Transcript EndocarditisRhematicHeartValvularDisease

Inflammatory and Valvular
Heart Diseases
Rheumatic Fever and Heart Disease
• Rheumatic Fever - inflammatory
disease of heart potentially
involving all layers
• Systemic
• Abnormal immune response to group
A beta hemolytic strep (“strep
throat”)
• Transmission to heart via lymphatic
channels
Most common cause of valvular heart
disease
Rheumatic Fever and Heart Disease
• Rheumatic Heart Disease – chronic condition
characterized by scarring and deformity of heart
valves resulting from rheumatic fever
• Any or all layers of heart maybe affected
Rheumatic Fever and Heart Disease
• Rheumatic endocarditis (most serious)
• Erosion and swelling of valves (thickening)
• Vegetations
• Stenosis/Regurgitation
• Rheumatic Myocarditis
• Nodules and fibrin deposits  loss of
contractile powerCHF
• Rheumatic Pericarditis
• Fibrinous Exudate and pericardial
effusion
Rheumatic Fever and Heart Disease
• Nursing Assessment
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Previous history of rheumatic fever
Socioeconomic class
Fever
Cardiovascular (tachycardia; pericardial friction
rub; distant heart sounds; murmurs)
• Neurological: chorea
• Skin: subcutaneous nodules and erythema
marginatum
• Musculoskeletal: Polyarthritis
Rheumatic Fever and Heart Disease
• Primary Prevention
• Detection and treatment of
strep throat
• Secondary Prevention
• Prophylactic antibiotics to
prevent recurrent ARF
Rheumatic Fever and Heart Disease
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Acute Intervention
Antibiotics
Rest
Control Fever
Anti-Inflammatories
Infective Endocarditis
• Infection of the inner layer
(endocardium) of the heart that
usually affects the cardiac valves
• Was almost always fatal until
development of penicillin
• 5,000-8,000 cases diagnosed in U.S.
each year
Classification
• Subacute form
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Longer clinical course
Insidious onset
Streptococcus bovis or viridians
Staphylococcus epidermidis
HACEK group
Classification
• Acute form
• Shorter clinical course
• Rapid onset
• Causative organism more virulent
• Streptococcus pneumoniae
• Staphylococcus aureus
• Streptococcus groups A, B, C
• Fungi
Etiology and Pathophysiology
• Vegetations
• Fibrin, leukocytes, and microbes
• Adhere to the valve or endocardium
• Embolization of portions of vegetations
into circulation
Bacterial Endocarditis of the
Mitral Valve
Fig. 36-2
Etiology and Pathophysiology
• Left-sided more common with
bacterial infections and underlying
heart disease
• Right-sided lesions usually caused
by IV drug abuse
Etiology and Pathophysiology
• Risk Factors:
• Cardiac Conditions (blood flow turbulence
allows pathogen to infect previously
damaged valves or other surfaces)
• Rheumatic heart disease
• Prosthetic valves
• Aging
• IV drug abuse
• Invasive Medical and Dental Procedures
• UTI, skin/wound infections
Clinical Manifestations
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Nonspecific
Fever occurs in 90% of patients
Chills
Weakness
Malaise, Fatigue
Anorexia
Clinical Manifestations
• Vascular manifestations
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Splinter hemorrhages in nail beds
Petechiae
Osler’s nodes on fingers or toes
Janeway’s lesions on palms or soles
Clinical Manifestations
Clinical Manifestations
• Murmur in 80% of cases
• CHF
• in up to 80% with aortic valve
endocarditis
• 50% with mitral valve endocarditis
• Manifestations secondary to
embolism
Sites of Embolization
HISTORY
• Recent dental, urologic, surgical,
or gynecologic procedures
• Heart disease
• Recent cardiac catheterization
• Skin, respiratory, or urinary
tract infections
Diagnostic Studies
• Labs
• Blood cultures
• Echocardiography (detects
valvular vegetations, abscesses)
• Chest x-ray
Collaborative Care
• Prophylactic treatment for patients
having:
• Removal of drainage of infected
tissue
• Indwelling pacemakers
• Renal dialysis
• Ventriculoatrial shunts
Collaborative Care
• Antibiotic administration
• Monitor antibiotic serum levels
• Antipyretics
• Subsequent blood cultures
• REST
• Valve repair/replacement
Nursing Assessment
• Subjective
• History of valvular, congenital, or
syphilitic cardiac diseases
• Previous endocarditis
• Staph or strep infection
• Immunosuppressive therapy
Nursing Assessment
• Recent surgical procedures or
invasive procedures
• IV drug abuse
• Weight changes
• Chills
• Diaphoresis
Nursing Assessment
