount of water put back into the blood by the kidneys.
Dosage
● Tablets (2mg, 4mg, 8mg)

● Take this medication by mouth as directed by the patient’s physician, usually once
or twice daily. The dosage is based on the medical condition and response to
treatment. The doctor may direct the patient to start this medication at a low dose
and gradually increase to reduce risk of side effects.
Usual Adult Dose for Hypertension
4 mg to 8 mg orally per day in 1 or 2 divided doses. Maximum, 16 mg per day.
Indications
This medication is indicated for low-dose treatment of mild to moderate essential

hypertension, mild to moderate congestive heart failure and to reduce the cardiovascular
risk of individuals with hypertension or post-myocardial infarction and stable coronary
disease.
44
Contraindications:
● Pregnant ● Renal artery stenosis

● Liver problems ● Decreased kidney function
● High levels of potassium in the ● Low blood pressure or hypotension
blood ● Hereditary angioedema
● Decreased function of bone ● Decreased function of bone
marrow marrow
● Inherited disorder of continuing
episodes of swelling
Adverse Effects
● Feeling dizzy or ● Serious side effects: jaundice is visible in

lightheaded (when eyes and skin, any sign of bleeding (in gums
standing up or sitting up and bruising more easily than usual), pale
quickly) skin, sore throat, high temperature, severe
● Dry irritating cough stomach pain, swollen ankles, blood in the
● Back pain urine, little or no urination, loss of movement,
slow or unusual heart rate.
Drug Interaction:
● Aceclofenac: Increases the risk of renal failure, hyperkalemia, and hypertension
● Acebutolol: Perindopril may increase the hypotensive activities of Acebutolol
● Acetylsalicylic acid: The therapeutic efficacy of Perindopril can be decreased
● Budesonide: May reduce the effects of perindopril in lowering blood pressure
45
RT Management:
MANAGEMENT RATIONALE
Tell the patient about the side This help to know that their symptoms are
effects of the drug common
Monitor the patient’s blood To see if the medication given is effective to the
pressure patient
Ask the patient if they have an To ensure that the patient does not have an
allergy to a medicine allergic reaction called angioedema
This can cause injury and even death to the

developing fetus. When pregnancy is detected,
Ask if the patient is pregnant
ACEON tablets should be discontinued as soon
as possible
Other drugs may affect Perindopril including

Ask the patient if they take or use
prescription and over-the-counter medicines,
other medications
vitamins, and herbal products
Warn the patient about the serious The patient will know when to call the doctor or
adverse effects the emergency ambulance
To know if they are taking a blood pressure

medicine and to avoid using perindopril together
Ask the patient if they are diabetic
with any medication that contains a blood
pressure medicine (aliskiren)
46
Brand name: Aldactazide
Generic name: Spironolactone
Drug Classification: Potassium-sparing diuretic
Mode of Action
Completely blocks aldosterone dependent

sodium potassium exchange channels in the distal
convoluted tubule. This action leads to increased
sodium and water excretion, but more potassium
retention. This increased excretion of water leads
to diuretic and also antihypertensive effects.
Dosage:
● Tablets (25 mg, 50 mg, 100 mg)

● Usual Adult dose for Hypertension
● 55-100 mg per day. It is given as a single dose or is split into two doses.
● Duration: Continued for at least 2 weeks to achieve maximum response. The dose
may be adjusted according to patient response.
Child
This medication is not approved for usage in younger than 18 years old.
Senior
If 65 years older and above, it may need a lower dose or a different dosage
schedule.
Indications
It is indicated to treat a number of conditions including heart failure,

hyperaldosteronism, adrenal hyperplasia, hypertension, and nephrotic syndrome. Also, it
acts as a hormone therapy for transgender women.
Contraindications
● If patient has an adrenal gland disorder (Addison’s disease)

● Hyperkalemia (high levels of potassium in blood)
● If patient cannot urinate
● If patient is taking Eplerenone
47
Adverse Effects
● Drowsiness ● Serious side effects: allergic reactions

● Lightheadedness (skin rash, hives, fever, trouble breathing
● Leg cramps and swelling lips, tongue, mouth, or
● Vomiting throat), extreme thirst, mouth dryness,
● High potassium levels extreme weakness and tiredness, fast
● Headache heart rate, no urination, muscle
● Dizziness weakness, can not move legs and arms,
● Itching tingling or numb feeling in hand or feet,
● Irregular menstrual cycle or slow heart rate, redness in skin, blisters,
bleeding after menopause peeling in skin.
● Abdominal cramping
Drug Interaction
● Valsartan: Using spironolactone together, it may increase potassium levels in the

blood that can lead to kidney failure, muscle paralysis, irregular heart rhythm, and
myocardial infarction.
● Aliskiren: The risk of adverse effects can be increased when combined with
Spironolactone.
RT Management
Potassium level should be Spironolactone can cause hyperkalemia and

monitored can affect the heart
It is not recommended for pregnant and

Ask patient if pregnant
lactating women
To know if the patient is hyperkalemic.

Perform an ABG to the patient Hyperkalemia can increase incidence of
hospitalization and even death
Tell the patient about the side This helps to know that their symptoms are
Tell the patient to avoid foods with

Too much potassium can lead to severe
high potassium or consume salt
problems and this can be fatal
substitutes containing potassium
To see if the drug is effective in lowering their

Monitor patient’s blood pressure
blood pressure
48
Other drugs may affect Spironolactone that can
Ask the patient if they take or use
increase the amount of potassium in the body to
other medications
an unsafe level
49
Brand name: Coreg
Generic name: Carvedilol
Drug Classification: Alpha and beta blockers
Mode of Action
It works by blocking the action of certain

natural substances in the body, such as
epinephrine, on the heart and blood vessels. This
effect lowers the heart rate, blood pressure, and
strain on the heart.
Dosage
Usual Adult Dose for Congestive Heart Failure
Immediate-release tablets
● 3.125 mg twice a day for 2 weeks. Maximum dose, 25 mg twice a day in

patients weighing 85 kg or less and 50 mg twice a day in patients weighing
85 kg or greater
Extended-release capsules
● 10 mg once a day for 2 weeks. Maximum dose, 80 mg once a day
Indications
To treat mild to severe chronic heart failure, hypertension, and left ventricular
dysfunction following myocardial infarction in clinically stable patients.
Contraindications
● Asthma ● Severe liver disease

● Bronchitis ● Serious heart condition (heart block, sick sinus
● Emphysema syndrome, or slow heart rate unless patient has a
pacemaker)
Adverse Effects
● Dizziness ● Tiredness
● Lightheadedness ● Weight gain
● Drowsiness ● Dry eyes
● Diarrhea
50
Drug Interaction
● Furosemide: Although diuretics and beta-blockers are combined in clinical

practice, this may increase the risk of hyperglycemia and hyperglyceridemia in
some diabetic or latent patients.
● Aliskerin: Carvedilol may increase the hypotensive activities of Aliskiren
● Alfuzosin: Carvedilol may increase the hypotensive activities of Alfuzosin
● Ambenonium: Ambenonium may increase the bradycardic activities of Carvedilol
● Amitriptylinoxide: Amitriptylinoxide may decrease the antihypertensive activities
of Carvedilol
RT Management
Ask patient if they have an allergic To ensure that the patient will not have an
reaction to a specific medications allergy attack
Monitor patient’s blood pressure To see if the medication given is effective
Ask the patient if they use or take

