Inflammatory & Valvular Heart Disease: 220 Test II

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Inflammatory & Valvular Heart Disease: 220 Test II
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2014-02-22 18:26:29
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inflammatory valvular heart disease
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inflammatory & valvular heart disease: 220 test II: vickers
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  1. Infective endocarditis?
    infection of inner lining of heart that is continuous with heart valves
  2. Causes of infective endocarditis?
    • 1. bacteria:  all strep, chlamydia, MRSA
    • 2. fungus
    • 3. viral
  3. 11 predisposing factors for IE?
    • 1. prior IE
    • 2. prosthetic valves or valve disease
    • 3. cardiac lesions or abnormalities
    • 4. rheumatic heart disease
    • 5. pacemaker
    • 6. marfan's
    • 7. cardiomyopathy
    • 8. hospiral-acquired bacteremia
    • 9. IV drug abuse
    • 10. intravascular devices:  pulmonary art catheter
    • 11. procedures
  4. 5 procedures/infections that can cause IE?
    • 1. dental work & cleaning
    • 2. respiratory tract incisions:  biopsy, etc
    • 3. tonsillectomy & adenoidectomy
    • 4. presence of wound infection in GI/GU
    • 5. UTI
  5. What is usually the cause of IE?

    Prevention?
    dental work

    if at risk:  will get prophylactic ABX before dental work
  6. What places pt at increased risk for IE?
    damaged heart valves & damaged areas of inner heart lining b/c organisms in blood will infect these areas
  7. What are vegetations?

    How are they Dx?
    lesions on valves formed by organisms & inflammatory response to them

    Dx with echo or TEE
  8. Major concern if vegetation occurs on valve?
    can become embolism
  9. S/S of IE?
    • usually nonspecific & multi-organ system
    • 1. fever & chills
    • 2. arthralgias & decreased range of motion, myalgias, & back pain
    • 3. clubbing of fingers & splinter hemorrhages
    • 4. petechia:  oral, conjunctivae, upper ches, & LE
    • 5. weakness
    • 6. Janeways lesions (flat, painless, red spots) 7. Roth spots (retinal hemorrhage)
    • 8. osler nodes - painful, tender, red or purple, pea-size lesions
  10. Dx of IE?
    • 1. health Hx:  dental/urologic/surgical/gyne procudures; heart disease; recent cath; dialysis skin/resp/urinary tract infections
    • 2. blood cultures:  2 or 3 sets 20 min apart
    • 3. CXR
    • 4. TEE & echo
  11. 2 findings on blood culture with IE?
    WBC 10-11,000

    ERS >30mm/h

    CRP may be elevated
  12. Important consideration when drawing blood for IE?
    will not start ABX until cultures obtained
  13. What may checked r/t ABX therapy with IE?
    may check peak & trough & kidney function &/or liver function
  14. How long will IE pt be on ABX?
    4 to 6 wks - may have picc line
  15. Tx of IE?
    • 1. ID organisms & C&S
    • 2. ABX for 4 to 6 wks:  initially pt will be hospitalized
  16. 4 situations where prophylaxis for IE is used?
    • 1. previous IE
    • 2. prosthetic heart valve or prosthtic material used to repair valve
    • 3. congenital heart disease
    • 4 cardiac transplantation with valve issues
  17. How long should negative cultures for IE be kept?
    3 wks for slow-growing organisms
  18. 3 major criteria to Dx IE?
    • 1. positive cultures
    • 2. new or changed murmur
    • 3. intracardiac mass or vegetation on echo or TEE
  19. What will CXR be like with IE?
    may show enlarged heart
  20. EKG with IE?
    may show first or second degree AVB
  21. What procedure may be done with IE to detect valve functioning & coronary artery status?
    cardiac catheterization
  22. 3 nursing Dx with IE?
    • 1. decreased CO
    • 2. activity intolerance
    • 3. hyperthermia
  23. Nursing interventions & teaching for IE?
    • 1. rest with ROM for joint pain
    • 2. monitor for fever & petechiae
    • 3. monitor for cerebral emboli, pulmonary edema, & HF
    • 4. prevent probs r/t decreased mobility:  thromboembolism & skin BD
    • 5. monitor labs to det effectiveness of Tx
    • 6. Teach about prophylactic ABX for procedures
  24. Prevention of IE?
    Tx infections early, good nutrition & oral care, prophylactic ABX when needed
  25. Acute pericarditis?
    inflammation of pericardial sac
  26. Pericardium normally contains how much fluid?
    50mL
  27. Causes of pericarditis?
    can be caused by many viruses & bacteria, fungal(histoplasmosis & candida), toxoplasmosis, lyme disease

