rheumatic heart disease with mitral stenosis
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Clinical Presentation
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Submitted to Submitted by
Dr.R.Lakshmi MSc.,(N) Ph.d
Principal
Mrs.A.Thahira Begum msc.,(N) MPhil Mrs.Muthupriya
Reader Msc.,(N) I year
Dept.of medical surgical nursing
PATIENT PROFILE
Name Mr. Gobi
Age/Sex 25 years/ Male
Ward CTS VI.
Unit C.T.IV.
MRD number 40551
Marital status Unmarried
Education 10th std
Religion Hindu
Occupation tailor.
Family income Rs.1000/month
Address c/o Mrs.Bhavani
119,jothy nagar st.
Thiruthani T.k., Thiruvallore Dt.
Medical diagnosis Rheumatic heart Disease with mitral stenosis
Date of Admission 01-12-2011
Source of history Patient and the Cash sheet.
REASON FOR HOSPITALISATION:
Patient was admitted in the hospital with the complaints of dyspnea on exertion for 1 month. Palpitation, guiddiness for 2 months. Had profused sweating and chest pain for a week.
PRESENT MEDICAL HISTORY:
Patient came with the complaints of breathlessness and the chest pain on exertion , palpitation and profused sweating and got admitted in hospital for 1 month. Echo , ECG and
other routine investigations done and diagnosed as rheumatic heart disease. medications as T.aspirin, T.clopidogrel, T. ISDN were given. Now the patient symptoms was reduced.
PAST MEDICAL HISTORY:
At 2 years,patient had fever and later he developed past polio residual paralysis left lower limb. He had admitted on 3/2/2012 for the same complaints and got admitted and consulted cardiology department. Treatment given and went home. Again had same complains and admitted in 111ward for 12 days and got discharged. Now he admitted for similar complaints.
He is not a known diabetic milletus/ hypertension.
No history of coronary artery disease or seizures.
FAMILY HISTORY:
Family pedigree:
There is no significant history of chronic illness, communicable diseases, or psychiatric illness, surgery in his family.
SOCIO ECONOMIC HISTORY:
He is residing in thirutani.works as a tailor and earns Rs.1500/- month. He lives in his tiled house, which is well ventilated and lighted. They have a dog at home.disposal of waste by dumping. Tap water supply and drainage facility available. There is no kitchen garden. He socializes well with others.
PERSONAL HISTORY:
Mr. Gobi was born in thiruthani hospital, extrovert, mingling with others. Had belief on religious factors. Able to speak tamil.educated upto 10 months. he takes a mixed diet. He takes 3 meals per day. He is not a smoker or an alcoholic. His sleep pattern is normal. His bowel and bladder pattern is normal. He reads magazines during his licensure.
MARITAL HISTORY:
He was not yet married.
PHYSICAL EXAMINATION:
General appearance: Moderately built, dull and well oriented, well groomed
Hair and scalp Clean,equal distribution of hair. free of pediculi and dandruff
Conjunctiva Pink in colour, not icterus
Eyes No ptosis, nystagmus, no cornea
Opacities
Nose: No discharge, pain or impacted. No septal deviation
Ears Cerumen
Mouth and throat:
Lips
Dry lips, coated tongue. No denti caries
No cyanosis, moist, no gingival bleeding
Throat Tonsils not inflamed
Neck No nuchal rigidity
Trachea in midline
No lymphadenopathy
Thyroid gland enlargement
Chest No neck vein distension
Symmetrical chest movement Present
Bilateral air entry equal
S1,S2heard, middiastolic murmurs heard
Normal vesicular breath sounds
Heard
Abdomen Flat abdomen, no scars, rashes,
bowel Sounds heard, no organomegaly
Genitalia No lesion,discharge, no hypo and
Epispadiasis
Back and spine Normal spinal curvature
Extremities No congenital abnormalities
Had post polio residual attack on left lower limbs.
No pedal edema.
