1. Inflammatory and Valvular Heart Diseases

2. Rheumatic Fever and Heart Disease
Rheumatic Fever - inflammatory disease of heart potentially involving all layers
Systemic
Abnormal immune response to group A beta hemolytic strep (“strep throat”)
Transmission to heart via lymphatic channels
Most common cause of valvular heart disease

3. Rheumatic Fever and Heart Disease
Rheumatic Heart Disease – chronic condition characterized by scarring and deformity of heart valves resulting from rheumatic fever
Any or all layers of heart maybe affected

4. Rheumatic Fever and Heart Disease
Rheumatic endocarditis (most serious)
Erosion and swelling of valves (thickening)
Vegetations
Stenosis/Regurgitation
Rheumatic Myocarditis
Nodules and fibrin deposits  loss of contractile powerCHF
Rheumatic Pericarditis
Fibrinous Exudate and pericardial effusion

5. Rheumatic Fever and Heart Disease
Nursing Assessment
Previous history of rheumatic fever
Socioeconomic class
Fever
Cardiovascular (tachycardia; pericardial friction rub; distant heart sounds; murmurs)
Neurological: chorea
Skin: subcutaneous nodules and erythema marginatum
Musculoskeletal: Polyarthritis

6. Rheumatic Fever and Heart Disease
Primary Prevention
Detection and treatment of strep throat
Secondary Prevention
Prophylactic antibiotics to prevent recurrent ARF

7. Rheumatic Fever and Heart Disease
Acute Intervention
Antibiotics
Rest
Control Fever
Anti-Inflammatories

8. Infective Endocarditis
Infection of the inner layer (endocardium) of the heart that usually affects the cardiac valves
Was almost always fatal until development of penicillin
5,000-8,000 cases diagnosed in U.S. each year

9. Classification Subacute form Longer clinical course Insidious onset
Streptococcus bovis or viridians
Staphylococcus epidermidis
HACEK group

10. Classification Acute form Shorter clinical course Rapid onset
Causative organism more virulent
Streptococcus pneumoniae
Staphylococcus aureus
Streptococcus groups A, B, C
Fungi

11. Etiology and Pathophysiology
Vegetations
Fibrin, leukocytes, and microbes
Adhere to the valve or endocardium
Embolization of portions of vegetations into circulation

12. Bacterial Endocarditis of the Mitral Valve
Fig. 36-2

13. Etiology and Pathophysiology
Left-sided more common with bacterial infections and underlying heart disease
Right-sided lesions usually caused by IV drug abuse

14. Etiology and Pathophysiology
Risk Factors:
Cardiac Conditions (blood flow turbulence allows pathogen to infect previously damaged valves or other surfaces)
Rheumatic heart disease
Prosthetic valves
Aging
IV drug abuse
Invasive Medical and Dental Procedures
UTI, skin/wound infections

15. Clinical Manifestations
Nonspecific
Fever occurs in 90% of patients
Chills
Weakness
Malaise, Fatigue
Anorexia

16. Clinical Manifestations
Vascular manifestations
Splinter hemorrhages in nail beds
Petechiae
Osler’s nodes on fingers or toes
Janeway’s lesions on palms or soles

17. Clinical Manifestations

18. Clinical Manifestations
Murmur in 80% of cases
CHF
in up to 80% with aortic valve endocarditis
50% with mitral valve endocarditis
Manifestations secondary to embolism

19. Sites of Embolization

20. HISTORY Recent dental, urologic, surgical, or gynecologic procedures
Heart disease
Recent cardiac catheterization
Skin, respiratory, or urinary tract infections

21. Diagnostic Studies Labs Blood cultures
Echocardiography (detects valvular vegetations, abscesses)
Chest x-ray

22. Collaborative Care Prophylactic treatment for patients having:
Removal of drainage of infected tissue
Indwelling pacemakers
Renal dialysis
Ventriculoatrial shunts

23. Collaborative Care Antibiotic administration Subsequent blood cultures
Monitor antibiotic serum levels
Antipyretics
Subsequent blood cultures
REST
Valve repair/replacement

