Central Luzon Doctors’ Hospital

Educational Institution
Romulo Highway, San Pablo, Tarlac City

A CASE REPORT OF RHEUMATIC HEART DISEASE

S.Y. 2020-2021

In partial fulfillment of the requirements in NCM_109

SUBMITTED BY:
Abella, Ronelene F.
Antalan, Marializ Therese R.
Aspiras, Kristen Q.
Baking, Niña Janevier F.
Balaba, Mary Rose G.
Bautista, Jane S.
Bautista, Trishia Anne M.
Caruz, Jenica
Collado, Dwight Lester I.
Flores, Winslet G.
Gervacio, Gino L.
Laxamana, Analiza M.
Navarro, Nicholas C.
Ovejera, Adriane Gabriel P.
Panta, Lani C.
Ramil,
Santiago, Rodaiza P.
Sy, Eduardo Jr D.
Valdez, Eleizza Marie N.
Zipagan, Maria Charisse M.

June 2021
 I. INTRODUCTION

Rheumatic heart disease is a condition that causes permanent damage to the heart
valves. It can develop after a child has rheumatic fever. Rheumatic fever is the body’s
response to a strep infection of the throat or tonsils or “strep throat” from a bacterium called
Streptococcus pyogenes (group A streptococcus). Rheumatic fever may also follow scarlet
fever. This is a strep infection of the throat along with a red, rough-feeling skin rash.
Rheumatic fever may affect the joints, skin, tissue under the skin, brain, and heart. If it
affects the heart, it is called rheumatic heart disease.

Rheumatic fever occurs more often in children between ages 5 and 15. This is
especially true if they have had frequent cases of strep throat. Poor access to medical care is a
risk factor for rheumatic heart disease as strep infections are more likely to be missed and go
untreated.

RHD is preventable but continues to cause significant levels of mortality and

morbidity in countries with health systems too fragile to control it. Starting with an untreated
or inadequately treated strep throat, the disease progresses over time to inflict serious heart
damage and can lead to death for some of the world’s most vulnerable people.

Local

Rheumatic fever or rheumatic heart disease (RF/RHD) remains to be a major public

health concern in certain parts of Asia and uncontrolled in the Philippines. According to the
Philippine Heart Association (PHA), the RF/RHD prevalence in the country is one to two per
1,000.

The Philippine Pediatric Society Registry of Diseases (2005 to January 2015) divulged
that there were 1,634 out of 2,524,993 RF cases with or without heart involvement. RF with
heart involvement was 237 cases, or nine out of 100,000 cases. These data were based on
discharge diagnosis of patients managed in PPS-accredited hospitals nationwide.

From January 2014 to January 2015, the Dr. Jose R. Reyes Memorial Medical Center
Report on RF/RHD showed these data: 80 cases Outpatient Department (OPD) out of 9.05 or
nine out of 1,000 were RF patients with no heart involvement; at the OPD, 450 out of 9,065, or
49 out of 1,000 were RF cases with heart involvement; and at the ward, 17 out of 1,109, or 15
out of 1,000 had RF and RHD.

International

According to World Health Organization (2015), some 30 million people are

currently thought to be affected by rheumatic heart disease globally, 2 and in 2015 rheumatic
heart disease was estimated to have been responsible for 305 000 deaths and 11.5 million
disability-adjusted life years lost. Of these deaths 60% occurred prematurely (that is, before
the age of 70 years), although these figures are very uncertain owing to incomplete data in
many countries. Despite the availability of effective measures for prevention and treatment,
there has been little change in the contribution of rheumatic heart disease to overall global
mortality between 2000 and 2015.

Rheumatic heart disease persists in countries in all WHO regions. The African,
South-East Asia and the Western Pacific regions are the worst affected, accounting for 84%
of all prevalent cases and 80% of all estimated deaths due to rheumatic heart disease in
2015.2 India, in the South-East Asia Region, has the highest global prevalence, with about
27% of all cases globally. In the Western Pacific Region, the burden of rheumatic heart
disease is especially concentrated in China and indigenous populations living in Australia,
New Zealand and the Pacific Island States. In the Eastern Mediterranean Region, rheumatic
heart disease persists in certain countries such as Egypt, Sudan and Yemen. Overall,
however, the lack of good and reliable data from most regions means that the regional
burdens of rheumatic heart disease may be underestimated.
II. OBJECTIVES

General Objectives

◦ At the end of the case presentation, the nursing students are expected to be
knowledge about the concept of Rheumatic heart disease.

Specific Objectives:

At the end of the case presentation, the student nurses will be able:

◦ To assess patient if they manifest signs and symptoms of Rheumatic heart disease.

◦ To formulate appropriate nursing care plans suited for the Rheumatic heart disease
patient based on the assessment findings.

◦ To implement appropriate medical and surgical interventions for the management of

Rheumatic heart disease.

◦ Illustrate the pathophysiology in relation to the signs and symptoms specifically

manifested in Rheumatic heart disease.

◦ Describe the various drug classes used pertaining to Rheumatic heart disease and their
mechanisms of action, side effects,and pharmacokinetics.

◦ Evaluate interventions given concerning the patient suffering from Rheumatic heart
disease.
III. NURSING PROCESS

A. DATA BASE

a. Nursing Health History A

1. Demographic Data

Axel Lim is a 15 year old male, single and Christian. He was born on May 08,
2006 and currently lives in Tarlac City. He’s 156 cm in height and 50 kg in
weight. Axel Lim was admitted on July 3, 2021 at exactly 9:30 in the morning.
His vital signs upon admission were BP 140/80 mmHg, RR 32 cpm, CR 100 bpm
and have a temperature of 36°C. The data are verified and confirmed by his
mother.

2. Chief Complaint

Axel Lim was admitted with a chief complaint of facial edema, difficulty of
breathing and easy fatigability.

3. History of present illness

Present condition started 2 months prior to admission when patient noticed to

have on and off fever accompanied by abdominal pain, joint pain, and swelling
which is relieved by taking paracetamol. Consultation to a private medical doctor
and was diagnosed to have acute gastritis with sore throat. Unrecalled medications
were given. 1 week prior to admission, patient was noticed to have facial edema,
difficulty of breathing, and easy fatigability. Parents prompted to consult a private
clinic and patient was diagnosed with Rheumatic Heart Disease. He was then
referred to CLDH for further management and laboratories were requested and
done.
4. Past Medical History

A. Pediatric and Adult Illness

The patient had a history of fever accompanied by sore throat.

