HOLY ANGEL UNIVERSITYCOLLEGE OF NURSING

Angeles City

A Case Study About

MITRAL STENOSIS WITH ASSOCIATED CARDIOMEGALY

In Partial Fulfillment of the Requirement inRelated Learning Experience IV

For the Degree of Bachelor of Science in Nursing

Submitted to:

Mrs. Karen Cyril T. Cayanan, RN, MAN(Clinical Instructor)

Submitted By:

Tarrah Theresa CastroCristina Marie Decembrano

Aimee PangilinanAndren Pineda

Czarinna RabinoCatherine Anne Reyes

Group 4 (N-401)

July 6, 2010

I. INTRODUCTION

Mitral stenosis (mitral valve stenosis) is a narrowing of the mitral valve (pathway of

blood from left atrium to left ventricle) opening that increases resistance to blood flow from

the left atrium to the left ventricle; usually results from rheumatic fever, but infants can be

born with the condition. Mitral stenosis does not usually cause symptoms unless it is severe.

Doctors make the diagnosis after hearing a characteristic heart murmur through a stethoscope

placed over the heart.

Mitral Stenosis is the leading cause of congestive heart failure in developing

countries. In the case of the patient for this case study, chest xray has found out that the

patient has cardiomegaly. Cardiomegaly is also known as an enlarged heart. It is a condition

that can be caused by many factors, though there are several causes more prevalent than

others. Cardiomegaly is also associated with a host of other diseases and conditions such as

hemochromatosis, congestive heart failure and hyperthyroidism, though it is not caused by

them.

The interrelation of the two medical conditions is what this case study tries to

investigate and sought understanding of their pathophysiologies.

Since we are currently studying cardiovascular disorders in our NCM 104, the group

decided to make a case study related to heart diseases for the reason that we need to

strengthen our knowledge and to broaden our understanding and eventually be of help in our

chosen career.

STATISTICS

In the U.S.: The prevalence of MS has decreased due to the decline in rheumatic fever

in the US and developed countries. The mitral valve is the valve most commonly affected

with rheumatic heart disease.

Internationally: In underdeveloped areas, MS tends to progress more rapidly.

Occasionally, patients can become symptomatic before the age of 20.

Mortality/Morbidity: Without surgical intervention, the progressive nature of the

disease results in an 85% mortality rate twenty years after the onset of symptoms.

Sex: Two-thirds of all patients with MS are female.

Age: The onset of symptoms is usually between the third and fourth decades.

NURSING OBJECTIVES

 Upon reading this case study, the reader will be able to:

COGNITIVE

Acquire knowledge on the pathophysiologic nature of the disease, prognosis and

complications

Identify the contributing factors in the development of the disease

Interpret findings from Nursing professional assessment

Integrate learning from different nursing concepts with this disease

PSYCHOMOTOR

Determine an appropriate, immediate nursing management for the disease

condition of the patient.

AFFECTIVE

Recognize the importance of developing a practice of performing accurate and

complete assessment findings

Show genuine concern/ empathy for a patient with the disease condition

Appreciate more the role of the nursing profession in a patient’s relief and

recovery

II. NURSING ASSESSMENT

1. PERSONAL HISTORY

a. DEMOGRAPHIC DATA

Mrs. Mapusu was born on the third day of November. She was a 72 year old

Filipino female, married and a mother to her five offspring, currently residing in Villa

Theresa Subdivision, Angeles City. She was rushed to Angeles Medical Center

(AMC) on June 24, 2010. After days of hospitalization with continuous monitoring

and rendering of health care, she was discharged last June 28, 2010.

b. SOCIO-ECONOMIC AND CULTURAL FACTORS

Mrs. Mapusu, as business-minded as she was, has started a poultry and hog-

raising business together with his husband on the third year of their marriage, 47 years

ago; she has been taking care of their family business since then but has laid down the

management to her children when they had been well-trained on the business.

Currently she was not working anymore due to her old age and degenerating health.

However, she receives monthly allowance of 10,000-15,000 pesos a month.

According to her all of their expenses are within the budget she gets from her

children.

She graduated high school in Angeles City National High School and attended

college. She took up Business Accountancy at Holy Angel University but has reached

only her second year. She has to stop from studying due to financial constraints of her

family. She said to finish my degree was her dream but she was not able to do so.

Mrs. Mapusu is a devoted Roman Catholic. She attends the mass regularly

with her husband; along with them are her eldest son and his family. She attends

novena every Wednesday at Holy Rosary Parish church.

She and her family’s stability have brought them foods laid on their table—

Foods that represent their statute in life. She admits that she loves greasy and oily

foods. She jokingly said that the foods that are dangerous to health are the best ones to

eat at dinner. She admits that when it comes to health matters, she has insufficient

knowledge of what is to do. She follows a conventional way of treating illnesses.

Those are by taking over the counter drugs and have some rest. When feels something

about her health, she treats it like something not a big deal, and not bother to be

checked by her doctor.

2. FAMILY HEALTH HISTORY

In their family, there have been histories of Coronary Artery disease and

Diabetes Mellitus. There family consists of five children and she being the third child

is the only one diagnosed of mitral stenosis. Two of her siblings are found out to be

prone to heart complications due to high cholesterol levels.

3. HISTORY OF PAST ILLNESS

When she was 40, she remembers that she has been hospitalized due to

rheumatic fever. She knew that on that day, her heart must be unhealthy. But as years

pass by, she thought that everything is fine with her heart. Having rheumatic fever

must have a link to her present health condition.

4. HISTORY OF PRESENT ILLNESS

Four hours prior to admission, the patient experiences shortness of breath. Due

to the persistence of SOB, she sought consult and was admitted at Angeles Medical

Center thereafter.

Grandfather(Deceased)

(CAD)

Grandmother(DM)

Father(HPN)

(died of stroke)

Mother

Mrs. Mapusu(HPN & Mitral

Stenosis)

Eldest Sister (HPN)

2nd sister(none)

4th child (son)(HPN)

Grandmother(none)

Grandfather(HPN)

Youngest son

5. PHYSICAL EXAMINATION (IPPA- Cephalocaudal Approach)

a. Physical Examination (upon admission)

BP: 180/90 HR: 130 RR: 44

afebrile

pink palpebral conjunctiva, white sclera

AP, NRRR

SCE, (+) wheezes

soft abdomen, nontender, NABS

full and equal peripheral pulses

cyanotic

Neurological Exam

patient is conscious and coherent

CN-AU intact

MOTOR

5/5 5/5 100% 100%

5/5 5/5 100% 100%

Physical Examination: (06-25-10)

Skin: poor skin turgor, dry skin

HEENT: (-) lice, eyes always half close, no discharge from the ears and nose, pink gums, no complete set of teeth, whitish tongue.

LYMPH NODES: not palpable

CHEST: symmetrical

LUNGS: (+) wheezes upon auscultation

CARDIOVASCULAR: (+) murmurs

EXTREMITIES: (-) mobility on both lower extremities

(-) mobility on upper extremities

Physical Assessment

Vital Signs:

Temp – 36.5OC

Pulse Rate – 112bpm

Respiratory Rate – 39bpm

Blood Pressure – 170/120 mmHg

Skin:

Fair complexion

(+) dry skin

Cold to touch

(-) ecchymosis

(-) jaundice

(-) cyanosis

(-) sore / wound

Head, Skull and Face

(+) normocephalic (normal head size)

(-) nodules or masses

(+) symmetric facial features

(+) symmetric facial movements

Nails:

(+) pallor

Rough texture

Delayed capillary refill or return of pink / usual color during capillary refill – indicate

circulatory impairment

Eyes and Vision

(-) discharge

Sclera appears yellowish

(-) conjunctivitis

Eyebrows symmetrically aligned and equal movement

(-) edema / tearing

(+) Pupils Equally Round and Reactive in Light Accommodation (PERRLA)

Pupils are black in color and equal in size ( 3 to 4mm in diameter)

Pupils constrict when looking at near object and dilate when looking at far objects.

Able to read newsprint

Both eyes coordinated with parallel alignment.

Ears

(-) lesions

(-) ear discharges

normal voice tones are audible

Nose and Sinuses

(-) lesions

both nares are open, not plugged

(-) abnormal nasal discharge

(-) flaring of nares

symmetric and straight

Mouth and Throat

Yellowish teeth

pinkish gums

tongue moves freely

(-) palpable nodules

(+) halitosis

Lips

pink in color

(-) blisters

Neck

can move freely in any directions

(+) jugular vein distention

(-) lumps

Upper Extremities

(-) bruises

(-) deformities

(-) wounds

(+) edema on both hands

Lower Extremities

(-) bruises

(-) lesions

Respiratory

Thorax and Back

Respiratory rate – 20 bpm

(-) cough

(-) use of accessory muscles

full and symmetric chest expansion

(+) wheezes

Cardiac

Heart and Peripheral Vessels

Blood Pressure – 120/70 mmHg

Pulse Rate – 43

Veins slightly distended

Gastrointestinal

Abdomen, Anus and Rectum

Regular bowel movement (once a day)

(-) abdominal distention

(+) bowel sounds

(-) tenderness

(-) guarding

Urinary

Frequency of urination (3 times a day)

Yellowish urine

Musculoskeletal

(-) arthritis

(-) stiffness

joints can move freely

bones: no deformities

muscle weakness

Neurologic

(-) seizures

(-) paralysis

(-) tremors

Glasgow coma scale: Eye opening – 3; Verbal response – 4; and Motor response – 6

Hematologic

No history of blood transfusion or donation.

