VELEZ COLLEGE OF NURSING

F. RAMOS STREET, CEBU CITY

A CASE STUDY ON PATIENT, M.D.D., 16 YEARS OLD, MALE, DIAGNOSED WITH RHEUMATIC HEART DISEASE

SUBMITTED BY:

ABELLA, CHARMIS LOVE

ALCALA, ALTHEA
BACLAY, JAYE
BARING, LEAH LOUISSE
BRAULIO, PATRICIA MARIE
CALDERON, CARMELA ALLIAH
CASANA, ERIKA QUEEN 
DAPO, MARIA JOSHEIL 
LAGUE, INA KRIZIA
LAURENCE, KRYSTAL
 MEDIDAS, STEPHANIE NICOLE
MISA, MA. FAUSTINA MAXINE
ONG, RIKKI JAN
POSTANES, JERKIN RAZHED
RAVANES, ALEXI GABRIELLE
RUBIO, LIAM
TEJANO, KIMBERLY ROSE
VALENCIA, KYLE MATTHEW

WARD 1 PPA
SUBMITTED TO:
Ms. Elyza Kimberly Villarante
INTRODUCTION
Rheumatic Heart Disease
         Rheumatic Heart Disease (RHD) is the result of permanent heart valve damage secondary to acute rheumatic fever and the resultant rheumatic carditis
involving pericarditis, myocarditis, or valvulitis. With chronic rheumatic heart disease, patients develop valve stenosis with varying degrees of regurgitation, atrial
dilation, arrhythmias, and ventricular dysfunction, this also remains the leading cause of mitral valve stenosis and valve replacement.
Classifications of Heart Disease:
Class I - No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation or dyspnea.
Class II - Slight limitation of physical activity. Comfortable at rest but ordinary physical activity results in fatigue, palpitation or dyspnea.
Class III - Marked limitation of physical activity. Comfortable at rest but less than ordinary physical activity results in fatigue, palpitation or dyspnea.
Class IV - Unable to carry out any physical activity without discomfort. Symptoms at rest. If any physical activity is undertaken, discomfort is increased.
CAUSE:
         It is caused by rheumatic fever or an episode or recurrent episodes of ARF, where the heart has become inflamed. The heart valves can remain stretched
and/or scarred, and normal blood flow through damaged valves is interrupted. This can result in narrowing or leaking of the heart valve making it harder for the
heart to function normally.
SIGNS AND SYMPTOMS:

 Chest pain
 Fever
 Swollen, tender, red and extremely painful joints
 Red, raised, lattice-like rash, usually on the chest, back, and abdomen
 Shortness of breath and chest discomfort
 Uncontrolled movements of arms, legs, or facial muscles
 Weakness
 Palpitations
NURSING MANAGEMENT:

 Evaluate patient’s comfort level.

 Assess for effectiveness of drug therapy.
 Monitor and record temperature
 Administer penicillin therapy as prescribed to eradicate hemolytic streptococcus.
 Assess for signs and symptoms of acute rheumatic carditis (chest pain, palpitations, tachycardia, bradycardia)
  Monitor and document heart sounds especially presence of murmurs or extra heart sounds.
 Provide diversional activities that prevent exertion such as playing mobile games or watching videos.

MEDICAL MANAGEMENT:

 Antibiotics can usually treat strep throat (a Streptococcus bacterial infection) and stop acute rheumatic fever from developing. Children or young
adults with heart damage from rheumatic fever may need to take daily antibiotics until they are 25 to 30 years old. This helps to prevent another
bout of rheumatic fever and avoid the development of infective endocarditis – an infection of the heart valves or lining of the heart.

 Anti-inflammatory drugs may be used to reduce inflammation and lower the risk of heart damage.
SURGICAL MANAGEMENT:

There are different kinds of heart surgery for RHD:

 Balloon valvotomy / Commissurotomy. This operation can be done by threading a deflated balloon on wires up to the heart from a cut in the
groin. The narrowed mitral valve is opened by gently inflating a balloon inside the valve. It requires only a small cut in the groin, this reduces costs
and complications compared with open surgical repair, providing a safe and effective option for low resource settings.

 Valve repair. It is an open heart surgical procedure, which means surgeons need to open up the chest and operate directly on the hear. Surgeons
repair the shape and function of damaged valve leaflets allowing for more normal blood flow. Repair offers the best outcomes for children and adults
with RHD.

 Valve replacement. This is an open heart surgical procedure, which removes the damaged heart valve and replaces it with a mechanical prosthetic
(metallic valve) or bioprosthetic valve (tissue valve). Bioprosthetic valve replacements cause fewer blood clot complications than metal valves but
are more likely to wear out and require replacement. Mechanical valve replacement is associated with high risk of embolism and haemorrhagic
complications but usually last for life.
DIAGNOSTIC TESTS AND LABS:
         Along with a complete medical history and physical exam, tests used to diagnose rheumatic heart disease may include:
  Echocardiogram (echo)- This test uses sound waves to check the heart's chambers and valves. The echo sound waves create a picture on a
screen as an ultrasound transducer is passed over the skin overlying the heart. Echo can show damage to the valve flaps, backflow of blood
through a leaky valve, fluid around the heart, and heart enlargement. It’s the most useful test for diagnosing heart valve problems.

 Electrocardiogram (ECG)- This test records the strength and timing of the electrical activity of the heart. It shows abnormal rhythms (arrhythmias
or dysrhythmias) and can sometimes detect heart muscle damage. Small sensors are taped to your skin to pick up the electrical activity.

 Chest X-ray- An X-ray may be done to check your lungs and see if your heart is enlarged.
 Cardiac MRI- This is an imaging test that takes detailed pictures of the heart. It may be used to get a more precise look at the heart valves and
heart muscle.

 Blood tests- Certain blood tests may be used to look for infection and inflammation.
 Clinical Chemistry Test- this is to measure chemical components in blood or urine such as blood glucose, electrolytes, enzymes, hormones, lipids
(fats), other metabolic substances, and proteins.

Rheumatic Fever
         Rheumatic fever is an inflammatory disease that can be triggered by a streptococcal bacterial infection. It usually starts out as a strep throat infection or
scarlet fever that hasn’t been treated with antibiotics. Rheumatic fever can cause inflammation of connective tissues throughout the body including the heart, joints,
brain or skin. In more than half of all cases, rheumatic fever scars the valves of the heart, forcing this vital organ to work harder to pump blood. This damage to the
heart can lead to a serious condition known as rheumatic heart disease, which can eventually cause the heart to fail.
CAUSE:
         Rheumatic fever can occur after a throat infection from a bacteria called group A streptococcus. Group A streptococcus infections of the throat cause strep
throat or, less commonly, scarlet fever. The strep bacteria contain a protein similar to one found in certain tissues of the body. The body's immune system, which
normally targets infection-causing bacteria, attacks its own tissue, particularly tissues of the heart, joints, skin and central nervous system. This immune system
reaction results in swelling of the tissues (inflammation).
SIGNS AND SYMPTOMS:

 Fever
 Swollen, tender, red and extremely painful joints — particularly the knees and ankles
  Nodules (lumps under the skin)
 Fatigue
 Red, raised, lattice-like rash, usually on the chest, back, and abdomen
 Shortness of breath and chest discomfort
 Uncontrolled movements of arms, legs, or facial muscles
 Weakness
 Heart murmurs
NURSING MANAGEMENT:

 Monitor temperature frequently and patient’s response to antipyretics.

 Restrict sodium and fluids and obtain daily weight as indicated.
 Encourage continuous prophylactic antimicrobial therapy to prevent recurrence.
 Auscultate heart periodically for development of new heart murmur.
 Assess for effectiveness of drug therapy.
 Explain the need to rest and assure the patient that bed rest will be imposed no longer than necessary.
MEDICAL MANAGEMENT:

 Antibiotics.

 Anti-inflammatory treatment. Pain reliever, such as aspirin or naproxen (Naprosyn), to reduce inflammation, fever and pain. If symptoms are severe
or patient isn't responding to the anti-inflammatory drugs, doctor might prescribe a corticosteroid.
DIAGNOSTIC TESTS AND LABS:
         Tests may include:

 Blood test for repeated strep infection (such as an ASO test)

 Complete blood count (CBC)
 Electrocardiogram (EKG)
 Sedimentation rate (ESR -- a test that measures inflammation in the body)
 Throat culture
 Antibody Titer test

LABORATORY RESULTS
CHEST X-RAY
Date Taken: February 02 2020
Purpose: An x-ray exam allows the doctor to see the lungs, heart and blood vessels to help determine if you have pneumonia. When interpreting the x-ray, the
radiologist will look for white spots in the lungs (called infiltrates) that identify an infection. This exam will also help determine any complications related to
pneumonia such as abscesses or pleural effusions; fluids that surround the lungs.
Significant Findings:
 Inhomogeneous densities are seen at both lung fields
 The cardiac shadow is grossly enlarged with a cardiothoracic ratio of 0.77
 There is tenting of the right hemidiaphragm
  The osseous and soft tissue structuring are remarkable
Conclusion:
Pneumonia at both lung fields. Gross cardiomegaly, right pleuro diaphragmatic reaction

CLINICAL CHEMISTRY
Date Taken: February 03 2020
Purpose: This is to check the amount of electrolytes that are present in the body whether they are balance or imbalanced. It is important to have these checked
because electrolytes are minerals that carry a charge and exist to your body fluids. Sodium is vital to normal body function, including nerve and muscle function.
Potassium helps regulate fluid balance, nerve signals and muscle contractions. Magnesium is necessary for formation of bone and teeth to have a normal nerve
and body function.

