CAPITOL UNIVERSITY College of Nursing Cagayan de Oro City

A case study on

RHEUMATIC HEART DISEASE

In partial fulfillment for the requirements In Related Learning Experience 50

Submitted to:

Mr. Rick Wilson Bunao RN,MN Clinical Instructor

Submitted by: Rama, Jocef Ian D.

Table of Contents Introduction Acknowledgement Significance of the study Objectives of the study Patients profile Anatomy and physiology Pathophysiology Diagnostic test Medical and surgical management Drug study Nursing management NCP (nursing care plan) Evaluation, results and discussion Definition of terms Bibliography

INTRODUCTION
This is a case study about a 30 year old, male with Rheumatic heart disease, atrial fibrillation in rapid ventricular response, and cardiomegaly. The patient was admitted last July 22, 2012 at Northern Mindanao Medical Center complaining of shortness of breath, fever, and cough. . This study is aimed about the disease condition of the client and to know more about its manifestations, on its medical treatment and nursing treatment for us to provide the outmost and appropriate nursing care for the patient.

ACKNOWLEDGEMENT

This case study would not have been possible without the support and cooperation of a number of people. I wish to express my gratitude to the family of our client for their kind cooperation in our assessment of the patient. Deepest gratitude are also due to my duty mates, without whose knowledge and assistance this study would not have been successful. Special thanks also to Mr. Rick Wilson Bunao for the knowledge and teaching that you have imparted. Not forgetting to my beloved parents who sent me to school and are always had been there. I would also like to convey thanks to the nursing staff of male medical ward of Northern Minadanao Medical Center for your warmly accepting us in your ward. And lastly, all the greatest thanks to our GOD. If not for HIM all of this would be impossible.

Significance of the study

To the nursing education. The significance of this study to the nursing education is in letting us students know more about the disease condition and knowing how to appropriately provide the outmost nursing care to the client with that disease condition. It significantly can be of help because it can be of good contribution the nursing education. To the nursing practice. The study is of great significance because it can help student nurses sharpen their skills in giving the appropriate nursing care to prepare them for the real world of nursing. To the nursing research. On the course of this study, there could be points, methods, new information, and updates that could be significant to the nursing field that could be of good help and may give birth to new procedures and interventions.

Patients Profile

Rheumatic Heart Disease Name: Patient A Address: Tagoloan, Mis. Or. Birth: Date: 04/10/1982 Birth place: Tagoloan, Mis. Or. Civil status: married Nationality: Filipino Age: 30 Sex: male Religion: Catholic Insurance: Philhealth CC: fever, low back pain HPI: 1day prior to admission patient complained of fever and shortness of breathing Bradycardiac: 58 bpm Medications: Penicillin 250 mg 1 cap b.i.d. Aspirin 80 mg 1 tab after lunch Captopril 25 mg tab b.i.d. Physical examination -arousable, sleepy Heart -tachycardia, irregular rhythm Vital signs Temp: 36.5 BP: 120/80 resp: 25 Pulse: 58 Personal/social history: -occupation: none Religion: RC Family history (+) HPN maternal (+) cardiac paternal disease Sexual History Menopause: 53 -parity g6p6 -NSVD Spirinolactone 25 mg 1 tab od Digoxin 0.25 mg tab od

ANATOMY AND PHYSIOLOGY

The Heart The heart itself is made up of 4 chambers, 2 atria and 2 ventricles. De-oxygenated blood returns to the right side of the heart via the venous circulation. It is pumped into the right ventricle and then to the lungs where carbon dioxide is released and oxygen is absorbed. The oxygenated blood then travels back to the left side of the heart into the left atria, then into the left ventricle from where it is pumped into the aorta and arterial circulation.

The pressure created in the arteries by the contraction of the left ventricle is the systolic blood pressure. Once the left ventricle has fully contracted it begins to relax and refill with blood from the left atria. The pressure in the arteries falls whilst the ventricle refills. This is the diastolic blood pressure. The atrio-ventricular septum completely separates the 2 sides of the heart. Unless there is a septal defect, the 2 sides of the heart never directly communicate. Blood travels from right side to left side via the lungs only. However the chambers themselves work together . The 2 atria contract simultaneously, and the 2 ventricles contract simultaneously. Cardiac Conduction System Going back to the analogy of the central heating system, the pump, pipes and radiators are of no use unless connected to a power supply. The pump needs electricity to work. The human heart has a similar need for a power source and also uses electricity. Thankfully we don't need to plug ourselves in to the mains, the heart is able to create it's own electrical impulses and control the route the impulses take via a specialised conduction pathway. This pathway is made up of 5 elements: 1. The sino-atrial (SA) node 2. The atrio-ventricular (AV) node 3. The bundle of His 4. The left and right bundle branches 5. The Purkinje fibres

