Evolve.

Adapt.
Overcome.
CEFI is now ready.

Mitral Valve Disease

in Pregnancy
Group 4
BS Nursing 2

RLE- DR
CEFI
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Foreword
We have a huge responsibility as nurses to care for the "sickest of the ill." We do it in a fast-paced
environment that requires us to be thoughtful critical (quick) thinkers with competent (quick) hands that do not
hurry (because mistakes are made when people rush), all while maintaining a genuine concern about what we do
and the patients we serve. One of the most common scenes and conditions nowadays, particularly among young
patients who were pregnant at a young age and are experiencing various complications. Mitral valve disease
occurs when the mitral valve between the upper and lower left heart chambers fails to function properly. It may
be that the valve isn't closing properly, allowing blood to escape backward into the left atrium, or that the valve
is narrowed. The emphasis of this case study is on statistics, surveys, studies, and books produced and published
by a variety of medical experts.

The discussions in this study have shown that it would aid in the dissemination of knowledge and understanding
to my co-nursing students as well as future researchers who will do the same study.
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Dedication
We'd like to dedicate this case study to almighty God, our cherished
families and friends, our teachers, our alma mater - Calayan Educational
Foundation Inc., and our professor on this subject for inspiring us and being a
constant source of inspiration and wisdom.
We'd like to dedicate this project to our fellow nursing students; we think
it will be useful knowledge for them as well as future researchers who will be
assigned to improve and deepen the study in this case. _Group 4
BS Nursing II
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Objectives
• To gather and identify accurate personal and family health history.

• Act accordingly as per guidelines and protocols when presented the data.

• Apply nursing interventions necessary for the patient when the need arise.

• Make plans or preparations on problems that us expected to arise.

• Increase the understanding of said abnormality, for future reference with

similar or same disease.
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Introduction
Mitral valve disease occurs when the mitral valve doesn’t work properly, allowing
blood to flow backward into the left atrium. It may not be closing properly, which causes
blood to leak backward to the left atrium (regurgitation), or the valve may be narrowed
(stenosis). As a result, our heart does not pump enough blood out of the left ventricular
chamber to supply your body with oxygen-filled blood. This can cause symptoms such as
fatigue and shortness of breath. However, many people with mitral valve disease experience
no symptoms.

If left untreated, mitral valve disease can lead to serious, life-threatening

complications such as heart failure or irregular heartbeats, called arrhythmias.
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Present Illness
• At 33 weeks and 6 days of pregnancy, a Caesarean section was performed through a
lower midline incision as it had been recommended in order to avoid venous
collateral damage.
• Given perioperative antibiotic prophylaxis of Cefasolin 2.0 g IV.
• A female newborn weighing 1700 grams and 46 cm tall was born, Apgar score of 9 at
1 minute and 10 at 5 minutes.
• Treated with antibiotics Cefasolin 1.0 g intravenously three times daily, diuretics,
deep veins thrombosis prophylaxis.
• Diuresis was stimulated by furosemide bolus, the response was adequate. One day
later the patient was transferred to the Obstetrics Ward.
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Patient’s Data
Name: Patient X  Address: Brgy. Kanlurang Mayao, Red V.,
Gender: Female Lucena City, Province
Weight: 60 kg  Civil Status: Married

Height: 5’3ft  Nationality: Filipino

Age: 30 yrs. old  Religion: Roman Catholic

Birthdate: March 1, 2021  Occupation: Accountant

Attending Physician: Dr. C., Gatchalian RN.,MD Chief Complaint: “severe generalised
Lic. No. : 157823 weakness and dizziness”
 Diagnosis: Mitral Valve Stenosis, G1P0
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Physical Assessment
Vital Signs: • vesicular breath sounds with no
Temperature: 36.9 C crackles
Pulse : 62 bpm • rhythmic heart activity
RR: 14 cpm • heart rate 62 bpm
BP: 120/70 mmHg • clear heart sounds with a harsh
systolic murmur in the mitral area
O2 Saturation: 91%
(apex)
• presystolic murmur in the 4th
intercostal space on the left
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Parameters Normal Findings Actual Findings Interpretations

General Appearance (-) fatigue and weakness
(-) body odor
Clean and neat appearance
Normal, coherent thought process
Generally cheerful, positive mood
(+) fatigue and weakness Abnormal
(-) body odor Fatigue and weakness
Clean and neat appearance
Normal, coherent thought process
Shy, monotone speech.

Skin (-) rashes, lesions, sores (-) rashes, lesions, sores Abnormal
(-) discolorations Slightly pale Pale skin
(-) jaundice (-) jaundice
(-) cyanosis (-) cyanosis
(-) pallor (-) pallor
Normal skin turgor Normal skin turgor
Normal, even temperature Normal temperature

Hair Black or brown depending on race Black hair color Normal

Evenly distributed Evenly distributed  

(-) alopecia (-) alopecia  

(-) lice, nits, dandruff (-) dandruff

Shiny and healthy looking (-) oily

   
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Parameters Normal Findings Actual Findings Interpretations

Face Symmetrical facial expression (+) facial movements at will Normal

(-) facial movements at will (-) involuntary muscle movements Facial grimace and weakness

(-) involuntary muscle movements (+) Facial grimace

Shape may be oval, rounded, heart- (+) Weakness

shaped, square
Oval shaped
 
Eyes (+) PERRLA (+) PERRLA Normal

(+) evenly placed and inline (+) evenly placed and inline  

  (-) protrusion

(-) protrusion Sclera whitish or yellowish

Sclera whitish, moist, and clear Pinkish conjunctiva

Pinkish conjunctiva
Ears Parallel and symmetrical Parallel and symmetrical Normal

