Case Study CHF Final Output Group 2

UNIVERSITY OF MINDANAO
COLLEGE OF HEALTH SCIENCES EDUCATION

Bachelor of Science in Nursing
A Case Presentation on
CONGESTIVE HEART FAILURE DUE TO

UNTREATED HYPERTENSION WITH ATRIAL
FIBRILLATION
Submitted to:
Gabriel G. Cabading, PgC(UK), RN(USA)
Submitted by:
Dunque, Stephanie
Flores, Lynel
Lastrilla, Aira Joy
Manzanilla, Mariel
Moania, Tee Jay
Mohamadsali, Norhaida
Panuncillon, Shayne
Racho, Zanlee
Saclot, Sheila Mae
Date of Submission:
November 23, 2021

College of Health Sciences Education
3rd Floor, DPT Building
Matina Campus, Davao City
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Pages
TABLE OF CONTENT
I Title page i
II Table of Contents ii
III Description of the Disease/Illness 1
IV Definition of Terms 3
V Etiology 4
VI. Patient’s Profile 5
VII. Anatomy and Physiology of the Affected Body Parts 6
VIII. Pathophysiology of the Disease 16
IX Laboratory/Diagnostic Tests 26
Medical Management
35
X. 1. Pharmacotherapy
48
2. Nutrition Therapy
XI Surgical Management 50
Nursing Management
XII. 53
Nursing Care Plan
XIII Discharge Plan 59
XIV Client’s Health Education 71
Evidenced-based Research Findings related to the

XV 73
Disease/Illness
XVI Reference 75
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Description of the Disease/Illness
Heart failure (HF) is a clinical syndrome resulting from structural or functional
cardiac disorders that impair the ability of the ventricles to fill or eject blood. In the
past, Heart failure was often referred to as congestive heart failure (CHF), because
many patients experience pulmonary or peripheral congestion with edema. Currently,
Heart failure is recognized as a clinical syndrome characterized by signs and
symptoms of fluid overload or inadequate tissue perfusion. Fluid overload and
decreased tissue perfusion result when the heart cannot generate cardiac output (CO)
sufficient to meet the body’s demands for oxygen and nutrients. The term heart failure
indicates myocardial disease in which impaired contraction of the heart (systolic
dysfunction) or filling of the heart (diastolic dysfunction) may cause pulmonary or
systemic congestion. Some cases of Heart failure are reversible, depending on the
cause. Most often, Heart failure is a chronic, progressive condition that is managed
with lifestyle changes and medications to prevent episodes of acute decompensated
heart failure.
The body tries to compensate in different ways. The heart beats faster to take
less time for refilling after it contracts—but over the long run, less blood circulates, and
the extra effort can cause heart palpitations. The heart also enlarges a bit to make
room for the blood. The lungs fill with fluid, causing shortness of breath. The kidneys,
when they don’t receive enough blood, begin to retain water and sodium, which can
lead to kidney failure. With or without treatment, heart failure is often and typically
progressive, meaning it gradually gets worse.
Hypertension remains a significant risk factor for development of congestive
heart failure CHF), with various mechanisms contributing to both systolic and diastolic
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dysfunction. That's because the force pushing on the walls of the arteries as blood
moves through them is too strong. That pressure hurts the arteries and makes tiny
tears in them that can turn into scar tissue, which makes it easier for cholesterol, fat,
and other things to build up. That causes the vessels to narrow and stiffen.
Congestive heart failure (CHF) and atrial fibrillation (AF) are two of the most
prevalent medical conditions, both of which are linked with severe morbidity. These
illnesses have comparable risk factors, commonly coexist, and have additional
adverse consequences when they occur together. Electrical signals regulate the
heart's beat. Healthy heart tissue is essential for those signals to function properly.
Heart failure, on the other hand, can extend the atria and induce scarring and
thickening of heart tissue. The electrical signals are thrown off as a result of these
alterations, which disrupts the heart's rhythm and can lead to atrial fibrillation.
There are instances when symptoms are mild or when there is nothing at all.
But this does not avoid the possibility of cardiac failure. Heart failure symptoms can
range from moderate to severe, and they might come and go. However, common signs
and symptoms of heart failure includes shortness of breath or trouble breathing,
fatigue, swelling in the ankles, legs and abdomen, weight gain, dizziness, confusion,
difficulty concentrating, fainting, and rapid or irregular heartbeats (palpitations). These
symptoms may be early signs that fluid is building up and your heart failure is getting
worse. The goal of treatment for congestive heart failure is to have the heart beat more
efficiently so that it can meet the energy needs of the body. Specific treatment depends
upon the underlying cause of heart failure. Lifestyle modification is one of the most
important aspects as patient can incorporate to treat congestive heart failure. Failure
to do so can eventually lead to death.
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Definition of Terms
1. Atrial Fibrillation- is a heart condition that causes an irregular and often
abnormally fast heart rate.
2. Congestive Heart Failure- a serious condition in which the heart doesn't pump
blood as efficiently as it should.
3. Cyanotic- refers to abnormal blue discoloration of the skin due to lack of
oxygen in the blood.
4. Dyspnea- a tight feeling where a patient cannot breathe enough air into the
lungs (shortness of breath).
5. Edema- is a swelling that is caused by fluid build or trapped in the body.
6. Hypertension- a condition of persistent elevation of blood pressure.
7. Non-compliant- when a client refuses to comply or follow medical regimen.
8. Obese- is a condition that occurs when a person has excess weight or body
fat.
9. Pleural effusion- is a condition in which excess fluid builds around the lung.
10. Tachycardia- refers to a hear rate over 100 beats per minute.
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Etiology
Predisposing Factors Precipitating Factors
• Age: 55 years old • Non-compliant to medication

• Hereditary (Thiazide diuretics)
• Untreated hypertension (20
years)
• Obese
The table above shows the etiology of the disease. In terms of the predisposing
factors, it includes the age, gender, and hereditary. According to the study, the
prevalence of hypertension was found to be high in older adults. Hypertension was
shown to be substantially associated with factors such as age and having a family
history of hypertension. Individuals whose parents have hypertension have an
elevated risk of developing the condition, particularly if both parents are affected.
However, the inheritance pattern is unknown. While in the precipitating factors, the
patient is obese which is a big contributing factor in developing hypertension and if the
hypertension is remain untreated it could eventually lead to further complications and
even death. The patient is also non-compliant with medication, which really leads her
to congestive heart failure.
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Patient’s Profile
Name (Initial/Alias) : Ms. L.P
Age : 55 years old
Gender : Female
Birth Date : October 7, 1966
Occupation : Fish Vendor
Civil Status : Not Indicated
Address : Barangay 23-C, Davao City
Chief Complaint : Exertional Dyspnea associated with palpitation and headache,
flushing, chest pain.
Admitting Diagnosis : Not Indicated
Final Diagnosis : Congestive Heart Failure due to Untreated Hypertension with
Atrial Fibrillation
Past Medical History
Ms. L.P was admitted when she was 35 years old because of prolonged
dizziness and headache and was given a Thiazide diuretic but did not comply. Ms. L.P
is hypertensive, non-asthmatic, non-diabetic and has no known allergy to food or drug.
Family Medical History
Ms. L.P father died at age of 56 from a heart attack secondary to congestive
heart failure. Ms. L.P had no history of smoking and alcohol abuse.
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Anatomy and Physiology
Cardiovascular System
The cardiovascular system can be thought of as the transport system of the
body. This system has three main components: the heart, the blood vessel and the
blood itself. The heart is the system’s pump and the blood vessels are like the delivery
routes. Blood can be thought of as a fluid which contains the oxygen and nutrients the
body needs and carries the wastes which need to be removed. The following
information describes the structure and function of the heart and the cardiovascular
system as a whole.
The Heart
The heart, a muscular pump made up of cardiac muscle fibers, could be
considered a muscle rather than an organ. It has four chambers, or cavities, and beats
an average of 60-100 beats per minute (bpm) or about 100,000 times in one day. Each
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time the cardiac muscle contracts, blood is ejected from the heart and pushed
throughout the body within the blood vessels.
The heart is located in the mediastinum in the center of the chest cavity however
it is not exactly centered, more of the heart is on the left side of the mediastinum that
the right. The heart is about the size of a fist and shaped like an upside-down pear, it
lies directly behind the sternum. The tip of the heart at the lower edge is called the
apex.
Chambers of the Heart
The heart has two sides, the right side and the left side. The heart has four
chambers. The left and right side each have two chambers, a top chamber and a
bottom chamber. The two top chambers are known as the left and right atria (singular:
atrium). The atria receive blood from different sources. The left atrium receives blood
from the lungs and the right atrium receives blood from the rest of the body. The bottom
two chambers are known as the left and right ventricles. The ventricles pump blood
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out to different parts of the body. The right ventricle pumps blood to the lungs while
the left ventricle pumps out blood to the rest of the body. The ventricles have much
thicker walls than the atria which allows them to perform more work by pumping out
blood to the whole body.
Blood Vessels
Blood Vessel are tubes which carry blood. Veins are blood vessels which
carry blood from the body back to the heart. Arteries are blood vessels which carry
blood from the heart to the body. There are also microscopic blood vessels which
connect arteries and veins together called capillaries. There are a few main blood
vessels which connect to different chambers of the heart. The aorta is the largest artery
in our body. The left ventricle pumps blood into the aorta which then carries it to the
rest of the body through smaller arteries. The pulmonary trunk is the large artery which
the right ventricle pumps into. It splits into pulmonary arteries which take the blood to
the lungs. The pulmonary veins take blood from the lungs to the left atrium. All the
other veins in our body drain into the inferior vena cava (IVC) or the superior vena
cava (SVC). These two large veins then take the blood from the rest of the body into
the right atrium.
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Blood Vessel Structure and Function
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Blood vessels are flexible tubes that carry blood, associated oxygen, nutrients,
water, and hormones throughout the body.
Blood vessels are key components of the systemic and pulmonary circulatory
systems that distribute blood throughout the body. There are three major types of
blood vessels: arteries that carry blood away from the heart, branching into smaller
arterioles throughout the body and eventually forming the capillary network. The latter
facilitates efficient chemical exchange between tissue and blood. Capillaries in turn
merge into venules, then into larger veins responsible for returning the blood to the
heart. The junctions between vessels are called anastomoses.
Arteries and veins are comprised of three distinct layers while the much smaller
capillaries are composed of a single layer.
Tunica Intima
The inner layer (tunica intima) is the thinnest layer, formed from a single
continuous layer of endothelial cells and supported by a subendothelial layer of
connective tissue and supportive cells. In smaller arterioles or venules, this
subendothelial layer consists of a single layer of cells, but can be much thicker in larger
vessels such as the aorta. The tunica intima is surrounded by a thin membrane
comprised of elastic fibers running parallel to the vessel. Capillaries consist only of the
thin endothelial layer of cells with an associated thin layer of connective tissue.
Tunica Media
Surrounding the tunica intima is the tunica media, comprised of smooth muscle
cells and elastic and connective tissues arranged circularly around the vessel. This
layer is much thicker in arteries than in veins. Fiber composition also differs; veins
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contain fewer elastic fibers and function to control caliber of the arteries, a key step in
maintaining blood pressure.
Tunica Externa
The outermost layer is the tunica externa or tunica adventitia, composed
entirely of connective fibers and surrounded by an external elastic lamina which
functions to anchor vessels with surrounding tissues. The tunica externa is often
thicker in veins to prevent collapse of the blood vessel and provide protection from
damage since veins may be superficially located.
The Blood
The average human body contains about 4 to 5 liters of blood. As a liquid
connective tissue, it transports many substances through the body and helps to
maintain homeostasis of nutrients, wastes, and gases. Blood is made up of red blood
cells, white blood cells, platelets, and liquid plasma.
Red Blood Cells
Red blood cells, also known as erythrocytes, are by far the most common type
of blood cell and make up about 45% of blood volume. Erythrocytes are produced
inside of red bone marrow from stem cells at the astonishing rate of about 2 million
cells every second.
White Blood Cells
White blood cells, also known as leukocytes, make up a very small percentage
of the total number of cells in the bloodstream, but have important functions in the
body’s immune system.
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Platelets
Also known as thrombocytes, platelets are small cell fragments responsible for
the clotting of blood and the formation of scabs. Platelets form in the red bone marrow
from large megakaryocyte cells that periodically rupture and release thousands of
pieces of membrane that become the platelets.
Plasma
Plasma is the non-cellular or liquid portion of the blood that makes up about
55% of the blood’s volume. Plasma is a mixture of water, proteins, and dissolved
substances. Around 90% of plasma is made of water, although the exact percentage
varies depending upon the hydration levels of the individual.
The Conduction System and Heart Rhythm
The cardiac muscle has the capability to undergo depolarization (change in the
excitation of a cell), which allows the muscle cells to contract.
The electrical changes required to create a cardiac impulse are controlled by
the heart's own conduction system, which begins with a series of excitations in the
sinoatrial node (SAN), a specialized region of cardiac cells located in the right atrium.
This is the natural pacemaker of the heart. When it is functioning properly, it controls
the heart rhythm (sinus rhythm) and begins impulses that work on the myocardium,
promoting cardiac contraction. The cardiac impulse is carried from the SAN to the
atria, which begin to contract, and then to the atrioventricular node (AVN), which is
another mass of specialized cells.
The AVN is located in the inter-atrial septum, a region of tissue that connects
the RA and LA and provides a conduction channel between the atria and ventricles.
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Because the AVN's fibres are smaller, there is a minor delay (0.1 seconds) in the
impulse, giving the atria time to contract and empty into the ventricles before
ventricular contraction.
The impulse then goes down into the Bundle of His, a huge bundle of
specialized tissue that transmits it down the ventricles. In the interventricular septum,
the Bundle of His is divided into right and left bundles. Purkinje fibres then loop
upwards and travel in the lateral portions of the Right Ventricle and Left Ventricle
before continuing down to the inferior aspect of the heart.
Renin-Angiotensin-Aldosterone System
The Renin-Angiotensin-Aldosterone System (RAAS) is a hormone system
within the body that is essential for the regulation of blood pressure and fluid balance.
The system is mainly comprised of the three hormones renin, angiotensin
II and aldosterone. Primarily it is regulated by the rate of renal blood flow.
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Renin Release
The first stage of the RAAS is the release of the enzyme renin. Renin released
from granular cells of the renal juxtaglomerular apparatus (JGA) in response to one of
three factors:
• Reduced sodium delivery to the distal convoluted tubule detected by macula
densa cells.
• Reduced perfusion pressure in the kidney detected by baroreceptors in the
afferent arteriole.
• Sympathetic stimulation of the JGA via β1 adrenoreceptors.
The release of renin is inhibited by atrial natriuretic peptide (ANP), which is
released by stretched atria in response to increases in blood pressure.
Production of Angiotensin II
Angiotensinogen is a precursor protein produced in the liver and cleaved by renin to
form angiotensin I.
Angiotensin I is then converted to angiotensin II by angiotensin converting
enzyme (ACE). This conversion occurs mainly in the lungs where ACE is produced by
vascular endothelial cells, although ACE is also generated in smaller quantities within
the renal endothelium.
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Binding of Angiotensin II
Angiotensin II exerts its action by binding to various receptors throughout the body.
It binds to one of two G-protein coupled receptors, the AT1 and AT2 receptors. Most
actions occur via the AT1 receptor.
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PATHOPYHSIOLOGY
(Congestive Heart Failure due to Untreated Hypertension with Atrial Fibrillation)
Precipitating Factors
Pre-disposing Factors
✓ Non-compliant to medication (Thiazide diuretics)
✓ Age: 55 years old ✓ Untreated hypertension (20 years)
✓ Hereditary ✓ Obese
• Gender: Male • Alcohol Consumption
• Smoking
• Race: African • Psychological stress
• Atherosclerosis
Changes in arteriolar bed ↑ systemic vascular resistance
↑ Afterload
↓ Blood Flow to the organs
Juxtaglomerular cells
Renin
Angiotensinogen
Angiotensin l
Angiotensin-
Converting Enzyme
(ACE)
Angiotensin ll
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Arteriolar Vasoconstriction Adrenal Cortex Stimulation
↑ Peripheral resistance ↑ Aldosterone
↑ Na reabsorption
Fluid
retention
↑ H2O reabsorption
↑ elevation of
extracellular fluid (ECF)
HYPERTENSION
Carotid baroreceptor response
Increased activity of sympathetic nervous system
Heart rate increased and positive

