199075883 case-pres-chf-with-hyperipidemia-and-uti

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Mr. Osel Sherwin Melad
Clinical Instructor, Medicine Ward Rotation (Lower Annex)
College of Nursing
Silliman University
Dear Sir:
We are Level III students of Silliman University College of Nursing and currently assigned for this 2nd
semester duty in Medicine Ward Rotation at Negros Oriental
Provincial Hospital, Lower Annex, in the 7-3 pm or 2-10 pm shift during Saturdays and Sundays. In this connection, we would like to apply for a case study on the
case of Mrs. Lydia Rafales, a 63-yr. old resident of Looc, Dumaguete City, Negros Oriental. She was diagnosed with Congestive Heart Failure with hyperlipidemia
and UTI.

We are interested in this case since this can further enrich our knowledge and improve our skills toward the care of this patient. In this way, we could further share
our knowledge to all our classmates during the case presentation on Saturday March 25, 2006 at AVT II.
We are hoping for your favorable response.
Thank you very much and God Bless!
Sincerely Yours,
FRUSSELL V. ELTANAL
BSN-III
BERYL GRACE S. VINCOY
BSN-III
Acknowledgment:
We would like to express our gratefulness…
First of all to our Almighty God, for giving us the chance to have this kind of activity and for giving us the strength that we need,

To our teachers, for the concepts we have learned in the Medicine rotation, especially to Mr. Osel Sherwin Melad, who enriched us with their experiences and
inspiration to thrive for excellence,
To our clients, for their trust and accommodation, especially to Mrs. Lydia Rafales, for she is our very first client whom we chose for our case study,
To our C.I. group for the spirit of unity and for never giving up despite of the problems we encountered,
And to our loving parents and guardians who were there to support us financially and emotionally throughout the study,
And for those who in one way or another have help in our case analysis, we are filled with happiness and gratitude for your immeasurable help.
Thank You…
TOPIC DESCRIPTION:
The topic deals with the care of patient with a medical diagnosis of Congestive Heart Failure. This covers the psychosocial profile of the patient, which
includes the demographic data with genogram, history of present illness, chief complaints, past medical history, anatomy and physiology of the affected systems,
growth and development, physical assessment, pathophysiology of the disease, medical management, laboratory exams, pharmacology, nursing care plans,
functional health patterns, two pertinent reading related to the topic and evaluation of the case study.
CENTRAL OBJECTIVES:

At the end of the case analysis presentation, the learners shall improve their knowledge on the important concepts of caring with a patient who is diagnosed
of having congestive heart failure, and shall also manifest positive attitudes and skills towards providing care to those patients including their family and significant
others.
SPECIFIC OBJECTIVES:
Within our case study we will be able to:
1. Identify the demographic data of our patient including her genogram and ecomap
2. Review the anatomy and physiology of the affected systems
3. Trace and explain the pathophysiology of congestive heart failure
4. Utilize the nursing process with competence by making functional health patterns and nursing care plans for our patient
5. State the importance and the mechanism of actions of the medications given
6. Recognize the importance of laboratory exams
7. Utilize some medical management to give holistic care of our patient
NURSING HISTORY
Part I. Demographic Information
 Name of patient: Rafales, Lydia
 Civil Status: Married
 Name of husband: Rafales, Teofilo
 Sex: Female
 Age: 63

 Address: Looc, Dumaguete City
 Occupation: Vendor
 Religion: Roman Catholic
 Educational Attainment: Elementary Undergraduate
 Nationality: Filipino
 Room and Bed No.: FPA ward
 Doctor(s) in charge: Dr. Joyce Maningo
Date & Time of Admission: February 20, 2006 @ 11:10 am
Chief Complaint(s):
Dyspnea for one week
Diagnosis: Congestive Heart Failure with hyperlipidemia and UTI
General Impression of client (appearance upon first contact):
• Received sitting on bed, appeared weak and restless, and oriented to environment. Responsive and answered questions coherently. IV line ifusing
well @ right metacarpal vein @ KVO. O2 inhalation @ 2 L/min. T=37.6 C, P=73 bpm strong and regular, R=34 cpm shallow and effortless,
BP=160/90 mmHg.
Escolastico Duhaylungsod
- 50 years old Gorgonia Duhaylungsod
- died of cancer of the - 81 years old
liver

Teofilo Rafales Lydia Rafales
- 68 years old - 63 years old
- non-smoker/non-alcoholic - CHF; hyperlipidemia; UTI
drinker
Richard Rebecca Rosalyn Rowena Remelyn Richel Rosemarie Rosa Rosa Mae
46 y/o 44 y/o 42 y/o 40 y/o 38 y/o 36 y/o 33 y/o 30 y/o 24 y/o
Kidney failure cyst (operated) cyst asthma
GENOGRAM
ECOMAP
Kauban sa Hospital Family Church: Dumaguete
Cathedral

Lydia Rafales Organization
63 y/o
Hospital Personnel/NOPH
Neighborhood Market
GROWTH AND DEVELOPMENT
For many women and men in late adulthood life, sexuality has achieved a degree of stability. A sense of masculinity or femininity and comfortable patterns
of behavior have been established. This increased security and identity can promote greater intimacy in sexual and social relationships. This may also be a time
when adults allow themselves more freedom in exploring and satisfying sexual needs.
Although menopause alters reproductive functioning, it does not physically inhibit sexual functioning. Generally, a woman with strong self image, positive
sexual and social relationships, and knowledge regarding her body and menopause is likely to progress through this natural biologic stage without problems and
remain sexually active and satisfied.

During midlife, men may begin to experience changes in sperm production, erectile power, achievement of orgasm, and sex drive, although these changes
generally do not significantly alter reproductive or sexual functioning. Some men feel that these changes threaten their sexuality and “maleness” and may respond
negatively. Other men feel these changes make sex more pleasurable and intimate and often respond positively. Actual sexual dysfunctions, as a result of physical
and psychosocial changes, may arise at this time.
Midlife is often a time when both men and women reexamine life goals, careers, accomplishments, value systems, and familial and social relationships. As a
result, some people adapt, whereas others experience stress or a crisis. This reexamination can positively or negatively affect an individual’s and sexuality.
According to Robert Havighurst, middle-adulthood is the time wherein men and women of this age adjust to aging of their parents, as well as having
children to take care of. This is the reason why he labeled this as the “sandwich generation.” Moreover, he stated some developmental tasks that middle adults
should accomplish, this includes: assisting teen-age children to become responsible adults; achieving adult social civic responsibility; reaching and maintaining
satisfactory performance in one’s occupation (reach the peak of one’s career); relating to one’s spouse as a person; and, accepting and adjusting to physiologic
changes of middle age.
On the other hand, Erik Erickson stated that men and women under this stage should achieve a sense of generativity while avoiding self-absorption and
stagnation. This means that a person may achieve a feeling of productivity, creativity as evidenced by reaching one’s previously established goals or he may feel
unsuccessful because of his/her lack of accomplishments.
Our client is 55 years old, she has five children and a husband. She admitted that she easily gets irritated even before she had her menopause. She also
shared that she is stressed most of the time because she keeps on thinking about their family’s financial problem. She also admitted that she had some regrets of not
finishing school, and that she is still wondering what would have happen to her if only she strived hard to graduate in college despite of their poverty.
PHYSICAL ASSESSMENT
GENERAL SURVEY VITAL SIGNS
Sex: Female Temperature: 37.6 C
Race: Filipino Pulse Rate: 73 bpm strong and regular

Age: 63 Respiratory Rate: 34 cpm shallow and regular
Marital Status: Married BP: 160/90 mmHg
Signs of Distress: Present Height: 4’9”
Level of awareness: Conscious but restless Weight: 48 kls.
Body type: normal and slim
Posture: not erect
Gait: coordinated
Body movements: coordinated
Hygiene and grooming: poor
Dress/clothing: clean but not presentable
Body and odor: no foul odor
Mod and effect: irritable
Speech: clear and understandable
INTEGUMENTARY SYSTEM
The client works excessively outside her house and her skin is exposed to heat due to her work as grilled pork or “tocino” vendor. Her skin color is same as
before as claimed and there are no lesions. She has not experienced trauma with regards to her skin integrity. She doesn’t have food and drug allergies as claimed.
She doesn’t also take vitamins and she takes a bath once a day. She uses bath soap and a shampoo. She also uses ointment whenever she feels pain.
SKIN
Color-dark brown
Lesions-none
Edema-none
Scars-present on her legs and arms, but little only
Mobility/turgor-slightly poor turgor and mobility
Texture-not so smooth

Temperature-warm to touch
NAILS
She hasn’t experienced any trauma on her nails. She sometimes forgot to cut her nails and only cut it when she realized to do so.
Fingernails: capillary refill at boundary (3 seconds)
Color-slightly opaque, nail beds are not so visible
Shape-convex and well-rounded
Thickness-thick
Angle-not approximately 160°
HEAD
The client hasn’t experienced any trauma in her head. She sometimes feels headache and dizziness as claimed. She has an experience of having dandruff.
SCALP
Presence of little dandruff noted
No nits
Scaliness noted
HAIR
The client basically is not using any wig. Her hair is washed by shampoo. She haven’t experienced a great loss of hair strands.
Grayish in color
Not evenly distributed
Smooth
Coarse
Pliant

FACE
Contour-round shape
Symmetry-symmetrical
Involuntary movement-none
Edema-not noted
Masses-not noted
Scaliness noted around the cheek and just above the two eyebrows
EYEBROWS
Abundant, evenly distributed, no scaliness
Masses not noted
EYES
Literate
Conjunctiva and sclera
- Pinkish, not swelling, no nodules palpated
- Pupils (4 mm) equal in size, reactive to light and accommodation
Extra ocular Movements
- Can follow movements
Eyelids
- No masses palpated
- Symmetrical movements of eyelids
EARS

No deformities, appropriate size with the face and aligned with the lateral canthus of the eyes
Symmetrical
Cerumen noted with minimum amount
Pinkish ear canal
No drainage noted
NOSE
Symmetrical
No deformity
Size and shape is appropriate to her face
No presence of tenderness and nodules
Nasal mucosa is pink and moist
Nasal septum is close to midline, thicker anteriorly than posteriorly
SINUSES
Not tender
No masses and nodules palpated
MOUTH
Lips are ruddy pinkish, cracking of the lips noted
No lumps and masses noted
GUMS
 With tight margin of gums, no bleeding, discoloration and growth

TEETH
• With 15 teeth extracted, minimal dental caries noted
• No abnormal shape and position
• Yellow and with stains
ROOF OF THE MOUTH/HARD PALATE
• Whitish in color
• Dome-shaped
TONGUE
• Dull red in color
• Tongue can move with side to side
• Floor of the mouth is highly vascular
PHARYNX
The uvula rise together with the soft palate when the patient says ”ahh”
Enlargement of tonsils are not noted
No ulcerations
POSTERIOR AND ANTERIOR CHEST
Health History:
The client doesn’t smoke. She does have cough and increased secretions presently. Dyspnea noted and claimed.
POSTERIOR CHEST
Rate is not normal with 34 cycles per minute, regular
Rhythm is regular

Depth-normal, not too shallow
Effort-present
Use of accessory muscle is noted
Shape is elliptical with ribs sloping downward
It is symmetrical
Masses-absent
Tenderness- absent
Vibration is symmetrical
Crackles noted over her lungs and dull sounds
Vesicular sound in the upper posterior chest and the peripheral area, then in the middle part, presence of bronchovesicular sounds. Decreased breath
sound noted
ANTERIOR CHEST
Rate is not normal with 34 cycles per minute, regular
Rhythm is regular
Depth is normal and not too shallow
Effort is present
Use of accessory muscle is present
The ribs slope downward with symmetrical interspaces
Absent of masses and tenderness
Vibration is symmetrical
Crackles sounds noted
HEART
The client has experienced body weakness and she cannot do her ADLs effectively because she gets easily tired and fatigue as claimed. She doesn’t smoke
but she is exposed to smoke from grilling “tocino” everyday during those times.
LOCATION

