Nursing Care of Patients with Cardiac Valvular
or Inflammatory and Infectious
Cardiovascular Disorders

Stenosis
◦ Narrowed, Valve Does Not Open Completely
◦ Forward Blood Flow Hindered
◦ Decreases Cardiac Output

Regurgitation (Insufficiency)
◦ Valve Does Not Close Completely
◦ Blood Flow Backs Up



During Ventricular Systole, Mitral Valve Flaps
Normally Closed
In Mitral Valve Prolapse One/Both Flaps Bulge
Into Left Atrium
If Bulging Flaps Do Not Fit Together, Mitral
Regurgitation Occurs

Etiology
◦ Unknown
◦ Hereditary
◦ Women 20 to 55 Years of Age

Signs and Symptoms
◦
◦
◦
◦
◦
Often None
Anxiety
Chest pain
Dysrhythmias
Dyspnea

Signs and Symptoms (cont’d)
◦ Fatigue
◦ Palpitations

Complications
◦ Dilation of Left Side of Heart
◦ Heart Failure
◦ Infective Endocarditis
◦ Emboli

Diagnostic Tests
◦ Murmur Heard
◦ 2-D or Doppler Echocardiogram
◦ Coronary Angiogram

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

None, Unless Symptoms
Healthy Lifestyle
Avoid Stimulants/Caffeine
Stress Management
Beta Blockers for Tachycardia
Valve Surgery for Severe MVP

Pathophysiology
◦ Mitral Valve Thickening/Chordae Tendineae
Shortening
◦ Narrows Valve Opening
◦ Blood Flow Obstructed from Left Atrium
◦ Left Atrium Enlarges

Pathophysiology (cont’d)
◦ Backward Pressure Occurs Until Right Ventricle
Dilates/Fails
◦ Cardiac Output Reduced






Common – Prior Rheumatic Fever
Congenital Defects
Tumors
Rheumatoid Arthritis
Systemic Lupus Erythematosus
Calcium Deposits

Signs and Symptoms
◦
◦
◦
◦
◦
None Early
Murmur
Exertional Dyspnea, Cough, Hemoptysis
Fatigue
Palpitations

Signs and Symptoms (cont’d)
◦ Atrial Fibrillation
◦ Chest Pain

Complications
◦ Stroke
◦ Seizures

Diagnostic Tests
◦
◦
◦
◦
ECG: P-wave Changes
Chest X-Ray: Enlarged Chambers
2-D and Doppler Echocardiography
Coronary Angiogram

Therapeutic Interventions
◦ Prophylactic Antibiotics per Criteria
◦ Anticoagulants: Atrial Fibrillation
◦ Percutaneous Balloon Valvuloplasty

Surgery
◦ Mitral Valve Repair
 Commissurotomy
 Annuloplasty
◦ Mitral Valve Replacement

Pathophysiology
◦
◦
◦
◦
Mitral Valve Incomplete Closure
Backflow of Blood to Left Atrium
Left Atrium Dilates, Extra Volume to Left Ventricle
Left Ventricle Dilates from Extra Volume, Eventually
May Fail

Etiology
◦
◦
◦
◦
◦
Rheumatic Heart Disease (Most)
Endocarditis
Congenital Defects
Chordae Tendineae Dysfunction
Mitral Valve Prolapse

Signs and Symptoms
◦
◦
◦
◦
◦
None Early
Murmur
Dyspnea, Cough, Hemoptysis
Fatigue
Palpitations

Signs and Symptoms (cont’d)
◦ Atrial Fibrillation
◦ Chest Pain

Complications
◦ Atrial Fibrillation
◦ Pulmonary Hypertension
◦ Heart Failure

Diagnostic Tests
◦
◦
◦
◦
ECG: P-Wave Changes
Chest X-Ray: Enlarged Chambers
2-D and Doppler Echocardiography
Coronary Angiogram

Therapeutic Interventions
◦
◦
◦
◦
◦
None, Unless Symptoms
Prophylactic Antibiotics per Criteria
ACE Inhibitors
Anticoagulants: Atrial Fibrillation
Mitral Valve Repair/Replacement

Pathophysiology
◦
◦
◦
◦
◦
Aortic Valve Narrowed
Left Ventricle Contracts More Forcefully
Left Ventricle Hypertrophies
Decreased Cardiac Output
Eventual Heart Failure

Etiology
◦ Congenital Defects
◦ Rheumatic Heart Disease
◦ Calcification with Aging

