intro-chf edited

8/7/2019 intro-chf edited

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INTRODUCTION

Congestive heart failure, or heart failure, is a condition in which the heart isunable to adequately pump blood throughout the body and/or unable to prevent bloodfrom "backing up" into the lungs. It is present in 2 percent of persons age 40 to 59, more

than 5 percent of persons age 60 to 69, and 10 percent of persons age 70 and older. Itis greater in males than in females in patients aged 40-75 years. These risks includehaving diabetes, high cholesterol, obesity, having a lot of long-term stress, smoking, asedentary lifestyle and drinking excessive amounts of alcohol. In most cases, heartfailure is a process that occurs over time, when an underlying condition damages theheart or makes it work too hard, weakening the organ. Other less common causes ofCHF include valvular heart disease, hypertension, alcoholic cardiomyopathy, anddilated cardiomyopathy. In addition, there are rare causes, one of which is thyroidstorm.

Thyroid storm, also referred to as thyrotoxic crisis, is an acute, life-threatening,

hypermetabolic state induced by excessive release of thyroid hormones (THs) inindividuals with thyrotoxicosis. Because thyroid storm is almost invariably fatal if leftuntreated, rapid diagnosis and aggressive treatment are critical. Cardiac complicationsfrom thyrotoxicosis include arrhythmias, congestive heart failure, and pulmonaryhypertension. Congestive heart failure in thyrotoxicosis is predominantly caused byeither persistent tachyarrhythmias (tachycardia-induced cardiomyopathy) oruncontrolled hypertension as a consequence of thyrotoxicosis. Systolic dysfunction canoccur as a consequence of the persistent cardiac arrhythmias, but it usually resolvesonce the hyperthyroid state is treated. Pulmonary hypertension can also occur inthyrotoxicosis, either as a result of a primary effect of thyroid hormone on pulmonaryarteriolar resistance vessels, decompensated left heart failure, or via increased

pulmonary arterial blood flow (high-output).

Clinically significant CHF due to hyperthyroidism/thyroid storm is considered arare occurrence. Initially in the course of the disease, the patient is in a high cardiacoutput state, due to the factors mentioned above, limiting only exercise tolerance. Laterin the course of the disease, if untreated, the patient can develop severe systolicdysfunction with overt signs and symptoms of heart failure. This is more commonly seenin patients with pre-existing heart disease, such as ischemic, hypertensive, or alcoholiccardiomyopathy, the former being more common in the elderly.

Making a diagnosis of congestive heart failure includes a complete medical

evaluation, medical history, physical examination and diagnostic tests such as ECG,echocardogram, lab studies( BUN, creatinine, thyroid stimulating hormone, CBC andurinalysis), chest radiographs, etc. Symptoms that may be present is based on whatside of the heart is affected. In left sided heart failure, manifestations include arepulmonary congestion, cough, fatigability, tachycardia with S3 sound, anxiety, restless,dyspnea, bibasilar crackles etc, while in right sided failure, congestion of viscera andperipheral tissues, dependent edema, ascites weakness, nocturia etc are present.

With regard to the management of cardiac symptoms related to thyrotoxicosis,treatment is focused on reducing adrenergic drive to the heart and restoring normalcardiac rhythm. Beta-blockers are very effective for rapid hemodynamic improvement.

Either propranolol or metoprolol given intravenously can be used to improve heart ratecontrol either in sinus tachycardia or atrial fibrillation. In severe cases, a continuousinfusion of esmolol may be required for rate control. Amiodarone should be avoidedwhen treating atrial fibrillation from thyrotoxicosis because of its high iodine content,which may induce or exacerbate thyroid storm. If a patient is hemodynamically unstablefrom atrial fibrillation, direct current cardioversion should be employed. If symptoms ofpulmonary congestion appear, diuretics may be used. Other drugs for heart failure
http://www.wrongdiagnosis.com/d/diabetes/intro.htmhttp://www.wrongdiagnosis.com/c/cholesterol/intro.htmhttp://www.wrongdiagnosis.com/o/obesity/intro.htmhttp://www.wrongdiagnosis.com/o/obesity/intro.htmhttp://www.wrongdiagnosis.com/s/smoking/intro.htmhttp://www.medscape.com/resource/thyroid-diseasehttp://www.wrongdiagnosis.com/c/cholesterol/intro.htmhttp://www.wrongdiagnosis.com/o/obesity/intro.htmhttp://www.wrongdiagnosis.com/s/smoking/intro.htmhttp://www.medscape.com/resource/thyroid-diseasehttp://www.wrongdiagnosis.com/d/diabetes/intro.htm


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(angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and/oraldosterone receptor antagonists) are reasonable agents in patients who havedepressed left ventricular systolic function.

