Congestive Heart Failure (Pp.1- 50)

8/3/2019 Congestive Heart Failure (Pp.1- 50)

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CONGESTIVE HEART FAILURE

A Case Study Presented To

The Faculty of Nursing and Health Science Department

College of Arts and Sciences

Naval State University

Naval, Biliran

In Partial Fulfillment of the

Related Learning Experience Requirement

for the Degree of Bachelor of Science in Nursing

Daryll S. Dacdac

NOVEMBER 2011


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TABLE OF CONTENTS

Page

I. Introduction 4II. Objectives 5III. Nursing Assessment

1. Personal History 7

1.1 Patients Profile 7

1.2 Family & Individual Information, Social & Health History 7

1.3 Level of Growth and Development 22

1.3.1 Normal Development at Particular Age 22

1.3.2 The ill person at Particular Stage 27

2. Diagnostic Result 28

3. Present Profile of Functional Health Pattern 31

4. Pathophysiology and Rationale

4.1 Anatomy and Physiology 35

4.2 Schematic Diagram 38

4.3 Pathophysiology 42

4.4 Classical and Clinical signs and symptoms 44

IV. Nursing Intervention

1. Care Guide of Patient with Disease Condition 49

2. Actual Patient Care

2.1 Nursing Care Plan 51


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2.2 SOAPIE 65

2.3 Drug Therapeutic Record 67

2.4 Health Teaching Plan 75

V. Evaluation and Recommendation 79

VI. Implication of the Case Study 81

VII. Bibliography 82


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INTRODUCTION

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

populations 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 Mr. V., a 90 year old male, Filipino and is

currently diagnosed with Congestive Heart Failure. Its purpose is to review the

pathophysiology, pre-analytical 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.


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OBJECTIVES

General Objectives:

After 3 days of student- nurse- patient interaction, the nursing students will be

able to gain knowledge, attitude and skills in the care of patient with Congestive Heart

Failure.

Specific Objectives for the Student- Nurse:

After 45 minutes of the discussion, the nursing students will be able to:

1. acquire knowledge about Congestive Heart Failure as to:

1.1definition of terms;

1.2risk factors;

1.3signs and symptoms;

1.4pathophysiology;

1.5nursing care plan;

1.6prognosis;

1.7interventions?

2. demonstrate proper attitude in handling patient with Congestive Heart Failure

and;

3. apply the acquired skills in the care of patients with Congestive Heart Failure.

Specific Objectives for the Patient:

After 2 days of student nurse- patient interaction/ SO, the patient will be able to:

1. build trust towards the student- nurse;

2. acquire an overview of the disease as to:


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2.1definition of terms;

2.2risk factors;

2.3signs and symptoms;

2.4complications;

2.5interventions?

3. verbalize feelings about the situation or condition and;

4. participate in activities done by the student- nurse such as:

4.1interventions in the care of the condition;

4.2

techniques in managing complications?


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III. NURSING ASSESSMENT

1.1 Patients ProfilePatient Name: Mr. V

Age: 90 years old

Sex: Male

Religion: Roman Catholic

Civil Status: Married

Birthday: November 18, 1920

Birthplace: Calubian, Leyte

Occupation: None

Date of Admission: August 18, 2010 2:50 pm

Room: Male Medical Ward

Chief Complaints: Body Malaise, weakness, difficulty in breathing

Impression/ Diagnosis: Congestive Heart Failure

Physician: Dr. Borromeo

1.2.Family and Individual Information, Social, and Health History

PRESENT MEDICAL HISTORY

According to the significant other, two weeks prior to admission, patient was

experiencing on and off diarrhea and intermittent abdominal pain after drinking 3- 4

glasses of tuba at their neighborhood. He was not given any medication for diarrhea and

for the pain.


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The day prior to admission, August 18, 2010, patient claimed that his

abdominal pain was getting worst and his stool content was clear water. At around 2:50

pm the patient was delivered at Biliran Provincial Hospital via wheel chair experiencing

body malaise, weakness, difficulty in breathing and bipedal edema, patient hence

admitted.

PAST MEDICAL HISTORY

According to the significant other, she does not know if the patient had a

complete immunization during his childhood. Wala man siya allergy sa pagkaon, kana la

jud ang magkaluya siya ug maglisod pagginhawa pagmukaon siya ug kanang may mga

tambok na pagkaon. Karun ra man pud siya nag ing- ana nga may edad na. Di man namo

siya mabantayan sa iyang kaonon kay dili man mi tipon ug bahay as verbalized by the

significant other. He sometimes drinks tuba and fond of eating oily and fatty foods such

as Humda and fries. Most of the time the patient experienced weakness and complaining

of back pain at the lumbar area and in the back of the neck. And no alternative remedies

were done to treat the symptoms experienced by the patient according to the significant

other.

According to the SO, June 2010, Mr. V was also admitted in the same institution

due to weakness and hypertension. Treatment was not given properly because that day,

the significant others decided to discharge the patient due to lack of finance.

FAMILY HISTORY

According to the SO, patient has a history of hypertension in his paternal side.

