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

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)

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.

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 medications given, its classification, indications, contraindication and

side effect and thoroughly understand its significance.

know problems from the clients 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 clients 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 clients disease and prevent further
complication.

Understand the clients 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 Gordons 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.

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)

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

prolapse,

moderate

Disease
Mitral

with

Mitral

and

Regurgitation, mild aortic Regurgitation

valve

Tricuspid

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

Family History:

The family of client SQ has history of heart problems. Clients grandfather on her fathers
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.

CHAPTER V

PHYSICAL ASSESSMENT

SYSTEMS

INSPECTION

PALPATION

ASSESSED
SKIN

Brown in color

Warm to touch

Skin looks shiny Pitting edema

on

the

part

swollen

(Moderate +2)

(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 bodys

complexion
HAIR

Black in color

Straight

Evenly distributed

Thick

Lice and nits

Coarse

noted
EYES

Dry

Round
Watery eyes
Clear and bright

Iris

Black in color
Shape: Circular

10

PERCUSSION

AUSCULTATION

SYSTEMS

INSPECTION

PALPATION

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

(Hirschbergs

center of each

test)

cornea

[Shine light
directly in clients
eyes, note
position of the
light reflection off
the cornea in
each eye.]

11

PERCUSSION

AUSCULTATION

SYSTEMS

INSPECTION

PALPATION

ASSESSED
EARS

External ear is
consistent with
skin color

Warm to touch
Soft and nontender

Symmetrical (in
line with the
eyes)
Voice
whisper test

Client states
she was able to
hear clearly

NOSE

Symmetrically
on the midline
of the face
Nares patent

Nasolabial
fold
MOUTH

Present
bilaterally
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
12

PERCUSSION

AUSCULTATION

SYSTEMS

INSPECTION

PALPATION

PERCUSSION

AUSCULTATION

ASSESSED
NECK

Neck is
symmetrical
with the head
in a central
position
Midline

THYROID
GLAND

Thyroid tissue
moves up with
swallowing

Sternocleidomastoid

Able to move
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

bodys
complexion

Nipples

Flat
Brown in color

Areola

Brown in color

RESPIRATORY
SYSTEM

ANTERIOR
CHEST

Asymmetrical

Skin intact

Bronchial

rise and fall

breath sound

when

is loud and
13

breathing

SYSTEMS

INSPECTION

high pitched;

PALPATION

PERCUSSION

AUSCULTATION

ASSESSED
ANTERIOR
CHEST (contd.)

Inspiration is

Heard over

longer than

trachea

expiration
Skin color is
consistent with
body color
POSTERIOR
CHEST

Anteroposterior

Respiratory

diameter is less

excursion:

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
VASCULAR
SYSTEM

Blood Pressure:
70 / 30
Skin color on
hands: pallor

Legs: warm to
touch, painful
when touched
Capillary return:
3 4 seconds
Edema on
lower legs, feet,
and hands
Tight skin on
edematous site
14

Resonance:
hollow

 (lower legs,
feet, hands)

SYSTEMS

INSPECTION

PALPATION

PERCUSSION

AUSCULTATION

ASSESSED
CARDIOVASCULAR

Blood Pressure:
70 / 30

Capillary return:
3 4 seconds

PMI (Point

Heart rate :

of

93 beats per

Maximal

minute

Impulse)

GASTROINTESTINAL

ABDOMEN

Color is the same

with the body

No palpable
mass noted

sounds heard
as intermittent

Contour: Sym-

gurgling sound

rounded

RINARY

sound

Borborygmic

complexion

metric and slightly

GENITOU-

Tympany

Urinary Output: 2
3 times a day
Oriented to time
and place
Facial grimace:
frowning
Speech: talking
slowly (easily
tired)
Corneal Light
Reflex: light seen
symmetrically on
15

both eyes

SYSTEMS

INSPECTION

PALPATION

ASSESSED
NEUROLOGICAL

Gait: Weakness;
unable to walk
upright

CHAPTER VI

16

PERCUSSION

AUSCULTATION

NURSING ASSESSMENT

Gordons 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
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.

17

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 health Ineffective health Medium 1

ko magpa

maintenance

maintenance

r/t

Health
threatening since

injection

inadequate

not

kay

health

the health of the

mahadlok

information

ko (I am

awareness

scared of

or

maintaining

client can make

her
worse.

injection)
as
verbalized.