Central nervous system:
General appearance Well nourished, Moderately built
Cardiovascular system:
Oriented to place , person and time.easy going, mingling with others.
Inspection
Skin No edema, not pale
Conjunctiva Pink
Buccal mucosa No cyanosis
Lips ,tip of the nose, earlobe,gingivae No cyanosis
No periorbital edema
No puffiness of face
Nail beds No clubbing
Hair distribution Symmetrical
Legs No venous stasis, ulcers, edema
Chest Symmetrical chest movements
No visible neck vein pulsation
No dyspenic
Palpation All peripheral pulses palpable
Rate, rhythm and quality of pulses normal
Pulse quality: 2+-normal
Pulse rate: 86 beats/minute
Percussion Resonance over lung fields
Auscultation S1,S2 heard, no murmur
Respiratory system No dyspnea, symmetrical chest wall
Movements respiratory rate:30 sbreaths/minute
No dyspnea, symmetrical chest wall
Movements respiratory rate: 20 breaths/minute
Auscultation: No advenstitious breath sound.
Percussion: Normal resonance
Gastrointestinal system:
Inspection: No scar mark. Scapoid shape abdomen.
Auscultation: Bowel sounds heard normally in all four quadrents.
Percussion No fluid thrill.
Palpation Soft, No organomegaly,
Bowel movements Present, once a day
Musculo skeletal system: Normal power, peripheral pulses felt, had post polio residual attacks in left lower leg. no abnormalities.
Lymphatic system No lymphadenopathy
Endocrine system Tolerate hot and cold. Not a diabetic.No endocrine abnormalities
Genito-urinary system No genital ulcer, normal bladder action.
Integumentary system No pigmentation, skin turgor normal.
VITAL SIGNS:
Anthropometric measurements Weight: 55kg
Height : 162 cms
Vital signs Temperature: 98.8F
Pulse: 86b/min, regular
Respiration: 20b/min, regular
Blood pressure:120/90 mm/Hg
RHEUMATIC HEART DISEASE WITH MITRAL STENOSIS
RHEUMATIC HEART DISEASE:
DEFINITION:
Rheumatic fever is an inflammatory disease of the heart potentially involving all layers (endocardium,pericardium and myocardium). The resulting damage to the heart from rheumatic fever is termed as rheumatic heart disease, a chronic condition characterized by scaring and deformity of heart valves.
INCIDENCE:
Acute rheumatic fever is a complication of upto 3 % of sporadic upper respiratory infection caused by group A B hemolytic streptococci.
Common among 5-15 years of age group. About 1 million RHD cases in INDIA
- WHO 2008
The frequency of recurrence of rheumatic fever after streptococcal infection is greater.
ETIOLOGY:
Rheumatic fever occurs as a delayed sequale of a group A B hemolytic streptococcal infection of upper respiratory tract usually a pharyngeal infection.
In order to infection, socio economic factor s, familial factors and presence of an altered immune response have a pre disposing factor in the development of rheumatic fever.
It probably affects heart, joints, skin, central nervous system, because of the abnormal humoral and cell mediated immune response to group A B hemolytic streptococci cell membrane antigens.
PATHOPHYSIOLOGY:
Rheumatic endocarditis is not the infectious in the sense that tissues are not invaded and directly damaged by streptococcal infection.
Streptococcal infectio
Inflamed/ sensitive reaction takes place
Leucocytes gets accumulated
Formation of nodules
Replaced by scar tissues
Joints heart brain
Myocardium pericardium endocardium
Weakens the contractile power rheumatic endocarditis
Rheumatic myocarditis rheumatic pericarditis adverse effects
Resolves & no sequale translucent vegetation/growth
Formation (pin head sized beads)
Leaflets thickened & shortened Incomplete closure
Inflamed margins fuses Blood flows backward
through valve
valvular stenosis Regurgitation of valve
( mitral valve )
CLINICAL MANIFESTATIONS:
American heart association provides logic for diagnosis mr. JONES
Presence of two major or one major and two minor criteria indicates a high probability of rheumatic fever.
