Introduction

:

For the purpose of privacy and confidentiality, the real name of the patient in this Case Study is withheld and she will referred to as “
Patient X”

Patient X is a 98 years old female who was currently residing at San Miguel, Tarlac City. Patient X was admitted at the Central Luzon
Doctors’ Hospital last July 6, 2014 at 10:40pm with a chief complaint of difficulty of breathing.

Background Knowledge

Congestive Heart Failure describes the inability or failure of the heart to adequately meet the needs of organs and tissues for oxygen and
nutrients. This decrease in cardiac output, the amount of blood that the heart pumps, is not adequate to circulate the blood returning to the heart
from the body and lungs, causing fluid (mainly water) to leak from capillary blood vessels. This leads to the symptoms that may include shortness
of breath, weakness, and swelling.

What Causes Congestive Heart Failure?

There may be many potential reasons for a patient to develop heart failure. It may be due to structural damage to the heart, inability of the
heart to squeeze properly, medications or drugs that affect heart function, lung disease, and other underlying medical diseases. More than one
cause may be present at the same time.

Risk Factors

Congestive heart failure is often a consequence of atherosclerotic heart disease and therefore the risk factors are the same: poorly
controlled high blood pressure, high cholesterol, diabetes,smoking, and family history. Heart valve disease becomes a risk factor as the patient
ages. (ww.medicinenet.com)

Congestive Heart Failure Symptoms

The hallmark symptom of left heart failure is shortness of breath or dyspnea (dys=abnormal + pnea= breathing). This may occur while at
rest, with activity or exertion, while lying flat (orthopnea), or may awaken a patient from sleep (paroxysmal nocturnal dyspnea). The shortness of
breath may be due to fluid (water, mainly) accumulation in the lungs or the inability of the heart to be efficient enough to pump blood to the organs
of the body when called upon in times of exertion or stress. Chest pain or angina may be associated, especially if the underlying cause of the
failure is atherosclerotic heart disease. (www.medicinenet.com)

When to Call the Doctor

The Doctor should be called if there are signs and symptoms of congestive heart failure and any of these situations:

Symptoms of sudden heart failure, such as:
o Severe shortness of breath (trouble getting a breath even when resting).
o Suddenly getting an irregular heartbeat that lasts for a while, or getting a very fast heartbeat along
with dizziness, nausea, or fainting.
o Foamy, pink mucus with a cough and shortness of breath.
o Chest pain or pressure, or a strange feeling in the chest.
o Sweating.
o Shortness of breath.
o Nausea or vomiting.
o Pain, pressure, or a strange feeling in the back, neck, jaw, or upper belly, or in one or both shoulders or arms.
o Lightheadedness or sudden weakness.
o A fast or irregular heartbeat.

Old Birthdate: August 9. 2014 / 10:40pm Attending Doctor: Conrado R. Nursing health history A. Demographic Data Name: Patient X Address: San Miguel. 1915 Religion: Catholic Date of admission: july 6. Tarlac City Gender: Female Age: 98 yrs. . Genilo III MD Admitting Doctor: Maricis C. History of present illness 1 day prior to admission the patient manifest difficulty of breathing and easy fatigability with edema at both low extremities.Nursing Process A. Chief complaint Patient X was brought to the hospital and seek medical attention due to the chief complaint of difficulty of breathing C. Lopez MD B.

Review of System General Appearance Weight loss Weakness Weight gain Night sweats Anorexia Fatigue Generalized jaundice Note: the patient has weak in appearance Skin Itch Lesions Blister Bruising Rash Ecchymoses Bleeding Burns Drainage Note: No abnormalities in skin found Ears Pain  Hearing loss Discharge Tinnitus .

Note: the patient has slightly hearing loss due to aging Nose Obstruction Epistaxis Discharges Note: no abnormalities in skin found Throat & Mouth Sore throat Bleeding gums Tooth Ache Tooth Decay Note: No abnormalities in throat and mouth Chest Cough Hemoptysis WheezePain in Respiration Dyspnea Sputum Rales .

CVS Chest pain Palpitation Orthopnea Others__________ Dyspnea Edema Note: Chest pain. Dyspnea and rales is the symptoms of CHF. suctioning performed. Palpitation and Edema because of congestion GIT Intolerance Heartburn Nausea Jaundice Vomiting Pain Bleeding Excessive Gas Constipation Change in BM Melena .Note: the patient is unable to expel sputum.

