Trinity University of Asia

St. Lukes College of Nursing

E. Rodriguez Sr. Avenue, Cathedral Heights, Quezon City, Philippines

RHEUMATIC HEART DISEASE S/P MITRAL VALVE REPLACEMENT TULAK NG BIBIG, KABIG NG DIBDIB

A Grand Case Study Presented to the Faculty of St. Lukes College of Nursing Trinity University of Asia

In Partial Fulfillment of the Requirements of Related Learning Experience for the Degree of Bachelor of Science in Nursing

Submitted by: Batch Exaleron 3NU01 AGUSTIN, MA. AILEEN NICOLE ALBA, KIMBERLY Group 4

Group 3 AGLUBAT, MOLLY AIVON AGUILAR, DONA ROSE

ALCASID, JOHN PAUL ALIKES, GLORY

ALIPIO, DANIELLE ERIKA ALIVIO, ALRAYE KIRSTIE ALVAREZ, BETHANY

MARCH 2011 TABLE OF CONTENTS

Page No.

I.

OBJECTIVES . 3

II. INTRODUCTION
. . 4

III. PATIENTS PROFILE

.. 6

IV. ANATOMY AND PHYSIOLOGY

10

V. PATHOPHYSIOLOGY
14

VI. COURSE IN THE WARD

. 15

VII. DIAGNOSTIC PROCEDURE AND LABORATORY EXAMINATION

. 18

VIII.

DRUG STUDY 26

IX. NURSING THEORY

.. 43

X. NURSING CARE MANAGEMENT

... 46

XI. DISCHARGE PLANNING

.. 51

XII. BIBLIOGRAPHY
.

I. OBJECTIVES
A. General The core intention of this case study is to enlighten us on the subject of rheumatic heart disease and its features, as well as the various facets revolving around it and the nursing care required, with respect to the patient involved. B. Specific To amplify our understanding of the characteristics and ramifications of rheumatic heart disease, i.e. the meaning, signs and symptoms, causes, and the possible medical and nursing management concerning the subject. To give clarity and distinction to the disease process with the use of succinct explanations as well as exemplification of a process flow diagram. To understand the disease diagram and the prognosis of rheumatic heart disease To devise and put together a variety of nursing care plans concerning the patient and to realize the established plans by carrying out suitable nursing care.

To identify and become cognizant of the independent, interdependent, and dependent nursing interventions that are essential to the clients well-being and agreeable to his personal interests.

To come up with the best approach of nurses with clients who are with rheumatic heart disease. As an individual: To cultivate the values of maturity, sensibility and dependability in the health care setting, while taking into consideration the ethical issues involved in the situation.

As a nurse: To cultivate the nursing care in which a client with rheumatic heart disease. As a team/group: To demonstrate a sense of teamwork and reliability in duly accomplishing the tasks that are delegated to us, thus allowing us to present the case with finesse.

II. INTRODUCTION
Heart disease is a term used to describe a broad range of diseases that affect the heart and blood vessels. Rheumatic heart disease is the most serious complication of rheumatic fever. Acute rheumatic fever follows 0.3% of cases of group A beta-hemolytic streptococcal pharyngitis in children. As many as 39% of patients with acute rheumatic fever may develop varying degrees of pancarditis with associated valve insufficiency, heart, pericarditis, and even death. With chronic rheumatic heart disease, patients develop valve stenosis with varying degrees of regurgitation, atrial dilation, arrhythmias, and ventricular dysfunction. Rheumatic heart disease involves damage to the entire heart and its membranes. It is a complication of rheumatic fever and usually occurs after attacks of rheumatic fever. Rheumatic fever can damage the heart valves. If the heart valves are damaged, they will fail

to open and close properly. When this damage is permanent, the condition is called rheumatic heart disease. This valve damage can eventually lead to heart failure. The exact etiology of rheumatic fever is still controversial. The disease occurs after a latent period of two to three weeks following an infection with a group A beta-hemolytic streptococcus, typically a pharyngitis. Streptococci are considered the cause of the pharyngitis, because of elevated titres of antibodies to streptococcal antigens, such as streptolysin O, hyaluronidase or streptokinase in the serum. The more severe the initial streptococcal infection, the greater the chance of subsequent rheumatic fever. Some streptococcal antigens cross-react with cardiac antigen. This raises the possibility of an autoimmune etiology. There seems to be an additional hereditary factor for susceptibility to rheumatic fever after streptococcal infection. Simply getting older increases your risk of heart disease. Men are generally at more of a risk, but the risk increases for women after menopause. You are at more of a risk of your parents developed heart disease at a young age. Smoking is a risk factor because nicotine restricts blood vessels and carbon monoxide damages the inner lining of blood vessels, making them more susceptible to atherosclerosis. Additional risk factors include high blood pressure, high cholesterol, diabetes, obesity (lack of exercise and physical inactivity) and high stress, which damages arteries. Poor hygiene can increase risk of infection. Rheumatic fever occurs in equal numbers in males and females, but the prognosis is than worse for for males. if
80%

females

Ag G e roupof R kinR is heum aticH eart D eas is e

20% Adult Child 5-15

Children they throat most at

ages 5 to 15, particularly experience frequent infections, strep are

risk for developing rheumatic fever.

The incidence of rheumatic fever and rheumatic heart disease has not decreased in Figure 2.1 Pie Chart of Age Group of Risk in Rheumatic developing countries. Retrospective studies reveal developing countries to have the highest Heart Disease figures for cardiac involvement and recurrence rates of rheumatic fever. Estimations

worldwide are that at least 15.6 million children and young adults have rheumatic heart disease, and 233,000 patients die from this disease each year. Native Hawaiian and Maori (both of Polynesian descent) have a higher incidence of rheumatic fever (13.4 per 100,000 hospitalized children per year), even with antibiotic prophylaxis of streptococcal pharyngitis. Rheumatic fever is principally a disease of childhood, with a median age of 10 years, although it also occurs in adults (20% of cases). Heart diseases are varied and may include coronary, ischemic, valvular,

