CASE PRESENTATION

I. PATIENT ASSESSMENT

PROFILE OF PATIENT:-
Name : Mrs. Urbashi shoo
Age : 52 Yr.
Sex : Female
Address : At : pathala, po: Gobindpur , PS: Bargarh, Dist.: Baragarh
Qualification : Nil
Occupation : House wife
Monthly family income : 40, 000/-
Marital Status : Married
Religion : Hinduism
Registration Number : 12809/29/5/19
Name of the Hospital : VSSIMSAR,BURLA
Ward : Cardiology ward
Bed Number : 17
Diagnosis : Mitral valve regurgitation (MVR)
Operation :
Date of operation :
Name of doctor : Mr. . S.C. shoo
Date of admission : 29/5/2019
Date of discharge :
Date of data collection : 30/5/19
HISTORY OF ILLNESS

A. CHIEF COMPLAINTS WITH DURATION:-

Patient came to the hospital with complains of-Restlessness, chest pain, shortness of breath at night ,
heart palpitation, and hoarse voice.

A. PAST MEDICAL AND SURGICAL HISTORY;-

1. Past medical history:- :-Mrs. Urbashi sahoo was admitted at bargargh district Hospital
before 9 months under the diagnosis of diarrhea and vomiting.
2. Past surgical history: There is no evidence of past surgical history like gastrostomy,
mastiodectomy, appendectomy, colostomy etc.

B. PRESENT MEDICAL AND SURGICAL HISTORY:-

1. Present medical history:- Mrs. Urbashi sahoo came to burla medical with the complains of
breathlessness, chest pain, dizziness and tiredness, shortness of breath at nights, nausea, vomiting
etc. now she is treated at cardiology ward by the diagnosis of mitral valve regurgitation.
2. Present surgical history:- No

FAMILY HISTORY:-
Type:-joint family
No of members-5
Support person- patient husband santosh sahoo and her son sarat sahoo.
Any illness in family-no

FAMILY COMPOSITION:-
SL. NAME OF AGE/ RELATIONSHIP EDUCATION OCCUPATION MARITAL HEALTH
NO. FAMILY WITH PATIENT STATUS STATUS
MEMBER SEX

1 Santosh 48yr/ husband 9th businessman married healthy

sahoo male
2 Urbashi 40yr/f patient Nill House wife Married Un
sahoo emale Healthy
3 Sarat 33yr/ Son Bsc Businessman Married Healthy
sahoo male
4 Subhashini 29 Son in law Arts House wife Married Healthy
sahoo yr/fe
male
5 Sruti 5yr/fe Nill Nill Nill Healthy
sahoo male

FAMILY TREE:-
Urbashi sahoo,40yr,female
Santosh sahoo,48yrs,male

Sarat sahoo,33yrs,male Subhasini sahoo, 29yrs, female

Sruti sahoo ,5yrs,female

Kye
-Female -Patient -Male

HEALTH FACILITY NEAR HOME:-

Type-hospital
Distance-20km
Transportation facility-yes

HOUSING:-
Type- pucca
No of room-6
Toilet-indian
Electricity-yes
Drinking water source-tap
MARITAL HISTORY:- Mrs. Urbashi sahoo married to santosh sahoo before 34 years ago which has
arranged marriage and now one granddaughter will be present now she belongs to a happy life with her
son and son in law and granddaughter.

ENVIRONMENTAL HISTORY:- Patient is living with her family at his own home in pathala.
The house is pucca type. There are 6 rooms, 5 doors and windows in the home. The ventilation is
adequate. They have separate latrine. Separate kitchen is there for cooking purpose. They dispose
the garbage in open field. The overall cleanliness of house is clean, the surrounding is unclean due to
presence of mosquito breeding area.

SOCIO-ECONOMIC HISTORY:- Mrs. Urbashi sahoo is living in her own home with all
required facilities like TV, Freeze, bike, etc. she bbelongs to a joint family. Her husband is the head of the
family. There total income is Rs. 40,000/- per month. She belongs to higher middle class family.

NUTRITIONAL HISTORY:- My client takes both vegetarian and non-vegetarian foods. The
available food items are rice, dal, green vegetables, poato, meat, fish, egg, milk etc. He does not have
any likings and disliking of food

PERSONAL HISTORY:- my client has no habit of drug abuse and guttaka.

