3. Management
1. give antibiotics steadily to maintain level in blood.
2. provide analgesics - for pain/inflammation
3. oxygen to prevent tissue hypoxia.
4. surgical - commissurotomy, valvuloplasty, prosthetic heart valve
   
5. Nursing interventions
1. the cardio-care six 
2. help the client with chorea to grasp objects; prevent falls.
3. encourage family and friends to spend time with client and fight boredom during the long, tedious convalescence.
4. client and family teaching
1. explain all tests and treatments
2. nutrition
3. hygienic practices
4. to resume ADLs slowly and schedule rest periods
5. to report penicillin reaction: rash, fever, chills
6. to report findings of streptococcal infection
• sudden sore throat
• diffuse throat redness and oropharyngeal exudate
• swollen and tender cervical lymph glands
• pain on swallowing
• temperature of 101 to 104 degree Fahrenheit
• headache
• nausea
7. keep client away from people with respiratory infections
8. explain necessity of long-term antibiotics
9. arrange for a visiting nurse if necessary
10. help the family and client cope with temporary chorea
6. Diagnostic studies
1. antistreptolysin 0 titer - increased
2. ESR - increased
3. throat culture - positive for streptococci
4. WBC count - increased
5. RBC parameters - normocytic, normochromic anemia
6. C-reactive protein - positive for streptococci
   

III. Valve Disorders

1. Mitral stenosis
1. Definition - mitral valve thickens and gets narrower, blocking blood flow from the left atrium to left ventricle.
2. physiology (illustration)
1. function of the heart is the transport of oxygen, carbon dioxide, nutrients and waste products
2. cardiac cycle consists of: (illustration)
• systole - the phase of contraction during which the chambers eject blood
• diastole - the phase of relaxation during which the chambers fill with blood. When heart pumps, myocardial layer contracts and relaxes.
3. blood flow: (illustration 1  illustration 2)
• deoxygenated blood enters the right atrium through the superior and inferior vena cava
• enters the right ventricle via the tricuspid valve
• travels through the pulmonic valve to pulmonary arteries and lungs
• oxygenated blood returns from lungs through the pulmonary veins into left atrium and enters the left ventricle via bicuspid (mitral) valve.
• from the left ventricle, through the aortic valve through the aorta to the systemic circulation
4. the heart itself is supplied with blood by the left and right coronary arteries (illustration)
5. the vascular system is a continuous network of blood vessels.
• the arterial system consists of arteries, arterioles and capillaries and delivers oxygenated blood to tissues
• oxygen, nutrients and metabolic waste are exchanged at the microscopic level
• the venous system, veins and venules, returns the blood to the heart (illustration)
2. Epidemiology

a.                  of clients with mitral stenosis, 2/3 are female

b.                  most cases of mitral stenosis are caused by rheumatic fever

3. Findings
1. mild - no findings
2. moderate to severe
1. dyspnea on exertion
2. paroxysmal nocturnal dyspnea
3. orthopnea
4. weakness, fatigue, and palpitations
3. peripheral and facial cyanosis in severe cases
4. jugular vein distention
5. with severe pulmonary hypertensionor tricuspid stenosis - ascites
6. edema 
7. hepatomegaly
8. diastolic thrill at the cardiac apex 
9. when client lies on left side, loud S1 or opening snap and a diastolic murmurat the apex
10. crackles in lungs
    
4. Management
1. antiarrhythmics if needed
2. if medication fails, atrial fibrillationis treated with cardioversion.
3. low-sodium diet - to prevent fluid retention
4. oxygen if needed - to prevent hypoxia
5. surgery - mitral commissurotomy or valvotomy
5. Nursing interventions
1. the cardio-care six 
2. observe closely for findings of heart failure, pulmonary edema, and reactions to drug therapy.
3. if client has had surgery, watch for hypotension, arrhythmias, and thrombus formation.
4. monitor the cardio seven 
5. client and family 
1. explain the need for long-term antibiotic therapy and the need for additional antibiotics before dental care.
2. report early findings of heart failure such as dyspnea or a hacking, nonproductive cough.
6. Diagnostic studies/findings
1. history and physical exam
2. EKG- for changes of left atrial enlargement and right ventricle enlargement
3. echocardiogram - for restricted movement of the mitral valves and diastolic turbulance
   
1. Mitral insufficiency (or regurgitation)
1. Definition and related terms
1. a damaged mitral valve allows blood from the left ventricle to flow back into the left atrium during systole.
2. to handle the backflow, the atrium enlarges. So does the left ventricle, in part to make up for its lower output of blood.
2. Epidemiology
1. follows birth defects such as transpositionof the great arteries.
2. in older clients, the mitral annulus may have become calcified.
3. cause unknown; may be linked to a degenerative process.
4. occurs in 5 to 10% of adults.
3. Findings
1. client may be asymptomatic
2. orthopnea, dyspnea, fatigue, weakness, weight loss
3. chest pain and palpitations
4. jugular vein distention
5. peripheral edema
   
4. Management
1. low-sodium diet - to prevent fluid retention
2. oxygen as needed - to prevent tissue hypoxia
3. antibiotics - to treat infection
4. prophylactic antibiotics - to prevent infection
5. surgery - mitral valvuloplasty or valve replacement
5. Nursing interventions
1. the cardio-care six 
2. monitor the cardio seven 
3. monitor for left-sided heart failure, pulmonary edema, adverse reactions to drug therapy, and cardiac dysrhythmias especially atrial and ventricular fibrillation
4. if client has surgery, monitor postoperatively for hypotension, arrhythmias and thrombus formation
5. client and family teaching
1. diet restrictions and drugs
2. explain tests and treatments
3. prepare client for long-term antibiotic and follow-up care.
4. stress the need for prophylactic antibiotics during dental care.
5. teach client and family to report findings of heart failure:
   dyspnea and hacking, nonproductive cough.
6. Diagnostic findings
1. EKG for arrythmias and changes of left atrial enlargement
2. echocardiogram - to visualize regurgitant jets and flail chordae/leaflets
3. cardiac cath shows regurgitation of blood from left ventricle to left atrium