Adult Health Chapter 24&25
The nurse obtains a health history from a client with a prosthetic heart valve and new symptoms of infective endocarditis. Which question by the nurse is most appropriate to ask?
"Have you been to the dentist recently?" -Invasive procedures, particularly those involving mucosal surfaces (e.g., those involving manipulation of gingival tissue or periapical regions of teeth), can cause a bacteremia, which rarely lasts more than 15 minutes. However, if a client has any anatomic cardiac defects or implanted cardiac devices (e.g., prosthetic heart valve, pacemaker, implantable cardioverter defibrillator), bacteremia can cause bacterial endocarditis.
A nurse working at a pediatric clinic is teaching a group of parents. A parent asks the nurse if it is okay to let the young child recover from a sore throat naturally, rather than bringing the child to the clinic for diagnosis and treatment. What is the nurse's best response?
"It may be streptococcal sore throat. Rheumatic heart disease can be prevented with early treatment." - A sore throat may be streptococcal pharyngitis. Diagnosing and treating the sore throat can prevent rheumatic fever and, therefore, rheumatic heart disease. Letting children recover naturally can be dangerous if the sore throat is a streptococcal infection.
Infective endocarditis Definitive diagnosis
- A microorganism is found in 2 separate blood cultures - Evidence of vegetation on imaging of the heart (echocardiogram or TEE) May have... - Fatigue, anorexia, weight loss, cough, back/joint pain - Elevated WBC counts - Anemia, elevated inflammation markers (ESR or CRP)
Prevention of Infectious Diseases of the Heart
- Antibiotic prophylaxis before certain procedures - Ongoing oral hygiene - Female patients are advised NOT to use IUDs - Meticulous care should be taken in patients "at risk" who have catheters - Catheters should be removed as soon as they are no longer needed - Immunizations
Infective endocarditis Medical Management
- Antibiotic therapy - IV for 2-6 weeks - Can be given @ home with home health nurse - Monitor serum levels of antibiotic & blood cultures - Psychosocial support needed - confined to home with restrictive IV therapy. - Surgical management
Nursing Interventions for the Patient with Heart Failure Manage fluid volume
- Assess for symptoms of fluid overload - Daily weight - I&O - Diuretic therapy; timing of meds - Fluid intake; fluid restriction - Maintenance of sodium restriction
Myocarditis Nursing Management
- Assess vital signs Fever, tachycardia - If arrhythmias, continuous cardiac monitoring - Antiembolism stockings, passive & active exercises (prevent embolism)
Chronic Heart Failure Causes
- Atherosclerosis of coronary arteries - Cardiomyopathy - Valvular heart disease - Kidney disease, failure - Arrhythmias
Nursing Interventions for the Patient with Heart Failure Promote activity tolerance
- Bed rest for acute exacerbations - Encourage regular physical activity; build up to about 30 minutes daily - Exercise training - Pacing of activities; wait 2 hours after eating for physical activity - Avoid activities in extreme hot, cold, or humid weather - Modify activities to conserve energy - Positioning; elevation of the head of bed to facilitate breathing and rest, support of arms
Pericarditis Medical Management
- Bed rest until fever, chest pain, friction rub has subsided - Pain relief - Corticosteroids - Pericardiocentesis - removal of some pericardial fluid - Pericardiectomy - removal of the pericardium
Myocarditis Clinical Manifestations
- Depend on type of infection, degree of myocardial damage, ability of myocardium to recover - May be asymptomatic - Fatigue, dyspnea, syncope, palpitations, discomfort in chest and upper abdomen - Flu-like symptoms - Severe heart failure, sudden cardiac death
Chronic Heart Failure Clinical Manifestations
- Dyspnea - Fatigue - Activity intolerance - Fluid retention Congestion Pulmonary and peripheral edema
Assessment of the Patient with Heart Failure Focus
- Effectiveness of therapy - Patient's self-management - S&S of increased HF - Emotional or psychosocial response Health history
Infective endocarditis Clinical Manifestations - onset may be insidious
