Chapter 40: Inflammatory and Structural Heart Disorders - Nursing

Chapter 40 INFL AMMATORY AND STRUCTURAL HEART DISORDERS ENDOCARDITIS PERICARDITIS VALVE DISEASE CH 40  Infective Endocarditis (IE) Disease of the endocardium and the heart valves IE - poor prognosis and a decreased life expectancy Increase in the number of cases of IE ◦ largely related to an incr...

Chapter 40 INFL AMMATORY AND STRUCTURAL HEART DISORDERS ENDOCARDITIS PERICARDITIS VALVE DISEASE CH 40  Infective Endocarditis (IE) Disease of the endocardium and the heart valves IE - poor prognosis and a decreased life expectancy Increase in the number of cases of IE ◦ largely related to an increase in IV drug use Main risk factors ◦ History of IE----IV drug use----Prosthetic valve ◦ Health care–associated infection from use of an intravascular device ◦ Methicillin-resistant S. aureus (MRSA) ◦ Renal dialysis 2 Etiology and Pathophysiology Occurs in 3 stages ◦ Bacteremia ◦ Adhesion ◦ Vegetation ◦Fibrin, leukocytes, platelets, and microbes ◦Stick to the valve or endocardium ◦Parts break off and enter circulation (embolization) ◦Left-sided vegetation can move to brain, kidneys, spleen, and extremities ◦Right-sided vegetation can move to lungs (PE) 3  Clinical Manifestations- Assessment Nonspecific, involve multiple organ systems ◦Fever ◦Chills ◦Weakness ◦Malaise ◦Fatigue ◦Anorexia 4  Clinical Manifestations- Assessment Subacute form Heart failure ◦Arthralgias Manifestations secondary to septic ◦Myalgias embolism ◦Back pain ◦Splinter hemorrhages in nail beds ◦Abdominal discomfort ◦Petechiae ◦Weight loss ◦Osler’s nodes on fingertips or toes ◦Headache ◦Janeway’s lesions on fingertips, ◦Clubbing of fingers palms, soles of feet, and toes ◦Roth’s spots Vascular manifestations New/worse systolic murmur 5 Diagnostic Studies Health history-3-6 months/dental, surgical, gyn, IVDA, implants, infections, dialysis Laboratory tests ◦ Blood cultures-multiple sites ◦ CBC with differential ◦ ESR, C-reactive protein (CRP) Echocardiography Duke criteria for major and minor critieria 6  Interprofessional Care Prophylactic antibiotics - high skin, skin structures, or musculoskeletal tissue risk Heart conditions Active Infection Treatment ◦ CHD ◦ Accurate identification of organism ◦ Valvular disease ◦ Blood cultures ◦ Hx of IE ◦ IV antibiotics (long-term) ◦ Prosthetic Valve ◦ Repeat blood cultures Procedures ◦ Valve replacement if needed ◦ Certain dental procedures ◦ Antipyretics ◦ Respiratory tract incisions ◦ Fluids ◦ Tonsillectomy and adenoidectomy ◦ Rest ◦ Surgical procedures involving infected 7 Nursing Assessment Subjective data: History-FHP ◦ IVDA---Alcohol use ◦ Meds/Drugs—Immunosuppressive therapy ◦ Weight changes---Chills---Night sweats ◦ Hematuria ◦ Exercise intolerance, weakness, fatigue ◦ Cough, DOE, orthopnea, palpitations ◦ Pain, headache, joint, or muscle tenderness Objective-Clinical Manifestation slide and table 8 Nursing Clinical Problems and Planning 1) Impaired cardiac output 2) Infection 3) Fatigue 4) Substance use PLANNING Overall goals include ◦ Normal or baseline function ◦ Ability to perform ADLs without fatigue ◦ Understanding of the treatment plan to prevent recurrence 9  Nursing Implementation Health promotion ◦ Identify those at high risk ◦ Assess history and understanding of disease process ◦ Teach importance of adherence to treatment regimen Patient teaching ◦ Stress need to avoid people with infections ◦ Avoidance of stress and fatigue ◦ Plan rest periods ◦ Good oral hygiene ◦ Schedule regular dental visits ◦ Prophylactic antibiotics ◦ Drug rehabilitation 10  Nursing Implementation Ambulatory care & Discharge Planning ◦ Antibiotic therapy for 4 to 6 weeks ◦ Assess home setting ◦ Monitor laboratory data, including blood cultures ◦ Assess IV access and long-term lines ◦ Coping strategies ◦ Adequate rest ◦ Moderate activity ◦ Compression stockings ◦ ROM exercises ◦ Deep breath and cough every 2 hours 11  Nursing