B. Immunization Test
As stated by the mother the patient had a complete Immunization of BCG, DPT,
For Polio, Hepa B, MMR, for flu and for Pneumonia.

C. Hospitalization
The patient was hospitalized due to gastritis.

D. Injuries
The patient got injured “Oo nagkaroon siya ng pilay noong bata pa siya” as stated
by the mother.

E. Transfusion
The patient did not undergo in any transfusion as stated by the mother.

F. Medication
As stated by the mother the child taking a paracetamol to relieve fever also the
patient taking Vitamins.
G. Allergies
As stated by the mother the patient doesn’t have any allergies.
5. GENOGRAM
 b. Nursing Health History B
BEFORE DURING
HOSPITALIZATION HOSPITALIZATION
HEALTH PERCEPTION AND HEALTH MANAGEMENT:
 Patient’s chief concerns
were about facial edema,  During the patient’s
DOB and easy fatigability. hospitalization, he was on
Patient Axel expressed therapy for Furosemide to
concerns abou the feeling decrease the facial edema.
of tightness around his  He was also initially
face and the fullness prescribed with Pen G IV,
around his chest area. He to treat strep infections
said “Mabigat yung  He was prescribed with
pakiramdam ko, banda Captopril, to lower his
dito” while pointing to an blood pressure, Prednisone
Health Education and area close to his heart. He to help with his discomfort
practices also mentioned “Parang regarding DOB
hinihigit din yung mukha  During his stay at the
ko sa sobrang manas”. hospital, Patient Axel
 Patient Axel’s mother mentioned that he felt
expressed the use of relieved when he had said
liniments such as menthol, to his mother that the
for pain. tightness around his face
 Before hospitalization, and the heavy feeling
Patient Axel had an initial around his chest were
BP of 140/80 mmHg, a decreased, as medications
noticeable facial edema were started.
and difficulty of breathing
 Patient Axel’s mother said
that Axel had received and
completed his
Immunizations immunizations, he still
does yearly flu shots as
part of his school
requirements
Medical Consultations  Patient had visited a doctor  He was checked by Dr.
2 months (May 2021) prior Santos, who later
to being hospitalized confirmed, that Patient
where he was diagnosed Axel has RHD.
with acute gastritis with  Dr. Santos had explained
sore throat to Patient Axel and his
 No alternative mother all the possibilities
consultations were done as of acquiring RHD.
the family is more reliant
to professional medical
 help
 The healthcare team under
Patient Axel’s care had
educated him and his
 Patient expressed the lack
mother regarding the
of trust in the healthcare
consequences of not
system as he said “Hindi
seeing a professional when
Overall health approach ako nagpapacheck-up, pag
it is needed. They also
sumakit lang ng todo,
stressed the possibility of
doon palang siguro ako
him getting an RHD was
magpapadoctor.”
probably because of the
untreated strep throat that
he had previously.
NUTRITION-METABOLIC:
 Patient Axel demonstrated
his understanding in the
caution of sharing foods
and/or drinks with other
 Upon interview with
people. He verbalized
Patient Axel, he expressed
“Simula ngayon, hindi na
that he is fond of sharing
ako makiki-inom sa hindi
foods with his friends,
naman sa akin. Hindi narin
eating the same foods as
ako magooffer ng drinks
they eat and drinks on the
Daily food intake (quality, or foods sa iba, kase baka
same cups that his friends
frequency, amount and sila naman mahawa
drink on.
quantity) sakin.”
 He eats mostly junk food
 During his time at the
for snacks during time at
hospital, he is under DAT,
school and also drinks
with no restrictions,
carbonated liquids
although, it was made sure
occasionally.
that he had a balanced diet
 He prefers salty foods.
which includes a meat, a
cup of rice, a serving of
vegetables and fruits on
the side.
ELIMINATION:
Bowel movement pattern  The usual voiding pattern  No deviations on the
(time, frequency and amount) of Patient Axel is in the voiding pattern as Patient
morning, after waking up, Axel still is voiding in the
and only once per day. morning, after waking up,
 As Patient Axel usually once per day, and
remembers, he used to he does not complain of
pass stools for 2-3 times in any pain sensation while at
a day prior to being it.
diagnosed to have acute
gastritis. Stools were loose
 and they come in very
frequently.
 Patient Axel passes small  During hospitalization,
Urinary pattern (time, amounts of urine with no urination becomes more
frequency, amount and color) accompanying pain. frequent, still with no pain
felt.
ACTIVITY AND EXERCISE:

Patient is able to do self
care (bathing, toileting,
hygiene) activities
independently, having no
need of assistance.
 While on hospital, Patient
 Patient Axel expressed the
Axel is not able to do
feeling of getting easily
physical activities as he
tired when doing simple
did prior to being
Problems encountered during exercises, such as brisk
admitted. He is now more
a physical activity walking.
on his cellphone browsing
 He is also able to play or on social media, or, if
basketball with his friends, not, he is playing games
and sometimes feel tired through his phone.
when at game. He usually
takes minute breaks and
small sips of water to
combat the feeling of
tiredness.
 No common problems
 As Patient Axel is
(DOB, easy fatigability)
admitted to the hospital, he
were reported during his
Activity tolerance is not able to look after his
participation in household
siblings and is not able to
chores, or taking care of
do chores.
his siblings.
COGNITIVE AND PERCEPTUAL PATTERN:
 No reported hearing and  No reported hearing and
Hearing / Visual Problem
visual problems visual problems
 Oriented to people’s faces,  Time-oriented; No
time and place and no memory lapses were
Changes in Memory
sensory deficits are recorded while being
diminished admitted to the hospital.
 If only mild, he handles it  Expresses severe
Pain Management
himself discomfort to parents
REST AND SLEEP PATTERN:
Feeding  Upon interview, Patient  On hospital admission,
verbalized his likings Patient Axel is on DAT,
towards to-go foods. He with no specific
prefers to choose salty restrictions on diet.
 However, junk foods and
foods, taken with
carbonated drinks are no
carbonated drinks.
longer a part of Patient
 “Mas prefer ko yung salty
Axel’s diet, rather, he was
foods, para may lasa” as
given fruits and breads for
verbalized by the patient.
snacks.
 No changes in toileting
 Patient Axel usually
pattern – defecation was
moves his bowel once a
done once a day, usually
day, every morning. He
after waking up, no
has no difficulty in passing
constipation and pain.
Toileting stools.
Same with urination,
 Urination was less
which comes in more
frequent prior to being
frequently now than
admitted to the hospital,
before. Still no pain is
but no pain was reported.
reported.

