Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders PDF

4068_Ch23_432-461 18/11/14 4:42 PM Page 432 23 KEY TERMS Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders annuloplasty (AN-yoo-loh-PLAS-tee) beta-hemolytic streptococci (BAY-tuh-HEE-moh-LIT-ick STREP-toh-KOCK-eye) cardiac tamponade (KAR-dee-yak TAM...

4068_Ch23_432-461 18/11/14 4:42 PM Page 432 23 KEY TERMS Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders annuloplasty (AN-yoo-loh-PLAS-tee) beta-hemolytic streptococci (BAY-tuh-HEE-moh-LIT-ick STREP-toh-KOCK-eye) cardiac tamponade (KAR-dee-yak TAM-pon-AYD) cardiomegaly (KAR-dee-oh-MEG-ah-lee) cardiomyopathy (KAR-dee-oh-my-AH-pah-thee) chorea (core-REE-ah) commissurotomy (KOM-ih-shur-AHT-oh-mee) Dressler syndrome (DRESS-lers SIN-drohm) emboli (EHM-boh-lye) infective endocarditis (in-FEK-tive EN-doh-kar-DYE-tiss) insufficiency (IN-suh-FISH-en-see) international normalized ratio (IN-ter-NASH-uh-nul NOR-muh-lized RAY-she-oh) murmur (MUR-mur) myectomy (my-EK-tuh-mee) myocarditis (MY-oh-kar-DYE-tiss) pericardial effusion (PEAR-ih-KAR-dee-uhl ee-FYOOzhun) pericardial friction rub (PEAR-ih-KAR-dee-uhl FRICKshun RUB) pericardiectomy (PEAR-ih-kar-dee-EK-tuh-mee) pericardiocentesis (PEAR-ih-KAR-dee-oh-sen-TEE-siss) pericarditis (PEAR-ih-kar-DYE-tiss) petechiae (peh-TEE-kee-eye) regurgitation (ree-GUR-jih-TAY-shun) rheumatic fever (roo-MAT-ick FEE-vur) stenosis (steh-NOH-siss) thrombophlebitis (THROM-boh-fleh-BYE-tiss) valvotomy (val-VAW-tuh-mee) valvuloplasty (VAL-vyoo-loh-PLASS-tee) 432 TERRI BLEVINS LEARNING OUTCOMES 1. Explain the pathophysiology, etiology, signs and symptoms, and diagnostic tests for each of the valvular disorders. 2. Plan nursing care for a patient with a valvular disorder. 3. Compare and contrast the differences between commissurotomy, annuloplasty, and valve replacement. 4. Identify postoperative complications that can occur for the two types of cardiac valve replacements. 5. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for infective endocarditis, pericarditis, and myocarditis. 6. Explain the pathophysiology, etiology, signs and symptoms, complications, diagnostic tests, therapeutic measures, and nursing care for dilated, hypertrophic, and restrictive cardiomyopathy. 7. Explain the pathophysiology, etiology, signs and symptoms, complications, diagnostic tests, and therapeutic measures for thrombophlebitis. 8. List risk factors and prevention measures for thrombophlebitis. 9. Plan nursing care for thrombophlebitis. 4068_Ch23_432-461 18/11/14 4:42 PM Page 433 Chapter 23 Nursing Care for Valvular, Inflammatory, Infectious Cardiac or Venous Disorders CARDIAC VALVULAR DISORDERS LEARNING TIP Within the normal heart, blood flows in one direction because of the presence of heart v alves. There are four valves in the heart: mitral, tricuspid, pulmonic, and aortic (see Fig. 21.2). The chordae tendineae and papillary muscles are attachment structures for both the mitral and tricuspid v alves. They ensure that these valves close tightly. Damage to the valves or their surrounding structures can result in abnormal v alvular functioning (Fig. 23.1). The valves of the left side of the heart are most commonly affected. Forward blood flo w is hindered if the v alve is narrowed, or stenosed, and does not open completely. If the valve does not close completely , blood backs up; this is referred to as regurgitation or insufficiency. The abnormal blood flow increases the workload of the heart and increases the pressures in the affected heart chamber. Valvular damage may result from congenital defects, rheumatic fever, or infections. Rheumatic fever occurs as an autoimmune reaction to an upper respiratory (sore throat) group A beta-hemolytic streptococci infection. Two to 3 weeks after the streptococcal infection, rheumatic fever occurs. Although rheumatic fever can occur at an y age, it typically occurs between ages 5 and 15. Rheumatic fe ver and subsequent rheumatic heart disease and valvular damage can be pre vented by detecting and treating streptococcal infections promptly with penicillin. A throat culture is used to diagnose a streptococcal infection at the time of the infection. It is a rare complication of strep throat in the United States. Signs and symptoms include polyarthritis, subcutaneous nodules, chorea (brief, rapid, uncontrolled mo vements), carditis, fever, arthralgia, and pneumonitis. Rheumatic heart disease may not be evident for years after rheumatic fever. Valvular disorders are summarized in Table 23.1 and discussed in more detail in the following sections. Cusps Fusion of cusps preventing complete opening and emptying of heart chamber Normal valve in open position The opening of a stenosed valve and an insufficient valve look very similar, and the results of extra blood building up in a chamber are the same (see Fig. 23.1). However, the pathophysiology is different. Think of what the defect is in each disorder to understand why the blood is building up in that particular chamber. A stenosed valve does not open fully which does not allow the heart chamber to empty normally causing blood to build up in that chamber. Therefore, mitral stenosis does not allow the left atrium to empty easily, so blood builds up in the left atrium. An insufficient valve does not close fully, allowing blood to flow back into the chamber that is supposed to empty. Blood continues to build up in that chamber as a result. For example, mitral insufficiency allows blood to backflow from the left ventricle into the left atrium after the left atrium has emptied, resulting in blood buildup in the left atrium. Mitral Valve Prolapse Pathophysiology During ventricular systole, as pressure in the left v entricle rises, the flaps of the mitral valve normally remain closed and • WORD • BUILDING • regurgitation: re—again + gurgitare—to flood insufficiency: in—not + sufficiens—sufficient stenosis: stenos—narrow Cusps Opening of valve Opening of valve Opening of valve Stenosed valve in open position 433 Normal valve in closed position FIGURE 23.1 Openings of stenosed and insufficient valves compared with a normal valve. Insufficient valve in closed position allowing backflow of blood through the valve 4068_Ch23_432-461 18/11/14 4:42 PM Page 434 434 UNIT FIVE Understanding the Cardiovascular System TABLE 23.1 CARDIAC VALVULAR DISORDERS SUMMARY Valve Disorder Mitral valve prolapse Signs and Symptoms None Murmur Chest pain Palpitations Dizziness Syncope Fatigue Dyspnea Diagnostic Tests Echocardiography Cardiac catheterization Complications Emboli Infective endocarditis Therapeutic Measures None Beta blockers Antidysrhythmics Valvuloplasty Valve replacement Priority Nursing Diagnoses Activity Intolerance Decreased Cardiac Output Mitral stenosis None Murmur Chest pain Palpitations Fatigue Exertional dyspnea Cough Hemoptysis ECG Chest x-ray Echocardiography Doppler ultrasound TEE Cardiac catheterization Emboli Heart failure Anticoagulants None PBV Valvuloplasty Valve replacement Activity Intolerance Decreased Cardiac Output Mitral regurgitation None Murmur Chest pain Palpitations Fatigue Exertional dyspnea Cough Hemoptysis Acute: Pulmonary edema Shock ECG Chest x-ray Echocardiography Doppler ultrasound TEE Cardiac MRI Cardiac catheterization Emboli Heart failure None ACEI Anticoagulants Valvuloplasty Valve replacement Activity Intolerance Decreased Cardiac Output Aortic stenosis None Angina Murmur Syncope Heart failure ECG Chest x-ray Echocardiography Serial echocardiogram Cardiac catheterization Heart failure Valve replacement: surgical or transcatheter Activity Intolerance Decreased Cardiac Output Aortic regurgitation None Forceful pulse Murmur Chest pain Palpitations Fatigue Exertional dyspnea Corrigan’s pulse Diaphoresis ECG Chest x-ray Echocardiography Cardiac catheterization Heart failure Valve replacement Digitalis (Lanoxin) Diuretics Vasodilators Activity Intolerance Decreased Cardiac Output Note. ACEI = angiotensin-converting enzyme inhibitor; ECG = electrocardiogram; PBV = percutaneous balloon valvuloplasty; TEE = transesophageal endoscopy. 