INTRODUCTION

Congestive Heart Failure (CHF) is a condition which results from the inability of the heart to pump blood effectively to the rest of the body or that the heart requires higher filling pressure in order to pump effectively. It is a common disease and it get more common day by day. The American Heart Association records that nearly 5 million people experience heart failure and about 550, 000 new cases are diagnosed each year in the United States. Here in the Philippines, the Department of Health accounts Heart failure becomes more prevalent with age and is more common among men. The condition affects 1 percent of people aged 50 years and older and about 5 percent of those aged 75 years and older. However, cases could occur even in patients of lesser age. For women of childbearing age Postpartum Cardiomyopathy can occur in about 1 out of 2500 pregnant women which soon develops into heart failure. It is a rare condition and this usually occurs in women over 30 years of age. CHF is among the most serious diseases today, worldwide. Symptoms associated with it can be very debilitating and may severely affect the quality of life. It is an important cause of sickness and results in frequent doctor and hospital visits which consumes enormous amount of health care resources. Symptoms for CHF after childbirth range from mild to severe. The most prominent ones would be fatigue, shortness of breath, swelling, weight gain, rapid pulse and breathing. Cases are usually further classified using the New York Heart Association (NYHA) Classification System where patients are rated on a scale of Class I to IV. This case analysis is about a 30 year old female patient diagnosed of Congestive Heart Failure with a Functional Capacity of II-III where symptoms have developed after a normal spontaneous delivery. The student nurse aims to review the disease development, the signs and symptoms, and the treatment & management applied to this patient. This case analysis will enable not only the student nurse but also other readers to further understand the disease and to be more adept in managing patients of the same medical condition.

CASE PRESENTATION

Patient MI was admitted in GABMMC emergency room on February 5, 2012 with complaints of difficulty of breathing. The patient was observed to be conscious and coherent but was weak and pale; bipedal edema was also noted. Vital signs were recorded as follows: BP of 130/70, temperature of 36.8 C, CR of 98, and RR of 30. Intravenous access was initiated and a urinary catheter was inserted. Medications administered included Furosemide 40 mg, Lanoxin 0.5 mg IV, Nitroglycerin 5 mg, and NaHCO3. Her chest X-ray shows cardiomegaly and pulmonary edema. On the same date Patient MI was admitted in room 614 of the Medicine Ward diagnosed of Congestive Heart Failure with a functional capacity of II-III. Further validation to rule out valvular heart disease is also intended. Patient MI has been experiencing difficulty of breathing and bipedal edema days prior to admission. She first experienced the same problem a week after her delivery of her third child in Dr. Jose Reyes Memorial Medical Hospital on December 2011. She was then hospitalized and recovered. This February was the second onset. Aside from the mentioned problems, the patient was also found to have anemia. The patient has no known history of any cardiac or related disease. The only times she was hospitalized was during her previous deliveries of her children.

I.

PHYSICAL EXAMINATION

General Survey: The patient appears lethargic and can be aroused by moderate stimuli. Distress in breathing can be noted and is already incapable of too much exertion without being further distressed. The client can at least turn herself in bed to assume the most comfortable position. Skin Upon inspection, skin is light brown, with lighter tones on areas not exposed. She has moderate ascites wherein swelling is very much pronounced on the lower

extremities and the eyes. Upon palpation, skin feels moist, cool and clammy. Hair Patient MIs hair is dark brown in color, is evenly distributed, and is of moderate thickness. It appears to be oily too. Nails Upon inspection, nails are short and rounded. Cuticles are intact and nail bed is whitish. Upon performing the blanch test, nails are smooth and capillary refill less than 4 seconds. Skull and Face Upon inspection, head is normocephalic with no tenderness. Facial features are symmetrical as well as the facial movements. Eyes Eyebrows are evenly distributed and are symmetrical in appearance and movement. Eyelashes have also equal distribution although it can be barely seen through due to her eyes puffiness. The sclera on both eyes is white and the pupils are of dark brown color and PERRLA. Conjunctivas are pale. Ears and hearing Upon inspection and palpation, the auricles are symmetrical and have no lesions or tenderness. The auricle is aligned above the outer canthus of the eye. There is no discharge present although there is some cerumen. Nose and Sinuses External nose is of the same color as that the rest of the face; it is symmetrical and is normal in size. Some crusts are noted but there are no noticeable discharges. Maxillary and frontal sinuses are not tender. Mouth