Major criteria:
Carditis
Polyarthritis
Chorea
Erythema marginatum
Sub cutaneous nodules
a. Carditis
Carditis is the most important manifestation of acute rheumatic fever with three signs
Organic heart murmur , mitral stenosis
Cardiac enlargement and congestive heart failure
Pericarditis
b.Polyarthritis
Inflammatory process affects synovial membrane of joints causing swelling ,Heat, Redness, Tenderness and limitation of motion of larger joints like knees, Ankles and elbows
c.Chorea(Sydenham’s chorea)
It is the major cns manifestation characterized by weakness, Ataxia, Spontaneous rapid and purpose less choreic movements
d.Erythema marginatum
Very less common feature. Bright pink map like macular lesions on inner aspect of arm and thigh but never on face
e.Subcutaneous nodules
Subcutaneous nodules are firm small hard painless swelling found over bony prominences(knees, Elbows, Spine and Scapula)
Minor Criteria
Fever
Arthralgia
Prolonged PR interval
Lab findings
Previous occurrences of rheumatic fever
Non specific to make definite diagnosis but can supplement to confirm diagnosis
S.No Book Picture Patient Picture1234567
CarditisPolyarthritis
ChoreaNodules
FeverArthralgia
Lab findings
CarditisKnee pain--------------------------
FeverJoint pain
Echo report
DIAGNOSTIC EVALUATION
A sore throat or history of 1with in 5 weeks is the first symptom of possible rheumatic fever. Other history should asked like fever, headache, chest pain, abdominal pain, vomiting, malaise, diaphoresis may also occur
Throat culture are necessary to diagnose the infection, routine blood investivcation should be noted to diagnose fever and infection ECG shows sinus tachycardia/bradycardia/dysarythmias. ESR and CRP may be elevated. ASO titre may also done to conform the test. Chest XRAY shows enlarged heart.
S.No Book picture Patient picture1
23
45
6
History collectionFever weight lossFatigue diaphoresisChest pain, VomitingPhysical examinationX Ray
EGCBloodTotal countESRHPCRPASOSUGARPlateletEcho
Fever malaiseChest pain vomitingFood intake
Sinus tachycardiaCardiomegaly and lungParenchyma clear
6600 cells/m15mm/hr11.5mg/tl76-Ve80mg/dl2.06 laksChronic RHD with MS.No MR normal LV function
PREVENTION
Rheumatic fever and rheumatic endocarditis may be prevented through early and adequate treatment of streptococcal infection
Nurse should familier with signs and symptoms of streptococcal infection
High fever
Chills
Sore throat
Redness of the throat with exudate
Enlarged lymph nodes
Acute Rhinitis
COMPLICATION
The course cannot be predicted at the onset of disease but generalization can be made with in five months most symptoms disappear .Only 5% of symptoms last for more than six months
A complication results from acute rheumatic fever is chronic rheumatic carditis.It resuls from changes in valvular structure.It resuls in fibrous tissue groth in valve leaflets and chordea tendinea with scarring and contractures. Mitralvalve is most frequently involved.
MITRAL VALVEMITRAL VALVE STENOSIS:
DEFINITION:
Mitral valve stenosis in the narrowing of the opening in the mitral valve that impedes blood flow from the left atrium in to the left ventricle the mitral valve becomed thickended and fibrotic.
INCIDENCE:
Young woman 20-40 years of age are more common comparing to men
RISK FACTOR:
Rheumatic heart disease confeital malformation of the mitral valve, calcium accumulation as valve leaflets and aliria tumours and myocardial in chemia.
PATHOPHYSIOLOGY:
Normal mitral valve opening is as wide as diameter of three fingers.
