Siena College of Taytay

COLLEGE OF NURSING

A case study on

Acute Decompensated
Heart Failure

Besa, Ma. Jasmine M.

Cailles, Aelora Jullienne C.

Garcia, Nico Jay

Gatchalian, Jose Miko M.

Introduction
A. Background of The Study

Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle
doesn't pump blood as well as it should. Certain conditions, such as narrowed arteries in your
heart (coronary artery disease) or high blood pressure, gradually leave your heart too weak or
stiff to fill and pump efficiently. Citing the world health organization 2014 global status report,
the editorial noted that the risk of prematurely dying from noncommunicable diseases in the
Philippines (28 percent) is more than double in the United Kingdom (12 percent).

Pleural effusion, sometimes referred to as “water on the lungs” is the build-up of excess fluid
between the layers of the pleura outside of the lungs. The seriousness of the condition depends
on the primary cause of pleural effusion, whether breathing is affected, and whether can be
treated effectively. Causes of pleural effusion that can be effectively treated or controlled include
an infection due to virus, pneumonia or heart failure.

A Parapneumonic effusion is a type of pleural effusion that arises as a result of a pneumonia,

lung abscess, or bronchiectasis, there are 3 types of parapneumonic effusion. Uncomplicated,
complicated effusion, and empyema.

Five days after the patient was admitted, she was diagnosed as Acute Decompensated Heart
Failure. ADHF is a serious condition where there is a poor prognosis of the current heart disease.
In 75% of cases, acute decompensation occurs in a patient with known chronic heart failure. Of
importance, more than one-third of patients experiencing acute decompensated heart failure will
have preserved systolic function, and the outcomes of patients with preserved systolic function
seem to be like those with decreased systolic function. Factors implicated in the deterioration
included noncompliance with salt and water restriction (22%), noncardiac causes (mostly related
to pulmonary infections) (20%), medication adjustments (15%), use of an antiarrhythmic agent
within two days (15%) and arrhythmia (13%). Presenting signs and symptoms may be
progressive and include increase in body weight, shortness of breath and edema. The diagnosis
of acute decompensated heart failure may be difficult at times, and the clinical assessment and
patient profiling is essential for appropriate therapy.

B. Rationale for Choosing the Study

General Objectives
 We, BSN IV students, is expected to develop proper skills, right attitude and adequate
knowledge of concepts with principles in identifying the needs of a patient with Acute
Decompensated Heart Failure and be able to plan a comprehensive nursing care
management geared towards a safe recovery.
  This case study aims to express familiarity and knowledge regarding Acute
Decompensated Heart Failure.
 To be able to master all the skills learned during our lectures.
 To be able to effectively apply everything that we learned during lectures and RLE’s.
 This study focuses not only on the patient but also on the significant others as well.
 To provide holistic care and TLC for both the patients.
Specific Objectives

 Provide safe and quality nursing care by providing all the data and information about the
client.
 To gain knowledge, skills and identify the needs of the patient
 To organized and formulate nursing intervention of the patient
 Provide Collaboration and teamwork by establishing working rapport with group mates
and the health care team present on every procedure.
 To effectively provide health education through interview.
 To respect the client’s rights by maintaining confidentiality and privacy of information.
C. Significance of the Study

For the Patient. To help the patient recover from the disease, and decrease the factors contributing to the
illness of the patient.

For the Family and Significant Others of the Patient. To help them understand the client’s situation and
may be able to participate in taking care of the patient.

For the Nursing Students: This study may provide additional references for making a study about
Acute Decompensated Heart Failure. It may also provide information that would help for further
researches.

For the Clinical Instructors: To appreciate the study we have made, and determine student’s
weakness, strengths, challenges, and to be able to develop a holistic case study.

For the Nursing Staffs of RPHS Annex II. To help them in managing the client’s condition, prevent the
complications for the patient, and provide extra work to understand the patient’s needs.

D. Scope and Delimitation

For the completion of our study, we have assessed patient’s functional health and gathered health
history through an interview to the patient, physical assessment and implementing nursing procedures.
We also looked over her chart to know the medications given and her latest laboratory result. The
collection of data and executing of nursing intervention took last March 26, 2019 at female ward isolation
at RPHS Annex 2. However, the nursing management were only applied until March 28, 2019 during 6
am to 2 pm shift.
 E. Theoretical Framework
Dorothea Orem’s Self-Care Model
Nursing system
Wholly compensatory
 Our goal is to give care,
medications and
comfort to the patient.
Partially
compensatory
 Nurse can bring meal
and assisting patient
going to bathroom
during bowel
movement.
Supportive-educative
system
 Explaining patient
about her conditions at
she must and not to do
during hospitalization
Self-care deficit Self-care
Methods of helping
Self-Care
 Advocate and care for  The maintenance of
the patient such as sufficient intake of
collaborating with the air, food and water
team to plan for patient  Provision of care
care associated with the
 advocate for health and elimination process
well-being  A balance between
 Record vital signs and activities and rest
administering  The preventions of
medications. hazards to human life
 Discharging patients and well being
from nursing care when  The promotion of
they have regained their human functioning
abilities to perform their
own self-care needs
Patient’s Profile

Patient’s Name Patient J

Age 24 y/0

Birthday February 17, 1995

Birthplace Makati

Marital status Single

Address Inday Subdivision Brgy. San Jose Antipolo City

Nationality Filipino

Occupation None

Religion Catholic

Date of Admission March 25, 2019

Time of Admission 7:00 PM

Chief Complaint Difficulty of Breathing

Diagnosis Acute Decompensated Heart Failure

History of Present 1 month prior to consult, admitted at Antipolo Doctor’s Hospital,

Illness Noted with Cardiomegaly. Other laboratories are unremarkable. Noted
with conchi few hours prior to consult, noted with sudden onset of
dyspnea and chest pain, hence ER consult and admission.
GORDONS FUNCTIONAL ASSESSMENT

