Cherry Tabucol
Nova Ibarra
Tina CarylCorpuz
Everlasting Silverio
Mark Chris Garbin
Irish Antonio

Angelina Sibug RN, MSN
* Significance/ relevance to the concept
* Biographical Information
* Reasons for Seeking Health Care
* Client’s Expectations
* Present Illness
* Past Health History
* Spiritual Health
* Cephalocaudal

* Pathopysiology
* Labaratory Findings
* Doctor’s Orders
* Drug Study
* Nursing Care Plan
* Methods Approach
I. Introduction
After three weeks of exposure at CLDH hospital, we came up to study the case congestive heart failure.
To be more specific, what are those illnesses?
Congestive Heart Failure – often called congestive heart failure (CHF) or congestive cardiacfailure (CCF), occurs when the heart is unable to provide sufficient pump action to maintain blood flow to meet the needs of the body.
For the confidentiality and privacy of the patient, we named her as Patient A. Patient A is 51 years old, married, with 4 kids (2 girls and 2 boys), and from Tarlac City.
Significance/Relevance to the Concept
This case shows us student what we have read from books. It proves that complications or abnormalities can occur at any moment. This also taught us to deal with patient with problems competitively and the proper way of treating them.

II. Objectives
* To establish rapport between nurse and the patient
* To be able to know the proper care for patient with Congestive Heart Failure
* To be able to provide information and health teaching to the patient
* To be able to describe the development, pathophysiology and nursing care of a client who have undergone
* To be able to carry out hospital routines and the treatment prescribed to the patient
* To be able to perform nursing procedures and nursing considerations for a client in the preoperative and postoperative stages

III. Nursing Health History

For the confidentiality and privacy of the patient, we named her:
a. Biographical Information
Surname: B
First Name: A
Middle Name: C
Age: 51
Weight: 55.2 kg
Birthdate: Dec. 15, 1961
Birth Place: Balungao, Pangasinan
Nationality: Filipino
Address: Landig, Cuyapo, Nueva Ecija

b. Reasons for seeking Health Care
Mrs. A seeks for health care because of the chief complaint is difficulty of breathing.
c. Client Expectations
Mrs. A expectations in the following areas:
>Information needed about her disease process and involvement in decision making.
>Caring and compassion expressed by care providers
>Timeliness of caregivers’ response to client requests
>Relief of pain and symptoms
d. Present Illness
Mrs. A admitted to the Intensive Care Unit, last July 29, 2013(Monday) subsequently complaining of difficulty of breathing t. With an admitting impression in Congestive Heart Failure class IV-E with RVR.
e. Past Health History
There is no past confinement of the client.

f. Spiritual Health
Mrs. A is a Roman Catholic and makes it a point to visit and attend a mass every Sunday with her husband and children. Their beliefs about life, their source for guidance in acting their beliefs, and the relationship they have in exercising their faith is truly on a God-centered manner.
IV. Assessmentbbn

Area/region Findings Normal Findings Abnormal findings Interpretation/analysis Skin in general

Temperature Patients skin color is dark

Skin feels is warm to touch Light tones in light – skinned persons

Normal Abnormal

Abnormal Due to deficient supply of blood to the system

Due to heat intolerance

Areas to assess Findings Normal/abnormal Interpretation SKIN
Resilient, silky hair Normal Normal Scalp: > Characteristics

> Deformities

> Redness or scaliness Shiny and smooth w/o lesions, masses or mumps

No trauma findings

No redness or scaliness Normal
Normal Normal
> Characteristics

> Symmetry of facial features and movement
Rounded and smooth skull contour w/o any signs of enlargement

Symmetrical in facial features and movement


Normal Eyes > Characteristics
> Symmetry of eye features and movement Pink conjunctiva, anicteric sclera

Bilateral exopthalmus Abnormal The sclera should be white

Presence of edema Neck

> Symmetry
> Thyroid gland Enlarged and palpable mass on anterior portion of the neck

