Introduction:

For the purpose of privacy and confidentiality, the real name of the patient in this Case Study is withheld and she will referred to as
Patient X

Patient X is a 98 years old female who was currently residing at San Miguel, Tarlac City. Patient X was admitted at the Central Luzon
Doctors Hospital last July 6, 2014 at 10:40pm with a chief complaint of difficulty of breathing.

Background Knowledge

Congestive Heart Failure describes the inability or failure of the heart to adequately meet the needs of organs and tissues for oxygen and
nutrients. This decrease in cardiac output, the amount of blood that the heart pumps, is not adequate to circulate the blood returning to the heart
from the body and lungs, causing fluid (mainly water) to leak from capillary blood vessels. This leads to the symptoms that may include shortness
of breath, weakness, and swelling.

What Causes Congestive Heart Failure?

There may be many potential reasons for a patient to develop heart failure. It may be due to structural damage to the heart, inability of the
heart to squeeze properly, medications or drugs that affect heart function, lung disease, and other underlying medical diseases. More than one
cause may be present at the same time.

Risk Factors

Congestive heart failure is often a consequence of atherosclerotic heart disease and therefore the risk factors are the same: poorly
controlled high blood pressure, high cholesterol, diabetes,smoking, and family history. Heart valve disease becomes a risk factor as the patient
ages. (ww.medicinenet.com)

Congestive Heart Failure Symptoms

The hallmark symptom of left heart failure is shortness of breath or dyspnea (dys=abnormal + pnea= breathing). This may occur while at
rest, with activity or exertion, while lying flat (orthopnea), or may awaken a patient from sleep (paroxysmal nocturnal dyspnea). The shortness of
breath may be due to fluid (water, mainly) accumulation in the lungs or the inability of the heart to be efficient enough to pump blood to the organs
of the body when called upon in times of exertion or stress. Chest pain or angina may be associated, especially if the underlying cause of the
failure is atherosclerotic heart disease. (www.medicinenet.com)

When to Call the Doctor

The Doctor should be called if there are signs and symptoms of congestive heart failure and any of these situations:

Symptoms of sudden heart failure, such as:

o Severe shortness of breath (trouble getting a breath even when resting).
o Suddenly getting an irregular heartbeat that lasts for a while, or getting a very fast heartbeat along
with dizziness, nausea, or fainting.
o Foamy, pink mucus with a cough and shortness of breath.
o Chest pain or pressure, or a strange feeling in the chest.
o Sweating.
o Shortness of breath.
o Nausea or vomiting.
o Pain, pressure, or a strange feeling in the back, neck, jaw, or upper belly, or in one or both shoulders or arms.
o Lightheadedness or sudden weakness.
o A fast or irregular heartbeat.

Nursing Process
A. Nursing health history

A. Demographic Data
Name: Patient X
Address: San Miguel, Tarlac City
Gender: Female
Age: 98 yrs. Old
Birthdate: August 9, 1915
Religion: Catholic
Date of admission: july 6, 2014 / 10:40pm
Attending Doctor: Conrado R. Genilo III MD
Admitting Doctor: Maricis C. Lopez MD
B. Chief complaint
Patient X was brought to the hospital and seek medical attention due to the chief complaint of difficulty of breathing
C. History of present illness
1 day prior to admission the patient manifest difficulty of breathing and easy fatigability with edema at both low extremities.

Review of System

General Appearance

Weight loss
Weakness

Weight gain
Night sweats

Anorexia
Fatigue
Generalized jaundice

Note: the patient has weak in appearance

Skin

Itch
Lesions Blister

Bruising

Rash

Ecchymoses

Bleeding
Burns Drainage

Note: No abnormalities in skin found

Ears
Pain

Hearing loss

Discharge

Tinnitus

Note: the patient has slightly hearing loss due to aging

Nose

Obstruction

Epistaxis

Discharges

Note: no abnormalities in skin found

Throat & Mouth

Sore throat

Bleeding gums

Tooth Ache

Tooth Decay

Note: No abnormalities in throat and mouth

Chest

Cough

Hemoptysis

WheezePain in Respiration

Dyspnea

Sputum

Rales

Note: the patient is unable to expel sputum, suctioning performed. Dyspnea and rales is the symptoms of CHF.

