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Congestive heart failure is defined as “the state in which the heart is unable to pump
blood at a rate adequate for satisfying the requirements of the tissues with function
fluid retention, and reduced longevity” (Denolin, 1983, p. 445). Currently, congestive
heart failure or heart failure, continues to be a major public health problem worldwide. It
is the leading cause of morbidity and mortality in most developed countries. According to
the American Heart Association (2001), approximately 5 million patients have heart
failure and nearly 550,000 new patients are diagnosed each year. In addition, nearly
In the Philippines, cardiovascular diseases are the most common causes of mortality.
According to the Department of Health (2005), about 77,060 in a 100, 000 population
have died in the Philippines due to diseases of the heart. The aging of the population and
the emerging pandemic of cardiovascular diseases in the developing nations of the world
signal a rise in the incidence and prevalence of heart failure globally and magnify the
importance of its prevention. The prevention of heart failure is an urgent public health
This paper is a case report about B. A., a 49 year old female, Filipino, nonhypertensive,
nondiabetic, a post-mitral and aortic valve replacement patient and is currently diagnosed
with Congestive Heart Failure Functional Capacity II-III secondary to Valvular Heart
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
This case report is significant to my future nursing care because it helps stress the
importance of not only identification and treatment of patients with heart failure but also
the importance of promoting a healthy lifestyle and preventive strategies to decrease the
prevalence of heart failure in the general population. Also, it explores the need for a
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
THEORETICAL BACKGROUND
function” (Woods, et. al, 2010). It is not considered as a disease but a collection of signs
and symptoms, the final pathway of a group of diseases, the end-result of most
cardiovascular states.
heart failure may be classified into four functional states. “Class I (Mild) are patients with
cardiac disease but without resulting limitatios of physical activity. Ordinary physical
activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath), or
anginal pain. Class II (Mild) are patients with cardiac disease resulting in slight limitation
of physical activity. They are comfortable at rest. Ordinary physical activity results in
fatigue, palpitation, dyspnea, or anginal pain. On the other hand, Class III (Moderate) are
patients with cardiac disease resulting in marked limitation of physical activity. They are
comfortable at rest, but less than ordinary activity causes fatigue, palpitation, dyspnea or
anginal pain. The last classification is Class IV (Severe) are patients with cardiac disease
wherein there is inability to carry out any physical activity without discomfort.
rest. If any physical activity is undertaken, discomfort is increased (New York Heart
Association, 1964).
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
Causes. “An array of different problems can cause congestive heart failure. (1)
Among them is coronary (ischemic) heart disease resulting from insufficient blood flow
to the myocardium, or heart muscle. This is usually caused by atherosclerosis, the buildup
of fatty substances or plaque on the walls of the arteries that carry blood to the heart
muscle. The heart’s ability to perform decreases because ischemia results in the delivery
of less oxygen and fewer nutrients to the heart muscle. (2) A heart attack may also cause
congestive failure. During a heart attack, the heart muscle is deprived of oxygen,
resulting in tissue death and scarring. The development of heart failure depends on the
extent and location of scarring. (3) Long-standing high blood pressure is another
common cause of heart failure. Because there is greater resistance against which the heart
must pump, the heart muscle works harder. This results in an enlargement of the heart
muscle, especially of the left ventricle, the heart’s main pumping chamber. Eventually,
this enlarged muscle tissue weakens, setting the stage for heart failure, especially if the
pumping ability of the enlarged chamber greatly decreases. (4) Arrhythmias (irregular
heartbeats) can also lead to heart failure, but they usually have to be severe and
prolonged, with a rapid rate of more than 140 beats per minute, and must often occur in
the presence of an already weakened heart. They change the pattern of filling and
pumping of blood from the heart. This condition may also lower output of blood to the
point of heart failure. (5) Valvular heart diseases are another cause of heart failure, which
results when a narrowed or leaking valve fails to direct blood flow properly through the
heart. The problem may be congenital (inborn) or due to an infection such as endocarditis
or rheumatic fever. This increases the heart’s workload, thereby increasing risk of
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
developing heart failure. (6) Cardiomyopathy, a disease of the heart muscle itself, can
also lead to heart failure. Causes of cardiomyopathy include infection, alcohol abuse, and
cocaine abuse. When heart failure seems to have no known causes, it is known as
patients with heart failure. The particular symptoms that an individual experiences are
determined by which side of the heart is involved in the heart failure. For example, the
“left atrium receives oxygenated blood from the lungs and passes it onto the left
ventricle, which pumps it to the rest of the body” (Porth, 2007). When the left side isn’t
pumping efficiently, blood backs up in the vessels of the lungs, and sometimes fluid is
forced out of the lung vessels and into the breathing spaces themselves. This pulmonary
congestion causes shortness of breath. The other major symptoms of left-sided heart
failure are fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea , and the sputum
Porth (2007) adds that right-sided failure occurs when there is resistance to the flow of
blood from the right heart structures (right atrium, right ventricle, pulmonary or lung
artery) into the lungs or when the tricuspid valve, which separates the right atrium from
the right ventricle, fails to work properly. This results in a backup of fluid and pressure in
the veins that empty into the right side of the heart. Pressure then builds up in the liver
and the veins in the legs. The liver enlarges and may become painful and swelling of the
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
The major symptoms of right-sided heart failure are edema and nocturia (Woods, et. al,
2010). The different types of edema possible are dependent edema, edema that results in
enlargement or swelling of the liver, ascites, and edema of the skin or soft tissues.
Because congestive heart failure causes the body to fill with excess fluids, the kidneys
may not be able to dispose of the extra sodium and water, a condition known as kidney
failure. Sodium that would normally be eliminated through the urine remains in the body,
causing it to retain even more water, thereby aggravating the problem of excess fluid
Diagnosis. According to the Framingham Study (McKee, et. al, 1971), the
major criteria or 1 major criterion in conjunction with 2 minor criteria that they have
formulated. The major criteria includes paroxysmal nocturnal dyspnea, neck vein
acute pulmonary edema, S3 gallop, increased central venous pressure (greater than 16
centimeters fluid at right atrium), hepatojugular reflux and weight los greater than 4.5
effusion, decrease in vital capacity by one third from maximum recorded and tachycardia
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
(heart rate greates than 120 beats per minute). Minor criteria are acceptable only if they
chronic lung disease, cirrhosis, ascites, or the nephrotic syndrome). The Framingham
Heart Study criteria are 100% sensitive and 78% specific for identifying persons with
failure include irregular heart rhythms or arrythmias, stroke, thromboembolism and organ
dysfunctions. (1) One of these are malignant ventricular arrhythmias which are common
in end stage heart failure. For example, sustained ventricular tachycardia occurs in up to
10% of patients with advanced heart failure who are referred for cardiac transplantation
(Watson, 2000). In patients with ischemic heart disease, these arrhythmias often have
indicates a high risk for recurrent ventricular arrhythmias and sudden cardiac death.
Congestive heart failure predisposes to (2) stroke and (3) thromboembolism, with an
contributing to the increased thromboembolic risk in patients with heart failure include
low cardiac output (with relative stasis of blood in dilated cardiac chambers), regional
associated atrial fibrillation. Patients with heart failure and chronic venous insufficiency
may also be immobile, and this contributes to their increased risk of thrombosis,
including deep venous thrombosis and pulmonary embolism. Mild to moderate heart
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
failure is associated with an annual risk of stroke of about 1.5% (compared with a risk of
less than 0.5% in those without heart failure), rising to 4% in patients with severe heart
failure (Watson, 2000). (4) Organ dysfunction occurs when there is a decrease in the
oxygen supply to the different organ tissues in the body. Because of the lack of oxygen,
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
CASE PRESENTATION
secondary to Rheumatic Heart Disease. She lives with her husband, three children, a son-
in-law and a grandson in Sapang Palay, Bulacan. B. A. stopped going to school when she
was 1st year high school and is currently unemployed. She worked as a vendor before.