IV. PATIENT AND HER ILLNESS

1. ANATOMY AND PHYSIOLOGY

The cardiovascular/circulatory system transports food, hormones, metabolic wastes, and

gases (oxygen, carbon dioxide) to and from cells. Components of the circulatory system

include:

blood : consisting of liquid plasma and cells

blood vessels (vascular system): the "channels" (arteries, veins, capillaries) which

carry blood to/from all tissues. (Arteries carry blood away from the heart. Veins

return blood to the heart. Capillaries are thin-walled blood vessels in which gas/

nutrient/ waste exchange occurs.)

heart : a muscular pump to move the blood

There are two circulatory "circuits": Pulmonary circulation, involving the "right heart,"

delivers blood to and from the lungs. The pulmonary artery carries oxygen-poor blood from

the "right heart" to the lungs, where oxygenation and carbon-dioxide removal occur.

Pulmonary veins carry oxygen-rich blood from the lungs back to the "left heart."  Systemic

circulation, driven by the "left heart," carries blood to the rest of the body. Food products

enter the system from the digestive organs into the portal vein. Waste products are removed

by the liver and kidneys. All systems ultimately return to the "right heart" via the inferior and

superior vena cava.

A specialized component of the circulatory system is the lymphatic system, consisting of a

moving fluid (lymph/interstitial fluid); vessels (lymphatics); lymph nodes, and organs (bone

marrow, liver, spleen, thymus).  Through the flow of blood in and out of arteries, and into the

veins, and through the lymph nodes and into the lymph, the body is able to eliminate the

products of cellular breakdown and bacterial invasion.

Blood Components

Adults have up to ten pints of blood.

Forty-five percent (45%) consists of cells - platelets, red blood cells , and white blood

cells (neutrophils, basophils, eosinophils, lymphocytes, monocytes). Of the white

blood cells, neutrophils and lymphocytes are the most important.

Fifty-five percent (55%) consists of plasma, the liquid component of blood.

Major Blood Components Modified from: Joel DeLisa and Walter C. Stolov, "Significant Body Systems," in: Handbook of Severe Disability, edited by Walter

C. Stolov and Michael R. Clowers. US Department of Education,  Rehabilitation Services Administration, 1981, p. 37.

Component Type Source Function

Platelets, cell fragments Bone marrow life-span: 10 days

Blood clotting

Lymphocytes (leukocytes) Bone marrow, spleen, lymph nodes

Immunity T-cells attack cells containing viruses. B-cells produce antibodies. 

Red blood cells (erythrocytes), Filled with hemoglobin, a compound of iron and protein

Bone marrow life-span: 120 days

Oxygen transport

Neutrophil (leukocyte) Bone marrow Phagocytosis

Plasma, consisting of  90% water and 10% dissolved materials -- nutrients (proteins, salts, glucose), wastes (urea, creatinine),  hormones, enzymes

  1. Maintenance of pH level near 7.4

2. Transport of large molecules  (e.g. cholesterol)

3. Immunity (globulin)

4. Blood clotting (fibrinogen)

Vascular System - the Blood Vessels

Arteries, veins, and capillaries comprise the vascular system. Arteries and veins run

parallel throughout the body with a web-like network of capillaries connecting them. Arteries

use vessel size, controlled by the sympathetic nervous system, to move blood by pressure;

veins use one-way valves controlled by muscle contractions.

Arteries

Arteries are strong, elastic vessels adapted for carrying blood away from the heart at

relatively high pumping pressure.  Arteries divide into progressively thinner tubes and

eventually become fine branches called arterioles. Blood in arteries is oxygen-rich, with the

exception of the pulmonary artery, which carries blood to the lungs to be oxygenated. 

The aorta is the largest artery in the body, the main artery for systemic circulation.

The major branches of the aorta (aortic arch, ascending aorta, descending aorta) supply blood

to the head, abdomen, and extremities. Of special importance are the right and left coronary

arteries, that supply blood to the heart itself.

Major Branches of Systemic Circulation Source: Joel DeLisa and Walter C. Stolov, "Significant Body Systems," in: Handbook of Severe Disability,

edited by Walter C. Stolov and Michael R. Clowers. US Department of Education,  Rehabilitation Services Administration, 1981, p. 40.

  Name Serves

Head Carotid Brain & skull

Abdomen Mesenteric Celiac (Abdominal) Renal Iliac

Intestines Stomach, liver, spleen Kidney Pelvis

Upper Extremity Brachial (axillary) Radial & Ulnar Dorsal Carpal

Upper arm Forearm & hand Fingers

Lower Extremity Femoral Popliteal Dorsal pedis Posterior tibial

Thigh Leg Foot Foot

Capillaries

The arterioles branch into the microscopic capillaries, or capillary beds, which lie

bathed in interstitial fluid, or lymph, produced by the lymphatic system. Capillaries are the

points of exchange between the blood and surrounding tissues. Materials cross in and out of

the capillaries by passing through or between the cells that line the capillary. The extensive

network of capillaries is estimated at between 50,000 and 60,000 miles long.1

Veins

Blood leaving the capillary beds flows into a series of progressively larger vessels,

called venules, which in turn unite to form veins. Veins are responsible for returning blood to

the heart after the blood and the body cells exchange gases, nutrients, and wastes. Pressure in

veins is low, so veins depend on nearby muscular contractions to move blood along. Veins

have valves that prevent back-flow of blood.

Blood in veins is oxygen-poor, with the exception of the pulmonary veins, which

carry oxygenated blood from the lungs back to the heart.  The major veins, like their

companion arteries, often take the name of the organ served. The exceptions are the superior

vena cava and the inferior vena cava, which collect body from all parts of the body (except

from the lungs) and channel it back to the heart.

Artery/Vein Tissues

Arteries and veins have the same three tissue layers, but the

proportions of these layers differ. The innermost is the intima; next

comes the media; and the outermost is the adventitia. Arteries have

thick media to absorb the pressure waves created by the heart's

pumping. The smooth-muscle media walls expand when pressure

surges, then snap back to push the blood forward when the heart rests. Valves in the arteries

prevent back-flow.  As blood enters the capillaries, the pressure falls off. By the time blood

reaches the veins, there is little pressure. Thus, a thick media is no longer needed.

Blood vessel anatomy

Surrounding muscles act to squeeze the blood along veins. As with arteries, valves are again

used to ensure flow in the right direction. 

Anatomy of the Heart

The heart is about the size of a man's fist. Located between the lungs, two-thirds of it

lies left of the chest midline The heart, along with the pulmonary (to and from the lungs) and

systemic (to and from the body) circuits, completely separates oxygenated from

deoxygenated blood.

Internally, the heart is divided into four hollow chambers, two on the left and two on the

right. The upper chambers of the heart, the atria (singular: atrium), receive blood via veins.

Passing through valves (atrioventricular (AV)

valves), blood then enters the lower chambers, the

ventricles. Ventricular contraction forces blood

into the arteries.

Interior View Posterior View

Oxygen-poor blood empties into the right atrium via the superior and inferior vena

cavae. Blood then passes through the tricuspid valve into the right ventricle which contracts,

propelling the blood into the pulmonary artery. The pulmonary artery is the only artery that

carries oxygen-poor blood.  It branches to the right and left lungs. There, gas exchange occurs

-- carbon dioxide diffuses out, oxygen diffuses in.

Pulmonary veins, the only veins that carry oxygen-rich blood, now carry the

oxygenated blood from lungs to the left atrium of the heart. Blood passes through the

bicuspid (mitral) valve into the left ventricle. The ventricle contracts, sending blood under

high pressure through the aorta, the main artery for systemic circulation. The ascending aorta

carries blood to the upper body; the descending aorta, to the lower body.

Blood Pressure and Heart Rate 

The heart beats or contracts around 70 times per minute.1 The human heart will

undergo over 3 billion contraction/cardiac cycles during a normal lifetime. 

One heartbeat, or cardiac cycle, includes atrial contraction and relaxation, ventricular

contraction and relaxation, and a short pause. Atria contract while ventricles relax, and vice

versa.  Heart valves open and close to limit flow to a single direction. The sound of the heart

contracting and the valves opening and closing produces a characteristic "lub-dub" sound. 

The cardiac cycle consists of two parts: systole (contraction of the heart muscle in the

ventricles) and diastole (relaxation of the ventricular heart muscles). When the ventricles

contract, they force the blood from their chambers into the arteries leaving the heart. The left

ventricle empties into the aorta (systemic circuit) and the right ventricle into the pulmonary

artery (pulmonary circuit). The increased pressure on the arteries due to the contraction of the

ventricles (heart pumping) is called systolic pressure. 