18

illness

19

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.
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 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
20

Cues

Inference

Nursing

Priority

Rationale

Diagnosis

Subj:

Imbalanced

Imbalanced

High 4

It is Health deficit

Obj: observed

Nutrition less

Nutrition less

It is second high

leftover food

than body

than body

priority since

about of food

requirements

requirements r/t

maintaining a

served

lack of interest in

good nutrition

BMI 15.5

food due to chest

give vitality and

pain

energy for life

and it help beat
tiredness and
fatigue.

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
Diagnosis

21

Priority

Rationale

Subj: hapdos

Altered urinary

Altered urinary

kung mangihi

elimination

elimination r/t

It is third

ug dili nako

pain upon

priority

mapugngan (I

urinating

since

High 3

Life Threatening and

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
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.

22

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

namo gipadula

intolerance

intolerance r/t

since oxygen has

ky hangakun ug

imbalance

a vital role in the

sakit iyahang

oxygen supply

body particularly

High 2

Life threatening,

dughan.(we limit

in the respiration

her to play

and circulation.

because she feel

(Monahan 2010)

shortness of
breath and pain
in her chest)

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

23

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.
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

katulog ug

Pattern

Pattern r/t noise

Medium 1

Health
threatening

tarung kay

since the client

daghan tao( I

need enough

cannot sleep

sleep for her fast

right because

recovery, if

there are many

client is weak

people).

her recovery is

Obj: observed

slow or it can

24

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
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
kaayu akong

Altered comfort

Altered comfort
r/t chest pain

High 1

It is the highest
priority because

dughan, lisud

it is life

mag ginhawa

threatening

pati akong tiil

since pain is not

gasakit

a simple

Obj:

sensory

P- 8 out of 10

experience but
25

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
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
cant 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

pareha sa uban

self esteem

self- esteem r/t

crisis since the

role changes

client condition

mabuhat ang
tanan pero

Low 2

Foreseeable

alters her usual

26

nahadlok ko (I

activities to be

want to be like

like other people

other people that

does.

can do whatever
they want but I
am scared)
Obj: observed
worried and
unhappy,
Quite

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 clients 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 clients brother. Client SQ observed smiling.

27

Role-Relationship Pattern
Cues

Inference

Nursing

Priority

Rationale

Diagnosis
Subj: okay ra

Readiness for

kayo sa akoa

Enhanced

crisis since the

mgbantay sa

Family

family process of

akong manghud

Processes

the family are

Low 4

Foreseeable

bisag busy(it

very supportive

really ok for me

to one of their

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
Diagnosis

No problem
identified

28

Priority

Rationale

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
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

muhilak mogaan

Enhanced

helping each

akong paminaw

Coping

other to cope the

Low 5

Client and family

(when I cry I feel

feeling of their

better)

family member
by giving her full
support, and love

11. Value-Belief Pattern

29

Client SQ and her family believe and have faith in God. They always pray for the fast
recovery of clients condition. They also consult to hilot and albularyo because they also
believe that it can help in her condition.
Upon assessment, according to clients stepmother they follow what the doctors order
for her fast recovery. And she also stated that, Si God naga guide namo sa kanunay.
Value-Belief Pattern
Cues

Inference

Nursing

Priority

Rationale

Diagnosis

Sbj: si God na

Readiness for

gaguide man

Enhanced

readiness to

namo kanunay

Spiritual-Well

develop her

as verbalized.

Being

spiritual aspect

Low 6

Client shows

(God us

to boost her

always).

spirituality that
will assist her to
cope with
situation.

30

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
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
31

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
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

32

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

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.
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 persons 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.

33

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 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

34

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.

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.

35

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
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.

36

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.
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 )

Precipitating factors:

Predisposing factors:

Age (14 years old)

Health seeking behavior

Gender (female)

Hygienic practices

Environment

Recent travel

Recurrent infection (tonsillitis)

Streptococcal infection
Increased WBC
(POE: Upper Respiratory Tract)

Increased production of
antigens

Bind receptors in the

synovial joints

Antigen circulated to the

system

Auto-immune
response

Antigens are similar to

bodys own cell that may
result o attack of healthy
body cells by mistake.

Autoimmune response attack the

heart valves

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

fainting

fever

headache

Rheumatic Heart Disease

39

Body
weakness

CHAPTER lX

Medical Management

Date
Aug. 09,14
5:10 pm

Doctors Order

Significance

-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

Doctors Order

Significance

al, Nutrition and Diet Therapy. P.

366. 8th edition).
Laboratory
-CBC

Abnormal increases or decreases

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.

41

(m.betterhealth.vic.gov.au)
-Chest-PA

To provide important information

regarding the size, shape,
contour, and anatomic location of
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.

42

-gentamicin

To treat infection that caused by

streptococci bacteria.

