CONGESTIVE

HEART
FAILURE

LEARNING OBJECTIVES

At the end of this case study, the learner should be able

to:

Describe Congestive Heart Failure

Recognize its clinical signs and symptoms
Identify causative factors of heart failure
Identify diagnostic procedures used to determine

heart failure
Know the medical and surgical management

I.

INTRODUCTION

Congestive heart failure is defined as the state in which the

heart is unable to pump blood at a rate adequate for satisfying the

requirements of the tissues with function parameters remaining

within normal limits usually accompanied by effort intolerance, fluid

retention, and reduced longevity. Currently, congestive heart failure
or heart failure continues to be a major public health problem
worldwide. It is the leading cause of morbidity and mortality in most
developed countries. According to the American Heart Association,
approximately 5 million patients have heart failure and nearly
550,000 new patients are diagnosed each year. In addition, nearly
300,000 patients die from heart failure yearly.
In the Philippines, cardiovascular diseases are the most
common causes of mortality. According to the Department of
Health, about 77,060 in a 100,000 populations have died in the
Philippines due to diseases of the heart. The aging of the population
and the emerging pandemic of cardiovascular diseases in the
developing nations of the world signal a rise in the incidence and
prevalence of heart failure globally and magnify the importance of
its prevention. The prevention of heart failure is an urgent public
health need with national and global implications.
CHF is usually the result of other health problems. This may
include

hypertension,

Myocardial

Infarction,

Diabetes,

cardiomyopathy, arrhythmias, valve defects, infections, certain

kidney conditions, and Coronary Artery Disease. The most common
cause of CAD is atherosclerosis, in which waxy substances called
plaque (plak) build up inside the coronary arteries. It is a disease
where there is impaired blood flow in the arteries that supply
oxygen-rich blood to the heart muscle.
The particular symptoms that an individual experiences are
determined by which side of the heart is involved in the heart
failure. For example, the left atrium receives oxygenated blood from
the lungs and passes it onto the left ventricle, which pumps it to the
rest of the body. When the left side isnt pumping efficiently, blood
backs up in the vessels of the lungs, and sometimes fluid is forced
out of the lung vessels and into the breathing spaces themselves.

This pulmonary congestion causes shortness of breath. The other

major symptoms of left-sided heart failure are fatigue, dyspnea,
orthopnea,

paroxysmal

nocturnal

dyspnea,

and

the

sputum

production that comes from pulmonary congestion.

Right-sided failure occurs when there is resistance to the
flow of blood from the right heart structures (right atrium, right
ventricle, pulmonary or lung artery) into the lungs or when the
tricuspid valve, which separates the right atrium from the right
ventricle, fails to work properly. This results in a backup of fluid and
pressure in the veins that empty into the right side of the heart.
Pressure then builds up in the liver and the veins in the legs. The
liver enlarges and may become painful. The major symptoms of
right-sided heart failure are edema and nocturia. The different types
of edema possible are dependent edema, edema that results in
enlargement or swelling of the liver, ascites, and edema of the skin
or soft tissues
Complications of CHF include Kidney damage or failure, Heart
valve problems, Liver damage, and Stroke. Heart failure can reduce
the blood flow to your kidneys, which can eventually cause kidney
failure if left untreated. The valves of your heart may not function
properly if your heart is enlarged, or if the pressure in your heart is
very high. HF can also lead to a buildup of fluid that puts too much
pressure on the liver. This fluid backup can lead to scarring. And
because blood flow through the heart is slower than in a normal
heart, it's more likely you'll develop blood clots, which can increase
your risk of having a stroke.
This paper is a case report about N.E., a 59 year old female,
Filipino, hypertensive, nondiabetic, with bronchial asthma and is
currently diagnosed with Congestive Heart Failure secondary to
Acute Coronary Syndrome. Its purpose is to review the Case of a
patient with Congestive Heart Failure, know its pathophysiology,

preanalytical

factors,

and

treatment

and

identify

possible

recommendations for future nursing care.

II.

ANATOMY AND PHYSIOLOGY

Coronary Artery
blood supply of the heart

Veins are blood vessels that carry blood towards the heart
Vena Cava (largest vein) carries blood from the body back to the heart
Right Atrium receives deoxygenated blood from the body
Tricuspid Valve prevents the backflow of blood between the RA and the
RV
Right Ventricle pumps deoxygenated blood into the pulmonary artery
Pulmonary Artery carries deoxygenated blood from the RV to the lungs
Pulmonary Vein takes oxygenated blood from the lungs to the LA
Left Atrium receives oxygenated blood from the lungs
Mitral Valve prevents the backflow of blood between the LA and the LV

Left Ventricle pumps oxygenated blood into the aorta

Aorta (largest artery) takes oxygenated blood from the LV to the body
Arteries are blood vessels that carry blood away from the heart

III.

