Grand Case Presentation 10-30-10

8/6/2019 Grand Case Presentation 10-30-10

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Grand Case Presentation


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Congestive Heart Failure


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Members: Mr. John Verni G. Bangeles

M

r. Joel Ian D. Espenilla Ms. Carmina Lumio

Ms. Geraldine Suzet S. Ramirez

Ms. Cara Louise Garcia


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Contents: Introduction

Objectives

Health History

Definition of Complete Medical Diagnosis

Anatomy and Physiology and Pathophysiology

Laboratory and Diagnostic Results

Course in the Ward

Nursing care Plan

Drug Study

Evaluation and Prognosis

Discharge Plan


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Introduction


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Last July 25,2010 a group of 11 students headed by

their Clinical Instructor were assigned to have their dutyor R.L.E (Related Learning Experience) at Dr. Jose P.

Rizal Memorial Hospital at Calamba, Laguna to gain

more knowledge, skills and experience which will guide

and expose them in the real setting of their chosen field

Health Care.

The group was then divided into two for their case

study to be presented at the end of the semester.

On the first day, our group decided to choose our

target client for the said case study. So, each membergot the diagnosis and data of the patients that were

assigned to them by the Clinical Instructor. Finally, the

group chose Mr. Bangeless patient, Mr. C.D.


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Upon admission, patient C.D. complained of

difficulty breathing and bipedal edema. He was then

diagnosed with Congestive Heart Failure /Diffuse ToxicGoiter/Liver Cirrhosis/Moderate Risk Community

Acquired Pneumonia. The group chose this case

because his diagnoses were very interesting to study

since his diagnoses were not the type that one could

commonly encounter. Also, the diseases mentionedwere much connected with each other. Secondly, the

chosen client and his relatives are very approachable

and cooperative. In connection with this, the patient will

be staying for more than a week so the group will beable to conduct a more comprehensive assessment and

render specific interventions. Lastly, since the concept

that they are studying is about cardiovascular,

respiratory, hepatic, endocrine and metabolic disorders,

they could apply all that they have learned.


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Congestive Heart Failure is a disease which the

heart failed to pump and deliver sufficient blood supply to

the entire body. It may have developed due to valve

dysfunction, hyperthyroidism, hypertension andalcoholism. If left untreated, it can cause several

complications such as pulmonary edema, ascites, and

liver cirrhosis. But with proper treatment and

interventions, the progression of this disease and its

severity will be avoided. Good prognosis for the clientwill be achieved.


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Objectives


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General Objectives:

At the end of this study and presentation, students

are expected to gain more knowledge and new ideas or

information regarding Congestive Heart Failure and itsrelated diseases, Diffuse Toxic Goiter and Liver

Cirrhosis. These will aide the nursing students to be

familiarized with the disease process and the specific

nursing actions and interventions to be rendered if ever

they will encounter these diseases.


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Specific Objectives:

Student Centered

The students will be able to:

Understand the nature of the Congestive Heart Failure.

Recognize the different predisposing and precipitating

factors of Congestive Heart Failure.

Identify and get familiarized with the clinical manifestationsof Congestive Heart Failure.

Outline the anatomy and physiology of the cardiovascular

system.

Illustrate the pathophysiology of the disease.Relate Diffuse Toxic Goiter and Valve Dysfunction to the

disease as the major predisposing factors.

Relate Liver Cirrhosis to the disease as one of the major

complications present to the patient.


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Determine the health status of the patient through:

Knowing the present, past, and family health history of thepatient. It includes the Family Genogram of the patient.

Conducting Physical Examination.

Analyzing the past and present laboratory results of the patient

and correlate it to the condition of the patient.

Determine the appropriate nursing care that should be given tothe patient.

Determine the different drugs that the client is taking and know

its actions and benefits to the client. Also included are the

possible adverse reactions of those drugs.

Create good Nurse Patient Interaction. Teach the relatives of the client on the management of the

disease and how to prevent the complications.


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Client- Centered

To educate the client about the possible development of

the disease complication.

To educate the client about the disease and neededtreatment.

To encourage the client to follow prescribed medical

regimen regarding his health status.


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Health History


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GENERAL HEALTH HISTORY:

The client assigned was Mr. C. D. a patient

admitted to JPRMH (Jose P. Rizal Memorial Hospital. Hewas assessed and interviewed regarding his Health

History on July 19, 2010 and the following data was

gathered:


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I. PATIENTS DATA

Patient's Name:

Mr. C.D.

