Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure

Congestive heart failure is defined as “the state in which the heart is unable to pump blood at a rate adequate for satisfying the requirements of the tissues with function parameters remaining within normal limits usually accompanied by effort intolerance, fluid retention, and reduced longevity” (Denolin, 1983, p. 445). Currently, congestive heart failure or heart failure, continues to be a major public health problem worldwide. It is the leading cause of morbidity and mortality in most developed countries. According to the American Heart Association (2001), approximately 5 million patients have heart failure and nearly 550,000 new patients are diagnosed each year. In addition, nearly 300,000 patients die from heart failure yearly.

In the Philippines, cardiovascular diseases are the most common causes of mortality. According to the Department of Health (2005), about 77,060 in a 100, 000 population have died in the Philippines due to diseases of the heart. The aging of the population and the emerging pandemic of cardiovascular diseases in the developing nations of the world signal a rise in the incidence and prevalence of heart failure globally and magnify the importance of its prevention. The prevention of heart failure is an urgent public health need with national and global implications.

This paper is a case report about B. A., a 49 year old female, Filipino, nonhypertensive, nondiabetic, a post-mitral and aortic valve replacement patient and is currently diagnosed with Congestive Heart Failure Functional Capacity II-III secondary to Valvular Heart Disease secondary to Rheumatic Heart Disease. Its purpose is to review the 1

Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure

pathophysiology, preanalytical factors, and treatment in a congestive heart failure patient and identify possible recommendations for future nursing care.

This case report is significant to my future nursing care because it helps stress the importance of not only identification and treatment of patients with heart failure but also the importance of promoting a healthy lifestyle and preventive strategies to decrease the prevalence of heart failure in the general population. Also, it explores the need for a thorough case analysis of a client to deliver the best nursing care.

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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure

THEORETICAL BACKGROUND

Theoretical Background. Heart failure is defined as “the pathophysiologic state in which an abnormality of cardiac function is responsible for inadequate systemic function” (Woods, et. al, 2010). It is not considered as a disease but a collection of signs and symptoms, the final pathway of a group of diseases, the end-result of most cardiovascular states.

Classification. According to the New York Heart Association (1964), congestive heart failure may be classified into four functional states. “ Class I (Mild) are patients with cardiac disease but without resulting limitatios of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath), or anginal pain. Class II (Mild) are patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain. On the other hand, Class III (Moderate) are patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest, but less than ordinary activity causes fatigue, palpitation, dyspnea or anginal pain. The last classification is Class IV (Severe) are patients with cardiac disease wherein there is inability to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased (New York Heart Association, 1964). 3

and must often occur in the presence of an already weakened heart. They change the pattern of filling and pumping of blood from the heart. (3) Long-standing high blood pressure is another common cause of heart failure. this enlarged muscle tissue weakens. (2) A heart attack may also cause congestive failure. Eventually. the buildup of fatty substances or plaque on the walls of the arteries that carry blood to the heart muscle. (4) Arrhythmias (irregular heartbeats) can also lead to heart failure. thereby increasing risk of 4 . (1) Among them is coronary (ischemic) heart disease resulting from insufficient blood flow to the myocardium. the heart muscle is deprived of oxygen. with a rapid rate of more than 140 beats per minute. especially of the left ventricle. The heart’s ability to perform decreases because ischemia results in the delivery of less oxygen and fewer nutrients to the heart muscle. the heart muscle works harder. (5) Valvular heart diseases are another cause of heart failure.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure Causes. The development of heart failure depends on the extent and location of scarring. This increases the heart’s workload. The problem may be congenital (inborn) or due to an infection such as endocarditis or rheumatic fever. This results in an enlargement of the heart muscle. setting the stage for heart failure. which results when a narrowed or leaking valve fails to direct blood flow properly through the heart. During a heart attack. the heart’s main pumping chamber. especially if the pumping ability of the enlarged chamber greatly decreases. This is usually caused by atherosclerosis. Because there is greater resistance against which the heart must pump. This condition may also lower output of blood to the point of heart failure. resulting in tissue death and scarring. or heart muscle. “An array of different problems can cause congestive heart failure. but they usually have to be severe and prolonged.

The particular symptoms that an individual experiences are determined by which side of the heart is involved in the heart failure. and cocaine abuse. Pressure then builds up in the liver and the veins in the legs. For example. orthopnea. (6) Cardiomyopathy. and sometimes fluid is forced out of the lung vessels and into the breathing spaces themselves. alcohol abuse. dyspnea. 1992). Porth (2007) adds that right-sided failure occurs when there is resistance to the flow of blood from the right heart structures (right atrium. Causes of cardiomyopathy include infection. paroxysmal nocturnal dyspnea . This pulmonary congestion causes shortness of breath. 1992). The other major symptoms of left-sided heart failure are fatigue. Manifestations. Soufer (1992) further elaborates the manifestations often seen in patients with heart failure. which pumps it to the rest of the body” (Porth. right ventricle. This results in a backup of fluid and pressure in the veins that empty into the right side of the heart. it is known as idiopathic heart failure” (Soufer. which separates the right atrium from the right ventricle. When the left side isn’t pumping efficiently. the “left atrium receives oxygenated blood from the lungs and passes it onto the left ventricle. The liver enlarges and may become painful and swelling of the 5 . 2007). fails to work properly. blood backs up in the vessels of the lungs. a disease of the heart muscle itself. can also lead to heart failure. When heart failure seems to have no known causes. and the sputum production that comes from pulmonary congestion (Soufer. pulmonary or lung artery) into the lungs or when the tricuspid valve.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure developing heart failure.

The major symptoms of right-sided heart failure are edema and nocturia (Woods. thereby aggravating the problem of excess fluid associated with congestive heart failure (Soufer. causing it to retain even more water. et. The different types of edema possible are dependent edema. neck vein distention. the kidneys may not be able to dispose of the extra sodium and water. The minor criteria is composed of bilateral ankle edema. a condition known as kidney failure. nocturnal cough. acute pulmonary edema. dyspnea on ordinary exertion. edema that results in enlargement or swelling of the liver. radiographic cardiomegaly (increasing heart size on chest radiography). 1992). hepatomegaly. 1971). and edema of the skin or soft tissues. S3 gallop. hepatojugular reflux and weight los greater than 4. increased central venous pressure (greater than 16 centimeters fluid at right atrium). According to the Framingham Study (McKee. Sodium that would normally be eliminated through the urine remains in the body. decrease in vital capacity by one third from maximum recorded and tachycardia 6 .5 kilograms in 5 days in response to treatment. 1992).Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure ankles or legs occurs (Soufer. rales. ascites. 2010). Because congestive heart failure causes the body to fill with excess fluids. al. et. The major criteria includes paroxysmal nocturnal dyspnea. pleural effusion. Diagnosis. al. the diagnosis of congestive heart failure requires the simultaneous presence of at least 2 major criteria or 1 major criterion in conjunction with 2 minor criteria that they have formulated.

1971). ascites. and associated atrial fibrillation. For example. al. these arrhythmias often have mechanisms in scarred myocardial tissue. An episode of sustained ventricular tachycardia indicates a high risk for recurrent ventricular arrhythmias and sudden cardiac death. Watson (2000) discovered that the common complications of heart failure include irregular heart rhythms or arrythmias. and this contributes to their increased risk of thrombosis. Mild to moderate heart 7 . Complications. regional wall motion abnormalities (including formation of a left ventricular aneurysm). In patients with ischemic heart disease. including deep venous thrombosis and pulmonary embolism. (1) One of these are malignant ventricular arrhythmias which are common in end stage heart failure. The Framingham Heart Study criteria are 100% sensitive and 78% specific for identifying persons with definite congestive heart failure (McKee. 2000). stroke. sustained ventricular tachycardia occurs in up to 10% of patients with advanced heart failure who are referred for cardiac transplantation (Watson.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure (heart rate greates than 120 beats per minute). with an overall estimated annual incidence of approximately 2% (Watson. Factors contributing to the increased thromboembolic risk in patients with heart failure include low cardiac output (with relative stasis of blood in dilated cardiac chambers). thromboembolism and organ dysfunctions. Congestive heart failure predisposes to (2) stroke and (3) thromboembolism. 2000). cirrhosis. or the nephrotic syndrome). et. Minor criteria are acceptable only if they can not be attributed to another medical condition (such as pulmonary hypertension. chronic lung disease. Patients with heart failure and chronic venous insufficiency may also be immobile.

Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure failure is associated with an annual risk of stroke of about 1. rising to 4% in patients with severe heart failure (Watson. 2007). (4) Organ dysfunction occurs when there is a decrease in the oxygen supply to the different organ tissues in the body. compensatory mechanisms act but eventually decompensate leading to dysfunction of organs (Porth. 8 .5% (compared with a risk of less than 0.5% in those without heart failure). Because of the lack of oxygen. 2000).

Pulmonary Tuberculosis and Infective Endocarditis. is a 49 year old female. She worked as a vendor before. However. The client was admitted from home to the Emergency Room of the Philippine General Hospital on August 30. She also contracted fever but this was relieved after she took Bioflu.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure CASE PRESENTATION B. Filipino. Bulacan. nondiabetic and diagnosed with Congestive Heart Failure Functional Capacity II secondary to Valvular Heart Disease secondary to Rheumatic Heart Disease. stopped going to school when she was 1st year high school and is currently unemployed. She was admitted to the Female General Medicine Ward 1 at Bed 8 for monitoring and management and also to rule out Moderate Risk Community Acquired Pneumonia. three children. A. She was admitted to Sapang Palay District Hospital for management where she was administered with oxygen. has been experiencing chest heaviness and mild chest pain 5 days prior to admission. she was discharged and advised to followup to Philippine General Hospital. She lives with her husband. B. A. The fever recurred with maximum temperature of 38°C. A. B. nonhypertensive. a sonin-law and a grandson in Sapang Palay. She is a Roman Catholic and actively participates in church as a lector. 2010 with complaints of fever and shortness of breath. She was not taken to a physician until 3 days prior to admission when her chest pain worsened and radiated to the back and she experienced shortness of breath. On the same day. the client 9 .

A. she had regular checkups in Philippine General Hospital Out Patient Department. B. She underwent mitral and aortic valve replacement in Philippine General Hospital in 2004. no significant findings were made and Pulmonary Tuberculosis was ruled out. A. it was determined that B. 2010 due to heart attack. The client was first diagnosed with Rheumatic Heart Disease in the 1980s in Philippine Heart Center where she regularly went for checkup. Her father is a known hypertensive and died on August 14. 2010. was readmitted in July of 2005 because of hemoptysis and extreme fatigue. the client had fever again and has stomach discomfort. In October 2009. Since then. Upon transfer of residency. the client was admitted to San Lazaro Hospital in Bulacan for anti-rabies injection because of a dog bite. the client's family brought her to Philippine General Hospital. However. Her maintenance medications included Warfarin 5 mg/tab taken once daily (taken twice the week before admission) and Metroprolol 50 mg/tab taken once daily. A. One day prior to admission. she has been on regular follow-up with the Outpatient Department of the Hospital. has uncles with pulmonary problems specifically Pulmonary Tuberculosis though she does not live 10 . B. Her mother is a known cardiac patient of valvular heart disease and died in 1998. has valvular heart disease and was scheduled for operation. She has a family history of cardiovascular diseases and pulmonary tuberculosis. In the checkups between 2002-2003. She claimed that her chest pain worsened so on August 30.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure proclaimed that she felt well immediately after and her fever was gone so she delayed referral.

