arellano university chf grandcase presentation

8/3/2019 Arellano University CHF Grandcase Presentation.

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Arellano UniversityCollege of NursingLegarda, Manila

CHF 4, Cardiomegaly Secondary to CAD

A Case Study

Presented to the Faculty of the Arellano University

College of Nursing in Legarda, Manila

In Partial Fulfilment of the Requirements in Nursing Care Management 105 for the

Degree Bachelor of Science in nursing

Presented by:

BSN 4 12

Adviser: Mrs. Olivia Fajardo, R.N., M.A.N.

January 2012


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I.Introduction

Driven with our interest and as future nurses, we chose this case because of the

underlying knowledge behind CHF 4, Cardiomegally Secondary to CAD as it holds

vast amount knowledge that we section 12, can learn from. This case will be the

pathway to higher knowledge about CHF 4, Cardiomegally Secondary to CAD and

key to working more efficient when tackling this kind of disease.

By definition, Heart failure is a global term for the physiological state in which

cardiac output is insufficient in meeting the needs of the body and lungs. Often termed

"congestive heart failure" or CHF, this is most commonly caused when cardiac output

is low and the body becomes congested with fluid. By number, as of 2008 CHF is

present in 2 percent of person age 40 59 years old, more than 5 percent of person

age 60 69 years old and 10 percent of person ages 70 and older. According to WHO

more than 22 million people worldwide suffer from CHF. Here in the Philippines out of

the 86 million populations, 1.5 million have CHF and it is the 6th leading causes of

mortality in the Philippines, affecting males more often than females. Causes of CHF

are the following; Coronary artery disease, including angina and heart attack, is the

most common underlying cause of congestive heart failure. People who have a heart

attack are at high risk of developing congestive heart failure. Most people with heart

failure also experienced uncontrolled high blood pressurein the past, and about one out

of every three people with heart failure also has suffered from diabetes. As all of you

can see there is a number 4 in our title (CHF4) because according to the New York

Heart Association, heart failure are categorized in four class, namely class I

(uncompromised), II(slightly compromised), III (markedly compromised), and IV(

severely compromised), since our client is belong to the class IV, meaning, she cannot

perform or carry out normal physical activity without experiencing discomfort. Even at

rest she experience cardiopulmonary insufficiency.


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Congestive Heart Failure is subdivided into two main category; The Right Sided

Heart Failure and Left Sided Heart Failure, in relation to our client, she is experiencing

the Left Sided Heart Failure, as she shows sign and symptoms of it, specifically,

tachypnea and increased work of breathing. Rales or crackles, heard initially in the lung

bases, and when severe, throughout the lung fields suggest the development of

pulmonary edema (fluid in the alveoli). Cyanosis which suggests severe hypoxemia is a

late sign of extremely severe pulmonary edema. Diagnostic procedure commonly use to

support the clinical diagnosis of CHF are; Echocardiography, Chest X Ray,

Electrocardiogram (ECG/EKG).


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II. Objectives

General Objective:

Nowadays, heart problems are the majority disease of most of us. Its because of

lifestyle, knowledge deficit and other risk factors that causes this illness so we, BSN IV

Section 12 of Arellano University College of Nursing, aims to develop our skills in

performing assessment procedures and the necessary intervention for quality care of

the client, to enhance our knowledge in understanding the disease and identify specific

treatment for client who is suffering from it. We want emphasize that nurses should be

familiar with this because we are the instruments that will brought our country in lesser

morbidity and mortality rate on heart problems.

Specific Objectives:

At the end of the presentation the students will be able to:

y Give a brief introduction about CHF 4, Cardiomegally Secondary to CAD together

with the clinical manifestations.

y Present a theoretical framework for the study in relation to a nursing approach

applied to our client.

y Present the clients demographic and health history with its Gordons eleven

functional health patterns, to know how the client get the disease.

y Present the abnormal results of the physical assessment and compare it to the

normal values or findings which will help in analyzing the disease process.

y Present the different laboratory test and results done to the client with itsinterpretation.

y Discuss the normal Anatomy and Physiology of the Heart.

y Explain the Pathophysiology of CHF 4, Cardiomegally Secondary to CAD to

elaborate how the disease and its complications formed.


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y Identify Nursing Problems related to the situation of the client and apply

necessary intervention.

y Discuss the drugs that has been used and prescribed to the client, to emphasize

its action to the clients system.

y Discuss the appropriate discharge plan for the client.


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III. Theoretical Foundation

D o r o t h e a O r e m s S E L F - C A R E T H O R Y

According to this theory, self care is a learned behaviour and a deliberated

action in response to a need. Orem identifies 3 categories of self care requisites:

1.Universal self care requisites Common to all human beings and include both

physiological and social interaction needs.

2. Developmental self care requisites That are needs arise as the individual grows

and develops.

3. Health deviation self care requisites Result from the needs produced by disease

and illness states.