Anatomy and Physiology Numbness Tingling . Neuro Headaches Seizures Dizziness Paresis Paralysis Memory Loss Fainting Others: ________________ Notes: patient has memory loss due to aging.Note: no abnormalities in GIT found Genito Urinary Dysuria Nocturia Retension Polyuria Dribbling Hematuria Flank Pain Tea colored urine Oliguria Note: patient experience Oliguria and tea colored urine due to concentration.

one on the right side. Arteries carry blood away from the heart while veins carry blood into the heart. The Right Side of the Heart The right system receives blood from the veins of the whole body. The heart is composed of two independent pumping systems. arteries. atria. and veins. The vessels colored red indicate the transport of blood with relatively high content of oxygen and low content of carbon dioxide. The vessels colored blue indicate the transport of blood with relatively low content of oxygen and high content of carbon dioxide. and the other on the left. The ventricles are the major pumps in the heart. The external structures of the heart include the ventricles. This is "used" blood. an atrium and a ventricle. it is useful to be familiar with the anatomy of the heart and how it works.To understand what occurs in heart failure. which is poor in oxygen and rich in carbon dioxide. Each has two chambers. .

the first chamber on the left side.  The lungs restore oxygen to the blood and exchange it with carbon dioxide.  The chamber expands as its muscles relax to fill with blood that has returned from the body.  The blood enters a second muscular chamber called the right ventricle. This blood is now oxygen rich. There are four valves in the heart: . The Valves Valves are muscular flaps that open and close so blood will flow in the right direction.  The left ventricle is the strongest of the heart's pumps. The Left Side of the Heart The left system receives blood from the lungs. Its thicker muscles need to perform contractions powerful enough to force the blood to all parts of the body.  Here. a powerful muscular chamber that pumps the blood back out to the body. it moves to the left ventricle.  The oxygen-rich blood returns through veins coming from the lungs (pulmonary veins) to the heart. which is exhaled.  The right ventricle is one of the heart's two major pumps. the major artery that feeds blood to the entire body. The right atrium is the first chamber that receives blood.  Blood leaves the heart through the ascending aorta. The lower number (diastolic blood pressure) is measured when the left ventricle relaxes to refill with blood between beats. Its function is to pump the blood into the lungs.  It is received from the lungs in the left atrium.  This strong contraction produces systolic blood pressure (the first and higher number in blood pressure measurement).

Pathophysiology Left Sided Congestive Heart Failure Pathophysiology Reduced myocardial contractility Causes Increases cardiac workload o Myocardial Infarction Decreased diastolic filling o Hypertension Bloods dams back into the pulmonary capillary bed Obstructions of left atrial emptying Left sided CHF Left atrial pressure Stroke volume Pressure at the pulmonary capillary bed Tissue perfusion decreases Bloods flow to the kidneys . The tricuspid regulates blood flow between the right atrium and the right ventricle.  The mitral valve regulates blood flow between the left atrium and the left ventricle.  The aortic valve allows blood to flow from the left ventricle to the ascending aorta.  The pulmonary valve opens to allow blood to flow from the right ventricle to the lungs.

Pulmonary Cellular hypoxia RAAS stimulation Vasoconstriction and reabsorption of Na and water ECF volume S/S Total blood volume Systemic BP .

DRUG STUDY Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities .

Food will lessen chance of stomach upset -report any unusual bruising or bleeding. intracranial bleeding. hematoma. may take without regard to food. hematuria. purpura. GI disturbances.Clopidogre Anti platelet 75mg 1 bisulfate Drug 1 tab OD Inhibits platelet aggregation by inhibiting binding of adenosipinediphosphat e to its platelet receptor and subsequent ADPmediative activation of glycoprotein complex Lactation Active pathological bleeding such as peptic ulcer or intracranial hemorrhage. epistaxis. GI bleeding. diarrhea. eye bleeding (mainly conjunctiva). bruising. -Assess for any active bleeding as with ulcers or intracranial bleeding -take exactly as directed. advise all providers of prescribed therapy pruritus Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities . rash.

