I.

INTRODUCTION
A. Brief Description

The American College of Cardiology Foundation (ACCF)/American Heart Association

(AHA) guidelines define heart failure as a complex clinical syndrome that results from structural
or functional impairment of ventricular filling or ejection of blood, which in turn leads to the cardinal
clinical symptoms of dyspnea and fatigue and signs of Heart Failure, namely edema and rales.
The term “heart failure” is preferred over the older term “congestive heart failure”. Heart Failure
are now broadly categorized into Heart Failure with reduced ejection fraction, formerly systolic
failure and Heart Failure with preserved ejection fraction, formerly diastolic failure (Mann and
Chakinala, 2015).

Signs and symptoms of heart failure are shortness of breath (dypnea) when you lie down,
fatigue and weakness, swelling (edema) in the legs, ankles and feet, rapid or irregular heartbeat,
reduced ability to exercise, persistent cough or wheezing with white or pink blood-tinged phlegm,
chest pain if heart failure is caused by a heart attack.

The diagnosis of heart failure is often determined by careful history and physical
examination and characteristic chest radiograph findings. Blood test, electrocardiogram (ECG),
echocardiogram, stress test, and cardiac computerized tomography (CT) scan or magnetic
resonance imaging (MRI), coronary angiogram, and myocardial biopsy (Hinkle and Cheever,
2014).

B. Current Trends/Statistics

International
According to the American Heart Association Heart Diseases and Stroke Statistics Update
(2017), the number of adults living with heart failure increased from about 5.7 million (2009-2012)
to about 6.5 million (2012-2015) and there are 5.7 million people in the US diagnosed with Heart
Failure in the year of 2017.

National
The leading cause of heart failure is the rheumatic fever, accounting for 54.9% of cardiac
children and 46.6% of cardiac adults, giving and average of 47.1% in the year 2016 (Ajaconline
Organization. 2016).

Regional

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 The Manila Doctors Hospital consultant cardiologists stated that Region III has 4,526 or
10.3% PhilHealth patient claims for congestive heart failure (CHF) dated January 1 to December
31, 2014 among government hospitals and private care centers.

C. Reasons for Choosing the Case

Student Nurse
This case study serves as a tool in enhancing our critical thinking and clinical eye in
assessing the manifestations and knowing the appropriate procedures for Cardiogenic shock and
Congestive Heart Failure management. We chose this case for us to be able to further understand
the causes, risk factors, the exact pathophysiology and its compensatory mechanism as well as
the complications, diagnostic tests, treatments, nursing management and clinical implication of
this case. Also, to further understand the relationship between Rheumatic Heart Disease and
Congestive Heart Failure and why this leads to Cardiogenic shock.

Patient

We chose this case to help the patient to further understand his condition. To let him be
aware and understand the appropriate and correct health teachings by the student nurses. Also,
to lessen and alleviate the patient’s signs and symptoms through proper nursing care.

II. OBJECTIVES

a. General Objectives
Our group aims to broaden our knowledge with regards to caring for a patient with
Cardiogenic shock Congestive Heart Failure and to help our patient further understand his
condition and apply the proper heath teaching and proper nursing care to be able to lessen and
alleviate his sign and symptoms.

b. Specific Objectives
1. To assess the health status of the patient;
2. To recognize nursing problems and create nursing diagnoses based on the objective and
subjective data gathered;
3. Plan efficient nursing care to solve identified problems based from patient’s condition and
health needs by utilizing the Specific, Measurable, Attainable, Reliable and Timely method;
4. Implement and render appropriate nursing care;
5. Deliver the appropriate and helpful health teaching to help him understand his condition.

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III. NURSING PROCESS

A. Assessment

1. Personal Data
a. Demographic Data
Name: Patient A

Age: 20 y/o

Address: Maligaya, Tarlac City

Gender: Male

Date of Birth: November 16, 1998

Nationality: Filipino

Religion: Roman Catholic

Chief Complaint: Difficulty of breathing

Admitting Diagnosis: Cardiogenic shock Congestive Heart Failure secondary to

Rheumatic Heart Disease

Final Diagnosis: Cardiogenic shock Congestive Heart Failure secondary to

Rheumatic Heart Disease

Date Admitted: March 16, 2019

Time admitted: 4:43 pm

Attending Physician: Dra. Nikki Luz de Vera

Date and Time of Death: March 20, 2019. 9:34 PM

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b. Environmental Status

Patient A is a 20-year-old patient who lives in a rural area along the highway. They
are a nuclear type family. They live in a mixed type of house which is concrete and wood
consisting of three rooms with each had one window, two main doors, and one comfort
room. Their source of drinking water is mineral water. When it comes to waste disposal,
they burn it and there were times they collect it especially the plastic. The type of drainage
system is open drainage and the water is free flowing. The distance from their neighbors
is 5 meters away.

c. Lifestyle (habits, recreation, hobbies)

Patient A eats his meals three times a day. Sometimes, just drinking coffee with
biscuit like sky flakes every morning. He is fond of eating fried and fatty foods especially
chicharron, salty foods, and junk foods. According to him he can drink 3 glasses of juice
in one serving and he can consume cold water more than two liters per day. He also drinks
alcoholic beverages like beer and Emperador four times a week. He also smokes 1 pack
of cigarette per day. According to him, He always sleep 1 hour a day because after his
work, he will go to his friends and drink alcohol. However, he can able to take a nap at his
work.

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2. GENOGRAM
MATERNAL PATERNAL

HEART
78y.o
DSE.

GRANDFATHER GRANDMOTHER GRANDFATHER GRANDMOTHER

Heart Dse. Heart Dse.

HTN

UNCLE AUNT AUNT MOTHER UNCLE UNCLE AUNT AUNT FATHER

20 YEARS
21 Y/O 17 Y/O
OLD 5 y/o
MALE 10Y/O

PATIENT A BROTHER BROTHER SISTER

LEGEND

MALE FEMALE PATIENT DECEASED

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3. History of Past Illness

Patient A stated that he had complete vaccination and experienced common

childhood illnesses like fever, colds, sore throat, chicken pox, measles and mumps. He
did not seek any medical assistance/ help and took only over the countered drug like
paracetamol and herbal such as lagundi. He did not take any medication to treat his sore
throat. Patient A has no known allergies to foods, medications, animals, insects and any
other environmental agents.

Last December 2018, he had productive cough for 1 month, dysuria and sore
throat as well, he did not take any medication for that however he used herbal such as
lagundi. He ignored his symptoms and continued to work.

On February 2019 patient came home from work at 6:00 pm in the afternoon, tired
and exhausted. He took a shower right away and went out with his friends to drink
alcohol and smoke cigarettes until 12:00 am in the morning. Patient experiencing
difficulty of breathing at that time and was rushed to Talon General Hospital at 4:00 am
in the morning and was admitted for one week. He was diagnosed with pleural effusion
and rheumatic heart Fever as written to his chart. His brother stated that the patient went
back to work, and in drinking alcohol and smoking cigarettes, he ignored his heath
condition.

4. History of Present Conditions

March 11, 2019, he manifested angina, difficulty of breathing and palpitations.

This prompted him to go to Tarlac Provincial Hospital and he was admitted at medicine
ward and diagnosed with Congestive Heart Failure secondary to Rheumatic Heart
Disease. He signed the Home Against Medical Advice (HAMA) form on March 13, 2019
due to financial matters. On March 14 and 15 his symptoms manifested again. He went
to Talon General Hospital and he was referred to Provincial Hospital at 3:30 in the
afternoon due to financial matters as stated by his brother and because of that they
decided to go to Emergency department at Tarlac Provincial Hospital around 4:43 in the
afternoon and transferred to ICU. He was admitted on March 16, 2019 with a chief
complaint of difficulty of breathing, easy fatigability, sudden weight gain, and angina. He
was diagnosed with cadiogenic shock, congestive heart failure secondary to rheumatic
heart disease.

