152637254 rle50-rhd-final-doc

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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



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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

Patient’s profile

Anatomy and physiology

Pathophysiology

Diagnostic test

Medical and surgical management

Drug study

Nursing managementNCP (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.

Patient’s 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 lunchCaptopril 25 mg ½ tab b.i.d.

Spirinolactone 25 mg 1 tab odDigoxin 0.25 mg ½ tab od

Personal/social history:-occupation: none

Religion: RC

Family history(+) HPN maternal

(+) cardiac paternal disease

Sexual HistoryMenopause: 53

-parity g6p6-NSVD

Physical examination-arousable, sleepy

Heart-tachycardia, irregular rhythm

Vital signs

Temp: 36.5BP: 120/80

resp: 25Pulse: 58

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.

Valves begin to heal w/ scar tissue formingInflammation subsides

Heart valve tissues become inflamed

Unmanaged, subsequent exposure to the antigen

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

↑ WBC count

FEVER

ARTHRALGIA

↑ ESR

Activity intolerance

Restriction of leaflet motion

Impeding to full swing action

Aortic Valvular stenosis

↑ blood volume to LV

Leaflets may become deformed by healing tissue

Valve fails to close completely

Aortic Regurgitation

↑blood volume and pressure in the LA ↓cardiac output

↑pulmonary venous blood flow & pressure

Pulmonary congestion

Stimulate SNS

Release of epinephrine and norepinephrine

vasoconstriction

Further damage to the heart

muscles

↑ Capillary permeability

Plasma leaked out

Accumulation of excessive fluid in the pleural space

Release of renin by kidneys

Dyspnea

Non productive cough

Pleural effusion

Orthopnea

Impaired sleepGITSkin Kidney

Cold clammy, pallor

↑ HR & Contractility

↓ gastric secretions

↓ digestion

↓ BM

↓ Renal perfusion

Formation of angiotensin I

S3 Heart sound

↑ blood volume to RV

Continuous flow of blood from the CVC

↑ blood volume of RV and RA

Tricuspid regurgitation

Wide pulse pressure

cyanosis

Murmurs

↑ RR

Use of accessory muscles

↑ RBC

Impaired gas exchange

Pulmonary hypertension

Respiratory failure

ACE converts angiotension I to II

Promotes the release of aldosterone

R Ventricular failure

Congestion of the viscera and peripheral tissue

Blood backs to hepatic veins

↑ Pressure w/in portal vessels

Promotes retention of Na+ and water

Fluid volume overload

Portal hypertension

Forced fluid into the abdominal cavityAscites

Anorexia

Abdominal pain

Nausea

Development of ↑ pressure

↑ Preload and afterload

Further ↑stress on the ventricular wall

Further ↑ in the workload of the heart

↑ Thickness of the heart muscle

↑ventricular pressure and resistance to ventricular filling

Subsequent ↓ in cardiac output

JVD

Dec. vocal tactile

fremitusDullness

when percussed

Weight gain

↑ workload of the heart

↑ contraction

↓ Elasticity

Fatigue↓ oxygenation in brain tissues

-dizziness, light-headedness

Activity intolerance

Stimulates ADH production

Peripheral edema

Fail to contract

Death

↑bp

↓ UO

Fast, bounding pulse

Weakness

s/sx:

fever, chills, pleuritic chest pain, dyspnea

Cyanosis, pallor

↓ lung expansion

Nursing care plan

ASSESSMENT DATA

(Subjective & Objective Cues)

NURSING DIAGNOSIS

(problem and etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subj:

“dili kaau ko kalihoklihok kay dali rako kapoyon” as verbalized.

Obj:

-peripheral edema(+3)

- cold clammy skin

- 4 sec. capillary refill

Decrease cardiac output related to incompetent valve stenosis as manifested by arrhythmia, prolonged capillary refill and generalized edema.

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.

