ACKNOWLEDGEMENT

This case study would not have been possible without the guidance and the help of several individuals who in one way or another contributed and extended their valuable assistance in the preparation and completion of this study.

First and foremost, to the Almighty Father, for His unceasing love and blessings; for giving us enough power and fortitude to face all the hardships in the making of this work. To Him be all glory and praise!

To our Clinical Instructor Mr Hamed Leo Fabre, R.N., M.N., thank you for your invaluable time, knowledge and effort rendered to us.

The Staff and Personnel at Northern Mindanao Medical Center-Intensive care Unit for giving us the opportunity to complete this endeavor.

To our families, classmates and friends for giving us the inspiration to finished this seemingly impossible task. To the group, we would like to recognize each other for our own radical efforts in order to complete this case study; for sticking together through thick and thin and for simply being there. With this, we are proud to say that we are indeed the RLE50 Group 5.

Lastly, to each of us who helped realize this job into completion, may it be direct or indirect, no matter how minimal, the gratitude and pleasure for the achievement of this task is ours to share.

A Case Study on Rheumatic Heart Disease RLE 50 Group 5

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ABSTRACT This is a case study of a 27-year old, Male who had a Rheumatic Heart Disease with Mitral Regurgitation admitted at Northern Mindanao Medical Center

INTRODUCTION Getting your head in sync with your heart and harnessing the power of coherence gives you the energy efficiency you need to achieve changes that haven't been possible before. --Doc Childre and Howard Martin, The HeartMath Solution

The heart is one of the most important organs in the entire human body. It is really nothing more than a pump, composed of muscle which pumps blood throughout the body, beating approximately 72 times per minute of our lives. The heart pumps the blood, which carries all the vital materials which help our bodies function and removes the waste products that we do not need. The walls of the heart are made up of three layers, while the cavity is divided into four parts. There are two upper chambers, called the right and left atria, and two lower chambers, called the right and left ventricles. Sometimes there are also some problems that can affect the heart like with this case of our patient that has rheumatic heart disease.

Rheumatic heart disease is a complication of rheumatic fever, which is also a complication of sore throat and mumps. So basically this disease is the end result of untreated common infections. The valves of the heart are damaged; they may not be opening and/or closing properly which then causes regurgitation of blood. The heart is inflamed and thus scarring may result, which then causes accumulation of blood on the scars, causing damage to the heart membranes. The heart gets damaged by the toxin of streptococcus (the bacteria that causes rheumatic fever) thus causing it to beat abnormally. Heart ventricles are also damaged causing it to dysfunction.

RHD does not always cause symptoms. When it does, symptoms may include: Chest pain, heart palpitations, breathlessness on exertion, breathing problems when lying down (orthopnea), waking from sleep with the need to sit or stand up (paroxysmal nocturnal dyspnea),swelling (edema), fainting (syncope), stroke, fever associated with infection of damaged heart valves.

Worldwide, 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) addresses the diagnosis and treatment of this latter population. Estimations worldwide are that 5-30 million children and young adults have
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chronic rheumatic heart disease, and 90,000 patients die from this disease each year. (http://www.who.int/en/)

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 10-24years old. (Philippine Health Statistics 2003, 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.

(http://www.doh.gov.ph/)

Our major objective of this case study is to gain knowledge about rheumatic heart disease, the signs and symptoms of it and ways how to identify the early manifestations. We could as well lead them to the proper treatment to lessen their agony brought by the said disease, in anyhow. By having a wide understanding of the disease, we could impart teachings on how we could prevent the occurrence of the disease. It is our responsibility to render information and impart health teachings to improve the condition to our patients to the best of our abilities. One of the characteristics that we, student nurses, should have is to be informative and only through a keen of disease such as this way for us to gain all the information that we need to learn.

Scope and Limitation: This study is focused on one patient only who happened to have rheumatic heart disease admitted at Northern Mindanao Medical Center. Through the exposure of the students in the Intensive Care Unit and familiarity on the disease, we decided to choose him to be the patient in conducting the study.

The scope of this study would include:

Data collected via assessment, interviews with the patient, family members and clinical records, any health problems for 3 days including the initial assessment and its appropriate nursing intervention that would be applied within her stay in the hospital, developing a plan of care that will reduce identified predicaments and complications, coordinating and delegating interventions within the plan of care to assist the client to reach maximum
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functional health. Further evaluations of the effectiveness of nursing interventions have been rendered to the client.

An array of factors influencing the limitations of this study includes: Data collected is limited only to assessment and interview to the patients significant others, patients chart and nurse on duty, the interaction, assessment and care were only limited to a total of 8 hours (2 days clinical duty) with actual nursing intervention done.

SIGNIFICANCE OF THE STUDY Nursing Education

This study can be a useful learning guide in nursing education as this can be used by students as a reference for future studies regarding Rheumatic Heart Disease and related cases. This case study will enable the students to learn how to assess patients with any signs of kidney disorders and be able to provide appropriate nursing care and management.

Furthermore, the students will learn about the nursing interventions and have an idea of the rationale behind its actions. They can apply these interventions in the real setting when they encounter the same or similar condition. In this way, they are acquiring more knowledge about the disease that they can use to further develop their skills as student nurses and future nurses. It may open a new door in the practice of getting quality care. This study might also inspire other individuals to come up with their own research about this disorder or any similar condition.

Nursing Practice This case study can be used as a tool in nursing practice because it provides nursing interventions for patients with Rheumatic Heart Disease. This study can give a good introduction to the disorder so that an established nursing action can be quickly utilized. Through this study, important information regarding this illness has been gathered which will be helpful on the researchers to have an in-depth understanding on the said disorder.

Nursing Research The case can be used as a baseline data for further research of the current management of patients with Rheumatic Heart Disease. There might be some information in this study that can be of good use for future research. It is important to do
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research every now and then to gain new information, better interventions and techniques to provide to the patients. Aside from being beneficial as a simple academic informative material, this study might serve as a guide for orienting people about the substance of the disease, and how this disease affects people. Therefore through this study, the researchers should have introduced the symptoms (for early detection), treatment (for information), and management.

