A case study of…

Acute Decompensated Heart Failure with Reduced Ejection Fraction

I. LEARNING OBJECTIVES

A. General Objectives: With the help of this case study, the student nurses will have a better
grasp of the patient’s general health and condition elicit discussion regarding the nature of
origin of the study as well as the patient’s treatment plan, the medical and nursing
intervention that are/were used to treat the patient who had been diagnosed with ADHF.

B. Speci c Objectives:

(1) To gather demographic data about the patient

(2) To be well-informed on the patient’s health history including the past and current
hospitalization

(3) Describe the di erent types of heart failure.

(4) To discuss anatomy and physiology of the related disease

(5) Enumerate the di erent drugs given to the patient

(6) TO establish essential nursing care plan to re implemented for the patient wellness and
recovery.

(7) To learn new clinical skills well as sharpen our current clinical skills require in the
management if the patient with ADHF.

II. INTRODUCTION 

Acute Decompensated Heart Failure is characterized  by the abrupt or gradual emergence of

heart failure. With signs & symptoms that requires unplanned hospitalization or emergency
room visits. ADHF is a sudden and life-threatening condition, it occurs in people with a history
of heart disease. 

III. PATIENT’S PROFILE

Name: AQ Nationality: Filipino Room No.: S.R.1
Age: 55 years old Religion: Roman Catholic Sex: Female
Birthday: July 05, 1967 Educational Attainment: High Date & Time of Admission:
School Graduate May 15, 2023 ; 1:30 AM
 

IV. PATIENT'S HISTORY 

• CHIEF COMPLAINT:  

Patient AQ was referred from Ospital ng Lungsod ng San Jose Del Monte to Kairos Hospital
with a chief complaint of hypotension. According to her family, Patient AQ experienced a high
temperature (hyperthermia) and a di culty of breathing (dyspnea). 

• HISTORY of PRESENT ILLNESS:  

Patient AQ was diagnosed with Acute Decompensated Heart Failure w/ reduced ejection
fraction upon admission on May 15, 2023.  

• PAST MEDICAL HISTORY:  

Patient AQ was recently admitted to Ospital ng Lungsod ng San Jose Del Monte on May 11,
2023 because of hypotension. She was then transferred to Kairos on May 15, 2023 because of
the ICU Setup. 

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V. COURSE IN THE WARD

▪︎ May 15, 2023. Patient AQ was admitted under the service of Dr. Elfa at 1:30 AM. Consent
was needed to secure for admission and management. IVF heplock ordered with an NPO diet
upon admission. With in need lab tests of CBC-PC, Na, K, RAT, 12L ECG, and for repeat Plain
Cranial CT-Scan. Following treatments given are; Dobutamine drip D5W 250 cc + 2 amps
titrate by 3cc/hr to maintain BP > or equal 90/60. Furosemide 40mg TIV now. Digoxin 0.25mg
TIV now. Enoxaparin 0.4cc SQ OD. Ivabradine 5mg/tab OD. Omeprazole 40mg TIV now then
OD. Atorvastatin 40mg/tab ODHS. Aspirin 80mg/tab OD lunch. ECG was repeated. Ordered for
IFC insertion. Cardiac monitor was ordered to be hooked. 5-6 LPM via ML of O2 support
should be maintained. Baseline VS upon admission was recorded with a BP of (110/70mmhg),
T (37.1), PR (160), RR (22), and Wt ( 48 kg). VS monitored Q1 and I & O qshift strictly.  

▪︎ 8:00 AM. VS recorded; BP (130/100), T (34.7), PR (108), RR (21), & SPO2 (99%) 

▪︎ 9:00 AM. VS recorded; BP (133/98), T (34.7), PR (110), RR (23), SPO2  (99%), & UO (600 ML) 

▪︎ 10:00 AM. VS recorded; BP (143/90), T (34.8), PR (97), RR (22), SPO2 (99%), & UO (50ML) 

▪︎ 11:00 AM. VS recorded; T (34.2), PR (119), RR (20), SPO2 (99%), & UO (56 ML) 

▪︎ 12:00 PM. VS recorded; BP (150/80), T (35), PR (122), RR (21), SPO2 (99%), & UO (72 ML) 

▪︎ 1:00 PM. VS recorded; BP (140/90), T (35), PR (124), RR (22), SPO2 (99%), & UO (73 ML) 

▪︎ 2:00 PM. VS recorded; BP (142/100), T (35.8), PR (60 manual, 124 monitor), RR (22), SPO2
(99%), & UO (42ML) 

▪︎ 3:00 PM. VS recorded; BP (131/75), T (34.1), PR (66 manual, 124 monitor), RR (22), SPO2
(99%) 

