CASE PRESENTATION ON MITRAL STENOSIS

PRESENTED BY: Mr. STAWAN UTTAM CHOUGULE

DEMOGRAPHIC DATA
Mrs. Devare Madhura Eknath 58 years/female 10th Nov 13 Hindu Housewife

PRESENT COMPLAINTS

Breathlessness Tachycardia Fatigue

1 month

HISTORY OF PRESENT ILLNESS

Breathlessness, Tachycardia, Fatigue since 1 month. Dr. Akkalkotkar did angiography. Patient was operated for MVR on 13th Oct13.

PAST HISTORY
No history of any major illness in past.

MEDICATION HISTORY

No history of any medication.

SOCIOECONOMIC STATUS
Middle class family Own flat Good IPR Participates in all religious or social activities

DIETIC HISTORY
Patient had mixed diet pattern and preferred veg. She used to eat more of green vegetables and cereals.

ACTIVITY EXPERIENCE:
Patient had normal activity pattern. She used to do household work.

SLEEP/REST
She used to sleep 7 hours in night.

PHYSICAL EXAMINATION GENERAL APPEARANCE:

conscious & oriented. Patient was under weight Patient was on ventilator support artery line inserted on right hand

 Weight: 40kg Height: 5.3 ft

VITAL SIGNS
Temperature: 98.6 f Pulse: 88 beats/ min Respiration: 22 breaths /min on pressure SIMV mode Blood Pressure:120/70 mmhg SPO2 : 99 %

CHEST AND RESPIRATORY SYSTEM

ADVENTITIOUS SOUNDS: Wheeze sound heard

NERVOUS SYSTEM
Mental Status: Conscious Motor Co-Ordination Upper Extremities : normal activity Lower Extremities : normal activity Involuntary Movements: not Present

INVESTIGATION

NORMAL INVESTIGATION DIAGNOSTIC TEST VALUES HAEMATOLOGY

12.10. 13

14.10.13 15.10.1 3

HAEMOGLOBIN

12.5 to 17.5 gm/dl 4.5 to 6 x 10^6/ml 35.0 to 50.4 % 80.0 to 99.9 fl

9.4

9.6

3.61

3.58

RBC P.C.V. MCV MCH

21.6 83.6 29.4

21.8 84.5 28.6

27.0 to 31.0 pg
33.0 to 37.0 g/dl

MCHC

34.6

35.2

TOTAL WBC/CUMM POLYMORPHS % LYMPHOCYTES % EOSINOPHILS MONOCYTES BASOPHILS PLATELET COUNT/CUMM % % % 40-65% 30-50% 2-8% 2-4% 0-1% 1.5-4 lakh

9600 71 22

9800 70 24

02
03 00 134000 12/12 1.0 2 min 10 sec 3 min 20 sec

02
02 00 128000

PROTHROMBIN TIME
INR PTT BLEEDING TIME

11-14 sec
0.8-1.2 sec 25-35 sec 1 to 5 mins.

UREA CREATININE CPK-MB TROP-T

14 to 50 mg / dl 0.6 to 1.4 mg / dl Up to 25 IU/L

30 0.8 62 POSITIVE

ECG

MITRAL STENOSIS
DEFINITION
Mitral stenosis is a narrowing of the mitral valve in the heart. This restricts the flow of blood through the valve.

HEART

Mitral Valve

LAYERS

LYMPHATIC SYSTEM IN HEART

All of the lymphatic drainage of the thorax is directed toward the bronchomediastinal trunks, thoracic duct, and descending intercostal lymphatic trunks.

 NERVE SUPPLY OF THE HEART

Both the parasympathetic and sympathetic nerves form the superficial and deep cardiac plexuses The superficial cardiac plexus is situated below the arch of aorta in front of the right pulmonary artery, it is formed by
The superior cervical cardiac branch of the left sympathetic chain The inferior cervical cardiac branch of left vagus

RISK FACTORS

Rheumatic fever Recurrent strep infection Radiation treatment involving the chest Medications, such as ergot preparations used for migraines.