effects of myocardial contraction
Vasoconstriction of blood vessels & ↑ afterload of the heart
Negative remodeling of the heart and

Left ventricle’s pumping power weakens
worsening of the left ventricular function
Blood can back up into the pulmonary

veins
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↑ pulmonary vein and capillary
pressure
Fluid leaked into interstitial space
Bulging of neck Pleural effusion CONGESTIVE HEART FAILURE

vein
+ Neck distention
Neurohormonal activation Mechanical remodeling Ion channel and gap junction remodeling
Increased left
Renin-angiotensin- Adrenergic atrial stretch and Altered action Intracellular Heterogenous
aldosterone axis stimulation pressure potential calcium distribution of
activation currents overload connexins
Fibrosis with Increased firing

Ischemia impaired from ectopic Alteration in
conduction and foci conduction and
Increased wave front (pulmonary refractoriness & cell
sodium and fragmentation veins) excitation
water
retention
Fluid Triggered activity, re-entry, and automaticity of the heart
retention/accumulation
on the lower body parts
Atrial structure and electrical remodeling
Ankle edema
ATRIAL FIBRILLATION
Disorganized atrial depolarizations

without effective atrial contraction
Abnormal electrical signals in fibrillating atria to Increased heart Disorganized atrial

propagate to ventricles before ventricles have rate electrical circuits
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fully recovered from previous contraction
Ventricular contraction becomes weak;
↓ blood ejected ↓ Preload to ↓ Irregularly irregular
cardiac output pulse/rhythm
↓ Time to clear
Ca2+ from
↓ Diastolic Irregular, often faster relay of
monocytes
More residual ventricular filling electrical impulses through AV node
cytosol between
blood in time and purkinje fibers
contraction
ventricles as
diastole starts, ↑
↓ Perfusion of Tachycardia
end-diastolic ↑ In cytosolic (Ca2+)
volume prior to brain & other
prior to subsequent
next ventricular body tissue
myocyte contractions Dynamic
contraction Precordium
↑ Force of Cool Cyanotic

