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Nursing 172 > Week 8: Chp 30 Valvular Disease > Flashcards

Week 8: Chp 30 Valvular Disease Flashcards

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1
Q

Risk Factors Of Valvular Disease

A
  • increases with age
  • infectious diseases such as infective endocarditis (IE), rheumatic fever, myocardial infarction, heart failure, congenital defects, and degenerative changes
  • pregnancy increases risk of valvular disease because of the increased workload on the heart
  • patients with risk factors for coronary artery disease are also at risk for valvular disease
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2
Q

Most common valvular diseases

A

-aortic stenosis and
-mitral regurgitation
>the least common valves affected are the tricuspid and pulmonic valves because of the low-pressure system in the right heart

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3
Q

Several types of Valvular Disease

A
  • stenosis
  • insufficiency or regurgitation
  • prolapse
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4
Q

Regurgitation

A

backward flow through the valve

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5
Q

In response to backward flow through the valve, regurgitation, or resistance to forward flow through the constricted or stenosed valve what develops?

A

signs of right or left sided Heart failure

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6
Q

Mitral Valve regurgitation

A

causes backward flow of blood into the left atrium
-the increased blood volume raises the pressure in the atrium and pulmonary vessels and results in pulmonary edema and left sided heart failure

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7
Q

Aortic Valve Stenosis

A

obstructs the flow of blood from the left ventricle (LV), causing increased LV pressure

  • left ventricle hypertrophy occurs to generate adequate force to open the valve
  • over-time the left ventricle fails, also resulting in the signs of left sided heart failure
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8
Q

What happens in insufficiency of the tricuspid valve?

A

causes backward flow and increased pressure in the right atrium, which results in signs of right-sided heart failure such as JVD, generalized edema and ascites

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9
Q

Types of Valvular disease: Stenosis

A

stiffening and thickening of the valve leaflets, caused by calcium deposits or scarring, narrow the opening and obstruct flow

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10
Q

Types of Valvular Disease: Regurgitation or Insufficiency

A

blood flows or leaks backward- ventricle to atria, aorta to left ventricle, pulmonic circulation to the right ventricle– because of incomplete closing of the valve

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11
Q

Types of Valvular Disease: Prolapse

A

valve leaflets bulge backwards and do not close, causing regurgitation

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12
Q

First clinical sign of valvular disease

A

auscultation of a murmur

  • a murmur can be a result of a high rate of blood flow through a valve, forward blood flow through a narrowed valve (stenosis), or backward blood flow through an incompetent valve (regurgitation)
  • a cardiac murmur can be classified as systolic, diastolic, or continuous on the basis of where in the cardiac cycle it is best heard
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13
Q

Cardiac Murmurs can be classified how?

A

systolic, diastolic, or continuous on the basis of where in the cardiac cycle it is best heard

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14
Q

Cardiac murmurs classification: Systolic murmurs

A

can be heard during S1 or lub when the ventricles are contracting

  • during this time the aortic or pulmonic valves should be open, and the mitral and tricuspid valves should be closed
  • can be heard with aortic or pulmonic stenosis or mitral or tricuspid regurgitation
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15
Q

Cardiac Murmurs classification: Diastolic murmurs

A

can be heard during S2 or dub, when the ventricles are relaxing and the heart is filling

  • the mitral and tricuspid valves should be open to allow for ventricular filling, and the aortic and pulmonic valves should be closed
  • can be heard with aortic and pulmonic valve regurgitation or mitral and tricuspid stenosis
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16
Q

Clinical Manifestations of valvular disease

A
  • SOB, dyspnea, orthopnea
  • crackles
  • angina
  • syncope, dizziness
  • dysrhythmias
  • palpitations
  • fatigue
  • weight gain
  • edema
  • cool, pale extremities with weak pulses
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17
Q

Diagnostic Tests

A
  • Echocardiogram to identify valve abnormalities and ejection fraction
  • Chest x-ray to identify left or right heart hypertrophy and pulmonary edema
  • Stress Testing: to identify functional capacity
  • Heart Catheterization as a definitive test for stenosis done prior to corrective surgery
  • CT or MRI
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18
Q

Diagnostic Tests

A
  • Echocardiogram to identify valve abnormalities and ejection fraction
  • Chest x-ray to identify left or right heart hypertrophy and pulmonary edema
  • Stress Testing: to identify functional capacity
  • Heart Catheterization: as a definitive test for stenosis done prior to corrective surgery
  • CT or MRI
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19
Q

