Case Study of Congestive Heart Failure

Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
Congestive heart failure is defined as “the state in which the heart is unable to pump
blood at a rate adequate for satisfying the requirements of the tissues with function
parameters remaining within normal limits usually accompanied by effort intolerance,
fluid retention, and reduced longevity” (Denolin, 1983, p. 445). Currently, congestive
heart failure or heart failure, continues to be a major public health problem worldwide. It
is the leading cause of morbidity and mortality in most developed countries. According to
the American Heart Association (2001), approximately 5 million patients have heart
failure and nearly 550,000 new patients are diagnosed each year. In addition, nearly
300,000 patients die from heart failure yearly.
In the Philippines, cardiovascular diseases are the most common causes of mortality.
According to the Department of Health (2005), about 77,060 in a 100, 000 population
have died in the Philippines due to diseases of the heart. The aging of the population and
the emerging pandemic of cardiovascular diseases in the developing nations of the world
signal a rise in the incidence and prevalence of heart failure globally and magnify the
importance of its prevention. The prevention of heart failure is an urgent public health
need with national and global implications.
This paper is a case report about B. A., a 49 year old female, Filipino, nonhypertensive,
nondiabetic, a post-mitral and aortic valve replacement patient and is currently diagnosed
with Congestive Heart Failure Functional Capacity II-III secondary to Valvular Heart
Disease secondary to Rheumatic Heart Disease. Its purpose is to review the
1
pathophysiology, preanalytical factors, and treatment in a congestive heart failure patient
and identify possible recommendations for future nursing care.
This case report is significant to my future nursing care because it helps stress the
importance of not only identification and treatment of patients with heart failure but also
the importance of promoting a healthy lifestyle and preventive strategies to decrease the
prevalence of heart failure in the general population. Also, it explores the need for a
thorough case analysis of a client to deliver the best nursing care.
2
THEORETICAL BACKGROUND
Theoretical Background. Heart failure is defined as “the pathophysiologic state in
which an abnormality of cardiac function is responsible for inadequate systemic
function” (Woods, et. al, 2010). It is not considered as a disease but a collection of signs
and symptoms, the final pathway of a group of diseases, the end-result of most
cardiovascular states.
Classification. According to the New York Heart Association (1964), congestive
heart failure may be classified into four functional states. “Class I (Mild) are patients with
cardiac disease but without resulting limitatios of physical activity. Ordinary physical
activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath), or
anginal pain. Class II (Mild) are patients with cardiac disease resulting in slight limitation
of physical activity. They are comfortable at rest. Ordinary physical activity results in
fatigue, palpitation, dyspnea, or anginal pain. On the other hand, Class III (Moderate) are
patients with cardiac disease resulting in marked limitation of physical activity. They are
comfortable at rest, but less than ordinary activity causes fatigue, palpitation, dyspnea or
anginal pain. The last classification is Class IV (Severe) are patients with cardiac disease
wherein there is inability to carry out any physical activity without discomfort.
Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at
rest. If any physical activity is undertaken, discomfort is increased (New York Heart
Association, 1964).
3
Causes. “An array of different problems can cause congestive heart failure. (1)
Among them is coronary (ischemic) heart disease resulting from insufficient blood flow
to the myocardium, or heart muscle. This is usually caused by atherosclerosis, the buildup
of fatty substances or plaque on the walls of the arteries that carry blood to the heart
muscle. The heart’s ability to perform decreases because ischemia results in the delivery
of less oxygen and fewer nutrients to the heart muscle. (2) A heart attack may also cause
congestive failure. During a heart attack, the heart muscle is deprived of oxygen,
resulting in tissue death and scarring. The development of heart failure depends on the
extent and location of scarring. (3) Long-standing high blood pressure is another
common cause of heart failure. Because there is greater resistance against which the heart
must pump, the heart muscle works harder. This results in an enlargement of the heart
muscle, especially of the left ventricle, the heart’s main pumping chamber. Eventually,
this enlarged muscle tissue weakens, setting the stage for heart failure, especially if the
pumping ability of the enlarged chamber greatly decreases. (4) Arrhythmias (irregular
heartbeats) can also lead to heart failure, but they usually have to be severe and
prolonged, with a rapid rate of more than 140 beats per minute, and must often occur in
the presence of an already weakened heart. They change the pattern of filling and
pumping of blood from the heart. This condition may also lower output of blood to the
point of heart failure. (5) Valvular heart diseases are another cause of heart failure, which
results when a narrowed or leaking valve fails to direct blood flow properly through the
heart. The problem may be congenital (inborn) or due to an infection such as endocarditis
or rheumatic fever. This increases the heart’s workload, thereby increasing risk of
4
developing heart failure. (6) Cardiomyopathy, a disease of the heart muscle itself, can
also lead to heart failure. Causes of cardiomyopathy include infection, alcohol abuse, and
cocaine abuse. When heart failure seems to have no known causes, it is known as
idiopathic heart failure” (Soufer, 1992).
Manifestations. Soufer (1992) further elaborates the manifestations often seen in
patients with heart failure. The particular symptoms that an individual experiences are
determined by which side of the heart is involved in the heart failure. For example, the
“left atrium receives oxygenated blood from the lungs and passes it onto the left
ventricle, which pumps it to the rest of the body” (Porth, 2007). When the left side isn’t
pumping efficiently, blood backs up in the vessels of the lungs, and sometimes fluid is
forced out of the lung vessels and into the breathing spaces themselves. This pulmonary
congestion causes shortness of breath. The other major symptoms of left-sided heart
failure are fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea , and the sputum
production that comes from pulmonary congestion (Soufer, 1992).
Porth (2007) adds that right-sided failure occurs when there is resistance to the flow of
blood from the right heart structures (right atrium, right ventricle, pulmonary or lung
artery) into the lungs or when the tricuspid valve, which separates the right atrium from
the right ventricle, fails to work properly. This results in a backup of fluid and pressure in
the veins that empty into the right side of the heart. Pressure then builds up in the liver
and the veins in the legs. The liver enlarges and may become painful and swelling of the
5
ankles or legs occurs (Soufer, 1992).
The major symptoms of right-sided heart failure are edema and nocturia (Woods, et. al,
2010). The different types of edema possible are dependent edema, edema that results in
enlargement or swelling of the liver, ascites, and edema of the skin or soft tissues.
Because congestive heart failure causes the body to fill with excess fluids, the kidneys
may not be able to dispose of the extra sodium and water, a condition known as kidney
failure. Sodium that would normally be eliminated through the urine remains in the body,
causing it to retain even more water, thereby aggravating the problem of excess fluid
associated with congestive heart failure (Soufer, 1992).
Diagnosis. According to the Framingham Study (McKee, et. al, 1971), the
diagnosis of congestive heart failure requires the simultaneous presence of at least 2
major criteria or 1 major criterion in conjunction with 2 minor criteria that they have
formulated. The major criteria includes paroxysmal nocturnal dyspnea, neck vein
distention, rales, radiographic cardiomegaly (increasing heart size on chest radiography),
acute pulmonary edema, S3 gallop, increased central venous pressure (greater than 16
centimeters fluid at right atrium), hepatojugular reflux and weight los greater than 4.5
kilograms in 5 days in response to treatment. The minor criteria is composed of bilateral
ankle edema, nocturnal cough, dyspnea on ordinary exertion, hepatomegaly, pleural
effusion, decrease in vital capacity by one third from maximum recorded and tachycardia
6
(heart rate greates than 120 beats per minute). Minor criteria are acceptable only if they
can not be attributed to another medical condition (such as pulmonary hypertension,
chronic lung disease, cirrhosis, ascites, or the nephrotic syndrome). The Framingham
Heart Study criteria are 100% sensitive and 78% specific for identifying persons with
definite congestive heart failure (McKee, et. al, 1971).
Complications. Watson (2000) discovered that the common complications of heart
failure include irregular heart rhythms or arrythmias, stroke, thromboembolism and organ
dysfunctions. (1) One of these are malignant ventricular arrhythmias which are common
in end stage heart failure. For example, sustained ventricular tachycardia occurs in up to
10% of patients with advanced heart failure who are referred for cardiac transplantation
(Watson, 2000). In patients with ischemic heart disease, these arrhythmias often have
mechanisms in scarred myocardial tissue. An episode of sustained ventricular tachycardia
indicates a high risk for recurrent ventricular arrhythmias and sudden cardiac death.
Congestive heart failure predisposes to (2) stroke and (3) thromboembolism, with an
overall estimated annual incidence of approximately 2% (Watson, 2000). Factors
contributing to the increased thromboembolic risk in patients with heart failure include
low cardiac output (with relative stasis of blood in dilated cardiac chambers), regional
wall motion abnormalities (including formation of a left ventricular aneurysm), and
associated atrial fibrillation. Patients with heart failure and chronic venous insufficiency
may also be immobile, and this contributes to their increased risk of thrombosis,
including deep venous thrombosis and pulmonary embolism. Mild to moderate heart
7
failure is associated with an annual risk of stroke of about 1.5% (compared with a risk of
less than 0.5% in those without heart failure), rising to 4% in patients with severe heart
failure (Watson, 2000). (4) Organ dysfunction occurs when there is a decrease in the
oxygen supply to the different organ tissues in the body. Because of the lack of oxygen,
compensatory mechanisms act but eventually decompensate leading to dysfunction of
organs (Porth, 2007).
8
CASE PRESENTATION
B. A. is a 49 year old female, Filipino, nonhypertensive, nondiabetic and diagnosed with
Congestive Heart Failure Functional Capacity II secondary to Valvular Heart Disease
secondary to Rheumatic Heart Disease. She lives with her husband, three children, a son-
in-law and a grandson in Sapang Palay, Bulacan. B. A. stopped going to school when she
was 1st year high school and is currently unemployed. She worked as a vendor before.
She is a Roman Catholic and actively participates in church as a lector.
The client was admitted from home to the Emergency Room of the Philippine General
Hospital on August 30, 2010 with complaints of fever and shortness of breath. She was
admitted to the Female General Medicine Ward 1 at Bed 8 for monitoring and
management and also to rule out Moderate Risk Community Acquired Pneumonia,
Pulmonary Tuberculosis and Infective Endocarditis.
B. A. has been experiencing chest heaviness and mild chest pain 5 days prior to
admission. She also contracted fever but this was relieved after she took Bioflu. She was
not taken to a physician until 3 days prior to admission when her chest pain worsened and
radiated to the back and she experienced shortness of breath. The fever recurred with
maximum temperature of 38°C. She was admitted to Sapang Palay District Hospital for
management where she was administered with oxygen. On the same day, she was
discharged and advised to followup to Philippine General Hospital. However, the client
9
proclaimed that she felt well immediately after and her fever was gone so she delayed
referral. One day prior to admission, the client had fever again and has stomach
discomfort. She claimed that her chest pain worsened so on August 30, 2010, the client's
family brought her to Philippine General Hospital.
The client was first diagnosed with Rheumatic Heart Disease in the 1980s in Philippine
Heart Center where she regularly went for checkup. Upon transfer of residency, she had
regular checkups in Philippine General Hospital Out Patient Department. In the check-
ups between 2002-2003, it was determined that B. A. has valvular heart disease and was
scheduled for operation. She underwent mitral and aortic valve replacement in Philippine
General Hospital in 2004. Since then, she has been on regular follow-up with the
Outpatient Department of the Hospital. Her maintenance medications included Warfarin 5
mg/tab taken once daily (taken twice the week before admission) and Metroprolol 50
mg/tab taken once daily. B. A. was readmitted in July of 2005 because of hemoptysis and
extreme fatigue. However, no significant findings were made and Pulmonary
Tuberculosis was ruled out. In October 2009, the client was admitted to San Lazaro
Hospital in Bulacan for anti-rabies injection because of a dog bite.
She has a family history of cardiovascular diseases and pulmonary tuberculosis. Her
mother is a known cardiac patient of valvular heart disease and died in 1998. Her father is
a known hypertensive and died on August 14, 2010 due to heart attack. B. A. has uncles
with pulmonary problems specifically Pulmonary Tuberculosis though she does not live
10
with them. The client knows no one in the family with mental illness or history of
diabetes mellitus.
Nursing Assessment. Complete assessment on the status of the client based on the
nursing health history was conducted on August 31, 2010. Pertinent nursing health
history problems were clusted per functional health pattern. Physical examination was
also conducted on the same date. Pertinent physical assessment findings are classified per
system.
In the Health perception and health management pattern, the client reports that she is a
healthy person is one who rarely gets sick. To maintain her health, she follows the
doctors’ advice and tells that she has never had a problem with following the health
professionals' orders. In addition, she drinks her medicines regularly and takes periods of
rest. She claims to have no traditional health beliefs. According to the client, she thinks
the reason she felt ill was because she does the household chores even when she was
supposed to rest and she carries her grandson around which led to shortness of breath and
fatigue. B. A. claims that she felt more comfortable and relieved when she was admitted
to the hospital.
B. A claims that her overall health varies, with periods of fatigue and strength.
Whenever she feels episodes of chest heaviness or fatigue, she sits in front of the electric
fan to ventilate herself and rest until she regains strength. She is a nonalcoholic and a
11
nonsmoker. She claims to have taken only few sips of beer before when she was in her
20s but she has never drunk more than a glass and she has never tried to smoke in the
past. However, she experiences second hand smoke daily since her husband smokes at
least 3 sticks a day. B. A. has never taken illegal drugs. During the hospital rotation, the
client experienced chest pain with a grade of 4, radiating to back and persisting after 10
minutes.
In the nutritional and metabolic pattern, B. A. reports that every day she eats about three
meals per day which are cooked at home, with the occasional snack in between meals.
Because she has been cautioned from eating fatty and salty foods, she seldom eats pork.
In addition, it was explained to her that green leafy vegetables affect the mechanism of
action of one of her medications which is Warfarin so she also refrains eating said
vegetables. The food she eats varies from vegetables, fruits, fish and chicken. The client
claims that she eats a lot of vegetables and fruits, and leaves behind the fatty portion of
the meat she eats. Also, she only eats small portions of the meat, especially if it is salty,
and eats about one cup of rice per meal. She dislikes other fatty, salty and sweet foods
except chicharon and fries though she has regulated her intake of both to at least once
every two months. She enjoys vegetables and fruits and seldom use condiments except
vinegar.
Her fluid intake is about 3 glasses a day or sometimes one 500 ml bottle of water per day.
She remembers that when she was in the hospital, her fluid intake was regulated at 1 Liter
12
per day and she has adapted this at home. The client verbalized a noticeable decrease in
weight since she was diagnosed with heart disease. At the time of the interview, the
client also reported a decrease in appetite, although there is no problem in eating despite
having all her teeth replaced with dentures. When she gets sick, she gets well rather
quickly, and her only previous skin problem was hematoma, which she explained was
caused by her medication (Warfarin).
In the elimination pattern, the client moves her bowels everyday. She complains that
there are times that she cannot defecate easily because she finds it difficult to stop
breathing and expel her feces forcefully. She described her feces as brown, soft and
broken into small pieces about 3 cm in diameter. Also, B. A. urinates about 3 times per
day, without difficulty or pain. She describes her urine as clear, yellow in color and
without any foul odor. She measures her urine to be about 250 ml or one half of a mineral
bottle. In addition, the client does not suffer from diaphoresis.
In the Activity-Exercise Pattern, B. A. claims that she has less energy than before to do
her daily activities. She has refrained from washing clothes and carrying heavy things
since she easily experiences shortness of breath. However, she is able to do household
chores, carry her grandson, go to the market and serve at the church though with
considerable effort. She does not exercise anymore except walk around the house and
stretching. The client’s pastimes include watching TV, listening to the radio, and playing
with or watching her grandchild play. She is independent in grooming, eating, bathing,
13
elimination, dressing, maintaining cleanliness, and daily movement. However, she is
unable to do household chores as before and go to the market without assistance of a
family member. She requires the supervision of a family member because she easily gets
tired and experience shortness of breath. Her level of self-care is Level 2.
In the Sleep-rest Pattern, B. A. claims that she finds it difficult to sleep at night and
especially during mornings and only takes naps in between because she has not yet
adapted to the hospital environment,. However on her second night, she reported that she
has been able to sleep well. In supine position and flat on bed, B. A. claims that she has
difficulty breathing and feels that she is “drowning”. She is on moderate high back rest
and requires 2 pillow to be able to sleep comfortably without difficulty of breathing. She
is able to climb 3 flights of stairs before being out of breath. She also claims that she is
easy to awaken and she does not have a special ritual for bedtime. The relaxing activities
for her include saying the rosary, watching TV and watching her grandson.
In the Cognitive-Perceptual Pattern, B. A. has no hearing problem and does not use a
hearing aid. However, she does have a visual problem. She uses glasses with grade of
300. Her memory is still intact, and she learns best by actual performance of a task and
reading. The client does not feel pain in any part of her body though she sometimes feels
chest heaviness and pain which she relieves by ventilating herself with electric fan and
taking a rest. The client was a former president of the Lector/Commentator League and
treasurer of the Parish Pastoral Council in their town but was forced to resign because of
14
her health condition. She claims that she misses doing her work but is resigned to resting
and staying at home because she understands that it is for her own benefit.
In the Role-Relationship Pattern, the family of B. A. is said to be extended and
patriarchal, with B. A. making decisions regarding health actions and daily expenditures.
She lives with her husband, her three children, a daughter-in-law and a grandson. Her
husband is a contractual painter of houses and automobiles and their usual income varies
from P3000-P5000 per month. Their children always contributes to the medical expenses
of the client. Currently, they feel worried about their mother's condition and contributes
to any way they can to alleviate her condition. The usual problem of the family involves
the drinking habit of the client's husband and financial problems. They usually resolve it
by conversations with the family.
In the Sexuality-Reproductive Pattern, B. A. stated that she and her husband has not
engaged in sexual intercourse in recent years. She claims that this is because they are
already old. She has used pills as a family planning method from 1989 to 2002 but has
since stopped using them though no problems were encountered upon their use. The
client had her first menstrual period when she was 11 years old. She describes her
menstrual period to be regular and usually lasts from 3 to 4 days. She usually consumes 3
pads in a day and has never experienced dysmennorhea. Her last menstruation was on
August 1, 2010. B. A. is a G3P3 mother and has no history of complications at birth.
15
In the Coping-Stress Tolerance Pattern, the client reports that she does not want to be a
burden to her family and perceives herself as “weak”. However, she has already accepted
this fact and coped with the weakness in her own way. She does not perceive any
difference in her physique except weight loss. She is easily cries and becomes tensed or
nervous though this has been lessened once she was admitted in the hospital. B. A. feels
anxious about her condition but she believes that everything will be alright in the end
more so because she feels relatively fine. Whenever she feels tensed, she talks to her
significant others or pray the rosary. She usually feels nervous whenever there are
arguments in the family but this has been lessened according to her significant other out
of consideration for the client. She sits and calms herself by praying and talking with the
involved parties to relieve her tension. She coped with her condition by changing her
lifestyle for the better, avoiding foods that are contraindicated to her condition and taking
rest periods. However, she does feel bothered about the expenses incurred by her children
for her medical condition.
In the Value/Belief Pattern, the client expresses that her only wish is to see her children
and her grandchildren grow up. She does not fear death but she wishes that she will live
longer because of her family. God, family and health are important for B. A. She claims
that her religion helps her get through her condition because it gives her energy and
happiness.
In the general or constitutional condition of the client, the client has adequate weight for
16
age. She has lost weight since hospitalization. However, she states that general state of
health is fine. She displays signs of weakness on exertion and ability to conduct usual