Implementation & Evaluation Patient teaching ◦ Monitor body temperature ◦ Signs and symptoms of complications ◦ Nature of disease and how to reduce risk of reinfection ◦ Stress follow-up care, good nutrition, prompt treatment of common infections ◦ Signs and symptoms of infection ◦ Need for prophylactic antibiotic therapy Evaluation Expected outcomes are that the patient will ◦ Maintain adequate tissue and organ perfusion ◦ Maintain normal body temperature ◦ Report an increase in physical and emotional comfort 12  Pericarditis Pericardial Sac inflammation and fluid accumulation Normal = 10-15 mL volume Causes Infectious-Bacterial, fungal, viral Noninfectious-MI, Cancers, Aortic Dissection, renal failure, trauma Autoimmune-Meds, Post-Op, RF, RA, SLE, Scleroderma, AS Dressler Syndrome = Post MI irritation and fluid 4-6 weeks after 13 Clinical Manifestation Chest Pain Worse with deep inspiration and lying flat Radiation arm, neck, shoulder, upper back Tachypnea, shallow breathing, coughing, hiccups Pericardial friction tub-left lower sternum when forward Complications Pericardial effusion leading to Tamponade ◦ Compression of the heart preventing filling volumes-Low CO ◦ Muffled heart sounds, tachycardia, JVD, 14 Diagnostics EKG—diffuse ST segment elevation-not like an MI CXR-enlargement of silouette Echocardiogram CT MRI Labs ◦ CBC, CRP, ESR, Troponin ◦ Pericardial fluid testing, cultures and biopsy 15 Interprofessional Care Treat cause Antibiotics NSAIDS-initially Corticosteroids-autoimmune Procedures Pericaridocentesis Pericarcial window 16 Nursing Management Pain management ◦ GI monitoring Position of comfort ◦ Bed rest, HOB elevated 45degrees-leaning forward Monitor VS and CO for tamponade 17  Valvular Heart Disease Heart has 2 atrioventricular valves Mitral Tricuspid 2 semilunar valves Aortic Right Left Pulmonic Fig. 35.1 18 Valvular Heart Disease Stenosis (constriction/narrowing) ◦ Valve opening is smaller ◦ Forward blood flow is impeded ◦ Pressure differences on the two sides of the valve reflect degree of stenosis Regurgitation (incompetence or insufficiency) ◦ Incomplete closure of valve leaflets ◦ Results in backward flow of blood Either can lead to heart failure… 19 Mitral Valve Stenosis Most common cause ◦ rheumatic heart disease = scarring and contractures Results in decreased blood flow from left atrium to left ventricle Increased pressure LA and Pulmonary system Clinical manifestations = Think “Left side of Heart” ◦ Exertional dyspnea ◦ Loud S1 ◦ Diastolic murmur ◦ Fatigue Fig. 40.7 C,D ◦ Palpitations ◦ Hoarseness, hemoptysis ◦ Atrial fibrillation with risk for stroke 20  Mitral Valve Regurgitation Damage caused by: MI, Chronic rheumatic heart disease, Mitral valve prolapse, Ischemic papillary muscle Clinical manifestations = dysfunction, IE Think “Left side of Heart” Incomplete valve closure  Backward flow Acute MR ◦ Pulmonary edema ◦ Untreated- cardiogenic shock ◦ Thready peripheral pulses --Cool, clammy extremities Chronic MR ◦ Left atrial enlargement, ventricular dilation, eventual ventricular hypertrophy, decreased CO ◦ Weakness, fatigue, palpitations, dyspnea, PND, edema, S3, Murmur 21  Mitral Valve Prolapse Abnormality--Leaflets prolapse back into left atrium during systole Clinical manifestations--Most asymptomatic for life--Only 10% with symptoms ◦ Murmur d/t regurgitation ◦ Severe MR uncommon ◦ Dysrhythmias can cause palpitations, light-headedness, and syncope ◦ Infective endocarditis—Prophylaxis needed ◦ Chest pain unresponsive to nitrates Treat symptoms with β-blockers Valve surgery for MR if develops Teaching Plan and Education 22  Aortic Valve Stenosis Congenital aortic stenosis (AS) generally found in childhood, adolescence, or young adulthood In adults-degenerative or caused by rheumatic fever Obstruction of blood flow from left ventricle to aorta Left ventricular hypertrophy and increased myocardial oxygen consumption Decreased CO leads to decreased tissue