VI. PHYSICAL ASSESSMENTS AND REVIEW OF SYSTEMS

A. Head and Neck 


Head and Neck
Inspections::

“Wala naman hindi naman sumasakit ang ulo ko.” - Normal Head size

- No sessions and/or swelling around the neck

Eyes
Inspections:

- (+) PERRLA

“Nagsasalamin ako pa minsan-minsan.” - Symmetrical Blinking

- 250 eye grade

Nose and Sinuses
Inspections:

“Parang mas tumalas nga ang pang=amoy ko - Nose is symmetrical with no discoloration,
ngayon.” swelling, presence of obstructions, or bleeding

- Client was able to identify odors (Student

Nurses perfume)

Ears
Inspection:

“Mayos pa naman ang pandinig ko.” - Ear lobes are bean-shaped, parallel and
symmetrical.

- No discharges
Face Inspections:

- There are no presence of lesions or lumps

 Mouth and Throat
Inspections:

“Wala naman, ayun lang nasusuka ko yung mga - Dry lips without lesion or swelling.
nakakain ko nung nakaraan, medyo masakit sa
lalamunan.”

Level of Consciousness Inspections:

- The client is alert and responsive

Extremities
Inspections:

“Wala naman sumasakit sa mga parte ng datawan - Swelling on the parts where the IV was inserted.

ko ito (kamay) medio namamaga lang dahil sa - Tehere are bruises on her feet and forearms due
swero.” to needle trauma.

Urinary
Inspection:

“Mahapdi pag umiihi, sumasakit, hindi rin maka-ihi - Slight pain due to the catheter.
nang mấy pag pinipilit.

Cardiovascular Inspections:

V.S BP T PR RR

Baseline: 110/70 37.1 160 22

Last taken: 125/90 36 56 20

Diagnostic Procedure Done:

RBC - ^ 6.21

Hemoglobin - > 122

Hematocrit - > 0.40

WBC - > 8.03

Na - 141.8

K - > 5.25

Ionized Calcium - > 1.27

Capillary Re ll Test:

Color - Pink-whitish

Time - Returned within 1 second

VII. GORDON’S FUNCTIONAL HEALTH PATTERN

Functional Health Pattern Prior to Admission During Hospitalization

Health Perception/Health Patient AQ visits the doctor for Patient AQ observes and
Management a check up every two weeks or complies with the doctor’s
every month depending on the orders regarding her
doctor’s recommendation. medications, food & uid
consumption, and position of
comfort during her
hospitalization.
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 Nutritional - Metabolic Pattern Prior to admission, Patient AQ
emphasized that she
consumes fruits and
vegetables when they are
available, but not frequently.
She also eats sh and mostly
meat because her children
prefer it.
Elimination Pattern Patient AQ used to urinate
frequently as a result of her
medications. She also stated
that she defecates every other
day.
Activity - Exercise Pattern Patient AQ pointed out that
she does her duties/tasks in
their household but it got
limited when she started
taking her medications.
Cognitive - Perceptual Pattern Patient AQ is a high school
graduate-- she can speak,
write, read and understand
without any problem.
Sleep - Rest Pattern Patient AQ does not get an
adequate sleep because she
takes care of her children. She
said that her sleep often gets
interrupted.
Self-Perception/ Self Concept The patient did not specify any
Pattern information towards her past
perception about herself.
Although she cleared that she
is doing good even before.
Role - Relationship Patient AQ lives with her
husband, children, and
grandchildren. They have 11
members in their household.
She is a mother of 7 children
and she takes care of them.
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The doctor ordered her NPO
upon admission. She was
allowed to eat  again after
another doctor’s visit, but she
still feels queasy and
nauseated because of her
oxygen. Following
observation,  AQ’s feeding
pattern improved and she
began to take her meals
without dif culty.
A Foley catheter was inserted
as per Doctor’s order. During
our hourly monitoring, AQ’s
urine output is mostly above
50 mL and light yellow in color.
She has mentioned that she
already had her bowel
movement.
Patient AQ does not have nor
perform any activity during
hospitalization. The doctor did
not give any information about
her activities and exercises.
Patient AQ does not have any
problem with her cognitive
abilities. She is conscious and
understands the questions that
are asked to her.
During hospitalization, Patient
AQ cannot sleep properly
because of the hourly visits of
the nurses/doctors to monitor
her condition. She only has
short periods of sleep.
Patient AQ mentioned that she
feels alright and does not have
any negative emotions about
herself.
During hospitalization, her
husband and her youngest
daughter are the ones that
look after her. Some of her
children visit her, but they are
only permitted to stay
downstairs and is not allowed
to enter her room.
Sexuality - Reproductive
Pattern
Coping/Stress Tolerance
Value - Belief Pattern
According to Patient AQ, she
is already in the menopausal
stage and it started when she
was 50 years old. AQ’s rst
menstruation was around 14
years old.
Before hospitalization, Patient
AQ likes to go outside of her
house and visit her neighbors
to communicate and bond.
Patient AQ’s religion is Roman
Catholic, according to her, she
visits the church whenever she
can.
Patient AQ did not mention
any sexual or reproductive
pattern during her
hospitalization.
During hospitalization, Patient
AQ only sleeps and does not
do any other leisure activities.
The interventions and her
hospitalization does not
interfere or affect with her
religious beliefs and practices .

