Foundation University

COLLEGE OF NURSING
Dumaguete City

A CASE STUDY ON CONGENITAL HEART FAILURE WITH HCVD ASSOCIATED WITH CARDIOMEGALY

In partial fulfillment of the requirements in Nursing Care Management (NCM) 106

Submitted by:
Niña Ricci M. Misa, SN-FUCN

Submitted to:
Mr. Peter A. Orlino, RN-FUCN

Submitted on:
October 10, 2017
Mr. Peter Orlino
Clinical Instructor, Emergency Room Rotation – A1
College of Nursing, Foundation University
Dumaguete City

Dear Mr. Orlino,

I, Niña Ricci M. Misa, a level IV section A1 student of Foundation University College of Nursing, would like to apply on a case study of my
patient admitted at Negros Oriental Provincial Hospital for our Emergency Room rotation. I would like to ask for your permission for a case study as it
will surely enhance my knowledge, skills and capabilities as a future nurse. I will assure to you that the patient’s confidentiality will be kept, and the
data gathered will be used for educational purposes only.
This analysis would provide comprehensive information regarding to Congenital Heart Failure with HCVD and Cardiomegaly. In this way, I
could further share our knowledge to our fellow classmates throughout the case presentation.
I am hoping for your kind consideration. Thank you very much!

Sincerely,

Niña Ricci M. Misa, SN-FUCN

 TABLE OF CONTENTS

I. Life Purpose, Vision, Mission

II. Central Objectives, Specific Objectives
III. Acknowledgement
IV. Introduction
V. Demographic Profile
VI. Developmental Milestones
VII. Anatomy and Physiology
VIII. Review of Related Literature
IX. Pathophysiology
X. Medical Management
XI. Treatment Modalities
XII. Drug Study
XIII. Nursing Management
XIV. Physical Assessment
XV. Nursing Theories
XVI. Gordon's Functional Health Pattern
XVII. Summary of Nursing Diagnoses
XVIII. Nursing Care Plans
XIX. Annotated Readings
XX. Conclusion
XXI. References
Life Purpose

To educate and develop individuals to become productive, creative, useful and responsible citizens of society.

Vision

To be a dynamic, progressive school that cultivates effective learning, generates creative ideas, responds to societal needs and offers equal

opportunity for all.

Mission

In its quest for excellence in mind, body and character and the pursuit of truth and freedom, Foundation University commits itself to:

1. develop students of sound character and broad culture;

2. prepare students for a definite career;

3. imbue students with the spirit of universal brotherhood; and

4. advocate truth, promote justice and advance knowledge

Central Objective

At the end of the presentation, through the use of a variety of learning approaches, the learners will be able to expand knowledge, competent

skills and acquire positive attitudes and values towards the emergency care of a patient having Congestive Heart Failure with Hypertensive

Cardiovascular Disease associated with Cardiomegaly.

SPECIFIC OBJECTIVES: This case study is conducted for students to be able to:

1. Recognize different factors that contributed to the patient’s condition.

2. Identify different manifestations of the patient, and how they are managed.

3. Understand the treatment regimen of the patient.

4. Know the appropriate nursing interventions during the nursing care of the patient.

5. Discuss and discover the nature and progression of the condition.

6. Identify possible nursing diagnosis and its corresponding management.

7. Trace the pathophysiology of the disease process.

8. Enhance knowledge about the condition.

 ACKNOWLEDGEMENT

I would like to thank Our Heavenly Father for guiding and protecting me as I made this casebook. In accomplishing my tasks as a student nurse,

especially in completing our case study, I have gained knowledge and realized many things.

To my patient, whom I'll call Patient AE for confidentiality, To my patient's family who have whole heartedly accepted me and allowed me to obtain

information about my patient;

To the Dean and the Faculty of nursing who taught me well in preparation to a hospital duty;

To my family, for their unending love, understanding, guidance and support, as well as the encouragements in times of difficulties, you gave me the

strength to accomplish and reach my goals in life;

Lastly, to my C.I. Mr. Peter A. Orlino, RN, who pushed us to our limits and made us ER-capable student nurses. I learned a lot from him and I am

thankful he was always patient with all of us;

Thank you for understanding and for being a guide to me and to my CI group. I wouldn't have learned so much if it weren't for all of you.
 INTRODUCTION

Heart failure is a progressive disorder in which damage to the heart causes weakening of the cardiovascular system. It manifests by fluid
congestion or inadequate blood flow to tissues. Heart failure progresses by underlying heart injury or inappropriate responses of the body to heart
impairment. Heart failure may result from one or the sum of many causes. It is a progressive disorder that must be managed in regard to not only the
state of the heart, but the condition of the circulation, lungs, neuroendocrine system and other organs as well. Furthermore, when other conditions
are present (e.g. kidney impairment, hypertension, vascular disease, or diabetes) it can be more of a problem. Finally, the impact it can have on a
patient psychologically and socially are important as well. Heart failure is a cumulative consequence of all insults to the heart over someone’s life. It is
estimated that nearly 5 million Americans have heart failure. The prevalence of heart failure approximately doubles with each decade of life. As
people live longer, the occurrence of heart failure rises, as well as other conditions that complicate its treatment. Even when symptoms are absent or
controlled, impaired heart function implies a reduced duration of survival. Fortunately, many factors that can prevent heart failure and improve
outcome are known and can be applied at any stage (Gibson, Ortiz & Jaski, Heart Failure, 2013).

The increase in incidence and prevalence of CHF poses an urgent national and global public health priority. According to the American Heart
Association, 550, 000 new cases occur each year. More than five million Americans are afflicted with this disorder. It remains the leading cause of
hospitalizations among medicare beneficiaries. CHF has etiologies and occurs commonly following acute and chronic cardiac injury. According to the
Framingham investigators, the lifetime risk of developing CHF at age 40 is approximately 20%. The major risk factors of CHF parallel those for CAD,
and include diabetes, hypertension, hypercholesterolemia, smoking, genetic factors, and aging (Sauer, Shah, & Laurindo, 2010).

CHF is among the most serious diseases. The fatigue and shortness of breath associated with CHF can be very debilitating, leaving some
patients unable to perform even their activities of daily living such as cooking, cleaning, and grooming themselves. This level of disability severely
affects their quality of life. In the past five years, the Medicare program has reported a 5 percent annual increase in the number of patients with this
diagnosis. There are two prominent reason for the increased incidence of CHF: the aging population and modern medical care. More effective
medical treatments for heart attacks have decreased the mortality rates. The survivors of these heart attacks comprise a rapidly growing group of
younger patients with CHF. The aging population creates a greater number of people who have risk factors for CHF, such as chronic high blood
pressure, diabetes, and coronary artery disease. The NYHA classification system helps patients and doctors tell if heart failure is improving, staying
the same, or getting worse. In the NYHA Classification System for heart failure discussed Class IV as stated, "The patient suffers from severe to
complete limitation of activity. Shortness of breath, fatigue, or heart palpitations with any physical exertion and symptoms appear even at rest"
(Quinn, 2006).

With a lived experience of Congestive Heart Failure, patient AE suffered HCVD with Cardiomegaly as complications of the disease. Patient’s
mother claimed that he was only diagnosed when he had himself checked up once in Holy Child Hospital after suffering shortness of breath while
walking in downtown. Lasix was given as a maintenance medication but stopped when they thought patient is already healthy, as claimed by
patient’s mother. Patient is admitted in the ER for continuous monitoring and on strict medication adherence, under Dr. Saad’s care.
 DEMOGRAPHIC DATA

NAME OF PATIENT: Patient A.E.

AGE: 35 years old
SEX: Male
STATUS: Single
EDUCATIONAL BACKGROUND: High School level
BIRTHDATE: August 24, 1982
OCCUPATION: None
RELIGION: Roman Catholic
ADDRESS: Balugo, Dumaguete City, Negros Oriental
NATIONALITY: Filipino
DATE/TIME OF ADMISSION: September 7, 2017 (12:45 PM)
ADMISSION TYPE: Emergency
ATTENDING PHYSICIAN: Saad, Ophelio D., M.D.
WARD TYPE: D
PHILHEALTH: NON-NHID
CHIEF COMPLAINTS:
“Kani iang kutas lima na ka adlaw nya iya ubo duha ka semana na, nya iyag hupong sa iyang tiil ng ten days na”, claimed by SO.

GENERAL IMPRESSION:
Received patient on bed, awake but not fully alert, only stimulated when touched or when voice is loud and clear. Dextrose 5% in 1/3 Normal
saline at 10 gtt/min infusing well at the right metacarpal vein, no signs of inflammation noted. FBC in place attached to urobag- drained. Patient on
high fowler’s position, O2 administered at 2L/min via nasal cannula. Vital signs: BP= 220/120 mmHg, T= 36.0 C, P= 99 bpm, R= 24 cpm, O2= 97%.
 DEVELOPMENTAL MILESTONES

Erik Erikson

Erikson’s (1959) theory of psychosocial development has eight distinct stages, taking in five stages up to the age of 18 years and three further
stages beyond, well into adulthood. Erikson suggests that there is still plenty of room for continued growth and development throughout one’s life.
Erikson puts a great deal of emphasis on the adolescent period, feeling it was a crucial stage for developing a person’s identity.

Like Freud, Erikson assumes that a crisis occurs at each stage of development. For Erikson (1963), these crises are of a psychosocial nature
because they involve psychological needs of the individual (i.e. psycho) conflicting with the needs of society (i.e. social).

According to the theory, successful completion of each stage results in a healthy personality and the acquisition of basic virtues. Basic virtues
are characteristic strengths which the ego can use to resolve subsequent crises. Failure to successfully complete a stage can result in a reduced
ability to complete further stages and therefore a more unhealthy personality and sense of self. These stages, however, can be resolved
successfully at a later time.

Intimacy vs. Isolation

Occurring in young adulthood (ages 18 to 40 yrs), we begin to share ourselves more intimately with others. We explore relationships leading
toward longer-term commitments with someone other than a family member. Successful completion of this stage can result in happy relationships
and a sense of commitment, safety, and care within a relationship. Avoiding intimacy, fearing commitment and relationships can lead to isolation,
loneliness, and sometimes depression. Success in this stage will lead to the virtue of love (McLeod, 2008).

Stage six of the Erikson stages is very apparent for young adults who are in their 30s. People at this stage become worried about finding the
right partner and fear that if they fail to do so, they may have to spend the rest of their lives alone. Young adults are most vulnerable to feel intimacy
and loneliness because they interact with a lot of people in this phase of their lives. It’s not always a success story for every young adult to find
someone with whom they can share a lifelong commitment. Some may choose to spend the rest of their lives as singles (PsychologyNotesHQ,
2017).

Correlation:
In relation to Erikson's Intimacy vs. Isolation, my patient is 35 years old, qualifying under the stage. Patient's mother claimed that patient has a
childlike behavior believing him to a special child. Thus, patient will most likely choose to stay single for the rest of his life as his mentality is
considered underdeveloped for him to want to find a partner in life to commit to.
 ANATOMY AND PHYSIOLOGY

Cardiovascular System

The heart is a muscular pumping organ located medial to the lungs

along the body’s midline in the thoracic region. The bottom tip of the heart,
known as its apex, is turned to the left, so that about 2/3 of the heart is
located on the body’s left side with the other 1/3 on right. The top of the
heart, known as the heart’s base, connects to the great blood vessels of
the body: the aorta, vena cava, pulmonary trunk, and pulmonary veins
(Taylor, n.d.).

Circulatory Loops
There are 2 primary circulatory loops in the human body: the pulmonary
circulation loop and the systemic circulation loop (Taylor, n.d.)
.
a. Pulmonary circulation transports deoxygenated blood from the right
side of the heart to the lungs, where the blood picks up oxygen and returns
to the left side of the heart. The pumping chambers of the heart that
support the pulmonary circulation loop are the right atrium and right
ventricle
b. Systemic circulation carries highly oxygenated blood from the left
side of the heart to all of the tissues of the body (with the exception of the
heart and lungs). Systemic circulation removes wastes from body tissues
and returns deoxygenated blood to the right side of the heart. The left atrium and left ventricle of the heart are the pumping chambers for the
systemic circulation loop.
(Taylor, n.d.)

Blood Vessels
- Blood vessels are the body’s highways that allow blood to flow quickly and efficiently from the heart to every region of the body and back
again. The size of blood vessels corresponds with the amount of blood that passes through the vessel. All blood vessels contain a hollow
area called the lumen through which blood is able to flow. Around the lumen is the wall of the vessel, which may be thin in the case of
 capillaries or very thick in the case of arteries. All blood vessels are lined with a thin layer of simple squamous epithelium known as the
endothelium that keeps blood cells inside of the blood vessels and prevents clots from forming. The endothelium lines the entire circulatory
system, all the way to the interior of the heart, where it is called the endocardium. There are three major types of blood vessels: arteries,
capillaries and veins. Blood vessels are often named after either the region of the body through which they carry blood or for nearby
structures. For example, the brachiocephalic artery carries blood into the brachial (arm) and cephalic (head) regions. One of its branches,
the subclavian artery, runs under the clavicle; hence the name subclavian. The subclavian artery runs into the axillary region where it
becomes known as the axillary artery (Taylor, n.d.).

1. Arteries and Arterioles: Arteries are blood vessels that carry blood away from the heart. Blood carried by arteries is usually highly oxygenated,
having just left the lungs on its way to the body’s tissues. The pulmonary trunk and arteries of the pulmonary circulation loop provide an
exception to this rule – these arteries carry deoxygenated blood from the heart to the lungs to be oxygenated. Arteries face high levels of
blood pressure as they carry blood being pushed from the heart under great force. To withstand this pressure, the walls of the arteries are
thicker, more elastic, and more muscular than those of other vessels. The largest arteries of the body contain a high percentage of elastic
tissue that allows them to stretch and accommodate the pressure of the heart. Smaller arteries are more muscular in the structure of their
walls. The smooth muscles of the arterial walls of these smaller arteries contract or expand to regulate the flow of blood through their lumen.
In this way, the body controls how much blood flows to different parts of the body under varying circumstances. The regulation of blood flow
also affects blood pressure, as smaller arteries give blood less area to flow through and therefore increases the pressure of the blood on
arterial walls. Arterioles are narrower arteries that branch off from the ends of arteries and carry blood to capillaries. They face much lower
blood pressures than arteries due to their greater number, decreased blood volume, and distance from the direct pressure of the heart. Thus
arteriole walls are much thinner than those of arteries. Arterioles, like arteries, are able to use smooth muscle to control their aperture and
regulate blood flow and blood pressure (Taylor, n.d.)

