TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING

CLINICAL CASE ANALYSIS

Name of Patient X Age: 82 years old Gender: Female

Address Capas, Tarlac Date Admitted: 09/28/2021
Diagnosis Congestive Heart Failure

NURSING HISTORY
Present Health History:
Patient X is an 82-year-old female and a seller of dried fish, anchovies, shrimp paste., accompanied by her
daughter, Patient X was admitted to the Emergency Room of the Hospital, with a chief Complaints of Shortness
of Breath (Dyspnea), body malaise and swelling of the Bilateral Lower Extremity (BLE). Patient X was Further
Assessed by the ER Medical Doctor, according to the doctor she is having tachycardia, with chest congestion,
upon auscultation crackles heard on all lobes, and Patient X also complained for light headedness during the
assessment.
Family Health History:

Past Medical History:

Patient X is not a Smoker but her late husband does smoking for habit. Patient X has history of diabetes mellitus
when she was 65 years-old (17 Years Ago), has a history of hypertension when she was 72 years-old (10 Years
Ago) and has the history of Coronary Artery Disease when she was 75 years-old (7 Years Ago)
PATHOPHYSIOLOGY

BOOK-BASED
CLIENT-BASED
DIAGNOSTIC PROCEDURES

Test Name Date Purpose/Indication Reference Values Actual Results Interpretation/ Analysis Nursing Responsibilities
Performed

CMP- Upon The purpose of  Glucose: 70 to  Glucose: 80 mg/dL From the results, the Before:
Comprehensive admission comprehensive 100 mg/dL  Calcium: 8.5 mg/dL albumin and total protein  Explain to the significant other that
Metabolic Panel metabolic panel is to  Calcium: 8.5 to  Sodium: 136 mEq/L of the patient is elevated. the patient may need to fast
(14 Blood Test) conduct a broad 10.2 mg/dL  Potassium: 3.7 mEq/L While the other are within before the blood draw for a CMP.
assessment of various  Sodium: 135 to  Bicarbonate: 25 mEq/L normal limits. In most cases, it takes for 10-12
aspects of physical 145 mEq/L  Chloride: 97 mEq/L hours before the test, but the
well-being. With 14  Potassium: 3.7 to  Blood Urea Nitrogen patient should follow any specific
measurements, it can 5.2 mEq/L (BUN): 10 mg/dL instructions provided by the
detect a range of  Bicarbonate: 23  Creatinine: 0.8 mg/dL doctor.
abnormalities in blood to 29 mEq/L  Albumin: 6.2 g/dL  Ask the significant other about any
sugar, nutrient balance,  Chloride: 96 to  Total Protein: 9.5 g/dL medications or dietary
and liver and kidney 106 mEq/L  Alkaline Phosphatase supplements that the patient
health.  Blood Urea (ALP): 25 U/L regular takes.
Nitrogen (BUN): 6  Alanine  Then inform the doctor about it. so
to 20 mg/dL Aminotransferase that the doctor can then tell you
 Creatinine: 0.6 to (ALT): 10 U/L whether needed to adjust
1.3 mg/dL  Aspartate medication schedule before taking
 Albumin: 3.4 to Aminotransferase the blood sample.
5.4 g/dL (AST): 15 U/L  Assist the patient to the room
 Total Protein: 6.0  Bilirubin: 0.9 mg/dL where the procedure will be
to 8.3 g/dL performed.
 Alkaline During:
Phosphatase  Collaborate with the medical
(ALP): 20 to 130 technologist who will perform the
U/L procedure.
 Alanine After:
Aminotransferas  Remember that some people find
e (ALT): 4 to 36 that their arm is tender or may
U/L have bruising after their blood is
 Aspartate drawn, but monitor for serious or
Aminotransferas lasting effects, which are
e (AST): 8 to 33 uncommon.
U/L  Allow patient to eat. Because the
  Bilirubin: 0.1 to patient had fast before the test, it
1.2 mg/dL is okay that she brings something
with her to eat after the blood has
been drawn.
Chest X-ray Upon A chest X-ray is an Normal lung fields, Cardiomegaly with haziness Enlargement of the heart Before:
(CXR) admission imaging test that uses cardiac size, on all lobes with haziness on all lobes  Confirm the patient’s identity.
X-rays to look at the mediastinal  Have the patient change into a
structures and organs structures, thoracic hospital gown and ask to remove
in your chest and to see spine, ribs, and all metal-containing objects around
if your lungs and heart diaphragm. the body.
are working normally or  Assist the patient to the Chest X-
not. ray room
During:
 Ask the patient to take deep
breaths and relax
 Give reassurance and words of
encouragement
 Ensure comfort of the patient
After:
 Provide comfort to your patient