Signs and
Symptoms
◦
◦
◦
◦
None Early
Angina
Murmur
Syncope
◦
◦
◦
◦
Orthopnea
Dyspnea on Exertion
Fatigue
Pulmonary Edema

Complications
◦ Heart Failure
◦ Dysrhythmias
◦ Endocarditis

Diagnostic Tests
◦
◦
◦
◦
◦
ECG
Chest X-Ray: Enlarged Left Ventricle
2-D and Doppler Echocardiography
Serial Echocardiography
Cardiac Catheterization

Therapeutic Interventions
◦ Surgery
 Aortic Valve Replacement
 Valvotomy
◦ Treat Heart Failure Symptoms
◦ Prophylactic Antibiotics per Criteria




Aortic Valve Does Not Close
Left Ventricle’s Volume Increases
Left Ventricle Dilates
Left Ventricle Fails
◦ Decreased Cardiac Output
◦ Pulmonary Edema

Etiology
◦
◦
◦
◦
◦
Rheumatic Heart Disease (Most)
Congenital Defects
Syphilis
Endocarditis
Severe Hypertension

Etiology (cont’d)
◦ Rheumatoid Arthritis
◦ Aortic Dissection

Signs and Symptoms
◦ None Early
◦ Exertional Dyspnea, Fatigue
◦ Corrigan’s Pulse: Palpated Pulse Forceful, Quickly
Collapses
◦ Widened Pulse Pressure
◦ Angina at Night

Diagnostic Tests
◦
◦
◦
◦
ECG
Chest X-Ray
2-D and Doppler Echocardiography
Coronary Angiogram

Complications
◦ Endocarditis
◦ Heart Failure

Therapeutic Interventions
◦ Vasodilator
◦ Surgical Valve Replacement
◦ Prophylactic Antibiotic Therapy per Criteria

Nursing Assessment
◦ History
◦ Vital Signs
◦ Signs and Symptoms

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Pain
Decreased Cardiac Output
Activity Intolerance
Excess Fluid Volume
Ineffective Therapeutic Regimen Management
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Relieve Pain
Maintain Vital Signs/Oxygen Saturation
Maintain Desired Activities
Maintain Clear Lung Sounds
Understand Disease/Treatment

Pain Relief
◦ Rating Scale
◦ NTG
◦ Pace Activities

Normal Cardiac Function
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◦
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Vital Signs
Intake and Output
Daily Weights
Sodium Restriction
Smoking Cessation
Medications as Ordered

Improve Quality of Life
◦ Assist ADLs
◦ Rest Periods
◦ Energy Conservation

Maintain Fluid Volume
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◦
◦
◦
Daily Weights
Assess for Edema
Intake/Output
Diuretics as Ordered
 Monitor Potassium Levels

Education
◦ Medications
◦ Anticoagulants
 Monthly INR/PT Tests
 Medic Alert Identification

Education (cont’d)
◦ Include Caregivers for Elderly
◦ Revised Endocarditis Prevention – Prophylactic
Antibiotics
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
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Reports Satisfactory Pain Relief
Vital Signs Normal/No Heart Failure Signs
Reports Reduced Fatigue, Task Completion
Remains Free of Edema, Maintains Weight,
Clear Lung Sounds

Verbalizes Understanding of Teaching/with
No Symptom Recurrence

Minimally Invasive Surgery
◦ Endoscopy
◦ Robotic

Traditional
◦ Open Cardiac Surgery with Cardiopulmonary Bypass

Stenosed Valve Repair
◦ Balloon Valvotomy
◦ Commissurotomy

Insufficient Valve Repair
◦ Annuloplasty

Mechanical
◦ Durable
◦ Creates Turbulent Blood Flow
 Lifelong Anticoagulation
◦ Used for Younger Adults

Biological
◦ Types
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Porcine (Pig)
Bovine (Cow)
Allografts (Human)
Autograft
Cultural Considerations

Biological (cont’d)
◦ Not as Durable as Mechanical Valves
◦ No Lifelong Anticoagulation
◦ Used for Older Adults

Biological Valves
◦ Degenerative Changes
◦ Calcification

Mechanical Valves
◦
◦
◦
◦
INR/PT Monitoring for Bleeding Risk
Thrombus/Embolism Formation
Anemia
Endocarditis

Assessment
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◦
◦
◦
Circulatory Status
Pain Control Needs
Diagnostic Tests
Typing and Cross-matching of Blood Needed


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Acute or Chronic Pain
Anxiety
Deficient Knowledge

