ACKNOWLEDGEMENT

In fulfilling the tasks as student nurses, especially in accomplishing their case study, they had

received many blessings, such as meeting great people who helped them by enlightening their

mind and encouraging them in doing this study.

To have reached this far even though they still have to tread a very long road in nursing, they

would like to thank the following;

Almighty God for blessing them with good health, grace and wisdom.

To the client and her family, for the trust and cooperation as well as the information in fulfilling

this case study.

To the faculty and staff of BCSI nursing department, thank you for helping them to accomplish

this task which allowed them to learn more than what they expected.

To their parents and guardians who have been working very hard from dawn till dusk, thank you

for all the support they had given to them especially with the financial support which motivates

them now to work harder and get higher grades.

To their dear friends, loved ones, classmates and schoolmates for the tap in the shoulder, the

encouragement and for being there through good and difficult times.

To all of them, thank you so much, their group has learned to value and to appreciate each

other as they work hand in hand in accomplishing this study.

Case Presentors

1
 CHAPTER I

Introduction

Rheumatic heart disease is a serious complication of rheumatic fever, a disease in which

infection of the upper respiratory tract by streptococcal bacteria leads to heart disease. The

infection typically affects the heart valves (valvular rheumatic heart disease), but it can also

affect other heart structures.

Worldwide statistics shows that, rheumatic heart disease remains a major health

problem. The mortality rate from this disease remains 1-10%. A comprehensive resource

provided by the World Health Organization (WHO, 2014) addresses the diagnosis and treatment

of this later population. Estimations worldwide are that 5-30 million children and young adults

have chronic rheumatic heart disease, and 90,000 patients die from this disease each year.

In the Philippines about 2,389 Filipinos under all age groups die because of chronic

rheumatic heart disease each year and 873 of that are young Filipinos under 10-24 years old.

(Philippine Health Statistics 2009, DOH) The Office of the Secretary under the Department of

Health released an administrative order no. 23-B on July 1 1996 entitled Addendum To Manual

Of Operation Of Rheumatic Fever/Rheumatic Heart Disease (RF/RHD); Guidelines on the

Referral, Confirmation, Diagnosis, Registration and Management of RF-RHD Cases. This

guideline is the answer of Philippine Government to address Rheumatic Heart Disease cases in

the country.

In General Santos City areas there are 96 individuals recorded with heart problem in no

particular age. This was gathered as of the first and second quarter of 2014 (CHO,2014)

2
 The group chose this case because it is an interesting topic to study. Aside from the

reason that the concept in NCM 103 is about cardiovascular system, we want to study and

understand further about RHD. Also is able to know the causes or factors that may contribute to

this disease, and we able to prevent or manage this kind of condition.

3
 CHAPTER II

OBJECTIVES

General Objective:

This case study aims to develop and broaden the knowledge and skills through effective

utilization of nursing process in dealing with the course of nursing management in patients with

RHD.

Specific Objectives:

The reader will be able to:

 have awareness and perception about the disease

 know the contributing factors to the existence of the disease

 understand the medication’s given, its classification, indications, contraindication and

side effect and thoroughly understand its significance.

 know problems from the client’s health pattern and formulate an effective and

appropriate nursing care plan for prioritized problem

 understand the anatomy and physiology of cardiovascular system, including its

circulation

 know the pathophysiology of rheumatic heart disease

 understand the abnormalities of diagnostic laboratory examination of the client and

relate the result to the client’s present condition.

 Know the therapeutic management of the disease.

4
  Know appropriate nursing care plan.

The client and family will be able to:

 Know and evaluate their risk and possibility in developing RHD

 Understand the essence of their cooperation and strict compliance in the pharmacologic

and non-pharmacologic ways in treating the client’s disease and prevent further

complication.

 Understand the client’s condition and aggravating factors.

 Understand and apply the management of the illness;

 undertand supporting factors in different aspects such as financially, morally,

emotionally and spiritually.

The Student Nurses will be able to:

 Obtain baseline information including demographic data and health history;

 Assess the client physically using the IPPA (Inspection, Palpation, Percussion, and

Auscultation);

 Identify the existing problems of the client using the Gordon’s Assessment guide and

formulate Nursing Care Plan;

 Discuss the different factors causing the disease and how it does affects the client;

 Give health teaching to both client and significant others regarding the present condition.

5
 CHAPTER III

Patient Data Base

Name: Client SQ

Age: 14 years old

Gender: Female

Address: Polomolok, South Cotabato

Birth Date: August 28, 2000

Birth place: Polomolok, South Cotabato

Religion: Roman Catholic

Occupation: N/A

Educational Attainment: Grade 5 (Elementary Level)

Language / Dialect Spoken: Cebuano

Civil Status: Single

Parents:

Mother: Elsie Quiam (Deceased)

6
 Father: Hilario Quiam

Date of Admission: August 9, 2014

Admitting Diagnosis: Rheumatic Heart Disease (RHD)

Chief Complaint: Chest pain, edema, difficulty of breathing

Final Diagnosis: Rheumatic Heart Disease with Mitral valve

prolapse, moderate Mitral and Tricuspid

Regurgitation, mild aortic Regurgitation

7
 CHAPTER IV

Health History

Past Illness

When client SQ was 3 years old sometime in the year 2003, she had a fever, cough and

common colds. Her fever was intermittent and complained of pain in her throat. According to her

stepmother her fever usually lasted for 3-4 days. Few weeks after, the fever recurs and they

gave paracetamol for treatment. In the same year she had tonsillitis which occurs five times.

She had the same illnesses until she reached the age of 5. It was during this age also that she

was hospitalized at Polomolok Hospital, because of high fever, chest pain, difficulty of breathing

and edema on her lower extremities.

The client had a complete immunization such as BCG, DPT, OPV, Hepa vaccine and

measles.

History of Present Illness

Last August 06, 2014, the client was playing with her classmate at school when she

suddenly fainted. Her parents immediately brought her home and allowed her to rest because

she complained of difficulty of breathing. They did not brought her to the hospital because she

said that she felt better already. Two days prior to admission, her condition was getting worst.

She had a difficulty of breathing, chest pain, malaise, and pitting edema as well as joint pain in

8
her lower extremities. They immediately rushed her to General Santos City Hospital for

admission.

Family History:

The family of client SQ has history of heart problems. Client’s grandfather on her father’s
side had a heart problem. On her mother side, her grandmother had the heart problem too. Her
mother died of leukemia when she was still two years old. There are four siblings in the family
and client SQ is the third to the eldest. Of all the siblings, she is the only one who has the heart
problem.

9
 CHAPTER V

PHYSICAL ASSESSMENT

SYSTEMS INSPECTION PALPATION PERCUSSION AUSCULTATION

ASSESSED
SKIN  Brown in color  Warm to touch
 Skin looks shiny  Pitting edema
on the swollen (Moderate +2)
part – (hands,  Skin is tight on
lower legs, and the edematous
feet) site
 Poor skin turgor
HEAD  Shape:  Non-tender
normocephalic
and symmetrical
FACE  Symmetrical
SCALP  Lighter in color  Intact
than the body’s
complexion
HAIR  Black in color  Straight
 Evenly distributed  Thick
 Lice and nits  Coarse
noted  Dry
EYES  Round
 Watery eyes
 Clear and bright
 Iris  Black in color
 Shape: Circular

10
 SYSTEMS INSPECTION PALPATION PERCUSSION AUSCULTATION
ASSESSED

 Sclera  White in color

 Conjunctiva  Pale
 Smooth
 Eyelids  Upper eyelid
normally covers
one-half of upper
iris
 Moist and shiny
 Palpebral  Symmetrical
Fissures
 Eyelashes  Curving outward
 Evenly
distributed
 Thick , black in
color
 Eyebrows  Black, evenly
distributed
 Symmetrical
 Corneal light  Light reflex seen
reflex symmetrically in
(Hirschberg’s center of each
test) cornea
[Shine light
directly in client’s
eyes, note
position of the
light reflection off
the cornea in
each eye.]