CAUSES

BOOK PICTURE Rheumatic fever. Congenital heart defect

PATIENT PICTURE PRESENT PRESENT

PATHOPHYSIOLOGY

CLINICAL MANIFESTATION

BOOK PICTURE

PATIENT PICTURE

Shortness of breath or dyspnea

PRESENT

Fatigue or weakness

PRESENT

Palpitations

PRESENT

Hemoptysis

ABSENT

PATHOPHYSIOLOGY

DIAGNOSTIC TEST

BOOK PICTURE Chest x-ray

PATIENT PICTURE Mild to moderate cardiomegaly with left atrial enlargement suggesting of Valvular heart disease. Normal epicardial artery 1. Rheumatic heart disease 2. Severe mitral stenosis

Coronary angiography Echocardiogram

3. Mild aortic regurgitation

4. Moderate pulmonary hypertension 5. LVEF=60% 6. Atrial fibrillation Electrocardiogram Radionuclide studies Chest x-ray Done Not done Mild to moderate cardiomegaly with left atrial enlargement suggesting of Valvular heart disease.

S. DRUG N

DOSE

ACTION

INDICATION CONTRAIN- SIDE-EEFECT DICATIONS

NURSES RESPONSIBILITY

1 Tb.Ditide 50mg (triamteren bd e) Therapeutic classPotassiumsparing Diuretics

Triamterene inhibits the epithelial sodium channels on principal cells in the late distal convoluted tubule and collecting tubule, which are responsible for 1-2% of total sodium reabsorptio n. As sodium

For the treatment of edema associated with congestive heart failure, cirrhosis of the liver, and the nephrotic syndrome; also in steroidinduced edema, idiopathic edema, and edema due

Patient with hypersensiti ve to its components and dose with pathologic bleeding

CNSAgitation,confusion,c onvulsions CVSHypotension, GIabdominal pain, constipation, MUSCULO SKELETALArthralgia, myalgia. HEMATOLOGICpurpura

1.consider alternative treatment for patients identified as metabolizes. 2.Monitor blood pressure.

S. DRUG N 2. SUPRACEF Cefuroxime sodium THERAPEUTIC Antibiotic PHARMACOLOGIC classsecond generation cephalospori n

DOSE

ACTION

INDICATION

CONTRAINDI- SIDE-EEFECT CATIONS Patient hypersensitive to drugs or other cephalosporin 's. CVSPhlebitis, thrombocytopeni a GIDiarrhea, nausea, vomiting, anorexia. HEMATOLOGICHemolytic anemia, thrombocytopeni a SKINMaculopapular and erythmatus rashes. OTHERanaphylaxis

NURSES RESPONSIBILITY 1. monitor patient for signs and symptoms of super infection. 2. advise patient receiving drug to report discomfort at IV injection site. 3. assess for hypersensitivity of the patient.

1.5gm Inhibits injectio cell-wall n IV synthesis promoting osmotic instability usually bactericida l

Pharyngitis/To nsillitis Acute Bacterial Otitis MediaAcute Bacterial Maxillary Sinusitis Acute Bacterial Exacerbations of Chronic Bronchitis and Secondary Bacterial Infections of Acute BronchitisUnc omplicated Skin and SkinStructure

S. DRUG N

DOSE

ACTION

INDICATION CONTRAINDICATIONS manageme nt of moderate to moderately severe pain in adults. 1. patients hypersensitive to drug 2. breast feeding women 3. acute intoxication from alcohol, hypnotics, etc.

SIDE-EEFECT

NURSES RESPONSIBILITY 1. Re-assess patient level of pain at least 30 min after drug administration. 2. Monitor CV & respiratory status. 3. Monitor for risk of seizures. 4. For better onset, give drug before onset of intense pain.

3. TRAMADOL 50 mg Unknown (Tramadol injectio thought to hydrochloride) n IV bind to receptor Therapeutic and inhibit classreuptake Analgesic of Pharmacologic noradrenal -synthetic ine & active serotonine analgesic. .

CNSDizziness, headache, seizure, anxiety, CVVasodilation. ENTVisual disturbances. GIConstipation, nausea, vomiting. GUMenopausal symptoms RESPIRATORYRespiratory depression.