When the ventricles relax, blood flows in from the atria. The decreased pressure due

to the relaxation of the ventricles (heart resting) is called diastolic pressure.

Blood pressure is measured in mm of mercury, with the systole in ratio to the diastole.

Healthy young adults should have a ventricular systole of 120mm, and 80mm at ventricular

diastole, or 120/80. 

Receptors in the arteries and atria sense systemic pressure. Nerve messages from

these sensors communicate conditions to the medulla in the brain. Signals from the medulla

regulate blood pressure.

Electrocardiography (ECG, EKG)

An electrocardiogram measures changes

in electrical potential across the heart and

detects contraction pulses that pass over the

surface of the heart. There are three slow,

negative changes, known as P, R, and T.

Positive deflections are the Q and S waves. The

P wave represents atrial contraction ("the lub"), the T wave the ventricular contraction ("the

dub"). 

The Lymphatic System

The lymphatic system functions 1) to absorb excess fluid, thus preventing tissues

from swelling; 2) to defend the body against microorganisms and harmful foreign particles;

and 3) to facilitate the absorption of fat (in the villi of the small intestine). 

Capillaries release excess water and plasma into intracellular spaces, where they mix

with lymph, or interstitial fluid.  "Lymph" is a milky body fluid that also contains proteins,

fats, and a type of white blood cells, called "lymphocytes,"  which are the body's first-line

defense in the immune system. 

Lymph flows from small lymph capillaries into lymph vessels that are similar to veins

in having valves that prevent backflow. Contraction of skeletal muscle causes movement of

the lymph fluid through valves. Lymph vessels connect to lymph nodes, lymph organs (bone

marrow, liver, spleen, thymus), or to the cardiovascular system.

Lymph nodes are small irregularly shaped masses through which lymph vessels flow.

Clusters of nodes occur in the armpits, groin, and neck. All lymph nodes have the

primary function (along with bone marrow) of producing lymphocytes. 

The spleen filters, or purifies, the blood and lymph flowing through it. 

The thymus secretes a hormone, thymosin, that produces T-cells, a form of

lymphocyte.

BLOOD VESSELS

,

Wall of an artery consists of three (3) distinct layers of tunics

Tunica intima

o Composed of simple, squamous epithelium called endothelium.

o Rests on a connective tissue membrane that is rich in elastic and collagenous

fibers.

Tunica media

o Makes up the bulk of the arterial wall.

o Includes smooth muscle fibers, which encircle the tube, and a thick layer of

elastic connective tissue.

Tunica adventitia

o Is relatively thin.

o Consists chiefly of connective tissue with irregularly arranged elastic and

collagenous fibers.

o This layer attaches the artery to the surrounding tissues.

o Also contains minute vessels (vasa vasorum--vessels of vessels) that give rise

to capillaries and provide blood to the more external cells of the artery wall.

Smooth muscles in the walls of arteries and arterioles are innervated by the

sympathetic branches of the autonomic nervous system. 17986

Impulses on these vasomotor fibers cause the smooth muscles to contract causing

vasoconstriction.

If these impulses are inhibited, the muscle fibers relax and the diameter of the vessel

increases--vasodilation.

Capillaries OH-130 and 20.3 A,B

Flow of blood through the capillaries is regulated by vessels with smooth muscles in

their walls.

o Metarteriole--is a vessel that emerges from an arteriole, passes through the

capillary network and empties into a venule.

Proximal portions of the metarterioles are surrounded by scattered

smooth muscle cells whose contraction and relaxation help regulate the

amount and force of the blood.

Distal portion of a metarteriole has no smooth muscle fibers and is

called a thoroughfare channel.

Serves as a low resistance channel that increases blood flow.

True Capillaries

o Emerge from arterioles or metarterioles and are not on the direct flow route

from arteriole to venule.

o At their site of origin, there is a ring of smooth muscle fibers called a

precapillary sphincter that controls the flow of blood entering a true

capillary.

Continuous Capillaries 17991

Are named because the cytoplasm of the endothelial cells is continuous when viewed

in cross-section through a microscope.

o Cytoplasm appears as an uninterrupted ring, except for the endothelial

junction.

Fenestrated Capillaries 17992

Differ from continuous capillaries in that their endothelial cells have numerous pores

or fenestrations where the cytoplasm is very thin or absent.

Found in kidneys, villi of the small intestine, choroid plexi of the ventricles of the

brain, and endocrine glands.

Sinusoids or Discontinuous Capillaries 17994

Are wider than capillaries and more torturous

o Contain spaces between endothelial cells instead of having the usual

endothelial lining.

Basal lamina is incomplete or missing.

o In addition, sinusoids contain specialized lining cells that are adapted to the

function of the tissue.

o In the liver, sinusoids contain phagocytic cells called stellate

reticuloendothelial (Kupffer) cells.

o Other regions containing sinusoids include the spleen, parathyroid glands,

adrenal cortex, and bone marrow.

Venules and Veins OH-131 and 20.1 A,B 17975

Venules are the microscopic vessels that continue from the capillaries and merge to

form veins.

Veins which carry blood back to the heart, follow pathways roughly parallel to those

of the arteries.

Walls of veins are similar to those of arteries, in that they are composed of three

distinct layers.

o Middle layer is poorly developed.

o As a result, veins have thinner walls that contain less smooth muscle and less

elastic tissue than arteries.

Many veins, particularly those in the arms and legs, have flaps or valves which project

inward from the lining.

o Valves are usually composed of two leaflets that close if the blood begins to

back up in the veins.

Valves are open as long as the blood flow is toward the heart and

closed if it is in the opposite direction.

Veins also function as blood reservoirs that can be drawn upon in time of need.

o If a hemorrhage accompanied by drop in blood pressure occurs, the muscular

walls of the veins are stimulated reflexively by the sympathetic nervous

system.

Veins constrict and help to raise the blood pressure.

This mechanism ensures a nearly normal blood flow even if as much as

25% of the blood volume is lost.

MITRAL STENOSIS

Natural History:

Mitral Stenosis is a progressive disease in most patients. As depicted in figure below

an average of 19 years elapses before the onset of dyspnea.

 

Recognised MS                   Dyspnea         Valve Replacement/PMBV

I--------------------I-------------------I------------------I------------------I Death

Rheumatic Fever

0 ------------Time in years--------19

 

Before the surgical era the outlook for patients with this disease was unfavourable. From

1925 Rowe et al 17studied 250 patients with mitral stenosis. By 10 years 39% of patients had

died, 22% had become more dyspneic, and 16% had developed at least one thromboembolic

complication. By 20 years, 79% had died 8% had become more symptomatic, and 26% had

developed at least one thromboembolic event. Progression of disease is the rule at least in the

symptomatic group. The younger patients follow a more benign course then their old counter

parts .

DIAGNOSIS :

The diagnosis of mitral stenosis is suspected on history and confirmed by physical

examination, electrocardiography and echocardiography. Cardiac catheterization may aid the

diagnosis and treatment in selected individuals.

History:

History of acute rheumatic fever, although many patients do not recall this.

History of murmur

Effort induced dyspnea is the most common complaint and is often triggered by

exertion, fever, anemia, onset of atrial fibrillation or pregnancy.

Orthopnea progressing to paroxysmal nocturnal dyspnea.

Effort induced fatigue

Hemoptysis, due to rupture of thin dilated bronchial veins, is a late finding.

Chest pain may be due to right ventricular ischemia, concomitant coronary

atherosclerosis or secondary to a coronary embolism.

Thromboembolism may be the first symptom of MS.

Palpitations

Recumbent cough

Physical:

The physical exam findings depend on how advanced the disease is and the degree of

underlying cardiac decompensation.

Peripheral and facial cyanosis, can be seen more if the patient is polycythemic

Jugular venous distention, with positive hepatojugular reflex

Respiratory distress, evidence of pulmonary edema (rales, etc.)

Diastolic thrill palpable over apex.

The murmur of mitral stenosis is best heard at the apex with little radiation. It is

nearly holodiastolic with pre-systolic accentuation due to the atrial kick. It is usually

described as low-pitched, decrescendo, and rumbling, and can be heard best with the

patient in the left lateral decubitus position. The murmur appears about 0.08 seconds

after S2, and is heralded by an "opening snap". This is a brief, loud sound which is

caused as the stenotic valve suddenly halts its normal opening at the start of diastole.

Loud S1 followed by S2 and opening snap best heard at left sternal border. This is

succeeded by a low pitched rumbling diastolic murmur best heard over the apex, with

the patient in the left lateral decubitus position. This may diminish in intensity with

increasing stenosis. This S1 becomes more pronounced after exercise.

The duration of the diastolic murmur, not the intensity, correlates with the severity of

mitral narrowing 13.The holosystolic murmur of mitral regurgitation may accompany

the valvular deformity of mitral stenosis.

Digital clubbing

Systemic embolization

Signs of right heart failure in severe MS include ascites, hepatomegaly and peripheral

edema. If pulmonary hypertension is present there may be a right ventricular lift, an

increased pulmonic second sound and a high-pitched decrescendo diastolic murmur of

pulmonary insufficiency (Graham Steele's murmur).

