Mitral Stenosis Presentation

8/13/2019 Mitral Stenosis Presentation

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PRESENTED BY:

Mr. STAWAN UTTAM CHOUGULE

C SE PRESENT TION ONMITR L STENOSIS


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DEMOGRAPHIC DATA

Mrs. Devare Madhura Eknath

58 years/female

10

th

Nov 13Hindu

Housewife


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PRESENT COMPLAINTS

Breathlessness

Tachycardia

Fatigue

1 month


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HISTORY OF PRESENT ILLNESS

Breathlessness, Tachycardia, Fatigue

since 1 month.

Dr. Akkalkotkar did angiography.

Patient was operated for MVR on 13th

Oct13.


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PAST HISTORY

No history of any major illness in past.


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MEDICATION HISTORY

No history of any medication.


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SOCIOECONOMIC STATUS

Middle class family

Own flat

Good IPR Participates in all religious or social

activities


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DIETICHISTORY

Patient had mixed diet pattern and

preferred veg. She used to eat more of

green vegetables and cereals.


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ACTIVITY EXPERIENCE:

Patient had normal activity pattern.

She used to do household work.


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SLEEP/REST

She used to sleep 7 hours in night.


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PHYSICAL EXAMINATION

GENERAL APPEARANCE:

conscious & oriented.

Patient was under weight Patient was on ventilator support

artery line inserted on right hand


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Weight: 40kg

Height: 5.3 ft


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VITAL SIGNS

Temperature: 98.6 f

Pulse: 88 beats/ min

Respiration: 22 breaths /min on

pressure SIMV mode

BloodPressure:120/70 mmhg

SPO2: 99 %


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CHEST AND RESPIRATORY

SYSTEM

ADVENTITIOUS SOUNDS: Wheezesound heard


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NERVOUS SYSTEM

MentalStatus: Conscious

MotorCo-Ordination

UpperExtremities :

normal activity

LowerExtremities :

normal activity

InvoluntaryMovements: notPresent


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INVESTIGATION

12 10 14 10 13 15 10 1


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INVESTIGATIONDIAGNOSTIC TEST NORMALVALUES

12.10.

13

14.10.13 15.10.1

3

HAEMATOLOGY

HAEMOGLOBIN12.5 to 17.5

gm/dl

9.4 9.6

RBC

4.5 to 6 x

10^6/ml

3.61 3.58

P.C.V. 35.0 to 50.4 %21.6 21.8

MCV 80.0 to 99.9 fl

83.6 84.5

MCH 27.0 to 31.0 pg29.4 28.6

MCHC 33.0 to 37.0 g/dl

34.6 35.2

9600 9800


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TOTAL WBC/CUMM 9600 9800

POLYMORPHS % 40-65% 71 70

LYMPHOCYTES % 30-50% 22 24

EOSINOPHILS % 2-8% 02 02

MONOCYTES % 2-4% 03 02

BASOPHILS % 0-1% 00 00

PLATELET

COUNT/CUMM1.5-4 lakh

134000 128000

PROTHROMBIN TIME 11-14 sec12/12

INR 0.8-1.2 sec 1.0

PTT 25-35 sec2 min 10

sec

BLEEDING TIME 1 to 5 mins.3 min 20

sec


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UREA 14 to 50 mg / dl 30

CREATININE 0.6 to 1.4 mg / dl 0.8

CPK-MB Up to 25 IU/L 62

TROP-T POSITIVE


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ECG


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MITR L STENOSISDEFINITION

Mitral stenosis is a narrowing of the mitral

valve in the heart. This restricts the flow ofblood through the valve.


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HEART


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Mitral Valve


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LYMPHATIC SYSTEM IN HEART

All of the lymphatic drainage of the

thorax is directed toward the

bronchomediastinal trunks, thoracic

duct, and descending intercostallymphatic trunks.


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NERVE SUPPLY OF THE HEART

Both the parasympathetic and sympathetic nerves

form the superficial and deep cardiac plexuses

The superficial cardiac plexus is situated below the

arch of aorta in front of the right pulmonary artery,

it is formed by

The superior cervical cardiac branch of the left

sympathetic chain

The inferior cervical cardiac branch of left vagus


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RISK FACTORS


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Rheumatic fever

Recurrent strep infection

Radiation treatment involving the chest

Medications, such as ergot preparations

used for migraines.