activities is impaired. She has no exercise tolerance. In the skin, no rashes or itching was
observed. On inspection, no pigmentation is seen. There skin is moist and smooth. She
has normal hair distribution and nail beds are pail but has brisk capillary refill. The client
has no breast lumps. No tenderness or swelling was observed. There was also no nipple
discharge.
For the HEENT system or Head, Eyes, Ears, Nose, Mouth, Throat system, no headaches
were complained. However, the client complained of dizziness that can be associated to
decrease in oxygen supply to the brain. Vision is normal and no nose bleeding was
reported. The client does not have colds, obstruction and discharge. She has 1 missing
front teeth and uses full dentures. No neck stiffness was observed and pain, tenderness
and masses in thyroid or other areas was not seen. The client is cold to touch and has
good skin turgor. She displayed absence of lesions or dryness in lips. Mucosa was pinkish
and gag reflex was intact. Uvula is in midline and no lymphadenopathy was observed.
There is pinkish mucosa and no lesions were present.
In the cardiovascular system, no heaves or thrills were inspected. A sternotomy scar is
seen in the midsternal about 3 centimeters. Point of maximal impulse is at the 6th
intercostal space, left of the midclavicular line. S1 is louder than S2 at the apex while S2
is louder than S1 at the base. Both S1 and S2 are regular. No extra heart sounds or
17
murmurs were heard. Peripheral pulses are strong and equal. Nails are pale but has brisk
capillary refill. No nail clubbing was observed. Hematoma is seen in Left lower arm and
Right upper arm.precordial pain, substernal distress, palpitations, syncope was not
observed. There was dyspnea on exertion and client has 2-pillow orthopnea. There was
no nocturnal paroxysmal dyspnea, edema and cyanosis. No hypertension, heart murmurs,
varicosities, phlebitis or claudication were assessed.
In the respiratory system, no pain was reported. Shortness of breath is on exertion and no
wheezing or stridor was heard on auscultation. There was no hemoptysis, respiratory
infections, tuberculosis (or exposure to tuberculosis), fever or night sweats. In the
gastrointestinal system, the client has decreased appetite. She does not experience
dysphagia, indigestion, food idiosyncrasy, abdominal pain and heartburn. No nausea,
vomiting, hematemesis, jaundice, constipation, or diarrhea was reported. The client has
normal stools and no flatulence, hemorrhoids or recent changes in bowel habits was
reported.
In the genitourinary system, no urgency or frequency in urination was reported. There
was no dysuria, nocturia, polyuria or oliguria in the patient. However, hematuria was seen
on laboratory tests. There was no unusual color of urine, stones, infections and nephritis
observed. No hesitancy, change in size of stream, dribbling, acute retention or
incontinence, change in libido was reported. The client had menarche at the age of 11.
She has her menses every month and her last period was on August 1, 2010. No
18
dysmenorrhea, or vaginal discharge was reported. She has had 3 pregnancies and all are
alive. In the musculoskeletal system, no pain, swelling, redness or heat of muscles or
joints were reported. There was no limitation of motion. However, the client reports
muscular weakness on knees.
In the neurologic or psychiatric component, no convulsions, paralyses or tremors were
observed. The client experiences no difficulties with memory or speech, and there is no
sensory or motor disturbances. Client is not emotional and does not express depression.
She is however, anxious about condition.
In the allergic component, adverse reactions to drugs, food, insects, skin rashs are not
observed. There was however dizziness experienced after administration of Metorpolol
on the second day of ward duty. In the immunologic component, anemia is not present
and no adverse reactions to blood transfusion was reported. There is however a bleeding
tendency since the client is on Warfarin therapy. In the lymphatic system, local or general
lymph node enlargement or tenderness was absent. In the endocrine system, there is no
polydipsia or polyuria.
Laboratory Results. Diagnostic and laboratory results done to the patient together with
their indications are listed below. Significant results, their nursing implications and their
relation to the course of treatment will be discussed on the case analysis part of this
paper.
19
The chest x-ray done on August 8, 2010 was indicated to view the structures of the chest
(bones, heart, lungs) for any abnormalities. Also, the client was suspected of Pulmonary
Tuberculosis and Community-Acquired Pneumonia so this chest x-ray is to rule out or
confirm said conditions. It is also indicated for a definite diagnosis of cardiomegaly or
congestive heart failure in the patient and is done to reassess the patient's heart condition
(size, shape, structure). The chest x-ray revealed that there are fibrous and reticulonodular
opacities seen in the Unperfused Lung Segments. There is also associated superintraction
of the right hilar structure. The lungs are normoinsular and two prosthetic valves are
noted at the region of the mitral and aortic valves. There is prominence with the aortic
root as seen on lateral view.
Blood chemistry screen made on August 30, 2010 was indicated for the client because
she is diagnosed with congestion in the heart and is at risk for fluid, electrolyte or acid-
base imbalance. In addition, the functions of her kidneys and extent of damage of livers
and heart were assessed. Significant findings show that the client has decreased calcium
in the blood.
Complete Blood Count done on August 30, 2010 is indicated for the client to look for
signs of inflammation and infection and marker of anemia which can cause similar
symptoms as Congestive Heart Failure or may contribute to Congestive Heart Failure. No
abnormal results were seen. The client has adequate amount of blood components.
20
Prothrombin Time and Activated Partial Thromboplastin Time was assessed on August
30, 2010 to screens for coagulation deficiency of factors II, V, VII and X and monitor the
oral anticoagulant therapy (warfarin) of the patient. In addition, it tests for abnormalities
involving the coagulation proteins of the intrinsic pathyway. It is a routine screening of
coagulation disorders. It has been found out that the client has prolonged Activated
Partial Thromboplastin Time and Prothrombin.
Findings by the two-dimensional and doppler echocardiography done on September 1,
2010 was indicated for the client to determine systolic and diastolic left ventricular
performance, cardiac output (ejection fraction), and pulmonary artery and ventricular
filling pressures. It is also be used to identify performance of valves. It showed concentric
left ventricular hypertrophy with segmental wall motion abnormality and mildly
depressed overall systolic function. The aortic and mitral prosthetic valves have good
opening and closing. There is mild tricuspid regurgitation. The pulmonary artery pressure
is normal. Ejection fraction is 53% Teicholtz's and 47% Simpsons.
Electrocardiography is performed on September 2, 2010 to assess for ST-segment
elevated myocardial infarction after the episode of chest pain. It showed bradycardia with
45 beats per minute and no signs of myocardial infarction.
Holo-abdominal Ultrasound is performed on September 1, 2010 to view the peritoneal
cavity and identify possible problems that may be the cause of hematuria. Findings show
21
that there is non-specific calcifications which are likely parenchymal. In addition, fatty
infiltrations of the pancreas are present. Bilateral renal cysts were seen. There is normal
proximal and mid-abdominal aorta and para-aortic areas, spleen and urinary bladder.
Blood Culture Sensitivity Testing was made on August 31, 2010. It was indicated for the
client to identify if the client has Infective Endocarditis. Findings display that there is no
growth after 2 days of incubation.
22
DISCUSSION
Pathophysiology. Regardless of the precipitating event, the common mechanism of heart
failure is quite complex. Compensatory mechanisms exist on every level all the way to
organ interactions. When this compensatory mechanisms and adaptation are
ovelwhelmed, heart failure happens (MacIntyre, et. al, 2000). In this section, we focus on
the pathophysiological mechanisms that led to the presentation of signs and symptoms of
the client, their current treatment and identified nursing diagnosis. Figure 1 shows the
pathophysiology of the disease with the risk factors, medications, presenting signs and
symptoms and nursing diagnosis identified.
Porth (2007) discloses that due to the infiltration of group A beta-hemolytic streptococci,
antibodies in the body react to destroy the bacteria simultaneously causing acute
inflammation to the heart. Rheumatic heart disease has developed. During the acute
inflammatory stage of the disease, the valvular structures become swollen. Small
vegetative lesions develop on the valve leaflets. It then proceeds to the development of
fibrous scar tissue which tends to contract and cause deformity of the valve leaflets and
shortening of the chordae tendinae. This results to Valvular Heart Disease.
Then, tricuspid, mitral and aortic insufficiency develops. During much of the systole, the
mitral valve is subjected to high pressure generated by the left ventricle as it pumps blood
to the systemic circulation. Increased preload occurs because the incomplete closure of
23
24
the mitral valve permits the regurgitation of blood from the left ventricle into the left
atrium (Porth, 2007). In addition, incomplete closure of the aortic valve also results in
increased preload as the left ventricle is forced to pump the entire diastolic volume
received from the left atrium and the regurgitant volume from the aorta. Increased
afterload occurs as there is increased pressure for the heart to generate the movement of
the increased volume from the left ventricle into the aorta. The increased volume work
causes increased pressure for the left ventricle to pump more blood. This eventually leads
to left ventricular hypertrophy (Porth, 2007).
As the workload increases, the walls of the chamber grow thicker, losing their elasticity
and eventually may lead to myocardial dysfunction and eventually myocardial failure
(Woods, et. al., 2010). This results to the failure of the heart to pump with as much force
as a healthy heart. Systolic dysfunction or failure is evident leading to altered systemic
perfusion and decrease in end-systolic volume. A decrease in end-systolic volume causes
a decrease in cardiac output which also contributes to the decrease perfusion of tissues in
the body. Alterations in systemic perfusion result in neuroendocrine activation. This
includes increase in sympathetic activity, activation of the renin-angiotensin-aldosterone
pathway and eventual decrease in oxygen supply in tissues.
Woods (2010) explains that increased activity of the sympathetic nervous system or the
renin-angiotensin-aldosterone system [RAAS] results in vasoconstriction of the small
arterioles. In the RAAS, vasoconstriction leads to increased peripheral vascular
25
resistance. The RAAS also increases aldosterone production thus enabling the retention
of sodium and water. This leads to an increase in plasma volume. Increased plasma
volume and decreased end systolic volume leads to increased venous pressure tpo the
lungs. This increase in hydrostatic pressure causes an increase in the rate of filtration of
fluid out of the capillaries and into the interstitial compartment (Woods, 2010). As a
result, the lungs fill with fluid, a condition called, pulmonary edema and eventually
pulmonary congestion.
On the other hand, increased activity of the systemic nervous system is caused by the
release of epinephrine and norepinephrine (Porth, 2007). The purpose of this initial
response is to increase heart rate and contractility and support the failing myocardium.
Sympathetic stimulation causes peripheral vasoconstriction. Peripheral vasoconstriction
may cause capillary endothelial damage.
Decreased oxygen supply in tissues is detrimental because if oxygen delivery to cells is
insufficient for the demand, prolonged compensatory mechanisms can lead to cell death
(Hobler & Karey, 1973). As seen in Figure 1, there is decreased oxygen supply to the
myocardium, brain, gastrointestinal tract and liver. Decreased oxygen supply to the liver
predisposes it to liver dysfunction. With decreased oxygen, the gastrointestinal tract
increases acid production, in the course of time, leading to the development of superficial
mucosal lesions in the stomach and duodenum.
26
Decreased perfusion to the tissues and eventual decrease in oxygen supply causes
increased myocardial workload as it attempts to compensate for the reduction (Smeltzer
& Bare, 2010). Eventually, compensatory mechanisms fail and even the myocardium
experiences a decrease in oxygen supply (Porth, 2007). This decreases oxygen supply to
the brain and induces decreased oxygen supply in the blood. When this happens, the heart
muscle must use alternative, less efficient forms of fuel so that it can perform its function
of pumping blood to the body or commonly called anaerobic metabolism (Porth, 2007).
The by-product of using this less efficient fuel is a compound called lactic acid that builds
up in the muscle and causes chest pain.
Case Analysis. B. A. is diagnosed with Congestive Heart Failure Functional
Classification II due to easy fatigability in doing ordinary activities like walking. She is
only able to walk 3 flights of stairs and experiences shortness of breath after walking to
and from an area 1 meter away. Congestive Heart Failure in the client developed as a
complication of her Valvular Heart Disease diagnosed in 2004 secondary to Rheumatic
Heart Disease which was diagnosed in the client in the 1980s. B. A. underwent prosthetic
valve replacement in 2004.
Valvular Heart Disease is one of the most common causes of heart failure. It is “a
common form of heart disease that present with disorders of the heart valves. Most
disorders are a consequence of rheumatic heart disease” (Woods, et. al., 2010). Cardiac
damage from Rheumatic Heart Disease results from reacting antibodies that causes acute
27
inflammation of the heart. It damages valve leaflets resulting to Valvular Heart Disease
(Porth, 2007). Heart valves are destroyed when the valvular leaflets and chordae tendinae
become fibrous causing the two commisures to close and the chordae tendinae to shorten
causing valvular Heart disease (Woods, et. al., 2010).
Rheumatic Heart Disease is a serious heart condition that follows infection with a
bacterium called Group A Beta-Hemolytic Streptococcus (Steer & Carapetis, 2009).
Zabriskie (1985) discovered that risk factors for developing infection leading to
Rheumatic Heart Disease include overcrowding, poor hygiene, lack of access to medical
services and living in rural areas. As seen in Figure 1, the client presented with the
following risk factors which led to the development of Rheumatic Heart Disease.
However, many other risk factors may contribute to the the development of a cardiac
failure. Woods (2010) lists the risk factors for developing cardiovascular diseases which
include a “family history of heart disease, hypertension, male sex, cigarette smoking,
overweight, high levels of blood fats, diabetes mellitus, physical inactivity and
pychological stress”. The risk factors that may have contributed to the client's disease
include a family history of cardiac diseases and eating large amounts of salt and high fat
foods.
Assessment on the status of the client's health perception and management, psychosocial,
perception, reproductive, nutrition, elimination, rest and activity and oxygenation was
28
clustered.
Oxygenation. The client has varied periods of fatigue and strength. Vital signs are
as follows - respiratory rate is 30 breaths per minute, blood pressure is at 90/60 mmHg,
heart rate is at 45 beats per minute and temperature is 36.1°C. The client has slow heart
rate which may be caused by the intake of maintenance drug which is metoprolol.
B. A. is nonalcoholic and nonhypertensive. During the hospital rotation, the client
experienced chest pain with a grade of 4, radiating to back and persisting after 10
minutes. She also complained of dizziness or light-headedness. This can be caused by
decreased circulation of oxygen to the brain because of increased cardiac workload.
In supine position and flat on bed, B. A. claims that she has difficulty breathing and feels
that she is “drowning”. She is on moderate high back rest and requires 2 pillow to be able
to sleep comfortably without difficulty of breathing. In other words, the client has 2-
pillow orthopnea which is caused by pulmonary congestion in the client. She is able to
climb 3 flights of stairs before being out of breath. These may be reflections of the
decreased cardiac output of the heart caused by depressed systolic functioning.
The client does not display signs of pallor or cyanosis. She does not have difficulty
breathing or use accessory muscles. No nasal flaring was observed. The inspiratory and
expiratory ratio is 2 is to 1. The anterior-posterior lateral ratio is 1 is to 2. She does not
29
display signs of a barrel, pigeon or funnel chest. Her chest is symmetric and there is
symmetrical chest expansion. She has normal breath sounds and no adventitious breath
souds were heard.
During cardiac assessment, a sternotomy scar is seen in the midsternal about 3
centimeters. Point of maximal impulse is at the 6 th intercostal space, left of the
midclavicular line.No extra heart sounds or murmurs were heard. Peripheral pulses are
strong and equal. Nails are pale but has brisk capillary refill. No nail clubbing was
observed. Hematoma is seen in Left lower arm and Right upper arm.
Rest and Activity. B. A. claims that she has less energy than before to do her daily
activities. She has refrained from washing clothes and carrying heavy things since she
easily experiences shortness of breath. She is unable to do household chores as before
and go to the market without assistance of a family member. She requires the supervision
of a family member because she easily gets tired and experience shortness of breath. Her
level of self-care is Level 2.
On physical assessment, the client displayed shortness of breath upon exertion. She is
able to walk at a distance of about 3 meters with a slow but steady gait. There were no
crepitations or joint pains. However, there is muscle weakness on knees. Muscle strength
is at 4/5 on both lower limbs and 5/5 on the upper limbs.
30
Elimination. The client moves her bowels everyday. She complains that there are
times that she cannot defecate easily because she finds it difficult to stop breathing and
expel her feces forcefully. She described her feces as brown, soft and broken into small
pieces about 3 cm in diameter. Also, B. A. urinates about 3 times per day, without
difficulty or pain. She describes her urine as clear, yellow in color and without any foul
odor. She measures her urine to be about 250 ml or one half of a mineral bottle.
On physical assessment, no periorbital edema or generalized edema was observed. Skin is
smooth and cold to touch. No visible pulsations were inspected on the abdomen. On
asucultation, normoactive bowel sounds at 3 per minute were heard. No enlarged organ
was palpated. Costovertebral angle tenderness was not assessed due to complaints of
back pain.
Nutrition. Every day, B. A. eats about three meals per day which are cooked at
home, with the occasional snack in between meals. Because she has been cautioned from
eating fatty and salty foods, she seldom eats pork. In addition, it was explained to her that
green leafy vegetables affect the mechanism of action of one of her medications which is
Warfarin so she also refrains eating said vegetables. The food she eats varies from
vegetables, fruits, fish and chicken. The client claims that she eats a lot of vegetables and
fruits, and leaves behind the fatty portion of the meat she eats. Also, she only eats small
portions of the meat, especially if it is salty, and eats about one cup of rice per meal. She
dislikes other fatty, salty and sweet foods except chicharon and fries though she has
31
regulated her intake of both to at least once every two months. She enjoys vegetables and
fruits and seldom use condiments except vinegar.
Her fluid intake is about 3 glasses a day or sometimes one 500 ml bottle of water per day.
She remembers that when she was in the hospital, her fluid intake was regulated at 1 Liter
per day and she has adapted this at home. The client verbalized a noticeable decrease in
weight since she was diagnosed with heart disease. At the time of the interview, the
client also reported a decrease in appetite, although there is no problem in eating despite
having all her teeth replaced with dentures. When she gets sick, she gets well rather
quickly, and her only previous skin problem was hematoma, which she explained was
caused by her medication (Warfarin).
On physical assessment, the client looks according to age, fairly-nourished, fairly
developed, and an ectomorph. Tongue is in midline and no perforation or lesions were
observed. There is 1 missing front tooth and the client has full dentures. Trachea is in
midline and there is thyroid is nontender and nonpalpable. Normoactive bowel sounds are
heard on ausculation. The client has a flabby and soft abdomen. A scar is seen on the
epigastric and right lower quadrant about 2 centimeters long. Her height is 5'2 inches
high and she displays constant weight at 51 kilograms.
Cognitive. For B. A., a healthy person is one who rarely gets sick. To maintain her
health, she drinks her medicines regularly and takes periods of rest. According to the
32
client, she thinks the reason she felt ill was because she does the household chores even
when she was supposed to rest and she carries her grandson around which led to
shortness of breath and fatigue. On physical assessment, the client was conscious,
coherent and oriented to time, person and place. No signs of distress was observed.
Normal range of motion of the neck is observed and there was no neck rigidity. The client
can walk has a slow but steady gait.
Perception. B. A. has no hearing problem and does not use a hearing aid.
However, she does have a visual problem. She uses glasses with grade of 300. Her
memory is still intact, and she learns best by actual performance of a task and reading.
The client does not feel pain in any part of her body though she sometimes feels chest
heaviness and pain which she relieves by ventilating herself with electric fan and taking a
rest.
On physical assessment, the client's head is normocephalic and no masses or lesions were
observed. The client displayed symmetrical lids and absence of ptosis or swelling.
Conjunctiva is pinkish and no lesions were observed. Sclera is anicteric and cornea and
lens are clear. Both pupils of the left and right eye are equal, 3 millimeter in size and has
brisk and uniform reaction to light and accommodation. There is uniform convergence of
the eyes and intact extraocular activity. The client is nearsighted with a grade of 300. The
client's ears are normoset and nontender. There was no lymphadenopathy. Discharge or
impacted cerumen was not observed. There is symmetrical gross hearing capacity and no
33
hearing deficit.
Psychosocial. The client does not want to be a burden to her family and perceives
herself as “weak”. However, she has already accepted this fact and coped with the
weakness in her own way. She does not perceive any difference in her physique except
weight loss. She is easily cries and becomes tensed or nervous though this has been
lessened once she was admitted in the hospital. B. A. feels anxious about her condition
but she believes that everything will be alright in the end more so because she feels
relatively fine. Whenever she feels tensed, she talks to her significant others or pray the
rosary. She usually feels nervous whenever there are arguments in the family but this has
