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Nursing Care of Patients with Cardiac Valvular or Inflammatory and Infectious Cardiovascular Disorders Stenosis ◦ Narrowed, Valve Does Not Open Completely ◦ Forward Blood Flow Hindered ◦ Decreases Cardiac Output Regurgitation (Insufficiency) ◦ Valve Does Not Close Completely ◦ Blood Flow Backs Up During Ventricular Systole, Mitral Valve Flaps Normally Closed In Mitral Valve Prolapse One/Both Flaps Bulge Into Left Atrium If Bulging Flaps Do Not Fit Together, Mitral Regurgitation Occurs Etiology ◦ Unknown ◦ Hereditary ◦ Women 20 to 55 Years of Age Signs and Symptoms ◦ ◦ ◦ ◦ ◦ Often None Anxiety Chest pain Dysrhythmias Dyspnea Signs and Symptoms (cont’d) ◦ Fatigue ◦ Palpitations Complications ◦ Dilation of Left Side of Heart ◦ Heart Failure ◦ Infective Endocarditis ◦ Emboli Diagnostic Tests ◦ Murmur Heard ◦ 2-D or Doppler Echocardiogram ◦ Coronary Angiogram None, Unless Symptoms Healthy Lifestyle Avoid Stimulants/Caffeine Stress Management Beta Blockers for Tachycardia Valve Surgery for Severe MVP Pathophysiology ◦ Mitral Valve Thickening/Chordae Tendineae Shortening ◦ Narrows Valve Opening ◦ Blood Flow Obstructed from Left Atrium ◦ Left Atrium Enlarges Pathophysiology (cont’d) ◦ Backward Pressure Occurs Until Right Ventricle Dilates/Fails ◦ Cardiac Output Reduced Common – Prior Rheumatic Fever Congenital Defects Tumors Rheumatoid Arthritis Systemic Lupus Erythematosus Calcium Deposits Signs and Symptoms ◦ ◦ ◦ ◦ ◦ None Early Murmur Exertional Dyspnea, Cough, Hemoptysis Fatigue Palpitations Signs and Symptoms (cont’d) ◦ Atrial Fibrillation ◦ Chest Pain Complications ◦ Stroke ◦ Seizures Diagnostic Tests ◦ ◦ ◦ ◦ ECG: P-wave Changes Chest X-Ray: Enlarged Chambers 2-D and Doppler Echocardiography Coronary Angiogram Therapeutic Interventions ◦ Prophylactic Antibiotics per Criteria ◦ Anticoagulants: Atrial Fibrillation ◦ Percutaneous Balloon Valvuloplasty Surgery ◦ Mitral Valve Repair Commissurotomy Annuloplasty ◦ Mitral Valve Replacement Pathophysiology ◦ ◦ ◦ ◦ Mitral Valve Incomplete Closure Backflow of Blood to Left Atrium Left Atrium Dilates, Extra Volume to Left Ventricle Left Ventricle Dilates from Extra Volume, Eventually May Fail Etiology ◦ ◦ ◦ ◦ ◦ Rheumatic Heart Disease (Most) Endocarditis Congenital Defects Chordae Tendineae Dysfunction Mitral Valve Prolapse Signs and Symptoms ◦ ◦ ◦ ◦ ◦ None Early Murmur Dyspnea, Cough, Hemoptysis Fatigue Palpitations Signs and Symptoms (cont’d) ◦ Atrial Fibrillation ◦ Chest Pain Complications ◦ Atrial Fibrillation ◦ Pulmonary Hypertension ◦ Heart Failure Diagnostic Tests ◦ ◦ ◦ ◦ ECG: P-Wave Changes Chest X-Ray: Enlarged Chambers 2-D and Doppler Echocardiography Coronary Angiogram Therapeutic Interventions ◦ ◦ ◦ ◦ ◦ None, Unless Symptoms Prophylactic Antibiotics per Criteria ACE Inhibitors Anticoagulants: Atrial Fibrillation Mitral Valve Repair/Replacement Pathophysiology ◦ ◦ ◦ ◦ ◦ Aortic Valve Narrowed Left Ventricle Contracts More Forcefully