Grand Case Presentation

Congestive Heart Failure

Members:
Mr. John Verni G. Bangeles Mr. Joel Ian D. Espenilla Ms. Carmina Lumio Ms. Geraldine Suzet S. Ramirez Ms. Cara Louise Garcia

Contents:
Introduction Objectives Health History Definition of Complete Medical Diagnosis Anatomy and Physiology and Pathophysiology Laboratory and Diagnostic Results Course in the Ward Nursing care Plan Drug Study Evaluation and Prognosis Discharge Plan

Introduction

Last July 25,2010 a group of 11 students headed by their Clinical Instructor were assigned to have their duty or R.L.E (Related Learning Experience) at Dr. Jose P. Rizal Memorial Hospital at Calamba, Laguna to gain more knowledge, skills and experience which will guide and expose them in the real setting of their chosen field Health Care. The group was then divided into two for their case study to be presented at the end of the semester. On the first day, our group decided to choose our target client for the said case study. So, each member got the diagnosis and data of the patients that were assigned to them by the Clinical Instructor. Finally, the group chose Mr. Bangeless patient, Mr. C.D.

Upon admission, patient C.D. complained of difficulty breathing and bipedal edema. He was then diagnosed with Congestive Heart Failure /Diffuse Toxic Goiter/Liver Cirrhosis/Moderate Risk Community Acquired Pneumonia. The group chose this case because his diagnoses were very interesting to study since his diagnoses were not the type that one could commonly encounter. Also, the diseases mentioned were much connected with each other. Secondly, the chosen client and his relatives are very approachable and cooperative. In connection with this, the patient will be staying for more than a week so the group will be able to conduct a more comprehensive assessment and render specific interventions. Lastly, since the concept that they are studying is about cardiovascular, respiratory, hepatic, endocrine and metabolic disorders, they could apply all that they have learned.

Congestive Heart Failure is a disease which the heart failed to pump and deliver sufficient blood supply to the entire body. It may have developed due to valve dysfunction, hyperthyroidism, hypertension and alcoholism. If left untreated, it can cause several complications such as pulmonary edema, ascites, and liver cirrhosis. But with proper treatment and interventions, the progression of this disease and its severity will be avoided. Good prognosis for the client will be achieved.

Objectives

General Objectives: At the end of this study and presentation, students are expected to gain more knowledge and new ideas or information regarding Congestive Heart Failure and its related diseases, Diffuse Toxic Goiter and Liver Cirrhosis. These will aide the nursing students to be familiarized with the disease process and the specific nursing actions and interventions to be rendered if ever they will encounter these diseases.

Specific Objectives: Student Centered The students will be able to: Understand the nature of the Congestive Heart Failure. Recognize the different predisposing and precipitating factors of Congestive Heart Failure. Identify and get familiarized with the clinical manifestations of Congestive Heart Failure. Outline the anatomy and physiology of the cardiovascular system. Illustrate the pathophysiology of the disease. Relate Diffuse Toxic Goiter and Valve Dysfunction to the disease as the major predisposing factors. Relate Liver Cirrhosis to the disease as one of the major complications present to the patient.

Determine the health status of the patient through:

Knowing the present, past, and family health history of the patient. It includes the Family Genogram of the patient. Conducting Physical Examination. Analyzing the past and present laboratory results of the patient and correlate it to the condition of the patient. Determine the appropriate nursing care that should be given to the patient. Determine the different drugs that the client is taking and know its actions and benefits to the client. Also included are the possible adverse reactions of those drugs. Create good Nurse Patient Interaction. Teach the relatives of the client on the management of the disease and how to prevent the complications.

Client- Centered To educate the client about the possible development of the disease complication. To educate the client about the disease and needed treatment. To encourage the client to follow prescribed medical regimen regarding his health status.

Health History

GENERAL HEALTH HISTORY: The client assigned was Mr. C. D. a patient admitted to JPRMH (Jose P. Rizal Memorial Hospital. He was assessed and interviewed regarding his Health History on July 19, 2010 and the following data was gathered:

I. PATIENTS DATA Patient's Name: Mr. C.D. Hospital Case No.: 1119810 Address: Bantayan, Brgy. 2, Poblacion, Calamba, Laguna Birth Date: July 28, 1950 Place of Birth: Calamba city, Laguna Age: 59 years old Insurance: None Sex: Male Date & Time Admitted: July 19, 2010 11:20PM