Test name Value Amount Unit Normal Set

Potassium L 3.80 mEq/L 4.00-5.60

Sodium L 131.00 mEq/L 136.00-142.00

Magnesium N 1.9 Mg/dL 1.5312-2.5547

Indications: As seen there is an slight increase of potassium and sodium. This may be an effect of the medications the patient was taking including the Furosemide
and Potassium Chloride. Furosemide which inhibits the production of sodium and then Potassium Chloride as a supplement for the Potassium content. Another
factor would be the IV fluid of the patient which causes an increase and supplement for the electrolytes of the patient.
Date Taken: February 02 2020

Test name Value Amount Unit Normal Set

Calcium(Ionized) 4.60 mg/dL 4.60-5.10

Potassium L 3.20 mEq/L 4.00-5.60

Sodium L 129.00 mEq/L 136.00-142.00

Indications: The cause of low Potassium and Sodium may have come up from an effect where the patient have urinated and may also have released feces. As we
know that the patient has been taking maintenance medications that include lactulose and furosemide. In which lactulose promotes formation of stool and its
production as it is a laxative. While Furosemide is a diuretic that promotes urination towards the patient.
 GORDON’S FUNCTIONAL HEALTH PATTERN 

CLIENT IN CONTEXT  PRESENT STATE  INTERVENTIONS 

Informant: Mother and Patient Physical Examination (Head-to-Toe Assessment)

Reliability: 80% Date: February 12, 2020

M.D.D, 16 years old, Male, Filipino, Roman Time of Assessment:  1 pm                                             

Catholic, Single from St. Ana, St. Labangon, Cebu
City, Was admitted for the third time in Cebu Velez BP: 120/70 mmHg                                                                      PR: 99 bpm
General Hospital (CVGH) last, February 2, 2020 at RR: 33 cpm T: 36.2 °C
1:46 AM. He was admitted at Ward 1, Room 113 A
and co-managed by Dr. Amatong and Dr. Monico- General Appearance: 
Perez.
At 1 pm, patient was examined sitting on bed, awake, conscious, cooperative, coherent, afebrile,
CHIEF COMPLAINT
well groomed, appropriate change in facial expression, able to walk and with the following v/s: BP:
In complaints of sudden onset of dyspnea and 120/70 mmHg                                                                      PR: 99 bpm, RR: 33 cpm, T: 36.2
generalized body weakness while performing °C/axilla                                                                        
effortless activity at home, patient was initially
admitted in VSMMC however, due to persistency BMI Categories: 
and worsening of symptoms, he was transferred to
CVGH for further management. Patient also Weight: 38kg                                                                                      Height: 170 cm
indicated that no other symptoms such as chest Underweight: 13. 1                                                             IBW: 66kg
pain or fever were present.
Skin: 
HISTORY OF PRESENT ILLNESS
Skin color is brown, soft, warm and moderately dry with good turgor and without edema. No strong
January 2020 (patient’s second admission in odor evident and skin is lesion free.
CVGH) or 1 mos PTA, patient was admitted in
CVGH due to complaints of dyspnea while Scalp and Hair:
performing effortless activity at home. Due to the
presence of symptoms such as dyspnea and overall Hair is lustrous, silky strong and elastic. No lesions seen.
body weakness, patient was tested for any
abnormal heart rhythms using the Nails:
electrocardiogram. With the presence of
arrhythmias and history of Rheumatic Fever, patient Nails are clean and groomed, with capillary refill less than 2 seconds. Pink undertones are seen. 
was advised to undergo a mitral valve replacement
surgery to prevent worsening of condition. Since, Head and Face:
the suggested surgical procedure is not available in
CVGH, patient was advised to have his surgical Head is normocephalic and symmetric. Full ROM- up, down and sideways- is normal. Face is
operation in Perpetual Succour Hospital. However, proportionate and symmetric. Movements are equally bilaterally. Parotid glands are normal size.
patient was unable to comply due to financial Trachea is midline and lymph nodes are nonpalpable. 
constraints and was thus discharged.
Eyes, Ears and Nose: 
After his discharge, patient spent most of his
time at home together with his siblings. He wasn’t Clients outer canthus aligns with tips of the pinnas. No swelling, discharge or lesions of eyelids. Pink
able to go to school and thus decided to stop since
conjunctiva and clear white sclera, free of discharge, lesions, redness or lacerations.Pupil are equal,
he can no longer keep up with his school related
round and reactive to light and accommodation.Eyebrows are symmetric in shape and movement.
activities due to his condition. Few days after his
discharged, patient’s dyspnea and overall body Eyelashes evenly distributed and curled outward. Can read nameplate at 2 ft. distance and able to
weakness had worsened. Since, home interventions read storybook  at 14cm.
are no longer enough to address his symptoms,
patient was admitted to VSMMC. No excessive cerumen, discharge, lesions, excoriations or foreign body are in external canal.
Tympanic membrane is pearly grey with normal landmarks.Clients was able to correctly repeat two-
6 days PTA in February 2, 2020 in CVGH, syllables whispered word such as water.
patient’s dyspnea and body weakness worsened
and thus was initially admitted to VSMMC to which Nose is midline in face, septum is straight, nares are patent. No discharge or tenderness present.
he stayed for 5 days. During his stay, SO indicated No tenderness palpated over sinuses. 
that patient was given with his usual maintenance
medications (Captopril 25 mg/tab BID, Carvedilol Mouth and Throat:
6.25 mg/tab ½ tab BID, Hydrochlorothiazide 1 tab
Clients has 28 yellowish teeth. Lips are pink and moderately dry. Tongue and buccal mucosa
BID and Aspirin) and a single tab of Furosemide
appear pink and moist. Tonsils are pink and symmetric and enlarged to 1+. No exudate, swelling or
which only gave a temporary relief. During his stay,
He was able to rest and received continuous
monitoring. However, on the 5th day of his stay, his lesions present. 
dyspnea and body weakness reappered and thus
his SO decided to transfer him to CVGH at 1:46 AM Chest & Lungs:
via ambulance for further management
Equal chest expansion. Labored and irregular breathing with 33 cpm. No adventitious sounds
PAST MEDICAL HISTORY HISTORY evident. 
Last March 2019, patient was admitted in CVGH
due to severe fever to which he was diagnosed with
Rheumatic Fever. He then developed valve
regurgitation after an acute severe episode of
Rheumatic Fever. Since then, patient had an
Heart:
maintenance medications of Captopril 25 mg/tab
BID, Carvedilol 6.25 mg/tab ½ tab BID, Apical pulse is at the 5 intercostal pulse at left midclavicular line. Heart rate is 99 with irregular
th

Hydrochlorothiazide 1 tab BID and Aspirin. All were rhythm and murmurs heard  every after s2.No engorged veins seen and JVP is not distended,
taken with good compliance. bulging or protruding at 45 degrees or greater. 
Ever since his initial hospitalization, patient can no
longer performed his usual daily activities which Abdomen:
includes playing basketball. He mentioned that
Abdomen is flat. Umbilicus is pink, no discharge, odor, redness or herniation.Abdomen is soft to
whenever he performed any strenuous activities, he
palpate without masses or tenderness. 
experiences shortness of breath. He then spend
most of his free time at home resting together with Musculoskeletal:
his siblings. However, despite the presence of his
condition, he continuously go to school but had Feet and legs are symmetric in shape, size, and positioning. Extremities are warm and mobile, with
several absences. He also mentioned that since his adequate capillary refill. Full ROM and no swelling, redness or tenderness.
educators are aware of his condition, they were also
very considerate to him.
However, after his hospitalization this January
2020, he and his family decided to allow him to left
his school as he could no longer keep up with his
schedule and routine. When asked about his Muscle Strength
feelings regarding this concerned, patient indicated
that as of now his main priority is improving his
health and that his education will only follow. 5/5             5/5

Aside from his initial admission, patient also had 5/5             5/5
two other hospitalization. In all of his hospitalization,
patient indicated that his chief complaint was Scale for grading muscle strength:
dyspnea. Whenever he feels he was difficulty in
breathing, his family does not hesitate in admitting 5- Active motion against full resistance                                            4- Active motion against some
him immediately to prevent worsening of resistance 3- Active motion against gravity                                                     
symptoms. 2- Passive ROM 1- Slight flicker of
contraction                                                       0- No muscular contraction
January 2020, patient was diagnosed with RHD
with severe mitral valve insufficiency and thus was Neurological Assessment
advised for mitral valve replacement but wasn’t able
to comply due to financial constraints. Mental Status: 
SO reported that patient had no childhood illnesses Client is alert (awake, responsive and coherent). In the Glasgow Coma Scale, client scores 15
and claims to be a healthy child. He also received observed by as follows: eye opening response is spontaneous ( rated 4); oriented verbal response
all childhood immunizations in CVG-OPD. Patient (rated 5); obeys verbal comands (rated 6).
has no known food or drug allergies.
PRENATAL HISTORY Cerebellar Function:

Patient’s mother obstetrical score is G3P2(2002) Client is able to turn palms up and down rapidly without difficult. Client is able to touch finger to
and had her first prenatal check-up AOG (1st thumb and finger to nose smoothly, accurately and without difficulty. No fasciculation, tics or
trimester). Since then, she had routine visits and tremors.
claims to have not missed any consultation. She
also reported receiving a full dose of Tetanus Sensory Function: 
Toxoid immunization but was unable to recall AOG
it was received. She denies engaging in any sort of With eyes closed, client correctly identifies light touch on his forehead and cheek; (+) graphesthesia
vices during pregnancy such as smoking and ( number 3 and shape triangle), (+) stereognosis (able to identify a coin)  
drinking alcohol. Her supplements included taking
Iron and folic acid but dosages were unrecalled.
She also claims not having experienced  any illness Cranial Nerves:
during pregnancy
 CN I (Olfactory) - Able to identify smell such as alcohol and coffee
LABOR AND DELIVERY HISTORY
CN II (Optic) – Client has 20/20 vision OD and OD. Can read nameplate 2 in. without difficulty. 
Patient’s mother had induced labor at 37 weeks
AOG for approximately 8 hours. She had her NSVD CN III, IV, VI (Oculomotor, Trochlear, Abducens) –  Eyelid covers 2 mm of the iris. Eyes move in
delivery in CVGH last Jan. 2, 2004 assisted by her a smooth coordinated motion in all directions. Bilateral illuminated pupils constrict simultaneously. 
own obstetrician. Essential newborn care was done
but newborn screening was unrecalled. CN V (Trigeminal) - Temporal and masseter muscles contract bilaterally. Can identify sharp and
dull stimuli and light touch to the forehead, cheeks and chin. 

