CASE STUDY:

CHRONIC HEART FAlLURE (CHF)

Submitted by: Mary Cris D. Canon BSN 3W1-2 Submitted to: Ms. Catherine Cabrera

I.

INTRODUCTION

HEART FAILURE, the inability of the heart to pump enough blood to meet
the metabolic demands of the body, is the end result of many conditions. Frequently, it is a long - term effect of coronary heart disease and myocardial infarction when left ventricular damage is extensive enough to impair cardiac output. Cardiac output falls, leading to decreased tissue

perfusion. These normal mechanisms may result in vascular congestion and hence, the commonly used term congestive heart failure (CHF). As these mechanisms are exhausted, heart failure ensues, with increased morbidity and mortality. Heart failure, also called congestive heart failure, occurs when cardiac output is inadequate to meet the metabolic demands of the body. The heart rate increase as a Compensatory mechanism to increase cardiac output, and vasoconstriction occurs to try to maintain blood pressure. Eventually, the chronic increase in preload and after load contributes to chamber dilation and hypertrophy, worsening heart failure. Underlying causes of heart failure include congenital heart disease, rheumatic heart disease, endocarditis, myocarditis, and no cardiovascular causes such as, chronic pulmonary disease, various metabolic diseases, Diseases and anemia. Complications of heart failure include pneumonia, pulmonary edema, pulmonary emboli, refractory heart failure, and myocardial failure.

II.

PATHOPHYSIOLOGY
decreased cardiac output decreased systemic BP decreased perfusion to kidneys

Myocardial dysfunction
Ischemic heart disease Hyperthyroidism Myocardial infarction

Valve disease Alcohol, cocaine abuse HPN Activation of baroreceptors Left ventricle Aortic arch

Stimulation of vasomotor regulatory centers in medulla

Activation of sympathetic nervous system

Increased Ca echolamines

Aldosteron

vasoconstriction

Sodium & H2O retention Anginine vasopressin Endothelin Cytokines

Increased after load Increased BP Increased heart rate

VENTRICULAR

PATHOPHYSIOLOGY

REMODELING

Heart Failure, also known as Congestive Heart Failure, is a clinical syndrome that results from the progressive process of remodeling, in which mechanical and biochemical forces alter the size, shape, and function of the ventricles ability to pump enough oxygenated blood to meet the bodys metabolic requirements. Compensatory mechanisms of increased heart rate, vasoconstriction, and hypertrophy eventually fail, leading to the characteristic syndrome of heart failure:

Elevated ventricular or atrial pressures, sodium and water retention, decreased cardiac output, and circulatory and pulmonary congestion. Systolic dysfunction occurs when the left ventricle is unable to relax and fill sufficiently to accommodate enough oxygenated blood returning from the pulmonary circuit. Systolic dysfunction leads to increased vascular resistance and increased after load. Diastolic dysfunction leads to pulmonary vascular congestion.

III.

HISTORY

My patient name is E.V.S, 48 years old, single parent. Birthday is July 24 1963, lives in Malabon City. She is a Filipino citizen and she is Roman Catholic. She is admitted last August 5 2011. This interview was taken Aug 08 2011, and the information was the client herself.

 Chief Complaint Nahihirapan ako huminga. As verbalized by the patient as stated. Medical Diagnosis History of Present Illness 4 days prior to consult patient experienced headache and BP of 160/90 mmHg. She just stay rested on her bed until the pain subsides. 1 day prior to consult, patient complained of dizziness and blurring of vision, she decided to seek consultation.

IV.

NURSING PHYSICAL ASSESSMENT

General Appearance Client has medium frame body built. Upright in posture smooth rhythmic gait. She is appropriately dressed. Well groomed and has no body and breath odor. No obvious physical deformity. Weight is 54.5

kgs; Height is 53. Vital signs : Temp: 36.6; BP: 150/100 mmhg ; PR : 63 and RR : 22 HR : 51 Eyes: Eye condition is straight normal, has thick eyebrows, has effective closure of the eyelids with no fallen lashes. Bilateral and frequent blink response. The eyeballs are symmetrical and firm. Conjunctiva is clear and bulbar is clear while palpebral is pink in color. Sclera is white. Lacrimal apparatus is moist. Patient experienced blurring of vision. Ears: The auricle is in normal racial tone, symmetrical and non tender. Pinna recoils when folded. External canal has some cerumen. Patient was able to respond to normal voice and also to whispered voice. Nose: External nose is in normal racial tone. Non flaring and septum is at midline. Mucosa is pink, both nares are potent. Nasal cavity is moist and sinuses are non tender. Mouth: Lips are slightly dry and symmetrical. Mucosa is pink. Tongue is in midline, rough, pink and is movable. Teeth are complete and gums are pink and non tender. Pharynx: Uvula is in midline, mucosa is pink and tonsils are not inflamed as well as the posterior pharynx and gag reflex is present. Upper Extremities: Motor strength is 4/5. Good muscle tone. No lesions and deformities. Peripheral pulses are normal and lymph nodes are not palpable. Lower Extremities: Motor strength is 3/5 no lesions and deformities noted. Peripheral pulses are normal and lymph nodes are not palpable.

 Genitalia: Patient refuses to asses her genitals. Pubic hair is present without any lesions and any diseases.

V.

RELATED TREATMENT
Administer medication and assess the patients response to pharmacologic regimen. Assess fluid intake, including intake and output -optimize volume status. Weigh pt. daily at the same time and on the same scale after urination Auscultate lung sounds to detect an increase or decrease in pulmonary crackles. Determine the degree of jugular venous distention. Identify and evaluate the severity of dependent edema. Monitor PR and BP. Checking for postural hypotension due to dehydration. Examine skin turgor and mucous membrane for signs and symptoms of fluid overload.