Ward/Room No./Bed No.: Medical Ward Bed 3 Nationality: Filipino Inclusive Date of Confinement: July 19 Aug. 1, 2010 Civil Status: Married Discharge Date & Time: August 1, 2010; 3:25 PM Religion: Iglesia in Cristo Attending Physician: Dr. A. G. B. Occupation: none Educational Background: High School graduate

Payment Source for Discharges: Self/Family: Family members Name of Spouse (if married): Mrs. B. D. Age: 55 yrs old Occupation: Teacher Educational Attainment: College Grad. (Education)

Level of Consciousness upon Admission  Drowsy  Disoriented  Responds to pain

Admitted per: Stretcher:

Chief Complaint/s: (+) DOB (+) bipedal edema

Impression/ Admitting Diagnosis: to consider Diffuse Toxic Goiter/ Congestive Heart Failure Stage 4/ Community Acquired Pneumonia Moderate risk Final Diagnosis: Diffuse Toxic Goiter/ Congestive Heart Failure Stage 4/ Community Acquired Pneumonia/ Chronic Liver Disease

II. PRESENT HEALTH HISTORY Two weeks prior to admission, the patient noticed edema forming on his both legs. One week prior to admission, the patient experienced mild difficulty of breathing that last for 5 to 10 minutes after walking. Also, he noticed his edema having bluish discoloration. Four days prior to admission, the patient was still experiencing mild difficulty of breathing and bipedal edema. Two days prior to admission, the patient developed cough and colds. One day prior to admission, the patient had fever. An hour prior to admission, Mr. C. D. experienced severe difficulty of breathing while watching TV. Upon assessment on the first day, the patient verbalized severe difficulty of breathing.

III. PAST HEALTH HISTORY Patient has no history of childhood illnesses and accidents/injuries. He has no known allergies to any food or drug. Also, he doesnt have any immunizations. Last February 2005, the patient was admitted at J. P. Rizal Memorial Hospital because of Hypertension. He took Captopril, Propanolol, and Furosemide as prescribed by his physician. He was able to comply with his medical regimen for about a month only because of financial constraints.

IV. FAMILY HEALTH HISTORY Mr. C. D.s father, Mr. M. D., had history of hypertension and died of lung cancer. His mother, Mrs. L. D. had history of diabetes and died because of cardiovascular disease. Four of his siblings including him, has hypertension: H. M., L. T., B. L. and M. D.. H. M., the eldest has asthma. L. T. also has lung cancer. Like patient C. D. , his sister S. D. also has goiter. T. D. has also diabetes. Her wife, B. D., also has hypertension. Two of his children also have some illness. The eldest, A. D., suffers from asthma, while T.S. suffers from cardiovascular disease.

M. D 65 y/o

L. D 72 y/o

H. M 65 y.o July 7, 1945

L.T 61 y.o April 27, 1949 Housewife

C. D 59 y.o July 28, 1950 HS Graduate Unemployed

S. D 58 y.o July 14, 1952 Vendor

T. D 55 y.o August 24, 1955 Unemployed

B. L 51 y.o Nov. 17, 1959 Employed

M. D 50 y.o July 19, 1960 Manager

B. D 55 y.o Dec. 8, 1955 Teacher

LEGEND: Hypertension. . . . Lung Cancer. . . . . . . Asthma. . . . . . . Diabetes . . . . . Goiter. . . . . . . CVD . . . . . . . Deceased. . . . . . . X

A. D 38 y.o October 16, 1972 Factory Worker

S. T 34 y.o Sept. 21, 1976 Accountant

H. R 30 y.o June 16, 1980 Housewife/ Vendor

G. D
P. V P. D 35 y.o March 27, 1975 Technician 32 y.o Feb. 12, 1978 Housewife

2 9 y.o February 28, 1981 Factory Worker

PHYSICAL ASSESSMENT (HEAD TO TOE)

ANTHROPOMETRIC MEASUREMENTS: Abdominal circumference = 92 cm. (July 25, 2010)
88 cm. (July 31, 2010)

GENERAL SURVEY Upon assessment the patient had slight body odor and he had a poor personal hygiene. He wore an old shirt and a short during the assessment and interview. The patient was not very attentive because he was experiencing difficulty breathing and cough but he was cooperative with us especially in answering our questions. The client was drowsy but oriented on time, person, place. His speech is slightly slurred, but was able to respond to our questions coherently. Patient is ectomorph in built, and if he walks to the comfort room to urinate or defecate he walks uncoordinatedly and he was shuffling thats why he needs assistance.

