Inflammatory & Valvular Heart Disease: 220 Test II
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infection of inner lining of heart that is continuous with heart valves
Causes of infective endocarditis?
- 1. bacteria: all strep, chlamydia, MRSA
- 2. fungus
- 3. viral
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
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
What is usually the cause of IE?
if at risk: will get prophylactic ABX before dental work
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
What are vegetations?
How are they Dx?
lesions on valves formed by organisms & inflammatory response to them
Dx with echo or TEE
Major concern if vegetation occurs on valve?
can become embolism
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
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
2 findings on blood culture with IE?
CRP may be elevated
Important consideration when drawing blood for IE?
will not start ABX until cultures obtained
What may checked r/t ABX therapy with IE?
may check peak & trough & kidney function &/or liver function
How long will IE pt be on ABX?
4 to 6 wks - may have picc line
Tx of IE?
- 1. ID organisms & C&S
- 2. ABX for 4 to 6 wks: initially pt will be hospitalized
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
How long should negative cultures for IE be kept?
3 wks for slow-growing organisms
3 major criteria to Dx IE?
- 1. positive cultures
- 2. new or changed murmur
- 3. intracardiac mass or vegetation on echo or TEE
What will CXR be like with IE?
may show enlarged heart
EKG with IE?
may show first or second degree AVB
What procedure may be done with IE to detect valve functioning & coronary artery status?
3 nursing Dx with IE?
- 1. decreased CO
- 2. activity intolerance
- 3. hyperthermia
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
Prevention of IE?
Tx infections early, good nutrition & oral care, prophylactic ABX when needed
inflammation of pericardial sac
Pericardium normally contains how much fluid?
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
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
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
Hallmark finding with pericarditis?
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)
Best way to differentiate pericardial friction rub from pleural?
will be timed with pulse & not respirations
2 complications associated with pericarditis?
pericardial effusion & cardiac tamponade
Effects of pericardial effusion?
may compress nearby structures:
- pulmonary: resp distress
- phrenic nerve: hiccups
- laryngeal nerve: hoarseness
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
Interventions that may help with pain & dyspnea associated with pericarditis?
- 1. sit up and lean over
- 2. Relieve anxiety, pain, & fever
What will develop if pericardial effusion increases?
TAMPONADE & compression of the heart
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
Classic s/s of cardiac tamponade?
pulsus paradoxis: systolic drop in BP with inspiration
Dx of pericarditis?
ECG, CXR, echo, periocarditis may be done with fluid sent to lab
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
Lab findings tht may occur with pericarditis?
leukocytosis & elevation of CRP & ESR
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
Med use for reeccurent pericarditis?
colchicine/Colsalide - antiinflammatory drug
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
Pain relief measures for pericarditis?
- 1. high fowlers & tripod position
- 2. anitiinflammatory meds
Teaching for pt taking anti-inflammatory meds?
- 1. GI - take with food or milk
- 2. avoid alcohol
- 3. make get PPI with it
Major concerns with pericarditis?
decreased CO, effusion, & tamponade
- 1. may get volume expanders & inotropic agents (dopamine)
- 2. D/C anticoagulants
Complications of pericardiocentesis?
- 1. dysrhythmias
- 2. further cardiac tamponade
- 3. pneumomediastinum
- 4. pneumothorax
- 5. myocardial laceration
- 6. coronary artery laceration
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
Causes of RF?
almost always occurs 2to 3 wks after group A Beta hemolytic strep infection of uper resp system - usually strep throat
What test should be done if suspect RF?
will test for antibodies to strep b/c will not be positive for strep anymore
What body systems are affected by RF?
- 1. heart
- 2. skin
- 3. joints: arthralgias/arthritis
- 4. CNS: chorea
Age group usually affected by RF?
RF effect on valves?
swelling & erosion of valves, vegetations form, valve stenosis (usually mitral or aortic),
RF effect on myocardium?
Aschoff's bodies -nodules caused by swelling
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
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
Most important manifestation of RF?
3 s/s that occur with this?
- 1. heart murmur or murmurs mitral/aortic
- 2. cardiac enlargement & HF
- 3. pericarditis & complications that may occur with it
Chorea associated with pericardeitis?
When does it usually occur?
usually several mo after initial infection
- 1. involuntary mvmt - face, limbs
- 2. muscle weakness
- 3. disturbances of speech & gate
S/S of polyarthritis associated with RF?
swelling, heat, redness, tenderness, & limitations o motion
Complication of RF?
When can it occur?
chronic rheumatic carditis
mo - years after initial infection
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
Tx of RF?
drug therapy: penicillin, salicylates, NSAIDs, & corticosteroids (joint inflammation & pain)
Prevention of RF?
prompt Tx of sore throat & strep infections
Tx for strep throat?
