The Next The Next

Sequel: Sequel:
ScaRRing My ScaRRing My
HEART HEART
A Case Presentation
on
Rheumatic Heart
Rheumatic Heart
Disease
Disease
by RLE - 33
Xeon Kristian Bonifacio Xeon Kristian Bonifacio
Angelica Benito Angelica Benito
Kathleen Diones Kathleen Diones
Fritzie Ann Furigay Fritzie Ann Furigay
Maria Kristina Mora Maria Kristina Mora
Ma. Enrica Pattaguan Ma. Enrica Pattaguan
Glaiza Polingday Glaiza Polingday
Serianne Soriano Serianne Soriano
Princess Mae Torres Princess Mae Torres
ntroduction
!heu"atic #eart Disease
Rheumatic heart disease is an inflammatory disease which may develop after
a Group-A streptococcal infection (such as strep throat or scarlet fever) and can
involve the heart, joints, skin, and brain. t commonly appears in children a!es "
throu!h #".
Rheumatic heart disease primarily affects children between a!es $ and #"
years and occurs appro%imately &' days after strep throat or scarlet fever. n up to
a third of cases, the underlyin! strep infection may not have caused any symptoms.
(he rate of development of rheumatic fever in individuals with untreated
strep infection is estimated to be )*. (he rate of development is far lower in
individuals who have received antibiotic treatment. +ersons who have suffered a
case of rheumatic heart disease have a tendency to develop flare-ups with repeated
strep infections.
(he recurrence of rheumatic heart disease is relatively common in the
absence of maintenance of low dose antibiotics, especially durin! the first three to
five years after the first episode. ,eart complications may be lon!-term and severe,
particularly if valves are involved.
Diagnosis$ "odified %ones criteria
(. -uckett .ones, /-, first published these criteria in #011. (hey have been
periodically revised by the American ,eart Association in collaboration with other
!roups. (wo major criteria, or one major and two minor criteria, when there is also
evidence of a previous strep infection, support the dia!nosis of rheumatic heart
disease.
Ma&or criteria
%oints (/i!ratory polyarthritis)2 a temporary mi!ratin! inflammation of the
lar!e joints, usually startin! in the le!s and mi!ratin! upwards.
' 3ima!ine heart-shaped 45 (6arditis)2 inflammation of the heart muscle
which can manifest as con!estive heart failure with shortness of breath,
pericarditis with a rub, or a new heart murmur.
(odules (subcutaneous nodules - a form of Aschoff bodies)2 painless, firm
collections of colla!en fibers on the back of the wrist, the outside elbow, and
the front of the knees. (hese now occur infre7uently.
Erythema mar!inatum2 a lon! lastin! rash that be!ins on the trunk or arms
as macules and spread outward to form a snakelike rin! while clearin! in the
middle. (his rash never starts on the face and is made worse with heat.
Sydenham8s chorea (9t. :itus8 dance)2 a characteristic series of rapid
movements without purpose of the face and arms. (his can occur very late in
the disease.
Minor criteria
;ever2 temperature elevation
Arthral!ia2 .oint pain without swellin!
<aboratory abnormalities2 increased =rythrocyte sedimentation rate,
increased 6 reactive protein, leukocytosis
=lectrocardio!ram abnormalities2 a prolon!ed +R interval
=vidence of Group A 9trep infection2 positive culture for Group A 9trep,
elevated or risin! Antistreptolysin 4 titre
+revious rheumatic disease or inactive heart disease
'ther signs and sy")to"s
Abdominal pain
>osebleeds
Treat"ent
(he mana!ement of acute rheumatic heart disease is !eared toward the
reduction of inflammation with anti-inflammatory medications such as aspirin or
corticosteroids. ndividuals with positive cultures for strep throat should also be
treated with antibiotics. Another important cornerstone in treatin! rheumatic heart
disese includes the continuous use of low dose antibiotics (such as penicillin,
sulfadia?ine, or erythromycin) to prevent recurrence.
nfection
+atients with positive cultures for streptococcus pyogenes should be treated
with penicillin as lon! as aller!y is not present. (his treatment will not alter the
course of the acute disease.
nfla""ation
+atients with si!nificant symptoms may re7uire corticosteroids. 9alicylates
are useful for pain.
#eart failure
9ome patients develop si!nificant carditis which manifests as con!estive
heart failure. (his re7uires the usual treatment for heart failure2 diuretics and
di!o%in. @nlike normal heart failure, rheumatic heart disese responds well to
corticosteroids.
Physical$ +hysical findin!s in a patient with rheumatic heart disease include cardiac
and noncardiac manifestations of acute rheumatic fever. 9ome patients develop
cardiac manifestations of chronic rheumatic heart disease.
6ardiac manifestations of acute rheumatic heart disease2
+ancarditis is the most serious and second most common complication of
rheumatic heart disease ("'*). n advanced cases, patients may complain of
dyspnea, mild-to-moderate chest discomfort, pleuritic chest pain, edema,
cou!h, or orthopnea.
4n physical e%amination, carditis is most commonly detected by a new
murmur and tachycardia out of proportion to fever. >ew or chan!in!
murmurs are considered necessary for a dia!nosis of rheumatic
valvulitis.
9ome cardiolo!ists have proposed that echo--oppler evidence of
mitral insufficiency, particularly in association with aortic insufficiency,
may be sufficient for a dia!nosis of carditis (even in the absence of
accompanyin! auscultatory findin!s)A however, !iven the sensitivity of
modern -oppler devices, this remains controversial.
4ther cardiac manifestations include con!estive heart failure and
pericarditis.
+atients in whom the dia!nosis of acute rheumatic fever is made
should be e%amined fre7uently because of the pro!ressive nature of
the disease.
>ew or chan!in! murmurs2 (he murmurs of acute rheumatic fever are
typically from valve insufficiency. (he followin! murmurs are most commonly
observed durin! acute rheumatic fever2
Apical pansystolic murmur is a hi!h-pitched, blowin!-7uality murmur
of mitral re!ur!itation that radiates to the left a%illa. (he murmur is
unaffected by respiration or position. ntensity varies but is !rade &B$
or !reater. (he mitral insufficiency is related to dysfunction of the
valve, chordae, and papillary muscles.
Apical diastolic murmur (also known as a 6arey-6oombs murmur) is
heard with active carditis and accompanies severe mitral insufficiency.
t is related to relative mitral stenosis, as the lar!e volume of
re!ur!itant flow recrosses the mitral valve durin! ventricular fillin!. t
is heard best with the bell of the stethoscope, while the patient is in
the left lateral position and the breath held in e%piration. (his murmur
is low pitched, rumblin!, and resembles the roll of a distant drum.
Casal diastolic murmur is an early diastolic murmur of aortic
re!ur!itation and is hi!h-pitched, blowin!, decrescendo, and heard
best alon! the ri!ht upper sternal border after deep e%piration while
the patient is leanin! forward.
6on!estive heart failure
,eart failure may develop secondary to severe valve insufficiency or
myocarditis.
(he physical findin!s associated with heart failure include tachypnea,
orthopnea, ju!ular venous distention, rales, hepatome!aly, a !allop rhythm,
and peripheral swellin! and edema.
+ericarditis
A pericardial friction rub indicates that pericarditis is present.
ncreased cardiac dullness to percussion and muffled heart sounds are
consistent with pericardial effusion.
A parado%ical pulse (drop in systolic blood pressure with inspiration)
with decreased systemic pressure and perfusion and evidence of
diastolic indentation of the ri!ht ventricle on echocardio!ram reflect
impendin! pericardial tamponade. n this clinical emer!ency,
pericardial effusion should be treated by pericardiocentesis..
6ardiac manifestations of chronic rheumatic heart disease2 :alve deformities,
thromboembolism, cardiac hemolytic anemia, and atrial arrhythmias are the
most common cardiac manifestations of chronic rheumatic heart disease.
Patient*s Profile
>ame2 /r. .ones
9e%2 /ale
A!e2 ")
-ate of Cirth2 -ecember &$, #0"1
+lace of Cirth2 :illasis, +an!asinan
Address2 sabela
6ivil 9tatus2 /arried
>ationality2 ;ilipino
4ccupation2 +oliceman
Reli!ion2 Roman 6atholic
-ialect2 lokano, (a!alo!, =n!lish, Dbana!
=ducational Attainment2 6olle!e Graduate (C.9. in 6riminolo!y)
-ate of Admission2 -ecember #), &''E
(ime of Admission2 12&' +./.
+lace of Admission2 9aint +aul ,ospital
Attendin! +hysician2 -r. :aleriano 6ombate
6ase >umber2 ))0F
-iet2 -A(
Admitted per2 ambulant
6hief 6omplaint2 difficulty of breathin! (-4C)
Admittin! -ia!nosis2 Rheumatic ,eart -isease (R,-)
;inal -ia!nosis2 Rheumatic ,eart -isease (R,-)
nitial :ital 9i!ns2
(emperature2 )$.1
'
6
+ulse Rate2 "F bpm
Respiratory Rate2 )&cpm
Clood +ressure2 #''BE' mm,!
(ursing #ealth #istory
#istory of Present llness
<ast -ecember F, the patient was confined at 9aint +aul ,ospital, (u!ue!arao
6ity. (wo days before admission, he had -4C, chest pain and productive cou!h.