The father of the patient and one of the patients sons died due to hypertension. The

patients mother had a history of arthritis.


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Physical Assessment

Body Parts

Physiologic

I P P A

Skin:Color:

Texture:

Turgor:

Lesions:

Hair:Color:

Amount

anddistribution:

Texture:

Parasites:

Scalp:Symmetry:

Texture:

Lesions:

Nails:

Color:

Brownness to

yellowish

Short; grayish

Unevenly

distributed andalopecia

Absence of

parasites

Symmetrical inshape

No lesions

Pale, andslightly cloudy

Dry andwrinkled

Skin turgor

back to normal

within 4- 5seconds

Presence ofbruise in both

knees

Dry and oily

Slightly intact

and smooth


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Shape:

Texture:

Condition

of nail bed:

CapillaryRefill test:

HeadSize:

Shape:

Consistency:

Face:

Symmetry:

FacialFeatures:

Neck:Appearance:

ROM:

Tracheaposition:

Convex

Pallor

Appropriate to

body size

Rounded

Symmetrical

Patient showsfacial grimace

when hemoves

suddenly and

when he feelsabdominal pain

Wrinkled skin

is noted

Able to movein any

directionflexion and

extension inslow

movement

Centrallylocated

Smooth

Back to normalwithin 2- 3

seconds

Hard

Not tender


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Thyroid

position:

LymphNodes:

Size:

Mobility:

Consistency:

Tenderness:

Jugularveins:

Eyes:Position &

Appearance:

Lacrimal

Apparatus:

PERRLA:

VisualAcuity:

Centrally

located

Visible

Appears

cloudy toyellowish;

sunken; moist,lashes are short

Pupils

constrictswhen light is

near anddilates when it

is far

Patients couldnot see clearly

and takes 30seconds to 1

minute torecognized

faces of hissignificant

Palpable

Not enlarge

Not movable

Soft

Not tender

Carotid pulseis palpable but

weak, with a

pulse rate of45

No discharge

upon palpation,no tendernessnoted


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Peripheral

Vision:

ExtraoccularMovement:

Ears:

External EarSize:

Shape:

Location:

Lesions:

Tenderness:

Auditory

Canal:Cerumen:

Color:

Consistency:

other

When looking

straight ahead,client can

recognizedobjects but

could not seeclearly in the

peripheryusing penlight

Both eyescoordinated

move in unison

with parallelalignment

Symmetrical

Symmetrical

Auricle aligned

with outer

canthus of eyeabout 100from

vertical

No lesions

Small amount

of cerumennoted

Yellow to

brownness

Moist

Not tender


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Nose andSinuses:

ExternalNose:

SkinAppearance:

Nares:

Tenderness:

Internal Nose:

Appearance:

Septum:

Sinuses:

Tenderness:

Transillumina

tion:

Mouth andOropharynx

Lips:Color:

Consistency:

Buccal

Mucosa:

Color:

Skin color is

uniform

No dischargeor flaring;

hooked withnasal cannula

Mucosa pink

Intact andmidline

Not inflamed

Pallor

Dry

Pallor

Not tender

Not tender; all

sinuses are notinflamed and

painless upon

palpation

Not tender


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Consistency:

Gums:

Color:

Consistency:

Teeth:Number:

Color:

Tongue:Symmetrical:

Movement :

Color :

Soft Palate:

Color:

Consistency:

TonsilsPosition:

Tenderness:

Thorax and

Lungs:Anterior and

Moist

Pallor

Moist

28 teeth are

lost and 3incisor left at

upper teeth and2 incisor left at

lower teeth

Presence of

dental carries,yellowish incolor

Symmetrical

Able to move

freely

Pinkish on the

side & withwhite coatingon the center

Pallor

Moist

Located at theside of the

throat

Not tender


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Posterior:

Color:

Intercostal

Spaces:

Chest

Symmetry:

Respiration:

Shape:

Position ofSternum:

Position ofTrachea:

Tenderness:

Vocal

Fremitus:

ThoracicExpansion:

Posterior

ICS:

AnteriorICS:

Lateral

ICS:

BreathSounds:

Skin color isuniform

First rib and

clavicleobscured

Asymmetrical

35 cycles perminute

Barrel chest

noted

Centrallylocated

Centrallylocated

Not tender

Not assessed

Asymmetryless than 3 cm

Not assessed

Resonancebetween the 6

th

ICS at the levelof the

diaphragm

Not assessed

Crackles are

heardspecifically

at the baseof the lower


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CardiacAssessment

Intercostal

Space:

Midsternal

Line:

Midclavicular

Line:

Anterior

AxillaryLine:

Aortic Area:

Pulmonic

area:

Erbs point

Tricuspid

area:

Mitral Area:

Blood

Pressure:

Pulse rate:

BrachialPulse

First rib and

clavicleobscured

In line with the

body

Center of the

midstrenal line

R & L anteriorline

Vertical from

the anterioraxillary fold

No pulsation

No pulsation

No pulsation

No pulsation

No pulsation

52 beats perminute

lung lobe

140/ 60

mmHg


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Dorsalis

Pedis

Breast:Size:

Symmetry

Color

Areola &

Nipple:Size

Color:

Shape:

Texture:

Discharges:

Temperature:

Turgor:

Tenderness:

Lymph Nodes

Abdomen:

Color:

Skinintegrity:

Presence of

Edema

Breast even

with the chestwall

Symmetrical

Brownness

Everted and

equal in size

Brownness

Round

Brownness to

yellowish incolor;

glistening skin

Abdominalgirth is 112 cm

Not assessed

Smooth

No discharges

noted uponpalpation

Warm to touch

Good; back to

normal within1- 2 seconds

Not tender

Not palpable

Distended;warm to touch


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Umbilicusposition:

Contour:

Bowel

sounds:

Musculoskele

tal system:

Gait:

Strength:

ROM upper

extremities:

Centrallylocated in the

umbilical area

Not assessed

Not assessed;

patient is notallowed tostand

25 % grade ofthe muscle

strength;patient able to

moveaccording to

his age, but

most of themusclesactivity test

such ashamstring, &

sternocleidomastoid test needs

a support fromthe SO

Dry and

wrinkled skinis noted; motor

function isweak and

slow; able toperform

extension,flexion of the

Skin is warm

to touch; lesssensation of

discriminatingthe sharp and

dull object

Hypoactive

bowel soundnoted


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Cranial nerve I - patient could hardly identify smell due to the nasal cannula

hooked with him; he can identify the odor of his foods being eaten

Cranial nerve II - patient could not see clearly and it took at least 30 seconds to 1

minute to recognized faces of his significant other

Cranial nerve III - the extra ocular movement is intact in both eyes when assessedand by using the penlight

Cranial nerve IV - patient could move his eyes up and down

Cranial nerve V - facial sensation of the patient is intact. He was able to feel when

touching his face

ROM lower

extremities:

arms in slow

manner;patient shows

fatigabilityduring the

assessment andexert in

gasping of airfor breathing;

able to changehis position

slowly fromlying to side

lying position

Glistening skin

is noted in bothlegs; bipedaledema isnoted;

presence ofpatches at the

sole of the feet;bruise noted at

both knees;able to adduct

and abduct his

both legs inslow manner

Warm to

touch; plantarreflex isdifficult toelicit


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Cranial nerve VI - patient could move his eyeballs symmetrically when instructed

Cranial nerve VII - patient is able to smile, frown when instructed

Cranial nerve VIII - patient could not hear clearly. When asked questions, it took 2 or

3 times in repeating the question before he could identify what was

being asked. He could hear voices when talked near the ears of the

patient.

Cranial nerve IX - patient has positive gag reflex. He could freely move his tongue

up and down and side to side.

Cranial nerve X - patient talked in slow and low tone of voice

Cranial nerve XI - patient was able to move his head by moving side to side with

limited and slow movement.

Cranial nerve XII - patient able to protrude his tongue and can move freely from up

and down and side to side

Neurologic Assessment

Level of consciousness - patient is conscious, and oriented to place where he lived

in and he was also aware that he was in the Biliran

Provincial Hospital

Mood - patient shows uninterested during the first day of

interaction. Most of the time, patient sleeps and shows

irritable when he was disturb and when feels pain. He

shows facial grimace when he experienced abdominal pain.

Speech - during the assessment, patient talked slowly and in low

voice. He could not identify the question being asked and it

took repetition for what was being asked before his

response.


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Cognitive abilities - the patient is conscious. During the assessment, patient

sleeps most of the time and talk when he needs something

to do with his SO like when he wants to urinate. He can

utter few words in low voice when he asked and express

facial expression when experienced pain.

Sensory -during assessment, patient has less sensation of

discriminating the sharp and dull object.


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1.3LEVEL OF GROWTH AND DEVELOPMENT

Normal Growth and Development at Particular Age

I. Physical changes

A. Cardiovascular SystemThe heart loses about 1% of its reserve plumbing capacity every year after we turn

30. Changes in blood vessels that serve brain tissue reduce nourishment to the brain,

resulting in the malfunction and death of brain cells. By the time we turn 80 and older,

cerebral blood flow is 20% less, and renal blood flow is 50% less than when we were age

30. As we age our heart goes through certain structural changes: the walls of the heart

thicken and the heart becomes heavier, heart valves stiffen and are more likely to calcify,

and the aorta, the major vessel carrying blood out of the heart, becomes larger.

B. Musculoskeletal SystemBones

Aging is accompanied by the loss of bone tissue. The haversian systems in

compact bone undergo slow erosion, lacunae are enlarged, canals become widened, and

the endosteal cortex converts to spongy bone. The endosteal surface gradually erodes

until the rate of loss exceeds the rate of deposition. Bone remodeling cycle takes longer to

complete because bone cells slow in the rate of resorption and deposition of bone tissue.

The rate of mineralization also slows down. The number of bone cells also decreases

because the bone marrow becomes fatty and unable to provide an adequate supply of

precursor cells. Because bones become less dense, they become more prone to fractures.

Although bone degeneration is inevitable, it is variable if steps are taken before the mid-

twenties -around this time our bones break down faster than they rebuild. Bone densityincreases when our bones are stressed, so physical activity is important. Vitamins and

good diet also help build up bone mass.


