INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point.

When asked to provide several answers, list them in order of

priority or significance. Do not assume information that is not provided.

Heart Failure Scenario:

M.G., a “frequent flier,” is admitted to the emergency department with a diagnosis of heart failure. She was discharged from the hospital 10 days ago and comes in today
stating, “I just had to come to the hospital today because I can't catch my breath and my legs are as big as tree trunks.” After further questioning, you learn she is strictly
following the fluid and salt restriction ordered during her last hospital admission. She reports gaining 1 to 2 pounds every day since her discharge.

1. What error in teaching most likely occurred when M.G. was discharged 10 days ago?
 A breakdown of successful communication occurred regarding when to call with early weight gain. It is imperative that patients understand when to call their
provider after being discharged from the hospital for exacerbated HF. Comprehensive patient education starting at admission is considered a standard of care and is
mandated by The Joint Commission when providing care to hospitalized patients. The goal of the discharge treatment plan is to facilitate successful patient self-
management, minimize symptoms, and prevent readmission

Case Progress:
During the admission interview, the nurse makes a list of the medications M.G. took at home.
Nursing Assessment: Medications Taken at Home
Enalapril (Vasotec) 5 mg PO bid
Pioglitazone (Actos) 45 mg PO every morning
Furosemide (Lasix) 40 mg/day PO
Potassium chloride 20 mEq/day PO
2. Which of these medications may have contributed to M.G.'s heart failure? Explain.
 Thiazolidinediones, such as pioglitazone, may increase the risk of heart failure and should not be used in patients with symptoms of heart failure. They commonly
cause peripheral edema and weight gain (which are the result of both water retention and increased deposit of adipose tissue.

3. Make a Drug study of the medications listed above.

GENERIC NAME MECHANISM OF ACTION SIDE EFFECTS NURSING RESPONSIBILITY

 Enalapril Suppresses renin-angiotensin-aldosterone BASELINE ASSESSMENT
system (prevents conversion of angiotensin I Frequent (7%–5%):  Obtain BUN, serum creatinine, CrCL.
to angiotensin II, a potent vasoconstrictor; Headache, dizziness.  Receive full medication history, esp.
may inhibit angiotensin II at local vascular, Occasional (3%–2%): potassium-sparing diuretics.
renal sites). Decreases plasma angiotensin II, Orthostatic hypotension,
 Obtain B/P immediately before each
increases plasma renin activity, decreases fatigue, diarrhea, cough,
dose (be alert to fluctuations).
aldosterone secretion. Therapeutic Effect: In syncope.
 In pts with renal impairment,
hypertension, reduces peripheral arterial autoimmune disease, or taking drugs
Rare (less than 2%): Angina,
resistance. In HF, increases cardiac output; that affect leukocytes/ immune
abdominal pain, vomiting,
decreases peripheral vascular resistance, response, CBC should be performed
nausea, rash, asthenia.
B/P, pulmonary capillary wedge pressure, before beginning therapy, q2wks for 3
heart size. mos, then periodically thereafter.
BRAND NAME INDICATION
 Indicated for the management of INTERVENTION/EVALUATION
essential or renovascular  Assist with ambulation if dizziness
Vasotec
hypertension as monotherapy or in occurs.
combination with other  Monitor CBC, serum BUN, potassium,
antihypertensive agents, such as creatinine, B/P.
thiazide diuretics, for an additive  Monitor daily pattern of bowel activity,
effect. stool consistency.
 Indicated for the treatment of
symptomatic congestive heart failure, PATIENT/FAMILY TEACHING
usually in combination with diuretics
and digitalis.  To reduce hypotensive effect, go from
lying to standing slowly. Several
 Indicated for the management of
weeks may be needed for full
asymptomatic left ventricular
therapeutic effect of B/P reduction.
dysfunction in patients with an
ejection fraction of ≤ to 35 percent to  Skipping doses or voluntarily
decrease the rate of development of discontinuing drug may produce severe
overt heart failure and the incidence rebound hypertension. Limit alcohol
of hospitalization for heart failure intake.
DRUG ILLUSTRATION CONTRAINDICATION ADVERSE REACTION  Report vomiting, diarrhea, diaphoresis,
  Hypersensitivity to enalapril. Excessive hypotension (“first-
 History of angioedema from dose syn\cope”) may occur in pts
previous treatment with ACE with HF, severe salt or volume
inhibitors. depletion. Angioedema (facial, lip
 Idiopathic/hereditary angioedema. swelling), hyperkalemia occurs
 Concomitant use of aliskiren in pts rarely. Agranulocytosis,
with diabetes. neutropenia may be noted in pts
 Coadministration with or within 36 with renal impairment, collagen
hrs of switching to or from a vascular diseases (scleroderma,
neprilysin inhibitor (e.g., sacubitril). systemic lupus erythematosus). persistent cough, difficulty in
CLASSIFICATION Nephrotic syndrome may be breathing; swelling of face, lips,
noted in those with history of tongue.
DOSAGE/FREQUENCY/ROUTE
renal disease.
DOSAGE: 5 mg

