Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure

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 (Denolin, 1983, p. 445). 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 (2001), 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 (2005), about 77,060 in a 100, 000 population 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.

This paper is a case report about B. A., a 49 year old female, Filipino, nonhypertensive, nondiabetic, a post-mitral and aortic valve replacement patient and is currently diagnosed with Congestive Heart Failure Functional Capacity II-III secondary to Valvular Heart Disease secondary to Rheumatic Heart Disease. Its purpose is to review the pathophysiology, preanalytical factors, and treatment in a congestive heart failure patient and identify possible recommendations for future nursing care.

This case report is significant to my future nursing care because it helps stress the importance of not only identification and treatment of patients with heart failure but also the importance of promoting a healthy lifestyle and preventive strategies to decrease the prevalence of heart failure in the general population. Also, it explores the need for a thorough case analysis of a client to deliver the best nursing care.

THEORETICAL BACKGROUND

Theoretical Background. Heart failure is defined as the pathophysiologic state in which an abnormality of cardiac function is responsible for inadequate systemic function (Woods, et. al, 2010). It is not considered as a disease but a collection of signs and symptoms, the final pathway of a group of diseases, the end-result of most cardiovascular states.

Classification. According to the New York Heart Association (1964), congestive heart failure may be classified into four functional states. Class I (Mild) are patients with cardiac disease but without resulting limitatios of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath), or anginal pain. Class II (Mild) are patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain. On the other hand, Class III (Moderate) are patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest, but less than ordinary activity causes fatigue, palpitation, dyspnea or anginal pain. The last classification is Class IV (Severe) are patients with cardiac disease wherein there is inability to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased (New York Heart Association, 1964).

Causes. An array of different problems can cause congestive heart failure. (1) Among them is coronary (ischemic) heart disease resulting from insufficient blood flow to the myocardium, or heart muscle. This is usually caused by atherosclerosis, the buildup of fatty substances or plaque on the walls of the arteries that carry blood to the heart muscle. The hearts ability to perform decreases because ischemia results in the delivery of less oxygen and fewer nutrients to the heart muscle. (2) A heart attack may also cause congestive failure. During a heart attack, the heart muscle is deprived of oxygen, resulting in tissue death and scarring. The development of heart failure depends on the extent and location of scarring. (3) Long-standing high blood pressure is another common cause of heart failure. Because there is greater resistance against which the heart must pump, the heart muscle works harder. This results in an enlargement of the heart muscle, especially of the left ventricle, the hearts main pumping chamber. Eventually, this enlarged muscle tissue weakens, setting the stage for heart failure, especially if the pumping ability of the enlarged chamber greatly decreases. (4) Arrhythmias (irregular heartbeats) can also lead to heart failure, but they usually have to be severe and prolonged, with a rapid rate of more than 140 beats per minute, and must often occur in the presence of an already weakened heart. They change the pattern of filling and pumping of blood from the heart. This condition may also lower output of blood to the point of heart failure. (5) Valvular heart diseases are another cause of heart failure, which results when a narrowed or leaking valve fails to direct blood flow properly through the heart. The problem may be congenital (inborn) or due to an infection such as endocarditis or rheumatic fever. This increases the hearts workload, thereby increasing risk of developing heart failure. (6) Cardiomyopathy, a disease of the heart muscle itself, can also lead to heart failure. Causes of cardiomyopathy include infection, alcohol abuse, and cocaine abuse. When heart failure seems to have no known causes, it is known as idiopathic heart failure (Soufer, 1992).

Manifestations. Soufer (1992) further elaborates the manifestations often seen in patients with heart failure. 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 (Porth, 2007). 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 leftsided heart failure are fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea , and the sputum production that comes from pulmonary congestion (Soufer, 1992).

Porth (2007) adds that 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 and swelling of the ankles or legs occurs (Soufer, 1992).

The major symptoms of right-sided heart failure are edema and nocturia (Woods, et. al, 2010). 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.

Because congestive heart failure causes the body to fill with excess fluids, the kidneys may not be able to dispose of the extra sodium and water, a condition known as kidney failure. Sodium that would normally be eliminated through the urine remains in the body, causing it to retain even more water, thereby aggravating the problem of excess fluid associated with congestive heart failure (Soufer, 1992).

Diagnosis. According to the Framingham Study (McKee, et. al, 1971), the diagnosis of congestive heart failure requires the simultaneous presence of at least 2 major criteria or 1 major criterion in conjunction with 2 minor criteria that they have formulated. The major criteria includes paroxysmal nocturnal dyspnea, neck vein distention, rales, radiographic cardiomegaly (increasing heart size on chest radiography), acute pulmonary edema, S3 gallop, increased central venous pressure (greater than 16 centimeters fluid at right atrium), hepatojugular reflux and weight los greater than 4.5 kilograms in 5 days in response to treatment. The minor criteria is composed of bilateral ankle edema, nocturnal cough, dyspnea on ordinary exertion, hepatomegaly, pleural effusion, decrease in vital capacity by one third from maximum recorded and tachycardia (heart rate greates than 120 beats per minute). Minor criteria are acceptable only if they can not be attributed to another medical condition (such as pulmonary hypertension, chronic lung disease, cirrhosis, ascites, or the nephrotic syndrome). The Framingham Heart Study criteria are 100% sensitive and 78% specific for identifying persons with definite congestive heart failure (McKee, et. al, 1971).

Complications. Watson (2000) discovered that the common complications of heart failure include irregular heart rhythms or arrythmias, stroke, thromboembolism and organ dysfunctions. (1) One of these are malignant ventricular arrhythmias which are common in end stage heart failure. For example, sustained ventricular tachycardia occurs in up to 10% of patients with advanced heart failure who are referred for cardiac transplantation (Watson, 2000). In patients with ischemic heart disease, these arrhythmias often have mechanisms in scarred myocardial tissue. An episode of sustained ventricular tachycardia indicates a high risk for recurrent ventricular arrhythmias and sudden cardiac death. Congestive heart failure predisposes to (2) stroke and (3) thromboembolism, with an overall estimated annual incidence of approximately 2% (Watson, 2000). Factors contributing to the increased thromboembolic risk in patients with heart failure include low cardiac output (with relative stasis of blood in dilated cardiac chambers), regional wall motion abnormalities (including formation of a left ventricular aneurysm), and associated atrial fibrillation. Patients with heart failure and chronic venous insufficiency may also be immobile, and this contributes to their increased risk of thrombosis, including deep venous thrombosis and pulmonary embolism. Mild to moderate heart failure is associated with an annual risk of stroke of about 1.5% (compared with a risk of less than 0.5% in those without heart failure), rising to 4% in patients with severe heart failure (Watson, 2000). (4) Organ dysfunction occurs when there is a decrease in the oxygen supply to the different organ tissues in the body. Because of the lack of oxygen, compensatory mechanisms act but eventually decompensate leading to dysfunction of organs (Porth, 2007).

CASE PRESENTATION

B. A. is a 49 year old female, Filipino, nonhypertensive, nondiabetic and diagnosed with Congestive Heart Failure Functional Capacity II secondary to Valvular Heart Disease secondary to Rheumatic Heart Disease. She lives with her husband, three children, a son in-law and a grandson in Sapang Palay, Bulacan. B. A. stopped going to school when she was 1st year high school and is currently unemployed. She worked as a vendor before. She is a Roman Catholic and actively participates in church as a lector.

The client was admitted from home to the Emergency Room of the Philippine General Hospital on August 30, 2010 with complaints of fever and shortness of breath. She was admitted to the Female General Medicine Ward 1 at Bed 8 for monitoring and management and also to rule out Moderate Risk Community Acquired Pneumonia, Pulmonary Tuberculosis and Infective Endocarditis.

B. A. has been experiencing chest heaviness and mild chest pain 5 days prior to admission. She also contracted fever but this was relieved after she took Bioflu. She was not taken to a physician until 3 days prior to admission when her chest pain worsened and radiated to the back and she experienced shortness of breath. The fever recurred with maximum temperature of 38C. She was admitted to Sapang Palay District Hospital for management where she was administered with oxygen. On the same day, she was discharged and advised to followup to Philippine General Hospital. However, the client proclaimed that she felt well immediately after and her fever was gone so she delayed referral. One day prior to admission, the client had fever again and has stomach discomfort. She claimed that her chest pain worsened so on August 30, 2010, the client's family brought her to Philippine General Hospital.

The client was first diagnosed with Rheumatic Heart Disease in the 1980s in Philippine Heart Center where she regularly went for checkup. Upon transfer of residency, she had regular checkups in Philippine General Hospital Out Patient Department. In the checkups between 2002-2003, it was determined that B. A. has valvular heart disease and was scheduled for operation. She underwent mitral and aortic valve replacement in Philippine General Hospital in 2004. Since then, she has been on regular follow-up with the Outpatient Department of the Hospital. Her maintenance medications included

Warfarin 5 mg/tab taken once daily (taken twice the week before admission) and Metroprolol 50 mg/tab taken once daily. B. A. was readmitted in July of 2005 because of hemoptysis and extreme fatigue. However, no significant findings were made and Pulmonary Tuberculosis was ruled out. In October 2009, the client was admitted to San Lazaro Hospital in Bulacan for anti-rabies injection because of a dog bite.