Cecause of persistent -4C, he was brou!ht to the said hospital. ,e underwent =6G,
chest %-ray, 6C6 and 6rea, >a and G e%amination durin! his confinement. ,e took
the same dru!s just like his home medication such as Galium -urule. After ) days
of confinement, he was dischar!ed. ,is condition improved.
-urin! the ni!ht of -ecember #&, &''E, he canHt sleep well because of -4C.
,e panted e%tremely. ,e canHt really sleep whatever he did. ,e sat, stood then lied
on bed yet he canHt really sleep. ,is wife placed 1 pillows on his back but still the
-4C was not relieved. n addition to this, he had sharp, stabbin! chest pain. (o
ease the pain, his wife massa!ed his chest yet nothin! happened. ,e still had -4C,
chest pain and panted as well. 6onse7uently, his wife !ave him -iumide-G.
;ortunately, his complaints were relieved. ,e was able to sleep at )2'' am.
,owever, on the ne%t day at e%actly #'2'' am, he had episodes of -4C a!ain. (his
time he was not able to endure the difficulty anymore. ,e was just sittin! but all of
the sudden he had dyspnea. (his prompted his wife to brin! him back to the
hospital. At first, he was brou!ht to /ila!ros -istrict ,ospital, sabela. ,owever, he
was not admitted in the said hospital. (hus, he was immediately brou!ht to 9aint
+aul ,ospital, (u!ue!arao 6ity ridin! in an ambulance.
#istory of Past llness
(he patient had completed all his vaccinations (C6G, 4+:, -+(, anti-
measles). Ihen he was #& years old he had tonsillitis. /oreover, it had recurred yet
he was not truly aware of it. (he said disease lasted for ) days only. ,ence, he
i!nored it. ,e had his first hospitali?ation in the year #00". ,e had appendicitis.
(hus, he was confined and had under!one Appendectomy at +rovincial ,ospital,
la!an, sabela. (his had left a si%-inch scar on his abdomen. -urin! this, time it
was known that he had peptic ulcer. <ikewise, a chest %-ray revealed that he had
enlar!ement of the heart. n .une &''1, he was hospitali?ed at /ila!ros -istrict
,ospital, sabela for & times because of -4C and peptic ulcer. At first, he was
dia!nosed with asthma. ,owever, based on further findin!s it was not asthma
instead it was R,-. ,e was confined there for " days. 9ince the said hospital still
lacked with facilities, he decided to transfer in another hospital. ,e was brou!ht to
6:/6 and it was confirmed that he had R,-. 6onse7uently, after another " days of
confinement in the latter, he had his monthly check-up with his physician
(cardiolo!ist). /oreover, he was prescribed with home medication. ,e went for
monthly injection of Cen?yl +enicillin #'''@. =very after ) months, he had his >R.
<ast 9eptember #1, he was hospitali?ed a!ain at 9+, for 1 days because of
-4C. After his confinement, his condition had improved. ,owever, startin! on
>ovember &0, &''E, he had difficulty in sleepin! because of dyspnea. (his -4C
persisted until he was hospitali?ed a!ain durin! the month of -ecember.
Fa"ily #eath #istory
(he patient has a known history of heart disease in his family. ,is mother
died because brain tumorBcancer. <ikewise, throu!h chest %-ray it was revealed
that her heart is enlar!ed. ,ypertension is also considered as the prevailin! cause
of death of some of the patientHs relatives. <astly, the patientHs other relativesB
family members have asthma.
Gordon*s ++ Functional #ealth Pattern
#ealth Perce)tion,#ealth Manage"ent Pattern
Before #os)italization During #os)italization
JAn! kalusu!an ay mahala!a.K
J,indi ako maluso! kasi
nan!an!ayayat na.K
J9obran! nahihirapan ako sa
kala!ayan n! kalusu!an ko.K
Jniiwasan kon! ma!puyat.K
Jniiwasan ko din! ma!alit la!i
kasi kapa! na!a!alit ako
nahihirapan akon! humin!a.K
avoidance of bein! hot-tempered
weekly check-up
monthly injection (Cen?yl
+enicillin #''' @)
intake of medicine as ordered by
the physician
avoidance of foods hi!h in salt
and cholesterolBfats
nternational >ormali?ed Ratio
every after ) months
J9yempre mas mahala!a an!
kalusu!an n!ayon! !aniton!
naospital ako.K
J<alon! hindi ako maluso! kasi
sobran! pumayat at nahihirapan
na ako.K
J>a!-iba an! pakiramdam ko,
lalon! nahihirapan ako madalas
pan! maospital.K
Jniiwasan ko tala!an! ma!alit at
ma!nerbiyos la!i kasi lalo lan!
akon! nahihirapan! humin!a.K
J(initiis kon! kumain n!
mataban! at iniiwasan ko yun
may mataas na kolesterol.K
followin! the doctorHs order
compliance to the dru! re!imen
and treatment done
(utritional,Meta-olic Pattern
Before #os)italization During #os)italization
with poor appetite (walan! isan!
pin!!an n! pa!kain an! kinakain)
usually eats fried fish and
ve!etable which are cooked
tastelessly
eats ) times daily and rarely takes
snacks in between meals
loves eatin! ve!etable especially
with J!ataK
loves also to eat <akatan (banana)
sometimes he eats bulalo,
papaitan and sini!an! na baboy
with mi%ture of ve!etables
no food aller!ies
takes @ltima as a food supplement
the skin is not too warm and not
still with poor appetite (hindi
nauubos an! isan! pin!!an n!
pa!kain, most of the times
kalahati lan! an! nakakain)
eats ve!etable and fish which are
cooked tastelessly
eats )% daily
eats <akatan (banana) as a
dessert
the skin is warmer ()E.0L6),dry
and with edema particularly on
the le!s
drinks less water (&-) !lasses
daily)
usually eats fruits (!rapes, ponkan
and apple), cassava cake and
too cold at the same time it is
smooth and sli!htly moist
wound heals easily
drinks a lot of water
appro%imately F-#' !lasses
everyday
perspires easily even without
doin! anythin! or just sittin!
!ets hun!ry easily
drinks a lot but eats less when
tired
bread as his snacks
doesnHt perspire that much
!ets hun!ry easily
sometimes when he spits, a little
amount of blood is present
Eli"ination Pattern
Before #os)italization During #os)italization
9eptember (defecates with blood
(black tarry stool) because of his
peptic ulcer)
>ovember (bowel pattern !oes
back to normal-no blood is
e%creted)
defecates #-&% everyday with
yellow to brown stool
usually has diarrhea (defecates )-
1% daily with soft, yellow to brown
stool)
voids $% a day with dark yellow
urine
every voidin! measures &''-
&"'cc of urine
doesnHt use any la%atives and
devices for control
doesnHt have any difficulty in
voidin! and defecatin!
doesnHt control voidin! and
defecatin!
voids most of the times at
daytime
defecates #-)% daily with yellow to
brown but sometimes !reen to
black stool
voids $% everyday with dark
yellow urine measurin! &''cc
each voidin!
doesnHt use any suppositories and
devices for control
doesnHt control his ur!e to void or
defecate
voids or defecates as needed
defecates with dry and hard
yellow to brown stool for & days
but not consecutively
with loose bowel movement for #
day after havin! constipation
(defecates )% with soft, yellow to
brown stool)
voids usually durin! daytime
Acti.ity,E/ercise Pattern
Before #os)italization During #os)italization
fond of !amblin! (serves as his
recreation)
if heHs at home, he watches (:
and listens to music
sometimes he helps in cookin!
and doin! simple household
chores (fetchin! water-in small
amount only)
he !ets tired easily (J/insan
hinihin!al ako tapos nahihirapan
n! humin!a.K)
J/eron yun! time na kahit mali!o
lan! hinihin!al na ako.K
J,indi na ako !aanon! na!susu!al
at na!tatrabaho kahit simple lan!
kasi madali tala!a akon! hin!alin.
Gapa! na!pupuyat ako dahil sa
su!al, susumpun!in ako at
mahihirapan! humin!a.K
can do simple thin!s alone
listens to music
asks assistance in doin! thin!s
(A-<Hs and self-care activities-
toothbrushin!, chan!in!
clothes,washin! after defecation)
dependent to 94Hs
KGahit kapa! pumupunta lan! ako
n! 6R hinihin!al na ako at
nahihirapan! humin!a.K
JGahit n!a nakaupo lan! ako at
nakayuko hihin!alin na ako at
mahihirapan! humin!a.K
,e feels weak most of the times
even without doin! anythin!.
Slee),!est Pattern
Before #os)italization During #os)italization
JGulan! la!i an! tulo! ko.K
sleeps &-) hours only most of the
times (started on >ovember
&0,&''E)
J/insan alas-tres na n! uma!a
ako nakakatulo!.K
Iakes up at E2''am and
sometimes at F2''am
JGapa! uma!a, wala pan! # oras
an! tulo! ko paputul-putol pa.K
without ade7uate rest
canHt sleep well because of
difficulty of breathin! and chest
pain
doesnHt use any sleep aids or
routines
J<alon! kulan! an! tulo! ko
n!ayon syempre la!i akon!
!ini!isin! kapa! may iinumin!
!amot.K
9leeps for & hours only durin! the
whole day most of the times
J/edyo umayos lan! an! tulo! ko
nun! bini!yan ako n! pampatulo!