The client was admitted from home to the Emergency Room of the Philippine General
Hospital on August 30, 2010 with complaints of fever and shortness of breath. She was
admitted to the Female General Medicine Ward 1 at Bed 8 for monitoring and
management and also to rule out Moderate Risk Community Acquired Pneumonia,
B. A. has been experiencing chest heaviness and mild chest pain 5 days prior to
admission. She also contracted fever but this was relieved after she took Bioflu. She was
not taken to a physician until 3 days prior to admission when her chest pain worsened and
radiated to the back and she experienced shortness of breath. The fever recurred with
maximum temperature of 38°C. She was admitted to Sapang Palay District Hospital for
management where she was administered with oxygen. On the same day, she was
discharged and advised to followup to Philippine General Hospital. However, the client
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
proclaimed that she felt well immediately after and her fever was gone so she delayed
referral. One day prior to admission, the client had fever again and has stomach
discomfort. She claimed that her chest pain worsened so on August 30, 2010, the client's
The client was first diagnosed with Rheumatic Heart Disease in the 1980s in Philippine
Heart Center where she regularly went for checkup. Upon transfer of residency, she had
regular checkups in Philippine General Hospital Out Patient Department. In the check-
ups between 2002-2003, it was determined that B. A. has valvular heart disease and was
scheduled for operation. She underwent mitral and aortic valve replacement in Philippine
General Hospital in 2004. Since then, she has been on regular follow-up with the
mg/tab taken once daily (taken twice the week before admission) and Metroprolol 50
mg/tab taken once daily. B. A. was readmitted in July of 2005 because of hemoptysis and
Tuberculosis was ruled out. In October 2009, the client was admitted to San Lazaro
She has a family history of cardiovascular diseases and pulmonary tuberculosis. Her
mother is a known cardiac patient of valvular heart disease and died in 1998. Her father is
a known hypertensive and died on August 14, 2010 due to heart attack. B. A. has uncles
with pulmonary problems specifically Pulmonary Tuberculosis though she does not live
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
with them. The client knows no one in the family with mental illness or history of
diabetes mellitus.
Nursing Assessment. Complete assessment on the status of the client based on the
nursing health history was conducted on August 31, 2010. Pertinent nursing health
history problems were clusted per functional health pattern. Physical examination was
also conducted on the same date. Pertinent physical assessment findings are classified per
system.
In the Health perception and health management pattern, the client reports that she is a
healthy person is one who rarely gets sick. To maintain her health, she follows the
doctors’ advice and tells that she has never had a problem with following the health
professionals' orders. In addition, she drinks her medicines regularly and takes periods of
rest. She claims to have no traditional health beliefs. According to the client, she thinks
the reason she felt ill was because she does the household chores even when she was
supposed to rest and she carries her grandson around which led to shortness of breath and
fatigue. B. A. claims that she felt more comfortable and relieved when she was admitted
to the hospital.
B. A claims that her overall health varies, with periods of fatigue and strength.
Whenever she feels episodes of chest heaviness or fatigue, she sits in front of the electric
fan to ventilate herself and rest until she regains strength. She is a nonalcoholic and a
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
nonsmoker. She claims to have taken only few sips of beer before when she was in her
20s but she has never drunk more than a glass and she has never tried to smoke in the
past. However, she experiences second hand smoke daily since her husband smokes at
least 3 sticks a day. B. A. has never taken illegal drugs. During the hospital rotation, the
client experienced chest pain with a grade of 4, radiating to back and persisting after 10
minutes.
In the nutritional and metabolic pattern, B. A. reports that every day she eats about three
meals per day which are cooked at home, with the occasional snack in between meals.
Because she has been cautioned from eating fatty and salty foods, she seldom eats pork.
In addition, it was explained to her that green leafy vegetables affect the mechanism of
action of one of her medications which is Warfarin so she also refrains eating said
vegetables. The food she eats varies from vegetables, fruits, fish and chicken. The client
claims that she eats a lot of vegetables and fruits, and leaves behind the fatty portion of
the meat she eats. Also, she only eats small portions of the meat, especially if it is salty,
and eats about one cup of rice per meal. She dislikes other fatty, salty and sweet foods
except chicharon and fries though she has regulated her intake of both to at least once
every two months. She enjoys vegetables and fruits and seldom use condiments except
vinegar.
Her fluid intake is about 3 glasses a day or sometimes one 500 ml bottle of water per day.
She remembers that when she was in the hospital, her fluid intake was regulated at 1 Liter
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
per day and she has adapted this at home. The client verbalized a noticeable decrease in
weight since she was diagnosed with heart disease. At the time of the interview, the
client also reported a decrease in appetite, although there is no problem in eating despite
having all her teeth replaced with dentures. When she gets sick, she gets well rather
quickly, and her only previous skin problem was hematoma, which she explained was
In the elimination pattern, the client moves her bowels everyday. She complains that
there are times that she cannot defecate easily because she finds it difficult to stop
breathing and expel her feces forcefully. She described her feces as brown, soft and
broken into small pieces about 3 cm in diameter. Also, B. A. urinates about 3 times per
day, without difficulty or pain. She describes her urine as clear, yellow in color and
without any foul odor. She measures her urine to be about 250 ml or one half of a mineral
In the Activity-Exercise Pattern, B. A. claims that she has less energy than before to do
her daily activities. She has refrained from washing clothes and carrying heavy things
since she easily experiences shortness of breath. However, she is able to do household
chores, carry her grandson, go to the market and serve at the church though with
considerable effort. She does not exercise anymore except walk around the house and
stretching. The client’s pastimes include watching TV, listening to the radio, and playing
with or watching her grandchild play. She is independent in grooming, eating, bathing,
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
family member. She requires the supervision of a family member because she easily gets
In the Sleep-rest Pattern, B. A. claims that she finds it difficult to sleep at night and
especially during mornings and only takes naps in between because she has not yet
adapted to the hospital environment,. However on her second night, she reported that she
has been able to sleep well. In supine position and flat on bed, B. A. claims that she has
difficulty breathing and feels that she is “drowning”. She is on moderate high back rest
and requires 2 pillow to be able to sleep comfortably without difficulty of breathing. She
is able to climb 3 flights of stairs before being out of breath. She also claims that she is
easy to awaken and she does not have a special ritual for bedtime. The relaxing activities
for her include saying the rosary, watching TV and watching her grandson.
In the Cognitive-Perceptual Pattern, B. A. has no hearing problem and does not use a
hearing aid. However, she does have a visual problem. She uses glasses with grade of
300. Her memory is still intact, and she learns best by actual performance of a task and
reading. The client does not feel pain in any part of her body though she sometimes feels
chest heaviness and pain which she relieves by ventilating herself with electric fan and
taking a rest. The client was a former president of the Lector/Commentator League and
treasurer of the Parish Pastoral Council in their town but was forced to resign because of
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
her health condition. She claims that she misses doing her work but is resigned to resting
and staying at home because she understands that it is for her own benefit.
patriarchal, with B. A. making decisions regarding health actions and daily expenditures.
She lives with her husband, her three children, a daughter-in-law and a grandson. Her
husband is a contractual painter of houses and automobiles and their usual income varies
from P3000-P5000 per month. Their children always contributes to the medical expenses
of the client. Currently, they feel worried about their mother's condition and contributes
to any way they can to alleviate her condition. The usual problem of the family involves
the drinking habit of the client's husband and financial problems. They usually resolve it
In the Sexuality-Reproductive Pattern, B. A. stated that she and her husband has not
engaged in sexual intercourse in recent years. She claims that this is because they are
already old. She has used pills as a family planning method from 1989 to 2002 but has
since stopped using them though no problems were encountered upon their use. The
client had her first menstrual period when she was 11 years old. She describes her
menstrual period to be regular and usually lasts from 3 to 4 days. She usually consumes 3
pads in a day and has never experienced dysmennorhea. Her last menstruation was on
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
In the Coping-Stress Tolerance Pattern, the client reports that she does not want to be a
burden to her family and perceives herself as “weak”. However, she has already accepted
this fact and coped with the weakness in her own way. She does not perceive any
difference in her physique except weight loss. She is easily cries and becomes tensed or
nervous though this has been lessened once she was admitted in the hospital. B. A. feels
anxious about her condition but she believes that everything will be alright in the end
more so because she feels relatively fine. Whenever she feels tensed, she talks to her
significant others or pray the rosary. She usually feels nervous whenever there are
arguments in the family but this has been lessened according to her significant other out
of consideration for the client. She sits and calms herself by praying and talking with the
involved parties to relieve her tension. She coped with her condition by changing her
lifestyle for the better, avoiding foods that are contraindicated to her condition and taking
rest periods. However, she does feel bothered about the expenses incurred by her children
In the Value/Belief Pattern, the client expresses that her only wish is to see her children
and her grandchildren grow up. She does not fear death but she wishes that she will live
longer because of her family. God, family and health are important for B. A. She claims
that her religion helps her get through her condition because it gives her energy and
happiness.
