Transcript Valvular heart disease

VALVULAR HEART DISEASE
Key points
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Valvular heart disease may have congenital or acquired causes.
Valves on the left side are most commonly affected due to higher
pressures.
Valvular disease is classified as:
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Stenosis – narrowed opening that impedes blood moving forward.
Insufficiency – improper closure – some blood flows backward
(regurgitation).
Congenital valvular disease may affect all four valves and cause
either stenosis or insufficiency.
Acquired valvular disease is classified as one of three types:
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Degenerative disease – due to damage over time from mechanical stress;
mostly results from hypertension.
Rheumatic disease – gradual fibrotic changes, calcification of valve
cusps. The mitral valve is most commonly affected.
Infective endocarditis – infectious organisms destroy the valve.
Streptococcal infections are a common cause.
Risk Factors for Valvular
Heart Disease
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Hypertension
Rheumatic fever (mitral stenosis and insufficiency)
Infective endocarditis
Congenital malformations
Marfan syndrome
Diagnostic Procedures and Nursing
Interventions
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Chest x-ray (chamber enlargement, pulmonary
congestion, and valve calcification).
12-lead electrocardiogram (ECG) shows chamber
hypertrophy.
Echoco (US) show s chamber size, hypertrophy,
specific valve dysfunction, ejection function, and
amount of regurgitant flow.
Exercise tolerance testing (stress echo); impact of the
valve problem on functioning during stress.
Angiography reveals chamber pressures, ejection
fraction, regurgitation, and pressure gradients
Therapeutic Procedures and Nursing
Interventions
Percutaneous balloon valvuloplasty may open the stenotic
aortic or mitral
valves. A catheter is inserted through the femoral artery
and advanced to
the heart. A balloon is inflated at the stenotic lesion to open
the fused
commissures and improve leaflet mobility.
 Surgical management includes valve repair, chordae
tendineae reconstruction and prosthetic valve replacement.
 Prosthetic valves may be mechanical or tissue. Mechanical
valves last longer but require anticoagulation. Tissue valves
last 10 to 15 years.
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Assessments
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Monitor for signs and symptoms.
Left-sided valve damage results in dyspnea,
fatigue, increased pulmonary artery pressure, and
decreased cardiac output.
Right-sided valve damage results in dyspnea,
fatigue, increased right atrial pressure, peripheral
edema, jugular vein distention, and hepatomegaly
Mitral stenosis
Mitral
insufficiency
Aortic stenosis
Aortic
insufficiency
Palpitations
Proximal nocturnal
Dyspnea
Angina
Angina
Hemoptysis
Orthopnea
Angina
S3
Hoarseness
Palpitations
Syncope
Diastolic murmur
Dysphagia
S3 and/or S4
Decreased SVR
Widened pulse
pressure
Jugular vein
distention
Crackles in lungs
S3 and/or S4
Orthopnea
Systolic murmur
Systolic murmur
Cough
Atrial fibrillation
Narrowed pulse
pressure
Diastolic
murmur
Atrial fibrillation
Tricuspid
stenosis
Tricuspid
insufficiency
Atrial
dysrhythmias
Conduction
delays
Diastolic
murmur
Supraventricul
ar
tachycardia
Systolic
murmur
Decreased
cardiac
output
Pulmonic
stenosis
Cyanosis
Systolic
murmur
Pulmonic
insufficiency
Diastolic
murmur
Assess/Monitor
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Oxygen status
Vital signs
Cardiac rhythm
Hemodynamics
Heart and lung sounds
Exercise tolerance
NANDA Nursing Diagnoses
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Decreased cardiac output
Impaired gas exchange
Activity intolerance
Acute pain
Nursing Interventions
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Administer O2 as prescribed to improve myocardial oxygenation.
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Maintain fluid and sodium restriction.
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Administer medications as prescribed.
 Diuretics to decrease preload.
 Antihypertensive agents (beta-blockers, calcium-channel blockers,
ACE
 Inotropic agents to increase contractility – digoxin (Lanoxin),
dobutamine.
 Anticoagulation therapy for clients with mechanical valve
replacement
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Assist the client to conserve energy and decrease myocardial oxygen
consumption.
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Post-surgery care is similar to coronary artery bypass surgery (care for
sternal incision, activity limits for 6 weeks, report fever).
Nursing Interventions
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Client Education
 Prophylactic
antibiotics are recommended prior to
dental work, surgery, or other invasive procedures.
