Manibabhula nursing

college, bardoli

Subject: Medical surgical nursing

Topic: Case Study on Rheumatic Heart
Disease

Submitted To: Submitted By:

Mr. ManjunathBeth Mrs. Meghana Goswami
Asst. Professor. 2nd year M.Sc Nursing
M.B.N.C M.B.N.C

Submitted on:
 PATIENT INFORMATION :
 Patient’s Name : Krishnaben Budhalal Sudha
 Age : 48 years Sex : female
 Address : Mayur Vihar, Surat.
 Admission Date : 05/01/2017
 Ward : Cardio Thoracic Ward
 Registration Number : 134567
 Education : Illiterate
 Occupation : Housewife
 Religion : Hindu
 Blood group : O +ve
 Diagnosis : RHD (Rheumatic Heart Disease) + Sever MS
(Mitral Stenosis) +Mild MR (Mitral
Regurgitation) + Grade III AR (Aortic
Regurgitation)
 Operation : DVR ( Double Valve Replacement)
 Date of operation : 10/04/2018
 Income per month : 5000 Rs./ month
 Weight : 65 kg
 Height :158 cm
 Health Habits :
- Smoking : Bidi smoker 4-5/ day
- Tobacco chewing : No
- Alcohol Consumption : No
 Vegetarian : Yes
 Non-vegetarian : No

 Chief complaints with duration :

Karishnaben was relatively asymptomatic before 15 days. One day she had
suddenly started exertional dysponea, palpitation, tachycardia and increase in BP.
She had admitted in private hospital at Junagadh and he diagnosed as he has
having RHD.
  HISTORY OF THE PATIENT :

1)Present health history :

Krishnaben was relatively asymptomatic before 15 days. One day she had
suddenly started exertional dysponea, palpitation, tachycardia and increase in BP.
She had admitted in private hospital at Junagadh and she diagnosed as having
RHD. She had some investigations like Echocardiography, ECG over there and
then doctor suggested to go to Ahmedabad for further treatment and operation.
Then she got the reference of the Dr. Samir Dani admitted in Worckhardt
hospital,Surat.

2)Past illness history :

When Krishnaben was 5 yrs old she had got the streptococcal infection of
the throat with fever and severe joint pain. Due to this infection she developed the
rheumatic endocarditis. At that time she was residing in Headband with her grand
mother so she got the treatment from the private hospital of Ahmedabad. She had
received the treatment, penicillin prophylaxis given at that time. But as we know
that complication of this infection may result in rheumatic heart disease (RHD).
After getting recovery her father took her in the Junagadh. Then she adjusts there,
completed her marriage was done.
Otherwise there was no any past history of illness like T.B, Hypertension,
Diabetes mellitus, Hepatitis, jaundice etc.

3) Family history :

Sr. Name of Family Age in Relations Education Health status

No. Members Year hip Occupation
With
Patient
1 Budhalal R. Sudha 52 Husband Illiterate Shop keeper Healthy
2 Karishnaben B. 48 Self Illiterate Housewife Unhealthy
Sudha
3 Sahil B. Sudha 25 Son 10h std. Shop keeper Healthy
4 Mohit B. Sudha 22 Son 12th std Help his Healthy
father
5 Ragini B. Sudha 20 Daughter 10th std. Household Healthy
work
4)Personal history :
Krishnaben is looking well nourished, her skin colour is brown. She has a
habit of bidi smoking (4-5 Bidis/day). She is vegetarian. In the routine food she
takes dal, roti, rice and sabji 2 times in a day. She would like to take tea, she takes
tea 5-6 times in a day. Some times in the food she likes veg. biriyani, sher
Khurma, samosa, idali sambhar etc. she does not like any soup and salad.

i) Personal hygiene :
- Oral hygiene : once a time with neem stick
- Bath : once in a day daily
- Sleep and Rest : 7 hours/ day and 1 hour rest in afternoon time daily
ii) Elimination :
- Bowel per day : Regular per day, once in morning time daily.
- Urine frequency : 1500 ml/ day
iii) Mobility and Exercise :
- Moderate : Moderate exercise she has doing.
- Joint pain during walking. Restricted movement of the leg.
iv) Sexual and Marital history : she is in menopause period.

