INTRODUCTION

Congestive heart failure, or heart failure, is a condition in which the heart is

unable to adequately pump blood throughout the body and/or unable to prevent blood
from "backing up" into the lungs. It is present in 2 percent of persons age 40 to 59, more
than 5 percent of persons age 60 to 69, and 10 percent of persons age 70 and older. It
is greater in males than in females in patients aged 40-75 years. These risks include
having diabetes, high cholesterol, obesity, having a lot of long-term stress, smoking, a
sedentary lifestyle and drinking excessive amounts of alcohol. In most cases, heart
failure is a process that occurs over time, when an underlying condition damages the
heart or makes it work too hard, weakening the organ. Other less common causes of
CHF include valvular heart disease, hypertension, alcoholic cardiomyopathy, and
dilated cardiomyopathy. In addition, there are rare causes, one of which is thyroid
storm.

Thyroid storm, also referred to as thyrotoxic crisis, is an acute, life-threatening,

hypermetabolic state induced by excessive release of thyroid hormones (THs) in
individuals with thyrotoxicosis. Because thyroid storm is almost invariably fatal if left
untreated, rapid diagnosis and aggressive treatment are critical. Cardiac complications
from thyrotoxicosis include arrhythmias, congestive heart failure, and pulmonary
hypertension. Congestive heart failure in thyrotoxicosis is predominantly caused by
either persistent tachyarrhythmias (tachycardia-induced cardiomyopathy) or
uncontrolled hypertension as a consequence of thyrotoxicosis. Systolic dysfunction can
occur as a consequence of the persistent cardiac arrhythmias, but it usually resolves
once the hyperthyroid state is treated. Pulmonary hypertension can also occur in
thyrotoxicosis, either as a result of a primary effect of thyroid hormone on pulmonary
arteriolar resistance vessels, decompensated left heart failure, or via increased
pulmonary arterial blood flow (high-output).

Clinically significant CHF due to hyperthyroidism/thyroid storm is considered a

rare occurrence. Initially in the course of the disease, the patient is in a high cardiac
output state, due to the factors mentioned above, limiting only exercise tolerance. Later
in the course of the disease, if untreated, the patient can develop severe systolic
dysfunction with overt signs and symptoms of heart failure. This is more commonly seen
in patients with pre-existing heart disease, such as ischemic, hypertensive, or alcoholic
cardiomyopathy, the former being more common in the elderly.

Making a diagnosis of congestive heart failure includes a complete medical

evaluation, medical history, physical examination and diagnostic tests such as ECG,
echocardogram, lab studies( BUN, creatinine, thyroid stimulating hormone, CBC and
urinalysis), chest radiographs, etc. Symptoms that may be present is based on what
side of the heart is affected. In left sided heart failure, manifestations include are
pulmonary congestion, cough, fatigability, tachycardia with S 3 sound, anxiety, restless,
dyspnea, bibasilar crackles etc, while in right sided failure, congestion of viscera and
peripheral tissues, dependent edema, ascites weakness, nocturia etc are present.

With regard to the management of cardiac symptoms related to thyrotoxicosis,

treatment is focused on reducing adrenergic drive to the heart and restoring normal
cardiac rhythm. Beta-blockers are very effective for rapid hemodynamic improvement.
Either propranolol or metoprolol given intravenously can be used to improve heart rate
control either in sinus tachycardia or atrial fibrillation. In severe cases, a continuous
infusion of esmolol may be required for rate control. Amiodarone should be avoided
when treating atrial fibrillation from thyrotoxicosis because of its high iodine content,
which may induce or exacerbate thyroid storm. If a patient is hemodynamically unstable
from atrial fibrillation, direct current cardioversion should be employed. If symptoms of
pulmonary congestion appear, diuretics may be used. Other drugs for heart failure
(angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and/or
aldosterone receptor antagonists) are reasonable agents in patients who have
depressed left ventricular systolic function.

The treatment of heart failure depends on the exact cause, but it can usually be
treated effectively. The overall goals of treatment are to correct underlying causes, to
relieve symptoms, and to prevent worsening of the condition. Symptoms are relieved by
removing excess fluid from the body, improving blood flow, improving heart muscle
function, and increasing delivery of oxygen to the body tissues. Severe heart failure may
require surgery, such as balloon sedilaton of artery blockages, heart transplantation,
pacemaker implants to control the heart rhythm, and insertion of portable pumps to
infuse medications. In cases of valve defects, surgery to repair or replace the damaged
valves may be necessary.