Upper lobe is parallel with outer canthus Upper lobe is parallel with outer canthus
of the eye of the eye

Skin is same color with complexion Skin is same color with complexion

(-) tenderness or lesions (-) tenderness or lesions

(+) scant amount of cerumen (+) scant amount of cerumen

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Parameters Normal Findings Actual Findings Interpretations

Nose Nose in the midline Nose in the midline Normal

Nose are patent Nose are patent

Pinkish to red nasal mucosa Pinkish to red nasal mucosa

(-) bone and cartilage deviation (-) bone and cartilage deviation

(-) discharges (-) discharges

(-) lesions (-) lesions

(-) tenderness or pain (-) tenderness or pain

Mouth Symmetrical in appearance and Symmetrical in appearance and Normal

movement movement
 
Lips pinkish to red in color Pinkish lips

Uvula in the midline Uvula in the midline

Gums pinkish to redness in color Gums pinkish color

(-) edema (-) edema

(-) lesions or sores (-) lesions or sores

(-) pain and tenderness in movement (-) pain and tenderness in movement

(-) bleeding of gums (-) bleeding of gums

(-) halitosis (-) halitosis

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Parameters Normal Findings Actual Findings Interpretations

Neck Symmetrical and straight Symmetrical and straight Normal

Trachea is palpable and inline Trachea is palpable and inline

Normal swallowing reflex Normal swallowing reflex

Normal ROM Normal ROM

(-) mass or lumps (-) mass or lumps

(-) jugular venous distention (-) jugular venous distention

(-) enlargement of thyroid (-) enlargement of thyroid

Nails Pinkish in color Cyanosis of the nail beds Abnormal

(-) clubbing and spooning (-) clubbing or spooning Cyanosis of the nail beds

Clean and well-groomed Cleaned and well-groomed

Chest and Lungs (-) SOB vesicular breath sounds Abnormal

(-) pain when breathing (-) SOB Chest pain when breathing

(-) abnormal sound (+) pain when breathing  

(-) abnormal sound

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Parameters Normal Findings Actual Findings Interpretations

Breast Symmetrical Symmetrical Normal

(-) tenderness or pain (-) tenderness or pain  

(-) nipple discharges (-) nipples discharges

(-) lesions or dimpling (-) lesions or dimpling

Nipples are rounded, everted, same size, Nipples are rounded or piercing nipples
and equal in color
 

Heart (-) murmurs (+) murmurs Abnormal

(-) abnormal or irregular rhythm (+) abnormal or irregular rhythm harsh systolic murmur
Abdomen Skin color is uniform Skin color is uniform Normal

(-) lesions (-) lesions

(-) masses or lumps (-) masses or lumps

(-) ascites (-) ascites

(-) muscle guarding (-) muscle guarding

(-) pain or tenderness or cramps (-) pain or tenderness or cramps

(-) vomiting (-) vomiting

(-) diarrhea (-) diarrhea

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Parameters Normal Findings Actual Findings Interpretations

External Genetalia (-) pain and tenderness (+) pain Abnormal

(-) masses, sores, lesions (-) masses, sores, lesions (+) pain

(-) discharges or bleeding (+) vaginal discharge  

(-) odor (-) odor

(-) itching (-) itching

(-) skin discolorations (-) skin discolorations

(-) sign of infection (-) sign of infection

   
Lower Extremities (+) normal and complete ROM (+) normal and complete ROM Normal

(-) skin discoloration (-) skin discoloration

(-) lesions, scars, masses (-) lesions, scars, masses

(-) involuntary movements (-) involuntary movements

(-) edema (-) edema

Symmetrical and equal Symmetrical and equal

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Laboratory Result
Electrocardiography (ECG) monitor registered sinus rhythm, PR interval 123 ms, QRS complex 103 ms, QTc
interval 433 ms. QRS-T angle 79 degrees.
Conclusion: enlargement of the left atrium.

Echocardioscopy revealed fibrotic thickening of mitral valve cusps with no signs of calcification, immobile posterior
cusp, doming of anterior cusp, symmetrical fusion of both MV commissures, MV opening in the center of the valve,
MV area 0.9 cm2, regurgitate blood flow due to MV insufficiency.
Conclusions: fibrotic MV changes, severe MV stenosis, left atrial dilation, pulmonary arterial hypertension.

•After evaluating the patient’s complaints, physical examination, laboratory, instrumental, and radiological
assessment data, clinical diagnosis was made:
•Diagnosis:
 Complex MV disease with critical stenosis and insufficiency,
Moderate pulmonary hypertension
• A cardiologist’s consultation was recommended to the patient at the 12th week of pregnancy.
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APTT • Is a screening test that helps evaluate a • The typical aPTT value is 30 to 40 seconds.
( Activated Partial person's ability to appropriately form blood The patients test result is 35
Thromboplastin time) clots.

FIBRINOGEN • Is a blood plasma protein that's made in the • The normal range is 200 to 400 mg/dL (2.0 to 4.0
(Coagulation factors) liver. Fibrinogen is one of 13 coagulation g/L).
factors responsible for normal blood The patients result is 300 mg/dL
clotting. When you start to bleed, your
body initiates a process called the
coagulation cascade, or clotting cascade.

