NRSG 250: Exam 2 - Valve Disorders & Infectious Diseases

What are the 2 types of heart valve disorders?

1. stenosis = valve won’t open

2. regurgitation = valve won’t close

What are the risk factors for valve disorders?

1. rheumatic fever

2. endocarditis

3. congenital heart disease

4. IV drug use

What are the manifestations of valve disorders?

1. decreased cardiac output = fatigue, weakness

2. pulmonary congestion = dyspnea, orthopnea, activity intolerance

3. cardiac manifestations = chest pain, palpitations, murmurs

4. fluid overload = peripheral edema, weight gain, JVD

5. S/S of HF

What diagnostics are used for valve disorders?

1. Echocardiogram = gold standard

2. ECG

3. CXR

What is valvular stenosis?

valve won’t open

• obstructs forward blood flow

• creates pressure overload

• heart works harder to pump blood forward

What is the patho of valvular stenosis?

1. Valve Narrows (i.e., fibrosis, fusion, calcification)

2. Blood Has Trouble Moving Forward (small valve office)

3. Pressure Builds Up Behind Valve

4. Cardiac Hypertrophy

5. Heart Failure Symptoms

What are the key characteristics of valvular stenosis?

1. narrow valve opening

2. increased pressure overload

3. ventricular hypertrophy

What is valvular regurgitation?

valve won’t close

• blood leaks backward

• creates volume overload

• heart works harder to move blood twice

What is the patho of valvular regurgitation?

1. valves fail to close

2. blood leaks backward

3. volume overload

4. chamber dilation

5. HF S/S

What are the key characteristics of valvular regurgitation?

1. backward blood flow

2. increased volume overload

3. chamber dilation

What is the normal function of the mitral valve?

separates left atrium and left ventricle

• opens during diastole → allows ventricular filling

• closes during systole → prevents backflow

Major mitral disorders:

• mitral stenosis

• mitral regurgitation

What is mitral stensois?

narrowing of mitral valve opening → obstructs blood flow from LA to LV

What is the most common cause of mitral stenosis?

rheumatic heart disease

What is the patho of mitral stenosis?

1. mitral valve narrows

2. blood backs up into LA

3. increased LA pressure

4. pulmonary congestion

5. dyspnea & orthopnea

What are the manifestations of mitral stenosis?

primarily r/t pulmonary congestion

1. dyspnea on exertion

2. orthopnea

3. paroxysmal nocturnal dyspnea

4. fatigue

5. palpitations

Assessment:

1. crackles

2. activity intolerance

3. afib

4. signs of pulmonary edema

5. murmur

What does the murmur in mitral stenosis sound like?

low-pitched diastolic rumble that is heart best at the apex

What are the complications of mitral stenosis?

1. afib

2. stroke

3. HF

What is mitral regurgitation?

incomplete closure of the mitral valve allowing blood to flow backward into the LA during systole

What causes mitral regurgitation?

1. mitral valve prolapse

2. infective endocarditis

3. MI

4. DCM

What are the manifestations of mitral regurgitation?

1. fatigue

2. weakness dyspnea

3. palpitations

Assessment findings:

1. holosystolic murmur

2. S3 heart sound

3. pulmonary congestion

4. decreased exercise tolerance

* decreased forward cardiac output despite increased ventricular workload

What are the complications of mitral regurgitation?

1. afib

2. HF

3. pulmonary HTN

What is mitral valve prolapse (MVP)?

mitral leaflets bulge into LA during systole; most common valvular abnormality

What are the manifestations of MVP?

1. often asymptomatic

2. palpitations

3. chest discomfort

4. anxiety

5. exercise intolerance

Assessment findings:

1. mid-systolic click

2. late systolic murmur

* MVP can lead to mitral regurgitation!!!!

What is aortic stenosis?

narrowing of aortic valve obstructing flow from LV to aorta

What causes aortic stensosi?

1. age-related calcification (most common)

2. congenital bicuspid valve

3. rheumatic heart disease

What is the patho of aortic stenosis?

1. aortic valve anrrows

2. LV must pump harder

3. LV hypertrophy

4. decreased cardiac output

5. HF S/S

What are the manifestations of aortic stensosi?