    coxsackie B is most IDd virus

    also:  uremia, bacterial infection, MI, cardiac surgery, tuberculosis, neoplasm, inflammation caused by radiation to the chest, trauma
  28. S/S of percarditis?
    • 1. chest pain
    • 2. dyspnea/rapid shallow breathing:  b/c deep breathing hurts
    • 3. pericardial friction rub
    • 4. fever
    • 5. anxiety
  29. Characteristics of percarditis pain?
    intense pleuritic chest pain worse over precordium or substernally that may radiate to trapezius or neck & is increased by lying supine or anything that increases intrathoracic pressure:  coughing, swallowing, moving trunk

    eased by sitting up & leaning forward
  30. Hallmark finding with pericarditis?
    friction rub
  31. How is pericardial friction rub best heard?
    steth diaphragm placed at lower L sternal border of chest with pt leaning forward - may be intermittent & short-lived (hard to hear)
  32. Best way to differentiate pericardial friction rub from pleural?
    will be timed with pulse & not respirations
  33. 2 complications associated with pericarditis?
    pericardial effusion & cardiac tamponade
  34. Effects of pericardial effusion?
    may compress nearby structures:

    • pulmonary: resp distress
    • phrenic nerve:  hiccups
    • laryngeal nerve:  hoarseness
  35. S/S of pericardial effusion?
    • 1. muffle heart sounds
    • 2. s/s of pressure to nearby structures:  lungs, phrenic nerve, laryngeal nerve

    BP usually maintained
  36. Interventions that may help with pain & dyspnea associated with pericarditis?
    • 1. sit up and lean over
    • 2. Relieve anxiety, pain, & fever
  37. What will develop if pericardial effusion increases?
    TAMPONADE & compression of the heart
  38. S/S of cardiac tamponade?
    • 1. chest pain
    • 2. anxiety, confusion
    • 3. decreased CO
    • 4. muffled heart sounds
    • 5. narrowed pulse pressure
    • 6. tachycardia, tachypnea
    • 7. JVD
    • 8. pulsus paradoxis
    • dyspnea may be only clinical manifestation
  39. Classic s/s of cardiac tamponade?
    pulsus paradoxis:  systolic drop in BP with inspiration
  40. Dx of pericarditis?
    ECG, CXR, echo, periocarditis may be done with fluid sent to lab
  41. EKG changes associated with pericarditis?

    Action that should be done when see these changes?
    diffuse ST segment elevations - must differentiate from ST elevations associated with MI
  42. Lab findings tht may occur with pericarditis?
    leukocytosis & elevation of CRP & ESR
  43. Tx of acute pericarditis?
    find cause:  Tx depends on cause

    • 1. ABX
    • 2. NSAIDs for pain & inflammation (may give asa or corticosteroids)
    • 3. bed rest
    • 4. percardiocentesis for large effusion or tamponade
    • 4.
  44. Med use for reeccurent pericarditis?
    colchicine/Colsalide - antiinflammatory drug
  45. Nursing interventions for pericarditis?
    • 1. priority:  mgmt of pain & anxiety
    • 2. distinguish from MI pain:  usually in precordium or L trapezius , sharp, & increases with inspiration; diffuse instead of local ST elevation without evolving ECG changes
    • 3.
  46. Pain relief measures for pericarditis?
    • 1. high fowlers & tripod position
    • 2. anitiinflammatory meds
  47. Teaching for pt taking anti-inflammatory meds?
    • 1. GI - take with food or milk
    • 2. avoid alcohol
    • 3. make get PPI with it
  48. Major concerns with pericarditis?
    decreased CO, effusion, & tamponade
  49. Pre-pericardiocentesis?
    • 1. may get volume expanders & inotropic agents (dopamine)
    • 2. D/C anticoagulants
  50. Complications of pericardiocentesis?
    • 1. dysrhythmias
    • 2. further cardiac tamponade
    • 3. pneumomediastinum
    • 4. pneumothorax
    • 5. myocardial laceration
    • 6. coronary artery laceration
  51. Rheumatic fever & rheumatic heart disease?
    rheumatic fever is inflammatory disease of heart involving all layers of the heart