The treatment of heart failure depends on the exact cause, but it can usually be

treated effectively. The overall goals of treatment are to correct underlying causes, torelieve symptoms, and to prevent worsening of the condition. Symptoms are relieved byremoving excess fluid from the body, improving blood flow, improving heart musclefunction, and increasing delivery of oxygen to the body tissues. Severe heart failure mayrequire surgery, such as balloon sedilaton of artery blockages, heart transplantation,pacemaker implants to control the heart rhythm, and insertion of portable pumps toinfuse medications. In cases of valve defects, surgery to repair or replace the damagedvalves may be necessary.

This case study involves a patient who was diagnosed to have Congestive HeartFailure class III secondary to thyrotoxic heart disease. The said diagnosis captures our

attention since it was concerning three major systems in the body the cardiovascularrespiratory and endocrine. It is also a great opportunity for us students to handle patientwith this particular diagnosis in which a heart disease occurred due to a complication ofthyroid storm.

OBJECTIVES

General

To describe the nature of the disease (Congestive Heart Failure) with thyrotoxicheart disease as its primary cause.

Specific

To gather pertinent data regarding the course of treatment to a patient with thesaid diagnosis

To develop an appropriate nursing diagnosis to the patient with the disease. To discuss the 3 body systems involved: cardiovascular, endocrine and

respiratory system and explain how they affect each in this given diagnosis To identify methods and tests used to confirm the disease. To identify the different nursing considerations based on physical assessment,

laboratory results when caring patient with congestive heart failure.

To explain the different treatment options in managing pt with congestive heartfailure.

THEORETICAL FRAMEWORK

Roys Adaptation Model

Sister Callista Roy defines adaptation as The process and outcome whereby thethinking and feeling person uses conscious awareness and choice to create human andenvironmental integration. Roys work focuses on the increasing complexity of person


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and environment self organization, and on the relationship between and amongpersons, universe and what can be considered a Supreme Being or God.

We have determined that the pt. who is involved in this case has an alteration inthe four modes as formulated by Sister Callista Roy.

1. The physiologic mode involves the bodys basic physiologic needs andway of adapting with regard to fluid and electrolytes, activity and rest,circulation and oxygen, nutrition and elimination, protection, the sensesand neurologic and endocrine function. In our pt. he suffers from difficultyof breathing which was the main reason for seeking medical attention.Therefore oxygen, adequate rest and proper positioning were rendered inorder to return his normal breathing pattern. Fluid volume excess wasalso seen to be a pt. problem that is why medication (diuretic) wasadministered and diet modification was applied.,

2.The self-concept mode includes two components: the physical self, whichinvolves sensation, and body image and the personal self, which involvesself-ideal, self- consistency and the moral- ethical self. The physical selfwas compromised for the reason that he has a Congestive Heart Failurein which he suffers from weakness, dizziness and other symptoms thatcaused a change in normal body functioning. For the Personal selfthe pt.is an alcoholic drinker, smoker and was once used an illegal drugs due tostress, so there is an ineffective coping mechanism.

3. The role function mode is determined by the need for social integrity andrefers to the performance of duties based on given positions withinsociety. Before, the pt. was applying for another job, but since he wasconfined, he could not pursue it anymore.

4. The interdependence mode involves ones relations with significant othersand support systems that provide help, affection, and attention. At his agethe pt. does not have his own family which made him too dependent to hismother and sisters.

After determining the demand that caused problem to the client, the nursing careis then directed at helping the client to adapt in his present situation. For the patient whois the center of this case, health teaching is appropriate regarding his social lifestyle,explaining the importance of smoke cessation and withdrawal from alcohol intake isnecessary to prevent further complications. Strict compliance in the diet is alsoessential, thus significant others must include in the teaching for the implementation of alow fat and low salt diet. Teaching the importance of having a routine consultation isneeded in his present situation. Above all this, it is also essential that the pt. is obligedto help himself to achieve a fast recovery by complying with prescribed drugs, dietmodification and following the physicians order.

