chapter024
TRANSCRIPT
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Timby/Smith: Introductory Medical-Surgical Nursing, 10/e
Timby/Smith: Introductory Medical-Surgical Nursing, 10/e
Chapter 24: Caring for Clients with Valvular Disorders of the Heart
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Aortic Valve Disorders of the Aortic Valve
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Aortic Valve Disorders of the Aortic Valve • Aortic Valve
– Three cusps
– Left ventricle: Functions
– Facilitates unrestricted passage of oxygenated blood
– Coronary arteries: First blood vessels perfused
– Two valvular conditions
• Aortic stenosis and aortic regurgitation
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
QuestionQuestionIs the following statement true or false?
The aortic valve is the only cardiac valve to have three cusps.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
AnswerAnswerFalse.
ALL cardiac valves have three cusps, except the mitral valve.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Aortic ValveDisorders of the Aortic Valve• Aortic Stenosis
– Narrowing of the opening in the aortic valve
– Pathophysiology and Etiology
• Age-related degenerative change
• Congenital defect
• Rheumatic carditis and infective endocarditis
• Myocardial ischemia; Left-sided heart failure; Risk of mortality
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Aortic ValveDisorders of the Aortic Valve
• Aortic Stenosis
– Assessment Findings: Signs and Symptoms
• Insufficient cardiac output: Dizziness, fainting, and angina
• Dyspnea and fatigue during activity
• Ventricular enlargement; Carotid pulse feels weak
• Lateral or distal displacement of heart pulsations
• PMI; split S2 heart sound
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Aortic ValveDisorders of the Aortic Valve• Aortic Stenosis
– Assessment Findings: Diagnostic Findings
• Chest radiograph: Reveals ventricular enlargement
• Echocardiogram: Validates ventricular thickening and diminished transvalvular size
• Electrocardiogram (ECG): Reflects force of contracting muscle
• Left-sided cardiac catheterization: High pressure of blood
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Aortic ValveDisorders of the Aortic Valve• Medical and Surgical Management
– Support heart’s pumping activity
– Drug therapy: Digitalis and diuretic
– Restricted sodium
– Antibiotics; Nitrates; Beta-adrenergic blockers
– Balloon valvuloplasty
– Surgical aortic valve replacement
– Coronary arteriogram
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
QuestionQuestionIs the following statement true or false?
In aortic stenosis, the drug of choice is an ACE inhibitor.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
AnswerAnswerFalse.
In aortic stenosis, the drug of choice is not an ACE inhibitor but diuretics and cardiac glycosides.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Aortic ValveDisorders of the Aortic Valve• Nursing Management
– Monitors subjective and objective symptoms; Therapeutic or adverse responses
– Explains purposes and techniques of diagnostic tests
– Administers prescribed medications
– Implements measures to ensure adequate cardiac output and tissue oxygenation
– Assists clients with dietary modifications
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Aortic ValveDisorders of the Aortic Valve• Aortic Regurgitation
– Valvular Incompetence: Aortic valve does not close tightly
– Pathophysiology and Etiology
• Cause: Damage to the valve cusps or papillary muscles
• Consequence of various disorders
• Increase aortic and mitral regurgitation
• Reduces cardiac output; Fluid overload
• Factors hindering supply to heart muscle
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Aortic ValveDisorders of the Aortic Valve• Aortic Regurgitation
– Assessment Findings: Signs and Symptoms
• Tachycardia; palpitations; dyspnea and chest pain
• Physical examination
• Moist and flushed skin; Water-hammer pulse; Wide pulse pressure
• Forceful contractions of the enlarged left ventricle; Heart murmur
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Aortic ValveDisorders of the Aortic Valve• Aortic Regurgitation
– Assessment Findings: Diagnostic Findings
• Cardiac catheterization: High left ventricular pressure
• Chest radiograph: Heart enlargement and dilated aortic valve
• ECG: Myocardial ischemia
• Radionuclide scan: Severity of the disease
• Echocardiography: Images of atypical valvular and myocardial function
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
QuestionQuestionIs the following statement true or false?
As a result of aortic regurgitation, a chest radiograph will show cardiomegaly and a dilated aorta.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
AnswerAnswerTrue.