Left Ventricle Hypertrophies Decreased Cardiac Output Eventual Heart Failure Etiology ◦ Congenital Defects ◦ Rheumatic Heart Disease ◦ Calcification with Aging Signs and Symptoms ◦ ◦ ◦ ◦ None Early Angina Murmur Syncope ◦ ◦ ◦ ◦ Orthopnea Dyspnea on Exertion Fatigue Pulmonary Edema Complications ◦ Heart Failure ◦ Dysrhythmias ◦ Endocarditis Diagnostic Tests ◦ ◦ ◦ ◦ ◦ ECG Chest X-Ray: Enlarged Left Ventricle 2-D and Doppler Echocardiography Serial Echocardiography Cardiac Catheterization Therapeutic Interventions ◦ Surgery Aortic Valve Replacement Valvotomy ◦ Treat Heart Failure Symptoms ◦ Prophylactic Antibiotics per Criteria Aortic Valve Does Not Close Left Ventricle’s Volume Increases Left Ventricle Dilates Left Ventricle Fails ◦ Decreased Cardiac Output ◦ Pulmonary Edema Etiology ◦ ◦ ◦ ◦ ◦ Rheumatic Heart Disease (Most) Congenital Defects Syphilis Endocarditis Severe Hypertension Etiology (cont’d) ◦ Rheumatoid Arthritis ◦ Aortic Dissection Signs and Symptoms ◦ None Early ◦ Exertional Dyspnea, Fatigue ◦ Corrigan’s Pulse: Palpated Pulse Forceful, Quickly Collapses ◦ Widened Pulse Pressure ◦ Angina at Night Diagnostic Tests ◦ ◦ ◦ ◦ ECG Chest X-Ray 2-D and Doppler Echocardiography Coronary Angiogram Complications ◦ Endocarditis ◦ Heart Failure Therapeutic Interventions ◦ Vasodilator ◦ Surgical Valve Replacement ◦ Prophylactic Antibiotic Therapy per Criteria Nursing Assessment ◦ History ◦ Vital Signs ◦ Signs and Symptoms Pain Decreased Cardiac Output Activity Intolerance Excess Fluid Volume Ineffective Therapeutic Regimen Management Relieve Pain Maintain Vital Signs/Oxygen Saturation Maintain Desired Activities Maintain Clear Lung Sounds Understand Disease/Treatment Pain Relief ◦ Rating Scale ◦ NTG ◦ Pace Activities Normal Cardiac Function ◦ ◦ ◦ ◦ ◦ ◦ Vital Signs Intake and Output Daily Weights Sodium Restriction Smoking Cessation Medications as Ordered Improve Quality of Life ◦ Assist ADLs ◦ Rest Periods ◦ Energy Conservation Maintain Fluid Volume ◦ ◦ ◦ ◦ Daily Weights Assess for Edema Intake/Output Diuretics as Ordered Monitor Potassium Levels Education ◦ Medications ◦ Anticoagulants Monthly INR/PT Tests Medic Alert Identification Education (cont’d) ◦ Include Caregivers for Elderly ◦ Revised Endocarditis Prevention – Prophylactic Antibiotics Reports Satisfactory Pain Relief Vital Signs Normal/No Heart Failure Signs Reports Reduced Fatigue, Task Completion Remains Free of Edema, Maintains Weight, Clear Lung Sounds Verbalizes Understanding of Teaching/with No Symptom Recurrence Minimally Invasive Surgery ◦ Endoscopy ◦ Robotic Traditional ◦ Open Cardiac Surgery with Cardiopulmonary Bypass Stenosed Valve Repair ◦ Balloon Valvotomy ◦ Commissurotomy Insufficient Valve Repair ◦ Annuloplasty Mechanical ◦ Durable ◦ Creates Turbulent Blood Flow Lifelong Anticoagulation ◦ Used for Younger Adults Biological ◦ Types Porcine (Pig) Bovine (Cow) Allografts (Human) Autograft Cultural Considerations Biological (cont’d) ◦ Not as Durable as Mechanical