Critical Care Nursing -- Acute Heart Diseases

Complications of rheumatic fever & heart disease (length of symptoms vs chronic):

<5% of symptoms last more than 6 months Chronic rheumatic carditis may occur

While doing an admission assessment, the nurse notes clubbing of the patient's fingers. Based on this finding, the nurse will question the patient about which disease process? a) Endocarditis b) Acute kidney injury c) Myocardial infarction d) Chronic thrombophlebitis

A

While admitting a patient with pericarditis, the nurse will assess for what manifestations of this disorder? a) Pulsus paradoxus Correct b) Prolonged PR intervals c) Widened pulse pressure d) Clubbing of the fingers

A Pericarditis can lead to cardiac tamponade, an emergency situation. Pulsus paradoxus greater than 10 mm Hg is a sign of cardiac tamponade that should be assessed at least every 4 hours in a patient with pericarditis. Prolonged PR intervals occur with first-degree AV block. Widened pulse pressure occurs with valvular heart disease. Clubbing of fingers may occur in subacute forms of infective endocarditis and valvular heart disease.

The patient had a history of rheumatic fever and has been diagnosed with mitral valve stenosis. The patient is planning to have a biologic valve replacement. What protective mechanisms should the nurse teach the patient about using after the valve replacement? a) Long-term anticoagulation therapy b) Antibiotic prophylaxis for dental care c) Exercise plan to increase cardiac tolerance Incorrect d) Take β-adrenergic blockers to control palpitations.

B The patient will need to use antibiotic prophylaxis for dental care to prevent endocarditis.

A balloon inflated to separate valve (surgical treatment for stenosis):

Balloon valvuloplasty

The following assessment findings are indicative of which acute heart disease? -sharp, sudden, substernal precordial pain radiating to left side of the neck, shoulder, or back -grating, oppressive pain, aggravated by BREATHING, COUGHING, and/or SWALLOWING -Pain worsened by the supine position; relieved when the client sits up and leans forward -Pericardial friction rub

Pericarditis

Type of cardiomyopathy that incurs stiffness of the ventricle by left ventricular hypertrophy and endocardial fibrosis and thickening

Restrictive cardiomyopathy

Type of cardiomyopathy characterized by the following: -decreased cardiac output with high diastolic pressure -enlarged atria due to rigid ventricle walls -slowed diastolic filling -left ventricular hypertrophy -ventricular rigidity impairing systole

Restrictive cardiomyopathy (characteristics of)

Type of cardiomyopathy with the following symptoms: -fatigue -dyspnea -orthopnea -chest pain -edema -liver engorgement

Restrictive cardiomyopathy (symptoms of)

The following etiology and pathophysiology characterize which acute heart disease? -toxins from strep stimulate the immune system -antibodies made to attack the strep also attack the connective tissues of the heart -endocarditis, myocarditis, and/or pericarditis (cause it or caused by it?) -the valves are affected when endocarditis occurs in the inner-most layer where they are located

Rheumatic Fever (etiology/pathophysiology)

Heart sound that occurs right after S2, marked by early rapid filling of the ventricle with blood at the very beginning of diastole (sounds like "sub-dub-ta" or think: "slosh-ing-in"):

S3 (ventricular gallop)

Heart sound that occurs just before S1, marked by increased ventricular stiffness, late in diastole (sounds like "ta-lub-dub" or "a-stiff-wall")

S4 (atrial gallop)

Occurs when blood turbulence within heart allows causative agent to infect previously damaged valves or other endothelial surfaces:

(Etiology of) endocarditis

Three types of secondary cardiomyopathy

*Dilated *Restrictive *Hypertrophic

What happens with untreated dilated cardiomyopathy (3 things)?