SKIN There are no lesions observed and there are no palpable masses. The skin is cool to touch. The color of his extremities is slightly jaundice/yellowish, while his bipedal edema which is nonpitting was black in color. He has good skin turgor, and the texture of the skin is rough. HEAD The head is symmetrical, round and appropriate for his body size. No masses were noted. He has uneven hair. His scalp is clean. EYES Eyelids are symmetrical and there is no presence of edema noted. Eyebrows are equal. Pupils are equally round and reactive to light and accommodation. The conjunctiva is pale. The periorbital region is sunken. The sclera are cloudy. EARS Ears are symmetrical. Tenderness of the ears not observed. No discharges noted. Slight deafness on both ears.

NOSE AND SINUSES There is no inflammation and the nostrils are patent except the left which is filled of mucous secretions upon inspection. Tenderness of sinus is not observed. No discharges noted. Presence of nasal flaring noted. MOUTH The lips are slightly dried and pallor in appearance. Mucosa is pale. Tongue is in midline. Gums are pale in color. The patient is wearing dentures. NECK Jugular Vein Distention noted. No masses were present. CHEST AND LUNGS His breathing pattern is shallow. Slight difficulty of breathing is observed. The patient used accessory muscles to breath. Lung expands symmetrically. He had episodes of productive cough as observed. Crackles were heard upon auscultation.

HEART No tenderness and bulging are observed. Heart sounds are distinct but irregular. Presence of S3 noted. AXILLAE Axillae are symmetrical and lymph nodes are non palpable. No lesions, no edema, no masses, no tenderness and rigidity are noted. ABDOMEN Shape of the abdomen is globular and fluid wave. Bowel sounds are hypoactive 3 gurgling sounds/minute. BACK AND EXTREMITIES The patient is slightly kypotic. Range of motion of upper extremities are full, while the lower are limited. Nails were also assessed. Capillary refill is about 3 seconds. They are pale in color, no cyanosis is present, and no clubbing. Bipedal non-pitting edema which was black in color was noted

GORDONS FUNCTIONAL HEALTH PATTERN Health Perception Health Management Pattern

According to patient CD, he has no problems with his senses except for his eyesight and hearing. Its been blurred since he was 40 years old. He finds it hard to read words written in small letters. He also has slight deafness on both ears. When it comes to his general health status, he stated that its not that good. Its been deteriorating since he got sick. Andami dami ko nga daw sakit sabi ng doctor, as verbalized by the patient. So to help in the management of his diseases, he stopped smoking and drinking alcoholic beverages. According to him, he used to be a heavy smoker and drinker. He started with his vices at the age of 15. Antigas nga ng ulo nan e kaya palageng nasesermonan ng doctor e, as verbalized by his son. Patient CD sometimes neglects to take his medications. He always reason out that instead of buying medicines hell just spend it to their basic necessities. But when forced and supervised by his children, patient CD follows the prescribed regimen for him. Now, he is able to eat properly and on time. According to his son, he had no accidents, injuries, and surgeries in the past. He also has no known allergies to food and medicines.

Nutrition- Metabolism Patient CDs typical food intake includes the following: at breakfast, he just drinks coffee. For his lunch, he eats rice and whatever viand that is cooked by his son. For his dinner, sometimes he has to wait for his son to come home and eats whatever he brings home. He no longer works thats why he doesnt have his own money to buy his food. It is only his children that provide him his basic needs. According to his son, he has poor appetite. There were times that he eats only once a day. For his fluid intake, he consumes at least 5- 6 glasses of water in a day. Nabawasan nga timbang ni tatay mula nung magkasakit siya e, as verbalized by his son. Since he got sick, his weight dropped tremendously. As stated by his son he used to be 53 kg, but now it dropped to only 48 kg.

Elimination Patient CD doesnt defecate regularly. Normally, it takes him two days before he could pass stool characterized as brownish hard formed stool. But during these past few weeks, he only defecates 2 times a week. He urinates 4 5 times a day, sometimes with scanty amount of urine. He described it to be dark yellow. According to him, he doesnt have any problems with regards to his voiding patterns. Activity- Exercise Mr. CD does not exercise regularly. Naglalakadlakad lang ako mayat maya, as verbalized by the patient. He doesnt have a routine exercise other than walking around their vicinity. But he feels so tired after walking. During his leisure time, he just watches TV or listens to the radio. He easily gets exhausted after any activity so he minimizes doing so. But despite this, he is bale to do his activities independently. According to him, he has no any history if falls.