The SA node is the natural pacemaker of the heart. You may have heard of permanent pacemakers (PPMs) and temporary pacing wires (TPWs) which are used when the SA node has ceased to function properly. The SA node releases electrical stimuli at a regular rate, the rate is dictated by the needs of the body. Each stimulus passes through the myocardial cells of the atria creating a wave of contraction which spreads rapidly through both atria. The heart is made up of around half a billion cells, In the picture above you can see the difference in muscle mass of the various chambers. The majority of the cells make up the ventricular walls. The rapidity of atrial contraction is such that around 100 million myocardial cells contract in less than one third of a second. So fast that it appears instantaneous. The electrical stimulus from the SA node eventually reaches the AV node and is delayed briefly so that the contracting atria have enough time to pump all the blood into the ventricles. Once the atria are empty of blood the valves between the atria and ventricles close. At this point the atria begin to refill and the electrical stimulus passes through the AV node and Bundle of His into the Bundle branches and Purkinje fibres. Imagine the bundle branches as motorways, if you like, with the Purkinje fibers as A and B roads that spread widely across the ventricles . In this way all the cells in the ventricles receive an electrical stimulus causing them to contract. Using the same domino analogy, around 400 million myocardial cells that make up the ventricles contract in less than one third of a second. As the ventricles contract, the right ventricle pumps blood to the lungs where carbon dioxide is released and oxygen is absorbed, whilst the left ventricle pumps blood into the aorta from where it passes into the coronary and arterial circulation. At this point the ventricles are empty, the atria are full and the valves between them are closed. The SA node is about to release another electrical stimulus and the process is about to repeat itself. However, there is a 3rd section to this process. The SA node and AV node contain only one stimulus. Therefore every time the nodes release a stimulus they must recharge before they can do it again. Imagine you are washing your car and have a bucket of water to rinse off the soap. You throw the bucket of water over the car but find you need another one. The bucket does not magically refill. You have to pause to fill it. In the case of the heart, the SA node recharges whilst the atria are refilling, and the AV node recharges when the ventricles are refilling. In this way there is no need for a pause in heart function. Again, this process takes less than one third of a second. The times given for the 3 different stages are based on a heart rate of 60 bpm , or 1 beat per second. The term used for the release (discharge) of an electrical stimulus is "depolarisation", and the term for recharging is "repolarisation". So, the 3 stages of a single heart beat are: 1. Atrial depolarisation 2. Ventricular depolarisation Atrial and ventricular repolarisation.

PATHOPHYSIOLOGY
Predisposing factors: - 15 yrs. Old - Exposure to GABHS (his auntie has the same dse) - (-) immunization Precipitating factors: Malnutrition Poor living conditions Congested neighborhood Improper food handling

Presence of Group A beta-hemolytic streptococcus Attach to epithelial cells of the upper respiratory tract Activated antigen-presenting cells present the bacterial antigen to helper T-cells. Activated B-cells Production of antibodies against the cell wall against of streptococcus Antibodies cross react with cardiac myosin and antigens of tissue glucoprotein in the joints, skin, brain and other connective tissue.

Induces cytokines release Inflammatory response Unmanaged, subsequent exposure to the antigen Unmanaged, subsequent exposure to the antigen Heart valve tissues become inflamed Inflammation subsides Valves begin to heal w/ scar tissue forming

FEVER ARTHRALGIA ESR WBC count Activity intolerance

Restriction of leaflet motion Impeding to full swing action Aortic Valvular stenosis Leaflets may become deformed by healing tissue Valve fails to close completely Wide pulse pressure Aortic Regurgitation blood volume to LV cyanosis Orthopnea pulmonary venous blood flow & pressure Pulmonary congestion Dyspnea Use of accessory muscles RR vasoconstriction Stimulate SNS S3 Heart sound Murmurs

blood volume and pressure in the LA

cardiac output

Non productive cough

Release of epinephrine and norepinephrine Kidney RBC HR & Contractility Further damage to the heart muscles

Capillary permeability Plasma leaked out Accumulation of excessive fluid in the pleural space Pleural effusion

blood volume to RV Continuous flow of blood from the CVC blood volume of RV and RA Tricuspid regurgitation

