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