N313 - Cardiology: Valvular Heart Disease, Aortic Aneurysms

What is infective endocarditits (IE)

Infection of inner layer, muscle

What are risk factors for IE?

• Cardiac conditions

• IV drug use

• Central venous catheter

Cardiac IE Risks include

• valvular disease

• cardiomyopathy

• Prior IE

• Congestive heart disease

Cardiac IE valvular disease risks include:

• mistrostenosis

• stenosis

• regurgitation

What is cardiomyopathy?

• disease of heart muscle

Why is prior IE a risk for IE?

• It can come back later

Why is IV drug use a risk for IE?

• opioids increase risk of IV

Why care central venous catheters an increased risk for IE?

• increased risk for bacteria in the bloodstream

  • CLABSI

• Hospital acquired infection

Why are hospital acquired infections so important?

sepsis → fluids fluids fluids

What are clinical manifestations of IE?

• Low grade fever

• heart failure

Low grade fever manifestations

• older populations don’t present with fevers right away → major problems

• malaise

• chills

• fatigue

• loss of appetite

Heart failure + IE

• 80% of PTs with IE in the aortic valve → WILL develop HF

How does a PT get an infection (IE)

• Bacteria in the blood stream goes into the heart

  • decreases life span

  • mortality

  • immediate upgrade to CVU

If someone’s got endocarditis, and it's day 4 of antibiotics, which of these four are indicative that it is ineffective

• normal temperature

• negative blood culture

• systolic heart murmur

• clear breath sounds

What are some IE management options?

• health history

• blood cultures

• drug therapy

What is the purpose of a blood culture

• determines type of bacteria

  • throw antibiotics and switch when we know waht culture it is

What drug therapy is available for an IE

• prophylactic (after or before procedure) antibiotics

What are prophylactic antibiotics used for?

• heart transplant

• prosthetic heart valves

• tonsillectomy

• dental work, give antibiotics before and after

What target groups for prophylactic antibiotics are there?

• congenital heart disease

• unrepaired cyanotic CHD

• repaired congenital heart defect with prosthetic material or device for 6 months after the procedure

• repaired CHD with residual defects at the site or next to the site opf prosthetic patch or prosthetic devices

• Heart transplant recipients who develop heart valve disease

• History transplant recipients who develop heart valve disease

• history of IE

• prosthetic heart valve or prosthetic material used to repair heart valve

What conditions or procedures require antibiotic prophylaxis

• oral

  • dental manipulation involving the gums or roots of the teeth

  • dental manipulation involving puncture of the oral mucosa

• respiratory

  • respiratory tract infections (biopsy)

  • tonsillectomy and adenoidectomy

• Surgical procedures that involve infected skin, skin structures, or MS tissue

What are some valvular heart diseases?

• stenosis

• regurgitation

What is valvular stenosis?

• narrowing of our valves

  • less blood → less oxygen

  • pooling blood → backs up into lungs → backing up into the body

What is valvular regurgitation?

• not a fully closing valve

• incompetence/insufficiency

• incomplete closure (doesn’t completely shut)

  • blood backs up

what are some mitral valve conditons?

• CAD

• HTN

• IE

What is mitral valve stenosis?

narrowing of the mitral valve

What is the etiology of rheumatic heart disease?

• biggest leading cause of MVS

  • strep throat

How does strep throat cause rheumatic heart disease?

• leads to mitral valve stenosis → abnormal response → inflammation of joint → scarring &inability to open up all the way

• irreversabile

What is mitral annul calcification

• calcium collects in annulus of mitral valve causing stiffness and non compliance

What are some causes of mitral annul calcification

• CKD

• HTN

What are clinical manifestations of mitral valve disease/stenosis

• diastolic murmur

• exertional dyspnea

• Atrial fibrillation

• hemodynamic impact

Why does MVS cause diastolic murmurs?

• mitral valve opens during ventricle diastolic → atrium is contracted → hear turbulence of blood forcing through stenotic mitral valve

What is exertional dyspnea

dyspnea during activity

Why does exertional dyspnea occur with MVS?

• blood cant move from LA to LV → blood collects in LA → backs up into lungs

What are pulmonary vascular manifestations?

• congested/overload

• leads to increased hydrostatic pressure → fluid out into interstitial spaces of lungs → affecting alveolar gas exchange

Why is atrial fibrillation a clinical manifestation?

• pooling of the blood int he heart → causing clots → and clots get dislodged → leading to stroke

What is a BIG SIGN of atrial fibrilation

quivering

What is a priority for a PT who is quivering who is showing atrial fibrillation?