This case study involves a patient who was diagnosed to have Congestive Heart
Failure class III secondary to thyrotoxic heart disease. The said diagnosis captures our
attention since it was concerning three major systems in the body the cardiovascular
respiratory and endocrine. It is also a great opportunity for us students to handle patient
with this particular diagnosis in which a heart disease occurred due to a complication of
thyroid storm.

OBJECTIVES
General

To describe the nature of the disease (Congestive Heart Failure) with thyrotoxic
heart disease as its primary cause.

Specific

• To gather pertinent data regarding the course of treatment to a patient with the
said diagnosis
• To develop an appropriate nursing diagnosis to the patient with the disease.
• To discuss the 3 body systems involved: cardiovascular, endocrine and
respiratory system and explain how they affect each in this given diagnosis
• To identify methods and tests used to confirm the disease.
• To identify the different nursing considerations based on physical assessment,
laboratory results when caring patient with congestive heart failure.
• To explain the different treatment options in managing pt with congestive heart
failure.

THEORETICAL FRAMEWORK
Roy’s Adaptation Model

Sister Callista Roy defines adaptation as “The process and outcome whereby the
thinking and feeling person uses conscious awareness and choice to create human and
environmental integration. Roy’s work focuses on the increasing complexity of person
and environment self organization, and on the relationship between and among
persons, universe and what can be considered a Supreme Being or God.

We have determined that the pt. who is involved in this case has an alteration in
the four modes as formulated by Sister Callista Roy.

1. The physiologic mode involves the body’s basic physiologic needs and
way of adapting with regard to fluid and electrolytes, activity and rest,
circulation and oxygen, nutrition and elimination, protection, the senses
and neurologic and endocrine function. In our pt. he suffers from difficulty
of breathing which was the main reason for seeking medical attention.
Therefore oxygen, adequate rest and proper positioning were rendered in
order to return his normal breathing pattern. Fluid volume excess was
also seen to be a pt. problem that is why medication (diuretic) was
administered and diet modification was applied.,

2. The self-concept mode includes two components: the physical self, which
involves sensation, and body image and the personal self, which involves
self-ideal, self- consistency and the moral- ethical self. The physical self
was compromised for the reason that he has a Congestive Heart Failure
in which he suffers from weakness, dizziness and other symptoms that
caused a change in normal body functioning. For the Personal self the pt.
is an alcoholic drinker, smoker and was once used an illegal drugs due to
stress, so there is an ineffective coping mechanism.

3. The role function mode is determined by the need for social integrity and
refers to the performance of duties based on given positions within
society. Before, the pt. was applying for another job, but since he was
confined, he could not pursue it anymore.

4. The interdependence mode involves one’s relations with significant others

and support systems that provide help, affection, and attention. At his age
the pt. does not have his own family which made him too dependent to his
mother and sisters.

After determining the demand that caused problem to the client, the nursing care
is then directed at helping the client to adapt in his present situation. For the patient who
is the center of this case, health teaching is appropriate regarding his social lifestyle,
explaining the importance of smoke cessation and withdrawal from alcohol intake is
necessary to prevent further complications. Strict compliance in the diet is also
essential, thus significant others must include in the teaching for the implementation of a
low fat and low salt diet. Teaching the importance of having a routine consultation is
needed in his present situation. Above all this, it is also essential that the pt. is obliged
to help himself to achieve a fast recovery by complying with prescribed drugs, diet
modification and following the physician’s order.

Client’s Presentation
Nursing History

A. Biographical Data
 Mr. RJ is a 37 yrs old male and single who lives at Mandaluyong City with his
mother. His 2 sisters have their own family and works abroad. He was born on March
15, 1973 and he is Protestant. He just lost his job as a company driver when he got
some health problems. He was admitted at ER 11: 10 am in Mandaluyong City Medical
Center with complaints of difficulty of breathing, and dizziness. He was transferred to
ICU around 4:30 pm.

B. Reason for seeking health care

The patient complained of difficulty of breathing and dizziness.

