nursing care of patients with cardiac valvular or inflammatory and infectious cardiovascular...
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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