HOLY ANGEL UNIVERSITY COLLEGE OF NURSING Angeles City

A Case Study About

MITRAL STENOSIS WITH ASSOCIATED CARDIOMEGALY

In Partial Fulfillment of the Requirement in Related 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 Castro Cristina Marie Decembrano Aimee Pangilinan Andren Pineda Czarinna Rabino Catherine 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 patients 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 hograising 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 familys 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.

Grandfather (Deceased) (CAD)

Grandmothe r (DM)

Grandfather (HPN)

Grandmothe r (none)

Father (HPN) (died of

Mother

Eldest Sister (HPN)

2nd sister (none)

Mrs. Mapusu (HPN & Mitral Stenosis)

4th child (son) (HPN)

Youngest son

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.

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: Skin: Fair complexion (+) dry skin Cold to touch (-) ecchymosis (-) jaundice (-) cyanosis (-) sore / wound Temp 36.5OC Pulse Rate 112bpm Respiratory Rate 39bpm Blood Pressure 170/120 mmHg

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 Platelets, cell fragments Lymphocytes (leukocytes)

Source
Bone marrow life-span: 10 days

Function
Blood clotting

Bone marrow, Immunity spleen, lymph T-cells attack cells containing nodes viruses. B-cells produce antibodies. Bone marrow life-span: 120 days Bone marrow Oxygen transport

Red blood cells (erythrocytes), Filled with

hemoglobin, a compound of iron and protein

Neutrophil (leukocyte) Plasma, consisting of 90% water and 10%

dissolved materials -- nutrients (proteins, salts, glucose), wastes (urea, creatinine), hormones, enzymes

Phagocytosis

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 Head Abdomen

Carotid Mesenteric Celiac (Abdominal) Renal Iliac Brachial (axillary) Radial & Ulnar Dorsal Carpal

Serves
Brain & skull Intestines Stomach, liver, spleen Kidney Pelvis Upper arm Forearm & hand Fingers

Upper Extremity

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 Blood vessel anatomy 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. 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.

Interior View

Posterior View

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.

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 o

Composed of simple, squamous epithelium called endothelium. Rests on a connective tissue membrane that is rich in elastic and collagenous fibers.

Tunica media
o o

Makes up the bulk of the arterial wall. Includes smooth muscle fibers, which encircle the tube, and a thick layer of elastic connective tissue.

Tunica adventitia
o o

Is relatively thin. Consists chiefly of connective tissue with irregularly arranged elastic and collagenous fibers.

o o

This layer attaches the artery to the surrounding tissues. 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.

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.

In the liver, sinusoids contain phagocytic cells called stellate reticuloendothelial (Kupffer) cells.

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 o

Middle layer is poorly developed. 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 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:

Dyspnea

Valve Replacement/PMBV

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

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) 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.

Electrocardiogram (EkG):

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 Trauma/ Injury to arterial wall (endothelial lining) - Rheumatic Fever 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 Hemoptysis Pulmonary hypertension Right-sided Heart failure Decrease blood flow and oxygen (O2) supply Burst in veins/ capillaries

 O2 supply to the muscle cells

Cerebral Perfusion Syncope and Dizziness

Heart pumps harder than normal Increase Cardiac Output

Heart rate (Tachycardia )

Body compensate s Anaerobic metabolism

Body compensate s by prioritizing perfusion of vital organs blood flow to the extremities Pallor and Cyanosis

Tissue Perfusion Body will compensate Ventilation to oxygen concentratio n Respiratory rate (Tachypne Use accessory a) muscles Due to O2 supply, body compensate s Anaerobic metabolism

Renal Tissue Perfusio n

Reductio n of glomerul ar filtration rate

Lactic acid accumulatio n Irritates nerve endings Chest Pain and fatigue

Increase blood pressure

Stroke volume Palpitations Hydrostatic Pressure

Elevat ed BUN level

Fluid shift from intravascular to interstitial space

Fluid accumulation in the interstitial space

Lactic acid accumulation

(Third Spacing)