C. History of Present Illness

The patient was apparently well, two days prior to admission the patient
experienced dyspnea while washing his clothes. Therefore he decided to take some
rest and eventually it was relieved and he also refused to seek medical attention. Then
three hours prior to admission the patient complained again of dyspnea with body
weakness and felt dizzy. He was brought to Mandaluyong city medical center (ER) due
to above complaints. He was diagnosed of CHF class III secondary to thyrotoxic heart
disease. On the same day he was transferred to Intensive Care Unit (ICU). He had an
admitting vital signs of 90/60mmHg for blood pressure, 24 cpm for respiratory rate,
110bpm for pulse rate and 38.10C for temperature.

D. Past Health History

Prior to

Medical The patient has been hospitalized last March 2010 due to
history hyperthyroidism. He manifested symptoms of palpitations,
nervousness, heat intolerance and weight loss. During his stay at the
hospital, necessary interventions were given that helped his condition
to improve. When he was discharged, he was not able to work well
which made him lost his job. Precipitating factors such as smoking,
using of illegal drugs (shabu), drinking alcoholic beverages, stress
and failure to comply with his home medications lead to worsening of
his symptoms.
Surgical The patient doesn’t undergo any surgical procedure.
history
Home Prophythiouracil (PTU) for maintenance 150 mg PO
Medications
Allergies None
Injuries and None
accidents
Childhood Complete
illness
immunizatio
n

E. Family History

Content Spous Childre Siblings Parents

e n
The patient has 2 older The patient’s father
 sisters which currently who was 64 years old
Age and N/A N/A works abroad and have died due to
health their own family. The eldest cerebrovascular
status sister is 42 years old while accident (CVA) last
second elder sister is 40 2003. While his
years old. Their mother also suffered
communication is not too from CVA last 2004.
often and sometimes they
give money for his
medications.

F. Social History

The patient started to drink alcoholic beverages and smoke when he was
25 years old. He consumes 3 packs of cigarettes a day (1095 packs a day) while
drinks alcohol every other day. The patient also engaged himself in using illegal
drugs such as “shabu” and “marijuana” due to stress. The patient usually spends his
time inside the house. He previously worked as a company driver. He’s fond of
watching television when his at home. His previous work caused him the stress which
resulted to usage of illegal drugs. He’s an undergraduate student and he is financially
supported by his sisters. His family is an active protestant member while he seldom
attends church.

GORDON’S 11TH HEALTH FUNCTIONAL

PATTERN

I. HEALTH PERCEPTION – HEALTH MANAGEMENT PATTERN

BEFORE DURING INTERPRETATION

HOSPITALIZATION HOSPITALIZATION
( Nov 15- Dec 22, 2010)

He described himself as The patient was admitted Achieving and maintaining

physically fit since he has
capability to do tasks of his
daily activities on his own.
He consumes 3 packs of
cigarettes a day and drinks
alcoholic beverages every
other day. He remembered
having a complete
immunization during his
childhood years. He fairly
lives conditionally at home.
due to difficulty of health is a process that
breathing, dizziness and needs effective strategies
weakness. He felt better for staying healthy and
when he received some improving one's health.
certain procedures to Despite of the patient’s
improve his condition. He is previous habit, he realized
participative on his plan of that it will just worsen his
care that he continuously condition so he stopped
takes his medications and doing his vices and
also decided to quit adhering to his treatment.
smoking and drink alcohol
due to his current condition.
 II. NUTRITIONAL- METABOLIC PATTERN
BEFORE
HOSPITALIZATION
He makes sure that he is
maintaining his proper
weight, has good appetite,
no food intolerance or any
dietary restrictions. He eats
different types of food
especially fried like chicken,
fish and egg. He also
makes sure that he won’t
get dehydrated by taking an
average fluid intake of 3
liters per day
III. ELIMINATION PATTERN
BEFORE
HOSPITALIZATION
There are no strains
whenever he had a bowel
movement. Normally, he
defecates twice a day
which is in morning and at
evening. He would easily
eliminate his bowel
movement. Voiding would
also not be a problem since
he urinates 7 times a day.
DURING
HOSPITALIZATION
( Nov 15- Dec 22, 2010)
The patient had been
advised to have a low-fat
and low salt diet to prevent
any worsening of
symptoms. His fluid intake
has also been decreased
of about 1 liter/day.
DURING
HOSPITALIZATION
( Nov 15- Dec 22, 2010)
His bowel movement habit
and urine output is
inconsistent upon admitted.
He defecates once a day
while urinates 10 times a
day. Foley catheter was
also been inserted on his
first few weeks in the
hospital and was been
removed when he was able
to do so. During our duty,
the patient can already
ambulate therefore he was
INTERPRETATION
A human body cannot exist
for a long time without
enough nourishment from
food. We eat food o sustain
life, to enable us to grow &
be healthy so that we can
carry out our task at work at
play. The patient has a diet
to have him a stable
condition and prevent
complications particularly
difficulty of breathing due to
lungs congestion and edema
is also present on his lower
extremities. Decreased fluid
intake is necessary.
INTERPRETATION
Elimination pattern
describes the regulation,
control, and removal of by-
products and wastes in the
body which is an essential
function in our body. On the
patient’s condition,
elimination pattern is
altered due to decreased
gastrointestinal and renal
perfusion. Medication like
diuretics caused his urine
output to increase.

