Rheumatic Heart Disease
Rheumatic Heart Disease NUR 471
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Date Created: 09/19/16
Chronic Cardiac: Rheumatic Heart Disease, Endocarditis, and Valve Disorders Lori Rusch PhD, RN Creighton University College of Nursing NUR 496/471 1 Lecture Objectives: u Identify types of structural heart disease. u Identify the difference between regurgitation, stenosis, and prolapse. u Discuss the various types of valve disorders. u Identify types of inflammatory heart disease. u Describe the care management of patients with structural and inflammatory heart disease. 2 3 4 http://www.heart-valve-surgery.com/heart-surgery-blog/2007/08/23/symptoms- 5 Structural Heart Diseases Valve Disorders Cardiomyopathy 6 Valve Disorders Overview u Valve disorder isterfere with blood flow to, from, and within the heart u Types: Stenosis, Regurgitation, Prolapse u Causes (structured of inflammatory processes) u Rheumatic Heart Disease u Endocarditis u MI – damage to heart muscle à dying muscle cannot control valve u Congenital Defects u Dilated Cardiomyopathy 7 Major Valve Disorder T ypes u Stenosis: u Valve opening is narrowed or stiffened and restricts forward blood flow into the next chamber . u Blood volume and pressure increases BEHIND the stenotic valve uLeads to hypertrophy of chamber uAlso leads to decreased cardiac output 8 9 10 http://www.webmd.com/heart-disease/heart-failure/aortic-valve-with-stenosis Major Valve Disorder T ypes u Regurgitation : u Valvedoes not close completely and allows retrograde blood flow u Blood volume and pressure increase BEHIND the regurgitant valve b/c the blood “backflows” into the previous chamber upon systole u Leads to dilation of the chamber and decreased cardiac output 1 12 13 Major Valve Disorder T ypes u Prolapse : u Valve cusps bulge into the left atrium during systole (mitral valve is most common) u Allows leakage of small amounts of blood back into the atrium u Increased familial incidence u Most patients are asymptomatic, over time it can develop into something more serious u “CLICK” heard with heart sounds 1 15 feghalicardiology.com Specific Acquired Valve Diseases u Mitral Valve Stenosis u Mitral Valve Regurgitation u Mitral Valve Prolapse u Aortic Valve Stenosis u Aortic Valve Regurgitation u T ricuspid Valve Stenosis & Regurg 1 Mitral Valve Stenosis u Increases resistance to blood flow from Left Atrium è Left Ventricle u Pressures in the LA increase, leading to: u Increased LA pressure u Increased pressure in the pulmonary vasculature u Eventual LA hypertrophy 1 Mitral Valve Regurgitation u Mitral valve does not close completely u During Systole: blood is forced through the open valve back into the LA u Backward flow creates a volume overload for the LA and pulmonary vasculature u Leads to LA enlargement, L V dilation, and left-sided heart failure 8 Clinical Manifestations of Mitral Valve Disease u Palpitations u Weakness/Fatigue – u Arrhythmias (atrial) decreased CO u Brisk carotid pulses u Hoarseness u Angina u S3 Gallop u Seizures u Low-pitched diastolic murmur u CVA u Dyspnea – blood u Hemoptysis (coughing around lungs up blood) u Peripheral edema 1 Acute Clinical Manifestations of Mitral Valve Regurgitation Pulmonary Edema New Systolic murmur Low CO Shock 0 Mitral V alve Prolapse u Valve cusps bulge into the Manifestations: left atrium during systole Many asymptomatic allowing leakage of small Systolic Murmur amounts of blood back into Click! the atrium u Increased familial Dysrhythmias Palpitations & dizziness incidence Angina u Most common form of valve disease in the U.S. Dyspnea – backflow of blood Activity intolerance 2 Aortic Stenosis u Obstructs blood flow from Manifestations the LV à Aortaduring systole Symptoms develop u Increased pressure & volume when aortic valve is in V leads to: 1/3 normal size u Increased cardiac Classically include: workload & oxygen consumption Angina DOE u LV hypertrophy Syncope u Decreased Cardiac Output heart failure u Decreased CO leads to Systolic murmur pulmonary HTN →poor prognosis 2 Aortic Regurgitation u Allows backward blood flow from the aorta into the L V during diastole resulting in volume overload of L V u LV dilates and hypertrophies to compensate u Contractility declines and blood volume of LA & pulmonary vessels increase→ pulmonary HTN and right heart failure 3 Aortic Regurgitation u Chronic S/S: Acute S/S: u Usually Profound dyspnea asymptomatic for Angina years Weakness u Exertional dyspnea Hypotension u Orthopnea Cardiac collapse of sudden onset u Paroxysmal nocturnal dyspnea u Nocturnal angina 4 Tricuspid & Pulmonic Valve Disease u Tricuspid and Pulmonic Valve disease are uncommon u Stenosis occurs more than regurgitation u Tricuspid Stenosis is almost exclusive to pts who have had Rheumatic Fever or IV drug abuse history. u Pulmonic Stenosis is almost always congenital 25 Possible Interventions for