Valvular Heart Disease Heart contains Two atrioventricular
valves Mitral Tricuspid Two semilunar valves Aortic Pulmonic
Valvular Disease
Slide 3
Valvular Heart Disease Types of valvular heart disease depend
on Valve or valves affected Two types of functional alterations
Stenosis Regurgitation HeartPoint: HeartPoint Gallery Flashcards
about Ch 19 NETI KQ- on your own
Slide 4
Pathophysiology Stenosis- narrowed valve, increases afterload
Regurgitation or insufficiency- increases preload. The heart has to
pump same blood **Blood volume and pressures are reduced in front
of the affected valve and increased behind the affected valve. This
results in heart failure All valvular diseases have a
characteristic murmur murmurs
Slide 5
Valvular Heart Disease Valvular disorders occur in children and
adolescents primarily from congenital conditions in adults from
degenerative heart disease Risk Factors Rheumatic Heart Disease MI
Congenital Heart Defects Aging CHF
Slide 6
Mitral Valve Stenosis Pathophysiology Decreased blood flow into
LV LA hypertrophy Pulmonary pressures increase Pulmonary
hypertension Decreased CO
Slide 7
Fig. 37-9 Fish mouth
Slide 8
Mitral Valve Stenosis Manifestations Primary symptom is DOE
Later get symptoms of R heart failure A fib is common MVS murmur
Usually secondary to rheumatic fever
Slide 9
Mitral Valve Regurgitation Pathophysiology Manifestations
Regurgitation of blood into LA during systole LA dilation and
hypertrophy Pulmonary congestion RV failure LV dilation and
hypertrophy- to accommodate increased preload and decreased CO
Thready pulses Cool extremities Symptoms of LV failure Third heart
sound (S3) MVR murmur
Slide 10
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Mitral Valve Prolapse Pathophysiology Manifestations
Abnormality of the mitral valve leaflets, papillary muscles or
chordae Etiology unknown Most common valvular heart disease in US
Female 2x > Male Usually asymptomatic Click murmur Atypical
chest pain does not respond to NTG Tachydysrhythmias may develop-
SVT Risk for endocarditis may be increased heart association
guidelines
Slide 12
Mitral Valve Prolapse May or may not be present with chest pain
If pain occurs, episodes tend to occur in clusters, especially
during stress Pain may be accompanied by dyspnea, palpitations, and
syncope Does not respond to antianginal treatment MVP murmur
(mid-systolic click) MVP murmur (mid-systolic click) TEE MVP
Slide 13
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Aortic Valve Stenosis Pathophysiology Aortic Valve Problems
Increase in afterload Incomplete emptying of LA LV hypertrophy
Reduced CO RV strain Pulmonary congestion Poor prognosis when
experiencing symptoms and not treated- 10-20%sudden cardiac
death
Slide 15
Aortic Valve Stenosis Manifestations May be asymptomatic for
many years due to compensation AVS murmur Nitroglycerin is
contraindicated because it reduces preload S yncope A ngina D
yspnea Exertional Syncope, Angina, DOE are classic symptoms This
triad reflects LVF Later get signs of RHF
Slide 16
Bicuspid Aortic Valve Congenital Heart Defect Most Common
Congenital Heart Disease Familial Male>Female
Slide 17
Aortic Valve Regurgitation Pathophysiology Increased preoad-
60% of SV can be regurgitated Characteristic water hammer pulse
Regurgitation of blood into the LV LV dilation and hypertrophy
Decreased CO YouTube - Corrigan's sign
Slide 18
Aortic Valve Regurgitation Manifestations Sudden manifestations
of cardiovascular collapse Left ventricle exposed to aortic
pressure during diastole Weakness Severe dyspnea Chest pain
Hypotension Constitutes a medical emergency AVR murmur
Slide 19
Tricuspid and Pulmonic Valve Disease Pathophysiology
Manifestations Uncommon Both conditions cause an increase in blood
volume in R atrium and R ventricle Result in Right sided heart
failure Tricuspid- Rheumatic Pulmonic- Congenital RHF
Slide 20
Diagnostic Tests Echo- assess valve motion and chamber size CXR
EKG Cardiac cath- get pressures
YouTube - Robotic Mitral Valve Repair Surgery Animation
Slide 28
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This is a mechanical valve prosthesis of the more modern
tilting disk variety (for the mitral valve). Such mechanical
prostheses will last indefinitely from a structural standpoint, but
the patient requires continuing anticoagulation because of the
exposed non- biologic surfaces.
