Congestive Heart Failure FC IV
Valvular Heart Disease
Secondary to
Rheumatic Heart Disease

A case Presentation
A Presented to:
The Faculty
College of Nursing
Adventist University of the Philippines

In Partial fulfillment
Of the Course
N303 Curative and Rehabilitative Nursing Care
1st Semester

By:
Tha Hnem
Section F

Presentation Date:
September, 4, 2007
I. Introduction

Heart failure, also called congestive heart failure (CHF), is a life-threatening condition in which the heart can no longer pump enough blood to the rest of the body. Heart failure is almost always a chronic, long-term condition, although it can sometimes develop suddenly.
Rheumatic fever and Valvular Heart Disease also contributed to Heart Failure. This condition may affect the right side, the left side, or both sides of the heart. Rheumatic heart disease refers to the cardiac manifestations of rheumatic fever, including pancarditis (myocarditis, pericarditis, and endocarditis) during the early acute phase and chronic valvular disease later. Long-term antibiotic therapy can minimize recurrence of rheumatic fever, reducing the risk of permanent cardiac damage and eventual valvular deformity. In valvular heart disease, three types of mechanical disruption can occur; stenosis, or narrowing, of the valve opening: incomplete closure of the valve; or prolepses of the valve. They can result from such disorders as endocarditis (most common), congenital defects, and inflammation, and they can lead to heart failure.
When the heart valve malfunction is significant, the heart eventually fails to pump properly, leading to congestive heart failure (CHF). With heart failure, many organs don't receive enough oxygen and nutrients, which damages them and reduces their ability to function properly. Most areas of the body can be affected when both sides of the heart fail. As the heart's pumping action is lost, blood may back up into other areas of the body, including: The liver, the gastrointestinal tract and extremities (right-sided heart failure), and the lungs (left-sided heart failure).

A. Significance of the study
The significant of the study mainly talks a bout the patient’s diagnosis together with the underlying problem lead to CHF, and the past or present medical history including the developmental tasks, description of clinical care, and managements, that will be further study.

B. Prevalence/Statistics:

Although untreated rheumatic fever may lead to CHF. Rheumatic fever may involve any age group; it is rather uncommon in infancy and in children younger than four and in adults after fifty. It most commonly affects children aged five to fifteen years. Long-term antibiotic therapy can minimize recurrence of rheumatic fever, reducing the risk of permanent cardiac damage and eventual valvular deformity. However, severe pancarditis occasionally produces fatal heart failure during the acute phase. Of the patients who survive this complication; about 20% die within 10 years. The overall incidence of RHD is in third rank behind coronary and hypertensive heart disease. Thus, rheumatic fever is the most common precursor of heart disease among individuals under the age of forty. The incidence of rheumatic fever is reported to increase to as high as 5 to 50 percent following streptococcal infection is reported to be considerably higher in patients with know RHD than in those who have recovered from previous attacks of rheumatic fever completely without cardiac damage.
According to the National health and nutrition examination surveys, an estimated 4.8 million Americans have CHF, with approximately equal numbers of men and women. Almost 1.4 million are under 60 years of age. CHF is present in 2% of persons age 40 to 59, more than 5% of persons age 60 to 69 and 10% of age 70 and older. Prevalence is at least 25% greater among the black population then among the white population.

II. Patient Profile
A. Demographic data:

History of Present illness:
Past Medical history
My patient was a diagnosed case of RHD since age 8 or 9 and was advised for valve replacement then but was not complied due to financial constraint. And several consults with different physicians and he was given monthly shots of Venzathine, benzy, pander, but was later shifted to sumapen with poor compliance to medications.
He had consults at SLMC and PHC with latest 2b-echo result taken last July 2003 with the finding of RHD, Aortic insufficiency. He was prescribed with medications such as carvedilol, burinex, epinephrine, captopril, lanoxin, and multivitamins with poor compliance. Patient was able to tolerate his condition.
Few days prior to admission, patient was noted to have dry cough associated with easy fatigability. Paroxysmal nocturnal dyspnea, use three pillows orthopnea and yellowish discoloration of the eyes.
One day prior to admission, the patient complaint difficulty of breathing, chest pain but still no consult was done until the morning of prior to admission; he was rashed to Mandaluyoung City. Medications or where he was stated on Furosemide IV, lanoxin IV, and captopril. The relatives applied to using the patient to his institution and hence, he was admitted in MAMC.

Family Medical History: John family Medical History: both his mother and father side has Hypertension and Diabetes Mellitus. No others history is unremarkable.