FUNCTIONAL BEFORE DURING ANALYSIS

HEALTH HOSPITALIZATION HOSPITALIZATION
PATTERN

HEALTH According to Patient J, The patient is hooked Patient J is

PERCEPTION – she was diagnosed last with an oxygen mask previously in denial
HEALTH year of having with a regulation of 5L of her health
MANAGEMENT cardiomegaly, but she per minute. Patient J is condition. It is her
ignored and was denial on bedrest without coping mechanism
of developing the bathroom privilege. while adjusting to
disease. She said, she’s She under estimated her distressing
too young to have this her condition and now situation which
diseased therefore, she regrets it. She is interfered her
did not seek any having difficulty on treatment. She was
medical help and was breathing and unable to given an oxygen
not taking any position herself on bed mask to supplement
medications or without pillows on her her oxygen needs
maintenance drugs. sides. She is prescribed and prevent
with Ceftriaxone 2gm desaturation of
TIV OD, NaC 600mg oxygen levels in her
tab ODHS, Salbutamol body. Her difficulty
+ Ipra Neb q8, in breathing could
Trimetazidine 35mg be a result of the
tab BID, Furosemid fluids in her lungs.
20g TIV q8, (See Drug Study
Omeprazole 40mg TIV section for drug
ODBB, Azithromycin explanations)
500mg tab OD for 3
days, Levocetirizine +
Monteleukast 5/10mg
tab ODHS, Butamitrate
Citrate tab TID,
Febuxostat 40mg tab
OD, Aldactone 50g tab
BID, and Lanoxin
0.25mg tab OD.

NUTRITONAL – Patient J is fond of Patient J is on low salt, Eating instant

METABOLIC eating instant noodles, low fat diet. Her oral noodles and canned
 canned goods or easy fluid consumption is goods is considered
to cook foods. She is limited to 1000 L of as unhealthy diet as
drinking water, but she water daily. Her IV it contains high
doesn’t know how fluids rates if limited to amount of sodium.
much water she 12cc per hour. She was Drinking alcohol
consumes daily. Patient also hooked with a should be in
J stated that she is D5Water 500cc IV drip moderate amount
drinking alcohol as with 4 ampules of only as drinking of
frequent as 4x a week. Dobutamine and is too much alcohol
She is also a cigarette regulated at 35cc per could increases
smoker. hour. chances of
developing high
blood pressures and
raise the levels of
some fats in the
bloods
(triglycerides). A
low sodium diet is
important to follow
in order to control
heart failure
symptoms as it will
prevent and control
the amount of fluid
around in your heart,
lungs and in legs.
Due to her edema,
she was limited to
oral fluid
consumption to
prevent a fluid
overload.

ELIMINATION Prior to hospital Patient J insists on Edema that occurs in

admission, Patient J going to bathroom the diseases of the
remember that she is when urinating because heart is mainly cause
urinating at least 4 every time she urinates, by salt retention
times a day and has no her bowel movements which holds the
bowel problems. follows. But her excess fluid in the
physician instructed body. Since her
her in bed rest to body weight is
 consume her energy. 137kg., her urine
She was ordered to amount is expected
urinate in a diaper to be in between of
instead, but she doesn’t 1000 - 1500 cc for 8
like the feeling of hours. Therefore,
being on diaper. she is considered as
Therefore, the oliguric as her urine
physician ordered to output is only 600cc.
insert a Foley catheter.
Her urine output is
about 600 cc for the 6-
2 pm shift, it is dark
yellow and hazy in
appearance. She has no
pain in urination. Her
stool is soft but she
was no ordered to have
a Fecalysis. She has
grade 4 bipedal pitting
edema.

ACTIVITY – Patient J admitted that Patient J is on bed rest A bedrest is an

EXERCISE she is physically but maintained on essential
inactive. She has no Fowler’s position and management for
job because she’s easily tired when patients with
focused on taking care exerting efforts. Her congestive heart
of her 3-year-old child respiratory rate is 30 failure to prevent
and niece. Her leisure per minute and her excess needs for
activities were spent cardiac rate is 109 per oxygen consumption
with her friends and minute. and preserve energy
they usually drink and excessive
alcohol. workload of heart.

COGNITIVE – Patient J had no In Patient J’s Patient J’s cognition

PERCEPTUAL problems with her perception, she thinks and perception is
vision, hearing, taste she has no problems normal.
and sense of touch. She with her vision,
has no trouble in hearing, taste and sense
 recalling past events. . of touch. She is
oriented to time place,
and person during
assessment.

SLEEP –REST Patient J had difficulty According to Patient J, Paroxysmal

in breathing which she has trouble with nocturnal
often make it harder for sleeping because of the dyspnea (PND) is a
her to sleep. She chest discomfort. She sensation of
usually wakes up in the usually takes a nap shortness of breath
middle of the night throughout the day to that awakens the
because of trouble in regain her lack of patient, often after 1
breathing normally. sleep. or 2 hours of sleep,
She frequently takes and is usually
rest in the afternoon. relieved in the
upright position.

SELF In Patient J’s According to the The patient has hope

PERCEPTION – perception, she’s too patient, she is having a to get better despite
SELF CONCEPT young to have a heart hard time adjusting her troubles with her
disease therefore she because of her current condition.
ignored her condition. condition. She is tired
most of the time.

ROLES Patient J is currenty Patient J’s sister is the The patient’s family
RELATIONSHIP living with her sisters, one who stays with the is supportive in for
her child and her niece. her. Some family and the recovery of the
She did not mention friends came to visit patient’s health.
anything about her her during
partner and her father. hospitalization.

SEXUALITY – According to patient J, Due to her condition, According to

REPRODUCTIVE her menstruation Patient J is sexually Sigmund Freud’s
started when she was inactive. psychosexual
11 years old and has theory, Patient J is
regular menstruation. Genital Stage
With regards to her (puberty to adult),
sexual satisfaction, she sexual instinct is
is currently not in a directed to
relationship. She was heterosexual
pregnant once and her pleasure, rather than
child is already 3 years self-pleasure like
 old. during the phallic
stage.

COPING- STRESS Patient J’s support Patient J is hoping to According to Erik

TOLERANCE system is her family. recover soon because Erikson’s
She said, when she was she’s thinking about Psychosocial
facing problems, she her child. She has a Theory, Patient J is
usually tells her family strong communication on Intimacy vs.
and friends to release with her sister and her Isolation stage
the stress. mother and usually wherein this period
opens up about her is centered in
feelings. forming intimate
and loving
relationship with
other people. It is a
stage where an
individual share
themselves with
others.