DIFFERENTIAL DIAGNOSIS

Aortic Regurgitation

May give diastolic murmur and left sided failure but left ventricle is enlarged and

murmur is usually parasternal and high pitched

Chronic Obstructive Pulmonary Disease and Emphysema

May have cyanosis and edema, and can occur with MS, Patients with MS are

frequently diagnosed as asthmatics.

Other Problems to be Considered

Atrial Myxoma

Laboratory Studies:

Complete blood count (CBC), in cases of hemoptysis and to rule out anemia

Blood culture, in cases of suspected endocarditis

Electrolytes

Imaging Studies:

Chest X-Ray (CXR):

o Signs of pulmonary overload:

1. Prominence of pulmonary arteries,

2. Enlargement of right ventricle and

3. Evidence of CHF (interstitial edema with kerley B lines).

Left atrial enlargement with straightening of the left heart border, double density seen

on CXR and also menifested by elevation of the left mainstem bronchus

Pulmonary venous pattern changes with redistribution of flow toward the apices

Prominent pulmonary arteries at the hilum with rapid tapering

Kerley's B line Pulmonary edema pattern (late)

Electrocardiogram (EkG):

In sinus rhythm, enlarged left atrium is signified by a broad notched P wave most

prominent in lead II, with a negative terminal force in V1 15,16

With severe pulmonary hypertension, right axis deviation and right ventricular

hypertrophy can be seen.

Atrial fibrillation is a common but nonspecific finding in MS.

 

Echocardiography:

Transthoracic two dimensional echocardiography is the most sensitive and specific

non-invasive method for diagnosing mitral stenosis . With 2 dimensional echocardiography

mitral valve area can be calculated using different techniques. With two dimensional ECHO,

the size of the mitral orifice can be measured along with cardiac chamber sizes. The addition

of color Doppler can evaluate the transvalvular gradient, pulmonary artery pressure and

accompanying mitral regurgitation.

2. Pathophysiology (Book-based) schematic diagram

Non-Modifiable factors-Hereditary -Age (>40 y/o) - Gender

Modifiable Factors- Stress -Alcohol- Sedentary Lifestyle -Smoking- Diet -with history of - Hypertension rheumatic fever- Diabetes Mellitus

- Rheumatic FeverTrauma/ Injury to arterial wall (endothelial lining)

Increase inflammatory process

Increase healing of valve leaflets

Increase collagen content and scarring

Fusion of leaflets Thickening, fibrosis, and calcifications of leaflet

cusps

Thickening, fusion, shortening of the chordae tendinae

Blood flow narrowed and valve opening is reduced

Increase pressure of blood in the left atrium (left arterial pressure)

Heart murmur is heard upon auscultation

Increase pulmonary venous and capillary pressure and resistance

Pulmonary congestion

Left atrium enlarges

Burst in veins/ capillaries

Hemoptysis

Decrease blood flow and oxygen (O2) supply

Pulmonary hypertension

Right-sided Heart failure

Increase Cardiac Output

Increase blood pressure

Heart pumps harder than

normal

O2 supply to the muscle cells

Cerebral Perfusion

Body compensates by prioritizing perfusion of vital organs

Tissue Perfusion

Body compensates

Anaerobic metabolism

Lactic acid accumulation

Irritates nerve endings

Chest Pain and fatigue

Syncope and Dizziness

Heart rate(Tachycardia)

Stroke volume Hydrostatic Pressure

Palpitations Fluid shift from intravascular to interstitial space

Fluid accumulation in the interstitial

space

(Third Spacing)

Edema

blood flow to the extremities

Pallor and Cyanosis

Body will compensate

Ventilation to oxygen

concentration

Respiratory rate

(Tachypnea)

Use accessory muscles

Due to O2 supply, body compensates

Anaerobic metabolism

Lactic acid accumulation

Difficulty of Breathing

Orthopnea

Paroxysmal nocturnal dyspnea

Renal Tissue

Perfusion

Reduction of glomerular filtration rate

Elevated BUN level

B. Sythesis of the disease

b.1 Definition of the disease

Mitral Stenosis is an obstruction of blood flowing from the left atrium into the left

ventricle. It is most often caused by rheumatic fever, which progressively thickens and

contracts the mitral valve leaflets. Eventually the mitral valve orifice narrows and

progressively obstructs blood flow into the ventricle (Brudner & Suddhart, 2000).

b.2 Predisposing/ Precipitating factors

There are some risk factors that may aggravate the development Mitral Stenosis (MS), this

includes:

Predisposing Factors (NON-MODIFIABLE)

Age - a person above 40 years of age are at risk to develop MS.

This is due to degenerative changes in the vascular areas, heart and

blood volume.

Gender - women are affected more often than men by a 2:1 to 3:1

ratio. Females are prone to MS before the age of 65 years of age.

However females have higher propensity to MS after the age of 65

years. This is due to decrease estrogen levels in menopause, HDL

decreases, LDL increases, atherosclerosis and/or rheumatic heart

disease develops.

Hereditary – person with family history of heart illness such as

MS are at risk of developing MS.

Precipitating Factors (MODIFIABLE)

Stress - sympathetic response stimulation cause increased secretion

of norepinephrine. These results to vasoconstriction and

tachycardia, increase cardiac workload occurs.

Sedentary living - regular pattern of exercise improves circulation

to different body parts to maintain vascular tones and enhance

release to chemical activators (tissue plasminogen activator which

prevent platelet aggregation.

Diet - increase dietary intake of foods high in sodium, fats and

cholesterol predisposed a person to cardiovascular disorders.

Hypertension - increase systemic vascular resistance, endothelial

damage, increase platelet adherence, increase permeability of

endothelial lining, results from increase blood pressure

Diabetes Mellitus -

o Glucose from carbohydrates cannot be transported into the

cells due to insulin deficiency or increase resistance to

insulin.

o The body then, mobilizes are converted into glucose

o Hyperlipidemia results which enhance the risk of atherosc.

Rheumatic fever- heart inflammation that happens but can

disappear gradually usually within 5 months. However, it may

permanently damage the heart valves resulting to rheumatic

disease. In rheumatic heart disease the valve between the left

atrium and ventricle (Mitral valve) is most commonly damage

which can eventually lead to Mitral stenosis or mitral regurgitation.

Smoking - Nicotine causes vasoconstriction and vasospasm of the

arteries, increase myocardial oxygen demand and adhesion of

platelets. In addition cigarette smoking has been associated with

decrease level of HDL (good cholesterol).

Alcohol - positively correlates with increase blood pressure.

b.3 Pathologic Changes

Mild mitral stenosis does not usually cause symptoms. Some people with more severe

mitral stenosis have atrial fibrillation or heart failure. People with atrial fibrillation may feel

palpitations (awareness of heartbeats). People with heart failure become easily fatigued and

short of breath. Shortness of breath may occur only during physical activity at first, but later,

it may occur even during rest. Some people can breathe comfortably only when they are

propped up with pillows or sitting upright. Those people with a low level of oxygen in the

blood and high blood pressure in the lungs may have a plum-colored flush in the cheeks

(called mitral facies). People may cough up blood (hemoptysis) if the high pressure causes a

vein or capillaries in the lungs to burst. The resulting bleeding into the lungs is usually slight,

but if hemoptysis occurs, the person should be evaluated by a doctor promptly because

hemoptysis indicates severe mitral stenosis or another serious problem.

b.4 Signs and Symptoms with rationale

Signs and Symptoms Rationale

> Chest pain

> fatigue

> Syncope and Dizziness

> Palpitations

> Tachycardia

> Tachypnea

> Difficulty of Breathing

> Cessation of blood supply to arteries

specifically to the aorta caused by

thrombotic occlusion causes accumulation

of metabolites within ischemic part of the

arteries in which affects the nerve endings.

> This may be a consequence of inadequate

cardiac output

>This is due to decreased cerebral tissue

perfusion.

> This is due to the increase stroke volume

as the body compensates as the heart

pumps faster. Palpitations that occur during

mild exertion may indicate the presence of

heart failure, and anemia.

> The heart pumps faster to compensate for

the decrease blood flow to the body.

> Increase respiratory rate is experienced

by the patient as body’s compensation of

decrease tissue perfusion to increase the

oxygen concentration of the blood.

> Due to use of accessory muscles and

> Edema

> Pallor & Cyanosis

>Orthopnea

> Paroxysmal nocturnal dyspnea

> Hemoptysis

> Elevated BUN level

decrease O2 supply, the body compensates

and anaerobic metabolism occur. Lactic

acid accumulates resulting to dyspnea.

> Shifting of fluid into the interstitial space

due to increase in the vascular area

(hydrostatic) pressure.

> Due to decrease tissue perfusion the

patient turn dull and pale.

> Due to use of accessory muscles and

decrease O2 supply, the body compensates

and is usually a symptom of more

advanced heart failure

> Due to use of accessory muscles and

decrease O2 supply, the body compensates

and is usually manifested by shortness of

breath that usually occurs 2-5 hours after

the onset of sleep

> Due to increase venous and capillary

pressure as well as resistance leads to burst

of veins and capillaries

> Due to decrease renal tissue perfusion

which results to reduce glomerular

filtration rate thus, the BUN level becomes

elevated.