Medication Management

A

for valvular disease is dependent on the etiology and degree of the disease

  • valvular disease with infectious etiology require antimicrobial therapy, whereas advanced valvular diseases require general HF management
  • determined by the type of valve utilized in valve replacement; patients who undergo valve replacement with a mechanical prosthetic valve will need to be anticoagulated for life to prevent thrombotic events such as strokes
  • Tissue valves have recommended anticoagulation for only 6 months after placement but have less longevity (typically considered in patients who are older or cannot be anticoagulated0
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20
Q

Medications

A

general HF management:

  • angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), or angiotensin receptor-neprilysin inhibitors (ARNIs) with beta blockers to reduce heart rate and blood pressure
  • Diuretics to decrease preload and pulmonary congestion
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21
Q

Safety Alert

A

care must be taken when managing blood pressure for patients with aortic stenosis

  • these patients require higher preload in order to generate adequate pressure for blood flow through the stenosed valve
  • decreasing preload can lead to decreased cardiac output and hypotension
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22
Q

Surgical Management

A

surgical intervention to to repair or replace diseased valves is often indicated and is based on the degree of valve dysfunction, symptom severity, and surgical risk

  • for patients needing valve replacement, open-heart surgery with a mechanical or bioprosthetic valve remains the standard approach; these patients undergo anesthesia and are placed on cardiopulmonary bypass, and the diseased valves are replaced through a sternal incision or multiple smaller chest incisions
  • for patient with comorbidities, this comes with an increased risk of operative mortality; fewer of these patients undergo surgery
  • a more recent treatment option for aortic valve replacement is prosthetic valves that allow a transcatheter approach to valve replacement; transcatheter aortic valve replacement (TAVR)
  • reparative surgery yields better outcomes than replacement
23
Q

Surgical Management: Transcatheter Aortic Valve Replacement (TAVR)

A

a new valve is deployed through a catheter that is peripherally inserted and guided to the heart
-the TAVR procedure is recommended for intermediate and high-operative-risk patients with aortic stenosis

24
Q

Reparative Surgery

A

yields better outcomes than replacement surgery
-balloon valvuloplasty, commissurotomy, and mitral valve angioplasty
>balloon valvuloplasty is a transcatheter procedure to repair stenosed valves; it involves inserting a balloon catheter through an appropriate vessel and advancing it to the heart; the balloon is inflated in the affected valve to enlarge the opening
>Commissurotomy is a surgical procedure done to incise fused leaflets, widening the valve opening
>Valve angioplasty is a reconstructive procedure to repair the ring (annulus) that attaches and supports the valve leaflets

25
Q

Nursing Management: Assessment and Analysis

A

-murmurs resulting from turbulent blood flow through diseased valves are heard with valve disease
-patients may be asymptomatic until valve function becomes significantly impaired, at which time clinical manifestations of HF related to decreased cardiac output and pulmonary congestion become prevalent:
>SOB, angina, syncope, dysrhythmias, palpitations, dizziness, fatigue, weight gain, poor color, cool extremities, weak peripheral pulses

26
Q

What is heard with valve disease?

A

murmurs resulting from turbulent blood flow through diseased valves

27
Q

Nursing Diagnosis

A
  • decreased cardiac output r/t decreased stroke volume secondary to valve disease
  • activity intolerance r/t decreased cardiac output secondary to HF due to valve disease
28
Q

Nursing Interventions: Assessment

A
  • vital signs
  • pain
  • monitoring for irregular heart rhythm
  • peripheral vascular assessment
  • breath sounds
  • activity tolerance
  • auscultate heart sounds
  • daily weights, intake and output
  • monitor international normalized ratio (INR)
29
Q

Assessment: Vital Signs

A

hypertension, tachycardia, and tachypnea are indicative of HF due to increased resistance to flow and backflow of blood to the pulmonary system

  • tachycardia occurs as a compensatory mechanism to increase cardiac output and oxygenation
  • fever is indicative of infection and increases metabolic demands
  • decreased Sp02 occurs with pulmonary congestion
30
Q

Assessment: Pain

A

chest pain and palpitations may occur with some murmurs

31
Q

Assessment: Monitoring for irregular heart rhythm

A

dysrhythmias, specifically atrial fibrillation, are common in valve disease

32
Q

Assessment: Peripheral vascular assessment

A

poor color, cool extremities, weak peripheral pulses, delayed capillary refill, and edema can indicate inadequate cardiac output

33
Q

Assessment: Breath Sounds

A

crackles and orthopnea indicate pulmonary congestion

34
Q

Assessment: Activity tolerance

A

dyspnea on exertion, weakness, and fatigue indicate worsening HF

35
Q

Assessment: monitor heart sounds

A

murmurs are typically the initial manifestation of valvular disease

36
Q

Assessment: Daily weights, intake and output

A

weight increases and intake greater than output can be indicative of HF

37
Q

Assessment: Monitor international normalized ratio (INR)

