nurs 4110 med surg 2 Exam 2 Study Guide

Management of Patients with Structural, Infectious, and Inflammatory Cardiac Disorders (Chapter 28) 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 Valves of the Heart Specific Valvular Disorders • Mitral valve prolapse – a portion of one or both mitral valve leaflets balloons back into the atrium during systole; Blood then regurgitates from the left ventricle back into the left atrium • Mitral regurgitation – involves blood flowing back from the left ventricle into the left atrium during systole; edges of mitral valve leaflets do not close completely during systole because leaflets and chordae tendineae have thickened and fibrosed, resulting in their contraction • Mitral stenosis – an obstruction to blood flowing from the left atrium into the left ventricle; It most often is caused by rheumatic endocarditis, which progressively thickens mitral valve leaflets and chordae tendineae • Aortic regurgitation – flow of blood back into the left ventricle from the aorta during diastole; It may be caused by inflammatory lesions that deform aortic valve leaflets or dilation of the aorta, preventing complete closure of the aortic valve • Aortic stenosis – narrowing of the orifice between the left ventricle and aorta; stenosis often is a result of degenerative calcifications Nursing Management: Valvular Heart Disorders #1 • Patient education – educates the patient with valvular heart disease about the diagnosis, progressive nature of the disease, and treatment plan; educates the patient that an infectious agent, usually a bacterium, is able to adhere to a diseased heart valve more readily than to a normal valve; educates the patient about how to minimize the risk of developing infective endocarditis • Monitor VS trends – measures the patient’s heart rate, blood pressure, and respiratory rate, compares these results with previous data, and notes any changes; Heart and lung sounds are auscultated, and peripheral pulses palpated • Monitor for complications o Heart failure – fatigue, DOE, decreased activity tolerance, an increase in coughing, hemoptysis, multiple respiratory infections, orthopnea, and PND o Dysrhythmias – by palpating the patient’s pulse for strength and rhythm (i.e., regular or irregular) and asking whether the patient has experienced palpitations or felt forceful heartbeats o Other symptoms: dizziness, syncope – increased weakness, or angina pectoris • Medication schedule: education – provides education about the name, dosage, actions, adverse effects, and any drug–drug or drug–food interactions of prescribed medications for heart failure, dysrhythmias, angina pectoris, or other symptoms; Specific precautions are emphasized, such as the risk to patients with aortic stenosis who experience angina pectoris and take nitroglycerin • Daily weights: monitor for weight gain – educates the patient to take a daily weight and report sudden weight gain, as defined by the primary provider; assist the patient with planning activity and rest periods to achieve an acceptable lifestyle Nursing Management: Valvular Heart Disorders #2 • Plan activity with rest periods • Sleep with head of bed elevated Question #1 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.) A. MVP is not hereditary B. Caffeine is tolerated in small amounts C. Avoid alcohol D. Stop use of tobacco products E. Prophylactic antibiotics are not prescribed before dental procedures Rationale: MVP is hereditary, and caffeine should be avoided Surgical Management: Valvular Heart Disorders • Valvuloplasty – Repair, rather than replacement, of a cardiac valve is referred to as valvuloplasty; Patients who undergo valvuloplasty do not require continuous anticoagulation o Commissurotomy – Repair may be made to commissures between the leaflets in a procedure o Balloon valvuloplasty – Percutaneous balloon valvuloplasty is the technique most commonly performed in the United States as a bridge to surgical valve replacement or transfemoral aortic valve replacement for closed commissurotomy; Balloon valvuloplasty is beneficial for mitral valve stenosis in younger patients and for patients with complex medical conditions that place them at high risk for complications of more extensive surgical procedures o Annuloplasty – repair of the valve annulus (i.e., junction of valve leaflets and muscular heart wall); General anesthesia and cardiopulmonary bypass are required for most annuloplasties o Leaflet repair – elongated, ballooning, or other excess tissue leaflets is removal of the extra tissue. Elongated tissue may be tucked and sutured (i.e., leaflet plication). A wedge of tissue may be cut from the middle of the leaflet and the