Intro to Valvular DiseaseMorris, an 82 year-old man, went to the doctor to get a physical. A few days later, the doctor saw Morris walking down the street with a gorgeous young woman on his arm. A couple of days later, the doctor spoke to Morris and said, 'You're really doing great, aren't you?' Morris replied, 'Just doing what you said, Doc: 'Get a hot mamma and be cheerful.'' The doctor said, 'I didn't say that.. I said, 'You've got a heart murmur; be careful.'
Valvular Heart DiseaseHeart contains
Two atrioventricular valves Mitral Tricuspid
Two semilunar valvesAorticPulmonic
**review areas to listen**
Tricuspid
Valvular Heart DiseaseTypes of valvular heart disease depend on
Valve or valves affectedTwo types of functional alterations
StenosisRegurgitation
Valvular disorders occur in children and adolescents primarily from congenital conditions and in adults from degenerative heart disease
Stenosis and Insufficiency
Valvular Heart Disease
Flashcards about Ch 19 NETI KQ- on your own
Risk FactorsRheumatic Heart Disease MICongenital Heart DefectsAgingCHF
PathophysiologyStenosis- narrowed valve, increases afterloadRegurgitation 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 failureAll valvular diseases have a characteristic murmur murmurs
Mitral StenosisDec. flow into LVLA hypertrophyPulmonary pressures increasePulmonary hypertensionDec. CO* early symptom is DOELater get symptoms of R heart failureA fib is common- anticoagulantsUsually secondary to rheumatic fever
Treatment
Mitral Valve Replacment
Mitral Regurgitation
Mitral insufficiency
Mitral Regurgitation (Insufficiency)
Regurg of blood into LA during systoleLA dilation and hypertrophyPulmonary congestionRV failureLV dilation and hypertrophy-to accommodate inc. preload and dec CO
Mitral Valve ProlapseA type of mitral insufficiencyUsually asymptomatic- click murmurMay get atypical chest pain related to fatigueTachydysrhythmias may developRisk for endocarditis may be increased
Mitral Valve ProlapseUsually benign, but serious complications can occur
Mitral valve regurgitation Infective endocarditis Sudden death Cerebral ischemia
Mitral Valve Prolapse
Dysrhythmias Paroxysmal supraventricular tachycardiaVentricular tachycardia
Palpitations LightheadednessDizziness
Mitral Valve ProlapseMay or may not be present with chest pain
If pain occurs, episodes tend to occur in clusters, especially during stressPain may be accompanied by dyspnea, palpitations, and syncope Does not respond to antianginal treatment
Aortic StenosisIncrease in afterloadReduced COLV hypertrophyIncomplete emptying of LAPulmonary congestionRV strain
Symptoms
Syncope
Angina
Dyspnea
This triad reflects left ventricular failure
Aortic StenosisMay be asymptomatic for many years due to compensationDOE, angina, and exertional syncope are classic symptomsLater get signs of R heart failureUntreated-poor prognosis- 10-20%sudden cardiac death
Aortic Valve Stenosis
Poor prognosis when experiencing symptoms and valve obstruction is not relievedNitroglycerin is contraindicated because it reduces preload
Aortic Regurgitation
Aortic RegurgitationGet increased preoad- 60% of SV can be regurgitatedCharacteristic water hammer pulseRegurgitation of blood into the LVLV dilation and hypertrophyDec. CO
Echocardiography
Aortic Valve RegurgitationClinical manifestations
Sudden manifestations of cardiovascular collapseLeft ventricle exposed to aortic pressure during diastoleWeakness
Aortic Valve RegurgitationSevere dyspnea Chest painHypotension Constitutes a medical emergency
Water Hammer pulse
Pulse, water hammer: A jerky pulse that is full and then collapses because of aortic insufficiency (when blood ejected into the aorta regurgitates back through the aortic valve into the left ventricle ).
Also called a Corrigan pulse or a cannonball, collapsing, pistol-shot, or trip-hammer pulse. YouTube - Corrigan's sign
Austin Flint
Tricuspid and Pulmonic Valve Disorders
Result in R side heart failure
Diagnostic TestsEcho- assess valve motion and chamber sizeCXREKGCardiac cath- get pressures
MedicationsLike Heart Failure
ACE inhibitorsDigoxinDiureticsVasodilatorsBeta blockersAnticoagulants*Prophylactic antibioticsAntiarrhythmics
Medical/ Surgical TreatmentPercutaneous balloon valvuloplastySurgical therapy for valve repair or replacement:
**Valve repair is typically the surgical procedure of choice
Open commissurotomy- open stenotic valvesAnnuloplasty- can be used for both
Valve replacement may be required for certain patients Heart valve surgery
Mechanical-need anticoagulantBiologic-only last about 15 yearsRoss ProcedureMedlinePlus: Interactive Health Tutorials- on own
Ross Procedure
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 5 to 10 years (but sometimes shorter) because of wear and calcification.
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.
Medical Animation. Aortic valve replacement
Nursing DiagnosesActivity intoleranceExcess fluid volumeDecreased cardiac outputIneffective therapeutic regimen management
What is new?Percutaneous Transcatheter Heart Valve Implantation-Metallic clip -for the treatment of mitral regurgitationLonger-lasting replacement valvesStem cell research and the use of endothelial cells
CardiomyopathyCondition is which a ventricle has become enlarged, thickened or stiffened. As a result heart’s ability as a pump is reduced
Cardiomyopathy-CausesPrimary-idiopathicSecondary
Ischemia- from CADinfectious diseaseexposure to toxins -alcohol, cocaineMetabolic disordersNutritional deficienciesPregnancy
3 Types of Cardiomyopathy
DilatedHypertrophicRestrictive
PathophysiologyDilated
Most common- heart failure in 25-40%Cocaine and alcohol abuseChemotherapy, pregnancyHypertensionGenetic* Heart chamber dilate and contraction is impaired and get dec. EF%*Dysrhythmias are common- SVT Afib and VTPrognosis poor-need transplant
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.
