PAGOD NA ANG PUSO KO, . .

TITANIC
NA ANG LABAS NITO.

CONGESTIVE HEART FAILURE

A Case Presentation on the Cardiovascular System

OBJECTIVES
General Objective: After two hours of case presentation, the students will be able to acquire the knowledge, enhance their skills and develop attitude towards caring of the patient with cases regarding cardiovascular disorders. Specifically, this aims to: KNOWLEDGE: 1. Identify the precipitating factors regarding the pathophysiology of the disease being manifested by the client. 2. Enumerate the signs and symptoms of the diseases manifested by the client. 3. Discuss the pathophysiology of Congestive Heart Failure. SKILLS: 1. Demonstrate the appropriate approach used in dealing with clients with CHF. 2. Perform dependent and independent interventions, being done to the client, appropriately and with care. 3. Perform comprehensive nursing care and interventions with competence and confidence in rendering care to clients with CHF. ATTITUDE: 1. Establish rapport to client and folks. 2. Encourage folks to cooperate in the interventions that are being performed to the client. 3. Collaborate with all the health team to promote efficient care to the client.

PATIENTS PROFILE
NAME: S.L ADDRESS: Hamtic, Antique CIVIL STATUS: Married BIRTHDAY: April, 20, 1965 AGE: 44 yrs 10 mo. RELIGION: Roman Catholic OCCUPATION: Housewife DATE OF ADMISSION: March 10, 2010 PHYSICIAN: Dr.C and Dr.A CC: Cough DIAGNOSIS: CHF III-IV sec to Valvular Heart disease (VSD-severe MVR-TR) Umbilical Hernia, 2 AF with MVR-RBBB, CAP-MR

NURSING HISTORY
Past Medical History
Patient S.L has been admitted last February 12, 2010 with chief complaint of abdominal pain associated with nausea and 1 episode of vomiting approximately 50cc. She was diagnosed to have CHF III 2 dilated cardiomyopathy but she was discharged after a week. She had no major surgeries in the past, but she was diagnosed with CHF 13 years ago. She has maintenance drugs including furosemide, aldazide.

 Childhood Illness The patient had no major illness during her childhood. She had common colds, cough and fever but did not opt for hospitalization. She also had chicken pox when she was in elementary.

 Present Medical History Two days prior to admission, patient experienced weakness, decreased appetite, orthopnea, whitish to yellowish productive cough and associated with difficulty of breathing. There was no fever noted and the patient took Levopront 10 ml three times a day for 5 days but still experienced productive cough so the patient opted for admission.

 Family History of Illness (-) Hypertension - maternal and paternal side (-) Diabetes mellitus (-) Bronchial Asthma - paternal side (-) Cancer (-) TB (-) Heart Failure

 Educational Background Patient is an elementary graduate and started her high school level (3rd year) but was not able to finish it due to financial constraints. She is able to read, write and calculate.

 Occupation The patient raises pigs, chicken and sells it. She raises them in their house and it has been their livelihood since birth. She also plants vegetables in their backyard and is able to sell those in order to further sustain their needs.

 Persons Significant to Patient Her husband, her 4 children and her relatives.

Social Role Client is a wife, a mother and a daughter, and helps the family financially together with her husband who is a carpenter.

 Economic Status
The family has no definite income monthly and only depends on the amount earned from selling vegetables, poultry products and the availability of work of her husband. The total income of the family is at least P 2000 per month. When it comes to their medical expenses, they depend on their relatives assistance and have debts. The patient has 4 children, 1 in high school and 3 are not studying.

 Lifestyle
Patient is a non-smoker, a nonalcoholic drinker, and a non-coffee drinker. Patient usually eats yellow vegetables (like squash and camote roots) She avoids eating green leafy vegetables (like laswa) because she cant digest it easily and then usually experience dyspepsia and abdominal cramping. She oftentimes drinks soft drinks as she likes, 3 8oz. of coke per week.

PHYSICAL ASSESSMENT

VITAL SIGNS
UPON ADMISSION (March 1, 2010) TEMPERATURE PULSE RESPIRATION BLOOD PRESSURE 36 o C 96 bpm 24 bpm 110/ 70 mmHg UPON ASSESSMENT (March 4, 2010) 36. 4 o C 72 bpm 22 bpm 100/60 mmHg

GENERAL APPEARANCE
Physical Appearance
Patient is lying on semi-fowlers position, awake with IVF of PNSS x KVO + 20 meqs KCl infusing well at left metacarpal vein. Bony prominences visible. She is 4 feet 9 inches in height and weighs 34 kgs. BMI= 16.22 and is underweight. Able to sit, stand and walk without assistance. Client grooming is maintained by folks and no halitosis noted.

 Psychological Presence Oriented to person, place and time and irritable. Patient also answers questions appropriately in congruence to age and situation. He is conversant to folks and alert upon interview. Speech is audible, understandable, and in moderate pace, exhibits thought association. Dependent to folks for her needs.

SKIN
Fair skin with no freckles. Skin is wrinkled, dry, rough and sagging with minimum perspiration, sensitive to heat and pressure. No bleeding, edema, and lesions. Temperature uniform upon touch on upper extremity and lower extremity. Skin moves back slowly upon checking of skin turgor approximately two seconds.

HEAD AND FACE

Symmetrical head and face. Short straight black hair. Hair is evenly distributed in the scalp with presence of some white hairs. Hair is free from infestations, flakes and lesions upon parting the hair. Brittle and dry hair noted. Face is fair colored and no masses present. Face is round. Skull , face and jaws are symmetrical. Symmetrical head movement. No pain noted in the mandible during palpations.

EYES
Patient eyes open spontaneously. Sclerae are white, pupils are equally round both react and accommodate to light, approximately 2-3mm with pale conjunctiva. Eyes are symmetrical with no ptosis and discharges noted. No masses, or swelling in upper and lower eye. Eyebrows and eyelashes are well distributed. Patient is able to read nameplate in a 2 feet distance.

EARS
Ears are symmetrical and in normal shape. No unusual discharges noted. No nodules and deformities and foreign body seen. Patient is able to hear normal voice tones. No pain noted over mastoid process upon palpation. Auricles have the same color with face. Pinnas are mobile, firm and non tender.