1. exertional chest pain

2. syncope w/ activity

3. fatigue

4. dyspnea on exertion

Assessment findings:

1. harsh systolic murmur at right sternal border

2. diminished peripheral pulses

3. decreased exercise tolerance

What are the complications of aortic stenosis?

1. HF

2. ventricular dysrhythmias

3. sudden cardiac death

What is the nursing priority for aortic stenosis?

monitor for worsening dyspnea, syncope, and chest pain

What is aortic regurgitation?

incomplete closure of the aortic valve allowing flow back into the LV during diastole

What are the causes of aortic regurgitation?

1. Infective endocarditis & rheumatic heart disease

2. Congenital valve abnormalities

3. Hypertension

4. Aortic root dilation

What is the patho of aortic regurgitation?

1. Aortic Valve Leaks

2. Blood Returns to LV

3. LV Volume Overload

4. LV Dilation

5. Heart Failure

What are the manifestations of aortic regurgitation?

1. Dyspnea on exertion

2. Orthopnea

3. PND

4. Fatigue

5. Palpitations

Assessment findings:

1. Bounding pulses

2. Wide pulse pressure (> 40-60 mmHg difference btwn SBP & DBP)

3. Diastolic blowing murmur

4. Visible carotid pulsations

What is used for the tx of valvular heart diseases?

Medication:

• anticoagulants

• prophylactic antibiotics when indicated

Other:

• cardioversion → dysrhthmias

• activity modification & symptom management

Surgical:

• valve repair → leaflet repair; annuloplasty

• balloon valvuloplasty

• valve replacement

What nursing interventions are used for valvular heart disease?

1. Monitor cardiac status and hemodynamics

2. Assess for worsening heart failure

3. Monitor anticoagulation laboratory values

4. Educate patients regarding medications and follow-up care

5. Observe for postoperative complications

What are the 4 layers of the heart, and what are they for?

1. Endocardium = Inner lining of heart chambers and valves

2. Myocardium = Cardiac muscle responsible for pumping

3. Epicardium = Protective outer layer of the heart wall

4. Pericardium = Sac surrounding heart:

   • Visceral pericardium covers heart surface

   • Parietal pericardium lines the pericardial sac

What are the 3 types of cardiac infections?

1. endocarditis

2. myocarditis

3. pericarditis

What is infective endocarditis?

inflammation or infection of endocardium and valves characterized by vegetations on valves

Types:

• native vs prosthetic valve

• acute vs subacute (more common) IE

What are the causes of native valve IE?

1. staphylococcus aureus

2. viridians streptoococci

3. enterococci

What are the causes of prosthetic valve IE?

1. staphylococcus epidermidis

2. staphylococci

3. fungal pathogens

What are the causes of acute IE?

follows open-heart surgery or infection in body

What are the causes of subacute IE?

1. associated w/ low-cirulence organisms

2. may be inactive for long periods

What are the risk factors for IE?

1. IV drug use

2. immunodeficiency

3. structural cardiac defects

What is the patho of IE?

1. bacteremia

2. valve injury → decrease blood flow

3. bacterial attachment

4. vegetation formation (may embolize)

5. valve destruction

6. HF / emboli

What are the complications of IE?

1. valvular insufficiency

2. MI & HF

3. septic emboli

4. stroke

5. death if untreated

What are the manifestations of IE?

1. systemic infection

   • fever, chills, fatigue, & weight loss

2. cardiac findings

   • new/changing murmur

   • HF s/s

3. Embolic findings

   • petechiae

   • splinter hemorrhages of nails

   • Janeway lesions = flat-reddened maculae on hands & feet

   • Osler nodes = red-purple raised nodules of hands & feet (soles)

   • Roth spots = hemorrhagic lesions that appear as round or oval spots on the conjuctiva

What diagnostics are used for IE?

Labs:

• elevated inflammatory markers

• positive blood cultures

  • obtain before antibiotics

  • multiple cultures from separate sites

Echo:

• TTE first

• TEE most sensitive

What is used to tx IE?

Medication:

• prolonged IV antibiotics (4-6 weeks)

• prophylactic antibiotics before procedures

Other:

• treat causative organism

• monitor for complications

• surgery

What would indicate surgery for IE?

1. severe valve damage

2. HF

3. persistent infection

4. large vegetations

What nursing interventions are used for IE?

