congestive heart failure (pp.1- 50)
TRANSCRIPT
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CONGESTIVE HEART FAILURE
A Case Study Presented To
The Faculty of Nursing and Health Science Department
College of Arts and Sciences
Naval State University
Naval, Biliran
In Partial Fulfillment of the
Related Learning Experience Requirement
for the Degree of Bachelor of Science in Nursing
Daryll S. Dacdac
NOVEMBER 2011
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TABLE OF CONTENTS
Page
I. Introduction 4II. Objectives 5III. Nursing Assessment
1. Personal History 7
1.1 Patients Profile 7
1.2 Family & Individual Information, Social & Health History 7
1.3 Level of Growth and Development 22
1.3.1 Normal Development at Particular Age 22
1.3.2 The ill person at Particular Stage 27
2. Diagnostic Result 28
3. Present Profile of Functional Health Pattern 31
4. Pathophysiology and Rationale
4.1 Anatomy and Physiology 35
4.2 Schematic Diagram 38
4.3 Pathophysiology 42
4.4 Classical and Clinical signs and symptoms 44
IV. Nursing Intervention
1. Care Guide of Patient with Disease Condition 49
2. Actual Patient Care
2.1 Nursing Care Plan 51
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2.2 SOAPIE 65
2.3 Drug Therapeutic Record 67
2.4 Health Teaching Plan 75
V. Evaluation and Recommendation 79
VI. Implication of the Case Study 81
VII. Bibliography 82
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INTRODUCTION
Congestive heart failure is defined as the state in which the heart is unable to
pump blood at a rate adequate for satisfying the requirements of the tissues with function
parameters remaining within normal limits usually accompanied by effort intolerance,
fluid retention, and reduced longevity (Denolin, 1983, p. 445). Currently, congestive
heart failure or heart failure continues to be a major public health problem worldwide. It
is the leading cause of morbidity and mortality in most developed countries. According to
the American Heart Association (2001), approximately 5 million patients have heart
failure and nearly 550,000 new patients are diagnosed each year. In addition, nearly
300,000 patients die from heart failure yearly.
In the Philippines, cardiovascular diseases are the most common causes of
mortality. According to the Department of Health (2005), about 77,060 in a 100, 000
populations have died in the Philippines due to diseases of the heart. The aging of the
population and the emerging pandemic of cardiovascular diseases in the developing
nations of the world signal a rise in the incidence and prevalence of heart failure globally
and magnify the importance of its prevention. The prevention of heart failure is an urgent
public health need with national and global implications.
This paper is a case report about Mr. V., a 90 year old male, Filipino and is
currently diagnosed with Congestive Heart Failure. Its purpose is to review the
pathophysiology, pre-analytical factors, and treatment in a congestive heart failure patient
and identify possible recommendations for future nursing care.
This case report is significant to my future nursing care because it helps stress the
importance of not only identification and treatment of patients with heart failure but also
the importance of promoting a healthy lifestyle and preventive strategies to decrease the
prevalence of heart failure in the general population. Also, it explores the need for a
thorough case analysis of a client to deliver the best nursing care.
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OBJECTIVES
General Objectives:
After 3 days of student- nurse- patient interaction, the nursing students will be
able to gain knowledge, attitude and skills in the care of patient with Congestive Heart
Failure.
Specific Objectives for the Student- Nurse:
After 45 minutes of the discussion, the nursing students will be able to:
1. acquire knowledge about Congestive Heart Failure as to:
1.1definition of terms;
1.2risk factors;
1.3signs and symptoms;
1.4pathophysiology;
1.5nursing care plan;
1.6prognosis;
1.7interventions?
2. demonstrate proper attitude in handling patient with Congestive Heart Failure
and;
3. apply the acquired skills in the care of patients with Congestive Heart Failure.
Specific Objectives for the Patient:
After 2 days of student nurse- patient interaction/ SO, the patient will be able to:
1. build trust towards the student- nurse;
2. acquire an overview of the disease as to:
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2.1definition of terms;
2.2risk factors;
2.3signs and symptoms;
2.4complications;
2.5interventions?
3. verbalize feelings about the situation or condition and;
4. participate in activities done by the student- nurse such as:
4.1interventions in the care of the condition;
4.2
techniques in managing complications?
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III. NURSING ASSESSMENT
1.1 Patients ProfilePatient Name: Mr. V
Age: 90 years old
Sex: Male
Religion: Roman Catholic
Civil Status: Married
Birthday: November 18, 1920
Birthplace: Calubian, Leyte
Occupation: None
Date of Admission: August 18, 2010 2:50 pm
Room: Male Medical Ward
Chief Complaints: Body Malaise, weakness, difficulty in breathing
Impression/ Diagnosis: Congestive Heart Failure
Physician: Dr. Borromeo
1.2.Family and Individual Information, Social, and Health History
PRESENT MEDICAL HISTORY
According to the significant other, two weeks prior to admission, patient was
experiencing on and off diarrhea and intermittent abdominal pain after drinking 3- 4
glasses of tuba at their neighborhood. He was not given any medication for diarrhea and
for the pain.
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The day prior to admission, August 18, 2010, patient claimed that his
abdominal pain was getting worst and his stool content was clear water. At around 2:50
pm the patient was delivered at Biliran Provincial Hospital via wheel chair experiencing
body malaise, weakness, difficulty in breathing and bipedal edema, patient hence
admitted.