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 5. PHYSICAL ASSESSMENT (IPPA)

I. SOCIAL STATUS

Patient A is a 20 years old male, born on November 18, 1998 and currently residing at
Maligaya, Tarlac City. He lives with his father, stepmother and four siblings. He used to work as
a “helper” to help his family. He has a good relationship with his family and friends. He likes to
joke around, but after he experienced symptoms of his illness, he was unable to mingle to the
people around him due to difficulty of breathing and easy fatigability.

Norms:

Social status includes family relationships/friendships that state the patient’s support system
in time of stress and in time of need. It meets a fundamental human need for social ties, making
life less stressful and social support buffers the negative effects of stress, thus indicating indirectly
contributing to good health outcomes. (Kozier, 2004)

Analysis:

Patient A social status is affected by his condition. Though he has a close family relationship
and has an active social life before, his condition stops him from interacting outside or even inside
home.

II. MENTAL STATUS

He was able to identify the time, date and place where he is. Patient A was able to tell us
what happened to him and the reason why he needs to be hospitalized. He was able to answer
question accordingly but talks slow to catch his breath.

Norms:

The client should be oriented to time and place, can identify past and recent memories and
should be able to verbalize concrete messages. The client’s ability to read and write should match
his educational level. The client should be able to respond to questions and should be able to
evaluate and act appropriately in situation. (Estes, Health Assessment and Physical Examination,
third edition)

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 Analysis:

He was able to respond to questions and he is oriented to date, time and place. Being
responsive and being able to answer questions accordingly are the major determinants which
indicate patient’s mental capabilities are still functioning well.

III. EMOTIONAL STATUS

Before patient A was very hardworking to help his family. He is aware of his responsibilities.
After his condition occur and worsen, he couldn’t do his responsibilities and rarely talks and stays
quite most of the time. Patient stated that he is aware of his condition and he accepted it.

Norms:

Young adult is a time of separation and independence from the family and of new
commitments, responsibilities, and accountability in social, work, and home relationship roles.
(Allen, Estes, Health Assessment and Physical Examination)

Analysis:

Based on the assessment he is aware of his condition and can able to cope. He is emotionally
stable with regards accepting his condition. Emotional status is one of the important assessments
for patients with heart failure, impaired doing self-management skills usually triggers depression.

IV. SENSORY PERCEPTION

Sense of sight

In assessing patients’ sense of sight, we have asked him to read a phrase “Close the door
when leaving” 10 feet away and was able to read it clearly. With the use of penlight, the following
were observed: pupils are reactive to light and accommodation, both eyes are symmetrical and
round, sclera is yellowish in color.

Norms:

The client who has a visual acuity of 20/20 is considered to have normal visual acuity. The
eyes must be symmetrical during the six cardinal gazes test. The sclera should be white with
some small blood vessels. Papillary constriction should occur when struck by light. Ideal focus
distances for reading and writing average between 15 from the eyes. (Estes, Health Assessment
and Physical Examination)

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 Analysis:

Based on the assessment stated above, Patient visual acuity is normal. Sclera is yellow due
to his condition. Liver conditions may cause jaundice or yellow eyes.

Sense of hearing

In the auditory assessment, voice whisper test was utilized. We have instructed the patient
to repeat the words “I can do this”. The procedure was repeated to the other ear with a phrase of
“kaya ko to”. He was able to repeat it correctly.

Norms:

For the auditory acuity, the client should be able to repeat the whispered words from two feet.
(Health Assessment and Physical Examination, Mary Allen Zator Estes)

Analysis:

Patient A sense of hearing is normal.

Sense of smell

Patient nose is in the midline of the face and is symmetrical; there are no obstructions or
secretions. And by providing two cotton balls, one is scented with perfume and the other with
alcohol, he was able to identify the smell correctly.

After his condition worsens, he became sensitive to the smell of smoke and dust.

Norms:

Nose must be symmetrical and along of the face. Each nostril must be patent and recognize
the smell of an object. (Mary Ellen Zator Estes, Health Assessment and Physical Examination)

Analysis:

Sense of smell was affected by his condition.

Sense of taste

Before, he is a picky eater but has good sense of taste. Now patient admitted he loses his
appetite and food became less tasteful.

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 Norms:

The patient should be able to distinguish the taste if it is sweet, salty, sour and bitter which
should be intact in the posterior 1/3 of the tongue (Health Assessment and Physical Examination,
Mary Ellen Zator Estes).

Analysis:

Sense of taste was affected by his condition.

Tactile Sensitivity

In assessing the touch sensation, we instructed the patient to close his eyes and tell us what
he feels. We put pressure on his right arm and responded that he felt pain. Same procedure was
done on both his legs; and as for inspection patient has pitting edema, he said that his legs feels
numb and tingles upon applying pressure.

Norms:

The skin contains receptors for pain, touch, pressure and temperature. Sensory signals are
transmitted along rapid sensory pathways, and less distinct signals such as pressure of localized
touch are sent via slower sensory pathways. (Mary Ellen Zator Estes, Health Assessment and
Physical Examination)

Analysis:

Upon the assessment, his tactile sensitivity is normal on his upper extremities. Tingling and
numbness on lower extremities are caused by poor tissue perfusion. Problems on the kidney or
circulation of blood may contribute on having edema and results to less sensation felt on lower
extremities.

V. MOTOR AND GAIT STABILITY

Before he was hospitalized, he has a good motor stability and gait. According to him, he goes
to the gym 2-3 times a week. He is also very active in his work.

During the assessment patient has no difficulty in moving but due to difficulty of breathing
and easy fatigability his mobility is limited. He is not allowed to move around and stays only in
bed. He can move his arms upward but loses control when putting it down. He also has weakness
felt in both of his lower extremities with tingling sensation and numbness.

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 Norms:

In standing position, the torso and head are uptight. The head is midline and perpendicular
to the horizontal line of the shoulders and the pelvis. The shoulders and hips are level, symmetry
of the scapulae and iliac crests. The arms are freely from the shoulders. The feet are aligned, and
the toes point forward. Walking initiated in one smooth rhythmic fashion. The foot is lifted 2.5 to
cm to the floor and propelled 30 to 45 cm forward in a straight path. The client remains erect and
balanced during all stages of gait and should be able to transfer easily to various positions. There
should be absence of discomfort during range of motion exercise. (Mary Ellen Zator Estes, Health
Assessment and Physical Examinations)

Analysis:

Due to his present condition, patient has limited mobility and difficulty in performing ADL’s.

VI. BODY TEMPERATURE

Temperature was taken by using an axillary thermometer at the left axilla, the temperature
reading is:

Date Assessed Time Temperature

March 19, 2019 9:00 AM 36.3℃

10:00 AM 36.7℃
(TUESDAY)
11:00 AM 35.9℃
12:00 PM 36.3℃
1:00 PM 36.6℃
2:00 PM 37.2℃
March 20, 2019 3:00 PM 37.4℃

(WEDNESDAY)

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 Norms:

A normal range of body temperature is 36-37.2 ℃

Analysis:

Upon assessment his temperature is within normal range.

