PATHOPHYSIOLOGY

Predisposing factors: - 15 yrs. Old - Exposure to GABHS (his auntie has the same dse) - (-) immunization Presence of Group A beta-hemolytic Attach to epithelial cells of the upper Activated antigen-presenting cells present the bacterial antigen to helper T-cells. Activated BProduction of antibodies against the cell wall against of streptococcus Antibodies cross react with cardiac myosin and antigens of tissue glucoprotein in the joints, skin, brain and other connective tissue. Induces cytokines release Inflammatory response Unmanaged, subsequent exposure to the antigen Heart valve tissues become inflamed Inflammation subsides Valves begin to heal w/ scar tissue forming FEVER ARTHRALG IA ESR WBC count Activity intolerance Precipitating factors: - Malnutrition - Poor living conditions - Congested neighborhood

Restriction of leaflet motion Impeding to full swing action Aortic Valvular stenosis Leaflets may become deformed by healing tissue Valve fails to close completely Aortic Regurgitation blood volume to LV cyanosis blood volume and pressure in the LA pulmonary venous blood flow & pressure Pulmonary congestion Capillary permeability Plasma leaked out Accumulation of excessive fluid in the pleural space Pleural effusion Dec. vocal tactile fremitus blood volume to RV Continuous flow of blood from the CVC blood volume of RV and RA Tricuspid regurgitation s/sx: fever, chills, pleuritic chest Fast, bounding pulse Orthopne a Dyspnea Non productive cough Skin Cold clammy, pallor Use of accessory muscles RR vasoconstrictio n GIT Kidne y Renal perfusion Release of renin by kidneys cardiac output Stimulate SNS Release of epinephrine and norepinephrine RBC HR & Contractility Further damage to the heart muscles Wide pulse pressure S3 Heart sound Murmurs

Impaired sleep

gastric secretions digestion BM

Formation of angiotensin I ACE converts angiotension I to II

bp

Promotes the release of aldosterone

Dullness when percuss ed lung expansion Impaired gas exchange Pulmonary hypertension Respiratory failure R Ventricular failure

JV D Fluid volume overload Peripheral edema oxygenation in brain -dizziness, lightheadedness Cyanosis, pallor

Promotes retention of Na+ and water

Stimulates ADH production

UO

Preload and afterload Further stress on the ventricular wall Further in the workload of the heart Thickness of the heart muscle ventricular pressure and resistance to ventricular filling Subsequent in cardiac output Development of pressure workload of the heart contraction Elasticity Fail to contract Death

Fatigu e Weakne ss Activity intolerance

Congestion of the viscera and peripheral tissue Blood backs to hepatic veins Pressure w/in portal vessels Portal hypertension Forced fluid into the abdominal cavity Ascites

Abdominal pain Anorexia Nause a Weight gain

Nursing care plan

NURSING CARE PLAN ASSESSMENT DATA (Subjective & Objective Cues)

Subj: dili kaau ko kalihoklihok kay dali rako kapoyon as verbalized.

NURSING DIAGNOSIS (problem and etiology)

Decrease cardiac output related to incompetent valve stenosis as manifested by arrhythmia, prolonged capillary refill and generalized edema.

GOALS AND OBJECTIVES

After 2 of nursing intervention pt will lessen/ eradicate streessors that can help in reducing the workload of the heart participate in activities that reduce the workload of the heart like stress management, therapeutic medication, and balanced activity rest pattern.

NURSING INTERVENTIONS AND RATIONALE

Independent:

EVALUATION

GOAL PARTIALLY MET After 2 of nursing intervention pt was able to participate in activities that reduced the workload of the heart

- Keep client on bed, promote rest, semi fowler position is preferred and may elevate feet in shock situations - Encourage slowly dangling of legs before standing - Limit visitors - Review diagnostic studies like CXR, ECG - Encourage relaxation techniques such as deep breathing exercises Dependent: Collaborative: - Discuss sign and symptoms that require prompt reporting to health care provider ( muscle cramps, headache and dizziness)

Obj: -peripheral edema(+3) - cold clammy skin - 4 sec. capillary refill

Obj: To be able to decrease edema - To be able to promote blood circulation To be able to demonstrate an increase in activity tolerance -

NURSING CARE PLAN ASSESSMENT DATA (Subjective & Objective Cues)

S: galisod ko Subjective: ug ginhawa as verbalized by the akong gapanghupong patient mga

NURSING DIAGNOSIS (problem and etiology)

Impaired gas exchange Excess fluid volume related related to fluid shift on alveoli to increased ADH secondary to pulmonary production and edema as manifested by as sodium/water retention respiratory rate of 28 bpm manifested by bipedal and

GOALS AND OBJECTIVES

GOALS: Goal: After 18hrs of nursing After day of intervention, the patient continuous nursing will improve respiration intervention the OBJECTIVES: patient will be able to To be able to reduce recurrence of decrease respiratory fluid excess28 bpm to rate from as manifested by by atleast 24 bpm decrease abdominal positioning the patient girth, reduce edema in semi fowler position from (+3) to (+1). of and administration oxygen inhalation

NURSING INTERVENTIONS AND RATIONALE

Independent: color of the skin, use Monitor of accessory muscle oxygen Note presence of underlying saturation, that potential and condition depth, pattern fluid rate of respiration excess Position patient in semi Note presence of edema and fowler position calculate its grade
Secure oxygen at bedside

EVALUATION

tiil as verbalized by the Objective data: patient

Respiratory rate of 28 bpm Use of Objective: accessory muscle Orthopnea Bipedal Edema grade 3 Crackles

edema (grade 2).