Edema

Difficulty of Breathing

Orthopne a Paroxysmal nocturnal dyspnea

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 > Chest pain Rationale > 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. > fatigue > This may be a consequence of inadequate cardiac output > Syncope and Dizziness >This is due to decreased cerebral tissue perfusion. > Palpitations > 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. > Tachycardia > The heart pumps faster to compensate for the decrease blood flow to the body. > Tachypnea > Increase respiratory rate is experienced by the patient as bodys compensation of decrease tissue perfusion to increase the oxygen concentration of the blood. > Difficulty of Breathing > Due to use of accessory muscles and

decrease O2 supply, the body compensates and anaerobic metabolism occur. Lactic acid accumulates resulting to dyspnea. > Edema > Shifting of fluid into the interstitial space due to increase in the vascular area (hydrostatic) pressure. > Pallor & Cyanosis > Due to decrease tissue perfusion the patient turn dull and pale. >Orthopnea > Due to use of accessory muscles and decrease O2 supply, the body compensates and is usually a symptom of more advanced heart failure > Paroxysmal nocturnal dyspnea > 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 > Hemoptysis > Due to increase venous and capillary pressure as well as resistance leads to burst of veins and capillaries > Elevated BUN level > Due to decrease renal tissue perfusion which elevated. results to reduce glomerular filtration rate thus, the BUN level becomes

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) Pulmonary hypertension Right-sided Heart failure Decrease blood flow and oxygen (O2) supply

 O2 supply to the muscle cells

Cerebral Perfusion Syncope and Dizziness

Heart pumps harder than normal Increase Cardiac Output

Heart rate

Body compensate s Anaerobic metabolism

Body compensate s by prioritizing perfusion of vital organs blood flow to the extremities Pallor and Cyanosis June 24, 2010

Tissue Perfusion Body will compensate Ventilation to oxygen concentratio n Respiratory rate (Tachypne Use accessory a) muscles Due to O2 supply, body compensate s Anaerobic metabolism

Renal Tissue Perfusio n

Reductio n of glomerul ar filtration rate

Date??

(Tachycardia) -June Lactic acid accumulatio n Irritates nerve endings Chest Pain and fatigue
(june 25, 2010)

24,2010
Increase blood pressure
Stroke volume Palpitations (June 24, 2010)

Elevat ed BUN level

June 24, 2010

Hydrostatic Pressure Fluid shift from intravascular to interstitial space

Fluid accumulation in the interstitial space

Lactic acid accumulation

(Third Spacing)

Edema (June 25, 2010)

Difficulty of Breathing (June 24, 2010)

Orthopne a
(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. damage, Increase increase systemic platelet vascular adherence, resistance, increase endothelial 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

permeability of endothelial lining, results from increase blood

(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 > Chest pain Rationale > 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. > Fatigue > This may be a consequence of inadequate cardiac output > Syncope and Dizziness >This is due to decreased cerebral tissue perfusion. > Palpitations > 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. > Tachycardia > The heart pumps faster to compensate for the decrease blood flow to the body. June 24, 2010 June 24, 2010 June 25, 2010 June 25, 2010 Date of Occurrence June 24, 2010

> Increase respiratory rate is > Tachypnea experienced by the patient as bodys compensation of decrease tissue perfusion to increase the oxygen concentration of the blood. June 24, 2010

> Difficulty of Breathing

> Due to use of accessory muscles and decrease O2 supply, the body compensates and anaerobic metabolism occur. Lactic acid accumulates resulting to dyspnea.

June 24, 2010

> Edema

> Shifting of fluid into the interstitial space due to increase in the vascular area (hydrostatic) pressure.

June 25, 2010

> Pallor & Cyanosis

> Due to decrease tissue perfusion the patient turn dull and pale.