Sleep- Rest Patient CDs usual sleeping time is at 8 or night in the evening. He is able to sleep for at least 6 8 hours. Hirap lang ako makatulog agad pero maaga akong nagigising as stated by the patient. It takes him a long time before he could finally fall asleep. But he wakes up by 3 or 4 in the morning. He doesnt take anything to aid in his sleep. Kapag nakatulog na ko dire- diretso na pati hindi ako masyadong nananaginip, as stated by the client. Cognitive- Perceptual Patient CD is oriented to time and space. According to his son, he sometimes forgetful of some practical things. When it comes to decision making about his healthcare, financial difficulties is what hinders him to totally avail all his medical needs. He also doesnt have any problems with regards to his senses except for his eyesight.

Roles Relationship Patient CD currently lives with his youngest son, GD. According to GD, theirs is a broken family. Their parents separated 10 years ago. Currently their mom is living with another man and has two children. CD and his wife, BD always argue about his vices. BD always complains about his alcoholism. As stated by GD, Palage nga sila nag- aaway dati kasi winawaldas ni tatay yung mga kita niya sa pagbili lang ng alak at yosi. Minsan na din yang nalulong sa sabong kaya ayun hiniwalayan ni nanay. When it comes to family problems, as much as possible GD tries to assist his father in solving them. Currently GD is the one working to support their daily needs. He is now employed as a factory worker in Cabuyao. Self Perception Self Concept According to patient CD, he is very moody thats why they (he and his wife) always argue. He cant easily get along with other people. Patient CD stated that since he got sick, he always feel weak when doing any activity.

Sexuality- Reproduction (The patient refused to be interviewed about this) Coping - Stress During these past two years, the biggest changes that happened in his life was his health slowly deteriorating. Thats why he has to be dependent on his children to support his basic and medical needs since he cannot anymore work. He currently lives with his youngest son who helps him with his needs. Patient CD used to be a heavy smoker and drinker but since he got ill, he had to stop. According to him, he made use of those as scapegoat whenever he feels so stressed. Values Belief Patient CD is a member of Iglesia ni Cristo. For him, religion is very important. Diyos ang gumawa ng lahat kahit problema kaya itinataas ko na lang lahat sa kanya, as stated by the patient.

Definition of Complete Medical Diagnosis

Congestive Heart Failure

Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to deliver oxygen rich blood to the body. Congestive heart failure can be caused by diseases that weaken the heart muscle, diseases that cause stiffening of the heart muscles, or diseases that increase oxygen demand by the body tissue beyond the capability of the heart to deliver adequate oxygen-rich blood. The heart has two atria (right atrium and left atrium) that make up the upper chambers of the heart, and two ventricles (left ventricle and right ventricle) that make up the lower chambers of the heart. The ventricles are muscular chambers that pump blood when the muscles contract. The contraction of the ventricle muscles is called systole. Many diseases can impair the pumping action of the ventricles. For example, the muscles of the ventricles can be weakened by heart attacks or infections (myocarditis). The diminished pumping ability of the ventricles due to muscle weakening is called systolic dysfunction. After each ventricular contraction (systole) the ventricle muscles need to relax to allow blood from the atria to fill the ventricles. This relaxation of the ventricles is called diastole.

 Diseases such as hemochromatosis (iron overload) or amyloidosis can cause stiffening of the heart muscle and impair the ventricles' capacity to relax and fill; this is referred to as diastolic dysfunction. The most common cause of this is long standing high blood pressure resulting in a thickened (hypertrophied) heart. Additionally, in some patients, although the pumping action and filling capacity of the heart may be normal, abnormally high oxygen demand by the body's tissues (for example, with hyperthyroidism or anemia) may make it difficult for the heart to supply an adequate blood flow (called high output heart failure). In some individuals one or more of these factors can be present to cause congestive heart failure. The remainder of this article will focus primarily on congestive heart failure that is due to heart muscle weakness, systolic dysfunction.

Symptoms The symptoms of congestive heart failure vary among individuals according to the particular organ systems involved and depending on the degree to which the rest of the body has "compensated" for the heart muscle weakness. An early symptom of congestive heart failure is fatigue. While fatigue is a sensitive indicator of possible underlying congestive heart failure, it is obviously a nonspecific symptom that may be caused by many other conditions. As the body becomes overloaded with fluid from congestive heart failure, swelling (edema) of the ankles and legs or abdomen may be noticed. This can be referred to as "right sided heart failure" as failure of the right sided heart chambers to pump venous blood to the lungs to acquire oxygen results in buildup of this fluid in gravity-dependent areas such as in the legs. The most common cause of this is longstanding failure of the left heart, which may lead to secondary failure of the right heart. Right-sided heart failure can also be caused by severe lung disease (referred to as "cor pulmonale"), or by intrinsic disease of the right heart muscle (less common) In addition, fluid may accumulate in the lungs, thereby causing shortness of breath, particularly during exercise and when lying flat. In some instances, patients are awakened at night, gasping for air.