contraction and Hypoxia causes
clammy respiratory
skin centers in brain
to compensate
by ↑ rate of
More forceful breathing
contractions of
sometimes overfilled
ventricles are felt Respiratory
Headache
against the chest wall distress
Dyspnea
Chest pain Palpitation
s
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Narrative:
The diagram shows the pathophysiology of hypertension, congestive heart
failure, and atrial fibrillation. In hypertension, the predisposing factors or non-
modifiable includes age and hereditary, age because she is already 55 years old and
aging has risk for developing hypertension is 90 percent. Next is hereditary, the
patient’s father died due to heart attack secondary to congestive heart failure which
contribute to the development of hypertension of the patient. While the precipitating
factors or modifiable includes non-compliant to medication, untreated hypertension,
and obesity. Obesity will cause the heart to work harder to pump blood through the
body. But all that extra effort puts strain on the arteries, and arteries, in turn, resist this
flow of blood, causing the blood pressure to rise. Non-compliant to her medication,
noncompliance to antihypertensive drugs as a measured cause of continuously
increasing rate of hypertension. Untreated hypertension when she was 35 years old
contribute to development of her current condition which is hypertensive.
Most of the systemic vascular resistance arises from the changes in the arterial
system, as the vessel walls of the venous system have relatively thin elastic layers
and no smooth muscle layer to exert force onto the blood within. On the other hand,
arteries have a very thick arterial wall and outermost vessel layer, allowing them to
maintain the high pressures needed to perfuse the tissues and organs with blood.
Afterload is increased due to an increase in systemic vascular resistance and because
arteries are affected by making them less elastic, which leads to decreased blood flow
of the organs in the body. When the Renin-Angiotensin-Aldosterone system is
activated due to a change in body hemodynamics, the sympathetic nervous system
stimulates and sends nerve impulses juxtaglomerular cells in the kidneys to release
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renin into the bloodstream. Once renin has been released into the blood, it will activate
a substance in the liver, angiotensinogen. Renin then acts to splint from
angiotensinogen into the angiotensin I. The conversion of angiotensin I to angiotensin
II is catalyzed by an angiotensin-converting enzyme (ACE). In sequence, renin and
angiotensin-converting enzyme (ACE) act on their substrates to produce the active
hormone angiotensin II, which raises blood pressure in two ways. First, angiotensin II
is potent arteriolar vasoconstriction. When this happens, it raises blood pressure by
increasing systemic vascular resistance. Second, angiotensin II stimulates the
secretion of the adrenal cortex to stimulate the release of aldosterone to increase,
which increases the reabsorption of sodium ions and water by the kidneys, leading to
increased elevation of the extracellular fluid (ECF). As a result, an increased systemic
vascular resistance and increased elevation of the extracellular fluid increase blood
pressure or hypertension. Hypertension, also known as high or raised blood pressure,
is a condition in which the blood vessels have persistently raised pressure.
In Heart Failure, the heart is unable to pump enough blood to meet the body’s
needs; this may be due – among other causes – to abnormalities of the heart muscle
after a myocardial infarction, or problems with heart valves or heart rhythm. HF can
affect the left or the right ventricle, and is consequently referred to as left or right HF.
In patients with HF, cardiac output (stroke volume multiplied by the heart rate) is
reduced. As a result, two tightly regulated compensatory mechanisms are activated.
Sympathetic compensatory mechanism – the baroreceptors sense a decrease
in blood pressure (BP), leading to the release of catecholamine (noradrenaline), which
stimulates beta-1 adrenoceptor cells in the heart that would affect blood brain barrier
that cause headache and then this culminates in an increased heart rate, contraction
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and stroke volume, which will increase the cardiac output. Although it can be helpful
in the short term to maintain cardiac output, in the long term the mechanism can be
damaging and actually exacerbate HF.
Renin-angiotensin-aldosterone (RAA) compensatory mechanism – the under
perfusion due to reduced BP is detected by the kidneys. This activates the RAA
pathway, which controls BP and electrolyte balance. Vasoconstriction, salt and fluid
retention are some of the consequences. In the short term, this maintains organ
perfusion, but in the long term, it exacerbates cardiac dysfunction and remodeling.
Thus, left ventricle’s pumping power weakens that causes blood to come back up into
the veins that may eventually lead to bulging of the neck veins which will develop
positive neck distention.
In Congestive Heart Failure or also known as cardiac failure is a set of
manifestations caused by the failure of the heart's function as a pump supporting the
blood flow through the body. Now, in Congestive Heart Failure there would be a
change in ion channel and gap junction. A variety of ion channel current abnormalities
have been reported in CHF models, including altered action potential currents. Altered
action potential currents is a common finding on human heart failure in which there is
an altered expression of a variety of depolarizing and hyperpolarizing currents in the
myocardium. Notably, CHF is accompanied by an increase in the calcium and sodium
transmembrane exchange channel current, which exchanges three monovalent
sodium ions for every one divalent calcium ion. This net positive intracellular calcium
overload can predispose to delayed after depolarization, resulting in arrhythmias
initiated by triggered activity. Indeed, data from a pacing-induced model of CHF
demonstrate that abnormalities in calcium handling prolong the atrial action potential
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and foster AF through triggered activity. Adrenergic stimulation occurs in CHF, and is
a well-known cause of triggered activity. In parallel to ion channel remodeling present
in patients with CHF, heterogeneous distribution of connexins, which form gap
junctions, has been observed in atrial hemodynamic overload in humans with a history
of CHF. Thus, it causes for the alterations in conduction and refractoriness and cell
excitation that result from various changes in the heart.
Furthermore, mechanical remodeling that would increase left atrial stretch and
pressure is present in Congestive Heart Failure as well. This remodeling occurred due
to mechanical stress on the heart muscle that would cause of heart failure and the
pressure in the left atrium will increase in order to be able to fill the left ventricle
properly. With this, structural remodeling includes left atrial enlargement, which
predisposes to Atrial Fibrillation. Also, myocyte stretch increases firing from ectopic
foci such as the pulmonary veins through mechanoelectrical feedback. Myocyte
stretch is associated with increases left atrial pressure. Additionally, increased fibrosis
results from myocyte stretch that also known as Cardiac Fibrosis in which it forms
scarring localized to the region of heart damage that would lead to heart failure. Also,
ischemia will form when left ventricle damaged or when the heart become enlarged
causing reduced blood flow and prevent the heart muscle from receiving enough
oxygen.
Neurohormonal activation is another principal feature of Congestive Heart
Failure that promotes Atrial Fibrillation. Upregulation of both the Renin-angiotensin-
Aldosterone and Adrenergic Systems (RAAS) causes myocardial fibrosis, which
impairs impulse propagation. Moreover, low cardiac output and arterial pressure that
occurs in patient with Congestive Heart Failure will cause to activate neurohormonal
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activation in which causes severe heart failure and even result to ischemia in which
there has an inadequate blood supply in the heart muscle. Another one, the activity of
the Renin-angiotensin Aldosterone Axis Activation (RAAS) functions is increase in
patient with Congestive Heart Failure that would elevate blood volume and arterial
tone in a prolonged manner. It does this by Increased sodium and water retention that
can cause fluid retention/accumulation on the lower body parts and pleural space that
may lead to the development of edema and pleural effusion. Overall, the
pathophysiological mechanisms of patient with Congestive Heart Failure are complex
and potentially involve elements of reentry, triggered activity and enhanced
automaticity factors that causes Atrial Fibrillation. In atrial fibrillation, it is characterized
by rapid and disorganized atrial activation leading to impaired atrial function and
resulting in disorganized atrial depolarizations without effective atrial contraction.
There would be an abnormal electrical signal in fibrillating atria can propagate
the ventricles’ chamber before the ventricles have fully recovered from the previous
contraction. The next is that the ventricular contraction becomes weak to pump that
would result to decreased the blood ejection or ejection fraction. As the blood ejection
reduce, there would be more residual blood in ventricles as diastole starts, increase
end-diastolic volume prior to next ventricular contraction. Also, to abnormal electrical
signal in fibrillating atria, the heart rate will be increased and it will lead to decreased
time to clear calcium from monocytes cytosol between contraction because
supposedly calcium particles enter the heart muscle cells during each heartbeat and
contribute to the electrical signal that coordinates the heart to pump. When this occur,
there will be an increase in cytosolic (calcium ion) prior to subsequent myocyte
contractions initiate heart increase force heart muscle’ contraction. If there is increase
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end-diastolic volume and increase force heart muscle’ contraction this will result to
more forceful contractions of sometimes overfilled ventricles are felt against the chest
wall resulting to palpitation and chest pain.
Furthermore, to atrial fibrillation if heart rate will be increased the heart diastolic
ventricular filling time will reduce and the preload (initial stretching of the cardiac
myocytes prior to contraction) decrease causing the cardiac output to reduce also. As
the cardiac output decreases the perfusion of brain and other body tissue is now
reduced. Inadequate peripheral perfusion can result to have cool and clammy skin,
becomes cyanotic, and in brain causes hypoxia. Hypoxia causes respiratory centers
which is the medulla oblongata is the primary respiratory control center in brain to
compensate by increase rate of breathing. If perfusion continues to become
inadequate it will cause headache or respiratory distress to have shortness of breath
or also called dyspnea.
Moreover, atrial fibrillation can cause disorganized atrial electrical circuits of the
heart. There will be an irregular, often faster relay of electrical impulses through
atrioventricular node and purkinje fibers in conduction system leading to develop
irregularly irregular pulse/ heart rhythm. This irregularly irregular pulse can cause
tachycardia and dynamic precordium becomes visible front of the chest wall over the
heart.
25
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Laboratory/ Diagnostic Test

Phone No.: (082)300-5456/300-0647 Local 117
Name of Laboratory Test: Complete Blood Count Result with Platelet Count and
Blood Typing
Examination References Results Clinical Significances

Hemoglobin ➢ The result of 112g/L indicated low
hemoglobin level. This signifies
that left ventricular dysfunction
decreases cardiac output and
causes renal hypo-perfusion,
thereby releasing proinflammatory
M 140-180g/L
cytokines disrupting multiple
F 120-150g/L
aspects of erythropoiesis.
Besides, inhibition of the renin-
angiotensin system is associated
with decreased erythropoietin
production and reduced
hemoglobin levels.
Hematocrit ➢ Hematocrit level of 0.33 shows
abnormally low. A low hematocrit
may result from an increased
M 0.40-0.54
plasma volume (hemodilution) or
F 0.37-0.47
from reduced red blood cell
volume (anemia).
RBC count ➢ The result of 3.53 indicated RBC

count is abnormally low. This is
M 4.5-5.5 x
due to proinflammatory cytokines
10**/L
released, it decreases EPO
F 4.0-5.5 x
secretion and thereby reducing
10**/L
bone marrow response resulting
into low RBC production.
WBC count ➢ The result of WBC count is within
the normal range. The white blood
cell count (WBC) is used as part
5.0 100 x of a full complete blood count
7.0
106/L (CBC) to help diagnose an
infection or inflammatory process
that affect the number of WBCs.
Platelet count ➢ Platelet result is within normal

range. Normal platelet counts
142-424 272 signify there’s no problem with
client’s blood clot formation.
Reticulocyte ➢ A reticulocyte count is used to

count determine the number and/or
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percentage of reticulocytes in the

blood to help evaluate conditions
that affect red blood cells (RBCs),
such as anemia or bone marrow
disorders.
Nucleated ➢ The presence of nucleated RBC

RBC can indicate a number of diseases
or blood conditions, such as
leukemia, anemia, or problems
with the spleen. A count of
nucleated RBC might suggest that
the body is so desperate for red
blood cells that it has begun
producing them outside of the
bone marrow.
Toxic ➢ Toxic granulations are darker-

Granulation colored granules. These granules
are often larger and more
abundant than normal granules.
Their presence is non-specific and
usually signals a bacterial
infection or inflammation.
Erythrocyte ➢ Erythrocyte sedimentation rate is

Rate a test that indirectly measures the
M 0-10mm/hr
degree of inflammation present in
F 0.20mm/hr
the body.
Bleeding ➢ The bleeding time test is used to

Time evaluate how well a person's
blood is clotting. The test
evaluates how long it takes the
2-4 min
vessels cut to constrict and how
long it takes for platelets in the
blood to seal off the hole.
Clotting time ➢ Clotting time measures how long it

takes blood to clot. It is use to test
or check client’s bleeding
2-5min
problems.
Differential
References Results Clinical Significances
Count
➢ The result of neutrophil count is in
Neutrophil 0.51-0.37 0.35
normal range. This determines
27
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that the neutrophil in the body are

well functioning by preventing
infections through blocking,
disabling, digesting, or warding off
invading particles and
microorganisms in the body.
➢ A result of 0.60 suggest high

lymphocytes count in blood. This
Lymphocyte 0.25-0.33 indicate client’s body is dealing
with an infection or other
inflammatory condition.
➢ Monocyte’s result shows within
normal range. This means that the
monocyte is doing their role in
Monocyte 0.02-0.06 0.03 both the inflammatory and anti-
inflammatory processes that take
place during an immune
response.
➢ Eosinophils are a type of disease-
fighting white blood cell. High
eosinophils often indicate a
Eosinophils 0.01-0.04 0.02
parasitic infection, an allergic
reaction or cancer.
➢ Basophils are necessary for the

immune system’s natural
response to invaders, such as
infectious microorganisms. When
responding to an allergen,
basophils will release histamine,
Basophils 0-0.01
which is partially responsible for
inflammation during an allergic
reaction. If basophil levels are low,
this may be a sign of an allergic
reaction or another condition.
➢ Stabs (band cells) are immature

neutrophils. A higher percentage
or ratio generally indicates that the
bone marrow has received a
Stabs 0.02-0.05
signal of low neutrophil count and
is responding adequately by
making more white blood cells.
➢ The blood type of client shows

Blood typing “O” blood type “O”. This means that
the patient can donate blood to
28
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anyone but can receive blood to

type O only.
➢ Rh positive is the most common

blood type. Rh positive signifies
Rh typing Positive
that your blood has protein.
➢ This test is used to examine

Malarial client’s blood to identify the
Smear species of the malaria parasite.
➢ Peripheral Smear is a test for

evaluating blood-related problems
Peripheral
such as those in red blood cells,
Smear
white blood cells, or platelets.
29
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Name of Laboratory Test: Lipid Profile
Content References Results Clinical Significances

