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 patient’s relief and
recovery

II. NURSING ASSESSMENT

1. PERSONAL HISTORY

a. DEMOGRAPHIC DATA

Mrs. Mapusu was born on the third day of November. She was a 72 year old
Filipino female, married and a mother to her five offspring, currently residing in Villa
Theresa Subdivision, Angeles City. She was rushed to Angeles Medical Center
 (AMC) on June 24, 2010. After days of hospitalization with continuous monitoring
and rendering of health care, she was discharged last June 28, 2010.

b. SOCIO-ECONOMIC AND CULTURAL FACTORS

Mrs. Mapusu, as business-minded as she was, has started a poultry and hog-
raising business together with his husband on the third year of their marriage, 47 years
ago; she has been taking care of their family business since then but has laid down the
management to her children when they had been well-trained on the business.
Currently she was not working anymore due to her old age and degenerating health.
However, she receives monthly allowance of 10,000-15,000 pesos a month.
According to her all of their expenses are within the budget she gets from her
children.
She graduated high school in Angeles City National High School and attended
college. She took up Business Accountancy at Holy Angel University but has reached
only her second year. She has to stop from studying due to financial constraints of her
family. She said to finish my degree was her dream but she was not able to do so.
Mrs. Mapusu is a devoted Roman Catholic. She attends the mass regularly
with her husband; along with them are her eldest son and his family. She attends
novena every Wednesday at Holy Rosary Parish church.
She and her family’s stability have brought them foods laid on their table—
Foods that represent their statute in life. She admits that she loves greasy and oily
foods. She jokingly said that the foods that are dangerous to health are the best ones to
eat at dinner. She admits that when it comes to health matters, she has insufficient
knowledge of what is to do. She follows a conventional way of treating illnesses.
Those are by taking over the counter drugs and have some rest. When feels something
about her health, she treats it like something not a big deal, and not bother to be
checked by her doctor.

2. FAMILY HEALTH HISTORY

In their family, there have been histories of Coronary Artery disease and
Diabetes Mellitus. There family consists of five children and she being the third child
 is the only one diagnosed of mitral stenosis. Two of her siblings are found out to be
prone to heart complications due to high cholesterol levels.

Grandfather Grandmothe Grandfather Grandmothe

(Deceased) r (HPN) r
(CAD) (DM) (none)

Father Mother
(HPN)
(died of

Eldest Sister 2nd sister Mrs. Mapusu 4th child Youngest

(HPN) (none) (HPN & Mitral (son) son
Stenosis) (HPN)

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:

• Temp – 36.5OC
• Pulse Rate – 112bpm
• Respiratory Rate – 39bpm
• Blood Pressure – 170/120 mmHg
Skin:

• Fair complexion
• (+) dry skin
• Cold to touch
• (-) ecchymosis
• (-) jaundice
• (-) cyanosis
• (-) sore / wound

Head, Skull and Face

• (+) normocephalic (normal head size)

• (-) nodules or masses
• (+) symmetric facial features
• (+) symmetric facial movements
Nails:

• (+) pallor
• Rough texture
• Delayed capillary refill or return of pink / usual color during capillary refill – indicate
circulatory impairment

Eyes and Vision

• (-) discharge
• Sclera appears yellowish
• (-) conjunctivitis
• Eyebrows symmetrically aligned and equal movement
• (-) edema / tearing
• (+) Pupils Equally Round and Reactive in Light Accommodation (PERRLA)
• Pupils are black in color and equal in size ( 3 to 4mm in diameter)
• Pupils constrict when looking at near object and dilate when looking at far objects.
• Able to read newsprint
• Both eyes coordinated with parallel alignment.

Ears

• (-) lesions
• (-) ear discharges
• normal voice tones are audible

Nose and Sinuses

• (-) lesions
• both nares are open, not plugged
• (-) abnormal nasal discharge
• (-) flaring of nares
• symmetric and straight
Mouth and Throat

• Yellowish teeth
• pinkish gums
• tongue moves freely
• (-) palpable nodules
• (+) halitosis

Lips

• pink in color
• (-) blisters

Neck

• can move freely in any directions

• (+) jugular vein distention
• (-) lumps

Upper Extremities

• (-) bruises
• (-) deformities
• (-) wounds
• (+) edema on both hands

Lower Extremities

• (-) bruises
• (-) lesions
Respiratory

Thorax and Back

• Respiratory rate – 20 bpm

• (-) cough
• (-) use of accessory muscles
• full and symmetric chest expansion
• (+) wheezes

Cardiac

Heart and Peripheral Vessels

• Blood Pressure – 120/70 mmHg

• Pulse Rate – 43
• Veins slightly distended

Gastrointestinal

Abdomen, Anus and Rectum

• Regular bowel movement (once a day)

• (-) abdominal distention
• (+) bowel sounds
• (-) tenderness
• (-) guarding

Urinary

• Frequency of urination (3 times a day)

• Yellowish urine
Musculoskeletal

• (-) arthritis
• (-) stiffness
• joints can move freely
• bones: no deformities
• muscle weakness

Neurologic

• (-) seizures
• (-) paralysis
• (-) tremors
• Glasgow coma scale: Eye opening – 3; Verbal response – 4; and Motor response – 6

Hematologic

• No history of blood transfusion or donation.

IV. PATIENT AND HER ILLNESS

1. ANATOMY AND PHYSIOLOGY

The cardiovascular/circulatory system transports food, hormones, metabolic wastes, and

gases (oxygen, carbon dioxide) to and from cells. Components of the circulatory system
include:

• blood: consisting of liquid plasma and cells

• blood vessels (vascular system): the "channels" (arteries, veins, capillaries) which
carry blood to/from all tissues. (Arteries carry blood away from the heart. Veins
return blood to the heart. Capillaries are thin-walled blood vessels in which gas/
nutrient/ waste exchange occurs.)
• heart: a muscular pump to move the blood

There are two circulatory "circuits": Pulmonary circulation, involving the "right heart,"
delivers blood to and from the lungs. The pulmonary artery carries oxygen-poor blood from
the "right heart" to the lungs, where oxygenation and carbon-dioxide removal occur.
Pulmonary veins carry oxygen-rich blood from the lungs back to the "left heart." Systemic
circulation, driven by the "left heart," carries blood to the rest of the body. Food products
enter the system from the digestive organs into the portal vein. Waste products are removed
by the liver and kidneys. All systems ultimately return to the "right heart" via the inferior and
superior vena cava.

A specialized component of the circulatory system is the lymphatic system, consisting of a

moving fluid (lymph/interstitial fluid); vessels (lymphatics); lymph nodes, and organs (bone
marrow, liver, spleen, thymus). Through the flow of blood in and out of arteries, and into the
veins, and through the lymph nodes and into the lymph, the body is able to eliminate the
products of cellular breakdown and bacterial invasion.
Blood Components

Adults have up to ten pints of blood.

• Forty-five percent (45%) consists of cells - platelets, red blood cells, and white blood
cells (neutrophils, basophils, eosinophils, lymphocytes, monocytes). Of the white
blood cells, neutrophils and lymphocytes are the most important.

Fifty-five percent (55%) consists of plasma, the liquid component of blood.