IV. ACTIVITY-EXERCISE PATTERN
BEFORE
HOSPITALIZATION
Patient is completely
independent in doing
everyday activities such as
hygiene, grooming, toileting
and other health care
needs. He spends his time
watching television, and
listening to music.
V. SLEEP REST PATTERN
BEFORE
HOSPITALIZATION
He can easily sleep at night
completely for about 6-8
hours upon getting home
from work. But before he
admitted he wasn’t able to
sleep well.
able to go to the comfort Insertion of foley catheter
room by himself. intend to conserve the
energy of the patient.
DURING
HOSPITALIZATION
( Nov 15- Dec 22, 2010)
Since he was hospitalized,
his activities were limited to
sitting, standing and lying
on bed due to weakness.
DURING
HOSPITALIZATION
( Nov 15- Dec 22, 2010)
The patient stated that he
has difficulty of sleeping
due to shortness of breath
in a flat position. He needs
to be in fowler’s position to
be able to sleep.
INTERPRETATION
Exercise is important to the
physical and mental health
of every individual as it can
help continue to do the
things and stay
independent without the
risk of disease. The
patient’s immobility were
due to breathlessness and
weakness but as days
passed, his condition
improved which made him
able to do some of his
ADL”s.
INTERPRETATION
Poor sleeping habits can
have a direct influence, not
only on the quality, but also
on the length of life as it
affects physical well being.
The patient must do some
positioning or have an
oxygen therapy to have
adequate rest and sleep to
overcome his fatigue and
body weakness.
 VI. COGNITIVE- PERCEPTUAL PATTERN
BEFORE
HOSPITALIZATION
Patient is alert, oriented
and conscious. He speaks
normally to his known
language which is Filipino.
The patient does not
use/wear any eyeglasses to
have a clear vision. When
problem arises, he can
define the problem and
seek for a solution to
resolve it.
VII. SELF PERCEPTION AND SELF –CONCEPT PATTERN
BEFORE
HOSPITALIZATION
He doesn’t have a work to
make him busy. Therefore,
he has more time in
drinking alcoholic drinks
and smoking.
DURING
HOSPITALIZATION
( Nov 15- Dec 22, 2010)
He still doesn’t use/wear
any eyeglasses to have a
clear vision. His other
senses were not affected
as well. He was weak on
the first day of his stay and
was able to ambulate as
the day progresses.
DURING
HOSPITALIZATION
( Nov 15- Dec 22, 2010)
His concern at the moment
is to be treated from his
illness and have a fast
recovery. He views life
positively. He is open to
whatever will happen to him
in the future.
INTERPRETATION
A person needs to be
mentally alert to do things
accurately and run his
activities or do’s in right
way. The patient’s normal
functioning of senses helps
him perform things easily
and keep his well being
healthy that prevents health
problems. Fatigue and body
weakness must be
overcome by proper
nutrition, adequate rest,
sleep and medications
INTERPRETATION
A positive or negative view
to our self can affect our
well being. The patient’s
positive outlook in life is
important for it will help him
to realize that being
participative on his plan of
care is essential that will aid
on his fast recovery.
 VIII. ROLE - RELATIONSHIP PATTERN

BEFORE DURING INTERPRETATION

HOSPITALIZATION HOSPITALIZATION
( Nov 15- Dec 22, 2010)

He is single and lives with Only his mother who We have different role in
his mother. He is active accompanied him in the life. Even though the patient
socializing and is hospital. Due to his was not satisfied on his
comfortable meeting new condition, he was not able current situation, he was
people. to socialize with his friends. trying to do the tasks that
will promote his recovery
and be able to assume his
role as a son.