NOSE
No presence of discharges, lesions, polyps, bleeding and foreign body noted. No pain on maxillary and frontal sinuses. Nose is symmetrical and not flaring upon inspiration. Pinkish nasal mucosa and is able to distinguish odor between alcohol and cologne.

MOUTH AND OROPHARYNX

Gag reflex is present. Lips are moist and pinkish in color. No lesions or inflammation noted. Tongue is in the midline of the mouth. The dorsum of the tongue is pink, moist and with lesions. It is symmetrical and moves freely. The buccal mucosa is moist, smooth, and free of lesions. No swelling and bleeding in the gums. Hard and smooth palates are concave and pinkish. Erosion of the teeth noted. No halitosis noted.

NECK
Color is the same as to the rest of the body. Symmetrical with full ROM. No masses, swelling, enlargement of lymph nodes and thyroid as inspected. Carotid pulse is steady and palpable. Carotid pulse = 75.

THORAX / CHEST
Chest is symmetrical in both sides with symmetrical placement of all structure. Chest pain noted. Spinal column is straight, right and left shoulders are symmetrical. Chest wall is intact, no tenderness, no masses noted. Dilated superficial vein are not seen. The costal angle widens slightly during inhalation due to expansion of the thorax. No scars. Cardiac rate was 72 bpm upon auscultation, rales and crackles noted.

BACK
Normal spine curvature. Neither scars nor lumps noted. Shoulders are symmetrical. No inflammation, lesions, ecchymosis noted on the back.

ABDOMEN
Firm, round in shape, uniform in color and pigmentation. Protrusion of umbilical area noted. Abdomen is firm and smooth. Symmetrical movement of the abdomen on respiration. Abdominal circumference approximately 78 cm.

UPPER EXTREMITIES
Bony prominences visible in the upper extremities. Muscles are well proportionate in size and are well toned. With IVF of PNSS 1L x KVO + 20 meqs KCl @ left metacarpal vein and infusing well. Full ROM at both arms. Radial and brachial pulse bilaterally equal in rate and rhythm. Pulse is equal to 72bpm. Capillary refill is normal at 2 sec. No edemas, lesions, swellings, masses and tenderness noted on any part of the upper extremities. No clubbing on fingernails.

LOWER EXTREMITIES
Lower extremities are similar in color with the rest of the body. Muscles are well proportionate in size and are well toned. No edemas, lesions, swellings, tenderness noted in the lower extremities. No clubbing on toenails. Full ROM in lower extremities. Popliteal, dorsalis pedis and posterior tibialis are palpable and 71 bpm as palpated.

GENITO URINARY AREA

Patient is able to void with no bleeding, discomfort or pain. Urine is dark yellow as observed. Micturition is five times a day with urine output approximately 1,300 cc in a day.

GENITO ANAL AREA

Has no pain in bowel movement. Patient able to defecate once every two days depending on the amount of food taken. Stool is solid, soft and dark brown.

COURSE OF HOSPITALIZATION

 During March 1, 2010 at around 9:40 AM, the patient was admitted with a chief complaint of cough with vital signs T = 36C, P = 96 bpm, R = 24 bpm and BP = 110/70 mmHg. Oxygen was then administered at 2 lpm via nasal cannula. O2 sat result was 9598%. At around 9:48 AM, ECG 12 leads was done by heart station personnel and after a few minutes, the patient was brought to xray room for Xray PA view left lateral. PNSS 1 L x 10 cc/H was then started as venoclysis at left cephalic vein at around 10:40 AM.

 By 11:45 AM, the patient was transferred to department F per wheelchair. At 7 PM, PAI with 1 nebule salbutamol was done by pulmonary personnel. 20 mEq KCl was then incorporated to IVF at around 10:20 PM. Fresh blood associated with bowel movement and urination were positive during March 4, 2010. Direct rectal examination suggests good sphincter tone and blood was negative on examining finger.

LABORATORY AND DIAGNOSTIC PROCEDURES

URINALYSIS
Definition: A routine urinalysis is a test for urinary and systemic disorders. This test is used to evaluate physical characteristics (color, odor, turbidity and opacity) of urine, determines specific gravity and pH; detects and measure protein, glucose, and ketone bodies and examines sediments for blood cells; casts and crystals.

 Diagnostic laboratory methods include visual examination, reagent strip screening, refractometry for specific gravity and microscopic inspections of centrifuged sediments. Purpose: To screen the patients urine for renal or urinary tract diseases. To help detect metabolic or systemic disease unrelated to renal disorder. Essential component of a complete physical examination, especially when performed on admission to a health-care facility.

MARCH 1, 2010
Physical Properties Color: Straw Transparency: Slightly hazy Reaction: Acidic (6.0) Specific Gravity: 1.010 Chemical Tests Sugar: Negative Albumin: trace

MICROSCOPIC FINDINGS
Findings Normal Findings Results Implication

Pus Cells RBC

0-1/hpf 0-3/hpf

+10-15/hpf 6-8/hpf

Overhydration Bleeding in the urinary system

Renal Epithelial Cells: None Amorphous Urates: Bacteria: Few Few Round Epithelial Cells: Mucus Threads: Few Squamous Epithelial Cells: None Yeast Cells: Few None

Crystals:

CHEST RADIOGRAPHY
Chest X-ray PA
Definition:
The penetration of x-rays or electromagnetic waves in the chest can cause an image to form on special film. The best view to obtain with the patient erect and film exposed in posterior-anterior fashion and is exposed on full expiration. A projection of the chest used to diagnosed conditions affecting the chest, its contents and nearby structures. Chest radiographs are most common film taken, being diagnostic of many conditions.

Purpose:
To evaluate the pulmonary and cardiac systems, and to reveal any pathological findings and pulmonary disorders. Evaluate known or suspected pulmonary disorders, chest trauma, cardiovascular disorders and skeletal disorders.

MARCH 3,2010
Follow-up to radiograph reveal both lung fields to be clear. The pulmonary vascular markings are not accentuated. The cardiac silhouette is still markedly enlarged. Rest of the cardio-pulmonary findings are unchanged in comparison with previous radiograph of Feb. 11, 2010. Impression: Marked cardiomegaly pericardial effusion still not ruled out. Suggest 2-D echocardiography. For further evaluation.