S1 (BELOW) – located at LMCL (Left midclavicular line)
- below the nipple at the 5th
ICS
- with 97 beats per minute strong and irregular
S2 (UPPER) – located at the right sternal border at the 2nd
ICS
- with 97 bpm strong and irregular
S1 (UPPER) – at the left sternal border at the 2nd
ICS
- normal and regular on its sound and rhtythm
ANATOMY AND PHYSIOLOGY
Cardiovascular System: The Heart
ANATOMY OF THE HEART
Location and Size
The size and weight of the heart give few hints of its incredible strength. Approximately the size of a person’s fist, the hollow, come-shaped heart weighs
less than a pound. The heart is located within the bony thorax and is flanked on each side by the lungs. Its more pointed apex is directed toward the left hip and

rests on the diaphragm, approximately at the level of the fifth intercostals space. It’s broader posterosuperior aspect, or base, from which the great vessels of the
body emerge, points toward the right shoulder and lies beneath the second rib.
Coverings and Wall
The heart is enclosed by a double sac of serous, the pericardium. The visceral pericardium, tightly hugs the external surface of the heart and is actually part
of the heart wall. It is continuous at the base with the loosely applied parietal pericardium, which is reinforced on its superficial face by dense connective tissue.
This fibrous layer helps protect the heart and anchors it to surroundings structures, such as the diaphragm and the sternum. A slippery lubricating fluid (serous
fluid) is produced by the serous pericardial membranes. This fluid allows the heart to beat easily in a relatively frictionless environment as the pericardial layers
slide smoothly across each other.
The heart walls are composed of three layers: the outer epicardium, the myocardium, and the innermost endocardium. The myocardium consists of thick
bundles of cardiac muscle twisted and whorled into ringlike arrangements. It is the layer that actually contracts. The myocardium is reinforced internally by a
dense, fibrous connective tissue network called the “skeleton of the heart.” The endocardium is a thin, glistening sheet of endothelium that lines the heart chambers.
It is continuous with the linings of the blood vessels leaving and entering the heart.
Chambers and Associated Great Vessels
The heart has four hollow chambers or cavities – two atria and two ventricles. Each of these chambers is lined with endocardium, which helps blood flow
smoothly through the heart. The superior atria are primarily receiving chambers. As a rule, they are not important in the pumping activity of the heart. Blood flows
into the atria under low pressure from the veins of the body and then continues on to fill the ventricles. The inferior thick-walled ventricles are the discharging
chambers, or actual pumps of the heart. When they contract, blood is propelled out of the heart and into the circulation. The heart is somewhat twisted; the right
ventricle forms most of its anterior surface; the left ventricle forms its apex. The septum the divides the heart longitudinally is reffered to as the interventricular or
interatrial septum, depending on which chamber it divide and separates.
Although it is a single organ, the heart functions as a double pump. The right side works as the pulmonary circuit pump. It receives relatively oxygen-poor
blood from the veins of the body through the large superior and inferior venae cavae and pumps it out through the pulmonary trunk. The pulmonary trunk splits into
the right and left pulmonary arteries, which carry blood to the lungs, where oxygen is picked up and carbon dioxide is unloaded. Oxygen-rich blood drains from the
lungs and is returned to the left side of the heart through the four pulmonary veins. The circulation just described from the right side of the heart to the lungs and
back to the left side of the heart, is called the pulmonary circulation. Its only function is to carry blood to the lungs for gas exchange and then return it to the heart.
Blood returned to the left side of the heart is pumped out of the heart into the aorta from which the systematic arteries branch to supply essentially all body
tissues. Oxygen-poor blood circulates from the tissues back to the right atrium via the systematic veins, which empty their cargo into either the superior or inferior
vena cava. This second circuit, from the left side of the heart through the body tissues and the back to the right side of the heart, is called the systematic circulation.

It supplies oxygen-and nutrient-rich blood to all body organs. Because the left ventricle is the systematic pump that pumps blood over a much longer pathway
through the body, its walls are substantially thicker than those of the right ventricle, and it is a much powerful pump.
Valves
The heart is equipped with four valves, which allow blood to flow in only one direction through the heart chambers- from the atria, the ventricles and out the
great arteries leaving the heart. The atrioventricular, or AV valves are located between the atrial ventricular chambers on each side. The AV valves prevent
backflow into the atria when the ventricles contract. The left AV valve- the bicuspid, or mitral, valve-consists of two cusps, or flaps, of endocardium. The right AV
valve, the tricuspid valve, has three cusps. Tiny white cords, the chordae tendineae-literally, “heart strings”-anchor the cusps to the walls of the ventricles. When
the heart is relaxed and blood is passively filling its chambers, the AV valve flaps hang limply into the ventricles. As the ventricles contract, they press on the blood
in their chambers, and the intraventricular pressure (pressure inside the ventricles) begins to rise. This causes the AV- valve flaps to be forced upward, closing the
valves. At this point the chordae tendineae are working to anchor the flaps in a closed position. If the flaps were unanchored, they would blow upward into the atria
like an umbrella being turned inside out by a gusty wind. In this manner, the AV valves prevent backflow into the atria when the ventricles are contracting.
The second set of valves, the semilunar valves, guards the bases of the two large arteries leaving the ventricular chambers. Thus they are known as the
pulmonary and aortic semilunar valves. Each semilunar valve has three cusps that fit tightly together when the valves are closed. When the ventricles
arecontracting and forcing blood out of the heart, the cusps are forced open flattened against the walls of the arteries by the tremendous force of rushing blood.
Then when the ventricles relax, the blood begins to flow backward toward the heart, and the cusps fill with blood, closing the valves. This prevents arterial blood
from reentering the heart.
Each set of valves operates at a different time. The AV valves are open during heart relaxation and closed when the ventricles are contracting. The
semilunar valves are closed during heart relaxation and are forced open when the ventricles contract. As they open and close in response to pressure changes in the
heart, the valves force blood to continually move forward on its journey through the heart.
Cardiac Circulation
Although the heart chambers are bathed with blood almost continuously, the blood contained in the heart does not nourish the myocardium. The blood
supply that oxygenates and nourishes the heart is provided by the right and left coronary arteries branch from the base of the aorta and encircle the heart in the
atrioventricular groove at the junction of the atria and ventricles. The coronary arteries and their branches (the anterior interventricular and circumflex arteries on
the left, and the posterior interventricular and marginal arteries on the right) are compressed when the ventricles are contracting and fill when the heart is relaxed.
The myocardium is drained by several cardiac veins, which empty into an enlarged vessel on the backside of the heart called the coronary sinus. The coronary
sinus, in turn, empties into the right atrium.
When the heart beats at a very rapid rate, the myocardium may receive an inadequate blood supply because the relaxation periods (when the blood is able to
flow to the heart tissue) are shortened.

PHYSIOLOGY OF THE HEART
As the heart beats or contracts, the blood makes continuous round trips---in and out of the heart, through the rest of the body, and then back to the heart---
only to be sent out again. The amount of work that a heart does is almost too incredible to believe. In one day, it pushes the body’s supply of 6 quarts or so of
blood through the blood vessels over 1000 times, meaning that it actually pumps about 6000 quarts of blood in a single day.
Conduction System of the Heart
Cardiac muscle cells can and do contract spontaneously and independently, even if all nervous connections are severed. Moreover, these spontaneous
contractions occur in a regular and continuous way. Although cardiac muscles can beat independently, the muscle cells in different areas of the heart have different
rhythms. The atrial cells beat about 60 times per minute, but the ventricular cells contract much more slowly (20-40/min). Therefore, without some type of
unifying control system, the heart would be an uncoordinated and inefficient pump.
Two types of controlling systems act to regulate heart activity. One of these involves the nerves of the autonomic nervous system that act like “brakes” and
“accelerators” to increase or decrease the heart rate depending on which division is activated. The second system is the intrinsic conduction system, or nodal
system, that is built into the heart tissue. The intrinsic conduction system is composed of a special tissue nowhere else in the body; it is much like a cross between
muscle and nervous tissue. This system causes heart muscle depolarization in only one direction—from the atria to the ventricles. In addition, it enforces a
contraction rate of approximately 75 beats per minute on the heart; thus, the heart beats as coordinated unit.
One of the most important parts of the intrinsic conduction system is a cresent-shaped node of tissue called the sinoatrial (SA)node, located in the right
atrium. Other components include the atrioventricular (AV)node at the junction of the atria and ventricles, the atrioventricular(AV) bundle (bundle of His) and the
right and left bundle branches located in the interventricular septum, and finally the Purkinje fibers, which spread within the muscle of the ventricle walls.
Because the SA node has the highest rate of depolarization in the whole system, it starts each heart beat and sets the pace for the whole heart. Consequently,
the SA node is often called the pacemaker.
Cardiac Cycle And Heart Sounds
In a healthy heart, the atria contract simultaneously. Then as they start to relax, contraction of the ventricles begins. Systole and diastole mean heart
contraction and relaxation respectively. The term cardiac cycle refers to the events of one complete heartbeat, during which both atria and ventricles contract and
then relax. The normal cardiac cycle is about 0.8 second.

When using stethoscope, you can hear two distinct sounds during each cardiac cycle. These heart sounds are often described by two sylaables, “lub” and
“dup”, ans the sequence is lub-dup, pause, and so on. The first heart sound (lub) is caused by closing of AV valves. The second sound, (dup) occurs when the
semilunar valves close at the end of systole. The first heart sound is longer and louder than the second heart sound, which tends to be short and sahrp.
Blood flows silently as long as the flow is smooth and uninterrupted. If it strikes obstructions, its flows become turbulent and generate sounds, such as heart
murmurs, that can e heard with a stethoscope.
Cardiac Output
Cardiac output is the amount of blood pumped out by each side of the heart (actually each ventricle) in one minute. It is the product of the heart rate (HR)
and the stroke volume (SV). Stroke volume is the volume of blood pumped out by a ventricle with each heartbeat. In general, stroke volume increases as the force of
ventricular contraction increases.
Since the normal adult volume is about 1500 ml, the entire blood supply passes through the body once each minute. Cardiac output varies with the demands
of the body. It rises when the stroke volume is increased or the heart betas faster or both; it drops when either or both of these factors decrease.
Regulation of Stroke Volume
A healthy heart pumps out about 60% of the blood that enters it. As noted above, this is approximately 70 ml (about 2 ounces) with each heartbeat.
According to Starling’s law of the heart, the critical factor controlling strike volume is how much the cardiac muscle cells are stretched just before they contract.
The more they are stretched, the stronger the contraction will be. The important factor stretching the heart muscle is venous return, the amount of blood entering the
heart and distending its ventricles. If one side of the heart suddenly begins to pump more blood than the other, the increased venous to the opposite ventricle will
force it to pump out an equal amount, thus preventing back up of blood in the circulation.
Anything that increase the volume or speed of venous return also increases stroke volume and force of contraction. For example, a slow heartbeat allows
more time for the ventricles to fill. Exercise speeds venous return because it results in increased heart rate and force. The enhanced squeezing action of active
skeletal muscles on the veins returning blood to the heart, the so called muscular pump, also plays a major role in increasing the venous return. On the other hand,
low venous return such as might result from severe blood loss or an extremely rapid heart rate, decreases stroke volume causing the heart to beat less forcefully.
Regulation of the Heart Rate
In healthy people, stroke volume tends to be relatively constant. However, when blood volume drops suddenly or when the heart has been seriously
weakened, stroke volume declines, and cardiac output is maintained by a faster heartbeat. Although heart contraction does not depend on the nervous system, its
rate can be changed temporarily by the automatic nerves. Indeed, the most important external influence on heart rate is the activity of the autonomic nervous
system. Heart rate is also modified by various chemicals,hormones, and ions.