FREQUENCY: Two times a day

(bid)

ROUTE: Orally (po)

GENERIC NAME MECHANISM OF ACTION SIDE EFFECTS/ NURSING RESPONSIBILITY

Pioglitazone ACTOS decreases insulin resistance in ADVERSE REACTION
the periphery and in the liver resulting in - swelling (edema), when INTERVENTION/EVALUATION
increased insulin-dependent glucose used in combination with - Assess peripheral edema using girth measurements,
disposal and decreased hepatic glucose sulfonylurea or insulin volume displacement, and measurement of pitting
output. Unlike sulfonylureas, - low blood sugar edema. Report increased swelling in feet and ankles or a
pioglitazone is not an insulin (hypoglycemia) sudden increase in body weight due to fluid retention.
secretagogue. - upper respiratory infection Also report signs of pulmonary edema such as dyspnea
BRAND NAME INDICATION - headache and abnormal breath sounds (rales/crackles).
Actos Management of type 2 diabetes mellitus; - heart failure - Assess any pain that might indicate fractures,
may also be used with a sulfonylurea, - sinus infection especially in the arms, hand, and feet in women. Protect
and support any suspected fracture sites, and report the
 metformin, or insulin when the - fracture of bone problem to the physician for further evaluation.
combination of diet, exercise, and - sore throat (pharyngitis) - Monitor signs of drug-induced hepatitis, including
metformin does not achieve glycemic - muscle pain anorexia, abdominal pain, severe nausea and vomiting,
control. - aggravated diabetes yellow skin or eyes, skin rashes, flu-like symptoms, and
DRUG ILLUSTRATION CONTRAINDICATION - diabetic swelling in the eye muscle/joint pain. Report these signs to the physician.
 Hypersensitivity to pioglitazone (macular edema) - Be alert for signs of hypoglycemia, especially during
 Diabetic ketoacidosis - increased cholesterol and after exercise. Common neuromuscular signs
 Moderate-severe hepatic impairment - decreased serum include anxiety; restlessness; tingling in hands, feet,
(alanine aminotransferase [ALT] triglycerides lips, or tongue; chills; cold sweats; confusion; difficulty
over 2.5x urate-lowering therapy - decreased in concentration; drowsiness; excessive hunger;
[ULN]) hematocrit/hemoglobin headache; irritability; nervousness; tremor; weakness;
 Chronic heart failure (NYHA class - bladder cancer unsteady gait.
III, IV) - decreased visual - Report persistent or repeated episodes of
CLASSIFICATION acuity/blurred vision hypoglycemia to the physician.
Antidiabetics - shortness of breath - Monitor signs of anemia, including unusual fatigue,
- increased transaminases shortness of breath with exertion, and bruising. Notify
DOSAGE/FREQUENCY/ROUTE (amino acids) physician immediately if these signs occur.
DOSAGE: 45mg - weight gain - Assess blood pressure periodically. A sudden or
FREQUENCY: every morning - blood in urine sustained increase in blood pressure (hypertension) may
ROUTE: PO - abdominal pain indicate problems in diabetes management and should
- feeling unwell (malaise) be reported to the physician.
- itching - Report increased swelling in feet and ankles or a
- loss of appetite sudden increase in body weight due to fluid retention.
- dark urine - Implement aerobic exercise and endurance training
- clay-colored stools programs to maintain optimal body weight, improve
- yellowing of skin or eyes insulin sensitivity, and reduce the risk of macrovascular
(jaundice) disease (heart attack, stroke) and microvascular
- cold symptoms (stuffy problems (reduced blood flow to tissues and organs that
nose, sneezing, cough) causes poor wound healing, neuropathy, retinopathy,
- back pain and nephropathy).
- tooth problems
PATIENT/FAMILY TEACHING
Rare side effects of • Encourage patient to monitor blood glucose before
pioglitazone include: and after exercise and to adjust food intake to maintain
 - liver failure normal glycemic levels.
• Emphasize the importance of adhering to nutritional
guidelines and the need for periodic assessment of
glycemic control (serum glucose and glycosylated
hemoglobin levels) throughout the management of
diabetes mellitus.
• Advise patient about symptoms of hyperglycemia
(confusion, drowsiness; flushed, dry skin; fruit-like
breath odor; rapid, deep breathing, polyuria; loss