-aspirin

For the relief of mild to moderate

pain including rheumatic pain
sciatica. (Deglin, Vallerand.
Nurses Pocket Pharmacology
Guide.2009).

-prednisone

Suppression of inflammation,
modification of the normal immune
response.
(Deglin, Vallerand. Nurses 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.
Nurses Drug Handbook 6th
edition).

-monitor v/s q 1

The client needed to be monitored

strickly because she had a chest

43

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
9:45pm

Cardiology

-If dobutamine is not

available, start dopamine
drip 200/250cc to run
30cc/hr BP- 70/30
-hold Gentamycin for now
hold prednisone

Dobutamine was not given.

It was ordered to hold the

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.

44

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

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
clients condition has improved
regarding chief complain during
admission.

45

-IVF to KVO please

The client was having an edema

thats 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 clients 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.

-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.

46

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
QUANTITATIVE
DIMENSION
LV (ed)
LV (es)
RV(ed)

PATIENT
4.47 cm
2.63 cm
3.08 cm

NORMAL
(4.5-5.0)

LA (es)
RA (es)

3.24 cm
3.86 cm

(3.0-3.5)
(3.5-4.5)

(2.2-4.0)

FUNCTION
LVEDV
LVESV
STROKE
VOLUME
CO
CI
47

PATIENT
90.99 ml
25.36 ml
65.63 ml
6.69 l/min

NORMAL

AORTA

2.08 cm

(3.5)

Ejection
fraction %

PA
IVS (ed)

2.01 cm
0.71 cm

(3.0-4.0)
(0.8-1.1)

IVS (es)
LVPW (ed)

1.04 cm
0.71 cm

LVPW (es)

1.5 cm

(0.8-1.1)

LVET

VCF
(CIR/SEC)
EPSS
Wall Stress
(S)
Wall Stress
(5)
Rhythm

72.1 %

(55.0-77.0)

42.1

(20-42 %)
(0.8-1.5)

0.25 cm

(<=1.0)
(<195)
(<600)

SPECTRAL & COLOR FLOW DOPPLER

VALVE

VELOCITY
M/SEC

AORTIC
MITRAL
TRICUSPID
PULMONIC
PAT

1.73
2.01/2.38
1.25/0.62
1.27
1.44

PEAK
GRADIENT
mmHg
11.97
15.99/22.69
6.25/1.52
6.43

ORIFICE AREA
cm2

REGURGITATION
%

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:
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
48

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
REMARKS
ALT

RESULT

15.

REFERENCE VALUES

U/L

9-52

ROENTGENOLOGICAL REPORT

Date: 08-10-14
CHEST PA

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:
49

Within Normal Range

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

REMARKS

15.7

REFERENCE
VALUE
M 140-170 g/L
F 120-140 g/L
M 0.40-0.50 %
F 0.37-0.43 %
4.5-5.5x10^12/L

Hemoglobin Mass
Concentration
Erythrocyte Volume
Fraction
Erythrocyte Number
Concentration

125

Leucocyte Number
Segmenters

0.79

0.55-0.65

High Segmenters
means infection or
inflammation

Stab
Eosinophils

0.04

0.02- 0.06
0.02-0.04

Lymphocytes

0.17

0.25-0.25

324

0.03-0.06
0.00-0.10
140-440x10^9/L

Monocytes
Basophils
Platelet count

0.40

50

Within Normal
Range
Within Normal
Range
High Erythrocyte
Number
Concentration
means that the heart
is not able pump
blood efficiently
resulting in decrease
amount of oxygen
getting into the
tissues

Within Normal
Range
Low Lymphocytes
means infection or
inflammation

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:
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 mu

Contraindication:

51

Contraindicated in: Previous hypersensitivity to penicillins (crosssensitivity 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.

52

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:
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

53

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.

54

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:
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
55

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)

56

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.

Dosage:
20 mg 1 tab BID

Contraindication:
Contraindicated with infections, especially tuberculosis, fungal
infections, amebiasis, vaccine and varicella, and antibioticresistant infections.

Adverse effects:
57

GI: anorexia, nausea, vomiting

Misc: Moon face, buffalo hump

Derm: Acne, slow wound healing, petechiae

Nursing Responsibilities:

Verify doctors 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).

58

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

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)

59

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.

60

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

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
61

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.

62

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

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
63

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:
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

64

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
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)

65

Activity

High 2

It is Health Threatening

Intolerance r/t

It is second

imbalanced
high priority

oxygenation
supply

since
maintaining
proper
oxygenation
endure or
complete
required or
desired daily
activities, and
give vitality and
energy for life
and it help beat
tiredness and
fatigue.