In the general or constitutional condition of the client, the client has adequate weight for
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
age. She has lost weight since hospitalization. However, she states that general state of
health is fine. She displays signs of weakness on exertion and ability to conduct usual
activities is impaired. She has no exercise tolerance. In the skin, no rashes or itching was
observed. On inspection, no pigmentation is seen. There skin is moist and smooth. She
has normal hair distribution and nail beds are pail but has brisk capillary refill. The client
has no breast lumps. No tenderness or swelling was observed. There was also no nipple
discharge.
For the HEENT system or Head, Eyes, Ears, Nose, Mouth, Throat system, no headaches
were complained. However, the client complained of dizziness that can be associated to
decrease in oxygen supply to the brain. Vision is normal and no nose bleeding was
reported. The client does not have colds, obstruction and discharge. She has 1 missing
front teeth and uses full dentures. No neck stiffness was observed and pain, tenderness
and masses in thyroid or other areas was not seen. The client is cold to touch and has
good skin turgor. She displayed absence of lesions or dryness in lips. Mucosa was pinkish
and gag reflex was intact. Uvula is in midline and no lymphadenopathy was observed.
seen in the midsternal about 3 centimeters. Point of maximal impulse is at the 6th
intercostal space, left of the midclavicular line. S1 is louder than S2 at the apex while S2
is louder than S1 at the base. Both S1 and S2 are regular. No extra heart sounds or
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
murmurs were heard. Peripheral pulses are strong and equal. Nails are pale but has brisk
capillary refill. No nail clubbing was observed. Hematoma is seen in Left lower arm and
Right upper arm.precordial pain, substernal distress, palpitations, syncope was not
observed. There was dyspnea on exertion and client has 2-pillow orthopnea. There was
In the respiratory system, no pain was reported. Shortness of breath is on exertion and no
gastrointestinal system, the client has decreased appetite. She does not experience
vomiting, hematemesis, jaundice, constipation, or diarrhea was reported. The client has
normal stools and no flatulence, hemorrhoids or recent changes in bowel habits was
reported.
was no dysuria, nocturia, polyuria or oliguria in the patient. However, hematuria was seen
on laboratory tests. There was no unusual color of urine, stones, infections and nephritis
incontinence, change in libido was reported. The client had menarche at the age of 11.
She has her menses every month and her last period was on August 1, 2010. No
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
dysmenorrhea, or vaginal discharge was reported. She has had 3 pregnancies and all are
joints were reported. There was no limitation of motion. However, the client reports
observed. The client experiences no difficulties with memory or speech, and there is no
sensory or motor disturbances. Client is not emotional and does not express depression.
In the allergic component, adverse reactions to drugs, food, insects, skin rashs are not
on the second day of ward duty. In the immunologic component, anemia is not present
and no adverse reactions to blood transfusion was reported. There is however a bleeding
tendency since the client is on Warfarin therapy. In the lymphatic system, local or general
lymph node enlargement or tenderness was absent. In the endocrine system, there is no
polydipsia or polyuria.
Laboratory Results. Diagnostic and laboratory results done to the patient together with
their indications are listed below. Significant results, their nursing implications and their
relation to the course of treatment will be discussed on the case analysis part of this
paper.
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
The chest x-ray done on August 8, 2010 was indicated to view the structures of the chest
(bones, heart, lungs) for any abnormalities. Also, the client was suspected of Pulmonary
congestive heart failure in the patient and is done to reassess the patient's heart condition
(size, shape, structure). The chest x-ray revealed that there are fibrous and reticulonodular
opacities seen in the Unperfused Lung Segments. There is also associated superintraction
of the right hilar structure. The lungs are normoinsular and two prosthetic valves are
noted at the region of the mitral and aortic valves. There is prominence with the aortic
Blood chemistry screen made on August 30, 2010 was indicated for the client because
she is diagnosed with congestion in the heart and is at risk for fluid, electrolyte or acid-
base imbalance. In addition, the functions of her kidneys and extent of damage of livers
and heart were assessed. Significant findings show that the client has decreased calcium
in the blood.
Complete Blood Count done on August 30, 2010 is indicated for the client to look for
signs of inflammation and infection and marker of anemia which can cause similar
abnormal results were seen. The client has adequate amount of blood components.
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
Prothrombin Time and Activated Partial Thromboplastin Time was assessed on August
30, 2010 to screens for coagulation deficiency of factors II, V, VII and X and monitor the
oral anticoagulant therapy (warfarin) of the patient. In addition, it tests for abnormalities
coagulation disorders. It has been found out that the client has prolonged Activated
2010 was indicated for the client to determine systolic and diastolic left ventricular
performance, cardiac output (ejection fraction), and pulmonary artery and ventricular
left ventricular hypertrophy with segmental wall motion abnormality and mildly
depressed overall systolic function. The aortic and mitral prosthetic valves have good
opening and closing. There is mild tricuspid regurgitation. The pulmonary artery pressure
elevated myocardial infarction after the episode of chest pain. It showed bradycardia with
cavity and identify possible problems that may be the cause of hematuria. Findings show
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
that there is non-specific calcifications which are likely parenchymal. In addition, fatty
infiltrations of the pancreas are present. Bilateral renal cysts were seen. There is normal
proximal and mid-abdominal aorta and para-aortic areas, spleen and urinary bladder.
Blood Culture Sensitivity Testing was made on August 31, 2010. It was indicated for the
client to identify if the client has Infective Endocarditis. Findings display that there is no
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
DISCUSSION
failure is quite complex. Compensatory mechanisms exist on every level all the way to
ovelwhelmed, heart failure happens (MacIntyre, et. al, 2000). In this section, we focus on
the pathophysiological mechanisms that led to the presentation of signs and symptoms of
the client, their current treatment and identified nursing diagnosis. Figure 1 shows the
pathophysiology of the disease with the risk factors, medications, presenting signs and
Porth (2007) discloses that due to the infiltration of group A beta-hemolytic streptococci,
antibodies in the body react to destroy the bacteria simultaneously causing acute
inflammation to the heart. Rheumatic heart disease has developed. During the acute
inflammatory stage of the disease, the valvular structures become swollen. Small
vegetative lesions develop on the valve leaflets. It then proceeds to the development of
fibrous scar tissue which tends to contract and cause deformity of the valve leaflets and
Then, tricuspid, mitral and aortic insufficiency develops. During much of the systole, the
mitral valve is subjected to high pressure generated by the left ventricle as it pumps blood
to the systemic circulation. Increased preload occurs because the incomplete closure of
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
24
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
the mitral valve permits the regurgitation of blood from the left ventricle into the left
atrium (Porth, 2007). In addition, incomplete closure of the aortic valve also results in
increased preload as the left ventricle is forced to pump the entire diastolic volume
received from the left atrium and the regurgitant volume from the aorta. Increased
afterload occurs as there is increased pressure for the heart to generate the movement of
the increased volume from the left ventricle into the aorta. The increased volume work
causes increased pressure for the left ventricle to pump more blood. This eventually leads
As the workload increases, the walls of the chamber grow thicker, losing their elasticity
and eventually may lead to myocardial dysfunction and eventually myocardial failure
(Woods, et. al., 2010). This results to the failure of the heart to pump with as much force
a decrease in cardiac output which also contributes to the decrease perfusion of tissues in
Woods (2010) explains that increased activity of the sympathetic nervous system or the
25
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
resistance. The RAAS also increases aldosterone production thus enabling the retention
of sodium and water. This leads to an increase in plasma volume. Increased plasma
volume and decreased end systolic volume leads to increased venous pressure tpo the
lungs. This increase in hydrostatic pressure causes an increase in the rate of filtration of
fluid out of the capillaries and into the interstitial compartment (Woods, 2010). As a
result, the lungs fill with fluid, a condition called, pulmonary edema and eventually
pulmonary congestion.