Other medications combined with Carvedilol
other medications (prescribe or
may not be safe and advisable
non-prescribed)
Tell the patient to avoid hazardous The drug may make the patient drowsy or dizzy
tasks such as driving and will occur within 1 hour after taking the dose
Ask patient if she is pregnant Carvedilol may harm the unborn baby
This drug may reduce blood flow to the hands

Tell patient to avoid tobacco use and feet causing them to feel cold. Smoking
may worsen this effect
Tell the patient about the side This helps to know that their symptoms are
51
Brand name: Roxanol
Generic name: Morphine Sulfate
Drug Classification: Opioid Receptor Agonist
Mode of Action
Morphine binds to the opioid receptors in the CNS (central
nervous system). This causes CNS to become depressed.
Depression leads to less sensation and neurotransmitters
transmitting pain to the body and a decreased perception of pain.
Morphine also releases histamine throughout the body.
Morphine’s therapeutic effects are pain relief and it also causes
blood vessels to dilate because of the CNS depression and the
general relaxation from it.
Dosage:
Usual Adult Oral Dose
10 to 30 mg every 4 hours or as directed by a physician.
Indications: Morphine is used for the management of chronic, moderate to severe pain.
Opioids, including morphine, are effective for the short term management of pain. In the
emergency department, morphine is given for musculoskeletal pain, abdominal pain,
chest pain, arthritis, and even headaches when patients fail to respond to first and
second-line agents. Morphine is rarely used for procedural sedation. However, for small
procedures, physicians will sometimes combine a low dose of morphine with a low dose
of benzodiazepine-like lorazepam. Morphine can decrease heart rate, blood pressure,
and venous return.
Contraindications:
● Hypersensitivity to morphine ● Head injuries

● Respiratory insufficiency or ● Brain tumor
depression ● Suspected surgical abdomen
● Asthma exacerbation ● GI (gastrointestinal) obstruction
● Heart failure secondary to chronic
lung disease
● Cardiac arrhythmias
52
Adverse Effects:
● Hypotension ● Sweating
● Sighing ● Shivering
● Weak or shallow breathing ● Fever
● Chest pain ● Hallucinations
● Fast or pounding heartbeats ● Twitching
● Extreme drowsiness ● Constipation
● Nausea ● Urinary retention
● Vomiting ● Muscle stiffness
● Loss of appetite ● Feelings of extreme happiness or
● Dizziness sadness
Drug Interaction:
● Acebutolol: The risk or severity of adverse effects can be increased when

Morphine is combined with Acebutolol.
● Acetophenazine: The risk or severity of hypotension and CNS depression can be
increased when Acetophenazine is combined with Morphine
● Aclidinium: The risk or severity of adverse effects can be increased when
Aclidinium is combined with Morphine.
● Betaxolol: The risk or severity of adverse effects can be increased when Betaxolol
is combined with Morphine.
● Carvedilol: The serum concentration of Morphine can be increased when it is
combined with Carvedilol.
RT Management:
Tell the patient or the watcher This helps to know that their symptoms or the
about the side effects of the drug patient's symptoms are common
If overdosed with morphine, there is a high risk

Educate the patient and watcher to
of respiratory depression (decrease in
only take the dosage required as
respiratory rate or tidal volume), Cheyne-Stokes
prescribed by their physician
respiration, cyanosis, coma, or even death
This drug should only be used when clearly

Ask the patient if she is pregnant
needed, it may harm the unborn baby
Avoid drinking alcohol when taking

It will make the patient more dizzy or drowsy
the drug
Ask the patient if they are allergic to This product may contain inactive ingredients
53
any medications and this might cause an allergic reaction for the
patient
Ask the patient if they are still Recovering from a surgery is contraindication
recovering from a surgery from taking morphine sulfate
Tell patient to avoid alcohol, Patients can become apneic at lower doses if
additional opioids, combining morphine with any of these
benzodiazepines, and barbiturates substances mentioned above. Also, this might
54
Brand name: GoNitro
Generic name: Nitroglycerin
Drug Classification: Nitrates
Mode of Action
As with other nitrates used to treat anginal

chest pain, nitroglycerin converts to nitric oxide
(NO) in the body. NO then activates the enzyme
guanylyl cyclase, which converts guanosine
triphosphate (GTP) to guanosine 3',5'-monophosphate (cGMP) in vascular smooth
muscle and other tissues. cGMP then activates many protein kinase-dependent
phosphorylations, which enhances the reuptake of calcium into the sarcoplasmic
reticulum, increases extracellular calcium, and opens the calcium-gated potassium
channel. This ultimately results in the dephosphorylation of myosin light chains within
smooth muscle fibers. This activity causes the relaxation of smooth muscle within blood
vessels, resulting in the desired vasodilatory effect. Nitroglycerin also reduces coronary
artery spasm, decreasing systemic vascular resistance as well as systolic and diastolic
blood pressure
Dosage:
For chronic angina pectoris
Oral Dosage in Adults (extended-release capsules)
2.5 to 6.5 mg PO 3 to 4 times daily; titrate to clinical response and adverse reactions as
needed.
Indications: Nitroglycerin is indicated for the acute relief of an attack or acute prophylaxis
of angina pectoris due to coronary artery disease. Intravenous nitroglycerin is prescribed
to treat angina pectoris in patients who have not responded to sublingual nitroglycerin
and beta-blockers, to treat perioperative hypertension, to control congestive heart failure
in the setting of acute myocardial infarction, and to induce intraoperative hypotension.
Contraindications:
● Severe anemia
● Increased Intracranial Pressure
● Hypersensitive to Gonitro
● Pregnancy
Adverse Effects:
55
● Headache ● Diaphoresis (heavy perspiration)
● Dizziness ● Syncope (temporary loss of consciousness)
● Lightheadedness
● Nausea
● Palpitations
Drug Interaction:
● PDE-5-Inhibitors: Combining this with Gonitro can cause severe hypotension,

syncope, or myocardial ischemia.
● sGC-Stimulators (soluble guanylate cyclase): This can cause hypotension
when sGC-Stimulators and Gonitro are combined.
● Aspirin: Increased exposure to nitroglycerin occurs when high dose aspirin (1000
mg) and nitroglycerin are administered together. The simultaneous injection of
nitroglycerin and high dose aspirin may improve the vasodilatory and
hemodynamic effects of nitroglycerin.
● Antihypertensives: Patients receiving antihypertensive drugs, beta-adrenergic
blockers, and nitrates should be observed for possible additive hypotensive
effects.
RT Management:
This drug might cause an allergic reaction to the