Able to do normal hygiene  Patient Axel continues to
independently, such as do his hygiene practices
Hygiene
bathing, oral care and independently without
voiding. needing any assistance
 Patient Axel usually sleeps
at 10-11:00pm in the  During hospitalization,
evening and had to wake Patient Axel is put on a
up early in the morning, at modified high back rest to
around 6-6:30am because facilitate in better
Sleep Concerns of school duties. ventilation, however, he
 He takes no noon naps as sometimes reports of sleep
most of his day time was disturbances due to routine
spent at school. monitoring of nurses in his
 No episodes of dyspnea room.
were reported.
SELF PERCEPTION AND SELF CONCEPT:
 Worried because of being
idle and not being able to
Self-Perception  Appears to be confident
attend school due to
disease
Description of Self  Appears to be confident  Anxious
 
There are noticeable
changes in body due to  Appears to be weak due to
Body Image
puberty but does not affect the said disease
his self-perception
ROLE RELATIONSHIP PATTERN:
 Patient Axel’s support  Axel’s support system are
Support System
system are his parents his parents
 As the eldest child, he  Father performs Patient
performs household chores Axel’s responsibilities
Family Function
and assist in guidance of while the mother guards
younger siblings axel during hospitalization
 Sufficient income because
both parents have jobs that
 Adequate source of
can cater to their
Sufficiency of Income income because they also
children’s needs. Mother is
have health insurance
a nurse, and father is a
health and safety staff
 Accessible healthcare  Accessible healthcare
resources because they resources because they
Accessibility of Healthcare
live in a city and there are live in a city and there are
and Nutritional Resources
health center and health center and
pharmacies near pharmacies near
SEXUALITY AND REPRODUCTIVE:
 There are noticeable
changes in voice in which  The same deep voice,
First noticeable changes in
it deepened, presence of presence of Adam’s apple,
voice
Adam’s apple, and facial and facial hair
hair
COPING AND STRESS TOLERANCE:
 His coping mechanism
 His coping mechanism
with stress while being
Coping Mechanism with stress is by playing
hospitalized, is only by
computer games
resting
Any anger issues that may
 none  none
affect hospitalization
VALUE BELIEF PATTERN:
 As the mother stated,
Patient Axel has no
personal values that were
 Since with his age, still
Things and personal values held important to him
follows family values and
held important since he is still 15 years
beliefs
old. With his age, still
follows family values and
beliefs
Family and social values that  Family or social values  Focuses more on scientific
 that affect life specifically
in terms of health, Patient
Axel is not familiar with
albularyo since both views and values when it
affect life
parents works in medical comes to health
field. Focuses more on
scientific views when it
comes to health
 As a Christian, Patient
Axel recognizes that there
 Being hospitalized, Patient
Spirituality is a being greater than
Axel still religiously prays
himself as he consistently
offers prayer
 Hospitalization did not
Religious practices that affect  Offers prayer every
affect his usual offering of
hospitalization morning and every night
prayer every day
c. Physical Assessment

SKILLS IN PHYSICAL ASSESSMENT

1. SKIN
AREA/FEATURE TO KEY ANALYSIS AND
TECHNIQUE
ASSESS FINDINGS INTERPRETATION
Dusky Smooth Due to decrease oxygenation
Color Inspection

No lesions present.
Inspection
Lesions
Palpation

Slightly decrease in
Inspection and temperature
Moisture
Palpation Cold clammy skin is noted.
Due to response of SNS;
Temperature Palpation 36 ℃ vasoconstriction
AREA/FEATURE TO KEY ANALYSIS AND
TECHNIQUE
ASSESS FINDINGS INTERPRETATION
Texture (quality, Palpation Skin texture is smooth.
thickness, suppleness)
Mobility and turgor Palpation Skin elasticity spring back to its previous
(elasticity) state after being pinched

No abnormality detected.
2. HAIR

AREA/FEATURE TO KEY ANALYSIS AND

TECHNIQUE
ASSESS FINDINGS INTERPRETATION

Color and Distribution Inspect No signs of abnormality are present.

Hair texture of patient is fine and equally
Texture and oiliness Palpation
distributed

Infestation is noted due to

Infestation Inspection Presence of lies and dandruff are noted.
poor hygiene
3. SCALP

AREA/FEATURE TO KEY ANALYSIS AND

TECHNIQUE
ASSESS FINDINGS INTERPRETATION
Scaliness and scars Inspection No presence of lesions, lumps, or Due to scalp irritability
masses only dandruff is noted. in hair product/poor
hygiene.

Tenderness, lesions, lumps, Palpation No presence of redness, tenderness,

masses and lesions.
4. NAILS

AREA/FEATURE KEY ANALYSIS AND

TECHNIQUE
TO ASSESS FINDINGS INTERPRETATION
Color, shape, and texture Inspection Nailbeds are normal, pink color, firm and
smooth.

Palpation

Capillary refill Palpation Prolonged capillary refill. (4 seconds) Decrease tissue perfusion

Lesions Inspection Tissue surrounding the nail is intact.

5. SKULL

AREA/FEATURE TO KEY ANALYSIS AND

TECHNIQUE
ASSESS FINDINGS INTERPRETATION
Shape and symmetry Inspection The head is round and appropriate to body
size.

Contour, Masses, Palpation The head is normally hard and smooth without
Depressions and masses or lesions.
Tenderness
6. FACE

AREA/FEATURE TO KEY ANALYSIS AND

TECHNIQUE
ASSESS FINDINGS INTERPRETATION
Facial features Inspection Symmetrical

Edema and masses Inspection No edema and masses

7. EYES

AREA/FEATURE TO ANALYSIS AND

TECHNIQUE KEY FINDINGS
ASSESS INTERPRETATION
Visual Acuity Inspection Grossly normal

Inspection Eye movement is normal both eyes can follow

the direction of the gaze and converge of the
object as it moves toward the nose.

No involuntary rhythmical oscillation of the

eyed noted.

External anatomical Inspection Upper eyelid overlaps iris.

structures
No inflammation, crusting, edema, or masses
noted.

Palpation The lacrimal gland is not palpable.

Tears flow freely from the lacrimal gland over

the cornea and conjunctiva to the lacrimal duct

Inspection Bulbar is transparent with small blood vessels.

Pale in appearance of the palpebral conjunctiva. Decrease tissue perfusion

Sclera is anicteric
 Corneas and lenses are transparent.