Presence of mass during palpitation Abnormal Due to lack of iodine Nails Capillary refill (-)slow capillary refill, (-) crushing pain Normal Normal Lungs Characteristics rales, (+), cough (+) Abnormal Excessive accumulation of mucous membrane Musculoskeletal Characteristics Fine tremors Abnormal Due to body weakness Neurologic Characteristics Irritable and restless Abnormal Due to body weakness Abdomen Characteristics (+) symmetrical (-) bruit sound (-) pain Normal Paracentesis done
After Physical assessment there was no abnormalities expect for resilient and silky hair, bilateral exopthalmus of her eyes, excessive sweating of his skin enlarged and palpable mass on the anterior portion of the neck, fine tremors, irritable and restless.
Name: MilwidaDela Cruz
Age: 46
Temperature: 36
Blood Pressure: 110/80
Respiratory rate: 20
Pulse rate: 75
Date Performed: July 16, 2013
APPEARANCE INSPECTION • Relaxed, erect posture; coordinated movement
• Clean, neat; no body odor • Irritable
• Posture iserect and properly aligned

• Clean,Neat, no body odor • Abnormal due to illness
PALPATION • Skin texture must be soft. Hair is evenly distributed and varies the color from the race.
• Free from any lesion, wounds, scars and scabies. • Skin has dark complexion , the hair is evenly distributed
• Skin is dry
• Pale, Grayish color .
• No signs of lesion, wounds, scars, and scabies. • Normal
* Abnormal due to illness

• Normal
PALPATION • Evenly distributed hair and uniform in color.
• Thick, silky and resilient hair.
• Black shiny hair, it may be thick smooth. Neither brittle nor dry. • The hair is black shinny, well distributed and it is thin and coarse. • Normal

• Normal

• The skull is rounded and smooth
• Absence of nodules and masses. • Head is rounded and smooth.
• Absence of nodules and masses. • Normal

PERRLA • Eyebrows are evenly distributed and skin is intact.
• Eyelashes are equally distributed.
• Pupil constrict when expose to sunlight.
• Cornea is clear transparent.
• The color of the iris depends on the person’s race.
• The sclera should be white in color. • Eyebrows are evenly distributed.
• Eyelashes turn outward.
• Pupils constrict when expose to sunlight
• Cornea is transparent.
• The sclera is white in color.
• Pupils are equal and reactive to light
• Normal
• Normal

• Normal

• Normal

• Normal
• Normal

PALPATION • Convex curvature, angle of nail plate is 160º
• Smooth texture, highly vascular, clean and pink in color.
• Prompt to return of pink or usual color in capillary refill(1-2 sec) in color • No clubbing and spoon nail
• Nails are short and clean
• Capillary refill is about 2 sec. in color • Normal
• Normal
PALPATION • Ear lobes are bean shaped, parallel and symmetrical.
• The ear canal normally has some cerumen
• The pinna should recoils when folded • Ears are parallel and symmetrical.

• There is presence of some cerumen.

• Pinna recoils when folded • Normal

• Normal
• Normal
PALPATION • Symmetrical and straight, no discharge or flaring and uniform in color.
• No tenderness, no lesion and air moves freely as client breathe through the nares.
• Patient is with O2 inhalation and on and off difficulty of breathing
• Symmetrical and straight, no discharge.
• No tenderness and lesion, no obstruction.
• Normal
• Normal
• Normal

PALPATION • Normal lips color varies from the race.
• Teeth are whitish in color.
• Tongue is in central position, pink in color, moist and moves freely. • The lips are pinkish in color.
• Teeth are whitish in color.
• Tongue is in central position, pink in color and moves freely. • Normal
• Normal
• Normal
NECK INSPECTION PALPATION • Muscle equal in size; head centered, good range of motion, (hyperextension, flexion and rotation), necked color is proportion to the skin.
• Jugular neck vein is not visible
• Lymph nodes are not palpable.
• Trachea is in central placement in the neck.
• Thyroid gland is not visible in inspection, moves up when swallowing. • Muscles equal in size; head centered, good range of motion is present and neck color is proportioned to skin color.

• Distended jugular neck veins
• No palpable lymph nodes.
• Trachea is in central placement in the neck.
• Thyroid gland is not visible. • Normal

* Abnormal

• Normal

• normal

AUSCULTAION • Chest is symmetrical, spine is vertically aligned and spinal column is straight.
• Quit, rhythmic and effortless respiration.
• No presence of lumps and tenderness • Chest is symmetrical, spine is vertically aligned and spinal column is straight.