VALUES - BELIEF Patient J’s religion is Patient J is praying for The belief of the
Catholic. She believes her recovery. patient’s family is
that the most important helping them in
in life is to live with it hoping for the
and be happy. patient’s recovery.
PHYSICAL ASSESSMENT

BODY PARTS METHODS NORMAL ACTUAL FINDINGS ANALYSIS

OF FINDINGS
ASSESSMENT

Head Inspection The head of the pt is There is no lumps or No deviation

rounded, normal masses, no lesions
Palpation cephalic and found, the head was
symmetrical. There symmetrical.
are no nodules or
masses and
depressions when
palpated.

Scalp Inspection White, clean, no White, no areas of No deviation

areas of tenderness tenderness.
Palpation

Hair Inspection Evenly distributed Hair is evenly Greasy hair is the

thick hair, no distributed and result of overactive
infection, silky and greasy sebaceous glands,
resilient hair. which are producing
too much sebum.
Although sebum
benefits the hair,
keeping it healthy,
smooth and
preventing it from
drying out and
breaking, too much
can cause the hair to
look slick and
greasy.

Skin Inspection Uniform in color, The skin is in A bruise, or

unblemished and no uniform color, and contusion, appears
Palpation presence of any foul no presence of any on the skin due to
odor, good skin foul odor, skin trauma. The injury
turgor and skin temperature of 36. causes tiny blood
temperature is degree Celsius, vessels called
within normal limit. within normal. capillaries to burst.
Bruises are found Blood gets trapped
 on the right arm. below the skin’s
Bilateral Pedal surface, which
Edema was found causes a bruise.
and is already in
Edema refers to
grade 4.
visible swelling
caused by a buildup
of fluid within
tissues. When an
indentation remains
after the swollen skin
is pressed, this is
called pitting edema.
Pitting edema is
classified based on
the depth and
duration of the
indentation. Grade 4:
The pressure leaves
an indentation of 8
mm or deeper. It
takes more than 20
seconds to rebound.

Face Inspection Oval, round; Face appeared No deviations

symmetrical; facial smooth and with
expression based on uniform skin
mood. consistency; no
presence of nodules
and masses. No
abnormalities were
found.

Eyes Inspection Eye brows and eye No eye discharge or No deviations

lashes evenly pain, excessive
distributed; eyelids tearing, or itchiness
has no discharge and but with blurring
has no discoloration, vision. Eyelids are
pupils dark brown in uniform in shape,
color, round, equal in Pupils are round in
size, normally 3-4 shape, equal in size
mm in diameter; & reactive to light.
 conjunctiva pink in Normal in size (3-4
color; sclera white in mm) Pale
color. conjunctiva and
white sclera.

Ears Inspection Parallel and Parallel and No deviation

symmetrical; symmetrical;
proportional to the proportional to the
size of the head; able size of the head;
to hear; color same able to hear
as facial; no normally as per
discharge. whisper test was
done

Nose Inspection Symmetrical and Symmetrical and Nasal flaring occurs

straight; no straight; no when your nostrils
discharge; no flaring; discharge; (+) widen while
uniform color; no flaring; uniform breathing, and may
tenderness; no color; no be a sign that you're
lesions. tenderness; no having difficulty
lesions. breathing.

Mouth & Inspection Lips pink in color; Lips are cyanotic in Blue lips occur when
Throat moist, smooth in color; missing teeth the skin on the lips
texture; ability to both on upper and takes on a bluish tint
purse lips; teeth are lower parts; ability or color. This
smooth to purse lips; generally is due to
lack of oxygen in the
blood

Neck Inspection Neck muscles equal No masses No deviations

in size; coordinated palpated; smooth
Palpation smooth head movement with no
movement with no discomfort; lymph
discomfort; lymph nodes not palpable.
nodes not palpable;
trachea placed in the
midline of the neck.

Chest Inspection Quiet rhythmic (+) crackles upon (+)Pleural effusion,

respiration; normal auscultation; (+) sometimes referred
Auscultation RR; no deviation difficulty of to as “water on the
breathing; RR of 30 lungs,” is the build-
 Percussion when breathing. bpm, PR of 109 bpm up of excess fluid
and O2sat of 92%. between the layers
Crackles is of the pleura outside
auscultated the lungs.

There was an
accumulation of
fluid in the pleural
space, in the right
there is 60ml of
fluid and in the left
there is 360ml of
fluid.

Abdomen Inspection Globular, Uniform Globular in shape; No deviations

color; no evidence of (+) distended
Auscultation enlarged liver or abdomen; no
Palpation spleen; audible tenderness
bowel sounds; no
tenderness.

Extremities Inspection The extremities are Bruises are found A bruise, or

symmetrical in size on the right arm. contusion, appears
and length; muscles Patient was having on the skin due to
are normally firm trouble with lifting trauma. The injury
and with smooth her legs due to causes tiny blood
coordinated Bilateral Pedal vessels called
movement; no Edema was found capillaries to burst.
presence of and is already in Blood gets trapped
deformities, grade 4. below the skin’s
tenderness and surface, which
swelling; the bone causes a bruise.
and joints move
smoothly. Edema refers to
visible swelling
caused by a buildup
of fluid within
tissues. When an
indentation remains
after the swollen skin
is pressed, this is
called pitting edema.
Pitting edema is
classified based on
the depth and
duration of the
indentation. Grade 4:
The pressure leaves
an indentation of 8
mm or deeper. It
takes more than 20
seconds to rebound.
ANATOMY AND PHYSIOLOGY

ANATOMY OF HEART

Right Side of heart – pumps deoxygenated blood into the pulmonary arteries around the lungs.

Left Side of heart – receives oxygenated blood and pumps it to the rest of the body.

Superior Vena Cava: Deoxygenated blood from the head, neck, chest, and upper extremities,
flows through this vein into the right atrium of the heart.