D-DIMERS • This is to help rule out the presence of an • The reference concentration of D-dimer is < 250
inappropriate blood clot (thrombus). Some ng/mL, or < 0.4 mcg/mL.
of the conditions that the D-dimer test is The patients result is (1270 mcg/l)
used to help rule out include: Deep vein
thrombosis (DVT) Pulmonary embolism
(PE)
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ANTI CARDIOLIPIN • The most common antiphospholipid antibody, • Normal range:

ANTIBODIES (aCL) a group of autoantibodies associated with IgG anticardiolipin:
excessive clotting and autoimmune diseases, Weak positive: 15-40U/ml
such as lupus. They are frequently detected Positive: >40U/ml
with other antiphospholipid antibodies, such as IgM anticardiolipin:
lupus anticoagulant Weak positive: 15-40U/ml
Positive: >40 U/ml

Isotypes of • The Beta-2 glycoprotein 1 antibody tests are • The normal range for IgG= 95-243 mg/dL,
immunoglobulins (IgG, used along with cardiolipin antibody and lupus IgA= 981-1267 mg/dL, IgM= 78-232 mg/dL
IgA, IgM) of anti-β2- anticoagulant testing to help diagnose the for the 1st trimester of pregnancy.
glycoprotein I cause of an unexplained blood clot or recurrent The patient’s test result is: IgG= 198 mg/dL, IgA=
autoantibodies) miscarriages, to help diagnose 1105 mg/dL, IgM= 158 mg/dL indicating that
antiphospholipid syndrome (APS), or to detect all values are within normal ranges.
the autoantibodies
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Radiology Test
Mitral Regurgitation Chest x-ray
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Phonocardiograms from normal and abnormal heart sounds

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Two options of treatment were considered:

1.pregnancy termination due to maternal indications followed by heart surgery
(valvuloplasty or prosthesis) and
2.percutaneous balloon valvuloplasty in conjunction with preserving pregnancy, which
put the mother at a higher risk of various complications.
Due to the patient’s decision to continue with the pregnancy, conservative treatment
was administered and the patient was prescribed;
Metoprolol tablets 12.5 mg/day in order to improve her heart function.
Medical surveillance by a:
> general practitioner, an obstetrician-gynecologist, and
a cardiologist (every one or two weeks) was recommended.
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Anatomy and Physiology

Normal heart anatomy and physiology need the
atria and ventricles to work sequentially, contracting and
relaxing to pump blood out of the heart and then to let the
chambers refill. When blood leaves each chamber of the
heart, it passes through a valve that is designed to prevent
backflow of blood. 
A normal heart has two upper (receiving) and two
lower (pumping) chambers. The upper chambers, the
right and left atria, receive incoming blood. The lower
chambers, the more muscular right and left ventricles,
pump blood out of your heart. The heart valves, which
keep blood flowing in the correct direction, are gates at
the chamber openings (for the tricuspid and mitral valves)
and exits (for the pulmonary and aortic valves).
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Mitral valve stenosis — or mitral stenosis —

is a narrowing of the heart's mitral valve. This
abnormal valve doesn't open properly, blocking
blood flow into the main pumping chamber of your
heart (left ventricle). Mitral valve stenosis can make
you tired and short of breath, among other problems.
The main cause of mitral valve stenosis is an
infection called rheumatic fever, which is related to
strep infections. Rheumatic fever — now rare in the
United States, but still common in developing
countries — can scar the mitral valve. Left
untreated, mitral valve stenosis can lead to serious
heart complications.
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MITRAL STENOSIS
Pathophysiology Obstruction to left atrial emptying

Difficulty in LV filling LA pressure Change in LA functioning

Pulmonary venous pressure

Perivascular edema luminal narrowing Pulmonary artery pressure

Reversal of pulmonary Cardiac output Severe pulmonary Stable with mild

blood flow hypertension symptoms

Pulmonary compliance Pulmonary

vascular resistance
Work of breathing

Right ventricular
overload

Tricuspid
regurgitation
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Mitral Regurgitation

Regurgitation of LV SV
Reduced CO & LA dilatation

LA dilation
Atrial arrhythmias, Thrombus
Reactive PHTN & Right heart failure

LV volume overload
LVH (concentric) & LV dilatation

LV failure
Pulmonary edema, systemic
hypotension
Evolve.
Adapt.
Overcome.
CEFI is now ready.

Course in Ward
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April 25 The patient was referred at the Quezon Medical Center and hospitalized at the High Risk
Pregnancy Department at the 31st week of pregnancy due to fetal distress. The only complaint
the woman had was mild generalized weakness. Physical Examination was performed and HR
is abnormal at 59 bpm with systolic murmur in the mitral area (apex) and presystolic murmur in
the 4th intercostal space on the left and BP being too low at 110/65 mmHg. Gynecological
examination showed no visible pathology, normal vaginal discharge was observed, and uterine
cervix was closed. Ultrasound examination is performed to check for FHT, which returned
normal.
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DOCTOR’S RATIONALE NURSING RESPONSIBILITIES

ORDER
April 25, 2021 Admit to ER under • For pregnancy monitoring, management, and • .Admitted the patient as ordered.
the service of Dr. evaluation of the patient’s condition in relation to • Prepared and filled out necessary
Gatchalian chief complaints (severe generalized weakness documents
and dizziness) • Obtained initial vital signs and
recorded
• Assisted the patient to room of
choice.
• Obtain health history taking

V/S q shift • To monitor deviation from normal values and • Monitored vital signs every shift,
to know the baseline. recorded and reported immediately
any deviations
Therapeutics: • For hydration and to facilitate electrolyte • Verified doctor’s order
IVF: PNSS 1L x 12 replacement and serves as an access for IV • Regulated at 20-21 gtts/min. and
hours medication. put on IV tag
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DOCTOR’S ORDER RATIONALE NURSING