PERSONAL HYGENIC:-
ORAL HYGINE:-frequency- ....2times.............agent-.......colgatte.........

BATH PER DAY:-frequency ....2times.............. agent-.....soap and shampoo............

DIET:-both veg and nonveg

No of meal per day- 2

Fluid:-glases/day....8.........

Tea/coffee:- cups/day......nill ............

SLEEP AND REST:-hours/day.........4.......... drugs used for sleeping- no

ELIMINATION:-
BOWEL/DAY:- Regular

URINE FREQUANCY:-during day....4times.................night.....3times.........

MOBILITY AND EXERCISE:-

WALKING HABIT-yes, she is regular walking

EXERCISE /ACTIVITY-sedentary exercise

MENSTRUAL HISTORY:-regular

LMP-.............14/5/19..........any other problem.........no................

SEXUAL AND MARITAL HISTORY:-

Spouse general health:- good

Spouse occupation:-working

Relationship:-satisfactory

Staying together:-yes

OBSERVATION AND ASSESSMENT:-

GENERAL APPEARANCE:- Good

SENSORIUM:- conscious

Emotional status:-confused

Foul body odour:-no

Foul btreath:-No

PHYSICAl EXAMINATION
VITAL SIGNS:-

Height:-164cm

Weight:-52kg

SL. VITAL SIGN VALUE INFERENCE

NO.
1 Temperature 98.2
2 Pulse 110beats/min
3 Respiration 34breaths/min
4 Blood pressure 100/80mmhg

GENERAL APPEARANCE:-
Nourishment : Under nourished
Body gait : Normal/abnormal
Health : Unhealthy
Activity : Dull
MENTAL STATUS:-
 Level of consciousness : Conscious
Look : Anxious and restless
POSTURE:-
Body curves : Normal body curve
Movement : Little movement possible but pain will be
arise.
HEAD AND FACE:-
Scalp : Clean
Hair : Healthy
Appearance of face : Looking dull, anxious
Facial symmetry : Bilaterally symmetrical
pediculosis : No
EYES:-
Eyebrows : Black in colour
Eye lashes : Equally distributed, black in colour
Eye lids : swelling
Eye balls : No abnormality present
Conjuctiva : No infection
Sclera : White in colour
Cornea and iris : No abnormality present
Pupils : Reactive to light
Lens : No abnormality present
Fundus : No abnormality present
Eye muscles : No abnormality present
Vision : Normal vision
EARS:-
External ear : No discharge present
Tympanic membrane : No infection, intact
Hearing : Can hear
Symmetry : Biaterally symmetrical
Hearing acuity : Present
Any discharge : No ischarge
Swelling : No swelling
Vertigo : No vertigo
Tinnitus : No tinnitus
NOSE:-
External nares : No discharge
Nostrils : Patent
Symmetry : Symmetrical
Deformity : No nasal septum deviation
Flaring : No nasal flaring
Discharge : No discharge
Patency of nostrill : Patent
Epistaxis : No
 Sinusitis : No
MOUTH AND PHARYNX:-
Lips : Dry, black in colour
Odour of mouth : No bad odour
Teeth : Properly distributed
Mucus membrane and : Intact
gums
Tongue : No infection
Throat and pharynx : No infection
NECK:-
Lymph nodes : No swelling
Thyroid gland : Palpable, no swelling
Range of motion : Possible
RESPIRATORY SYSTEM:-
Shape and symmetry : Bilaterally symmetrical
Breathing rate : 34breaths/min
Characteristics : Regular
Cough : cough
Dyspnea on rest : dyspnea on rest
Dyspnea on exertion : Present
CARDIOVASCULAR SYSTEM:-
Pulse : 110beats/min
Blood ressure : 100/80 mmHg
Colour of skin : Black in colour, no cyanosis
Numbness : No numbness
Tingling : Tingling present
Edema : Edema present
Palpitation : palpitation
GASTROINTESTINAL SYSTEM:-
Skin integrity : Intact
Appetite : Poor
Digestion : No digestion of food
Bowel sound : normal
Nausea : Present
Vomitting : No vomitting
Abdominal distension : No abdominal distension
Constipation : No constipation

