CHF Revised

I.
INTRODUCTION
A. OVERVIEW
Heart failure, sometimes referred to as congestive heart failure, is the
inability of the heart to pump sufficient blood to meet the needs of the tissues for
oxygen and nutrients. Heart failure is a clinical syndrome characterized by signs
and symptoms of fluid overload or inadequate tissue perfusion. The underlying
mechanism of the heart failure involves impaired contractile properties of the
heart (systolic dysfunction) or filling of the heart (diastolic) that leads to a lower-
than-normal cardiac output. The low cardiac output can lead to compensatory
mechanisms that cause increased workload on the heart and eventual resistance to
filling of the heart.
Heart failure is a life-long diagnosis managed with lifestyle changes and
medications to prevent acute congestive episodes. Congestive heart failure is
usually an acute presentation of heart failure. Common underlying conditions
include coronary atherosclerosis (primary cause), valvular disease,
cardiomyopathy, inflammatory or degenerative muscle disease, and arterial
1
I. INTRODUCTION
hypertension. A number of systemic factors can contribute to the development and
severity of cardiac failure. Increased metabolic rate (fever, thyrotoxicosis),
hypoxia, and anemia require an increased cardiac output to satisfy systemic
oxygen demand. Dysrhythmia decreased the efficiency of myocardial function.
Source: Johnson, Joyce Young. Handbook for Brunner & Suddarth’s Textbook of Medical –
Surgical Nursing, Eleventh Edition. Lippincott Williams & Wilkins.
Clinical Manifestations
 Symptoms of inadequate tissue perfusion
 Diminished cardiac output with accompanying dizziness, confusion,
fatigue, exercise or heat intolerance, cool extremities, and oliguria
 Congestion of tissues
 Increased pulmonary venous pressure (pulmonary edema) manifested by
cough and shortness of breath
 Dysrhytmia may indicate heart failure or may be noted as a result of the
treatment for heart failure.
 Increased systemic venous pressure, as evidenced by generalized
peripheral edema and weight gain
Left-Sided Heart Failure
Most often precedes right-sided heart failure
Backward Failure
 Pulmonary congestion; cough; fatigability; tachycardia with an S3 heart
sound; anxiety; restlessness
2
I. INTRODUCTION
 Dyspnea on exertion (DOE), orthopnea, paroxysmal nocturnal dyspnea
(PND)
 Cough may be dry and nonproductive but is most often moist.
 Bibasilar crackles advancing to crackles in all lung fields
 Large quantities of frothy sputum, which is sometimes pink (blood tinged)
Forward Failure
Tachycardia, weak, thread pulse, anxiety, oliguria and nocturia, altered digestion,
ashen, pale, cool and clammy skin
Right-Sided Heart Failure
 Congestion of the viscera and peripheral tissues
 Edema of lower extremities (dependent edema), usually pitting edema,
weight gain, hepatomegaly
 Distended neck veins, (jugular vein distention), ascites, anorexia, and
nausea
 Nocturia and weakness
Source: Johnson, Joyce Young. Handbook for Brunner & Suddarth’s Textbook of Medical –
Surgical Nursing, Eleventh Edition. Lippincott Williams & Wilkins.
3
I. INTRODUCTION
B. STATISTICAL DATA
Local
The prevalence rate was 1.6% or 1648 cases of CHF for every 100 000
patient claims for medical conditions in 2014. The mean age was 52.6±15.1 years.
There was no sex predilection. Only 22.67% of the hospitalization claims for CHF
listed possible specific etiologies, the most common of which was hypertensive
heart disease (86.7%). There were more cases of systolic compared to diastolic
heart failure. The mean length of hospital stay was 5.9 days (+8.2) days (median 4
days), with an overall in-hospital mortality rate of 8.2%.
There were 16 cases of heart failure for every 1000 Filipino patients
admitted due to a medical condition in 2014. Hypertension was possibly the most
common etiologic factor. Compared to western and Asia-Pacific countries, the
local mortality rate was relatively higher.
Source: http://pubmedcentralcanada.ca/pmcc/articles/PMC5372042/
International
The number of adults living with heart failure increased from about 5.7
million (2009-2012) to about 6.5 million (2011-2014), according to the American
Heart Association’s 2017 Heart Disease and Stroke Statistics Update.
Based on the latest statistics, the number of people diagnosed with heart
failure, which means the heart is too weak to pump blood throughout the body, is
projected to rise by 46 percent by 2030, resulting in more than 8 million people
adults with heart failure. According to experts, there are several reasons for the
4
I. INTRODUCTION
rise in heart failure, that can be attributed to medical advances, because more
people are surviving heart attacks which means they face higher heart failure risk
afterward, said Paul Muntner, Ph.D., a member of the statistical update’s writing
panel and a professor and vice chair in the Department of Epidemiology at the
University of Alabama at Birmingham. But the aging of America and other health
problems are also major contributors.
C. SCOPE AND LIMITATION
On the 1st March of 2018, student nurses were assigned at Laguna Medical
Center, Santa Cruz, Laguna, Medical Ward from 6 am to 3 pm shift under the
supervision of Ma’am Ma. Janice M. Bernardo, MAN, MSN. The patient was
received lying in bed, with IV Heplock & Foley Catheter. The assigned student
nurses includes head-to-toe assessment, monitoring and recording of vital signs,
IV regulation, charting the patient’s data and nurse’s management, and providing
health teachings are part of their duty.
After the patient’s confinement, the assigned student nurses decided to
conduct a phone call instead of home visit due to the worsening condition of the
patient. A phone call was carried out for further health history & assessment and
also to grasp the patient’s progress last April 21, 2018. During the phone call, the
assigned student nurses clarify their intentions and motives, they also asked the
wife of the patient to permit them to ask questions, and as a result, they had
willingly participated all throughout the interview.
5
I. INTRODUCTION
D. BACKGROUND OF THE STUDY
This case study aims to identify patient’s problems and health needs in
order to promote the general health of the patient by providing proper
interventions through the application of nursing process.
This case was chosen by the student nurses for them to practice their
skills in formulating and implementing a nursing care plan, in conducting a
thorough assessment to help in managing the patient's case and also to develop
their sense of teamwork as they execute their case study with the help of the
concepts in Medical Surgical course, Human Anatomy and Physiology and
other science related studies.
General Objective:
At the end of the case presentation the nursing students from BSN III-A
will be able to gain knowledge and comprehend their case even more, and also to
further understand and gain extensive knowledge form the case.
Specific Objectives:
 The student will be able to enumerate the predisposing and precipitating
factors that contribute to Congestive Heart Failure.
 Provide a thorough assessment and data gathering that could help and a
significant factor in formulating a nursing care plan.
 State and identify the appropriate nursing diagnosis and make
interventions.
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I. INTRODUCTION
 Provide specific and suitable health teachings to promote awareness.
 Plan appropriate nursing care intervention.
 To implement plan of care.
 To formulate an individualized nursing care plan.
 Provide health teaching to the patient or to the significant others.
 Determine the effectiveness of every plan and the outcome for the health
education provided.
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II. PATIENT’S PROFILE
Case No.: 166345
Patient’s Name: Hil
Address: Calauan, Laguna
Gender: Male
Birthday: July 22, 1992
Age: 25 years old
Nationality: Filipino
Civil Status: Married
Allergies: No known allergies
Admitting Time: 12:10 PM
Admitting Date: February 23, 2018
Admitting Diagnosis: t/c CHF
Principal Diagnosis: CHF
Admitting Physician: Aileen M. Abadier, MD
Chief Complaint: Generalized Edema