5) Health facility near Home :

In Veraval there was PHC near by patient’s home. It is about 4 km. away
from patient’s house. There are other private doctors in her village. Transport
facility is available in the form of Government bus services as well as private
vehicles are also available for transportation.

6) Housing :

Krishnaben has her own pakka house in village Veraval. The house is having 2
rooms, 1 kitchen and facilities of toilet and bathroom are also available in house.
There are also facilities of electricity and drinking water from the gram panchayat
bor.

 NURSING ASSESSMENT :

a) General observation :
 Sensorium : he is conscious and well oriented
 Foul body odour : no any bad odour from his body
 Foul breath : no
 Posture : normal
 Hair : brown and shiny hair, Clean no any dandruff.

b) Vital sign :
 Temperature : 99 F.
 Pulse : 92 /min.  Regular  Irregular  high volume  Bounding
 water hammer  Tachycardia (some time)
  Respiration : 26 /min.  Normal  Tachypnea  Crackle  Wheeze
 BP : 100/70 mm of Hg.

c) Subjective data :
 Palpitation : yes
 Fatigue : Present
 Dizziness : Yes on awaking from the bed.

d) Objective Data :

Assessment of Cardiovascular system :

 Heart rate : 92 beats/min.
 Rhythm : Regular
 Apical Pulse : 92 beats/min.
 Jugular vein distention : No.
 Heart sound : S1, S2 Present , No murmur.

Respiratory System :
 Respiration rate : 26 breaths /min.
 Breath sound : Crackle in lower zone of Lungs .
 Dysponea : Present.
 Pulmonary effusion : No.
 Cough: Productive cough.

Abdomen :
 Hepatomegaly : No.

Skin :
 Color of mucous membrane : Pink
 Peripheral Cyanosis : No. Clubbing: No.
 Ecchymosis : No

Urinary system :
 Urine output : 1700 ml/24hrs.

Extremities :
 Edema : No
 Color and Temperature of Skin : Cold and clammy.

 DIAGNOSTIC TESTS :
i) Biochemical Test:
Sr. Biochemical test Patient’s Report Normal Value
no.
1. CBC
 - Hb 11. 9 gm % F – 12- 14 gm %
4500-11000/cu
- Total count 6800 / cumm mm
- Differential count 66 – 70 %
 Polymorphs 46 % 20 – 45 %
 Lymphocytes 47 % 1–4%
 Eeosinophil 03 % 2–4%
 Monocytes 04 % 0–1%
 Basophil 00 % 150000 – 450000
- Platelet 289,000/ cumm M:17mm
counts 0.4 mm / hr F :312mm
- ESR 1 hr

2. Sr. Electrolytes
- Bl. Urea 24.0 mg / dl 13- 40 mg / dl
-
Sr. Creatinine 0.53 mg / dl 0.8- 1.4 mg / dl
-
Sr. Na+ 141m Eq/ L 135 – 149 m Eq/
-
Sr. K+ 4.1 m Eq/ L L
-
Sr. Cl- 104 m Eq/ L 3.5 – 5.5mEq/L
-
Sr. Bil. Total : 0.50 mg % 98 –108m Eq/L
Direct : - 0.0 – 1.0 mg %
Indirect : - 0.0 –0.2 mg %
- S. G. P. T 16.0 IU/L 0.0 –0.75 mg %
- Sr. Alkaline Phosphate 204.5 U/L 0 – 40 U/L
- Total Proteins : 124 – 341 U/L
Albumin : 6.36 G/L 6.6 – 8.3 G/L
Globulin : 4.42 G/L 3.5 – 5.0 G/L
A/G ratio : 1.94 G/L 2.3 – 3.3 G/L
- S. G. O. T. 2.22 1.0 – 4.0
25.0 U/L F : 10 – 35 U/L
- Bl. Sugar 65-140mg/dl.
110 mg/dl.
3. Prothombine time
- Patient 13.8 Second
- Control 12.9 second
- INR 1.072 second