(Malpiden-9tilmo% #'m!() &
beses.K
J/adalas tala!a wala akon! tulo!
la!in! sinusumpon!, nahihirapan!
humin!a.K
usually sleeps at )2'' am and
sometimes he wakes up at
F2''am and sometimes at
02''am
at daytime he sleeps less than an
hour
J/adalas akon! nakaupo kapa!
wala akon! !ina!awa o kaya
kapa! na!papahin!a lan! kasi lalo
akon! nahihirapan! humin!a
kapa! nakahi!a.N
0ogniti.e,Perce)tual Pattern
Before #os)italization During #os)italization
@ses readin! eye!lasses
with !ood sense of hearin!, touch,
and smell
J/ataban! an! panlasa ko, kapa!
kumakain ako halos lahat n!
pa!kain na nalalasahan ko
mataban!.K
he has !ood memory, he
remembers thin!s easily
he feels pain easily
he asks his 94Hs to massa!e or
else apply =fficascent oil in that
area with pain
he can speak in =n!lish, (a!alo!,
Dbana! and lokano
he is insistent (ipinipilit an! isan!
dahilan o ba!ay kahit mali)
J,indi ako bi!laan kun!
ma!desisyon, hindi padalus-
dalos.K
JAko lan! an! na!dedesisyon.K
he stands firm on his decision
still uses readin! eye!lasses
nothin! chan!ed in his sense of
hearin!, touch and smell
J/ataban! pa rin an! panlasa ko.K
his memory is still !ood
he has !ood pain perception
if he is in pain, he lets his 94Hs
rub and massa!e that area with
pain
sometimes he applies =fficascent
oil in that area with pain
he speaks in =n!lish, (a!alo!,
Dbana! and lokano
he is still insistent (he fi!hts for
what he knows is ri!ht)
he decides on thin!s without
askin! assistance from his wife
Self,Perce)tion and Self,0once)t Pattern
Before #os)italization During #os)italization
he views himself as a hot-
tempered and impatient one
JAburido ako dahil sa kala!ayan
ko.K
J/a!alin! akon! kumain at
ma!trabaho noon, n!ayon hindi
na.K
JGaya ko pan! ma!piuyat kahit
papano.K
still he sees himself as hot-
tempered and impatient
he !ets an!ry easily
he is conscious of his body
(J9obran! payat ko na.K)
J<alon! hindi na ako ma!alin!
kumain at ma!trabaho n!ayon
la!i kasi akon! naoospital.K
J>!ayon hindi ko na tala!a
+asi!aw akon! ma!salitaAK
J/edyo okey pa katawan ko hindi
pa naman nakukuba.K
kayan! ma!puyat nahihirapan ako
n! sobra lalo na wala akon!
masyadon! tulo!.
J>erbiyoso tala!a ako, hindi ko
maiwasan! ma!salita nan!
pasi!aw.K
J/edyo nakukuba na n!a ako
n!ayon.K
most of the times he doesnHt
establish eye to eye contact when
talkin! to somebody
J/ahina na ako n!ayon.K
!ole,!elationshi) Pattern
Before #os)italization During #os)italization
most of the times he has
ar!umentation with his children
particularly the boys
he shows fatherly attitude to his
children
he attempts to fill or say sorry for
his shortcomin!s
he assumes that he can still be a
!ood father despite of his
weakness (physically and
physiolo!ically)
his family shows their all-out
support by takin! !ood care of
him and attendin! to all his needs
he deals well with his family,
however, at some point they have
misunderstandin!
he becomes close to his children
especially to the !uys
he feels sorry for bein! dependent
and weak
Se/uality,!e)roducti.e Pattern
Before #os)italization During #os)italization
circumcised at the a!e of $
views himself as a real man yet
Jmababaw an! luhaK
J/ahina na rin an!
pa!kalalaki.K(referrin! to
manhood)
with $ children (1 boys and &
!irls)
Jmatandan! lalakiK
J/ahina na an! akin!
pa!kalalaki.K (referrin! to
manhood)
Jwala n! amorK
Jwala n! karisma sa babaeK
0o)ing,Stress Pattern
Before #os)italization During #os)italization
doesnHt share his problem
(sinasarili)
he doesnHt think much of his
problem instead he diverts it into
recreational activities such as
!amblin!
he perceives his disease as a
problem
J,indi ako masyadon!
na!papaapekto sa problema,
pinapalipas ko lan! minsan pero
kun! kailan!an! harapin
hinaharap ko syempre.K
J>andiyan naman an! pamilya ko
kapa! nararamdaman nila an!
problema ko.K
he always thinks of his disease
he is bothered thinkin! how he
will !et well
he prays and asks God to cure his
disease
his family especially his wife is
always beside him !ivin!
Bprovidin! all his needs
1alue,Belief Pattern
Before #os)italization During #os)italization
he believes in !host and faith
healerB7uack doctor
he uses mesicinal plants such as
sambon! believin! that it can help
in treatin! his illness and he
believes that it is !ood for the
kidney
he doesnHt attend in mass durin!
9undays yet he believers stron!ly
in God
J/as matata! paniniwala ko sa
-iyos para pa!alin!in niya an!
sakit ko para bumalik din sa
normal an! katawan ko, pero
kun! hindi niya ako pa!a!alin!in
pasensya na lan! ako.K
J,indi naiimpluwensiyahan n!
m!a albularyo n!ayon yun!
paniniwala ko. An! -iyos lan! an!
makakatulon! sa akin. Ialan!
imposible sa kanya.K
2a-oratory E/a"ination
Electrocardiogra)hic !e)ort
-ecember F, &''E
:entricular Rate2 $'-#'' per minute
OR9 -uration2 '.'1
A%is2 -1'
")ression$
:entricular fibrillation with moderate ventricular response
<eft a%is deviation
+robable old antero septal wall myocardial infarction
<ateral wall ischemia
Electrocardiogra)hic !e)ort
-ecember #1, &''E
")ression$
:entricular ;ibrillation with avera!e ventricular response
<:,
( wave chan!e &' to di!italis
0hest X,!ay 3Pa 1ie45
-ecember F, &''E
(he lun!s are clear. (he ri!ht main pulmonary artery is prominent with
normal pulmonary vascular markin!s.
(he trachea is sli!htly shifted to the ri!ht.
(he heart is markedly enlar!ed transversely with cardiothoracic ratio of '.$0.
(he superior mediastinum is narrow.
(he hemidiaphra!ms are smooth.
(he costophrenic sulci are intact.
(he rest of the visuali?ed soft and osseous structures are unremarkable.
")ression$
9evere cardiome!aly
+ulmonary hypertension considered
+ulmonary edema present
&-- echo correlation su!!ested
0hest X,!ay 3Pa 1ie45
-ecember #1, &''E
;ollow up, in comparison with the previous radio!raph dated #&B'FB'E,
shows clear lun! fields.
(he heart is markedly enlar!ed transversely.
(he hemediaphra!ms are smooth.
(he costophrenic sulci are intact.
(he rest of the findin!s are unchan!ed.
")ression$
9evere cardiome!aly
+ulmonary hypertension considered
Blood 0he"istry !e)ort
Dece"-er 67 899:
E/a"ination !e;uested$ 0rea7 (a7 K
Para"eter (or"al 1alues Actual !esults Analysis
6reatinine $"-#&' umolB< FF.E1 >ormal
9odium #)"-#"" mmolB< #)". & >ormal
+otassium ).$-"." mmolB< 1.)' >ormal
#e"atology !e)ort
Dece"-er 67 899:
E/a"ination !e;uested$ 0B0
Para"eter (or"al 1alues Actual !esults Analysis
Ihite blood
cell count
"-#' % #'P0B< "." >ormal
,ematocrit #).'-#F.' !Bd< #).# >ormal
,emo!lobin )0.'-"1.'* )0 >ormal
-ifferential
6ount2
9e!menters '.$'-'.E' '. E" >ormal
<ymphocytes '.&'-'.)' '.&" >ormal
Physical Assess"ent
-ate Assessed2 -ecember#1, &''E
(ime Assessed2 12)' +/
nitial :ital 9i!ns2
(emperature2 )$.1
'
6
+ulse Rate2 "F bpm
Respiratory Rate2 )&cpm
Clood +ressure2 #''BE' mm,!
General A))earance$
(he patient is awake, lyin! on bed, conscious and coherent with :; of
Q#-"I R < % G:4 patent and infusin! well at the left arm.
,e looks very weak and tired.
,e is well !roomed.
(he patient can follow instructions and commands easily.
Area
Assessed
Techni;ues
<sed
(or"al
Findings
Actual
Findings
Analysis
SK(
6olor nspection <i!ht to deep
brown
-eep brown >ormal
(e%ture +alpation 9mooth, soft -ry skin -ue to a!in!
(ur!or +alpation 9kin snaps
back
immediately
when pinched
skin snaps back >ormal
,air
-istribution
nspection =venly
distributed
=venly
distributed
>ormal
(emperature +alpation Iarm to touch Iarmer to
touch
-ue to
increased
pyro!ens in
the body
/oisture +alpation -ry, skin folds
are normally
moist
-ry -ue to a!in!
and
dehydration
(A2S
6olor of
nailbed
nspection +ink and 6lean +ink and 6lean >ormal
(e%ture +alpation 9mooth 9mooth >ormal
9hape nspection 6onve%
curvature
6onve%
curvature
>ormal
>ail Case nspection ;irm ;irm >ormal
6apillary Refill
time
Clanch (est &-) seconds & seconds >ormal
9i?e nspection 9hort 9hort >ormal
#A!