Inferior Vena Cava is also a large vein that leads blood from the lower extremities (trunk,
organs, pelvic region) into the right atrium of the heart.

Right atrium collects deoxygenated blood returning from the body

Tricuspid valve separates the right atrium and right ventricle.

Right ventricle receives deoxygenated blood from the right atrium.

Pulmonary valve allows blood flow from right ventricle to pulmonary artery.
Pulmonary artery sends the deoxygenated blood from the right ventricle to the lungs.
Pulmonary veins send oxygenated blood to the left atrium.

Left atrium collects oxygenated blood from the lungs and moves it to left ventricle

Mitral Valve separates left atrium and left ventricle.

Left ventricle receives blood from the left atrium and sends it to the aorta.

Aortic valve opens to allow oxygen-rich blood to pass into the Aorta from the left ventricle, and
then closes to prevent blood to flow back.

Aorta: Considered the larges vessel in the body, the aorta carries oxygen-rich blood from the left
ventricle to the rest of the body.

ANATOMY OF LUNGS
The lungs are in the chest on either side of the heart in the rib cage. They are conical in shape with a
narrow-rounded apex at the top, and a broad concave base that rests on the convex surface of
the diaphragm.

Right lung - has both more lobes and segments than the left. It is divided into three lobes, an upper,
middle, and a lower, by two fissures, one oblique and one horizontal

Left lung - is divided into two lobes, an upper and a lower, by the oblique fissure, which extends
from the costal to the mediastinal surface of the lung both above and below the hilum.

Alveoli - is a hollow cavity found in the lung parenchyma and is the basic unit of ventilation.

Bronchus is a passage of airway in the respiratory system that conducts air into the lungs.

Trachea - is a cartilaginous tube that connects the pharynx and larynx to the lungs, allowing the
passage of air, and so is present in almost all air-breathing animals with lungs.

ANATOMY OF URINARY SYSTEM

Urinary system is the major excretory system of the body. Organs of other systems eliminate
some waste products; however, if the kidneys fail to function, these other excretory organs
cannot adequately compensate. The urinary system consists of two kidneys, the primary
excretory organs. Each kidney’s excretory products are carried by a ureter to a single urinary
bladder. The bladder is emptied of the waste liquid by the urethra.

Kidneys are retroperitoneal and are located on each side of the vertebral column near the psoas
major muscles. They extend from the lower portion of the rib cage at the level of the last thoracic
(T12) vertebra to the third lumbar (L3) vertebra. Each kidney is surrounded by an outer layer of
connective tissue, called the renal capsule. Renal fascia surrounds the adipose tissue and helps
anchor the kidneys to the abdominal wall.
Hilum is a small area on the concave, medial side of the kidney that is continuous with an
adipose and connective tissue-filled cavity of the kidney, called the renal sinus.
The kidneys are organized into two major regions: an outer cortex and an inner medulla that
surrounds the renal sinus.

The medulla is composed of many cone-shaped structures called renal pyramids, whose bases
project into the cortex. These projections are called medullary rays. Between the renal pyramids
and their medullary rays, there are extensions of cortical tissue toward the medulla, called renal
columns. The renal pyramids are a collection of tubes and ducts that transport fluid throughout
the kidney and modify it into urine.

The tips of the pyramids, the renal papillae, point toward the renal sinus. In the renal sinus,
another set of tubes collects the urine for movement to the bladder. When urine leaves a renal
papilla, it empties into a small, funnel-shaped chamber surrounding the tip of the papilla called a
minor calyx.
Urine from several minor calyces are emptied into a larger, funnel-shaped chamber called a
major calyx. In each kidney, there are between 8 and 20 minor calyces converging to form about
2 or 3 major calyces. From the major calyces, urine empties into a single, enlarged, funnel-
shaped chamber called the renal pelvis. The renal pelvis is embedded in and surrounded by the
renal sinus. At the hilum, it narrows significantly, forming the small-diameter tube called the
ureter. Urine moves from the renal pelvis into the ureter for transport to the bladder.

Nephron is the histological and functional unit of the kidney.

Glomerulus - a network of capillaries twisted around each other like a ball of yarn.

Bowman Capsule - Surrounding the glomerulus is an indented, double-walled chamber.

Podocytes - specialized cells which wrap around the glomerular capillaries.

Afferent arteriole supplies blood to the glomerulus for filtration.

Efferent arteriole transports the filtered blood away from the glomerulus

Loop of Henle - he portions of a nephron that leads from the proximal convoluted tubule to
the distal convoluted tubule.
 PATHOPHYSIOLOGY

Predisposing Factor
Precipitating Factor
Alcoholic
Age: 24
Cigarette Smoker
Gender: Female
High Sodium Diet
Obesity

Raise level of triglycerides

Tachycardia

Decreased cardiac output

Less unoxygenated blood

Increased pressure in
lymph vessels Increase pressure in right atrium
and systemic venous circulation

Pleural Effusion
Decreased renal perfusion

Difficulty of breathing
Increased sodium retention

Decreased oxygen
consumption Increased osmotic pressure

Compensation of heart
muscle Increased ADH

Increased Water Reabsorption

Fluid Overload / Edema

Drug Study

Date Drug Name, Dosage, Pharmacodynamics Pharmacokinetics Indication Nursing

Ordered Frequency, Route Consideration

3-25-19 Drug Name: Decreases viscosity of Absorption: To liquefy - Patient with

pulmonary secretions by abnormal, viscid, known or history
N.A.C breaking disulfide links Rapidly absorbed from or thickened of atopy and
that bind glycoproteins the gastrointestinal mucus secretions asthma, history of
( N-Acetylceistine ) tract. Bioavailability:
in mucus. Reduces liver in chronic bronchospasm,
damage from 4-10% (oral). Time to pulmonary history of. peptic
acetaminophen peak plasma disorders ulcer disease,
Dosage: concentration: 1-2
overdose. Usually, (including esophageal varices.
acetaminophen’s toxic hours (oral solution), emphysema, Children.
600mg
metabolites bind with 1-3.5 hours bronchitis, Pregnancy and
glutathione in the liver, (effervescent tablet). tuberculosis, lactation.
which detoxifies bronchiectasis, and
Frequency:
them.When cystic fibrosis) and
OD HS acetaminophen overdose Distribution: in pneumonia,
depletes glutathione pulmonary
Crosses the placenta
stores, toxic metabolites complications of
and detected in cord
Route: bind with protein in liver thoracic or
blood. Volume of
cells, killing cardiovascular
distribution: 0.47 L/kg.
Oral them.Acetylcysteine surgery, and
Plasma protein
maintains or restores tracheostomy care
binding: 66-87%.
levels of glutathione or
acts as its substitute,
which reduces liver
damage from Metabolism:
acetaminophen
overdose. Metabolised in the
liver and metabolism
in the gut wall to form
cysteine and disulfides;
cysteine is further
metabolised to form
glutathione and other
metabolites.
Undergoes extensive
first-pass metabolism.