HEMATOLOGY
Definition: Hematology refers to the scientific study of blood and blood forming tissues. It is a combination report of a series of tests of the peripheral blood. The quantity, percentage, variety, concentrations, and quality of blood cells are identified. Hematology includes the study of etiology, diagnosis, treatment, prognosis, and prevention of blood diseases. Purpose: To determine the presence of infection. To aid in diagnosis of certain disease. Constitute in the major signs and symptoms of determining certain blood disorders. Basic screening test that address disorders, hemoglobin and cell production, synthesis and function are also determined.

MARCH 1, 2010
Results Hemoglobin Hematocrit 115 g/L 0.35 vol. fr. Reference Values F: 120-160 g/L F: 0.37-0.47 vol. fr. Significance Anemia Anemia

RBC Count
WBC Differential Count Neutrophil

4.26 x 1012/L
8.8 x 109/L

F: 4.2-5.4 x 1012/L
4.5-11 x 109/L

Normal
Normal

90%

45-73%

Infection

Segmenter
Stab Juvenile Eosinophil

83%
6% 1% 1%

50-70%
2-5% 0-1% 1-5%

Infection
Infection Normal Normal

Basophil
Lymphocyte Monocyte

0%
7% 2%

0-1%
20-40% 3-9%

Normal
Anemia Anemia

Results

Reference Values

Significance

Platelet Count

499 x 109/L

150-450 x 109/L

Anemia, acute infection and inflammation

MCV MCH MCHC

82.0 fl 32.6 g/dl 32.6 g/dl

F: 79-98 fl 25.4-34.6 pg F: 30-36 g/dl

Normal Normal Normal

CULTURE AND SENSITIVITY TEST

Definition A sputum culture is a test to detect and identify bacteria or fungi (plural of fungus) that are infecting the lungs or breathing passages. A sample of sputum is placed in a container with substances that promote the growth of bacteria or fungi. If no bacteria or fungi grow, the culture is negative. If organisms that can cause infection (pathogenic organisms) grow, the culture is positive. The type of bacterium or fungus will be identified with a microscope or by chemical tests. If bacteria or fungi that can cause infection grow in the culture, other tests may be done to determine which antibiotic will be most effective in treating the infection. This is called susceptibility or sensitivity testing. Purpose: To isolate and identify the cause of pulmonary infection, thus aiding in the diagnosis of respiratory diseases.

March 3, 2010
Specimen: Sputum Culture Isolate: Few Colonies of Candida Species

GRAM STAIN, KOH

Definition The Gram staining, the most common and useful staining procedure, separates bacteria into two classifications, according to the composition of their cell walls: gram-positive organism, which retain crystal violet stain after decolorization, and gramnegative organism, which lose the purple stain but counter-stain red safranin. Microscopic examination of the Gram-stained smear typically allows tentative identification of the suspected organism. Examining a direct smear of the specimen for inflammatory cells, such as neutrophils and macrophages, can also provide clues about the type of infection present and consequent mobilization of the immune system.

March 2, 2010
Specimen: Sputum Gram stained smear shows few gram negative bacilli and occasional gram positive cocci in pairs. Polymorphonuclear leukocytes are 100-120/hpf and epithelial cells are 0-4/hpf. KOH amount: NEGATIVE FOR FUNGUS

PROTHROMBIN TIME
Prothrombin time measures the time required for a fibrin clot to form in a citrated plasma sample after addition of calcium ions and tissue thromboplastin (factor III)
Purpose: To evaluate the extrinsic coagulation system ( factors V, VII, and X and prothrombin and fibrinogen) To monitor response to oral anticoagulant therapy

March 1, 2010
Specimen: Plasma
Prothrombin Time % Activity 88.34% Result Normal Values 80-100% Normal Significance

Patient

14.6 sec

10-15 sec

Normal

BLOOD CHEMISTRY REPORT

Definition: Blood chemistry is the chemical composition of the blood. The levels of various substances in the blood can provide clues to a patient's condition. Routine blood work to check blood chemistry is often a part of a diagnostic work-up, with the blood being analyzed to check for specific elements which could contribute clues to the diagnosis.
Purpose: Blood tests are used to determine physiological and biochemical states such as disease, mineral content, drug effectiveness, and organ function.

March 1, 2010
Test Name Creatinine SGPT (ALT) Sodium Result 53.07 mol/L 38.41 U/L 133 mmol/L Reference Range 53-88 mol/L 30-65 U/L 135-148 mmol/L Significance Normal Normal Diuretic Administration Potassium 3.52 mmol/L 3.8-5.5 mmol/L Diuretic Administration Calcium 1.63 mmol/L 2.12-2.52 mmol/L Diuretic Administration

ELECTROCARDIOGRAM
The electrocardiogram (ECG or EKG) is a diagnostic tool that measures and records the electrical activity of the heart in exquisite detail. An ECG records the electrical impulses that stimulate the heart to contract. It also records dyafunctions that influence the conduction ability of the myocardium. It provides a continuous picture of electrical activity during a complete cycle. Interpretation of these details allows diagnosis of a wide range of heart conditions. These conditions can vary from minor to life threatening. An ECG is used to measure: Any damage to the heart How fast your heart is beating and whether it is beating normally The effects of drugs or devices used to control the heart (such as a pacemaker) The size and position of your heart chambers

March 1, 2010
Conclusion: Atrial Fibrillation with Moderate Ventricular Response Incomplete RBBB

OVERVIEW
ANATOMY AND PHYSIOLOGY OF THE HEART

The heart is located under the ribcage in the center of the chest between the right and left lungs. Its muscular walls beat, or contract, pumping blood continuously to all parts of the body. The size of the heart can vary depending on the age, size, and the condition of the heart. A normal, healthy, adult heart most often is the size of an average clenched adult fist. Some diseases of the heart can cause it to become larger.

The Septum
The right and left sides of the heart are divided by an internal wall of tissue called the septum. The area of the septum that divides the atria (the two upper chambers of the heart) is called the atrial or interatrial septum. The area of the septum that divides the ventricles (the two lower chambers of the heart) is called the ventricular or interventricular septum.

Heart Chambers
The heart is divided into four chambers. The two upper chambers of the heart are called atria. The atria receive and collect blood. The two lower chambers of the heart are called ventricles. The ventricles pump blood out of the heart into the circulatory system to other parts of your body.