On the other hand, increased activity of the systemic nervous system is caused by the
release of epinephrine and norepinephrine (Porth, 2007). The purpose of this initial
response is to increase heart rate and contractility and support the failing myocardium.
insufficient for the demand, prolonged compensatory mechanisms can lead to cell death
(Hobler & Karey, 1973). As seen in Figure 1, there is decreased oxygen supply to the
myocardium, brain, gastrointestinal tract and liver. Decreased oxygen supply to the liver
increases acid production, in the course of time, leading to the development of superficial
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
Decreased perfusion to the tissues and eventual decrease in oxygen supply causes
& Bare, 2010). Eventually, compensatory mechanisms fail and even the myocardium
experiences a decrease in oxygen supply (Porth, 2007). This decreases oxygen supply to
the brain and induces decreased oxygen supply in the blood. When this happens, the heart
muscle must use alternative, less efficient forms of fuel so that it can perform its function
of pumping blood to the body or commonly called anaerobic metabolism (Porth, 2007).
The by-product of using this less efficient fuel is a compound called lactic acid that builds
Classification II due to easy fatigability in doing ordinary activities like walking. She is
only able to walk 3 flights of stairs and experiences shortness of breath after walking to
and from an area 1 meter away. Congestive Heart Failure in the client developed as a
Heart Disease which was diagnosed in the client in the 1980s. B. A. underwent prosthetic
Valvular Heart Disease is one of the most common causes of heart failure. It is “a
common form of heart disease that present with disorders of the heart valves. Most
disorders are a consequence of rheumatic heart disease” (Woods, et. al., 2010). Cardiac
damage from Rheumatic Heart Disease results from reacting antibodies that causes acute
27
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
inflammation of the heart. It damages valve leaflets resulting to Valvular Heart Disease
(Porth, 2007). Heart valves are destroyed when the valvular leaflets and chordae tendinae
become fibrous causing the two commisures to close and the chordae tendinae to shorten
Rheumatic Heart Disease is a serious heart condition that follows infection with a
Zabriskie (1985) discovered that risk factors for developing infection leading to
Rheumatic Heart Disease include overcrowding, poor hygiene, lack of access to medical
services and living in rural areas. As seen in Figure 1, the client presented with the
following risk factors which led to the development of Rheumatic Heart Disease.
However, many other risk factors may contribute to the the development of a cardiac
failure. Woods (2010) lists the risk factors for developing cardiovascular diseases which
include a “family history of heart disease, hypertension, male sex, cigarette smoking,
overweight, high levels of blood fats, diabetes mellitus, physical inactivity and
pychological stress”. The risk factors that may have contributed to the client's disease
include a family history of cardiac diseases and eating large amounts of salt and high fat
foods.
Assessment on the status of the client's health perception and management, psychosocial,
perception, reproductive, nutrition, elimination, rest and activity and oxygenation was
28
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
clustered.
Oxygenation. The client has varied periods of fatigue and strength. Vital signs are
as follows - respiratory rate is 30 breaths per minute, blood pressure is at 90/60 mmHg,
heart rate is at 45 beats per minute and temperature is 36.1°C. The client has slow heart
rate which may be caused by the intake of maintenance drug which is metoprolol.
experienced chest pain with a grade of 4, radiating to back and persisting after 10
In supine position and flat on bed, B. A. claims that she has difficulty breathing and feels
that she is “drowning”. She is on moderate high back rest and requires 2 pillow to be able
to sleep comfortably without difficulty of breathing. In other words, the client has 2-
pillow orthopnea which is caused by pulmonary congestion in the client. She is able to
climb 3 flights of stairs before being out of breath. These may be reflections of the
The client does not display signs of pallor or cyanosis. She does not have difficulty
breathing or use accessory muscles. No nasal flaring was observed. The inspiratory and
29
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
display signs of a barrel, pigeon or funnel chest. Her chest is symmetric and there is
symmetrical chest expansion. She has normal breath sounds and no adventitious breath
midclavicular line.No extra heart sounds or murmurs were heard. Peripheral pulses are
strong and equal. Nails are pale but has brisk capillary refill. No nail clubbing was
observed. Hematoma is seen in Left lower arm and Right upper arm.
Rest and Activity. B. A. claims that she has less energy than before to do her daily
activities. She has refrained from washing clothes and carrying heavy things since she
and go to the market without assistance of a family member. She requires the supervision
of a family member because she easily gets tired and experience shortness of breath. Her
On physical assessment, the client displayed shortness of breath upon exertion. She is
able to walk at a distance of about 3 meters with a slow but steady gait. There were no
crepitations or joint pains. However, there is muscle weakness on knees. Muscle strength
30
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
Elimination. The client moves her bowels everyday. She complains that there are
times that she cannot defecate easily because she finds it difficult to stop breathing and
expel her feces forcefully. She described her feces as brown, soft and broken into small
pieces about 3 cm in diameter. Also, B. A. urinates about 3 times per day, without
difficulty or pain. She describes her urine as clear, yellow in color and without any foul
odor. She measures her urine to be about 250 ml or one half of a mineral bottle.
smooth and cold to touch. No visible pulsations were inspected on the abdomen. On
asucultation, normoactive bowel sounds at 3 per minute were heard. No enlarged organ
was palpated. Costovertebral angle tenderness was not assessed due to complaints of
back pain.
Nutrition. Every day, B. A. eats about three meals per day which are cooked at
home, with the occasional snack in between meals. Because she has been cautioned from
eating fatty and salty foods, she seldom eats pork. In addition, it was explained to her that
green leafy vegetables affect the mechanism of action of one of her medications which is
Warfarin so she also refrains eating said vegetables. The food she eats varies from
vegetables, fruits, fish and chicken. The client claims that she eats a lot of vegetables and
fruits, and leaves behind the fatty portion of the meat she eats. Also, she only eats small
portions of the meat, especially if it is salty, and eats about one cup of rice per meal. She
dislikes other fatty, salty and sweet foods except chicharon and fries though she has
31
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
regulated her intake of both to at least once every two months. She enjoys vegetables and
Her fluid intake is about 3 glasses a day or sometimes one 500 ml bottle of water per day.
She remembers that when she was in the hospital, her fluid intake was regulated at 1 Liter
per day and she has adapted this at home. The client verbalized a noticeable decrease in
weight since she was diagnosed with heart disease. At the time of the interview, the
client also reported a decrease in appetite, although there is no problem in eating despite
having all her teeth replaced with dentures. When she gets sick, she gets well rather
quickly, and her only previous skin problem was hematoma, which she explained was
observed. There is 1 missing front tooth and the client has full dentures. Trachea is in
midline and there is thyroid is nontender and nonpalpable. Normoactive bowel sounds are
heard on ausculation. The client has a flabby and soft abdomen. A scar is seen on the
epigastric and right lower quadrant about 2 centimeters long. Her height is 5'2 inches
Cognitive. For B. A., a healthy person is one who rarely gets sick. To maintain her
health, she drinks her medicines regularly and takes periods of rest. According to the
32
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
client, she thinks the reason she felt ill was because she does the household chores even
when she was supposed to rest and she carries her grandson around which led to
shortness of breath and fatigue. On physical assessment, the client was conscious,
coherent and oriented to time, person and place. No signs of distress was observed.
Normal range of motion of the neck is observed and there was no neck rigidity. The client
Perception. B. A. has no hearing problem and does not use a hearing aid.
However, she does have a visual problem. She uses glasses with grade of 300. Her
memory is still intact, and she learns best by actual performance of a task and reading.
The client does not feel pain in any part of her body though she sometimes feels chest
heaviness and pain which she relieves by ventilating herself with electric fan and taking a
rest.
