Arellano University College of Nursing Legarda, Manila

CHF 4, Cardiomegaly Secondary to CAD

A Case Study Presented to the Faculty of the Arellano University College of Nursing in Legarda, Manila

In Partial Fulfilment of the Requirements in Nursing Care Management 105 for the Degree Bachelor of Science in nursing

Presented by: BSN 4 12 Adviser: Mrs. Olivia Fajardo, R.N., M.A.N.

January 2012

I. Introduction Driven with our interest and as future nurses, we chose this case because of the underlying knowledge behind CHF 4, Cardiomegally Secondary to CAD as it holds vast amount knowledge that we section 12, can learn from. This case will be the pathway to higher knowledge about CHF 4, Cardiomegally Secondary to CAD and key to working more efficient when tackling this kind of disease.

By definition, Heart failure is a global term for the physiological state in which cardiac output is insufficient in meeting the needs of the body and lungs. Often termed "congestive heart failure" or CHF, this is most commonly caused when cardiac output is low and the body becomes congested with fluid. By number, as of 2008 CHF is present in 2 percent of person age 40 59 years old, more than 5 percent of person age 60 69 years old and 10 percent of person ages 70 and older. According to WHO more than 22 million people worldwide suffer from CHF. Here in the Philippines out of the 86 million populations, 1.5 million have CHF and it is the 6th leading causes of mortality in the Philippines, affecting males more often than females. Causes of CHF are the following; Coronary artery disease, including angina and heart attack, is the most common underlying cause of congestive heart failure. People who have a heart attack are at high risk of developing congestive heart failure. Most people with heart failure also experienced uncontrolled high blood pressure in the past, and about one out of every three people with heart failure also has suffered from diabetes. As all of you can see there is a number 4 in our title (CHF4) because according to the New York Heart Association, heart failure are categorized in four class, namely class I (uncompromised), II(slightly compromised), III (markedly compromised), and IV( severely compromised), since our client is belong to the class IV, meaning, she cannot perform or carry out normal physical activity without experiencing discomfort. Even at rest she experience cardiopulmonary insufficiency.

Congestive Heart Failure is subdivided into two main category; The Right Sided Heart Failure and Left Sided Heart Failure, in relation to our client, she is experiencing the Left Sided Heart Failure, as she shows sign and symptoms of it, specifically, tachypnea and increased work of breathing. Rales or crackles, heard initially in the lung bases, and when severe, throughout the lung fields suggest the development of pulmonary edema (fluid in the alveoli). Cyanosis which suggests severe hypoxemia is a late sign of extremely severe pulmonary edema. Diagnostic procedure commonly use to support the clinical diagnosis of CHF are; Echocardiography, Chest X Ray, Electrocardiogram (ECG/EKG).

II. Objectives

General Objective: Nowadays, heart problems are the majority disease of most of us. Its because of lifestyle, knowledge deficit and other risk factors that causes this illness so we, BSN IV Section 12 of Arellano University College of Nursing, aims to develop our skills in performing assessment procedures and the necessary intervention for quality care of the client, to enhance our knowledge in understanding the disease and identify specific treatment for client who is suffering from it. We want emphasize that nurses should be familiar with this because we are the instruments that will brought our country in lesser morbidity and mortality rate on heart problems.

Specific Objectives: At the end of the presentation the students will be able to: Give a brief introduction about CHF 4, Cardiomegally Secondary to CAD together with the clinical manifestations. y Present a theoretical framework for the study in relation to a nursing approach applied to our client. y Present the clients demographic and health history with its Gordons eleven functional health patterns, to know how the client get the disease. y Present the abnormal results of the physical assessment and compare it to the normal values or findings which will help in analyzing the disease process. y Present the different laboratory test and results done to the client with its interpretation. y y Discuss the normal Anatomy and Physiology of the Heart. Explain the Pathophysiology of CHF 4, Cardiomegally Secondary to CAD to elaborate how the disease and its complications formed.

Identify Nursing Problems related to the situation of the client and apply necessary intervention.

Discuss the drugs that has been used and prescribed to the client, to emphasize its action to the clients system.

Discuss the appropriate discharge plan for the client.

III. Theoretical Foundation Dorothea Orems SELF - CARE THORY According to this theory, self care is a learned behaviour and a deliberated action in response to a need. Orem identifies 3 categories of self care requisites: 1. Universal self care requisites Common to all human beings and include both physiological and social interaction needs. 2. Developmental self care requisites That are needs arise as the individual grows and develops. 3. Health deviation self care requisites Result from the needs produced by disease and illness states.

In relation to our client and according to the categories; in terms of Universal requisites, Since our client case is about heat failure, in which her left ventricle cannot pump out oxygenated blood effectively, tendency pressure will build up to the Left ventricles which causes backflow of blood to the left atrium and to the lungs causing pulmonary edema, thus our client experiencing difficulty of breathing because of impaire gas exchange of oxygen and carbon dioxide, hence our client needs to rest and avoid extraneous activity to avoid aggravation of her condition. In developmental requisites, according to Erik Erikson developmental theory with her age of 55 y/o she is in stage of generativity v.s. stagnation, however because of her condition right now, and being hospitalized, she cannot do her role as a mother to her family, which causes her to perceive as worthless, but still shes hoping to recover from her condition. In health deviation requisites, our client should be aware on the potential complications of her condition, modify lifestyle to accommodate changes in the health status and adhere to all medical regimens given to her, for her to recover soon.

IV. Nursing History

A. Biographical Data Clients Name: TDGP Address: Yellowbell St. NBBN Navotas City Gender: Female Date of Birth: February, 22 1962 Age: 48 yrs old Nationality: Filipino Religion: Roman Catholic Date of Admission: December 4 2011 Medical Diagnosis: CHF 4, Cardiomegally secondary to CAD

B. Chief Complaint Clients chief complaint was nahihirapan akong huminga at sumasakit din ung dibdib ko, as stated by the client.

C. History of Present Illness Two months prior to admission, the client had an onset of productive cough and colds associated with difficulty of breathing. No fever or associated symptoms are experienced. There is no consultation done. A month prior to admission, cough persisted, and there was onset of easy fatigability, light-headedness, and dyspnea on exertion and is slightly relieved by rest.

Weeks prior to admission, dyspnea on exertion was no longer relieved by rest, and even she was sleeping, she still experience DOB, sometimes this DOB was awakening her while she sleeps. Few hours prior to admission, the severity of DOB increases accompanied by chest pain and back pain prompted consult at emergency room and was admitted.