Hospital Case No.:

1119810

Address:

Bantayan, Brgy. 2, Poblacion,

Calamba, Laguna

Birth Date: July 28, 1950

Place of Birth:

Calamba city, Laguna

Age:

59 years oldInsurance:

None

Sex:

Male

Date & Time Admitted: July 19, 2010 11:20PM

Ward/Room No./Bed No.:

Medical Ward Bed 3

Nationality:

Filipino

Inclusive Date of Confinement:

July 19 Aug. 1, 2010

Civil Status:

Married

Discharge Date & Time:

August 1, 2010; 3:25 PM

Religion:

Iglesia in Cristo

Attending Physician: Dr. A. G. B.

Occupation:

none

Educational Background:

High School graduate


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Payment Source for Discharges:

Self/Family:

Family members

Name of Spouse (if married):

Mrs. B. D.

Age:

55 yrs old

Occupation:

Teacher

Educational Attainment:

College Grad. (Education)

Admitted per: Stretcher:

Level of Consciousness upon Admission

Drowsy

Disoriented

Responds to pain


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Chief Complaint/s: (+) DOB

(+) bipedal edema

Impression/ Admitting Diagnosis: to consider Diffuse

Toxic Goiter/ Congestive Heart Failure Stage 4/

Community Acquired Pneumonia Moderate risk

Final Diagnosis: Diffuse Toxic Goiter/ Congestive Heart

Failure Stage 4/ Community Acquired Pneumonia/

Chronic Liver Disease


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II. PRESENT HEALTH HISTORY

Two weeks prior to admission, the patient noticed edema

forming on his both legs.

One week prior to admission, the patient experienced mild

difficulty of breathing that last for 5 to 10 minutes after walking. Also,

he noticed his edema having bluish discoloration.

Four days prior to admission, the patient was still experiencing

mild difficulty of breathing and bipedal edema.

Two days prior to admission, the patient developed cough and

colds.

One day prior to admission, the patient had fever.

An hour prior to admission, Mr. C. D. experienced severe

difficulty of breathing while watching TV.

Upon assessment on the first day, the patient verbalized

severe difficulty of breathing.


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III. PAST HEALTH HISTORY

Patient has no history of childhood illnesses and

accidents/injuries. He has no known allergies to any food

or drug. Also, he doesnt have any immunizations.

Last February 2005, the patient was admitted at J. P. Rizal

Memorial Hospital because of Hypertension. He took

Captopril, Propanolol, and Furosemide as prescribed by

his physician. He was able to comply with his medical

regimen for about a month only because of financial

constraints.


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IV. FAMILY HEALTH HISTORY

Mr. C. D.s father, Mr. M. D., had history of

hypertension and died of lung cancer. His mother, Mrs.

L. D. had history of diabetes and died because of

cardiovascular disease. Four of his siblings includinghim, has hypertension: H. M., L. T., B. L. and M. D.. H.

M., the eldest has asthma. L. T. also has lung cancer.

Like patient C. D. , his sister S. D. also has goiter. T. D.

has also diabetes. Her wife, B. D., also has

hypertension. Two of his children also have some illness.The eldest, A. D., suffers from asthma, while T.S. suffers

from cardiovascular disease.


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M. D

65 y/o

L. D

72 y/o

M. D50 y.o

July 19, 1960

Manager

B. L

51 y.o

Nov. 17, 1959

Employed

H.M

65 y.o

July 7, 1945

L.T 61 y.o

April 27, 1949

Housewife

C. D 59 y.o

July 28, 1950

HS GraduateUnemployed

S. D

58 y.o

July 14, 1952

Vendor

B. D

55 y.o

Dec. 8, 1955

Teacher

T. D

55 y.o

August 24, 1955Unemployed

A. D

38 y.o

October 16, 1972

Factory Worker

P. D 35

y.oMarch 27, 1975

Technician

S. T

34 y.o

Sept. 21, 1976

Accountant

P. V

32 y.o

Feb. 12, 1978

Housewife

H. R

30 y.o

June 16, 1980

Housewife/

Vendor

G. D2

9 y.oFebruary 28, 1981

Factory Worker

LEGEND:

Hypertension. . . .

Lung Cancer. . . . . . .

Asthma. . . . . . .

Diabetes . . . . .

Goiter. . . . . . .

CVD . . . . . . .

Deceased. . . . . . . X


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PHYSICAL ASSESSMENT (HEAD TO TOE)

ANTHROPOMETRIC MEASUREMENTS:

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

GENERAL SURVEY

Upon assessment the patient had slight body odor and he had

a poor personal hygiene. He wore an old shirt and a short during the

assessment and interview. The patient was not very attentivebecause he was experiencing difficulty breathing and cough but he

was cooperative with us especially in answering our questions. The

client was drowsy but oriented on time, person, place. His speech is

slightly slurred, but was able to respond to our questions coherently.