- Fever - may be intermittent or absent - Heart murmur - Clusters of petechiae - Small painful nodules (Osler nodes) on pads of fingers or toes - Irregular, red/purple, painless flat macules (Janeway lesions) - palms, fingers, hands, soles, toes - Hemorrhages with pale centers caused by emboli (Roth spots) - Splinter hemorrhages (red/brown lines) under the fingernails and toenails - Embolism and stroke - Heart Failure
Infective endocarditis Antibiotic prophylaxis
- For those at risk Previous infectious endocarditis, prosthetic heart valves, heart transplant, valve regurgitation, congenital heart disease - Before (sometimes after) dental procedures - Procedures which involved the airway - Data is mixed - no longer strictly required. Good oral hygiene for at-risk patients - Poor oral hygiene can lead to bacteremia
Clinical Manifestations of Heart Failure Right Sided
- Heart cannot eject sufficient blood into pulmonary circulation - Viscera and peripheral congestion - Jugular venous distention (JVD) - Dependent edema - Hepatomegaly - Ascites - Weight gain
Clinical Manifestations of Heart Failure Left Sided (most common)
- Heart cannot eject sufficient blood into systemic circulation - Pulmonary congestion, crackles - S3 or "ventricular gallop" - Dyspnea on exertion (DOE) - Low O2 sat - Dry, nonproductive cough initially - Oliguria
Pericarditis Assessment & Diagnostic Findings
- History, signs, symptoms - Echocardiogram - may show inflammation, pericardial effusion, tamponade, heart failre - May be used to guide pericardiocentesis (drainage of pericardium) - CT - Cardiac MRI - 12-lead ECG changes.
Congestive Heart Failure
- Left ventricle cannot effectively pump blood out of the aorta into systemic circulation. - Heart cannot eject sufficient blood into systemic circulation - Pulmonary congestion, crackles - S3 or "ventricular gallop" - Dyspnea on exertion (DOE) - Low O2 sat - Dry, nonproductive cough initially - Oliguria
Pericarditis Clinical Manifestations
- May be asymptomatic - Chest pain or Other pain - neck, scapular, behind clavicle - May worsen with deep inspiration, when supine, or turning - Friction rub - heard most clearly at left sternal border - Mild fever, increased WBC, anemia, elevated ESR, CRP - Dyspnea, non-productive cough - Increased heart rate as body tries to maintain cardiac output
Pericarditis Pathophysiology
- May have fluid accumulation in pericardial sac called pericardial effusion - May exert increased pressure on the heart leading to cardiac tamponade.
Myocarditis Assessment & Diagnostic Findings
- May have no abnormalities - Tachycardia, chest pain - Endometrial biopsy = definitive diagnosis - Cardiac MRI with contrast - Cardiac enlargement - Faint heart sounds - Pericardial friction rub, gallop rhythm or systolic murmur - WBC, CRP, ESR may be elevated.
Patient Education for the Patient with Heart Failure
- Medications - Diet: low-sodium diet and fluid restriction - Monitor for signs of excess fluid, hypotension, and symptoms of disease exacerbation, including daily weight - Exercise and activity program - Stress management - Prevention of infection - Know how and when to contact health care provider - Include family in education
Assessment of the Patient with Heart Failure Physical Exam
- Mental status - lung sounds - crackles and wheezes - heart sounds: S3 - fluid status or signs of fluid overload - daily weight and I&O - assess responses to medications
Planning and Goals for the Patient With Heart Failure Goals
- Promote activity and reduce fatigue - Relieve fluid overload symptoms - Decrease anxiety or increase the patient's ability to manage anxiety - Encourage the patient to verbalize his or her ability to make decisions and influence outcomes - Educate the patient and family about management of the therapeutic regimen
Collaborative Problems and Potential Complications of the Patient with HF
- Pulmonary edema - Hypotension, poor perfusion, and cardiogenic shock - Arrhythmias - Thromboembolism - Pericardial effusion
Infective endocarditis Nursing Management
- Temperature - Heart sounds, murmurs - Medication administration- timing critical for consistent therapeutic levels - Monitor invasive lines -Patient education rest - Infection control for patient and caregive
Myocarditis Medical Management
- Treat underlying cause - Bed rest - decrease cardiac workload - If young, limit activities for 6 months - No NSAIDS - likely increase cardiac injury and viral replication.
