Chapter 28: Management of Patients with Structural, Infectious and Inflammatory Cardiac Disorders

The nurse determines that a client recently diagnosed with subacute bacterial endocarditis understands discharge teaching upon which client statement?

"I have to call my doctor so I can get antibiotics before seeing the dentist." Antibiotic prophylaxis is recommended for high-risk clients immediately before and sometimes after dental procedures.

A client with a confirmed DVT is being discharged from the ED. Which client statement indicates that the client has received proper nursing instruction and understands how to manage this condition?

"I need to do my leg exercises five times or more every hour." Exercise prevents venous stasis by promoting venous circulation, relieves swelling, and reduces pain. Promoting venous blood flow prevents the formation of thrombi and subsequent potential for emboli in the unaffected extremity. Bending the knees is contraindicated for a client with DVT because it interferes with venous circulation and may increase the size of the existing clot or contribute to the formation of additional thrombi. Clients with DVT should apply warm, moist compresses to the area of discomfort because warmth dilates blood vessels, improves circulation, and relieves swelling, all of which relieve discomfort; moist heat is more comforting than dry heat. Adequate fluid volume dilutes blood cells in plasma and reduces the risk for platelet aggregation.

A nurse and a nursing student are performing a physical assessment of a client with pericarditis. The client has an audible pericardial friction rub on auscultation. When leaving the room, the student asks the nurse what causes the sound. The nurse's best response is which of the following?

"The pericardial surfaces lose their lubricating fluid because of inflammation and rub against each other." A pericardial friction rub occurs when the pericardial surfaces lose their lubricating fluid due to inflammation. The rub is audible on auscultation and is synchronous with the heartbeat. The layers of the heart never become loose from each other. The great vessels are not in contact with the inside of the pericardium, where the inflammation is located. The lungs have nothing to do with a pericardial friction rub.

A nurse is teaching a client about valve replacement surgery. Which statement by the client indicates an understanding of the benefit of an autograft replacement valve?

"The valve is made from my own heart valve, and I will not need to take any blood-thinning drugs when I am discharged." Autografts (i.e., autologous valves) are obtained by excising the client's own pulmonic valve and a portion of the pulmonary artery for use as the aortic valve. Anticoagulation is unnecessary because the valve is the client's own tissue and is not thrombogenic. The autograft is an alternative for children (it may grow as the child grows), women of childbearing age, young adults, clients with a history of peptic ulcer disease, and people who cannot tolerate anticoagulation. Aortic valve autografts have remained viable for more than 20 years.

A nursing student is assigned to a patient with a mechanical valve replacement. The patient asks the student, "Why do I have to take antibiotics before getting my teeth cleaned?" Which response by the nursing student is most appropriate?

"You are at risk of developing an infection in your heart." The patient is at risk for endocarditis and should take prophylactic antibiotics before any invasive procedure. Antibiotics have nothing to do with how much the teeth bleed. Cleaning of the teeth will not cause the valve to malfunction. Using the word "vegetative" with the patient may not be understood; therefore, it is not the most appropriate answer.

Which of the following nursing interventions should a nurse perform when a patient with cardiomyopathy receives a diuretic?

Check for dependent edema regularly The nurse should regularly monitor for dependent edema if the client with cardiomyopathy receives a diuretic. Oxygen is administered either continuously or when dyspnea or dysrhythmias develop. Bed rest is not necessary. The nurse should ensure that the client's activity level is reduced and should sequence any activity that is slightly exertional between periods of rest.

The nurse is caring for a patient diagnosed with pericarditis. What serious complication should this patient be monitored for?

Cardiac tamponade The inflammatory process of pericarditis may lead to an accumulation of fluid in the pericardial sac (pericardial effusion) and increased pressure on the heart, leading to cardiac tamponade (see Chapter 29).

While assessing a patient with pericarditis, the nurse cannot auscultate a friction rub. Which action should the nurse implement?

Ask the patient to lean forward and listen again. The most characteristic sign of pericarditis is a creaky or scratchy friction rub heard most clearly at the left lower sternal border. Having the patient lean forward and to the left uses gravity to force the heart nearer to the chest wall, which allows the friction rub to be heard. These assessment data are not life-threatening and do not require a call to the health care provider. The nurse should try multiple times to auscultate the friction rub before deciding that the rub is gone. Chest tubes are not the treatment of choice for not hearing friction rubs.

A nurse is caring for a client who had an aortic balloon valvuloplasty. The nurse should inspect the surgical insertion site closely for which complication(s)?

Bleeding and infection Possible complications of an aortic balloon valvuloplasty include aortic regurgitation, emboli, ventricular perforation, rupture of the aortic valve annulus, ventricular dysrhythmia, mitral valve damage, infection, and bleeding from the catheter insertion sites.

A client seeks medical attention for dyspnea, chest pain, syncope, fatigue, and palpitations. A thorough physical examination reveals an apical systolic thrill and heave, along with a fourth heart sound (S4) and a systolic murmur. Diagnostic tests reveal that the client has hypertrophic cardiomyopathy (HCM). Which nursing diagnosis may be appropriate?