Nursing Assessment. Pertinent physical assessment findings are classified per system. Pertinent nursing health history problems were clusted per functional health pattern. She claims to have no traditional health beliefs. she drinks her medicines regularly and takes periods of rest. with periods of fatigue and strength. To maintain her health. A. B. Whenever she feels episodes of chest heaviness or fatigue. She is a nonalcoholic and a 11 . A claims that her overall health varies. claims that she felt more comfortable and relieved when she was admitted to the hospital. 2010. B. According to the client. Complete assessment on the status of the client based on the nursing health history was conducted on August 31. The client knows no one in the family with mental illness or history of diabetes mellitus. In addition. she follows the doctors’ advice and tells that she has never had a problem with following the health professionals' orders. Physical examination was also conducted on the same date. she thinks the reason she felt ill was because she does the household chores even when she was supposed to rest and she carries her grandson around which led to shortness of breath and fatigue. In the Health perception and health management pattern. she sits in front of the electric fan to ventilate herself and rest until she regains strength.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure with them. the client reports that she is a healthy person is one who rarely gets sick.

She remembers that when she was in the hospital. fish and chicken. The food she eats varies from vegetables. Her fluid intake is about 3 glasses a day or sometimes one 500 ml bottle of water per day. A. she only eats small portions of the meat. During the hospital rotation. She dislikes other fatty. A. fruits. she experiences second hand smoke daily since her husband smokes at least 3 sticks a day. Also. her fluid intake was regulated at 1 Liter 12 . and leaves behind the fatty portion of the meat she eats. However. In the nutritional and metabolic pattern. salty and sweet foods except chicharon and fries though she has regulated her intake of both to at least once every two months. the client experienced chest pain with a grade of 4. Because she has been cautioned from eating fatty and salty foods. reports that every day she eats about three meals per day which are cooked at home. B. she seldom eats pork. In addition. and eats about one cup of rice per meal. The client claims that she eats a lot of vegetables and fruits. especially if it is salty. She enjoys vegetables and fruits and seldom use condiments except vinegar. with the occasional snack in between meals. B. has never taken illegal drugs.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure nonsmoker. She claims to have taken only few sips of beer before when she was in her 20s but she has never drunk more than a glass and she has never tried to smoke in the past. it was explained to her that green leafy vegetables affect the mechanism of action of one of her medications which is Warfarin so she also refrains eating said vegetables. radiating to back and persisting after 10 minutes.

When she gets sick. A. B. She does not exercise anymore except walk around the house and stretching. She measures her urine to be about 250 ml or one half of a mineral bottle. claims that she has less energy than before to do her daily activities. although there is no problem in eating despite having all her teeth replaced with dentures. the client moves her bowels everyday. She describes her urine as clear. she gets well rather quickly. she is able to do household chores. The client verbalized a noticeable decrease in weight since she was diagnosed with heart disease. 13 .Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure per day and she has adapted this at home. Also. She complains that there are times that she cannot defecate easily because she finds it difficult to stop breathing and expel her feces forcefully. bathing. listening to the radio. the client does not suffer from diaphoresis. She described her feces as brown. go to the market and serve at the church though with considerable effort. yellow in color and without any foul odor. carry her grandson. In the elimination pattern. The client’s pastimes include watching TV. which she explained was caused by her medication (Warfarin). soft and broken into small pieces about 3 cm in diameter. In the Activity-Exercise Pattern. B. In addition. At the time of the interview. without difficulty or pain. A. the client also reported a decrease in appetite. eating. and playing with or watching her grandchild play. She is independent in grooming. and her only previous skin problem was hematoma. She has refrained from washing clothes and carrying heavy things since she easily experiences shortness of breath. However. urinates about 3 times per day.

Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure elimination. she does have a visual problem. However. watching TV and watching her grandson. B. She uses glasses with grade of 300. claims that she finds it difficult to sleep at night and especially during mornings and only takes naps in between because she has not yet adapted to the hospital environment. she is unable to do household chores as before and go to the market without assistance of a family member. has no hearing problem and does not use a hearing aid. In the Cognitive-Perceptual Pattern. In the Sleep-rest Pattern. A. She is able to climb 3 flights of stairs before being out of breath. Her level of self-care is Level 2. She also claims that she is easy to awaken and she does not have a special ritual for bedtime. A. However. B.. claims that she has difficulty breathing and feels that she is “drowning”. A. Her memory is still intact. dressing. The relaxing activities for her include saying the rosary. B. maintaining cleanliness. However on her second night. The client does not feel pain in any part of her body though she sometimes feels chest heaviness and pain which she relieves by ventilating herself with electric fan and taking a rest. She is on moderate high back rest and requires 2 pillow to be able to sleep comfortably without difficulty of breathing. and she learns best by actual performance of a task and reading. The client was a former president of the Lector/Commentator League and treasurer of the Parish Pastoral Council in their town but was forced to resign because of 14 . In supine position and flat on bed. she reported that she has been able to sleep well. She requires the supervision of a family member because she easily gets tired and experience shortness of breath. and daily movement.

2010. making decisions regarding health actions and daily expenditures. In the Sexuality-Reproductive Pattern. A. A. She describes her menstrual period to be regular and usually lasts from 3 to 4 days. Her husband is a contractual painter of houses and automobiles and their usual income varies from P3000-P5000 per month. Currently. a daughter-in-law and a grandson. The usual problem of the family involves the drinking habit of the client's husband and financial problems. A. her three children. She claims that this is because they are already old. the family of B. is said to be extended and patriarchal. She claims that she misses doing her work but is resigned to resting and staying at home because she understands that it is for her own benefit. stated that she and her husband has not engaged in sexual intercourse in recent years. Their children always contributes to the medical expenses of the client.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure her health condition. The client had her first menstrual period when she was 11 years old. is a G3P3 mother and has no history of complications at birth. with B. they feel worried about their mother's condition and contributes to any way they can to alleviate her condition. A. Her last menstruation was on August 1. 15 . They usually resolve it by conversations with the family. B. She lives with her husband. She has used pills as a family planning method from 1989 to 2002 but has since stopped using them though no problems were encountered upon their use. She usually consumes 3 pads in a day and has never experienced dysmennorhea. B. In the Role-Relationship Pattern.

she has already accepted this fact and coped with the weakness in her own way. However.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure In the Coping-Stress Tolerance Pattern. she talks to her significant others or pray the rosary. feels anxious about her condition but she believes that everything will be alright in the end more so because she feels relatively fine. She usually feels nervous whenever there are arguments in the family but this has been lessened according to her significant other out of consideration for the client. A. She claims that her religion helps her get through her condition because it gives her energy and happiness. She is easily cries and becomes tensed or nervous though this has been lessened once she was admitted in the hospital. In the general or constitutional condition of the client. A. She does not fear death but she wishes that she will live longer because of her family. God. the client has adequate weight for 16 . She does not perceive any difference in her physique except weight loss. the client expresses that her only wish is to see her children and her grandchildren grow up. Whenever she feels tensed. avoiding foods that are contraindicated to her condition and taking rest periods. However. the client reports that she does not want to be a burden to her family and perceives herself as “weak”. B. She sits and calms herself by praying and talking with the involved parties to relieve her tension. She coped with her condition by changing her lifestyle for the better. family and health are important for B. In the Value/Belief Pattern. she does feel bothered about the expenses incurred by her children for her medical condition.

A sternotomy scar is seen in the midsternal about 3 centimeters. The client does not have colds. She displays signs of weakness on exertion and ability to conduct usual activities is impaired. However. Nose. There is pinkish mucosa and no lesions were present. Eyes. No extra heart sounds or 17 . the client complained of dizziness that can be associated to decrease in oxygen supply to the brain. Mucosa was pinkish and gag reflex was intact. Both S1 and S2 are regular. no pigmentation is seen. Ears. She has normal hair distribution and nail beds are pail but has brisk capillary refill. The client is cold to touch and has good skin turgor. Mouth. no heaves or thrills were inspected. tenderness and masses in thyroid or other areas was not seen. She has lost weight since hospitalization. On inspection. Uvula is in midline and no lymphadenopathy was observed. The client has no breast lumps. There skin is moist and smooth. left of the midclavicular line. Throat system. no headaches were complained. no rashes or itching was observed.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure age. Vision is normal and no nose bleeding was reported. She displayed absence of lesions or dryness in lips. obstruction and discharge. She has no exercise tolerance. No neck stiffness was observed and pain. she states that general state of health is fine. S1 is louder than S2 at the apex while S2 is louder than S1 at the base. No tenderness or swelling was observed. In the skin. She has 1 missing front teeth and uses full dentures. There was also no nipple discharge. In the cardiovascular system. However. For the HEENT system or Head. Point of maximal impulse is at the 6th intercostal space.

However. indigestion. dribbling. substernal distress. or diarrhea was reported. jaundice. edema and cyanosis. No hesitancy. heart murmurs. nocturia. She does not experience dysphagia. No hypertension. no urgency or frequency in urination was reported.precordial pain. The client had menarche at the age of 11. respiratory infections. In the gastrointestinal system. Nails are pale but has brisk capillary refill. hemorrhoids or recent changes in bowel habits was reported. the client has decreased appetite. No nausea. palpitations. The client has normal stools and no flatulence. tuberculosis (or exposure to tuberculosis). hematemesis. acute retention or incontinence. polyuria or oliguria in the patient. change in size of stream. There was no nocturnal paroxysmal dyspnea. no pain was reported. There was no dysuria. varicosities. In the respiratory system. There was no hemoptysis. vomiting. She has her menses every month and her last period was on August 1. fever or night sweats. In the genitourinary system. There was no unusual color of urine. constipation. Hematoma is seen in Left lower arm and Right upper arm. phlebitis or claudication were assessed.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure murmurs were heard. food idiosyncrasy. abdominal pain and heartburn. Shortness of breath is on exertion and no wheezing or stridor was heard on auscultation. 2010. syncope was not observed. hematuria was seen on laboratory tests. infections and nephritis observed. Peripheral pulses are strong and equal. No 18 . There was dyspnea on exertion and client has 2-pillow orthopnea. No nail clubbing was observed. stones. change in libido was reported.