BIRTH HISTORY CN VII (Facial)  - Client smiles, frowns wrinkles forehead, shows teeth and raised eyebrows.
Movements are symmetric. Can identify food given. 
Patient M.D.D. was delivered via Normal
Spontaneous Vaginal Delivery in cephalic CN VIII ( Vestibulocochlear)- Client hears whispered words from 2ft, (-) Romberg Test
presentation but with regards to the birth weight of
the patient, it was unrecalled by the S.O. The CN IX & X (Glossopharyngeal/Vagus) – Uvula and soft palate rise bilaterally and symmetrically on
patient was born without any unusualities such as phonation. Gag reflex intact and can swallow without difficulty. 
Cord Coil, Meconium-Stained and any other
Congenital Anomalies. Essential Newborn Cord CN XI (Accessory) - Client is able to shrug shoulders and turn head against resistance.
Care was done. Patient M.D.D. did not have any
assisted respiratory effort during the time of birth. CN XII (Hypoglossal)- Tongue movement is symmetric and smooth and bilateral strength is
The patient did not receive any medications when apparent.
he was born.
 

FEEDING HISTORY
Patient M.D.D. had a latch-on time of 3 months and
did not have any feeding unusualities. In regards to
the patient's history of feeding method, the patient
was fully breastfed and the amount, frequency and
feeding habits were all unrecalled  by his mother.
The patient did not have any feeding problems and
started supplemental feeding when he was 5
months old. The supplemental food that was
introduced was Cerelac. Patient M.D.D. has a good
appetite and prefers foods such as legumes,
vegetables, pork and rice that is prepared by his S.
O. The patient started taking vitamins such as
Ceelin and Propan TLC when he was 7 months old
and stopped taking it recently. The patient's dosage
and frequency of his vitamin intake were all
unrecalled.

ELIMINATION PATTERN
The patient is both bladder and bowel trained.
Patient M.D.D. usually urinates 8 times a day and
defecates once a day. The color of the patient's
urine is yellow without any turbidity. Stool color is
usually brown but sometimes yellowish brown.
Recently, the patient does not have any unsualities
in his elimination pattern such as Hesitancy,
Constipation, Enuresis, Dribbling, Diarrhea,
Incontinence, Hemtochezia, Dysuria, Hematuria
and Melena. However, the patient is given
Lactulose every before bedtime to assist during
bowel evacuation since bearing down is
contraindicated in his present condition.

 
 APPENDIX A

ANATOMY AND PHYSIOLOGY

CARDIOVASCULAR SYSTEM

 
The circulatory system is composed of the heart and the network of arteries, veins, and capillaries that transport blood throughout the body; it is a system
that permits blood and lymph circulation to transport nutrients (such as amino acids and electrolytes), oxygen, carbon dioxide, hormones, blood cells, etc. to and
from cells in the body to nourish it and help to fight diseases, stabilize body temperature and pH, and to maintain homeostasis.
Heart

 The heart is a muscular pumping organ located medial to the lungs along the body’s midline in the thoracic region.
 One atrium and one ventricle for each circulation.
  Systemic and a pulmonary circulation there are four chambers in total: left atrium, left ventricle, right atrium and right ventricle.
 Location: The heart is located in the thoracic cavity in between the lungs, 60% of it lying to the left of the median plane. The heart’s lateral projection
extends from rib 3 to
 Pericardium: The pericardium is the membrane that surrounds and protects the heart. It is composed of two layers separated by a narrow cavity.

The inner layer is firmly attached to the heart wall and is known as the visceral layer of epicardium.
The outer layer is composed of relatively inelastic connective tissue and is termed the parietal layer. This fibrous layer prevents distension of the heart, thus
preventing excessive stretching of the heart muscle fibres.
The cavity between the two layers contains a small volume of fluid which serves as a lubricant, facilitating the movement of the heart by minimising friction. 
Layers:

 The epicardium is the thin, transparent outer layer of the wall and is composed of delicate connective tissue.
 The myocardium, comprised of cardiac muscle tissue, makes up the majority of the cardiac wall and is responsible for its pumping action. The thickness of
the myocardium
 mirrors the load to which each specific region of the heart is subjected.
 The endocardium is a thin layer of endothelium overlying a thin layer of connective tissue. It provides a smooth lining for the chambers of the heart and
covers the valves.
 The endocardium is continuous with the endothelial lining of the large blood vessels attached to the heart.

Structure:
Cardiac muscle fibres are shorter in length and larger in diameter than skeletal muscle fibres. They also exhibit branching, which gives an individual fibre a Y-
shaped appearance. A typical cardiac muscle fibre is 50-100μm long and has a diameter of about 14μm. In contrast to skeletal muscle, cardiac muscle does not
fatigue, cannot be repaired when damaged and is regulated by the autonomic nervous system.
Chambers:

 The right atrium forms the dorsocranial section of the base of the heart and receives blood from the cranial vena cava, caudal vena cava and coronary
sinus. The interatrial septum is a thin partition dividing the right and left atria and possesses a characteristic oval depression called the fossa ovalis which is
 a remnant of the foetal foramen ovalis. The right atrium also houses the sinoatrial node. Blood flows from the right atrium to the right ventricle through the
tricuspid valve (also known as the right atrioventricular valve).
 The right ventricle forms most of the anterior surface of the heart and is crescent-shaped in cross-section. The cusps of the tricuspid valve are connected to
tendon-like cords, the chordae tendinae, which, in turn, are connected to cone-shaped papillary muscles within the ventricular wall. The right ventricle is
separated from the left by a partition called the interventricular septum. The trabeculaseptomarginalis is a muscular band that traverses the lumen of the
right ventricle. Deoxygenated blood passes from the right ventricle through the pulmonary semi-lunar valve to the pulmonary trunk, which conveys the
blood to the lungs.
 The left atrium forms the dorsocaudal section of the base of the heart and is similar to the right atrium in structure and shape. It receives oxygenated blood
from the lungs via the pulmonary veins. Blood passes from the left atrium to the left ventricle through the bicuspid or left atrioventricular valve. The left
atrium lies under the tracheal bifurcation and enlargement of this area of the heart can cause breathing difficulties.
 The left ventricle forms the apex of the heart and is conical in shape. Blood passes from the left ventricle to the ascending aorta through the aortic semi-
lunar valve. From here some of the blood flows into the coronary arteries, which branch from the ascending aorta and carry blood to the heart wall. The
remainder of the blood travels throughout the body.

 
Pulmonary circulation transports deoxygenated blood from the right side of the heart to the lungs, where the blood picks up oxygen and returns to the left side of
the heart. The pumping chambers of the heart that support the pulmonary circulation loop are the right atrium and right ventricle.
Systemic circulation carries highly oxygenated blood from the left side of the heart to all of the tissues of the body (with the exception of the heart and lungs).
Systemic circulation removes wastes from body tissues and returns deoxygenated blood to the right side of the heart. The left atrium and left ventricle of the heart
are the pumping chambers for the systemic circulation loop.
Systemic Circulation route: The unoxygenated blood returns to the heart via our superior and inferior vena cava to the right atrium of the heart passing the
coronary sinuses. Once the blood enters the atrium, it flows to the right ventricle of the heart passing the tricuspid valve, then it flows to the pulmonary trunk
passing the pulmonary or semilunar valve then it continues to flow into the lungs, where the gas exchange occurs. The unoxygenated blood is being oxygenated
and continues to flow to the left atrium of the heart then past the bicuspid valve then enters the left ventricle then blood is being ejected to the systemic circulation.
Blood Vessels

 Body’s highways that allow blood to flow quickly and efficiently from the heart to every region of the body and back again. • Size of blood vessels
corresponds with the amount of blood that passes through the vessel.
 All blood vessels contain a hollow area called the lumen through which blood is able to flow.
  Lined with a thin layer of simple squamous epithelium known as the endothelium.
 Keeps blood cells inside of the blood vessels and prevents clots from forming.
 Endothelium lines the entire circulatory system, all the way to the interior of the heart, where it is called the endocardium.