OBJECTIVES OF THE STUDY: Nurse Cantered: General: To enhance skills, comprehension and approach in the practice of nursing and be able to establish knowledge on the risk factors, prognosis nursing management, current trends and incidence of the disease condition that was chosen. To come up with a comprehensive presentation of the disease condition by means of correct presentation of the data gathered through the use of nursing process. Specific: 1. To present the current trends about the disease condition; the reason for choosing such case for presentation; and the importance of the case study. 2. Describe and explain the disease together with the risk factors contributing to the occurrence of the condition. 3. Review the anatomy and physiology of the organs involved. 4. Analyze the clients disease process along with its signs and symp toms, laboratory results and its complications, 5. Interpret the results in the laboratory and diagnostic procedures done with the patient. 6. Enumerate the different medications administered for the condition, their indications and specific nursing responsibilities. 7. Formulate significant nursing diagnoses, with their significantly related nursing care plans as well as the discharge plan. Patient Cantered: General: To be able for the client to fully understand and recognize the disease condition, emphasize the importance of making appropriate action and to guide the patient towards recovery. Specific: 1. To impart knowledge about the importance of healthy lifestyle. 2. To render proper nursing management and medical regimen needed by the patient. 3. To identify predisposing factors that aggregate the present condition of the patient.
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ASSESSMENT Nursing Health History The following nursing health history includes the health history of the patient. The researchers deemed it important to include assessing factors which may have contributed to the patients present condition. Patients Profile: Patient X, a 27 years old male from Zone 1 Cugman Cagayan De Oro City. He was admitted at Northern Mindanao Medical Center Intensive Care Unit last May 26, 2013. The family, including the patient himself, was baptized to the nearest Philippine Independent Church from where they lived in. Chief complaint: According to his mother, the patient was experiencing shortness of breath especially during supine position. History Of Present illness: Morning prior to admission, patient had onset of tolerable shortness of breath. No consultation done but still taking his maintenance. Prior to admission, there was increase severity of shortness of breath where he had shortness of breath at rest. Thus client opt consultation. Hence admission, he is then diagnosed with Rheumatic Heart Disease with mitral regurgitation, and tricuspid regurgitation. Family History of Illness: None of the members of the family were diagnosed of RHD. Functional Health Pattern: Patient never smoke nor drinks alcohol based beverages. He drinks coffee occasionally. He had no allergies to any food and drugs. Nutritional and Metabolic Pattern: Patient is currently on low salt low fat diet. Consumed full share with good appetite. Elimination Pattern: Patient Xs usual elimination pattern is firm brownish stool once a day without drinking any laxatives. His last bowel movement was on last February 6, 2013. He used to urinate 4 times a day with urine amber in color, for about 1 cup urine per urination. Activity-Exercises Patterns: Musculoskeletal are weak and could not perform activities of daily living except in feeding himself. Joints and muscles are sometimes painful as verbalized by the
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patient. He was totally dependent in dressing, grooming and toileting (ADL=3), assisted with person in bathing, bed mobility, general mobility (ADL=2), andtotally dependent in meal preparation, and cleaning (ADL=4). Legend:

Level (0) - Full Self care Level (1) - Requires use of equipment or device Level (2) - Requires assistance or supervision from another person Level (3) - Requires assistance or supervision from another person or device Level (4) - dependent and does not participate Sleep-Rest Pattern Patient X is having sleep pattern disturbances due to his sleeping position available for his conditions. He is comfortable sleeping on a high-fowlers position, or sleeping while leaning on a pillow placed on a table in front of him. He usually sleeps 4 to 5 hours every night and sometimes sleeps in the morning. Cognitive-Perceptual Pattern Patient X was not able to finish primary education due to his present illnesses. Patient is alert and well oriented to time and place except of the date. Self-Perception and Self-Concept Pattern He always feels exhausted. He usually does not share his feelings with regards to the situation. He prefers displaying a flat affect expression when asked about how he feels on certain situations. Role-Relationship Pattern He lived with his family. He is the oldest among the 5 children of his parents. He is financially supported by his family. He doesnt have any problem with his family. Sexuality-Reproductive Pattern He was never been to sexual activities. Coping-Stress Tolerance Pattern In the hospital, He experienced a quality nurse-service experience. Everything was in order and on time. At home, He managed stress by enjoying what television can offer, and conversing with his family. He asked support from his family which is always there.
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Value-Belief Pattern The family is Filipinista. His family went to church Sunday. This is very important to them because this is the only way to have them courage whenever aches and problems brought them down.

PHYSICAL ASSESSMENT Integumentary System General color of the skin is brown but the soles of the feet and the palms of his hands are pallor in color. Skin turgor is firm when assessed. Skin in the lower extremities is dry accompanied with crusts. Pitting edema grade 2 is noted on both feet. There is no presence of lesions noted. Skin hair is well distributed. Head, Eyes, Ears, Nose and Throat (HEENT) The head of the client is small for his age. Eyes are jaundice in color with pale conjunctiva. Pupils are equally round and reactive to light accommodation. Pupil measures 3 mm on both eyes. Lips are dry and pallor. Tongue is pink. Teeth are incomplete with presence of plaque on the upper and lower central and lateral incisors. The pinnas of the ears are flexible, without deformity and are aligned with the external cantus of eyes. RESPIRATORY SYSTEM: Upon inspection, Cyanosis on the upper and lower extremities are slightly noted. More visible on the nail beds of the patient. Respiratory rate and rhythm are abnormal as evidence by increased respiratory rate that ranges from 40 50 cycles per minute and a fluctuating oxygen saturation that ranges from 70% to 90%. Uses sternocleidomastoid muscle as an accessory muscle for inspiration apart from the other major muscles used in breathing. (diaphragm and intercostal muscles) orthopnea is manifested. Resonance is heard over right and left lung during percussion.Distribution of vibrations are equal upon assessing for tactile fremitus. Chest excurtion is normal. Clear lungs sound are auscultated.

Cardiovascular system: Upon inspection, pulsations of the veins on the neck, on the precordial area are visible. Lesions are not noted. With capillary refill of 4 seconds. (Percussion is not
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performed because patient verbalized discomfort during percussion)Pulsations are palpated at the precordial area for apical impulses noting its rate, rhythm, amplitude, contour, symmetry and elasticity. Apical impulse is palpated in the mitral area which measures 2cm in size. Amplitude is small like gentle tap with brief duration lasting through the first two thirds of the systole and often less. The aortic, pulmonic, tricuspid, mitral, erbs point and the apex area of the precordium are auscultated using the diaphragm and the bell of the stethoscope noting for normal and abnormal heart sounds and any murmur. Upon auscultation, s1 and s2 are heard in all areas. Murmur noted in all areas except at apex.

Gastrointestinal System Upon inspection, superficial veins noted at the 3 rd and 4th quadrants of the abdomen. There is an abnormal build up of fluid in the abdomen or ascites noted. Because of this, protruding contour of the abdomen is noted. Lesions are not noted at the anterioposterior aspect of the abdomen. The four quadrants of the abdomen are auscultated using the flat disc diaphragm for bowel sounds and the bell of the stethoscope for arterial and venous vascular sounds. Bowel sounds are present in all four quadrants with 5 to 15 clicks per min. Upon percussion, dullness is heard over fluid and tympany over intestines. Further percussion of organs was not performed due to patients verbalization of discomfort when percussed.

Genitourinary System He has yellowish urine 3 times daily with no discomfort. Reproductive System The genitalia is normal and has no problem. Musculoskeletal System He has a complete set of fingers and toes. Edematous feet . No dimpling is observed; there are equal gluteal folds. Decreased range of motion. There are no fractures or dislocations; no clicks in the joints. Decreased muscle tone. Arms and legs are symmetrical in size and decreased movement. Spine is slightly lordotic as a compensatory action of a protruding abdomen.

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DEVELOPMENTAL DATA 3Cs by Linda E. Hall The student nurses are instruments by which certain nursing problems which are faced by the client and the client's family are addressed and met. Quality professional nursing care requires the nurses to identify and solve overt and covert nursing problems. This theory emphasizes a client-centered approach because it is the primary role of the nurse to alleviate the patient from whatever suffering he/she is in and help her/him meet the needs. Her framework is efficient enough to address and meet the different requirements of the three aspects of her "pendulum model" which consists of client-oriented, nursing-centered and disease-centered approach.

Nursing is participation in care, core and cure aspects of patient care, where CARE is the sole function of nurses, whereas the CORE and CURE are shared with other members of the health team. The core is the person or patient to whom nursing care is directed and needed. The core has goals set by himself and not by any other person. The core behaved according to his feelings, and value system.

The cure, on the other hand is the attention given to patients by the medical professionals. The model explains that the cure circle is shared by the nurse with other health professionals. These are the interventions or actions geared on treating or curing the patient from whatever illness or disease he may be suffering from.

The care explains the role of nurses, and focused on performing that noble task of nurturing the patients, meaning the component of this model is the motherly care provided by nurses, which may include imited to provision of comfort measures, provision of patient teaching activities and helping the patient meet their needs where help is needed.