Decreased CO Decreased cardiac output is an appropriate nursing diagnosis for a client with HCM because the hypertrophied cardiac muscle decreases the effectiveness of the heart's contraction, decreasing cardiac output. Heart failure may complicate HCM, causing fluid volume excess; therefore, the nursing diagnosis of Risk for deficient fluid volume isn't applicable. Ineffective thermoregulation and Risk for peripheral neurovascular dysfunction are inappropriate because HCM doesn't cause these problems.

During assessment of a client admitted for cardiomyopathy, the nurse notes the following symptoms: dyspnea on exertion, fatigue, fluid retention, and nausea. The initial appropriate nursing diagnosis is which of the following?

Decreased cardiac output A primary nursing diagnosis for cardiomyopathy is decreased cardiac output related to structural disorders caused by cardiomyopathy or to dysrhythmia from the disease process and medical treatments. Dyspnea on exertion, fatigue, and fluid retention are related to poor cardiac output. Nausea is related to poor perfusion of the gastrointestinal system. Autonomic dysreflexia is related to a spinal cord injury. Ineffective airway clearance relates to the inability to clear secretions from the airway, which is not an initial problem with cardiomyopathy. Disturbed sensory perception is related to specific senses and not to initial cardiomyopathy.

A client with mitral stenosis is admitted to the hospital. What assessment findings would indicate right ventricular failure?

Distended jugular veins, pedal edema, nausea Signs and symptoms of progressive right ventricular failure include distended jugular veins, pedal edema, and nausea resulting from blood backing up into the superior and inferior venae cavae, jugular veins, and gastrointestinal tract. Dyspnea, orthopnea, and pulmonary edema are signs and symptoms of left-sided heart failure.

A client is admitted to the hospital with possible acute pericarditis and pericardial effusion. The nurse knows to prepare the client for which diagnostic test to confirm the client's diagnosis?

Echocardiography Echocardiography is useful in detecting the presence of pericardial effusions associated with pericarditis. An echocardiogram may detect inflammation, pericardial effusion, tamponade, and heart failure. It may help confirm the diagnosis.

A client reporting heart palpitations is diagnosed with atrial fibrillation caused by mitral valve prolapse. To relieve the symptoms, the nurse should teach the client which dietary intervention?

Eliminate caffeine and alcohol To minimize symptoms of mitral valve prolapse, the nurse should instruct the client to avoid caffeine and alcohol. The nurse encourages the client to read product labels, particularly on over-the-counter products such as cough medicine, because these products may contain alcohol, caffeine, ephedrine, and adrenaline, which may produce arrhythmias and other symptoms. The nurse also explores possible diet, activity, sleep, and other lifestyle factors that may correlate with symptoms.

A nursing student is caring for a client with end-stage cardiomyopathy. The client's spouse asks the student to clarify one of the last treatment options available that the physician mentioned. After checking with the primary nurse, the student would most likely discuss which of the following?

Heart transplant When heart failure progresses and medical treatment is no longer effective, surgical intervention, including heart transplantation, is considered. The other three choices have to do with failing valves and valve repairs.

Which type of graft is used when a heart valve replacement is made of tissue from an animal heart valve?

Heterograft Heterograft, also called bioprosthesis, refers to replacement of tissue from animal tissue, usually pigs but also cows or horses. An autograft is a heart valve replacement made from the client's own heart valve. Allograft refers to replacement using human tissue and is a synonym for homograft.

A nurse reviewing a client's echocardiogram report reads the following statements: "The heart muscle is asymmetrically thickened and the overall size and mass are increased, especially along the septum. The ventricular walls are thickened, reducing the size of the ventricular cavities. Several areas of the myocardium show evidence of scaring." The nurse knows these manifestations are indicative of which type of cardiomyopathy?

Hypertrophic In hypertrophic cardiomyopathy (HCM), the heart muscle asymmetrically increases in size and mass, especially along the septum. It often affects nonadjacent areas of the ventricle. The increased thickness of the heart muscle reduces the size of the ventricular cavities and causes the ventricles to take a longer time to relax after systole. The coronary arteriole walls are also thickened, which decreases the internal diameter of the arterioles. The narrow arterioles restrict the blood supply to the myocardium, causing numerous small areas of ischemia and necrosis. The necrotic areas of the myocardium ultimately fibrose and scar, further impeding ventricular contraction. Because of the structural changes, HCM had also been called idiopathic hypertrophic subaortic stenosis (IHSS) or asymmetric septal hypertrophy (ASH). Restrictive (or constrictive) cardiomyopathy (RCM) is characterized by diastolic dysfunction caused by rigid ventricular walls that impair ventricular stretch and diastolic filling. Arrhythmogenic right ventricular cardiomyopathy (ARVC) occurs when the myocardium of the right ventricle is progressively infiltrated and replaced by fibrous scar and adipose tissue.

A patient with endocarditis is being discharged home. In evaluating the effectiveness of patient teaching about how to prevent recurrence of the infection, the student nurse would expect the patient to state:

I will ask for antibiotics whenever I have dental work done." The patient should take antibiotics for dental procedures that involve manipulation of gingival tissue or the periapical area of the teeth or perforation of the oral mucosa. Exceptions include routine anesthetic injections through noninfected tissue, placement of orthodontic brackets, loss of deciduous teeth, bleeding from trauma to the lips or oral mucosa, dental x-rays, adjustment of orthodontic appliances, and placement of removable prosthodontic or orthodontic appliances.