4. HIV Negative Negative

5. HBsAg Negative Negative

ii) Special Tests :
Sr. Biochemical Patient’s Report Normal Value
no. test
1. X-ray chest BVM Prominent. - Lungs clear.
LVH. - No cavity
- BVM Normal
2. ECG Q wave in l, aVL, V1 to V6 - Rate : 60-100/min
Normal rhythm. - P : Height<2.5mm
Rate : 90 /min. - Width< 2.5mm
- ORS: < 0.10 Sec.
- Depth & width of
Q wave - <0.04mm
3. Echocardiogr o Mitral valve : thick, damming,
aphy pliable and tips calcified, moderate SVP
o Aortiv vlave : thick and
calcified
o Tricuspid valve and pulmonary
valve is normal
o LVEF – 60%
o Aorta – 34 mm, LA – 48 mm
o RA and RV – normal
o Aortic signal – O2 Max. – 62 mm
Hg
O2mean – 34 mm Hg
O2mini – 39 m/s
o LVOT diameter – 21 mm
o AR jet width – 8.8 mm
o Conclusion : Severe Mitral
Stenosis with mild MR + grade III AR+
Moderate TR with severe PAH
Done by : Dr. Milind Khuradre
4. TMT Not done - No anginal pain.
- No exercise induce
ST
depression/elevatio
n.
- No exercise
induces arrhythmia
seen.
5. Angiography LMCA + + DVD + old anterior wall MI +
Mild LV dysfunction
- Done by : Dr. Samir Dani
- Technician : C. Gadhiya
- Access : femoral arterial closed
- Pigtail : NIH/ Multipurpose
 - Dye : non – ionic
- Sites : left and right coronary angiography
and left and right renal angiography
- Report : LMCA : normal
- LAD : normal, Mid LAD : normal, RCA :
normal
- Final diagnosis : RHD ( severer mitral
stenosis with mild MR + grade III AR)
- Recommendation : DVR

 PROVISIONAL DIAGNOSIS :- RHD (Rheumatic Heart Disease) + Sever

MS (Mitral Stenosis) +Mild MR (Mitral
Regurgitation) + Grade III AR (Aortic
Regurgitation)
 FINAL DIAGNOSIS :- Severe Mitral Stenosis with mild MR + grade III
AR+ Moderate TR.

DRUG SHEET

Patient Name : krishnaben B. Sudha Age : 48 Years Wt : 65 kg

Diagnosis : MS with MR + Grade III AR

Sr. Drugs Dose Mechanis Indicatio Side effects Nursing

No. Name Route m of ns Considerati
Action on
1 Inj. 5-10 Stimulate - CCF, LVF, Nausea, - Monitor urine
Dopamin Microgram cardiac shock vomiting, output.
per min activity and syndrome atopic - Monitor BP.
I.V vaso due to MI, beats, - Assessed for
constriction septicemia, angianal accurate
effect. renal pain, doses.
failure, tachycardi
heart a,
surgery,. palpitation
, widened
QRS.

2. Inj. 2.5 Cardiac - CCF, - tachycardia, - Monitor urine

Dobutami Microgram muscles Hypotensio B.P. and output.
n per kg per stimulant n, LVF ventricular - Monitor BP.
min ectopic activity, - Assessed for
I.V headache, accurate
shortness of doses.
breath.
3. Inj. Lasix 20-40 mg Diuretic - Edema, Salt - Fluid and - Observe for
I.V. retention, electrolyte renal function
 - Pulmonary imbalance, i.e Urine
congestion anorexia, output chart,
Nausea, specific
vomiting, gravity and
weakness, - S. Creatinine
muscle cramps, - Observed for
fatigue, S. K+
drowsiness, - Assessed for
epigastric ringing in ear,
distress. etc abdominal
pain, sore
throat and
fever.
4. Inj. 1 Gm Antibiotics - Serious - Skin rash, - Give slowly
Fortum I.V infection of urticaria, - See the
the neutropenia, injection site
respiratory thrombocytope for phlebitis.
tract, ENT, nia, pain at
skin, injection site,
G.I.etc. fever,
headache,
phlebitis.
5. Inj. 500 mg Antibiotics - Bacteraemi - Hypersensitivit - Give slowly
Amikacin IV as, y reactions, - Assessed for
septicemias nausea, accurate
, burns and vomiting,nephr doses.
post otoxicity, - Monitor urine
operative ototoxicity output.
infections
 INTRODUCTION OF VALVULAR DISEASES

The valves of the heart controls the flow of blood through the heart and into
the pulmonary artery aorta by opening and closing at appropriate times as the heart
contracts and relaxes through the cardiac cycle.

