mitral stenosis presentation
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PRESENTED BY:
Mr. STAWAN UTTAM CHOUGULE
C SE PRESENT TION ONMITR L STENOSIS
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DEMOGRAPHIC DATA
Mrs. Devare Madhura Eknath
58 years/female
10
th
Nov 13Hindu
Housewife
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PRESENT COMPLAINTS
Breathlessness
Tachycardia
Fatigue
1 month
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HISTORY OF PRESENT ILLNESS
Breathlessness, Tachycardia, Fatigue
since 1 month.
Dr. Akkalkotkar did angiography.
Patient was operated for MVR on 13th
Oct13.
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PAST HISTORY
No history of any major illness in past.
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MEDICATION HISTORY
No history of any medication.
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SOCIOECONOMIC STATUS
Middle class family
Own flat
Good IPR Participates in all religious or social
activities
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DIETICHISTORY
Patient had mixed diet pattern and
preferred veg. She used to eat more of
green vegetables and cereals.
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ACTIVITY EXPERIENCE:
Patient had normal activity pattern.
She used to do household work.
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SLEEP/REST
She used to sleep 7 hours in night.
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PHYSICAL EXAMINATION
GENERAL APPEARANCE:
conscious & oriented.
Patient was under weight Patient was on ventilator support
artery line inserted on right hand
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Weight: 40kg
Height: 5.3 ft
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VITAL SIGNS
Temperature: 98.6 f
Pulse: 88 beats/ min
Respiration: 22 breaths /min on
pressure SIMV mode
BloodPressure:120/70 mmhg
SPO2: 99 %
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CHEST AND RESPIRATORY
SYSTEM
ADVENTITIOUS SOUNDS: Wheezesound heard
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NERVOUS SYSTEM
MentalStatus: Conscious
MotorCo-Ordination
UpperExtremities :
normal activity
LowerExtremities :
normal activity
InvoluntaryMovements: notPresent
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INVESTIGATION
12 10 14 10 13 15 10 1
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INVESTIGATIONDIAGNOSTIC TEST NORMALVALUES
12.10.
13
14.10.13 15.10.1
3
HAEMATOLOGY
HAEMOGLOBIN12.5 to 17.5
gm/dl
9.4 9.6
RBC
4.5 to 6 x
10^6/ml
3.61 3.58
P.C.V. 35.0 to 50.4 %21.6 21.8
MCV 80.0 to 99.9 fl
83.6 84.5
MCH 27.0 to 31.0 pg29.4 28.6
MCHC 33.0 to 37.0 g/dl
34.6 35.2
9600 9800
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TOTAL WBC/CUMM 9600 9800
POLYMORPHS % 40-65% 71 70
LYMPHOCYTES % 30-50% 22 24
EOSINOPHILS % 2-8% 02 02
MONOCYTES % 2-4% 03 02
BASOPHILS % 0-1% 00 00
PLATELET
COUNT/CUMM1.5-4 lakh
134000 128000
PROTHROMBIN TIME 11-14 sec12/12
INR 0.8-1.2 sec 1.0
PTT 25-35 sec2 min 10
sec
BLEEDING TIME 1 to 5 mins.3 min 20
sec
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UREA 14 to 50 mg / dl 30
CREATININE 0.6 to 1.4 mg / dl 0.8
CPK-MB Up to 25 IU/L 62
TROP-T POSITIVE
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ECG
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MITR L STENOSISDEFINITION
Mitral stenosis is a narrowing of the mitral
valve in the heart. This restricts the flow ofblood through the valve.
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HEART
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Mitral Valve
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LYMPHATIC SYSTEM IN HEART
All of the lymphatic drainage of the
thorax is directed toward the
bronchomediastinal trunks, thoracic
duct, and descending intercostallymphatic trunks.
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NERVE SUPPLY OF THE HEART
Both the parasympathetic and sympathetic nerves
form the superficial and deep cardiac plexuses
The superficial cardiac plexus is situated below the
arch of aorta in front of the right pulmonary artery,
it is formed by
The superior cervical cardiac branch of the left
sympathetic chain
The inferior cervical cardiac branch of left vagus
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RISK FACTORS
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Rheumatic fever
Recurrent strep infection
Radiation treatment involving the chest
Medications, such as ergot preparations
used for migraines.