S.N DRUG 4. Tab Lanoxin

DOSE 0.0625-0.25 mg/day

ACTION

INDICATION CONTRAINDI-CATIONS SIDE-EEFECT NURSES RESPONSIBILITY Coronary 1.Ventricular fibrillation artery disease 2.Known hypersensitivity Atrial reaction to digitalis Fibrillation (reactions seen include unexplained rash, swelling of the mouth, lips or throat or a difficulty in breathing) Ventricular tachycardia Presence of digoxin toxicity Beriberi heart disease Hypersensitive carotid sinus syndrome Cardiac arrhythmias Digoxin Toxicity Assess cardiac function Measure liquids precisely Assess for signs of toxicity, especially in children and the elderly Give IV slowly over 5 minutes

Digoxin binds to a site on the extracellular BRAND Or aspect of the NAME: 10-15 mcg/kg -subunit of Lanoxin the Na+/K+ ATPase pump GENERIC in the NAME: membranes of digoxin heart cells Classificati (myocytes) and on: decreases its Cardiac function. This glycoside causes an increase in the level of sodium ions in the myocytes, which leads to a rise in the level of intracellular calcium ions.

Note possible drug interactions

Assess for hyperthyroidism or hypothyroidism Obtain ECG Monitor CBC, serum electrolytes, calcium, MG, renal and liver function tests Obtain written heart rate parameters for drug administration as drug may cause extreme bradycardia Do not administer if HR is <50. Hold if HR is 90-110 bpm in children

Obtain pulse deficit of apical and radial pulse

Monitor weight and I&o Use antacid if gastric distress occurs Use caution during withdrawal Do not take with grapefruit juice Take after meals to lessen gastric irritation

MEDICAL
MANAGEMENT

BOOK PICTURE

PATIENT PICTURE

Drug therapy- Diuretics, Nitrates, betablockers, calcium channel blockers, ACE inhibitors, angiotensin receptor blockers (ARBs), or digoxin.
Anticoagulants /Antiplatelet

Inj. Lanoxin 0.125mg TID

Tab ecosprin 150 mg

Antibiotic therapy-People who have had rheumatic fever need long-term preventive treatment with penicillin.
Nebulisation

Inj.Magnex forte 1.5 g BD Inj.amikacin 500mg BD

Duolin + budecort

Spirometry

3 times/ day

Chest physiotherapy

frequently

SURGICAL MANAGEMENT

BOOK PICTURE

PATIENT PICTURE

Mitral valvuloplasty

NOT DONE

Mitral valve replacement

DONE

 Administer oxygen by face mask or artificial airway to ensure adequate oxygenation of tissues. Adjust the oxygen flow rate to higher or lower level, as blood gas measurements indicate. Administer an osmotic diuretic, such as mannitol, if ordered to increase renal blood flow and urine output. To ease emotional stress, allow frequent rest periods as possible.

 Allow family members to visit and comfort the patient as much as possible. Monitor and record blood pressure, pulse, respiratory rate, and peripheral pulse every 1 to 5 minutes until the patient stabilizes. Record hemodynamic pressure readings every 15 minutes. Monitor ABG values, complete blood count, and electrolyte levels.

NURSING DIAGNOSIS
Decreased cardiac output R/T mechanical factor (preload, afterload) secondary to Valvular dysfunction. High risk for infection related to operation. Self-care deficit related to operation. Activity intolerance R/T diminished cardiac reserve. Anxiety R/T altered heart action. Knowledge deficit R/T disease condition, treatment & prognosis.

NURSING THEORY
OREMS THEORY
Orem describes Six universal self care requisites common to men, women and children. The maintenance of sufficient intake of air, water and food. The provision of care associated with elimination process with excrement. The maintenance of a balance between activity and rest.

 The maintenance of balance between solitude and social interaction. Prevention of hazards to human life functioning and human well-being. The promotion of human functioning and development within social group in accordance with human potentials, known human limitations and the human desire to be normal. Application of Orems self care nursing model.

NURSING ASSESSMENT HR-sinus rhythm BP 130/78 mmhg CVP -10 to 12 mmhg Urine output (24hrs)900ml

PROBLEM

NURSING SYSTEM

GOAL

SELFCARE REQUISITE Prevention of hazards to human life, functioning and human wellbeing.

NURSING ACTION

REWIEW

Decreased Wholly cardiac compensat output R/T ory mechanical factor (preload, afterload) secondary to Valvular dysfunction.