NEUROLOGICAL SYSTEM:-
Level of consciousness : Alert
Orientation : Oriented to time, place and person
Headache : No headache
Confusion : yes
 Convulsion : No convlsion
Inco-ordination : Yes inco-ordination due to breathing problem
Weakness : No weakness
Tingling and numbness : No tingling and numbness
Paralysis : No
Sensation : Present
Memory : Intact

MUSCULOSKELETAL SYSTEM:-
General appearance : Looking thin
Physical deformity : No physical deformity
Posture : Normal posture
Movement : Little movement possible
Range of motion : Possible
Spinal curvature : Normal spinal curvature
Joint Rom : Possible
Joint pain : yes
Changes in ADL : Can not perform ADL
INTEGUMENTARY SYSTEM:-
Colour : Black
Skin turgor : Decreased skin turgor
Bluish discolouration : No bluish discolouration
Lesions : No lesions
Rashes : No rashes
SPECIAL NOTES:-

DEFINITION OF THE DISEASE:-

Mitral valve regurgitation involves blood flowing back from the left ventricle into the left
atrium during systole often edges of mitral valve leaflets do not close completely during
systole because leaflets and chordaetendineae have thickened and fibrosed,resulting in their
contraction.
Mitral valve regurgitation is a condition in which the hear
closetightly,which allows blood to flow backward in the heart.

RELATED ANATOMY AND PHYSIOLOGY:-

The heart lies behined in the thoracic cavity in the mediastinum between the lungs. It lies obliquely, a little
more to the left then than the right, and presents a base above , and midline at the level of the 5th intercostal
space, i.e. a little below the nipple and slightly nearer the [Link] base extends to the level of the 2nd rib.

ORGANS ASSOCIATED WITH THE HEART:-

INFERIORLY:- the apex rests on the central tendon of the diaphragm.

SUPERIORLY:- the great blood vessels,i.e. the aorta, superior vena cava,pulmonary artery and pulmonary
veins.

POSTERIORLY:- the oesophagus ,trachea,left and right bronchus, descending aorta,inferior venacava and
thoracic vertebrae.

LATERALLY:- The lungs the left lung overlaps the left side of the heart.

ANTERIORLY:- the strenum,ribs and intercostal muscles.

STRUCTURE:- The heart is com posed ofr three layers of tissue pericarium, myocardium, and
endocardium.

Epicardium/pericardium. The epicardium is the outermost layer of the heart wall and is just another
name for the visceral layer of the pericardium. Thus, the epicardium is a thin layer of serous
membrane that helps to lubricate and protect the outside of the heart. Below the epicardium is the
second, thicker layer of the heart wall: the myocardium.
 Myocardium. The myocardium is the muscular middle layer of the heart wall that contains the
cardiac muscle tissue. Myocardium makes up the majority of the thickness and mass of the heart
wall and is the part of the heart responsible for pumping blood. Below the myocardium is the thin
endocardium layer.
Endocardium. Endocardium is the simple squamous endothelium layer that lines the inside of the
heart. The endocardium is very smooth and is responsible for keeping blood from sticking to the
inside of the heart and forming potentially deadly blood clots.

Valves of the Heart

The heart functions by pumping blood both to the lungs and to the systems of the body. To prevent blood
-way valves are present in
the heart. The heart valves can be broken down into two types: atrioventricular and semilunar valves.

Atrioventricular valves. The atrioventricular (AV) valves are located in the middle of the heart
between the atria and ventricles and only allow blood to flow from the atria into the ventricles. The
AV valve on the right side of the heart is called the tricuspid valve because it is made of three
cusps (flaps) that separate to allow blood to pass through and connect to block regurgitation of
blood. The AV valve on the left side of the heart is called the mitral valve or the bicuspid valve
because it has two cusps. The AV valves are attached on the ventricular side to tough strings called
chordae tendineae. The chordae tendineae pull on the AV valves to keep them from folding
backwards and allowing blood to regurgitate past them. During the contraction of the ventricles,
the AV valves look like domed parachutes with the chordae tendineae acting as the ropes holding
the parachutes taut.