paresthesia. restlessness. hypomagnesemia. fever photosensitivity. pruritis necrotizing angitis -monitor the blood pressure. distal tubules and ascending tubules loop of henle leading to excretion of water together with sodium. chloride and potassium diuretic. sodium. uric acid and BUN -monitor neurologic manifestation of hypokalemia.Lasix Loop diuretic 1 amp IVP q8 Drug Name Classification Dosage Inhibits sodium and chloride reabsorption at the proximal tubules. hearing loss. chronic aortitis. Hypersensitivity Action Contraindication to sulfonylurea’s anuria Orthostatic hypotension. vertigo. hyperchloremia -monitor intake and output -assess patient for tinnitus. hyponatremia. fluid intake and output. glucose. calcium. antihypertensive. thrombophlebitis. electrolytes: potassium. ear pain Adverse Effect Nursing Responsibilities . dizziness. magnesium.headache. urticarial.

fatigue. headache. and adverse symptoms to repot -simulated gastric acid are inhibited Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities . bradycardia.assess knowledge/ teach patient appropriate use. dizziness. possible side effects/ appropriate interventions. insomnia Long term therapy -use caution in presence of renal hepatic impairment -assess potential for interactions with other pharmacological agents patient may be taking . depression. hallucination. as well as food and pentagastrin Hypersensitivity History of acute Porphyria Cardiac arrhythmias.Ranitidine Histamine H2 50mg Receptor blocking drug IV q12 Competitively inhibits gastric acid secretion by blocking the effect of histamine H2 receptors both daytime and nocturnal basal gastric acid secretion.

alcoholism. advanced age. cough. constipation. rhinitis. renal impairment. sinusitis. dyspnea. muscle cramps. dyspepsia. hypothyroidism Nausea. diarrhea. vomiting. diet. impaired hepatic function.Rosuvastati n calcium Antihyperlipidemic 20 mg 1 tab OD A fungal metabolite that inhibits the enzyme (HGMCoA) that catalyzes the first step in the cholesterol synthesis pathway. serum LDLs (associated with increased risk of coronary artery disease) and either an increase or no change in serum HDLs (associated with decreased) Drug Name -Arrange for proper consultation about need for diet and exercise changes -Offer support and encouragement to deal with disease. especially higher doses -Provide comfort measures to deal with headache. drug therapy. pneumonia Classification Dosage Action -Administer drug at bed time -Monitor patient closely for signs of muscle injury. and follow-up care. or nausea In serum cholesterol. resulting in a decrease hypersensitivity. Contraindication Adverse Effect Nursing Responsibilities .

Kaliumdurul e electrolytic and water balance agent 1 tab TID Principal intracellular cation. maintenance of normal kidney function. heat cramps. transmission of nerve impulses. and for enzyme activity. see S&S. contraction of cardiac. Appendix F). and smooth muscles. essential for maintenance of intracellular isotonicity. . Severe renal impairment. severe hemolytic reactions. If oliguria occurs. abdominal distension. flaccid paralysis. untreated Addison’s disease.Hyperkalemia -Monitor I&O ratio and pattern in patients receiving the parenteral drug. early postoperative oliguria (except during GI drainage). -Be alert for potassium intoxication (hyperkalemia. difficulty in swallowing. irritability. Irregular heartbeat is usually the earliest clinical indication of hyperkalemia. may result from any therapeutic dosage. Oliguria. skeletal. anuria. -Monitor for and report signs of GI ulceration (esophageal or epigastric pain or hematemesis). stop infusion promptly and notify physician. Pain. paresthesias of extremities. adynamic ileus. digitalis intoxication with AV conduction disturbance. and the patient may be asymptomatic. patients receiving potassium-sparing diuretics. Nausea. muscle weaknessand heaviness of limbs. -Monitor patients receiving parenteral potassium closely with cardiac monitor. hyperkalemia. acute dehydration. diarrhea. crush syndrome. listlessness. mental confusion. Plays a prominent role in both formation and correction of imbalances in acid–base metabolism. vomiting.

sinus arrest. and in those for whom bradycardia has caused syncope. CNS : fatigue. CV: hypotension. EENT: visual disturbances. GI : Nausea. sleep disturnbances. -Watch carefully for pulmonary toxicity. exertional dyspnea. 1 tab TID -Those with cardiogenic shock. -Monitor blood pressure and heart rate and rhythm frequently. Notify prescriber or significant change in assessment result. Contraindicate d In patients hypersensitivity to drug or iodine. ataxia. bradycardia. second or third degree AV block. headache. edema. heart failure. peripheral neuropathy. -Watch for evidence of pneumonitis. insomnia. abnormal smell. arrhythmias. optic neuropathy. tremor. and pleuritic chest pain. paresthesia. severe SA node disease resulting in bradycardia unless an artificial pacemaker is present. -Perform continuous ECG monitoring when starting or changing doses. malaise. . non productive cough.Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities Cordaron e Antiarrhythmics 200mg Effects result from blockade of potassium chloride leading to a prolongation potential duration. heart block. or neuritis resulting in visual impairment.

hyperthyroidism. abnormal taste. constipation. SKIN : photosensitivity. Hematologic : coagulation abnormalities Hepatic : hepatic failure . blue gray skin.vomiting. anorexia. hepatic dysfunction Metabolic : hypothyroidism. abdominal pain. . SEVERE PULMONARY TOXICITY. Respiratory : acute respiratory isease distress syndrome. solar dermatitis.

