I.

INTRODUCTION This was a case study of a 21 years old male patient with admitting diagnosis of Chronic Congestive Heart Failure with Severe Aortic Regurgitation leading to Rheumatic Heart Disease.

Rheumatic heart disease is a condition in which the heart valves are damaged by rheumatic fever. Rheumatic fever begins with a strep throat (also called strep pharyngitis). Strep throat is caused by Group A Streptococcusbacteria. It is the most common bacterial infection of the throat. Rheumatic fever is an inflammatory disease. It can affect many of the body's connective tissues especially those of the heart, joints, brain or skin. Anyone can get acute rheumatic fever, but it usually occurs in children five to 15 years old. The rheumatic heart disease that results can last for life. Rheumatic fever causes heart damage particularly scarring of the heart valves forcing the heart to work harder to pump blood and may eventually cause congestive heart failure.

The following are the most common symptoms for rheumatic fever. However, each individual may experience symptoms differently fever; swollen, tender, red and extremely painful joints particularly the knees, ankles, elbows, or wrists; nodules over swollen joints; red, raised, lattice-like rash, usually on the chest, back, and abdomen; uncontrolled movements of arms, legs, or facial muscles; weakness and shortness of breath.

Management of Chronic Congestive Heart Failure with Severe Aortic Regurgitation leading to Rheumatic Heart Disease includes elevation of the head of the bed, have patient lean on overted table or sit on edge of the bed. Keep environmental pollution to a minimum like dust, smoke and feather pillows, according to individual condition. Regular monitoring of vital signs especially the blood pressure and the heart rate of the patient is essential.

Incidence (annual) of Rheumatic heart disease 194 annual cases Incidence Rate: approx 1 in 23,505 or 0.00% or 11,571 people. Estimated 12 million patients worldwide require further treatments to prevent disability and death. Estimated 8 million school age children worldwide require further treatments to prevent disability and death. May affect 15 per 1,000 school children. Deaths from Rheumatic heart disease: 3,676 deaths. May affect 1.0 deaths per 100,000 menRheumatic Heart Disease and 1.5 deaths per 100,000 women for Rheumatic Heart Disease.

With a good case like this, the group will be able to gain knowledge, acquire skills and have a positive attitude about Congestive Heart Failure. Furthermore, the group will be able to formulate plan of actions, subsequently investigate and manage patient problem by rendering quality health care services. Through this case study, the group can apply the necessary nursing management to the patient suffering from CHF during emergency hours that needs immediate nursing intervention

II. OBJECTIVES General Objectives: This case study aims to develop the knowledge, skills and attitudes of the second year nursing students through effective utilization of nursing process in dealing with the course of nursing management in patients with Rheumatic Heart Disease.

Specific Objectives: At the end of the study, the second year nursing students will be able to: 1. Discuss the patients profile, past medical history, personal and social history as well as the present illness of the patient. 2. Assess the overall condition of the patient through cephalocaudal assessment. 3. Discuss the anatomy and physiology of the involved system.
4. Discuss the pathophysiology of Rheumatic Heart Disease

5. Utilize the nursing process as a baseline guide to the delivery of health care to the patient. 6. Identify medications prescribed by the physician and its therapeutic actions. 7. Discuss the discharge planning to provide continous care even client is at home.

III.

Patients Profile Patient X 21 years old Male February 26, 1988 Single #142 Cuta West, Batangas City Filipino Roman Catholic February 07,2010 From Emergency Room Cardio Dr. Gonzales, Andrew M. Dr. Magadia, Abegael V. Gley Ann C. Lanorias Difficulty of breathing (DOB) Chronic congestive heart failure with severe aortic regurgitation

Name: Age: Sex: Date of Birth: Civil Status: Address: Nationality: Religion: Date of Admission: Type of Admission: Service: Attending Physician: Resident on Duty: Attending Nurse: Chief Complaint: Admitting Diagnosis:

Final Diagnosis:

Rheumatic Heart Disease

IV.

Clinical Appraisal

A. Past Health History Patient X is a Fully Immunized Child with no allergy to drugs, animals, insect bites and to other medications. During his childhood life, he acquired tonsillitis manifested with fever. It was happen frequently until he was diagnosed when he was 10 years old with a heart disease. Meanwhile he was a victim before of a vehicular accident which causes to him to have many scars to his extremities. Unluckily vehicular accident happen two times during his adolescent life. The disease experiencing by the patient was not chronic before but because of unhealthy lifestyle like drinking alcoholic beverages and inadequate sleep the disease got worst. Last January 09,2010 he was admitted in Jesus of Nazareth Hospital with a following chief complaint of chest pain and difficulty in breathing. After 6 days he was discharge on January 15, 2010.

B. Family History Patient X have four siblings and he was the second child of his family.His elder sister named Ms. M was her care taker of him. His Tita help their financial problem and help him in his recovery. His father Mr. M was died at the age of 42 and his mother Mrs. E was in Palawan. His grandparents were still alive. His father has a history of Diabetes and her mother have asthma.

