Inflammatory and structural heart disorders Flashcards
Infective endocarditis
Disease of endocardial layer of the heart including heart valves
affects aortic and mitral valves most often
Classification of IE
By cause:
-IV drug use IE
-Fungal IE
By site of involvement
-prosthetic valve endocarditis
By severity
-Subacute form affects those with preexisting valve disease
-Acute for affects those with healthy valves
IE causative orgnaisms
Bacterial is most common
-Staphylococcus aureas (30%)
-Streptococcus viridans
-Coagulase negative staphylococci
Viruses
Fungi
Risk factors for IE
categories of high, moderate, and low risk exist
Principal risk factors:
-prosthetic valves
-hemodialysis
-IV drug abuse
-aging
-intravascular devices resulting in HAIs
Stages of IE
Bacteremia
Adhesion
Vegetation
-made of fibrin, leukocytes, platelets, and microbes
-stick to the valve or endocardium
-Parts break off and enter circulation
-Left veg can move to brain, kidneys, spleen
-Right veg can move to lungs
Clinical manifestation of IE
not super specific
FEVER, chills, weakness, malaise, fatigue, anorexia
Subacute:
-arthralgias, myalgias, back pain, abdominal pain, weight loss, headache, clubbing of fingers
Vascular manifestation of IE
-Splinter hemorrhages in nail beds
-Petechiae (pinpoints)
-Osler’s nodes on fingertips or toes
-Janeway’s lesions on pads of fingers and toes
-Roth’s spots (eyes)
Sound and secondary manifestation of IE
systolic murmur
HF
Secondary septic embolisms affect CNS, extremeties, spleen, and kidneys
Diagnostic studies for IE
History
Lab tests (from 3 places)
-blood cultures
-CBC with differential
-ESR, CRP
Echo (veg)
Chest xray (cardiomegaly)
ECG (1st or 2nd AV block)
Duke criteria
Prophylactic antibiotic treatment for who?
ppl undergoing certain dental procedures
Resp tract incisions
tonsillectomy and ademoidectomy
surgical procedures involving infected skin, skin structures, or musculoskeletal tissue
Interprofessional care for IE
-identify organism
-long term IV antibiotics
-repeat blood cultures (2 sets every 24 to 48 hrs)
-valve replacement if necessary
-antipyretics
-fluid
-rest
important assessment things
staph or strep infections
immunosuppressants
recent procedures
Typical nursing diagnoses for IE
impaired CO
activity intollerance
What to teach patients with high IE risk to promote health
Stress need to avoid infectious people (esp URI)
-avoid stress and fatigue
-plan rest periods
-have good oral hygiene
-prophylactic antibiotics
-drug rehab
Ambulatory care for IE
antibiotics for 4-6 weeks
-assess home setting
-monitor labs including blood cultures
-assess IV lines
-coping strategies
Adequate rest
-moderate activity
-compressio stockings
-ROM exercises
-deep breathing and coughing every 2 hrs
Teaching for home care of IE after hospitalization
-Monitor body temp (to see if antibiotics are effective)
-look for other signs of infection
-teach nature of the disease and how to reduce risk of reinfaction
-stress follow-up care, good nutrition, and prompt treatment of common infections (cold)
-Teach ab prophylactic antibiotics before procedures
Valvular heart disease types
defined according to valves affected and type of dysfunction (stenosis vs regurgitation)
Stenosis
constricting/ narrowing
-valve opening is smaller
-forward blood flow is impeded
-pressure differences on the two sides of the valve reflect the degree of stenosis
Regurgitation
incomplete or insufficiency of closure
-results in backward blood flow
Mitral valve stenosis
-common cause
common cause is rheumatic heart disease
-scarring of valve leaflets and chordae tendineae
-contractures develop with adhesions between commissures of the leaflets
Results in decreased blood flow from LA to LV
-increased atrial pressure/volume
-increased pulmonary vasculature pressure
-risk for atrial fibrillation
Clinical manifestations of mitral valve stenosis
exertional dyspnea
LOUD S1
diastolic murmur
fatigue
palpitations
hoarseness (atria pushes on larynx)
hemoptysis (pulmonary htn)
Afib –> stroke
Mitral valve regurgitation: what is needed for normal functioning?
Need
-mitral leaflets
-mitral annulus
-chordae tendinea
-papillary muscles
What messes up normal functioning of mitral valve, resulting in regurgitation?
MI
chronic rheumatic heart disease
mitral valve prolapse
ischemic papillary muscle dysfunction
IE
What even is mitral valve regurgitation?!
