Nursing Case Study for Rheumatic Heart Disease
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Outline
Ms. Patel, a 19-yr-old female who recently immigrated to the US from India due to poor conditions in her home village, presents to the Emergency Department (ED) with “fluttering” in the chest which is sometimes uncomfortable. She also complains of fatigue and occasional shortness of breath. She has no primary care provider and works at her family’s hotel primarily cleaning rooms. She says this issue is impacting her work.
What further nursing assessments need to be performed for Ms. Patel?
- Head-to-toe assessment with a focus on heart and lungs. 12 lead EKG and place on a heart monitor. O2 sats. Use facility-approved pain evaluation tool – since this may be cardiac related (“fluttering in the chest”) use the PQRST method. P=provacation/palliation, Q=quality, R=region/radiation, S=severity scale, T=timing)
What focused questions need to be included in the admission interview?
- The point is to assess for rheumatic fever history. What were the living conditions in India (crowded, poverty, no healthcare access)? Does she remember having very bad or frequent sore throat symptoms (checking for strep A infection history)? Rheumatic fever diagnosis or symptoms (fever, painful joints especially knees, ankles, elbows and wrists; pain that moves between different joints; fatigue, jerky uncontrollable body movements).
Upon further assessment, the patient has mild peripheral edema. Heart auscultation indicates a harsh pansystolic murmur and lung auscultation reveals crackles in all fields. Vital signs were as follows:
BP 134/84 mmHg SpO2 92% on Room Air
HR 102 bpm and regular
RR 12 bpm at rest, 30 with movement
Temp 37.2°C
What orders does the nurse anticipate?
- Transthoracic (non-invasive) echocardiogram (echo)
Cardiac labs
Chest radiographs
12 lead EKG if not done in triage
Cardiac enzymes were drawn, results are still pending. EKG ordered, results: 12-lead EKG report reads: “Sinus tachycardia with mild to moderate mitral regurgitation.”
A chest x-ray and transthoracic echocardiogram were ordered. Ms. Patel asks why she needs these tests. Pregnancy test was negative. The provider confides in the nurse that he suspects rheumatic heart disease.
How can the nurse best explain the need for the tests?
- Transthoracic (non-invasive) echocardiogram – checking the heart valves and cardiac health in case rheumatic fever caused damage
Cardiac labs – to see if the problem is acute vs chronic
Chest radiographs – best and least invasive way to get cardiac and lung data
12 lead EKG if not done in triage – to determine if there are dysrhythmias, to check for acute vs chronic pathology, a baseline for future treatment (patient is at risk for afib) - Pregnancy test – sometimes when a woman becomes pregnant previously asymptomatic heart conditions may produce symptoms, heart damage can lead to pregnancy or delivery complications, and this should be assessed due to her being of childbearing age.
What potential risk factors does Ms. Patel have for rheumatic heart disease?
- Coming from impoverished conditions (“The disease persists among the rural poor and marginalized populations with little or no access to primary health care.”) If yes to rheumatic fever history screening, this is the cause of rheumatic heart disease (RHD)
The nurse has Ms. Patel on continuous cardiac monitoring per the provider’s order. He notices a change in the P wave on the monitor, however, the QRS complex remains narrow. He checks on the patient, and she reports no chest pain but feels a “flutter” in her chest. Cardiac enzymes were negative.
How does the nurse interpret this EKG finding? What does it mean? What may explain it?
- This could be premature atrial contractions that may come and go. They can be caused by structural problems or for no reason at all. She may have heart valve issues which is why it is important to tell the provider of any EKG changes.
The provider is advised of the EKG changes. He comes in to tell the patient about the chest x-ray which indicates cardiomegaly and mild interstitial pulmonary edema. An echocardiogram reveals mitral regurgitation, thickened mitral leaflets, and dilated left atrium and ventricle.
After the provider leaves, Ms. Patel asks what that means.
How can the nurse help explain what the provider said to Ms. Patel?
- Cardiomegaly = enlarged heart maybe from chronic valve problems and strain on the heart from rheumatic fever
Mild interstitial pulmonary edema – fluid in lungs due to heart getting “backed up” from a valve not working correctly. - An echocardiogram reveals mitral regurgitation, thickened mitral leaflets, and dilated left atrium and ventricle = heart valve has changes consistent with RHD, the heart is enlarged from increased work due to valve problems.
The provider consults cardiology for the patient. When the specialist arrives, he mentions possible heart surgery, according to the patient, but is not specific.
What type of surgery does the nurse consider researching more to educate the patient?
- The determination of the exact procedure is up to the specialist. However, discussing and educating about cardiac catheterization and/or valve replacement surgery options is appropriate. Heart valve replacement discussion should include biological and mechanical options.