CVS

Chest pain

Palpitation

Orthopnea

Others__________

Dyspnea

Edema

Note: Chest pain, Palpitation and Edema because of congestion

GIT

Intolerance

Heartburn

Nausea

Jaundice

Vomiting

Pain

Bleeding

Excessive Gas

Constipation

Change in BM

Melena

Note: no abnormalities in GIT found

Genito Urinary

Dysuria

Nocturia

Retension

Polyuria

Dribbling

Hematuria

Flank Pain

Tea colored urine

Oliguria

Note: patient experience Oliguria and tea colored urine due to concentration.

Neuro

Headaches
Seizures

Dizziness

Paresis

Paralysis

Memory Loss

Fainting

Others: ________________
Notes: patient has memory loss due to aging.

Anatomy and Physiology

Numbness

Tingling

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.

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.

The right atrium is the first chamber that receives blood.

The chamber expands as its muscles relax to fill with blood that has returned from the body.

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

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

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.

The oxygen-rich blood returns through veins coming from the lungs (pulmonary veins) to the heart.

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

Here, it moves to the left ventricle, a powerful muscular chamber that pumps the blood back out to the body.

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.

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 between beats.

Blood leaves the heart through the ascending aorta, the major artery that feeds blood to the entire body.

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:

The tricuspid regulates blood flow between the right atrium and the right ventricle.

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

The mitral valve regulates blood flow between the left atrium and the left ventricle.

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

Pathophysiology

Left Sided Congestive Heart Failure

Pathophysiology
Reduced myocardial contractility

Causes

Increases cardiac workload

o Myocardial Infarction

Decreased diastolic filling

o Hypertension

Bloods dams back

into the pulmonary
capillary bed

Obstructions of left atrial emptying

Left sided CHF

Left atrial
pressure

Stroke volume
Pressure at the
pulmonary capillary
bed

Tissue perfusion
decreases

Bloods flow to the

kidneys

Pulmonary

Cellular hypoxia

RAAS stimulation

Vasoconstriction and
reabsorption of Na and
water
ECF volume

S/S
Total blood volume
Systemic BP

DRUG STUDY
Drug Name

Classification

Dosage

Action

Contraindication

Adverse Effect

Nursing Responsibilities

Clopidogre

Anti platelet

75mg

1 bisulfate

Drug

1 tab
OD

Inhibits platelet
aggregation by
inhibiting binding of
adenosipinediphosphat
e to its platelet receptor
and subsequent ADPmediative activation of
glycoprotein complex

Lactation Active
pathological
bleeding such as
peptic ulcer or
intracranial
hemorrhage.

GI bleeding, purpura,
bruising,
hematoma,
epistaxis,
hematuria,
eye bleeding
(mainly conjunctiva),
intracranial bleeding,
GI disturbances,
diarrhea, rash,

-Assess for any active

bleeding as with ulcers or
intracranial bleeding
-take exactly as directed,
may take without regard to
food. Food will lessen
chance of stomach upset
-report any unusual bruising
or bleeding; advise all
providers of prescribed
therapy

pruritus

Drug Name

Classification

Dosage

Action

Contraindication

Adverse Effect

Nursing Responsibilities

Lasix

Loop diuretic

1 amp
IVP
q8

Drug Name

Classification

Dosage

Inhibits sodium and

chloride
reabsorption at the
proximal tubules,
distal tubules and
ascending tubules
loop of henle
leading to excretion
of water together
with sodium,
chloride and
potassium diuretic,
antihypertensive.

