Question

N-CLASS/ONLINE CASE STUDY CHAPTER 36 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, 0 saturation 92% Irregular heart rate with a grade II 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% Ta(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 is also known as bicuspid valve or left atrioventricular valve through which blood from the left atrium pump to left ventricle. Mitral valve stenosis is the narrowing of mitral valve which cause an obstruction of blood flow from the left atrium to left ventricle.The possible cause of Mitral valve stenosis in L.S is rheumatic fever when she was a child because mitral valve stenosis is one of the complication of rheumatic fever.It make the wall of the valve thick and cause narrowing of valve opening.
• L.S has shortness of breaths during exertion(while doing daily activities) and when lying down (she wakes up during sleep ) These are the clinical manifestations for mitral valve stenosis.
• The obstruction in the blood flow due to mitral valve narrowingrestrict the noemal blood flow to left ventricle. This leads to pooling of blood in the left atrium.Increase boold volume causes pressure in the left atrium and causes enlargement. this finally develop left sided heart failure.
• The subjective( perceived by the patient) clinical manifestations are shortness of breath during daily activities and Awakening at night due to shortness of breath. The objective (Physical examination and investigations) clinical manifestations are irregular heart beat with grade II diastolic murmur, crackles in the bilateral base of lungs Atrial fibrilation in ECG.
• The treatment options for L.S can be based on managing the symptoms ,treating hypertension and other causative factors with the help of medications,life style modifications and surgical managements like mitral valve repair, cardiac reconstruction or cardiac transplant.

• Nursing diagnosis	Goals	Interventions
  Decreased cardiac output related to inadequate pumping of blood secondary to Structural changes in the heart as evidenced by dysrhythmias.	To improve cardiac output To reduce dyspnea develop activities which reduce cardiac work load	Provide adequate oxygen supply to improve gas exchange Assist with daily living activities and provide adequate rest Provide high fowlers position to improve breathing pattern
  Activity intolerance related to dyspnea secondary to inadequate oxygen supply secondary to decreased systemic blood circulation.	To improve breathing pattern To improve tolerance to daily activities. maintain vital signs in the normal limit during activities.	Elevate the head of the bed while lying down and monitor breathing pattern and oxygenation. Adjust and plan the level of activities and, intensity and arrange rest in between the activities. Monitor vital signs frequently.