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

2. 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

3. Valves of the Heart

4. Specific Valvular Disorders
Mitral valve prolapse: A portion of one or both mitral valve leaflets balloons back into the atrium during systole. Hereditary.
Mitral regurgitation (Insufficiency): Involves blood flowing back from the left ventricle into the left atrium during systole.
Mitral stenosis: An obstruction to blood flowing from the left atrium into the left ventricle.
Aortic regurgitation (Insufficiency): Flow of blood back into the left ventricle from the aorta during diastole.
Aortic stenosis: Narrowing of the orifice between the left ventricle and aorta.

5. Valvular Disease Chart

6. Heart Valves

7. Mitral Valve Prolapse
Mitral & Aortic valve disorders are most common valve problems. Tricuspid & Pulmonic are rare. Pulmonic stenosis is congenital.
Mitral Valve Prolapse (MVP) occurs when valve leaflets are enlarged and prolapse into L atrium during systole. Most often a benign condition, and usually asymptomatic, but can cause CP, palpitations, exercise intolerance, or fainting. A mid-systolic “click” heard at the apex is characteristic of MVP

8. Mitral Regurgitation (Insufficiency)
Mitral Regurgitation (Insufficiency): Rheumatic heart disease is the main cause. Other causes are papillary muscle rupture from ischemic heart disease, congenital defects, and infective endocarditis
Fibrosis and calcification prevent valve from closing completely. Blood backflows, then L ventricle must work harder to eject extra blood. This cause hypertrophy of ventricle.
More women than men are affected.
S/S may take decades to emerge. Fatigue and weakness (first), dyspnea on exertion, and orthopnea are later developments.

9. Mitral Regurgitation (Cont)
Mitral Regurgitation (cont): Other S/S include c/o palpitations, atypical CP, anxiety. Extremities may be cool and clammy and peripheral pulses are thready. A-Fib may occur.

10. Mitral Stenosis
Mitral Stenosis: Commonly caused by Rheumatic Fever. Other causes are lupus, RA.
Valve leaflet becomes stiffened after calcification. L atrium must work harder to pump blood thru the narrowed valve. Pulmonary pressure increases which may cause the right ventricle to hypertrophy.
First symptom may be dyspnea on exertion. Paroxysmal dyspnea (sudden dyspnea at night), A-Fib, and dry cough may occur, A diastolic rumbling murmur may be heard.
If untreated, R-sided HF may occur.

11. Aortic Regurgitation (Insufficiency)
Aortic Regurgitation (Insufficiency): Infective Endocarditis, congenital defects, longterm HTN, and Marfan syndrome (a rare genetic connective tissue disease) are factors in aortic regurgitation.
Valve leaflets do not close properly during diastole allowing backflow of blood from the aorta into the L ventricle. The L ventricle dilates and hypertrophies from the greater blood volume.

12. Aortic Regurgitation (Cont)
S/S do not appear until L ventricular failure happens. Dyspnea on exertion, orthopnea, and paroxysmal dyspnea begin. Nocturnal angina w/diaphoresis and palpitation, particularly when lying on the left side, occur late in the disease. Pulse is bounding and pulse pressure is widened w/increased systolic pressure and decreased diastolic pressure. On auscultation, there is a high- pitched, blowing diastolic murmur.

13. Aortic Stenosis
Aortic Stenosis: Most common valve disorder in the US. Atherosclerosis w/degenerative calcification of the valve is common factor in older adults. In younger pt’s, congenital valve malformations and rheumatic fever are primary causes.
Aortic valve opening narrows and obstructs L ventricular outflow during systole. Increased pressure required to eject blood causes L ventricular hypertrophy. Cardiac output is decreased to the point that the body’s demands cannot be met during exertion. Systolic HF begins and pulmonary congestion produces symptoms. When the valve opening becomes <1cm, surgery is urgent.

14. Aortic Stenosis (Cont)
Classic S/S of aortic stenosis are dyspnea, fatigue, and syncope on exertion. Later, extreme fatigue, weakness, and peripheral cyanosis become apparent.

15. 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

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

17. 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.

18. 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.

19. Treatment of Valve Disorders
Depends on valve affected and degree of impairment
Yearly monitoring and drug therapy for symptoms is standard when disease is not severe. Later, heart surgery may be needed.
Rest is an important part of therapy.
Before invasive procedures, prophylactic ATB are necessary for all pt’s w/valve disease
Surgical TX is required when valve disease becomes severe.

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

21. Surgical TX
Balloon valvuloplasty is sometimes used to open stenosed valves. It’s performed w/ a balloon tip catheter, which is threaded via the femoral artery into the heart and into the diseased valve. The balloon is inflated to enlarge the opening, then deflated and removed. Often, stenosis recurs in 6 months.
Direct commissurotomy occurs during cardiopulmonary bypass w/open heart surgery. Thrombi are removed from the atria and leaflets are incised along with calcification debridement; this opens the valve orifice.

22. Surgical TX (Cont)
Mitral Valve Annuloplasty is performed for acquired mitral regurgitation. Involves making the valve ring (annulus) smaller w/sutures. Leaflets are repaired to provide good closure of the valve at systole.
Valve replacement: Using mechanical (prosthetic) or biologic (tissue from cadavers) valves. If mechanical, pt. needs anticoagulant therapy for their lifetime due to clot formation. Mechanical valves are more durable. The aortic valve is always replaced w/ a mechanical valve due to high pressure in aorta.
Biologic valves require no anticoagulants, but may wear out in 15 years, requiring additional surgery.

23. Balloon Valvuloplasty

24. Annuloplasty Ring Insertion

25. Valve Leaflet Resection and Repair With Ring Annuloplasty

26. Valve Replacement

27. Mechanical & Biologic Tissue Valves

28. 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

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

30. 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
Dilated cardiomyopathy
Arrhythmogenic cardiomyopathy
Unclassified cardiomyopathies

31. Cardiomyopathies That Lead to Congestive Heart Failure

32. Cardiomyopathy
Dilated: Extensive enlargement of ventricles w/impairment of contractions. Caused by chemotherapy, alcohol abuse, infection, inflammation, poor nutrition, and connective tissue disorders. Advances to HF.
Hypertrophic: Increased growth of L ventricle muscle. May be hereditary, caused by HTN, or hypoparathyroidism. Sudden death may occur
Restrictive: Stiffened ventricles prevent adequate relaxation after systole, affecting filling. Caused by systemic diseases such as amyloidosis or sarcoidosis. Progresses to R-sided HF.

33. Cardiomyopathies
A group of diseases that affect the structure or function of the heart
S/S include dyspnea, activity intolerance, angina, dizziness, HTN, palpitations
Diagnosis is made by cardiac cath, echocardiography, ECG, or CT/MRI scans
Treatment includes drugs to increase contractility (such as digoxin), antihypertensives, diuretics, antiarrhythmics, and anticoagulants
Possible heart transplant pt’s
Should avoid sodium!

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

35. 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.

36. 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

37. 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

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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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.

45. 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

46. 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

47. Clinical Manifestations: Infectious Diseases of the Heart
Fever
New heart murmur, friction rub at left lower sternal border (pericarditis)
Osler nodes (painful, red, raised lesions found on the hands and feet), Janeway lesions (non-tender, small erythematous or hemorrhagic macular or nodular lesions on the palms or soles only a few millimeters in diameter), Roth spots (retinal hemorrhages), 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

48. 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

49. 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.

50. 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.