A nursing student is caring for a client with end-stage cardiomyopathy. The client's spouse asks the nurse to clarify one of the last treatment options available that the physician mentioned earlier. After checking with the primary nurse, the nursing student would most likely discuss which of the following?

Left ventricular assist device When heart failure progresses and medical treatment is no longer effective, surgical intervention, including heart transplantation, is considered. Because of the limited number of organ donors, many clients die waiting. In some cases, a left ventricular assist device is implanted to support the failing heart until a suitable donor becomes available. The other three choices have to do with failing valves and valve repairs.

Which nursing intervention would reduce cardiac workload in a client with myocarditis?

Maintain the client on bed rest. The nurse should maintain the client on bed rest to reduce cardiac workload and promote healing. The nurse would administer a prescribed antipyretic only if the client has a fever. The nurse elevates the client's head to promote maximal breathing potential. Treatment for myocarditis does not preclude allowing the client to have visitors or use the telephone.

A nurse is assessing a patient who has had valvular heart disease for more than 15 years. Which signs and symptoms should the nurse expect? (Choose all that apply.)

Paroxysmal nocturnal dyspnea Orthopnea Cough Paroxymal nocturnal dyspnea, orthopnea, and coughing occur in long-term valvular disease. Pericardial friction rub is a sound auscultated in clients with pericarditis, not valvular disease. Pulsus paradoxus is a marked decrease in amplitude during inspiration, a sign of cardiac tamponade.

If a client were to develop rheumatic carditis, which cardiac structure would most likely be affected?

Mitral valve In rheumatic carditis, cardiac structures that usually are affected include the heart valves (particularly the mitral valve), endocardium, myocardium, and pericardium.

The school nurse is providing care to a child with a sore throat. With any sign of throat infection, the nurse stresses which of the following?

Obtaining a throat culture When a child has a sore throat and symptoms of a possible infection occur, it is essential that a culture is obtained. A culture can identify group A beta-hemolytic streptococcal infection, which needs to be eliminated with use of an antibiotic. Warm, salt gargles; increasing fluids; and administering antiseptic lozenges are helpful for symptom control. Obtaining a throat culture is a priority.

Your client has been diagnosed with mitral valve prolapse syndrome. What is an important subject to include in the client's teaching?

Restriction of alcohol Because alcohol can suppress antidiuretic hormone, leading to loss of extracellular fluid, clients with mitral valve prolapse syndrome are advised to restrict or eliminate its use. A decreased activity level, nutrition, and stopping chewing tobacco are not important subjects to cover when teaching a client with mitral valve prolapse syndrome.

A client comes to the clinic reporting fever, chills, and sore throat and is diagnosed with streptococcal pharyngitis. A nurse knows that early diagnosis and effective treatment is essential to avoid which preventable disease?

Rheumatic fever Rheumatic fever is a preventable disease. Diagnosing and effectively treating streptococcal pharyngitis can prevent rheumatic fever and thereby rheumatic heart disease.

Which instruction should a nurse provide a client with a history of rheumatic fever before the client has any dental work done?

To take prophylactic antibiotics Clients with a history of rheumatic fever are susceptible to infective endocarditis and should be asked to take prophylactic antibiotics before any invasive procedure, including dental work. Steroids are prescribed to suppress the inflammatory response and aspirin to control the formation of blood clots around heart valves. Activities that require minimal activity are recommended to reduce the work of the myocardium and counteract the boredom of weeks of bed rest.

A nurse is caring for a client receiving warfarin (Coumadin) therapy following a mechanical valve replacement. The nurse completed the client's prothrombin time and International Normalized Ratio (INR) at 7 a.m., before the morning meal. The client had an INR reading of 4. The nurse's first priority should be to:

assess the client for bleeding around the gums or in the stool and notify the physician of the laboratory results and most recent administration of warfarin. For a client taking warfarin following a valve replacement, the INR should be between 2 and 3.5. The nurse should notify the physician of an elevated INR level and communicate assessment data regarding possible bleeding. The nurse shouldn't administer medication such as warfarin or vitamin K without a physician's order. The nurse should notify the physician before holding a medication scheduled to be administered during another shift.

A nurse caring for a client with cardiomyopathy determines a diagnosis of anxiety related to a fear of death. Which behavior would indicate to the nurse recognizes that the client's level of anxiety has decreased when the client

is able to discuss the prognosis freely. As anxiety decreases, clients will be able to discuss prognosis freely, verbalize fears and concerns, participate in support groups, and demonstrate appropriate coping mechanisms.

A client with a recent history of atrial fibrillation has been prescribed warfarin. When confirming whether the prescribed dose is safe and appropriate for the client, the nurse should:

review the client's international normalized ratio (INR). Warfarin doses are adjusted on the basis of the client's INR. Blood levels are not taken for the drug, and the client's heart rate is not the indicator of efficacy or safety.