24. Nursing Assessment Subjective
History of valvular, congenital, or syphilitic cardiac diseases
Previous endocarditis
Staph or strep infection
Immunosuppressive therapy

25. Nursing Assessment Recent surgical procedures or invasive procedures
IV drug abuse
Weight changes
Chills
Diaphoresis

26. Nursing Assessment Bloody urine Exercise intolerance
Generalized weakness
Fatigue
Cough
Dyspnea on exertion
Night sweats
Chest, back, abdominal pain

27. Nursing Assessment Objective Olser’s nodes Splinter hemorrhages
Janeway’s lesions
Petechiae
Clubbing

28. Nursing Assessment Tachypnea Crackles Arrhythmias Leukocytosis
Increased ESR and cardiac enzymes
Positive cultures
ECG showing chamber enlargement

29. Nursing Diagnoses Decreased cardiac output Activity intolerance
Ineffective health maintenance

30. Acute Pericarditis Caused by inflammation of pericardial sac
Etiologies: Infectious vs Non-Infectious
S&S: dyspnea, CP, pericardial friction rub
Complications
Pericardial effusion
Cardiac tamponade
Treatment
Antibiotics
NSAIDS
Corticosteroids
Positioning head at 45 degree angle
Pericardiocentesis

31. Valvular Heart Disease

32. Valvular Heart Disease
Heart contains two atrioventricular valves and two semilunar valves

33. Valvular Heart Disease
Types of valvular heart disease depends on:
Valve or valves affected
Two types of functional alterations
Stenosis
Regurgitation

34. Valvular Heart Disease
Stenosis
Valve orifice is restricted
Impending forward blood flow
Creates a pressure gradient across open valve
Degree of stenosis reflected in pressure gradient differences
Regurgitation
Incomplete closure of valve leaflets
Results in backward flow of blood

35. Mitral Valve Stenosis Due to rheumatic heart disease
Causes scarring of valve leaflets and chordae tendineae
Contractures develop with adhesions between commissures of the leaflets
Stenotic mitral valve assumes funnel shape due to thickening and shortening of valve structures

36. Mitral Valve Stenosis Pathophysiology:
Incomplete emptying of LA  Increased LA pressure LA dilatation and hypertrophy
Increased LA pressureElevated pulmonary pressurepulmonary congestion
Incomplete emptying of LAinsufficient volumes to ventricles  decreased C.O.
Afib is common  risk of embolism

37. Clinical Manifestations
Dyspnea
Occasionally accompanied by hemoptysis
Primary symptom because of reduced lung compliance
Palpitations from atrial fibrillation
Fatigue
Opening snap
Low-pitched rumbling diastolic murmur
Chest pain
Seizures (from emboli)
Stroke
Emboli can arise from stagnant blood in left atrium

38. Mitral Valve Regurgitation
Mitral Valve fails to close properly
LV ejects blood into aorta and back into LA

39. Mitral Valve Regurgitation
Majority of cases attributed to:
MI (MI with left ventricular failure places patient at risk for rupture of chordae tendineae)
Chronic rheumatic heart disease
Isolated rupture of chordae tendineae
Mitral valve prolapse
Ischemic papillary muscle dysfunction
Infectious endocarditis

40. Mitral Valve Regurgitation
Acute Onset (e.g. papillary dysfunction due to M.I.)
Backward flow  increased LA pressure  Increased Pulmonary Pressure  Pulmonary Edema
Chronic Onset
Backward flow  LA dilates and hypertrophies  Increased pulmonary pressures  pulmonary congestion  right sided failure

41. Mitral Valve Regurgitation Clinical Manifestations
Asymptomatic for years until development of some degree of left ventricular failure
Initial symptoms include:
Weakness
Fatigue
Dyspnea that gradually progress to orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema

42. Aortic Valve Stenosis
Usually discovered in childhood, adolescence, or young adulthood
Those seen later in life usually have aortic stenosis from rheumatic fever or senile fibrocalcific degeneration of a normal valve

43. Aortic Valve Stenosis
Results in obstruction of flow from LV to aorta during systole
Effect is left ventricular hypertrophy and increased myocardial oxygen consumption because of increased myocardial mass
Leads to reduced CO and pulmonary hypertension

44. Aortic Valve Stenosis Clinical Manifestations
Symptoms of angina pectoris
Syncope
Heart failure
Occurs when valve orifice is 1/3 normal size

45. Aortic Valve Stenosis
Poor prognosis when experiencing symptoms and valve obstruction is not relieved
Why would Nitroglycerine be contraindicated with aortic valve stenosis?