Valve Disease u May need valve repair or replacement u Mitral or tricuspid valve repair-most desired u Valve replacement may be required for mitral, aortic, tricuspid, and occasionally pulmonic valve u Symptom control u Look at cardiac output and heart 26 failure What is Cardiomyopathy? u A group of diseases of the heart MUSCLE (myocardium). u Disease process which impairs the structural and functional abilities of the heart. supply the body with adequate blood and nutrients http://www.photonics.com/Article.aspx?AID=44525 7 Types of Cardiomyopathies ¡ È ability of heart muscle to pump blood effectively § Dilated: ▪ Blood can’t get out! ▪ Systolic function is impaired ▪ Heart muscle is stretched ▪ Diastolic function is OK ▪ Most common – pt w/ heart failure § Hypertrophic : ▪ Blood can’t get in! ▪ Systolic function is OK ▪ Diastolic function is impaired § Restrictive : (not super important) ▪ Blood can’t get in! ▪ Least common 2 Dilated Dilated/large 2 Ventricle Systole Diastole Restrictiv e Stiff ventricle Can’t relax and fill Hypertrophic Enlarged septum, Thickened heart muscle. 3 31 Heart Failure u Inability of the heart to pump blood adequately **decreased cardiac output** u Characterized by: u Ventricular dysfunction u Reduced activity tolerance u Diminished quality of life u Shortened life expectancy 3 Discuss: Assessment for Structural Heart Disease u What will we expect to see from the population experiencing Valve Disorders? u Decreased perfusion u Weak pulses u Shortness of breath u Crackles in lungs u Pitting & pulmonary Edema u Pooling of blood in extremities u Fatigue u Higher resting heart rate (heart is 33 compensating for decreased output) Discuss: Interventions for Structural Heart Disease u Symptom control u Think about cardiac output and heart failure management u Fluid restriction? <2000 a day u Diuretic.. What will I teach them about the diuretic? u Activity specific u Rest breaks u Feet up when sitting u Squeezing legs & socks u Dietary changes – low sodium diet (decrease fluid volume) talk about what can you have u May need valve repair or replacement 34 u Mitral or tricuspid valve repair-most desired Inflammatory Heart Diseases Rheumatic Heart Acute Pericarditis Myocarditis Infective Endocarditis 3 Rheumatic Heart Disease GroupA,Beta-StrepUpperRespiratoryInfection Rheumatic Fever (inflammatory disease of the heart, joints, CNS) Rheumatic Heart Disease (resulting damage to the heart valves) 3 Rheumatic Fever/Heart Disease u Risk Factors for Rheumatic Fever: u Poor-inner city neighborhoods u Crowded living u Damp weather u Malnutrition u Immunocompromised state 3 Rheumatic Heart Disease – Pathophysiology u Inflammatory autoimmune response in heart (all 3 layers) u Microscopic lesions develop, age into scar tissue, contribute to transient heart failure u Major damage is to heart valves u Most likely have decreased CO w/ damage to heart valve Rheumatic Fever/Heart Disease Clinical Manifestations of Rheumatic Fever u Fever , malaise, HA, rash, tender joints--Subcutaneous nodules over joints Clinical Manifestations of Rheumatic Heart Disease u Carditis/Endocarditis— usually 20-40 years later u Murmur u Cardiac enlargement and CHF (Cardiomyopathy) u Chest pain u Pleural friction Rub u Effusions – fluid in pericardium u Cardiac Tamponade – blood or flood between myocardium & pericardium u Most commonly the Left side of the heart is affecte39 Rheumatic Fever/Heart Disease u Once Rheumatic fever has occurred, the person is more susceptible to future episodes and increased heart damage. u What health management considerations should be included in the care management process? 4 Rheumatic Heart Disease – Medical Management u Early antibiotic treatment of strep u Oral/IV antibiotics; aspirin, NSAIDS (decrease inflammation) u Steroids (decrease inflammation) u Cardiac medications (support function of heart) u Bed rest Rheumatic Heart Disease – Nursing Care Management u Assess for: u Heart failure manifestations u Change in murmur volume uMurmur might become more pronounced as rheumatic heart disease become worse u Promote: rest, pain relief, emotional support u Eradicate infecting organism u Teach patient to decrease myocardial oxygen demand/cardiac workload Review 43 Acute Pericarditis u Inflammation of the pericardial sac. u Can be caused by infection, noninfectious, and other diseases like rheumatic fever . u Progressive, frequently severe, sharp chest pain. Pain is generally worse with deep inspiration and when lying supine. It is relieved by sitting up and leaning forward. u Decrease patients pain and anxiety u Steroids u Ativan/morphine --- pain relieving, decrease anxiety u Position patient in tripod 44 Myocarditis u Inflammation of the myocardium u Can be caused by viral, bacterial, fungal infections u Most commonly caused by viral u May lead to dilated cardiomyopathy u Watch and treat for decreased cardiac output 