During times of physical or emotional stress, the nerves of the sympathetic division of the autonomic nervous system stimulate the SA and AV nodes and the
cardiac muscle itself. As a result, the heart beats more rapidly. This is familiar phenomenon to anyone who has ever been frightened or has had run to catch a bus.
As fast as the heart pumps under ordinary conditions, it really speeds up when special demand are placed on it. Since a faster blood flow increases the rate at which
fresh blood reaches body cells, more oxygen and glucose are made available to them during periods of stress. When demand declines, the heart adjusts.
Parasympathetic nerves, primarily the vagus nerves, slow and steady the heart, giving it more time to rest during noncrisis times.
Various hormones and ions can have a dramatic effect on heart activity. Epinephrine, which mimics the effect of the sympathetic nerves, and thyroxine both
increase heart rate. Electrolyte imbalances pose a real threat to the heart. For example, reduced levels of ionic calcium in the blood depress the heart; whereas
hypercalcemia causes such prolonged contractions that the heart may stop entirely. Excesses or lack of needed ions such as sodium and potassium also modify heart
activity. A deficit of potassium ions in the blood, for example, causes the heart to beat feebly, and abnormal heart rhythms appear.
The pumping action of the healthy heart maintains a balance between cardiac output and venous return. But the pumping efficiency of the heart is depressed
so that the circulation is inadequate to meet tissue needs, congestive heart failure (CHF) occurs. Because the heart is a double pump, each side can fail
independently of the other. If the left heart fails, pulmonary congestion occurs. The right side of the heart continues to propel blood to the lungs, but the left side is
unable to eject the running blood into the systemic circulation. As blood vessels within the lungs become swollen with blood, the pressure within them
increases,and fluid leaks from the circulation into the lung tissue, causing pulmonary edema. If untreated, the person suffocates. If the right side of the heart fails,
peripheral congestion occurs as blood backs up in the circulation. Edema is most noticeable in the distal parts of the body: The feet, ankles, and fingers become
swollen and puffy. Failure of one side of the heart puts a greater strain on the opposite side, and eventually the whole heart fails.
Congestive Heart Failure (left-sided heart failure)
Congestive heart failure is a syndrome rather than a disease, heart failure occurs when the heart cannot pump enough blood to meet the body’s metabolic
needs. Heart failure results in intravascular and interstitial volume overload and poor tissue perfusion. An individual with heart failure experiences reduced
exercise tolerance, a reduced quality of life, and a shortened life span.
Etiology
The pumping action of the heart is not able to meet the body’s demand for blood, resulting in inadequate perfusion. Some of the causes of the heart failure
are hypertension; CAD, MI, chronic obstructive pulmonary disease (COPD), cardiac valve damage, arrythmias (dysrhythmias), and cardiomyopathy.
The causes of the heart failure can be divided into three subgroups: (1) abnormal loading conditions, (2) abnormal muscle function, and (3) conditions or
diseases that precipitate or exacerbate heart failure.
1. Abnormal Loading Conditions-

Venous return stretches the heart and improves contractility. When the heart is overloaded with blood, excessive stretch and
decreased contraction occurs. Overload develops because blood does not leave the ventricles during contraction.
Preload refers to the stretch of the ventricular myocardial fibers just before the ventricular contraction. The load or the stretch placed
on the ventricular fibers corresponds to the end-diastolic ventricular volume and pressure. Preload is determined by the condition of the heart valves (especially the
mitral valve), blood volume, ventricular wall compliance, and venous tone. Increased preload usually increases contractility and stretch due to the filling pressures
from venous return and previous volume.
Afterload corresponds to the amount of tension that the heart must generate to overcome systemic pressure and allow adequate
ventricular emptying. In other words, afterload indicates how “hard” the heart must pump to force blood into the circulation.
2. Abnormal Muscle Function
There are certain conditions that directly interfere with myocardial contractility. Intrinsic conditions are inherent in the cardiac muscle
and include MI; myocarditis, an inflammation of the myocardium associated with viral, bacterial, fungal, or parasitic diseases or toxic
chemical injury; cardiomyopathy, and ventricular aneurysm. Such disorders impair the contractile function of the myocardial fibrils,
which reduces ventricular emptying and stroke volume.
3. Conditions that Precipitate or Exacerbate Heart Failure
• Physical or Emotional Stress – strenuous physical exercise and strong emotions (fear, excitement, anxiety) increase sympathetic
nervous tone and catecholamine release. This increases myocardial work by increasing heart rate, myocardial contractility, and blood
pressure.
• Dysrythmias – Cardiac dysrhythmias, most notably tachycardia (rapid heart rate), are the most common factors precipitating heart
failure. A rapid heartbeat shortens the time for ventricular filling (diastole), which in turn reduces cardiac output and decreases
myocardial perfusion. In addition, the workload and oxygen requirements of the myocardium increases.
• Infections – any systemic infection increases the oxygen demands of the body tissues. The heart must keep with these demands.
Fever and hypoxemia, which occur in some pulmonary infections, further tax the ailing heart and may precipitate failure.
• Anemia - reduction in the oxygen – carrying capacity of the blood, as in anemia, necessitates increased cardiac output to meet the
body’s need for oxygen. Whereas a normal heart may adjust to the increased workload, a compromised heart cannot, and failure
ensues.

• Thyroid disorders – thyrotoxicosis, associated with hyperthyroidism, augments the metabolic needs of the body, accelerating heart rate
and the workload of the heart. If the thyroxicosis is untreated, heart failure may occur. In hypothyroidism, the thyroid produces an
inadequate amount of thyroxine (thyroid hormone). This can indirectly lead to heart failure by predisposing the client to coronary
artherosclerosis.
• Pregnancy – heart failure ranks high among cause of death during pregnancy. Pregnancy increases the metabolic needs of the body,
thereby increasing the workload of the heart. Pregnant women with rheumatic valvular disease are particularly prone to heart failure.
Signs and Symptoms
Early Clinical Manifestations of Left-Sided Heart Failure
• Dyspnea caused by pulmonary congestion
• Orthopenia or orthopnea as blood is redistributed from legs to the central circulation when the patient lies down at night

• Paroxysmal nocturnal dyspnea due to the reabsorption of the interstitial fluid when lying down and reduced sympathetic stimulation
with sleeping
• Fatigue associated with reduced oxygenation and an inability to increase cardiac output in response to physical activity
Later Clinical Manifestations of Left-Sided Heart Failure
• Crackles due to pulmonary congestion
• Hemoptysis resulting from bleeding veins in the bronchial system caused by venous distention
• Patient of maximal impulse displaced toward the left anterior axillary line caused by left ventricular hypertrophy
• Tachycardia due to sympathetic stimulation
• S3 caused by rapid ventricular filling
• S4 resulting from atrial contraction against a noncompliant ventricle
• Cool, pale skin resulting from peripheral vasoconstriction
• Restlessness and confusion due to reduced cardiac output
EVALUATION
Thank God, we’ve done for it…
After long hard days of making this valuable paper, at last we found justice. Making a case analysis paper is not an easy task, but is a fulfilling experience.
We have gone at this far because we were able to use the Nursing Process that has been taught unto us by our beloved faculty of the College of Nursing in Silliman

University. First, we used thoroughly the proper assessment that has to be done during the contact with our client. We used the Gordon’s Functional Health Patterns,
our effective communication skills and by using our senses to critically observed the client’s responses. By then, we gathered all the information and cues we had
assessed and immediately planned our care. We put our plan into action.
We would like to extend our thanks to our C.I. Mr. Osel Sherwin Melad that despite of the hectic schedule we’ve been facing, he is always there to support
and guide us. Thanks for the group conferences and ward class that broadens our knowledge about laboratory and diagnostic exams, nature of some diseases and
how it can be intervened.
It is such an honor to present to you our case, CHF, and we are thanking each and everyone for by this event we had able to provide a quality care to our
patient. This event not only taught us how to be vigilant in giving care but it made also an impact unto our side and that is, to learn to value time and individual’s
importance.
PHARMACOLOGY
1. furosemide
(fur oh' se mide)
Apo-Furosemide (CAN), Furoside (CAN), Lasix, Myrosemide (CAN)
Pregnancy Category C

Drug class
Loop diuretic
Therapeutic actions
Inhibits the reabsorption of sodium and chloride from the ascending limb of the loop of Henle, leading to a sodium-rich diuresis.
Indications
 Oral, IV: Edema associated with CHF, cirrhosis, renal disease
 IV: Acute pulmonary edema
 Oral: Hypertension
Contraindications and cautions
 Contraindicated with allergy to furosemide, sulfonamides; allergy to tartrazine (in oral solution); anuria, severe renal failure; hepatic coma; pregnancy; lactation.
 Use cautiously with SLE, gout, diabetes mellitus.
Available forms
Tablets—20, 40, 80 mg; oral solution—10 mg/mL, 40 mg/5 mL; injection—10 mg/mL
Dosages
ADULTS
 Edema: Initially, 20–80 mg/day PO as a single dose. If needed, a second dose may be given in 6–8 hr. If response is unsatisfactory, dose may be increased in 20-
to 40-mg increments at 6- to 8-hr intervals. Up to 600 mg/day may be given. Intermittent dosage schedule (2–4 consecutive days/wk) is preferred for maintenance,
or 20–40 mg IM or IV (slow IV injection over 1–2 min). May increase dose in increments of 20 mg in 2 hr. High-dose therapy should be given as infusion at rate
not exceeding 4 mg/min.
 Acute pulmonary edema: 40 mg IV over 1–2 min. May be increased to 80 mg IV given over 1–2 min if response is unsatisfactory after 1 hr.
 Hypertension: 40 mg bid PO. If needed, additional antihypertensive agents may be added.
PEDIATRIC PATIENTS
Avoid use in premature infants: stimulates PGE2 synthesis and may increase incidence of patent ductus arteriosus and complicate respiratory distress syndrome.
 Edema: Initially, 2 mg/kg/day PO. If needed, increase by 1–2 mg/kg in 6–8 hr. Do not exceed 6 mg/kg. Adjust maintenance dose to lowest effective level.