11
 SYSTEMS INSPECTION PALPATION PERCUSSION AUSCULTATION
ASSESSED
EARS  External ear is  Warm to touch
consistent with  Soft and non-
skin color tender
 Symmetrical (in
line with the
eyes)
 Voice  Client states
whisper test she was able to
hear clearly
NOSE  Symmetrically
on the midline
of the face
 Nares patent
 Nasolabial  Present
fold bilaterally
MOUTH  Symmetrical
 Mucous
membrane is
pale
 Lips  Pale, dry
(evidenced by
cracked lips)
 Tongue  Position:
midline of the
mouth
 Temporo-  Temporoman-
mandibular dibular joint
joint (TMJ) articulate
smoothly without
clicking

SYSTEMS INSPECTION PALPATION PERCUSSION AUSCULTATION

ASSESSED
NECK  Neck is

12
 symmetrical
with the head
in a central
position
 Midline
THYROID  Thyroid tissue
GLAND moves up with
swallowing
 Sternocleido  Able to move
-mastoid head through a
full range of
motion (ROM)
without any
discomfort
 Trachea  Positioned in
line and straight
BREASTS AND  Skin color
REGIONAL matches of the
NODES body’s
complexion
 Nipples  Flat
 Brown in color
 Areola  Brown in color
RESPIRATORY
SYSTEM

ANTERIOR  Asymmetrical  Skin intact  Bronchial

CHEST rise and fall breath sound
when is loud and
breathing high pitched;

SYSTEMS INSPECTION PALPATION PERCUSSION AUSCULTATION

ASSESSED
ANTERIOR  Inspiration is  Heard over
CHEST (contd.) longer than trachea
expiration

13
  Skin color is
consistent with
body color
POSTERIOR  Anteroposterior  Respiratory  Resonance:
CHEST diameter is less excursion: hollow
than the equal
transverse expansion
diameter (1:2)
 Tactile  Symmetrical
Fremitus tactile fremitus
is present and
equal on both
sides
LATERAL  RR: 11 cpm
CHEST  Symmetrical
movement
PERIPHERAL  Blood Pressure:  Legs: warm to
VASCULAR 70 / 30 touch, painful
SYSTEM  Skin color on when touched
hands: pallor  Capillary return:
3 – 4 seconds
 Edema on
lower legs, feet,
and hands
 Tight skin on
edematous site
 (lower legs,
feet, hands)

SYSTEMS INSPECTION PALPATION PERCUSSION AUSCULTATION

ASSESSED
CARDIOVAS-  Blood Pressure:  Capillary return:
CULAR 70 / 30 3 – 4 seconds
 PMI (Point  Heart rate :
of 93 beats per

14
 Maximal minute
Impulse)

GASTRO-
INTESTINAL

ABDOMEN  Color is the same  No palpable  Tympany  Borborygmic

with the body mass noted sound sounds heard
complexion as intermittent
 Contour: Sym- gurgling sound
metric and slightly
rounded
GENITOU-  Urinary Output: 2
RINARY – 3 times a day
 Oriented to time
and place
 Facial grimace:
frowning
 Speech: talking
slowly (easily
tired)
 Corneal Light
Reflex: light seen
symmetrically on
both eyes

SYSTEMS INSPECTION PALPATION PERCUSSION AUSCULTATION

ASSESSED
NEUROLO-  Gait: Weakness;
GICAL unable to walk
upright

15
 CHAPTER VI

NURSING ASSESSMENT

Gordon’s 11 Functional Health Pattern

1. Health Perception- Health management Pattern

Client SQ stepmother stated that, “when she was a child, she was active and

playful. At the age of 3 years old she had an intermittent fever and complained of pain in

her throat”. The parents did not bring her to hospital. Instead, they only given her

paracetamol for treatment of fever and brought her to “hilot” for they believed that the

16
 child will be fine if they brought her. She had also an experienced of cough and colds.

Until, she reached the age of 5 when they rushed her to hospital because of high fever

and difficulty of breathing as well as edema in her lower extremities and it was found out

by the doctor that the client has tonsillitis and diagnosed of heart problem but the doctor

can not confirmed which part of the heart had been affected because they did not

comply the laboratory test like 2D echo as ordered. The client parents were advised to

limit her from eating junk foods, salty foods, and fatty foods as well. But then, without

their knowing the client continues eating junk foods until she was 14 years old.

Two days prior to admission client was at school and playing, when she felt chest

pain, and difficulty of breathing, and fainted. She rested for 2 days until they noticed that

the client had pitting edema and cannot able to ambulate because of joint pains, the

reason that they brought her at General Santos City Hospital.

Upon assessment client SQ was observed weak and mild edema. She was also

complaining of chest pain and difficulty of breathing while talking as been observed.

Client SQ cried because she is afraid of injection and looks scared. “Dili ko magpa

injection kay mahadlok ko” (I’ am scared of injection) as verbalized.

Health- Perception Health Management Pattern

Cues Inference Nursing Priority Rationale

Diagnosis

1. Subj: “Dili Ineffective Ineffective Medium 1 Health

ko magpa health health threatening

17
injection maintenance maintenance r/t since not

kay inadequate maintaining the

mahadlok health health of the

ko” (I’ am information or client can make

scared of awareness her illness

injection) worse.

as

verbalized

18
 2. Nutritional- Metabolic Pattern

The client stepmother stated that, she eat rice, fried fish, or dried fish for breakfast and a

glass of water. For her lunch, she usually eat rice and fish with a glass of water. And for her

supper, a cup of rice and vegetables. She can drink about 4 to 5 glasses of water a day. Her

weight was 38 kilogram last 2013 and gained another 2 kilogram this year.

19
 Prior to assessment client SQ eat three times a day but more on junk foods and soft

drinks (Coke) her water intake including soft drinks and is 4 to 5 glasses a day. “ginabawalan

namo siya magkaon ug junk foods pero magkaon gihapon”(we limit her to eat junk foods but still

eating) as verbalized. Client SQ continue her eating habits and not worry about her health

status.

Upon assessment client SQ verbalized that “gusto nako daghan akong kaunon pero

magsakit akong dughan”. ( I wanted to eat as much as I can but I felt pain in my chest) as

verbalized. It was observed that there are left over food in her bed about ¾ of food served and

junk foods in was also observed. Client SQ also stated that after eating she feel fatigue and

have difficulty of breathing. Her weight 36 kilogram, Height 5 inches tall with a total BMI of 15.5

which is below normal, the normal value is 17.1- 23.

Nutritional-Metabolic Pattern

Cues Inference Nursing Priority Rationale

Diagnosis

Subj: Imbalanced Imbalanced High 4 It is Health

Obj: observed Nutrition less Nutrition less deficit
leftover food than body than body It is second high
about ¾ of food requirements requirements r/t priority since
served lack of interest in maintaining a
BMI 15.5 food due to good nutrition
chest pain give vitality and
energy for life
and it help beat
tiredness and
fatigue.

20
 3. Elimination Pattern

According to client SQ she can urinate 4 to 5 times a day and had a regular bowel for

atleast once a day.

Prior to admission, she urinated twice a day and feels pain and defecated once a day.

The client started complaining that she felt pain when she urinates and has fever.

Upon assessment the client verbalized “hapdos kung mangihi ug dili nako mapugngan”.

( I feel burning sensation when urinating and cannot hold it). Irritability has been observed.

Elimination Pattern

Cues Inference Nursing Priority Rationale

Diagnosis

Subj: “hapdos Altered urinary Altered urinary High 3 Life Threatening and
kung mangihi elimination elimination r/t It is third
ug dili nako pain upon priority
mapugngan” (I urinating since
feel burning proper
sensation when elimination
urinating and can help
cannot hold it feel
energetic
Obj: observed and
irritable relaxed
and
client need to eliminate
the waste product from
her body because waste

21
 product is toxin and if not
eliminated it can caused
complication like
infection

4. Activity –Exercise Pattern

Before hospitalization client SQ had a limited activity, she cannot run and play
around. She cannot do the house hold chores, because too much exertion can
aggravates her condition. She easily feels tired and even had a shortness of breath
when talking fast and eating too much.