B. Psychosocial/Developmental tasks:

a. Sigmund Freud (Psychosexual):
Genital Stage: Puberty and after
In this stage, energy is directed toward full sexual maturity and function and development of skills needed to cope up with the environment. The patient was not a achieved this psychosexual developmental stage because his age is 8 or 9 years old, and he had RHD, and also Aortic insufficiency, so that the patient could not reach this genital stage of Sigmund Freud. He is depending on others shoulder. In this case, the patient needs more moral support and good care and love.

b. Erik Erickson (Psychosocial):
Young adulthood stage: 18 to 25 years old
Intimacy and solidarity versus isolation
According to Erickson the intimacy includes the ability to experience an open, supportive, tender, relationship with another person without fear of losing one’s own identity in the process of growing close. The patient is so much trouble to relationship with others, especially, with girls because he knows that he is unhealthy person, and always thinks about his condition and health status. Beside this, he is the youngest son in his sibling and always depended on his family, and he closed with only his parents and feared to lose his parents.

c. Lawrence Kohlberg (Moral):
Law- and –order- Orientation
The person wants to establish a rule from authorities, and the reason for decisions, and behavior is that social and sexual rules and traditions demand of the response. The patient does not have too much confidence with his life. He always feels that he can not come out to every and or in the society expectation in the future. Every thing he did is violation to every rule of life.

d. Jean Piaget (Cognitive):
Formal Operations Period
From roughly 11 to 15 years old, formal operations characterize thinking throughout adulthood and are applied to more areas. Egocentrism continues to decline. However, according to Piaget these changes do not involve a changed in the 4 structure of thought only a change in its content and stability. In this case, the patient cognitive development is altered because of these psychologic factors. He could not think wisely and optimist. He could not manage his thought toward something worth. He thinks negatively about his life.

e. Robert Havighurst (Developmental):
Young adulthood stage:
Selecting mate and finding a congenital social group, learning to live with a partner, and starting a family. This developmental task of Robert Harvighurst is so far to task for him that because he never thinks about girl, friend, work, a mate, or family because of his present health condition.

C. Past Medical History of the Patient. Since he was age 8 or 9 years old, he had RHD. He was admitted to St. Luke Medical Center with the finding of RHD, Aortic insufficiency in July 2003.

D. Gordon’s Assessment
1. Health Perception-Health Management Pattern
John is 22 and 6 months years old, he can explain about his feeling very well. According to him, he was so tired of his health condition. Because he is bearing RHD since he was 8 years old, and advised to valve replacement. Unfortunately, he can not able to do so the advised because of financial problem. However, he consults with several physicians and took monthly short term medications, which treatment can not be healed the disease. And, his disease was gradually become more severe and, he consults again at SLMC and PHC in July 2003. Both hospitals found RHD and aortic/mitral insufficiency, and advised to admit the hospital. He took some medications and he was able to tolerate his condition and continued his study. However, 4 years later, his disease arose again and he wanted to consult with the physician in the hospital. But a few days prior to admission, he was noted to have dry cough, dyspnea, three pillows orthopnea, chest pain and consult to MAMC and hence admitted at Aug, 10, 2007 at 2:55 AM. His expectation was to get well and go home but now present of his condition, he feels hopeless in his life.

2. Nutritional –Metabolic Pattern
John has a good appetite and no problem with food. His favorite food is chicken and beef. He has no problem with eating and drinking as well. But after his admission at the hospital, he could not eat what he wants to eat and drink because the present of his health condition, they allowed to eat only low salt and low fat, and limited to drink water 1 liter per-day. He has edematous in his lower extremities and at the same time he has cough and prone to have dehydration. He has dry lips and skin, and always asking to drink water. According to him, he has allergy with seafood, dust and Cigarette smoke.

3. Elimination Pattern
My client elimination pattern is not normal. He has no constipation but his urine output is too much comparing to his intake. Especially, Aug, 19, 07, his urine output was 2395cc and intake was only 1057cc and Aug, 20, 07: output- 3705cc and intake- 1070cc only. But he has no difficulty in urination.

4. Activity and Exercise Activity and exercise pattern John well done before his admission, but he can not do more exercise because of his heart problem, he easily felt fatigability and exhaustion. But now, his functional capacity is already class IV, it means: severe limitation of physical activity because symptoms occur even at rest. He had chest pain and difficulty of breathing; even he could not change his position himself. He is needed at least one assistance to change position.

5. Sleep-rest Pattern My client did not have any problem with sleep pattern before; he usually slept 8 hours per day. But now he doesn’t have enough time to sleep because of difficulty of breathing and chest pain. When he was lying down, he experienced difficulty of breathing. Especially, Aug, 12, 07; during my care, even he could not breath well in semi-fowler’s positions, but the position of 90 degree, he can breath and feel comfortable.

6. Cognitive- Perpetual Pattern
According to John, he has no problem with vision and hearing. He can hear normal tone and see clearly.

7. Self Perception and Self-concept Pattern The patient thinks his disease is can be cured easily, but gradually become severe and feels more uncomfortable with his health problem. After he knew about his disease, he feels so hopeless for his future life. But his parents always help him through moral and psychology support. He was not happy with his classmate or friends, his best friends are his family only. Thus, he really feared to lose his parents. The most important thing for his life is to cure his disease and to support his parents.