Slide 30
This is an excised porcine bioprosthesis. The main advantage of
a bioprosthesis is the lack of need for continued anticoagulation.
The drawback of this type of prosthetic heart valve is the limited
lifespan, on average from 10 to 15 years (but sometimes shorter)
because of wear and calcification.
Slide 31
Ross Procedure
Slide 32
Mitral Regurgitation MitraClip 3D Animation
Slide 33
Medical Animation. Aortic valve replacement
Slide 34
Medical/ Surgical Treatment Percutaneous balloon valvuloplasty
Surgical therapy for valve repair or replacement: Valve repair is
typically the surgical procedure of choice Open commissurotomy-
open stenotic valves Annuloplasty- can be used for both Valve
replacement may be required for certain patients Heart valve
surgery Heart valve surgery Mechanical-need anticoagulant
Biologic-only last about 15 years Ross Procedure MedlinePlus:
Interactive Health Tutorials
Cardiomyopathy Condition is which a ventricle has become
enlarged, thickened or stiffened. As a result hearts ability as a
pump is reduced
Slide 37
Cardiomyopathy Primary-idiopathic Secondary Ischemia- from CAD
Infectious disease Exposure to toxins Metabolic disorders
Nutritional deficiencies Pregnancy
Slide 38
3 Types Dilated Hypertrophic Restrictive
Slide 39
Dilated Cardiomyopathy Most common- heart failure in 25-40%
Cocaine and alcohol abuse Chemotherapy, pregnancy Hypertension
Genetic * Heart chamber dilate and contraction is impaired and get
decreased EF% *Dysrhythmias are common- SVT Afib and VT Prognosis
poor-need transplant
Slide 40
This very large heart has a circular shape because all of the
chambers are dilated. It felt very flabby, and the myocardium was
poorly contractile. This is an example of a cardiomyopathy.
Hypertrophic Cardiomyopathy Genetic HCM -also known as IHSS or
HOCM Get hypertrophy of the ventricular mass and impairs
ventricular filling and CO Symptoms develop during or after
physical activity Sudden cardiac death may be first symptom
Symptoms are dyspnea, angina and syncope
Slide 45
Hypertrophic Cardiomyopathy Massive ventricular hypertrophy
Rapid, forceful contraction of the LV Impaired relaxation or
diastole Obstruction to aortic outflow Primary defect is diastolic
filling **HCM most common cause of SCD in young adulthood
Slide 46
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There is marked left ventricular hypertrophy, with asymmetric
bulging of a very large interventricular septum into the left
ventricular chamber. This is hypertrophic cardiomyopathy. About
half of these cases are genetic. Both children and adults can be
affected, and sudden death can occur.