D. History of Past Illness Regarding to the clients past illness, the client was diagnosed of PTB last 2009 in which it was treated for 6 months, on the same year she was diagnosed also of CAD, medication was given and health teachings was made to resolve her CAD, but no complaint to the said management. Furthermore in the past, the client claimed to us that she was already acquired chickenpox, measles and other childhood diseases in which it was treated with home remedies and unrecalled medication. No allergies noted.

E. Family Health History Diabetes Mellitus Heart Disease Had a heart disease Had a heart disease None

Cancer

Asthma

Hypertension

Siblings

None

None

None

Hypertensive

Father Mother

Diabetic None

None None

None None

Hypertensive Hypertensive

F. Social History

According to the client, she is non alcoholic beverage drinker and do not smoke. Client owned her house with 1 room and 1 comfort room with Manual flush
type. Water supply is from NAWASA, and garbage is collected every morning, electricity is from Meralco, and means of transportation is thru public means. She usually stays at home to do the household choirs. She has middle self esteem with close relationship to his family and values the mano po system. She can able to speak Tagalog.

V. Gordons Functional Health Pattern

Pattern

Before Hospitalization

During Hospitalization

Analysis

Health Perception Health Management Pattern

The client tells us that before, she doesnt want any consultation or even go for checkups because she perceives that she is healthy and there is nothing wrong with her. She was also fond of eating foods high in cholesterol and protein as well as foods rich in sodium, even though she knows that too much intake of cholesterol and sodium will aggravates her condition.

According to the client, her health is progressing although still with intermittent DOB. She really wants to go home, so she complied with all medication that was given to her and followed all the advised and health teaching of all the health care provider because she believed that this is for her own good.

According to Murray and Zentner, the ability of a client to adopt and maintain healthy behaviour depends on the clients perception of his current health status and his level of knowledge regarding the effect of the behaviours and how to maintain this behaviour. The client must identify the behaviours to be maintained or changed. In our clients condition, she perceived that she is still healthy even though she was fond of eating foods high in cholesterol, protein and sodium, in that matter our client shows ineffective health maintenance and she should change her attitudes or behaviours toward his health. She must comply to

the therapeutic regimen given to her , if she will adhere all the therapeutic regimen given to her, possibility is that she will be cure and she will be ok.

Nutritional and Metabolic Pattern.

We werent able to get the clients 1 week food recall but we are able to get the clients preferred foods. She told us that she was fond of eating foods high in cholesterol, and sodium such as chicaron, papaitan, and ihaw ihaw. She consume 7 8 glass of water per day and fond of drinking coffee consuming 4- 5 glass of coffee per day and she weighs 88lbs during the admission

During hospitalization, the clients was on low sodium and low fat diet. She eats fruits like apples and oranges, she also eats bread. She consumes 2 3 glass of water a day and according to our client he told us that her weight decrease from 88lbs to 82lbs

As what our data says, before hospitalization our clients diet further aggravates her present condition, eating too much foods high in cholesterol and sodium, according to the fundamentals of nursing by Kozier, eating so much foods high in cholesterol is bad specially to the heart, too much cholesterol in the circulation can lead to cholesterol plaque deposit(atherosclerosis), that will narrow the lumen thus results to CAD and complicates to heart failure. During hospitalization, our clients diet was on low fat & low sodium as well as decreases her intake of water. Since low fat diet prevents further build up of

fats to her Coronary Artery thus preventing complications, and decrease her sodium and water intake to avoid aggravation of her edema.
Bowel: Patient usually defecates once a day without experiencing discomforts, usually morning or afternoon. Stool was brown in colour and is well-formed. Bowel: The patient has no output for 4 days

Elimination Pattern

Bladder: Patient voids 3 4 times a day, she told us that her urine colour is clear and aromatic in odour.

Bladder: She voids 6 times during the shift. Her urine is aromatic in odor and amber yellow in color. Without difficulty in voiding.

During his hospitalization our client experienced constipation in which she cannot pass a single stool for 4 days, according to Joyce black, many factors can contribute to constipation, one of this is decrease in mobility; which lead to decrease peristaltic movement. In relation to our client, her CHF is categorized to 4 meaning, severely compromised, that even at rest she experience sign and symptoms of the disease, thats why one of the management is bed rest to prevent further dyspnea and fatigue. To her voiding pattern, it is expected that she urinates more because of the diuretics (furosemide) she was taking.

Activity and exercise Pattern

According to our client, when the sign and symptoms of CHF was not that evident to her, she usually do first the household chores, when she has a free time, she loves to walk around to her neighbours and mingle with them, but when sign and symptoms of CHF was severely compromising her, that even at rest she develops sign and symptoms like easy fatigability and dyspnea, so she refrained from strenuous activity.

The client is on complete bed rest. She still suffering from easy fatigability due to his present condition that limits him to move around, although the client claimed that she can still feed himself and do hygienic practices with minimal assistance.

According to Pender, Murdaugh and Parson, exercise stimulates an increased production of endorphins w/c promote a sense of well being. In relation to our client, before her hospitalization she tells us that she cannot perform strenuous activity like doing house hold chores, because of easy fatigability and dyspnea on exertion, in that manner our client usually stay at bed to rest, however, the clients sense of well being has decrease. Regarding to her confinement, the client is on CBR, for a simple reason to conserve her energy and oxygen consumption. Before her confinement and during our client used to experience paroxysmal nocturnal dyspnea during night in w/c the client usually go to sleep, according to kozier Illness that causes physical

Sleep and rest Pattern

The client told us that when the sign and symptoms of CHF were not that evident, her sleeping pattern was usually 7 8 hours, sleeping at around 10 and waking at around 5 or 6am, however, when sign and symptoms were evident to her, she

The patient cannot take her usual sleep pattern during hospitalization. She only sleeps for 3-4 hours for the whole day because she is experiencing shortness of breath even during rest. She also experience slight fatigue even at rest.

develops paroxysmal nocturnal dyspnea, in which in the middle of her sleep she wakes up because of DOB, although she claimed to us that she take naps at the afternoon to compensate. The client was able to read and write, and claimed to us that he doesnt experienced sensory perceptual deficits, she also claimed that she can communicate well without any difficulty and can comprehend well. She can speak tagalong and her native dialect of ilokano. The client is conscious, coherent and responsive , still no complaints to his senses and can understand well.

distress can result in sleeping problems.

There is no difference before and during hospitalization.

Cognitive Perceptual Pattern

Self Perception and Self Concept Pattern

The client to us that she has middle self esteem, she also told us that she is friendly, the client also claimed that she want to live his life to the fullest.

Her condition made him realize his mortality. she is recalling her regrets in life. She thinks that it is too late to change because of her condition, although our client states that she is still positive and optimistic about her condition.