On physical assessment, the client's head is normocephalic and no masses or lesions were
observed. The client displayed symmetrical lids and absence of ptosis or swelling.
Conjunctiva is pinkish and no lesions were observed. Sclera is anicteric and cornea and
lens are clear. Both pupils of the left and right eye are equal, 3 millimeter in size and has
brisk and uniform reaction to light and accommodation. There is uniform convergence of
the eyes and intact extraocular activity. The client is nearsighted with a grade of 300. The
client's ears are normoset and nontender. There was no lymphadenopathy. Discharge or
impacted cerumen was not observed. There is symmetrical gross hearing capacity and no
33
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
hearing deficit.
Psychosocial. The client does not want to be a burden to her family and perceives
herself as “weak”. However, she has already accepted this fact and coped with the
weakness in her own way. She does not perceive any difference in her physique except
weight loss. She is easily cries and becomes tensed or nervous though this has been
lessened once she was admitted in the hospital. B. A. feels anxious about her condition
but she believes that everything will be alright in the end more so because she feels
relatively fine. Whenever she feels tensed, she talks to her significant others or pray the
rosary. She usually feels nervous whenever there are arguments in the family but this has
been lessened according to her significant other out of consideration for the client. She
sits and calms herself by praying and talking with the involved parties to relieve her
tension. She coped with her condition by changing her lifestyle for the better, avoiding
foods that are contraindicated to her condition and taking rest periods. However, she does
feel bothered about the expenses incurred by her children for her medical condition.
health actions and daily expenditures. She lives with her husband, her three children, a
automobiles and their usual income varies from P3000-P5000 per month. Their children
always contributes to the medical expenses of the client. Currently, they feel worried
about their mother's condition and contributes to any way they can to alleviate her
34
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
condition. The usual problem of the family involves the drinking habit of the client's
husband and financial problems. They usually resolve it by conversations with the family.
The client's only wish is to see her children and her grandchildren grow up. She does not
fear death but she wishes that she will live longer because of her family. God, family and
health are important for B. A. She claims that her religion helps her get through her
condition because it gives her energy and happiness. On physical assessment, the client
displayed signs of anxiety through silent pauses and different facial expressions.
Reproductive. B. A. stated that she and her husband has not engaged in sexual
intercourse in recent years. She claims that this is because they are already old. She has
used pills as a family planning method from 1989 to 2002 but has since stopped using
them though no problems were encountered upon their use. The client had her first
menstrual period when she was 11 years old. She describes her menstrual period to be
regular and usually lasts from 3 to 4 days. She usually consumes 3 pads in a day and has
a G3P3 mother and has no history of complications at birth. On physical assessment, the
Complications of heart failure are varied. However, in this discussion, we will focus on
35
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
the actual and suspected complications in the patient during course in the ward.
One of the chief complaint of the client was fever. The client has increased risk for
Endocarditis was presumed to be the cause of fever. In nursing literature, it has been
stated by a study that prosthetic valve replacement increases risk for infective
Another chief complaint was chest pain or angina. The client presenting with chest pain is
at increased risk for myocardial infarction. This is typical if severe, prolonged chest
discomfort is present. The onset of chest discomfort must be abrupt and lasts longer than
radiate to the arms, shoulders, back, neck or jaw (Woods, et. al, 2010). This list of
the client similar to pneumonia. These includes pleuritic chest pain, shortness of breath,
raised respiratory rate and fever of 38°C (Porth, 2007). Pulmonary tuberculosis was also
36
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
complications present in the patient and determine the cause of presenting symptoms.
Infective Endocarditis is ruled out when the blood culture findings were negative.
Myocardial Infarction which was suspected on the onset of chest pain was also negative
Pneumonia and pulmonary tuberculosis were ruled out as chest x-ray findings were
Other significant laboratory findings include the presence of hematuria which may be
pancreas were also observed on ultrasound and the high intake of cholesterol and salt are
one of the many factors suspected to have caused this. In the echocardipgraphy of the
client, the presence of mild tricuspid regurgitation was observed which may have been
caused by the valvular heart disease present in client before. It is important to note that
only the mitral and aortic valves were replaced in surgery before. Ejection Fraction with
53% Teicholtz’s, 47% Simpson’s and heart rate of 45 beats per min seen in
electrocardiography reflects the decreased cardiac output of the client caused by mildly
depressed overall systolic functioning as seen also in the echocardiography. The presence
37
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
of minimal Albumin in urine seen in the urinalysis is suspected to have come from
possible liver damage or caused by the damage on the capillary endothelial damage.
As of discharge day, the client has not presented signs of peripheral congestion like
edema, its most presenting sign. However, this only emphasizes the importance of
monitoring as said complication is not only probable but is almost the norm for
acute heart failure has only recently been emphasized, as reflected in the updated
from 2009. These guidelines recommend hospitalization for acute heart failure if the
severe decompensated heart failure (low blood pressure, renal dysfunction, altered
The goal is to continue the diagnostic and therapeutic processes started. Patient’s volume
and hemodynamic status is optimized using careful clinical monitoring and the heart
failure medical regimen is optimized. Heart failure education, behavior modification, and
exercise and diet recommendation are made. The patient must be on a stable oral regimen
for at least 24 hours before discharge. During the period of hospitalization of the client,
38
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
complications. Both medical and nursing care are taken into account.
Medical Plan of Care. Heart failure treatment has both pharmacologic and
nonpharmacologic therapy prescribed by the doctor. This is used to maintain the client at
Pharmacologic Therapy. Smeltzer & Bare, et. al. (2010) enumerate the
adrenergic blocking agents, diuretics, digitalis and calcium channel blockers. Beta-
adrenergic blocking agents given to patients with heart failure have been recommended
for patient swith asymptomatic systolic dysfunction. ACE inhibitors promote vasodilation
and diuresis by decreasing afterload and preload, thus reducing the workload of the heart
(Smeltzer & Bare, et. al., 2010) . However, they are not being given to client because
hypotension is present in the client and ACE Inhibitors given with Beta blockers which
are the client's maintenance drugs further decrease blood pressure and heart rate. In
contrast, ARBs, though having the same mechanism of action as ACE inhibitors, does not
produce cough which usually discomforts heart failure patients (Smeltzer & Bare, et. al.,
2010). This drug was also not prescribed to the patient with the same reason as ACE
Inhibitor.
On the other hand, diuretics are prescribed to remove extracellular fluid by increasing the
39
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
rate of urine produced in patients with signs and symptoms of overload (Smeltzer &
Bare, et. al., 2010). However, this was not prescribed to the client because there were no
increase the force of myocardial contraction and slow conduction through the
atrioventricular mode (Smeltzer & Bare, et. al., 2010). However, this drug was also not
given to the client because it increases the risk for digitalis toxicity. Also, when a person
is hypokalemic, digitalis absorption is faster and there is increased risk for toxicity.
(Smeltzer & Bare, et. al., 2010). However, they were not prescribed to client because it is
thromboembolic event. It lyses clots or possible clots before it even enters the cardiac
blocker (Karch, 2010). Beta-adrenergic blocking agents have been found to reduce
mortalilty and morbidity in patients with heart failure by reducing the adverse effects
from the constant stimulation of the sympathetic nervous system (Smeltzer & Bare,et. al.
40
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
decreasing the influence of the sympathetic nervous system on these tissues and the
excitability of the heart, decreasing cardiac output and the release of renin, and lowering
blood pressure. It also acts in the Central Nervous System to reduce sympathetic outflow
and vasoconstrictor tone. This was indicated for the client due to high probability of
increased blood pressure. Metoprolol is a maintenance drug for the client after prosthetic
valve replacement.
bradycardia (HR less than 45 beats/min) and heart failure. Things to watch out for
include sudden decrease in blood pressure, heart rate, dizziness, shortness of breath and
blurred vision. Spratto & Woods (2008) outlines that nursing implications in giving this
drug include telling client to report difficulty breathing, night cough, swelling of
extremities, slow pulse, confusion, depression, rash, fever, sore throat and assessing
anticoagulants (Karch, 2010). Its pharmacologic action is to interfere 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 (Deglin &
Vallerand, 2009). This was indicated for the client as a measure of prevention of
thrombus formation and embolization after prosthetic valve placement done in 2004. It
41
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
has been, since then, a maintenance drug used by the client in combination with
contraindicated to open wounds, active ulcer disease, severe liver or kidney disease,
uncontrolled hypertension and recent brain, eye, or spinal cord injury or surgery. It must
be used with caution in patients with malignancy and women with childbearing potential.