6olor nspection Clack (varies) Clack >ormal
-istribution nspection =venly
distributed
=venly
distributed
>ormal
/oisture nspection >either
e%cessively dry
nor oily
-ry -ue to a!in!
and
dehydration
#EAD
9calp
9ymmetry
nspection 9ymmetrical 9ymmetrical >ormal
9kull 9i?e nspection >ormocephalic >ormocephalic >ormal
9hape nspection
and
+alpation
Round Round >ormal
>odulesB
/asses
+alpation Absence of
nodules and
masses
>o nodules >ormal
FA0E
9ymmetry nspection 9ymmetrical 9ymmetrical >ormal
;acial
/ovement
nspection 9ymmetrical 9ymmetric
facial
movements
>ormal
9kin color nspection 9ame as body
color
9ame as body
color(li!ht
brown)
>ormal
E=ES
=yebrows nspection 9ymmetrical,
hair evenly
distributed
9ymmetrical,
hair evenly
distributed
>ormal
=yelashes nspection 9li!htly curved
upward
9trai!ht >ormal
=yelids nspection do not cover
pupil as sclera,
close
symmetrically
do not cover
pupil as sclera,
close
symmetrically
>ormal
Ability to blink nspection Clinks
voluntarily
Clinks
voluntarily
>ormal
;re7uency of
blinkin!
nspection &' blinks per
minute
&' blinks per
minute
>ormal
4cular
movement
nspection =ye moves
freely
=ye moves
freely
>ormal
0on&uncti.a
6olor nspection (ransparent
with li!ht color
+ale -ue to
decreased
blood supply
(e%ture nspection 9hiny and 9hiny and >ormal
smooth smooth
+resence of
lesions
nspection >o lesions >o lesions >ormal
2acri"al
A))aratus
0ornea
6larity
nspection
nspection
>o swellin!
6lear
>o swellin!
6lear
>ormal
>ormal
(e%ture nspection 9hiny, smooth,
transparent
9hiny, smooth,
transparent
>ormal
Pu)ils
6olor nspection Clack Clack >ormal
Reaction to
li!ht
nspection +upils =7ually
Round and
React to <i!ht
Accommodation
(+=RR<A)
+upils =7ually
Round and
React to <i!ht
Accommodation
(+=RR<A)
>ormal
9i?e nspection =7ual =7ual >ormal
9hape nspection Round and
constrict briskly
Round and
constrict briskly
>ormal
9ymmetry nspection =7ual in si?e =7ual in si?e >ormal
:isual Acuity nspection Able to read
clearly
Able to read
clearly
>ormal
4cular nspection =yes move
freely
=yes move
freely
>ormal
Ears
symmetry nspection 9ymmetrical 9ymmetrical >ormal
9i?e nspection 9ame wB both
sides
9ame wB both
sides
>ormal
(e%ture +alpation ;irm, non-
tender
;irm, non-
tender
>ormal
-ischar!es nspection >o dischar!e >o dischar!e >ormal
('SE
9ymmetry,
color
nspection 9ymmetrical,
tan
9ymmetrical,
tan
>ormal
6ilia hair nspection =venly
distributed
=venly
distributed
>ormal
>ares nspection 9ymmetric 9ymmetric >ormal
>asal
dischar!e
nspection >o dischar!e >o dischar!e >ormal
9inuses +alpation >ot tender >ot tender >ormal
M'<T#
2i)s
6olor nspection +inkish to
sli!htly brown
+ale -ue to
decreased
blood
circulation
9ymmetry nspection 9ymmetrical 9ymmetrical >ormal
/oisture +alpation 9oft and moist -ry -ue to
dehydration
Gu"s
6olor nspection +inkish +inkish >ormal
/oisture +alpation moist -ry -ue to
dehydration
Buccal
Mucosa
6olor
nspection Glistenin! pink Glistenin! pink >ormal
/oisture +alpation moist -ry -ue to
dehydration
Tongue
6olor nspection +inkish +inkish >ormal
9ymmetry nspection 9ymmetrical 9ymmetrical >ormal
/obility nspection /oves freely /oves freely >ormal
<.ula
<ocation nspection At the midline At the midline >ormal
9ymmetry nspection 9ymmetrical 9ymmetrical >ormal
Tonsils
6olor nspection +inkish +inkish >ormal
-ischar!es nspection >o dischar!es >o dischar!es >ormal
Teeth
6olor nspection 6olor ivory
white, no tooth
decay
6olor ivory
white, no tooth
decay
>ormal
>umber of
teeth
nspection )& )' -ue to tooth
decay (tooth
e%traction)
(E0K
+osition nspection ,ead- 6entered ,ead- 6entered >ormal
/ovement nspection /oves freely /oves freely >ormal
6onsistency nspection >o
=nlar!ement
>o
=nlar!ement
>ormal
Trachea
symmetry nspection 9ymmetrical 9ymmetrical >ormal
+osition +alpation /idline at the
suprasternal
notch
/idline at the
suprasternal
notch
>ormal
Thyroid
consistency nspection
/oves upward
when
swallowin!
/oves upward
when
swallowin!
>ormal
#EA!T
,eart rate Auscultation $'-#''bpm 1' bpm
,eart sounds Auscultation 6lear, without /urmurs -ue to
murmurs valvular
re!ur!itation
T#'!AX A(D
2<(GS
Posterior
Thora/
9ymmetry nspection 9ymmetrical 9ymmetrical >ormal
Respiratory
rate
nspection >ormally #&-&'
cpm
&$ cpm -ue to -4C
9pinal
ali!nment
nspection 9pine vertically
ali!ned
9pine vertically
ali!ned
>ormal
9kin inte!rity nspection 9kin intact 9kin intact >ormal
Anterior
Thora/
Creathin!
pattern
Auscultation Creathin! is
automatic and
effortless,
re!ular and
even and
produces no
noise.
Creathin! is
with effort,
produces noise
when
breathin!.
-ue to
retained
secretions in
the bronchi
<un!B breath
sounds
Auscultation Croncho-
vesicular
Ihee?es -ue to air
passin! to a
constricted
bronchus as a
result of
secretions.
ABD'ME(
6ontour nspection ;lat ;lat >ormal
(e%ture +alpation 9mooth 9mooth >ormal
;re7uency and
character
Auscultation AudibleA soft
!ur!lin! sound
occur
irre!ularly and
ra!es from "-
)' minutes
AudibleA soft
!ur!lin! sound
occur
irre!ularly and
ra!es from "-
)' minutes
>ormal
2esions nspection >o lesions >o lesions >ormal
Presence of
scar
nspection >o scar >o scar >ormal
<PPE!
EXT!EMT=
9kin color nspection (an (an >ormal
9ymmetry nspection 9ymmetrical 9ymmetrical >ormal
,air
distribution
nspection =venly
distributed
=venly
distributed
>ormal
2'>E!
EXT!EMT=
9kin color nspection (an (an >ormal
9ymmetry nspection 9ymmetrical assymmetrical -ue to sli!ht
edema
,air
distribution
nspection =venly
distributed
=venly
distributed
>ormal
(E<!'2'G0
<evel of
consciousness nterview ;ully conscious,
perceptive to
events,
responds to
painful stimulus
;ully conscious,
perceptive to
events,
responds to
painful stimulus
>ormal
Cehavior and
appearance
nterview /akes eye
contact with
the e%aminer
/akes eye
contact with
the e%aminer
>ormal
/ood nterview =%presses
feelin!s which
correspond to
situation
=%presses
feelin!s which
correspond to
situation
>ormal
Manneris"s
and actions
2anguage
:oice inflection nterview 6lear and
stron!
6lear and
stron!
>ormal
/anner and
speech
nterview 6an !ive
appropriate
answers to
7uestions
6an !ive
appropriate
answers to
7uestions
>ormal
Mental
Status
4rientation
nterview 4riented with
time
4riented with
time
>ormal
Ti"e
Recall recent
and remote
memory
nterview Recall events
readily,
immediate
recall of remote
information
Recall events
readily,
immediate
recall of remote
information
>ormal
.ud!ments
and thou!hts
nterview 6an make
lo!ical
decisions
6an make
lo!ical
decisions
>ormal
Anato"y and Physiology
(he cardiovascular system is sometimes called the blood-vascular or simply the
circulatory system. t consists of the heart, which is a muscular pumpin! device,
and a closed system of vessels called arteries, veins, and capillaries. As the name
implies, blood contained in the circulatory system is pumped by the heart around a
closed circle or circuit of vessels as it passes a!ain and a!ain throu!h the various
NcirculationsN of the body.
(he vital role of the cardiovascular system in maintainin! homeostasis depends on
the continuous and controlled movement of blood throu!h the thousands of miles of
capillaries that permeate every tissue and reach every cell in the body. t is in the
microscopic capillaries that blood performs its ultimate transport function. >utrients
and other essential materials pass from capillary blood into fluids surroundin! the
cells as waste products are removed.
>umerous control mechanisms help to re!ulate and inte!rate the diverse functions
and component parts of the cardiovascular system in order to supply blood to
specific body areas accordin! to need. (hese mechanisms ensure a constant
internal environment surroundin! each body cell re!ardless of differin! demands for
nutrients or production of waste products.