Elimination:

Via urine (13-38%).

Elimination half-life:
6.25 hours for total
acetylcysteine (oral);
2-6 hours (IV).
Date Drug Name, Dosage, Pharmacodynamics Pharmacokinetics Indication Nursing
Ordered Frequency, Route Consideration

8-1-18 Drug Name: Omeprazole interferes Absorption: used to reduce the - Be aware that
with gastric acid amount of acid in long-term use of
Omeprazole secretion by inhibiting absorption of your stomach. omeprazole may
the hydrogenpotassium- omeprazole takes place increase the risk of
adenosine triphosphatase in the small intestine To treat gastric carcinoma
Dosage: (H+K+-ATPase) and is usually gastroesophageal
enzyme system, or completed within 3 to reflux disease
40mg 6 hours (GERD) without
proton pump, in gastric
parietal cells. esophageal lesions,
to prevent erosive
Frequency: Distribution: esophagitis

ODBB Approximately 0.3

L/kg, corresponding to
the volume of
Route: extracellular water

Intravenously
Metabolism:

Omeprazole is heavily
metabolized in the
liver by the
cytochrome P450
(CYP) enzyme system.
Elimination:

After a single dose oral

dose of a buffered
solution of
omeprazole, negligible
(if any) amounts of
unchanged drug were
excreted in urine. Most
of the dose (about
77%) was eliminated
in urine as at least six
different metabolites.
Date Drug Name, Dosage, Pharmacodynamics Pharmacokinetics Indication Nursing
Ordered Frequency, Route Consideration

3-26-19 Drug Name: Azithromycin prevents Absorption: Azithromycin is Obtain culture and
bacteria from growing indicated for the sensitivity test
Azithromycin by interfering with their Bioavailability of treatment of results, if possible,
protein synthesis. It azithromycin is 37% patients with mild before starting
binds to the 50S subunit following oral to moderate therapy.
Dosage: of the bacterial administration. infections caused
ribosome, thus by susceptible Use azithromycin
500mg tab cautiously in
inhibiting translation of strains of the
mRNA. Nucleic acid Distribution: microorganisms patients with
synthesis is not affected hepatic
Frequency: After oral dysfunction (drug
administration, is metabolized in
OD azithromycin is widely the liver) or renal
distributed in tissues dysfunction
with an apparent (effects are
Route: steady-state volume of unknown in this
distribution of 31.1 group).
Oral L/kg
Give azithromycin
capsules 1 hour
before or 2 to 3
Metabolism:
hours after food.
this drug is eliminated Give tablets or
by the liver suspension without
regard to food
Elimination:

Biliary excretion of
azithromycin,
primarily as unchanged
drug, is a major route
of elimination. Over a
1 week period,
approximately 6% of
the administered dose
is found as unchanged
drug in urine
Date Drug Name, Dosage, Pharmacodynamics Pharmacokinetics Indication Nursing
Ordered Frequency, Route Consideration

8-1-18 Drug Name: Levocitirizine: not Absorption: Levocetirizine is Administer

available indicated for the levothyroxine
Levocitirizine + Levocetirizine is relief of symptoms tablets as a single
Montelukast Montelukast: rapidly and extensively associated with daily dose 30 to 60
absorbed following allergic rhinitis minutes before
Montelukast , is a oral administration
leukotriene receptor breakfast. If
Dosage: Montelukast is for patient has
antagonist used as an Montelukast the treatment of
alternative to anti- difficulty
5mg Rapidly absorbed asthma and to
inflammatory swallowing, crush
following oral prevent exercise- tablet and suspend
10mg medications in the
administration induced in a small amount
management and bronchoconstriction
chronic treatment of (bioavailability is of water or food.
asthma and exercise- 64%)
Frequency:
induced bronchospasm
ODHS (EIB). WARNING
Distribution: Montelukast isn’t
for acute asthma
Levocetirizine:
Route: attack or status
Approximately 0.4
asthmaticus.
Oral L/kg.

Montelukast: 8 to 11 L

Metabolism:

Levocetirizine is
poorly metabolized
and mostly excreted
via the urine

Montelukast:

Metabolized in the
liver

Elimination:

Levocitirizine:

Excreted in urine.

Montelukast:

montelukast and its

metabolites are
excreted almost
exclusively via the
bile.
Date Drug Name, Dosage, Pharmacodynamics Pharmacokinetics Indication Nursing
Ordered Frequency, Route Consideration

8-1-18 Drug Name: Butamirate citrate, the Absorption: Symptomatic Assess cough type
sole active ingredients treatment of and frequency
Butamitrate Citrate of Sinecod, is a cough Based on available data, it cough of various Monitor the
suppressant which is can be assumed that the origins. adverse reactions
neither chemically, nor ester butamirate is well and
Dosage: pharmacologically rapidly absorbed and that it Assess patients
related to opium is hydrolyzed into phenyl- vital signs
50mg 2-butyric acid and
alkaloids
diethylaminoethoxyethanol.

Frequency:
Distribution:
TID
Butamirate has a high
volume of distribution
Route: ranging between 81 and
112 L
Oral

Metabolism:

There are no human data on

the alcoholic metabolite.

Elimination:
 Excretion of the three
metabolites takes place
primarily via the kidneys;
following conjugation in
the liver, the acid
metabolites undergo large-
scale binding to glucuronic
acid. Urinary 2-
phenylbutyric acid
conjugate levels are much
higher than in plasma.