Patient has adequate output as evidenced by Normal SR, HR-60-100 beats/ min BP 120/80mmhg Urine 1ml/kg/hr. CVP-2-8 mmhg Warm periphery

-Monitor ECG for arrhythmias -Continuous hemodynamic monitoring. -Assess hourly intake & output. -Give packed cell 2000 ml -Start injection dopamine 4mg/hr. -Adjust NTG according to BP. -Check electrolyte & collect according to it. -Check peripheral temperature. -Exclude tamponade

Cardiac output is maintained as evidenced by normal BP, Pulse, and warm periphery.

NURSING ASSESSMENT TLC-11,300 Temp-98.6f

PROBLEM

NURSING SYSTEM

GOAL

SELFCARE REQUISITE

NURSING ACTION

REWIEW

High risk for Wholly infection compensat related to ory operation.

Patient will Prevention not get of hazards to infection from human life. hospital environment

-Assess for sign of infection. -Change the dressing regularly. -To give catheter care regularly. -Check hemodynamic parameters. -Remove all the invasive lines as early as possible.

Risk of infection prevented evidenced by WBC count within normal and no signs of infections.

NURSING ASSESSMENT Patient is semiconscious.

PROBLEM

NURSING SYSTEM

GOAL

SELFCARE REQUISITE Promotion of human functioning & development with in social group.

NURSING ACTION

REWIEW

Self-care deficit Wholly All the related to compensat routine operation. ory activities of the patient will be done by the nurses and the family members.

To check whether all the iv lines are in place. Cardiac monitoring to be done properly. Give psychological support and Educate the relatives about the care of the patient. Give every 2 hourly position to the patient. Maintain the hygiene of the patient.

Care provide adequately by the nurses and the family members .

 Teach the patient about disease including etiology possible complications and associated symptoms to report to physician. Assist patient during diagnostic workup and assist with decision for medical or surgical treatment. Include patients family in teaching and decision making process. Instruct the patient in the name, dose, and purpose of medications. Explain activity allowances and limitations.

 Explain diet and fluid restriction. Instruct the patient about antibiotic prophylaxis to prevent infective endocarditis. Provide instruction to women regarding appropriate choice of contraception and risk associated with pregnancy. Instruct the patient about maintaining good oral hygiene, daily care, and regular visits to dentist.

 DAY 1
Patients was conscious. Patient had Breathlessness , Tachycardia, Fatigue. Angiography was done and was advised for MVR.

DAY 2

Patient was stable. Patient was seen by Dr. Thakur and was planned for MVR.

DAY 3
Patient was stable. Pre-op medications were given and patient was posted for MVR. Post-op patient was on ventilator and inotropic support. Patient was hemodynamically stable.

DAY 4
Patient was conscious and Extubated. Oxygen administration was given at the rate of 6 l/min by mask. Vital parameters were normal. Patient was on inotropic support.

DAY 5
Patient was conscious and welloriented. Drains were removed. Inotropic support was lowered. Patient was planned to be shifted to ward next day.

DAY 6
Patient was conscious and welloriented. Inotropic support was stopped. Patient was shifted to ward.

DAY 7
Patient was conscious and welloriented. Patient was hemodynamically stable.

DAY 8
Patient was conscious and welloriented. Patient was hemodynamically stable.

DAY 9
Patient was conscious and welloriented. Patient was planned for discharge. Patient got discharge in evening.

PATIENTS EVALUATION: Patient had good prognosis as compared to the admission. Patient was able to maintain hemodynamic parameters without inotropic support. Patient was stable and was satisfied by the care provided.

TRENDS: 1. MVR

2. ROBOTIC MVR

3.ENDOSCOPIC

4. HEART VALVE REPAIR THROUGH CATHETER

BIBLIOGRAPHY
Ross and Wilson,text book of anatomy and physiology. Luckmann joan, Saunders, Manual of Nursing Care 1st edition, W.B. Saunders publication, copyright, page-727-729. Joyce M.Black and Esther MatassarianJacobs, Medical Surgical Nursingpsycho physiologic approach, 4th edition, copyright 1999, W.B. Saunders, page 2122-2124.