Clients Presentation

Nursing History

A. Biographical Data


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Mr. RJ is a 37 yrs old male and single who lives at Mandaluyong City with hismother. His 2 sisters have their own family and works abroad. He was born on March15, 1973 and he is Protestant. He just lost his job as a company driver when he gotsome health problems. He was admitted at ER 11: 10 am in Mandaluyong City MedicalCenter with complaints of difficulty of breathing, and dizziness. He was transferred to

ICU around 4:30 pm.

B. Reason for seeking health care

The patient complained of difficulty of breathing and dizziness.

C. History of Present Illness

The patient was apparently well, two days prior to admission the patient

experienced dyspnea while washing his clothes. Therefore he decided to take somerest and eventually it was relieved and he also refused to seek medical attention. Thenthree hours prior to admission the patient complained again of dyspnea with bodyweakness and felt dizzy. He was brought to Mandaluyong city medical center (ER) dueto above complaints. He was diagnosed of CHF class III secondary to thyrotoxic heartdisease. On the same day he was transferred to Intensive Care Unit (ICU). He had anadmitting vital signs of 90/60mmHg for blood pressure, 24 cpm for respiratory rate,110bpm for pulse rate and 38.10C for temperature.

D. Past Health History

Prior to

Medicalhistory

The patient has been hospitalized last March 2010 due tohyperthyroidism. He manifested symptoms of palpitations,nervousness, heat intolerance and weight loss. During his stay at thehospital, necessary interventions were given that helped his conditionto improve. When he was discharged, he was not able to work wellwhich made him lost his job. Precipitating factors such as smoking,using of illegal drugs (shabu), drinking alcoholic beverages, stressand failure to comply with his home medications lead to worsening ofhis symptoms.

Surgicalhistory

The patient doesnt undergo any surgical procedure.

HomeMedications

Prophythiouracil (PTU) for maintenance 150 mg PO

Allergies None

Injuries andaccidents

None

Childhoodillness

immunizatio

n

Complete

E. Family History

Content Spouse

Children

Siblings Parents

The patient has 2 older The patients father


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Age andhealthstatus

N/A N/Asisters which currentlyworks abroad and havetheir own family. The eldestsister is 42 years old whilesecond elder sister is 40

years old. Theircommunication is not toooften and sometimes theygive money for hismedications.

who was 64 years olddied due tocerebrovascularaccident (CVA) last2003. While his

mother also sufferedfrom CVA last 2004.

F. Social History

The patient started to drink alcoholic beverages and smoke when he was25 years old. He consumes 3 packs of cigarettes a day (1095 packs a day) while

drinks alcohol every other day. The patient also engaged himself in using illegaldrugs such as shabu and marijuana due to stress. The patient usually spends histime inside the house. He previously worked as a company driver. Hes fond ofwatching television when his at home. His previous work caused him the stress whichresulted to usage of illegal drugs. Hes an undergraduate student and he is financiallysupported by his sisters. His family is an active protestant member while he seldomattends church.

GORDONS 11TH HEALTH FUNCTIONAL

PATTERN

I. HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN

BEFOREHOSPITALIZATION

DURINGHOSPITALIZATION

( Nov 15- Dec 22, 2010)

INTERPRETATION

He described himself asphysically fit since he hascapability to do tasks of hisdaily activities on his own.He consumes 3 packs ofcigarettes a day and drinksalcoholic beverages every

other day. He rememberedhaving a completeimmunization during hischildhood years. He fairlylives conditionally at home.

The patient was admitteddue to difficulty ofbreathing, dizziness andweakness. He felt betterwhen he received somecertain procedures toimprove his condition. He is

participative on his plan ofcare that he continuouslytakes his medications andalso decided to quitsmoking and drink alcoholdue to his current condition.

Achieving and maintaininghealth is a process thatneeds effective strategiesfor staying healthy andimproving one's health.Despite of the patientsprevious habit, he realized

that it will just worsen hiscondition so he stoppeddoing his vices andadhering to his treatment.


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II. NUTRITIONAL- METABOLIC PATTERN



( Nov 15- Dec 22, 2010)

INTERPRETATION

He makes sure that he ismaintaining his properweight, has good appetite,no food intolerance or anydietary restrictions. He eats

different types of foodespecially fried like chicken,fish and egg. He alsomakes sure that he wontget dehydrated by taking anaverage fluid intake of 3liters per day

The patient had beenadvised to have a low-fatand low salt diet to preventany worsening ofsymptoms. His fluid intake

has also been decreasedof about 1 liter/day.

