CASE PRESENTATION ON MITRAL STENOSIS

PRESENTED BY: Mr. STAWAN UTTAM CHOUGULE

DEMOGRAPHIC DATA
 Mrs. Devare Madhura Eknath  58 years/female  10th Nov ’13  Hindu  Housewife

PRESENT COMPLAINTS • Breathlessness • Tachycardia • Fatigue 1 month .

Tachycardia.HISTORY OF PRESENT ILLNESS • Breathlessness. Fatigue since 1 month. • Patient was operated for MVR on 13th Oct’13. . Akkalkotkar did angiography. • Dr.

.PAST HISTORY • No history of any major illness in past.

MEDICATION HISTORY • No history of any medication. .

SOCIOECONOMIC STATUS • • • • Middle class family Own flat Good IPR Participates in all religious or social activities .

. She used to eat more of green vegetables and cereals.DIETIC HISTORY • Patient had mixed diet pattern and preferred veg.

ACTIVITY EXPERIENCE: • Patient had normal activity pattern. . She used to do household work.

.SLEEP/REST • She used to sleep 7 hours in night.

Patient was under weight Patient was on ventilator support artery line inserted on right hand .PHYSICAL EXAMINATION GENERAL APPEARANCE: • • • • conscious & oriented.

• Weight: 40kg • Height: 5.3 ft .

VITAL SIGNS • Temperature: 98.6 f • Pulse: 88 beats/ min • Respiration: 22 breaths /min on pressure SIMV mode • Blood Pressure:120/70 mmhg • SPO2 : 99 % .

CHEST AND RESPIRATORY SYSTEM • ADVENTITIOUS SOUNDS: Wheeze sound heard .

NERVOUS SYSTEM • Mental Status: Conscious • Motor Co-Ordination Upper Extremities : normal activity • Lower Extremities : normal activity • Involuntary Movements: not Present .

INVESTIGATION .

1 3 HAEMOGLOBIN 12.10.8 84.58 RBC P.5 to 6 x 10^6/ml 35.13 15.6 35.5 gm/dl 4.5 28.C.0 to 37.2 .6 3.61 3.0 pg 33. MCV MCH 21.0 to 99.0 to 31.V.6 83.4 9.10.4 % 80.0 to 50.0 g/dl MCHC 34.10.5 to 17.6 29.6 27.4 21.9 fl 9. 13 14.NORMAL INVESTIGATION DIAGNOSTIC TEST VALUES HAEMATOLOGY 12.

TOTAL WBC/CUMM  POLYMORPHS %  LYMPHOCYTES %  EOSINOPHILS  MONOCYTES  BASOPHILS PLATELET COUNT/CUMM % % % 40-65% 30-50% 2-8% 2-4% 0-1% 1.2 sec 25-35 sec 1 to 5 mins.8-1. .5-4 lakh 9600 71 22 9800 70 24 02 03 00 134000 12/12 1.0 2 min 10 sec 3 min 20 sec 02 02 00 128000 PROTHROMBIN TIME  INR  PTT BLEEDING TIME 11-14 sec 0.

4 mg / dl Up to 25 IU/L 30 0.UREA CREATININE CPK-MB TROP-T 14 to 50 mg / dl 0.8 62 POSITIVE .6 to 1.

ECG .

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MITRAL STENOSIS DEFINITION • Mitral stenosis is a narrowing of the mitral valve in the heart. This restricts the flow of blood through the valve. .

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HEART .

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Mitral Valve .

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LAYERS .

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.LYMPHATIC SYSTEM IN HEART • All of the lymphatic drainage of the thorax is directed toward the bronchomediastinal trunks. and descending intercostal lymphatic trunks. thoracic duct.

it is formed by – – The superior cervical cardiac branch of the left sympathetic chain – The inferior cervical cardiac branch of left vagus .• NERVE SUPPLY OF THE HEART • Both the parasympathetic and sympathetic nerves form the superficial and deep cardiac plexuses • The superficial cardiac plexus is situated below the arch of aorta in front of the right pulmonary artery.

RISK FACTORS .

.• • • • Rheumatic fever Recurrent strep infection Radiation treatment involving the chest Medications. such as ergot preparations used for migraines.

CAUSES .

Congenital heart defect PATIENT PICTURE PRESENT PRESENT .BOOK PICTURE Rheumatic fever.