Warnings
- Thiazolidinediones, including pioglitazone and
rosiglitazone, cause or exacerbate congestive heart
failure in some patients
- After initiation of these drugs, as well as after dose

GENERIC NAME: MECHANISM OF ACTION: SIDE NURSING RESPONSIBILITY

Furosemide Inhibits reabsorption of sodium, EFFECTS/ADVERSE
 chloride in ascending loop of Henle REACTION
and proximal/distal renal tubules.
Therapeutic Effect: Increases Expected: Increased BASELINE ASSESSMENT
excretion of water, sodium, chloride, urinary frequency/ volume.  Check vital signs, esp. B/P, pulse, for
magnesium, calcium Frequent: Nausea, hypotension before administration. Assess
dyspepsia, abdominal baseline renal function, serum electrolytes,
BRAND NAME: INDICATION: cramps, diarrhea or esp. serum sodium, potassium.
Lasix Treatment of edema associated with constipation, electrolyte  Assess skin turgor, mucous membranes for
HF and renal/hepatic disease; acute disturbances. hydration status; observe for edema.
pulmonary edema. Treatment of Occasional: Dizziness,
DRUG ILLUSTRATION:  Assess muscle strength, mental status.
hypertension (not recommended as light-headedness, headache,  Note skin temperature, moisture. Obtain
initial treatment). blurred vision, paresthesia, baseline weight.
photosensitivity, rash,  Initiate I&O monitoring. Auscultate lung
fatigue, bladder spasm, sounds.
restlessness, diaphoresis.  In pts. with hepatic cirrhosis and ascites,
Rare: Flank pain. consider giving initial doses in a hospital
Vigorous diuresis may lead setting.
to profound water INTERVENTION/EVALUATION
loss/electrolyte depletion,
CLASSIFICATION:  Monitor B/P, vital signs, serum electrolytes,
resulting in hypokalemia,
Diuretic. Antihypertensive I&O, weight. Note extent of diuresis.
hyponatremia, dehydration.
 Watch for symptoms of electrolyte imbalance:
Sudden volume depletion
Hypokalemia may result in changes in muscle
may result in increased risk
strength, tremor, muscle cramps, altered
of thrombosis, circulatory
mental status, cardiac arrhythmias;
collapse, sudden death.
hyponatremia may result in confusion, thirst,
Acute hypotensive episodes
DOSAGE: CONTRAINDICATION: may occur, sometimes cold/clammy skin. Consider potassium
40 mg Hypersensitivity to furosemide. several days after supplementation if hypokalemia occurs.
FREQUENCY: Anuria. Cautions: Hepatic cirrhosis, beginning therapy.
q.d. hepatic coma, severe electrolyte Ototoxicity (deafness, PATIENT/FAMILY TEACHING
ROUTE: depletion, prediabetes, diabetes, vertigo, tinnitus) may  Expect increased frequency, volume of
PO systemic lupus erythematosus. Patients occur, esp. in pts. with urination.
with prostatic hyperplasia/urinary severe renal impairment.  Report palpitations, signs of electrolyte
stricture. Can exacerbate diabetes imbalances (noted previously), hearing
mellitus, systemic lupus abnormalities (sense of fullness in ears,
erythematosus, gout, tinnitus).
pancreatitis. Blood  Eat foods high in potassium such as whole
dyscrasias have been grains (cereals), legumes, meat, bananas,
reported. apricots, orange juice, potatoes (white, sweet),
raisins.
 Avoid sunlight, sunlamps.