RESPONSIBILITIES
Laboratory:
1. APTT ( Activated Partial •Evaluate a person's ability to appropriately • Verified doctor’s order
Thromboplastin time) form blood clots • Informed the patient about
2. SPA ( suprapubic Aspirate) •Cannulate the urinary bladder for urine the diagnostic
3. Fibrinogen (Coagulation factors) collection • Filled out necessary
•Measures the time that it takes for a fibrin request forms
4. D-dimers (a test to rule out clot to form • Informed the laboratory
presence of blood clot) •Rule out the presence of an inappropriate department about the
5. Anti-cardiolipin (aCL) antibodies, blood clot exams
•Detects the presence of cardiolipin • Followed up results and
6. Different isotypes of antibodies in the blood attached it to the patient’s
immunoglobulins (IgG, IgA, IgM) of •This test measures the amount of chart.
anti-β2-glycoprotein I autoantibodies) immunoglobulins, also known as antibodies,
in your blood
Refer Refer for further assessment and treatment • Referred and endorsed
Physical examination findings: vesicular breath sounds with no crackles, rhythmic heart activity, heart rate 62 bpm,
clear heart sounds with a harsh systolic murmur in the mitral area (apex) and presystolic murmur in the 4th
intercostal space on the left, arterial blood pressure 120/70 mmHg. Laboratory tests are within normal range.
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DOCTOR’S ORDER RATIONALE NURSING RESPONSIBILITIES

May 2, • Verified doctor’s order

2021 Refer to vascular For consultation and proper intervention • Referred and endorsed accordingly.
surgeon
Apply compression To lower the risk of thrombotic events • Assisted the patient
stockings. • Provided health teachings
Medications: To prevent the blood from clotting • Verified DO
•Fraxiparin 0.3 ml/day • Observed 14 rights of drug administration
SQ • Monitored vital signs
At the 32nd week of gestation a follow-up sonography showed persistent fetal distress. Cardiologic assessment showed
no dynamics in the condition of the woman’s cardiovascular system: tolerance to physical effort remained unchanged
and the patient’s health condition was normal. Since the patient’s cardiologic condition enabled her to continue the
pregnancy, further management was adjusted considering the best outcome for the fetus. It was decided to discontinue
cardiac medications. In order to design a personalized pregnancy care and optimal treatment tactics, multidisciplinary
team discussion consisting of an obstetrician-gynecologist, cardiologist, heart surgeon and anesthesiologist was planned
for the 34th gestational week.
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May 9, 2021 • Unfortunately, the patient’s condition worsened at the 33rd gestational week: she experienced severe
generalized weakness, anxiety, and shortness of breath accompanied by the sensation of substernal pressure
when lying down.
• The patient’s examination showed no regular uterine contractions. Fetal Nonstress Test remained reactive,
fetal heart sounds were clear and rhythmic, 135 bpm.
• Pulmonary oedema and pleural effusions were diagnosed after performing chest radiography.

DOCTOR’S ORDER RATIONALE NURSING RESPONSIBILITIES

May 9, Obtain vital signs of the mother To obtain baseline data • Monitored vital signs and recorded and
2021 and fetus reported immediately any deviations

Perform IE To track the pregnancy and • Provide privacy to the patient

condition of the cervix • Record the findings
Vesicular breath sounds with no crackles, rhythmic heart activity, heart rate 59 bpm, clear heart sounds with a harsh
systolic murmur in the mitral area (apex) and presystolic murmur in the 4th intercostal space on the left, arterial blood
pressure 110/65 mmHg was found.
Gynecological examination showed no visible pathology, normal vaginal discharge was observed, and uterine cervix
was closed. Ultrasound examination was made and it was found rhythmic fetal heart activity, fetal heart rate was 140
bmp.
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DOCTOR’S ORDER RATIONALE NURSING RESPONSIBILITIES

May 9, Diagnostic: • To check the condition of lungs and • Monitored vital signs and recorded and
2021 Chest radiography heart reported immediately any deviations.
Echocardioscopy • To rule out specific conditions • Verified doctor’s order
Ultrasound • Informed the patient about the diagnostic.
• Followed up results and attached it to the
patient’s chart.
Medications: • Makes it easier for the heart to • Verified DO
Metoprolol (12.5 mg/day) pump blood • Observed 14 rights of drug administration
Furosemide (20mg/day) • Reduce extra fluid • Monitored vital signs

Move to ICU • To closely monitor the patient’s • Monitor vital signs and report deviations.
condition
Echocardioscopicevaluation of MV showed no dynamics, although mild pericardial effusion and a slight diastolic
inversion of the free atrial wall were observed.
•Ultrasound imaging showed collection of fluid within the pleural space: 300 ml on the left and 650 ml on the right.
Pharmacotherapy was recommenced and the patient was: administered β-blocker (Metoprolol tablets 12.5 mg/day) and
minimal dose of loop diuretic (Furosemide tablets 20 mg/day).
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May 9, 2021 • Despite the treatment, the patient’s condition gradually worsened and she was moved to
the intensive care unit (ICU) due to respiratory failure.
•It was managed using oxygen therapy via a conventional face mask (oxygen flow 4 l/pm):
sufficient spontaneous breathing, respiratory rate 17/min, SpO2 –100%.
•Cardio-pulmonary ultrasound examination was performed to the patient and increased
fluid in the right pleural cavity, fluid in the left pleural cavity and pericardium were
found.
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DOCTOR’S ORDER RATIONALE NURSING RESPONSIBILITIES