B. Pathophysiology (Client-based) schematic diagram

Non-Modifiable factors-Age (>40 y/o)- Gender : Female-Hereditary- CAD, HPN & DM

Modifiable Factors- Stress- History of rheumatic fever- Diet- Hypertension- Diabetes Mellitus- Rheumatic Fever

Trauma/ Injury to arterial wall (endothelial lining)

Increase inflammatory process

Increase healing of valve leaflets

Increase collagen content and scarring

Fusion of leaflets Thickening, fibrosis, and calcifications of leaflet

cusps

Thickening, fusion, shortening of the chordae tendinae

Blood flow narrowed and valve opening is reduced

Increase pressure of blood in the left atrium (left arterial pressure)

Heart murmur is heard upon auscultation

(DATE??)

Increase pulmonary venous and capillary pressure and resistance

Pulmonary congestion

Left atrium enlarges(Cardiomegaly)

Decrease blood flow and oxygen (O2) supply

Pulmonary hypertension

Right-sided Heart failure

Increase Cardiac Output

Increase blood pressure

Heart pumps harder than

normal

O2 supply to the muscle cells

Cerebral Perfusion

Body compensates by prioritizing perfusion of vital organs

Tissue Perfusion

Body compensates

Anaerobic metabolism

Lactic acid accumulation

Irritates nerve endings

Chest Pain and fatigue

(june 25, 2010)

Syncope and Dizziness

Date?? Heart rate

(Tachycardia) -June 24,2010

Stroke volume Hydrostatic Pressure

Palpitations(June 24, 2010)

Fluid shift from intravascular to interstitial space

Fluid accumulation in the interstitial

space

(Third Spacing)

Edema(June 25, 2010)

blood flow to the extremities

Pallor and Cyanosis

June 24, 2010

Body will compensate

Ventilation to oxygen

concentration

Respiratory rate

(Tachypnea)

Use accessory muscles

Due to O2 supply, body compensates

Anaerobic metabolism

Lactic acid accumulation

Difficulty of Breathing

(June 24, 2010)

Orthopnea(June 24, 2010)

Renal Tissue

Perfusion

Reduction of glomerular filtration rate

Elevated BUN level

June 24, 2010

B. Sythesis of the disease

b.1 Definition of the disease

Mitral Stenosis is an obstruction of blood flowing from the left atrium into the left

ventricle. It is most often caused by rheumatic fever, which progressively thickens and

contracts the mitral valve leaflets. Eventually the mitral valve orifice narrows and

progressively obstructs blood flow into the ventricle (Brudner & Suddhart, 2000).

b.2 Predisposing/ Precipitating factors

There are some risk factors that may aggravate the development Mitral Stenosis (MS),

this includes:

Predisposing Factors (NON-MODIFIABLE)

Age – Mrs. Mapusu is 72 of age are at risk to develop MS. This is

due to degenerative changes in the vascular areas, heart and blood

volume.

Gender –Mrs. Mapusu is a women and she is also 72 years old

making her more prone in acquiring mitral stenosis since women

are affected more often than men by a 2:1 to 3:1 ratio. However

females have higher propensity to MS after the age of 65 years.

This is due to decrease estrogen levels in menopause, HDL

decreases, LDL increases, atherosclerosis and/or rheumatic heart

disease develops.

Precipitating Factors (MODIFIABLE)

Stress – she moves around the house, and thinks a lot of things

making her stress all the time. Sympathetic response stimulation

cause increased secretion of norepinephrine. These results to

vasoconstriction and tachycardia, increase cardiac workload

occurs.

Sedentary living – She lacks exercise, moves around the house but

most of the time she lies down the sofa. Regular pattern of exercise

improves circulation to different body parts to maintain vascular

tones and enhance release to chemical activators (tissue

plasminogen activator which prevent platelet aggregation.

Diet – Mrs. Mapusu likes to eat foods rich in sodium, fats and

cholesterol, such as chicharon. And if these are increase the more

predisposed a person to cardiovascular disorders.

Hypertension – Mrs Mapusu is hypertensive with a blood pressure

of 180/90 mmHg. Increase systemic vascular resistance,

endothelial damage, increase platelet adherence, increase

permeability of endothelial lining, results from increase blood

pressure

Diabetes Mellitus – Mrs. Mapusu also has DM II.

o Glucose from carbohydrates cannot be transported into the

cells due to insulin deficiency or increase resistance to

insulin.

o The body then, mobilizes are converted into glucose

Rheumatic fever- Mrs. Mapusu had this when she was 40 y/o;

heart inflammation that happens but can disappear gradually

usually within 5 months. However, it may permanently damage the

heart valves resulting to rheumatic disease. In rheumatic heart

disease the valve between the left atrium and ventricle (Mitral

valve) is most commonly damage which can eventually lead to

Mitral stenosis or mitral regurgitation.

b.3 Pathologic Changes

Mild mitral stenosis does not usually cause symptoms. Some people with more severe

mitral stenosis have atrial fibrillation or heart failure. People with atrial fibrillation may feel

palpitations (awareness of heartbeats). People with heart failure become easily fatigued and

short of breath. Shortness of breath may occur only during physical activity at first, but later,

it may occur even during rest. Some people can breathe comfortably only when they are

propped up with pillows or sitting upright. Those people with a low level of oxygen in the

blood and high blood pressure in the lungs may have a plum-colored flush in the cheeks

(called mitral facies). People may cough up blood (hemoptysis) if the high pressure causes a

vein or capillaries in the lungs to burst. The resulting bleeding into the lungs is usually slight,

but if hemoptysis occurs, the person should be evaluated by a doctor promptly because

hemoptysis indicates severe mitral stenosis or another serious problem.

b.4 Signs and Symptoms with rationale with their specific dates for the occurrences

of each manifestation

Signs and Symptoms Rationale Date of Occurrence

> Chest pain

> Fatigue

> Syncope and Dizziness

> Palpitations

> Tachycardia

> Cessation of blood supply to

arteries specifically to the aorta

caused by thrombotic occlusion

causes accumulation of

metabolites within ischemic part

of the arteries in which affects the

nerve endings.

> This may be a consequence of

inadequate cardiac output

>This is due to decreased cerebral

tissue perfusion.

> This is due to the increase stroke

volume as the body compensates

as the heart pumps faster.

Palpitations that occur during mild

exertion may indicate the presence

of heart failure, and anemia.

> The heart pumps faster to

compensate for the decrease blood

flow to the body.

June 24, 2010

June 25, 2010

June 25, 2010

June 24, 2010

June 24, 2010

> Tachypnea

> Difficulty of Breathing

> Edema

> Pallor & Cyanosis

>Orthopnea

> Increase respiratory rate is

experienced by the patient as

body’s compensation of decrease

tissue perfusion to increase the

oxygen concentration of the blood.

> Due to use of accessory muscles

and decrease O2 supply, the body

compensates and anaerobic

metabolism occur. Lactic acid

accumulates resulting to dyspnea.

> Shifting of fluid into the

interstitial space due to increase in

the vascular area (hydrostatic)

pressure.

> Due to decrease tissue perfusion

the patient turn dull and pale.

> Due to use of accessory muscles

and decrease O2 supply, the body

compensates and is usually a

symptom of more advanced heart

failure

June 24, 2010

June 24, 2010

June 25, 2010

June 25, 2010

June 25, 2010

V. THE PATIENT AND HIS CARE

a. Medical Management

A. IVF

Medical Management General Description Indication(s) or Purpose(s)

Date Ordered, Date Performed, Date Changed or D/C

Client Response to Treatment

PNSS

(0.9 Sodium Chloride)

KVO

Sodium Chloride is an isotonic crystalloid solution that acts as a vehicle for many parenteral drugs and as an electrolyte replenisher for maintenance or replacement of deficits in extracellular fluid.

Hypovolemia

Dehydration

Facilitation of drug administration

Date Ordered:

June 24, 2010

Date Performed:

June 24, 2010

The patient didn’t develop any undesirable

response such as redness, swelling or

pain.

Nursing Responsibilities

Before:

Check the patient’s name and doctor’s order administration Check the patency of IV tubing Explain to the patient the indication of IVF infusion Always observe standard precautions

During:

Regulate the gtts/min as ordered Monitor and ensure appropriate infusion flow to avoid fluid overload During the therapy, if the insertion site swells or bulges instruct patient/ SO to apply warm compress

After:

Proper documentation Label the IV bottle with the following name of the patient, # of IVF, date and time started, gtts/min, time to be consumed In terminating the IVF prepare all necessary things such as alcohol, cotton balls, micro pore tape and bandage scissors Discard properly the IV set to avoid contamination

Medical Management General Description Indication(s) or Purpose(s)

Date Ordered, Date Performed, Date Changed or D/C

Client Response to Treatment

Oxygen Inhalation via NC

The oxygen therapy is usually ordered

once decreased oxygen saturation in the blood or tissues

is demonstrated.