The main desired action on the client includes the lyse of possible clots and
treatment to prevent formation of emboli or thrombus. Spratto & Woods (2008) state that
one of the nursing implications in giving this drug is watching out for signs of bleeding.
The common signs, onset or worsening of bleeding include the occurrence of petechiae,
vision and mental status changes (Smeltzer& Bare,et. al. 2010). Other nursing
implications include reminding patient to not double doses and have limited intake of
inhibitors or the anti-secretory drugs (Karch, 2010). According to Deglin & Vallerand
secretory surface of the gastric parietal cells. It blocks the final step of acid
42
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
production. Karch (2010) adds that the medication is usually given to the
client with heart failure for the management of duodenal ulcers and eventual prevention
of bleeding from the upper gastrointestinal tract in people who have life-threatening
or its components. Caution is advised for patients with liver disease wherein dosage
reduction may be necessary and in pregnancy, lactation, or children as safety has not yet
been established.
The main desired action on the client includes prevention of gastrointestinal bleeding and
hypersecretion caused by ulcers or leisions in the gastrointestinal tract. Spratto & Woods
(2008) reminds nurses that this drug should be administered before meals because
synthesis of bacterial cell wall, causing cell death, according to Deglin & Vallerand
(2009). This was indicated for the client due to suspected infective endocarditis.
43
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
The main desired action on the client includes prevention or treatment for possible
endocarditis or pneumonia. Spratto & Woods (2008) outlines adds that the nursing
implications in giving this drug include assessing patient for infection at beginning of and
throughout therapy, observing patient for signs and symptoms of anaphylaxis like rash,
dissipate heat (Karch, 2010). This was indicated for the client due to fever on admission
to reduce fever and provide temporary relief of minor aches and pains (Deglin &
acetaminophen. Spratto & Woods (2008) enumerates the nursing implications in giving
this drug and these are administering thedrug with food if GI upset occurs and
the client's temperature and montoring for signs of infection are undertaken.
Treatment Modality. Physicians prescribe two additional therapy for the client
with heart failure, namely, Nutritional therapy and Supplemental Oyxgen therapy.
44
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
asually recommended. Dietary restriction on sodium reduces fluid retention and due to
symptoms of peripheral and pulmonary congestion. Smeltzer & Bare (2010) stated that
the significance of the sodium-restricted diet is to decrease the amount of blood volume
which decreased myocardial workload. The computed diet for the client is based on a 1,
800 calorie diet which is recommended for the client. Total Calorie Requirement is 1800
kilocalories per day. Carbohydrate is limited to 270 grams per day while Protein is
failure progresses. This is based on the degree of congestion or hypoxia (Smeltzer &
Bare, 2010). The client is hooked to a nasal cannula with pressure of 4 LPN.
Nursing Plan of Care. Care of nurses are shown to have increase the management of a
Problem Identification. Figure 2 shows the concept map for the different problems
identified in the patient. The following nursing problems were identified on August 31,
2010.
45
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
46
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
and enables the individual to take measures to deal with threat”. Subjective cues that
and anxiety about prognosis of disease, “Natatakot talaga akong mawala kasi gusto ko
pa sanang makitang lumaki ang apo ko”. Objective cues include changing facial
2004). Subjective cues for this diagnosis include “feeling of fullness”, decreased appetite
and minimal consumption of meals. Objective cues include the weight loss from 55
kilograms to 51 kilograms. B. A.'s height is 5'2 inches. The client is prescribed with a
cardiac diet consisting of low salt and restricted fat. Total calorie intake recommended is
1800 kilocalories per day. Carbohydrates to be consumed are at 270 grams per day and
Risk for Ineffective Myocardial and Cerebral Tissue Perfusion is another nursing problem
identified and it is defined as “an increased risk for decreasing in oxygen resulting in the
failure to nourish the tissues at the capillary level” (Doenges, 2004). Subjective cues
include chest pain with a grade of 4, radiating to back and persisting to more than 10
minutes. Dizziness and chest heaviness were also reported. Objective cues include vital
signs of 90/60 and heart rate of 45 beats per minute. Pallor and pale nail beds are other
47
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
signs of ineffective tissue perfusion. The client is on oxygen therapy through a nasal
Doenges (2004) as “inspiration and/or expiration that does not provide adequate
ventilation”. Subjective cues for identifying the problem include shortness of breath on
exertion. Client has 2 pillow orthopnea and complains of easy fatigability. She reports
feelings of “drowning” on supine position so she is placeed on Moderate High Back Rest.
Objective cues include use of accessory muscles on exertion with a respiratory rate of 30
respirations per minute. There is normal hemoglobin count and left ventricular
Risk for Infection is defined as “at increased risk for being invaded by pathogenic
organisms” (Deonges, 2004). This risk for infection is actually due to the client's former
surery which is prosthetic valve replacement in mitral and aortic valves. She is
procedure in open heart surgery, prosthetic mitral and aortic valve replacement in 2004.
She also a known cardiac patient due to other diseased like Valvular Heart Disease and
Rheumatic Fever. Objective cues include the onset of fever with a temperature of 35.8
°C. Client is medicated with Ceftriaxone and there is also a presence of heplock at the left
arm. The client's WBC values are normal and blood culture shows negative results after 2
days of incubation.
48
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
Doenges (2004) as “inadequate blood pumped by the heart to meet the metabolic
demands of the body”. Decreased Cardiac Output is also part of the pathophysiologic
diagram because it is part of the progression of the disease. Subjective cues include
history of cardiac problems as a patient of Valvular Heart Disease and Rheumatic Heart
Disease. The client is fond of fatty and salty foods. She does not exercise though she
walks to and from the market. Vital signs are monitored every 4 hours. There is easy
fatigability and client can walk only 3 flights of stairs. Potassium content in blood is 3.9
mmol/L. Prothrombin time is 22.3 secs and Partial Thromboplastin Time is 56.8 secs.
focuses more on the activities that the client can undertake. The client is ambulatory and
always does things for herself. However, ordinary physical activities like walking are an
complications of bleeding in the client. The client has upper gastrointestinal bleeding
though she does not complain of stomach pain. The client is on warfarin therapy that
takes increases risk for bleeding. The client was advised to avoid green leafy vegetables
49
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
because they counteract the mechanism of warfarin. Objective signs include hematuria,
the client is monitored for pulmonary embolism which can lead to cardiac death. Cues
include blood pressure of 90/60 and a heart rate 0f 49 beats per minute. The client is
ambulatory and experiences chest pain on exertion. She is on moderate high back rest and
on warfarin therapy. Prothrombin time is 22.3 secs and Partial Thromboplastin Time is
56.8 secs.
the intensity of symptoms and underlying causes were taken into account first before
Output emerged as the priority problem because of the presenting symptoms such as very
slow heart rate of 45 beats per minute and low blood pressure for age at 90/60. Also,
ejection fraction is slightly lower than normal. These are needs that prompted addressing
the problem first. Also, if Decreased Cardiac Output has been resolved, other problems
50
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
51
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
the nursing care plan, the most presenting signs and symptoms were given priority first
before the conceptualized care plan. Nursing Interventions Classifications (2001) was
On the day following assessment, Decreased Cardiac Output related to decreased end-
systolic volume was addressed first. In the succeeding days, evaluation of care was still
continued. The goal for this problem is that by the end of the shift, Mrs. Aquino will
demonstrate adequate cardiac output as evidenced by normal blood pressure and pulse
contractility” (Johnson, et. al, 2001). This was chosen to address the problems of
decreased heart rate, increased preload and afterload and reduced contractility of the
patient.