GENERIC NAME: MECHANISM OF ACTION: SIDE

EFFECTS/ADVERSE NURSING RESPONSIBILITY
Potassium ions participate in a REACTION
Potassium chloride number of essential physiological  Hives Assessment
processes, including the maintenance History: Allergy to tartrazine, aspirin; severe renal
 difficult breathing
of intracellular tonicity; the impairment; untreated Addison’s disease;
 swelling of your
transmission of nerve impulses; the hyperkalemia; adynamia episodica hereditaria; acute
face,
contraction of cardiac, skeletal, and dehydration; heat cramps, GI disorders that cause
smooth muscle; and the maintenance  lips, tongue, or
throat delay in passage in the GI tract, cardiac disorders,
of normal renal function. lactation
 stomach bloating,
 severe vomiting, Physical: Skin color, lesions, turgor; injection sites; P,
BRAND NAME: INDICATION:
baseline ECG; bowel sounds, abdominal examination;
 severe stomach pain
This medication is a mineral urinary output; serum electrolytes, serum bicarbonate
K-Dur supplement used to treat or prevent  nausea
low amounts of potassium in the  weakness Interventions
blood.  chest pain, Arrange for serial serum potassium levels before and
DRUG ILLUSTRA  irregular heartbeats, during therapy.
 loss of movement Administer liquid form to any patient with delayed GI
emptying.
Administer oral drug after meals or with food and a
full glass of water to decrease GI upset.
Caution patient not to chew or crush tablets; have
patient swallow tablet whole.
Mix or dissolve oral liquids, soluble powders, and
effervescent tablets completely in 3–8 oz of cold
water, juice, or other suitable beverage, and have
patient drink it slowly.
Arrange for further dilution or dose reduction if GI
effects are severe.
Agitate prepared IV solution to prevent “layering” of
potassium; do not add potassium to an IV bottle in the
hanging position.
CLASSIFICATION CONTRAINDICATION: Monitor IV injection sites regularly for necrosis, tissue
Potassium chloride (K-Dur) is sloughing, phlebitis.
contraindicated to; Monitor cardiac rhythm carefully during IV
Minerals and electrolytes administration.
Addison’s Disease Caution patient that expended wax matrix capsules
Excess body acid will be found in the stool.
Dehydration Caution patient not to use salt substitutes.
High levels of potassium in the
otassiumGE/FREQUENCY/ROUTE: blood Patient/Family Teaching
Familial hyperkalemic periodic Take drug after meals or with food and a full glass of
paralysis water to decrease GI upset. Do not chew or crush
20 mEq, orally, daily A high amount of chloride in the tablets, swallow tablets whole. Mix or dissolve oral
blood liquids, soluble powders, and effervescent tablets
Thomsen disease completely in 3–8 ounces of cold water, juice, or other
 Complete heart block suitable beverage, and drink it slowly. Take the drug
Severe heart block as prescribed; do not take more than prescribed.
Compression of the esophagus Do not use salt substitutes.
Stomach or intestinal ulcer You may find wax matrix capsules in the stool. The
Stomach or intestinal ulcer wax matrix is not absorbed in the GI tract.
Stomach muscle paralysis and Have periodic blood tests and medical evaluation.
decreased function You may experience these side effects: Nausea,
Blockage of the stomach or intestine vomiting, diarrhea (taking the drugs with meals,
Decreased kidney function diluting them further may help).
Severe burn Report tingling of the hands or feet, unusual tiredness
Inflammation of the epiglottis or weakness, feeling of heaviness in the legs, severe
Problems with food passing through nausea, vomiting, abdominal pain, black or tarry
the esophagus stools, pain at IV injection site.
Cessation of urine production

Reference: Robert, J. (2021). Saunders Drug Handbook. Elsevier

After reviewing M.G.'s medications, the physician writes these medication orders:
Medication Orders
Enalapril (Vasotec) 5 mg PO bid
Carvedilol (Coreg) 100 mg PO every morning
Glipizide (Glucotrol) 10 mg PO every morning
Furosemide (Lasix) 80 mg IV push (IVP) now, then 40 mg/day IVP
Potassium chloride (K-Dur) 20 mEq/day PO
4. What is the rationale for changing the route of the furosemide (Lasix)?
  • M.G. needs to quickly reduce fluid volume since it is overloaded with fluid. The vascular system receives IV administration directly, where it might begin to

function right away. Because the entire gastrointestinal (GI) system suffers from poor blood flow in HF, it may take longer for drugs taken orally to take effect.

5. You administer furosemide (Lasix) 80 mg IVP. Identify three parameters you would use to monitor the effectiveness of this medication.