PAST MEDICAL HISTORY
According to the significant other, she does not know if the patient had a
complete immunization during his childhood. Wala man siya allergy sa pagkaon, kana la
jud ang magkaluya siya ug maglisod pagginhawa pagmukaon siya ug kanang may mga
tambok na pagkaon. Karun ra man pud siya nag ing- ana nga may edad na. Di man namo
siya mabantayan sa iyang kaonon kay dili man mi tipon ug bahay as verbalized by the
significant other. He sometimes drinks tuba and fond of eating oily and fatty foods such
as Humda and fries. Most of the time the patient experienced weakness and complaining
of back pain at the lumbar area and in the back of the neck. And no alternative remedies
were done to treat the symptoms experienced by the patient according to the significant
other.
According to the SO, June 2010, Mr. V was also admitted in the same institution
due to weakness and hypertension. Treatment was not given properly because that day,
the significant others decided to discharge the patient due to lack of finance.
FAMILY HISTORY
According to the SO, patient has a history of hypertension in his paternal side.
The father of the patient and one of the patients sons died due to hypertension. The
patients mother had a history of arthritis.
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Physical Assessment
Body Parts
Physiologic
I P P A
Skin:Color:
Texture:
Turgor:
Lesions:
Hair:Color:
Amount
anddistribution:
Texture:
Parasites:
Scalp:Symmetry:
Texture:
Lesions:
Nails:
Color:
Brownness to
yellowish
Short; grayish
Unevenly
distributed andalopecia
Absence of
parasites
Symmetrical inshape
No lesions
Pale, andslightly cloudy
Dry andwrinkled
Skin turgor
back to normal
within 4- 5seconds
Presence ofbruise in both
knees
Dry and oily
Slightly intact
and smooth
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Shape:
Texture:
Condition
of nail bed:
CapillaryRefill test:
HeadSize:
Shape:
Consistency:
Face:
Symmetry:
FacialFeatures:
Neck:Appearance:
ROM:
Tracheaposition:
Convex
Pallor
Appropriate to
body size
Rounded
Symmetrical
Patient showsfacial grimace
when hemoves
suddenly and
when he feelsabdominal pain
Wrinkled skin
is noted
Able to movein any
directionflexion and
extension inslow
movement
Centrallylocated
Smooth
Back to normalwithin 2- 3
seconds
Hard
Not tender
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Thyroid
position:
LymphNodes:
Size:
Mobility:
Consistency:
Tenderness:
Jugularveins:
Eyes:Position &
Appearance:
Lacrimal
Apparatus:
PERRLA:
VisualAcuity:
Centrally
located
Visible
Appears
cloudy toyellowish;
sunken; moist,lashes are short
Pupils
constrictswhen light is
near anddilates when it
is far
Patients couldnot see clearly
and takes 30seconds to 1
minute torecognized
faces of hissignificant
Palpable
Not enlarge
Not movable
Soft
Not tender
Carotid pulseis palpable but
weak, with a
pulse rate of45
No discharge
upon palpation,no tendernessnoted
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Peripheral
Vision:
ExtraoccularMovement:
Ears:
External EarSize:
Shape:
Location:
Lesions:
Tenderness:
Auditory
Canal:Cerumen:
Color:
Consistency:
other
When looking
straight ahead,client can
recognizedobjects but
could not seeclearly in the
peripheryusing penlight
Both eyescoordinated
move in unison
with parallelalignment
Symmetrical
Symmetrical
Auricle aligned
with outer
canthus of eyeabout 100from
vertical
No lesions
Small amount
of cerumennoted
Yellow to
brownness
Moist
Not tender
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Nose andSinuses:
ExternalNose:
SkinAppearance:
Nares:
Tenderness:
Internal Nose:
Appearance:
Septum:
Sinuses:
Tenderness:
Transillumina
tion:
Mouth andOropharynx
Lips:Color:
Consistency:
Buccal
Mucosa:
Color:
Skin color is
uniform
No dischargeor flaring;
hooked withnasal cannula
Mucosa pink
Intact andmidline
Not inflamed
Pallor
Dry
Pallor
Not tender
Not tender; all
sinuses are notinflamed and
painless upon
palpation
Not tender
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Consistency:
Gums:
Color:
Consistency:
Teeth:Number:
Color:
Tongue:Symmetrical:
Movement :
Color :
Soft Palate:
Color:
Consistency:
TonsilsPosition:
Tenderness:
Thorax and
Lungs:Anterior and
Moist
Pallor
Moist
28 teeth are
lost and 3incisor left at
upper teeth and2 incisor left at
lower teeth
Presence of
dental carries,yellowish incolor
Symmetrical
Able to move
freely
Pinkish on the
side & withwhite coatingon the center
Pallor
Moist
Located at theside of the
throat
Not tender
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Posterior:
Color:
Intercostal
Spaces:
Chest
Symmetry:
Respiration:
Shape:
Position ofSternum:
Position ofTrachea:
Tenderness:
Vocal
Fremitus:
ThoracicExpansion:
Posterior
ICS:
AnteriorICS:
Lateral
ICS:
BreathSounds:
Skin color isuniform
First rib and
clavicleobscured
Asymmetrical
35 cycles perminute
Barrel chest
noted
Centrallylocated
Centrallylocated
Not tender
Not assessed
Asymmetryless than 3 cm
Not assessed
Resonancebetween the 6
th
ICS at the levelof the
diaphragm
Not assessed
Crackles are
heardspecifically
at the baseof the lower
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CardiacAssessment
Intercostal
Space:
Midsternal
Line:
Midclavicular
Line:
Anterior
AxillaryLine:
Aortic Area:
Pulmonic
area:
Erbs point
Tricuspid
area:
Mitral Area:
Blood
Pressure:
Pulse rate:
BrachialPulse
First rib and
clavicleobscured
In line with the
body
Center of the
midstrenal line
R & L anteriorline
Vertical from
the anterioraxillary fold
No pulsation
No pulsation
No pulsation
No pulsation
No pulsation
52 beats perminute
lung lobe
140/ 60
mmHg
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Dorsalis
Pedis
Breast:Size:
Symmetry
Color
Areola &
Nipple:Size
Color:
Shape:
Texture:
Discharges:
Temperature:
Turgor:
Tenderness:
Lymph Nodes
Abdomen:
Color:
Skinintegrity:
Presence of
Edema
Breast even
with the chestwall
Symmetrical
Brownness
Everted and
equal in size
Brownness
Round
Brownness to