She has a family history of cardiovascular diseases and pulmonary tuberculosis. Her mother is a known cardiac patient of valvular heart disease and died in 1998. Her father is a known hypertensive and died on August 14, 2010 due to heart attack. B. A. has uncles with pulmonary problems specifically Pulmonary Tuberculosis though she does not live with them. The client knows no one in the family with mental illness or history of diabetes mellitus.

Nursing Assessment. Complete assessment on the status of the client based on the nursing health history was conducted on August 31, 2010. Pertinent nursing health history problems were clusted per functional health pattern. Physical examination was also conducted on the same date. Pertinent physical assessment findings are classified per system.

In the Health perception and health management pattern, the client reports that she is a healthy person is one who rarely gets sick. To maintain her health, she follows the doctors advice and tells that she has never had a problem with following the health professionals' orders. In addition, she drinks her medicines regularly and takes periods of rest. She claims to have no traditional health beliefs. According to the client, she thinks the reason she felt ill was because she does the household chores even when she was supposed to rest and she carries her grandson around which led to shortness of breath and fatigue. B. A. claims that she felt more comfortable and relieved when she was admitted to the hospital.

B. A claims that her overall health varies, with periods of fatigue and strength. Whenever she feels episodes of chest heaviness or fatigue, she sits in front of the electric fan to ventilate herself and rest until she regains strength. She is a nonalcoholic and a nonsmoker. She claims to have taken only few sips of beer before when she was in her 20s but she has never drunk more than a glass and she has never tried to smoke in the past. However, she experiences second hand smoke daily since her husband

smokes at least 3 sticks a day. B. A. has never taken illegal drugs. During the hospital rotation, the client experienced chest pain with a grade of 4, radiating to back and persisting after 10 minutes.

In the nutritional and metabolic pattern, B. A. reports that every day she eats about three meals per day which are cooked at home, with the occasional snack in between meals. Because she has been cautioned from eating fatty and salty foods, she seldom eats pork. In addition, it was explained to her that green leafy vegetables affect the mechanism of action of one of her medications which is Warfarin so she also refrains eating said vegetables. The food she eats varies from vegetables, fruits, fish and chicken. The client claims that she eats a lot of vegetables and fruits, and leaves behind the fatty portion of the meat she eats. Also, she only eats small portions of the meat, especially if it is salty, and eats about one cup of rice per meal. She dislikes other fatty, salty and sweet foods except chicharon and fries though she has regulated her intake of both to at least once every two months. She enjoys vegetables and fruits and seldom use condiments except vinegar.

Her fluid intake is about 3 glasses a day or sometimes one 500 ml bottle of water per day. She remembers that when she was in the hospital, her fluid intake was regulated at 1 Liter per day and she has adapted this at home. The client verbalized a noticeable decrease in weight since she was diagnosed with heart disease. At the time of the interview, the client also reported a decrease in appetite, although there is no problem in eating despite having all her teeth replaced with dentures. When she gets sick, she gets well rather quickly, and her only previous skin problem was hematoma, which she explained was caused by her medication (Warfarin).

In the elimination pattern, the client moves her bowels everyday. She complains that there are times that she cannot defecate easily because she finds it difficult to stop breathing and expel her feces forcefully. She described her feces as brown, soft and broken into small pieces about 3 cm in diameter. Also, B. A. urinates about 3 times per day, without difficulty or pain. She describes her urine as clear, yellow in color and without any foul odor. She measures her urine to be about 250 ml or one half of a mineral bottle. In addition, the client does not suffer from diaphoresis.

In the Activity-Exercise Pattern, B. A. claims that she has less energy than before to do her daily activities. She has refrained from washing clothes and carrying heavy things since she easily experiences shortness of breath. However, she is able to do household chores, carry her grandson, go to the market and serve at the church though with considerable effort. She does not exercise anymore except walk around the house and stretching. The clients pastimes include watching TV, listening to the radio, and playing with or watching her grandchild play. She is independent in grooming, eating, bathing, elimination, dressing, maintaining cleanliness, and daily movement. However, she is unable to do household chores as before and go to the market without assistance of a family member. She requires the supervision of a family member because she easily gets tired and experience shortness of breath. Her level of self-care is Level 2.

In the Sleep-rest Pattern, B. A. claims that she finds it difficult to sleep at night and especially during mornings and only takes naps in between because she has not yet adapted to the hospital environment,. However on her second night, she reported that she has been able to sleep well. In supine position and flat on bed, B. A. claims that she has difficulty breathing and feels that she is drowning. She is on moderate high back rest and requires 2 pillow to be able to sleep comfortably without difficulty of breathing. She is able to climb 3 flights of stairs before being out of breath. She also claims that she is easy to awaken and she does not have a special ritual for bedtime. The relaxing activities for her include saying the rosary, watching TV and watching her grandson.

In the Cognitive-Perceptual Pattern, B. A. has no hearing problem and does not use a hearing aid. However, she does have a visual problem. She uses glasses with grade of 300. Her memory is still intact, and she learns best by actual performance of a task and reading. The client does not feel pain in any part of her body though she sometimes feels chest heaviness and pain which she relieves by ventilating herself with electric fan and taking a rest. The client was a former president of the Lector/Commentator League and treasurer of the Parish Pastoral Council in their town but was forced to resign because of her health condition. She claims that she misses doing her work but is resigned to resting and staying at home because she understands that it is for her own benefit.

In the Role-Relationship Pattern, the family of B. A. is said to be extended and patriarchal, with B. A. making decisions regarding health actions and daily expenditures. She lives with her husband, her three children, a daughter-in-law and a grandson. Her husband is a contractual painter of houses and automobiles and their usual income

varies from P3000-P5000 per month. Their children always contributes to the medical expenses of the client. Currently, they feel worried about their mother's condition and contributes to any way they can to alleviate her condition. The usual problem of the family involves the drinking habit of the client's husband and financial problems. They usually resolve it by conversations with the family.

In the Sexuality-Reproductive Pattern, B. A. stated that she and her husband has not engaged in sexual intercourse in recent years. She claims that this is because they are already old. She has used pills as a family planning method from 1989 to 2002 but has since stopped using them though no problems were encountered upon their use. The client had her first menstrual period when she was 11 years old. She describes her menstrual period to be regular and usually lasts from 3 to 4 days. She usually consumes 3 pads in a day and has never experienced dysmennorhea. Her last menstruation was on August 1, 2010. B. A. is a G3P3 mother and has no history of complications at birth. In the Coping-Stress Tolerance Pattern, the client reports that she does not want to be a burden to her family and perceives herself as weak. However, she has already accepted this fact and coped with the weakness in her own way. She does not perceive any difference in her physique except weight loss. She is easily cries and becomes tensed or nervous though this has been lessened once she was admitted in the hospital. B. A. feels anxious about her condition but she believes that everything will be alright in the end more so because she feels relatively fine. Whenever she feels tensed, she talks to her significant others or pray the rosary. She usually feels nervous whenever there are arguments in the family but this has been lessened according to her significant other out of consideration for the client. She sits and calms herself by praying and talking with the involved parties to relieve her tension. She coped with her condition by changing her lifestyle for the better, avoiding foods that are contraindicated to her condition and taking rest periods. However, she does feel bothered about the expenses incurred by her children for her medical condition.

In the Value/Belief Pattern, the client expresses that her only wish is to see her children and her grandchildren grow up. She does not fear death but she wishes that she will live longer because of her family. God, family and health are important for B. A. She claims that her religion helps her get through her condition because it gives her energy and happiness.

In the general or constitutional condition of the client, the client has adequate weight for age. She has lost weight since hospitalization. However, she states that general state of health is fine. She displays signs of weakness on exertion and ability to conduct usual activities is impaired. She has no exercise tolerance. In the skin, no rashes or itching was observed. On inspection, no pigmentation is seen. There skin is moist and smooth. She has normal hair distribution and nail beds are pail but has brisk capillary refill. The client has no breast lumps. No tenderness or swelling was observed. There was also no nipple discharge.

For the HEENT system or Head, Eyes, Ears, Nose, Mouth, Throat system, no headaches were complained. However, the client complained of dizziness that can be associated to decrease in oxygen supply to the brain. Vision is normal and no nose bleeding was reported. The client does not have colds, obstruction and discharge. She has 1 missing front teeth and uses full dentures. No neck stiffness was observed and pain, tenderness and masses in thyroid or other areas was not seen. The client is cold to touch and has good skin turgor. She displayed absence of lesions or dryness in lips. Mucosa was pinkish and gag reflex was intact. Uvula is in midline and no lymphadenopathy was observed. There is pinkish mucosa and no lesions were present.

