LOGO

CASE STUDY on

CONGESTIVE HEART FAILURE
Group V

OBJECTIVES

General Objectives:
Be capable enough to acquire knowledge about

proper Nursing care to be rendered to the patient. So as to
enhance our skills, widen up concepts to have deeper understanding on the disease and apply more appropriate treatment and nursing management through proper establishment of trust and rapport, setting out right and proper attitude for future application of nursing principles and responsibilities.

Specific Objectives: Cognitive
To acquire the proper knowledge about the disease

through chart reading, physical examination, observation
and nurse patient interaction. To have deeper

comprehension regarding the disease entity including the
definition of the disease, manifestation, complications, pathological condition, its avoidance, curative preferences and proper clinical management.

Specific Objectives: Cognitive
To become knowledgeable enough of the effective and applicable treatments, appropriate care and proper management

regarding the case of the patient. As well as to be intelligent
enough to know the disease occurring in the human body and how it affects the normal bodily functions and processes. To be aware enough of the possible complications that might arise during home treatment.

And last for us to learn how to improve nursing care plan
and know the important nursing managements.

Specific Objectives: Affective
To establish trust and rapport as a basic foundation
for a better communication, effective nurse-patient

interaction and proper handling of the patient for
rendering of a quality nursing care.

To develop a more just and humane characteristics
for future nursing management.

Specific Objectives: Psychomotor
To enhance and develop skills through practicing

on duty with the use of gained knowledge and proper
attitude. To become better and effective health care provider by seeking alternative and helpful ways of acquiring the

knowledge and to become better researcher to build up
our research ability.

PATIENT’S PROFILE

PATIENT’S PROFILE
Service: Name: Age: Male Medical Ward Mr. BJ 65 years old Occupation: Farmer Chief Complain: Difficulty of Breathing Admission Date: September 1, 2012 Attending physician: Dr. Glenn Isip Date of Discharge: September 6, 2012 Length of stay: 5 days Admitting Diagnosis:

Date of Birth: March 19, 1947 Gender: Male

Address: Brgy. Lanigay, Polangui, Albay

Civil Status:
Religion: Nationality:

Separated
Roman Catholic Filipino

Congestive Heart Failure, Bronchial
Asthma Final Diagnosis:

Educational Level:
Elementary Graduate

Cardiomegaly, Severe

MEDICAL HISTORY

PRESENT MEDICAL HISTORY
In the present medical history of Mr. JB, he mentioned that he had episodes of difficulty of breathing accompanied with restlessness. He also mentioned that he was experiencing pain in the hypogastric area in times of weakness. The severity of it is tolerable according to Mr. JB and had a score of 6 out of 10 in the pain scale. Her

wife also told that Mr. JB has swelling at both legs. There
is no other complaint that Mr. JB and wife had been mentioning or experiencing.

PRESENT MEDICAL HISTORY

Vital Signs:

T: 35.3 C
P: 130 BPM R: 20 BPM

Wt: 58kg
Ht: 5’8

BP: 120/90 mmHg

Past Medical History
In his past medical history, he just experienced simple

fever, cold and cough.
• Problems at Birth: None • Childhood Illnesses: Fever, cold, cough • Immunization to Date: None • Adult Illnesses: Congestive Heart Failure

• Surgeries: None
• Accidents: None • Allergies: None

Family Medical History
In Mr. BJ’s family history, he mentioned that

his father died because of hypertension and his
mother died because of aging. One of his brother

died because of hypertension, the other 2 died
because of lung problem and the other one died

because of Hepatitis.

Lifestyle
Mr. BJ is now 65 years old, due to difficulty of breathing he was not able to perform his daily activity such as exercise and different household chores, he also stop smoking and drinking of alcoholic beverages, eats food like vegetables, fruits, rice and sometimes meat.

CEPHALO-CAUDAL ASSESSMENT

CEPHALO-CAUDAL ASSESSMENT
HEAD/SKULL
is proportional to the size of the body, round, with prominences in the frontal and the occipital area, has dizziness is white, clean and free from masses, lumps and scar, nits, dandruff and any lesions is white and some are black in color and thinning, hair strands are fine and evenly distributed is round-shaped, symmetrical, and wrinkles are present, no involuntary muscle movements

SCALP

HAIR

FACE

CEPHALO-CAUDAL ASSESSMENT
EYES
are parallel and evenly placed, symmetrical, nonprotruding, both eyes are brown and clear, able to move in all direction, able to see/read, Pupils are Equal, Round and Reactive to Light and Accommodation, pale conjunctiva