Total
Cholesterol The findings indicate abnormalities in the
100- lipid profile. The result of high total
199mg/dL 250 ↑ cholesterol level, too much LDL, high
triglycerides, and low HDL signifies an
increased possibility of cholesterol
LDL
plaque buildup in the client’s arteries.
<70mg/dL 90 ↑ When the arteries become hardened and
narrowed with cholesterol plaque, the
heart has to strain much harder to pump
HDL blood through them. As a result, blood
pressure becomes abnormally high.
>40mg/dL 30 ↓ Unfortunately, Mrs. L.P has untreated
hypertension, which is a disease
Triglycerides associated with congestive heart failure.
It also increases the risk for other
<150mg/dL 200 ↑ cardiovascular diseases due to forming
clots that cause heart attack and stroke.
Name of Laboratory Test: Fasting Blood Sugar
Examination References Results Clinical Significances

Blood Sugar ➢ The result of blood sugar shows
within normal range. This indicates
80 - 100 80
that Mrs. L. P’s blood sugar is
under control.
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Name of Laboratory Test: Arterial Blood Gas Result
Content References Results Clinical Significances

pH The ABG result of Mrs. L.P shows
7.35–7.45 7.33 respiratory acidosis with hypoxia. This
indicates that the client is developing
paCO2 35–45
50 pulmonary edema. When the left side of
mmHg the heart is failing, it can't handle the
paO2 blood it gets from the lungs. Pressure
>90 mmHg 70 then builds up in the veins of the lungs,
causing fluid to leak into the lung tissues.
HCO3 This may cause CHF and pulmonary
18–24mEq/l 25
edema. When pulmonary edema
BE develops, carbon dioxide retention
-2 occurs, resulting in respiratory acidosis.
Decreased tissue oxygen delivery may
SaO2 also produce lethal lactic acidosis. Some
85%
of the common symptoms of respiratory
Lactate acidosis that was manifested by the client
2.0 include fatigue or drowsiness, confusion,
shortness of breath, dyspnea, etc.
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Name of Laboratory Test: Electrocardiogram
Result Clinical Significance

It shows a narrow QRS ➢ The doctor ordered an electrocardiogram as the client
complex tachycardia manifested tachycardia and irregular rhythm during
with an irregularly physical examination. This test helps the doctor
irregular rhythm. A determine or detect heart disease, heart attack, an
diagnosis of Atrial enlarged heart, or abnormal heart rhythms that may
Fibrillation with rapid cause heart failure.
ventricular response.
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Name of Laboratory Test: Echocardiography

A diagnosis of ➢ The doctor ordered an echocardiogram considering
Congestive heart failure that the physical examination of the client shows
with atrial fibrillation. dynamic precordium, tachycardia, and irregular
rhythm. This test helps the doctor evaluate the heart
muscle function to see how well the heart is pumping
and detect problems with heart valves that may cause
heart failure. The result of congestive heart failure
with atrial fibrillation indicates medical emergencies.
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Name of Laboratory Test: Chest X-Ray

Congestive heart failure. ➢ The doctor ordered Chest X-ray since the client
manifested respiratory distress, cyanotic, and had
labored breathing during the physical examination.
This Lab exam helps the doctor see if the heart is
enlarged and if the lungs are congested with fluid.
The result of congestive heart failure indicates that
the client’s heart doesn't pump blood as efficiently as
it should. As a result, this leads to a backup of blood,
which increases blood pressure and causes fluid to
collect in the air sacs in the lungs.
34
Medical Management Matina Campus, Davao City
Telefax: (082)
Drug Study Phone No.: (082)300-5456/300-0647 Local 117
MECHANISM OF ADVERSE NURSING

DRUG INDICATION CONTRAINDICATION
ACTION EFFECT RESPONSIBILITY
Generic Name: ACE inhibitors block September 11, Enalapril is ▪ Dry, tickly cough 1. Review doctors order
Enalapril Maleate the conversion of 2021 @09:00H Dr. contraindicated in ▪ Dizziness, before administration.
angiotensin I to the Cabahug ordered patients who are lightheadedness, 2. Monitor patients on
Brand Name: vasoconstrictor Enalapril to reduce hypersensitive to this or weakness diuretic therapy for
Vasotec angiotensin II. ACE the blood pressure product and in patients ▪ Headache
excessive hypotension
inhibitors also of the client. with a history of ▪ Diarrhea after the first few doses
prevent the angioedema related to ▪ Mild skin rash of enalapril
degradation of -indicated to previous treatment with ▪ Blurred vision
bradykinin and other reduce high blood an angiotensin 3. Assess allergy to
vasodilatory pressure and to converting enzyme enalapril and impaired
prostaglandins. It prevent or treat inhibitor and in patients renal function.
also increases heart failure. with hereditary or 4. Monitor patient closely
Drug Classification: plasma renin levels idiopathic angioedema. in any situation that may
Angiotensin- and reduce lead to drop in BP
converting enzyme aldosterone levels. Cautions: secondary to reduced
(ACE) inhibitors Net result is May increase risk for low fluid volume because
systemic blood pressure for excessive hypotension
Dosage: vasodilation. people with moderate to may occur.
20 mg PO or via severe kidney damage.
NGT BID 5. Assess fluid levels of
the patient.
6. Give potassium
supplements and
potassium-sparing
diuretics cautiously
because ACE inhibitors
can cause potassium
35
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retention and
hyperkalemia.
7. Monitor
cardiopulmonary status
closely as the drug can
cause severe effects
8. Teach patient that this
medication should not be
stopped without medical
consultation.
9. Advise patients to rise
slowly in order to avoid
postural hypotension.
10. Instruct patient to
avoid potassium
containing salt
substitutes.
36
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MECHANISM OF INDICATION CONTRAINDICATION ADVERSE NURSING

DRUG
Generic Name: Nitroglycerin forms Nitroglycerine is ▪ Nitroglycerin is ▪ Headache which 1. Check doctors order
Nitroglycerine free radical nitric given to the client contraindicated in may be severe before administration.
oxide (NO) which because she patients that have and persistent 2. Administer IV
Brand Name: activates experienced having reported allergic may occur nitroglycerin with extreme
Nitrosan guanylate cyclase, chest pain and symptoms to the immediately caution to patients with
resulting in an discomfort due to medication. after use. hypotension or
increase of guanosine narrowed heart ▪ Known history of ▪ Vertigo hypovolemia since the IV
3'5' monophosphate arteries. increased intracranial drug may precipitate a
(cyclic GMP) in ▪ Dizziness
-Nitroglycerin is pressure, severe severe hypotensive state.
smooth muscle and ▪ Weakness
indicated for the anemia, right-sided
other tissues. These 3. Monitor patient closely
acute relief of an myocardial infarction ▪ palpitation other
events lead to for change in levels of
attack or acute are contraindications manifestations
dephosphorylation of consciousness and for
prophylaxis of to nitroglycerin of postural
myosin light chains, dysrhythmias. If
angina pectoris due therapy. hypotension
which regulate the intoxication occurs,
to coronary artery may develop.
contractile state in infusion should be stopped
disease.
smooth muscle, and promptly
Cautions:
Drug result in 4. Assess for headaches.
Classification: vasodilatation. ▪ Only the smallest
Nitrates/Anti-angina dose required for 5. Assess ambulation as
effective relief of the needed, especially with
Dosage: acute anginal attack older adult or debilitated
50mg to run at 1- should be used. patients.
hour IV OD Excessive use may 6. Take baseline BP and
lead to the
heart rate with patient in
development of sitting position before
tolerance. initiation of treatment with
transdermal preparations.
37
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▪ The drug should be 7. Assess for and report

discontinued if blurred vision or dry
blurring of vision or mouth.
drying of the mouth 8. Assess for and report
occurs. Excessive the following topical
dosage of reactions. Contact
nitroglycerin may dermatitis from the
produce severe transdermal patch; pruritus
headaches. and erythema.
9. Nitroglycerine should be
kept in the original glass
container and must be
tightly capped after each
use to prevent loss of
tablet potency.
10. Advice patient to
change position slowly and
avoid prolonged standing.
38
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Generic Name: Digoxin induces an - Indicated to treat Contraindicated for ▪ Dizziness or 1. Review Doctors order
Digoxin increase in heart failure and persons having: lightheadedness. before administration.
intracellular sodium abnormal heart ▪ Ventricular fibrillation ▪ Drowsiness. 2. Check dosage and
Brand Name: that will drive an influx rhythms preparation carefully.
Lanoxin of calcium in the heart (arrhythmias). It ▪ Wolff-Parkinson- ▪ Vision changes
and cause an helps the heart White syndrome (blurred or 3. Monitor apical pulse for
increase in work better and it yellow) 1 full min before
▪ Hypersensitivity to
contractility. Cardiac helps control your administering. Withhold
the drug. ▪ Trouble in
output increases with heart rate. dose and notify health care
breathing; and
a subsequent ▪ Hypomagnesemia. professional if pulse rate is
Client is given ▪ Rash
decrease in ▪ Hypokalemia <60 bpm in an adult, <70
Digoxin because
ventricular filling bpm in a child, or <90 bpm
the ECG result of
pressures. in an infant.
the client shows a
narrow QRS Cautions: 5. Notify health care
complex Avoid rapid IV professional promptly of
tachycardia with an administration in any significant changes in
irregular rhythm. A digitalized patients; rate, rhythm, or quality of
diagnosis of Atrial may produce serious pulse.
Fibrillation with arrhythmias. 6. Monitor BP periodically
Drug rapid ventricular in patients receiving IV
Classification: response. digoxin.
Digitalis
glycosides/Cardiac 7. Monitor ECG during IV
Glycosides administration and 6 hr.
after each dose. Notify
Dosage: health care professional if
250mcg/ml PO or bradycardia or new
via NGT OD arrhythmias occur.
39
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8. Avoid giving with meals;

this will delay absorption.
9. Monitor the patient’s
serum potassium level
because a decreased
potassium level places the
patient at increased risk of
digoxin toxicity.
10. Have emergency

equipment ready; have K+
salts, lidocaine, phenytoin,
atropine, and cardiac
monitor readily available in
case toxicity develops.
40
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Generic Name: Metoprolol is a beta-1- September 11, Metoprolol is CNS: 1. Check doctors order
Metoprolol tartrate adrenergic receptor 2021 @09:00H contraindicated for Fatigue, before administration.
inhibitor specific to clients Blood persons having: weakness, 2. Take apical pulse before
Brand Name: cardiac cells with pressure still anxiety, administering. If <50 bpm
Lopressor negligible effect on increases ▪ Asthma attack depression, or if arrhythmia occurs,
beta-2 receptors. This 180/120mmHg. As dizziness,
▪ Low blood pressure withhold medication and
inhibition decreases well as the pulse drowsiness, notify health care
cardiac output by rate of the client is ▪ Sinus bradycardia insomnia, memory professional.
producing negative increases to 140 ▪ Myasthenia gravis loss, mental
chronotropic and bpm. Moreover, status changes, 3. Monitor BP, and pulse
inotropic effects clients ECG shows ▪ Liver problems; and and nervousness, frequently during dose
without presenting diagnosis of Atrial ▪ Peripheral vascular adjustment and periodically
activity towards Fibrillation with disease CV: Bradycardia, during therapy.
membrane rapid ventricular pulmonary 4. Assess frequency and
stabilization nor response. edema, characteristics of anginal
intrinsic Cautions: hypotension, and
- Metoprolol is Beta blockers, like attacks periodically during
sympathomimetics. peripheral therapy
indicated for the Lopressor, can cause vasoconstriction
treatment of angina, depression of 5. Monitor vital signs and
Drug heart failure, myocardial contractility ECG every 5–15 min during
Classification: GI:
myocardial and may precipitate and for several hrs. after
Beta blockers Constipation,
infarction, atrial heart failure and parenteral administration. If
diarrhea, drug-
fibrillation, and cardiogenic shock. If
Dosage: induced hepatitis, heart rate <40 bpm,
hypertension. In signs or symptoms of especially if cardiac output
100mg PO or via dry mouth,
result it slows down heart failure develop,
NGT OD flatulence, gastric is also decreased,
the heart rate and treat the patient pain, nausea, and administer atropine 0.25–
makes it easier for according to 0.5 mg IV.
the heart to pump vomiting
recommended
41
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blood around the guidelines. It may be 6. Administer metoprolol

