Valvular heart disease Key points - PowerPoint Presentation

Slide1

Valvular heart disease

Slide2

Key points

Valvular

heart disease may have congenital or acquired causes.

Valves on the left side are most commonly affected due to higher pressures.

Valvular

disease is classified as:

Stenosis – narrowed opening that impedes blood moving forward.

Insufficiency – improper closure – some blood flows

backward (regurgitation

).

Congenital

valvular

disease may affect all four valves and cause either stenosis

or insufficiency

.

Acquired

valvular

disease is classified as one of three types:

Degenerative disease – due to damage over time from mechanical

stress; mostly results from hypertension.

Rheumatic disease – gradual fibrotic changes, calcification of valve

cusps. The

mitral valve is most commonly affected.

Infective endocarditis – infectious organisms destroy the

valve. Streptococcal

infections are a common cause.

Slide3

Risk Factors for

Valvular

Heart

Disease

Hypertension

Rheumatic fever (mitral stenosis and insufficiency)

Infective endocarditis

Congenital malformations

Marfan

syndrome

Slide4

Diagnostic Procedures and Nursing Interventions

Chest x-ray (chamber

enlargement, pulmonary congestion, and

valve calcification).

12-lead electrocardiogram (ECG) shows chamber hypertrophy.

Echoco

(US) show s

chamber size, hypertrophy, specific valve

dysfunction, ejection

function, and amount of

regurgitant

flow

.

Exercise tolerance

testing (stress echo);

impact

of the

valve problem on functioning during stress.

Angiography

reveals chamber pressures, ejection fraction, regurgitation,

and pressure

gradients

Slide5

Therapeutic Procedures and Nursing Interventions

Percutaneous

balloon

valvuloplasty

may open the

stenotic

aortic or

mitral valves

. A catheter is inserted through the femoral artery and advanced to

the heart. A

balloon is inflated at the

stenotic

lesion to

open

the fused

commissures

and improve

leaflet

mobility

.

Surgical management includes valve repair, chordae

tendineae

reconstruction and

prosthetic valve replacement.

Prosthetic valves may be mechanical or tissue. Mechanical valves last

longer but

require anticoagulation. Tissue valves last 10 to 15 years.

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Assessments

Monitor

for signs and symptoms

.

Left-sided valve damage results in

dyspnea

,

fatigue,

increased pulmonary artery pressure,

and

decreased cardiac output.

Right-sided valve damage results in

dyspnea, fatigue

, increased right atrial pressure,

peripheral edema, jugular vein distention, and hepatomegaly

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Mitral stenosis

Mitral insufficiency

Aortic stenosis

Aortic insufficiency

Palpitations

Proximal nocturnal

Dyspnea

Angina

Angina

Hemoptysis

Orthopnea

Angina

S3

Hoarseness

Palpitations

Syncope

Diastolic murmur

Dysphagia

S3 and/or S4

Decreased SVR

Widened pulse

pressure

Jugular vein

distention

Crackles in lungs

S3 and/or S4

Orthopnea

Systolic murmur

Systolic murmur

Cough

Atrial fibrillation

Narrowed pulse

pressure

Diastolic murmur

Atrial fibrillation

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Tricuspid stenosis

Tricuspid

insufficiency

Pulmonic stenosis

Pulmonic

insufficiency

Atrial dysrhythmias

Conduction delays

Cyanosis

Diastolic murmur

Diastolic murmur

Supraventricular

tachycardia

Systolic murmur

Decreased cardiac

output

Systolic murmur

Slide9

Assess/Monitor

Oxygen

status

Vital signs

Cardiac rhythm

Hemodynamics

Heart and lung sounds

Exercise tolerance

Slide10

NANDA Nursing Diagnoses

Decreased

cardiac output

Impaired gas exchange

Activity intolerance

Acute pain

Slide11

Nursing Interventions

Administer O2

as prescribed to improve myocardial oxygenation.

Maintain fluid and sodium restriction.

Administer medications as prescribed.

Diuretics to decrease preload.

Antihypertensive agents (beta-blockers, calcium-channel blockers,

ACE

Inotropic agents to increase contractility – digoxin (

Lanoxin

),

dobutamine

.

Anticoagulation therapy for clients with mechanical valve

replacement

Assist

the client to conserve energy and decrease myocardial oxygen consumption.

Post-surgery care is similar to coronary artery bypass surgery (care for

sternal incision

, activity limits for 6 weeks, report fever).

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Nursing Interventions

Client EducationProphylactic antibiotics are recommended prior to dental work,

surgery, or

other invasive procedures.