IX. SEXUALITY- REPRODUCTIVE PATTERN

BEFORE DURING INTERPRETATION

HOSPITALIZATION HOSPITALIZATION
(Nov 15- Dec 22, 2010)

He is single and his sexual It stays the same. Having a partner is one of
needs are not met. The the basic needs of a
patient does not have any person. Although the
reproductive health patient doesn’t have his
problems or any own family and sexual
dysfunctions. needs are not met, he is
contented on what he have
 X. COPING – STRESS TOLERANCE PATTERN

BEFORE DURING INTERPRETATION

HOSPITALIZATION HOSPITALIZATION
( Nov 15- Dec 22, 2010)

The patient was unable to He makes sure that stress Stress is a normal
tolerate stress which won’t go in his way. He psychological and physical
resulted to smoking, sleeps to relieve stress and reaction to the demands of
drinking of alcoholic interacts with other people life that he was able to cope
beverages and usage of especially his mother that up using techniques that
drug. serves as his strength while would help him relieves
admitted. stress. Even though the
patient cannot tolerate to
much stress, it shows that
he was trying to change this
attitude.

XI. VALUE- BELIEF PATTERN

BEFORE DURING INTERPRETATION

HOSPITALIZATION HOSPITALIZATION
(Nov 15- Dec 22, 2010)

He never had any regrets in
his life. He is a spiritually
inclined person being a
Protestant. He prays for
guidance and strength on
his everyday life
Even though he is admitted
to the hospital, it would not
be a hindrance to pray. He
still looks up to pray and
bear on his mind and heart
the good values.
Strong faith with God and
good values really helps to
surpass any situations that
a person is experiencing.
The patient’s belief was
important to help him
overcome the problem that
he encountered.
PHYSICAL ASSESSMENT

Assessment Normal Findings Findings Analysis

a. General Relaxed Restless Resulted from

appearance decreased brain
perfusion
b. Vital signs
BP 120/80 mmHg 90/60mmHg Due to inability of the
heart to pump
sufficient blood

RR 12-20 cpm 24 cpm Body is trying to

(tachypnea) supply additional
oxygen to meet the
body’s demand.

PR 60-100 110bpm Result of a

compensatory
mechanism effort to
increase cardiac
output.

Temperature 36.5-37.5 38.1 Due to increase

release of T3 and T4
which could affect to
body temperature.

Weight BMI= 65 kg Due to presence of

edema
Height 5’3”

c. Skin Warm and moist Cold and clammy Stimulated

temperature sympathetic system
and moisture caused peripheral
blood vessels to
constrict

d. Skin color According to race Pallor Resulted to

decreased perfusion
 to extremities

e. Neck muscles Equal in size Distended neck Resulted to increased

veins venous pressure

f. Capillary refill 3-4 seconds 5 secs Resulted to

decreased perfusion
to extremities

g. Breathing Regular, Use of accessory Resulted from

pattern 12-20 cpm muscle attempting to create
an extra respiratory
effort to inhale
needed oxygen

h. Breath Sound Clear breath Fine crackles Resulted from

sounds increased left
(Broncho ventricular and left
Vesicular, atrial pressures,
Vesicular and which cause
Bronchial) excessive
accumulation of fluid
interstitial and
alveolar spaces.

i. Heart Sound S1 and S2 S3 Occurs as the left

ventricle becomes
less compliant

j. Abdominal Flat Ascites Result from fluid

contour accumulation from
the abdomen

k. Lower Absence of edema Bipedal edema Resulted to increased

extremities venous pressure

ANATOMY AND PHYSIOLOGY

HEART
The human heart is a muscular organ that provides a continuous blood
circulation through the cardiac cycle and is one of the most vital organs in the human
body. The heart is an organ but made up of a collection of different tissues. It is divided
into four main chambers: the two upper chambers are called the left and right atria and
two lower chambers are called the right and left ventricles. There is a thick wall of
muscle separating the right side and the left side of the heart called the septum.
Normally with each beat the right ventricle pumps the same amount of blood into
the lungs that the left ventricle pumps out into the body. Physicians commonly refer to
the right atrium and right ventricle together as the right heart and to the left atrium and
ventricle as the left heart.

