Rheumatic Heart Disease With Mitral Stenosis

Clinical Presentation

On

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


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.


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

.


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

Documents

Rheumatic Heart Disease With Mitral Stenosis