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Joints

Cartilage becomes more rigid, fragile, and susceptible to fibrillation. Loss of

elasticity and resiliency is attributed to more cross-linking of collagen to elastin, decrease

in water content, and decreasing concentrations of glycosaminoglycans. Joints are also

more prone to fracture due to the loss of bone mass.

Muscles

Decrease in the range of motion of the joint is related to the change of ligaments

and muscles. As the body ages, muscle bulk and strength declines especially after the age

of 70. As much as 30% of skeletal muscles are lost by age 90. Muscle fibers, RNA

synthesis and mitochondrial volume loss may all be contributors to muscle decline. Other

factors that could contribute to muscle loss of the aged are: change in activity level,

reduced nerve supply to muscle, cardiovascular disease, and nutritional deficiencies.

C. Nervous SystemOne of the effects of aging on the nervous system is the loss of neurons. By the age of

30, the brain begins to lose thousands of neurons each day. The cerebral cortex can lose

as much as 45% of its cells and the brain can weigh 7% less than in the prime of our

lives. Associated with the loss of neurons comes a decreased capacity to send nerve

impulses to and from the brain. Because of this the processing of information slows

down. In addition the voluntary motor movements slow down, reflex time increases, and

conduction velocity decreases. As we age there are some degenerative changes along

with some disease's involving the sense organ's that can alter vision, touch, smell, and

taste. Loss of hearing is also associated with aging. It is usually the result of changes in

important structures of the inner ear.

D. Digestive SystemThe changes associated with aging of the digestive system include loss of strength

and tone of muscular tissue and supporting muscular tissue, decreased secretory

mechanisms, decreased motility of the digestive organs, along with changes in

neurosensory feedback regarding enzyme and hormone release, and diminished response

to internal sensations and pain. In the upper GI tract common changes include periodontal


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disease, difficulty in swallowing, reduced sensitivity to mouth irritations and sores, loss

of taste, gastritis, and peptic ulcer disease. Changes that may appear in the small intestine

include appendicitis, duodenal ulcers, malabsoration, and maldigestion.

E. Urinary System

As we get older kidney function diminishes. By the age of 70 and older, the filtering

mechanism is only about half as effective as it was at age 40. Because water balance is

altered and the sensation of thirst diminishes with age, older people are more susceptible

to dehydration. This causes more urinary tract infections in the elderly. Other problems

may include nocturia (excessive urination at night), increased frequency of urination,

polyuria (excessive urine production), dysuria (painful urination), incontinence, and

hematuria (blood in the urine

F. Respiratory SystemsWith the advancing of age, the airways and tissue of the respiratory tract become less

elastic and more rigid. The walls of the alveoli break down, so there is less total

respiratory surface available for gas exchange. This decreases the lung capacity by as

much as 30% by the age of 70 or older.

G. VisionChanges in vision begin at an early age. The cornea becomes thicker and less curved.

The anterior chamber decreases in size and volume. The lens becomes thicker and more

opaque, and also increases rigidity and loses elasticity. The ciliary muscles atrophy and

the pupil constricts. There is also a reduction of rods and nerve cells of the retina.

H. HearingApproximately one third of people over the age of 65 have hearing loss. The

ability to distinguish between high and low frequency diminishes with age. Loss of

hearing for sounds of high-frequency (presbycusis) is the most common, although the

ability to distinguish sound localization also decreases. It is believed that the hearing loss

isn't so much an age change as it is due to the accumulation of noise damage.


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I. Taste and SmellSensitivity to odors and taste decline with age. The sense of smell begins to

degenerate with the loss of olfactory sensory neurons and loss of cells from the olfactory

bulb. The decline in taste sensation is more gradual than that of smell. The elderly have

trouble differentiating between flavors. The number of fungiform papillae of the tongue

decline by 50% by the age of 50. Taste could also be affected by the loss of salivary

gland secretions, notably amylase. This loss of taste and smell can have a significant

effect on an elder's health. With the reduced ability to taste and smell, it is difficult to

adjust food intake as they can no longer rely on their taste receptors to tell them if

something is too salty, or too sweet. This can also cause the problem in that they might

not be able to detect if something is spoiled, making them at a higher risk for food

poisoning.

J. CellularAgingAs people age, oxygen intake decreases as well as the basal metabolic rate. The

decrease in the metabolic rate, delayed shivering response, sedentary lifestyle, decreased

vasoconstrictor response, diminished sweating, and poor nutrition are reasons why the

elderly cannot maintain body temperature. There is also a decrease in total body water

(TBW).

K. Organism AgingAging is generally characterized by the declining ability to respond to stress,

increasing homeostatic imbalance and increased risk of disease. Because of this, death is

the ultimate consequence of aging. Differences in maximum life span between species

correspond to different "rates of aging". For example, inherited differences in the rate of

aging make a mouse elderly at 3 years and a human elderly at 90 years. These genetic

differences affect a variety of physiological processes, probably including the efficiency

of DNA repair, antioxidant enzymes, and rates of free radical production.