Patient is ectomorph in built, and if he walks to the comfort

room to urinate or defecate he walks uncoordinatedly and he was

shuffling thats why he needs assistance.


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SKIN

There are no lesions observed and there are no palpable

masses. The skin is cool to touch. The color of his extremities is

slightly jaundice/yellowish, while his bipedal edema which is non-pitting was black in color. He has good skin turgor, and the texture of

the skin is rough.

HEAD

The head is symmetrical, round and appropriate for his body

size. No masses were noted. He has uneven hair. His scalp isclean.

EYES

Eyelids are symmetrical and there is no presence of edema

noted. Eyebrows are equal. Pupils are equally round and reactive to

light and accommodation. The conjunctiva is pale. The periorbitalregion is sunken. The sclera are cloudy.

EARS

Ears are symmetrical. Tenderness of the ears not observed.

No discharges noted. Slight deafness on both ears.


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NOSE AND SINUSES

There is no inflammation and the nostrils are patent except the

left which is filled of mucous secretions upon inspection.

Tenderness of sinus is not observed. No discharges noted.Presence of nasal flaring noted.

MOUTH

The lips are slightly dried and pallor in appearance.Mucosa is

pale. Tongue is in midline. Gums are pale in color. The patient is

wearing dentures.

NECK

Jugular Vein Distention noted. No masses were present.

CHEST AND LUNGS

His breathing pattern is shallow. Slight difficulty of breathing is

observed. The patient used accessory muscles to breath. Lung

expands symmetrically. He had episodes of productive cough as

observed. Crackles were heard upon auscultation.


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HEART

No tenderness and bulging are observed. Heart sounds are

distinct but irregular. Presence of S3 noted.

AXILLAE

Axillae are symmetrical and lymph nodes are non palpable. No

lesions, no edema, no masses, no tenderness and rigidity are

noted.

ABDOMEN

Shape of the abdomen is globular and fluid wave. Bowel

sounds are hypoactive 3 gurgling sounds/minute.

BACK AND EXTREMITIES

The patient is slightly kypotic. Range of motion of upper

extremities are full, while the lower are limited.

Nails were also assessed. Capillary refill is about 3 seconds.

They are pale in color, no cyanosis is present, and no clubbing.

Bipedal non-pitting edema which was black in color was noted


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GORDONS FUNCTIONAL HEALTH PATTERN

Health Perception Health Management Pattern

According to patient CD, he has no problems with his senses

except for his eyesight and hearing. Its been blurred since he was 40years old. He finds it hard to read words written in small letters. He also

has slight deafness on both ears.

When it comes to his general health status, he stated that its not

that good. Its been deteriorating since he got sick. Andami dami ko

nga daw sakit sabi ng doctor, as verbalized by the patient. So to help

in the management of his diseases, he stopped smoking and drinking

alcoholic beverages. According to him, he used to be a heavy smoker

and drinker. He started with his vices at the age of 15.

Antigas nga ng ulo nan e kaya palageng nasesermonan ng

doctor e, as verbalized by his son. Patient CD sometimes neglects to

take his medications. He always reason out that instead of buyingmedicines hell just spend it to their basic necessities. But when forced

and supervised by his children, patient CD follows the prescribed

regimen for him. Now, he is able to eat properly and on time.

According to his son, he had no accidents, injuries, and surgeries

in the past. He also has no known allergies to food and medicines.


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Nutrition- Metabolism

Patient CDs typical food intake includes the

following: at breakfast, he just drinks coffee. For hislunch, he eats rice and whatever viand that is cooked by

his son. For his dinner, sometimes he has to wait for his

son to come home and eats whatever he brings home.

He no longer works thats why he doesnt have his own

money to buy his food. It is only his children that providehim his basic needs. According to his son, he has poor

appetite. There were times that he eats only once a day.

For his fluid intake, he consumes at least 5- 6 glasses of

water in a day.Nabawasan nga timbang ni tatay mula nung

magkasakit siya e, as verbalized by his son. Since he

got sick, his weight dropped tremendously. As stated by

his son he used to be 53 kg, but now it dropped to only

48 kg.


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Elimination

Patient CD doesnt defecate regularly. Normally, it takes him

two days before he could pass stool characterized as brownish hardformed stool. But during these past few weeks, he only defecates 2

times a week.

He urinates 4 5 times a day, sometimes with scanty amount

of urine. He described it to be dark yellow. According to him, he

doesnt have any problems with regards to his voiding patterns.Activity- Exercise

Mr. CD does not exercise regularly. Naglalakadlakad lang ako

mayat maya, as verbalized by the patient. He doesnt have a

routine exercise other than walking around their vicinity. But he feels

so tired after walking.