In relation to our client and according to the categories; in terms of Universal

requisites, Since our client case is about heat failure, in which her left ventricle cannot

pump out oxygenated blood effectively, tendency pressure will build up to the Leftventricles which causes backflow of blood to the left atrium and to the lungs causing

pulmonary edema, thus our client experiencing difficulty of breathing because of impaire

gas exchange of oxygen and carbon dioxide, hence our client needs to rest and avoid

extraneous activity to avoid aggravation of her condition. In developmental requisites,

according to Erik Erikson developmental theory with her age of 55 y/o she is in stage of

generativity v.s. stagnation, however because of her condition right now, and being

hospitalized, she cannot do her role as a mother to her family, which causes her to

perceive as worthless, but still shes hoping to recover from her condition. In health

deviation requisites, our client should be aware on the potential complications of her

condition, modify lifestyle to accommodate changes in the health status and adhere to

all medical regimens given to her, for her to recover soon.


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IV. Nursing History

A. Biographical Data

Clients Name: TDGP

Address: Yellowbell St. NBBN Navotas City

Gender: Female

Date of Birth: February, 22 1962

Age: 48 yrs old

Nationality: Filipino

Religion: Roman Catholic

Date of Admission: December 4 2011

Medical Diagnosis: CHF 4, Cardiomegally secondary to CAD

B. Chief Complaint

Clients chief complaint was nahihirapan akong huminga at sumasakit din ungdibdib ko, as stated by the client.

C. History of Present Illness

Two months prior to admission, the client had an onset of productive cough and

colds associated with difficulty of breathing. No fever or associated symptoms are

experienced. There is no consultation done.

A month prior to admission, cough persisted, and there was onset of easy

fatigability, light-headedness, and dyspnea on exertion and is slightly relieved by rest.


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Weeks prior to admission, dyspnea on exertion was no longer relieved by rest,

and even she was sleeping, she still experience DOB, sometimes this DOB was

awakening her while she sleeps. Few hours prior to admission, the severity of DOB

increases accompanied by chest pain and back pain prompted consult at emergency

room and was admitted.

D. History of Past Illness

Regarding to the clients past illness, the client was diagnosed of PTB last 2009 in

which it was treated for 6 months, on the same year she was diagnosed also of CAD,

medication was given and health teachings was made to resolve her CAD, but no

complaint to the said management. Furthermore in the past, the client claimed to us that

she was already acquired chickenpox, measles and other childhood diseases in which it

was treated with home remedies and unrecalled medication. No allergies noted.

E. Family Health History

Diabetes

MellitusCancer

Heart

DiseaseAsthma Hypertension

Siblings None None

Had a

heart

disease

None Hypertensive

Father Diabetic None

Had a

heart

disease

None Hypertensive

Mother None None None None Hypertensive


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F. Social History

According to the client, she is non alcoholic beverage drinker and do not

smoke. Client owned her house with 1 room and 1 comfort room with Manual flush

type. Water supply is from NAWASA, and garbage is collected every morning, electricity

is from Meralco, and means of transportation is thru public means. She usually stays at

home to do the household choirs. She has middle self esteem with close relationship

to his family and values the mano po system. She can able to speak Tagalog.


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V. Gordons Functional Health Pattern

Pattern Before Hospitalization During Hospitalization

Health Perception HealthManagement Pattern

The client tells us thatbefore, she doesnt want anyconsultation or even go forcheckups because sheperceives that she is healthyand there is nothing wrongwith her. She was also fond

of eating foods high incholesterol and protein aswell as foods rich in sodium,even though she knows thattoo much intake ofcholesterol and sodium willaggravates her condition.

According to the client, herhealth is progressingalthough still withintermittent DOB. She reallywants to go home, so shecomplied with all medicationthat was given to her and

followed all the advised andhealth teaching of all thehealth care providerbecause she believed thatthis is for her own good.

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sochsoh


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Nutritional and MetabolicPattern.

We werent able to get theclients 1 week food recallbut we are able to get theclients preferred foods.She told us that she wasfond of eating foods high incholesterol, and sodiumsuch as chicaron, papaitan,and ihaw ihaw. She

consume 7 8 glass ofwater per day and fond ofdrinking coffee consuming4- 5 glass of coffee per dayand she weighs 88lbsduring the admission

During hospitalization,the clients was on lowsodium and low fat diet.She eats fruitslike apples and oranges,she also eats bread. Sheconsumes 2 3 glass ofwater a day and accordingto our client he told us that

her weight decrease from88lbs to 82lbs

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Elimination Pattern

Bowel: Patient usually

defecates once a daywithout experiencing

discomforts, usually

morning or afternoon. Stoolwas brown in colour

and is well-formed.

Bladder: Patient voids 3 4

times a day, she told us thather urine colour is clear and

aromatic in odour.

Bowel: The patient has nooutput for 4 days

Bladder: She voids 6 timesduring the shift. Her urine isaromatic in odor and amberyellow in color. Withoutdifficulty in voiding.

DococfoJcacod

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Activity and exercisePattern

According to our client,when the sign andsymptoms of CHF was notthat evident to her, sheusually do first the

household chores, when shehas a free time, she loves towalk around to herneighbours and mingle withthem, but when sign andsymptoms of CHF wasseverely compromising her,that even at rest shedevelops sign andsymptoms like easyfatigability and dyspnea, so

she refrained from strenuousactivity.