However. In the musculoskeletal system. In the endocrine system. The client experiences no difficulties with memory or speech. anemia is not present and no adverse reactions to blood transfusion was reported. There is however a bleeding tendency since the client is on Warfarin therapy. In the immunologic component. no convulsions. In the lymphatic system. Significant results. there is no polydipsia or polyuria. redness or heat of muscles or joints were reported. swelling. anxious about condition. In the allergic component. There was however dizziness experienced after administration of Metorpolol on the second day of ward duty. She is however. no pain. skin rashs are not observed.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure dysmenorrhea. 19 . She has had 3 pregnancies and all are alive. Diagnostic and laboratory results done to the patient together with their indications are listed below. Client is not emotional and does not express depression. and there is no sensory or motor disturbances. local or general lymph node enlargement or tenderness was absent. the client reports muscular weakness on knees. In the neurologic or psychiatric component. paralyses or tremors were observed. food. or vaginal discharge was reported. insects. Laboratory Results. There was no limitation of motion. adverse reactions to drugs. their nursing implications and their relation to the course of treatment will be discussed on the case analysis part of this paper.

the client was suspected of Pulmonary Tuberculosis and Community-Acquired Pneumonia so this chest x-ray is to rule out or confirm said conditions. 2010 is indicated for the client to look for signs of inflammation and infection and marker of anemia which can cause similar symptoms as Congestive Heart Failure or may contribute to Congestive Heart Failure. shape. lungs) for any abnormalities. heart. Blood chemistry screen made on August 30. Complete Blood Count done on August 30. The lungs are normoinsular and two prosthetic valves are noted at the region of the mitral and aortic valves. There is also associated superintraction of the right hilar structure. The chest x-ray revealed that there are fibrous and reticulonodular opacities seen in the Unperfused Lung Segments. No abnormal results were seen. The client has adequate amount of blood components. There is prominence with the aortic root as seen on lateral view. Significant findings show that the client has decreased calcium in the blood. the functions of her kidneys and extent of damage of livers and heart were assessed. 2010 was indicated to view the structures of the chest (bones. In addition. 20 . structure). It is also indicated for a definite diagnosis of cardiomegaly or congestive heart failure in the patient and is done to reassess the patient's heart condition (size. 2010 was indicated for the client because she is diagnosed with congestion in the heart and is at risk for fluid. electrolyte or acidbase imbalance.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure The chest x-ray done on August 8. Also.

it tests for abnormalities involving the coagulation proteins of the intrinsic pathyway. It has been found out that the client has prolonged Activated Partial Thromboplastin Time and Prothrombin. It is also be used to identify performance of valves. Findings by the two-dimensional and doppler echocardiography done on September 1. It is a routine screening of coagulation disorders. V. and pulmonary artery and ventricular filling pressures. The aortic and mitral prosthetic valves have good opening and closing. There is mild tricuspid regurgitation. In addition. It showed bradycardia with 45 beats per minute and no signs of myocardial infarction. It showed concentric left ventricular hypertrophy with segmental wall motion abnormality and mildly depressed overall systolic function.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure Prothrombin Time and Activated Partial Thromboplastin Time was assessed on August 30. Electrocardiography is performed on September 2. 2010 to assess for ST-segment elevated myocardial infarction after the episode of chest pain. Findings show 21 . VII and X and monitor the oral anticoagulant therapy (warfarin) of the patient. 2010 was indicated for the client to determine systolic and diastolic left ventricular performance. 2010 to view the peritoneal cavity and identify possible problems that may be the cause of hematuria. 2010 to screens for coagulation deficiency of factors II. Ejection fraction is 53% Teicholtz's and 47% Simpsons. Holo-abdominal Ultrasound is performed on September 1. cardiac output (ejection fraction). The pulmonary artery pressure is normal.

spleen and urinary bladder. 2010.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure that there is non-specific calcifications which are likely parenchymal. Blood Culture Sensitivity Testing was made on August 31. In addition. 22 . fatty infiltrations of the pancreas are present. Bilateral renal cysts were seen. There is normal proximal and mid-abdominal aorta and para-aortic areas. Findings display that there is no growth after 2 days of incubation. It was indicated for the client to identify if the client has Infective Endocarditis.

When this compensatory mechanisms and adaptation are ovelwhelmed. the valvular structures become swollen. the mitral valve is subjected to high pressure generated by the left ventricle as it pumps blood to the systemic circulation.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure DISCUSSION Pathophysiology. It then proceeds to the development of fibrous scar tissue which tends to contract and cause deformity of the valve leaflets and shortening of the chordae tendinae. Porth (2007) discloses that due to the infiltration of group A beta-hemolytic streptococci. the common mechanism of heart failure is quite complex. presenting signs and symptoms and nursing diagnosis identified. During the acute inflammatory stage of the disease. Compensatory mechanisms exist on every level all the way to organ interactions. Then. This results to Valvular Heart Disease. tricuspid. Small vegetative lesions develop on the valve leaflets. During much of the systole. et. mitral and aortic insufficiency develops. their current treatment and identified nursing diagnosis. Rheumatic heart disease has developed. 2000). In this section. Figure 1 shows the pathophysiology of the disease with the risk factors. al. Regardless of the precipitating event. antibodies in the body react to destroy the bacteria simultaneously causing acute inflammation to the heart. Increased preload occurs because the incomplete closure of 23 . medications. we focus on the pathophysiological mechanisms that led to the presentation of signs and symptoms of the client. heart failure happens (MacIntyre.

Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure 24 .

Systolic dysfunction or failure is evident leading to altered systemic perfusion and decrease in end-systolic volume. losing their elasticity and eventually may lead to myocardial dysfunction and eventually myocardial failure (Woods. activation of the renin-angiotensin-aldosterone pathway and eventual decrease in oxygen supply in tissues. In the RAAS. vasoconstriction leads to increased peripheral vascular 25 . Woods (2010) explains that increased activity of the sympathetic nervous system or the renin-angiotensin-aldosterone system [RAAS] results in vasoconstriction of the small arterioles. This includes increase in sympathetic activity. A decrease in end-systolic volume causes a decrease in cardiac output which also contributes to the decrease perfusion of tissues in the body. incomplete closure of the aortic valve also results in increased preload as the left ventricle is forced to pump the entire diastolic volume received from the left atrium and the regurgitant volume from the aorta. 2007). Alterations in systemic perfusion result in neuroendocrine activation.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure the mitral valve permits the regurgitation of blood from the left ventricle into the left atrium (Porth. 2007). In addition. As the workload increases. al. Increased afterload occurs as there is increased pressure for the heart to generate the movement of the increased volume from the left ventricle into the aorta. the walls of the chamber grow thicker.. This eventually leads to left ventricular hypertrophy (Porth. The increased volume work causes increased pressure for the left ventricle to pump more blood. This results to the failure of the heart to pump with as much force as a healthy heart. 2010). et.

As a result. brain. With decreased oxygen. 1973). On the other hand. leading to the development of superficial mucosal lesions in the stomach and duodenum. 26 . increased activity of the systemic nervous system is caused by the release of epinephrine and norepinephrine (Porth. 2007). gastrointestinal tract and liver. This increase in hydrostatic pressure causes an increase in the rate of filtration of fluid out of the capillaries and into the interstitial compartment (Woods. a condition called. The purpose of this initial response is to increase heart rate and contractility and support the failing myocardium. Increased plasma volume and decreased end systolic volume leads to increased venous pressure tpo the lungs. in the course of time. the gastrointestinal tract increases acid production. prolonged compensatory mechanisms can lead to cell death (Hobler & Karey. there is decreased oxygen supply to the myocardium.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure resistance. As seen in Figure 1. Peripheral vasoconstriction may cause capillary endothelial damage. 2010). Sympathetic stimulation causes peripheral vasoconstriction. the lungs fill with fluid. Decreased oxygen supply in tissues is detrimental because if oxygen delivery to cells is insufficient for the demand. pulmonary edema and eventually pulmonary congestion. Decreased oxygen supply to the liver predisposes it to liver dysfunction. This leads to an increase in plasma volume. The RAAS also increases aldosterone production thus enabling the retention of sodium and water.

compensatory mechanisms fail and even the myocardium experiences a decrease in oxygen supply (Porth. This decreases oxygen supply to the brain and induces decreased oxygen supply in the blood. al. She is only able to walk 3 flights of stairs and experiences shortness of breath after walking to and from an area 1 meter away. Congestive Heart Failure in the client developed as a complication of her Valvular Heart Disease diagnosed in 2004 secondary to Rheumatic Heart Disease which was diagnosed in the client in the 1980s. A. et. B. is diagnosed with Congestive Heart Failure Functional Classification II due to easy fatigability in doing ordinary activities like walking. A. Case Analysis. Eventually. the heart muscle must use alternative. Cardiac damage from Rheumatic Heart Disease results from reacting antibodies that causes acute 27 . When this happens. The by-product of using this less efficient fuel is a compound called lactic acid that builds up in the muscle and causes chest pain. B. 2007). 2010). It is “a common form of heart disease that present with disorders of the heart valves.. 2010). less efficient forms of fuel so that it can perform its function of pumping blood to the body or commonly called anaerobic metabolism (Porth. Most disorders are a consequence of rheumatic heart disease” (Woods.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure Decreased perfusion to the tissues and eventual decrease in oxygen supply causes increased myocardial workload as it attempts to compensate for the reduction (Smeltzer & Bare. underwent prosthetic valve replacement in 2004. 2007). Valvular Heart Disease is one of the most common causes of heart failure.

hypertension. elimination. many other risk factors may contribute to the the development of a cardiac failure. Assessment on the status of the client's health perception and management. Zabriskie (1985) discovered that risk factors for developing infection leading to Rheumatic Heart Disease include overcrowding. As seen in Figure 1. poor hygiene. diabetes mellitus.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure inflammation of the heart. al. However.. The risk factors that may have contributed to the client's disease include a family history of cardiac diseases and eating large amounts of salt and high fat foods. It damages valve leaflets resulting to Valvular Heart Disease (Porth. the client presented with the following risk factors which led to the development of Rheumatic Heart Disease. male sex. lack of access to medical services and living in rural areas. psychosocial. physical inactivity and pychological stress”. overweight. 2007). cigarette smoking. Woods (2010) lists the risk factors for developing cardiovascular diseases which include a “family history of heart disease. rest and activity and oxygenation was 28 . nutrition. reproductive. 2010). et. Rheumatic Heart Disease is a serious heart condition that follows infection with a bacterium called Group A Beta-Hemolytic Streptococcus (Steer & Carapetis. perception. 2009). high levels of blood fats. Heart valves are destroyed when the valvular leaflets and chordae tendinae become fibrous causing the two commisures to close and the chordae tendinae to shorten causing valvular Heart disease (Woods.