#eart
(he heart is a muscular pump that provides the force necessary to circulate the
blood to all the tissues in the body. ts function is vital because, to survive, the
tissues need a continuous supply of o%y!en and nutrients, and metabolic waste
products have to be removed. -eprived of these necessities, cells soon under!o
irreversible chan!es that lead to death. Ihile blood is the transport medium, the
heart is the or!an that keeps the blood movin! throu!h the vessels. (he normal
adult heart pumps about " liters of blood every minute throu!hout life. f it loses its
pumpin! effectiveness for even a few minutes, the individual8s life is jeopardi?ed.
6lick a topic below to learn more about the heart. (he human heart is a four-
chambered muscular or!an, shaped and si?ed rou!hly like a man8s closed fist with
two-thirds of the mass to the left of midline. (he heart is enclosed in a pericardial
sac that is lined with the parietal layers of a serous membrane. (he visceral layer of
the serous membrane forms the epicardium.
0ha"-ers of the #eart
(he internal cavity of the heart is divided into four chambers2
o Ri!ht atrium
o Ri!ht ventricle
o <eft atrium
o <eft ventricle
(he two atria are thin-walled chambers that receive blood from the veins. (he two
ventricles are thick-walled chambers that forcefully pump blood out of the heart.
-ifferences in thickness of the heart chamber walls are due to variations in the
amount of myocardium present, which reflects the amount of force each chamber is
re7uired to !enerate.(he ri!ht atrium receives deo%y!enated blood from systemic
veinsA the left atrium receives o%y!enated blood from the pulmonary veins.
1al.es of the #eart
+umps need a set of valves to keep the fluid flowin! in one direction and the heart
is no e%ception. (he heart has two types of valves that keep the blood flowin! in
the correct direction. (he valves between the atria and ventricles are called
atrioventricular valves (also called cuspid valves), while those at the bases of the
lar!e vessels leavin! the ventricles are called semilunar valves.
(he ri!ht atrioventricular valve is the tricuspid valve. (he left atrioventricular valve
is the bicuspid, or mitral, valve. (he valve between the ri!ht ventricle and
pulmonary trunk is the pulmonary semilunar valve. (he valve between the left
ventricle and the aorta is the aortic semilunar valve.
Ihen the ventricles contract, atrioventricular valves close to prevent blood from
flowin! back into the atria. Ihen the ventricles rela%, semilunar valves close to
prevent blood from flowin! back into the ventricles.
Path4ay of Blood through the #eart
Ihile it is convenient to describe the flow of blood throu!h the ri!ht side of the
heart and then throu!h the left side, it is important to reali?e that both atria
contract at the same time and both ventricles contract at the same time. (he heart
works as two pumps, one on the ri!ht and one on the left, workin! simultaneously.
Clood flows from the ri!ht atrium to the ri!ht ventricle, and then is pumped to the
lun!s to receive o%y!en. ;rom the lun!s, the blood flows to the left atrium, then to
the left ventricle. ;rom there it is pumped to the systemic circulation.
Blood Su))ly to the Myocardiu"
(he myocardium of the heart wall is a workin! muscle that needs a continuous
supply of o%y!en and nutrients to function with efficiency. ;or this reason, cardiac
muscle has an e%tensive network of blood vessels to brin! o%y!en to the
contractin! cells and to remove waste products. (he ri!ht and left coronary
arteries, branches of the ascendin! aorta, supply blood to the walls of the
myocardium. After blood passes throu!h the capillaries in the myocardium, it enters
a system of cardiac (coronary) veins. /ost of the cardiac veins drain into the
coronary sinus, which opens into the ri!ht atrium. (he work of the heart is to pump
blood to the lun!s throu!h pulmonary circulation and to the rest of the body
throu!h systemic circulation. (his is accomplished by systematic contraction and
rela%ation of the cardiac muscle in the myocardium.
0onduction Syste"
An effective cycle for productive pumpin! of blood re7uires that the heart be
synchroni?ed accurately. Coth atria need to contract simultaneously, followed by
contraction of both ventricles. 9peciali?ed cardiac muscle cells that make up the
conduction system of the heart coordinate contraction of the chambers.
(he conduction system includes several components. (he first part of the
conduction system is the sinoatrial node . Iithout any neural stimulation, the
sinoatrial node rhythmically initiates impulses E' to F' times per minute. Cecause it
establishes the basic rhythm of the heartbeat, it is called the pacemaker of the
heart. 4ther parts of the conduction systeminclude the atrioventricular node,
atrioventricular bundle, bundle branches, and conduction myofibers. All these
components coordinate the contraction and rela%ation of the heart chambers.
0ardiac 0ycle
(he cardiac cycle refers to the alternatin! contraction and rela%ation of the
myocardium in the walls of the heart chambers, coordinated by the conduction
system, durin! one heartbeat. 9ystole is the contraction phase of the cardiac cycle,
and diastole is the rela%ation phase. At a normal heart rate, one cardiac cycle lasts
for '.F second.
#eart Sounds
(he sounds associated with the heartbeat are due to vibrations in the tissues and
blood caused by closure of the valves. Abnormal heart sounds are called murmurs.
#eart !ate
(he sinoatrial node, actin! alone, produces a constant rhythmic heart rate.
Re!ulatin! factors are reliant on the atrioventricular node to increase or decrease
the heart rate to adjust cardiac output to meet the chan!in! needs of the body.
/ost chan!es in the heart rate are mediated throu!h the cardiac center in the
medulla oblon!ata of the brain. (he center has both sympathetic and
parasympathetic components that adjust the heart rate to meet the chan!in! needs
of the body. +eripheral factors such as emotions, ion concentrations, and body
temperature may affect heart rate. (hese are usually mediated throu!h the cardiac
center.
Blood
Clood is the fluid of life, transportin! o%y!en from the lun!s to body tissue and
carbon dio%ide from body tissue to the lun!s. Clood is the fluid of !rowth,
transportin! nourishment from di!estion and hormones from !lands throu!hout the
body. Clood is the fluid of health, transportin! disease fi!htin! substances to the
tissue and waste to the kidneys. Cecause it contains livin! cells, blood is alive. Red
blood cells and white blood cells are responsible for nourishin! and cleansin! the
body. Iithout blood, the human body would stop workin!
Blood 1essels
Clood vessels are the channels or conduits throu!h which blood is distributed to
body tissues. (he vessels make up two closed systems of tubes that be!in and end
at the heart. 4ne system, the pulmonary vessels, transports blood from the ri!ht
ventricle to the lun!s and back to the left atrium. (he other system, the systemic
vessels, carries blood from the left ventricle to the tissues in all parts of the body
and then returns the blood to the ri!ht atrium. Cased on their structure and
function, blood vessels are classified as arteries, capillaries, or veins.
Arteries
Arteries carry blood away from the heart. +ulmonary arteries transport blood that
has low o%y!en content from the ri!ht ventricle to the lun!s. 9ystemic arteries
transport o%y!enated blood from the left ventricle to the
body tissues. Clood is pumped from the ventricles into lar!e elastic arteries that
branch repeatedly into smaller and smaller arteries until the branchin! results in
microscopic arteries called arterioles. (he arterioles play a key role in re!ulatin!
blood flow into the tissue capillaries. About #' percent of the total blood volume is
in the systemic arterial system at any !iven time.
(he wall of an artery consists of three layers. (he innermost layer, the tunica intima
(also called tunica interna), is simple s7uamous epithelium surrounded by a
connective tissue basement membrane with elastic fibers. (he middle layer, the
tunica media, is primarily smooth muscle and is usually the thickest layer. t not
only provides support for the vessel but also chan!es vessel diameter to re!ulate
blood flow and blood pressure. (he outermost layer, which attaches the vessel to
the surroundin! tissue, is the tunica e%terna or tunica adventitia. (his layer is
connective tissue with varyin! amounts of elastic and colla!enous fibers. (he
connective tissue in this layer is 7uite dense where it is adjacent to the tunic media,
but it chan!es to loose connective tissue near the periphery of the vessel.
0a)illaries
6apillaries, the smallest and most numerous of the blood vessels, form the
connection between the vessels that carry blood away from the heart (arteries) and
the vessels that return blood to the heart (veins). (he primary function of
capillaries is the e%chan!e of materials between the blood and tissue cells.
6apillary distribution varies with the metabolic activity of body tissues. (issues such
as skeletal muscle, liver, and kidney have e%tensive capillary networks because they
are metabolically active and re7uire an abundant supply of o%y!en and nutrients.
4ther tissues, such as connective tissue, have a less abundant supply of capillaries.
(he epidermis of the skin and the lens and cornea of the eye completely lack a
capillary network. About " percent of the total blood volume is in the systemic
capillaries at any !iven time. Another #' percent is in the lun!s.
9mooth muscle cells in the arterioles where they branch to form capillaries re!ulate
blood flow from the arterioles into the capillaries.
1eins
:eins carry blood toward the heart. After blood passes throu!h the capillaries, it
enters the smallest veins, called venules. ;rom the venules, it flows into
pro!ressively lar!er and lar!er veins until it reaches the heart. n the pulmonary
circuit, the pulmonary veins transport blood from the lun!s to the left atrium of the
heart. (his blood has a hi!h o%y!en content because it has just been o%y!enated in
the lun!s. 9ystemic veins transport blood from the body tissue to the ri!ht atrium
of the heart. (his blood has a reduced o%y!en content because the o%y!en has
been used for metabolic activities in the tissue cells.