During hospitalization her situation became worsen, she had a difficulty of

breathing, edema, chest and joint pain. She cannot move properly because she was
very dizzy and aching of pains. She verbalized “dili kaayu ko galihuk kay galusud ko
ginhawa”.
Assessment done on her fourth day of admission the client had an RR-11, with
02 inhalation of 2-4L, capillary refill of 3-4. As observed was restless, nasal flaring was
present and need assistance when moving.

Activity – Exercise Pattern

Cues Inference Nursing Priority Rationale

Diagnosis

Subj: “dili na siya Activity Activity High 2 Life threatening,

namo gipadula intolerance intolerance r/t since oxygen
ky hangakun ug imbalance has a vital role in
sakit iyahang oxygen supply the body
dughan”.(we particularly in the
limit her to play respiration and

22
because she feel circulation.
shortness of (Monahan 2010)
breath and pain
in her chest)

Obj: capillary
refill back 3-4
seconds,
O2 2-4L
Difficulty of
breathing

5. Sleep – Rest Pattern

Prior to illness client SQ stated that she normally sleeps all night, but when her lower

and upper extremities start swelling, she experienced shortness of breath and uses 2 to 3

pillow to make her feel better and she elevate her head “hangakon ko kung isa lng ang unan

gusto ko mas taas” (I feel shortness of breath if using one pillow I want higher) as she

verbalized. Client SQ parent is worried and rush her at General Santos City Hospital

because she is weak, and edema on her lower and upper extremities.

23
 Upon assessment client SQ was weak, cannot stand and edematous. Client SQ

verbalized “ dili ko katulog ug tarung kay daghan tao” (I cannot sleep right because there are

many people). Client SQ was observed yawning and looks tired.

Sleep – Rest Pattern

Cues Inference Nursing Priority Rationale

Diagnosis

Subj: “dili ko Disturbed Sleep Disturbed Sleep Medium 1 Health

katulog ug Pattern Pattern r/t noise threatening
tarung kay since the client
daghan tao”( I need enough
cannot sleep sleep for her
right because fast recovery, if
there are many client is weak
people). her recovery is
Obj: observed slow or it can
yawning and lead to worsen
look tired her condition.

6. Cognitive –Perceptual Pattern

Before hospitalization the client knew that she must not do any vigorous
activities. She also said that she is afraid of what might happen to her condition will
aggravate.

Two days prior to admission when her condition began, her fear arises. She
verbalized, “mahadlok ko magpabilin sa balay kay galain akong paminaw”. When she
was brought to the hospital she was complaining of pain on her chest and joints on lower
extremities. She said “sakit kaayu akong dughan, lisud mag ginhawa apti akong tiil

24
 gasakit”. She cannot hold her tears when pain arises. When asked if she can rate the
pain from 1-10, her answer was 8, as per observed the client was irritable, and facila
grimace was present. She also said that the pain was radiating on her shoulder and left
arm. On the other hand she cannot also properly move her lower extremities because of
pain.

Cognitive- Perceptual Pattern

Cues Inference Nursing Priority Rationale

Diagnosis

Subj: “ sakit Altered comfort Altered comfort High 1 It is the highest

kaayu akong r/t chest pain priority because
dughan, lisud it is life
mag ginhawa threatening
pati akong tiil since pain is
gasakit” not a simple
Obj: sensory
P- 8 out of 10 experience but
Q-stabbing a complex
R-shoulder integration of
S-severe sensory,
T-aspirin affective and
cognitive
dimensions.

7. Self-Perception-Self-Concept Pattern

Prior to admission, Client SQ know that she had failure in her heart since she was

25
 Five years old, since then her behavior is changed, she is quite, and wants to be alone. The

Client stepmother said that she limits her school activities and even she wants to join but she

can’t because of her condition.

During assessment client SQ verbalized “gusto ko pareha sa uban mabuhat ang tanan

pero nahadlok ko” (I want to be like other people that can do whatever they want but I am

scared) she also added that in her age, she claims that instead of playing and going to school,

she is lying on her bed suffering from heart disease. Client SQ observed worried and unhappy.

Self-Perception-Self Concept Pattern

Cues Inference Nursing Priority Rationale

Diagnosis

Subj: “gusto ko Situational low Situational low Low 2 Foreseeable

pareha sa uban self esteem self- esteem r/t crisis since the
mabuhat ang role changes client condition
tanan pero alters her usual
nahadlok ko” (I activities to be
want to be like like other people
other people does.
that can do
whatever they
want but I am
scared)
Obj: observed
worried and
unhappy,
Quite

26
8. Role-Relationship Pattern

According to the client, before she was hospitalized, she is a good sister to her siblings;

instead of serving and caring for her younger sister, she is being served by them especially

during meals. According to the client’s stepmother, client SQ is a good sister and daughter

to her family, that in return as a family, they do whatever they can help their love one.

During hospitalization, the focus of the family is client SQ. she is being accompanied by

her older brother to his parents watching her at the hospital. “okay ra kayo sa akoa

mgbantay sa akong manghud bisag busy”(it really ok for me to watch my younger sister

even I am busy) as verbalized by client’s brother. Client SQ observed smiling.

Role-Relationship Pattern

Cues Inference Nursing Priority Rationale

Diagnosis

Subj:” okay ra Readiness for Low 4 Foreseeable

kayo sa akoa Enhanced crisis since the
mgbantay sa Family family process
akong manghud Processes of the family are
bisag busy”(it very supportive
really ok for me to one of their

27
 to watch my family members
younger sister to cope her
even I am busy)

Obj: observed illness.

smiling

9. Sexuality- Reproductive Pattern

Client SQ started her menarche at age of 12, and has a regular menstrual period every
month.

Cues Inference Nursing Priority Rationale

Diagnosis
No problem
identified

10. Coping-Stress Tolerance Pattern

According to client SQ, in order for her to relieve her stress and cope with worries, she

cries. ”kung muhilak mo gaan akong paminaw” (when I cry I feel better) Crying is also reason

when she feel pain her chest. Sometimes, when she have a problem, she talks to her father, if

her father is not around, she talk to her mother, and whenever she feel pain, she talk and

consult to her father.

During the hospitalization, she calls both of her parents whenever she is sad and wanted

28
to do something, because of that, where her father also had disease, she choose to cope

problems and talk much to her father.

Coping-Stress Tolerance Pattern

Cues Inference Nursing Priority Rationale

Diagnosis

Subj: . ”kung Readiness for Low 5 Client and family

muhilak mogaan Enhanced helping each
akong paminaw” Coping other to cope the
(when I cry I feel feeling of their
better) family member
by giving her full
support, and
love

11. Value-Belief Pattern

Client SQ and her family believe and have faith in God. They always pray for the fast

recovery of client’s condition. They also consult to “hilot” and albularyo because they also

believe that it can help in her condition.

Upon assessment, according to client’s stepmother they follow what the doctor’s order

for her fast recovery. And she also stated that,” Si God naga guide namo sa kanunay”.

Value-Belief Pattern

29
 Cues Inference Nursing Priority Rationale
Diagnosis

Sbj: “si God na Readiness for Low 6 Client shows

gaguide man Enhanced readiness to
namo kanunay” Spiritual-Well develop her
as verbalized. Being spiritual aspect
(God us to boost her
always). spirituality that
will assist her to
cope with
situation.

Chapter Vll
Anatomy and Physiology
A.) The Heart
Coronary Arteries
Because the heart is composed of cardiac

muscle tissue that continuously contracts and

relaxes. It must have a constant supply of oxygen

30
and nutrients. The coronary arteries are the network of blood vessels that carry oxygen and

nutrient-rich blood to the cardiac muscle.

Superior Vena Cava

The superior vena cava is one of the main veins bringing de-oxygenated blood from

the blood to the heart, veins from the head and upper body feed into SVC. Which empires into

the right atrium of the heart.

Inferior Vena Cava

The inferior vena cava is one of the two main veins bringing de-oxygenated blood from

the body to the to the heart. Veins from the legs and lower torso feed into the inferior vena

cava, which empties into the right atrium of the heart.

Aorta
The aorta is the largest single blood vessel in the body. It is approximately the diameter

of your thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts

of the body.