Medical Management of the Patient with Heart Failure
- Vary according to the severity of the patient's condition, comorbidities, and cause - Treatment may include Oral and IV medications Lifestyle modifications Supplemental O2 Surgical interventions: ICD and heart transplant - Comprehensive education and counseling to patient and family is needed
Heart Failure Pulmonary or Systemic congestion caused by either
- contraction of the heart (systolic dysfunction) - or filling of the heart (diastolic dysfunction) - Some cases are reversible depending on the cause - Most HF is a chronic, progressive condition managed with lifestyle changes and medications
Dilated cardiomyopathy
- most common... > 75 causes. - Hypertension, pregnancy, ETOH, viral infection
Which classification of medications play a pivotal role in the management of HF caused by systolic dysfunction? A) ACE inhibitors B) Beta-blockers C) Diuretics D) Digitalis
A. ACE inhibitors Rationale: ACE inhibitors play a pivotal role in the management of HF caused by systolic dysfunction. They slow the progression of HF, improve exercise tolerance, and decrease the number of hospitalizations in patients with HFrEF.
A total artificial heart (TAH) is an electrically powered pump that circulates blood into the pulmonary artery and the aorta, thus replacing the functions of both the right and left ventricles. What makes it different from an LVAD?
An LVAD only supports a failing left ventricle. - A TAH is considered an extension of LVADs, which only support a failing left ventricle. TAHs are targeted for clients who are unlikely to live more than a month without further interventions.
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.
Which of the following is not an appropriate recommendation for an exercise program for the patient with HF? A) Follow the exercise period with a cool-down activity B) High-intensity training will provide the most benefit C) Wait 2 hours after eating a meal before performing the physical activity D) Begin with low-impact activities such as walking
B. High-intensity training will provide the most benefit Rationale: The primary provider, nurse, and patient should collaborate to develop a schedule that promotes pacing and prioritization of activities. The schedule should alternate activities with periods of rest and avoid having two significant energy-consuming activities occur on the same day or in immediate succession. The patient should increase the duration of the activity, then the frequency, before increasing the intensity of the activity.
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
Heart Failure
Heart failure (HF) is a clinical syndrome resulting from - structural or functional cardiac disorders that impair the ability of a ventricle to fill or eject blood - the heart is unable to pump enough blood to meet the body's metabolic demands or needs - Heart failure = myocardial disease
An adult client with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. The medical history reveals diabetes mellitus, hypertension, and pernicious anemia. The client underwent an appendectomy 20 years earlier and an aortic valve replacement 2 years before this admission. What history finding is a major risk factor for infective endocarditis?
History of aortic valve replacement
In which type of cardiomyopathy does the heart muscle actually increase in size and mass weight, especially along the septum?
Hypertrophic - Because of structural changes, hypertrophic cardiomyopathy had also been called idiopathic hypertrophic subaortic stenosis or asymmetric septal hypertrophy. Restrictive cardiomyopathy is characterized by diastolic dysfunction caused by rigid ventricular walls that impair ventricular stretch and diastolic filling. Arrhythmogenic right ventricular cardiomyopathy occurs when the myocardium of the right ventricle is progressively infiltrated and replaced by fibrous scar and adipose tissue.
Myocarditis
Inflammation involving myocardium - Heart dilation - Thrombi on the heart wall - Degeneration of muscle fiber - Complications Cardiomyopathy Heart failure
The nurse is caring for a client newly diagnosed with myocarditis. Which diagnostic test would the nurse find most helpful in confirming the diagnosis?
Myocardial biopsy
The nurse is caring for a client with aortic regurgitation. The nurse knows to expect what symptoms during the physical examination?
Orthopnea and dyspnea
A client with a myocardial infarction develops acute mitral valve regurgitation. The nurse knows to assess for which manifestation that would indicate that the client is developing pulmonary congestion?
Shortness of breath
A nurse is caring for a client with pericarditis and auscultates a pericardial friction rub. What action does the nurse ask the client to do to distinguish a pericardial friction rub from a pleural friction rub?