(he walls of veins have the same three layers as the arteries. Althou!h all the
layers are present, there is less smooth muscle and connective tissue. (his makes
the walls of veins thinner than those of arteries, which is related to the fact that
blood in the veins has less pressure than in the arteries. Cecause the walls of the
veins are thinner and less ri!id than arteries, veins can hold more blood. Almost E'
percent of the total blood volume is in the veins at any !iven time. /edium and
lar!e veins have venous valves, similar to the semilunar valves associated with the
heart, that help keep the blood flowin! toward the heart. :enous valves are
especially important in the arms and le!s, where they prevent the backflow of blood
in response to the pull of !ravity.
!ole of 0a)illaries
n addition to formin! the connection between the arteries and veins, capillaries
have a vital role in the e%chan!e of !ases, nutrients, and metabolic waste products
between the blood and the tissue cells. 9ubstances pass throu!h the capillaries wall
by diffusion, filtration, and osmosis. 4%y!en and carbon dio%ide move across the
capillary wall by diffusion. ;luid movement across a capillary wall is determined by
a combination of hydrostatic and osmotic pressure. (he net result of the capillary
microcirculation created by hydrostatic and osmotic pressure is that substances
leave the blood at one end of the capillary and return at the other end.
Blood Flo4
Clood flow refers to the movement of blood throu!h the vessels from arteries to the
capillaries and then into the veins. +ressure is a measure of the force that the blood
e%erts a!ainst the vessel walls as it moves the blood throu!h the vessels. <ike all
fluids, blood flows from a hi!h pressure area to a re!ion with lower pressure. Clood
flows in the same direction as the decreasin! pressure !radient2 arteries to
capillaries to veins.
(he rate, or velocity, of blood flow varies inversely with the total cross-sectional
area of the blood vessels. As the total cross-sectional area of the vessels increases,
the velocity of flow decreases. Clood flow is slowest in the capillaries, which allows
time for e%chan!e of !ases and nutrients.
Resistance is a force that opposes the flow of a fluid. n blood vessels, most of the
resistance is due to vessel diameter. As vessel diameter decreases, the resistance
increases and blood flow decreases.
:ery little pressure remains by the time blood leaves the capillaries and enters the
venules. Clood flow throu!h the veins is not the direct result of ventricular
contraction. nstead, venous return depends on skeletal muscle action, respiratory
movements, and constriction of smooth muscle in venous walls.
Drug Study
Drug (a"e Dosage Action ndications 0ontraindications Ad.erse Effects
(ursing
!es)onsi-ilities
6AR-49=<
Generic >ame2
/etoprolol
6lassification2
Antihypertensive2
Ceta-Clockers
"' m! #
tab 4-
nhibits
sympathetic
stimulation on
peripheral S-
adrener!ic
receptor.
/etoprolol8s S-
blockin!
activity is
manifested by
a reduction in
heart rate and
cardiac output,
and control of
blood pressure
both at rest
and durin!
e%ercise.
,ypertension
T an!ina
pectoris
9econd- and third-
de!ree heart block,
6,;, sinus
bradycardia
6aution2 hepatic,
renal, or thyroid
dysfunctionA
asthmaA peripheral
vascular diseaseA
;ati!ue, weakness,
nausea, vomitin!,
diarrhea, nasal
stuffiness,
depression,
bradycardia,
bronchospasm,
a!ranulocytosis,
9hortness of
breath, peripheral
edema,
hypotension, sleep
disturbances,
+ruritus, tinnitus,
dry skin
6heck the clientHs
medical history
for
hypersensitivity.
4btain initial vital
si!ns
instruct patient
to take dru! after
meal
monitor vital
si!ns, especially
blood pressure
and pulse rate
nstruct the
client to remain
in a sittin!
position for
several minutes
before standin!
to avoid
orthostatic
hypotension
/aintain bed rest
Drug (a"e Dosage Action ndications 0ontraindications Ad.erse Effects
(ursing
!es)onsi-ilities
64@/A->
Generic >ame2
Iarfarin
6lassification2
Anticoa!ulants

" m! #
tab 4-
nterferes with
synthesis of
:itamin G-
dependent
clottin! factors
resultin! in
depletion of
clottin! factors
, :, U, U.
t prevents
further
e%tension of the
formed clot and
prevent
secondary
thromboembolic
complications
which may
result in serious
and possible
fatal se7uelae.
+rophyla%is
andBor
treatment of
venous
thrombosis and
its e%tension,
pulmonary
embolism,
thromboembolic
complications
associated with
atrial fibrillation
6lients with blood
dycrasias, peptic
ulcer,
cerebrovascular
accident (6:A),
hemophilia, or
severe
hypertension.
@se with caution in
client with acute
traumatic injury
and impaired
hepatic and renal
function.+re!nant
women
,emorrha!e from
any tissue or
or!an.
4ther adverse
reactions are
infre7uent and
consist of
alopecia,
dermatitis, fever,
nausea, diarrhea,
abdominal
crampin!, purple
toes syndrome
and
hypersensitivity
reactions.
6heck the clientHs
medical history
for
hypersensitivity.
A baseline +( or
>R should be
obtained before
warfarin is
administered
Advise patient to
avoid alcohol and
lar!e amounts of
!reen leafy
ve!etables, fish,
liver coffee, or
tea when takin!
warfarin
/onitor vital
si!ns
/onitor older
adults closely for
bleedin!.
Advise patient to
report bleedin!
and to avoid
activities that
may cause injury
or cuts and
bruises.
Drug (a"e Dosage Action ndications 0ontraindications Ad.erse Effects
(ursing
!es)onsi-ilities
:A9(AR=< /R
Generic >ame2
(rimeta?idine
6lassification2
Antian!inal -ru!s
)" m! #
tab 4-
Cy preservin! the
ener!y
metabolism in
cells e%posed to
hypo%ia or
ischaemia,
trimeta?idine
prevents a
decrease in
intracellular A(+
levels, thereby
ensurin! the
proper
functionin! of
ionic pumps and
transmembranous
sodium-
potassium flow
while maintainin!
cellular
homeostasis.
<on!-term
treatment of
episodes of
coronary
insufficiencyA
an!ina pectoris
,ypersensitivity to
any of the
constituents of
:astarel /R.
<actation
Rare cases of
!astrointestinal
disorders (nausea
and vomitin!).
6heck the clientHs
medical history
for
hypersensitivity.
obtain baseline
vital si!ns for
future
comparison
Administer oral
form of dru! with
meals, with a full
!lass of water to
decrease G
upset.
/onitor vital
si!ns especially
blood pressure
and pulse rate
Advise patient to
report if di??iness
or faintness
occurs, this may
indicate
hypotension
/aintain bed rest
Drug (a"e Dosage Action ndications 0ontraindications Ad.erse Effects
(ursing
!es)onsi-ilities
;@R49=/-=
Crand >ame2
<asi%
6lassification2
Antihypertensive2
<oop -iuretics
&' m!
: 7 F
hours
Acts by
inhibitin!
sodium and
chloride
reabsorption
from the
ascendin! loop
of ,enle.
t promotes the
renal e%cretion
of water,
sodium,
chloride,
ma!nesium,
hydro!en, and
calcium and
depletes
potassium.
=dema due to
cardiac,
hepatic T renal
disease,
burnsA mild to
moderate
hypertension,
acute heart
failure, chronic
renal failure,
nephrotic
syndrome.
+resence of severe
electrolyte
imbalances,
hypovolemia,
hypersensitivity to
sulphonamides and
furosemide, renal
failure
9evere
hypovolemia,
dehydration and
electrolyte
imbalances, rashes,
nausea, diarrhea,
blurred vision,
di??iness,
headache,
hypotension.hepatic
dysfunction.
>ote whether
client is
hypersensitive to
sulfonamides
assess vital
si!ns, serum
electrolytes,
wei!ht and urine
output for
baseline levels
administer :
furosemide
slowly
/onitor intake
and output to
determine body
fluid !ain or loss
monitor vital
si!ns
instruct client to
arise slowly to
prevent di??iness
resultin! from
fluid loss
Drug (a"e Dosage Action ndications 0ontraindications Ad.erse Effects
(ursing
!es)onsi-ilities
-@/-=
Generic >ame2
;urosemide
6lassification2
Antihypertensive2
-iuretics
# tab
4-
;urosemide acts
by inhibitin!
sodium and
chloride
reabsorption,
primarily in the
ascendin! loop
of ,enle.
+atients
re7uirin!
diuresis and
concomitant
potassium
supplementation
as in cardiac,
pulmonary,
hepatic, renal
and peripheral
edema of
various
etiolo!ies.
,yperkalemia,
precomatose states
associated with
liver cirrhosis,
Addison8s disease
and concomitant
administration of
potassium-sparin!
diuretics. +atients
with prostatic
hypertrophy or
impairment of
micturition
Aller!ic reaction.
,yperuricemia
may occur with
furosemide
therapy.
>ote patientHs
hypersensitivity
to dru!.
assess vital
si!ns, serum
electrolytes,
wei!ht and urine
output for
baseline levels
instruct patient
to take dru! after
meal
monitor urinary
output to
determine body
fluid !ain or loss
monitor vital
si!ns
Drug (a"e Dosage Action ndications 0ontraindications
Ad.erse
Effects
(ursing
!es)onsi-ilities
4/=+RAM4<=
+=+(94<:
Crand >ame2
+rilosec
6lassification2
Antacids T
Antiulcerants
&' m!
