Case for heart failure and hypertension

Mr. AB, a 57-year old gentle man, consulted at the clinic because of shortness of breath, progressive over the past five days. He has
been a patient at the clinic for the past 7 years, treated in the past for myocardial infarction, hypertension, non-insulin dependent
diabetes mellitus and stasis dermatitis of the right leg. He smoked 1 pack per day since he was 20; tried to stop but not successful. He
also likes to eat chicharon, bulalo and other native delicacies.

He has experienced episodes of shortness of breath during the past four months, especially when exerting himself. He fatigues easily
and has lost "all my energy to do anything." He also complains of anorexia. Last night he awoke suddenly from sleep because "I
couldn’t catch my breath" and developed a dry cough. The breathing problem improved when he sat on the edge of his bed for an
hour. He generally sleeps with two, sometimes three pillows. He has not experienced chest pain, leg pain or fainting spells.

Examination in the office reveals a slightly obese man who appears depressed and older than his stated age. He is unkept and
unshaven. His breathing is labored and his lips have a blue tinge.

Vital Signs: Blood Pressure 140/85 mmHg in the right arm; Heart Rate 110/min; Respiratory Rate 26/min; Temperature 36.8 oC.
Examination of the lungs reveals dullness to percussion in both bases with decreased excursion of the diaphragms. Course rhonchi and
moist, inspiratory crackles are heard bilaterally in the lower lung fields.

Examination of the cardiovascular system: Neck veins are prominent and distended to the mandible when the patient is sitting upright.
The apical pulse is palpated in the 5ICS, left of the MCL. S3 is palpable at the apex. S1 and S2 are diminished. S3 is heard at the apex.

Examination of the abdomen: The anterior wall is round and soft. The liver edge is palpable and tender. The spleen is not palpable.
Examination of the extremities revealed diminished peripheral pulses. There is an irregular pulse. There is pitting edema of both lower
extremities.

The patient is hospitalized.

ADMISSION LABORATORY TESTS

CBC:

Leukocyte count = 8,4000/mm3 with normal differential count normal- 5,000-10,000/mm3

Hemoglobin 14.6g/dL, Hematocrit 40%; normal 40-45%

Platelet count 290,000/mm3- normal 150,000 to 450,000/mm3

Chemistries:

Glucose 112mg/dL (non-fasting); normal =

BUN 33mg/dL; normal = 7 to 20 mg/dL
Creatinine 1.6mg/dL; normal = 0.6 to 1.2 mg/dL
Total Bilirubin 1.9gm/dL, normal = 0.1 to 1.2 mg/dL
Direct Bilirubin 0.3mg/dL; normal= < 0.3 mg/dL
Total Protein 5.8g/dL, normal = 6-8.3 g/dL
Albumin 3.1g/dL; normal = 3.5 to 5.5 g/dL
Electrolytes:
 Sodium 132mEq/L, normal = 135-145 mEq/L
 Chloride 93mEq/L, normal = 95-105 mEq/L
 Potassium 4.0mEq/L, normal = 3-5 mEq/L
 Bicarbonate 23mEq/L; normal = 22-28 mEq/L
Urine: Specific Gravity 1.032, 1 plus protein, hyaline casts. = normal urinalysis should have no protein, sugar;

Chest X-ray:

"Marked prominence of the pulmonary vascular shadows (bilateral), bilateral pleural effusions, increased haziness and decreased
radiolucency of the lung parachyma (bilateral), increased transverse diameter of the heart."
Tasks:

Discuss the pathophysiology of heart failure (correlate the physical exam findings)

What in the physical examination supports the diagnosis of heart failure. (list your findings)

Discuss the pathophysiology of hypertension and the risks of this patient. ( include all risks obtainable from the
history)

What would be your nursing diagnosis in this case and create nursing care plans for this patient. (Include
education of patient and his family)