Date Drug Name, Dosage, Pharmacodynamics Pharmacokinetics Indication Nursing

Ordered Frequency, Route Consideration
8-1-18 Drug Name: A loop diuretic inihibits Absorption: For treatment of -Closely monitor
water reabsorption in the edema associated BP and vital signs
Furosemide nephron by blocking the 60% absorbed in with congestive
sodium-potassium- patients with normal heart failure,
chloride cotransporter renal function cirrhosis of the
Dosage: (NKCC2) in the thick liver and renal
ascending limb of the disease.
40mg Distribution:
loop of henle.

Not available
Frequency:

q8 Metabolism:

Small amount
Route: metabolized in the
liver
Intravenous

Elimination:

Excreted in the urine.

Date Drug Name, Dosage, Pharmacodynamics Pharmacokinetics Indication Nursing
Ordered Frequency, Route Consideration

8-2-18 Drug Name: Semisynthetic third- Absorption: For treatment of -Determine history
generation the infections of hypersensitivity
Ceftriaxone cephalosporin antibiotic. Immediate after IV to cephalosporins
Preferentially binds to infusion and penicillins
one or more of the
Dosage: penicillin-binding
proteins located on the Distribution:
2g
walls of susceptible
Widely distributed in
organisms. This inhibits
tissues and fluids
third and final stage of
Frequency: bacterial cell wall
synthesis, killing the
Q24 Metabolism:
bacterium.
Not metabolized
Route:

Intravenous Elimination:

33-65% excreted
unchanged in urine
Date Drug Name, Dosage, Pharmacodynamics Pharmacokinetics Indication Nursing
Ordered Frequency, Route Consideration

3-25-19 Drug Name: Stimulates B2 Absorption: For bronchospasm - allow at least 1

adrenergic receptors in with reversible minute between
Salbutamol bronchial smooth Reaches lung directly obstructive airway inhalation
muscle of the lung after inhalation diseases

Dosage: -advise to rinse

Distribution: mouth with water
2.5ml
Not available after each
inhalation to
minimize dry
Frequency:
mouth
Metabolism:
Q8
Metabolized in
intestinal tract and
Route: liver

Inhalation
Elimination:

Excreted via urine

Date Drug Name, Dosage, Pharmacodynamics Pharmacokinetics Indication Nursing
Ordered Frequency, Route Consideration

7-30-18 Drug Name: Anti-ischemic agent Absorption: Indicated for use - Taken with food
which improves in angina pectoris
Trimetazidine myocardial glucose Well absorbed
utilization through -May cause
inhibition of long-chain dizziness and
Dosage: 3-ketoacyl CoA thiolase Distribution: drowsiness
activity which results in
35mg Not available
reduction in fatty acid
oxidation and a
stimulation of glucose
Frequency: oxidation. Metabolism:

BID Hepatically into

inactive metabolites

Route:
Elimination:
Oral
Urine
Date Drug Name, Dosage, Pharmacodynamics Pharmacokinetics Indication Nursing
Ordered Frequency, Route Consideration

7-30-18 Drug Name: Febuxostat, a xanthine Absorption: For the treatment Instruct patients to
oxidase inhibitor, of hyperuricemia contact health care
Febuxostat achieves its therapeutic The absorption of provider if they
effect by decreasing radiolabeled febuxostat experience chest
serum uric acid. following oral dose pain, rash,
Dosage: administration was shortness of breath
estimated to be at least
40mg 49%

Advise patients
that product may
Frequency: Distribution: be taken without
OD The mean apparent regard to meals
steady state volume of
distribution (Vss/F) of
Route: febuxostat was
approximately 50 L
Oral (CV ~40%)

Metabolism:

Febuxostat is
extensively metabolized
by both conjugation via
uridine diphosphate
glucuronosyltransferase
(UGT) enzymes
including UGT1A1,
UGT1A3, UGT1A9,
and UGT2B7 and
oxidation via
cytochrome P450
(CYP) enzymes
including CYP1A2,
2C8 and 2C9 and non-
P450 enzymes.

Elimination:

Febuxostat is
eliminated primarily
through both hepatic
and renal pathways.
Date Drug Name, Dosage, Pharmacodynamics Pharmacokinetics Indication Nursing
Ordered Frequency, Route Consideration

7-30-18 Drug Name: Aldactone is a specific Absorption: For the monitor I and O
pharmacologic management of ratios and daily
Aldactone antagonist of Absorbed in the GI edema and sodium weight, BP
aldosterone, acting tract retention when the
primarily through patient is only Take with meals or
Dosage: competitive binding of partially milk; avoid
receptors at the Distribution: responsive to, or is excessive ingestion
50mg of food high in
aldosterone-dependent intolerant of, other
Not available potassium or use of
sodium-potassium therapeutic
exchange site in the measures. salt substitutes
Frequency: distal convoluted renal
tubule. Aldactone causes Metabolism:
BID
increased amounts of
Rapidly and
sodium and water to be
extensively
excreted, while
Route: metabolized. The
potassium is retained.
metabolic pathway of
Oral spironolactone is
complex and can be
divided into two main
routes: those in which
the sulfur moiety is
retained and those in
which the sulfur
moiety is removed by
dethioacetylation.
Elimination:

The metabolites are

excreted primarily in
the urine and
secondarily in bile
Date Drug Name, Dosage, Pharmacodynamics Pharmacokinetics Indication Nursing
Ordered Frequency, Route Consideration

7-30-18 Drug Name: Lanoxin, a cardiac Absorption: For the treatment Drug-induced
glycoside similar to and management arrhythmias may
Lanoxin digitoxin, is used to treat Absorption of digoxin of congestive increase the
congestive heart failure from the elixir cardiac severity of heart
and supraventricular pediatric formulation insufficiency, failure and
Dosage: arrhythmias due to has been demonstrated arrhythmias and hypotension.
reentry mechanisms, and to be 70% to 85% heart failure.
0.25mg complete ( 60% to 80% Before giving
to control ventricular
rate in the treatment of for tablets). loading dose
chronic atrial ,obtain baseline
Frequency: fibrillation. data heart rate and
Distribution: rhythm, blood
OD pressure
Not available
Before fore giving
drug, take apical-
Route:
radial pulse for
Metabolism:
Oral 1minute. Record
Metabolized in the and notify
liver prescriber of
significant changes