Acute vs chronic
incomplete valve closure
-backward flow of blood
-LV and LA need to work harder
Acute MR –> pulmonary edema
chronic MR –> LA enlargement, ventricular dilation, eventual ventricular hypertrophy
Acute MR manifestations
Thready peripheral pulse
Cool clammy extremeties
Chronic MR manifestations
Asymptomatic for years
LV failure
-weakness, fatigue, palpitations, dyspnea
-progress to orthopnea, parozysmal nocturnal dyspnea
-peripheral edema
-Audible S3 an murmur
Mitral valve prolapse
Abnormality of mitral valve leaflets and papillary muscle or chordae
-leaflets prolapse back into LA during systole
Usually benign, but sometimes can have complications (HF, MI, SCD,)
Unknown cause, but genetic link in some
Diagnostic test for mitral valve prolapse
Echo:
-M-mode or
2D
Clinical manifestation of mitral valve prolapse
Most ppl asymptomatic
-only 10% EVER get symptoms
-murmur from regurgitation
-severe MR is uncommon though
Dysrhythmias can cause
-palpitations
-light headedness
-syncope
IE
chest pain unresponsive to nitrates
How to treat MVP
beta blockers help with chest pain and palpitations
valve surgery if severe MR
Patient teaching for MVP
-antibiotic prophylaxis if MR present
-take your meds
-healthy diet –> avoid caffeine
-avoid OTC stimulants
-exercise
-know when to call HCP or EMS
Aortic valve stenosis: child vs adult
Congenital aortic stenosis (AS) usually found in childhood or adolescence
In adults, its usually a result of rheumatic fever or degeneration
What is AVS?
obstruction of blood flow from left ventricle to aorta
-causes left ventricular hypertrophy and increased myocardial oxygen consumption
-decreased CO leads to decreased tissue perfusion, pulmonary hypertension, and HF
**poor prognosis if untreated
clinical manifestations of AVS
angina
syncope
exertional dyspnea
Ausculatory findings in AVS
Normal to soft S1
Decreased or absent S2
Systolic murmur with radiation to carotids
Prominent S4
Treatment of AVS
poor prognosis if symptomatic and not corrected
Use nitroglycerin cautiously
-reduces preload and BP
-can worsen chest pain though
Aortic Valve Regurgitation: acute vs chronic
Acute AR
- from trauma, IE, or aortic dissection
-LIFE THREATENING EMERGENCY
Chronic
-rheumatic heart disease, congenital bicuspid aortic valve, syphilis, CT prob, or post-surgical issue
What is AVR?
Backward blood flow from ascending aorta into left ventricle
with chronic AR, LV dilation and hypertrophy occur
Decrease in myocardial contractility
Pulmonary htn and RV failure
Clinical manifestations of acute AR
-severe dypnea
-chest pain
-hypotension
-cardiogenic shock
-life-threatening emergency
Clinical manifestation of chronic AR
may be asymptomatic for years
-exertional dyspnea, orthopnea, paroxysmal dyspnea
-angina
-“water-hammer” pulse if severe
-soft or absent S1
-S3 or S4
-Murmur
Tricuspid valve stenosis
Almost always caused by rheumatic fever
Manifests
-fluttering discomfort in neck
-fatigue
-RUQ pain
Pulmonic valve stenosis
-Almost always congenital
-Causes RV htn and hypertrophy
Manifestations
-syncope
-dyspnea
-angina
Diagnostic studies for valvular heart diseases
Patient history/ physical
Echo and TEE
Chest xray
ECG (hr and hypertrophy)
Heart catheterization (pressure and valve size)
Conservative therapy for valvular heart disease
-Dependent on valve invovled and disease severity
-prevent exacerbations of HF, pulmonary edema, thromboembolism, and recurrent RF and IE
Prophylactic antibiotics to prevent recurrent RF and IE
Drugs for HF
-vasodilators (nitrats, ACE-is)
-positive inotropes (dioxin)
-diuretics
-B-blockers
No sodium, anticoagulation, anti-dysrhythmic drugs
Vavlular heart disease: Percutaneous transluminal balloon valvuloplasty
-split open the fused commissures
-treats stenosis for all valves
-balloon-tipped catheter inserted via femoral artery
-inflated to separate the valve leaflets
Surgical therapy for valvular heart disease: valve repair
Valve repair
-preferred surgical procedure
-lower operative mortality rate than valve replacement
-might not restore total func
Types:
1. Commissurotomy (valvulotomy)
-closed or open (open is common)
2. Valvuloplasty
-open, minimally invasive
-usually for MR or TR
3. Annuloplasty
Surgical therapy for valvular heart disease: Valve replacement
- Mechanical
-more durable
-lasts longer
-higher risk of thromboembolism
-requires long-term anticoagulation
2.Biologic (tissue)
-bovine, porcine, and human
-better blood flow
-less durable
Transcatheter aortic valve replacement
For severe AS
-transfemoral approach
- Edwards Sapien 3 valve
- CoreValve transcatheter aortic valve
Health promotion for Valvular disorders
Early treatment of strep
Prophylactic antibiotics for those with history
-teach patients symptoms to report
Acute and ambulatory care for valvular disorders
Individualize rest and exercise
avoid strenuous activity
discourage tobacco
ongoing cardiac assessments to make sure drugs are working
Monitor INR for patient on anticoagulants
Patient teaching: valvular disorders
-drug actions and side effects
-importance of prophylactic antibiotics
-info related to anticoagulation therapy
-when to seek medical care
Follow up care for valvular disorders
Notify HCP for
-signs of infection, HF, or bleeding
-planned invasive or dental work
Medical-alert device or bracelet