Ask the patient if they are allergic to
patient as the patient is hypersensitive to
any medications
nitroglycerin
Monitor the patient’s blood To see if the patient’s blood pressure is in

pressure normal range after taking the drug
Discuss first with the physician if it is safe taking

Ask patient if she is pregnant this drug, it might cause harm to the unborn
baby
Ask patient if they are taking other Some drugs are contraindicated combining with
medicines Gonitro and might cause additive hypotensive
Too see if the body is responding well or unwell

Monitor patient’s vital signs
to the medication
56
The patient will know the common side effects
Educate the patient about the side
and patient will not worry if they are
effects
experiencing any side effects of the drug
Know if patient has history of

increased intracranial pressure,
severe anemia, right-sided These are contraindicated to nitroglycerin
myocardial infarction, or
hypersensitivity
57
Brand name: Viagra
Generic Name: Sildenafil citrate
Drug Classification: PAH, PDE-5 Inhibitors,
Phosphodiesterase-5 Enzyme Inhibitors
Mode of Action:
Sildenafil has no direct relaxant effect on
isolated human corpus cavernosum, but
enhances the effect of nitric oxide (NO) by
inhibiting phosphodiesterase type 5 (PDE5), which is responsible for degradation of
cGMP in the corpus cavernosum.
Dosage:
Indications: Sildenafil is used to treat high blood pressure in the lungs (pulmonary
hypertension). It works by relaxing and widening the blood vessels in the lungs which
allows the blood to flow more easily.
Contraindications:
● Multiple Myeloma ● Stroke

● Leukemia ● Low Blood Pressure
● Sickle Cell Anemia ● Liver Problems
● Pigmentary Retinopathy ● Severe Renal Impairment
● Hearing Loss ● Peyronie's Disease
● Significant Uncontrolled High ● A Bent Penis With Erection
Blood Pressure ● Fibrous Tissue Formation in the
● A Heart Attack Penis
● A Sudden Worsening Of Heart ● Problems With Food Passing
Related Chest Pain Called Angina Through The Esophagus
● Narrowing Of The Aortic Heart ● Life-Threatening Irregular Heart
Valve Rhythm
● Hypertrophic Cardiomyopathy ● Chronic Heart Failure
Adverse Effects:
● Headache ● Flushing
● Feeling sick ● Stuffy or Runny Nose
● Back and Muscle Pain ● Blurred vision or bluish vision
● Dizziness
● Rash
58
Drug Interaction:
● Ritonavir: Viagra should be taken at 25 mg per 48 hours in order to be used safely

along with this drug, since ritonavir increases the concentration of Viagra.
● CYP3A4 inhibitors: Viagra should be taken at 25 mg doses with CYP3A4
inhibitors. CYP3A4 inhibitors also increase the concentration of Viagra.
● Alpha-blockers: Patient should be stabilized on alpha-blocker therapy prior to
using Viagra in order to use it safely, and it should be prescribed at the lowest
dose. Otherwise, the two medications together could cause low blood pressure.
● Cardiovascular conditions: If the patient has cardiovascular issues, it may be
best to steer clear of Viagra completely, since Viagra can make the patient more
likely to go into cardiac arrest.
RT Management:
This drug might cause an allergic reaction

Ask the patient if they are allergic to any
to the patient as the patient is
medications
hypersensitive to nitroglycerin
Monitor the patient’s blood pressure To see if the patient’s blood pressure is in
normal range after taking the drug
Discuss first with the physician if it is safe

Ask patient if she is pregnant taking this drug, it might cause harm to
the unborn baby
Ask patient if they are taking other Some drugs are contraindicated
medicines combining with Gonitro and might cause
additive hypotensive
Monitor patient’s vital signs Too see if the body is responding well or
unwell to the medication
The patient will know the common side

Educate the patient about the side effects effects and patient will not worry if they
are experiencing any side effects of the
drug
59
Brand name: Samsca
Generic name: Tolvaptan
Classification: Vasopressin V2-receptor
antagonist
Mode of action:
Vasopressin works on the luminal

membranes of renal collecting ducts as
well as the vasculature's walls through V2
receptors. Upon blocking V2 receptors in
the renal collecting ducts, aquaporins do not insert themselves into the walls thus
preventing water absorption. In addition, this certain action ultimately results in an
increase in urine volume, decrease urine osmolality, and increase electrolyte-free water
clearance to reduce intravascular volume and an increase serum sodium levels.
Dosage:
Oral dosage in Adults
Starting dose: 15 mg once daily on an empty stomach
Increase dose to 30 mg once daily, after at least 24 hours; maximum of 60 mg

once daily, as needed
Indications: SAMSCA is indicated for the treatment of clinically significant hypervolemic

and euvolemic hyponatremia (serum sodium <125 mEq/L or less marked hyponatremia
that is symptomatic and has resisted correction with fluid restriction), including patients
with heart failure and Syndrome of Inappropriate Antidiuretic Hormone (SIADH).
Contraindications:
● Use in patients with ● Taking strong CYP3A inhibitors

Autosomal Dominant ● Anuria
Polycystic Kidney Disease ● Hypersensitivity (e.g., anaphylactic
(ADPKD) outside of FDA- shock, rash generalized) to tolvaptan or
approved REMS any component of the product
● Unable to sense or respond to
thirst
● Hypovolemic hyponatremia
Adverse effects:
60
● Increased thirst ● Drowsiness
● Dry mouth ● Dry skin
● Loss of appetite ● Nausea
● Constipation ● Fruity breath odor
Drug interaction:
● CYP3A Inhibitors: Tolvaptan is metabolized by CYP3A, and use with strong CYP
3A inhibitors causes a marked (5-fold) increase in exposure.
● CYP3A Inducers: Moderate to strong CYP3A inhibitors (e.g., rifampin) as this can
lead to a reduction in the plasma concentration of tolvaptan by 85% and decreased
effectiveness of SAMSCA treatment.
● Angiotensin Receptor Blockers: In clinical studies, adverse reactions of
hyperkalemia were approximately 1 to 2% higher when tolvaptan was administered
with angiotensin receptor blockers, angiotensin converting enzyme inhibitors and
potassium sparing diuretics compared to administration of these medications with
placebo.
● V2-Receptor Agonist: Tolvaptan interferes with the V2-agonist activity of
desmopressin (dDAVP). Avoid concomitant use of SAMSCA with a V2-agonist
RT Management:
Tell patient to avoid excessive This may increase the risk of developing osmotic
or chronic alcohol consumption demyelination syndrome
Monitor serum sodium and As serious neurologic sequelae can result from over
neurologic status rapid correction of sodium
Some drugs are contraindicated with Samsca such

Ask patient if they are taking
as drugs which increases serum potassium for it
other medicines
may increase risk of hyperkalemia
Educate the patient about the The patient will know the common side effects and
side effects patient will not worry/become agitated
To see if the body is responding well or unwell to