III. PATIENT’S HISTORY
A. Present History
Prior to admission, Patient Hil was experiencing progressive generalized
edema for the last 5 months. Upon admission, the patient was also accompanied
by difficulty in breathing, dizziness, and fatigue besides the generalized edema.
First the edema was only on lower peripheries but as the day goes by, the
edema evolves also on upper extremities. The patient also experiences paroxysmal
nocturnal dyspnea (PND), orthopnea, and cough during the last 5 months. The
patient also realized that there’s an increase in the girth of his abdomen. At times,
the patient also experiences nausea and vomiting.
To relieve the symptoms of what the patient is enduring, the patient took
medication such as Robitussin (guaifenesin). The patient also apply or inhale
Vicks when the nausea and vomiting attacks.
Before the day of hospitalization, February 22, 2018, prior to sleeping the
patient experiences difficulty of breathing but was relieved later on and then at the
middle of the night, the patient were awaken due to shortness of breath. At the
morning, the patient and his family was beginning to be anxious and worried
because of the edema on his face.
During the hospitalization last March 1, 2018, the patient was handled by
one of the Group 2 students and was physical assessed and was taken vital signs.
For the 8 am, the vital signs were BP=140/80, T=36.2, P= 96 bpm, R= 20cpm.
The patient was experiencing shortness of breath with shallow breathing, so the
patient was administrated with Oxygen via Nasal Cannula at 3 liters per minute as
ordered by the doctor. At 12 pm, the patient's blood pressure is 120/100, P= 79
bpm, R= 22 cpm, T= 36.2. The intake measured was 450 ml and output calibrated
was 150 ml.
At the second handling of the patient last March 7, 2018, the assigned
student nurse was able to talk to the patient with a good mood. At the lunch, the
patient’s irritability came back. The patient at that time was able to sit by himself
but even though he has the endurance to do it, a facial grimacing can be seen due
to the illness. The difficulty in breathing subsided but there was still an
irregularity in his intake and output. The intake measured was 250 ml and output
calibrated was 100 ml. The patient’s vital sings in the morning was BP = 130/100,
P = 95, T= 36.4, R = 26. At the afternoon, BP = 120/90, P = 110, R = 24, and T =
37.
B. Past History
General: Patient Hil was already exposed in alcohol and cigarettes when he was
only 13 years old. At 18 years old, the patient was starting to have elevated blood
pressure, ranging from 130/90 – 140/80.
Infectious Diseases:
Before Hospitalization During Hospitalization
Common colds, cough, fever, measles,
mumps, chicken pox
Allergy: No known allergies
10
Transfusions: None
Hospitalizations, Operations, Injuries: No past hospitalization, operation, or
injury.
C. Family History
Narrative:
According to the patient, they have history of heart diseases. For the
patient's family history, hypertension and MI runs in the family. For the siblings
11
of the patient, there is no presence of heart diseases except for the patient,
diagnosed with CHF.
D. Developmental History
Erik Erikson's Psychosocial Development
Stage 6: = 18 – 40 y/o – “Intimacy vs. Isolation”
Description:
Stage six of the Erikson stages is very apparent for young adults who are
in their 30s. People at this stage become worried about finding the right partner
and fear that if they fail to do so, they may have to spend the rest of their lives
alone.
The patient was married at 20 years old and has children of 3. The
patient’s wife supports him to the fullest. The wife always visits and the one
who’s takes care of the patient. The patient told the students that he was very
lucky to have his wife and assists him back to health. The patient has no problem
with the relationship with his wife. The patient’s wife spends most of her time to
aid her husband. The children also lessen the patient’s enduring symptoms which
makes the patient slightly improve his emotional and psychological well-being.
E. Socioeconomic
The patient is living in the house with his family. When he was younger,
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he had work. He assists in the carpenters in a construction site in his town. Thus
the patient was influenced in drinking alcohol and smoking cigarettes. Before the
hospitalization, the patient was working as a carpenter of making houses near he
lives. The wife of the patient handles their small sari-sari store. The business that
they are handling is where they also get from all the expenses they need to support
the patient’s needs.
According to the wife, during and after the hospitalization the patient
becomes very picky in food. So they need to spend a lot to satisfy the requests of
her husband even though sometimes they are near to scarcity.
F. Psychological
The patient was always sleeping and hardly to move due to his condition.
The patient responds occasionally. The wife said that sometimes you will not have
the interest to talk to him because due to snobbish behavior and he became very
irritable. Sometimes when the wife tries to have a conversation with him, the
patient will shrew at her telling that why she has that tone of voice. The daughter
also said that when the patient endures pain as verbalized by the patient, he
becomes very irritable and disoriented to the point that you can no longer talk to
him.
G. Socio-cultural
During his younger days, the patient spends a lot of time working and
studying if he must. He was always drinking liquors and smoking cigarettes with
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his co-workers and classmates. After the stroke, he stopped hanging out with his
co-workers and friends; he also stopped drinking and smoking.
H. Spiritual
The family is affiliated to Roman Catholic. According to the patient’s
wife, their family attends to church regularly, every Sunday, and always prays and
asks for God's guidance.
After the hospitalization, the patient believes that God has still purpose for
him.
I. Nutrition
BEFORE DURING AFTER
The patient likes eating During hospitalization, After hospitalization, the

salty and fatty food like the patient eats 3 times a patient has increased
fried chicken and any day, he regularly eats appetite, he likes eating
meat dishes. When porridge. His intake was porridge, goto, and
vegetables are only in the 450 ml (February 28, always like having extra
entrée, he always 2018) and 250 ml (March rice. He drinks water 6 –
requests for some meat. 7, 2018) 7 glasses per day.
The patient also likes
eating lots of rice, or any
high in carbohydrates.
Before the
hospitalization, the
patient was having a hard
time eating due to his
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generalized edema.
J. Elimination
BEFORE DURING AFTER
URINATION
Before the During the After the hospitalization,

hospitalization, according hospitalization, the the patient regularly
to him, regularly voids 5 patient was in diaper and changes diaper for 2 – 3
times a day. Foley Catheter, the times a day.
output calibrated was 150
ml (February 28, 2018)
and 100 ml (March 7,
2018)
DEFECATION
Before the During the After the hospitalization,

hospitalization, the hospitalization, the the patient on his diapers
patient defecates 1 to 2 patient on his diapers defecated 2 – 3 times a
times a day with defecates 0 to 1 times a day with unknown
unknown consistency. day. consistency.
K. Exercise
BEFORE DURING AFTER
Before the hospitalization During hospitalization, After hospitalization, the

and the appearance of the patient stops his daily patient tries to stretch his
manifestations, the routine exercise due to limbs every morning.
patient regularly walks his illness.
before going to work.
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L. Hygiene
BEFORE DURING AFTER
Before hospitalization, During hospitalization, After hospitalization, the

the patient usually takes a the patient’s wife wife of the patient assists
the patient to the
bath once and brushes his provides hygienic care
bathroom and for
teeth twice every day. for him with the help of brushing his teeth; the
And during at night the assigned student wife will hand over a
small basin with water
before sleeping, he cleans nurse by changing
and his toothbrush with
himself and changes his clothes. toothpaste.
clothes to provide
comfort.
M. Sleep & Rest
BEFORE DURING AFTER
Before hospitalization, During hospitalization, After hospitalization, the

the patient sleeps normal. the patient sleeps most of patient had difficulty of
The patient sleeps at 9 the time but awakes due sleeping because the
pm and wakes at 6 or 7 to dyspnea. patient feels any time he
am for his work. will die due to his
dyspnea.
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IV. DIET PLAN
DIET PLAN
Wt. = 74 kg
Ht. = 5 feet 7 inch = 170.18 cm
BMI = 74/(1.70)2 = 25.55
DBW = 170.18 – 100 = 70.18 kg
= 70.18 – 7.02 (10% of 70.18)
=63.16 or 63 kg/s
NDAP = 112 lbs + 7(4)
= 112+28
= 140 lbs/2.2 = 63.6 kg
TEA = 64 kg x 27.5 = 1760 kcal
CHO = 65% = 0.65 x 1760 = 1144 kcal/4 = 290g
CHON = 20% = 0.20 x 1760 = 352 kcal/4 = 90g
FATS = 15% = 0.15 x 1760 = 264 kcal/9 = 30g
SAMPLE CALCULATION
Diet Prescription: 1760
FOOD NO. CHO CHON FAT ENERGY

EXCHANGES (g) (g) (g) (kcal)
Veg., List 2 3 1 16
I-A
Veg., List 1 3 1 16
I-B
Fruit, List 3 30 120
II
Milk, List 1 12 8 5 125
III
Sugar List 7 35 140
VII
Partial Sum = 83
290 (prescribed CHO)
- 83 (partial sum of CHO)
207/23 = 9 no. of rice exchanges
IV. DIET PLAN
Rice, List 9 207 18 900

IV
Partial Sum = 28
90 (prescribed CHON)
- 28
62/8 = 8 no. meat exchanges
Meat, List 6 48 6 246
Va
Meat, List 2 16 12 172
Vb
Partial Sum = 23
30 (prescribed fat)
- 23
7/5 = 1 no. of fat exchanges
Fat, List 1 5 45
VI
TOTAL 290 92 28 1780
Breakfast AM Snack Lunch PM Snack Dinner
- Apple - Orange - Sitaw at - Binatog - Chicken

(65g) Juice (2 Kalabasa (1/2 cup) Curry
- Oatmeal tsp)  Sitaw - Coffee (2  Carrots
(1/2 cup) - Ham (1/2 cup) tsp sugar) (1/2 cup)
(2 tsp Sandwhic  Squash  Potato
sugar) h (1/2 cup) (390
- Boiled  Pan de - Buttered cups)
Chicken’s American Shrimp  Chicken
Egg (1 pc) o (2  Shrimp Breast
- Bear slice) “Sugpo” (90g)
Brand  Ham (1 (50g)  Corn Oil
Sachet slice)  Butter (2 (3 tsp)
Low Fat tsp) - Rice (80g)
Milk (250 - Rice (160 - Ice Cream,
g) g) regular
- Biko (40 (90g)
g) - Fruit
- Banana Cocktail
“lakatan” (1/4 cup)
(80g)
V. PHYSICAL ASSESSMENT
PHYSICAL ASSESSMENT
Assessment Method Findings Implications