Pulmonary Artery

The pulmonary artery is the vessel transporting de-oxygenated blood from the right

ventricle to the lungs. A common misconception is that all arteries carry oxygen-rich blood. It is

more appropriate to classify arteries as vessels carrying blood away from the heart.

Pulmonary Vein

31
 The pulmonary vein is the vessel transporting oxygen-rich blood from the lungs to the

left atrium. A common misconception is that all veins carry de-oxygenated blood. It is more

appropriate to classify veins as vessels carrying blood to the heart.

The Right Side of the Heart

The right system receives blood from the veins of the whole body. This is "used" blood,

which is poor in oxygen and rich in carbon dioxide. The right atrium is the first chamber that

receives blood. The chamber expands as its muscle relaxes to fill with blood that has returned

from the body. The blood enters a second muscular chamber called right ventricle. The right

ventricle is one of the heart's two major pumps. Its function is to pump the blood into the lungs.

The Left Side of the Heart

The left system receives blood from the lungs. This blood is now oxygen-rich. The

oxygen-rich blood returns through veins coming from the lungs (pulmonary veins) to the heart.

It is received from the lungs in the left atrium, the first chamber on the left side. The left

ventricle is the strongest of the heart's pumps. Its thicker muscles need to perform contractions

powerful enough to force the blood to all parts of the body. This contraction produces systolic

blood pressure. The lower number (diastolic blood pressure) is measure when the left ventricle

relaxes to refill with blood between beats.

The Valves
Valves are muscular flaps that open and close so blood will flow in the right direction.

There are 4 valves in the heart;

i.) Tricuspid Valve - regulates blood flow between the right atrium and right ventricle.

ii.) Pulmonary Valve - opens to allow blood flow from the right ventricle to the lungs.

iii.) Mitral Valve – regulated blood flow between the left atrium and the left ventricle.

iv.) Aortic Valve – allows blood to flow from the left ventricle to the ascending aorta.

32
 The heart is the muscular organ of the circulatory system that constantly pumps blood

throughout the body. Approximately the size of a clenched fist, the heart is composed of

cardiac muscle tissue that is very strong and able to contract and relax rhythmically throughout

a person’s lifetime.

B.) The Electrical Conduction System

The heart is composed primarily of muscle tissue. A network of nerve fibers

coordinates the contraction and relaxation of the cardiac muscle tissue to obtain an efficient

wave-like pumping action of the heart. The heartbeats are triggered and regulated by the

conducting system, a network of specialized muscle cells that form an independent electrical

system in the heart muscles. These cells are connected by channels that pass chemically

caused by electrical impulses.

The Sinoatrial Node (often called the SA node or sinus node) serves as the natural

pacemaker for the heart. Nestled in the upper area of the right atrium. It sends the electrical

impulse that triggers each heartbeat. The impulse spreads through the atria, prompting the

cardiac muscle tissue to contract in a coordinated wave-like manner.

The impulse that originated from the sinoatrial node strikes the Atrioventricular Node

(or AV node) which is situated in the lower portion of the right atrium. The AV node in turn

sends an impulse through the nerve-like contraction of the ventricles.

The electrical network serving the ventricles leaves the atrioventricular node through

the Right and Left Bundle Branches. These nerve fibers send impulses that cause the cardiac

muscle to contract.

C.) Circulatory System

The circulatory system is a vast network of

organs and vessels that is responsible for the flow of

blood, nutrients, oxygen and other gases, and

33
hormones to and from cells. Without the circulatory system, the body would not be able to fight

disease or maintain a stable internal environment.

i.) Pulmonary Circulatory System - The pulmonary circulation carries the blood to and

from the lungs. In the heart, the blood flows from the right atrium into the right ventricle;

the tricuspid valve prevents backflow from

ventricles to atria. The right ventricle contracts to

force blood into the lungs through the pulmonary

arteries. In the lungs oxygen is picked up and

carbon dioxide eliminated, and the oxygenated

blood returns to the heart via the pulmonary veins,

thus completing the circuit. In pulmonary

circulation, the arteries carry oxygen-poor blood,

and the veins bear oxygen-rich blood.

ii.) Systemic Circulatory System - In the

systemic circulation, which serves the body except for the lungs, oxygenated

blood from the lungs returns to the heart from two pairs of pulmonary veins, a

pair from each lung. It enters the left atrium, which contracts when filled,

sending blood into the left ventricle (a large percentage of blood also enters the

ventricle passively, without atrial contraction). The bicuspid, or mitral, valve

controls blood flow into the ventricle. Contraction of the powerful ventricle

forces the blood under great pressure into the aortic arch and on into the aorta.

The coronary arteries stem from the aortic root and nourish the heart muscle

itself. Three major arteries originate from the aortic arch, supplying blood to the

head, neck, and arms. 

34
 iii.) Coronary Circulatory System - The major vessels of the coronary circulation

are the left main coronary that divides

into left anterior

descending and circumflex branches,

and the right main coronary artery.

The left and right coronary

arteries originate at the base of the

aorta from openings called the coronary

ostia located behind the aortic valve leaflets.The left and right coronary arteries

and their branches lie on the surface of the heart, and therefore are sometimes

referred to as the epicardial coronary vessels. These vessels distribute blood

flow to different regions of the heart muscle.

CHAPTER VIII

PATHOPHYSIOLOGY

Rheumatic heart disease is cardiac inflammation and scarring triggered by an

autoimmune reaction to infection with group A streptococci. In the acute stage, this condition

consists of pancarditis, involving inflammation of the myocardium, endocardium, and

epicardium. Chronic disease is manifested by valvular fibrosis, resulting in stenosis and/or

insufficiency.

Rheumatic fever is rare before age 5 years and after age 25 years; it is most frequently

observed in children and adolescents. The highest incidence is observed in children aged 5-15

35
years and in underdeveloped or developing countries where antibiotics are not routinely

dispensed for pharyngitis and where compliance is low.

The average annual incidence of acute rheumatic fever in children aged 5-15 years is

15.2 cases per 100,000 population in Fiji compared with 3.4 cases per 100,000 population in

New Zealand, and it less than 1 case per 100,000 population in the United States. Group A

beta-haemolytic streptococcus is thought to be responsible for 15-30% of tonsillitis in children

and 5-10% in adults. Although rheumatic fever was previously the most common cause of heart

valve replacement or repair, this disease is currently relatively uncommon, trailing behind the

incidence of aortic stenosis due to degenerative calcific disease, bicuspid aortic valve disease,

and mitral valve prolapse.

Client SQ, a 14 year old female patient was diagnosed to have

Rheumatic Heart Disease last August 9, 2014. She has predisposing and

precipitating factors that affects condition of those who has the disease.

Predisposing factors starts with genetics for it is hereditary; her father has a heart

disease and her mother was diseased because of Leukemia. One of the predisposing factors is

age; the most common ages that is prone to have RHD is 5-15years old. Client SQ is

considered a second hand smoker, since her father smokes for more than 6 years, just around

the house, as well as her brother.

Precipitating factors are non-compliance to medication and to laboratory exams that

should be complied when she was 5 years old after she was diagnosed to have RHD. Her

lifestyle; eating habits affected her condition, she always eat junk foods even if it was restricted

to her by the physician since then. When client SQ was 3 years old, she had a tonsillitis that

was not treated, she experienced recurrent tonsillitis; 5 times a year since then.

36
 Both predisposing and precipitating factors can cause high risk to have this kind of

disease that will lead for the client to be immuno-compromised. Streptococcal infection;

manifested by an increased WBC that results to an increased production of antigen. An antigen

is any substance that cause the immune system to produce antibodies against it and may be a

substance from the environment such as bacteria or viruses. Antigen circulates to the system

that come up to binding of receptors in the synovial joints. So, autoimmune response attack the

heart valves; inflammation of the layer of the heart occurs, that results to difficulty of the heart to

pump; as manifested by chest pain. Increase cardiac workload happens and scarring of the

heart valves that creates damage to the mitral valve of the client. Because of these, there is a

decrease blood flow in the bone marrow which then results to decrease blood cell production,

especially the production of white blood cells. If there will be a decrease production of WBC, the

immune defense reaction will also be decreased, that lead to systemic infection.