PATHOPHYSIOLOGY .

CLINICAL MANIFESTATION .

BOOK PICTURE PATIENT PICTURE • Shortness of breath or dyspnea PRESENT • Fatigue or weakness PRESENT • Palpitations PRESENT • Hemoptysis ABSENT .

PATHOPHYSIOLOGY .

DIAGNOSTIC TEST .

BOOK PICTURE Chest x-ray PATIENT PICTURE Mild to moderate cardiomegaly with left atrial enlargement suggesting of Valvular heart disease. Moderate pulmonary hypertension 5. Atrial fibrillation Electrocardiogram Radionuclide studies Chest x-ray Done Not done Mild to moderate cardiomegaly with left atrial enlargement suggesting of Valvular heart disease. Rheumatic heart disease 2. . Severe mitral stenosis Coronary angiography Echocardiogram 3. Mild aortic regurgitation 4. Normal epicardial artery 1. LVEF=60% 6.

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S. DRUG N

DOSE

ACTION

INDICATION CONTRAIN- SIDE-EEFECT DICATIONS

NURSES RESPONSIBILITY

1 Tb.Ditide 50mg (triamteren bd e) Therapeutic classPotassiumsparing Diuretics

Triamterene inhibits the epithelial sodium channels on principal cells in the late distal convoluted tubule and collecting tubule, which are responsible for 1-2% of total sodium reabsorptio n. As sodium

For the treatment of edema associated with congestive heart failure, cirrhosis of the liver, and the nephrotic syndrome; also in steroidinduced edema, idiopathic edema, and edema due

Patient with hypersensiti ve to its components and dose with pathologic bleeding

CNSAgitation,confusion,c onvulsions CVSHypotension, GIabdominal pain, constipation, MUSCULO SKELETALArthralgia, myalgia. HEMATOLOGICpurpura

1.consider alternative treatment for patients identified as metabolizes. 2.Monitor blood pressure.

S. DRUG N 2. SUPRACEF Cefuroxime sodium THERAPEUTIC Antibiotic PHARMACOLOGIC classsecond generation cephalospori n

DOSE

ACTION

INDICATION

CONTRAINDI- SIDE-EEFECT CATIONS Patient hypersensitive to drugs or other cephalosporin 's. CVSPhlebitis, thrombocytopeni a GIDiarrhea, nausea, vomiting, anorexia. HEMATOLOGICHemolytic anemia, thrombocytopeni a SKINMaculopapular and erythmatus rashes. OTHERanaphylaxis

NURSES RESPONSIBILITY 1. monitor patient for signs and symptoms of super infection. 2. advise patient receiving drug to report discomfort at IV injection site. 3. assess for hypersensitivity of the patient.

1.5gm Inhibits injectio cell-wall n IV synthesis promoting osmotic instability usually bactericida l

Pharyngitis/To nsillitis Acute Bacterial Otitis MediaAcute Bacterial Maxillary Sinusitis Acute Bacterial Exacerbations of Chronic Bronchitis and Secondary Bacterial Infections of Acute BronchitisUnc omplicated Skin and SkinStructure

S. DRUG N

DOSE

ACTION

INDICATION CONTRAINDICATIONS manageme nt of moderate to moderately severe pain in adults. 1. patients hypersensitive to drug 2. breast feeding women 3. acute intoxication from alcohol, hypnotics, etc.

SIDE-EEFECT

NURSES RESPONSIBILITY 1. Re-assess patient level of pain at least 30 min after drug administration. 2. Monitor CV & respiratory status. 3. Monitor for risk of seizures. 4. For better onset, give drug before onset of intense pain.

3. TRAMADOL 50 mg Unknown (Tramadol injectio thought to hydrochloride) n IV bind to receptor Therapeutic and inhibit classreuptake Analgesic of Pharmacologic noradrenal -synthetic ine & active serotonine analgesic. .

CNSDizziness, headache, seizure, anxiety, CVVasodilation. ENTVisual disturbances. GIConstipation, nausea, vomiting. GUMenopausal symptoms RESPIRATORYRespiratory depression.