Heart Valves
Shown counterclockwise in the picture, the valves include the aortic valve, the tricuspid valve, the pulmonary valve, and the mitral valve.

Blood Flow
The arrows in the drawing show the direction that blood flows through the heart. From the right atrium, blood is pumped into the right ventricle. From the right ventricle, blood is pumped to the lungs through the pulmonary arteries. The light red arrows show the oxygen-rich blood coming in from the lungs through the pulmonary veins into the heart's left atrium. From the left atrium, the blood is pumped into the left ventricle. The left ventricle pumps the blood to the rest of the body through the aorta.

 For the heart to work properly, the blood must flow in only one direction. The heart's valves make this possible. Both of your heart's ventricles have an "in" (inlet) valve from the atria and an "out" (outlet) valve leading to the arteries. Healthy valves open and close in very exact coordination with the pumping action of the heart's atria and ventricles. Each valve has a set of flaps called leaflets or cusps that seal or open the valves. This allows pumped blood to pass through the chambers and into your arteries without backing up or flowing backward.

Electrical system
The electrical system also is called the cardiac conduction system. If you've ever seen the heart test called an EKG (electrocardiogram), you've seen a graphical picture of the heart's electrical activity. The heart's electrical system is made up of three main parts: The sinoatrial (SA) node, located in the right atrium of your heart The atrioventricular (AV) node, located on the interatrial septum close to the tricuspid valve The His-Purkinje system, located along the walls of your heart's ventricles A heartbeat is a complex series of events that take place in the heart. A heartbeat is a single cycle in which your heart's chambers relax and contract to pump blood. This cycle includes the opening and closing of the inlet and outlet valves of the right and left ventricles of the heart.

 Each heartbeat has two basic parts: diastole and atrial and ventricular systole. During diastole, the atria and ventricles of the heart relax and begin to fill with blood. At the end of diastole, the heart's atria contract (atrial systole) and pump blood into the ventricles. The atria then begin to relax. The heart's ventricles then contract (ventricular systole), pumping blood out of the heart. Each beat of the heart is set in motion by an electrical signal from within the heart muscle. In a normal, healthy heart, each beat begins with a signal from the SA node. This is why the SA node is sometimes called the heart's natural pacemaker. The pulse, or heart rate, is the number of signals the SA node produces per minute.

The signal is generated as the two vena cavae fill the heart's right atrium with blood from other parts of the body. The signal spreads across the cells of the heart's right and left atria. This signal causes the atria to contract. This action pushes blood through the open valves from the atria into both ventricles. The signal arrives at the AV node near the ventricles. It slows for an instant to allow the heart's right and left ventricles to fill with blood. The signal is released and moves along a pathway called the bundle of His, which is located in the walls of the heart's ventricles. From the bundle of His, the signal fibers divide into left and right bundle branches through the Purkinje fibers that connect directly to the cells in the walls of the heart's left and right ventricles. The signal spreads across the cells of the ventricle walls, and both ventricles contract. However, this doesn't happen at exactly the same moment. The left ventricle contracts an instant before the right ventricle. This pushes blood through the pulmonary valve (for the right ventricle) to the lungs, and through the aortic valve (for the left ventricle) to the rest of the body. As the signal passes, the walls of the ventricles relax and await the next signal. This process continues over and over as the atria refill with blood and other electrical signals come from the SA node.

CONGESTIVE HEART FAILURE

THE DISEASE PROCESS

Heart failure, often referred to as Congestive Heart Failure (CHF), is the inability of heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. CHF means that the patient has a fluid overload condition (congestion) has been identified. Over time, conditions such as narrowed arteries in your heart (coronary artery disease) or high blood pressure gradually leave your heart too weak or stiff to fill and pump efficiently. Heart failure often develops after other conditions have damaged or weakened your heart. Over time, the heart can no longer keep up with the normal demands placed on it to pump blood to the rest of your body. The main pumping chambers of your heart (the ventricles) may become stiff and not fill properly between beats. Also, your heart muscle may weaken, and the ventricles stretch (dilate) to the point that the heart can't pump blood efficiently throughout your body. The term "congestive heart failure" comes from blood backing up into or congesting the liver, abdomen, lower extremities and lungs.

ETIOLOGY AND RISK FACTORS

Congestive heart failure (CHF) is a syndrome, not a disease that can be brought about by several causes. CHF is a weakening of the heart brought on by an underlying heart or blood vessel problem, often a combination of several different problems, including the following: Weakened heart muscle Damaged heart valves Blocked blood vessels supplying the heart muscle (coronary arteries), leading to a heart attack Toxic exposures, like alcohol or cocaine Infections High blood pressure that results in thickening of the heart muscle (left ventricular hypertrophy) Pericardial disease, such as pericardial effusion (a large collection of fluid around the heart in the space between the heart muscle and the thick layer of pericardium surrounding the heart) and/or a thickened pericardium, which does not allow the heart to fill properly Congenital heart diseases Prolonged, serious arrhythmias While these conditions often combine to produce CHF, sometimes the causes of diseased heart muscles are not known; this is called idiopathic cardiomyopathy or heart muscle disease of unknown cause.

CHF is often a result of the following lifestyle habits: Unhealthy habits, such as smoking and excessive use of alcohol, are often to blame. Obesity and lack of activity may contribute to CHF, either directly or indirectly through accompanying high blood pressure, diabetes, and coronary artery disease. Years of uncontrolled high blood pressure damages both heart and blood vessels. Along with lifestyle risk factors, a number of diseases (for example, diabetes, heart attack [myocardial infarction], and congenital heart disease) can damage the heart and lead to congestive heart failure. Over a hundred other, less common, causes of CHF include a variety of infections, exposures, complications of other diseases, toxic effects, and genetic predisposition.