It is designed to help restore or improve

breathing function in patients with a variety of

diseases or conditions

To increase the oxygen saturation of the body

during dyspnea

Date Ordered:

June 24, 2010

Date Performed:

June 24, 2010

The patient verbalized feeling of comfort while in oxygen therapy and

exhibit improvement on her breathing

Nursing Responsibilities

Before:

Check the patient’s name and doctor’s order administration Explain to the patient the indication of oxygen therapy Always observe standard precautions

During:

Regulate the oxygen to 2-3 lpm.

After:

Proper documentation Observe the patient skin integrity to prevent skin breakdown on pressure points from the oxygen delivery device.

B. DRUG

Generic name and Brand name

General Classificationand mechanism of

action

Indication or Purpose why medication is

given for the particular disease

condition

Date Ordered, Date Started, Date Changed

or D/C

Client Response to Medication with actual

side effects

GN:

Indapamide

BN:

Bi-Preterax

ACE Inhibitors

Diuretic

Angiotensin-converting enzyme inhibitor and

diuretic acting on cortical dilution segment in fixed

combination.

Treatment for Hypertension

Date Ordered:

June 24, 2010

Date Started:

June 24, 2010

Patient’s BP decreased from 180/90 mmHg to

130/70 mmHg.

Increased urine output

Nursing Responsibilities:

Before:

Check the doctor’s ordered Check the patient name Check the Vital Signs especially BP Check the name of the drug and dosage Monitor the intake and output

During:

Give the drug with an empty stomach

After:

Stress the importance of not chewing effervescent tablets, swallowing them whole, or letting them dissolve on the tongue before swallowing

Monitor output Document the date and time it was administered

Generic name and Brand name

General Classificationand mechanism of

action

Indication or Purpose why medication is

given for the particular disease

condition

Date Ordered, Date Started, Date Changed

or D/C

Client Response to Medication with actual

side effects

GN:

Digoxin

BN:

Lanoxin

Cardiotonic

Antiarrhythmic

Increases the force and velocity of myocardial contraction, resulting in

positive inotropic effects. Digoxin produces

antiarrhythmic effects by decreasing the

conduction rate and increasing the effective refractory period of the

AV node.

Treatment for heart failure, and arrhythmia

Date Ordered:

June 24, 2010

Date Started:

June 24, 2010

Heart rate decreased to 65 bpm from 130 bpm

Nursing Responsibilities:

Before:

Check the doctor’s ordered Check the patient name Check the Vital Signs especially the pulse rate Check the name of the drug and dosage

During:

Maybe taken with or without food

After:

Stress the importance of not chewing effervescent tablets, swallowing them whole, or letting them dissolve on the tongue before swallowing

Document the date and time it was administered

Generic name and Brand name

General Classificationand mechanism of

Indication or Purpose why medication is

given for the Date Ordered, Date

Started, Date Changed Client Response to

Medication with actual

action particular disease condition

or D/C side effects

GN:

Rosiglitazone maleate

BN:

Avandia

Antidiabetic

Increases tissue sensitivity to insulin. This peroxisome proliferator-activated receptor agonist regulates the transcription

of insulin-responsive genes found in key target tissues, such as adipose tissue, skeletal muscle

and the liver. Enhanced tissue sensitivity to

insulin lowers the blood glucose

To achieve glucose control in type 2 diabetes mellitus

Date Ordered:

June 24, 2010

Date Started:June 24, 2010

Pt’s blood glucose turned normal.

Nursing Responsibilities:

Before:

Check the doctor’s ordered Check the patient name Check the Vital Signs Check the name of the drug and dosage Explain to patient the importance of taking the drug

During:

Make sure the drug was swallowed.

After:

Stress the importance of not chewing effervescent tablets, swallowing them whole, or letting them dissolve on the tongue before swallowing

Document the date and time it was administered Check for the CBG

Generic name and Brand name

General Classificationand mechanism of

action

Indication or Purpose why medication is

given for the particular disease

condition

Date Ordered, Date Started, Date Changed

or D/C

Client Response to Medication with actual

side effects

GN: Penicillin Treatment for Date Ordered: Pt didn’t manifest signs

Phenoxymethylpenicillin K

BN:

Sumapen

Phenoxymethylpenicillin inhibits the final cross-

linking stage of peptidoglycan production

through binding and inactivation of

transpeptidases on the inner surface of the

bacterial cell membrane, thus inhibiting bacterial

cell wall synthesis. It may be less active against

some susceptible organisms, particularly

gram-negative bacteria. It is suitable for mild to

moderate infections, not for chronic, severe or

deep-seated infections.

respiratory tract infection, viral

infections

June 24, 2010

Date Started:

June 24, 2010

of infection

Nursing Responsibilities:

Before:

Check the doctor’s ordered Check the patient name Check the Vital Signs Check the name of the drug and dosage

During:

Explain to patient the importance of taking the drug

Take the drugs with an empty stomach

After:

Stress the importance of not chewing effervescent tablets, swallowing them whole, or letting them dissolve on the tongue before swallowing

Document the date and time it was administered

Generic name and Brand name

General Classificationand mechanism of

action

Indication or Purpose why medication is

given for the particular disease

condition

Date Ordered, Date Started, Date Changed

or D/C

Client Response to Medication with actual

side effects

GN:

Warfarin

Anticoagulants, Antiplatelets &

Fibrinolytics

Treatment and prevention of venous

Date Ordered:

June 24, 2010

Pt did not experience bleeding.

BN:

Warfarin

(Thrombolytics)

Warfarin inhibits synthesis of vit K-

dependent coagulation factors VII, IX, X and II and anticoagulant protein C and its cofactor protein

S. No effects on established thrombus but further extension of the clot can be prevented.

Secondary embolic phenomena are avoided.

thrombosis Date Started:

June 24, 2010

Nursing Responsibilities:

Before:

Check the doctor’s ordered Check the patient name Check the Vital Signs Check the name of the drug and dosage

During:

Maybe taken with or without food

After:

Stress the importance of not chewing effervescent tablets, swallowing them whole, or letting them dissolve on the tongue before swallowing

Document the date and time it was administered

Generic name and Brand name

General Classificationand mechanism of

action

Indication or Purpose why medication is

given for the particular disease

condition

Date Ordered, Date Started, Date Changed

or D/C

Client Response to Medication with actual

side effects

GN:

Atenolol

Beta blockers

Atenolol is a β1-selective adrenergic-blocking

agent. It competitively

Management for angina pectoris and hypertension

Date Ordered:

June 24, 2010

Pt’s BP decreased from 180/90 mmHg to 130/70

mmHg.

BN:

Therabloc

blocks adrenergic stimulation of β1-

adrenergic receptors within the myocardium

and vascular smooth muscle. Low doses of atenolol selectively inhibit cardiac and

lipolytic β1-receptors but with little effect on the

β2-adrenergic receptors of bronchial and vascular smooth muscle. At high

doses (ie, >100 mg daily), this selectivity of

atenolol for β1-adrenergic receptors may diminish

and the drug may competitively block β1-

and β2-adrenergic receptors. Atenolol does not exhibit any intrinsic

sympathomimetic activity nor any

membrane-stabilizing activity.

Date Started:

June 24, 2010

Pt’s heart rate decreased from 130 bpm to 65

bpm.

Nursing Responsibilities:

Before:

Check the doctor’s ordered Check the patient name Check the Vital Signs especially the pulse rate Check the name of the drug and dosage

During:

Maybe taken with or without food

After:

Stress the importance of not chewing effervescent tablets, swallowing them whole, or letting them dissolve on the tongue before swallowing

Document the date and time it was administered Check for bp and pulse rate

Generic name and Brand name

General Classificationand mechanism of

action

Indication or Purpose why medication is

given for the particular disease

condition

Date Ordered, Date Started, Date Changed

or D/C

Client Response to Medication with actual

side effects

GN:

Atropine sulfate

BN:

Antidotes, Detoxifying Agents & Drugs Used in Substance Dependence,

Antispasmodics

Atropine is an

Bradycardia Date Ordered:

June 24, 2010

Date Started:

Pt’s heart rate increased from 43 bpm to 72 bpm.

Anespin anticholinergic agent which competitively

blocks the muscarinic receptors in peripheral

tissues such as the heart, intestines, bronchial

muscles, iris and secretory glands. Some central stimulation may

occur. Atropine abolishes bradycardia and reduces heart block due to vagal activity. Smooth muscles in the bronchi and gut are relaxed while glandular

secretions are reduced. It also has mydriatic and

cycloplegic effect.

June 24, 2010

Nursing Responsibilities:

Before:

Check the doctor’s ordered Check the patient name Check the Vital Signs especially the pulse rate Check the name of the drug and dosage

During:

Wipe the iv port and administer the med

After:

Document the date and time it was administered Check for pulse rate

Generic name and Brand name

General Classificationand mechanism of

action

Indication or Purpose why medication is

given for the particular disease

condition

Date Ordered, Date Started, Date Changed

or D/C

Client Response to Medication with actual

side effects

GN:

Spironolactone

BN:

Aldactone

Diuretics

Antihypertensive

Normally, aldosterone attaches to receptors on

the walls of distal convoluted tubule cells,

To treat edema due to heart failure

Date Ordered:

June 24, 2010

Date Started:

June 24, 2010

Pt’s BP decreased from 180/90 mmHg to 130/70

mmHg.