    rheumatic heart disease is chronic rheumatic fever that causes scarring & deformity of heart valves
  52. Causes of RF?
    almost always occurs 2to 3 wks after group A Beta hemolytic strep infection of uper resp system - usually strep throat
  53. What test should be done if suspect RF?
    will test for antibodies to strep b/c will not be positive for strep anymore
  54. What body systems are affected by RF?
    • 1. heart
    • 2. skin
    • 3. joints:  arthralgias/arthritis
    • 4. CNS: chorea
  55. Age group usually affected by RF?
    young adults
  56. RF effect on valves?
    swelling & erosion of valves, vegetations form, valve stenosis (usually mitral or aortic),
  57. RF effect on myocardium?
    Aschoff's bodies -nodules caused by swelling
  58. Dx of rheumatic fever?
    cluster of s/s with lab data:

    presence of 2 major criteria or 1 major & 2 minor with evidence of preceding group A strep infection
  59. Major & minor criteria for RF Dx?

    Other Dx used?
    major:  carditis, arthritis, chorea, erythema marginatum (bright pink rings on trunk & inner limbs), subcutaneous nodules (painless swellings over joints)

    minor:  fever, polyarthralgia, lab findings:  increased ESR, WBC, or CRP

    positive throat culture, antistreptolysin titer, echo
  60. Most important manifestation of RF?

    3 s/s that occur with this?
    carditis

    • 1. heart murmur or murmurs mitral/aortic
    • 2. cardiac enlargement & HF
    • 3. pericarditis & complications that may occur with it
  61. Chorea associated with pericardeitis?

    When does it usually occur?

    S/S?
    Sydenham's chorea:

    usually several mo after initial infection

    • 1. involuntary mvmt - face, limbs
    • 2. muscle weakness
    • 3. disturbances of speech & gate
  62. S/S of polyarthritis associated with RF?
    swelling, heat, redness, tenderness, & limitations o motion
  63. Complication of RF?

    When can it occur?
    chronic rheumatic carditis

    mo - years after initial infection
  64. Dx studies used in RF?

    What may they show?
    • 1. echo - valvular insufficiency & pericardial fluid or thickening
    • 2. CXR - enlarged heart if HF
    • 3. EKG - AVB
  65. Tx of RF?
    drug therapy:  penicillin, salicylates, NSAIDs, & corticosteroids (joint inflammation & pain)

    supportive measures
  66. Prevention of RF?
    prompt Tx of sore throat & strep infections
  67. Tx for strep throat?
    IM or PO penicillin X 10 days
  68. Primary goals in Tx of RF?
    • 1. Tx infection
    • 2. prevent cardiac complications
    • 3. relieve joint pain, fever, & other s/s
  69. Nursing care of RF?
    • 1. admin ABX, anti-inflammatory, antiemetics, pain meds
    • 2. monitor fluid intake
    • 3. optimal rest (strict bedrest with carditis) to reduce cardiac workload
    • 4. relieve joint pain:  positioning, heat, meds
    • 5. should ambulate if no carditis - after acute s/s have subsided
  70. Pt teaching with RF?
    • 1. prevent reoccurence:  long-term prophylactic ABX:  monthly injections of penicillin G
    • 2. report s/s of cardiac valve disease:  excessive fatigue, dizziness, palpitations, or exertional dyspnea
  71. 2 types of valvular heart disease?
    stenotic valves & regurgitation/incompentent valve
  72. Stenosis?
    closed when should be open - restricted; impedes forward flow of blood
  73. Regurgitation?
    open when should be closed - incompetent closure of valve causes backward flow of blood
  74. Both stenosis & regurgitation have what effect on heart?
    increase the workload of the heart and decrease CO
  75. Main cause of mitral stenosis?
    rheumatic heart disease