inflammatory, hypertensive, hereditary, and infectious causes. The resources say that it is the number one, and for the past several years beginning in the early 90s, the complex group of heart diseases has been the Philippines' top killer. From 1942 to the 1980s, infectious diseases used to be the Philippines' top killer. A 1984 study identifies rheumatic heart disease, ischemic and hypertensive heart diseases as the major types involved. Another study blames cigarette smoking, the easy accessibility of cigarettes even to adolescents, and the usual suspects of increasing fat intake, increasing diabetes cases, and high cholesterol levels as predisposing factors. The symptoms of rheumatic fever usually start about one to five weeks after your child has been infected with Streptococcus bacteria. Joint inflammation - including swelling, tenderness, and redness over multiple joints. The joints affected are usually the larger joints in the knees or ankles. The inflammation "moves" from one joint to another over several days. Small nodules or hard, round bumps under the skin. A change in your child's neuromuscular movements (this is usually noted by a change in your child's handwriting and may also include jerky movements). Rash (a pink rash with odd edges that is usually seen on the trunk of the body or arms and legs). Fever. Weight loss. Fatigue. Stomach pains.

III.PATIENTS PROFILE
A. Demographic Data Name: J.K. Address: Majuro Marshall Island Age: 9 Gender: Female Civil status: Single Occupation: None Nationality: Marshallese Religion: Protestant Date and time of Admission: January 28, 2011, 1:04am Admitting Diagnosis: Rheumatic Heart Disease, Mitral Regurgitation, Tricuspid Regurgitation, s/p Mitral Valve Repair

B. Chief Complaint:

On and off fever

C. Present History of Illness: Patient is a 9yr old female diagnosed case of Rheumatic Heart Disease, Mitral Regurgitation, Tricuspid Regurgitation, s/p Mitral Valve Repair. One month prior to admission the patient had recurrent fever (100-102F) relieved by Tylenol. This was accompanied by headache and abdominal pain. The patient also experienced easy fatigability and reported occasional vomiting. She was admitted for further work-up and evaluation. D. Past History of Illness: Last 2009 the patient was diagnosed with Rheumatic Heart Disease, mitral valve regurgitation and tricuspid regurgitation and undergone S/P Mitral Valve Repair (Feb.17,2009). The patient had Pneumonia and was admitted at Marshall Island, Chronic gastroenteritis and also experienced pain on the tonsils as stated by the father. E. Family History of Illness:

The patient had a family history of hypertension and bronchial asthma. F. Social history: The patients marital status single and is living with her mother, father and older brother. The mother usually does the cooking and the family all goes out to shop for supplies. The father said that they have a one-floor house that is not too big or too small with 3 bedrooms and 1 bathroom. The patient goes to school and is currently at grade 3 and the school from their house can be seen due to its proximity. The patient walks, with no assistive device, and her older brother. The patient usually plays with her peers but experiences easy fatigability. She can only withstand playing for 10 minutes. The patient also does not any history of smoking, drinking of alcohol or any recreational drugs. G. Allergies: No known allergies

H. Assessment February 02, 2011 8:00am Temperature: _36.5_ C Oral __ Rectal __ Axillary ___ Tympanic Pulse Rate: _98_bpm Radial Apical ___; Regular ___ Irregular ____ Respiratory Rate: _23_cpm Abdominal ____ Diaphragmatic Blood Pressure: _120 /_50_ mmHg Left Arm ____ Right Arm Standing ___ Sitting Lying Down____ Weight: _19.5_kg Height: _3 feet _11_inches 1. Gordons Functional Health Patterns Gordons Functional Health Pattern Health Perception-Health Management Pattern NutritionalMetabolic Before Hospitalization Subjective The patient was able to run with her playmates right after class for 2-3 hours. The patient was able to consume a whole meal. Her height and weight are proportional her skin and mucosal membranes are well moist. The patient was able to urinate freely and eliminates stool 3-4 times a week. She experienced painfree during defecation and urination. Her recreational activities are usually playing with her schoolmates and friends. She was also able to walk long distance. The patient goes to school during weekdays and participates well in her class. After Hospitalization Subjective The patient was only able to run and play with her friends for less than 1 hour due to early fatigability The patient loss her appetite and was not able to consume enough food to meet her daily needs. She experienced thinning and loses weight. Her skin and mucosal membranes are dry The patient had pain during defecation and urination. Her elimination of stool was 1-2 times in a week Objective The patient would only watch TV all day during hospitalization The patients parents are physically fit but she was very thin. She has no fatty tissue and really skinny

Elimination

The patient only defecated

Activity-exercise

CognitivePerceptual

She was still able to play with her schoolmates but lesser time. She still walks but experiences exhaustion in just few meters from the origin The patient was only being taught by her parents every morning due to prolonged

She doesnt want to stand up or participate conversation during interaction. She would only watch TV. She is able to understand English as language of communication but doesnt like to talk.

hospitalization Sleep-Rest The patient was able to sleep for 8-9 hours every day. The patient usually wakes up midnight and complains of chest pain and has difficulty in sleeping again The patient was really shy as verbalized by the father

She would only nod for yes or no The patient would sleep for 1-2 hours but awake most of the time The patient is very shy and doesnt talk to strangers like healthcare providers. She only talks with her mother or father The patient doesnt give attention to healthcare providers

Self-Perception/ Self-Concept

The patient was able to make friends to a lot of people and makes eye contact. The patient is able to continue good relationship with her family and friends. The patient has no complications during birth The patient is able to handle stress from school or at their house The patients family would go to the church every week

Role-relationship

The patient has easy fatigability and experience difficulty in maintaining relationship with friends

Sexualityreproductive Coping/stress Tolerance Value-belief

The patient would just go home to handle stress from school The patient cannot go to church every now and then since she gets exhausted easily

The patient watches TV most of the time at her room They dont pray every time we open the door for early vital signs

IV.

ANATOMY AND PHYSIOLOGY

The heart is a hollow, muscular organ about the size of ones fist. It lies within the

pericardium and between the lungs but projects more on the left half of the thoracic cavity. It is located posterior to the sternum, anterior to the esophagus and thoracic aorta, and rests on the surface of the diaphragm.