• Rapid chest movement

• No presence of lumps and tenderness during palpation. • Normal

• Due to dyspnea


• Normal
• No murmurs must be heard.
• No tenderness, masses and lumps in palpation. • Rales sounds is heard upon ascultation

• No tenderness, masses and lumps in palpation. • Due to ventricular obstruction

PALPATION • Uniform in color, flat rounded no evidence of enlargement of liver and spleen.
• No abdominal distention

• Audible bowel sounds

• No tenderness; relaxed abdomen with smooth, consistent tension.
• It must be regular pattern not deep. • No Organomegaly
• Presence of abdominal distention

• Audible bowel sounds

• Abdominal tenderness

• Normal
• Due to accumulation of fluid in the abdomen

• Due to fluid accumulation

PERCUSSION • Muscles are equal size on both sides of the body.
• Bones and joints, no deformities, tenderness and swelling, joints move smoothly. • Presence of edema in both extremities ( + 1) • Abnormal
Inadequate blood supply

V. Anatomy and Physiology

The heart is a muscular pump that contains four chambers: right atrium, left atrium, right ventricle and left ventricle. The two small atria make up the top of the heart, and the two large ventricles make up the bottom of the heart. The right atrium pumps blood to the right ventricle, and the left atrium pumps blood to the left ventricle. A wall, called the septum, separates the right atrium and right ventricle, from the left atrium and left ventricle.

Blood flows through the heart in the following manner:
* The right atrium receives oxygen-poor blood from the body, and then pumps the blood through the tricuspid valve and into the right ventricle.
* The right ventricle pumps the blood through the pulmonic valve and to the lungs, where it picks up more oxygen.
* The left atrium receives the oxygen-rich blood from the lungs, and then pumps the blood through the mitral valve and into the left ventricle.
* The left ventricle pumps blood through the aortic valve and to the rest of the body.
* The blood supplies oxygen to the body and the cycle starts again.
Anatomy examples:
* Normal circulation through the heart
* The human heart
* Cross-section of heart at the level of the atria
* Cross-section of heart at the level of the ventricles
* The heart sits inside the pericardium
* The heart valves
Coronary Arteries
The coronary arteries supply oxygen to the heart muscle.
The heart has three main coronary arteries:
* Right coronary artery: supplies the right ventricle
* Left coronary artery: supplies the left ventricle
* Posterior circumflex artery: supplies the posterior aspect of both ventricles
Anatomy examples:
* Coronary angiogram
* Front view of the heart and coronary arteries
* Back view of the heart and coronary arteries
Cardiac Conduction System
An electrical impulse stimulates the muscle fibers in the heart to contract. The impulse spreads through the heart in a very organized manner, so that the atria contract first, followed by the ventricles.
The electrical impulse proceeds in the following manner:
* The electrical impulse originates at the sinoatrial (SA) node, which is located in the wall of the right atrium.
* The SA node is the heart’s natural pacemaker: it regulates the heart rate.
* The impulse proceeds through the atria, stimulating them to contract.
* After the atria are stimulated to contract, the atrioventricular (AV) node slows the electrical impulse before it proceeds to the ventricles. This pause allows the ventricles to fill with blood before they contract.
* The AV node is located between the atria and the ventricles.
* After the pause, the impulse then proceeds through the ventricles, stimulating them to contract.
Anatomy examples:
* The cardiac conduction system
* ECG showing electrical activity of heart

VI. Pathophysiology
Age Stress
Gender Diet
Heredity Lifestyle
Clogging of the coronary blood vessels
Persistent increase of BP
Increase myocardial demand
Heart compensate to double pump
Blood backs up in the left side is unable to eject blood to systemiccirculation
Systemic circulation ?
? lungs swollen with blood
Peripheral congestion,?
Distended neck vein, fluid leaks
Edema (feet, ankles and finger ),