 Increased urine output

• Daily weight, looking for weight loss

• Intake and output (I&O)

• Decreased dependent edema

• Decreased shortness of breath, diminished crackles in the bases of the lungs, decreased work of breathing, and decreased O2 demands

• Decreased jugular venous distention (JVD)

6. What laboratory tests should be ordered for M.G. related to the order for furosemide (Lasix)?

 Electrolytes test, urine test, blood test, blood glucose test, and urine test.

7. What is the purpose of the beta blocker-carvedilol?

 Carvedilol lowers heart rate and facilitates easier blood circulation throughout the body. Additionally, it widens some blood arteries in a manner comparable to an

alpha blocker. This contributes to lowering blood pressure.

CASE STUDY PROGRESS

The next day, M.G. has shown only slight improvement, and digoxin (Lanoxin) 125mcg PO daily is added to her orders.

8. What is the action of the digoxin?

  Digoxin works by increasing cardiac contractility, and thus increasing cardiac output.

9. Which findings from M.G.'s assessment would indicate an increased possibility of digoxin toxicity? Explain your answer.

 Low potassium levels can increase the potential for digoxin toxicity. M.G. is taking furosemide, a loop diuretic that excretes potassium as well as sodium and water.
Potassium levels should be monitored carefully during digoxin therapy. Digitalis toxicity may also develop in people have a low level of magnesium in their body
10. M.G.'s symptoms improve with IV diuretics and the digoxin. She is placed back on oral furosemide (Lasix) once her weight loss is deemed adequate to achieve a
euvolemic state. What will determine whether the oral dose will be adequate to consider her for discharge?
 It is critical to provide the primary care provider with accurate, timely assessment data after the change from IV to oral diuretic therapy. One of the fluid
management goals for patients with HF is to maintain a target weight. This is done by monitoring daily morning weight, keeping an accurate I&O, and recording
subjective symptoms.

11. M.G. is ready for discharge. Using the mnemonic MAWDS, what key management concepts should be taught to prevent relapse and another admission?
 The most essential aspect of teaching hospitalized patients is to focus on realistic key points. Teaching should be aimed at successful communication of data to
improve symptoms and prevent readmission, without overwhelming the learner. The five most essential concepts for patients with HF are included in MAWDS
instructions.
Medications: Take as directed, do not skip a dose, and do not run out of medications.
Activity: Stay as active as you can while limiting your symptoms.
Weight: Weigh every morning. Call if you gain or lose 2 pounds overnight or 5 pounds from your target weight.
Diet: Follow a low-salt diet, and limit fluids to less than 2 quarts or liters per day.
Symptoms: Know what symptoms to report to your provider; report early to prevent readmission.

INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of
priority or significance. Do not assume information that is not provided.

CAD Scenario:
You are a nurse at a freestanding cardiac prevention and rehabilitation center. Your new patient in risk-factor modification is B.T., a 41-year-old traveling salesman, who is
married and has three children. He tells you that his work does not let him slow down.
During a recent evaluation for chest pain, he underwent a cardiac catheterization procedure that showed moderate single-vessel disease with a 50% stenosis in the mid right
coronary artery (RCA). He was given a prescription for sublingual (SL) nitroglycerin (NTG), told how to use it, and referred to your cardiac rehabilitation program for
sessions of 3 days a week. B.T.'s wife comes along to help him with healthy lifestyle changes. You take a nursing history, as indicated in the following.

Family History
Father died suddenly at age 42 of a myocardial infarction (MI)
Mother (still living) had a quadruple coronary artery bypass graft (CABG × 4) at age 52
Past History and Current Medications
Metoprolol (Lopressor) 25 mg PO every 12 hours
Aspirin (ASA) 325 mg per day PO
Simvastatin (Zocor) 20 mg PO every evening
Lifestyle Habits
Smokes an average of 1½ packs of cigarettes per day (PPD) for the past 20 years. Drinks an “occasional” beer, and “a 6-pack every weekend when watching football”
Dietary history:
High in fried and fast foods because of his traveling
Exercise:
“I don't have time to take walks.”
General Assessment:
White Male Weight 235 lb Height 5 ft, 8 in.
Waist circumference 48 in.
Blood pressure 148/88 mm Hg
Pulse 82 beats/min
Respiratory rate 18 breaths/min
Temperature 36.9 ° C