Slide 50
Hypertrophic Cardiomyopathy Manifestations Dyspnea Fatigue-dec
CO Angina, syncope S4 and systolic murmur Diagnostics Echo- TEE
Heart cath
Slide 51
Hypertrophic Cardiomyopathy Treatment Goal- improve ventricular
filling and relieve LV outflow obstruction Beta blockers Calcium
channel blockers Digoxin- only for A-fib if present
Antidysrhythmics ICD AV pacing
Slide 52
Hypertrophic Cardiomyopathy Ventriculomyotomy and myomectomy-
incising the septum muscle and removing some of the hypertrophied
muscle PTSMA- alcohol induced percutaneous trans luminal septal
myocardial ablation - inject alcohol into small branch of LAD which
causes ischemia and MI of septal wall. Live Search Videos:
cardiomyopathy
Slide 53
Nursing Relieve symptoms Prevent complications Provide pysch
and emotional support Teaching- Avoid strenuous exercise and
dehydration Avoid anything increasing the SVR (afterload) makes
obstruction worse Chest pain Rest and elevation of feet for venous
return NO vasodilators like nitroglycerine
Slide 54
Restrictive Cardiomyopathy Least common Rigid ventricular walls
that impair filling Requires high diastolic filling pressure to
maintain CO Cannot Increase CO Signs of CHF Prognosis-poor
Slide 55
Restrictive Cardiomyopathy Diagnostics Echo-wall motion and EF
ECG CXR Hemodynamics Perfusion scan Cardiac cath Myocardial
biopsy
Slide 56
Restrictive Cardiomyopathy Treatment No specific Treatment-
goal to improve diastolic filling Medications HF and dysrhythmias
Teaching Avoid strenuous activity, dehydration, increases in SVR
High risk for IE
Slide 57
Restrictive Cardiomyopathy Treatment Surgery Vad-bridge to
transplant Heart Transplant Myoplasty ICD- antiarrhythmics are
negative inotropes Dual chamber pacemaker Hypertrophic excision of
ventricular septum-myotomy, inject denatured alcohol in coronary
artery that feeds the top portion of septum.
Slide 58
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Nursing Diagnoses Decreased Cardiac Output Fatigue Ineffective
Breathing Pattern Fear Ineffective Role Performance Anticipatory
grieving
Slide 61
Case study 15 Ms. C. 81y/o admitted to CCU with SOB. She has a
hx of mitral valve regurgitation with left ventricular enlargement.
She received 100mg lasix IV in ER and her dyspnea improved. She has
O2 at 3L/min. She has crackles bibasilar and monitor is SR rate
94-96 with occ. PVCs. The only med ordered is MSO4 2-4mg IV as
needed for chest pain or dyspnea. As you go to assess her you find
her in bed at 60 degree angle. She is pale, has circumoral cyanosis
and respirations are rapid and labored.
Slide 62
Question 1 What action should you take first? 1.Listen to
breath sounds 2.Ask when the dyspnea started 3.Increase her O2 to
6L minute 4.Raise the HOB to 75-85 degrees
Slide 63
Case Study 15- #2 Which one of these complications are you most
concerned about, based on your assessment? 1. Pulmonary edema 2.
Cor pulmonale 3. Myocardial infarction 4. Pulmonary embolus
Slide 64
#3 Which action will you take next? 1. Call the physician about
clients condition. 2. Place client on a non-rebreather mask with
FiO2 at 95%. 3. Assist client to cough and deep breathe. 4.
Administer ordered morphine sulfate 2mg IV.
Slide 65
#4 What additional assessment data are most important to obtain
at this time? 1. Skin color and capillary refill 2. Orientation and
pupil reaction to light 3. Heart sounds and PMI 4. Blood pressure
and apical pulse
Slide 66
#5 Clients B/P is 98/52 and AP is 116 and irregular in ST rate
110-120 with frequent multifocal PVCs. You call the physician and
receive these orders. Which one should be done first? 1. Obtain
serum dig level 2. Give furosemide 100mg. IV 3. Check blood
potassium level 4. Insert #16 french foley catheter
Slide 67
#6 Which order could be assigned to an LVN? 1. Obtain serum
digoxin level 2. Give furosemide 100mg. IV 3. Check blood potassium
level 4. Insert #16 french foley catheter
Slide 68
#7 While you are waiting for the the potassium level, you give
morphine sulfate 2mg IV to the the client. A new graduate asks why
you are giving her the morphine. What is the best response? 1. It
will help prevent any chest pain from occurring. 2. It will
decrease her respiratory rate. 3. It will make her more comfortable
if she has to be intubated. 4. It will decrease venous return to
her heart.