A human body cannot existfor a long time withoutenough nourishment fromfood. We eat food o sustainlife, to enable us to grow &

be healthy so that we cancarry out our task at work atplay. The patient has a dietto have him a stablecondition and preventcomplications particularlydifficulty of breathing due tolungs congestion and edemais also present on his lowerextremities. Decreased fluidintake is necessary.

III. ELIMINATION PATTERN



( Nov 15- Dec 22, 2010)

INTERPRETATION

There are no strainswhenever he had a bowelmovement. Normally, hedefecates twice a daywhich is in morning and atevening. He would easilyeliminate his bowelmovement. Voiding wouldalso not be a problem sincehe urinates 7 times a day.

His bowel movement habitand urine output isinconsistent upon admitted.He defecates once a daywhile urinates 10 times aday. Foley catheter wasalso been inserted on hisfirst few weeks in thehospital and was beenremoved when he was ableto do so. During our duty,the patient can alreadyambulate therefore he was

Elimination patterndescribes the regulation,control, and removal of by-products and wastes in thebody which is an essentialfunction in our body. On thepatients condition,elimination pattern isaltered due to decreasedgastrointestinal and renalperfusion. Medication likediuretics caused his urineoutput to increase.


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able to go to the comfortroom by himself.

Insertion of foley catheterintend to conserve theenergy of the patient.

IV. ACTIVITY-EXERCISE PATTERN



( Nov 15- Dec 22, 2010)

INTERPRETATION

Patient is completelyindependent in doingeveryday activities such ashygiene, grooming, toiletingand other health careneeds. He spends his timewatching television, andlistening to music.

Since he was hospitalized,his activities were limited tositting, standing and lyingon bed due to weakness.

Exercise is important to thephysical and mental healthof every individual as it canhelp continue to do thethings and stayindependent without therisk of disease. Thepatients immobility weredue to breathlessness andweakness but as days

passed, his conditionimproved which made himable to do some of hisADLs.

V. SLEEP REST PATTERN



( Nov 15- Dec 22, 2010)

INTERPRETATION

He can easily sleep at nightcompletely for about 6-8hours upon getting homefrom work. But before headmitted he wasnt able tosleep well.

The patient stated that hehas difficulty of sleepingdue to shortness of breathin a flat position. He needsto be in fowlers position tobe able to sleep.

Poor sleeping habits canhave a direct influence, notonly on the quality, but alsoon the length of life as itaffects physical well being.The patient must do somepositioning or have anoxygen therapy to haveadequate rest and sleep toovercome his fatigue andbody weakness.


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VI. COGNITIVE- PERCEPTUAL PATTERN



( Nov 15- Dec 22, 2010)

INTERPRETATION

Patient is alert, orientedand conscious. He speaksnormally to his knownlanguage which is Filipino.The patient does notuse/wear any eyeglasses tohave a clear vision. Whenproblem arises, he candefine the problem and

seek for a solution toresolve it.

He still doesnt use/wearany eyeglasses to have aclear vision. His othersenses were not affectedas well. He was weak onthe first day of his stay andwas able to ambulate asthe day progresses.

A person needs to bementally alert to do thingsaccurately and run hisactivities or dos in rightway. The patients normalfunctioning of senses helpshim perform things easilyand keep his well beinghealthy that prevents health

problems. Fatigue and bodyweakness must beovercome by propernutrition, adequate rest,sleep and medications

VII. SELF PERCEPTION AND SELF CONCEPT PATTERN



( Nov 15- Dec 22, 2010)

INTERPRETATION

He doesnt have a work tomake him busy. Therefore,

he has more time indrinking alcoholic drinksand smoking.

His concern at the momentis to be treated from his

illness and have a fastrecovery. He views lifepositively. He is open towhatever will happen to himin the future.

A positive or negative viewto our self can affect our

well being. The patientspositive outlook in life isimportant for it will help himto realize that beingparticipative on his plan ofcare is essential that will aidon his fast recovery.


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VIII. ROLE - RELATIONSHIP PATTERN



( Nov 15- Dec 22, 2010)

INTERPRETATION

He is single and lives withhis mother. He is activesocializing and iscomfortable meeting newpeople.

Only his mother whoaccompanied him in thehospital. Due to hiscondition, he was not ableto socialize with his friends.

We have different role inlife. Even though the patientwas not satisfied on hiscurrent situation, he wastrying to do the tasks thatwill promote his recoveryand be able to assume hisrole as a son.

IX. SEXUALITY- REPRODUCTIVE PATTERN



(Nov 15- Dec 22, 2010)

INTERPRETATION

He is single and his sexualneeds are not met. Thepatient does not have anyreproductive health

problems or anydysfunctions.