# tab
4-
(hou!ht to be a
!astric pump
inhibitor in that it
blocks the final step
of acid production
by inhibitin! the
hydro!enBpotassium
A(+ase system at
the secretory
surface of the
!astric parietal cells
9hort-term
treatment of
active
duodenal ulcer,
erosive
esopha!itis,
active beni!n
!astric ulcer,
G=R-
,ypersensitivity,
pre!nancy,
lactation
,eadache,
di??iness,
fati!ue, thirst,
increased
appetite, nausea
and vomitin!,
diarrhea T skin
rash.
6heck the
patientHs medical
history for
hypersensitivity.
determine
patientHs pain,
includin! the
type, duration,
severity,
fre7uency and
location
advise patient to
take dru! with a
!lass of water on
an empty
stomach at least
one hour before
to decrease food
induced acid
secretion or at
bedtime
instruct patient
to report pain,
cou!hin! or
vomitin! of
bloodalert patient
to avoid foods
and li7uids that
can cause !astric
irritation
Drug (a"e Dosage Action ndications 0ontraindications Ad.erse Effects
(ursing
!es)onsi-ilities
>4R(=>
Generic >ame2
midapril
6lassification2
Antihypertensive2
A6= nhibitors
#' m!
R tab
4-
(he hypotensive
effect of imidapril
,6l is mainly due
to A6= inhibition
and the
conse7uent
reduction in
an!iotensin ,
resultin! in
dilatation of
peripheral vessels
and reduction in
vascular resistance
(reatment of
hypertension
+atients with
known
hypersensitivity to
A6= inhibitors,
pre!nancy,
breastfeedin!
@se with caution in
patient with renal
and hepatic
impairments
dry cou!h,
discomfort in the
throat,
palpitation,
headache and
rash ;ati!ue,
di??iness, hot
flush, diarrhea,
nausea and
vomitin!.
6heck the clientHs
medical history
for
hypersensitivity
4btain baseline
vital si!ns for
future
comparisons
(ake dru! before
meal
/onitor vitals
si!ns, especially
blood pressure
and pulse rate
advise client that
antihypertensives
may cause
di??iness
resultin! from
orthostatic
hypotension
Report if
di??iness or
faintness occurs,
this may indicate
hypotension
/aintain bed rest
Drug (a"e Dosage Action ndications 0ontraindications Ad.erse Effects (ursing
!es)onsi-ilities
A+R4R
Crand >ame2
>icorandil
6lassification2
Antian!inal dru!
#' m!
R tab
C-
>icorandil acts by
rela%in! the
smooth muscle of
the blood vessels,
especially those of
the venous
system. t acts by
activatin!
potassium
channels in
vascular smooth
muscle and hence,
causes a
hyperpolari?ation
of the smooth
muscle cells
(reatment of
chronic stable
an!ina
pectoris.
Gnown or
idiosyncratic
hypersensitivity to
nicorandil,
nicotinamide and
nicotinic acid.
+atients with
cardio!enic shock,
hypotension and
left ventricular
failure with low
fillin! pressures.
-ue to the risk of
severe hypotension
,eadache,
/alaise,
palpitations,
vasodilationBflush,
myal!ia
tachycardia,
arrhythmia, a
decrease in blood
pressure andBor
an increase in
heart rate may
occur, nausea,
:omitin!,
anore%ia,
diarrhea,
constipation,
-i??iness,
nsomnia,
nervousness,
dyspnea,
pruritus, rash,
sweatin!. (innitus
6heck the clientHs
medical history
for
hypersensitivity.
obtain baseline
vital si!ns for
future
comparison
Administer oral
form of dru! with
meals, with a full
!lass of water to
decrease G
upset.
/onitor vital
si!ns especially
blood pressure
and pulse rate
(ursing 0are Plan
ASSESSME(T DAG('SS P2A(((G (TE!1E(T'( !AT'(A2E E1A2<AT'(
9ubjective -ata2
JGapa!
nahihirapan akon!
humin!a
sumasakit na din
an! dibdib ko.K, as
verbali?ed by the
patient
- pain scale of
FB#'
4bjective -ata2
facial
!rimace
e%pressive
behavior
restlessness
6hest pain
rBt hypo%ia
At the end of #
hour, the
patient will be
able to report
pain if relieve in
a pain scale of
'B#'
-etermined level of
pain from FB#'.
+ositioned patient
comfortably on bed.
+rovided patient
ade7uate rest
+rovided 7uiet
environment
+rovided comfort
measures such as
chan!in! the
patientHs position
fre7uently
Administered o%y!en
as ordered (&-)
<+/).
(o be able to know
what are the
particular
interventions to
relieve pain.
(o promote wellness
(o prevent fati!ue
(o be able to have
enou!h rest
(o alleviate pain
caused by pressure on
nerve endin!s
(o improve
o%y!enation
Goal partially
met. (he
patient
reported pain
controlled and
a decreased in
pain scale of
"B#'.
ASSESSME(T DAG('SS P2A(((G (TE!1E(T'( !AT'(A2E E1A2<AT'(
9ubjective data2
J>ahihirapan
akon! humin!aK
as verbali?ed by
the patient.
4bjective data2
RR2 )& cpm
use of
accessory
muscles to
breathin!
nasal
flarin!
neffective
breathin!
pattern rBt
respiratory
muscle
fati!ue.
At the end of )'
minutes, the
patient will
establish a
normal and
effective
respiratory
pattern.
=levated head of bed
as appropriate
=ncoura!ed slower
and deeper
respirationsB pursed-
lip breathin!.
=ncoura!ed
ade7uate rest
periods.
Administered o%y!en
at lowest
concentration
=ncoura!ed to do
rela%ation techni7ues
such as2
- listenin! to music
- talkin! to relatives
(o promote
physiolo!ical ease of
ma%imal inspiration.
(o assist client in
takin! control of the
situation (breathin! is
considered to be the
best bronchodilator)
(o limit use of ener!y
and avoid fati!ue. (o
provide comfort.
(o prevent
accumulation o%y!en
that causes respiratory
depression
(o promote sense of
well-bein! and comfort
Goal partially
met. (he
patient was
able to
establish an
effective
respiratory
pattern as
manifested by
absence of
nasal flarin!
and use of
accessory
muscles to
breathe but
respiratory
rate is still &)
cpm.
ASSESSME(T DAG('SS P2A(((G (TE!1E(T'( !AT'(A2E E1A2<AT'(
9ubjective -ata2
Jnuubo siya at
hindi niya mailabas
an! plema,K as
verbali?ed by the
94.
4bjective -ata2
@nproductive
cou!h
(V) crackles
upon
auscultation
RRW)& cpm
neffective
airway
clearance
related to
secretions in
the bronchi.
At the end of
the shift, the
pt. will be able
to promote
airway patency,
e%pectorate or
clear secretions
readily and
stabili?ed vBs.
4bserved the
patientHs respiratory
pattern
nstructed 94 to
!ive ade7uate fluid
intake to the patient
within his cardiac
tolerance.
=ncoura!ed 94 to
!ive warm versus
cold li7uids as
appropriate
nstructed 94 to let
the patient
e%pectorate
secretions
+erformed chest
physiotherapy(deep
breathin! e%ercises)
+rovided
opportunities for
sleep and rest
+rovides baseline
data to !au!e the
efficacy of nursin!
intervention.
(o prevent
dehydration and to
help loosen the
secretions
Iarm water lessens
the occurrence or
a!!ravation of
cou!hin!
(o prevent
accumulation of
sputum in the
tracheobronchial tree
thus prevents further
obstruction
6hest physical
therapy techni7ue
utili?es forces of
!ravity and motion to
facilitate secretion
removal.
9leep and rest will
prevent fluid loss
Goal met. At
the end of the
shift, the
patient was
able to
e%pectorate
some
secretions and
his vital si!ns
was
stabili?edA
RRW &) cpm.
periods
Repositioned client
as often.
from too much
e%ertion e%acerbated
by increase work of
breathin!
(o allow lun!s to be
fully ventilated,
mobili?es secretions.
ASSESSME(T DAG('SS P2A(((G (TE!1E(T'( !AT'(A2E E1A2<AT'(
9ubjective data2
J/adali akon!
mapa!od kahit na
ma! X iba lan!
ako n! posisyonK,
as verbali?ed by
the patient.
4bjective -ata2
the client
seems so
tired and
weak
Activity
intolerance
rBt locali?ed
weakness in
the upper T
lower
e%tremities.
At the end of #
hour, the
patient will be
able to
participate
willin!ly in
necessary
activities and
report
measurable
increase in
activity
tolerance.
/onitored vital si!ns
every & hours.
=ncoura!ed
e%pression of
feelin!s contributin!
to the condition.
-etermined the
patientHs ability to
participate in
activities in level of
mobility.
+lanned care with
rest periods between
activities
nstructed method to
conserve ener!y
such as sittin!
instead of standin!
durin! activities.
=ncoura!ed routines
like back rubbin! to
promote restful
sleep.