Vascular System - the Blood Vessels

Major Blood Components

Modified from: Joel DeLisa and Walter C. Stolov, "Significant Body Systems," in: Handbook of Severe Disability, edited by Walter C.
Stolov and Michael R. Clowers. US Department of Education,
Rehabilitation Services Administration, 1981, p. 37.

Component Type Source Function

Platelets, cell fragments Bone marrow Blood clotting
life-span: 10
days
Lymphocytes (leukocytes) Bone marrow, Immunity
spleen, lymph T-cells attack cells containing
nodes viruses. B-cells produce
antibodies.
Red blood cells (erythrocytes), Filled with Bone marrow Oxygen transport
hemoglobin, a compound of iron and protein life-span: 120
days
Neutrophil (leukocyte) Bone marrow Phagocytosis

Plasma, consisting of 90% water and 10% 1. Maintenance of pH level

dissolved materials -- nutrients (proteins, near 7.4
salts, glucose), wastes (urea, creatinine), 2. Transport of large
hormones, enzymes molecules
(e.g. cholesterol)
3. Immunity (globulin)

4. Blood clotting (fibrinogen)

Arteries, veins, and capillaries comprise the vascular system. Arteries and veins run
parallel throughout the body with a web-like network of capillaries connecting them. Arteries
use vessel size, controlled by the sympathetic nervous system, to move blood by pressure;
veins use one-way valves controlled by muscle contractions.
Arteries
Arteries are strong, elastic vessels adapted for carrying blood away from the heart at
relatively high pumping pressure. Arteries divide into progressively thinner tubes and
eventually become fine branches called arterioles. Blood in arteries is oxygen-rich, with the
exception of the pulmonary artery, which carries blood to the lungs to be oxygenated.

The aorta is the largest artery in the body, the main artery for systemic circulation.
The major branches of the aorta (aortic arch, ascending aorta, descending aorta) supply blood
to the head, abdomen, and extremities. Of special importance are the right and left coronary
arteries, that supply blood to the heart itself.

Major Branches of Systemic Circulation

Source: Joel DeLisa and Walter C. Stolov, "Significant Body Systems," in: Handbook of Severe Disability, edited
by Walter C. Stolov and Michael R. Clowers. US Department of Education,
Rehabilitation Services Administration, 1981, p. 40.

Name Serves
Head Carotid Brain & skull

Abdomen Mesenteric Intestines

Celiac (Abdominal) Stomach, liver, spleen
Renal Kidney
Iliac Pelvis

Upper Extremity Brachial (axillary) Upper arm

Radial & Ulnar Forearm & hand
Dorsal Carpal Fingers

Lower Extremity Femoral Thigh

Popliteal Leg
Dorsal pedis Foot
Posterior tibial 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

Blood vessel anatomy

comes the media; and the outermost is the adventitia. Arteries have thick media to absorb the
pressure waves created by the heart's pumping. The smooth-muscle media walls expand when
pressure surges, then snap back to push the blood forward when the heart rests. Valves in the
arteries prevent back-flow. As blood enters the capillaries, the pressure falls off. By the time
blood reaches the veins, there is little pressure. Thus, a thick media is no longer needed.
Surrounding muscles act to squeeze the blood along veins. As with arteries, valves are again
used to ensure flow in the right direction.

Anatomy of the Heart

The heart is about the size of a man's fist. Located between the lungs, two-thirds of it
lies left of the chest midline The heart, along with the pulmonary (to and from the lungs) and
systemic (to and from the body) circuits, completely separates oxygenated from
deoxygenated blood.

Internally, the heart is divided into four hollow chambers, two on the left and two on the
right. The upper chambers of the heart, the atria (singular: atrium), receive blood via veins.
Passing through valves (atrioventricular (AV) valves), blood then enters the lower chambers,
the ventricles. Ventricular contraction forces blood into the arteries.
 Interior View Posterior View

Oxygen-poor blood empties into the right atrium via the superior and inferior vena
cavae. Blood then passes through the tricuspid valve into the right ventricle which contracts,
propelling the blood into the pulmonary artery. The pulmonary artery is the only artery that
carries oxygen-poor blood. It branches to the right and left lungs. There, gas exchange occurs
-- carbon dioxide diffuses out, oxygen diffuses in.

Pulmonary veins, the only veins that carry oxygen-rich blood, now carry the
oxygenated blood from lungs to the left atrium of the heart. Blood passes through the
bicuspid (mitral) valve into the left ventricle. The ventricle contracts, sending blood under
high pressure through the aorta, the main artery for systemic circulation. The ascending aorta
carries blood to the upper body; the descending aorta, to the lower body.

Blood Pressure and Heart Rate

The heart beats or contracts around 70 times per minute.1 The human heart will
undergo over 3 billion contraction/cardiac cycles during a normal lifetime.

One heartbeat, or cardiac cycle, includes atrial contraction and relaxation, ventricular
contraction and relaxation, and a short pause. Atria contract while ventricles relax, and vice
versa. Heart valves open and close to limit flow to a single direction. The sound of the heart
contracting and the valves opening and closing produces a characteristic "lub-dub" sound.

The cardiac cycle consists of two parts: systole (contraction of the heart muscle in the
ventricles) and diastole (relaxation of the ventricular heart muscles). When the ventricles
contract, they force the blood from their chambers into the arteries leaving the heart. The left
ventricle empties into the aorta (systemic circuit) and the right ventricle into the pulmonary
artery (pulmonary circuit). The increased pressure on the arteries due to the contraction of the
ventricles (heart pumping) is called systolic pressure.

When the ventricles relax, blood flows in from the atria. The decreased pressure due
to the relaxation of the ventricles (heart resting) is called diastolic pressure.

Blood pressure is measured in mm of mercury, with the systole in ratio to the diastole.
Healthy young adults should have a ventricular systole of 120mm, and 80mm at ventricular
diastole, or 120/80.

Receptors in the arteries and atria sense systemic pressure. Nerve messages from
these sensors communicate conditions to the medulla in the brain. Signals from the medulla
regulate blood pressure.

Electrocardiography (ECG, EKG)

An electrocardiogram measures changes

in electrical potential across the heart and
detects contraction pulses that pass over the
surface of the heart. There are three slow,
negative changes, known as P, R, and T.
Positive deflections are the Q and S waves. The
P wave represents atrial contraction ("the lub"), the T wave the ventricular contraction ("the
dub").

The Lymphatic System

The lymphatic system functions 1) to absorb excess fluid, thus preventing tissues
from swelling; 2) to defend the body against microorganisms and harmful foreign particles;
and 3) to facilitate the absorption of fat (in the villi of the small intestine).

Capillaries release excess water and plasma into intracellular spaces, where they mix
with lymph, or interstitial fluid. "Lymph" is a milky body fluid that also contains proteins,
fats, and a type of white blood cells, called "lymphocytes," which are the body's first-line
defense in the immune system.
 Lymph flows from small lymph capillaries into lymph vessels that are similar to veins
in having valves that prevent backflow. Contraction of skeletal muscle causes movement of
the lymph fluid through valves. Lymph vessels connect to lymph nodes, lymph organs (bone
marrow, liver, spleen, thymus), or to the cardiovascular system.