Monitor patient’s vital signs
the medication
The risk of dehydration and hypovolemia is greater

Know if patient is anuric,
in potentially volume-depleted patients receiving
hypovolemic, and hyponatremia
diuretics, or those who are fluid-restricted
61
Brand name: Simdax
Generic name: Levosimendan
Drugs classification: Calcium Sensitizers
Mode of action:
It increases the sensitivity of the heart to

calcium, thus increasing cardiac contractility without
a rise in intracellular calcium. Levosimendan exerts
its positive inotropic effect by increasing calcium
sensitivity of myocytes by binding to cardiac troponin
C in a calcium-dependent manner. It also has a
vasodilatory effect, by opening adenosine
triphosphate (ATP)-sensitive potassium channels in
vascular smooth muscle to cause smooth muscle relaxation. The combined inotropic and
vasodilatory actions result in an increased force of contraction, decreased preload and
decreased afterload. Moreover, by opening also the mitochondrial (ATP)-sensitive
potassium channels in cardiomyocytes, the drug exerts a cardioprotective effect.
Dosage:
6-24 mcg/kg over 10 min followed by 0.05-0.2 mcg/kg/min continuous infusion,

adjust according to response.
Indications:
For short term treatment of acutely decompensated severe chronic heart failure
(CHF). Also being investigated for use/treatment in heart disease.
Contraindications:
● History of torsade de pointes

● Severe renal impairment
● Severe hepatic impairment
Adverse Effects:
● Headache ● Hypokalemia
● Dizziness ● Insomnia
● Hypotension ● GI disturbances
● Ventricular Tachycardia ● Anemia
● Extrasystoles ● Arrhythmias
● Atrial FIbrillation ● Tachycardia
62
Drug Interaction:
● Acebutolol: Levosimendan may increase the arrhythmogenic activities of

Acebutolol.
● Acetyldigitoxin: Acetyldigitoxin may increase the arrhythmogenic activities of
Levosimendan.
● Acrivastine: The risk or severity of QTc prolongation can be increased when
Acrivastine is combined with Levosimendan.
● Adenosine: Adenosine may increase the arrhythmogenic activities of
Levosimendan.
● Ajmaline: Levosimendan may increase the arrhythmogenic activities of Ajmaline.
RT Management:
Tell the patient about the side

This help to know that their symptoms are common
effects of the drug
pressure patient
Warn the patient about the The patient will know when to call the doctor or the
serious adverse effects emergency ambulance
To see if the medication given is effective to the

Closely monitor ECG
patient
63
Brand name: Natrecor
Generic name: Nesiritide
Drugs classification: Natriuretic Peptides
Mode of action:
Nesiritide works by facilitating

cardiovascular homeostasis through the
negative regulation of the renin-angiotensin-
aldosterone system. This regulation will in
order stimulate cyclic guanosine
monophosphate and smooth muscle cell
relaxation. In simpler terms, it promotes
vasodilation, natriuresis, and diuresis.
Dosage:
● Administered through intravenous (IV) use only (There is limited experience

with administering NATRECOR for longer than 96 hours)
● Recommended dosage of: 2 mcg/kg followed by a continuous infusion of
0.01 mcg/kg/min
● Do not exceed 0.03 mcg/kg/min
● Pediatric trials not established
Indications:
Indicated for the treatment of patients with acutely decompensated heart

failure who have dyspnea at rest or with minimal activity. In this population, the use
of Natrecor also reduces pulmonary capillary wedge pressure and improved short
term (3 hours) symptoms of dyspnea.
Contraindications:
● Worsening Renal Function

● Pregnancy
● Pediatric patient
64
Adverse Effects:
● Hypotension ● Headache
● Nausea ● Dizziness
● Back pain ● Hypersensitivity reactions
● Infusion site extravasation ● Rash
● Pruritus
Drug Interaction:
● Acebutolol: The risk or severity of adverse effects can be increased when

Acebutolol is combined with Nesiritide.
● Amobarbital: Amobarbital may increase the hypotensive activities of Nesiritide.
● Heparin, Insulin, Ethacrynic Acid, Bumetanide, Enalapril; Enalaprilat,
Hydralazine, And Furosemide: These drugs should not be coadministered as
infusions through the same IV catheter with nesiritide
RT Management:

effects of the drug
The drug should lower the patient’s blood pressure

Check patient’s vital signs
not increase it further however it can also cause
especially the blood pressure
severe hypotension
Monitor creatinine levels during The drug can impair renal function as observed by
and after drug administration an increased serum creatinine levels
Can be caused by a miscalculation on the required

dosage of the patient or mechanical error such as
Avoid overdosing of the drug an infusion-pump malfunction or an infusion-pump
programming error. Common sign seen is severe
hypotension
65
Brand name: Nitropress
Generic name: Nitroprusside sodium
Drugs classification: Vasodilators
Mode of action:
One molecule of sodium nitroprusside is

metabolized by combination with hemoglobin to
produce one molecule of cyanmethemoglobin and
four CN- ions; methemoglobin, obtained from
hemoglobin, can sequester cyanide as
cyanmethemoglobin; thiosulfate reacts with
cyanide to produce thiocyanate; thiocyanate is
eliminated in the urine; cyanide not otherwise
removed binds to cytochromes. Cyanide ion is normally found in serum; it is derived from
dietary substrates and from tobacco smoke. Cyanide binds avidly (but reversibly) to ferric
ion (Fe+++), most body stores of which are found in erythrocyte methemoglobin (metHgb)
and in mitochondrial cytochromes. When CN is infused or generated within the
bloodstream, essentially all of it is bound to methemoglobin until intraerythrocytic
methemoglobin has been saturated.
Sodium nitroprusside is further broken down in the circulation to release nitric oxide
(NO), which activates guanylate cyclase in the vascular smooth muscle. This leads to
increased production of intracellular cGMP, which stimulates calcium ion movement from
the cytoplasm to the endoplasmic reticulum, reducing the level of available calcium ions
that can bind to calmodulin. This ultimately results in vascular smooth muscle relaxation
and vessel dilation.
Dosage:
● Depending on the desired concentration on intravenous administration, the

solution containing 50 mg of Nitropress must be further diluted in 250-1000 mL of
sterile 5% dextrose injection.
● Diluted solution should be protected from light, using the supplied opaque sleeve,
aluminum foil, or other opaque material.
● Maximum dosage of 10 mcg/kg/minute IV for 10 minutes in all age groups.
Indications:
For immediate reduction of blood pressure of patients in hypertensive crises,

reduce bleeding during surgery, and for the treatment of acute congestive heart failure
66
Contraindications:
● Aortic coarctation
● Arteriovenous shunt
● Heart Failure
● Pregnancy
Adverse Effects:
● Thiocyanate toxicity ● Diaphoresis