Increased urinary output

causing sodium and water reabsorption in the

blood.

Nursing Responsibilities:

Before:

Check the doctor’s ordered Check the patient name Check the Vital Signs especially the BP Check the name of the drug and dosage

During:

Maybe taken with or without food

After:

Stress the importance of not chewing effervescent tablets, swallowing them whole, or letting them dissolve on the tongue before swallowing

Document the date and time it was administered Check for BP and pulse rate

Generic name and Brand name

General Classificationand mechanism of

action

Indication or Purpose why medication is

given for the particular disease

condition

Date Ordered, Date Started, Date Changed

or D/C

Client Response to Medication with actual

side effects

GN:

Gliclazide

BN:

Diamicron

Antidiabetic

Gliclazide is a sulfonylurea which stimulates insulin

secretion by the pancreas. Its action on insulin

For Type 2 diabetes mellitus

Date Ordered:

June 24, 2010

Date Started:

June 24, 2010

The pt’s glucose level turned to normal and did

not show any manifestation of

increased glucose level.

secretion is mainly due to the restoration of the

early phase, resulting in a physiological release of insulin. Thus, gliclazide

restores glycaemic control throughout 24

hrs. It normalizes fasting and postprandial blood

sugar.

Nursing Responsibilities:

Before:

Check the doctor’s ordered Check the patient name Check the Vital Signs Check the name of the drug and dosage

During:

Should be taken with food

After:

Stress the importance of not chewing effervescent tablets, swallowing them whole, or letting them dissolve on the tongue before swallowing

Document the date and time it was administered

Generic name and Brand name

General Classificationand mechanism of

action

Indication or Purpose why medication is

given for the particular disease

condition

Date Ordered, Date Started, Date Changed

or D/C

Client Response to Medication with actual

side effects

GN:Morphine Sulfate

Analgesic

Morphine is a phenanthrene derivative

Pain

Acute pulmonary

Date Ordered:

June 24, 2010

Pt relieved from pain

BN:Morphine

which acts mainly on the CNS and smooth

muscles. It binds to opiate receptors in the

CNS altering pain perception and response. Analgesia, euphoria and dependence are thought to be due to its action at the mu-1 receptors while

respiratory depression and inhibition of

intestinal movements are due to action at the mu-2

receptors. Spinal analgesia is mediated by morphine agonist action at the K receptor. Cough is suppressed by direct action on cough centre.

edema Date Started:

June 24, 2010

Nursing Responsibilities:

Before:

Check the doctor’s ordered Check the patient name Check the Vital Signs Check the name of the drug and dosage

During:

Wipe the iv port with alcohol and administer it via iv push

After:

Document the date and time it was administered

Generic name and Brand name

General Classificationand mechanism of

action

Indication or Purpose why medication is

given for the particular disease

condition

Date Ordered, Date Started, Date Changed

or D/C

Client Response to Medication with actual

side effects

GN:

Furosemide

Antihypertensive

Diuretic

To reduce edema caused by heart failure

Date Ordered:June 24, 2010

Patient’s BP decreased from 180/90 mmHg to

130/70 mmHg.

BN:Lasix

Inhibits sodium and water reabsorption in the

loop of henle and increases urine

formation.

To manage mild to moderate hypertension

Date Started:

June 24, 2010

Increased urine output

Nursing Responsibilities:

Before:

Check the doctor’s ordered Check the patient name Check the Vital Signs especially the BP Check the name of the drug and dosage

During:

Wipe the port with an alcohol and SIVP

After:

Check for any complications Document the date and time it was administered

Indication or Purpose Date Ordered, Date Client Response to

Generic name and Brand name

General Classification

and mechanism of action

why medication is given for the

particular disease condition

Started, Date Changed or D/C

Medication with actual side effects

GN:

BN:

Humulin R

Insulin Preparations

The time course of action of any insulin may vary considerably in different individuals or at different

times in the same individual. As with all

insulin preparations, the duration of action of

Humulin is dependent on dose, site of injection,

blood supply, temperature and physical

activity.

Treatment of patients with diabetes mellitus,

for the control of hyperglycemia.

Date Ordered:

June 24, 2010

Date Started:

June 24, 2010

DM is being controlled by the medications

Nursing Responsibilities:

Before:

Check the doctor’s ordered Check the patient name Check the Vital Signs Check the name of the drug and dosage

During:

Administer the drug subcutaneously

After:

Document the date and time it was administered

C. Diet

Type of Diet General Description Indication/Purpose

Date Ordered, Date Date Started,

Date Changed or D/C

Client’s Response and/or Reaction to the

Diet

1. Nothing Per Orem (NPO)

There nothing will be taken by mouth either liquid or solid: ordered pre operatively and post

operatively.

Ordered preoperatively and post operatively to prevent aspiration or

obstruction of respiratory airway to

avoid further occurrence of complications.

Date Ordered:

June 24, 2010

Date Started:

June 24, 2010

The patient follows the diet prescribed by the physician. And able to

participate in what specific diet needed.

2. Low Fat Diet containing limited amount of fat and

consisting chiefly of easily digestible foods of

high carbohydrate content. It includes all vegetables, lean meats, fish, fowl, pasta, cereals

and whole wheat or enriched bread

Indicated in heart diseases, to prevent the further narrowing of the

artery due t accumulation of fats or

lipids in the tunica intima.

To reduce serum levels of LDL (Low Density

Lipoprotein)

Date Ordered:

June 24, 2010

Date Started:

June 24, 2010

The patient was willing to improve his diet by following the given

health teachings given to him regarding his diet

especially in limiting his cholesterol intake.

3. Low Sodium Diet that restricts the use of sodium chloride plus

other compounds

Is indicated when edema is present, in

hypertension, and certain

Date Ordered: The patient was able to follow the instructed diet given to him by limiting

containing sodium such as baking powder or soda, monosodium glutamate, sodium citrate , sodium.

propionate and sodium sulfate

cardiac conditions, (CAD), to reduce fluid

retention

June 24, 2010

Date Started:

June 24, 2010

his sodium intake.

Nursing Responsibilities on NPO

Before:

Check the doctor’s ordered Check the patient name. Assure IVF therapy if patient is on NPO Explain the purpose and reason of the diet prescribed to the patient / SO

During:

Assess patient condition Remind the patient and So that he is on NPO stats until further notification of the doctor

After:

Instruct SO not to give anything through the moth either liquid or solid Observed patient response to diet Document the date it was ordered and implemented

Nursing Responsibilities on Low Fat Low Sodium

Before: Check the doctor’s order Check the patient name. Explain the purpose and reason of the diet prescribed to the patient / SO

During:

Assess patient condition Remind the patient and So that he is on low fat low sodium diet

After:

Observed patient response to diet Document the date it was ordered and implemented

D.Activity/ExerciseThere was no exercise being ordered by the physician, as seen in the doctor’s order.

2. NURSING MANAGEMENTASSESSMENT NURSING

DIAGNOSISSCIENTIFIC

EXPLANATIONPLANNING NURSING

INTERVENTIONRATIONALE EXPECTED

OUTCOME

S >

O > weakness > pallor >slow capillary refill >decreased heart rate-43 bpm (june 25, 2010) >skin slightly cold to touch

Decreased cardiac output related to valvular disease 2° mitral stenosis

Mitral stenosis the narrowing of the mitral valve opening, thus, there has been decreased blood flow.

Short-term:

After 2 hours, patient will verbalize knowledge of the disease process, individual risk factors, and treatment plan

Long-term:

After 2 days, patient will participate in activities that reduce the workload of the heart such as stress management/rest plan

- establish rapport

- monitor and record vital signs

- assess patient’s condition

- review diagnostic studies such as ECG tracing, x-ray

- promote adequate rest by decreasing stimuli and provide quiet environment

- encourage use of relaxation techniques

- encourage changing position

- to gain trust and confidence of the patient

- to obtain baseline data

- to note for any problems

- to assess the condition of the heart and its ability to work

- to promote relaxation and decrease cardiac workload

- to reduce anxiety and aid in proper circulation

- to reduce risk of orthostatic hypotension

Short-term:

Patient shall verbalize knowledge of the disease process, individual risk factors, and treatment plan

Long-term:

Patient shall participate in activities that reduce the workload of the heart such as stress management/rest plan

slowly, dangling legs before standing

- discuss to the patient the disease process and the importance of the treatment plan

- teach stress management techniques

- provide for small frequent feeding diet restriction

- administer supplemental oxygen as indicated

- to promote understanding and provide information regarding own condition

- to reduce workload of the heart

- to maintain adequate nutrition and fluid balance

- to increase oxygen available to tissue

CUESNURSING

DIAGNOSISSCIENTIFIC

EXPLANTIONOBJECTIVE

NURSING INTERVENTIONS

RATIONALEEXPECTED OUTCOME

S> “masakit ku buntuk pag migigising ku, medyo magkasakit mangisnawa”

O> lethargy > slight confusion > general weakness >pallor > edema in both hands

Impaired Gas Exchange related to altered blood flow 2° mitral

stenosis

Due to mitral valve stenosis,

blood flow decreases thus

oxygenated blood is not sufficiently

distributed to different parts of

the body.