 Pulmonary edema: 1 mg/kg IV or IM. May increase by 1 mg/kg in 2 hr until the desired effect is seen. Do not exceed 6 mg/kg.
PATIENTS WITH RENAL IMPAIRMENT
Up to 4 g/day has been tolerated. IV bolus injection should not exceed 1 g/day given over 30 min.
Pharmacokinetics
Route Onset Peak Duration
Oral 60 min 60–120
min
6–8 hr
IV, IM 5 min 30 min 2 hr
Metabolism: Hepatic; T1/2: 30–60 min
Distribution: Crosses placenta; enters breast milk
Excretion: Urine, feces
IV facts
Preparation: Store at room temperature; exposure to light may slightly discolor solution.
Infusion: Inject directly or into tubing of actively running IV; inject slowly over 1–2 min.
Incompatibilities: Do not mix with acidic solutions. Isotonic saline, lactated Ringer's injection, and 5% dextrose injection may be used after pH has been adjusted (if
necessary); precipitates form with gentamicin, netilimicin, milrinone in 5% dextrose, 0.9% sodium chloride.
Adverse effects
 CNS: Dizziness, vertigo, paresthesias, xanthopsia, weakness, headache, drowsiness, fatigue, blurred vision, tinnitus, irreversible hearing loss
 CV: Orthostatic hypotension, volume depletion, cardiac arrhythmias, thrombophlebitis
 Dermatologic: Photosensitivity, rash, pruritus, urticaria, purpura, exfoliative dermatitis, erythema multiforme
 GI: Nausea, anorexia, vomiting, oral and gastric irritation, constipation, diarrhea, acute pancreatitis, jaundice
 GU: Polyuria, nocturia, glycosuria, urinary bladder spasm
 Hematologic: Leukopenia, anemia, thrombocytopenia, fluid and electrolyte imbalances
 Other: Muscle cramps and muscle spasms
Interactions

Drug-drug
 Increased risk of cardiac arrhythmias with digitalis glycosides (due to electrolyte imbalance)
 Increased risk of ototoxicity with aminoglycoside antibiotics, cisplatin
 Decreased absorption of furosemide with phenytoin
 Decreased natriuretic and antihypertensive effects with indomethacin, ibuprofen, other NSAIDs
 Decreased GI absorption with charcoal
 May reduce effect of insulin or oral antidiabetic agents because blood glucose levels can become elevated
Nursing considerations
CLINICAL ALERT!
Name confusion has occurred between furosemide and torsemide; use extreme caution.
Assessment
 History: Allergy to furosemide, sulfonamides, tartrazine; electrolyte depletion anuria, severe renal failure; hepatic coma; SLE; gout; diabetes mellitus; lactation,
pregnancy
 Physical: Skin color, lesions, edema; orientation, reflexes, hearing; pulses, baseline ECG, BP, orthostatic BP, perfusion; R, pattern, adventitious sounds; liver
evaluation, bowel sounds; urinary output patterns; CBC, serum electrolytes (including calcium), blood sugar, liver and renal function tests, uric acid, urinalysis,
weight
Interventions
 Administer with food or milk to prevent GI upset.
 Reduce dosage if given with other antihypertensives; readjust dosage gradually as BP responds.
 Give early in the day so that increased urination will not disturb sleep.
 Avoid IV use if oral use is at all possible.
 Do not mix parenteral solution with highly acidic solutions with pH below 3.5.
 Do not expose to light, may discolor tablets or solution; do not use discolored drug or solutions.
 Discard diluted solution after 24 hr.
 Refrigerate oral solution.
 Measure and record weight to monitor fluid changes.

 Arrange to monitor serum electrolytes, hydration, liver function.
 Arrange for potassium-rich diet or supplemental potassium as needed.
Teaching points
 Record intermittent therapy on a calendar or dated envelopes. When possible, take the drug early so increased urination will not disturb sleep. Take with food or
meals to prevent GI upset.
 Weigh yourself on a regular basis, at the same time and in the same clothing, and record the weight on your calendar.
 These side effects may occur: Increased volume and frequency of urination; dizziness, feeling faint on arising, drowsiness (avoid rapid position changes;
hazardous activities, like driving; and consumption of alcohol); sensitivity to sunlight (use sunglasses, wear protective clothing, or use a sunscreen); increased thirst
(suck on sugarless lozenges; use frequent mouth care); loss of body potassium (a potassium-rich diet or potassium supplement will be needed).
 Report loss or gain of more than 3 lb in 1 day, swelling in your ankles or fingers, unusual bleeding or bruising, dizziness, trembling, numbness, fatigue, muscle
weakness or cramps.
Adverse effects in Italic are most common; those in Bold are life-threatening.
2. digoxin
(di jox' in)
Digitek, Lanoxicaps, Lanoxin, Novo-Digoxin (CAN)
Pregnancy Category C
Drug classes
Cardiac glycoside
Cardiotonic
Therapeutic actions
Increases intracellular calcium and allows more calcium to enter the myocardial cell during depolarization via a sodium–potassium pump mechanism; this increases
force of contraction (positive inotropic effect), increases renal perfusion (seen as diuretic effect in patients with CHF), decreases heart rate (negative chronotropic
effect), and decreases AV node conduction velocity.

Indications
 CHF
 Atrial fibrillation
 Contraindicated with allergy to digitalis preparations, ventricular tachycardia, ventricular fibrillation, heart block, sick sinus syndrome, IHSS, acute MI, renal
insufficiency and electrolyte abnormalities (decreased K+
, decreased Mg++
, increased Ca++
).
 Use cautiously with pregnancy and lactation.
Available forms
Lanoxicaps capsules—0.05, 0.1, 0.2 mg; tablets—0.125, 0.25, mg, elixir—0.05 mg/mL; injection—0.25 mg/mL; pediatric injection—0.1 mg/mL
Dosages
Patient response is quite variable. Evaluate patient carefully to determine the appropriate dose.
ADULTS
Loading dose, 0.75–1.25 mg PO or 0.125–0.25 mg IV. Maintenance dose, 0.125–0.25 mg/day PO.
Lanoxicaps capsules
0.4–0.6 mg PO; maintenance dose: 0.5–0.1 mg/day PO.
PEDIATRIC PATIENTS
 Loading dose:
Oral
(mcg/kg)
IV
(mcg/kg)
Premature 20–30 15–25
Neonate 25–35 20–30
1–24 mo 35–60 30–50
2–5 yr 30–40 25–35
5–10 yr 20–35 15–30
> 10 yr 10–15 8–12
Maintenance dose, 25%–35% of loading dose in divided daily doses. Usually 0.125–0.5 mg/day PO.
GERIATRIC PATIENTS WITH IMPAIRED RENAL FUNCTION

Creatinine Clearance
(mL/min)
Dose
10–25 0.125 mg/day
26–49 0.1875 mg/day
50–79 0.25 mg/day
Pharmacokinetics
Oral 30–120 min 2–6 hr 6–8 days
IV 5–30 min 1–5 hr 4–5 days
Metabolism: Some hepatic; T1/2: 30–40 hr
Distribution: May cross placenta; enters breast milk
Excretion: Largely unchanged in the urine
IV facts
Preparation: Give undiluted or diluted in fourfold or greater volume of sterile water for injection, 0.9% sodium chloride injection, 5% dextrose injection, or lactated
Ringer's injection. Use diluted product promptly. Do not use if solution contains precipitates.
Infusion: Inject slowly over 5 min or longer.
Incompatibility: Do not mix with dobutamine.
Adverse effects
 CNS: Headache, weakness, drowsiness, visual disturbances, mental status change
 CV: Arrhythmias
 GI: GI upset, anorexia
Interactions
Drug-drug
 Increased therapeutic and toxic effects of digoxin with thioamines, verapamil, amiodarone, quinidine, quinine, erythromycin, cyclosporine (a decrease in digoxin
dosage may be necessary to prevent toxicity; when the interacting drug is discontinued, an increase in the digoxin dosage may be necessary)

 Increased incidence of cardiac arrhythmias with potassium-losing (loop and thiazide) diuretics
 Increased absorption or increased bioavailability of oral digoxin, leading to increased effects with tetracyclines, erythromycin
 Decreased therapeutic effects with thyroid hormones, metoclopramide, penicillamine
 Decreased absorption of oral digoxin if taken with cholestyramine, charcoal, colestipol, antineoplastic agents (bleomycin, cyclophosphamide, methotrexate)
 Increased or decreased effects of oral digoxin (adjust the dose of digoxin during concomitant therapy) with oral aminoglycosides
Drug-alternative therapy
 Increased risk of digoxin toxicity if taken with ginseng, hawthorn, or licorice therapy
 Decreased absorption with psyllium
 Decreased serum levels with St. John's wort
Assessment
 History: Allergy to digitalis preparations, ventricular tachycardia, ventricular fibrillation, heart block, sick sinus syndrome, IHSS, acute MI, renal insufficiency,
decreased K+
, decreased Mg++
increased Ca++
 Physical: Weight; orientation, affect, reflexes, vision; P, BP, baseline ECG, cardiac auscultation, peripheral pulses, peripheral perfusion, edema; R, adventitious
sounds; abdominal percussion, bowel sounds, liver evaluation; urinary output; electrolyte levels, liver and renal function tests
Interventions
 Monitor apical pulse for 1 min before administering; hold dose if pulse < 60 in adult or < 90 in infant; retake pulse in 1 hr. If adult pulse remains < 60 or infant <
90, hold drug and notify prescriber. Note any change from baseline rhythm or rate.
 Take care to differentiate Lanoxicaps from Lanoxin; dosage is very different
 Check dosage and preparation carefully.
 Avoid IM injections, which may be very painful.
 Follow diluting instructions carefully, and use diluted solution promptly.
 Avoid giving with meals; this will delay absorption.
 Have emergency equipment ready; have K+
salts, lidocaine, phenytoin, atropine, cardiac monitor on standby in case toxicity develops.
 Monitor for therapeutic drug levels: 0.5–2 ng/mL.

Teaching points
 Do not stop taking this drug without notifying your health care provider.
 Take pulse at the same time each day, and record it on a calendar (normal pulse for you is___); call your health care provider if your pulse rate falls below ____.
 Weigh yourself every other day with the same clothing and at the same time. Record this on the calendar.
 Wear or carry a medical alert tag stating that you are using this drug.
 Have regular medical checkups, which may include blood tests, to evaluate the effects and dosage of this drug.
 Report unusually slow pulse, irregular pulse, rapid weight gain, loss of appetite, nausea, vomiting, blurred or "yellow" vision, unusual tiredness and weakness,
swelling of the ankles, legs or fingers, difficulty breathing.
3. captopril
(kap' toe pril)
Apo-Capto (CAN), Capoten, Gen-Captopril (CAN), Novo-Captopril (CAN), Nu-Capto (CAN)
Pregnancy Category C (first trimester)
Pregnancy Category D (second, third trimesters)
Drug classes
Angiotensin-converting enzyme (ACE) inhibitor
Antihypertensive
Therapeutic actions
Blocks ACE from converting angiotensin I to angiotensin II, a powerful vasoconstrictor, leading to decreased blood pressure, decreased aldosterone secretion, a
small increase in serum potassium levels, and sodium and fluid loss; increased prostaglandin synthesis also may be involved in the antihypertensive action.
Indications
 Treatment of hypertension alone or in combination with thiazide-type diuretics
 Treatment of CHF in patients unresponsive to conventional therapy; used with diuretics and digitalis
 Treatment of diabetic nephropathy

 Treatment of left ventricular dysfunction after MI
 Unlabeled uses: Management of hypertensive crises; treatment of rheumatoid arthritis; diagnosis of anatomic renal artery stenosis, hypertension related to
scleroderma renal crisis; diagnosis of primary aldosteronism, idiopathic edema; Bartter's syndrome; Raynaud's syndrome
 Contraindicated with allergy to captopril, history of angiodema.
 Use cautiously with impaired renal function; CHF; salt or volume depletion, lactation, pregnancy.
Available forms
Tablets—12.5, 25, 50, 100 mg
Dosages
ADULTS
 Hypertension: 25 mg PO bid or tid; if satisfactory response is not noted within 1–2 wk, increase dosage to 50 mg bid–tid; usual range is 25–150 mg bid–tid PO
with a mild thiazide diuretic. Do not exceed 450 mg/day.
 CHF: 6.25–12.5 mg PO tid in patients who may be salt or volume depleted. Usual initial dose, 25 mg PO tid; maintenance dose, 50–100 mg PO tid. Do not
exceed 450 mg/day. Use in conjunction with diuretic and digitalis therapy.
 Left ventricular dysfunction after MI: 50 mg PO tid, starting as early as 3 days post MI. Initial dose of 6.25 mg, then 12.5 mg tid, increasing slowly to 50 mg tid.
 Diabetic nephropathy: 25 mg PO tid.
PEDIATRIC PATIENTS
Safety and efficacy not established.
GERIATRIC PATIENTS AND PATIENTS WITH RENAL IMPAIRMENT
Excretion is reduced in renal failure; use smaller initial dose; adjust at smaller doses with 1- to 2-wk intervals between increases; slowly adjust to smallest effective
dose. Use a loop diuretic with renal dysfunction.
Pharmacokinetics
Route Onset Peak
Oral 15 min 30–90 min
Metabolism: T1/2: 2 hr