Arteries

 Arteries are blood vessels that carry blood away from the heart.
 Blood carried by arteries is usually highly oxygenated.
 The pulmonary trunk and arteries of the pulmonary circulation loop provide an exception to this rule – these arteries carry deoxygenated blood from the
heart to the lungs to be oxygenated.
 High levels of blood pressure.
 Arteries are thicker, more elastic, and more muscular.
 Smaller arteries are more muscular in the structure of their walls.
 Smooth muscles of the arterial walls of these smaller arteries contract or expand to regulate the flow of blood through their lumen.

 
Arterioles

 Narrower arteries that branch off from the ends of arteries and carry blood to capillaries.
 Lower blood pressures than arteries due to their greater number, decreased blood volume, and distance from the direct pressure of the heart. 
 Able to use smooth muscle to control their aperture and regulate blood flow and blood pressure.

Capillaries

 Smallest and thinnest of the blood vessels in the body and also the most common.
 Capillaries connect to arterioles on one end and venules on the other.
  Carry blood very close to the cells of the tissues of the body in order to exchange gases, nutrients, and waste products.
 The walls of capillaries consist of only a thin layer of endothelium so that there is the minimum amount of structure possible between the blood and the
tissues.
 Precapillary sphincters are bands of smooth muscle found at the arteriole ends of capillaries.
 These sphincters regulate blood flow into the capillaries.

Veins

 Large return vessels of the body and act as the blood return counterparts of arteries.
 Subjected to very low blood pressures.
 Thinner, less elastic, and less muscular than the walls of arteries.
 Rely on gravity, inertia, and the force of skeletal muscle contractions to help push blood back to the heart. 
 Some veins contain many one-way valves that prevent blood from flowing away from the heart.

Venules

 Small vessels that connect capillaries, but unlike arterioles, venules connect to veins instead of arteries. 
 Pick up blood from many capillaries and deposit it into larger veins for transport back to the heart.

Coronary Circulation
The heart has its own set of blood vessels that provide the myocardium with the oxygen and nutrients necessary to pump blood throughout the body. The left and
right coronary arteries branch off from the aorta and provide blood to the left and right sides of the heart. The coronary sinus is a vein on the posterior side of the
heart that returns deoxygenated blood from the myocardium to the vena cava.
Hepatic Portal Circulation
The veins of the stomach and intestines perform a unique function: instead of carrying blood directly back to the heart, they carry blood to the liver through the
hepatic portal vein. Blood leaving the digestive organs is rich in nutrients and other chemicals absorbed from food. The liver removes toxins, stores sugars, and
processes the products of digestion before they reach the other body tissues. Blood from the liver then returns to the heart through the inferior vena cava.

 Blood
o The average human body contains about 4 to 5 liters of blood. 

o Liquid connective tissue.

o Transports many substances through the body and helps to maintain homeostasis of nutrients, wastes, and gases.

o Made up of red blood cells, white blood cells, platelets, and liquid plasma.

 Red Blood Cells

o Erythrocytes

o Most common type of blood cell makes up about 45% of blood volume.

o Produced inside of red bone marrow from stem cells.

o Biconcave disks.

o Transport oxygen in the blood through the red pigment hemoglobin.

o Hemoglobin contains iron and proteins joined to greatly increase the oxygen carrying capacity of erythrocytes.

 White Blood Cells

o Leukocytes

o Very small percentage of the total number of cells in the bloodstream. 

o Important functions in the body’s immune system.

  

 Granular leukocytes
o Neutrophils, eosinophils, and basophils.

 Neutrophils contain digestive enzymes that neutralize bacteria that invade the body.
 Eosinophils contain digestive enzymes specialized for digesting viruses that have been bound to by antibodies in the blood. 
 Basophils release histamine to intensify allergic reactions and help protect the body from parasites.

 Agranular leukocytes
o • Lymphocytes and monocytes.

  Lymphocytes include T cells and natural killer cells that fight off viral infections and B cells that produce antibodies against infections by
pathogens.
 Monocytes develop into cells called macrophages that engulf and ingest pathogens and the dead cells from wounds or infections.

 Platelets
o Thrombocytes

o Small cell fragments responsible for the clotting of blood and the formation of scabs.

o Form in the red bone marrow from large megakaryocyte cells that periodically rupture and release thousands of pieces of membrane that become
the platelets. 
o Survive in the body for up to a week.

 Plasma
 o Non-cellular or liquid portion of the blood that makes up about 55% of the blood’s volume.

o Mixture of water, proteins, and dissolved substances.

o 90% of plasma is made of water.

o Plasma includes antibodies and albumins.

o Albumins help maintain the body’s osmotic balance by providing an isotonic solution for the cells of the body.

o Transportation medium

Fetal Circulation

When blood goes through the placenta, it picks up oxygen. The oxygen rich blood then returns to the fetus via the third vessel in the umbilical cord (umbilical vein). The
oxygen rich blood that enters the fetus passes through the fetal liver and enters the right side of the heart via the ductus venosus.

The hole between the top two heart chambers (right and left atrium) is called the foramen ovale. This hole allows the oxygen rich blood to go from the right atrium to
left atrium and then to the left ventricle and out the aorta. As a result the blood with the most oxygen gets to the brain.

Blood coming back from the fetus’s body also enters the right atrium, but the fetus is able to send this oxygen poor blood from the right atrium to the right ventricle (the
chamber that normally pumps blood to the lungs). Most of the blood that leaves the right ventricle in the fetus bypasses the lungs through the second of the two extra
fetal connections known as the ductus arteriosus.

The ductus arteriosus sends the oxygen poor blood to the organs in the lower half of the fetal body. This also allows for the oxygen poor blood to leave the fetus through
the umbilical arteries and get back to the placenta to pick up oxygen.

APPENDIX B
 Drug Study

 
1. Carvedilol (6.25mg/tab, 1/2 tab BID PO)

Classification:

a. Therapeutic Class: Antihypertensives

b. Pharmacologic Class: Beta Blockers

Action: Blocks simulation of beta (myocardial) and beta (pulmonary, vascular, and uterine) -adrenergic receptor sites. Also has alpha. Blocking activity; which
1 2

may result in orthostatic hypotension.

Indication: Hypertension. HF (ischemic or cardiomyopathic) with digoxin, diuretics, and ACE inhibitors. Left ventricular dysfunction after myocardial infarction.
 
Contraindications: History of serious hypersensitivity reactions (Steven-Johnson syndrome, angioedema, anaphylaxis); Pulmonary edema; Cardiogenic shock;
Bradycardia, heart block or sick sinus syndrome (unless a pacemaker is in place). Cautions: HF; Renal impairment; Hepatic impairment; Diabetes mellitus (may
mask signs of hyperglycemia); Thyrotoxicosis; Peripheral vascular disease, history of severe allergy reactions.

 
Adverse Effects: Dizziness, fatigue, weakness, anxiety, depression, drowsiness, insomnia, memory loss, mental status changes, nervousness, nightmares,
blurred vision, dry eyes, bradycardia, pulmonary edema, diarrhea, constipation, nausea, hyperglycemia.

 
Nursing Considerations:

a. Monitor BP and pulse frequently during dose adjustment period and periodically during therapy.
b. Monitor intake and output ratios and daily weight Assess patient routinely for evidence of fluid overload.
c. Monitor for drug toxicity and overdose.
d. Take apical pulse before administering the drug.
 
 
2. Captopril (28mg/tab, 1 tab BID)
 Classification: 

a. Therapeutic Class: Antihypertensives

b. Pharmacologic Class: ACE inhibitors

Action: Angiotensin converting enzyme (ACE) inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II. ACE inhibitors also prevent the
degradation of bradykinin and other vasodilatory prostaglandins. ACE inhibitors also ↑ plasma renin levels and ↓ aldosterone levels.
 
Indication: Hypertension, heart failure. Reduction of risk of death, heart failure-related hospitalizations, and development of overt heart failure following myocardial
infarction. Treatment of diabetic nephropathy in patients with type 1 diabetes mellitus and retinopathy.

 
Contraindications: History of angioedema with previous use of ACE inhibitors; Concurrent use with aliskiren in patients with diabetes or moderate-to-severe renal
impairment. Caution to patients with collagen vascular disease, renal impairment, hypovolemia, hyponatremia, and concurrent diuretic therapy.
Adverse Effects: Dizziness, fatigue, headache, insomnia, cough, hypotension, chest pain, taste disturbances, abdominal pain, anorexia, constipation, diarrhea,
nausea, vomiting, proteinuria, impaired renal function.
Nursing Considerations:

a. Monitor BP and pulse frequently during initial dose adjustment and periodically during therapy.
b. Assess patient for signs of angioedema (dyspnea, facial swelling)
c. Monitor renal function. Assess urine protein prior to and periodically during therapy for up to 1 year in patients with renal impairment or those receiving >150
mg/day of captopril.
d. Monitor CBC with differential prior to initiation of therapy, every 2 weeks for the first 3 months, and periodically for up to 1 year in patients at risk for
neutropenia.
  

3. Potassium Chloride (Kdurule, 2 tabs PO BID)

 Classification: Mineral and electrolyte replacements/supplements
 
Action: Maintain acid-base balance, isotonicity, and electrophysiologic balance of the cell.
 