Hypersensitivity

Action

Contraindication

to sulfonylureas
anuria

Orthostatic
hypotension,
thrombophlebitis,
chronic aortitis,
vertigo,headache,
dizziness, paresthesia,
restlessness, fever
photosensitivity,
urticarial, pruritis
necrotizing angitis

-monitor the blood pressure,

fluid intake and output,
electrolytes: potassium,
sodium, calcium, magnesium,
glucose, uric acid and BUN
-monitor neurologic
manifestation of hypokalemia,
hypomagnesemia,
hyponatremia, hyperchloremia
-monitor intake and output
-assess patient for tinnitus,
hearing loss, ear pain

Adverse Effect

Nursing Responsibilities

Ranitidine

Histamine H2

50mg

Receptor
blocking drug

IV
q12

Competitively
inhibits gastric acid
secretion by
blocking the effect
of histamine H2
receptors both
daytime and
nocturnal basal
gastric acid
secretion, as well
as food and
pentagastrin

Hypersensitivity
History of acute
Porphyria

Cardiac arrhythmias,
bradycardia, headache,
fatigue, dizziness,
hallucination,
depression, insomnia

Long term therapy

-use caution in presence of

renal hepatic impairment
-assess potential for
interactions with other
pharmacological agents patient
may be taking
- assess knowledge/ teach
patient appropriate use,
possible side effects/
appropriate interventions, and
adverse symptoms to repot

-simulated gastric
acid are inhibited

Drug Name

Classification

Dosage

Action

Contraindication

Adverse Effect

Nursing Responsibilities

Rosuvastati
n calcium

Antihyperlipidemic

20 mg 1
tab OD

A fungal metabolite
that inhibits the
enzyme (HGMCoA) that catalyzes
the first step in the
cholesterol
synthesis pathway,
resulting in a
decrease

hypersensitivity,
impaired hepatic
function,
alcoholism, renal
impairment,
advanced age,
hypothyroidism

Nausea, dyspepsia,
diarrhea, constipation,
vomiting, rhinitis,
sinusitis, cough,
dyspnea, pneumonia

Classification

Dosage

Action

-Administer drug at bed time

-Monitor patient closely for
signs of muscle injury,
especially higher doses
-Provide comfort measures to
deal with headache, muscle
cramps, or nausea

In serum
cholesterol, serum
LDLs (associated
with increased risk
of coronary artery
disease) and either
an increase or no
change in serum
HDLs (associated
with decreased)

Drug Name

-Arrange for proper

consultation about need for
diet and exercise changes

-Offer support and

encouragement to deal with
disease, diet, drug therapy, and
follow-up care.

Contraindication

Adverse Effect

Nursing Responsibilities

Kaliumdurul
e

electrolytic
and water
balance agent

1 tab
TID

Principal
intracellular cation;
essential for
maintenance of
intracellular
isotonicity,
transmission of
nerve impulses,
contraction of
cardiac, skeletal,
and smooth
muscles,
maintenance of
normal kidney
function, and for
enzyme activity.
Plays a prominent
role in both
formation and
correction of
imbalances in
acidbase
metabolism.

Severe renal
impairment; severe
hemolytic
reactions; untreated
Addisons disease;
crush syndrome;
early postoperative
oliguria (except
during GI
drainage);
adynamic ileus;
acute dehydration;
heat cramps,
hyperkalemia,
patients receiving
potassium-sparing
diuretics, digitalis
intoxication with
AV conduction
disturbance.

Nausea, vomiting,
diarrhea, abdominal
distension.
Pain, mental confusion,
irritability, listlessness,
paresthesias of
extremities, muscle
weaknessand heaviness
of limbs, difficulty in
swallowing, flaccid
paralysis.
Oliguria,
anuria.Hyperkalemia

-Monitor I&O ratio and

pattern in patients receiving
the parenteral drug. If oliguria
occurs, stop infusion promptly
and notify physician.
-Monitor for and report signs
of GI ulceration (esophageal
or epigastric pain or
hematemesis).
-Monitor patients receiving
parenteral potassium closely
with cardiac monitor. Irregular
heartbeat is usually the earliest
clinical indication of
hyperkalemia.
-Be alert for potassium
intoxication (hyperkalemia,
see S&S, Appendix F); may
result from any therapeutic
dosage, and the patient may be
asymptomatic.