● Cyanide toxicity ● Dizziness
● SInus tachycardia ● Nausea
● Palpitations ● Headaches
● Vomiting ● Abdominal pain
Drug Interaction:
● Acetaminophen; Chlorpheniramine; Dextromethorphan; Phenylephrine: Use

sympathomimetic agents with caution in patients receiving therapy for
hypertension. Patients should be monitored to confirm that the desired
antihypertensive effect is achieved. Sympathomimetics can increase blood
pressure and heart rate, and antagonize the antihypertensive effects of
vasodilators when administered concomitantly. Anginal pain may be induced when
coronary insufficiency is present.
● Aliskiren: Aliskiren can enhance the effects of vasodilators on blood pressure if
given concomitantly. This additive effect may be desirable, but dosages must be
adjusted accordingly. Blood pressure and electrolytes should be routinely
monitored in patients receiving aliskiren.
● Alpha-blockers: Additive hypotensive effects may occur when nitroprusside is
used concomitantly with other antihypertensive agents. Dosages should be
adjusted carefully, according to blood pressure.
RT Management

effects of the drug
Verify patient chart if there is an Hepatic or renal impairment can cause an increased
existing hepatic disease or risk for thiocyanate or cyanide toxicity. Lower
renal impairment infusion rates must be used instead.
67
The drug can increase intracranial pressure and
Monitor patient’s intracranial
should be more cautious on patients with an already
pressure
existing high intracranial pressure
Blood pressure should be produced by the drug but

Monitor vital signs should not be low enough to compromise other
organs
68
Brand Name: SYMJEPI
Generic Name: Epinephrine Injection
Drug Classification: Adrenergic
bronchodilators, Catecholamines,
Vasopressors
Mode of Action:
SYMJEPI is a disposable,
prefilled syringe used to treat life-
threatening, allergic emergencies
including anaphylaxis in people who are at risk for or have a history of serious allergic
emergencies. Each prefilled syringe contains a single (1 time) dose of epinephrine.
SYMJEPI is for immediate self (or caregiver) administration and does not take the place
of emergency medical care. Patient should get emergency help right away after using
SYMJEPI. SYMJEPI is for people who have been prescribed this medicine by their
healthcare provider.
Dosage:
● Patients greater than or equal to 30 kg (approximately 66 pounds or more):0.3 mg

● Patients 15 kg to 30 kg (33 pounds to 66 pounds): 0.15 mg
Indications:
SYMJEPI is indicated in the emergency treatment of allergic reactions (Type I)

including anaphylaxis to stinging insects (e.g., order Hymenoptera, which include bees,
wasps, hornets, yellow jackets and fire ants) and biting insects (e.g., triatoma,
mosquitoes), allergen immunotherapy, foods, drugs, diagnostic testing substances (e.g.,
radiocontrast media) and other allergens, as well as idiopathic anaphylaxis or exercise-
induced anaphylaxis. SYMJEPI is intended for immediate administration in patients who
are determined to be at increased risk for anaphylaxis, including individuals with a history
of anaphylactic reactions.
Contraindications:
None
Adverse Effects:
69
● Fast, Irregular pr “Pounding” ● Paleness
Heartbeat ● Feelings of over excitement,
● Sweating Nervousness Or Anxiety
● Headache ● Dizziness
● Weakness ● Nausea and Vomiting
● Shakiness ● Breathing Problems
Drug Interaction:
● Cardiac Glycosides, Diuretics, And Antiarrhythmics: Patients who receive

epinephrine while concomitantly taking cardiac glycosides, diuretics or anti-
arrhythmics should be observed carefully for the development of cardiac problems.
● Antidepressants, Monoamine Oxidase Inhibitors, Levothyroxine, And
Antihistamines: The effects of epinephrine may be potentiated by tricyclic
antidepressants, monoamine oxidase inhibitors, levothyroxine sodium and certain
antihistamines, notably chlorpheniramine, tripelennamine and diphenhydramine.
● Beta-Adrenergic Blockers: The cardiostimulating and bronchodilating effects of
epinephrine are antagonized by beta-adrenergic blocking drugs, such as
propranolol.
● Alpha-Adrenergic Blockers: The vasoconstricting and hypertensive effects of
epinephrine are antagonized by alpha-adrenergic blocking drugs, such as
phentolamine.
● Ergot Alkaloids: Ergot alkaloids may also reverse the pressor effects of
epinephrine. Patients who receive epinephrine while concomitantly taking cardiac
glycosides, diuretics, or antiarrhythmics should be observed carefully for the
development of cardiac arrhythmias.
● Blocking drugs, such as propranolol: The vasoconstricting and hypertensive
effects of epinephrine are antagonized by alpha-adrenergic blocking drugs, such
as phentolamine
RT Management:

effects of the drug
pressure patient
Ask the patient if they have an To ensure that the patient does not have an allergic
allergy to a medicine reaction called angioedema
70
Inform patient if any accidental
To ensure patients safety of the wrong placement of
injection happens, get medical
injection
get help right away
71
RESPIRATORY THERAPY CARE PLAN
August 1, 2022
Name: Patient Yu
Age: 65 years old
Sex: Female
Height: 5’5
Weight: 85 kg
Physician: Benny Bilang, RTRP, MD
Admission: August 1, 2022; 9pm
Subjective
The patient stated “nanlisod gihapon kog ginhawa og mura kog malumos pag
matulog.”
Objective
Vital Signs
Date: August 1, 2022
Vital Signs taken at 10 pm (1 hour after admission)
Time 10:00 pm
BP 140/95
Temp 37.2 °C
RR 27
HR 110
Sp02 54%
72
Glasgow Coma Scale
Response Point Scale
Eye Response 4 Eyes open Spontaneously
Verbal Response 4 Confused conversation
Motor Response 6 Obeys command
GCS Score 14 Mild
Physical Assessment
Head
■ Upon inspection, the patient’s head has no lesion or indication of

trauma. Hair is grayish in color, normal amount and evenly
distributed over the scalp.
■ Upon palpation, no palpable mass, lumps or tenderness are noted.
Eyes
■ Upon inspection, eyes are symmetrically aligned. No discharges

and discoloration. Conjunctiva is clear and reddish.
■ Upon assessing for light reaction, the pupils constrict briskly.
■ Upon palpation, lumps and tenderness were not noted on both

eyelids.
Nose
■ Upon inspection, nasal flaring is present; no nasal septum

deformities are present.
■ Upon palpation, there is no soreness and no tenderness in the

frontal and maxillary sinus.
Mouth
73
■ Upon inspection, the patient is experiencing dryness of lips and
cyanosis is present in the patient's mouth.
Neck
■ Upon inspection, the trachea is in the midline position. No lesions.