Pupils are black, round and equal in diameter.

Inspection Both pupils constrict quickly in response to

light.

Equal in size.

Pupillary dilatation occurs when pupils

accommodate objects at a distance, with
symmetrical convergence of eyes.

PERRLA (4mm)
8. EARS

AREA/FEATURE TO ANALYSIS AND

TECHNIQUE KEY FINDINGS
ASSESS INTERPRETATION
External ear Inspection External ear is symmetrical with upper Poor hygiene
attachment at eye corner level and is fleshed
colored.

Excessive ear wax is noted.

Palpation External ear is firm, smooth, with no

presence of lesions and pain

Auditory acuity Inspection Having Slightly difficulty of repeating the Due to Excessive ear wax
whispered words.
9. NOSE AND SINUSES

AREA/FEATURE TO
TECHNIQUE KEY FINDINGS ANALYSIS AND INTERPRETATION
ASSESS
Nose Inspection The patient’s nasal structure is
symmetrically located in the midline
of the face and there was no presence
of swelling, lesions.

Each nostril is patent.

Nasal cavities Inspection The patient’s septum is midline and

intact.

Nasal sinuses Palpation None-tender air-filled cavities.

The sound is resonant

10. Mouth

AREA/FEATURE TO
TECHNIQUE KEY FINDINGS ANALYSIS AND INTERPRETATION
ASSESS
Breath

Inspection Lips is cyanotic in appearance and Due to decrease oxygenation

Lips mucosa is pale.

Gums Inspection Gums are pale Decrease tissue perfusion

Palpation Gums are firm.

Teeth Inspection Dental Caries are observed. Unhygienic practices

Tongue Inspection Tongue lays midline.

Uvula is in midline position

Pharynx Inspection Tonsil not inflamed.

12. THORAX and LUNGS

AREA/FEATURE TO
TECHNIQUE KEY FINDINGS ANALYSIS AND INTERPRETATION
ASSESS
Inspection DOB is observed (Respiratory rate
-100)

Thorax rises and falls together

Shape, symmetry, and

diameter
Ribs slope downward with
symmetrical intercostal spaces.

Breath sounds Auscultation Diminished breath sound Due to pulmonary congestion and pleural
effusion
B. ANTERIOR THORAX

AREA/FEATURE TO ANALYSIS AND

TECHNIQUE KEY FINDINGS
ASSESS INTERPRETATION
Tactile Fremitus Palpation Decrease vibration to both lungs. Accumulation of fluid in
the pleural space
13. CARDIOVASCULAR

AREA/FEATURE TO
TECHNIQUE KEY FINDINGS ANALYSIS AND INTERPRETATION
ASSESS
Heart Inspection Orthostatic hypotension Decrease cardiac output

Palpation Fast pounding pulse. Congestion of peripheral tissue

Auscultation Murmur sound with s3 Due to regurgitation of blood

14. ABDOMEN

AREA/FEATURE TO ANALYSIS AND

TECHNIQUE KEY FINDINGS
ASSESS INTERPRETATION
Generalized appearance of Inspection Distended abdomen is observed. Due to accumulation of fluid in the
abdomen peritoneal cavity

Bowel sounds Percussion 3/min Due to stimulation of SNS

 15. BACK AND EXTREMITIES

ANALYSIS AND
TYPE TECHNIQUE KEY FINDINGS
INTERPRETATION
Range of Motion Inspection Decrease ROM Due to joint pain

Muscle tone Palpation Weak muscle Due to fatigue and

increase workload of
the heart
Spine Inspection Spine straight

Gait Inspection Gait is coordinated

d. Laboratory Findings

WHITE BLOOD CELLS (WBC)- White blood cells are also called leukocytes. They protect
you against illness and disease.Think of white blood cells as your immunity cells. In a sense,
they are always at war. They flow through your bloodstream to fight viruses, bacteria, and other
foreign invaders that threaten your health. When your body is in distress and a particular area is
under attack, white blood cells rush in to help destroy the harmful substance and prevent illness.

Laboratory Findings:

NORMAL ANALYSIS &

DATE FINDINGS
VALUES INTERPRETATION
The finding of the patient’s
July 3, 2021 15.00 H 10 g/L 5.00-10.00 WBC is higher than the
normal range value.

RED BLOOD CELLS (RBC)- Red blood cells, or erythrocytes, are one of the components of
blood. (The others are plasma, platelets and white blood cells.) They are continuously produced
in our bone marrow. Just two or three drops of blood can contain about one billion red blood
cells – in fact, that’s what gives our blood that distinctive red color. Red blood cells carry oxygen
from our lungs to the rest of our bodies. Then they make the return trip, taking carbon dioxide
back to our lungs to be exhaled.

Laboratory Findings:
 NORMAL ANALYSIS &
DATE FINDINGS
VALUES INTERPRETATION
The finding of the patient’s
July 3, 2021 5.00 10-12 L 4.50-5.20 RBC is within in normal
range value.

HEMOGLOBIN- A hemoglobin level is usually measured as a part of a complete blood count

(CBC). A hemoglobin test measures the amount of hemoglobin in your blood. Hemoglobin is a
protein in your red blood cells that carries oxygen to your body's organs and tissues and
transports carbon dioxide from your organs and tissues back to your lungs.

Laboratory Findings:

NORMAL ANALYSIS &

DATE FINDINGS
VALUES INTERPRETATION
The finding of the patient’s
July 3, 2021 125L g/L 140-170 hemoglobin is lower than
the normal range value.

HEMATOCRIT- Red blood cells, or erythrocytes, are one of the components of blood. (The
others are plasma, platelets and white blood cells.) They are continuously produced in our bone
marrow. Just two or three drops of blood can contain about one billion red blood cells – in fact,
that’s what gives our blood that distinctive red color. Red blood cells carry oxygen from our
lungs to the rest of our bodies. Then they make the return trip, taking carbon dioxide back to our
lungs to be exhaled.

Laboratory Findings:

NORMAL ANALYSIS &

DATE FINDINGS
VALUES INTERPRETATION
The finding of the
patient’s hematocrit is
July 3, 2021 0.39 L 0.42-0.51
lower than the normal
range value.

PLATELET COUNT- Platelets, also called thrombocytes, are tiny fragments of cells that are
essential for normal blood clotting. They are formed from very large cells called megakaryocytes
in the bone marrow and are released into the blood to circulate. The platelet count is a test that
determines the number of platelets in your sample of blood.