During his leisure time, he just watches TV or listens to the

radio. He easily gets exhausted after any activity so he minimizes

doing so. But despite this, he is bale to do his activities

independently. According to him, he has no any history if falls.


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Roles Relationship

Patient CD currently lives with his youngest son, GD.

According to GD, theirs is a broken family. Their parents separated

10 years ago. Currently their mom is living with another man andhas two children. CD and his wife, BD always argue about his vices.

BD always complains about his alcoholism. As stated by GD,

Palage nga sila nag- aaway dati kasi winawaldas ni tatay yung mga

kita niya sa pagbili lang ng alak at yosi. Minsan na din yang nalulong

sa sabong kaya ayun hiniwalayan ni nanay.

When it comes to family problems, as much as possible GD

tries to assist his father in solving them. Currently GD is the one

working to support their daily needs. He is now employed as a

factory worker in Cabuyao.

Self Perception Self Concept

According to patient CD, he is very moody thats why they (he

and his wife) always argue. He cant easily get along with other

people. Patient CD stated that since he got sick, he always feel

weak when doing any activity.


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Sexuality- Reproduction

(The patient refused to be interviewed about this)

Coping - Stress

During these past two years, the biggest changes that

happened in his life was his health slowly deteriorating. Thats why

he has to be dependent on his children to support his basic and

medical needs since he cannot anymore work. He currently lives

with his youngest son who helps him with his needs.Patient CD used to be a heavy smoker and drinker but since he

got ill, he had to stop. According to him, he made use of those as

scapegoat whenever he feels so stressed.

Values Belief

Patient CD is a member of Iglesia ni Cristo. For him, religion isvery important. Diyos ang gumawa ng lahat kahit problema kaya

itinataas ko na lang lahat sa kanya, as stated by the patient.


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Definition of Complete Medical

Diagnosis


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Congestive Heart Failure

Congestive heart failure (CHF) is a condition in which the heart's function asa pump is inadequate to deliver oxygen rich blood to the body. Congestive

heart failure can be caused by diseases that weaken the heart muscle,

diseases that cause stiffening of the heart muscles, or diseases that

increase oxygen demand by the body tissue beyond the capability of the

heart to deliver adequate oxygen-rich blood.

The heart has two atria (right atrium and left atrium) that make up the upper

chambers of the heart, and two ventricles (left ventricle and right ventricle)

that make up the lower chambers of the heart. The ventricles are muscular

chambers that pump blood when the muscles contract. The contraction of

the ventricle muscles is called systole.

Many diseases can impair the pumping action of the ventricles. For example,the muscles of the ventricles can be weakened by heart attacks or infections

(myocarditis). The diminished pumping ability of the ventricles due to muscle

weakening is called systolic dysfunction. After each ventricular contraction

(systole) the ventricle muscles need to relax to allow blood from the atria to

fill the ventricles. This relaxation of the ventricles is called diastole.


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Diseases such as hemochromatosis (iron overload) or amyloidosis can

cause stiffening of the heart muscle and impair the ventricles' capacity to

relax and fill; this is referred to as diastolic dysfunction. The most common

cause of this is long standing high blood pressure resulting in a thickened

(hypertrophied) heart. Additionally, in some patients, although the pumping

action and filling capacity of the heart may be normal, abnormally high

oxygen demand by the body's tissues (for example, withhyperthyroidism or anemia) may make it difficult for the heart to supply an

adequate blood flow (called high output heart failure).

In some individuals one or more of these factors can be present to cause

congestive heart failure. The remainder of this article will focus primarily on

congestive heart failure that is due to heart muscle weakness, systolicdysfunction.


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Symptoms

The symptoms of congestive heart failure vary among individuals according

to the particular organ systems involved and depending on the degree to

which the rest of the body has "compensated" for the heart muscle

weakness. An early symptom of congestive heart failure is fatigue. While fatigue is a

sensitive indicator of possible underlying congestive heart failure, it is

obviously a nonspecific symptom that may be caused by many other

conditions.

As the body becomes overloaded with fluid from congestive heart failure,swelling (edema) of the ankles and legs or abdomen may be noticed. This

can be referred to as "right sided heart failure" as failure of the right sided

heart chambers to pump venous blood to the lungs to acquire oxygen results

in buildup of this fluid in gravity-dependent areas such as in the legs. The

most common cause of this is longstanding failure of the left heart, which

may lead to secondary failure of the right heart. Right-sided heart failure can

also be caused by severe lung disease (referred to as "cor pulmonale"), or

by intrinsic disease of the right heart muscle (less common)

In addition, fluid may accumulate in the lungs, thereby causing shortness of

breath, particularly during exercise and when lying flat. In some instances,

patients are awakened at night, gasping for air.


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Some may be unable to sleep unless sitting upright.

