Valvular Heart Disease NCLEX

Mitral stenosis manifestations

- Dyspnea on exertion,, hemoptysis, fatigue - Atrial fibrillation - palpitations - JVD, edema - Low-pitched diastolic murmur

Risk factors for valvular heart disease

- Hypertension - rheumatic fever - infective endocarditis - congenital malformation - Marfan syndrome - degenerative calcification - age (fibrotic thickening, stiffer aorta)

Mitral regurgitation manifestations

- Murmur - Pulmoary edema, JVD Chronic: weakness, fatigue, palpitations -S3 gallop, murmur - Hepatomegaly

VHD conservative therapy

- Prophylactic antiobiotic therpay (Rherumatic fever, IE) - Sodium restriction - Drug therapy; vasodilators (nitrates), digoxin, diuretics, B-blockers - Anticoagulation therapy - Antidysrhythmic drugs - percutaneous transluminal balloon valvuloplasty - percutaneous valve replacement

Valvular Heart Disease Diagnostics

- chest xray - complete blood count - EKG - echocardiogram (Doppler and transesophageal) - Heart catheterization

teaching for mitral valve prolapse

- take drugs as prescribed (B-blockers) - adopt healthy eating habits - avoid caffeine - check diet pill or OTC for caffeine - Exercise program, - contact HCP of symptoms develops or worsen

Pt on anticoagulants (warfarin) after surgery for valve replacement must have INR checked regularly to determine proper dosage and adequacy of therapy. What is the therapeutic range for this pt?

2.5-3.5

A nurse educator is reviewing expected findings in a client who has right-sided valvular heart disease with a group of other nurses. Which of the following findings should the nurse include in the discussion? (SATA) a. Dyspnea b. Client repots fatigue c. Bradycardia d. Pleural friction rub e. Peripheral edema

A, B, E

A pt is diagnosed with mitral stenosis and new onset atrial fibrillation. Which interventions could the nurse delegate to unlicensed assistive personnel? (SATA) a. Obtain and record daily weight b. Determine apical pulse rate c. Observe for overt signs of bleeding d. Teach the pt how to get a medic alert bracelet e. Obtain and record vital signs, including pulse ox

A, C, E

The nurse is caring for a pt with aortic stenosis. Which assessment data obtained by the nurse would be most important to report to the health care provider? a. The patient complains of chest pressure when ambulating. b. A loud systolic murmur is heard along the right sternal border. c. A thrill is palpated at the second intercostal space, right sternal border. d. The point of maximum impulse (PMI) is at the left midclavicular line.

ANS: A Chest pressure (or pain) occurring with aortic stenosis is caused by cardiac ischemia, and reporting this information would be a priority. A systolic murmur and thrill are expected in a patient with aortic stenosis. A PMI at the left midclavicular line is normal.

While caring for a pt with aortic stenosis, the nurse identifies a nursing diagnosis of acute pain related to decreased coronary blood flow. An appropriate nursing intervention for this patient would be to a. promote rest to decrease myocardial oxygen demand. b. teach the patient about the need for anticoagulant therapy. c. teach the pt to use sublingual nitroglycerin for chest pain. d. raise the head of the bed 60 degrees to decrease venous return.

ANS: A Rest is recommended to balance myocardial oxygen supply and demand and to decrease chest pain. The patient with aortic stenosis requires higher preload to maintain cardiac output, so nitroglycerin and measures to decrease venous return are contraindicated. Anticoagulation is not recommended unless the patient has atrial fibrillation.

A nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. The nurse should recognize which of the following data as risk factors for this condition? (SATA) a. Surgical repair of an atrial septal defect at age 2 b. Measles infection during childhood c. Hypertension for 5 years d. Weight gain of 10 pounds in past year e. Diastolic murmur present

ANS: A, C, E B: Having a streptococcal infection or rheumatic fever during childhood is a risk factor for VHD D: could indicate fluid collection related to left-sided valvular heart disease

A nurse is completing discharge teaching with a client who had a surgical placement of a mechanical heart valve. Which of the following statements by the client indicates understanding of the teaching? a. "I will be gals to get back to my exercise routine right away." b. "I will have my prothrombin time checked on a regular basis." c. "I will talk to my dentist about no longer needing antibiotics before dental exams." d. "I will continue to limit my intake of foods containing potassium."

