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Test 3 🏁🏁🏁 > Valvular problems, infective endocarditis, pericarditis, cardiomyopathy, Invasive Tx: CABG > Flashcards

Valvular problems, infective endocarditis, pericarditis, cardiomyopathy, Invasive Tx: CABG Flashcards

1
Q

Preload

A
  • volume of blood in ventricles at end of diastole (end diastolic pressure)
  • Increased in:
    — Hypervolemia
    — Regurgitation of cardiac valves
    — Heart failure
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2
Q

After load:

A
  • resistance left ventricle must overcome to circulate blood
  • Increased in:
    — Hypertension
    — Vasoconstriction
  • Increased afterload= increased cardiac workload
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3
Q

Valvular Disorders

A
  • Valves do not open (stenosis) or close (regurgitation) completely
  • Blood flow is jeopardized
  • The Mitral Valve may also prolapse- stretching of the valve leaflet into the atrium during systole
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4
Q

Types of Valvular Disorders

A

Mitral Valve Prolapse
- stretching of valve leaflet into the atrium during systole
Mitral Stenosis
- mitral valve does not open completely during diastole
Mitral regurgitation
- mitral valve does not close completely before systole
Aortic Stenosis
- aortic valve does not open completely during systole
Aortic Regurgitation
- aortic valve does not close completely prior to diastole

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5
Q

Valvular disorders

A
  • Pathology is determined on which valve is affected (mitral, pulmonic, aortic, tricuspid) and alteration (stenosis [constriction] or regurgitation [insufficiency], or prolapse
  • Occurs in children and teens from congenital heart defects or rheumatic heart disease
  • Occurs in older adults from cardiovascular disease (previous MI, cardiomyopathy) Rheumatic heart disease from untreated streptococcal infections.
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6
Q

Mitral Valve Prolapse

A
  • Valve leaflets stretch and bulge (prolapse) into the left atrium during systole In many cases, cause is unknown.
  • The cause may be a hereditary condition more frequently seen in woman
  • *Patients usually are asymptomatic
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7
Q

Mitral Valve Prolapse
Teachings:

A
  • possibly hereditary
  • may be at *risk for infective endocarditis
  • need to minimize potential symptoms
    — avoid alcohol, caffeine, OTC cough meds, explore diet, activity, and sleep
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8
Q

Mitral Valve Prolapse Assessment:

A
  • “mitral/systolic click” & possible murmur heard on some are prescribed antiarrhythmics
  • Echocardiography used to diagnose & monitor progression of MVP auscultation
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9
Q

Mitral Valve Prolapse Treatment:

A

Most MVP do not require medication
- so are prescribe antiarythmics
- *echocardiography used to dx and monitor progression of MVP
- maybe prescribed prophylactic antibiotics

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10
Q

Mitral Regurgitation

A
  • Incomplete closure of valve during systole allows backflow of blood into Left atrium when left vent contracts
  • left atrium hypertrophies & dilates
  • Looks like HF
  • Progresses slowly, usually pt is symptom free for decades
  • Causes:
    — Aging (degenerative changes) & ischemia of Lf. Vent.
    — Infective endocarditis
    — rhumatic fever
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11
Q

Mitral Regurgitation S/S

A
  • When left vent fails from chronic overload:
    — dyspnea, fatigue & chronic weakness
  • DOE and orthopnea develop later
  • Atypical chest pains
  • palpitations
  • *afib
  • changes in respirations
  • PND
    *
  • WHEN RT sided HF develops:
    — neck vein distention (JVD)
    — hepatomegaly
    — pitting edema
    — * high-pitched systolic murmur at apex on auscultation
  • Severe regurgitation- third heart sound develops (S3)
  • diminished s1 heart sounds (mitral valve closure)
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12
Q

Mitral Regurgitation 2

A
  • Preload- increases with regurgitation
  • Hypoxia – sympathetic stimulation- vasocontriction (HTN)
  • Afterload – Increases
  • ACE-I
  • ARBs
  • Vasodilators
  • morphine
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13
Q

Mitral Regurgitation Nursing Management

A
  • Activity restricted
  • Low sodium diet (salt holds volume)
    — stay away for canned foods, processed foods, fast foods, bacon, etc.
  • Meds to anticipate
    — diuretics (mostly pre surgery)
    — ACE-I
    — ARBs
    — BB
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14
Q