8. Role Relationship Pattern John has one sister and one brother. He is the youngest son and they loved him too much. He always received all attention from them but the big problem for his health is financial problem. Since he was 8 years old, his families know that he needed to replace his valve, but they could not help him because of lack of money to pay for the treatment, but they always try their best to take care of him.

9. Sexuality – Reproductive Pattern I did not interview the patient about sexuality-reproductive pattern.

10. Coping and Stress Tolerance Pattern My client did not experience any big changes or crises in his life in the past two years, but at the present his health status is a big crisis and changes in his life.

11. Value and Belief Pattern My client was born in SDA parents. Religion is essential in his life, especially, when he is in trouble, he reads the Bible which helps him to overcome his difficulties. And he also prays for getting strength from God who is been strengthens him. Religion is the best medicine for him as psychological problem. He believed that medicine and medical doctors are God’s agents to heal the sickness people in the world.

III. Anatomy and Physiology

Human Heart
The human heart is a hollow, pear-shaped organ about the size of a fist. The heart is made of muscle that rhythmically contracts, or beats, pumping blood throughout the body. There are four valves in the heart. The mitral valve is situated between the left atrium and left ventricle. The aortic valve is located at the outlet of the left ventricle. These two valves close and open harmoniously and rhythmically for the circulation of the other half of the heart. The circulation of the left half is carried out by the tricuspid valve and the pulmonic valve. The tricuspid valve is located between the right atrium and the right ventricle. The pulmonary valve is situated at the outlet of the right ventricle blood is pumped by the right ventricle to the lungs via the pulmonary arteries following closure of the tricuspid valve and opening of the pulmonic valve in order to pick up oxygen (Oxygenated blood, this process is essential for life. The oxygenated blood returns to the left atrium via the pulmonary veins, and again the blood is pushed down to the left ventricle through the mitral valve. The blood now fully loaded with oxygenated and important nutrients, is pumped by the left ventricle, following closure of the mitral valve and opening of the aortic valve, and is carried to all parts of the body via the aorta and its branches. The aorta is the largest trunk like artery, with a diameter about equal to that of a large garden hose. After delivering the oxygenated and nutrients throughout the body, the used blood returns to the right atrium through two large vessels, the inferior vena cava and the superior vena cava. The inferior vena cava collects blood from the area of the body below the heart. Where the superior vena cava is receives blood from above the heart. Thus, the left ventricle is responsible for pumping oxygenated blood with nutrients throughout the entire body and for bringing the used of blood back to the right atrium. Complete circulation of the cardiovascular system takes about ten to fifteen seconds.