Integumentary
Skin Inspection With dry Dry skin on the lower part
appearance of the legs because of
pressure from inside the
tissue.
Reference: https://medical-
dictionary.thefreedictionary.com/oe
dema
Cold, clammy
Over-activity of the
skin
sympathetic nervous system.
This leads to narrowing of
arteries and excessive
stimulation of sweat glands.
This means that less blood
flow to the skin makes
them cold and clammy at the
time when the excessive
stimulation to the sweat
glands makes the skin wet.
Reference: https://medical-
dictionary.thefreedictionary.com/oe
dema
Nails Inspection With pale Prolonged capillary refill time

appearance of indicates compromised
nail beds, arterial perfusion.
capillary refill Reference:Brunner & Suddarth’s
time of 3 Textbook of Medical Surgical
Nursing 13th Edition, Chapter 25,
seconds. p667.
If your fingernail beds are

looking a little ghostly, you
may have anemia, a blood
disorder characterized by a
low red blood cell count.
“Anemia resulting from low
levels of iron can lead to
inadequate oxygen in the
blood, which causes the skin
and tissues to become pale,
particularly the tissues under
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the nails
Reference:
https://www.shape.com/lifestyle/bea
uty-style/7-things-your-nails-can-
tell-you-about-your-health
Eyes and Vision

Eyelids Inspection Puffy eyes Heart problems can contribute
to “Bags under the eyes.”
And puffy eyes may actually
be the first sign of a medical
problem. That’s because
puffy eyes often become
more noticeable with any
condition that causes fluid
retention.
Reference:
https://www.youtube.com/watch?v=
bn0s576wX8w
Palpebral Inspection Pale Paleness is due to inadequate
conjunctiva circulation of oxygens.
Decreased perfusion and
vasoconstriction
Reference:Brunner & Suddarth’s

Textbook of Medical Surgical
Nursing 13th Edition, Chapter 60
p.1759 and Unit 7, p.902
Mouth and Inspection With dry lips Causes of chapping and cracking
Oropharynx in the corners of the lips is due
difficulty of breathing and
inadequate supply of blood.
Reference: Live Strong (2015)

Retrieved From
http://www.healthline.com/health/
pneumonia
Neck Inspection Jugular Vein Increased venous pressure

distention leads to jugular venous
distention and increased
capillary hydrostatic pressure
throughout the venous
system.
20

p799.
Chest and Lungs

Heart Auscultation With Cardiac Atrial fibrillation is an
Rate of uncoordinated artrial
128 bpm, electrical activation that
Irregular rapid causes a rapid, disorganized,
heartbeats, and uncoordinated twitching
tachyarrythmia of atrial musculature.
(atrial
Palpation fibrillation) Reference:Brunner & Suddarth’s
p703.
Pulse deficit is a clinical sign

Radial Pulse of wherein, one is able to find a
96 bpm difference in count between
heart beat (Apical beat or
Auscultation Heart sounds) and peripheral
pulse.
This occurs even as the heart
is contracting, the pulse is not
reaching the periphery.
Reference:
https://drsvenkatesan.com/2008/08/
Respiratory 13/what-is-pulse-deficit-what-is-
the-mechanism-of-pulse-deficit-
Tract where-does-it-occur/
The shortness of breath may

be accompanied by fatigue or
a sensation of smothering or
Respiratory sternal compression. In the
rate of 26 cpm later stages of left ventricular
failure, the pulmonary
circulation remains
congested,
and dyspnea occurs with mild
exertion. Moreover, the
patient may develop
orthopnea or paroxysmal
nocturnal dyspnea.
21
Reference:
https://www.ncbi.nlm.nih.gov/books
/NBK213/
Pulmonary edema secondary
to left-sided congestive heart
With
failure can also cause rales
adventitious
breath sounds
of rales Reference:
https://www.practicalclinicalskills.c
om/rales
Abdomen Inspection Abdominal Portal hypertension and the

distention – resulting increase in capillary
abdominal pressure and obstruction of
girth of 103 venous blood flow through
cm. the liver are contributing
factors.

p475.
Lower Inspection Presence of Peripheral edema is a

extremities edema both common finding in patients
legs, graded 3+ with CHF and peripheral
6mm vascular diseases. Such as
deep vein thrombosis and
chronic venous insufficiency.
p1765.
Presence of
Because of changes in
ulcer both legs
peripheral nerves, infection
begin and if left untreated
may lead to ulceration.
Ulceration unresponsive to
treatment are leading cause of
diabetic foot and amputation.
22

p1765.
Mental Status
Level of Inspection Aware and Awareness is the ability to
Consciousness alert. directly know and perceive, to
(March 1, feel, or to be cognizant of
2018) events. More broadly, it is the
state or quality of being
conscious of something.
Alertness is the state of active

attention by high sensory
awareness such as being
watchful and prompt to meet
danger or emergency.
Retrieved
from:www.psychologydictionary.co
m
23
VI. ANATOMY AND PHYSIOLOGY
The cardiovascular system consists of the heart, which is an anatomical
pump, with its intricate conduits (arteries, veins, and capillaries) that traverse the
whole human body carrying blood. The blood contains oxygen, nutrients, wastes,
and immune and other functional cells that help provide for homeostasis and basic
functions of human cells and organs.
The pumping action of the heart usually maintains a balance between
cardiac output and venous return. Cardiac output (CO) is the amount of blood
pumped out by each ventricle in one minute. The normal adult blood volume is 5
liters and it usually passes through the heart once a minute.
The cardiac cycle refers to events that occur during one heart beat and is
split into ventricular systole (contraction/ejection phase) and diastole
(relaxation/filling phase). A normal heart rate is approximately 60 - 100bpm, and
24
the cardiac cycle spreads over 0.8 seconds. The heart sounds transmitted are due
to closing of heart valves, and abnormal heart sounds, called murmurs, usually
represent valve incompetency or abnormalities.
Blood is transported through the whole body by a continuum of blood
vessels. Arteries are blood vessels that transport blood away from the heart, and
veins transport the blood back to the heart. Capillaries carry blood to tissue cells
and are the exchange sites of nutrients, gases, wastes, etc.
The heart is a muscular organ weighing between 250-350 grams located
obliquely in the mediastinum. It functions as a pump supplying blood to the body
and accepting it in return for transmission to the pulmonary circuit for gas
exchange.
The heart contains 4 chambers that essentially make up 2 sides of 2
chamber (atrium and ventricle) circuits; the left side chambers supply the
systemic circulation, and the right side chambers supply the pulmonary
circulation. The chambers of each side are separated by an atrioventricular valve
(A-V valve). The left-sided chambers are separated by the mitral (bicuspid) valve,
and right-sided chambers are divided by the tricuspid valve. Blood flows through
the heart in only one direction enforced by a valvular system that regulates
opening and closure of valves based on pressure gradients.
25
The systemic circuit originates in the left side of the heart and functions by
receiving oxygen-laden blood into the left atrium from the lungs and flows one
way down into the left ventricle via the mitral valve. From the left ventricle,
oxygen rich blood is pumped to all organs of the human body through the aortic
semilunar valve.
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VII. PATHOPHYSIOLOGY
PRECIPITATING FACTORS:
 Early exposure to
PRE-DISPOSING FACTORS:
smoking (Age 13)
 Family history of
 Early alcohol
hypertension
consumption, 3-6
 Chronic Hypertension bottles/week (Age 13)
 Increased fatty food

intake
Thick ventricles and stiff heart

muscles
Blood back up
Decreased cardiac output

and stroke volume
Increased
heart rate RAAS Activation
(110 bpm)
 Pulmonary edema
Sodium and Fluid retention
(dyspnea with RR of
26cpm)
 Sodium
 Peripheral edema level (132
Volume overload
(bipedal grd.3 6mm meq/L)
and ascites of
104cm)  Anasarca
 Bipedal pitting
edema grd. 3 From right ventricle to From left ventricle to the
(6mm) vena cava lungs
 Ascites (104cm
abdml girth)
27
Decreased blood Decreased blood

