Nursing 432: Perfusion & Heart Infections

• Nursing 432 Perfusion disorders include:
  • Infective Endocarditis
  • Cardiac Valvular Disorders
  • Cardiomyopathy
  • Aortic Aneurysms

Infectious Diseases of the Heart

• Any layer of the heart may be affected by an infectious process
• Diseases are named according to which layer of the heart is affected (epi-, myo-, endo-carditis)
• Diagnosis is based on symptoms and echocardiogram results
• Blood cultures can identify the infectious agent and monitor therapy
• Treatment involves appropriate antimicrobial therapy, requiring the full course
• Patient education is essential for infection prevention and health promotion

Infective Endocarditis (IE)

• IE involves infection of the inner heart layer, including the valves
• Antibiotic therapy has improved the prognosis in the past few years
• IE can be classified as subacute, acute, or by the cause or site of involvement
• Subacute IE involves preexisting valve disease and has a longer clinical course
• Acute IE affects healthy valves and is rapidly progressive
• Organisms causing IE include bacteria such as Strep and Staph, viruses, and fungi
• Key risk factors include age, IV drug use, prosthetic valves and the use of intravascular, cardiac devices, and renal dialysis

Clinical Manifestations of Infective Endocarditis

• Nonspecific signs/symptoms include:
  • Low-grade fever (90%)
  • Chills
  • Weakness
  • Malaise
  • Fatigue
  • Anorexia
• Subacute form signs/symptoms include:
  • Arthralgias
  • Myalgias
  • Back pain
  • Abdominal discomfort
  • Weight loss
  • Headache
  • Clubbing of fingers
• Other signs/symptoms include:
  • Murmur in most patients
  • Heart failure
  • Manifestations secondary to embolism include spleen, kidneys, limbs, brain, and lungs

Diagnostic Studies for Infective Endocarditis

• Obtain history
• Laboratory tests:
  • Blood cultures (30 min apart; 2 different sites)
  • CBC with differential (mild leukocytosis if acute type)
  • ESR, C-reactive protein (CRP)
• Echocardiography
• Chest x-ray (to check for cardiomegaly)
• ECG (check 1st or 2nd degree AV block)
• Cardiac catheterization checks valve function, if surgery is needed
• Major diagnostic criteria:
  • Requires at least two of the following:
    • Two positive blood cultures 12 hours apart
    • New or changed heart murmur
    • Positive mass or vegetation noted by echocardiogram

Infective Endocarditis: Nursing Implementation

• Administer antibiotic therapy for 4-6 weeks
• Assess home setting
• Monitor lab data, including blood cultures
• Assess IV lines
• Use coping strategies
• Prevent immobility issues: compression stockings, ROM, C&DB q2h
• Patient teaching regarding health promotion includes:
  • Disease background
  • Avoid people with infections, stress, and fatigue
  • Oral hygiene
  • Treatment program for IV drug use
  • Follow-up care and early treatment of common infections are critical
  • Monitor body temperature, notify provider for any recurrent infection symptoms (fever, chills, fatigue)
  • Complications include any stroke, pulmonary edema, and heart failure.

Valvular Heart Disease

• The heart has two atrioventricular valves: mitral and tricuspid
• The heart has two semilunar valves: aortic and pulmonic
• Types of valvular heart disease depend on the valve(s) affected
• Types of valvular heart disease depend on the type of functional alteration(s): stenosis or regurgitation
• Study focuses on the valves in the L side of the heart (mitral and aortic)

Valvular Heart Disease - Stenosis

• Stenosis is the constriction or narrowing of valves
• Valve orifice is smaller meaning forward blood flow is impeded
• Pressure differences reflect the degree of stenosis

Valvular Heart Disease - Regurgitation

• Regurgitation is the incompetence/insufficiency of valves
• Incomplete closure of valve leaflets
• Results in backward flow of blood