May 15, Prepare patient for C-Section To immediately end the pregnancy due to • Prepared and filled out necessary
2021 the maternal’s rapid worsening condition documents
and acute cardiopulmonary insufficiency • Obtained initial vital signs and
recorded
• Educated the patient
Place the patient on NPO The body’s reflexes and functions are • Explain to the SO and patient
stopped due to anesthesia
Medications: To reduce risk of infection. • Verified DO
Cefasolin 2.0g IV • Observed 14 rights of drug
administration
• Monitored vital signs
• A female newborn weighing 1700 grams and 46 cm tall was born, Apgar score of 9 at 1 minute and 10 at 5
minutes. After the operation the patient was transferred to the intensive care unit (ICU).
• At 33 weeks and 6 days of pregnancy, a Caesarean section was performed through a lower midline incision as it
had been recommended in order to avoid venous collateral damage.
•The patient was given perioperative antibiotic prophylaxis of Cefasolin2.0 g intravenously.
•A female newborn weighing 1700 grams and 46 cm tall was born, Apgar score of 9 at 1 minute and 10 at 5 minutes.
After the operation the patient was transferred to the intensive care unit (ICU).
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DOCTOR’S ORDER RATIONALE NURSING

RESPONSIBILITIES
May Medications:
16, Cefasolin 1.0g IV TID To reduce risk of infection
2021 Diuretics To lessen the body salt and water
DVT prophylaxis To prevent DVT
May Medications:
17-28 •Metoprolol tablets 25 mg once or twice •Makes the heart easier to pump blood • Verified DO
2021 daily (depending on arterial pressure) • Observed 14 rights of
•Furosemide tablets 20 mg/d •Reduce extra fluid drug administration
•Spironolactone tablets 25 mg/day •Treat heart failure • Monitored vital signs
•Reduce extra fluid
•Lasix 40 mg IV (depending on diuresis), •Reduce the clotting ability of the blood. Reduce
•Fraxiparin 0.3 ml/d subcutaneously. the risk of harmful blood clots forming in blood
vessels

Wound care To prevent infection • Gradually teach the

patient/ SO to clean
the wound
• Health teachings
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May 29, 2021 • The postoperative period was normal with positive dynamics. After taking into account
the improvement of the woman’s general condition, absence of complaints, normalized
airiness of the lungs, and decreasing levels of fluid in pleural and pericardial spaces, the
patient and the newborn were discharged from the hospital six days after delivery.
Breastfeeding, pharmacotherapy (β-blockers and diuretics), surgical wound care and
follow-up with a cardiologist one month after the Caesarean section were recommended.
• The mother visited the hospital for follow-up check-up with the cardiologist. The wound
is healing properly. The mother’s condition improved.
Evolve.
Adapt.
Overcome.
CEFI is now ready.

Nursing Care Plan

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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Activity After 8 hours of INDEPENDENT After 8 hours of
“Sobrang nanghihina Intolerance nursing intervention •Observe and monitor the patient’s •It can affect the activity level of nursing intervention
ako” as verbalized by Related To the patient will be able sleep pattern and the amount of the patient. the patient able to:
patient. Imbalanced O2 to: sleep achieved over the past few
Supply As •Alleviate her feelings days. •Alleviate her feelings
Evidenced By: of chest pain and •Note client reports of weakness, •Symptoms may be result of/or of chest pain and
OBJECTIVE: General shortness of breath. fatigue, pain, difficulty contribute to intolerance of shortness of breath.
(+) Shortness of Weakness accomplishing tasks, and/or activity.
Breathe •Progressively insomnia. •Progressively
(+) Chest pain demonstrated •Assess cardiopulmonary response •To compare and obtain baseline demonstrated
(+) Weakness tolerance of activity to physical activity, including vital data tolerance of activity
(+) Facial grimace by walking. signs before, during, and after by walking.
(+) Abnormal heart activity.
sounds •Identify and/or •Identify and/or
(+) Fatigue engage in activities •Use portable pulse oximetry to •To help compensate for the engage in activities
appropriate to assess for oxygen desaturation increased oxygen demands appropriate to
VITAL SIGNS: situation during activity. during physical activity. situation
T:36.8 C •Investigate the patient’s •Causative factors may be
PR:62bpm perception of causes of activity temporary or permanent as well
RR:14 cpm intolerance. as physical or psychological.
BP: 120/70 mmHg To determine current status and
•Ascertain ability to stand and move needs associated with participation
about and degree of assistance  
necessary/use of equipment
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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

• Encourage verbalization of • This helps the patient to cope.
feelings regarding limitations.

• Have the patient perform the • Helps in increasing the tolerance

activity more slowly, in a longer for the activity
time with more rest or pauses, or
with assistance if necessary.
• Gradually increase activity with • Gradual progression of the activity
active range-of-motion exercises prevents overexertion
in bed, increasing to sitting and
then standing.
• Encourage physical activity • Helps promote a sense of
consistent with the patient’s autonomy while being realistic
energy levels. about capabilities.
Dependent
• Administering medication as • As a treatment in the patient’s
prescribe by the doctor. condition.
Collaborative
• Ask for a cardiologist for
diagnosing and treatment of the • To treat problems of the heart
condition. and blood vessels. 
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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Impaired Gas After 8 hours of Independent After 8 hours of