ANS: B Anticoagulant therapy with warfarin is necessary for pt following placement of a mechanical heart valve A: client will be on activity limitations for 6 weeks following surgery of heart valve C: Antibiotics recommended prior to dental work following heart valve placement D: Dietary recommendations include limiting sodium

The nurse is caring for a 64-yr-old patient admitted with mitral valve regurgitation. Which information obtained by the nurse when assessing the patient should be communicated to the health care provider immediately? a. The patient has 4+ peripheral edema. b. The patient has diffuse bilateral crackles. c. The pt has a loud systolic murmur across the precordium. d. The pt has a palpable thrill felt over the left anterior chest

ANS: B Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and needs immediate interventions such as diuretics. A systolic murmur and palpable thrill would be expected in a patient with mitral regurgitation. Although 4+ peripheral edema indicates a need for a change in therapy, it does not need to be addressed urgently.

After receiving change-of-shift report on four patients, which patient should the nurse assess first? a. Pt with rheumatic fever who has sharp chest pain with a deep breath b. Pt with acute aortic regurgitation whose blood pressure is 86/54 mm Hg c. Pt with infective endocarditis who has a murmur and splinter hemorrhages d. Pt with dilated cardiomyopathy who has bilateral crackles at the lung bases

ANS: B Hypotension in patients with acute aortic regurgitation may indicate cardiogenic shock. The nurse should immediately assess this patient for other findings such as dyspnea, chest pain or tachycardia. The findings in the other patients are typical of their diagnoses and do not Indicate a need for urgent assessment and intervention

A nurse is caring for an older adult client who is to undergo a percutaneous balloon valvuloplasty. The client's fa,Miley member ask the nurse to explain the expected outcome of this procedure. Which of the following responses should the nurse give? a. "This will improve blood flow of the coronary arteries." b. "This will assist with the ability to perform active items of daily living." c. "This will prolong the life span of living with this valve disorder." d. "This will revers the effects to the damaged area."

ANS: B Surgery is indicated for older adult client when manifestations interfere with activities of daily living

After receiving information about four pts during change-of-shift report, which pt should the nurse assess first? a. Pt with acute pericarditis who has a pericardial friction rub b. Pt who has just returned to the unit after balloon valvuloplasty c. Pt who has hypertrophic cardiomyopathy and a heart rate of 116 d. Pt with a mitral valve replacement who has an anticoagulant scheduled

ANS: B The pt who has just arrived after balloon valvuloplasty will need assessment for complications such as bleeding and hypotension. The information about the other patients is consistent with their diagnoses and does not indicate any complications or need for urgent assessment or intervention

During discharge teaching with an older pt who had a mitral valve replacement with a mechanical valve, the nurse must instruct the pt on the a. use of daily aspirin for anticoagulation. b. correct method for taking the radial pulse. c. need for frequent laboratory blood testing. d. need to avoid any physical activity for 1 month.

ANS: C Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to prevent clotting on the valve. This will require frequent international normalized ratio testing. Daily aspirin use will not be effective in reducing the risk for clots on the valve. Monitoring of the radial pulse is not necessary after valve replacement. Patients should resume activities of daily living as tolerated.

The nurse will plan discharge teaching about prophylactic antibiotics before dental procedures for which patient? a. Patient admitted with a large acute myocardial infarction b. Patient being discharged after an exacerbation of heart failure c. Patient who had a mitral valve replacement with a mechanical valve d. Patient being treated for rheumatic fever after a streptococcal infection

ANS: C Current American Heart Association guidelines recommend the use of prophylactic antibiotics before dental procedures for patients with prosthetic valves to prevent infective endocarditis (IE). The other patients are not at risk for IE

A 21-yr-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient? a. Biologic valves will require immunosuppressive drugs after surgery. b. Mechanical mitral valves need to be replaced sooner than biologic valves. c. Lifelong anticoagulant therapy is needed after mechanical valve replacement. d. Ongoing cardiac care by a health care provider is not necessary after valvuloplasty.

