Question

I. Read Chapter 36 from your Text Book and PP

II. NCLEX Review Questions Chapter 36 from Evolve Resources

III. Case Study: Mitral Stenosis

Patient Profile

L.S. is a 59-year-old female who goes to see her primary care provider because of increasing fatigue and shortness of breath with activity. She has a history of hypertension, hypothyroidism, rheumatoid arthritis, and rheumatic fever as a child. She is taking the following medications:

Triamterene/hydrochlorothiazide 37.5/25 mg PO daily

Levothyroxine 150 mcg PO daily

Methotrexate 15 mg PO every Sunday

Subjective Data

Does not exercise, but was always able to do daily activities such as go up and down the stairs of her home and go grocery shopping

The last few weeks has noticed that she gets short of breath with her normal daily activities

Has been waking up at night short of breath

Denies any pain in her chest

Does not have any pain in her joints as long as she takes her “arthritis medicine”

Objective Data

Physical Examination

Temperature 98.5° F, pulse 88 and irregular, respirations 24, blood pressure 134/82, O₂ saturation 92%

Irregular heart rate with a grade III diastolic murmur

Crackles in bilateral bases of lungs

No peripheral edema noted

Diagnostic Studies

ECG shows atrial fibrillation with heart rate of 90

Echocardiogram reveals mitral valve stenosis with mild left-sided heart failure

Laboratory Studies:

Hemoglobin       12 g/dL

Hematocrit        37%

T₄ (total)                      5.1 mcg/dL

Discussion Questions

What is mitral stenosis? What could be the possible cause of L.S.’s mitral stenosis

What clinical manifestations of mitral valve stenosis does L.S. have?

How did the mitral valve stenosis contribute to the development of left-sided heart failure?

What clinical manifestations of left-sided heart failure does L.S. have?

What are the treatment options for L.S.?

What would be some pertinent nursing diagnoses and goals for L.S.?

What are the priority nursing interventions for these nursing diagnoses?

Answer 1

Mitral valve which is also known as bicuspid valve or left atrioventricular valve is the valve which guards the opening between left atrium and left ventricle,allows blood to flow from left atrium to ventricle during diastole and prevents blood in ventricle from returning to the atrium.Mitral valve stenosis is the narrowing of the mitral valve so that valve dosen't open fully and results in the obstructing the blood to flow to the left ventricle.

Possible causes of mitral stenosis:

• rheumatic fever
• mitral valve repair
• mitral valve replacement
• rheumatoid arthritis
• obstruction due to large vegetation due to infective endocarditis
• mitral annular calcification
• malignant carcinoid syndrome

Clinical manifestations of mitral stenosis:

• dyspnea
• dizziness
• pulmonary edema
• lower limb edema
• Paroxysmal Nocturnal Dyspnea (PND)
• hemoptysis
• embolic vents such as stroke,myocardial infarction
• atrial fibrillation if not treated

Clinical manifestations of mitral valve stenosis that L.S. have:

• short of breath during normal activities ( dyspnea on exertion)
• short of breath at night ( PND)
• atrial fibrillation

Mitral stenosis can lead to left heart failure because in mitral stenosis the mitral valve is not opened fully and the heart has to work very hard to pump blood through the valve and leads to left sided heart failure.

Clinical manifestations of left-sided heart failure that L.S. have:

• shortness of breath due to the back up of fluid into lungs ( Dyspnea on exertion)
• Tachycardia
• PND

Treatment options for L.S:

• Betablockers and calcium channel blockers for heart rate control
• Anticoagulation with warfarin
• percutaneous mitral balloon valvotomy
• Mitral valve replacemt ( MVR )

Pertinent nursing diagnoses and goals for L.S.:

1.Decreased cardiac output related to mitral stenosis as evidenced by ECG changes(atrial fibrillation)

Goals:

• Patient will have adequate cardiac output as evidenced by absence of dysarrhythmias
• Patient will report decreaed dyspnea
• Patient will partcipate in acivities that reduce cardiac work load.

Interventions:

• Assess heart rate,blood pressure,temperature,peripheral pulses
• Assess for abnormal heart sounds and lung sounds
• Moitor oxygen saturation and ABG's
• Administer cardiac glycoside,Betablockers,calcium channel blockers to treat atrial fibrillation which is a sign of left sided heart failure
• Provide high fowlers position.

2.Fluid volume excess related to left sided heart failure as evidenced by crackles in bilteral bases of lungs n ausculation

Goals:

• Patient will have clear lung sounds with absence of crackles
• Patient will have increased knowledge of measures to be taken to treat fluid volume excess.

Interventions:

• Monitor weight of the patient
• Monitor intake and output of the patient as she will be on fluid restriction.
• Monitor blood pressure,heart rate
• Assess for lung crackles ,changes in respiratory pattern,dyspnea
• Administer diuretics as prescribed.