Semilunar valves. The semilunar valves, so named for the crescent moon shape of their cusps, are
located between the ventricles and the arteries that carry blood away from the heart. The semilunar
valve on the right side of the heart is the pulmonary valve, so named because it prevents the
backflow of blood from the pulmonary trunk into the right ventricle. The semilunar valve on the left
side of the heart is the aortic valve, named for the fact that it prevents the aorta from
regurgitating blood back into the left ventricle. The semilunar valves are smaller than the AV valves
and do not have chordae tendineae to hold them in place. Instead, the cusps of the semilunar

Conduction System of the Heart

The heart is able to both set its own rhythm and to conduct the signals necessary to maintain and
coordinate this rhythm throughout its structures. About 1% of the cardiac muscle cells in the heart
are responsible for forming the conduction system that sets the pace for the rest of the cardiac
muscle cells.
The conduction system starts with the pacemaker of the heart a small bundle of cells known as
the sinoatrial (SA) node. The SA node is located in the wall of the right atrium inferior to the
superior vena cava. The SA node is responsible for setting the pace of the heart as a whole and
directly signals the atria to contract. The signal from the SA node is picked up by another mass of
conductive tissue known as the atrioventricular (AV) node.

ETIOLOGY & CAUSES:-

BOOK PICTURE PATIENT PICTURE
Mitral valve prolapse Mitral valve prolapse
Damaged tissue cords
 Rheumatic fever
Endocarditis
Heart attack
Abnormality of the heart
muscle(cardiomyopathy)
Trauma such as car accident can lead to
mitral valve regurgitation.
Congenital heart disease.
Radiation therapy
Atrial fibrilation Age
Age Stress
Stress Alcohol consumption
Alcohol consumption

PATHOPHYSIOLOGY:-

due to etiological factor

due to scaring and retraction of the valve leaflets

incomplete closure of mitral valve

blood flow backward into the left atrium

left atrial and left ventricular enlargement

left atrial dialtes

the LV most pump harder to preverse and also hypertrophies

left ventricular failure and rirht sided heart failure

mitral valve regurgitation

CLINICAL MANIFESTATIONS:-

BOOK PICTURE PATIENT PICTURE

Dyspnea Dyspnea
Fatigue Fatigue
Weakness Weakness
Asymptomatic
Palpitation
Shortness of breathing
Shortness of breath on exertion
Cough for pulmonary congestion
A racing or irregular heartbeat Cough
Dizziness
Lightheadedness
Chestpain Lightheadedness
Edema
edema

DIAGNOSTIC EVALUATION:-
BOOK PICTURE PATIENT PICTURE
History collection History collection
Physical examination Physical examination
Echocardiogram Echocardiogram
ECG ECG
Chest x-ray Chest x-ray
Cardiac MRI Cardiac MRI
Cardiac CT Cardiac CT
Exercise test or stress test Exercise test or stress test
Cardiac catheterization Cardiac catheterization

MEDICAL MANAGE MENT PATIENT PICTURE COMPARE TO BOOK PICTURRE)

BOOK PICTURE PATIENT PICTURE

Provide diuretic medicationthat helps Provide diuretic medicationthat helps
to eliminate excess body water and to eliminate excess body water and
decrease ventricular pressure. decrease ventricular pressure.

ability to to pump. ability to to pump.

Given milrinone and amrinone are
Given milrinone and amrinone are potent vasodilatorsand increase heart
potent vasodilatorsand increase heart contractility.
contractility. Provide antibiotic as prescribed by
Provide antibiotic as prescribed by the the physician order to control the
physician order to control the infection.
infection. Maintain bed rest while symptoms of
Maintain bed rest while symptoms of the mitral valve regurgitation.
the mitral valve regurgitation.
appropriate coping
appropriate coping [Link] deriphyline as
[Link] deriphyline as prescribed by the physician order.
 prescribed by the physician order. Provide tab. Planep as prescribed by
Provide tab. Planep as prescribed by the physician order.
the physician order. Provide calm and quite environment.
Provide calm and quite environment.
MEDICATIONS:-

SL NAME OF DOSE,RO INDICATION CONTRA NURSES ROLE

N THE DRUG UT,FREQU INDICATION
O ENCY

1 Digoxin 0.25mg, Increased Av block, Monitor apical pulse 1 full

orally, od myocardial arrhythmia. minute before administering.

contractility

2 Eplerrenone 25mg, orally HTN, MI, Heart Severe renal Assess the client condition.

failure impairment

3 Acitrom -2 2mgorally, Abnormal blood Hypersensitivity, Asess baseline mental status.

clot, stroke alopecia

4 deriphyline 1amp, iv, tds Asthma , lung Cystic fibrosis, To check urine output &

disease, bronchitis alcoholisim thyroid function.