CLINICAL MANIFESTATIONS (SIGNS AND SYMPTOMS)

Right Sided Heart Failure Increased Systemic pressure Jugular vein distention Hepatomegaly Ascites Dependent peripheral edema Weight gain Anorexia, nausea Gastric distress Left Sided Heart Failure Dyspnea Cough Tachycardia Pulsus alterans Fatigue and weakness Memory loss and confusion Palpitations Hypotension

MEDICAL MANAGEMENT
If no underlying correctible cause of heart failure is established, medical treatment is composed of lifestyle changes and medications. Lifestyle changes recommended by the health care provider can help relieve symptoms, slow the progression of heart failure, and improve one's quality of life. Lifestyle changes that may be helpful in preventing or relieving heart failure include those recommended by the American Heart Association and other organizations as part of a heart-healthy lifestyle. Medications help control both the underlying causes of heart failure and the symptoms. Medications are the most critical part of therapy for heart failure. Usually, several types of medications are required to address as many of the physiologic imbalances as possible. These medications include:

Ace Inhibitors - enlarge the small arteries or arterioles, which relieve the systolic workload of the left ventricle. The heart has to work less to pump blood through the arteries. This also generally lowers blood pressure. They block the production of angiotensin II, which is abnormally high in congestive heart failure. Digitalis - improves the pumping ability of the heart, causing it to pump more forcefully, a so-called positive inotrope. Dopamine - increase the pumping ability of the heart. These are used as a temporary support of a very weak left ventricle that is not responding to standard CHF therapy. Diuretics - cause the kidneys to remove excess salt and accompanying water from the bloodstream, thereby reducing the amount of blood volume in circulation. With a lower volume of blood, your heart does not have to work so hard. The number of red and white blood cells is not changed. Ca channel Blockers - arterial vasodilators that are not used for treatment of heart failure per se because clinical trials have proven no benefit for prolongation of life. Calcium channel blockers are useful for lowering blood pressure if the cause of the CHF is high blood pressure and the patient is not responding to ACE inhibitors. Beta Blockers - drugs slow down the heart rate, lower blood pressure, and have a direct affect on the heart muscle to lessen the workload of the heart.

SURGICAL MANAGEMENT
The only alternative is a heart transplant. This option is for patients who are not elderly and who do not have other medical conditions that would make it unlikely for a heart transplant to be successful. Heart transplant evaluations are done in specialized centers. Other treatment or procedures, such as angioplasty or a pacemaker, may be offered, depending on the underlying cause of the heart failure.

 Angioplasty: This is an alternative to coronary bypass surgery for some people whose heart failure is caused by coronary artery disease and is compounded by heart damage/heart attack. Angioplasty is used to treat narrowing or blockage of a coronary artery that supplies the left ventricle with blood. A long, thin tube called a catheter is inserted through the skin, into a blood vessel, and threaded into the affected artery. This procedure is performed while the person is under local anesthesia.

 Pacemaker: This device controls the rhythm of the heartbeats. A pacemaker is an electrode on the tip of a wire, usually implanted inside the heart by an electrophysiologist or specialized cardiologist in the cardiac cath lab. This wire goes to the right ventricle, frequently with a second wire to the right atrium (dual chamber pacemaker). A pacemaker can stimulate a heart that is beating too slowly to beat faster, or it can control an irregular heartbeat (sometimes, this requires medications in addition to the pacemaker).

 Left ventricle assist device (LVAD): A surgically implanted to mechanically bypass the left ventricle. A clinical trial showed that complications are too high and the device did not significantly prolong life if used on a long-term basis. This device is used as a temporary left ventricle support to get the patient awaiting a heart transplant out of bed.

Totally implantable artificial hearts are being developed for patients with severe, end stage heart failure. These devices are most commonly used as a temporary bridge to heart transplantation. This technique is constantly improving but is still limited to specialized centers and is considered experimental at this time

NURSING MANAGEMENT
Keeping an input and output record to identify a negative balance. Weighing the patient daily at the same time and on the same scale. Auscultating lung sounds at least daily to detect an increase or decrease in pulmonary crackles. Provide general counseling and education about sodium restriction. Encourage patient to exercise regularly Recommend avoidance of excessive fluid intake, alcohol, and smoking. Assessing symptoms of fluid overload (eg. Orthopnea, paroxysmal nocturnal dyspnea, and dyspnea on exertion) and evaluating changes.

PATHOPHYSIOLOGY OF THE DISEASE PROCESS

MEDICATIONS

WARFARIN

Generic Name: Warfarin Brand Name: Coumadin Classification: Anticoagulant Indications: Pulmonary embolism, DVT, MI, rheumatic heart disease with heart valve damage, prosthetic heart valves, chronic arterial fibrillation Dosage: 1mg/tab OD Action: Interferes 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. Adverse reaction: CNS: fever, headache GI: diarrhea, anorexia, nausea, vomiting, cramps, mouth ulcerations GU: hematuria, menstrual excessive bleeding Hematologic: hemorrhage Skin: dermatitis, urticaria, rash, necrosis

Contraindications: Contraindicated in patients hypersensitive to drug and in those with bleeding from the GI, GU or respiratory tract; aneurysm; Cerebrovascular hemorrhage; severe or malignant hypertension; severe renal or hepatic disease. Contraindicated during pregnancy, threatened abortion, eclampsia, or pre eclampsia,and after recent surgery involving large open eyes, brain or spinal cord. Avoid using in patients with a history of warfarin induced necrosis.

Nursing considerations: Draw blood to establish baseline coagulation parameters before therapy. PT and INR determinations are essential for proper control. INR range for chronic atrial fibrillation is usually 2-3. Give drug at the same time daily. Avoid all IM injections. Regularly inspect patient for bleeding gums, bruises on arms or legs, petechiae, nosebleeds, melena, tarry stools, hematuria, and hematesis. With hold drug and call prescriber at once in the event of fever or rash. Effect can be neutralized by oral or parenteral vit. K.

Patient teaching: Tell patient and family to watch for signs of bleeding or abnormal bruising and call prescriber at once if they occur. Warn patient to avoid OTC drugs containing aspirin, other salicylates, or drugs that may interact with warfarin unless ordered by prescriber. Tell patient to consult a prescriber before using miconazole vaginal and bruising have occurred. Instruct patient to notify prescriber if menstruation is heavier than usual, she may need dosage adjustment. Tell patient to use electric razor when shaving, and use a soft toothbrush Tell patient to read food labels. Food, nutritional supplements and multivitamins that contain vitamin k may impair coagulation Tell patient to eat daily, consistent diet of food and drinks containing vitamin K, because eating varied amounts may alter anticoagulant effects

BUMETANIDE
Generic Name: Bumetanide Brand Name: Burinex Classification: Loop Diuretic: Edema associated with CHF, cirrhosis, renal disease, acute pulmonary edema Dosage: 1mg OD Actions: Inhibits the reabsorption of sodium and chloride from the proximal and distal renal tubules and the loop of Henle, leading to a natriuretic diuresis.