In the cardiovascular system, no heaves or thrills were inspected. A sternotomy scar is seen in the midsternal about 3 centimeters. Point of maximal impulse is at the 6th intercostal space, left of the midclavicular line. S1 is louder than S2 at the apex while S2 is louder than S1 at the base. Both S1 and S2 are regular. No extra heart sounds or murmurs were heard. Peripheral pulses are strong and equal. Nails are pale but has brisk capillary refill. No nail clubbing was observed. Hematoma is seen in Left lower arm and Right upper arm.precordial pain, substernal distress, palpitations, syncope was not observed. There was dyspnea on exertion and client has 2-pillow orthopnea. There was no nocturnal paroxysmal dyspnea, edema and cyanosis. No hypertension, heart murmurs, varicosities, phlebitis or claudication were assessed.

In the respiratory system, no pain was reported. Shortness of breath is on exertion and no wheezing or stridor was heard on auscultation. There was no hemoptysis, respiratory infections, tuberculosis (or exposure to tuberculosis), fever or night sweats. In the gastrointestinal system, the client has decreased appetite. She does not experience dysphagia, indigestion, food idiosyncrasy, abdominal pain and heartburn. No nausea, vomiting, hematemesis, jaundice, constipation, or diarrhea was reported. The client has

normal stools and no flatulence, hemorrhoids or recent changes in bowel habits was reported.

In the genitourinary system, no urgency or frequency in urination was reported. There was no dysuria, nocturia, polyuria or oliguria in the patient. However, hematuria was seen on laboratory tests. There was no unusual color of urine, stones, infections and nephritis observed. No hesitancy, change in size of stream, dribbling, acute retention or incontinence, change in libido was reported. The client had menarche at the age of 11. She has her menses every month and her last period was on August 1, 2010.

dysmenorrhea, or vaginal discharge was reported. She has had 3 pregnancies and all are alive. In the musculoskeletal system, no pain, swelling, redness or heat of muscles or joints were reported. There was no limitation of motion. However, the client reports muscular weakness on knees.

In the neurologic or psychiatric component, no convulsions, paralyses or tremors were observed. The client experiences no difficulties with memory or speech, and there is no sensory or motor disturbances. Client is not emotional and does not express depression. She is however, anxious about condition.

In the allergic component, adverse reactions to drugs, food, insects, skin rashs are not observed. There was however dizziness experienced after administration of Metorpolol on the second day of ward duty. In the immunologic component, anemia is not present and no adverse reactions to blood transfusion was reported. There is however a bleeding tendency since the client is on Warfarin therapy. In the lymphatic system, local or general lymph node enlargement or tenderness was absent. In the endocrine system, there is no polydipsia or polyuria.

Laboratory Results. Diagnostic and laboratory results done to the patient together with their indications are listed below. Significant results, their nursing implications and their relation to the course of treatment will be discussed on the case analysis part of this paper. The chest x-ray done on August 8, 2010 was indicated to view the structures of the chest (bones, heart, lungs) for any abnormalities. Also, the client was suspected of

Pulmonary Tuberculosis and Community-Acquired Pneumonia so this chest x-ray is to rule out or confirm said conditions. It is also indicated for a definite diagnosis of cardiomegaly or congestive heart failure in the patient and is done to reassess the patient's heart condition (size, shape, structure). The chest x-ray revealed that there are fibrous and reticulonodular opacities seen in the Unperfused Lung Segments. There is also associated superintraction of the right hilar structure. The lungs are normoinsular and two prosthetic valves are noted at the region of the mitral and aortic valves. There is prominence with the aortic root as seen on lateral view.

Blood chemistry screen made on August 30, 2010 was indicated for the client because she is diagnosed with congestion in the heart and is at risk for fluid, electrolyte or acidbase imbalance. In addition, the functions of her kidneys and extent of damage of livers and heart were assessed. Significant findings show that the client has decreased calcium in the blood.

Complete Blood Count done on August 30, 2010 is indicated for the client to look for signs of inflammation and infection and marker of anemia which can cause similar symptoms as Congestive Heart Failure or may contribute to Congestive Heart Failure. No abnormal results were seen. The client has adequate amount of blood components.

Prothrombin Time and Activated Partial Thromboplastin Time was assessed on August 30, 2010 to screens for coagulation deficiency of factors II, V, VII and X and monitor the oral anticoagulant therapy (warfarin) of the patient. In addition, it tests for abnormalities involving the coagulation proteins of the intrinsic pathyway. It is a routine screening of coagulation disorders. It has been found out that the client has prolonged Activated Partial Thromboplastin Time and Prothrombin.

Findings by the two-dimensional and doppler echocardiography done on September 1, 2010 was indicated for the client to determine systolic and diastolic left ventricular performance, cardiac output (ejection fraction), and pulmonary artery and ventricular filling pressures. It is also be used to identify performance of valves. It showed concentric left ventricular hypertrophy with segmental wall motion abnormality and mildly depressed overall systolic function. The aortic and mitral prosthetic valves have

good opening and closing. There is mild tricuspid regurgitation. The pulmonary artery pressure is normal. Ejection fraction is 53% Teicholtz's and 47% Simpsons.

Electrocardiography is performed on September 2, 2010 to assess for ST-segment elevated myocardial infarction after the episode of chest pain. It showed bradycardia with 45 beats per minute and no signs of myocardial infarction.

Holo-abdominal Ultrasound is performed on September 1, 2010 to view the peritoneal cavity and identify possible problems that may be the cause of hematuria. Findings show that there is non-specific calcifications which are likely parenchymal. In addition, fatty infiltrations of the pancreas are present. Bilateral renal cysts were seen. There is normal proximal and mid-abdominal aorta and para-aortic areas, spleen and urinary bladder.

Blood Culture Sensitivity Testing was made on August 31, 2010. It was indicated for the client to identify if the client has Infective Endocarditis. Findings display that there is no growth after 2 days of incubation.

DISCUSSION

Pathophysiology. Regardless of the precipitating event, the common mechanism of heart failure is quite complex. Compensatory mechanisms exist on every level all the way to organ interactions. When this compensatory mechanisms and adaptation are ovelwhelmed, heart failure happens (MacIntyre, et. al, 2000). In this section, we focus on the pathophysiological mechanisms that led to the presentation of signs and symptoms of the client, their current treatment and identified nursing diagnosis. Figure 1 shows the pathophysiology of the disease with the risk factors, medications, presenting signs and symptoms and nursing diagnosis identified. Porth (2007) discloses that due to the infiltration of group A beta-hemolytic streptococci, antibodies in the body react to destroy the bacteria simultaneously causing acute inflammation to the heart. Rheumatic heart disease has developed. During the acute inflammatory stage of the disease, the valvular structures become swollen. Small

vegetative lesions develop on the valve leaflets. It then proceeds to the development of fibrous scar tissue which tends to contract and cause deformity of the valve leaflets and shortening of the chordae tendinae. This results to Valvular Heart Disease.Then, tricuspid, mitral and aortic insufficiency develops. During much of the systole, the mitral valve is subjected to high pressure generated by the left ventricle as it pumps blood to the systemic circulation. Increased preload occurs because the incomplete closure of the mitral valve permits the regurgitation of blood from the left ventricle into the left atrium (Porth, 2007). In addition, incomplete closure of the aortic valve also results in increased preload as the left ventricle is forced to pump the entire diastolic volume received from the left atrium and the regurgitant volume from the aorta. Increased afterload occurs as there is increased pressure for the heart to generate the movement of the increased volume from the left ventricle into the aorta. The increased volume work causes increased pressure for the left ventricle to pump more blood. This eventually leads to left ventricular hypertrophy (Porth, 2007).As the workload increases, the walls of the chamber grow thicker, losing their elasticity and eventually may lead to myocardial dysfunction and eventually myocardial failure (Woods, et. al., 2010). This results to the failure of the heart to pump with as much force as a healthy heart. Systolic dysfunction or failure is evident leading to altered systemic perfusion and decrease in end-systolic volume. A decrease in end-systolic volume causes a decrease in cardiac output which also contributes to the decrease perfusion of tissues in the body. Alterations in systemic perfusion result in neuroendocrine activation. This includes increase in sympathetic activity, activation of the renin-angiotensin-aldosterone pathway and eventual decrease in oxygen supply in tissues. Woods (2010) explains that increased activity of the sympathetic nervous system or the renin-angiotensinaldosterone system [RAAS] results in vasoconstriction of the small arterioles. In the RAAS, vasoconstriction leads to increased peripheral vascular resistance. The RAAS also increases aldosterone production thus enabling the retention of sodium and water. This leads to an increase in plasma volume. Increased plasma volume and decreased end systolic volume leads to increased venous pressure tpo the lungs. This increase in hydrostatic pressure causes an increase in the rate of filtration of fluid out of the capillaries and into the interstitial compartment (Woods, 2010). As a result, the lungs fill with fluid, a condition called, pulmonary edema and eventually pulmonary congestion.