5 Planeb 25mg,orally, mi pregnancy Asess the patient condition

od

6 Lasix 2ml,iv Nephrotic Vomiting, Asess baseline mental status.

syndrome, ARF& diarrhea, urinary

CRF retention

SPECIAL NOTES:-
Patient is looking weak.. Patient is feeling nausea and restlessness. Patient is having severe pain with
fever.

NURSING CARE PLAN

THEORY APPLICATION:-As my patient Mr. Rajesh Parida, a 40 years male was unable to

14 BASIC NEEDS
Breath normally
 Eat and drink adequately

Eliminate body waste

Move and maintain desirable position

Sleep and rest

Select suitable clothes- dress and undress

Maintain body temperature

Keep the body clean and well groomed and protect integument

Avoid dangers

Proper communication

Work in such a way that there is a sense of accomplishments

Play or participate in various forms of recreations

Learn, discover or satisfy the curiosity that leads to normal development and health

As my patient was in the risk for infection, I applied Florence nightingale theory on providing care,
Nightingale believed that the environment could be altered to improve conditions so that the
natural laws would allow healing to occur.
This grew from empirical observation that poor or difficult environments led to poor health
and disease.
She linked health with five environmental factors

5 essential components of healthy environment

[Link] or fresh air.

[Link] water
[Link] drainage
[Link]
[Link] (direct sunlight)

[Link] ventilation focus on the architectural aspect of the hospital.

2. Light has quite as real and tangible effects to the body. Her nursing intervention includes direct
exposure to sunlight.
3. Cleanliness and sanitation. She assumes that dirty environment was the source of infection and
rejected the "germ theory". Her nursing interventions focus on proper handling and disposal of
bodily secretions and sewage, frequent bathing for patients and nurses, clean clothing and
handwashing.
4. Warmth, quiet and diet environment. She introduce the manipulation of the environment for
patient's adaptation such as fire, opening the windows and repositioning the room seasonally, etc.
5. Unnecessary noise is not healthy for recuperating patients.
6. Dietary intake.
7. Petty management proposed the avoidance of psychological harm, no upsetting news. Strictly war
issues and concerns should not be discussed inside the hospital. She includes the use of small pets of
psychological therapy.

NURSING CARE PLAN:-

DAY 1

PROBLEMS:-
Chest pain
Reduced coronary blood flow

NURSING DIAGNOSIS ACCORDING TO PRIORITY BASIS:-

Ascute pain related to reduced blood flow as manifested by severe chest pain & radiation of pain
to neck & arms.
Ineffective cardiopulmonary and peripheral tissue perfusion related to reduced coronary blood
flow coronary thrombous as manifested by decrease in BP, dyspnea, peripheral edema.

ASSESSM DIAGNOS GOAL INTERVENTION RATIONALE EVALUATION

ENT IS
Subjective Ascute pain To relieve the To know the pain After 2 hrs,
data:- related to pain level of description of chest level of patient. patient
Patient reduced patient. pain including onset, verbalized relief
complains blood flow location, radiation, of pain. The pain
of feeling as duration. score is 4/10.
pain. manifested To know the
Objective by severe Obtain a 12 lead ECG abnormality
data:- chest pain & during pain as
Patient radiation of prescribed.
looks pain to neck To make proper
restlessness & arms. Provide comfortable chest expansion
position to patient.( and ease in
mainly semi- breathing.
position)

Administer
nitroglycerine, To decrease pain
morphine and
thrombolytics as
prescribed.

Assess the vital signs To check heart

of patient mainly heart rate.
rate and respiratory
rate.

To relieve anxiety
Provide psychological
 support.

