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Transcript of cardiomyopathy
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).