Mitral Stenosis

A
  • Mitral valve narrows preventing blood from LA to LV.
  • Mitral valve is thickened/calcified and becomes tight/stiff
  • Rheumatic fever or endocarditis progressively thickens mitral valve.
  • dx with TEE
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15
Q

Mitral Stenosis Causes:

A
  1. Rheumatic Fever
  2. Endocarditis
    - Infective Endocarditis
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16
Q

Mitral Stenosis and Rheumatic Fever

A
  • Rheumatic Fever (more specifically rheumatic heart disease which directly affects the heart)
    — Bacteria (Group A Streptococcus) specifically
    — strep pyogenes infection causes pharyngitis aka “strep throat”
    — Early damage- mitral regurgitation
    — Later damage- mitral stenosis occurs with repeated bouts of strep pyogenes infections
  • See Chart 28-3 for signs and symptoms of Rheumatic Fever
    — sore throat, fever, red or swollen tonsils, petichiae on roof of mouth, swollen lymph nodes
  • ask if pts had an illness with sore throat
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17
Q

Mitral Stenosis caused by Endocarditis

A
  • Inflammation or infection of the heart valve
  • Caused by bacteria, viruses and rarely fungi
  • primarily occurs in prostetic heart valves, pacemaker, cardiac defects or IV drug users
  • There are many types of endocarditis but for the most part when infection has to deal with being from a bacteria, virus or fungi, it is usually infective endocarditis.
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18
Q

How does infective endocarditis happen?

A
  • Infective endocarditis can occur in:
    — Normal valve (extremely bad bacteria ex. Strep. Viridans, Staph. Aureus )
    — already damaged valve ( from bacteria that’s not as bad- following dental work/surgery)
    — Prosthetic valve
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19
Q

Mitral Stenosis (narrowed opening) S/S

A
  • Pulmonary congestion and rt HF occur first.
  • Later, when lf ventricle receives insufficient blood volume, preload is decreased and cardiac output (CO) falls.
  • S/S: DOE (usually first sign), orthopnea, paroxysmal nocturnal dyspnea, palpitations, dry cough
  • As pul htn get worse: hemoptysis, pulmonary edema occur
  • Later: hepatomegaly (Rt HF) and pitting edema (Rt HF) occur late in disorder
  • Because of *afib indicates that pt may decompensate, *physician should be notified immediately of development of an irregularly irregular rhythm
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20
Q

Mitral Stenosis S/S

A
  • Pulmonary congestion and rt HF occur first.
  • Fatigued
  • SOB
  • DOE (Exercise intolerance)
  • Cough/hemoptysis
  • JVD, pitting edema
  • Afib- notify HCP
    — Indicated that pt may decompensate
  • “rumbling” diastolic murmur on auscultation
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21
Q

Mitral Stenosis Treatment

A
  • Anticoagulants
  • If AFIb-cardioversion
  • Beta Blockers
  • Digoxin (toxic level= 1.2) know dig toxicity s/s VBAAN
  • Calcium Channel Blockers (calms heart)
  • Avoid strenuous activities, sports, pregnancy
  • Surgical Intervention
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22
Q

Aortic regurgitation

A

(Aortic valve does not close all the way)
- Blood flows back from aorta into lf vent during diastole
- Lf vent dilates and eventually hypertrophies
- CAUSES: endocarditis, congenital abnormalities, chest trauma (car accident against steering wheel), deterioration of a surgically replaced aortic valve
- Asymptomatic for many years due to Lf vent compensation
— bounding arterial pulse on palpation (esp. head and neck)
— Exertional dyspnea and fatigue
— high-pitched blowing diastolic murmur

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23
Q

Aortic regurgitation Treatment of choice:

A
  • Aortic valve replacement or repair (valvuloplasty)
  • In severe AR: vasodilators (dobutamine & sodium nitroprusside)
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24
Q

Aortic Stenosis

A
  • most common valve dysfunction in US
  • narrowed opening does not allow normal blood flow out the lf vent during systole
    — This increased afterload results in vent hypertrophy
    — (This is the greatest risk for developing Lf HF)
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25
Q

Aortic Stenosis CAUSES

A
  • “wear & tear”
  • atherosclerosis & degenerative calcification of aortic valve are major causes in geriatric patients
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26
Q

Aortic Stenosis Distinguishing Assessments:

A
  • narrowed pulse pressure
  • systolic crescendo-decrescendo murmur
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27
Q

Aortic Stenosis Treatment:

A
  • No medical therapy- surgery is usually indicated to replace valve
28
Q

Aortic Stenosis Important Teaching:

A

Taking nitroglycerin increases risk of syncope & decreased coronary blood flow

29
Q

Nsg Education of Valvular disorders

A
  • disease process
  • progression of disease
  • treatment plan reporting new s/s or changes in symptoms
  • Infectious agents
    — How to minimize risk of developing infective endocarditis
  • How to take daily weight and when to report
    — same scale, same way
30
Q

Nsg Assessement of Valvular disorders

A
  • Hx rheumatic fever, endocarditis, IV drug abuse
  • Assess for s/s HF
    — Fatigue, DOE, decreased activity tolerance, increased coughing, hemoptysis, multiple respiratory infections, orthopnea, Paroxysmal nocturnal dyspnea
  • Dysrhythmias
    — Palpate pulse strength, rhythm
    — Ask if pt is or has been experiencing palpitations or felt forceful heartbeats
  • Symptoms such as dizziness, syncope, increased weakness (fall risk)
31
Q

Nsg Interventions of Valvular disorders

A
  • Assist with planning activity and rest periods that are acceptable to their lifestyle
  • Advise rest and sleep sitting in a chair or bed with the HOB elevated for pts who experience symptoms of pul. Congestion
  • Drug Therapy: stool softeners, diuretics, BB, dig, O2, prophylactic antibiotics, nitrates*
  • Check daily wt & advise pt when/how to take at home
32
Q

Valvular problems- Medical Interventions
Procedures:

A
  • Echocardiography
  • Transesophageal echocardiography (TEE)
  • Cardiac catheterization
33
Q

Echocardiography

A

to visualize structure and movement of heart
Stress echo
- evaluates symptomatic response and assess functional capacity
- med version of stress echo: Adenosine (adenocart)

34
Q

Transesophageal echocardiography (TEE)

A
  • More invasive procedure than echo
  • Done to visualize heart valves
  • This requires conscious sedation
35
Q

Cardiac catheterization

A

assesses severity of stenosis

36
Q

Surgical management: Valve Repair / replacement options

A
  • Balloon valvuloplasty (repair)
  • Invasive nonsurgical procedure
  • Benefits rarely lasting longer than 6 months
  • Commissurotomy-most common
37
Q

Surgical management: Valve Repair / replacement options

A

Balloon valvuloplasty (repair)
- Invasive nonsurgical procedure
- Benefits rarely lasting longer than 6 months
- commissurotomy- most common

38
Q

Nursing Post-op Valvuloplasty Care

A
  • Do not require continuous anticoagulation
  • after procedure, observe for bleeding
  • Observe for signs of heart failure and emboli
  • Assess for signs of regurgitant valve
  • Closely monitor heart sounds, CO and heart rhythm
  • Teach how to minimize risk of developing infective endocarditis
39
Q

Surgical management: valve repair/ Replacement options

A

Valve replacement
- Biological (from other species (pig/cow) vs Mechanical Valve

40
Q

Valve replacement

A
  • Mechanical
    — Lifetime anticoagulant therapy indicated
  • Biological
    — Valve from other species (pig/cow)
41
Q

Surgical management: valve repair/ Replacement options
Nursing Post-op Care

A
  • Monitor hemodynamics
  • Monitor signs of bleeding
  • Instruct client about anticoagulant therapy
  • Educate about all prescribed medications
  • Educate how to minimize risk of developing endocarditis
    — Maintain good oral hygiene with soft bristle tooth brush
    — Prophylactic antibiotics required prior to dental procedures
    — Avoid dental procedures for 6 months
  • Educate echocardiograms are usually performed 3-4wks post hospitalizations and repeated every 1-2 yrs
  • TAVI: transcathether aortic valve implantation: pt doesn’t have to have chest cracked open
42
Q

Cardiomyopathy

A

Abnormality of heart muscle leading to functional changes

43
Q

Types of cardiomyopathy:

A

Each causes decreased tissue perfusion:
- *Dilated Cardiomyopathy: decreased CO
- *Restrictive: Diastolic dysfunction
- *Hypertrophic: Autosomal dominant condition
- Arrhythmogenic Rt ventricular: Replacement of myocardial tissue with fibrous and fatty tissue Affects young adults

44
Q

Dilated Cardiomyopathy

A

Dilated (most common)
- Dilation of ventricles WITHOUT simultaneous hypertrophy
- End result= poor systolic function (decreased CO)
— Ventricles have increased (systolic & diastolic) volumes
— BUT a decreased ejection fraction all which decrease CO
- chest x-ray to see if heart is getting bigger