VII. RESPIRATORY STATUS

The respiratory rate, pattern and adventitious breath sounds were assessed, and the results
are:

Date Assessed Time Respiratory rate Breathing Sounds

Pattern

March 20, 2019 9:00 AM 23 cpm Tachypnea Crackles

10:00 AM 25 cpm Tachypnea Crackles
11:00 AM 24 cpm Tachypnea Crackles
12:00 PM 24 cpm Tachypnea Crackles
1:00 PM 31 cpm Tachypnea Crackles
2:00 PM 21 cpm Tachypnea Crackles
March 19, 2019 3:00 PM 24 bpm Tachypnea Crackles

WEDNESDAY

Patient has decreased fremitus. Dull sound upon percussion. He is also in orthopneic
position when he is having difficulty of breathing shortness of breath. Use of intercostals
muscles when breathing was noted. Purse lip breathing was also observed. Bluish lips and
cyanotic nail beds were also observed as well. He is also on oxygen therapy via face mask 5
L/ min.

Norms:

Normal respiratory rate for adults is 12-20cpm. Average is 18. In terms of pattern, normal
respirations must be regular and even in rhythm. The normal depth of respirations is
nonexaggerated and effortless (Health assessment and physical examination 3rd edition Mary
Ellen Zator Estes).

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 Analysis:

Based on the statements above, respiratory status of the patient was affected by his condition.
Blood backs up in the pulmonary veins because the heart can’t keep up with the supply and fluid
leaks into the lungs. This results to difficulty of breathing when lying flat and shortness of breath.

VIII. CIRCULATORY STATUS

Date Assessed Time Heart rate Blood pressure

March 19, 2019 9:00 AM 121 bpm 100/70 mmHg

(TUESDAY) 10:00 AM 119 bpm 100/80 mmHg
11:00 AM 120 bpm 90/70 mmHg
12:00 PM 111 bpm 100/70 mmHg
1:00 PM 132 bpm 90/70 mmHg
2:00 PM 101 bpm 100/70 mmHg
March 20, 2019 4:00 PM 119 cpm 100/70 mmHg
(WEDNESDAY)

Upon assessment, capillary refill returns after 4 seconds. Heart rate is taken through the
apical pulse. Patient is having tachycardia. Blood pressure are within normal range but on
Tuesday March 19 11:00 am and 1:00 pm his blood pressure drops to 90/70 mmHg.

Norms:

The normal cardiac rate or pulse rate of an adult is 60-100 bpm. The average blood pressure
of a healthy adult ranges from 110 to 120 systole 70 to 80 diastole. The normal capillary refill test
was done, and it returns to normal state within 2-3 second. (Kozier, Fundamentals of Nursing,
seventh edition)

Analysis:

Circulatory status was affected due to his condition. Patients with heart failure has a clinical
manifestations of increased heart rate to try to compensate with the heart condition by pumping
more blood into the heart.

IX. NUTRITIONAL STATUS

According to the patient he is a picky eater. He eats more than three times a day. He is fond
of eating fatty and salty foods like bagoong. He also like eating chicharon and sisig. According to

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his brother he doesn’t eat without condiments like soy sauce and calamansi. He rarely eats
vegetables and fruits. He drinks 5-6 glasses of water a day. He also consumes 6-8 bottles of beer
per night.

During admission, the diet given to patient A is low salt and low in fat. He loses his appetite
due to decrease sense of taste. His fluid intake is limited to 1L/day. Before the hospitalization, he
weighs 69kgs with a BMI of 24.55 and experienced sudden weight gain in which he weighs 74
kgs with a BMI of 26.33. Now, he weighs 72 kgs (25.62).

Norms:

According to the Health Asian Diet Pyramid, there should be a daily intake of rice, grains,
bread, fruit and vegetables; optional daily for fish, shellfish, and dairy products; weekly for sweets,
eggs, and poultry, and monthly for meat. There should be an increase intake of a wide variety of
fruits and vegetables. Include in the diet foods higher in vitamin C and E, omega-3 fatty acid rich
foods. Fluid intake is on the average of 8-10 glasses per day. (Mohan,2002)
The degree of overweight or obesity as well as the degree of underweight can be determined
using BMI. The normal BMI ranges from 18 to 22. (Estez, Health Assessment, 2006)

BODY MASS INDEX CHART

BMI INTERPRETATION

Below 18.5 Underweight

18.6-24.9 Healthy Weight

25-29.9 Overweight

30 Obese

Based on:Smeltzer, S. C. (2004). Suddarth and Brunner’s Medical Surgical Nursing Volume 1,
(4th Edition). Lippincott William and wilkins

Analysis:

Based on the statements above patient nutritional status is very poor as well as his water
intake. There was a sudden weight gain due to fluid retention in the body before the hospitalization
in which he was classified as overweight. However, during his hospitalization, he loses his
appetite and his BMI lowers down from 26.33 to 25.62.

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X. ELIMINATION STATUS

Before hospitalization patient defecates once every 2 days and urinates 3-5 times a day and
has difficulty urinating. During his admission at ICU, he hasn’t defecated since and he urinates 7-
8 times. Abdominal girth measures 102cm.

Norms:

Normal bowel movement of a person must be 1 to 2 times a day and voiding 3-4 times a day
with an output of 1200 to 1500 ml a day. A normal stool is brown in color and well deformed, urine
is clear to yellowish in color. (Kozier, Fundamentals of Nursing)

WAIST OR ABDOMINAL GIRTH VALUES

RISK MEN WOMEN

Centimeter Inches Centimeter Inches

Very Low <90 <39 <70 <28.5

Low 80-99 31.5-39 70-89 28.5-35

High 100-120 39.5-47 90-109 35.5-43

Very High >120 >49 >110 >43.5

Adapted from: (Lee, D. and Nieman, D. (2012), Nutritional Assessment (6th edition). McGraw-Hill
Education)

Analysis:

He experienced dysuria. Upon admission patient was constipated and abdominal girth
classified as high risk. Increased urination due to the action of his medication (Diuretics:
Furosemide)

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XI. REPRODUCTIVE STATUS

Patient A was circumcised when he was 9 years old during his 4th grade. When asked if he
was engaging in sexual activity, he admitted that he is sexually active but not after his condition
worsen.

Norms:

Describes client’s pattern of satisfaction and dissatisfaction with sexuality pattern, describes
reproductive patterns and circumcision in men. It also includes family planning method.

Analysis:

Patient A reproductive status is normal.

XII. SLEEP-REST PATTERN

Patient sleeps for only an hour a day because of his work and night outs with his friends. He
sleeps at 4 am and wakes up at 5 am. At work he was able to take a nap. After his condition
worsens, he can’t sleep properly due to difficulty of breathing and shortness of breath.

Norms:

Adult average amount of sleep per day is 7 to 8 hours a day. (Estes, Health Assessment)

Analysis:

Patient A sleep and rest pattern are very poor before and now. His condition keeps him from
having an average amount of sleep and rest.

XIII. STATE AND SKIN APPENDAGES

During our assessment, dry skin and pale cracked lips are seen. His skin is yellowish in color.
His hair is thick, coarse and dry with proper distribution of the scalp, eyebrows and eyelashes.
There is also presence of pitting edema (grade 2 2-6mm) in both of his lower extremities, shiny
appearance of lower extremities was noted. Yellowish skin was also observed. His nails were
trimmed, and nail beds are pale in color. His capillary refill returns after 4 seconds. There was
also Heparin lock on his right hand.

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 Norms:

When the skin is pinched then released, it should turn to its original contour rapidly. Hair
varies from dark to pale blonde based on the amount of melanin present. The body is covered in
vellus hair. Terminal hair is found in the eyebrow, eyelashes, and scalp, and in the axilla and pubic
area after puberty. Skin surfaces should be non-tender. It should normally feel smooth, even and
firm. (Estes, Health Assessment and Physical Examination)

Analysis

Based on the assessment Patient A skin appendages is affected also by his condition. Heart
conditions, liver problem and kidney problem may cause what we have seen in the patient (pitting
edema, cyanotic lips and nail beds and slow capillary refill).