In other words. claims that she has difficulty breathing and feels that she is “drowning”. The anterior-posterior lateral ratio is 1 is to 2. A.1°C. B. Vital signs are as follows . The inspiratory and expiratory ratio is 2 is to 1. The client has varied periods of fatigue and strength. She does not have difficulty breathing or use accessory muscles. is nonalcoholic and nonhypertensive. She is on moderate high back rest and requires 2 pillow to be able to sleep comfortably without difficulty of breathing. In supine position and flat on bed. radiating to back and persisting after 10 minutes. Oxygenation. B.respiratory rate is 30 breaths per minute. During the hospital rotation. the client has 2pillow orthopnea which is caused by pulmonary congestion in the client. The client does not display signs of pallor or cyanosis. She does not 29 . heart rate is at 45 beats per minute and temperature is 36.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure clustered. The client has slow heart rate which may be caused by the intake of maintenance drug which is metoprolol. These may be reflections of the decreased cardiac output of the heart caused by depressed systolic functioning. This can be caused by decreased circulation of oxygen to the brain because of increased cardiac workload. the client experienced chest pain with a grade of 4. She is able to climb 3 flights of stairs before being out of breath. A. blood pressure is at 90/60 mmHg. She also complained of dizziness or light-headedness. No nasal flaring was observed.

She is unable to do household chores as before and go to the market without assistance of a family member. the client displayed shortness of breath upon exertion. Point of maximal impulse is at the 6 th intercostal space. a sternotomy scar is seen in the midsternal about 3 centimeters. She requires the supervision of a family member because she easily gets tired and experience shortness of breath. Peripheral pulses are strong and equal. A. pigeon or funnel chest.No extra heart sounds or murmurs were heard. claims that she has less energy than before to do her daily activities. There were no crepitations or joint pains.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure display signs of a barrel. During cardiac assessment. there is muscle weakness on knees. She is able to walk at a distance of about 3 meters with a slow but steady gait. On physical assessment. Rest and Activity. No nail clubbing was observed. She has normal breath sounds and no adventitious breath souds were heard. Hematoma is seen in Left lower arm and Right upper arm. Nails are pale but has brisk capillary refill. Her chest is symmetric and there is symmetrical chest expansion. However. Muscle strength is at 4/5 on both lower limbs and 5/5 on the upper limbs. B. left of the midclavicular line. Her level of self-care is Level 2. She has refrained from washing clothes and carrying heavy things since she easily experiences shortness of breath. 30 .

A. A. Also. especially if it is salty. she only eats small portions of the meat. B. it was explained to her that green leafy vegetables affect the mechanism of action of one of her medications which is Warfarin so she also refrains eating said vegetables. soft and broken into small pieces about 3 cm in diameter. She describes her urine as clear. B. On physical assessment. salty and sweet foods except chicharon and fries though she has 31 . Nutrition. no periorbital edema or generalized edema was observed. Because she has been cautioned from eating fatty and salty foods. The client moves her bowels everyday. Costovertebral angle tenderness was not assessed due to complaints of back pain. fruits. with the occasional snack in between meals. She measures her urine to be about 250 ml or one half of a mineral bottle. she seldom eats pork. No visible pulsations were inspected on the abdomen. The client claims that she eats a lot of vegetables and fruits. Also. urinates about 3 times per day. Every day. eats about three meals per day which are cooked at home.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure Elimination. without difficulty or pain. She described her feces as brown. and leaves behind the fatty portion of the meat she eats. fish and chicken. She complains that there are times that she cannot defecate easily because she finds it difficult to stop breathing and expel her feces forcefully. normoactive bowel sounds at 3 per minute were heard. In addition. Skin is smooth and cold to touch. yellow in color and without any foul odor. On asucultation. The food she eats varies from vegetables. She dislikes other fatty. No enlarged organ was palpated. and eats about one cup of rice per meal.

the client looks according to age.. and her only previous skin problem was hematoma. fairly developed. At the time of the interview. Trachea is in midline and there is thyroid is nontender and nonpalpable. Her height is 5'2 inches high and she displays constant weight at 51 kilograms. Normoactive bowel sounds are heard on ausculation. A scar is seen on the epigastric and right lower quadrant about 2 centimeters long. Cognitive. although there is no problem in eating despite having all her teeth replaced with dentures. she gets well rather quickly. She enjoys vegetables and fruits and seldom use condiments except vinegar. The client verbalized a noticeable decrease in weight since she was diagnosed with heart disease. and an ectomorph. a healthy person is one who rarely gets sick. According to the 32 . For B. When she gets sick. She remembers that when she was in the hospital. A. Her fluid intake is about 3 glasses a day or sometimes one 500 ml bottle of water per day. To maintain her health. she drinks her medicines regularly and takes periods of rest. fairly-nourished. On physical assessment. There is 1 missing front tooth and the client has full dentures. her fluid intake was regulated at 1 Liter per day and she has adapted this at home.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure regulated her intake of both to at least once every two months. which she explained was caused by her medication (Warfarin). The client has a flabby and soft abdomen. Tongue is in midline and no perforation or lesions were observed. the client also reported a decrease in appetite.

Conjunctiva is pinkish and no lesions were observed. On physical assessment. coherent and oriented to time. However. Sclera is anicteric and cornea and lens are clear. the client's head is normocephalic and no masses or lesions were observed. There is symmetrical gross hearing capacity and no 33 . has no hearing problem and does not use a hearing aid. On physical assessment. The client's ears are normoset and nontender. The client displayed symmetrical lids and absence of ptosis or swelling. There is uniform convergence of the eyes and intact extraocular activity. The client is nearsighted with a grade of 300. The client does not feel pain in any part of her body though she sometimes feels chest heaviness and pain which she relieves by ventilating herself with electric fan and taking a rest. Her memory is still intact. Normal range of motion of the neck is observed and there was no neck rigidity. Perception. She uses glasses with grade of 300. she does have a visual problem. There was no lymphadenopathy. No signs of distress was observed. Discharge or impacted cerumen was not observed. and she learns best by actual performance of a task and reading. Both pupils of the left and right eye are equal. person and place. B. A. she thinks the reason she felt ill was because she does the household chores even when she was supposed to rest and she carries her grandson around which led to shortness of breath and fatigue.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure client. 3 millimeter in size and has brisk and uniform reaction to light and accommodation. the client was conscious. The client can walk has a slow but steady gait.

Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure

hearing deficit.

Psychosocial. The client does not want to be a burden to her family and perceives herself as “weak”. However, she has already accepted this fact and coped with the weakness in her own way. She does not perceive any difference in her physique except weight loss. She is easily cries and becomes tensed or nervous though this has been lessened once she was admitted in the hospital. B. A. feels anxious about her condition but she believes that everything will be alright in the end more so because she feels relatively fine. Whenever she feels tensed, she talks to her significant others or pray the rosary. She usually feels nervous whenever there are arguments in the family but this has been lessened according to her significant other out of consideration for the client. She sits and calms herself by praying and talking with the involved parties to relieve her tension. She coped with her condition by changing her lifestyle for the better, avoiding foods that are contraindicated to her condition and taking rest periods. However, she does feel bothered about the expenses incurred by her children for her medical condition.

The family of B. A. is extended and patriarchal, with B. A. making decisions regarding health actions and daily expenditures. She lives with her husband, her three children, a daughter-in-law and a grandson. Her husband is a contractual painter of houses and automobiles and their usual income varies from P3000-P5000 per month. Their children always contributes to the medical expenses of the client. Currently, they feel worried about their mother's condition and contributes to any way they can to alleviate her 34

Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure

condition. The usual problem of the family involves the drinking habit of the client's husband and financial problems. They usually resolve it by conversations with the family.

The client's only wish is to see her children and her grandchildren grow up. She does not fear death but she wishes that she will live longer because of her family. God, family and health are important for B. A. She claims that her religion helps her get through her condition because it gives her energy and happiness. On physical assessment, the client displayed signs of anxiety through silent pauses and different facial expressions. Respiration was not increased on narrations.

Reproductive. B. A. stated that she and her husband has not engaged in sexual intercourse in recent years. She claims that this is because they are already old. She has used pills as a family planning method from 1989 to 2002 but has since stopped using them though no problems were encountered upon their use. The client had her first menstrual period when she was 11 years old. She describes her menstrual period to be regular and usually lasts from 3 to 4 days. She usually consumes 3 pads in a day and has never experienced dysmennorhea. Her last menstruation was on August 1, 2010. B. A. is a G3P3 mother and has no history of complications at birth. On physical assessment, the client displayed symmetrical breasts. No lesions, masses or dimpling were observed. There was no discharge from the nipple.

Complications of heart failure are varied. However, in this discussion, we will focus on 35

Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure

the actual and suspected complications in the patient during course in the ward.

One of the chief complaint of the client was fever. The client has increased risk for infection due to prosthetic valve replacement in 2004. Because of this, Infective Endocarditis was presumed to be the cause of fever. In nursing literature, it has been stated by a study that prosthetic valve replacement increases risk for infective endocarditis (Okies, et. al, 1971).

Another chief complaint was chest pain or angina. The client presenting with chest pain is at increased risk for myocardial infarction. This is typical if severe, prolonged chest discomfort is present. The onset of chest discomfort must be abrupt and lasts longer than 15 to 30 minutes. The comfort is usually midsternal, “crushing”, or squeezing and may radiate to the arms, shoulders, back, neck or jaw (Woods, et. al, 2010). This list of symptoms were experienced by the client on the hospital rotation.

Community-acquired pneumonia was considered because of the presenting symptoms of the client similar to pneumonia. These includes pleuritic chest pain, shortness of breath, raised respiratory rate and fever of 38°C (Porth, 2007). Pulmonary tuberculosis was also considered because of similar symptoms of wasy fatigability, anorexia, weight loss, dyspnea and orthopnea (Porth, 2007).