June 25, 2010

>Orthopnea

> Due to use of accessory muscles and decrease O2 supply, the body compensates and is usually a symptom of more advanced heart failure

June 25, 2010

V. THE PATIENT AND HIS CARE a. Medical Management A. IVF

Medical Management

General Description

Indication(s) or Purpose(s) Hypovolemia Dehydration Facilitation of drug administration

Date Ordered, Date Performed, Date Changed or D/C Date Ordered: June 24, 2010 Date Performed: June 24, 2010

Client Response to Treatment The patient didnt develop any undesirable response such as redness, swelling or pain.

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.

Nursing Responsibilities Before: Check the patients name and doctors 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) To increase the oxygen saturation of the body during dyspnea

Date Ordered, Date Performed, Date Changed or D/C Date Ordered: June 24, 2010 Date Performed: June 24, 2010

Client Response to Treatment The patient verbalized feeling of comfort while in oxygen therapy and exhibit improvement on her breathing

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

Nursing Responsibilities Before: Check the patients name and doctors 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.

Generic name and Brand name

General Classification and mechanism of action ACE Inhibitors Diuretic Angiotensin-converting enzyme inhibitor and diuretic acting on cortical dilution segment in fixed combination.

GN: Indapamide BN: Bi-Preterax

Indication or Purpose why medication is given for the particular disease condition Treatment for Hypertension

Date Ordered, Date Started, Date Changed or D/C Date Ordered: June 24, 2010 Date Started: June 24, 2010

Client Response to Medication with actual side effects Patients BP decreased from 180/90 mmHg to 130/70 mmHg. Increased urine output

B. DRUG

Nursing Responsibilities: Before: Check the doctors 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 Classification and mechanism of action 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.

GN: Digoxin BN: Lanoxin

Indication or Purpose why medication is given for the particular disease condition Treatment for heart failure, and arrhythmia

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

Client Response to Medication with actual side effects

Date Ordered: June 24, 2010 Date Started: June 24, 2010

Heart rate decreased to 65 bpm from 130 bpm

Nursing Responsibilities: Before: Check the doctors 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 Classification and mechanism of action Antidiabetic Increases tissue sensitivity to insulin. This peroxisome proliferatoractivated 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

GN: Rosiglitazone maleate BN: Avandia

Indication or Purpose why medication is given for the particular disease condition To achieve glucose control in type 2 diabetes mellitus

Date Ordered, Date Started, Date Changed or D/C Date Ordered: June 24, 2010 Date Started: June 24, 2010

Client Response to Medication with actual side effects Pts blood glucose turned normal.

Nursing Responsibilities: Before: Check the doctors 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 Classification and mechanism of action Penicillin Phenoxymethylpenicillin inhibits the final crosslinking 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.

GN: Phenoxymethylpenicillin K BN: Sumapen

Indication or Purpose why medication is given for the particular disease condition Treatment for respiratory tract infection, viral infections

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

Client Response to Medication with actual side effects

Date Ordered: June 24, 2010 Date Started: June 24, 2010

Pt didnt manifest signs of infection

Nursing Responsibilities:

Before: Check the doctors 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 Classification and mechanism of action Anticoagulants, Antiplatelets & Fibrinolytics (Thrombolytics) Warfarin inhibits synthesis of vit Kdependent 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.

GN: Warfarin BN: Warfarin

Indication or Purpose why medication is given for the particular disease condition Treatment and prevention of venous thrombosis

Date Ordered, Date Started, Date Changed or D/C Date Ordered: June 24, 2010 Date Started: June 24, 2010

Client Response to Medication with actual side effects Pt did not experience bleeding.