The electric energy that stimulates the heart occurs in the sinoatrial node, which
produces a definite potential and then discharges, sending an impulse across the atria.
In the atria the electrical signal move from cell to cell while in the ventricles the signal is
carried by specialized tissue called the Purkinje fibers which then transmit the electric
charge to the myocardium.

Heart Circulation

Blood enters the right atrium from the systemic circulation through the superior
and inferior vena cava and from the heart the coronary sinus. Here, the blood flows into
the right ventricle while it relaxes through the tricuspid valve. The right ventricle begins
to contract which pushes blood against tricuspid valve, forcing it closed. After pressure
within the right ventricle increases, the pulmonary valve is forced to open, and blood
flows into the pulmonary trunk. The pressure within the pulmonary trunk increases as
right ventricle relaxes and the backflow of blood forces the pulmonic valve to close.

The pulmonary trunk branches to form the right and left pulmonary arteries,
which carry blood to the lungs, where carbon dioxide is released and oxygen is picked
up. Blood returning from the lungs enter the left atrium through the pulmonary veins. It
then travels through the mitral valve to the left ventricle, from where it is pumped
through the aortic semilunar valve to the aorta and to the rest of the body. The
(relatively) deoxygenated blood finally returns to the heart through the inferior vena
cava and superior vena cava, and enters the right atrium where the process began.

THYROID GLAND

The thyroid gland is a butterfly-shaped organ located in the lower neck, anterior
to the trachea. It consists of two lateral lobes connected by an isthmus. The gland is
about 5cm long and 3cm wide and weighs about 30 g. The blood flow into it is very high,
approximately 5x the blood flow to the liver. This reflects the high metabolic activity of
the thyroid gland.

Hormones

The thyroid gland produces 3 hormones: thyroxine (T4), triiodothyronine (T3) and
calcitonin. T3 and T4 secretion is controlled by TSH(thyrotropin) from the anterior
pituitary gland. TSH controls the rate of thyroid hormone release. In turn, the level of
thyroid hormone in the blood determines the release of TSH.

The primary function of thyroid hormone is to control cellular metabolic activity.

T4, a relatively weak hormone maintains body metabolism in a steady state. T3 is about
5x as potent as T4 and has a more rapid metabolic action. These hormones accelerate
metabolic processes by increasing the level of specific enzymes that contribute to
oxygen consumption and altering the responsiveness of tissues to other hormones.
These hormones also influence cell replication and are important in brain development
and normal growth.

LUNGS

Ventilation supplies atmospheric air to the alveoli. The next step in the process of
respiration is the diffusion of gases between the alveoli and the blood in the pulmonary
capillaries. The respiratory membranes is all of the areas in which gas exchange
between air and blood occurs.

Diffusion of gases in the lungs

Oxygen diffuses into the arterial ends of pulmonary capillaries and carbon
dioxide diffuses into the alveoli because of differences in partial pressures. As a result
of diffusion at the venous ends of pulmonary capillaries, the PO2 in the blood is equal to
the PO2 in the alveoli and the PCO2 in the blood is equal to the PCO 2 in the alveoli. The
PO2 of blood in the pulmonary veins is less than in the pulmonary capillaries because of
mixing with deoxygenated blood from veins draining the bronchi and bronchioles.
Oxygen diffuses out of the arterial ends of tissue capillaries and CO2 diffuses out of the
tissue because of differences in partial pressures. As a result of diffusion at the venous
ends of tissue capillaries, the PO2 in the blood is equal to the PO2 in the tissue and the
PCO2 in the blood is equal to the PCO2 in the tissue.

LABORATORY
NOVEMBER 15, 2010

THYROID FUNCTION TEST

Test Findings Reference Analysis Nursing Alert

Value
 T4 13.3 4.0-12 ug/d Hyperthyroidis There is an
m increased
metabolic rate,
temperature of
the patient. The
nurse
implement
actions in which
it will provide
comfort,
promote proper
nutrition, self-
esteem and
providing
emotional
support.
TSH 0.3 (0.4-6.0 uIu/ml) Decreased Decreased TSH
including
increased T3 &
T4 is the
hormonal
imbalance
present in
hyperthyroidism.
Same
management as
above.

