m
  


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 Ê



 
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 Ê
General Objective:
After two hours of case presentation, the students will be able to acquire the
knowledge, enhance their skills and develop attitude towards caring of the patient
with cases regarding cardiovascular disorders.
Specifically, this aims to:
KNOWLEDGE:
1. Identify the precipitating factors regarding the pathophysiology of the disease
being manifested by the client.
2. Enumerate the signs and symptoms of the diseases manifested by the client.
3. Discuss the pathophysiology of Congestive Heart Failure.
SKILLS:
1. Demonstrate the appropriate approach used in dealing with clients with CHF.
2. Perform dependent and independent interventions, being done to the client,
appropriately and with care.
3. Perform comprehensive nursing care and interventions with competence and
confidence in rendering care to clients with CHF.
ATTITUDE:
1. Establish rapport to client and folks.
2. Encourage folks to cooperate in the interventions that are being performed to
the client.
3. Collaborate with all the health team to promote efficient care to the client.
m

m  
NAME: S.L
ADDRESS: Hamtic, Antique
CIVIL STATUS: Married
BIRTHDAY: April, 20, 1965
AGE: 44 yrs 10 mo.
RELIGION: Roman Catholic
OCCUPATION: Housewife
DATE OF ADMISSION: March 10, 2010
PHYSICIAN: Dr.C and Dr.A
CC: Cough
DIAGNOSIS: CHF III-IV sec to Valvular Heart disease
(VSD-severe MVR-TR)
Umbilical Hernia, 2° AF with MVR-RBBB,
CAP-MR


  
È m
 


Patient S.L has been admitted last
February 12, 2010 with chief complaint of
abdominal pain associated with nausea
and 1 episode of vomiting approximately
50cc. She was diagnosed to have CHF III
2° dilated cardiomyopathy but she was
discharged after a week. She had no major
surgeries in the past, but she was
diagnosed with CHF 13 years ago. She has
maintenance drugs including furosemide,
aldazide.
È Ê    


The patient had no major illness
during her childhood. She had
common colds, cough and fever but
did not opt for hospitalization. She
also had chicken pox when she was
in elementary.
È m
 


Two days prior to admission, patient
experienced weakness, decreased
appetite, orthopnea, whitish to
yellowish productive cough and
associated with difficulty of
breathing. There was no fever noted
and the patient took Levopront 10 ml
three times a day for 5 days but still
experienced productive cough so
the patient opted for admission.
È ›  

  


(-) Hypertension - maternal and
paternal side
(-) Diabetes mellitus
(-) Bronchial Asthma
- paternal side
(-) Cancer
(-) TB
(-) Heart Failure
È ?   
Patient is an elementary graduate
and started her high school level (3rd
year) but was not able to finish it
due to financial constraints. She is
able to read, write and calculate.
È M 
The patient raises pigs, chicken and
sells it. She raises them in their
house and it has been their
livelihood since birth. She also
plants vegetables in their backyard
and is able to sell those in order to
further sustain their needs.
È m

 m 
Her husband, her 4 children and her
relatives.

È   
Client is a wife, a mother and a
daughter, and helps the family
financially together with her husband
who is a carpenter.
È ? 

The family has no definite income
monthly and only depends on the
amount earned from selling vegetables,
poultry products and the availability of
work of her husband. The total income
of the family is at least P 2000 per
month. When it comes to their medical
expenses, they depend on their
relatives¶ assistance and have debts.
The patient has 4 children, 1 in high
school and 3 are not studying.
È 
 
Patient is a non-smoker, a non-
alcoholic drinker, and a non-coffee
drinker. Patient usually eats yellow
vegetables (like squash and camote
roots) She avoids eating green leafy
vegetables (like ³laswa´) because she
can¶t digest it easily and then usually
experience dyspepsia and abdominal
cramping. She oftentimes drinks soft
drinks as she likes, 3 8oz. of coke per
week.
 m Ê







ÕmM  ÕmM 
M ??

(March 1, 2010) (March 4, 2010)

TEMPERATURE 36 o C 36. 4 o C

PULSE 96 bpm 72 bpm

RESPIRATION 24 bpm 22 bpm

BLOOD 110/ 70 mmHg 100/60 mmHg

PRESSURE



mm


Ê
È m
   
Patient is lying on semi-fowlers
position, awake with IVF of PNSS x
KVO + 20 meqs KCl infusing well at left
metacarpal vein. Bony prominences
visible. She is 4 feet 9 inches in height
and weighs 34 kgs. BMI= 16.22 and is
underweight. Able to sit, stand and
walk without assistance. Client
grooming is maintained by folks and no
halitosis noted.
È m
   m

Oriented to person, place and time
and irritable. Patient also answers
questions appropriately in
congruence to age and
situation. He is conversant to folks
and alert upon interview. Speech is
audible, understandable, and in
moderate pace, exhibits thought
association. Dependent to folks for
her needs.


È Fair skin with no freckles. Skin is
wrinkled, dry, rough and sagging
with minimum perspiration, sensitive
to heat and pressure. No bleeding,
edema, and lesions. Temperature
uniform upon touch on upper
extremity and lower extremity. Skin
moves back slowly upon checking of
skin turgor approximately two
seconds.
 



Ê
È Symmetrical head and face. Short
straight black hair. Hair is evenly
distributed in the scalp with presence of
some white hairs. Hair is free from
infestations, flakes and lesions upon
parting the hair. Brittle and dry hair
noted.
È Face is fair colored and no masses
present. Face is round. Skull , face and
jaws are symmetrical. Symmetrical
head movement. No pain noted in the
mandible during palpations.

È Patient eyes open spontaneously.
Sclerae are white, pupils are equally
round both react and accommodate
to light, approximately 2-3mm with
pale conjunctiva. Eyes are
symmetrical with no ptosis and
discharges noted. No masses, or
swelling in upper and lower eye.
Eyebrows and eyelashes are well
distributed. Patient is able to read
nameplate in a 2 feet distance.


È Ears are symmetrical and in normal
shape. No unusual discharges
noted. No nodules and deformities
and foreign body seen. Patient is
able to hear normal voice tones. No
pain noted over mastoid process
upon palpation. Auricles have the
same color with face. Pinnas are
mobile, firm and non tender.