 DEFINITION :

When any of the valves do not open or close properly, blood flow is
affected. When valves do not open completely (usually because of stenosis), the
result is reduced blood flow through the valve. When valves do not close
completely, blood leaks back through the valve in a process termed regurgitation
or insufficiency.

 ETIOLOGY :-

NON MODIFIABEL RISK FACTORS

ACCORDING TO BOOK IN PATIENT

 Age 48 year
 Sex Female
 Positive Family history Positive family History (Her father
having RHD)
 MODIFIABLE RISK FACTORS
 Hyperlipidemia High Cholsesterole, Low HDL
 Acute Rheumatic Fever and In childhood patient had the
infectious endocarditis infection of Acute Rheumatic
Fever
 Hypertension No
 Diabetes mellitus No
 Cigarette smocking Present( 4-5 bidis/day)
 Obesity ( Central Obesity) Obese
 Physical Inactivity Present
 Type A personality Anxious Nature
 Use of oral contraceptive Not Applicable

 PATHOPHYSIOLOGY :
Acute rheumatic fever or infective endocarditis causes fibrosis & retraction of
the valve leaflets

The cordae tendineae contract and shorten and the mitral commissures fuse

As the valves become calcified and immobile the valvular orifice narrows

It prevents normal passage of blood from the left atrium to the left ventricle

The valve orifice normally is 4 to 6 cm2, when it is mildly stenosed, the orifice is
reduced to 2 cm
This mild stenosis allows blood to flow from the left atrium to left ventricle only if
increased pressure is generated

The obstruction of blood flow across the mitral valve during diastolic filling
creates a pressure gradient between the left atrium and left ventricle of
approximately 20 mm of Hg in critical stenosis. ( in critical stenosis the opening
of the valve is reduced to 1 cm2)

Therefore, the pressure in the atrium is elevated to approximately 25 mm of Hg

The elevated left atrial pressure in turn raises the pulmonary venous and
pulmonary capillary pressure

The left ventricle is not affected, but the left atrium has great difficulty in
emptying itself through the narrow orifice into the ventricle

Therefore, left atrium dilates and hypertrophies

Because no valve protects the pulmonary veins from a backward flow from this
atrium, the pulmonary circulation becomes markedly congested

The left atrial hypertrophies to accommodate the increase in pressure and

volume, and the right ventricular hypertrophies because of the chronic
pulmonary hypertension
Right ventricular failure can result and adequate filling of the left ventricle can
result in reduced cardiac output

 SIGN AND SYMPTOMS :-

IN BOOK IN PATIENT

 Palpitation Present
 Apprehension Present
 Dysponea Present
 Nausea and Vomiting No
 Cold and clammy extremities Present
 Arrhythmias Present
 Orthopnea Present
 Fatigue Present
 Restlessness Present
 Crackles No
 Peripheral Cyanosis No
 Cough Present
 Atrial fibrillation/ atrial dysrhythmia. No
 High – pitched systolic murmur No
 S1 – Diminished, S2 – heard Present
 Right ventricular failure : neck vein No
distention, peripheral edema,
hepatomegaly
 Tachycardia Present
 Lightheadedness Present
 Syncope No
 Chest discomfort Present
 Anxiety and palpitation Present

 MANAGEMENT :

 Medical management treatment :-

First Husainbhai was put on medical treatment. He was on following

medicines.
- Inj. Dopamine 5-10 Microgram/min
- Inj. Doutamin 2-5 microgram/min.
- Inj. Lasix 20 mg IV 12 hourly ( If SBP >100 mm of Hg)
- Inj. Fortum 1 Gm IV 12 hourly
- Inj. Amikacin 500 mg IV 12 hourly
- Tab. Warf (5 mg ) 1 OD
- Tab. Alprax 0.25 mg 1 HS
- Liq. Cremaffin 3TSF HS
 B.P. Monitoring every 30 min.