IM or PO penicillin X 10 days
Primary goals in Tx of RF?
- 1. Tx infection
- 2. prevent cardiac complications
- 3. relieve joint pain, fever, & other s/s
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
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
2 types of valvular heart disease?
stenotic valves & regurgitation/incompentent valve
closed when should be open - restricted; impedes forward flow of blood
open when should be closed - incompetent closure of valve causes backward flow of blood
Both stenosis & regurgitation have what effect on heart?
increase the workload of the heart and decrease CO
Main cause of mitral stenosis?
rheumatic heart disease
may also be caused by rheumatoid arthritis & systemic lupus erythematosus
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
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
2 complications that may occur with RF?
- 1. embolism of vegetations
- 2. valvular heart disease
Primary s/s of mitral stenosis?
exertional dyspnea r/t decreased lung compliance
Heart sounds associated with mitral stenosis?
loud first heart sound & low-pitched rumbling diastolic murmur
Complication that may occur with mitral stenosis?
Mitral vavle prolapse?
failure of leaflets to fit together causes displacement of one leaflet edge toward the atrium during systole -- usually benign
Predisposing factor for mitral valve prolapse?
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
What may be the cause of palpitations with MVP?
When do s/s of MVP tend to occur?
during times of stress
Drug that may be prescribed for MVP?
beta blockers to control palpitations & chest pain
Teaching for pt with MVP?
- 1. usually benign
- 2. stay hydrated
- 3. avoid caffeine & stimulants
- 4. exercise regularly & nutrition
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
Causes of aortic stenosis?
congenital or rheumatic fever
S/S of aortic stenosis?
- 1. angina
- 2. syncope
- 3. dyspnea on exertion
- 4. HF
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
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
6 Causes of aortic regurgitation?
- 1. bacterial endocarditis
- 2. trauma
- 3. aortic dissection: emergency!!
- 4. chronic rheumatic heart disease
- 5. syphillis
- 6. congenital
S/S of acute aortic regurgitation?
- 1. abrupt onset of profound dyspnea
- 2. chest pain
- 3. cardiogenic shock
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)
L ventricle ejects blood --> backs up through mitral valve to L atrium --> pulmonary edema
Causes of mitral regurgitation?
- 1. congenital
- 2. infection
- 3. inflammation
- 4. mitral prolapse
- 5. MI
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
S/S of chronic mitral regurgitation?
- 1. weakness & fatigue
- 2. exertional dyspnea
- 3. palpitations
Most common s/s of valvular issues?
teach to avoid caffeine
Preventing valvular heart disease?
prevent recurrent rheumatic fever & IE: prophylactic ABX
Tx of valvular disease?
prevent exacerbations of HF, pulmonary edema, thromboembolism, & recurrent endocarditis
5 Tx of HF in valvular heart disease?
- 2. positive inotropes
- 3. beta blockers
- low-Na diet
Valvular heart diseases commonly cause what dysrhythmia?
Med that may be prescribed?
Complication of mitral prolapse?
Nursing consideration r/t valvular heart disease?
must get as much rest as possible & plan activites with limitations in mind
Surgical therapy for valvular heart diseases?
valve repair or replacement
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
What will be heard on auscultation of a mechanical valve?
clicking as blood flows through it
Major complication r/t mechanical valve?
coumadin with INR 2.5-3
Teaching for pt with bio valve?
need prophylactic ABX before & after dental cleaning & procedures
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
heart muscle disease that affect the strutural or functional ability of myocardium
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
Causes of hypertrophic cardiomyopathy?
- 1. aortic stenosis
- 2. genetic
- 3. hypertension
Causes of restrictive cardiomyopathy?
- 1. anyloidosis
- 2. endomyocardial fibrosis
- 3. neoplams
- 4. post-radiation
- 5. sarcoidosis
- 6. ventricular thrombus
Most common form of CMP?
Most important consideration with dilated CMP?
low EF & CO & stasis of blood in L ventricle
2 complications that could occur with dilated cardiomyopathy?
- 1 arrhythmias with altered K levels
- 2. embolism r/t blood stasis
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
What will CXR of dilated cardiomyopathy pt look like?
Dx of dilated CMP?
CXR, ECG, echo, cardiac cath
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
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
EKG with dilated CMP?
tachycardia, bradycardia, & dysrhythmias with conduction disturbances:
What lab value will indicate HF in pt with dilated CMP?
2 common causes of dilated CMP?
infectious myocarditis & alcoholic dilated cardiomyopathy
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
Effect of cocaine on the heart?
intense vasoconstriction of coronary arteries --> MI, ischemia, or dilated CMP
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