yellowish incolor;
glistening skin
Abdominalgirth is 112 cm
Not assessed
Smooth
No discharges
noted uponpalpation
Warm to touch
Good; back to
normal within1- 2 seconds
Not tender
Not palpable
Distended;warm to touch
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Umbilicusposition:
Contour:
Bowel
sounds:
Musculoskele
tal system:
Gait:
Strength:
ROM upper
extremities:
Centrallylocated in the
umbilical area
Not assessed
Not assessed;
patient is notallowed tostand
25 % grade ofthe muscle
strength;patient able to
moveaccording to
his age, but
most of themusclesactivity test
such ashamstring, &
sternocleidomastoid test needs
a support fromthe SO
Dry and
wrinkled skinis noted; motor
function isweak and
slow; able toperform
extension,flexion of the
Skin is warm
to touch; lesssensation of
discriminatingthe sharp and
dull object
Hypoactive
bowel soundnoted
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Cranial nerve I - patient could hardly identify smell due to the nasal cannula
hooked with him; he can identify the odor of his foods being eaten
Cranial nerve II - patient could not see clearly and it took at least 30 seconds to 1
minute to recognized faces of his significant other
Cranial nerve III - the extra ocular movement is intact in both eyes when assessedand by using the penlight
Cranial nerve IV - patient could move his eyes up and down
Cranial nerve V - facial sensation of the patient is intact. He was able to feel when
touching his face
ROM lower
extremities:
arms in slow
manner;patient shows
fatigabilityduring the
assessment andexert in
gasping of airfor breathing;
able to changehis position
slowly fromlying to side
lying position
Glistening skin
is noted in bothlegs; bipedaledema isnoted;
presence ofpatches at the
sole of the feet;bruise noted at
both knees;able to adduct
and abduct his
both legs inslow manner
Warm to
touch; plantarreflex isdifficult toelicit
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Cranial nerve VI - patient could move his eyeballs symmetrically when instructed
Cranial nerve VII - patient is able to smile, frown when instructed
Cranial nerve VIII - patient could not hear clearly. When asked questions, it took 2 or
3 times in repeating the question before he could identify what was
being asked. He could hear voices when talked near the ears of the
patient.
Cranial nerve IX - patient has positive gag reflex. He could freely move his tongue
up and down and side to side.
Cranial nerve X - patient talked in slow and low tone of voice
Cranial nerve XI - patient was able to move his head by moving side to side with
limited and slow movement.
Cranial nerve XII - patient able to protrude his tongue and can move freely from up
and down and side to side
Neurologic Assessment
Level of consciousness - patient is conscious, and oriented to place where he lived
in and he was also aware that he was in the Biliran
Provincial Hospital
Mood - patient shows uninterested during the first day of
interaction. Most of the time, patient sleeps and shows
irritable when he was disturb and when feels pain. He
shows facial grimace when he experienced abdominal pain.
Speech - during the assessment, patient talked slowly and in low
voice. He could not identify the question being asked and it
took repetition for what was being asked before his
response.
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Cognitive abilities - the patient is conscious. During the assessment, patient
sleeps most of the time and talk when he needs something
to do with his SO like when he wants to urinate. He can
utter few words in low voice when he asked and express
facial expression when experienced pain.
Sensory -during assessment, patient has less sensation of
discriminating the sharp and dull object.
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1.3LEVEL OF GROWTH AND DEVELOPMENT
Normal Growth and Development at Particular Age
I. Physical changes
A. Cardiovascular SystemThe heart loses about 1% of its reserve plumbing capacity every year after we turn
30. Changes in blood vessels that serve brain tissue reduce nourishment to the brain,
resulting in the malfunction and death of brain cells. By the time we turn 80 and older,
cerebral blood flow is 20% less, and renal blood flow is 50% less than when we were age
30. As we age our heart goes through certain structural changes: the walls of the heart
thicken and the heart becomes heavier, heart valves stiffen and are more likely to calcify,
and the aorta, the major vessel carrying blood out of the heart, becomes larger.
B. Musculoskeletal SystemBones
Aging is accompanied by the loss of bone tissue. The haversian systems in
compact bone undergo slow erosion, lacunae are enlarged, canals become widened, and
the endosteal cortex converts to spongy bone. The endosteal surface gradually erodes
until the rate of loss exceeds the rate of deposition. Bone remodeling cycle takes longer to
complete because bone cells slow in the rate of resorption and deposition of bone tissue.
The rate of mineralization also slows down. The number of bone cells also decreases
because the bone marrow becomes fatty and unable to provide an adequate supply of
precursor cells. Because bones become less dense, they become more prone to fractures.
Although bone degeneration is inevitable, it is variable if steps are taken before the mid-
twenties -around this time our bones break down faster than they rebuild. Bone densityincreases when our bones are stressed, so physical activity is important. Vitamins and
good diet also help build up bone mass.
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Joints
Cartilage becomes more rigid, fragile, and susceptible to fibrillation. Loss of
elasticity and resiliency is attributed to more cross-linking of collagen to elastin, decrease
in water content, and decreasing concentrations of glycosaminoglycans. Joints are also
more prone to fracture due to the loss of bone mass.