2. Capillaries: Capillaries are the smallest and thinnest of the blood vessels in the body and also the most common. They can be found running
throughout almost every tissue of the body and border the edges of the body’s avascular tissues. Capillaries connect to arterioles on one end
and venules on the other. Capillaries carry blood very close to the cells of the tissues of the body in order to exchange gases, nutrients, and
waste products. The walls of capillaries consist of only a thin layer of endothelium so that there is the minimum amount of structure possible
between the blood and the tissues. The endothelium acts as a filter to keep blood cells inside of the vessels while allowing liquids, dissolved
gases, and other chemicals to diffuse along their concentration gradients into or out of tissues. Precapillary sphincters are bands of smooth
muscle found at the arteriole ends of capillaries. These sphincters regulate blood flow into the capillaries. Since there is a limited supply of
blood, and not all tissues have the same energy and oxygen requirements, the precapillary sphincters reduce blood flow to inactive tissues
and allow free flow into active tissues (Taylor, n.d.)
 3. Veins and Venules: Veins are the large return vessels of the body and act as the blood return counterparts of arteries. Because the arteries,
arterioles, and capillaries absorb most of the force of the heart’s contractions, veins and venules are subjected to very low blood pressures.
This lack of pressure allows the walls of veins to be much thinner, less elastic, and less muscular than the walls of arteries. Veins rely on
gravity, inertia, and the force of skeletal muscle contractions to help push blood back to the heart. To facilitate the movement of blood, some
veins contain many one-way valves that prevent blood from flowing away from the heart. As skeletal muscles in the body contract, they
squeeze nearby veins and push blood through valves closer to the heart. When the muscle relaxes, the valve traps the blood until another
contraction pushes the blood closer to the heart. Venules are similar to arterioles as they are small vessels that connect capillaries, but unlike
arterioles, venules connect to veins instead of arteries. Venules pick up blood from many capillaries and deposit it into larger veins for
transport back to the heart (Taylor, n.d.).

Coronary Circulation
The heart has its own set of blood vessels that provide the myocardium with the oxygen and nutrients necessary to pump blood throughout the
body. The left and right coronary arteries branch off from the aorta and provide blood to the left and right sides of the heart. The coronary sinus is a
vein on the posterior side of the heart that returns deoxygenated blood from the myocardium to the vena cava (Taylor, n.d.).

Hepatic Portal Circulation

The veins of the stomach and intestines perform a unique function: instead of carrying blood directly back to the heart, they carry blood to the
liver through the hepatic portal vein. Blood leaving the digestive organs is rich in nutrients and other chemicals absorbed from food.
The liver removes toxins, stores sugars, and processes the products of digestion before they reach the other body tissues. Blood from the liver then
returns to the heart through the inferior vena cava (Taylor, n.d.).

Blood
- The average human body contains about 4 to 5 liters of blood. As a liquid connective tissue, it transports many substances through the body and
helps to maintain homeostasis of nutrients, wastes, and gases. Blood is made up of red blood cells, white blood cells, platelets, and liquid plasma
(Taylor, n.d.).

 Red Blood Cells: Red blood cells, also known as erythrocytes, are by far the most common type of blood cell and make up about 45% of blood
volume. Erythrocytes are produced inside of red bone marrow from stem cells at the astonishing rate of about 2 million cells every second. The
shape of erythrocytes is biconcave—disks with a concave curve on both sides of the disk so that the center of an erythrocyte is its thinnest part.
The unique shape of erythrocytes gives these cells a high surface area to volume ratio and allows them to fold to fit into thin capillaries. Immature
erythrocytes have a nucleus that is ejected from the cell when it reaches maturity to provide it with its unique shape and flexibility. The lack of a
nucleus means that red blood cells contain no DNA and are not able to repair themselves once damaged. Erythrocytes transport oxygen in the
blood through the red pigment hemoglobin. Hemoglobin contains iron and proteins joined to greatly increase the oxygen carrying capacity of
 erythrocytes. The high surface area to volume ratio of erythrocytes allows oxygen to be easily transferred into the cell in the lungs and out of the
cell in the capillaries of the systemic tissues (Taylor, n.d.).

 White Blood Cells: White blood cells, also known as leukocytes, make up a very small percentage of the total number of cells in the bloodstream,
but have important functions in the body’s immune system. There are two major classes of white blood cells: granular leukocytes and agranular
leukocytes (Taylor, n.d.).

1. Granular Leukocytes: The three types of granular leukocytes are neutrophils, eosinophils, and basophils. Each type of granular leukocyte is
classified by the presence of chemical-filled vesicles in their cytoplasm that give them their function. Neutrophils contain digestive enzymes that
neutralize bacteria that invade the body. Eosinophils contain digestive enzymes specialized for digesting viruses that have been bound to by
antibodies in the blood. Basophils release histamine to intensify allergic reactions and help protect the body from parasites.

2. Agranular Leukocytes: The two major classes of agranular leukocytes are lymphocytes and monocytes. Lymphocytes include T cells and natural
killer cells that fight off viral infections and B cells that produce antibodies against infections by pathogens. Monocytes develop into cells called
macrophages that engulf and ingest pathogens and the dead cells from wounds or infections (Taylor, n.d.).

 Platelets: Also known as thrombocytes, platelets are small cell fragments responsible for the clotting of blood and the formation of scabs. Platelets
form in the red bone marrow from large megakaryocyte cells that periodically rupture and release thousands of pieces of membrane that become
the platelets. Platelets do not contain a nucleus and only survive in the body for up to a week before macrophages capture and digest them
(Taylor, n.d.).

 Plasma: Plasma is the non-cellular or liquid portion of the blood that makes up about 55% of the blood’s volume. Plasma is a mixture of water,
proteins, and dissolved substances. Around 90% of plasma is made of water, although the exact percentage varies depending upon the hydration
levels of the individual. The proteins within plasma include antibodies and albumins. Antibodies are part of the immune system and bind to
antigens on the surface of pathogens that infect the body. Albumins help maintain the body’s osmotic balance by providing an isotonic solution for
the cells of the body. Many different substances can be found dissolved in the plasma, including glucose, oxygen, carbon dioxide, electrolytes,
nutrients, and cellular waste products. The plasma functions as a transportation medium for these substances as they move throughout the body
(Taylor, n.d.).

Functions of the Cardiovascular System

The cardiovascular system has three major functions: transportation of materials, protection from pathogens, and regulation of the body’s
homeostasis (Taylor, n.d.).
 Transportation: The cardiovascular system transports blood to almost all of the body’s tissues. The blood delivers essential nutrients and oxygen
and removes wastes and carbon dioxide to be processed or removed from the body. Hormones are transported throughout the body via the
blood’s liquid plasma (Taylor, n.d.).

 Protection: The cardiovascular system protects the body through its white blood cells. White blood cells clean up cellular debris and fight
pathogens that have entered the body. Platelets and red blood cells form scabs to seal wounds and prevent pathogens from entering the body
and liquids from leaking out. Blood also carries antibodies that provide specific immunity to pathogens that the body has previously been exposed
to or has been vaccinated against (Taylor, n.d.).

 Regulation: The cardiovascular system is instrumental in the body’s ability to maintain homeostatic control of several internal conditions. Blood
vessels help maintain a stable body temperature by controlling the blood flow to the surface of the skin. Blood vessels near the skin’s surface
open during times of overheating to allow hot blood to dump its heat into the body’s surroundings. In the case of hypothermia, these blood vessels
constrict to keep blood flowing only to vital organs in the body’s core. Blood also helps balance the body’s pH due to the presence of bicarbonate
ions, which act as a buffer solution. Finally, the albumins in blood plasma help to balance the osmotic concentration of the body’s cells by
maintaining an isotonic environment (Taylor, n.d.).

The Circulatory Pump

The heart is a four-chambered “double pump,” where each side (left and right) operates as a separate pump. The left and right sides of the
heart are separated by a muscular wall of tissue known as the septum of the heart. The right side of the heart receives deoxygenated blood from the
systemic veins and pumps it to the lungs for oxygenation. The left side of the heart receives oxygenated blood from the lungs and pumps it through
the systemic arteries to the tissues of the body. Each heartbeat results in the simultaneous pumping of both sides of the heart, making the heart a
very efficient pump (Taylor, n.d.).

Regulation of Blood Pressure

Several functions of the cardiovascular system can control blood pressure. Certain hormones along with autonomic nerve signals from the
brain affect the rate and strength of heart contractions. Greater contractile force and heart rate lead to an increase in blood pressure. Blood vessels
can also affect blood pressure. Vasoconstriction decreases the diameter of an artery by contracting the smooth muscle in the arterial wall. The
sympathetic (fight or flight) division of the autonomic nervous system causes vasoconstriction, which leads to increases in blood pressure and
decreases in blood flow in the constricted region. Vasodilation is the expansion of an artery as the smooth muscle in the arterial wall relaxes after the
fight-or-flight response wears off or under the effect of certain hormones or chemicals in the blood. The volume of blood in the body also affects blood
pressure. A higher volume of blood in the body raises blood pressure by increasing the amount of blood pumped by each heartbeat. Thicker, more
viscous blood from clotting disorders can also raise blood pressure (Taylor, n.d.).
Hemostasis
Hemostasis, or the clotting of blood and formation of scabs, is managed by the platelets of the blood. Platelets normally remain inactive in the
blood until they reach damaged tissue or leak out of the blood vessels through a wound. Once active, platelets change into a spiny ball shape and
become very sticky in order to latch on to damaged tissues. Platelets next release chemical clotting factors and will begin to produce the protein fibrin
to act as structure for the blood clot. Platelets also begin sticking together to form a platelet plug. The platelet plug will serve as a temporary seal to
keep blood in the vessel and foreign material out of the vessel until the cells of the blood vessel can repair the damage to the vessel wall (Taylor,
n.d.).
 Respiratory System

The cells of the human body require a constant stream of oxygen to

stay alive. The respiratory system provides oxygen to the body’s cells while
removing carbon dioxide, a waste product that can be lethal if allowed to
accumulate. There are 3 major parts of the respiratory system: the airway, the
lungs, and the muscles of respiration. The airway, which includes the nose,
mouth, pharynx, larynx, trachea, bronchi, and bronchioles, carries air between
the lungs and the body’s exterior. The lungs act as the functional units of the
respiratory system by passing oxygen into the body and carbon dioxide out of
the body. Finally, the muscles of respiration, including the diaphragm and
intercostal muscles, work together to act as a pump, pushing air into and out of
the lungs during breathing (Taylor, n.d.).

Nose and Nasal Cavity

The nose and nasal cavity form the main external opening for the
respiratory system and are the first section of the body’s airway—the
respiratory tract through which air moves. The nose is a structure of the face
made of cartilage, bone, muscle, and skin that supports and protects the
anterior portion of the nasal cavity. The nasal cavity is a hollow space within
the nose and skull that is lined with hairs and mucus membrane. The function
of the nasal cavity is to warm, moisturize, and filter air entering the body before
it reaches the lungs. Hairs and mucus lining the nasal cavity help to trap dust,
mold, pollen and other environmental contaminants before they can reach the
inner portions of the body. Air exiting the body through the nose returns
moisture and heat to the nasal cavity before being exhaled into the
environment (Taylor, n.d.).

Mouth
The mouth, also known as the oral cavity, is the secondary external opening for the respiratory tract. Most normal breathing takes place
through the nasal cavity, but the oral cavity can be used to supplement or replace the nasal cavity’s functions when needed. Because the pathway of
air entering the body from the mouth is shorter than the pathway for air entering from the nose, the mouth does not warm and moisturize the air
entering the lungs as well as the nose performs this function. The mouth also lacks the hairs and sticky mucus that filter air passing through the nasal
cavity. The one advantage of breathing through the mouth is that its shorter distance and larger diameter allows more air to quickly enter the body
(Taylor, n.d.).

Pharynx
The pharynx, also known as the throat, is a muscular funnel that extends from the posterior end of the nasal cavity to the superior end of
the esophagus and larynx. The pharynx is divided into 3 regions: the nasopharynx, oropharynx, and laryngopharynx. The nasopharynx is the superior
region of the pharynx found in the posterior of the nasal cavity. Inhaled air from the nasal cavity passes into the nasopharynx and descends through
the oropharynx, located in the posterior of the oral cavity. Air inhaled through the oral cavity enters the pharynx at the oropharynx. The inhaled air
then descends into the laryngopharynx, where it is diverted into the opening of the larynx by the epiglottis. The epiglottis is a flap of elastic cartilage
that acts as a switch between the trachea and the esophagus. Because the pharynx is also used to swallow food, the epiglottis ensures that air
passes into the trachea by covering the opening to the esophagus. During the process of swallowing, the epiglottis moves to cover the trachea to
ensure that food enters the esophagus and to prevent choking (Taylor, n.d.).

Larynx
The larynx, also known as the voice box, is a short section of the airway that connects the laryngopharynx and the trachea. The larynx is
located in the anterior portion of the neck, just inferior to the hyoid bone and superior to the trachea. Several cartilage structures make up the larynx
and give it its structure. The epiglottis is one of the cartilage pieces of the larynx and serves as the cover of the larynx during swallowing. Inferior to
the epiglottis is the thyroid cartilage, which is often referred to as the Adam’s apple as it is most commonly enlarged and visible in adult males.
The thyroid holds open the anterior end of the larynx and protects the vocal folds. Inferior to the thyroid cartilage is the ring-shaped cricoid cartilage
that holds the larynx open and supports its posterior end. In addition to cartilage, the larynx contains special structures known as vocal folds, which
allow the body to produce the sounds of speech and singing. The vocal folds are folds of mucous membrane that vibrate to produce vocal sounds.
The tension and vibration speed of the vocal folds can be changed to change the pitch that they produce (Taylor, n.d.).

