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8
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 7
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 6
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 5
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 4
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 3
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 NOW
PRESENTING
.....

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 BSN 4B – Group 1
Acula, Jannet
Alama, Gladys
Capuyan, Dennis Timothy
Codilla, Marites
Elmido, Jim
Emping, Roxanne
Ida, Stephen Mark
Loreto, Karen
Patalinghug, Herminia
Serafica, Jacqueline
Sy, Hannah Theresa
Tagalog, Alfi

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 A case Study

Western Leyte College of Ormoc City,

Inc.
College of Nursing
In partial fulfillment of the
requirements in
Nursing Care Management 204
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 OBJECTIVE
S

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 necessary knowledge
about the General
whole concept
Objectives
of heart failure. It also
intends to assist nurses
in planning and
analyzing specific
nursing interventions
that should be
performed. To further
>> 0exercise nurse’s critical
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 Specific Objectives:
After mastering the contents, the readers will be able to;

1.Define the word “heart failure”.

2.Understand the underlying cause,
different factors that contribute to the
development of the disease, and the
accompanying clinical manifestations
and complication.
3.Differentiate the normal anatomy and
physiology and the pathophysiologic
condition of the disease.
4.Identify necessary nursing care to be
performed to enhance patient conditions
and to prevent complications.
>> 5.Understand
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>> importance
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3 regular
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>> 0 >> 1 >> 2 >> 3 >> 4 >>
 NAME: E. Dawaton CASE
#: 87-54-26
AGE: 37 Years old
ADDRESS: Gaas, Ormoc City

B-DATE: Nov. 8,1972

OCCUPATION: Jeepney driver
RELIGION: Roman Catholic
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 CHIEF COMPLAINTS:
Loss of appetite
since 2 days prior to
admission
accompanied w/
dyspnea on exertion
and tenderness in the
RUQ of the abdomen.
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 Condition started 2 days prior to
CURRENT HEALTH
admission due to loss of appetite,
w/ exertional dyspnea upon
STATUS:
driving, shortness of breath when
lying flat, edema on lower
extremities. He also complained of
tenderness in the RUQ of the
abdomen. Symptoms persisted
which made patient’s family to
seek medical consultation and was
admitted at Ormoc District
Hospital on August 6, 2009 at
>> 11:40
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>> was
2 >>diagnosed
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PAST MEDICAL ILLNESS:
Common childhood diseases experienced
were chicken pox, measles and mumps.
Client has no history of previous
hospitalization nor undergone any surgical
procedure. Common adult illnesses
experienced were common colds, fever, and
cough in which client treated with herbal
preparations such as decoction of guava
leaves. When symptoms persist, client didn’t
immediately seek medical consultation due to
financial constraints. He does not take
vitamins or any food supplements. He
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 Digoxin .25mg 1tab OD for HR 100bpm
Furosemide 40mg IVTT q° 12hrs for
SBP less than 90mmHg
Spironolactone 25mg 1tab BID
Captopril 25mg 1tab TID
Ranitidine 50mg IVTT q° 8hrs.

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 Client is a responsible father
and a faithful husband to his
wife. He claimed to have a
harmonious relationship w/ his
family, neighbors and co-
drivers. He is not actively
involved in any organization in
their church and in their
community.
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 >
24-H Dietary intake review
 
(Before Hospitalization: )
Breakfast: 1 cup rice, paksiw, half glass of water
Lunch: 1 cup rice, paksiw, half glass of water
Dinner: 1 ½ cup rice, caldereta, half glass of water
Client likes to eat vegetables and seafoods. He’s
not picky and has no allergies to any food. He has no
problem or difficulty in chewing. Religion doesn’t affect
his diet.
 
