Chapter 28 Management of Patients With Structural, Infectious, and Inflammatory Cardiac Disorders

Valvular Disorders Regurgitation: The valve does not close properly, and blood backflows through the valve. Stenosis: The valve does not open completely, and blood flow through the valve is reduced. Valve prolapse: The stretching of an atrioventricular valve leaflet into the atrium during diastole

Valves of the Heart

Specific Valvular Disorders Mitral valve prolapse Mitral regurgitation Mitral stenosis Aortic regurgitation Aortic stenosis

Nursing Management: Valvular Heart Disorders Patient education Monitor VS trends Monitor for complications Heart failure Dysrhythmias Other symptoms Medication schedule: education Daily weights: monitor for weight gain

Nursing Management: Valvular Heart Disorders (cont’d) Plan activity with rest periods Sleep with HOB elevated

Question The nurse is providing education for a client diagnosed with mitral valve prolapse (MVP). What should be included in the teaching plan? (Select all that apply.) MVP is not hereditary. Caffeine is tolerated in small amounts. Avoid alcohol. Stop use of tobacco products. Prophylactic antibiotics are not prescribed before dental procedures.

Answer Avoid alcohol. Stop use of tobacco products. Prophylactic antibiotics are not prescribed before dental procedures. Rationale: MVP is hereditary, and caffeine should be avoided.

Surgical Management: Valvular Heart Disorders Valvuloplasty Commissurotomy Balloon valvuloplasty Annuloplasty Leaflet repair Chordoplasty Valve replacement Mechanical Tissue Bioprosthesis Homografts Autografts

Balloon Valvuloplasty

Annuloplasty Ring Insertion

Valve Leaflet Resection and Repair With Ring Annuloplasty

Valve Replacement

Nursing Management: Valvuloplasty and Valve Replacement Balloon valvuloplasty Monitor for heart failure and emboli Assess heart sounds every 4 hours Same care as after cardiac catheterization Surgical valvuloplasty or valve replacements Focus is hemodynamic stability and recovery from anesthesia Frequent assessments with attention to neurologic, respiratory, and cardiovascular systems

Nursing Management—Valvuloplasty and Valve Replacement (cont’d) Patient education Anticoagulation therapy Prevention of infective endocarditis Follow up Repeat echocardiograms

Cardiomyopathy Cardiomyopathy is a series of progressive events that culminates in impaired cardiac output and can lead to heart failure, sudden death, or dysrhythmias. Types Restrictive cardiomyopathy Hypertrophic cardiomyopathy Arrhythmogenic cardiomyopathy Unclassified cardiomyopathies

Cardiomyopathies That Lead to Congestive Heart Failure

Question What is the main electrolyte involved in cardiomyopathy? Calcium Phosphorus Potassium Sodium

Answer Sodium Rationale: Sodium is the major electrolyte involved with cardiomyopathy. Cardiomyopathy often leads to heart failure, which develops, in part, from fluid overload. Fluid overload is often associated with elevated sodium levels.

Nursing Process: The Patient With Cardiomyopathy (Assessment) History (predisposing factors, family history) Chest pain Review of diet (Na reduction, vitamin supplements) Psychosocial history: impact on family, stressors, depression Physical assessment: VS pulse pressure; pulsus paradoxus; weight gain or loss; PMI; murmurs; S3 or S4; pulmonary auscultation for crackles, JVD, and edema

Nursing Process: The Patient with Cardiomyopathy (Nursing Diagnosis) Decreased cardiac output Risk for ineffective cardiac, cerebral, peripheral, and renal tissue perfusion Impaired gas exchange Activity intolerance Anxiety Powerlessness Noncompliance with medication and diet therapies

Collaborative Problems and Potential Complications Heart failure Ventricular dysrhythmias Atrial dysrhythmias Cardiac conduction defects Pulmonary or cerebral embolism Valvular dysfunction

Nursing Process: The Patient With Cardiomyopathy (Planning and Goals) Improvement or maintenance of cardiac output Increased activity tolerance Reduction of anxiety Adherence to the self-care program Increased sense of power with decision making Absence of complications

Nursing Process: The Patient With Cardiomyopathy (Nursing Interventions) Improve cardiac output and peripheral blood flow Rest, positioning (legs down), supplemental O2, medications, low Na diet, avoid dehydration Increase activity tolerance and improving gas exchange Cycle rest and activity, ensure patient recognizes symptoms that indicate the need for rest Reduce anxiety Eradicate or alleviate perceived stressors, educate family about diagnosis, assist with anticipatory grieving