• Lymph nodes are small irregularly shaped masses through which lymph vessels flow.
Clusters of nodes occur in the armpits, groin, and neck. All lymph nodes have the
primary function (along with bone marrow) of producing lymphocytes.
• The spleen filters, or purifies, the blood and lymph flowing through it.
• The thymus secretes a hormone, thymosin, that produces T-cells, a form of
lymphocyte.

BLOOD VESSELS

,
• Wall of an artery consists of three (3) distinct layers of tunics
• Tunica intima
o Composed of simple, squamous epithelium called endothelium.
o Rests on a connective tissue membrane that is rich in elastic and collagenous
fibers.
• Tunica media
o Makes up the bulk of the arterial wall.
o Includes smooth muscle fibers, which encircle the tube, and a thick layer of
elastic connective tissue.
• Tunica adventitia
o Is relatively thin.
o Consists chiefly of connective tissue with irregularly arranged elastic and
collagenous fibers.
o This layer attaches the artery to the surrounding tissues.
o Also contains minute vessels (vasa vasorum--vessels of vessels) that give rise
to capillaries and provide blood to the more external cells of the artery wall.
• Smooth muscles in the walls of arteries and arterioles are innervated by the
sympathetic branches of the autonomic nervous system. 17986
• Impulses on these vasomotor fibers cause the smooth muscles to contract causing
vasoconstriction.
• If these impulses are inhibited, the muscle fibers relax and the diameter of the vessel
increases--vasodilation.

• Capillaries OH-130 and 20.3 A,B

• Flow of blood through the capillaries is regulated by vessels with smooth muscles in
their walls.
o Metarteriole--is a vessel that emerges from an arteriole, passes through the
capillary network and empties into a venule.
 Proximal portions of the metarterioles are surrounded by scattered
smooth muscle cells whose contraction and relaxation help regulate the
amount and force of the blood.
 Distal portion of a metarteriole has no smooth muscle fibers and is
called a thoroughfare channel.
 Serves as a low resistance channel that increases blood flow.
• True Capillaries
o Emerge from arterioles or metarterioles and are not on the direct flow route
from arteriole to venule.
 o At their site of origin, there is a ring of smooth muscle fibers called a
precapillary sphincter that controls the flow of blood entering a true
capillary.
• Continuous Capillaries 17991

• Are named because the cytoplasm of the endothelial cells is continuous when viewed
in cross-section through a microscope.
o Cytoplasm appears as an uninterrupted ring, except for the endothelial
junction.

• Fenestrated Capillaries 17992

• Differ from continuous capillaries in that their endothelial cells have numerous pores
or fenestrations where the cytoplasm is very thin or absent.
• Found in kidneys, villi of the small intestine, choroid plexi of the ventricles of the
brain, and endocrine glands.
• Sinusoids or Discontinuous Capillaries 17994

• Are wider than capillaries and more torturous

o Contain spaces between endothelial cells instead of having the usual
endothelial lining.
• Basal lamina is incomplete or missing.
o In addition, sinusoids contain specialized lining cells that are adapted to the
function of the tissue.
o In the liver, sinusoids contain phagocytic cells called stellate
reticuloendothelial (Kupffer) cells.
o Other regions containing sinusoids include the spleen, parathyroid glands,
adrenal cortex, and bone marrow.

• Venules and Veins OH-131 and 20.1 A,B 17975

• Venules are the microscopic vessels that continue from the capillaries and merge to
form veins.
• Veins which carry blood back to the heart, follow pathways roughly parallel to those
of the arteries.
• Walls of veins are similar to those of arteries, in that they are composed of three
distinct layers.
o Middle layer is poorly developed.
o As a result, veins have thinner walls that contain less smooth muscle and less
elastic tissue than arteries.
• Many veins, particularly those in the arms and legs, have flaps or valves which project
inward from the lining.
o Valves are usually composed of two leaflets that close if the blood begins to
back up in the veins.
 Valves are open as long as the blood flow is toward the heart and
closed if it is in the opposite direction.
• Veins also function as blood reservoirs that can be drawn upon in time of need.
o If a hemorrhage accompanied by drop in blood pressure occurs, the muscular
walls of the veins are stimulated reflexively by the sympathetic nervous
system.
 Veins constrict and help to raise the blood pressure.
 This mechanism ensures a nearly normal blood flow even if as much as
25% of the blood volume is lost.
MITRAL STENOSIS
Natural History:
Mitral Stenosis is a progressive disease in most patients. As depicted in figure below
an average of 19 years elapses before the onset of dyspnea.

Recognised MS Dyspnea Valve Replacement/PMBV

I--------------------I-------------------I------------------I------------------I Death
Rheumatic Fever
0 ------------Time in years--------19

Before the surgical era the outlook for patients with this disease was unfavourable. From
1925 Rowe et al 17studied 250 patients with mitral stenosis. By 10 years 39% of patients had
died, 22% had become more dyspneic, and 16% had developed at least one thromboembolic
complication. By 20 years, 79% had died 8% had become more symptomatic, and 26% had
developed at least one thromboembolic event. Progression of disease is the rule at least in the
symptomatic group. The younger patients follow a more benign course then their old counter
parts .
DIAGNOSIS :
The diagnosis of mitral stenosis is suspected on history and confirmed by physical
examination, electrocardiography and echocardiography. Cardiac catheterization may aid the
diagnosis and treatment in selected individuals.
History:
• History of acute rheumatic fever, although many patients do not recall this.
• History of murmur
• Effort induced dyspnea is the most common complaint and is often triggered by
exertion, fever, anemia, onset of atrial fibrillation or pregnancy.
• Orthopnea progressing to paroxysmal nocturnal dyspnea.
• Effort induced fatigue
• Hemoptysis, due to rupture of thin dilated bronchial veins, is a late finding.
• Chest pain may be due to right ventricular ischemia, concomitant coronary
atherosclerosis or secondary to a coronary embolism.
• Thromboembolism may be the first symptom of MS.
• Palpitations
• Recumbent cough
Physical:
The physical exam findings depend on how advanced the disease is and the degree of
underlying cardiac decompensation.
• Peripheral and facial cyanosis, can be seen more if the patient is polycythemic
• Jugular venous distention, with positive hepatojugular reflex
• Respiratory distress, evidence of pulmonary edema (rales, etc.)
• Diastolic thrill palpable over apex.
• The murmur of mitral stenosis is best heard at the apex with little radiation. It is
nearly holodiastolic with pre-systolic accentuation due to the atrial kick. It is usually
described as low-pitched, decrescendo, and rumbling, and can be heard best with the
patient in the left lateral decubitus position. The murmur appears about 0.08 seconds
after S2, and is heralded by an "opening snap". This is a brief, loud sound which is
caused as the stenotic valve suddenly halts its normal opening at the start of diastole.
• Loud S1 followed by S2 and opening snap best heard at left sternal border. This is
succeeded by a low pitched rumbling diastolic murmur best heard over the apex, with
the patient in the left lateral decubitus position. This may diminish in intensity with
increasing stenosis. This S1 becomes more pronounced after exercise.
• The duration of the diastolic murmur, not the intensity, correlates with the severity of
mitral narrowing 13.The holosystolic murmur of mitral regurgitation may accompany
the valvular deformity of mitral stenosis.
• Digital clubbing
• Systemic embolization
• Signs of right heart failure in severe MS include ascites, hepatomegaly and peripheral
edema. If pulmonary hypertension is present there may be a right ventricular lift, an
increased pulmonic second sound and a high-pitched decrescendo diastolic murmur of
pulmonary insufficiency (Graham Steele's murmur).
DIFFERENTIAL DIAGNOSIS
Aortic Regurgitation
• May give diastolic murmur and left sided failure but left ventricle is enlarged and
murmur is usually parasternal and high pitched
Chronic Obstructive Pulmonary Disease and Emphysema
• May have cyanosis and edema, and can occur with MS, Patients with MS are
frequently diagnosed as asthmatics.
Other Problems to be Considered
 • Atrial Myxoma
Laboratory Studies:
Complete blood count (CBC), in cases of hemoptysis and to rule out anemia
Blood culture, in cases of suspected endocarditis
Electrolytes
Imaging Studies:
Chest X-Ray (CXR):
o Signs of pulmonary overload:
1. Prominence of pulmonary arteries,
2. Enlargement of right ventricle and
3. Evidence of CHF (interstitial edema with kerley B lines).
• Left atrial enlargement with straightening of the left heart border, double density seen
on CXR and also menifested by elevation of the left mainstem bronchus
• Pulmonary venous pattern changes with redistribution of flow toward the apices
Prominent pulmonary arteries at the hilum with rapid tapering
• Kerley's B line Pulmonary edema pattern (late)
Electrocardiogram (EkG):
• In sinus rhythm, enlarged left atrium is signified by a broad notched P wave most
prominent in lead II, with a negative terminal force in V1 15,16
• With severe pulmonary hypertension, right axis deviation and right ventricular
hypertrophy can be seen.
• Atrial fibrillation is a common but nonspecific finding in MS.

