NCM121 INTENSIVE NURSING PRACTICUM

Case study:
Left-sided Heart Failure
 CASE SCENARIO
A 67-year-old, widowed, Christian, retired bank manager, male patient from Tondo, Manila who drinks
alcoholic beverages heavily (3 glasses per day), eats salty and fatty foods in great amount, sedentary
lifestyle, is a chain smoker for 2 decades. The patient lives alone (with caregiver), receives monthly
remittance from his two children living/working abroad as health practitioners and also receives monthly
pension of Php7,000 from SSS. Despite regular medical checkup, patient was still unable to manage his
blood pressure, and was known to be hypertensive for 15 years. Later on, he was diagnosed with
cardiomyopathy. Both parents were known to be hypertensive, and both died of cardiovascular diseases.
He was brought to the emergency department because of angina pectoris, difficulty of breathing, and
shortness of breath. Vital signs were taken BP-150/110 mmHg, PR- 85bpm with S3 and S4 murmur, RR-
28 bpm, body temperature of 36.5 degrees Celsius, and SpO2 of 80%.The doctor ordered for different
diagnostic procedures and revealed Creatinine Kinase MB Isoenzymes of 23 IU/L, Troponin I of 0.12
ng/mL and Troponin T of 0.24 ng/mL, triglycerides, and cholesterol of 250 mg/dL, erythrocyte of
5,500,00/mm3, ejection fraction of 34% and increase in weight of 2 lbs. in 2 days. The patient was given
Simvastatin, Lanoxin, and Captopril as part of maintenance drug therapy.
 INTRODUCTION
Heart failure is defined by the American Heart Association and American College of Cardiology as “a complex clinical
syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with
or eject blood.”
•In systolic heart failure, cardiac output is decreased directly through reduced left ventricular function. In diastolic
heart failure, cardiac output is compromised by poor ventricular compliance, impaired relaxation, and worsened end-
diastolic pressure (King et.al., 2012).

Objective of the Study

• This study aims to:
• Provide knowledge and awareness about HFrEF (Heart Failure with reduced Ejection Fraction) and the different
classifications of Heart Failure based on the pumping ability.
• Compile the risk factors that contribute to development of HFrEF.
• Describe the presentation of a patient with HFrEF and the proper evaluation process, including diagnostic
imaging if necessary.
• Review the treatment and management of HFrEF.
• Outline the importance of interprofessional collaboration and communication in determining the HFrEF and
initiating nursing interventions to reduce morbidity and death in those affected.
 MORBIDITY & MORTALITY RATE
   
GLOBALLY
    An estimated 64.3 million people are living with
heart failure worldwide. In developed countries,
the prevalence of known heart failure is
generally estimated at 1% to 2% of the general
adult population.
    
    The incidence of heart failure in European
countries and the USA ranges widely from 1 to
9 cases per 1000 person-years and strongly
depends, again, on the population studied and
the diagnostic criteria used. In developed
countries, incidence rates have stabilized
between 1970 and 1990 and are now thought
to be decreasing (Rutten, 2020).
 MORBIDITY & MORTALITY RATE
   
LOCALLY (Philippines)

    There were 16 cases of heart failure for every 1000 Filipino patients
admitted due to a medical condition in 2014. Hypertension was possibly
the most common etiologic factor. Compared to western and Asia-Pacific
countries, the local mortality rate was relatively higher (Tumanan-
Mendoza, et.al., 2017).

    Based on the PSA data released on February 22, 125,913 or 17.9

percent of the total deaths during the said period died of ischemic heart
disease followed by cerebrovascular disease (68,180 or 9.7 percent)
(Kabagani, 2022).
 NURSING THEORETICAL FRAMEWORK
Theory of Self-Care Deficit

This theory delineates when nursing is needed. Nursing is

required when an adult (or in the case of a dependent, the
parent or guardian) is incapable of or limited in providing
continuous effective self-care. Orem identified 5 methods of
helping:

1. Acting for and doing for others

2. Guiding others

3. Supporting another

4. Providing an environment promoting personal development

about meet future demands

5. Teaching another
 PATIENT PROFILE
• Admitted to: Critical Care Unit • Educational Status: College Graduate- BS
Accountancy
• Date of Admission: March 02, 2022  • Religion: Born again Christian
• Nationality: Filipino
• Patient Name: J. D. L.
• Civil Status: Widowed
• Address: Tondo, Manila • Occupation: Unemployed, Retired Bank Manager
• Age: 67 y/o • Health Care Financing: Self-paying and
PhilHealth (SSS pension and children financial
• Gender: Male support)
• Informant: Patient
• Date of Birth: January 28, 1955
• Reliability: 100%
 PATIENT PROFILE
• Admission Data: 
1. Chief Complaint: Chest pain (angina pectoris), difficulty breathing and
shortness of breath
2. Initial Diagnosis: Cardiomyopathy, To rule out Acute Myocardial Infarction
3. Final Diagnosis: Left-sided Heart Failure with Reduced Ejection Fraction
4. Attending Physician: Dr. Paulo Mejia, Dr. Jeeno Jay Frani
 PATIENT HISTORY
CHIEF COMPLAINT: Chest pain, difficulty breathing and shortness of breath

