Nursing Care of Patients with Cardiac Valvular or Inflammatory and Infectious

Cardiovascular Disorders

Stenosis ◦ Narrowed, Valve Does Not Open Completely◦ Forward Blood Flow Hindered◦ Decreases Cardiac Output

Regurgitation (Insufficiency) ◦ Valve Does Not Close Completely◦ Blood Flow Backs Up

During Ventricular Systole, Mitral Valve Flaps Normally Closed

In Mitral Valve Prolapse One/Both Flaps Bulge Into Left Atrium

If Bulging Flaps Do Not Fit Together, Mitral Regurgitation Occurs

Etiology◦ Unknown◦ Hereditary ◦ Women 20 to 55 Years of Age

Signs and Symptoms◦ Often None◦ Anxiety ◦ Chest pain◦ Dysrhythmias◦ Dyspnea

Signs and Symptoms (cont’d)◦ Fatigue◦ Palpitations

Complications◦ Dilation of Left Side of Heart

◦ Heart Failure

◦ Infective Endocarditis

◦ Emboli

Diagnostic Tests◦ Murmur Heard

◦ 2-D or Doppler Echocardiogram ◦ Coronary Angiogram

None, Unless Symptoms Healthy Lifestyle Avoid Stimulants/Caffeine Stress Management Beta Blockers for Tachycardia Valve Surgery for Severe MVP

Pathophysiology◦ Mitral Valve Thickening/Chordae Tendineae

Shortening◦ Narrows Valve Opening◦ Blood Flow Obstructed from Left Atrium◦ Left Atrium Enlarges

Pathophysiology (cont’d)◦ Backward Pressure Occurs Until Right Ventricle

Dilates/Fails◦ Cardiac Output Reduced

Common – Prior Rheumatic Fever Congenital Defects Tumors Rheumatoid Arthritis Systemic Lupus Erythematosus Calcium Deposits

Signs and Symptoms◦ None Early◦ Murmur◦ Exertional Dyspnea, Cough, Hemoptysis ◦ Fatigue ◦ Palpitations

Signs and Symptoms (cont’d)◦ Atrial Fibrillation◦ Chest Pain

Complications◦ Stroke ◦ Seizures

Diagnostic Tests◦ ECG: P-wave Changes◦ Chest X-Ray: Enlarged Chambers◦ 2-D and Doppler Echocardiography◦ Coronary Angiogram

Therapeutic Interventions◦ Prophylactic Antibiotics per Criteria◦ Anticoagulants: Atrial Fibrillation◦ Percutaneous Balloon Valvuloplasty

Surgery◦ Mitral Valve Repair

Commissurotomy Annuloplasty

◦ Mitral Valve Replacement

Pathophysiology◦ Mitral Valve Incomplete Closure◦ Backflow of Blood to Left Atrium◦ Left Atrium Dilates, Extra Volume to Left Ventricle◦ Left Ventricle Dilates from Extra Volume,

Eventually May Fail

Etiology◦ Rheumatic Heart Disease (Most)◦ Endocarditis ◦ Congenital Defects◦ Chordae Tendineae Dysfunction◦ Mitral Valve Prolapse

Signs and Symptoms◦ None Early◦ Murmur◦ Dyspnea, Cough, Hemoptysis ◦ Fatigue ◦ Palpitations

Signs and Symptoms (cont’d)◦ Atrial Fibrillation◦ Chest Pain

Complications◦ Atrial Fibrillation◦ Pulmonary Hypertension◦ Heart Failure

Diagnostic Tests◦ ECG: P-Wave Changes◦ Chest X-Ray: Enlarged Chambers◦ 2-D and Doppler Echocardiography◦ Coronary Angiogram

Therapeutic Interventions◦ None, Unless Symptoms◦ Prophylactic Antibiotics per Criteria◦ ACE Inhibitors ◦ Anticoagulants: Atrial Fibrillation◦ Mitral Valve Repair/Replacement

Pathophysiology◦ Aortic Valve Narrowed◦ Left Ventricle Contracts More Forcefully◦ Left Ventricle Hypertrophies◦ Decreased Cardiac Output◦ Eventual Heart Failure