Echocardiography:
Transthoracic two dimensional echocardiography is the most sensitive and specific
non-invasive method for diagnosing mitral stenosis . With 2 dimensional echocardiography
mitral valve area can be calculated using different techniques. With two dimensional ECHO,
the size of the mitral orifice can be measured along with cardiac chamber sizes. The addition
of color Doppler can evaluate the transvalvular gradient, pulmonary artery pressure and
accompanying mitral regurgitation.
 Modifiable Factors
2. Pathophysiology (Book-based) schematic diagram
- Stress -
Alcohol
- Sedentary Lifestyle -Smoking
Non-Modifiable factors - Diet -with
-Hereditary history of
-Age (>40 y/o) - Hypertension
- Gender rheumatic fever
- 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
Thickening, fibrosis, Thickening, fusion,
leaflets
and calcifications of shortening of the
leaflet cusps chordae tendinae

Blood flow narrowed and valve opening is reduced

Increase pressure of blood in the left Heart murmur is heard

atrium (left arterial pressure) upon auscultation

Increase pulmonary venous and capillary pressure and resistance

Burst in veins/
Pulmonary congestion capillaries

Left atrium enlarges

Hemoptysis
Pulmonary
hypertension

Right-sided Heart failure

Decrease blood flow and
oxygen (O2) supply
 Body
↓ O2 supply ↓ Renal
↓ Cerebral compensate ↓ Tissue
to the Perfusion Heart pumps s by Perfusion Tissue
muscle cells harder than Perfusio
prioritizing
normal perfusion of n
Body Syncope
Increase vital organs Body will
compensate and
Cardiac compensate
s Dizziness ↓ blood flow Reductio
Output ↑ Ventilation
to the n of
Anaerobic extremities to ↑ oxygen glomerul
metabolism ↑ Heart rate concentratio ar
(Tachycardia n filtration
Pallor and ↑
) rate
Lactic acid Cyanosis Respiratory
accumulatio rate Elevat
n Increase blood ed
(Tachypne BUN
Irritates pressure
a) level
↑ Stroke
nerve Use accessory
volume ↑ Hydrostatic Pressure
endings muscles
Fluid shift Due to ↓ O2
Chest Pain Palpitations from supply,
and intravascular body
fatigue to interstitial compensate
space s
Fluid
accumulation Anaerobic
in the metabolism
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 Rationale

> Chest pain > 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 body’s 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
> Hemoptysis
> Due to use of accessory muscles and
decrease O2 supply, the body compensates
and is usually manifested by shortness of
breath that usually occurs 2-5 hours after
the onset of sleep
> Due to increase venous and capillary
pressure as well as resistance leads to burst
of veins and capillaries

> Elevated BUN level > Due to decrease renal tissue perfusion
which results to reduce glomerular
filtration rate thus, the BUN level becomes
elevated.
B. Pathophysiology (Client-based) schematic diagram
Modifiable Factors
Non-Modifiable factors - Stress
-Age (>40 y/o) - History of rheumatic fever
- Gender : Female - Diet
-Hereditary- CAD, HPN & - Hypertension
DM - 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
Thickening, fibrosis, Thickening, fusion,
leaflets
and calcifications of shortening of the
leaflet cusps chordae tendinae

Blood flow narrowed and valve opening is reduced

Heart murmur is heard
upon auscultation
Increase pressure of blood in the left
atrium (left arterial pressure) (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 Body
↓ Cerebral ↓ Tissue ↓ Renal
to the compensate
Perfusion Heart pumps Perfusion Tissue
muscle cells s by
harder than prioritizing Perfusio
normal perfusion of n
Body Syncope Increase vital organs Body will
compensate and compensate
s Cardiac
Dizziness ↓ blood flow Reductio
Output ↑ Ventilation
to the n of
to ↑ oxygen
Anaerobic Date?? extremities glomerul
metabolism concentratio ar
↑ Heart rate
Pallor and n filtration
(Tachycardia) -June Cyanosis ↑
rate
Lactic acid 24,2010 Respiratory
accumulatio June 24, rate Elevat
n Increase blood 2010 ed
(Tachypne
Irritates pressure BUN
a)
↑ Stroke level
nerve ↑ Hydrostatic Use accessory
volume muscles June
endings Pressure
Fluid shift Due to ↓ O2 24,
from 2010
Palpitations supply,
Chest Pain intravascular
(June 24, body
and
2010) to interstitial compensate
fatigue
(june 25, space s
Fluid
2010) accumulation Anaerobic
in the metabolism
interstitial
space
Lactic acid accumulation
(Third Spacing)

Edema Difficulty
of
(June 25, Breathing
2010) (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. Increase systemic vascular resistance,
endothelial damage, increase platelet adherence, increase
permeability of endothelial lining, results from increase blood
pressure
 Diabetes Mellitus – Mrs. Mapusu also has DM II.
o Glucose from carbohydrates cannot be transported into the
cells due to insulin deficiency or increase resistance to
insulin.
o The body then, mobilizes are converted into glucose
 Rheumatic fever- Mrs. Mapusu had this when she was 40 y/o;
heart inflammation that happens but can disappear gradually
usually within 5 months. However, it may permanently damage the
heart valves resulting to rheumatic disease. In rheumatic heart
disease the valve between the left atrium and ventricle (Mitral
valve) is most commonly damage which can eventually lead to
Mitral stenosis or mitral regurgitation.