It stays the same. Having a partner is one ofthe basic needs of aperson. Although thepatient doesnt have his

own family and sexualneeds are not met, he iscontented on what he have


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X. COPING STRESS TOLERANCE PATTERN



( Nov 15- Dec 22, 2010)

INTERPRETATION

The patient was unable totolerate stress whichresulted to smoking,drinking of alcoholicbeverages and usage ofdrug.

He makes sure that stresswont go in his way. Hesleeps to relieve stress andinteracts with other peopleespecially his mother thatserves as his strength whileadmitted.

Stress is a normalpsychological and physicalreaction to the demands oflife that he was able to copeup using techniques thatwould help him relievesstress. Even though thepatient cannot tolerate tomuch stress, it shows thathe was trying to change thisattitude.

XI. VALUE- BELIEF PATTERN



(Nov 15- Dec 22, 2010)

INTERPRETATION

He never had any regrets in

his life. He is a spirituallyinclined person being aProtestant. He prays forguidance and strength onhis everyday life

Even though he is admitted

to the hospital, it would notbe a hindrance to pray. Hestill looks up to pray andbear on his mind and heartthe good values.

Strong faith with God and

good values really helps tosurpass any situations thata person is experiencing.The patients belief wasimportant to help himovercome the problem thathe encountered.


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PHYSICAL ASSESSMENT

Assessment Normal Findings Findings Analysis

a. Generalappearance

b. Vital signsBP

RR

PR

Temperature

Weight

Height

c. Skin

temperatureand moisture

d. Skin color

Relaxed

120/80 mmHg

12-20 cpm

60-100

36.5-37.5

BMI=

53

Warm and moist

According to race

Restless

90/60mmHg

24 cpm(tachypnea)

110bpm

38.1

65 kg

Cold and clammy

Pallor

Resulted fromdecreased brain

perfusion

Due to inability of theheart to pumpsufficient blood

Body is trying tosupply additional

oxygen to meet thebodys demand.

Result of acompensatory

mechanism effort toincrease cardiac

output.

Due to increaserelease of T3 and T4which could affect tobody temperature.

Due to presence ofedema

Stimulated

sympathetic systemcaused peripheralblood vessels to

constrict

Resulted todecreased perfusion


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HEART

The human heart is a muscular organ that provides a continuous bloodcirculation through the cardiac cycle and is one of the most vital organs in the humanbody. The heart is an organ but made up of a collection of different tissues. It is divided

into four main chambers: the two upper chambers are called the left and right atria andtwo lower chambers are called the right and left ventricles. There is a thick wall ofmuscle separating the right side and the left side of the heart called the septum.Normally with each beat the right ventricle pumps the same amount of blood intothe lungs that the left ventricle pumps out into the body. Physicians commonly refer tothe right atrium and right ventricle together as the right heart and to the left atrium andventricle as the left heart.

The electric energy that stimulates the heart occurs in the sinoatrial node, whichproduces a definite potential and then discharges, sending an impulse across the atria.In the atria the electrical signal move from cell to cell while in the ventricles the signal is

carried by specialized tissue called the Purkinje fibers which then transmit the electriccharge to the myocardium.

Heart Circulation

Blood enters the right atrium from the systemic circulation through the superiorand inferior vena cava and from the heart the coronary sinus. Here, the blood flows intothe right ventricle while it relaxes through the tricuspid valve. The right ventricle beginsto contract which pushes blood against tricuspid valve, forcing it closed. After pressurewithin the right ventricle increases, the pulmonary valve is forced to open, and bloodflows into the pulmonary trunk. The pressure within the pulmonary trunk increases as

right ventricle relaxes and the backflow of blood forces the pulmonic valve to close.

The pulmonary trunk branches to form the right and left pulmonary arteries,which carry blood to the lungs, where carbon dioxide is released and oxygen is pickedup. Blood returning from the lungs enter the left atrium through the pulmonary veins. Itthen travels through the mitral valve to the left ventricle, from where it is pumpedthrough the aortic semilunar valve to the aorta and to the rest of the body. The(relatively) deoxygenated blood finally returns to the heart through the inferior venacava and superior vena cava, and enters the right atrium where the process began.

THYROID GLANDThe thyroid gland is a butterfly-shaped organ located in the lower neck, anterior

to the trachea. It consists of two lateral lobes connected by an isthmus. The gland isabout 5cm long and 3cm wide and weighs about 30 g. The blood flow into it is very high,approximately 5x the blood flow to the liver. This reflects the high metabolic activity ofthe thyroid gland.