 Some may be unable to sleep unless sitting upright. The extra fluid in the body may cause increased urination, particularly at night. Accumulation of fluid in the liver and intestines may cause nausea, abdominal pain, and decreased appetite.

Therapy Heart failure therapy requires lifestyle changes, such as losing weight, quitting smoking, limiting alcohol consumption, and reducing salt and fluid in the diet. These changes can improve the heart's ability to function and may help people with weakened hearts feel stronger. Additionally, most people will need to take medications to manage the symptoms of living with a weakened hear-for the rest of their lives. Physicians recommend that people take their medications at the same time each day and keep a record that includes the name of the medication, the dosage, the number of times per day the medication is taken, and the symptom or condition the medication is intended to treat.

 Commonly prescribed medications for heart failure include diuretics, Angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), digitalis, beta-blockers, nitrates, and vasodilators. The types and doses of these medications may be adjusted in people with liver and kidney disease. Surgical procedures that may improve heart failure include valve replacement surgery, coronary artery bypass surgery (when heart failure is caused by insufficient blood supply to the heart muscle), correction of congenital heart defects, cardiac resynchronization therapy, and ventricular assist devices.

Risk factors. Age Gender Ethnicity Family History and Genetics Chronic Alcohol Abuse Medical Conditions that Increase the Risk for Heart Failure Coronary artery disease Heart attack. High blood pressure. Diabetes. Obesity. Valvular heart disease. Severe emphysema

Prevention The key to preventing heart failure is to reduce your risk factors. You can control or eliminate many of the risk factors for heart disease high blood pressure and coronary artery disease, for example by making lifestyle changes along with the help of any needed medications. Lifestyle changes you can make to help prevent heart failure include: Not smoking Controlling certain conditions, such as high blood pressure, high cholesterol and diabetes Staying physically active Eating healthy foods Maintaining a healthy weight Reducing and managing stress

Liver Cirrhosis

Liver Cirrhosis The fibrosis and nodule formation cause distortion of the normal liver architecture which interferes next to blood flow through the liver. Cirrhosis can also lead to an inability of the liver to act its biochemical functions. Chronic inflammation will lead to zone necrosis & bridging fibrosis (both are purely pathological terms), and the nouns of regenerating nodules causing increase surrounded by Portal Pressure (due to fibrosis in liver,this increase PP will effect complications like bleeding from the stomach..etc) along near accumilation of waste product surrounded by blood (since the hepaocytes can not perform its function & remove these toxic materials which will accomplish the brain causing Encephalpathy).

Diffuse toxic goiter Graves disease, the most common cause of hyperthyroidism (overactivity of the thyroid gland), with generalized diffuse overactivity ("toxicity") of the entire thyroid gland which becomes enlarged into a goiter. There are three clinical components to Graves disease: Hyperthyroidism (the presence of too much thyroid hormone), Ophthalmopathy specifically involving exophthalmos (protrusion of the eyeballs), Dermopathy with skin lesions. The ophthalmopathy can cause sensitivity to light and a feeling of "sand in the eyes." With further protrusion of the eyes, double vision and vision loss may occur. The ophthalmopathy tends to worsen with smoking. The dermopathy of Graves disease is a rare, painless, reddish lumpy skin rash that of Graves disease is an autoimmune process. It is caused by thyroidstimulating antibodies which bind to and activate the thyrotropin receptor on thyroid cells.

 Graves disease can run in families. The rate of concordance for Graves disease is about 20% among monozygotic (identical) twins, and the rate is much lower among dizygotic (nonidentical) twins, indicating that genes make only a moderate contribution to the susceptibility to Graves disease. No single gene is known to cause the disease or to be necessary for its development. There are well-established associations with certain HLA types. Linkage analysis has identified gene loci on chromosomes 14q31, 20q11.2, and Xq21 that are associated with susceptibility to Graves disease. Factors that can trigger the onset of Graves disease include stress, smoking, radiation to the neck, medications (such as interleukin-2 and interferonalpha), and infectious organisms such as viruses. The diagnosis of Graves disease is made by a characteristic thyroid scan (showing diffusely increase uptake), the characteristic triad of ophthalmopathy, dermopathy, and hyperthyroidism, or blood testing for TSI (thyroid stimulating immunoglobulin) the level of which is abnormally high.