EARS

are parallel, symmetrical, proportional to the size
of the head, bean-shaped, skin is same color as the surrounding area, clean with minimal

amount of serumen, able to hear whisper
spoken 1 foot away

NOSE

is located in midline, symmetrical and patent,

with few cilia and clean, can smell properly

CEPHALO-CAUDAL ASSESSMENT
MOUTH LIPS

are slightly black and dry, symmetrical, lip margin welldefined

GUMS
TEETH TONGUE UVULA

pinkish, moist, no swelling, no retraction, no discharges not complete
pinkish color, moist, shiny and freely movable at the center, symmetrical and freely movable

CEPHALO-CAUDAL ASSESSMENT
NECK
is proportional to the size of the body and head, symmetrical and straight, no palpable lumps, masses, or areas of tenderness, free movable without difficulty, symmetrical and able to resist force, has distended neck vein chest contour is symmetrical, spine is slightly bent forward, chest wall moves symmetrically during respiration - no lumps, masses, areas of tenderness, sides of the thorax expand symmetrically - wheezing sounds heard at both lungs

THORAX and LUNGS

CEPHALO-CAUDAL ASSESSMENT
ABDOMEN - no scar, color is uniform, symmetrical movements caused by respiration, and color is the same as the surrounding skin - percussion is dull at the liver’s lower boarder - soft abdomen, no lumps or masses - tenderness in the lower abdomen, guarding behavior HEART

apical pulse is visible and palpable, S3
sound heard upon auscultation

MUSCUSKELETAL

muscle weakness

CEPHALO-CAUDAL ASSESSMENT
UPPER EXTREMITIES ARM

PALM NAILS

skin color is Tan, symmetrical, thin of hairs, there are visible veins, fingers are symmetrical warm, moist and there is loss of elasticity, there are no areas of tenderness pallor and warm convex curvature, smooth texture, pale nail beds and it takes more than 3 seconds before it turns back to its original color

CEPHALO-CAUDAL ASSESSMENT
LOWER EXTREMITIES LEGS

skin is tan, dry, absence of hair, length symmetrical, there is presence of edema on feet with a scale of 3+ (deep pitting, indentation remains for a short time, leg looks swollen), warm and poor muscle tone five toes in each foot, sole have rough surface, nail beds are pale

TOES

LABORATORY DIAGNOSTIC EXAM

LABORATORY DIAGNOSTIC EXAM
X-RAY EXAMINATION

Findings: Markedly enlarged cardiac shadow, partial densities at both hilar area and left lower lung field, minimal acceleration of costophrenic markings. Impressions: 1. Cardiomegaly, Severe 2. Chronic Bronchitis with Bibasal Pneumonia

LABORATORY DIAGNOSTIC EXAM
X-RAY EXAMINATION

LABORATORY DIAGNOSTIC EXAM

LABORATORY DIAGNOSTIC EXAM

LABORATORY DIAGNOSTIC EXAM

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY
Modifiable Factors

smoking

stress
History of Hypertension MYOCARDIAL DYSFUNCTION

over-exercise
alcohol abuse

Non-modifiable Factors

age

heredity

PATHOPHYSIOLOGY
MYOCARDIAL DYSFUNCTION    decreased CO decreased systemic BP decreased tissue perfusion

Increased Left Atrial Pressure

LSCHF

blood dams back into the pulmonary capillary
Signs & Symptoms:  Dyspnea  PND  Crackles  Wheezing  Dizziness  Weakness  S3 sound  Pulsus Alterans

RAAS stimulation

Activation of Baroreceptor

PULMONARY EDEMA

PATHOPHYSIOLOGY

vasoconstriction  increased afterload  increased BP  increased HR  ventricular remodeling

PATHOPHYSIOLOGY
Activation of Baroreceptor

stimulation of vasomotor regulatory centers in medulla
vasoconstriction  increased afterload  increased BP  increased HR  ventricular remodeling

activation of sympathetic nervous system

increased catecholamines (epinephrine & norepinephrine)

PATHOPHYSIOLOGY
LSCHF
decreased myocardial contractility RV Signs & Symptoms:  JVD  Fatigue  Pitting Edema  Weight gain  S3 Sound

Increased RA pressure

RSCHF

Increased venous pressure

NURSING CARE PLAN

ASSESSMENT/CUES
SUBJECTIVE: (none) OBJECTIVE:

-increased heart rate AEB, PR of 130bpm
-changes in BP: 90/70 mmHg (hypotensive) -presence of S3 sound upon auscultation -decreased urine output (200ml)

NURSING DIAGNOSIS & INFERENCE (1)

Decreased cardiac output may be related to altered myocardial contractility /inotropic changes.
Modifiable factors such as prolonged smoking and alcoholism Myocardial dysfunction Decreased myocardial contractility Decreased cardiac output

PLANNING
SHORT TERM:

After 8 hours of interventions, the patient’s pulse rate is
within normal range (from 130bpm to 100bpm),

improve BP in a near to normal range (110/80)

LONG TERM: After 1 week of interventions, the symptoms will be alleviated.