Adverse reaction: CNS: Asterixis, dizziness, vertigo, paresthesias, confusion, fatigue, nystagmus, weakness, headache, drowsiness, fatigue, blurred vision, tinnitus, irreversible hearing loss CV: Orthostatic hypotension, volume depletion, cardiac arrhythmias, thrombophlebitis GI: Nausea, anorexia, vomiting, diarrhea, gastric irritation and pain, dry mouth, acute pancreatitis, jaundice GU: Polyuria, nocturia, glycosuria, renal failure Hematologic: Hypokalemia, leukopenia, anemia, thrombocytopenia Local: Pain, phlebitis at injection site Other: Muscle cramps and muscle spasms, weakness, arthritic pain, fatigue, hives, photosensitivity, rash, pruritus, sweating, nipple tenderness Contraindications: Contraindicated with allergy to bumetanide; electrolyte depletion; anuria, severe renal failure; hepatic coma; lactation.

Patient teaching: Record alternate day or intermittent therapy on a calendar or dated envelopes. Take the drug early in day so increased urination will not disturb sleep; take with food or meals to prevent GI upset. Weigh yourself on a regular basis, at the same time, and in the same clothing; record the weight on your calendar. These side effects may occur: Increased volume and frequency of urination; dizziness, feeling faint on arising, drowsiness (avoid rapid position changes; hazardous activities, such as driving; and alcohol consumption); sensitivity to sunlight (use sunglasses, sunscreen, and wear protective clothing); increased thirst (suck sugarless lozenges; use frequent mouth care); loss of body potassium (a potassium-rich diet, or supplement will be needed). Report weight change of more than 3 lb in 1 day; swelling in ankles or fingers; unusual bleeding or bruising; nausea, dizziness, trembling, numbness, fatigue; muscle weakness or cramps.

DIGOXIN
Generic Name: Digoxin Brand Name: Lanoxin Classification: Anti-arrythmic Indication: CHF, Atrial Fibrillation Dosage: 0.25mg tab OD Action: Increases intracellular calcium and allows more calcium to enter the myocardial cell during depolarization via a sodiumpotassium pump mechanism; this increases force of contraction (positive inotropic effect), increases renal perfusion (seen as diuretic effect in patients with CHF), decreases heart rate (negative chronotropic effect), and decreases AV node conduction velocity.

Nursing Considerations: History: Allergy to bumetanide, electrolyte depletion, anuria, severe renal failure, hepatic coma, SLE, gout, diabetes mellitus, lactation Physical: Skin color, lesions; edema; orientation, reflexes, hearing; pulses, baseline ECG, BP, orthostatic BP, perfusion; R, pattern, adventitious sounds; liver evaluation, bowel sounds; urinary output patterns; CBC, serum electrolytes (including calcium), blood sugar, liver and renal function tests, uric acid, urinalysis Give with food or milk to prevent GI upset. Mark calendars or use reminders if intermittent therapy is best for treating edema. Give single dose early in day so increased urination will not disturb sleep. Avoid IV use if oral use is possible. Arrange to monitor serum electrolytes, hydration, liver function during long-term therapy. Provide diet rich in potassium or supplemental potassium.

Adverse reaction: CNS: Headache, weakness, drowsiness, visual disturbances, mental status change CV: Arrhythmias GI: GI upset, anorexia Contraindication: Contraindicated with allergy to digitalis preparations, ventricular tachycardia, ventricular fibrillation, heart block, sick sinus syndrome, IHSS, acute MI, renal insufficiency and electrolyte abnormalities (decreased K+, decreased Mg++, and increased Ca++). Use cautiously with pregnancy and lactation.

Nursing Consideration: History: Allergy to digitalis preparations, ventricular tachycardia, ventricular fibrillation, heart block, sick sinus syndrome, IHSS, acute MI, renal insufficiency, decreased K+, decreased Mg++ increased Ca++ Physical: Weight; orientation, affect, reflexes, vision; P, BP, baseline ECG, cardiac auscultation, peripheral pulses, peripheral perfusion, edema; R, adventitious sounds; abdominal percussion, bowel sounds, liver evaluation; urinary output; electrolyte levels, liver and renal function tests Monitor apical pulse for 1 min before administering; hold dose if pulse < 60 in adult or < 90 in infant; retake pulse in 1 hr. If adult pulse remains < 60 or infant < 90, hold drug and notify prescriber. Note any change from baseline rhythm or rate. Take care to differentiate Lanoxicaps from Lanoxin; dosage is very different Check dosage and preparation carefully. Avoid IM injections, which may be very painful. Follow diluting instructions carefully, and use diluted solution promptly. Avoid giving with meals; this will delay absorption. Have emergency equipment ready; have K+ salts, lidocaine, phenytoin, atropine, cardiac monitor on standby in case toxicity develops. Monitor for therapeutic drug levels: 0.52 ng/mL.

Patient Teaching: Do not stop taking this drug without notifying your health care provider. Take pulse at the same time each day, and record it on a calendar call your health care provider if your pulse rate falls below . Weigh yourself every other day with the same clothing and at the same time. Record this on the calendar. Wear or carry a medical alert tag stating that you are using this drug. Have regular medical checkups, which may include blood tests, to evaluate the effects and dosage of this drug. Report unusually slow pulse, irregular pulse, rapid weight gain, loss of appetite, nausea, vomiting, blurred or "yellow" vision, unusual tiredness and weakness, swelling of the ankles, legs or fingers, difficulty breathing.

AZITHROMYCIN
Generic Name: Azithromycin Brand Name: Azomycin Dosage: 500 mg TID Classification: Antibiotic, macrolide Action: A macrolide antibiotic derived from erythromycin. Acts by binding to the P site of the 50s ribosomal subunit and may inhibit RNA-dependent protein synthesis by stimulating the dissociation of peptidyl t-RNA from ribosomes.

