Chapter 24. Structural, Infectious, and Inflammatory Cardiac Disorders

valvular disease

the most affected valve = aortic valve

4 different types

• stenosis: hard to open and close (can get stuck one way or other)

• insufficiency: not enough blood flow

• regurgitation: blood flows backwards

• prolapse: displacement of valve leaflets (more open than they should be/don’t work properly)

risk factors: infectious diseases such as IE (infective endocarditis - infection in and around heart), congenital defects, degenerative changes, pregnancy, smoking, hyperlipidemia, hypertension

clinical manifestations: SOB, angina, syncope, dysrhythmia, palpitation, dizziness, fatigue, weight gain

diagnostic testing:

• EKG to look for signs of left or right ventricular hypertrophy (standing order if pt has chest pain as time = cell death)

• echo (ultrasound) identifies leaflet abnormalities

• chest x-ray to see if the heart is enlarged

• stress testing to identify functional capacity

• heart cath as definitive test of stenosis prior to correction

medications:

• BETA BLOCKERS: reduce heart rate and blood pressure (thus cardiac workload)

• CALCIUM CHANNEL BLOCKERS: produce vasodilation and reduce afterload (decreasing regurgitant flow in mitral and aortic stenosis)

• DIURETICS: to decrease preload and pulmonary congestion

valve replacement: open heart oftentimes, percutaneous approach possible now

• REPLACEMENT WITH MECHANICAL VALVE → NEED TO BE ANTICOAGULATED FOR LIFE - NCLEX)

valve repair (yields better outcomes than replacement)

• balloon valvuloplasty: percutaneous procedure to repair stenosed aortic or mitral valves

  • involves inserting balloon catheter through appropriate vessel and advancing to heart - balloon inflated in affected valve to enlarge opening

• commissurotomy: surgical procedure done to incise fused leaflets, widening opening

• mitral valve annuloplasty: reconstructive procedure to repair ring (annulus) that attaches and supports valve leaflets

• transcatheter aortic valve implantation (TAVI) - most common

assessment

• vital signs

  • tachycardia, HTN, tachypnea indicative of HF due to increased resistance to flow and backflow of blood to pulmonary system

  • tachycardia occurs as compensatory mechanism to increase CO and oxygenation

  • fever = indicative of infection and increases metabolic demands

  • decrease SpO2 occurs with pulmonary congestion

• monitor for irregular rhythm

  • dysrhythmias (a-fib) common in valve disease and decreased cardiac output

• skin color, temp, peripheral pulses, capillary refill time

  • poor color, cool extremities, weak peripheral pulses, sluggish refill time can indicate inadequate CO

• breath sounds

  • crackles and orthopnea indicate pulmonary congestion

• activity tolerance

  • dyspnea on exertion, weakness, and fatigue indicate worsening HF

• auscultate heart sounds

  • murmurs initial manifestation of valvular disease

• monitor INR

  • patient with valve replacement (especially mechanical) need to maintain INR that is 2-3 times normal

interventions:

• medications: diuretics, calcium channel blockers, beta blockers, antibiotics, anticoagulation

• monitor fluids (possibly restrict)

teaching:

• necessity for prophylactic antibiotics to prevent reoccurrence of infectious valvular disease with dental procedures as the gums are very vascular

• strict adherence to anticoagulation regimen if they have a prosthetic valve to prevent thombo/embolitic events

  • avoid activities/sports that are high risk for injury

  • report any injuries or falls to provider

  • report anticoagulant use prior to procedures

  • care with shaving (electric razors preferred)

  • care with flossing to avoid bleeding

  • limit alcohol

  • LIMIT INTAKE OF GREEN LEAFY VEGETABLES (impair effectiveness and can lead to clots)

endocarditis

infection of the endocardium that affects mostly the mitral and aortic valve but can affect any

risk factors: age greater than 60, immunodeficiency, presence of prosthetic heart valves, prior history of endocarditis, congenital heart disease, IV drug use or presence of IV access device, hemodialysis, diabetics, frequent exposure to health-care system, rheumatic heart disease, dental procedures

clinical manifestations:

• Osler’s nodes - red, painful nodes on pads of fingers and toes

• Janeway’s lesions - red, painless spots on palms and soles

• weight loss

• night sweats

• new or changing murmur

• fever

• petechiae

• fatigue

• confusion (in elderly)

• rigor

lab/diagnostic tests

• blood cultures (if infection resistant to antibiotic)

• EKG to ensure nothing else is going on

• TTE - through skin and ultrasound

• TEE - through throat and inside to look at posterior heart view

  • only as needed (if theres too much adipose tissue or cannot see with TTE)

management:

• TREAT THE INFECTION - antibiotics

• valve repair or replacement surgery if irreparably damaged

nursing care

• assessment

• interventions: refer to addiction counseling if necessary

• teaching: good oral hygiene, notify providers before any dental procedures

valvular disease

the most affected valve = aortic valve

4 different types

• stenosis: hard to open and close (can get stuck one way or other)

• insufficiency: not enough blood flow

• regurgitation: blood flows backwards

• prolapse: displacement of valve leaflets (more open than they should be/don’t work properly)

risk factors: infectious diseases such as IE (infective endocarditis - infection in and around heart), congenital defects, degenerative changes, pregnancy, smoking, hyperlipidemia, hypertension

clinical manifestations: SOB, angina, syncope, dysrhythmia, palpitation, dizziness, fatigue, weight gain

diagnostic testing:

• EKG to look for signs of left or right ventricular hypertrophy (standing order if pt has chest pain as time = cell death)

• echo (ultrasound) identifies leaflet abnormalities

• chest x-ray to see if the heart is enlarged

• stress testing to identify functional capacity

• heart cath as definitive test of stenosis prior to correction

medications:

• BETA BLOCKERS: reduce heart rate and blood pressure (thus cardiac workload)

• CALCIUM CHANNEL BLOCKERS: produce vasodilation and reduce afterload (decreasing regurgitant flow in mitral and aortic stenosis)

• DIURETICS: to decrease preload and pulmonary congestion

valve replacement: open heart oftentimes, percutaneous approach possible now

• REPLACEMENT WITH MECHANICAL VALVE → NEED TO BE ANTICOAGULATED FOR LIFE - NCLEX)

valve repair (yields better outcomes than replacement)

• balloon valvuloplasty: percutaneous procedure to repair stenosed aortic or mitral valves

  • involves inserting balloon catheter through appropriate vessel and advancing to heart - balloon inflated in affected valve to enlarge opening

• commissurotomy: surgical procedure done to incise fused leaflets, widening opening

• mitral valve annuloplasty: reconstructive procedure to repair ring (annulus) that attaches and supports valve leaflets

• transcatheter aortic valve implantation (TAVI) - most common

assessment

• vital signs

  • tachycardia, HTN, tachypnea indicative of HF due to increased resistance to flow and backflow of blood to pulmonary system

  • tachycardia occurs as compensatory mechanism to increase CO and oxygenation

  • fever = indicative of infection and increases metabolic demands

  • decrease SpO2 occurs with pulmonary congestion

• monitor for irregular rhythm

  • dysrhythmias (a-fib) common in valve disease and decreased cardiac output

• skin color, temp, peripheral pulses, capillary refill time

  • poor color, cool extremities, weak peripheral pulses, sluggish refill time can indicate inadequate CO

• breath sounds

  • crackles and orthopnea indicate pulmonary congestion

• activity tolerance

  • dyspnea on exertion, weakness, and fatigue indicate worsening HF

• auscultate heart sounds

  • murmurs initial manifestation of valvular disease

• monitor INR

  • patient with valve replacement (especially mechanical) need to maintain INR that is 2-3 times normal

interventions:

• medications: diuretics, calcium channel blockers, beta blockers, antibiotics, anticoagulation

• monitor fluids (possibly restrict)

teaching:

• necessity for prophylactic antibiotics to prevent reoccurrence of infectious valvular disease with dental procedures as the gums are very vascular

• strict adherence to anticoagulation regimen if they have a prosthetic valve to prevent thombo/embolitic events

  • avoid activities/sports that are high risk for injury

  • report any injuries or falls to provider

  • report anticoagulant use prior to procedures

  • care with shaving (electric razors preferred)

  • care with flossing to avoid bleeding

  • limit alcohol

  • LIMIT INTAKE OF GREEN LEAFY VEGETABLES (impair effectiveness and can lead to clots)

endocarditis

infection of the endocardium that affects mostly the mitral and aortic valve but can affect any

risk factors: age greater than 60, immunodeficiency, presence of prosthetic heart valves, prior history of endocarditis, congenital heart disease, IV drug use or presence of IV access device, hemodialysis, diabetics, frequent exposure to health-care system, rheumatic heart disease, dental procedures

clinical manifestations:

• Osler’s nodes - red, painful nodes on pads of fingers and toes

• Janeway’s lesions - red, painless spots on palms and soles

• weight loss

• night sweats

• new or changing murmur

• fever

• petechiae

• fatigue

• confusion (in elderly)

• rigor

lab/diagnostic tests

• blood cultures (if infection resistant to antibiotic)

• EKG to ensure nothing else is going on

• TTE - through skin and ultrasound

• TEE - through throat and inside to look at posterior heart view

  • only as needed (if theres too much adipose tissue or cannot see with TTE)

management:

• TREAT THE INFECTION - antibiotics

• valve repair or replacement surgery if irreparably damaged

nursing care

• assessment

• interventions: refer to addiction counseling if necessary

• teaching: good oral hygiene, notify providers before any dental procedures

pericarditis

infection of the pericardium (sac around the heart)

• idiopathic = majority

clinical manifestations

• FRICTION RUB

• fever

• orthopnea - difficulty breathing when lying down

• pericardial effusion - extra fluid buildup around heart

• pleuritic chest pain - sudden and sharp burning pain when breathing in or out

• EKG changes

diagnosis

• EKG (ST elevation and PR depression)

• chest x-ray to see if the heart is enlarged

  • can identify if enlargement is from pericardial effusion on an MRI)

• TTE

• CT scan

• labs

  • serial cardiac enzymes to rule out MI

  • blood cultures

  • CBC with high WBC count

  • positive inflammatory markers such as c-reactive protein and sed rates

nursing care

• goals = alleviate pain and stop inflammatory process

• antibiotics to treat infection

• corticosteroids

• NSAIDS

• keep HOB elevated to relieve SOB and pain

  • pericardial effusion exerts pressure on surrounding organs → orthopnea and dyspnea

• assess for hypotension, tachycardia, and pulsus paradoxus (exaggerated fall in pt’s BP during inspiration > 10 mmHg)

• cardiac tamponade: clinical syndrome caused by accumulation of fluid in pericardial space → reduced ventricular filling and subsequent hemodynamic compromise - compresses heart

  • can remove fluid to allow for better heart function

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