46. Aortic Valve Regurgitation
May result from disease of aortic valve leaflets, aortic root, or both
Caused by:
Bacterial endocarditis
Trauma
Aortic dissection
Constitutes life-threatening emergency
Chronic aortic regurgitation results from:
Rheumatic heart disease
Congenital bicuspid aortic valve
Syphilis
Chronic rheumatic heart conditions

47. Aortic Valve Regurgitation
Physiologic consequence:
Retrograde blood flow from ascending aorta to left ventricle
Elevated LV pressures
LV dilatation and hypertrophy
Results in volume overload

48. Tricuspid Valve Disease
Tricuspid valve stenosis
Seen in IV drug users
Right atrial output is obstructed
Results in right atrial enlargement and elevated systemic venous pressure

49. Tricuspid Valve Disease Clinical Manifestations
Peripheral edema
Ascites
Hepatomegaly
Murmur

50. Collaborative Care Drug therapy Digitalis Diuretics Antiarrhythmics
b-blockers
Anticoagulants
Low-sodium diet

51. Collaborative Care
Percutaneous transluminal balloon valvuloplasty to split open fused commissures
Surgical therapy for valve repair
Annuloplasty
Valvuloplasty
Commissurotomy
Valve Replacement
Mechanical Vs. Biological

52. Nursing Assessment Objective Fever Diaphoresis Peripheral edema
Crackles
Wheezes
Abnormal heart sounds
Ascites
Hepatomegaly
Cardiomegaly
Valve calcification
Pulmonary congestion on x-ray

53. Nursing Assessment Diagnostic Tests:
Calcification or vegetation of leaflets or prolapse
Chamber enlargement
Arrhythmias
Conduction deficits on ECG

54. Nursing Implementation
Prevention of rheumatic valvular disease by diagnosing and treating streptococcal infection and providing prophylactic antibiotics for patients with history
Patient with history of endocarditis must also be treated with prophylactic antibiotics

55. Nursing Implementation
Teach when to seek medical treatment
Design activity to patient’s limitations
Discourage smoking
Avoid strenuous activity
Nursing assessment to monitor effectiveness of medications

56. Nursing Implementation
Medic Alert bracelet
Teach importance of completing antibiotic regimen
Teach drug side effects
INR for anticoagualtion therapy
Follow-up care

57. Case Study Patient Profile: Subjective Data Objective Data
Mrs. S., a 54-year-old Hispanic woman, is admitted to the hospital for valvular heart disease.
Subjective Data
Was told she had streptococcal throat infection as a child
Was diagnosed 10 years ago with rheumatic heart disease
Has shortness of breath at rest; cannot get out of bed without becoming dyspneic
Takes digoxin (0.25 mg once a day)
Objective Data
Physical Examination
Ankle edema
Irregular pulse
Crackles at lung bases
Murmurs of mitral stenosis, mitral insufficiency, and aortic insufficiency
Diagnostic Studies
Chest x-ray and ECG indicate enlarged left atrium

58. Case Study: Question #1
Explain the cause of Mrs. S.’s valvular heart disease. What valves are most likely to become involved with rheumatic heart disease?

59. Case Study: Question #2
Differentiate between the characteristics of mitral stenosis and mitral regurgitation.

60. Case Study: Question #3
What other conservative treatment measures might be initiated for Mrs. S. (in addition to digoxin?)

61. Case Study: Question #4
On the basis of the assessment data provided, write one or more nursing diagnoses.

62. Case Study: Question #5
What are important nursing measures for Mrs. S.?