Slide 69
#8 Her K is 3.1. the physician orders KCL 20meq. IV. How will
you administer it. 1. Utilize a syringe pump to infuse the KCL over
10 minutes. 2. Dilute the KCL in 100 ml of D5W and infuse over 1
hour. 3. Use a 5ml syringe and push the KCL over at least 1 minute.
4. Add the KCL to 1 liter of D5W and administer over 8 hours.
Slide 70
#9 After you have infused the KCL, you give the lasix. Which of
these nursing actions will be most useful in evaluating whether the
lasix is having the desired effect? 1. Obtain the clients daily
weight 2. Measure the hourly urine output 3. Monitor blood pressure
4. Assess the lung sounds
Slide 71
#10 The physician orders a natrecor 100mcg IV bolus and an
infusion of 0.5 mcg/ min. Which assessment data is most important
to monitor during the infusion? 1. Lung sounds 2. Heart rate 3.
Blood pressure 4. Peripheral edema
Slide 72
#11 Which nurse should be assigned care for this client? 1. A
float RN who has worked on CCU step down for 9 years and has
floated before to CCU 2. An RN from a staffing agency who has 5
years CCU experience and is orienting to your CCU today 3. A CCU RN
who is already assigned to care for a newly admitted client with
chest trauma 4. The new graduate RN who needs more experience in
caring for client with left ventricular failure.
Slide 73
#12 Which information would be important to report to the
physician? 1. Crackles and oxygen saturation 2. Atrial fibrillation
and fuzzy vision 3. Apical murmur and pulse rate 4. Peripheral
edema and weight
Slide 74
#13 All meds are scheduled for 9 AM. Which would you hold until
you discuss it with the physician? Furosemide 40mg po bid Ecotrin
81mg po daily KCL 10meq three times a day Captopril 6.25mg po three
times a day Lanoxin.125mg po every other day
Slide 75
Aortic Aneurysms Aorta Largest artery Responsible for supplying
oxygenated blood to essentially all vital organs Aneurysm- Abnormal
dilation of a blood vessel at a site of weakness or a tear in the
vessel wall. Usually secondary to atherosclerosis Most commonly
affect the aorta
Slide 76
Aortic Aneurysms Atherosclerotic plaques deposit beneath the
intima Plaque formation is thought to cause degenerative changes in
the media Leading to loss of elasticity, weakening, and aortic
dilation
Slide 77
May have aneurysm in more than one location Growth rate
unpredictable Larger the aneurysm greater risk of rupture May also
involve the aortic arch or the thoracic aorta, Most (3/4) are found
in abdominal aorta below renal arteries are found in the thoracic
area
Slide 78
Dilated aortic wall becomes lined with thrombi than can
embolize Leads to acute ischemic symptoms in distal branches
Important to assess peripheral pulses
Slide 79
Aortic Aneurysms Male>female Risk increases with age Studies
suggest strong genetic predisposition *Male gender and smoking
stronger risk factors than hypertension and diabetes
Atherosclerosis Risks: Age>60 Male White Family Hx AAA Smoking
HTN CAD
Slide 80
Aortic Aneurysms Usually atherosclerosis May also result from
Trauma Infection Surgery Inflammation Infection Genetic
Marfans
Slide 81
Types of Aneursyms 2 basic classifications- True and False True
aneurysm Wall of artery forms the aneurysm At least one vessel
layer still intact Fusiform-Circumferential, relatively uniform in
shape Saccular-Pouchlike with narrow neck connecting bulge to one
side of arterial wall
Slide 82