Excretion: Urine
Adverse effects
 CV: Tachycardia, angina pectoris, MI, Raynaud's syndrome, CHF, hypotension in salt- or volume-depleted patients
 Dermatologic: Rash, pruritus, pemphigoid-like reaction, scalded mouth sensation, exfoliative dermatitis, photosensitivity, alopecia
 GI: Gastric irritation, aphthous ulcers, peptic ulcers, dysgeusia, cholestatic jaundice, hepatocellular injury, anorexia, constipation
 GU: Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, urinary frequency
 Hematologic: Neutropenia, agranulocytosis, thrombocytopenia, hemolytic anemia, pancytopenia
 Other: Cough, malaise, dry mouth, lymphadenopathy
Interactions
Drug-drug
 Increased risk of hypersensitivity reactions with allopurinol
 Decreased antihypertensive effects with indomethacin
 Increased captopril effects with probenecid
Drug-food
 Decreased absorption of captopril with food
Drug-lab test
 False-positive test for urine acetone
Assessment
 History: Allergy to captopril, history of angioedema, impaired renal function, CHF, salt or volume depletion, pregnancy, lactation
 Physical: Skin color, lesions, turgor; T; P, BP, peripheral perfusion; mucous membranes, bowel sounds, liver evaluation; urinalysis, renal and liver function
tests, CBC and differential
Interventions
 Administer 1 hr before or 2 hr after meals.

 Alert surgeon and mark patient's chart with notice that captopril is being taken; the angiotensin II formation subsequent to compensatory renin release during
surgery will be blocked; hypotension may be reversed with volume expansion.
 Monitor patient closely for fall in BP secondary to reduction in fluid volume (excessive perspiration and dehydration, vomiting, diarrhea); excessive hypotension
may occur.
 Reduce dosage in patients with impaired renal function.
Teaching points
 Take drug 1 hr before or 2 hr after meals; do not take with food. Do not stop without consulting your health care provider.
 Be careful of drop in blood pressure (occurs most often with diarrhea, sweating, vomiting, dehydration); if light-headedness or dizziness occurs, consult your
health care provider.
 Avoid over-the-counter medications, especially cough, cold, allergy medications that may contain ingredients that will interact with ACE inhibitors. Consult
your health care provider.
 These side effects may occur: GI upset, loss of appetite, change in taste perception (limited effects, will pass); mouth sores (perform frequent mouth care); rash;
fast heart rate; dizziness, light-headedness (usually passes after the first few days; change position slowly, and limit your activities to those that do not require
alertness and precision).
 Report mouth sores; sore throat, fever, chills; swelling of the hands, feet; irregular heartbeat, chest pains; swelling of the face, eyes, lips, tongue, difficulty
breathing.
4. clindamycin
(klin da mye' sin)
clindamycin hydrochloride
Oral:
Cleocin, Cleocin Suppository, Dalacin C (CAN)
clindamycin palmitate hydrochloride
Oral:

Cleocin Pediatric
clindamycin phosphate
Oral, parenteral, topical dermatologic solution for acne, vaginal preparation:
Cleocin Phosphate, Cleocin T, Cleocin Vaginal Ovules, Clinda-Derm (CAN), Dalacin C (CAN)
Pregnancy Category B
Drug class
Lincosamide antibiotic
Therapeutic actions
Inhibits protein synthesis in susceptible bacteria, causing cell death.
Indications
 Systemic administration: Serious infections caused by susceptible strains of anaerobes, streptococci, staphylococci, pneumococci; reserve use for penicillin-
allergic patients or when penicillin is inappropriate; less toxic antibiotics (erythromycin) should be considered
 Parenteral: Treatment of septicemia caused by staphylococci, streptococci; acute hematogenous osteomyelitis; adjunct to surgical treatment of chronic bone and
joint infections due to susceptible organisms; do not use to treat meningitis; does not cross the blood–brain barrier.
 Topical dermatologic solution: Treatment of acne vulgaris
 Vaginal preparation: Treatment of bacterial vaginosis
Systemic administration
 Contraindicated with allergy to clindamycin, history of asthma or other allergies, tartrazine (in 75- and 150-mg capsules); hepatic or renal dysfunction; lactation.
 Use cautiously in newborns and infants due to benzyl alcohol content; associated with gasping syndrome.
Topical dermatologic solution, vaginal preparation
 Contraindicated with allergy to clindamycin or lincomycin.
 Use cautiously with history of regional enteritis or ulcerative colitis; history of antibiotic-associated colitis.

Available forms
Capsules—75, 150, 300 mg; granules for oral solution—75 mg/5 mL; injection—150 mg/mL; topical gel—10 mg; topical lotion—10 mg; topical solution—10 mg;
vaginal cream—2%; vaginal suppository—100 mg
Dosages
ADULTS
Oral
150–300 mg q 6 hr, up to 300–450 mg q 6 hr in more severe infections.
Parenteral
600–2,700 mg/day in two to four equal doses; up to 4.8 g/day IV or IM may be used for life-threatening situations.
Vaginal
One applicator (100 mg clindamycin phosphate) intravaginally, preferably at hs for 7 consecutive days; or insert vaginal suppository, preferably at hs for 7
consecutive days, 3 days for Cleocin Vaginal Ovules.
Topical
Apply a thin film to affected area bid.
PEDIATRIC PATIENTS
Oral
For clindamycin HCl, 8–20 mg/kg/day in three or four equal doses. For clindamycin palmitate HCl, 8–25 mg/kg/day in three or four equal doses; for children
weighing < 10 kg, use 37.5 mg tid as the minimum dose.
Parenteral
Neonates: 15–20 mg/kg/day in three or four equal doses.
> 1 mo: 15–40 mg/kg/day in three or four equal doses or 300 mg/m2
/day to 400 mg/m2
/day; in severe infections, give 300 mg/day regardless of weight.
GERIATRIC PATIENTS OR PATIENTS WITH RENAL FAILURE
Reduce dose, and monitor patient's serum levels carefully.
Pharmacokinetics
Oral Varies 1–2 hr 8–12 hr
IM 20–30 min 1–3 hr 8–12 hr
IV Immediate Minutes 8–12 hr
Topical Minimal systemic

absorption
Metabolism: Hepatic; T1/2: 2–3 hr
Excretion: Urine and feces
IV facts
Preparation: Store unreconstituted product at room temperature. Reconstitute by adding 75 mL of water to 100-mL bottle of palmitate in two portions. Shake well;
do not refrigerate reconstituted solution. Reconstituted solution is stable for 2 wk at room temperature. Dilute reconstituted solution to a concentration of 300 mg/50
mL or more of diluent using 0.9% sodium chloride injection, 5% dextrose injection, or lactated Ringer's solution. Solution is stable for 16 days at room temperature.
Infusion: Do not administer more than 1,200 mg in a single 1-hr infusion. Infusion rates: 300 mg in 50 mL diluent, 10 min; 600 mg in 50 mL diluent, 20 min;
900 mg in 50–100 mL diluent, 30 min; 1,200 mg in 100 mL diluent, 40 min.
Incompatibilities: Do not mix with calcium gluconate, ampicillin, phenytoin, barbiturates, aminophylline, and magnesium sulfate. May be mixed with sodium
chloride, dextrose, calcium, potassium, vitamin B complex, kanamycin, gentamicin, penicillin, carbencillin. Incompatible in syringe with tobramycin.
Adverse effects
 CV: Hypotension, cardiac arrest (with rapid IV infusion)
 GI: Severe colitis, including pseudomembranous colitis, nausea, vomiting, diarrhea, abdominal pain, esophagitis, anorexia, jaundice, liver function changes
 Hematologic: Neutropenia, leukopenia, agranulocytosis, eosinophilia
 Hypersensitivity: Rashes, urticaria to anaphylactoid reactions
 Local: Pain following injection, induration and sterile abscess after IM injection, thrombophlebitis after IV use
Topical dermatologic solution
 CNS: Fatigue, headache
 Dermatologic: Contact dermatitis, dryness, gram-negative folliculitis
 GI: Pseudomembranous colitis, diarrhea, bloody diarrhea; abdominal pain, sore throat
 GU: Urinary frequency
Vaginal preparation
 GU: Cervicitis, vaginitis, vulvar irritation

Interactions
Drug-drug
 Increased neuromuscular blockade with neuromuscular blocking agents
 Decreased GI absorption with kaolin, aluminum salts
Assessment
 History: Allergy to clindamycin, history of asthma or other allergies, allergy to tartrazine (in 75- and 150-mg capsules); hepatic or renal dysfunction; lactation;
history of regional enteritis or ulcerative colitis; history of antibiotic associated colitis
 Physical: Site of infection or acne; skin color, lesions; BP; R, adventitious sounds; bowel sounds, output, liver evaluation; complete blood count, renal and liver
function tests
Interventions
 Culture infection before therapy.
 Administer oral drug with a full glass of water or with food to prevent esophageal irritation.
 Do not give IM injections of more than 600 mg; inject deep into large muscle to avoid serious problems.
 Do not use for minor bacterial or viral infections.
 Monitor renal and liver function tests, and blood counts with prolonged therapy.
Topical dermatologic administration
 Keep solution away from eyes, mouth and abraded skin or mucous membranes; alcohol base will cause stinging. Shake well before use.
 Keep cool tap water available to bathe eye, mucous membranes, abraded skin inadvertently contacted by drug solution.
Vaginal preparation
 Give intravaginally, preferably at hs.
Teaching points
 Take oral drug with a full glass of water or with food.
 Take full prescribed course of oral drug. Do not stop taking without notifying health care provider.