been lessened according to her significant other out of consideration for the client. She
sits and calms herself by praying and talking with the involved parties to relieve her
tension. She coped with her condition by changing her lifestyle for the better, avoiding
foods that are contraindicated to her condition and taking rest periods. However, she does
feel bothered about the expenses incurred by her children for her medical condition.
The family of B. A. is extended and patriarchal, with B. A. making decisions regarding
health actions and daily expenditures. She lives with her husband, her three children, a
daughter-in-law and a grandson. Her husband is a contractual painter of houses and
automobiles and their usual income varies from P3000-P5000 per month. Their children
always contributes to the medical expenses of the client. Currently, they feel worried
about their mother's condition and contributes to any way they can to alleviate her
34
condition. The usual problem of the family involves the drinking habit of the client's
husband and financial problems. They usually resolve it by conversations with the family.
The client's only wish is to see her children and her grandchildren grow up. She does not
fear death but she wishes that she will live longer because of her family. God, family and
health are important for B. A. She claims that her religion helps her get through her
condition because it gives her energy and happiness. On physical assessment, the client
displayed signs of anxiety through silent pauses and different facial expressions.
Respiration was not increased on narrations.
Reproductive. B. A. stated that she and her husband has not engaged in sexual
intercourse in recent years. She claims that this is because they are already old. She has
used pills as a family planning method from 1989 to 2002 but has since stopped using
them though no problems were encountered upon their use. The client had her first
menstrual period when she was 11 years old. She describes her menstrual period to be
regular and usually lasts from 3 to 4 days. She usually consumes 3 pads in a day and has
never experienced dysmennorhea. Her last menstruation was on August 1, 2010. B. A. is
a G3P3 mother and has no history of complications at birth. On physical assessment, the
client displayed symmetrical breasts. No lesions, masses or dimpling were observed.
There was no discharge from the nipple.
Complications of heart failure are varied. However, in this discussion, we will focus on
35
the actual and suspected complications in the patient during course in the ward.
One of the chief complaint of the client was fever. The client has increased risk for
infection due to prosthetic valve replacement in 2004. Because of this, Infective
Endocarditis was presumed to be the cause of fever. In nursing literature, it has been
stated by a study that prosthetic valve replacement increases risk for infective
endocarditis (Okies, et. al, 1971).
Another chief complaint was chest pain or angina. The client presenting with chest pain is
at increased risk for myocardial infarction. This is typical if severe, prolonged chest
discomfort is present. The onset of chest discomfort must be abrupt and lasts longer than
15 to 30 minutes. The comfort is usually midsternal, “crushing”, or squeezing and may
radiate to the arms, shoulders, back, neck or jaw (Woods, et. al, 2010). This list of
symptoms were experienced by the client on the hospital rotation.
Community-acquired pneumonia was considered because of the presenting symptoms of
the client similar to pneumonia. These includes pleuritic chest pain, shortness of breath,
raised respiratory rate and fever of 38°C (Porth, 2007). Pulmonary tuberculosis was also
considered because of similar symptoms of wasy fatigability, anorexia, weight loss,
dyspnea and orthopnea (Porth, 2007).
Initial laboratory results were made to eliminate possibilities of Infective Endocarditis,
36
Community-Acquired Pneumonia and Pulmonary Tuberculosis, find out other
complications present in the patient and determine the cause of presenting symptoms.
Infective Endocarditis is ruled out when the blood culture findings were negative.
Myocardial Infarction which was suspected on the onset of chest pain was also negative
as the electrocardiography reports normal heart structure with bradycardia at a rate of 45
beats per minute.
Pneumonia and pulmonary tuberculosis were ruled out as chest x-ray findings were
negative of infiltrates or cavities in the upper lungs.
Other significant laboratory findings include the presence of hematuria which may be
caused by suspected capillary endothelial damage caused by vasonconstriction or the
presence of bilateral renal cysts seen on ultrasound. Fatty Infiltration or streaks in
pancreas were also observed on ultrasound and the high intake of cholesterol and salt are
one of the many factors suspected to have caused this. In the echocardipgraphy of the
client, the presence of mild tricuspid regurgitation was observed which may have been
caused by the valvular heart disease present in client before. It is important to note that
only the mitral and aortic valves were replaced in surgery before. Ejection Fraction with
53% Teicholtz’s, 47% Simpson’s and heart rate of 45 beats per min seen in
electrocardiography reflects the decreased cardiac output of the client caused by mildly
depressed overall systolic functioning as seen also in the echocardiography. The presence
37
of minimal Albumin in urine seen in the urinalysis is suspected to have come from
possible liver damage or caused by the damage on the capillary endothelial damage.
As of discharge day, the client has not presented signs of peripheral congestion like
edema, its most presenting sign. However, this only emphasizes the importance of
monitoring as said complication is not only probable but is almost the norm for
congestive heart failure.
Treatment. Despite the advances in heart failure treatment, a systematic approach to
acute heart failure has only recently been emphasized, as reflected in the updated
American College of Cardiology/American Heart Association heart failure guidelines
from 2009. These guidelines recommend hospitalization for acute heart failure if the
severe decompensated heart failure (low blood pressure, renal dysfunction, altered
mentation), dyspnea at rest, hemodynamically significant arrhythmia or acute coronary
syndrome is present (Hunt, et. al, 2009).
The goal is to continue the diagnostic and therapeutic processes started. Patient’s volume
and hemodynamic status is optimized using careful clinical monitoring and the heart
failure medical regimen is optimized. Heart failure education, behavior modification, and
exercise and diet recommendation are made. The patient must be on a stable oral regimen
for at least 24 hours before discharge. During the period of hospitalization of the client,
B. A underwent a series of treatment for management of heart failure and its
38
complications. Both medical and nursing care are taken into account.
Medical Plan of Care. Heart failure treatment has both pharmacologic and
nonpharmacologic therapy prescribed by the doctor. This is used to maintain the client at
her most stable condition and prevent complications from happening.
Pharmacologic Therapy. Smeltzer & Bare, et. al. (2010) enumerate the
medications usually prescribed to heart failure patients. These include angiotensin-
converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta-
adrenergic blocking agents, diuretics, digitalis and calcium channel blockers. Beta-
adrenergic blocking agents given to patients with heart failure have been recommended
for patient swith asymptomatic systolic dysfunction. ACE inhibitors promote vasodilation
and diuresis by decreasing afterload and preload, thus reducing the workload of the heart
(Smeltzer & Bare, et. al., 2010) . However, they are not being given to client because
hypotension is present in the client and ACE Inhibitors given with Beta blockers which
are the client's maintenance drugs further decrease blood pressure and heart rate. In
contrast, ARBs, though having the same mechanism of action as ACE inhibitors, does not
produce cough which usually discomforts heart failure patients (Smeltzer & Bare, et. al.,
2010). This drug was also not prescribed to the patient with the same reason as ACE
Inhibitor.
On the other hand, diuretics are prescribed to remove extracellular fluid by increasing the
39
rate of urine produced in patients with signs and symptoms of overload (Smeltzer &
Bare, et. al., 2010). However, this was not prescribed to the client because there were no
symptoms of fluid overload or retention like edema. Conversely, digitalis is used to
increase the force of myocardial contraction and slow conduction through the
atrioventricular mode (Smeltzer & Bare, et. al., 2010). However, this drug was also not
given to the client because it increases the risk for digitalis toxicity. Also, when a person
is hypokalemic, digitalis absorption is faster and there is increased risk for toxicity.
Calcium channel blockers cause vasodilation, reducing systemic vascular resistance
(Smeltzer & Bare, et. al., 2010). However, they were not prescribed to client because it is
contraindicated in patients with systolic heart failure. Conversely, anticoagulants are
prescribed to client especially if client has history of atrial fibrillation or a
thromboembolic event. It lyses clots or possible clots before it even enters the cardiac
community (Smeltzer & Bare, et. al., 2010).
Medications, their indications and contraindications, nursing implications and
pharmacologic actions of the drugs prescribed are enumerated below.
Beta-blocker. Metropolol belongs to the class of beta1-selective adrenergic
blocker (Karch, 2010). Beta-adrenergic blocking agents have been found to reduce
mortalilty and morbidity in patients with heart failure by reducing the adverse effects
from the constant stimulation of the sympathetic nervous system (Smeltzer & Bare,et. al.
2010). According to Deglin & Vallerand (2009), metoprolol's pharmacologic action is to
40
competitively block beta-adrenergic receptors in the heart and juxtaglomerular apparatus,
decreasing the influence of the sympathetic nervous system on these tissues and the
excitability of the heart, decreasing cardiac output and the release of renin, and lowering
blood pressure. It also acts in the Central Nervous System to reduce sympathetic outflow
and vasoconstrictor tone. This was indicated for the client due to high probability of
increased blood pressure. Metoprolol is a maintenance drug for the client after prosthetic
valve replacement.
Some contraindications to administration of metoprolol include cardiogenic shock, sinus
bradycardia (HR less than 45 beats/min) and heart failure. Things to watch out for
include sudden decrease in blood pressure, heart rate, dizziness, shortness of breath and
blurred vision. Spratto & Woods (2008) outlines that nursing implications in giving this
drug include telling client to report difficulty breathing, night cough, swelling of
extremities, slow pulse, confusion, depression, rash, fever, sore throat and assessing
before and after administration of drug.
Anticoagulant. Warfarin is a cardiac drug that belongs to the class of oral
anticoagulants (Karch, 2010). Its pharmacologic action is to interfere with the hepatic
synthesis of vitamin K-dependent clotting factors (factors II, prothrombin, VII, IX, and
X), resulting in their eventual depletion and prolongation of clotting times (Deglin &
Vallerand, 2009). This was indicated for the client as a measure of prevention of
thrombus formation and embolization after prosthetic valve placement done in 2004. It
41
has been, since then, a maintenance drug used by the client in combination with
metoprolol. Karch (2010) adds that some contraindications to administration of warfarin
is uncontrolled bleeding because warfarin increases the probability of bleeding. It is also
contraindicated to open wounds, active ulcer disease, severe liver or kidney disease,
uncontrolled hypertension and recent brain, eye, or spinal cord injury or surgery. It must
be used with caution in patients with malignancy and women with childbearing potential.
The main desired action on the client includes the lyse of possible clots and
treatment to prevent formation of emboli or thrombus. Spratto & Woods (2008) state that
one of the nursing implications in giving this drug is watching out for signs of bleeding.
The common signs, onset or worsening of bleeding include the occurrence of petechiae,
ecchymoses, or hematomas, conjuctival hemorrhages, bleeding gums, hypotension,
tahycardia, dizziness epotaxis, hemoptysis, abdominal distention, headache, blurred
vision and mental status changes (Smeltzer& Bare,et. al. 2010). Other nursing
implications include reminding patient to not double doses and have limited intake of
Vitamin K (Karch, 2010).
Proton-pump inhibitor. Omeprazole belongs to the class of the proton pump
inhibitors or the anti-secretory drugs (Karch, 2010). According to Deglin & Vallerand
(2009), omeprazole's pharmacologic action is suppressing gastric acid secretion by
specific inhibition of the hydrogen-potassium ATPase enzyme system at the
secretory surface of the gastric parietal cells. It blocks the final step of acid
42
production. Karch (2010) adds that the medication is usually given to the
client with heart failure for the management of duodenal ulcers and eventual prevention
of bleeding from the upper gastrointestinal tract in people who have life-threatening
illnesses. Some contraindications to watch out for include hypersensitivity to omeprazole
or its components. Caution is advised for patients with liver disease wherein dosage
reduction may be necessary and in pregnancy, lactation, or children as safety has not yet
been established.
The main desired action on the client includes prevention of gastrointestinal bleeding and
hypersecretion caused by ulcers or leisions in the gastrointestinal tract. Spratto & Woods
(2008) reminds nurses that this drug should be administered before meals because
absorption of the drug is compromised if introduced to the body with meals.
It is also important to caution patient to swallow capsules whole and not to
open, chew, or crush them.Adverse effects like severe headache, worsening of
symptoms, fever, chills must be assessed after giving drug.
Third-generation cephalosporin. Ceftriaxone belongs to the class of third-
generation cephalosphorins (Karch, 2010). Its pharmacologic action is inhibiting the
synthesis of bacterial cell wall, causing cell death, according to Deglin & Vallerand
(2009). This was indicated for the client due to suspected infective endocarditis.
Contraindications to ceftriaxone include allergy to acetaminophen. It must be used with
caution in patients with impaired hepatic function and chronic alcoholism.
43
The main desired action on the client includes prevention or treatment for possible
endocarditis or pneumonia. Spratto & Woods (2008) outlines adds that the nursing
implications in giving this drug include assessing patient for infection at beginning of and
throughout therapy, observing patient for signs and symptoms of anaphylaxis like rash,
pruritus, laryngeal edema and wheezing.
Antipyretic, Analgesic. Paracetamol belongs to the class of antipyretics and
analgesics. Its pharmacologic action is reducing fever by acting directly on the
hypothalamic heat-regulating center to cause vasodilation and sweating, which helps
dissipate heat (Karch, 2010). This was indicated for the client due to fever on admission
to reduce fever and provide temporary relief of minor aches and pains (Deglin &
Vallerand, 2009). Some contraindications to watch out for include allergy to
acetaminophen. Spratto & Woods (2008) enumerates the nursing implications in giving
this drug and these are administering thedrug with food if GI upset occurs and
discontinuing the drugs if hypersensitivity reactions occur. Also, constant assessment of
the client's temperature and montoring for signs of infection are undertaken.
Treatment Modality. Physicians prescribe two additional therapy for the client
with heart failure, namely, Nutritional therapy and Supplemental Oyxgen therapy.
Nutritional Therapy. Cardiac diet consists of low-sodium and restricted
cholesterol diet. In addition, avoidance of drinking excessive amounts of fluid are
44
asually recommended. Dietary restriction on sodium reduces fluid retention and due to
symptoms of peripheral and pulmonary congestion. Smeltzer & Bare (2010) stated that
the significance of the sodium-restricted diet is to decrease the amount of blood volume
which decreased myocardial workload. The computed diet for the client is based on a 1,
800 calorie diet which is recommended for the client. Total Calorie Requirement is 1800
kilocalories per day. Carbohydrate is limited to 270 grams per day while Protein is
limited to 50 g per day. Fats, on the other hand, are restricted.
Supplemental Oxygen Therapy. Oxygen therapy becomes necessary as heart
failure progresses. This is based on the degree of congestion or hypoxia (Smeltzer &
Bare, 2010). The client is hooked to a nasal cannula with pressure of 4 LPN.
Nursing Plan of Care. Care of nurses are shown to have increase the management of a
patient with heart failure. Thus, it is important to plan care efficiently.
Problem Identification. Figure 2 shows the concept map for the different problems
identified in the patient. The following nursing problems were identified on August 31,
2010.
First problem identified is anxiety. Anxiety (mild) is defined by Doenges (2004) as “a
vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the
source often nonspecific or unknown to the individual)or a feeling of apprehension
45
46
caused by anticipation of danger. It is an altering signal that warns of impending danger
and enables the individual to take measures to deal with threat”. Subjective cues that
identify anxiety include verbalization of nervousness, “Madali talaga akong kabahan”,
and anxiety about prognosis of disease, “Natatakot talaga akong mawala kasi gusto ko
pa sanang makitang lumaki ang apo ko”. Objective cues include changing facial
expression, pauses when reflecting, sudden dizziness or difficulty of breathing.
Next problem identified is Imbalanced Nutrition: Less than Body requirements. It is
defined as the “intake of nutrients insufficient to meet metabolic needs” (Doenges,
2004). Subjective cues for this diagnosis include “feeling of fullness”, decreased appetite
and minimal consumption of meals. Objective cues include the weight loss from 55
kilograms to 51 kilograms. B. A.'s height is 5'2 inches. The client is prescribed with a
cardiac diet consisting of low salt and restricted fat. Total calorie intake recommended is
1800 kilocalories per day. Carbohydrates to be consumed are at 270 grams per day and
protein is recommended to have at least 50 kilograms per day.
Risk for Ineffective Myocardial and Cerebral Tissue Perfusion is another nursing problem
identified and it is defined as “an increased risk for decreasing in oxygen resulting in the
failure to nourish the tissues at the capillary level” (Doenges, 2004). Subjective cues
include chest pain with a grade of 4, radiating to back and persisting to more than 10
minutes. Dizziness and chest heaviness were also reported. Objective cues include vital
signs of 90/60 and heart rate of 45 beats per minute. Pallor and pale nail beds are other
47
signs of ineffective tissue perfusion. The client is on oxygen therapy through a nasal
cannula with 4 LPN as needed.
A nursing diagnosis identified is Ineffective Breathing Pattern which is defined by
Doenges (2004) as “inspiration and/or expiration that does not provide adequate
ventilation”. Subjective cues for identifying the problem include shortness of breath on
exertion. Client has 2 pillow orthopnea and complains of easy fatigability. She reports
feelings of “drowning” on supine position so she is placeed on Moderate High Back Rest.
Objective cues include use of accessory muscles on exertion with a respiratory rate of 30
respirations per minute. There is normal hemoglobin count and left ventricular
hypertrophy is identified in the electrocardiogram.
Risk for Infection is defined as “at increased risk for being invaded by pathogenic
organisms” (Deonges, 2004). This risk for infection is actually due to the client's former
surery which is prosthetic valve replacement in mitral and aortic valves. She is
predisposed to infective endocarditis. Subjective cues include history of surgical
procedure in open heart surgery, prosthetic mitral and aortic valve replacement in 2004.
She also a known cardiac patient due to other diseased like Valvular Heart Disease and
Rheumatic Fever. Objective cues include the onset of fever with a temperature of 35.8
°C. Client is medicated with Ceftriaxone and there is also a presence of heplock at the left
arm. The client's WBC values are normal and blood culture shows negative results after 2
days of incubation.
48
Another nursing problem identified is Decreased Cardiac Output. It is defined by
Doenges (2004) as “inadequate blood pumped by the heart to meet the metabolic
demands of the body”. Decreased Cardiac Output is also part of the pathophysiologic
diagram because it is part of the progression of the disease. Subjective cues include
history of cardiac problems as a patient of Valvular Heart Disease and Rheumatic Heart
Disease. The client is fond of fatty and salty foods. She does not exercise though she
walks to and from the market. Vital signs are monitored every 4 hours. There is easy
fatigability and client can walk only 3 flights of stairs. Potassium content in blood is 3.9
mmol/L. Prothrombin time is 22.3 secs and Partial Thromboplastin Time is 56.8 secs.
There is shortness of breath on exertion.
Activity Intolerance is defined as “insufficient physiological or psychological energy to
endure or complete required or desired daily activities” (Doenges, 2004). Manifestations
of the disease is similar to Decreased Cardiac Output. However, activity intolerance
focuses more on the activities that the client can undertake. The client is ambulatory and
always does things for herself. However, ordinary physical activities like walking are an
effort to her and companions are needed to prevent syncope.
PC: Bleeding is a collaborative problem that looks out or monitors potential
complications of bleeding in the client. The client has upper gastrointestinal bleeding
though she does not complain of stomach pain. The client is on warfarin therapy that
takes increases risk for bleeding. The client was advised to avoid green leafy vegetables
49
because they counteract the mechanism of warfarin. Objective signs include hematuria,
hematoma and left lower arm and right upper arm.
PC: Pulmonary Embolism is collaborative problem that monitors probability of potentila
pulmonary embolism present in client. Because of prosthetic valve replacement in 2004,
the client is monitored for pulmonary embolism which can lead to cardiac death. Cues
include blood pressure of 90/60 and a heart rate 0f 49 beats per minute. The client is
ambulatory and experiences chest pain on exertion. She is on moderate high back rest and
on warfarin therapy. Prothrombin time is 22.3 secs and Partial Thromboplastin Time is
56.8 secs.
Problem Prioritization. Figure 3 shows the pyramid of prioritization of the
nursing diagnosis. Maslow's Hierarchy of needs is utilized though in some circumstances,
the intensity of symptoms and underlying causes were taken into account first before
their recommended position in Maslow's concept. As can be seen, Decreaed Cardiac
Output emerged as the priority problem because of the presenting symptoms such as very
slow heart rate of 45 beats per minute and low blood pressure for age at 90/60. Also,
ejection fraction is slightly lower than normal. These are needs that prompted addressing
the problem first. Also, if Decreased Cardiac Output has been resolved, other problems
like Activity Intolerance may not be needed to be intervened on.
50
51