 Encourage the client to follow the prescribed exercise
program.
 Encourage adherence to dietary restrictions; consider
nutritional consultation.
 Teach the client energy conservation.
Complications and Nursing Implications
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Heart failure is the inability of the heart to maintain
adequate circulation to meet tissue needs for
oxygen and nutrients.
Ineffective valves result in heart failure.
Monitoring a client’s heart failure class (I to IV) is
often the gauge for surgical intervention for
valvular problems.
ANGINA AND
MYOCARDIAL INFARCTION
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Angina pectoris is a clinical syndrome usually
characterized by episodes of pain or pressure
in the anterior chest . The cause is usually
insufficient coronary blood flow which results
in a decreased oxygen supply to meet an
increased myocardial demand for oxygen in
response to physical exertion or emotional
stress.
Key Points
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The continuum from angina to myocardial infarction (MI) is
termed acute coronary syndrome. Symptoms of acute
coronary syndrome are due to an imbalance between
myocardial oxygen supply and demand.
Angina pectoris is a warning sign for acute MI.
Women and older adults may not always experience
symptoms typically associated with angina or MI.
The majority of deaths from an MI occur within 1 hr of
symptom onset. Early recognition and treatment of acute MI is
essential to prevent death.
Research shows improved outcomes following an MI in
clients treated with aspirin, beta-blockers, and angiotensinconverting enzyme (ACE) inhibitors.
Key Points
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When blood flow to the heart is compromised, ischemia
causes chest pain. Anginal pain is often described as a
tight squeezing, heavy pressure, or constricting feeling
in the chest. The pain may radiate to the jaw, neck, or
arm.
The three types of angina are:
Stable angina (exertional angina) occurs with exercise or
emotional stress and is relieved by rest or nitroglycerin.
 Unstable angina (preinfarction angina) occurs with exercise
or emotional stress, but it increases in occurrence, severity,
and duration over time.
 Variant angina (Prinzmetal’s angina) is due to coronary
artery spasm, often occurring at rest.
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Pain unrelieved by rest or nitroglycerine and lasting for
more than 15 min differentiates MI from angina.
An abrupt interruption of oxygen to the heart muscle
produces myocardial ischemia. Ischemia may lead to
tissue necrosis (infarction) if blood supply and oxygen
are not restored. Ischemia is reversible; infarction
results in permanent damage.
When the cardiac muscle suffers ischemic injury,
cardiac enzymes are released into the bloodstream,
providing specific markers of MI.
Key Points
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MIs are classified based on:
 The
affected area of the heart (anterior, anterolateral).
 The depth of involvement (transmural versus
nontransmural).
 The EKG changes produced (Q wave, non-Q wave).
Non-Q-wave MIs are more common in older adults,
women, and clients with diabetes.
Risk Factors for Angina and MI
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Male gender
Hypertension
Smoking history
Increased age
Hyperlipidemia
Metabolic disorders: Diabetes mellitus, hyperthyroidism
Methamphetamine or cocaine use
Stress: Occupational, physical exercise, sexual activity
Obesity
Lack of exercise
Hx of cardiac disease
Diagnostic Procedures and Nursing Interventions
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ECG: Check for changes on serial ECGs.
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Clients with non-ST elevation MIs have other indicators.
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Angina: ST depression and/or T-wave inversion (ischemia)
MI: T-wave inversion (ischemia), ST-segment elevation (injury),
and an abnormal Q wave (necrosis)
ST segment depression that resolves with relief of chest pain
New development of left bundle branch block
T-wave inversion in all chest leads
Serial Cardiac Enzymes: Typical pattern of elevation and
decrease back to baseline occurs with MI.
Cardiac catheterization reveals the exact location of coronary
artery obstructions and the degree of ischemia and necrosis.
Therapeutic Procedures and Nursing Interventions
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Percutaneous transluminal coronary angioplasty
(PTCA) uses a balloon at the tip of a catheter guided
under fluoroscopy to press plaque against the vessel
wall and to dilates the obstructed coronary artery to
increase/restore tissue perfusion.
Stents may be placed to maintain patency. Following a
PTCA, monitor for bleeding (heparin), acute vessel
closure (emergency coronary artery bypass graft), and
dysrhythmias (reperfusion).
Coronary artery bypass graft (CABG) surgery restores
myocardial tissue perfusion by the addition of grafts
bypassing the obstructed coronary arteries.