Mitral Valve Disease - Stenosis

• Adult causes:
  • Rheumatic heart disease (scarring of valve leaflets and chordae tendinae, adhesions between commissures of leaflets)
• Decreased blood flow from LA → LV, increased LA pressure and volume, increased pressure in pulmonary BVs
• Risk factor for atrial fibrillation
• Clinical manifestations:
  • Exertional dyspnea
  • Fatigue, chest pain (perfusion )
  • Seizures/stroke (emboli)
• Heart sounds include:
  • Loud S₁
  • Low-pitched diastolic murmur
  • Palpitations

Mitral Valve Disease - Regurgitation

• Damage occurs from MI, IE, mitral valve prolapse, chronic rheumatic heart disease, and ischemic papillary muscle
• Incomplete closure = Backward blood flow
• Acute MR: pulmonary edema
• Chronic MR: L atrial enlargement, ventricular hypertrophy = Decrease in CO
• Acute manifestations: thready peripheral pulses and cool, clammy extremities
• Chronic manifestations: asymptomatic for years until LV failure develops (weakness, fatigue)

Mitral Valve Prolapse

• Mitral valve leaflets prolapse up into left atrium during systole; unknown cause; familial incidence in some
• Usually benign (valve closes effectively); dx with echocardiography; treated with beta blockers or valve surgery if regurgitation
• Clinical manifestations: only 10%
  • Systolic murmur (regurgitation)
  • Dysrhythmias (palpitations, light-headed, dizzy)
  • Infective endocarditis can occur
  • Chest pain unresponsive to nitrates
• Teaching: healthy lifestyle (diet, hydration, exercise, avoid stimulants such as caffeine)

Aortic Valve Disease - Stenosis

• Congenital or degenerative
• Obstructs blood flow from LV to aorta, LV hypertrophy and ↑ myocardial O2 consumption, ↓ CO, pulm HTN, and HF
• Clinical manifestations: angina, syncope, DOE, murmur, S4
• Use nitro cautiously (reduces preload and BP, which can worsen chest pain)

Aortic Valve Disease - Regurgitation

• Can be acute or chronic
• Backward blood flow from aorta into LV
• Manifestations: acute AR
  • Severe dyspnea
  • Chest pain
  • Decreased BP, cardiogenic shock; life-threatening emergency
• Manifestations: chronic AR
  • Asymptomatic for years
  • LV dilation and hypertrophy
  • Decreased myocardial contractility
  • Pulmonary HTN and R HF
  • DOE
  • Orthopnea
  • PND
  • Angina; "water-hammer” pulse if severe, S3 or S4, murmur

Valvular Heart Disease Interprofessional Care

• Diagnosis:
  • Patient's history/physical exam
  • Chest CT or Xray
  • Echocardiogram
  • ECG
  • Cardiac cath
• Conservative treatment includes:
  • Prophylactic antibiotics to prevent recurrent RF, IE
  • Depends on valve involved and severity
  • Prevent exacerbations of HF, pulmonary edema, thromboembolism, recurrent endocarditis
• Meds to treat, control HF include:
  • Vasodilators (e.g., nitrates, ACE inhibitors)
  • Positive inotropes (e.g., digoxin)
  • Diuretics
  • ẞ-Adrenergic blockers
• Antidysrhythmic drugs, including Ca++ channel blockers

Valvular Heart Disease Interprofessional Care - Surgical Therapy

• Valve repair is the surgical procedure of choice
  • Lower mortality
  • May not restore total valve function
  • Includes Commissurotomy (valvulotomy)
  • Valvuloplasty: open; minimally invasive
  • Annuloplasty
• Valve Replacement can be mechanical or biologic
  • Mechanical (artificial) valve
  • Last longer; risk of thromboembolism
  • Long-term anticoagulation
• Biologic (tissue)
  • Bovine, porcine, and human
  • No anticoagulation but will need replaced faster

Aortic Aneurysms - Etiology and Risk Factors

• Causes:
  • Degenerative
  • Congenital
  • Mechanical (penetrating or blunt trauma)
  • Inflammatory
  • Infectious
• Risk Factors:
  • Increased age and in men
  • HTN and CAD
  • Family history
  • High cholesterol, ↑ BMI
  • Leg PAD, carotid artery disease, previous stroke
  • Smoking
  • Whites and Native Americans are at ↑ risk than African Americans, Hispanics, Asian