È No presence of discharges, lesions,
polyps, bleeding and foreign body
noted. No pain on maxillary and
frontal sinuses. Nose is symmetrical
and not flaring upon inspiration.
Pinkish nasal mucosa and is able to
distinguish odor between alcohol
and cologne.
  

  m


È Gag reflex is present. Lips are moist
and pinkish in color. No lesions or
inflammation noted. Tongue is in the
midline of the mouth. The dorsum of
the tongue is pink, moist and with
lesions. It is symmetrical and moves
freely. The buccal mucosa is moist,
smooth, and free of lesions. No
swelling and bleeding in the gums.
Hard and smooth palates are concave
and pinkish. Erosion of the teeth noted.
No halitosis noted.
È

Ê
È Color is the same as to the rest of
the body. Symmetrical with full
ROM. No masses, swelling,
enlargement of lymph nodes and
thyroid as inspected. Carotid pulse
is steady and palpable. Carotid
pulse = 75.
 
Ê 
È Chest is symmetrical in both sides with
symmetrical placement of all structure.
Chest pain noted. Spinal column is
straight, right and left shoulders are
symmetrical. Chest wall is intact, no
tenderness, no masses noted. Dilated
superficial vein are not seen. The
costal angle widens slightly during
inhalation due to expansion of the
thorax. No scars. Cardiac rate was 72
bpm upon auscultation, rales and
crackles noted.

Ê
È Normal spine curvature. Neither
scars nor lumps noted. Shoulders
are symmetrical. No inflammation,
lesions, ecchymosis noted on the
back.

 

È Firm, round in shape, uniform in
color and pigmentation. Protrusion
of umbilical area noted. Abdomen is
firm and smooth. Symmetrical
movement of the abdomen on
respiration. Abdominal
circumference approximately 78 cm.
mm
È Bony prominences visible in the upper
extremities. Muscles are well proportionate
in size and are well toned. With IVF of
PNSS 1L x KVO + 20 meqs KCl @ left
metacarpal vein and infusing well. Full
ROM at both arms. Radial and brachial
pulse bilaterally equal in rate and rhythm.
Pulse is equal to 72bpm. Capillary refill is
normal at 2 sec. No edemas, lesions,
swellings, masses and tenderness noted
on any part of the upper extremities. No
clubbing on fingernails.
 
È Lower extremities are similar in color
with the rest of the body. Muscles
are well proportionate in size and
are well toned. No edemas, lesions,
swellings, tenderness noted in the
lower extremities. No clubbing on
toenails. Full ROM in lower
extremities. Popliteal, dorsalis pedis
and posterior tibialis are palpable
and 71 bpm as palpated.

  




Patient is able to void with no bleeding,

discomfort or pain. Urine is dark yellow as
observed. Micturition is five times a day
with urine output approximately 1,300 cc in
a day.


 





Has no pain in bowel movement. Patient

able to defecate once every two days
depending on the amount of food taken.
Stool is solid, soft and dark brown.
 Ê  
m



È During March 1, 2010 at around 9:40
AM, the patient was admitted with a
chief complaint of cough with vital
signs T = 36°C, P = 96 bpm, R = 24
bpm and BP = 110/70 mmHg. Oxygen
was then administered at 2 lpm via
nasal cannula. O2 sat result was 95-
98%. At around 9:48 AM, ECG 12
leads was done by heart station
personnel and after a few minutes, the
patient was brought to xray room for X-
ray PA view left lateral. PNSS 1 L x 10
cc/H was then started as venoclysis at
left cephalic vein at around 10:40 AM.
È By 11:45 AM, the patient was
transferred to department F per
wheelchair. At 7 PM, PAI with 1
nebule salbutamol was done by
pulmonary personnel. 20 mEq KCl
was then incorporated to IVF at
around 10:20 PM. Fresh blood
associated with bowel movement
and urination were positive during
March 4, 2010. Direct rectal
examination suggests good
sphincter tone and blood was
negative on examining finger.

 
 




Ê
m Ê



ë

È A routine urinalysis is a test for
urinary and systemic disorders. This
test is used to evaluate physical
characteristics (color, odor, turbidity
and opacity) of urine, determines
specific gravity and pH; detects and
measure protein, glucose, and
ketone bodies and examines
sediments for blood cells; casts and
crystals.
È Diagnostic laboratory methods include
visual examination, reagent strip
screening, refractometry for specific
gravity and microscopic inspections of
centrifuged sediments.
m
 
È To screen the patients urine for renal or
urinary tract diseases.
È To help detect metabolic or systemic
disease unrelated to renal disorder.
È Essential component of a complete
physical examination, especially when
performed on admission to a health-care
facility.

Ê 
m
m

È Color: Straw
È Transparency: Slightly hazy
È Reaction: Acidic (6.0)
È Specific Gravity: 1.010
È Chemical Tests
È Sugar: Negative
È Albumin: trace
Ê Ê mÊ


›

 
›

  
 
  

m


 
 


 
 
 






Ê
 Renal Epithelial Cells:

Amorphous Urates: None
Few Bacteria:
Round Epithelial Cells: Few
Few Mucus Threads:
Squamous Epithelial Cells: None
Few Yeast Cells:
None
Ê 
 
m 
Ê 
m
ë

The penetration of x-rays or electromagnetic waves in
the chest can cause an image to form on special film.
The best view to obtain with the patient erect and film
exposed in posterior-anterior fashion and is exposed on
full expiration. A projection of the chest used to
diagnosed conditions affecting the chest, its contents and
nearby structures. Chest radiographs are most common
film taken, being diagnostic of many conditions.
m
 
È To evaluate the pulmonary and cardiac systems, and to
reveal any pathological findings and pulmonary
disorders.
È Evaluate known or suspected pulmonary disorders, chest
trauma, cardiovascular disorders and skeletal disorders.

Ê 
È Follow-up to radiograph reveal both lung
fields to be clear. The pulmonary vascular
markings are not accentuated. The cardiac
silhouette is still markedly enlarged. Rest
of the cardio-pulmonary findings are
unchanged in comparison with previous
radiograph of Feb. 11, 2010.


 
È Marked cardiomegaly pericardial effusion
still not ruled out. Suggest 2-D
echocardiography. For further evaluation.
 