b.3 Pathologic Changes

Mild mitral stenosis does not usually cause symptoms. Some people with more severe
mitral stenosis have atrial fibrillation or heart failure. People with atrial fibrillation may feel
palpitations (awareness of heartbeats). People with heart failure become easily fatigued and
short of breath. Shortness of breath may occur only during physical activity at first, but later,
it may occur even during rest. Some people can breathe comfortably only when they are
propped up with pillows or sitting upright. Those people with a low level of oxygen in the
blood and high blood pressure in the lungs may have a plum-colored flush in the cheeks
(called mitral facies). People may cough up blood (hemoptysis) if the high pressure causes a
vein or capillaries in the lungs to burst. The resulting bleeding into the lungs is usually slight,
but if hemoptysis occurs, the person should be evaluated by a doctor promptly because
hemoptysis indicates severe mitral stenosis or another serious problem.

b.4 Signs and Symptoms with rationale with their specific dates for the occurrences
of each manifestation

Signs and Symptoms Rationale Date of Occurrence

> Chest pain > Cessation of blood supply to June 24, 2010
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 June 25, 2010

inadequate cardiac output

> Syncope and Dizziness >This is due to decreased cerebral June 25, 2010
tissue perfusion.

> Palpitations > This is due to the increase stroke June 24, 2010
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 June 24, 2010
compensate for the decrease blood
flow to the body.
 > Increase respiratory rate is
> Tachypnea experienced by the patient as June 24, 2010
body’s compensation of decrease
tissue perfusion to increase the
oxygen concentration of the blood.

> Difficulty of Breathing > Due to use of accessory muscles June 24, 2010
and decrease O2 supply, the body
compensates and anaerobic
metabolism occur. Lactic acid
accumulates resulting to dyspnea.

> Edema > Shifting of fluid into the June 25, 2010
interstitial space due to increase in
the vascular area (hydrostatic)
pressure.

> Pallor & Cyanosis > Due to decrease tissue perfusion June 25, 2010
the patient turn dull and pale.

>Orthopnea > Due to use of accessory muscles June 25, 2010

and decrease O2 supply, the body
compensates and is usually a
symptom of more advanced heart
failure
V. THE PATIENT AND HIS CARE

a. Medical Management

A. IVF

Medical Management General Description Indication(s) or Date Ordered, Date Client Response to
Purpose(s) Performed, Date Treatment
Changed or D/C

PNSS Sodium Chloride is an Hypovolemia Date Ordered: The patient didn’t

isotonic crystalloid develop any undesirable
(0.9 Sodium solution that acts as a Dehydration June 24, 2010 response such as
Chloride) vehicle for many redness, swelling or
Facilitation of drug Date Performed:
KVO parenteral drugs and as administration pain.
an electrolyte June 24, 2010
replenisher for
maintenance or
replacement of deficits
in extracellular fluid.
Nursing Responsibilities

Before:

 Check the patient’s name and doctor’s order administration

 Check the patency of IV tubing
 Explain to the patient the indication of IVF infusion
 Always observe standard precautions

During:

 Regulate the gtts/min as ordered

 Monitor and ensure appropriate infusion flow to avoid fluid overload
 During the therapy, if the insertion site swells or bulges instruct patient/ SO to apply warm compress

After:

 Proper documentation
 Label the IV bottle with the following name of the patient, # of IVF, date and time started, gtts/min, time to be consumed
 In terminating the IVF prepare all necessary things such as alcohol, cotton balls, micro pore tape and bandage scissors
 Discard properly the IV set to avoid contamination
Medical Management General Description Indication(s) or Date Ordered, Date Client Response to
Purpose(s) Performed, Date Treatment
Changed or D/C

Oxygen Inhalation via The oxygen therapy To increase the oxygen Date Ordered: The patient verbalized
NC is usually ordered saturation of the body feeling of comfort while
once decreased during dyspnea June 24, 2010 in oxygen therapy and
oxygen saturation in
Date Performed: exhibit improvement on
the blood or tissues
is demonstrated. her breathing
June 24, 2010
It is designed to help
restore or improve
breathing function in
patients with a variety of
diseases or conditions
Nursing Responsibilities

Before:

 Check the patient’s name and doctor’s order administration

 Explain to the patient the indication of oxygen therapy
 Always observe standard precautions

During:

 Regulate the oxygen to 2-3 lpm.

After:

 Proper documentation
 Observe the patient skin integrity to prevent skin breakdown on pressure points from the oxygen delivery device.
 B. DRUG

Indication or Purpose
Generic name and General Classification why medication is Date Ordered, Date Client Response to
Brand name and mechanism of given for the Started, Date Changed Medication with actual
action particular disease or D/C side effects
condition
GN: ACE Inhibitors Treatment for Date Ordered: Patient’s BP decreased
Hypertension from 180/90 mmHg to
Indapamide Diuretic June 24, 2010 130/70 mmHg.
BN: Angiotensin-converting Date Started: Increased urine output
enzyme inhibitor and
Bi-Preterax diuretic acting on cortical June 24, 2010
dilution segment in fixed
combination.

Nursing Responsibilities:

Before:

 Check the doctor’s ordered

 Check the patient name
 Check the Vital Signs especially BP
 Check the name of the drug and dosage
 Monitor the intake and output

During:

 Give the drug with an empty stomach

After:

 Stress the importance of not chewing effervescent tablets, swallowing them whole, or letting them dissolve on the tongue
before swallowing
 Monitor output
 Document the date and time it was administered
 Indication or Purpose Date Ordered, Date Client Response to
Generic name and General Classification why medication is Started, Date Changed Medication with actual
Brand name and mechanism of given for the or D/C side effects
action particular disease
condition
GN: Cardiotonic Treatment for heart Date Ordered: Heart rate decreased to
failure, and arrhythmia 65 bpm from 130 bpm
Digoxin Antiarrhythmic June 24, 2010

BN: Increases the force and Date Started:

velocity of myocardial
Lanoxin contraction, resulting in June 24, 2010
positive inotropic effects.
Digoxin produces
antiarrhythmic effects by
decreasing the
conduction rate and
increasing the effective
refractory period of the
AV node.
Nursing Responsibilities:

Before:

 Check the doctor’s ordered

 Check the patient name
 Check the Vital Signs especially the pulse rate
 Check the name of the drug and dosage

During:

 Maybe taken with or without food

After:

 Stress the importance of not chewing effervescent tablets, swallowing them whole, or letting them dissolve on the tongue
before swallowing
 Document the date and time it was administered
 Indication or Purpose
Generic name and General Classification why medication is Date Ordered, Date Client Response to
Brand name and mechanism of given for the Started, Date Changed Medication with actual
action particular disease or D/C side effects
condition
GN: Antidiabetic To achieve glucose Date Ordered: Pt’s blood glucose
control in type 2 turned normal.
Rosiglitazone maleate Increases tissue diabetes mellitus June 24, 2010
sensitivity to insulin. This
BN: peroxisome proliferator- Date Started:
activated receptor agonist June 24, 2010
Avandia
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
Nursing Responsibilities:

Before:

 Check the doctor’s ordered

 Check the patient name
 Check the Vital Signs
 Check the name of the drug and dosage
 Explain to patient the importance of taking the drug

During:

 Make sure the drug was swallowed.