Trachea
The trachea, or windpipe, is a 5-inch long tube made of C-shaped hyaline cartilage rings lined with pseudo-stratified ciliated columnar
epithelium. The trachea connects the larynx to the bronchi and allows air to pass through the neck and into the thorax. The rings of cartilage making
up the trachea allow it to remain open to air at all times. The open end of the cartilage rings faces posteriorly toward the esophagus, allowing the
esophagus to expand into the space occupied by the trachea to accommodate masses of food moving through the esophagus (Taylor, n.d.).
The main function of the trachea is to provide a clear airway for air to enter and exit the lungs. In addition, the epithelium lining the trachea
produces mucus that traps dust and other contaminants and prevents it from reaching the lungs. Cilia on the surface of the epithelial cells move the
mucus superiorly toward the pharynx where it can be swallowed and digested in the gastrointestinal tract (Taylor, n.d.).
Bronchi and Bronchioles
At the inferior end of the trachea, the airway splits into left and right branches known as the primary bronchi. The left and right bronchi run into
each lung before branching off into smaller secondary bronchi. The secondary bronchi carry air into the lobes of the lungs—2 in the left lung and 3 in
the right lung. The secondary bronchi in turn split into many smaller tertiary bronchi within each lobe. The tertiary bronchi split into many smaller
bronchioles that spread throughout the lungs. Each bronchiole further splits into many smaller branches less than a millimeter in diameter called
terminal bronchioles. Finally, the millions of tiny terminal bronchioles conduct air to the alveoli of the lungs (Taylor, n.d.).

As the airway splits into the tree-like branches of the bronchi and bronchioles, the structure of the walls of the airway begins to change. The
primary bronchi contain many C-shaped cartilage rings that firmly hold the airway open and give the bronchi a cross-sectional shape like a flattened
circle or a letter D. As the bronchi branch into secondary and tertiary bronchi, the cartilage becomes more widely spaced and more smooth muscle
and elastin protein is found in the walls. The bronchioles differ from the structure of the bronchi in that they do not contain any cartilage at all. The
presence of smooth muscles and elastin allow the smaller bronchi and bronchioles to be more flexible and contractile (Taylor, n.d.).

The main function of the bronchi and bronchioles is to carry air from the trachea into the lungs. Smooth muscle tissue in their walls helps to
regulate airflow into the lungs. When greater volumes of air are required by the body, such as during exercise, the smooth muscle relaxes to dilate
the bronchi and bronchioles. The dilated airway provides less resistance to airflow and allows more air to pass into and out of the lungs. The smooth
muscle fibers are able to contract during rest to prevent hyperventilation. The bronchi and bronchioles also use the mucus and cilia of their epithelial
lining to trap and move dust and other contaminants away from the lungs (Taylor, n.d.).

Lungs
The lungs are a pair of large, spongy organs found in the thorax lateral to the heart and superior to the diaphragm. Each lung is surrounded by a
pleural membrane that provides the lung with space to expand as well as a negative pressure space relative to the body’s exterior. The negative
pressure allows the lungs to passively fill with air as they relax. The left and right lungs are slightly different in size and shape due to the heart
pointing to the left side of the body. The left lung is therefore slightly smaller than the right lung and is made up of 2 lobes while the right lung has 3
lobes (Taylor, n.d.).

The interior of the lungs is made up of spongy tissues containing many capillaries and around 30 million tiny sacs known as alveoli. The alveoli
are cup-shaped structures found at the end of the terminal bronchioles and surrounded by capillaries. The alveoli are lined with thin simple squamous
epithelium that allows air entering the alveoli to exchange its gases with the blood passing through the capillaries (Taylor, n.d.).

Muscles of Respiration
Surrounding the lungs are sets of muscles that are able to cause air to be inhaled or exhaled from the lungs. The principal muscle of
respiration in the human body is the diaphragm, a thin sheet of skeletal muscle that forms the floor of the thorax. When the diaphragm contracts, it
moves inferiorly a few inches into the abdominal cavity, expanding the space within the thoracic cavity and pulling air into the lungs. Relaxation of the
diaphragm allows air to flow back out the lungs during exhalation (Taylor, n.d.).

Between the ribs are many small intercostal muscles that assist the diaphragm with expanding and compressing the lungs. These muscles are
divided into 2 groups: the internal intercostal muscles and the external intercostal muscles. The internal intercostal muscles are the deeper set of
muscles and depress the ribs to compress the thoracic cavity and force air to be exhaled from the lungs. The external intercostals are found
superficial to the internal intercostals and function to elevate the ribs, expanding the volume of the thoracic cavity and causing air to be inhaled into
the lungs (Taylor, n.d.).

Pulmonary Ventilation
Pulmonary ventilation is the process of moving air into and out of the lungs to facilitate gas exchange. The respiratory system uses both a
negative pressure system and the contraction of muscles to achieve pulmonary ventilation. The negative pressure system of the respiratory system
involves the establishment of a negative pressure gradient between the alveoli and the external atmosphere. The pleural membrane seals the lungs
and maintains the lungs at a pressure slightly below that of the atmosphere when the lungs are at rest. This results in air following the pressure
gradient and passively filling the lungs at rest. As the lungs fill with air, the pressure within the lungs rises until it matches the atmospheric pressure.
At this point, more air can be inhaled by the contraction of the diaphragm and the external intercostal muscles, increasing the volume of the thorax
and reducing the pressure of the lungs below that of the atmosphere again. To exhale air, the diaphragm and external intercostal muscles relax while
the internal intercostal muscles contract to reduce the volume of the thorax and increase the pressure within the thoracic cavity. The pressure
gradient is now reversed, resulting in the exhalation of air until the pressures inside the lungs and outside of the body are equal. At this point, the
elastic nature of the lungs causes them to recoil back to their resting volume, restoring the negative pressure gradient present during inhalation
(Taylor, n.d.).

External Respiration
External respiration is the exchange of gases between the air filling the alveoli and the blood in the capillaries surrounding the walls of the
alveoli. Air entering the lungs from the atmosphere has a higher partial pressure of oxygen and a lower partial pressure of carbon dioxide than does
the blood in the capillaries. The difference in partial pressures causes the gases to diffuse passively along their pressure gradients from high to low
pressure through the simple squamous epithelium lining of the alveoli. The net result of external respiration is the movement of oxygen from the air
into the blood and the movement of carbon dioxide from the blood into the air. The oxygen can then be transported to the body’s tissues while carbon
dioxide is released into the atmosphere during exhalation (Taylor, n.d.).

Internal Respiration
Internal respiration is the exchange of gases between the blood in capillaries and the tissues of the body. Capillary blood has a higher partial
pressure of oxygen and a lower partial pressure of carbon dioxide than the tissues through which it passes. The difference in partial pressures leads
to the diffusion of gases along their pressure gradients from high to low pressure through the endothelium lining of the capillaries. The net result of
internal respiration is the diffusion of oxygen into the tissues and the diffusion of carbon dioxide into the blood (Taylor, n.d.).

Transportation of Gases
The 2 major respiratory gases, oxygen and carbon dioxide, are transported through the body in the blood. Blood plasma has the ability to
transport some dissolved oxygen and carbon dioxide, but most of the gases transported in the blood are bonded to transport molecules. Hemoglobin
is an important transport molecule found in red blood cells that carries almost 99% of the oxygen in the blood. Hemoglobin can also carry a small
amount of carbon dioxide from the tissues back to the lungs. However, the vast majority of carbon dioxide is carried in the plasma as bicarbonate ion.
When the partial pressure of carbon dioxide is high in the tissues, the enzyme carbonic anhydrase catalyzes a reaction between carbon dioxide and
water to form carbonic acid. Carbonic acid then dissociates into hydrogen ion and bicarbonate ion. When the partial pressure of carbon dioxide is low
in the lungs, the reactions reverse and carbon dioxide is liberated into the lungs to be exhaled (Taylor, n.d.).

Homeostatic Control of Respiration

Under normal resting conditions, the body maintains a quiet breathing rate and depth called eupnea. Eupnea is maintained until the body’s
demand for oxygen and production of carbon dioxide rises due to greater exertion. Autonomic chemoreceptors in the body monitor the partial
pressures of oxygen and carbon dioxide in the blood and send signals to the respiratory center of the brain stem. The respiratory center then adjusts
the rate and depth of breathing to return the blood to its normal levels of gas partial pressures (Taylor, n.d.).
 PERIPHERAL SYSTEM

The peripheral nervous system refers to parts of the nervous system outside the brain and spinal cord.
It includes the cranial nerves, spinal nerves and their roots and branches, peripheral nerves, and
neuromuscular junctions. The anterior horn cells, although technically part of the central nervous system
(CNS), are sometimes discussed with the peripheral nervous system because they are part of the motor unit.
In the peripheral nervous system, bundles of nerve fibers or axons conduct information to and from the
central nervous system. The autonomic nervous system is the part of the nervous system concerned with the
innervation of involuntary structures, such as the heart, smooth muscle, and glands within the body. It is
distributed throughout the central and peripheral nervous systems (Jasvinder Chawla, 2016).

Subdivisions of the peripheral nervous system

The sensory (afferent) division carries sensory signals by way of afferent nerve fibers from receptors in
the central nervous system (CNS). It can be further subdivided into somatic and visceral divisions. The
somatic sensory division carries signals from receptors in the skin, muscles, bones and joints. The visceral
sensory division carries signals mainly from the viscera of the thoracic and abdominal cavities. The motor
(efferent) division carries motor signals by way of efferent nerve fibers from the CNS to effectors (mainly
glands and muscles). It can be further subdivided into somatic and visceral divisions. The somatic motor
division carries signals to the skeletal muscles. The visceral motor division, also known as the autonomic
nervous system, carries signals to glands, cardiac muscle, and smooth muscle. It can be further divided into
the sympathetic and parasympathetic divisions. The sympathetic division tends to arouse the body to action.
The parasympathetic divisions tend to have a calming effect. Nerve fibers of the PNS are classified according
to their involvement in motor or sensory, somatic or visceral pathways. Mixed nerves contain both motor and
sensory fibers. Sensory nerves contain mostly sensory fibers; they are less common and include the optic and
olfactory nerves. Motor nerves contain motor fibers (Jasvinder Chawla, 2016).

Anatomy of nerves and ganglia

A nerve is an organ composed of multiple nerve fibers bound together by sheaths of connective tissue.
The sheath adjacent to the neurilemma is the endoneurium, which houses blood capillaries that feed nutrients
and oxygen to the nerve. In large nerves, fibers are bundled into fascicles and wrapped in a fibrous
perineurium. The entire nerve is covered with a fibrous epineurium. A ganglion is a cluster of neuron cell
bodies enveloped in an epineurium continuous with that of a nerve. A ganglion appears as a swelling along
the course of a nerve. The spinal ganglia or posterior or dorsal root ganglia associated with the spinal nerves contain the unipolar neurons of the
sensory nerve fibers that carry signals to the cord. The fiber passes through the ganglion without synapsing. However, in the autonomic nervous
system, a preganglionic fiber enters the ganglion and in many cases synapses with another neuron. The axon of the second neuron leaves the
ganglion as the postganglionic fiber (Jasvinder Chawla, 2016).

Cranial nerves
The cranial nerves emerge from the base of the brain and lead to muscles and sense organs in the head and neck for the most part. The
twelve pairs of cranial nerves with their functions are as follows:
 Olfactory nerve (I): Sensory nerve that carries impulses for smell to the brain.
 Optic nerve (II): Sensory nerve that carries impulses for vision to the brain.
 Oculomotor nerve (III): Motor nerve that carries impulses to the extrinsic eye muscles, which help direct the position of the eyeball. This nerve
also carries impulses to the muscles that regulate the size of the pupil.
 Trochlear nerve (IV): Motor nerve that carries impulses to one extrinsic eye muscle (the superior oblique muscle). Once again, this muscle
helps regulate the position of the eyeball.
 Trigeminal nerve (V): A mixed nerve. The sensory fibers of this nerve carry impulses for general sensation (touch, temperature and pain)
associated with the face, teeth, lips and eyelids. The motor fibers of this nerve carry impulses to some of the mastication muscles of the face.
 Abducens nerve (VI): A mixed nerve, but primarily a motor nerve. This nerve carries impulses to the lateral rectus muscle of the eye. This
muscle is an extrinsic eye muscle that is involved in positioning the eyeball.
 Facial nerve (VII): A mixed nerve. The sensory fibers of this nerve carry taste sensations from the tongue. The motor fibers of this nerve carry
impulses to many of the muscles of the face and they carry impulses to the lacrimal, submandibular, and sublingual glands.
 Vestibulocochlear nerve (VIII): A sensory nerve that carries impulses for hearing and equilibrium from the ear to the brain.
 Glossopharyngeal nerve (IX): A mixed nerve. The sensory fibers of this nerve carry basic sensory information and taste sensations from the
pharynx and tongue to the brain. The motor fibers of this nerve carry impulses associated with swallowing to the pharynx.
 Vagus nerve (X): A mixed nerve. The sensory fibers of this nerve carry impulses from the pharynx, larynx, and most internal organs to the
brain. The motor fibers of this nerve carry impulses to internal organs of the chest and abdomen and to the skeletal muscles of the larynx and
pharynx.
 Accessory nerve (XI): A mixed nerve, but primarily motor. Carries impulses to muscles of the neck and back.
 Hypoglossal nerve (XII): Primarily a motor nerve. This nerve carries impulses to the muscles that move and position the tongue.
(Jasvinder Chawla, 2016)
Spinal nerves
Thirty one pairs of spinal nerves exist: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal.
 Proximal branches: Each spinal nerve branches into a posterior root and an anterior root. The spinal or posterior root ganglion is occupied by
cell bodies from afferent neurons. The convergence of posterior and anterior roots forms the spinal nerve. The cauda equina is formed by the
roots arising from segments L2 to Co of the spinal cord.
 Distal branches: After emerging from the vertebral column, the spinal nerve divides into a posterior ramus, an anterior ramus, and a small
meningeal branch that leads to the meninges and vertebral column. The posterior ramus innervates the muscles and joints of the spine and
the skin of the back. The anterior ramus innervates the anterior and lateral skin and muscles of the trunk, plus gives rise to nerves leading to
the limbs (see image below).
 Click to see the PDF chart: Nerve and nerve root distribution of major muscles.
 Nerve plexuses: The anterior rami merge to form nerve plexuses in all areas except the thoracic region (see the image below).
 Cutaneous innervation and dermatomes: Each spinal nerve except C1 receives sensory input from a specific area of the skin called a
dermatome. A dermatome map is a diagram of the cutaneous regions innervated by the branches of each spinal nerve, such a map is an
oversimplification, however – each of you is unique as to what you feel.
(Jasvinder Chawla, 2016)