45
Q

Dilated Cardiomyopathy Causes

A
  • pregnancy, heavy alcohol intake, viral infection, chemo
  • Family genetics may be involved in some cases.
  • Because of genetic component, echo & EKG should be done to screen all first-degree blood relatives
46
Q

Restrictive Cardiomyopathy

A

Restrictive:
- Rigid ventricular walls do not stretch during filling (diastole), leads to right HF, decreased SV, decreased CO
- Systolic function is usually normal
- Causes: idiopathic in most cases
- S/S: dyspnea, nonproductive cough, chest pain

47
Q

Hypertrophic Cardiomyopathy

A
  • Hypertrophic- autosomal dominant condition
    — single gene autosomal dominant genetic trait.
    — Progressive thickening of ventricular muscle, decreased CO
  • Heart asymmetrically (not evenly all over; in certain places only) increases in size and mass especially along septum.
    — Increased thickness of heart, decreases size of vent. cavity & increases time it takes for vent to relax after systole
    — Arterioles narrow and restrict blood to the heart
  • Much testing is done performed every 12-18months
    — These screening may extend every 5yrs from 18-70yrs for those with a family history.
48
Q

Arrhythmogenic Cardiomyopathy

A
  • Arrhythmogenic Rt ventricular
  • Uncommon & genetic
  • Replacement of myocardial tissue with fibrous and fatty tissue
  • Should be suspected especially in sudden death of young athletes
  • First degree blood relatives should be screened for disease
  • 12 lead EKG, holter monitor, echo, cardiac MRI
  • Some pts affected by dysrhythmias may benefit from having an implantable cardioverter defibrillator
49
Q

Cardiomyopathy- ASSESSMENT

A
  • Similar to HF
  • Fatigue (dyspnea)
  • Dysrhythmias
  • Extra heart sounds (S3 & S4)
  • Edema in legs
  • Sodium levels (major electrolyte related to cardiomyopathy; use low sodium)
  • ETOH
  • JVD
50
Q

Cardiomyopathy- Therapeutic Management

A
  • Monitor for signs of HF
  • Encourage rest and minimize stress
  • Anticipate ACE inhibitors?
  • Ventricular assistive devices
  • Heart Transplant
  • Total Artificial Heart
51
Q

Endocarditis

A
  • Inflammation or infection of the heart valve
  • Caused by bacteria, viruses and rarely fungi primarily occurs in prostetic heart valves, pacemaker, cardiac defects or IV drug users
  • There are many types of endocarditis but for the most part when infection has to deal with being from a bacteria, virus or fungi, it is usually infective endocarditis. See Chart 28-4 Risk Factors pg 810
  • How does infective endocarditis happen? Infective endocarditis can occur in:
    — Normal valve (extremely bad bacteria ex. Strep. Viridans, Staph. Aureus )
    — already damaged valve ( from bacteria that’s not as bad- following dental work/surgery)
    — Prosthetic valve
52
Q

Infective Endocarditis

A

Common causes: IV drug use, valve replacement (bacteria, viruses, fungi)
- Points of entry for infecting organisms:
— Oral cavity (esp if dental surgery has been performed)
— Skin rashes, lesions, or abscesses
— Infections
— Surgery or invasive procedures including IV line placement

53
Q

Infective Endocarditis- ASSESSMENT

A
  • Spiking fever
  • fever associated with chills, night sweats, fatigue, WT. loss
  • Heart murmurs
  • Elevated WBC
  • Signs of heart failure
  • Embolic complications from clots breaking loose
  • Splinter hemorrhages: in nail bed (black, longitudinal, lines, or small red streaks on the nail bed
54
Q

Infective Endocarditis- NSG Management

A
  • IV Antimicrobial therapy
    — penicillins
    — Cephalosporins
  • Teach client to monitor for signs of infection
  • NSAIDS
  • Rest, fluids
  • Good oral hygiene (soft bristled tooth brush, teach what to avoid)
  • Antiembolic stockings (plus monitor for signs of emboli)
  • Avoid anticoagulants unless pt has prosthetic valve
  • Surgical interventions to remove infected valve or repair valve
55
Q

Pericarditis

A
  • Inflammation of the pericardium
  • Compression of the heart occurs as the pericardial sac inflames
  • May be asymptomatic
  • Most common symptom is chest pain
  • Chart 28-5Causes of Pericarditis
  • Can cause heart failure or *cardiac tamponade
  • pts 1-2 weeks after MI are at risk of pericarditis
56
Q

Cardiac tamponade- emergency!!!!