Etiology◦ Congenital Defects ◦ Rheumatic Heart Disease◦ Calcification with Aging

Signs and Symptoms◦None Early◦Angina◦Murmur◦Syncope

◦Orthopnea◦Dyspnea on

Exertion◦Fatigue ◦Pulmonary Edema

Complications◦ Heart Failure ◦ Dysrhythmias◦ Endocarditis

Diagnostic Tests◦ ECG ◦ Chest X-Ray: Enlarged Left Ventricle◦ 2-D and Doppler Echocardiography◦ Serial Echocardiography ◦ Cardiac Catheterization

Therapeutic Interventions◦ Surgery

Aortic Valve Replacement Valvotomy

◦ Treat Heart Failure Symptoms◦ Prophylactic Antibiotics per Criteria

Aortic Valve Does Not Close Left Ventricle’s Volume Increases Left Ventricle Dilates Left Ventricle Fails

◦ Decreased Cardiac Output◦ Pulmonary Edema

Etiology◦ Rheumatic Heart Disease (Most)◦ Congenital Defects ◦ Syphilis◦ Endocarditis◦ Severe Hypertension

Etiology (cont’d)◦ Rheumatoid Arthritis ◦ Aortic Dissection

Signs and Symptoms◦ None Early◦ Exertional Dyspnea, Fatigue ◦ Corrigan’s Pulse: Palpated Pulse Forceful, Quickly

Collapses◦ Widened Pulse Pressure◦ Angina at Night

Diagnostic Tests◦ ECG◦ Chest X-Ray ◦ 2-D and Doppler Echocardiography◦ Coronary Angiogram

Complications◦ Endocarditis ◦ Heart Failure

Therapeutic Interventions◦ Vasodilator ◦ Surgical Valve Replacement◦ Prophylactic Antibiotic Therapy per Criteria

Nursing Assessment◦ History◦ Vital Signs◦ Signs and Symptoms

Pain Decreased Cardiac Output Activity Intolerance Excess Fluid Volume Ineffective Therapeutic Regimen

Management

Relieve Pain Maintain Vital Signs/Oxygen Saturation Maintain Desired Activities Maintain Clear Lung Sounds Understand Disease/Treatment

Pain Relief ◦ Rating Scale ◦ NTG◦ Pace Activities

Normal Cardiac Function ◦ Vital Signs◦ Intake and Output◦ Daily Weights ◦ Sodium Restriction◦ Smoking Cessation ◦ Medications as Ordered

Improve Quality of Life ◦ Assist ADLs◦ Rest Periods◦ Energy Conservation

Maintain Fluid Volume◦ Daily Weights ◦ Assess for Edema ◦ Intake/Output ◦ Diuretics as Ordered

Monitor Potassium Levels

Education◦ Medications ◦ Anticoagulants

Monthly INR/PT Tests Medic Alert Identification

Education (cont’d)◦ Include Caregivers for Elderly◦ Revised Endocarditis Prevention – Prophylactic

Antibiotics

Reports Satisfactory Pain Relief Vital Signs Normal/No Heart Failure Signs Reports Reduced Fatigue, Task Completion Remains Free of Edema, Maintains Weight,

Clear Lung Sounds

Verbalizes Understanding of Teaching/with No Symptom Recurrence

Minimally Invasive Surgery◦ Endoscopy◦ Robotic

Traditional ◦ Open Cardiac Surgery with Cardiopulmonary

Bypass

Stenosed Valve Repair◦ Balloon Valvotomy◦ Commissurotomy

Insufficient Valve Repair◦ Annuloplasty

Mechanical ◦ Durable◦ Creates Turbulent Blood Flow

Lifelong Anticoagulation◦ Used for Younger Adults

Biological ◦ Types

Porcine (Pig) Bovine (Cow) Allografts (Human) Autograft Cultural Considerations

Biological (cont’d)◦ Not as Durable as Mechanical Valves◦ No Lifelong Anticoagulation◦ Used for Older Adults

Biological Valves◦ Degenerative Changes◦ Calcification

Mechanical Valves ◦ INR/PT Monitoring for Bleeding Risk◦ Thrombus/Embolism Formation◦ Anemia◦ Endocarditis

Assessment◦ Circulatory Status ◦ Pain Control Needs◦ Diagnostic Tests◦ Typing and Cross-matching of Blood Needed