Autonomic nervous system

The visceral reflexes are mediated by the autonomic nervous system (ANS), which has two divisions (sympathetic and parasympathetic). The
target organs of the ANS are glands, cardiac muscle, and smooth muscle: it operates to maintain homeostasis. Control over the ANS is, for the most
part, involuntary. The ANS differs structurally from the somatic nervous system in that 2 neurons leading from the ANS to the effector exist, a
preganglionic neuron and a postganglionic neuron (Jasvinder Chawla, 2016).
Anatomy of the sympathetic division: The sympathetic division is also called the thoracolumbar division because of the spinal nerve it uses.
Paravertebral ganglia occur close to the vertebral column. Preganglionic ganglia are short, while postganglionic neurons, traveling to their effector,
are long. When 1 preganglionic neuron fires, it can excite multiple postganglionic fibers that lead to different target organs (mass activation). In the
thoracolumbar region, each paravertebral ganglion is connected to a spinal nerve by 2 communicating rami, the white communicating ramus and the
gray communicating ramus. Nerve fibers leave the paravertebral ganglia by gray rami communicantes and splanchnic nerves (Jasvinder Chawla,
2016).
 Anatomy of the parasympathetic division: The parasympathetic division is also referred to as the craniosacral division because its fibers travel
in some cranial nerves (III, VII, IX, X) and sacral nerves (S2-4). The parasympathetic ganglia (terminal ganglia) lie in or near the target
organs. The parasympathetic fibers leave the brainstem by way of the oculomotor, facial, glossopharyngeal, and vagus nerves. The
parasympathetic system uses long preganglionic and short postganglionic fibers (Jasvinder Chawla, 2016).
 REVIEW OF RELATED LITERATURE

Congestive Heart Failure

The term congestive heart failure (CHF) is used in interchangeably with the term heart failure; they both indicate the same condition. Heart
failure is a condition that results from the inability of the heart to pump blood effectively to the rest of the body or the heart requires a higher filling
pressure in order to pump effectively. Put simply, heart failure means that your heart can't pump enough blood to keep all the your body's tissues and
organs working properly. It is important to note that the definition of congestive heart failure does not identify any particular problem with the heart or
blood vessels. That is because the heart itself is not a disease, but develops as a result of other conditions that damage the heart (Quinn, 2006).

CHF usually proceeds progressively, and the heart does not necessarily stop beating until it is severely damaged. Four out of five people over
age 65 with this condition will survive long than one year (Teichroew, 2016).

Type of heart failure Description

 Left-sided heart failure Fluid may back up in your lungs, causing shortness of breath.
 Right-sided heart failure Fluid may back up into your abdomen, legs and feet, causing swelling.
 Systolic heart failure the left ventricle can't contract vigorously, indicating a pumping problem.
 Diastolic heart failure The left ventricle can't relax or fill fully, indicating a filling problem.
(University of Maryland Medical Center, 2017)

Hallmarks of Heart Failure

Fluid Congestion
If the heart becomes less efficient as a pump, the body will try to compensate for it. One way it attempts to do this is by using hormones and
nerve signals to increase blood volume (by water retention in the kidneys). A drop in blood flow to the kidneys will also lead to fluid retention. Blood
and fluid pressure backed up behind the heart result in excess salt water entering the lungs and other body tissues. However, it is important to note
that not all swelling due to fluid retention is a reflection of heart failure. Clinical symptoms due to fluid congestion:
 shortness of breath
 edema (pooling of fluid in lungs and body)
(Gibson, Ortiz & Jaski, 2013)
Reduced Blood Flow to the Body
The heart’s inability to pump blood to the muscles and organs isn’t always apparent in early stages of heart failure. Often times, it is unmasked
only during increases in physical activity. In advanced heart failure, many tissues and organs may not even receive the oxygen they require for
functioning at rest. Clinical symptoms due to poor blood flow to the body:
 difficulty exercising
 fatigue
 dizziness (due to low blood pressure)
(Gibson, Ortiz & Jaski, 2013)

Common Signs and Symptoms of Heart Failure include:

 Fatigue
 Shortness of breath
 Wheezing or cough
 Fluid retention and weight gain
 Loss of appetite
 Abnormally fast or slow heart rate
(University of Maryland Medical Center, 2017)

Warning Signs and Symptoms

a. Shortness of breath (also called dyspnea) - breathlessness during activity (most commonly), at rest, or while sleeping, which may come on
suddenly and wake you up. You often have difficulty breathing while lying flat and may need to prop up the upper body and head on two
pillows. You often complain of waking up tired or feeling anxious and restless.
b. Persistent coughing or wheezing - coughing that produces white or pink blood-tinged mucus.
c. Buildup of excess fluid in body tissues (edema) - swelling in the feet, ankles, legs or abdomen or weight gain. You may find that your
shoes feel tight.
d. Tiredness, fatigue - a tired feeling all the time and difficulty with everyday activities, such as shopping, climbing stairs, carrying groceries or
walking.
e. Lack of appetite, nausea - a feeling of being full or sick to your stomach.
f. Confusion, impaired thinking - memory loss and feelings of disorientation. A caregiver or relative may notice this first.
g. Increased heart rate - heart palpitations, which feel like your heart is racing or throbbing.
(Anonymous, Heart.org, 2017)
Causes
Congestive heart failure often occurs after other conditions have damaged or weakened the heart. These conditions include high blood
pressure and coronary artery disease. Other risk factors include the presence of faulty heart valves and diseases or infections that cause damage to
the heart muscle such as weakness or stiffening, heart defects, and abnormalities in the heartbeat. Other diseases associated with heart failure
include diabetes, kidney conditions, HIV/AIDS, and alcoholism. Illnesses associated with heart failure are pneumonia, anemia, or hyperthyroidism,
which place extra strains on a heart that is already failing (Teichroew, 2016).

Risk factor

Who Is At Risk?
In some ways we are all at risk, especially as we age. That’s one reason it’s so important to develop heart-healthy habits earlier in life
(Anonymous, Heart.org, 2017)

HF By the Numbers
 Likelihood: Of all adults age 40 and above, 1 in 5 Americans will develop heart failure in their lifetime.
 Number of People: Today, over six million Americans are living with HF and the number is predicted to rise by 46% percent over the next
fifteen years to an estimate of almost eight million Americans by 2030.
 Risk Factors: Certain conditions like high blood pressure increase the risks for eventual heart failure. It is important to note that one out of
every three American adults has high blood pressure.
(Anonymous, Heart.org, 2017)

About 5.7 million people in the United States have heart failure. The number of people who have this condition is growing.
Heart failure is more common in:
 People who are age 65 or older. Aging can weaken the heart muscle. Older people also may have had diseases for many years that led to
heart failure. Heart failure is a leading cause of hospital stays among people on Medicare.
 Blacks are more likely to have heart failure than people of other races. They’re also more likely to have symptoms at a younger age, have
more hospital visits due to heart failure, and die from heart failure.
 People who are overweight. Excess weight puts strain on the heart. Being overweight also increases your risk of heart disease and type
2 diabetes. These diseases can lead to heart failure.
 People who have had a heart attack. Damage to the heart muscle from a heart attack and can weaken the heart muscle.
 Children who have congenital heart defects also can develop heart failure. These defects occur if the heart, heart valves, or blood vessels
near the heart don’t form correctly while a baby is in the womb. Congenital heart defects can make the heart work harder. This weakens the heart
muscle, which can lead to heart failure. Children don’t have the same symptoms of heart failure or get the same treatments as adults (NHLBI, 2015).

Complications
Nearly 290,000 people die from heart failure each year. Nevertheless, although heart failure produces very high mortality rates, treatment
advances are improving survival rates (University of Maryland Medical Center, 2017).

Cardiac Cachexia
If patients with heart failure are overweight to begin with, their condition tends to be more severe. Once heart failure develops, however, an
important indicator of a worsening condition is the occurrence of cardiac cachexia, which is unintentional rapid weight loss (a loss of at least 7.5% of
normal weight within 6 months).
(University of Maryland Medical Center, 2017).

Impaired Kidney Function

Heart failure weakens the heart’s ability to pump blood. This can affect other parts of the body including the kidneys (which in turn can lead to
fluid build-up). Decreased kidney function is common in patients with heart failure, both as a complication of heart failure and other diseases
associated with heart failure (such as diabetes). Studies suggest that, in patients with heart failure, impaired kidney function increases the risks for
heart complications, including hospitalization and death (University of Maryland Medical Center, 2017).

Congestion (Fluid Buildup)

In left-sided heart failure, fluid builds up first in the lungs, a condition called pulmonary edema. Later, as right-sided heart failure develops, fluid
builds up in the legs, feet, and abdomen. Fluid buildup is treated with lifestyle measures, such as reducing salt in the diet, as well as drugs, such as
diuretics (University of Maryland Medical Center, 2017).

Arrhythmias (Irregular Beatings of the Heart)

Atrial fibrillation
- is a rapid quivering beat in the upper chambers of the heart. It is a major cause of stroke and very dangerous in people with heart failure.
Left bundle-branch block
- is an abnormality in electrical conduction in the heart. It develops in about 30% of patients with heart failure.
Ventricular tachycardia and ventricular fibrillation
- are life-threatening arrhythmias that can occur in patients when heart function is significantly impaired.
Angina and Heart Attacks.
 - While coronary artery disease is a major cause of heart failure, patients with heart failure are at continued risk for angina and heart attacks.
Special care should be taken with sudden and strenuous exertion, particularly snow shoveling, during colder months (University of Maryland
Medical Center, 2017).

Diagnosis
Doctors can often make a preliminary diagnosis of heart failure by medical history and careful physical examination.
A thorough medical history may identify risks for heart failure that include:
 High blood pressure
 Diabetes
 Abnormal cholesterol levels
 Heart disease or history of heart attack
 Thyroid problems
 Obesity
 Lifestyle factors (such as smoking, alcohol use, and drug use)
The following physical signs, along with medical history, strongly suggest heart failure:
 Enlarged heart
 Abnormal heart sounds
 Abnormal sounds in the lungs
 Swelling or tenderness of the liver
 Fluid retention in legs and abdomen
 Elevation of pressure in the veins of the neck
(University of Maryland Medical Center, 2017).

Laboratory Tests
Both blood and urine tests are used to check for problems with the liver and kidneys and to detect signs of diabetes. Lab tests can measure:
 Complete blood counts to check for anemia
 Kidney function blood and urine tests
 Sodium, potassium, and other electrolytes
 Cholesterol and lipid levels
 Blood sugar (glucose)
 Thyroid function
 Brain natriuretic peptide (BNP), a hormone that increases during heart failure. BNP testing can be very helpful in correctly diagnosing heart
failure in patients who come to the emergency room complaining of shortness of breath (dyspnea).
 (University of Maryland Medical Center, 2017).

Electrocardiogram
An electrocardiogram (ECG) is a test that measures and records the electrical activity of the heart. It is also called an EKG. An electrocardiogram
cannot diagnose heart failure, but it may indicate underlying heart problems. The test is simple and painless to perform. It may be used to diagnose:
 Previous heart attack
 Abnormal cardiac rhythms
 Enlargement of the heart muscle, which may help to determine long-term outlook
 A finding called a prolonged QT interval may indicate people with heart failure who are at risk for severe complications and therefore need more
aggressive therapies.
A completely normal ECG means that heart failure is unlikely.
(University of Maryland Medical Center, 2017).

Echocardiography
The best diagnostic test for heart failure is echocardiography. Echocardiography is a noninvasive test that uses ultrasound to image the heart as it is
beating. Cardiac ultrasounds provide the following information:
 Evaluations of valve function
 Information about how well the heart is pumping, especially a measurement called left ventricle ejection fraction (LVEF)
 Type of heart failure
 Changes in the structure of the heart that may be a result of heart failure
Doctors use information from the echocardiogram for calculating the ejection fraction (how much blood is pumped out during each heartbeat), which
is important for determining the severity of heart failure. Stress echocardiography may be needed if coronary artery disease is suspected.
(University of Maryland Medical Center, 2017).

Angiography
Doctors may recommend angiography if they suspect that blockage of the coronary arteries is contributing to heart failure. This procedure is
invasive.
 A thin tube called a catheter is inserted into one of the large arteries in the arm or leg.
 It is gently guided through the artery until it reaches the heart.
 The catheter measures internal blood pressure at various locations, giving the doctor a comprehensive picture of the extent and nature of the
heart failure.
 Dye is then injected through the tube into the heart.
 X-rays called angiograms are taken as the dye moves through the heart and arteries.
  These images help locate problems in the heart's pumping action or blockage in the arteries.
(University of Maryland Medical Center, 2017).

Radionuclide Ventriculography
an imaging technique that uses a tiny amount of radioactive material (called a trace element). It is very sensitive in revealing heart
enlargement or evidence of fluid accumulation around the heart and lungs. It may be done at the same time as coronary artery angiography. It can
help diagnose or exclude the presence of coronary artery disease and helps demonstrate how the heart works during exercise (University of
Maryland Medical Center, 2017).