“Nahihirapan po Exchange nursing intervention •Assess the lungs for areas of •Any irregularity of breath sounds may nursing intervention
ako huminga” as Related To the patient will be decreased ventilation and auscultate be a cause of impaired gas exchange. the patient was able
verbalized by the Increased able to: presence of adventitious sounds. to breath
patient. Pulmonary properly ,less facial
Vascular -alleviate feelings of •Monitor for alteration in BP and •BP, HR, and respiratory rate all grimace ,decreases
Objective: Resistance As chest pain and HR. increase with initial hypoxia and weakness, regular
(+) Shortness of Evidenced By: shortness of breath hypercapnia. If BP and HR decrease, heart sounds And
Breathe General Mild -decrease weakness and dysrhythmias may occur. Vital signs is
(+) Chest pain Weakness -Regular heart normal:
(+) Weakness sounds •Assess respiratory rate, depth, also •Rapid and shallow breathing patterns Temp: 36.2°C
(+) Facial grimace -verbalize reduction the use of accessory muscles, nasal and hypoventilation affect gas BP:120/ 80mmHg
(+) Abnormal heart of fatigue flaring, and abnormal breathing exchange also may be seen with RR: 14 bpm
sounds patterns. hypoxia. PR: 62 bpm
(+) Fatigue
•Monitor patient’s behavior and •Changes in behavior and mental
mental status for onset of status can be early signs of impaired
Vital signs : restlessness, agitation, confusion, and gas exchange.
T:35.9 extreme lethargy.
PR:62bpm
RR:14 •Monitor oxygen saturation •Pulse oximetry is a useful tool to
BP: 110/70 mmHg continuously, using pulse oximeter. detect changes in oxygenation.
 COLLEGE OF INFORMATION SYSTEM
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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

• Position patient with head of bed • Allows to increased thoracic

elevated, in a semi-Fowler’s capacity, full descent of diaphragm,
position (head of bed at 45 and increased lung expansion
degrees when supine) as tolerated. preventing the abdominal contents
from crowding.

Dependent:
• Maintain an oxygen • Supplemental oxygen may be
administration device as ordered required to maintain PaO2 at an
by the doctor, attempting to acceptable level.
maintain oxygen saturation at
90% or greater.

• Encourage or assist with • Ambulation facilitates lung

ambulation as per physician’s expansion, secretion clearance, and
order. stimulates deep breathing.

Collaborative
• Ask for the radiologist. Monitor • Chest x-ray studies reveal the
chest x-ray reports. etiological factors of the impaired
gas exchange.
 COLLEGE OF INFORMATION SYSTEM
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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Deficient Knowledge After 8 hours of intervention, Independent: After 8 hours of

“Ano ang gagawinko Related Insufficient patient will be able to -Review specific surgery -Provides knowledge intervention, patient able
para maiwasan Knowledge And verbalized the: performed and procedure base from which patient to verbalized her
nalumala ang sugat ko Information Due To •Participate on learning process done and future can make informed learnings as evidenced
sa CS” as verbalized Recent Invasive •Correctly perform necessary expectations. choices. of:
by the patient. Procedure. procedures and explain reasons •Participate on learning
for actions. -Recommend planned or -Promotes return of process
Objective: •Verbalize understanding of progressive exercise. normal function and
(+) Inaccurate follow condition, effects of procedure enhances feelings of •Correctly perform
through of instruction and potential complications. general well-being. necessary procedures and
or performance on a explain reasons for
test or a procedure. -Identify sign and -Early recognition and actions.
(+) Inappropriate symptoms requiring treatment of developing
behavior medical evaluation complications may •Verbalize understanding
(+) Insufficient prevent progression to of condition, effects of
Knowledge more serious or life- procedure and potential
threatening situation. complications.
Vital Signs:
RR: 18 bpm -Provide information -Reducing the amount of
PR: 70 cpm relevant only to the information helps to keep
BP: 110/70 mmHg situation. client focused and
Temperature: 35.3 C prevents them form
feeling overwhelmed.
COLLABORATIVE
•Refer to the physician. -for other guidelines in
treating the wound.
 COLLEGE OF NURSING
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MEDICAL MANAGEMENT

No medications can correct a mitral valve defect. However, certain drugs can reduce symptoms by
easing your heart's workload and regulating its rhythm.

•Diuretics to reduce fluid accumulation in your • Anti-arrhythmics to treat atrial fibrillation or

lungs or legs, which can accompany mitral valve
regurgitation. Spironolactine (25 mg PO OD)
•Blood thinners (anticoagulants) to help prevent
blood clots and may be used if you have atrial
fibrillation. Fraxiparine (0.3 g PO OD)
•Beta blockers or calcium channel blockers to slow
your heart rate and allow your heart to fill more
effectively. Metropolol ( 25 mg PO OD )
other rhythm disturbances associated with mitral
valve stenosis.
• Antibiotics to prevent a recurrence of rheumatic
fever if that's what caused your mitral stenosis.
Cefazolin (1.0 g IV TID )
 COLLEGE OF NURSING
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MEDICAL MANAGEMENT
Oxygen Therapy
•The goal of oxygen therapy is to provide
adequate transport of oxygen in the blood while
decreasing the work of breathing and reducing
stress on the myocardium.
•Oxygen transport to the tissue depends on actor
such as cardiac output, arterial oxygen content
concentration of hemoglobin, and metabolic
requirements.
 COLLEGE OF NURSING
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MEDICAL MANAGEMENT

Two options of treatment were considered:

1.Pregnancy termination due to maternal

indications followed by heart surgery
(valvuloplasty or prosthesis) and
2.Percutaneous balloon valvuloplasty in
conjunction with preserving pregnancy, which
put the mother at a higher risk of various
complications.
Evolve.
Adapt.
Overcome.
CEFI is now ready.

Drug Study
 COLLEGE OF NURSING
Calayan Educational Foundation, Inc.