• OXYGENATION

• INCREASED RISK OF STROKE

• HR of 140-160

What are the hemodynamic impacts of MVS?

• increased preload (IPAOP)

• Increased pulmonary after load

What is increased preload

• increased volume on left side → increased fluid in PV → increased pressure

• increased pressure and/or resistance for the blood to pump out

What is mitral valve regurgitation etiology?

• MI

  • prevent valve from closing

  • worse case scenario

  • acutely

  • rapid fluid shift into out lungs → flash pulmonary edema

Rheumatic arthritis + IE

• stiffens valve → prevents valve closure

• ineffective endocarditis

  • scar valve tissue → damaging

• papillary muscle dysfunction

what are clinical manifestations of mitral valve regurgitation

• systolic murmur

• peripheral edema

• S3 heart sound

What is a systolic murmur?

• Turbulence of blood in four directions, aortic → atrium, occurs during systole → increased ventricle → backs up into atrium → leads to S3 sound

What is peripheral edema?

• Blood backs up into pulmonary valve → reduces oxygen diffusion → decreased perfusion → decreased cardiac output (HR x Stroke volume)

• Congestion in right side of heart → peripheral edema

What is the etiology of aortic valve stenosis

• rheumatic fever

• degenerative changes

What is rheumatic fever?

Degential

What are some degenerative changes?

• wear and tear

• happens in older populations

What are some clinicial manifestations of aortic valve stenosis?

• systolic murmur S4

  • narrowing heart opening → turbulence of blood flow

• Signs of LV failure

• Hemodynamic

What are some signs of LV failure - angina?

• manifestations → angina/chest pain

• Syncope

• Exertional dyspnea

Do we give someone w aortic valve stenosis w LV failure nitro?

NO

Why dont we give someone with aortic valve stenosis nitro?

• vasodilator → opens diameter of vessel → decreased BP

• PTs are PRELOAD dependent

  • LV is reliant on the fluid present within that chamber → adds additional pressure in AV to provide USUAL increased pressure → nitro will further drop cardiac output

Aortic valve stenosis hemodynamic indicaitons

• increased oxygen demand

• preload dependent

What is the etiology of aortic valve regurgitation?

• RHD, congenital malformation

• Syphilis, post op complication

What are chronic clinical manifestations of aortic valve regurgitation?

• Diastolic murmur

  • Water hammer pulse (Strong and quick beat that will quickly stop due to ceased blood flow)

• Fatigue

• Exertional dyspnea

• Orthopnea

  • SOB when lying down

• Paroxysmal nocturnal dyspnea

  • Sudden SOB while sleeping that wakes em up

• Chest pain is less common

What are HF predisposing factors

• Diastolic murmur

  • Water hammer pulse (Strong and quick beat that will quickly stop due to ceased blood flow)

• Fatigue

• Exertional dyspnea

• Orthopnea

  • SOB when lying down

• Paroxysmal nocturnal dyspnea

  • Sudden SOB while sleeping that wakes em up

• Chest pain is less common

What are the hemodynamics of aortic valvular regurgitation

• Increased fluid of heart → increased preload → backs up into lungs causing pulmonary congestion → backlog (?) from right side → leads to HF on BOTH left and right

  • Left sided hf causes right sided hf

• Decreased contractility

• Pulmonary congestion

What are diagnostics for valvular heart disease?

• echocardiogram

• Chest xray

• 12 lead EKG

• cardiac catheterization

What is a noninvasive way to diagnose valvular heart disease?

• echocardiogram

  • bed side

What is the purpose of an echocardiogram?

• sees vavles

• sees ejection fraction

What is the purpose of a chest xray?

• shows pulmonary congestion

What is the purpose of a 12 lead EKG

• may show atrial fibrillation → irregular heartbeat

What is the purpose of a cardiac chaeterization?

• radial line or fem line to visualize heart

What conservative treatment options are available for valvular heart disease?

• prophylactic antiobiotic therapy

  • RF

  • IE

• Sodium restriction

• drug therapy to control HF

• Anticoagualtion therapy

• antidysrhythmic drugs

• percutaneous transluminal balloon valvuloplasty

• percutaneous valve replacement

What drug therapy is available to treat or control HF

• vasodilators

  • nitrates

  • ace inhibitors

• Positive inotropes

  • digoxin

• Diuretics

• B blockers

What surgical therapy is available for valvular heart disease?

• valve repair

• valve replacement

Valve repair surgeries include

• annuloplasty

• commissurotomy

• valvuloplasty

What medications are available for valvular heart disease?

• duretics

• and/or vasodilators

  • EXCEPT NITRO

Why do we give blood thinners to valvular heart disease PTs?