IV. Pathophysiology
Rheumatic heart disease refers to the cardiac manifestations of rheumatic fever, including pancarditis (myocarditis, pericarditis, and endocarditis) during the early acute phase and chronic valvular disease later. The most destructive effect of rheumatic fever is carditis, which develops in up to 50% of patients. It may affect the endocardium, myocardium, pericardium, or the heart valves. Pricarditis causes a pericardial friction rug and, occationally, pain and effusion. Myocarditis produces characteristic lesions called Aschoff bodies (in the acute stages) and cellular swelling and fragmentation of interstitial collagen, leading to formation of a progressively fibrotic nodule and interstitial scars. Endocarditis causes valve leaflet swelling, erosion along the lines of leaflet closure, and blood, platelet, and fibrin deposits, which form beadlike vegetations. Endocarditis usually affects the miral valve in males. In both sexes, endocarditis affects the tricuspid valve occasionally and the pulmonic valve only rarely. Severe rheumatic carditis may cause heart failure with dyspnea, right-upper-quadrant pain, tachycardia, tachypnea, significant mitral and aortic murmurs, and a hacking, nonproductive cough. In valvular heart disease, three types of mechanical disruption can occur; stenosis, or narrowing, of the valve opening; incomplete closure of the valve; or prolapse of the valve. They can result from such disorders as endocarditis (most common), congesital defects, and inflammation, and they can lead to heart failure. Valvular heart disease occurs in varying forms; Mitral insufficiency: in this form, blood from the left ventricle flows back into the left atrium during systole, causing the atrium to enlarge to accommodate the backflow. As a result, the left ventricle also dilates to accommodate the increased volume of blood from the atrium and to compensate for diminishing cardiac output. Ventricular hypertrophy: and increased end-diastolic pressure result in increased pulmonary artery pressure, eventually leading to left and right ventricular failure. Mitral stenosis: narrowing of the valve by valvular abnormalities, fibrosis, or calcification obstructs blood flow form the left atrium to the left ventricle. Consequently, left atrial volume and pressure rise and the chamber dilate. Greater resistance to blood flow cause pulmonary hypertension, right ventricular hypertrophy, and right ventricular failure. Also, inadequate filling of the left ventricle produces low cardiac output. Mitral valve prolapse (MVP). One or both valve leaflets protrude into the left atrium. MVP syndrome is the term used when the anatomic prolapse is accompanied by signs and symptoms unrelated to the valvular abnormality. Aortic insufficiency. Blood flows back into the left ventricle during diastole, causing fluid overload in the ventricle, which dilates and hypertrophies. The excess volume causes fluid overload in the left atrium and, finally, the pulmonary system. Left ventricle failure and pulmonary edema eventually result. Aortic stenosis. Increased left ventricular pressure tries to overcome the resistance of the narrowed valvular opening. The added workload increases the demand for oxygen, and diminished cardiac output causes poor coronary artery perfusion, ischemia of the left ventricle, and left ventricular failure. Pulmonic insufficiency: Blood ejected into the pulmonary artery during systole flows back into the right ventricle during diastole, causing fluid overload into eh ventricle, ventricular hypertrophy and, finally, right ventricular failure. Pulmonic stenosis: Obstructed right ventricular outflow causes right ventricular hypertrophy, eventually resulting in right ventricular failure. Tricuspid insufficientcy: Blood flows back into the right atrium during systole, decreasing blood flow to the lungs and left side of the heart. Cardiac output also lessens. Fluid overload in the right side of the heart can eventually lead to right ventricular failure. Tricuspid stenosis: Obstructed blood flow from the right atrium to the right ventricle causes the right atrium to dilate and hypertrophy. Eventually, this leads to right ventricular failure and increases pressure in the vena cava. In congestive heart failure usually occurs in a damaged left ventricle (left-sided heart failure) but may occur in the right ventricle (right-sided heart failure) either as a primary disorder or secondary to left-sided heart failure. Sometimes left and right-sided heart failure develop simultaneously.
Heart failure or congestive heart failure (CHF) means that the heart is unable to pump enough blood to meet the body’s demands. Deteriorating cardiac function is primarily due to two major mechanisms: (1) impairment of myocardial contractile force (eg., heart attack, cardiomyopathy), and (2) mechanical abnormality (eg., valvular heart diseases-narrowing or leaking of heart valves and various congenital heart disease). However, in many cases, both mechanical abnormalities as well as the impairment of myocardial contractile force are responsible for the production of CHF. Numerous underlying heart diseases (e.g., CAD, hypertensive heart disease, rheumatic heart disease, congenital heart disease, cardiomyopathy) may cause CHF. Therefore, CHF is not the primary diagnosis of heart disease; rather, it is the expression of the end result of abnormal cardiac function of differing degrees resulting from a variety of underlying disease.
There are many ways to classify CHF. For example, it may be placed in two major categories: (1) left ventricular failure and (2) right ventricular failure, depending upon the underlying cardiac disease and the resultant involvement of a particular cardiac chamber. In left sided heart failure: if the left ventricle falls behind by as little as one drop with each beat, a large amount of blood can “pile up” in the lungs in a few hours. There won’t be room for a normal exchange of air, and the patient will become short of breath. In right sided heart failure: is usually caused by left-sided heart failure, but can also be caused by pulmonary emboli, pulmonary hypertension, COPD, right ventricular infarctions, myocardial contusions atherosclerotic cardiovascular disease, cardiomyopathy, valvular heart disease, atrial or ventricular septal defects, pulmonary stenosis, or sleep apnea. In many cases with advanced CHF, both ventricles are involved; in this circumstance, in many cases with advanced CHF, both ventricles are involved; in this circumstance, the term biventricular failure is used. In many cases, CHF starts with left ventricular failure only, but right ventricular failure often follows as cardiac function deteriorates, so that the end result is biventricular failure. It can be said, therefore, that the most common cause of right ventricular failure is left ventricular failure in most cases with advanced heart disease.
Congestive heart failure is also classified according to functional capacity. For instance, the New York Heart Association Functional Classification provides an extremely useful guideline for categorizing patients with HF:
Class I: Patients with documented heart disease (any type) who are completely symptom free.
Class II: Slight limitation of physical activity because symptoms (e.g., shortness of breath, chest pain) occur only with more than ordinary physical activity.
Class III: Marked limitation of physical activity because symptoms occur even with ordinary physical activity (e.g., eating meals).
Class IV: Severe limitation of physical activity because symptoms occur even at rest (e.g., in a sitting or lying position). Of course, the functional class may change from time to time, even in the same individual, depending upon progress of the underlying heart disease and responses to treatment. For example, the patient with functional III or IV CHF on admission to the hospital may be discharged with a functional I or II condition when cardiac functional improves markedly after treatment. On the other hand, functional I or II patients may progressively change to functional III or even IV when the underlying heart disease rapidly deteriorates and when response to treatment is poor.