Subjective Ineffective Promoting Assess the client Provide the The chance of
data:- cardiopulm adequate condition. baseline data. adequate
Patient onary and tissue tissue perfusion
complains peripheral perfusion. Initially and every to some extent.
of dyspnea. hours, assess, To know the
tissue
Objective document & report to abnormalities.
perfusion
data:- the physician- cool,
related to moist and cyanotic
mouth is reduced extremities.
dry, coronary Helps in reducing
decreased blood flow Ensure physical rest myocardial oxygen
blood coronary for patient by keeping consumption.
pressure. thrombous the patient on bed or
as chair rest.
manifested
by Administer oxygen Enriches supply of
therapy as prescribed . circulating oxygen.
decrease
in BP,
dyspnea,
peripheral
edema.
DAY 2

PROBLEMS:-
Chest pain
Activity intolerance

NURSING DIAGNOSIS ACCORDING TO PRIORITY BASIS:-

1. Acute pain related to reduced blood flow as manifested by severe chest pain & radiation of pain to neck &
arms.
2. Activity intolerance related to ataxia as evidenced by limited range o f motion.
ASSESSMEN DIAGNOS GOAL INTERVENTION RATIONALE EVALUATIO
T IS N
Subjective Acute pain To relieve Assess To know the pain After 2 hrs,
data:- related to the pain description of chest level of patient. patient
Patient reduced level of pain including onset, verbalized
complains of blood flow patient. location, radiation, relief of pain.
feeling pain. as duration. The pain score
Objective manifested To know the is 4/10.
data:- by severe Obtain a 12 lead abnormality
Patient looks chest pain & ECG during pain as
restlessness radiation of prescribed.
pain to neck To make proper
& arms. Provide comfortable chest expansion and
position to patient.( ease in breathing.
mainly semi-
position) To decrease pain

Administer To check heart rate.

nitroglycerine,
morphine and
thrombolytics as
prescribed. To relieve anxiety

Assess the vital signs

of patient mainly
heart rate and
respiratory rate.

Provide psychological
support.
.Subjective Activity To Assess for These are The activity
data:- intolerance improve mucous csigns and level of the
Patient related to the membranes and symptoms client has been
complains that ataxia as activity skin ofdisease. improved to
he is feeling evidenced level of the color,dyspnea,ch some extent.
very weak in by limited patient. est pain.
doing daily range of Assess the Indicate
activity. motion . patient for factors
Objective anemia,fluid contributin
data:- electrolyte g to
The patient is imbalance, severity of
doing his daily retaintion of fatigue.
activity very waste prodsucts.
slowly and Maintain the
irritately. client of Rest reduce
complete bed oxygen
rest orencourage consumptio
adequate rest n and
and provide cardiac
assistance with workload.
care and desired Client with
activites. arfmay
need to
Discuss activity restrict
restriction andf activity and
gradual resumption may feel
 of desired activity. weak,
Encourage use of requiring
energy saving and measures
relaxation techniques to conserve
and diversion energy and
activities. reduce
boredom.
DAY 3

PROBLEMS:-
Limited range of motion.
Nausea & vomiting`

NURSING DIAGNOSIS ACCORDING TO PRIORITY BASIS:-

Activity intolerance related to ataxia as evidenced by limited range of motion.

Imbalanced nutrritional status lessthan body requirement related to dietary restriction, loss
of apetite,nosea,vomiting as evidenced by weak ness.

ASSESS NURSING GOAL INTERVENTION RATIONALE EVALUATION

MENT DIAGNOSIS
.Subjectiv Imbalance Maintain Monitor weekly Provideinfor The nutritional status
e data:- d proper weight and mation is maintained to
Patient nutrrition nutrition serum about extent.
complains al status al intake protein,albumin, nutrition
of feeling lessthan electrolyte level. status.
weakness. body Provide or Oral hygiene
Objective requireme encourage minimizes
data:- nt related frequent oral mouth
Patient to dietary hygiein. dryness.
weight is restriction Assess and To know the
17osing. , loss of document dietary
apetite,no dietary intake. need.
sea,vomiti Provide Minimize
ng as frequent small anorexia and
evidenced feeding. nausea.
by weak Promote intake Complete
ness. of high protein
biological value provide
proteinfoodsegg, fopositive
dairy nitrogen
products,meats. balance
Provide only needed for
enough fluid growth.
intake to Enough fluid
replaceurine intake avoid
output. edema
caused by
excessive
fluid intake.
.Subjectiv Activity To Assess for These The activity level is
e data:- intoleranc improve mucous are some extent
Patient e related the membranes and csigns
complains to ataxia activity skin and
that he is as level of color,dyspnea,ch sympto
feeling evidenced the est pain. ms
very weak by limited patient. Assess the ofdiseas
in doing range of patient for e.
daily motion. anemia,fluid Indicate
activity. electrolyte factors
Objective imbalance, contribu
data:- retaintion of ting to
The waste prodsucts. severity
patient is Maintain the of
doing his client of fatigue
daily complete bed Rest
activity rest reduce
very orencourage oxygen
slowly adequate rest consump
and and provide tion and
irritately. assistance with cardiac
care and desired workloa
activites. d.
Client with
Discuss activity arfmay need to
restriction andf restrict activity
gradual resumption and may feel
of desired activity. weak, requiring
Encourage use of measures to
energy saving and conserve energy
relaxation and reduce
techniques and boredom.
diversion activities.