Teaching
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Pain Management
Endotracheal Tube/Ventilator
Communicating
Chest Tubes
Coughing/Deep Breathing

Teaching
◦ IV Lines
◦ Urinary Catheter

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Preoperative Medications
Antiseptic Scrub Showers
NPO

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Pain
Ineffective Airway Clearance
Impaired Gas Exchange
Decreased Cardiac Output
Risk for Infection
Deficient Knowledge
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Pain/Provide Relief
Vital Signs, ECG
ABGs
Intake and Output
Lung Sounds
Incision

Promote Lung Expansion
◦ Cough and Deep Breathe
◦ Turn
◦ Ambulate

Prevent Infection
◦ Hand Hygiene
◦ Cleanse Stethoscope
 Each Patient, Each Handwashing
◦ Sterile Technique
◦ Monitor Temperature

Teaching
◦
◦
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Pain Management
Medications
Activity
Follow-up Monitoring/Care

Infection of Endocardium

Pathophysiology
◦
◦
◦
◦
Invading Organism Attaches to Endocardium
Vegetative Lesion Forms
Damages Valve Leaflets
Emboli/Heart Failure Possible


Entry of Organism into Bloodstream
Risk Factors
◦
◦
◦
◦
◦
Immunocompromised
Artificial Heart Valve
Congenital/Valvular Heart Disease
IV Drug Use
Gingival Disease

Prevention
◦ Oral/Dental care
◦ Prophylactic Antibiotics per Criteria

Signs and Symptoms
◦
◦
◦
◦
◦
◦
Fever
Murmur
Splinter Hemorrhages
Petechiae
Janeway Lesions
Osler’s Nodes

Complications
◦ Vegetative Emboli
◦ Heart Valve Stenosis/Regurgitation
◦ Heart Failure

Diagnostic Tests
◦ Blood Cultures
◦ Echocardiography

Therapeutic Interventions
◦
◦
◦
◦
IV Antimicrobial Drug
Rest/Supportive Care
Home IV Antimicrobial Therapy
Surgical Valve Replacement/Repair

Nursing Management
◦ Vital Signs/Cardiac Function
◦ Report Heart Failure/Emboli Signs
◦ Teach
 Good Hygiene, Oral/Dental Care
 Report Symptoms: Fever, Chills, Sweats

Inflammation of Pericardium
◦ Acute
◦ Chronic

Pathophysiology
◦ Inflammation of the Pericardium
◦ Ventricular Filling Reduced
 Decreased Cardiac Output and BP




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Infections, Lyme Disease
Drug Reactions
Connective Tissue Disorders
Neoplastic Disease
Postmyocardial Infarction
Dressler’s Syndrome


Renal Disease or Uremia
Trauma

Signs and Symptoms
◦ Chest Pain; Substernal, Radiates, Grating
 Increases with Deep Inspiration
 Relieved by Sitting Up/Forward
◦ Pericardial Friction Rub
◦ Dyspnea

Signs and Symptoms (cont’d)
◦ Low-grade Fever
◦ Cough
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ECG
Echocardiogram
WBC
Pericardial Fluid
CT Scan
MRI

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Pericardiocentsis
Treat Cause
◦
◦
◦
◦
Antibiotics
Hemodialysis
Pericardial Window
Pericardiectomy


Bedrest
NSAIDs

Complications
◦ Pericardial Effusion
◦ Cardiac Tamponade
 Immediate Pericardiocentesis



Vital Signs
Cardiac Function/Tamponade Signs
Pain Relief
◦ NSAIDs, Corticosteroids
◦ Position of Comfort

Education

Pathophysiology and Etiology
◦ Inflammation of Myocardium
◦ Rare
◦ Often Follows Virus

Signs and Symptoms
◦ None
◦ Possible Viral Infection Signs
◦ Chest Pain, Tachycardia

Diagnostic Tests
◦
◦
◦
◦
Endomyocardial Biopsy
MRI
Echocardiogram
ECG

Therapeutic Interventions
◦ Reduce Heart’s Workload
◦ Oxygen
◦ Treat Cause
 Antimicrobial
◦ Treat Heart Failure

Nursing Care
◦
◦
◦
◦
Vital Signs/Cardiac Status
Diversional Activities
Energy Conservation
Education

Nonpenetrating
◦ Blunt Trauma

Penetrating
◦ External Injury
◦ Internal Injury


Enlargement of Heart Muscle
No Cure

Dilated Cardiomyopathy
◦
◦
◦
◦
Ventricular Cavity Enlarges
Contractility Decreases
Stasis of Blood
Most Common Form