-Eventually the compensatory mechanisms -don't work -Severe left ventricle dilation occurs -Generalized cardioByopathy develops

Treatment for endocarditis includes (4):

-IV antibiotics -oral antibiotics -corrective surgery -REST

Other surgical procedures for valvular/acute heart disease (besides balloon valvuloplasty) (3):

-direct/open commissurotomy -mitral valve annuloplasty -replacement procedures

General/common drug therapy for acute heart diseases:

-diuretics -beta blockers (LOLs) -digoxin -O2 -sometimes nitrates -prophylactic antibiotics -antigoagulants

Clinical manifestations of myocarditis include (some systemic, some more localized):

-fever, fatigue, malaise, pharyngitis, dyspnea, lymphadenopathy, N/V -friction rub, chest pain, S3, crackles, JVD, edema

Interventions for pericarditis (general) include (6):

-hospitalization for diagnostic evaluation, observation for complications, and symptom relief -NSAIDS -Corticosteroid therapy (for inflammation) -Comfortable positioning (usually SITTING) -pericardial drainage -pericardiectomy or pericardiocentesis

Diagnostic studies for endocarditis include (5):

-lab -echo -CXR -EKG -Cath

Other general/common nonsurgical interventions for acute heart disease:

-management of AFib -cardioversion -rest with limited activity

Treatment for myocarditis includes (3)

-modified bedrest -IV immune globulin drugs -management of complications

Characteristics of murmers (PQLRI)

-pitch: if high, use diaphragm; if low, use bell -quality: blowing, harsh, musical -location: point of origin (where is it the loudest?) -radiation: areas around origin -intensity: loudness, on scale of 1-6; grades 4-6 can actually feel vibration (palpate)

Possible causes of pericarditis include:

-sometimes idiopathic -infection -radiation therapy -MI (possible causes of which acute heart disease?)

MR ASS:

Systolic murmer *heard right after S1 M - mitral R - regurg A - aortic S - stenosis S - systolic

Patients with ACUTE aortic valve regurgitation will present with/as:

Trauma, aortic dissection (this is an EMERGENCY!)

Collaborative care for rheumatic fever:

antibiotics (1st line collaborative care for which acute heart disease)?

A patient with CHRONIC mitral valve regurgitation will present with/as:

asymptomatic -- then heart failure with dyspnea, peripheral edema, S3, and murmur

Patients with CHRONIC aortic valve regurgitation (RF, RHD, congenital) will present with/as:

asymptomatic-- then dyspnea, orthopnea, angina, S3 or S4

Left-sided endocarditis is more common with:

bacterial infections and underlying heart disease

Intervention for UREMIC pericarditis:

dialysis

Murmer that sounds like "lub-dubb-shhhh":

diastolic

What heart dx would need an exercise plan to increase cardiac tolerance?

heart failure

Audible vibration caused by turbulent blood flow through the heart (long-lasting whooshing sound):

heart murmer

what heart dx (valvular disease) would need betal blockers to control palpitations?

mitral valve prolapse

Interventions for chronic pericarditis (2):

radiation or chemotherapy

Type of cardiomyopathy with the following treatments: -diuretics -steroids -anticoagulants -fluid restriction -O2 -transplant

restrictive cardiomyopathy

This acute heart disease can develop as an abnormal immune or inflammatory response to group A beta-hemolytic strep:

rheumatic fever

Inflammatory disease of the heart involving all three layers (general):

rheumatic fever (general def.)

Murmer that sounds like "lubb-shhhh-dubb":

systolic

Long-term anticoagulation therapy is not used with biologic valve replacement UNLESS

the patient has atrial fibrillation.

A patient with ACUTE mitral valve regurgitation will present with/as...

thready peripheral pulses and cool/clammy extremeties

Right-sided endocarditis is more common with:

IV drug abuse

In valvular heart disease, decreased blood flow from LA to LV is characteristic of:

Mitral Valve Stenosis (characterized by)

In valvular heart disease, which specific type is indicated when valve leaflets prolapse back into the LA during systole?

Mitral valve prolapse

Patients with this specific type of valvular heart disease are usually asymptomatic for life:

Mitral valve prolapse

In valvular heart disease, the following feature characterizes which specific type? -backward flow of blood (from MI, chronic RHD)

Mitral valve regurgitation/insufficiency (characterized by)

This specific type of valvular heart disease is usually a complication of rheumatic heart disease:

Mitral valve stenosis (usually a complication of)

Focal or diffuse inflammation of the myocardium which may be acute or chronic is called:

Myocarditis

The following features characterize which acute heart disease? -sometimes myocardium is damaged with arrhythmias and left-sided enlargement -rarely, but may be complicated by heart failure, cardiomyopathy, and sudden death

Myocarditis

This type of -carditis usually goes away spontaneously

Myocarditis

This type of acute heart disease may be caused by any of the following: -viruses, bacteria, fungi, parasites, radiation, pharmacologic agents -coxsackievirus & epstein-barr virus, influenza A/B, mumps, diptheria, lyme disease -SLE, RA -drug hypersensitivity (PCN, sulfas, HCTZ) -environmental toxins (lead, arsenic, CO) -insects (wasps, scorpions, spiders)

Myocarditis

Treatment for cardiac tamponade consists of:

Needle, Knife, Drain! -pericardiocentesis, pericardial window, drain into sac.