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ANATOMY AND PHYSIOLOGY A. Lymphatic System Lymphatic System consists of fluid called lymph flowing inside the lymphatic vessels, some structure and tissues that contain lymphatic tissue and bone marrow. Bone marrow houses Stem cells that develop into lymphocytes and provide immunity. When interstitial fluid passes in to lymphatic vessels, it is called Lymph i.e. Clear water. Interstitial fluid and lymph are basically same except for location. Filtration forces water and dissolved substances from the capillaries into the interstitial fluid. Not all of this water is returned to the blood by osmosis, and excess fluid is picked up by lymph capillaries to become lymph. Functions of the lymphatic system: 1) Draining interstitial fluid: To maintain the pressure and volume of the extracellular fluid by returning excess water and dissolved substances from the interstitial fluid to the circulation. 2) 2) Protecting against invasion: Lymph nodes and other lymphoid tissues is the site for production of immuno-competent lymphocytes and macrophages in the specific immune response. T lymphocytes rupture foreign cells or produce toxins while B lymphocytes differentiate in to plasma cells that secrete antibodies. 3) 3) Transporting Dietary lipids: Lymphatic vessels carry lipids and lipid soluble vitamins (ADEK) absorbed by gastro- intestinal tract. Lymph capillaries: Close ended vessels lies in the space between cells. It carries many pores which allow interstitial fluid including large lipids to get inside the lymphatic circulation but do not allow coming out. Lacteals: Each Villi in the small intestine has centrally placed lymphatic vessels called Lacteal. It transport lipids absorbed in the intestine. From lymph capillaries fluid flows into lymph veins(lymphatic vessels) which virtually parallel the circulatory veins and are structurally very similar to them, including the presence of semilunar valves. Lymphatic Vessels: Lymph capillaries unite to form Lymphatic vessels. Resemble vein in structure except it is thin and have more valves. Lymph capillaries containing lymph are found through out the body except in1.Avascular tissue2.Central Nervous System3.Spleenic pulp4.Bone marrow Lymphatic Ducts: The lymphatic veins flow into one of two lymph ducts. 1. The right lymph duct drains the right arm, shoulder area, and the right side of the head and neck. It is half inch in length.
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2. The left lymph duct (thoracic duct), drains everything else, including the legs, GI tract and other abdominal organs, thoracic organs, and the left side of the head and neck and left arm and shoulder. It is 15-18 inches in length and is a major vessel of the system. These ducts then drain into the subclavian veins on each side where they join the internal jugular veins to form the

brachiocephalic veins. Formation and flow of lymph: The excess fluids in the interstitial space i.e. about 3 lit/ day drains in to the lymphatic vessels and become lymph. Arteries (blood plasma)Blood capillaries Interstitial space Lymph capillaries (Lymph)Lymphatic Vessels Lymphatic Ducts Subclavian vein .Heart Lymph nodes lie along the lymph veins successively filtering lymph. Afferent lymph veins enter each node, efferent veins lead to the next node becoming afferent veins upon reaching it. Lymphokinetic motion (flow of the lymph) due to: 1) Lymph flows down the pressure gradient. 2) Muscular and respiratory pumps push lymph forward due to function of the semilunar valves. Other lymphoid tissue:

1. Lymph nodes: Lymph nodes are small encapsulated organs located along the pathway of lymphatic vessels. They vary from about 1 mm to 1 to 2 cmin diameter and are widely distributed throughout the body, with large concentrations occurring in the areas of convergence of lymph vessels. They serve as filters throughwhich lymph percolates on its way to the blood. Antigen-activated lymphocytes differentiate and proliferate bycloning in the lymph nodes.

2. Diffuse Lymphatic Tissue and Lymphatic nodules: The alimentary canal, respiratory passages, and genitourinary tract are guarded by accumulations of lymphatic tissue that are not enclosed by a capsule (i.e. they are diffuse) and are found in connective tissue beneath the epithelial mucosa. These cells intercept foreign antigens and then travel to lymph nodes to undergo differentiation and proliferation. Local concentrations of lymphocytes in these systems and other areas are called lymphatic nodules .In general these are single and random but are more concentrated in the GI tract in the ileum, appendix, cecum, and tonsils.

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3.The Thymus gland: The thymus is bilobed organ which is located in between the lungs, posterior to the sternum. The thymus is where immature lymphocytes differentiate into Tlymphocytes. The thymus is fully formed and functional at birth. Characteristic features of thym ic structure persist until about puberty. The transformation of primitive or immature lymphocytes into T-lymphocytes and their proliferation in the lymph nodes is promoted by a thymic hormone called thymosin . Occasionally the thymus persists and may become cancerous after puberty and and the continued secretion of thymosin and the production of abnormal T-cells may contribute to some autoimmune disorders. 4. The spleen The spleen oval and largest lymphatic mass which filters the blood and reacts immunologically to blood-borne antigens. In addition to large numbers of lymphocytes the spleen contains specialized vascular spaces, a meshwork of reticular cells and fibers, and a rich supply of macrophages which monitor the blood. The human spleen holds relatively little blood compared to other mammals, but it has the capacity for contraction to release this blood into the circulation during anoxic stress. White pulp in the spleen contains lymphocytes and is equivalent to other lymph tissue, while red pulp contains large numbers of red blood cells that it filters and degrades. The spleen functions in both immune and hematopoietic systems. Immune functions include: proliferation of lymphocytes, production of antibodies, and removal of antigens from the blood. Hematopoietic functions include: formation of blood cells during fetal life, removal and destruction of aged, damaged and abnormal red cells and platelets, retrieval of iron from hemoglobin degradation, storage of red blood cells.

IMMUNE SYSTEM I. Non-specific responses General mechanisms for discouraging pathogens which donot require the identity of the pathogen's antigenic nature. These are the first line of defense against invasion by pathogens. A. Surface Membrane Barriers 1. Skin a. acidic pH b. Keratinization protects unbroken skin against acids and bases of bacterial enzymes and toxins. 2. Mucous membranes a. HCl in the stomach kills many pathogens, denatures proteins
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b. Saliva contains lysozyme, a bactericide c. Lacrimal fluid contains lysozyme d. Mucus traps organisms B. Cellular And Chemical Defenses 1. Phagocytes - engulf particulates, including microorganisms, which pass through the external barriers. 2. Natural killer cells- these large lymphocytes lyseand kill tumor and virus-infected cells before activation of a specific immune response. 3. Inflammation a. reduces spread of damaging agents to nearby tissues b. increases disposal of cell debris and pathogens c. facilitates repair processes d. caused by histamine and prostaglandins released by basophils and other cells.