Indications: Treatment/prevention of potassium depletion.
Contraindications: Hyperkalemia; Severe renal impairment; Untreated Addison’s disease. Caution to patients who have cardiac disease; Renal impairment;
Diabetes mellitus; Hypomagnesemia.
Adverse Effects: Confusion, restlessness, weakness, arrhythmias, abdominal pain, diarrhea, flatulence, nausea, vomiting, paralysis, paresthesia.
Nursing Considerations:

a. Assess for signs and symptoms of hypokalemia (weakness, fatigue, U wave on ECG, arrhythmias, polyuria, and polydipsia) and hyperkalemia.
b. Monitor serum potassium before and periodically during therapy. Monitor renal function, serum bicarbonate, and pH.
c. Monitor serum chloride because hypochloremia may occur if replacing potassium without concurrent chloride.

4. Lactulose (Mavelox, 30cc with Hs PO)

 Classification:
a. Therapeutic Class: Laxatives
b. Pharmacologic Class: Osmotics 
Action: Increases water content and softens the stool. Lowers the pH of the colon, which inhibits the diffusion of ammonia from the colon into the blood, thereby
reducing blood ammonia levels.
 
 Indications: Treatment for chronic constipation. Adjunct in the management of portal-systemic (hepatic) encephalopathy (PSE).
 
Contraindications: Patients on low-galactose diets. Caution in patients who have diabetes mellitus; Excessive or prolonged use may lead to independence.
 
Adverse Effects: Belching, cramps, distention, flatulence, diarrhea, hyperglycemia.

 
 
 
Nursing Considerations:

a. Assess patient for abdominal distention, presence of bowel sounds, and normal pattern of bowel function.
b. Assess amount and consistency and amount of stool produced.
c. Assess mental status before and periodically throughout the course of therapy.
d. Lab Test Considerations: ↓ blood ammonia concentrations by 25-50%
e. May cause ↑ blood glucose levels in diabetic patients.
f. Monitor serum electrolytes periodically when used chronically. May cause diarrhea resulting in hypokalemia and hypernatremia. 

 
 
5. Furosemide

Classification: Loop-diuretics
Action: Inhibits sodium and chloride reabsorption at the proximal and distal tubules and the ascending loop of henle.
Indication: Acute pulmonary edema, Edema, HTN.
Contraindication: Allergy, Electrolyte depletion, Severe renal failure, Hepatic coma.
Adverse Effects: Hypokalemia, volume depletion, hypotension, CNS effects, GI upset, hyperglycemia.
Nursing Considerations:

a. Monitor weight, BP, and PR routinely with long-term use.

b. Watch for signs of hypokalemia, such as muscle weakness and cramps.
c. Monitor px with severe symptoms of urine retention due to bladder emptying disorders, prostate enlargement, or urethral narrowing or worsening of
symptoms, especially during initial ttt.
d. Monitor uric acid level, especially in px with history of gout

 
 
6. Nitroglycerin
Classification: Nitrates/ Vasodilators/ Antianginals
Action: Reduces cardiac oxygen demand by decreasing left ventricular end-diastolic pressure (preload) and, to lesser extent, systemic vascular resistance
(afterload). Also increases blood flow through the collateral coronary vessels.
Indication: To prevent chronic anginal attacks, acute angina pectoris; to prevent or minimize anginal attacks before stressful events, HTN from surgery, HF after
MI, angina pectoris in acute situations; to produce controlled hypotension during surgery (I.V infusion), moderate to severe pain from chronic anal
fissure.

 
Contraindications: allergy, severe anemia, head trauma or cerebral hemorrhage, hepatic or renal disease, hypotension, hypovolemia, and conditions that limit
the cardiac output
Adverse effects: decrease in blood flow, headache, dizziness, nausea, vomiting, incontinence, hypotension, reflex tachycardia, syncope, angina, flushing, pallor,
and increased perspiration.
Nursing Consideration:
a.       Clearly monitor V/S, particularly BP, during infusion, especially in px with an MI. Excessive hypotension can worsen ischemia.
b.       Monitor BP and intensity and duration of drug response.
c.       Wipe off nitroglycerin paste or remove patch before defibrillation to avoid px burns.
d.       Drug may cause headaches, especially at the beginning of therapy. Dosage may be reduced temporarily, but tolerance usually develops. Treat headache
with aspirin or acetaminophen.

 
 
 
 
7. Digoxin
Classification: Cardiac Glycosides
Action: Increases intracellular calcium and allows more calcium to enter myocardial cells during depolarization, causing the ff effects:

 Increased force of myocardial contraction (a positive inotropic effects).

 Increased cardiac output and renal perfusion (which has a diuretic effect, increasing urine output and decreasing blood volume while decreasing renin
release and activation of the RAA system)
 Slowed heart rate, owing to slowing of the rate of cellular depolarization (a negative chronotropic effect)

 Decreased conduction velocity through the atrioventricular node

Indication:  HF, rapid digitalization (tablet),  gradual digitalization (tablet), Atrial fibrilization chronic (PO, IV), Atrial arrhythmias
Contraindication: Allergy, Ventricular tachycardia or fibrillation, Idiopathic subaortic stenosis, Acute MI, Electrolyte abnormalities 
Adverse effects: Headache, Weakness, Drowsiness, Vision change (a yellow halo around objects is often reported), GI upset, Anorexia, Arrhythmia, Digoxin
toxicity, Nausea, Vomiting, Malaise, Depression, Irregular heart rhythm including heart block, atrial arrhythmias, and ventricular tachycardia.
Nursing Considerations
 a. Drug-induced arrhythmias may increase the severity of HF and hypotension.
b. In children, cardiac arrhythmias, including sinus bradycardia, are usually early signs of toxicity.
c. Monitor px for toxicity.
d. Monitor digoxin level.
e. Monitor potassium level carefully.

 
8. Phenoxymethyl
Classification: Antibiotic/ Natural penicillins
Action: Inhibits cell-wall synthesis during bacterial multiplication.
Indication: Fusospirochetosis (Vincent infection) and staphylococcal infections, Pneumococcal infections, Streptococcal infections, to prevent recurrent rheumatic
fever or chorea.
Contraindications: Allergy, Renal disease
Adverse effects: Nausea, vomiting, diarrhea, abd pain, glossitis, stomatitis, gastritis, sore mouth, furry tongue, yeast infection, pain and inflammation at injection
site, rash, fever, wheezing, and with repeated exposure to anaphylaxis 
Nursing Consideration:
a.       Periodically assess renal and hematopoietic function in px receiving long-term therapy.
b.       Drug may alter normal colon flora. Monitor px for diarrhea and initiate therapeutic measures as needed. Drug may need to be stopped.
c.       After ttt for streptococcal infections, reculture px to determine whether streptococci have been eradicated.

 
  
 
 

NURSING CARE PLAN

KEY ISSUES DESIRED OUTCOME INTERVENTIONS ACTUAL OUTCOME

1. Decreased Cardiac Output secondary to Rheumatic After 2 days of patient-student nurse Independent Interventions: After 2 days of nursing
Heart Disease related to alteration in heart rate, rhythm and interaction, patient will be able to: intervention, the patient:
 Assess for reports of fatigue
conduction as characterized by presence of abnormal heart
and reduced activity  Verbalized
sounds
intolerance. understanding
A. Demonstrate adequate cardiac Rationale: Fatigue and towards the
output as evidenced by blood exertional dyspnea are importance of
Scientific Basis:  pressure, pulse rate and common problems of low positioning for this
rhythm within normal cardiac outputs particular case
     The development of rheumatic aortic stenosis is usually
parameters for the patient;
gradual, which allows time for cardiac compensation and an  Verbalized
strong peripheral pulses; and  Assess patient for
asymptomatic period. As stenosis worsens, symptoms of left willingness to refer to
an ability to tolerate activity understanding and
heart failure including poor cardiac output, and poor coronary the nurses or SO if
without symptoms of dyspnea compliance with medical
perfusion develop, including angina, syncope, and shortness of ever chest pain or
syncope or chest pain regiment including
breath with exertion. Patients having aortic stenosis may any other symptoms
medications, activity level
demonstrate a palpable thrill at the right upper sternal border or B. Exhibits warm and dry skin and are felt
and diet.
suprasternal notch. The classic murmur is a systolic ejection eupnea
Rationale: This promotes
murmur at the right upper sternal border, often with a diastolic  Exhibited warm and
C. Remains free of side effects the participation and
decrescendo murmur if there is concurrent aortic regurgitation. In dry skin
from medications used to cooperation of the patient
contrast to congenital aortic pathologies, there is rarely an
achieve adequate cardiac through his recovery.  Latest HR= 99 and
associated opening click
output RR=24
 Check symptoms for chest
D. Explains actions and pain.  Showed enthusiasm
Source: Paotonu, D. S. (2017, March 10). Acute Rheumatic precautions to take for cardiac Rationale: Low cardiac towards the teachings
disease output can further decrease of actions and
Fever and Rheumatic Heart Disease. Retrieved February myocardial perfusion. precautions to take
13, 2020, from for cardiac disease
 Positioned client in semi-
https://www.ncbi.nlm.nih.gov/books/NBK425394/
fowler’s to high-fowler’s.
Rationale: Upright position
is recommended to reduce
preload and ventricular
filling when fluid overload is
the cause

Collaborative Interventions:

 Auscultated both lung

regularly
Rationale: This is to check
the presence of abnormal
heart sounds
 Examine laboratory data
esp. Arterial blood gases,
electrolytes including
potassium.
Rationale: Patient may be
receiving cardiac glycosides
and potential for toxicity is
greater with hypokalemia.

 Review Results of EKG and

chest Xray.
Rationale: EKG can reveal
evidence of left ventricular
hypertrophy, indicating
aortic sterosis or chronic
 systemic hypertension.