1. Monitor temperature trends & cardiac status

2. Assess for embolic events

3. Manage central-line care

4. Reinforce antibiotic adherence

5. Ensure adequate rest

What is rheumatic carditis (rheumatic endocarditis)?

autoimmune inflammatory response that may affect all layers of the heart and significantly damages the valves (mitral) → may lead to chronic valvular disease

What is the patho of rheumatic carditis?

1. Group A streptococcal

2. pharyngitis

3. rheumatic fever

4. autoimmune response

5. cardiac inflammation = Aschoff bodies lesions into scar tissues (all layers)

6. valve scarring

What are the manifestations of rheumatic carditis?

1. new/changing murmur

2. tachycardia

3. dysrhythmias

4. pericardial friction rub

5. cardiomegaly HF

6. precordial pain

7. prolonged PR interval

What are the complications of rheumatic carditis?

1. mitral stenosis

2. aortic stenosis

3. chronic valvular dysfunction

What are the diagnostics for rheumatic carditis?

1. hx of strep infection

2. Antistreptolysin O (ASO) titer

3. C-reactive protein (CRP)

4. Erythrocyte sedimentation rate (ESR)

5. ECG

6. Echocardiogram

What is the tx for rheumatic carditis?

Medication:

• antibiotics for strep infection

• anti-inflammatory (NSAIDS & corticosteroids)

Other:

• bed rest during acute phase

• management of HF if present

What nursing interventions are used for rheumatic carditis?

1. assess hx of recent sore throat

2. monitor cardiac status

3. evaluate for signs of HF

4. med adherence

5. complete antibiotic therapy

What is myocarditis?

inflammation of the myocardium (heart muscle), resulting in impaired contractility and reduced cardiac output

What are causes of myocarditis?

1. viral infection (most common)

2. bacterial infections

3. autoimmune disorders

4. drug or toxin exposure

What is the patho of myocarditis?

1. myocardial Inflammation

2. Decreased Contractility

3. Reduced Cardiac Output

4. Heart Failure / Dysrhythmias

What are the manifestations of myocarditis?

1. Fatigue

2. Fever

3. Flu-like illness

4. Chest pain

5. Palpitations

6. Dyspnea

What are complications of myocarditis?

1. Heart failure

2. Cardiogenic shock

3. Sudden cardiac death

4. Dysrhythmias

What diagnostics are used for myocarditis?

Labs:

• elevated CRP & ESR

• leukocytosis

• elevated cardiac biomarkers (troponin)

What nursing interventions are used for myocarditis?

1. monitor cardiac rhythm

2. assess for worsening HF

3. administer O2 as ordered

4. promote rest & activity restriction

5. monitor fluid balance

6. administer prescribed meds

7. teach report worsening dyspnea or chest pain

8. adhere to follow-up care

What is pericarditis?

inflammation of the pericardium, the sac surrounding the heart

Types:

• infectious

• non-infectious

What are the causes of infectious pericarditis?

1. viral (most common)

2. bacterial

3. fungal

What are the causes of noninfectious pericarditis?

1. post-MI (Dressler syndrome)

2. autoimmune disorders

3. uremia

4. malignancy

5. cardiac surgery

What is the patho of pericarditis?

1. Pericardial Inflammation

2. Irritation of Pericardial Layers

3. Chest Pain + Friction Rub

4. ↓ Cardiac Filling and Contracting

5. ↓ Cardiac Output

6. ↓ Heart Failure

What are the manifestations of pericarditis?

Hallmark findings:

1. chest pain

   • sharp, pleuritic

   • worse w/ inspiration or coughing

   • worse w/ laying flat

   • better w/ tripod position

2. cardiac findings

   • pericardial friction rub

   • tachycardia

3. systemic findings:

   • fever & increased WBC

   • ↑ CRP/ESR

What is the tx used for pericarditis?

Medications:

• NASAIDS

• Colchicine

• corticosteroids

• antibiotics if bacterial

What nursing interventions are used for pericarditis?

1. monitor chest pain characteristics

2. monitor heart sounds & vital signs

3. Assess for signs of tamponade:

   • Beck’s Triad (hypotension, JVD, & muffled heart sounds

4. activity restriction during acute inflammation

5. report worsening chest pain, dyspnea, or dizziness