ANS: C Long-term anticoagulation therapy is needed after mechanical valve replacement, and this would restrict decisions about career and childbearing in this patient. Mechanical valves are durable and last longer than biologic valves. All valve repair procedures are palliative, not curative, and require lifelong health care. Biologic valves do not activate the immune system and immunosuppressive therapy is not needed.

When caring for a pt with mitral valve stenosis, it is most important that the nurse assess for a. diastolic murmur. b. peripheral edema. c. shortness of breath on exertion. d. right upper quadrant tenderness.

ANS: C The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting in hypoxemia and dyspnea. The other findings also may be associated with mitral valve disease but are not indicators of possible hypoxemia, which is a priority.

While caring for a 23-yr-old pt with mitral valve prolapse (MVP) without valvular regurgitation, the nurse determines that discharge teaching has been effective when the pt states that it will be necessary to a. take antibiotics before any dental appointments. b. limit physical activity to avoid stressing the heart. c. avoid over-the-counter (OTC) drugs that contain stimulants. d. take an aspirin a day to prevent clots from forming on the valve.

ANS: C Use of stimulant drugs should be avoided by patients with MVP because they may exacerbate symptoms. Daily aspirin and restricted physical activity are not needed by patients with mild MVP. Antibiotic prophylaxis is needed for patients with MVP with regurgitation but will not be necessary for this patient.

A nurse is completing the admission physical assessment of a client who has mitral valve insufficiency. Which of the following findings should the nurse expect? a. S4 heart sound b. Petechiae c. Neck vein distention D. Splenomegaly

ANS: C neck vein distention is expected in pt who has pulmonary congestion due to mitral valve insufficiency A: S3 heart sound is expected. S4 is doing in aortic stenosis B: petechiae is expected finding in client with infective endocarditis D: Hepatomegaly, not splenomegaly, is expected in client with left sided heart valve damage

Which action could the nurse delegate to unlicensed assistive personnel (UAP) trained as electrocardiogram (ECG) technicians working on the cardiac unit? a. Select the best lead for monitoring a patient with an admission diagnosis of Dressler syndrome. b. Obtain a list of herbal medications used at home while admitting a new patient with pericarditis. c. Teach about the need to monitor the weight daily for a patient who has hypertrophic cardiomyopathy. d. Watch the heart monitor for changes in rhythm while a patient who had a valve replacement ambulate

ANS: D Under the supervision of registered nurses (RNs), UAPs check the patient's cardiac monitor and obtain information about changes in heart rate and rhythm with exercise. Teaching and obtaining information about home medications (prescribed or complementary) and selecting the best leads for monitoring patients require more critical thinking and should be done by the RN.

Aortic stenosis manifestations

Angina, syncope, dyspnea on exertion, HF; - systolic murmur, - S4 sounds - narrowed pulse pressure

The nurse is caring for a pt with mitral regurgitation. Where should the nurse listen to best hear a murmur typical of mitral regurgitation?

Apex of the heart, fifth intercostal space, midclavicular line

What valve should a woman of childbearing age have?

Biologic valve because she cannot take anticoagulants

Most common cause of valve disorders in children and adolescents?

Congenital heart conditions

Surgical therapy for valvular heart disease

Depends on valves involved, pathology and severity of disease, and pts clinical conditon

What valve is appropriate for a younger patient?

Mechanical because it is more durable

Surgical repair: valve replacement

Mechanical or biological valves Mechanical: made from artificial materials - more durable and last longer - increased risk for thromboembolism (pt need long term anticoagulation) Biologic: made from bovine, porcine, and human heart tissue - less durable and cause early calcification, tissue degeneration, and stiffening of leaflets

Surgical therapy: valve repair

Preferred over replacement Valvuloplasty: uses sutures to repair torn leaflets

How is a percutaneous transluminal coronary angioplasty (PTCA) performed? (type of CV revascularization procedure)

Threads a balloon tipped catheter from the femoral artery or vein to the stenotic valve. Balloon is inflated to separate valve leaflets

aortic regurgitation manifestations

dyspnea, *water hammer pulse*, murmur, Austin Flint murmur

Left sided valves

mitral and aortic

Mitral valve stenosis most common cause

rheumatic heart disease

Right sided valves

tricuspid and pulmonic