Other Imaging Tests

Chest x-rays can show whether the heart is enlarged. Computed tomography (CT) and magnetic resonance imaging (MRI) may also be used
to evaluate the heart valves and arteries (University of Maryland Medical Center, 2017).

Exercise Stress Test

The exercise stress test measures heart rate, blood pressure, electrocardiographic changes, and oxygen consumption while a patient is
performing physically, usually walking on a treadmill. It can help determine heart failure symptoms. Doctors also use exercise tests to evaluate long-
term outlook and the effects of particular treatments. A stress test may be done using echocardiography or may be done as a nuclear stress test
(myocardial perfusion imaging).

(University of Maryland Medical Center, 2017)

Treatment and Medications

Although heart failure produces extremely high mortality rates, specific treatments, particularly beta—blockers and devices that stabilize heart
rhythms, are now dramatically improving survival rates in patients with severe heart failure (Quinn, 2006).
Treatment for heart failure depends on its severity. All patients need dietary salt restriction and other lifestyle adjustments, medication, and
monitoring. Patients with very weakened hearts may need implanted devices (such as pacemakers, implantable cardiac defibrillators, or devices that
help the heart pump blood) or surgery, including heart transplantation (University of Maryland Medical Center, 2017).
Doctors usually treat heart failure, and the underlying conditions that cause it, with a combination of medications. These medications include:
a. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs)
b. Beta blockers
c. Diuretics
d. Aldosterone blockers
 e. Digitalis
f. Hydralazine or nitrates
Other medications that may be helpful include:
a. Statins
b. Aspirin and Warfarin
(University of Maryland Medical Center, 2017)

Nursing Management
Patient care management goal: to treat the underlying or precipitating factors and to reduce cardiac work load.
1. Provide oxygen to relieve ischemia at a flow rate based on institutional policy and the patient’s condition.
2. Assess and document continuous ECG rhythm, vital signs, mental status, heart and lung sounds, urine output, and any signs or symptoms
indicating changes in these parameters.
3. Maintain activity restrictions based on the patient’s activity tolerance to reduce myocardial oxygen demands.
4. Administer I.V. morphine in small doses to decrease venous return, preload, myocardial oxygen consumption ,pain, and anxiety.
5. Begin diuretics to decrease preload and blood volume.
6. Start digitalis to increase contractility and decrease heart rate.
7. Consider vasopressors to increase contractility and support blood pressure.
8. Use nitrates to decrease preload and pulmonary and cardiac congestion.
9. Use afterload-reducing agents to decrease SVR and to aid ventricular ejection.
10. If a pulmonary artery catheter is in place ,assess and document PAP,PAWP, cardiac output, and SVR, as ordered.
11. Provide patient education, and ensure that the patient can recognize signs and symptoms necessitating medical attention (e,g,, increased
shortness of breath, weight gain, decreased activity tolerance, or change in pulse rate or rhythm) and that he or she understands dietary
restrictions.
12. Refer the family to appropriate sources for CPR training.
13. Ensure that the family can activate the emergency medical system if any problems occur at home.
(Anonymous, 2010)
 Hypertensive Cardiovascular Disease
Hypertensive Cardiovascular problem is a medical term for enlargement of the heart, heart failure and coronary artery problem that results
from high blood pressure (Forte, n.d.).

What Causes Hypertensive Cardiovascular problem?

High blood pressure is the major contributor to hypertensive cardiovascular problem. When blood pressure increases, it places pressure on
blood vessels. This causes the heart to have to pump harder, which overtime affects the heart muscle causing it to enlarge. High blood pressure can
also cause stroke and heart problem due to the increased amount of oxygen that is needed by the heart. It also contributes to blood vessel walls
thickening, which can worsen atherosclerosis, increasing the risks of stroke and heart attacks (Forte, n.d.).

What Are The Complications If Not Treated?

When left untreated hypertensive cardiovascular problem can cause angina, heart attack, stroke, heart failure, arrhythmias and sudden death
(Forte, n.d.).

How Do I Prevent Hypertensive Cardiovascular problem?

Preventive measures can be taken to help lower the risks of developing this problem. Regular monitoring of blood pressure along with
treatment if necessary is recommended as well as exercising regularly and eating a healthy diet. Excessive alcohol consumption should be avoided
as well as cigarette smoking. Maintaining proper weight is also important to reduce the risks of developing hypertensive cardiovascular problem
(Forte, n.d.).
 Cardiomegaly
Cardiomegaly means an enlarged heart. Mild cardiomegaly refers to less severe forms. This is a sign of another heart-related condition. You
may not know you have an enlarged heart unless you undergo imaging tests or have symptoms of the underlying condition. The earlier the
underlying cause is detected, the better the outcome. Keep reading to learn more about mild cardiomegaly (Cherney, 2017).

Symptoms of mild cardiomegaly

Mild cardiomegaly usually doesn’t cause any noticeable symptoms. Symptoms usually don’t appear unless cardiomegaly becomes moderate or
severe. These symptoms could include:
 abdominal bloating
 abnormal heart rhythms, known as arrhythmia
 chest pain
 coughing, especially when lying down
 dizziness
 fatigue
 shortness of breath
 swelling, or edema, especially in the ankles, feet, and legs (Cherney, 2017).

Causes
Mild cardiomegaly is caused by either ventricular hypertrophy or ventricular dilation (Cherney, 2017).

Risk Factors
You have a higher risk for cardiomegaly if you are at risk for heart-related diseases. Risk factors include:
 a family history of heart disease
 a sedentary lifestyle
 hypertension
 diabetes
 obesity
 history of alcohol or drug abuse
 having a metabolic disorder, such as thyroid disease (Cherney, 2017).

Diagnostics
Imaging tests are the best way to detect an enlarged heart. These measure your heart’s size, movement of blood throughout the chambers and
valves, and your heart’s electrical activity. Your doctor may order one or more of the following:
  echocardiogram
 chest X-ray
 CT scan
 electrocardiogram (EKG)
Once your doctor has diagnosed you with mild cardiomegaly, they’ll determine the underlying cause. Further testing might include:
 a full physical exam
 cardiac catheterization
 a stress test
 blood tests
(Cherney, 2017).

Treatment
For heart conditions, the preferred first line of treatment is medication. Your doctor may recommend different medications for the following:
 atrial fibrillation: antiarrhythmic drugs and blood thinners
 heart valve disease or hypertension: diuretics, alpha- or beta-blockers, ACE inhibitors, or calcium channel blockers, which all work together
to reduce stress on the heart by relaxing blood vessels and reducing excess pumping action
 anemia: iron supplements
In the case of hemochromatosis, instead of medications, phlebotomy (blood removal) is performed to get rid of excess iron (Cherney, 2017).
 MEDICAL MANAGEMENT

Laboratory Exams and Correlation

DATE LABORATORY EXAMS RESULT NORMAL CORRELATION

VALUES

9/7/17 Immuno Chemistry

Cardiac Markers:

Troponin T 120.5 pg/ml 0-14 pg/ml Troponin T is a myofibrillar protein found in striated musculature. A high
troponin and even slight elevations may indicate some degree of
damage to the heart. For my patient's case, his troponin T level
dramatically elevated because of his heart problem.

NOPH Blood Chemistry

Sample type: Serum

Assays:
Uric acid is produced from the natural breakdown of your body's cells
Uric Acid 10.7 mg/dl 3.6 -7.7 mg/dl and from the foods you eat. Increased uric acid serum levels are a
common finding in patients with high blood pressure, insulin resistance,
obesity and CV disease. Relating to the high uric level of my patient, he
is hypertensive and has a cardiovascular disease also, as he is
diagnosed by the doctor as having HCVD and CHF.
K+ 3.27 mmol/L 3.5-5.3 mmol/L "Hypokalemia, or low potassium, is common in heart-failure patients and
is associated with poor outcomes, as is chronic kidney disease," said C.
Barrett Bowling, M.D., a fellow in the UAB Division of Gerontology,
Geriatrics and Palliative Care (University of Alabama at Birmingham,
2010). Having a heart problem, my patient has a low potassium level as
an effect of having congestive heart failure.

Na+ 128.2 mmol/L 135-148 mmol/L Like most other causes of hyponatremia, heart failure impairs the ability
to excrete ingested water by increasing antidiuretic hormone levels.
When cardiac output and systemic blood pressure are reduced,
"hypovolemic" hormones, such as renin (with a subsequent increase in
angiotensin II formation), antidiuretic hormone (ADH), and
norepinephrine, respond (Uptodate, n.d.). Patients with low potassium
levels may manifest body weakness and confusion. For my patient's
case, he arrived in the ER experiencing weakness and confusion as
claimed by patient’s mother. Assessing his neurological status on duty
day, patient was generally weak and confused, not aware of his
surroundings as he appeared restless too.

TREATMENT MODALITIES
 Date Time Doctor's Orders Rationale

9/7/2017 1 PM  Admit under my care – Dr. Saad  To be cared and monitored

 V/S every four hours  To monitor vital sign abnormalities
 Chest Xray, Immuno Chemistry, Blood  The tests help rule out the possible causes of the disease condition
Chem. through the results. Troponin T needs to be checked to monitor the
heart's condition.
 Start PLR 1L 10 gtt/min  To hydrate patient during his admission in the hospital
 Soft Diet  For easier chewing and swallowing of food
 O2 therapy at 2L/min  Aids with patient's shortness of breath
 Attach FBC  To conserve patient's energy in going to the CR as he has SOB
 Captopril 25mg 1 tab 5L PRN q6h > 160/80  Captopril aids the patient's hypertension
mmHg
 Furosemide 20mg IVTT q8h  Furosemide helps with the edema of lower extremities associated with
CHF
 Potassium Chloride 10mg 1 tab TID  Replenishes the patient's low blood potassium level

 Omeprazole 40mg IVTT OD  Aids with the reduction of the production of stomach acid

 Febuxostat 40mg 1 tab OD  Helps with the patient's high uric acid level
9/8/17 8 AM  Furosemide 20mg IVTT q8h c BP prec.
 Captopril 25mg 1 tab 5L PRN q6h > 160/80
mmHg
 Perindopril 5mg 1 tab OD
 Carvidelol 6.25mg 1 tab OD
 Omeprazole 40mg IVTT OD
 Enoxaparin 0.4 q12h
 Febuxostat 40mg 1 tab OD 8pm
 Potassium Chloride 10mg 1 tab TID
9/9/17 8 AM  Omeprazole 40mg IVTT OD
 Perindopril 5mg 1 tab OD
 Carvedilol 6.25mg 1 tab OD
 Captopril 25mg 1 tab 5L PRN q6h > 160/80
mmHg
 Furosemide 20mg IVTT q8h
 Furosemide helps with the edema of lower extremities associated with
CHF
 Captopril aids the patient's hypertension
 Perindopril is used to treat hypertension and CHF
 Carvidelol is used to treat mild to severe CHF
 Aids with the reduction of the production of stomach acid
 Helps with preventing complications concerning the heart such as heart
attacks
 Helps with the patient's high uric acid level
 Replenishes the patient's low blood potassium level

 Aids with the reduction of the production of stomach acid
 Perindopril is used to treat hypertension and CHF
 Carvidelol is used to treat mild to severe CHF
 Captopril aids the patient's hypertension
 Furosemide helps with the edema of lower extremities associated with
CHF
 DRUG STUDY

Furosemide 20mg IVTT q8h c BP prec.

Generic name: Furosemide

Brand name: Lasix
Drug classification: Loop Diuretic
Mechanism of action: Furosemide inhibits reabsorption of Na and chloride mainly in the medullary portion of the ascending Loop of Henle.
Excretion of potassium and ammonia is also increased while uric acid excretion is reduced. It increases plasma-renin levels and secondary
hyperaldosteronism may result. Furosemide reduces BP in hypertensives as well as in normotensives. It also reduces pulmonary oedema before
diuresis has set in.
Indication: Edema associated with CHF, Acute Pulmonary edema, Hypertension, Cirrhosis
Side effects: Fluid and electrolyte imbalance, Rashes, photosensitivity, nausea, diarrhoea, blurred vision, dizziness, headache, hypotension. Bone
marrow depression (rare), hepatic dysfunction. Hyperglycaemia, glycosuria, ototoxicity. Potentially Fatal: Rarely, sudden death and cardiac arrest.
Hypokalaemia and magnesiumdepletion can cause cardiac arrhythmias.
Contraindication: Severe sodium and water depletion, hypersensitivity to sulphonamides and furosemide, hypokalaemia, hyponatraemia, pre-
comatose states associated with liver cirrhosis, anuria or renal failure. Addison’s disease.
Nursing Responsibilities:
 Reduce dosage if given with other antihypertensives; readjust dosage gradually as BP responds.
 Administer with food or milk to prevent GI upset.
 Give early in the day so that increased urination will not disturb sleep.
 Avoid IV use if oral use is at all possible.
 WARNING: Do not mix parenteral solution with highly acidic solutions with pH below 3.5.
 Do not expose to light, may discolor tablets or solution; do not use discolored drug or solutions.
 Discard diluted solution after 24 hr.
 Refrigerate oral solution.
 Measure and record weight to monitor fluid changes.
 Arrange to monitor serum electrolytes, hydration, liver and renal function.
 Arrange for potassium-rich diet or supplemental potassium as needed.
(Vera, 2011)
Captopril 25mg 1 tab 5L PRN q6h > 160/80 mmHg