Pathophysiology Hypertrophic-HCM
**GeneticAlso known as IHSS or HOCMGet hypertrophy of the ventricular mass and impairs ventricular filling and COSymptoms develop during or after physical activitySudden cardiac death may be first symptomSymptoms are dyspnea, angina and syncope
HOCM Patho1. Massive ventricular hypertrophy2. Rapid, forceful contraction of the LV3. Impaired relaxation or diastole4. Obstruction to aortic outflowPrimary defect is diastolic filling**HCM most common cause of SCD in young adulthood
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Fig. 37-14
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.
HCM- Symptoms (SAD)DyspneaFatigue- dec. COAngina, SyncopeS4 and systolic murmur
Hypertrophic DiagnosticsEcho- TEE
Heart Cath
Treatment of HOCM
cardiomyopathy - Live Search Video
PTSMA- alcohol induced percutaneous trans luminal septal myocardial ablation
- inject alcohol into small branch of LAD which causes ischemia and MI of septal wall. (Grey’s Anatomy episode relief of heart failure)
InterventionsGoal- improve vent filling and relieve LV outflow obstruction
Beta blockers- metoprololCalcium channel blockersDig- only for A-fib if present Anti-arrhythmics- amiodorone or sotalolICD- to dec. risk of sudden deathAV pacing
Surgical TreatmentVentriculomyotomy and myomectomy- incising the septum muscle and removing some of the hypertrophied muscle
Nursing
Relieve symptomsPrevent complicationsProvide pysch and emotional supportTeaching-
Avoid strenuous exercise and dehydrationAvoid anything increasing the SVR (afterload) makes obstruction worseIf chest pain- rest and elevation of feet for venous returnAvoid vasodilators like nitroglycerine- decrease venous return to the heart
PathophysiologyRestrictive
Least commonRigid ventricular walls that impair fillingContraction and EF normalSigns of CHFPrognosis-poor
PathophysiologyRestrictive
Least commonRigid ventricular walls that impair fillingContraction and EF normalSigns of CHFPrognosis-poor
Diagnostics for CMP
Echo-wall motion and EF
EKGCXRHemodynamicsPerfusion scanCardiac cathMyocardial biopsy
TreatmentMedications
Same as for heart failure except for hypertrophic
SurgeryVad-bridge to transplant or destination therapyHeart TransplantMyoplastyICD- antiarrhythmics are negative inotropesDual chamber pacemakerHypertrophic- excision of ventricular septum-myotomy, inject denatured alcohol in coronary artery that feeds the top portion of septum.
Nursing DiagnosesDecreased Cardiac OutputFatigueIneffective Breathing PatternFearIneffective Role PerformanceAnticipatory grieving
Case study 15Ms. 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. PVC’s. 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.
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
Cont.Upon assessment, you find crackles and she is coughing pink frothy sputum. Her O2 sat is 85% with O2 increased to 6L/min. She has 3-4+ pitting edema in her feet and mid- calf. She has JVD with HOB elevated to 75 degree angle.
Case Study 15- #2Which one of these complications are you most concerned about, based on your assessment?1. Pulmonary edema2. Cor pulmonale3. Myocardial infarction4. Pulmonary embolus
#3Which action will you take next?1. Call the physician about client’s 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.
#4What additional assessment data are most important to obtain at this time?1. Skin color and capillary refill2. Orientation and pupil reaction to light3. Heart sounds and PMI4. Blood pressure and apical pulse
#5Client’s B/P is 98/52 and AP is 116 and irregular in ST rate 110-120 with frequent multifocal PVC’s. You call the physician and receive these orders. Which one should be done first?1. Obtain serum dig level2. Give furosemide 100mg. IV3. Check blood potassium level4. Insert #16 french foley catheter
#6Which order could be assigned to an LVN?1. Obtain serum digoxin level2. Give furosemide 100mg. IV3. Check blood potassium level4. Insert #16 french foley catheter
#7While 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.
#8Her K is 3.1. the physician orders KCL 20meq. IV before giving the furosemide. 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.
#9After 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 client’s daily weight2. Measure the hourly urine output3. Monitor blood pressure4. Assess the lung sounds
#10The 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 sounds2. Heart rate3. Blood pressure4. Peripheral edema
#11Which 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 CCU2. An RN from a staffing agency who has 5 years CCU experience and is orienting to your CCU today3. A CCU RN who is already assigned to care for a newly admitted client with chest trauma4. The new graduate RN who needs more experience in caring for client with left ventricular failure.
A few days later, she is transferred to the step-down unit. Her weight has decreased 4 kg. She denies SOB at rest, has crackles only in the bases. She is receiving O2 at 1L/min. She has a grade III/IV murmur and her pulse is very irregular. The monitor shows atrial fibrillation, rate 80-100. She denies dizziness, but states her vision feels “fuzzy.” She has 2+ ankle edema. VS are B/P 108/62, 86, 24, O2 sat 95%. Medications:Lasix 40mg twice daily KCL 10mEq dailyAspirin 81mg daily Captopril 6.25mg tidDigoxin 0.25mg daily’
#12Which information would be most important to report to the physician?1. Crackles and oxygen saturation2. Atrial fibrillation and fuzzy vision3. Apical murmur and pulse rate4. Peripheral edema and weight
#13All meds are scheduled for 9 AM. Which would you hold until you discuss it with the physician?Furosemide 40mg po bidEcotrin 81mg po dailyKCL 10meq three times a dayCaptopril 6.25mg po three times a dayLanoxin .125mg po every other day