The pericardium is a double-layered dense connective tissue sac which encloses the heart. The outer parietal layer is fibrous sac which suspends the heart to the sternum. The layer is heart a consists sac-like (the middle of three

layers: the pericardium (the outerstructure), layer of myocardium layer). When the immune system begins to attack the heart, it may affect any or through the heart and oxygenation through the body. all of the three layers. If there is an The heart valves are fibrous flaps of tissue found between the heart chambers and in the blood vessels. They allow blood to flow into and out of the ventricles but prevent the backflow into and out of the ventricles but prevent the backflow of the blood. This ensures one-way flow of blood through the heart. infection of the endocardium, the

muscle), and endocardium (the inner

An atrioventricular (AV) valve is located between each atrium and its ventricle. The AV valve between the right atrium and the right ventricle has three cusps and is called the tricuspid valve. The AV valve between the left atrium and left ventricle has two cusps and is called the bicuspid, or mitral (resembling a bishops miter, a two-pointed hat) valve. Each ventricle contains cone-shaped, muscular

pillars called papillary muscles. These muscles are attached by thin, strong connective tissue strings called chordae tendinae to the free margins of the cusps of the atrioventricular valves. The AV valves ensure one-way flow from the atrium to the ventricle. The semilunar valves prevent backflow from the aorta and the pulmonary trunk into the left and right ventricles respectively. Each of these has three cup-like flaps that expand and cover the exits from the ventricles when they fill with blood. The semilunar valve leading to the aorta is valve the aortic the semilunar while

semilunar valve leading to the pulmonic semilunar valve. pulmonary Each valve trunk is the consists of three pocket-like semilunar cusps.

The left ventricle will be used to illustrate the operation of the heart valves. The right ventricle valves work in the same way. When the left ventricle relaxes, blood pushes the cusps of the bicuspid valve toward the ventricle, the valve opens, and the blood flows into the ventricle. The chordae tendinae are slack when the valve opens. When thetoward the ventricle and enters the pockets of the semilunar cusps, back ventricle is relaxed, causing them to fill blood in the aorta flows and expand. The semilunar cusps meet at the midline of the aorta and the semilunar valve closes, preventing the backflow of blood into the ventricle.

When the left ventricle contract, blood pushes the cusps of the bicuspid valve back toward the atrium. When the cusps meet, the valve is closed, preventing the backflow of the blood into the atrium. The papillary muscles contract and the chordae tendinae are drawn

taut, preventing the cusps of the valve from moving backwards into the atria. When the ventricle contracts, blood pushes on the cusps of the semilunar valves, pushing blood out of them. As the cusps empty, they flatten against the wall of the aorta and the semilunar valve opens. Rheumatic heart disease leads mostly to mitral stenosis. As discussed earlier, valves are like doors that open and close depending upon the pressure on each side. With mitral stenosis, blood continues to flow in one direction, but because of the stenosis, or narrowing, less blood moves through the heart. The Immune System Exposure of the body to an antigen can result in the activation of B cells and the production of antibodies. The antibodies bind to the antigens, and though several different mechanisms the antigens can be destroyed. Because antibodies are in body fluids, antibody-mediated immunity is effective against extracellular antigens, such as bacteria, viruses (when they are outside the cells), and toxins. Antibody-mediated immunity can also cause immediate hypersensitivity reactions.

Antibodies response to an

are

proteins They

produced are

in

antigen.

Y-shaped

molecules consisting of four polypeptide chains: two identical heavy chains and two identical light chains. The end of each arm of the antibody is the variable region, which is the part of the antibody that combines with the antigen. The variable region of the particular antibody can only join with a particular antigen. The rest of the antibody is the constant region, which has several functions.

Cell mediated immunity is a function of cytotoxic T cells and is most effective against microorganisms that live inside the cells of the body. All viruses and some bacteria, fungi, and parasites are examples of intracellular microorganisms. Cell mediated immunity is essential for fighting viral infections. When virus infects cells, they direct the cells to make new viruses, which are then released and infect other cells. Thus, cells are turned into virus manufacturing plants. Cell-mediated immunity fights viral infections by destroying virally infected cells. A cytotoxic T cell binds into a target cell and releases chemical that cause the target cell to lyse. Perforin forms a channel in the plasma membrane of the target cell through which water enters the cell, causing lysis. The cytotoxic T cell then moves on to destroy additional target cells. In rheumatic heart disease, the bodys immune cells are unable to distinguish between Group A streptococcus bacterias antigens and antigens present on the bodys own cells, resulting in the immune cells attacking the body.

V. PATHOPHYSIOLOGY OF RHEUMATIC HEART DISEASE

VI.

COURSE IN THE WARD

On the 27th of January 2011, a 9-year old female from Marshall Island was admitted under the service of Dr. Romeo Saavedra in Medical Unit of St. Lukes Medical Center with initial assessment and diagnosis of Rheumatic Heart Disease, Severe Mitral Regurgitation, Severe Tricuspid Regurgitation and S/P Mitral Repair last February 17, 2009. She has admitting vital signs of, 37.7C, 92bpm for pulse rate, 27cpm respiratory rate and 90/60mmgHg for blood pressure. The physician ordered chest x-ray, BUN, Creatinine, Sodium and Potassium Test, EKG, Complete Blood Count and Urinalysis. The additional diagnostic examinations were ASO Titer, 2DEcho with Cola Doppler and later on ruled out of infective endocarditis and Blood Culture and Sensitivity. She was put into regular diet. On 28th of January, PRBC of 2 units were prepared and she was scheduled for mitral valve replacement. The informed consent is secured. On the 30th of January, chest x-ray results available, indicated, t/c volume loss and pneumonia. February 1, 2011, Tuesday, 6:35am Patient was put into NPO Scheduled operation at exactly 8:00am Given Cefordion, 500mg in operating room. IVF started D5 .03NaCl 1L, 30cc/hour

At 11:35pm vital signs was ordered for every 15 minutes February 2, 2011, Wednesday, 8:43am Start KCl drip 40mg/100ml preparation, 10cc/hour to run for an hour NTG drip to follow, 10mg/10ml preparation, 3.6cc/hour 8/F EXTUBATION Hooked O2 support at 2LPM/NC NPO for two hours and may have sips of water with strict respiration precaution once fully awake.