INTERVENTION & RATIONALE
INDEPENDENT:

1. assist and teach patient of proper ROM exercise.
-promote circulation 2. Auscultate apical pulse, assess heart rate, and rhythm. -to provide baseline data

INTERVENTION & RATIONALE
INDEPENDENT: 3. Monitor urine output -to check if there’s a change in urine volume and if the pt respond to the intervention

4. Assess level of consciousness -indicate inadequate cerebral perfusion secondary to

decreased CO

INTERVENTION & RATIONALE
INDEPENDENT: 5. Provide quiet environment -to help reduce emotional stress

INTERVENTION & RATIONALE
DEPENDENT: 3. Administer digoxin as

1. Administer supplemental
oxygen as indicated.

prescribed.
-treatment for atrial

-to improve circulation.
2. Administer diuretics as prescribed. -to decrease fluid overload

fibrillation

EVALUATION
SHORT TERM: After 8 hours of interventions, the patient’s pulse rate decreases from 130bpm to 93bpm, and a BP of 120/90 from 90/70mmHg. -goal met.

LONG TERM:
Goal partially met

ASSESSMENT/CUES
Subjective: “Minsan, nahihirapan akong huminga”, as verbalized by the pt. Objective: Patient manifested: -(+) DOB AEB RR= 20 CPM with pale conjunctiva and nail beds -productive cough -wheezing

-presence of crackles upon auscultation (bibasilar)

NURSING DIAGNOSIS & INFERENCE (2)

Impaired Gas Exchange - The exchange in

oxygenation and carbon dioxide gases is impeded
due to the obstruction caused by the accumulation

of bronchial secretions in the alveoli. Oxygen
cannot diffuse easily. NDx: Impaired gas exchange related to

accumulation of fluid in the alveoli.

PLANNING
After 8 hours of nursing interventions, the patient will be able to demonstrate improvement in gas exchange AEB a decrease in respiratory rate from 20 cpm to 16 cpm

INTERVENTION & RATIONALE
INDEPENDENT: 1. Elevate head of bed -to promote lung expansion

2. Change position q 2 hrs.
-to promote drainage of secretions 3. Monitor and record vital signs -for comparison purposes

INTERVENTION & RATIONALE
INDEPENDENT: 4. Observe color of skin, mucous membranes and

nail bed
-to assess if there’s a presence of peripheral cyanosis. 5. Promote adequate rest periods -rest will prevent fatigue and decrease oxygen demands for metabolic demands

INTERVENTION & RATIONALE
INDEPENDENT:

6. Keep environment allergen free
-to reduce irritant effects on airways 7. Suction secretions PRN -to clear airway when secretions are blocking the airway

INTERVENTION & RATIONALE
Dependent: 1. Administer oxygen therapy as ordered. -O2 therapy is indicated to increase oxygen saturation

2. Administer bronchodilator (Salbutamol) stat

-promote good gas exchange

EVALUATION
After 8 hours of nursing intervention the
patient’s respiratory rate decreases from 20 cpm

to 18cpm.
-goal met.

ASSESSMENT/CUES
Subjective:(none) Objective:

-bipedal pitting edema (more than 3 seconds)
-JVD (6 cm) -weight gain(from 125.4 lbs to 127.9 lbs)

NURSING DIAGNOSIS & INFERENCE (3)
Excess Fluid Volume When blood flow through the renal artery is decreased, the baroreceptor reflex is stimulated and rennin is released into the bloodstream. Renin interacts with angiotensinogen to produce angiotensin I. When angiotensin I contacts ACE, it is converted to angiotensin II, a potent vasoconstrictor. Angiotensin II increases arterial vasoconstriction, promote release of norepinephrine from sympathetic nerve endings, and stimulates the adrenal medulla to secrete aldosterone, which enhances sodium and water absorption. Stimulation of the rennin-angiotensin system causes plasma volume to expand and preload to increase. NDx: Excessive Fluid volume r/t sodium and water retention AEB bipedal pitting edema secondary to RSCHF

PLANNING
Short Term:

After 8 hours of interventions, the patient will decrease
circulating fluid volume excess thus decreasing weight and edema. Long Term:

After 3-4 days of interventions, the patient will manifest
fluid balance as evidence by equal amount of output to input.

INTERVENTION & RATIONALE
INDEPENDENT:
1. Weigh patient daily and compare to previous

weights.
-Body weight is a sensitive indicator of fluid balance

and an increase indicates fluid volume excess.
2. Monitor I & O every 4 hours -I&O balance reflects fluid status

INTERVENTION & RATIONALE
INDEPENDENT: 3. Assess the need for an indwelling urinary catheter -May include increased fluids or sodium intake, or compromised overload 4. Instruct patient regarding fluid restrictions as appropriate. -Heart failure causes venous congestion, resulting in increased capillary pressure. regulatory mechanisms. Indicates fluid

INTERVENTION & RATIONALE
INDEPENDENT: 5. Do not elevate legs if the client is dyspneic. -Elevation of legs increases venous return to the heart.