NOVEMBER 15, 2010

SEROLOGY REPORT

Troponin I – Result: Negative (-)

NOVEMBER 15, 2010

CHEST X RAY

Impression: Consider bilateral pleural effusion, more for the right:

Underlying mass cannot be ruled out, suggest CT scan.
Suspicious left hilar convex density, suggest follow up.
Probable cardiomegaly

NURSING ALERT: Pleural effusion is a collection of fluid in the pleural space which
occur secondary to congestive heart failure. Patient may experience shortness of
breath. Proper positioning , assisting with thoracentesis/chest tube drainage and other
specific treatments must be directed for underlying cause.
NOVEMBER 15, 2010

HEMATOLOGY

Test Findings Normal Analysis Nursing

Values Alert

Hemoglobin 120 (140-180) Anemia In CHF, anemia is

 present due to inability
of the heart to pump
sufficient blood to meet
the metabolic needs of
tissues for oxygen and
nutrients. The patient
may feel easy
fatigability and
decrease of activity
tolerance. Adequate
rest periods, proper
nutrition and use of
safety precautions must
be implemented.
Hematocrit 0.35 0.40-0.54 Overhydration In CHF, due to inability
of the heart to pump,
pulmonary venous
blood volume and
pressure increase,
forcing fluid from the
pulmonary capillaries
into the pulmonary
tissues and alveoli
causing pulmonary
interstitial edema and
impaired gas exchange.
Patient must be
instructed to limit fluid
intake to prevent
worsening of
symptoms.
Erythrocyte 4.03 4-6 * 10 Anemia Same as hemoglobin
Leukocyte 2.7 5-10*10 Leukopenia The patient is risk for
count infection that the doctor
ordered for antibiotic.
Handwashing must be
always followed for
infection control.
Differentials

Segmenters 0.62 0.45-0.65 Normal

Lymphocytes 0.38 0.20-0.35 Infection Same as above

NOVEMBER 17, 2010

CLINICAL CHEMISTRY

Test Result Reference Analysis

Sodium 137.40 135-148 Normal

Potassium 3.64 3.50-5.30 Normal
NOVEMBER 17, 2010

CLINICAL LABORATORY

Test Result Reference Value Analysis Nursing alert

Cholesterol 4.2 ( up to 5.2 Normal

mmol/L )
HDL 1.27 ( 0.78- Normal
2.08 mmo/L )
LDL 2.39 ( up to 3.85 Normal
mmo/L )
Triglycerides 1.2 ( 0.40- Normal
1.81 mmo/L )
SGOT 133.7 ( < 35 u/L ) Increased SGOT is
increased when
there is damage of
tissue organs such
as heart, liver etc
and when there is
presence of high
metabolic activity
(thyroid storm).
The treatment
must focus on the
underlying cause
of the disease.
SGPT 74.4 ( 91 u/L ) Decreased Not clinically
significant
Urea Nitrogen 5.2 ( 2,5-6.9 mmo/L ) Normal

Creatinine 60.3 ( 53-124 umol/L ) Normal

Albumin 26.1 ( 35-53 g/L ) Decreased There is presence

of edema in which
nurse must
instruct pt to limit
fluid intake as
ordered by the
doctor and elevate
the affected part
for venous return.

NOVEMBER 17, 2010

ABDOMINAL UTZ

Impression: Diffuse liver parenchymal disease

GB Polyps
Minimal ascites
Normal pancreas, spleen, kidney and urinary bladder by UTZ
Non dilated biliary tree
 Incidental note of minimal pleural effusion right

NURSING ALERT: There may be presence of tissue damage of the liver which may be
due to patient’s excessive intake of alcohol. Instruct patient to stop doing his vices
including smoking and use of illegal drugs to prevent worsening of symptoms. Ascites
could be managed by low-sodium diet, bedrest which promote sodium excretion and
prescribed diuretic medications.The nurse must also assess abdominal girth, monitor
intake and output and weight to assess for fluid status.

NOVEMBER 17, 2010

UTZ OF THE THYROID GLAND

Impression: Enlarged thyroid gland with coarsened echo texture consider parenchymal
Disease correlation with other parameters is recommended

NURSING ALERT: Hormonal imbalance is present specifically increase T3/T4 release,

in which the patient may experience palpitations, nervousness, heat intolerance, etc.
Promoting comfort, O2 therapy, medications must be implemented.