On the other hand, increased activity of the systemic nervous system is caused by the release of epinephrine and norepinephrine (Porth, 2007). The purpose of this initial response is to increase heart rate and contractility and support the failing myocardium. Sympathetic stimulation causes peripheral vasoconstriction. Peripheral vasoconstriction may cause capillary endothelial damage.

Decreased oxygen supply in tissues is detrimental because if oxygen delivery to cells is insufficient for the demand, prolonged compensatory mechanisms can lead to cell death (Hobler & Karey, 1973). As seen in Figure 1, there is decreased oxygen supply to the myocardium, brain, gastrointestinal tract and liver. Decreased oxygen supply to the liver predisposes it to liver dysfunction. With decreased oxygen, the gastrointestinal tract increases acid production, in the course of time, leading to the development of superficial mucosal lesions in the stomach and duodenum. Decreased perfusion to the tissues and eventual decrease in oxygen supply causes increased myocardial workload as it attempts to compensate for the reduction (Smeltzer & Bare, 2010). Eventually, compensatory mechanisms fail and even the myocardium experiences a decrease in oxygen supply (Porth, 2007). This decreases oxygen supply to the brain and induces decreased oxygen supply in the blood. When this happens, the heart muscle must use alternative, less efficient forms of fuel so that it can perform its function of pumping blood to the body or commonly called anaerobic metabolism (Porth, 2007). The by-product of using this less efficient fuel is a compound called lactic acid that builds up in the muscle and causes chest pain.

Case Analysis. B. A. is diagnosed with Congestive Heart Failure Functional Classification II due to easy fatigability in doing ordinary activities like walking. She is only able to walk 3 flights of stairs and experiences shortness of breath after walking to and from an area 1 meter away. Congestive Heart Failure in the client developed as a complication of her Valvular Heart Disease diagnosed in 2004 secondary to Rheumatic Heart Disease which was diagnosed in the client in the 1980s. B. A. underwent prosthetic valve replacement in 2004.

Valvular Heart Disease is one of the most common causes of heart failure. It is a common form of heart disease that present with disorders of the heart valves. Most disorders are a consequence of rheumatic heart disease (Woods, et. al., 2010). Cardiac damage from Rheumatic Heart Disease results from reacting antibodies that causes acute inflammation of the heart. It damages valve leaflets resulting to Valvular Heart Disease (Porth, 2007). Heart valves are destroyed when the valvular leaflets and chordae tendinae become fibrous causing the two commisures to close and the chordae tendinae to shorten causing valvular Heart disease (Woods, et. al., 2010).

Rheumatic Heart Disease is a serious heart condition that follows infection with a bacterium called Group A Beta-Hemolytic Streptococcus (Steer & Carapetis, 2009). Zabriskie (1985) discovered that risk factors for developing infection leading to Rheumatic Heart Disease include overcrowding, poor hygiene, lack of access to medical services and living in rural areas. As seen in Figure 1, the client presented with the following risk factors which led to the development of Rheumatic Heart Disease.

However, many other risk factors may contribute to the the development of a cardiac failure. Woods (2010) lists the risk factors for developing cardiovascular diseases which include a family history of heart disease, hypertension, male sex, cigarette smoking, overweight, high levels of blood fats, diabetes mellitus, physical inactivity and pychological stress. The risk factors that may have contributed to the client's disease include a family history of cardiac diseases and eating large amounts of salt and high fat foods. Assessment on the status of the client's health perception and management, psychosocial, perception, reproductive, nutrition, elimination, rest and activity and oxygenation was clustered. Oxygenation. The client has varied periods of fatigue and strength. Vital signs are as follows - respiratory rate is 30 breaths per minute, blood pressure is at 90/60 mmHg, heart rate is at 45 beats per minute and temperature is 36.1C. The client has slow heart rate which may be caused by the intake of maintenance drug which is metoprolol. B. A. is nonalcoholic and nonhypertensive. During the hospital rotation, the clientexperienced chest pain with a grade of 4, radiating to back and persisting after 10 minutes. She also complained of dizziness or light-headedness. This can be caused by decreased circulation of oxygen to the brain because of increased cardiac workload. In supine position and flat on bed, B. A. claims that she has difficulty breathing and feels that she is drowning. She is on moderate high back rest and requires 2 pillow to be able to sleep comfortably without difficulty of breathing. In other words, the client has 2pillow orthopnea which is caused by pulmonary congestion in the client. She is able to climb 3 flights of stairs before being out of breath. These may be reflections of the decreased cardiac output of the heart caused by depressed systolic functioning. The client does not display signs of pallor or cyanosis. She does not have difficulty breathing or use accessory muscles. No nasal flaring was observed. The inspiratory and expiratory ratio is 2 is to 1. The anterior-posterior lateral ratio is 1 is to 2. She does not display signs of a barrel, pigeon or funnel chest. Her chest is symmetric and there is

symmetrical chest expansion. She has normal breath sounds and no adventitious breath souds were heard. During cardiac assessment, a sternotomy scar is seen in the midsternal about 3 centimeters. Point of maximal impulse is at the 6 th intercostal space, left of the midclavicular line.No extra heart sounds or murmurs were heard. Peripheral pulses are strong and equal. Nails are pale but has brisk capillary refill. No nail clubbing was observed. Hematoma is seen in Left lower arm and Right upper arm. Rest and Activity. B. A. claims that she has less energy than before to do her daily activities. She has refrained from washing clothes and carrying heavy things since she easily experiences shortness of breath. She is unable to do household chores as before and go to the market without assistance of a family member. She requires the supervision of a family member because she easily gets tired and experience shortness of breath. Her level of self-care is Level 2. On physical assessment, the client displayed shortness of breath upon exertion. She is able to walk at a distance of about 3 meters with a slow but steady gait. There were no crepitations or joint pains. However, there is muscle weakness on knees. Muscle strength is at 4/5 on both lower limbs and 5/5 on the upper limbs. Elimination. The client moves her bowels everyday. She complains that there are times that she cannot defecate easily because she finds it difficult to stop breathing and expel her feces forcefully. She described her feces as brown, soft and broken into small pieces about 3 cm in diameter. Also, B. A. urinates about 3 times per day, without difficulty or pain. She describes her urine as clear, yellow in color and without any foul odor. She measures her urine to be about 250 ml or one half of a mineral bottle. On physical assessment, no periorbital edema or generalized edema was observed. Skin is smooth and cold to touch. No visible pulsations were inspected on the abdomen. On asucultation, normoactive bowel sounds at 3 per minute were heard. No enlarged organ was palpated. Costovertebral angle tenderness was not assessed due to complaints of back pain. Nutrition. Every day, B. A. eats about three meals per day which are cooked at home, with the occasional snack in between meals. Because she has been cautioned from eating fatty and salty foods, she seldom eats pork. In addition, it was explained to her that green leafy vegetables affect the mechanism of action of one of her medications which is Warfarin so she also refrains eating said vegetables. The food she eats varies from vegetables, fruits, fish and chicken. The client claims that she eats a lot of vegetables and fruits, and leaves behind the fatty portion of the meat she eats. Also, she only eats small portions of the meat, especially if it is salty, and eats about one cup of rice per meal. She dislikes other fatty, salty and sweet foods except chicharon and

fries though she has regulated her intake of both to at least once every two months. She enjoys vegetables and fruits and seldom use condiments except vinegar.

Her fluid intake is about 3 glasses a day or sometimes one 500 ml bottle of water per day. She remembers that when she was in the hospital, her fluid intake was regulated at 1 Liter per day and she has adapted this at home. The client verbalized a noticeable decrease in weight since she was diagnosed with heart disease. At the time of the interview, the client also reported a decrease in appetite, although there is no problem in eating despite having all her teeth replaced with dentures. When she gets sick, she gets well rather quickly, and her only previous skin problem was hematoma, which she explained was caused by her medication (Warfarin).

On physical assessment, the client looks according to age, fairly-nourished, fairly developed, and an ectomorph. Tongue is in midline and no perforation or lesions were observed. There is 1 missing front tooth and the client has full dentures. Trachea is in midline and there is thyroid is nontender and nonpalpable. Normoactive bowel sounds are heard on ausculation. The client has a flabby and soft abdomen. A scar is seen on the epigastric and right lower quadrant about 2 centimeters long. Her height is 5'2 inches high and she displays constant weight at 51 kilograms.

Cognitive. For B. A., a healthy person is one who rarely gets sick. To maintain her health, she drinks her medicines regularly and takes periods of rest. According to the client, she thinks the reason she felt ill was because she does the household chores even when she was supposed to rest and she carries her grandson around which led to shortness of breath and fatigue. On physical assessment, the client was conscious, coherent and oriented to time, person and place. No signs of distress was observed. Normal range of motion of the neck is observed and there was no neck rigidity. The client can walk has a slow but steady gait.