Vital sign: 140/100mmgHg blood pressure May give 1 unit of PRBC Chest X-ray at 10:00pm done D5 .03 NaCl to run for 20cc/hour to consume, then shift to D5 IMB, Given Nalbuphine and Furosemide IV at 11:30pm Continuous furosemide for 12 hours (12am-12pm) After PRBC transfusion, flush with 5cc of PNSS then shift to Heplock

On 3rd of February 10:00 am, the patient was transferred to PICU, connected to cardiac monitor and attached CVP lines. Monitor VS for every 15 minutes and hourly thereafter. The nurse on duty endorsed, left radial arterial line, right hand heplock, Left IJV, white port for CVP and brown port for NTG, with two (2) JP drains, with foley catheter and pacing wire. Vital signs recorded, 90-120/60-80mmHg, 20-30bpm respiratory rate, >95% O2 Saturation. She is still for chest x-ray in PICU. Medications were as follows: Nalbuphine 2mg IV, q6 and PRN if there is pain and client is agitated, Ketorolac 10mg IV q6 and Furosemide 10mg IV q12. On 4th of February, NTG was shifted to 5cc/hr (4mg/kg/min). Blood pressure of 100/50mmHg is recorded on 5th of February. At around 2:40pm, she is into vital signs monitoring hourly, D5 IMB 1L to run for 27cc/hour and NTG to run for 3cc/hour. Given Captopril 7mg 1tab PO, once a day if systolic is greater than 100. Shes for repeat PT/PTT. The arterial line was removed at 4:00pm and the NV line was only removed. The IVF rate was decreased into 20cc/hour. February 6, 2011, Monday, 6:40am Vital signs taken, BP: 138/60mmHg, The Captopril dosage was increased into 12mg NTG was ordered to gradually decrease. The physician ordered to stop Heparin for medication. The diet was changed into Diet for Age (Coumadin Precaution) IVF rate was decreased into KVO (10cc/hour). Transferred out to PICU and returned to Medical Unit Furosemide discontinued as ordered. Vital Signs monitoring every 2 hours.

February 7, 2011, Tuesday Vital signs taken, 90/70mmHg No edema noted by the physician Clear breath sounds Good appetite Possible discharge ordered by Dr. Romeo Saavedra.

VII.

DIAGNOSTIC PROCEDURE & LABORATORY EXAMINATION

Date: February 5, 2011 Time: 8:12 Specimen: Plasma Test

Prothrombin time (Control) Prothrombin time (Test) Prothrombin time (%) INR Partial Thromboplastin Time

Result
12.5 sec 36.2 sec 16% 3.05 65.1 sec

Normal Range
11.9-14.2 0.90-1.19 29.5-39.9

Interpretation Increased INR means that the warfarin/ heparin therapy is effective. It minimizes formation of clot or thrombus in the newly placed valve.

Date: February 5, 2011 Time: 12:33 Specimen: Plasma Test

Prothrombin time (Control) Prothrombin time (Test) Prothrombin time (%) INR Partial Thromboplastin Time

Result
12.5 sec 34.1 sec 17% 2.87 77.2 sec

Normal Range
11.9-14.2 0.90-1.19 29.5-39.9

Interpretation Increased INR means that the warfarin/ heparin therapy is effective. It minimizes formation of clot or thrombus in the newly placed valve.

Date: February 5, 2011 Time: 5:28 Specimen: Plasma Test

Prothrombin time (Control) Prothrombin time (Test) Prothrombin time (%) INR Partial Thromboplastin Time

Result
12.5 sec 29.2 sec 21% 2.46 158.7 sec

Normal Range
11.9-14.2 0.90-1.19 29.5-39.9

Interpretation Increased INR means that the warfarin/ heparin therapy is effective. It minimizes formation of clot or thrombus in the newly placed valve.

Date: February 4, 2011 Time: 6:53 Specimen: Complete Blood Count Test
Hgb Hct RBC WBC Differential count Neutrophil Lymphocytes Monocyte Platelet count

Result
13.3 g/dL 39.6% 5.17 mil/mm3 19, 390 mm3 82% 9% 9% 176, 000

Normal Range
11.6-15.5 36-47 4.20-5.40 4,800-10,800 40-74 19-48 3-9 150,000400,000

Interpretation Leukocytosis due to the inflammatory process mediated by RHD

MCV

MCV MCH MCHC

77 fL 26 pg 34%

82-98 28-33 32-38

Date: February 4, 2011 Time: 6:43 Specimen: Plasma Test

Prothrombin time (Control) Prothrombin time (Test) Prothrombin time (%) INR Partial Thromboplastin Time

Result
12.4 sec 22.8 sec 29% 1.91 83.7 sec

Normal Range
11.9-14.2 0.90-1.19 29.5-39.9

Interpretation Leukocytosis due to the inflammatory process mediated by RHD

Date: February 4, 2011 Time: 6:01 Specimen: Blood Test

SGPT/ALT Sodium Potassium Calcium

Result
60 u/L 136 mmol/L 3.8 mmol/L 9.1 mg/dL

Normal Range
30-65 u/L 136-145 mmol/L 3.5-5.1 mmol/L 8.5-10.1 mg/dL

Interpretation

Date: February 2, 2011 Time: 8:41 Specimen: Plasma

Test
Prothrombin time (Control) Prothrombin time (Test) Prothrombin time (%) INR Partial Thromboplastin Time Date: February 2, 2011

Result
12.1 sec 13.7 sec 63 % 1.14 35.1

Normal Range
11.9-14.2 sec 0.90-1.19 29.5-39.9

Interpretation

Time: 8:41 Test

Hgb Hct RBC WBC Differential count Neutrophil Lymphocytes Monocyte Platelet count MCV MCH MCHC

Result
11.4 g/dL 34.3% 4.66 mil/mm3 15,920 mm3 91% 2% 7% 175,000 74 fL 25 pg 33%

Normal Range
11.6-15.5 g/dL 36-47% 4.20-5.40 mil/mm3 4,800-10,800 40-74 19-48 3-9 150,000400,000 82-98 28-33 32-38

Interpretation Leukocytosis due to the inflammatory process mediated by RHD

Test
SGPT/ALT

Result
60 u/L

Normal Range
30-65

Interpretation

Sodium Potassium Calcium Magnesium

142 mmol/L 3.2 mmol/L 9.2 mg/dL 2.4 mg/dL

136-145 3.5-5.1 8.5-10.1 1.8-2.4

Dept. of echocardiography

Interpretation
Intact atrial septum, appears midline Intact ventricular septum 1+ aortic regurgitation Posterior mitral valve leaflet restricted in nomotion 3+ mitral regurgitation Non coaptation of the mitral valve leaflets Tricuspid regurgitation with a systolic gradient of 48mmHg Mitral valve annulus 3.2 cm Dilated L ventricle Dilated L atrium

Date: January 28, 2011 Test

Chest diagnostic radiology

Result

Normal Range
-

Interpretation
Consider volume loss or pneumonia, left lower lobe

Multi-chambered cardiomegaly without venous congestion.