The patients lips are pale in color, symmetrical, and a bit dry. She is edentulous with gums and mucosa moist and pink in color. Tongue is at the midline, fully movable with no lesions. No distinct mouth odor was noted and voice is audible. Neck Upon inspection and palpation, the neck is symmetrical with no masses or swelling. The trachea is in the midline and non-tender. There are no palpable lymph nodes. Jugular veins are distended and pounding. Thorax and Lungs The chest is consistent in color with the rest of the body; there are no structural deformities. Patient is notably dyspneic and has some retractions in the 6 th intercostals space. Some wheeze can be heard upon auscultation. Heart and Vascular System Palpitations are very much noticeable with the patient upon inspection and palpation. Auscultating the patients heart sound, it was noted that it is bounding and that there is a presence of heart murmurs. Abdomen The skin color is consistent with the rest of the body. Moderate ascites can be noted. There is positive bowel sounds. No tenderness or lesions noted. Extremities Upon inspection, skin is normal in color on both hands and feet. Pulses on radial femoral, posterior tibial and dorsalispedis are palpable symmetrically. Skin is cool and clammy and some pitting edema of lower extremities was noted; graded 2+. The patient has some problem with mobility on her right upper extremity.

II.

PATHOPHYSIOLOGY

III.

LABORATORY FINDINGS Hematologic Report

February 5, 2012 Constituent Hemoglobin Hematocrit Leukocyte Segmenter Lymphocytes Platelet Result 112 gm/L 0.354 10.6 x 109 /L 0.64 0.36 285 x 109 /L Normal Range 120-180 0.370-0.540 4.6-10 109 /L 0.60-0.70 0.20-0.40 150-450 109 /L

February 8, 2012 Constituent Hemoglobin Hematocrit Leukocyte Segmenter Lymphocytes Eosinophils Platelet Result 99 gm/L 0.323 9.2 x 109 /L 0.67 0.32 0.01 225 x 109 /L Normal Range 120-180 0.370-0.540 4.6-10 109 /L 0.60-0.70 0.20-0.40 0-0.05 150-450 109 /L

Analysis:

Electrolytes

February 5, 2012 Constituent Sodium (Na) Potassium (K) Result 135.8 mmol/L 5.25 mmol/L Normal Range 135-145 3.4-4

February 12, 2012 Constituent Sodium (Na) Potassium (K) Result 137.8 mmol/L 4.71 mmol/L Normal Range 135-145 3.4-4

BLOOD CHEMISTRY REPORT February 6, 2012 Constituent Alkaline Phosphatase (ALP) AST/ SGOT Cholesterol Glucose Total Protein Albumin Globulin A/G Ratio Triglycerides Uric Acid (BUA) 629.7 U/L 153.7 mg/dl 100.3 mg/dl 6.1 g/dl 2.5 g/dl 7.6 g/dl 1.4 105 mg/dl 13.35 mg/dl 10-50 0-200 <100 6.4-8.5 3.4-4.8 3-3.5 1.1-1.8 0-200 24-70 Result 338.8 U/L Normal Range 35-129

February 8, 2012

Constituent Alkaline Phosphatase (ALP) ALT/ SGPT AST/ SGOT Creatinine Urea Nitrogen (BUA) Sodium (Na) Potassium (K)

Result 211.7 U/L

Normal Range 35-129

81 U/L 0.92 U/L 0.71 mg/dl 22.9 mg/dl 136.8 mg/dl 2.19 mg/dl

10-50 0-38 0.5-1.2 6-20 135-145 3.4-4.0

BUN/ Creatinine February 12, 2012 Constituent Urea Creatinine Result 11.2 mmol/L 97 mmol/L Normal Range 2.5-7.1 62-133

IV.

MEDICAL-SURGICAL-NURSING MANAGEMENT

A. Medical Management The following procedures were performed for the patient: o Urinary Catheterization o IV Insertion/ Removal o Oxygen Inhalation The following diagnostics were ordered for the patient: o CBC & Blootyping, PT, PTT, FBS, TC, TG, AST, TPAG, BUN, Creatinine, Na, K o Chest X-Ray PA o 12 Lead EKG

o ABG o 2D Echocardiography The following pharmacological management was administered: o Furosemide 40 mg IV Q6 o Trimetazidine 35 mg Tab BID o Clopidogrel 75 mg Tab o Ranitidine 50 mg IV Q8 o Ceftriazone 2 g IV o Clarithromycin 800 mg Cap Q12 o FeSO4 Cap TID o Furosemide 80 mg Q12 o Allopurinol 300 mg o Kalium Durate Tab TID o D5W B. Surgical Management No surgical management was initiated with the patient.

C. Nursing Management Monitor patients vital signs and maintain within normal range. Ensure proper and timely administration of medications and observe for both the desired and adverse effects. Assist patient in bed to assume the most comfortable position as much as possible. Monitor and record patients intake and output also to ascertain the effectiveness of the pharmacologic management (diuretics) of the condition. Maintain supplemental oxygen at levels ordered by the physician and maintain airway patency. Initiate pressure ulcer prevention strategies by encouraging frequent position changes.

 Ensure compliance to low salt & low fat diet by performing health teaching to both the patient and the support person.

V. VI.

DRUG STUDY NCP