Elimination:

Excreted in the urine

Date Drug Name, Dosage, Pharmacodynamics Pharmacokinetics Indication Nursing
Ordered Frequency, Route Consideration

7-30-18 Drug Name: For inotropic support in Absorption: For inotropic Tell patient to
the short- term treatment support in the report adverse
Dobutamine of patients with cardiac Not Available short- term reactions promptly,
decompensation due to treatment of especially labored
depressed contractility patients with breathing and
Dosage: resulting either from Distribution: cardiac drug-induced
organic heart disease decompensation headache
18cc/hour Not available
due to depressed
contractility
resulting either Instruct patient to
Metabolism: from organic heart report discomfort
disease at I.V. insertion
Route: Not Available
site
Intravenously

Elimination:

n human urine, the

major excretion
products are the
conjugates of
dobutamine and 3-O-
methyl dobutamine.
 LABORATORY RESULTS

HEMATOLOGY

March 25,2019

PARAMETER RESULT NORMAL VALUES ANALYSIS

Hemoglobin 191 120 – 160 g/L red blood cell

production
increases to make
up for chronically
low blood oxygen
levels due to poor
heart or lung
function.

Hematocrit 68 Can caused Low

availability of
37 – 48%
oxygen (smoking)

Neutrophils 84 40 – 60% Neutrophils are

also increased in
any acute
inflammation, so
will be raised after
a heart attack and
other infarct

Lymphocytes 16 20 – 40% They can occur on

another
infection(pleural
effusion), or
caused by intense
physical exercise,
and severe stress
 Urinalysis

March 25,2019

Parameter Result

Color Dark yellow

Transparency Hazy

Specific gravity 1.0

WBC 15 – 20

RBC 5

Bacteria Many

Chem Form 1

March 26,2019

Parameters Result Normal Values Analysis

Uric acid 623 143 - 339 uric acid levels are associated
with increased risk of
ischemic heart disease and
blood pressure

Triglycerides 1.69 0.33 – 1.65 Binge drinking of alcohol

can cause dangerous spikes
in triglyceride level

HDL 0.78 >1.56 The chemicals found in

cigarettes
can lower your HDL cholesterol

Albumin 24.6 35 - 53 Caused by various conditions,

including heart failure, and
most cases caused by acute and
chronic inflammatory responses

Sodium 131.3 135 – 148 A low sodium level has many

causes, including consumption
 of too many fluids, heart failure
and use of diuretics

IMMUNO HEMATOLOGY

PROTHROMBIN TIME

MARCH 27,2019

Patient 14.4 sec 10 – 15

Control 12.4 sec

% activity 86. 11% 82 - >100%

INR 1.16 0.85 – 1.15

HEMATOLOGY

MARCH 28,2019

red blood cell

production increases
to make up for
Hemoglobin 170 120 – 160 chronically low blood
oxygen levels due to
poor heart or lung
function.

Can caused Low

Hematocrit 50 37 – 48% availability of oxygen
(smoking)

Neutrophils are also

increased in any
Neutrophils 86 40 – 60% acute inflammation,
so will be raised after
a heart attack and
 other infarct

They can occur on

another infection
(pleural effusion), or
Lymphocytes 68 20 – 40%
caused by intense
physical exercise, and
severe stress

Low number of
monocytes can be
Monocytes 02 4 – 8%
caused by the
infection in the lungs
ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective Ineffective Inspiration ST: After 15 Nsg. Nsg. Action GOAL MET
Data: breathing and/or expiration that Order:
minutes of Independent: ST: After 15
pattern R/T does not provide
“Nahihirapan pleural adequate ventilation. nursing To minutes of
ako huminga” assist Place patient A sitting nursing
effusion as intervention, the with proper position
as verbalized evidenced by client intervention,
by the patient client will in body permits the client was
the alignment maximum
perform deep finding able to perform
ultrasound for lung
and breathing method deep breathing
for maximum excursion and exercises.
Objective decreased exercises breathing chest
Data: oxygen pattern. expansion.
saturation as LT: After 1 hour
RR: 30
evidenced by of nursing
O2 Sat: 92% RR of 30, O2
intervention, the This method LT: After 1
saturation of
Nasal Flaring client will be relaxes hour of nursing
92% Encourage muscles and intervention,
able to remain exercising
Dyspnea, increases the the client was
respiratory rate deep patient’s able to remain
Crackles breathing
within oxygen level. respiratory rate
established of 21 breathes
per minute.
limits.

Dependent: To provide
Provide oxygen
oxygen
 therapy, as demands
ordered

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Objective Decreased Inadequate ST: After 15 Nsg. Nsg. Order: GOAL

Data: cardiac minutes of nursing Action: UNMET
output R/T blood pumped intervention, the
BP: 90/60 Congestive by the heart to client will Maintain ST: After 15
meet the adequate Independent: minutes of
PR: 119 Heart demonstrates
Failure as metabolic adequate cardiac ventilation Ensure nursing
RR: 30 evidenced demands of output as evidenced and patient intervention,
the body. perfusion remain on In severe heart the client was
by by blood
O2 Saturation as in the bed rest or failure, unable to
hypotension, pressure and pulse
of 92% following: maintain restriction of demonstrate
PR of 119, rate and rhythm
activity level activity often adequate
Chest pain RR of 30 o2 within normal
that does not facilitates cardiac output
sat of 92%, parameters for
Fatigue compromise temporary as evidenced
chest pain, patient
cardiac recompensation. by
fatigue and
Cyanosis hypotension,
cyanosis. output.
difficulty in
breathing and
tachycardia
Advise
patient to
use a urinal
for toileting
and avoid Getting out of
use of a bed to use a
bedpan urinal does not
stress the heart
any more than
staying in bed
Dependent: to toilet.
Administer
oxygen
therapy as
prescribed.
The failing
heart may not
be able to
respond to
increased
oxygen
demands
ASSESSM NURSING ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATIO
ENT DIAGOSIS N