Use of accessory muscles for breathing is visible.
■ Upon palpation, there were no lymph nodes or lumps.
Chest
■ Upon inspection, increased work of breathing is visible. No

deformities and lesions noted.
■ Upon auscultation, there is a rapid, irregular heart beat. Fine

crackles are also present in patients' lungs.
Abdomen
■ Upon inspection, there are no visible lesions and scars.
■ Upon auscultation, there were no abnormal bowel sounds noted.
Upper extremities
■ Upon inspection, there are no rashes or lesions observed. Signs

cyanosis is seen on patients' hands. On the left hand a pulse
oximeter is attached with a reading of 73% Sp02.
■ Upon palpation, no tenderness and deformity were present.
Lower extremities
■ Upon inspection, the legs are swollen.
■ Upon palpation, there is tenderness at the swollen area.
74
Laboratories
Chest X-ray
Impression: Pulmonary edema due to heart failure
Arterial Blood Gas
ABG Element Result Normal Range
pH 7.30 7.35 - 7.45
PaCO2 28 mmHg 35 - 45 mmHg
HCO3 18 mmol/L 22 - 26 mmol/L
PaO2 61 mmHg 80 - 100 mmHg
Interpretation: Partially Compensated Respiratory Alkalosis with Uncorrected

Hypoxemia
75
Electrocardiogram
Impression: Arrhythmia
Analysis
Shortness of breath is related to decreased cardiac output secondary to

cardiogenic pulmonary edema.
Planning
At the end of the 8 hour shift, the patient will be able to alleviate shortness of
breath as evidence by:
● Improved vital sign specifically
○ Blood pressure within normal range
○ Heart rate within normal range
○ Respiratory rate within normal range
○ Oxygen saturation within normal range
● Absence of nasal flaring
● Expressed relief and improvement in shortness of breath
76
Intervention
Dependent Independent
Administer medications. Monitor vital signs.

✓ Vasodilator
✓ Diuretics
✓ Alpha and beta blockers
Extract arterial blood gas. Assist patient in raising the head of the bed.
Oxygen therapy Monitor patient’s signs of cyanosis.
Check for the patient's use of accessory

muscles.
Monitor patient’s response to oxygen

therapy.
Auscultate patients chest for any abnormal

sounds.
Monitor patient’s weight gain.
Vital Signs Sheet
Taken hourly from the admission time 9:00 pm until 12:00 am which was
the time the patient fell asleep.
Time Temp BP RR HR SpO2%
9:00 pm 37.4˚C 150/90 30 135 54
10:00 pm 37.5˚C 140/95 27 129 58
11:00 pm 37.9˚C 130/90 25 125 60
12:00 am 37.2˚C 145/90 25 127 63
77
Evaluation
Goal was unmet
After 4 hours of providing healthcare to the patient from the admission time
until the patient fell asleep, the goal was not met. There were no significant
changes in the patient's vital signs. Shortness of breath, nasal flaring and use of
accessory muscles were still present, although the patient expressed relief of
anxiety.
Recommendation
Recommendation Rationale
Increase CPAP pressure and oxygenation to

To improve oxygenation
relieve uncorrected hypoxemia
Continue to provide medication as ordered by This will help alleviate the patient’s
the physician sign & symptoms
To check for patients blood

Continue to monitor patient’s ABG oxygenation, carbon dioxide and pH
level
Asses for patient’s response to medication

To evaluate medicine efficacy
and therapy
Monitor patient’s breathing (e.g. if patient is To determine if patient’s breathing is

still using accessory muscles for breathing) still in distress
Encourage the patient to eat a

Educate the patient on having proper nutrition
balanced diet.
Semi-fowler position contributes to

Place the patient to sit in a sitting or semi-
full lung expansion. Raise swollen
fowler’s position
legs when sitting.
78
August 3, 2022
Name: Patient Yu
Age: 65 years old
Sex: Female
Height: 5’5
Weight: 85 kg
Subjective
The patient stated, “medyo kapos gihapon sa hangin.”
Objective
Date: August 3, 2022; 7:30 am

Vital Signs
Patient vital signs taken every 3 hours from a 7am-3pm shift.
7:00 am 37.3˚C 145/90 22 128 90
10:00 am 37.4˚C 135/95 23 125 91
1:00 pm 38˚C 130/90 22 120 90
3:00 pm 37.9˚C 125/90 21 115 92
Glasgow Coma Scale

Verbal Response 5 Oriented
GCS Score 1 Mild Brain Injury
79
Physical Assessment
Head

Eyes


eyelids.
Nose
■ Upon inspection, a nasal cannula is inserted at 15cm H2O at 70%

FiO2 connected to a wall source.
Mouth
■ Upon inspection, the patient is experiencing dryness of lips and

signs of cyanosis in the patient's mouth have reduced.
Neck

Use of accessory muscles for breathing is visible.
Chest
■ Upon inspection, increased work of breathing was reduced. No

deformities and lesions are noted.
■ Upon auscultation, irregular heart beat is still present. Fine crackles

are still present in the patient's lungs.
80
Abdomen
Upper extremities

oximeter is attached with a reading of 75% Sp02.
Lower extremities
■ Upon inspection, the swollen legs had reduced in size.
■ Upon palpation, there is tenderness at the swollen area.
Laboratories
Arterial Blood Gas
Date: August 3, 2022 taken at 8 am
pH 7.30 7.35 - 7.45
PaCO2 50 mmHg 35 - 45 mmHg
Interpretation: Partially compensated Respiratory acidosis with corrected

hypoxemia
81
Chest X-ray
Findings: Pulmonary edema due to left ventricular dysfunction.
Analysis
Fine crackles upon auscultation related to Left Ventricular Dysfunction secondary

to Cardiogenic Pulmonary Edema.
Planning
That within the 8 hour shift of providing healthcare, the patient will experience the
following:
● Improved vital signs specifically:
○ Blood pressure within the normal range of 110/70-130/90 mmHg
○ Heart rate within 60-100 beats per minute
○ Respiratory rate within the normal range of 12-20 cycles per minute
○ Peripheral oxygen saturation within the normal range of 95% -100%
● Improved ABG values that reach the normal ranges of:
○ pH of 7.35 - 7.45 73
○ paCO2 of 35 - 45 mmHg
○ HCO3 of 22-26 mmol/L
○ PaO2 of 80-100 mmHg
● Decreased use of accessory muscles
82
● Normal breath sound
● Decrease of excess fluid in the lungs.
Intervention

✓ Vasodilator
✓ Diuretics
✓ Alpha and beta blockers
Oxygen therapy. Monitor patient’s signs of cyanosis.

muscles.
Monitor patient’s response to oxygen therapy.

sounds.
Evaluation
Goal was partially met.
After 3 days of providing care, the goal was partially met. The patient’s
shortness of breath improved as evidence by:
● Improved vital signs:
○ Blood pressure of 125/90 mmHg
○ Respiratory rate of 21 bpm
○ Heart rate of 115 60-100 bpm
○ SpO2% of 92% at 3:00 pm
83
● Improved ABG values
○ pH of 7.30
○ paCO2 of 50 mmHg
○ HCO3 of 30 mmol/L
○ PaO2 of 81 mmHg
● Decreased use of accessory muscles
● Occasional nasal flaring
Recommendation
Recommendation Rationale
Maintain current oxygen therapy