Perception. B. A. has no hearing problem and does not use a hearing aid. However, she does have a visual problem. She uses glasses with grade of 300. Her memory is still intact, and she learns best by actual performance of a task and reading. The client does not feel pain in any part of her body though she sometimes feels chest heaviness and pain which she relieves by ventilating herself with electric fan and taking a rest.

On physical assessment, the client's head is normocephalic and no masses or lesions were observed. The client displayed symmetrical lids and absence of ptosis or swelling. Conjunctiva is pinkish and no lesions were observed. Sclera is anicteric and cornea and lens are clear. Both pupils of the left and right eye are equal, 3 millimeter in size and has brisk and uniform reaction to light and accommodation. There is uniform convergence of the eyes and intact extraocular activity. The client is nearsighted with a grade of 300. The client's ears are normoset and nontender. There was no lymphadenopathy. Discharge or impacted cerumen was not observed. There is symmetrical gross hearing capacity and hearing deficit.

Psychosocial. The client does not want to be a burden to her family and perceives herself as weak. However, she has already accepted this fact and coped with the weakness in her own way. She does not perceive any difference in her physique except weight loss. She is easily cries and becomes tensed or nervous though this has been lessened once she was admitted in the hospital. B. A. feels anxious about her condition but she believes that everything will be alright in the end more so because she feels relatively fine. Whenever she feels tensed, she talks to her significant others or pray the rosary. She usually feels nervous whenever there are arguments in the family but this has been lessened according to her significant other out of consideration for the client. She sits and calms herself by praying and talking with the involved parties to relieve her tension. She coped with her condition by changing her lifestyle for the better, avoiding foods that are contraindicated to her condition and taking rest periods. However, she does feel bothered about the expenses incurred by her children for her medical condition.

The family of B. A. is extended and patriarchal, with B. A. making decisions regarding health actions and daily expenditures. She lives with her husband, her three children, a daughter-in-law and a grandson. Her husband is a contractual painter of houses and automobiles and their usual income varies from P3000-P5000 per month. Their children always contributes to the medical expenses of the client. Currently, they feel worried about their mother's condition and contributes to any way they can to alleviate her condition. The usual problem of the family involves the drinking habit of the client's husband and financial problems. They usually resolve it by conversations with the family.

The client's only wish is to see her children and her grandchildren grow up. She does not fear death but she wishes that she will live longer because of her family. God, family and health are important for B. A. She claims that her religion helps her get through her condition because it gives her energy and happiness. On physical assessment, the client displayed signs of anxiety through silent pauses and different facial expressions. Respiration was not increased on narrations.

Reproductive. B. A. stated that she and her husband has not engaged in sexual intercourse in recent years. She claims that this is because they are already old. She has used pills as a family planning method from 1989 to 2002 but has since stopped using them though no problems were encountered upon their use. The client had her first menstrual period when she was 11 years old. She describes her menstrual period to be regular and usually lasts from 3 to 4 days. She usually consumes 3 pads in a day and has never experienced dysmennorhea. Her last menstruation was on August 1, 2010. B. A. is a G3P3 mother and has no history of complications at birth. On physical assessment, the client displayed symmetrical breasts. No lesions, masses or dimpling were observed. There was no discharge from the nipple.

Complications of heart failure are varied. However, in this discussion, we will focus on the actual and suspected complications in the patient during course in the ward. One of the chief complaint of the client was fever. The client has increased risk for infection due to prosthetic valve replacement in 2004. Because of this, Infective Endocarditis was presumed to be the cause of fever. In nursing literature, it has been stated by a study that prosthetic valve replacement increases risk for infective endocarditis (Okies, et. al, 1971). Another chief complaint was chest pain or angina. The client presenting with chest pain is at increased risk for myocardial infarction. This is typical if severe, prolonged chest discomfort is present. The onset of chest discomfort must be abrupt and lasts longer than 15 to 30 minutes. The comfort is usually midsternal, crushing, or squeezing and may radiate to the arms, shoulders, back, neck or jaw (Woods, et. al, 2010). This list of symptoms were experienced by the client on the hospital rotation. Community-acquired pneumonia was considered because of the presenting symptoms of the client similar to pneumonia. These includes pleuritic chest pain, shortness of breath, raised respiratory rate and fever of 38C (Porth, 2007). Pulmonary tuberculosis was also considered because of similar symptoms of wasy fatigability, anorexia, weight loss, dyspnea and orthopnea (Porth, 2007).

Initial laboratory results were made to eliminate possibilities of Infective Endocarditis, Community-Acquired Pneumonia and Pulmonary Tuberculosis, find out other complications present in the patient and determine the cause of presenting symptoms.Infective Endocarditis is ruled out when the blood culture findings were negative. Myocardial Infarction which was suspected on the onset of chest pain was also negative as the electrocardiography reports normal heart structure with bradycardia at a rate of 45 beats per minute.

Pneumonia and pulmonary tuberculosis were ruled out as chest x-ray findings were negative of infiltrates or cavities in the upper lungs. Other significant laboratory findings include the presence of hematuria which may be caused by suspected capillary endothelial damage caused by vasonconstriction or the presence of bilateral renal cysts seen on ultrasound. Fatty Infiltration or streaks in pancreas were also observed on ultrasound and the high intake of cholesterol and salt are one of the many factors suspected to have caused this. In the echocardipgraphy of the client, the presence of mild tricuspid regurgitation was observed which may have been caused by the valvular heart disease present in client before. It is important to note that only the mitral and aortic valves were replaced in surgery before. Ejection Fraction with 53% Teicholtzs, 47% Simpsons and heart rate of 45 beats per min seen in electrocardiography reflects the decreased cardiac output of the client caused by mildly depressed overall systolic functioning as seen also in the echocardiography. The presence of minimal Albumin in urine seen in the urinalysis is suspected to have come from possible liver damage or caused by the damage on the capillary endothelial damage.

As of discharge day, the client has not presented signs of peripheral congestion like edema, its most presenting sign. However, this only emphasizes the importance of monitoring as said complication is not only probable but is almost the norm for congestive heart failure.

Treatment. Despite the advances in heart failure treatment, a systematic approach to acute heart failure has only recently been emphasized, as reflected in the updated American College of Cardiology/American Heart Association heart failure guidelines from 2009. These guidelines recommend hospitalization for acute heart failure if the

severe decompensated heart failure (low blood pressure, renal dysfunction, altered mentation), dyspnea at rest, hemodynamically significant arrhythmia or acute coronary syndrome is present (Hunt, et. al, 2009).

The goal is to continue the diagnostic and therapeutic processes started. Patients volume and hemodynamic status is optimized using careful clinical monitoring and the heart failure medical regimen is optimized. Heart failure education, behavior modification, and exercise and diet recommendation are made. The patient must be on a stable oral regimen for at least 24 hours before discharge. During the period of hospitalization of the client, B. A underwent a series of treatment for management of heart failure and its complications. Both medical and nursing care are taken into account. Medical Plan of Care. Heart failure treatment has both pharmacologic and nonpharmacologic therapy prescribed by the doctor. This is used to maintain the client at her most stable condition and prevent complications from happening. Pharmacologic Therapy. Smeltzer & Bare, et. al. (2010) enumerate the medications usually prescribed to heart failure patients. These include angiotensinconverting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), betaadrenergic blocking agents, diuretics, digitalis and calcium channel blockers. Beta-adrenergic blocking agents given to patients with heart failure have been recommended for patient swith asymptomatic systolic dysfunction. ACE inhibitors promote vasodilation and diuresis by decreasing afterload and preload, thus reducing the workload of the heart (Smeltzer & Bare, et. al., 2010) . However, they are not being given to client because hypotension is present in the client and ACE Inhibitors given with Beta blockers which are the client's maintenance drugs further decrease blood pressure and heart rate. In contrast, ARBs, though having the same mechanism of action as ACE inhibitors, does not produce cough which usually discomforts heart failure patients (Smeltzer & Bare, et. al., 2010). This drug was also not prescribed to the patient with the same reason as ACE Inhibitor. On the other hand, diuretics are prescribed to remove extracellular fluid by increasing the rate of urine produced in patients with signs and symptoms of overload (Smeltzer & Bare, et. al., 2010). However, this was not prescribed to the client because there were no symptoms of fluid overload or retention like edema. Conversely, digitalis is used to increase the force of myocardial contraction and slow conduction through the atrioventricular mode (Smeltzer & Bare, et. al., 2010). However, this drug was also not given to the client because it increases the risk for digitalis toxicity. Also, when a person is hypokalemic, digitalis absorption is faster and there is increased risk for toxicity.