Nursing Interventions. In the formulation and implemenation of interventions in
the nursing care plan, the most presenting signs and symptoms were given priority first
before the conceptualized care plan. Nursing Interventions Classifications (2001) was
also utilized to plan care.
On the day following assessment, Decreased Cardiac Output related to decreased end-
systolic volume was addressed first. In the succeeding days, evaluation of care was still
continued. The goal for this problem is that by the end of the shift, Mrs. Aquino will
demonstrate adequate cardiac output as evidenced by normal blood pressure and pulse
rate and rhythm.
One of the Nursing Interventions Classification used was Hemodynamic Regulation
[4150] which is defined as “optimization of heart rate, preload, afterload and
contractility” (Johnson, et. al, 2001). This was chosen to address the problems of
decreased heart rate, increased preload and afterload and reduced contractility of the
patient.
During nursing intervention, the student nurse has (1) monitored hemodynamic stability
indicators (vital signs, peripheral pulses, capillary refill time, pallor) and compared with
baseline. The hemodynamic stability indicators are the baseline to indicate the status of
cardiac output (Smeltzer, et. al., 2010). She has (2) monitored for peripheral edema,
52
jugular vein distention and S3 and S4 heart sounds. As peripheral edema, jugular vein
distention, extra heart sounds indicate progressing congestion (Smeltzer, et. al., 2010).
Another Nursing Intervention Classification used was Cardiac Care [4040] which is
defined as “limitation of complication resulting from an imbalance between myocardial
oxygen supply and demand for a patient with symptoms of impaired cardiac function”.
This classification was used to decrease demands particularly of oxygen on the heart and
alleviate symptoms of impaired cardiac function.
During nursing intervention, the student nurse has (1) placed Mrs. Aquino in preferred
position of comfort or in semi-Fowler's position as this position decreases the workload
of breathing, and venous return and preload to the heart (Kozier & Erb, et. al., 2010). She
was able to (2) teach Mrs. Aquino conscious breathing technique. Stress responses and
attacks contributing to myocardial oxygen demand can be reduced by relaxation
techniques (Kozier & Erb, et. al., 2010). (3) The promotion of a calm and restful
environment was done to reduce myocardial oxygen demand that can be achieved by
allowing for rest and relaxation periods (Kozier & Erb, et. al., 2010). The student nurse
has (4) planned activity providing rest periods for the Mrs. Aquino to conserve energy
and reduce cardiac workload (Smeltzer, et. al., 2010). She has also been able to (5) stress
the importance of avoiding straining/ bearing down, especially during defecation as
Valsalva maneuver causes vagal stimulation, reducing heart rate (bradycardia), which
53
may be followed by rebound tachycardia, both of which impairs cardiac output (Smeltzer,
et. al, 2010).
The next Nursing Intervention Classification used is Cardiac Care: Rehabilitative [4046]
which is defined as the “promotion of maximum functional activity level for a patient
who has experienced an episode of impaired cardiac function that resulted from an
imbalance between myocardial oxygen supply and demand” (Johnson, et. al., 2001). This
classification was chosen to increase patient's independence and assess and recommend
possible activity levels for the patient.
During nursing intervention, the student nurse was able to (1) instruct the patient and
family on appropriate prescribed medications as increase in knowledge especially during
home management decreases number of rehospitalizations (Paul, 2008). The student
nurse also (2) instructed the patient and family on cardiac risk factors and possible
modifications. Risk factors like high cholesterol and sodium intake are lifestyle problems
that can be addressed with proper knowledge (Paul, 2008). The student nurse (3)
instructed the patient and family on any lifting/weight limitations, as appropriate as this
increases demand for oxygen compromising the transport to different tissues in the body
(Kozier & Erb, et. al., 2010). The student nurse also (4) explained the importance of a
cardiac diet, as required. High sodium intake causes water retention (Porth, 2007).
54
The last Nursing Interventions Classification used for the problem Decreased Cardiac
Output related to decreased end-systolic volume is Fluid Monitoring [4130]. Johnson
(2001) defines it as a “collection and analysis of patient to regulate fluid balance”. This
classification was chosen because of the importance of monitoring signs of further
complications of congestion in the client.
During nursing intervention, the student nurse was able to (2) monitor intake and output
of the client. Intake and output monitoring helps monitor presence of excess or deficient
fluid in the client (Kozier & Erb, et. al., 2010). The student nurse was also able to (1)
monitor weight and advise client to weigh daily at 8am as tolerated. Weighing checks for
possible increase in mass and fluid volume in the body undetected on the surface (Kozier
& Erb, et. al., 2010). This is important for the client to learn also as increase in weight is
a factor for reconsultation and possible rehospitalization once discharged (Paul, 2008).
On the second intervention day, Anxiety related to threat to or change in health status was
addressed. Activity Intolerance related to increased cardiac workload was intended to be
carried out on this day but was terminated. The problem Decreased Cardiac Output
related to decreased end-systolic volume was also reevaluated.
The goal of this nursing intervention is for the client to report that anxiety is reduced to
manageable level. One of the Nursing Interventions Classification in this diagnosis is
Anxiety Reduction [5820] which is defined as “minimizing apprehension, dread,
55
foreboding, or uneasiness related to an unidentified soure of anticipated danger”
(Johnson, et. al., 2001). This classification was chosen to decrease the client's
apprehension related to prognosis of disease. During nursing intervention, the student
nurse (1) provided factual information concerning diagnosis, treatment and prognosis.
Increased knowledge on prognosis of disease promotes understanding of diagnosis,
treatment and prognosis and compliance to treatment.
Another Nursing Intervention Classification used was Coping Enhancement [5230]
which is defined as “assisting a patient to adapt to perceived stressors, changes, or threats
which interfere with meeting life demands and roles” (Johnson, et. al., 2001). This
classification was chosen because it allows the nurse to identify possible stressors and at
the same time, allows the patient to reflect on self and trace possible sources of anxiety
and address them on her own. During nursing intervention, the student nurse was able to
(1) review extent of feelings of anxiety of clients as there is a need to know the extent of
disequilibrium and need for intervention to prevent or resolve the crisis (Doenges, 2006).
She was also able to (2) discuss indication and method of treatment as this promotes
active participation of client in therapeutic regimen (Doenges, 2006). She has taken (3)
note of expressions of indecision, dependence on others, and inability to manage own
activities of daily living. This may indicate need to lean on others for a time (Doenges,
2006). Last, she (5) assessed the presence of positive coping skillls/inner strengths e.g
(use of relaxation techniques, willingness to express feelings, use of support systems).
56
Past coping skills may be reused to relieve tension and preserve individual's sense of
control (Doenges, 2006).
The goal for Activity Intolerance related to increased cardiac workload is that the client
will be able to demonstrate sufficient energy to endure or complete required or desired
daily activities. One of the Nursing Intervention Classification of this problem is Activity
Therapy [4310] which is defined as “prescription of and assistance with specific physical
and cognitive, social, and spiritual activities to increase the range, frequency, or duration
of an individual's activity” (Johnson, et. al., 2010). This classification was chosen
because it addresses encompassingly the problem on the client's execution of activities
and on how nurses can increment these activities as appropriate.
During nursing intervention, the student nurse must be able to (1) determine the patient's
perception of causes of fatigue or activity intolerance. These perceptions may be
temporary or permanent, physical or psychological. Assessment of these perceptions
guides treatment (Doenges, 2006). She must be able to (2) assess the patient's level of
mobility through the 6-minute walk. This aids in defining what patient is capable of,
which is necessary before setting realistic goals (Doenges, 2006). She must be able to (3)
assess the patient's cardiopulmonary status before activity. Assessment before and after
activity provides for comparison on achieved level of activity tolerance (Doenges, 2006).
She has to (4) observe and document response to activities (walking, deep-breathing,
ROM). Assessment before and afer activity provides for comparison on achieved level of
57
activity tolerance (Doenges, 2006). She must be able to (5) establish guidelines and goals
of activity with the patient and caregiver. Motivation is enhanced if the patient
participates in goal setting (Doenges, 2006). (6) Progress activity gradually. This prevents
overexerting the heart and promotes attainment of short-range goals (Doenges, 2006).
Another Nursing Intervention Classification is Energy Mangement [0180] which is
defined as “regulating the use of energy to treat or prevent fatigue and optimize function”
(Johnson, et. al., 2001). This classification was chosen so that the client's easy fatigability
would be addressed thorough the regulation of energy. During intervention, the student
nurse was able to (1) assess the patient's schedule and allow rest periods between all
activities. Rest between activities provides time for energy conservation and recovery.
Heart rate recovery following activity is greatest at the beginning of a rest period
(Doenges, 2006). She was able to (2) assist with activities of daily living as indicated
though she allowed the client to do what she can do for herself. Caregivers need to
balance providing assistance with facilitating progressive endurance that will ultimately
enhance the patient's activity tolerance and self-esteem (Doenges, 2006). She was able to
(3) encourage verbalization of feelings regarding limitations. Acknowledgment that living
with activity intolerance is both physically and emotionally difficult aids coping
(Doenges, 2006).
On the third intervention day, Risk for Ineffective Myocardial and Cerebral Tissue
Perfusion related to increased cardiac workload was carried out. Even though the
58
problem has not yet been included in the nursing care plan, it warranted immediate
intervention as the presenting signs and symptoms were manifested.
Interventions for this problem included (1) monitoring for levels of consciousness,
dyspnea, dizziness, difficulty of breathing, (2) positioning to Moderate High Back rest on
preferred position, (3) raising side rails and (4) promoting clam and restful environment,
(5) clustering activities with caregiver to limit extreme activities, (6) instructing client to
report chest pain and (7) ensuring rest periods.
Evaluation. Evaluation is always carried out after intervention and reevaluated on
the succeeding days. It is used to determine whether the objectives and outcome criteria
were met.
For the problem Decreased Cardiac Output related to decreased end-systolic volume, one
of the Nursing Outcome Classification is Cardiac Pump Effectiveness [0400] which is
defined as “adequacy of blood volume ejected from the left ventricle to support systemic
perfusion pressure” (Johnson, et. al., 2001). This classification was chosen because it
allows the nurse to address the main etiology which is decreased end-systolic volume.
Objectives of this problem was to display hemodynamic stability, report absence of
severe congestion, demonstrate decreased episodes of shortness of breath and orthopnea
and tachypnea and reduce the workload of the heart.
59
The outcome criteria for these objectives include to (1) display hemodynamic stability by
having the following (blood pressure, heart rate, respiratory rate, temperature, peripheral
pulses, capillary refill time, nail beds, color) within normal parameters. Of the indicators,
only the heart rate was not within normal parameters with 50 beats per minute. Another
was to (2) demonstrate absence of peripheral edema, jugular vein distention and S3 and
S4 heart sounds. There was no indications of either of the three. The next criteria was to
(3) demonstrate decreased episodes of shortness of breath, tachypnea and orthopnea. Of
the three, only orthopnea is still the same as before and client is still on moderate high
back rest. Another was to (4) demonstrate conscious breathing technique which was
correctly performed by the client. The next one was for the client to (5) verbalize the
desire to participate in activities that reduce the workload of the heart like stress
management which was stated by the client.
The next outcome classification is Cardiac Disease Self-Management [1617] which is
defined as “personal actions to manage heart disease, its treatment, and prevent disease
progression” (Johnson, et. al. 2001). This was chosen to promote independence in
decision-making and treatment of the client. Objectives of this diagnosis is for the client
to participate in treatment regimen, state adequate knowledge about disease process,
participate in cardiac rehabilitation program and limit sodium, fat and cholesterol intake.
The outcome criteria for this objectives include (1) verbalization of the desire to
participate in the treatment regimen which was stated by the client, (2) stating 3 risk
60
factors (diet, exercise, smoking cessation) and the importance of their modification. The
client was able to perform this outcome. Another criteria includes (3) verbalization of the
understanding of required diet which the client's significant other has been able to fulfill.
Another nursing outcome classification is Circulation Status[0401] which is defined as
“unobstructed, unidirectional blood flow at an appropriate pressure through large vessels
of the systemic and pulmonary circuits” (Johnson, et. al., 2001). This classification was
chosen because of the increased volume and pressure in the heart and plasma which may
change the flow of blood. The objective of this classification is to maintain normal
weight for age. The outcome criteria for this objective is to report the absence of weight
loss and weight gain.
For the Nursing Diagnosis Anxiety related to threat or change in health status, the goal is
for the client toreport that anxiety is reduced to manageable level. One of the nursing
classification for this diagnosis is Anxiety Control [1402] which is defined as “personal
actions to eliminate or reduce feelings of apprehension, tension, or uneasiness from an
unidentifiable source”(Johnson, et. al., 2001). This classification was chosen because it
allows self-assessment and personal management of the client's source of anxiety.
Objectives of this classification include verbalizing understanding of condition/disease
process and potential complications. The outcome criteria for this objective is to use own
words and understanding in describing the disease process ro condition and its potential
complications.
61
Another Nursing Outcome Classification is Coping [1302] which is defined as “personal
actions to manage stressors that tax an individual's resources” (Johnson, et. al., 2001). As
with the preceding classification, this promotes and enhances independence in identifying
source of problem. In addition, it allows the nurse to assist the client in her endeavor and
promotes camaraderie and rapport between the two. Objectives of this classification
include reporting a decrease in stress, verbalize understanding of treatment procedures
and using behaviors to reduce stress. Outcome criteria include (1)consistently reporting a
decrease in stress. The client has been able to report a reduced feeling of stress on the
succeeding day. Another outcome criteria is (2) verbalizing in own words the relevant
information about treatment wherein the client has been able to identify the action and
indications of her medications. Last outcome criteria is (3) demonstrating at 3 least
behaviors to reduce stress ( use of relaxation techniques, willingness to express feelings,
use of support systems). The client has been able to utilize and demonstrate said
behaviors.
For the nursing diagnosis Risk for Ineffective Myocardial and Tissue Perfusion, the client
was evaluated and exhibited absence of pallor, syncope, dizziness and chest pain with
vital signs of 110/70 mmHg, 56 beats per minute, 24 breaths per minute and at a
temperature of 36. 1 °C.
Because of the journal entitled “Hospital Discharge Education for Patients With Heart
Failure: What Really Works and What Is the Evidence?” was used by the student nurse as
62
a supplementary material for learning, health instructions and emphasis of importance of
weight monitoring, sodium and fluid restrictions, physical activities, regular medication
use, monitoring signs and symptoms of disease worsening, and early search for medical
care was made. The purpose was to promote self care, reduce readmission and helping
the patient spot problems easily.
63
CONCLUSION
Most nursing literature for heart failure focus on guidelines in improving self-
management of patients and key role that nurses play as deliverer of patient education.
They aim to enhance nurses' knowledge of heart failure self-management principles with
key topics of symptom and weight management, dietary recommendations, medications,
and activity discussed (Washburn & Hornburger, 2008).
Recommendations for nursing care include the immersion of the Guidance on
Management of Heart Failure in Northern Ireland (Clinical Resource Efficiency Resource
Tam [CREST], 2005). Non-pharmacological lifestyle measures play a central role in
managing patients with heart failure. Education and advice play a vital role in the
patient’s quality of life and in the prevention of readmission to hospital. It is necessary for
patients to understand and interpret changes in their normal functioning and judge the
severity of any deterioration in their symptoms. Compliance remains an important factor.
Advice and information should be reinforced at every opportunity as it is fundamental in
helping patients to cope with and manage their illness.
Self management includes weight monitoring wherein an increase in weight can be an
early indication that the patient is retaining fluid (Paul, 2008). Measurement of weight
provides a good indicator of fluid retention/loss. Patients should be encouraged to weigh
themselves each day at approximately the same time. Weight should be taken early in the
64
morning preferably before breakfast with the same amount of clothes and after having
passed urine. Patients should be advised to report an increase of more than 1 kg sustained
over 3 days to the appropriate health professional (Paul, 2008).
It also involves salt restriction. Salt in the diet promotes fluid retention, a low salt diet is
required in the management of heart failure. A salt restriction is usually recommended to
most patients, maximum of 2 gms per day. Patient should have awareness of high salt
content in processed foods, no salt at the table and that salt substitutes are not
recommended as they contain sodium and may be high in potassium (Paul, 2008).
Another is fluid restriction wherein excessive fluid intake will negate the effects of
diuretic therapy and therefore restriction is recommended (Paul, 2008). In hospital or
with severe cases fluid should be restricted to 1 – 1.5 litres a day (CREST, 2005).
In addition to that, nutrition and dietary advice wherein a well balanced cardiac diet
should always be encouraged, is a must. Heart failure and the associated medications
used to treat the condition may cause loss of appetite and malabsorption resulting
(CREST, 2005). Small amounts of food offered regularly supplemented by nutritious
drinks should be encouraged. High energy foods may be offered (CREST, 2005). Often
cholesterol levels may be low at this stage of the condition and treatment for
hypercholesterolaemia may not be as important.
65
Overall, the clinical experience in Female Medicine Ward has allowed me to experience
handling cases related to the expected competencies for Nursing Interventions 105 mostly
on oxygenation. Thoroughout the interaction with the client, I have been able to improve
on my communication skills. However, in contrast to my other groupmates, I have not
been able to carry out major skills because my client does not have much contraptions.
Nevertheless, caring for a patient with congestive heart failure needs utmost focus and
dedication.
I realized that it is important to value and always keep in mind the theoretical knowledge
imparted to us during lectures in addressing client needs. It also helps that we remember
that diseases are also human experiences and care for the client is always centered on her
well-being. Implementing interventions were a challenge however. We must always keep
in mind the importance of appropriateness centering on individualized care. For me, the
most fulfilling part is being able to establish rapport with the client and the significant
other. It builds up trust in the relationship and at the same time, confidence to the student
nurse. It also enhances the compliance of the client towards treatment and advice.
In doing this case study, I have been able to increase my knowledge on my case which is
congestive heart failure. It also helped me realize areas I have to improve on in dealing
with a major case especially on assessment and analysis. The importance of doing
interventions that reflect the patient's case was also emphasized.
66
REFERENCES
American College of Cardiology and the American Heart Association, Inc. (2001).
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in
the Adult: Executive Summary. Journal of the American College of Cardiology 2001,
7:38, 1. Retrieved from http://content.onlinejacc.org/cgi/reprint/38/7/2101.pdf
Department of Health. (2010) Philippine Health Statistics 1960 - 2005, DOH. Retrieved
from http://portal.doh.gov.ph/kp/statistics/leading_mortality
Deglin, J. H., Vallerand, A. H. (2009). Davis's Drug Guide for Nurses 11th ed.
Philadelphia: F.A. Davis
Denolin H, Kuhn H, Krayenbuehl HP, et al. (1983). The definition of heart failure. Eur
Heart J (1983)4:445–8. Retrieved from http://aje.oxfordjournals.org/lookup/ijlink?
linkType=PDF&journalCode=ehj&resid=4/7/445
Doenges, M. (2006). Nursing Care Plans. Philadelphia: F.A. Davis Company
Hobler, K.E., L.C. Carey (1973). "Effect of acute progressive hypoxemia on cardiac
output and plasma excess lactate". Ann Surg 177 (2): 199–202. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1355564/pdf/annsurg00252-0071.pdf
Hunt S.A., Abraham W.T., Chin M.H., Feldman A.M., Francis G.S., Ganiats T.G., et al.
(2009). Focused update incorporated into the ACC/AHA 2005 Guidelines for the
Diagnosis and Management of Heart Failure in Adults A Report of the American College
of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Developed in Collaboration With the International Society for Heart and Lung
Transplantation. J Am Coll Cardiol. Apr 14 2009;53(15):e1-e90 Retrieved from
http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.109.192064
Johnson, M., Bulechek, G., Dochterman, J., Maas, M., Moorhead S. (2001). Nursing
Diagnoses, Outcomes & Interventions: NANDA, NOC and NIC Linkages. USA: Mosby,
Inc.
Outcomes Classification (NOC). USA: Mosby, Inc.
Interventions Classification (NIC). USA: Mosby, Inc.
Karch, M. (2010). 2010 Lippincott’s Nursing Drug Guide. Philadelphia: Lippincott