_________________ is used cautiously for chest pain because it can reduce BP and worsen _______________ in patients with ___________________.

Nitroglycerin; chest pain; aortic stenosis

what are the three CLASSIC assessment findings and 5 other possible assessment findings in CARDIAC TAMPONADE?

3 (beck's triad): -Elevated CVP with JVD -muffled heart sounds -pulsus paradoxus others include... -dyspnea -cough -syncope -anxiety -restlessness

The patient had myocarditis and is now experiencing fatigue, weakness, palpitations, and dyspnea at rest. The nurse assesses pulmonary crackles, edema, and weak peripheral pulses. Sinoatrial tachycardia is evident on the cardiac monitor. The Doppler echocardiography shows dilated cardiomyopathy. What collaborative and nursing care of this patient should be done to improve cardiac output and the quality of life? (Select all that apply.) a) Decrease preload and afterload. b) Relieve left ventricular outflow obstruction. c) Control heart failure by enhancing myocardial contractility. d) Improve diastolic filling and the underlying disease process. e) Improve ventricular filling by reducing ventricular contractility.

A and C The patient is experiencing dilated cardiomyopathy. To improve cardiac output and quality of life, drug, nutrition, and cardiac rehabilitation will be focused on controlling heart failure by decreasing preload and afterload and improving cardiac output, which will improve the quality of life. Relief of left ventricular outflow obstruction and improving ventricular filling by reducing ventricular contractility is done for hypertrophic cardiomyopathy. There are no specific treatments for restrictive cardiomyopathy, but interventions are aimed at improving diastolic filling and the underlying disease process.

When caring for a patient with infective endocarditis, the nurse will assess the patient for which vascular manifestations (select all that apply)? a) Osler's nodes b) Janeway's lesions c) Splinter hemorrhages d) Subcutaneous nodules e) Erythema marginatum lesions

A, B, and C

complication of upper respiratory infections or throat (with a 3% chance of developing as a complication from strep infections):

Acute rheumatic fever

This type of acute heart disease, defined as "damage to the structure of one or more of the heart valves", can occur in any heart valve, is usually congenital (childhood murmers), and is characterized by: -prolapse (MITRAL, -insufficiency/regurgitation (MITRAL or AORTIC) -stenosis (MITRAL or AORTIC)

Acute valvular disease

The following characteristics and clinical presentations are characteristic of which specific type of valvular heart disease? -backward flow from ascending aorta into LV

Aortic valve regurgitation

The following characteristics and clinical presentations are characteristic of which specific type of valvular heart disease? -congenital stenosis (also degenerative or RF) -obstruction of flow from LV to aorta -LV hypertrophy, decreased cardiac output, HF -increased mortality rate if untreated -angina, syncope, dyspnea, systolic murmer, S4

Aortic valve stenosis

The nurse conducts a complete physical assessment on a patient admitted with infective endocarditis. Which finding is significant? a) Respiratory rate of 18 and heart rate of 90 b) Regurgitant murmur at the mitral valve area c) Heart rate of 94 and capillary refill time of 2 seconds d) Point of maximal impulse palpable in fourth intercostal space

B A regurgitant murmur of the aortic or mitral valves would indicate valvular disease, which is a complication of endocarditis. All the other findings are within normal limits.

What nursing action should the nurse prioritize during the care of a patient who has recently recovered from rheumatic fever? a) Teach the patient how to manage his or her physical activity. b) Teach the patient about the need for ongoing anticoagulation. c) Teach the patient about the need for continuous antibiotic prophylaxis. d) Teach the patient about the need to maintain standard infection control procedures.

C Patients with a history of rheumatic fever frequently require ongoing antibiotic prophylaxis, an intervention that necessitates education. This consideration is more important than activity management in preventing recurrence. Anticoagulation is not indicated in this patient population. Standard precautions are indicated for all patients.

