Transcript
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 patient’s 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. Patient’s Profile
Name: Patient X
Age: 21 years old
Sex: Male
Date of Birth: February 26, 1988
Civil Status: Single
Address: #142 Cuta West, Batangas City
Nationality: Filipino
Religion: Roman Catholic
Date of Admission: February 07,2010
Type of Admission: From Emergency Room
Service: Cardio
Attending Physician: Dr. Gonzales, Andrew M.
Resident on Duty: Dr. Magadia, Abegael V.
Attending Nurse: Gley Ann C. Lanorias
Chief Complaint: Difficulty of breathing (DOB)
Admitting Diagnosis: Chronic congestive heart failure with severe aortic
regurgitation
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 can’t 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 there’s 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 eye-
eye 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.
Hemoglobin 13.5 M: 14-18 g/ dL
F: 12-16 g/dL
Abnormal. A
decrease in
hemoglobin usually
shows an ineffective
oxygenation in the
lungs. In cases of
Heart Failure, the
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 Light yellow
transparency Slightly turbid
sugar Negative
protein Negative
pH 6.0
Specific gravity 1.010
MICROSCOPIC
pus 13-15/ hpf
RBC >50/hpf
Epithelial cell Few
A. urates Few
bacteria Moderate
Crystals Calcium oxalate-few
Mucus threads
others 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-fowler’s 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 he’s condition is getting better unlike before. He can walk around
and also has diminished difficulty of breathing. However, he cannot do his ADL’s
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.
o 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:
o Instructed the patient to maintain proper hygiene and explain its
importance.
o Instructed the patient to have a good personal hygiene which includes a
bath everyday, oral care, hair care and genital care.
o Instructed the client’s 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 patient’s 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 wouldn’t 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, Ma’am 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 Suddarth’s 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. Dieulafoy£§s 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
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