flow to the lungs flow to the body
 Bipedal pitting
edema grd. 3
Peripheral edema/ Pulmonary edema
(6mm)
jugular vein distention ()
 Ascites (104cm)
 Adventitious Weak
breath sound pulse/dyspnea
(rales)
 Dyspnea
(26cpm)
CONGESTIVE HEART FAILURE
28
29
30
VIII. DIAGNOSTIC PROCEDURES
Blood Chemistry 3 –Febuary 26, 2018
PARAMETER NORMAL RESULT INTERPRETATION IMPLICATION
White Blood Cell 4-10 11.7 HIGH An increased count (leukocystosis) commonly signals
(x10^9/L) infection, such as an abscess.
Source: Nurse’s Quick Check, Diagnostic Tests,
Lippincott Williams & Wilkins, 2006
Since the patient also has ulcerations on his lower limbs.
Hemoglobin 130 – 180 118 LOW A low hemoglobin count may be a sign of a disease or
(g/L) condition which needs medical attention, because it could
lead to inadequate oxygenation of the vital organs.
Reference:
http://www.md-health.com/Low-Hemoglobin.html
Since the patient has right sided heart failure, it now

affects the systemic circulation of blood in the different
systems of the body that would lead to impairment of
some of the vital organs.
Segmented 55-65 89.9 HIGH The presence of mature, hypersegmented neutrophils that
Neutrophils (%) have more nuclear segments than normal indicate hepatic
disease.
Source: Nurse’s Quick Check, Diagnostic Tests,
Lippincott Williams & Wilkins, 2006
The patient has ascites and according to the patient’s

ultrasound of liver (February 26, 2018), the patient has
contracted liver with hepatocellular change.
Lymphocytes 25-35 4.2 LOW Low lymphocyte count (LLC) is a common finding during
(%) the systemic inflammatory response, and clinical and
31
animal studies suggest that LCC plays a putative role in

accelerated atherosclerosis. For instance, there is recent
evidence that LLC is associated with worse outcomes in
patients with heart failure, chronic ischemic heart disease
and acute coronary syndromes.
Reference:
https://www.ncbi.nlm.nih.gov/pubmed/21671854
Since LLC is associated with heart diseases, and the

patient was diagnosed with CHF.
February 26, 2018
PARAMETER NORMAL RESULT INTERPRETATION IMPLICATION

VALUE
Sodium 135-145 132 LOW A low sodium level in the blood may result from excess water
mEq/L or fluid in the body, diluting the normal amount of sodium so
that the concentration appears low. This type of hyponatraemia
can be the result of chronic conditions such as kidney failure
(when excess fluid cannot be efficiently excreted) and
congestive heart failure, in which excess fluid accumulates in
the body. SIADH (syndrome of inappropriate anti-diuretic
hormone) is a disease whereby the body produces too much
anti-diuretic hormone (ADH), resulting in retention of water in
the body.
Reference:
https://www.webmd.boots.com/a-to-z-guides/hyponatraemia
32
Potassium 3.5-5.3 3.0 LOW Dehydration, diarrhoea, excessive sweating (hyperhidrosis) and
mEq/L laxative abuse are common causes of low potassium levels.
It may also be caused by a lack of potassium in the diet;
however, this is uncommon.
Other causes include medicines that affect the amount of
potassium in the body, such as diuretics, also known as water
pills.
Reference:
https://www.webmd.boots.com/a-to-z-guides/low-potassium-hypokalaemia
Creatinine 0.50-1.70 1.94 HIGH Elevated creatinine level signifies impaired kidney function or
kidney disease. As the kidneys become impaired for any reason,
the creatinine level in the blood will rise due to poor clearance
of creatinine by the kidneys. Abnormally high levels of
creatinine thus warn of possible malfunction or failure of the
kidneys.
Reference:
https://www.medicinenet.com/creatinine_blood_test/article.htm
Blood Urea 8.0-25.0 20.73 LOW Low blood urea nitrogen counts can be caused by liver
Nitrogen (BUN) problems, malnutrition, not eating enough protein, or
overhydration.
Reference:
https://www.healthline.com/health/blood-urea-nitrogen-test
33
Febuary 24, 2018
PROCEDURE FINDINGS IMPLICATION

Electrocardiogram (ECG) Atrial Fibrillation Typically characterized by left ventricular dilation and
subsequent systolic dysfunction, this disorder can be
caused by both atrial and ventricular arrhythmias, most
commonly chronic atrial fibrillation.
Reference:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC305772
1/
Febuary 26, 2018

Electrocardiogram (ECG) Rhythm: Tachyarhythmia Heart failure associated with tachyarrhythmias can very
often be reversed by dealing with the underlying
tachyarrhythmia. Typically characterized by left
ventricular dilation and subsequent systolic dysfunction,
this disorder can be caused by both atrial and
ventricular arrhythmias. In tachycardia-induced heart
failure the patient's often debilitating symptoms can be
ameliorated.
Reference:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC305772
1/
34
February 26, 2018
ULTRASOUND Contracted liver with Since the patient has heart failure and the patient’s heart cannot pump enough
hepatocellular change blood throughout the body, there is an inadequacy in the oxygen carried by the
blood. Thus the liver cannot function appropriately and can lead to
impairment.
Dilated intrahepatic duct Biliary obstruction caused by small simple cysts is very rare. We present a
case of biliary dilatation caused by a simple cyst with a 4-cm
diameter. Biliary obstruction caused by a simple cyst is very rare,1–
4
and dilatation of the intrahepatic bile duct in association with tumor
lesions usually indicates malignancy.
Reference:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4254236/
Massive ascites Ascites is defined as the accumulation of fluid in the peritoneal cavity. It is a
common clinical finding, with various extraperitoneal and peritoneal causes,
but it most often results from liver cirrhosis.
Reference:
Brunner &Suddarth’s Textbook of Medical Surgical Nursing 13th Edition,
Chapter 49, p1336
Reactive cholecystitis Inflammation of the gallbladder which can be acute or chronic.
35
Corticomedulary junction The corticomedullary junction of the kidney is seen here, with the cortex in
distinct which can be seen a medullary ray (renal column) extending to the medulla.
Distended bowel Distended bowel syndrome is a condition in which the abdomen becomes
enlarged.
Reference:
https://healthfully.com/distended-bowel-syndrome-5070987.html
36
IX. MEDICAL MANAGEMENT
DATE DOCTOR’S ORDER INTERPRETATION
 9/27/17  Pls. admit to med  Hospital policy designates the exact

4:15 pm procedure that should be followed when
admitting the patient to the holding area or
PR- 102 opening room suite. Admission will help to
O₂ Sat- 95 monitor the client’s condition. The admitting
BP- 110/70 procedure is continued with reassessment of
SPO₂ 98% the patient and allowanced of time for last
HR- 95 minutes question. (references: medical-surgical
HGT- 53 nursing 5th edition by Lewis, Heitkemper and Dirksen
Chapter 17, pages 380)
 The recording of temperature, pulse rate, and

 TPR q shift
respiratory rate part of physical examination.
Acute changes and tends over time are
documented and unexpected changes and
values that deviate significantly from a
patient’s normal values are brought to the
attention of the patient’s primary health care
provider. (references: brunner and Suddarth’s
textbook and medical-surgical nursing 13th edition by
Janice L. Hinkle and Kerry H. Cheever chapter 5
page 67)
 Informed consent is the patient’s

 Secure consent autonomous decision about whether to
undergo a procedure. Before signing the
consent, the risk and benefit of the procedure
must be explained in terms he patient could
easily understand. This is to prepare patient
psychologically and the health workers from
battery. (references: maternal and child health
37
nursing 6th edition by Adele Pilliteri chapter 24, page
658 and Brunner and Suddarth’s textbook of medcal
surgical nursing 13th edition by Janice L. Hinkle and
Kerry H. Cheever chapter 27 page 406)
 Oxygen administration is a treatment that

delivers oxygen gas to breathe. Oxygen
 0₂ administration 2-4
therapy may be prescribed when there is
lpm
a condition that causes the blood oxgen
levels to be too low. (references:
https://www.nhlbi.nih.gov/hea;th/health-
topics/topics/oxt)
 Following a low salt and low fat diet

helps keep blood pressure and swelling
 Low salt and low fat (edema) under control. It can also make
breathing easier if there is a heart failure.
(references: https://www.wedmd.com/heart-
disease/heart -failure/lowsalt/sodium-eating)
 CBC – a complete blood count test gives

important information about the kinds
and numbers of cells in the
 LABS;
blood,especially RBC, WBC, and
 CBC
platelets. Source: http://www.webmd.com/a-to-
z-guides/complete-blood-count-cbc#1
 Several simple urine tests are often

doneby nurses on the nursing units.
These include tests for specific gravity,
38
pH, and the presence of abnormal
 UA constituents such as glucose, ketones,
protein, and occult blood. Source: Kozier
&Erb’s Fundamentals of Nursing 9th edition Unit
8 pg. 808-825
 Help find the cause of common

symptoms such as a cough, shortness of
breath, or chest pain. Find lung
conditions such as pneumonia, lung
cancer, COPD, collapsed lung
 CXR PA,
(pneumothorax) or cystic fibrosis and
monitor treatment for this conditions.
Source: www.webmd.com/heart-disease/cheast-
x-ray
 Deterioration in renal function is