4068_Ch23_432-461 18/11/14 4:42 PM Page 435 Chapter 23 Nursing Care for Valvular, Inflammatory, Infectious Cardiac or Venous Disorders stay within the atrioventricular junction. In mitral valve prolapse (MVP), however, one or both flaps bulge backward into the left atrium (like a parachute) during systole. This can happen when one flap is too lar ge or if a defect occurs in the chordae tendineae that secure the v alve to the heart w all. If the bulging flaps do not fit together, blood can leak backward into the left atrium (mitral regurgitation). Increased pressure on the papillary muscles results in ischemia within the muscle, causing further dysfunction of the mitral valve. Etiology MVP can be due to a hereditary collagen tissue disorder, with unknown etiology, an infection damaging the mitral v alve, ischemic heart disease, or cardiomyopathy. MVP is the most common form of valvular heart disease. It typically occurs in women, mainly from ages 15 to 30, who are thin and ha ve slight chest deformities. Signs and Symptoms Most patients with MVP do not have symptoms, and prognosis is very good (see Table 23.1). MVP severity ranges from having a murmur to chordae tendineae rupture with mitral regurgitation. The murmur, which is best heard at the heart ape x, begins midsystolic and becomes more intense until the end of systole. Symptoms may include atypical chest pain not related to exertion, dysrhythmias causing palpitations, dizziness or syncope, fatigue, dyspnea, or anxiety. Complications Rare complications include mitral re gurgitation, dysrhythmias, heart failure (HF), or infective endocarditis. 435 Therapeutic Measures Unless patients have severe mitral regurgitation, MVP is a benign disorder. No treatment is needed unless symptoms are present (Box 23-2). The severity of MVP and symptoms produced determine the treatment used. A healthy lifestyle, including a good diet, e xercise, stress management, and avoidance of stimulants and caffeine, can be important to prevent symptoms. Beta blockers reduce the heart rate and may help relieve chest pain. Aspirin or anticoagulants may be ordered to help prevent formation of blood clots on the v alve. Surgical repair or replacement of the v alve can be done for severe cases of MVP. (See Box 23-2 and the sur gical interventions section later in the chapter.) CRITICAL THINKING Mrs. Tepley ■ Mrs. Tepley, age 32, has MVP and reports palpitations whenever she experiences stress. She drinks three cups of coffee daily. 1. What might you hear when auscultating Mrs. Tepley’s heart sounds? 2. Why does Mrs. Tepley experience palpitations? Would experiencing palpitations make you fearful? 3. What patient-centered information does Mrs. Tepley need to manage her MVP? Suggested answers are at the end of the chapter. Diagnostic Tests Auscultation for a click caused by the stress on the chordae tendineae or valve leaflets when they prolapse, or a murmur (if blood is leaking backward), is the first diagnostic step for MVP. Other diagnostic tests are used when MVP is suspected (Box 23-1). A normal electrocardiogram (ECG) is usually seen with MVP , although in verted (downward) T waves (indicating ischemia) may be seen (see Fig. 25.7). A twodimensional echocardiogram with Doppler can sho w valve abnormalities and identify mitral regurgitation from MVP. For more severe cases, cardiac catheterization can sho w the bulging flaps of the mitral valve on a coronary angiogram. Box 23-1 Diagnostic Tests for Cardiac Valvular Disorders • History and physical examination • Electrocardiogram • Chest x-ray examination • Echocardiography • Cardiac catheterization Box 23-2 Therapeutic Measures for Cardiac Valvular Disorders • Rheumatic fever prophylaxis • Prophylactic antibiotic therapy per high-risk infective endocarditis criteria • Anticoagulant therapy • Medication therapy • Digitalis • Diuretics • Angiotensin-converting enzyme inhibitors • Beta blockers • Antidysrhythmics • Percutaneous balloon valvuloplasty • Surgery • Valvuloplasty • Closed commissurotomy • Open commissurotomy • Annuloplasty • Valve replacement 4068_Ch23_432-461 18/11/14 4:42 PM Page 436 436 UNIT FIVE Understanding the Cardiovascular System Mitral Stenosis Pathophysiology Mitral stenosis results from thick ening of the mitral v alve flaps and shortening of the chordae tendineae, causing narrowing of the mitral valve opening. Older patients with mitral stenosis usually have calcification and fibrosis of the mitral valve flaps. The narrowed opening obstructs blood flow from the left atrium into the left ventricle. The left atrium enlarges to hold the extra blood volume caused by the obstruction. As a result of this increased blood volume, pressure rises in the left atrium. Pressures then rise in the pulmonary circulation and the right ventricle as blood volume backs up from the left atrium. The right ventricle dilates to handle the increased volume. Eventually the right ventricle fails from this excessive workload, reducing the blood v olume delivered to the left ventricle and subsequently decreasing cardiac output. Etiology The major cause of mitral stenosis is rheumatic fever. It often takes two to four decades after the illness for symptoms to appear. Because rheumatic fever is rare in developed nations, less mitral stenosis is being seen e xcept in older adults who were e xposed to rheumatic fe ver as children. Mitral stenosis is still a problem in underde veloped areas where rheumatic fever still occurs. Less common causes include congenital defects of the mitral v alve, tumors, rheumatoid arthritis, systemic lupus erythematosus, and calcium deposits. Signs and Symptoms Patients may be asymptomatic (see Table 23.1). A click or low-pitched murmur may be heard. This murmur is a rumbling sound over the heart apex during diastole and is more pronounced right before systole. Pulmonary symptoms, such as exertional dyspnea, cough, hemoptysis (bloody sputum), and respiratory infections can occur. Fatigue, intolerance to activity, dizziness, or syncope result from decreased cardiac output. Edema of ankles and feet may be present. P alpitations from atrial flutter or fibrillation caused by atrial enlar gement and chest pain from decreased cardiac output may be experienced. mitral valve opening and decreased motion of the v alve. Computed tomography (CT) scan and magnetic resonance imaging (MRI) may be done. A cardiac catheterization is typically done only if needed to v alidate unclear echocardiography results for preoperative evaluation or postprocedure for symptom recurrence. Therapeutic Measures No treatment is needed if symptoms are not present. Moni toring of the stenosis is done to provide invasive treatment if needed. Anticoagulants are given to patients at risk of development of emboli from stasis of blood in the