After:

 Stress the importance of not chewing effervescent tablets, swallowing them whole, or letting them dissolve on the tongue
before swallowing
 Document the date and time it was administered
 Check for the CBG
 Indication or Purpose Date Ordered, Date Client Response to
Generic name and General Classification why medication is Started, Date Changed Medication with actual
Brand name and mechanism of given for the or D/C side effects
action particular disease
condition
GN: Penicillin Treatment for Date Ordered: Pt didn’t manifest signs
Phenoxymethylpenicillin respiratory tract of infection
K Phenoxymethylpenicillin infection, viral June 24, 2010
inhibits the final cross- infections
BN: linking stage of Date Started:
peptidoglycan production June 24, 2010
Sumapen 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.

Nursing Responsibilities:
Before:

 Check the doctor’s ordered

 Check the patient name
 Check the Vital Signs
 Check the name of the drug and dosage

During:

 Explain to patient the importance of taking the drug

 Take the drugs with an empty stomach

After:

 Stress the importance of not chewing effervescent tablets, swallowing them whole, or letting them dissolve on the tongue
before swallowing
 Document the date and time it was administered
 Indication or Purpose
Generic name and General Classification why medication is Date Ordered, Date Client Response to
Brand name and mechanism of given for the Started, Date Changed Medication with actual
action particular disease or D/C side effects
condition
GN: Anticoagulants, Treatment and Date Ordered: Pt did not experience
Antiplatelets & prevention of venous bleeding.
Warfarin Fibrinolytics thrombosis June 24, 2010

BN: (Thrombolytics) Date Started:

Warfarin Warfarin inhibits June 24, 2010

synthesis of vit K-
dependent coagulation
factors VII, IX, X and II
and anticoagulant protein
C and its cofactor protein
S. No effects on
established thrombus but
further extension of the
clot can be prevented.
Secondary embolic
phenomena are avoided.
 Nursing Responsibilities:

Before:

 Check the doctor’s ordered

 Check the patient name
 Check the Vital Signs
 Check the name of the drug and dosage

During:

 Maybe taken with or without food

After:

 Stress the importance of not chewing effervescent tablets, swallowing them whole, or letting them dissolve on the tongue
before swallowing
 Document the date and time it was administered
 Indication or Purpose Date Ordered, Date Client Response to
Generic name and General Classification why medication is Started, Date Changed Medication with actual
Brand name and mechanism of given for the or D/C side effects
action particular disease
condition
GN: Beta blockers Management for angina Date Ordered: Pt’s BP decreased from
pectoris and 180/90 mmHg to 130/70
Atenolol Atenolol is a β1-selective hypertension June 24, 2010 mmHg.
adrenergic-blocking
BN: agent. It competitively Date Started: Pt’s heart rate decreased
Therabloc blocks adrenergic June 24, 2010 from 130 bpm to 65
stimulation of β1- bpm.
adrenergic receptors
within the myocardium
and vascular smooth
muscle. Low doses of
atenolol selectively
inhibit cardiac and
lipolytic β1-receptors but
with little effect on the
β2-adrenergic receptors of
bronchial and vascular
smooth muscle. At high
doses (ie, >100 mg
daily), this selectivity of
atenolol for β1-adrenergic
receptors may diminish
and the drug may
competitively block β1-
and β2-adrenergic
receptors. Atenolol does
not exhibit any intrinsic
sympathomimetic
activity nor any
membrane-stabilizing
activity.
Nursing Responsibilities:

Before:

 Check the doctor’s ordered

 Check the patient name
 Check the Vital Signs especially the pulse rate
 Check the name of the drug and dosage

During:

 Maybe taken with or without food

After:

 Stress the importance of not chewing effervescent tablets, swallowing them whole, or letting them dissolve on the tongue
before swallowing
 Document the date and time it was administered
 Check for bp and pulse rate

Generic name and General Classification
Brand name and mechanism of
action
GN: Antidotes, Detoxifying
Agents & Drugs Used in
Atropine sulfate Substance Dependence,
Indication or Purpose Date Ordered, Date Client Response to
why medication is Started, Date Changed Medication with actual
given for the or D/C side effects
particular disease
condition
Bradycardia Date Ordered: Pt’s heart rate increased
from 43 bpm to 72 bpm.
June 24, 2010

BN: Antispasmodics Date Started:

Anespin Atropine is an June 24, 2010

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.
Nursing Responsibilities:

Before:

 Check the doctor’s ordered

 Check the patient name
 Check the Vital Signs especially the pulse rate
 Check the name of the drug and dosage

During:

 Wipe the iv port and administer the med

After:

 Document the date and time it was administered

 Check for pulse rate
 Indication or Purpose Date Ordered, Date Client Response to
Generic name and General Classification why medication is Started, Date Changed Medication with actual
Brand name and mechanism of given for the or D/C side effects
action particular disease
condition
GN: Diuretics To treat edema due to Date Ordered: Pt’s BP decreased from
heart failure 180/90 mmHg to 130/70
Spironolactone Antihypertensive June 24, 2010 mmHg.
BN: Normally, aldosterone Date Started: Increased urinary output
attaches to receptors on
Aldactone the walls of distal June 24, 2010
convoluted tubule cells,
causing sodium and
water reabsorption in the
blood.
Nursing Responsibilities:

Before:

 Check the doctor’s ordered

 Check the patient name
 Check the Vital Signs especially the BP
 Check the name of the drug and dosage

During:

 Maybe taken with or without food

After:

 Stress the importance of not chewing effervescent tablets, swallowing them whole, or letting them dissolve on the tongue
before swallowing
 Document the date and time it was administered
 Check for BP and pulse rate
 Indication or Purpose Date Ordered, Date Client Response to
Generic name and General Classification why medication is Started, Date Changed Medication with actual
Brand name and mechanism of given for the or D/C side effects
action particular disease
condition
GN: Antidiabetic For Type 2 diabetes Date Ordered: The pt’s glucose level
mellitus turned to normal and did
Gliclazide Gliclazide is a June 24, 2010 not show any
sulfonylurea which manifestation of
BN: stimulates insulin Date Started:
increased glucose level.
secretion by the pancreas.
Diamicron June 24, 2010
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.
Nursing Responsibilities:

Before:

 Check the doctor’s ordered

 Check the patient name
 Check the Vital Signs
 Check the name of the drug and dosage

During:

 Should be taken with food

After:

 Stress the importance of not chewing effervescent tablets, swallowing them whole, or letting them dissolve on the tongue
before swallowing
 Document the date and time it was administered
Generic name and General Classification
Brand name and mechanism of
action
Indication or Purpose Date Ordered, Date Client Response to
why medication is Started, Date Changed Medication with actual
given for the or D/C side effects
particular disease
condition

GN: Analgesic Pain Date Ordered: Pt relieved from pain

Morphine Sulfate
Morphine is a Acute pulmonary June 24, 2010
BN: phenanthrene derivative edema
Morphine which acts mainly on the Date Started:
CNS and smooth
muscles. It binds to June 24, 2010
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.
Nursing Responsibilities:

Before:

 Check the doctor’s ordered

 Check the patient name
 Check the Vital Signs
 Check the name of the drug and dosage

During:

 Wipe the iv port with alcohol and administer it via iv push

After:

 Document the date and time it was administered

 Indication or Purpose Date Ordered, Date Client Response to
Generic name and General Classification why medication is Started, Date Changed Medication with actual
Brand name and mechanism of given for the or D/C side effects
action particular disease
condition
GN: Antihypertensive To reduce edema Date Ordered: Patient’s BP decreased
caused by heart failure June 24, 2010 from 180/90 mmHg to
Furosemide Diuretic 130/70 mmHg.
To manage mild to Date Started:
BN: Inhibits sodium and moderate hypertension Increased urine output
Lasix water reabsorption in the June 24, 2010
loop of henle and
increases urine
formation.