Calcium channel blockers cause vasodilation, reducing systemic vascular resistance (Smeltzer & Bare, et. al., 2010). However, they were not prescribed to client because it is contraindicated in patients with systolic heart failure. Conversely, anticoagulants are prescribed to client especially if client has history of atrial fibrillation or a thromboembolic event. It lyses clots or possible clots before it even enters the cardiac community (Smeltzer & Bare, et. al., 2010).

Medications, their indications and contraindications, nursing implications and pharmacologic actions of the drugs prescribed are enumerated below. Beta-blocker. Metropolol belongs to the class of beta1-selective adrenergic blocker (Karch, 2010). Beta-adrenergic blocking agents have been found to reduce mortalilty and morbidity in patients with heart failure by reducing the adverse effects from the constant stimulation of the sympathetic nervous system (Smeltzer & Bare,et. al. 2010). According to Deglin & Vallerand (2009), metoprolol's pharmacologic action is to competitively block beta-adrenergic receptors in the heart and juxtaglomerular apparatus, decreasing the influence of the sympathetic nervous system on these tissues and the excitability of the heart, decreasing cardiac output and the release of renin, and lowering blood pressure. It also acts in the Central Nervous System to reduce sympathetic outflow and vasoconstrictor tone. This was indicated for the client due to high probability of increased blood pressure. Metoprolol is a maintenance drug for the client after prosthetic valve replacement. Some contraindications to administration of metoprolol include cardiogenic shock, sinus bradycardia (HR less than 45 beats/min) and heart failure. Things to watch out for include sudden decrease in blood pressure, heart rate, dizziness, shortness of breath and blurred vision. Spratto & Woods (2008) outlines that nursing implications in giving this drug include telling client to report difficulty breathing, night cough, swelling of extremities, slow pulse, confusion, depression, rash, fever, sore throat and assessing before and after administration of drug. Anticoagulant. Warfarin is a cardiac drug that belongs to the class of oralanticoagulants (Karch, 2010). Its pharmacologic action is to interfere with the hepatic synthesis of vitamin K-dependent clotting factors (factors II, prothrombin, VII, IX, and X), resulting in their eventual depletion and prolongation of clotting times (Deglin & Vallerand, 2009). This was indicated for the client as a measure of prevention of thrombus formation and embolization after prosthetic valve placement done in 2004. It has been, since then, a maintenance drug used by the client in combination with metoprolol. Karch (2010) adds that some contraindications to administration of warfarin is uncontrolled bleeding because warfarin increases the probability of bleeding. It is also contraindicated to open

wounds, active ulcer disease, severe liver or kidney disease, uncontrolled hypertension and recent brain, eye, or spinal cord injury or surgery. It must be used with caution in patients with malignancy and women with childbearing potential. The main desired action on the client includes the lyse of possible clots and treatment to prevent formation of emboli or thrombus. Spratto & Woods (2008) state that one of the nursing implications in giving this drug is watching out for signs of bleeding. The common signs, onset or worsening of bleeding include the occurrence of petechiae, ecchymoses, or hematomas, conjuctival hemorrhages, bleeding gums, hypotension, tahycardia, dizziness epotaxis, hemoptysis, abdominal distention, headache, blurred vision and mental status changes (Smeltzer& Bare,et. al. 2010). Other nursing implications include reminding patient to not double doses and have limited intake of Vitamin K (Karch, 2010). Proton-pump inhibitor. Omeprazole belongs to the class of the proton pump inhibitors or the anti-secretory drugs (Karch, 2010). According to Deglin & Vallerand (2009), omeprazole's pharmacologic action is suppressing gastric acid secretion by specific inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal cells. It blocks the final step of acid production. Karch (2010) adds that the medication is usually given to the client with heart failure for the management of duodenal ulcers and eventual prevention of bleeding from the upper gastrointestinal tract in people who have life-threatening illnesses. Some contraindications to watch out for include hypersensitivity to omeprazole or its components. Caution is advised for patients with liver disease wherein dosage reduction may be necessary and in pregnancy, lactation, or children as safety has not yet been established.

The main desired action on the client includes prevention of gastrointestinal bleeding and hypersecretion caused by ulcers or leisions in the gastrointestinal tract. Spratto & Woods (2008) reminds nurses that this drug should be administered before meals because absorption of the drug is compromised if introduced to the body with meals. It is also important to caution patient to swallow capsules whole and not to open, chew, or crush them.Adverse effects like severe headache, worsening of symptoms, fever, chills must be assessed after giving drug. Third-generation cephalosporin. Ceftriaxone belongs to the class of thirdgeneration cephalosphorins (Karch, 2010). Its pharmacologic action is inhibiting the synthesis of bacterial cell wall, causing cell death, according to Deglin & Vallerand (2009). This was indicated for the client due to suspected infective endocarditis.Contraindications to ceftriaxone include allergy to acetaminophen. It must be used with caution in patients with impaired hepatic function and chronic alcoholism.

The main desired action on the client includes prevention or treatment for possible endocarditis or pneumonia. Spratto & Woods (2008) outlines adds that the nursing implications in giving this drug include assessing patient for infection at beginning of and throughout therapy, observing patient for signs and symptoms of anaphylaxis like rash, pruritus, laryngeal edema and wheezing.

Antipyretic, Analgesic. Paracetamol belongs to the class ofantipyretics and analgesics. Its pharmacologic action is reducing fever by acting directly on the hypothalamic heatregulating center to cause vasodilation and sweating, which helps dissipate heat (Karch, 2010). This was indicated for the client due to fever on admission to reduce fever and provide temporary relief of minor aches and pains (Deglin & Vallerand, 2009). Some contraindications to watch out for include allergy to acetaminophen. Spratto & Woods (2008) enumerates the nursing implications in giving this drug and these are administering thedrug with food if GI upset occurs and discontinuing the drugs if hypersensitivity reactions occur. Also, constant assessment of the client's temperature and montoring for signs of infection are undertaken. Treatment Modality. Physicians prescribe two additional therapy for the client with heart failure, namely, Nutritional therapy and Supplemental Oyxgen therapy. Nutritional Therapy. Cardiac diet consists of low-sodium and restricted cholesterol diet. In addition, avoidance of drinking 44 excessive amounts of fluid are asually recommended. Dietary restriction on sodium reduces fluid retention and due to symptoms of peripheral and pulmonary congestion. Smeltzer & Bare (2010) stated that the significance of the sodium-restricted diet is to decrease the amount of blood volume which decreased myocardial workload. The computed diet for the client is based on a 1, 800 calorie diet which is recommended for the client. Total Calorie Requirement is 1800 kilocalories per day. Carbohydrate is limited to 270 grams per day while Protein is limited to 50 g per day. Fats, on the other hand, are restricted. Supplemental Oxygen Therapy. Oxygen therapy becomes necessary as heart failure progresses. This is based on the degree of congestion or hypoxia (Smeltzer & Bare, 2010). The client is hooked to a nasal cannula with pressure of 4 LPN.

Nursing Plan of Care. Care of nurses are shown to have increase the management of a patient with heart failure. Thus, it is important to plan care efficiently.

Problem Identification. Figure 2 shows the concept map for the different problems identified in the patient. The following nursing problems were identified on August 31, 2010. First problem identified is anxiety. Anxiety (mild) is defined by Doenges (2004) as a vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual)or a feeling of apprehension caused by anticipation of danger. It is an altering signal that warns of impending danger and enables the individual to take measures to deal with threat. Subjective cues that identify anxiety include verbalization of nervousness, Madali talaga akong kabahan, and anxiety about prognosis of disease, Natatakot talaga akong mawala kasi gusto ko pa sanang makitang lumaki ang apo ko. Objective cues include changing facial expression, pauses when reflecting, sudden dizziness or difficulty of breathing.

Next problem identified is Imbalanced Nutrition: Less than Body requirements. It is defined as the intake of nutrients insufficient to meet metabolic needs (Doenges, 2004). Subjective cues for this diagnosis include feeling of fullness, decreased appetite and minimal consumption of meals. Objective cues include the weight loss from 55 kilograms to 51 kilograms. B. A.'s height is 5'2 inches. The client is prescribed with a cardiac diet consisting of low salt and restricted fat. Total calorie intake recommended is 1800 kilocalories per day. Carbohydrates to be consumed are at 270 grams per day and protein is recommended to have at least 50 kilograms per day.

Risk for Ineffective Myocardial and Cerebral Tissue Perfusion is another nursing problem identified and it is defined as an increased risk for decreasing in oxygen resulting in the failure to nourish the tissues at the capillary level (Doenges, 2004). Subjective cues include chest pain with a grade of 4, radiating to back and persisting to more than 10 minutes. Dizziness and chest heaviness were also reported. Objective cues include vital signs of 90/60 and heart rate of 45 beats per minute. Pallor and pale nail beds are other signs of ineffective tissue perfusion. The client is on oxygen therapy through a nasal cannula with 4 LPN as needed.