Disturbed sleep

High 3

Health Threatening and

pattern r/t chest

It is third

pain secondary
to noise

priority since

66

having enough
hours of sleep
is vital for fast
recovery and it
can help feel
energetic and
relaxed.

67

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, Nurses 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

Verbalize sense of comfort

Participate in desirable and realistic health-seeking behaviors.

Nursing Intervention

Rationale

Determine the type of discomfort the

client is experiencing

To assess further and give proper

intervention

Ascertain locus of control

68

Presence of external locus of control

may hamper efforts to achieve sense of

peace or comfort

Discuss concerns with client and active-

listen to identify underlying issues

needs, ability to change own situation

Determine how client is managing pain

and pain components

Help to determine clients specific

Lack of control may be related to other

issues

Assess clients understanding towards

her situation and her methods of

To give further assistance and health

teaching in managing present condition

managing condition

Review knowledge base and note coping

skills that have been used previously to

Brings clients awareness and promotes

use in current situation

change behavior and promote wellbeing

Discuss activities to promote ease such

as

breathing

exercise,

therapeutic

To promote ease and relaxation and

refocus attention

massage

periods when

To maximize participation

Establish realistic activity goals with

Enhances

Schedule activities for

client has the most energy

client

like

breathing

exercise

and

commitment

optimal outcomes

avoiding aggravating factors

Dependent

69

To relieve pain

to

promote

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.

70

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 weve
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.

71

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.

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

72

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 Alcovers 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,
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.

73

Chapter XVII

Bibliography

Black, 2009
Deglin, Vallerand. Nurses Pocket Pharmacology Guide
Delmar, C..pp. 215-721.2008
Doenges, Marilynn, et al.Nurses 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

74

Kozier, et al. Fundamental of Nursing, 2012

Roth, et al..Nutrition Diet Therapy. Pp 366, 8th edition
Schull, Patricia Dewyer/ Nurses Drug Handbook 6th edition-United States
Timby and Smith. Introductory Medical Surgical Nursing. 8th edition 2010. Pp.1004

www.mayoclinic.com

Internet sources:

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

www.scrib.com

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

www.DOH.gov.ph
www.health.harvard.educ
www.m.betterhealth.vic.gov.au

APPENDICES
75

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

76

 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.

77

78

79

TERMS

80

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

81

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

- Potassium

SVC

- Superior Vena Cava

TID

- Thrice a Day

VS

- Vital Sign

- Every

IV

- Intravenous

Cc

- Cubic Centimeter

KVO

- Keep Vein Open

PO

- Per Orem

RBC

- Red Blood Cell

82

WBC

- White Blood Cell

PA

- Physician Assistant

RHD

- Rheumatic Heart Disease

Documentation

August 23, 2013

Silwy -8 , Brgy. Luwalhati, Polomolok South Cotabato

83

August 30, 2014

Second Home Visit

84

September 26, 2014

Case Study Making
School Library

85

Curriculum Vitae

Name: Angelica Joy L. Jovenal

Nick Name: Jela
Age: 23
Birthday: October 23 1991
Place of Birth: Olangapo City
86

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

Motto in life: Look before you leap

Curriculum Vitae

Name: Jennifer L. Tavella

Nick Name: Jenny
Birthday: May 11, 1978
Place of Birth: Davao City
Address: Fatima ,Uhaw General santos City
87

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

the bitterness of ignorance

Curriculum Vitae

Name: Vea Lorry Danuya

Nick Name: Yang
Age: 18
Birthday: April 10, 1996
Place of Birth: Tagum , Davao del Sur
88

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

Name: Wencel A. Porras

Nick Name: Wnez
Age: 27
Birthday: July 17, 1987
Place of Birth: Oroquieta City, Misamis Occidental

89

Address: Blk. 32, Lot 13, Sarangani Province

Motto in life: Adapt and Overcome

Curriculum Vitae

Name: Vinazer Piang

Nick Name: Vina
Age: 18
Birthday: June 4, 1996
Place of Birth: Cotabato City
90

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

Motto in life: Everythings happen for a reason

Curriculum Vitae

Name: Jhomar L. Onio

Nick Name: Pj
Age: 24
Birthday: March 15, 1990
Place of Birth: Penaplata, Island Garden City of Samal
91

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

Motto in life: I simple love to be Original

Curriculum Vitae

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
92

Motto in life: It is what it is

Curriculum Vitae

Name: Joy P. Bugas

Nick Name: Joy-Joy
Age: 22
Place of Birth: General Santos City
Address: San Francisco St, Cahilsot Village, Calumpang,
93

General Santos City

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

94