Before hospitalization our client looks himself as healthy individual who is friendly and loves to entertain her friends and neighbour but because of her confinement and her condition, our client realizes that she is no longer healthy and can die anytime, according to Kozier Events

Roles /Relationship Pattern

The client has a close family relationship, especially to her sister, whom she is with every single day of her life.

The client tells us that she misses his family especially her sister, although her sister was visiting her, she also told us that she wants to go home as soon as possible.

or situations may change the level of self concept over time. Illness and trauma can also affect the selfconcept. As what our client says to us. Before, she used to be with her sister everyday because of their job as a carinderia vendor, but due to her confinement and her illness, she cannot be with her sister. The client refuse to talk about it, because he is not comfortable

Sexuality/ Reproductive Pattern

The client refuse to talk about it, because he is not comfortable The patient stated that when she was stressed, she usually laughs on it and handles stress like it is nothing. And she sees things positively.

The client refuse to talk about it, because he is not comfortable The client tells us that her confinement made her stress and according to her, she is still very optimistic and positive that she can handle this thing out.

Coping Stress Tolerance Pattern

As what our client told to us. During his confinement and due to her condition she was on stress but she stated that she is very positive that she can still handle things out, in that manner our client has effective coping mechanism.

Value/Belief

Patient is a Roman Catholic. According to the client, she goes to Sunday mass with his family.

According to the patient, there are no practices that affect his hospitalization. She follows therapeutic regimen and she has a strong faith to God whom he believes will help him recover soon.

Because of his hospitalization, the client wasnt able to go to the church but still optimistic that god will help her to recover and live long.

VI. Physical Assessment (12/08/11)

General Survey: When we perform our physical assessment, the client was on sitting position, conscious and coherent, very responsive to all our questions and instructions, and poor grooming, no obvious deformities. Complaints difficulty of breathing that precipitated on minimal and moderate activity and experiencing sudden attacks of dyspnea at night, also complaints dry hacking cough, easy fatigability, dizziness, lightheadedness, restlessness; skin appears pale and feels cool and clammy skin. Vital Signs: Temperature: 36.1C Pulse Rate: 111bpm Respiratory Rate: 27cpm Blood Pressure: 80/60mmHg

Body Parts

Normal Findings

Actual Findings

Analysis

Head Skull (Inspection and Palpation)

Round, (norm, cephalic and, symmetric, with frontal. Parietal , and occipital prominence) Smooth skull contour, uniform consistency and absence of masses (*Fundamental of Nursing-

We found out that his head skull is round, (norm, cephalic and symmetric with frontal, parietal and occipital prominence) smooth skull contour, uniform consistency and absence of masses.

Normal

Kozier 8th ed.; Unit 7,Chapter 30 p.584 - 585) Normal hair is evenly distributed, thick, silky and resilient. No infection or infestation variable body hair.(* Fundamental of Nursing-Kozier 8th ed.; unit 7 Chapter 30, p.582) Symmetric or slightly facial features, palpebral features, equal in size, symmetric nasolabial folds, symmetric facial; movements.(* Fundamental of NursingKozier 8th ed.; unit 7 Chapter 30, p.584 His hair is not evenly distributed, thin, and not silky. No infection or infestation variable body hair.

Hair (Inspection)

Not normal, due to aging process.

Face (inspection)

Symmetric or slightly facial features, palpebral features, equal in size, symmetric nasolabial folds, symmetric facial; movements.

Normal

Eyes (Inspection)

Normal eyes should be aligned and symmetrically without protruding and appearing sunken. Cornea is transparent (* Fundamental

Her eyes are symmetrically aligned and without protruding and appearing sunken.

Normal

of Nursing-Kozier 8th ed.; unit 7 Chapter 30, p.588) Normal ear should have the same colour as the facial skin. Auricle should be align with the outer cantus of the eye, about 10 degree from vertical. (* Fundamental of Nursing-Kozier 8th ed.; unit 7 Chapter 30, p.594 598) Normal nose should be symmetric and straight, no discharge or flaring, no lesions, air moves freely as the client breaths through the nares. Mucosa should be pink and there should be no lesion uniform in colour. (* Fundamental of NursingKozier 8th ed.;Unit 7 Chapter 30 p.599 - 600) We found out that his hear have the same colour as the facial skin. The auricle is align with the outer cantus of the eye

Ears( Inspection)

Normal

Nose (Inspection)

Her nose is symmetric and straight, no discharge or flaring, no lesions, air moves freely as our client breath through the nares.

Normal

Mouth/Lips (Inspection)

Normal mouth/lips should be uniform pink in colour, soft moist and smooth in textures symmetric of contour and ability to purse lips. Tongue should be in central position pink in colour, moist, move freely and no tenderness. Gums should be pink in colour and moist. . (* Fundamental of NursingKozier 8th ed.;Unit 7 Chapter 30 p. 601 - 604)

His mouth/lips are pale soft moist and smooth in textures symmetric of contour and ability to purse lips. Tongue in central position pale in colour, moist, move freely and no tenderness. Gums are pale in colour and moist.

The clients mouth/lips are pale in color for a reason that ventricular failure from which stroke volume decreases which leads to stimulation of sympathetic nervous system that further impedes perfusion to organs and tissues by constricting peripheral blood vessels thats why clients lip/mouth appears pale.

Neck (Inspection and Palpation)

Normal Neck should have; muscles equal in size, head is centered. Coordinated smooth movements without discomfort. Head should be flexes 45, and hyperextend up to 60. Lymphnodes should not be palpable,

The clients neck have the equal muscle size in his neck, head is centered. Movements are coordinated and smooth without any discomfort. The client was able to flex his neck 45, and hyperextend up to 60.