C. Personal History The patient personal habit was watching T.V. and playing cards. The patient had poor sleeping pattern because he cant sleep very well when he was in supine position. He avoid foods that are salty and rich in fats. He ate 3 times a

day. His personal habits before was bad because of drinking alcholic beverages. Walking everyday was his exercise.

D. Social History Patient X believes in albularyo and some myths because he said, some of them are true and theres no bad in believing. He was an undergraduate of highschool eventually second year high school. With regards to money matters he said, the money was not enough and his elder sister was not working yet only his tita support them. They lived in a one compound at the Cuta, Batangas City. They were secured enough to their place. Services available to their community was used enough by them because they were EBD user. His family was tightly bonded and had a good relationship with one another.

E. Psychologic History His major stressor was the money itself because without this his theraphy cannot be continue. He always experienced nervousness and his usual coping pattern was to take some advised to his family. He communicated well with eyeeye contact and lying at his bed. He used verbal and non-verbal communication.

F. History of Present Illness It was February 07, 2010 when he was admitted at Jesus of Nazareth Hospital with admitting diagnosis of chronic congestive heart failure with severe aortic regurgitation with a chief complaint of difficulty in breathing. This is the fifth time of him being admitted in the hospital. The associated signs and symptoms manifested by the patient were edema, difficulty in breathing, unable to sleep, decrease appetite and nausea.

VI. DIAGNOSTIC AND LABORATORY EXAM Examination Result Reference Value Analysis

White Blood Cell

7.6

5.0-10.0x10u/L

Normal. No signs of infection

Red Blood Cell

5.20

M: 4.5-6.3x10 u/L F: 4.2-5.4x10 u/L

Normal. There is a proper oxygenation. Abnormal.

Hemoglobin

13.5

M: 14-18 g/ dL F: 12-16 g/dL

A
in usually

shows an ineffective oxygenation lungs. Heart In in cases the of the

Failure,

haemoglobin decreases because of pulmonary congestion.

Hematocrit

47

M: 36-58 F: 36-46

Normal. No significant sign of hemorrhage.

Platelet

143

150-400x10 u/L

Abnormal. High risk for viral infection.

Segmenter

45%

45-65%

Normal. No signs of clotting.

Lymphocytes

50%

20-40%

Abnormal. High risk for viral infection

Monocytes

5%

2-8%

Normal.

Creatinine

159.1

53.0-115 mmol/L

Abnormal. Reduced blood flow to the kidney due to congestive heart failure.

Sodium

135.4

135.0-145 mmol/L

Normal. Indicates osmotic balance.

Potassium

4.07

3.50- 5.30 mmol/L

Normal. There is normal and regular pulse rate.

HEMATOLOGY SUMMARY:

The hematology examination done on February 9, 2010 at around 10:00pm shows that the client has a low level of lymphocytes and platelet counts suggesting that the client may have a systemic viral infection, which can be brought about by the disease. The decrease in the haemoglobin may be a result of the decrease oxygenation of the blood due to pulmonary congestion in heart failure. The White Blood Cell count, specifically the segmenters or the neutrophils and appeared to be normal.

URINALYSIS color transparency sugar protein pH Specific gravity MICROSCOPIC pus RBC Epithelial cell 13-15/ hpf >50/hpf Few Light yellow Slightly turbid Negative Negative 6.0 1.010

A. urates bacteria Crystals Mucus threads others

Few Moderate Calcium oxalate-few

Pus in clamps: 0-1/hpf

Urinalysis
-

In our case, we determine that the patient have some bacteria in his urine

so he is at risk of infections. Urine may be cloudy (turbid) because it contains red or white blood cells, bacteria, fat, mucus, digestive fluid (chyle), or pus from a bladder or kidney infection. There is also presence of moderate bacteria in the urine . It may be a symptom of urinary tract infection or contamination of the external genitalia.

VII. PATOPHYSIOLOGY

PATOPHYSIOLOGY

Rheumatic Heart Disease that leads Congestive Heart Failure

IX. PROGNOSIS Congestive heart failure (CHF), or heart failure, is a condition in which the heart can't pump enough blood to the body's other organs. This can result from narrowed