VIII.ANATOMY AND PHYSIOLOGY

• The heart is a hollow, bromuscular organ, pyramid-shaped with a size of a st that is

located slightly on the left side of the chest protected by the ribcage.

• Enclosed in the pericardium, occupies the middle mediastinum between the lungs

and their pleural coverings.

• Weight: Female: 230g - 280g Male: 280g - 340g

• Layers:

Pericardium: outermost

Myocardium: middle

Endocardium: innermost

PURPOSE OF THE HEART

• It is the primary organ of the circulatory system as it controls the heart rate’s rhythm

and speed and maintains blood pressure by pumping blood from the veins and to the

ventricle.

• Normal HR (adults): 60-100bpm

• Normal BP (adults): 120/80mmHg

CHAMBERS OF THE HEART

1. Right Atrium - Two large veins deliver oxygen-poor blood to the right atrium. The

superior vena cava carries blood from the upper body. The inferior vena cava brings blood

from the lower body. Then the right atrium pumps the blood to the right ventricle.

2. Right Ventricle - The lower right chamber pumps oxygen-poor blood to the lungs

through the pulmonary artery. The lungs reload blood with oxygen.

3. Left Atrium - After the lungs ll the blood with oxygen, the pulmonary veins carry the

blood to the left atrium. This upper chamber pumps the blood to the left ventricle.

4. Left Ventricle - The left ventricle is slightly larger than the right. It pumps oxygen-rich

blood to the rest of the body.

VALVES OF THE HEART

• TRICUSPID: Door between the right atrium and right ventricle.

• MITRAL: Door between the left atrium and left ventricle.

• PULMONARY: Opens when blood ows from the right ventricle to the pulmonary

arteries (the only arteries that carry oxygen poor blood to the lungs).

• AORTIC: Opens when blood ows out of the left ventricle to the aorta (the artery that

carries oxygen-rich blood to the body).

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 BLOOD VESSELS

• Arteries: carry oxygen-rich blood from the heart to the body’s tissues. The exception

is the pulmonary arteries, which go to the lungs.

• Veins: carry oxygen-poor blood back to the heart.

• Capillaries: are small blood vessels where the body exchanges oxygen-rich and

oxygen-poor blood.

• Left coronary artery: Divides into two branches (the circum ex artery and the left

anterior descending artery).

• Circum ex artery: Supplies blood to the left atrium and the side and back of the left

ventricle.

• Left anterior descending artery (LAD): Supplies blood to the front and bottom of the

left ventricle and the front of the septum.

• Right coronary artery (RCA): Supplies blood to the right atrium, right ventricle, bottom

portion of the left ventricle and back of the septum.

CARDIAC BLOOD FLOW

1. Vena Cava

2. Right Atrium

3. Tricuspid Valve

4. Right Ventricle

5. Pulmonic Valve

6. Pulmonary Trunk

7. Pulmonary Artery

8. Pulmonary Veins

9. Left Atrium

10. Mitral Valve

11. Left Ventricle

12. Aortic Valve

13. Aorta

IX. PATHOPHYSIOLOGY

Acute decompensated heart failure with reduced ejection fraction (ADHF-REF) is a

serious medical condition characterized by the sudden worsening of symptoms in

individuals with pre-existing heart failure and a reduced ejection fraction. Ejection fraction

refers to the percentage of blood pumped out of the heart's left ventricle with each

heartbeat.

In heart failure with reduced ejection fraction (HFrEF), the heart muscle is weakened and

fails to e ectively pump blood throughout the body. ADHF-REF speci cally refers to the

acute exacerbation of these symptoms, leading to a rapid onset or worsening of heart

failure.

Common causes of ADHF-REF include uncontrolled hypertension (high blood pressure),

heart attacks, arrhythmias (irregular heart rhythms), infections, and non-compliance with

medications or dietary restrictions. In some cases, the exact trigger may not be

immediately identi able.