PATHOPHYSIOLOGY

Predisposing Factors:
*Elderly age (weakened
heart muscle)

Cardiac Insult:

Precipitating Factors:
*Heart Disease
*Faulty Diet
*Tobacco Use
*Sedentary Lifestyle
*Increased systemic
oxygen demand
*Previous Heart
Attack

Increased workload of
the right ventricle

Increased workload of
the left ventricle

Right-ventricular
hypertrophy as (prolonged)

Left-ventricular
hypertrophy (prolonged)

Weakening of left
ventricular pump

Weakening of left
ventricular pump

Backflow of blood to the

systemic venous circulation

Backflow of blood to the

pulmonary circulation

Right-Sided Heart
Failure:
*Cardiomegaly
*Hepatomegaly
*Cardiac cirrhosis
*Congestion of the
gastro-intestinal
tract with: nausea,
anorexia
*Anasarca or
systemic edema
*Ascites
*Jugular vein
distention

Decreased blood
flow to the left
cardiac chambers

Left-Sided Heart
Failure:
*Crackles
*Dyspnea
*Orthopnea
*Paroxysmal
*Nocturnal Dyspnea
*Cough
*Pink, frothy
sputum
*Cardiac asthma
*Cheyne-stokes
*respirations

Decreased systemic
blood flow

IV.

PATIENTS

Cerebral hypoxia
Systemic hypoxia
Systemic
PROFILE
hypoxemia
Pallor
Fatigue

Patients Name:

PATIENT SJ

Ward Rm:

EMERGENCY

Age:

73 y/o

Sex:

MALE

Civil Status:

Married

Nationality:

Filipino

Religion:

Catholic

Physicians Diagnosis:
CC:

Decreased systemic
blood flow

CHF 2
DOB

History of Present Illness:

A few hours PTC, patient had DOB allegedly synonymous with an
asthma attack. She was brought to Chinese General Hospital where
CXR was done with unrecalled results and was nebulized 2x with
Salbutamol. She was also given Fluimicil, Salbutamol nebulization and
was discharged. A few hours later, patient was able to tolerate food but
once again experienced DOB. She was nebulized once more and was
given Fluimucil when she was noted by her relatives to be gasping,
hence consult to MCU-ER

Past Medical History:

(+) Bronchial Asthma, last attack June 2015
(+) HPN
() DM
() Allergy
Family History:
(+) HPN, Mother
Personal and Social History:
() Smoker
() Alcohol drinker

PHYSICAL EXAMINATION
VITAL SIGNS:

BP 220/100 PR 139 bpm

RR

Gasping

TEMP: 37.1C
SKIN:

Good skin turgor, warm to touch, no lesion, no

rashes
HEENT:

Anicteric Sclera, PERRLA

CHEST/LUNGS:

Symmetric

chest

expansion

with

supraclavicular

retractions,
clear breath sounds
HEART:

Adynamic precordium, tachycardic, regular rhythm,

(-) murmurs
ABDOMEN:

Flabby abdomen, NABS, soft, non-tender

EXTREMITIES:

Full and equal pulse, (-) edema

NEUROGICAL:

GCS 15

V.

LABORATORY PROCEDURES

TEST
Urinalysis

RATIONALE

NORMAL VALUES

Done to screen

Color: Yellow

Patient RM for

Amber

urinary tract
infections and to
detect metabolic or
systemic diseases

ACTUAL
RESULTS
Yellow
Turbid

Transparency:

5.0

Clear

1.025

INTERPRETATION
Presence of blood,
albumin, ketones, and
sugar may be a sign of
heart failure

pH: 4.5 8.0

unrelated to renal

Sp. Gravity: 1.010

NEG Albumin,

++ Blood, +

disorder

Sugar, Ketones,

Albumin, +

Bilirubin, Blood

Sugar, + Ketones

Prothrombin

To determine how

11 14 sec

11.2

Time

long it takes for

24 35 sec

27.7

APTT

blood to clot, help

2.5 6.5 mmol/L

4.64

WNL

recognize bleeding
problems

BUN

These are markers

WNL

of renal sufficiency,
Creatinine
Sodium
Potassium

Glucose
Total

balance of Na & K
indicates how well

58 127 mmol/L
135 148 mmol/L
3.5 5.3 mmol/L

142.60

the kidneys & heart

102.60

are functioning

To determine blood sugar

5.05 6.45

level is within healthy

mmol/L

WNL

determine approximate

0.40 2.30

risks for CVD

mmol/L

TPAG measures the

0.90 1.56

proteins that help

maintain circulatory and

Total Protein immunity functions

Albumin

mmol/L
1.70 4.60

WNL
7.34 HIGH
WNL
WNL

mmol/L
WNL

Globulin

indicator of heart
disease since the client
si hypertensive.