arteries that supply blood to the heart muscle. The "failing" heart keeps working but not as efficiently as it should. People with heart failure can't exert themselves because they become short of breath and tired. February 7, 2010, 7:02pm upon his admission to Jesus of Nazareth Hospital with the chief complaint of difficulty of breathing, His vital signs were 100/60mmHg, 75 beats per minute, 36.5 C, and 25 breaths per minute. After thorough examination, he underwent some laboratory tests like blood chemistry, complete blood count, chest X ray and Urinalysis.Tests result for blood chemistry revealed a decreased in platelet and lymphocyte count which means that the patient are at high risk of viral infection. There is also increased creatinine which indicates that there is a reduced blood flow to the kidney due to congestive heart failure. Patient X was positioned in Semi-fowlers position and given oxygen therapy. He was later on examined by Dr. Andrew Gonzales, his attending physician. Student nurses from the Lyceum of the Philippines University Batangas did a complete physical examination of the patient. They were also allowed to handle him for two days during their stay. These days, the students rendered care for the patient. The patient was given the medications like namely Lanoxin, Aspilet or Aspirin, Nexium, Inoflox, and Dobutamie. Salt is also restricted to his diet. Student nurses also played their part in giving quality care. After 2 days of hospital stay, there was improvement in the patient as verbalization that hes condition is getting better unlike before. He can walk around and also has diminished difficulty of breathing. However, he cannot do his ADLs including his self care. His vital signs were frequently assessed for any abnormalities. This we can say that the prognosis was good. Unfortunately the patient was not discharged during the stay of the student nurses.

XII. DISCHARGE PLANNING

The recovery and rehabilitation process following congestive heart failure may be prolonged thus require patience and perseverance on the part of the patient and family. MEDICATIONS:
o

Reinforced the importance of medication compliance to patient and her relatives: the time, frequency, duration, dosage and route.

Advised to report unusual manifestations and side effects of drugs to the physician.

o Instructed the patient and family to take and continue home medication at home prescribed by her physician the following drugs: Aspilet 80mg 1tab OD Nexium 40mg 1 tab OD Inflox 200mg 1tab BID Lanoxin 25mg IV Q4 Dobutamine 250 mg IV to incorporate

EXERCISE: o Advised the patient not to do strenuous activities, practice good breathing exercises and have a long periods of rest after every activity to reduce fatigue and to regain his strength.
o

Have a moderate exercise that the patient can tolerate like brisk walking.

TREATMENT: o Explained to the patient and relatives facts about Congestive Heart Failure and its management.
o

Encouraged the patient to comply with the treatments and therapies needed.

o Instructed the patient and family to monitor if the patient will complain for chest pain and difficulty of breathing and to take medications prescribed in right frequency, dosage and route.

HYGIENE AND ENVIRONMENT:

Instructed the patient to maintain proper hygiene and explain its importance. Instructed the patient to have a good personal hygiene which includes a bath everyday, oral care, hair care and genital care.

Instructed the clients relative to provide a calm, non stressful environment. Instructed the patient to always have a good sleep, start the day good and avoid stress that may worsen his condition.

OUTPATIENT DEPARTMENT: o Instructed the patient and family to have a continuous check up and consultation at Jesus of Nazareth Out Patient Department section when there will be the discharge form of the patient. DIET: o Instructed the patient to have a low-sodium, low fat-diet, because too much sodium in the diet causes your body to retain water and makes it harder for your heart to pump. o Eat nutritious foods like vegetables, fruits and non-fat milk and avoid smoking and drinking.

SPIRITUAL:
o

Discussed with the patients relative on alternative ways in showing affection and care. Encouraged the patient to hold his faith in God.

o Instructed the patient and family to ask for the guidance of Almighty God for fast recovery and coping to his present condition. SEXUALITY: o Have a proper genital care everyday and have a good hygiene.

XIII. ACKNOWLEDGEMENT We wish to convey our indebt, heartfelt appreciation and sincere gratitude to the following, for those help, this study wouldnt be possible. To the staff nurses of the station II, for their warmth acceptance and trust on our knowledge, skills and attitude in handling cases and trust on our knowledge, skills and attitude in handling cases like this. To our Clinical Instructor, Maam Pagcaliwagan, for her moral support, guidance and stimulating questions and suggestions. To our group mates for making this one week duty an unforgettable experience. To our family for their never ending moral and financial support. To our patient, and her relatives, for their warmth acceptance and in outmost cooperation allowing us to undergo an assessment to be the subject of the study sealed with confidentiality and professionalism.

And above all to our Almighty Father, for giving us, wisdom, intelligence and strength in the completion of this case study.

BIBLIOGRAPHY Bare, Brenda G., Brunner and Suddarths Textbook of Medical Surgical Nursing 11th edition, Volume 1 and 2, Lippincott Williams and Wilkins, 2006 Doenges, Marilyn E. Nurses Pocket Guide, 8th edition, F.A. Davis Co., 2002 McCann, Schilling Judith A., Nursing Drug handbook 2007, 27th edition, Lippincott William and Wilkins, 2007 Reilly HF, Al-Kawas FH. Dieulafoys lesion. Diagnosis and management. Dig Dis Sci, 1991;36:1702-1707 Health Assessment in Nursing Third Edition by Lippincott Williams and WIlkins Websites: http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=1307465&pageindex=1 http://www.wikipedia.com www.emedicine.com/med/byname/Rheumatic Heart Disease http://www.siumed.edu/~dking2/crr/rnguide.htm#glomerulus