Ms. Patel is discharged after an influenza vaccine with instructions to follow up with cardiology. Discharge medications include:
Spironolactone PO 50 mg daily
Aspirin PO 81 mg daily
Enalapril PO 2.5 mg daily
What Is the rationale for these medications?
- Flu shot – prevention is key especially with underlying cardiac patients
Spironolactone PO 50 mg daily – diuretic to reduce preload
Aspirin PO 81 mg daily – antiplatelet to help prevent coronary vessel thrombosis
Enalapril PO 2.5 mg daily – ACE to reduce afterload because the patient has signs of heart dysfunction
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Transcript
Hey everyone. My name is Abby. We’re going to go through a case study for rheumatic heart disease together. Let’s get started. In this scenario, Ms. Patel is a 19 year old female who recently immigrated to the US from India due to poor conditions in her home village. Today, she presents to the emergency department with fluttering in the chest, which is sometimes uncomfortable. She also complains of fatigue and occasional shortness of breath. She has no primary care provider and works at her family’s hotel, primarily cleaning the rooms. She says the issue is starting to impact her work. Now let’s take a look at critical thinking checks number one and number two below.
Great job upon further assessment. The patient has mild peripheral edema. Heart auscultation indicates a pansystolic murmur and lung auscultation reveals crackles in all fields. Her vital signs are as follows: her blood pressure is 134/84 mmHg. Oxygen saturation on room air 92%, heart rate 102 beats per minute with a regular rhythm, and a respiratory rate of 12 at rest and 30 with exertion. Her temperature is 37.2 degrees Celsius. After looking at these vital signs, let’s take a look at the critical thinking checks below. We’ll go to number three.
Excellent work. Cardiac enzymes were drawn and the results are still pending. The EKG was ordered and the 12 lead report reads: Sinus tachycardia with mild to moderate mitral regurgitation. A chest x-ray and a transthoracic echocardiogram were ordered. A pregnancy test was negative. Ms. Patel asks why she needs these tests. The provider confides in the nurse that he suspects rheumatic heart disease. Let’s take a look at our critical thinking checks number four and number five below.
Great job. The nurse has Ms. Patel on continuous cardiac monitoring per the provider’s order. He notices a change in the P wave on the monitor, however, the QRS complex remains narrow. He checks on the patient and she reports no chest pain but feels a “flutter” in her chest. Cardiac enzymes were negative. Now let’s take a look at our critical thinking check number six below.
Well done. The provider is advised of the EKG changes and he comes in to tell the patient about the chest X-ray which indicates cardiomegaly and mild interstitial pulmonary edema. An echocardiogram reveals mitral regurgitation, thickened mitral leaflets, and dilated left atrium and ventricle. After the provider leaves, Ms. Patel asks what that means. Knowing all of this, let’s take a look at critical thinking check number seven below.
Excellent. The provider consults cardiology for the patient. When the specialist arrives, he mentions possible heart surgery, but is not specific about what type. Now that we know all of this, let’s take a look at our critical thinking check number eight below.
Great job, Ms. Patel is discharged after an influenza vaccine with instructions to follow up with cardiology. Discharge medications include spironolactone, which she will take by mouth 50 milligrams per day. That’s her diuretic. She’s also been prescribed an aspirin by mouth of 81 milligrams per day. Lastly, she’s going to start a new medication called Enalapril. She’ll take that by mouth as well, 2.5 milligrams every day, and that will bring us to our critical thinking check number nine. Let’s go there now.
Great work everyone, that wraps up this case study on rheumatic heart disease. Please take a look at the attached study tools and test your knowledge with a practice quiz. We love you all. Now, go out and be your best self today. And as always happy nursing.
References:
Contemporary Diagnosis and Management of Rheumatic Heart Disease: Implications for Closing the Gap: A Scientific Statement from the American Heart Association
Raman ; Kumar, Manuel J. Antunes, Andrea Beaton, Mariana Mirabel, Vuyisile T. Nkomo, Emmy Okello, Prakash Raj Regmi, Boglarka Reményi, Karen Sliwa-Hähnle, Liesl Joanna Zühlke, Craig Sable. Originally published19 Oct 2020, https://doi.org/10.1161/CIR.0000000000000921; from uptodate: Clinical manifestations and diagnosis of rheumatic heart disease
Authors:Liesl Zühlke, MBChB DCH FCPaeds Cert Card MPH FESC FACC MSc PhDFerande Peters, MBBCH FCP(SA) FESC FACC FRCP (London) last updated Dec, 2021; Management and prevention of rheumatic heart disease
Authors:Liesl Zühlke, MBChB DCH FCPaeds Cert Card MPH FESC FACC MSc PhDBlanche Cupido, MBChB, FCP, Cert CardioSection Editor:Patricia A Pellikka, MD, FACC, FAHA, FASE, last updated Oct, 2021
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