 
ë
:
È Hematology refers to the scientific study of blood and
blood forming tissues. It is a combination report of a
series of tests of the peripheral blood. The quantity,
percentage, variety, concentrations, and quality of blood
cells are identified. Hematology includes the study of
etiology, diagnosis, treatment, prognosis, and prevention
of blood diseases.
m
 :
È To determine the presence of infection.
È To aid in diagnosis of certain disease.
È Constitute in the major signs and symptoms of
determining certain blood disorders.
È Basic screening test that address disorders,
hemoglobin and cell production, synthesis and
function are also determined.

Ê 
 
   
 
   
 


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Differential Count

Neutrophil 90% 45-73% Infection

— Segmenter 83% 50-70% Infection

— Stab 6% 2-5% Infection

— Juvenile 1% 0-1% Normal

Eosinophil 1% 1-5% Normal

Basophil 0% 0-1% Normal

Lymphocyte 7% 20-40% Anemia

Monocyte 2% 3-9% Anemia

  
   
   
 



 

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ë

A sputum culture is a test to detect and identify bacteria
or fungi (plural of fungus) that are infecting the lungs or
breathing passages. A sample of sputum is placed in a
container with substances that promote the growth of
bacteria or fungi. If no bacteria or fungi grow, the culture
is negative. If organisms that can cause infection
(pathogenic organisms) grow, the culture is positive. The
type of bacterium or fungus will be identified with a
microscope or by chemical tests.
If bacteria or fungi that can cause infection grow in the
culture, other tests may be done to determine which
antibiotic will be most effective in treating the infection.
This is called susceptibility or sensitivity testing.
m
 
To isolate and identify the cause of pulmonary infection,
thus aiding in the diagnosis of respiratory diseases.
 !"#

È Specimen: Sputum
È Culture Isolate:
Few Colonies of
Candida Species




ë

The Gram staining, the most common and useful
staining procedure, separates bacteria into two
classifications, according to the composition of their
cell walls: gram-positive organism, which retain
crystal violet stain after decolorization, and gram-
negative organism, which lose the purple stain but
counter-stain red safranin.
Microscopic examination of the Gram-stained
smear typically allows tentative identification of the
suspected organism. Examining a direct smear of
the specimen for inflammatory cells, such as
neutrophils and macrophages, can also provide
clues about the type of infection present and
consequent mobilization of the immune system.
 !"#

Specimen: Sputum
Gram stained smear shows few
gram negative bacilli and occasional
gram positive cocci in pairs.
Polymorphonuclear leukocytes are
100-120/hpf and epithelial cells are
0-4/hpf.

KOH amount:
NEGATIVE FOR FUNGUS
m   

È Prothrombin time measures the time
required for a fibrin clot to form in a
citrated plasma sample after addition of
calcium ions and tissue thromboplastin
(factor III)

m
 
È To evaluate the extrinsic coagulation
system ( factors V, VII, and X and
prothrombin and fibrinogen)
È To monitor response to oral anticoagulant
therapy
 !"#
È Specimen: Plasma

m
 
 
  
 


  
 

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ë
:
È Blood chemistry is the chemical composition of the
blood. The levels of various substances in the
blood can provide clues to a patient's condition.
Routine blood work to check blood chemistry is
often a part of a diagnostic work-up, with the blood
being analyzed to check for specific elements
which could contribute clues to the diagnosis.

m
 
È Blood tests are used to determine physiological
and biochemical states such as disease, mineral
content, drug effectiveness, and organ function.
 !"#
    
   
 
  
 


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 Ê Ê
 

È The electrocardiogram (ECG or EKG) is a diagnostic tool
that measures and records the electrical activity of the
heart in exquisite detail. An ECG records the electrical
impulses that stimulate the heart to contract. It also
records dyafunctions that influence the conduction ability
of the myocardium. It provides a continuous picture of
electrical activity during a complete cycle. Interpretation
of these details allows diagnosis of a wide range of heart
conditions. These conditions can vary from minor to life
threatening.
An ECG is used to measure:
È Any damage to the heart
È How fast your heart is beating and whether it is beating
normally
È The effects of drugs or devices used to control the heart
(such as a pacemaker)
È The size and position of your heart chambers
 !"#

Conclusion:
Atrial Fibrillation with
Moderate Ventricular Response
Incomplete RBBB
 
ANATOMY AND PHYSIOLOGY
OF THE HEART
ÈThe heart is located under
the ribcage in the center of
the chest between the right
and left lungs. Its muscular
walls beat, or contract,
pumping blood continuously
to all parts of the body.

ÈThe size of the heart can

vary depending on the age,
size, and the condition of the
heart. A normal, healthy, adult
heart most often is the size of
an average clenched adult
fist. Some diseases of the
heart can cause it to become
larger.
#$$%&'(

È The right and left sides of the heart are

divided by an internal wall of tissue called
the septum. The area of the septum that
divides the atria (the two upper chambers
of the heart) is called the atrial or interatrial
septum.
È The area of the septum that divides
the ventricles (the two lower chambers of
the heart) is called the ventricular or
interventricular septum.
 $ !&Ê# ()$!*
È The heart is divided into four chambers. The
two upper chambers of the heart are called
atria. The atria receive and collect blood.
È The two lower chambers of the heart are
called ventricles. The ventricles pump blood
out of the heart into the circulatory system to
other parts of your body.
$ !& +,$*
È Shown counterclockwise in the picture, the
valves include the aortic valve, the tricuspid
valve, the pulmonary valve, and the mitral
valve.
+--.+-/
ÈThe arrows in the drawing
show the direction that blood
flows through the heart. From
the right atrium, blood is
pumped into the right ventricle.
From the right ventricle, blood
is pumped to the lungs through
the pulmonary arteries.

ÈThe light red arrows show the

oxygen-rich blood coming in
from the lungs through the
pulmonary veins into the
heart's left atrium. From the left
atrium, the blood is pumped
into the left ventricle. The left
ventricle pumps the blood to
the rest of the body through
the aorta.
È For the heart to work properly, the blood
must flow in only one direction. The heart's
valves make this possible. Both of your
heart's ventricles have an "in" (inlet) valve
from the atria and an "out" (outlet) valve
leading to the arteries.