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CAUSES


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BOOK PICTURE PATIENT PICTURE

Rheumatic fever. PRESENT

Congenital heart defect PRESENT


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PATHOPHYSIOLOGY

CLINICAL MANIFESTATION


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Shortness of breath or dyspnea PRESENT

Fatigue or weakness PRESENT

Palpitations PRESENT

Hemoptysis ABSENT


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PATHOPHYSIOLOGY


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DIAGNOSTIC

TEST



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Chest x-ray Mild to moderate cardiomegaly with

left atrial enlargement suggesting of

Valvular heart disease.Coronary angiography Normal epicardial arteryEchocardiogram 1. Rheumatic heart disease

2. Severe mitral stenosis

3. Mild aortic regurgitation

4. Moderate pulmonary

hypertension

5. LVEF=60%

6. Atrial fibrillation

Electrocardiogram DoneRadionuclide studies Not doneChest x-ray Mild to moderate cardiomegaly with

left atrial enlargement suggesting of

Valvular heart disease.


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S.

N

DRUG DOSE ACTION INDICATION CONTRAIN-

DICATIONS

SIDE-EEFECT NURSES

RESPONSIBILITY


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N DICATIONS RESPONSIBILITY

1 Tb.Ditide

(triamteren

e)

Therapeutic

class-

Potassium-

sparing

Diuretics

50mg

bd

Triamterene

inhibits the

epithelial

sodium

channels on

principal

cells in the

late distalconvoluted

tubule and

collecting

tubule,

which are

responsiblefor 1-2% of

total

sodium

reabsorptio

n. As

sodium

For the

treatment

of edema

associated

with

congestive

heart

failure,cirrhosis of

the liver,

and the

nephrotic

syndrome;

also insteroid-

induced

edema,

idiopathic

edema, and

edema due

Patient with

hypersensiti

ve to its

components

and dose

with

pathologic

bleeding

CNS-

Agitation,confusion,c

onvulsions

CVS-

Hypotension,

GI-

abdominal pain,

constipation,MUSCULO SKELETAL-

Arthralgia, myalgia.

HEMATOLOGIC-

purpura

1.consider

alternative

treatment for

patients identified

as metabolizes.

2.Monitor blood

pressure.

S.

N

DRUG DOSE ACTION INDICATION CONTRAINDI-

CATIONS

SIDE-EEFECT NURSES

RESPONSIBILITY


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N CATIONS RESPONSIBILITY

2. SUPRACEF

Cefuroxime

sodium

THERA-

PEUTIC

Antibiotic

PHARMA-COLOGIC

class-

second

generation

cephalospori

n

1.5gm

injectio

n IV

Inhibits

cell-wall

synthesis

promoting

osmotic

instability

usually

bactericida

l

-

Pharyngitis/To

nsillitis Acute

Bacterial

Otitis

MediaAcute

Bacterial

Maxillary

Sinusitis AcuteBacterial

Exacerbations

of Chronic

Bronchitis and

Secondary

BacterialInfections of

Acute

BronchitisUnc

omplicated

Skin and Skin-

Structure

Patient

hypersensitive

to drugs or

other

cephalosporin

's.

CVS-

Phlebitis,

thrombocytopeni

a

GI-

Diarrhea, nausea,

vomiting,

anorexia.

HEMATOLOGIC-Hemolytic

anemia,

thrombocytopeni

a

SKIN-

Maculopapularand erythmatus

rashes.

OTHER-

anaphylaxis

1. monitor patient

for signs and

symptoms of

super infection.

2. advise patient

receiving drug to

report discomfort

at IV injection

site.3. assess for

hypersensitivity of

the patient.

S.

N

DRUG DOSE ACTION INDICATION CONTRAINDI-

CATIONS

SIDE-EEFECT NURSES

RESPONSIBILITY


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N CATIONS RESPONSIBILITY

3. TRAMADOL

(Tramadol

hydrochloride)

Therapeutic

class-

Analgesic

Pharmacologic

-syntheticactive

analgesic.

50 mg

injectio

n IV

Unknown

thought to

bind to

receptor

and inhibit

reuptake

of

noradrenal

ine &serotonine

.

manageme

nt of

moderate

to

moderately

severe pain

in adults.

1. patients

hypersensitive

to drug

2. breast feeding

women

3. acute

intoxication

from alcohol,

hypnotics, etc.

CNS-

Dizziness,

headache,

seizure, anxiety,

CV-

Vasodilation.

ENT-

Visual

disturbances.GI-

Constipation,

nausea,

vomiting.

GU-

Menopausalsymptoms

RESPIRATORY-

Respiratory

depression.

1. Re-assess

patient level of

pain at least 30

min after drug

administration.