The client is on completebed rest. She still sufferingfrom easy fatigability due tohis present condition thatlimits him to move around,

although the client claimedthat she can still feedhimself and do hygienicpractices with minimalassistance.

AMeine

serehusthbathuhoRcooreeco

Sleep and rest Pattern

The client told us that whenthe sign and symptoms ofCHF were not that evident,her sleeping pattern wasusually 7 8 hours, sleepingat around 10 and waking ataround 5 or 6am, however,when sign and symptomswere evident to her, she

The patient cannot take herusual sleep pattern duringhospitalization. She onlysleeps for 3-4 hours for thewhole day because she isexperiencing shortness ofbreath even during rest. Shealso experience slightfatigue even at rest.

Batonnuath


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develops paroxysmalnocturnal dyspnea, in whichin the middle of her sleepshe wakes up because ofDOB, although she claimed

to us that she take naps atthe afternoon tocompensate.

ds

Cognitive PerceptualPattern

The client was able to readand write, and claimed to usthat he doesnt experiencedsensory perceptual deficits,she also claimed that shecan communicate wellwithout any difficulty and cancomprehend well. She canspeak tagalong and hernative dialect of ilokano.

The client is conscious,coherent and responsive ,still no complaints to hissenses and can understandwell.

Ta

Self Perception and Self Concept Pattern

The client to us that she hasmiddle self esteem, she alsotold us that she is friendly,the client also claimed thatshe want to live his life to thefullest.

Her condition made himrealize his mortality.she is recalling herregrets in life. Shethinks that it is too late tochange because of hercondition, although our clientstates that she is stillpositive and optimistic abouther condition.

Bchfrenhcothaa


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Roles /RelationshipPattern

The client has a close familyrelationship, especially toher sister, whom she is withevery single day of her life.

The client tells us that shemisses his family especiallyher sister, although hersister was visiting her, shealso told us that she wantsto go home as soon aspossible.

Auwbcahillh

Sexuality/ ReproductivePattern

The client refuse to talk

about it, because he is notcomfortable

The client refuse to talk

about it, because he is notcomfortable

T

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Coping Stress TolerancePattern

The patient stated that whenshe was stressed, sheusually laughs on it andhandles stress like it isnothing. And she seesthings positively.

The client tells us that herconfinement made herstress and according to her,she is still very optimisticand positive that she canhandle this thing out.

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Value/Belief

Patient is a RomanCatholic. According to theclient, she goes to Sundaymass with his family.

According to the patient,

there are no practices

that affect his

hospitalization. She followstherapeutic

regimen and she has astrong

faith to God whom he

believes will help himrecover soon.

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VI. Physical Assessment(12/08/11)

General Survey: When we perform our physical assessment, the client was on sitting position,

very responsive to all our questions and instructions, and poor grooming, no obvious deformitie

breathing that precipitated on minimal and moderate activity and experiencing sudden attacks o

complaints dry hacking cough, easy fatigability, dizziness, lightheadedness, restlessness; skin

cool and clammy skin.

Vital Signs:

Temperature: 36.1C

Pulse Rate: 111bpm

Respiratory Rate: 27cpm

Blood Pressure: 80/60mmHg

Body Parts Normal Findings Actual Findings

Head Skull (Inspection and

Palpation)

Round, (norm, cephalic and,

symmetric, with frontal.

Parietal , and occipital

prominence) Smooth skull

contour, uniform consistency

and absence of masses

(*Fundamental of Nursing-

We found out that his head

skull is round, (norm,

cephalic and symmetric with

frontal, parietal and occipital

prominence) smooth skull

contour, uniform consistency

and absence of masses.


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Kozier 8th ed.; Unit

7,Chapter 30 p.584 - 585)

Hair(Inspection)

Normal hair is evenly

distributed, thick, silky andresilient. No infection or

infestation variable body

hair.(* Fundamental of

Nursing-Kozier 8th ed.; unit 7

Chapter 30, p.582)

His hair is not evenly

distributed, thin, and notsilky. No infection or

infestation variable body

hair.

Face (inspection)

Symmetric or slightly facial

features, palpebral features,

equal in size, symmetricnasolabial folds, symmetric

facial; movements.(*

Fundamental of Nursing-

Kozier 8th ed.; unit 7 Chapter

30, p.584

Symmetric or slightly facial

features, palpebral features,

equal in size, symmetricnasolabial folds, symmetric

facial; movements.

Eyes (Inspection)

Normal eyes should be

aligned and symmetrically

without protruding and

appearing sunken. Cornea is

transparent (* Fundamental

Her eyes are symmetrically

aligned and without

protruding and appearing

sunken.


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of Nursing-Kozier 8th ed.;

unit 7 Chapter 30, p.588)

Ears( Inspection)

Normal ear should have the

same colour as the facialskin. Auricle should be align

with the outer cantus of the

eye, about 10 degree from

vertical. (* Fundamental of

Nursing-Kozier 8th ed.; unit 7

Chapter 30, p.594 598)

We found out that his hear

have the same colour as thefacial skin. The auricle is

align with the outer cantus of

the eye

Nose (Inspection)

Normal nose should be

symmetric and straight, nodischarge or flaring, no

lesions, air moves freely as

the client breaths through

the nares. Mucosa should

be pink and there should be

no lesion uniform in colour.