NOVEMBER 18, 2010

2D ECHO

Interpretation

Dilated left ventricular cavity with normal wall thickness. There is hypokinesia of the
basal , lateral and anterior walls. The rest of the segments are kinetic.
Dilated left atrium, right atrium and right ventricle. The right ventricle is likewise
hypokinetic
Normal main pulmonary artery and aortic root dimensions
Thickened leaflets of the mitral with flow configuration
Structurally normal tricuspid, aortic and pulmonic with valves; no intracardial thrombus
Echo free space adjacent the left atrium and left ventricle posterior wall

NOVEMBER 18, 2010

CHEST X RAY

Bilateral pleural effusion, right more than left

NURSING ALERT: Pleural effusion is a collection of fluid in the pleural space which
occur secondary to congestive heart failure. Patient may experience shortness of
breath. Proper positioning and other specific treatments must be directed for underlying
cause.
NOVEMBER 20, 2010

PROTHROMBIN TIME

Patient Protime : 15.9 secs (NV: 11-14 secs)

Control: 12.6 secs
INR: 1.62
% activity: 60% (NV: 70-100%)
NURSING ALERT: Clopidogrel, an antiplatelet drug, is one of patient’s medications that
may affect the coagulation process. The nurse must implement necessary actions and
provide health teaching to prevent bleeding. Since there is tissue damage of the liver
and congestion, it may impairs the liver’s ability to synthesize coagulants.

DECEMBER 9, 2010

UTZ

Report:
Free fluid is seen on both hemithoraces with approximate volume of 2,619 on the
right and 531cc on the left

Impression:
Pleural effusion, bilateral

NURSING ALERT: Pleural effusion is a collection of fluid in the pleural space which
occur secondary to congestive heart failure. Patient may experience shortness of
breath. Proper positioning and other specific treatments must be directed for underlying
cause.

DECEMBER18, 2010

PLEURAL FLUID ANALYSIS

Test Result Unit Normal Analysis Nursing alert

values
Sugar 4.38 mmol/L 3.89-5.84 Normal
LDH 36.3 u/L 207-414 Decrease Presence of
tissue damage
CHON 10.2 g/L 40-81 Decrease An imbalance
between the
pressure within
blood vessels
(which drives
fluid out of the
blood vessel) and
the amount of
protein in blood
(which keeps
fluid in the blood
vessel) can result
in accumulation
of fluid (called a
transudate)

DISCHARGE PLANNING
MEDICATION

The patient should adhere his medication regimen following the rules of right
dose, right route, right time and right frequency. These medications are PTU 50g TID,
Clopidogrel 75g OD, Allopurinol 100g OD.

EXERCISE
 Instruct patient to avoid prolonged bed rest however rest must be provided when
severe symptoms occur. He must be encouraged to perform an activity slowly than
usual, for a shorter duration or with assistance initially to prevent increase workload of
the heart.

TREATMENT

The patient should follow the physician’s and should take his medication at the
right dose, right route, right time and right frequency.

HEALTH TEACHING

• The patient with his family should be teach in assessing for skin breakdown when
at home, and institute preventive measures such as frequent changes of position,
positioning to avoid pressure, elastic pressure stockings and leg exercises.
• Teach also them how the progression of the disease is influenced by compliance
with the treatment plan.
• Convey that monitoring symptoms and daily weights, restricting sodium intake,
avoiding excess fluids, preventing infection, avoiding noxious agents such as
alcohol, tobacco and participating in regular exercise all aid in preventing the
exacerbation of cardiac failure.
• Instruct him also to avoid stress and teach some management such as massage,
therapeutic touch, silence etc to handle it.

OUT-PATIENT

• The patient should return on the schedule date of his follow-up check-up on Jan.
10, 2011
• Instruct the continuous take of his medication as prescribed

DIET

• Instruct pt to have a small frequent feedings to decrease the amount of energy

needed for digestion while providing adequate nutrition
• Teach pt to adhere a low-sodium diet by reading food labels and avoiding
commercially prepared convenience foods.
• Advise patient to avoid highly seasoned foods such as coffee, tea, cola and
alcohol

SPIRITUAL

• He should enhance his relationship with God through faith and trust in His divine,
power and believed that the Lord will help in his recovery.