4. Anti-microbial proteins a. Non-Specific complement activation b. Interferons- block tumor and viral reproduction c. Interleukin I- stimulates the immune response 5. Fever a. Due to pyrogens secreted by leucocytes b. Disrupts metabolism of pathogens II. Specific Responses This second line of defense responses are activated by, and directed against, a specific antigen. Antigen - a protein or other substance which elicits immune system activation in a "foreign" host. A. Humoral Immunity- the B-cell response 1. Antigen challenge- "non-self" antigen binds to antigen-specific surface receptors on generic B-cell. 2.Clonal selection- multiplication of B-cells produces cells which all contain the same antigen-specificsurface receptor. a. Primary response- plasma cells secrete free antibodies of the same structure as the antigen-specific surface receptor. The primary response takes 7 to 10 days to reach maximum antibody levels. b. Secondary response- memory cells which retain the ability to quickly clone to produce more plasma cells should the antigen be

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encountered again. The secondary response takes from 1 to 2 days to reachmaximum antibody levels. 3. Antibodies form antigen- antibody complexes which have the following affects: a. Opsonization- labeling of antigens or foreign cells b. Neutralization- inactivation of bacterial toxins c. Agglutination- clumping of cell-bound antigens d. Precipitation- removes soluble antigen from solution e. Complement fixation- which causes cell lysis. Complement protein binds to a site on the constant (Fc) portion of the antibody. 4. Classes of antibodies: IgD - (monomer) antigen receptor on B-cell IgM - (pentamer) first antibody released by plasma cells during primary response IgG - (monomer) comprises most circulating antibodies, responses IgA - (dimer) antibody found in secretions IgE - (monomer) secreted in mucosa, mediates inflammation in allergic reaction. B. Cell Mediated Immunity- the T-cell response -requires an intermediary cell to be stimulated. These intermediary cells can be infected body cells or macrophages as below. Identification of these cells and their antigens is by means of MHC proteins. MHC (Major Histocompatibility Complex) antigens are recognition proteins which identify a cell as being "self". They are displayed together with part of the antigen from invading viruses to be recognized by T-cell lymphocytes. There are two classes of MHC antigens: Class I is present on all body cells; Class II is present only on cells of the immune system. There are several types of T cells. 1. Generic cytotoxic T-cells a. respond to antigens complexed by MHC I proteins from infected body cells. b. attack and kill virus or bacteria-infected cells and tumor cells c. Maintain immunologic surveillance d. clone to produce mature cytotoxic cells and cyt otoxic memory cells 2. Helper T-cells a. respond to antigens complexed with MHC II proteins on antigen presenting cells b. act as co-stimulator cells for B-cells and other T-cells and. Activated Helper cells release
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c. Interleukin II and act as a co-stimulator for an effective B-cell response. 3. Suppressor T-cells- regulatory cells which tend toshut down B and T-cell responses. 4. Cytokines- chemical mediators involved in cellular immunity. a. Interleukin I- co-stimulator for activated T-cells b. Interleukin II- stimulates both B and T-cell proliferation

B. Cardiovascular System

Four compartments

The heart is divided into 4 chambers: 2 on the right hand side and 2 on the left. Each upper chamber is known as an atrium and each lower chamber as a ventricle. The 4 compartments are known as: the right atrium; the right ventricle; the left atrium and the left ventricle. Blood comes into the heart via the atria, which are the smaller chambers, and is pumped out via the larger ones the ventricles
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The Left Ventricle is the pumping chamber for the systemic circulation. Because a greater blood

pressure is required to pump blood through the much more extensive systemic circulation than through the pulmonary circulation, the left ventricle is larger and its walls are thicker than those of the right ventricle. When the left ventricle contracts, it pumps oxygenated blood through the aortic semilunar valve, into a large artery, the aorta, and throughout the body. The following events occur in the left ventricle, simultaneously and analogously with those of the right ventricle. Interventricular septum- Muscle that separates two ventricle from each other. Interatrial septum- Cardiac Muscle that separates two atrium from each other. Coronary sulcus (artioventricular groove)- marks the junction of the atria and ventricles. Anterior interventricular sulcus and posterior interventricular sulcus- mark the junction of the ventricles on the front and back of the heart, respectively.

Superior and inferior vena cava These are the 2 large veins which enter the heart on the right hand side and

bring blood low in oxygen into the right atrium. The superior (top) vena cava brings in blood from the head and arms and upper body; the inferior (lower) vena cava brings in blood from the trunk and legs the lower body. Arteries Carry blood away from the heart. They are the thickest blood vessels, with muscular walls that contract to keep the blood moving away from the heart and through the body. Arterial walls have three layers: The endothelium Is on the inside and provides a smooth lining for blood to flow over as it moves through the artery.

The media Is the middle part of the artery, made up of a layer of muscle and elastic tissue.

The adventitia Is the tough covering that protects the outside of the artery.

Types of arteries: a. Coronary arteries

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The heart is just a big muscle which pumps blood around the body. This oxygen is brought to the heart by the coronary arteries. The right and left coronary arteries branch off the aorta the large main blood vessel which leaves the heart with

fresh oxygen-rich blood so they are ensured of a good blood supply rich in oxygen. b. Pulmonary arteries The right and left pulmonary arteries branch off the main pulmonary trunk. Blood that needs oxygen is pumped into them from the right ventricle and they take it to the lungs where it is loaded up with oxygen. Veins Carry blood back to the heart. They're not as muscular as arteries, but they contain valves that prevent blood from flowing backward. Veins have the same three layers that arteries do, but are thinner and less flexible. The two largest veins are the superior and inferior vena cava. Pulmonary veins The right and left pulmonary veins bring the oxygen-rich blood back from the lungs to the heart into the left atrium. Aorta The aorta is the largest artery in the body. Fresh blood full of oxygen is pumped by the left ventricle into the aorta, round the aortic arch and out into the upper body via the 3 main arteries branching off the aortic arch and into the thorax, trunk and lower body via the descending aorta. Valves Valves are one-way doors. There are valves separating the chambers of the heart. As the heart beats, the valves open and blood is pumped from one chamber to another chamber. Layers of the heart Pericardium The pericardium is the double walled sac that contains the heart and the roots of the great vessels that leave from or enter the heart. There are two layers of the pericardial sac, which are the fibrous pericardium and the serous pericardium. The serous pericardium is further divided into two layers, which are the parietal pericardium and the visceral pericardium. The parietal pericardium is inseparably fused to the fibrous pericardium, while the visceral pericardium is actually a part of the epicardium, which is the outermost single layer of the pericardium. The visceral layer extends into the starting point of great vessels, thus, becoming one with the parietal layer of the serous pericardium. Myocardium

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The myocardium is the basic muscle that makes up the heart. This muscle is involuntary and, this is striated in nature. The cardiac muscle structure consists of basic units of cardiac muscle cells known as myocytes. Coordinated contraction of the cardiac muscles is what makes the heart propel blood to various parts of the body. Endocardium The endocarium is the innermost, thin and smooth layer of epithelial tissue that lines the inner surface of all the heart chambers and valves. This layer is made of thin and flat cells that are in direct contact with the blood that flows in and out of the heart. Each heart valve is formed by a fold of endocardium with connective tissue between the two layers.

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DIAGNOSTIC LABORATORY RESULTS

LABORATORY & HEMATOLOGY RESULTS

URINALYSIS REPORT June 12,2013 INTERPRETATION PHYSICAL PROPERTIES:

Color Clarity pH Specific gravity

yellow clear 7.0 1.030 CHEMICAL PROPERTIES:

Normal Normal Normal Normal

proteins Glucose

negative negative

Normal Normal

SEDIMENT/MICROSCOPIC EXAMINATION

Pus cells (WBC) Red blood cells Coarsely granular Mucus threads

0-2

Normal

few

Mucus threads are usually present in small numbers. Increased numbers are indicative of chronic inflammation of the urethra and bladder.