Initial laboratory results were made to eliminate possibilities of Infective Endocarditis, 36

Pneumonia and pulmonary tuberculosis were ruled out as chest x-ray findings were negative of infiltrates or cavities in the upper lungs. Myocardial Infarction which was suspected on the onset of chest pain was also negative as the electrocardiography reports normal heart structure with bradycardia at a rate of 45 beats per minute. Other significant laboratory findings include the presence of hematuria which may be caused by suspected capillary endothelial damage caused by vasonconstriction or the presence of bilateral renal cysts seen on ultrasound. the presence of mild tricuspid regurgitation was observed which may have been caused by the valvular heart disease present in client before. In the echocardipgraphy of the client. It is important to note that only the mitral and aortic valves were replaced in surgery before.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure Community-Acquired Pneumonia and Pulmonary Tuberculosis. Fatty Infiltration or streaks in pancreas were also observed on ultrasound and the high intake of cholesterol and salt are one of the many factors suspected to have caused this. 47% Simpson’s and heart rate of 45 beats per min seen in electrocardiography reflects the decreased cardiac output of the client caused by mildly depressed overall systolic functioning as seen also in the echocardiography. Ejection Fraction with 53% Teicholtz’s. The presence 37 . find out other complications present in the patient and determine the cause of presenting symptoms. Infective Endocarditis is ruled out when the blood culture findings were negative.

behavior modification. as reflected in the updated American College of Cardiology/American Heart Association heart failure guidelines from 2009. hemodynamically significant arrhythmia or acute coronary syndrome is present (Hunt. 2009). As of discharge day. The goal is to continue the diagnostic and therapeutic processes started. B. et. Treatment.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure of minimal Albumin in urine seen in the urinalysis is suspected to have come from possible liver damage or caused by the damage on the capillary endothelial damage. During the period of hospitalization of the client. and exercise and diet recommendation are made. the client has not presented signs of peripheral congestion like edema. Heart failure education. A underwent a series of treatment for management of heart failure and its 38 . The patient must be on a stable oral regimen for at least 24 hours before discharge. However. renal dysfunction. al. These guidelines recommend hospitalization for acute heart failure if the severe decompensated heart failure (low blood pressure. Patient’s volume and hemodynamic status is optimized using careful clinical monitoring and the heart failure medical regimen is optimized. altered mentation). dyspnea at rest. its most presenting sign. a systematic approach to acute heart failure has only recently been emphasized. Despite the advances in heart failure treatment. this only emphasizes the importance of monitoring as said complication is not only probable but is almost the norm for congestive heart failure.

betaadrenergic blocking agents. Beta- adrenergic blocking agents given to patients with heart failure have been recommended for patient swith asymptomatic systolic dysfunction.. 2010) . they are not being given to client because hypotension is present in the client and ACE Inhibitors given with Beta blockers which are the client's maintenance drugs further decrease blood pressure and heart rate. However. On the other hand. Heart failure treatment has both pharmacologic and nonpharmacologic therapy prescribed by the doctor. al. This is used to maintain the client at her most stable condition and prevent complications from happening. This drug was also not prescribed to the patient with the same reason as ACE Inhibitor. Smeltzer & Bare. et. Both medical and nursing care are taken into account. thus reducing the workload of the heart (Smeltzer & Bare. In contrast. Medical Plan of Care. diuretics are prescribed to remove extracellular fluid by increasing the 39 . al. ARBs. al. (2010) enumerate the medications usually prescribed to heart failure patients. et. Pharmacologic Therapy. does not produce cough which usually discomforts heart failure patients (Smeltzer & Bare. ACE inhibitors promote vasodilation and diuresis by decreasing afterload and preload. though having the same mechanism of action as ACE inhibitors. diuretics. et. digitalis and calcium channel blockers.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure complications. These include angiotensinconverting enzyme (ACE) inhibitors. 2010). angiotensin receptor blockers (ARBs)..

Conversely. Also. However. et. al. this was not prescribed to the client because there were no symptoms of fluid overload or retention like edema. et. this drug was also not given to the client because it increases the risk for digitalis toxicity. al. Beta-blocker.. their indications and contraindications.. anticoagulants are prescribed to client especially if client has history of atrial fibrillation or a thromboembolic event.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure rate of urine produced in patients with signs and symptoms of overload (Smeltzer & Bare. when a person is hypokalemic. 2010). However. 2010)..et. metoprolol's pharmacologic action is to 40 .. However. According to Deglin & Vallerand (2009). It lyses clots or possible clots before it even enters the cardiac community (Smeltzer & Bare. al. Conversely. 2010). Metropolol belongs to the class of beta1-selective adrenergic blocker (Karch. et. al. digitalis absorption is faster and there is increased risk for toxicity. 2010). nursing implications and pharmacologic actions of the drugs prescribed are enumerated below. digitalis is used to increase the force of myocardial contraction and slow conduction through the atrioventricular mode (Smeltzer & Bare. they were not prescribed to client because it is contraindicated in patients with systolic heart failure. al. 2010). Calcium channel blockers cause vasodilation. reducing systemic vascular resistance (Smeltzer & Bare. Beta-adrenergic blocking agents have been found to reduce mortalilty and morbidity in patients with heart failure by reducing the adverse effects from the constant stimulation of the sympathetic nervous system (Smeltzer & Bare. 2010). Medications. et.

and lowering blood pressure. It also acts in the Central Nervous System to reduce sympathetic outflow and vasoconstrictor tone. resulting in their eventual depletion and prolongation of clotting times (Deglin & Vallerand. slow pulse. Some contraindications to administration of metoprolol include cardiogenic shock. dizziness. 2010). depression. Spratto & Woods (2008) outlines that nursing implications in giving this drug include telling client to report difficulty breathing. Warfarin is a cardiac drug that belongs to the class of oral anticoagulants (Karch. swelling of extremities. This was indicated for the client due to high probability of increased blood pressure. and X). This was indicated for the client as a measure of prevention of thrombus formation and embolization after prosthetic valve placement done in 2004. prothrombin. sinus bradycardia (HR less than 45 beats/min) and heart failure. decreasing cardiac output and the release of renin. fever. Anticoagulant. heart rate. IX. Metoprolol is a maintenance drug for the client after prosthetic valve replacement. It 41 .Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure competitively block beta-adrenergic receptors in the heart and juxtaglomerular apparatus. sore throat and assessing before and after administration of drug. 2009). confusion. rash. shortness of breath and blurred vision. VII. night cough. Things to watch out for include sudden decrease in blood pressure. Its pharmacologic action is to interfere with the hepatic synthesis of vitamin K-dependent clotting factors (factors II. decreasing the influence of the sympathetic nervous system on these tissues and the excitability of the heart.

2010). According to Deglin & Vallerand (2009). active ulcer disease. headache. dizziness epotaxis. The main desired action on the client includes the lyse of possible clots and treatment to prevent formation of emboli or thrombus. It must be used with caution in patients with malignancy and women with childbearing potential. al. Karch (2010) adds that some contraindications to administration of warfarin is uncontrolled bleeding because warfarin increases the probability of bleeding. blurred vision and mental status changes (Smeltzer& Bare. Other nursing implications include reminding patient to not double doses and have limited intake of Vitamin K (Karch. It blocks the final step of acid 42 . omeprazole's pharmacologic action is suppressing gastric acid secretion by specific inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal cells. conjuctival hemorrhages. or hematomas. The common signs. 2010). Proton-pump inhibitor. bleeding gums. hypotension. abdominal distention. 2010). tahycardia. Spratto & Woods (2008) state that one of the nursing implications in giving this drug is watching out for signs of bleeding. uncontrolled hypertension and recent brain. a maintenance drug used by the client in combination with metoprolol. ecchymoses. Omeprazole belongs to the class of the proton pump inhibitors or the anti-secretory drugs (Karch. It is also contraindicated to open wounds. eye. hemoptysis.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure has been. severe liver or kidney disease. or spinal cord injury or surgery. onset or worsening of bleeding include the occurrence of petechiae. since then.et.

chills must be assessed after giving drug. chew. causing cell death. Caution is advised for patients with liver disease wherein dosage reduction may be necessary and in pregnancy. This was indicated for the client due to suspected infective endocarditis. The main desired action on the client includes prevention of gastrointestinal bleeding and hypersecretion caused by ulcers or leisions in the gastrointestinal tract. Ceftriaxone belongs to the class of thirdgeneration cephalosphorins (Karch. Third-generation cephalosporin. Contraindications to ceftriaxone include allergy to acetaminophen. Some contraindications to watch out for include hypersensitivity to omeprazole or its components. according to Deglin & Vallerand (2009).Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure production. Karch (2010) adds that the medication is usually given to the client with heart failure for the management of duodenal ulcers and eventual prevention of bleeding from the upper gastrointestinal tract in people who have life-threatening illnesses. Its pharmacologic action is inhibiting the synthesis of bacterial cell wall.Adverse effects like severe headache. lactation. worsening of symptoms. It is also important to caution patient to swallow capsules whole and not to open. 2010). or children as safety has not yet been established. fever. or crush them. Spratto & Woods (2008) reminds nurses that this drug should be administered before meals because absorption of the drug is compromised if introduced to the body with meals. It must be used with caution in patients with impaired hepatic function and chronic alcoholism. 43 .

Nutritional therapy and Supplemental Oyxgen therapy. observing patient for signs and symptoms of anaphylaxis like rash. Also.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure The main desired action on the client includes prevention or treatment for possible endocarditis or pneumonia. Some contraindications to watch out for include allergy to acetaminophen. In addition. which helps dissipate heat (Karch. Its pharmacologic action is reducing fever by acting directly on the hypothalamic heat-regulating center to cause vasodilation and sweating. This was indicated for the client due to fever on admission to reduce fever and provide temporary relief of minor aches and pains (Deglin & Vallerand. Spratto & Woods (2008) outlines adds that the nursing implications in giving this drug include assessing patient for infection at beginning of and throughout therapy. namely. Physicians prescribe two additional therapy for the client with heart failure. laryngeal edema and wheezing. Nutritional Therapy. Antipyretic. Cardiac diet consists of low-sodium and restricted cholesterol diet. avoidance of drinking 44 excessive amounts of fluid are . 2010). 2009). Paracetamol belongs to the class of antipyretics and analgesics. Analgesic. Treatment Modality. constant assessment of the client's temperature and montoring for signs of infection are undertaken. pruritus. Spratto & Woods (2008) enumerates the nursing implications in giving this drug and these are administering thedrug with food if GI upset occurs and discontinuing the drugs if hypersensitivity reactions occur.

First problem identified is anxiety. it is important to plan care efficiently. Supplemental Oxygen Therapy. The computed diet for the client is based on a 1. The following nursing problems were identified on August 31. This is based on the degree of congestion or hypoxia (Smeltzer & Bare. 2010.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure asually recommended. Fats. Oxygen therapy becomes necessary as heart failure progresses. 2010). Dietary restriction on sodium reduces fluid retention and due to symptoms of peripheral and pulmonary congestion. on the other hand. 800 calorie diet which is recommended for the client. Figure 2 shows the concept map for the different problems identified in the patient. Care of nurses are shown to have increase the management of a patient with heart failure. Nursing Plan of Care. Anxiety (mild) is defined by Doenges (2004) as “a vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual)or a feeling of apprehension 45 . Total Calorie Requirement is 1800 kilocalories per day. Smeltzer & Bare (2010) stated that the significance of the sodium-restricted diet is to decrease the amount of blood volume which decreased myocardial workload. Thus. are restricted. Carbohydrate is limited to 270 grams per day while Protein is limited to 50 g per day. Problem Identification. The client is hooked to a nasal cannula with pressure of 4 LPN.

Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure 46 .