Echocardiogram Upon Echocardiogram is a  Aortic annulus: Ejection Fraction is 25% An ejection fraction of less Before:
admission test that uses sound 20-31 mm than 45% is considered a  Obtain informed consent about the
waves to produce live  Sinus Valsalva: potential indicator of heart procedure.
images of the heart. 29-45mm issues.  Explain the procedure to the
 Sino tubular patient’s significant other/s and its
This test allows the
junction: 22- importance.
doctor to monitor how 36mm  Assist the patient to void and
the heart and its valves  Ascending aorta: empty the bladder prior and to
are functioning. 22-36 mm change into a gown.
 Aortic arch: 22-  Assist the patient into a dark room
The images of an 36mm and explain the need to darkened
echocardiogram can  Descending arch: the examination field.
2-30 mm
help get information
During:
about:
 Blood clot in the  A normal ejection  Inform significant others that a
heart chambers fraction vary by conducive gel is applied to the
 Fluid in the sac gender. chest area of the patient and a
o Men: 52- transducer will be placed over it.
around the heart
72%  Warn patient that he/she may feel
 Problems with the o Women: 54- minor discomfort
aorta 74%  Position the patient on his/her left
 Problems with the side
functions of heart
valves After:
 Pressures in heart  Remove conductive gel from the
patient’s skin
 Inform the significant others that
the study will be interpreted by the
physician
MEDICAL MANAGEMENT
Pharmacologic Management:

Name of Drug Dosage, Mechanisms of Indication Contraindication Side Effects / Adverse Nursing Responsibilities
Frequency, Action Effects
Route
Generic name: Route: Inhibits sodium and To reduce edema caused Anuria unresponsive to Side Effects: Before
Furosemide Oral Route (PO) water reabsorption in by cirrhosis, heart failure, furosemide;  Feeling of constant  Obtain patient’s
the loop of Henle and and renal disease, hypersensitivity to movement of self or weight before and
Brand name: Dosage: increases urine including nephrotic furosemide, sulfonamides, surroundings periodically during
Lasix 40 mg formation. As the syndrome. or their components  hives or welts furosemide therapy
body’s plasma  increased sensitivity of to monitor fluid
Drug classification:  Frequency: volume decreases, the skin to sunlight loss.
 Antihypertensive Once Daily (OD) aldosterone  muscle spasm  Be aware that
 Diuretic production increases,  redness or other elderly patients are
which promotes discoloration of the more susceptible to
sodium reabsorption skin hypotensive and
and the loss of electrolyte altering
potassium and Side Effects that need effects and thus are
hydrogen ions. medical attention: at greater risk for
Furosemide also  chest pain shock and
increases the  chills thromboembolism.
excretion of calcium,  cough or hoarseness
magnesium,  fever During
bicarbonate,  general feeling of  Instruct patient to
ammonium, and tiredness or weakness take furosemide at
phosphate. By  headache the same time each
reducing intracellular  lower back or side pain day to maintain
and extracellular fluid  painful or difficult therapeutic effects.
volume, the drug urination Urge her to take it as
reduces blood  shortness of breath prescribed, even if
pressure and she feels well.
 sore throat.
decreases cardiac  Instruct patient to
output. Over time, take the last dose of
cardiac output furosemide several
returns to normal. hours before
bedtime to avoid
sleep interruption
 from diuresis. If
patient receives
once-daily dosing,
advise her to take
the dose in the
morning to avoid
sleep disturbance
caused by nocturia.
 Advise patient to
change position
slowly to minimize
effects of orthostatic
hypotension and to
take furosemide
with food or milk to
reduce GI distress.
 Notify prescriber if
patient experiences
hearing loss, vertigo,
or ringing, buzzing,
or sense of fullness
in her ears. Drug
may need to be
discontinued.