Goal partially met. GOAL MET partially After met a day of nursing intervention the After 8 hrs of patient respiratory rate continuous nursing decrease from patient intervention, 28 bpm to 26 bpm.

Abdominal girth of 30cm

Objective: To be able to reduce accumulation of fluid (edema) on feet and different part of the body To be able to increase output

Note pattern of urination Minimize activities and energy expenditures by assisting ADLs O Measure I and DEPENDENT Give oxygen as prescribed by the physician Dependent: Restrict Na and Fluid as indicated Administer diuretics as prescribed

was able to reduce recurrence of fluid excess as manifested by decreased abdominal girth and decreased edema from grade 3 to grade 2.

Drug study

CAPITOL UNIVERSITY COLLEGE OF NURSING

Name of Student:_______________________________________ Name of Patient:________________________________________ DRUG STUDY (Generis name, brand name, classification, dosage, route, frequency) Aspirin 80 mg 1 tab OD (after lunch, 1pm) Class: Analgesic(non-opioid) Antirheumatic

Date of Assignment:__________________________________________ Ward:_____________________________ Bed No. _______________ DRUG STUDY NURSING RESPONSIBILITIES/ PRECAUTIONS >asses for allergy to salicylates or NSAIDs > give med with food or after meals.

MECHANISM OF ACTION Inhibits the synthesis of prostaglandins.

INDICATIONS >inflammatory conditions

CONTRAINDIATIONS >allergy to salicylates or NSAIDs

ADVERSE EFFECTS OF THE DRUG Acute Aspirin toxicity: respiratory alkalosis, tachypnea, hemorrhage Aspirin intolerance: exacerbation of bronchospasm, rhinitis GI: nausea, dyspepsia, heartburn Hematologic: occult blood loss, homeostatic defects Hypersensitivity: anaphylactic reaction

Eg. Rheumatic fever, >Use cautiously with rheumatic heart disease patients with hepatic impairement

Issue: 05 April 2006 CAPITOL UNIVERSITY

Revision Code: 003

Name of Student:_______________________________________ Name of Patient:________________________________________ DRUG STUDY (Generis name, brand name, classification, dosage, route, frequency) Carvedilol 6.25 mg 1 tab b.i.d. class: alpha & beta adrenergic blocker antihypertensive

COLLEGE OF NURSING Date of Assignment:__________________________________________ Ward:_____________________________ Bed No. _______________ DRUG STUDY NURSING RESPONSIBILITIES/ PRECAUTIONS >assess history of heart failure >monitor for orthostatic hyp[otension >take drug with meals

MECHANISM OF ACTION Competitively blocks alpha-, beta-, and beta2adrenergic receptors and has some sympathomimetic activity at beta2receptors.

INDICATIONS >treatment for mild to severe heart failure of ischemic cardiomyopathic origin.

CONTRAINDIATIONS > decompensated heart failure, bronchial asthma, heart block >use cautiously with hepatic impairement

ADVERSE EFFECTS OF THE DRUG CNS: dizziness, vertigo, tinnitus, fatigue CV: bradycardia, orthosttic hypotension, heart failure GI: gastric pain, flatulence, hepatic failure

Issue: 05 April 2006

Revision Code: 003

Name of Student:_______________________________________ Name of Patient:________________________________________ DRUG STUDY (Generis name, brand name, classification, dosage, route, frequency) Spirinolactone 25 mg 1 tab b.i.d. PO Class: potassium-sparing diuretic

CAPITOL UNIVERSITY COLLEGE OF NURSING Date of Assignment:__________________________________________ Ward:_____________________________ Bed No. _______________ DRUG STUDY NURSING RESPONSIBILITIES/ PRECAUTIONS >assess for allergy to spirinolactone >assess skin for urticaria and rashes >measure and record regular weight >monitor mobilization of liquids >avoid foods rich in potassium

MECHANISM OF ACTION Competitively blocks the effects of aldosterone in the renal tubules causing loss of sodium and water and retains potassium.