DAY 4

PROBLEMS:-

Breathlessness
Loss of appetite

NURSING DIAGNOSIS ACCORDING TO PRIORITY BASIS:-

1. Impaired gas exchange related to diffusion defect as evidenced by decreased respiration rate.
2. Imbalanced nutrritional status lessthan body requirement related to dietary restriction, loss of
apetite,nosea,vomiting as evidenced by weak ness.
ASSESSMENT DIAGNOSIS GOAL INTERVENTION RATIONALE EVALUATI
ON
[Link] Impaired To Regularly monitor Provide baseline data The gas
data:- gas maintain patients respiratory rate for better exchange
Patient exchange adequate and pattern. intervention. has been
complains related to ventilatio Assist the client into high maintaine
diffusion n and Allow full lung d to some
breath defect as oxygenati excursion & enhances extent as
properly. evidenced on. Administered low flow air exchange. evidence
Objective by oxygen therapy by normal
data:- decreased The appropriate respiratio
Patient feel respiration Ensure that oxygen amount of oxygen is n rate of
problem rate. delivery systemis applied continuously the
during to the patient. delivered so that the patient.
breathing and patient does not
respiration Encourage diaphragmatic desturate. Correct
rate is breathing& effective hypoxemia.
14/min coughing.
Assist client to maintain Improve ventilation
a comfortable position to by openining airway.
facilitate breathing.
To facilitate breathing
Administer elevate the head of
bronchodilator as bed.
prescribed by physician
order. Bronchodilator relax
and dilate airway.
[Link] Imbalanced Maintain Monitor weekly Provideinformatio The
data:- nutrritional proper weight and serum n about nutrition nutritional
Patient status nutritiona protein,albumin,electr status. status is
complains of lessthan l intake olyte level. Oral hygiene maintaine
feeling body Provide or encourage minimizes mouth d to some
weakness. requirement frequent oral hygiein. dryness. extent.
Objective related to Assess and document To know the
data:- dietary dietary intake. dietary need.
Patient restriction, Provide frequent Minimize anorexia
weight is loss of small feeding. and nausea.
19osing. apetite,nose Promote intake of Complete protein
a,vomiting high biological value provide fopositive
as evidenced proteinfoodsegg,dairy nitrogen balance
by weak products,meats. needed for
ness. Provide only enough growth.
fluid intake to Enough fluid
replaceurine output. intake avoid
edema caused by
excessive fluid
intake.
DAY 5

PROBLEMS:-
Chest pain
Reduced coronary blood flow
NURSING DIAGNOSIS ACCORDING TO PRIORITY BASIS:-

Acute pain related to reduced blood flow as manifested by severe chest pain & radiation of pain to neck &
arms.
Ineffective cardiopulmonary and peripheral tissue perfusion related to reduced coronary blood flow
coronary thrombous as manifested by decrease in BP, dyspnea, peripheral edema.

ASSESSM DIAGNOS GOAL INTERVENTION RATIONALE EVALUATION

ENT IS
Subjective Ascute pain To relieve the To know the pain After 2 hrs,
data:- related to pain level of description of chest level of patient. patient
Patient reduced patient. pain including onset, verbalized relief
complains blood flow location, radiation, of pain. The pain
of feeling as duration. score is 4/10.
pain. manifested To know the
Objective by severe Obtain a 12 lead ECG abnormality
data:- chest pain & during pain as
Patient radiation of prescribed.
looks pain to neck To make proper
restlessness & arms. Provide comfortable chest expansion
position to patient.( and ease in
mainly semi- breathing.
position)

Administer
nitroglycerine, To decrease pain
morphine and
thrombolytics as
prescribed.