S.N DRUG 4. Tab Lanoxin

DOSE 0.0625-0.25 mg/day

ACTION

INDICATION CONTRAINDI-CATIONS SIDE-EEFECT NURSES RESPONSIBILITY Coronary 1.Ventricular fibrillation artery disease 2.Known hypersensitivity Atrial reaction to digitalis Fibrillation (reactions seen include unexplained rash, swelling of the mouth, lips or throat or a difficulty in breathing) Ventricular tachycardia Presence of digoxin toxicity Beriberi heart disease Hypersensitive carotid sinus syndrome · Cardiac arrhythmias · Digoxin Toxicity Assess cardiac function Measure liquids precisely Assess for signs of toxicity, especially in children and the elderly Give IV slowly over 5 minutes

Digoxin binds to a site on the extracellular BRAND Or aspect of the NAME: 10-15 mcg/kg α-subunit of Lanoxin the Na+/K+ ATPase pump GENERIC in the NAME: membranes of digoxin heart cells Classificati (myocytes) and on: decreases its Cardiac function. This glycoside causes an increase in the level of sodium ions in the myocytes, which leads to a rise in the level of intracellular calcium ions.

Note possible drug interactions
Assess for hyperthyroidism or hypothyroidism Obtain ECG Monitor CBC, serum electrolytes, calcium, MG, renal and liver function tests Obtain written heart rate parameters for drug administration as drug may cause extreme bradycardia Do not administer if HR is <50. Hold if HR is 90-110 bpm in children

Obtain pulse deficit of apical and radial pulse
Monitor weight and I&o Use antacid if gastric distress occurs Use caution during withdrawal Do not take with grapefruit juice Take after meals to lessen gastric irritation

MEDICAL MANAGEMENT .

Nebulisation Inj.125mg TID Tab ecosprin 150 mg Antibiotic therapy-People who have had rheumatic fever need long-term preventive treatment with penicillin.Diuretics. Nitrates. ACE inhibitors. calcium channel blockers.Magnex forte 1.amikacin 500mg BD Duolin + budecort Spirometry 3 times/ day Chest physiotherapy frequently .5 g BD Inj. or digoxin. betablockers. angiotensin receptor blockers (ARBs). Lanoxin 0.BOOK PICTURE PATIENT PICTURE Drug therapy. Anticoagulants /Antiplatelet Inj.

SURGICAL MANAGEMENT .

BOOK PICTURE PATIENT PICTURE Mitral valvuloplasty NOT DONE Mitral valve replacement DONE .

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if ordered to increase renal blood flow and urine output. allow frequent rest periods as possible.• Administer oxygen by face mask or artificial airway to ensure adequate oxygenation of tissues. • To ease emotional stress. • Administer an osmotic diuretic. . as blood gas measurements indicate. such as mannitol. • Adjust the oxygen flow rate to higher or lower level.

and electrolyte levels. • Monitor and record blood pressure. respiratory rate.• Allow family members to visit and comfort the patient as much as possible. pulse. • Record hemodynamic pressure readings every 15 minutes. • Monitor ABG values. and peripheral pulse every 1 to 5 minutes until the patient stabilizes. complete blood count. .

 Activity intolerance R/T diminished cardiac reserve. . treatment & prognosis.NURSING DIAGNOSIS  Decreased cardiac output R/T mechanical factor (preload.  High risk for infection related to operation.  Self-care deficit related to operation. afterload) secondary to Valvular dysfunction.  Anxiety R/T altered heart action.  Knowledge deficit R/T disease condition.

• The provision of care associated with elimination process with excrement. water and food. • The maintenance of sufficient intake of air. . women and children. • The maintenance of a balance between activity and rest.NURSING THEORY OREM’S THEORY • Orem describes Six universal self care requisites common to men.

• Application of Orem’s self care nursing model. • The promotion of human functioning and development within social group in accordance with human potentials. known human limitations and the human desire to be normal.• The maintenance of balance between solitude and social interaction. • Prevention of hazards to human life functioning and human well-being. .

and warm periphery. . -Check peripheral temperature. -Exclude tamponade Cardiac output is maintained as evidenced by normal BP. functioning and human wellbeing. HR-60-100 beats/ min BP – 120/80mmhg Urine – 1ml/kg/hr. Pulse. afterload) secondary to Valvular dysfunction.NURSING ASSESSMENT HR-sinus rhythm BP – 130/78 mmhg CVP -10 to 12 mmhg Urine output (24hrs)900ml PROBLEM NURSING SYSTEM GOAL SELFCARE REQUISITE Prevention of hazards to human life. CVP-2-8 mmhg Warm periphery -Monitor ECG for arrhythmias -Continuous hemodynamic monitoring. -Give packed cell 2000 ml -Start injection dopamine 4mg/hr. -Adjust NTG according to BP. -Check electrolyte & collect according to it. NURSING ACTION REWIEW Decreased Wholly cardiac compensat output R/T ory mechanical factor (preload. -Assess hourly intake & output. Patient has adequate output as evidenced by Normal SR.