After
 Emphasize the
importance of
weight and diet
control, especially
limiting sodium
intake.
 Instruct patient to
keep follow-up
appointments with
prescriber to
monitor progress.
Urge her to notify
 prescriber about
persistent, severe
nausea, vomiting,
and diarrhea
because they may
cause dehydration.
 Inform diabetic
patient that
furosemide may
increase blood
glucose level and
advise her to check
her blood glucose
level frequently.

Generic name: Route: Increases the force To treat heart failure, Hypersensitive carotid sinus Common digoxin side Before
Digoxin Oral Route (PO) and velocity of atrial flutter, atrial syndrome, hypersensitivity effects may include:  Before giving each
myocardial fibrillation, and to digoxin, presence or  Nausea dose, take patient’s
Brand name: Dosage: contraction, resulting paroxysmal atrial history of digitalis toxicity  diarrhea apical pulse and
Lanoxin 0.25 mg in positive inotropic tachycardia with rapid or idiosyncratic reaction to  feeling weak or notify prescriber if
effects. Digoxin digitalization digoxin, ventricular dizzy. it’s below 60
Drug classification:  Frequency: produces fibrillation, ventricular  headache beats/minute (or
 Antiarrhythmic Once Daily (OD) antiarrhythmic tachycardia unless heart  Weakness other specified
 Cardiotonic effects by decreasing failure occurs unrelated to  anxiety level).
the conduction rate digoxin therapy
 depression  Emphasize
and increasing the importance of
 rash.
effective refractory taking digoxin
period of the AV exactly as
Need emergency medical
node. prescribed. Warn
help side effects:
about possible
toxicity from taking
 nausea, vomiting,
too much and
diarrhea, stomach pain
decreased
 fast, slow, or uneven
effectiveness from
heart rate
taking too little.
 a light-headed feeling,
 Instruct patient to
like you might pass out.
take digoxin at
 bloody or black, tarry
same time each day
 stools.
 confusion, weakness,
hallucinations, unusual
thoughts, or behavior.
 breast swelling or
tenderness.
 blurred vision,
yellowed vision
signs of an allergic reaction
to digoxin:
 Hives
 difficulty breathing
swelling of your face, lips,
tongue, or throat.
to help increase
compliance.
 Inform patient that
small, white 0.25-
mg tablets can
easily be confused
with other drugs.
Caution against
carrying digoxin in
anything other than
its original labeled
container.
During
 Monitor patient
closely for signs of
digitalis toxicity,
such as altered
mental status,
arrhythmias, heart
block, nausea,
vision disturbances,
and vomiting. If
they appear, notify
prescriber, check
serum digoxin level
as ordered, and
expect to withhold
drug until level is
known. Monitor
ECG tracing
continuously
 Frequently obtain
ECG tracings as
ordered in elderly
patients because of
their smaller body
mass and reduced
 renal clearance.
Elderly patients,
especially those
with coronary
insufficiency, are
more susceptible to
arrhythmias—
particularly
ventricular
fibrillation—if
digitalis toxicity
occurs.
 Monitor patient’s
serum potassium
level regularly
because
hypokalemia
predisposes to
digitalis toxicity and
serious
arrhythmias. Also
monitor potassium
level often when
giving potassium
salts because
hyperkalemia in
patients receiving
digoxin can be fatal.