Abdominal cramps. -Prepare enema by adding 200g (300ml) to 700 ml of water or normal saline solution. -Monitor mental status -Replace fluid intake. diarrhea. flatulence. which lowers the pH of colon contents. dilute with water or fruit juice or give with food. Contraindicate d in patients on a low galactose diet. belching. resulting distention promotes peristalsis. 1tbsp HS Produces an osmotic effect in colon . probably as a result of bacterial degradation. -To minimize sweet taste. . vomiting. Nausea.Drug Name Classification Dosage Action Contraindication Adverse Effect Nursing Responsibilities Lactulose Contraindicat ed in patients on a low galactose diet. Also decrease ammonia. gaseous distension. -Inform patient about adverse reactions and tell him to notify prescriber if reactions become bothersome or if diarrhea occurs.

5. To maximize EVALUATION For further management . 3. Determine presence or degree of sleep disturbance s. Ask client to rate fatigue.ASSESSMENT DIAGNOSIS PLANNING Subjective: Easy fatigability related to decreased tissue perfusion. After nursing intervention the patient will able to show strength and energy Objective:Patient manifested:   Generalized weakness (+) DOB INTERVENTION 1. Obtain client descriptions of fatigue. Assist with RATIONALE 1. 4. 2. To evaluate fluid status and cardiopulm onary response to activity. Assess vital signs. 5. Fatigue can be a consequen ce of sleep deprivation . 4. Plan intervention s to allow individually adequate rest periods. To assist in evaluating impact on client’s life. 3. 6. To determine degree of fatigability. 2.

7. 8. 7. 11. To conserve energy for other tasks. Avoid exposure to temperatur e and humidity extremes 8. participatio n. Indicate the need to alter activity level 9.self-care needs and ambulation.Assist client to identify appropriate coping behaviors. 9. as indicated. Instruct client in ways to monitor responses to activity and significant signs or symptoms. Promote overall health measures 10. 11.Promote sense of control and improves selfesteem. To promote energy 10.Presence of hypoxemia reduces oxygen available for cellular uptakes and contributes to fatigue.Provide supplement al oxygen. Has negative impact on energy level. . 6.

4. Change position q 2 hrs. enhance expectorati on of secretions in order to improve ventilation 4. Intervention 1. 7. To avoid coughing 5.Assessment Subjective: Objective:Patient manifested:    productive cough yellowish in color presence of rales upon auscultation (+) DOB Diagnosis Impaired Gas exchange ventilation perfusion and equality Planning After nursing intervention the will able to breath w/o oxygen therapy. Suction secretions Rationale Evaluation 1. Promote adequate rest periods 6. Keep back dry. Observe color of skin. noting presence of peripheral cyanosis. Keep environment allergen free 8. To obtain For further baseline evaluation and data management 2. 3. Cyanosis of nail beds may represent vasoconstr iction or the body’s response to fever/ chills 3. To promote maximal inspiration. Monitor and record vital signs 2. and decrease secretion production. Rest will prevent fatigue and decrease oxygen demands . mucous membranes and nail beds. 5. Elevate head of bed and encourage frequent position changes.

O2 therapy is indicated to increase oxygen saturation . 8. 7.PRN 9. 6. 9. Administer oxygen therapy as ordered. for metabolic demands To promote drainage of secretions To reduce irritant effects on airways To clear airway when secretions are blocking the airway.

Do not elevate legs if the client is dyspnic. Assess patient’s general condition 4.Assessment Diagnosis Planning Subjective: (none) Excess Fluid Volume -After nursing intervention the patient will be able to decrease difficulty of breathing. 6. To obtain baseline data 3. To gain patient’s trust and cooperation 2. I&O balance reflects fluid status 5. Monitor and record VS 3. Establish rapport 2. - Intervention 1. Encourage or provide oral care q2 8. To determine what approach to use in treatment 4. Follow lowsodium diet and/or fluid restriction 7. Assess for presence of peripheral edema. Decreased systemic blood pressure to stimulation Evaluation For further management and evaluation . Objective:Patient manifested:   Edema on extremitie s( 6mm) DOB -patientsedema will decrease from (6mm) to 0. Monitor I&O every 4 hours 5. Monitor for Rationale 1.