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II. Cognitive developmentAccording to Piagets phases of cognitive development, it ends with the formal

operations phase. In older adults, changes in cognitive abilities are more often

differences in speed than ability. Overall the older adult maintains intelligence,

problem solving, judgment, creativity, and other well- practiced cognitive skills.

Intellectual loss generally reflects a disease process such as atherosclerosis, which

causes the blood vessels to narrow and diminishes perfusion of nutrients to the brain.

Older adults do not experiencing cognitive impairments.

III. Moral developmentAccording to Kohlberg, moral development is completed in the early adult years.

Most old people stay at Kohlbergs conventional level of moral development and

some are at the preconventional level. An older person at the preconventional level

obeys rules to avoid pain and the displeasure of others. At stage 1, a person defines

good and bad in relation to self, whereas older people at stage 2 may act to meet

anothers need as well as their own. Older adults at the conventional level follow

societys rules of conduct in response to the expectation of others.

IV. Spiritual developmentOlder adults can contemplate new religious and philosophical views and try to

understand ideas missed previously or interpreted differently. Involvement in religion

often helps the older adult to resolve issues related to the meaning of life, to

adversity, or to good fortune. The old- old person who cannot attend formal

services often continues religious participation in a more private manner. Many older

adults watch television evangelists and some, being vulnerable to fund- raising

ventures, sent these organizations money that they can ill afford to spare.


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The Illness Person at the Particular Stage

Declining physical and sensory- perceptual abilities limit the ability of old- old

stage adult to respond to environmental hazards and stressors. In old- old age group, ill

client may experience behavioral and emotional changes, changes in self- concept and

body image, and lifestyle changes. Behavioral and emotional changes associated with

short- term illness are generally mild and short lived. The individual may become

irritable and lack the energy or desire to interact in the usual fashion with family

members with friends.

The clients self- esteem and self- concept may also be affected to a certain illness

which can also change the clients body image or physical appearance. Many factors can

play a part in low self- esteem and a disturbance in self- concept: loss of body parts and

function, pain, disfigurement, dependence on others, unemployment, financial problems,

inability to participate in social functions, strained relationship with others, and spiritual

distress.


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2. DIAGNOSTIC RESULTSDiagnostic Test Normal Values Patients Result Significance

Blood Chemistry

*Sodium

*Potassium

*FBS

*Creatinine

Hematology

*Haemoglobin

*Haematocrit

*WBC

*Neutrophil

135- 155 mmol/L

3.5- 5.5 mmol/L

3.33 6.10 mmol/L

M:61.8-123.7 mmol/L

F: 53- 97.2 mmol/L

M:134- 180 g/L

F:120- 160 g/L

M: 44- 54 vol. %

F: 38- 45 vol. %

5- 10 x 10/ L12

55-75%

153.5mmol/L

3.8mmol/L

a. mmo

l/L

180.3 mmol/L

90 g/L

28.4 %

8.7 x 10 /L12

75.1%

Normal

Normal

Normal

Increase; indicates

systemic disease

such as

hypertension and

renal insufficiency

(Ref: Joyce Black

And J. Hawks,

Medical- Surgical

Nursing, 8th

Edition,

Pp. 1383 & 2000-

2001)

Decrease; indicates

hemodilution (fluid

overload)

Decrease; indicates

hemodilution (fluid

overload)Normal

Slightly increase;

indicates acute

infection


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*Lymphocytes

*Monocytes

Urinalysis

Macro:

*Blood

*pH

*SpecificGravity

Micro:

*WBC

*RBC

20- 35%

2-6%

Negative

6-8

1.010- 1.025

Negative

Negative

18. 9%

6.0%

Negative

6.01.015

0-1HPF

0-1 HPF

Decrease; indicates

exhausted immune

system

Normal

(Ref: Barbara

Kozier, Glenora

Erb, At Al,

Fundamentals Of

Nursing, 7th

Edition

2004, Pp. 759t)

Black and Hawks;

Medical- Surgical

Nursing; 8th

edition,

volume 2, pp. 2001

Normal

Normal

Normal

Normal

Normal

(Ref: www.

Naturalhealthtechni

ques.com


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The chest x-ray done on August 19, 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 high

suspicions of granulomatous pulmonary nodule in the right upper lung zone.

Inflammatory process is also considered in the left upper lung zone. It also suggested

undergoing another chest x-ray in an apicolordotic view for further evaluation of

athermanous and tortuous aorta.

Ultrasound was performed on August 22, 2010 to view the peritoneal cavity and

identify possible problems that may be the cause of hematuria. A part that has been

examined is the flat plate of the abdomen. Finding shows that the marginal sclerosis and

osteophytes are already widen on the bodies of the lumbar vertebrae with preserved disc

spaces. In addition, ultrasound revealed non- obstructive bowel pattern. There is also a

degenerative change of the lumbar spine.


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3. PRESENT PROFILE OF FUNCTIONAL HEALTH PATTERN

GORDONS HEALTH PATTERN

I. Health Perception Health Management PatternPrior to hospitalization, the patient experienced diarrhea and weakness after he drinks

tuba. He had his unusual pattern of eating due to abdominal pain experienced by the

patient.

