1. Chapter 28 Management of Patients With Structural, Infectious, and Inflammatory Cardiac Disorders

2. Valvular Disorders
Regurgitation: The valve does not close properly, and blood backflows through the valve.
Stenosis: The valve does not open completely, and blood flow through the valve is reduced.
Valve prolapse: The stretching of an atrioventricular valve leaflet into the atrium during diastole

3. Valves of the Heart

4. Specific Valvular Disorders
Mitral valve prolapse
Mitral regurgitation
Mitral stenosis
Aortic regurgitation
Aortic stenosis

5. Nursing Management: Valvular Heart Disorders
Patient education
Monitor VS trends
Monitor for complications
Heart failure
Dysrhythmias
Other symptoms
Medication schedule: education
Daily weights: monitor for weight gain

6. Nursing Management: Valvular Heart Disorders (cont’d)
Plan activity with rest periods
Sleep with HOB elevated

7. Question
The nurse is providing education for a client diagnosed with mitral valve prolapse (MVP). What should be included in the teaching plan? (Select all that apply.)
MVP is not hereditary.
Caffeine is tolerated in small amounts.
Avoid alcohol.
Stop use of tobacco products.
Prophylactic antibiotics are not prescribed before dental procedures.

8. Answer Avoid alcohol. Stop use of tobacco products.
Prophylactic antibiotics are not prescribed before dental procedures.
Rationale: MVP is hereditary, and caffeine should be avoided.

9. Surgical Management: Valvular Heart Disorders
Valvuloplasty
Commissurotomy
Balloon valvuloplasty
Annuloplasty
Leaflet repair
Chordoplasty
Valve replacement
Mechanical
Tissue
Bioprosthesis
Homografts
Autografts

10. Balloon Valvuloplasty

11. Annuloplasty Ring Insertion

12. Valve Leaflet Resection and Repair With Ring Annuloplasty

13. Valve Replacement

14. Nursing Management: Valvuloplasty and Valve Replacement
Balloon valvuloplasty
Monitor for heart failure and emboli
Assess heart sounds every 4 hours
Same care as after cardiac catheterization
Surgical valvuloplasty or valve replacements
Focus is hemodynamic stability and recovery from anesthesia
Frequent assessments with attention to neurologic, respiratory, and cardiovascular systems

15. Nursing Management—Valvuloplasty and Valve Replacement (cont’d)
Patient education
Anticoagulation therapy
Prevention of infective endocarditis
Follow up
Repeat echocardiograms

16. Cardiomyopathy
Cardiomyopathy is a series of progressive events that culminates in impaired cardiac output and can lead to heart failure, sudden death, or dysrhythmias.
Types
Restrictive cardiomyopathy
Hypertrophic cardiomyopathy
Arrhythmogenic cardiomyopathy
Unclassified cardiomyopathies

17. Cardiomyopathies That Lead to Congestive Heart Failure

18. Question What is the main electrolyte involved in cardiomyopathy?
Calcium
Phosphorus
Potassium
Sodium

19. Answer
Sodium
Rationale: Sodium is the major electrolyte involved with cardiomyopathy. Cardiomyopathy often leads to heart failure, which develops, in part, from fluid overload. Fluid overload is often associated with elevated sodium levels.

20. Nursing Process: The Patient With Cardiomyopathy (Assessment)
History (predisposing factors, family history)
Chest pain
Review of diet (Na reduction, vitamin supplements)
Psychosocial history: impact on family, stressors, depression
Physical assessment: VS pulse pressure; pulsus paradoxus; weight gain or loss; PMI; murmurs; S3 or S4; pulmonary auscultation for crackles, JVD, and edema

21. Nursing Process: The Patient with Cardiomyopathy (Nursing Diagnosis)
Decreased cardiac output
Risk for ineffective cardiac, cerebral, peripheral, and renal tissue perfusion
Impaired gas exchange
Activity intolerance
Anxiety
Powerlessness
Noncompliance with medication and diet therapies

22. Collaborative Problems and Potential Complications
Heart failure
Ventricular dysrhythmias
Atrial dysrhythmias
Cardiac conduction defects
Pulmonary or cerebral embolism
Valvular dysfunction

23. Nursing Process: The Patient With Cardiomyopathy (Planning and Goals)
Improvement or maintenance of cardiac output
Increased activity tolerance
Reduction of anxiety
Adherence to the self-care program
Increased sense of power with decision making
Absence of complications