During nursing intervention, the student nurse has (1) monitored hemodynamic stability
indicators (vital signs, peripheral pulses, capillary refill time, pallor) and compared with
baseline. The hemodynamic stability indicators are the baseline to indicate the status of
cardiac output (Smeltzer, et. al., 2010). She has (2) monitored for peripheral edema,
52
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
jugular vein distention and S3 and S4 heart sounds. As peripheral edema, jugular vein
distention, extra heart sounds indicate progressing congestion (Smeltzer, et. al., 2010).
Another Nursing Intervention Classification used was Cardiac Care [4040] which is
oxygen supply and demand for a patient with symptoms of impaired cardiac function”.
This classification was used to decrease demands particularly of oxygen on the heart and
During nursing intervention, the student nurse has (1) placed Mrs. Aquino in preferred
of breathing, and venous return and preload to the heart (Kozier & Erb, et. al., 2010). She
was able to (2) teach Mrs. Aquino conscious breathing technique. Stress responses and
techniques (Kozier & Erb, et. al., 2010). (3) The promotion of a calm and restful
environment was done to reduce myocardial oxygen demand that can be achieved by
allowing for rest and relaxation periods (Kozier & Erb, et. al., 2010). The student nurse
has (4) planned activity providing rest periods for the Mrs. Aquino to conserve energy
and reduce cardiac workload (Smeltzer, et. al., 2010). She has also been able to (5) stress
Valsalva maneuver causes vagal stimulation, reducing heart rate (bradycardia), which
53
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
may be followed by rebound tachycardia, both of which impairs cardiac output (Smeltzer,
The next Nursing Intervention Classification used is Cardiac Care: Rehabilitative [4046]
which is defined as the “promotion of maximum functional activity level for a patient
who has experienced an episode of impaired cardiac function that resulted from an
imbalance between myocardial oxygen supply and demand” (Johnson, et. al., 2001). This
classification was chosen to increase patient's independence and assess and recommend
During nursing intervention, the student nurse was able to (1) instruct the patient and
nurse also (2) instructed the patient and family on cardiac risk factors and possible
modifications. Risk factors like high cholesterol and sodium intake are lifestyle problems
that can be addressed with proper knowledge (Paul, 2008). The student nurse (3)
instructed the patient and family on any lifting/weight limitations, as appropriate as this
increases demand for oxygen compromising the transport to different tissues in the body
(Kozier & Erb, et. al., 2010). The student nurse also (4) explained the importance of a
cardiac diet, as required. High sodium intake causes water retention (Porth, 2007).
54
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
The last Nursing Interventions Classification used for the problem Decreased Cardiac
(2001) defines it as a “collection and analysis of patient to regulate fluid balance”. This
During nursing intervention, the student nurse was able to (2) monitor intake and output
of the client. Intake and output monitoring helps monitor presence of excess or deficient
fluid in the client (Kozier & Erb, et. al., 2010). The student nurse was also able to (1)
monitor weight and advise client to weigh daily at 8am as tolerated. Weighing checks for
possible increase in mass and fluid volume in the body undetected on the surface (Kozier
& Erb, et. al., 2010). This is important for the client to learn also as increase in weight is
a factor for reconsultation and possible rehospitalization once discharged (Paul, 2008).
On the second intervention day, Anxiety related to threat to or change in health status was
carried out on this day but was terminated. The problem Decreased Cardiac Output
The goal of this nursing intervention is for the client to report that anxiety is reduced to
55
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
(Johnson, et. al., 2001). This classification was chosen to decrease the client's
nurse (1) provided factual information concerning diagnosis, treatment and prognosis.
which interfere with meeting life demands and roles” (Johnson, et. al., 2001). This
classification was chosen because it allows the nurse to identify possible stressors and at
the same time, allows the patient to reflect on self and trace possible sources of anxiety
and address them on her own. During nursing intervention, the student nurse was able to
(1) review extent of feelings of anxiety of clients as there is a need to know the extent of
disequilibrium and need for intervention to prevent or resolve the crisis (Doenges, 2006).
She was also able to (2) discuss indication and method of treatment as this promotes
active participation of client in therapeutic regimen (Doenges, 2006). She has taken (3)
activities of daily living. This may indicate need to lean on others for a time (Doenges,
2006). Last, she (5) assessed the presence of positive coping skillls/inner strengths e.g
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
Past coping skills may be reused to relieve tension and preserve individual's sense of
The goal for Activity Intolerance related to increased cardiac workload is that the client
daily activities. One of the Nursing Intervention Classification of this problem is Activity
Therapy [4310] which is defined as “prescription of and assistance with specific physical
and cognitive, social, and spiritual activities to increase the range, frequency, or duration
of an individual's activity” (Johnson, et. al., 2010). This classification was chosen
During nursing intervention, the student nurse must be able to (1) determine the patient's
guides treatment (Doenges, 2006). She must be able to (2) assess the patient's level of
mobility through the 6-minute walk. This aids in defining what patient is capable of,
which is necessary before setting realistic goals (Doenges, 2006). She must be able to (3)
assess the patient's cardiopulmonary status before activity. Assessment before and after
activity provides for comparison on achieved level of activity tolerance (Doenges, 2006).
She has to (4) observe and document response to activities (walking, deep-breathing,
ROM). Assessment before and afer activity provides for comparison on achieved level of
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
activity tolerance (Doenges, 2006). She must be able to (5) establish guidelines and goals
of activity with the patient and caregiver. Motivation is enhanced if the patient
participates in goal setting (Doenges, 2006). (6) Progress activity gradually. This prevents
overexerting the heart and promotes attainment of short-range goals (Doenges, 2006).
defined as “regulating the use of energy to treat or prevent fatigue and optimize function”
(Johnson, et. al., 2001). This classification was chosen so that the client's easy fatigability
would be addressed thorough the regulation of energy. During intervention, the student
nurse was able to (1) assess the patient's schedule and allow rest periods between all
activities. Rest between activities provides time for energy conservation and recovery.
Heart rate recovery following activity is greatest at the beginning of a rest period
(Doenges, 2006). She was able to (2) assist with activities of daily living as indicated
though she allowed the client to do what she can do for herself. Caregivers need to
balance providing assistance with facilitating progressive endurance that will ultimately
enhance the patient's activity tolerance and self-esteem (Doenges, 2006). She was able to
with activity intolerance is both physically and emotionally difficult aids coping
(Doenges, 2006).
On the third intervention day, Risk for Ineffective Myocardial and Cerebral Tissue
Perfusion related to increased cardiac workload was carried out. Even though the
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
problem has not yet been included in the nursing care plan, it warranted immediate
Interventions for this problem included (1) monitoring for levels of consciousness,
dyspnea, dizziness, difficulty of breathing, (2) positioning to Moderate High Back rest on
preferred position, (3) raising side rails and (4) promoting clam and restful environment,
(5) clustering activities with caregiver to limit extreme activities, (6) instructing client to
the succeeding days. It is used to determine whether the objectives and outcome criteria
were met.
For the problem Decreased Cardiac Output related to decreased end-systolic volume, one
defined as “adequacy of blood volume ejected from the left ventricle to support systemic
perfusion pressure” (Johnson, et. al., 2001). This classification was chosen because it
allows the nurse to address the main etiology which is decreased end-systolic volume.
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
The outcome criteria for these objectives include to (1) display hemodynamic stability by
having the following (blood pressure, heart rate, respiratory rate, temperature, peripheral
pulses, capillary refill time, nail beds, color) within normal parameters. Of the indicators,
only the heart rate was not within normal parameters with 50 beats per minute. Another
was to (2) demonstrate absence of peripheral edema, jugular vein distention and S3 and
S4 heart sounds. There was no indications of either of the three. The next criteria was to
the three, only orthopnea is still the same as before and client is still on moderate high
back rest. Another was to (4) demonstrate conscious breathing technique which was
correctly performed by the client. The next one was for the client to (5) verbalize the
desire to participate in activities that reduce the workload of the heart like stress
defined as “personal actions to manage heart disease, its treatment, and prevent disease
progression” (Johnson, et. al. 2001). This was chosen to promote independence in
decision-making and treatment of the client. Objectives of this diagnosis is for the client
participate in cardiac rehabilitation program and limit sodium, fat and cholesterol intake.