Drug Name

Classification

Dosage

Action

Contraindication

Adverse Effect

Nursing Responsibilities

Cordaron
e

Antiarrhythmics

200mg

Effects result
from blockade
of potassium
chloride
leading to a
prolongation
potential
duration.

Contraindicate
d In patients
hypersensitivity
to drug or
iodine.

CNS : fatigue,
malaise, tremor,
peripheral
neuropathy,
ataxia,
paresthesia,
insomnia, sleep
disturnbances,
headache.

-Monitor blood pressure

and heart rate and
rhythm frequently.

1 tab
TID

-Those with
cardiogenic
shock, second
or third degree
AV block,
severe SA node
disease
resulting in
bradycardia
unless an
artificial
pacemaker is
present, and in
those for whom
bradycardia
has caused
syncope.

CV: hypotension,
bradycardia,
arrhythmias, heart
failure, heart
block, sinus arrest,
edema.
EENT: visual
disturbances, optic
neuropathy, or
neuritis resulting
in visual
impairment,
abnormal smell.
GI : Nausea,

-Perform continuous ECG

monitoring when
starting or changing
doses. Notify prescriber
or significant change in
assessment result.
-Watch carefully for
pulmonary toxicity.
-Watch for evidence of
pneumonitis, exertional
dyspnea, non productive
cough, and pleuritic
chest pain.

vomiting,
abnormal taste,
anorexia,
constipation,
abdominal pain.
Hematologic :
coagulation
abnormalities
Hepatic : hepatic
failure , hepatic
dysfunction
Metabolic :
hypothyroidism,
hyperthyroidism.
Respiratory : acute
respiratory isease
distress syndrome,
SEVERE
PULMONARY
TOXICITY.
SKIN :
photosensitivity,
solar dermatitis,
blue gray skin.

Drug Name

Classification

Dosage

Action

Contraindication

Adverse Effect

Nursing Responsibilities

Lactulose

Contraindicat
ed in
patients on a
low
galactose
diet.

1tbsp
HS

Produces an
osmotic effect
in colon ;
resulting
distention
promotes
peristalsis. Also
decrease
ammonia,
probably as a
result of
bacterial
degradation,
which lowers
the pH of colon
contents.

Contraindicate
d in patients on
a low galactose
diet.

Abdominal
cramps, belching,
diarrhea,
flatulence,
gaseous
distension.
Nausea, vomiting.

-To minimize sweet

taste, dilute with water
or fruit juice or give with
food.
-Prepare enema by
adding 200g (300ml) to
700 ml of water or
normal saline solution.
-Monitor mental status
-Replace fluid intake.
-Inform patient about
adverse reactions and
tell him to notify
prescriber if reactions
become bothersome or
if diarrhea occurs.

ASSESSMENT

DIAGNOSIS

PLANNING

Subjective:

Easy fatigability
related to
decreased
tissue perfusion.

After nursing
intervention the
patient will able
to show strength
and energy

Objective:Patient
manifested:

Generalized
weakness
(+) DOB

INTERVENTION
1. Assess vital
signs.
2. Determine
presence or
degree of
sleep
disturbance
s.
3. Obtain
client
descriptions
of fatigue.
4. Ask client
to rate
fatigue.
5. Plan
intervention
s to allow
individually
adequate
rest
periods.
6.
Assist with

RATIONALE
1. To evaluate
fluid status
and
cardiopulm
onary
response
to activity.
2. Fatigue
can be a
consequen
ce of sleep
deprivation
.
3. To assist in
evaluating
impact on
clients life.
4. To
determine
degree of
fatigability.
5. To
maximize