INDICATIONS >treatment for hypokalemia or prevention of hypokalemia in patients receiving cardiac glycosides Eg. digoxin

CONTRAINDIATIONS >allergy to spirinolactone >hyperkalemia >renal disease

ADVERSE EFFECTS OF THE DRUG CNS: dizziness, headache, drowsiness Derma: rash, urticaria, GI: cramps, diarrhea, vomiting GU: impotence Hema: Hyperkalemia, hyponatremia, agranulocytosis

Issue: 05 April 2006

Revision Code: 003

Name of Student:_______________________________________ Name of Patient:________________________________________ DRUG STUDY (Generis name, brand name, classification, dosage, route, frequency) Digoxin 0.25 mg 1 tab OD PO Class: Cardiac glycoside cardiotonic

CAPITOL UNIVERSITY COLLEGE OF NURSING Date of Assignment:__________________________________________ Ward:_____________________________ Bed No. _______________ DRUG STUDY NURSING RESPONSIBILITIES/ PRECAUTIONS >assess for allergy to cardiac glycosides >monitor apical pulse for 1min before administration. Hold dose if <60 bpm

MECHANISM OF ACTION

INDICATIONS

CONTRAINDIATIONS >allergy to cardiac glycosides >ventricular tachycardia >ventricular fibrillation >heart block

ADVERSE EFFECTS OF THE DRUG CNS: headache, weakness, drowsiness, visual disturbance CV: arrhythmias GI: GI upset, anorexia

Increases intracellular >heart failure calcium to enter the myocardial wall during > atrial fibrilation depolarization via NaK pump.

Issue: 05 April 2006

Revision Code: 003

Name of Student:_______________________________________ Name of Patient:________________________________________ DRUG STUDY (Generis name, brand name, classification, dosage, route, frequency) Penicillin 500mg 1 cap PO OD Class: antibiotic

CAPITOL UNIVERSITY COLLEGE OF NURSING Date of Assignment:__________________________________________ Ward:_____________________________ Bed No. _______________ DRUG STUDY NURSING RESPONSIBILITIES/ PRECAUTIONS >assess allergy to penicillin and cephalosphorin >culture infection before beginning treatment >avoid patient to do selftreatment >do not administer with milk, fruit juices, or soft drinks

MECHANISM OF ACTION Bactericidal. Inhibits cell wall synthesis of sensitive organism.

INDICATIONS >for moderately severe infections caused by sensitive organism Eg. streptococci

CONTRAINDIATIONS >allergy to penicillin

ADVERSE EFFECTS OF THE DRUG CNS: lethargy, hallucinations, seizures, GI: glossitis, stomatitis, gastritis, sore mouth, nausea and vomiting, diarrhea GU: nephritis, oliguria, hematuria Hema: anemia, thrombocytopenia

Issue: 05 April 2006

Revision Code: 003

Name of Student:_______________________________________ Name of Patient:________________________________________ DRUG STUDY (Generis name, brand name, classification, dosage, route, frequency) Ciprofloxacin 200 mg IVTT q12 class: antibacterial

CAPITOL UNIVERSITY COLLEGE OF NURSING Date of Assignment:__________________________________________ Ward:_____________________________ Bed No. _______________ DRUG STUDY NURSING RESPONSIBILITIES/ PRECAUTIONS >asses allergy to ciprofloxacin and flouroquinolones

MECHANISM OF ACTION Bactericidal Interferes with DNA replication in susceptible bacteria preventing cell replication

INDICATIONS >treatment for gram negative bacteria

CONTRAINDIATIONS >allergy ciprofloxacin and flouroquinolones

ADVERSE EFFECTS OF THE DRUG CNS: headaches, dizziness, somnolence CV: arrhythmias, hypotension, angina GI: nausea and vomiting, dry mouth, diarrhea

Issue: 05 April 2006

Revision Code: 003

DISCHARGE PLANNING
D- Diet Encourage patient to eat nutritious foods, limiting intake of food and sodium. F- Follow- up Instruct patient to have a follow-up visit after 1 week at his doctors clinic. A- Activity Level Encourage following activity with restrictions, resuming activity gradually, and resting whenever tired. Advise patient to have assistance and support as tolerated when ambulating and to perform ADLs involving hygiene and self-care, with support if needed. T- Treatment Emphasize the importance of prophylaxis against recurrent streptococcal pharyngitis and continuous therapy to prevent recurrent rheumatic fever and rheumatic heart disease. D- Discharge Plan Explain to the patient and parents the disease process and its treatment to promote understanding of acute and lifelong prophylactic treatment. Teach patient and parents to prevent further streptococcal infections b good hand washing and avoiding people with sore throat. Encourage the patient and parents to contact the primary healthcare provider if a sore throat occurs. Advise patient to return to physical education classes gradually, with the guidance of the physician. Encourage patient to take frequent naps and rest periods. Encourage relaxing environment using relaxation techniques, listening to music and quiet activities Teach patient and parents about the importance in keeping their environment clean and practicing proper food handling and sterilizing kitchen utensils. Advise the parents that child cannot return to school until health care provider assesses that all disease activity is gone. Parents may need to discuss with teachers how the child can catch up with school..

M- Medications Make sure that the patient understands the purpose, dosage, route, and possible side effects of all prescribed home medications. Instruct patient and the family to strictly follow the orders for take home meds upon discharge as prescribed by the physician.