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CAUSES
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BOOK PICTURE PATIENT PICTURE
Rheumatic fever. PRESENT
Congenital heart defect PRESENT
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PATHOPHYSIOLOGY
CLINICAL MANIFESTATION
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BOOK PICTURE PATIENT PICTURE
Shortness of breath or dyspnea PRESENT
Fatigue or weakness PRESENT
Palpitations PRESENT
Hemoptysis ABSENT
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PATHOPHYSIOLOGY
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DIAGNOSTIC
TEST
BOOK PICTURE PATIENT PICTURE
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Chest x-ray Mild to moderate cardiomegaly with
left atrial enlargement suggesting of
Valvular heart disease.Coronary angiography Normal epicardial arteryEchocardiogram 1. Rheumatic heart disease
2. Severe mitral stenosis
3. Mild aortic regurgitation
4. Moderate pulmonary
hypertension
5. LVEF=60%
6. Atrial fibrillation
Electrocardiogram DoneRadionuclide studies Not doneChest x-ray Mild to moderate cardiomegaly with
left atrial enlargement suggesting of
Valvular heart disease.
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S.
N
DRUG DOSE ACTION INDICATION CONTRAIN-
DICATIONS
SIDE-EEFECT NURSES
RESPONSIBILITY
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N DICATIONS RESPONSIBILITY
1 Tb.Ditide
(triamteren
e)
Therapeutic
class-
Potassium-
sparing
Diuretics
50mg
bd
Triamterene
inhibits the
epithelial
sodium
channels on
principal
cells in the
late distalconvoluted
tubule and
collecting
tubule,
which are
responsiblefor 1-2% of
total
sodium
reabsorptio
n. As
sodium
For the
treatment
of edema
associated
with
congestive
heart
failure,cirrhosis of
the liver,
and the
nephrotic
syndrome;
also insteroid-
induced
edema,
idiopathic
edema, and
edema due
Patient with
hypersensiti
ve to its
components
and dose
with
pathologic
bleeding
CNS-
Agitation,confusion,c
onvulsions
CVS-
Hypotension,
GI-
abdominal pain,
constipation,MUSCULO SKELETAL-
Arthralgia, myalgia.
HEMATOLOGIC-
purpura
1.consider
alternative
treatment for
patients identified
as metabolizes.
2.Monitor blood
pressure.
S.
N
DRUG DOSE ACTION INDICATION CONTRAINDI-
CATIONS
SIDE-EEFECT NURSES
RESPONSIBILITY
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N CATIONS RESPONSIBILITY
2. SUPRACEF
Cefuroxime
sodium
THERA-
PEUTIC
Antibiotic
PHARMA-COLOGIC
class-
second
generation
cephalospori
n
1.5gm
injectio
n IV
Inhibits
cell-wall
synthesis
promoting
osmotic
instability
usually
bactericida
l
-
Pharyngitis/To
nsillitis Acute
Bacterial
Otitis
MediaAcute
Bacterial
Maxillary
Sinusitis AcuteBacterial
Exacerbations
of Chronic
Bronchitis and
Secondary
BacterialInfections of
Acute
BronchitisUnc
omplicated
Skin and Skin-
Structure
Patient
hypersensitive
to drugs or
other
cephalosporin
's.
CVS-
Phlebitis,
thrombocytopeni
a
GI-
Diarrhea, nausea,
vomiting,
anorexia.
HEMATOLOGIC-Hemolytic
anemia,
thrombocytopeni
a
SKIN-
Maculopapularand erythmatus
rashes.
OTHER-
anaphylaxis
1. monitor patient
for signs and
symptoms of
super infection.
2. advise patient
receiving drug to
report discomfort
at IV injection
site.3. assess for
hypersensitivity of
the patient.
S.
N
DRUG DOSE ACTION INDICATION CONTRAINDI-
CATIONS
SIDE-EEFECT NURSES
RESPONSIBILITY
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N CATIONS RESPONSIBILITY
3. TRAMADOL
(Tramadol
hydrochloride)
Therapeutic
class-
Analgesic
Pharmacologic
-syntheticactive
analgesic.
50 mg
injectio
n IV
Unknown
thought to
bind to
receptor
and inhibit
reuptake
of
noradrenal
ine &serotonine
.
manageme
nt of
moderate
to
moderately
severe pain
in adults.
1. patients
hypersensitive
to drug
2. breast feeding
women
3. acute
intoxication
from alcohol,
hypnotics, etc.
CNS-
Dizziness,
headache,
seizure, anxiety,
CV-
Vasodilation.
ENT-
Visual
disturbances.GI-
Constipation,
nausea,
vomiting.
GU-
Menopausalsymptoms
RESPIRATORY-
Respiratory
depression.
1. Re-assess
patient level of
pain at least 30
min after drug
administration.
2. Monitor CV &
respiratory
status.
3. Monitor forrisk of seizures.
4. For better
onset, give drug
before onset of
intense pain.
