Inflammatory and Valvular Heart Diseases
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Transcript of Inflammatory and Valvular Heart Diseases
Inflammatory and Valvular Heart Diseases
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
channelsMost common cause of valvular 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
channelsMost 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 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 powerCHF
• Rheumatic Pericarditis• Fibrinous Exudate and pericardial
effusion
• Rheumatic endocarditis (most serious)• Erosion and swelling of valves (thickening)• Vegetations• Stenosis/Regurgitation
• Rheumatic Myocarditis• Nodules and fibrin deposits loss of
contractile powerCHF
• Rheumatic Pericarditis• Fibrinous Exudate and pericardial
effusion
Rheumatic Fever and Heart Disease
• Nursing Assessment• 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
• Nursing Assessment• 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
•Primary Prevention•Detection and treatment of strep throat
•Secondary Prevention•Prophylactic antibiotics to prevent recurrent ARF
Rheumatic Fever and Heart Disease
Acute Intervention Antibiotics Rest Control Fever Anti-Inflammatories
Acute Intervention Antibiotics Rest Control Fever Anti-Inflammatories
Infective EndocarditisInfective 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
• 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
ClassificationClassification
• Subacute form• Longer clinical course
• Insidious onset
• Streptococcus bovis or viridians
• Staphylococcus epidermidis
• HACEK group
• Subacute form• 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
• Acute form• Shorter clinical course
• Rapid onset
• Causative organism more virulent•Streptococcus pneumoniae•Staphylococcus aureus•Streptococcus groups A, B, C•Fungi
Etiology and PathophysiologyEtiology and Pathophysiology
• Vegetations• Fibrin, leukocytes, and microbes• Adhere to the valve or endocardium• Embolization of portions of vegetations
into circulation
• 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 PathophysiologyEtiology and Pathophysiology
• Left-sided more common with bacterial infections and underlying heart disease
• Right-sided lesions usually caused by IV drug abuse
• Left-sided more common with bacterial infections and underlying heart disease
• Right-sided lesions usually caused by IV drug abuse
Etiology and PathophysiologyEtiology 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
• 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 ManifestationsClinical Manifestations
• Nonspecific
• Fever occurs in 90% of patients
• Chills
• Weakness
• Malaise, Fatigue
• Anorexia
• Nonspecific
• Fever occurs in 90% of patients
• Chills
• Weakness
• Malaise, Fatigue
• Anorexia
Clinical ManifestationsClinical Manifestations
• Vascular manifestations• Splinter hemorrhages in nail beds
• Petechiae
• Osler’s nodes on fingers or toes
• Janeway’s lesions on palms or soles
• Vascular manifestations• Splinter hemorrhages in nail beds
• Petechiae
• Osler’s nodes on fingers or toes
• Janeway’s lesions on palms or soles
Clinical Manifestations
Clinical ManifestationsClinical Manifestations
• Murmur in 80% of cases
• CHF • in up to 80% with aortic valve
endocarditis
• 50% with mitral valve endocarditis
• Manifestations secondary to embolism
• 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
HISTORYHISTORY
• Recent dental, urologic, surgical, or gynecologic procedures
• Heart disease
• Recent cardiac catheterization
• Skin, respiratory, or urinary tract infections
• 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
• Labs
• Blood cultures
• Echocardiography (detects valvular vegetations, abscesses)
• Chest x-ray
Collaborative CareCollaborative Care
• Prophylactic treatment for patients having:• Removal of drainage of infected
tissue
• Indwelling pacemakers
• Renal dialysis
• Ventriculoatrial shunts
• 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
• Antibiotic administration• Monitor antibiotic serum levels
• Antipyretics
• Subsequent blood cultures
• REST
• Valve repair/replacement
Nursing AssessmentNursing Assessment
• Subjective• History of valvular, congenital, or
syphilitic cardiac diseases
• Previous endocarditis
• Staph or strep infection
• Immunosuppressive therapy
• Subjective• History of valvular, congenital, or
syphilitic cardiac diseases
• Previous endocarditis
• Staph or strep infection
• Immunosuppressive therapy
Nursing AssessmentNursing Assessment
• Recent surgical procedures or invasive procedures
• IV drug abuse
• Weight changes
• Chills
• Diaphoresis
• Recent surgical procedures or invasive procedures
• IV drug abuse
• Weight changes
• Chills
• Diaphoresis
Nursing AssessmentNursing Assessment
• Bloody urine
• Exercise intolerance
• Generalized weakness
• Fatigue
• Cough
• Dyspnea on exertion
• Night sweats
• Chest, back, abdominal pain
• Bloody urine
• Exercise intolerance
• Generalized weakness
• Fatigue
• Cough
• Dyspnea on exertion
• Night sweats
• Chest, back, abdominal pain
Nursing AssessmentNursing Assessment
• Objective• Olser’s nodes
• Splinter hemorrhages
• Janeway’s lesions
• Petechiae
• Clubbing
• Objective• Olser’s nodes
• Splinter hemorrhages
• Janeway’s lesions
• Petechiae
• Clubbing
Nursing AssessmentNursing Assessment
• Tachypnea
• Crackles
• Arrhythmias
• Leukocytosis
• Increased ESR and cardiac enzymes
• Positive cultures
• ECG showing chamber enlargement
• Tachypnea
• Crackles
• Arrhythmias
• Leukocytosis