Laboratory Findings:

NORMAL ANALYSIS &

DATE FINDINGS
VALUES INTERPRETATION
The finding of the
patient’s platelet count
July 3, 2021 351 10g/L 200-400
is within in normal
range value.

e. Review of Anatomy and Physiology

Cardiovascular System
 The major function of the cardiovascular system is transportation using blood as a

transport vehicle, the system carries oxygen, nutrients, cell wastes, hormones, and many other

substances vital for body homeostasis to and from the cells. The force to move the blood around

the body is stimulated by the heart. This system has three main components: the heart, the blood

vessel, and the blood itself. The heart is a muscle about the size of a fist and is roughly cone-

shaped. It is about 12cm long, 9cm across the broadest point, and about 6cm thick. The

pericardium is a fibrous covering that wraps around the whole heart. It holds the heart in place

but allows it to move as it beats. The wall of the heart itself is made up of a special type of

muscle called cardiac muscle.

The heart's job is to pump blood around the body. The heart is located in between the two

lungs. It lies left of the middle of the chest. The heart has two sides, the right side, and the left

side.
 The heart has four chambers. The left and right sides each have two chambers, a top

chamber, and a bottom chamber. The two top chambers are known as the left and right atria

(singular: atrium). The atria receive blood from different sources. The left atrium receives blood

from the lungs and the right atrium receives blood from the rest of the body.

The bottom two chambers are known as the left and right ventricles. The ventricles pump

blood out to different parts of the body. The right ventricle pumps blood to the lungs while the

left ventricle pumps out blood to the rest of the body. The ventricles have much thicker walls

than the atria which allows them to perform more work by pumping out blood to the whole body.

Blood Vessels are tubes that carry blood.

Veins are blood vessels that carry blood from the

body back to the heart. Arteries are blood vessels

that carry blood from the heart to the body. There

are also microscopic blood vessels that connect

arteries and veins called capillaries. There are a

few main blood vessels that connect to different

chambers of the heart. The aorta is the largest

artery in our body.

The left ventricle pumps blood into the aorta which then carries it to the rest of the body

through smaller arteries. The pulmonary tract is the large artery which the right ventricle pumps

into. It splits into pulmonary arteries which take the blood to the lungs. The pulmonary veins

take blood from the lungs to the left atrium. All the other veins in our body drain into the inferior
vena cava (IVC) or the superior vena cava (SVC). These two large veins then take the blood

from the rest of the body into the right atrium.

Valves are fibrous flaps of tissue found between the heart chambers and in the blood

vessels. They are rather like gates that prevent blood from flowing in the wrong direction. Valves

between the atria and ventricles are known as the right and left atrioventricular valves, otherwise

known as the tricuspid and mitral valves respectively. Valves between the ventricles and the

great arteries are known as the semilunar valves. The aortic valve is found at the base of the

aorta, while the pulmonary valve is found at the base of the pulmonary trunk. There are also

many valves found in veins throughout the body. However, there are no valves found in any of

the other arteries besides the aorta and pulmonary trunk.

Pulmonary circulation is the portion of the cardiovascular system which carries oxygen-

depleted blood away from the heart to the lungs and returns oxygenated blood to the heart. The

term is contrasted with the systemic circulation.

Arteries are blood vessels that carry blood away from the heart. All arteries, except for

the pulmonary and umbilical arteries, carry oxygenated blood.

Pulmonary arteries carry deoxygenated blood that has just returned from the body to the

heart towards the lungs, where carbon dioxide is exchanged for oxygen.
 Systemic arteries can be subdivided into two types – muscular and elastic – according to

the relative compositions of elastic and

muscle tissue in their tunica media as well

as their size and the makeup of the internal

and external elastic lamina. The larger

arteries (>10mm diameter) are generally

elastic, and the smaller ones (0.1-10mm)

tend to be muscular. Systemic arteries

deliver blood to the arterioles, and then to

the capillaries, where nutrients and gasses

are exchanged.

The aorta is the root systemic artery.

It receives blood directly from the left ventricle of the heart via the aortic valve. As the aorta

branches and these arteries branch, in turn, they become successively smaller in diameter, down

to the arteriole. The very first branches off of the aorta are the coronary arteries, which supply

blood to the heart muscle itself. These are followed by the branches of the aortic arch, namely

the brachiocephalic artery, the left common carotid, and the left subclavian arteries. Aorta is the

largest artery in the body, originating from the left ventricle of the heart and extends down to the

abdomen, where it branches off into two smaller arteries (the common iliac). The aorta brings

oxygenated blood to all parts of the body in the systemic circulation.

Arterioles, the smallest of the true arteries, help regulate blood pressure by the variable

contraction of the smooth muscle of their walls and deliver blood to the capillaries.
 Veins are blood vessels that carry blood towards the heart. Most veins carry

deoxygenated blood from the tissues back to the lungs; exceptions are the pulmonary and

umbilical veins, both of which carry oxygenated blood. Veins differ from arteries in structure

and function. Arteries are more muscular than veins and they carry blood away from the heart.

Veins are classified in several ways, including superficial vs. deep, pulmonary vs. systemic, and

large vs. small.

f. Pathophysiology
 B. Nursing Care Plan (Decrease Cardiac Output, Acute Pain and Activity Intolerance)
NURSING EXPECTED OUTCOME OR
CUES PLAN OR GOAL NURSING INTERVENTION RATIONALE
DIAGNOSIS EVALUATION
Subjective Data: Decreased After 20 minutes of Independent Intervention:  To determine After 20 minutes of
“Naninikip po ang cardiac output nursing intervention, the  Monitor vital signs the level of nursing intervention, the
dibdib ko at related to patient will be able to: such as blood assistance patient was able to:
nahihirapanakonghu altered  The patient will be pressure, apical required by the  The patient was
minga.” as verbalized myocardial able to get rid of the pulse and peripheral patient and able to breathe
by the patient. contractility as chest pain and pulse frequently. monitoring the within normal
 Fatigue evidenced by shortness of breath  Monitor cardiac patient's range and
 Palpitations mitral stenosis. that he is rhythm and response to the expresses a
experiencing. frequency. supplied decrease feeling of
Objective Data: After 2 hours of nursing  Place the patient in a intervention. chest pain or
 Edema intervention, the patient semi fowler’s  Patients with angina.
 Pallor will be able to: position that is at 45 signs and After 2 hours of nursing
 Dyspnea  The patient’s blood degrees. symptoms of intervention, the patient
 Angina pressure will be:  Encourage the heart failure was able to:
 Prolonged lowered down from patient to stress should be  The patient’s blood
capillary refill 140/80 to 120/80. management monitored for pressure was
time of longer techniques such as cardiac rhythm lowered down from
than 2 quiet environment on a regular 140/80 to 120/80.
seconds After 24 hours to 48 hours and meditation. basis.
Vital signs of nursing intervention, the  Monitor intake and  To allow After 24 hours to 48 hours
 BP: 140/80
 mmHg patient will be able to: output. expansion and of nursing intervention, the
 RR: 32 cpm  The episodes of  Encourage the ventilation, the patient was able to:
 PR:100 bpm dyspnea, agina and patient to do deep position is  The patient was
 T: 36 °C dysrhythmia that breathing exercise. beneficial for able to demonstrate
the patient was lung expansion. improved breathing
experiencing will  Instruct client to It may aid in the pattern and
be able to decrease avoid stressful improvement of decreased episodes
by means of activities. the patient's of chest pain.
continuous nursing oxygenation.
intervention.  Instruct the patient  Continuous
to elevate his legs noises can
when he is on a trigger the
sitting position. sympathetic
nervous system
Dependent Intervention: and may give
 Administer oxygen stress to the
supplement as patient.
ordered by the  To decrease
physician. oxygen