Hepatomegaly ?
Cortal hypertension Pulmonary edema/ congestion

Congestive Heart Failure
The pumping action of the healthy heart maintains a balance between cardiac output and venous return. But when the pumping efficiency of the heart is depressed so that circulation is in adequate to meet tissue needs, congestive heart failure occurs.
Congestive Heart Failure is usually a progressive condition that reflects weakening of the heart by coronary atherosclerosis (clogging of the coronary vessels with fatty build up ), persistent high blood pressure, or multiple myocardial infarctions ( leading to repair with non-contracting scar tissue ).
Because the heart is a double pump, each side can fail independently of the other. If the left heart fails, pulmonary congestion occurs. The right side of the heart continues to propel blood to the lungs, but the left is unable to eject the returning blood into the systemic circulation. As blood vessels swollen with blood, the pressure within them increases, and fluid leaks from the circulation into the lung tissue, causing pulmonary edema. If untreated the person suffocates.
If the right side of the heart fails, peripheral congestion occurs as bloods back up in the systemic systemic circulation. Edema is the most noticeable in the distal parts of the body. The feet the ankles,and fingers become swollen and puffy. Failure of one side of the heart puts a greater strain on the opposite side, and eventually the whole heart fails.
VII. Medical Management
a. Drug Study
b. Laboratory Findings and Interpretation
c. Doctor’s order
Drug’s name Action Route and dosage Classification Indication Contraindication Adverse effect Nursing responsibilities

Aldactone (spironolactone)

Cause loss of sodium bicarboante and calcium while saving potassium and hydrogen ions

25mg tab

*potassium sparing diuretics

Counteract potassium loss caused by other diuretics.

Hypersensitivity, hyperkalemia
*use cautiously in: hepatic dysfunction, geriatric or debilitated patients or patients with D.M
CNS: dizziness, clumsiness, headache
CV: arrhythmias
GI: constipation
• Monitor I and o ratios and daily weight during therapy
• Monitor Blood Pressure
• Monitor BUN, serum creatinine and electrolytes before and periodically during therapy


Lasix (furosemide)


Blocks stimulation of beta1(myocardial) adrenergic receptors does not usually affect beta2 adrenergic receptor sites
Inhibits the re absorption of sodium and chloride from the loop of henle and distal renal tubule
Increases renal excretion of water, sodium, chloride, magnesium, hydrogen, and calcium. May have renal and peripheral vasodilatory effect
Increases the force of myocardial contraction.
Prolongs refractory period of the AV node. Decreases conduction through the SA and AV nodes

Every 8 hours
0.25 mg
1/2 TAB once a day
Anti angina

Loop diuretics

anti arrythmics, inotropics
Angina pectoris
Prevention of M.I
Management of stable, symptomatic heartfailure due to ischemic hypertensive origin
Edema due to CHF, hepatic or renal disease, hypertension
Treatment of CHF. Tachyarrythmias: atrial fibrillation and atrial flutter (slows ventricular rate), paroxysmal atrial tachycardia

Uncompensated CHF, pulmonary edema, cardiogenic shock bradycardia or heartblock
Hypersensitivity cross sensitivity with thiazides and sulfonamides may occur.
Pre- existing electrolyte imbalance hepatic coma or anuria. Some liquid products may contain alcohol, avoid patients with alcohol intolerance

Hypersensitivity. Uncontrolled ventricular arrhythmias. AV block, idiopathic hypertropicsubaortic stenosis. Constrictive pericarditis. Known alcohol intolerance
Cns: Fatigue, weakness, anxiety, depression dizziness, drowsiness, insomnia
Blurred vision
Stuffy nose
CV: bradycardia
CNS: dizziness
EENT: hearing loss
CV: hypotension
GI: constipation
Dry mouth
Nausea and vomiting
CNS: fatigue, headache, weakness
EENT: blurred vision, yellow or green vision

CV: arryhtmias
Ecg changes
AV- block
GI: anorexia
ENDO: gynecomasta
HEMAT: thrombocytopenia
Hyperkalemia with acute toxicity
EENT: hearing loss
-Monitor bpand pulse frequency during dose adjustments and periodically during therapy
-Monitor vital signs every 5-15 min during and for several hrs after parenteral administration

– asses fluid status during therapy
Monitor daily weight, I and o ratios
-Amount and location of edema, lung sounds, skin turgor, and mucous membranes
– monitor BP, and pulse before and during administration
– monitor apical pulse for 1 full min before administering. With hold dose and notify physician if pulse rate is less than 60beats per minute