 Closely monitor fluid intake

including IV lines.
Rationale: In patients with
decreased cardiac output
with poorly functional
ventricles may not be able
to tolerate IV fluids. 

2. Imbalanced Nutrition: Less Than Body Requirements After 2 days of student nurse – patient Independent Interventions: After 2 days of nursing
related to Insufficient Dietary Intake as evidenced by weight loss interaction, the patient will be able to: intervention, the patient:
 Identify client at risk for
from 48 kg to 38 kg with BMI of 13.15 kg/m2 categorized as
A. Demonstrate  progressive malnutrition.  Increase his appetite
Malnourished.
weight gain toward goal  Rationale: to assess by eating more than
causative / contributing the previous days
B. Display free signs of factor during his
Scientific Basis: malnutrition as reflected by hospitalization
weight loss, insufficient interest  Assess nutritional needs
    Imbalanced Nutrition: Less Than Body Requirements would  Enumerate foods he
in food, and satiety related to age and growth
mean the intake of nutrients insufficient to meet metabolic needs. phase, presence of was allowed to eat
immediately upon ingesting
Adequate nutrition is essential to meet the body’s demands. congenital anomalies or and foods which he
food
Several diseases can greatly affect the nutritional status of an metabolic or malabsorption needs to take control
individual such as, per the condition of the patient, Rheumatic C. Verbalize understanding of problems. and lessen
Heart Disease. causative factors when known Rationale: to identify  Name which foods he
and necessary interventions  nutritional needs  preferred eating while
Source: Wayne, G. (2017, September 23). Imbalanced Nutrition: taking into
Less Than Body Requirements – Nursing Diagnosis & Care D. Demonstrate behaviors and
 Assess drug interactions, consideration his
Plan. Retrieved February 12, 2020, from lifestyle changes to regain
disease effects, allergies,
and/or maintain appropriate condition
https://nurseslabs.com/imbalanced-nutrition-less-body- and use of laxatives or
weight.  Seen patient eating
requirements/ diuretics.
together with family
Rationale: It may affect the
member
appetite, food intake, or
absorption   Patient was not able
 Assess current weight to gain weight but has
compared to usual weight boosted his food
and norms for age, gender, intake.
and body size.
Rationale: to identify
deviations from the norm
and to establish baseline
parameters

 Ascertain client's
understanding of individual
nutritional needs and ways
the client is meeting those
needs.
Rationale: to determine
informational needs or
client/SO 

 Monitor patients vital signs

especially PO
Rationale: to facilitate
patient’s intake

 Inform patient of his BMI

result
Rationale: The patient is
made aware of the
relationship between his
height and weight and how
it can also affect his
nutrition. The result of his
BMI will help determine his
 risk of other diseases.

 Determine lifestyle factors

that may affect weight.
Rationale: Socioeconomic
resources, amount of
money available for
purchasing food, proximity
of store, and available
storage space for food are
all factors that may impact
food choices and intake

 Discuss the importance of

having a balanced and
healthy meal in line with his
nutrition and disease.
Rationale: The patient will
be educated about his
nutrition now that he was
diagnosed with Rheumatic
Heart Disease.

 Observe for absence of

subcutaneous fat and
muscle wasting, loss of hair,
fissuring of nails, delayed
healing, gum bleeding,
swollen abdomen, and so
on.
Rationale: it indicate
 protein-energy malnutrition

 Note swallowing difficulties

and diminished desire or
refusal to eat.
Rationale: to obtain dietary
history 

 Explore lifestyle factors

such as specific eating
habits, the meaning of food
to client. Rationale:
Identifies eating practices
that may need to be
corrected and provides
insight into dietary
interventions that may
appeal to client

 Classify appropriate foods

the patient may eat, such as
foods rich in vegetables,
whole grain, and fruits, that
would help boost his
nutrition and possibly gain
weight in proportion with his
height.
Rationale: The patient will
determine the foods he is
allowed to eat in line with
his current health status.

 Encourage patient to eat

 snacks in between
Rationale: to encourage
patient to eat more

 Provide actual food choices

such as lugaw, utan bisaya,
tinolang isda, etc.
Rationale: provide patient
with food choices to
increase his scope on food
intake

 Promote a pleasant relaxing

environment including
socialization when possible.
Rationale: to enhance
intake

 Promote adequate and

timely fluid intake. Limit
fluids 1 hour prior to meal.
Rationale: to reduce
possibility of satiety

 Encourage SO to eat meals

together with the patient
Rationale: to also
encourage patient to eat at
the same time increase his
appetite

Collaborative Intervention:
 Collaborate with an
 interdisciplinary team such
as the physician and
dietician for changing food
meals served to soft meals
Rationale: to set nutritional
goals when client has
specific dietary needs,
malnutrition is profound, or
long-term feeding problems
exist

 Collaborate with the staff

nurse, physician, and
dietician to schedule his rest
periods and timing of foods
Rationale: to balance his
rest time and eating time

 Construct a sample meal

plan that is low in sodium
and purine content.
Rationale: To lessen the
risk of fluid retention and
overload.
 Develop a meal plan that
has low to none Saturated
and Trans Fat
Rationale: To lower the risk
of developing blood
cholesterol and heart attack

 Provide dietary,
environmental, and
 behavioral modifications
such as optimization of
clients intake of protein,
carbohydrates, fats, calories
within eating style and
needs.
Rationale: to establish a
nutritional plan that meet
individual needs

3. Fatigue related to decreased distribution of oxygen to the After 2 days of student nurse- patient After 2 days of nursing
body secondary to rheumatic disease as manifested by episodes interaction, the patient will be able to: Independent Interventions:  intervention:
of tachypnea and body weakness.
 Encouraged client to do
A. Client will report sense of
whatever possible (walking,
Scientific Basis:  display/sense of energy  Client was able to
sitting up in a chair).
   Fatigue is a subjective complaint with both acute and chronic B. Perform  activities of daily Increase activity level as rest well without
illness. It is the self-recognized state in which an individual living and participate in desired tolerated. Rationale: To disturbances. 
experiences an overwhelming sustained sense of exhaustion activities at level of ability assess/restrict px ability to  Client was able to do
and decreased capacity for physical and mental work. Patients participate in self care  his ADL’s such as
C. Participate in a recommended
with rheumatic disease may experience fatigue.  (walking, sitting on
program.  Restrict environmental
the bed,going to the
  D. Identify basis of fatigue and stimuli during planned times
comfort room and
individual areas of control for rest and sleep.
eating)
Source: Wayne, G. (2017, September 24). Fatigue – Nursing Rationale: Distractions in
Diagnosis & Care Plan. Retrieved February 12, 2020, from px physical surroundings  Latest recorded vital
https://nurseslabs.com/fatigue/ can disturb sleep/rest and signs of: BP 120:70,
contribute to fatigue. Temperature 36.2 PR
99, and RR 33. 
 Determined the presence of
sleep disturbances.  When asked if he still
Rationale: Changes in feels weak, client
verbalized ‘dili naman
 sleep patterns may be a ko luya.
contributing factor in
developing fatigue.

 Assessed vital signs to

evaluate cardiopulmonary
response to activity.
Rationale: To determine
oxygenation and tolerance
of activities.

Collaborative Interventions: 
 Instruct client and
caregivers in alternative
ways of doing familiar
activities to conserve
energy like: (taking frequent
short breaks and
asking/accepting
assistance). Rationale:
Promotes balance in
periods of activity and
active participation in
planning and evaluating
therapeutic management.

4. Impaired comfort related to insufficient situational  control as After 2 days of student nurse – patient After 2 days of nursing
manifested by dyspnea  interaction, the patient will be able to:  Independent Intervention: intervention, the patient:
  Determine the type of  Will name
Scientific basis: A. Engage in behaviors or lifestyle discomfort the client is interventions that
changes to increase level of experiencing such as help improve comfort
      The symptoms of heart valve problems - which are often the
ease physical pain. Have the
result of rheumatic heart disease - can include: chest discomfort  Will state that level of
or pain, irregular or rapid heartbeat, shortness of breath, fatigue, B. Verbalize sense of comfort or client rate total comfort,
comfort has
or weakness.  contentment  using a scale of 0 to 10.
increased
Rationale: a comfort scale
Source: Retrieved from C. Participate in desirable and is similar to a pain rating  Will participate in
https://www.heartandstroke.ca/heart/conditions/rheumatic-heart- realistic health-seeking scale and can help the activities that improve
disease behaviors client identify the focus of comfort and ease
discomfort

 Determine how the client is

managing pain and pain
components.
Rationale: lack of control
may be related to other
issues or emotions such as
fear, loneliness, or anger

 Encourage/plan care to
allow individually adequate
rest periods.
Rationale: to prevent
fatigue

 Interact with the client in

a therapeutic manner.
Rationale: the nurse
could be the most
important comfort
intervention for meeting
 client’s needs

 Encourage the client to

do whatever possible
such as walking.
Rationale: this enhances
self-esteem and
independence 

Collaborative intervention
 Collaborate with others
when the client expresses
interest in lessons,
counselling, coaching,
and/or monitoring.
Rationale: to
meet/enhance emotional
and/or spirtiual 

5. Activity Intolerance related to decreased oxygen supply as After 2 days of patient care, the patient Independent Interventions After 2 days of nursing
evidenced by labored and irregular breathing will be able to: intervention:
 Assessed the blood
    pressure, respiratory rate  
and physical appearance
Scientific Basis:  A. Identify factors that aggravate  Patient was able to
before and after performing
activity tolerance take adequate rest
 Weak, thread pulses and decreased blood pressure can result non-strenuous activities.
into decreased cardiac output, which is due to lack of oxygen B. Patient will be able to display Rationale: To evaluate  Patient was able to
supply physiological movements over cardiopulmonary response perform some
time to an activity. activities of daily
living like walking,
C. Patient will report the ability to  Assess for frequency of
Source: Wayne, G. (2017, September 24). Activity Intolerance– perform required activities of shortness of breath and getting fresh air, and
Nursing Diagnosis & Care Plan. Retrieved February 12, 2020, daily living dizziness. going to the bathroom
from Rationale: determines with assistance
D. Be able to conduct activities
https://nurseslabs.com/fatigue/ ; ; ;https://nurseslabs.com/activity- severity of fatigue,
within limits of patient’s activity  The px has
decreased oxygen supply
intolerance/ decreased blood
E. Participate willingly in and hypotension
pressure and is
necessary or desired activities
 Refrained from performing experiencing
nonessential activities or tachypnea
procedures.
 