Pathophysiology

Etiology: Group A: streptococcus pharyngitis Predisposing factors:
-MI
-HPN
-DM
-Aortic stenosis or regurgitation
-Mitral stenosis or regurgitation
-Valular heart disease
-Ventricular septal defect
-Pulmonic valve stenosis or regurgitation
-Systemic HPN
-Tricuspid valve regurgitation
-Atherosclerosis
-Rheumatic Fever
-Rheumatic heart disease
-age 22 years old

V. Nursing Care Plan

Problem#1: Difficulty of Breathing (Aug 14, 07)
Cues:
Subjuctive:
• Chest pain 6/10
• DOB
Objective:
• RR-30 (12-20)
• PR-57-69 (60-90)
• BP-80-100/57-70
• O2sat 90 %( 95-100%)
• Restlessness
• Irritability
• crackle
Nursing Diagnosis: Impaired gas exchange related to decrease oxygen-carrying capacity of the blood secondary to decrease cardiac out put.
Rationale: In the left heart failure the left ventricle falls behind by as little as one drop with each heat, large amount of blood can “pile up” in the lungs in a few hours. The extra volume of blood will compress the small air passages and watery fluid will leak out of the over loaded capillaries into the tissue spaces between the air passages. So there won’t be room for a normal exchange of air, and the patient will become SOB. (The human heart a basic guide to heart disease: 1997:27)
Goal: After 30 minutes of nursing intervention, the patient will have adequate oxygenation and relief from dyspnea. Nursing intervention:
Independent
• Monitor V/S especially respiratory status for rate, regularity, depth, ease of effort at rest or with exertion.
Rationale: Changes in respiratory pattern or patency of airway may result in gas exchange imbalances. (Comer: 2005.p.47)
• Monitor for mental status changes.
Rationale: Hypoxia affects all body systems & mental status changes can result from decrease O2 to brain tissue. (ibid)
• Position in semi- or high-fowler’s position
Rationale: Promotes breathing & lung expansion to enhance gas distribution.(ibid)
• Instruct in breathing exercises as warranted.
Rationale: Assists to restore function to diaphragm and improves gas exchange.(ibid)
• Allow for periods of rest between activities.
Rationale: To promote breathing pattern (ibid)
• Instruct patient to avoid activities that promote dyspnea or fatigue.
Rationale: Activity increase O2 consumption and demand, and can impair breathing pattern. (ibid)
Dependent:
• Administer oxygenation @ 2L per min. via cannula as indicated. Rationale: Maintains adequate oxygenation without depression of respiratory drive. (ibid)
• Administer medications as ordered. (eg., morphine, isoket, isodril). Rationale: To control chest pain, and reduce the work load on the heart. (Comer: 2005:5)
• Administer IVF as ordered.
Rationale: Increase and decrease in fluids may be required to maintain left ventricular end-diastolic pressure and to maintain adequate cardiac output.
(Comer. 2005:45)
Evaluation: Goal met:
After 30 minutes of nursing intervention, the patient had adequate oxygenation and relief from difficulty of breathing.

Problem#2: Chest pain (Aug, 11, 07)
Cues:
Subjective:
• Shortness of breath
• Pain scale 6/10
Objective:
• restlessness
• irritability
• hypoxemia
• dyspea
• cyanosis
• O2 saturation 90% (96-100)
• RR- 30
• Three pillows orthopnea

Nursing Diagnosis: Altered comfort: chest pain related to reduce coronary blood flow secondary to while lying down amb Pain scale is 6/10 verbalized by patient..
Rationale: Chest pain occurs during exertion because the blood supply to the enlarged heart muscle is inadequate. Eventually, heart failure develops causing fatigue and shortness of breath during exertion. (Merck Manual of Medical Information; 2003. p: 163)
Goal: After an hour of nursing intervention, the patient will verbalize decrease of chest pain from 6/10 to 4/10.
Nursing Intervention
Independent:
• Assess for characteristic of chest pain, noting verbal report, non verbal cues
Rationale: Verbal history and deeper investigation of precipitating factors should be postponed until pain is relieved. (Doenges: 2002:74)
• Provide quiet environment, calm activities, and comfort measure.
Rationale: Decrease external stimuli which may aggravate anxiety and cardiac strain. (ibid)
• monitor V/S
Rationale: Provide information about change in V/S. (Comer: 2005: 47)
• Instruct in breathing exercises as needed.
Rationale: Assists to restore function to diaphragm, decrease work of breathing and improves gas exchange. (Comer: 2005:47)
• Position in semi-or high-fowler’s position.
Rationale: Promotes breathing and lungs expansion to enhance gas distribution. (Comer: 2005:47) Dependent:
• Administer oxygen therapy as prescribed by physician.
Rationale: Increase oxygen available for myocardial uptake.(Doenges: 1997:64)
• Administer Morphine sulphate and digoxin as ordered.
Rationale: To relief of pain and to treat of CHF, tachyarrhythmia. (Davis drug Guide for Nurses: 2005:303)
• Administer IVF as ordered.
Rationale: To prevent dehydration (ibid)
Evaluation: Goal met:
After an hour of nursing intervention, the client verbalized decrease of chest pain, the scale from 6/10 to 4/10.