1. There are several risk factors for coronary artery disease (CAD). For each risk factor listed, mark whether it is nonmodifiable or modifiable.
a. Age (Non-Modifiable)
b. Smoking (Modifiable)
c. Family history of CAD (Non-Modifiable)
d. Obesity (Modifiable)
e. Physical inactivity (Modifiable)
f. Gender (Non-Modifiable)
g. Hypertension (Modifiable)
h. Diabetes mellitus (Modifiable)
i. Hyperlipidemia (Modifiable)
j. Ethnic background (Non-Modifiable)
k. Stress (Modifiable)
I. Excessive Alcohol (Modifiable)

Case Progress:
You review B.T.'s most recent lab results.
Laboratory Testing (Fasting)
Total cholesterol 240 mg/dL
HDL 35 mg/dL
LDL 112 mg/dL
Triglycerides 178 mg/dL

4. Which lab values are of concern currently? Explain your answers.

 Total cholesterol 240 mg/dL (Elevated)
Normal: Less than 200 mg/dL. Borderline high: 200 to 239 mg/dL. High: At or above 240 mg/dL.
CAD is caused by plaque buildup in the walls of the arteries that supply blood to the heart (called coronary arteries) and other parts of the body. Plaque is
made up of deposits of cholesterol and other substances in the artery. Plaque build-up causes the inside of the arteries to narrow over time, which can partially or
totally block the blood flow. This process is called atherosclerosis.
 HDL 35 mg/dL Low
HDL cholesterol levels should be above 40 mg/dL.
This type of fat is actually good for the patient because it lowers the risk of heart disease. The higher the number, the lower the risk. Sixty mg/dL or above is
considered the level to protect the patient against heart disease.

 LDL 112 mg/dL (Near optimal)

Optimal: Less than 100 mg/dL (This is the goal for people with diabetes or heart disease.)
The bad parts also known as the LDL particles – like to stick to the lining of the arteries, like soap scum in pipes. As it sticks there, it generates an
inflammatory response and the body starts converting it into plaque. Plaque in the blood vessels makes them stiffer and narrower, restricting blood flow to vital
organs such as the brain and heart muscle, leading to high blood pressure. Additionally, chunks can break off and cause a heart attack or a stroke.

 Triglycerides 178 mg/dL Borderline High

Normal: Less than 150 mg/dL
High levels of triglycerides are linked with a higher heart disease risk. Triglycerides increase the risk of CAD by increasing the LDL level, decreasing HDL
level, disrupting the function of artery walls, and activating the thrombogenic factors and plasminogen activators. It may also contribute to hardening of the arteries
or thickening of the artery walls (arteriosclerosis) — which increases the risk of stroke, heart attack and heart disease.

5. B.T. asks you, “So, how is my ‘good cholesterol’ doing today?” Which is considered the “good cholesterol,” and why? What do his HDL and LDL levels indicate to
you?
 Due to its preventive qualities, HDL (high density lipoprotein) cholesterol is regarded as the "good" cholesterol. It serves to carry the cholesterol from the
perivascular tissues to the liver for elimination. B.T. has low levels of HDL and increased LDL. His risk of a MI is increased by this combo (Myocardial infarction).

6. Identify health-related problems if he will stay on salt, sugar, fat, chocolate, and caffeine in his diet.; the problem that is potentially life threatening should be listed
first.
 High risk of sudden cardiac death due to a number of risk factors, including family history, being male, smoking, inactivity (sedentary lifestyle), obesity, stress,
HTN, hyperlipidemia, and a high-fat, low-fiber diet.

7. Of all of his behaviors, which one is the most significant in promoting cardiac disease?
 He certainly smokes the most dangerously. The American Heart Association estimates that smokers have a two to four times higher risk of getting CAD than
nonsmokers do. The risk of (Myocardial infarction) is more than twice as high for daily pack smokers as it is for nonsmokers.

8. What is the highest priority problem that you need to address with B.T.? How will you determine this? Identify the teaching strategy you would use with him.

 The issue that need B.T.'s attention the most is and his wife is that they must make a commitment to changing their habits and leading better lives. It's crucial to
persuade B.T. should focus on quitting smoking because it is his biggest risk factor that has an impact on the lives of everyone in his household. The introduction of
B.T. to include the Philippine Cancer Society, the Philippine Lung Center, and the Philippine Heart Association.

9. Create a HOME CARE checklist on B.T.

ACTIVITIES
1. Sign up for a DOH smoking cessation
program.
2. Utilize all of the DOH's recommendations for
the smoking cessation program.
3. Take medicines exactly as prescribed.
4. Prepare and healthy meal (low-fat)
5. Learn what calms you down (walking,
breathing exercise, playing easy sports)