Hormones

The thyroid gland produces 3 hormones: thyroxine (T4), triiodothyronine (T3) andcalcitonin. T3 and T4 secretion is controlled by TSH(thyrotropin) from the anteriorpituitary gland. TSH controls the rate of thyroid hormone release. In turn, the level ofthyroid hormone in the blood determines the release of TSH.

The primary function of thyroid hormone is to control cellular metabolic activity.T4, a relatively weak hormone maintains body metabolism in a steady state. T3 is about5x as potent as T4 and has a more rapid metabolic action. These hormones acceleratemetabolic processes by increasing the level of specific enzymes that contribute to
http://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Circulatory_systemhttp://en.wikipedia.org/wiki/Cardiac_cyclehttp://en.wikipedia.org/wiki/Human_bodyhttp://en.wikipedia.org/wiki/Human_bodyhttp://en.wikipedia.org/wiki/Heart_chamberhttp://en.wikipedia.org/wiki/Atrium_(heart)http://en.wikipedia.org/wiki/Ventricle_(heart)http://en.wikipedia.org/wiki/Septumhttp://en.wikipedia.org/wiki/Lungshttp://en.wikipedia.org/wiki/Electric_energyhttp://en.wikipedia.org/wiki/Sinoatrial_nodehttp://en.wikipedia.org/wiki/Electric_potentialhttp://en.wikipedia.org/wiki/Purkinje_fibershttp://en.wikipedia.org/wiki/Myocardiumhttp://en.wikipedia.org/wiki/Mitral_valvehttp://en.wikipedia.org/wiki/Aortahttp://en.wikipedia.org/wiki/Inferior_vena_cavahttp://en.wikipedia.org/wiki/Inferior_vena_cavahttp://en.wikipedia.org/wiki/Superior_vena_cavahttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Circulatory_systemhttp://en.wikipedia.org/wiki/Cardiac_cyclehttp://en.wikipedia.org/wiki/Human_bodyhttp://en.wikipedia.org/wiki/Human_bodyhttp://en.wikipedia.org/wiki/Heart_chamberhttp://en.wikipedia.org/wiki/Atrium_(heart)http://en.wikipedia.org/wiki/Ventricle_(heart)http://en.wikipedia.org/wiki/Septumhttp://en.wikipedia.org/wiki/Lungshttp://en.wikipedia.org/wiki/Electric_energyhttp://en.wikipedia.org/wiki/Sinoatrial_nodehttp://en.wikipedia.org/wiki/Electric_potentialhttp://en.wikipedia.org/wiki/Purkinje_fibershttp://en.wikipedia.org/wiki/Myocardiumhttp://en.wikipedia.org/wiki/Mitral_valvehttp://en.wikipedia.org/wiki/Aortahttp://en.wikipedia.org/wiki/Inferior_vena_cavahttp://en.wikipedia.org/wiki/Inferior_vena_cavahttp://en.wikipedia.org/wiki/Superior_vena_cava


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oxygen consumption and altering the responsiveness of tissues to other hormones.These hormones also influence cell replication and are important in brain developmentand normal growth.

LUNGS

Ventilation supplies atmospheric air to the alveoli. The next step in the process ofrespiration is the diffusion of gases between the alveoli and the blood in the pulmonarycapillaries. The respiratory membranes is all of the areas in which gas exchangebetween air and blood occurs.Diffusion of gases in the lungs

Oxygen diffuses into the arterial ends of pulmonary capillaries and carbondioxide diffuses into the alveoli because of differences in partial pressures. As a resultof diffusion at the venous ends of pulmonary capillaries, the PO2 in the blood is equal to

the PO2 in the alveoli and the PCO2 in the blood is equal to the PCO2 in the alveoli. ThePO2 of blood in the pulmonary veins is less than in the pulmonary capillaries because ofmixing with deoxygenated blood from veins draining the bronchi and bronchioles.Oxygen diffuses out of the arterial ends of tissue capillaries and CO2 diffuses out of thetissue because of differences in partial pressures. As a result of diffusion at the venousends of tissue capillaries, the PO2 in the blood is equal to the PO2 in the tissue and thePCO2in the blood is equal to the PCO2 in the tissue.