Nursing Responsibilities:

Before:

 Check the doctor’s ordered

 Check the patient name
 Check the Vital Signs especially the BP
 Check the name of the drug and dosage

During:

 Wipe the port with an alcohol and SIVP

After:

 Check for any complications

 Document the date and time it was administered

Generic name and General Classification
Brand name
and mechanism of
action
Indication or Purpose Date Ordered, Date Client Response to
why medication is Started, Date Changed Medication with actual
given for the or D/C side effects
particular disease
condition

GN: Insulin Preparations Treatment of patients Date Ordered: DM is being controlled

with diabetes mellitus, by the medications
BN: The time course of action for the control of June 24, 2010
of any insulin may vary hyperglycemia.
Humulin R considerably in different Date Started:
individuals or at different June 24, 2010
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.
Nursing Responsibilities:

Before:

 Check the doctor’s ordered

 Check the patient name
 Check the Vital Signs
 Check the name of the drug and dosage

During:

 Administer the drug subcutaneously

After:

 Document the date and time it was administered

 C. Diet

Date Ordered, Date Client’s Response

Date Started, and/or Reaction to the
Type of Diet General Description Indication/Purpose Date Changed or D/C Diet

1. Nothing Per Orem There nothing will be Ordered preoperatively Date Ordered: The patient follows the
(NPO) taken by mouth either and post operatively to diet prescribed by the
liquid or solid: ordered prevent aspiration or June 24, 2010 physician. And able to
pre operatively and post obstruction of Date Started: participate in what
operatively. respiratory airway to specific diet needed.
avoid further occurrence June 24, 2010
of complications.

2. Low Fat Diet containing limited Indicated in heart

amount of fat and diseases, to prevent the
consisting chiefly of further narrowing of the Date Ordered: The patient was willing
easily digestible foods of artery due t to improve his diet by
June 24, 2010 following the given
high carbohydrate accumulation of fats or
content. It includes all lipids in the tunica Date Started: health teachings given to
vegetables, lean meats, intima. him regarding his diet
fish, fowl, pasta, cereals June 24, 2010 especially in limiting his
and whole wheat or To reduce serum levels
cholesterol intake.
enriched bread of LDL (Low Density
Lipoprotein)

3. Low Sodium Diet that restricts the use Is indicated when edema Date Ordered: The patient was able to
of sodium chloride plus is present, in follow the instructed diet
other compounds hypertension, and given to him by limiting
 containing sodium such certain cardiac June 24, 2010 his sodium intake.
as baking powder or conditions, (CAD), to
soda, monosodium reduce fluid retention Date Started:
glutamate, sodium
June 24, 2010
citrate , sodium.
propionate and sodium
sulfate

Nursing Responsibilities on NPO

Before:

 Check the doctor’s ordered

 Check the patient name.
 Assure IVF therapy if patient is on NPO
 Explain the purpose and reason of the diet prescribed to the patient / SO

During:

 Assess patient condition

 Remind the patient and So that he is on NPO stats until further notification of the doctor

After:

 Instruct SO not to give anything through the moth either liquid or solid
 Observed patient response to diet
 Document the date it was ordered and implemented
Nursing Responsibilities on Low Fat Low Sodium

Before:
 Check the doctor’s order
 Check the patient name.
 Explain the purpose and reason of the diet prescribed to the patient / SO

During:

 Assess patient condition

 Remind the patient and So that he is on low fat low sodium diet

After:

 Observed patient response to diet

 Document the date it was ordered and implemented

D.Activity/Exercise
There was no exercise being ordered by the physician, as seen in the doctor’s order.

2. NURSING MANAGEMENT
 ASSESSMENT NURSING SCIENTIFIC PLANNING NURSING RATIONALE EXPECTED
DIAGNOSIS EXPLANATION INTERVENTION OUTCOME

S> Decreased Mitral stenosis the Short-term: - establish - to gain trust Short-term:
cardiac output narrowing of the rapport and
related to mitral valve confidence of
the patient
valvular disease opening, thus, After 2 hours, patient
2° mitral stenosis there has been will verbalize
O > weakness decreased blood - monitor and - to obtain Patient shall
knowledge of the
> pallor flow. record vital baseline data verbalize knowledge
disease process,
>slow capillary signs of the disease
refill individual risk
factors, and treatment process, individual
>decreased heart - assess - to note for any
rate-43 bpm (june plan risk factors, and
patient’s problems
25, 2010) condition treatment plan
>skin slightly
cold to touch - review - to assess the
diagnostic condition of
studies such as the heart and
Long-term: ECG tracing, its ability to
x-ray work
Long-term:
- promote - to promote
After 2 days, patient
adequate rest relaxation and
will participate in by decreasing decrease
activities that reduce stimuli and cardiac Patient shall
the workload of the provide quiet workload participate in
heart such as stress environment
activities that reduce
management/rest
- encourage use - to reduce the workload of the
plan
of relaxation anxiety and heart such as stress
techniques aid in proper management/rest plan
circulation

- encourage - to reduce risk

changing of orthostatic
position hypotension
slowly,
dangling legs
before
standing

- discuss to the
patient the - to promote
disease understanding
process and and provide
 NURSING SCIENTIFIC NURSING EXPECTED
CUES OBJECTIVE RATIONALE
DIAGNOSIS EXPLANTION INTERVENTIONS OUTCOME