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Bloody urine
Exercise intolerance
Generalized weakness
Fatigue
Cough
Dyspnea on exertion
Night sweats
Chest, back, abdominal pain
Nursing Assessment
• Objective
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Olser’s nodes
Splinter hemorrhages
Janeway’s lesions
Petechiae
Clubbing
Nursing Assessment
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Tachypnea
Crackles
Arrhythmias
Leukocytosis
Increased ESR and cardiac enzymes
Positive cultures
ECG showing chamber enlargement
Nursing Diagnoses
Decreased cardiac output
Activity intolerance
Ineffective health maintenance
Acute Pericarditis
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Caused by inflammation of pericardial sac
Etiologies: Infectious vs Non-Infectious
S&S: dyspnea, CP, pericardial friction rub
Complications
• Pericardial effusion
• Cardiac tamponade
• Treatment
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Antibiotics
NSAIDS
Corticosteroids
Positioning head at 45 degree angle
Pericardiocentesis
Valvular Heart Disease
Valvular Heart Disease
• Heart contains two atrioventricular
valves and two semilunar valves
Valvular Heart Disease
• Types of valvular heart disease
depends on:
• Valve or valves affected
• Two types of functional alterations
• Stenosis
• Regurgitation
Valvular Heart Disease
• Stenosis
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Valve orifice is restricted
Impending forward blood flow
Creates a pressure gradient across open valve
Degree of stenosis reflected in pressure gradient
differences
• Regurgitation
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Incomplete closure of valve leaflets
Results in backward flow of blood
Mitral Valve Stenosis
• Due to rheumatic heart disease
• Causes scarring of valve leaflets and
chordae tendineae
• Contractures develop with adhesions
between commissures of the leaflets
• Stenotic mitral valve assumes funnel
shape due to thickening and
shortening of valve structures
Mitral Valve Stenosis
• Pathophysiology:
• Incomplete emptying of LA 
Increased LA pressure LA
dilatation and hypertrophy
• Increased LA pressureElevated
pulmonary pressurepulmonary
congestion
• Incomplete emptying of
LAinsufficient volumes to
ventricles  decreased C.O.
• Afib is common  risk of embolism
Clinical Manifestations
• Dyspnea
• Occasionally accompanied by hemoptysis
• Primary symptom because of reduced lung compliance
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Palpitations from atrial fibrillation
Fatigue
Opening snap
Low-pitched rumbling diastolic murmur
Chest pain
Seizures (from emboli)
Stroke
• Emboli can arise from stagnant blood in left atrium
Mitral Valve Regurgitation
• Mitral Valve fails to close properly
• LV ejects blood into aorta and back
into LA
Mitral Valve Regurgitation
• Majority of cases attributed to:
• MI (MI with left ventricular failure places
patient at risk for rupture of chordae
tendineae)
• Chronic rheumatic heart disease
• Isolated rupture of chordae tendineae
• Mitral valve prolapse
• Ischemic papillary muscle dysfunction
• Infectious endocarditis
Mitral Valve Regurgitation
• Acute Onset (e.g. papillary
dysfunction due to M.I.)
• Backward flow  increased LA
pressure  Increased Pulmonary
Pressure  Pulmonary Edema
• Chronic Onset
• Backward flow  LA dilates and
hypertrophies  Increased
pulmonary pressures  pulmonary
congestion  right sided failure
Mitral Valve Regurgitation
Clinical Manifestations
• Asymptomatic for years until development
of some degree of left ventricular failure
• Initial symptoms include:
• Weakness
• Fatigue
• Dyspnea that gradually progress to
orthopnea, paroxysmal nocturnal
dyspnea, and peripheral edema
Aortic Valve Stenosis
• Usually discovered in childhood,
adolescence, or young adulthood
• Those seen later in life usually have aortic
stenosis from rheumatic fever or senile
fibrocalcific degeneration of a normal valve
Aortic Valve Stenosis
• Results in obstruction of flow from LV to
aorta during systole
• Effect is left ventricular hypertrophy and
increased myocardial oxygen consumption
because of increased myocardial mass
• Leads to reduced CO and pulmonary
hypertension
Aortic Valve Stenosis
Clinical Manifestations
• Symptoms of angina pectoris
• Syncope
• Heart failure
• Occurs when valve orifice is 1/3 normal
size
Aortic Valve Stenosis
• Poor prognosis when experiencing
symptoms and valve obstruction
is not relieved
• Why would Nitroglycerine
be contraindicated with
aortic valve stenosis?