È Healthy valves open and close in very

exact coordination with the pumping action
of the heart's atria and ventricles. Each
valve has a set of flaps called leaflets or
cusps that seal or open the valves. This
allows pumped blood to pass through the
chambers and into your arteries without
backing up or flowing backward.
+$"&!0" +*1*&$(
È The electrical system also is called the cardiac
conduction system. If you've ever seen the heart test
called an EKG (electrocardiogram), you've seen a
graphical picture of the heart's electrical activity.
The heart's electrical system is made up of three main parts:
È The sinoatrial (SA) node, located in the right atrium of
your heart
È The atrioventricular (AV) node, located on the interatrial
septum close to the tricuspid valve
È The His-Purkinje system, located along the walls of your
heart's ventricles

È A heartbeat is a complex series of events that take place

in the heart. A heartbeat is a single cycle in which your
heart's chambers relax and contract to pump blood. This
cycle includes the opening and closing of the inlet and
outlet valves of the right and left ventricles of the heart.
È Each heartbeat has two basic parts: diastole and
atrial and ventricular systole. During diastole, the
atria and ventricles of the heart relax and begin to
fill with blood.
È At the end of diastole, the heart's atria contract
(atrial systole) and pump blood into the ventricles.
The atria then begin to relax. The heart's ventricles
then contract (ventricular systole), pumping blood
out of the heart.
È Each beat of the heart is set in motion by an
electrical signal from within the heart muscle. In a
normal, healthy heart, each beat begins with a
signal from the SA node. This is why the SA node
is sometimes called the heart's natural pacemaker.
The pulse, or heart rate, is the number of signals
the SA node produces per minute.
È The signal is generated as the two vena cavae fill the heart's right
atrium with blood from other parts of the body. The signal spreads
across the cells of the heart's right and left atria. This signal causes
the atria to contract. This action pushes blood through the open
valves from the atria into both ventricles.
È The signal arrives at the AV node near the ventricles. It slows for an
instant to allow the heart's right and left ventricles to fill with blood.
The signal is released and moves along a pathway called the bundle
of His, which is located in the walls of the heart's ventricles.
È From the bundle of His, the signal fibers divide into left and right
bundle branches through the Purkinje fibers that connect directly to
the cells in the walls of the heart's left and right ventricles. The
signal spreads across the cells of the ventricle walls, and both
ventricles contract. However, this doesn't happen at exactly the
same moment.
È The left ventricle contracts an instant before the right ventricle. This
pushes blood through the pulmonary valve (for the right ventricle) to
the lungs, and through the aortic valve (for the left ventricle) to the
rest of the body.
È As the signal passes, the walls of the ventricles relax and await the
next signal.
È This process continues over and over as the atria refill with blood
and other electrical signals come from the SA node.
Ê
 


 
 
m Ê
È Heart failure, often referred to as Congestive Heart Failure
(CHF), is the inability of heart to pump sufficient blood to
meet the needs of the tissues for oxygen and nutrients.
CHF means that the patient has a fluid overload condition
(congestion) has been identified. Over time, conditions
such as narrowed arteries in your heart (coronary artery
disease) or high blood pressure gradually leave your heart
too weak or stiff to fill and pump efficiently.

È Heart failure often develops after other conditions have

damaged or weakened your heart. Over time, the heart
can no longer keep up with the normal demands placed on
it to pump blood to the rest of your body. The main
pumping chambers of your heart (the ventricles) may
become stiff and not fill properly between beats. Also, your
heart muscle may weaken, and the ventricles stretch
(dilate) to the point that the heart can't pump blood
efficiently throughout your body. The term "congestive
heart failure" comes from blood backing up into ² or
congesting ² the liver, abdomen, lower extremities and
lungs.




Ê 
È Congestive heart failure (CHF) is
a syndrome, not a disease that È
can be brought about by several
causes. CHF is a weakening of
the heart brought on by an
underlying heart or blood vessel
problem, often a combination of
several different problems,
including the following:
È Weakened heart muscle
È Damaged heart valves
È Blocked blood vessels supplying È
the heart muscle (coronary
arteries), leading to a heart attack
È Toxic exposures, like alcohol or
cocaine
È Infections
È High blood pressure that results
in thickening of the heart muscle
(left ventricular hypertrophy)
Pericardial disease, such as
pericardial effusion (a large
collection of fluid around the heart
in the space between the heart
muscle and the thick layer of
pericardium surrounding the
heart) and/or a thickened
pericardium, which does not allow
the heart to fill properly
È Congenital heart diseases
Prolonged, serious arrhythmias
È While these conditions often
combine to produce CHF,
sometimes the causes of
diseased heart muscles are not
known; this is called idiopathic
cardiomyopathy or heart muscle
disease of unknown cause.
CHF is often a result of the following lifestyle habits:
È Unhealthy habits, such as smoking and excessive
use of alcohol, are often to blame.
È Obesity and lack of activity may contribute to CHF,
either directly or indirectly through accompanying
high blood pressure, diabetes, and coronary artery
disease.
È Years of uncontrolled high blood pressure damages
both heart and blood vessels.
Along with lifestyle risk factors, a number of diseases
(for example, diabetes, heart attack [myocardial
infarction], and congenital heart disease) can damage
the heart and lead to congestive heart failure. Over a
hundred other, less common, causes of CHF include a
variety of infections, exposures, complications of other
diseases, toxic effects, and genetic predisposition.
Ê

Ê






2


m 3
Right Sided Heart Failure Left Sided Heart Failure
È Increased Systemic È Dyspnea
pressure È Cough
È Jugular vein È Tachycardia
distention È Pulsus alterans
È Hepatomegaly È Fatigue and
È Ascites weakness
È Dependent È Memory loss and
peripheral edema confusion
È Weight gain È Palpitations
È Anorexia, nausea È Hypotension
È Gastric distress
Ê






È If no underlying correctible cause of heart failure is
established, medical treatment is composed of lifestyle
changes and medications.
È Lifestyle changes recommended by the health care
provider can help relieve symptoms, slow the
progression of heart failure, and improve one's quality of
life. Lifestyle changes that may be helpful in preventing
or relieving heart failure include those recommended by
the American Heart Association and other organizations
as part of a heart-healthy lifestyle.