atrium. Atrial fibrillation, an irre gular heart rhythm, may de velop and require treatment. For HF, symptoms are treated with medications (see Chapter 26). For less severe cases, percutaneous balloon valvuloplasty, which uses a balloon to dilate the stenosed heart valve, is done in a cardiac catheterization lab (Fig. 23.2). Surgical treatment can include valvular repair (valvuloplasty), but mitral valve replacement is typically needed (Fig. 23.3; see Box 23-2). Mitral Regurgitation Pathophysiology Mitral regurgitation, or insufficiency, is the incomplete closure of the mitral valve leaflets. It allows backflow of blood into the left atrium with each contraction of the left ventricle. This blood is then extra volume that is added to the incoming blood from the lungs. With chronic mitral regurgitation, the increase in blood volume dilates and increases pressure in the left atrium. In response to the e xtra blood volume delivered by the left atrium, the left ventricle compensates by dilating. If the compensatory mechanism of dilation is inadequate, pressures rise in the pulmonary circulation and then in the right ventricle as blood volume backs up from the left atrium. The left ventricle and eventually the right ventricle may fail from this increased strain. Complications Emboli can form from the stasis of blood in the left atrium and may cause stroke and seizures. If the right ventricle fails, symptoms related to HF are seen (see Chapter 26). Pulmonary edema may develop from the backup of blood into the lungs. Diagnostic Tests Mitral stenosis is diagnosed with data from the patient history and physical examination and findings from diagnostic tests (see Box 23-1). The ECG shows enlargement of the left atrium and right v entricle and changes in the P w aveform (see Fig. 25.2). Atrial flutter or fibrillation may be seen (see Chapter 25). A chest x-ray e xamination confirms enlargement of the af fected heart chambers. Transthoracic two-dimensional color flow Doppler echocardiography and Doppler ultrasound are the nonin vasive gold standard for evaluation of v alvular disease. They show the narro wed FIGURE 23.2 Percutaneous balloon valvuloplasty. 4068_Ch23_432-461 18/11/14 4:42 PM Page 437 Chapter 23 Nursing Care for Valvular, Inflammatory, Infectious Cardiac or Venous Disorders 437 and regurgitation of blood. Cardiac MRI may be used for some people to determine treatment approaches. Cardiac catheterization further identifies regurgitation effects. Therapeutic Measures Mechanical mitral valve Without symptoms, there is no general medical treatment. Angiotensin-converting enzyme (ACE) inhibitors are often used to reduce afterload. If atrial fibrillation with rapid heart rate is present, it can be controlled with digitalis, calcium channel blockers, or beta blockers. Anticoagulants are used for emboli prevention. Symptoms of HF are treated with therapies for HF (see Chapter 26). When symptoms develop or surgery is indicated to prevent further left ventricular dysfunction, mitral valve repair or replacement is done. F or acute mitral regurgitation, emergency surgery may be needed (see Box 23-2). Aortic Stenosis Pathophysiology FIGURE 23.3 Mitral valve replacement with mechanical valve. Etiology Causes of mitral re gurgitation include rheumatic heart disease, endocarditis, rupture or dysfunction of the chordae tendineae or papillary muscle, MVP, hypertension, myocardial infarction (MI), cardiomyopathy, annulus calcification, aging, or congenital defects. Signs and Symptoms Initially, patients may be asymptomatic; however, symptoms may develop gradually and are similar to those of mitral stenosis (see Table 23.1). A murmur begins with S1 (first heart sound) and continues during systole up to S 2 (second heart sound). Exertional dyspnea (shortness of breath), f atigue, syncope (feeling faint), cough, and edema may occur. Palpitations and an irre gular pulse due to atrial f ibrillation may result. Weakness from decreased cardiac output occurs if the left ventricle begins to fail. If acute mitral re gurgitation develops, as in papillary muscle rupture follo wing MI, pulmonary edema and shock symptoms will be exhibited. Complications Atrial fibrillation may develop from the enlargement of the left atrium. Pulmonary hypertension or heart failure may occur (see Chapter 26). Endocarditis is a risk due to the damaged valve. Diagnostic Tests A patient history and physical e xamination are done. The ECG shows enlargement of the left atrium and left ventricle and changes in the P waveform (see Fig. 25.2). Atrial flutter or fibrillation may be seen. A chest x-ray e xamination confirms hypertrophy of the af fected heart chambers. Twodimensional echocardiography with Doppler or transesophageal echocardiography shows left atrial enlar gement Blood flow from the left ventricle into the aorta is obstructed through the stenosed aortic valve. The opening of the aortic valve may be narrowed from thickening, scarring, calcification, or fusing of the v alve’s flaps. To compensate for the difficulty in ejecting blood into the aorta, the left v entricle contracts more forcefully. In chronic stenosis, the left ventricle hypertrophies to maintain normal cardiac output. As narrowing increases, the compensatory mechanisms are unable to continue and the left ventricle fails to move blood forward, resulting in decreased cardiac output and HF. Etiology The major causes of aortic stenosis are congenital defects or rheumatic heart disease. Calcification of the aortic valve can be related to aging and occurs after age 60.Aortic stenosis is the most commonly acquired valvular heart disease in adults. As the population ages, it is expected to increase in prevalence. Signs and Symptoms Many years or decades may pass before signs or symptoms of aortic stenosis are observed (see Table 23.1). When symptoms do occur, evaluation is essential because the disease can progress dramatically. If the mitral v alve is also diseased, signs and symptoms can appear earlier. Angina pectoris (chest pain) is the primary symptom that occurs as a result of a lack of oxygen to the myocardium. In the young patient, angina indicates severe obstruction. Other signs and symptoms include a murmur , syncope from dysrhythmias or decreased cardiac output, and HF signs and symptoms. The murmur is a systolic murmur that begins just after the f irst heart sound, increasing in intensity till midsystole, then decreasing and ending right before the second heart sound. Orthopnea, dyspnea on e xertion, and fatigue are indicators of left v entricular failure, resulting in pulmonary edema and right sided heart failure. Complications HF, life-threatening dysrhythmias, or endocarditis can occur. 