Case Study

Congestive heart failure

Case Study

contents
Nursing history Physical assessment Diagnostic procedure Laboratory investigation Drug information Pathophysiology Medical management Nursing management References

Case Study

Nursing history
A 3 months infant patient with congestive heart failure admitted to KFMC hospital at 17-4-11 complaining from swelling and redness on left armpit since two days, diagnosed as axillary abscess secondary to BCG vaccine. There is no family medical history for any diseases. For the last two months she was unable to complete her breast feeding, the mother noted that she become fatigued and have rapid shallow breathing during feeding. The mother was anxious and feared from the health status of her child.

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Physical assessment
General appearance: poor weight gain. vital signs: T: 36 C. RR:42 breath/min BP:89/52 mmHg. MAP:64. beat/min. P:130 Length: 57.2 cm. Wt: 4.4 Kg

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Physical assessment cont

Integumentary system: Good-skin intact, paleness, cyanotic lips. , swelling and redness on left axilla. Pulmonary system: Tachypnea during feeding RR:42/min Cardiovascular system: congestive heart failure, murmur on auscultation and tachycardia P:130/min Gastrointestinal system: Slow sucking, fatigued during breast feeding.

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Physical assessment cont

Musculoskeletal system: move all limps freely. Genitourinary system: voiding freely on diaper no Foley catheter. Neuro status: conscious, active.

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Diagnostic procedure:
Echocardiography: Was done on 17-4-11 and conclusion is large ventricular septal defect and atrial septal defect close. Chest x-ray: Was done on 18-4-11 shows cardiomegaly with increased pulmonary vasculature

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Laboratory investigation:
Date Done Test

17-4-11

WBC

Normal Value Patients value 12.70 10^3/l 6-17.5

Remarks normal

17-4-11
17-4-11 17-4-11 17-4-11 17-4-11 17-4-11

RBC
HGB HCT Neutrophile % Lymphocyte % Monocyte%

4.16 10^3/l
10.7 g/dl 32.1 31.0% 54.6% 8.65%

3.2-5.2
10.5-12.5 40-55 40-75% 20-45% 2-10%

normal
normal low low high normal

17-4-11
17-4-11 17-4-11 17-4-11 17-4-11

Eosinophile%
Basophile% potassium calcium sodium

5.06%
0.697% 4.2 mmol/L 2.35 mmol/L 130 mmol/L

1-6%
0-1%

normal
normal low normal normal

Name of Drug LASIX

Drug Class Loop diuretic

Use / Action Indication Action : Inhibits reabsorption of sodium and chloride .Indication: Edema associated with heart failure-Acute pulmonary edema.

StrengthDoseRouteFrequency

Nursing Teaching

10mg /ml5mg IV - BID

- Client may experience loss of body potassium , increased volume and frequency of urination .

Digoxi n

Cardiac glycoside. Cardiotoni c

0.1 mcg/ml Action: Increases intracellular calcium 0.05mcg/m and allows more l calcium to enter the PO - BID myocardial cell. Indication: Heart failure - Atrial fibrillation

-Report slow pulse, rapid weight gain, nausea, diarrhea, vomiting.. -Checked childs apical pulse always before administrating digoxin (the drug is not given if the pulse is below 90-100 b/m in infants). -Report signs and of Hypersensitivity (rash). -Inform the parents that drug can cause diarrhea.

Bactri m

Antibiotic

Treating many kinds of infections that are by bacteria.caused

20mg/ml 10mg/ml PO - BID

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Pathophysiology
Heart failure is often separated into two categories: right sided and left sided failure. In right sided failure, the right ventricle is unable to pump blood effectively into the pulmonary artery resulting in increased pressure in the right atrium and systemic venous circulation. Systemic venous hypertension causes Hepatosplenomegaly and occasionally edema. In left sided failure, the left ventricle is unable to pump blood into the systemic circulation resulting in increased pressure in the left atrium and pulmonary veins. The lungs become congested with blood, causing elevated pulmonary pressure and pulmonary edema.

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Medical management

Improve cardiac function: Through administration of digitalis glycosides [digoxin (lanoxin)]. Remove accumulated fluid and sodium: Treatment consists of diuretics, possible fluid restriction and possible sodium restriction. Diuretics to eliminate excess water and salt to prevent re-accumulation. Decrease cardiac demands: The workload on the heart is reduced when metabolic needs are kept to a minimum. This is accomplished by limiting physical activities( bed rest) preserving body temperature, treating any infection, reducing the effort of breathing (semi fowlers position) and using medication to sedate an irritable child. Improve tissue oxygenation and decrease oxygen consumption: Supplemental cool humidified oxygen is usually provided to increase the amount of oxygen during inspiration.