Muscles
Decrease in the range of motion of the joint is related to the change of ligaments
and muscles. As the body ages, muscle bulk and strength declines especially after the age
of 70. As much as 30% of skeletal muscles are lost by age 90. Muscle fibers, RNA
synthesis and mitochondrial volume loss may all be contributors to muscle decline. Other
factors that could contribute to muscle loss of the aged are: change in activity level,
reduced nerve supply to muscle, cardiovascular disease, and nutritional deficiencies.
C. Nervous SystemOne of the effects of aging on the nervous system is the loss of neurons. By the age of
30, the brain begins to lose thousands of neurons each day. The cerebral cortex can lose
as much as 45% of its cells and the brain can weigh 7% less than in the prime of our
lives. Associated with the loss of neurons comes a decreased capacity to send nerve
impulses to and from the brain. Because of this the processing of information slows
down. In addition the voluntary motor movements slow down, reflex time increases, and
conduction velocity decreases. As we age there are some degenerative changes along
with some disease's involving the sense organ's that can alter vision, touch, smell, and
taste. Loss of hearing is also associated with aging. It is usually the result of changes in
important structures of the inner ear.
D. Digestive SystemThe changes associated with aging of the digestive system include loss of strength
and tone of muscular tissue and supporting muscular tissue, decreased secretory
mechanisms, decreased motility of the digestive organs, along with changes in
neurosensory feedback regarding enzyme and hormone release, and diminished response
to internal sensations and pain. In the upper GI tract common changes include periodontal
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disease, difficulty in swallowing, reduced sensitivity to mouth irritations and sores, loss
of taste, gastritis, and peptic ulcer disease. Changes that may appear in the small intestine
include appendicitis, duodenal ulcers, malabsoration, and maldigestion.
E. Urinary System
As we get older kidney function diminishes. By the age of 70 and older, the filtering
mechanism is only about half as effective as it was at age 40. Because water balance is
altered and the sensation of thirst diminishes with age, older people are more susceptible
to dehydration. This causes more urinary tract infections in the elderly. Other problems
may include nocturia (excessive urination at night), increased frequency of urination,
polyuria (excessive urine production), dysuria (painful urination), incontinence, and
hematuria (blood in the urine
F. Respiratory SystemsWith the advancing of age, the airways and tissue of the respiratory tract become less
elastic and more rigid. The walls of the alveoli break down, so there is less total
respiratory surface available for gas exchange. This decreases the lung capacity by as
much as 30% by the age of 70 or older.
G. VisionChanges in vision begin at an early age. The cornea becomes thicker and less curved.
The anterior chamber decreases in size and volume. The lens becomes thicker and more
opaque, and also increases rigidity and loses elasticity. The ciliary muscles atrophy and
the pupil constricts. There is also a reduction of rods and nerve cells of the retina.
H. HearingApproximately one third of people over the age of 65 have hearing loss. The
ability to distinguish between high and low frequency diminishes with age. Loss of
hearing for sounds of high-frequency (presbycusis) is the most common, although the
ability to distinguish sound localization also decreases. It is believed that the hearing loss
isn't so much an age change as it is due to the accumulation of noise damage.
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I. Taste and SmellSensitivity to odors and taste decline with age. The sense of smell begins to
degenerate with the loss of olfactory sensory neurons and loss of cells from the olfactory
bulb. The decline in taste sensation is more gradual than that of smell. The elderly have
trouble differentiating between flavors. The number of fungiform papillae of the tongue
decline by 50% by the age of 50. Taste could also be affected by the loss of salivary
gland secretions, notably amylase. This loss of taste and smell can have a significant
effect on an elder's health. With the reduced ability to taste and smell, it is difficult to
adjust food intake as they can no longer rely on their taste receptors to tell them if
something is too salty, or too sweet. This can also cause the problem in that they might
not be able to detect if something is spoiled, making them at a higher risk for food
poisoning.
J. CellularAgingAs people age, oxygen intake decreases as well as the basal metabolic rate. The
decrease in the metabolic rate, delayed shivering response, sedentary lifestyle, decreased
vasoconstrictor response, diminished sweating, and poor nutrition are reasons why the
elderly cannot maintain body temperature. There is also a decrease in total body water
(TBW).
K. Organism AgingAging is generally characterized by the declining ability to respond to stress,
increasing homeostatic imbalance and increased risk of disease. Because of this, death is
the ultimate consequence of aging. Differences in maximum life span between species
correspond to different "rates of aging". For example, inherited differences in the rate of
aging make a mouse elderly at 3 years and a human elderly at 90 years. These genetic
differences affect a variety of physiological processes, probably including the efficiency
of DNA repair, antioxidant enzymes, and rates of free radical production.
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II. Cognitive developmentAccording to Piagets phases of cognitive development, it ends with the formal
operations phase. In older adults, changes in cognitive abilities are more often
differences in speed than ability. Overall the older adult maintains intelligence,
problem solving, judgment, creativity, and other well- practiced cognitive skills.
Intellectual loss generally reflects a disease process such as atherosclerosis, which
causes the blood vessels to narrow and diminishes perfusion of nutrients to the brain.
Older adults do not experiencing cognitive impairments.
III. Moral developmentAccording to Kohlberg, moral development is completed in the early adult years.
Most old people stay at Kohlbergs conventional level of moral development and
some are at the preconventional level. An older person at the preconventional level
obeys rules to avoid pain and the displeasure of others. At stage 1, a person defines
good and bad in relation to self, whereas older people at stage 2 may act to meet
anothers need as well as their own. Older adults at the conventional level follow
societys rules of conduct in response to the expectation of others.