(During Hospitalization :)
The client hardly ate, if ever he does, he only
consumed a tablespoon or two of rice and viand. His
fluid intake was limited to 800cc per day.
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 BLADDER ELIMINATION
>Before hospitalization:
Client usually voids 2x at day
time and 3x during night time. His
approximate fluid intake is 1.5 L/day and daily
caffeine intake is approximately 200 cc/day.
Complained slow and small amounts of urine
voided. Client has no history of UTI or STI, no
medication taken that may affect bladder
elimination.
During hospitalization:
Voided 4x daily. Noyour
caffeine
name
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 Before hospitalization:
Claimed to have normal
bowel elimination. Defecates 2x daily,
usually in the morning and in the
evening. Doesn’t take any laxatives.
During hospitalization:
Defecated once a day. No
problem reported.

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Slide 28 © 2003 By Default!

COGNITION AND PERCEPTION:

He has no problem w/ his 5 senses. Only answers
questions that were asked and doesn’t expound
more. Follows verbal cues but expresses ideas
directly to AND
ACTIVITY the point.
EXERCISE:
With regards to client’s regular daily activities, he
works as a jeepney driver. His usual day starts
at 3 am preparing for work which usually starts
4am until 5pm. He is usually at home by 5:30 pm
watching TV before retiring to bed at 8 pm.
He utilizes his leisure time in watching
television and mingles w/ his neighbors and plays
basketball.
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A Free sample background from www.powerpointbackgrounds.com
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EP-REST PATTERN:
Client has an average of 8 hours of sleep/day before
his confinement. During hospitalization, he usually sleeps 5
hours and doesn’t normally take naps in the afternoon. Slept
with 2 pillows in sitting position. Complained of shortness of
breath when lying flat.
SELF-PERCEPTION AND
SELF-CONCEPT:
Client viewed himself as a normal individual. He’s not contented
with his work because it does not sustain the needs of his
family. He talks and speaks in a low tone of voice with poor
eye contact.

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COPING AND STRESS
TOLERANCE:

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SEXUALITY AND
REPRODUCTION:

VALUES AND
BELIEF PATTERN:
Client is a Roman Catholic but rarely attends Sunday
masses. He admitted he had no organization/religious
affiliation. Sometimes, he viewed illness as a
punishment of wrong doings.

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 GENOGRAM

? Nicanor Anita Quilos

Federico Marciano Esperanza Beivenido Adoracion Frederico Igling Reming Egle Maria
(CHF) 74y.o. 72y.o . 61y.o. 60y.o. 78y.o. 73y.o. 68y.o. 65y.o. 62y.o

C W
Flordeliza Wilfredo Edison Frederico Jr. Imelda
C CLIENT 41y.o 39y.o 37y.o 32y.o. 35y.o.

MALE

FEMALE

MALE (Deceased) Edmar Marvin Ma. Christine Edison Jr.

FEMALE (Deceased) 16y.o. 14y.o 12y.o. 10y.o.

W
CLIENT’S WIFE

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 DISEASE
BACKGROUND

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 Heart failure is the inability of the heart to pump
sufficient blood to meet the needs of the tissues for
oxygen and nutrients.

*Clinical manifestations of HEART FAILURE:

General
Pale, cyanotic skin
Edema in both feet, legs, and ankles
Decreased activity tolerance
Unexplained confusion or altered mental status
Cardiovascular
Tachycardia
Third heart sound (S3)
Murmurs (with valvular dysfunction)
Apical pulse, enlarged & left lateral displacement
Increased jugular vein distention (JVD)
Cerebrovascular
Lightheadedness
Dizziness
Confusion
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 Gastrointestinal
- Nausea & Anorexia
- Ascites
- Enlarged Liver
- Hepatojugular test, increased
Renal
Decreased urinary frequency during the day
Nocturia
Respiratory
Dyspnea on exertion
Orthopnea
Paroxymal nocturnal dyspnea
Bilateral crackles that do not clear with cough
Cough on exertion or when supine
CAUSES
Coronary Artery Disease
Cardiomyopathy
Hypertension
Valvular disorders
Diabetes Mellitus
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