Subjective Activity Limitation in ST Goal: Nsg.action Nsg. Order GOAL:

Data: Intolerance independent, PARTIALLY
r/t purposeful After 8 hours Independent:
MET
“nag cr Congestive physical of nursing
intervention, To promote Instruct patient To decrease energy ST: After 8
lang po heart failure movement of
Patient J will optimal level of in energy expenditure and hours of
kami as evidenced the body
report function and fatigue nursing
pagod by weakness, conservation
prevent
napo ako” tachypnea decrease techniques. intervention,
as of weakness complications Patient J was
and fatigue.
verbalized and fatigue able to report
by the and normal decrease of
client respiratory weakness and
rate. fatigue and
respiratory rate
Objective To improve respiratory of 21 per
Data: LT Goal: Position patient function and prevent minute.
on a high fowlers pressure injury.
RR: 30 Within 3
respirations days of LT: After 3
per minute nursing days of nursing
intervention, intervention,
Fatigue and the client
weakness the client was
will report unable to
absence of report absence
weakness Dependent: of weakness
and fatigue and fatigue.
Keep patient in To prevent
bed rest without excessive fatigue
 bathroom and conserve
privileges, as energy.
ordered

Assist
with ADLs To decrease activity
(activities of of patient that could
daily worsen the
living) regularly condition.
as indicated by
the physician.

ASSESSMENT NURSING ANALYSIS PLANNING RATIONALE EVALUATION

DIAGOSIS INTERVENTION
SUBJECTIVE: Excess fluid Fluid volume After 8 hours of Monitor and record To obtain baseline After 8 hours
volume rt excess or nursing vital sign data of nursing
“namamanas increase hypervolemia interventions interventions,p
yung binti ko venous occurs from an patient will atient
tas parang may pressure as increase in total verbalize verbalized
tumutulong Advise patient to
evidence by body water. This understanding of elevate feet when understanding
tubig” grade 4 fluid excess the measures to This prevent and of measures to
sitting down
As verbalized pitting edema usually results prevent and lessen fluid prevent and
by the patient and difficulty from lessen fluid accumulation in lessen fluid
of breathing compromised volume excess. lower extremities volume excess
Instruct patient
regulatory
regarding restricting
mechanisms for
OBJECTIVES: fluid intake
sodium and water Intake of fluid up Goal unmet
Grade 4 Pitting as seen in CHF to 1000ml is
edema equivalent to 1 kg.
Increase in weight
Difficulty of due to fluid
breathing retention.
Therefore limiting
is necessary to
avoid fluid
retention
ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective Acute Pain Unpleasant ST Goal: Nsg. Order Nsg. Action GOAL MET
Data: R/T sensory and
myocardial emotional After 15-30 Independent: In acute pain, bed ST: After 15
infarction as experience mins. of rest may necessary mins, Patient
N.I., Patient To assist client to Suggest the to limit pain. T’s pain scale
“Masakit evidenced by arising from explore methods patient to lie Sitting position
verbalization actual or T’s pain decreases
yung dibdib scale of 8 for in bed in promotes from 8 to 4
ko” as of pain and a potential alleviation/control sitting
pain scale of tissue will oxygenation via
verbalized by improved to of pain position or maximum chest
the patient 8/10. damage or High
described in 4 expansion and
Fowler’s facilitates the
terms of Position for relaxing of tension
such comfort and of the abdominal
damage. promote muscles, allowing
Objective total bed improved
Data: rest. breathing.
Pain scale of
8/10 in.

Restlessness

BP: 100/60

T: 36.6
Isosorbide
P: 83
mononitrate dilates
RR: 33 Dependent: (widens) blood
vessels, making it
Administer easier for blood to
Isosorbide flow through them
To Promote Mononitrate
Wellness and easier for
according to the heart to pump.
doctor’s
order.
Discharge Instructions for Acute Decompensated Heart Failure

You have been diagnosed with Acute Decompensated Heart Failure commonly known as a heart
attack, occurs when blood flow decreases or stops to a part of the heart, causing damage to the
heart muscle. The most common symptom is chest pain or discomfort which may travel into the
shoulder, arm, back, neck, or jaw.

Home Care

 Take your medicines exactly as directed. Don’t skip doses. Talk with your healthcare
provider if your medicines aren't working for you. Together you can come up with
another treatment plan.
 Remember that recovery after a heart attack takes time. Plan to rest for at least 4 to 8
weeks while you recover. Then return to normal activity when your doctor says it’s OK.
 Call emergency hotline right away if you have chest pain or pain that goes to your
shoulder, neck, or back. Don't drive yourself to the hospital.
 Ask your family members to learn CPR. This is an important skill that can save lives
when it's needed.
 Learn to take your own blood pressure and pulse. Keep a record of your results. Ask your
doctor when you should seek emergency medical attention. He or she will tell you which
blood pressure reading is dangerous.
Diet and Lifestyle

 DO NOT drink any alcohol for at least 2 weeks. Ask your provider when you may start.
Limit how much you drink. Women should have only 1 drink a day, and men should have
no more than 2 a day. Try to drink alcohol only when you are eating.
 If you smoke, stop. Ask your provider for help quitting if you need it. DO NOT let
anybody smoke in your home, since second-hand smoke can harm you. Try to stay away
from things that are stressful for you. If you are feeling stressed all the time, or if you are
feeling very sad, talk with your provider. They can refer you to a counselor.
 Consume a diet high in vegetables, fruits, whole grains, low-fat dairy products,
poultry, fish, legumes, non-tropical oils, and nuts, and reduce intake of sweets, sugar-
added beverages and red meats. Avoid salty foods.
Home Medication

 Salbu + Ipra neb every 8hrs

 Butamitrate citrate tab Thrice a day
 Levocetirizine + Monteleukast 5/10 mg Once a day / Bed time
 Trimetazidine 35mg Twice a day
 Febusostat 4g tab Once a day
Follow-up care

 Follow up with your healthcare provider or cardiologist within 14 days

Write down your questions so you remember to ask them during your visits.