METOPROLOL
THERAPEUTIC ACTION CONTRAINDICATION TOXICITY INDICATION SAFE DOSE
CLASSIFICATION
Beta Blocker Competitively blocks  Drug hypersensitivity, sinu • Severe HTN (hypertension) Dosage: 25 mg
Beta-adrenergic s bradycardia, greater than  hypotension Early intervention in acut
Generic Name: receptors in the heart  the first degreeheart block, • Sinus bradycardia e  Route: PO
Metropolol and juxtaglomerular app  cardiogenic shock, or over • Atrioventricular MI (myocardial infarctio
aratus, decreasing the in t cardiac failure when block n) Frequency: OD
Brand Name: fluence of the sympathet used to treat hypertension  • Heart failure Angina pectoris
Tropol XL ic nervous system on the orangina. • Cardiogenic shock Stable symptomatic heart
se tissue and the excitabi • Cardiac arrest  
lity of the heart, decreasi • Bronchospasm failure resulting from isc
ng cardiac output and • Impairment of hemia,
the release of renin, and  consciousness HTN, or cardiomyopathy
lowering BP; acts in the • Coma
CNS to reduce  • Nausea
sympathetic outflow  • Vomiting
and vasoconstrictor tone • Cyanosis
• Hypoglycaemia
• Hyperkalaemia
 COLLEGE OF NURSING
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THERAPEUTIC ACTION
CLASSIFICATION
Antibiotic inhibits cell wall
biosynthesis by binding
Generic name: penicillin-binding
Cefazolin proteins which stops
peptidoglycan synthesis.
Brand name: Penicillin-binding
Kefzol, Ancef proteins are bacterial
proteins that help to
catalyze the last stages of
peptidoglycan synthesis,
which is needed to
maintain the cell wall.  or bleeding near the
CEFAZOLIN
CONTRAINDICATION
contraindicated in patients
who have a history of
immediate hypersensitivity
reactions to cefazolin or the
cephalosporin class of
antibacterial drugs,
penicillins, or other beta-
lactams
TOXICITY INDICATION SAFE DOSE
Side effects: Susceptible bacterial Dosage: 1.0 g
genital itching, white infections including
patches in mouth septicemia, respiratory, Route: IV
loss of appetite, heart biliary or GU tract, skin
burn gas and skin structure, bone Frequency: TID
Nausea, vomiting, and joint, endocarditis.
diarrhea, headache,
dizziness, confusion,
weakness
Tiredness, drowsiness
pain, redness, swelling,
place where cefazolin
was injected
 COLLEGE OF NURSING
Calayan Educational Foundation, Inc.

SPIRONOLACTINE
THERAPEUTIC ACTION CONTRAINDICATION TOXICITY INDICATION SAFE DOSE
CLASSIFICATION
Diuretics Antagonizes aldosteron Contraindicated in patients h • Liver toxicity that  Indicated for patients Dosage: 25mg
e in the distal tubules,  ypersensitive to drug and in t can manifest as with congestive heart
Generic Name: increasing  hose with anuria, acute or pr elevations in serum failure taking digitalis Route: PO
Spironolactine sodium and water excre ogressive renal insufficiency aminotransferases when other therapies are
tion. , Addison disease, or hyperk and alkaline considered inappropriate. Frequency: OD
Brand Name: alemia. phosphatase in a
Aldactone hepatocellular
mixed pattern after
nearly one month
of taking
spironolactone, and
this resolves over
time after
discontinuation of
the drug.
 COLLEGE OF NURSING
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FUROSEMIDE
THERAPEUTIC ACTION CONTRAINDICATION TOXICITY INDICATION SAFE DOSE
CLASSIFICATION
Anti-Hypertensive Inhibits sodium and chl Contraindications to • Extensions of FDA has approved Dosage: 20mg
oride reabsorption at th furosemide use include diuretic activity furosemide to
Generic Name: e proximal and distal tu patients with documented • Dehydration treat conditions with Route: PO
Furosemide bules and the ascending allergy to furosemide and • Reduced blood volume overload and
 loop of Henle patients with anuria. volume edema secondary to Frequency: OD
Brand Name: • Electrolyte congestive heart failure
Lasix imbalances exacerbation, liver
failure, or renal failure,
including nephrotic
syndrome.  
 COLLEGE OF NURSING
Calayan Educational Foundation, Inc.

Fraxiparine
THERAPEUTIC ACTION CONTRAINDICATION TOXICITY INDICATION SAFE DOSE
CLASSIFICATION
Anticoagulants / The action of this • Acute infective • Discomfort or • Used for Dosage: 0.3 g
Antithrombotics medication is to endocarditis redness at prophylaxis of
prevent the blood • haemorrhage or injection site thromboembolic Route: Subq
Generic Name: from clotting after haemostasis disorder • Hardening of skin disorders and
Fraxiparine having surgery, • active peptic or lump at general surgery in Frequency: OD
during haemodialysis, ulceration injection site orthopedic surgery,
Brand Name: during hospitalisation • haemorrhagic • Bleeding from the treatment of deep
nadroparin for acute illness or in cerebrovascular event injection site or vein thrombosis,
intensive care unit • severe uncontrolled surgical wound prevention of
with extended bed hypertension • Skin damage at clotting during
rest and is also used • diabetic or the injection site hemodialysis
to treat existing blood haemorrhagic • Signs of a serious
clots that are blocking retinopathy allergic reaction
blood vessels. • injuries to or • Skin rash
It is a medicine that operations on the • Sudden change or
works by delaying the CNS, eyes or ears loss of vision
action by which • history of • Sudden severe
blood clots form. thrombocytopenia headache
with nadroparin. • weakness
especially on one
side of the body
 COLLEGE OF NURSING
Calayan Educational Foundation, Inc.