LABORATORY

NOVEMBER 15, 2010

THYROID FUNCTION TEST

Test Findings ReferenceValue

Analysis Nursing Alert


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T4 13.3 4.0-12 ug/d Hyperthyroidism

There is anincreased

metabolic rate,temperature ofthe patient. The

nurseimplementactions in which

it will providecomfort,

promote propernutrition, self-esteem and

providingemotionalsupport.

TSH 0.3 (0.4-6.0 uIu/ml) Decreased Decreased TSHincludingincreased T3 &

T4 is thehormonalimbalancepresent in

hyperthyroidism.Same

management asabove.

NOVEMBER 15, 2010

SEROLOGY REPORT

Troponin I Result: Negative (-)

NOVEMBER 15, 2010

CHEST X RAY

Impression: Consider bilateral pleural effusion, more for the right:Underlying mass cannot be ruled out, suggest CT scan.Suspicious left hilar convex density, suggest follow up.Probable cardiomegaly

NURSING ALERT: Pleural effusion is a collection of fluid in the pleural space whichoccur secondary to congestive heart failure. Patient may experience shortness ofbreath. Proper positioning , assisting with thoracentesis/chest tube drainage and otherspecific treatments must be directed for underlying cause.NOVEMBER 15, 2010

HEMATOLOGY

Test Findings NormalValues

Analysis NursingAlert

Hemoglobin 120 (140-180) Anemia In CHF, anemia is


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present due to inabilityof the heart to pumpsufficient blood to meetthe metabolic needs oftissues for oxygen and

nutrients. The patientmay feel easyfatigability anddecrease of activitytolerance. Adequaterest periods, propernutrition and use ofsafety precautions mustbe implemented.

Hematocrit 0.35 0.40-0.54 Overhydration In CHF, due to inabilityof the heart to pump,

pulmonary venousblood volume andpressure increase,forcing fluid from thepulmonary capillariesinto the pulmonarytissues and alveolicausing pulmonaryinterstitial edema andimpaired gas exchange.Patient must be

instructed to limit fluidintake to preventworsening of symptoms.

Erythrocyte 4.03 4-6 * 10 Anemia Same as hemoglobin

Leukocytecount

2.7 5-10*10 Leukopenia The patient is risk for infection that the doctorordered for antibiotic.Handwashing must bealways followed forinfection control.

Differentials

SegmentersLymphocytes

0.620.38

0.45-0.650.20-0.35

NormalInfection Same as above

NOVEMBER 17, 2010

CLINICAL CHEMISTRY

Test Result Reference Analysis

Sodium 137.40 135-148 Normal

Potassium 3.64 3.50-5.30 Normal


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NOVEMBER 17, 2010

CLINICAL LABORATORY

Test Result Reference Value Analysis Nursing alert

Cholesterol 4.2 ( up to 5.2mmol/L )

Normal

HDL 1.27 ( 0.78-2.08 mmo/L )

Normal

LDL 2.39 ( up to 3.85mmo/L )

Normal

Triglycerides 1.2 ( 0.40-

1.81 mmo/L )

Normal

SGOT 133.7 ( < 35 u/L ) Increased SGOT isincreased whenthere is damage oftissue organs suchas heart, liver etcand when there ispresence of highmetabolic activity(thyroid storm).The treatment

must focus on theunderlying causeof the disease.

SGPT 74.4 ( 91 u/L ) Decreased Not clinicallysignificant

Urea Nitrogen 5.2 ( 2,5-6.9 mmo/L ) Normal

Creatinine 60.3 ( 53-124 umol/L ) Normal

Albumin 26.1 ( 35-53 g/L ) Decreased There is presenceof edema in which

nurse mustinstruct pt to limitfluid intake asordered by thedoctor and elevatethe affected partfor venous return.

NOVEMBER 17, 2010

ABDOMINAL UTZ

Impression: Diffuse liver parenchymal diseaseGB PolypsMinimal ascitesNormal pancreas, spleen, kidney and urinary bladder by UTZNon dilated biliary tree


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Incidental note of minimal pleural effusion right

NURSING ALERT: There may be presence of tissue damage of the liver which may bedue to patients excessive intake of alcohol. Instruct patient to stop doing his vicesincluding smoking and use of illegal drugs to prevent worsening of symptoms.Ascites

could be managed by low-sodium diet, bedrest which promote sodium excretion andprescribed diuretic medications.The nurse must also assess abdominal girth, monitorintake and output and weight to assess for fluid status.

