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Chapter 12 Cardiovascular Disorders Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Objectives Describe the etiology and pathophysiology of atherosclerotic coronary artery disease. Identify the pathophysiology and clinical manifestations of acute heart failure. (continued) Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 2 Objectives (continued) Explain the treatment of selected cardiovascular disorders: coronary artery disease, cardiomyopathy, and valvular disease. Discuss the nursing priorities for managing a patient with an acute cardiovascular disorder. Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 3 Coronary Artery Disease Atherosclerotic disease affects arteries throughout the body In the heart, atherosclerotic changes are known as coronary artery disease (CAD) This disease process is also known as coronary heart disease (CHD) Strong association between risk factors and the development of CAD Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 4 Nonmodifiable CAD Risk Factors Age Gender Race Family history Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 5 Modifiable CAD Risk Factors Elevated serum lipids Hypertension Cigarette smoking Prediabetes or diabetes mellitus Obesity Chronic kidney disease Metabolic syndrome Diet high in saturated fat, cholesterol, and calories Physical inactivity Elevated homocysteine level Postmenopause (modification is controversial) Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 6 Women and Heart Disease Symptoms occur later in life HRT is no longer recommended for prevention of atherosclerotic cardiovascular disease CV disease kills >500,000 women annually Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 7 Pathophysiology of Coronary Artery Disease Atherosclerotic plaque narrows lumen of artery Chronic inflammatory disorder Plaque rupture and coronary thrombosis Plaque regression is possible with change in risk factors Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 8 Acute Coronary Syndromes (ACS) Term describes array of clinical presentations Range from unstable angina to acute myocardial infarction (MI) Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 9 Symptoms of ACS Angina: lack of oxygen causes myocardial ischemia, which is felt as chest pain Stable angina: predictable, fixed lesions Unstable angina: change in previously established pattern, more intense, indication of plaque instability Symptoms of angina may differ in women Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 10 Anginal Patterns FIGURE 12-1 Common Sites for Anginal Pain. A, Upper part of chest. B, Beneath sternum, radiating to neck and jaw. C, Beneath sternum, radiating down left arm. D, Epigastric. E, Epigastric, radiating to neck, jaw, and arms. F, Neck and jaw. G, Left shoulder. H, Intrascapular. Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 11 Medical Management for Angina Accurate assessment of chest pain symptoms ST-segment elevated or new left bundle branch block—patient will be treated for myocardial infarction (MI) Chest pain without electrocardiogram (ECG) changes—pharmacological management Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 12 Nursing Diagnosis Priorities Acute pain related to transmission and perception of cutaneous, visceral, muscular, or ischemic impulses Ineffective cardiopulmonary tissue perfusion related to decreased myocardial oxygen supply or increased myocardial oxygen demand, or both Activity intolerance related to cardiopulmonary dysfunction (continued) Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 13 Nursing Diagnosis Priorities (continued) Powerlessness related to lack of control over current situation Anxiety related to threat to biological, psychological, or social integrity Deficient knowledge: discharge regimen related to lack of previous exposure to information Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 14 Question The patient with angina should be taught to avoid which of the following items? A. B. C. D. Caffeinated coffee Aspirin Physical activity Valsalva maneuver Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 15 Answer D. Valsalva maneuver The patient with angina should be taught the importance of alerting the nurse to any symptoms of chest pain or discomfort, and avoiding the Valsalva maneuver. The Valsalva maneuver causes an increase in intrathoracic pressure that decreases venous return to the right side of the heart and is associated with low blood pressure and symptomatic bradycardia. Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 16 Nursing Management of CAD and Angina Nursing priorities include: Recognizing myocardial ischemia Controlling chest pain Maintaining a calm environment Providing patient education Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 17 Recognizing Myocardial Ischemia Chest pain assessment Intensity Location Duration Quality Radiation Precipitating factors 12-lead ECG Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 18 Evaluation of Prehospital Chest Pain FIGURE 12-2 Evaluation of Prehospital Chest Pain, ACS and Treatment Options. STEMI, ST elevation myocardial infarction; EMS, emergency medical services; PCI, percutaneous catheter intervention. (Illustration modifi ed from Antman EM, et al: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction – executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction), Circulation 110(9):e82). Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 19 Controlling Chest Pain Supplemental oxygen Nitrates Analgesia Morphine Aspirin Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 20 Myocardial Infarction Irreversible necrosis due to an abrupt decrease or total cessation of coronary blood flow Plaque rupture New coronary artery thrombosis Coronary artery spasm close to ruptured plaque Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 21 Cardiovascular Disorders Ischemia: T-wave inversion Injury: elevated ST-segments Infarction: development of pathological Q waves MI: evolution occurs over 6 weeks after infarction Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 22 Zones of Ischemia, Injury, and Infarction FIGURE 12-3 Zone of ischemia, zone of injury, and zone of infarction are shown through ECG waveforms and reciprocal waveforms corresponding to each zone. Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 23 ECG Changes FIGURE 12-4 ECG Changes Indicative of Ischemia, Injury, and Infarction (Necrosis) of the Myocardium. A, Normal ECG. B, Ischemia indicated by inversion of the T wave. C, Ischemia and current of injury indicated by T-wave inversion and ST-segment elevation. The ST segment may be elevated above or depressed below the baseline, depending on whether the tracing is from a lead facing toward or away from the infarcted area and depending on whether epicardial or endocardial injury occurs. Epicardial injury causes STsegment elevation in leads facing the epicardium. D, Ischemia, injury, and myocardial necrosis. The Q wave indicates necrosis of the myocardium. Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 24 Acute MI-Classification Transmural MI Non-Q-wave MI Subendocardial Subepicardial 12-lead ECG in transmural MI New pathological Q-waves Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 25 Acute MI-Location FIGURE 12-5 Location of Infarctions in Myocardium. Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 26 MI Location Anterior wall infarction Left lateral wall infarction Inferior wall infarction Right ventricular infarction Posterior wall infarction Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 27 Correlations among Ventricular Surfaces, Electrocardiographic Leads, and Coronary Arteries Surface of Left Ventricle Electrocardiographic Coronary Artery Leads Usually Involved Inferior II, III, aVF Right coronary artery Lateral V5-V6, I, aVL Left circumflex Anterior V2-V4 Left anterior descending Anterior lateral V1-V6, I, aVL Left main coronary artery Septal V1-V2 Left anterior descending Posterior V1-V2 Left circumflex or right coronary artery (reciprocal changes) Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 28 Anterior Wall MI FIGURE 12-6 Changes Seen on a 12-Lead ECG with An Anterior Wall MI. A, Infarction location on the cardiac wall. B, ECG leads with expected ST-segment elevation. C, A 12-lead ECG from a patient experiencing left anterior wall MI. LAD, left anterior descending artery. Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 29 Lateral Wall MI FIGURE 12-6 Changes Seen on a 12-Lead ECG with An Anterior Wall MI. A, Infarction location on the cardiac wall. B, ECG leads with expected ST-segment elevation. C, A 12-lead ECG from a patient experiencing left anterior wall MI. LAD, left anterior descending artery. Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 30 Inferior Wall MI FIGURE 12-8 Changes Seen on a 12-Lead ECG with an Inferior Wall MI. A, Infarction location on cardiac wall. B, ECG leads with expected ST-segment elevation. C, A 12-lead ECG from a patient experiencing inferior wall MI. Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 31 Acute MI Non-ST-segment elevation MI ST segment not elevated in every acute MI Known as a NSTEMI Need to be treated aggressively to prevent damage Cardiac biomarkers Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 32 Cardiac Biomarkers FIGURE 12-9 Cardiac Biomarkers During MI. (From Antman EM, et al: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction – executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction), Circulation 110(9):e82, 2004.) Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 33 Complications of Myocardial Infarction Dysrhythmias Ventricular aneurysm Ventricular septal rupture Papillary muscle rupture Cardiac wall rupture Pericarditis Heart failure Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 34 Ventricular Aneurysm FIGURE 12-10 Ventricular Aneurysm After Acute Myocardial Infarction. LA, left atrium; LV, left ventricle; PA, pulmonary artery; RA, right atrium; RV, right ventricle. Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 35 Ventricular Septal Rupture FIGURE 12-11 Ventricular Septal Rupture After Acute Myocardial Infarction. LA, left atrium; LV, left ventricle; PA, pulmonary artery; RA, right atrium; RV, right ventricle. Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 36 Papillary Muscle Rupture FIGURE 12-12 Papillary Muscle Rupture After Acute Myocardial Infarction. LA, left atrium; LV, left ventricle; PA, pulmonary artery; RA, right atrium; RV, right ventricle. Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 37 Question The RN is caring for a patient with an acute MI. Upon auscultation of the chest the nurse notes that the patient had developed a pericardial friction rub. The RN suspects the patient is developing: heart failure. B. papillary muscle rupture. C. pericarditis. D. ventricular septal wall dysfunction. A. Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 38 Answer C. Pericarditis. Pericarditis is inflammation of the pericardial sac. It can occur after an acute MI. The damaged epicardium becomes rough and inflamed and irritates the pericardium lying adjacent to it, precipitating pericarditis. Pericardial friction rub is a common initial sign. It is best auscultated at the sternal border and is described as a grating, scraping, or leathery scratching. Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 39 Medical Management of AMI Recanalization of the coronary artery Fibrinolytic therapy Percutaneous coronary intervention (PCI) Anticoagulation Dysrhythmia prevention Tight glucose control Prevention of ventricular remodeling Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 40 Nursing Diagnosis Priorities Acute pain related to transmission and perception of cutaneous, visceral, muscular, or ischemic impulses Decreased cardiac output related to alterations in preload Decreased cardiac output related to alterations in afterload Decreased cardiac output related to alterations in contractility (continued) Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 41 Nursing Diagnosis Priorities (continued) Decreased cardiac output related to alterations in heart rate or rhythm Activity intolerance related to cardiopulmonary dysfunction Ineffective cardiopulmonary tissue perfusion related to decreased myocardial oxygen supply or increased myocardial oxygen demand, or both Disturbed sleep pattern related to fragmented sleep (continued) Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 42 Nursing Diagnosis Priorities (continued) Anxiety related to threat to biological, psychological, or social integrity Ineffective coping related to situational crisis and personal vulnerability Powerlessness related to lack of control over current situation or disease progression Deficient knowledge: discharge regimen related to lack of previous exposure to information Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 43 Nursing Management of AMI Nursing priorities include: Balancing myocardial oxygen supply and demand Preventing complications Providing patient education Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 44 Cardiac Arrest and Sudden Cardiac Death Between 400,000 and 460,000 people die suddenly of cardiac causes each year When the onset of symptoms is rapid, the most likely mechanism of death is ventricular tachycardia (VT), which degenerates into ventricular fibrillation (VF) Known as sudden cardiac death Strategies to improve outcomes Community-wide programs for cardiopulmonary resuscitation (CPR) Automated external defibrillators (AEDs) Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 45 Therapeutic Hypothermia Depending on the length of time the patient was unconscious following the cardiac arrest, cognitive defects can occur Caused by lack of cerebral blood flow and resultant hypoxia to the brain For comatose patients at high risk for hypoxic brain injury after cardiac arrest, therapeutic hypothermia to about 33° centigrade is initiated for several hours to preserve brain function Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 46 Heart Failure Description The number of patients with heart failure is increasing in the United States More than five million Americans have a diagnosis of heart failure, and about 550,000 new cases are diagnosed each year (continued) Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 47 Heart Failure (continued) Pathophysiology Heart failure is a condition in which the heart cannot pump blood at a volume required to meet the body’s needs Any condition that impairs the ability of the ventricles to fill or eject blood can cause heart failure CAD and MI are most frequent Other causes include valvular dysfunction, infection, cardiomyopathy, and hypertension Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 48 New York Heart Association Functional Classification of Heart Failure I Normal daily activity does not initiate symptoms. II Normal daily activities initiate onset of symptoms, but symptoms subside with rest. III Minimal activity initiates symptoms; patients are usually symptom-free at rest. IV Any type of activity initiates symptoms, and symptoms are present at rest. Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 49 Clinical Manifestations of Left Heart Failure Signs Tachypnea Tachycardia Cough Bibasilar crackles Gallop rhythms Increased PAP Hemoptysis Cyanosis Pulmonary edema Symptoms Fatigue Dyspnea Orthopnea Paroxysmal nocturnal dyspnea Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 50 Clinical Manifestations of Right Heart Failure Signs Peripheral edema Hepatomegaly Splenomegaly Hepatojugular reflux Ascites Jugular venous distention Increased CVP Pulmonary hypertension Symptoms Weakness Anorexia Indigestion Weight gain Mental changes Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 51 Systolic vs. Diastolic Heart Failure Systolic heart failure Decreased contractility of left ventricle Diastolic heart failure Decreased relaxation, stretching, or filling of left ventricle during diastole Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 52 Acute vs. Chronic Heart Failure Acute heart failure Sudden onset No compensatory mechanisms Chronic heart failure Ongoing syndrome Can deteriorate into acute heart failure Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 53 Neuro-Hormonal Compensatory Mechanisms Sympathetic nervous system Renin-angiotensin-aldosterone system Ventricular hypertrophy Ventricular remodeling Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 54 RAAS in Heart Failure FIGURE 12-14 Renin-Angiotensin-Aldosterone System (RAAS), its Role in Heart Failure, and Drug Actions. Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 55 Complications of Heart Failure Shortness of breath Dyspnea Orthopnea Paroxysmal nocturnal dyspnea Cardiac asthma Pulmonary edema Dysrhythmias Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 56 Pulmonary Edema FIGURE 12-15 As Pulmonary Edema Progresses, it Inhibits Oxygen and Carbon Dioxide Exchange at the Alveolar Capillary Interface. A, Normal relationship. B, Increased pulmonary capillary hydrostatic pressure causes fluid to move from the vascular space into the pulmonary interstitial space. C, Lymphatic flow increases in an attempt to pull fluid back into the vascular or lymphatic space. D, Failure of lymphatic flow and worsening of left-sided heart failure results in further movement of fluid into the interstitial space and the alveoli. Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 57 Medical Management of Heart Failure Relief of symptoms and enhancement of cardiac performance Correct precipitating causes Palliative care for end-stage heart failure Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 58 Nursing Diagnosis Priorities Impaired gas exchange related to ventilation/ perfusion mismatch or intrapulmonary shunting Decreased cardiac output related to alterations in preload Decreased cardiac output related to alterations in contractility Decreased cardiac output related to alterations in heart rate or rhythm (continued) Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 59 Nursing Diagnosis Priorities (continued) Activity intolerance related to cardiopulmonary dysfunction Anxiety related to threat to biological, psychological, or social integrity (continued) Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 60 Nursing Diagnosis Priorities (continued) Ineffective coping related to situational crisis and personal vulnerability Disturbed sleep pattern related to circadian desynchronization Deficient knowledge: discharge regimen related to lack of previous exposure to information Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 61 Nursing Management of Heart Failure Nursing priorities include: Optimizing cardiopulmonary function Promoting comfort and emotional support Monitoring effectiveness of pharmacological therapy Providing adequate nutrition Providing patient education Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 62 Cardiomyopathy Disease of the heart muscle Categories: Hypertrophic Restrictive Dilated (continued) Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 63 Cardiomyopathy (continued) FIGURE 12-16 Types of Cardiomyopathies and Differences in Ventricular Diameter during Systole and Diastole Compared with a Normal Heart. A, Hypertrophic. B, Restrictive. C, Dilated. D, Normal. Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 64 Hypertrophic Obstructive Cardiomyopathy Genetically inherited disease affecting the myocardial sarcomere Left ventricle becomes stiff, noncompliant, and hypertrophied Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 65 Dilated Cardiomyopathy Characterized by gross dilation of both ventricles without hypertrophy Types: Ischemic dilated cardiomyopathy Familial dilated cardiomyopathy Acquired dilated cardiomyopathy Other causes Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 66 Restrictive Cardiomyopathy Least common Results in ventricular wall rigidity due to myocardial fibrosis Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 67 Nursing Diagnosis Priorities Decreased cardiac output related to alterations in preload Decreased cardiac output related to alterations in afterload Decreased cardiac output related to alterations in contractility Decreased cardiac output related to alterations in heart rate or rhythm (continued) Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 68 Nursing Diagnosis Priorities (continued) Impaired gas exchange related to ventilation/ perfusion mismatch or intrapulmonary shunting Activity intolerance related to cardiopulmonary dysfunction (continued) Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 69 Nursing Diagnosis Priorities (continued) Anxiety related to threat to biological, psychological, or social integrity Powerlessness related to lack of control over current situation or disease progression Deficient knowledge: discharge regimen related to lack of previous exposure to information Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 70 Nursing Management of Cardiomyopathy Nursing priorities focus on: Achieving a stable fluid balance Monitoring effects of pharmacological therapy Increasing mobility Providing patient and family education Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 71 Valvular Heart Disease Structural and/or functional abnormalities of single or multiple cardiac valves, resulting in alteration of blood flow across valve Two types: Stenotic Regurgitant (insufficient) (continued) Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 72 Valvular Heart Disease (continued) Mitral valve stenosis Mitral valve regurgitation Aortic valve stenosis Aortic valve regurgitation Tricuspid valve stenosis Tricuspid valve regurgitation Pulmonic valve disease Mixed valvular lesions Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 73 Question Which of the following physical signs is indicative of mitral stenosis? A. B. C. D. Diastolic murmur and LV hypertrophy Diastolic murmur and atrial fibrillation Systolic murmur and P mitrale Systolic murmur and LV hypertrophy Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 74 Answer Diastolic murmur and atrial fibrillation Physical signs of mitral stenosis include: B. Chest radiograph: pulmonary congestion, redistribution of blood flow to upper lobes ECG: Atrial fibrillation/other atrial dysrhythmias Auscultation: diastolic murmur Catheterization: elevated pressure gradient across valve; increased LAP, PAOP, and PAP; low CO Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 75 Medical Management of Valvular Disease Pharmacological To control symptoms of heart failure Surgical To replace or repair affected valve Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 76 Nursing Management of Valvular Disease Nursing priorities focus on: Maintaining adequate cardiac output Optimizing fluid balance Providing patient education Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. 77