45 Infective Endocarditis (IE) Bacteremia arises as complication of infection elsewhere in the body or from medical/dental procedure Blood borne bacteria lodges in the endocardial layer of the heart causing infection and inflammation of the inner lining of the heart & contiguous heart valves Vegetative growths form on the valve surface Narrowed valve orifice reduces movement of blood Infective Endocarditis u Potential Complications u MI u Heart failure u Vegetative growths lodge on valve surface or break off to form emboli Infective Endocarditis – Etiology Acute IE Subacute IE (more common) u Usually caused by u Usually caused by virulent organisms low-virulence organisms with u Most likely to follow limited ability to open-heart surgery or infect other infection elsewhere in organs body u May exist for long period in inactive state Infective Endocarditis – Clinical Manifestations u Symptoms mimic other systemic diseases, depending on infecting organism and associated complications u Most common symptom – fever accompanied by tachycardia, flu-like symptoms, anorexia, weight loss, and headache. u HALLMARK SIGNS: Rash on hands/feet, papules, painful “Janeway” lesions, splinter hemorrhages in fingernails Infective Endocarditis – Clinical Manifestations u Other symptoms: u Heart murmur u Dyspnea, cough, and chest pain u Pericardial effusion and possible tamponade u Heart failure u Focal neurological complaints and stroke syndromes (result of emboli) u ECG and vascular changes Infective Endocarditis – Care Management u Find cause and start treatment to eradicate infecting organism, minimize damage, and prevent heart failure u Treatment: hospitalization, IV antibiotics, surgery to repair or replace valve Infective Endocarditis- Patient Education u Long term antibiotics u Report fever u Signs and symptoms of stroke, heart failure, pulmonary embolism, u Activity tolerance, TED hose, ROM u Follow up care, good oral hygiene, antibiotic use, limited exposure to illness 52 CARE MANAGEMENT Inflammatory & Structural Heart Diseases 3 Care Management Priority Desired Outcomes: The Patient/Population will have: u Adequate CO u Adequate gas exchange u Absence of emboli u Adequate activity tolerance u Understanding importance of preventative measures 5 Care Management Evaluation Parameters ID & treatment of underlying cause Minimal valve damage that decreases cardiac output Appropriate fluid balance Adequate anticoagulation Managed pain &/or Anxiety Able to complete ADLs without fatigue 5 Care Management u Additional Goals of Interdisciplinary Care: u Maintain BP within therapeutic limits u Minimize edema u Maintain weight at an optimal level u Prevent clot formation u Prevent infection u Manage dysrhythmias 6 Assessments Health • VS, O2 sat • Assess heart & lung sounds frequently; listening for increased crackles murmurs • Respiratory effort & dyspnea • I&O evaluation • If you’re looking at the heart, you’re looking at kidneys • Current weight, recent weight • Assess extremities for edema 5 Assessments Diagnostic tests: • EKG • ABGs • Electrolytes – particularly NA & K+ and CA++ • CXR • Hemodynamic assessment – pressures within heart & within body; shows how valves are working • Echocardiogram – structure & function on screen • Cardiac catheterization 5 Assessments Functional u Occupation u Family roles Environmental (home/work) u stairs? u Bed vs. recliner? u High stress environment? 5 Interventions Symptom Management u Treat underlying cause u Calm & reassuring approach u Physical & emotional rest u Low Na, High K+ diet u Fluid restriction—spread throughout day 6 Medications 61 Interventions General Medication Management u ACE inhibitors u Digoxin u Diuretics u Inotropic Agents u Vasodilators u Dopamine, dobutamine u Morphine u Anticoagulants u (if indicated) u Statins u Antiarrhythmic u Beta Blockers u (if indicated) u Calcium channel blockers 6 Interventions: Rheumatic Heart/Endocarditis Medication Management u Corticosteroids - swelling u Antibiotics - u Antipyretics 6 Interventions Skills and T echnologies u Surgical Interventions: u Transplant u Valve Surgery: repair or replacement u VAD-ventricular assist device u Cardiac resynchronization therapy u ICD-implantable cardioverter-defibrillator u Pacemaker 6 Interventions Client and Family Education u Smoking Cessation u 911 activation and CPR u Daily Weight Monitoring u Need to report wt gain of 3-5# in 1-2 days u Same time everyday , same amount of clothing u Write down and track daily weights 6 Interventions Client and Family Education u Diet u Low Na, High K+ u Importance of taking all meds u Activity u Pace activities, possible cardiac rehab program, watch heavy lifting, and over exertion u Worrisome/Reportable Symptoms u Chest pain, new onset of DOE, signs of infection, Heart failure signs 66 Interventions Referrals u Heart Failure Clinic u Home Health Community Support & Education 6