Adverse Reactions:
CNS: dizziness, vertigo, headache, fatigue, somnolence CV: palpitations, chest pain GI: nausea, vomiting, diarrhea, abdominal pain, dyspepsia, flatulence, melena, cholestatic jaundice GU: monilia, vaginitis, nephritis Skin: rash, photosensitivity Other: angioedema, pseudomembranous colitis

Contraindications: Hypersensitivity to azithromycin, any macrolide antibiotic, or erythromycin.

Nursing Considerations: Tablets and oral suspension can be taken with or without food; however, there is an increased tolerability when tablets are taken with food. It should be taken 1 hour to or 2 hours after a meal. Use cautiously in patients with impaired hepatic function. Obtain culture and sensitivity tests before first dose. Therapy can begin before results are obtained. May cause overgrowth of nonsusceptible bacteria or fungi. Monitor for signs and symptoms of superinfection. Tell patient to take all of the medication prescribed, even after he feels better.

Client/Family Teaching: Tablets may be taken with food or milk to improve tolerability. Food decreases absorption. Finish all medication unless otherwise directed. Avoid ingesting Al- or Mg containing antacids simultaneously with Azithromycin. Notify provider if nausea and vomiting is excessive or debilitating. Avoid sun exposure and use protection when outside. Report lack of response or any unusual side effects. With STDs, encourage partner to seek medical evaluation and treatment to prevent re-infections. Use condoms during intercourse throughout therapy.

LEVOFLOXACIN
Generic Name: Levofloxavin Brand Name: Levaquin Classification: Antibiotic Indication: Treatment of adults with community-acquired pneumonia, acute maxillary sinusitis caused by susceptible bacteria Treatment of acute exacerbation of chronic bronchitis caused by susceptible bacteria Treatment of complicated and uncomplicated skin and skin structure infections caused by susceptible bacteria Treatment of complicated and uncomplicated UTIs and acute pyelonephritis caused by susceptible bacteria Treatment of chronic bacterial prostatitis due to Escherichia coli, Enterococcus faecalis, Staphylococcus species Treatment of nosocomial pneumonia due to methicillinsensitive Staphylococcus aureus, Pseudomonas strains, Serratia species, Escherichia coli, Klebsiella species, Haemophilus influenzae, Streptococcus pneumoniae Dosage: 500 mg/ tab OD

Action: Bactericidal: Interferes with DNA by inhibiting DNA synase replication in susceptible gram-negative and gram-positive bacteria, preventing cell reproduction. Adverse Reaction: CNS: Headache, dizziness, insomnia, fatigue, somnolence, blurred vision GI: Nausea, vomiting, dry mouth, diarrhea, abdominal pain (occur less with this drug than with oflaxacin), constipation, flatulence Hematologic: Elevated BUN, AST, ALT, serum creatinine, and alkaline phosphatase; neutropenia, anemia Other: Fever, rash, photosensitivity, muscle and joint tenderness Contraindication: Contraindicated with allergy to fluoroquinolones, lactation. Use cautiously with renal dysfunction, seizures, pregnancy.

Nursing Consideration: Arrange for culture and sensitivity tests before beginning therapy. Continue therapy as indicated for condition being treated. Administer oral drug 1 hr before or 2 hr after meals with a glass of water; separate oral drug from other cation administration, including antacids, by at least 2 hr. Ensure that patient is well hydrated during course of therapy. Discontinue drug at any sign of hypersensitivity (rash, photophobia) or at complaint of tendon pain, inflammation, or rupture. Monitor clinical response; if no improvement is seen or a relapse occurs, repeat culture and sensitivity test.

Patient Teaching: Take oral drug on an empty stomach, 1 hr before or 2 hr after meals. If an antacid is needed, do not take it within 2 hr of levofloxacin dose. Drink plenty of fluids while you are using this drug. These side effects may occur: Nausea, vomiting, abdominal pain (eat frequent small meals); diarrhea or constipation (consult nurse or physician); drowsiness, blurred vision, dizziness (use caution if driving or operating dangerous equipment); sensitivity to sunlight (avoid exposure, use a sunscreen if necessary). Report rash, visual changes, severe GI problems, weakness, tremors.

FLUCONAZOLE
Generic Name: Fluconazole Brand Name: Funzela Classification: Antifungal Indication: Treatment of oropharyngeal, esophageal, vaginal, and systemic candidiasis Treatment of cryptococcal meningitis Prophylaxis of candidiasis in bone marrow transplants Dosage: 150 mg/tab Action: Binds to sterols in the fungal cell membrane, changing membrane permeability; fungicidal or fungistatic depending on concentration and organism. Adverse Reaction: CNS: Headache GI: Nausea, vomiting, diarrhea, abdominal pain Other: Rash

Contraindication: Contraindicated with hypersensitivity to fluconazole, lactation. Use cautiously with renal impairment. Nursing Consideration: Culture infection prior to therapy; begin treatment before lab results are returned. Decrease dosage in cases of renal failure. Infuse IV only; not intended for IM or SC use. Do not add supplement medication to fluconazole. Administer through sterile equipment at a maximum rate of 200 mg/hr given as a continuous infusion. Monitor renal function tests weekly, discontinue or decrease dosage of drug at any sign of increased renal toxicity.

Patient Teaching: Drug may be given orally or intravenously as needed. The drug will need to be taken for the full course and may need to be taken long term. Use hygiene measures to prevent reinfection or spread of infection. Arrange for frequent follow-up while you are using this drug. Be sure to keep all appointments, including those for blood tests. These side effects may occur: Nausea, vomiting, diarrhea (eat frequent small meals); headache (analgesics may be ordered). Report rash, changes in stool or urine color, difficulty breathing, increased tears or salivation.

CALCIUM CARBONATE
Generic Name: Calcium Carbonate Brand Name: Caltrate Classification: Antacid, adsorbent and antiflatulents Indication: Acid indigestion, calcium supplement Dosage: 1 tab OD Action: Reduces total acid load in the GI tract, elevates gastric PH to reduce pepsin activity, strengthens gastric mucosal barrier, and increases esophageal sphincter tone. Adverse Reaction: CNS: headache, irritability, weakness GI: rebound hyperacidity, nausea, constipation, flatulence.

Contraindication: Patient with ventricular fibrillation or hypercalcemia. Nursing Consideration: Record amount and consistency of stools Monitor calcium levels Watch for evidence of hypercalcemia (nausea, vomiting, headache, confusion and anorexia) Patient Teaching: Not to take calcium carbonate indiscriminately or switch antacids without prescribers advice Urge to notify about signs and symptoms of GI bleeding such as tarry stool, or coffee-ground vomitus.