body. necessary to lower the with meals or directly after
dose of Lopressor or to eating.
discontinue it. 7. Instruct patient to take
medication as directed, at
the same time each day,
even if feeling well; do not
skip or double up on
missed doses.
8. Advise patient to change
positions slowly to minimize
orthostatic hypotension.
9. Ensure that patient
swallows the ER tablets
whole; do not cut, crush, or
chew.
10. instruct patient to do not
stop taking this drug unless
instructed to do so by a
health care provider.
42
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MECHANISM OF NURSING
DRUG INDICATION CONTRAINDICATION ADVERSE EFFECT
ACTION RESPONSIBILITY
Generic Name: Atorvastatin is a statin September 11, Atorvastatin is CNS: 1. Review Doctors order
Atorvastatin calcium medication and a 2021 @09:00H contraindicated in Headache and before administration.
competitive inhibitor of client’s lipid profile patients with active asthenia 2. Advise patient that
Brand Name: the enzyme HMG- results manifest hepatic disease this medication should
Lipitor CoA abnormality. Total (including cholestasis, GI: be used in conjunction
(hydroxymethylglutaryl Cholesterol 250 hepatic Flatulence, with diet restrictions.
coenzyme A) mg/Dl (high); LDL encephalopathy, abdominal pain,
reductase, which 90 mg/dL(high); hepatitis, and jaundice) cramps, 3. Instruct patient to
catalyzes the HDL 30 mg/dL or unexplained constipation, take drug at the same
conversion of HMG- (low); and persistent elevations in nausea, dyspepsia, time each day to
CoA to mevalonate. Triglycerides 200 serum heartburn, liver maintain its effects.
Atorvastatin acts mg/dL (high) aminotransferase failure 4. Monitor liver function
primarily in the liver, concentrations tests prior to initiation of
- It is given to the
where decreased because all statins are Respiratory: therapy and as clinically
client to prevent
Drug Classification: hepatic cholesterol hepatically cleared and Sinusitis, indicated.
cardiovascular
Hydroxymethylglutaryl- concentrations can cause elevations pharyngitis
events and with 5. Instruct patient to
CoA (HMG-CoA) stimulate the in liver biochemistries,
abnormal lipid take medication as
reductase inhibitors upregulation of there is a concern that Other:
profiles. directed. If a dose is
(statins) hepatic low-density patients with Rhabdomyolysis
lipoprotein (LDL) underlying liver with acute renal missed, omit and
Dosage: receptors, which disease may be at failure, arthralgia, resume usual schedule
40mg PO or via NGT increases hepatic increased risk for myalgia with next dose. Do not
OD @ bedtime uptake of LDL. hepatotoxicity. double up on missed
doses.
6. Check lipid panel at
baseline, 6–8 weeks
after starting or
adjusting the
43
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medication/dose, and
then every 4–6 months.
7. Check LFTs at
baseline, approximately
12 weeks after starting
therapy, then annually
or more frequently if
indicated.
8. Advise patient to
avoid drinking more
than one quart of
grapefruit juice or 2
glasses of alcohol per
day during therapy.
9. Instruct female
patients to notify health
care professional
promptly if pregnancy is
planned or suspected or
if breastfeeding.
10. Instruct patient to
notify health care
professional promptly if
unexplained muscle
pain, or weakness
occurs.
44
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MECHANISM OF NURSING
DRUG INDICATION CONTRAINDICATION ADVERSE EFFECT
ACTION RESPONSIBILITY
Generic Name: Nicardipine inhibits the September 11, Atorvastatin is Cardiovascular: 1. Check doctors order
Nicardipine transmembrane influx 2021 @ 08:00H contraindicated in Angina pectoris, before administration.
hydrochloride of calcium ions into Dr. Loot ordered patients with: atrioventricular 2. Inspect Cardene I.V.
cardiac muscle and Nicardipine since block, ST segment
▪ Severe narrowing of Premixed Injection
Brand Name: smooth muscle without client’s blood depression, inverted
the aortic heart valve visually for particulate
Cardene changing serum pressure increases T wave, deep-vein matter and discoloration
calcium 180/120mmHg. ▪ Chronic heart failure thrombophlebitis prior to administration,
concentrations. The ▪ A hemorrhage in the whenever solution and
contractile processes -Nicardipine brain Digestive: container permit.
of cardiac muscle and hydrochloride dyspepsia
vascular smooth injection is ▪ Low blood pressure 3. Administer Cardene
muscle are dependent indicated for the ▪ Liver problems; and Body as a Whole: I.V. by a central line or
upon the movement of short-term fever, neck pain through a large
extracellular calcium treatment of ▪ Liver problems peripheral vein.
ions into these cells hypertension when 4. Change the infusion
through specific ion oral therapy is not site every 12 hours if
channels. The effects feasible or administered via
of nicardipine are more desirable and to peripheral vein.
selective to vascular control angina
Drug smooth muscle than (chest pain). 5. Check the container
Classification: cardiac muscle. On the for minute leaks prior to
Dihydropyridine other hand, nicardipine use by squeezing the
calcium Channel produced relaxation of bag firmly; ensure that
Blockers coronary vascular the seal is intact.
smooth muscle at drug 6. Do not add
Dosage: levels which cause supplementary
50mg @ 25cc/hr IV little or no negative medication to the bag.
inotropic effect.
45
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Protect from light until

ready to use.
7. Do not combine
Cardene I.V. Premixed
Injection with any
product in the same
intravenous line or
premixed container.
8. Monitor blood
pressure and heart rate
continually during
infusion and avoid too
rapid or excessive blood
pressure drop during
treatment.
9. Assess episodes of
angina pectoris at rest
and during exercise.
10. Watch for signs of
hyperglycemia, including
confusion, drowsiness,
flushed/dry skin, fruit-like
breath odor, rapid/deep
breathing, polyuria, loss
of appetite, and unusual
thirst.
46
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Brand Name: It is for the dietary It is indicated for ▪ Not to be used 1. Check the doctor’s
Glucobest management of the dietary for parenteral order.
patients suffering from management of (intravenous)
protein-energy protein-energy use. 2. Ask the patient if he
malnutrition malnutrition with
▪ Not for use in or she has an allergy.
associated with type II diabetes. children unless 3. Check the blood
diabetes or glycemic recommended by
disorders. It provides sugar regularly as
a physician or
the following: healthcare directed by the doctor.
▪ Low lactose, professional.
▪ Low Glycemic index, 4. Make sure the client
▪ Has fiber from FOS
consumes it within 24
and dextrin
▪ Gluten-free hours.
▪ Sucrose-free 5. Refrigerate the
▪ Fructose-free
▪ Trans fat-free unused portion of the
▪ Has 28 Vitamins and powder.
Minerals
▪ Source of Omega-3
(Alpha-linolenic
acid); and
▪ High in Chromium
47
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Nutrition Therapy
➢ DASH. Dietary Approach to stop hypertension.
➢ Eat more fruits, vegetables, and low-fat dairy foods.
➢ Cut back on foods that are high in saturated fat, cholesterol, and trans fats.
➢ Increase intake of soluble fiber such as whole-grain foods. Also include intake
of high in omega oil.
➢ Encourage patient to reduce sodium intake and eat a variety of foods rich in
nutrients that help lower blood pressure, such as potassium, calcium and
magnesium.
➢ Use oils that contain monounsaturated fatty acids and n-3 fatty acids (such as
canola and olive oil).
➢ Decrease intake of saturated fat, polyunsaturated fat and trans fatty acids; in
particular, follow these guidelines:
• Decrease consumption of butter and margarine.
• Decrease consumption of fatty meats.
• Decrease consumption of dairy products made from 2% or whole