The outcome criteria for this objectives include (1) verbalization of the desire to
participate in the treatment regimen which was stated by the client, (2) stating 3 risk
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
factors (diet, exercise, smoking cessation) and the importance of their modification. The
client was able to perform this outcome. Another criteria includes (3) verbalization of the
understanding of required diet which the client's significant other has been able to fulfill.
of the systemic and pulmonary circuits” (Johnson, et. al., 2001). This classification was
chosen because of the increased volume and pressure in the heart and plasma which may
change the flow of blood. The objective of this classification is to maintain normal
weight for age. The outcome criteria for this objective is to report the absence of weight
For the Nursing Diagnosis Anxiety related to threat or change in health status, the goal is
for the client toreport that anxiety is reduced to manageable level. One of the nursing
classification for this diagnosis is Anxiety Control [1402] which is defined as “personal
unidentifiable source”(Johnson, et. al., 2001). This classification was chosen because it
process and potential complications. The outcome criteria for this objective is to use own
words and understanding in describing the disease process ro condition and its potential
complications.
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
actions to manage stressors that tax an individual's resources” (Johnson, et. al., 2001). As
with the preceding classification, this promotes and enhances independence in identifying
source of problem. In addition, it allows the nurse to assist the client in her endeavor and
promotes camaraderie and rapport between the two. Objectives of this classification
and using behaviors to reduce stress. Outcome criteria include (1)consistently reporting a
decrease in stress. The client has been able to report a reduced feeling of stress on the
succeeding day. Another outcome criteria is (2) verbalizing in own words the relevant
information about treatment wherein the client has been able to identify the action and
use of support systems). The client has been able to utilize and demonstrate said
behaviors.
For the nursing diagnosis Risk for Ineffective Myocardial and Tissue Perfusion, the client
was evaluated and exhibited absence of pallor, syncope, dizziness and chest pain with
vital signs of 110/70 mmHg, 56 beats per minute, 24 breaths per minute and at a
Because of the journal entitled “Hospital Discharge Education for Patients With Heart
Failure: What Really Works and What Is the Evidence?” was used by the student nurse as
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
weight monitoring, sodium and fluid restrictions, physical activities, regular medication
use, monitoring signs and symptoms of disease worsening, and early search for medical
care was made. The purpose was to promote self care, reduce readmission and helping
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
CONCLUSION
Most nursing literature for heart failure focus on guidelines in improving self-
management of patients and key role that nurses play as deliverer of patient education.
They aim to enhance nurses' knowledge of heart failure self-management principles with
managing patients with heart failure. Education and advice play a vital role in the
patient’s quality of life and in the prevention of readmission to hospital. It is necessary for
patients to understand and interpret changes in their normal functioning and judge the
early indication that the patient is retaining fluid (Paul, 2008). Measurement of weight
themselves each day at approximately the same time. Weight should be taken early in the
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
morning preferably before breakfast with the same amount of clothes and after having
passed urine. Patients should be advised to report an increase of more than 1 kg sustained
It also involves salt restriction. Salt in the diet promotes fluid retention, a low salt diet is
most patients, maximum of 2 gms per day. Patient should have awareness of high salt
content in processed foods, no salt at the table and that salt substitutes are not
recommended as they contain sodium and may be high in potassium (Paul, 2008).
Another is fluid restriction wherein excessive fluid intake will negate the effects of
with severe cases fluid should be restricted to 1 – 1.5 litres a day (CREST, 2005).
In addition to that, nutrition and dietary advice wherein a well balanced cardiac diet
should always be encouraged, is a must. Heart failure and the associated medications
used to treat the condition may cause loss of appetite and malabsorption resulting
drinks should be encouraged. High energy foods may be offered (CREST, 2005). Often
cholesterol levels may be low at this stage of the condition and treatment for
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
Overall, the clinical experience in Female Medicine Ward has allowed me to experience
handling cases related to the expected competencies for Nursing Interventions 105 mostly
on oxygenation. Thoroughout the interaction with the client, I have been able to improve
been able to carry out major skills because my client does not have much contraptions.
Nevertheless, caring for a patient with congestive heart failure needs utmost focus and
dedication.
I realized that it is important to value and always keep in mind the theoretical knowledge
imparted to us during lectures in addressing client needs. It also helps that we remember
that diseases are also human experiences and care for the client is always centered on her
in mind the importance of appropriateness centering on individualized care. For me, the
most fulfilling part is being able to establish rapport with the client and the significant
other. It builds up trust in the relationship and at the same time, confidence to the student
nurse. It also enhances the compliance of the client towards treatment and advice.
In doing this case study, I have been able to increase my knowledge on my case which is
congestive heart failure. It also helped me realize areas I have to improve on in dealing
with a major case especially on assessment and analysis. The importance of doing
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
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Hobler, K.E., L.C. Carey (1973). "Effect of acute progressive hypoxemia on cardiac
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Hunt S.A., Abraham W.T., Chin M.H., Feldman A.M., Francis G.S., Ganiats T.G., et al.
(2009). Focused update incorporated into the ACC/AHA 2005 Guidelines for the
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
APPENDICES
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
71
Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
SOURCES:Karch, M. (2010). 2010 Lippincott’s Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins ; Spratto,
G, Woods, A. L. (2008). PDR Nursing Drug Handbook. Philadelphia:Thomson Delmar Learning Inc.MIMS Philippines. (2010)
CPM Medica.
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
Hospital Discharge Education for Patients With Heart Failure: What Really Works
and What Is the Evidence?
SUMMARY:
This journal article talks about the important guidelines in educating patients with heart
failure before disharge, thereby promoting self care, reducing readmissions and helping
patients spot problems easily. Its aim is to focus attention to the comprehensive strategies
provided by the specially trained nurses that have been able to improve outcomes for
patients with heart failure, specifically the nurses' roles as educators in providing
comprehensive discharge education.
It emphasizes the role of the nurse in teaching and evaluating patients' self-care abilities
in weight monitoring, sodium and fluid restrictions, physical activities, regular
medication use, monitoring signs and symptoms of disease worsening, and early search
for medical care. It also underlines the importance of understanding barriers of patients'
to self care like complex medication regimen, cognitive impairment and lack of
motivation and the importance of learning strategies to educate patients to overcome
these barriers.
REACTION:
This journal is relevant to my client, diagnosed with Congestive Heart Failure FC II 2ᵒ
Valvular Heart Disease 2ᵒ Rheumatic Heart Disease for discharge on September 2, 2010
if blood culture is negative (or Infective Endocarditis is ruled out). Discharge education is
a vital part of discharge planning because it addresses the home management of the client
and her competency in dealing and monitoring the disease out of the hospital.
I would be able to apply this in the care to my client as incoporated in the discharge
planning. Philippine General Hospital also outlines the importance of discharge education
in discharge planning though it is not as comprehensive as the journal recommends.
However, during my intervention week, I have been able to stress to Mrs. Aquino the
importance of weight monitoring, sodium and fluid restrictions, limited physical
activities, regular medication use, monitoring signs and symptoms of disease worsening,
and early search for medical care at home. We have been monitoring her weight daily at
8am with the client managing the weighing scale to increase awareness to its use.
Nevertheless, according to the journal, an in-depth education and the giving of written
materials is important to discharge education. The latter has been included, as
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Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
The impact of this journal to my future nursing care is that it helps in stressing to me the
importance of health teaching in the future management of illness. Also, it has been
called to my attention the differences in the health system of the United States (the so-
called ideal health system) and the Philippines. There is less intensive coordination of the
community and hospital nurses in the Philippines. In the US, it is possible for them to
have telephone monitoring, one-on-one sessions and at-home interventions as part of
their care after discharge which is highly improbable in the Philippines. Maybe, one day,
as part of my future nursing career, I would be one of those who will be able to make this
system possible in the Philippines.
SOURCE: Paul, S. (2008) Hospital Discharge Education for Patients With Heart Failure:
What Really Works and What Is the Evidence? Crit Care Nurse. 2008;28: 66-82. Retrieved from
http://ccn.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT
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