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Nursing Care Plan

Nursing Diagnosis Ineffective breathing pattern related to decrease cardiac out put. Goal The patient will Exhibit improve d breathin g pattern. Implementation Assess patient respiratory rate frequently. Monitor patient vital signs for any abnormality. Elevate head of bed infant become more comfortable in semi fowler position. Avoid any constricting clothing or restraints around abdomen and chest. Administer oxygen as prescribed by physician. Observed patient for sign of hypoxia (cyanosis , shortness of breath, fatigue). Evaluation The patient improved her breathing pattern and quality of breathing. SpO2:97%. RR: 37/min.

Assessment Subjective Data: Difficult breathing. Weakness. Cough. Objective Data: Fatigue. Rapid shallow breathing. Use accessory muscle with breathing. SpO2: 94%. RR: 42/min. Chest x-ray: Increased

Monitor pulse oximetry.

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Assessment Subjective Data: Difficult feeding. fatigued and rapid shallow breathing during feeding. Slow sucking Objective Data: Feeding difficulties. cyanosis during feeding Anorexia Dyspnea following feeding Wt:4.4 kg

Nursing Diagnosis Altered growth and developm ent related to inadequat e oxygen, nutrients to tissue and difficult feeding.

Goal The patient will Achieve normal growth, Increase her weight.

Implementation Provide well balanced highly nutritive diet.

Evaluation The patient has been achieved normal growth.

Administer vitamin supplement as prescribed by physician.

Monitor weight and height on growth chart. Instruct the mother to Feed infant in the knee-chest position. Ensure that the head is elevated while feeding , he will suck more strongly, ingest more, tire less, and gain weight. Use soft nipple to feed infant. Provide frequent burping and pauses of rest.

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Assessment Subjective Data: Cool extremities. Sweating. Cyanotic lips. Objective Data:
P: 130/min BP:89/52mmhgMAP:64. Potassium:4.2

Nursing Diagnosis Decreased cardiac out put related to structural defect.

Goal

Implementation Administer digoxin as ordered by physician. checked childs apical pulse always before administrating digoxin (as general rule the drug is not given if the pulse is below 90-100 b/m in infants). Ensure adequate intake of potassium. Monitor vital signs frequently.

Evaluation The patient improved her cardiac output by the time.

The patient will Exhibit improved cardiac output.

Cool extremities. Sweating. Cyanotic lips. Weak peripheral pulses. Chest x-ray: Cardiomegaly Echo: VSD. capillary refill time less than 3

Observe for signs of dehydration.

Observed for sign of digoxin toxicity(vomiting, nausea, bradycardia ).

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Assessment
Subjective Data: Redness axilla Swelling axilla

Nursing Diagnosis

Goal

Implementation

Evaluation

Impaired Skin Integrity related to Presence Objective Data: of infection. Lymphocyte: 54.6% Neutrophile: 30% Axillary abscess Redness and swelling axilla T:36

Monitor for signs of infection (fever, vomiting and diarrhea). Administer antibiotic as prescribed by physician. Note skin color, texture, swelling for any changes. Monitor vital signs frequently. Avoid contact with infected patient.

Instructed mother to maintain clean, dry clothes, preferably cotton fabric. Ensure adequate nutrition and fluid intake.

Assessment
Subjective Data: Fear anxiety Concern Objective Data: Anxiety Fiscal grimace discomfort

Nursing Diagnosis
Anxiety related to child with life threatening illness.

Goal
Family will be decrease anxiety and copes with childs symptoms in a positive way.

Implementation
Discuss with parents their fears regarding child symptoms. Encourage family to participate in care of child while hospitalized.

Evaluation
Family copes with childs symptoms in a positive way. Anxiety had been decreased.

Encourage family to include others in childs care to prevent their own exhaustion.
Provide accurate information about the situation of the child. Encourage family to as ask question and answer it.

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References:
1. Sandra, M. N. (2001). Manual of Nursing Practice. Philadelphia. Lippincott. 2. Sharon J. R & Leonide L. M. & Deborah K. G. Maternity Nursing family, newborn and women health care. Philadelphia. Lippincott.

Presented by: Fatima basager Iman al-ghamdi Aisha aljowair Aydah al-harby