 These side effects may occur: Nausea, vomiting (eat small, frequent meals); superinfections in the mouth, vagina (use frequent hygiene measures; request
treatment if severe).
 Report severe or watery diarrhea, abdominal pain, inflamed mouth or vagina, skin rash or lesions.
Topical dermatologic administration
 Apply thin film of acne solution to affected area twice daily, being careful to avoid eyes, mucous membranes, abraded skin; if solution contacts one of these
areas, flush with copious amounts of cool water.
 Report abdominal pain, diarrhea.
Vaginal preparation
 Use vaginal preparation for 7 or 3 consecutive days, preferably at bedtime. Refrain from sexual intercourse during treatment with this product.
 Report vaginal irritation, itching; diarrhea, no improvement in complaint being treated.
Adverse effects in Italic are most common; those in Bold are life threatening.
5. Generic name: Simvastatin (Synvinolin)
Brand name: Lipex, Zocor
Mechanism of action:
Inhibits HMG-CoA reductase, which is an early (and rate-limiting) step in cholesterol biosynthesis.
Indications:
 To reduce risk of death from CV disease and CV events in proteins at high-risk for coronary events
 To reduce total and LDL cholesterol levels in patients with homozygous familial hypercholesterolemia
Contraindications:
 Contraindicated in patients hyper sensitive to drug and in those with active liver disease or conditions that cause unexplained persistent
elevations of transaminase levels. Also, contraindicated in pregnant and breast-feeding women of childbearing potential.
Adverse reactions/side effects:
CNS: headache, asthenia
GI: abdominal pain, constipation, diarrhea, dyspepsia, flatulence, nausea, vomiting
Respiratory: upper respiratory tract infection
6. Generic name: Roxithromycin

Brand name: Macrol
Indications: upper and lower respiratory tract, skin and soft tissue and GUT infections (excluding gonoaxcal infections) and otitis media.
Contraindications: allergy to other macrolides. Concomitant therapy with ergot alkaloid vasoconstrictors.
Adverse reactions:
 Dizziness; epigastric pain, nausea, vomiting, diarrhea
7. Generic name: cefixime
Brand name: zefral
Indication:
 Bronchitis, secondary infections of chronic respiratory tract diseases, pneumonia
Contraindications:
 History of shock. Hypersensitivity
Adverse reactions:
 Shock, hypersensitivity reactions, dermatogenic effects; 61 disturbances

USUAL PATTERN INITIAL APPRAISAL ONGOING APPRAISAL ONGOING APPRAISAL
1. Health Perception Health
Management
 Generally health is not so good for
the past year
 Client experiences colds, fever and
flue recurrently with 2-3 mos. Gap
 She takes OTC drugs as a remedy
to these conditions like biogesic
 Also takes oregano to help ease the
common colds. She uses 7 leaves
of it and drinks 3 glasses from the
extract of oregano
 She also visits a physician every
now and then for check-up of some
health problems she experiences
 Sahe is a non-smoker and not an
alcoholic drinker
 She verbalized “maglisod ko ug
pagtuman sa isulti sa doctor nako
kay wala man pod mi kwarta”
 Verbalized that her health as of now
is “daot na”
 Verbalized “kapoy kayo akong
lawas”
 She wishes to get well soon
 V/S 5pm
T: 36.70
C
PR: 74 bpm, strong and regular
RR: 34 cpm, shallow and regular
BP: 160/90 mmhg
 Lab results:
Blood chemistry
♦ BUN------------------ 24mg/dl
♦ Creatinine------------ 0.94mg%
♦ FBS------------------- 86mg/dl
♦ Uric Acid------------ 6.5mg/dl
♦ Cholesterol----------151 mg/dl
 Verbalized “maayo-ayo na akong
paminaw”
 V/S 3pm
T: 37.4 degrees Celsius
RR: 31 cpm, deep and regular
BP: 150/80 mmhg
 Medications: same with additional
Aldazide
 IVF plain NSS at KVO right
metacarpal vein
 Oxygen Inhalation at 1L/min.
 V/S 8pm
BP: 170/80 mmhg
 Verbalized “maayo-ayo na akong
paminaw”
 V/S 3pm
BP: 150/80 mmhg
 Medications: same
 IVF plain NSS at KVO right
metacarpal vein
 Oxygen Inhalation off

♦ Triglyceride----------81mg/dl
♦ Chol-HDL-----------30 mg/dl
♦ LDL -----------------104 mg/dl
Urinalysis
 Color----------------yellow
 Transpaerncy------clear
 Sp.Gravity---------1.010
 Glucose-------------Neg.
 Protein--------------trace
 pH-------------------6.0
Microscopic Examination
 Pus cells------------10-15/hpf
 RBC-----------------0-2
 Epithelial cells-----moderate
Clinical Examination
 Na+-----------------136mEq/l
 K+------------------4.0mEq/L
CBC
 Hemoglobin------13.8gm%
 Hematocrit-------42.1%
 WBC--------------6,100/cumm
 Seg---------------80%
 Neutrophils-----
 Lymphocytes--15%
 Eosinophils----1%
 Monocytes-----3%

2. Nutritional Metabolic Pattern
 For breakfast: Milk (2-3 glasses), 2
pieces of bread and rice (1 ½ cup)
for her viand she will have any of
the following: vegetables, sardines,
“inon-onan”, and “ginamos”
 For lunch: she will have “law-oy”,
vegetables and consumes 1 ½ cup
of rice
 For supper: she usally eats noodles
and “inon-onan” and consumes 1 ½
cup of rice
 She drinks 6 glasses of water daily
 Also drinks 2 cups of coffee
 Platelet count----330,000
Medications
 Furosemide 20g OD
 Digoxin 0.25mg ½ tab O.D.
P.O.
 Captopril 25 mg ½ tab O.D.
P.O.
 Clindamycin 300 mg q 6 hrs.
IVTT
 Cefuroxime 1 g q 8 hrs. IVTT
 Simvastatin 20 mg 1 tab BID
P.O.
 Cefixime 200mg 1 tab BID P.O.
 Roxithromycin 300 mg
O.D. P.O.
 IVTT Plain NSS at KVO left
metacarpal vein
 Oxygen inhalation at 2L/min.
 Her diet is low fat and low salt diet
 Verbalized “ wala kayo ko gana sa
pagkaon”
 Consumes ¾ of her share for meal
 Meal consists of beef stew and fish
 Abrasion from scratching is seen on
her left forearm
 Client reported that it is itchy
 Skin has poor skin turgor and
 Her diet is still low fat and low salt
 Verbalized “ wala kayo ko gana sa
pagkaon”
 Verbalized “ wala kayo nahurot
akong kan-on kay gahi man”
 Drank 750 ml of water
 Lunch consists: 1 cup of rice, I piece
fried chicken, isda (inon-onan)-
consumed half of her share for meal
 Supper: ½ rice was consumed, I
piece of fish, soup of beef stew (1/2
cup), consumed “2x”2 meat of beef
 Red spots were seen on her forearm
 Her diet is still low fat and low salt
 Verbalized “ wala kayo nahurot
akong kan-on kay gahi man”
 Breakfast: consumed ½ cup, I piece
hotdog, 1 piece of grilled fish, I
banana, 1 cup of rice
 Drank 350 ml of water
 Normal skin color and temperature
 Red spots were seen on her forearm
from scratching. Client reported that
it is itchy
 Moderately good capillary refill

 Her favorite food is fish and has
moderately good appetite
 She is advised by the physician not
to eat foods rich in purines because
of her arthrtitis
3. Elimination Pattern
 Defecates 3-4 times a day
 Character of stool is not formed.
Verbalized “basa-basa gamay”;
yellowish in color
 Reported to experience moderate
pain on gastric region when she
defecates
 Urinates 6 times aday and reported
very minimal pain
 Characteristics of urine is
yellowish in color and is about ½
glass or 120 ml
 Perspiration is moderate
4. Activity exercise Pattern
 Does household chores as a
housewife
 She sells tocino either raw or
grilled
 She gets enough rest but not
enough energy for her daily
activities
 She seldoms spend time for leisure
mobility
 Capillary refill: 3-4 sec.
 Verbalized “Katol akong panit,
dayong akong kaloy maona samad”
 Red spots were seen on her
forearm from scratching. Client
reported that it is itchy
 skin color is slightly pale
 Defecated twice. Character of stool
is not formed, yellowish in color
and small in amount
 Still experiences moderate pain on
gastric region when she defecates
 Urinated 6 times, and amount is 120
ml/ urination; very minimal pain
during urination
 Has minimal perspiration
 Claimed to have difficulty
breathing
 Appeared weak and lethargic
 Hair is not fixed well, hygiene is
from scratching. Client reported that
it is itchy
 Moderately good capillary refill
mobility
 Defecated twice. Character of stool
is not formed, yellowish in color and
small in amount
 Still experiences moderate pain on
 Urinated 6 times, and amount is 120
ml/ urination; no pain during
urination
 Has minimal perspiration
 Claimed to have difficulty breathing
 Still appeared weak and lethargic
poor
 Has not yet taken a bath
 Appeared restless
 Stays in bed most of the time
 Movement is minimal
mobility
 wound on left leg seen from
scratching
 defecated twice (slightly formed,
yellowish in color and small in
amount
 still experiences moderate pain on
 urinated 6 times (1/2 cup/urination)
 Participated in tolerable desired
activities
 Met own self-care needs with
minimum assistance from other
person
 Improved posture
 decreased Labored breathing
 decreased use of accessory muscles

activities
 She enjoys chatting with her
neighbors
 She does not perform any exercise
 Perceived ability for the following:
Bathing: 2 cooking: 2
Toileting: 2 Home maintenance: 2
Dressing: 2 shopping: 2
Grooming: 2 bed mobility: 2
Feeding: 2 General Mobility: 2
 Claimed to have difficulty
breathing
 Claimed that often times she does
the household with assistance
5. Sleep- Rest Pattern
 Sleeps from 8pm and wakes at 4am
 Has enough rest
 No difficulty in getting herself to
sleep
 Does not take drugs or other
medium in order for her to sleep
 Uses 2 pillows
 Can sleep with lights on
poor
 Has not yet taken a bath
 Movement is minimal
 barely converse with her watchers
 posture is bent
 bed in semi-fowler’s position
 perceived ability for the following
 feeding :2
 bathing : 2
 toileting : 2
 bed mobility : 2
 dressing : 2
 grooming : 2
 general mobility : 2
 sleeps at 8pm and wakes t 4pm
 reported to have difficulty getting
enough rest because of the need to
wake up when medical personnel
 Still barely converse with her
watchers
 posture is bent
 feeding 2
 bathing : 2
 toileting : 2
 dressing : 2
 grooming : 2
 reported to have difficulty getting
enough rest because of the need to
wake up when medical personnel
perform their interventions
 no difficulty or problems with
patients adjacent to her
 can sleep with lights on
 appeared rested but still lethargic
poor
 Still has not yet taken a bath but had
sponge bath by her daughter
 Movement is still minimal
 Converse now with her watchers
 posture has slightly improved:
minimized use of 3 point position
 feeding 2
 bathing : 2
 toileting : 2
 dressing : 2
 grooming : 2
 yawning was Absent
 sleepy eyes was Absent
 sleeps with 2 pillows propped under