Acute or Chronic Pain Anxiety Deficient Knowledge

Teaching◦ Pain Management ◦ Endotracheal Tube/Ventilator◦ Communicating ◦ Chest Tubes ◦ Coughing/Deep Breathing

Teaching◦ IV Lines◦ Urinary Catheter

Preoperative Medications Antiseptic Scrub Showers NPO

Pain Ineffective Airway Clearance Impaired Gas Exchange Decreased Cardiac Output Risk for Infection Deficient Knowledge

Pain/Provide Relief Vital Signs, ECG ABGs Intake and Output Lung Sounds Incision

Promote Lung Expansion◦ Cough and Deep Breathe◦ Turn ◦ Ambulate

Prevent Infection◦ Hand Hygiene ◦ Cleanse Stethoscope

Each Patient, Each Handwashing◦ Sterile Technique◦ Monitor Temperature

Teaching◦ Pain Management◦ Medications◦ Activity ◦ Follow-up Monitoring/Care

Infection of Endocardium

Pathophysiology◦ Invading Organism Attaches to Endocardium ◦ Vegetative Lesion Forms◦ Damages Valve Leaflets◦ Emboli/Heart Failure Possible

Entry of Organism into Bloodstream Risk Factors

◦ Immunocompromised ◦ Artificial Heart Valve◦ Congenital/Valvular Heart Disease◦ IV Drug Use◦ Gingival Disease

Prevention◦ Oral/Dental care◦ Prophylactic Antibiotics per Criteria

Signs and Symptoms◦ Fever ◦ Murmur ◦ Splinter Hemorrhages ◦ Petechiae◦ Janeway Lesions ◦ Osler’s Nodes

Complications◦ Vegetative Emboli ◦ Heart Valve Stenosis/Regurgitation ◦ Heart Failure

Diagnostic Tests◦ Blood Cultures ◦ Echocardiography

Therapeutic Interventions◦ IV Antimicrobial Drug◦ Rest/Supportive Care◦ Home IV Antimicrobial Therapy◦ Surgical Valve Replacement/Repair

Nursing Management◦ Vital Signs/Cardiac Function◦ Report Heart Failure/Emboli Signs◦ Teach

Good Hygiene, Oral/Dental Care Report Symptoms: Fever, Chills, Sweats

Inflammation of Pericardium ◦ Acute◦ Chronic

Pathophysiology◦ Inflammation of the Pericardium ◦ Ventricular Filling Reduced

Decreased Cardiac Output and BP

Infections, Lyme Disease Drug Reactions Connective Tissue Disorders Neoplastic Disease Postmyocardial Infarction Dressler’s Syndrome

Renal Disease or Uremia Trauma

Signs and Symptoms◦ Chest Pain; Substernal, Radiates, Grating

Increases with Deep Inspiration Relieved by Sitting Up/Forward

◦ Pericardial Friction Rub◦ Dyspnea

Signs and Symptoms (cont’d)◦ Low-grade Fever◦ Cough

ECG Echocardiogram WBC Pericardial Fluid CT Scan MRI

Pericardiocentsis Treat Cause

◦ Antibiotics ◦ Hemodialysis◦ Pericardial Window ◦ Pericardiectomy

Bedrest NSAIDs

Complications◦ Pericardial Effusion ◦ Cardiac Tamponade

Immediate Pericardiocentesis

Vital Signs Cardiac Function/Tamponade Signs Pain Relief

◦ NSAIDs, Corticosteroids ◦ Position of Comfort

Education

Pathophysiology and Etiology◦ Inflammation of Myocardium ◦ Rare ◦ Often Follows Virus

Signs and Symptoms◦ None ◦ Possible Viral Infection Signs◦ Chest Pain, Tachycardia

Diagnostic Tests◦ Endomyocardial Biopsy ◦ MRI ◦ Echocardiogram◦ ECG

Therapeutic Interventions◦ Reduce Heart’s Workload◦ Oxygen◦ Treat Cause

Antimicrobial◦ Treat Heart Failure

Nursing Care◦ Vital Signs/Cardiac Status◦ Diversional Activities ◦ Energy Conservation◦ Education

Nonpenetrating◦ Blunt Trauma

Penetrating◦ External Injury ◦ Internal Injury

Enlargement of Heart Muscle No Cure

Dilated Cardiomyopathy◦ Ventricular Cavity Enlarges◦ Contractility Decreases◦ Stasis of Blood◦ Most Common Form