An EXTREME EMERGENCY marked by unchecked increase in pressure in the pericardial sac which results from blood or fluid that accumulates in the sac and compresses the heart & obstructs blood flow to the ventricles and reduces cardiac output:

Cardiac Tamponade

Disease of the heart muscle (general term) that affects the functional ability of the heart

Cardiomyopathy

The patient with pericarditis is complaining of chest pain. After assessment, which intervention should the nurse expect to implement to provide pain relief? a) Corticosteroids b) Morphine sulfate Incorrect c) Proton pump inhibitor d) Nonsteroidal antiinflammatory drugs

D Nonsteroidal antiinflammatory drugs (NSAIDs) will control pain and inflammation. Corticosteroids are reserved for patients already taking corticosteroids for autoimmune conditions or those who do not respond to NSAIDs. Morphine is not necessary. Proton pump inhibitors are used to decrease stomach acid to avoid the risk of GI bleeding from the NSAIDs.

An 80-year-old patient with uncontrolled type 1 diabetes mellitus is diagnosed with aortic stenosis. When conservative therapy is no longer effective, the nurse knows that the patient will need to do or have what done? a) Aortic valve replacement b) Take nitroglycerin for chest pain. c) Open commissurotomy (valvulotomy) procedure d) Percutaneous transluminal balloon valvuloplasty (PTBV) procedure

D The percutaneous transluminal balloon valvuloplasty (PTBV) procedure is best for this older adult patient who is a poor surgery candidate related to the uncontrolled type 1 diabetes mellitus. Aortic valve replacement would probably not be tolerated well by this patient, although it may be done if the PTBV fails and the diabetes is controlled in the future.Open commissurotomy procedure is used for mitral stenosis.

MS ARD:

Diastolic murmer *heard after S2 and before S1 M - mitral S - stenosis A - aortic R - regurgitation D - diastolic

Type of cardiomyopathy with the following characteristics: -damaged muscle fibers -lowered contractility of left ventricle with lowered stroke volume -left ventricle ____ ?

Dilated Cardiomyopathy (characteristics of)

Type of cardiomyopathy that primarily affects systolic function

Dilated Cardiomyopathy (primarily affects...)

Cardiomyopathy with the following symptoms: -SOB -orthopnea -dyspnea -fatigue -dry cough -peripheral edema -JVD -tachycardia

Dilated cardiomyopathy (symptoms of)

Cardiomyopathy that is treated by the following: -ACE inhibitors (prils) -lifestyle modification -treatment of underlying symptoms

Dilated cardiomyopathy (treatment of)

General term for an infection/inflammation of the endocardium, the heart valves, or cardiac prosthesis which-- not always, but typically-- results from bacterial invasion:

Endocarditis

The following clinical manifestations indicate which acute heart disease? -intermittent fever, chills, weakness, fatigue, anorexia -arthralgias, back pain, weight loss, headache, clubbing of fingers -onset of new murmer -splinter hemorrhages, petechiae, osler's node, janeway's lesions, roths

Endocarditis

Caused by vegetation; fibrin/leukocytes/microbes adherence to valve or endocardium; emobilization of vegetations into circulation; bacterial agents:

Endocarditis (pathophysiology of)

Inflammation or alteration of the pericardium, the membranous sac that encloses the heart:

Pericarditis

Type of cardiomyopathy with the following characteristics: -increased pulmonary pressure -mitral insufficiency due to hypertrophy of papillary muscles -failure of left ventricle to relax properly, leading to decreased filling -thickened septum -left ventricular hypertrophy -not enough blood to coronary arteries leading to injury, ischemia, infarct (?)

Hypertrophic cardiomyopathy (characteristics of)

Type of cardiomyopathy that primarily affects diastolic function:

Hypertrophic cardiomyopathy (primarily affects...)

Type of cardiomyopathy with the following symptoms: -sudden cardiac death -angina -dyspnea -fatigue -dysrhythmias

Hypertrophic cardiomyopathy (symptoms of)

This type of cardiomyopathy is treated with the following: -treatment of underlying symptoms (Dysrhythmias, etc.) -prophylactic antibiotics -transplant

Hypertrophic cardiomyopathy (treatment of)