Clinical Presentation On

Submitted to Dr.R.Lakshmi MSc.,(N) Ph.d Principal Mrs.A.Thahira Begum msc.,(N) MPhil Reader Dept.of medical surgical nursing

Submitted by

Mrs.Muthupriya Msc.,(N) I year

PATIENT PROFILE Name Age/Sex Ward Unit MRD number Marital status Education Religion Occupation Family income Address Mr. Gobi 25 years/ Male CTS VI. C.T.IV. 40551 Unmarried 10th std Hindu tailor. Rs.1000/month c/o Mrs.Bhavani 119,jothy nagar st. Thiruthani T.k., Thiruvallore Dt. Medical diagnosis Date of Admission Source of history Rheumatic heart Disease with mitral stenosis 01-12-2011 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: Hair and scalp Conjunctiva Eyes Moderately built, dull and well oriented, well groomed Clean,equal distribution of hair. free of pediculi and dandruff Pink in colour, not icterus No ptosis, nystagmus, no cornea Opacities Nose: Ears Mouth and throat: Lips Throat Neck No discharge, pain or impacted. No septal deviation Cerumen Dry lips, coated tongue. No denti caries No cyanosis, moist, no gingival bleeding Tonsils not inflamed 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 Extremities Normal spinal curvature No congenital abnormalities Had post polio residual attack on left lower limbs.

No pedal edema. Central nervous system: General appearance Well nourished, Moderately built Oriented to place , person and time.easy going, mingling with others.

Cardiovascular system: Inspection Skin Conjunctiva Buccal mucosa Lips ,tip of the nose, earlobe,gingivae No edema, not pale Pink No cyanosis No cyanosis

No periorbital edema No puffiness of face Nail beds Hair distribution Legs Chest No clubbing Symmetrical No venous stasis, ulcers, edema 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 Auscultation Respiratory system Resonance over lung fields S1,S2 heard, no murmur No dyspnea, symmetrical chest wall Movements respiratory rate:30 sbreaths/minute

No dyspnea, symmetrical chest wall Movements respiratory rate: 20 breaths/minute Auscultation: Percussion: Gastrointestinal system: Inspection: Auscultation: No scar mark. Scapoid shape abdomen. Bowel sounds heard normally in all four quadrents. No advenstitious breath sound. Normal resonance

Percussion Palpation Bowel movements Musculo skeletal system:

No fluid thrill. Soft, No organomegaly, Present, once a day Normal power, peripheral pulses felt, had post polio residual attacks in left lower leg. no abnormalities. No lymphadenopathy Tolerate hot and cold. Not a diabetic.No endocrine abnormalities No genital ulcer, normal bladder action. No pigmentation, skin turgor normal.

Lymphatic system Endocrine system Genito-urinary system Integumentary system

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 Myocardium Weakens the contractile power heart pericardium brain endocardium rheumatic endocarditis

Rheumatic myocarditis Resolves & no sequale Formation

rheumatic pericarditis

adverse effects translucent vegetation/growth (pin head sized beads) Incomplete closure Blood flows backward through valve

Leaflets thickened & shortened Inflamed margins fuses

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(Sydenhams 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 1 2 3 4 5 6 7 Book Picture Carditis Polyarthritis Chorea Nodules Fever Arthralgia Lab findings Patient Picture Carditis Knee pain ------------------------Fever Joint 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 1 History collection Fever weight loss Fatigue diaphoresis Chest pain, Vomiting 2 Physical examination 3 X Ray

Patient picture Fever malaise Chest pain vomiting Food intake Sinus tachycardia Cardiomegaly and lung Parenchyma clear

4 5

EGC Blood Total count ESR HP CRP ASO SUGAR Platelet Echo

6600 cells/m 15mm/hr 11.5mg/tl 76 -Ve 80mg/dl 2.06 laks Chronic 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 VALVE
MITRAL 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 1. 2. 3. 4. 5. 6.