 Input chart

 Urine Output chart

 O2 Inhalation SOS.

 Surgical management :
Krishnaben was operated for valvular surgery. She had replaced the valve
mitral valve and aortic valve .
When valvuloplasty or valve repair is not a viable alternative, such as when
the annulus or leaflet of the valve is immobilized by calcifications, valve
replacement is performed. General anesthesia and cardiopulmonary bypass are
used for all valve replacement. Most procedures are performed through a median
sternotomy, although the mitral valve often is approached through a right
thoracotomy incision.

Once the valve is visualized the leaflets and other valve structures such as
chordae and papillary muscles are removed. Sutures are placed around the annulus
and then into the valve prosthesis. The replacement valve is slid down the suture
into position and tied into place. The incision is closed and the surgeon evaluates
the function of the heart and the quality of the prosthetic repair. The patient is
weaned from cardiopulmonary bypass and surgery is completed.

 Types of valve prostheses :

Four types of valve prostheses may be used –
1) Mechanincal valves,
2) Xenografts,
3) Homografts and
4) Autographs.

 Mechanincal valves :
The mechanical valves are of the ball and cage or disc design. Mechanical
valves are thought to be more durable than the other types of prosthetic valves and
often are used for younger patients. Thromboemboli are significant compilations
associated with mechanical valves. So long term anticoagulation with warfarin is
required.
Complications
Sr. Complications In patient
no.
1. Change in hemodynamics No
2. Bleeding No
3. Thrombo-embolism No
4. Infection Present
5. Congestive cardiac failure No
6. Hypertension Present
7. Dysrhythmias No
8. Hemolysis No
9. Mechanical obstruction No

 Nursing management :
1. Ineffective Breathing pattern related to pulmonary congestion.
2. Decrease cardiac output related to impaired cardiac function.
3. Dysrhythmias due to secondary to ischemia
4. Substernal pain, chest tightness, pressure and heaviness
5. Activity intolerance due to fatigue.
6. Anxiety related to hospitalization
7. Knowledge deficit about self care
 NURSING CARE PLAN

Nursing Expected Planning Nursing Intervention Evaluation

Diagnosis Outcome
Altered To relieve  Proper positioning  Fowlers position is given to the patient Dyspnea is relieved.
Breathing dysponea  O2 administration  Oxygen was started at 6 lit./ min
pattern related  Restrict fluid  Maintained urine out put chart
to pulmonary  Fluid was restricted.
congestion.  Inj. Lasix was given as per advice by the
cardiologist.
Decrease To maintain  Monitor vital sign.  Advised to take complete bed rest. Improve cardiac
cardiac output cardiac output  Cardiac  Assessed rhythm and invasive BP. functioning indicated
related to monitoring.  Provide warmth to the patient. by
impaired cardiac  BP monitoring.  Provided intropic support by inj. Dopamine - Adequate urine
function.  Provide complete and Dobutamin as advised by the doctor. output.
rest.  Monitored urine output hrly. - Reduce
 Inotropic support breathlessness.
by medicine. - BP comes at normal
range.
Dysrhythmias Client will have  Take ECG and  Teach client/ family about need for continuous  Antidysrhy
due to no Dysrhythmias  Put the patient on monitoring and also assess the apical pulse. thmics drugs reduce
secondary to continuous  Take 12 lead ECG and notify the PVCs per the myocardial
ischemia cardiac minute to physician. irritability.
monitoring.
 Nursing Expected Planning Nursing Intervention Evaluation
Diagnosis Outcome
Substernal Client will  Take 12 lead ECG,  I assessed the patient for chest discomfort, Patient gets relief from
pain, chest have administering O2, including location, radiation, duration of pain the chest pain and also
tightness, improved administering medication and factors that affect it. he has felt comfortable.
pressure and comfort in therapy and give the  I had taken 12 lead ECG during pain.
heaviness chest physical comfort to the  I had also given the analgesia and
patient. nitroglycerine to relieve the pain.
 I had also given the O2 supply to the patient as
prescribed by the doctor.
 I have given backrest to promote the patient
comfort.
 Also given the oral liquid diet as tolerated by
the patient.
 Limitation of visitors.