Hypertrophic Cardiomyopathy
◦ Left Ventricle Muscle Wall Enlargement
◦ Decreases Ventricular Filling
◦ Can Cause Sudden Death in Athletes

Restrictive Cardiomyopathy
◦
◦
◦
◦
◦
Cardiac Muscle Stiffness
Impairs Ventricular Stretch
Limits Ventricular Filling
Systolic Emptying of Ventricle Normal
Rarest Form

Signs and Symptoms
◦ Heart Failure
◦ Dilated Cardiomyopathy
 Exertional Dyspnea, Orthopnea, Fatigue
◦ Hypertrophic Cardiomyopathy
 Exertional Dyspnea, Angina at Rest

Signs and Symptoms (cont’d)
◦ Restrictive Cardiomyopathy
 Exertional Dyspnea, Syncope, Arrhythmias

Diagnostic Tests
◦
◦
◦
◦
Chest X-Ray (Cardiomegaly)
Echocardiography
ECG
Cardiac Catheterization

Therapeutic Interventions
◦
◦
◦
◦
No Cure
Palliative Care
Heart Failure Treatment
Anticoagulants

Therapeutic Interventions (cont’d)
◦ Dilated




ACE Inhibitors, Beta Blockers, Diuretics, Digoxin
Biventricular Pacing
Implantable Defibrillators
Heart Transplant

Therapeutic Interventions (cont’d)
◦ Restrictive
 Vasodilators
 Heart Transplant

Therapeutic Interventions (cont’d)
◦ Hypertrophic




Beta Blockers
Calcium Channel Blockers
Myectomy
Septal Ablation

Nursing Diagnoses
◦ Decreased Cardiac Output
◦ Activity Intolerance
◦ Anxiety





Vital Signs
Heart Failure/Emboli Signs
Signs of Digoxin Toxicity
Activity Tolerance/Energy Conservation
Emotional Support


Education
Home Health Care

Patient and Significant Other Education
◦
◦
◦
◦
Medications
Emergency Contacts
CPR
Hospice


Clot Formation
Inflammation Within Vein

Pathophysiology
◦
◦
◦
◦
Clot Formation and Inflammation Within Vein
Superficial Veins
Deep Veins (DVT)
Emboli Danger

Etiology
◦ Venous Stasis
 Reduced Blood Flow
◦ Damage to Vein Lining
 IV Catheters

Etiology (cont’d)
◦ Increased Blood Coagulation




Smoking
Oral Contraceptives
Estrogen Therapy
Hematological Disorders

Prevention
◦
◦
◦
◦
◦
Identify Risk Factors
Prevent Dehydration
Prophylactic Anti-embolism Devices
Early Ambulation
Range-of-Motion Exercises

Prevention (cont’d)
◦ Prophylactic Medication
 Low Molecular Weight Heparin
 Enoxaparin (Lovenox)
 Fondaparinux (Arixtra)
 Heparin
 Warfarin (Coumadin)

Signs and Symptoms
◦ None
◦ Superficial Veins
 Redness, Warmth, Swelling, Tenderness

Signs and Symptoms
◦ Deep Veins
 Leg Usually
 Swelling, Edema, Pain, Warmth, Tenderness
 Homans’ Sign in 40% of Cases

Complications
◦ Pulmonary Embolism
 Life-threatening Emergency
◦ Chronic Venous Insufficiency
◦ Varicose Veins
◦ Recurrent Deep Vein Thrombosis

Diagnostic Tests
◦
◦
◦
◦
◦
Duplex Ultrasound
Impedance Plethysmography
Magnetic Resonance Imaging (MRI)
Venography
d-dimer and Coagulation Tests

Therapeutic Interventions
◦ Superficial Veins




Warm, Moist Heat
Analgesics
NSAIDs
Compression Stockings

Therapeutic Interventions (cont’d)
◦ Deep Veins





Low-molecular Weight Heparin/Heparin
Warfarin (Coumadin)
Bedrest (Elevate Extremity)
Warm, Moist Heat
Compression Stocking Therapy

Therapeutic Interventions (cont’d)
◦ Deep Veins (cont’d)
 Thrombolytic Therapy
 Thrombectomy
 Vena Cava Filter

Nursing Diagnoses
◦
◦
◦
◦
Acute Pain
Impaired Skin Integrity
Anxiety
Deficient Knowledge






Identify Risk Factors
Monitor Those at Risk for Signs
Administer Meds per INR/PT
Relieve Pain
Monitor for Pulmonary Embolism
Educate