4068_Ch23_432-461 18/11/14 4:42 PM Page 438 438 UNIT FIVE Understanding the Cardiovascular System Diagnostic Tests Aortic Regurgitation ECG usually shows enlargement of the left v entricle and left atrium. A chest x-ray examination confirms hypertrophy of the left ventricle and calcification of the aortic valve. Left atrial enlargement may be seen b ut occurs primarily when mitral stenosis is also present. Two-dimensional and Doppler echocardiography show thickening of the left ventricular wall, impaired movement of the aortic v alve, and the severity of the disease. Cardiac catheterization will show elevated left ventricular pressure and decreased cardiac output. Pathophysiology Therapeutic Measures Generally, the treatment of choice is v alve replacement because of the risk of sudden death when severe symptoms are present (see Box 23-2). If mechanical v alves are used, they require lifelong anticoagulation. For older adults, biological valves are usually used because the y do not require anticoagulation therapy and last about 12 years. F or those considered too high risk for traditional open-heart surgery, an aortic valve implantation can be done with a catheter via the femoral artery (visit www.medtronic.com to view this procedure— Medtronic CoreValve® system). Valvotomy (expansion of a balloon to open the mitral valve) is used only for those who are unable to have valve replacement. Symptoms of HF are treated. Medications that reduce the contractility of the heart and subsequently cardiac output are avoided to prevent further HF. CRITICAL THINKING Mrs. Pryor Mrs. Pryor, age 48, has aortic stenosis and is admitted to the hospital with angina. She had an episode of syncope 2 days ago. She reports that she tires easily. ■ 1. Mrs. Pryor asks what aortic stenosis is. What should the nurse tell her, and how should it be documented? 2. Why might Mrs. Pryor be experiencing angina? 3. What nursing care related to safety needs is important to include in Mrs. Pryor’s plan of care? Think of how you would feel knowing you will continue to have episodes of syncope and fatigue. What concerns would you have regarding completing your activities of daily living? 4. What nursing diagnoses and care are relevant for Mrs. Pryor’s report of being tired? 5. Digoxin (Lanoxin) 0.25 mg is prescribed for Mrs. Pryor. Digoxin is available in 0.125-mg tablets. How many tablets will the nurse give? Suggested answers are at the end of the chapter. The aortic valve cusps may be scarred, thick ened, or shortened in chronic aortic re gurgitation. A backflow of blood from the aorta into the left ventricle occurs if the aortic valve cusps do not close completely. The left ventricle’s blood volume increases with this backflow of blood that is in addition to the normal flow of blood from the left atrium. To handle the increased volume, the left ventricle compensates with dilation and hypertrophy to deliver a stronger contraction. This stronger contraction ejects more blood volume with each beat to maintain cardiac output. Over time, the heart’s contraction is not effective, and the left ventricle fails, causing a cardiac output drop and pulmonary edema. Etiology Congenital defects, aging, rheumatic heart disease, syphilis, severe hypertension, and ank ylosing spondylitis can cause aortic regurgitation. An acute cause of aortic re gurgitation may be endocarditis or aortic dissection. Signs and Symptoms Symptoms may not become apparent for many years with chronic aortic re gurgitation (see Table 23.1). Initially , the patient may report feeling a forceful heartbeat that is more pronounced when lying down. Also, palpitations and pounding in the head may be experienced. Then exertional dyspnea, fatigue, and worsening levels of dyspnea (orthopnea, paroxysmal nocturnal dyspnea) occur after years of progressive valvular dysfunction. A murmur is heard during diastolic after the second heart sound. The palpated pulse is forceful and then quickly collapses (Corrigan’ s pulse). The diastolic blood pressure decreases to widen the pulse pressure. This compensates for an increase in systolic blood pressure. Angina pectoris may occur late. The angina is atypical, often happening at rest or at night along with diaphoresis, when a lo wer pulse rate results in deli very of less oxygen to the myocardium. Ev entually symptoms of HF develop if the left v entricle fails. In acute dysfunction, profound symptoms of pulmonary distress, chest pain, and shock symptoms occur. Complications Endocarditis is a risk due to the damaged valve. HF may occur. Diagnostic Tests The ECG sho ws left v entricle hypertrophy, ST-segment depression (see Fig. 25.10), and T-wave inversion (see Fig. 25.7) in some leads. A chest x-ray confirms hypertrophy of the left ventricle and aorta. With severe regurgitation, left atrial enlargement may also be seen. An echocardiogram, Doppler echocardiography, or transesophageal echocardiography show an enlarged left ventricle and severity of the aortic regurgitation. Cardiac catheterization reveals elevated left ventricular diastolic pressure and, with contrast injection, sho ws the regurgitation of blood into the left ventricle. 4068_Ch23_432-461 18/11/14 4:42 PM Page 439 Chapter 23 Nursing Care for Valvular, Inflammatory, Infectious Cardiac or Venous Disorders Therapeutic Measures Treatment with vasodilator therapy may be useful for some patients to reduce systolic blood pressure and subsequently cardiac workload until surgery is needed. Occasionally, surgical valve repair can be done, but valve replacement is typically needed when symptoms develop (see Box 23-2). Nursing Process for the Patient With a Cardiac Valvular Disorder Data Collection A history is obtained that includes information presented in Table 23.2. Vital signs are measured and recorded. Heart sounds are auscultated to detect murmurs. Any signs and symptoms of HF are noted and reported (see Chapter 26). Nursing Diagnoses, Planning, Interventions, and Evaluation The major nursing diagnoses for all valvular disorders are the same and include those for HF as well, if symptoms of HF are present. See “Nursing Care Plan for the P atient With a Cardiac Valvular Disorder.” Patient Education Education, an important nursing intervention, promotes understanding of the valvular disorder, health maintenance, prevention 439 of complications, and early recognition of symptoms so that medical care can be sought. For older adult patients, it is important to include caregivers or family members in teaching sessions to assist with understanding of the information being taught. Teaching is provided for medications the patient is taking. If the patient is on anticoagulants for atrial f ibrillation or mechanical valve replacement, medical identification should be used, and monthly appointments to check international normalized ratio (INR)/prothrombin time (PT) values should be kept. Information on endocarditis pre vention is essential for patients with most v alvular problems. Damaged cardiac valves are prone to developing infection from organisms such as Streptococcus viridans or Staphylococcus epidermidis. During invasive procedures in which bleeding is possible, these organisms can enter the circulation, attach to damaged valves, and multiply. Patients should discuss with their health care provider (HCP) the American Heart Association guidelines for prophylactic antibiotics to prevent endocarditis (see the prevention section for endocarditis later in this chapter). Cardiac Valve Repairs A balloon valvotomy opens a stenosed heart valve. A balloon catheter is inserted through the diseased valve and then inflated to open the stenosed valve leaflets. For mitral valve valvoplasty, the balloon catheter is inserted via the venous circulation into TABLE 23.2 DATA COLLECTION FOR PATIENTS WITH CARDIAC VALVULAR DISORDERS Data Collection Subjective Data Health History Infections (rheumatic fever, endocarditis, streptococcal or staphylococcal, syphilis)? Congenital defects? Cardiac disease (myocardial infarction, cardiomyopathy)? Respiratory Dyspnea at rest, on exertion, when lying, or that awakens patient? Cough or hemoptysis? Cardiovascular Chest pain—when does it occur? Palpitations, dizziness, fatigue, activity intolerance? Medications What medications are you taking? Knowledge of Condition What is the reason that you are here today? What does your diagnosis mean to you? Coping Skills How does patient normally cope with stressors? Support system? Adaptations in lifestyle and/or environment? Objective Data Respiratory Crackles, wheezes, tachypnea Cardiovascular Murmurs, extra heart sounds, dysrhythmias, edema, jugular venous distention, Corrigan’s pulse, increased or decreased pulse pressure Integumentary Clubbing; cyanosis; diaphoresis; cold, clammy skin; pallor Diagnostic Test Findings Review ordered test results. 