Rationale: Patients with
limited activity tolerance
needs to prioritize important
tasks first
 Encouraged bed rest.
Rationale: to save energy
 Taught client and SO on
how to recognize signs of
over-activity or over
exertion.
Rationale: Knowledge
promotes awareness and
prevents complications of
overexertion
 Assisted client in ADLs
while avoiding dependency.
Rationale: Reduces
oxygen consumption while
careful balance in providing
assistance facilitates
progression of endurance in
 an activity  
 Modified room into a rest-
inducing area by dimming
the light,providing adequate
ventilation and allowing
patient to lie down.
Rationale: To decrease
weakness

6. Impaired gas exchange related to ventilation-perfusion A. Independent Intervention:   Patient manifested

imbalance [as in altered blood flow] as evidenced by using of After 2 days of student nurse – patient unlabored
accessory muscles (sternocleidomastoid muscles), increased interaction, the patient will be able to: respirations at 12-20
respiratory rate and having pallor lips secondary to Rheumatic    Note for respiratory rate, per minute, oximetry
Heart Disease A. To participate in treatment use of accessory muscles, results within normal
regimen (breathing exercises pursed-lip breathing, areas range and baseline
and use of oxygen) within a of pallor/cyanosis, such as HR.
level of ability or situation.  Patient maintains
Scientific Basis: peripheral (nail beds)
B. To follow prescribed versus central (circumoral) clear lung fields and
pharmacologic regimen or general duskiness. remains free of signs
High altitudes, hypoventilation, and altered oxygen-carrying
C. To improve breathing pattern, Rationale: to maximize of respiratory
capacity of the blood from reduced hemoglobin are other factors
oxygenation and verbalize “ respiratory effort distress.
that affect gas exchange.   Patient verbalizes
mas maayo na akong pag  Observe for dyspnea on
Source: Wayne, G., Wayne, G., & Wayne. (2017, September ginhawa karon kaysa atong ni exertion or gasping, “mas maayo na ako
23). Impaired Gas Exchange – Nursing Diagnosis & Care Plan. aging adlaw” changing of positions pamati karon”
D. To manifest resolution or  Patient participates in
Retrieved from https://nurseslabs.com/impaired-gas-exchange/ frequently to ease
absence of symptoms of breathing. Rationale: To the treatment
respiratory distress. decrease dyspnea and regimen and is
improve quality of life following his
 Reinforce the need for pharmacologic
adequate rest, while regimen.
 Patient is slowly
encouraging activity and
exercise (e.g. walking) walking without any
Rationale: All vital signs signs of respiratory
difficulties
 are impacted by chances  Patient manifested no
of oxygenation signs of cyanosis.
  Monitor Vital signs and  Patient had a normal
cardiac rhythm. Rationale: capillary refill test
to determine oxygenation >2secs.
and levels of carbon
dioxide retention
  Evaluate pulse oximetry.
Rationale: To monitor
oxygen saturation.
 Elevate head of bed and
position the client
appropriately.  Rationale:
Elevation or upright
position facilitates
respiratory function by
gravity

Collaborative Interventions: 

Provide supplemental
oxygen at lowest
concentration indicated by
laboratory results and client
symptoms or situation.
Rationale: To alleviate
patient and restore its
breathing.
7. Risk for Infection related to chronic recurrence of rheumatic After 2 days of student nurse – patient Independent Interventions After 2 days of nursing
heart disease and compromised circulation secondary to mitral interaction, the patient will: 1. Assess current condition intervention, the patient:
valve insufficiency. such as the presence,
A. Remain to be free of any signs existence of and history of risk  Remained free of any
Scientific Basis: of infection such as redness, factors. Rationale: These signs of infection
delayed healing, fever, pain, represent a break in the such as redness,
Rheumatic heart disease is a condition in which the heart valves tenderness, warmth, or body’s normal first line of delayed healing,
have been permanently damaged by rheumatic fever. The heart swelling fever, pain,
defense.
valve damage may start shortly after untreated or under-treated B. Be able to verbalize at least 3 tenderness, warmth
streptococcal infection such as strep throat or scarlet fever. interventions to prevent or 2. Assess and monitor or swelling.
Untreated or under-treated strep infections can increase the risk reduce risk of infection nutritional status. Rationale:  Verbalized 4
C. Demonstrate meticulous hand intervention needed
for rheumatic heart disease. Children who get repeated strep Patients with poor nutritional
washing technique accordingly to prevent or reduce
throat infections are at the most risk for rheumatic fever and status may be anergic or
D. Verbalize understanding of risk of infection (eg:
rheumatic heart disease (Johns Hopkins Medicine, 2020) lifestyle and environment unable to muster a cellular
increased water
changes to promote safe immune response to intake, hand hygiene,
Reference: environment pathogens making them doing gargle and
susceptible to infection. eating well) 
Johns Hopkins Medicine (2020). Rheumatic Heart Disease.
 Showed enthusiasm
Retrieved from 3. Check patient’s medications
upon lifestyle and
https://www.hopkinsmedicine.org/health/conditions-and- or treatment modalities that environment changes
diseases/rheumatic-heart-disease may cause  Is doing his oral care
immunosuppression. and gargle part of his
Rationale: Antineoplastic bedtime and morning
agents, corticosteroids and so rituals.
on, can reduce immunity.  remains free of
infection, as
4. Monitor patient for signs of evidenced by normal
actual infection such as vital signs and
redness, swelling, increased absence of signs and
pain, elevated temperature, symptoms of
and appearance of urine. infection.
Rationale: These can indicate  When asked about
onset of infection. any pain in the throat
5. Practice proper hand when swallowing, will
hygiene and instructed S.O, verbalize “ wa ra ga
client, and visitors to wash sakit ako tutunlan” 
hands regularly. Rationale: It  Has been drinking a
is a first-line defense against lot of fluids.
healthcare-associated
infections (HAIs).

6. Provide a clean and well-

ventilated environment.
Rationale: To reduce risk for
infection

7. Encourage fluid intake of

2,000 to 3,000 ml of water per
day as tolerated unless
contraindicated. Rationale:
Fluids promote diluted urine
and frequent emptying of
bladder – reducing the stasis
of urine, in turn, reduces risk
for bladder infection or urinary
tract infection.

8. Advise to limit visitors and to

be away from any crowded
places.Rationale: Restricting
visitation reduces the
transmission of pathogens.

9. Demonstrate and allow

return demonstration of hand
washing. Rationale: Patient
and S.O need opportunities to
 master new skill to reduce risk
for infection.

10.Encourage oral hygiene

(brushing and gargle)
Rationale: To kill or prevent
bacteria on the throat.

Collaborative Interventions:

 Collaborate with dietary

regarding food modifications
to ensure diet is protein-rich
and calorie-rich such as
eggs, vegetables, potatoes,
whole milk and whole milk
products and avocado.
Rationale: It helps support
the immune system
responsiveness.