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 6. Laboratory and Diagnostic Procedures

Diagnostic Indications and Purpose Results References Interpretations of results

Procedure

1. 2DECHO Doppler echocardiography Dimension:

CARDIOGRAPHY in adults medically
LV (ed) – 6.5 4.5-5.0 - Above normal range left ventricle thickens may
WITH COLOR necessary for the following
indicate hypertrophy of the end – diastolic diameter
DOPPLER indications:

• Evaluation of aortic IVS (ed) – 0.9 0.8-1.1 - Normal

diseases
DATE:
• Evaluation of LVPW (ed) – - Above normal range; if the myocardium is more than
January 28, 2019 1.9 0.8-1.1
aortocoronary 1.1 cm thick, the diagnosis LV Hypertrophy can be

bypass grafts made

• Evaluation of
- Normal
hypertrophic Aorta – 2.5 2.0-3.5
- Above normal range; may indicate left atrial
cardiomyopathy
LA – 4.2 3.0-3.5 enlargement
(idiopathic
hypertrophic
- Mild pulmonary hypertension with pulmonic
subaortic stenosis) PA- 2.3 3.0-4.0 regurgitation
• Evaluation of
- Above normal range; if the end-diastolic diameter is
prosthetic valves
RV (ed) – 4.7 2.2-4.0 above 4.0 cm thick right ventricular hypertrophy can
• Evaluation of septal be diagnosed

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 defects RA (es) - 5.2 3.5-4.5 - Above normal range; right atrium is thicker than 4.5
cm right atrium hypertrophy can be made.
• Evaluation of site of
left-to-right or right-
Function:
to-left shunts
LVEDV - 212
• Evaluation of the
severity of valve LVESV- 186

stenosis and STROKE VOL- - Below normal range; if the heart rate increases SV will
26 50-100 ml
regurgitation have to go down to maintain a normal cardiac output.

EF%- - 12 55.0-77.0 - Below normal range; heart isn’t functioning as well as

it could. The amount of blood being out of the heart is
less than the body needs.
FS%- 5.5 28.0-42.0 - Use to asses left ventricular dysfunction if below 28
LV dysfunction may be diagnosed
EPSS- 2.2 <1

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2. SPECTRAL AND COLOR FLOW DOPPLER
Valve Max Velocity Peak Gradient mmHg
AORTIC 0.3/0.5 0.6/1.4
MITRAL 1.0/0.3 4.3/0.5
TRICUSPID 0.5/0.4 1.2/0.7
PULMONIC 0.4 0.7
PA PRESSURE PAT=89

QUALITATIVE DATA

➢ Dilated left ventricle with normal wall thickness with hypokinesia. Spontaneous echo contrast noted.
➢ Dilated left atrium, right atrium and right ventricle.
➢ Structurally normal aortic valve, mitral valve, tricuspid valve and pulmonic valve.

COLOR DOPPLER

➢ Abnormal color flow display noted across the mitral valve and pulmonic valve.
➢ Normal mitral valve E/A velocity ratio.
➢ Pulmonary artery pressure=50 mmHg by PAT

CONCLUSION

➢ Dilated left ventricular with normal wall thickness with global hypokinesia consistent with dilated cardiomyopathy with reduced ejection
fraction. Spontaneous echo contras noted.
➢ Dilated left atrium, right atrium, right ventricle.
➢ Mitral regurgitation 2+.
➢ Mild pulmonary hypertension with pulmonic regurgitation.
➢ Pulmonary edema
➢ No intracardiac thrombus or pericardial effusion noted.

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 3. CHEST AP SUPINE

RESULT

➢ Pulmonary vasculature is prominent with central haziness noted in both lungs

➢ Heart is not enlarged.
➢ Diaphragm and sulci are intact.
➢ Bony thorax is unremarkable.

IMPRESION

➢ Cardiomegaly with pulmonary congestion and bilateral interstitial edema.

4. ABDOMINO-PELVIC UTZ

Date: February 17, 2019

Indication/ Purpose: Abdomino Pelvic Ultrasound is used to diagnose a variety of conditions, such as: abdominal pain or distention,
abnormal liver function, enlarged abdominal organ, kidney stones, gallstones or an abdominal aortic aneurysm (AAA).

RESULTS:

Liver is normal in size with a homogenous parenchyma no mass lesion. Intrahepatic ducts and common bile ducts are not dilated. Gallbladder
is normal in size and echo-free lumen. Gall bladder wall is normal in thickness. Pancreas and spleen are normal in size and echo pattern.
Abdominal aorta is not dilated. The right kidney measures 6.6 x 4.0 cm. The left kidney measures 10.6 x 5.8 cm. Both kidneys are within
normal size and echogenicity. A calculus is seen in the right kidney measuring 0.6 cm. No mass or cyst or hydronephrosis. There is no
ascites. Urinary bladder is empty.

IMPRESSION:

➢ Right nephrolithiasis.

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 ➢ Normal scan of the liver, gall bladder, pancreas, sleep and left kidney

5. ELECTROCARDIOGRAM

DATE: March 18, 2019

INTERPRETATION

✓ Sinus tachycardia
✓ Possible left arterial abnormality
✓ Marked right axis deviation
✓ Lateral infarct
✓ Possible anteroseptal infarct
✓ Right ventricular hypertrophy
✓ Inferior T-wave abnormality maybe due the hypertrophy and or ischemia

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Diagnostic/ Indication/ Findings Reference value Interpretations Nursing Responsibilities
Laboratory Purposes
Procedure
Analysis of blood CREATININE • Check electrolytes, the minerals that
1. BLOOD chemistry can 147.62 mmol/L 53-106 mmol/L *High help keep the body’s fluid level
CHEMISTRY provide serum creatinine levels in balance, and are necessary to help
important the blood indicate that the the muscles, heart, and other organs
information kidneys aren't functioning work properly.
about the properly.
function of the ENZYME • Check the urine output
Date: March 17, kidneys and SGOT/AST
2019 other organs. 1748.77 5.0-34.0 U/L *Indicate liver failure or • Check the vital signs
This common damage
panel of blood LIVER • Monitor and regulate the Intravenous
tests measures FUNCTION TEST fluid
levels of BILIRUBIN
important 197 mg/dl 66-178 mg/dl *Above normal bilirubin • Limit salt intake
electrolytes and indicates an accumulation of
other chemicals bilirubin in the
blood. • Monitor liver function test
Jaundice will be noted
ELECTROLYTES
MAGNESIUM *Normal
0.8 umol/L 0-8.6umol/L

SODIUM *Below normal, it indicates

126.6 mmol/L 135-148 mmol/L hyponatremia. Low sodium

23 | P a g e
 in the blood. Fluid shifting
into the interstitial causing
edema

POTASSIUM *Normal
4.16 mmol/L 3.50-5.30
mmol/L

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Diagnostic/ Indication/ Findings Reference value Interpretations Nursing
Responsibilities
Laboratory Purposes
Procedure

HEMATOLOGY -Help to diagnose • HEMOGLOBIN • Monitor vital signs

anemia, infection, 115 g/L M: 135-170 g/L Indicates anemia
hemophilia, F: 120-153 g/L • Evaluate patient

disorders and response

leukemia. • HEMATOCRIT
0.479 % M: 0.390-0.500 % Normal
Date: -Include laboratory
F: 0.350-0.450 %
assessments of
March 16, 2019
blood formation and • RBC
blood disorders. • 3.9-5.7 x10^1/2/L
• 5.62 x10^1/2/L Normal
Some examples of
these tests are: Full
blood count - A count • MCV
of the total number of 85.2 fl • 80-96 fl Normal

red blood cells, white • MCHC

blood cells and 311 g/L • 334-335 g/L RBC do not have enough
platelets present in hemoglobin.
blood.
• MCH
• 27.5-33.2 pg Iron deficiency anemia can
26.5 pg
cause low MCH levels