-monitor apical pulse for 1 full minute before administering.
With hold dose and notify physician if pulse rate is <60bpm.
-assess for pain, and limitation of movement (note type loaction and intensity before and at the peak after administration
-observe IV site for redness or infiltration; extravasation can lead to tissue irritation and sloughing
– monitor intake and output ratios and daily weights. Assess for peripheral edema and auscultate lungs for crackles throughout therapy

Clinical laboratory Result Reference Method Interpretation Creatinine Increase 108umol/L 62-106umol/L Vitros 350 Blood urea nitrogen Increase 6.3mmol/L 2.5-6.1mmol/L Vitros 350 Albumin 30g/L 35-50g/L Vitros 350
1. Creatinine
-Raised creatinine levels will be developing when the filtration mechanism becomes gradually damaged by long-term raised blood pressure or diabetes. As the kidneys become increasingly unable to cope, so the creatinine level rises
2. BUN
-A disease condition is often present. One of the most common causes of RBC’s in the urine, is infection or inflammation of the urinary tract itself
3. Albumin
-Decreased blood albumin levels may occur when your body does not get or absorb enough nutrients and may be a sign of kidney diseases and liver diseases.
Chest x-ray (CXR)
* There is a hazed capacity in the right lower lung field
* Heart is enlarge
* Diaphragm is intact. Costophrenic sulci are intact
* The rest is visualized chest structure are unremarkable
* Consider pneumonia, right lower lobe
* Cardiomegaly
* Clinical correlation is recommended

* Community Acquired Pneumonia
* High risk (with hypoxemia)
* Rheumatic Heart Disease

PROCEDURES: S/P Paracentesis
1st- july 29 (First Session)
2nd- july 30( Second Session)
3rd- july 31, 2013( Third Session)
VIII. Nursing Management
a. NCP

Assessment Diagnosis Analysis Planning Nursing Interventions Rationale Evaluation Subjective:

>with productive cough yellowish in color
>(+) Difficulty of Breathing
>with pale conjunctiva, nail beds and buccal mucosa
>30 Ineffective airway clearance related to retained secretions as evidence by presence of rales on both lung feilds Inability to clear secretions or obstructions from the respiratory tract to maintain a clean airway Short Term:
> After 3-4 hours of nursing interventions, the patient will be able to establish and maintain airway AEB absence of signs of respiratory distress.

Long Term:
>After 2-3 days of nursing interventions, the patient will be able to demonstrate improve airway clearance AEB reduction of congestion with breath sounds clear and improve RR. >Monitor and record vital signs.

>Monitor respirations and breath sounds, noting rate and sounds.

>Position appropriately and discourage use of oil-based products around nose.

>Auscultate breath sounds and assess air movement.

>Encourage deep breathing and coughing exercises.

>Keep back dry and loosen clothing.
>Instruct patient have adequate rest periods and limit activities to level of activity intolerance.

>Give expectorants and bronchodilators as ordered.

>Suction secretions PRN.
>Administer oxygen therapy and other medications as ordered. >To obtain baseline data
>To determine respiratory distress and accumulation of secretions.

>To prevent vomiting with aspiration into lungs

>To ascertain status and note progress
>To maximize effort
>To promote comfort and adequate ventilation

>Rest will prevent fatigue and decrease oxygen demands for metabolic demands

>To further mobilize secretions
>To clear airway when secretions are blocking the airway

>Indicated to increase oxygen saturation Short Term:
>The patient shall have been able to and maintain airway patency AEB absence of respiratory distress.

Long Term:
>The patient shall have been able to demonstrate improve airway clearance AEB reduction of congestion with breath sounds clear and improved RR.
Assessment Diagnosis Analysis Planning Nursing Interventions Rationale Evaluation Subjective:

>rales on both lung field
>productive cough
>frothy sputum

Patient may manifest:
>pursed lip breathing
> V/S
• HR-110 Ineffective breathing pattern related to fatigue and decreased lung expansion and pulmonary congestion secondary to CHF inspiration and/or expiration that does not provide adequate ventilation Short Term:
>After 3-4hours of nursing interventions, the patient and patient’s SO will verbalize understanding of patient’s condition.