Types of Aneurysms Saccular Fusiform-most are fusiform and 98%
are below the renal artery
Slide 83
Types of aneursyms False aneurysm ( also called pseudoaneurysm)
Not an aneurysm Disruption of all layers of arterial wall Results
in bleeding contained by surrounding structures
Slide 84
Ascending Aortic Aneurysm Aortic Arch Clinical Manifestations
ASH Angina Swelling Hoarseness If presses on superior vena cava
decreased venous return can cause distended neck veins edema of
head and arms
Slide 85
Thoracic Aortic Aneurysm Clinical Manifestations Frequently
asymptomatic Coughing Hoarseness Difficulty swallowing May have
substernal, neck, back pain Swelling (edema) in the neck or arms
Myocardial infarction Stroke
Slide 86
Abdominal Aortic Aneurysm Clinical Manifestations Abdominal
aortic aneurysms (AAA) Often asymptomatic Frequently detected On
physical exam Pulsatile mass in periumbilical area Bruit may be
auscultated Often found when patient examined for unrelated problem
(i.e., CT scan, abdominal x-ray)
Slide 87
Aortic Aneurysm Clinical Manifestations AAA May mimic pain
associated with abdominal or back disorders Pain correlates to the
size May spontaneously embolize plaque Causing blue toe syndrome
patchy mottling of feet/toes with presence of palpable pedal pulses
It can rupture causing shock and death in 50% of rupture cases
Slide 88
Complications Rupture- signs of ecchymosis Back pain
Hypotension Pulsating mass (rupture triad) Thrombi Renal Failure
Death
Slide 89
Aortic Aneurysm- Complications Rupture- serious complication
related to untreated aneurysm Anterior rupture Massive hemorrhage
Most do not survive long enough to get to the hospital Posterior
rupture Bleeding may be tamponaded by surrounding structures, thus
preventing exsanguination and death Severe pain May/may not have
back/flank ecchymosis
Slide 90
Turners sign and Cullens Sign Live Search Videos: aortic
aneurysm
http://www.austincc.edu/adnlev4/rnsg2331online/module05/aneurys
m_case_study.htm
http://www.austincc.edu/adnlev4/rnsg2331online/module05/aneurys
m_case_study.htm
Slide 91
Aortic Aneurysm Diagnostic Studies X-rays Chest - Abdomen - ECG
-to rule out MI Echocardiography Ultrasound CT scan MRI
Angiography
Surgery Usually repaired if >5cm Open procedure- abd
incision, cross clamp aorta,aneuysm opened and plaque removed, then
graft sutured in place Pre-op assess all peripheral pulses
Post-op-check urine output and peripheral pulses hourly for 24
hours
Slide 94
Endovascular stents- placed through femoral artery
Slide 95
YouTube - Abdominal Aortic Aneurysm Graft Repair
Slide 96
Endovascular graft procedure New approach is percutaneous
femoral access Advantages Shorter operative time Shorter anesthesia
time Reduction in use of general anesthesia Reduced groin
complications within first 6 months YouTube - Cook's modular AAA
graft an "engineering achievement" YouTube - Cook's modular AAA
graft an "engineering achievement"
Slide 97
Aortic Dissection Blood invades or dissects the layers of the
vessel wall
Slide 98
Dissecting aneurysms are unique and life threatening. A break
or tear in the tunica intima and media allows blood to invade or
dissect the layers of the vessel wall. The blood is usually
contained by the adventitia, forming a saccular or longitudinal
aneurysm.
Slide 99
Aortic dissection occurs when blood enters the wall of aorta,
separating its layers, and creating a blood filled cavity.