    may also be caused by rheumatoid arthritis & systemic lupus erythematosus
  76. Mitral stenosis?
    funnel shape with flow obstruction that creates pressure gradient b/t L atrium & L ventricle & increased pressure in pulmonary vasculature that leads to hypertrophy of pulmonary vessels
  77. S/S of mitral stenosis?
    • 1. dyspnea on exertion
    • 2. hemoptysis
    • 3. A Fib with associated fatigue & palpitations
    • 4. stroke
    • 5. hoarsenss from compression of laryngeal nerve
    • 6. chest pain from compressed coronary circulation
  78. 2 complications that may occur with RF?
    • 1. embolism of vegetations
    • 2. valvular heart disease
  79. Primary s/s of mitral stenosis?
    exertional dyspnea r/t decreased lung compliance
  80. Heart sounds associated with mitral stenosis?
    loud first heart sound & low-pitched rumbling diastolic murmur
  81. Complication that may occur with mitral stenosis?
    emboli
  82. Mitral vavle prolapse?
    failure of leaflets to fit together causes displacement of one leaflet edge toward the atrium during systole -- usually benign
  83. Predisposing factor for mitral valve prolapse?
    familial Hx
  84. S/S of MVP?
    • most pt are asymptomatic
    • 1. palpitations
    • 2. dyspnea
    • 3. chest pain
    • 4. activity intoleracne
    • 5. syncopy
    • 6. murmur that is more intense through systole or clicks heard during systole
    • 7. dysrhythmias:  PVC, SVT, & V tach
  85. What may be the cause of palpitations with MVP?
    stress
  86. When do s/s of MVP tend to occur?
    during times of stress
  87. Drug that may be prescribed for MVP?
    beta blockers to control palpitations & chest pain
  88. Teaching for pt with MVP?
    • 1. usually benign
    • 2. stay hydrated
    • 3. avoid caffeine & stimulants
    • 4. exercise regularly & nutrition
  89. Aortic Stenosis?
    obstruction of flow from L ventricle to aorta during systole --> L ventricular hypertrophy --> more O2 needs of heart --> decreased CO --> decreased tissue perfusion, pulmonary HTN, & HF
  90. Causes of aortic stenosis?
    congenital or rheumatic fever
  91. S/S of aortic stenosis?
    • 1. angina
    • 2. syncope
    • 3. dyspnea on exertion
    • 4. HF
  92. Consideration r/t angina associated with aortic stenosis?
    cannot give nitro - will decrease BP & reduce ability of heart to pump through the stenosis & will increase angina pain
  93. What will occur r/t aortic regurgitation over time?
    retrograde blood flow from ascending aorta into L ventricle --> volume overload --> L ventricle compensates by dilation & hypertrophy --> L ventricle failure --> pulmonary hypertension --> R ventricular failure
  94. 6 Causes of aortic regurgitation?
    • 1. bacterial endocarditis
    • 2. trauma
    • 3. aortic dissection:  emergency!!
    • 4. chronic rheumatic heart disease
    • 5. syphillis
    • 6. congenital
  95. S/S of  acute aortic regurgitation?
    • 1. abrupt onset of profound dyspnea
    • 2. chest pain
    • 3. cardiogenic shock
  96. S/S of chronic aortic regurgitation?
    • 1. fatigue & exertional dyspnea
    • 2. orthopnea & nocturnal dyspnea
    • 3. PND
    • 4. water-hammer pulse (strong, quick beat that collapses immediately)
  97. Mitral regurgitation?
    L ventricle ejects blood --> backs up through mitral valve to L atrium --> pulmonary edema
  98. Causes of mitral regurgitation?
    • 1. congenital
    • 2. infection
    • 3. inflammation
    • 4. mitral prolapse
    • 5. MI
  99. S/S of acute mitral regurgitation?
    • poorly tolerated
    • 1. new systolic murmur
    • 2. pulmonary edema
    • 3. cardiogenic shock:  s/s of resp distress & severly decreased CO:  decreased UO, BP, s/s of decreased perfusion
  100. S/S of chronic mitral regurgitation?
    • 1. weakness & fatigue
    • 2. exertional dyspnea
    • 3. palpitations
  101. Most common s/s of valvular issues?

    Intervention?
    palpitations

    teach to avoid caffeine
  102. Preventing valvular heart disease?
    prevent recurrent rheumatic fever & IE:  prophylactic ABX
  103. Tx of valvular disease?
    prevent exacerbations of HF, pulmonary edema, thromboembolism, & recurrent endocarditis
  104. 5 Tx of HF in valvular heart disease?
  105. 1. vasodilators
    • 2. positive inotropes
    • 3. beta blockers
    • diuretics
    • low-Na diet
  106. Valvular heart diseases commonly cause what dysrhythmia?