 BUN/CREAT,
manifested by rises in the blood urea
nitrogen (BUN) and creatinine values.
Sources: Barbara K. Timby and Nacy E. Smith’s
Medical and Surgical Nursing 10th edition Unit
19 pg. 909
 an electrolyte test is used to identify

 Na⁺ , K⁺
problems with body’s (salt) balance.
Electrolyte testing may be carried out as
a part of routine blood test, called U+Es.
(references:http://www.webmd.boots.com/a-to-z-
guidestesting-sodium-potassium-and-more)
39
 It measures the amount of glucose in the

 FBS blood to test for diabetes or prediabetes.
Typical fasting time at least 8 hours.
(references:https://www.webmd.com/cholesterol-
managemnet/fasting -blood-tests)
 Electrocardiograhy (ECG) is the graphic

 ECG,
recording of the electrical currents
generated by the heart muscle. Sources:
Barbara K. Timby and Nacy E. Smith’s Medical
and Surgical Nursing 10th edition Unit 6 pg. 310
 A Doppler ultrasound is a test that uses

 Doppler Scan of both
high frequency sound waves to measure
legs
the amount of blood flow through the
arteries and veins, usually those that
supply blood to arms and legs.
(references: https://www.healthline.com/doppler-
ultrasound-exam-of-an-arm-or-leg)
 It is a source of water and electrolytes, it

 Start PNSS 1 L ×
should be used with great care with
KVO
congestive heart failure which there
exists edema with sodium retention.
(references:
http://webcache.googleusercontent.com/Normal_
saline_solution.html)
40
 Burinex1 tab OD  To inhibit sodium and chloride

reabsorption in the ascending loop of
Henle (Sources: Jones &Barlett learning;2011
Nurse’s Drug handbook Tenth Edition)
 Indicated for angina pectoris

 Trimetazidine 35 BID
(Sources: Jones &Barlett learning;2011 Nurse’s
Drug handbook Tenth Edition)
 To reduce thrombolytic events in patients

 Clopidogrel 75 OD
with atherosclerosis documented by
recent stroke, MI, or peripheral arterial
disease.(Sources: Jones &Barlett learning;2011
 Indicated for organic and functional

chronic diseases of the lower limbs;
 Daflon 500 g
heavy legs (Sources: Jones &Barlett
learning;2011 Nurse’s Drug handbook Tenth
Edition)
 To acquire baseline, to aid in assessment

 Monitor BP/CR/HGT
of the cardiovascular system and to aid in
diagnosis of the disease. (references:
https://www.nursingtimes.net/clinical/aarchive/as
sessmentskills.article)
 Indicated in the treatment of insulin

8:49 am  Stat D50-50 Fast Drip hypoglycemia to restore blood glucose
1 vial as ordered by levels.
41
9:15 am Dr. Pestacio thru (references:https://drugs.com/pro/dextrose-
50.html)
HGT- 15O mg/dl phone call

hypoglycaemia to restore blood glucose
9/28/17  D50-50 FD as side
levels.(references:https://drugs.com/pro/dextros
1:20 am drip hold
e-50.html)
(+) seizure
Hct- 50 mg/dl
T- 36.4 C
O₂Sat 98  Give another D50-50
levels.(references:https://drugs.com/pro/dextros
to as SLPE
e-50.html)
 The purpose of the following up

2:20 AM  Ff. up labs laboratories is to determine the patient’s
Hct- 79 mg/dl
outcomes in relation to the desired goals
4 am- 90/70
of therapy.
5am- 59 mg/dl (references:http://www.cpmc.org/learning/labtest
(+) allergy to all s.html)
antibiotics
 Monitor Hgt q 6 Hs blood to test for diabetes or prediabetes.
and q shift (references:https://www.webmd.com/cholesterol-
managemnet/fasting -blood-tests)\
 It is used to prevent or treat certain

infections caused by bacteria.
 Stat Ceftriaxone 1 gm
(references:http://chealth.canoe.com/drug/getdru
q 12 (ANST)
g/ceftriaxone)
42
 Patients receive medications appropriate
to their clinical needs, in doses that meet
9:00 AM  Cont. other meds their own individual requirements, for an
Hgt- 48 mg/dl adequate period of time.
(+) DM- meds (references:httpapps.who.int/medicinedocs/en/d/J
1:05 aft Hgt 107 h3011e/1.html)
mg/dl
O₂ Sat 96%
Med Hx  To keep clean and dry at all times to
DM- prasions  Daily dressing of promote healing
Check-up done here (references:http://health.canoe.com/drugchangin
wound
g-dressing)
at PPL
BP- 160/100
Multiple drug
allergies not known  Hook 2 vials D50-
levels. (references:
to informant 50 as side drip
https://drugs.com/pro/dextrose-50.html)
 Intravenous Fluids restore tissue

perfusion by optimizing intravascular
 IVF TF: D5NSS 1
volume, supporting the pumping action
L + D50-50 I vial
of the heart and improving the
× KVO
competence of the vascular system.
Sources: Brunner and Suddarth’s Textbook
Nursing Chapter 15 pg. 301
 This position allows for improved

breathing due to chest expansion and
 Moderate high
oxygenation.
back rest
(references:http://www.nursefrontier.com
-position-definition/explanation)
 To treat various conditions such as
43
 Hydrocortisone arthritis,severe allergies, blood
250 mg IV now diseases,breathing problems, and skin
diseases.(references: Jones &Barlett
Edition)
 Treatment and prevention for angina

pectoris.(references:nursingcrib.com/drug-
 Isoket 10 mg +
guides/)
D5W 90 ml via
soluset × 10
mgtts/min
 Require for close observation and

Crea 1.94  Transfer to ICU
monitoring.
K- 3 U
(references:http://cpmc.org/learning/documents/i
cu-ws.html)
CXR- severe
cardiomegaly  To prevent ischemic complications of
r/o Pneumonia  Enoxaparin 40 RU unstable angina.(references: Jones &Barlett
(+) Pneumonia Sc q 12 learning;2011 Nurse’s Drug handbook Tenth
(+) low first wound Edition)
4:45 pm
Hgt- 43 mg/dl
 IVF to follow perfusion by optimizing intravascular
 Start PNSS 1 Liter  It is a source of water and electrolytes, it
+ 40 mg KCL × should be used with great care with
44
KVO congestive heart failure which there
(references:
 To prevent hypokalemia
 KCL 600 g 1 Tab
(references: Jones &Barlett learning;2011
BID c meals × 3 Nurse’s Drug handbook Tenth Edition)
days then repeat
serum ,
 Discontinuation of such medications

 D/C Daflon involves optimising all treatments to
achieve individual care goals. (references:
http://www.bmj.com/content/349/bmj.g7013)

 D50-50 2 vials as hypoglycemia to restore blood glucose
side drip, now then levels.
uptHgt after 1 hour (references:https://drugs.com/pro/dextrose-
50.html)

 RptHgt at 9pm
6:30 pm blood to test for diabetes or prediabetes.
(references:https://www.webmd.com/cholesterol-
Hgt- 112 mg/dl
managemnet/fasting -blood-tests)
9pm
Hgt- 37 mg/dl  Give another 2
vials D50-50 as
side drip now then
levels.
another 2 vials (references:https://drugs.com/pro/dextrose-
45
after 1 hour 50.html)
 D50-50 2 vials as  Indicated in the treatment of insulin

2 am side drip hypoglycaemia to restore blood glucose
Hgt- 41 mg/dl levels.
(+) hypokalemia (references:https://drugs.com/pro/dextrose-
50.html
(+) basal rales
(+) wheezes
(+) infected wound  IVF TF: D5NSS 1
 It is a source of water and electrolytes, it
severe Liter+ D50-50 vial
should be used with great care with
× KVO
congestive heart failure which there
(references:
 Furosemide 20 mg
TIV q 12  To inhibit sodium and chloride
reabsorption.(references: Jones &Barlett
Edition)
 Hook 3 D50-50 1
7:20 am  Indicated in the treatment of insulin
vial now
BP- 130/80 hypoglycaemia to restore blood glucose
O2sat 97% levels.

(references:https://drugs.com/pro/dextrose-
(P) seizure
50.html
RR- 27
 May give glucose

9/29/17 H2O of non  Energy is required for the normal
8:15 am fatmilk mix c functioning of the organs in the body.
46
glucose These energy mostly came from
sugars(glucose).
(references:http://www.caninsulin.com/Glucose-
metabolism.asp)

9:35 am
Hgt- 37 mg/dl  Rpt ECG now v. o
Dra. Melendez
 To prevent chronic angina attacks, acute

 NTG patch over
angina pectoris ; to prevent or minimize
ACW
angina attacks before stressful
events.(references: Jones &Barlett
learning;2011 Nurse’s Drug handbook
Tenth Edition)
 A do-not-resuscitate order, or DNR

9/29/17 Akosi Obed Edum M.
order, is a medical order written by a
baybayonanak ng
doctor. It instructs health care providers
pasyentenasi Johnny M.
not to do cardiopulmonary resuscitation
Baybayon
(CPR) if a patient’s breathing stops or if
aynagdesisyonna wag ng
the patient’s heart stops beating.
ipa CPR ang pasyente (references:
kung sakalingtumigil ang https://medlineplus.gov/encypatientinstructions/0
paghinga o pagtigil ng 00473.htm)
tibok ng puso.
Signed by Obed Edum U.