All of these, come up to clinical manifestations of fever, headache, fainting and body

weakness.

37
 ACTUAL PATHOPHYSIOLOGY
( Diagram )

Predisposing factors: Precipitating factors:

 Age (14 years old)  Health seeking behavior

 Gender (female)  Hygienic practices

 Environment  Recent travel

Streptococcal infection

Increased WBC
(POE: Upper Respiratory Tract)

Increased production of

antigens

Bind receptors in the Antigen circulated to the

synovial joints
system

Auto-immune
response
Autoimmune response attack the heart

valves
Antigens are similar to
body’s own cell that may
result o attack of healthy
body cells by mistake. Scarring of the valves of the

heart (mitral valve prolapse)

Inflammation

Joint pains

38
 Decrease cardiac supply of blood

Decreased immune defense reaction

Systemic infection occurs

Body
fainting fever headache
weakness

Rheumatic Heart Disease

39
 CHAPTER lX

Medical Management

Date Doctor’s Order Significance

Aug. 09,14
5:10 pm
-Please admit The client need to be admitted

since the client complained

shortness of breath and edema

and the client has history of

rheumatic heart disease when she

was 5 years old..

(Kozier.et.al,Fundamentals of

Nursing,12th edition)

-secure consent To protect both patient and

institution from undesirable

incidence.
-low fat diet In a person with rheumatic heart

disease, consumption of diet

containing saturated fats should

be limited.(www.diet.com)
-Low salt diet Sodium in the diet could attract

more water and could contribute

to edema, hypertension, and

rheumatic heart disease. ( Roth et

40
Date Doctor’s Order Significance

al, Nutrition and Diet Therapy. P.

366. 8th edition).

Laboratory Abnormal increases or decreases
-CBC
in cell counts as revealed in a

complete blood count may

indicate if there is an underlying

medical condition that calls for

further evaluation (www. Mayo

clinic. org)

-U/A To know the components and

characteristics of urine. (Timby &

Smith. Introductory Medical

Surgical

Nursing 8th edition. 2010 pp. 1004)

-platelet To measure how many platelet

count in the blood. (Nurses

Pocket Companion @ 2009 by

Spring House Corp.)

-ECG To detect heart abnormalities by

measuring the electrical activity

generated by heart as it contracts.

(m.betterhealth.vic.gov.au)
-Chest-PA To provide important information

regarding the size, shape,

contour, and anatomic location of

41
 the heart, lungs, bronchi, and

great vessels.

(www.health.harvard.educ.)
-2D echo It gives valuable information on

the structure and function of the

heart. (doctor.ndtv.com)
-ESR Blood test to check inflammation

or abnormal proteins in the body.

(www.health.harvard.educ.)
-Na & K To identify fluid balance and

kidney Function. (Black.2009)

-Creatinine Blood test measures the level of

creatinine in the blood.

(Black,2009)
Meds
D5w 1L x 60cc/ hr Helpful in rehydrating and

excretory porpuses.

(RNpedia.com)

-penicillin To treat streptococcal bacteria for

the patient with RHD.

-gentamicin To treat infection that caused by

streptococci bacteria.
-aspirin For the relief of mild to moderate

pain including rheumatic pain

sciatica. (Deglin, Vallerand.

Nurse’s Pocket Pharmacology

Guide.2009).
-prednisone Suppression of inflammation,

42
 modification of the normal immune

response.

(Deglin, Vallerand. Nurse’s Pocket

Pharmacology Guide.2009)
-paracetamol To relieve fever.

-dobutamine Not given.

-omeprazole Reduces gastric acid secretion

and increases gastric mucus and

bicarbonate production, creating

protective coating on gastric

mucosa and easing discomfort

from excess gastric acid. (Schull.

Nurse’s Drug Handbook 6th

edition).
-monitor v/s q 1 The client needed to be monitored

strickly because she had a chest

pain, difficulty of breathing and

edema. Unusual results should be

assessed and documented to be

alert of what would be the patient

condition and gives immediate

attention. (Kehr, 2010).

O2 inhalation @ 2-4 2L The client had difficulty of

breathing with the RR of 11 cpm

that is why she needed O2

therapy for ventilation support.

Aug.09,14 Cardiology

43
9:45pm

-If dobutamine is not Dobutamine was not given.

available, start dopamine
drip 200/250cc to run
30cc/hr BP- 70/30
-hold Gentamycin for now It was ordered to hold the
hold prednisone
medication because the physician

waiting for the laboratory results.

-for blood culture x 2 sites To check for bacteria or other

(if w/ funds) micro organisms in a blood

2D echo with doppler sample.

-start digoxin 0.25 mg (IV) It was given to the client since she

tonight, then digoxin 0.25 had shortness of breath.

mg/tab, 1tab OD
Aug.10,14 -follow up laboratory For further confirmation and

assessment.
Continue meds Continuing medication is needed

the progress of the client. This

may help to reduce the risk of the

client in developing another

problem.
-Follow up test requested For maintenance and continuity of

-continue present the given care.

management
-d/c aspirin and start To reduce swelling and fluid

furosemide retention caused by various

20 mg (IV) q 12 medical problems, including heart

disease and to relieve chest pain

of the client.
-spinoroloctone 25 mg/tab Spinoroloctone was given as

1 tab OD tablet because during this day of

44
 admission client has no IV, instead

of furousemide as her diuretic.

-still for 2D echo if with no

vegetation
-may send patient home The physician ordered that the

client may go home and continue

her maintenance, in addition the

client’s condition has improved

regarding chief complain during

admission.
-IVF to KVO please The client was having an edema

that’s why she only need small

amount of IV fluid to be infused

and to prevent cardiac overload.

Aug.13,14 -continue meds Continuation of meds is needed

for the client’s condition to

complete the required meds

therapy/management.
Aug.14,14 -give benzathine benzyl This medication is prescribed to

penicillin the client to prevent rheumatic

1.2 million unit (IV) ANST fever to worsen. It is a long acting

given natural penicillin antibiotic and

works by stopping the growth of

bacteria.
Home meds

-lanoxin 0.25 g 1 Tab OD It was given to the client since

she had a shortness of breath.

45
 -spironolactone 25 g 1 Tab Weak diuretic and

OD antihypertensive response when

compared with other diuretics,

conservation of potassium.
-refer to Dr. Alcover The client was refer to Dr. Alcover

for further evaluation.

CHAPTER X

DIAGNOSTICS

Clinical Chemistry

Examination Result Reference Value Remarks

Creatinine 55. mmol/L 62. – 106. Low Blood Creatinine

Level can mean
lower muscle mass
caused by a disease

Calcium 138. mmol/L 137. – 145. Within normal range

Potassium 5.3 mmol/L 3.5 – 5.1 High Potassium level

may indicate
infection,
hyperkalemia.