È Medications help control both the underlying

causes of heart failure and the symptoms. Medications
are the most critical part of therapy for heart failure.
Usually, several types of medications are required to
address as many of the physiologic imbalances as
possible. These medications include:
È  
- enlarge the small arteries or arterioles, which
relieve the systolic workload of the left ventricle. The heart has to
work less to pump blood through the arteries. This also generally
lowers blood pressure. They block the production of angiotensin II,
which is abnormally high in congestive heart failure.
È  
- improves the pumping ability of the heart, causing it to
pump more forcefully, a so-called positive inotrope.
È   - increase the pumping ability of the heart. These are
used as a temporary support of a very weak left ventricle that is not
responding to standard CHF therapy.
È 
- cause the kidneys to remove excess salt and
accompanying water from the bloodstream, thereby reducing the
amount of blood volume in circulation. With a lower volume of
blood, your heart does not have to work so hard. The number of
red and white blood cells is not changed.
È Ê    
- arterial vasodilators that are not used for
treatment of heart failure per se because clinical trials have proven
no benefit for prolongation of life. Calcium channel blockers are
useful for lowering blood pressure if the cause of the CHF is high
blood pressure and the patient is not responding to ACE inhibitors.
È   
- drugs slow down the heart rate, lower blood
pressure, and have a direct affect on the heart muscle to lessen the
workload of the heart.
Ê





È The only alternative is a heart transplant.
This option is for patients who are not
elderly and who do not have other medical
conditions that would make it unlikely for a
heart transplant to be successful. Heart
transplant evaluations are done in
specialized centers.

È Other treatment or procedures, such as

angioplasty or a pacemaker, may be
offered, depending on the underlying
cause of the heart failure.
È 
 This is an alternative to
coronary bypass surgery for some
people whose heart failure is caused
by coronary artery disease and is
compounded by heart damage/heart
attack. Angioplasty is used to treat
narrowing or blockage of a coronary
artery that supplies the left ventricle
with blood. A long, thin tube called a
catheter is inserted through the skin,
into a blood vessel, and threaded into
the affected artery. This procedure is
performed while the person is under
local anesthesia.
È m  : This device controls the
rhythm of the heartbeats. A pacemaker
is an electrode on the tip of a wire,
usually implanted inside the heart by
an electrophysiologist or specialized
cardiologist in the cardiac cath lab. This
wire goes to the right ventricle,
frequently with a second wire to the
right atrium (dual chamber pacemaker).
A pacemaker can stimulate a heart that
is beating too slowly to beat faster, or it
can control an irregular heartbeat
(sometimes, this requires medications
in addition to the pacemaker).
È  




A surgically implanted to
mechanically bypass the left
ventricle. A clinical trial showed that
complications are too high and the
device did not significantly prolong
life if used on a long-term basis.
This device is used as a temporary
left ventricle support to get the
patient awaiting a heart transplant
out of bed.
Totally implantable artificial hearts are
being developed for patients with
severe, end stage heart failure.
È These devices are most commonly
used as a temporary bridge to heart
transplantation.
È This technique is constantly
improving but is still limited to
specialized centers and is
considered experimental at this time







È Keeping an input and output record to identify a
negative balance.
È Weighing the patient daily at the same time and on
the same scale.
È Auscultating lung sounds at least daily to detect an
increase or decrease in pulmonary crackles.
È Provide general counseling and education about
sodium restriction.
È Encourage patient to exercise regularly
È Recommend avoidance of excessive fluid intake,
alcohol, and smoking.
È Assessing symptoms of fluid overload (eg.
Orthopnea, paroxysmal nocturnal dyspnea, and
dyspnea on exertion) and evaluating changes.
m
 m  
 

m Ê
Ê






È 6  Warfarin
È    Coumadin
È Ê

 
Anticoagulant
È  

Pulmonary embolism, DVT, MI, rheumatic heart disease with heart
valve damage, prosthetic heart valves, chronic arterial fibrillation
È 
 1mg/tab OD
È 
Interferes with the hepatic synthesis of Vitamin K dependent
clotting factors (factors II prothrombin, VII, IX, and X), resulting in
their eventual depletion and prolongation of clotting times.
È 
 
CNS: fever, headache
GI: diarrhea, anorexia, nausea, vomiting, cramps, mouth
ulcerations
GU: hematuria, menstrual excessive bleeding
Hematologic: hemorrhage
Skin: dermatitis, urticaria, rash, necrosis
Ê  

È Contraindicated in patients hypersensitive to
drug and in those with bleeding from the GI,
GU or respiratory tract; aneurysm;
Cerebrovascular hemorrhage; severe or
malignant hypertension; severe renal or
hepatic disease.
È Contraindicated during pregnancy,
threatened abortion, eclampsia, or pre
eclampsia,and after recent surgery involving
large open eyes, brain or spinal cord.
È Avoid using in patients with a history of
warfarin induced necrosis.
 

 

È Draw blood to establish baseline coagulation
parameters before therapy. PT and INR
determinations are essential for proper control.
È INR range for chronic atrial fibrillation is usually
2-3.
È Give drug at the same time daily.
È Avoid all IM injections.
È Regularly inspect patient for bleeding gums,
bruises on arms or legs, petechiae, nosebleeds,
melena, tarry stools, hematuria, and hematesis.
È With hold drug and call prescriber at once in the
event of fever or rash.
È Effect can be neutralized by oral or parenteral
vit. K.
m   
È Tell patient and family to watch for signs of bleeding or
abnormal bruising and call prescriber at once if they occur.
È Warn patient to avoid OTC drugs containing aspirin, other
salicylates, or drugs that may interact with warfarin unless
ordered by prescriber.
È Tell patient to consult a prescriber before using miconazole
vaginal and bruising have occurred.
È Instruct patient to notify prescriber if menstruation is
heavier than usual, she may need dosage adjustment.
È Tell patient to use electric razor when shaving, and use a
soft toothbrush
È Tell patient to read food labels. Food, nutritional
supplements and multivitamins that contain vitamin k may
impair coagulation
È Tell patient to eat daily, consistent diet of food and drinks
containing vitamin K, because eating varied amounts may
alter anticoagulant effects



È 6  Bumetanide
È    Burinex
È Ê

 
Loop Diuretic: Edema associated with
CHF, cirrhosis, renal disease, acute
pulmonary edema
È 
 1mg OD
È 

Inhibits the reabsorption of sodium and
chloride from the proximal and distal renal
tubules and the loop of Henle, leading to a
natriuretic diuresis.