perfusion, pulmonary hypertension, and HF ◦Poor prognosis if left untreated 23  Aortic Valve Stenosis Clinical manifestations ◦ Can worsen chest pain ◦ Angina ◦ Syncope ◦ Exertional dyspnea Auscultatory findings ◦ Normal to soft S1 ◦ Decreased or absent S2 ◦ Systolic murmur with radiation to the carotids ◦ Prominent S4 Use nitroglycerin cautiously ◦ Reduces preload and BP 24 Aortic Valve Regurgitation Acute AR ◦ IE, trauma, or aortic dissection ◦ Life-threatening emergency Chronic AR ◦ Rheumatic heart disease, congenital bicuspid aortic valve, syphilis, connective tissue problem, or post- surgical cause Backward blood flow from ascending aorta into left ventricle With chronic AR, left ventricular dilation and hypertrophy Decrease in myocardial contractility Pulmonary hypertension and right ventricular failure 25  Aortic Valve Regurgitation Clinical manifestations of acute AR Clinical manifestations of chronic AR ◦ Severe dyspnea ◦ May be asymptomatic for years ◦ Chest pain ◦ Exertional dyspnea, orthopnea, paroxysmal ◦ Hypotension dyspnea ◦ Cardiogenic shock ◦ Angina ◦ Life-threatening emergency ◦ Soft or absent S1 ◦ S3 or S4 ◦ Murmur ◦ Water-hammer pulse if severe ◦ https://www.youtube.com/watch?v=6mqJUU12POY 26  Right Sided Heart Valves TRICUSPID--Almost usually caused by (TOF) rheumatic fever ◦ Congenital valve disease Clinical manifestations Stenosis--Almost always congenital ◦ Fluttering discomfort in neck ◦ Fatigue Causes right ventricular hypertension and hypertrophy ◦ Right upper quadrant pain Clinical manifestations ◦ Syncope PULMONIC ◦ Dyspnea ◦ Angina Regurgitation--Often asymptomatic-Can cause RV dilation. Often asymptomatic until adulthood Potential causes ◦ Pulmonary hypertension ◦ Surgical repair of tetralogy of Fallot 27 Valvular Heart Disease Diagnostic Studies History and physical assessment Real-time 3-D echocardiography TEE Doppler color flow Chest x-ray ECG Heart catheterization 28  Valvular Heart Disease Interprofessional Care Conservative therapy ◦ Dependent on valve involved and disease ◦ Drugs to treat/control HF severity ◦ Prevent exacerbations of HF, pulmonary ◦ Vasodilators (e.g., nitrates, ACE edema, thromboembolism, and recurrent RF inhibitors) and IE ◦ Positive inotropes (e.g., digoxin) ◦ Prophylactic antibiotic therapy to prevent recurrent RF and IE ◦ Diuretics ◦ β-blockers ◦ Low sodium diet ◦ For atrial dysrhythmias ◦ Calcium channel blockers, β-blockers ◦ Anti-dysrhythmic drugs ◦ Anticoagulation therapy for A-fib 29 Surgical therapy Percutaneous transluminal balloon valvuloplasty (PTBV) Split open fused commissures Treats mitral, tricuspid, and pulmonic, and AS Balloon-tipped catheter inserted via femoral artery Inflated to separate valve leaflets Valve repair Preferred surgical procedure Lower operative mortality rate than replacement May not restore total valve function Commissurotomy (valvulotomy) Valvuloplasty Annuloplasty Valve replacement-Mechanical or Biological Transcatheter aortic valve replacement (TAVR) For severe AS Fig. 40.9 Transfemoral approach 30  Valvular Heart Disease Interprofessional Care Valve replacement ◦Biologic (tissue) ◦ Mechanical (artificial) ◦ Bovine, porcine, and human ◦ More durable, last longer ◦ More natural blood flow ◦ Risk of thromboembolism ◦ No anticoagulation required ◦ Require long-term anticoagulation ◦ Less durable 31  Nursing Assessment Subjective data Objective data ◦ Medical history or implanted devices ◦ S3 and S4 ◦ IVDA, fatigue ◦ Dysrhythmias ◦ Palpitations, weakness, activity ◦ Increase or decrease in pulse pressure intolerance, dizziness, fainting ◦ Hypotension ◦ DOE, cough, hemoptysis, orthopnea, PND ◦ Water-hammer or thready peripheral ◦ Angina or atypical chest pain pulses ◦ Hepatomegaly, ascites Objective data ◦ Weight gain ◦ Fever ◦ Diaphoresis, flushing, cyanosis, clubbing, peripheral edema ◦ Crackles, wheezes, hoarseness 32  Clinical Problems and Planning Impaired cardiac function Fatigue Fluid imbalance