Long Term:
>After 3-4 days of nursing interventions, the patient’s respiratory pattern will be effective without causing fatigue. >Establish rapport

>Monitor Vital Signs

>Inspect thorax for symmetry of respiratory movement

>Observe breathing pattern for nasal flaring, pursed lip breathing or prolonged expiratory phase and use of accessory muscles

>Measure tidal volume and vital capacity
>Assess emotional response

>Position patient in optimal body alignment in semi-fowler’s for breathing >to gain comfort feelings from the patient and patient’s SO

>to gain baseline data

>to determines adequacy of breathing
>to identifies increased work of breathing
>indicates volume of air moving in and out of lungs

>detects use of hyperventilation as a causative factor
>optimizes diaphragmatic contraction

> The patient and patient’s SO shall have verbalized understanding of patient’s condition.

> The patient’s respiratory pattern shall have been effective without causing fatigue.
Assessment Diagnosis Analysis Planning Nursing Interventions Rationale Evaluation Subjective:

>generalized weakness
>limited range of motion as observed

Activity intolerance related to imbalance oxygen supply and demand as evidence by ROM, generalized weakness and DOB Insufficient physiological or psychological energy to endure or complete required or desired daily activities Short Term:
>After 3-4 hours of nursing interventions, the patient will use identified techniques to improve activity intolerance.

Long Term:
>After 2-3 days of nursing interventions, the patient will report measurable increase in activity intolerance. >Establish rapport
>Monitor and record V/S

>Assess patient’s general condition
>Adjust client’s daily activities and reduce intensity of level. Discontinue activities that cause undesired psychological changes.

>Instruct client in unfamiliar activities and in alternate ways of conserve energy.

>Encourage patient to have adequate bed rest and sleep.

>Provide the patient with a calm and quiet environment.

>Assist client in ambulation

>Assist the client in a semi-fowler’s position
>Elevate the head of the bed

>Instruct the SO not to leave the client unattended

>Encourage the client to maintain a positive attitude.

>Give client information that provides evidence of daily or weekly progress

>Provide client with a positive atmosphere.
>to gain client’s participation and cooperation in the nurse patient interaction

>to obtain baseline data

>to note for any abnormalities and deformities present within the body

>to prevent strain and overexertion

>to conserve energy and promote safety

>to relax the body

>to provide relaxation

>to prevent risk for falls that could lead to injury

>to promote easy breathing

>to maintain an open airway

>to avoid risk for falls
>to enhance sense of well being
>to sustain motivation of client
>to help minimize frustration and rechannel energy Short Term:
> The patient shall have used identified techniques to improve activity intolerance.

Long Term:
> The patient shall have reported measurable increase in activity intolerance.
Assessment Diagnosis Analysis Planning Interventions Rationale Evaluation S=
>bulging of eyes
>decrease appetite
>weight loss
>poor muscle tone
>lack of available food Nutritional imbalance, risk for less than body requirements Intake of nutrients insufficient to meet metabolic needs After nursing intervention the patient demonstrate stable weight with normal laboratory values and be free of signs and malnutrition • Monitor daily food intake. Weight daily and report losses.
• Encourage patient to eat and increase and snacks using high calorie foods that are easily digested

• Consult with dietitian to provide diet high in calories, protein, carbohydrate and vitamins ? Continued weight loss of adequate caloric intake may indicate failure of anti-thyroid therapy

? Aids in keeping caloric intake high enough to keep up with rapid expenditure of calories caused by hyper metabolic state

? May need assistance to ensure adequate intake of nutrients identify appropriate supplements After nursing intervention the patient demonstrate stable weight with normal laboratory values and be free of signs and malnutrition

M- Lasix- 40mg 1 tab OD
Aldactone- 25mg OD
Lanoxin- 0.25mg 1/2 tab OD
Metropolol- 50mg 1 tab BID
Safdicure- 300mg 1 cap for 5 days

E- Bed rest, restrain from any strenuous activities.

T- oral care, Proper personal hygiene

H- Advice pt. to consume and take meds as prescribed.
– Advice pt. to avoid strenuous activity to conserve energy.
– Advice pt. to remain at rest to prevent fatigue

– follow up check up on august 12, 2013 at 12 nn

D-low salt include tomato soup, salted crackers, bakon, canned meats, and fish. low fat, try lemon and herbs as a subtition. Provide potassium supplements, dercrease fluid intake.

S- Not applicable