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TEST WHITE BLOOD CELS RED BLOOD CELLS HEMOGLOBIN

RESULT 5.6

UNIT 10^3/uL

REFERENCE 5.0 10.0 4.2 5.4 12.0 16.0 37.0 47.0

INTERPRETATION Normal

3.16

10^6/uL

Anemic

8.2

g/dL

poor diet/nutrition or malabsorption nutritional deficiency (iron, vitamin B12, folate), Normal Normal Normal Beginning stages of a decrease in vitamin B12 or folic acid (a type of vitamin) in the body. Conditions in which platelets are used up (consumed) or destroyed faster than normal Normal

HEMATOCRIT

27.2

MCV MCH MCHC RDW-CV

86.1 25.9 30.1 21.9

fL Pg g/dL %

82.0 98.0 27.0 31.0 31.5 35.0 12.0 17.0

PDW

7.5

fL

9.0 16.0

MPV DIFFERENTIAL COUNT Lymphocyte (%) Neutrophil (%) Monocyte (%) Eusinophils (%) Basophils (%) Bands/scabs (%) PLATELET

7.9

fL

8.0 12.0

18.4 65.8 14.8 0.5 0.5

% % % % % %

17.4 48.2 43.4 76.2 4.5 10.5 1.0 3.0 0.0 2.0 1.0 2.0 150 - 400

Normal Normal infection Normal Normal --Normal

274

10^3/uL

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X-RAY REPORT Chest APT here is opacification of the right hemithorax spacing the upper lung with obscuration of the right heart border bilateral hemidiaphragm, moderate to massive pleural effusion suggest follow up check up. True cardiac size is difficult to assess but appears enlarge. Aorta is unremarkable Left costophrenic sulcus is intact No other remarkable finding

Analysis: Chest Xray suggest that the patient has pleural effusion. The test also suggests that the heart isquite enlarge and could be possibly because of the congestion. The inability of the heart to pump normallyand allow normal flow of the blood is impaired and tries to accommodate those extra volumes of blood. 2D ECHO
VALVE MAX.VELOCITY M/SEC PEAK GRADIEN T mmHg 4.65 / 7.74 21.21 / 6.18 5.13 / 0.95 1.73 Orifice VTI Area RATIO Jet Area Cm2 1+ 32% 28% + Grading

AORTIC MITRAL TRICUSPID PULMONIC

PA PRESSURE

1.08 / 1.39 2.30 / 1.24 1.13 / 0.49 0.66

54mm

PAT

97

TRJ

QPQS

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PATHOPHYSIOLOGY

Predisposing Factors: Male Progression from rheumatic heart disease Genetics

Precipitating Factors: Poverty Lifestyle Improper food handling Uncompliance to medication

Presence of Group-A hemolyrtic streptococcus

Attach to epithelial cells of the upper respiratory tract

Increase production of antigen

Binds to receptors in joints, skin, brain and other connective tissue

Autoimmune response

Attacks the heart valves

Inflammation of the layers of the heart

Difficulty of the heart to pump

Increase cardiac workload

Scarring of the heart valves that damages the mitral valve

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Restriction of leaflets motion

Deformed leaflets resulting to valve failing to close completely

Regurgitation of blood with streptococcus

Ventricular dilation

Left side of the heart fails

Right side of the heart fails

Increase workload of the heart

Increase blood volume in the right ventricle right atrium

Left ventricle is weak progressis

Impaired gas exchange

Decrease lung expansion

Blood backs up from the left ventricle to left atrium

Blood backs up going back to

Hepatic vein Congestion in the pulmonary vein Hepatomegaly Cardiac cirrhosis Movement of fluid to the alveoli Ascites resulting to abdominal pain, nausea and anorexia Portal vein

Liver

Pulmonary edema

dyspnea, orthopnea, restless, cyanosis, cheyne stroke respiration,crackles, coughing A Case Study on Rheumatic Heart Disease RLE 50 Group 5 Page 24

NURSING CARE PLAN

1. Impaired gas exchange related to fluid shift on alveoli secondary to pulmonary edema
Assessment Subjective Cues: Ga lisud ko hinga as verbalized Objective Cues: Use of accessory muscles when breathing Dyspnea Orthopnea Crackles Cyanosis Oxygen saturation: 70-90%

Goals and Objectives: Short-term: After 15-30 minutes of nursing intervention, the patient will be able to demonstrate improved ventilation and adequate oxygenation of tissues. Long-term: After 8 hours of nursing interventions, the patielt will have improve respiration.

Nursing Intervention Elevated head of bed/position clients head appropriately, in a semi-Fowler's position as tolerated to allow increased lung expansion because the abdominal contents are not crowding the lungs. Demonstrated and encouraged frequent deep breathing/coughing exercises to promote optimal chest expansion. Demonstrate and encourage the client to use pursed-lip breathing to increased use of intercostal muscles, decreased respiratory rate, increased tidal volume, and improved oxygen saturation levels. Minimize activities andenergy expenditures byassisting ADLs to reduce oxygen and energy demand Evaluation Short-term: After 15-30 minutes of nursing intervention, the patient was able to demonstrate improved ventilation and adequate oxygenation of tissues.
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Goals met. Long-term: After 8 hours of nursing interventions, the patient has an improved respiration. Goals met.

2. Decrease cardiac output related to altered stroke volume.

ASSESSMENT Objective: Vital Signs: BP: 100/62 mmhg PR: 112 bpm O2 Sat: 70%-90% Capillary refill time: 4 seconds Clammy skin noted GOALS AND OBJECTIVES Short Term After 2 hours of nursing intervention, patient blood pressure will be normalized Long Term:
After 3 days of nursing intervention, patient will maintain adequate cardiac output and cardiac index.

NURSING INTERVENTIONS AND RATIONALE: Independent: 1. On low-salt, low-fat diet to prevent hypertension. 2. Placed on a moderate high back rest to decreases oxygen consumption and risk of decomposition.
3. Stress importance of accomplishing daily rest periods, alternating rest and activity increases tolerance to activity progression. 4. Frequent position changes,leg exercises when lying down to decrease peripheral venous pooling that may be potentiated by vasodilators.

Dependent: 1. Administered Digoxin as ordered by the physician to help reduce heart rate.

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Evaluation: Short Term After 2 hours of nursing intervention, patient heart rate is lowered down to 100 GOALS MET. Long Term:
After 3 days of nursing intervention, patient maintained adequate cardiac output and cardiac index as evidence by stable signs. GOALS MET.

Excess fluid volume related to increased ADH production and sodium/water retention
ASSESSMENT Objective:
Edema Abdominal girth of 30cm Urine output of 400cc per day

GOALS AND OBJECTIVES 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

NURSING INTERVENTIONS AND RATIONALE: Independent:

Restricted-sodium diet as appropriate to favor the renal excretion of excess fluid. Change position frequently. Elevate feet when sitting. Inspect skin surface, keep dry, and provide padding. Edema formation, slowed circulation, altered nutritional intake, and prolonged immobility/bedrest are cumulative stressors that affect skin integrity and require close supervision/preventive interventions. Instruct in need for antiembolic stockings or bandages as ordered to help promote venous return and to minimize fluid accumulation in the extremities.

Dependent: 2. Administered Furosemide as ordered by the physician to help increase urine output.

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Evaluation: Short Term After 8 hrs of continuous nursing intervention, patient was able to reduce recurrence of fluid excess as manifested by decreased abdominal girth and edema GOALS MET.

DRUG STUDY

Omeprazole is a generic name of Prilosec, an Antisecretory drug given 20 mg per orem once a day. A gastric acid-pump inhibitor: Suppresses gastric acid secretion by specific inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of aid production. Forshort-term treatment of active duodenal ulcer and first-line therapy in treatment of the heart burn of symptoms of GERD. Adverse effects are rash, inflammation, urticaria, prurits, alopecia, dry skin, cancer in preclinical studies, back pain and fever. Contraindicated to patients with hypersensitivity to omeprazole or its components and use cautiously with pregnancy, lactation. The nurse should administer before meals. Caution patient to swallow capsules wholenot to open, chew, or crush them. If using oral suspension, empty packet into a small cup containing 2 tbsp of water. Stir and have patient drink immediately, fill cup with water and have patient drink this water. Do not use any other diluents.