milk.
➢ Avoid sweets, alcohol, and carbonated drinks.
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Fluid Balance Sheet
INTAKE OUTPUT
7-3
IVF IVF ENTERAL DRAIN
shift OTHERS BLOOD TPN URINE STOOL OTHERS
1 2 TUBE ORAL
8 120 25
9 120 25 200
10 120 25
11 120 25 1000
12 120 25
1 120 25
2 120 250 200
3 120 25 50
TOTAL 960 425 200 1250
TOTAL per shift: 1585 cc TOTAL per shift: 1250 cc
NOD: Balance per shift: +335 cc
INTAKE OUTPUT
2-10
1 2 TUBE ORAL
3
4
5
6
7
8
9
10
TOTAL
TOTAL per shift: TOTAL per shift:
NOD: Balance per shift:
INTAKE OUTPUT
10-6
1 2 TUBE ORAL
11
12
1
2
3
4
5
6
TOTAL
TOTAL per shift: TOTAL per shift:
NOD: Balance per shift:
FINAL
TOTAL
24 hour total
NOD: 24 hour total INTAKE OUTPUT
24 hour
BALANCE
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Surgical Management
Coronary Artery Bypass Graft (CABG) Surgery
If coronary arteries (arteries that supply blood to the heart) become blocked or
lined with plaque causing less-than-normal blood flow through them, the heart muscle
can’t get the right amount of oxygen-rich blood to work properly. The heart cannot
pump normally, and this can lead to heart failure.
Coronary artery bypass surgery
reroutes the blood supply around a
blocked section of the artery.
During this procedure, surgeons
remove healthy blood vessels
from another part of the body, such
as a leg or the chest wall. They
then surgically attach the vessels to the diseased artery so that the blood can flow
around the blocked section. After a bypass operation, it’s especially important for you
to reduce the amount of fat and cholesterol you eat, because these substances cause
the arteries to clog. Doctors also recommend increasing physical activity to strengthen
the heart muscles.
Valve Surgery
Heart valve surgery is a procedure to treat heart valve disease. Heart valve
disease involves at least one of the four heart valves not working properly. Heart
valves keep blood flowing in the correct direction through your heart.
50
Telefax: (082)
Phone No.: (082)300-5456/300-0647 Local 117
As heart failure gets worse,
changes in the left ventricle
(lower chamber of the heart) may
cause the papillary muscles to
stretch out of shape. The
papillary muscles support mitral
valve leaflet function to keep
blood flowing in only one
direction. When the papillary muscles get weak, they can’t properly support the mitral
valve leaflets, and the valve starts to leak. Mitral valve repair usually involves
reshaping the leaflets and supporting the mitral valve with a ring.
Mitral valve repair surgery helps to: Preserve the natural anatomy of the heart, improve
the heart’s ability to pump properly, decrease heart failure symptoms, and improve
survival. Heart failure can be caused by aortic valve stenosis (stiffness) or regurgitation
(leaky valve). If the valve cannot open fully, or if blood leaks backward into the left
ventricle, the heart must pump more strongly to meet the body’s needs for oxygen-rich
blood and heart failure can occur.
Heart Transplant
Heart transplant is recommended
only when necessary and when all other
treatment options have been tried or
considered. Patients who are considered
for a heart transplant must not have other
medical conditions that would prevent a
51
Telefax: (082)
Phone No.: (082)300-5456/300-0647 Local 117
successful surgery and recovery, and there must be an excellent chance of long-term
transplant success. Some people have severe, progressive heart failure that can’t be
helped by medications or dietary and lifestyle changes. In such cases, a heart
transplant may be the only effective treatment option.
52
Nursing Management
Nursing Care Plan
Name: L.P Age:55 Sex: Female Address: Barangay 23-C, Davao City
DOB: 10/7/1966 ID #: 54675 Allergy: None
Attending Physician: Dr. Loot & Dr. Cabahug Chief Complaint: Dyspnea associated with palpitation and headache
Admitting diagnosis: Congestive heart failure due to untreated hypertension with atrial fibrillation
NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Date: 9/11/21 Ineffective That within my 2 Independent: Goal met.
Time: 8:00 am breathing hours span of my 1.Monitor VS. 1. To gain baseline data
“Maglisod kog pattern related care, the client 2. Position patient in optimal 2. To breath efficiently After 2 hours span
ginhawa nars.” as to decreased will have normal body alignment in semi- of my care, the
verbalized lung expansion breathing pattern fowler’s position. client will have
and pulmonary as evidenced by: 3. Auscultate breath sounds 3. This is to detect normal breathing
Objective: congestion at least every 4 hours. decreased or adventitious pattern as
• Dyspnea secondary to breath sounds. evidenced by:
• Labored Pleural Effusion a) Respiratory 4. Observe breathing pattern 4. Identifies increased
Breathing rate within for SOB, nasal flaring, work of breathing
• (+) Respiratory normal range pursed-lip breathing or a) Respiratory
Distress An ineffective (12-20 cpm) prolonged expiratory phase rate of 14 cpm
breathing b) Absence of and use of accessory b) Absent of
Vital signs: pattern is a labored muscle. labored
RR – 35 CPM condition of breathing 5. Utilize pulse oximetry to 5. Utilize pulse oximetry to breathing
O2 sat: 88% room inadequate c) SpO2 within check oxygen saturation and check oxygen saturation c) SpO2 of 90%
air ventilation due normal range pulse rate. and pulse rate. d) Absent of
to an (90-100%) 6. Measure tidal volume and 6. Indicates volume of air respiratory
Diagnostic & Lab impairment in d) Absence of vital capacity moving in and out of lungs distress
test: the mechanism respiratory 7. Assist patient to use 7. Determines adequacy of
• C-X-ray: Pleural of inspiration distress relaxation techniques breathing 9-11-21 @10 am
Effusion and expiration. 8. Inspect thorax for 8. Reduces muscle
Prolonged symmetry of respiratory tension, decreases work of
inadequate movement breathing
53
ventilation may Dependent:
lead to 9. Provide respiratory 9. Aid in relieving the
compromised support. Oxygen inhalation is patient from dyspnea.
respiratory given as ordered.
function 10.Hook patient to 10. To monitor patient’s
performance, mechanical ventilator. respiratory status.
such as
providing
oxygen for the
tissues, and
removing waste
products.
Breathing
pattern
alteration may
also transpire in
several
circumstances
from Congestive
Heart Failure.
54
NURSING NURSING
Date: 9/11/21 Alteration in That within my 1-2 Independent: Goal Partially met.
Time: 8:00 am comfort: Chest hours span of care, 1. Monitor vital sign. 1.To have a baseline
Subjective: Pain related to client will able to data. After 1- 2 hours
“Sakit akong tissue ischemia free from chest pain 2. Monitor and document 2. To monitor span nursing care,
dughan nars.” as secondary to as evidenced by: respirations since it may client was partially
characteristic of pain.
verbalized. Hypertension. increase as a result of free from chest pain
a) Pain score of 0 pain. as evidenced by:
Objective: from 8/10 3. Place client in position
3. To alleviate pain by
• (+) chest pain Ischemia is any b) Heart rate within of comfort. her comfortable a) Pain score of 3
noted reduction in normal range positioning. b) Heart rate of 110
• (+) tachycardia blood flow (60-100bpm) 4. Encourage patient to do 4. To minimize stressful c) Blood pressure
with irregular resulting in c) Blood pressure relaxation technique. stimuli. of 120/80 mmHg.
rhythm noted decreased within normal 5. Use a pain rating scale 5. To monitor pain
• Pain score of 8/10
oxygen and range to assess the patient's score.
nutrient 120/80mmHg
perception of the pain's
supplies to a
tissue. Ischemia severity.
Vital signs:
BP- 180/120 mmHg may be 6. Consider healing touch 6. Healing touch is a
HR – 150 bpm reversible, in if the patient doesn’t form of alternative
RR – 35 cpm which case the tolerate any other form medicine that derives
affected tissue of stimuli such as back from the thought of
Medication: will recover if rubs or ROM. human touch lowering
Nitroglycerine blood flow is cortisol levels in the
50mg to run at 1- restored, or it body. Healing touch
hour IV OD may be
55
6
Metoprolol 100mg irreversible, may, therefore, lower
PO or via resulting in stress and anxiety.
NGT OD tissue death. 7. Instruct patient to report 7. To aid discomfort.
Pain is a pain immediately.
common DEPENDENT
symptom 8. Administer supplemental 8. Increases amount of
associated with oxygen by means of nasal oxygen available for
ischemia. cannula or face mask, as myocardial uptake
indicated. and thereby may
relieve discomfort
associated with
tissue ischemia.
9. Administer 9. To treat patient’s
Nitroglycerine 50mg to chest pain.
run at 1-hour IV OD as
ordered.
10. Administer Metoprolol 10. Important second-
100mg PO or via NGT line agents for pain
OD control through
effect of blocking
sympathetic
stimulation, thereby
. reducing heart rate,
systolic BP, and
myocardial oxygen
demand.
56
NURSING NURSING
9-11-21 @ 8am Fluid volume That within my 2- INDEPENDENT Goal met.
excess related to 3 days span of 1) Monitor vital signs and 1) To have baseline date and
Objective: accumulation of nursing care, patient’s weight. weight monitoring. After 2-3 days span
• Bilateral ankle fluid in the client will achieve 2) Monitor for jugular vein 2) To evaluate the presence of a of my nursing care
edema interstitial space fluid balance as distension with the head serious underlying causing the, client achieved
• (+) neck as evidenced by evidenced by: of bed elevated 30 to 45 the pressure in the veins to fluid balance by as
distention edema secondary degrees. rise. evidenced by:
• Excessive to Congestive a. Reducing or 3) Monitor I & O every 4 3) To enhances compliance with
intake Heart Failure absence of hours. the regimen. a. Absent of edema.
(1, 585 mL) edema. 4) Elevate, compress, and 4) Elevation increases venous b. Absent of neck
• Balance fluid b. Absence of reposition the return to the heart and, in distention
shift +335 mL Fluid volume neck edematous extremities. turn, decreases edema. c. Reduced fluid
excess or distention 5) Change position every 2 5) Repositioning prevents fluid intake
Medication: hypervolemia is c. Reduce fluid hours. accumulation in dependent
• Enalapril an excessive fluid intake areas.
20mg PO BID in the 6) Educate patient to 6) Restriction of sodium aids in
extracellular restrict fluid intake and decreasing fluid retention.
compartment; it sodium intake.
does not shift 7) Explain the need to use 7) To help promote venous
between anti-embolic stockings. return and minimize fluid
compartments. accumulation in the
Fluid overload extremities.
cause like DEPENDENT 9-13-21 @ 4 pm
interstitial edema 8) Administer ACE inhibitor, 8) ACE inhibitors, which help to
and circulatory Enalapril 20mg PO BID reduced sodium and water
overload and as prescribed. retention.
57
when it becomes 9) Report to the physician 9) To prevent fluid overload from
severe, it causes to reduce IV flow rates. IV therapy.
Congestive Heart COLLABORATION
Failure 10) Plan and approach 10) To monitor patient’s diet
patient’s diet to the and collaboration to NDs.
nutritionist and dietician.
58
Discharge Plan
Medication:
• Encourage the patient to adhere to the home medication prescribed by the
doctor.
• Educate the patient with the purpose of each drug and side effects.
• Instruct patient to take medicine at the exact time and the prescribed dosage.
• Instruct to take prescribed medication such as antihypertensive drug with the
prescribed duration.
• Take medicines as prescribed by the doctor and do not self-medicate.
Exercise:
• Ten minutes of brisk or moderate walking three times a day.
• Flexibility exercises include stretching and yoga.
• Strength training usually involves lifting weights
Treatment:
• Comply with the treatment regimen.
• Emphasize rehabilitation through enough rest and proper diet.
• Regular monitoring of blood pressure.
• Instruct patient to keep updated with any follow-up examinations/therapy
checkups after discharge.
Health Teachings:
• Explain the importance of medication compliance.
• Compliance to follow-up examinations.
• Eat more fruits, vegetables, and low-fat dairy foods
59
• Cut back on foods that are high in saturated fat, cholesterol, and trans fats
• Eat more whole-grain foods, fish, poultry, and nuts
• Reduce the amount of salt in the diet.
• Lose weight if you are overweight or have obesity
• Avoid drinking too much alcohol
• Stop smoking
Out-patient follow up:
• Instruct the patient to return to their attending physician for scheduled checkup
and consultation or possible return after 1 week of discharge.
• Stress out to the patient to seek immediate consultation if the adverse reaction
of the drug occurs.
Diet:
Meal Plan -DASH Diet