8.Readiness for enhanced health management as evidenced After 2 days of patient-student nurse  Verify client’s level of After 2 days of nursing
by clients verbalization of “Ok lang ba maglakaw lakaw ko interaction, patient will be able to: understanding of intervention, the patient:
aron dili  ko luya?” therapeutic regimen. Note
   Showed
specific health goals.
  understanding  of the
A. Understand what and how the R: This provides an
disease as client
Objective: disease will affect his lifestyle opportunity to ensure
verbalized,“Naay
B. Identify health behaviors to accuracy and completeness
The client was cooperative and follows instructions. damage na akong
prevent progression of illness. of knowledge base for
heart, bantayanan
  C. Identify steps necessary to future learning.
kon muubos o
reach desired health goals.
Scientific Basis: mutaas grabi ako
D. Understand the importance of  Listen to patient's concerns
pulso.”
following therapeutic regimen. (physical, emotional and
Demonstration of behaviors or cues that reflect learners'
E. Demonstrate proper breathing environmental stressors)
motivation to learn at a specific time. Reflects not only the desire  Assumed
or willingness to learn but also the ability to learn at specific time. exercise and positioning. R: Could impact the responsibility of his
F. Promote sense of confidence to patient's ability to control his own health as he
continue efforts to achieve well- own health verbalized “Magtumar
Source: being. ko permi sa akong
 Identify patients steps tambal aron dili
Berman, A. et al.(2008). Kozier & Erb's fundamentals of necessary to reach desired mulala ako
nursing :concepts, process, and practice. Upper Saddle River, health goals. kondisyon.”
N.J. : Pearson Prentice Hall R: Understanding the
process enhances  Understand the
commitment and likelihood  importance of taking
of achieving the goals. the medicine at the
right route and time.
M:
 Educate patient the right  Understand the
timing of taking his importance of
medication. assessing the pulse
R: To achieve full effects of and BP before taking
medication and desired the medication.
outcome
 Demonstrated proper
E: deep breathing
exercise and proper
 Advised S.O to clean home
position when lying in
regularly and surroundings.
bed.
R: To avoid reinfection or
infection of individuals.
 Enumerated things to
 Encouraged patient and
prevent progress of
S.O to maintain calm and
disease and maintain
peaceful environment
well-being; eat
R: This promote rest nutritious food, do
periods and sleeping. proper hygiene and
maintain clean
  Instructed S.O. to put the environment .
patient away to those who
have colds, cough or any  Continue to flourish
crowded places. his spirituality as
evidenced by his
R:Prevent
verbalization of
infection/reinfection
“Ipadayon lang gyud
T: nako ang pag-ampo.”
 Instructed to have a follow
up check up with caregiver
on the scheduled date.
R: This allows the caregiver
to choose the right
intervention base on
condition of patient.
O:
 Instructed patient to notify
health care professional
immediately if rash, mouth
sores, sore throat, fever,
swelling of hands or feet,
irregular heart beat, chest
pain, dry cough,
hoarseness, swelling,
difficulty swallowing or
breathing occurs, or if taste
impairment or skin rash
persists. 
R: To prevent progress of
these symptoms and to
address problem
immediately.
  Encouraged the use of
exercise, relaxation skills
and deep breathing.
R: Assist in management of
stress, and promote general
health and well-being.

 Instructed to elevate head

of bed or use two pillows in
lying position.
R: To address/prevent
difficulty in breathing.

 Instruct patient and family

on correct technique for
monitoring BP. Advised
them to check BP at least
weekly and to report
significant changes to
health care professional.
R: Medications might cause
toxicity or an indication to
change dosage if there’s
too much alteration in BP.

D:
 Review specific dietary
restrictions of patient. Limit
intake of food rich in purines
and sodium, saturated fats,
cholesterol and sugary
 foods.
R: To promote wellness
and progress of disease.
S:
 Advised patient and S.O to
always trust and believe in
God.
R: To give hope to patient
and family.

 Advised to always be strong

and optimistic in life.
R: Strengthen someone’s will
to live.

 Encouraged patient to
spend time to meditate.
R: Provides inner peace and
break from a lot of thoughts.
 APPENDIX C

DISCHARGE PLAN

May go home was ordered by:

 Dr. Rudy Amatong
 
M:
 Instructed patient to take medications as directed by the physician at the same time each day, even if feeling well. Take missed doses as soon as
remembered but not if almost time for next dose, do not double dose. Warn patient not to discontinue medications unless directed by health care
professional.
 Informed family that they have the right to refuse to these medications.
 Reminded patient/ SO to always read the medication before taking if it is the right medication and right dosage.
 Instructed SO to give medication to the right patient, never give these medications to other people even if their condition appears to be the same as the
patient.
 Instructed SO to assess patient first before giving medication by checking his pulse (normal: 60-100).
 Instructed patient to notify health care professional immediately if rash, mouth sores, sore throat, fever, swelling of hands or feet, irregular heart beat, chest
pain, dry cough, hoarseness, swelling, difficulty swallowing or breathing occurs, or if taste impairment or skin rash persists. 
 Instructed patient and family on correct technique for monitoring BP. Advise them to check BP at least weekly and to report significant changes to health
care professional.
  Educate patient and SO to effects and precautionary measures to the following drugs:

1. Carvedilol  6.25mg/tab ½ tab twice a day. Advise patient to hold dose and contact health care professional if pulse is <50 bpm or BP changes
significantly.
May cause drowsiness or dizziness. Caution patients to avoid driving or other activities that require alertness until response to the drug is known.

2. Captopril 25 mg/tab 1tab twice a day May cause dizziness. Caution patient to avoid driving and other activities requiring alertness until response to
medication is known.

3. Potassium chloride tabs (Kdurule) 1tab PO BID. Do not crush, chew, or suck on a tablet or capsule. Sucking on the pill could irritate your mouth or
throat. Avoid taking supplements or products that contain potassium without first asking your doctor. If you take certain products together you may
accidentally get too much potassium.

4. Lactulose 30cc qHS (every bedtime) PO for BM greater or equal to three times a day. Caution patients that this medication may cause belching,
flatulence, or abdominal cramping. Health care professional should be notified if this becomes bothersome or if diarrhea occurs. Encourage patients to use
other forms of bowel regulation, such as increasing bulk in the diet, increasing fluid intake, and increasing mobility.

5. Furosemide 40 mg/tab 1 tab PO BID. Advise patient to contact health care professional if weight gain more than 3 lbs in 1 day. Caution patient to use
sunscreen and protective clothing to prevent photosensitivity reactions.

6. Nitroglycerin patch smog OD. Apply patch on nonhairy area of skin. Instruct patient to place patch at different sites each day.

7. Digoxin (lanoxin) tablet 0.25 mg/tab q12H PO. Teach patient to take pulse and to contact health care professional before taking medication if pulse rate
is <60 or >100. Instruct patient to keep digoxin tablets in their original container and not to mix in pill boxes with other medications; they may look similar to
and may be mistaken for other medications.

8. Phenoxymethylpenicillin (sumapen) 250 mg/cup BID. Complete the full course of the antibiotic, even if you feel your infection has cleared up. You
should take phenoxymethylpenicillin when your stomach is empty of food (so an hour before you eat, or two hours afterwards).
 
E:
 Advised S.O to clean home regularly and surroundings to avoid reinfection or infection of other individuals.
 Encouraged patient and S.O to maintain calm and peaceful environment to promote rest periods and sleeping.
 Instructed S.O. to put the patient away to those who have colds, cough or any crowded places.
 Maintain good ventilation.
 
 
 T:
 Instructed to have a follow up check up with Dr. Amatong on the scheduled date.

H:
 Rest when you feel it is needed.
 Encouraged deep breathing exercise.
 Instructed to elevate legs when in sitting position.
 Encouraged to slowly start doing activities until able to return to his ADLs.
 Patient is at an increased risk of severe infection: avoid crowded places and those who are sick.
 Instructed patient to take the complete course of each medication.
 Instructed patient to avoid doing extraneous activities.
 Wash hands regularly, especially after you go to the bathroom and before you eat.
 Wear clean clothing.
 Instructed patient to have enough sleep.

O:
 Instructed client to contact health care providers if the following signs and symptoms are felt: fever, swollen and painful joints, nodules, rashes, stomach
pain, involuntary movements and generalized weakness.
 Instructed to seek care immediately if the following signs and symptoms are felt: shortness of breath, chest pain and swelling.
 
 
D:
 Advise a nutritious diet high in vegetables, whole grains, fruits, and protein.
 Limit intake of food rich in purines and sodium.
 Limit saturated fats, avoid artificial trans fat.
 Limit cholesterol found in red meat and high-fat dairy products.
 Avoid sugary foods.
 Potassium supplementation may be necessary because of the mineralocorticoid effect of corticosteroid and the diuretics, if used.
 Instructed to watch alcohol intake. Alcohol can reduce the effectiveness of medications.
 Increase fluid intake as tolerated.

S:
 Advised patient and S.O to always trust and believe in God.
 Advised to always be strong and optimistic in life.
 Encouraged patient to do meditation.
 Encouraged patient to take time for self-reflection.
  Recommend patient to attend support groups that boosts spirituality.

CITATION:

Wayne, G. (2017, September 23). Imbalanced Nutrition: Less Than Body Requirements – Nursing Diagnosis & Care Plan. Retrieved February 12, 2020,
from https://nurseslabs.com/imbalanced-nutrition-less-body-requirements/

American Cancer Society. (2016, February 5). Normal weight ranges: Body mass index (BMI). Retrieved February 12, 2020, from
https://www.cancer.org/cancer/cancer-causes/diet-physical-activity/body-weight-and-cancer-risk/adult-bmi.html

Department of Health & Human Services. (2012, September 30). Heart disease and food. Retrieved February 12, 2020, from
https://www.betterhealth.vic.gov.au/health/ConditionsAndTreatments/heart-disease-and-food

Chin, T. K. (2019, December 4). Pediatric Rheumatic Heart Disease. Retrieved February 10, 2020, from https://emedicine.medscape.com/article/891897-
overview#a3

Abbott, J. D. (2018, November 30). Rheumatic Heart Disease. Retrieved February 10, 2018, from https://www.dynamed.com/condition/rheumatic-heart-
disease

Rheumatic heart disease and rheumatic fever. (n.d.). Retrieved February 10, 2020, from https://chw.org/medical-care/herma-heart/conditions/rheumatic-
heart-disease

Heart and Stroke Foundation of Canada. (n.d.).Rheumatic heart disease. Retrieved February 10, 2020, from
https://www.heartandstroke.ca/heart/conditions/rheumatic-heart-disease
 The Johns Hopkins Medicine. (n.d.). Rheumatic Heart Disease. Retrieved February 10, 2020, from https://www.hopkinsmedicine.org/health/conditions-
and-diseases/rheumatic-heart-disease