A nursing diagnosis identified is Ineffective Breathing Pattern which is defined by Doenges (2004) as inspiration and/or expiration that does not provide adequate ventilation. Subjective cues for identifying the problem include shortness of breath on exertion. Client has 2 pillow orthopnea and complains of easy fatigability. She reports feelings of drowning on supine position so she is placeed on Moderate High Back Rest. Objective cues include use of accessory muscles on exertion with a respiratory rate of 30 respirations per minute. There is normal hemoglobin count and left ventricular hypertrophy is identified in the electrocardiogram.

Risk for Infection is defined as at increased risk for being invaded by pathogenic organisms (Deonges, 2004). This risk for infection is actually due to the client's former surery which is prosthetic valve replacement in mitral and aortic valves. She is predisposed to infective endocarditis. Subjective cues include history of surgical procedure in open heart surgery, prosthetic mitral and aortic valve replacement in 2004. She also a known cardiac patient due to other diseased like Valvular Heart Disease and Rheumatic Fever. Objective cues include the onset of fever with a temperature of 35.8 C. Client is medicated with Ceftriaxone and there is also a presence of heplock at the left arm. The client's WBC values are normal and blood culture shows negative results after 2 days of incubation. Another nursing problem identified is Decreased Cardiac Output. It is defined by Doenges (2004) as inadequate blood pumped by the heart to meet the metabolic demands of the body. Decreased Cardiac Output is also part of the pathophysiologic diagram because it is part of the progression of the disease. Subjective cues include history of cardiac problems as a patient of Valvular Heart Disease and Rheumatic Heart Disease. The client is fond of fatty and salty foods. She does not exercise though she walks to and from the market. Vital signs are monitored every 4 hours. There is easy fatigability and client can walk only 3 flights of stairs. Potassium content in blood is 3.9 mmol/L. Prothrombin time is 22.3 secs and Partial Thromboplastin Time is 56.8 secs. There is shortness of breath on exertion.

Activity Intolerance is defined as insufficient physiological or psychological energy to endure or complete required or desired daily activities (Doenges, 2004). Manifestations of the disease is similar to Decreased Cardiac Output. However, activity intolerance focuses more on the activities that the client can undertake. The client is ambulatory and always does things for herself. However, ordinary physical activities like walking are an effort to her and companions are needed to prevent syncope.

PC: Bleeding is a collaborative problem that looks out or monitors potential complications of bleeding in the client. The client has upper gastrointestinal bleeding though she does not complain of stomach pain. The client is on warfarin therapy that takes increases risk for bleeding. The client was advised to avoid green leafy vegetables because they counteract the mechanism of warfarin. Objective signs include hematuria, hematoma and left lower arm and right upper arm.

PC: Pulmonary Embolism is collaborative problem that monitors probability of potentila pulmonary embolism present in client. Because of prosthetic valve replacement in 2004, the client is monitored for pulmonary embolism which can lead to cardiac death. Cues include blood pressure of 90/60 and a heart rate 0f 49 beats per minute. The client is ambulatory and experiences chest pain on exertion. She is on moderate high back rest and on warfarin therapy. Prothrombin time is 22.3 secs and Partial Thromboplastin Time is 56.8 secs.

Problem Prioritization. Figure 3 shows the pyramid of prioritization of the nursing diagnosis. Maslow's Hierarchy of needs is utilized though in some circumstances, the intensity of symptoms and underlying causes were taken into account first before their recommended position in Maslow's concept. As can be seen, Decreaed Cardiac Output emerged as the priority problem because of the presenting symptoms such as very slow heart rate of 45 beats per minute and low blood pressure for age at 90/60. Also, ejection fraction is slightly lower than normal. These are needs that prompted addressing the problem first. Also, if Decreased Cardiac Output has been resolved, other problems like Activity Intolerance may not be needed to be intervened on.

Nursing Interventions. In the formulation and implemenation of interventions in the nursing care plan, the most presenting signs and symptoms were given priority first before the conceptualized care plan. Nursing Interventions Classifications (2001) was also utilized to plan care.

On the day following assessment, Decreased Cardiac Output related to decreased endsystolic volume was addressed first. In the succeeding days, evaluation of care was still continued. The goal for this problem is that by the end of the shift, Mrs. Aquino will demonstrate adequate cardiac output as evidenced by normal blood pressure and pulse rate and rhythm.

One of the Nursing Interventions Classification used was Hemodynamic Regulation [4150] which is defined as optimization of heart rate, preload, afterload and contractility (Johnson, et. al, 2001). This was chosen to address the problems of decreased heart rate, increased preload and afterload and reduced contractility of the patient.

During nursing intervention, the student nurse has (1) monitored hemodynamic stability indicators (vital signs, peripheral pulses, capillary refill time, pallor) and compared with baseline. The hemodynamic stability indicators are the baseline to indicate the status of cardiac output (Smeltzer, et. al., 2010). She has (2) monitored for peripheral edema,

jugular vein distention and S3 and S4 heart sounds. As peripheral edema, jugular vein distention, extra heart sounds indicate progressing congestion (Smeltzer, et. al., 2010).

Another Nursing Intervention Classification used was Cardiac Care [4040] which is defined as limitation of complication resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac function. This classification was used to decrease demands particularly of oxygen on the heart and alleviate symptoms of impaired cardiac function.

During nursing intervention, the student nurse has (1) placed Mrs. Aquino in preferred position of comfort or in semi-Fowler's position as this position decreases the workload of breathing, and venous return and preload to the heart (Kozier & Erb, et. al., 2010). She was able to (2) teach Mrs. Aquino conscious breathing technique. Stress responses and attacks contributing to myocardial oxygen demand can be reduced by relaxation techniques (Kozier & Erb, et. al., 2010). (3) The promotion of a calm and restful environment was done to reduce myocardial oxygen demand that can be achieved by allowing for rest and relaxation periods (Kozier & Erb, et. al., 2010). The student nurse has (4) planned activity providing rest periods for the Mrs. Aquino to conserve energy and reduce cardiac workload (Smeltzer, et. al., 2010). She has also been able to (5) stress the importance of avoiding straining/ bearing down, especially during defecation as Valsalva maneuver causes vagal stimulation, reducing heart rate (bradycardia), which may be followed by rebound tachycardia, both of which impairs cardiac output (Smeltzer, et. al, 2010).

The next Nursing Intervention Classification used is Cardiac Care: Rehabilitative [4046] which is defined as the promotion of maximum functional activity level for a patient who has experienced an episode of impaired cardiac function that resulted from an imbalance between myocardial oxygen supply and demand (Johnson, et. al., 2001). This classification was chosen to increase patient's independence and assess and recommend possible activity levels for the patient.

During nursing intervention, the student nurse was able to (1) instruct the patient and family on appropriate prescribed medications as increase in knowledge especially during home management decreases number of rehospitalizations (Paul, 2008). The student nurse also (2) instructed the patient and family on cardiac risk factors and possible modifications. Risk factors like high cholesterol and sodium intake are lifestyle problems that can be addressed with proper knowledge (Paul, 2008). The student nurse (3) instructed the patient and family on any lifting/weight limitations, as appropriate as this increases demand for oxygen compromising the transport to different tissues in the body (Kozier & Erb, et. al., 2010). The student nurse also (4) explained the importance of a cardiac diet, as required. High sodium intake causes water retention (Porth, 2007).

The last Nursing Interventions Classification used for the problem Decreased Cardiac Output related to decreased end-systolic volume is Fluid Monitoring [4130]. Johnson (2001) defines it as a collection and analysis of patient to regulate fluid balance. This classification was chosen because of the importance of monitoring signs of further complications of congestion in the client.

During nursing intervention, the student nurse was able to (2) monitor intake and output of the client. Intake and output monitoring helps monitor presence of excess or deficient fluid in the client (Kozier & Erb, et. al., 2010). The student nurse was also able to (1) monitor weight and advise client to weigh daily at 8am as tolerated. Weighing checks for possible increase in mass and fluid volume in the body undetected on the surface (Kozier & Erb, et. al., 2010). This is important for the client to learn also as increase in weight is a factor for reconsultation and possible rehospitalization once discharged (Paul, 2008).

On the second intervention day, Anxiety related to threat to or change in health status was addressed. Activity Intolerance related to increased cardiac workload was intended to be carried out on this day but was terminated. The problem Decreased Cardiac Output related to decreased end-systolic volume was also reevaluated.

The goal of this nursing intervention is for the client to report that anxiety is reduced to manageable level. One of the Nursing Interventions Classification in this diagnosis is Anxiety Reduction [5820] which is defined as minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified soure of anticipated danger (Johnson, et. al., 2001). This classification was chosen to decrease the client's apprehension related to prognosis of disease. During nursing intervention, the student nurse (1) provided factual information concerning diagnosis, treatment and prognosis. Increased knowledge on prognosis of disease promotes understanding of diagnosis, treatment and prognosis and compliance to treatment.