Medication Card

Patient X
BED no. 105

BED no. 105

Patient X FRAXIPARINE
9am

9am
METROPOLOL 0.3 g Subq OD
25 mg PO OD
8am-1 pm- 6pm
BED no. 105

Patient X
CEFAZOLIN
1.0 g IV TID
BED no. 105

Patient X
9am

SPIRONOLACTINE
25 mg PO OD
 COLLEGE OF NURSING
Calayan Educational Foundation, Inc.

Discharge Plan
INCISION CARE
Shower as needed. Pat your incision dry
Watch the incision for signs of infection, like more redness or drainage
Hold a pillow against the incision when laughing or coughing and when getting up from a sitting or lying
position
Keep the wound area clean by washing it with mild soap and water. You don't need to scrub it. Often, just
letting the water run over your wound in the shower is enough.
It take as long as 6 weeks for the incision to heal
PHYSICAL ACTIVITY
Get up slowly
Avoid sexual activity until your doctor says it is safe to do so
Refrain from lifting heavy things; Lifting anything over 10 pounds, including children, pets, grocery bags,
suitcases or briefcases is PROHIBITED for SIX WEEKS after your surgery.
Take several short walks with rest periods in between, rather than one long walk; Walking is one of the best
overall exercises you can do. It improves circulation, muscle tone, strength and the way your feel about yourself.
 COLLEGE OF NURSING
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BREAST CARE
Wear a well-fitting bra or supportive bra fits well and is not too tight
If your breasts become painfully overfull, hard, and swollen, you can use ice packs for 15 to
20 minutes at a time
 Make sure your baby is latched properly to avoid sore or cracked nipples
Wash your hands before touching your breasts.
Keep your breasts and nipples clean by washing them daily with warm water in the shower
or bath. Also, avoid using soap on your breasts.
WHEN TO CALL THE DOCTOR
Your pulse or heartbeat is not steady
You feel pain and pressure in your chest, Having trouble breathing, Severe pain in the
abdomen.
Fainting or dizziness, Weakness in the muscles of your face, arms, or legs
If you have a fever higher than 38 °C; a lump; or red, sore, or hot area in the breast that does
not go away after nursing
 COLLEGE OF NURSING
Calayan Educational Foundation, Inc.

DIET
Drink a lot of water, at least 8-10 glasses of water a day
Eat fresh fruit and vegetables, whole grains, and bran cereals especially Foods high in protein
likemeat and fish, eggs, dairy products, Foods high in vitamin C oranges, grapefruits,
strawberries, melons, and papayas and Limit sodium (salt) as directed.
MEDICATIONS
-Take your medication as directed. Take your medicines exactly as directed. Don’t skip doses.
-Do not change the amount or the schedule. -Do not stop taking prescription medication
without talking to your doctor. Do not share prescription medication. -Check with your doctor
before taking any over-the-counter medicines, herbal products, or vitamin supplements.
 COLLEGE OF NURSING
Calayan Educational Foundation, Inc.

Prognosis
A 30 year old woman was admitted due to severe generalized weakness and dizziness and diagnosed
with mitral valve disease with critical stenosis and mitral valve insufficiency, moderate-severe pulmonary
hypertension, heart failure and acute respiratory failure.
Current medicines are Metoprolol = 25mg BID, Furosemide = 20mg/d PO, Spironolactone = 25mg/d  PO.
Vital signs: Temperature: 36.9, Pulse : 80bpm, RR: 15, BP: 120/80.
The woman’s general condition, absence of complaints, normalized airiness of the lungs, and decreased level of
fluid in pleural and pericardial spaces. The wound is healing properly. The mother’s condition improved and
showing a good prognosis.
 COLLEGE OF INFORMATION SYSTEM
Calayan Educational Foundation, Inc.

References
https://www.mayoclinic.org/diseases-conditions/mitral-valve-regurgitation/symptoms-causes/syc-20350178
https://academic.oup.com/eurheartj/article/37/2/133/2398345
https://www.mayoclinic.org/diseases-conditions/mitral-valve-disease/symptoms-causes/syc-20355107#:~:text=In%20mitral%20valve%20disease%2C
%20the%20mitral%20valve%20between%20the%20upper,may%20be%20narrowed%20(stenosis).
https://healthengine.com.au/info/cardiovascular-system-heart#:~:text=This%20system%20has%20three%20main,which%20need%20to%20be%20removed.
https://www.healthline.com/health/mitral-valve-disease
https://emedicine.medscape.com/article/155724-overview
https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.slideshare.net%2Fhanisahwarrior%2Fvalvular-heart-disease-
47133867&psig=AOvVaw2KcKniagZvDMy8b7U5oaf_&ust=1620654018161000&source=images&cd=vfe&ved=0CAwQ3YkBahcKEwjImOr83LzwAhUA
AAAAHQAAAAAQDA
https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=uh3323
https://www.healthline.com/health/mitral-valve-disease#takeaway
https://www.researchgate.net/publication/272082446_Critical_care_of_patients_with_paediatric_valvar_cardiac_disease
https://www.mayoclinic.org/diseases-conditions/mitral-valve-stenosis/symptoms-causes/syc-20353159
https://www.eurekaselect.com/169760/article
https://nurseslabs.com/activity-intolerance/
https://nurseslabs.com/impaired-gas-exchange/
Evolve.
Adapt.
Overcome.
CEFI is now ready.

Thank you!