Chapter 28

Management of Patients With

Structural, Infectious, and
Inflammatory Cardiac Disorders

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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

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Valves of the Heart

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Specific Valvular Disorders

Mitral valve prolapse: A portion of one or both mitral valve
leaflets balloons back into the atrium during systole.
Hereditary.
Mitral regurgitation (Insufficiency): Involves blood flowing
back from the left ventricle into the left atrium during
systole.
Mitral stenosis: An obstruction to blood flowing from the
left atrium into the left ventricle.
Aortic regurgitation (Insufficiency): Flow of blood back
into the left ventricle from the aorta during diastole.
Aortic stenosis: Narrowing of the orifice between the left
ventricle and aorta.
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Valvular Disease Chart

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Heart Valves

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Mitral Valve Prolapse

Mitral & Aortic valve disorders are most common valve
problems. Tricuspid & Pulmonic are rare. Pulmonic
stenosis is congenital.
Mitral Valve Prolapse (MVP) occurs when valve
leaflets are enlarged and prolapse into L atrium during
systole. Most often a benign condition, and usually
asymptomatic, but can cause CP, palpitations, exercise
intolerance, or fainting. A mid-systolic click heard at the
apex is characteristic of MVP

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Mitral Regurgitation (Insufficiency)

Mitral Regurgitation (Insufficiency): Rheumatic heart
disease is the main cause. Other causes are papillary muscle
rupture from ischemic heart disease, congenital defects, and
infective endocarditis
Fibrosis and calcification prevent valve from closing completely.
Blood backflows, then L ventricle must work harder to eject
extra blood. This cause hypertrophy of ventricle.
More women than men are affected.
S/S may take decades to emerge. Fatigue and weakness
(first), dyspnea on exertion, and orthopnea are later
developments.
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Mitral Regurgitation (Cont)

Mitral Regurgitation (cont): Other S/S include c/o
palpitations, atypical CP, anxiety. Extremities may be
cool and clammy and peripheral pulses are thready.
A-Fib may occur.

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Mitral Stenosis
Mitral Stenosis: Commonly caused by Rheumatic Fever.
Other causes are lupus, RA.
Valve leaflet becomes stiffened after calcification. L
atrium must work harder to pump blood thru the
narrowed valve. Pulmonary pressure increases which
may cause the right ventricle to hypertrophy.
First symptom may be dyspnea on exertion. Paroxysmal
dyspnea (sudden dyspnea at night), A-Fib, and dry cough
may occur, A diastolic rumbling murmur may be heard.
If untreated, R-sided HF may occur.
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Aortic Regurgitation (Insufficiency)

Aortic Regurgitation (Insufficiency): Infective
Endocarditis, congenital defects, longterm HTN, and
Marfan syndrome (a rare genetic connective tissue
disease) are factors in aortic regurgitation.
Valve leaflets do not close properly during diastole
allowing backflow of blood from the aorta into the L
ventricle. The L ventricle dilates and hypertrophies from
the greater blood volume.

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Aortic Regurgitation (Cont)

S/S do not appear until L ventricular failure happens.
Dyspnea on exertion, orthopnea, and paroxysmal
dyspnea begin. Nocturnal angina w/diaphoresis and
palpitation, particularly when lying on the left side, occur
late in the disease. Pulse is bounding and pulse pressure
is widened w/increased systolic pressure and decreased
diastolic pressure. On auscultation, there is a highpitched, blowing diastolic murmur.

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Aortic Stenosis
Aortic Stenosis: Most common valve disorder in the US.
Atherosclerosis w/degenerative calcification of the valve is
common factor in older adults. In younger pts, congenital
valve malformations and rheumatic fever are primary causes.
Aortic valve opening narrows and obstructs L ventricular
outflow during systole. Increased pressure required to eject
blood causes L ventricular hypertrophy. Cardiac output is
decreased to the point that the bodys demands cannot be met
during exertion. Systolic HF begins and pulmonary congestion
produces symptoms. When the valve opening becomes
<1cm, surgery is urgent.

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Aortic Stenosis (Cont)

Classic S/S of aortic stenosis are dyspnea, fatigue,
and syncope on exertion. Later, extreme fatigue,
weakness, and peripheral cyanosis become
apparent.

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Nursing Management: Valvular Heart

Disorders
Patient education
Monitor VS trends
Monitor for complications
Heart failure
Dysrhythmias
Other symptoms
Medication schedule: education
Daily weights: monitor for weight gain
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Nursing Management: Valvular Heart

Disorders (contd)
Plan activity with rest periods
Sleep with HOB elevated

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Question
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.
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Answer
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.