A

patients with valve replacements on warfarin need to maintain an INR that is two to three times normal

38
Q

Nursing Actions

A
  • provide supplemental oxygen and elevate head of bed
  • administer medications as ordered: diuretics, ACE inhibitors, ARBs, ARNIs, beta blockers, antibiotics, anticoagulants
  • restrict sodium and fluids
39
Q

Nursing Actions: Provide supplemental oxygen and elevate the head of the bed

A

oxygen and positioning increase oxygenation and ventilation

40
Q

Nursing Actions: Administer medications as ordered; diuretics, ACE inhibitors, ARBs, ARNIs, beta blockers, antibiotics, anticoagulants

A

medications are indicated for the relief of symptoms, not as a curative measure

  • diuretics help decrease fluid overload
  • ACE inhibitors, ARBs, ARNIs, and beta blockers decrease heart rate and blood pressure thus decreasing myocardial workload
  • antibiotics are indicated if the valvular disease is caused by an infection such as IE
  • anticoagulation decreases the risk of thrombus formation in patients with prosthetic valve or patients in atrial fibrilation
41
Q

Diuretics help with what?

A

decreasing fluid overload

42
Q

ACE inhibitors, ARBs, ARNIs, and beta blockers do what?

A

decrease heart rate and blood pressure thus decreasing myocardial workload

43
Q

Anticoagulation medications do what?

A

decrease the risk of thrombus formation in patients with prosthetic valve or patients in atrial fibrillation

44
Q

Nursing Actions: Restrict sodium and fluid

A

to decrease fluid overload and reduce HF symptoms

45
Q

Teaching

A
  • medication teaching
  • consider prophylactic antimicrobials for dental procedures only for patients at high risk
  • strict adherence to anticoagulation regimen if prosthetic valve
  • anticoagulation precautions
  • maintain consistent intake of leafy green vegetables if taking warfarin
46
Q

Teaching: mediation teaching

A

understanding and adhering to the medication treatment plan are essential for effective medication treatment

47
Q

Teaching: consider prophylactic antimicrobials for dental procedures only for patients at high risk

A

prevent recurrence of infectious valvular disease

48
Q

Teaching: Strict adherence to anticoagulation regimen if prosthetic valve

A

prevent thrombotic/ embolic events (i.e stroke)

49
Q

Teaching: Anticoagulation precautions

A

avoid activities/ sports that have a high risk for injury, report any injuries or falls to your provider, report anticoagulant use prior to any procedure, take care with flossing to avoid bleeding and limit alcohol consumption
-avoid activities/ actions that increase bleeding risk

50
Q

Teaching: Maintain consistent intake of leafy green vegetables if taking warfarin

A

green leafy vegetables impair the effectiveness of the anticoagulant warfarin

51
Q

Successful management

A

requires maximizing cardiac output through repair or replacement of the damaged valve and controlling the symptoms of HF

52
Q

Patients with Valvular disease can achieve a high functional status by?

A

complying with the prescribed medical therapy, maintaining a healthy diet, and engaging in regular exercise
-vital signs within normal limits, increased energy, and an ability to actively participate in work and activities of daily living are indicative of disease control

53
Q

Safety Alert: Orthostatic Hypotension

A

moving from a supine to an upright position is normally associated with a slight decrease in blood pressure

  • this is due to the pooling of blood in the lower extremities when the upright position is assumed, reducing the amount of blood returning to the heart and perfusion to the brain
  • In most people, the autonomic nervous system sends signals to the blood vessels in the lower extremities to constrict; signals are also sent to the heart to increase rate; both mechanisms increase cardiac output
  • In cardiac patients on many antihypertensive medications, the automatic response can be impaired, thus, moving to an upright position results in feeling of dizziness and syncope, which puts the patient at risk for falls
  • patient should be cautioned to transition from the supine or sitting to the standing position slowly by sitting briefly before before standing
  • some anti-hypertensive medications should be given with caution, starting with a lower dose and evaluating the patients response, especially in older adults, to reduce incidence of orthostatic hypotension
54
Q

Measure orthostatic hypotension

A

have the patient assume a supine (laying flat) position for at least 2 minutes and record the blood pressure and heart rate

  • then have the patient assume an upright position and record BP and heart rate
  • generally a reduction of 20 mm hg or more in systolic reading and/ or 15 mm hg in diastolic value denotes the presence of orthostatic hypotension

Nursing 172 (120 decks)

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