 Provide fluid and consumption

and risk of
electrolytes as
decompensation.
ordered by the
physician.  To provide
oxygenation to
the client.
 To lessen the
workload of the
heart and to
provide rest as
well.
 To promote
venous return.
 To increase
oxygen
available for
cardiac function
and tissue
perfusion.
 To minimize
dehydration and
dysrhythmias.
 NURSING NURSING EXPECTED OUTCOME OR
CUES PLAN/GOAL RATIONALE
DIAGNOSIS INTERVENTION EVALUATION
Subjective Data: Acute pain After 1-2 hours of Independent After 1-2 hours of nursing
related to nursing interventions, Intervention: interventions, the patient was
 “Masakit ang disease the patient will be able  Assess  To determine relieved from pain as evidenced by:
dibdib ko” as process to relieve of signs and causative underlying
verbalized by the symptoms of pain factor for pain cause of pain.  Verbalization of relief from
patient. experienced as including pain
evidenced by: location,  Pain scale from 6/10 to
Objective Data: characteristics, 1/10.
 Pain scale: 6/10  Verbalization of onset,  Stable vital signs as
 Restlessness relief of pain duration, evidenced by:
 Facial Grimace  Stable Vital frequency,  BP: 120/80
 Guarding Signs quality,  PR: 90 bpm
behavior  Use of relaxation intensity, and  RR: 20 bpm
 BP:140/90 mmHg skills and precipitating  Assist patient  T: 36.9 °C
 PR: 100 cpm diversional factors. in evaluating  Use of relaxation skills and
 RR: 32 bpm activities as impact of pain diversional activities such
 T: 36.0°C indicated for  Evaluate on client’s as:
individual client’s life.
 breathing exercises
situation. response to
 sleeping
pain and rate
from 0-10 pain  back massaging
scale  Vital signs  talking to family
give an
overview of
 Monitor vital extent of pain.
signs.
 To promote
non
 Provide pharmacologi
comfort c pain
measures management.
 (touch,
repositioning),
quiet
environment  To divert
and calm attention and
activities. reduce tension
from pain.
 Relaxation
techniques and  To prevent
diversional fatigue and to
activities. promote rest.

 Encourage
adequate rest
periods.
 These
Dependent medications
Intervention: block pain
 Administer impulses by
medications as inhibiting
needed prostaglandin
(Analgesics). synthesis in
the CNS.