After
 Teach patient and
SO how to take her
pulse and instruct
her to do so before
each dose. Urge her
to notify prescriber
if pulse falls below
60 beats/minute or
 suddenly increases.
 Urge patient or SO
to notify prescriber
if she experiences
adverse reactions,
such as GI distress
or pulse changes.
 Instruct patient to
carry medical
identification that
indicates her need
for digoxin.
 Advise patient or
SO to consult
prescriber before
using other drugs,
including OTC
products.
Generic Name: Dosage: 5mg Used to block the Captopril is used alone or Allergy to other ACE  Hypotension BEFORE:
Captopril action of angiotensin- in combination of other inhibitors. Aortic stenosis,  Dizziness  Monitor blood
2 converting enzyme drugs for the outflow obstruction,  Dry mouth pressure and pulse
Brand Name: Route: PO (ACE) which is management of renovascular disease.  Itching frequently.
Capoten naturally produced in hypertension. It is also Pregnancy and Lactation.  Sleep problems  Instruct patient to
the body. ACE used in combination with Caution in cases where  Rashes avoid drinking
Classification: Frequency: OD produces other drugs in the patients also have  Diarrhea alcohol while
ACE Inhibitors angiotensin-2 II treatment of heart failure Leukemia, COPD, renal or  Constipation taking captopril.
which causes after a heart attack. Also thyroid disease  Hair loss
constriction and used to treat kidney  Dry irritating cough DURING:
narrowing of the problems caused by  Changes in the way  Take drug 1 hour
blood vessels thereby diabetic nephropathy. things taste before meal, do
increasing blood  Upset stomach not take with food.
pressure. By blocking  Abdominal pain  Encourage patient
ACE, production of  Shortness of breath to drink plenty of
angiotensin-2 II water each day
 Agranulocytosis
decreases allowing while taking
 Neutropenia
the blood vessels to captopril.
relax and widen
resulting in decrease
 blood pressure. AFTER:
 Instruct patient to
notify prescriber
when having an
ongoing vomiting
or diarrhea, or if
sweating more
than usual.
 Instruct patient to
avoid strenuous
exercise without
the doctor’s
approval if being
treated for heart
failure.
 Monitor patient for
adverse reactions
brought about by
the drug.
Generic Name: Dosage: 50mg It reduces the hearts To control hypertension, Hypersensitivity; severe CNS: BEFORE:
Carvedilol rate and force of CHF (ischemic or chronic heart failure,  Dizziness  Assess vital signs
Route: PO contraction and cardiomyopathic) with bronchial asthma or related  Headache  Take carvedilol
Brand Name: Coreg thereby reduces the digoxin, diuretics, and bronchospastic conditions;  fatigue with food. Taking it
Frequency: BID work of the heart. ACE inhibitors, left severe hepatic impairment. EENT: with food reduces
Classification: Beta- Carvedilol also blocks ventricular dysfunction Patients with NYHA class IV  Dry eyes risk of having side
adrenergic Blocker adrenergic receptors after myocardial cardiac failure, 2nd or 3rd AV  Blurred vision effects.
on arteries and infarction. block, sick sinus syndrome CV:  Monitor patient’s
causes the arteries to (unless a permanent  Low blood pressure blood glucose level
relax and the blood pacemaker is in place),  Slower heart rate as ordered.
pressure to fall. cardiogenic shock or severe MUSCO:  Warn patient that
bradycardia. Lactation.  Unusual tiredness the drug may
 Lack of energy or cause orthostatic
weakness hypotension, light
GI: headedness, and
 Diarrhea dizziness.
 Nausea
 Dry itchy skin DURING:
 OTHERS:  Give only the
 Weight gain ordered dose.
 Changes in sex drive
or performance AFTER:
 High blood sugar  Advice patient to
change position
slowly to minimize
orthostatic
hypotension.
 Advice patient to
notify health care
professional if slow
pulse, difficulty
breathing, rash,
fever, sore throat,
unusual bleeding,
or bruising occurs.

Generic Name: Dosage: 20mg Atorvastatin Atorvastatin may be used Hypersensitivity, active liver Adverse effects may include: BEFORE:
Atorvastatin competitively inhibits as a preventive agent for disease or unexplained  Headache  Note that
Route: PO HMG-CoA reductase, non-fatal myocardial persistent elevations of  Flatulence atorvastatin is an
Brand Name: the enzyme that infarction, fatal ad non-fat serum transaminase,  Diarrhea adjunct to not a
Lipitor Frequency: HS catalyzes the al stroke, porphyria, pregnancy,  Nausea substitute for low-
conversion of HMG- revascularization lactation  Vomiting cholesterol diet.
Classification: CoA mevalonic acid. procedures,  Anorexia
Antihyperlipidemic, This results in the hospitalization for  Angioedema DURING:
HMG-CoA reductase induction of the LDL congestive heart failure  Myalgia  Tell patient to take
inibitor receptors, leading to and Angina in patients  Rash/pruritus drug at the same
lowered LDL- with coronary heart  Alopecia time each day,
Cholesterol disease.  Allergy preferably in the
concentration.  Infection evening. May be
 Chest pain taken with food to
maintain its
effects.
 Instruct patient to
take a missed dose
as soon as
 possible. If it’s
almost time for the
next dose, she
should skip the
missed dose.