Aortic Valve Regurgitation
• May result from disease of aortic valve leaflets,
aortic root, or both
• Caused by:
• Bacterial endocarditis
• Trauma
• Aortic dissection
• Constitutes life-threatening emergency
• Chronic aortic regurgitation results from:
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Rheumatic heart disease
Congenital bicuspid aortic valve
Syphilis
Chronic rheumatic heart conditions
Aortic Valve Regurgitation
• Physiologic consequence:
• Retrograde blood flow from ascending
aorta to left ventricle
• Elevated LV pressures
• LV dilatation and hypertrophy
• Results in volume overload
Tricuspid Valve Disease
• Tricuspid valve stenosis
• Seen in IV drug users
• Right atrial output is obstructed
• Results in right atrial
enlargement and elevated
systemic venous pressure
Tricuspid Valve Disease
Clinical Manifestations
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Peripheral edema
Ascites
Hepatomegaly
Murmur
Collaborative Care
• Drug therapy
• Digitalis
• Diuretics
• Antiarrhythmics
 b-blockers
• Anticoagulants
• Low-sodium diet
Collaborative Care
• Percutaneous transluminal balloon
valvuloplasty to split open fused
commissures
• Surgical therapy for valve repair
• Annuloplasty
• Valvuloplasty
• Commissurotomy
• Valve Replacement
• Mechanical Vs. Biological
Nursing Assessment
• Objective
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Fever
Diaphoresis
Peripheral edema
Crackles
Wheezes
Abnormal heart sounds
Ascites
Hepatomegaly
Cardiomegaly
Valve calcification
Pulmonary congestion on x-ray
Nursing Assessment
• Diagnostic Tests:
• Calcification or vegetation of leaflets or
prolapse
• Chamber enlargement
• Arrhythmias
• Conduction deficits on ECG
Nursing Implementation
• Prevention of rheumatic valvular disease
by diagnosing and treating streptococcal
infection and providing prophylactic
antibiotics for patients with history
• Patient with history of endocarditis must
also be treated with prophylactic
antibiotics
Nursing Implementation
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Teach when to seek medical treatment
Design activity to patient’s limitations
Discourage smoking
Avoid strenuous activity
Nursing assessment to monitor
effectiveness of medications
Nursing Implementation
• Medic Alert bracelet
• Teach importance of completing antibiotic
regimen
• Teach drug side effects
• INR for anticoagualtion therapy
• Follow-up care
Case Study
• Patient Profile:
• Mrs. S., a 54-year-old Hispanic woman, is admitted to the
hospital for valvular heart disease.
• Subjective Data
• Was told she had streptococcal throat infection as a child
• Was diagnosed 10 years ago with rheumatic heart disease
• Has shortness of breath at rest; cannot get out of bed
without becoming dyspneic
• Takes digoxin (0.25 mg once a day)
• Objective Data
• Physical Examination
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Ankle edema
Irregular pulse
Crackles at lung bases
Murmurs of mitral stenosis, mitral insufficiency, and aortic
insufficiency
• Diagnostic Studies
• Chest x-ray and ECG indicate enlarged left atrium
Case Study: Question #1
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Explain the cause of Mrs. S.’s
valvular heart disease. What
valves are most likely to become
involved with rheumatic heart
disease?
Case Study: Question #2
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Differentiate between the
characteristics of mitral stenosis
and mitral regurgitation.
Case Study: Question #3
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What other conservative treatment
measures might be initiated for
Mrs. S. (in addition to digoxin?)
Case Study: Question #4
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On the basis of the assessment
data provided, write one or more
nursing diagnoses.
Case Study: Question #5
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What are important nursing
measures for Mrs. S.?