Assess the vital signs To check heart

of patient mainly heart rate.
rate and respiratory
rate.

To relieve anxiety
Provide psychological
support.
Subjective Ineffective Promoting Assess the client Provide the The chance of
data:- cardiopulm adequate condition. baseline data. adequate
Patient onary and tissue tissue perfusion
complains peripheral perfusion. Initially and every to some extent.
of dyspnea. hours, assess, To know the
tissue
Objective document & report to abnormalities.
perfusion
data:- the physician- cool,
related to moist and cyanotic
mouth is reduced extremities.
dry, coronary Helps in reducing
decreased blood flow Ensure physical rest myocardial oxygen
blood coronary for patient by keeping consumption.
pressure. thrombous the patient on bed or
 as chair rest.
manifested
by Administer oxygen Enriches supply of
decrease therapy as prescribed . circulating oxygen.
in BP,
dyspnea,
peripheral
edema.

HEALTH EDUCATION:-
Encourage the patient to breath deeply & change position frequently.
Provide psychological & emotional support to the patient.
Instruct the patient in relaxation and diversional techniques and guided imagery to relieve tension and
anxiety.
Educate the patient and family members regarding disease condition and its procedure.
Encourage patient to use active and passive exercises.
Instruct the patint for bed rest.
Ensure bed rest to reduce heart rate, stroke volume and cardiac contractility.
Record daily weight and intake output.
Avoid risky behaviors.
Encourage small meal and snacks through out the day.
Record daily calorie intake and weight.
Provide range of motion exercises program.
Maintaining adequate cardiac output.
Assist the patient in activities of the daily living.
Eat a heart healthy diet that is low in sodium and fat and limits fat and cholestrol.
Reduce stress.
Avoid or limit caffeine intake.
Modify daily activities and get enough rest to avoid stressing the heart.

COMPLICATIONS IN PATIENT:-
There is no complications in patient during the time of hospitalization.

PROGRESS OF PATIENT:-
[Link] sahoo, a 52 years/ female patient was admitted on 29.05.2019. Patient had mitral valve
regurgitation on 29.05.2019 at burla. Patient primarily treated at Bargarh District hospital, with Regd. No.
28196 and came to here on 5.06.2019 for further management. Then conservative treatment was started
to the patient, IV fluid administration, IV antibiotics, wound care etc. Pa

-
I Sagarika barik , MSc ( Nursing) provided comprehensive nursing care to the patient named Mrs. Urbashi sahoo, a
52 years/ female diagnosis- mitral valve regurgitation. During the time of care, the family members were co-
operative and were able to follow the instructions. Due to shortage of adequate articles for providing care, i faced
little problem during care.

SUMMARY:-
The patient Mrs. Urbashi sahoo had got admitted on 29.05.2019 in burla hospital with the complains of -
Restlessness, chest pain, shortness of breath at night , heart palpitation, and hoarse voice . On diagnosis patient
was diagnosed with mitral valve [Link] had on conservative treatment with fluid management,
wound care, infection prevention, drug therapy etc. During hospital stay, the health condition of patient had
improved and he was better as before.

CONCLUSION:-.
As part of my clinical requirement, I have taken Mrs. Urbashi sahoo, a 52 years/female who has diagnosed as mitral
valve regurgitation. I have provided 5 days continuous care to the patient and through this I could able able to gain
some knowledge regarding care of patient with mitral valve regurgitation.
BOOK:-
th edition: publish by.
Lippincott Williums and wilkins, Pp:-1725-1752.
Javed Ansari and Davinden kaur.(2011), Text book of medical surgical nursing volume-ii; 1st
edition: publish by pee vee, Pp:- 555-559.
[Link], Heitkempeer, Harding, Kwong.(2017), Roberts medical surgical nursing,
assessment and management of clinical problems; 3rd south asia edition: publish by RELX
India [Link] , new delhi; page no. 1288-1293.
-
publishers, Pp- 842-849.

DOI:-
[Link]
[Link]
[Link]
[Link]
[Link]