ECHOCARDIOGRAPHIC REPORT

Date: August 13, 2014

46
 QUANTITATIVE

DIMENSION PATIENT NORMAL FUNCTION PATIENT NORMAL

LV (ed) 4.47 cm (4.5-5.0) LVEDV 90.99 ml
LV (es) 2.63 cm LVESV 25.36 ml
RV(ed) 3.08 cm (2.2-4.0) STROKE 65.63 ml
VOLUME
LA (es) 3.24 cm (3.0-3.5) CO 6.69 l/min
RA (es) 3.86 cm (3.5-4.5) CI
AORTA 2.08 cm (3.5) Ejection 72.1 % (55.0-77.0)
fraction %
PA 2.01 cm (3.0-4.0) 42.1 (20-42 %)
IVS (ed) 0.71 cm (0.8-1.1) VCF (0.8-1.5)
(CIR/SEC)
IVS (es) 1.04 cm EPSS 0.25 cm (<=1.0)
LVPW (ed) 0.71 cm (0.8-1.1) Wall Stress (<195)
(S)
LVPW (es) 1.5 cm Wall Stress (<600)
(5)
LVET Rhythm

SPECTRAL & COLOR FLOW DOPPLER

VALVE VELOCITY PEAK ORIFICE AREA REGURGITATION

M/SEC GRADIENT cm2 %
mmHg
AORTIC 1.73 11.97
MITRAL 2.01/2.38 15.99/22.69
TRICUSPID 1.25/0.62 6.25/1.52
PULMONIC 1.27 6.43
PAT 1.44

2D- ECHOGRAM:

 The left ventricle has normal internal dimension with normal thickness of the septum and
posterior wall, with good wall motion and contractility and an election fraction of 72%
 The left atrium is normal in size. The right atrium and right ventricle are not dilated.
 The aortic, tricuspid, and pulmonic valves appear structurally normal
 The anterior leaflet of the mitral valve is thickened and prolapses into the left atrium
during systole.
 The interatrial and interventricular septa are intact
 No thrombus or vegetation is seen

DOPPLER:

47
  There is an eccentric mosaic color flow seen across mitral valve during systole indicative
of moderate mitral regurgitation
 There is an eccentric mosaic color flow seen across tricuspid valve during systole
indicative of moderate tricuspid regurgitation
 There is mosaic color flow seen across aortic valve during diastole indicative of mild
aortic regurgitation
 The mitral in flow velocity ratio is reversed indicative of diastolic dysfunction
 Pulmonary pressure by 1x14 mmHg which is normal

CONCLUSION:

 Normal sized left ventricle with good wall motion and contractility and adequate over all
systolic function (EF 72%)
 Anterior mitral valve prolapse
 Moderate mitral regurgitation
 Moderate tricuspid regurgitation
 Mild aortic regurgitation
 Doppler evidence of diastolic relaxation abnormality
 Normal pulmonary pressure

Clinical Chemistry

Date: August 9, 2014

TEST RESULT REFERENCE VALUES

REMARKS

ALT 15. U/L 9-52 Within Normal Range

ROENTGENOLOGICAL REPORT

Date: 08-10-14

CHEST PA

48
  The lung fields are clear
 The heart is not enlarged
 The trachea is midline
 The diaphragm, costophrenic sulci and bony thorax are intact
 The rest of the included structures are unremarkable.

IMPRESSION: NORMAL CHEST FINDINGS

Significance:

This test provides important information regarding the size, shape, contour and anatomic
location of the heart, lungs, bronchi and great vessels

HEMATOLOGY

Date: August 9, 2014

EXAMINATION RESULT REFERENCE REMARKS

VALUE
Hemoglobin Mass 125 M 140-170 g/L Within Normal
Concentration F 120-140 g/L Range
Erythrocyte Volume 0.40 M 0.40-0.50 % Within Normal
Fraction F 0.37-0.43 % Range
Erythrocyte Number 15.7 4.5-5.5x10^12/L High Erythrocyte
Concentration Number
Concentration
means that the heart
is not able pump
blood efficiently
resulting in decrease
amount of oxygen
getting into the
tissues
Leucocyte Number
Segmenters 0.79 0.55-0.65 High Segmenters
means infection or
inflammation
Stab 0.02- 0.06
Eosinophils 0.04 0.02-0.04 Within Normal
Range
Lymphocytes 0.17 0.25-0.25 Low Lymphocytes
means infection or
inflammation
Monocytes 0.03-0.06
Basophils 0.00-0.10

49
 Platelet count 324 140-440x10^9/L Within Normal
Range

CHAPTER XI

DRUG STUDY

Drug Order
Generic Name: Penicillin G
Brand Name: Penadur

Classification
Pharmacologic Class: Penicillin
Therapeutic Class: Anti-infective, antibiotic

Indications:
 Severe infections caused by sensitive organisms
(Streptococci)
 URTI caused by sensitive streptococci
 Treatment of syphilis bejel, congenital syphilis
 Prophylaxis of rheumatic fever and chorea

Mechanism of Action:

50
 Interferes with bacterial cell wall synthesis during active
multiplication, causing cell wall death and resultant bactericidal
activity against susceptible bacteria.

Dosage:
Q6 IVTT ANST 4 m”u”

Contraindication:
 Contraindicated in: Previous hypersensitivity to penicillins (cross-
sensitivity may exist with cephalosporins and other beta-lactams).
 Hypersensitivity to procaine or benzathine.

Adverse effects:
 GI: diarrhea, epigastric distress, nausea, vomiting,
pseudomembranous colitis
 Dermatologic: rashes
 Local: Pain at IM site, phlebitis at IV site
 Other: Superinfections, sodium overload leading to heart failure

Nursing Responsibilities:
 Assess Hypersensitivity to drug
 Assess for any contraindications to the drug
 Educate about side effects of the drug
 Monitor client for at least 30 minutes
 Instruct to report difficulty of breathing, rashes, severe pain at
injection site, mouth sores, unusual bleeding or bruising

Rationale:
Penicillin G is given to the client to prevent rheumatic fever from
recurring.

51
Drug Order
Generic Name: Gentamicin
Brand Name: Garamycin

Classification
Pharmacologic Class: Aminoglycoside
Therapeutic Class: Anti-infective

Indications:
Treatment of serious gram-negative bacillary infections and
infections caused by staphylococci when penicillins or other less
toxic drugs are contraindicated.

Mechanism of Action:
Inhibits protein synthesis in bacteria at level of 30S ribosome.

Dosage:
80 mg IVTT q8 ANST

Contraindication:

52
 Contraindicated in: Hypersensitivity to aminoglycosides; Most
parenteral products contain bisulfites and should be avoided in
patients with known intolerance.

Adverse effects:
 GI: diarrhea, nausea, vomiting
 Muscle: paralysis
 Respiratory: apnea

Nursing Responsibilities:
 Monitor intake and output and daily weight to assess hydration
status and renal function.
 Assess signs of super-infection (fever, Upper respiratory tract
infection, vaginal infection, increasing malaise, diarrhea
 Assess for infection (VS, wounds)

Rationale:
This drug is given to patient since the patient is complaining of
abdominal problems.

53
Drug Order
Generic Name: Salicylates
Brand Name: Bayer Aspirin

Classification
Pharmacologic Class: Salicylates
Therapeutic Class: Antipyretic, Non-opioid analgesics

Indications:
 Inflammatory disorders including: rheumatoid arthritis,
osteoarthritis; mild to moderate pain.
 Prophylaxis of transient ischemic attacks and MI

Mechanism of Action:
Produce analgesia and reduce inflammation and fever by
inhibiting the production of prostaglandins.

Dosage:

54
 300 mg 1 tab q6

Contraindication:
Contraindicated in: Hypersensitivity to salicylates, severe anemia,
history of blood coagulation defects, vitamin K deficiency, 1 week
before and after surgery.

Adverse effects:
GI: bleeding, dyspepsia, epigastric distress, nausea, abdominal
pain, anorexia, hepatoxicity, vomiting
Nursing Responsibilities:
 Instruct client to take salicylates with a full glass of water and to
remain in an upright position for 15 – 30 minutes alter
administration
 Teach client on a sodium-restricted diet to avoid effervescent
tablets or buffered – aspirin preparations.

Rationale:
This drug is given to the client to reduce pain on integumentary
structures (i.e., arthritis, acute rheumatic fever)

55
Drug Order
Generic Name: Prednisone
Brand Name: Sterapred

Classification
Pharmacologic Class: Corticosteroid
Therapeutic Class: Anti-inflammatory, immunosuppressant

Indications:
Short term management of various inflammatory and allergic
disorders, such as rheumatoid arthritis, collagen diseases,
dermatologic diseases, status asthmaticus, and autoimmune
disorders.

Mechanism of Action:
In pharmacologic doses, all agents suppress inflammation and the
normal immune response. All agents have numerous intense
metabolic effects.

56
Dosage:
20 mg 1 tab BID

Contraindication:
Contraindicated with infections, especially tuberculosis, fungal
infections, amebiasis, vaccine and varicella, and antibiotic-
resistant infections.