(o provide baseline
dataA to evaluate the
de!ree of condition
and the effectiveness
of the intervention
(o determine the
necessary intervention
to be made for the
clientHs condition
(o determine the
assistance needed by
the patient
(o reduce fati!ue and
to have enou!h rest
periods.
(o restore ener!y
needed to perform
A-<Hs
(o increase ener!y to
do A-<Hs
Goal met.
At the end of
# hour, the
patient was
able to2
Y+articipate
willin!ly in
necessary
activities
Yreport
measurable
increase in
activity
tolerance
+romoted overall
health measures
(nutrition, vitamin
supplementation, T
ade7uate fluid
intake.
+romoted safety
measures like liftin!
the side rails of the
bed.
nvolved client and
94 in plannin! of
activities as much as
possible.
(o promote wellness
(o prevent injury T
fall
involvement of client
and 94 durin! the
plan of care helps to
attain !oals
ASSESSME(T DAG('SS P2A(((G (TE!1E(T'( !AT'(A2E E1A2<AT'(
4bjective -ata2
;lushed
skin
(W )E.0L6
RRW )&
cpm
Altered body
temperature2
,yperthermia
rBt increased
production of
pyro!ens in
the body
At the end of )'
minutes, the
patient will be
able to obtain
body
temperature
within normal
ran!e
/onitored vBs and
recorded particularly
temperature
+rovided the patient
continues (9C
+ositioned the
patient in a
comfortable and safe
position
+rovided proper
room ventilation by
openin! the fan and
window panes
Advised the patientHs
94 to chan!e the
patientHs clothin! to
loose and li!ht
colored clothes
Advised the patient
(o determine basal
body temperature, to
have baseline data
and to have a basis for
evaluatin! the
effectiveness of
interventions
(o promote surface
coolin! and heat lose
by evaporation and
conduction
(o promote client
safety and to maintain
patent airway to
address increased RR
(o promote surface
coolin! and heat loss
by convection
<oose clothin! and
li!ht colored clothin!
promotes body surface
coolin!. <i!ht colored
clothes are more
absorbent to address
diaphoresis
(o replace fluids and
Goal met. (he
patient was
able to obtain
body
temperature
within normal
ran!e.
to increase fluid
intake to F-#'
!lassesBday
nstructed the client
to maintain bed rest
electrolyte to support
circulatory volume and
tissue perfusion and to
prevent dehydration
(o reduce metabolic
demands and o%y!en
consumption.
ASSESSME(T DAG('SS P2A(((G (TE!1E(T'( !AT'(A2E E1A2<AT'(
9ubjective -ata2
J,indi ako
makatulo! dahil
main!ay dito sa
ward.K as
verbali?ed by the
patient.
4bjective dataA
restlessness
fre7uent
yawnin!
fre7uent
chan!e in
position
-isturbed
sleep pattern
rBt e%cessive
noise in the
ward.
At the end of #
hour, the
patient will be
able to2
Y:erbali?e
understandin!
of sleep
disturbance T
Ydentify
individually
appropriate
interventions to
promote sleep.
4bserved habits of
sleep periodicity T
wake up time.
+romoted comfort T
rela%ation.
6reated a restful
environment.
-iscussed effective
bedtime rituals (e.!.
Goin! to bed the
same time each
day).
=ncoura!ed client to
have ade7uate
e%ercise.
=ncoura!ed intake of
hi!h protein food.
=ncoura!ed to avoid
caffeine T
carbonated drinks in
the evenin!.
<imited ni!ht time
fluid T encoura!ed
(o evaluate sleep
pattern T dysfunction

(o assist client to
establish optimal
sleep pattern
(o promote sleep
(o enhance clientHs
ability to fall asleep
(o enhance >R=/ for
body restoration
+rotein contains
tryptophanA which is a
6>9 depressant
6affeine T carbonated
drinks are 6>9
stimulant
(o avoid disturbance
of sleep dBt voidin!
Goal met.
After an hour
the patient
was able to2
Y:erbali?e
understandin!
of sleep
disturbance T
Ydentify
individually
appropriate
interventions
to promote
sleep.
to void before
retirin!.
nstructed to !o to
bed when sleepy.
=ncoura!ed 94 to do
rela%ation
techni7ues to the
client such as back
rubbin!.
(o facilitate sleep
Cack rubs help to
rela% muscles2
rela%ation decreased
an%iety which
facilitates sleep
ASSESSME(T DAG('SS P2A(((G (TE!1E(T'( !AT'(A2E E1A2<AT'(
9ubjective data2
J>an!hihina ako
saka pakiramdam
ko la!i akon!
pa!odK as
verbali?ed by the
patient.
4bjective data2
restlessness

;ati!ue rBt
hypo%ia.
At the end of &
days, the
patient will be
able to manifest
si!ns of
improved
o%y!enation as
evidenced by
decreased
restlessness.
4& supplementation
!iven (&-) <+/)
=ncoura!ed
ade7uate rest
periods.
+rovided
environment
conducive to relief of
fati!ue.
nstructed in
methods to conserve
ener!y
Assisted with self
care needs
-iscussed routines
to promote restful
sleep.
(o improve
o%y!enation
+eriods of rest provide
comfort to the
patient.
(o avoid e%haustion.
(o decrease fati!ue.
(o minimi?e tiredness
(o provide information
on how to promote
rela%ation
Goal met. (he
patient was
able to
manifest
improved
si!ns of
o%y!enation
as evidenced
by decreased
restlessness.
ASSESSME(T DAG('SS P2A(((G (TE!1E(T'( !AT'(A2E E1A2<AT'(
4bjective data2
6hronic
disease-
(V) R,-
poor
appetite
Risk for
infection rBt
chronic
disease
process.
At the end of )'
minutes, the
client will
verbali?e
understandin! of
individual
causative and
risk factors.
>oted risk factors for
the occurrence of
infection.
4bserved for
locali?ed si!ns for
infection at insertion
sites.
Assessed skin
conditions around
insertion sites of
pins, wires, and
ton!s, notin!
inflammation and
draina!e.
9tressed proper hand
washin! techni7ues
by all care!ivers and
94Hs of the patient.
nstructed clientB94
in techni7ues to
protect the inte!rity
of the skin.
Administered
antibiotic therapy
dentifyin! the
possible causative
factors helps
preventBcontrol the
occurrence of
infection.
:isible sin!s of
infection enable the
mana!ement of more
severe infections.
(he skin is our
primary defense
a!ainst infectious
diseases.
,and washin!
techni7ue is a first-line
defense a!ainst
nosocomial infections.
6are for the skin
inte!rity prevents the
occurrence of
infection.
Antibiotics inhibit cell
Goal met. (he
client was able
to verbali?ed
understandin!
of causative
and risk
factors.
durin! acute phase
of disease process.
nstructed patient to
continue lon! term
antibiotic re!imen.
(au!ht patient to
report to the
physician any upper
respiratory infection,
elevated temperature
T any abnormal
findin!s.
wall synthesis of
microor!anisms,
destroyin! causative
a!ent.
Antibiotic therapy is
needed for continuous
medication process.
9uch findin!s may
indicate recurrence of
disease T more
possible complications.
Patho)hysiology of !heu"atic #eart Disease
Etiology
(Group A Ceta-,emolytic 9treptococci)
Preci)itating Factors
cold and damp weatherBclimate
improper use of antibioticsB
improper antibiotic therapy
Predis)osing Factors
!enetic susceptibility
!ender
previous infections caused by
GAC,9 9treptococci !ains entry throu!h breaks in
the skin and mucous membranes
+atho!ens !ain entry in the
bloodstream
Goes to the heart
9treptococci establishes a hold
on the valve
:e!etate on the mar!ins of the
valve leaflets
A

Heart murmurs
4bstruction of the forward flow of
blood
Cack flow of blood into the
pulmonary circulation
ncreased pulmonary C+Bpulmonary
con!estion
C


Reduced leaflet motion
A


nflammation of the mar!ins of
the valve leaflet
9hortenin! and thickenin! of the
valve leaflets
;ailure of the mitral valve to close
completely
:alvular Re!ur!itation
,eart murmurs
6



-ecreased 9C+ 6on!estion of venous circulation
GA9 ncreased 9C+
Repeatedly activated
-ecreased immune resistance
Cacteria cannot be locali?ed
ncreased capillary permeability
/yocardium +ericardium
6ardiac tamponade
schemia An!ina pectoris
/yocardial
infarction
:entricular
fibrillation
6ardiac arrest
-eath
,emoptysis
nterferin! 64& X 4& e%chan!e
-ecreased 4& saturation of
the blood
schemia
- ncreased ,R
- -i??iness and confusion
- Ieakness
- =asy fati!ability
4rthopnea +leural =ffusion
ncreased pressure in the
pulmonary capillaries
Rupture of pulmonary
capillaries
;luids coats the alveolar
e%chan!e space
C


+ulmonary =dema
6


-ecreased cardiac output
-ecreased 9C+
6on!estion of venous circulation GA9
ncreased capillary permeability
-ecreased immune resistance
Cacteria cannot be locali?ed
+ancarditis
/yocardium +ericardium
6on!estion of venous circulation
ncreased capillary permeability
ncreased =6;
/yocardium +ericardium /yocardium +ericardium
+eripheral edema
mbalance venous and hydrostatic pressure
Accumulation of fluids and rou!henin! of the pericardium
/yocardium +ericardium
;riction rub