HISTORY OF PRESENT ILLNESS:

Despite regular checkups, the patient has been known to be Hypertensive for 15 years now. He was
also later on diagnosed with Cardiomyopathy. He was brought to the emergency department
because of angina pectoris, difficulty breathing and shortness of breath. He was then admitted for
further diagnostic exams, treatment and management.

• PAST MEDICAL HISTORY:

• Growth Development: Late Adulthood

• Childhood Disease: Chickenpox, German measles, Dengue Fever (1995)

• Immunization: Fully immunized

 PATIENT HISTORY
• Allergies: None
• Hospitalization: Dengue Fever back in 1995 when the patient was 40 y/o.
• Surgeries: No known history
• Previous Accident: No known history
• Injuries: No known history
FAMILY HEALT HISTORY (GENOGRAM)
 PERSONAL AND SOCIAL HISTORY
LIFESTYLE:
• Personal habits: heavy drinker (3 glasses of beer/day), chain
smoker for 2 decades, 
• Diet: fond of eating salty and fatty foods in great amount
• Sleep Patterns: Usually sleeps 4-6 hrs a day. Intermittent due to
having to get up to void in the middle of the night.
• Activities of Daily Living: Sedentary lifestyle
• Instrumental ADLs: None
• Recreation/Hobbies: None
 PERSONAL AND SOCIAL HISTORY
SOCIAL DATA:
• Family relationships/friendships:
Patient is already a widow, has two children living and working abroad as
health practitioners. Currently, he lives alone with supervision of a caregiver.
• Educational History:
Patient is a graduate of BS Accountancy.
• Occupational History:
Patient has been a Bank Manager for almost 25 years but is now a retiree.
• Economic Status:
Since he is already retired, he relies on his SSS pension of Php7,000.00
monthly, as well as the monthly remittances he receives from his two children
who are abroad.
 GORDON’S LEVEL OF FUNCTIONING
LEVEL OF BEFORE HOSPITALIZATION DURING HOSPITALIZATION ANALYSIS/INFERENCE
FUNCTIONING
Health Perception/ “Regular naman ang check up ko pero “Bukod pala sa regular na check Patient knowledge increased;
Health Management mahirap talaga iwasan ang nakasanayan up at pag inom ng gamot, patient’s compliance to health and
ko na tulad ng paninigarilyo at pag inom, kailangan ko din pala iwasan ang medication regimen improved.
okay lang naman yun basta iniinom ko ang mga pag inom at paninigarilyo
gamot ko sa presyon na Losartan ay dahil tataas pa rin ang presyon
mamemaintain ko ang bp ko sa normal na ko at posible pa rin ako
level” magkasakit sa puso, hindi ko na
pipilitin ang mga gusto ko kung
makakasama naman”
 GORDON’S LEVEL OF FUNCTIONING
LEVEL OF BEFORE HOSPITALIZATION DURING HOSPITALIZATION ANALYSIS/INFERENCE
FUNCTIONING
Nutritional and Metabolic “Palagi talagang beef o pork ang ulam ko. “Masama pala ang pagkain ng Patient chose to maintain a healthy
Pattern Tapos ang merienda ko naman ay madalas beef at pork palagi lalo na ang diet and restrict fluid intake to
pizza at hamburger. Mahilig ako sa maalat, mga pagkain na maalat, ngayon maintain normal blood pressure
mamantika at mga pritong pagkain” ay gulay at isda na ang madalas and prevent complications.
na ulam ko. Iniwasan ko na rin
ang mga prito at makolesterol na
pagkain.Sinabi rin ng doktor na
hanggang 1 litrong tubig lang ang
pwede kong inumin sa isang
araw”
 GORDON’S LEVEL OF FUNCTIONING
LEVEL OF BEFORE HOSPITALIZATION DURING HOSPITALIZATION ANALYSIS/INFERENCE
FUNCTIONING
Elimination Pattern “Nahihirapan ako umihi, minsan napapansin ko “Dumalas ang pag-ihi ko, kahit sa Patient experiences side effects of the
na tatlong beses lang ako sa isang araw gabi ay kailangan kong bumangon medications for Heart failure
nakakaihi at sobrang konti lang. Nahihirapan din ng mga 2 hanggang 3 beses para (Diuretics) causing frequent urination
ako dumumi minsan ay inaabot ng ilang araw” umihi. Sa pagdumi naman, lalo and constipation,
akong nahirapan. Sobrang tigas ng
dumi ko. Mahirap iiri”