Problem#3: difficulty in sleeping (Aug, 12, 07)
Cues:
Subjective:
• DOB
• Chest pain 6/10
Objective:
• Restlessness
• O2 sat-90%
• Irritability
• Three pillows Orthopnea
Nursing diagnosis:
Disturbed sleep pattern related to difficulty of breathing secondary to three pillows orthopnea or decrease cardiac output.
Rationale: Orthopnea is shortness of breath when a person lies down that is relieved by sitting up. Some people whose heart pumps inadequately experience this condition. This condition is an extreme form of orthopnea and a sign of severe heart failure. (Merck Manual of Medical Information: 2003:225)
Goal: After 8 hours of nursing intervention the patient will have adequate sleep without complication of discomfort.
-After one hour of nursing intervention, the patient will sleep without complaining of difficulty of breath.
Nursing interventions:
Independent:
• Position in semi-fowler’s or high- fowler’s position.
Rationale: Promotes easier breathing and prevents pooling of blood in the pulmonary vasculature. (Comer: 45)
• Maintain quiet and comfortable environment.
Rationale: Mental/ emotional stress increases myocardial workload. (Doenges: 1997, p.64)
• Provide neutral environ-mental temperature.
Rationale: Extremes of temperature increases O2 and energy needs. Which is increases the work of heart.
• Instruct in breathing exercises as warranted.
Rationale: Assists to restore function to diaphragm decreases work of breathing & improves gas exchange. (Comer, p.47)
• Monitor V/S especially HR.
Rationale: Patient with unstable angina has an increased risk of a cute-life threatening dysrhythmics. (Doenges, 1997:p.64)
Dependent:
• Administer morphine sulphate as ordered.
Rationale: Alters the perception of and response to painful stimuli while producing generalized CNS depression. (ibid)
• Administer diazepam as ordered.
Rationale: To relief pain or anxiety. (Davis drug guide: 2005, p.293)
• Administered O2 as ordered.
Rationale: Maintains adequate oxygenation without depression of respiratory drive.
(Comer; 2005:p. 46)
Evaluation: Goal met: After a shift of nursing intervention the patient has adequate sleep and without complaints of DOB and discomfort.

Problem# 4: Fatigue (Aug.20, 2007)
Cues:
Subjective:
• Thirsty
• DOB
• Weakness
• Discomfort
• Fatigue
Objective:
• HR-58
• PR- 30
• Restlessness
• Oxygen sat. 90%
• Irritablity
Nursing Diagnosis:
Activity intolerance related to insufficient oxygen secondary to decrease cardiac output. amb discomfort, weakness, and fatigue while change position.
Rationale: when the heart pumps insufficiently as it does in heart failure, blood flow to the muscles may be inadequate during physical activity, causing feelings of weakness and fatigue. (Merck Manual of medical information: 2003, p.106).
Goal: After a shift of nursing intervention the patient will tolerate increased in activity and without complaint of DOB.

Nursing Intervention;
Independent:
• Monitor vital signs response to activity.
Rationale: provides information about change in V/S and energy level. (Comer: p.47)
• Assess level of fatigue, ability to perform ADL and other activities in relation to severity of condition
Rationale: provides information about energy reserves and response to activity (comer, p.41)
• Assess dyspnea and exertion, skin CD or changes during rest and when active.
Rationale: indicates hypoxia and increase O2 need during energy expenditure. (Comer, 2003, p.41)
• Promote comfort measures and provide for relief of pain. Rationale: to enhance ability to participate in activities (Doenges: 2005:p. 63)
• Position in semi-fowler’s position.
Rationale: promotes easier breathing and prevents, Pooling of blood in the pulmonary vasculature. (Come: p.45).
• Administer O2 as ordered.
Rationale: Supplemental O2 may be required because of hypoxia. (Comer: 2005, p.45)
• Administer medication as ordered. Eg: morphine, isoket, Isodril, digoxin.
Rationale: for treatment of CHF and chest pain. (ibid)
• Administer IVF as ordered.
Rationale: to prevent dehydration. (ibid)
Evaluation: Goal met:
After a shift of nursing intervention the patient tolerated and increased in activity without others difficulty complaint.