NURSING NURSING EXPECTED OUTCOME OR

CUES PLAN OR GOAL RATIONALE
DIAGNOSIS INTERVENTION EVALUATION
Subjective Data: Activity After 2 to 3 hours of Independent  To provide After 2 to 3 hours of nursing
“Napapagod ako palagi intolerance nursing intervention, the Intervention: baseline data to intervention, the patient was
kahit hindi masyadong related to patient will be able to:  Assess the help make able to:
mabigat ang aking decreased  The patient will patient’s nursing goals.  Verbalized having
ginagawa.” as verbalized cardiac output be able to physical  Adequate reduced fatigue.
by the patient. as evidenced by verbalize having activity energy is needed  Established an effective
imbalanced reduced fatigue. and during activity. respiratory pattern of 20
Objective Data: oxygen supply  The patient will mobility  To identify the cpm.
- Paleness and demand. be able to level. cardio-  The patient’s blood
- Dozing on and off establish an  Evaluate pulmonary pressure was lowered
Vital signs- effective the status of the down from 140/80 to
- BP: 140/80 respiratory pattern nutritional patient in order 120/80.
mmHg of 20 cpm. status of to know the
- RR: 32 cpm  The patient’s the patient’s ability
- PR: 100 bpm blood pressure patient. to tolerate an
- T: 36 °C will be: lowered  Monitor activity.
down from vital signs  To help improve
140/80 to 120/80. before and the patient’s
after confidence and
activity. self-esteem.
 Provide  To help improve
emotional joint function
support to and prevent
the muscle atrophy.
patient,  To help pace the
regarding patient’s energy
 abilities. and to provide
 Encourage the patient
the patient maximum
with comfort.
active  To allow the
range of best
motion performance
exercises. during patient
 Educate activity.
the patient  To have the
to resume patient be more
activity ready and
cautiously comfortable,
once and to make
asymptom sure that the
atic. patient is not
 Encourage exerting too
the patient much effort at a
to have time which will
periods of help to not
rest. contribute to
 Make a levels of fatigue.
 schedule  To know the
of patient’s limits
activities and also
and maximum
include performance
the when it comes
breaks. to activity.
 Notice  To increase the
and amount of
observe oxygen in the
the lungs.
patient’s  To improve and
response enhance the
to activity. performance of
the heart.
Dependent
Intervention:
 Administe
r oxygen
as ordered
by the
doctor.
 C. Drug Study
DOSAGE/STOCK CLASSIFI CONTRA ADVERSE NURSING
NAME INDICATION SIDE EFFECTS
DOSE/FORM CATION INDICATIONS EFFECTS RESPONSIBILITIES
CNS: fatigue,
Generic:  Dosage: 1.2 M Intramuscular  Hypersensitivit CV:
Pharmacolo  Lethargy
penicillin Units q 6◦ gic class: penicillin G y to penicillins, hypotension,  Assess client’s V/S
 Headache
G  Stock Dose: benzathine is betalactamase pulmonary regularly.
Penicillin  Abdomina
benzathine indicated in the inhibitors hypertension  Encourage the
2.4 M units l pain
Therapeutic EENT: blurred mother to let the
 Form: treatment of (piperacillin/  Vomiting
class: Anti- vision kid rest and
Injectable infections, tazobactam), or
infective  Dyspnea GI: epigastric provide quiet
 Route: IM syphilis, benzathine
 Diarrhea distress environment to
Brand: congenital ● Renal failure
Bicillin L- syphilis, pinta  injection blood in stool regain energy.
● Pregnancy
A and yaw. site GU:  Encourage the
reactions hematuria, patient to lie down
(pain, proteinuria,
It is also redness, inside lying
Hematologic:
indicated as swelling, thrombocytope position to get
prophylaxis in bruising, nia plenty of rest until
Rheumatic or METABOLIC dizziness
fever and/or irritation) : diminishes
chorea— hypernatremia,
Prophylaxis  Encourage patient
hyperkalemia
with penicillin to do pursed-lip
Respiratory:
G benzathine dyspnea, breathing to
has proven hypoxia promote effective
effective in SKIN: rash, breathing for
preventing urticaria, dyspnea.
recurrence of sweating
these  Eliminate smells
conditions. from the
environment to
reduce gastric
 stimulation and
vomiting.
 Encourage to
increase fluid
intake at least 10
glasses a day to
prevent
dehydration in
case of a diarrhea.
 Instruct the mother
of the patient or
the patient himself
if he experiences
rashes to notify the
physician
immediately as
maybe this a sign
of hypersensitivity.
 GENERIC
CLASSIFIC DOSAGE/STOCK SIDE ADVERSE NURSING
NAME/BRAND ACTION INDICATION CONTRAINDICATION
ATION DOSE/FORM EFFECTS EFFECTS RESPONSIBILITIES
NAME
Generic Diuretics 40mg/tablet Furosemid Edema due to Hypersensitivity Headache Dehydration Check vital signs
name: (water e is a type heart failure for baseline before
furosemide pills) of Hypotension Dizziness Hypocalcemi the patient take this
medicine Liver disease a drug.
Brand name: called a Urinary retention Drowsiness
Lasix diuretic. Renal disease Hypochlorem Assess the patient
Increases Fainting ia for allergies to this
renal Hypertension drug.
excretion Dry mouth Hypokalemia
of water, Promote bed rest to
sodium, Muscle Hypomagne the patient.
chloride, weakness semia
magnesiu Increase fluid
m, Tiredness Hyponatremi intake to prevent
potassium, a dehydration.
and
calcium. Tell the patient to
eat a healthy diet
that is high in
minerals such as
meat, cereals, fish,
milk, dairy foods,
fruit, vegetables,
and nuts.
 GENERIC DOSAGE/STO
CLASSIFICATI SIDE ADVERSE NURSING
NAME/BRAND CK ACTION INDICATION CONTRAINDICATION
ON EFFECTS EFFECTS RESPONSIBILITIES
NAME DOSE/FORM
Generic Corticosteroi 20mg/tablet It works to Allergy Hypersensitivity Increase in Weight gain Assess the patient
name: ds treat other problems Appetite if there is known
prednisone conditions by Diabetes mellitus Cataracts Hypersensitivity to
reducing Asthma Insomnia this drug.
Brand name: swelling and Osteoporosis
Deltasone redness and by COPD Increase Reduce the sodium
changing the sugar Fluid intake to the
way the Multiple retention patient’s diet.
immune sclerosis Mood
system works. changes Stomach Split the dose or
Cancer Ulcer the tablet if the
patient having
Rheumatoid Moon face insomnia if
arthritis indicated or tell the
Adrenal patient to turn off
Lupus suppression the lights and
provide quality
Addison’s environment.
disease
Encourage the
patient to walk at
least 30 minutes a
day and avoid too
much sweet foods.

Tell the patient that

this drug affects
mood.
 Tell the patient if
there is weight gain
for about 1 lbs a
day or 2-3 lbs for
few days, notify the
Physician.

DOSAGE/STOCK CLASSIFI CONTRA ADVERSE NURSING

NAME INDICATION SIDE EFFECTS
DOSE/FORM CATION INDICATIONS EFFECTS RESPONSIBILITIES
Generic: Oral  Hypersensitivit  Cough  Nausea  Monitor the
captropil 25 mg/tab It is used to y to ACE  Flushing  Fever patient’s vital
Angiotensin
Converting treat high inhibitors (warmth,  Chills signs.
Stock Dose blood pressure,  History of redness, or  Ill feeling  Encourage the
Enzyme
12.5 mg heart failure, ACEI-induced tingly  Lightheade patient to increase
(ACE)
25 mg heart problems angioedema feeling) dness fluid intake.
Inhibitors
50 mg after a heart  Hereditary or  Numbness  Weakness  Advise the mother
Brand: 100 mg attack, and idiopathic , tingling, to provide a quiet
 Rapid
Capoten diabetic kidney angioedema or burning weight gain environment and
disease. pain in  Little or no let her child take
your urination rest.
hands or  Shortness  Instruct the mother
feet of breath to notify the health
  Loss  Chest pain care provider if the
of or pressure child experiences
taste pounding adverse effects.
sensati heartbeats
on  Slow or
 Mild skin unusual
itching or heart rate
rash  Sore throat
 Painful
mouth
sores
 Pain when
swallowing
 Skin sores
 Cold or flu
symptoms

DOSAGE/STOCK CLASSIFI CONTRA ADVERSE NURSING

NAME INDICATION SIDE EFFECTS
DOSE/FORM CATION INDICATIONS EFFECTS RESPONSIBILITIES
Generic: Oral It is used to  Acute  Headache  Nausea  Monitor the
digoxin 0.25 mg/tab treat myocardial  Dizziness  Stomach patient’s vital
Cardiac
arrhythmias infarction  Weakness pain signs.
glycoside
Stock Dose and heart  Hypersensitivit  Diarrhea  Weight  Encourage the
0.125 mg failure. y to the drug  Anxiety loss child to take rest.
0.25 mg  Ventricular  Depression  Behavioral  Encourage the
fibrillation  Rash changes patient to increase
 Myocarditis  Bloody or fluid intake.
Brand:  Hypomagnesem black, tarry  Observe for signs
Lanoxin ia stools and symptoms of
 Hypokalemia  Fast, slow toxicity.
 Wolf- or uneven  Instruct the mother
Parkinson- heart rate to notify the health
White  Blurred care provider if the
syndrome vision child experiences
 Yellow or adverse effects.
green-
tinted
vision
 C. Medical and Nursing Management