Generic name: Captopril

Brand name: Capoten
Drug classification: ACE inhibitor, Antihypertensive
Mechanism of action: Captopril competitively inhibits the conversion of angiotensin I (ATI) to angiotensin II (ATII), thus resulting in reduced ATII
levels and aldosterone secretion. It also increases plasmarenin activity and bradykinin levels. Reduction of ATII leads to decreased sodium and water
retention. By these mechanisms, captopril produces a hypotensive effect and a beneficial effect in congestive heart failure.
Indication: Treatment of hypertension alone or in combination with thiazide-type diuretics; Treatment of CHF in patients unresponsive to
conventional therapy, used with diuretics and digitalis; Treatment of diabetic nephropathy; Treatment of left ventricular dysfunction after MI
Side effects: Hypotension, tachycardia, chest pain, palpitations, pruritus, hyperkalemia. Proteinuria; angioedema, skin rashes; taste disturbance,
nonproductive cough, headache; Potentially Fatal: Neutropenia, usually occurs within 3 mth of starting therapy especially in patients with renal
dysfunction or collagen diseases. Hyperkalaemia. Anaphylactic reactions.
Contraindication: Known hypersensitivity to the drug. Bilateral renal artery stenosis, hereditary angioedema; renal impairment; pregnancy.
Nursing Responsibilities:
 Administer 1 hr before meals.
 WARNING: Alert surgeon and mark patient’s chart with notice that captoprilis being taken; the angiotensin II formation subsequent to
compensatory renin release during surgery will be blocked; hypotension may be reversed with volume expansion.
 WARNING: Ensure that patient is not pregnant before beginning treatment. Encourage use of contraceptives; if pregnancy is detected, stop
drug.
 Monitor patient closely for fall in BP secondary to reduction in fluid volume (due to excessive perspiration, and dehydration, vomiting,
or diarrhea); excessive hypotension may occur.
 Reduce dosage in patients with impaired renal function.
(Vera, 2011)
Perindopril 5mg 1 tab OD

Generic name: Perindopril Erbumine

Brand name: Aceone
Drug classification: ACE inhibitor, Cardiovascular agent, Antihypertensive
Mechanism of action: Angiotensin-converting enzyme (ACE) inhibitor. ACE catalyzes the conversion of angiotensin I to angiotensin II, a
vasoconstrictor substance. Therefore, angiotensin II levels are decreased by perindopril, thus decreasing vasopressor activity and aldosterone
secretion.
Indication: Hypertension, CHF
Side effects: CNS: Dizziness, light-headedness (in the absence of postural hypotension), headache, mood and sleep disorders,
fatigue. CV: Palpitations. Endocrine: Hyperkalemia. GI: Nausea, vomiting, epigastric pain, diarrhea, taste disturbances,
dyspepsia. Urogenital: Proteinuria, impotence, sexual dysfunction. Special Senses: Dry eyes, blurred vision. Body as a Whole: Cough, angioedema,
pruritus, muscle cramps, sinusitis, hypertonia, fever. Skin: Rash.
Contraindication: Hypersensitivity to perindopril or any other ACE inhibitor; history of angioedema induced by an ACE inhibitor, pregnancy [category
C (first trimester), category D (second and third trimester)]; patients with hypertrophic cardiomyopathy, renal artery stenosis.
Nursing Responsibilities:
 Monitor BR and HR carefully following initial dose for several hours until stable, especially in patients using concurrent diuretics, on salt
restriction, or volume depleted.
 Place patient immediately in a supine position if excess hypotension develops.
 Monitor kidney function in patients with CHF closely.
 Monitor serum lithium levels and assess for S&S of lithium toxicity frequently when used concurrently; increased caution is needed when
diuretic therapy is also used.
(RobHolland, n.d.)
Carvidelol 6.25mg 1 tab OD

Generic name: Carvedilol

Brand name: Coreg, Kredex
Drug classification: Alpha and Beta Adrenergic Antagonist, ANS agent, Antihypertensive
Mechanism of action: Adrenergic receptor blocking agent that combines selective alpha activity and nonselective beta-adrenergic blocking actions.
Both activities contribute to blood pressure reduction. Peripheral vasodilatation and, therefore, decreased peripheral resistance results from alpha1-
blocking activity of Coreg. It is 3–5 times more potent than labetalol in lowering blood pressure.
Indication: Management of essential hypertension, CHF, in conjunction with other heart failure medications, left ventricular dysfunction post MI.
Side effects: Body as a Whole: Increased sweating, fatigue, chest pain, pain. CV: Bradycardia, hypotension, syncope, hypertension, angina.
GI: Diarrhea, nausea, abdominal pain, vomiting. Metabolic: Hyperglycemia, weight increase, gout. CNS: Dizziness, headache
Contraindication: Patients with class IV decompensate cardiac failure, bronchial asthma, or related bronchospastic conditions (e.g., chronic
bronchitis and emphysema), second- and third-degree AV block, cardiogenic shock or severe bradycardia; pregnancy (category C), lactation.
Nursing Responsibilities:
 Monitor for therapeutic effectiveness which is indicated by lessening of S&S of CHF and improved BP control.
 Monitor for worsening of symptoms in patients with PVD.
 Monitor digoxin levels with concurrent use; plasma digoxin concentration may increase.
(RobHolland, n.d.)
Omeprazole 40mg IVTT OD

Generic name: Omeprazole

Brand name: Losec, Prilosec, Prilosec OTC, Zegerid
Drug classification: PPI, GI agent
Mechanism of action: An antisecretory compound that is a gastric acid pump inhibitor. Suppresses gastric acid secretion by inhibiting the H+, K+-
ATPase enzyme system [the acid (proton H+) pump] in the parietal cells. It suppresses gastric acid secretion relieving gastrointestinal distress and
promoting ulcer healing.
Indication: Duodenal and gastric ulcer. Gastroesophageal reflux disease including severe erosive esophagitis (4 to 8 wk treatment). Long-term
treatment of pathologic hypersecretory conditions such as Zollinger-Ellison syndrome, multiple endocrine adenomas, and systemic mastocytosis. In
combination with clarithromycin to treat duodenal ulcers associated with Helicobacter pylori.
Side effects: CNS: Headache, dizziness, fatigue. GI: Diarrhea, abdominal pain, nausea, mild transient increases in liver function
tests. Urogenital: Hematuria, proteinuria. Skin: Rash.
Contraindication: Long-term use for gastroesophageal reflux disease (GERD), duodenal ulcers; proton pump inhibitors (PPIs), hypersensitivity;
children <2 y; use of OTC formulation in children <18 y or GI bleeding; pregnancy (category C); use of Zegerid in metabolic alkalosis, hypocalcemia,
vomiting, GI bleeding.

Nursing Responsibilities:

 Give before food, preferably breakfast; capsules must be swallowed whole (do not open, chew, or crush).
 Lab tests: Monitor urinalysis for hematuria and proteinuria. Periodic liver function tests with prolonged use.
 Instruct patient and family to report any changes in urinary elimination such as pain or discomfort associated with urination, or blood in urine;
Report severe diarrhea
(RobHolland, n.d.)
Enoxaparin 0.4 q12h

Generic name: Enoxaparin

Brand name: Lovenox
Drug classification: Anticoagulants; Low Molecular weight Heparin
Mechanism of action: Low molecular weight heparin with antithrombotic properties. Does not affect PT. Does affect thrombin time (TT) and
activated thromboplastin time (aPTT) up to 1.8 times the control value. Antithrombotic properties are due to its antifactor Xa and antithrombin
(antifactor IIa) in the coagulation activities. An effective anticoagulation agent; used for prophylactic treatment as an antithrombotic agent following
certain types of surgery.
Indication: Prevention of deep vein thrombosis (DVT) after hip, knee, or abdominal surgery, treatment of DVT and pulmonary embolism,
management of acute coronary syndrome.
Side effects: Body as a Whole: Allergic reactions (rash, urticaria), fever, angioedema arthralgia, pain and inflammation at injection site, peripheral
edema, arthralgia, fever. Digestive: Abnormal liver function tests. Hematologic: Hemorrhage , thrombocytopenia, ecchymoses,
anemia. Respiratory: Dyspnea. Skin: Rash, pruritus.
Contraindication: Patients with active major bleeding, GI bleeding, hemophilia, heparin hypersensitivity, heparin-induced thrombocytopenia (HIT),
thrombocytopenia associated with an antiplatelet antibody in the presence of enoxaparin, bleeding disorders, idiopathic thrombocytopenia purpura
(ITP), hypersensitivity to enoxaparin; porcine protein hypersensitivity, neonates.

Nursing Responsibilities:
 Lab tests: Baseline coagulation studies; periodic CBC, platelet count, urine and stool for occult blood.
 Monitor platelet count closely. Withhold drug and notify physician if platelet count less than 100,000/mm3.
 Monitor closely patients with renal insufficiency and older adults who are at higher risk for thrombocytopenia.
 Monitor for and report immediately any sign or symptom of unexplained bleeding.

(RobHolland, n.d.)
Febuxostat 40mg 1 tab OD 8pm

Generic name: Febuxostat

Brand name: Atenurix
Drug classification: Xanthine Oxidase inhibitor
Mechanism of action: Decreases serum uric acid by inhibiting xanthine oxidase.
Indication: Atenurix is a xanthine oxidase (XO) inhibitor indicated for the chronic management ofhyperuricemia in patients with gout. Atenurix is
not recommended for the treatment of asymptomatichyperuricemia.
Side effects: Dizziness, Rash, Nausea, Abnormal LFTs, Arthralgia
Contraindication: Coadministration with azathioprine, mercaptopurine, or theophylline.
Nursing Responsibilities:
 Instruct patients to contact health care provider if they experience chest pain, rash, shortness ofbreath, or neurologic symptoms suggesting a
stroke.
 Advise patients that product may be taken without regard to meals.
 Advise patient that concomitant prophylaxis with an NSAID or colchicine for gout flares may beused
(Barredo, n.d.)
Potassium Chloride 10mg 1 tab TID

Generic name: Potassium Chloride

Brand name: Kalium Durules, K-10, Apo-K, Klotrix, Rum-K
Drug classification: Electrolyte and Water balance agent; Replacement Solution
Mechanism of action: Principal intracellular cation; essential for maintenance of intracellular isotonicity, transmission of nerve impulses, contraction
of cardiac, skeletal, and smooth muscles, maintenance of normal kidney function, and for enzyme activity. Plays a prominent role in both formation
and correction of imbalances in acid–base metabolism.
Indication: To prevent and treat potassium deficit secondary to diuretic or corticosteroid therapy. Also indicated when potassium is depleted by
severe vomiting, diarrhea; intestinal drainage, fistulas, or malabsorption; prolonged diuresis, diabetic acidosis. Effective in the treatment of
hypokalemic alkalosis (chloride, not the gluconate).
Side effects: GI: Nausea, vomiting, diarrhea, abdominal distension. Body as a Whole: Pain, mental confusion, irritability, listlessness, paresthesias
of extremities, muscle weakness and heaviness of limbs, difficulty in swallowing, flaccid paralysis. Urogenital: Oliguria, anuria. Hematologic:
Hyperkalemia. Respiratory: Respiratory distress. CV: Hypotension, bradycardia; cardiac depression, arrhythmias, or arrest; altered sensitivity to
digitalis glycosides. ECG changes in hyperkalemia: Tenting (peaking) of T wave (especially in right precordial leads), lowering of R with deepening of
S waves and depression of RST; prolonged P-R interval, widened QRS complex, decreased amplitude and disappearance of P waves, prolonged Q-
T interval, signs of right and left bundle block, deterioration of QRS contour and finally ventricular fibrillation and death.
Contraindication: Severe renal impairment; severe hemolytic reactions; untreated Addison's disease; crush syndrome; early postoperative oliguria
(except during GI drainage); adynamic ileus; acute dehydration; heat cramps, hyperkalemia, patients receiving potassium-sparing diuretics, digitalis
intoxication with AV conduction disturbance.
Nursing Responsibilities:
 Monitor I&O ratio and pattern in patients receiving the parenteral drug. If oliguria occurs, stop infusion promptly and notify physician.
 Lab test: Frequent serum electrolytes are warranted.
 Monitor for and report signs of GI ulceration (esophageal or epigastric pain or hematemesis).
 Monitor patients receiving parenteral potassium closely with cardiac monitor. Irregular heartbeat is usually the earliest clinical indication of
hyperkalemia.
  Be alert for potassium intoxication (hyperkalemia, see S&S, Appendix F); may result from any therapeutic dosage, and the patient may be
asymptomatic.
 The risk of hyperkalemia with potassium supplement increases (1) in older adults because of decremental changes in kidney function
associated with aging, (2) when dietary intake of potassium suddenly increases, and (3) when kidney function is significantly compromised.
(RobHolland, n.d.)
 NURSING MANAGEMENT

Nursing History
A. Chief Complaints
“Ga lisod mn ni syag ginhawa lima na ka adlaw, kani iyang hupong sa iyang tiil ten days na”, as verbalized by patient’s mother.
B. Impression/Diagnosis
CHF 2’ Cardiomegaly 2’ HCVD
C. History of Present Illness
PTA, patient's mother claimed that he was previously brought to Holy Child hospital last August 2016 because of trouble breathing and went
through echocardiography, which gave a result about a heart problem. He was prescribed with Lasix and had been doing good ever since and so
the mother decided for him to not come back for check-up and stop the Lasix, assuming that he's already well. When patient started having
difficulty breathing, they brought him to NOPH instead of Holy Child hospital to save expenses. On admission, patient's mother claimed that
patient had difficulty in breathing a cough for 2 weeks and edema on both lower extremities.
D. Past Health History
Childhood Illnesses:
 Fever, cough
Immunization:
 Fully immunized
Medical
 Previous Hospitalization: Holy Child Hospital due to shortness
 Takes prescribed drugs for heart condition
 Takes OTC drugs for fever and cough
Allergies
 No food and drug allergies
Habits and lifestyle
 Patient does not smoke but drinks alcoholic beverages occasionally
 Watches TV
 Plays video games most of the time
 E. Family History with Genogram

Hypertension is the heredofamilial disease of patient's family.

Silang, A. Silang, L.
Elemia, J. Elemia,T. 72 y.o. (1999 died) 80 y.o. (2003 died)
84 y.o. 84 y.o. died COD: Prostate CA COD: Pneumonia
COD: kagulangon COD: unknown Work: Farmer Work: Tindira
Work: Pedicab Work: Karenderya Ed.A.: Grade 4 Ed.A.: Grade 6
Driver Ed. A.: unknown
Ed. A.: unknown

Saloma, N. Elemia, R. Elemia, K.