Another Nursing Intervention Classification used was Coping Enhancement [5230] which is defined as assisting a patient to adapt to perceived stressors, changes, or threats which interfere with meeting life demands and roles (Johnson, et. al., 2001). This classification was chosen because it allows the nurse to identify possible stressors and at the same time, allows the patient to reflect on self and trace possible sources of anxiety and address them on her own. During nursing intervention, the student nurse was able to (1) review extent of feelings of anxiety of clients as there is a need to know the extent of disequilibrium and need for intervention to prevent or resolve the crisis (Doenges, 2006). She was also able to (2) discuss indication and method of treatment as this promotes active participation of client in therapeutic regimen (Doenges, 2006). She has taken (3) note of expressions of indecision, dependence on others, and inability to manage own activities of daily living. This may indicate need to lean on others for a time (Doenges, 2006). Last, she (5) assessed the presence of positive coping skillls/inner strengths e.g (use of relaxation techniques, willingness to express feelings, use of support systems). Past coping skills may be reused to relieve tension and preserve individual's sense of control (Doenges, 2006). The goal for Activity Intolerance related to increased cardiac workload is that the client will be able to demonstrate sufficient energy to endure or complete required or desired daily activities. One of the Nursing Intervention Classification of this problem is Activity Therapy [4310] which is defined as prescription of and assistance with specific physical and cognitive, social, and spiritual activities to increase the range, frequency, or

duration of an individual's activity (Johnson, et. al., 2010). This classification was chosen because it addresses encompassingly the problem on the client's execution of activities and on how nurses can increment these activities as appropriate.

During nursing intervention, the student nurse must be able to (1) determine the patient's perception of causes of fatigue or activity intolerance. These perceptions may be temporary or permanent, physical or psychological. Assessment of these perceptions guides treatment (Doenges, 2006). She must be able to (2) assess the patient's level of mobility through the 6-minute walk. This aids in defining what patient is capable of, which is necessary before setting realistic goals (Doenges, 2006). She must be able to (3) assess the patient's cardiopulmonary status before activity. Assessment before and after activity provides for comparison on achieved level of activity tolerance (Doenges, 2006). She has to (4) observe and document response to activities (walking, deep-breathing, ROM). Assessment before and afer activity provides for comparison on achieved level of activity tolerance (Doenges, 2006). She must be able to (5) establish guidelines and goals of activity with the patient and caregiver. Motivation is enhanced if the patient participates in goal setting (Doenges, 2006). (6) Progress activity gradually. This prevents overexerting the heart and promotes attainment of short-range goals (Doenges, 2006).

Another Nursing Intervention Classification is Energy Mangement [0180] which is defined as regulating the use of energy to treat or prevent fatigue and optimize function (Johnson, et. al., 2001). This classification was chosen so that the client's easy fatigability would be addressed thorough the regulation of energy. During intervention, the student nurse was able to (1) assess the patient's schedule and allow rest periods between all activities. Rest between activities provides time for energy conservation and recovery. Heart rate recovery following activity is greatest at the beginning of a rest period (Doenges, 2006). She was able to (2) assist with activities of daily living as indicated though she allowed the client to do what she can do for herself. Caregivers need to balance providing assistance with facilitating progressive endurance that will ultimately enhance the patient's activity tolerance and self-esteem (Doenges, 2006). She was able to (3) encourage verbalization of feelings regarding limitations. Acknowledgment that living with activity intolerance is both physically and emotionally difficult aids coping (Doenges, 2006).

On the third intervention day, Risk for Ineffective Myocardial and Cerebral Tissue Perfusion related to increased cardiac workload was carried out. Even though the

problem has not yet been included in the nursing care plan, it warranted immediate intervention as the presenting signs and symptoms were manifested. Interventions for this problem included (1) monitoring for levels of consciousness, dyspnea, dizziness, difficulty of breathing, (2) positioning to Moderate High Back rest on preferred position, (3) raising side rails and (4) promoting clam and restful environment, (5) clustering activities with caregiver to limit extreme activities, (6) instructing client to report chest pain and (7) ensuring rest periods. Evaluation. Evaluation is always carried out after intervention and reevaluated on the succeeding days. It is used to determine whether the objectives and outcome criteria were met.

For the problem Decreased Cardiac Output related to decreased end-systolic volume, one of the Nursing Outcome Classification is Cardiac Pump Effectiveness [0400] which is defined as adequacy of blood volume ejected from the left ventricle to support systemic perfusion pressure (Johnson, et. al., 2001). This classification was chosen because it allows the nurse to address the main etiology which is decreased endsystolic volume. Objectives of this problem was to display hemodynamic stability, report absence of severe congestion, demonstrate decreased episodes of shortness of breath and orthopnea and tachypnea and reduce the workload of the heart.

The outcome criteria for these objectives include to (1) display hemodynamic stability by having the following (blood pressure, heart rate, respiratory rate, temperature, peripheral pulses, capillary refill time, nail beds, color) within normal parameters. Of the indicators, only the heart rate was not within normal parameters with 50 beats per minute. Another was to (2) demonstrate absence of peripheral edema, jugular vein distention and S3 and S4 heart sounds. There was no indications of either of the three. The next criteria was to (3) demonstrate decreased episodes of shortness of breath, tachypnea and orthopnea. Of the three, only orthopnea is still the same as before and client is still on moderate high back rest. Another was to (4) demonstrate conscious breathing technique which was correctly performed by the client. The next one was for the client to (5) verbalize the desire to participate in activities that reduce the workload of the heart like stress management which was stated by the client.

The next outcome classification is Cardiac Disease Self-Management [1617] which is defined as personal actions to manage heart disease, its treatment, and prevent

disease progression (Johnson, et. al. 2001). This was chosen to promote independence in decision-making and treatment of the client. Objectives of this diagnosis is for the client to participate in treatment regimen, state adequate knowledge about disease process, participate in cardiac rehabilitation program and limit sodium, fat and cholesterol intake. The outcome criteria for this objectives include (1) verbalization of the desire to participate in the treatment regimen which was stated by the client, (2) stating 3 risk factors (diet, exercise, smoking cessation) and the importance of their modification. The client was able to perform this outcome. Another criteria includes (3) verbalization of the understanding of required diet which the client's significant other has been able to fulfill. Another nursing outcome classification is Circulation Status[0401] which is defined as unobstructed, unidirectional blood flow at an appropriate pressure through large vessels of the systemic and pulmonary circuits (Johnson, et. al., 2001). This classification was chosen because of the increased volume and pressure in the heart and plasma which may change the flow of blood. The objective of this classification is to maintain normal weight for age. The outcome criteria for this objective is to report the absence of weight loss and weight gain. For the Nursing Diagnosis Anxiety related to threat or change in health status, the goal is for the client toreport that anxiety is reduced to manageable level. One of the nursing classification for this diagnosis is Anxiety Control [1402] which is defined as personal actions to eliminate or reduce feelings of apprehension, tension, or uneasiness from an unidentifiable source(Johnson, et. al., 2001). This classification was chosen because it allows self-assessment and personal management of the client's source of anxiety. Objectives of this classification include verbalizing understanding of condition/disease process and potential complications. The outcome criteria for this objective is to use own words and understanding in describing the disease process ro condition and its potential complications.

Another Nursing Outcome Classification is Coping [1302] which is defined as personal actions to manage stressors that tax an individual's resources (Johnson, et. al., 2001). As with the preceding classification, this promotes and enhances independence in identifying source of problem. In addition, it allows the nurse to assist the client in her endeavor and promotes camaraderie and rapport between the two. Objectives of this classification include reporting a decrease in stress, verbalize understanding of treatment procedures and using behaviors to reduce stress. Outcome criteria include (1)consistently reporting a decrease in stress. The client has been able to report a reduced feeling of stress on the succeeding day. Another outcome criteria is (2) verbalizing in own words the relevant information about treatment wherein the client has been able to identify the action and indications of her medications. Last outcome criteria is (3) demonstrating at 3 least behaviors to reduce stress ( use of relaxation techniques, willingness to express feelings, use of support systems). The client has been able to utilize and demonstrate said behaviors.

For the nursing diagnosis Risk for Ineffective Myocardial and Tissue Perfusion, the client was evaluated and exhibited absence of pallor, syncope, dizziness and chest pain with vital signs of 110/70 mmHg, 56 beats per minute, 24 breaths per minute and at a temperature of 36. 1 C. Because of the journal entitled Hospital Discharge Education for Patients With Heart Failure: What Really Works and What Is the Evidence? was used by the student nurse as a supplementary material for learning, health instructions and emphasis of importance of weight monitoring, sodium and fluid restrictions, physical activities, regular medication use, monitoring signs and symptoms of disease worsening, and early search for medical care was made. The purpose was to promote self care, reduce readmission and helping the patient spot problems easily.