During hospitalization, the SO was aware that the patient had hypertension. Their

goals were to recover their father and were able to discharge as soon as possible. During

assessment, patient was weak and could not mobilize his body properly. He could not

open his eyes and could utter only few words in low voice. Upon admission, the patient

received 3 Litters per minutes of Oxygen immediately and 1 tablet of 100 mg of

Spironolactone twice a day.

II. Nutritional Metabolic PatternPrior to hospitalization, patient was fond of eating foods that are rich in oil and fat

such as Humba and drinking tuba at least 1 litter. According to the SO, he does not have

any allergy in foods and in medicine. She claimed that his father could not eat properly

because of the incomplete teeth and can only eat soft foods like lugaw and cereals. He

drinks water at least 5 to 6 glasses of water only per day.

Upon hospitalization, patient could not eat properly because he could not chew the

food properly and he could not eat in sitting position unless assisted by his significant

other due to the developing ascites and abdominal pain. The SO verbalized, Pukawon ra

na siya namo ug mukaon na siya. The patient has low sodium, low- fat diet as prescribed

by the physician. The SO also added that his father drinks water in small amount and

could not drink at least 2 glasses in a day and or sometimes just a sip of it.


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III. Elimination PatternTwo weeks prior to hospitalization, patient was experiencing watery stool in small

amount. Nakalibang siya kadtong ning labay nga duha ka-adlaw, dulaw nya basa ug

gamay ra kayo, as verbalized by the SO. He can urinate two times a day without any

pain upon urination. Eight days prior to admission, SO added that his fathers feet were

swelling and getting bigger after experiencing abdominal pain.

Upon hospitalization, Gikan atong na- admit siya nya nahatagan na ug tambal, mag-

ihi- ihi siya. Manga unom ka-beses o sobra pa sa usa ka-adlaw. Pero wala pa siya

nalibang sukad adtong na-admit siya as verbalized by the SO. During the assessment,

patient urinates in a bed pan and his urine was yellowish to clear in colour. His feet were

still swelling and his abdomen develops ascites and both of it were yellowish in colour.

IV. Activity Exercise PatternAccording to the SO, patient can walk slowly when assisted with grandson. He just

stayed in their house most of the time and watching TV every afternoon.

During hospitalization, patient was lying in his bed. He could not sit down by himself

due to the ascites and abdominal pain. He sleeps most of the time and awakes when the

time he ate and was assisted by his SO. He needs assistance in urinating using the bed

pan.

V. Sleep- Rest PatternAccording to the SO, prior to admission, patient sleeps around 8 P.M. and awakes at

around 7 A.M. or sometimes 8 in the morning. He sleeps for about 1 to 2 hours every

afternoon whenever he does not watch television.

Upon hospitalization, the SO states that, Mag sige ra siya ug katug, makamatngon

gad siya kung among pukawon, naay oras nga mag sige ra siya ug katug jud nya amo na

lang pukawon pagpakaon.


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VI. Cognitive- Perceptual PatternPrior to admission, SO stated that, the patient has defect in his sight and hearing. But

patient was not able to use any aid or any devices in his sight and hearing problem.

During hospitalization, the patient is conscious and oriented to place. During the

assessment, patient sleeps most of the time and talk when he needs something to do with

his SO like when he wants to urinate. He can utter few words in low voice when he asked

and express facial expression when experienced pain.

VII. Self- Perceptual PatternAccording to the SO, prior to admission, the patient experienced poor appetite. He

showed unwillingness when his wife asked about his condition. The SO also added that

they were concerned about his fathers condition especially to his abdomen because of

the ascites and in financial aspects too.

During the hospitalization, the patient becomes thin and sometimes unresponsive. The

SO stated that, Bahala na lang kung kulang amo kwarta basta ang amo lang ang

pagpakaayo sa among amahan nga mabalik lang iyang panglawas ni-ari.

VIII. Role Relationship patternThe family of Mr. V is said to be extended and patriarchal. He lives with his wife

who is 86 years old. His two grandsons live also with them who helped in their daily

needs. According to his wife, they depend to their 5 daughters who supported them

financially. Their 5 daughters were separated from them and all of them were married.

During the stay of the patient in the hospital, their children always contribute to the

medical expenses of the client. Currently, they feel worried about their father's condition

and contribute to any way they can to alleviate his condition. The usual problem of the

family involves the drinking habit of the patient and financial problems. They usually

resolve it by conversations with the family.


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IX. Sexuality- Sexual FunctionMr. V is a 90 years old male, married with 5 children. According to his wife, she and

his husband has not engaged in sexual intercourse in recent years. She claims that this is

because they are already old. She also added that, her daughter noticed that there is a

whitish secretion on the penis of his father when she cleansed her fathers genitalia.

X. Coping- Stress ManagementAccording to the SO, patient stays only on their house. When his father experienced

pain, they just let their father rest and no medications were given to alleviate to ease the

pain. And during the hospitalization, she claimed that his father always lying on bed and

always sleeping. In addition, they helped his father to cope with his condition by

changing his lifestyle for the better, avoiding foods that are contraindicated to his fathers

condition and taking rest periods. However, the patient does feel bothered about the

expenses incurred by his children for his medical condition.