4068_Ch23_432-461 18/11/14 4:42 PM Page 440 440 UNIT FIVE Understanding the Cardiovascular System the right atrium. Then the catheter is threaded through a small hole pierced into the right atrial septum that emer ges into the left atrium. The catheter is passed through the mitral valve, and the inflation of the balloon within the mitral v alve opens the stenosed valve flaps. Complications may include dysrhythmias, emboli, hemorrhage, and cardiac tamponade. A balloon valvuloplasty results in fewer complications than traditional open-heart surgery. A commissurotomy repairs a stenosed valve. The valve flaps that have adhered to each other and thus closed the opening between them, known as the commissure, are separated to enlarge the valve opening. The patient is placed on cardiopulmonary bypass (CPB; see Chapter 21), and an • WORD • BUILDING • commissurotomy: commissura—joining together + tome—incision NURSING CARE PLAN for the Patient with a Cardiac Valvular Disorder Nursing Diagnosis: Decreased Cardiac Output related to valvular stenosis or insufficiency or heart failure Expected Outcome: The patient will have adequate cardiac output as evidenced by vital signs within normal limits (WNL), no dyspnea, and minimal fatigue. Evaluation of Outcome: Are patient’s vital signs WNL with no dyspnea or fatigue? Intervention Assess vital signs, oxygen saturation, chest pain, and fatigue. Rationale Vital signs, chest pain, and fatigue are indicators of cardiac output decline. Evaluation Are vital signs WNL with no chest pain? Intervention Give oxygen as ordered. Rationale Supplemental oxygen provides more oxygen to the heart by increasing the oxygen saturation in the blood. Evaluation Is oxygen saturation WNL? Intervention Provide bedrest or rest periods as ordered. Rationale Cardiac workload and oxygen needs are reduced with rest. Evaluation Are vital signs WNL and no fatigue reported? Intervention Elevate head of bed 45 degrees. Rationale Venous return to heart is reduced and chest expansion improved, which increases the amount of oxygen coming into the lungs. Evaluation Are vital signs WNL without use of accessory muscles of respiration? GERIATRIC Intervention Note cardiac medication side effects and teach patient side effects to report. Rationale Toxic side effects are more common owing to altered metabolism and excretion of medications in the older adult. Evaluation Are side effects present for medications patient is taking? Does patient understand side effects to report? Nursing Diagnosis: Activity Intolerance related to decreased oxygen delivery from decreased cardiac output Expected Outcome: The patient will show normal changes in vital signs with less fatigue in response to activity. Evaluation of Outcome: Does patient have normal changes in vital signs with activity? Does patient report decreased fatigue with activity? Intervention Assist as needed with activities of daily living (ADLs). Rationale Conserve energy with ADL assistance. Evaluation Are all ADLs completed? Are vital signs WNL with activity? Intervention Provide rest between activities. Rationale Cardiac workload and oxygen needs are reduced with rest. Evaluation Is patient able to perform activities when allowed extra time? GERIATRIC Intervention Slow pace of care and allow patient extra time to perform activities. Rationale Patients can often perform activities if allowed time to slowly perform them and rest at intervals. Evaluation Does blood pressure remain WNL when changing position? Intervention Ensure safety when mobilizing older patient. Rationale Orthostatic hypertension is common in the older adult. Evaluation Does patient ambulate without injury? 4068_Ch23_432-461 18/11/14 4:42 PM Page 441 Chapter 23 Nursing Care for Valvular, Inflammatory, Infectious Cardiac or Venous Disorders 441 atriotomy (incision into the atrium) is made to e xpose the valve. The valve cusps are either incised with a knife or broken apart with a dilator . The atrium is se wn closed, CPB is discontinued, and surgery continues as described in Chapter 21. Commissurotomy is most commonly performed on the mitral valve. Annuloplasty is the repair or reconstruction of the valve flaps or annulus. It may in volve the use of prosthetic rings. The mitral valve is the most common v alve repaired in this way. Sutures or a ring may be placed in the valve annulus to improve closure of the leaflets. Similar procedures are used on the tricuspid valve; however, the aortic valve is not readily repaired in this manner. Heart Valve Replacement Valves used for cardiac v alve replacement may be either mechanical or biological. Research is ongoing to de velop tissue engineered heart v alves. Biological (tissue) v alves come from xenograft (porcine [pig] and bo vine [cow]) or allograft (human donor) (see “Cultural Considerations”). Allografts are available in limited numbers because they rely on donors. An autograft (Ross procedure) uses the patient’ s own pulmonary valve to replace the removed aortic valve; an allograft (human donor) pulmonary v alve then replaces the patient’s pulmonary valve. Visit www.lifenet.org for more information on allografts. For mitral valve replacement, a left atriotomy is made after the patient is on CPB. For an aortic valve replacement, an incision is made abo ve the right coronary artery in the aorta. Then in either v alvular procedure, the diseased valve is excised and the new valve sutured in place. The incision is closed, and sur gery then continues as described in Chapter 21. Complications of Valve Replacement Tissue valves have a low incidence of thrombus formation and do not require lifelong anticoagulant therapy, but they do not last as long as mechanical v alves because of degenerative changes and calcif ication. Mechanical valves are durable (lasting 20–30 years) b ut create turb ulent blood flow, requiring lifelong anticoagulant therap y to prevent blood clots (Fig. 23.4). Anemia from hemolysis of red blood cells (RBCs) as the y come in contact with mechanical valve structures can occur. Also endocarditis can occur due to micro-or ganisms growing on the v alve leaflets or the se wing ring of mechanical v alves. These FIGURE 23.4 Mechanical valve prosthesis. An SJM Masters Series valve. Courtesy of St. Jude Medical, Inc., St. Paul, MN. growths can make valves incompetent or break off to become emboli. Nursing Process for the Preoperative Cardiac Surgery Patient DATA COLLECTION. Baseline data collection is important for postoperative comparison and to be gin discharge planning. Pain control needs and circulatory status are essential items. Results of diagnostic laboratory tests, x-ray e xaminations, and other studies are also significant. Typing and crossmatching for ordered units of blood is done. NURSING DIAGNOSES, PLANNING, INTERVENTIONS, AND EVALUATION. See the “Nursing Process for Preoperati ve Patients” in Chapter 12. Nursing Process for the Postoperative Cardiac Surgery Patient After cardiac surgery, the patient goes to an intensi ve care unit (ICU) or cardiac universal bed unit (CUB). In the ICU, • WORD • BUILDING • annuloplasty: annulus—ring + plasty—formed Cultural Considerations Cardiac Valves Because the pig is considered a forbidden animal to religious Jews and Muslims, only bovine, synthetic, or human valves should be used for these patients. Because the cow is sacred among Hindus, only porcine, synthetic, or human valves should be used for Hindu patients. 