Adverse effects:
 GI: anorexia, nausea, vomiting
 Misc: Moon face, buffalo hump
 Derm: Acne, slow wound healing, petechiae
Nursing Responsibilities:
 Verify doctor’s order
 Taper doses when discontinuing high-dose or long-term therapy
 Monitor intake and output and daily weights

Rationale:
 Prednisone is prescribed to the client to treat the symptoms of low corticosteroid
levels (lack of certain substances that are usually produced by the body and are
needed for normal body functioning). 

57
Drug Order
Generic Name: Acetaminophen
Brand Name: Paracetamol

Classification
Pharmacologic Class: Synthetic non-opioid p-aminophenol derivative
Therapeutic Class: Anti-pyretic, non -opioid analgesic

Indications:
Mild pain, fever

Mechanism of Action:
Inhibits the synthesis of prostaglandins that may serve as
mediators of pain and fever, primarily in the CNS. Has no
significant anti-inflammatory properties or GI toxicity.

Dosage:
500 mg IVTT PRN

58
Contraindication:
Contraindicated in: previous hypersensitivity; products containing
alcohol, aspartame, saccharin, sugar or tartrazine should be
avoided in patients who have hypersensitivity to these
compounds.

Adverse effects:
 GI: hepatic failure, hepatoxicity (overdose)
 Derm: rash

Nursing Responsibilities:
 Pain: Assess type, location and intensity prior to and 30 – 60
minutes following administration
 Fever: Assess fever.
 Toxicity and overdose: If overdose occurs, acetylcysteine
(Acetadote) is the antidote
 Advise client to take medication exactly as directed and not to
take more than the recommended amount.
 Advise client to consult health care provider if discomfort or fever
is not relieved by routine doses of this drug or if fever is greater
than 39.5 degrees Celsius or lasts longer than 3 days.

Rationale:
This is given to the patient for the relief of pain and fever.

59
Drug Order
Generic Name: Dobutamine
Brand Name: Dobutrex

Classification
Pharmacologic Class: Adrenergic
Therapeutic Class: Inotropic

Indications:
Short-term (<48 hrs) management of heart failure caused by
depressed minor effect on heart rate or peripheral blood vessels.

Mode of Action:
Stimulates beta, (myocardial) adrenergic receptors with relatively
minor effect on heart rate or peripheral blood vessels.

Dosage:
250 / 250 @ 5cc/hr

60
Contraindication:
Contraindicated in: Hypersensitivity to dobutamine or bisulfites;
idiopathic hypertrophic sub-aortic stenosis.

Adverse effects:
 CNS: headache
 Respiratory: Shortness of Breath
 CV: hypertension, increased heart rate, premature ventricular
contractions
 GI: nausea, vomiting

Nursing Responsibilities:
 Monitor BP, heart rate, cardiac output
 Explain to client the rationale for instituting this medication and the
need for frequent monitoring.
 Advise client to inform nurse immediately if chest pain; dyspnea;
or numbness, tingling, or burning of extremities occur.
Rationale:
This drug is given to the client to produce less increase in heart
rate and less decrease in peripheral vascular resistance.

61
Drug Order
Generic Name: Omeprazole
Brand Name: Prilosec

Classification
Pharmacologic Class: Proton Pump Inhibitor
Therapeutic Class: Anti-ulcer agent

Indications:
GERD / maintenance of healing erosive esophagitis.

Mode of Action:
Binds to an enzyme on gastric parietal cells in the presence of
acidic gastric pH, preventing the final transport of hydrogen ions
into the gastric lumen.

Dosage:
20 mg 1 cap BID

62
Contraindication:
Contraindicated in: Hypersensitivity to drug
Adverse effects:
 CNS: dizziness, drowsiness, fatigue, headache, weakness
 GI: Abdominal pain, acid regurgitation
 CV: Chest Pain
Nursing Responsibilities:
 Instruct client to take medications as directed to the full course of
therapy even if feeling better
 Advise client to consult health care professional before taking any
Rx, OTC, or herbal products with omeprazole.
Rationale:
This is given to reduce abdominal pain caused by stomach acid.

Drug Order
Generic Name: Digoxin
Brand Name: Lanoxin

Classification
Pharmacologic Class: Antibody fragments
Therapeutic Class: Antidotes

Indications:
Heart failure, paroxysmal, supraventricular tachycardia

Mode of Action:
Inhibits sodium potassium active adenosine trophosphatase,
promoting movement of calcium from extracellular to intracellular
cytoplasm and strengthening myocardial contraction

Dosage:

63
 0.25 mg 1D 1 tab

Contraindication:
Contraindicated in patients hypersensitive to drug and in those
with digitalis induced toxicity

Adverse effects:
Fatigue, muscle weakness, arrhythmias, heart block
Nursing Responsibilities:
 Check VS before and after administering digoxin
 Alert: Excessively slow pulse rate (60 beats per minute or less)
may be a sign of digitalis toxicity
Rationale: Digoxin is prescribed because it helps make the heart beat stronger
and with a more regular rhythm.
CHAPTER XII

Prioritized Nursing Problem

A. Problem List

High 1 Altered comfort r/t chest pain

High 2 Activity Intolerance r/t imbalance oxygenation supply
High 3 Disturbed sleep pattern r/t chest pain secondary to noise

B. Top 3 Problem

Pattern Priority Rationale

Altered comfort High 1 Life threatening, since pain is

r/t chest pain
not a simple, sensory

experience but a complex

64
 integration of sensory

affective and cognitive

dimensions. It is involved

actual or potential tissue

damage that could put the

client at risk for developing

complications.

(Monahan 2010)

It is Health Threatening
Activity High 2
Intolerance r/t It is second
imbalanced
high priority
oxygenation
since
supply
maintaining

proper

oxygenation

endure or

complete

required or

desired daily

activities, and

give vitality and

energy for life

65
 and it help beat

tiredness and

fatigue.

Disturbed sleep High 3

Health Threatening and
pattern r/t chest
pain secondary It is third
to noise
priority since

having enough

hours of sleep

is vital for fast

recovery and it

can help feel

energetic and

relaxed.

66
 CHAPTER XIV

ASSESSMENT

Subjective: ““ sakit kaayu akong dughan, lisud mag ginhawa pati akong tiil gasakit”

Objective:

Diagnosis: Altered comfort r/t chest pain

Need: Physioloic need

Background of the Study: Perceived lack of ease, relief and transcendence in physical and physiological

dimension because of unpleasant sensory experience arising. (Doenges, Nurse’s pocket guide 2012)

Planning: Within 8hours of duty the client will be able to:

 Engage in behaviors or lifestyle changes to increase level of ease

67
 Verbalize sense of comfort

 Participate in desirable and realistic health-seeking behaviors.

Nursing Intervention Rationale

 Determine the type of discomfort the  To assess further and give proper

client is experiencing intervention

 Ascertain locus of control  Presence of external locus of control

may hamper efforts to achieve sense of

peace or comfort

 Discuss concerns with client and active-  Help to determine client’s specific

listen to identify underlying issues needs, ability to change own situation

 Determine how client is managing pain  Lack of control may be related to other

and pain components issues

 Assess client’s understanding towards  To give further assistance and health

her situation and her methods of teaching in managing present condition

managing condition

 Review knowledge base and note coping  Brings client’s awareness and promotes

skills that have been used previously to use in current situation

change behavior and promote well-

being

 Discuss activities to promote ease such  To promote ease and relaxation and

as breathing exercise, therapeutic refocus attention

massage

 Schedule activities for periods when  To maximize participation

client has the most energy

68
  Establish realistic activity goals with  Enhances commitment to promote

client like breathing exercise and optimal outcomes

avoiding aggravating factors

Dependent  To relieve pain

 Administer analgesic as ordered

Collaborative  To promote relaxation, cooperation

 Involve SO in schedule planning and

decisions about treatments

Evaluation

After 8 hours of duty the client was able to respond to interventions, teachings, and actions

performed. She also verbalized decreased pain level from 8 to 5. Goal partially met.

69
 CHAPTER XV

PROGNOSIS

Medical Prognosis:

The client is 14 years old and thus still has a strong disposition to survive but still there Is a
complication arising in her condition. The client condition is considered as life threatening but
with immediate and proper management it can be prevented. The client as well as he significant
others are doing well in complying the treatment regimen given.