2. Monitor CV &

respiratory

status.

3. Monitor forrisk of seizures.

4. For better

onset, give drug

before onset of

intense pain.

S.N DRUG DOSE ACTION INDICATION CONTRAINDI-CATIONS SIDE-EEFECT NURSES RESPONSIBILITY


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4. Tab

Lanoxin

BRAND

NAME:

Lanoxin

GENERIC

NAME:

digoxin

Classificati

on:

Cardiac

glycoside

0.0625-0.25

mg/day

Or

10-15 mcg/kg

Digoxin binds

to a site on the

extracellular

aspect of the

-subunit of

the Na+/K+

ATPase pump

in the

membranes of

heart cells

(myocytes) and

decreases its

function. This

causes anincrease in the

level of sodium

ions in the

myocytes,

which leads to

a rise in the

level of

intracellularcalcium ions.

Coronary

artery disease

Atrial

Fibrillation

1.Ventricular fibrillation

2.Known hypersensitivity

reaction to digitalis

(reactions seen include

unexplained rash,

swelling of the mouth,lips or throat or a

difficulty in breathing)

Ventricular tachycardia

Presence of digoxin

toxicity

Beriberi heart disease

Hypersensitive carotid

sinus syndrome

Cardiac

arrhythmias

Digoxin

Toxicity

Assess cardiac function

Measure liquids precisely

Assess for signs of toxicity, especially in children and

the elderly

Give IV slowly over 5 minutes

Note possible drug interactions

Assess for hyperthyroidism or hypothyroidism

Obtain ECG

Monitor CBC, serum electrolytes, calcium, MG, renal

and liver function tests

Obtain written heart rate parameters for drug

administration as drug may cause extreme

bradycardia

Do not administer if HR is


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MANAGEMENT



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Drug therapy- Diuretics, Nitrates, beta-

blockers, calcium channel blockers, ACEinhibitors, angiotensin receptor blockers

(ARBs), or digoxin.

Inj. Lanoxin 0.125mg TID

Anticoagulants /Antiplatelet Tab ecosprin 150 mg

Antibiotic therapy-People who have had

rheumatic fever need long-term preventive

treatment with penicillin.

Inj.Magnex forte 1.5 g BD

Inj.amikacin 500mg BD

Nebulisation Duolin + budecort

Spirometry 3 times/ day

Chest physiotherapy frequently

SURGICAL MANAGEMENT


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SURGICAL MANAGEMENT



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Mitral valvuloplasty NOT DONE

Mitral valve

replacement

DONE


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Administer oxygen by face mask or artificial airway

to ensure adequate oxygenation of tissues.

Adjust the oxygen flow rate to higher or lower level,

as blood gas measurements indicate. Administer an osmotic diuretic, such as mannitol,

if ordered to increase renal blood flow and urine

output.

To ease emotional stress, allow frequent restperiods as possible.


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Allow family members to visit and comfort the

patient as much as possible. Monitor and record blood pressure, pulse,

respiratory rate, and peripheral pulse every 1 to 5

minutes until the patient stabilizes.

Record hemodynamic pressure readings every 15minutes.

Monitor ABG values, complete blood count, and

electrolyte levels.

NURSING DIAGNOSIS


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NURSING DIAGNOSIS

Decreased cardiac output R/T mechanical

factor (preload, afterload) secondary to Valvular

dysfunction.

High risk for infection related to operation. Self-care deficit related to operation.

Activity intolerance R/T diminished cardiac

reserve.

Anxiety R/T altered heart action. Knowledge deficit R/T disease condition,

treatment & prognosis.


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NURSING THEORYOREMS THEORY Orem describes Six universal self care

requisites common to men, women andchildren.

The maintenance of sufficient intake of air,water and food.

The provision of care associated withelimination process with excrement.

The maintenance of a balance betweenactivity and rest.


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The maintenance of balance between

solitude and social interaction. Prevention of hazards to human life

functioning and human well-being.

The promotion of human functioning anddevelopment within social group in

accordance with human potentials, known

human limitations and the human desire to

be normal. Application of Orems self care nursing

model.

NURSING

ASSESS-

PROBLEM NURSING

SYSTEM

GOAL SELFCARE

REQUISITE

NURSING ACTION REWIEW


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MENT

Q

HR-sinus

rhythm

BP

130/78

mmhg

CVP -10 to

12 mmhg

Urine

output(24hrs)-

900ml

Decreased

cardiac

output R/T

mechanical

factor

(preload,

afterload)

secondary to

Valvulardysfunction.