Encourage the client to follow the prescribed exercise

program.

Encourage adherence to dietary restrictions; consider

nutritional

consultation.

Teach the client energy conservation.

Slide13

Complications and Nursing Implications

Heart

failure is the inability of the heart to maintain adequate circulation to

meet tissue

needs for oxygen and nutrients.

Ineffective

valves result in heart failure.

Monitoring a client’s heart failure class (I to IV) is often the gauge for

surgical intervention

for

valvular

problems.

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Angina and Myocardial Infarction

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Angina pectoris is a clinical syndrome usually characterized by episodes of pain or pressure in the anterior chest . The cause is usually insufficient coronary blood flow which results in a decreased oxygen supply to meet an increased myocardial demand for oxygen in response to physical exertion or emotional stress.

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Key Points

The continuum from angina to myocardial infarction (MI) is termed

acute coronary

syndrome

. Symptoms of acute coronary syndrome are due to

an imbalance

between myocardial oxygen supply and demand.

Angina pectoris is a warning sign for acute MI.

Women and older adults may not always experience symptoms typically

associated with

angina or MI.

The majority of deaths from an MI occur within 1

hr

of symptom onset.

Early

recognition

and treatment

of acute MI is essential to prevent death.

Research shows improved outcomes following an MI in clients treated with

aspirin, beta-blockers

, and angiotensin-converting enzyme (ACE) inhibitors.

Slide18

Key Points

When blood flow to the heart is compromised, ischemia causes chest pain.

Anginal

pain

is often described as a tight squeezing, heavy pressure, or constricting

feeling in

the chest. The pain may radiate to the jaw, neck, or arm.

The three types of angina are:

Stable angina (

exertional

angina) occurs with exercise or emotional

stress and

is relieved by rest or nitroglycerin.

Unstable angina (

preinfarction

angina) occurs with exercise or

emotional stress

, but it increases in occurrence, severity, and duration over

time

.

Variant angina (

Prinzmetal’s

angina) is due to coronary artery spasm,

often occurring

at rest.

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Key Points

Pain unrelieved by rest or nitroglycerine and lasting for more than 15

min differentiates

MI from angina.

An abrupt interruption of oxygen to the heart muscle produces

myocardial ischemia

. Ischemia may lead to tissue necrosis (infarction) if blood supply

and oxygen

are not restored. Ischemia is reversible; infarction results in

permanent damage

.

When the cardiac muscle suffers ischemic injury, cardiac enzymes are released

into the

bloodstream, providing specific markers of MI.

Slide21

Key Points

MIs are classified based on:

The affected area of the heart (anterior, anterolateral).

The depth of involvement (

transmural

versus

nontransmural

).

The EKG changes produced (Q wave, non-Q wave). Non-Q-wave MIs are

more common

in older adults, women, and clients with diabetes.

Slide22

Risk Factors for Angina and MI

Male

gender

Hypertension

Smoking history

Increased age

Hyperlipidemia

Metabolic disorders: Diabetes mellitus, hyperthyroidism

Methamphetamine or cocaine use

Stress: Occupational, physical exercise, sexual

activity

Obesity

Lack of

exercise

Hx

of cardiac disease

Slide23

Diagnostic Procedures and Nursing Interventions

ECG:

Check for changes on serial ECGs.

Angina: ST depression and/or T-wave inversion (ischemia)

MI: T-wave inversion (ischemia), ST-segment elevation (injury), and

an abnormal

Q wave (necrosis)

Clients with non-ST elevation MIs have other indicators.

ST segment depression that resolves with relief of chest pain

New development of left bundle branch block

T-wave inversion in all chest leads

Serial Cardiac Enzymes: Typical pattern of elevation and decrease back to

baseline occurs

with MI

.

Cardiac catheterization reveals the exact location of coronary artery

obstructions and

the degree of ischemia and necrosis

.

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Therapeutic Procedures and Nursing Interventions

Percutaneous

transluminal

coronary angioplasty (PTCA) uses a balloon at

the tip

of a catheter guided under fluoroscopy to press plaque against the vessel

wall and

to

dilates

the obstructed coronary artery to increase/restore tissue perfusion.

Stents may be placed to maintain patency. Following a PTCA, monitor for

bleeding (heparin),

acute vessel closure (emergency coronary artery bypass graft),

and dysrhythmias

(reperfusion).

Coronary artery bypass graft (CABG) surgery restores myocardial tissue

perfusion by

the addition of grafts bypassing the obstructed coronary arteries.