 
È Ê  Asterixis, dizziness, vertigo, paresthesias, confusion,
fatigue, nystagmus, weakness, headache, drowsiness, fatigue,
blurred vision, tinnitus, irreversible hearing loss
È ÊOrthostatic hypotension, volume depletion, cardiac
arrhythmias, thrombophlebitis
È 6 Nausea, anorexia, vomiting, diarrhea, gastric irritation and
pain, dry mouth, acute pancreatitis, jaundice
È 6Õ Polyuria, nocturia, glycosuria, renal failure
È
  Hypokalemia, leukopenia, anemia,
thrombocytopenia
È   Pain, phlebitis at injection site
È M  Muscle cramps and muscle spasms, weakness, arthritic
pain, fatigue, hives, photosensitivity, rash, pruritus, sweating,
nipple tenderness

Ê  

È Contraindicated with allergy to bumetanide; electrolyte depletion;
anuria, severe renal failure; hepatic coma; lactation.
m   
È Record alternate day or intermittent therapy on a calendar or
dated envelopes.
È Take the drug early in day so increased urination will not
disturb sleep; take with food or meals to prevent GI upset.
È Weigh yourself on a regular basis, at the same time, and in
the same clothing; record the weight on your calendar.
È These side effects may occur: Increased volume and
frequency of urination; dizziness, feeling faint on arising,
drowsiness (avoid rapid position changes; hazardous
activities, such as driving; and alcohol consumption);
sensitivity to sunlight (use sunglasses, sunscreen, and wear
protective clothing); increased thirst (suck sugarless lozenges;
use frequent mouth care); loss of body potassium (a
potassium-rich diet, or supplement will be needed).
È Report weight change of more than 3 lb in 1 day; swelling in
ankles or fingers; unusual bleeding or bruising; nausea,
dizziness, trembling, numbness, fatigue; muscle weakness or
cramps.
 

È 6  Digoxin
È    Lanoxin
È Ê

 
Anti-arrythmic
È   CHF, Atrial Fibrillation
È 
 0.25mg ½ tab OD
È 
Increases intracellular calcium and allows more
calcium to enter the myocardial cell during
depolarization via a sodium±potassium pump
mechanism; this increases force of contraction
(positive inotropic effect), increases renal perfusion
(seen as diuretic effect in patients with CHF),
decreases heart rate (negative chronotropic effect),
and decreases AV node conduction velocity.
 
Ê
 

È History: Allergy to bumetanide, electrolyte depletion,
anuria, severe renal failure, hepatic coma, SLE, gout,
diabetes mellitus, lactation
È Physical: Skin color, lesions; edema; orientation, reflexes,
hearing; pulses, baseline ECG, BP, orthostatic BP,
perfusion; R, pattern, adventitious sounds; liver
evaluation, bowel sounds; urinary output patterns; CBC,
serum electrolytes (including calcium), blood sugar, liver
and renal function tests, uric acid, urinalysis
È Give with food or milk to prevent GI upset.
È Mark calendars or use reminders if intermittent therapy is
best for treating edema.
È Give single dose early in day so increased urination will
not disturb sleep.
È Avoid IV use if oral use is possible.
È Arrange to monitor serum electrolytes, hydration, liver
function during long-term therapy.
È Provide diet rich in potassium or supplemental
potassium.

 
È Ê Headache, weakness, drowsiness, visual
disturbances, mental status change
È ÊArrhythmias
È 6GI upset, anorexia

Ê  
È Contraindicated with allergy to digitalis
preparations, ventricular tachycardia, ventricular
fibrillation, heart block, sick sinus syndrome,
IHSS, acute MI, renal insufficiency and electrolyte
abnormalities (decreased K+, decreased Mg++,
and increased Ca++).
È Use cautiously with pregnancy and lactation.
 
Ê
 
È

 Allergy to digitalis preparations, ventricular tachycardia,
ventricular fibrillation, heart block, sick sinus syndrome, IHSS, acute MI,
renal insufficiency, decreased K+, decreased Mg++ increased Ca++
È m
  Weight; orientation, affect, reflexes, vision; P, BP, baseline
ECG, cardiac auscultation, peripheral pulses, peripheral perfusion,
edema; R, adventitious sounds; abdominal percussion, bowel sounds,
liver evaluation; urinary output; electrolyte levels, liver and renal function
tests
È Monitor apical pulse for 1 min before administering; hold dose if pulse <
60 in adult or < 90 in infant; retake pulse in 1 hr. If adult pulse remains <
60 or infant < 90, hold drug and notify prescriber. Note any change from
baseline rhythm or rate.
È Take care to differentiate Lanoxicaps from Lanoxin; dosage is very
different
È Check dosage and preparation carefully.
È Avoid IM injections, which may be very painful.
È Follow diluting instructions carefully, and use diluted solution promptly.
È Avoid giving with meals; this will delay absorption.
È Have emergency equipment ready; have K+ salts, lidocaine, phenytoin,
atropine, cardiac monitor on standby in case toxicity develops.
È Monitor for therapeutic drug levels: 0.5±2 ng/mL.
m 
  
È Do not stop taking this drug without notifying your
health care provider.
È Take pulse at the same time each day, and record it on
a calendar call your health care provider if your pulse
rate falls below .
È Weigh yourself every other day with the same clothing
and at the same time. Record this on the calendar.
È Wear or carry a medical alert tag stating that you are
using this drug.
È Have regular medical checkups, which may include
blood tests, to evaluate the effects and dosage of this
drug.
È Report unusually slow pulse, irregular pulse, rapid
weight gain, loss of appetite, nausea, vomiting, blurred
or "yellow" vision, unusual tiredness and weakness,
swelling of the ankles, legs or fingers, difficulty
breathing.

  Ê

È 6  Azithromycin
È    Azomycin
È 
500 mg TID
È Ê

 
Antibiotic, macrolide
È 
A macrolide antibiotic derived from
erythromycin. Acts by binding to the P site
of the 50s ribosomal subunit and may inhibit
RNA-dependent protein synthesis by
stimulating the dissociation of peptidyl t-RNA
from ribosomes.

 

È CNS: dizziness, vertigo, headache, fatigue,
somnolence
È CV: palpitations, chest pain
È GI: nausea, vomiting, diarrhea, abdominal
pain, dyspepsia, flatulence, melena,
cholestatic jaundice
È GU: monilia, vaginitis, nephritis
È Skin: rash, photosensitivity
È Other: angioedema, pseudomembranous colitis

Ê  

È Hypersensitivity to azithromycin, any
macrolide antibiotic, or erythromycin.
 