VI.

NCP
DIAGNOOSIS PLANNING INNTERVENTION EVALUATION

Nursing Care Plan # 1

ASSESSMENT

Subjective: Nahihirapan ako huminga. As verbalized by the patient. Decreased cardiac output related to altered contractility of Pre load and After load. Short term goal: 15 mins. After nursing intervention, the client will be able to have a patent airway. Long term goal: After 4 hours of nursing intervention, the patient heart will pump effectively. INDEPENDENT: Position client semi- fowlers position. Advice client to Increase water intake Advice client to Decrease sodium intake Weigh client daily Assess edema. Check and Auscultate for crackles. Monitor vs. Short term goal: ACHIEVED 15 mins. After nursing intervention, the client was able to have a patent airway. Long term goal: ACHIEVED After 4 hours of nursing intervention, the patient heart was able to pump effectively.

Objective: Peripheral edema (+2) Wt. gain of 1kg/week Dyspnea Cough Oliguria RR: 45 cpm Wheezes orthopnea

collaborative: Administer oxygen as prescribed. Administer medication that reduces after load.

Nursing Care Plan # 2

ASSESSMENT SUBJECTIVE: Namumutla na ako as verbalize by The client. OBJECTIVE: Cool, ashen Skin. Orthopnea Crackles V/S taken as Follows: T: 36.2 C PR: 130 bpm RR: 45 cpm Bp: 90/70 mmHg

DIAGNOOSIS Decreased cardiac output related to altered myocardial contractility /isotropic Changes.

PLANNING Short term goal : 30 mins. After nursing intervention the client will be able to normalize her vital signs.

INNTERVENTION INDEPENDENT: Auscultate apical pulse; assess heart rate, and Rhythm. Inspect skin for pallor, Cyanosis. Monitor urine output, noting decreasing output and dark or concentrated urine Note changes in Sensory. Provide quiet Environment. Collaborative: Administer supplemental oxygen As indicated. Administer diuretics as Prescribed.

EVALUATION Short term : ACHIEVED 30 mins. After nursing intervention the client was able to normalize her vital signs.

Long term goal: After 8 hours of nursing intervention the patient will display vital signs within acceptable limits, dysrhythmias controlled and no symptoms of Failure.

Long term: ACHIEVED After 8 hours of nursing intervention the patient was able to display vital signs within acceptable limits, dysrhythmias controlled and no symptoms of Failure.

Nursing Care Plan # 3

ASSESSMENT Subjective: Nahihirapan ako kumilos, nanghihina ang katawan ko. As verbalized by the patient.

DIAGNOOSIS Activity intolerance and fatigue related to imbalance between oxygen supply and demand because of decreased cardiac output.

PLANNING Short term goal: 1 hour after nursing intervention the client will be able to perform light activity with minimal assistance.

INNTERVENTION INDEPENDENT: Assist the client while performing daily activity Increase potassium intake, by eating foods rich in potassium (banana). Position client semifowlers position. Advice client to Increase water intake Monitor vs. Ensure safety and security of the client.

EVALUATION Short term goal: ACHIEVED 1 hour after nursing intervention the client verbalized that she can perform light activity with minimal assistance.

Objective: Fatigue Feeling of heaviness of arms and legs Dyspnea Chest pain RR : 45 cpm

Long term goal: After 5 hours of nursing intervention the client will be able to perform activity of daily living.

Long term goal: ACHIEVED After 5 hours of nursing intervention the client verbalized that she was able to perform activity of daily living.

COLLABORATIVE: Administer supplemental oxygen As indicated.

VII.

NURSING DIAGNOSIS AND PATIENT GOAL

DIAGNOSIS GOAL

Nahihirapan ako huminga. As verbalized by the patient.

Short term goal: 15 mins. After nursing intervention, the client will be able to have a patent airway. Long term goal: After 4 hours of nursing intervention, the patient heart will pump effectively.

Namumutla na ako as verbalize by The client

Short term goal : 30 mins. After nursing intervention the client will be able to normalize her vital signs.

Long term goal: After 8 hours of nursing intervention the patient will display vital signs within acceptable limits, Dysrhythmias controlled and no symptoms of Failure.

Nahihirapan ako kumilos, nanghihina ang katawan ko. As verbalized by the patient.

Short term goal: 1 hour after nursing intervention the client will be able to perform light activity with minimal assistance.

Long term goal: After 5 hours of nursing intervention the client will be able to perform activity of daily living.

VIII. NURSING MANAGEMENT

1. Monitor for signs of respiratory distressI a. Provide pulmonary hygiene as needed b. Administer oxygen as prescribed c. Keep the head of the bed elevated d. Monitor ABG values. 2. Monitor for signs of altered cardiac output, including a. Pulmonary edema

3.

4.

5. 6.

b. Arrhythmias, including extreme tachycardia and bradycardia c. Characteristic ECG and heart sound changes Evaluate fluid status a. Maintain strict fluid intake and output measurements b. Monitor daily weights c. Assess for edema and severe diaphoresis d. Monitor electrolyte values and hematocrit level e. Maintain strict fluid restrictions as prescribed Administer prescribed medications which may include: a. Antiarrhythmias to increase cardiac performance b. Diuretics, to reduce venous and systemic congestion c. Iron and folic acid supplements to improve nutritional status. Prevent Infection Reduce cardiac demands a. Keep the child warm b. Schedule nursing interventions to allow for rest c. Do not allow an infant to feed for more than 45 minutes at a time d. Provide gavages feedings if the infant becomes fatigued before ingesting an adequate amount 7. Promote adequate nutrition. Maintain a high-calorie, low-sodium as prescribed. 8. Promote optimal growth and development 9. As appropriate, refer the family to a community health nurse for follow up care after discharge.

0 IX. EVALUATION