4068_Ch23_432-461 18/11/14 4:42 PM Page 442 442 UNIT FIVE Understanding the Cardiovascular System the patient is monitored for 1 to 2 days. As recovery progresses, the patient is transferred to a step-down or general surgical unit for continued cardiac monitoring. In the CUB unit, the patient recovers in the same room until discharge, which avoids transfers to other units and increases continuity of care. DATA COLLECTION. The patient is accompanied to ICU/CUB by the anesthesiologist, who gi ves the nurse a report of the procedure, complications, and hemodynamic and ventilatory management of the patient. The patient is connected to a cardiac monitor and mechanical v entilator for up to 24 hours. The patient is placed under a w arming device, such as a forced air blanket, as needed. A head-to-toe assessment of the patient, including dressings, tubes (chest and, nasogastric tube, urinary catheter) and intravenous (IV) lines, is performed. Of importance are signs of a wakening, shivering, pain, lung and heart sounds, and palpation of the entire chest and neck to detect crepitus (air in the subcutaneous tissue from opening the chest). Trends in cardiac output are monitored. Body temperature is continuously monitored if w arming measures are used. Warming is discontinued when the core body temperature nears 98.6°F (37°C). Warming should occur slowly to avoid peripheral vasodilation, which can result in shock. While being re warmed, patients are assessed for shivering, which may be felt as a f ine vibration at the mandibular angle of the ja w. Shivering greatly increases cardiac oxygen needs. P aralyzing agents given with narcotics eliminate shivering. Complete blood count (CBC), electrolytes, coagulation studies, and arterial blood gases (ABGs) are monitored. After the initial transfer assessment, vital signs, oxygen saturation, and cardiac pressures are monitored and recorded every 15 to 30 minutes, with decreasing frequency as the patient stabilizes. Input and output (I&O) is measured. A 12lead ECG is done to detect perioperati ve MI. A chest x-ray examination is done to check central line and endotracheal tube placement and to detect a pneumothorax or hemothorax, diaphragm elevation, or mediastinal widening from bleeding. At this point, the family can see the patient. Awakening with many questions, strange auditory and tactile sensations, and the inability to speak are frightening and frustrating to the patient. Gi ve explanations regarding procedures in simple terms. Keeping eye contact with the patient and using touch appropriately can be soothing to the patient. If lip reading is unsuccessful, use simple closed-ended questions, nonverbal gestures, communication boards, or magic slates. After cardiac surgery, pain is monitored in relation to the patient’s preoperative anginal or inf arction-associated pain. Chest pain after surgery can be frightening. Kno wing that chest pain can occur from the sur gical incision rather than from anginal or MI pain is comforting to the patient. NURSING DIAGNOSES, PLANNING, INTERVENTIONS, AND EVALUATION. Nursing diagnoses for postoperative cardiac surgery are discussed in the “Nursing Care Plan for the Postoperative Patient Undergoing Cardiac Surgery.” Additional general postoperative nursing care is discussed in Chapter 12. NURSING CARE PLAN for the Postoperative Patient Undergoing Cardiac Surgery Nursing Diagnosis: Pain related to sternotomy or pericarditis Expected Outcomes: The patient will state that pain is relieved or tolerable. Patient will be able to rest and perform respiratory treatments. Evaluation of Outcomes: Does patient state pain is within acceptable levels? Is patient able to rest and perform respiratory therapies? Intervention Ask about characteristics of pain with each episode. Rationale A thorough description is needed to determine cause and plan actions. Evaluation Does patient describe pain on scale of 0 to 10? Intervention Splint chest incision with all movement, including coughing and deep breathing. Rationale Stabilizes sternum and incision to increase comfort. Evaluation Can patient splint chest incision independently? Intervention Encourage patient to report pain even when it is mild. Rationale It is easier to keep pain under control when mild. Evaluation Does patient report pain when mild? Intervention Turn, reposition every 2 hours. Rationale Changes muscle position, relieving stiffness. Evaluation Is patient comfortable without stiffness? 4068_Ch23_432-461 18/11/14 4:42 PM Page 443 Chapter 23 Nursing Care for Valvular, Inflammatory, Infectious Cardiac or Venous Disorders 443 NURSING CARE PLAN for the Postoperative Patient Undergoing Cardiac Surgery Intervention Offer back rubs frequently. Rationale Relaxes tense muscles retracted during operation. Evaluation Is patient able to rest comfortably? Intervention Instruct patient to take a deep breath before movement and exhale slowly during movement. Rationale Keeps muscles relaxed, minimizing tension with guarding and pain. Evaluation Can patient perform coughing and deep-breathing techniques as instructed? Nursing Diagnosis: Decreased Cardiac Output related to myocardial depression, hypothermia, bleeding, unstable dysrhythmias, or hypoxemia Expected Outcomes: The patient will remain free of major side effects of pharmacological support. The patient will maintain vital signs WNL, palpable peripheral pulses, urine output greater than 30 mL/hr, and normal sinus rhythm. Evaluation of Outcomes: Is patient free of major side effects? Are vital signs WNL? Intervention Monitor vital signs. Rationale Trends reflect problems. Evaluation Are vital signs WNL? Intervention Monitor peripheral circulation. Rationale Mottling or weak pulses may indicate poor cardiac output (CO). Evaluation Do peripheral pulses remain strong with normal skin color, temperature, capillary refill? Intervention Monitor intake and output. Rationale Fluid deficit or excess can alter CO. Evaluation Does total intake equal output? Intervention Listen to lung sounds and note character of sputum. Rationale Wet lung sounds may indicate HF or pulmonary edema. Evaluation Are lungs clear? Intervention Monitor temperature closely while rewarming the patient. Rationale Febrile state increases heart rate and myocardial oxygen consumption. Evaluation Does temperature remain less than or equal to 98.6°F (37°C)? Intervention Monitor for shivering. Rationale Shivering increases the blood pressure, decreasing CO and increasing risk for bleeding. Evaluation Is patient’s shivering controlled? Intervention Monitor chest tube drainage for increase or sudden decrease. Rationale Drainage greater than 200 mL/hr may lead to hypovolemia and decreased CO. Evaluation Is patient free from cardiac