Elemia, E. Silang, J. Garcia, L.
77 y.o. 73 y.o. 69 y.o. Elemia, F.
58 y.o. died 62 y.o. (Aug.27) 55 y.o.
Hypertensive Married Married 73 y.o.
COD: Throat CA Married (2 Married
Work: Karenderya Work: Housewife Work: Taxi Driver Hypertensive, Heart children) Work:
Ed. A.: 2nd yr. HS Ed. At.: Elem. Level Ed. At.: High School problem Work: Panday Housewife
Grad. COD: unknown Ed.A.: Grade 6
Ed. At.:
Work: Karenderya Grade 6
Elemia, R. Ed. A.: unknown
75 y.o. Elemia, B. Elemia, A.
Married 70 y.o. 68 y.o. died
Anggot, M. C.
Work: Retired Married COD: Intestinal CA Silang, L.
57 y.o.
Factory Worker Work: Panday Married 70 y.o.
Married (no
Ed. At.: Elem. Grad. Ed. At.: Work: Pedicab DM
children)
Elementary level Driver Work: none
Work: housewife
Ed. At.: Grade 2 Ed. A.: 2nd yr HS
Ed. A.: 4th yr. HS

LEGEND:

Patient =
Elemia, A.
Elum, E. PATIENT 32 y.o.
Female = 38 y.o. Elemia, A. Work: Security
Married (1 child) 35 y.o. Guard
Work: Housewife
Male = Ed. At.: HS Grad.
Single Ed. At.: STI College
Ed. At.: 2nd yr. HS Grad.

Deceased =
F. PSYCHOSOCIAL HISTORY
Patient was energetic and a game lover, also having a childish attitude and bad behavior as claimed by his mother. Listens and responds
attentively during interview. He is working as a construction worker by contractual. His relationship with his family is good. Patient claimed that he
has a lot of friends and that he never had been to any trouble. He got married a year ago and decided to move to a new house with his wife. He
claimed that he has no difficulties in relating with his parents as well as his in-laws, as claimed by mother.

G. ENVIRONMENTAL HISTORY
Patient lives in a semi-urban environment in Balugo. Patient's mother verbalized their house is located in a lower land setting. They would climb
the common cemented stairs if they want to go out of their house, as claimed by mother.

H. SPIRITUAL HISTORY
Patient’s religion is Roman Catholic and goes to church with mother during Sundays at a nearby chapel or sometimes at Cathedral Church as
claimed by mother.
 PHYSICAL ASSESSMENT

Body Part Normal Findings Abnormal Findings (September 9, 2017)

Skin Skin is evenly colored, intact and there are no Skin is intact, dry, evenly colored, pale, and warm to touch.

redness, discharges, lumps and lesions. Skin is Uniform in color, with blemishes. Presence of foul odor. Mild

normally warm to touch. No edema noted. perspiration noted due to warm environment. Edema noted on

lower extremties. There are no signs of redness and discharges.

No palpable masses and lesions. Palms of the hands and soles of

the feet are thick. Good skin turgor noted. T= 36.9 C.

Nails Pink tones should be seen, 160 degree angle Capillary refill not more than 2 seconds. Thick, hard, smooth and

between the nail base and skin. It is hard and firm, pinkish nails. Nail plate is attached to nail bed. Short, dirty

basically immobile, smooth and firm. nails noted. 160 degree angle between the nail base and skin.
Head, Hair, Scalp Black colored hair for Asian ethnicity. Scalp is clean The head of the client is round and symmetrical. Hair is black in

and dry with no lesions, swelling and discharges. color, no hair dye noted. Scalp is moist and a little bit flaky. No lice

Hair is smooth and firm. No presence of lice. noted, no lesions, and discharges. No injuries noted. There are no

nodules or masses and depressions when palpated.

Shape of face is round. Equal parts on both sides of The round face of the client appeared smooth and has uniform
Face
a dividing line. No masses, no tenderness. Absence consistency and with no presence of nodules or masses. Pale

of swelling, redness, and discharges. conjunctiva, nailbeds, and buccal mucosa. Shape of face is

symmetrical. With no deformities, no masses and no lesions noted.

No involuntary movements noted. No discharges noted. Swelling

and redness absent on temporal area. Non-tender upon palpation.

Neck Neck is centered and without masses. Thyroid The neck muscles are equal in size. The client showed

cartilage, cricoid cartilage and thyroid gland move coordinated, smooth head movement with no discomfort. Neck is

symmetrically. Trachea is located in the midline. located at the center without masses. Thyroid cartilage, cricoid
 cartilage and thyroid gland move symmetrically. Trachea is located

midline. The lymph nodes of the client are not palpable. The

thyroid gland is not visible on inspection and the glands ascend

during swallowing but are not visible.

Chest Chest wall is symmetrical. Free from lesions. Anterior chest is symmetrical. No lesions noted. The chest wall is

Regular respiratory rate (30 – 60 cpm) with no nasal intact with no tenderness and masses. There’s a full and

flaring, no use of accessory muscles and manifest symmetric expansion and the thumbs separate 2-3 cm during deep

no signs of difficulty of breathing. Absence of inspiration when assessing for the respiratory excursion. Vibrations

adventitious sounds like, crackles, wheezing, friction felt during tactile fremitus. RR: 32 cpm, rapid, deep breathing, use

that can be heard on the chest wall. Client of accessory muscle noted. Nasal flaring noted. No chest

manifested quiet, rhythmic and effortless indrawing. Presence of wheezing heard on the chest wall. The

respirations. right and left shoulders and hips are of the same height. Ratio of

Antero-posterior diameter and Transverse diameter is 1:2

respectively.
 Heart Symmetrical chest wall. No lesions noted. No Symmetrical chest wall. Absence of lesions. Absence of chest

murmur heard. No friction rub heard. No visible palpitations. S1 and S2 heard clearly, There were no visible

pulsations on the aortic and pulmonic areas. No pulsations on the aortic and pulmonic areas. HR: 102 bpm, rapid

presence of heaves or lifts. S1 and S2 heard clearly, and irregular. BP: 180/100 mmhg.

no adventious heart sounds noted.

Extremities Both extremities are equal in size. Have the same Both extremities are equal in size. Have the same contour with

contour with prominences of joints. No involuntary prominences of joints. No involuntary movements. Edema is noted.

movements. No edema. Color is even. Temperature Color is even. Temperature is warm and even. Has equal

is warm and even. Has equal contraction and even. contraction and even. Cannot perform complete range of motion

Can perform complete range of motion. No crepitus due to weak condition. No crepitus is noted on joints.

must be noted on joints.

 NURSING THEORIES

Sister Callista Roy

The Adaptation Model of Nursing was developed by Sister Callista Roy in 1976. After working with Dorothy E. Johnson, Roy became
convinced of the importance of describing the nature of nursing as a service to society. This prompted her to begin developing her model with the
goal of nursing being to promote adaptation. She first began organizing her theory of nursing as she developed course curriculum for nursing
students at Mount St. Mary's College. She introduced her ideas as a basis for an integrated nursing curriculum (Roy Adaptation Model, n.d.).

According to Roy's model, a person is a bio-psycho-social being in constant interaction with a changing environment. He or she uses innate
and acquired mechanisms to adapt. The model includes people as individuals, as well as in groups such as families, organizations, and communities.
This also includes society as a whole (Roy Adaptation Model, n.d.).

The Adaptation Model states that health is an inevitable dimension of a person's life, and is represented by a health-illness continuum. Health
is also described as a state and process of being and becoming integrated and whole (Roy Adaptation Model, n.d.).

The environment has three components: focal, which is internal or external and immediately confronts the person; contextual, which is all
stimuli present in the situation that all contribute to the effect of the focal stimulus; and residual, whose effects in the current situation are unclear. All
conditions, circumstances, and influences surrounding and affecting the development and behavior of people and groups with particular
consideration of mutuality of person and earth resources, including focal, contextual, and residual stimuli. The model includes two subsystems, as
well (Roy Adaptation Model, n.d.).

The cognator subsystem is a major coping process involving four cognitive-emotive channels: perceptual and information processing, learning,
judgment, and emotion. The regulator subsystem is a basic type of adaptive process that responds automatically through neural, chemical, and
endocrine coping channels (Roy Adaptation Model, n.d.).

The Adaptive Model makes ten explicit assumptions:

1. The person is a bio-psycho-social being.
2. The person is in constant interaction with a changing environment.
 3. To cope with a changing world, a person uses coping mechanisms, both innate and acquired, which are biological, psychological, and social in
origin.
4. Health and illness are inevitable dimensions of a person's life.
5. In order to respond positively to environmental changes, a person must adapt.
6. A person's adaptation is a function of the stimulus he is exposed to and his adaptation level.
7. The person's adaptation level is such that it comprises a zone indicating the range of stimulation that will lead to a positive response.
8. The person has four modes of adaptation: physiologic needs, self-concept, role function, and interdependence.
9. Nursing accepts the humanistic approach of valuing others' opinions and perspectives. Interpersonal relations are an integral part of nursing.
10. There is a dynamic objective for existence with the ultimate goal of achieving dignity and integrity.
There are also four implicit assumptions which state:
1. A person can be reduced to parts for study and care.
2. Nursing is based on causality.
3. A patient's values and opinions should be considered and respected.
4. A state of adaptation frees a person's energy to respond to other stimuli (Roy Adaptation Model, n.d.).

Correlation
In relation to the theory, my patient is a bio-psycho-social being as he responds to a changing environment such when he was diagnosed with
a heart problem. Patient's mother claimed that he was having a hard time at first because of the change in daily routine, change in dietary lifestyle,
and activities. After a while, he got used to his new lifestyle and adapted to it such as avoiding in doing strenuous activities or anything that can lead
to SOB. With Roy's definition of health, it is true that health is an inevitable dimension of a person's life. Patient's wellness is compromised due to his
problem and such is inevitable because as patient's mother claimed, he got his heart problem from her. In relation to Roy's definition of environment,
patient is affected by it, such that of his heart condition that required him to change his lifestyle. The way he does things now and cope with them are
the effects of a circumstance or an event, which is his heart condition. Evaluating Roy's definition of nursing, her list of assumptions is patient-
centered and goal-oriented towards meeting the patient's needs. The nurse must make base the nursing care plan on the patient's progress towards
health. In my case, I wasn't able to fully care for my patient during his whole stay in the hospital since he was an emergency case. Nevertheless, I
was able to talk and discuss with his family, particularly his mother and sometimes his sister who comes to visit.
 FUNCTIONAL HEALTH PATTERN
USUAL PATTERN INNITIAL APPRAISAL (9/8/17)
Health Perception/ Health- Management Pattern Health Perception/ Health- Management Pattern

-patient's mother claimed patient's health has not been really good even - patient's mother claimed that patient's health has gotten worse
when young because of shortness-of-breath events but states that they're - Takes medicine prescribed by doctor
tolerable even when climbing stairs -currently on soft diet (no spices and fatty food)
-had fever the past month -still having difficulties with breathing
- smokes and drinks alcoholic beverages -restless on his bed
-hardly finds ways to follow nurses and doctors orders as claimed by -weak body, looked energy-drained
patient's mother -medications as ordered:
-no colds the past year Furosemide 20mg IVTT q8h c BP prec.
-has a healthy diet, eats fruits and vegetables Captopril 25mg 1 tab 5L PRN q6h > 160/80 mmHg
- previous hospitalizations: Holy Child hospital Perindopril 5mg 1 tab OD
-always at home since he stopped schooling Carvidelol 6.25mg 1 tab OD
-hypertensive Omeprazole 40mg IVTT OD
-takes Lasix since 2016 but stopped Enoxaparin 0.4 q12h
Febuxostat 40mg 1 tab OD 8pm

-V/S taken
T: 36.9 C
P: 72bpm
R: 32cpm
BP: 180/100mmHg

-Laboratory Results:
Troponin T = 120.5 pg/ml
Uric Acid = 10.7 mg/dl
K+ = 3.27 mmol/L
Na+ = 128.2 mg/dl

-PA findings:
Patient appears restless and weak, continues to change sitting position.
 Dyspnea as observed, and wheezing noted upon auscultation. Edema on
both lower extremities noted.

