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Rheumatic Heart Disease

by: Alex Dickinson

Rheumatic Heart Disease NUR 471

Marketplace > Creighton University > NURSING > NUR 471 > Rheumatic Heart Disease
Alex Dickinson

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Identify types of structural heart disease. Identify the difference between regurgitation, stenosis, and prolapse. Discuss the various types of valve disorders. Identify types of inflammatory he...
Care Management Outcomes
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This 67 page Class Notes was uploaded by Alex Dickinson on Monday September 19, 2016. The Class Notes belongs to NUR 471 at Creighton University taught by in Fall 2016. Since its upload, it has received 7 views. For similar materials see Care Management Outcomes in NURSING at Creighton University.


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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 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 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 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 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


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