Aortic Aneurysms - Classification

• True aneurysm:
  • Wall of artery forms aneurysm
  • At least 1 vessel layer is still intact
  • Fusiform or saccular
• False aneurysm:
• Also called pseudoaneurysm
• Not an aneurysm
• Disruption of all layers of arterial wall: results in bleeding contained by surrounding

Aortic Aneurysm (AA)- Clinical Manifestations

• Thoracic AAs are:
  • Often asymptomatic
  • Most common manifestation: deep diffuse chest pain; may extend to interscapular area
• Ascending aorta/aortic arch symptoms include:
  • Angina, TIAS
  • Coughing and SOB
  • Hoarseness +/- dysphagia
  • If presses on superior VC: distended neck veins; face and arm edema
• Abdominal AA (AAA)
  • Often asymptomatic
  • Frequently detected on physical exam or treatment of other problem (i.e., CT scan, abdominal x-ray)
  • May mimic pain assoc. with abdominal or back disorders
  • May spontaneously embolize Causing “blue toe syndrome”: patchy mottling of feet/toes with palpable pedal pulses
  • DON'T PALPATE!

Aortic Aneurysm - Complications

• Rupture serious complication:
  • Rupture into retroperitoneal space with bleeding may be tamponaded by surrounding structures, thus preventing exsanguination and death with severe back pain
  • May/may not have back/flank ecchymosis (Grey Turner sign)
  • Rupture into thoracic or abdominal cavity with massive hemorrhage; most do not survive long enough to get to hospital

Aortic Aneurysm : EVAR: Interprofessional Care

• Endovascular Aneurysm Repair (EVAR) is an alternative to conventional surgery
• Sutureless aortic Dacron graft delivered via sheath and placed into abdominal aorta aneurysm via femoral artery cutdown
• Graft deployed against vessel wall by balloon inflation; anchored to vessel by series of small hooks
• Blood flows through graft; aneurysm shrinks over time since it cannot expand
• Advantages: less risk than surgery, shorter recovery, higher patient satisfaction, less cost
• Disadvantages: endoleak, aneurysm growth or rupture, aortic dissection, bleeding, infection

Aortic Aneurysm : Interprofessional Care

• Open surgical procedure includes:
  • If ruptured, emergency surgery with a 90% mortality from AAAS
  • Preop: hydration; stabilize electrolytes, coagulation, and hematocrit
  • Open aneurysm repair (OAR): incise diseased segment; remove intraluminal thrombus or plaque
  • Insert synthetic graft: Dacron or polytetrafluoroethylene (PTFE)
  • Suture native aortic wall around graft, which acts as a protective cover.

Nursing Management of AA: Postoperative Care

• Monitor cardiovascular status:
  • Continuous ECG monitoring
  • Electrolyte monitoring
  • ABG monitoring
  • O2 administration
  • Antidysrhythmic and antihypertensive meds
  • Pain control
  • Resume cardiac medications
• Monitor infection:
  • Antibiotic administration
  • Assess body temperature
  • Monitor WBC
  • Adequate nutrition
  • Observe surgical incision
• GI status:
  • Record NG tube output
  • Assess flatus; bowel sounds; signs of bowel ischemia (ileus, fever, abdominal distention, diarrhea, bloody stools)
• Nurologic
  • LOC
  • Pupile size and reaction to light
  • Facial Symmetry
  • Speech
  • Movement in extremeties
  • Quality of Hand Grasps
• Preripheral Perfusion:
  • Pulse Assessment- mark locations with felt tip pen
• Peripheral Perfusion
  • Extremity assessment, neurovascular status
  • May need doppler to assess
• Renal Perfusion:
  • Urinary output
  • Fluid intake
  • Daily weight
  • CVP/PA Pressure
  • Blood urea nitrogen/creatinine