(* Fundamental of Nursing-

Kozier 8th

ed.;Unit 7 Chapter30 p.599 - 600)

Her nose is symmetric and

straight, no discharge orflaring, no lesions, air moves

freely as our client breath

through the nares.


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Mouth/Lips (Inspection) Normal mouth/lips should be

uniform pink in colour, soft

moist and smooth in texturessymmetric of contour and

ability to purse lips. Tongue

should be in central position

pink in colour, moist, move

freely and no tenderness.

Gums should be pink in

colour and moist. .

(* Fundamental of Nursing-Kozier 8th ed.;Unit 7 Chapter

30 p. 601 - 604)

His mouth/lips are pale soft

moist and smooth in textures

symmetric of contour andability to purse lips. Tongue

in central position pale in

colour, moist, move freely

and no tenderness. Gums

are pale in colour and moist.

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Neck (Inspection and

Palpation)

Normal Neck should have;

muscles equal in size, head

is centered. Coordinated

smooth movements without

discomfort. Head should be

flexes 45, and hyperextend

up to 60. Lymphnodes

should not be palpable,

The clients neck have the

equal muscle size in his

neck, head is centered.

Movements are coordinated

and smooth without any

discomfort. The client was

able to flex his neck 45, and

hyperextend up to 60.


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thyroid gland not visible on

inspection. Gland ascend

during swallowing but is not

visible. (* Fundamental of

Nursing- Kozier 8th ed.;Unit

7 Chapter 30 p. 607 - 609)

Lymphnodes are not

palpable, thyroid gland is not

visible upon inspection.

Gland ascend during

swallowing.

Chest/Thorax/Lungs

(Inspection/Palpation

/auscultation/Percusion)

Normal Chest/Thorax should

have no discoloration, no

sternum retraction, no chest

exertion, no masses, and

normal muscles tone. No

chest retraction. Chest

symmetric and spine

vertically aligned. Skin is

intact uniform in

temperature, chest wall

intact no tenderness


Kozier 8th ed.;Unit 7 Chapter

30 p. 610 - 618)

The client was experiencing

sudden attacks of difficulty

of breathing also she

experienced paroxysmal

nocturnal dyspnea (PND)

and complaints of productive

cough and easy fatigability

even without doing

something strenuous.

Adventitious lung and heart

sound were noted, like

crackles in the lungs and 3rd

heart sound (S3) in the heart

upon auscultation

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Abdomen (IAPP)

Unblemished skin, uniform

in color, flat rounded. No

evidence of enlargement of

liver or spleen. Audible

bowel sound, absence of

bruit sounds. No tenderness.



30,p.631- 638)

The client has unblemished

skin, uniform in color, flat

rounded. No evidence f

enlargement of liver and

spleen, however there was a

decrease in bowel sound.

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Upper Extremities

(inspection /Palpation)

Normal upper extremities

should have; muscle not

tender, firm, equal in size,

bilaterally w/o fasciculation,

equal in number and no

abnormalities.



Upon assessing his upper

extremities we found out that

his muscle is equal in size

and no abnormalities.


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30, p.640 641)

Nail (Inspection)

Convex curvature, smooth

texture, high vascular and

pink in light skinned clients.

Intact epidermis and prompt

return of ink or usual color,

(* Fundamentals of Nursing-

Kozier 8th ed.; unit 7, chapter

30 p.582),

Her nails are convex

curvature, smooth in texture,

pink and intact but the

capillary refill last for 6 secs

It

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th

p

tis

p

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a

Lower extremities

( Inspection/Palpation)

Equal in size, no tremors,

smooth coordinated

movement, no tenderness

and swelling as well as

edema, can perform ROM,

palpable pulse should berecognize, warm to touch (*

Fundamentals of Nursing-

Kozier 8th ed.; unit 7, chapter

There was some presence

of edema in her lower

extremities.

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VII. Anatomy and Physiology

HEART

The human heart is a cone shaped, hollow,

muscular organ located in the mediastinum between the

lungs. It is about the size of an adult fist. The heart rest on

the diaphragm, tilting forward and to the left, in the clients

chest. Each beat of the heart pumps about 60cc or ml of

blood or 5L/min. During the strenuous activity, the heart

can double the amount of blood pumped to meet the

increased oxygen needs of the peripheral tissue.

The heart is encapsulated by a protective covering

called the Pericardium. Cardiac muscle tissue is

composed of three layers: Epicardium, Myocardium and Endocardium. The

myocardium, the middle layer is composed of striated muscle fibers interlaced into

bundles. This middle layer is responsible for contractile force of the heart. The

innermost layer w/c is the endocardium is composed of endothelial tissue, which is

responsible for the inside lining of the heart.

CHAMBERS OF THE HEART

A muscular wall w/c is called the septum separates the heart into two halves: the

Right and the Left. Each half has an upper chamber w/c is term as the Atrium and a

lower chamber, the Ventricle.