In stenosis
Open narrows to width of a pencil
Difficult for LA to pump out blood to LV
Resistance increased
Blood volume increased in left atrium
Stretches and hypertroptied left atrium
No valve to protect pulmonary veins
Congested pulmonary circulation
Increased pulmonary arterial prenure
Right ventricle contraction
Right ventricular failure
CLINICAL MANIFESTATION:
The first symptom of mmirral stenosis is often the breathing difficulty (dyspnea) on exertion as a result of pulmonary venous hypertension.
Patient have progressive fatigue as a result of low cardiac output.They may expectorate blood (hemoptysis), cough, wheeze and experience palpitation, orthopnea, paroxysomal nocturnal dyspnea and repeated respiratory infection.
S.No BOOK PICTURE PATIENT PICTURE1.2.3.4.5.6.
Breathing difficultyProgressive fatigueHemoptysisPalitationOrthopneaPND
Dyspnea on excitionFatigue-Palpitation--
DIAGNOSTIC FINDING:
Pulse weak and often irregural decause of atrial fibrillation low pitched diastolic murmur
Heard at apex. Echo to diagnose mitral stennosis.
ECG and cardiac catheterization with angiography may be used to help determine the severity of stenosis.
S.No BOOK PICTURE PATIENT PICTURE1.
2.3.4.
Physical examination PulseRespirationAuscultationEGCECHOCardiac catheterisation
Regular but weakDyspneaNo murmurs heared
Mitral stenosis
MANAGEMENT :
Patient with mitral stenosis are advised to avoid strenuous activities and competive sports both of which increase the heart rate.
Medical management:
Antibiotic therapy doconot modify the disease of carditis.
Pancillin can be advised
Salicylater and corficosteroidsare the two antiflamatory for the management.
Drug therapy also include digoxin, diureties blockers and anti dysrhythmias
If patient has atrial fibrillation.
Anticoagulants can also be prescribed.
For Acute RHD:
Steroids – Predinisolone
NSAIDS-Aspirin
Diuretics –Lasix
Antibiotics – Pencillin
Oxygen therapy
Back rest
For chronic RHD:
Surgical replacement of the valve.
SURGICAL MANAGEMENT:
There are two surgical procedures
1. Valvuloplasty
2. Valve replacement
Valvuloplasty:
The repair rather than a replacement of a heart valve is called valvuloplasty.
Most valvuloplasty requires general anaesthesia and often rquire cardiopulmonary bypass. However some procedure can be performed in cardiac catheterization and not require bypass.
There are various types
a.Commissurotomy:
The most common procedure. It performs to separate the fused leaflets. Where leaflets are adhere to one another and close the commissure ie, stenosis (junction of leaflet)
b.Closed commissurotomy :
They donot require cardiopulmonary bypass. The valve is not directly visualized, done as percutaneous balloon valvuloplasty.
c.Balloon valvuloplasty:
It is beneficial for mitral stenosis in younger patients, done in cath lab. Patient receives mild sedation. One or two catheters inserted into mild sedation. One or two catheters inserted into right atrium
Atrial septum
Left atrium
Mitral valve
Left ventricle
Aorta
A wire is placed and catheter is removed . a lage balloon catheter is placed over the wire and positioned with balloon on mitral valve.
d.Closed surgical valvuloplasty:
It has been perfomed for mitral, aortic, tricuspid and pulmonary valve stenosis. A small hole is cut into the heart and the surgeon’s finger or a dilator is used to open the commisure.
e.Open commissurotomy:
It can be done under direct visualization of heart by cardio pulmonary bypass is exposed and done easily.
Valve replacement:
When Valvuloplasty or valve repair is not a viable alternative than valve replacement is performed.
General anesthesia and cardio pulmonary bypass are used for valve replacement.
Median sternotomy done and mitral valve approached through a right thorocotomy incision. The leaflet are removed and valve will be left in place.
Types of valves:
Mechanical valve
Tissue valve
Homografts
NURSING MANAGEMENT:
Nurse educates about the diagnosis and preventive measures . first degree relatives may be advised to have echo.