XI. Value- Belief SystemMr. V and his family was Roman Catholic but seldom visit a church. According to

the SO, it was long time ago when his father visit the church. They believe in Kwak

doctors but they were not able to consult in a Kwak doctor once. During the

hospitalization, they do not wish to see a priest at present. According to the SO, their

family accepts of his fathers condition. They do not fear death but they wishes that their

father will live longer for their family.


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4. PATHOPHYSIOLOGY AND RATIONALE

4.1 Anatomy and Physiology

To understand what occurs in heart failure, it is useful to be familiar with the

anatomy of the heart and how it works. The heart is composed of two independent

pumping systems, one on the right side, and the other on the left. Each has two chambers,

an atrium and a ventricle. The ventricles are the major pumps in the heart.

The external structures of the heart include the ventricles, atria, arteries, and

veins. Arteries carry blood away from the heart while veins carry blood into the heart.

The vessels colored blue indicate the transport of blood with relatively low content of

oxygen and high content of carbon dioxide. The vessels colored red indicate the transport

of blood with relatively high content of oxygen and low content of carbon dioxide.


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The Right Side of the Heart

The right system receives blood from the veins of the whole body. This is "used" blood,

which is poor in oxygen and rich in carbon dioxide.

y The right atrium is the first chamber that receives blood.

y The chamber expands as its muscles relax to fill with blood that has returned from

the body.

y The blood enters a second muscular chamber called the right ventricle.

y The right ventricle is one of the heart's two major pumps. Its function is to pump

the blood into the lungs.

y The lungs restore oxygen to the blood and exchange it with carbon dioxide, which

is exhaled.

The Left Side of the Heart

The left system receives blood from the lungs. This blood is now oxygen rich.

y The oxygen-rich blood returns through veins coming from the lungs (pulmonary

veins) to the heart.

y

It is received from the lungs in the left atrium, the first chamber on the left side.

y Here, it moves to the left ventricle, a powerful muscular chamber that pumps the

blood back out to the body.

y The left ventricle is the strongest of the heart's pumps. Its thicker muscles need to

perform contractions powerful enough to force the blood to all parts of the body.

y This strong contraction produces systolic blood pressure (the first and higher

number in blood pressure measurement). The lower number (diastolic blood

pressure) is measured when the left ventricle relaxes to refill with blood betweenbeats.

y Blood leaves the heart through the ascending aorta, the major artery that feeds

blood to the entire body.


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The Valves

Valves are muscular flaps that open and close so blood will flow in the right direction.

There are four valves in the heart:

y The tricuspid regulates blood flow between the right atrium and the right

ventricle.

y The pulmonary valve opens to allow blood to flow from the right ventricle to the

lungs.

y The mitral valve regulates blood flow between the left atrium and the left

ventricle.

y The aortic valve allows blood to flow from the left ventricle to the ascending

aorta.

The Heart's Electrical System

The heartbeats are triggered and regulated by the conducting system, a network of

specialized muscle cells that form an independent electrical system in the heart muscles.

These cells are connected by channels that pass chemically caused electrical impulses.


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4.2 Schematic Diagram of the Disease Process

Congestive Heart Failure

Non- modifiable Risk Factor Modifiable Risk Factor

*Family History of

Hypertension (Father)

* Age (older than 65)

*Gender (Men)

Race

*Lack of access tomedical service due to

low socio- economicstrata (unemployed)

*Poor Nutrition

(inadequate food intake)

*High Sodium andCholesterol in diet

Alcohol Consumption

Sedentary Lifestyle

Decreased elasticity of blood vessels and

formation of plaques on blood vessels

Narrowing of the blood vessels

Necrosis and Scarring of the vascular endothelium

Impediment of blood flow to the body


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Increased workload of the heart

Dilation of ventricles

Increased in preload

Increased in stretching of myocardial muscle

Excessive stretching of myocardial muscle

Ineffective cardiac muscle contraction and

increase Oxygen demand of cardiac muscle cells

Decreased contraction of cardiac muscle

Decreased cardiac output and systemic perfusion

Activation of neurohormonal pathways in

order to increase circulating blood vessels


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Continued neurohormonal stimulation

Cardiac remodeling

Decreased blood filling

Increased stroke volume and

decreased cardiac output

Inadequate perfusion Increased wall

tension

Separation of

mitral valve

Increase pulmonary

pressure

Impaired left

ventricular relaxation

*Pallor Decreased

blood flow

to the

kidney

Decreased

perfusion in

the coronary

arteries

Increased

pulmonary

pressure

*Fatigue

&weakness

Deprivation

of cardiac

muscles cells

of nutrients

needed for

survival

Kidney produce

hormone

Salt & water

retention

*Edema


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Normal balance

between Oxygen

supply &demand is

disrupted

Increased diastolic

pressure exceeding

hydrostatic & osmoticpressure in pulmonary

capillaries

Ischemia Increased capillary

ressure in the lun s

Fluid shifts from the

circulating blood into

the interstitial,

bronchioles, bronchi

and alveoli

Conversion of

aerobic metabolismto anaerobic

metabolism

Pulmonary

congestion

Decreased

lung

expansion

Fluid trapped

in pulmonary

trees

*Dyspnea

*Bilateral

Crackles

Decreased

adenosine

Causes reduced

contractility

Increasedlactic acid

production

Decreased thehearts ability

Irritation of

myocardial

cells

Chest Pain


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4.3 Discussion of the Disease Process