Baybayon
 To control bouts of increase seizure
47
(P) Seizure activity. (references: Jones &Barlett
10:30 am  May give learning;2011 Nurse’s Drug handbook Tenth
Edition)
160/100 diazepam 5 mg IV
O2sat -98% prn in seizure
10:40 am Hgt 58
mg/dl
levels.
 May give 2 vials
D50-50 now
50.html)

1:30 pm
levels.
Hgt- 110 mg/dl  Give 3 vials of (references:https://drugs.com/pro/dextrose-
D50-50 now 50.html)
 It is ordered diet as tolerated when the

gastrointestinal tract is tolerating food
3:30 pm and is ready for advancement to the next
Hgt- 49 mg/dl  May have diet as stage.
tolerated (references:https://www.livestrong.comarticle/wh
at-is-the-meaning-of-diet-as-tolerated/)
 To prevent chronic angina attacks, acute
5:40 pm angina pectoris ; to prevent or minimize

angina attacks before stressful
 NTG over anterior
events.(references: Jones &Barlett
chest wall once
daily
Edition)

9/30/17
48
12mn  Give D50-50 2 levels.
Hgt- 90 mg/dl vials TIV SD now (references:https://drugs.com/pro/dextrose-
50.html)
9/30/17
54 mg/dl
(+) Episodes of  Give 2 vials D50-
levels.
hypoglycaemia 50 as side drip
(+) min Pleural
50.html)
effusion, (+) rales
(+) di KCL
 To keep clean and dry at all times to
supplem,  Daily wound care promote healing
diEnoxoparin, AMI
(references:http://health.canoe.com/drugchangin
(+) multiple g-dressing)
allergies including
betadine  Patients receive medications appropriate
 Continue med to their clinical needs, in doses that meet
their own individual requirements, for an
adequate period of time.
(references:httpapps.who.int/medicinedocs/en/d/J
h3011e/1.html)
 an electrolyte test is used to identify

problems with body’s (salt) balance.
 Repeat Serum
Electrolyte testing may be carried out as
Na/K
a part of routine blood test, called U+Es.
(references:http://www.webmd.boots.com/a-to-z-
guidestesting-sodium-potassium-and-more)
 low blood glucose or hypoglycaemia is

 Relay episode of
one of the most common problems
hypoglycaemia associated with diabetes, in particular,
49
insulin treatment.
(references:http://www.joslin.org/info/)
9/30/17  To prevent hypokalemia

(references: Jones &Barlett learning;2011
 NaCl I tab BID × 3
days
 Patients receive medications appropriate

10/1/17
to their clinical needs, in doses that meet
7:25 am  Cont. Meds
h3011e/1.html)

 IVF TF D5NSS perfusion by optimizing intravascular
 Oxygen administration is a treatment that
 ˇO2 to 2 lpm delivers oxygen gas to breathe. Oxygen

therapy may be prescribed when there is
a condition that causes the blood
50
oxgenlevels to be too low. (references:
https://www.nhlbi.nih.gov/hea;th/health-
topics/topics/oxt)

10/2/17
5:30 am  Rpt ECG
(-) DOB/ Chest
pain
Bipedal edema

10/3/17
perfusion by optimizing intravascular
5:50 pm  Shift IVF to NSS 1
L
10/4/17  Patients receive medications appropriate

 Cont. Meds to their clinical needs, in doses that meet
h3011e/1.html)
 Patient may continue treatment at home
 MGH
 Indicated for angina pectoris

 Home meds (Sources: Jones &Barlett learning;2011 Nurse’s
-trimetazidine 35 Drug handbook Tenth Edition)
BID
 To reduce thrombolytic events in patients
51
-clopidogrel 75 with atherosclerosis documented by
OD recent stroke, MI, or peripheral arterial
disease.(Sources: Jones &Barlett learning;2011
 Indicated for organic and functional

chronic diseases of the lower limbs;
-Daflon 500 mg heavy legs (Sources: Jones &Barlett
tab TID learning;2011 Nurse’s Drug handbook Tenth
Edition)
 Used to treat or prevent vitamin

deficiency due to poor diet, certain
illnesses.
- Vit B complex
(references:https:www.webmd.com/drugs/2/drug
OD
s-3387/vitamins-b-complex-oral/details)
 Management and prophylaxis of angina

pectoris; adjunct in CHF.
- Montra 30 g 1 (references:http://www.mims.com/philippines/dru
g/info/montra)
tab
52
X. DRUG STUDY
NAME OF DOSAGE INDICATION/ MODE OF ADVERSE NURSING

DRUG CONTRAINDICATION ACTION REACTION RESPONSIBILITIES
Generic 50 mg tab q6° Indication: Heart failure Inhibits CNS:dizziness, asthenia,  Monitor the
Name: Losartan in patients with current or vasoconstrictive fatigue, headache, insomnia. patients BP
Frequency: prior symptoms. and aldosterone CV:edema, chest pain. closely to
Brand every 6 hours Since the patient has secreting action EENT: nasal congestion, evaluate
Name: Cozaar elevated BP = 130/100. angiotensin II sinusitis, pharyngitis, sinus effectiveness of
Route: Per Contraindications: receptor on the disorder. therapy.
Classification: Orem  Contraindicated in surface of GI:abdominal pain, nausea,  Monitor
Angiotensin II patients vasocular smooth diarrhea, dyspepsia. patients who are
receptor blocker Onset: hypersensitive to muscle and other GU:UTI also taking
unknown drug. Breast- tissue each use. METABOLIC:hyperkalemia, diuretics for
feeding isn’t hypoglycemia, hyponatremia, symptomatic
Peak: 1 hour recommended weight gain. hypotension.
during losartan MUSCULOSKELETAL:  Regularly
Duration: therapy. Muscle cramps, myalgia, back assess the
unknown  Use cautiously in or leg pain. patients renal
patients with RESPIRATORY: cough, function (via
impaired renal or upper respiratory tract creatinine and
hepatic function. infection. BUN levels).
 Patients with
severe heart
failure whose
renal function
depends on the
angiotensin-
aldosterone
system may
develop acute
renal failure
during therapy.
53
X. DRUG STUDY
Close monitor
patient’s BP,
renal function,
and potassium
levels,
especially
during first few
weeks of
therapy and
after dosage
adjustments.
Reference: Wolters Kluwer; 2016 Nursing Drug Handbook 36th Edition
NAME OF DOSAGE INDICATION/ MODE OF ADVERSE REACTION NURSING

DRUG CONTRAINDICATION ACTION RESPONSIBILITIES
Generic 40 mg IV q 6 Indication: Generalized Inhibits CNS:vertigo, headache, dizziness,  Consider 10
Name:Furosemide Edema associated with sodium and paresthesia, weakness, restlessness, Golden
Frequency: Q Congestive Heart chloride fever Rights of
Brand Name: 6 hours Failure reabsorption at CV:orthostatic hypotension, administering
Lasix Generalized edema of the proximal thrombophlebitis, with IV medication
Route: pitting edema, grade 3, 6 and distal administration  Monitor
Classification: Intravenous mm. tubules and EENT:transient deafness, blurred or weight, BP,
Loop Diuretics the ascending yellowed vision, tinnitus and pulse rate
Onset:Within Contraindication: loop of Henle. GI:abdominal discomfort and pain, routinely with
5 minutes Contraindicated in diarrhea, anorexia, nausea, long-term use
patients hypersensitive vomiting, constipation, pancreatitis  If oliguria or
Peak:30 to drug and in those with GU:azotemia, nocturia, polyuria, azotemia
minutes anuria. frequent urination, oliguria develops or
HEMATOLOGIC:agranulocytosis, increases,
54
X. DRUG STUDY
Duration:2 aplastic anemia, leukopenia, drug may
hours thrombocytopenia, anemia need to be
HEPATIC:hepatic dysfunction, stopped
jaundice  Monitor fluid
METABOLIC:volume depletion intake and
and dehydration, asymptomatic output and
hyperuricemia, impaired glucose electrolyte,
tolerance, hypokalemia, BUN, and
hypochloremic alkalosis, carbon
hyperglycemia, dilutional dioxide levels
hyponatremia, hypocalcemia, frequently
hypomagnesemia  Watch for
MUSCULOSKELETAL:muscle signs of
spasm hypokalemia,
SKIN:dermatitis, purpura, such as
photosensitivity reactions, transient muscle
pain at I.M. injection site, toxic weakness and
epidermal necrolysis, Stevens cramps
Johnson syndrome, erythema 
multiforme
Reference: Jones & Bartlett Learning; 2011 Nurse’s Drug Handbook Tenth Edition