A
  • Blood or fluid that fills the space between the sac that encases the heart and the heart muscle
  • s/s:
    — chest pain (worse on inspiration)discomfort relieved by sitting forward
    — decreased BP
  • Causes: acute pericarditis
  • Tx: pericardiocentesis- to remove fluid and relieve pressure on the heart
  • Nsg interventions:
    — pain management
    — fluids & meds
    — oxygen as ordered
57
Q

Pericarditis- ASSESSMENT

A
  • Pain
  • ST elevation
  • Signs of heart failure
  • Pericardial friction rub
  • Asses for hx of systemic lupus erythematosus (SLE) or any systemic connective tissue disease
    — Acute pericarditis is most commonly associated with acute exacerbations of systemic connective tissue disease, including SLE.
58
Q

Pericarditis- Therapeutic management

A
  • Assess and treat pain
  • Administer O2 and place client in high fowler’s
  • Assess for cardiac tamponade
    — JVD with clear lungs
    — Narrow pulse pressure (difference between SBP & DBP)
    — Decreased CO
    — Muffled heart sounds
  • Physician may decide to perform pericardiocentesis
59
Q

Coronary Artery bypass graft surgery (CABG)

A

is a surgical procedure in which occluded coronary arteries are bypassed with the patient’s own venous or arterial blood vessels or synthetic grafts. Indication: to increase blood flow to heart muscles in clients with severe angina

60
Q

Coronary Artery bypass graft surgery (CABG) Pre op care:

A

includes educating and psychologically preparing client for surgery, and discontinuing digitalis, diuretics, aspirin and anticoagulants.

61
Q

Coronary Artery bypass graft surgery (CABG) Post op care:

A

includes care of mechanical ventilation, chest tubes, hemodynamic monitoring (Pulmonary artery and arterial pressures), monitoring heart rate and rhythm, offering pain relief and providing activity as tolerated with progress as ordered.

62
Q

Nursing Interventions- CABG Pre-op

A
  • Anxiety is common so communicate to alleviate fears Teach about procedure
    — Saphenous vein or internal mammary artery is used for graft. As many as 5 arteries may be bypassed. Synthetic grafts may be used as well.
    — Pt will have sternal incision, possibly a left leg incision, chest tubes, urinary catheter, hemodynamic monitoring, endotracheal tube connected to a ventilator, will not be able to speak
  • If procedure is elective: demonstrate and have pt return demo of how to splint the chest incision, cough and deep breathe, leg and arm exercises
  • Teach about meds to be administered
  • Teach medications will be changed after surgery.
  • Prepare them for post op care
63
Q

Nursing Interventions- Pre-op CABG Meds

A
  • Teach about meds to be administered Aspirin- assoc. w/ decreased periop morbidity and mortality
  • Antiarrhymics
  • Antihypertensives
  • Prophylactic antibiotics 20-30 min before surgery
  • Beta blockers- given 24hr before to decrease risk of post-op afib, decrease O2 demand
  • CCBs- relax vessels, increase O2 supply to heart
  • Potassium Chloride- to maintain normal K levels
  • Statins- decrease rates of post-op MI, afib
64
Q

CABG Post- op care

A
  • Teach ETT/vent are standard treatment after surgery. May be on vent for 3-6hrs
  • Monitor
    — Hypoxemia/hypokalemia frequent causes of dysrhythmias
  • Check neuro status frequently
  • Report any pain
    — Most of pain will be at incision site
  • Analgesics for pain
  • Turn, cough, deep breathe to prevent pulmonary complications
  • Early ambulation to decrease risk for DVT or possible embolism
    Pg 778 care plan of pt who’s had a CABG
65
Q

Nursing care of ETT

A

Includes:
- assessing bilat breath sounds
- bilat chest exursion
- marking tube at level it touches nose or mouth
- securing the tube to stabilize it in place
- encouraging fluids to facilitate removal of secretions
- offering alternative methods of comm

66
Q

CABG Post-op NURSING CARE:

A
  • Receives mechanical ventilation, chest tubes present, ETT in place so pt will not be able to talk.
  • Monitor for dysrhythmias, F&E imbalances, I&Os, edema, hypotension, hypothermia, pain
  • Monitor mid-sternal incision and leg incisions, chest tube insertion sites, central line insertion site (rt jugular)
  • Promote activity
  • Pain management
  • Provide emotional support to both patient and family

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