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• WBC
11.6
• 4.5-11 x40^g/L Indicates another problem
such as infection, stress,
inflammation and trauma

• LYMPHOCYTES
Normal
0.245% • 0.230-0.350%

Platelet

288,000 • 150,000-450,000
Normal

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 8. PATHOPHYSIOLOGY
Book based
MODIFIABLE FACTORS

• Tobacco used
• Obesity 9. NON- MODIFIABLE FACTORS
• Diet ( High fat and High salt diet) • Age
• Faulty heart valves • Gender
• Arrhythmia • Lineage/ Genetics
• Infarction (MI, CAD) • African American
• Uncontrolled blood pressure
• Recreational Drug use
• Invaders

Due to Left sided heart failure

Increased stroke volume and cardiac work Back flow from lungs to right ventricle via pulmonary
load artery due to pulmonary congestion

Left Ventricle overwork leads to dilated right

ventricle Increased stroke volume of right ventricle

Mitral Regurgitation Dilated right atrium and dilated/ stenosed pulmonary artery;
pulmonic valve regurgitation

Blood flow occurs from left ventricle to Left atrium

back to the lungs via pulmonary vein Tricuspid valve Regurgitation

Dilated pulmonary vein and Dilated left atrium Blood flow occurs from right ventricle to right atrium
back to the systemic circulation

Pulmonary Congestion/ pulmonary

hypertension/ pulmonary edema Dilated right atrium

Peripheral & periorbital edema, ascites

LEFT SIDED HEART FAILURE
RIGHT SIDED HEART FAILURE

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 Decreased renal tissue perfusion
Compensatory
mechanism

Easy Neurohormones Release of Anti

fatigability release: RENIN diuretic Hormones

Angiotensin 1 Production Decreased Urine Output

Angiotensin 2 conversion

Blood vessels constriction Increased Blood Pressure

Increased aldosterone

Decreased Na in vascular space and Increased Na in Interstitial Space due to

accumulation of fluid in the vessels

Increased water reabsorption

Fluid overload in the body Generalized edema

CONGESTIVE HEART FAILURE

COMPLICATION
REDUCED EJECTION
FRACTION

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 Patient based

MODIFIABLE FACTORS

• Tobacco used NON- MODIFIABLE FACTORS

• Alcohol intake
• Age: 20 years old
• Diet (High fat and High salt diet)
• Gender: Male
• Altered sleep pattern (only sleep
• Family History (Father: HTN,
1 hour a day and take a nap at
mother: CHF)
work)
• Recurrent strep throat

Injury to the heart muscle = loss of function of

Due to Left sided heart failure
cardiac myocytes

Left Ventricle overwork leads to enlargement of Back flow from lungs to right ventricle via pulmonary
Left Ventricle artery due to pulmonary congestion

Mitral Regurgitation Dilated right atrium and dilated and pulmonic valve
regurgitation

Blood flow occurs from left ventricle to Left atrium

back to the lungs via pulmonary vein Blood flow occurs from right ventricle to right atrium
back to the systemic circulation

Dilated left atrium

Dilated right atrium
Pulmonary Congestion and
pulmonary hypertension Accumulation of fluid on superior and Inferior Vena cava

SIGNS AND SYMPTOMS

-DOB, SOB, ORTHOPNEA, CRACKLES, CYANOSIS Decreased Na in vascular space and
Increased Na in Interstitial Space

LEFT SIDED HEART FAILURE

Increased water reabsorption

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 SIGNS AND SYMPTOMS
-Ascites, Lower extremity pitting edema,
numbness of the extremities, easy
fatigability, pale skin, slow capillary refill

RIGHT SIDED HEART FAILURE

LABORATORY AND DIAGNOSTIC RESULTS

2Decho: dilated left ventricle, left atrium, right atrium, right ventricle, mitral valve and pulmonic
valve regurgitation, mild pulmonary hypertension. Reduced ejection fraction (12%)

CHEST AP: Cardiomegaly with Pulmonary congestion, bilateral interstitial edema

ABDOMINOPELVIC: minimal ascites, nephrolithiasis

BLOOD CHEMISTRY: SGOT: 1748.77 (3.88-106). SGPT: 55 (5-34 U/L). SODIUM: 126.6 (135-145
mmol/L)

LIVER FUNCTION TEST: Bilirubin: 197 mg/dl (66-178)

Hemoglobin: 115 (120-153 g/L)

CONGESTIVE HEART FAILURE

REDUCED EJECTION FRACTION

2Decho: EF: 12%

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 B. PLANNING

NCP #1
Age :20yearsold
Sex: Male
Diagnosis: Cardiogenic Shock, Congestive Heart Failure secondary to Rheumatic Heart Disease
ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

SUBJECTIVE DATA: Ineffective breathing Within 30mins. of INDEPENDENT After 30mins.of

pattern related to rendering proper - Position in an - To facilitate lung
rendering proper
“Nahihirapan akong nursing nursing
accumulation of interventions orthopneic position expansion.
huminga para akong interventions
fluids in the lungs. patient will be - Deep breathing - To provide patient was able to
nalulunod” as able to improve exercise relaxation improve breathing
verbalized by the SCIENTIFIC breathing and technique and and alleviated
alleviate signs facilitate effective symptoms & signs
patient RATIONALE: and symptoms of of DOB.
respiratory pattern
DOB.
Fluid back up from - Assist in ambulation - To support the
left ventricle back to and performing patient
OBJECTIVE DATA: activities of daily
the lungs via
living, self-care
- Nasal flaring pulmonary vein due
- patient is to left ventricular
orthopneic - Provide comfort
dysfunction and
measures by; loosen - To provide comfort
- Used intercostal deoxygenated blood clothing, stretching and lessen irritation
muscle when from right ventricle linens, cleaning the
surrounding
breathing can’t goes to lungs
- Provide adequate rest - To conserve energy
- Difficulty of due to pulmonary relaxation
period
breathing when congestion. This can
- Provide diversional - To divert attention
lying down. lead to Difficulty of activities such as;

31 | P a g e
 - Chest pain breathing, shortness music therapy and
noted of breath and therapeutic
communications - To provide safety
- Shortness of productive cough.
- Put up side rails
breath noted
DEPENDENT
- Crackles heard
- To provide
upon - Oxygen therapy as
adequate oxygen in
ordered
auscultation the lungs
- Easily fatiguability

- Vital signs as follows:

T: 36.5

PR: 132 bpm

RR: 31 cpm

BP: 100/70 mmHg

LABS:

CHEST AP: Pulmonary

congestion and
pulmonary edema

32 | P a g e
NCP #2
Age :20yearsold
Sex: Male
Diagnosis: Cardiogenic Shock, Congestive Heart Failure secondary to Rheumatic Heart Disease
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE Ineffective Tissue Short-Term: INDEPENDENT Short-Term:

DATA: Perfusion related
Within 8 hours of - Place in comfortable - To provide comfort After 8 hours of
to decreased
“Minsan rendering proper position rendering proper
cardiac output
namamanhid ang nursing interventions nursing
mga paa ko” as the patient will be able - Monitor and record vital - To have a baseline data interventions the
verbalized by the to demonstrate signs patient was able
SCIENTIFIC
patient. behaviors to improve to demonstrate
RATIONALE:
circulation, as - Measure capillary refill - To determine adequacy of behaviors to
evidence by: systemic circulation improve
OBJECTIVE DATA: circulation, as
Due to decreased • Engage foot-
- Inspect lower - That often accompany
- Numbness on the cardiac output, evidence by:
ankle diminished peripheral
extremities
lower extremities there is decreased exercises • Engage
circulation
- Poor capillary refill, preload and stroke • Capillary refill foot-
4secs. volume thus there time from - Maintain on bed rest - Restricted activity reduces ankle
- Cyanotic nailbed is decreased blood 4secs to 2secs. oxygen demands of the exercises
- Pitting edema +2 pumped out from heart • Capillary
- Pale lips the blood. - Provide quiet and refill time
- To conserve energy and
- Weak in Decrease in stroke restful atmosphere lower tissue oxygen from
appearance volume decreases demands 4secs to
- Easy fatigability perfusion 2secs.
Vital signs as throughout the

33 | P a g e
follows: body. - Provide safety by - Weakness and fatigue are
T: 35.7 raising side rails signs of hypoxia which may
P: 115 bpm cause injury to the patient
R: 31 cpm
- Encourage change in - These measures reduce
BP:
lifestyle that could venous
100/70bpm
improve tissue compression/venous stasis
SPO2: 87%
perfusion such as: and arterial
LABS: vasoconstriction.
1) avoiding crossed
2Decho:
legs at the knee
Reduced ejection when sitting
fraction: 12% 2) changing positions
at frequent intervals
HEMOGLOBIN:
3) rising slowly from a
115g/L(Normal: 135-
supine/sitting to
170g/L)
standing position
4) avoiding smoking

COLLABORATIVE
- Administer - Oxygen increase arterial
saturation
supplemental
oxygen as
ordered

34 | P a g e
NCP #2
Age :20yearsold
Sex: Male
Diagnosis: Cardiogenic Shock, Congestive Heart Failure secondary to Rheumatic Heart Disease
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE -Excess fluid volume related to Within 6 hours INDEPENDENT After 6 hours of
DATA: compromised regulatory of rendering -elevate feet when -To prevent and lessen fluid rendering
“nagmamanas mga mechanism as evidenced by edema proper nursing sitting accumulation in the lower proper nursing
paa ko” as and weight gain. interventions, extremities interventions,
verbalized by SCIENTIFIC RATIONALE the patient’s the patient’s
patient. Fluid volume excess or urine output -Restrict fluid intake - increase in weight due to urine output
OBJECTIVE DATA: hypervolemia occurs from an will increase into 1000ml/day as fluid retention. Therefore, increased from
- (+) pitting edema increase in total body sodium from less than ordered limiting is necessary to avoid less than 30
on lower content and an increase in total 30 ml/hour to fluid retention ml/hour to
extremities graded body water. This fluid excess 100cc per hour 100cc per hour
2. usually results from compromised and absence - Record I&O -to have baseline data and absence of
- Weight gain. From: regulatory mechanisms for sodium of edema. -Provide comfort -To promote comfort and edema.
69 (BMI:24.55) to and water as seen in CHF, kidney measures such as: relaxation and to reduce
74kgs (BMI:26.33) failure, and liver failure. *sponge bath stressful situation.
- Shiny skin lower Bibliography: *stretch linens
extremities Gulanick, Meg, PhD, * comfortable clothes
- Increased RN,et.al(2003).Nursing Care Plan: such as loose cotton
abdominal size. Nursing Diagnosis & Interpretation. *provide adequate
101cm West line Dive St. Louise. Mosby ventilations by
- Easy fatigability Inc.5th opening window
- Weakness ed, p. 65.
- Vital signs as -Provide adequate -To conserve energy

35 | P a g e
 follows: Heart failure is caused by rest and sleep.
Bp: decreased cardiac output which
100/70mmHg may lead to decreased renal DEPENDENT
T: 35.7 perfusion as a result, Sympathetic -Administer diuretics -For pharmacological
P:115 bpm stimulation of the kidney leads to the such as furosemide treatment. It increases urine
R: 24cpm release of renin, with a resultant with BP precaution as output to treat fluid retention
2Decho: increase in the circulating levels of prescribe by the
*Reduced ejection angiotensin II and aldosterone. The physician
fraction (12%) activation of the renin-angiotensin- COLLABORATIVE
aldosterone system promotes salt -Low salt diet -sodium attracts water.
and water retention
Bibliography:
(Modified from A Nohria et al:
Neurohormonal, renal and vascular
adjustments, in Atlas of Heart
Failure: Cardiac Function and
Dysfunction, 4th ed, WS Colucci
[ed]. Philadelphia, Current Medicine
Group 2002, p. 104.)

36 | P a g e
 B. IMPLEMENTATION

1. DRUGS

Name of Drugs Route of Mechanism of Indication/ Side Effects Nursing

administration, Action Responsibilities
Contraindication
dose and
frequency of
administration

Generic Name: 40mg IV OD before Inhibits the activity INDICATION • Observe 10

breakfast of the acid (proton) rights in
Omeprazole • Omeprazole - Headache
pump, located at administration
decreases the - dizziness.
the secretory of medication.
amount of acid - diarrhea
Brand Name: surface of the • Watch out for
produced in the - abdominal
gastric parietal cell. adverse or
Prilosec stomach. pain
This blocks the side effects
• Omeprazole - nausea
Drug formation of gastric • Administer
decrease myocardial - vomiting
acid. before
contractility - constipation
breakfast
and
Classification:
flatulence.
Antiulcer Agents, CONTRAINDICATION
- Cough
PPI
• Contraindicated in - rash
patients - back pain.
hypersensitive to the
drug or any

37 | P a g e
component of the
enteric formulation.

38 | P a g e
 Name of Drug Route of Mechanism of Indication/ Side Effects Nursing
Administration, Action Contraindication Responsibilities
Dose and
Frequency of
Distribution

Generic Name: 0.25mg IV OD Digoxin increases INDICATION - Fatigue • Follow

the force of - Muscle Doctor’s
• Heart failure.
contraction of the Weakness Order
• Atrial fibrillation and
digoxin muscle of the - Rash • Observe the
atrial flutter (slow
heart by inhibiting - Anorexia 10 right of the
ventricular rate)
the activity of an - Nausea patient before
Brand Name: • Paroxysmal atrial
enzyme (ATPase) - Vomiting giving
tachycardia.
that controls - Dizziness medication.
CONTRAINDICATION
movement of • Count apical
Lanoxin
calcium, sodium, • Hypersensitivity; pulse in 1 full
and potassium • Uncontrolled ventricular minute and
into heart muscle. arrhythmias; withhold
Classification:
Calcium controls • Idiopathic hypertrophic medication if
the force of subaortic stenosis; the apical
Cardiac Glycoside contraction. • Constrictive pericarditis; pulse is below
• Known alcohol intolerance normal range
(elixir only.
(Positive Inotrope)

39 | P a g e
Name of Drugs Route of Mechanism of Indication/ Side Effects Nursing
administration, Action Responsibilities
Contraindication
dose and
frequency of
administration

Generic Name: 50mg IV q8 Binds to mu- INDICATION • Observe 10

opioid receptors rights in
tramadol • Relief of moderate to - Headache
and inhibits the administration
moderately severe - dizziness.
reuptake of of medication.
pain - nausea
Brand Name: norepinephrine • Watch out for
CONTRAINDICATION - vomiting
and serotonin; adverse or
Ultram - constipation
causes many • Contraindicated in side effects
and flatulence.
effects similar to patients • Limit use in
- Cough
the opioids hypersensitive to the patients with
- Urticaria
drug or any past or
- Dry mouth
Drug component present
- Flatulence
Classification: history of
- Tachycardia
addiction
- Sweating
Analgesic