Activity-Exercise Pattern “Hindi ako nag eexercise, hindi rin ako “Sinabihan ako nila Doc na iwasan Patient does not participate in any
naglalakad lakad, madalas nasa bahay lang ako na muna ang mga pagkilos, kahit activity-exercise pattern because it is
o kaya pag lalabas ako ay naka kotse naman, paglalakad hanggang sa bumuti na contraindicated with his condition.
nahihirapan ako maglakad lakad dahil masakit ang lagay ko.”
mabilis akong hingalin at mapagod”
 GORDON’S LEVEL OF FUNCTIONING
LEVEL OF BEFORE HOSPITALIZATION DURING HOSPITALIZATION ANALYSIS/INFERENCE
FUNCTIONING
Sleep-Rest Pattern “Nahihirapan ako matulog ng mahimbing at “Nakatulong sakin yung tinuro Patient showed improvement in
nagigising ako palagi ng madaling araw na maglagay ng 3 unan sa ulo sleeping pattern during
dahil nahihirapan ako huminga” kapag nakahiga, kaya maayos hospitalization
na yung pag tulog at pahinga ko
   
kumpara noon”
Cognitive-Perceptual “Medyo malabo na mata ko, 1.75 grado ng “ Wala naman nagbago nung Patient showed no signs of
Pattern dalawa kong mata pero nasanay narin maospital ako, naaalala ko parin abnormalities with regards to his
naman ako, maayos naman ang memorya inumin mga gamot ko” thought process and was
ko hindi ko naman nakakalimutan inumin conscious and coherent to the
mga gamot ko, Wala naman problema sa questions of the interviewers.
pandinig ko, pang-amoy, pati yung
pakiramdam ko.”
 GORDON’S LEVEL OF FUNCTIONING
LEVEL OF BEFORE HOSPITALIZATION DURING HOSPITALIZATION ANALYSIS/INFERENCE
FUNCTIONING
Self-Perception and “Nung una nahirapan ako tanggapin at “Hindi ko na masyado iniisip Patient showed acceptance and a
Self-Concept Pattern napa patanong na lang kung bakit sa itong kondisyon ko, habang positive attitude towards his
dinami dami ng tao ay ako pa” tumatagal natanggap ko na rin” condition and his view towards
  life.

Role-Relationship “Ako na lang mag-isa ngayon dito kasi “Medyo nakakalungkot kapag Patient has experienced
Pattern yung dalawang anak ko nasa abroad na. mga espesyal na okasyon at loneliness and frequently
Yung caregiver na lang ang kasama ko. caregiver lang ang kasama ko. reminisces about the past with his
Nagpapadala na lang ng pandagdag sa Pero katagalan ay nakasanayan wife and children. This could be
panggastos yung dalawa kong anak. ” ko na rin naman. Minsan lang the reason why somehow he
talaga ay parang mapapaisip ka neglected his health reflected by
tungkol sa dating andito pa si his unhealthy lifestyle.
Misis at ang mga anak namin.”
 GORDON’S LEVEL OF FUNCTIONING
LEVEL OF BEFORE HOSPITALIZATION DURING HOSPITALIZATION ANALYSIS/INFERENCE
FUNCTIONING
Sexuality and “Matagal na akong walang ganyan simula “Ganun parin naman, wala Patient has an inactive sex life.
Reproductive Pattern nung mamatay ang asawa ko” nagbago”
 
Coping Stress Tolerance “Kapag may problema ako, mas “Ganun parin naman, kapag Patient uses verbalization of his
gumagaan loob ko kung inoopen ko sa may problema ako at nasstress opinions to her family as his
pamilya ko, pero madalas dinadaan ko sa sa mga bagay bagay ay gusto coping mechanism to stress along
inom at paninigarilyo kasama mga kong pinaguusapan talaga pero with drinking alcohol and
kaibigan ko” ngayon hindi na ako umiinom at smoking; Patient improved stress
naninigarilyo. tolerance by eliminating alcohol
and smoking.
Value-Belief Pattern “Naniniwala ako sa may nasa itaas na “Wala naman ibinigay ‘ang nasa Patient showed that he has strong
hindi Niya ako pababayaan sa kundisyon itaas na hindi natin faith and beliefs.
ko” makakayanan.”
 PHYSICAL ASSESMENT
Date: Mar. 02, 2022
Initial Vital Signs
Temperature: 36.5°C Pulse Rate: 85 bpm
Respiratory Rate: 28 bpm Blood Pressure: 150/110 mmHg

SpO2: 80%

Height: 5’ 7”
Weight: 220 lbs.
 PHYSICAL ASSESMENT
ASSESSMENT FINDINGS INFERENCES
Fatigue accompanied by a feeling of
Generally related to poor perfusion of the skeletal muscles in
heaviness in the limbs.
Decreased activity tolerance patients with lowered cardiac output.
GENERAL (+) Weight gain of 2 lbs for 2 days

Due to fluid retention.