• prevents pooling of blood → clotting → stroke

What blood thinners are preferred for valvular heart disease?

• eloquid

• zeralto

• warfarin

What should we keep in mind if we are giving a PT warfarin?

• leads to higher bleeding tendancies

What treatment is available for HF mangement?

• afib priority

  • OXYGEN

What is a transaortic valve replacement

• Transaortic valve replacement

  • Biological valve

    • On anticoagulants for 3-6 months

  • Mechanical valve

    • On anticoagulants for LIFE

Why is surgery necessary for valvular disease?

• repeated use can cause HF

What nursing assessments do we use for valvular disease?

• know fi PTs had dental work or surgery

What nursing diagnosises do we use for valvular disease?

• Decreased CO → decreased blood flow → not perfusion tissues or organs

• Decreased perfusion

• Fluid imbalance

What are signs of decreased perfusion?

• Cool skin

• Pale skin

• Prolonged cap refill

• Decreased hair flow

• Fatigue

• SOB

What are signs of fluid imbalance?

• SOB

• Dyspnea

• Crackles

• Congestion on chest xray

• Fluid affecting right side → blood does not pump effectively → edema in body in LE

  • Urinary output

  • Daily weights

What are nursing interventions for valvular disease?

• streptococcus

• activity restrictions

• energy conservation

• medication eduction

What streptococcus interventions are availabe?

strep throat → give antibiotics

Activity restrictions include

• Frequent breaks

• Teach PT to know limits

• Assistance when needed → standing, walking, stand by assist, walker, cardiac rehab

Energy conservation includes

• Cluster care

• Periods of rest

• Assistance when needed

• Frequent breaks

Medication education includes

• Anticoagulants

  • if they have afub

    • OXYGEN

    • MONITOR FOR BLEEDING

• BP medications

  • monitor BP at home

• Diuretics

  • daily weights

  • dietary restrictions

    • decrease salt intake

What is peripheral artery disease? (PAD)

arterial thickening and narrowing of the arteries

What causes PAD?

• Inflammation build up

• Atherosclerosis

  • Similar to CAD

  • Buildup of plaque from local injury and inflammation caused by lipid deposits from too much cholesterol circulating in the blood (specifically LDL)

  • Damage in vessel walls aggregate and depot fat deposits → caused by HTN, smoking, diabetes

What are risk factors for PAD?

• Age 

  • Clots

• Diabetes

  • Sugar in blood stream → causes nerve damage

• HTN

• SMOKING

What are clinical manifestations of PAD that start manifesting at 60-70% occulsion

• Intermittent claudication

• Burning, tightness, weakness, soreness, pressure, heaviness

• Tingling or numbness, burning

• Signs of reduced ARTERIAL blood flow

What is intermittent claudication

• calf pain when walking

Why do PAD PTs feel tingling or numbness, burning?

• Nerves are impacted → reducing sensation

What are signs of arterial blood flow?

• Pallor

  • When foot is elevated

  • White blanching of the foot

• Shiny taught thin skin

  • Pulses +1, thready

  • Doppler

• Pain is worse while sleeping and/or at rest → HR slows down → decreasing CO → decreased blood flow and oxygenation

• Dependent rubor

  • Legs turn red when lower than the heart

What are diagnostics for PAD

• Doppler ultrasound with duplex

  • most common

• Angiogram/MRI

  • Invasive

  • Femoral

  • Severe cases

What treatments are available for PAD?

• manage HTN

• Dietary changes

• stop smoking

• lipid management

• Fibric acid derivative (genfibrozil)

• Anti platelet medications

• Exercise

How can a PT manage HTN?

• ACE inhibitor (pril)

  • Lisinopril

• Healthy diet

  • decrease salt intake

What is a DASH diet?

• diet for PAD PTs

  • Reduce salt intake

  • Reduce fat intake

  • Fresh fruits

  • Vegetables

  • Grains

  • Lean protein

  • Mediterranean diet

Why should PAD PTs stop smoking

• stop smoking

  • Risk factor

  • Clot build up

  • Plaque formation

What lipid management is available

• - statins

• atorvastatin

  • cholesterol medication

Side effects of lipid management medications include

• muscle pain

• joint pain

• GI issues

• Bad for liver

What fibric acid derivative is available

Gemfibrozil

What antiplatelet medications are available?

• Aspirin and clopidogrel (Plavix)

  • Prevent clot formation

• Anticoagulants

  • 1 - aspirin 81 mg

  • Or 2 combination - Plavix

the BIGGEST side effect of anticoagulants?

• bleeding