Ê
 

È Tablets and oral suspension can be taken with or
without food; however, there is an increased
tolerability when tablets are taken with food. It
should be taken 1 hour to or 2 hours after a meal.
È Use cautiously in patients with impaired hepatic
function.
È Obtain culture and sensitivity tests before first
dose. Therapy can begin before results are
obtained.
È May cause overgrowth of nonsusceptible bacteria
or fungi. Monitor for signs and symptoms of
superinfection.
È Tell patient to take all of the medication prescribed,
even after he feels better.
Ê  ›  
  
È Tablets may be taken with food or milk to
improve tolerability. Food decreases absorption.
È Finish all medication unless otherwise directed.
È Avoid ingesting Al- or Mg containing antacids
simultaneously with Azithromycin.
È Notify provider if nausea and vomiting is
excessive or debilitating.
È Avoid sun exposure and use protection when
outside.
È Report lack of response or any unusual side
effects.
È With STDs, encourage partner to seek medical
evaluation and treatment to prevent re-infections.
Use condoms during intercourse throughout
therapy.
   
Ê

È 6 Levofloxavin
È   Levaquin
È Ê

 Antibiotic
È  
 Treatment of adults with community-acquired pneumonia,
acute maxillary sinusitis caused by susceptible bacteria
 Treatment of acute exacerbation of chronic bronchitis
caused by susceptible bacteria
 Treatment of complicated and uncomplicated skin and skin
structure infections caused by susceptible bacteria
 Treatment of complicated and uncomplicated UTIs and
acute pyelonephritis caused by susceptible bacteria
 Treatment of chronic bacterial prostatitis due to Escherichia
coli, Enterococcus faecalis, Staphylococcus species
 Treatment of nosocomial pneumonia due to methicillin-
sensitive Staphylococcus aureus, Pseudomonas strains, Serratia
species, Escherichia coli, Klebsiella species, Haemophilus
influenzae, Streptococcus pneumoniae
È 
500 mg/ tab OD

È Bactericidal: Interferes with DNA by inhibiting DNA synase
replication in susceptible gram-negative and gram-positive
bacteria, preventing cell reproduction.
È 
 
È Ê Headache, dizziness, insomnia, fatigue, somnolence,
blurred vision
È 6Nausea, vomiting, dry mouth, diarrhea, abdominal pain
(occur less with this drug than with oflaxacin), constipation,
flatulence
È
  Elevated BUN, AST, ALT, serum creatinine,
and alkaline phosphatase; neutropenia, anemia
È M Fever, rash,  

 ! muscle and joint
tenderness

Ê  
È Contraindicated with allergy to fluoroquinolones, lactation.
È Use cautiously with renal dysfunction, seizures, pregnancy.
 
Ê
 
È Arrange for culture and sensitivity tests before
beginning therapy.
È Continue therapy as indicated for condition being
treated.
È Administer oral drug 1 hr before or 2 hr after meals
with a glass of water; separate oral drug from other
cation administration, including antacids, by at least
2 hr.
È Ensure that patient is well hydrated during course of
therapy.
È Discontinue drug at any sign of hypersensitivity
(rash, photophobia) or at complaint of tendon pain,
inflammation, or rupture.
È Monitor clinical response; if no improvement is seen
or a relapse occurs, repeat culture and sensitivity
test.
m 
  
È Take oral drug on an empty stomach, 1 hr before
or 2 hr after meals. If an antacid is needed, do not
take it within 2 hr of levofloxacin dose.
È Drink plenty of fluids while you are using this
drug.
È These side effects may occur: Nausea, vomiting,
abdominal pain (eat frequent small meals);
diarrhea or constipation (consult nurse or
physician); drowsiness, blurred vision, dizziness
(use caution if driving or operating dangerous
equipment); sensitivity to sunlight (avoid
exposure, use a sunscreen if necessary).
È Report rash, visual changes, severe GI problems,
weakness, tremors.
 Ê

 
È 6 Fluconazole
È   Funzela
È Ê

 Antifungal
È  
 Treatment of oropharyngeal, esophageal, vaginal, and
systemic candidiasis
 Treatment of cryptococcal meningitis
 Prophylaxis of candidiasis in bone marrow transplants
È 
150 mg/tab
È 
Binds to sterols in the fungal cell membrane, changing
membrane permeability; fungicidal or fungistatic depending
on concentration and organism.
È 
 
Ê Headache
6Nausea, vomiting, diarrhea, abdominal pain
M  Rash
Ê  
È Contraindicated with hypersensitivity to fluconazole,
lactation.
È Use cautiously with renal impairment.


Ê
 
È Culture infection prior to therapy; begin treatment before
lab results are returned.
È Decrease dosage in cases of renal failure.
È Infuse IV only; not intended for IM or SC use.
È Do not add supplement medication to fluconazole.
È Administer through sterile equipment at a maximum rate
of 200 mg/hr given as a continuous infusion.
È Monitor renal function tests weekly, discontinue or
decrease dosage of drug at any sign of increased renal
toxicity.
m 
  
È Drug may be given orally or intravenously as
needed. The drug will need to be taken for the full
course and may need to be taken long term.
È Use hygiene measures to prevent reinfection or
spread of infection.
È Arrange for frequent follow-up while you are using
this drug. Be sure to keep all appointments,
including those for blood tests.
È These side effects may occur: Nausea, vomiting,
diarrhea (eat frequent small meals); headache
(analgesics may be ordered).
È Report rash, changes in stool or urine color,
difficulty breathing, increased tears or salivation.
Ê
ÊÊ



È 6 Calcium Carbonate
È   Caltrate
È Ê

 
Antacid, adsorbent and antiflatulents
È  
Acid indigestion, calcium supplement
È 
1 tab OD
È 
Reduces total acid load in the GI tract, elevates gastric PH
to reduce pepsin activity, strengthens gastric mucosal
barrier, and increases esophageal sphincter tone.
È 
 
CNS: headache, irritability, weakness
GI: rebound hyperacidity, nausea, constipation, flatulence.
Ê  
È Patient with ventricular fibrillation or
hypercalcemia.
È 
Ê
 
È Record amount and consistency of stools
È Monitor calcium levels
È Watch for evidence of hypercalcemia (nausea,
vomiting, headache, confusion and anorexia)
È m 
  
È Not to take calcium carbonate indiscriminately or
switch antacids without prescriber¶s advice
È Urge to notify about signs and symptoms of GI
bleeding such as tarry stool, or coffee-ground
vomitus.




