CONGESTIVE HEART FAILURE

Mr J.M., a 75-year old widower, noticed that he felt tired a lot lately stating, "Mabilis tsaka
madalas na akong mahapo kahit konti lang ung ginagawa ko". His son even commented that his father
seemed to lack interest in usual activities and that he seemed to be a bit confused in his responses to
everyday situation. He also noticed his father has difficulty sleeping but feels better with 2 pillows at his
head. Mr J.M. had developed a non-productive cough, so his son made an appointment with his
healthcare provider.

The nurse assessed Mr J.M. and noted crackles in both bases of his lungs, a lower than normal
blood pressure and slight tachycardia (based on previous consults), and a slight weight gain in seven (7)
months since his last check-up. Suspecting that Mr J.M. may be experiencing heart failure, the nurse
consulted and referred him to a physician. The physician agreed with the nurse's assessment and Mr
J.M. was prescribed digoxin, furosemide (Lasix) and potassium chloride 40 mEqs (IV), Oxygen at 3Lpm
via nasal canula to maintain 02 Saturation at above 93%

As they were preparing documents for Mr J.M. to be admitted in the ward for further diagnosis
and monitoring, the nurse gathers data for initial interview. His son verbalized that his father was
diagnosed with Diabetes Mellitus Type II 15 years ago and hypertension 6 years ago. He was then
prescribed Metformin 500mg/ tab twice a day and Captopril 25 mg/ tab once a day.

Physical Examination reveals:

Vital signs:

BP: 110/ 70

T. 36.8 degrees Centigrade

PR: 89 BPM

RR: 25 BPM

Weight: 76 kg.

• GCS: E- 4; V- 4; M- 6 (disoriented) 14/15

• Crackles at the base of the lungs

• (+) S4 sounds

• Bipedal Edema grade 2+

• Muscle strength of 3/5 on both lower extremities

• Physician diagnosed patient with Class Ill Heart Failure

DIAGNOSTIC TESTS

• Cardiac markers

BNP: 453pg/mL Troponin (+)

2D Echo — waiting for results

• BUN & Creatinine — within normal limits

• CBC - RBC 4.8/ mcL

WBC- 9,000/ mcL

Platelet count- 320,000/ mcL

• Sodium- 139 mEq

• Potassium- 2.9 mEq

• FBS- 7 mmol/L

• HbAIC- 6.5 % • Lipid profile, Uric acid- within normal range

• Chest X-ray — Cardiomegaly with right and left ventricular hypertrophy, fluid in lower lung fields

On the first day of admission until the 4th day, diagnostic examination work-up was performed and
with the following orders and treatments:

Vital signs every 4 hours

Strict Intake and output

Weigh patient daily pre-breakfast, post-void

IVF of PNSS 1 L to run on KVO

Medications:

KCI 40mEq IV (incorporated to 1 L of PNSS) run for 24 hours

Digoxin 0.25 microgram one a day

Furosemide (Lasix) 40 mglV every 8 hours

Metformin 500mg/ tab twice a day and

Captopril 25 mg/ tab once a day.

Oxygen maintained at 3 LPM via nasal canula

Nebulization of Normal saline every 12 hours

Chest physiotherapy

Complete bedrest without bathroom privileges

 Capillary blood glucose (CBG) monitoring daily

Diet: Low salt, low fat

On the 5th day of admission, Mr J.M. ordered treatment and procedures:

CBC, Sodium, Potassium

IVF shifted to heparin/ saline lock

Oxygen at 1LPM via nasal canula (well tolerated)

Maintained on low salt, low fat, with banana

Up and about, with minimal bathroom privileges (with assistance)

Prepare discharge summary

On the 6th day, the physician ordered may go home with the following instructions: Continue
medication of:

Digoxin 0.25 microgram/ tab once a day

Furosemide 40 mg/ tab twice a day

Metformin 500 mg/ tab twice a day

Captopril 25 mg/ tab once a day

Diet: low salt, low fat with banana

Exercise: Minimal walking with assistance, avoid going up and down the stairs

Follow- up: one week after discharge with the laboratory exam results

Guide questions:

1. What are the significant assessment findings that you have noted on the case?

2. Based on the case given above, Identify the risk factors related to the case.

3. Trace the pathophysiology of the condition and course of the disease mentioned on the case.
(Connect the signs and symptoms, laboratory and diagnostic procedures as well as the prioritized
problem/ nursing diagnosis)

4. What are your nursing responsibilities related to the laboratory and diagnostic examination
including the procedures and medications?

5. What are the treatments and procedures performed during the course of hospitalization?
6. Enumerate appropriate discharge plan and health teaching for your patient.

7. Identify at least three (3) priority nursing problems and formulate 3 nursing care plans with
appropriate objective and evaluation of care (with Scientific Rationale on the Nursing Diagnosis
and Rationale on the Interventions).

8. Determine the applicable nursing theory for the implementation of care.

9. Research on readings or journal of current issues related to the case mentioned and provide your
reflection.