Prophylactic antibiotic therapy should be instructed and asked to monitor any symptoms deviated from normal nurses teaches to avoid caffine, alcohol
Avoid overcounter of drugs such as cough medicine
Nurse explain diet pattern, activity, sleep and other life style factors that may correlate with the symptoms.
LIST OF NURSING DIAGNOSES:
Pain related to inflammation of the Cardiac muscles
Activity intolerance related to imbalance between oxygen supply and demand
Impaired breathing pattern related to pulmonary congestion
Imbalanced nutrition less than body requirements related to inadequate intake of food
Risk for injury related to guiddiness
Deficient knowledge regarding follow up care
Impaired home management related to general malaise and guiddiness
S.NO
DRUG NAME
DOSE ROUTE FREQ
ACTION SIDE EFFECTS NURSES ROLE
1. T.Atenolol 25mg Oral Bd βadrenergic antagonist,blocks β1receptors located in heart muscle
Dizziness,syncope, lethargy,GI symptoms
Monitor heart rate
Watch for side effects
Observe GI changes
2. T.Digoxin o.25mg Oral Od Act by increasing the force and velocity of myocardium
Muscle weakness, dizziness,drowsy, arythmias
Monitor vitals
Digoxin toxicity
Check lab values
3. T.verapamil 60mg Oral Tds It dilates coronary arteries and inhibits coronary artery spasm
Dizziness,vertgo, hypotension, peripheral edema, tachy cardia
Administer after food
Watch for changes
4. T.Frusemide 20mg Oral Tds Loop diuretics. It decreases the renal resistence & increases renal blood flow
Hyponatremia, hypotension, dizziness,collapse, GIsymptoms
Take after food
Schedule dose to avoid nocturia
Watch for hypo symptoms
6. T.Cardone 100mg Oral Bd
7. Syp.Kcl 2tsp Oral Tds Maintain intra cellular isotonicity. Maintains normal renal function
Nausea, vomiting, diarrhea, oliguria, pain, paralysis, ARDS
Administer with precaution
Watch for hyperkalemia
Observe GI changes
SUBJECTIVE DATA: patient complaints of pain in the operated area.
OBJECTIVE DATA: He Is Very Tired
NURSING DIAGNOSIS: Acute pain related to inflammation secondary to surgical manipulation
GOAL: patient’s pain will be minimized
PLANNING IMPLEMENTATION RATIONALE EVALUATION
Patient’s pain was reduced to 4. He was comfortable with the health team.
Assess patients pain Patients pain was on visual analogue pain scale
Help to plan care
Provide adequate rest periods before activities
Provided adequate rest periods in between activities
Minimizes pain
Provide additional pillows
Provide additional pillow Provides comfort
Provide a warm back rub
Provide a warm gentle back rub
Provides muscle relaxant
Provide diversional therapy
Provide magazines to read Diverts alteration from pain
Administer analgesic as per order
Administered inj. Voveron 75mg
Relieves pain
SUBJECTIVE DATA: The patient verbilises that he feels dificulti in breathing and unable to move
OBJECTIVE DATA: Patient Look dyspna on excertion , palpitation increased the breath 26/min irregular.
NURSING DIAGNOSIS: Impaired breathing pattern related to pulmonary congestion
GOAL: The patient breathing pattern will be improved with in 20min
PLANNING IMPLEMENTATION RATIONALE EVALUATION
Monitor vital Monitored vital signs Provides base line patient respiratory
signs resp 26/min data rate returns to normal of 26 breaths /min
Provide comfort position
Sitting up with legs down its advised
Helps in reducing pre load
Monitor oxygen saturation
Spo2 – 96% Helps to identify oxygen need
Administer nasal oxygen
--- Satisfies O2 demand
Provide low sodium diet
Salt free diet given Improves health status
Encourage adequate rest
Encouraged adequate rest and sleep
Promotes oxygenation to the tissues
SUBJECTIVE DATA: The patient verbilises that he feels dificulti in breathing and unable to carryout his activites of daily living
OBJECTIVE DATA: Patient Looks drowsy,tired and needs support for activites of daily living
NURSING DIAGNOSIS: Activity intolerance related to dyspnea and palpitation
GOAL: The patient level of activity will be improved.