Impaired sleep

Skin Cold clammy, pallor

GIT

Renal perfusion Release of renin by kidneys Formation of angiotensin I

gastric secretions digestion BM

Fast, bounding pulse Dec. vocal tactile fremitus s/sx: Dullness when percussed fever, chills, pleuritic chest pain, dyspnea JVD Fluid volume overload Peripheral edema Impaired gas exchange Pulmonary hypertension Respiratory failure R Ventricular failure Congestion of the viscera and peripheral tissue Blood backs to hepatic veins Pressure w/in portal vessels Portal hypertension Abdominal pain Forced fluid into the abdominal cavity Ascites Nausea Weight gain Anorexia Death Elasticity Fail to contract -dizziness, lightheadedness Cyanosis, pallor ventricular pressure and resistance to ventricular filling oxygenation in brain tissues ACE converts angiotension I to II Promotes the release of aldosterone Promotes retention of Na+ and water Preload and afterload Further stress on the ventricular wall Fatigue Further in the workload of the heart Weakness Thickness of the heart muscle Activity intolerance Stimulates ADH production bp

UO

lung expansion

Subsequent in cardiac output Development of pressure workload of the heart contraction

Nursing care plan

NURSING CARE PLAN ASSESSMENT DATA (Subjective & Objective Cues)

Subj:

NURSING DIAGNOSIS (problem and etiology)

GOALS AND OBJECTIVES

After 2 of nursing intervention pt will lessen/ eradicate streessors that can help in reducing the workload of the heart participate in activities that reduce the workload of the heart like stress management, therapeutic medication, and balanced activity rest pattern.

NURSING INTERVENTIONS AND RATIONALE

Independent:

EVALUATION

Decrease cardiac output related to incompetent valve stenosis as dili kaau ko kalihoklihok kay dali rako manifested by arrhythmia, kapoyon as verbalized. prolonged capillary refill and generalized edema.

GOAL PARTIALLY MET After 2 of nursing intervention pt was able to participate in activities that reduced the workload of the heart

Obj: -peripheral edema(+3) - cold clammy skin - 4 sec. capillary refill

- Keep client on bed, promote rest, semi fowler position is preferred and may elevate feet in shock situations - Encourage slowly dangling of legs before standing - Limit visitors - Review diagnostic studies like CXR, ECG - Encourage relaxation techniques such as deep breathing exercises Dependent:

Obj: Collaborative: To be able to decrease edema - To be able to promote blood circulation To be able to demonstrate an increase in activity tolerance - Discuss sign and symptoms that require prompt reporting to health care provider ( muscle cramps, headache and dizziness)

ASSESSMENT DATA (Subjective & Objective Cues)

Subjective: gapanghupong akong mga tiil as verbalized by the patient Objective: Bipedal Edema grade 3 Abdominal girth of 30cm

NURSING DIAGNOSIS (problem and etiology)

Excess fluid volume related to increased ADH production and sodium/water retention as manifested by bipedal edema (grade 2).

GOALS AND OBJECTIVES

Goal: After 8hrs of continuous nursing intervention the patient will be able to reduce recurrence of fluid excess as manifested by decrease abdominal girth, reduce edema from (+3) to (+1). Objective: To be able to reduce accumulation of fluid (edema) on feet and different part of the body To be able to increase output

NURSING INTERVENTIONS AND RATIONALE

Independent: Note presence of underlying condition that potential fluid excess Note presence of edema and calculate its grade

EVALUATION

Note pattern of urination Measure I and O

GOAL MET partially met After 8 hrs of continuous nursing intervention, patient was able to reduce recurrence of fluid excess as manifested by decreased abdominal girth and decreased edema from grade 3 to grade 2.

Dependent: Restrict Na and Fluid as indicated Administer diuretics as prescribed

NURSING CARE PLAN ASSESSMENT DATA (Subjective & Objective Cues)

S: galisod ko ug ginhawa as verbalized by the patient Objective data: Respiratory rate of 28 bpm Use of accessory muscle Orthopnea Crackles

NURSING DIAGNOSIS (problem and etiology)

Impaired gas exchange related to fluid shift on alveoli secondary to pulmonary edema as manifested by respiratory rate of 28 bpm and

GOALS AND OBJECTIVES

GOALS: After 1 day of nursing intervention, the patient will improve respiration OBJECTIVES: To be able to decrease respiratory rate from 28 bpm to atleast 24 bpm by positioning the patient in semi fowler position and administration of oxygen inhalation

NURSING INTERVENTIONS AND RATIONALE

Monitor color of the skin, use of accessory muscle oxygen saturation, depth, pattern and rate of respiration Position patient in semi fowler position Secure oxygen at bedside

EVALUATION

Goal partially met. After a day of nursing intervention the patient respiratory rate decrease from 28 bpm to 26 bpm.