Doctor’s order:
 Pen G 1.2 M Units IV
 Captopril 25mg/tab, ½ tab BID
 Furosemide 40mg/tab 1 tab BID
 Prednisone 20mg/tab 1 tab TID PC
 Lanoxin 0.25mg/tab 1 tab BID

Medical Management
1. Eradicate infection
• Preventive and prophylactic therapy is indicated after rheumatic fever and acute rheumatic
heart disease to prevent damage of the valves
• Primary prophylaxis ( initial course of antibiotics administered to eradicate the streptococcal
infection) also serves as the first course of secondary prophylaxis ( prevention of recurrent
rheumatic fever and rheumatic heart disease)
• An injection of 0.6-1.2 million units of benzathine penicilin G intramuscularly every 4 weeks
is the recommended regimen for secondary prophylaxis.
• Administer the same dosage every 3 weeks in areas where rheumatic fever is endemic, in
patients with residual carditis, and in high risk patients
• Patients with rheumatic fever with carditis and valve disease should receive antibiotics for at
least 10 years until the age of 40.
• Patients are required to have a single dose of antibiotics 1 hour before surgical and dental
procedure to help prevent bacterial endocarditis
• Patients who had a rheumatic fever without valve damage do not need endocarditis
prophylaxis
• Do not use penicillin, ampicillin, or amoxicillin for endocarditis prophylaxis in patients
already receiving penicillin for secondary rheumatic fever prophylaxis (relative resistance of
PO streptococci to penicillin and aminopenicillins.
2. Maximize cardiac output
• Corticosteroids are used to treat carditis, especially if heart failure is evident.
• If heart failure develops, treatment including ACE inhibitors, beta blockers and diuretics, is
effective.
3. Promote comfort
• Client with arthritic manifestations obtain relief with salicylates.
• Bed rest is usually prescribed to reduce cardiac effort until evidenced of inflammation has
subsided.

Nursing Management
 Monitor vital signs
 Assess the child’s pain perception using an appropriate scale every 2 to 3 hours.
 Examine affected joints, degree of joint pain, level of joint movement.
 Elevate involved extremities above heart level.
 Advise positional changes every 2 hours while maintaining body alignment.
 Encourage the use of nonpharmacologic interventions such as imagery, relaxation,
distraction, cutaneous stimulation, heat application.
 Stress the importance of limited activity or amount of joint movement allowed.

D. Discharge Plan
Discharge Plan Guidelines
  Identify the age of patient
 Explain the discharge plan with the family or guardian of the patient.
 Identify the language they used for better communication.
 Tell them if they have questions.
 Lastly, ask them if they understand the whole instructions about discharge plan.

Discharge Plan 

 Diet more on vegetables and fruits.

 Limit fatty foods and also salty foods.
 Don't expose him to plenty people.
 Give light exercise like walking.
 Avoid strenuous activities.
 Provide some activities at home like card games, breathing exercises and, meditating.
 Do not leave him alone, always accompany him.
 Provide a well-ventilated room.
 Don't treat him like isolated and always be patient.

IV. EVALUATION
 The student nurses were able to determine the causes of this pertaining disease by
collecting the substantial amount of data and thorough research of the disease. Also, it
helped them to understand the problems, risk factors, while also briefly explaining the
purpose of this case study.

After the nursing interventions, the student nurses gain knowledge on how to
assess patient that manifest signs and symptoms of Rheumatic heart disease. They
learned to illustrate the pathophysiology in relation to the signs and symptoms
specifically manifested in Rheumatic heart disease. Student nurses also formulated
appropriate nursing care plans for the patient based on the assessment findings and
implemented appropriate medical and surgical interventions for the management of
Rheumatic heart disease.

V. Recommendation
 Diet and Activity

 Fluid and sodium intake should be restricted. Potassium supplementation may be necessary if

steroids or diuretics are used.

 Patient should be placed on bed rest, followed by a period of indoor activity before being

permitted to return to school. Full activity should not be allowed until the levels of acute

phase reactants have returned to normal.

Long-Term Monitoring

 The patient should not be allowed to resume full activities until all clinical symptoms

have abated and laboratory values have returned to normal levels.

 Patient should remain on antibiotic prophylaxis at least until their early twenties.

 Patient should be examined regularly to detect signs of mitral stenosis, pulmonary

hypertension, arrhythmias, and congestive heart failure.

VI. REFERENCES/BIBLIOGRAPHY
(World Health Organization [WHO], 2018) (Philippine Pediatric Society Registry of Diseases,
2015)

(Thomas K Chin, 2019)

Gersten, T., 2021. What Are White Blood Cells? - Health Encyclopedia - University of
Rochester Medical Center. [online] Urmc.rochester.edu. Available at:
<https://www.urmc.rochester.edu/encyclopedia/content.aspx?
ContentID=35&ContentTypeID=160> [Accessed 10 July 2021]. Labtestsonline.org. 2021.
Platelet Count - Understand the Test & Your Results. [online] Available at:
<https://labtestsonline.org/tests/platelet-count> [Accessed 10 July 2021]. Tests, M., 2020.
Hematocrit Test: MedlinePlus Medical Test. [online] Medlineplus.gov. Available at:
<https://medlineplus.gov/lab-tests/hematocrit-test/?
fbclid=IwAR1QUU2rh8XSJn4rQBGqrZXqZ83IBeQBW4hS1_9QTVUSyhwcnWXKIOqDxWU
> [Accessed 10 July 2021]. Lynne, E., 2021. Abnormal Hemoglobin Levels Can Cause Certain
Health Conditions. [online] Verywell Health. Available at:
<https://www.verywellhealth.com/importance-of-hemoglobin-2249107> [Accessed 10 July
2021]. Gersten, T., 2021. What Are Red Blood Cells? - Health Encyclopedia - University of
Rochester Medical Center. [online] Urmc.rochester.edu. Available at:
<https://www.urmc.rochester.edu/encyclopedia/content.aspx?
ContentID=34&ContentTypeID=160&fbclid=IwAR1ZpVLsxfuAlZumiL_2GBqObb7xYgdycBk
-f-kjeBm421kjT4cVHLCw7x0> [Accessed 10 July 2021].