1. Timby/Smith: Introductory Medical-Surgical Nursing, 11/e
Chapter 24: Caring for Clients With Valvular Disorders of the Heart

2. Heart Structures
Four cardiac valves: aortic, mitral, tricuspid, and pulmonic
Structures can be affected by malformations at birth, inflammatory and infectious disorders, age- related degeneration, structural damage after MI, or injury from intracardiac procedure.
Left side of heart: aortic and mitral valves
Right side of heart: pulmonic and tricuspid valves

3. Valves of the Heart

4. Disorders of the Aortic Valve
Aortic Stenosis
Pathophysiology and Etiology: aortic valve: three cusps or leaflets
Narrowing of the opening in the aortic valve, valve cusps become stiff and rigid; muscular wall of left ventricle enlarges and thickens in response to stiff, calcified valve
Older adults: narrowing of aortic valve, degenerative change; young adults: congenital defect
Other causes: rheumatic carditis and infective endocarditis

5. Disorders of the Aortic Valve—(cont.)
Assessment Findings
Asymptomatic; dyspnea and fatigue during activity, dizziness, fainting, angina, carotid pulse feels weak, S2 heart sound is split (“lub-t-tub”)
Diagnostic Findings
Chest radiograph, echocardiogram, ECG, cardiac catheterization
Medical Management: maintaining adequate cardiac output (digitalis), diuretic, sodium restriction, antibiotics, nitrates, beta-adrenergic blockers
Surgical Management: balloon valvuloplasty, aortic valve replacement, transcatheter aortic valve implantation

6. Disorders of the Aortic Valve—(cont.)
Nursing Management
Monitor symptoms
Explain purposes and techniques of diagnostic tests
Administer prescribed medications
Institute measures for adequate cardiac output and tissue oxygenation
Dietary modifications

7. Question
The nurse assesses the client diagnosed with aortic stenosis. On auscultation, the nurse assesses a grade 2 heart murmur. A description of this heart murmur includes: A) A very loud murmur with a palpable thrill B) A heart murmur that is moderately loud C) A very quiet murmur that can be heard when auscultating the heart D) A very faint murmur that may not be heard in all positions

8. Answer
C) A very quiet murmur that can be heard when auscultating the heart Rationale: The S2 heart sound is split; that is, there is a definite separation between the sounds of the aortic valve and pulmonic valve closing.

9. Disorders of the Aortic Valve—(cont.)
Aortic Regurgitation
Pathophysiology and Etiology
Aortic valve does not close tightly and blood can leak backward; valvular incompetence
Causes: damage to valve cusps or papillary muscles, rheumatic carditis, endocarditis, syphilis, age-related stretching or proximal aorta, systemic inflammatory conditions
Use of Fen-Phen, Redux
Fluid overload in left ventricle; high pressure, interferes with atrial emptying

10. Disorders of the Aortic Valve—(cont.)
Assessment Findings
Tachycardia, skin flushed or moist, water-hammer pulse, systolic BP is high, diastolic BP is low or normal, heart murmur
First: palpitations when lying flat or on left side
Later stages: dyspnea, chest pain
Diagnostic Findings
Cardiac catheterization, chest radiograph, ECG, radionuclide scan, transesophageal echocardiography, CT, MRI

11. Disorders of the Aortic Valve—(cont.)
Medical Management: cardiac glycosides, beta- blockers, diuretics, prophylactic antibiotics; modify lifestyle
Surgical Management: aortic valve replacement, vascular graft
Nursing Management
Prepares patient for diagnostic procedures, monitors response, reports changes in heart rate and rhythm, dyspnea, chest pain, loss of consciousness
Prophylactic antibiotic therapy, BP teaching

12. Question
For which one of the following assessments should the nurse withhold a cardiac glycoside such as digoxin (Lanoxin) when caring for a client with a valvular disorder of the heart? A) The client’s diastolic blood pressure is 80 mm Hg. B) The client’s heart rate is 50 beats/minute. C) The client has an S2 heart sound. D) The client’s heart rhythm is irregular.