After 2 hours of Nursing

Intervention the patient will demonstrate

improve ventilation absence of distress.

>Establish rapport

>Monitor record Vital Signs

>Elevated head and bed/position client appropriately

>Maintain adequate I/O but avoid fluid overload

>Encourage adequate rest and limit activities

>Provide calm and clean environment

>Reinforce need for adequate rest, while encouraging activity and exercise

>To gain patient trust and cooperation

>For base line data

>To maintain airway

>For mobilization of secretions

>Helps limits oxygen needs or consumption

>To promote comfort

>To decrease dyspnea and

After 1 -2 hours of nursing

interventions patient will demonstrate relieved and

maintain adequate oxygen

improve quality life

SOAPIE(June 25, 2010)

S> “Patse lulukluk ampong tatalakad Karin ku mu magkasakit sisisngap.”

O> Received lying on bed, awake, conscious & coherent with on going IVF of PNSS

@ approx. 800 cc level KVO infusing well on the right arm.

> With DOB on activities

> Get tired easily

> initial V/S taken & recorded: BP- 130/70 mmHg, T- 36.1°C, PR- 86 bpm, RR-

30 bpm

A> Activity Intolerance r/t generalized weakness 2° mitral stenosis

P> After 1° of nursing interventions, pt. will be able to demonstrate ways to modify

activities to reduce exertional dyspnea.

I> Assessed for weakness & fatigue

> Monitored & recorded V/S Q4°

> Provided adequate rest periods

> Assisted in doing activities such as walking & positioning.

> Provided comfort measures such as changing the linens.

> Encouraged deep breathing exercise

> Instructed S.O. to provide a quiet environment to pt.

> Encouraged verbalization of discomfort

> Instructed to increase activity levels gradually while conserving energy by stopping

3 mins. During exertional activity.

E> Goal met AEB pt.’s demonstration on ways to modify activities to reduce

exertional dyspnea.

VI. PATIENT DAILY PROGRESS IN THE HOSPITAL (from ADMISSION to DISCHARGE)

CRITERIA ADMISSIONJune 24, 2010 June 25, 2010

DISCHARGEJune 28, 2010

NURSING PROBLEMS1. Ineffective Breathing pattern r/t chest pain 2º mitral stenosis

√

2.Activity Intolerance r/t generalized weakness 2º mitral stenosis

√

3. Decreased Cardiac output r/t valvular disease

√

4. Impaired Gas exchange r/t altered blod flow

√

VITAL SIGNSTemp: ºC 37 36.5 36.4PR: bpm 130 43 72RR: bpm 40 20 22BP: mmHg 180/90 120/70 100/60

DIAGNOSTIC AND LABORATORY PROCEDURESSPECIAL HEMATOLOGICAL PROCEDURES

√

BLOOD CHEMISTRY √XRAY √ECG √ABG √CBG √CREATININE √MEDICAL MANAGEMENTPNSS √ √ √

02 THERAPY √ √DRUGSINSULIN HR √DUAVENT √MORPHINE √LANOXIN √ √ √DIAMICRON √ √AVANDIA √ √SUMAPEN √ √WARFARIN √ √BIPRETERAX √ √THEROBLOC √ALDACTONE √FUROSEMIDE √ √ATROPINE SULFATE √DIETNPO √LSLF √ √

VII. DISCHARGE PLANNING

1. General condition of client upon discharge

The patient appeared awake, coherent, and alert upon discharge.

2. METHOD

Medications: Bipreterax 1.25/4 mg 1tab (AM) ½ tab (PM)

Warfarin 2 mg ½ tab (AM)

Lanoxin 0.25 mg ½ tab OD

Diamicron 80 mg 1 tab BID

Avandia 4 mg 1 tab (AM) OD

Sumapen 250 mg 1 tab BID

Exercise:

Encourage brisk walking.

Progressive Activity

Activity progression is based on the metabolic equivalent of the task (MET), the

energy expenditure.

An exercise session is terminated if any one of the following occurs: cyanosis,

cold sweats, faintness, extreme fatigue, BP greater that 160/95 mmHg.

Treatment:

Encourage further laboratory tests like ECG, CXR, Hemodynamic Studies and Blood

Coagulation Tests and encourage patient to continue medication given by the doctor.

Health Teachings:

Encourage eating of fruits, vegetables and food low in fat and sugar. Limit strenuous

activities.. Emphasize to the patient the importance of strict compliance to the

medications given and return to usual home activities, relationships and to work at

earliest opportunity would be beneficial.

Outpatient:

Must see her doctor regularly to ensure health safety.

Diet:

Encourage patient to eat low Sugar, low fat diet, with increased fruits and

vegetables/Diabetic Diet

Sex:

We must health reduce the patient that she must resume sexual activity 4 to 8 weeks after

hosptalization. Encourage to take medicine given by the doctor before sexual intercourse.

Caution patient not to eat or drink alcoholic beverages immediately before intercourse.

The patient must assume less fatiguing position. The partner takes the active role. They

must perform sexual activity in a cool, familiar environment .She must Refrain from

sexual activity during a fatiguing day, after eating a large meal, or after drinking alcohol.

And if dyspnea, chest pain, dizziness or palpitations occur, moderation should be

observed; if symptoms persist, stop sexual activity.

IX. RECOMMENDATION

As a student nurse we must know the different measurements to prevent the occurrence

of having disease. One of our responsibly to impart knowledge on how to prevent this disease

especially people who doesn’t have the enough knowledge in this disease .There are some people

who tend to ignore unusual things that they fell, but we must always remember early prevention

is the best way to prevent this disease. the government must also be aware of this, they must do

some program especially in a urban areas discussing the possible complication, the prevention

and how to manage this disease because this help to minimized the occurrence of this disease.

Further more, to people who diagnosed with mitral stenosis resulting to cardiomegaly,

this following management is very important to remember in order to prevent further

exacerbation of this disease:

Treatments

Treatment of cardiac disease is not simple. A patient's heart and life depend upon its

successful treatment. For some people, careful lifestyle changes and medications can control the

disease. In more serious cases, surgery may be required. In any case, the disease requires lifelong

management.

Take your medications

Medications may be needed to help your heart work more efficiently and receive more

oxygen-rich blood. The medications you are on depend on you and your specific heart problem.

Check It is important to know:

the names of your medications

what they are for

how often and at what times to take your medications

Your doctor or nurse should review your medications with you. Keep a list of your

medications and bring them to each of your doctor visits. If you have questions about your

medications, ask your doctor or pharmacist.

Lower high blood cholesterol

A high-fat diet can contribute to increased fat in your blood. Ask your doctor to have a

measurement of your fasting lipid measurement. Follow a low-fat, low-cholesterol eating plan.

When proper eating does not control your cholesterol levels, your doctor may prescribe

medications.

Control high blood pressure

High blood pressure can damage the lining of your coronary arteries and lead to coronary artery

disease. Check your blood pressure on a regular basis. A healthy diet, exercise, medications and

controlling sodium in your diet can help control high blood pressure.

Achieve and maintain your ideal body weight

Obesity is defined as being very overweight (greater than 25 percent body fat for men or

30 percent body fat for women). When you are very overweight, your heart has to do more work,

and you are at increased risk of high blood pressure, high cholesterol levels and diabetes. Ask

your doctor what your ideal weight should be. A healthy diet and exercise program aimed at

weight loss can help improve your health.

Control Stress and Anger

Uncontrolled stress or anger is linked to increased coronary artery disease risk. You may need to

learn skills such as time management, relaxation, or yoga to help lower your stress levels.

Exercise

In the calories-in to calories-out equation, exercise helps to take off excess body weight.

More importantly, moderate amounts of physical exercise help build a stronger circulatory

system and decrease the risk of death from coronary artery disease. Patients with advanced forms

of the disease may need to limit their exercise, and should check with their doctor for special

advice

X. BIBLIOGRAPHY

Books

Gail W. Stuart & Michele T. Laraia. Principles and Practice of Psychiatric Nursing, 8 th

edition. ELSEVIER (SINGAPORE) PTE LTD. (2005)

Joyce M. Black & Jane Hokanson Hawks. Medical Surgical Nursing, Clinical Management

for Positive Outcomes, vol. 1 & 2, 7 th edition. ELSEVIER (SINGAPORE) PTE LTD. (2005).

Joyce Young Hokanson. Brunner & Suddarth’s Textbook of Medical Surgical Nursing, 10 th

Edition. Lippincott Williams & Wilkins, 2004.

Mosby. Mosby’s Nursing PDQ. ELSEVIER (SINGAPORE) PTE LTD. (2004)

Electronic Media

http://www.wrongdiagnosis.com/a /stats.htm

http://webschoolsolutions.com/patts/systems/heart.htm#intro

http://www.emedicine.com/MED/topic3430.htm

http://www.cayugacc.edu/people/facultypages/greer/biol204/vessels1.html

http://www.wrongdiagnosis.com/a /stats-country.htm

MsDict Viewer. Version 2.00. (2003).