Valves ◦ No Lifelong Anticoagulation ◦ Used for Older Adults Biological Valves ◦ Degenerative Changes ◦ Calcification Mechanical Valves ◦ ◦ ◦ ◦ INR/PT Monitoring for Bleeding Risk Thrombus/Embolism Formation Anemia Endocarditis Assessment ◦ ◦ ◦ ◦ Circulatory Status Pain Control Needs Diagnostic Tests Typing and Cross-matching of Blood Needed Acute or Chronic Pain Anxiety Deficient Knowledge Teaching ◦ ◦ ◦ ◦ ◦ Pain Management Endotracheal Tube/Ventilator Communicating Chest Tubes Coughing/Deep Breathing Teaching ◦ IV Lines ◦ Urinary Catheter Preoperative Medications Antiseptic Scrub Showers NPO Pain Ineffective Airway Clearance Impaired Gas Exchange Decreased Cardiac Output Risk for Infection Deficient Knowledge Pain/Provide Relief Vital Signs, ECG ABGs Intake and Output Lung Sounds Incision Promote Lung Expansion ◦ Cough and Deep Breathe ◦ Turn ◦ Ambulate Prevent Infection ◦ Hand Hygiene ◦ Cleanse Stethoscope Each Patient, Each Handwashing ◦ Sterile Technique ◦ Monitor Temperature Teaching ◦ ◦ ◦ ◦ Pain Management Medications Activity Follow-up Monitoring/Care Infection of Endocardium Pathophysiology ◦ ◦ ◦ ◦ Invading Organism Attaches to Endocardium Vegetative Lesion Forms Damages Valve Leaflets Emboli/Heart Failure Possible Entry of Organism into Bloodstream Risk Factors ◦ ◦ ◦ ◦ ◦ Immunocompromised Artificial Heart Valve Congenital/Valvular Heart Disease IV Drug Use Gingival Disease Prevention ◦ Oral/Dental care ◦ Prophylactic Antibiotics per Criteria Signs and Symptoms ◦ ◦ ◦ ◦ ◦ ◦ Fever Murmur Splinter Hemorrhages Petechiae Janeway Lesions Osler’s Nodes Complications ◦ Vegetative Emboli ◦ Heart Valve Stenosis/Regurgitation ◦ Heart Failure Diagnostic Tests ◦ Blood Cultures ◦ Echocardiography Therapeutic Interventions ◦ ◦ ◦ ◦ IV Antimicrobial Drug Rest/Supportive Care Home IV Antimicrobial Therapy Surgical Valve Replacement/Repair Nursing Management ◦ Vital Signs/Cardiac Function ◦ Report Heart Failure/Emboli Signs ◦ Teach Good Hygiene, Oral/Dental Care Report Symptoms: Fever, Chills, Sweats Inflammation of Pericardium ◦ Acute ◦ Chronic Pathophysiology ◦ Inflammation of the Pericardium ◦ Ventricular Filling Reduced Decreased Cardiac Output and BP Infections, Lyme Disease Drug Reactions Connective Tissue Disorders Neoplastic Disease Postmyocardial Infarction Dressler’s Syndrome Renal Disease or Uremia Trauma Signs and Symptoms ◦ Chest Pain; Substernal, Radiates, Grating Increases with Deep Inspiration Relieved by Sitting Up/Forward ◦ Pericardial Friction Rub ◦ Dyspnea Signs and Symptoms (cont’d) ◦ Low-grade Fever ◦ Cough ECG Echocardiogram WBC Pericardial Fluid CT Scan MRI Pericardiocentsis Treat Cause ◦ ◦ ◦ ◦ Antibiotics Hemodialysis Pericardial Window Pericardiectomy Bedrest NSAIDs Complications ◦ Pericardial Effusion ◦ Cardiac Tamponade Immediate Pericardiocentesis Vital Signs Cardiac Function/Tamponade Signs Pain Relief ◦ NSAIDs, Corticosteroids ◦ Position of Comfort Education Pathophysiology and Etiology ◦ Inflammation of