Part 3: Inflammatory/Valvular Disease

Question 1

Infective Endocarditis Manifestations

Answer 1

Signs of infections: fever, malaise, anorexia, chills, weakness, fatigue.
New murmurs associated with affected valves

**Janeway’s lesions: flat, tiny, nontender red spots on palms or hands or soles of feet. (early sign)
**Roth’s spots: retinal hemorrhage with pale center
Splinter hemorrhages in nailbeds (red or black longitudinal streaks)
**Petechiae: especially in mucus membranes
**Osler’s nodes: tender, painful, erythematous papules on pads of fingers or toes. (late sign)

Heart failure signs and symptoms
Systemic emboli: Right side: lungs
Left side: CVA, spleen, kidneys

Question 2

Diagnostics for Infective Endocarditis

Answer 2

Blood cultures for causative agent-Strep. Viridans and Staph. Aureus most common.
Elevated WBC
Elevated ESR
Echocardiogram, or transesophageal echo to determine valve abnormalities
CXR to determine HF

Question 3

Infective Endocarditis Treatment

Answer 3

Appropriate anti-infective agent
Given IV for up to 6 weeks
Usually given in acute care setting for up to 1 week, then patient discharged with IV treatment to continue at home
Some patients may need valve replacement if valve damage is severe

Question 4

IE Nursing Care

Answer 4

Assess vital signs, signs of heart failure, signs for emboli (can be pulmonary, cerebral, or micro-emboli to organs and peripheral tissues)

Bedrest if signs of heart failure or febrile

Aseptic technique with invasive procedures

Question 5

IE Prevention

Answer 5

Prophylactic treatment for patients at risk when undergoing procedures

Patients who have had valve replacements or valve disease, history of endocarditis, pacemakers, etc. must be given antibiotics when they undergo certain procedures(e.g. dental)

Question 6

IE Teaching

Answer 6

Need to know how to manage site, IV infusions, pump, aseptic technique, schedule maintained to keep blood level in therapeutic range
Take temp daily
Oral hygiene: prevent bacteremia
use soft toothbrush
do not use water irrigation devices or floss
Need for prophylactic antibiotics

Question 7

Pericarditis

Answer 7

Pericardial friction rub, best heard with diaphragm at lower left sternal border

To differentiate from pleural rub, ask patient to hold their breath. A pleural rub is audible during inspiration. If the patient is holding their breath and the sound is still audible, it must be cardiac in origin.

Precordial chest pain or left shoulder pain. Grating and oppressive
Pain is worse when lying down, coughing, swallowing, deep breathing
Relieved by sitting forward with forearms on legs

Dyspnea
Fever (if bacterial)

Question 8

Pericarditis Diagnostics

Answer 8

Elevated WBC
EKG: low voltage QRS, elevation of ST segment in most leads (can be mistaken for MI)
CXR usually normal unless large effusion develops
Echocardiogram: abnormal if effusion is present

Question 9

Pericarditis Treatment

Answer 9

NSAIDs
Salicylates or indomethacin (Indocin)
May cause GI irritation or ulcers. Must be taken with food
Should relieve pain within 48 hours

Steroids
Used if patient does not respond to NSAIDs

Question 10

Cardiac Tamponade

Answer 10

This complication of pericarditis is a rapid accumulation of fluid in the pericardium. The pericardium usually contains between 15 and 50 mls of fluid.
Inflammation leads to serous exudate which can build up within the pericardial sac. Eventually, the fluid compresses the heart and it is unable to beat effectively.

Question 11

Cardiac Tamponade cont.d

Answer 11

As fluid builds up in the pericardial sac, the heart becomes compressed and is unable to fill or contract properly. EKG complexes appear small (low voltage)
When auscultating the chest, heart sounds are distant and muffled because of the surrounding fluid.

Beck’s triad:

1) JVD
2) Distant heart sounds
3) Hypotension and narrow pulse pressure

Will also have tachycardia, tachypnea

Question 12

Pulsus paradoxus

Answer 12

Decrease in SBP with deep inspiration
SBP with expiration minus the SBP with deep inhalation = pulsus parodoxus
Normal differential <10mmHg
>10mmHg is suggestive of Cardiac tamponade

Question 13

Aortic Stenosis

Answer 13

Aortic valve is narrowed (hard time opening), usually as a result of calcific degenerative changes.

When the left ventricle contracts, it struggles to eject blood out into the aorta because of the narrow valve. The left ventricle will hypertrophy and fail.

Blood backs up in the left side of the heart , then the pulmonary circulation, and will eventually lead to right ventricular failure.

Symptoms: Angina, dyspnea, syncope

Question 14

Aortic Regurgitation

Answer 14

The leaflets don’t close properly so blood leaks back into the LV during diastole.

This reduces the amount of oxygenated blood available to the coronary arteries, which fill passively during diastole. Myocardial ischemia results.

The LV cannot handle the increased blood volume seeping back through the leaky valve. Eventually, it hypertrophies and fails.

Question 15

Mitral Stenosis: Diastolic murmur

Answer 15

Usually caused by rheumatic heart disease

The leaflets fuse together and create a narrow opening. Blood backs up into the left atrium and pulmonary circulation.

Can progress to right ventricular failure if untreated.
Patients c/o respiratory symptoms—dyspnea, wheezing, crackles

Question 16

Mitral Regurgitation

Answer 16

The mitral valve does not close properly so blood flows back from the left ventricle to left atrium and pulmonary circulation during systole.

Less blood is pumped into the systemic circulation leading to a low cardiac output state.