• Increased ESR and cardiac enzymes
• Positive cultures
• ECG showing chamber enlargement
Nursing DiagnosesNursing Diagnoses
Decreased cardiac output
Activity intolerance
Ineffective health maintenance
Decreased cardiac output
Activity intolerance
Ineffective health maintenance
Acute Pericarditis• Caused by inflammation of pericardial sac• Etiologies: Infectious vs Non-Infectious• S&S: dyspnea, CP, pericardial friction rub• Complications• Pericardial effusion• Cardiac tamponade
• Treatment• Antibiotics• NSAIDS• Corticosteroids• Positioning head at 45 degree angle• Pericardiocentesis
• Caused by inflammation of pericardial sac• Etiologies: Infectious vs Non-Infectious• S&S: dyspnea, CP, pericardial friction rub• Complications• Pericardial effusion• Cardiac tamponade
• Treatment• 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• 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
• Types of valvular heart disease depends on:• Valve or valves affected
• Two types of functional alterations
• Stenosis • Regurgitation
Valvular Heart Disease
• Stenosis • Valve orifice is restricted
• Impending forward blood flow
• Creates a pressure gradient across open valve
• Degree of stenosis reflected in pressure gradient differences
• Regurgitation • Incomplete closure of valve leaflets
• Results in backward flow of blood
• Stenosis • Valve orifice is restricted
• Impending forward blood flow
• Creates a pressure gradient across open valve
• Degree of stenosis reflected in pressure gradient differences
• Regurgitation • 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
• 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 pressureElevated
pulmonary pressurepulmonary congestion• Incomplete emptying of
LAinsufficient volumes to ventricles decreased C.O.• Afib is common risk of embolism
• Pathophysiology:• Incomplete emptying of LA
Increased LA pressure LA dilatation and hypertrophy• Increased LA pressureElevated
pulmonary pressurepulmonary congestion• Incomplete emptying of
LAinsufficient 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
• 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
• Dyspnea• Occasionally accompanied by hemoptysis• Primary symptom because of reduced lung compliance
• 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 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
• 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
• 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 RegurgitationClinical 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
• 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
• 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
• 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 StenosisClinical Manifestations
• Symptoms of angina pectoris
• Syncope
• Heart failure • Occurs when valve orifice is 1/3 normal
size
• 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?
• 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:• Rheumatic heart disease• Congenital bicuspid aortic valve• Syphilis• Chronic rheumatic heart conditions
• 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:• 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
• 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 stenosis
• Seen in IV drug users
• Right atrial output is obstructed
• Results in right atrial enlargement and elevated systemic venous pressure
Tricuspid Valve DiseaseClinical Manifestations
• Peripheral edema
• Ascites
• Hepatomegaly
• Murmur
• Peripheral edema
• Ascites
• Hepatomegaly
• Murmur
Collaborative Care
• Drug therapy
• Digitalis
• Diuretics
• Antiarrhythmics blockers
• Anticoagulants
• Low-sodium diet
• Drug therapy
• Digitalis
• Diuretics
• Antiarrhythmics 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
• 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• Fever• Diaphoresis• Peripheral edema• Crackles• Wheezes• Abnormal heart sounds• Ascites• Hepatomegaly• Cardiomegaly• Valve calcification• Pulmonary congestion on x-ray
• Objective• 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
• 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
• 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
• Teach when to seek medical treatment
• Design activity to patient’s limitations
• Discourage smoking
• Avoid strenuous activity
• Nursing assessment to monitor effectiveness of medications
• 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
• 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
• 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
• 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
• 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• Explain the cause of Mrs. S.’s
valvular heart disease. What valves are most likely to become involved with rheumatic heart disease?
• 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• Differentiate between the
characteristics of mitral stenosis and mitral regurgitation.
• Differentiate between the characteristics of mitral stenosis and mitral regurgitation.
Case Study: Question #3
• What other conservative treatment measures might be initiated for Mrs. S. (in addition to digoxin?)
• What other conservative treatment measures might be initiated for Mrs. S. (in addition to digoxin?)
Case Study: Question #4• On the basis of the assessment
data provided, write one or more nursing diagnoses.
• On the basis of the assessment data provided, write one or more nursing diagnoses.
Case Study: Question #5• What are important nursing
measures for Mrs. S.?• What are important nursing
measures for Mrs. S.?