Acetylsalicylic called analgesics (pain

acid

(ASA)

belongs

to

the

group

of

medications

relievers), antipyretics (fever

reducers), anti-inflammatories

(inflammation reducers), and platelet aggregation inhibitors (anticlotting agents), given 80mg to the patient orally to works by interfering with the production of compounds in the body that cause pain, fever, inflammation, and blood clots. It is used to relieve pain, fever, and inflammation in various conditions such as lower back and neck pain. ASA is also used for rheumatic fever in combination with other medications. There are signs of an allergic reaction while taking aspirin (the active ingredient contained in Acetylsalicylic Acid) hives; difficulty breathing, swelling of your face, lips, tongue, or throat. Some are serious Side effects like black, bloody, or tarry stools, coughing up blood or vomit that looks like coffee grounds, severe nausea, vomiting, or stomach pain, fever lasting

longer than 3 days, swelling, or pain lasting longer than 10 days, or hearing problems,
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ringing in your ears. And less serious side effects of aspirin may include upset stomach, heartburn, drowsiness, or headache. Adverse Effects of Aspirin may causes stomach irritation & bleeding (even more so when consumed with alcohol), in those <16 yr with virus, flu or chicken pox, aspirin increases risk of Reye's disease (serious (often fatal) liver & neurological disease). Contraindicated to people who are allergic

to ibuprofen or naproxen or who have salicylate intolerance or a more generalized drug intolerance to NSAIDs, and caution should be exercised in those with asthma or NSAIDprecipitated bronchospasm. Owing to its effect on the stomach lining, manufacturers recommend people with peptic ulcers, mild diabetes, or gastritis seeks medical advice before using aspirin. Even if none of these conditions is present, the risk of stomach bleeding is still increased when aspirin is taken with alcohol or warfarin. Nursing considerations are for patients who have had oral or dental surgery or tonsillectomy in the last seven days avoid chewable or dispersible aspirin tablets, or aspirin in crushed tablets or gargles, assess pain and/or pyrexia one hour before or after medication. In long-term therapy monitor renal and liver function and ototoxicity, assess other medication for possible interactions - especially warfarin which is a special hazard, be aware that aspirin is a common constituent of a variety of over-the-counter medications.

Diphenhydramine HCl Oral is the generic term of Benadryl, 50mg given to the patient orally. It used to relieve symptoms of allergy, hay fever, and the common cold. These symptoms include rash, itching, watery eyes, itchy eyes/nose/throat, cough, runny nose, and sneezing. It is also used to prevent and treat nausea, vomiting and dizziness caused by motion sickness. Diphenhydramine can also be used to help you relax and fall asleep. This medication works by blocking a certain natural substance (histamine) that your body makes during an allergic reaction. Its drying effects on such symptoms as watery eyes and runny nose are caused by blocking another natural substance made by your body (acetylcholine). Indications includes Relief of symptoms associated with perennial and seasonal allergic rhinitis; vasomotor rhinitis; allergic conjunctivitis; mild, uncomplicated urticaria and angioedema; amelioration of allergic reactions to blood or plasma; dermatographism; adjunctive therapy in anaphylactic reactions, Active and prophylactic treatment of motion sicknessNighttime sleep aid. Parkinsonism (including drug-induced parkinsonism and extrapyramidal reactions), in the elderly intolerant of more potent agents, for milder forms of the disorder in other age groups, and in combination with centrally acting anticholinergic antiparkinsonian drugs Syrup formulation: Suppression of cough due to colds or allergy. Side effects are Drowsiness, dizziness, constipation, stomach upset, blurred vision, or dry

mouth/nose/throat may occur. To relieve dry mouth, suck (sugarless) hard candy or ice chips, chew (sugarless) gum, drink water, or use a saliva substitute. Adverse effects
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are CNS depression, dizziness, headache, sedation; paradoxical stimulation in children; dryness of mouth, thickened respiratory secretion, blurring of vision, urinary retention; GI disturbances; blood dyscrasias. Contraindicated to Hypersensitivity, neonates and lactation. Nursing responsibilities are to monitor patient response, and arrange for

adjustment of dosage to lowest possible effective dose and assess for allergy to any antihistamines.

Spironolactone is the generic name of Aldactone given 100 mg per day per orem. Used to treat high blood pressure. Lowering high blood pressurehelps prevent strokes, heart attacks, and kidney problems. It is also used to treat swelling (edema) caused by certain conditions (e.g., congestive heart failure) by removing excess fluid and improving symptoms such as breathing problems. This medication is also used to treat low potassium levels and conditions in which the body is making too much of a natural chemical (aldosterone). Adverse Effects are Lethargy, Headache, Mental confusion, Rash, Urticaria, Stevens-Johnson syndrome, toxic epidermal necrolysis, Drug rash with eosinophilia and systemic symptoms (DRESS), Gynecomastia, Impotence, Menstrual disorders, Abdominal cramping, Diarrhea, Gastritis, Nausea, Vomiting Side effects are Drowsiness, or lightheadedness, occur. To stomach minimize

upset, diarrhea, nausea,

vomiting,

headache may

lightheadedness, get up slowly when rising from a seated or lying position. If any of these effects persist or worsen, notify your doctor or pharmacist promptly. Precautions are may increase your potassium levels. Before using potassium supplements or salt substitutes that contain potassium, consult your doctor or pharmacist. Limit foods high in potassium such as bananas, tomatoes, potatoes, and low-salt milk. Consult your doctor or pharmacist for more details, including recommendations. Interactions to some products that may interact with this drug include: certain hormones

(ACTH),digoxin, lithium, mitotane, drugs that may increase the level of potassium in the blood (such as amiloride, cyclosporine, eplerenone, tacrolimus, triamterene, birth

control pills containing drospirenone). Contraindications and should not be taken under any circumstance by pregnant women due to the high risk of feminization of male fetuses. Nursing responsibilities are to check blood pressure before initiation of therapy and at regular intervals throughout therapy, Lab tests: Monitor serum electrolytes (sodium and potassium) especially during early therapy; monitor digoxin level when used concurrently, Assess for signs of fluid and electrolyte imbalance, and signs of digoxin toxicity, Monitor daily I&O and check for edema. Report lack of diuretic response or development of edema; both may indicate tolerance to drug, Weigh patient under standard conditions before therapy begins and daily throughout therapy. Weight is a useful index of need for dosage adjustment. For patients with ascites, physician
A Case Study on Rheumatic Heart Disease RLE 50 Group 5 Page 30

may want measurements of abdominal girth, Observe for and report immediately the onset of mental changes, lethargy, or stupor in patients with liver disease, Adverse reactions are generally reversible with discontinuation of drug. Gynecomastia appears to be related to dosage level and duration of therapy; it may persist in some after drug is stopped.