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Treatment of Valve Disorders

Depends on valve affected and degree of impairment
Yearly monitoring and drug therapy for symptoms is
standard when disease is not severe. Later, heart surgery
may be needed.
Rest is an important part of therapy.
Before invasive procedures, prophylactic ATB are
necessary for all pts w/valve disease
Surgical TX is required when valve disease becomes
severe.
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Surgical Management:
Valvular Heart Disorders
Valvuloplasty

Valve replacement

Commissurotomy

Mechanical

Balloon valvuloplasty

Tissue

Annuloplasty

Bioprosthesis

Leaflet repair

Homografts

Chordoplasty

Autografts

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Surgical TX
Balloon valvuloplasty is sometimes used to open
stenosed valves. Its performed w/ a balloon tip catheter,
which is threaded via the femoral artery into the heart
and into the diseased valve. The balloon is inflated to
enlarge the opening, then deflated and removed. Often,
stenosis recurs in 6 months.
Direct commissurotomy occurs during
cardiopulmonary bypass w/open heart surgery. Thrombi
are removed from the atria and leaflets are incised along
with calcification debridement; this opens the valve
orifice.
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Surgical TX (Cont)
Mitral Valve Annuloplasty is performed for acquired mitral
regurgitation. Involves making the valve ring (annulus) smaller
w/sutures. Leaflets are repaired to provide good closure of the
valve at systole.
Valve replacement: Using mechanical (prosthetic) or biologic
(tissue from cadavers) valves. If mechanical, pt. needs
anticoagulant therapy for their lifetime due to clot formation.
Mechanical valves are more durable. The aortic valve is always
replaced w/ a mechanical valve due to high pressure in aorta.
Biologic valves require no anticoagulants, but may wear out in
15 years, requiring additional surgery.

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Balloon Valvuloplasty

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Annuloplasty Ring Insertion

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Valve Leaflet Resection and Repair With

Ring Annuloplasty

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Valve Replacement

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Mechanical & Biologic Tissue Valves

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Nursing Management: Valvuloplasty and

Valve Replacement
Balloon valvuloplasty
Monitor for heart failure and emboli
Assess heart sounds every 4 hours
Same care as after cardiac catheterization
Surgical valvuloplasty or valve replacements
Focus is hemodynamic stability and recovery from
anesthesia
Frequent assessments with attention to neurologic,
respiratory, and cardiovascular systems
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Nursing ManagementValvuloplasty and

Valve Replacement (contd)
Patient education
Anticoagulation therapy
Prevention of infective endocarditis
Follow up
Repeat echocardiograms

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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
Restrictive cardiomyopathy
Hypertrophic cardiomyopathy
Dilated cardiomyopathy
Arrhythmogenic cardiomyopathy
Unclassified cardiomyopathies
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Cardiomyopathies That Lead to

Congestive Heart Failure

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Cardiomyopathy
Dilated: Extensive enlargement of ventricles w/impairment of
contractions. Caused by chemotherapy, alcohol abuse,
infection, inflammation, poor nutrition, and connective tissue
disorders. Advances to HF.
Hypertrophic: Increased growth of L ventricle muscle. May be
hereditary, caused by HTN, or hypoparathyroidism. Sudden
death may occur
Restrictive: Stiffened ventricles prevent adequate relaxation
after systole, affecting filling. Caused by systemic diseases
such as amyloidosis or sarcoidosis. Progresses to R-sided HF.

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Cardiomyopathies
A group of diseases that affect the structure or function
of the heart
S/S include dyspnea, activity intolerance, angina,
dizziness, HTN, palpitations
Diagnosis is made by cardiac cath, echocardiography,
ECG, or CT/MRI scans
Treatment includes drugs to increase contractility (such
as digoxin), antihypertensives, diuretics, antiarrhythmics,
and anticoagulants
Possible heart transplant pts
Should avoid sodium!
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Question
What is the main electrolyte involved in cardiomyopathy?
A.Calcium
B.Phosphorus
C.Potassium
D.Sodium

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Answer
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.

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Nursing Process: The Patient With

Cardiomyopathy (Assessment)
History (predisposing factors, family history)
Chest pain
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

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Nursing Process: The Patient with

Cardiomyopathy (Nursing Diagnosis)
Decreased cardiac output
Risk for ineffective cardiac, cerebral, peripheral, and
renal tissue perfusion
Impaired gas exchange
Activity intolerance
Anxiety
Powerlessness
Noncompliance with medication and diet therapies
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Collaborative Problems and Potential

Complications
Heart failure
Ventricular dysrhythmias
Atrial dysrhythmias
Cardiac conduction defects
Pulmonary or cerebral embolism
Valvular dysfunction

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Nursing Process: The Patient With

Cardiomyopathy (Planning and Goals)
Goals
Improvement or maintenance of cardiac output
Increased activity tolerance
Reduction of anxiety
Adherence to the self-care program
Increased sense of power with decision making
Absence of complications

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Nursing Process: The Patient With