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Assessments

May

be asymptomatic

Chest pain (

substernal

/

precordial

, may radiate to the neck, arms,

shoulders or

jaw; tight squeezing or heaviness in the chest, burning, aching,

dull, constant

)

Dyspnea

Pallor and cool, clammy skin

Tachycardia and/or palpitations

Anxiety/fear, feeling of

doom

Angina is accompanied by severe apprehension and a feeling

of impending death.

Sweating (diaphoresis)

Nausea and

vomiting

A feeling of weakness or numbness in the arms, wrists, and

hands

Dizziness, decreased level of consciousness

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Assessment

Angina is usually a result of atherosclerotic heart disease

and is

associated with a significant obstruction of a major

coronary artery

.

Factors

affecting

anginal

pain are physical

exertion, exposure

to cold, eating a heavy meal, or stress or any

emotion- provoking

situation that increases blood pressure,

heart rate

, and myocardial workload

.

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Assess/Monitor

Vital

signs every 15 min until stable, then every hour

Serial ECG, continuous ST segment monitoring

Location, severity, quality, and duration of pain

Continuously monitor cardiac rhythm

Oxygen saturation levels

Hourly urine output – greater than 30 mL/

hr

indicates renal perfusion

Laboratory data: Cardiac enzymes, electrolytes, ABGs

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NANDA Nursing Diagnoses

Ineffective cardiac tissue perfusion secondary to CAD as evidenced by chest pain or other prodromal symptoms Death anxiety

Decreased

cardiac output

Acute pain

Anxiety/fear

Activity intolerance

Deficient knowledge about underlying disease and methods for avoiding complications

Noncompliance, ineffective management of therapeutic

regimen related to failure to accept necessary lifestyle

changes

Slide34

Nursing

Interventions

The objective is to decrease

O2

demand of myocardium and to increase

O2

supply

Administer

oxygen (4 to 6 L), as prescribed.

Obtain and maintain IV access.

Promote energy conservation

Administer medications as prescribed.

Vasodilators;

Nitroglycerin is

the medication

of choice.

Analgesics reduce

pain (Morphine

is the medication of

choice).

Beta-blockers

(

propranolol )

have

antidysrhythmic

and antihypertensive

Thrombolytic

agents can be effective in dissolving thrombi if

administered the

first 6

hr

following an MI.

Antiplatelet; Aspirin is the medication of choice.

Anticoagulants

Glycoprotein

IIB/IIIA inhibitors (thrombolytic agents) prevent the

binding of

fibrogen

and thus block platelet aggregation.

Slide35

Teach the client to avoid straining, strenuous exercise, or emotional stress when

possible.

Client education regarding response to chest pain:

Stop activity and rest.

Place nitroglycerin tablet under tongue to dissolve (quick absorption).

Repeat every 5 min if the pain is not relieved.

Call 911 if the pain is not relieved in 15 min.

Prepare the client for diagnostic examinations as prescribed and revascularization

procedures (angiography, angioplasty, CABG).

Encourage lifestyle modifications to lower incidence of recurrence: smoking

cessation, limiting saturated fat/cholesterol, weight management, and blood

pressure control. Make appropriate referrals (for example, dietician).

Slide36

Complications and Nursing Implications

Acute

MI is a complication of angina not relieved by rest or nitroglycerin.

Cardiogenic shock is a serious complication of pump failure, commonly

following an

MI of 40% or more of the left ventricle. It is Class IV heart

failure (tachycardia

, hypotension

,

inadequate urinary output (less than

30

mL/

hr

), altered level of consciousness, respiratory distress (crackles,

tachypnea),

cool, clammy skin, decreased

peripheral pulses, and chest pain.

Intervention: O2, ET, morphine IV

and/or nitroglycerin

, vasopressors IV

and/or

positive inotropes Other

possible emergency

interventions include

use of an

intra-

aortic

balloon pump

and/or emergency CABG

Ischemic mitral regurgitation due to myocardial ischemia may be evidenced

by the

development of new cardiac murmur

.

Dysrhythmias due to myocardial

hypoperfusion

require vigilant

continuous cardiac

monitoring.

Ventricular aneurysms/rupture due to myocardial necrosis may present

as sudden

chest pain, dysrhythmias, and severe hypotension.

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Prevention

Self care action plan changing habits.

Stop smoking

Increase level of exercise

Cut down on fatty foods

Eat more oats, which decrease cholesterol

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Lose wt if u DR. thinks you are overweight.

Make sure your BP is not high by regular check

Consider another method of contraceptive if you take pill

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