È 6  Amino Vita

È    Amino Vita
È Ê

  Multivitamins Supplement
È  
In cases where there are considerable nutrient losses
(febrile illnesses, infectious diseases, strenuous physical
activities). As adjuvant in the therapy of malnutrition,
chronic illnesses. Conditions associated w/ protein loss &/or
increased nutritional requirements (burns, wounds, bone
fracture, convalescence, stress, postsurgical operations).
Nutritional supplement in protein & vit deficiencies
associated w/ restrictive or deficient diet (anorexia,
starvation).
È 
 OD
È 
Supplement nutritional losses and vitamin deficiencies.
Maybe used as dietary supplements.
 

È 6  Hexitidine
È    Bactidol gargle
È Ê

  Antiseptic
È  
Minor sore throat; halitosis; general oral hygiene; improves
appearance of mouth tissues; protects tooth surfaces against
formation of decay acids.
È 
 Gargle TID
È 
Hexetidine, a hexahydropyrimidine, arrests the thiamine
metabolism of microorganisms, thereby inhibiting their growth.
Hexetidine has both antibacterial and antifungal properties   
and possesses a broad spectrum of activity against both gram-
positive and gram-negative organisms that cause mouth and
throat infections.
Hexetidine has been proven to exhibit an analgesic property. It
possesses an anti-infective (preventive and curative) property. It
has been shown to have a cicatrizing action. It also exhibits a mild
hemostatic action.

 
È Transient numbness & alteration in taste
may occur.
È Allergic contact dermatitis, taste alterations,
transient anesthesia, mouth or tongue
irritation.

 m 


È Not recommended for use in children <6 yr.
Shake well before use. Do not swallow
È Store below 25°C.
 

È 6  Endostein
È    Ectrin/ Zertin
È Ê

  Mucolytics
È  
Acute bronchitis, chronic bronchitis & its
exacerbations. Resp disorders
characterised by abnormal bronchial
secretions & impaired mucus transport.
È 
 300 mg/cap BID

È Erdosteine contains two sulfhydryl groups, which are
freed after metabolic transformation in the liver. The
liberated sulfhydryl groups break the disulphide bonds,
which hold the glycoprotein fibres of mucus together.
This makes the bronchial secretions more fluid and
enhances elimination.

È Absorption: Rapid absorption after oral admin.

Distribution: Protein binding: 64.5%.
Metabolism: Undergoes 1st-pass metabolism to form
an active metabolite, N-thiodiglycolyl-homocysteine.
Excretion: Elimination half-life: About 1.46 hr
(erdosteine), and about 1.62 hr (metabolite). Mainly via
the urine, as metabolites.

 
È Epigastralgia, nausea, vomiting, loose stools,
spasmodic colitis, headache.
Ê  
È Known hypersensitivity to erdosteine. Because of a
possible interference of erdosteine metabolites with
the methionine metabolism, erdosteine is
contraindicated in patients suffering from hepatic
cirrhosis and deficiency of the cystathionine-
synthetase enzyme.
È Suspension: Phenylketonuria, due to the presence
of aspartame.
 m 

È Pregnancy, lactation.
È Store below 25°C
m

Ê

È 6  Spironolactone
È    Aldactone
È Ê

 Potassium Sparring Diuretic
È  
 Primary hyperaldosteronism, including diagnosis, short-
term preoperative treatment, long-term maintenance
therapy for those who are poor surgical risks and those
with bilateral micronodular or macronodular adrenal
hyperplasia.
 Edema when other approaches are inadequate or
ineffective.
 Essential hypertension (usually in combination with other
drugs).
 Prophylaxis of hypokalemia in clients taking digitalis.
È 
 50 mg OD

È Mild diuretic that acts on the distal tubule to inhibit sodium exchange
for potassium, resulting in increased secretion of sodium and water
and conservation of potassium. An aldosterone antagonist. Manifests
a slight antihypertensive effect. Interferes with synthesis of
testosterone and may increase formation of estradiol from
testosterone, thus leading to endocrine abnormalities.

 
È Dizziness, blurred vision, N&V, fatigue anorexia, insomnia, nasal
congestion, gynecomastia.
È Ê  
È Acute renal insufficiency, progressive renal failure, hyperkalemia,
and anuria. Clients receiving potassium supplements, amiloride, or
triamterene.

Ê
 
± Food may increase absorption of spironolactone
± Protect drug from light.
± Asses for drug tolerance characterized by edema /reduced urine
output.
m 
  
È Take as directed with a snack/meal to minimize
GI upset. Report if nausea, bloating, anorexia,
vomiting, or diar rhea persist. Take early in day to
prevent frequent night time urination.
È Avoid foods or salt substitutes high in potassium;
drug is potassium-spar ing. Record BP and
weight twice a week for provider review. Report
any in- creased swelling of extremities or weight
gain of more than 5 lb (2.2 kg weekly.
È Do not drive/operate dangerous machinery until
drug effects realized; may cause drowsiness or
unsteady gait.
È Drug may cause breast swelling and diminished
sex drive by reducing testosterone levels.
Ê
ÊÊ



È 6  Calcium Carbonate
È    Antacid, Electrolyte
È Ê

 
Antacid, adsorbent and antiflatulents
È  
Relief acid indigestion, heartburn, sour stomach,& upset
stomach. Calcium supplement
È 
 1 tab OD
È 
Reduces total acid load in the GI tract, elevates gastric
PH to reduce pepsin activity, strengthens gastric
mucosal barrier, and increases esophageal sphincter
tone.
È 
 
CNS: headache, irritability, weakness
GI: rebound hyperacidity, nausea, constipation,
flatulence.
Ê  
È Patient with ventricular fibrillation or
hypercalcemia.

Ê
 
È Record amount and consistency of stools
È Monitor calcium levels
È Watch for evidence of hypercalcemia (nausea,
vomiting, headache, confusion and anorexia)
m 
  
È Not to take calcium carbonate indiscriminately or
switch antacids without prescriber¶s advice
È Urge to notify about signs and symptoms of GI
bleeding such as tarry stool, or coffee-ground
vomitus.



Ê
m

Êm4

Êm4

Êm4
 


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 !u