The extra fluid in the body may cause increased urination, particularly at

night.

Accumulation of fluid in the liver and intestines may

cause nausea, abdominal pain, and decreased appetite.

Therapy

Heart failure therapy requires lifestyle changes, such as losing weight,

quitting smoking, limiting alcohol consumption, and reducing salt and fluid in

the diet. These changes can improve the heart's ability to function and may

help people with weakened hearts feel stronger.

Additionally, most people will need to take medications to manage the

symptoms of living with a weakened hear-for the rest of their lives.

Physicians recommend that people take their medications at the same time

each day and keep a record that includes the name of the medication, the

dosage, the number of times per day the medication is taken, and the

symptom or condition the medication is intended to treat.


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Commonly prescribed medications for heart failure include diuretics,

Angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor

blockers (ARBs), digitalis, beta-blockers, nitrates, and vasodilators. The

types and doses of these medications may be adjusted in people with liver

and kidney disease.

Surgical procedures that may improve heart failure include valve

replacement surgery, coronary artery bypass surgery (when heart failure is

caused by insufficient blood supply to the heart muscle), correction of

congenital heart defects, cardiac resynchronization therapy, and ventricular

assist devices.


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Risk factors.

Age

Gender

Ethnicity

Family History and Genetics

Chronic Alcohol Abuse

Medical Conditions that Increase the Risk for Heart Failure

Coronary artery disease

Heart attack.

High blood pressure.

Diabetes.

Obesity.

Valvular heart disease.

Severe emphysema


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Prevention

The key to preventing heart failure is to reduce your risk factors. You can

control or eliminate many of the risk factors for heart disease high blood

pressure and coronary artery disease, for example by making lifestyle

changes along with the help of any needed medications.

Lifestyle changes you can make to help prevent heart failure include:

Not smoking

Controlling certain conditions, such as high blood pressure, high cholesterol

and diabetes

Staying physically active

Eating healthy foods

M

aintaining a healthy weight Reducing and managing stress


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Liver Cirrhosis


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Liver Cirrhosis

The fibrosis and nodule formation cause distortion of the

normal liver architecture which interferes next to blood flowthrough the liver. Cirrhosis can also lead to an inability of the

liver to act its biochemical functions. Chronic inflammation will

lead to zone necrosis & bridging fibrosis (both are purely

pathological terms), and the nouns of regenerating nodules

causing increase surrounded by Portal Pressure (due to fibrosis

in liver,this increase PP will effect complications like bleeding

from the stomach..etc) along near accumilation of waste

product surrounded by blood (since the hepaocytes can not

perform its function & remove these toxic materials which willaccomplish the brain causing Encephalpathy).


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Diffuse toxic goiter

Graves disease, the most common cause of hyperthyroidism (overactivity of

the thyroid gland), with generalized diffuse overactivity ("toxicity") of the

entire thyroid gland which becomes enlarged into a goiter.

There are three clinical components to Graves disease:

Hyperthyroidism (the presence of too much thyroid hormone),

Ophthalmopathy specifically involving exophthalmos (protrusion of the

eyeballs),

Dermopathy with skin lesions.

The ophthalmopathy can cause sensitivity to light and a feeling of "sand in

the eyes." With further protrusion of the eyes, double vision and vision loss

may occur. The ophthalmopathy tends to worsen with smoking. The

dermopathy of Graves disease is a rare, painless, reddish lumpy skin rash

that of Graves disease is an autoimmune process. It is caused by thyroid-

stimulating antibodies which bind to and activate the thyrotropin receptor on

thyroid cells.


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Graves disease can run in families. The rate of concordance for Graves

disease is about 20% among monozygotic (identical) twins, and the rate is

much lower among dizygotic (nonidentical) twins, indicating that genes makeonly a moderate contribution to the susceptibility to Graves disease. No

single gene is known to cause the disease or to be necessary for its

development. There are well-established associations with certain HLA

types. Linkage analysis has identified gene loci on chromosomes 14q31,

20q11.2, and Xq21 that are associated with susceptibility to Graves disease. Factors that can trigger the onset of Graves disease include stress, smoking,

radiation to the neck, medications (such as interleukin-2 and interferon-

alpha), and infectious organisms such as viruses.

The diagnosis of Graves disease is made by a characteristic thyroid scan

(showing diffusely increase uptake), the characteristic triad of

ophthalmopathy, dermopathy, and hyperthyroidism, or blood testing for TSI

(thyroid stimulating immunoglobulin) the level of which is abnormally high.


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Current treatments for the hyperthyroidism of Graves disease

consist of antithyroid drugs, radioactive iodine, and surgery.There is regional variation in which of these measures tends to

be used -- for example, radioactive iodine is favored in North

America and antithyroid drugs nearly everywhere else. The

surgery, subtotal thyroidectomy, is designed to remove the

majority of the overactive thyroid gland.