 Current treatments for the hyperthyroidism of Graves disease consist of antithyroid drugs, radioactive iodine, and surgery. There is regional variation in which of these measures tends to be used -- for example, radioactive iodine is favored in North America and antithyroid drugs nearly everywhere else. The surgery, subtotal thyroidectomy, is designed to remove the majority of the overactive thyroid gland. The disease is named for Robert Graves who in 1835 first identified the association of goiter, palpitations, and exophthalmos.

Anatomy and Physiology and Pathophysiology

THE HEART Heart is a hollow muscular organ that pumps blood through the body. The heart, blood, and blood vessels make up the circulatory system, which is responsible for distributing oxygen and nutrients to the body and carrying away carbon dioxide and other waste products. The heart is the circulatory system's power supply. It must beat ceaselessly because the body's tissuesespecially the brain and the heart itself-depend on a constant supply of oxygen and nutrients delivered by the flowing blood. If the heart stops pumping blood for more than a few minutes, death will result.

 The human heart is shaped like an upside-down pear and is located slightly to the left of center inside the chest cavity. About the size of a closed fist, the heart is made primarily of muscle tissue that contracts rhythmically to propel blood to all parts of the body. This rhythmic contraction begins in the developing embryo about three weeks after conception and continues throughout an individual's life. The muscle rests only for a fraction of a second between beats. Over a typical life span of 76 years, the heart will beat nearly 2.8 billion times and move 169 million liters (179 million quarts) of blood. STRUCTURE OF THE HEART The human heart has four chambers. The upper two chambers, the right and left atria, are receiving chambers for blood. The atria are sometimes known as auricles. They collect blood that pours in from veins, blood vessels that return blood to the heart. The heart's lower two chambers, the right and left ventricles, are the powerful pumping chambers. The ventricles propel blood into arteries, blood vessels that carry blood away from the heart.

 A wall of tissue separates the right and left sides of the heart. Each side pumps blood through a different circuit of blood vessels: The right side of the heart pumps oxygen-poor blood to the lungs, while the left side of the heart pumps oxygen-rich blood to the body. Blood returning from a trip around the body has given up most of its oxygen and picked up carbon dioxide in the body's tissues. This oxygen-poor blood feeds into two large veins, the superior vena cava and inferior vena cava, which empty into the right atrium of the heart. The right atrium conducts blood to the right ventricle, and the right ventricle pumps blood into the pulmonary artery. The pulmonary artery carries the blood to the lungs, where it picks up a fresh supply of oxygen and eliminates carbon dioxide. The blood that is oxygen-rich returns to the heart through the pulmonary veins, which empty into the left atrium. Blood passes from the left atrium into the left ventricle, from where it is pumped out of the heart into the aorta, the body's largest artery. Smaller arteries that branch off the aorta distribute blood to various parts of the body.

A. THE HEART VALVES Four valves within the heart prevent blood from flowing backward in the heart. The valves open easily in the direction of blood flow, but when blood pushes against the valves in the opposite direction, the valves close. Two valves, known as atrioventricular valves, are located between the atria and ventricles. The right atrioventricular valve is formed from three flaps of tissue and is called the tricuspid valve. The left atrioventricular valve has two flaps and is called the bicuspid or mitral valve. The other two heart valves are located between the ventricles and arteries. They are called semilunar valves because they each consist of three half-moon-shaped flaps of tissue. The right semilunar valve, between the right ventricle and pulmonary artery, is also called the pulmonary valve. The left semilunar valve, between the left ventricle and aorta, is also called the aortic valve. B. THE MYOCARDIUM Muscle tissue, known as myocardium or cardiac muscle, wraps around a scaffolding of tough connective tissue to form the walls of the heart's chambers. The atria, the receiving chambers of the heart, have relatively thin walls compared to the ventricles, the pumping chambers. The left ventricle has the thickest walls-nearly 1 cm (0.5 in) thick in an adult-because it must work the hardest to propel blood to the farthest reaches of the body.

C. THE PERICARDIUM A tough, double-layered sac known as the pericardium surrounds the heart. The inner layer of the pericardium, known as the epicardium, rests directly on top of the heart muscle. The outer layer of the pericardium attaches to the breastbone and other structures in the chest cavity and helps hold the heart in place. Between the two layers of the pericardium is a thin space filled with a watery fluid that helps prevent these layers from rubbing against each other when the heart beats. D. THE ENDOCARDIUM The inner surfaces of the heart's chambers are lined with a thin sheet of shiny, white tissue known as the endocardium. The same type of tissue, more broadly referred to as endothelium, also lines the body's blood vessels, forming one continuous lining throughout the circulatory system. This lining helps blood flow smoothly and prevents blood clots from forming inside the circulatory system. E. THE CORONARY ARTERIES The heart is nourished not by the blood passing through its chambers but by a specialized network of blood vessels. Known as the coronary arteries, these blood vessels encircle the heart like a crown. About 5 percent of the blood pumped to the body enters the coronary arteries, which branch from the aorta just above where it emerges from the left ventricle. Three main coronary arteries-the right, the left circumflex, and the left anterior descending-nourish different regions of the heart muscle. From these three arteries arise smaller branches that enter the muscular walls of the heart to provide a constant supply of oxygen and nutrients. Veins running through the heart muscle converge to form a large channel called the coronary sinus, which returns blood to the right atrium.