IV. Spiritual developmentOlder adults can contemplate new religious and philosophical views and try to
understand ideas missed previously or interpreted differently. Involvement in religion
often helps the older adult to resolve issues related to the meaning of life, to
adversity, or to good fortune. The old- old person who cannot attend formal
services often continues religious participation in a more private manner. Many older
adults watch television evangelists and some, being vulnerable to fund- raising
ventures, sent these organizations money that they can ill afford to spare.
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The Illness Person at the Particular Stage
Declining physical and sensory- perceptual abilities limit the ability of old- old
stage adult to respond to environmental hazards and stressors. In old- old age group, ill
client may experience behavioral and emotional changes, changes in self- concept and
body image, and lifestyle changes. Behavioral and emotional changes associated with
short- term illness are generally mild and short lived. The individual may become
irritable and lack the energy or desire to interact in the usual fashion with family
members with friends.
The clients self- esteem and self- concept may also be affected to a certain illness
which can also change the clients body image or physical appearance. Many factors can
play a part in low self- esteem and a disturbance in self- concept: loss of body parts and
function, pain, disfigurement, dependence on others, unemployment, financial problems,
inability to participate in social functions, strained relationship with others, and spiritual
distress.
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2. DIAGNOSTIC RESULTSDiagnostic Test Normal Values Patients Result Significance
Blood Chemistry
*Sodium
*Potassium
*FBS
*Creatinine
Hematology
*Haemoglobin
*Haematocrit
*WBC
*Neutrophil
135- 155 mmol/L
3.5- 5.5 mmol/L
3.33 6.10 mmol/L
M:61.8-123.7 mmol/L
F: 53- 97.2 mmol/L
M:134- 180 g/L
F:120- 160 g/L
M: 44- 54 vol. %
F: 38- 45 vol. %
5- 10 x 10/ L12
55-75%
153.5mmol/L
3.8mmol/L
a. mmo
l/L
180.3 mmol/L
90 g/L
28.4 %
8.7 x 10 /L12
75.1%
Normal
Normal
Normal
Increase; indicates
systemic disease
such as
hypertension and
renal insufficiency
(Ref: Joyce Black
And J. Hawks,
Medical- Surgical
Nursing, 8th
Edition,
Pp. 1383 & 2000-
2001)
Decrease; indicates
hemodilution (fluid
overload)
Decrease; indicates
hemodilution (fluid
overload)Normal
Slightly increase;
indicates acute
infection
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*Lymphocytes
*Monocytes
Urinalysis
Macro:
*Blood
*pH
*SpecificGravity
Micro:
*WBC
*RBC
20- 35%
2-6%
Negative
6-8
1.010- 1.025
Negative
Negative
18. 9%
6.0%
Negative
6.01.015
0-1HPF
0-1 HPF
Decrease; indicates
exhausted immune
system
Normal
(Ref: Barbara
Kozier, Glenora
Erb, At Al,
Fundamentals Of
Nursing, 7th
Edition
2004, Pp. 759t)
Black and Hawks;
Medical- Surgical
Nursing; 8th
edition,
volume 2, pp. 2001
Normal
Normal
Normal
Normal
Normal
(Ref: www.
Naturalhealthtechni
ques.com
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The chest x-ray done on August 19, 2010 was indicated to view the structures of
the chest (bones, heart, lungs) for any abnormalities. Also, the client was suspected of
Pulmonary Tuberculosis and Community-Acquired Pneumonia so this chest x-ray is to
rule out or confirm said conditions. It is also indicated for a definite diagnosis of
cardiomegaly or congestive heart failure in the patient and is done to reassess the patient's
heart condition (size, shape, structure). The chest x-ray revealed that there are high
suspicions of granulomatous pulmonary nodule in the right upper lung zone.
Inflammatory process is also considered in the left upper lung zone. It also suggested
undergoing another chest x-ray in an apicolordotic view for further evaluation of
athermanous and tortuous aorta.
Ultrasound was performed on August 22, 2010 to view the peritoneal cavity and
identify possible problems that may be the cause of hematuria. A part that has been
examined is the flat plate of the abdomen. Finding shows that the marginal sclerosis and
osteophytes are already widen on the bodies of the lumbar vertebrae with preserved disc
spaces. In addition, ultrasound revealed non- obstructive bowel pattern. There is also a
degenerative change of the lumbar spine.
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3. PRESENT PROFILE OF FUNCTIONAL HEALTH PATTERN
GORDONS HEALTH PATTERN
I. Health Perception Health Management PatternPrior to hospitalization, the patient experienced diarrhea and weakness after he drinks
tuba. He had his unusual pattern of eating due to abdominal pain experienced by the
patient.
During hospitalization, the SO was aware that the patient had hypertension. Their
goals were to recover their father and were able to discharge as soon as possible. During
assessment, patient was weak and could not mobilize his body properly. He could not
open his eyes and could utter only few words in low voice. Upon admission, the patient
received 3 Litters per minutes of Oxygen immediately and 1 tablet of 100 mg of
Spironolactone twice a day.
II. Nutritional Metabolic PatternPrior to hospitalization, patient was fond of eating foods that are rich in oil and fat
such as Humba and drinking tuba at least 1 litter. According to the SO, he does not have
any allergy in foods and in medicine. She claimed that his father could not eat properly
because of the incomplete teeth and can only eat soft foods like lugaw and cereals. He
drinks water at least 5 to 6 glasses of water only per day.