PLANNING IMPLEMENTATION RATIONALE EVALUATION
Assess the general condition of the patient
Patient looks drowsy and tired
Provides base line data about health status
He is gradulally returning to perform his activities
Encourage to choose activites that increase cardiac output
Encourged about milder activities
Improve oxygenation
Avoid strenuous exercises
Mild exercises advised
Prevents overload
Advice adequate rest to the patient
Encourged adequate rest between work schedule
Promotes comfort
Improves level of activity by the patient
Level of activity should be improved
Promote self esteem
Conceratrate on diat Low sodium and iron diet advised
Improves immunity
SUBJECTIVE DATA: patient refuses food.
OBJECTIVE DATA: patient eat less than the served food, refuses food sometime.
NURSING DIAGNOSIS: imbalanced nutritional status less than body requirements related to anorexia.
GOAL: patient’s food intake will be improved.
INTERVENTIONS IMPLEMENTATION RATIONALE EVALUATION
Asses the nutritional status
Assess the client. He has anorexia
Helps to plan care Patient’s food intake was gradually
improved.Provide frequent oral care
Provided frequent mouth wash
Provides appetite
Provide a conductive environment to eat
Provided a conductive environment to eat
Promotes appetite
Serve food according to likes and dislikes in frequent small quantities
Served food in frequent small quantities
Promotes appetite
Educate regarding foods to be taken and avoided
Educated regarding foods to be taken and recorded
Helps to improve the understanding about the diet to be eaten
Provide nutritional support
Provided nutritional support
Promotes confidence
HEALTH EDUCATION
DIET:
The diet should be well balanced with low salt and low fat.
DAILY WEIGHT:
Weight yourself at the same time each morning after you urinate but before breakfast. Use the same scale everyday.
Keep a record of your daily weight .
ACTIVITY:
Stop any activity immediately if you feel short of breath , notice irregular heart beats, feel faint or dizzy or you have chest pain. Rest until the symptoms subside. If they do not subside within 20 minutes.
DRESS:
Wear comfortable loose fitting clothes that do not pull undue pressure on your incision.
REST:
You need a balance of rest and exercise for your recovery. Plan it do rest between activities. Resting also includes sitting quietly for 20-30 minutes , Rest 30 minutes after meals before exercise .
WALKING:
This one of the best form of exercise because it increases circulation throughout the body and to the heart muscles.
EXERCISE:
Stop any type of exercise if you feel shortness of breath, dizziness, leg cramps , unusual fatigue, or chest pain. Notify this to your doctor immediately.
SUBJECTIVE DATA: The patient verbilises that he will be cured completely or not, whether his condition is recurrent. He says that he was not clear about his treatment.
OBJECTIVE DATA: Patient was curious to know about disease condition and management , his level of knowledge is poor regarding treatment.
NURSING DIAGNOSIS: deficient knowledge regarding disease condition and treatment plan.
GOAL: The patient will gain confidence and knowledge regarding disease and treatments
.
PLANNING IMPLEMENTATION RATIONALE EVALUATION
Assess the level of knowledge of the patient
Patient was worried more about the disease condition
Provides baseline data
Patient had gained good knowledge regarding his health condition and trestmentEducate the patient
regarding the disease condition
Diseased condition was clearly explained with picture
Gains confidence over prognosis
Clarify doubts for the patient
Patients had doubts and got claried
Avoids unwanted querres
Encourage about followup exercises and medications
Information gives to patient
Improves health status
Reassure the patient Reassurance the patient Evaluates the care
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