Slide 100
Aortic Dissection Often misnamed dissecting aneurysm Not a type
of aneurysm Occurs most commonly in thoracic aorta Result of a tear
in the intimal lining of arterial wall Male>Female Occurs most
frequently between 30s-60s Acute and life threatening Mortality
rate 90% if not surgically treated
Slide 101
Aortic Dissection As heart contracts, each systolic pulsation
pressure on damaged area Further dissection May occlude major
branches of aorta Cutting off blood supply to brain, abdominal
organs, kidneys, spinal cord, and extremities People with Marfans
at risk
Slide 102
Aortic Dissection Manifestations Abrupt severe ripping or
tearing pain Mild or marked HTN early Weak or absent pulses and BP
in upper extremeties Syncope
Slide 103
Aortic Dissection Collaborative Care Initial goal BP and
myocardial contractility to diminish pulsatile forces within aorta
Conservative therapy If no symptoms Can be treated conservatively
for a period of time Success of the treatment judged by relief of
pain Emergency surgery is needed if involves ascending aorta
Slide 104
Aortic Dissection Collaborative Care Drug therapy IV Beta-
adrenergic blocker Esmolol (Brevibloc) Other antihypertensive
agents Calcium channel blockers Sodium Nitroprusside Angiotensin
converting enzyme
Slide 105
Aortic Dissection Collaborative Care Surgical therapy When drug
therapy is ineffective or When complications of aortic dissection
are present Heart failure, leaking dissection, occlusion of an
artery Surgery is delayed to allow edema to decrease and permit
clotting of blood Even with prompt surgical intervention 30-day
mortality of acute aortic dissections remains high (10%-28%)
Slide 106
Nursing Diagnoses Risk for Ineffective Tissue Perfusion Risk
for Injury Anxiety Pain Knowledge Deficit
Slide 107
Nursing Management Acute Intervention- Post-op ICU monitoring
Arterial line Central venous pressure (CVP) or pulmonary artery
(PA) catheter Continuous ECG monitoring Oxygen
administration/Mechanical ventilation Pulse oximetry/ Arterial
blood gas monitoring Urinary catheter Nasogastric tube Electrolyte
monitoring Antidysrhythmic/pain medications
Slide 108
Nursing Management Infection Neurologic Status Peripheral
perfusion status Renal perfusion status Gastrointestinal status
Ambulatory /Home care
Slide 109
Prevention 1.Ultrasound 2.Prevent atherosclerosis 3.Treat and
control hypertension 4.Diet- low cholesterol, low sodium and no
stimulants 5.Careful follow-up if less than 5cm.
Slide 110
Priority Question # 29 During the initial post-operative
assessment of a patient who has just transferred to the
post-anesthesia care unit after repair of an abdominal aortic
aneruysm all of these data are obtained. Which has the most
immediate implications for the clients care? A. The arterial line
indicates a blood pressure of 190/112. B. The monitor shows sinus
rhythm with frequent PACs. C. The client does not respond to verbal
stimulation. D. The clients urine output is 100ml of amber
urine.
Slide 111
Priority Question #30 It is the manager of a cardiac surgery
units job to develop a standardized care plan for the
post-operative care of client having cardiac surgery. Which of
these nursing activities included in the care plan will need to be
done by an RN? A. Remove chest and leg dressings on the second
post-operative day and clean the incisions with antibacterial
swabs. B. Reinforce patient and family teaching about the need to
deep breathe and cough at least every 2 hours while awake. C.
Develop individual plan for discharge teaching based on discharge
medications and needed lifestyle changes. D. Administer oral
analgesisc medications as needed prior to assisting patient out of
bed on first post-operative day.
Slide 112
Priority Question # 25 These clients present to the ER
complaining of acute abdominal pain. Prioritize them in order of
severity. A. A 35 year old male complaining of severe, intermittent
cramps with three episodes of watery diarrhea, 2 hours after
eating. B. An 11 year old boy with a low-grade fever, left lower
quadrant tenderness, nausea, and anorexia for the past 2 days. C. A
40 year old female with moderate left upper quadrant pain, vomiting
small amounts of yellow bile, and worsening symptoms over the past
week. D. A 56 year old male with a pulsating abdominal mass and
sudden onset of pressure-like pain in the abdomen and flank within
the past hour.