Problem # 5: Edema of lower extremities (Aug.19-20, 2007)
Cues: Subjective:
• Dyspnea (SOB)
• Orthopnea
• Anxiety
Objective:
• Edema of his feet
• Weight-gain 2kg
• Dyspnea
• BP- changes
• RR-30
• PR- 58
• Low salt low fat diet order
• Limit fluid intake 1L/day
• Increase urine output
Nursing Diagnosis:
Excess fluid volume related to ineffective pumping of the heart. Excess fluid volume related to decrease cardiac output.
Rationale: swelling is due to the accumulation of fluid (edema) in tissues. It occurs when blood pools in the leg veins, increasing pressure in the leg veins and forcing fluids out of the veins into tissues. Blood may pool because the heart cannot pump out all of the blood it receives from the rest of the body. (Merck manual of medical information; 2003, p. 107).
Goals: After a shift of nursing intervention the patient edema will be minimal in his feet.
Nursing interventions
Independent:
• Monitor urine output.
Rationale: urine output may be scanty and concentrated because of reduced renal perfusion (Doenges:”NCP”1997:53)
• Establish fluid intake schedule.
Rationale: involving patient in therapy regimen may enhance sense of control and cooperation with restrictions (ibid)
• Monitor V/S.
Rationale: Fluid volume excess will cause increase in BP (Comer; 2005, p.42)
• Provide small, frequent easily digestible meals.
Rationale: small, frequent meals may enhance digestion. (ibid)
• Maintain fluid/ sodium aid especially decrease fat & salt.
Rationale: Reduces total body H2O/ prevents fluid re-accumulation. (ibid)
• Auscultate breath sounds.
Rationale: To check for presence of congestion. (ibid)
• Monitor weight daily.
Rationale: document changes of edema in response to therapy. (ibid)
• Elevate lower extremities.
Rationale: to decrease of edematous. (ibid)
• Place in semi-fowler’s position as appropriate.
Rationale: to facilitate movement of diaphragm improving respiratory effort. (ibid)

Dependent:
• Administer medications as ordered (eg. Lasix, bumex)
Rationale: promotes diuretic without excessive potassium lasses increase rate of urine flow and may inhibit re-absorption of sodium in the renal tubules. (ibid)
• Administer albumin as ordered.
Rationale: to relief or reduction of associated edema. (Drug Guide for nursing, 2005, p. 14)
• Administer oxygen 2L as ordered.
Rationale: to prevent hypoxia caused by increase fluid and hypoventilation. (Comer, 2005, 42)
Evaluation: Goal met:
After a shift of nursing intervention the patient edematous is decreased in the lower extremities.

Problem #6; excessive urine output (dehydration) (Aug, 20, 07)
Cues:
Subjective:
• excessive thirst
• dry mouth
Objective;
• dry lips
• output is greater than intake ( output-1590ml & intake-400ml per shift)
• urinary frequency
• dehydration
• diuretics used
• edema in lower extremities
• weight- 50lbs (before-47 lbs)
• easy to fatigability
Nursing Diagnosis: Fluid volume imbalance related to dehydration due to used of diuretics medication secondary to edema in lower extremities.
Rationale: the patients are administering diuretic when appeared edema, because when the pressure in the veins is abnormally high, water if forced out of the veins and into the surrounding tissues. It’s important to note that this fluid accumulates in the spaces between the cells of the body not inside the cells themselves. Since water runs downhill even inside the body, the fluid will accumulate in the lowest part of the body-usually the feet. (Phibbs. Breadon; 1997.p.28)
Goal: After a shift of nursing intervention, the patient will maintain urine output 30ml/hr and with no signs and symptoms of dehydration like no dry mouth and lips.
Nursing Interventions:
Independent
• Monitor V/S every two hours.
Rationale: fever, tachycardia, dyspnea, or hypotension may be symptom of hypovolemia and dehydration. (Comer; 2005.p.134)
• Measure intake and output.
Rationale: estimates patient’s fluid balance. (ibid)
• Assess patient for thirst, dry lips, poor skin turgor, and weakness.
Rationale: may indicate fluid imbalance. (ibid)
• Weight patient daily.
Rationale: monitor for weight loss resulting from fluid losses. (ibid)
• Provide frequent oral care, eye care.
Rationale: to prevent injury from dryness. (ibid)
Dependent:
• Administer albumin as ordered.
Rationale: prevention or treatment of hypovolemic shock. (Mins; 2005. p.386)
• Administer furosemide from 40mg to 20mg as ordered.
Rationale: treatment for edema and management of oliguria (Mins; 2005. p.481)
Evaluation: Goal met:
After a shift of nursing intervention, the patients maintain urine output is 30ml/hr and no signs and symptoms of dehydration (no dry lips)