The hallmark symptoms of ADHF-REF include:

1. Shortness of breath (dyspnea): Di culty breathing, especially during physical activity or

when lying down.

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2. Fluid retention: Swelling of the ankles, legs, or abdomen due to uid accumulation.

3. Fatigue and weakness: Feeling tired and lacking energy.

4. Rapid or irregular heartbeat (palpitations).

ACUTE DECOMPENSATED HEART FAILURE

REDUCTION OF EJECTION FRACTION

PUMPING ABILITY IS LESS THAN NORMAL

LEADS TO SWELLING OR SCAR TISSUE BUILDUP THAT AFFECTS THE VENTRICAL ABILITY TO
FILL AND PUMP

CARDIAC DYSRHYTHMIA
ATRIAL FIBRILATION

SOB

WEAKNESS.FATIGUE

XII. NURSING CARE PLAN

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 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Acute pain Short Term:

Independent:
- this will give a Short Term:

Data: related to - The patient - Determine better idea of - The patient

abdominal expected to be how the patient how can we was able to
“Sumasakit pain as able to discuss usually implement discuss the
ang tiyan ko evidenced by the pain she responds to ways to reduce pain she felt.

pag kumakain”
patient's self felt.
pain.
pain and the - The patient's
- As verbalized report of pain - The patient's psychological stomach / GI
by the patient
and a pain stomach / GI - assess verbal e ects of pain complaint of
scale of 6/10. complaint of complaints of to the patient.
pain had been
Objective pain will be pain alleviated by
Data: alleviated by the medication
BP: 130/100
the medication given.

PR: 108
to be given.

RR: 21

SPO2: 99%

TEMP: 34.7 °C

Urine Output:
600ml

abdominal pain
scale: 6/10

Long Term:
implement - Verbal Long Term:

- The patient's measures to complaints will - The patient's

pain will be reduce pain:
give speci c pain has been
lessened. a. perform location, lessen. The
Patient will be actions to severity and Patient was
able to display restore uid type of pain.
able to display
improved body balance
- In order to improved body
malaise and b.change reduce malaise and
should be able the position
peritoneal uid was able to
to know the c.divertional accumulation.
know the
cause of the activities to - Makes the cause of the
pain, through signi cant patient more pain, through
examinations. others.
comfortable.
examinations
- Divert the
Dependent:
attention of the
- provide or patient to the
assist in giving conversation.
therapeutic
medication as
ordered by the
doctor
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 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Activity Short term:

Independent:
- This Short Term:

Data:
Intolerance - The patient - Assess ability information - The patient
"nahihirapan related to will be able to and tolerance provides a was able to
akong immobility as achieve an to engage in baseline for increased
gumalaw" as evidenced by increased activities.
planning care.
conditioned of
verbalized by the patient is condition - Assess usual - This may physical state.

the patient.
on bedrest. physical state.
daily activities suggest extent - The patient
- The patient of patient vs. of immobility/ demonstrated
Objective will tolerated mobility as an increase in
Data:
demonstrate activities a ected by the activity level as
BP: 140/90
an increase in during weakness will manifested by
PR: 124
activity level as complain of also serve as gradual
RR: 22
manifested by patient
data where tolerance to
SPO2: 99%
gradual interventions active range of
TEMP: 35 °C
tolerance to will be based.
motion.
Urine Output: active range of - Gradual
42ml
motion.
progression of
the activity
prevents
overexertion.

Long term:
- Encourage - Prolonged Long Term:

- The patient gradual immobility may - The patient

will be able to increase of lead to the was be able to
increase and activity as development increased and
achieve patient of pressure achieved
desired activity condition ulcers.
desired activity
level, improves.
- Maintains level,
progressively, - Monitor skin muscle progressively,
with no integrity strength, with no
intolerance several times exibility and intolerance
symptoms per day
joint and symptoms
noted. - Provide range tendon noted.
of motion alignment.
actions (active, Over time,
passive or repeated
assistive) per exercises help
prescribed increase
limitations.
intolerance.

