Question

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 a heart rate of 90
• An 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

1. What is mitral stenosis? What could be the possible cause of L.S.’s mitral stenosis?
2. What clinical manifestations of mitral valve stenosis does L.S. have?
3. How did the mitral valve stenosis contribute to the development of left-sided heart failure?
4. What clinical manifestations of left-sided heart failure does L.S. have?
5. What are the treatment options for L.S.?
6. What would be some pertinent nursing diagnoses and goals for L.S.?
7. What are the priority nursing interventions for these nursing diagnoses?

Answer 1

Ans) Mitral stenosis is a narrowing of the mitral valve opening that blocks (obstructs) blood flow from the left atrium to the left ventricle. Mitral stenosis usually results from rheumatic fever, but infants can be born with the condition. Mitral stenosis does not cause symptoms unless it is severe.

- Causes of mitral valve stenosis include: Rheumatic fever. A complication of strep throat, rheumatic fever can damage the mitral valve. Rheumatic fever is the most common cause of mitral valve stenosis.

- Signs & Symptoms of Mitral Valve Stenosis
Shortness of breath with exertion or when lying flat. Shortness of breath and coughing during the night. Swollen ankles and feet. Heart palpitations (rapid, fluttering heartbeat)

- A narrowed mitral valve interferes with blood flow. This can cause pressure to build in your lungs, leading to fluid accumulation. The fluid buildup strains the right side of the heart, leading to right heart failure. When blood and fluid back up into your lungs, it can cause a condition known as pulmonary edema.

- Left sided heart failure – pulmonary edema is the striking feature. Other signs are tachypnea, tachycardia, third heart sound, pulsus alternans, cardiomegaly

- If localized lesion treatment (based on cosmesis or symptoms) is desired, topical treatment with potent or ultrapotent topical corticosteroids is first line. For those with extensive involvement, rapid progression, or a goal of preventing new lesions, phototherapy or systemic therapy should be offered.