Normal

thyroid gland not visible on inspection. Gland ascend during swallowing but is not visible. (* Fundamental of Nursing- Kozier 8th ed.;Unit 7 Chapter 30 p. 607 - 609) Normal Chest/Thorax should have no discoloration, no sternum retraction, no chest exertion, no masses, and normal muscles tone. No chest retraction. Chest symmetric and spine vertically aligned. Skin is intact uniform in temperature, chest wall intact no tenderness (* Fundamental of NursingKozier 8th ed.;Unit 7 Chapter 30 p. 610 - 618)

Lymphnodes are not palpable, thyroid gland is not visible upon inspection. Gland ascend during swallowing. For dyspnea/orthopnea it is the result of impaired gas exchanged due to pulmonary congestion; insufficient oxygen may lead to difficulty of breathing. For PND it is the result when the fluid that accumulated in the dependent extremities during the day begins to reabsorb into the circulating blood volume when the person lies down at night, because the impaired left ventricle cannot eject the increase circulating blood volume, the pressure in the pulmonary circulation increases, causing further shifting of fluid into the alveoli. The fluid filled alveoli cannot exchange O2 and

Chest/Thorax/Lungs (Inspection/Palpation /auscultation/Percusion)

The client was experiencing sudden attacks of difficulty of breathing also she experienced paroxysmal nocturnal dyspnea (PND) and complaints of productive cough and easy fatigability even without doing something strenuous. Adventitious lung and heart sound were noted, like crackles in the lungs and 3rd heart sound (S3) in the heart upon auscultation

C02, thus experiencing dyspnea. For productive cough It is one of the indicators of pulmonary congestion because of accumulation of fluid. For the complaints of easy fatigability Due to heart failure there is inadequate cardiac output, so her body cannot increase in energy demand, and because of pulmonary congestion impaired gas exchange occurs as manifested by difficulty of breathing. Fatigue may also result from the increase energy expended in breathing. For the crackles As the heart failure worsens, crackles may auscultate throughout all the lung fields which an indicative of pulmonary congestion or edema and at this point decrease in O2 saturation may occur. For S3 heart sound It is the gallop sound occurs during

rapid ventricular filling due to failure of left ventricle on ejecting blood into the system during systole.

Abdomen (IAPP)

Unblemished skin, uniform in color, flat rounded. No evidence of enlargement of liver or spleen. Audible bowel sound, absence of bruit sounds. No tenderness. (* Fundamental of NursingKozier 8th ed.; unit 7 Chapter 30,p.631- 638)

The client has unblemished skin, uniform in color, flat rounded. No evidence f enlargement of liver and spleen, however there was a decrease in bowel sound.

As what we says earlier, the client was on complete bed rest, meaning she nee to minimize her movement, resulting to decrease peristaltic movement, causing constipation, and if her peristaltic was hasten by her immobility tendency is that her bowel sound will decrease as a result.

Upper Extremities (inspection /Palpation)

Normal upper extremities should have; muscle not tender, firm, equal in size, bilaterally w/o fasciculation, equal in number and no abnormalities. (* Fundamental of NursingKozier 8th ed.; unit 7 Chapter

Upon assessing his upper extremities we found out that his muscle is equal in size and no abnormalities.

Normal

30, p.640 641)

Nail (Inspection)

Convex curvature, smooth texture, high vascular and pink in light skinned clients. Intact epidermis and prompt return of ink or usual color, (* Fundamentals of NursingKozier 8th ed.; unit 7, chapter 30 p.582),

Her nails are convex curvature, smooth in texture, pink and intact but the capillary refill last for 6 secs

It is due to left ventricular failure from which stroke volume decreases which leads to stimulation of sympathetic nervous system that further impedes perfusion to organs and tissues by constricting peripheral blood vessels thats why skin appears pale and feels cool and clammy.

Lower extremities ( Inspection/Palpation)

Equal in size, no tremors, There was some presence smooth coordinated of edema in her lower movement, no tenderness extremities. and swelling as well as edema, can perform ROM, palpable pulse should be recognize, warm to touch (* Fundamentals of NursingKozier 8th ed.; unit 7, chapter

Since LV cannot pump out oxygenated blood to the systemic circulation, tendency is that blood pressure decreases, and we know that the major organ responsible for the regulation of the blood pressure is the bean shaped kidney, the kidney will then

30 p.640),

detect decrease blood pressure, resulting in the secretion of the hormone RENIN, this rennin will then go to the liver whereas, this RENIN will convert angiotensinogen to angiotensin I, angiotensin I will then go to the lungs to be converted to angiotensin II, this angiotensin II will now stimulates the adrenal gland to produce more mineralocorticoids (sodium) and we know that if there is an increase in sodium there will be accompanying water retention, thats why edema occurs.

VII. Anatomy and Physiology HEART The human heart is a cone shaped, hollow, muscular organ located in the mediastinum between the lungs. It is about the size of an adult fist. The heart rest on the diaphragm, tilting forward and to the left, in the clients chest. Each beat of the heart pumps about 60cc or ml of blood or 5L/min. During the strenuous activity, the heart can double the amount of blood pumped to meet the increased oxygen needs of the peripheral tissue. The heart is encapsulated by a protective covering called the Pericardium. Cardiac muscle tissue is

composed of three layers: Epicardium, Myocardium and Endocardium. The myocardium, the middle layer is composed of striated muscle fibers interlaced into bundles. This middle layer is responsible for contractile force of the heart. The innermost layer w/c is the endocardium is composed of endothelial tissue, which is responsible for the inside lining of the heart.

CHAMBERS OF THE HEART A muscular wall w/c is called the septum separates the heart into two halves: the Right and the Left. Each half has an upper chamber w/c is term as the Atrium and a lower chamber, the Ventricle. The RIGHT side, w/c is composed of the Right Atrium (RA) and Right Ventricle (RV). The right atrium receives deoxygenated venous blood (venous return) from all peripheral tissue by way of the superior vena cava and the inferior vena cava and also from the heart muscle by way of the coronary sinus. Most of this venous return flows passively from the RA, through the opened Tricuspid Valve then into the RV during ventricular diastole or filling. When there are blood remains to the RA after ventricular

diastole, it is being propelled into the RV during the atrial systole or contraction.The right ventricle is a flat muscular pump located behind the sternum. The RV generates enough pressure, about 25 mmHg to close the tricuspid valve, open the pulmonic valve, and propel blood into the pulmonary artery and the lungs. The LEFT side, after blood is reoxygenated in the lungs, it flowsfreely form the four pulmonary veins into the Left Atrium (LA). Blood then flows through an opened mitral valve into the Left Ventricle (LV). When the LV is almost full, the LA contracts, pumping the remaining blood volume into the LV. With the systolic contraction the LV generates enough pressure, approximately 120 mmHg to close the mitral valve and open the aortic valve. Blood the propelled into the aorta and into the systemic circulation. The LV is the largest and most muscular chamber of the heart. Its wall is two to three times the thickness of the right ventricular wall. CORONAR ARTERIES The heart receives blood to meet its metabolic needs through the coronary artery system. The blood leaving the LV exits through the aorta, the bodys main artery. Two coronary arteries, referred to as the "left" and "right" coronary arteries, emerge from the beginning of the aorta, near the top of the heart. The initial segment of the left coronary artery is called the left main coronary. This blood vessel is approximately the width of a soda straw and is less than an inch long. It branches into two slightly smaller arteries: the left anterior descending coronary artery and the left circumflex coronary artery. The left anterior descending coronary artery is embedded in the surface of the front side of the heart. The left circumflex coronary artery circles around the left side of the heart and is embedded in the surface of the back of the heart. Just like branches on a tree, the coronary arteries branch into progressively smaller vessels. The larger vessels travel along the surface of the heart; however, the smaller branches penetrate the heart