    Med that may be prescribed?
    Afib

    anticoagulants
  107. Complication of mitral prolapse?
    mitral regurgitation
  108. Nursing consideration r/t valvular heart disease?
    must get as much rest as possible & plan activites with limitations in mind
  109. Surgical therapy for valvular heart diseases?
    valve repair or replacement
  110. Advantages & disadvantages of mechanical & biological valves?
    mechanical:  lasts longer but requires long-term anticoagulant therapy

    biological:  no anticoagulation therapy but won't last as long r/t calcification & endocarditis increased
  111. What will be heard on auscultation of a mechanical valve?
    clicking as blood flows through it
  112. Major complication r/t mechanical valve?

    Prevention?
    embolism

    coumadin with INR 2.5-3
  113. Teaching for pt with bio valve?
    need prophylactic ABX before & after dental cleaning & procedures
  114. Teaching for pt with valve replacement?
    • 1. wear medic alert bracelet
    • 2. INR checked routinely if on coumadin
    • 3. inform MD of any s/s of infection, HF, bleeding, or planned dental or invasive procedures
  115. Cardiomyopathy?  (CMP)
    heart muscle disease that affect the strutural or functional ability of myocardium
  116. Causes of dilated cardiomyopathy?
    • 1. cardiotoxic agents:  alcohol, cocaine, doxorubicin
    • 2. CAD
    • 3. genetic or familial
    • 4. HTN
    • 5. metabolic disorders
    • 6. muscular dystrophy
    • 7. myocarditis
    • 8. pregnancy
    • 9. valve disease
  117. Causes of hypertrophic cardiomyopathy?
    • 1. aortic stenosis
    • 2. genetic
    • 3. hypertension
  118. Causes of restrictive cardiomyopathy?
    • 1. anyloidosis
    • 2. endomyocardial fibrosis
    • 3. neoplams
    • 4. post-radiation
    • 5. sarcoidosis
    • 6. ventricular thrombus
  119. Most common form of CMP?
    dilated
  120. Most important consideration with dilated CMP?
    low EF & CO & stasis of blood in L ventricle
  121. 2 complications that could occur with dilated cardiomyopathy?
    • 1 arrhythmias with altered K levels
    • 2. embolism r/t blood stasis
  122. S/S of dilated CMP?
    • same as CHF
    • 1. decreased exercise tolerance & fatigue
    • 2. dry cough
    • 3. dyspne & orthopnea
    • 4., palpitations
    • 5. anorexia
    • 6. S3 & S4
    • 7. tachycardia
    • 8. crackls
    • 9. edema
    • 10. weak peripheral pulses
    • 11 pallor
    • 11. hepatomegaly
    • 12. JVD
    • 13. dysrhythmias
    • 14. systemic embolization
  123. What will CXR of dilated cardiomyopathy pt look like?
    enlarged heart
  124. Dx of dilated CMP?
    CXR, ECG, echo, cardiac cath
  125. Management of dilated CMP?
    same as for CHF but pt may need Dobures or Primacor home infusion or outpatient infusion

    end-stage may need transplant
  126. Teaching for dilated CMP?
    • 1. family need to know CPR
    • 2. low Na diet
    • 3. 6 to 8 glasses of water unless fluid restricted
    • 4. reasonable weight & avoid large meals
    • 5. avoid alcohol, caffeine, diet pills, & OTC cold meds with stimulants
    • 6. stress reduction activites
    • 7. report s/s of HF
  127. EKG with dilated CMP?
    tachycardia, bradycardia, & dysrhythmias with conduction disturbances:
  128. What lab value will indicate HF in pt with dilated CMP?
    elevated BNP
  129. 2 common causes of dilated CMP?
    infectious myocarditis & alcoholic dilated cardiomyopathy
  130. Tx for dilated CMP?
    • Tx HF:
    • 1. abstain from all alcohol
    • 2. meds that may be used:  diuretics, nitrates, ACE inhibitors, antidysrhtymics, anticoagulation, may take statins
  131. Effect of cocaine on the heart?
    intense vasoconstriction of coronary arteries --> MI, ischemia, or dilated CMP

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