30 - Day Hypertensive Plan Cycle Menu
(1500 kcal per day)
Week 1
Sunday Calories
Breakfast ½ cup of rice 130
1 cup of kamote tops salad 123
½ cup mashed potato 88
1 cup skim milk 80
Lunch 3 oz. fish 175
1 cup green beans 31
2 bread thin sliced 139
1 cup slice boiled okra 33
Afternoon Snack 1 avocado (medium, 250
whole)
Dinner 4 oz. lean pork chop 133
1 large baked sweet potato 210
1 small 6’’-6-7/8” long 90
banana 80
1 cup skim milk
Total 1,562 kcal
60
Monday Calories
Breakfast 2 slice light whole wheat 138
bread
1 cup cold cereal 307
1 cup skim milk 80
Lunch 2 oz. grilled chicken 128
1/2 slice, large pita bread 165
1 cup of lettuce salad with 22
assorted green
vegetables
3 pieces of rambutan fruit 69
Afternoon Snack ½ boiled sweet potato 86
6 oz. orange juice 77
Dinner ½ cooked cup brown rice 111
1 cup shrimp sinigang 148
soup
2 cups stewed tomatoes 132
2 cup of cucumber salad 104
Total 1,567 kcal
Tuesday Calories
1 cup ampalaya con 450
carne
4 oz grapefruit juice 44
Lunch ½ cooked cup brown rice 111
2 oz. fresh tuna 66
1 cup stir fried spring 122
vegetables
Afternoon Snack 2 tbsp. mixed nuts 102
Dinner ½ slice large pita bread 165
6 oz. roast chicken 276
3oz baked orange fish 65
Total 1,532kcal
Wednesday Calories
Breakfast 1 cup fried rice 228
2 cups of 44
lettuce salad with
assorted green
1 cup skim milk 80
Lunch 1 cup mashed potato 214
1 cup peppers, sweet, 30
green
2 cups chopped broccoli 62
1 medium orange 62
Afternoon Snack 2 cookies 80
1 cup grapes red/ green 104
61
Dinner ½ cup rice 111
1 and ½ ginisang 240
ampalaya with egg)
½ cup beef stew 250
Total 1,505kcal
Thursday Calories
Breakfast ½ cup mashed potato 88
2 slices of apple 18
2 slices toast loaf bread 132
vegetables
2 cups boiled okra 66
Afternoon Snack 1 slice tuna sandwich 287
juice
1 cup orange juice 111
Dinner 1 cup ampalaya con 450
carne
4 slices thin pineapple 122
Total 1,538 kcal
Friday Calories
Breakfast 1 cup cooked rice 200
1 cup adobong kangkong 84
2 cups Stewed tomatoes 132
1 cup of skim milk 80
2 cups slice Okra, Boiled 66
2 cups cucumber salad 104
Afternoon Snack 1 large apple 166
Dinner 1 large baked sweet 210
potato
1 cup ginisang cabbage 150
3 oz. baked orange fish 65
1 cup chopsuey 102
Total 1,534 kcal
Saturday Calories
Breakfast 1 cup cooked oatmeal 140
1 cup skim milk 80
2 cups of 44
lettuce salad with
assorted green
2 oz. fresh tuna 66
whole)
62
soup
Total 1,548 kcal
Week 2
Sunday Calories
Breakfast 1 cup skimmed milk 80
½ cup brown rice 108
1 cup steamed broccoli 80
1 cup grilled salmon 280
Lunch 1 cup shellfish soup 156

1 slice wheat bread 70
1 glass banana smoothie 176
Snack 1 whole star fruit 28

1 medium size papaya 138
Banana medium size 105
Dinner 1 cup sauteed cabbage 87

½ cup pork chop 250
Strawberries, 5 pieces 29
Total 1,587 kcal
Monday Calories
1 glass skimmed milk 50
1 cup ginisang ampalaya 226
with egg
Lunch 1 cup steamed broccoli 80

1 glass apple juice 114
1 cup chopsuey 502
Snack 1/2 slice mango 54

Grapefruit red or pink (2 208
pcs)
Dinner ½ cup mashed potato 88
1 cup boiled Okra 68
1 cup cucumber salad 52
Total 1,563 kcal

Tuesday Calories
Breakfast 1 cup brown rice 248
3-ounce fish 175
63
Lunch 1 cup stewed chicken 258
Large baked sweet potato 210
Lean pork chop (4 oz) 133
Snack 3 pieces dates 60

1 slice papaya 15
Dinner 2 sliced bread 139
1 cup spinach salad 183
1 cup carrot soup 69
Total 1521 kcal

Wednesday Calories
Breakfast 1 large baked sweet 210
potato 123
2 cups camote tops salad 80
1 cup skimmed milk
Lunch ½ cup rice 150
1 cup cauliflower salad 393
1 Guava 40
Snack Banana medium size 105

1 whole tangerine 53
½ slice mango 54
Dinner 1 cup cabbage salad 220
Orange juice (250ml) 110
Total 1,538 kcal
Thursday Calories
Breakfast 2 slice bread 133
1 cup Spinach salad 107
Lunch 1 cup adobong kangkong, 84
bland
Snack 1 cup avocado 250
2 slice watermelon 171
Dinner 1 slice tuna sandwich 287

1 glass lemon juice 41
Total 1,525 kcal
Friday Calories
Breakfast ½ cup chicken porridge 170
1 cup skimmed milk 80
1 cup sauteed cabbage 87
2 small bananas 180
Lunch Steam tilapia (100g) 129
64
0
1/2 mashed squash 44
1 cup steam camote tops 123
1 glass calamansi juice 80
Snack 1 slice pineapple 51

1 whole pear 100
Dinner 1 cup pinakbet 110

Steam tuna (100g) 130
Sweet baked potato 210
Total 1,546 kcal
Saturday Calories
Breakfast 1 cup sinigang shrimp 148
1 glass tomato juice 41
Lunch 1 slice tuna sandwich 287

1 cup chopsuey 502
Snack 1 whole peach 59


1 glass low fat milk 110
Total 1,585 kcal
Week 3
Sunday Calories
Breakfast 1 cup fried rice 228
2 cups of 44
lettuce salad with
assorted green
1 cup skim milk 80
Lunch 1 cup mashed potato 214
1 cup peppers, sweet, 30
green
2 cups chopped broccoli 1 62
medium orange 62
Afternoon Snack 2 cookies 80
1 cup grapes red/ green 104
Dinner ½ cup rice 111
1 and ½ ginisang 240
ampalaya with egg)
Total 1,505kcal
65
Monday Calories
Breakfast 1 cup cooked rice 200
1 cup adobong kangkong 84
2 cups Stewed tomatoes 132
1 cup of skim milk 80
2 cups slice Okra, Boiled 66
Afternoon Snack 1 large apple 166
Dinner 1 large baked sweet 210
potato
1 cup ginisang cabbage 150
3 oz. baked orange fish 65
1 cup chopsuey 102
Total 1,534 kcal
Tuesday Calories
1 cup of kamote tops 123
salad
1 cup skim milk 80
2 bread thin-sliced 139
1 cup slice boiled okra 33
whole)
Dinner 4 oz. lean pork chop 133
1 large baked sweet 210
potato
1 small 6’’-6-7/8” long 90
banana
1 cup skim milk 80
Total 1,562 kcal
Wednesday Calories
Breakfast 1 cup cooked oatmeal 140
1 cup skim milk 80
2 cups of 44
lettuce salad with
assorted green
2 oz. fresh tuna 66
whole)
66
soup
Total 1,548 kcal

Thursday Calories
Breakfast 2 slice light whole wheat 138
bread
1 cup cold cereal 307
1 cup skim milk 80
1 cup of lettuce salad with 22
assorted green
vegetables
3 pieces of rambutan fruit 69
Afternoon Snack ½ boiled sweet potato 86
6 oz. orange juice 77
soup
2 cups stewed tomatoes 132
2 cup of cucumber salad 104
Total 1,567 kcal
Friday Calories
Breakfast ½ cup mashed potato 88
2 slices of apple 18
2 slices toast loaf bread 132
vegetables
2 cups boiled okra 66
Afternoon Snack 1 slice tuna sandwich 287
juice
1 cup orange juice 111
Dinner 1 cup ampalaya con 450
carne
4 slices thin pineapple 122
Total 1,538 kcal
Saturday Calories
1 cup ampalaya con 450
carne
4 oz grapefruit juice 44
2 oz. fresh tuna 66
122
67
0
1 cup stir fried spring
vegetables
Afternoon Snack 2 tbsp. mixed nuts 102
Dinner ½ slice large pita bread 165
6 oz. roast chicken 276
3oz baked orange fish 65
Total 1,532kcal
Week 4
Sunday Calories
Breakfast 1 cup sinigang shrimp 148
1 glass tomato juice 41
Lunch 1 slice tuna sandwich 287

1 cup chopsuey 502
Snack 1 whole peach 59


1 glass low fat milk 110
Total 1,585 kcal

Monday Calories
Breakfast ½ cup chicken porridge 170
1 cup skimmed milk 80
1 cup sauteed cabbage 87
2 small bananas 180
Lunch Steam tilapia (100g) 129

1/2 mashed squash 44
1 cup steam camote tops 123
1 glass calamansi juice 80
Snack 1 slice pineapple 51

1 whole pear 100
Dinner 1 cup pinakbet 110

Steam tuna (100g) 130
Sweet baked potato 210
Total 1,546 kcal
Tuesday Calories
Breakfast 2 slice bread 133
1 cup Spinach salad 107
68
Lunch 1 cup adobong kangkong, 84
bland
Snack 1 cup avocado 250
2 slice watermelon 171
Dinner 1 slice tuna sandwich 287

1 glass lemon juice 41
Total 1,525 kcal
Wednesday Calories
Breakfast 1 large baked sweet 210
potato 123
2 cups camote tops salad 80
1 cup skimmed milk
Lunch ½ cup rice 150
1 cup cauliflower salad 393
1 Guava 40
Snack Banana medium size 105

1 whole tangerine 53
½ slice mango 54
Total 1,538 kcal
Thursday Calories
Breakfast 1 cup brown rice 248
3-ounce fish 175
Lunch 1 cup stewed chicken 258

Large baked sweet potato 210
Lean pork chop (4 oz) 133
Snack 3 pieces dates 60

1 slice papaya 15
Dinner 2 sliced bread 139
1 cup spinach salad 183
1 cup carrot soup 69
Total 1521 kcal

Friday Calories
Breakfast 1 cup skimmed milk 80
1 cup steamed broccoli 80
1 cup grilled salmon 280
Lunch 1 cup shellfish soup 156
69
0
1 slice wheat bread 70
1 glass banana smoothie 176
Snack 1 whole star fruit 28

1 medium size papaya 138
Banana medium size 105
Dinner 1 cup sauteed cabbage 87

Strawberries, 5 pieces 29
Total 1,587 kcal
Saturday Calories
1 glass skimmed milk 50
1 cup ginisang ampalaya 226
with egg
Lunch 1 cup steamed broccoli 80
1 cup chopsuey 502
Snack 1/2 slice mango 54