BOOK PICTURE Breathing difficulty Progressive fatigue Hemoptysis Palitation Orthopnea PND

PATIENT PICTURE Dyspnea on excition Fatigue 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 1. BOOK PICTURE Physical examination Pulse Respiration Auscultation EGC ECHO Cardiac catheterisation PATIENT PICTURE Regular but weak Dyspnea No murmurs heared Mitral stenosis

2. 3. 4.

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 surgeons 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 T.Atenolol

DOSE

ROUTE

FREQ

ACTION

SIDE EFFECTS

NURSES ROLE Monitor heart rate Watch for side effects Observe GI changes

1.

25mg

Oral

Bd

adrenergic antagonist,blocks 1receptors located in heart muscle

Dizziness,syncope, lethargy,GI symptoms

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 Take after food Schedule dose to avoid nocturia Watch for hypo symptoms

4.

T.Frusemide

20mg

Oral

Tds

Loop diuretics. It decreases the renal resistence & increases renal blood flow

Hyponatremia, hypotension, dizziness,collapse, GIsymptoms

6. 7.

T.Cardone Syp.Kcl

100mg 2tsp

Oral Oral

Bd Tds Maintain intra cellular isotonicity. Maintains normal renal function Nausea, vomiting, diarrhea, oliguria, pain, paralysis, ARDS Administer with precaution Watch for hyperkalemia Observe changes GI

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: patients pain will be minimized

PLANNING Assess patients pain

IMPLEMENTATION

RATIONALE

EVALUATION Patients pain was reduced to 4. He

Patients pain was on visual Help to plan care analogue pain scale

Provide adequate Provided adequate rest Minimizes pain rest periods before periods in between activities activities Provide pillows additional Provide additional pillow Provides comfort muscle

was comfortable with the health team.

Provide a back rub

warm Provide a warm gentle back Provides rub relaxant

Provide diversional Provide magazines to read therapy Administer analgesic as order

Diverts alteration from pain

Administered inj. Voveron Relieves pain per 75mg

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 PLANNING Monitor signs Provide vital IMPLEMENTATION Monitored vital resp 26/min RATIONALE EVALUATION

signs Provides base line patient respiratory data rate returns to normal of 26 breaths /min comfort Sitting up with legs down Helps in reducing

position

its advised

pre load Helps to identify oxygen need Satisfies O2 demand Improves status health

Monitor oxygen Spo2 96% saturation Administer oxygen Provide sodium diet Encourage adequate rest nasal --low Salt free diet given

Encouraged adequate rest Promotes and sleep 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.

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

Assess the general Patient looks drowsy Provides base line He is gradulally condition of the and tired data about health returning to perform patient status his activities

Encourage to choose Encourged about Improve oxygenation activites that increase milder activities cardiac output Avoid exercises strenuous Mild advised exercises Prevents overload

Advice adequate rest Encourged adequate Promotes comfort to the patient rest between work schedule Improves level of Level of activity Promote self esteem activity by the patient should be improved Conceratrate on diat Low sodium and iron Improves immunity diet advised

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: patients food intake will be improved. INTERVENTIONS IMPLEMENTATION RATIONALE EVALUATION Patients food intake was gradually improved.

Asses the nutritional Assess the client. He has Helps to plan care status anorexia Provide frequent oral Provided frequent mouth Provides appetite care wash

Provide a conductive Provided a conductive Promotes appetite environment to eat environment to eat Serve food according to Served food in frequent Promotes appetite likes and dislikes in small quantities frequent small quantities Educate regarding Educated regarding foods Helps to improve foods to be taken and to be taken and recorded the understanding avoided about the diet to be eaten Provide support nutritional Provided support nutritional 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 . PLANNING IMPLEMENTATION RATIONALE EVALUATION

Assess the level of Patient was worried more Provides knowledge of the about the disease data patient condition

Patient had gained good knowledge regarding his health condition and Educate the patient Diseased condition was Gains confidence trestment regarding the disease clearly explained with over prognosis condition picture Clarify doubts for Patients had doubts and Avoids the patient got claried querres Encourage about Information followup exercises patient and medications Reassure the patient gives to Improves status unwanted health

baseline

Reassurance the patient

Evaluates the care