AFTER:
 Advise patient to
notify prescriber
immediately if she
develops
unexplained
muscle pain,
tenderness, or
weakness,
especially if
accompanied by
fatigue.

NURSING CARE PLANS

 NURSING CARE PLAN 1
NURSING CARE PLAN 2
Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Evaluation
Subjective Excessive fluid Short term goal: INDEPENDENT Short term goal:
The patient verbalized, Nursing
volume as Within 5 – 10 minutes 1. Establish rapport with the patient 1. To have effective communication After 10 minutes of nursing
Assessment Planning Nursing Interventions Rationale Evaluation
“Nurse ang sakit ng Diagnosis
evidenced by of nursing and S/O. between the nurse and patient. interventions, the patient
dibdip ko nahihirapan Decreased
Subjective: bilateral leg Within interventions,
6 hours of the Independent: was able to relieve
After 6 hoursfromof
akong huminga
“Nurse at hirap Cardiac
nahihirapan edema secondarynursing
Output patient will be able to
interventions, 2. Assist
Establish rapportthe patient
with in a supine
the patient and companion. 2. The upperTo gain body can
their help
trust andusfor them to shortness of breath.
nursing interventions,
po akong
ako makagalaw
huminga, to Congestive
nahihilo secondary to relieve
the from
patient shortness
will position, with 2-3 pillows, but do assume the verbalize
easily position without
what they feel the patient was able
dahilatsaparang
ako pamamaga ng Congestive Heart Failure of breath.
demonstrate not elevate the legs higher than
Provide 2L supplementary oxygen via nasal cannula. putting towardspressure
extra on your
the situation. Long termto: goal:
dalawang paa
nanghihina ko.”
ako” As Heart Failure as adequate cardiac the heart level. neck and back. For maximum After 6-7 hours of nursing
verbalized by the evidenced by outputLong term goal: Provide a restful environment.
as evidenced comfortToand helpvenous
patientflow.
to improve interventions, the patient
Be relieved from
patient. Increased Heart by blood pressure, breathing. established
shortness the ff:
of breath.
Objective Rate and Within
pulse rate, 6-7 hours ofMaintain
respiratory 3. Regulate
the patient oxygen therapy toposition. 3. It supplies oxygen to the body
in high-Fowler’s
 Swelling of bilateral Elevated Blood
Objective: nursing
rate, interventions,
and oxygen 4L/min. thus relieving shortness of breath. - Swelling of theobserved
No crackles lower
lower extremities.
Shortness of breath Pressure the patient
saturation within will Listen for adventitious sounds such as crackles while To reduce stress and provide extremities
uponsubsided from
auscultation.
(Edema, pitting 2+)
(dyspnea) normalestablish
range andthe 4. Auscultate
asff: auscultating the lungs breath sounds
and heart q2
sounds. 4. A change in breath sound or
comfort. +2 to +1 and indicates
 Shiny skin. hrs. and prn for the decreased decreased crackle sound indicates reduced shortness of
well as being relieved Vital Signs returned
crackle sounds. decreased fluid present in the
Presence
Tenderness
of and - Swelling
from shortnessof the
of lower
lungs.
To allow better chest expansion, breath.
within normal range:
too warmsound
Adventitious to touch extremities
breath will subside
with absence thereby improving pulmonary
in the lower
(crackles) from +2 to +1 that will
of crackles. capacity. - Blood pressure
BP: 120/80 was
5. Minimize oxygen demand by
extremities. also show reducedCheck5. Restrict
and note forthe patient’s activity
palpitations and
and/or irregular reduced from 140/90 mmHg
maintain the client on a bed rest. maintaining bed rest and limiting
VitalBlood
Signs Urea
taken and shortness of breath.heartbeats. To determine
the client’s activity. whether pulmonary to 120/80mmHg.
PR: 85bpm
Nitrogen (BUN)/
recorded: edema is present because of
Creatinine slightly - Blood pressure will be 6. These worsening
