Nursing Care Plan for Mitral Stenosis
Mitral stenosis (MS) is the obstruction of the mitral valve that causes constriction of blood flow to the ventricles. Patients with Mitral Stenosis typically have thickened mitral leaflets, commissura are fused, and the chordae tendineae were thickened and shortened. Transverse diameter of the heart usually within normal limits, but calcification of the mitral valve and left atrial enlargement can be seen.
Assessment
Review of System
Psychosocial Assessment
Nursing Diagnosis:
Mitral stenosis (MS) is the obstruction of the mitral valve that causes constriction of blood flow to the ventricles. Patients with Mitral Stenosis typically have thickened mitral leaflets, commissura are fused, and the chordae tendineae were thickened and shortened. Transverse diameter of the heart usually within normal limits, but calcification of the mitral valve and left atrial enlargement can be seen.
Assessment
- Main Complaint: patients with mitral stenosis usually complain of shortness of breath, cyanosis and coughing.
- History of present illness: Clients are usually taken to hospital after shortness of breath, cyanosis or coughing is accompanied by high fever / no.
- Past medical history: The client had suffered from rheumatic fever disease, SLE (Systemic Lupus Erithematosus), RA (rheumatoid Rhemautoid), myxoma (a benign tumor in the left atrium).
- The family medical history: no hereditary factors that influence the occurrence of mitral stenosis.
Review of System
- B1 (Breath): Shortness / respiration increases, low tone 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, leg edema, atrial arrhythmias such as atrial fibrillation (rapid heart rate and irregular), hemoptysis, embolism and thrombosis, strength weakened pulse, tachycardia, peripheral edema (start happening right heart failure), BJ 1 loud systolic murmur, palpitations, hemoptysis, apical diastolic murmur.
- B3 (Brain): chest and abdominal pain.
- B4 (Bladder): excess fluid imbalance, oliguric.
- B5 (Bowel): dysphagia, nausea, vomiting, no appetite.
- B6 (Bone): weakness, sweating, tired .
Psychosocial Assessment
- Shortness of breath affect the interaction.
- Limited activity.
- Afraid of surgery.
- Stress due to the condition of the disease with a poor prognosis.
Nursing Diagnosis:
- Impaired tissue perfusion r / t decrease in peripheral blood circulation; cessation of arterial-venous flow; decrease in activity.
- Risk for fluid volume overload r / t the displacement pressure in the pulmonary venous congestive; Decreased perfusion of organs (kidney); increased retention of sodium / water; hydrostatic pressure increase or decrease in plasma proteins (absorbing fluid in the interstitial area / network).
- Ineffective breathing pattern r / t permeation fluid, pulmonary congestion secondary to changes in alveolar capillary membrane and fluid retention intertestial.
- Impaired gas exchange r / t changes in capillary-alveolar membrane (displacement of fluid into the interstitial area / alveoli).
- Activity intolerance r / t decreased cardiac output to the tissue.
- Acute pain r / t strain the left atrium.