Nursing Responsibilities: Before: Check the doctors 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 Classification and mechanism of action Beta blockers Atenolol is a 1-selective adrenergic-blocking agent. It competitively blocks adrenergic stimulation of 1adrenergic receptors within the myocardium and vascular smooth muscle. Low doses of atenolol selectively inhibit cardiac and lipolytic 1-receptors but with little effect on the 2-adrenergic receptors of bronchial and vascular smooth muscle. At high doses (ie, >100 mg daily), this selectivity of atenolol for 1-adrenergic receptors may diminish and the drug may competitively block 1and 2-adrenergic receptors. Atenolol does not exhibit any intrinsic sympathomimetic activity nor any membrane-stabilizing activity.

GN: Atenolol BN: Therabloc

Indication or Purpose why medication is given for the particular disease condition Management for angina pectoris and hypertension

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

Client Response to Medication with actual side effects

Date Ordered: June 24, 2010 Date Started: June 24, 2010

Pts BP decreased from 180/90 mmHg to 130/70 mmHg. Pts heart rate decreased from 130 bpm to 65 bpm.

Nursing Responsibilities: Before: Check the doctors 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 Classification and mechanism of action Antidotes, Detoxifying Agents & Drugs Used in Substance Dependence, Antispasmodics Atropine is an 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.

GN: Atropine sulfate BN: Anespin

Indication or Purpose why medication is given for the particular disease condition Bradycardia

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

Client Response to Medication with actual side effects

Date Ordered: June 24, 2010 Date Started: June 24, 2010

Pts heart rate increased from 43 bpm to 72 bpm.

Nursing Responsibilities: Before: Check the doctors 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 Classification and mechanism of action Diuretics Antihypertensive Normally, aldosterone attaches to receptors on the walls of distal convoluted tubule cells, causing sodium and water reabsorption in the blood.

GN: Spironolactone BN: Aldactone

Indication or Purpose why medication is given for the particular disease condition To treat edema due to heart failure

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

Client Response to Medication with actual side effects

Date Ordered: June 24, 2010 Date Started: June 24, 2010

Pts BP decreased from 180/90 mmHg to 130/70 mmHg. Increased urinary output

Nursing Responsibilities: Before: Check the doctors 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 Classification and mechanism of action Antidiabetic Gliclazide is a sulfonylurea which stimulates insulin secretion by the pancreas. Its action on insulin 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.

GN: Gliclazide BN: Diamicron

Indication or Purpose why medication is given for the particular disease condition For Type 2 diabetes mellitus

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

Client Response to Medication with actual side effects

Date Ordered: June 24, 2010 Date Started: June 24, 2010

The pts glucose level turned to normal and did not show any manifestation of increased glucose level.

Nursing Responsibilities: Before: Check the doctors 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 Classification and mechanism of action

Indication or Purpose why medication is given for the particular disease condition Pain Acute pulmonary edema

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

Client Response to Medication with actual side effects

GN: Morphine Sulfate BN: Morphine

Analgesic Morphine is a phenanthrene derivative 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.

Date Ordered: June 24, 2010 Date Started: June 24, 2010

Pt relieved from pain

Nursing Responsibilities: Before: Check the doctors 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 Classification and mechanism of action Antihypertensive Diuretic Inhibits sodium and water reabsorption in the loop of henle and increases urine formation.

GN: Furosemide BN: Lasix

Indication or Purpose why medication is given for the particular disease condition To reduce edema caused by heart failure To manage mild to moderate hypertension

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

Client Response to Medication with actual side effects

Date Ordered: June 24, 2010 Date Started: June 24, 2010

Patients BP decreased from 180/90 mmHg to 130/70 mmHg. Increased urine output

Nursing Responsibilities: Before: Check the doctors 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

Generic name and Brand name

General Classification and mechanism of action 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.

Indication or Purpose why medication is given for the particular disease condition Treatment of patients with diabetes mellitus, for the control of hyperglycemia.

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

Client Response to Medication with actual side effects

GN: BN: Humulin R

Date Ordered: June 24, 2010 Date Started: June 24, 2010

DM is being controlled by the medications

Nursing Responsibilities: Before: Check the doctors 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 Date Ordered, Date Date Started, Date Changed or D/C Clients Response and/or Reaction to the Diet

Type of Diet

General Description

Indication/Purpose

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. 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) Is indicated when edema is present, in hypertension, and

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

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

Date Ordered: June 24, 2010

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

certain cardiac conditions, (CAD), to reduce fluid retention

Date Started: June 24, 2010

his sodium intake.