The disease is named for Robert Graves who in 1835 first

identified the association of goiter, palpitations, and

exophthalmos.


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Anatomy and Physiology and

Pathophysiology


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THE HEART

Heart is a hollow muscular organ that pumps blood through the body. The

heart, blood, and blood vessels make up the circulatory system, which isresponsible for distributing oxygen and nutrients to the body and carrying

away carbon dioxide and other waste products. The heart is the circulatory

system's power supply. It must beat ceaselessly because the body's tissues-

especially the brain and the heart itself-depend on a constant supply of

oxygen and nutrients delivered by the flowing blood. If the heart stops

pumping blood for more than a few minutes, death will result.


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The human heart is shaped like an upside-down pear and is located slightly

to the left of center inside the chest cavity. About the size of a closed fist, the

heart is made primarily of muscle tissue that contracts rhythmically to propel

blood to all parts of the body. This rhythmic contraction begins in thedeveloping embryo about three weeks after conception and continues

throughout an individual's life. The muscle rests only for a fraction of a

second between beats. Over a typical life span of 76 years, the heart will

beat nearly 2.8 billion times and move 169 million liters (179 million quarts)

of blood.

STRUCTURE OF THE HEART

The human heart has four chambers. The upper two chambers, the right and

left atria, are receiving chambers for blood. The atria are sometimes known

as auricles. They collect blood that pours in from veins, blood vessels that

return blood to the heart. The heart's lower two chambers, the right and left

ventricles, are the powerful pumping chambers. The ventricles propel blood

into arteries, blood vessels that carry blood away from the heart.


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A wall of tissue separates the right and left sides of the heart. Each side

pumps blood through a different circuit of blood vessels: The right side of the

heart pumps oxygen-poor blood to the lungs, while the left side of the heartpumps oxygen-rich blood to the body. Blood returning from a trip around the

body has given up most of its oxygen and picked up carbon dioxide in the

body's tissues. This oxygen-poor blood feeds into two large veins, the

superior vena cava and inferior vena cava, which empty into the right atrium

of the heart. The right atrium conducts blood to the right ventricle, and the right ventricle

pumps blood into the pulmonary artery. The pulmonary artery carries the

blood to the lungs, where it picks up a fresh supply of oxygen and eliminates

carbon dioxide. The blood that is oxygen-rich returns to the heart through the

pulmonary veins, which empty into the left atrium. Blood passes from the left

atrium into the left ventricle, from where it is pumped out of the heart into theaorta, the body's largest artery. Smaller arteries that branch off the aorta

distribute blood to various parts of the body.

A THE HEART VALVES


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A. THE HEART VALVES

Four valves within the heart prevent blood from flowing backward in the

heart. The valves open easily in the direction of blood flow, but when blood

pushes against the valves in the opposite direction, the valves close. Two

valves, known as atrioventricular valves, are located between the atria andventricles. The right atrioventricular valve is formed from three flaps of tissue

and is called the tricuspid valve. The left atrioventricular valve has two flaps

and is called the bicuspid or mitral valve. The other two heart valves are

located between the ventricles and arteries. They are called semilunar

valves because they each consist of three half-moon-shaped flaps of tissue.

The right semilunar valve, between the right ventricle and pulmonary artery,

is also called the pulmonary valve. The left semilunar valve, between the left

ventricle and aorta, is also called the aortic valve.

B. THE MYOCARDIUM

Muscle tissue, known as myocardium or cardiac muscle, wraps around a

scaffolding of tough connective tissue to form the walls of the heart's

chambers. The atria, the receiving chambers of the heart, have relatively thin

walls compared to the ventricles, the pumping chambers. The left ventricle

has the thickest walls-nearly 1 cm (0.5 in) thick in an adult-because it must

work the hardest to propel blood to the farthest reaches of the body.

C THE PERICARDIUM


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C. THE PERICARDIUM

A tough, double-layered sac known as the pericardium surrounds the heart. The

inner layer of the pericardium, known as the epicardium, rests directly on top of the

heart muscle. The outer layer of the pericardium attaches to the breastbone and

other structures in the chest cavity and helps hold the heart in place. Between the

two layers of the pericardium is a thin space filled with a watery fluid that helps

prevent these layers from rubbing against each other when the heart beats.

D. THE ENDOCARDIUM

The inner surfaces of the heart's chambers are lined with a thin sheet of shiny, white

tissue known as the endocardium. The same type of tissue, more broadly referred to

as endothelium, also lines the body's blood vessels, forming one continuous liningthroughout the circulatory system. This lining helps blood flow smoothly and prevents

blood clots from forming inside the circulatory system.