Williams & Wilkins
67
Kozier, B., Erb, G., Snyder, S., Berman, A. (2010) Kozier & Erb's Fundamentals of
Nursing: Concepts, Process, and Practice 8th Edition. USA: Pearson Education
MacIntyre, K., Capewell, .S, Stewart, S., Chalmers, J. W., Boyd, J., Finlayson, A. (2000).
Evidence of improving prognosis in heart failure: trends in case fatality in 66 547 patients
hospitalized between 1986 and 1995. Circulation. Sep 5 2000;102(10):1126-31.
McKee, P. A., Castelli, W.P., McNamara, P.M., Kannel, W.B. (1971) The natural history
of congestive heart failure: the Framingham study. N. Engl. J Med. 1971 Dec
23;285(26):1441-6.
Okies, J. E., Viroslav, J., T. W. Williams, Jr. (1971). Endocarditis after Cardiac Valvular
Replacement. Chest 1971;59;198-202
Paul, S. (2008) Hospital Discharge Education for Patients With Heart Failure: What
Really Works and What Is the Evidence? Crit Care Nurse. 2008;28: 66-82. Retrieved
from http://ccn.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT
Porth, C. M. (2007). Essentials of Pathophysiology: Concepts of Altered Health States 2nd
ed. Philadelphia: Lippincott Williams & Wilkins
Clinical Resource Efficiency Support Team [CREST]. (2005). Guidelines For Heart
Failure Nursing services within Northern Ireland. Retrieved from http://www.gain-
ni.org/Library/Guidelines/chronic-heart-summary.pdf
Smeltzer, S., Bare, B., Hinkle, J., Cheever, K. (2010). Brunner & Suddhart's Textbook of
Medical-Surgical Nursing. Philadelhia: Lippinccot Williams & Wilkins
Soufer, R. (1992). Yale School University School of Medicine Heart Book [Chapter 14:
Heart Failure] USA: Hearst Books.
Spratto, G, Woods, A. L. (2008). PDR Nursing Drug Handbook. Philadelphia:Thomson