To maintain adequate oxygenation for the patient
treatment
ABG values are improving and are compensating

Continue ABG monitoring
however not all are within the normal range
Check if the patient will be in Patient oxygenation status has now improved but
labored breathing must still be continually observed
Continue monitoring the vital Vital signs monitoring can help determine patient’s
signs response to therapies and medications given
Continue medications and Patient status has been seen to be improving with
interventions the current therapy and medications given.
High oxygenations are useful to treat hypoxemia

preventing hypoxia however prolonged high
Adjust oxygen concentration
concentrations of oxygen can cause complications
when it is needed
such as oxygen toxicity, airway irritation and
damage
84
August 6, 2022
Name: Patient Yu
Age: 65 years old
Sex: Female
Height: 5’5
Weight: 85 kg
Subjective
“Hapsay na akong tulog, og di na kaayo ko gina kapos sa hangin”
Objective
Vital Signs
Date: August 6, 2022
Patient vital signs taken every 3 hours from a 7am-3pm shift.
7 am 37.3˚C 120/90 21 105 92
10 am 37.4˚C 110/80 20 98 93
1 pm 38˚C 120/90 19 100 95
3 pm 37.9˚C 120/90 17 95 97
Glasgow Coma Scale
Verbal Response 5 Oriented
GCS Score 15 Mild
85
Physical Assessment
Head

Eyes


eyelids.
Nose
■ Upon inspection, a nasal cannula is inserted at 15cm H2O at 70%

FiO2 connected to a wall source.
Mouth
■ Upon inspection, the lips are moist and no discoloration was noted.
■ Upon palpation, there was no inflammation and swelling noted.

Teeth and gums are in good condition. No masses and lesions
were detected.
Neck

Use of accessory muscles for breathing is no longer evident.
Chest
■ Upon inspection, no more signs of increased work of breathing. No

deformities and lesions are noted.
■ Upon auscultation, heartbeat rhythm has improved. No abnormal

sound in the lungs.
86
Abdomen
Upper extremities

oximeter is attached with a normal reading of 97% Sp02.
Lower extremities
■ Upon inspection, the swelling in the legs was gone.
■ Upon palpation, no edema present.
Laboratories
Chest x-ray
Findings: Pulmonary edema due to left ventricular dysfunction.
87
Arterial Blood Gas
pH 7.38 7.35 - 7.45
paCO2 48 mmHg 35 - 45 mmHg
Interpretation: Partially Compensated Respiratory Acidosis with Corrected

Hypoxemia
Analysis
Shortness of breath due to decreased cardiac output secondary to cardiogenic

pulmonary edema.
Planning
At the end of an 8 hour shift the patients shortness of breath will be improved as
evidenced by the following:
● Maintain normal vital signs.
● Maintain normal ABG values
● Absence use of accessory muscles
● Normal breathing pattern
Intervention

✓ Vasodilator
✓ Diuretics
88
Oxygen therapy. Monitor patient’s signs of cyanosis.

muscles.
Monitor patient’s response to oxygen therapy.

sounds.
Evaluation
Goal was met
After 6 days of providing care, the goal was met as evidence by:
● Maintained normal vital signs, Improved ABG values, Corrected

Hypoxemia, Absence use of accessory muscles, Absence of nasal flaring,
Swollen legs back to normal, No signs of cyanosis
Recommendations
● Proper nutrition and balanced diet
To prevent heart disease and its complications.
● Monitor weight
One sign of cardiogenic pulmonary edema is gaining weight fast
● Continue monitoring vital signs
Assess the response of the patient towards the given treatment and
intervention
● Continue monitoring ABG and oxygen status
To monitor oxygenation and acid-base status of the patient.
● Request Echocardiography
To monitor the progression of health disease and if treatments are
89
effective in improving lung functions
● Request chest radiograph
To monitor progression of lung and cardiac abnormalities.
● Encourage patient to participate in regular exercises.
Strengthening exercises help with conditioning in increasing activity

tolerance.
● Educate and instruct the watcher.
To assist the patient for long term care and follow up.
90
PULMONARY REHABILITATION
According to the official American Thoracic Society/ European Respiratory

Society, pulmonary rehabilitation is a complete evaluation of the patient where it is a
comprehensive intervention that includes exercise training, education, and behavior
change. It is intended to enhance the physical and mental health of people with chronic
respiratory diseases, encourage long-term persistence to health-improving practices, and
facilitate people to live independently, as well as, vocational and social function.
Patients with cardiogenic pulmonary edema are more likely to work with a team of
healthcare professionals, possibly including cardiologists, nurse educators, nutrition
specialists, exercise specialists, mental health specialists and occupational therapists.
Medications
It is important to keep the patient and family members informed about the purpose,
side effects, dosage of the medications and explain to them why it is necessary to comply
with the prescribed medications given by the physician.
Most patients with cardiogenic pulmonary edema are already taking medication for
congestive heart failure such as, angiotensin-converting enzyme inhibitors, beta blocker,
diuretics, angiotensin receptor blockers, and inotropic agents. All dosages of the
medications mentioned will depend on the physician’s order.
● Angiotensin-converting enzyme inhibitor: Perindopril
- ACE inhibitors will help the body to reduce the levels of angiotensin 2 and
this will widen up the blood vessels.
● Angiotensin receptor blocker: Candesartan
- ARB works by blocking the action of a substance in the body that causes
the blood vessels to tighten. As a result, this relaxes the blood vessels and
increases the supply of blood and oxygen to the heart.
● Diuretics: Spironolactone
- Diuretics will help the kidneys release more sodium into the urine where
sodium helps remove water from the blood, decreasing the amount of fluid
flowing through the veins and arteries. Thus, this reduces blood pressure.
● Beta blockers: Acebutolol
91
- They work by lowering the force and beat of the heart where it lowers the
blood pressure of the patient. Beta blockers also help widen veins and
arteries to improve blood flow.
● Inotropic agents
- Are used to treat hypotension or signs of organ hypoperfusion.
The health care provider should also take note of the following:
● Instruct the patient the drug should be given at the right dosage as followed by the
doctors prescription
● Inform the patient and family member about the adverse effects of the drugs
● Health care provider might need to persuade the patient and family member to
take the prescribed drugs by reminding them that it will make the patient much
healthier if they keep taking the medication
Treatment
Strenuous activities are not recommended for patients with cardiogenic pulmonary
edema, so treatment is the best option as it can relieve their symptoms and slow the
progression of the disease.
● Continuous Positive Airway Pressure
CPAP by mask can be used to treat patients who have cardiogenic

pulmonary edema. CPAP reduces venous return and cardiac filling pressure,
which is helpful in reducing pulmonary vascular congestion. It will also improve the
lung compliance, and the work of breathing is decreased. Also, one of the
beneficial effects of CPAP is to improve secretion removal. An effective CPAP
therapy requires careful planning, individualized patient assessment, and
implementation.
● Noninvasive Ventilation
The therapy of acute respiratory failure in the presence of cardiogenic