The nurse asks the client to hold the breath during auscultation. - pericardial surfaces lose their lubricating fluid as a result of inflammation. The audible rub on auscultation is synchronous with the heartbeat. To distinguish between a pleural rub and a pericardial rub, the client should hold the breath. The pericardial rub will continue.
Valvular Disorders Regurgitation
The valve does not close properly, and blood backflows through the valve
Valvular Disorders Stenosis
The valve does not open completely, and blood flow through the valve is reduced
Infective endocarditis
Usually develops in - people with prosthetic heart valves or structural cardiac defects - also occurs in patients who are IV drug abusers - and in those with debilitating diseases indwelling catheters hemodialysis prolonged IV therapy High mortality rate Bacteria enter the bloodstream and settle in the heart lining, a heart valve, or a blood vessel
Pericardial effusion is the
accumulation of fluid in the pericardial sac
A client is diagnosed with pericarditis. What symptom will be the nurse's priority for treatment?
acute pain - Pain is the primary symptom of the client with pericarditis. Pain relief and the absence of complications are two major nursing goals.
Medications Used to Treat HF Hydralazine and isosorbide dinitrate:
alternative to ACE inhibitors; observe for decreased BP
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 with systemic lupus erythematosus reports palpitations, dyspnea on exertion, and leg swelling. The client's symptoms may indicate:
cardiomyopathy
The most characteristic symptom of pericarditis is
chest pain. - The pain or discomfort usually remains fairly constant, but it may worsen with deep inspiration and when lying down or turning. Other signs may include a mild fever, increased WBC count, anemia, and an elevated ESR or C-reactive protein level.
Cardinal signs of cardiac tamponade:
falling systolic BP, narrowing pulse pressure, rising venous pressure, distant heart sounds
Primary presenting symptoms of infective endocarditis are
fever and a heart murmur. In addition small, painful nodules (Osler nodes) may be present in pads of fingers or toes.
Both mitral stenosis and mitral regurgitation can result from
general aging of the valve.
Tissue valves are less likely to
generate blood clots and so long-term anticoagulation therapy is not required.
Hypertrophic cardiomyopathy
genetic, leading cause of sudden death in adolescents and young adults, esp athletes
The murmur in aortic insufficiency is
high-pitched and blowing and is heard at the third or fourth intercostal space at the left sternal border.
Mitral insufficiency has a
high-pitched, blowing murmur at the apex.
Clinical manifestations:
ill-defined chest pain or fullness, pulsus paradoxus, engorged neck veins, labile or low BP, shortness of breath
Medications Used to Treat HF Digitalis:
improves contractility; monitor for digitalis toxicity especially if patient is hypokalemic
Medications Used to Treat HF IV medications:
indicated for hospitalized patients admitted for acute decompensated HF - Dopamine: vasopressor to increase BP and myocardial contractility; adjunct with loop diuretics - Dobutamine: used for patients with left ventricular dysfunction; increases cardiac contractility and renal perfusion - Milrinone: decreases preload and afterload; causes hypotension and increased risk of dysrhythmias - Vasodilators: IV nitro, nitroprusside, nesiritide; enhance symptom relief
Restrictive/constrictive cardiomyopathy -
least common type, rigid ventricular walls
Aortic regurgitation usually manifests as progressive
left ventricular failure, resulting from blood flowing backward from the aorta to the left ventricle, and eventually into the lungs.
Mitral stenosis has a
low-pitched rumbling murmur heard at the apex.
Often the first and only sign of mitral valve prolapse is identified when a physical examination of the heart reveals an extra heart sound, referred to as a
mitral click.
If a client were to develop rheumatic carditis, which cardiac structure would most likely be affected?
mitral valve
Janeway lesions
nontender hemorrhagic lesions - fingers, toes, nose, earlobes - associated with endocarditis
Pericardiocentesis -
removal of some pericardial fluid
Pericardiectomy -
removal of the pericardium
The nurse completes an assessment of a client admitted with pericarditis. What client symptom will the nurse correlate with the diagnosis of pericarditis?
reports of constant chest pain
Cardiac tamponade is the
restriction of heart function because of this fluid, resulting in decreased venous return and decreased CO
Medications Used to Treat HF Angiotensin-converting enzyme (ACE) inhibitors:
vasodilation; diuresis; decreases afterload; monitor for hypotension, hyperkalemia, and altered renal function; cough
In mitral valve stenosis, the valve is unable to open fully. This means
less blood is able to move from the left atrium into the left ventricle.