Delmar Learning Inc.
Steer, A., Carapetis, J. (2009). Prevention and treatment of rheumatic heart disease in the
developing world. Nat Rev Cardiol 2009; 6:689-698. Retrieved from
http://www.nature.com/nrcardio/journal/v6/n11/abs/nrcardio.2009.162.html
The Criteria Committee for the New York Heart Association.(1964). Nomenclature and
Criteria for Diagnosis of Diseases of the Heart and Great Vessels Ninth Edition. New
York: Little Brown and Company. p. 253-255.
68
Washburn, S. C.,Hornberger, C.A. (2008). Nurse educator guidelines for the management
of heart failure. J Contin Educ Nurs.2008 Jun;39(6):263-7.
Watson, R.D.S., Gibbs, C. R., Lip, G. Y. H. (2000). ABC of heart failure: Clinical
features and complications. BMJ.2000 January 22;320(7229): 236–239. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117436/pdf/236.pdf
Woods, S., Froelicher, E., Motzer, S., Bridges, E. (2010). Cardiac Nursing 6th ed. China:
Wolters Kluwer Health/ Lippincott Williams & Wilkins
Zabriskie, JB. (1985). Rheumatic fever: the interplay between host, genetics and
microbes. Circulation. 1985; 71:1077-1086.
69
APPENDICES
Appendix 1: Physical Assessment Findings on B. A. on August 31, 2010