S.N DRUG DOSE ACTION INDICATION CONTRAINDI-CATIONS SIDE-EEFECT NURSES RESPONSIBILITY
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4. Tab
Lanoxin
BRAND
NAME:
Lanoxin
GENERIC
NAME:
digoxin
Classificati
on:
Cardiac
glycoside
0.0625-0.25
mg/day
Or
10-15 mcg/kg
Digoxin binds
to a site on the
extracellular
aspect of the
-subunit of
the Na+/K+
ATPase pump
in the
membranes of
heart cells
(myocytes) and
decreases its
function. This
causes anincrease in the
level of sodium
ions in the
myocytes,
which leads to
a rise in the
level of
intracellularcalcium ions.
Coronary
artery disease
Atrial
Fibrillation
1.Ventricular fibrillation
2.Known hypersensitivity
reaction to digitalis
(reactions seen include
unexplained rash,
swelling of the mouth,lips or throat or a
difficulty in breathing)
Ventricular tachycardia
Presence of digoxin
toxicity
Beriberi heart disease
Hypersensitive carotid
sinus syndrome
Cardiac
arrhythmias
Digoxin
Toxicity
Assess cardiac function
Measure liquids precisely
Assess for signs of toxicity, especially in children and
the elderly
Give IV slowly over 5 minutes
Note possible drug interactions
Assess for hyperthyroidism or hypothyroidism
Obtain ECG
Monitor CBC, serum electrolytes, calcium, MG, renal
and liver function tests
Obtain written heart rate parameters for drug
administration as drug may cause extreme
bradycardia
Do not administer if HR is
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MANAGEMENT
BOOK PICTURE PATIENT PICTURE
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Drug therapy- Diuretics, Nitrates, beta-
blockers, calcium channel blockers, ACEinhibitors, angiotensin receptor blockers
(ARBs), or digoxin.
Inj. Lanoxin 0.125mg TID
Anticoagulants /Antiplatelet Tab ecosprin 150 mg
Antibiotic therapy-People who have had
rheumatic fever need long-term preventive
treatment with penicillin.
Inj.Magnex forte 1.5 g BD
Inj.amikacin 500mg BD
Nebulisation Duolin + budecort
Spirometry 3 times/ day
Chest physiotherapy frequently
SURGICAL MANAGEMENT
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SURGICAL MANAGEMENT
BOOK PICTURE PATIENT PICTURE
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Mitral valvuloplasty NOT DONE
Mitral valve
replacement
DONE
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Administer oxygen by face mask or artificial airway
to ensure adequate oxygenation of tissues.
Adjust the oxygen flow rate to higher or lower level,
as blood gas measurements indicate. Administer an osmotic diuretic, such as mannitol,
if ordered to increase renal blood flow and urine
output.
To ease emotional stress, allow frequent restperiods as possible.
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Allow family members to visit and comfort the
patient as much as possible. Monitor and record blood pressure, pulse,
respiratory rate, and peripheral pulse every 1 to 5
minutes until the patient stabilizes.
Record hemodynamic pressure readings every 15minutes.
Monitor ABG values, complete blood count, and
electrolyte levels.
NURSING DIAGNOSIS
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NURSING DIAGNOSIS
Decreased cardiac output R/T mechanical
factor (preload, afterload) secondary to Valvular
dysfunction.
High risk for infection related to operation. Self-care deficit related to operation.
Activity intolerance R/T diminished cardiac
reserve.
Anxiety R/T altered heart action. Knowledge deficit R/T disease condition,
treatment & prognosis.
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NURSING THEORYOREMS THEORY Orem describes Six universal self care
requisites common to men, women andchildren.
The maintenance of sufficient intake of air,water and food.
The provision of care associated withelimination process with excrement.
The maintenance of a balance betweenactivity and rest.
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The maintenance of balance between
solitude and social interaction. Prevention of hazards to human life
functioning and human well-being.
The promotion of human functioning anddevelopment within social group in
accordance with human potentials, known
human limitations and the human desire to
be normal. Application of Orems self care nursing
model.
NURSING
ASSESS-
PROBLEM NURSING
SYSTEM
GOAL SELFCARE
REQUISITE
NURSING ACTION REWIEW
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MENT
Q
HR-sinus
rhythm
BP
130/78
mmhg
CVP -10 to
12 mmhg
Urine
output(24hrs)-
900ml
Decreased
cardiac
output R/T
mechanical
factor
(preload,
afterload)
secondary to
Valvulardysfunction.
Wholly
compensat
ory
Patient has
adequate
output as
evidenced by
Normal SR,
HR-60-100
beats/ min
BP
120/80mmhgUrine
1ml/kg/hr.