S> “masakit ku Impaired Gas Due to mitral After 2 hours of >Establish rapport >To gain patient After 1 -2 hours
buntuk pag Exchange related valve stenosis, Nursing trust and of nursing
migigising ku, to altered blood blood flow Intervention the cooperation interventions
medyo flow 2° mitral decreases thus patient will patient will
magkasakit stenosis oxygenated blood demonstrate >Monitor record >For base line demonstrate
mangisnawa” is not sufficiently improve Vital Signs data relieved and
distributed to ventilation maintain adequate
O> lethargy different parts of absence of >Elevated head and >To maintain oxygen
> slight the body. distress. bed/position client airway
confusion appropriately
> general
weakness >Maintain adequate
>pallor I/O but avoid fluid >For mobilization
> edema in both overload of secretions
hands
>Encourage
adequate rest and >Helps limits
limit activities oxygen needs or
consumption
>Provide calm and
clean environment >To promote
comfort
>Reinforce need for
adequate rest, while
encouraging activity >To decrease
and exercise 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- 36.1°C, PR- 86 bpm, RR-
30 bpm
A> Activity Intolerance r/t generalized weakness 2° mitral stenosis
P> After 1° of nursing interventions, pt. will be able to demonstrate ways to modify
activities to reduce exertional dyspnea.
I> Assessed for weakness & fatigue
> Monitored & recorded V/S Q4°
> Provided adequate rest periods
> Assisted in doing activities such as walking & positioning.
> Provided comfort measures such as changing the linens.
> Encouraged deep breathing exercise
> Instructed S.O. to provide a quiet environment to pt.
> Encouraged verbalization of discomfort
> Instructed to increase activity levels gradually while conserving energy by stopping
3 mins. During exertional activity.
E> Goal met AEB pt.’s demonstration on ways to modify activities to reduce
exertional dyspnea.
VI. PATIENT DAILY PROGRESS IN THE HOSPITAL (from ADMISSION to
DISCHARGE)

CRITERIA ADMISSION DISCHARGE

June 24, 2010 June 25, 2010 June 28, 2010
NURSING
PROBLEMS
1. Ineffective Breathing
pattern r/t chest pain 2º √
mitral stenosis
2.Activity Intolerance r/t √
generalized weakness 2º
mitral stenosis
3. Decreased Cardiac √
output r/t valvular
disease
4. Impaired Gas √
exchange r/t altered blod
flow
VITAL SIGNS
Temp: ºC 37 36.5 36.4
PR: bpm 130 43 72
RR: bpm 40 20 22
BP: mmHg 180/90 120/70 100/60

DIAGNOSTIC AND
LABORATORY
PROCEDURES
SPECIAL √
HEMATOLOGICAL
PROCEDURES
BLOOD CHEMISTRY √
XRAY √
ECG √
ABG √
CBG √
CREATININE √
MEDICAL
MANAGEMENT
PNSS √ √ √
02 THERAPY √ √
DRUGS
INSULIN HR √
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) ½ tab (PM)

Warfarin 2 mg ½ tab (AM)
Lanoxin 0.25 mg ½ tab OD
Diamicron 80 mg 1 tab BID
Avandia 4 mg 1 tab (AM) OD
Sumapen 250 mg 1 tab BID

Exercise:
Encourage brisk walking.
Progressive Activity
 Activity progression is based on the metabolic equivalent of the task (MET), the
energy expenditure.
An exercise session is terminated if any one of the following occurs: cyanosis,
cold sweats, faintness, extreme fatigue, BP greater that 160/95 mmHg.

Treatment:
Encourage further laboratory tests like ECG, CXR, Hemodynamic Studies and Blood
Coagulation Tests and encourage patient to continue medication given by the doctor.

Health Teachings:
Encourage eating of fruits, vegetables and food low in fat and sugar. Limit strenuous
activities.. Emphasize to the patient the importance of strict compliance to the
medications given and return to usual home activities, relationships and to work at
earliest opportunity would be beneficial.

Outpatient:
Must see her doctor regularly to ensure health safety.

Diet:
Encourage patient to eat low Sugar, low fat diet, with increased fruits and
vegetables/Diabetic Diet

Sex:
We must health reduce the patient that she must resume sexual activity 4 to 8 weeks after
hosptalization. Encourage to take medicine given by the doctor before sexual intercourse.
Caution patient not to eat or drink alcoholic beverages immediately before intercourse.
The patient must assume less fatiguing position. The partner takes the active role. They
must perform sexual activity in a cool, familiar environment .She must Refrain from
sexual activity during a fatiguing day, after eating a large meal, or after drinking alcohol.
And if dyspnea, chest pain, dizziness or palpitations occur, moderation should be
observed; if symptoms persist, stop sexual activity.
IX. RECOMMENDATION
 As a student nurse we must know the different measurements to prevent the occurrence
of having disease. One of our responsibly to impart knowledge on how to prevent this disease
especially people who doesn’t have the enough knowledge in this disease .There are some people
who tend to ignore unusual things that they fell, but we must always remember early prevention
is the best way to prevent this disease. the government must also be aware of this, they must do
some program especially in a urban areas discussing the possible complication, the prevention
and how to manage this disease because this help to minimized the occurrence of this disease.

Further more, to people who diagnosed with mitral stenosis resulting to cardiomegaly,
this following management is very important to remember in order to prevent further
exacerbation of this disease:

Treatments
Treatment of cardiac disease is not simple. A patient's heart and life depend upon its
successful treatment. For some people, careful lifestyle changes and medications can control the
disease. In more serious cases, surgery may be required. In any case, the disease requires lifelong
management.

Take your medications

Medications may be needed to help your heart work more efficiently and receive more
oxygen-rich blood. The medications you are on depend on you and your specific heart problem.
Check It is important to know:

• the names of your medications

• what they are for
• how often and at what times to take your medications

Your doctor or nurse should review your medications with you. Keep a list of your
medications and bring them to each of your doctor visits. If you have questions about your
medications, ask your doctor or pharmacist.
Lower high blood cholesterol

A high-fat diet can contribute to increased fat in your blood. Ask your doctor to have a
measurement of your fasting lipid measurement. Follow a low-fat, low-cholesterol eating plan.
When proper eating does not control your cholesterol levels, your doctor may prescribe
medications.

Control high blood pressure

High blood pressure can damage the lining of your coronary arteries and lead to coronary artery
disease. Check your blood pressure on a regular basis. A healthy diet, exercise, medications and
controlling sodium in your diet can help control high blood pressure.

Achieve and maintain your ideal body weight

Obesity is defined as being very overweight (greater than 25 percent body fat for men or
30 percent body fat for women). When you are very overweight, your heart has to do more work,
and you are at increased risk of high blood pressure, high cholesterol levels and diabetes. Ask
your doctor what your ideal weight should be. A healthy diet and exercise program aimed at
weight loss can help improve your health.

Control Stress and Anger

Uncontrolled stress or anger is linked to increased coronary artery disease risk. You may need to
learn skills such as time management, relaxation, or yoga to help lower your stress levels.

Exercise

In the calories-in to calories-out equation, exercise helps to take off excess body weight.
More importantly, moderate amounts of physical exercise help build a stronger circulatory
system and decrease the risk of death from coronary artery disease. Patients with advanced forms
of the disease may need to limit their exercise, and should check with their doctor for special
advice

X. BIBLIOGRAPHY

Books

Gail W. Stuart & Michele T. Laraia. Principles and Practice of Psychiatric Nursing, 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 & Suddarth’s Textbook of Medical Surgical Nursing, 10th
Edition. Lippincott Williams & Wilkins, 2004.

Mosby. Mosby’s Nursing PDQ. ELSEVIER (SINGAPORE) PTE LTD. (2004)

Electronic Media

http://www.wrongdiagnosis.com/a /stats.htm

http://webschoolsolutions.com/patts/systems/heart.htm#intro

http://www.emedicine.com/MED/topic3430.htm

http://www.cayugacc.edu/people/facultypages/greer/biol204/vessels1.html

http://www.wrongdiagnosis.com/a /stats-country.htm
MsDict Viewer. Version 2.00. (2003).