EVALUATION
For further
management

self-care
needs and
ambulation.
7. Avoid
exposure to
temperatur
e and
humidity
extremes
8. Instruct
client in
ways to
monitor
responses
to activity
and
significant
signs or
symptoms.
9. Promote
overall
health
measures
10.Provide
supplement
al oxygen,
as
indicated.
11.Assist client
to identify
appropriate
coping
behaviors.

participatio
n.
6. To
conserve
energy for
other
tasks.
7. Has
negative
impact on
energy
level.
8. Indicate
the need
to alter
activity
level
9. To promote
energy
10.Presence
of
hypoxemia
reduces
oxygen
available
for cellular
uptakes
and
contributes
to fatigue.
11.Promote
sense of
control and
improves
selfesteem.

Assessment
Subjective:

Objective:Patient
manifested:

productive
cough
yellowish in
color
presence of
rales upon
auscultation
(+) DOB

Diagnosis
Impaired Gas
exchange
ventilation
perfusion and
equality

Planning
After nursing
intervention the
will able to
breath w/o
oxygen therapy,
and decrease
secretion
production.

Intervention
1. Monitor and
record vital
signs
2. Observe
color of skin,
mucous
membranes
and nail
beds, noting
presence of
peripheral
cyanosis.
3. Elevate
head of bed
and
encourage
frequent
position
changes.
4. Keep back
dry.
5. Promote
adequate
rest periods
6. Change
position q 2
hrs.
7. Keep
environment
allergen free
8. Suction
secretions

Rationale

Evaluation

1. To obtain
For further
baseline
evaluation and
data
management
2. Cyanosis
of nail
beds may
represent
vasoconstr
iction or
the bodys
response
to fever/
chills
3. To promote
maximal
inspiration,
enhance
expectorati
on of
secretions
in order to
improve
ventilation
4. To avoid
coughing
5. Rest will
prevent
fatigue
and
decrease
oxygen
demands

PRN
9. Administer
oxygen
therapy as
ordered.

6.

7.

8.

9.

for
metabolic
demands
To promote
drainage
of
secretions
To reduce
irritant
effects on
airways
To clear
airway
when
secretions
are
blocking
the airway.
O2 therapy
is
indicated
to increase
oxygen
saturation

Assessment

Diagnosis

Planning

Subjective:
(none)

Excess Fluid
Volume

-After nursing
intervention the
patient will be
able to
decrease
difficulty of
breathing.

Objective:Patient
manifested:

Edema on
extremitie
s( 6mm)
DOB

-patientsedema
will decrease
from (6mm) to
0.
-

Intervention
1. Establish rapport
2. Monitor and
record VS
3. Assess patients
general condition
4. Monitor I&O
every 4 hours
5. Assess for
presence of
peripheral
edema. Do not
elevate legs if the
client is dyspnic.
6. Follow lowsodium diet
and/or fluid
restriction
7. Encourage or
provide oral care
q2
8. Monitor for

Rationale
1. To gain
patients
trust and
cooperation
2. To obtain
baseline
data
3. To
determine
what
approach to
use in
treatment
4. I&O balance
reflects
fluid status
5. Decreased
systemic
blood
pressure to
stimulation

Evaluation
For further
management
and evaluation

distended neck
veins and ascites
9. Evaluate urine
output in
response to
diuretic therapy.
10.Assess the need
for an indwelling
urinary catheter.
11.Institute/instruct
patient regarding
fluid restrictions
as appropriate.

of
aldosterone
, which
causes
increased
renal
tubular
absorption
of sodium
Low-sodium
diet helps
prevent
increased
sodium
retention,
which
decreases
water
retention.
Fluid
restriction
may be
used to
decrease
fluid intake,
hence
decreasing
fluid
volume
excess.
6. The client
senses
thirst
because the
body
senses

dehydration
. Oral care
can
alleviate
the
sensation
without an
increase in
fluid intake.
7. Heart
failure
causes
venous
congestion,
resulting in
increased
capillary
pressure.
When
hydrostatis
pressure
exceeds
interstitial
pressure,
fluids leak
out of
htecpaillari
es and
present as
edema in
the legs,
and
sacrum.
Elevation of
legs
increases

venous
return to
the heart.
8. Inidicates
fluid
overload
9. Focus is on
monitoring
the
response to
the
diuretics,
rather than
the actual
amount
voided
10.Treatment
focuses on
diuresis of
excess
fluid.
11.This helps
reduce
extracellula
r volume.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective:
(none)