Minimize activities and energy expenditures by assisting ADLs DEPENDENT Give oxygen as prescribed by the physician

Drug study

CAPITOL UNIVERSITY COLLEGE OF NURSING Name of Student:_______________________________________ Date of Assignment:__________________________________________ Name of Patient:________________________________________ Ward:_____________________________ Bed No. _______________ DRUG STUDY DRUG STUDY (Generis name, brand name, classification, dosage, route, frequency) NURSING RESPONSIBILITIES/ PRECAUTIONS

MECHANISM OF ACTION

INDICATIONS

CONTRAINDIATIONS

ADVERSE EFFECTS OF THE DRUG

Aspirin 80 mg 1 tab OD (after lunch, 1pm) Class: Analgesic(non-opioid) Antirheumatic

Inhibits the synthesis of prostaglandins.

>inflammatory conditions Eg. Rheumatic fever, rheumatic heart disease

>allergy to salicylates or NSAIDs >Use cautiously with patients with hepatic impairement

Acute Aspirin toxicity: respiratory alkalosis, tachypnea, hemorrhage Aspirin intolerance: exacerbation of bronchospasm, rhinitis GI: nausea, dyspepsia, heartburn Hematologic: occult blood loss, homeostatic defects Hypersensitivity: anaphylactic reaction

>asses for allergy to salicylates or NSAIDs > give med with food or after meals.

Issue: 05 April 2006

Revision Code: 003

CAPITOL UNIVERSITY COLLEGE OF NURSING Name of Student:_______________________________________ Date of Assignment:__________________________________________ Name of Patient:________________________________________ Ward:_____________________________ Bed No. _______________ DRUG STUDY DRUG STUDY (Generis name, brand name, classification, dosage, route, frequency) NURSING RESPONSIBILITIES/ PRECAUTIONS

MECHANISM OF

INDICATIONS

CONTRAINDIATIONS

ADVERSE EFFECTS OF

ACTION

THE DRUG

Carvedilol 6.25 mg 1 tab b.i.d. class: alpha & beta adrenergic blocker antihypertensive

Competitively blocks alpha-, beta-, and beta2- adrenergic receptors and has some sympathomimetic activity at beta2receptors.

>treatment for mild to severe heart failure of ischemic cardiomyopathic origin.

> decompensated heart failure, bronchial asthma, heart block >use cautiously with hepatic impairement

CNS: dizziness, vertigo, tinnitus, fatigue CV: bradycardia, orthosttic hypotension, heart failure GI: gastric pain, flatulence, hepatic failure

>assess history of heart failure >monitor for orthostatic hyp[otension >take drug with meals

Issue: 05 April 2006

Revision Code: 003

CAPITOL UNIVERSITY COLLEGE OF NURSING Name of Student:_______________________________________ Date of Assignment:__________________________________________ Name of Patient:________________________________________ Ward:_____________________________ Bed No. _______________ DRUG STUDY

DRUG STUDY (Generis name, brand name, classification, dosage, route, frequency) Spirinolactone 25 mg 1 tab b.i.d. PO Class: potassium-sparing diuretic

MECHANISM OF ACTION Competitively blocks the effects of aldosterone in the renal tubules causing loss of sodium and water and retains potassium.

INDICATIONS

CONTRAINDIATIONS

ADVERSE EFFECTS OF THE DRUG CNS: dizziness, headache, drowsiness Derma: rash, urticaria, GI: cramps, diarrhea, vomiting GU: impotence Hema: Hyperkalemia, hyponatremia, agranulocytosis

NURSING RESPONSIBILITIES/ PRECAUTIONS >assess for allergy to spirinolactone >assess skin for urticaria and rashes >measure and record regular weight >monitor mobilization of liquids >avoid foods rich in potassium

>treatment for hypokalemia or prevention of hypokalemia in patients receiving cardiac glycosides Eg. digoxin

>allergy to spirinolactone >hyperkalemia >renal disease

Issue: 05 April 2006

Revision Code: 003

CAPITOL UNIVERSITY COLLEGE OF NURSING Name of Student:_______________________________________ Date of Assignment:__________________________________________ Name of Patient:________________________________________ Ward:_____________________________ Bed No. _______________ DRUG STUDY

DRUG STUDY (Generis name, brand name, classification, dosage, route, frequency) Digoxin 0.25 mg 1 tab OD PO Class: Cardiac glycoside cardiotonic

MECHANISM OF ACTION Increases intracellular calcium to enter the myocardial wall during depolarization via Na-K pump.