The severity of the valvular imcompetence determines the symptoms:
Weakness, fatigue, dyspnea
May have symptoms of right ventricular failure

Question 17

Tricuspid valve disease

Answer 17

Tricuspid stenosis-blood cannot pass easily from the RA to RV. The RA enlarges, blood can also back up into systemic circulation causing splenomegaly and hepatomegaly.

Cardiac output falls because the volume of blood going forward into the left side of the heart is inadequate.

Tricuspid regurgitation-blood leaks back from RV to RA during systole.

Question 18

Pulmonic valve disease

Answer 18

Pulmonic stenosis-usually congenital. RV becomes hypertrophic and fails. Patient has signs of right heart failure.

Pulmonary regurgitation-often occurs secondary to pulmonary hypertension. RV failure results.

Question 19

Treatment of valvular disease

Answer 19

Stenotic valves can be stretched with a balloon-tipped catheter—valvuloplasty. Best in children and teens. Ineffective when valve is stiff or calcified.

Question 20

Valve Replacement: Biological

Answer 20

Autograft-one of the patient’s own valves is moved to another spot (pulmonic to aortic)
Autologous valve-made from the patient’s own tissue and mounted on a frame (can use pericardium)
Allograft-human donor valve
Xenograft-valve from another species, usually pig.

*Patients with a biological valve only need anti-coagulants for a few months.

Question 21

Valve Replacement

Answer 21

Regardless of the type of valve used for replacement, all patients are at risk for endocarditis and ***MUST receive prophylactic antibiotics for invasive procedures, especially dental procedures. Usually start the antibiotics two days before the scheduled procedure.

Question 22

Carotid Stenosis

Answer 22

Atherosclerosis can cause plaque build-up in any artery, not just the coronary arteries.

Plaques and narrowings in the carotid arteries can decrease blood supply to brain, resulting in ischemic strokes.

Carotid endarterectomy involves making an incision into the carotid artery and scraping out the plaque build-up.

Can also do balloon angioplasty and stent.

Question 23

Carotid Endarterectomy

Answer 23

Complications:

Stroke during procedure (piece of plaque breaks off)

Massive hemorrhage

Question 24

So what happens if atherosclerotic plaques form in other arteries?

Answer 24

Dacron grafts used to bypass blockages/narrowings.

Most important—check pulses hourly post-op!

Question 25

Aortic Aneurysms

Answer 25

TRUE –fusiform (circumferential and relatively uniform in shape) & sacculated (pouchlike). The wall of the artery forms the aneurysm, with at least one vessel layer intact.

FALSE- pseudoaneurysm. This is not a “real” aneurysm but a disruption of all layers of the artery wall, resulting in bleeding that is contained by the surrounding structures, often caused by infection, trauma or graft surgery. This is an aortic dissection (see later slide)

Question 26

Things AA’s can lead to…

Answer 26

The disruption can be to the abdominal aorta or thoracic aorta (above or below the diaphragm). Thoracic aortic aneurysms are further divided into ASCENDING and DESCENDING.

The larger the aneurysm, the greater the risk for rupture

**Thrombi can develop in the dilated aorta leading to emboli and distal limb ischemia

Question 27

Causes of an AA

Answer 27

Degenerative changes due to plaque formation in the arterial wall leading to loss of elasticity, weakening and eventual dilation,
Congenital defects
Mechanical (e.g. after surgical procedure)
Inflammatory or infectious agents
Male gender and smoking place a person at a higher risk for abdominal aortic aneurysms, followed by HTN and DM;

Question 28

Clinical manifestations for AA

Answer 28

***Deep diffuse chest pain (most common)
Dysphagia
JVD
Edema of head and arms (large aneurysm can compress nearby structures like IVC/SVC-resulting in decreased venous return)
Pulsatile mass in periumbilical area slightly to Lt of midline; bruits; back pain
Epigastric discomfort; altered bowel elimination
Possible blue toe syndrome (patchy mottling of feet and toes in presence of palpable pedal pulses—from micro-emboli)

Question 29

AA Diagnostics/ Nursing Care

Answer 29

Diagnostic studies: Hx & physical; CXR; EKG; Echocardiogram; US; CT; MRI; Angiography

Collaborative & Nursing care: Goal is to detect early and prevent rupture
 Small aneurysm (< 4.5cm in women, < 5.5cm in men) ----monitor size every 6 months. Keep BP low and modify risk factors. Women have higher incidence of rupture.
 Larger aneurysms or those that interfere with aortic valve function will need repair.

Question 30

AA Complications

Answer 30

Death from rupture and bleeding into the retroperitoneal or chest cavity
Patient usually presents with pain in back and abdomen

*** Flank ecchymosis (Grey Turner’s sign)

Rupture results in massive hemorrhage leading to hypovolemic shock (tachycardia, hypotension, pale, clammy skin, decreased urine output, altered LOC, abdominal tenderness

Question 31

Aortic Dissection

Answer 31

Aortic dissection is a result of a tear in the intimal (innermost) lining of the artery. Blood escapes through the tear and collects between the layers of the aorta.

NOT the same thing as an AA
An aortic dissection is sometimes referred to as a “Dissecting Aortic Aneurysm” but there is actually no aneurysm present.

Question 32

Causes of Aortic Dissection

Answer 32

Affects men> women, usually between ages of 40-70 years.
Acute and life-threatening with very high mortality rate.
Most patients are older and have chronic HTN.
Blunt force trauma also a cause.
Pregnancy leads to increased stress on blood vessels due to increased intravascular volume.
Marfan syndrome—involves congenital defect of aortic root.
Highest stress placed on ascending aorta, aortic arch, and descending aorta below level of left subclavian artery.