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 overwhelmed,

heart failure happens (MacIntyre, et. al, 2000). In this section, it focuses on the

pathophysiological mechanisms that led to the presentation of signs and symptoms of the

client, and its current treatment and identified nursing diagnosis. Figure above shows the

pathophysiology of the disease with the risk factors, presenting signs and symptoms.

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. 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.

During much of the systole, the mitral valve is subjected to high pressure

generated by the left ventricle as it pumps blood to the systemic circulation. Increased

preload occurs because the incomplete closure of the mitral valve permits the

regurgitation of blood from the left ventricle into the left atrium (Porth, 2007). In

addition, incomplete closure of the aortic valve also results in increased preload as the

left ventricle is forced to pump the entire diastolic volume received from the left atrium

and the regurgitant volume from the aorta. Increased afterload occurs as there is increased

pressure for the heart to generate the movement of the increased volume from the left

ventricle into the aorta. The increased volume work causes increased pressure for the left

ventricle to pump more blood. This eventually leads to left ventricular hypertrophy

(Porth, 2007).

As the workload increases, the walls of the chamber grow thicker, losing their

elasticity and eventually may lead to myocardial dysfunction and eventually myocardial


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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

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 to 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). 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


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- Crackles in the

lungs

- Fatigue and

weakness

Manifested

Manifested

- Adventitious breath

sounds may be heard

in various areas of the

lungs. Usually,

bibasilar crackles that

do not clear with

coughing are detected

in the early phase of

left ventricular failure.

Crackles, heard

initially in the lung

bases, and when

severe, throughout the

lung fields suggest the

development of

pulmonary edema

(fluid in the alveoli).

Source:

http://www.medicine.com

/congestive_heartfailure/a

rticle.html

- Less blood to your

major organs and

muscles makes you feel

tired and weak.

Inadequate cardiac

output leads to hypoxic

tissues and slowed

removal of metabolic


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- Jugular vein

distention

- Nocturia

Manifested

Not manifested

wastes, which in turn

cause the client to tire

easily.

Source:

- Black, Joyce M. et.al;

Medical Surgical

Nursing Clinical

Management for

Positive Outcomes; 8th

edition; volume 2; p.

1437

- The right side of the

heart cannot eject blood

and cannot

accommodate all the

blood that normally

returns to it from the

venous circulation. The

increase in venous

pressure leads to

jugular vein distention.

Source:

http://www.medicine.co

m/congestive_heartfailu

re/article.html


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- Shortness of

breath (dyspnea)

- Sleep apnea

- Sudden weight

gain

Manifested

Manifested

Manifested

- With failure of the left

ventricular

myocardium (heart

muscle), the blood

tends to backup in the

lungs with elevated

pressure causing

shortness of breath

(dyspnea), orthopnea

(having to sit to

breathe) and

paroxysmal nocturnal

dyspnea

Source:

http://www.medicine.co

m/congestive_heartfailu

re/article.html

- As the body becomes

overloaded with fluid

from congestive heart

failure, patient may

experience a sudden

weight gain.

Source:



rticle.html


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- Swelling (edema)

in legs, ankles

Manifested - Edema from congestive

heart failure is a result

of the heart inability to

pump blood and fluids

back through the

cardiovascular system.

As the fluid "waits" to

be pumped back

through the heart, it

builds up in the leg and

begins to "leak" out of

the permeable structure

of the veins.

Source:



rticle.html


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IV. NURSING INTERVENTION

4.1 Care Guide of Patient with Disease Condition

The following are the goals of nursing management for the client with HeartFailure:

Guidelines Interventions

y Adhere to dietary restrictions

y Monitor blood pressure

y Modify activity

Sodium in the diet should be

limited to 4 g per day initially

until fluid and weight gain are

controlled.

Fluid restriction may also be

needed. Follow as what the

physician advice.

Clients or family members

should be taught how to

measure BP daily, especially if

the client has diastolic heart

failure.

During the severe stages of

heart failure, the client should

remain on bed rest with the

head of the bed elevated and

elastic stockings or wraps

worn to mobilize edema. Once

the client can breathe

comfortably during activity,

activity should be increased

gradually to help increase

strength.


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y Adhere to medications The multiple medications will

require some type of system to

prevent missed or duplicate

doses. Instruct to take the

diuretics in the morning to that

trip to the bathroom happen

during the day. Taking

diuretics in the evening or at

night often results in

interrupted sleep because the

urge to empty the bladder

continues for hours.

Reference: Black and Hawks,

Medical and Surgical Nursing 8th

edition, pp1446- 1447

Congestive Heart Failure (Pp.1- 50)

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