NOVEMBER 17, 2010

UTZ OF THE THYROID GLAND

Impression: Enlarged thyroid gland with coarsened echo texture consider parenchymalDisease correlation with other parameters is recommended

NURSING ALERT: Hormonal imbalance is present specifically increase T3/T4 release,in which the patient may experience palpitations, nervousness, heat intolerance, etc.Promoting comfort, O2 therapy, medications must be implemented.

NOVEMBER 18, 2010

2D ECHO

Interpretation

Dilated left ventricular cavity with normal wall thickness. There is hypokinesia of thebasal , lateral and anterior walls. The rest of the segments are kinetic.Dilated left atrium, right atrium and right ventricle. The right ventricle is likewisehypokineticNormal main pulmonary artery and aortic root dimensionsThickened leaflets of the mitral with flow configurationStructurally normal tricuspid, aortic and pulmonic with valves; no intracardial thrombusEcho free space adjacent the left atrium and left ventricle posterior wall

NOVEMBER 18, 2010

CHEST X RAY

Bilateral pleural effusion, right more than left

NURSING ALERT: Pleural effusion is a collection of fluid in the pleural space whichoccur secondary to congestive heart failure. Patient may experience shortness ofbreath. Proper positioning and other specific treatments must be directed for underlyingcause.NOVEMBER 20, 2010

PROTHROMBIN TIME

Patient Protime : 15.9 secs (NV: 11-14 secs)Control: 12.6 secsINR: 1.62% activity: 60% (NV: 70-100%)


19/20

NURSING ALERT: Clopidogrel, an antiplatelet drug, is one of patients medications thatmay affect the coagulation process. The nurse must implement necessary actions andprovide health teaching to prevent bleeding. Since there is tissue damage of the liverand congestion, it may impairs the livers ability to synthesize coagulants.

DECEMBER 9, 2010

UTZ

Report:Free fluid is seen on both hemithoraces with approximate volume of 2,619 on the

right and 531cc on the left

Impression:Pleural effusion, bilateral

NURSING ALERT: Pleural effusion is a collection of fluid in the pleural space whichoccur secondary to congestive heart failure. Patient may experience shortness ofbreath. Proper positioning and other specific treatments must be directed for underlyingcause.

DECEMBER18, 2010

PLEURAL FLUID ANALYSIS

Test Result Unit Normal

values

Analysis Nursing alert

Sugar 4.38 mmol/L 3.89-5.84 Normal

LDH 36.3 u/L 207-414 Decrease Presence of tissue damage

CHON 10.2 g/L 40-81 Decrease An imbalancebetween the

pressure withinblood vessels(which drivesfluid out of the

blood vessel) and

the amount ofprotein in blood(which keeps

fluid in the bloodvessel) can resultin accumulationof fluid (called a

transudate)

DISCHARGE PLANNING

MEDICATION

The patient should adhere his medication regimen following the rules of rightdose, right route, right time and right frequency. These medications are PTU 50g TID,Clopidogrel 75g OD, Allopurinol 100g OD.

EXERCISE
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20/20

Instruct patient to avoid prolonged bed rest however rest must be provided whensevere symptoms occur. He must be encouraged to perform an activity slowly thanusual, for a shorter duration or with assistance initially to prevent increase workload ofthe heart.

TREATMENT

The patient should follow the physicians and should take his medication at theright dose, right route, right time and right frequency.

HEALTH TEACHING

The patient with his family should be teach in assessing for skin breakdown whenat home, and institute preventive measures such as frequent changes of position,positioning to avoid pressure, elastic pressure stockings and leg exercises.

Teach also them how the progression of the disease is influenced by compliancewith the treatment plan.

Convey that monitoring symptoms and daily weights, restricting sodium intake,avoiding excess fluids, preventing infection, avoiding noxious agents such asalcohol, tobacco and participating in regular exercise all aid in preventing theexacerbation of cardiac failure.

Instruct him also to avoid stress and teach some management such as massage,therapeutic touch, silence etc to handle it.

OUT-PATIENT

The patient should return on the schedule date of his follow-up check-up on Jan.10, 2011

Instruct the continuous take of his medication as prescribed

DIET

Instruct pt to have a small frequent feedings to decrease the amount of energyneeded for digestion while providing adequate nutrition

Teach pt to adhere a low-sodium diet by reading food labels and avoidingcommercially prepared convenience foods.

Advise patient to avoid highly seasoned foods such as coffee, tea, cola and

alcohol

SPIRITUAL

He should enhance his relationship with God through faith and trust in His divine,power and believed that the Lord will help in his recovery.

intro-chf edited

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