muscle. The smallest branches, called capillaries, are so narrow that the red blood cells must travel in single file. In the capillaries, the red blood cells provide oxygen and nutrients to the cardiac muscle tissue and bond with carbon dioxide and other metabolic waste products, taking them away from the heart for disposal through the lungs, kidneys and liver. When cholesterol plaque accumulates to the point of blocking the flow of blood through a coronary artery, the cardiac muscle tissue fed by the coronary artery beyond the point of the blockage is deprived of oxygen and nutrients. This area of cardiac muscle tissue ceases to function properly. The condition when a coronary artery becomes blocked causing damage to the cardiac muscle tissue it serves is called a myocardial infarction or heart attack. REGULATION OF HEARTS FUNCTION a. INTRINSIC REGULATION Refers to the mechanism contained within the heart itself. The force of contraction produced by cardiac muscle is related to the degree of stretch of cardiac muscle fibers. The amount of blood in the ventricles at the end of ventricular diastole determines the degree to which the cardiac muscle fibers are stretched. Venous return is the amount of blood that returns to the heart, and the degree in which the ventricular walls are stretched at the end if diastole is called preload. If venous return increases, the heart fills to a greater volume and stretches the cardiac muscle fiber, producing an increase in preload. In response to the increased preload, cardiac muscle fiber contract with a greater force resulting to increase CO. As venous return increases, preload will also increases, resulting to an increase in CO. As venous return decreases, preload will also decrease, thus CO will also decrease. This relationship of the preload and the stroke volume is called Starlings Law of the heart

b. EXTRINSIC REGULATION Refers to the mechanism external to the heart, such as either hormonal or nervous regulation. Nervous influences are carried through the autonomic nervous system. Both sympathetic and parasympathetic nerve fiber innervates the heart. Sympathetic stimulation causes the heart rate and stroke volume to increase, whereas parasympathetic stimulation causes heart rate and stroke volume to decrease. The Baroreceptor, plays an important role in regulating the function of the heart. Barorecptors are stretch receptors that monitor blood pressure in the aorta and in the wall of the internal carotid arteries, which carry blood to the brain. Changes in blood pressure result in changes in the stretch of the walls of these blood vessels. Thus, changes in the blood pressure cause changes in the frequency of action potentials produced by the baroreceptors. The action potential are transmitted along the nerve fibers from the stretch receptors to the medulla oblagata of the brain. Within the medulla oblongata is a cardioregulatory center, which receives and integrates action potential from the baroreceptors, also the cardioregulatory mechanism influences sympathetic stimulation of the adrenal gland.

XIII. Pathophysiology Modifiable: Non modifiable:

y y

Age: 50 y/o Family history of heart disease

Menopause

Hypertension

Estrogen level decreases

Causes injury to the arterial wall (tunica intima)

Diet: High intake of foods rich in cholesterol and sodium

Coronary Artery thickens and become stiffer and less distensible

Inability to maintain LDL cholesterol level

Shedding and desquamation of superficial layer occurs

Coronary Artery narrows and become more irregular in shape

Increase blood cholesterol level (6.3mmol/L) and LDL (1.89 mmol/L)

Increase LDL level in the blood (1.89 mmol/L)

Promotes LDL and platelet to assimilate in the injured part

This makes it harder for the blood to pass through

Decrease oxygenated blood supply to the coronary artery (LADA)

Body compensate by increasing systolic pressure thus supplying the coronary artery enough blood.

Oxidized LDL attracts monocytes and macrophages to the site thus promoting inflammation to the site

Increase WBC level of 11.6

Sluggish blood flow results

Thrombus formation occurs

Lipids are then engulf by the macrophages, aggregation of platelets continue

Plaque begins to form from cells w/c imbedded into the endothelium

Chest pain occurs

Rapid increase in size of the thrombus in the coronary artery

Decrease blood flow in the preceding coronary artery

Decrease oxygenated blood supply in the myocardium area

Ischemia results

Anaerobic metabolism, increases lactic acid production and secretion in the myocardial area.

Decrease BP and SV

Decrease Cardiac Ouput

Decrease myocardial contractility

Myocardial muscles are sensitive to changes in PH, resulting to damage and become less functional

Acidosis results

Easy fatigability

Registered on pressoreceptor/baroreceptors in w/c it s stimulates the sympathetic nervous system to increase HR, and promoting peripheral vasoconstriction, However too much stimulation of the SNS also causes the hypothalamus to secrete vasopressin which cause fluid retention.

Increase BP, and CO will results

Increase venous return to the heart results

Left ventricular hypertrophy results

Heart fills greater volume and stretches the cardiac muscle fibers

Preload increase as result

This causes cardiac muscle fibesr to contract with a greater force

Cardiomegally

Stroke volume increase, thus resulting to increase in CO and venous return LV finally loses function to pump out blood because of severe exhaustion

Decrease BP and SV

Due to hypertrophy, LV cannot pump out blood efficiently to supply the systemic circulation

LV cannot move blood to the aorta into the systemic circulation

Pallor occurs

Kidney detect decrease blood pressure and volume Aldosterone increases sodium production as well as water retention

Juxtaglomerular apparatus release RENIN

RENIN goes to the liver where it will convert the angiotensinogen to angiotensin I

Blood pooling in the LV occurs

Angiotensin II stimulates the adrenal cortex to secrete aldosterone

Angiotensin I goes to the lungs whereas ACE convert the angiotensin I to angiotensin II

Increase pressure in the LV results to back flow of blood to the LA to the pulmonary capillaries

Edema on the dependent part (lower extremities) however this only occurs at day, as the client sleeps or lies down, the fluid will then goes back to the lungs

Increase pressure to the pulmonary circulation results to fluid passing from pulmonary capillary to the interstitial space and alveoli

Paroxysmal nocturnal dypnea

Crackles

Pulmonary Edema

Pulmonary congestion appear in the chest x - ray

Dyspnea

Fluid interferes with oxygen carbon dioxide exchange

On exertion

IX. Laboratory Data Chest X Ray result (12/05/11) Lungs are clear, pulmonary vessels are slightly accentuated. Heart is enlarged

with left ventricular form Impression: Cardiomegaly with pulmonary congestion.