40 | P a g e
Name of Drugs Route of Mechanism of Indication/ Side Effects Nursing
administration, Action Responsibilities
Contraindication
dose and
frequency of
administration

Generic Name: 10mg IV PRN Stimulates INDICATION • Observe 10

motility of upper rights of
metoclopramide • Relief of symptoms of - Restlessness
GI tract without administration of
acute and recurrent - Drowsiness
stimulating medication.
diabetic gastroparesis - Fatigue
Brand Name: gastric, biliary, • Watch out for
• Prophylaxis of - Insomnia
or pancreatic adverse or side
Reglan postoperative nausea and - Dystonia
secretions; effects
vomiting when - Nausea
appears to • Monitor blood
nasogastric suction is - Diarrhea
sensitize pressure
undesirable - Dizziness
tissues to action carefully
• Prevention of nausea and - Anxiety
Drug of • Monitor for
vomiting associated with
acetylcholline; extrapyramidal
Classification: emetogenic cancer
relaxes pyloric reactions, and
GI stimulant chemotherapy
sphincter consult
CONTRAINDICATION
Antiemetic physician if they
• Contraindicated with occur
hypersensitivity to
metroclopramide

41 | P a g e
Name of Drugs Route of Mechanism Indication/ Side Effects Nursing Responsibilities
administration, of Action
Contraindication
dose and
frequency of
administration

Generic Name: 2gm IVP Q12 Bactericidal: INDICATION • Observe 10 rights

Inhibits of administration of
ceftazidime • Dermatologic - Headache
synthesis of medication.
infections - Dizziness
bacterial cell • Administer
• Intra-abdominal - Lethargy
Brand Name: wall, causing medication after
infections - Nausea
cell death negative skin
Ceptaz CONTRAINDICATION - Vomiting
testing
- Diarrhea
• Contraindicated • Watch out for
- Anorexia
with allergy to adverse or side
- Decreased
cephalosporins or effects
WBC
Drug penicillins • Discontinue if
- Decreased
• Use cautiously with hypersensitivity
Classification: platelets
renal failure reaction occurs
Antibiotic

Cephalosporin

42 | P a g e
Name of Drugs Route of Mechanism Indication/ Side Effects Nursing Responsibilities
administration, of Action
Contraindication
dose and
frequency of
administration

Generic Name: 400mg IVP Q12 Bactericidal: INDICATION • Observe 10 rights

Interferes with of administration of
ciprofloxacin • For the treatment - Headache
DNA medication.
of infections - Dizziness
replication in • Administer
• Treatment of acute - Insomnia
Brand Name: susceptible medication after
otitis externa - Fatigue
bacteria negative skin
Ciloxan • Treatment of - Blurred Vision
preventing cell testing
chronic bacterial - Nausea
reproduction • Watch out for
prostatitis - Vomiting
adverse or side
CONTRAINDICATION - Abdominal
effects
Pain
Drug • Contraindicated • Discontinue if
- Fever
with allergy to hypersensitivity
Classification: - Rash
ciprofloxacin, reaction occurs
Antibacterial pregnancy and

Fluoroquinolone lactation
• Use cautiously with
renal dysfunction

43 | P a g e
Name of Drugs Route of Mechanism of Indication/ Side Effects Nursing Responsibilities
administration, Action
Contraindication
dose and
frequency of
administration

Generic Name: Nebulizer Q6 Anticholinergic, INDICATION • Observe 10 rights of

chemically administration of medication.
Ipratropium • Bronchodilator - Headache
related to • Check the breath sounds,
bromide for maintenance - Dizziness
atropine, which pulse rates and respiratory
treatment of - Nervousn
blocks vagally status.
bronchospasm ess
Brand Name: mediated • Explain the breathing process
associated with - Blurred
reflexes by to the patient during the
Atrovent COPD, chronic Vision
antagonizing the therapy.
bronchitis, and - Nausea
action of
- Insomnia • Then connect the hose of the
emphysema
acetylcholine. nebulizer to an air
CONTRAINDICATION - GI
Causes compressor.
Distress
Drug bronchodilation • Contraindicated • Then fill the medicine cup with
- Dry mouth
and inhibits with the required medication and
Classification: - Dyspnea
secretion from hypersensitivity appropriate saline solution as
- Back pain
Anticholinergic serous and to atropine, soy
- Chest pain prescribed by a doctor.
seromucuos bean or peanut
• Watch out for adverse or side
glands lining the • Use cautiously effects
nasal mucosa with narrow-
• Observe patient’s saturation
angle glaucoma
level

44 | P a g e
Name of Drugs Route of Mechanism Indication/ Side Effects Nursing Responsibilities
administration, of Action
Contraindication
dose and
frequency of
administration

Generic Name: 40mg IVP Q6 Inhibits the INDICATION • Observe 10 rights of

reabsorption administration of
furosemide • Edema associated - Dizziness
of sodium and medication.
with CHF, - Vertigo
chloride from • Watch out for adverse or
cirrhosis, renal - Blurred
Brand Name: the ascending side effects
disease Vision
limb of the • Take BP before
Lasix • Acute pulmonary - Tinnitus
loop of Henle, administering the
edema - Hearing loss
leading to a medication
• Hypertension - Nausea
sodium-rich
- Anorexia • Measure and record
CONTRAINDICATION
diuresis weight daily at the same
- Vomiting
Drug • Contraindicated time and same type of
- Constipation
with allergy to clothing
Classification: - Diarrhea
furosemide, • Monitor and record
- Purpura
Loop Diuretic sulfonamides
- Nocturia intake and output
• Use cautiously with • Do not mix parenteral
SLE, gout, solution with highly
diabetes mellitus acidic solutions
• Watch out for potassium
level

45 | P a g e
 2. MEDICAL MANAGEMENT

Medical management Date performed/ General description Indication/ purpose Nursing responsibilities
treatment discontinued

Standard oxygen sources can • Peri and post cardiac - Check if the mask is intact
Oxygen therapy via deliver from ½ minute (L/min). every or respiratory arrest and fit to the patient
March 16, 2019
face mask liter/minute of oxygen increases the • Hypoxia
- Regulate prescribed liters per
regulated at 5L/m percentage of O2 the patient breaths • Acute and chronic
minute
by 3-4%. Room air is 21% O2. So, if hypoxemia
- Check and record patient’s
a patient is on 4L/min O2 flow, then • Signs and symptoms
he or she is breathing air that is respiratory status
of shock
about 33-375 O2. • Low cardiac output - Check for oxygen saturation
and metabolic level of patient
acidosis (HCO3
- Provide frequent mouth care.
<18mmol/L)
Make sure the oxygen contains
proper humidification.

- Maintain humidifier clean and

filled with Distilled water

Heparin lock March 16, 2019 This medication is used to keep IV • Heplock is an -Change plaster every 4 hours
catheters open and flowing smoothly anticoagulant used in
-Observe the site for
and from clotting in the catheter by principally in the
inflammation and ask patient
making a certain natural substance treatment and
about any pain in the area.
in your body (anti-clotting protein) prophylaxis of

46 | P a g e
work better. It is known as thromboembolic - Assess the site for any signs
anticoagulant. disorders. of leakage, irritation, or
infiltration.

- A saline lock must be flushed

in a specific manner to prevent
blood being drawn into the IV
catheter and occluding the
device between uses.