Subjective cues for this diagnosis include “feeling of fullness”. Total calorie intake recommended is 1800 kilocalories per day. Carbohydrates to be consumed are at 270 grams per day and protein is recommended to have at least 50 kilograms per day. Subjective cues include chest pain with a grade of 4. Subjective cues that identify anxiety include verbalization of nervousness. Objective cues include vital signs of 90/60 and heart rate of 45 beats per minute. Objective cues include changing facial expression. 2004).'s height is 5'2 inches. Next problem identified is Imbalanced Nutrition: Less than Body requirements. The client is prescribed with a cardiac diet consisting of low salt and restricted fat. pauses when reflecting. decreased appetite and minimal consumption of meals. Objective cues include the weight loss from 55 kilograms to 51 kilograms.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure caused by anticipation of danger. Dizziness and chest heaviness were also reported. sudden dizziness or difficulty of breathing. 2004). radiating to back and persisting to more than 10 minutes. B. Pallor and pale nail beds are other 47 . It is an altering signal that warns of impending danger and enables the individual to take measures to deal with threat”. “Madali talaga akong kabahan”. “Natatakot talaga akong mawala kasi gusto ko pa sanang makitang lumaki ang apo ko”. A. Risk for Ineffective Myocardial and Cerebral Tissue Perfusion is another nursing problem identified and it is defined as “an increased risk for decreasing in oxygen resulting in the failure to nourish the tissues at the capillary level” (Doenges. It is defined as the “intake of nutrients insufficient to meet metabolic needs” (Doenges. and anxiety about prognosis of disease.

Objective cues include the onset of fever with a temperature of 35. Objective cues include use of accessory muscles on exertion with a respiratory rate of 30 respirations per minute. Subjective cues for identifying the problem include shortness of breath on exertion.8 °C. There is normal hemoglobin count and left ventricular hypertrophy is identified in the electrocardiogram. Client has 2 pillow orthopnea and complains of easy fatigability. She is predisposed to infective endocarditis. The client's WBC values are normal and blood culture shows negative results after 2 days of incubation. This risk for infection is actually due to the client's former surery which is prosthetic valve replacement in mitral and aortic valves.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure signs of ineffective tissue perfusion. 48 . She reports feelings of “drowning” on supine position so she is placeed on Moderate High Back Rest. 2004). A nursing diagnosis identified is Ineffective Breathing Pattern which is defined by Doenges (2004) as “inspiration and/or expiration that does not provide adequate ventilation”. Risk for Infection is defined as “at increased risk for being invaded by pathogenic organisms” (Deonges. She also a known cardiac patient due to other diseased like Valvular Heart Disease and Rheumatic Fever. Subjective cues include history of surgical procedure in open heart surgery. The client is on oxygen therapy through a nasal cannula with 4 LPN as needed. prosthetic mitral and aortic valve replacement in 2004. Client is medicated with Ceftriaxone and there is also a presence of heplock at the left arm.

Decreased Cardiac Output is also part of the pathophysiologic diagram because it is part of the progression of the disease. She does not exercise though she walks to and from the market. Potassium content in blood is 3.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure Another nursing problem identified is Decreased Cardiac Output. Activity Intolerance is defined as “insufficient physiological or psychological energy to endure or complete required or desired daily activities” (Doenges. It is defined by Doenges (2004) as “inadequate blood pumped by the heart to meet the metabolic demands of the body”. However. Manifestations of the disease is similar to Decreased Cardiac Output. activity intolerance focuses more on the activities that the client can undertake. There is easy fatigability and client can walk only 3 flights of stairs. The client is on warfarin therapy that takes increases risk for bleeding. PC: Bleeding is a collaborative problem that looks out or monitors potential complications of bleeding in the client. 2004). Subjective cues include history of cardiac problems as a patient of Valvular Heart Disease and Rheumatic Heart Disease. There is shortness of breath on exertion. ordinary physical activities like walking are an effort to her and companions are needed to prevent syncope. Vital signs are monitored every 4 hours.8 secs.3 secs and Partial Thromboplastin Time is 56. The client is ambulatory and always does things for herself. Prothrombin time is 22.9 mmol/L. The client is fond of fatty and salty foods. The client has upper gastrointestinal bleeding though she does not complain of stomach pain. The client was advised to avoid green leafy vegetables 49 . However.

Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure because they counteract the mechanism of warfarin. Objective signs include hematuria. Cues include blood pressure of 90/60 and a heart rate 0f 49 beats per minute. Because of prosthetic valve replacement in 2004. the intensity of symptoms and underlying causes were taken into account first before their recommended position in Maslow's concept. She is on moderate high back rest and on warfarin therapy. These are needs that prompted addressing the problem first. Also.3 secs and Partial Thromboplastin Time is 56. Problem Prioritization. Maslow's Hierarchy of needs is utilized though in some circumstances. As can be seen. other problems like Activity Intolerance may not be needed to be intervened on. The client is ambulatory and experiences chest pain on exertion. ejection fraction is slightly lower than normal. Prothrombin time is 22.8 secs. 50 . Figure 3 shows the pyramid of prioritization of the nursing diagnosis. PC: Pulmonary Embolism is collaborative problem that monitors probability of potentila pulmonary embolism present in client. Also. hematoma and left lower arm and right upper arm. if Decreased Cardiac Output has been resolved. Decreaed Cardiac Output emerged as the priority problem because of the presenting symptoms such as very slow heart rate of 45 beats per minute and low blood pressure for age at 90/60. the client is monitored for pulmonary embolism which can lead to cardiac death.

Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure 51 .

In the succeeding days. The hemodynamic stability indicators are the baseline to indicate the status of cardiac output (Smeltzer. Mrs. the student nurse has (1) monitored hemodynamic stability indicators (vital signs. The goal for this problem is that by the end of the shift. Decreased Cardiac Output related to decreased endsystolic volume was addressed first. Aquino will demonstrate adequate cardiac output as evidenced by normal blood pressure and pulse rate and rhythm. On the day following assessment. preload. increased preload and afterload and reduced contractility of the patient. 2010). She has (2) monitored for peripheral edema.. In the formulation and implemenation of interventions in the nursing care plan. et. 52 . capillary refill time. al. This was chosen to address the problems of decreased heart rate. 2001). peripheral pulses. During nursing intervention. the most presenting signs and symptoms were given priority first before the conceptualized care plan. pallor) and compared with baseline. Nursing Interventions Classifications (2001) was also utilized to plan care. evaluation of care was still continued. afterload and contractility” (Johnson.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure Nursing Interventions. et. al. One of the Nursing Interventions Classification used was Hemodynamic Regulation [4150] which is defined as “optimization of heart rate.

The student nurse has (4) planned activity providing rest periods for the Mrs. 2010). Stress responses and attacks contributing to myocardial oxygen demand can be reduced by relaxation techniques (Kozier & Erb. and venous return and preload to the heart (Kozier & Erb.. which 53 .. al. As peripheral edema. 2010). This classification was used to decrease demands particularly of oxygen on the heart and alleviate symptoms of impaired cardiac function. al. et. reducing heart rate (bradycardia). et. al... (3) The promotion of a calm and restful environment was done to reduce myocardial oxygen demand that can be achieved by allowing for rest and relaxation periods (Kozier & Erb. et. et. 2010). During nursing intervention. She has also been able to (5) stress the importance of avoiding straining/ bearing down. She was able to (2) teach Mrs. Aquino to conserve energy and reduce cardiac workload (Smeltzer.. Aquino conscious breathing technique. jugular vein distention.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure jugular vein distention and S3 and S4 heart sounds. especially during defecation as Valsalva maneuver causes vagal stimulation. 2010). et. al. Aquino in preferred position of comfort or in semi-Fowler's position as this position decreases the workload of breathing. Another Nursing Intervention Classification used was Cardiac Care [4040] which is defined as “limitation of complication resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac function”. al. 2010). the student nurse has (1) placed Mrs. extra heart sounds indicate progressing congestion (Smeltzer.

.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure may be followed by rebound tachycardia. et. The next Nursing Intervention Classification used is Cardiac Care: Rehabilitative [4046] which is defined as the “promotion of maximum functional activity level for a patient who has experienced an episode of impaired cardiac function that resulted from an imbalance between myocardial oxygen supply and demand” (Johnson. both of which impairs cardiac output (Smeltzer.. as appropriate as this increases demand for oxygen compromising the transport to different tissues in the body (Kozier & Erb. al. 2010). During nursing intervention. The student nurse also (2) instructed the patient and family on cardiac risk factors and possible modifications. the student nurse was able to (1) instruct the patient and family on appropriate prescribed medications as increase in knowledge especially during home management decreases number of rehospitalizations (Paul. et. 2007). This classification was chosen to increase patient's independence and assess and recommend possible activity levels for the patient. al. The student nurse (3) instructed the patient and family on any lifting/weight limitations. 2008). Risk factors like high cholesterol and sodium intake are lifestyle problems that can be addressed with proper knowledge (Paul. et. as required. al. 2008). 2001). 54 . 2010). High sodium intake causes water retention (Porth. The student nurse also (4) explained the importance of a cardiac diet.

This is important for the client to learn also as increase in weight is a factor for reconsultation and possible rehospitalization once discharged (Paul. Intake and output monitoring helps monitor presence of excess or deficient fluid in the client (Kozier & Erb. On the second intervention day. The goal of this nursing intervention is for the client to report that anxiety is reduced to manageable level.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure The last Nursing Interventions Classification used for the problem Decreased Cardiac Output related to decreased end-systolic volume is Fluid Monitoring [4130]... 2008). During nursing intervention. 2010). One of the Nursing Interventions Classification in this diagnosis is Anxiety Reduction [5820] which is defined as “minimizing apprehension. The student nurse was also able to (1) monitor weight and advise client to weigh daily at 8am as tolerated. Weighing checks for possible increase in mass and fluid volume in the body undetected on the surface (Kozier & Erb. dread. al. et. al. Anxiety related to threat to or change in health status was addressed. This classification was chosen because of the importance of monitoring signs of further complications of congestion in the client. 2010). The problem Decreased Cardiac Output related to decreased end-systolic volume was also reevaluated. the student nurse was able to (2) monitor intake and output of the client. et. 55 . Activity Intolerance related to increased cardiac workload was intended to be carried out on this day but was terminated. Johnson (2001) defines it as a “collection and analysis of patient to regulate fluid balance”.