Hypertrophic Cardiomyopathy◦ Left Ventricle Muscle Wall Enlargement◦ Decreases Ventricular Filling◦ Can Cause Sudden Death in Athletes

Restrictive Cardiomyopathy◦ Cardiac Muscle Stiffness◦ Impairs Ventricular Stretch◦ Limits Ventricular Filling◦ Systolic Emptying of Ventricle Normal◦ Rarest Form

Signs and Symptoms◦ Heart Failure ◦ Dilated Cardiomyopathy

Exertional Dyspnea, Orthopnea, Fatigue ◦ Hypertrophic Cardiomyopathy

Exertional Dyspnea, Angina at Rest

Signs and Symptoms (cont’d)◦ Restrictive Cardiomyopathy

Exertional Dyspnea, Syncope, Arrhythmias

Diagnostic Tests◦ Chest X-Ray (Cardiomegaly) ◦ Echocardiography◦ ECG◦ Cardiac Catheterization

Therapeutic Interventions◦ No Cure◦ Palliative Care◦ Heart Failure Treatment◦ Anticoagulants

Therapeutic Interventions (cont’d)◦ Dilated

ACE Inhibitors, Beta Blockers, Diuretics, Digoxin Biventricular Pacing Implantable Defibrillators Heart Transplant

Therapeutic Interventions (cont’d)◦ Restrictive

Vasodilators Heart Transplant

Therapeutic Interventions (cont’d)◦ Hypertrophic

Beta Blockers Calcium Channel Blockers Myectomy Septal Ablation

Nursing Diagnoses◦ Decreased Cardiac Output ◦ Activity Intolerance ◦ Anxiety

Vital Signs Heart Failure/Emboli Signs Signs of Digoxin Toxicity Activity Tolerance/Energy Conservation Emotional Support

Education Home Health Care

Patient and Significant Other Education◦ Medications◦ Emergency Contacts◦ CPR◦ Hospice

Clot Formation Inflammation Within Vein

Pathophysiology◦ Clot Formation and Inflammation Within Vein◦ Superficial Veins◦ Deep Veins (DVT)◦ Emboli Danger

Etiology◦ Venous Stasis

Reduced Blood Flow◦ Damage to Vein Lining

IV Catheters

Etiology (cont’d)◦ Increased Blood Coagulation

Smoking Oral Contraceptives Estrogen Therapy Hematological Disorders

Prevention◦ Identify Risk Factors◦ Prevent Dehydration◦ Prophylactic Anti-embolism Devices◦ Early Ambulation◦ Range-of-Motion Exercises

Prevention (cont’d)◦ Prophylactic Medication

Low Molecular Weight Heparin Enoxaparin (Lovenox) Fondaparinux (Arixtra)

Heparin Warfarin (Coumadin)

Signs and Symptoms◦ None ◦ Superficial Veins

Redness, Warmth, Swelling, Tenderness

Signs and Symptoms◦ Deep Veins

Leg Usually Swelling, Edema, Pain, Warmth, Tenderness Homans’ Sign in 40% of Cases

Complications◦ Pulmonary Embolism

Life-threatening Emergency◦ Chronic Venous Insufficiency◦ Varicose Veins◦ Recurrent Deep Vein Thrombosis

Diagnostic Tests◦ Duplex Ultrasound◦ Impedance Plethysmography◦ Magnetic Resonance Imaging (MRI)◦ Venography ◦ d-dimer and Coagulation Tests

Therapeutic Interventions◦ Superficial Veins

Warm, Moist Heat Analgesics NSAIDs Compression Stockings

Therapeutic Interventions (cont’d)◦ Deep Veins

Low-molecular Weight Heparin/Heparin Warfarin (Coumadin) Bedrest (Elevate Extremity) Warm, Moist Heat Compression Stocking Therapy

Therapeutic Interventions (cont’d)◦ Deep Veins (cont’d)

Thrombolytic Therapy Thrombectomy Vena Cava Filter

Nursing Diagnoses ◦ Acute Pain ◦ Impaired Skin Integrity ◦ Anxiety◦ Deficient Knowledge

Identify Risk Factors Monitor Those at Risk for Signs Administer Meds per INR/PT Relieve Pain Monitor for Pulmonary Embolism Educate