Nutritional-Metabolic Pattern Nutritional-Metabolic Pattern

-no weight loss
-no discomforts when eating -on soft diet (-) nothing spicy and fatty
-no diet restrictions until heart problem was diagnosed
-heal well - consumes less than half of his food; Poor appetite
-no skin problems
-drinks 5-6 glasses of water per day
Breakfast
1 cup of rice -With PLR @ 10 gtts/min
1 serving of beef loaf
1-2 glasses of water -no weight loss as verbalized by patient's mother
1 cup of coffee
- Has discomforts when eating or drinking due to shortness of breath
Lunch and Dinner -drank 1 glass of milk for breakfast
1 cup of rice
1 serving of vegetables
2 glasses of water

-has a very good appetite

-able to eat properly
-ate 3 times a day
-consumed 2 liters of water/day
Elimination Pattern Elimination Pattern
Bladder -on FBC; 500mL (9:17am)
-no discomfort in urinating - reddish in color
-urinated 5-6 times a day - no discomforts while urinating
-no complaints with the usual pattern of urinating
-doesn’t use any assistive device for urination - Defecated twice, with soft and blackish stools
- No excessive perspiration noted
-urine is light yellow in color - Doesn’t use assistive device to defecate
-1/2 – 1 glass per urination - No pain upon defecating

Bowel

-defecated 1-2 times a day, usually early in the morning

-yellowish-brown in color and hard in consistency
-no assistive device used in defecating
-no pain upon defecating

Activity-Exercise Pattern Activity-Exercise Pattern

-has sufficient energy to do daily routines -hospitalized lying in bed

-exercises twice a week by walking and washing the clothes in their -can ambulate with assistance
home -not given bed bath by significant others
-loves to watch TV as claimed by mother -difficulty in doing his usual routines
-able to ambulate, dress, go to toilet, and bath self - still difficulty breathing
-no assistance needed

6:00- 6:30 Wakes up

6:30-7:00 Eats breakfast
7:30- 11:00 watches TV
11:00-12:00 Lunch time
12:00:- 4:00 Plays video games
5:00-6:00 – stays at home
6:00-7:00 Dinner
7:00-9:00- watches TV
9:00 -sleep

Sleep-Rest Pattern Sleep-Rest Pattern

-usually sleeps at 9 pm and wakes up at 6am and eats breakfast -comfortable in the hospital
-generally rested and ready for ADLs - claims to have difficulty sleeping due to awakening of the nurses from
-no sleeping problems time to time and the urge to urinate frequently
-no nightmares -Naps between 12:00 p m- 3:00 pm
-no nap time - Not able to sleep properly due to the adjusted time of sleep
-no difficulty in sleeping - Awakening time: 5:00
-feeling rested after sleep - Sleeping time: irregular
- No awakening due to shortness of breath -Awakening due to shortness of breath
- When awakened due to noise, has troubles sleeping back again

Cognitive-Perceptual Pattern Cognitive-Perceptual Pattern

-no deficit in sensory perception (hearing, touch, smell and taste except
sight) - No hearing difficulties
-doesn't use reading glasses -can't converse well
-responsive - oriented to time and place
-no difficulty in learning - No changes in memory: able to understand things but has little trouble
retaining
- prefers to learn on her way but at the same time accepts others help
- Not in pain
Self-Perception Pattern Self-Perception Pattern

-feels good most of the time - patient's mother claimed that patient is a special child
-gets angry sometimes when working under pressure -patient's mother discussed about his
-not in a depressed state -answers question briefly
-speaks bisaya when conversing with other people

Role-Relationship Pattern Role-Relationship Pattern

-lives with his mother and 2 siblings -lives with his mother and 2 siblings
-civil status is single -civil status is single
-the child of the family because of his childish behavior despite being 35 -the child of the family because of his childish behavior despite being 35
years old years old

Sexuality-Reproductive Pattern Sexuality-Reproductive Pattern

- No recent check ups with regards to his reproductive area - No recent check ups with regards to her reproductive area

Coping-Stress Pattern Coping-Stress Pattern

-talks with his family and relatives during times of identity confusion and
-feels confident and not tense unless someone will try to prank him problems
-no big changes the past year -enjoys the company of friends as claimed by mother
-handling problems by asking help from other family members -usually talks to his mother when problems arise as claimed by mother
-solving problems are usually successful
-talks with his family and relatives during times of identity confusion and
problems
Value-Belief Pattern Value-Belief Pattern

-got the things aimed to have in life -haven’t visited the church since hospitalization
-a Roman Catholic - No practices/beliefs that would hinder the activities in the hospital
-attends mass with mother every Sundays at a nearby chapel
 Summary of Nursing Diagnoses

1. Impaired Gas Exchange

2. Ineffective Tissue Perfusion

3. Excess Fluid Volume

4. Risk for Impaired Gas Exchange

5. Risk for Impaired Skin Integrity

6. Deficient Knowledge

7. Decreased Cardiac Output

8. Acute Pain

9. Hyperthermia

10. Ineffective Breathing Pattern

11. Activity Intolerance

12. Ineffective Airway Clearance

13. Decreased Cardiac Output

14. Activity Intolerance

15. Fatigue
 NURSING CARE PLANS

Cues and Nursing Planning Interventions Rationale Evaluation

Evidences Diagnosis
1. Auscultate breath 1. Reveals presence of
Subjective: Impaired Gas At the end of our duty, At the end of our duty,
sounds, noting crackles, pulmonary congestion and

"Ga lisod mn ni syag Exchange due the patient will have: wheezes. collection of secretions, goal is partially met.

ginhawa lima na ka to vascular  Demonstrate indicating need for further The patient
adlaw ", as adequate ventilation intervention.
congestion in participated in the
verbalized by SO. and oxygenation of 2. Encourage frequent 2. Helps prevent
the heart position changes. atelectasis and treatment regimen,
tissues
 Demonstrate no pneumonia. and respiratory vital
restlessness 3. Maintain chair or bed 3. Reduces oxygen
Objective: sign returned to
 vital signs within rest, high fowler's demands and promotes
position. Support arms maximal lung inflation. normal.
patient’s normal
R = 60 cpm
ranges with pillows.

BP = 200/120  Participate in
4. Administer supplemental 4. Increases alveolar
treatment regimen
oxygen as indicated, O2 oxygen concentration,
 SOB/Dyspnea within level of
therapy. which may reduce tissue
ability/situation.
 Use of accessory hypoxemia.
muscles 5. Administer meds as 5. Reduces alveolar
 Restlessness indicated: Diuretics (lasix) congestion, enhancing gas
exchange.
 Cues and Nursing Planning Interventions Rationale Evaluation
Evidences Diagnosis
1. Establish a quiet 1. A quiet environment
Subjective: Ineffective At the end of our duty, At the end of our duty,
environment. reduces the energy

"Ga lisod mn ni syag Tissue the patient will have: demands on the goal is partially met.

ginhawa lima na ka Perfusion  Patient will patient. Respiratory vital sign

adlaw, karun ra ni demonstrate 2. Elevate head of bed. 2. Elevation improves
related to returned to normal.
sya na high blood normal breathing chest expansion and

sukad aning sa heart impaired gas

pattern and oxygenation.

niya", as verbalized exchange demonstrate good 3. Provide oxygen and 3. Oxygenation increases

by SO. activity tolerance monitor oxygen saturation the amount of oxygen

 Display vital signs via pulse oximetry, as circulating in the blood

Objective: within acceptable ordered. and, therefore,

limits, weakness, increases the amount

R = 60 cpm fatigue of available oxygen to
BP = 200/120 the myocardium,
decreasing myocardial
 SOB/Dyspnea
ischemia and pain.
 Fatigue
4. Assess results of cardiac 4. These enzymes
 Weakness
marker—troponin ordered elevate in the
 Activity
by physician. presence
intolerance
of myocardial
infarction at differing
 times

5. Assess cardiac and 5. Assessment

circulatory status.
establishes a baseline
and detects changes
that may indicate a
change in cardiac
output or perfusion.

6. Reposition the patient 6. To prevent bedsores

every 2 hours

7. Instruct patient on eating 7. To prevent heartburn

a small frequent feedings and acid indigestion
 Cues and Nursing Planning Interventions Rationale Evaluation
Evidences Diagnosis

Subjective: Excess Fluid At the end of our duty, 1. Monitor and record VS 1. To obtain baseline data At the end of our duty,

"Kani iyang hupong Volume the patient will have: goal was partially met.
2. Assess patient’s 2. To determine what
sa iyang tiil ten days related to  Patient will The patient
general condition approach to use in
na", as verbalized by verbalize
decreased treatment demonstrated
SO. understanding of
cardiac output decreasing edema as
causative factors
3. Auscultate breath 3. Checking for abnormal
and demonstrate claimed by patient’s
sounds breath sounds
behaviors to
Objective: mother.
resolve excess fluid
4. Assess for presence of 4. Decreased systemic
volume.
P= 98 bpm peripheral edema. blood pressure to
 Patient will
stimulation of
BP = 200/120 demonstrate
aldosterone, which
adequate fluid
causes increased renal
 Edema on lower balanced clearing
tubular reabsorption of
breath sounds, and
extremities sodium Low-sodium diet
decreasing edema.
helps prevent increased
sodium retention, which
decreases water
retention. Fluid restriction
 may be used to decrease
fluid intake, hence
decreasing fluid volume
excess

5. Obtain patient history to 5. May include increased

ascertain the probable fluids or sodium intake,

cause of the fluid or compromised

disturbance. regulatory mechanisms.

6. Evaluate urine output in 6. Treatment focuses on

response to diuretic diuresis of excess fluid.

therapy.

7. Institute/instruct patient 7. This helps reduce

regarding fluid extracellular fluid.
restrictions as
appropriate.
 CONCLUSION

The Emergency Room is the facility in a hospital where nurses and physicians are responsible for the provision of immediate medical care.
During our rotation in the ER, I was introduced to a 35 year old, restless patient who was demonstrating shortness of breath with the use of
accessory muscles and he looked very tired. He was admitted on September 7, 2017 and lived in Balugo, Dumaguete City. His diagnosis is
congestive heart failure secondary to HCVD and Cardiomegaly. With heart failure, blood moves through the heart and body at a slower rate, and
pressure in the heart increases. As a result, the heart cannot pump enough oxygen and nutrients to meet the body's needs. The chambers of the heart may
respond by stretching to hold more blood to pump through the body or by becoming stiff and thickened. This helps to keep the blood moving, but the heart
muscle walls may eventually weaken and become unable to pump as efficiently. As a result, the kidneys may respond by causing the body to retain fluid
(water) and salt. If fluid builds up in the arms, legs, ankles, feet, lungs, or other organs, the body becomes congested, and congestive heart failure is the term
used to describe the condition.
Eating a healthy diet, exercising regularly, having rest periods between activities, taking medications as prescribed, and preventing respiratory
infections are one of the simple ways to live an improved quality of living with Congestive Heart Failure. Introducing of infection to the lungs will
compromise the lungs' function and will result to more labored breathing and extra work for the whole body, which should be conserving energy for
the already falling heart to function as it compensates in its own way for the whole body. Although it was hard because I wasn't able to talk with my
patient due to him having labored breathing all of the time, with the following assessments and interview with his mother, I was able to come up with
the nursing diagnoses and formulated a care plan out of them.
 BIBLIOGRAPHY

INTERNET
Bernadette A. Tumanan-Mendoza, V. L.–D. (2017 йил 27-March). Epidemiologic burden of hospitalisation for congestive heart failure among adults aged ≥19 years in the
Philippines. Retrieved 2017 йил 29-September from NCBI: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5372042/

Vera, M. (2011 йил 12-November). Captopril (Capoten) Drug Study. Retrieved 2017 йил 29-September from Nurseslabs: https://nurseslabs.com/captopril-drug-study/

Vera, M. (2011 йил 22-December). Furosemide (Lasix) Drug Study. Retrieved 2017 йил 29-September from Nurseslabs: https://nurseslabs.com/furosemide-lasix-drug-study/

Anonymous. (n.d.). CARVEDILOL. Retrieved 2017 йил 29-September from RobHolland: http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/C028.html

Anonymous. (n.d.). ENOXAPARIN. Retrieved 2017 йил 29-September from RobHolland: http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/E015.html

Anonymous. (2017 йил 19-May). Erik Erikson’s Theory of Psychosocial Development. Retrieved 2017 йил 30-September from Psychology Notes HQ:
https://www.psychologynoteshq.com/erikerikson/

Anonymous. (2017). Heart Failure. Retrieved 2017 йил 28-September from University of Maryland Medical Center:
http://www.umm.edu/health/medical/reports/articles/heart-failure

Anonymous. (n.d.). High Uric Acid Level Causes. Retrieved 2017 йил 29-September from Mayoclinic: http://www.mayoclinic.org/symptoms/high-uric-acid-
level/basics/causes/sym-20050607

Anonymous. (2010 йил 24-May ). Nursing Interventions for Congestive Heart Failure. Retrieved 2017 йил 29-September from Nursing Files: http://nursingfile.com/nursing-care-
plan/nursing-interventions/nursing-interventions-for-congestive-heart-failure.html

Anonymous. (n.d.). OMEPRAZOLE. Retrieved 2017 йил 29-September from RobHolland: http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/O009.html

Anonymous. (n.d.). PERINDOPRIL ERBUMINE. Retrieved 2017 йил 29-September from RobHolland:
http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/P032.html

Anonymous. (n.d.). Potassium. Retrieved 2017 йил 29-September from Lab Tests Online: https://labtestsonline.org/understanding/analytes/potassium/tab/test/
Anonymous. (n.d.). POTASSIUM CHLORIDE. Retrieved 2017 йил 29-September from RobHolland:
http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/P063.html

Anonymous. (n.d.). Roy Adaptation Model. Retrieved 2017 йил 29-September from Nursing Theory: http://www.nursing-theory.org/theories-and-models/roy-adaptation-
model.php

Barredo, S. (n.d.). Febuxostat. Retrieved 2017 йил 29-September from Scribd: https://www.scribd.com/doc/209367929/Febuxostat

Cherney, K. (2017, June 17). Mild Cardiomegaly. Retrieved October 9, 2017, from Healthline: https://www.healthline.com/health/mild-cardiomegaly#diagnosis6

Forte, E. &. (n.d.). Hypertensive Cardiovascular Problem. Retrieved October 9, 2017, from Mediterranean Book: http://www.mediterraneanbook.com/2011/02/09/hypertensive-
cardio-vascular-disease/

Gibson, O. &. (2013). Heart Failure. Retrieved 2017 йил 28-September from Heart Failure: http://www.heartfailure.org/heart-failure/index.html

Gonzalo, A. (2011). Faye G. Abdellah. Retrieved 2017 йил 29-September from Nursing Theories: http://nursingtheories.weebly.com/faye-g-abdellah.html

Jasvinder Chawla, M. M. (2016 йил 30-June). Peripheral Nervous System Anatomy. Retrieved 2017 йил 30-September from Medscape:
http://emedicine.medscape.com/article/1948687-overview#a3

McLeod, S. (2008). Erik Erikson. Retrieved 2017 йил 20-September from Simply Psychology: https://www.simplypsychology.org/Erik-Erikson.html

Quinn, C. (2006). 100 Questions & Answers About Congestive Heart Failure. USA: Jones & Bartlett Learning.

Taylor, T. (n.d.). Cardiovascular System. Retrieved 2017 йил 30-September from InnerBody: http://www.innerbody.com/image/cardov.html#full-description

Taylor, T. (n.d.). Respiratory System. Retrieved 2017 йил 30-September from InnerBody: http://www.innerbody.com/anatomy/respiratory

Teichroew, J. K. (2016). Chronic Diseases: An encyclopedia of causes, effects, and treatments. Santa Barbara, USA: ABC-CLIO.