tamponade and hypovolemia? Intervention Monitor ECG. Rationale Premature ventricular contractions and atrial fibrillation decrease CO. Evaluation Does patient remain in normal sinus rhythm or controlled dysrhythmia? Intervention Monitor electrolytes. Rationale Low calcium and magnesium and high potassium decrease contractility and CO. Evaluation Are electrolytes WNL? Intervention Monitor arterial blood gases (ABGs). Rationale Acidosis decreases heart function, and a low CO may lead to further acidosis. Evaluation Are ABGs WNL? Nursing Diagnosis: Risk for Infection related to inadequate primary defenses from surgical wound Expected Outcome: The patient will remain free from infection. Evaluation of Outcome: Does patient remain free from infection? Continued 4068_Ch23_432-461 18/11/14 4:42 PM Page 444 444 UNIT FIVE Understanding the Cardiovascular System NURSING CARE PLAN for the Postoperative Patient Undergoing Cardiac Surgery—cont’d Intervention Practice excellent hand hygiene, and always cleanse stethoscope with ethanol-based cleanser or alcohol between patients. Rationale Hands and stethoscopes carry infectious agents. Evaluation Are infectious preventive techniques used? Does patient remain free from infection? Intervention Observe incision for signs and symptoms of infection, which are redness, warmth, fever, and/or edema. Rationale Redness, warmth, fever, and swelling indicate the body’s response to an invading pathogen. Evaluation Are signs and symptoms of infection present? Intervention Monitor drainage and maintain drains. Rationale Drains remove fluid from the surgical site to prevent infection development. Evaluation Are drainage amount and color normal for procedure? Are drains functioning? Intervention Maintain sterile technique for dressing changes. Rationale Sterile technique reduces infection development. Evaluation Is incision free of signs and symptoms of infection? Intervention Monitor and report abnormal findings for temperature, lung sounds, sputum, and urine consistency. Rationale Low-grade (immunosuppressed) or high-grade fever, crackles, yellow-green sputum color, or cloudy urine can indicate infection. Evaluation Is the patient’s temperature WNL, and are lung sounds, sputum, and urine clear? INFLAMMATORY AND INFECTIOUS CARDIAC DISORDERS The layers of the heart—the endocardium, pericardium, and myocardium (Fig. 23.5)—can become inflamed or infected, leading to endocarditis, pericarditis, and myocarditis, respectively. Infective Endocarditis Infective endocarditis (IE) is an infection of the endocardium that mostly occurs in hearts with artif icial or damaged valves. Men develop IE more often than women, as do older adults compared with younger. Pathophysiology Cardiac defects result in turb ulent blood flow that erodes the normally infection-resistant endocardium. IE be gins when the invading organism (most commonly a bacteria but possibly a fungi or other organism) attaches to eroded endocardium where platelets and f ibrin deposits ha ve formed a vegetative lesion. Then more platelets and fibrin cover the multiplying organism. This covering protects the microbes, reducing the ability to destroy them. Damage to valve leaflets occurs as the v egetations grow. As blood flows through the heart, these v egetations may break of f and become emboli. Damaged valves from conditions such as MVP with re gurgitation, rheumatic heart disease, congenital defects, and valve replacements are especially prone to bacterial invasion. The mitral valve is the valve most commonly infected, with the aortic valve being second. HF may result from valve damage, especially of the aortic valve. Etiology Risk factors include the following: FIGURE 23.5 Layers of the heart. • Compromised immune system • Artificial heart valve 4068_Ch23_432-461 18/11/14 4:42 PM Page 445 Chapter 23 Nursing Care for Valvular, Inflammatory, Infectious Cardiac or Venous Disorders • Congenital or valvular heart disease • History of endocarditis • IV drug use • Gingival gum disease. Prevention Dental disease may be a contributing factor to IE, so daily oral care and regular dental care is an important preventive measure. Antibiotic prophylaxis guidelines have been updated. Before a dental procedure, the American Heart Association (2014) now recommends that only individuals with an artif icial heart v alve or a v alve repaired with artificial material, a history of endocarditis, a heart transplant with abnormal valve function, or specific congenital heart defects receive antibiotics. Prophylaxis for procedures on the genitourinary or gastrointestinal (GI) tract or for most people who have orthopedic implants is no longer recommended. TABLE 23.3 INFECTIVE ENDOCARDITIS SUMMARY Signs and Symptoms Fever Chills Heart murmur Night sweats Fatigue Weight loss Weakness Aching in abdomen, joints, muscles, back Nailbed splinter hemorrhages Petechiae Diagnostic Tests and Findings Blood cultures Transesophageal echocardiography CBC Chest x-ray ECG Therapeutic Measures Acute therapy: IV antimicrobial medications such as penicillin, vancomycin, amphotericin B Antipyretics Rest Valve replacement Prophylactic antibiotic therapy per high-risk infective endocarditis criteria Complications Emboli Heart failure Abscesses Priority Nursing Diagnoses Activity Intolerance related to reduced oxygen delivery from decreased cardiac output Decreased Cardiac Output related to impaired valvular function or heart failure Ineffective Tissue Perfusion related to emboli Signs and Symptoms The onset of symptoms can be rapid or slo w. Fever (99°– 103°F [37.2°–39.4°C]) is a common sign, although the older adult may be afebrile (Table 23.3). Chills, aching muscles and joints, fatigue, dyspnea, cough, edema, and hematuria may occur. A new or different murmur is heard with valvular damage. Splinter hemorrhages may be seen in the distal nailbed (black or red-bro wn longitudinal short lines). Petechiae (tiny red or purple flat spots) resulting from microembolization of the vegetation may occur on mucous membranes, conjunctivae, or skin (Fig. 23.6). Jane way lesions (small, painless red-blue lesions on palms and soles) are an acute finding. Osler’s nodes (small, painful nodes on fingers and toes) from cardiac emboli are a late f inding (Fig. 23.7). Have you ever seen petechiae or palpated an Osler’s node? Look for the opportunity in clinical to see petechiae, Janeway lesions, or an Osler’s node. Complications Vegetative emboli can be a major complication of IE. If organ embolization occurs, signs and symptoms that reflect the organ that was affected by the emboli are seen. Brain emboli may produce changes in le vel of consciousness or stroke. Kidney emboli cause pain in the flank area, hematuria, or renal failure. Emboli in the spleen cause abdominal pain. Emboli in the small blood v essels can impair circulation in the e xtremities. Pulmonary emboli result in sudden dyspnea, cough, and chest pain. Heart structures can be damaged or destro yed by IE. Stenosis (narrowing) or regurgitation (leakage) of a heart valve may also result. As the infection progresses and causes more damage to heart structures, HF may occur . Abscesses may also develop in the heart or other parts of the body. Diagnostic Tests Table 23.3 lists diagnostic tests for IE. Positive blood cultures identify the causative organism, and echocardiography shows cardiac effects. 