Generic Name: 30 mg Tab OD Indications: Reduces Thought to reduce CNS:headaches,  Monitor BP
Isosorbide preload and afterload; as cardiac oxygen dizziness, weakness. and heart rate
mononitrate Frequency:Once a well as myocardial oxygen demand by CV:orthostatic and intensity
day demand; also lowers blood decreasing preload hypotension, and duration
Brand Name:Imdur pressure and afterload. Drug tachycardia, of drug
55
X. DRUG STUDY
Route:Oral Since the patient has also may increase palpitations, ankle response.
Classification: elevated BP = 130/100 blood flow through edema, flushing,  Drug may
antianginals Onset:½-4 hours the collateral fainting. cause
Contraindication: coronary vessels. GI:nausea, vomiting. headaches,
Peak:unknown  Contraindicated in EENT:sublingual especially at
patients with burning. beginning of
Duration:6-12 hypersensitivity or SKIN:cutaneous therapy, but
hours idiosyncrasy to vasodilation, rash. tolerance
nitrates and in usually
those with severe develops.
hypotension, angle Treat
closure glaucoma, headache with
increased aspirin or
intracranial acetaminophe
pressure, shock, or n.
acute MI with low
left ventricular
filling pressure.
 Use cautiously in
patients with blood
volume depletion
(such as from
diuretic therapy) or
mild hypotension.
56
X. DRUG STUDY
Generic 1 pra nebulizer Indications: To improve Relaxes CNS:tremor,  Monitor patient for
Name: albuterol q12 pulmonary function, bronchial, nervousness, effectiveness.
especially in those with uterine, and headache, insomnia,  Avoid contact of inhalation
Brand Name: Frequency:every AO. vascular dizziness, weakness, drug with eyes.
Salbutamol 12 hours Symptomatic relief of smooth CNS stimulation,  Do not increase in number
pulmonary congestion muscle by malaise. or frequency without
Classification: Route:Inhalantion related to congestive heart stimulating CV:tachycardia, physician’s advice.
Bronchodilators failure beta₂ palpitations,
Onset:5-15 mins. Contraindication: receptors. hypertension, chest
 Contraindicated in pain,
Peak:30-120 min. patients with lymphadenopathy.
hypersensitivity to GI:nausea, vomiting.
Duration:2-6 drug or its EENT:conjunctivitis,
hours ingredients. otitis media; dry and
 Use cautiously in irritated nose and
patients with CV throat with inhaled
disorders form; nasal
(including congestion; epistaxis;
coronary hoarness;
insufficiency and pharyngitis, rhinitis.
hypertenstion), RESPIRATORY:
hyperthyroidism, bronchospasm,
or diabetes mellitus cough, wheezing,
and in those who dyspnea, bronchitis,
are unusually increased sputum.
responsive to
adrenergics.
 Use extended-
release tablets
cautiously in
57
X. DRUG STUDY
patients with GI
narrowing.
58
XI. NURSING CARE PLAN
PROBLEM PRIORITIZATION PROBLEM PRIORITIZATION
1. Ineffective breathing pattern r/t decreased lung expansion and pulmonary congestion secondary to congestive heart failure.
Fluid volume excess r/t low albumin level 15 g/L secondary to congestive heart failure
2. Ineffective tissue perfusion related to Impaired transport of oxygen across alveolar and capillary membrane
59
Fluid volume excess r/t low albumin level 15 g/L secondary to congestive heart failure
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATIO RATIONALE EVALUATION

N
Subjective: Fluid volume excess After nursing  Monitor vital sign  Established  After nursing
“Napansin ko na r/t. low albumin level interventions, patient baseline data interventions,
lumalaki ang tiyan 15 g/L secondary to will demonstrate patient
ko” as verbalized congestive heart stabilized fluid demonstrated
failure volume and decrease  Reflects circulating stabilized fluid
Objective: edema and abdominal  Measure intake volume status, volume and
girth. and output developing fluid decreased edema
 Pallor shifts, and in and abdominal girth
 Weak in response to therapy
appearance
 Abdominal
distention  BP elevations are
noted usually associated
 Abdominal  Monitor BP with fluid volume
girth of excess
104 cm
 Bipedal
edema with  Indicative
grade 3 of pulmonary
6mm  Assess respiratory congestion/edema
 Irritability status
60
noted  Reflects
 RR of 26 accumulation
bpm of fluid (ascites)
 Abdominal  Monitor
girth of abdominal girth
104 cm  Decreases sensation
of thirst, especially
when fluid intake is
 Provide restricted
occasional ice
chips if NPO
 Sodium may be
restricted to
minimize fluid
retention in extra
vascular spaces.
Fluid restriction
may be necessary to
 Restrict sodium prevent dilutional
and fluids as hyponatremia
ordered
 Used with caution
to control edema
and ascites, block
effect
61
 Administer of aldosterone, and
medications as increase water
indicated: excretion while
 Diuretics sparing potassium.
(Furosemide)
2. Ineffective tissue perfusion related to impaired transport of oxygen across alveolar and capillary membrane
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATI RATIONALE EVALUATION

ON
Subjective: Ineffective tissue After nursing  Assess for  Particular cluster After nursing
“Objectives: perfusion related to intervention sign of of sign and intervention patient
 Capillary Impaired transport of patient will decreased symptoms occur identifies factors
refill of oxygen across identifies factors tissue with differing that improves
time 3 alveolar and capillary that improves perfusion causes. circulation
second membrane circulation Evaluation
 Dyspnea provides a
 Dysrhythmi baseline for
as future
(Tachyarhyt comparison
hmia)
 Bipedal
edema with  Early detection
grade 3  Assess for of the source
probable facilitates quick,
62
6mm contributing effective
 Pale in factors management
appearance related to
 Weak in temporarily
appearance impair
 Abdominal arterial
distended blood flow.  Cardiac pump
 Abdominal malfunction and
girth of 104 ischemic pain
cm may result in
 Irritable  Check distress
 BP 140/80 respirations
RR 26 and absence  For baseline data
PR 110 of work of
breathing
 Monitor V/S  Stable Blood

pressure is
needed to keep
sufficient tissue
 Record perfusion.
Blood
pressure
 Nonexistence of
peripheral pulses
must be reported
or managed
immediately
systemic
63
 Check for vasoconstriction
pallor. resulting from
Assess reduced cardiac
quality of output may be
every pulse manifested by
diminished skin
 Gently reposition
patient from
 Assist with from a supine to
position sitting or
changes standing position
can reduce the
risk orthostatic
Bp.
 Because of poor
 Monitor for tissue perfusion
development it can be develop
of gangrene, to the patient
venous
ulceration
 With arterial in
64
 Do not suffiency, leg
elevate legs elevation
above the deceases arterial
level of the blood supply to
heart the legs
 Encourage  Smoking tobacco

smoking is also associated
cessation with
catecholamines
release resulting
in
vasoconstriction
and decreased
tissue perfusion
 These measure
 Educate reduce venous
patient about compression
lifestyle that venous stasis and
could arterial
improve vasoconstriction
tissue
perfusion
65
3. Ineffective breathing pattern r/t decreased lung expansion and pulmonary congestion secondary to congestive heart failure
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATIO RATIONALE EVALUATION