As a result of aortic regurgitation, a chest radiograph will show an enlargement of the heart.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Aortic ValveDisorders of the Aortic Valve• Aortic Regurgitation
– Medical and Surgical Management
• Aortic regurgitation: Cardiac glycosides and diuretics
• Prophylactic antibiotics
• Modify lifestyle: Avoid demands on heart
• Replacement of the diseased aortic valve
• Vascular graft
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Aortic ValveDisorders of the Aortic Valve• Nursing Management
– Prepares the client for diagnostic procedures and monitors responses
– Reports change in vital signs, dyspnea, chest pain, and LOC
– Administers prescribed medications and evaluates the client’s response
– Ensures balanced physical activity
– Client teaching
• Advise client about drug therapy; Assess BP; Methods to control hypertension
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve
• Mitral Valve
– Location and function of mitral valve
– Stroke volume
• Bolus of oxygenated blood aorta receives
– Valvular disorder
• Rigid, incompetent, or prolapsed
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve• Mitral Stenosis
– Valve not open properly to facilitate filling of left ventricle
– Pathophysiology and Etiology
• Sequela of rheumatic carditis; Recurrence of endocarditis; Effects of inflammation
• Mitral valve not open completely: Incomplete emptying of left atrium
• Risk for arterial emboli; Pulmonary hypertension; Affects right ventricle
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve• Mitral Stenosis
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve• Assessment Findings: Signs and Symptoms
– Valve area is less than 2.5 cm2
• Fatigue and dyspnea; heart palpitations
• Pulmonary hypertension: More dyspneic at night
• Cough: Pink, frothy sputum
• Pulmonary congestion
• Changes in heart sounds: Earliest indication
• Low systolic BP
• Effects on right ventricle
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve• Assessment Findings: Diagnostic Findings
– Chest radiograph
• Enlarged left atrium; Mitral valve calcification
– Fluid congestion in the lungs
– Echocardiogram
• Decreased movement of the mitral valve cusps
• Changes in the size of the atrial chamber
– ECG—P wave notched
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve• Medical and Surgical Management
– Antibiotic therapy: Prevent infective endocarditis
– Preventing symptoms of heart failure: Drug therapy
– Cardioversion: Allows SA node to reestablish itself as pacemaker
– Surgical: Commissurotomy
– Nonsurgical: Valvotomy
• Closes in 6 months; complications
• Nursing interventions after valvotomy
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve• Medical and Surgical
Management
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve• Nursing Management
– Monitor client’s physical condition
– Prepare client for diagnostic tests
– Provide post-treatment care
– Client teaching on discharge
• Drug therapy
• Activity modification
• Signs and symptoms of complications
• Contact physician
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve• Mitral Regurgitation (Insufficiency)
– Pathophysiology and Etiology
• Causes: Rheumatic carditis and mitral valve prolapse
• Damage to the papillary muscles; Impaired myocardial function; Connective tissue disorders; Stretching of the valve opening; Malfunction of a replaced valve
• Balloon valvuloplasty; Anorectic drugs
• Complications: Cardiogenic shock; Pulmonary congestion
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve• Mitral Regurgitation (Insufficiency)
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve• Mitral Regurgitation (Insufficiency)
– Assessment Findings: Signs and Symptoms
• Chronic fatigue and dyspnea on exertion
• Heart palpitations
• Diminished S1 heart sound
• S3 heart sound: Impending heart failure
• Hypertension; Tachycardia
• Heart murmur
• Pulmonary congestion
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve• Mitral Regurgitation (Insufficiency)
– Assessment Findings: Diagnostic Findings
• Transesophageal echocardiography: Structural changes in the mitral valve
• Chest radiography: Enlarged chambers of the heart
• Radionuclide angiography: Volume of regurgitated blood
• ECG: Cardiac enlargement, papillary muscle dysfunction, and various associated dysrhythmias
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve• Mitral Regurgitation (Insufficiency)
– Medical and Surgical Management
• Asymptomatic clients: Physical examination and annual echocardiograms
• Exercise; Angiotensin-converting enzyme (ACE) inhibitor
• Tachycardia: Drug therapy
• Prophylactic antibiotics
• Intra-aortic balloon pump
• Surgery: Annuloplasty; Implantation of a biologic or prosthetic valve
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve• Mitral Regurgitation (Insufficiency)
– Nursing Management
• Monitors BP, heart rate, heart sounds, lung sounds, and weight
• Restricted sodium: Alternative diet
• Administers medications and reports signs of left- or right-sided heart failure immediately
• Emphasizes need for prophylactic antibiotics and periodic health assessments
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve
• Mitral Valve Prolapse
– Valve cusps enlarge, become floppy, and bulge backward into the left atrium
– Most common valvular disorder
– Common in young women
– Benign disease
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
QuestionQuestionIs the following statement true or false?
Mitral valve prolapse is the rarest of cardiac valvular disorders.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
AnswerAnswerFalse.
Mitral valve prolapse is the most common of cardiac valvular disorders.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve• Mitral Valve Prolapse
– Pathophysiology and Etiology
• Idiopathic; Tissue changes—connective tissue disorder; Association with CAD
• Valvular changes of rheumatic carditis
• Mitral valve prolapse syndrome; Decreased circulatory volume
• Changes in the mitral valve tissue layers
• Stretching of the papillary muscles
• Congestive heart failure
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve• Mitral Valve Prolapse
– Assessment Findings: Signs and Symptoms
• Chest pain, palpitations, fatigue, rapid heart rate, lightheadedness, and difficulty concentrating
• Chest pain: Prolonged and not easily relieved; auscultation of heart sound
• Significance of systolic murmur
• Echocardiography: Abnormal movement of mitral valve leaflets during systole
• ECG
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve• Mitral Valve Prolapse
– Medical and Surgical Management
• Periodic antibiotic therapy before invasive procedures
• Drug therapy: Reduce platelet aggregation —prevent thrombus formation
• Valve replacement
• Antianxiety medication: Valve prolapse syndrome; avoid caffeine; liberal fluid; adequate sodium intake
• Restrict alcohol
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disorders of the Mitral ValveDisorders of the Mitral Valve
• Mitral Valve Prolapse
– Nursing Management
• Methods to relieve chest pain; Position of client; Increasing activity
• Instructs the client to breathe deeply and slowly
• Client teaching regarding
• Caffeine, over-the-counter medications, alcohol, fluid intake, use of salt, and tranquilizers
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
End of Presentation