CVP-2-8 mmhg
Warm
periphery
Prevention of
hazards to
human life,
functioning
and human
wellbeing.
-Monitor ECG for
arrhythmias
-Continuous
hemodynamic
monitoring.
-Assess hourly intake
& output.
-Give packed cell
2000 ml-Start injection
dopamine 4mg/hr.
-Adjust NTG
according to BP.
-Check electrolyte &
collect according toit.
-Check peripheral
temperature.
-Exclude tamponade
Cardiac
output is
maintained
as evidenced
by normal
BP, Pulse,
and warm
periphery.
NURSING
ASSESS-
PROBLEM NURSING
SYSTEM
GOAL SELFCARE
REQUISITE
NURSING ACTION REWIEW
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MENT
Q
TLC-11,300
Temp-98.6f
High risk for
infection
related to
operation.
Wholly
compensat
ory
Patient will
not get
infection from
hospital
environment
Prevention
of hazards to
human life.
-Assess for sign of
infection.
-Change the dressing
regularly.
-To give catheter care
regularly.
-Check hemodynamic
parameters.
-Remove all the invasivelines as early as
possible.
Risk of
infection
prevented
evidenced
by WBC
count
within
normal and
no signs ofinfections.
NURSING
ASSESS-
PROBLEM NURSING
SYSTEM
GOAL SELFCARE
REQUISITE
NURSING ACTION REWIEW
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MENT
Patient is
semi-
conscious.
Self-care deficit
related to
operation.
Wholly
compensat
ory
All the
routine
activities of
the patient
will be done
by the
nurses and
the family
members.
Promotion of
human
functioning &
development
with in social
group.
To check whether all
the iv lines are in
place.
Cardiac monitoring
to be done properly.
Give psychological
support and Educate
the relatives about
the care of the
patient.
Give every 2 hourly
position to the
patient.
Maintain the
hygiene of thepatient.
Care provide
adequately by
the nurses
and the family
members .
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Teach the patient about disease including etiology
possible complications and associated symptoms toreport to physician.
Assist patient during diagnostic workup and assist
with decision for medical or surgical treatment.
Include patients family in teaching and decision
making process.
Instruct the patient in the name, dose, and purpose
of medications. Explain activity allowances and limitations.
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Explain diet and fluid restriction.
Instruct the patient about antibioticprophylaxis to prevent infective endocarditis.
Provide instruction to women regarding
appropriate choice of contraception and riskassociated with pregnancy.
Instruct the patient about maintaining good
oral hygiene, daily care, and regular visits todentist.
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DAY 1 Patients was conscious.
Patient had Breathlessness , Tachycardia,
Fatigue. Angiography was done and was advised
for MVR.
DAY 2
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DAY 2
Patient was stable.
Patient was seen by Dr. Thakur and
was planned for MVR.
DAY 3
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DAY 3
Patient was stable.
Pre-op medications were given and
patient was posted for MVR.
Post-op patient was on ventilator and
inotropic support.
Patient was hemodynamically stable.
DAY 4
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Patient was conscious and Extubated.
Oxygen administration was given at the rate of
6 l/min by mask.
Vital parameters were normal.
Patient was on inotropic support.
DAY 5
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Patient was conscious and well-oriented.
Drains were removed.
Inotropic support was lowered.
Patient was planned to be shifted to
ward next day.
DAY 6
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Patient was conscious and well-oriented.
Inotropic support was stopped.
Patient was shifted to ward.
DAY 7
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Patient was conscious and well-oriented.
Patient was hemodynamically stable.
DAY 8
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Patient was conscious and well-oriented.
Patient was hemodynamically stable.
DAY 9
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Patient was conscious and well-oriented.
Patient was planned for discharge.
Patient got discharge in evening.
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PATIENTS EVALUATION:-
Patient had good prognosis as compared
to the admission. Patient was able to maintain
hemodynamic parameters without inotropicsupport. Patient was stable and was satisfied
by the care provided.
TRENDS: 1. MVR
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2. ROBOTIC MVR
3.ENDOSCOPIC
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4. HEART VALVE REPAIR THROUGH CATHETER
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BIBLIOGRAPHY
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Ross and Wilson,text book of anatomyand physiology.
Luckmann joan, Saunders, Manual ofNursing Care 1stedition, W.B. Saunders
publication, copyright, page-727-729. Joyce M.Black and Esther Matassarian-
Jacobs, Medical Surgical Nursing-psycho physiologic approach, 4th edition,
copyright 1999, W.B. Saunders, page2122-2124.
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