Obj:

- To be able to decrease edema

- To be able to promote blood circulation

To be able to demonstrate an increase in activity tolerance

Independent:

- 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:

Collaborative:

- Discuss sign and symptoms that require prompt reporting to health care provider ( muscle cramps, headache and dizziness)

GOAL PARTIALLY MET

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

NURSING CARE PLAN

ASSESSMENT DATA


NURSING DIAGNOSIS




EVALUATION

Subjective:“gapanghupong akong mga tiil” as verbalized by the patient

Objective: Bipedal Edema grade 3 Abdominal girth of 30cm

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

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

Independent: Note presence of underlying

condition that potential fluid excess Note presence of edema and

calculate its grade

Note pattern of urination

Measure I and O

Dependent: Restrict Na and Fluid as indicatedAdminister diuretics as prescribed

GOAL MET partially metAfter 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.

ASSESSMENT DATA


NURSING DIAGNOSIS




EVALUATION

S: “galisod ko ug ginhawa” as verbalized by the patient

Objective data: Respiratory rate of 28 bpm Use of accessory muscle Orthopnea Crackles

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

GOALS:After 1 day of nursing intervention, the patient will improve respirationOBJECTIVES: 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

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

Minimize activities and energy expenditures by assisting ADL’s

DEPENDENT Give oxygen as prescribed by the

physician

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

NURSING CARE PLAN

Drug study

CAPITOL UNIVERSITYCOLLEGE 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)MECHANISM OF

ACTIONINDICATIONS CONTRAINDIATIONS ADVERSE EFFECTS OF

THE DRUG

NURSING RESPONSIBILITIES/

PRECAUTIONS

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



DRUG STUDY




THE DRUG


PRECAUTIONS

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 beta2- receptors.

>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




DRUG STUDY




THE DRUG


PRECAUTIONS

Spirinolactone

25 mg

1 tab

b.i.d.

PO

Class: potassium-sparing diuretic

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

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

Eg. digoxin

>allergy to spirinolactone

>hyperkalemia

>renal disease

CNS: dizziness, headache, drowsiness

Derma: rash, urticaria,

GI: cramps, diarrhea, vomiting

GU: impotence

Hema: Hyperkalemia, hyponatremia, agranulocytosis

>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




DRUG STUDY




THE DRUG


PRECAUTIONS

Digoxin

0.25 mg

1 tab

OD

PO

Class:

Cardiac glycoside

cardiotonic

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

>heart failure

> atrial fibrilation

>allergy to cardiac glycosides

>ventricular tachycardia

>ventricular fibrillation

>heart block

CNS: headache, weakness, drowsiness, visual disturbance

CV: arrhythmias

GI: GI upset, anorexia

>assess for allergy to cardiac glycosides

>monitor apical pulse for 1min before administration. Hold dose if <60 bpm




DRUG STUDY




THE DRUG


PRECAUTIONS

Penicillin

500mg

1 cap

PO

OD

Class: antibiotic

Bactericidal.

Inhibits cell wall synthesis of sensitive organism.

>for moderately severe infections caused by sensitive organism

Eg. streptococci

>allergy to penicillin CNS: lethargy, hallucinations, seizures,

GI: glossitis, stomatitis, gastritis, sore mouth, nausea and vomiting, diarrhea

GU: nephritis, oliguria, hematuria

Hema: anemia, thrombocytopenia

>assess allergy to penicillin and cephalosphorin

>culture infection before beginning treatment

>avoid patient to do self-treatment

>do not administer with milk, fruit juices, or soft drinks




DRUG STUDY




THE DRUG


PRECAUTIONS

Ciprofloxacin

200 mg

IVTT

q12

class: antibacterial

Bactericidal

Interferes with DNA replication in susceptible bacteria preventing cell replication

>treatment for gram negative bacteria

>allergy ciprofloxacin and flouroquinolones

CNS: headaches, dizziness, somnolence

CV: arrhythmias, hypotension, angina

GI: nausea and vomiting, dry mouth, diarrhea

>asses allergy to ciprofloxacin and flouroquinolones


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 doctor’s 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 ADL’s 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.

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