gap sutured closed o Chordoplasty – repair of chordae tendineae. The mitral valve is most often involved with chordoplasty. The tricuspid valve seldom requires chordoplasty because tricuspid valve disease is often a result of mitral or aortic valve disease or left ventricular dysfunction • Valve replacement o Mechanical – Mechanical valves are of the bileaflet, tilting-disc, or ball-and-cage design and are thought to be more durable than tissue prosthetic valves; therefore, they often are used for younger patients o Tissue – Tissue valves are less likely than mechanical valves to generate thromboemboli, and long-term anticoagulation is not required ▪ Bioprosthesis – Bioprostheses are tissue valves (e.g., heterografts) used for aortic, mitral, and tricuspid valve replacement. They are not thrombogenic; therefore, patients do not need long-term anticoagulation therapy. They are used for women of childbearing age because potential complications of long-term anticoagulation associated with menses, placental transfer to a fetus, and delivery of a child are avoided. They also are used for patients older than 70 years and others who cannot tolerate long-term anticoagulation ▪ Homografts – Homografts, or allografts (i.e., human valves), are obtained from cadaver tissue donations and are used for aortic and pulmonic valve replacement ▪ Autografts – Autografts (i.e., autologous valves) are obtained by excising the patient’s own pulmonic valve and a portion of the pulmonary artery for use as the aortic valve. Anticoagulation is unnecessary because the valve is the patient’s own tissue and is not thrombogenic. The autograft is an alternative for children (it may grow as the child grows), women of childbearing age, young adults, patients with a history of peptic ulcer disease, and people who cannot tolerate anticoagulation. Annuloplasty Ring Insertion Valve Leaflet Resection and Repair With Ring Annuloplasty Valve Replacement Nursing Management: Valvuloplasty and Valve Replacement #1 • Balloon valvuloplasty o Monitor for heart failure and emboli o Assess heart sounds every 4 hours o Same care as after cardiac catheterization • Surgical valvuloplasty or valve replacements o Focus is hemodynamic stability and recovery from anesthesia o Frequent assessments with attention to neurologic, respiratory, and cardiovascular systems Nursing Management – Valvuloplasty and Valve Replacement #2 • Patient education o Anticoagulation therapy o Prevention of infective endocarditis o Follow up o Repeat echocardiograms 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 o Dilated cardiomyopathy (DCM) – the most common form of cardiomyopathy; distinguished by significant dilation of the ventricles without simultaneous hypertrophy (i.e., increased muscle wall thickness) and systolic dysfunction; ventricles have elevated systolic and diastolic volumes but a decreased ejection fraction o Hypertrophic cardiomyopathy (HCM) – an autosomal dominant condition, occurring in men, women, and children (often detected after puberty); Echocardiograms, 12-lead ECGs, and complete history and physical examinations are typically performed every 12 to 18 months from age 12 to 18 years o Restrictive/constrictive cardiomyopathy (RCM) – characterized by diastolic dysfunction caused by rigid ventricular walls that impair diastolic filling and ventricular stretch; Systolic function is usually normal; RCM may be associated with amyloidosis (amyloid, a protein substance, is deposited within cells) and other such infiltrative diseases o Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) – occurs when the myocardium is progressively infiltrated and replaced by fibrous scar and adipose tissue. Initially, only localized areas of the right ventricle are affected, but as the disease progresses, the entire heart is affected. Eventually, the right ventricle dilates and develops poor contractility, right ventricular wall abnormalities, and dysrhythmias o Unclassified cardiomyopathy – Unclassified cardiomyopathies are different from or have characteristics of more than one of the previously described types and are caused by fibroelastosis, noncompacted myocardium, systolic dysfunction with minimal dilation, and mitochondrial diseases Cardiomyopathies That Lead to Congestive Heart Failure Question #2 What is the main electrolyte involved in cardiomyopathy? A. Calcium B. Phosphorus C. Potassium D. 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 Nursing Process: The Patient with Cardiomyopathy (Assessment) • History (predisposing factors, family history) • Chest pain • Review of systems: presence of orthopnea, syncope • 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