ORGAN PHYSICAL ASSESSMENT FINDINGS
VITAL SIGNS:
Blood Pressure 90/60 (sitting)
Heart Rate 44 beats per minute
Respiratory 30 breaths per minute
Rate 36.9 °C
Temperature
GENERAL Conscious, coherent, oriented to time, place and person
SURVEY (-) Signs of distress
Ectomorph, fairly developed, looks according to age
Fairly nourished, Slow but steady gait
SKIN (-) Pallor, cyanosis, kaundice, (-) Edema
(+) Hematoma: Left Lower Arm, Right Upper Arm
Smooth texture, Cold to touch
Good skin turgor
HEAD: Normocephalic, (-) Masses, lesions, scars
Hair Dry, normal, even distribution of hair, (-) Alopecia
Clean scalp
EYES Symmetrical Lids, (-) Ptosis, Swelling
(-) Periorbital Edema, (-) Lesions
Pinkish Conjunctiva, (-) Lesions
Anicteric Sclera
Clear cornea and Lens
Pupils: equal, 3mm, brisk and uniform reaction to light and accommodation
Uniform convergence
Intact visual extraocular activity
Nearsighted
EARS Normoset
(-) Tenderness, (-) Lymphadenopathy
(-) Discharge, (-) Impacted cerumen
Symmetrical gross
Symmetrical gross hearing capacity, (-) Hearing Deficit
NOSE Symmetrical Nasolabial Fold, (-) Obstruction
Pinkish Mucosa
Septum in Midline, (-) Perforation
(-) Discharge, Nostrils patent
Symmetrical gross smell
MOUTH (-) Pallor, cyanosis, jaundice
(-) Lesions, Dryness in Lips
Pinkish Mucosa, Gag relex intact
Tongue in midline, (-) Perforation, (-) Lesions
Missing (1) fron tooth, Dentures (full)
70
NECK Trachea in midline