foods are lung in sodium Actions - Respiratory
highcongestion. rate was
RR: 18cpm
elevated. 6. Upon discharge, advice patient
BP: 140/90 reduced from 140/90 should be respectively.
and cholesterol taken right away and to lowered to 20cpm from the
to lower her consumption of the
(Hypertensive)
Elevated mmHg to Monitor foods
oxygenshesaturation and
sells like ABGs.
anchovies determine whether there is baseline of 26cpm.97%
Auto saturation:
Comprehensive 120/80mmHg. and shrimp paste as part of presence of tachycardia since this is
PR:metabolic
112bpm panel health teaching. the early sign of heart failure. - Pulse rate GOALwasWAS
reduced
MET to
level (particularly
(Tachycardic) -Respiratory rate will 100.
sodium). be lowered from 26 To determine if there are any
RR:Presence of
26 (Tachypnea) cpm to 20cpm. Inspect patient’s skin for pallor or cyanosis. presence of palpitation which might
Crackling breath - Pulse rate will be occur due to dysrhythmias
sounds.
Auto saturation: 86% normal in a way that it DEPENDENT 1. It slowssecondary
the hearttorate chronic
that heart failure. Bpm that is within normal
corrects
 Vital Signs taken will be reduced to 100 Provide bedside commode, provide
1. Administer Digoxin (Lanoxin) stool pulse
softeners as rate
Fast and lower
irregular blood
heartbeat is present. range from the baseline of
and recorded: bpm from the baseline ordered.0.25mg OD. pressure. 112 bpm meaning patient is
BP: 140/90 of 112 bpm. To provide information regarding not tachycardic anymore.
(Hypertensive) Have patient avoid activities such as straining during 2. To helpthe treat hypertension.
heart’s ability to perfuse distal
- Crackle breath sound 2. Administer
defecation, captopril
holding breath 5mg,
during orally,changes.
position tissues with oxygenated blood. - There is clearer lung sound
PR: 112bpm will be reduced. OD, as prescribed. that indicates reduced fluid
(Tachycardic) 3. To reduce fluid in present in the in lungs.
- Oxygen saturationDependent: 3. Administer loop diuretics/ Lasix lungs. To check whether there is
RR: 26 cpm will be in normal range (furosemide)
Administer Digoxin 0.25mg, orally, OD as prescribed occurrence of diminished perfusion. - Oxygen saturation turned
(Tachypnea) of 95-98% from theby the doctor. Hypoperfusion in the limb will to 95% from the baseline of
baseline of 89%. COLLABORATIVE 1. Sodiumrendercauses higher blood
pallor. 89%.
 Oxygen saturation 1. Collaborate with a dietician to
Administer Captopril 5mg, orally, OD, as prescribed. pressure and patient has excess
of 89%. plan for the patient’s meal that fluid in the body that’s
To decrease work why she to the GOALS WERE PARTIALLY
of getting
includes
Collaborative: low sodium diet and fluid needs to lessen her fluid intake.
bathroom or struggling to use a MET.
Refer torestriction.
a physical therapist about cardiac High K diet
bedpan.is needed too because
rehabilitation as indicated. furosemide causes hypokalemia.
 Name of Students ALCOVER, JANNAH MAE S. CRISOSTOMO, MICAELA E.
DAGDAG, JAN COLINE S.D. DE VERA, ROCHELLE G.
DEL MUNDO, ZYRELLE M. DELA CRUZ, JEMIMA ALEEYAH L.
DELA ROSA, ANGELA R. FARIÑAS, FLORENCE D.
GARCIA, CRISHANE JAN U. GARCIA, PRINCESS MAUREE E.
GAVIOLA, KATHLEEN KYLE C. GAYLA, ABISH MARIEZA L.
RIVERA, JOHN BENEDICT R.
Date Submitted October 4, 2021 C.I.’s Signature

Form No.: TSU-COS-SF-04 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1

References:
 Jones and Bartlett (2015) Nurse’s Drug Handbook Fourteenth Edition, Ismail Digital Library https://doc-04-
84-apps-viewer.googleusercontent.com/
 Medicineinf (2018) Lasix (Furosemide) Side Effects, how it Works, Upsides & Downsides
http://medicineinf.com/2016/07/18/lasix-furosemide-side-effects-how-it-works-upsides-downsides
 Thorthon P. (2020) Digoxin, Drugs.com https://www.drugs.com/digoxin.html