13. Answer
B) The client’s heart rate is 50 beats/minute. Rationale: Before administering digoxin (Lanoxin), the nurse must assess the pulse rate before each dose. Withhold administration if the pulse is <60 or >120 beats/minute.

14. Disorders of the Mitral Valve
Mitral Stenosis
Pathophysiology and Etiology
Mitral valve; between left atrium and left ventricle; bicuspid valve; stroke volume
Causes: rheumatic carditis, recurrence of endocarditis
Inflammation causes thick, rigid commissures; incomplete emptying—arterial emboli, pulmonary hypertension, right-sided heart failure
Assessment Findings: fatigue and dyspnea after slight exertion, tachydysrhythmias, dyspneic at night; must sleep in sitting position; cough productive of pink, frothy sputum; crackles; changes in heart sounds; neck vein distention; peripheral edema

15. Disorders of the Mitral Valve—(cont.)
Diagnostic Findings
Chest radiograph, esophageal echocardiogram, ECG
Medical Management: antibiotic therapy, preventing/relieving symptoms of HF, daily aspirin, anticoagulants
Surgical Management: commissurotomy, cardioversion, percutaneous balloon valvuloplasty
Nursing Management
Monitor physical condition, diagnostic testing preparation, posttreatment care, discharge teaching—drug therapy, complication reporting

16. Disorders of the Mitral Valve—(cont.)
Mitral Regurgitation
Pathophysiology and Etiology
Causes: rheumatic carditis and mitral valve prolapse, damage to papillary muscles, impaired myocardial function after MI
Blood flows backward into the left atrium during ventricular systole and leaks into left ventricle during atrial diastole; cardiogenic shock
Assessment Findings
Chronic fatigue, dyspnea on exertion, palpitations, S1 heart sound is diminished, HTN, tachycardia, blowing murmur

17. Disorders of the Mitral Valve—(cont.)
Diagnostic Findings
Transthoracic or transesophageal echocardiography, chest radiography, radionuclide angiography, ECG
Medical Management: angiotensin-converting enzyme (Accupril), angiotensin receptor blocker (losartan); digitalis, calcium channel blockers, beta-blockers, antidysrhythmic drugs
Surgical Management: intra-aortic balloon pump, annuloplasty, valve replacements

18. Disorders of the Mitral Valve—(cont.)
Nursing Management
Monitor BP, heart rate, and rhythm
Assess heart sounds and lung sounds
Report signs of left- or right-sided HF
Education: prophylactic antibiotics

19. Disorders of the Mitral Valve—(cont.)
Mitral Valve Prolapse
Pathophysiology and Etiology
Valve cusps enlarge, become floppy, and bulge backward into the left atrium.
More common in young women than men
Causes: idiopathic, rheumatic carditis, inherited connective tissue disorder, CAD
Mitral valve prolapse syndrome: autonomic nervous system dysfunction

20. Mitral Valve Prolapse

21. Disorders of the Mitral Valve—(cont.)
Assessment Findings
Asymptomatic, chest pain (angina: onset does not correlate with physical exertion, duration is prolonged, not easily relieved), palpitations, fatigue, anxiety, rapid and irregular heart rate, shortness of breath, light-headedness, difficulty concentrating, “click” sound during ventricular systole
Diagnostic Findings
Echocardiography, ECG

22. Disorders of the Mitral Valve—(cont.)
Medical Management: antibiotic therapy, digitalis, beta-blockers, calcium channel blockers, low-dose aspirin, antianxiety medications
Surgical Management: valve replacement
Nursing Management
To relieve chest pain: lie flat with legs elevated at 90°
Restrict alcohol; avoid caffeinated beverages
Promote adequate fluids, exercise, monitor BP

23. Question
A client has a possible diagnosis of mitral stenosis. Which of the following symptoms correlate with this diagnosis?
A) Heart murmur
B) Heart failure
C) Palpitations
D) Pulmonary edema

24. Answer
A) Heart murmur C) Palpitations D) Pulmonary edema Rationale: All of the following are symptoms caused by the stricture of the mitral valve; heart failure may be a complication of the disease.