The RIGHT side, w/c is composed of the Right Atrium (RA) and Right Ventricle

(RV). The right atrium receives deoxygenated venous blood (venous return) from all

peripheral tissue by way of the superior vena cava and the inferior vena cava and also

from the heart muscle by way of the coronary sinus. Most of this venous return flows

passively from the RA, through the opened Tricuspid Valve then into the RV during

ventricular diastole or filling. When there are blood remains to the RA after ventricular


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diastole, it is being propelled into the RV during the atrial systole or contraction.The right

ventricle is a flat muscular pump located behind the sternum. The RV generates enough

pressure, about 25 mmHg to close the tricuspid valve, open the pulmonic valve, and

propel blood into the pulmonary artery and the lungs.

The LEFT side, after blood is reoxygenated in the lungs, it flowsfreely form the

four pulmonary veins into the Left Atrium (LA). Blood then flows through an opened

mitral valve into the Left Ventricle (LV). When the LV is almost full, the LA contracts,

pumping the remaining blood volume into the LV. With the systolic contraction the LV

generates enough pressure, approximately 120 mmHg to close the mitral valve and

open the aortic valve. Blood the propelled into the aorta and into the systemic

circulation. The LV is the largest and most muscular chamber of the heart. Its wall is two

to three times the thickness of the right ventricular wall.

CORONAR ARTERIES

The heart receives blood to meet its

metabolic needs through the coronary artery

system. The blood leaving the LV exits through

the aorta, the bodys main artery. Two coronary

arteries, referred to as the "left" and "right"

coronary arteries, emerge from the beginning of

the aorta, near the top of the heart. The initial

segment of the left coronary artery is called the

left main coronary. This blood vessel is approximately the width of a soda straw and is

less than an inch long. It branches into two slightly smaller arteries: the left anterior

descending coronary artery and the left circumflex coronary artery. The left anterior

descending coronary artery is embedded in the surface of the front side of the heart.

The left circumflex coronary artery circles around the left side of the heart and is

embedded in the surface of the back of the heart. Just like branches on a tree, the

coronary arteries branch into progressively smaller vessels. The larger vessels travel

along the surface of the heart; however, the smaller branches penetrate the heart


29/65

muscle. The smallest branches, called capillaries, are so narrow that the red blood cells

must travel in single file. In the capillaries, the red blood cells provide oxygen and

nutrients to the cardiac muscle tissue and bond with carbon dioxide and other metabolic

waste products, taking them away from the heart for disposal through the lungs, kidneys

and liver. When cholesterol plaque accumulates to the point of blocking the flow of

blood through a coronary artery, the cardiac muscle tissue fed by the coronary artery

beyond the point of the blockage is deprived of oxygen and nutrients. This area of

cardiac muscle tissue ceases to function properly. The condition when a coronary artery

becomes blocked causing damage to the cardiac muscle tissue it serves is called a

myocardial infarction or heart attack.

REGU

LATION OF HEARTS F

UNCT

ION

a. INTRINSIC REGULATION

Refers to the mechanism contained within the heart itself. The force

of contraction produced by cardiac muscle is related to the degree of stretch of cardiac

muscle fibers. The amount of blood in the ventricles at the end of ventricular diastole

determines the degree to which the cardiac muscle fibers are stretched. Venous return

is the amount of blood that returns to the heart, and the degree in which the ventricularwalls are stretched at the end if diastole is called preload. If venous return increases,

the heart fills to a greater volume and stretches the cardiac muscle fiber, producing an

increase in preload. In response to the increased preload, cardiac muscle fiber contract

with a greater force resulting to increase CO. As venous return increases, preload will

also increases, resulting to an increase in CO. As venous return decreases, preload will

also decrease, thus CO will also decrease. This relationship of the preload and the

stroke volume is called Starlings Law of the heart


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b. EXTRINSIC REGULATION

Refers to the mechanism external to the heart, such as either

hormonal or nervous regulation. Nervous influences are carried through the autonomic

nervous system. Both sympathetic and parasympathetic nerve fiber innervates the

heart. Sympathetic stimulation causes the heart rate and stroke volume to increase,

whereas parasympathetic stimulation causes heart rate and stroke volume to decrease.

The Baroreceptor, plays an important role in regulating the function of the heart.

Barorecptors are stretch receptors that monitor blood pressure in the aorta and in the

wall of the internal carotid arteries, which carry blood to the brain. Changes in blood

pressure result in changes in the stretch of the walls of these blood vessels. Thus,

changes in the blood pressure cause changes in the frequency of action potentialsproduced by the baroreceptors. The action potential are transmitted along the nerve

fibers from the stretch receptors to the medulla oblagata of the brain. Within the medulla

oblongata is a cardioregulatory center, which receives and integrates action potential

from the baroreceptors, also the cardioregulatory mechanism influences sympathetic

stimulation of the adrenal gland.