Dopamine Hydrochlorid is the generic name of Intropin which is an adrenergic and dopaminergic cardiac stimulant, prescribed for heart failure, given200 mg per 250 mL IVTT which helps to increases the pumping strength of the heart. Indicated for the correction of hemodynamic imbalances present in the shock syndrome due to myocardial infarctions, trauma, endotoxic septicemia, open heart surgery, renal failure, and chronic cardiac decompensation as in congestive failure. Where appropriate, restoration of blood volume with a suitable plasma expander or whole blood should be instituted or completed prior to administration of DOPAMINE. Precautions are should be exercised in patients with history of thickening and hardening of arteries, Raynaud's disease, Buerger's disease, diabetic endarteritis, increase in diastolic pressure, who are taking other medications, any allergy, during pregnancy and breastfeeding, Monitor urine flow, cardiac output and blood pressure regularly while taking this medication, Blood volume should be corrected before infusion of this medication. Serious Side Effects such as, chest pain, fast, slow, or pounding heartbeats, painful or difficult urination, blood in your urine, weakness, confusion, swelling in your feet or ankles, urinating less than usual or not at all, weak or shallow breathing, feeling like you might pass out, even while lying down, burning, pain, or swelling around the IV needle, cold feeling, numbness, or blue-colored appearance in your hands or feet or darkening or skin changes in your hands or feet while Less serious side effects of dopamine may include, headache, feeling anxious, nausea, vomiting; or chills, goosebumps. Contraindications in patients with pheochromocytoma, uncorrected tachyarrhythmias or ventricular fibrillation and hypersensitivity. Nursing responsibilities are Monitor blood pressure, pulse, peripheral pulses, and urinary output at intervals prescribed by physician. Precise measurements are essential for accurate titration of dosage, Report the following indicators promptly to physician for use in decreasing or temporarily suspending dose: Reduced urine flow rate in absence of hypotension; ascending tachycardia; dysrhythmias; disproportionate rise in diastolic pressure (marked decrease in pulse pressure); signs of peripheral ischemia (pallor, cyanosis, mottling, coldness, complaints of tenderness, pain, numbness, or burning sensation), Monitor therapeutic effectiveness. In addition to improvement in vital signs and urine flow, other indices of adequate dosage and perfusion of vital organs include loss of pallor, increase in toe

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temperature, adequacy of nail bed capillary filling, and reversal of confusion or comatose state.

Digoxin is the generic name of Lanoxin. It belongs to a class of medications called cardiac glycosides, 0.25 given to the patient orally. It works by affecting certain minerals (sodium and potassium) inside heart cells. This reduces strain on the heart and helps it maintain a normal, steady, and strong heartbeat. Digoxin (Lanoxin) is used in the treatment of congestive heart failure and abnormally rapid atrial rhythms (atrial fibrillation, atrial flutter, atrial tachycardia). Drug interactions include calcium channel blockers, beta blockers, diuretics, and others. Common side effects include vomiting, headache, nausea, dizziness, skin rash, and mental changes. Digoxin may be taken with or without food. Digoxin is primarily eliminated by the kidneys; therefore, the dose of digoxin should be reduced in patients with kidney dysfunction. Digoxin blood levels are used for adjusting doses in order to avoid toxicity. The usual starting dose is 0.06250.25 mg daily depending on age and kidney function. The dose may be increased every two weeks to achieve the desired response. Drug Interactions to drugs such as verapamil (Calan, Verelan, Verelan PM, Isoptin, Isoptin SR, Covera-HS),

quinidine (Qunaglute,Quinide), indomethacin (Indocin,Indocin-SR), Niravam), spironolactone (Aldactone), alprazolam

amiodarone (Cordarone), (Xanax, Xanax XR,

and itraconazole (Sporanox) can increase

digoxin levels and the risk of toxicity. The co-administration of digoxin and beta-blockers [for example propranolol (Inderal, Inderal LA) or calcium channel blockers (for example, verapamil), which also reduces heart rate, can cause serious slowing of the heart rate. Common Side effects includes nausea, vomiting, headache, dizziness, skin rash, and mental changes. Many digoxin side effects are dose dependent and happen when blood levels are over the narrow therapeutic range. Therefore, digoxin side effects can be avoided by keeping blood levels within the therapeutic level. Serious side effects associated with digoxin include heart block, rapid heartbeat, and slow heart rate. Digoxin has also been associated with visual disturbance (blurred or yellow vision), abdominal pain, and breast enlargement. Patients with low blood potassium levels can develop digoxin toxicity even when digoxin levels are not considered elevated. Similarly, high calcium and low magnesium blood levels can increase digoxin toxicity and produce serious disturbances in heart rhythm. Adverse Effects Dizziness, Mental disturbances, Diarrhea, Headache, Nausea, Vomiting, Maculopapular rash, Anorexia, Cardiac dysrhythmia, Arrhythmia in children (consider a toxicity).

Contraindicated to Kidney disease, such as kidney failure (renal failure), Heart problems and with history of electrolyte or vitamin problems (such as low or high blood potassium, calcium, magnesium, or thiamine levels). Nursing Responsibilities are to
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instruct patient to take digoxin at same time each day to ensure steady-state dosing and to contact health care provider for instructions if dose is missed, Teach patient and family name, action, administration, adverse reactions, and toxic effects of particular digoxin preparation, Emphasize importance of regular follow-up exams to determine effectiveness and to monitor for toxicity, Caution patient to avoid taking OTC medications without consulting health care provider. Antacids and antidiarrheals, for example, slow absorption of digoxin, Teach patient and family to take pulse and to seek health care provider's advice for rates less than 60bpm or more than 100 bpm (adults), Patients should maintain adequate dietary intake of potassium as directed by health care provider. Cefuroxime is the generic name of Ceftin which is a semisynthetic cephalosporin antibiotic, chemically similar to penicillin given 250-500 mg twice daily per orem. Cephalosporins stop or slow the growth of bacterial cells by preventing bacteria from forming the cell wall that surrounds each cell. The cell wall protects bacteria from the external environment and keeps the contents of the cell together. Without a cell wall, bacteria are not able to survive. Cefuroxime is effective against a wide variety of bacteria, such as Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, E. coli, N. gonorrhea, and many others. And it is use to treat a wide variety of bacterial infections. This medication is known as a cephalosporin antibiotic. It works by stopping the growth of bacteria.This antibiotic treats only bacterial infections. It will not work for viral infections (e.g., common cold, flu). Unnecessary use or overuse of any antibiotic can lead to its decreased effectiveness. Adverse effects that are in Large doses can cause cerebral irritation and convulsions; nausea, vomiting, diarrhea, GI disturbances; erythema multiforme, Stevens-Johnson syndrome, epidermal necrolysis and Potentially Fatal: Anaphylaxis, nephrotoxicity, pseudomembranous colitis. Side effects is generally well tolerated, and side effects are usually transient which

includes diarrhea, nausea, vomiting, abdominal pain, headache, rash, hives, vaginitis, and mouth ulcers. Allergic reactions, severe skin reactions, anemia, and seizures also may occur. Since cefuroxime is chemically related to penicillin, patients allergic to penicillin may develop an allergic reaction (sometimes even anaphylaxis) to cefuroxime. Cefuroxime like other antibiotics can alter the colon's normal bacteria, leading to overgrowth of a bacterium called Clostridium difficile. Overgrowth of this bacterium leads to the release of toxins that contribute to the development of Clostridium difficileassociated diarrhea, which may range in severity from mild diarrhea to

fatal pseudomembranous colitis. Drug interactions to Probenecid increases the concentration of cefuroxime in the blood. Drugs that reduce acidity in the stomach (for example, antacids, H2-blockers, proton pump inhibitors) may reduce absorption of cefuroxime. Contraindicated to Hypersensitivity to cephalosporins. Nursing
Page 33

A Case Study on Rheumatic Heart Disease RLE 50 Group 5

responsibilities are to assess the History Hepatic and renal impairment, lactation, pregnancy, Skin status, LFTs, renal function tests, culture of affected area, sensitivity tests

DISCHARGE PLAN NURSING PRIORITIES Enhance comfort and general well being Minimize complications Promote a positive emotional response Provide information regarding the disease condition. DISCHARGE GOALS Physical/psychological needs being met Complications prevented/resolved Patients understanding about his condition will widen.