FUNCTION OF THE HEART The heart's duties are much broader than simply pumping blood continuously throughout life. The heart must also respond to changes in the body's demand for oxygen. The heart works very differently during sleep, for example, than in the middle of a 5-km (3-mi) run. Moreover, the heart and the rest of the circulatory system can respond almost instantaneously to shifting situations-when a person stands up or lies down, for example, or when a person is faced with a potentially dangerous situation

Pathophysiology

Laboratory and Diagnostic Examinations

Date 07/19/10 y y y

Lab Test Hematology WBC Diff. Count: Neutrophils

Actual Result

Normal Values

Intepretation

Nursing Responsibility Check puncture site for signs of bleeding Secure site for possible infection

y y

3.1 x109/L y y 0.48

5-10 x109/L 0.51-0.67

Diff. Count: Lymphocytes

0.52

0.21-0.35

Hemoglobin

90 gm/dl

130-180 gm/dl

y y 07/20/10 y y y

Platelet Hematocrit

y y

180 x109/L 150-400 x109/L y 36-48 27

Low: Neutrophils decrease with viral infections, bone marrow suppression, and primary bone marrow disease High:Lymphocytes increase with infectious monoclueosis, viral and some bacterial infections, and hepatitis Low: Hemoglobin decreases in various anemias, severe or prolonged hemorrhage, and with excessive fluid intake Normal Low: Hematocrit decreases in severe anemias, and acute massive blood loss Normal Low: Hematocrit decreases in severe anemias, and acute massive blood loss Low: Hemoglobin decreases in various anemias, severe or prolonged hemorrhage, and with excessive fluid intake Normal Normal yNormal yNormal yNormal yNormal yNormal

Hematology WBC Hematocrit

y y

7.0 0.39

y y

5.0-10 x109/L 0.40-0.54

Check puncture site for signs of bleeding Secure site for possible infection

Hemoglobin

130

140-170 g/L

y y 07/20/10 y y y y y y

Diff.Ct.: Segmenters Diff. Ct.: Lymphocytes Urinalysis y Color Transparency Reaction Specific gravity Protein y y y y

y y

0.60 0.40 Amber Clear 6.0 1.025 Trace

y y

0.50-0.70 0.20-0.40

yYellow, Pale yellow, amber yClear y4.4-8.0 y1.020-1.028 yTrace amounts

Catch urine specimen in a sterile container Discard the first void in the morning

Diagnostic Imaging Report July 20, 2010 Chest PA View There is slight prominence of the pulmonary nasulature. The heart is enlarged. There is homogeneous opacity, with a lateral ascending component sen obscuring the left hemidiaphragm and cp sulcus. Impression: Cardiomegaly with pulmonary congestive changes Left moderate Pleural Effusion

July 29, 2010 Abd. Utz The liver is contracted with nodular borders and heterogeneous parenchyma with prominent hepatic veins. The intrahepatic ducts are not dilated. The gall bladder is normal size with echofree lumen and smooth non-thickened wall. No stone is seen. The common duct and portal vein are normal in caliber. The pancreas is normal in size with homogeneous parenchymal echo pattern. No focal lesion is seen. The pancreatic duct is not dilated. The spleen measurjing 9.6cm is normal in size with homogeneous parenchymal echo pattern. No focal lesion is seen. The right kidney is normal in size with isoechoic echo pattern. The left kidney is normal in size, The cortical thickness, cortico-medullary differentiation, renal sinus complexes perinephric areas are unremarkable. The pelvocalyceal systems and ureters are not dilated. The urinary bladder is well distended with echo free lumen and smooth non-thickened wall. The bowel loops are not dilated, No mass. There is ascites. There is fluid collection seen in both hemithorax.

Impressions: Features suggestive of liver cirrhosis and signs of passive congestion. Massive ascites. Normal sized right kidney with parenchymal disease Bilateral Pleural Effusion Normal gall bladder, pancreas, spleen, left kidney, and urinary bladder.