Wholly

compensat

ory

Patient has

adequate

output as

evidenced by

Normal SR,

HR-60-100

beats/ min

BP

120/80mmhgUrine

1ml/kg/hr.

CVP-2-8 mmhg

Warm

periphery

Prevention of

hazards to

human life,

functioning

and human

wellbeing.

-Monitor ECG for

arrhythmias

-Continuous

hemodynamic

monitoring.

-Assess hourly intake

& output.

-Give packed cell

2000 ml-Start injection

dopamine 4mg/hr.

-Adjust NTG

according to BP.

-Check electrolyte &

collect according toit.

-Check peripheral

temperature.

-Exclude tamponade

Cardiac

output is

maintained

as evidenced

by normal

BP, Pulse,

and warm

periphery.

NURSING

ASSESS-

PROBLEM NURSING

SYSTEM

GOAL SELFCARE

REQUISITE



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MENT

Q

TLC-11,300

Temp-98.6f

High risk for

infection

related to

operation.

Wholly

compensat

ory

Patient will

not get

infection from

hospital

environment

Prevention

of hazards to

human life.

-Assess for sign of

infection.

-Change the dressing

regularly.

-To give catheter care

regularly.

-Check hemodynamic

parameters.

-Remove all the invasivelines as early as

possible.

Risk of

infection

prevented

evidenced

by WBC

count

within

normal and

no signs ofinfections.

NURSING

ASSESS-

PROBLEM NURSING

SYSTEM

GOAL SELFCARE

REQUISITE



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MENT

Patient is

semi-

conscious.

Self-care deficit

related to

operation.

Wholly

compensat

ory

All the

routine

activities of

the patient

will be done

by the

nurses and

the family

members.

Promotion of

human

functioning &

development

with in social

group.

To check whether all

the iv lines are in

place.

Cardiac monitoring

to be done properly.

Give psychological

support and Educate

the relatives about

the care of the

patient.

Give every 2 hourly

position to the

patient.

Maintain the

hygiene of thepatient.

Care provide

adequately by

the nurses

and the family

members .


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Teach the patient about disease including etiology

possible complications and associated symptoms toreport to physician.

Assist patient during diagnostic workup and assist

with decision for medical or surgical treatment.

Include patients family in teaching and decision

making process.

Instruct the patient in the name, dose, and purpose

of medications. Explain activity allowances and limitations.


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Explain diet and fluid restriction.

Instruct the patient about antibioticprophylaxis to prevent infective endocarditis.

Provide instruction to women regarding

appropriate choice of contraception and riskassociated with pregnancy.

Instruct the patient about maintaining good

oral hygiene, daily care, and regular visits todentist.


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DAY 1 Patients was conscious.

Patient had Breathlessness , Tachycardia,

Fatigue. Angiography was done and was advised

for MVR.

DAY 2


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DAY 2

Patient was stable.

Patient was seen by Dr. Thakur and

was planned for MVR.

DAY 3


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DAY 3

Patient was stable.

Pre-op medications were given and

patient was posted for MVR.

Post-op patient was on ventilator and

inotropic support.

Patient was hemodynamically stable.

DAY 4


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Patient was conscious and Extubated.

Oxygen administration was given at the rate of

6 l/min by mask.

Vital parameters were normal.

Patient was on inotropic support.

DAY 5


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Patient was conscious and well-oriented.

Drains were removed.

Inotropic support was lowered.

Patient was planned to be shifted to

ward next day.

DAY 6


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Inotropic support was stopped.

Patient was shifted to ward.

DAY 7


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DAY 8


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DAY 9


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Patient was planned for discharge.

Patient got discharge in evening.


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PATIENTS EVALUATION:-

Patient had good prognosis as compared

to the admission. Patient was able to maintain

hemodynamic parameters without inotropicsupport. Patient was stable and was satisfied

by the care provided.

TRENDS: 1. MVR


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2. ROBOTIC MVR

3.ENDOSCOPIC


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4. HEART VALVE REPAIR THROUGH CATHETER


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BIBLIOGRAPHY


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Ross and Wilson,text book of anatomyand physiology.

Luckmann joan, Saunders, Manual ofNursing Care 1stedition, W.B. Saunders

publication, copyright, page-727-729. Joyce M.Black and Esther Matassarian-

Jacobs, Medical Surgical Nursing-psycho physiologic approach, 4th edition,

copyright 1999, W.B. Saunders, page2122-2124.


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Mitral Stenosis Presentation

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