HEMATOLOGY (12/06/11) COMPLETE BLOOD COUNT Result Normal Values Analysis

HEMOGLOBIN

11.3g/dl

14 18g/dl

Hgb level has decrease significantly, because interference in oxygen and carbon dioxide exchange brought about of by pulmonary edema.

HEMATOCRIT

0.33%

0.37 0.45%

Since our client has decrease level of HgB, tendency is that his Hct will also decrease WBC increases, for the reason that monocytes and macrophages are both attracted by oxydized LDL which promotes inflammation thus preventing further damage. Normal

WBC

11.6

4.11 x 10^9/l

RBC

5.7

5.0 6.4

EOSINOPHILS

0.03

0.02 % 0.04%

Normal

NEUTROPHIL/SEGMENTER

0.53

0.50% 0.70%

Normal

LYMPHOCYTES

0.33

0.20% 0.40%

Normal

MONOCYTES

0.05

0.02% 0.05%

Normal

Clotting Factor

Result

Reference Range

Analysis

PLATELET COUNTS

185

150-450

Normal

% ACTIVITY

80.3

73 127%

Normal

INR

1.14

0.88 1.21

Normal

APTT

37.4

30.4 41.2

Normal

Serum and Electrolytes (12/06/11) RESULT RANGE ANALYSIS

SODIUM

146 mEq. /L

136 145 mEq. /L

This is due to her diet of high in sodium

POTASSIUM

3.8 mEq. /L

3.5 5.1mEq. /L

Normal potassium electrolyte

URINALYSIS (12/07/11) RESULT

COLOR

LIGHT

TRANSPARENCY

CLEAR

SUGAR

NEGATIVE

PROTEIN

NEGATIVE

Ph

6.0

SPECIFIC GRAVITY

1.010

WBC

02

RBC

13

EPITHELIAL CELL

OCCASIONAL

CRYSTAL

AMORPHOUS URATE

OCCASIONAL

LIPOLIPIDS AND TRIGYCERIDES (12/07/11) RESULT NORMAL VALUES ANALYSIS Her cholesterol blood level is too high, factors that predispose her of having high cholesterol level is her diet. Eating foods high in cholesterol increases your risk on developing CAD Normal

CHOLESTEROL

6.3mmol/L

1.3 5.2

TRIGLYCERIDES

1.15mmol/L

0.17 1.70

HDL CHOLESTEROL

1.05mmol/L

1.04 1.55

Normal (GOOD cholesterol)

LDL

2.40mmol/L

1.89

Elevated LDL (BAD cholesterol) this deposits cholesterol in the arterial wall

X. Drug Study.

Drug Name

Classification

Mechanism of Action

Indication

Contraindication

Side Effects/Adverse Effects

Nursing Considerations

Generic Name: Furosemide

Loop diuretic

Brand Name: Apo-Furosemide Furoside Lasix

Inhibits reabsorption of sodium and chloride at proximal and distal tubule and in the loop of Henle

Pulmonary edema; edema in CHF,

Hypersensitivity to sulfonamides, anuria,

CNS: Headache, fatigue, weakness, paresthesias CV: Hypotension

Assess : y For any contraindication prior to administration of the drug. y Weight, I&O everyday to determine fluid loss, effect of drug may be decreased if used everyday Electrolytes (K, Na, Cl); include BUN, blood sugar, CBC, serum creatinine, blood pH, ABGs, uric acid, calcium, magnesium V/S specially blood pressure for hypotension prior to

hypovolemia, infants, electrolyte depletion EENT: Blurred vision

Dosage: 20mg/tab

Frequency: BID

ELECT: Hypokalemia, hypochloremic alkalosis, y hypomagnesemia, hyperuricemia, hypocalccemia, hyponatremia, metabolic alkalosis ENDO: Hyperglycmeia

GI: Nausea, diarrhea, dry mouth, vomiting, anorexia, cramps, oral, gastric irritations, pancreatitis

administration y Give with food to avoid gastroinestinal upset, preferably with breakfast (to prevent nocturia). digoxin level as well as sign and symptoms of digoxin toxicity such as: Vomiting Anorexia Nausea Diarrhea Abdominal pain Vision (yellow green halos)

GU: Polyuria, renal y failure, glycosuria HEMA: Thrombocytopenia , agranulocytosis, leucopenia, neutropenia, anemia INTEG: Rash, pruritus, purpura, Stevens-Johnson syndrome, sweating, photosensitivity, urticaria

Teach patient/family: y To discuss the need for a high-potassium diet or potassium replacement with prescriber y To increase fluid intake 2-4L/day unless contraindicated

To rise slowly from lying or sitting position; orthostatic hypotension may occur To recognize adverse reactions that may occur: muscle cramps, weakness, nausea, dizziness

Regarding entire regimen, including exercise, diet, stress relief for hypertension To take with food or milk for GI symptoms To take early in day to prevent sleeplessness

Drug Name

Classification

Mechanism of Action

Indication

Contraindication

Side Effects/Adverse Effects CNS: Headache, drowsiness, GI: cramps, bleeding, gastritis, vomiting, anorexia, nausea INTEG: Rash, pruritus, urticaria

Nursing Considerations

Generic Name: Spironolactone

Potassiumsparing diuretic

Brand Name: Aldactone, Novospiroton

Dosage: 25mg/tab

Competes with aldosterone at receptor sites in distal tubule, resulting in excretion of sodium chloride, water, retention of potassium, phosphate

Edema of CHF, hypertenstio n, diureticinduced hypokalemi a, primary hyperaldost eronism, edema of nephritic syndrome, cirrhosis of the liver with ascites

Hypersensitivity, anuria, severe renal disease, hyperkalemia,

Assess: y For any contraindication specially hyperkalemia before administration of th drug. y Give with food to avoid gastroinestinal upset, preferably with breakfast (to prevent nocturia).

Frequency: OD

ENDO: Imoptence, gynecomastia, irregular y menses, amenorrhea, post-menopausal bleeding, hirsutism, deepening voice y HEMA: Agranulocytosis

Electrolytes: Na, Cl, K, BUN, serum creatinine, ABGs, CBC

Weight, I&O everyday to determine fluid loss; effect of drug may be decreased if used every day; ECG periodically

ELECT: Hyeprcholoremic metabolic acidosis, hyperkalemia, hyponatremia

(long term therapy) y Hydration: skin turgor, thirst, dry mucous membranes V/S specially blood pressure for hypotension. Monitor digoxin level and sign and symptoms of toxicity such as: Vomiting Anorexia Nausea Diarrhea Abdominal pain Vision (yellow green halos)

Teach patient/family: y To avoid foods high in potassium content: oranges, banana, sodium substitutes, dried apricots, dates

To notify prescriber of cramps, diarrhea, lethargy, thirst, headache, skin rash, menstrual abnormalities, deepening of voice, breast enlargement Notify the physician if you experience digoxin toxicity.