- Gives
assistance to
patient when
moving
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 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Excess uid Short Term:

Independent:
- Tachycardia Short Term:

Data:
volume - The - Monitor vital and - The patients
“Namamaga related to patient's vital signs
hypertension vital signs
yung kamay compromised signs will be - Auscultate are common was in normal
ko pati regulatory in normal lungs and manifestation.
range.

masakit tiyan mechanism range.

heart sound
- Adventitious
ko” - as as evidenced - Assess for sounds Long Term:

verbalized by by swelling Long Term:

presence/ (crackles) and - The patient
the patient
and - The patient location of extra heart was able to
abdominal will be able to edema
sound are stabilize uid
Objective pain
stabilize uid - Note for indicative of volume as
Data:
volume as presence of uid excess.
evidenced by:

BP: 125/90
evidenced by:
neck and - Edema can
PR: 56
peripheral be either a a.balanced
RR: 20
a. balance vein cause or a intake and
SPO2: 97%
intake and distention
result of output

TEMP: 35.4 output

- Maintain various b.drain at
°C
b.drain at accurate I pathologic.
least
Urine Output: least and O. Note - Signs of 500-600mL of
42mL 500-600mL of decreased cardiac urine and
urine and urinary decompensat foley catheter
foley catheter output.
ion.

- Maintain - Signs of
accurate I cardiac
and O. Note decompensat
decreased ion.

urinary - Decreased
output.
renal
- Maintain perfusion,
infusion rate cardiac
or parenteral insu ciency
uids closely, and uid
administer via shifts may
control cause
device/ decreased
infusion urinary output
pump as and edema
necessary. formation.

- Sudden uid
bolus/
prolonged
excessive
administratio
n potentiates
volume
overload or
risk of cardiac
decompensat
ion.
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XIII. RECOMMENDATION/DISCHARGE PLANNING

I. Recommendations for patients who are still con ned/ admitted in the hospital.

Cardiac Diet (It's an eating plan that emphasizes foods that promote heart health, such as
vegetables and fruits, whole grains, lean poultry and oily sh like salmon and tuna that are high
in omega-3 fatty acids.) and Fluid restriction diet (2L/day).

Monitor what they’re having for breakfast for lunch and dinner. Make sure they’re not cheating
on that diet; otherwise, we will just be reintroducing the additional uid that we are removing.

Keep the legs elevated

Assess Edema in the legs that goes back to the patient’s responsiveness helping keep those
legs elevated whenever they’re in bed will help promote returning that extra uid back into the
vascular system, being excreted through the kidneys.

High Fowlers Position

Sitting upright helps the lungs expand and reduces dyspnea, which aids in respiratory health.

Discharge planning for patients that were already discharged from the hospital.

Medications:

- Consumption of medicine as directed on a regular basis to alleviate symptoms, rectify acute

hemodynamic abnormalities, and initiate a treatment that will prevent the disease's
development and increase long-term survival.

• Exercise:

Exercises that will bene t the Cardiovascular;

- Walking (outside or on a treadmill) - Stationary cycling


- Swimming

- Rowing

- Water Aerobics - Elliptical


- Aerobics

( Do this at least 3 to 4 times a week. Always do 5 minutes of stretching or moving around to

warm up the muscles and heart before exercising. Stop activity if you develop symptoms such
as chest pain, lightheadedness, or signi cant shortness of breath, And ask your doctor before
lifting weights.)

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 • Treatment:

• -  Maintain the present medication regimen/maintenance

• -  Minimize the exposure to environmental hazard such as Air pollution, Arsenic, Lead,
and Excessive heat.

• -  Consume Non-Fatty foods to prevent High Blood Pressure

• -  Have enough rest and sleep at least 7 to 9 hours each night.

• Health Teaching:

- Maintain a healthy lifestyle by working out for at least 3 to 4 weeks, giving up any vices you
may have, Continue the consumption of prescribed medication, and avoiding meals that are
oily, salty, and fatty since they put you at risk. Choose low-sodium alternatives instead, such
fresh meats, poultry, sh, dried and fresh beans, eggs, milk, and yogurt. Oatmeal, spaghetti,
and plain rice are all great low-sodium options. Additionally, You will need to learn to monitor
on changes in your heart rate, pulse, blood pressure, and weight. Any concerning changes
require a visit to the doctor.

• Outpatient or Observation:

- A doctor follow-up appointment every three months or once every six months.

- If you experience fatigue and weakness, heart palpitations, mental disorientation, or a rapid,
strong, or irregular heartbeat, call your doctor right away.

- If you have any concerns or questions regarding your present condition, consult to your
doctor.

• Diet:

• -  Consider salt-free meals like yogurt, dried and fresh beans, eggs, milk, fresh meats,
poultry, and sh. Oatmeal, pasta, and plain rice are all great low-sodium options.
However, if salt or other high-sodium components are added as they are being prepared,
the sodium level may rise.

• -  Simple carbohydrates and processed meals, as well as those heavy in salt, saturated
fat, and cholesterol, should be avoided. To better maintain optimal heart health, also
restrict the intake of alcohol and ca eine.

• Support:

- Promote self-esteem and con dence to manage new situations.


- The client's family members encourage any e ective coping skills they might observe.

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