HDL
LDL

High glucose, cholesterol

and LDL level may be an

0 5.2 mmol/L
Lipid profile can

Triglyceride

8.16 HIGH
9. 30 HIGH

range

Cholesterol

67.5

62 85 g/L
WNL

A/G Ratio

35 53 g/L
27 32 g/L
1.5 2 .5 g/L

WBC

CBC determines

5.0 10.0 x 109/L

15.2 HIGH

This signals a response

Neutrophils

blood oxygen levels,

40 60 %

79.8 HIGH

to bacterial infection

Eosinophils

inflammatory

16%

WNL

Basophils

response, or

01%

WNL

RBC

presence of infection 4.5 5.5 x 109/L

WNL

Hemoglobin

125 160 g/L

WNL

Hematocrit

0.38 0.50 L/L

WNL

MCV

80 100 fL

WNL

MCHC

320 360 g/dL

WNL

Platelet

150 450 x 109/L

WNL

VI.

NURSING CARE PLAN

Assessment
Subjective
data:
Nahihirapan
akong
huminga, hindi
ko malabas
yung plema
ko, as
verbalized by
the pt.
Objective data:
-abnormal
breath sound
-use of
accessory
muscles
-having
difficulty in
vocalizing
- restlessness
- RR 42 cpm
-O2 sat 92

Nsg.
Diagnosis
Ineffective
airway
clearance
related to
difficulty in
breathing as
evidenced
by presence
of abnormal
breath
sounds, use
of accessory
muscle,
restlessness
and difficulty
of vocalizing

Planning

Intervention

After 2
hours of
nursing
intervention
s, airway
patency of
the patient
will be
maintained
and signs of
dyspnea
will be
lessen.

Positioned the client

to High-fowlers
position.

To promote lung
expansion.

Noted the ability to

remove secretions
or cough effectively

Expenditures are
difficult when there
are thick secretions
and sputum

Moistened the air /

oxygen inspiration
Monitored breath
sounds from time to
time
Closely monitored
respiration rate and
02 saturation
Encouraged the
client to do deep
breathing and
coughing exercises.
Dependent
Nebulized the
patient with
Salbutamol +
ipratropium as
ordered

Rationale

Prevents drying of
mucous membranes
To check for the
accumulation of
secretions or
respiratory blisters

To maximize breathing
effort

Bronchodilator

Evaluation
After 2 hours of
nursing
interventions,
airway patency of
the patient has
been maintained
and signs of
dyspnea has been
lessened.

Administered
Fluimucil as ordered

Assessment

Nsg.
Diagnosis

Planning

Intervention

Mucolytic, will help

with the secretions

Rationale

Evaluation

Subjective
data:
Nahihirapan
akong kumilos,
parang ang
bigat ng likod
at dibdib ko.
as verbalized
by the patient
Objective data:
-weakness
-dyspnea
-tiredness
-limited ROM
- PR 104 bpm
- BP 180/90

Activity
intolerance
r/t
imbalanced
O2 supply
and demand
AEB:
Patients
statement,
Nahihirapan
akong
kumilos,
parang ang
bigat ng
likod at
dibdib ko.
weakness,
tiredness,
dyspnea,
limited ROM
and ABN
BP/pulse
response to
activity

After 8
hours of
nursing
care, the
patient will
report
measurable
increase in
activity
intolerance
with vital
signs within
normal
range

Positioned the client

to High-fowlers
position.

To promote lung
expansion.

Provide positive and

calm atmosphere

Helps minimize
frustrations,
rechanneling energy

Assist patient in
self-care activities
Monitor response of
patient to an
activity and
recognize the signs
and symptoms

To promote comfort
To indicate need to
alter activity level

Encourage patient
to have adequate
bed rest and sleep

To promote relaxation
of the body

Instruct to avoid
straining during
defecation

Valsalva maneuver
may disrupt blood
flow

Dependent
Administer Oxygen
therapy as indicated To provide sufficient
oxygenation of tissues

VII.

DRUG STUDY

After 2 hours of
nursing
interventions,
airway patency of
the patient has
been maintained
and signs of
dyspnea has been
lessened.