N
Subjective:  After an hour  After an hour
“Nahihirapan Ineffective breathing of nursing  Monitor V/S of nursing
akong huminga” pattern r/t decreased intervention,  For baseline intervention,
as lung expansion and the client will data the client be
verbalized pulmonary congestion be relieve  Monitor relieved from
secondary to from dyspnea respiratory dyspnea and
Objectives: congestive heart and breathing rate, rhythm  Rapid shallow breathing
 Dyspnea failure pattern will and depth respirations/dys pattern
 Tachypne return to pnea may be return to
a with RR normal. present because normal
of 26, of hypoxia or
irregular,s  Auscultate fluid
hallow breath sounds, accumulation
breathing noting in the abdomen
 Weak in crackles,
appearanc wheezes and
e rhonchi  Indicates
 Irritability developing
noted complications
 Pallor and increasing
 Investigate risk of infection
changes in
LOC
 Changes in
66
mentation may
reflect
 Keep head of hypoxemia and
bed elevated. respiratory
Position on failure
sides
 Facilitates
 Encourage breathing by
frequent reducing
repositioning pressure on the
and deep- diaphragm
breathing
exercises
 Aids in lung
expansion and
 Provide mobilizing
supplemental secretions
O
2 as order
 Administer  May be
medications necessary to
such as treat/prevent
Albuterol hypoxia
67
 To improve
pulmonary
function,
especially in
those with AO.
Since the
patient has
CHF.
68
XII. RECOMMENDATION
To the co-students:
This study will help you to fully understand how Congestive Heart Failure
occurs, what are the symptoms and management to be given to patient with this type
ofdisease. You will also learn what are the risk factors that affect the progression of
the disease. This will serve as your guide in presenting case presentations in your
future career.
To the faculty members:
This study will help you to regain your knowledge and also refreshes your
idea about Congestive Heart Failure. This may be helpful in teaching lessons of the
faculty members especially those who handled a topic that is related to Cardiovascular
function. They hope that this would be a great help to all of you.
To their beloved readers:
To their beloved readers who are concerned about Congestive Heart Failure.
This study will serve as guide for you to fully understand how it occurs, because all
the contents of this study were focused on the said disease. Diet, medication and
other health management to prevent progression of the disease are also included.
69
XIII. SUMMARY OF DISCHARGE
Medication
 Taking all of the prescribed medications. Medications must be continued
according to the doctor’s instruction.
1. trimetazidine 35 mg 2× a day 6 am , 6 pm
2. clopidogrel 75 mg OD 7 am with meals
3. Daflon 500 mg 1 tab 3× a day 6 am, 12nn, 6 pm
4. Vit B complex OD 6 am
5. Montra 30 mg 1 tab 7 am with meals
Exercise
 Provide patient with Passive Range of Motion.
Treatment
 No treatment
Health Teaching
 Emphasized to the patient’s relative the importance patient’s personal hygiene.
 Maintaining safe environment for the patient.
 Eating low salt and low fat foods; following a low salt and low fat diet helps
keep blood pressure and swelling (edema) under control. It can also make
breathing easier if there is a heart failure.
 For Doppler scan of both legs
 Regular monitoring blood sugar
70
XIII. SUMMARY OF DISCHARGE
Out-Patient Department
 Time and date of consultation: Follow-up after 1 week, October 18, 2017, Dr.
Pestacio
Spiritual
Advise the family to never lose her hope, and keep his faith despite of what happen
71
XIV. BIBLIOGRAPHY
Book References:
 Barbara K. Timby and Nacy E. Smith’s Medical and Surgical Nursing

10th edition Unit 19 pg. 909
 Brunner & Suddarth’s Textbook of Medical Surgical Nursing 13th Edition,
Chapter 20, p475
Chapter 25, p667
Chapter 60 p.1759 and Unit 7, p.902
Chapter 25, p655
Unit 3, p250
Chapter 60, p1765
 Brunner and Suddarth’s textbook and medical-surgical nursing 13th
edition by Janice L. Hinkle and Kerry H. Cheever chapter 5 page 67
 Je Abarra, Laboratory Values and Interpretation-A Nurse’s Ultimate

Guide, http://www.nursebuff.com/l aboratory-values-fornurses
 Jones & Bartlett Learning; 2011 Nurse’s Drug Handbook Tenth Edition
 Kozier & Erb’s Fundamentals of Nursing 9th edition Unit 8 pg. 808-825
 Maternal and Child Health Nursing 6th edition by Adele Pilliteri chapter
24, page 658 and Brunner and Suddarth’s textbook of medcal surgical
nursing 13th edition by Janice L. Hinkle and Kerry H. Cheever chapter 27
page 406
72
XIV. BIBLIOGRAPHY
Medical-Surgical nursing 5th edition by Lewis, Heitkemper and Dirksen Chapter
17, pages 380
Electronic References:
 http://chealth.canoe.com/drug/getdrug/ceftriaxone
 http://cpmc.org/learning/documents/icu-ws.html
 http://cpmc.org/learning/documents/icu-ws.html
 http://health.canoe.com/drugchanging-dressing
 http://health.canoe.com/drugchanging-dressing
 http://webcache.googleusercontent.com/Normal_saline_solution.html
 http://webcache.googleusercontent.com/Normal_saline_solution.html
 http://www.bmj.com/content/349/bmj.g7013
 http://www.bmj.com/content/349/bmj.g7013
 http://www.caninsulin.com/Glucose-metabolism.asp
 http://www.caninsulin.com/Glucose-metabolism.asp
 http://www.cpmc.org/learning/labtests.html
 http://www.nursefrontier.com-position-definition/explanation
 http://www.webmd.boots.com/a-to-z-guidestesting-sodium-potassium-and-
more
 httpapps.who.int/medicinedocs/en/d/Jh3011e/1.html
 https://drugs.com/pro/dextrose-50.html
 https://medlineplus.gov/encypatientinstructions/000473.htm
 https://www.healthline.com/doppler-ultrasound-exam-of-an-arm-or-leg
 https://www.livestrong.comarticle/what-is-the-meaning-of-diet-as-tolerated
 https://www.nursingtimes.net/clinical/aarchive/assessmentskills.article
 https://www.nursingtimes.net/clinical/aarchive/assessmentskills.article
 https://www.webmd.com/cholesterol-managemnet/fasting -blood-tests
 https://www.webmd.com/cholesterol-managemnet/fasting -blood-tests
 nursingcrib.com/drug-guides
 nursingcrib.com/drug-guides
73
XIV. BIBLIOGRAPHY
 httpapps.who.int/medicinedocs/en/d/Jh3011e/1.html
 http://www.webmd.boots.com/a-to-z-guidestesting-sodium-potassium-and-
more
 http://www.joslin.org/info/
www.nurseslabs.com
74

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I.

Heart failure, sometimes referred to as congestive heart failure, is the

oxygen and nutrients. Heart failure is a clinical syndrome characterized by signs

and symptoms of fluid overload or inadequate tissue perfusion. The underlying

mechanism of the heart failure involves impaired contractile properties of the

filling of the heart.

Heart failure is a life-long diagnosis managed with lifestyle changes and

medications to prevent acute congestive episodes. Congestive heart failure is

usually an acute presentation of heart failure. Common underlying conditions

include coronary atherosclerosis (primary cause), valvular disease,

cardiomyopathy, inflammatory or degenerative muscle disease, and arterial

hypertension. A number of systemic factors can contribute to the development and

severity of cardiac failure. Increased metabolic rate (fever, thyrotoxicosis),

hypoxia, and anemia require an increased cardiac output to satisfy systemic

oxygen demand. Dysrhythmia decreased the efficiency of myocardial function.

Surgical Nursing, Eleventh Edition. Lippincott Williams & Wilkins.

 Symptoms of inadequate tissue perfusion

 Diminished cardiac output with accompanying dizziness, confusion,

fatigue, exercise or heat intolerance, cool extremities, and oliguria

 Increased pulmonary venous pressure (pulmonary edema) manifested by

cough and shortness of breath

 Dysrhytmia may indicate heart failure or may be noted as a result of the

treatment for heart failure.

 Increased systemic venous pressure, as evidenced by generalized

peripheral edema and weight gain

Left-Sided Heart Failure

Most often precedes right-sided heart failure

 Pulmonary congestion; cough; fatigability; tachycardia with an S3 heart

sound; anxiety; restlessness

 Dyspnea on exertion (DOE), orthopnea, paroxysmal nocturnal dyspnea

 Cough may be dry and nonproductive but is most often moist.

 Bibasilar crackles advancing to crackles in all lung fields

 Large quantities of frothy sputum, which is sometimes pink (blood tinged)

ashen, pale, cool and clammy skin

Right-Sided Heart Failure

 Congestion of the viscera and peripheral tissues

 Edema of lower extremities (dependent edema), usually pitting edema,

weight gain, hepatomegaly

 Distended neck veins, (jugular vein distention), ascites, anorexia, and

 Nocturia and weakness

Surgical Nursing, Eleventh Edition. Lippincott Williams & Wilkins.

days), with an overall in-hospital mortality rate of 8.2%.

common etiologic factor. Compared to western and Asia-Pacific countries, the

local mortality rate was relatively higher.

million (2009-2012) to about 6.5 million (2011-2014), according to the American

Heart Association’s 2017 Heart Disease and Stroke Statistics Update.

projected to rise by 46 percent by 2030, resulting in more than 8 million people

problems are also major contributors.

C. SCOPE AND LIMITATION

nurses includes head-to-toe assessment, monitoring and recording of vital signs,

health teachings are part of their duty.

After the patient’s confinement, the assigned student nurses decided to

willingly participated all throughout the interview.

D. BACKGROUND OF THE STUDY

order to promote the general health of the patient by providing proper

interventions through the application of nursing process.

skills in formulating and implementing a nursing care plan, in conducting a

concepts in Medical Surgical course, Human Anatomy and Physiology and

other science related studies.

further understand and gain extensive knowledge form the case.

 The student will be able to enumerate the predisposing and precipitating

factors that contribute to Congestive Heart Failure.

significant factor in formulating a nursing care plan.