Clinical Chemistry (blood) Creatinine

Blood Urea nitrogen Sodium Potassium

0.50 mg/dL
10 132 4.0 mmol/L

0.60-1.2 mg/dL 7-18mg/dl 136145mmol/L 3.5-5.1

Test Anti-streptolysin O Fasting blood sugar

Result
< 200.0IU/ mL 85 mg/dL

Normal Range
< 200.00 IU/mL

Interpretation An increase in Anti-streptolysin indicates recent infection of Streptococcus.

70-110mg/ dL

Specimen: Urine Test Chemical examinations Color Transparency Glucose Bilirubin Ketone Specific gravity pH (reaction)

Result
Yellow

Normal Range

Interpretation

slightly hazy
negative negative negative </=1.005 6.0 (acidic) Negative

Protein Urobilinogen Nitrites Blood Luekocytes

Urine sediment analysis by flow cytometry Red blood cells White blood cells Epithelial cells Casts Bacteria

>/+8.0 EU/dL Negative Moderate (+) Trace

1 4 1 1 5

/ / / /

HPF HPF HPF HPF

0-2 0-3 0-3 0-3 0-50 Interpretation Intact atrial septum, appears midline Intact ventricular septum 1+ aortic regurgitation Posterior mitral valve leaflet restricted in 3+ mitral regurgitation Non-coaptation of the mitral valve leaflets Tricuspid regurgitation with septalic gradient of 48mmhg Mitral valve annulus 3.2cm Dilated left ventricle and atrium

Test Electrocardiography

Date: January 29, 2011 Test Blood group Rh-factor Result

0 (+)

Interpretation Client has O+ Bloodtype

Antibody screening Date: February 2, 2011 Test Creatinine Blood Urea Nitrogen Sodium Potassium Hematology( plasma) Partial thromboplastin time Test
Hemoglobin Hematocrit RBC WBC Differential Count

(-)

Result
142 3.2 9.2 2.4 35.1 sec

Normal Range
136-145 3.5-5.1 8.5-10.1 1.8-2.4

Interpretation

Result
11.4 34.3 4.66 15,920

29.5-39.9 Normal Range

11.6-15.5 36.0-47.0 4.20-5.60 4,800-10,820

Interpretation Leukocytosis due to the inflammatory process mediated by RHD

Date: February 3, 2011 Test Clinical chemistry Creatinine BUN Na K WBC Neutrophils Result
0.58 11 138 4.0 18,300 86 8

Normal Range
0.60-1.20 7-18 136-145 3.5-5.1

Interpretation

Lymphocytes
Hazy opacities in the right lung base which may relate to volume loss Unchanged left lower lobe opacities ET tube is no longer seen Rest of the finding are stationary

VIII. DRUG STUDY DRUG Generic name: captopril

DOSAGE Stock Dose: 25mg/tab

MECHANISM OF ACTION Blocks the conversion of angiotensin I to the vasoconstric tor angiotensin II. Increase plasma renin levels and reduce aldosterone level

INDICATION/ CONTRAINDICATIONS Indication: For management of hypertension

SIDE EFFECTS AND ADVERSE REACTIONS Side Effects: Nausea and vomiting Taste disturbances hypotension

NURSING CONSIDERATION Assessment: - Monitor blood pressure and pulse frequently during initial dose and during the therapy - Monitor patient for signs of angioedema (facial swelling, dyspnea) - Monitor weight and assess patient routinely for fluid overload Planning: - Administer 1 hr before or 2 hrs after meals. May be crushed if patient has difficulty swallowing. Implementation: - Instruct patient to take medication as directed. Do not double dose. - Caution patient to avoid salt substitutes or foods containing high levels of potassium or sodium unless directed by health care professionals. - Caution patient to change position slowly to minimize hypotension. - May cause

Brand name: Capoten

Ordered Dose: 25mg/tab -

Contraindications: Hypersensitivity to the drug History of angioedema with previous use of ACE inhibitors Adverse Reactions: Chest pain Abdominal pain Muscle cramps and weakness Angioedema

Functional Class: Anti-Hypertensive

Per Orem(Oral) Once a Day

Chemical Class: Angiotensinconverting enzyme (ACE) inhibitor

DRUG

DOSAGE

MECHANISM OF ACTION Binds to bacterial cell wall membrane, causing cell death

INDICATION/ CONTRAINDICATION Indication: Perioperative prophylaxis

SIDE EFFECTS AND ADVERSE REACTIONS Side Effects: Nausea Vomiting

NURSING CONSIDERATION Assessment: Assess for signs of infection at beginning and during therapy Planning: Administer around the clock. May be given on full or empty stomach. Implementation: Instruct patient to take medication around the clock and do not double dose. Instruct patient to notify health care provider if fever and diarrhea develop, especially if -

Generic name: cefazolin

Stock Dose: 500 mg/ml

Brand name: Ancef

Ordered Dose: 500 mg

Contraindication: Hypersensitivity to cephalosporins or penicillins

Adverse Reactions: Rashes Hemolytic anemia Diarrhea

Given dose: 1 ml Functional Class: Anti- infective Q8

Chemical Class: First generation cephalosporin

IV

diarrhea contains blood, mucus or pus.