445 Note. CBC = complete blood count; ECG = electrocardiogram. Therapeutic Measures Initial treatment begins with hospitalization. An antimicrobial drug is selected that will destroy the organism identified by the blood culture. For bacterial infections, penicillin (or vancomycin for those aller gic to penicillin) is commonly used. These medications are given IV over a period • WORD • BUILDING • petechiae: petecchia—skin spot 4068_Ch23_432-461 18/11/14 4:42 PM Page 446 446 UNIT FIVE Understanding the Cardiovascular System Nursing Process for the Patient With Infectious Endocarditis DATA COLLECTION. A patient history is obtained that includes risk factors for IE and recent infections or in vasive procedures (Table 23.4). Vital signs are recorded, and heart sounds are auscultated for murmurs. Signs of HF and emboli are noted. Notify the HCP immediately if circulatory impairment, such as cold skin, decreased capillary ref ill, cyanosis, or absent peripheral pulses in an e xtremity, or symptoms of organ-related emboli are detected. NURSING DIAGNOSES, PLANNING, IMPLEMENTATION, AND EVALUATION. See “Nursing Care Plan for the Patient With FIGURE 23.6 Petechiae. From Goldsmith, L. (1997). Adult & pediatric dermatology (p. 61). Philadelphia: F.A. Davis. Infective Endocarditis.” Teaching provides patients and families with the ability to pro vide IV antibiotics at home and promotes health maintenance to prevent future IE. Good hygiene including dental care is essential. Skin care includes bathing, using proper hand-washing technique with soap, avoiding nail biting, not popping pimples or lancing boils, and washing and applying antibiotic ointment to cuts. Brushing with a soft-bristle toothbrush (to pre vent gum trauma) twice a day reduces the formation of plaque (which traps bacteria). Biannual dental cleaning (with prophylactic antibiotics as specified) is important. Recognition of symptoms (e.g., fever, chills, sweats), seeking prompt medical care, and having blood cultures drawn before antibiotics are started, along with the patient’s statement of understanding and a willingness to follow lifestyle changes, support goal achievement. CRITICAL THINKING Mrs. Jones FIGURE 23.7 Osler’s nodes. From Goldsmith, L. (1997). Adult & pediatric dermatology (p. 188). Philadelphia: F.A. Davis. of 4 to 6 weeks, often once a day. A lengthy course of highdose antibiotics is needed to penetrate the v egetations to reach all of the microbes inside to kill them. Rest and supportive symptom care are also used. If afebrile and without complications, the patient is discharged to continue IV antibiotic therap y at home. Response to the drug is monitored by the home care nurse and laboratory testing. Surgical replacement or repair of valves is done for severely damaged heart valves, prosthetic valve infection, recurrent infection, multiple emboli from damaged valves, or HF. Antimicrobial therapy continues after surgery. ■ Mrs. Jones, age 28, is admitted to the hospital with a fever of 100°F (37°C), chills, fatigue, anorexia, and pain in her joints. A physical assessment reveals splinter hemorrhages in the left inde x finger nailbed and petechiae on her chest. She is diagnosed with a heart murmur and infective endocarditis. 1. 2. 3. 4. 5. 6. 7. 8. Why is a heart murmur heard with endocarditis? What do splinter hemorrhages look like? What do petechiae indicate? How would Mrs. Jones’s data collection findings be documented? What type of medication would the nurse expect to be ordered to treat the infection? Why does Mrs. Jones have chills if her temperature is elevated? What signs and symptoms might occur if the complications of heart failure develop? Tylenol 650 mg every 6 hours for pain is ordered. It comes as 325-mg tablets. How many tablets would be given per dose? Suggested answers are at the end of the chapter. 4068_Ch23_432-461 18/11/14 4:42 PM Page 447 Chapter 23 Nursing Care for Valvular, Inflammatory, Infectious Cardiac or Venous Disorders 447 TABLE 23.4 DATA COLLECTION FOR PATIENTS WITH INFECTIVE ENDOCARDITIS Subjective Data Health History Infections (rheumatic fever, scarlet fever, previous endocarditis, streptococcal or staphylococcal, syphilis)? Cardiac disease (valvular surgery, congenital)? Childbirth? Invasive procedures (surgery, dental, catheterization, IV therapy, cystoscopy, gynecological)? Malaise? Anorexia? Medications Steroids, immunosuppressants, prolonged antibiotic therapy, IV drug use, alcohol use? Respiratory Dyspnea on exertion or orthopnea (when lying down)? Cough? Cardiovascular Palpitations, chest pain, fatigue, or activity intolerance? Musculoskeletal Weakness, arthralgia, myalgia? Knowledge of Condition Patient’s understanding Objective Data Body Temperature Fever, diaphoresis Respiratory Crackles, tachypnea Cardiovascular Murmurs, tachycardia, dysrhythmias, edema Integumentary Nailbed splinter hemorrhages; petechiae on lips, mouth, conjunctivae, feet, or antecubital area; paleness Renal Hematuria Diagnostic Test Findings Positive blood cultures, anemia, elevated WBC count, elevated ESR, ECG showing conduction problems, echocardiogram showing valvular dysfunction and vegetations, chest x-ray exam showing heart enlargement (cardiomegaly) and lung congestion Note. ECG = electrocardiogram; ESR = erythrocyte sedimentation rate; IV = intravenous; WBC = white blood cell. NURSING CARE PLAN for the Patient With Infective Endocarditis Nursing Diagnosis: Decreased Cardiac Output related to impaired valvular function or heart failure as manifested by activity intolerance Expected Outcome: The patient will have adequate cardiac output as evidenced by vital signs WNL, no dyspnea, and minimal fatigue in response to activity. Evaluation of Outcome: Are patient’s vital signs WNL with no dyspnea and minimal fatigue? Can patient participate in desired activities? Intervention Assess vital signs, murmurs, dyspnea, and fatigue. Rationale Abnormal vital signs, dyspnea, and fatigue are indicators of cardiac output decline. Evaluation Are vital signs WNL with no dyspnea or fatigue? Intervention Give oxygen as ordered. Measure oxygen saturation. Rationale Supplemental oxygen will increase oxygen level in the blood. Evaluation Is oxygen saturation WNL? 4068_Ch23_432-461 18/11/14 4:42 PM Page 448 448 UNIT FIVE Understanding the Cardiovascular System NURSING CARE PLAN for the Patient With Infective Endocarditis Intervention Provide bedrest or rest periods as ordered. Rationale Cardiac workload and oxygen needs are reduced with rest. Evaluation Are vital signs WNL and no fatigue reported? Intervention Elevate head of bed 45 degrees. Rationale Venous return to heart is reduced and chest expansion improved. Evaluation Are vital signs WNL and respirations easy with no reported dyspnea or use of accessory respiratory muscles? Intervention Assist with activities of daily living (ADLs) as needed, providing rest periods. Rationale Assistance conserves energy. Cardiac workload and oxygen needs are reduced with rest. Evaluation Are ADLs completed? Does patient report less fatigue? Nursing Diagnosis: Deficient Diversional Activity related to restricted mobility from prolonged IV therapy Expected Outcome: The patient will state diversional activities are satisfying. Evaluation of Outcome: Does patient participate in diversional activities? Does patient state satisfaction with activities? Intervention Assess patient’s preferred activities and hobbies. Rationale Activity preference should be known to plan satisfactory diversi