Peripheral cyanosis
Due to increased adrenergic activity.
Cold clammy skin
SKIN Due to reduced cardiac output and decreased tissue
perfusion.
Slight alopecia
HAIR Normal age-related changes
(+) achromotrichia
Delayed capillary refill
Due to reduced cardiac output and decreased tissue
NAILS
perfusion.
Normocephalic
SKULL AND HEAD MOVEMENT Normal findings
Sensation intact over face.
Normal findings
FACE No facial asymmetry.
Muscles of facial expression intact.
 PHYSICAL ASSESMENT
ASSESSMENT FINDINGS INFERENCES
Pink conjunctiva Normal findings
White sclera Normal age-related changes
(-) jaundice
External ocular movements (EOMs)
EYES
intact
PERRLA
(+) presbyopia

(+) Presbycusis Normal age-related changes

EARS and HEARING (-) external deformity

NOSE No deformity or deviation Normal findings

Lips and gums are pallor Normal findings
MOUTH With dentures
(-) bleeding, lesions or inflammation
 PHYSICAL ASSESMENT
ASSESSMENT FINDINGS INFERENCES
(-) masses or tenderness Normal findings
Trachea at midline
Thyroid normal in size and consistency
NECK & THROAT
Carotid pulse full and equal
Without bruit
Lymph nodes not enlarged
RR 28 cpm (tachypneic) Rales/ crackles and wheezing on auscultation of the
Dyspneic lungs are signs of pulmonary edema secondary to
Orthopneic elevated left-sided filling pressure.
RESPIRATORY
Paroxysmal nocturnal dyspnea  
(CHEST and BACK)
(+) crackles and wheezing  
Slight kyphosis  
Axillary lymph nodes not enlarged Normal age-related changes
BP 150/110 mmHg The presence of S3 in heart failure is considered to
PR 85 bpm indicate a stiff left ventricle and is associated with
CARDIOVASCULAR Weak and thready pulse reduced cardiac output, elevated end-end diastolic
(+) S3 gallop and S4 murmur pressure, decreased ejection fraction and adverse
Visible PMI (Point of maximal impact) outcomes.
 PHYSICAL ASSESMENT
ASSESSMENT FINDINGS INFERENCES
Normal bowel sounds Constipation may be due to reduced fluid intake,
No abnormal tympany reduced mobility or some medications.
(-) bruit
GASTROINTESTINAL and ABDOMEN
(-) rigidity
(-) organomegaly
(+) constipation
(+) edema in ankles, legs and feet Result of plasma oncotic pressure due to low serum
Peripheral cyanosis albumin that is not infrequently seen in patients
(+) pallor with chronic end-stage heart failure.
MUSCULOSKELETAL
Diminished pulse volume
Extremities
Limited ROM of some joints
No asymmetry
No bruit in femoral artery
Nocturia Recumbency reduces the deficit in CO in relation to
  oxygen demand, renal vasoconstriction diminishes,
GENITOURINARY No external lesions on the genital. and urine formation increases (Dumitru, 2021)
No urethral discharge
No tenderness or masses
 PHYSICAL ASSESMENT
ASSESSMENT FINDINGS INFERENCES

(-) external lesions Normal findings

No tenderness or masses
RECTAL
Normal prostate, firm without
tenderness or nodules.
ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY
 PREDISPOSING FACTORS PRECIPITATING FACTORS

PATHO 


Age: 67 y/o
Sex: Male
Family history of




Lifestyle: Sedentary lifestyle
Diet: High Salt and High fat
Alcoholic and smoker for 2 decades
Diagnosed w/ Cardiomyopathy (15yrs. Ago)

PHYSIOLOGY
hypertension and  History of Hypertension
cardiovascular diseases.
 

Myocardial dysfunction
(Decrease CO, decrease systemic blood pressure, & decrease perfusion to kidneys)

Activates neurohormonal compensatory mechanism

Activation of renin-angiotensin- Activation of baroreceptors in

aldosterone system the aortic and carotid bodies

Conversion of angiotensinogen to Activation of sympathetic nervous system of releasing

angiotensin II catecholamines (epinephrine and norepinephrine)

Vasoconstriction
Increased Peripheral resistance

Sodium and fluid retention: Increase afterload, increase

Edema increase vasopressin and blood pressure, and increase
aldosterone heart rate.
S/S
Further stress on ventricular wall and dilatation •Dyspnea
Weight Gain
(remodeling) leading to worsening of ventricular function •Shortness of breath
(2lbs.in 2 days)
(Myocardial cell apoptosis leading to further dysfunction, •Difficulty of breathing
decreased ejection fraction) •Chest pain
•S3 &S4.

