valvular disorders and cardiomyopathy

inflammatory heart disorders

infective endocarditis

acute pericarditis

myocarditis

infective endocarditis

a disease of the endocardium of the heart and the heart valves

endocardium = the innermost layer of the heart

usually a poor prognosis

occurs when blood flow allows organisms to contact and infect previously damaged heart valves or other endothelial surfaces

the organisms make biofilms, which protect the organisms from immune defense and make antimicrobials less effective

vegetations are the primary lesions of IE

these can break off into the circulation and result in emboli

3 stages: bacteremia, adhesion, vegetation

IE s/s

fever, chills

weakness, malaise, fatigue

anorexia

vascular changes

systolic murmur

heart failure is common

vascular signs: splinter hemorrhages in the nail beds, petechiae, osler’s nodes (painful, tender, red or purple, pea sized lesions), janeway’s lesions (flat, painless, small, red spots), roth’s spots (hemorrhagic retinal lesions)

IE tx

identify organism

antibiotic therapy

valve replacement

nursing management for IE

avoid people with infections

stress the importance of avoiding fatigue, planning rest periods, using good oral hygiene, and scheduling regular dental exams

need to report hx of IE to all HCP

prophylactic antibiotic therapy may be needed

antibiotic tx for 4-6 weeks, can continue tx at home once hemodynamically stable

acute pericarditis

condition caused by inflammation of the pericardial sac (pericardium), often with fluid accumulation; in most cases the cause is unknown

the pericardial space holds 10-15mL of serous fluid

3 different types

acute: develops rapidly, causing the pericardial sac to become inflamed and leak fluid- INFLAMMATION

subacute: occurs weeks to months after an event

chronic: lasting more than 6 months

pericarditis s/s

progressive, severe, sharp chest pain

often worse with inspiration and when lying flat

sitting up and leaning forward relieves the pain

pain may radiate down neck, arms, or left shoulder

dyspnea due to pain

fever and anxiety

hallmark sign: pericardial friction rub

scratching, grading, high pitched sound due to the tissues rubbing together; can be difficult to hear

have pt hold their breath to distinguish between pericardial or pleural

pericarditis complications

pericardial effusion and cardiac tamponade

pericardial effusion

a build up of fluid in the pericardium

can occur rapidly or slowly

can cause cough, dyspnea, and tachypnea

phrenic nerve compression can cause hiccups

compression of the laryngeal nerve may cause hoarseness

heart sounds are distant and muffled

cardiac tamponade

develops as the pericardial effusion volume increases and compresses the heart- increased pressure

speed of fluid accumulation affects the severity of s/s

may report chest pain

can be confused, anxious, and restless

as compression increases, CO decreases

pulsus paradoxus- a large decrease is systolic BP during inspiration

can cause obstructive shock

acute pericarditis interprofessional care

tx depends on the underlying cause

pericardiocentesis is usually done for pericardial effusion with acute cardiac tamponade, purulent pericarditis, or suspected cancer

pericardial window is a surgical procedure for dx or drainage of excess fluid

antibiotics, corticosteroids, NSAIDs

nursing management of acute pericarditis

manage pt’s pain and airway

pain relief measures include keeping the pt on bed rest

HOB raised to 45 degrees

anti inflammatory medications and PPIs

avoid alcohol

myocarditis

a focal or diffuse inflammation of the myocardium

may be caused by virus, bacteria, fungi, radiation therapy, chemical factors

may develop HF, dysrhythmia, and sudden cardiac death

fever, fatigue, malaise, myalgias, pharyngitis, dyspnea, lymphadenopathy, and n/v

early cardiac signs appear 7-10 days after viral infection

pericarditis often accompanies myocarditis

myocarditis tx

manage symptoms

ACE inhibitors and beta blockers manage HF

diuretics reduce fluid volume and preload

digoxin improves heart contractility and reduces HR

anticoagulation reduces the risk for clot formation from blood stasis

myocarditis nursing management

place the pt in semi fowler’s position

spacing activities and rest periods

provide a quiet environment

assess for anxiety

valvular heart disease

occurs when the pressure on either side of an open valve is not equal

mitral valve stenosis

most common cause is rheumatic fever

deformities block the blood flow and creates a pressure difference between the left atrium and the left ventricle during diastole

left atrial pressure and volume increases

pt is at risk for a fib

main symptom is exertional dyspnea

may have hoarseness, hemoptysis, and chest pain

monitor for emboli

palpitations

loud, accentuated S1

low pitched, diastolic murmur

mitral valve regurgitation

mitral valve function depends on intact mitral leaflets, mitral annulus, chordae tendineae, papillary muscles, left atrium, and left ventricle

any defect of these structures can cause regurgitation

blood flows backward from the left ventricle to the left atrium because of incomplete valve closure during systole

may see thready peripheral pulses, cool, clammy extremities

tx depends on cause; may need valve repair or replacement

mitral valve prolapse

abnormality of the mitral valve leaflets and the papillary muscles or chordae that allows the leaflets to prolapse, or buckle, back into the left atrium during systole

usually benign and most pts are asymptomatic

aortic valce stenosis

causes obstruction of blood flow from the left ventricle to the aorta during systole

the result is left ventricular hypertrophy and increased myocardial oxygen consumption

reduced cardiac output leads to decreased tissue perfusion

may see angina, syncope, and exertional dyspnea

may be treated with nitroglycerin

aortic valve regurgitation

causes retrograde (backward) blood flow from the ascending aorta into the left ventricle during diastole

results in volume overload

leads to pulmonary HTN and right ventricular failure

acute have sudden signs of cardiovascular collapse: severe dyspnea, chest pain, hypotension

chronic develop a water hammer pulse

overtime exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea

tricuspid valve disease

tricuspid regurgitation can be primary or secondary

primary is less common; secondary caused by right ventricular dilation from pulmonary HTN, cor pulmonale, or pulmonary outflow

tricuspid stenosis is usually caused by rheumatic fever

can have flutter feeling in neck, fatigue, and possible right upper quadrant pain

pulmonic valve disease

pulmonic regurgitation is often asymptomatic

can be due to pulmonary HTN, surgical repair of tetralogy of fallot, or congenital valve disease

pulmonic stenosis is often due to congenital heart disease

results in right ventricular HTN and hypertrophy

mainly asymptomatic

interprofessional care for valvular heart disease

conservative therapy: prevent HF, tx with meds, low sodium diet, monitor for arrhythmias

percutaneous transluminal balloon valvuloplasty: used to treat stenosis

surgical intervention for valvular heart disease

valve repair: preferred over replacement when possible, has lower operative mortality rate than replacement, used in mitral or tricuspid

valve replacement: desirable valves are non thrombogenic, durable, and create minimal stenosis; wide variety of prosthetic mechanical or biologic valves

nursing management for valvular disorders

encourage early tx of strep infections and provide prophylactic antibiotics

design activities considering the pt limitations

avoid strenuous exercise but have an exercise plan

conserve energy and set priorities

avoid tobacco use

cardiomyopathy

a group of diseases that directly affect myocardial structure or function

primary is idiopathic conditions involving heart muscle

secondary is another disease process causing myocardial disease

dilated cardiomyopathy

the most common type

primary myocardial disorder

results in ventricular dilation, impaired systolic function, atrial enlargement, and blood stasis in the left ventricle

may develop acutely after an infection or slowley over time

may see decreased exercise capacity, fatigue, dyspnea at rest, paroxysmal nocturnal dyspnea, and orthopnea

tx is focused on controlling HF by enhancing heart contractility and decreasing preload and afterload

hypertrophic cardiomyopathy

genetic disorder that causes asymmetric left ventricular hypertrophy without ventricular dilation

early identification is important

massive ventricular hypertrophy; rapid, forceful contraction of the left ventricle; impaired relaxation; obstruction to aortic outflow

may not have s/s

may have dyspnea caused by an elevated ventricular diastolic pressure, fatigue, angina, syncope

goal is to improve ventricular filling by reducing ventricular contractility and relieving left ventricular outflow obstruction

restrictive cardiomyopathy

least common type

disease of the myocardium that impairs diastolic filling and stretch

symptoms are fatigue, exercise intolerance, and dyspnea

tx aims to improve diastolic filling and the underlying disease process