AMINO VITA
Generic Name: Amino Vita Brand Name: Amino Vita Classification: Multivitamins Supplement Indication: In cases where there are considerable nutrient losses (febrile illnesses, infectious diseases, strenuous physical activities). As adjuvant in the therapy of malnutrition, chronic illnesses. Conditions associated w/ protein loss &/or increased nutritional requirements (burns, wounds, bone fracture, convalescence, stress, postsurgical operations). Nutritional supplement in protein & vit deficiencies associated w/ restrictive or deficient diet (anorexia, starvation). Dosage: OD Action: Supplement nutritional losses and vitamin deficiencies. Maybe used as dietary supplements.

HEXITIDINE
Generic Name: Hexitidine Brand Name: Bactidol gargle Classification: Antiseptic Indication: Minor sore throat; halitosis; general oral hygiene; improves appearance of mouth tissues; protects tooth surfaces against formation of decay acids. Dosage: Gargle TID Action: Hexetidine, a hexahydropyrimidine, arrests the thiamine metabolism of microorganisms, thereby inhibiting their growth. Hexetidine has both antibacterial and antifungal properties in vivo and possesses a broad spectrum of activity against both grampositive and gram-negative organisms that cause mouth and throat infections. Hexetidine has been proven to exhibit an analgesic property. It possesses an anti-infective (preventive and curative) property. It has been shown to have a cicatrizing action. It also exhibits a mild hemostatic action.

Adverse Reaction: Transient numbness & alteration in taste may occur. Allergic contact dermatitis, taste alterations, transient anesthesia, mouth or tongue irritation.

Special Precautions: Not recommended for use in children <6 yr. Shake well before use. Do not swallow Store below 25C.

ERDOSTEIN
Generic Name: Endostein Brand Name: Ectrin/ Zertin Classification: Mucolytics Indication: Acute bronchitis, chronic bronchitis & its exacerbations. Resp disorders characterised by abnormal bronchial secretions & impaired mucus transport. Dosage: 300 mg/cap BID

Action: Erdosteine contains two sulfhydryl groups, which are freed after metabolic transformation in the liver. The liberated sulfhydryl groups break the disulphide bonds, which hold the glycoprotein fibres of mucus together. This makes the bronchial secretions more fluid and enhances elimination. Absorption: Rapid absorption after oral admin. Distribution: Protein binding: 64.5%. Metabolism: Undergoes 1st-pass metabolism to form an active metabolite, N-thiodiglycolyl-homocysteine. Excretion: Elimination half-life: About 1.46 hr (erdosteine), and about 1.62 hr (metabolite). Mainly via the urine, as metabolites.

Adverse Reaction: Epigastralgia, nausea, vomiting, loose stools, spasmodic colitis, headache. Contraindication: Known hypersensitivity to erdosteine. Because of a possible interference of erdosteine metabolites with the methionine metabolism, erdosteine is contraindicated in patients suffering from hepatic cirrhosis and deficiency of the cystathioninesynthetase enzyme. Suspension: Phenylketonuria, due to the presence of aspartame. Special Precautions: Pregnancy, lactation. Store below 25C

SPIRONOLACTONE
Generic Name: Spironolactone Brand Name: Aldactone Classification: Potassium Sparring Diuretic Indication: Primary hyperaldosteronism, including diagnosis, shortterm preoperative treatment, long-term maintenance therapy for those who are poor surgical risks and those with bilateral micronodular or macronodular adrenal hyperplasia. Edema when other approaches are inadequate or ineffective. Essential hypertension (usually in combination with other drugs). Prophylaxis of hypokalemia in clients taking digitalis. Dosage: 50 mg OD

Action: Mild diuretic that acts on the distal tubule to inhibit sodium exchange for potassium, resulting in increased secretion of sodium and water and conservation of potassium. An aldosterone antagonist. Manifests a slight antihypertensive effect. Interferes with synthesis of testosterone and may increase formation of estradiol from testosterone, thus leading to endocrine abnormalities. Adverse Reaction: Dizziness, blurred vision, N&V, fatigue anorexia, insomnia, nasal congestion, gynecomastia. Contraindication: Acute renal insufficiency, progressive renal failure, hyperkalemia, and anuria. Clients receiving potassium supplements, amiloride, or triamterene. Nursing Consideration: Food may increase absorption of spironolactone Protect drug from light. Asses for drug tolerance characterized by edema /reduced urine output.

Patient Teaching:
Take as directed with a snack/meal to minimize GI upset. Report if nausea, bloating, anorexia, vomiting, or diar rhea persist. Take early in day to prevent frequent night time urination. Avoid foods or salt substitutes high in potassium; drug is potassium-spar ing. Record BP and weight twice a week for provider review. Report any in- creased swelling of extremities or weight gain of more than 5 lb (2.2 kg weekly. Do not drive/operate dangerous machinery until drug effects realized; may cause drowsiness or unsteady gait. Drug may cause breast swelling and diminished sex drive by reducing testosterone levels.

CALCIUM CARBONATE
Generic Name: Calcium Carbonate Brand Name: Antacid, Electrolyte Classification: Antacid, adsorbent and antiflatulents Indication: Relief acid indigestion, heartburn, sour stomach,& upset stomach. Calcium supplement Dosage: 1 tab OD Action: Reduces total acid load in the GI tract, elevates gastric PH to reduce pepsin activity, strengthens gastric mucosal barrier, and increases esophageal sphincter tone. Adverse Reaction: CNS: headache, irritability, weakness GI: rebound hyperacidity, nausea, constipation, flatulence.

Contraindication: Patient with ventricular fibrillation or hypercalcemia. Nursing Consideration: Record amount and consistency of stools Monitor calcium levels Watch for evidence of hypercalcemia (nausea, vomiting, headache, confusion and anorexia) Patient Teaching: Not to take calcium carbonate indiscriminately or switch antacids without prescribers advice Urge to notify about signs and symptoms of GI bleeding such as tarry stool, or coffee-ground vomitus.

NURSING CARE PLAN

NCP # 1 NCP # 2 NCP # 3

THE END

BSN 3L RATIONALE