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XIII. Pathophysiology

Coronary Artery

thickens and become

stiffer and less

distensible

Non modifiable:

y Age: 50 y/o

y Family

history of

heart

y Menopause

This makes it harder

for the blood to pass

through

Coronary Artery

narrows and become

more irregular in

shape

Estrogen level

decreases

Inability to

maintain LDLcholesterol level

Oxidized LDL attracts

monocytes and

macrophages to the site

thus promoting

inflammation to the site

Hypertension

Causes injury to the

arterial wall (tunica

intima)

Shedding and

desquamation of

superficial layer occurs

Promotes LDL and

platelet to assimilate in

the injured part

Decrease

oxygenated blood

supply to the

coronary artery

(LADA)

Body compensate by

increasing systolic

pressure thus

supplying the coronary

artery enough blood.

Increase LDL level in

the blood (1.89

mmol/L)

M


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Plaque begins to form

from cells w/c

imbedded into the

endothelium

Lipids are then engulf

by the macrophages,

aggregation of platelets

continue

Thrombus

formation

occurs

Rapid increase

in size of the

thrombus in

the coronary

artery

Sluggish

blood flow

results

Decrease blood

flow in the

preceding coronary

artery

Decrease oxygenated

blood supply in the

myocardium area

Ischemia

results

Myocardial muscles are

sensitive to changes in

PH, resulting to damageand become less

functional

Decrease

myocardial

contractility

Decrease

CardiacOuput

Decrease BP and

SV

Registered on

pressoreceptor/baroreceptors in

w/c its stimulates the sympathetic

nervous system to increase HR, and

promoting peripheral

vasoconstriction,

However too much stimulation of

the SNS also causes the

hypothalamus to secrete

vasopressin which cause fluid

retention.

Increase BP,

and CO will

results

Easy

fatigability

Increase venous return to the heart

results


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Heart fills greater volume

and stretches the cardiac

muscle fibers

Preload

increase as

result

Left ventricular

hypertrophy

results

Cardiomegally

Due to hypertrophy, LV

cannot pump out blood

efficiently to supply the

systemic circulation

Decrease BP

and SV

LV finally loses

function to pump

out blood because

of severe

exhaustion

LV cannot move

blood to the

aorta into the

systemic

circulation

Blood pooling in

the LV occurs

Increase pressure

the LV results to b

flow of blood to t

LA to the pulmon

capillaries

Kidney detect

decrease blood

pressure and

volume

Juxtaglomerular

apparatus release

RENIN

RENIN goes to the liver where

it will convert the

angiotensinogen to

angiotensin I

Angiotensin I goes to the lungs

whereas ACE convert the

angiotensin I to angiotensin II

Angiotensin II

stimulates the

adrenal cortex to

secrete

aldosterone

Aldosterone

increases

sodium

production as

well as water

retention


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Increase pressure to

pulmonary circulation re

fluid passing from pulm

capillary to the interstiti

and alveoli

Pulmonary EdemaCrackles

Fluid interferes

with oxygen

carbon dioxide

exchange

Dyspnea

Paroxysmal nocturnal

dypnea

On exertion

Edema on the

dependent part

(lower

extremities)

however this

only occurs at

day, as the

client sleeps or

lies down, the

fluid will then

goes back to the

lungs


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IX. Laboratory Data

Chest X Ray result (12/05/11)

- Lungs are clear, pulmonary vessels are slightly accentuated. Heart is enlarged

with left ventricular form

- Impression: Cardiomegaly with pulmonary congestion.

HEMATOLOGY (12/06/11)

COMPLETE BLOODCOUNT

Result Normal Values Analysis

HEMOGLOBIN 11.3g/dl 14 18g/dl Hgb level has decreasesignificantly, becauseinterference in oxygen ancarbon dioxide exchangebrought about of bypulmonary edema.

HEMATOCRIT 0.33% 0.37 0.45% Since our client hasdecrease level of HgB,tendency is that his Hct walso decrease

WBC 11.6 4.11 x 10^9/lWBC increases, for thereason that monocytes anmacrophages are both

attracted by oxydized LDLwhich promotesinflammation thuspreventing further damag

RBC 5.7 5.0 6.4 Normal


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EOSINOPHILS 0.03 0.02 % 0.04% Normal

NEUTROPHIL/SEGMENTER 0.53 0.50% 0.70% Normal

LYMPHOCYTES 0.33 0.20% 0.40% Normal

MONOCYTES 0.05 0.02% 0.05% Normal

Clotting Factor Result Reference Range Analysis

PLATELETCOUNTS

185 150-450 Normal

% ACTIVITY 80.3 73 127% Normal

INR 1.14 0.88 1.21 Normal

APTT 37.4 30.4 41.2 Normal

Serum and Electrolytes(12/06/11)

RESULT RANGE ANALYSIS

SODIUM 146 mEq. /L 136 145 mEq. /L This is due to herdiet of high in

sodium


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POTASSIUM 3.8 mEq. /L 3.5 5.1mEq. /L Normal potassium

electrolyte

URINALYSIS (12/07/11)

RESULT

COLOR LIGHT

TRANSPARENCY CLEAR

SUGAR NEGATIVE

PROTEIN NEGATIVE

Ph 6.0

SPECIFIC GRAVITY 1.010

WBC 0 2

RBC 1 3

EPITHELIAL CELL OCCASIONAL

CRYSTAL

AMORPHOUS URATE OCCASIONAL


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LIPOLIPIDS AND TRIGYCERIDES (12/07/11)

RESULT NORMAL VALUES ANALYSIS

CHOLESTEROL 6.3mmol/L 1.3 5.2 Her cholesterolblood level is toohigh, factors thatpredispose her ofhaving highcholesterol level isher diet. Eatingfoods high incholesterolincreases your riskon developing CAD

TRIGLYCERIDES 1.15mmol/L 0.17 1.70 Normal

HDLCHOLESTEROL

1.05mmol/L 1.04 1.55 Normal (GOODcholesterol)

LDL 2.40mmol/L 1.89 Elevated LDL (BADcholesterol) this

deposits cholesterol

in the arterial wall


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X. Drug Study.