Drug Name

Classification

Mechanism of Action

Indication

Contraindication

Side Effects/Adverse Effects

Nursing Considerations

Generic Name: Digoxin

Cardiac glycoside,

Brand Name: Lanoxin

Dosage: 250mg/ml/amp amp

Frequency: OD

Inhibits the sodiumpotassium ATPase, which makes more calcium available for contractile proteins, resulting in increased cardiac output; increases force of contraction (+inotropic effect); decreases heart rate chronotropic effect); decreases AV conduction speed

CHF, atrial fibrillation, atrail flutter, atrial tachycardi a, cardiogeni c shock, paroxysma l atrial tachycardi a, rapid digitalizatio n in these disorders

Hypersensitivity to digitalis, ventricular fibrillation, ventricular tachycardia, carotid sinus syndrome, 2nd or 3rd degree heart block

CNS: Headache, drowsiness, fatigue.

Assess: y For any contraindication prior to administration y Cardiac Rhythm using the apical pulse for 1 min before giving drug; if pulse <60 in adult or <90 in an infant, take again in 1 hr; if <60 in adult, withhold the medication and the call prescriber; note rate, rhythm, character; monitor ECG continuously during parenteral loading dose

CV: Dysrhythmias, hypotension, bradycardia,

EENT: Blurred vision, yellowgreen halos, photophobia, diplopia

GI: Nausea, vomiting, anorexia, abdominal pain, diarrhea

Electrolytes: K, Na, Cl, Mg, Ca; renal function studies: BUN, creatinine; blood studies: ALT, AST, bilirubin, Hct, Hgb before initiating treatment and periodically thereafter I&O ratio, daily weights; monitor turgor, lung sounds, edema

Monitor drug levels (therapeutic level 0.5-2ng/ml), best time to monitor blood for therapeutic level is 6 8 hours after administration or prior to administration, also assess for any sign and symptoms of toxicity such as: Vomiting Anorexia Nausea

Diarrhea Abdominal pain Vision (yellow green halos)

Make sure to have digibind (antidote for toxicity) in the bedside Cardiac status: apical pulse, character, rate, rhythm

Teach patient/family: y Not to stop abruptly; teach all aspects of drug, to take exactly as ordered; how to monitor heart rate y To avoid OTC medications, since may adverse drug interactions may occur; do not take antacid at same time

To notify prescriber of loss of appetite, lower stomach pain, diarrhea, weakness, drowsiness, headache, blurred or yellow vision, rash, depression, toxicity Not to break, crush, or chew caps

To report shortness of breath, difficulty breathing, weight gain, edema, persistent cough Eat a lot of banana to increase potassium level.

Drug Name

Classification

Mechanism of Action

Indication

Contraindication

Side Effects/Adverse Effects

Nursing Considerations

Generic Name: SulbactamAmpicillin

Broad-spectrum anti-infective

Brand Name: Unasyn

Dosage: 750mg IV

Frequency: q8

Interferes with cell wall replication of susceptible organisms; the cell wall, rendered osmotically unstable, swells, bursts from osmotic pressure; combination extends spectrum of activity by lactamase inhibition

Skin infections, intraabdominal infections, pneumonia , gynecologi c infections, meningitis, septicemia

Hypersensitivity to penicillins, ampicillin, or sulbactam

HEMA: Anemia, Assess: increased bleeding y Assess for any time, bone marrow contraindication depression, subsequent to granulocytopenia administration GI: Nausea, vomiting, diarrhea, increased AST, ALT, abdominal pain, gastritis, stomatitis, glossitis, y Administer it 1hr before meal to enhance absorption, if client cannot tolerate maybe given with meals I&O ration; report hematuria, oliguria, since penicillin in high doses is nephrotoxic

GU: Oliguria, proteinuria, hematuria, vaginitis, moniliasis, y glomerulonephritis, dysuria

Any patient with compromised renal system, since drug is excreted slowly in poor renal system function; toxicity may occur rapidly

Liver function studies: AST, ALT if on longterm therapy Blood studies: WBC, RBC, Hct, Hgb, bleeding time

Renal studies: urinalysis, protein, blood, BUN, creatinine

Teach patient/family: y Increase fluid intake and eat nutritious food y To report superinfection: vaginal itching, losse, foulsmelling stools, black furry tongue To report immediately presudomembranous colitis: fever, diarrhea with pus, blood, or mucus; may occur up to 4 wks after treatment

To wear or carry emergency ID if allergic to penicillin products

Drug Name

Classification

Mechanism of Action

Indication

Contraindication

Side Effects/Adverse Effects

Nursing Considerations

Generic Name: Enoxaparin

Anticoagulant Antithrombotic

Brand Name: Lovenox

Dosage: 4000 U

Prevents conversion of fibrinogen to fibrin and prothrombin to thrombin by enhancing inhibitory effects of antithrombin III; produces higher ration of anti-factor Xa to IIa

Prevention of deepvein thrombosis, pulmonary emboli in hip and knee and hip replacemen t

Hypersensitivity to this drug, heparin, or pork; hemophilia, leukemia with bleeding, peptic ulcer disease thrombocytopenic purpura, heparininduced thrombocytopenia

GI: Nausea

HEMA: Hypochromic anemia, thrombocytopenia, bleeding

Assess: y For any contraindication prior to administration y Blood studies (Hct, CBC, coagulation studies, platelets, occult blood in stools, if platelet level is 100,000/mm3 with hold the drug

INTEG: Ecchymosis

Frequency: BID

For bleeding: gums, petichae, ecchymosis, black tarry stools, hematuria; notify prescriber

Teach patient/family: y To use soft-bristle toothbrush to avoid bleeding gums, to use electric razor y To report any signs of bleeding: gums, under skin, urine, stools

To avoid OTC drugs containing aspirin

Drug Name

Classification

Mechanism of Action

Indication

Contraindication

Side Effects/Adverse Effects

Nursing Considerations

Generic Name: Isosorbide Dinitrate

Anti-anginal Vasodilator

Brand Name: Apo-ISDN ISDN

Dosage: 5mg tab

Decreases preload, afterload, which is responsible for decreasing left ventricularend-diastolic pressure, systemic vascular resistance and reducing cardiac O2 demand

Chronic stable angina pectoris, prophylaxis of angina pain, CHF

Hypersensitivity to this drug or nitrates, severe anemia, increased intracranial pressure, cerebral hemorrhage, acute MI