M-EDICATION Instructed patient about the treatment regimen ordered by the doctors must be followed strictly and should not be stopped to prevent the aggravation of the condition. The full course should be followed. Explained the proper drug dosage and time of intake and as much as possible comply with the drug regimen. Informed the client about the possible side effects of the medication. Encouraged the client to report or inform the physician, if any of these side effects occur. Informed and explained to the client in simple terms that the other drugs, such over the counter drugs that she is taking, will probably have other effects of the medication given moreover emphasize the right of timing or taking the right interval of these drugs to maximize its effects and avoid further complications Provided information for better understanding regarding the therapeutic regimen. E-XERCISE Encourage the patient to have an active and passive ROM because it will promote blood circulation and to improve muscle strength in order to promote total range of motion. Instructed the patient to stay in a calm and clean environment as much as possible to free patient from stress.

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 Planned your daily activities around the times when you feel more energetic. These periods are usually in the morning or after a nap. T-REATMENT/ T-HERAPY Instructed patient to consult the physician first if what activities must she avoid or put into limits. Encouraged patient for the compliance of medication regimen to promote optimal health. Stress the importance of taking medications in a correct dosage, timing, and route. Lifestyle changes often help you continue your daily activities

H-EALTH TEACHINGS/ H-YGIENE Importance of personal hygiene to prevent infection. Intake of nutritious foods like, vegetables and fruits and intake of foods that is rich in protein such as meat, fish, egg etc. to promote fast healing. Strict compliance of medication regimen to promote wellness. Report immediately to the physician if any unusualities occur. Explain to the significant others the precaution, patients diet and signs and symptoms of the disease. Discouraged patient to participate in strenuous activities that might precipitate stress. Wash your hands often; keep them away from your face. Most germs are spread by hand-to-mouth contact. O-UTPATIENT Reminded patient and the family members to return to Northern Mindanao Medical Center Out Patient Department for follow up check up 1 week prior to discharge. Encouraged patient to visit regularly to the nearest Health Center in to the nearest health care facility. D-IET Eats foods low in cholesterol, saturated and salt. Make sure that the diet is well-balanced and contains plenty of fiber like vegetables, fiber and fruits. Eat a variety of foods from the five different foods groups to supply your body with the nutrients it needs. S-PIRITUAL Always ask God for guidance in everything especially with her condition. Praying also for all the people who are helping her with her ups and downs.

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CONCLUSION AND RECOMMENDATIONS Rheumatic heart disease is a condition involving permanent damage to a person's heart. It is cause by many factors. Knowing the precipitating factors leading to the development of this health problem, people should have an extra care when it comes to health.

Giving care to a patient whether a medical case or surgical case makes no difference. Rendering care to everyone who needs it is a real sense of responsibility. In making this case study, we were able to work the best we can be because this may help for the patients coping strategy regarding his/her condition by encouraging them either medical or nursing management or also we help them enable for better understanding towards therapeutic regimen. On the other hand, this study also helps us enhance our capability for future nurses and helps us obtain more knowledge.

We can say that nursing is significant therapeutic and dynamic process. It is therefore significant for the nurse caring for the patient to whole-heartedly understand what he/she is doing like in carrying out some basic skills in relation to identified goals, comfort and care, interventions and prevention of illness.

RELATED LEARNING EXPERIENCE

Related Learning Experiences (RLEs) are teaching-learning opportunities designed to develop the competencies of students utilizing processes in various health situations. These could be sourced from, but not limited to: lying-in clinics, schools, industrial establishments, community, out-patient clinics and general and specialty hospitals.

Our learning throughout the first year has been helped by an unerring optimism in the value of nursing, and an appreciation that each and every daily interaction augments our experienced. This enthusiasm, however, has caused an inhibitory effect on our self-directed researching, and created conflict in some placement areas. While developing our role as a nurse, our activities as a person at home and beyond have diminished, as we attempt to adjust to the demands of both domains. We resent distracting influences, and frequently domestic pressures restrain our desired pace to accumulate factual knowledge. As described by Palmer & Spouse, your learning can oscillate between two extremes, all or nothing, depicts the student nurses need to develop multi-tasking skills
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emotionally, mentally and physically as they are caught between the cultures of clinical areas, peer-driven University life and home. The conflicts arising from these settings create a disharmony, which we believe for some, may undermine nursing as a career choice.

Although many have agreed that the student nurses are very effective in delivering their duties and responsibilities in the clinical areas, there should still be improvement in the learning scheme of the education provider because there is no room for mistakes in the medical profession because it deals with a very fragile thing-life- and a single mistake may cause an enormous damage which is death. The students must be prepared and trained well before their exposure in the clinical areas so as not to commit error.

The competence of a future nurse is evaluated by evidence-based documents, instructors, mentors assignment and examination results and is based on a continuum of regular assessments. The learning experience of a student nurse remarkably influences own practice in clinical areas, as well as the performance level of the student in academic matters.

Our experience during this rotation adds up not just to our knowledge, but to our personality, as well. Our duty days was not that easy as others think of, but when we see our patient free from the pain, and hearing their appreciation to every care we gave, has enlightened us despite the very toxic day. And our learning will always be anchored with the support, guidance, and teachings of our Clinical Instructor, Sir Hammed Leo Fabre. We thank you for the knowledge you have shared on us. And to the Group 6 RLE 50, for their cooperation during the making of this case study, we know that we can make it as long as we have that determination to finish it.

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DEFINITION OF WORDS
Streptococcus (Streptococcus pyogenes, or GAS) - is a form of -hemolytic Streptococcus bacteria. It is a gram positive bacterium responsible for a wide range of both invasive and non-invasive infections.[1] The name derives from the Greek word 'streptos,' meaning 'twisted chain,' due to the fact that the bacterium resembles a string of small pearls when viewed under the microscope. Dyspnea - , shortness of breath (SOB), or air hunger, is the subjective symptom of breathlessness. Orthopnea - is shortness of breath which occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair. Hepatomegaly - is the condition of having an enlarged liver. Ascites - is a gastroenterological term for an accumulation of fluid in

the peritoneal cavity. Cardiac cirrhosis - is a liver condition caused by chronic heart failure. In patients with this condition, the liver is damaged as a result of interruptions to the blood flow, and fibrous deposits begin to develop. Portal vein- a vein that collects blood from one part of the body and distributes it in another through capillaries; especially : a vein carrying blood from the digestive organs and spleen to the liver

Crackles, crepitations, or rales - are the clicking, rattling, or crackling noises that may be made by one or both lungs of a human with a respiratory disease during inhalation. They are often heard only with

a stethoscope ("on auscultation"). Bilateral crackles refers to the presence of crackles in both lungs. Autoimmunity - is the failure of an organism in recognizing its own constituent parts as self, which allows an immune response against its own cells and tissues.
Ventricular dilation nothing but increase in the diameter of the chamber of the heart.

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REFERENCES

Joyce M. Black

& Jane Hokanson Hawks Medical-Surgical Nursing: Clinical

Management for Positive Outcomes (Single Volume), 7th Edition

Brunner and Suddarth's Textbook of Medical Surgical Nursing: In One Volume (Brunner & Suddarth's Textbook of Medical-Surgical Nursing)

NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions

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