DRUG Generic name: midazolam

DOSAGE Stock dose: 1 mg/ml

MECHANISM OF ACTION Acts at many levels of the CNS to produce generalized CNS depression

INDICATION/ CONTRAINDICATIONS Indication: Preprocedural sedation and anxiolysis in pediatric patients

SIDE EFFECTS AND ADVERSE REACTIONS Side Effects: Drowsiness Headache Blurred vision Nausea Vomiting

NURSING CONSIDERATION Assessment: Assess level of sedation and level of consciousne ss throughout and for 2-6 hours following administrati on Monitor vital signs throughout administrati on. Oxygen and resuscitative equipment should be immediately available

Brand name: Versed

Ordered Dose: 1mg

Contraindications: Given Dose: 1 ml Hypersensitivity Comatose patients or those with preexisting CNS depression

Adverse Reactions: Laryngospasm Respiratory depression

Functional Class: Anti-anxiety; sedative IV

Chemical Class: benzodiazepine

Once pre-op

Planning: administer over at least 2 minutes and allow an additional 2 or more minutes to fully evaluate the sedative effect Implementation: Inform patient that this medication will decrease mental recall of

DRUG

DOSAGE

MECHANISM OF ACTION Alters the perception of and response of painful stimuli while producing generalized CNS depression

INDICATIONS/ CONTRAINDICATION Indications: Moderate to severe pain Sedation before surgery

SIDE EFFECTS AND ADVERSE REACTIONS Side Effects: Dizziness Head ache Sedation

NURSING CONSIDERATION Assessment: Assess vital signs before and during administrati on - Assess type, location and intensity of pain before and 30 minutes after IV administrati on Planning: Administer drug slowly Implementation: Explain therapeutic value of medication before administrati on to enhance analgesic effect May cause drowsiness and dizziness, instruct patient to ask for assistance during ambulation Caution patient to change position slowly to minimize -

Generic name: nalbuphine

Stock Dose: 10 mg/ml

Brand name: Nubain

Desired dose: 2mg

Adverse Reactions: Contraindication: Hypersensitivity to nalbuphine or bisulfites Dry mouth Blurred vision Euphoria Clammy feeling

Computed Dose: 0.2 ml Functional Class: analgesic IV q6 Chemical Class: Opioid agonists/ analgesics

DRUG

DOSAGE

MECHANISM OF ACTION Inhibits prostaglandin synthesis, producing peripherally mediated analgesia.

INDICATION/ CONTRAINDICATION Indication: Short term management of pain

SIDE EFFECTS AND ADVERSE REACTIONS Side Effects: Drowsiness Dizziness Headache

NURSING CONSIDERATION Assessment: Assess pain before and 1-2 hours after drug administratio n Assess for rhinitis and asthma

Generic name: ketorolac

Stock Dose: 15 mg/ml

Brand name: Toradol

Ordered dose: 10mg

Contraindication: Hypersensitivity

Adverse Reactions: Dry mouth GI pain

Given dose in IV: Functional Class: Nonsteroidal anti inflammatory IV Chemical Class: Pyrroziline carboxylic acid q6 0.7 ml

Planning: Administer undiluted and over 15 sec. Implementation: May cause dizziness and drowsiness, advise patient to ask for assistance when moving. Advice patient to -

consult health care professional if rash, itching, visual disturbances , tinnitus, weight gain, edema, black stools, persistent headache occur.

DRUG

DOSAGE

MECHANISM OF

INDICATION/

SIDE EFFECTS AND ADVERSE

NURSING

ACTION Generic name: furosemide Stock Dose: 10 mg/ ml Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule.

CONTRAINDICATION Indication: Hypertension

REACTION Side Effects: Dizziness Headache Blurred vision

CONSIDERATION Assessment: Assess fluid status. Monitor daily weight, intake and output ratios, lung sounds, skin turgor and mucous membranes. Monitor vital signs before and during administration

Brand name: Lasix; Novosemide

Ordered Dose: 10mg

Contraindication: Hypersensitivity

Adverse Reaction: Dehydration Hypovolemi a

Given dose: 1 ml Functional Class: Diuretic IV

Increases renal excretion of water, sodium, chloride, magnesium, potassium and calcium

Chemical Class: Loop diuretic

q12

Planning: May be taken with food or milk to minimize gastric irritation Implementation: Caution patient to change position slowly to minimize orthostatic hypotension Advise patient -

to notify health care professional of weight gain more than 3lbs/day

DRUG

DOSAGE

MECHANISM OF ACTION Interferes with hepatic synthesis of vitamin Kdependent clotting factors

INDICATIONS/ CONTRAINDICATION Indications: Prevention of thrombus formation and embolization after prosthetic valve replacement Management of myocardial infarction

SIDE EFFECTS AND ADVERSE REACTION Side Effects: Nausea Vomiting

NURSING CONSIDERATION Assessment: Assess patient for signs of bleeding - Stool and urine should be monitored before and periodically throughout therapy Planning: Administer medication at same time each day Implementation: Instruct the patient to take medication exactly as prescribed Advise patient to report any symptoms of unusual bleeding or bruising. -

Generic name: warfarin

Stock dose: 1mg/ tab

Brand name: Coumadin

Ordered Dose: 3 mg

Adverse Reaction: Muscle cramps Fever

Given dose: 3 tabs Functional Class: Anticoagulants Per Orem Once Daily Chemical Class: coumarins

Contraindications: Uncontrolled bleeding

Notify physician if this occurs.

DRUG Generic name: nitroglycerin

DOSAGE Stock Dose: 10 mg/ 10 ml

MECHANISM OF ACTION Increases coronary blood flow by dilating coronary arteries and improving collateral flow to ischemic regions.