Upon hospitalization, patient could not eat properly because he could not chew the
food properly and he could not eat in sitting position unless assisted by his significant
other due to the developing ascites and abdominal pain. The SO verbalized, Pukawon ra
na siya namo ug mukaon na siya. The patient has low sodium, low- fat diet as prescribed
by the physician. The SO also added that his father drinks water in small amount and
could not drink at least 2 glasses in a day and or sometimes just a sip of it.
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III. Elimination PatternTwo weeks prior to hospitalization, patient was experiencing watery stool in small
amount. Nakalibang siya kadtong ning labay nga duha ka-adlaw, dulaw nya basa ug
gamay ra kayo, as verbalized by the SO. He can urinate two times a day without any
pain upon urination. Eight days prior to admission, SO added that his fathers feet were
swelling and getting bigger after experiencing abdominal pain.
Upon hospitalization, Gikan atong na- admit siya nya nahatagan na ug tambal, mag-
ihi- ihi siya. Manga unom ka-beses o sobra pa sa usa ka-adlaw. Pero wala pa siya
nalibang sukad adtong na-admit siya as verbalized by the SO. During the assessment,
patient urinates in a bed pan and his urine was yellowish to clear in colour. His feet were
still swelling and his abdomen develops ascites and both of it were yellowish in colour.
IV. Activity Exercise PatternAccording to the SO, patient can walk slowly when assisted with grandson. He just
stayed in their house most of the time and watching TV every afternoon.
During hospitalization, patient was lying in his bed. He could not sit down by himself
due to the ascites and abdominal pain. He sleeps most of the time and awakes when the
time he ate and was assisted by his SO. He needs assistance in urinating using the bed
pan.
V. Sleep- Rest PatternAccording to the SO, prior to admission, patient sleeps around 8 P.M. and awakes at
around 7 A.M. or sometimes 8 in the morning. He sleeps for about 1 to 2 hours every
afternoon whenever he does not watch television.
Upon hospitalization, the SO states that, Mag sige ra siya ug katug, makamatngon
gad siya kung among pukawon, naay oras nga mag sige ra siya ug katug jud nya amo na
lang pukawon pagpakaon.
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VI. Cognitive- Perceptual PatternPrior to admission, SO stated that, the patient has defect in his sight and hearing. But
patient was not able to use any aid or any devices in his sight and hearing problem.
During hospitalization, the patient is conscious and oriented to place. During the
assessment, patient sleeps most of the time and talk when he needs something to do with
his SO like when he wants to urinate. He can utter few words in low voice when he asked
and express facial expression when experienced pain.
VII. Self- Perceptual PatternAccording to the SO, prior to admission, the patient experienced poor appetite. He
showed unwillingness when his wife asked about his condition. The SO also added that
they were concerned about his fathers condition especially to his abdomen because of
the ascites and in financial aspects too.
During the hospitalization, the patient becomes thin and sometimes unresponsive. The
SO stated that, Bahala na lang kung kulang amo kwarta basta ang amo lang ang
pagpakaayo sa among amahan nga mabalik lang iyang panglawas ni-ari.
VIII. Role Relationship patternThe family of Mr. V is said to be extended and patriarchal. He lives with his wife
who is 86 years old. His two grandsons live also with them who helped in their daily
needs. According to his wife, they depend to their 5 daughters who supported them
financially. Their 5 daughters were separated from them and all of them were married.
During the stay of the patient in the hospital, their children always contribute to the
medical expenses of the client. Currently, they feel worried about their father's condition
and contribute to any way they can to alleviate his condition. The usual problem of the
family involves the drinking habit of the patient and financial problems. They usually
resolve it by conversations with the family.
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IX. Sexuality- Sexual FunctionMr. V is a 90 years old male, married with 5 children. According to his wife, she and
his husband has not engaged in sexual intercourse in recent years. She claims that this is
because they are already old. She also added that, her daughter noticed that there is a
whitish secretion on the penis of his father when she cleansed her fathers genitalia.
X. Coping- Stress ManagementAccording to the SO, patient stays only on their house. When his father experienced
pain, they just let their father rest and no medications were given to alleviate to ease the
pain. And during the hospitalization, she claimed that his father always lying on bed and
always sleeping. In addition, they helped his father to cope with his condition by
changing his lifestyle for the better, avoiding foods that are contraindicated to his fathers
condition and taking rest periods. However, the patient does feel bothered about the
expenses incurred by his children for his medical condition.
XI. Value- Belief SystemMr. V and his family was Roman Catholic but seldom visit a church. According to
the SO, it was long time ago when his father visit the church. They believe in Kwak
doctors but they were not able to consult in a Kwak doctor once. During the
hospitalization, they do not wish to see a priest at present. According to the SO, their
family accepts of his fathers condition. They do not fear death but they wishes that their
father will live longer for their family.
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4. PATHOPHYSIOLOGY AND RATIONALE
4.1 Anatomy and Physiology
To understand what occurs in heart failure, it is useful to be familiar with the
anatomy of the heart and how it works. The heart is composed of two independent
pumping systems, one on the right side, and the other on the left. Each has two chambers,
an atrium and a ventricle. The ventricles are the major pumps in the heart.
The external structures of the heart include the ventricles, atria, arteries, and
veins. Arteries carry blood away from the heart while veins carry blood into the heart.
The vessels colored blue indicate the transport of blood with relatively low content of
oxygen and high content of carbon dioxide. The vessels colored red indicate the transport
of blood with relatively high content of oxygen and low content of carbon dioxide.