INDICATIONS

CONTRAINDIATIONS

ADVERSE EFFECTS OF THE DRUG CNS: headache, weakness, drowsiness, visual disturbance CV: arrhythmias GI: GI upset, anorexia

NURSING RESPONSIBILITIES/ PRECAUTIONS >assess for allergy to cardiac glycosides >monitor apical pulse for 1min before administration. Hold dose if <60 bpm

>heart failure > atrial fibrilation

>allergy to cardiac glycosides >ventricular tachycardia >ventricular fibrillation >heart block

Issue: 05 April 2006

Revision Code: 003

CAPITOL UNIVERSITY COLLEGE OF NURSING Name of Student:_______________________________________ Date of Assignment:__________________________________________ Name of Patient:________________________________________ Ward:_____________________________ Bed No. _______________ DRUG STUDY

DRUG STUDY (Generis name, brand name, classification, dosage, route, frequency) Penicillin 500mg 1 cap PO OD Class: antibiotic

MECHANISM OF ACTION Bactericidal. Inhibits cell wall synthesis of sensitive organism.

INDICATIONS

CONTRAINDIATIONS

ADVERSE EFFECTS OF THE DRUG CNS: lethargy, hallucinations, seizures, GI: glossitis, stomatitis, gastritis, sore mouth, nausea and vomiting, diarrhea GU: nephritis, oliguria, hematuria Hema: anemia, thrombocytopenia

NURSING RESPONSIBILITIES/ PRECAUTIONS >assess allergy to penicillin and cephalosphorin >culture infection before beginning treatment >avoid patient to do selftreatment >do not administer with milk, fruit juices, or soft drinks

>for moderately severe infections caused by sensitive organism Eg. streptococci

>allergy to penicillin

Issue: 05 April 2006

Revision Code: 003

CAPITOL UNIVERSITY COLLEGE OF NURSING Name of Student:_______________________________________ Date of Assignment:__________________________________________ Name of Patient:________________________________________ Ward:_____________________________ Bed No. _______________ DRUG STUDY

DRUG STUDY (Generis name, brand name, classification, dosage, route, frequency) Ciprofloxacin 200 mg IVTT q12 class: antibacterial

MECHANISM OF ACTION Bactericidal Interferes with DNA replication in susceptible bacteria preventing cell replication

INDICATIONS

CONTRAINDIATIONS

ADVERSE EFFECTS OF THE DRUG CNS: headaches, dizziness, somnolence CV: arrhythmias, hypotension, angina GI: nausea and vomiting, dry mouth, diarrhea

NURSING RESPONSIBILITIES/ PRECAUTIONS >asses allergy to ciprofloxacin and flouroquinolones

>treatment for gram negative bacteria

>allergy ciprofloxacin and flouroquinolones

Issue: 05 April 2006

Revision Code: 003

DISCHARGE PLANNING
D- Diet Encourage patient to eat nutritious foods, limiting intake of food and sodium. F- Follow- up Instruct patient to have a follow-up visit after 1 week at his doctors clinic. A- Activity Level Encourage following activity with restrictions, resuming activity gradually, and resting whenever tired. Advise patient to have assistance and support as tolerated when ambulating and to perform ADLs involving hygiene and self-care, with support if needed. T- Treatment Emphasize the importance of prophylaxis against recurrent streptococcal pharyngitis and continuous therapy to prevent recurrent rheumatic fever and rheumatic heart disease. D- Discharge Plan Explain to the patient and parents the disease process and its treatment to promote understanding of acute and lifelong prophylactic treatment. Teach patient and parents to prevent further streptococcal infections b good hand washing and avoiding people with sore throat. Encourage the patient and parents to contact the primary healthcare provider if a sore throat occurs. Advise patient to return to physical education classes gradually, with the guidance of the physician. Encourage patient to take frequent naps and rest periods. Encourage relaxing environment using relaxation techniques, listening to music and quiet activities Teach patient and parents about the importance in keeping their environment clean and practicing proper food handling and sterilizing kitchen utensils. Advise the parents that child cannot return to school until health care provider assesses that all disease activity is gone. Parents may need to discuss with teachers how the child can catch up with school..

M- Medications Make sure that the patient understands the purpose, dosage, route, and possible side effects of all prescribed home medications. Instruct patient and the family to strictly follow the orders for take home meds upon discharge as prescribed by the physician.