Grapefruit red or pink (2 208
pcs)
Dinner ½ cup mashed potato 88
1 cup boiled Okra 68
Total 1,563 kcal
70
Health Teaching
Lifestyle changes
▪ Maintaining a healthy weight by exercising. Start slowly exercising within 5-10
mins a day of walking and increased a minute by week until the client achieved
the ultimate goal for a total of 30mins of activity a day.
▪ Monitor pulse rate while the client is exercising and after the client cooled down.
▪ Monitor blood pressure at home. Sit and rest for 5 minutes before taking the
blood pressure.
▪ Encourage client to check blood pressure 2 times, 1 minute apart, before taking
a medicine in the morning. Also check blood pressure before evening meal.
Keep a record of readings and bring it to follow-up visits.
▪ Encourage patient to eat a well-balanced diet that's low in fat and salt. Stay
away from fast-food restaurant.
▪ Instruct client to avoid stressful situations.
▪ Encourage client to limit the amount of caffeine intake and restrict alcohol
consumption.
▪ Encourage client to drink plenty of water and have a regular check-up.
▪ Encourage client to reduce sodium intake and eat a variety of foods rich in
nutrients that help lower blood pressure, such as potassium, calcium and
magnesium.
▪ Take medicine as prescribed. If there is an unpleasant side effects, contact the
physician immediately.
▪ Keep the client medical appointments. Close follow-up is important to stroke
rehabilitation and recovery.
71
▪ Instruct the client to never stop any of the medicines without first talking to the
physician. Encourage client to not skip a dose unless the client is told to.
72
Evidenced-based Research Findings related to the Disease/Illness
1. A New FDA Approved Therapy for Atrial Fibrillation
January 3, 2018; Yun Qiu Jiang
The FDA approved the Hybrid AF Therapy using the EPI-Sense System
to treat patients diagnosed with long-standing persistent atrial fibrillation. This
approval significantly expands atrial fibrillation treatment options for long-
standing persistent patients. The advantages of this therapy it has a minimally
invasive pericardioscospic epicardial ablation and Endocardial radiofrequency
(RF) catheter ablation. The Epicardial ablation aims to create durable and
contiguous lesions while reducing risk of injury to the adjacent structures of the
heart. It uses RF energy that applied to the posterior left atrial wall, distal from
the esophagus. On the other hand, Endocardial RF ablation it employs mapping
and ablation to target the regions requiring additional treatment, as well as
those areas impeded by pericardial reflections during the epicardial procedure.
Pulmonary vein isolation (PVI) completes the lesion set. People undergoing
Hybrid AF report feeling better, both physically and emotionally and the
procedure is safe and effective.
2. FDA Approves Treprostinil for Pulmonary Hypertension Linked to
Interstitial Lung Disease
April 1, 2021; Kevin Kunzmann
The supplemental for Tresprostinil (Tyvaso) Inhalation Solution has
been approved by the US Food and Drug Administration (FDA) for the
treatment of patients with pulmonary hypertension associated with interstitial
73
lung disease (PH-ILD) to help improve exercise ability. This indication is the
second granted by the FDA for the United Therapeutics drug, following its
approved as a pulmonary arterial hypertension (PAH) therapy in July 2009.
Investigators reported outcomes including significant improvement of PH-ILD
in adult patient in a six minute walk distance when treated with Treprostinil as
well as improvements among patients with differing PH-ILD etiology, disease,
age, gender, baseline hemodynamics, and dose differences for treatment. A
Treprostinil dose is of 12 breaths per session, 4 times daily, was well tolerated
and associated with a safety profile consistent in previous trials. According to
Rothblatt M, PhD, the FDA approval of Tyvaso for patients with pulmonary
hypertension associated with ILD is landmark treatment advancement for this
vulnerable patient population.
74
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archive/cardiac-system-1-anatomy-and-physiology-29-01-2018/
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to Interstitial Lung Disease Retrieved from https://www.hcplive.com/view/fda-
approves-treprostinil-pulmonary-hypertension-interstitial-lung-disease
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. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493174/
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RUBRIC ON ORAL CASE PRESENTATION
ACTIVITY: Oral Case Presentation
TASK: Students work cooperatively and present the case clearly understood
GOAL: At the end of the oral case presentation the learner are expected to:
1. demonstrate good communication skills throughout the case presentation.
2. enhance their knowledge and have an in-depth understanding on the disease process and its causes.
Type of Assessment: ( ) Self ( ) Peer ( ) Group ( ) Teacher

Criteria Expert Proficient Developing Novice Total
4 3 2 1 Points
Content
• Thoroughly explains and All elements are Two of the Only one of the None of the ___x4___
covers in depth all points. evidently elements are element is elements is
• Presents clear, concise included evidently evidently evidently
and relevant relationship included included included
to the case
• Clearly presented
material and traces the
diagram of the
pathophysiology of the
disease
• Completeness of the data
Mastery
• Discusses the relevant All indicators 2 indicators are Only 1 indicator No indicator is ___x4___
topics accurately and are manifested manifested is manifested manifested
comprehensively
Delivery / Vocal Projection

• Uses correct grammar All measures Two of the Only one of the
and English in the entire are evidently measures are measures is None of the ___x4___
presentation. presented evidently evidently measures is
• Exhibits no haling and presented presented evidently
repetition of words (ah, presented
uh, um)
• Exhibits a well-modulated
voice
• Uses correct
terminologies
• Shows confidence
• Receptive to criticism
Visual Aid All of the Two of the Only one of the none of the
• Uses clear and attractive features are features are features are features are ___x4___
materials clearly clearly clearly clearly
• Presents readable fonts, perceptible perceptible perceptible perceptible
symbols/words
Attitude
• Manifest punctuality in All 4 indicators 3 indicators are 2 indicators are 0-1 indicator is ___x4___
submitting the output as a are demonstrated demonstrated demonstrated
group demonstrated
• Well groomed
• Shows confidence
• Receptive to criticism
Total Score: _______
No. of Items: 80
Remarks/Recommendations:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
RUBRIC ON NURSING CARE PLAN (NCP) MAKING
NAME: _______________________________________________________ Period: _____________________________
Year Level: ______________________ Date: ______________________________
Criteria Poor Good Very Good Excellent Score

1 2 3 4
1. Cues & Evidences ● Not related to topic ● Somewhat related to ● Related to topic, with ● Clearly related to topic,
topic but feels some development, but well-developed and
incomplete. could be more specific. nicely detailed ______ x 4= ______
2. Nursing Diagnosis and ● Not related to topic ● Somewhat related to ● Related to topic, with ● Clearly related to topic,
Related Factors topic but feels some development, but well-developed and ______ x 4= ______
incomplete. could be more specific. nicely detailed
● Not related to the ● Somewhat related to ● Related to topic, with ● Clearly related to topic,
3. Nursing Objectives identified Nursing identified Nursing some development, but well-developed and
Problem / Diagnosis Problem / Diagnosis could be more specific nicely detailed
to the identified ● Able to follow the ______ x 4= ______
Nursing Problem / “SMART”
Diagnosis.
● Able to follow the
“SMART”
● Nursing Interventions is ● Nursing Interventions ● Related to topic, with ● Clearly related to topic,
4. Nursing Interventions NOT related to the are SOMEWHAT some development, but well-developed and
& Rationale identified Nursing related to identified could be more specific nicely detailed
Problem / Diagnosis Nursing Problem / to the identified ● Able to provide nursing ______ x 4= ______
Diagnosis Nursing Problem / interventions
● Nursing Interventions is Diagnosis. appropriate to the
not specific to the ● Some Nursing identified nursing
identified nursing Interventions is not needs.
needs. specific / appropriate
to the identified
nursing needs.
5. Nursing Evaluations ● Goal unmet ● Goal Partially met ● Goal Partially Met ● Goal Met
● Unable to evaluate the ● Able to evaluate the ● Able to evaluate the ● Able to evaluate the
effectiveness of the effectiveness of the effectiveness of the effectiveness of the ______ x 4= ______
given nursing given interventions but given interventions but given interventions
interventions. not specific to the needs re-evaluation clearly related to topic,
identified nursing well-developed and
needs. nicely detailed
● Not related to topic, ● Somewhat related to ● Related to topic, with ● Clearly related to topic,
6. Content very simple and topic, but feels some development, but well-developed and
undeveloped incomplete or overly could be more specific nicely detailed ______ x 4= ______
general or more fully developed
● Does not follow ● Some limited ● Good expression of ● Clear and effective
7. Organization organizational organization, but needs main idea, supporting organization; follows
guidelines; feels to be structured more ideas; with some guidelines carefully ______ x 4= ______
haphazard fully inconsistencies which
may distract
● Numerous errors in ● Frequent errors in ● Occasional errors in ● Only few minor errors
8. Mechanics spelling, capitalization, spelling, capitalization spelling, capitalization in spelling,
punctuation make this and punctuation but and punctuation which capitalization and ______ x 4= ______
difficult to understand. not difficult to are noticeable but do punctuation
understand not inhibit
understanding
Raw score
Total Score 128
dcpadernilla_rn2020
Final Grade: __________
_____________________________________________
Name & Signature of the Supervising Clinical Instructor:

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UNIVERSITY OF MINDANAO

COLLEGE OF HEALTH SCIENCES EDUCATION

CONGESTIVE HEART FAILURE DUE TO

November 23, 2021

III Description of the Disease/Illness 1

VI. Patient’s Profile 5

VII. Anatomy and Physiology of the Affected Body Parts 6

VIII. Pathophysiology of the Disease 16

XIV Client’s Health Education 71

Evidenced-based Research Findings related to the

Description of the Disease/Illness

Heart failure (HF) is a clinical syndrome resulting from structural or functional

many patients experience pulmonary or peripheral congestion with edema. Currently,

Heart failure is recognized as a clinical syndrome characterized by signs and

symptoms of fluid overload or inadequate tissue perfusion. Fluid overload and

indicates myocardial disease in which impaired contraction of the heart (systolic

dysfunction) or filling of the heart (diastolic dysfunction) may cause pulmonary or

with lifestyle changes and medications to prevent episodes of acute decompensated

progressive, meaning it gradually gets worse.

Hypertension remains a significant risk factor for development of congestive

and symptoms of heart failure includes shortness of breath or trouble breathing,

difficulty concentrating, fainting, and rapid or irregular heartbeats (palpitations). These

to do so can eventually lead to death.

1. Atrial Fibrillation- is a heart condition that causes an irregular and often

abnormally fast heart rate.

blood as efficiently as it should.

3. Cyanotic- refers to abnormal blue discoloration of the skin due to lack of

oxygen in the blood.

lungs (shortness of breath).

5. Edema- is a swelling that is caused by fluid build or trapped in the body.

6. Hypertension- a condition of persistent elevation of blood pressure.

7. Non-compliant- when a client refuses to comply or follow medical regimen.

Predisposing Factors Precipitating Factors

• Age: 55 years old • Non-compliant to medication

prevalence of hypertension was found to be high in older adults. Hypertension was

history of hypertension. Individuals whose parents have hypertension have an

hypertension is remain untreated it could eventually lead to further complications and

to congestive heart failure.

Name (Initial/Alias) : Ms. L.P

Age : 55 years old

Birth Date : October 7, 1966

Occupation : Fish Vendor

Civil Status : Not Indicated

Address : Barangay 23-C, Davao City

Chief Complaint : Exertional Dyspnea associated with palpitation and headache,

flushing, chest pain.

Admitting Diagnosis : Not Indicated

Final Diagnosis : Congestive Heart Failure due to Untreated Hypertension with

Past Medical History

is hypertensive, non-asthmatic, non-diabetic and has no known allergy to food or drug.

Family Medical History

Anatomy and Physiology

The cardiovascular system can be thought of as the transport system of the

The heart, a muscular pump made up of cardiac muscle fibers, could be

throughout the body within the blood vessels.

Chambers of the Heart

blood to the whole body.

the right atrium.

Blood Vessel Structure and Function

water, and hormones throughout the body.

heart. The junctions between vessels are called anastomoses.

capillaries are composed of a single layer.