CV: Postural hypotension, tachycardia, collapse, syncope

Assess: y For any contraindication prior to administration y B/P, pulse, respirations during beginning therapy

GI: Nausea, vomiting

INTEG: Pallor, sweating, rash

Frequency: OD

CNS: Vascular headache, flushing, dizziness, weakness, faintness Teach patient/family: y Make position changes slowly, particularly from recumbent to upright posture, to avoid orthostatic hypotension

Headache, lightheadedness, decreased B/P; may indicate a need for decreased dosage

Lie down at the first indication of light-headedness or faintness. To leave tabs in original container To avoid hazardous activities if dizziness occurs

The importance of complying with complete medical regimen To make position changes slowly to prevent orthostatic hypotension

Not to crush, chew sus rel caps, SL tabs

Drug Name

Classification

Mechanism of Action

Indication

Contraindication

Side Effects/Adverse Effects

Nursing Considerations

Generic Name: Simvastatin Brand Name: Zocor Dosage: 10 mg Frequency: OD HS

Lipid-lowering agents

Inhibit an enzyme 3hyrdorxy-3methyglutaryl coenzyme A (HMG-CoA) reductase, which is responsible for catalyzing an early step in the synthesis of cholesterol.

Adjunct to dietary therapy in the management of primary hypercholest erolemia and mixed dyslipidemia. Reduction of lipids/choles sterol reduces the risk of MI and stroke sequelae and decreases the need for bypass procedures/a ngioplasty

Hypersensitivity. Cross-sensitivity among agents may occur, acute hypotension,

CNS: Dizziness, headache, EENT: blurred vision GI: Abdominal cramps, flatus, heartburn, altered taste, dyspepsia, elevated liver enzymes, nausea, pancreatitis GU: Impotence DERM: Rashes, pruritus

Assess: y Assess for any allergy or contraindication prior to administration of medication y Obtain dietary history, especially with regard to fat consumption. Give in the evening; highest rates of cholesterol synthesis are between midnight and 5 AM.

Ophthalmic exams are recommended before and yearly during therapy.

Lab Test consideration: Evaluate serum cholesterol and triglyceride levels before initiating, after 4-6 weeks of therapy, and periodically thereafter. Monitor liver function test, including AST, before, at 6-12 weeks after initiation of therapy or after dose elevation, and then every 6 months. If AST levels increase to 3 times normal, HMG-CoA reductase inhibitor therapy should be discontinued, May also cause increase alkaline phosphatase and bilirrubin levels.

Teach patient/family: y Instruct patient to take medication as directed and not to skip doses or double up on missed doses. Advise patient to avoid drinking more that 1qt/day of grapefruit juice during therapy. Medication helps control but does not cure elevated serum cholesterol levels. y Advise patient that this medication should be used in conjunction with diet restrictions (fat, cholesterol, carbohydrates, and alcohol), exercise.

Instruct patient to notify health care professional if unexplained

muscle pain, tenderness, or weakness occurs, especially if accompanied by fever or malaise. y Emphasize the importance of follow-up exams to determine effectiveness and to monitor for side effects.

XI. NURSING CARE PLANS

XII. DISCHARGE PLAN

Medication:
y Review medication regimen  Label all medications ( Furosemide, Sprinolactone, Digitalis, Sulbactam Ampicillin, Enoxaparin, Isosorbide Dinitrate and Simvastatin)  Give written instruction to all medication especially to digitalis and diuretics. a. Digitalis therapy:  advised the client to assess first her cardiac rhythm using her apical pulse which is located at 5th intercostals space mid clavicular line, for 1 full minute, if her PR is <60BPM or >120BPM, withhold the drug, wait again for 1hr then take RR if it is >60BPM or <120BPM administer it, if not call her physician immediately  Also Advised her to eat food high in potassium specifically banana, to increase potassium level, because decrease in potassium level potentiates digitalis toxicity  Advised client to report any sign and symptoms of digitalis toxicity such as Vomiting, Anorexia, Nausea, Diarrhea, Abdominal pain and yellow green halos, immediately to her healthcare provider  Also advised client that if she will experience any toxic effect of digitalis, 1st thing to do is call your health care provider after which drink orange juice to increase you potassium level, thus preventing excessively depletion of her potassium level.  Also advised client to have Digibind along with her in case of toxicity

b. Diuretic therapy: Furosemide  Make sure to always assess sign and symptoms of hypokalemia in relation to Digitalis therapy, because as what i said a while ago, decrease in potassium level potentiate toxicity,  Also advised client to eat foods high in potassium such as avocado, banana, orange, and melon  Advised to take the drug, early in the morning or in the afternoon to prevent sleep pattern disturbance relate to nocturia

Exercise:
y Advised client to avoid any extraneous activity, because it may aggravates her condition, however may start gradual ambulation to prevent risk for venous thrombosis y Advised client to position herself leaning forward or semi fowlers, if she experience dyspnea y Advised to increase walking and other activities gradually, provided they do not cause fatigue and dyspnea.

Treatment:
y y Advised client to adhere to the medical regimen given to her. Also advised client to avoid any stress, because stress causes anxiety, this anxiety increases breathlessness which may be perceived by the client as an increase in the severity of heart failure

Health education:
y Teach client about the sign and symptoms of recurrence or complication (Right side heart failure)  Watch for: a. Weight gain report weight gain of more than 2 3 lbs in a few days b. Swelling of ankles, feet, jugular vein and abdomen c. Persistent cough with pinkish frothy sputum d. Easy fatigability e. PND

Outpatient:
y Emphasized to the client the importance of follow up check up for continues recovery of his condition.

Diet:
y Advised client to decrease intake of sodium, however needs to avoid completely fatty foods y y Provided list of foods with low residue and with vitamins supplement Advised to eat small frequent feeding

Spiritual:
y Encouraged client to have a firm belief and faith in god

XIV. Bibliography

 Physiology and Anatomy, by Greishelmer Wiedeman  Essential of Human Anatomy And Physiology 7thed, by Elaine N. Marieb  Saunders Nursing Drug Handbook,2007  DPDs 8th edition  Nurses Pocket Guide 9th ed.  Porth, C.M (2005) Pathophysiology  Gould, B.E. Pathophysiology for the health professions 3rd edition.  White Lois (2005) Foundation of Nursing, 2nd Edtion  Daniels, R. Et al (2010) Nursing Fundamentals Caring and clinical decision making 2nd edition.  Spratto, G.R. et al (2005) PDR Nurses Drug Handbook 2005 edition.  Loebl, S. Et al (1994) The Nurses Drug Handbook 7th edition.  Doenges, M.E. et al (2006) Nursing Care Plans Guidelines for individualizing client care across the life span