11. which decreases water retention. hence decreasing fluid volume excess. Fluid restriction may be used to decrease fluid intake.Assess the need for an indwelling urinary catheter.distended neck veins and ascites 9. 10. of aldosterone .Institute/instruct patient regarding fluid restrictions as appropriate. Evaluate urine output in response to diuretic therapy. 6. which causes increased renal tubular absorption of sodium Low-sodium diet helps prevent increased sodium retention. The client senses thirst because the body senses .

resulting in increased capillary pressure. When hydrostatis pressure exceeds interstitial pressure. Oral care can alleviate the sensation without an increase in fluid intake. Elevation of legs increases . fluids leak out of htecpaillari es and present as edema in the legs. Heart failure causes venous congestion.dehydration . 7. and sacrum.

Focus is on monitoring the response to the diuretics.venous return to the heart. Inidicates fluid overload 9. 8. rather than the actual amount voided 10. Assessment Diagnosis Planning Intervention Rationale Evaluation . 11.This helps reduce extracellula r volume.Treatment focuses on diuresis of excess fluid.

To determine what approach to use in treatment 15. which causes increased renal tubular absorption of sodium Low-sodium diet helps prevent increased sodium retention.To obtain baseline data 14.Evaluate urine output in response to diuretic therapy.Decreased systemic blood pressure to stimulation of aldosterone . 17. -patientsedema will decrease from ( grade 6) to 0.Monitor I&O every 4 hours 16. Do not elevate legs if the client is dyspnic. 21.Encourage or provide oral care q2 19. 12.Subjective: (none) Objective:Patient manifested:   Edema on extremitie s (grade 6) DOB Excess Fluid Volume related increased renal tubular absorption -After nursing intervention the patient will be able to decrease difficulty of breathing.Assess for presence of peripheral edema. For further management and evaluation .Assess the need for an indwelling urinary catheter.Monitor and record VS 14.Establish rapport 13.Institute/instruct patient regarding fluid restrictions as appropriate.To gain patient’s trust and cooperation 13.Assess patient’s general condition 15. 22.I&O balance reflects fluid status 16.Monitor for distended neck veins and ascites 20.Follow lowsodium diet and/or fluid restriction 18. - 12.

17.The client senses thirst because the body senses dehydration . Oral care can alleviate the sensation without an increase in fluid intake.Heart failure causes venous congestion. Fluid restriction may be used to decrease fluid intake. 18. resulting in . hence decreasing fluid volume excess.which decreases water retention.

increased capillary pressure. Elevation of legs increases venous return to the heart.Focus is on monitoring the response to the diuretics.Inidicates fluid overload 20. When hydrostatis pressure exceeds interstitial pressure. 19. and sacrum. fluids leak out of htecpaillari es and present as edema in the legs. rather than the actual amount .

This helps reduce extracellula r volume. 2. 22. A quiet environment reduces the energy demands on Evaluation For further management and evaluation. 3. 3. for location and for precipitati ng factors. precipitating factors and location to assist in accurate diagnosis. Assessment Diagnosis Subjective: Acute pain related to decresed tissue perfusion secondary to angina PainObjective:Pati ent manifested:    (+) DOB with a rate of 6 out of 10 with complaints of chest pain Planning The patient will verbalize decrease of pain. Establish a quiet environme Rationale 1. Provide comfort measures.voided 21. Intervention 1. To identify intensity. 2. .Treatment focuses on diuresis of excess fluid. Assess patient pain for intensity using a pain rating scale. To provide nonpharmaco logical pain management.

Tachycardia and elevated blood pressure usually occur with angina and reflect compensator y mechanisms secondary to sympathetic nervous system stimulation. 6. Elevation improves chest expansion and oxygenation. especially pulse and blood pressure. every 5 minutes until pain subsides. Monitor vital signs. . 4. Elevate head of bed. 5. 6. 4. the patient. Anginal pain is often precipitated by emotional stress that can be relieved nonpharmacologi cal measures such as relaxation. 5.unprovoked nt. Teach patient relaxation techniques and how to use them to reduce stress.