6. Cognitive Perceptual Pattern
 Has no problems in hearing and
visualizing
 Does not use eyeglasses or
reading glasses
 Being forgetful sometimes
 Whenever she feels weakness
of her body, she will just rest
 Educational attainment is grade
five
 She speaks bisaya
7. Self Perception Self Concept
Pattern
 Client claimed that her
children makes her angry when
they disobey her
 She ignores the things that will
make her angry
 She feels good about herself
and contended
8. Role Relationship Pattern
 Lived with her husband, 2
perform their interventions
 yawning noted
 sleepy eyes
 Frequent yawning observed
her head
 blankets keep her comfortable
 client verbalized the following:
 “wala raman pod ko problema sa
pandungog ug panan-aw”
 “dili raman ko magamit ug antipara
 “usahay malimot ko sa ubang
butang”
 Provide coherent answers to
questions
 Oriented to environment and is
aware of self but is lethargic
 Verbalized the following:
 “gulang nako, wala nay paglaum na
mobalik sa akong pagkabatan-
on”
 “’naa nakoy dagahang sakit”
her head
 still has no problem in hearing and
visualizing
 Provide coherent answers to
questions
 Oriented to environment and is
 Responsive to stimuli
 She hasn’t regretted anything
 She is satisfied of the life she had
 Feels incapable of doing things on
her own because of her condition
 Feels dependent to others for her
needs
her head
Provide coherent answers to
questions
Oriented to environment and is
Responsive to stimuli
She claimed that due to her
condition, she can no longer do her
usual task
She wishes to be cured form her
condition
Feels incapable of doing things on
her own because of her condition
Feels dependent to others for her
needs

children and 3 grandchildren
 Claimed to have no problems in
the family
 If ever there are problems, it is
discussed by the family
 Claimed to have good
relationship with her neighbors
 sometimes expressed her
emotions and inner feelings to
her neighbor
9. Sexually Reproductive Pattern
 has 9 children; 8 girls and 1
boy
 claimed to have a happy family
 doesn’t used any contraceptives
 is not sexually active anymore
 practices improper washing of
vagina
 18 years of marriage
 Menarche: 15 years old
 Menopausal: 40 years old
10. Coping Stress Tolerance
 Claimed that she easily gets
tense
 Major change in her life is the
deterioration of her health
 She solves problems by praying
to God
11. Value Belief Pattern
 Dependent on the pension of her
husband for financial resources
 Not able to do usual task
 Daughter and husband are present
as watchers
 Not able to do usual task
 Able to talk and laugh but lmited
 Verbalized that “naguol sila sa
akong pagkahospial ka yang kwarta
na ibayad
 Only 2 of her children is with her
out of 9
 No problems with her reproductive
system
 Verbalized “kapoy na mag-ing-ana
(referring to sexual activity)
 Shares her problems to student
nurses and family
 She was accompanied by her
husband all the time
 There was no problem in their
family that was difficult to solve
 The same daughter was seen
yesterday on her side as a watcher
 No reproductive problems
 No sexual concerns
 Rests on bed whenever she is tired
 Her husband is very supportive to
her needs
She was assisted by her daughter and
husband in doing desired activities
 The same daughter was seen
yesterday on her side as a watcher
 No reproductive problems
 No sexual concerns
 Client verbalized “ mag-ampo ko
kung magu-ol”
Shares her problems to student
nurses and family
 Rests on bed whenever she is tired

 A roman catholic
 Claimed to be highly spiritual
 Values her family and
relationship with other people
 Rest’s in Sim’s position whenever
she is tired
 Family is supportive to her needs
 Verbalizes that she commits to God
her condition
 Prays to God for her problems to be
solved
 Values her family so much and
relationships with other people
 Continues to pray and values her life
and self-worth
 Able to deal others with respect
 Continues to pray and values her life
and self-worth
 Able to deal others with respect
CUES/EVIDENCES NURSINGDIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective
♦ Coffee drinker as
claimed
♦ Verbalized “
maglisod ko ug
ginhawa”
Objective
♦ 63 years old
♦ Admitted with
medical diagnosis of
CHF 20
ASHD; UTI;
hyperlipidemia
♦ Oxygen 2 L/min
♦ IVF Plain NSS at
KVO rate
♦ V/S
T: 36.70
C
PR: 74 bpm, strong and
regular
RR: 34 cpm, shallow and
regular
BP: 160/90 mmhg
♦ Labored
breathing noted
♦ Use of accessory
muscles in breathing
♦ Body weakness
noted
2. Decreased cardiac
output related to heart
failure
Within our care, our
client will have an
increase in cardiac
output as evidenced by:
• V/S within normal
range
T: 36.50
C-37.50
C
PR: 60-100 bpm
RR: 16-20 cpm
BP:100-140/60-90mmhg
• Regular cardiac
rhythm
• decrease Labored
breathing
• decrease abnormal
lung sounds
• urine output of
1,500ml/24 hrs. and
characteristics remains
normal
• decrease use of
accessory muscles
• decrease body
weakness
Independent:
• Monitor V/S q 4 hrs.
• Assess BP for
hypertension and RR
for tachypnea
• monitor lung sounds
for adventitious
sounds such as
crackles and for
presence of coughing
• monitor intake and
output and analyze
findings . note color
and amount of urine
• Assess for change in
mental status
• Assess peripheral
→ provides baseline data
→ hypertension may be
caused by chronic
vasoconstriction or
may indicate fear or
anxiety, and increased
RR may indicate
fatigue or increased
pulmonary congestion
→ this indicates a further
decrease in cardiac
output and possibility
of developing
pulmonary edema
→ if intake exceeds
output, the client is at
risk for fluid overload
and may not be able to
clear fluids because of
decompensating heart.
Dark, concentrated
urine and oliguria may
reflect a decrease in
renal perfusion
→ may indicate
decreased cerebral
perfusion or hypoxia
→ decreased strength of
After, our client had an
increase in cardiac output
as evidenced by:
• 2 V/S were within
normal range
regular
RR: 31 cpm, deep and
regular
BP: 150/80 mmhg
• Regular cardiac
rhythm
• decreased Labored
breathing
• decreased abnormal
lung sounds
• urine output of
1,500ml/24 hrs. and
characteristics remains
normal: not met- 600ml
• decreased use of
accessory muscles
•decreased body

♦ Limited talk
♦ Presence of
crackles upon
auscultation
pulses for strength and peripheral pulses is
♦ Capillary refill is
3-4 secs.
♦ Senile turgor and
poor mobility
♦ Color of urine is
yellowish; amount is
quality
Provide Health Teachings
often found in clients
with decreased
cardiac output, and a
further decrease in
baseline may indicate
cardiac failure
weakness

600 ml o Encourage
psychological and
physical rest
o Encourage client to eat
as ordered and rest
afterwards
o Encourage to do deep
breathing and
coughing exercises
o Instruct client to quit
drinking coffee and
other drinks that
contain caffeine
o Encourage client to
ambulate
Collaborative
o Administer prescribed
medication as ordered
 Increased physical or
mental strain can
increase myocardial
and oxygen demands
 Prevents
complications and
enables client
preserve energy
 Promotes oxygenation
in the body and to
clear airway
 This maybe a factor of
a decreased cardiac
output
 Promote proper
circulation of blood
 Promotes therapeutic
effect to client and
enables us to know
the current respond to
medication
Subjective
♦ Verbalized
“kapoy kayo akong
lawas”
3. Activity intolerance
related to imbalance
between oxygen supply
and demand secondary
client will achieve an
increase in activity
tolerance as evidenced
Independent:
• Monitor V/S
before and
immediately after
 Significant changes in
V/S can occur with
compromised cardiac
After our care, our client
achieved an increase in
activity tolerance as
evidenced by:

♦ Verbalized “
maglisod ko ug
ginhawa”
Objective
♦ 63 years old
♦ Admitted with
CHF 20
ASHD; UTI;
hyperlipidemia
♦ V/S
T: 36.70
C
regular
regular
BP: 160/90 mmhg
♦ Oxygen 2 L/min
KVO rate
♦ Appeared weak and
lethargic
♦ Hair is not fixed
♦ Smell is not so
pleasant
♦ Appear restless
♦ Stays in bed most of
the time in a low
semi-fowler’s
position; faces on one
to disease condition by:
• V/S are within normal
range
T: 36.50
C-37.50
C
PR: 60-100 bpm
RR: 16-20 cpm
BP:100-140/60-90mmhg
• Reduced weakness and
fatigue
• Participation in
tolerable desired
activities
• Meeting own self-care
needs with minimum
assistance
• Improved posture
activity or receiving
medication
• Monitor client’s
response to activities.
Note for dyspnea,
diaphoresis, pallor and
tachycardia
oxygen supply
• Perform
procedures with
proper spacing
• Provide
assistance with self-
care activities as
indicated
• Schedule rest
periods with client
o Instruct client to avoid
activities that needs
pumping function and
medication effect
 Compromised cardiac
pumping can cause
immediate increase in
heart rate and oxygen
demands therefore by
aggravating weakness
and fatigue
 Assess if client’s
oxygen supply is
enough for her oxygen
demands
 Clustering activities
increases oxygen and
may cause fatigue and
weakness
 Client will be able to
meet personal care
needs without undue
myocardial stress
 Rest periods help
alleviate fatigue and
decrease workload
 Activities that needs
more supply than the
body can supply can
• 2 V/S are within
normal range
regular
regular
BP: 150/80 mmhg
• Reduced weakness and
fatigue
• Participated in
tolerable desired
activities
• Met own self-care
needs with minimum
assistance
• posture has slightly
improved: minimized
use of 3 point posit

more oxygen supply
side propped with 2
pillows
♦ Barely converse with
her watchers
♦ Posture is bent when
she sits
♦ Moderate
perspiration
♦ Perceived ability for
the following:
Feeding: 2
Bathing: 2
Toileting: 2
Dressing: 2
Grooming: 2
General Mobility: 2
Client needs assistance
from another person
o Instruct client to report
any problems with
activity intolerance
like difficulty in
breathing, pallor and
weakness
o Encourage client to
participate in activities
beneficial to her health
within tolerable level
cause fatigue and
weakness
 Immediate
interventions can be
done to compensate
with client’s needs
 Promotes cooperation
and easiness in
performing activities
with client. It also
promotes good
relationship with
persons involved with
the activities

Subjective
♦ Verbalized“
maglisod ko ug
ginhawa”
♦ Verbalized “kapoy
kayo akong lawas”
Objective
♦ 63 years old
♦ Admitted with
CHF 20
ASHD; UTI;
hyperlipidemia
♦ V/S
T: 36.70
C
regular
regular
BP: 160/90 mmhg
♦ Oxygen 2 L/min
KVO rate
♦ Appeared weak and
lethargic
1. Ineffective breathing
pattern related to
imbalance between
oxygen supply and
demand
client shall have
improved effective
respiratory pattern as
evidenced by:
range:
T: 36.50
C-37.50
C
PR: 60-100 bpm
RR: 16-20 cpm
BP:100-140/60-90mmhg
• Reduced weakness,
fatigue and
restlessness
• Improved breathing by
minimal use of
accessory muscles
Independent:
• Monitor V/S
before and
immediately after
activity or receiving
medication
capillary refill
response to activities.
Note for dyspnea,
diaphoresis, pallor and
tachycardia
• Maintain client’s
position in semi-
fowler’s
• Instruct client to avoid
activities that needs
more oxygen supply
V/S can occur with
compromised cardiac
medication effect
 To assess the status of
clients’ oxygenation
 Compromised cardiac
pumping function can
cause immediate
increase in heart rate
and oxygen demands
thereby aggravating
weakness and fatigue
 Elevation of patient’s
head is beneficial to
patient’s breathing
pattern
Activities that needs
more supply than the
body can supply can
cause fatigue and
weakness
had improved effective
respiratory pattern as
evidenced by:
normal range:
T: 36.50
C-37.50
C
PR: 60-100 bpm
RR: 16-20 cpm
BP:100-140/60-90mmhg
• Reduced weakness,
fatigue and
restlessness
• Improved breathing by
minimal use of
accessory muscles