INDICATIONS/ CONTRAINDICATIONS Indications: Acute treatment of angina pectoris Production of controlled hypotension during surgical procedures

SIDE EFFECTS AND ADVERSE REACTION Side Effects: Dizziness Headache Restlessness

NURSING CONSIDERATION Assessment: Assess location, duration, intensity, and precipitating factors of patients angina pain Monitor blood pressure and pulse before and after administrati on

Brand name: Tridil

Ordered Dose: 1mg/ml

Adverse Reaction: Blurred vision Hypotension Tachycardia

Functional Class: Anti- angina

Given dose: 1 mg/ml

Contraindications: Hypersensitivity Severe anemia Constrictive pericarditis

IV Chemical Class: Nitrates

Planning: Doses must be diluted and administere d as an infusion. Standard infusion set made of PVC may absorb 80% of the nitroglycerin . Special tubing should be provided Implementation: Caution patient to change position slowly to minimize orthostatic hypotension -

DRUG Generic name: acetaminophen

DOSAGE Stock Dose: 250mg/ 5 ml

MECHANISM OF ACTION Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS

INDICATIONS/ CONTRAINDICATION Indications: Mild pain Fever

SIDE EFFECTS AND ADVERSE REACTION Side Effects: Rash Urticaria

NURSING CONSIDERATION Assessment: Pain: assess type, location, and intensity prior to and 30-60 minutes following administrati on. - Fever: assess fever; note presence of associated signs (diaphoresis , tachycardia and malaise) Planning: Administer with full glass of water - May be given with food or on empty stomach Implementation: -advice patient to take medication exactly as directed and to not take more than the recommended amount. - Advice patient to consult health care professional if -

Brand name: Tempra

Ordered dose: 5 ml

Contraindication: Hypersensitivity

Adverse Reaction: Renal failure Leucopenia

Given Dose: 5 ml Functional Class: Antipyretic, analgesic Per Orem (oral)

Chemical Class: Nonopioid analgesic

Q4

DRUG Generic name: Potassium Chloride Brand name: Kalium durule Functional Class: Replacement solution Chemical Class: Electrolyte

DOSAGE Stock dose: 40mEq/20ml Ordered dose: 40mEq/100ml Infusion: 10ml/hr

MECHANISM OF ACTION Forms and corrects imbalances in acid-base metabolism

INDICATIONS/ CONTRAINDICATIONS Indication: - Hypokalemia Contraindication: - Early post operative oliguria

SIDE EFFECTS AND ADVERSE REACTION Side Effects: - Diarrhea - Nausea and vomiting - Flatulence Adverse Reaction: - Chest tightness - Shortness of breath - Heart failure

NURSING CONSIDERATION Assessment: - Closely monitor the patient with cardiac monitor - Be alert for potassium intoxication. Planning: - Administer the drug if the serum potassium is less than the normal level. Implementation: - Never give via IV push or in concentrate d amounts. - Take extreme care to prevent extravasatio n and infiltration.

VIII. NURSING THEORY

Theory of Comfort Katharine Kolcaba The Comfort Theory focuses on providing the recipients holistic comfort through nursing interventions. Comfort as defined by Katharine Kolcaba, is the state that is experienced by recipients of comfort measures. It is the immediate and holistic experience of being strengthened through having the needs met for the three types of comfort (relief, ease, and, transcendence) in four contexts of experience (physical, psychospiritual, social, and environmental). Kolcaba's comfort theory successfully addresses the 4 concepts comprising the metaparadigm of nursing. Nursing is described as the intentional assessment of comfort needs, design of comfort measures to address those needs, and reassessment of comfort levels after implementation compared to the previous baseline. Assessment and reassessment can be intuitive and/or subjective or objective. Person is described as the recipient of nursing care; the patient may be an individual, family, institution, or community. Environment is any aspect of patient, family, or institutional surroundings that can be manipulated by nurse(s) or loved one(s) to enhance comfort. Finally, health is viewed as the optimum functioning of the patient as they define it.

According to Kolcaba, health care needs are needs for comfort, arising from stressful healthcare situations that cannot be met by recipients traditional support systems. These needs include physical, psychospiritual, social, and environmental needs made apparent through monitoring and verbal or nonverbal reports, needs related to pathophysiological parameters, needs for education and support, and needs for financial counselling and intervention. The health care needs recognized in the case are physical (pain, weakness, fear and/or anxiety with regards to the procedure), psychospiritual (low self-esteem and/or inferiority), social (cultural differences with the healthcare providers, language barrier) and, environmental (change in environment like the weather since the patient came from a different country).

Kolcabas major concepts includes comfort measures, as nursing interventions designed to address specific comfort needs of recipients, including physiological, social, financial, psychological, spiritual, environmental, and physical. Comfort measures provided

for the patient both pre and post operative phases are detailed in the nursing care plan. Another concept is intervening variables, which are interacting forces that influence recipients perception of total comfort. These consist of variables such as past experiences, age, attitude, emotional state, support system, prognosis, finances, and the totality of elements in recipients experience. In the case, the recognized intervening variables are the patients developmental and language as a barrier in communication. In addition, health seeking behaviors are the subsequent outcomes related to the pursuit of health, in consultation with the nurse. It could be internal or external. Thus, the patient is expected to have a cooperative, assertive and trusting behavior towards the nurse and will be able to verbalize her feelings as well as viewpoints that could be a benefit to her health. On the other hand, institutional integrity are the corporations, communities, schools, hospitals, churches, reformatories, etc. that possess qualities or states of being complete, whole, sound, upright, appealing, honest, and sincere. The institutional integrity in the case presented is the patients family and the government who provides benefits for the patient.

Figure 1.1 Comfort Theory applied to Rheumatic Heart Disease S/P Mitral Valve Replacement

Application: Comfort Theory provides relevant aspects of comfort for pediatric nursing and exhibits the holistic nature of comfort as an important goal of care. Thus, it is used as a basis in providing care to the pediatric patient with Rheumatic Fever S/P Mitral Valve Replacement. This theory is useful in assessing and caring for patients in pain. Since Patient J.K. is post operative, pain management can be approached from a comfort perspective: physical, psychospiritual, environmental, sociocultural. In Kolcabas theory, the alternative and complementary therapies are based on a balance of body, mind, and spirit. Thus, holistic comfort is proposed as a framework for guiding nurses to use alternative and complementary therapies in the comfort care for pediatric patients. In the case of the patient, it is not just physical comfort that is provided but also in other aspects of her well-being. The theory emphasizes that the patient should receive individualized, compassionate care in a culture that promotes well-being and comfort of patients, families, and staff. This is similar to the goal of the nursing interventions done for the patient.

In the theory, nurses providing comfort by manipulating the environment (like what Nightingale believed) is a primary role, but also that comfort must also exist for the nurse herself. That is why the nurse primarily assessed herself and her capabilities in providing comfort and nursing interventions considering the use of other language in communicating with the patient. The theory is applicable to all facets of healthcare and management. Its application on geriatric and pediatric units should also be taken consideration. This is for the reason that behavioral and developmental changes are very crucial in these units.