Cardiomyopathy (Nursing Interventions)
Improve cardiac output and peripheral blood flow
Rest, positioning (legs down), supplemental O2,
medications, low Na diet, avoid dehydration
Increase activity tolerance and improving gas exchange
Cycle rest and activity, ensure patient recognizes
symptoms that indicate the need for rest
Reduce anxiety
Eradicate or alleviate perceived stressors, educate
family about diagnosis, assist with anticipatory
grieving
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Nursing Process: The Patient With

Cardiomyopathy (Nursing Interventions)
(contd)
Decrease the sense of powerlessness
Assist patients in identifying things that have been
lost (i.e., ability to play sports), assist patients in
identifying amount of control they still have left
Promote home- and community-based care
Educate patients about ways to balance lifestyle and
work while accomplishing therapeutic activities
Assess patient and family and their adjustment to
lifestyle changes, educate family about CPR and
AEDs, establish trust
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Nursing Process: The Patient With

Cardiomyopathy (Evaluation)
Maintain or improve cardiac function
HR and RR WNL, decreased dyspnea and increased
comfort, maintain or improve gas exchange, absence
of weight gain, maintain or improve peripheral blood
flow
Maintain or increase activity tolerance
Carry out activities of daily living (e.g., brush teeth,
feed self), reports increased tolerance to activity

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Nursing Process: The Patient With

Cardiomyopathy (Evaluation) (contd)
Reduce anxiety
Discusses prognosis, verbalizes fears and concerns,
participates in support groups, demonstrates
appropriate coping mechanisms
Decrease sense of powerlessness
Identifies emotional response to diagnosis, discusses
control that he or she has
Adhere to self-care program
Takes medications as prescribed, modifies diet to
accommodate sodium and fluid recommendations,
modifies lifestyle, identifies S&S to be reported
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Infectious Diseases of the Heart

Any of the layers of the heart may be affected by an infectious
process.
Diseases are named by the layer of the heart that is affected.
Diagnosis is made by patient symptoms and echocardiogram.
Blood cultures may be used to identify the infectious agent
and to monitor therapy.
Treatment is with appropriate antimicrobial therapy. Patients
require teaching to complete the course of appropriate
antimicrobial therapy and require teaching for infection
prevention and health promotion.

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Types of Infectious Disease of the Heart

Rheumatic endocarditis
Occurs most often in school-age children after group A
beta-hemolytic streptococcal pharyngitis; need to
promptly recognize and treat strep throat to prevent
rheumatic fever
Infective endocarditis
Usually develops in people with prosthetic heart valves
or structural cardiac defects; also occurs in patients
who are IV drug abusers and in those with debilitating
diseases, indwelling catheters, or prolonged IV therapy

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Types of Infectious Disease of the Heart

Pericarditis
Inflammation of the pericardium; many causes;
potential complications: pericardial effusion and
cardiac tamponade
Myocarditis
An inflammatory process involving the myocardium;
most common pathogens involved in myocarditis tend
to be viral; in endocarditis, they tend to be bacterial;
complications: cardiomyopathy and heart failure

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Clinical Manifestations: Infectious

Diseases of the Heart
Fever
New heart murmur, friction rub at left lower sternal border
(pericarditis)
Osler nodes (painful, red, raised lesions found on the hands and feet),
Janeway lesions (non-tender, small erythematous or hemorrhagic
macular or nodular lesions on the palms or soles only a few
millimeters in diameter), Roth spots (retinal hemorrhages), and
splinter hemorrhages in nailbeds (Rheumatic)
Cardiomegaly, heart failure, tachycardia, splenomegaly
Fatigue, dyspnea, syncope, palpitations, chest pain (myocarditis)
Diagnostic tools: blood cultures, echocardiogram, CBC, rheumatoid
factor, ESR, CRP, urinalysis, ECG, cardiac catheterization, CMR
imaging, TEE, CT scan
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Prevention
Antibiotic prophylaxis before certain procedures
Ongoing oral hygiene
Female patients are advised NOT to use IUDs
Meticulous care should be taken in patients at risk who
have catheters
Catheters should be removed as soon as they are no
longer needed
Immunizations

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Question
A patient with restrictive cardiomyopathy taking digoxin
presents with symptoms of anorexia, nausea, vomiting,
headache, and malaise. What should the nurse expect to
be included in the plan of care for this patient?
A.The patients digoxin will be changed to nifedipine.
B.The patients digoxin dose will be decreased.
C.Nothing; these are signs of restrictive cardiomyopathy
that are expected.
D.The patient will be admitted to an ICU.
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Answer
B. The patients digoxin dose will be decreased.
Rationale: Patients with restrictive cardiomyopathy are
sensitive to digitalis. Nurses must closely monitor these
patients for digitalis toxicity, which is evidenced by
dysrhythmia, anorexia, nausea, vomiting, headache,
and malaise. This patient presents with symptoms of
digoxin toxicity, so a decrease in dosage should be
anticipated. These patients should avoid nifedipine, and
they do not need to be admitted to the ICU.

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