2006). or uneasiness related to an unidentified soure of anticipated danger” (Johnson. 2006). willingness to express feelings. she (5) assessed the presence of positive coping skillls/inner strengths e.. al. 2006). et. the student nurse was able to (1) review extent of feelings of anxiety of clients as there is a need to know the extent of disequilibrium and need for intervention to prevent or resolve the crisis (Doenges. or threats which interfere with meeting life demands and roles” (Johnson. Increased knowledge on prognosis of disease promotes understanding of diagnosis.g (use of relaxation techniques. She has taken (3) note of expressions of indecision. the student nurse (1) provided factual information concerning diagnosis. changes. et. This classification was chosen to decrease the client's apprehension related to prognosis of disease. This may indicate need to lean on others for a time (Doenges. This classification was chosen because it allows the nurse to identify possible stressors and at the same time. 2001). Another Nursing Intervention Classification used was Coping Enhancement [5230] which is defined as “assisting a patient to adapt to perceived stressors. During nursing intervention. use of support systems). and inability to manage own activities of daily living. treatment and prognosis and compliance to treatment.. She was also able to (2) discuss indication and method of treatment as this promotes active participation of client in therapeutic regimen (Doenges.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure foreboding. al. Last. During nursing intervention. dependence on others. 56 . treatment and prognosis. 2001). allows the patient to reflect on self and trace possible sources of anxiety and address them on her own.

2010). She has to (4) observe and document response to activities (walking. physical or psychological. and spiritual activities to increase the range. Assessment of these perceptions guides treatment (Doenges.. 2006). et. These perceptions may be temporary or permanent. 2006). She must be able to (2) assess the patient's level of mobility through the 6-minute walk.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure Past coping skills may be reused to relieve tension and preserve individual's sense of control (Doenges. which is necessary before setting realistic goals (Doenges. One of the Nursing Intervention Classification of this problem is Activity Therapy [4310] which is defined as “prescription of and assistance with specific physical and cognitive. frequency. deep-breathing. social. She must be able to (3) assess the patient's cardiopulmonary status before activity. Assessment before and afer activity provides for comparison on achieved level of 57 . al. 2006). 2006). This aids in defining what patient is capable of. or duration of an individual's activity” (Johnson. During nursing intervention. The goal for Activity Intolerance related to increased cardiac workload is that the client will be able to demonstrate sufficient energy to endure or complete required or desired daily activities. This classification was chosen because it addresses encompassingly the problem on the client's execution of activities and on how nurses can increment these activities as appropriate. Assessment before and after activity provides for comparison on achieved level of activity tolerance (Doenges. ROM). the student nurse must be able to (1) determine the patient's perception of causes of fatigue or activity intolerance.

Another Nursing Intervention Classification is Energy Mangement [0180] which is defined as “regulating the use of energy to treat or prevent fatigue and optimize function” (Johnson. 2001). al. 2006).Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure activity tolerance (Doenges. Rest between activities provides time for energy conservation and recovery. She must be able to (5) establish guidelines and goals of activity with the patient and caregiver. Acknowledgment that living with activity intolerance is both physically and emotionally difficult aids coping (Doenges. Motivation is enhanced if the patient participates in goal setting (Doenges. Risk for Ineffective Myocardial and Cerebral Tissue Perfusion related to increased cardiac workload was carried out. et. 2006). This prevents overexerting the heart and promotes attainment of short-range goals (Doenges.. Even though the 58 . (6) Progress activity gradually. This classification was chosen so that the client's easy fatigability would be addressed thorough the regulation of energy. On the third intervention day. She was able to (2) assist with activities of daily living as indicated though she allowed the client to do what she can do for herself. the student nurse was able to (1) assess the patient's schedule and allow rest periods between all activities. 2006). During intervention. 2006). 2006). 2006). Heart rate recovery following activity is greatest at the beginning of a rest period (Doenges. Caregivers need to balance providing assistance with facilitating progressive endurance that will ultimately enhance the patient's activity tolerance and self-esteem (Doenges. She was able to (3) encourage verbalization of feelings regarding limitations.

Evaluation is always carried out after intervention and reevaluated on the succeeding days. For the problem Decreased Cardiac Output related to decreased end-systolic volume. 2001). (6) instructing client to report chest pain and (7) ensuring rest periods.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure problem has not yet been included in the nursing care plan. Objectives of this problem was to display hemodynamic stability. (3) raising side rails and (4) promoting clam and restful environment. dizziness.. demonstrate decreased episodes of shortness of breath and orthopnea and tachypnea and reduce the workload of the heart. dyspnea. report absence of severe congestion. it warranted immediate intervention as the presenting signs and symptoms were manifested. Evaluation. et. al. This classification was chosen because it allows the nurse to address the main etiology which is decreased end-systolic volume. 59 . one of the Nursing Outcome Classification is Cardiac Pump Effectiveness [0400] which is defined as “adequacy of blood volume ejected from the left ventricle to support systemic perfusion pressure” (Johnson. It is used to determine whether the objectives and outcome criteria were met. Interventions for this problem included (1) monitoring for levels of consciousness. difficulty of breathing. (5) clustering activities with caregiver to limit extreme activities. (2) positioning to Moderate High Back rest on preferred position.

et. respiratory rate. Objectives of this diagnosis is for the client to participate in treatment regimen. Of the three. state adequate knowledge about disease process. The next criteria was to (3) demonstrate decreased episodes of shortness of breath. its treatment. Another was to (2) demonstrate absence of peripheral edema. The next outcome classification is Cardiac Disease Self-Management [1617] which is defined as “personal actions to manage heart disease. tachypnea and orthopnea. 2001). peripheral pulses. The outcome criteria for this objectives include (1) verbalization of the desire to participate in the treatment regimen which was stated by the client. nail beds.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure The outcome criteria for these objectives include to (1) display hemodynamic stability by having the following (blood pressure. al. This was chosen to promote independence in decision-making and treatment of the client. fat and cholesterol intake. jugular vein distention and S3 and S4 heart sounds. Another was to (4) demonstrate conscious breathing technique which was correctly performed by the client. only the heart rate was not within normal parameters with 50 beats per minute. only orthopnea is still the same as before and client is still on moderate high back rest. (2) stating 3 risk 60 . heart rate. participate in cardiac rehabilitation program and limit sodium. There was no indications of either of the three. The next one was for the client to (5) verbalize the desire to participate in activities that reduce the workload of the heart like stress management which was stated by the client. capillary refill time. Of the indicators. color) within normal parameters. and prevent disease progression” (Johnson. temperature.

et. smoking cessation) and the importance of their modification. For the Nursing Diagnosis Anxiety related to threat or change in health status. One of the nursing classification for this diagnosis is Anxiety Control [1402] which is defined as “personal actions to eliminate or reduce feelings of apprehension. Objectives of this classification include verbalizing understanding of condition/disease process and potential complications. Another criteria includes (3) verbalization of the understanding of required diet which the client's significant other has been able to fulfill.. al.. unidirectional blood flow at an appropriate pressure through large vessels of the systemic and pulmonary circuits” (Johnson. et. This classification was chosen because it allows self-assessment and personal management of the client's source of anxiety. 2001). The outcome criteria for this objective is to report the absence of weight loss and weight gain. The outcome criteria for this objective is to use own words and understanding in describing the disease process ro condition and its potential complications. al. tension. The objective of this classification is to maintain normal weight for age. or uneasiness from an unidentifiable source”(Johnson. 61 . The client was able to perform this outcome. 2001).Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure factors (diet. This classification was chosen because of the increased volume and pressure in the heart and plasma which may change the flow of blood. Another nursing outcome classification is Circulation Status[0401] which is defined as “unobstructed. the goal is for the client toreport that anxiety is reduced to manageable level. exercise.

verbalize understanding of treatment procedures and using behaviors to reduce stress. Outcome criteria include (1)consistently reporting a decrease in stress. dizziness and chest pain with vital signs of 110/70 mmHg. Objectives of this classification include reporting a decrease in stress. willingness to express feelings. it allows the nurse to assist the client in her endeavor and promotes camaraderie and rapport between the two. Because of the journal entitled “Hospital Discharge Education for Patients With Heart Failure: What Really Works and What Is the Evidence?” was used by the student nurse as 62 . the client was evaluated and exhibited absence of pallor. syncope.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure Another Nursing Outcome Classification is Coping [1302] which is defined as “personal actions to manage stressors that tax an individual's resources” (Johnson. 56 beats per minute. As with the preceding classification. al. In addition. this promotes and enhances independence in identifying source of problem. The client has been able to report a reduced feeling of stress on the succeeding day. For the nursing diagnosis Risk for Ineffective Myocardial and Tissue Perfusion. Another outcome criteria is (2) verbalizing in own words the relevant information about treatment wherein the client has been able to identify the action and indications of her medications. 2001). et. use of support systems).. Last outcome criteria is (3) demonstrating at 3 least behaviors to reduce stress ( use of relaxation techniques. 24 breaths per minute and at a temperature of 36. 1 °C. The client has been able to utilize and demonstrate said behaviors.

sodium and fluid restrictions. and early search for medical care was made. reduce readmission and helping the patient spot problems easily. 63 . physical activities. regular medication use. The purpose was to promote self care. health instructions and emphasis of importance of weight monitoring. monitoring signs and symptoms of disease worsening.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure a supplementary material for learning.

Self management includes weight monitoring wherein an increase in weight can be an early indication that the patient is retaining fluid (Paul. Non-pharmacological lifestyle measures play a central role in managing patients with heart failure. medications. and activity discussed (Washburn & Hornburger. Advice and information should be reinforced at every opportunity as it is fundamental in helping patients to cope with and manage their illness. They aim to enhance nurses' knowledge of heart failure self-management principles with key topics of symptom and weight management. Compliance remains an important factor. 2008). Measurement of weight provides a good indicator of fluid retention/loss. Weight should be taken early in the 64 . dietary recommendations. It is necessary for patients to understand and interpret changes in their normal functioning and judge the severity of any deterioration in their symptoms. 2008). Education and advice play a vital role in the patient’s quality of life and in the prevention of readmission to hospital. Recommendations for nursing care include the immersion of the Guidance on Management of Heart Failure in Northern Ireland (Clinical Resource Efficiency Resource Tam [CREST].Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure CONCLUSION Most nursing literature for heart failure focus on guidelines in improving selfmanagement of patients and key role that nurses play as deliverer of patient education. Patients should be encouraged to weigh themselves each day at approximately the same time. 2005).