 Echocardiogram July 20, 2010 Vent. Rate (bpm) :106 PR int. (ms) : P/QRS/T int. (ms) : QT/QTc int. (ms): P/QRS/T axis (deg): RV1/SV5 amp. (mV) : RV5/SV1 amp. (mV) : Interpretation: sinus tachycardia

0.33 0.87

----333 -0.16 1.18

82 445 43

166 21

July 28, 2010

Left Ventricle LVEDD LVESD IVS (D) IVS (S) LVPW (D) LVPW (S) LVEDV LVESV SV (D) CO EF FS HR EPSS

Results 5.0 3.8 1.1 1.5 1,1 1.4 125 55 70 6.0 56% 24% 86 1.3

Normal Values 4.5-5.0

Left Atrium AP R-L

Results 3.6

Normal Values 3-3.5 cm

0.8-1.1

S-I

0.8-1.1

Right Ventricle RVEDD 4.4

91-125 ml

RVESD

Right Atrium AP 55-75% R-L S-I 4.5

<1.0

Vessels Aorta Diameter Opening PA 2.4 3.0 2.9 3.4-4.0 cm

Values MITRAL AORTIC TRICUSPID PULMONIC

Max. Velocity 0.9/0.5 1.1/1.2 0.6 0.4

Area (cm) Kel

Gradient 3.5/1.0 4.8/5.9 1.4 0.7

Regurgitation Fraction MILD

SEVERE

Doppler Spectral Data P.A.T PAT= 70 m/sec PAP= 68 mmHg DT= 150 m/sec WRT= 70 m/sec Normal left ventricular dimension and wall thickness with normal wall motion and contractility Dilated left atrium Dilated right ventricle with adequate contractility Dilated right atrium Normal --- main pulmonary artery and aortic root Thickened aortic value cups without restriction of motion Structurally normal mitral valve, tricuspid valve, and pulmonic valve No intracardiac thrombus Color Flow Doppler Study Abnormal color flow display noted across the mitral valve and tricuspid valve Reversed mitral E/A velocity ratio PAP= 68mmHg Conclusion 1.Normal left ventricular dimension with normal wall motion and contractility with good systolic function but with grade I diastolic dysfunction 2.Dilated left atrium 3.Dilated right ventricle with adequate contractility 4.Dilated right atrium 5.Mild mitral regurgitation 6.Severe tricuspid regurgitation 7.Severe pulmonary hypertenstion

Course in the Ward

Ranitidine 50mg IV q8 Furosemide 40mg IV q120 Captopril 20mg 1/2 tab BID Roxythromycin 150mg/tab BID Ambroxol 30mg TID Rationale: y For continuous management of the disease (CHF and CAP) 3. Refer accordingly Rationale: y To provide appropriate and accurate treatment and interventions.

y y y

Drug study was done (to determine the action and side effects of the drug) Monitored patient (to watch out for possible side effects) Advised and encouraged patients relative to continually provide the prescribed medications for the patient (for continuous treatment) Documentation done (for doctors referral)

DAY 4 (July 28, 2010) MEDICAL/ SURGICAL MANAGEMENT

1.

NURSING MANAGEMENT y y y y y y Checked and monitored patients chart for time to time (to check for new lab results) Referred to PROD for any abnormal lab results (to provide immediate response and interventions) Due medications given and recorded (to provide continuous and on-time treatment) Drug study was done (to determine the action and side effects of the drug) Monitored patient (to watch out for possible side effects) Advised and encouraged patients relative to continually provide the prescribed medications for the patient (for continuous treatment) Administered and regulated O2 inhalation 2-4lpm (to provide sufficient oxygenation) Secured nasal cannula (to prevent O2 spilling) Monitor patients breathing status (to identify the progress of intervention) Documentation done (for doctors referral) Drug study done (to determine the action and side effects of the drug) given with meals (to minimize GI irritation) monitored for drug overdose: depression, cold intolerance, hard non-pitting edema (to provide immediate intervention when

Pls. follow up lab results

Rationale: y To provide immediate interventions in any abnormal results. 2. Continue medical management Cefuroxime 750mg IV q80 Ranitidine 50mg IV q80 Furosemide 40mg IV q120 Captopril 20mg 1/2 tab BID Roxythromycin 150mg/tab BID Ambroxol 30mg TID Rationale: y For continuous management of the disease (CHF and CAP) 3. O2 inhalation 2 4 lpm Rationale: y To provide sufficient oxygenation. 3. Refer accordingly Rationale: To provide appropriate and accurate treatment and interventions.

y y y y y y y