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The Right Side of the Heart
The right system receives blood from the veins of the whole body. This is "used" blood,
which is poor in oxygen and rich in carbon dioxide.
y The right atrium is the first chamber that receives blood.
y The chamber expands as its muscles relax to fill with blood that has returned from
the body.
y The blood enters a second muscular chamber called the right ventricle.
y The right ventricle is one of the heart's two major pumps. Its function is to pump
the blood into the lungs.
y The lungs restore oxygen to the blood and exchange it with carbon dioxide, which
is exhaled.
The Left Side of the Heart
The left system receives blood from the lungs. This blood is now oxygen rich.
y The oxygen-rich blood returns through veins coming from the lungs (pulmonary
veins) to the heart.
y
It is received from the lungs in the left atrium, the first chamber on the left side.
y Here, it moves to the left ventricle, a powerful muscular chamber that pumps the
blood back out to the body.
y The left ventricle is the strongest of the heart's pumps. Its thicker muscles need to
perform contractions powerful enough to force the blood to all parts of the body.
y This strong contraction produces systolic blood pressure (the first and higher
number in blood pressure measurement). The lower number (diastolic blood
pressure) is measured when the left ventricle relaxes to refill with blood betweenbeats.
y Blood leaves the heart through the ascending aorta, the major artery that feeds
blood to the entire body.
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The Valves
Valves are muscular flaps that open and close so blood will flow in the right direction.
There are four valves in the heart:
y The tricuspid regulates blood flow between the right atrium and the right
ventricle.
y The pulmonary valve opens to allow blood to flow from the right ventricle to the
lungs.
y The mitral valve regulates blood flow between the left atrium and the left
ventricle.
y The aortic valve allows blood to flow from the left ventricle to the ascending
aorta.
The Heart's Electrical System
The heartbeats are triggered and regulated by the conducting system, a network of
specialized muscle cells that form an independent electrical system in the heart muscles.
These cells are connected by channels that pass chemically caused electrical impulses.
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4.2 Schematic Diagram of the Disease Process
Congestive Heart Failure
Non- modifiable Risk Factor Modifiable Risk Factor
*Family History of
Hypertension (Father)
* Age (older than 65)
*Gender (Men)
Race
*Lack of access tomedical service due to
low socio- economicstrata (unemployed)
*Poor Nutrition
(inadequate food intake)
*High Sodium andCholesterol in diet
Alcohol Consumption
Sedentary Lifestyle
Decreased elasticity of blood vessels and
formation of plaques on blood vessels
Narrowing of the blood vessels
Necrosis and Scarring of the vascular endothelium
Impediment of blood flow to the body
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Increased workload of the heart
Dilation of ventricles
Increased in preload
Increased in stretching of myocardial muscle
Excessive stretching of myocardial muscle
Ineffective cardiac muscle contraction and
increase Oxygen demand of cardiac muscle cells
Decreased contraction of cardiac muscle
Decreased cardiac output and systemic perfusion
Activation of neurohormonal pathways in
order to increase circulating blood vessels
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Continued neurohormonal stimulation
Cardiac remodeling
Decreased blood filling
Increased stroke volume and
decreased cardiac output
Inadequate perfusion Increased wall
tension
Separation of
mitral valve
Increase pulmonary
pressure
Impaired left
ventricular relaxation
*Pallor Decreased
blood flow
to the
kidney
Decreased
perfusion in
the coronary
arteries
Increased
pulmonary
pressure
*Fatigue
&weakness
Deprivation
of cardiac
muscles cells
of nutrients
needed for
survival
Kidney produce
hormone
Salt & water
retention
*Edema
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Normal balance
between Oxygen
supply &demand is
disrupted
Increased diastolic
pressure exceeding
hydrostatic & osmoticpressure in pulmonary
capillaries
Ischemia Increased capillary
ressure in the lun s
Fluid shifts from the
circulating blood into
the interstitial,
bronchioles, bronchi
and alveoli
Conversion of
aerobic metabolismto anaerobic
metabolism
Pulmonary
congestion
Decreased
lung
expansion
Fluid trapped
in pulmonary
trees
*Dyspnea
*Bilateral
Crackles
Decreased
adenosine
Causes reduced
contractility
Increasedlactic acid
production
Decreased thehearts ability
Irritation of
myocardial
cells
Chest Pain
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4.3 Discussion of the Disease Process
Regardless of the precipitating event, the common mechanism of heart failure is
quite complex. Compensatory mechanisms exist on every level all the way to organ
interactions. When this compensatory mechanisms and adaptation are overwhelmed,
heart failure happens (MacIntyre, et. al, 2000). In this section, it focuses on the
pathophysiological mechanisms that led to the presentation of signs and symptoms of the
client, and its current treatment and identified nursing diagnosis. Figure above shows the
pathophysiology of the disease with the risk factors, presenting signs and symptoms.
Porth (2007) discloses that due to the infiltration of group A beta-hemolytic
streptococci, antibodies in the body react to destroy the bacteria simultaneously causing
acute inflammation to the heart. During the acute inflammatory stage of the disease, the
valvular structures become swollen. Small vegetative lesions develop on the valve
leaflets. It then proceeds to the development of fibrous scar tissue which tends to contract
and cause deformity of the valve leaflets and shortening of the chordae tendinae.
During much of the systole, the mitral valve is subjected to high pressure
generated by the left ventricle as it pumps blood to the systemic circulation. Increased
preload occurs because the incomplete closure of the mitral valve permits the
regurgitation of blood from the left ventricle into the left atrium (Porth, 2007). In
addition, incomplete closure of the aortic valve also results in increased preload as the
left ventricle is forced to pump the entire diastolic volume received from the left atrium
and the regurgitant volume from the aorta. Increased afterload occurs as there is increased
pressure for the heart to generate the movement of the increased volume from the left
ventricle into the aorta. The increased volume work causes increased pressure for the left
ventricle to pump more blood. This eventually leads to left ventricular hypertrophy
(Porth, 2007).