DRUG/CLASS
SPIRONOLACT

ACTION
Blocks

INDICATION
Adjunctive

CONTRAINDIC
ATION
Allergy to

ADVERSE
EFFECTS
Headache,

NSG
INTERVENTIONS
- Avoid giving food

ONE

aldosterone,

therapy in the

aldactone,

drowsiness,

rich in potassium
- Advise to change

K-sparing

causing loss

TX of edema

renal disease,

cramping,

diuretic

of sodium and

assoc w/ HF,

anuria,

diarrhea,

water, and

hypokalemia

hyperkalemia

hyperkalemia

retention of
CLOPIDOGREL

potassium
Blocks ADP

At risk for

Allergy to

Headache,

BISULFATE

receptors to

ischemic

clopidogrel,

dizziness, rash,

Anti-platelet

inhibit

events, Tx for

PUD,

GI bleeding

platelet

acute

intracranial

aggregation

coronary

hemorrhage

syndrome

u/c bleeding d/o,

- if headache,
arrange for
analgesics
- Small frequent

increased
bleeding

ATORVASTATI

Inhibits the

Reduction of

impairment
Active liver

enzyme

elevated total

disease or

nausea, cough,

Dyslipidaemic

(HMG-CoA)

&LDL

elevated serum

HPN,

Agents

that catalyzes

cholesterol

transaminases

palpitation, liver

cholesterol

>3 times the

failure

synthesis

upper limit of

Reduces the

normal
Use IV

Adjunct

electrolytes

meals
- Monitor for

hepatic

ACETYLCYSTE

positions slowly
- Monitor

Headache,

- Review lipid
profile, TPAG
results
- Give drug at
bedtime
- Provide comfort
measures

nausea,

Drug is physically

INE

viscosity of

therapy for

formulation

vomiting, and

or chemically

Acetadote,

pulmonary

abnormal

cautiously in

diarrhea or

incompatible with

Mucomyst

secretions by

viscid or

patients with

constipation

tetracyclines,

splitting

thickened

asthma or a

erythromycin

disulfide

mucous

history of

lactobionate,

linkages

secretions in

bronchospasm

amphotericin B,

between

patients with

and ampicillin

mucoprotein

pneumonia

sodium.

molecular
complexes
OMEPRAZOLE

Suppresses

Short-term

Long-term use

headache,

Monitor urinalysis

Proton Pump

gastric acid

treatment of

for

dizziness,

for hematuria and

Inhibitors (PPI)

secretion by

active

gastroesophage

asthenia,

proteinuria.

inhibiting the

duodenal

al reflux

vertigo,

Periodic liver

H+, K+-

ulcer; First-

disease,

insomnia,

function tests with

ATPase

line therapy

duodenal ulcers;

enzyme

in treatment

lactation

system [the

of heartburn

acid (proton

or symptoms

H+) pump] in

of

the parietal

gastroesopha

cells.

geal reflux
disease

prolonged use.

IPRATROPIUM

Anticholinergi

Bronchodilato

Contraindicated

CNS: dizziness,

Teach the patient

c drug which

r for

with

blurred vision

pursed-lip

SALBUTAMOL

relaxes

maintenance

hypersensitivity

GI: nausea, dry

breathing,

Anticholinergi

smooth

therapy of

to atropine or its mouth

diaphragmatic

muscle in the

bronchospas

derivatives

breathing, and

lung

m.

PIPERACILLIN

Interfere with

nosocomial or

Hypersensitivity

diarrhea,

Monitor for

bacterial cell

community-

to penicillins,

nausea,

hemorrhagic

TAZOBACTAM

wall synthesis

acquired

cephalosphorins

constipation,

manifestations

Anti-

promotes loss

pneumonia

, or other drugs

vomiting,

because high dose

pseudomonal

of membrane

caused

pseudomembra

may induce

penicillin

integrity and

piperacillin-

nous colitis

coagulation

chest splinting

leads to death resistant,

of the

piperacillin/

organism

tazobactam

abnormalities

susceptible
ENOXAPARIN

Potentiates

Acute and

Intramuscular

Hemorrhage

Give only by deep

Anticoagulant

the actions of

extended

use.

Anemia

SC while lying

, low

an

prophylaxis of

Use with

Injection site

down. Do not mix

molecular

endogenous

deep-vein

prosthetic

hematoma

with other

weight

inhibitor of

Heparin

blood

LOSARTAN

coagulation
Inhibits

Hypertension,

thrombosis
Patients

dizziness,

Monitor patients

vasoconstricti

to reduce risk

hypersensitive

asthenia,

who are also

ve and

of CVA in

to drug, breast-

fatigue,

taking diuretics for

aldosterone-

patients with

feeding is not

headache,

symptomatic

secreting

hypertension

recommended

insomia

hypotension

action of

and left

angiotensin II

ventricular

by blocking

hypertrophy

angiotensin II
receptor

thrombosis

valves due to

Nausea

possible valve

injections/infusion
s