Problem # 7: Anxiety: (Aug, 12, 07)
Cues:
Subjective:
• DOB
• Fatigue
• Anxiety
• Chest pain 6/10
• Weakness
Objective:
• poor eye contact
• restlessness
• RR-30
• BP-89/58
• PR-58
• Cool skin especially his hands
Nursing diagnosis: anxiety related to change in health status. : Anxiety related to chest pain.
Rationale: The patient, who has heart failure, may experience chest pain, shortness of breath, and fatigue and it cause the patient anxiety.
Goal: after a shift of nursing intervention, the patient will be able to reduced and maintained at acceptable level of anxiety.
• Acknowledge awareness of anxiety.
Rationale: Acknowledgements of patient’s feelings and communicates acceptance of those feelings. (Gulanick et al; 1998; p.5)
• Help the patient understand the procedure of treating the disease. Discuss planned therapies and interventions.
Rationale: Accurate information allows the patient to deal more effectively with the reality of the situation, thereby reducing the anxiety and fear of the unknown, (Doenges et al: 2004; 759)
• Promote comfort measures and provide for relief of pain. Rationale: to enhance ability to participate in activities (Doenges: 2005:p. 63)
• Position in semi-fowler’s position.
Rationale: promotes easier breathing and prevents, Pooling of blood in the pulmonary vasculature. (Come: p.45).
• Monitor V/S.
Rationale: Provide information about change in V/S. (Comer: 2005: 47)
• Instruct in breathing exercises as needed.
Rationale: Assists to restore function to diaphragm, decrease work of breathing and improves gas exchange. (Comer: 2005:47)
• Position in semi-or high-fowler’s position.
Rationale: Promotes breathing and lungs expansion to enhance gas distribution. (Comer: 2005:47)
• Maintain frequent contact with the patient.
Rationale: Being supportive and approachable encourages communication and provides assurance that the patient is not alone. (Doenges et al; 2004; 145)
• Encourage patient’s interaction with family and others.
Rationale: Reduces feelings of isolation and allows for better interpersonal interaction inducing anxiety or fear. (Doenges et al; 1997; p.759)
• Maintain a calm quiet environment and a reassuring manner.
Rationale: Decreases oxygen demand and the work of breathing (William; 2005; 1647)
Dependent:
• Administer O2 as ordered.
Rationale: Supplemental O2 may be required because of hypoxia. (Comer: 2005, p.45)
• Administer diazepam as ordered.
Rationale: To relief pain or anxiety. (Davis drug guide: 2005, p.293)

Evaluation: Goal met: The patient’s anxiety was reduced as evidences by cooperative behavior and calm appearance after a shift of nursing intervention.

Patient laboratory test result
Chest X-ray
-the heart is moderately enlarged left atrial and biventricular prominence.
-there is upward redistribution of pulmonary blood flow.
-aorta is within normal
-main pulmonary artery is slightly prominent.
-diaphragm and bony thoracic cage are unremarkable.
Compression
-mitral valve pathology (predominantly mitral regurgitation) with pulmonary arterio-venous hypertension.

ECG
-Atrial fibrillation with fast ventricular response extreme left axis deviation. Intraventricular conduction delay poor R wave progression V1 – V6.

Echocardiographic Information
Interpretation: Extremely dilated left ventricular with global hypokinesia, with flattening of the interventicular septum on systole and diastole suggestive of volume and pressure overload.
-giant left atrium, without thrombus
-dialated right atrial dimension
-dialated righ ventricular dimention
-thickened mitral valve leaflets with poor cooptation of leaflets, widened E-point septal separation.
-structurally normal tricuspid and pulmonic valve.
Doppler
-mitral regurgitation severe aortic regurgitation severe tricuspid regurgitation. Moderate pulmonic regurgitation mild.

ABGs (Aug, 9, 2007) Aug, 10, 2007
Result normal value result pH- 7.46 (7.35-7.45) 7.37
PCO2- 29.6 (35-46) 26.8
PaO2-121.3 (95-100) 149
HCO3- 21.0 (22-26) 15.6

CBC: (Aug, 10, 2007)
Result Normal value
RBC- 4.90 4-6 x 1012/L
WBC- 10.80 5-10 X 109/L
Lymphocyte 0.15 0.25-0.35

Serum test (Aug, 10, 2007) 8/12/07 8/14/07 8/18/07 Result normal value result result result
Urea 8.5mmol/L 3.2-7.1
Sodium 129mmol/L 135-148 127
Potassium 4.03mmol/L 3.5-5.3 4.4 4.3 5.0 Aug, 11, 2007 Normal value
CK – MB 43U/L 0-16 45 67

Urine Cardiac Enzymes test Normal
Color – dark yellow AST- 2063 U/L 17-59
Transparency – Hazy ALT- 1538 21-72
Volume – 40ml Globulin-32g/L 20-30
Specific gravity – 1.025
Ph reaction - 6.0
Protein - ++

Doppler test: result Normal
Peak gradient (mmHg) 8.41 2.4-6.7

Echocardiographic Information M-mode/2D measurement (Aug, 13, 2007) Result Normal
LVEDD 9.88 4.0-5.0cm
IVS(D) 1.12 0.7-1.1 cm
EPSS 2.80