24. Nursing Process: The Patient With Cardiomyopathy (Nursing Interventions)
Improve cardiac output and peripheral blood flow
Rest, positioning (legs down), supplemental O2, medications, low Na diet, avoid dehydration
Increase activity tolerance and improving gas exchange
Cycle rest and activity, ensure patient recognizes symptoms that indicate the need for rest
Reduce anxiety
Eradicate or alleviate perceived stressors, educate family about diagnosis, assist with anticipatory grieving

25. Nursing Process: The Patient With Cardiomyopathy (Nursing Interventions) (cont’d)
Decrease the sense of powerlessness
Assist patients in identifying things that have been lost (i.e., ability to play sports), assist patients in identifying amount of control they still have left
Promote home- and community-based care
Educate patients about ways to balance lifestyle and work while accomplishing therapeutic activities
Assess patient and family and their adjustment to lifestyle changes, educate family about CPR and AEDs, establish trust

26. Nursing Process: The Patient With Cardiomyopathy (Evaluation)
Maintain or improve cardiac function
HR and RR WNL, decreased dyspnea and increased comfort, maintain or improve gas exchange, absence of weight gain, maintain or improve peripheral blood flow
Maintain or increase activity tolerance
Carry out activities of daily living (e.g., brush teeth, feed self), reports increased tolerance to activity

27. Nursing Process: The Patient With Cardiomyopathy (Evaluation) (cont’d)
Reduce anxiety
Discusses prognosis, verbalizes fears and concerns, participates in support groups, demonstrates appropriate coping mechanisms
Decrease sense of powerlessness
Identifies emotional response to diagnosis, discusses control that he or she has
Adhere to self-care program
Takes medications as prescribed, modifies diet to accommodate sodium and fluid recommendations, modifies lifestyle, identifies S&S to be reported

28. Infectious Diseases of the Heart
Any of the layers of the heart may be affected by an infectious process.
Diseases are named by the layer of the heart that is affected.
Diagnosis is made by patient symptoms and echocardiogram.
Blood cultures may be used to identify the infectious agent and to monitor therapy.
Treatment is with appropriate antimicrobial therapy. Patients require teaching to complete the course of appropriate antimicrobial therapy and require teaching for infection prevention and health promotion.

29. Types of Infectious Disease of the Heart
Rheumatic endocarditis
Occurs most often in school-age children after group A beta-hemolytic streptococcal pharyngitis; need to promptly recognize and treat “strep” throat to prevent rheumatic fever
Infective endocarditis
Usually develops in people with prosthetic heart valves or structural cardiac defects; also occurs in patients who are IV drug abusers and in those with debilitating diseases, indwelling catheters, or prolonged IV therapy

30. Types of Infectious Disease of the Heart
Pericarditis
Inflammation of the pericardium; many causes; potential complications: pericardial effusion and cardiac tamponade
Myocarditis
An inflammatory process involving the myocardium; most common pathogens involved in myocarditis tend to be viral; in endocarditis, they tend to be bacterial; complications: cardiomyopathy and heart failure

31. Clinical Manifestations: Infectious Diseases of the Heart
Fever
New heart murmur, friction rub at left lower sternal border (pericarditis)
Osler nodes, Janeway lesions, Roth spots, and splinter hemorrhages in nailbeds (Rheumatic)
Cardiomegaly, heart failure, tachycardia, splenomegaly
Fatigue, dyspnea, syncope, palpitations, chest pain (myocarditis)
Diagnostic tools: blood cultures, echocardiogram, CBC, rheumatoid factor, ESR, CRP, urinalysis, ECG, cardiac catheterization, CMR imaging, TEE, CT scan

32. Prevention Antibiotic prophylaxis before certain procedures
Ongoing oral hygiene
Female patients are advised NOT to use IUDs
Meticulous care should be taken in patients “at risk” who have catheters
Catheters should be removed as soon as they are no longer needed
Immunizations

33. Question
A patient with restrictive cardiomyopathy taking digoxin presents with symptoms of anorexia, nausea, vomiting, headache, and malaise. What should the nurse expect to be included in the plan of care for this patient?
The patient’s digoxin will be changed to nifedipine.
The patient’s digoxin dose will be decreased.
Nothing; these are signs of restrictive cardiomyopathy that are expected.
The patient will be admitted to an ICU.

34. The patient’s digoxin dose will be decreased.
Answer
The patient’s digoxin dose will be decreased.
Rationale: Patients with restrictive cardiomyopathy are sensitive to digitalis. Nurses must closely monitor these patients for digitalis toxicity, which is evidenced by dysrhythmia, anorexia, nausea, vomiting, headache, and malaise. This patient presents with symptoms of digoxin toxicity, so a decrease in dosage should be anticipated. These patients should avoid nifedipine, and they do not need to be admitted to the ICU.