47 | P a g e
 3. DIET

TYPE OF DIET INDICATION EXAMPLE

Low cholesterol -Eating at least four servings of fruits and -High fiber foods like beans and oats,
vegetables daily can lower LDL legumes,avocado,nuts especially
cholesterol levels and reduce LDL almonds and walnuts,fatty fish,whole
oxidation, which may reduce your risk of grains,fruits and berries,dark
heart disease. chocolate and garlic, soy foods, and
vegetables

Fresh vegetables, avocado, fresh

Low sodium
fruits, oats, unsalted nuts, grass-fed
The sodium-controlled diet is used to beef, goat cheese.
treat many medical conditions including
hypertension, congestive heart failure,
cirrhosis of the liver, kidney disease, and
other fluid or sodium retention.

4. EXERCISE

TYPE OF EXERCISE INDICATION EXAMPLE

1. Deep Breathing -for patients’ relaxation and comfort -Inhale-Exhale breathing

exercise
- This exercise is used to improve
pulmonary gas to exchange and
maintain respiratory functions
especially after generalized/ minimal
immobilization. This is also use as a
-Raising upper and lower
2. Passive Range of relaxation technique.
extremities.
Motion (PROM)
-helps prevent weak muscles or
stiffness cause by non-use
- Dancing, stationary
-increase level of density lipoprotein cycling, jogging as
3. Aerobic exercise if
(HDL) and improve the overall health tolerated not too much or
tolerated
of your blood vessels and heart. It also as tolerated

48 | P a g e
 controls weight, and reduce stress

- According to the American Heart

Association, aerobic exercises
provide the safest passage for a
person suffering from congestive
heart failure to recover with ease.
Active participation will ensure that
you are in the process of increasing
the efficiency of the heart and offering
the required strength that the heart
muscles require while operating.
Because of this action, the heart tends
to pump the needed blood at optimum
value and carry needed blood and
oxygen to tissues and organs.

D. EVALUATION

DISCHARGE PLAN (excluded)

IV. CONCLUSION

After the exposure, as student nurses, the group established trust and rapport with the
client and family. We also established teamwork and good collaboration with our colleagues. We
gain more knowledge about Cardiogenic shock because of our exposure in the area. We
developed our skills regarding on our patients’ condition.

Our experience in the intensive care unit gave us the knowledge that we need as a future
nurse. Now that we have been exposed in the different rooms, we gained knowledge that can
help us to formulate appropriate nursing diagnosis, plan effective patient care, implement the
proper nursing interventions to resolve the patient’s identified problems, evaluate outcome of
proper patient and established self-reliance within the patient case identification and
understanding. Intensive care unit served as a companion for us to be a more efficient and
effective nurse with a good clinical eye in having a proper assessment. The group learned so
many things. We got brilliant ideas from plenty of books that helped us to expand our knowledge
and wisdom regarding Cardiogenic shock secondary to rheumatic heart disease. Most importantly,

49 | P a g e
we established a good nurse-patient relationship that helped us to understand more about our
patient’s condition.

On the part of the patient, he was able to understand better about his health status. He
understood the importance of following the doctor’s orders to continue his prescribed medications,
and the importance of having low cholesterol and low sodium diet. After managing our patient, we
learned a lot about the etiology, manifestations, pathophysiology, and the proper course of
treatment and management for patient with Cardiogenic Shock secondary to Rheumatic heart
disease.

V. RECOMMENDATION
A. Student Nurse

To our fellow student nurses, case study is an essential tool that will help us and serve as an
educational companion to have a better understanding about specific cases including Cardiogenic
shock. Case studies will help us to be more familiar and aware of different causes, risk factors,
pathophysiology of different case, therapies and treatments on different cases. To establish an
effective collaboration with your group mates to accomplish a good case study

B. Patient

For the patient, she must continue to take the prescribed medication, have diet modification and
limit in salt and cholesterol consumption. She must eat a proper high quality protein food such
asHigh fiber foods like beans and oats, legumes,avocado,nuts especially almonds and
walnuts,fatty fish,whole grains,fruits and berries,dark chocolate and garlic, soy foods, and
vegetables,fresh vegetables, avocado, fresh fruits, oats, unsalted nuts, grass-fed beef, goat
cheese. Avoid consuming alcohol and eating processed foods that contains large amount of
sodium, she should maintain eating foods that is low in cholesterol and low sodium. Also do deep
breathing exercises and relaxation technique and do exercise gradually like jogging and bicycling
but not too much.

50 | P a g e
 VI. Review of Literature

Contemporary Management of Cardiogenic Shock: A Scientific Statement From the

American Heart Association
In the study of Katz et.al (2017) that cardiogenic shock is a high-acuity, potentially
complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently
associated with multisystem organ failure. Despite improving survival in recent years, patient
morbidity and mortality remain high, and there are few evidence-based therapeutic interventions
known to clearly improve patient outcomes. This scientific statement on cardiogenic shock
summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock;
reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care
practices; advocates for the development of regionalized systems of care; and outlines future
research priorities.

Main Considerations of Cardiogenic Shock and Its Predictors: Systematic Review

In the study of Sternieri et.al (2018) the mortality rate of post-infarction cardiogenic
shock (CS) was 80.0-90.0%. Recent studies how a significant reduction of hospital mortality to
approximately 50.0%. CS is defined as systemic tissue hypoperfusion resulting from systolic
and/or diastolic heart dysfunction, the main cause of which is acute myocardial infarction (AMI).
The main predictors are biological markers such as troponin, CKMB and lactate. A systematic
literature review and meta-analysis is performed in order to present and correlate the main
literary findings on CS and its evolution with possible changes in biomarkers such as troponin,
lactate and CKMB. After criteria of literary search with the use of the mesh terms: cardiogenic
shock; acute myocardial infarction; biomarkers; troponin; CKMB; lactate; clinical trials and use
of the bouleanos “and” between the mesh terms and “or” among the historical findings. Some
risk factors for its development in AMI are advanced age, female gender, anterior wall infarction,
diabetes mellitus, systemic arterial hypertension, previous history of infarction and angina. The
CS associated with AMI depends on its extent and its complications, being the main ones: mitral
regurgitation, rupture of the interventricular septum and rupture of the free wall of the left
ventricle. The diagnosis is based on the clinical manifestations, such as mental confusion,
oliguria, hypotension, tachycardia, fine pulse, sweating, and cold extremities; in hemodynamic
aspects: systolic blood pressure was < 90.0 mm Hg or 30 mm Hg below baseline, pulmonary
capillary pressure was > 18.0 mm Hg and cardiac index was < 2.2 L/min/m 2. Laboratory and
imaging exams should be requested to evaluate the possible etiology of CS, its systemic
repercussions and comorbidities. The treatment aims at the rapid reestablishment of the blood
flow in the affected artery, to improve the patient’s prognosis. The biomarkers dosage in the
daily clinical practice of the different cardiological centers can facilitate the diagnosis and the
conduction of the dubious cases and the best evaluation of the degree of myocardial suffering
after CS.

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 Prevention of Cardiogenic Shock After Acute Myocardial Infarction
In the study of Vanhaverbeke et.al (2019) Cardiogenic shock after an ST-segment
elevation acute myocardial infarction has a poor prognosis. Apart from immediate
revascularization, no other treatment has improved outcome. A recent large multicenter registry
has convincingly shown that the benefit of primary percutaneous intervention (PPCI) is critically
dependent on the elapsed time from first medical contact to balloon inflation. For every 10
minute treatment delay, 3.3 additional deaths per 100 PCI- treated patients occur. These data
strongly suggest that urgent recanalization of the culprit vessel resulting in reperfusion of the
jeopardized myocardium is currently the key treatment to offer patients in CGS after ST-
segment elevation acute myocardial infarction.

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