pulmonary edema is advised to include NIV. The studies from Gray, Goodacre S,
Newby DE, Ho KM, Wong K et al. revealed that during the first hour of starting
treatment, either CPAP or NIV significantly decreased the dyspnea score, heart
rate, acidity, and hypercapnia in patients with cardiogenic pulmonary edema. They
also revealed that intubation and mortality rates with NIV have decreased.
However, some studies revealed that there was no improvement at all.
92
● Invasive Ventilation
A mechanical ventilator is given when the patient is still not improving in the
set up of noninvasive ventilation and continuous positive airway pressure. Since
most patients with cardiogenic pulmonary edema have congestive heart failure, it
is most likely to have a volume overload which means there is a high preload or
increase in stroke volume, decreased alveolar pressure, and an increased LV (left
ventricle) afterload. The set up of mechanical ventilation will help to decrease
preload, increase alveolar pressure, and decrease LV afterload. It is a need to
decrease LV afterload so cardiac output will increase.
Diet
Patients with cardiogenic pulmonary edema are advised to change their diet due
to their heart problem. Changing of diet also focuses on weight management and good
nutrition as it relates to cardiopulmonary health. Dietary guidelines below must be
followed before the patient leaves the hospital to maintain a normal blood pressure and
healthy heart, taken into consideration and instructed:
● Low cholesterol diet
● Do not eat more than 2,000 mg of sodium each day. This is less than 1 teaspoon
of salt a day, including all the salt present in prepared or packed food.
- Do not add salt while cooking or at the table. Flavor food with garlic, lemon
juice, onion, vinegar, herbs, and spices instead of salt.
- Eat fewer processed foods and foods from restaurants, including fast foods.
- Use fresh or frozen food instead of canned.
- Always check food labels for sodium
- Ask the doctor before using salt substitutes that have potassium
● Eat balanced diet
● Always monitor the weight
● Encourage patient to maintain a healthy routine to have a healthy good living
Lifestyle Education
● Stay out of air pollution
● Learn breathing methods to help improve the lungs
93
● Take rest breaks often
● If the physician allows exercise, do it slowly. Walking is a good way to start an

exercise
● Get enough sleep
● Smoking and tobacco use is highly prohibited because it can worsen patient’s
condition
● Do not use alcohol and illegal drugs
● Advise foods that is allowed for the patient
● Maintain taking the prescribed medications from the physician
94
PROGNOSIS
Patient Yu is a 65 year old female diagnosed with Cardiogenic Pulmonary Edema.

The patient presented herself at the emergency room of San Pedro Hospital on August
01, 2022, complaining of shortness of breath on exertion and dizziness.
Upon admission, the patient’s medical records were reviewed, and her vital signs,
ABG analysis, and GCS score were also taken to assess her status. Several diagnostic
tests were performed to identify the disease that Patient Yu is suffering from. The
diagnostic tests included Chest x-ray, echocardiography, pulmonary arterial catheter,
ultrasonography, arterial blood gas analysis, electrocardiogram, blood urea nitrogen test,
and serum electrolytes test. These diagnostics all led to the diagnosis of Cardiogenic
Pulmonary Edema
Upon admission. The patient was compliant to all medications, diet, and
management. The management offered to Patient Yu, focused on relieving the severity
of her signs, symptoms and complications related to his diagnosis. This includes oxygen
therapy via nasal cannula. The medication the patient received was Perindopril,
Spironolactone, and Carvedilol. During the course of her admission, Patient Yu
responded well to the medication. Shortness of breath, swollen legs, and signs of
cyanosis were alleviated. The patient is in the process of recovering, as her laboratory
test and diagnostic test continue to improve. However, it is to be noted that her congestive
heart failure, the main cause of her pulmonary edema, still persists and must be properly
maintained to prevent further complications.
Overall, Patient Yu is in good prognosis. Her compliance to her medicines and her
behavior towards getting better is helping her to be in better shape. The patient will
continue eating a healthy and balanced diet to reverse her obesity.
95
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A Case Study on

CARDIOGENIC PULMONARY EDEMA

In Partial Fulfillment of the Requirements in

ADULT INTENSIVE RESPIRATORY CARE

The Bachelor of Science in Respiratory Therapy (BSRT) is an intensive ten-month

As mentioned earlier, cardiogenic pulmonary edema is defined as pulmonary

This case study will present cardiogenic pulmonary edema as a complication to a

a. To be able to create a comprehensive and detailed case study that is

b. Find a patient with distinct conditions that relate to cardiogenic pulmonary

c. Establish patient and their immediate family member’s trust to gain

e. Expound the patient's case through the manuscript supported by relevant

f. Create general and specific objectives that are specific, measurable,

g. Define the patient’s diseases with supporting references.

h. Present a detailed patient data which includes biographical data, clinical

i. Perform a cephalocaudal assessment to assess any abnormalities that may

l. Generate the pathophysiology of the patient’s condition including its risk

n. Enumerate the medication/s that are or can be prescribed to the patient.

o. Formulate at least three (3) respiratory therapy care plans focused on

p. Design a pulmonary rehabilitation plan can be integrated to the patient when

q. Formulate the patient’s prognosis by discussing the outcome of the patient's

Pulmonary edema is defined as a condition where there is movement of fluid from

As stated above, Cardiogenic pulmonary edema is mainly referred to as the

The initial events in Cardiogenic pulmonary edema involve hemodynamic

Personal Name : Patient Yu

Chief Complaint : Shortness of breath on exertion, dizziness, chest

Past Health History

Present Health History

Patient Yu is currently a 65-year-old mother who is working as a chef on a self-

Figure 1. Genogram of Patient Yu

RESULTS NORMAL VALUES

Blood Pressure: 150/90 120/80 mmHg

Eye Opening 4 (spontaneous)

The patient’s level of consciousness is described to be awake. The patient

Upon inspection the head is round, no lumps, hair is evenly distributed, no

Upon inspection eyes are symmetrical, no discharges, anicteric sclera,

Upon inspection the patient has an increased anteroposterior chest

Upon inspection there are no distention, lesions and abrasions. Umbilicus

Upon inspection there are no lesions and excoriation noted, no abrasions,

Upper and Lower Extremities

Havighurst's Developmental Tasks Theory

TASK MET/UNMET RATIONALE

Infancy & early childhood

Middle childhood (6-12

During this stage, they start At this stage, patient was an

Early adulthood (19 to 30

At this point, they begin to Patient graduated from college

Middle age (30 to 60 years

During this period, adults are

Later maturity (60 years old

Erik Erikson’s Stages of Psychosocial Development

TASK MET/UNMET RATIONALE

During this stage, infants are

Autonomy vs Shame (1 ½ According to the patient and

At this stage, the child

Identity vs Confusion (12

Intimacy vs Isolation (18 to

Ego integrity vs Despair

The heart is a four-chambered muscular organ approximately the size of a

It is a closed system where blood passes through to deliver oxygen,