E. THE CORONARY ARTERIES

The heart is nourished not by the blood passing through its chambers but by a

specialized network of blood vessels. Known as the coronary arteries, these blood

vessels encircle the heart like a crown. About 5 percent of the blood pumped to thebody enters the coronary arteries, which branch from the aorta just above where it

emerges from the left ventricle. Three main coronary arteries-the right, the left

circumflex, and the left anterior descending-nourish different regions of the heart

muscle. From these three arteries arise smaller branches that enter the muscular

walls of the heart to provide a constant supply of oxygen and nutrients. Veins running

through the heart muscle converge to form a large channel called the coronary sinus,which returns blood to the ri ht atrium.


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FUNCTION OF THE HEART

The heart's duties are much broader than simply pumping

blood continuously throughout life. The heart must also respond

to changes in the body's demand for oxygen. The heart works

very differently during sleep, for example, than in the middle ofa 5-km (3-mi) run. Moreover, the heart and the rest of the

circulatory system can respond almost instantaneously to

shifting situations-when a person stands up or lies down, for

example, or when a person is faced with a potentially

dangerous situation

Pathophysiology


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Pathophysiology


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Laboratory and Diagnostic

Examinations

Date Lab Test Actual Result Normal Values Intepretation Nursing


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Responsibility

07/19/10 y Hematologyy WBCy Diff. Count:

Neutrophils

y Diff. Count:Lymphocytes

y Hemoglobin

y Platelet

y Hematocrit

y 3.1 x109/Ly 0.48

y 0.52

y 90 gm/dl

y 180 x109/L

y 27

y 5-10 x109/Ly 0.51-0.67

y 0.21-0.35

y 130-180 gm/dl

150-400 x109/L

y 36-48

Low: Neutrophils decrease withviral infections, bone marrowsuppression, and primary bone

marrow disease

High:Lymphocytes increase withinfectious monoclueosis, viral andsome bacterial infections, andhepatitisLow: Hemoglobin decreases invarious anemias, severe orprolonged hemorrhage, and withexcessive fluid intakeNormal

Low: Hematocrit decreases insevere anemias, and acutemassive blood loss

Check puncturesite for signs ofbleeding

Secure site for

possible infection

07/20/10 y Hematologyy WBCy Hematocrit

y Hemoglobin

y Diff.Ct.: Segmentersy Diff. Ct.: Lymphocytes

y 7.0y 0.39

y 130

y 0.60y 0.40

y 5.0-10 x109/Ly 0.40-0.54

y 140-170 g/L

y 0.50-0.70y 0.20-0.40

NormalLow: Hematocrit decreases insevere anemias, and acutemassive blood lossLow: Hemoglobin decreases in

various anemias, severe orprolonged hemorrhage, and withexcessive fluid intakeNormalNormal

Check puncturesite for signs ofbleeding

Secure site for

possible infection

07/20/10 y Urinalysisy Color

y Transparencyy

Reactiony Specific gravity

y Amber

y Cleary

6.0y 1.025

yYellow, Pale yellow,amberyCleary

4.4-8.0y1.020-1.028

yNormal

yNormaly

NormalyNormal

Catch urinespecimen in asterile container

Discard the first


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Diagnostic Imaging Report

July 20, 2010

Chest PA View

There is slight prominence of the pulmonary nasulature.

The heart is enlarged.

There is homogeneous opacity, with a lateral ascending componentsen obscuring the left hemidiaphragm and cp sulcus.

Impression:

Cardiomegaly with pulmonary congestive changes

Left moderate Pleural Effusion

July 29 2010 Abd. Utz


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July 29, 2010 Abd. Utz

The liver is contracted with nodular borders and heterogeneous parenchyma with

prominent hepatic veins.

The intrahepatic ducts are not dilated.

The gall bladder is normal size with echofree lumen and smooth non-thickened wall. No

stone is seen.

The common duct and portal vein are normal in caliber.

The pancreas is normal in size with homogeneous parenchymal echo pattern.

No focal lesion is seen. The pancreatic duct is not dilated.

The spleen measurjing 9.6cm is normal in size with homogeneous parenchymal echo

pattern.No focal lesion is seen.

The right kidney is normal in size with isoechoic echo pattern.

The left kidney is normal in size,

The cortical thickness, cortico-medullary differentiation, renal sinus complexes perinephric

areas are unremarkable.

The pelvocalyceal systems and ureters are not dilated.

The urinary bladder is well distended with echo free lumen and smooth non-thickened

wall.

The bowel loops are not dilated,

No mass.

There is ascites.

There is fluid collection seen in both hemithorax.