When people need nursing care they are also in need of comfort, and this will never change. Indeed, comfort Theory provides a framework on which to put comfort first.

IX. NURSING CARE MANAGEMENT ASSESSMENT Subjective: The client nods her head when asked if she is scared. Objective: irritated facial tension poor eye contact NURSING DIAGNOSIS Mild anxiety related to surgery PLANNING Short term: After an hour of nursing intervention, the client will appear relax. INTERVENTIONS provide physical contact (hugging or rocking) provide comfort measures(e. g. quiet environmen t) allow the behaviour to belong to the client. do not respond personally stay with the client provide divertional activities (e.g watching television) RATIONALE to sooth fears and provide assurance EVALUATION Goal met.

to increase comfort

verbalizing personally escalates the situation

to offer assurance to divert anxiety

ASSESSMENT Subjective: Pain scale 4/10 on chest and 5/10 on incision site when moved. Hurts little more Objective: facial grimace guarding behaviour on chest and incision site RR: 35

NURSING DIAGNOSIS Acute pain

PLANNING Short term goal: After an hour of nursing intervention client will verbalized decreased in pain scale Long term goal: Client will report no pain and verbalized behavior that avoids pain.

INTERVENTIONS teach client to perform deep breathing exercise. provide comfort measures (e.g. touch, cold packs) provide divertional activities (e.g. watching T.V) use of relaxation techniques (e.g.) collaborate in treatment to administer pain relievers

RATIONALE this helps client to relax

EVALUATION Partially met. because the client reported decrease of pain scale from 4/10 to 2/10 but same on the incision site.

to promote non pharmacolo -gical manageme nt for pain. to destruct and reduced tension

ASSESSMENT Objective: temperature: 38C

NURSING DIAGNOSIS Hyperthermia

PLANNING Short term goal: After 1 hours of nursing intervention, the temperature will decrease by .2 Long term goal: After 8 hours of nursing intervention, the temperature will be back to normal.

INTERVENTIONS promote surface cooling by means of undressing, cool environmen t, tepid spongebath and local ice pack application especially in groin and axillary part. maintain bed rest

RATIONALE to promote non pharmacological manageme nt for pain.

EVALUATION Goal met.

advise to have high caloric diet administer antipyretic medications

to reduce metabolic demands for circulation to meet increase on metabolic demands helps lower the temperatur e

ASSESSMENT Subjective: I dont want to move.. as verbalized by the patient Pain scale: 5/10 Objective: patient was assisted by her father when going to comfort room functional level of classificatio n: 2 (requires help from other person for assistance) limited range of motion

NURSING DIAGNOSIS impaired physical mobility related to pain

PLANNING Short term: After 4 hours of nursing intervention, the client will be able to verbalized understanding of condition. Long term goal: After a day of nursing intervention, the client will be able to participate in ADLs and have an understanding on safety measures.

INTERVENTIONS provide safety measures to the client note behavioural responses to problems of immobility support affected body part encourage participatio n in self care encourage adequate amount of fluids and nutritious foods

RATIONALE so as to prevent client from injury. to identify factors that may lead to attainment of goals to maintain position of function of body part to enhance self concept and sense of independen ce to promote energy production

EVALUATION Goal met.

ASSESSMENT Objective: the client has a surgical site on her chest

NURSING DIAGNOSIS Impaired skin integrity related to surgical site.

PLANNING Short term: After 4 hours of nursing intervention, the client will demonstrate behavior of Long term goal: After a week of nursing intervention, will not manifest signs of infection and will display timely healing of skin lesion without complications

INTERVENTIONS encourage early ambulation or mobilization

RATIONALE promotes circulation and reduces and reduces risks for associated with immobility so as the client will be cooperative on the treatment rendered.

EVALUATION Goal met

assist the client in understandi ng and following medical regimen and developing program of preventive care and daily maintenance assist client to learn stress reduction therapy maintain clean clean and

to help client enhance

to avoid skin breakdown

unwrinkled linens appropriate dressing to wound

to protect wound and surrounding tissues

X. DISCHARGE PLANNING The patient should be given the lists of the medication she needs to take every day with all the proper explanation by giving health teachings about the contraindication of the drugs and its possible effects to the patients body. After the hospitalization, it is good that the patient will have simple but efficient exercises to promote circulation and wound healing. The following exercises would do o Walking for about 30 minutes with assistance The nurse should be able to remind the patient to follow her check up plans for better recovery after the confinement. Health teachings should be on proper way that the patient can understand. The nurse should be able to provide information about the importance of compliance to treatment plan at home. The client should have to follow the strict compliance for medication. In accordance, the nurse should give the follow up treatment dates coming from the physician so client will be able to set those dates free and be in the hospital for follow up. The patient should eat nutritious and heart friendly foods like fruits, vegetables, and milk to help the patient recover. Proper hydration is also important. The nurse should be able to remind the patient to play with her friends but educate in reminding about her condition in avoiding plays that can easily get tired The nurse should remind the patient and significant other to maintain good spiritual habit of going to church every week

XI. BIBLIOGRAPHY Doenges, M., & Moorhouse, M. F. Nurses Pocket Guide 12th Edition Karch, A. (2008). Lippincotts Nursing Drug Guide. Wolters Kluwer: Lippincott Williams & Wilkins Seeley, R., Stephens, T., & Tate, P. (2006). Anatomy and Physiology 7th Edition. New York, NY: MCGraw-Hill. Tomey, A. M., & Alligood, M. R. Nursing Theorists and Their Work Fourth Edition Wilson, B. A., Shannon, M., and Stang, C. (2006. Prentice Hall Nurses Drug Guide http://www.worldlifeexpectancy.com/country-health-profile http://www.mamashealth.com/rheumatic.asp http://emedicine.medscape.com/article/891897-overview http://www.chw.org/display/PPF/DocID/23071/router.asp http://www.histopathology-india.net/RHD.htm http://www.wrongdiagnosis.com/r/rheumatic_heart_disease/causes.htm