Left sided Heart Failure

 REVIEW OF RELATED LITERATURE
LOCAL LITERATURE
According to Rivera F.B (2021) cardiovascular disease is the most commonly diagnosed
medical condition among patients aged 65 years and above and is a major global
problem with an estimated worldwide prevalence of 38 million. Of those, there were 6.2
million adults in the USA who have heart failure (HF), and this number is expected to
rise in the future. The high morbidity and mortality rate associated with HF make it a
challenging public concern with significant financial burden on healthcare.
While the etiology and mechanistic processes underlying HF may be numerous, central
in its pathophysiology is a disturbance in the ability of the ventricles to either pump (HF
with reduced ejection fraction) or receive blood (HF with preserved ejection fraction)
blood. This dysfunction results in impaired perfusion and oxygen delivery to the
peripheral tissues. 
 REVIEW OF RELATED LITERATURE
FOREIGN LITERATURE
Patients should receive education on the importance of lifestyle modification for
improving the outcome of their disease. This includes reasonable salt consumption and
avoidance of alcohol, nicotine, and recreational drugs. Treating the underlying cause is
of extreme importance as some heart failure conditions may be reversible when the
precipitating factors are addressed, like cardiomyopathies induced by alcohol,
tachycardia or ischemia. Tight control of blood pressure will also help prevent further
deterioration. 
LABORATORY RESULTS AND DIAGNOSTIC PROCEDURES
1.Cardiac Biomarkers/enzymes:
• CK MB Isoenzymes - 23 IU/L
2.Troponin Levels
• Troponin I - 0.12 ng/mL
• Troponin T - 0.24 ng/mL
3.Complete Blood Count
• Erythrocyte - 5,500,000/mm3
4.Lipid Profile
• 250 mg/dL
5.Electrocardiography
6.2D Echo
 NURSING CARE PLANS
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: Decreased cardiac After 2 hours of INDEPENDENT: 1. Baseline oxygen saturation
is useful in establishing the
After 2 hours of
“Pakiramdam ko ay 1. Monitor oxygen
output related to nursing interventions saturation level and
diagnosis and severity of nursing interventions
parang ang bilis kong generalized the patient will report heart failure in acute settings
the goal is partially
ABGs. (Masip et al., 2012; Milo-
mapagod or hingalin
weakness as decreased episodes 2. Monitor blood Cotter et al., 2009). met. The patient
kahit na saglit na pressure (BP). 2. In acute heart failure, BP
paglalakad lang, o kung evidenced by chest of dyspnea and may be elevated because of demonstrated
3. Monitor urine output,
minsan kahit wala pain, orthopnea, angina. noting decreasing
increased systemic vascular adequate cardiac
resistance (SVR).
namang ginagawa,” as crackles and audible output and 3. Urine output may be output as evidenced
verbalized by the extra heart sounds concentrated urine. decreased due to decreased
renal perfusion – kidneys
by ejection fraction of
patient. 4. Encourage rest, semi
(S3 & S4). recumbent in bed or
react to reduced cardiac 55% and eupnea.
  output by retaining water
chair. Assist with and sodium.
OBJECTIVE: physical care as 4. Enforce complete bed rest NIC- Cardiac risk
BP 150/110 mmHg indicated. when necessary to decrease
Fatigue the cardiac workload on management
Activity intolerance DEPENDENT:
acute symptomatic attacks NOC- Cardiac pump
of HF.
Dyspnea 5. Give oxygen as 5. Supplemental oxygen effectiveness
Shortness of breath indicated by the increases oxygen availability
patient’s symptoms, to the myocardium and can
(+) S3and S4 help relieve symptoms of
oxygen saturation,
(+) Crackles and ABGs.
hypoxemia, ischemia, and
subsequent activity
6. Administer intolerance (Giordano, 2005;
medications as Haque et al., 1996).
indicated 6. For pharmacotherapeutic
management of the signs
and symptoms.
 NURSING CARE PLANS
ASSESSMENT  DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Impaired gas After 2 hours of INDEPENDENT:

1. Position patient with head of
1. Upright or semi-Fowler’s
position allows increased
After 2 hours 
“Nahihirapan exchange related nursing the bed elevated, in a semi- thoracic capacity, total nursing
akong huminga at to alveolar edema interventions, the Fowler’s position (head of the
bed at 45 degrees when
descent of the diaphragm,
and increased lung
interventions, the
kapos ako sa secondary to client will maintain supine) as tolerated. expansion preventing the client has
increased optimal gas 2. Regularly check the patient’s abdominal contents from maintained  optimal
paghinga”, as ventricular exchange as
position so that they do not crowding.
gas exchange as
slump down in bed. 2. Slumped positioning
verbalized by the pressure. evidenced by normal 3. Turn the patient every 2 hours. causes the abdomen to evidenced by normal
patient. respirations at 12-20
Monitor mixed venous oxygen
saturation closely after turning.
compress the diaphragm
and limits full lung respirations of 18
OBJECTIVE: breaths per minute If it drops below 10% or fails to expansion. breaths per minute.
return to baseline promptly, turn 3. -Turning is important to
- Pale conjunctiva the patient back into a supine prevent complications of
- Fatigue position and evaluate oxygen
status.
immobility, but in critically ill
patients with low
NIC: Respiratory
- crackles upon 4. Encourage deep breathing, hemoglobin levels or Monitoring
auscultation
using an incentive spirometer decreased cardiac output, NOC: Respiratory
as indicated. turning on either side can
5. Educate about smoking result in desaturation. Status Gas
cessation and provide 4. -To reduce alveolar Exchange
resources such as outpatient collapse.
facilities that can help. The 5. -Smoking causes damage
primary health care provider to the lungs and impairs
can prescribe medications that adequate gas exchange.
reduce withdrawal symptoms. 1. -Supplemental oxygen
DEPENDENT: improves gas exchange and
6. Administer oxygen as ordered oxygen saturation.
 NURSING CARE PLANS
ASSESSMENT  DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: Ineffective Tissue After 1 of nursing INDEPENDENT:
1. -Note urine output.
1. Reduce renal perfusion may
take place due to vascular
After 1 of nursing
Para kong Perfusion related interventions, the 2. -Encourage the patient to elevate occlusion. interventions, the
the legs at the heart level, never 2. -Raising extremities above
nanghihina at to decreased client will above the level of the heart. the heart level might slow client demonstrated  
mahirap huminga. cardiac output as demonstrate 3. - Provide warm blankets and
encourage to keep extremities
arterial blood flow and
therefore diminish perfusion
increased perfusion
Parang mabigat evidenced by increased perfusion warm by wearing socks and to the feet. as evidenced by 95-
slippers. 3. -Cold temperatures cause
yung dibdib”, as generalized as evidenced by 95- 4. -Recommend or provide foot and vasoconstriction, hence 100% O2 Sat.
verbalized by the weakness, 100% O2 Sat. ankle exercises when client is
unable to ambulate freely.
restricting blood flow.
4. -To reduce venous pooling
patient. dyspnea, and 5. -Apply intermittent compression and increase venous return. NOC: Tissue
devices or compression stockings 5. -To limit venous stasis,
OBJECTIVE: bipedal pitting (GCSs) to lower extremities improve venous return and Perfusion: Peripheral
- Pale conjuctiva, nail edema 6. - Encourage smoking cessation. reduce risk of DVT in client NIC: Circulatory
7. -Monitor for development of who is limited in activity.
beds and buccal gangrene, venous ulceration, and 6. -Smoking tobacco is also Care
mucosa symptoms of cellulitis
8. -Discourage sitting or standing for
associated with
catecholamines release
- With pitting extended period of time, wearing resulting in vasoconstriction
constrictive clothing, or crossing and ineffective tissue
edema on both legs when seated perfusion
forearms and DEPENDENT:
-Administer IV fluids as ordered.
7. -Restricts circulation and
leads to venous stasis and
hands 9. Administer oxygen as ordered edema
COLLABORATIVE: 8. -Sufficient fluid intake
- O2 sat 80% 10. -Refer to a dietitian for a well- maintains adequate filling
- Ejection fraction balanced, low saturated fat, low
cholesterol diet or other
pressures and optimizes
cardiac output needed for
40% modifications as indicated. tissue perfusion
9. -To enhance myocardial
perfusion.
 DRUG STUDY
Name of Drug Action Dosage Indications Contraindications Adverse Reactions Nursing Responsibilities