As the workload increases, the walls of the chamber grow thicker, losing their
elasticity and eventually may lead to myocardial dysfunction and eventually myocardial
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failure (Woods, et. al., 2010). This results to the failure of the heart to pump with as much
force as a healthy heart. Systolic dysfunction or failure is evident leading to altered
systemic perfusion and decrease in end-systolic volume. A decrease in end-systolic
volume causes a decrease in cardiac output which also contributes to the decrease
perfusion of tissues in the body. Alterations in systemic perfusion result in
neuroendocrine activation. This includes increase in sympathetic activity, activation of
the renin-angiotensin-aldosterone pathway and eventual decrease in oxygen supply in
tissues.
Woods (2010) explains that increased activity of the sympathetic nervous system
or the renin-angiotensin-aldosterone system [RAAS] results in vasoconstriction of the
small arterioles. In the RAAS, vasoconstriction leads to increased peripheral vascular
resistance. The RAAS also increases aldosterone production thus enabling the retention
of sodium and water. This leads to an increase in plasma volume. Increased plasma
volume and decreased end systolic volume leads to increased venous pressure to the
lungs. This increase in hydrostatic pressure causes an increase in the rate of filtration of
fluid out of the capillaries and into the interstitial compartment (Woods, 2010). As a
result, the lungs fill with fluid, a condition called, pulmonary edema and eventually
pulmonary congestion.
On the other hand, increased activity of the systemic nervous system is caused by
the release of epinephrine and norepinephrine (Porth, 2007). The purpose of this initial
response is to increase heart rate and contractility and support the failing myocardium.
Sympathetic stimulation causes peripheral vasoconstriction. Peripheral vasoconstriction
may cause capillary endothelial damage.
Decreased oxygen supply in tissues is detrimental because if oxygen delivery to
cells is insufficient for the demand, prolonged compensatory mechanisms can lead to cell
death (Hobler & Karey, 1973). Decreased perfusion to the tissues and eventual decrease
in oxygen supply causes increased myocardial workload as it attempts to compensate for
the reduction (Smeltzer & Bare, 2010). Eventually, compensatory mechanisms fail and
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- Crackles in the
lungs
- Fatigue and
weakness
Manifested
Manifested
- Adventitious breath
sounds may be heard
in various areas of the
lungs. Usually,
bibasilar crackles that
do not clear with
coughing are detected
in the early phase of
left ventricular failure.
Crackles, heard
initially in the lung
bases, and when
severe, throughout the
lung fields suggest the
development of
pulmonary edema
(fluid in the alveoli).
Source:
http://www.medicine.com
/congestive_heartfailure/a
rticle.html
- Less blood to your
major organs and
muscles makes you feel
tired and weak.
Inadequate cardiac
output leads to hypoxic
tissues and slowed
removal of metabolic
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- Jugular vein
distention
- Nocturia
Manifested
Not manifested
wastes, which in turn
cause the client to tire
easily.
Source:
- Black, Joyce M. et.al;
Medical Surgical
Nursing Clinical
Management for
Positive Outcomes; 8th
edition; volume 2; p.
1437
- The right side of the
heart cannot eject blood
and cannot
accommodate all the
blood that normally
returns to it from the
venous circulation. The
increase in venous
pressure leads to
jugular vein distention.
Source:
http://www.medicine.co
m/congestive_heartfailu
re/article.html
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- Shortness of
breath (dyspnea)
- Sleep apnea
- Sudden weight
gain
Manifested
Manifested
Manifested
- With failure of the left
ventricular
myocardium (heart
muscle), the blood
tends to backup in the
lungs with elevated
pressure causing
shortness of breath
(dyspnea), orthopnea
(having to sit to
breathe) and
paroxysmal nocturnal
dyspnea
Source:
http://www.medicine.co
m/congestive_heartfailu
re/article.html
- As the body becomes
overloaded with fluid
from congestive heart
failure, patient may
experience a sudden
weight gain.
Source:
http://www.medicine.com
/congestive_heartfailure/a
rticle.html
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- Swelling (edema)
in legs, ankles
Manifested - Edema from congestive
heart failure is a result
of the heart inability to
pump blood and fluids
back through the
cardiovascular system.
As the fluid "waits" to
be pumped back
through the heart, it
builds up in the leg and
begins to "leak" out of
the permeable structure
of the veins.
Source:
http://www.medicine.com
/congestive_heartfailure/a
rticle.html
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IV. NURSING INTERVENTION
4.1 Care Guide of Patient with Disease Condition
The following are the goals of nursing management for the client with HeartFailure:
Guidelines Interventions
y Adhere to dietary restrictions
y Monitor blood pressure
y Modify activity
Sodium in the diet should be
limited to 4 g per day initially
until fluid and weight gain are
controlled.
Fluid restriction may also be
needed. Follow as what the
physician advice.
Clients or family members
should be taught how to
measure BP daily, especially if
the client has diastolic heart
failure.
During the severe stages of
heart failure, the client should
remain on bed rest with the
head of the bed elevated and
elastic stockings or wraps
worn to mobilize edema. Once
the client can breathe
comfortably during activity,
activity should be increased
gradually to help increase
strength.
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y Adhere to medications The multiple medications will
require some type of system to
prevent missed or duplicate
doses. Instruct to take the
diuretics in the morning to that
trip to the bathroom happen
during the day. Taking
diuretics in the evening or at
night often results in
interrupted sleep because the
urge to empty the bladder
continues for hours.
Reference: Black and Hawks,
Medical and Surgical Nursing 8th
edition, pp1446- 1447