It also involves salt restriction. 2005). Often cholesterol levels may be low at this stage of the condition and treatment for hypercholesterolaemia may not be as important. Another is fluid restriction wherein excessive fluid intake will negate the effects of diuretic therapy and therefore restriction is recommended (Paul. Small amounts of food offered regularly supplemented by nutritious drinks should be encouraged. Heart failure and the associated medications used to treat the condition may cause loss of appetite and malabsorption resulting (CREST. 2005). nutrition and dietary advice wherein a well balanced cardiac diet should always be encouraged.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure morning preferably before breakfast with the same amount of clothes and after having passed urine. In hospital or with severe cases fluid should be restricted to 1 – 1. 2008). 2005).5 litres a day (CREST. Salt in the diet promotes fluid retention. A salt restriction is usually recommended to most patients. no salt at the table and that salt substitutes are not recommended as they contain sodium and may be high in potassium (Paul. Patients should be advised to report an increase of more than 1 kg sustained over 3 days to the appropriate health professional (Paul. is a must. 2008). 2008). maximum of 2 gms per day. Patient should have awareness of high salt content in processed foods. 65 . a low salt diet is required in the management of heart failure. High energy foods may be offered (CREST. In addition to that.

the most fulfilling part is being able to establish rapport with the client and the significant other. confidence to the student nurse. Thoroughout the interaction with the client. the clinical experience in Female Medicine Ward has allowed me to experience handling cases related to the expected competencies for Nursing Interventions 105 mostly on oxygenation. in contrast to my other groupmates. It also helps that we remember that diseases are also human experiences and care for the client is always centered on her well-being. In doing this case study. It also helped me realize areas I have to improve on in dealing with a major case especially on assessment and analysis. 66 . I have been able to increase my knowledge on my case which is congestive heart failure. It builds up trust in the relationship and at the same time. caring for a patient with congestive heart failure needs utmost focus and dedication. For me. I realized that it is important to value and always keep in mind the theoretical knowledge imparted to us during lectures in addressing client needs. However. Nevertheless. The importance of doing interventions that reflect the patient's case was also emphasized. I have been able to improve on my communication skills.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure Overall. I have not been able to carry out major skills because my client does not have much contraptions. Implementing interventions were a challenge however. It also enhances the compliance of the client towards treatment and advice. We must always keep in mind the importance of appropriateness centering on individualized care.

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(1985).Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure Washburn.2000 January 22..gov/pmc/articles/PMC1117436/pdf/236.. Cardiac Nursing 6th ed. S.320(7229): 236–239.. 71:1077-1086. JB. Y. Circulation. genetics and microbes. S. BMJ. C. Gibbs. Bridges.nlm. J Contin Educ Nurs. ABC of heart failure: Clinical features and complications.. Nurse educator guidelines for the management of heart failure.. Lip. C.39(6):263-7.pdf Woods. G. 1985.. S. China: Wolters Kluwer Health/ Lippincott Williams & Wilkins Zabriskie. (2010). R. E.ncbi. Watson. C. Motzer. Retrieved from http://www. 69 . Froelicher. R.A.2008 Jun. (2008).Hornberger. (2000). Rheumatic fever: the interplay between host.D. H.S.nih. E.

(-) Edema (+) Hematoma: Left Lower Arm. (-) Alopecia Clean scalp Symmetrical Lids. (-) Impacted cerumen Symmetrical gross Symmetrical gross hearing capacity. (-) Masses. (-) Lesions Anicteric Sclera Clear cornea and Lens Pupils: equal. Dryness in Lips Pinkish Mucosa. (-) Perforation (-) Discharge. (-) Ptosis. Slow but steady gait (-) Pallor. Cold to touch Good skin turgor Normocephalic. fairly developed. oriented to time. place and person (-) Signs of distress Ectomorph. on August 31. (-) Hearing Deficit Symmetrical Nasolabial Fold. brisk and uniform reaction to light and accommodation Uniform convergence Intact visual extraocular activity Nearsighted Normoset (-) Tenderness. (-) Lesions Missing (1) fron tooth. (-) Lymphadenopathy (-) Discharge. jaundice (-) Lesions. normal. Gag relex intact Tongue in midline. A. Nostrils patent Symmetrical gross smell (-) Pallor. Swelling (-) Periorbital Edema. 3mm. cyanosis. kaundice. scars Dry. (-) Obstruction Pinkish Mucosa Septum in Midline. Dentures (full) SKIN HEAD: Hair EYES EARS NOSE MOUTH 70 .9 °C Conscious. (-) Lesions Pinkish Conjunctiva. 2010 ORGAN VITAL SIGNS: Blood Pressure Heart Rate Respiratory Rate Temperature GENERAL SURVEY PHYSICAL ASSESSMENT FINDINGS 90/60 (sitting) 44 beats per minute 30 breaths per minute 36. cyanosis. Right Upper Arm Smooth texture. (-) Perforation. coherent.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure APPENDICES Appendix 1: Physical Assessment Findings on B. lesions. even distribution of hair. looks according to age Fairly nourished.

(-) Bronchophony Normal breath sounds. 4/5 on both lower limbs 5/5 upper limbs Costovertebral angle tenderness not assessed because of back pain complaints PHARYNX CHEST AND LUNGS HEART BREASTS ABDOMEN BACK & EXTREMITIE S 71 . (-) lesions (-) Masses. (-) clubbing Capillary refill time: 0-1 seconds (-) Crepitations. (+) Scar: Epigastric region. funnel. visible pulsations Normoactive bowel sounds. Left Midclavicular Line Distinct heart sounds with metal clicks S1 louder than S2 at apex. 1cm (+) Scar: Right Lower Quadrant. 3 per min. murmurs Symmetrical. (-) Adventitious breath sounds (-) Heaves. soft. (-) Lymphadenopathy Pinkish Mucosa. (-) Neck Vein Engorgement Uvula in Midline. Thrills (+) Sternotomy scar: midsternal. symmetrical chest expansion Symmetrical ascending and descending vocal tactile fremitus (-) Ergophony. (-) barrel. 3cm Point of Maximal Impulse at 6th Intercostal Space. pigeon Respiratory Rate: 30 breaths per minute Chest: symmetric. 2cm (-) Bruits. S2 louder than S1 at base S1 and S2 regular (-) Extra heart sounds. (-) Lesions (-) Use of accessory muscles Inspiratory-Expiratory ratio: 2:1 Anterior-Posterior Lateral ratio: 1:2. joint pain Muscle weakness on knees.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure NECK Trachea in midline Nontender. (-) muscle guarding Nonpalpable liver Strong and equal peripheral pulses Nail: pale. dimpling (-) Discharge Flabby. Nonpalpable thyroid Normal Range of mOtion (-) Neck rigidity.

taken once daily ANTIPYRETIC. (2010). given orally. given orally. given orally. ANALGESIC: Paracetamol. A. G. especially indicated for patients at risk for myocardial infarction To decrease blood pressure To prevent hypersecretion of juice in stomach To reduce fever 72 . (2010) CPM Medica.8'C SOURCES:Karch. 40 milligrams. Woods. 500 milligrams. taken once daily BETA1-SELECTIVE ADRENERGIC BLOCKER: Metoprolol. Spratto. if temperature is greater than or equal to 37. (2008). Philadelphia:Thomson Delmar Learning Inc. if temperature is more than 39'C Paracetamol. taken once daily PROTON-PUMP INHIBITOR: Omeprazole. 2010 Lippincott’s Nursing Drug Guide. DESIRED ACTION ON THE CLIENT Treatment of Possible Infection (undiagnosed) caused by the presence of black ulcers wherein bacteria from the digestive tract can enter the respiratory tract To decrease possibility of thromboembolism. given orally. M. 50 milligrams. PDR Nursing Drug Handbook. given intravenously. L. taken once daily ANTICOAGULANT: Warfarin 5 milligrams. Philadelphia: Lippincott Williams & Wilkins .Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure Appendix 2: Medication Orders and Nursing Implications DRUG ORDER THIRD GENERATION CEPHALOSPORIN: Cefuroxime 2 grams given intravenously. 300 milligrams. 1 tablet.MIMS Philippines.

written materials. thereby promoting self care. The latter has been included. the journal recommends a comprehensive approach in inpatient and outpatient education. It emphasizes the role of the nurse in teaching and evaluating patients' self-care abilities in weight monitoring. I have been able to stress to Mrs. according to the journal. Nevertheless. Discharge education is a vital part of discharge planning because it addresses the home management of the client and her competency in dealing and monitoring the disease out of the hospital. an in-depth education and the giving of written materials is important to discharge education. 2010 if blood culture is negative (or Infective Endocarditis is ruled out). Philippine General Hospital also outlines the importance of discharge education in discharge planning though it is not as comprehensive as the journal recommends. cognitive impairment and lack of motivation and the importance of learning strategies to educate patients to overcome these barriers. We have been monitoring her weight daily at 8am with the client managing the weighing scale to increase awareness to its use. regular medication use. during my intervention week. specifically the nurses' roles as educators in providing comprehensive discharge education. It also underlines the importance of understanding barriers of patients' to self care like complex medication regimen. one-on-one sessions and interventions to address the clients' social support. reducing readmissions and helping patients spot problems easily. sodium and fluid restrictions. monitoring signs and symptoms of disease worsening. monitoring signs and symptoms of disease worsening. Aquino the importance of weight monitoring. I would be able to apply this in the care to my client as incoporated in the discharge planning. REACTION: This journal is relevant to my client. and early search for medical care.Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure Appendix 3: Journal and Journal Reaction Hospital Discharge Education for Patients With Heart Failure: What Really Works and What Is the Evidence? SUMMARY: This journal article talks about the important guidelines in educating patients with heart failure before disharge. and early search for medical care at home. methods of discharge instruction. Lastly. motivation and education after discharge. limited physical activities. Its aim is to focus attention to the comprehensive strategies provided by the specially trained nurses that have been able to improve outcomes for patients with heart failure. regular medication use. However. sodium and fluid restrictions. as 73 . physical activities. diagnosed with Congestive Heart Failure FC II 2ᵒ Valvular Heart Disease 2ᵒ Rheumatic Heart Disease for discharge on September 2.

Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure appropriate. a comprehensive. discharge medications. follow-up appointments. (2008) Hospital Discharge Education for Patients With Heart Failure: What Really Works and What Is the Evidence? Crit Care Nurse. given the circumstances. Also. I personally think that it is a good idea to implement the inclusion of standardized educational materials and written instructions in discharge planning. There is less intensive coordination of the community and hospital nurses in the Philippines.aacnjournals. If this is not already done. S. SOURCE: Paul. I would be one of those who will be able to make this system possible in the Philippines. as part of my future nursing career. I am able to understand the unlikelihood of it happening in the near future. weight monitoring and what to do if symptoms worsens. one-on-one sessions and at-home interventions as part of their care after discharge which is highly improbable in the Philippines. it would be a good recommendation. 2008.28: 66-82. Retrieved from http://ccn. one day. As a student. It also recommends the provision of patient medication charts and low sodium recipes and food suggestions. diet. to my nursing care plan. it is possible that I can accomplish the above recommendations specifically the provision of educational materials in PGH. Discharge education is outlined in the Philippine General Hospital though not as comprehensive as the journal recommends. The impact of this journal to my future nursing care is that it helps in stressing to me the importance of health teaching in the future management of illness. However.org/cgi/external_ref?link_type=PERMISSIONDIRECT 74 . it has been called to my attention the differences in the health system of the United States (the socalled ideal health system) and the Philippines. Maybe. However. research-based and standardized booklet is called for. The journal concludes that it is vital to discharge education that patients or their caregivers are given written discharge instructions or other educational materials addressing all of the home concerns of the client like the activity level. In the US. it is possible for them to have telephone monitoring.

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