Health teaching as follows:
1. Follow low-sodium diet and/or fluid restriction Low-sodium diet helps prevent increased sodium retention, which decreases water retention. Fluid restriction may be used to decrease fluid intake, hence decreasing fluid volume

excess.

INTERVENTION & RATIONALE

DEPENDENT:
1. Administer diuretics (Furosemide) as

ordered.
-To decrease fluid overload

EVALUATION
Short Term: Pt. verbalized understanding of causative factors and demonstrate behaviors to resolve excess fluid volume.

Long Term:
Pt demonstrated adequate fluid balance AEB output equal

to exceeding intake, clearing breath sounds and decreasing
edema.

ASSESSMENT/CUES
SUBJECTIVE: “Masanit ang tiyan ko sa parte ng gitna”, as verbalized by the pt. OBJECTIVE:

- pain scale of 6 out of 10
-(+) guarding behavior

NURSING DIAGNOSIS (4)

Acute pain related to indigestion AEB
a pain scale of 6 out of 10.

PLANNING

After 8 hours of nursing intervention,
the pt. will report that the pain is alleviated

and has a scale of 3/10 from 6/10.

INTERVENTION & RATIONALE
Independent: 1. Position patient in dorsal recumbent. - Positioning patient on this position helps to reduce pain and to relax abdominal area. 2. Provide relaxation techniques such music therapy and visual imagery. -To relieve pain Dependent: Administer analgesics, as indicated. -Lessen pain

EVALUATION

After 8 hours of nursing intervention, the patient verbalized alleviation of pain, pain scale of 3/10.

ASSESSMENT/CUES
SUBJECTIVE:

“Nahihilo ako,” as verbalized by the patient. OBJECTIVE:
-dizziness

-restlessness

NURSING DIAGNOSIS (5)
Risk for falls Increased susceptibility to falling that may cause physical harm.

NDx: Risk for falls related to inadequate cerebral perfusion AEB dizziness.

PLANNING
After 8 hours of nursing intervention the patient will be prevented from injury and the patient will verbalize absence of dizziness.

INTERVENTION & RATIONALE
INDEPENDENT: 1. provide pillows at both sides (side rails) -to prevent patient from falling
2. assess LOC -to determine whether neurologic functioning is good or not 3. assess mood, coping abilities, personality styles -Individual’s temperament, typical behavior, stressors, and level of self-esteem can affect attitude toward safety issues, resulting in carelessness or increased risk-taking without consideration of consequences.

EVALUATION

After 8 hours of nursing intervention, the patient was free from injury.

DRUG STUDY

DISCHARGE PLAN

MEDICATION
 Advice/instruct the client to continue medication that are prescribed by the physician and their actions.

 Instruct

the

patient

or

the

significant

others

for

any

observable alterations on the patient condition.  Emphasize to the client the side effects of the different

medications to be taken.
 Reinforce importance of medication regimen  Discuss medication’s frequency, action,contraindication, doses and adverse reactions.

EXERCISE
 Instruct the patient to perform leg exercise as tolerated such as walking to facilitate mobilization on lower extremities.

 Advise client to remain physically active and follow the doctor’s
instructions about exercise and activity.  Advise client to rest often. Anytime he/she become even a little tired or short of breath. SIT DOWN and rest.  Instruct client to keep his/her feet and legs elevated while sitting. Do not dangle them.  Advise client to plan his/her activities to include rest periods

THERAPY
 Instruct the patient to continue medication. Also, activities of daily living and selfto encourage

care training are

important

maintenance of hygiene.  Explain cautiously the different side effect of some drugs to be taken.

HEALTH TEACHING
 Encourage the patient to eat foods rich in
vitamins and minerals/ nutritious food

 Encourage the patient to avoid salty and fatty
foods

 Encourage the patient to have enough rest

OUT-PATIENT CARE
 Instruct the client to come back for follow-up

check- up as scheduled by the attending
physician.

 Emphasize referral to an outpatient clinic if
there are some questions with regards to

the medication.

DIET
 Advised the patient that a low-sodium diet  Advise client to limit how much fluid intake. Remember: things like ice cream, Jell-O, or ice

still count as fluids!
 Emphasize the importance of eating nutritious foods

such as

vegetables and fruits rich in vitamins and

immunity components.

SPIRITUAL COUNSELING
 Encourage the patient learn to responsibility for mental, and spiritual accept their own physical, emotional, healing.

 Counsel client to have a regular visit on Church
(every Sunday), involve self on religious

activities
 Make God as the center of life

THANK YOU!