Patient will Prevention not get of hazards to infection from human life. . -Check hemodynamic parameters. hospital environment -Assess for sign of infection. -To give catheter care regularly.6f PROBLEM NURSING SYSTEM GOAL SELFCARE REQUISITE NURSING ACTION REWIEW High risk for Wholly infection compensat related to ory operation. -Change the dressing regularly. -Remove all the invasive lines as early as possible.300 Temp-98.NURSING ASSESSMENT TLC-11. Risk of infection prevented evidenced by WBC count within normal and no signs of infections.

Care provide adequately by the nurses and the family members . PROBLEM NURSING SYSTEM GOAL SELFCARE REQUISITE Promotion of human functioning & development with in social group. To check whether all the iv lines are in place. NURSING ACTION REWIEW Self-care deficit Wholly All the related to compensat routine operation. ory activities of the patient will be done by the nurses and the family members. Give every 2 hourly position to the patient.NURSING ASSESSMENT Patient is semiconscious. . Cardiac monitoring to be done properly. Give psychological support and Educate the relatives about the care of the patient. Maintain the hygiene of the patient.

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• Assist patient during diagnostic workup and assist with decision for medical or surgical treatment.• Teach the patient about disease including etiology possible complications and associated symptoms to report to physician. • Instruct the patient in the name. dose. • Explain activity allowances and limitations. and purpose of medications. . • Include patient’s family in teaching and decision making process.

• Provide instruction to women regarding appropriate choice of contraception and risk associated with pregnancy. .• Explain diet and fluid restriction. • Instruct the patient about maintaining good oral hygiene. • Instruct the patient about antibiotic prophylaxis to prevent infective endocarditis. and regular visits to dentist. daily care.

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Tachycardia. Fatigue. • Angiography was done and was advised for MVR.• DAY 1 • Patients was conscious. • Patient had Breathlessness . .

. Thakur and was planned for MVR. • Patient was seen by Dr.DAY 2 • Patient was stable.

DAY 3 • Patient was stable. • Pre-op medications were given and patient was posted for MVR. • Post-op patient was on ventilator and inotropic support. • Patient was hemodynamically stable. .

• Vital parameters were normal. • Oxygen administration was given at the rate of 6 l/min by mask. . • Patient was on inotropic support.DAY 4 • Patient was conscious and Extubated.

• Inotropic support was lowered. • Patient was planned to be shifted to ward next day. . • Drains were removed.DAY 5 • Patient was conscious and welloriented.

DAY 6 • Patient was conscious and welloriented. . • Patient was shifted to ward. • Inotropic support was stopped.

DAY 7 • Patient was conscious and welloriented. • Patient was hemodynamically stable. .

• Patient was hemodynamically stable.DAY 8 • Patient was conscious and welloriented. .

• Patient got discharge in evening. . • Patient was planned for discharge.DAY 9 • Patient was conscious and welloriented.

Patient was able to maintain hemodynamic parameters without inotropic support. .PATIENTS EVALUATION:• Patient had good prognosis as compared to the admission. Patient was stable and was satisfied by the care provided.

MVR .TRENDS: 1.

ROBOTIC MVR .2.

ENDOSCOPIC .3.

4. HEART VALVE REPAIR THROUGH CATHETER .

Saunders.Black and Esther MatassarianJacobs. • Luckmann joan.B.BIBLIOGRAPHY • Ross and Wilson. . 4th edition. Saunders publication.text book of anatomy and physiology. “Manual of Nursing Care” 1st edition. page-727-729. copyright 1999. copyright.B. W. page – 2122-2124. Saunders. • Joyce M. W. “Medical Surgical Nursing”psycho physiologic approach.