Drug Name Classification Mechanism ofAction

Indication Contraindication SideEffects/Ad

Effec

Generic Name:Furosemide

Brand Name:Apo-FurosemideFurosideLasix

Dosage:20mg/tab

Frequency:BID

Loop diuretic Inhibitsreabsorption ofsodium andchloride atproximal anddistal tubule andin the loop ofHenle

Pulmonaryedema;edema inCHF,

Hypersensitivityto sulfonamides,

anuria,

hypovolemia,

infants,

electrolytedepletion

CNS: Headfatigue, weaparesthesia

CV: Hypote

EENT: Blurvision

ELECT:

Hypokalemhypochlorealkalosis,hypomagnehyperuricemhypocalccehyponatremmetabolic a

ENDO:

Hyperglycm


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GI: Nauseadiarrhea, drmouth, vomanorexia, coral, gastric

irritations,pancreatitis

GU: Polyurfailure, glyc

HEMA:

Thrombocy, agranulocleucopenianeutropenia

anemia

INTEG: Rapruritus, puStevens-Josyndrome,sweating,photosensiurticaria


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Drug Name Classification Mechanism

of ActionIndication Contraindication Side

Effects/AdEffec

Generic Name:Spironolactone

Brand Name:Aldactone, Novo-spiroton

Dosage:25mg/tab

Frequency:OD

Potassium-sparing diuretic

Competeswithaldosteroneat receptorsites in distaltubule,resulting inexcretion ofsodiumchloride,water,

retention ofpotassium,phosphate

Edema ofCHF,hypertenstion, diuretic-inducedhypokalemia, primaryhyperaldosteronism,edema ofnephritic

syndrome,cirrhosis ofthe liverwith ascites

Hypersensitivity,anuria, severerenal disease,hyperkalemia,

CNS: Headdrowsiness

GI: crampsbleeding,gastritis,vomiting,anorexia, n

INTEG: Rapruritus, u

ENDO:

Imoptencegynecomairregularmenses,amenorrhepost-menobleeding,hirsutism,deepening

HEMA:

Agranulocy


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ELECT:

Hyeprcholometabolicacidosis,hyperkalem

hyponatrem


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Effects/AdEffec

Generic Name:Digoxin

Brand Name:Lanoxin

Dosage:250mg/ml/amp amp

Frequency:OD

Cardiac glycoside, Inhibits thesodium-potassium

ATPase,which makesmore calciumavailable forcontractileproteins,resulting in

increasedcardiacoutput;increasesforce ofcontraction(+inotropiceffect);decreasesheart ratechronotropic

effect);decreasesAVconductionspeed

CHF, atrialfibrillation,atrailflutter,atrialtachycardia,cardiogenic shock,paroxysma

l atrialtachycardia, rapiddigitalization in thesedisorders

Hypersensitivityto digitalis,ventricularfibrillation,ventriculartachycardia,carotid sinussyndrome, 2nd or3rd degree heartblock

CNS: Headdrowsinessfatigue.

CV: Dysrhyhypotensionbradycardia

EENT: Bluvision, yellogreen halosphotophobidiplopia

GI: Nauseavomiting, anabdominal

diarrhea


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Effects/AdEffec

Generic Name:Sulbactam-

Ampicillin

Brand Name:Unasyn

Dosage:750mg IV

Frequency:q8

Broad-spectrumanti-infective

Interferes withcell wallreplication ofsusceptibleorganisms; thecell wall,renderedosmoticallyunstable,swells, bursts

from osmoticpressure;combinationextendsspectrum ofactivity by -lactamaseinhibition

Skininfections,intra-abdominalinfections,pneumonia,gynecologicinfections,

meningitis,septicemia

Hypersensitivityto penicillins,ampicillin, orsulbactam

HEMA:Aneincreased btime, bone depressiongranulocyto

GI: Nauseavomiting, dincreased A

ALT, abdom

pain, gastristomatitis,glossitis,

GU: Oliguriproteinuria,hematuria,vaginitis,moniliasis,glomerulondysuria


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Effects/AdEffec

Generic Name:Enoxaparin

Brand Name:Lovenox

Dosage:4000 U

Frequency:BID

AnticoagulantAntithrombotic

Preventsconversionof fibrinogento fibrin andprothrombinto thrombinbyenhancinginhibitoryeffects of

antithrombinIII; produceshigher rationof anti-factorXa to IIa

Preventionof deep-veinthrombosis,pulmonaryemboli inhip andknee andhipreplacemen

t

Hypersensitivity tothis drug, heparin,or pork;hemophilia,leukemia withbleeding, pepticulcer diseasethrombocytopenicpurpura, heparin-induced

thrombocytopenia

GI: Nausea

HEMA:

Hypochromanemia,thrombocytbleeding

INTEG:

Ecchymosis


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Effects/AdEffec

Generic Name:IsosorbideDinitrate

Brand Name:Apo-ISDNISDN

Dosage:5mg tab

Frequency:OD

Anti-anginalVasodilator

Decreasespreload,afterload,which isresponsiblefordecreasingleftventricular-end-diastolic

pressure,systemicvascularresistanceand reducingcardiac O2demand

Chronicstableanginapectoris,prophylaxisof anginapain, CHF

Hypersensitivityto this drug ornitrates, severeanemia,increasedintracranialpressure, cerebralhemorrhage,acute MI

CV: Posturahypotensiontachycardiacollapse, sy

GI: Nauseavomiting

INTEG: Pasweating, ra

CNS: Vascheadache,flushing, dizweakness,faintness


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of ActionIndication Contraindication Sid

Effects/AEffec

Generic Name:Simvastatin

Brand Name:Zocor

Dosage:10 mg

Frequency:

OD HS

Lipid-loweringagents

Inhibit anenzyme 3-hyrdorxy-3-methyglutarylcoenzyme A(HMG-CoA)reductase,which isresponsiblefor catalyzing

an early stepin thesynthesis ofcholesterol.

Adjunct todietarytherapy inthemanagementof primaryhypercholesterolemia andmixeddyslipidemia.

Reduction oflipids/cholessterolreduces therisk of MIand strokesequelaeanddecreasesthe need forbypass

procedures/angioplasty

Hypersensitivity.Cross-sensitivityamong agentsmay occur, acutehypotension,

CNS: Dizzheadache

EENT: bluvision

GI:Abdomcramps, fheartburnaltered ta

dyspepsiaelevated lenzymes,nausea,pancreati

GU: Impo

DERM: Rpruritus


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XI. NURSING CARE PLANS


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XII. DISCHARGE PLAN

Medication:

y Review medication regimen

Label all medications ( Furosemide, Sprinolactone, Digitalis,

Sulbactam Ampicillin, Enoxaparin, Isosorbide Dinitrate and

Simvastatin)

Give written instruction to all medication especially to digitalis and

diuretics.

a. Digitalis therapy:

advised the client to assess first her cardiac rhythm using her

apical pulse which is located at 5th intercostals space mid

clavicular line, for 1 full minute, if her PR is 120BPM, withhold the drug, wait again for 1hr then take RR if it

is >60BPM or


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b. Diuretic therapy:

Furosemide

Make sure to always assess sign and symptoms of

hypokalemia in relation to Digitalis therapy, because as

what i said a while ago, decrease in potassium level

potentiate toxicity,

Also advised client to eat foods high in potassium such

as avocado, banana, orange, and melon

Advised to take the drug, early in the morning or in the

afternoon to prevent sleep pattern disturbance relate to

nocturia

Exercise:

y Advised client to avoid any extraneous activity, because it may aggravates

her condition, however may start gradual ambulation to prevent risk for

venous thrombosis

y Advised client to position herself leaning forward or semi fowlers, if she

experience dyspnea

y Advised to increase walking and other activities gradually, provided they do

not cause fatigue and dyspnea.

Treatment:

y Advised client to adhere to the medical regimen given to her.

y Also advised client to avoid any stress, because stress causes anxiety, this

anxiety increases breathlessness which may be perceived by the client as an

increase in the severity of heart failure


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Health education:

y Teach client about the sign and symptoms of recurrence or complication

(Right side heart failure)

Watch for:

a. Weight gain report weight gain of more than 2 3 lbs in a few

days

b. Swelling of ankles, feet, jugular vein and abdomen

c. Persistent cough with pinkish frothy sputum

d. Easy fatigability

e. PND

Outpatient:

y Emphasized to the client the importance of follow up check up for continues

recovery of his condition.

Diet:

y Advised client to decrease intake of sodium, however needs to avoid

completely fatty foods

y Provided list of foods with low residue and with vitamins supplement

y Advised to eat small frequent feeding

Spiritual:

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


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XIV. Bibliography

Physiology and Anatomy, by Greishelmer Wiedeman

Essential of Human Anatomy And Physiology 7thed, by Elaine N. Marieb

Saunders Nursing Drug Handbook,2007

DPDs 8th edition

Nurses Pocket Guide 9th ed.

Porth, C.M (2005) Pathophysiology

Gould, B.E. Pathophysiology for the health professions 3rd edition.

White Lois (2005) Foundation of Nursing, 2nd Edtion

Daniels, R. Et al (2010) Nursing Fundamentals Caring and clinical decisionmaking 2nd edition.

Spratto, G.R. et al (2005) PDR Nurses Drug Handbook 2005 edition.

Loebl, S. Et al (1994) The Nurses Drug Handbook 7 th edition.

Doenges, M.E. et al (2006) Nursing Care Plans Guidelines forindividualizing client care across the life span


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