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Impressions:

Features suggestive of liver cirrhosis and signs of passive congestion.

Massive ascites.

Normal sized right kidney with parenchymal diseaseBilateral Pleural Effusion

Normal gall bladder, pancreas, spleen, left kidney, and urinary bladder.


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Echocardiogram

July 20, 2010

Vent. Rate (bpm) :106

PR int. (ms) : - - -

P/QRS/T int. (ms) : - - - 82 166

QT/QTc int. (ms): 333 445

P/QRS/T axis (deg): - - 43 21 RV1/SV5 amp. (mV) : 0.33 0.16

RV5/SV1 amp. (mV) : 0.87 1.18

Interpretation:

sinus tachycardia

July 28 2010


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Left Ventricle Results Normal Values Left Atrium Results Normal Values

LVEDD 5.0 4.5-5.0 AP 3.6 3-3.5 cm

LVESD 3.8 R-L

IVS (D) 1.1 0.8-1.1 S-I

IVS (S) 1.5

LVPW (D) 1,1 0.8-1.1 Right Ventricle

LVPW (S) 1.4 RVEDD 4.4

LVEDV 125 91-125 ml RVESD

LVESV 55

SV (D) 70 Right Atrium

CO 6.0 AP

EF 56% 55-75% R-L 4.5

FS 24% S-I

HR 86

EPSS 1.3


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Values Max. Velocity Area (cm) Kel Gradient Regurgitation Fraction

MITRAL 0.9/0.5 3.5/1.0 MILD

AORTIC 1.1/1.2 4.8/5.9

TRICUSPID 0.6 1.4 SEVERE

PULMONIC 0.4 0.7

DopplerSpectral Data

P.A.T

PAT= 70 m/sec PAP= 68 mmHg DT= 150 m/secWRT= 70 m/secNormal left ventricular dimension and wall thickness with normal wall motion and contractility

Dilated left atrium

Dilated right ventricle with adequate contractilityDilated right atriumNormal --- main pulmonary artery and aortic rootThickened aortic value cups without restriction of motionStructurally normal mitral valve, tricuspid valve, and pulmonic valveNo intracardiac thrombus

Color Flow DopplerStudy

Abnormal color flow display noted across the mitral valve and tricuspid valveReversed mitral E/A velocity ratio

PAP= 68mmHgConclusion

1.Normal left ventricular dimension with normal wall motion and contractility with good systolic function but with grade I diastolicdysfunction2.Dilated left atrium3.Dilated right ventricle with adequate contractility4.Dilated right atrium5.Mild mitral regurgitation6.Severe tricuspid regurgitation7.Severe pulmonary hypertenstion


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Course in the Ward

Furosemide 40mg IV q120

of the drug)

y Monitored patient (to watch out for possible side effects)


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Captopril 20mg 1/2 tab BID

Roxythromycin 150mg/tab BID

Ambroxol 30mg TID

Rationale:y For continuous management of the disease (CHF and CAP)

3. Refer accordingly

Rationale:

y To provide appropriate and accurate treatment andinterventions.

y Monitored patient (to watch out for possible side effects)y Advised and encouraged patients relative to continually

provide the prescribed medications for the patient (forcontinuous treatment)

y Documentation done (for doctors referral)

DAY 4 (July 28, 2010)

MEDICAL/ SURGICAL MANAGEMENT NURSING MANAGEMENT

1. Pls. follow up lab results

Rationale:y To provide immediate interventions in any abnormal results.

2. Continue medical management

Cefuroxime 750mg IV q80

Ranitidine 50mg IV q80

Furosemide 40mg IV q120

Captopril 20mg 1/2 tab BID

Roxythromycin 150mg/tab BID

Ambroxol 30mg TID

Rationale:y For continuous management of the disease (CHF and CAP)

3. O2 inhalation 2 4 lpm

Rationale:y To provide sufficient oxygenation.

3. Refer accordingly

Rationale:

y Checked and monitored patients chart for time to time (tocheck for new lab results)

y

Referred to PROD for any abnormal lab results (to provideimmediate response and interventions)y Due medications given and recorded (to provide continuous

and on-time treatment)y Drug study was done (to determine the action and side effects

of the drug)y Monitored patient (to watch out for possible side effects)y Advised and encouraged patients relative to continually

provide the prescribed medications for the patient (forcontinuous treatment)

y Administered and regulated O2 inhalation 2-4lpm (to providesufficient oxygenation)

y Secured nasal cannula (to prevent O2 spilling)y Monitor patients breathing status (to identify the progress of

intervention)y Documentation done (for doctors referral)y Drug study done (to determine the action and side effects of

the drug)y given with meals (to minimize GI irritation)

Grand Case Presentation 10-30-10

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