Assessments
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May be asymptomatic
Chest pain (substernal/precordial, may radiate to the neck, arms, shoulders
or jaw; tight squeezing or heaviness in the chest, burning, aching, dull,
constant)
Dyspnea
Pallor and cool, clammy skin
Tachycardia and/or palpitations
Anxiety/fear, feeling of doom
Angina is accompanied by severe apprehension and a feeling
of impending death.
Sweating (diaphoresis)
Nausea and vomiting
A feeling of weakness or numbness in the arms, wrists, and hands
Dizziness, decreased level of consciousness
Assessment
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Angina is usually a result of atherosclerotic heart
disease and is associated with a significant
obstruction of a major coronary artery.
Factors affecting anginal pain are physical exertion,
exposure to cold, eating a heavy meal, or stress or
any emotion- provoking situation that increases
blood pressure, heart rate, and myocardial
workload.
Assess/Monitor
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Vital signs every 15 min until stable, then every hour
Serial ECG, continuous ST segment monitoring
Location, severity, quality, and duration of pain
Continuously monitor cardiac rhythm
Oxygen saturation levels
Hourly urine output – greater than 30 mL/ hr
indicates renal perfusion
Laboratory data: Cardiac enzymes, electrolytes,
ABGs
NANDA Nursing Diagnoses
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Ineffective cardiac tissue perfusion secondary to CAD as
evidenced by chest pain or other prodromal symptoms
Death anxiety
Decreased cardiac output
Acute pain
Anxiety/fear
Activity intolerance
Deficient knowledge about underlying disease and methods
for avoiding complications
Noncompliance, ineffective management of therapeutic
regimen related to failure to accept necessary lifestyle
changes
Nursing Interventions
The objective is to decrease O2 demand of myocardium and to
increase O2 supply
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Administer oxygen (4 to 6 L), as prescribed.
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Obtain and maintain IV access.
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Promote energy conservation
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Administer medications as prescribed.
 Vasodilators; Nitroglycerin is the medication of choice.
 Analgesics reduce pain (Morphine is the medication of choice).
 Beta-blockers (propranolol )have antidysrhythmic and antihypertensive
 Thrombolytic agents can be effective in dissolving thrombi if
administered the first 6 hr following an MI.
 Antiplatelet; Aspirin is the medication of choice.
 Anticoagulants
 Glycoprotein IIB/IIIA inhibitors (thrombolytic agents) prevent the
binding of fibrogen and thus block platelet aggregation.
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Teach the client to avoid straining, strenuous exercise, or emotional stress when
possible.
Client education regarding response to chest pain:
Stop activity and rest.
Place nitroglycerin tablet under tongue to dissolve (quick absorption).
Repeat every 5 min if the pain is not relieved.
Call 911 if the pain is not relieved in 15 min.
Prepare the client for diagnostic examinations as prescribed and revascularization
procedures (angiography, angioplasty, CABG).
Encourage lifestyle modifications to lower incidence of recurrence: smoking
cessation, limiting saturated fat/cholesterol, weight management, and blood
pressure control. Make appropriate referrals (for example, dietician).
Complications and Nursing Implications
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Acute MI is a complication of angina not relieved by rest or nitroglycerin.
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Cardiogenic shock is a serious complication of pump failure, commonly following an
MI of 40% or more of the left ventricle. It is Class IV heart failure (tachycardia,
hypotension , inadequate urinary output (less than
30 mL/hr), altered level of consciousness, respiratory distress (crackles, tachypnea),
cool, clammy skin, decreased peripheral pulses, and chest pain.
Intervention: O2, ET, morphine IV and/or nitroglycerin , vasopressors IV and/or
positive inotropes Other possible emergency interventions include use of an intraaortic balloon pump and/or emergency CABG
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Ischemic mitral regurgitation due to myocardial ischemia may be evidenced by the
development of new cardiac murmur.
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Dysrhythmias due to myocardial hypoperfusion require vigilant continuous cardiac
monitoring.
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Ventricular aneurysms/rupture due to myocardial necrosis may present as sudden
chest pain, dysrhythmias, and severe hypotension.
Prevention
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Self care action plan changing habits.
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Stop smoking
Increase level of exercise
Cut down on fatty foods
Eat more oats, which decrease cholesterol
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Lose wt if u DR. thinks you are overweight.
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Make sure your BP is not high by regular check
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Consider another method of contraceptive if you take
pill
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