An aortic murmur is
loud and rough and is heard over the aortic area.
A nurse is assessing a client with aortic stenosis. What type of murmur will the nurse expect to hear?
loud and rough during systole.
During a teaching session, a client who is having a valvuloplasty tomorrow asks the nurse about the difference between a mechanical valve replacement and a tissue valve. What answer from the nurse is correct?
"A mechanical valve is thought to be more durable and so requires replacement less often."
A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. Which client statement indicates to the nurse a need for additional teaching?
"I can still drink coffee and tea."
Pericarditis Inflammation of the pericardium
- Acute - Chronic - Recurrent - May be infectious or non-infectious
Gerontologic Considerations
- May present with atypical signs and symptoms such as fatigue, weakness, and somnolence - Decreased renal function can make older patients resistant to diuretics and more sensitive to changes in volume - Administration of diuretics to older men requires nursing surveillance for bladder distention caused by urethral obstruction from an enlarged prostate gland
Myocarditis Pathophysiology
- Viral, bacterial, or other - May be immune related, after acute systemic infection - Inflammatory reaction to toxins or medications.
The nurse is auscultating the heart of a client diagnosed with mitral valve prolapse. Which is often the first and only manifestation of mitral valve prolapse?
An extra heart sound
Which describes a valve used in replacement surgery that is made from the client's own heart valve?
Autograft - An example of an autograft is when the surgeon excises the pulmonic valve and uses it for an aortic valve replacement. An allograft, also called a homograft, refers to replacement using human tissue. Xenograft refers to animal tissue used in tissue replacement.
What is the main electrolyte involved in cardiomyopathy? A) Calcium B) Phosphorus C) Potassium D) Sodium
D. Sodium Rationale: Sodium is the major electrolyte involved with cardiomyopathy. Cardiomyopathy often leads to heart failure, which develops, in part, from fluid overload. Fluid overload is often associated with elevated sodium levels.
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
Splinter hemorrhage
Hemorrhage caused by trauma or injury to the nail bed that damages the capillaries and allow small amounts of blood flow.
Which nursing intervention would reduce cardiac workload in a client with myocarditis?
Maintain the client on bed rest.
Rheumatic endocarditis
May be a consequence of acute rheumatic fever - After an episode of group A beta-hemolytic streptococcal pharyngitis "strep throat" - Rheumatic heart disease: new heart murmur, cardiomegaly, risk factor for endocarditis, pericarditis, heart failure - Prompt treatment for strep throat can prevent development of rheumatic fever.
The nurse is assessing a client admitted with infective endocarditis. Which manifestation would the nurse expect to find?
Small painful lesions on the pads of the fingers and toes
In mitral valve regurgitation, the valve is leaky. This means
Some blood leaks back into the left atrium instead of moving forward into the left ventricle.
Osler node
Tender, red, raised lesions on the hands or feet
Valvular Disorders Valve prolapse:
The stretching of the valve leaflet into the atrium during systole.
The nurse is teaching a client with cardiomyopathy. Which statement is a valid teaching point?
The treatments include medications, medical devices, surgery, or transplantation.
Other causes of mitral valve disease include
coronary artery disease, heart failure, infection of the heart valves or rheumatic fever.
Medications Used to Treat HF Diuretics:
decreases fluid volume, monitor serum electrolytes
Medications Used to Treat HF Ivabradine:
decreases rate of conduction through the SA node; observe for decrease HR and BP
Cardiomyopathy
disease of the heart muscle decrease cardiac output
Medications Used to Treat HF Angiotensin II receptor blockers:
prescribed as an alternative to ACE inhibitors; work similarly
Medications Used to Treat HF Beta-blockers:
prescribed in addition to ACE inhibitors; may be several weeks before effects seen; use with caution in patients with asthma
