The general objectives for the conduction of this case study are for students to incorporate concepts and

enhanced knowledge in Medical Surgical Nursing to apply the appropriate nursing management for clients with Dilated Cardiomyopathy and Congestive Heart. This study aims to improve nursing interventions that can possibly help our patient in understanding and maintaining special needs. At the same time, it allows the students to utilize the different attitudes that were instilled on them, such as on being respectful, patient and empathetic and improve the selfesteem by gaining knowledge and competency in handling future cases like these.

Specific Objectives:
At the end of the case presentation, this case study specifically aims to: * Define Dilated Cardiomyopathy; Congestive Heart Failure accurately * Discuss briefly the causative factors that may have precipitated the onset of the condition * Discuss thoroughly the signs and symptoms manifested by patient * Discuss the different drugs; indications; mechanism of action, therapeutic effects, adverse effects and contraindications.

* Present accurately the condition of the patient * Acquire knowledge and understanding of the pathophysiology * Discuss the nursing care plan appropriate in providing care to alleviate the manifestation of the patient s symptoms * Identify and provide the health teachings needed for the continuum of care * Use the nursing care plan as the framework of the patient s care

Chief Complaint:
The patient came to the hospital complaining of difficulty of breathing. She asked to be brought to the facility because she felt something heavy is pressing on her chest, as she verbalized it, parang may nakadagan sa didbdib ko , and requested that she be administered oxygen because she is aware that the only way to alleviate the difficulty is through oxygen administration.

Chief Complaint:

Pt s Name: Age: Sex: Civil Status: Birthday: Occupation: Religion: Ad Date: Ad Time: Institution: Diagnosis:

SL 70y/o Female Married May 14, 1940 Homemaker Roman Catholic March 8, 2011 1:43am MCI 5th Floor Dilated

Cardiomyopathy; CHF

History of Present Illness:

One month PTA, the patient experienced difficulty of breathing, and was administered with oxygen to manage DOB. A day PTA, the patient experienced again DOB and verbalizes parang may nakadagan sa akin, kaya ginising ko na ang anak ko para magpadala sa ospital and was administered oxygen and according to her it was effective. Because of severe difficulty of breathing, the patient was prompted admission.

Past Medical History:

During childhood, the patient had chickenpox, mumps and measles and was given BCG, MMR and DPT as immunizations. She recalls no allergy to food, but previously had allergy to penicillin. The patient had been hospitalized before due to accident; she experienced 3rd degree burns when she was 35 years old; and was hospitalized twice, one during a complication in delivery and another when she got burned, and add to that her current hospitalization.

Family History of Illness:

The family has a history of congenital heart defect. The patient s mother died from it, and so is the patient s younger child. The patient s father died of old age.

Health Perception and Health Management Pattern:

She admits to being sickly as she verbalized, sickly na ako, wala na ako magawa sa buhay but keeps herself healthy by avoiding all the things that are not necessary in her nutrition, such as salt and fats. The patient is aware of and understands her diagnosis. She is compliant to her medications. Her plan for faster recovery is to have more rest and take medicines on time.

Nutritional-Metabolic Pattern:

The patient likes to eat but only the ones that will not contribute to her illness or disease such as vegetables like blanched potatoes. The patient is restricted to 1 L of water per day. According to the patient, illness and being hospitalized doesn t affect her appetite and nutritional intake at all as she has not lost her appetite.

24-Hour Recall Diet

Breakfast Lunch Dinner Breakfast Low salt noodles Chicken with ampalaya and corn Malunggay vegetables Bread and chicken glass of water glass of water glass of water 1 glass of water

Elimination Pattern:
The patient has no problem in urinating. She doesn t feel any discomfort voiding. She had bowel movement once only yesterday and has no problem in defecation but still has not moved today. The client is discouraged to perform the valsalva s maneuver that is why she is ordered to take laxative. She last urinated at 7:15 AM today prior to the interview and has not defecated yet that she was given Lactulose, a laxative so to lessen, if not, avoid valsalva s maneuver.

Activity-Exercise Pattern:
The patient is able to perform ADL but the doctor advised her not to have any bathroom privileges. She doesn t have any type of exercise. Shortness of breath is noted. Patient is able to move without assistance but needs the assistance to prevent any injury. Illness and hospitalization doesn t affect her general mobility and self-care, and according to her, she can still take care of herself but stated that she had difficulty in moving around and experiencing sort of boredom.

Sleep-Rest Pattern:

Cognitive-Perceptual Pattern:

Self Perception & Self Concept Pattern:

Coping & Stress Tolerance Pattern:

General Appearance:
We received the patient lying on bed awake with on-going IVF #2 PNSS 500 cc x 12 at 450 cc level, hooked @ L MCV, patent and infusing well. The body built of the patient is proportionate and coordinated. Her hygiene and grooming is clean and neat with no body odor or foul breath. However, there was an obvious sign of labored breathing. She has a responsive and cooperative affect and an understandable speech conscious and coherent.

Vital Signs: