Wednesday, December 21, 2011

Nursing Care Plan for Mitral Stenosis

Mitral stenosis (MS) is a blockage of the mitral valve that causes constriction of blood flow to the ventricles. Patients with Mitral stenosis typically have mitral valve leaflets are thickened, komisura are fused, and the chordae tendineae are thickened and shortened. Transverse diameter of the heart are usually within normal limits, but calcification of the mitral valve and left atrial enlargement can be seen. Here is a picture of mitral valve stenosis.

Nursing Care Plan for Mitral Stenosis
Mitral stenosis causes a change in shape of heart and changes in blood vessels of the lungs according to severity of Mitral Stenosis and heart conditions. Convexity left border of the heart indicates that the prominent stenosis. In most cases there are two disorders that mitral stenosis and mitral insufficiency, generally one of them stand out. Also very dilated left ventricle when the mitral insufficiency involved are very significant. Classical radiological signs of patients with Mitral stenosis is a double contour (double contour) which leads to an enlarged left atrium, and the presence of septum lines are localized.

This condition makes the pulmonary venous pressure increases, causing diversion of blood, chest X-ray look at the relative dilation of blood vessels compared to the top of the pulmonary blood vessels below the lungs. Narrowing of the mitral valve causes the valve does not open properly and blocks the flow of blood between the left heart chambers. When the mitral valve narrowing (stenosis), blood can not efficiently pass through the heart. This condition causes a person to become weak and become short of breath and other symptoms.

Mitral stenosis, a valve disorder most often caused by rheumatic heart disease. It is estimated that 99% mitral stenosis based on rheumatic heart disease. However, approximately 30% of patients with mitral stenosis can not find any previous history of the disease.

In all valvular heart disease, mitral stenosis most commonly found, namely ± 40% of all rheumatic heart disease, and affects women more than men, with a ratio of approximately 4: 1.

Myxoma (benign tumor in the left atrium) or blood clots can block blood flow as it passes through the mitral valve and cause the same effect as mitral valve stenosis.


Nursing Assessment - Nursing Care Plan for Mitral Stenosis

Anamnesa
  1. Demographic Data
    • Name
    • Age
    • Gender
    • Interest / nation
    • Religion
    • Education
    • Works
    • Address
  2. Main Complaints: patients with mitral stenosis is usually complain of shortness, cyanosis and coughing.
  3. History of Disease Now: The client is usually taken to hospital after shortness of breath, cyanosis or coughing is accompanied by high fever / no.
  4. History of past illness: The client had suffered from rheumatic fever disease, SLE (Systemic Lupus Erithematosus), RA (Rhemautoid arthritis), myxoma (benign tumor in the left atrium).
  5. Family History of Disease: there are no hereditary factors that influence the occurrence of mitral stenosis.

ROS (Review of Systems) 

B1 (Breath): Shortness / increased respiration, low tones at the apex by using a bell on his side to the left, shortness of breath and fatigue, cough, orthopnea in venous congestion there.

B2 (Blood): an increase in the jugular vein, odema leg, in the form of atrial arrhythmia atrial fibrillation (rapid heart rate and irregular), hemoptysis, embolism and thrombus, strength weakened pulse, tachycardia, peripheral edema (started happening right heart failure), BJ 1 harsh systolic murmur, palpitations, hemoptysis, apical diastolic murmurs.

B3 (Brain): chest pain and abdominal

B4 (Bladder): excess fluid imbalance, oliguria

B5 (Bowel): Dysphagia, nausea, vomiting, no appetite B6 (Bone): weakness, sweating, rapid fatigue.


Psychosocial assessment
  1. Shortness of breath affects the interaction
  2. Activities limited
  3. Fear of facing surgery
  4. Stress due to disease condition with a poor prognosis

Nursing Diagnosis Nursing Care Plan for Mitral Stenosis
  1. Impaired tissue perfusion
  2. Risk for excess fluid volume
  3. Ineffective breathing pattern
  4. Impaired gas exchange
  5. Activity intolerance
Nursing Care Plan for Mitral Stenosis

Nursing Diagnosis and Interventions for Mitral Stenosis
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