Nontender, Nonpalpable thyroid
Normal Range of mOtion
(-) Neck rigidity, (-) Neck Vein Engorgement
PHARYNX Uvula in Midline, (-) Lymphadenopathy
Pinkish Mucosa, (-) Lesions
CHEST AND (-) Use of accessory muscles
LUNGS Inspiratory-Expiratory ratio: 2:1
Anterior-Posterior Lateral ratio: 1:2, (-) barrel, funnel, pigeon
Respiratory Rate: 30 breaths per minute
Chest: symmetric, symmetrical chest expansion
Symmetrical ascending and descending vocal tactile fremitus
(-) Ergophony, (-) Bronchophony
Normal breath sounds, (-) Adventitious breath sounds
HEART (-) Heaves, Thrills
(+) Sternotomy scar: midsternal, 3cm
Point of Maximal Impulse at 6th Intercostal Space, Left Midclavicular Line
Distinct heart sounds with metal clicks
S1 louder than S2 at apex, S2 louder than S1 at base
S1 and S2 regular
(-) Extra heart sounds, murmurs
BREASTS Symmetrical, (-) lesions
(-) Masses, dimpling
(-) Discharge
ABDOMEN Flabby, soft, (+) Scar: Epigastric region, 1cm
(+) Scar: Right Lower Quadrant, 2cm
(-) Bruits, visible pulsations
Normoactive bowel sounds, 3 per min, (-) muscle guarding
Nonpalpable liver
BACK & Strong and equal peripheral pulses
EXTREMITIE Nail: pale, (-) clubbing
S Capillary refill time: 0-1 seconds
(-) Crepitations, joint pain
Muscle weakness on knees, 4/5 on both lower limbs
5/5 upper limbs
Costovertebral angle tenderness not assessed because of back pain complaints
71
Appendix 2: Medication Orders and Nursing Implications
DRUG ORDER DESIRED ACTION ON THE CLIENT
THIRD GENERATION Treatment of Possible Infection (undiagnosed) caused by the

CEPHALOSPORIN: presence of black ulcers wherein bacteria from the digestive
Cefuroxime 2 grams given intravenously, tract can enter the respiratory tract
taken once daily
ANTICOAGULANT: To decrease possibility of thromboembolism, especially
Warfarin 5 milligrams, 1 tablet, given indicated for patients at risk for myocardial infarction
orally, taken once daily
BETA1-SELECTIVE ADRENERGIC To decrease blood pressure
BLOCKER:
Metoprolol, 50 milligrams, given orally,
taken once daily
PROTON-PUMP INHIBITOR: To prevent hypersecretion of juice in stomach
Omeprazole, 40 milligrams, given orally,
taken once daily
ANTIPYRETIC, ANALGESIC: To reduce fever
Paracetamol, 300 milligrams, given
intravenously, if temperature is more than
39'C
Paracetamol, 500 milligrams, given orally,

if temperature is greater than or equal to
37.8'C
SOURCES:Karch, M. (2010). 2010 Lippincott’s Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins ; Spratto,
G, Woods, A. L. (2008). PDR Nursing Drug Handbook. Philadelphia:Thomson Delmar Learning Inc.MIMS Philippines. (2010)
CPM Medica.
72
Appendix 3: Journal and Journal Reaction
Hospital Discharge Education for Patients With Heart Failure: What Really Works
and What Is the Evidence?
SUMMARY:
This journal article talks about the important guidelines in educating patients with heart
failure before disharge, thereby promoting self care, reducing readmissions and helping
patients spot problems easily. Its aim is to focus attention to the comprehensive strategies
provided by the specially trained nurses that have been able to improve outcomes for
patients with heart failure, specifically the nurses' roles as educators in providing
comprehensive discharge education.
It emphasizes the role of the nurse in teaching and evaluating patients' self-care abilities
in weight monitoring, sodium and fluid restrictions, physical activities, regular
medication use, monitoring signs and symptoms of disease worsening, and early search
for medical care. It also underlines the importance of understanding barriers of patients'
to self care like complex medication regimen, cognitive impairment and lack of
motivation and the importance of learning strategies to educate patients to overcome
these barriers.
Lastly, the journal recommends a comprehensive approach in inpatient and outpatient

education, methods of discharge instruction, written materials, one-on-one sessions and
interventions to address the clients' social support, motivation and education after
discharge.
REACTION:
This journal is relevant to my client, diagnosed with Congestive Heart Failure FC II 2ᵒ
Valvular Heart Disease 2ᵒ Rheumatic Heart Disease for discharge on September 2, 2010
if blood culture is negative (or Infective Endocarditis is ruled out). Discharge education is
a vital part of discharge planning because it addresses the home management of the client
and her competency in dealing and monitoring the disease out of the hospital.
I would be able to apply this in the care to my client as incoporated in the discharge
planning. Philippine General Hospital also outlines the importance of discharge education
in discharge planning though it is not as comprehensive as the journal recommends.
However, during my intervention week, I have been able to stress to Mrs. Aquino the
importance of weight monitoring, sodium and fluid restrictions, limited physical
activities, regular medication use, monitoring signs and symptoms of disease worsening,
and early search for medical care at home. We have been monitoring her weight daily at
8am with the client managing the weighing scale to increase awareness to its use.
Nevertheless, according to the journal, an in-depth education and the giving of written
materials is important to discharge education. The latter has been included, as
73
appropriate, to my nursing care plan.
Discharge education is outlined in the Philippine General Hospital though not as

comprehensive as the journal recommends. The journal concludes that it is vital to
discharge education that patients or their caregivers are given written discharge
instructions or other educational materials addressing all of the home concerns of the
client like the activity level, diet, discharge medications, follow-up appointments, weight
monitoring and what to do if symptoms worsens. It also recommends the provision of
patient medication charts and low sodium recipes and food suggestions. As a student, it is
possible that I can accomplish the above recommendations specifically the provision of
educational materials in PGH. However, a comprehensive, research-based and
standardized booklet is called for. I personally think that it is a good idea to implement
the inclusion of standardized educational materials and written instructions in discharge
planning. If this is not already done, it would be a good recommendation. However, given
the circumstances, I am able to understand the unlikelihood of it happening in the near
future.
The impact of this journal to my future nursing care is that it helps in stressing to me the
importance of health teaching in the future management of illness. Also, it has been
called to my attention the differences in the health system of the United States (the so-
called ideal health system) and the Philippines. There is less intensive coordination of the
community and hospital nurses in the Philippines. In the US, it is possible for them to
have telephone monitoring, one-on-one sessions and at-home interventions as part of
their care after discharge which is highly improbable in the Philippines. Maybe, one day,
as part of my future nursing career, I would be one of those who will be able to make this
system possible in the Philippines.
SOURCE: Paul, S. (2008) Hospital Discharge Education for Patients With Heart Failure:
What Really Works and What Is the Evidence? Crit Care Nurse. 2008;28: 66-82. Retrieved from
http://ccn.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT
74

Case Study of Congestive Heart Failure

Hochgeladen von

Dokumentinformationen

Originalbeschreibung:

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Case Study of Congestive Heart Failure

Hochgeladen von

Copyright:

Verfügbare Formate

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

parameters remaining within normal limits usually accompanied by effort intolerance,

300,000 patients die from heart failure yearly.

need with national and global implications.

Disease secondary to Rheumatic Heart Disease. Its purpose is to review the

pathophysiology, preanalytical factors, and treatment in a congestive heart failure patient

and identify possible recommendations for future nursing care.

thorough case analysis of a client to deliver the best nursing care.

Theoretical Background. Heart failure is defined as “the pathophysiologic state in

which an abnormality of cardiac function is responsible for inadequate systemic

Classification. According to the New York Heart Association (1964), congestive

Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at

idiopathic heart failure” (Soufer, 1992).

Manifestations. Soufer (1992) further elaborates the manifestations often seen in

production that comes from pulmonary congestion (Soufer, 1992).

ankles or legs occurs (Soufer, 1992).

associated with congestive heart failure (Soufer, 1992).

diagnosis of congestive heart failure requires the simultaneous presence of at least 2

distention, rales, radiographic cardiomegaly (increasing heart size on chest radiography),

kilograms in 5 days in response to treatment. The minor criteria is composed of bilateral

ankle edema, nocturnal cough, dyspnea on ordinary exertion, hepatomegaly, pleural

can not be attributed to another medical condition (such as pulmonary hypertension,

definite congestive heart failure (McKee, et. al, 1971).

Complications. Watson (2000) discovered that the common complications of heart

mechanisms in scarred myocardial tissue. An episode of sustained ventricular tachycardia

overall estimated annual incidence of approximately 2% (Watson, 2000). Factors

wall motion abnormalities (including formation of a left ventricular aneurysm), and

compensatory mechanisms act but eventually decompensate leading to dysfunction of

organs (Porth, 2007).

B. A. is a 49 year old female, Filipino, nonhypertensive, nondiabetic and diagnosed with

Congestive Heart Failure Functional Capacity II secondary to Valvular Heart Disease

She is a Roman Catholic and actively participates in church as a lector.

Pulmonary Tuberculosis and Infective Endocarditis.

family brought her to Philippine General Hospital.

Outpatient Department of the Hospital. Her maintenance medications included Warfarin 5

extreme fatigue. However, no significant findings were made and Pulmonary

Hospital in Bulacan for anti-rabies injection because of a dog bite.

caused by her medication (Warfarin).

bottle. In addition, the client does not suffer from diaphoresis.

elimination, dressing, maintaining cleanliness, and daily movement. However, she is

unable to do household chores as before and go to the market without assistance of a

tired and experience shortness of breath. Her level of self-care is Level 2.

In the Role-Relationship Pattern, the family of B. A. is said to be extended and

by conversations with the family.

August 1, 2010. B. A. is a G3P3 mother and has no history of complications at birth.

for her medical condition.

There is pinkish mucosa and no lesions were present.

In the cardiovascular system, no heaves or thrills were inspected. A sternotomy scar is

no nocturnal paroxysmal dyspnea, edema and cyanosis. No hypertension, heart murmurs,

varicosities, phlebitis or claudication were assessed.

wheezing or stridor was heard on auscultation. There was no hemoptysis, respiratory

infections, tuberculosis (or exposure to tuberculosis), fever or night sweats. In the

dysphagia, indigestion, food idiosyncrasy, abdominal pain and heartburn. No nausea,

In the genitourinary system, no urgency or frequency in urination was reported. There

observed. No hesitancy, change in size of stream, dribbling, acute retention or

alive. In the musculoskeletal system, no pain, swelling, redness or heat of muscles or

muscular weakness on knees.

In the neurologic or psychiatric component, no convulsions, paralyses or tremors were

She is however, anxious about condition.

observed. There was however dizziness experienced after administration of Metorpolol

Tuberculosis and Community-Acquired Pneumonia so this chest x-ray is to rule out or

confirm said conditions. It is also indicated for a definite diagnosis of cardiomegaly or

root as seen on lateral view.