Patient goals ◦ Normal heart function ◦ Improved activity tolerance ◦ Understanding of the disease process and health maintenance measures 33 Nursing Implementation Health promotion ◦ Early treatment of streptococcal infections ◦ Prophylactic antibiotics for patients with history ◦ Teach patient symptoms to report Individualize rest and exercise--Limit activities Discourage tobacco use Ongoing monitoring and drug effectiveness Monitor INR for patient on anticoagulants 34  Nursing Implementation and Evaluation Patient teaching---Medical-alert device or bracelet ◦ Drug actions and side effects---prophylactic antibiotic therapy ◦ Information related to anticoagulation therapy Follow-up care --Notify HCP for ◦ Signs of infection, HF, or bleeding ◦ Planned invasive or dental work Expected patient outcomes ◦ Maintain adequate tissue and organ perfusion ◦ Achieve fluid balance ◦ Achieve optimal level of activity ◦ Describe disease process and measures to prevent complications 35  CARDIOMYOPATHY Cardiomyopathy (CMP) group of diseases that directly affect the structure or function of the myocardium. CMP classification ◦ primary-etiology of the heart disease is unknown ◦ Secondary-known myocardial disease is known and causes CMP Dilated-acute or chronic onset due to infection or other processes ◦ Vent. Dilation, impaired systole, atrial enlargement, stasis of blood in LV Hypertrophic-Asymmetric LEFT Ventricular Hypertrophy (no dilation) ◦ Impaired diastolic LV filling (unable to relax)-Obstructed LV outflow ◦ Most common cause of Sudden cardiac death (SCD) in young/athletes Restrictive-impaired diastolic filling and stretch (uncommon) ◦ Impaired diastolic filling and stretch with normal systole ◦ Unknown etiology  Cardiomyopathy Causes Dilated – more severely ill Restrictive – exercise intolerance ◦ Cardiotoxic agents: alcohol, cocaine, Amyloidosis doxorubicin Endomyocardial fibrosis ◦ Coronary artery disease Hypertension Neoplastic tumor ◦ Genetic (autosomal dominant) Post-radiation therapy ◦ Metabolic disorders Muscular dystrophy Sarcoidosis ◦ Myocarditis Ventricular thrombus ◦ Pregnancy ◦ Valve disease Hypertrophic-males, SCD Aortic stenosis Genetic (autosomal dominant) Hypertension  Cardiomyopathy Diagnostic Assessment History and physical examination Electrocardiogram b-Type natriuretic peptide (BNP) Chest x-ray Echocardiogram Nuclear imaging studies Heart catheterization Endomyocardial biopsy  Cardiomyopathy Assessment S&S Progresses to Heart Failure ◦ Decreased exercise capacity, Fatigue CH ◦ Dyspnea at rest and PND and Orthopnea ◦ Dry cough F ◦ Palpitations S& ◦ Abdominal bloating, hepatomegaly, JVD ◦ nausea vomiting anorexia ◦ S3, S4, murmurs S ◦ Dysrhythmias ◦ Pulmonary crackles ◦ Edema ◦ Weak peripheral pulses ◦ Pallor ◦ Blood flow stasis causes can lead to embolization  Cardiomyopathy Management Drug therapy Nitrates (except in hypertrophic CMP) β-Blockers Antidysrhythmics ACE inhibitors Diuretics Digitalis (except in hypertrophic unless atrial fibrillation) Anticoagulants (if indicated) Surgical intervention and devices Ventricular assist device Cardiac resynchronization therapy Implantable cardioverter-defibrillator Surgical repair Heart transplantation Cardiac rehabilitation Palliative and hospice care  Nursing Care plan for Cardiomyopathy EXAMPLES Decreased cardiac output related to CMP as evidenced by murmurs, dyspnea, dysrhythmias, and/or peripheral edema Excess fluid volume related to fluid retention secondary Congestive heart failure as evidenced by peripheral edema, weight gain, adventitious breath sounds, and/or neck vein distention Activity intolerance related to insufficient oxygenation secondary to decreased cardiac output and pulmonary congestion as evidenced by weakness, fatigue, shortness of breath, increase or decrease in pulse rate, and/or BP changes Care is like that of Heart Failure Identify interventions for each nursing diagnosis Table 40.17 Patient Teaching