Captopril Inhibits ACE, Tablets: 12.5mg, Hypertension (alone Contraindicated in CNS: Monitor patients BP
preventing 25mg, 50mg, 100mg or in combination with
patients dizziness,fainting,hea and pulse rate
Therapeutic Class: conversion of other hypersensitive to dache,malaise,fatigue frequently.
Antihypertensives angiotensin I to antihypertensive) drug or other ACE ,fever,
angiotensin II, a inhibitors and in insomnia,paresthesia. Assess patient for
Pharmacologic potent Diabetic nephropathy patients who had signs of angioedema.
Class: ACE vasoconstrictor. Less angioedema related CV:
Left ventricular tachycardia,hypotensi Drug cause
inhibitors  angiotensin II to previous treatment
dysfunction after on,chest pain,angina cough,most
decreases peripheral with an ACE
acute MI. pectoris,palpitations. frequently of all ACE
arterial resistance, inhibitors.
inhibitors 
decreasing
Use cautiously in GI: Abdominal
aldosterone In patients with
secretion, which patients with impaired pain,anorexia,constip
ation,diarrhea,dry impaired renal
reduces sodium and renal function or
function or collagen
water retention and serious autoimmune mouth,dysgeusia,
nausea, voiting. vascular disease,
lowers BP. disease, especially
monitor WBC and
systemic lupus
differential counts
erythematosus, and
before starting
in those who have
treatment, every 2
been exposed to
weeks for the first 3
other drugs that affect
months of therapy,
WBC counts or
and periodically
immune response.
thereafter.
 Name of Drug Action Dosage Indications Contraindications Adverse Reactions Nursing Responsibilities

Digoxin  Inhibits sodium Elixer: 0.5 mg/mL HF, rapid Contraindicated in CNS: Drug-induced arrhythmias
may increase the severity of
patients hypersensitive to
potassium (pediatric) digitalization tablet drug and in those with Agitation,fatigue,g HF and hypotension.
Brandname: Apo- activated digitalis-induced eneralized muscle Monitor patient for
Digoxin, Lanoxin adenosine Injection: 0.05 Elixer toxicity,ventricular
weakness,hallucin toxicity.Toxic effects on the

triphosphatase,pro mg/mL  fibrillation,or ventricular

ations,
heart may be life threatening
Therapeutic HF, gradual tachycardia unless and require immediate
attention. Signs and
Class: Inotropes moting movement Pediatric: 0.25 digitalization tablet caused by HF. dizziness,headach symptoms of toxicity include
of calcium from mg/mL Don’t use in patients with e,malaise,paresth anorexia,nausea,vomiting,visu
al changes,and cardiac
Pharmacologic extracellular to Atrial fibrillation Wolff-Parkinson- white esia,stupor,vertigo arrhythmias. Patients with low
class: Cardiac intracellular Tablets: 0.0625 (chronic)  syndrome unless the
. body weight,advanced
conduction accessory age,Renal impairment, and
glycosides  cytoplasm and mg, 0.125 mg, pathway has been electrolyte disturbances are at

strengthening 0.1875mg, 0.25 pharmacologically or increased risk.

mg. surgically disabled. Monitor digoxin level.

myocardial Therapeutic level ranges from
contraction.Also Use with extreme caution 0.8 to 2 nanograms/mL.
in elderly patients and in Obtain blood for digoxin level
acts on CNS to those with acute at least 6 to 8 hours after last
enhance vagal MI,incomplete AV oral dose, preferably just
before next scheduled dose.
block,sinus
tone, slowing bradycardia,PVCs, Monitor potassium level
conduction chronic constrictive carefully. Take corrective
through the SA pericarditis,hypertrophic action before hypokalemia
occurs. Hyperkalemia may
cardiomyopathy,renal
and AV nodes. insufficiency,severe results from digoxin toxicity
pulmonary disease,or
hypothyroidism.
 Name of Drug Action Dosage Indications Contraindications Adverse Reactions Nursing Responsibilities

Simvastatin Inhibits HMG- CoA Tablets: 5mg, 10mg, To reduce risk of death Contraindicated in CNS: Obtain LFT results
reductase,an early (and 20mg, 40mg, 80mg from CV disease and CV patients hypersensitive asthenia,headache  before initiation of
Brand name:Zocor rate- limiting) step in events in patients at high to drug and in those with treatment and thereafter
cholesterol biosynthesis. risk for coronary events; active liver disease or GI: abdominal when clinically
Therapeutic Class: to reduce total and LDL conditions that cause pain,constipation,diarrhe indicated.obtain lipid
Antilipemics cholesterol, unexplained persistent a  determinations after 4
Pharmacologic Class: apolipoprotein B, and elevations of weeks of therapy and
triglyceride level in transaminase levels. Respiratory: URL periodically there after.
HMG- CoA reductase
inhibitors  patients with primary
hyperlipidemia and Contraindicated for use Monitor all patients for
mixed dyslipidemia; to at its highest dosage myopathy (unexplained
reduce triglyceride (80mg/day) in patients muscle pain,weakness,or
levels; to reduce not previously prescribed tenderness). Periodic CK
triglyceride levels and simvastatin or in patients determinations may be
VLDL cholesterol levels who have had prior considered in patients
in patients with muscle toxicity. Patients whose dosage is being
dysbetalipoproteinemia. who can’t reach their increased,but there’s no
goal LDL cholesterol assurance that such
level on 40 mg dose monitoring will prevent
should be switched to an myopathy.
alternative agent. Only
patients who have Patient should follow a
tolerated the 80mg dose diet restricted in
without muscle toxicity saturated fat and
for more than 12 months cholesterol during
should continue taking therapy.
80 mg daily
 DISCHARGE PLANNING
MEDICATION INDICATION

Simvastatin Used to lower levels of "bad" cholesterol and to increase levels of “good”
cholesterol and to lower triglycerides as well as to reduce the risk of
stroke and heart attacks.