Nursing Prognosis:

In the nursing point of view, client SQ prognosis is good. In client condition, she is cooperative
enough upon taking her prescribed medications. With regards to health teachings we’ve
imparted to her, she never refuses to listen there taking care of her and assists her with her
needs as well as encouraged her to get better soon. Her family really tried so hard to come up
with the necessary finances with regard on her medications on her aster recovery. The client
was able to comply all the necessary medications s ordered by the physician despite on their
financial problems. But still her family tried their best to come up with the medications.

70
 CHAPTER XVI

DISCHARGE PLANNING

Medication:

1. Instructed client to take the following medications, observing the right dose, route and
timing:
 Benzyl Penicillin – 1.2 million units IV given ANST Q3 weeks on alternate
buttock.
 Lanoxin – 0.25g 1 tab OD
 Spironolactone – 25g 1 tab OD

Maintenance:

 Benzyle Penicillin – given every 3 weeks on alternate buttock.

 Encourage client to adhere to the prescribed medications by her attending physician and
to continue its entire therapeutic regimen.
 Explained to client the importance of taking the medications and its benefits that will
improve her condition.

71
Exercise:

1. Walking as tolerated
2. Promote circulation of blood to the extremities

Treatment:

1. Discussed with the family about the importance of completing the drug therapy, how to
do proper exercise and facilitate client in movement and activities of daily living.
2. Encourage significant others to assist when doing exercise to prevent injury.

Hygiene:

1. Tepid sponge bath to promote skin hydration and maintain skin integrity. Use of
moisturizing soap would be helpful to prevent drying of the skin.
2. Advised client to perform oral care, to cleanse and rinse carefully to remove crusts and
keep the mucous membrane moist.

Out-Patient:

Advised client to have follow-up check-up on August 21, 2014 at Doctor Alcover’s Clinic.

Diet:

Eating nutritious food would help the client regain full strength and energy.

1. Instruct client to eat low salt low fat diet and nutritious food such as vegetable and fruits.
2. Encourage client to eat green leafy vegetables since it contains large amounts of
vitamins and minerals needed by the body to function well and that would help improve
her condition. Also encourage the client to consume protein and calcium rich foods,

72
 since protein helps repair damaged tissues in the body, calcium is responsible for
strengthening bones.
Sources of protein rich foods: egg, meat, fish and beans
Calcium rich foods: malunggay leaves, dilis, cheese, milk and sardines.

Chapter XVII

Bibliography

Black, 2009

73
Deglin, Vallerand. Nurses Pocket Pharmacology Guide

Delmar, C..pp. 215-721.2008

Doenges, Marilynn, et al.Nurse’s Pocket Guide, 12th Edition. Philadelphia

Ester, Mary Ellen/ Health Assessment 2nd edition-Virginia.

F.A. Davis Company (pp.417, 559, 333, 564, 860, 69, 386, 775,188, 365, 346, 271, 800.2010).

Kehr, 2010

Kozier, et al. Fundamental of Nursing, 2012

Roth, et al..Nutrition Diet Therapy. Pp 366, 8th edition

Schull, Patricia Dewyer/ Nurse’s Drug Handbook 6th edition-United States

Timby and Smith. Introductory Medical Surgical Nursing. 8th edition 2010. Pp.1004

Internet sources: www.mayoclinic.com

www.news-medical.net
http://www.cvphysiology.com/Blood
%20Flow/BF001.html www.scrib.com

http://www.livescience.com/22486-
circulatory-system.html

www.diet.com

www.doctor.ndtv.com

www.DOH.gov.ph

www.health.harvard.educ

www.m.betterhealth.vic.gov.au

74
APPENDICES

DEFINITION OF TERMS

 Circumflex Branch- is an artery of the heart. It follows the left part of the coronary sulcus,
running first to the left and then to the right, reaching nearly as far as the posterior
longitudinal sulcus.

 Beta-Lactams – antibiotics are abroad class of antibiotics agents that contain a B-lactam
ring
 Cephalosporins – any of pleural antibiotics product by an imperfect fungus
 Contour- the outline or outer edge of something.
 Conundrum - a confusing or difficult problem.
 Effervescent – to bubble, hiss and foam as gas escapes

75
 Morphology- a branch of biology that deals with the form and structure of animals and
plants.
 Neurotransmitter- a substance in the body that carries a signal from one nerve cell to
another.
 Petechiae – a small red or purple spot caused by bleeding into the skin
 Vegetation- an abnormal growth upon a body part.

76
77
78
TERMS

79
 Abbreviations

GI - Gastro Intestinal

IVTT - Intravenous Through Tubing

BID - Twice a Day

CNS - Central Nervous System

BP - Blood Pressure

MHBR - Moderate Head Bed Rest

ANST - After Negative Skin Test

I&O - Intake & Output

80
OD - Once a Day

SO - Significant others

SE - Stool Exam

UA - Urinalysis

2Decho - Two-Dimensional echocardiogram

ECG - Electro cardiogram

CBC - Complete Blood Count

ESR - erythrocyte Sedimentation Rate

K - Potassium

SVC - Superior Vena Cava

TID - Thrice a Day

VS - Vital Sign

Q - Every

IV - Intravenous

Cc - Cubic Centimeter

KVO - Keep Vein Open

PO - Per Orem

RBC - Red Blood Cell

81
WBC - White Blood Cell

PA - Physician Assistant

RHD - Rheumatic Heart Disease

Documentation

August 23, 2013

Silwy -8 , Brgy. Luwalhati, Polomolok South Cotabato

82
August 30, 2014

Second Home Visit

83
September 26, 2014

Case Study Making

School Library

84
Curriculum Vitae

85
Name: Angelica Joy L. Jovenal

Nick Name: Jela

Age: 23

Birthday: October 23 1991

Place of Birth: Olangapo City

Address: Blk. 1 Lot 22, Agan Centro, Lagao General Santos City

Motto in life: “Look before you leap”

Curriculum Vitae

86
Name: Jennifer L. Tavella

Nick Name: Jenny

Birthday: May 11, 1978

Place of Birth: Davao City

Address: Fatima ,Uhaw General santos City

Motto in life: “It is better to take the hardship of education than to taste

the bitterness of ignorance”

Curriculum Vitae

87
Name: Vea Lorry Danuya

Nick Name: Yang

Age: 18

Birthday: April 10, 1996

Place of Birth: Tagum , Davao del Sur

Address: Prk. 20, Blk Lot25, Barangay Fatima, General Santos City

Motto in life: “In life beauty is not found in me but my personality will

Bring you to remember me”

Curriculum Vitae

88
Name: Wencel A. Porras

Nick Name: Wnez

Age: 27

Birthday: July 17, 1987

Place of Birth: Oroquieta City, Misamis Occidental

Address: Blk. 32, Lot 13, Sarangani Province

Motto in life: “Adapt and Overcome”

Curriculum Vitae

89
Name: Vinazer Piang

Nick Name: Vina

Age: 18

Birthday: June 4, 1996

Place of Birth: Cotabato City

Address: Zone 4, Blk 1. Barangay Fatima Uhaw, General Santos City

Motto in life: “Everything’s happen for a reason”

Curriculum Vitae

90
Name: Jhomar L. Onio

Nick Name: Pj

Age: 24

Birthday: March 15, 1990

Place of Birth: Penaplata, Island Garden City of Samal

Address: Cabe Subdivisionolico , J. Catolico Avenue General Santos City

Motto in life: “I simple love to be Original”

Curriculum Vitae

91
Name: Riss M. Venus

Nick Name: Dhay

Birthday: January 26, 1982

Place of Birth: Malandag, malungon Sarangani

Address: Phase II, Blk 8, Lot 22 Gensanville, Bula, General Santos City

Motto in life: “ It is what it is”

Curriculum Vitae

92
Name: Joy P. Bugas

Nick Name: Joy-Joy

Age: 22

Place of Birth: General Santos City

Address: San Francisco St, Cahilsot Village, Calumpang,

General Santos City

Motto in life: “Beauty is not definite, we define it”

93