Activity To relieve  Assessed for daily living  Assessed for daily living activity. Maintain daily living
intolerance the fatigue activity  Instructed the patient to do all activities in the activities.
due to fatigue. bed.
 Provided bed side commode.
 Assisting with daily living activitie
 Nursing Expected Planning Nursing Intervention Evaluation
Diagnosis Outcome
Anxiety Reduction of Plan to demonstrate  I had encouraged the client to ask  It enhances coping
related to anxiety appropriate range of questions and allow cline tot verbalize mechanism as well as
hospitalization feelings such as fears. reduces myocardial workload
participation in  Provide comfortable, quiet environment and O2 consumption.
treatment regimen. and necessary information.

Knowledge Ability to  Develop teaching for  Give teaching regarding diet, activity,  Patient performs the self
deficit about perform self patient and family. exercise, vital signs monitoring, care.
self care care activities  Provide verbal and medication regimen, CPR if appropriate  Family can help the patient
written instruction. family member learn. and also they can able to
 Involve family in  Provide several teaching sessions for detect the any cardiac
teaching. reinforcement and answering questions. emergencies.
 Provide information  After cardiac surgery patient have short
regarding follow up term memory, written information is
care. helpful so all the medication is written in
 Make appropriate the patient’s language with its dose, time
referrals. and other instruction.
 Management for phone contacts with
health care personnel help to alley
anxiety.
HEALTH TEACHING:-

 Told the patient to take his blood pressure at the same hour each time, without
more than usually activity preceding the measurement.
 Told the patient and family to keep a record of drugs used in the past.
 To encourage compliance with antihypertensive therapy, suggested establishing
a daily routine for taking medication.
 Warned the patient that uncontrolled hypertension may cause stroke and heart
attack. - Told her to report any adverse reactions to prescribed drugs.
 Advised her to avoid high-sodium antacids and over-the-counter cold and sinus
medications containing harmful vasoconstrictors.
 Helped the patient examine and modify his lifestyle behavior.
 Suggested stress-reduction groups, dietary changes, and an exercise program.
 Encouraged a change in dietary habits. Helped the obese patient plan a reducing
diet.
 Told to the patients to avoid high-sodium foods, table salt, and foods high in
cholesterol and saturated fat.

BLIOGRAPHY
 Books :

1. Black J.M. and Jacobs E.M. “Luckmann and Sorenson’s Medical

surgical Nursing A Psychological Approach”, 4th edition,
Philadelphia : W.B. Saunders international Education ; 1993. P.P.
2. Dossey B.G, Guzzetta C.E, “ Critical Care Nursing- Body-Mind-
Spirit”, 3rd edition J.B.Lippincott : Philadelphia ; P.P
3. Rotrock J. C’ “Perioperative Nursing Care Planning”, 2nd edition,
USA : C. V. Mosby company ;P.P. 323-328.
4. Thopmson J. M., M C Farland G. K. “Clinical Nursing”, 2nd edition,
USA : C. V .Mosby company ;1989. P.P.
5. Rodman M. J. and Smith D.W. “Clinical Pharmacology in Nursing”.
2nd edition, Philadelphia J.B. Lippincott Company 1984, P.P.
331, 341, 379.
 Journals :
1. Constancia P. E. The Ross Procedure. Aortic Valve Replacement
Using Autologus Pulmonary Valve. Critical Care Clinical 1991
Dec; 3(4) : 717 – 721.
2. Ohler L Et A. K. Aortic Valvuloplasty : Medical And Critical Care
Nursing Perspectives. Focus Critical Care 1989 Aug; 16(4) : 275
– 287.