Captopril Captopril is indicated in clinically stable patients with asymptomatic left

ventricular dysfunction following myocardial infarction to improve survival,
delay the onset of symptomatic heart failure, reduce hospitalizations for
heart failure and reduce recurrent myocardial infarction and coronary
revascularization procedures.
Lanoxin For the treatment of mild to moderate heart failure in adult patients. To
increase myocardial contraction in children diagnosed with heart failure.
To maintain control ventricular rate in adult patients diagnosed with
chronic atrial fibrillation.
 EXERCISE TREATMENT
Patient does not participate • Thrombolytics are often used to dissolve clots.​
• Antiplatelet drugs, such as clopidogrel, can be used to
in any activity-exercise prevent new clots from forming and existing clots
pattern because it is from growing.​
• Nitroglycerin can be used to widen your blood vessels.​
contraindicated with his • Beta-blockers lower your blood pressure and relax your
condition. heart muscle. This can help limit the severity of damage to
your heart.​
• ACE inhibitors can also be used to lower blood pressure
and decrease stress on the heart.​
• Pain relievers may be used to reduce any discomfort you
may feel.​
• Diuretics can help decrease fluid buildup to ease the
workload of the heart.​
 Health Teaching
• Avoid activity in extremes of heat and cold, which increase the work of the heart.
• Avoid drinking alcohol. Alcohol may weaken your heart. Ask your healthcare provider if it is
safe for you to drink any alcohol. If it is safe, talk to him or her about how much alcohol is
safe for you.
• Do not smoke. If you smoke, it is never too late to quit. Smoking weakens your heart and
makes shortness of breath and other symptoms worse. Ask your healthcare provider for
information if you need help quitting.
• Monitor Blood Pressure. You can check your blood pressure with a home monitor or at a
pharmacy. Be sure to report any unusual readings to your doctor and take any medications
he or she prescribes.
 OUTPATIENT
• Bring the list or the pill bottles to follow-up visits.
• Talk with your provider about any questions or fears you have.
• Your provider may call you to see how you are doing and to make sure you are
checking your weight and taking your medicines.
• Keep medical follow-up appointments at your provider's office.
• You will likely need to have certain lab tests to check your sodium and potassium levels
and monitor how your kidneys are working.
• Your provider may refer you to cardiac rehabilitation program. There, you will learn how
to slowly increase your exercise and how to take care of your heart disease.
 DIET SPIRITUAL CARE
• Eat a healthy diet. Follow the Cardiac diet as •Consider the person's and
planned. The cardiac diet emphasizes foods such as
vegetables, whole grains, and oily fish. family's religious beliefs
• Choose foods that are low in saturated and trans
fats. Healthy choices include lean meats, poultry
and cultural practices. These
without skin, non-fried fish, beans as well as fat-free may include doing a
or low-fat milk and milk products.
• Choose and prepare foods with little salt (sodium).
special ceremony or ritual, or
Too much salt can raise your risk of high blood following certain traditions.​
pressure. 
• Choose foods and beverages that are low in added
sugar. 
• Avoid canned or processed foods, eating fresh or
frozen foods.
 REFERENCES
Diagnosis of Heart Failure by History and Physical Examination, 2022,
https://www.thecardiologyadvisor.com/home/decision-support-in-medicine/cardiology/diagnosis-of-heart-failure-by-history-and-physical-ex
amination/
 
Doenges, M., Moorhouse, M., Murr, A., Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales 15 Edition, 2016 
Gonzalo, A., Nurselabs: Dorothea Orem: Self-care Deficit Theory, 2021,
https://nurseslabs.com/dorothea-orems-self-care-theory/#dorothea_orems_self-care_deficit_theory 
King, M., Kingery, J., Casey, B., Diagnosis and Evaluation of Heart Failure, 2012, found on
https://www.aafp.org/afp/2012/0615/p1161.html 
Vera, M., Nurselabs: 18 Heart Failure Nursing Care Plans, 2022 https://nurseslabs.com/heart-failure-nursing-care-plans/12/