♦ Bed is in semi-
fowler’s position and
faces on one side
♦ labored breathing
♦ Uses accessory
muscles
♦ Barely converse with
her watchers
CUES EVIDENCES
Subjective
 sleeps at 8pm and
wakes t 4pm
 sleep is interrrupted
 reported to have
difficulty getting
enough rest because
of the need to wake
up when medical
personnel perform
their interventions
 no difficulty or
problems with
patients adjacent to
her
 can sleep with lights
on
 sleeps with 2 pillows
propped under her
head
NURSING DX
6. Disturbed Sleeping
Pattern related to
hospital routines
OBJECTIVES
client will be free from
S/S of disturbed sleeping
pattern as evidenced by:
range:
T: 36.50
C-37.50
C
PR: 60-100 bpm
RR: 16-20 cpm
BP:100-140/60-
90mmhg
• Client will
verbalized good,
sound sleep
• Absence of yawning
• Absence of sleepy
eyes
o Instruct client to report
any problems with
like difficulty in
breathing, pallor and
weakness
INTERVENTIONS
Independent
• Monitor V/S q 4 hrs.
• Monitor S/S of
disturbed sleeping
pattern
• Assess level of
consciousness
• Encourage client to
drink warm liquid
before sleeping if
not contraindicated
• Perform back rub
• Provide rest and
 Immediate
done to compensate
RATIONALE
- to be able to assess
significant changes in the
client’s V/S which may
indicate S/S of disturbed
sleeping pattern
- evaluate improvements
of client’s sleeping
pattern
- evaluate improvements
of client’s sleeping
pattern
-this promotes sleep
-this will help client fall
asleep
- this will help client fall
asleep
EVALUATION
client was free from S/S
of disturbed sleeping
pattern as evidenced by:
normal range:
T: 36.50
C-37.50
C
PR: 60-100 bpm
RR: 16-20 cpm
BP:100-140/60-
90mmhg
• Client verbalized
good, sound sleep
• yawning was Absent
• sleepy eyes was
Absent

 blankets keep her
comfortable
Objective
 Appeared weak and
lethargic
 sleepy eyes
 Stays in bed most of
the time
 Frequent yawning
observed
 V/S 5pm
T: 36.70
C
regular
regular
BP: 160/90 mmhg
• barely converse with
her watchers
• Improved level of
consciousness
relaxation
techniques
• Health Teachings
• Advise patient to
limit intake of
caffeine prior to bed
time
• Offer reading
materials
• Environmental
manipulation
Collaborative
• Administer
medication as
ordered
- this delays sleep
-this can help client fall
asleep
-a comfortable
environment help client
fall asleep
-administering
medication can induce
sleep
• Improved level of
consciousness:not
met- client still
appear lethargic

CUES/EVIDENCE
S
Subjective
♦ 63 years old
♦ Admitted with
CHF 20
ASHD; UTI;
hyperlipidemia
♦ V/S
NURSING DX
4. Ineffective tissue
perfusion related to
decreased blood flow
secondary to disease
condition
OBJECTIVES
client will demonstrate
improved tissue
perfusion as evidenced
by:
range:
range:
T: 36.50
C-37.50
C
PR: 60-100 bpm
RR: 16-20 cpm
BP:100-140/60-
INTERVENTIONS
Independent:
• Monitor V/S q 4
hrs.
capillary refill
RATIONALE
V/S can occur with
compromised cardiac
medication effect
 To assess the status of
clients’ oxygenation
 Decreased blood flow
to the can cause
significant changes in
client’s skin
EVALUATION
demonstrated improved
tissue perfusion as
evidenced by:
• 2 of the 4 V/S are
within normal range:
range:
T: 36.50
C-37.50
C
PR: 60-100 bpm
RR: 16-20 cpm
BP:100-140/60-
90mmhg

T: 36.70
C
regular
regular
BP: 160/90 mmhg
♦ Oxygen 2 L/min
KVO rate
♦ skin color is
slightly pale
♦ Skin temp. is
warm
♦ Capillary refill is
3-4 secs.
♦ Senile turgor and
poor mobility
♦ Bed is in semi-
fowler’s position and
faces on one side
♦ labored breathing
♦ Uses accessory
muscles
90mmhg
• Normal skin color and
temperature
• Improved capillary
refill
• Absence of diminished
peripheral pulses
• Absence of pallor and
cyanosis
• Inspect for skin color
and temperature
changes
• Maintain client’s
position in semi-
fowler’s
• Instruct client to have
bed rest
• Instruct client to report
any problems related
to ineffective tissue
perfusion
conditions
 Elevation of patient’s
head is beneficial to
patient’s breathing
pattern
 Limitation of activity
can help minimize
risk of complications
 Immediate
done to compensate
• Normal skin color and
temperature
• Improved capillary
refill: Moderately
good capillary refill-3
sec
• diminished peripheral
pulses was absent
• pallor and cyanosis
was absent

CUES/EVIDENCES NURSING Dx OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective:
- verbalized, “kapoy na
kaayo”
- verbalized, “gulang
na ko, luya na
ang akong lawas”
Objective:
 perceived ability for
the following
 feeding :2
 bathing : 2
 toileting : 2
 dressing : 2
 grooming : 2
- v/s 5 pm
T: 36.70
C
regular
regular
BP: 160/90 mmhg
- Appeared weak and
lethargic
- Hair is not fixed well,
Self-care deficit r/t
Within our care, the
patient will be able to
safely perform self-care
activities to her
maximum ability as
evidenced by:
 Client will
perform simple
self-care
activities (self-
combing,
brushing teeth,
bathing, etc.) that
will not make her
tired.
 Client will
display activities
with minimal
assistance.
 Vital signs within
normal range:
T: 36.5-37.50
C
PR: 60-100 bpm, strong
and regular
RR: 16-20 cpm, shallow
and regular
BP: 100-140/60-90
mmHg
 Assess vital signs
q 4 hrs.
 Encourage patient
to go to the
bathroom to void
instead of using
bedpan as
tolerated.
 Encourage patient
to do self care
activities with
minimal
assistance such as
combing the hair,
brushing the
teeth, taking a
bath, etc. as
tolerated.
 Ensure that all
equipment
needed in
performing self-
care activities are
close to patient.
 Educated the
client on the
 To establish
baseline data
 To foster
independence if
able to perform
the activity alone.
 To promote
independence and
self-esteem.
 To conserve
energy.
 To increase the
willingness of the
patient in doing
self-care
After our care, the
patient was able to
perform self care
activities to her
maximum ability as
evidenced by:
 Client performed
simple activities
such as combing
her hair and
taking a bath.
 Client displayed
activities with
minimal
assistance.
 2 v/s within
normal range not
met
regular
regular
BP: 150/80 mmHg

 Black, J.M., et. al. Medical Surgical Nursing 6th
ed. 2001. The Curtis Center Independnce Square West Philadelphia,
Pennsylvania 19106
 Black ,J.M., Jacobs E. M. Medical-Surgical Nursing 5th
ed. 1997. The Curtis Center Independnce Square West Philadelphia,
Pennsylvania 19106
 Bullock, B.L., Rosendahl, P.P., Pathophysiology 3rd
ed. 1992. Lippincott Company 227 East Washington Square, Philadelphia,
Pennsylvania 19106
 Health and Home November-December 2000
 Lemone, P. et.al. Medical-Surgical Nursing.1996. Addison-Wesley Nursing. A division of the Benjamin/Cunnings Publishing
Company Inc.
 McAnce K.L., Huether S. E. Pathohysiology 2nd
ed 1994. Mosby-Year Book Inc. 11830 Westline Industrial Drive, St. Louis,
Missouri 63146

 McAnce K.L., Huether S. E. Pathohysiology 3rd ed 1998. Mosby-Year Book Inc. 11830 Westline Industrial Drive, St. Louis,
Missouri 63146
 Porth C. M, Pathophysiology. 4th
ed.1994. Lippincott Company 227 East Washington Square, Philadelphia, Pennsylvania 19106
 Smeltzer Medical Surgical Nursing 8th
ed.1996. Lippincott Company 227 East Washington Square, Philadelphia, Pennsylvania
19106
 www.lejacq.com

At the end of our case analysis presentation the learners had improved knowledge on the important concepts of caring
with a patient who is diagnosed of having congestive heart failure, and manifested positive attitudes and skills towards
providing care to those patients including their family and significant others.
Within our case study we were able to attain following: identify the demographic data of our patient including her
genogram and ecomap, reviewed the anatomy and physiology of the affected systems, traced and explained the
pathophysiology of CHF, utilized the nursing process with competence by making functional health patterns and nursing care
plans for our patient, stated the importance and the mechanism of actions of the medications given, recognized the
importance of lab exams and were able to utilize some medical management to give holistic care of our patient.

You Can Survive Heart Attack Even
When Alone
Let’s say it’s 6:15pm and you’re driving home (alone of course), after
unusually hard day on the job. You’re really tired, upset and frustrated.
Suddenly you start experiencing severe pain in your chest that starts to
radiate out into your arm and up into your jaw. You are only about 5 miles
from the hospital nearest your home; unfortunately you don’t know you’ll
be able to make it that far.
Date Laboratory and Diagnostic Result Normal Values Implications
February 20, 2006 Blood chemistry
BUN------------------ 24mg/dl
Creatinine------------ 0.94mg%
FBS------------------- 86mg/dl
Uric Acid------------ 6.5mg/dl
Cholesterol----------151 mg/dl
Triglyceride----------81mg/dl
Chol-HDL-----------30 mg/dl
LDL -----------------104 mg/dl
Urinalysis
Color----------------yellow
Transpaerncy------clear
Sp.Gravity---------1.010
Glucose-------------Neg.
Protein--------------trace
pH-------------------6.0
Pus cells------------10-15/hpf
RBC-----------------0-2
Epithelial cells-----moderate
Na+-----------------136mEq/l
K+------------------4.0mEq/L
CBC
Hemoglobin------13.8gm%
Hematocrit-------42.1%
WBC--------------6,100/cumm
Seg---------------80%
Neutrophils-----
Lymphocytes--15%
Eosinophils----1%
Monocytes-----3%
Platelet count----330,000
Blood chemistry
BUN---------------8-23mg/dl
Creatinine---------0.5-1.2mg%
FBS----------------60-110mg/dl
Uric acid----------2.4-5.7mg%
Cholesterol-------< 200mg/dl
Triglyceride------40-150mg/dl
Chol-HDL--------30-80mg/dl
LDL -------------60-180mg/dl
Urinalysis
Color---------straw-deep amber
Transparency----clear
Sp.Gravity-------1.010-1-1.025
Glucose-----------(-)
Protein------------(-)
pH-----------------4.6-8
Pus cells----------0-5/hpf
RBC---------------0-2
Epithelial cells---moderate
Na+----------------136mEq/l
K+-----------------4.0mEq/L
CBC
Hemoglobin------13.8gm%
Hematocrit-------42.1%
WBC--------------6,100/cumm
Seg---------------80%
Neutrophils-----55-70%
Lymphocytes---15%
Eosinophils-----1%
Monocytes------3%
Platelet count------330,000
Increase in BUN may indicate renal failur
Creatinine is the most accurate measure of
A FBS level over 140 mg for 2-3 times in
Normal examination of urine is useful in s
urinary tract as well as for the diagnosis a
Hemoglobin, which transports oxygen, is
indicate anemia, recent hemorrhage and fl
A low hct suggests anemia massive blood
Measures a number of WBCs in a microli
infection and inflammation as well as in m
Decreased may mean bone marrow depres
hepatitis, influenza, measles, mumps, rube
storage diseases, deficiency of folic acid o
Increase in lymphocytes may mean infecti
Eosinophils are responsible for allergic re
Promote coagulation by supplying phosph
hemostatic plug for vascular injuries. Dec
RBCs

What can you do? You’ve been trained in CPR but the guy that
taught the course neglected to tell you to perform it on yourself.
Without help, the person whose heart stops beating properly and
who begins to faint, has only about 10 sec. left before losing
consciousness. However, these victims can help themselves by coughing
repeated and very vigorously. A deep breath should be taken before each
cough, and the cough must be deep and prolonged, as when producing
sputum from deep inside the chest. A breath and cough must be repeated
about every 2 sec. without let up until help arrives, or until the heart is felt
to be beating normally again.
Deep breaths get oxygen into the lungs and coughing movements
squeeze the heart and keep the blood circulating. The squeezing pressure
on the hart attack victims can get to a hospital.

199075883 case-pres-chf-with-hyperipidemia-and-uti

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