Nursing Process: The Patient With Cardiomyopathy (Nursing Interventions) (cont’d) Decrease the sense of powerlessness Assist patients in identifying things that have been lost (i.e., ability to play sports), assist patients in identifying amount of control they still have left Promote home- and community-based care Educate patients about ways to balance lifestyle and work while accomplishing therapeutic activities Assess patient and family and their adjustment to lifestyle changes, educate family about CPR and AEDs, establish trust

Nursing Process: The Patient With Cardiomyopathy (Evaluation) Maintain or improve cardiac function HR and RR WNL, decreased dyspnea and increased comfort, maintain or improve gas exchange, absence of weight gain, maintain or improve peripheral blood flow Maintain or increase activity tolerance Carry out activities of daily living (e.g., brush teeth, feed self), reports increased tolerance to activity

Nursing Process: The Patient With Cardiomyopathy (Evaluation) (cont’d) Reduce anxiety Discusses prognosis, verbalizes fears and concerns, participates in support groups, demonstrates appropriate coping mechanisms Decrease sense of powerlessness Identifies emotional response to diagnosis, discusses control that he or she has Adhere to self-care program Takes medications as prescribed, modifies diet to accommodate sodium and fluid recommendations, modifies lifestyle, identifies S&S to be reported

Infectious Diseases of the Heart Any of the layers of the heart may be affected by an infectious process. Diseases are named by the layer of the heart that is affected. Diagnosis is made by patient symptoms and echocardiogram. Blood cultures may be used to identify the infectious agent and to monitor therapy. Treatment is with appropriate antimicrobial therapy. Patients require teaching to complete the course of appropriate antimicrobial therapy and require teaching for infection prevention and health promotion.

Types of Infectious Disease of the Heart Rheumatic endocarditis Occurs most often in school-age children after group A beta-hemolytic streptococcal pharyngitis; need to promptly recognize and treat “strep” throat to prevent rheumatic fever Infective endocarditis Usually develops in people with prosthetic heart valves or structural cardiac defects; also occurs in patients who are IV drug abusers and in those with debilitating diseases, indwelling catheters, or prolonged IV therapy

Types of Infectious Disease of the Heart Pericarditis Inflammation of the pericardium; many causes; potential complications: pericardial effusion and cardiac tamponade Myocarditis An inflammatory process involving the myocardium; most common pathogens involved in myocarditis tend to be viral; in endocarditis, they tend to be bacterial; complications: cardiomyopathy and heart failure

Clinical Manifestations: Infectious Diseases of the Heart Fever New heart murmur, friction rub at left lower sternal border (pericarditis) Osler nodes, Janeway lesions, Roth spots, and splinter hemorrhages in nailbeds (Rheumatic) Cardiomegaly, heart failure, tachycardia, splenomegaly Fatigue, dyspnea, syncope, palpitations, chest pain (myocarditis) Diagnostic tools: blood cultures, echocardiogram, CBC, rheumatoid factor, ESR, CRP, urinalysis, ECG, cardiac catheterization, CMR imaging, TEE, CT scan

Prevention Antibiotic prophylaxis before certain procedures Ongoing oral hygiene Female patients are advised NOT to use IUDs Meticulous care should be taken in patients “at risk” who have catheters Catheters should be removed as soon as they are no longer needed Immunizations

Question A patient with restrictive cardiomyopathy taking digoxin presents with symptoms of anorexia, nausea, vomiting, headache, and malaise. What should the nurse expect to be included in the plan of care for this patient? The patient’s digoxin will be changed to nifedipine. The patient’s digoxin dose will be decreased. Nothing; these are signs of restrictive cardiomyopathy that are expected. The patient will be admitted to an ICU.

The patient’s digoxin dose will be decreased. Answer The patient’s digoxin dose will be decreased. Rationale: Patients with restrictive cardiomyopathy are sensitive to digitalis. Nurses must closely monitor these patients for digitalis toxicity, which is evidenced by dysrhythmia, anorexia, nausea, vomiting, headache, and malaise. This patient presents with symptoms of digoxin toxicity, so a decrease in dosage should be anticipated. These patients should avoid nifedipine, and they do not need to be admitted to the ICU.