Objective:Patient
manifested:

Edema on
extremitie
s (grade
6)
DOB

Excess Fluid
Volume
related
increased
renal tubular
absorption

-After nursing
intervention
the patient will
be able to
decrease
difficulty of
breathing.
-patientsedema
will decrease
from ( grade 6)
to 0.
-

12.Establish rapport
13.Monitor and
record VS
14.Assess patients
general condition
15.Monitor I&O
every 4 hours
16.Assess for
presence of
peripheral
edema. Do not
elevate legs if the
client is dyspnic.
17.Follow lowsodium diet
and/or fluid
restriction
18.Encourage or
provide oral care
q2
19.Monitor for
distended neck
veins and ascites
20.Evaluate urine
output in
response to
diuretic therapy.
21.Assess the need
for an indwelling
urinary catheter.
22.Institute/instruct
patient regarding
fluid restrictions
as appropriate.

12.To gain
patients
trust and
cooperation
13.To obtain
baseline
data
14.To
determine
what
approach to
use in
treatment
15.I&O balance
reflects
fluid status
16.Decreased
systemic
blood
pressure to
stimulation
of
aldosterone
, which
causes
increased
renal
tubular
absorption
of sodium
Low-sodium
diet helps
prevent
increased
sodium
retention,

For further
management
and evaluation

which
decreases
water
retention.
Fluid
restriction
may be
used to
decrease
fluid intake,
hence
decreasing
fluid
volume
excess.
17.The client
senses
thirst
because the
body
senses
dehydration
. Oral care
can
alleviate
the
sensation
without an
increase in
fluid intake.
18.Heart
failure
causes
venous
congestion,
resulting in

increased
capillary
pressure.
When
hydrostatis
pressure
exceeds
interstitial
pressure,
fluids leak
out of
htecpaillari
es and
present as
edema in
the legs,
and
sacrum.
Elevation of
legs
increases
venous
return to
the heart.
19.Inidicates
fluid
overload
20.Focus is on
monitoring
the
response to
the
diuretics,
rather than
the actual
amount

voided
21.Treatment
focuses on
diuresis of
excess
fluid.
22.This helps
reduce
extracellula
r volume.

Assessment

Diagnosis

Subjective:

Acute pain
related to
decresed
tissue
perfusion
secondary to
angina

PainObjective:Pati
ent manifested:

(+) DOB
with a rate
of 6 out of
10
with
complaints
of chest
pain

Planning
The patient will
verbalize
decrease of
pain.

Intervention
1. Assess
patient
pain for
intensity
using a
pain rating
scale, for
location
and for
precipitati
ng factors.
2. Provide
comfort
measures.
3. Establish a
quiet
environme

Rationale
1. To identify
intensity,
precipitating
factors and
location to
assist in
accurate
diagnosis.
2. To provide
nonpharmaco
logical pain
management.
3. A quiet
environment
reduces the
energy
demands on

Evaluation
For further
management
and evaluation.

unprovoked

nt.
4. Elevate
head of
bed.
5. Monitor
vital signs,
especially
pulse and
blood
pressure,
every 5
minutes
until pain
subsides.
6. Teach
patient
relaxation
techniques
and how to
use them
to reduce
stress.

the patient.
4. Elevation
improves
chest
expansion
and
oxygenation.
5. Tachycardia
and elevated
blood
pressure
usually occur
with angina
and reflect
compensator
y
mechanisms
secondary to
sympathetic
nervous
system
stimulation.
6. Anginal pain
is often
precipitated
by emotional
stress that
can be
relieved nonpharmacologi
cal measures
such as
relaxation.