Nursing Responsibilities on NPO Before: Check the doctors 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 doctors 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/Exercise There was no exercise being ordered by the physician, as seen in the doctors order.

2. NURSING MANAGEMENT

ASSESSMENT

NURSING DIAGNOSIS Decreased cardiac output related to valvular disease 2 mitral stenosis

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

PLANNING

NURSING INTERVENTION establish rapport

RATIONALE

EXPECTED OUTCOME Short-term:

S>

Short-term:

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

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

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

monitor and record vital signs assess patients 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 slowly, dangling legs before standing discuss to the patient the disease process and

Patient shall 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

Long-term:

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

to promote understanding and provide

CUES S> masakit ku buntuk pag migigising ku, medyo magkasakit mangisnawa O> lethargy > slight confusion > general weakness >pallor > edema in both hands

NURSING DIAGNOSIS Impaired Gas Exchange related to altered blood flow 2 mitral stenosis

SCIENTIFIC EXPLANTION Due to mitral valve stenosis, blood flow decreases thus oxygenated blood is not sufficiently distributed to different parts of the body.

OBJECTIVE After 2 hours of Nursing Intervention the patient will demonstrate improve ventilation absence of distress.

NURSING INTERVENTIONS >Establish rapport

RATIONALE >To gain patient trust and cooperation >For base line data >To maintain airway

EXPECTED OUTCOME After 1 -2 hours of nursing interventions patient will demonstrate relieved and maintain adequate oxygen

>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

>For mobilization of secretions

>Helps limits oxygen needs or consumption >To promote comfort

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

>To decrease dyspnea and 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- 36.1C, PR- 86 bpm, RR30 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 NURSING PROBLEMS 1. Ineffective Breathing pattern r/t chest pain 2 mitral stenosis 2.Activity Intolerance r/t generalized weakness 2 mitral stenosis 3. Decreased Cardiac output r/t valvular disease 4. Impaired Gas exchange r/t altered blod flow VITAL SIGNS Temp: C PR: bpm RR: bpm BP: mmHg DIAGNOSTIC AND LABORATORY PROCEDURES SPECIAL HEMATOLOGICAL PROCEDURES BLOOD CHEMISTRY XRAY ECG ABG CBG CREATININE MEDICAL MANAGEMENT PNSS 02 THERAPY DRUGS INSULIN HR ADMISSION June 24, 2010 DISCHARGE June 28, 2010

June 25, 2010

37 130 40 180/90

36.5 43 20 120/70

36.4 72 22 100/60

DUAVENT MORPHINE LANOXIN DIAMICRON AVANDIA SUMAPEN WARFARIN BIPRETERAX THEROBLOC ALDACTONE FUROSEMIDE ATROPINE SULFATE DIET NPO 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) tab (PM) Warfarin 2 mg tab (AM) Lanoxin 0.25 mg 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 doesnt 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. Books

BIBLIOGRAPHY

Gail W. Stuart & Michele T. Laraia. Principles and Practice of Psychiatric Nursing, 8th edition. ELSEVIER (SINGAPORE) PTE LTD. (2005) Joyce M. Black & Jane Hokanson Hawks. Medical Surgical Nursing, Clinical Management

for Positive Outcomes, vol. 1 & 2, 7th edition. ELSEVIER (SINGAPORE) PTE LTD. (2005). Joyce Young Hokanson. Brunner & Suddarths Textbook of Medical Surgical Nursing, Edition. Lippincott Williams & Wilkins, 2004. Mosby. Mosbys Nursing PDQ. ELSEVIER (SINGAPORE) PTE LTD. (2004) 10th

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).