Myocardium ◦ Rare ◦ Often Follows Virus Signs and Symptoms ◦ None ◦ Possible Viral Infection Signs ◦ Chest Pain, Tachycardia Diagnostic Tests ◦ ◦ ◦ ◦ Endomyocardial Biopsy MRI Echocardiogram ECG Therapeutic Interventions ◦ Reduce Heart’s Workload ◦ Oxygen ◦ Treat Cause Antimicrobial ◦ Treat Heart Failure Nursing Care ◦ ◦ ◦ ◦ Vital Signs/Cardiac Status Diversional Activities Energy Conservation Education Nonpenetrating ◦ Blunt Trauma Penetrating ◦ External Injury ◦ Internal Injury Enlargement of Heart Muscle No Cure Dilated Cardiomyopathy ◦ ◦ ◦ ◦ Ventricular Cavity Enlarges Contractility Decreases Stasis of Blood Most Common Form Hypertrophic Cardiomyopathy ◦ Left Ventricle Muscle Wall Enlargement ◦ Decreases Ventricular Filling ◦ Can Cause Sudden Death in Athletes Restrictive Cardiomyopathy ◦ ◦ ◦ ◦ ◦ Cardiac Muscle Stiffness Impairs Ventricular Stretch Limits Ventricular Filling Systolic Emptying of Ventricle Normal Rarest Form Signs and Symptoms ◦ Heart Failure ◦ Dilated Cardiomyopathy Exertional Dyspnea, Orthopnea, Fatigue ◦ Hypertrophic Cardiomyopathy Exertional Dyspnea, Angina at Rest Signs and Symptoms (cont’d) ◦ Restrictive Cardiomyopathy Exertional Dyspnea, Syncope, Arrhythmias Diagnostic Tests ◦ ◦ ◦ ◦ Chest X-Ray (Cardiomegaly) Echocardiography ECG Cardiac Catheterization Therapeutic Interventions ◦ ◦ ◦ ◦ No Cure Palliative Care Heart Failure Treatment Anticoagulants Therapeutic Interventions (cont’d) ◦ Dilated ACE Inhibitors, Beta Blockers, Diuretics, Digoxin Biventricular Pacing Implantable Defibrillators Heart Transplant Therapeutic Interventions (cont’d) ◦ Restrictive Vasodilators Heart Transplant Therapeutic Interventions (cont’d) ◦ Hypertrophic Beta Blockers Calcium Channel Blockers Myectomy Septal Ablation Nursing Diagnoses ◦ Decreased Cardiac Output ◦ Activity Intolerance ◦ Anxiety Vital Signs Heart Failure/Emboli Signs Signs of Digoxin Toxicity Activity Tolerance/Energy Conservation Emotional Support Education Home Health Care Patient and Significant Other Education ◦ ◦ ◦ ◦ Medications Emergency Contacts CPR Hospice Clot Formation Inflammation Within Vein Pathophysiology ◦ ◦ ◦ ◦ Clot Formation and Inflammation Within Vein Superficial Veins Deep Veins (DVT) Emboli Danger Etiology ◦ Venous Stasis Reduced Blood Flow ◦ Damage to Vein Lining IV Catheters Etiology (cont’d) ◦ Increased Blood Coagulation Smoking Oral Contraceptives Estrogen Therapy Hematological Disorders Prevention ◦ ◦ ◦ ◦ ◦ Identify Risk Factors Prevent Dehydration Prophylactic Anti-embolism Devices Early Ambulation Range-of-Motion Exercises Prevention (cont’d) ◦ Prophylactic Medication Low Molecular Weight Heparin Enoxaparin (Lovenox) Fondaparinux (Arixtra) Heparin Warfarin (Coumadin) Signs and Symptoms ◦ None ◦ Superficial Veins Redness, Warmth, Swelling, Tenderness Signs and Symptoms ◦ Deep Veins Leg Usually Swelling, Edema, Pain, Warmth, Tenderness Homans’ Sign in 40% of Cases Complications ◦ Pulmonary Embolism Life-threatening Emergency ◦ Chronic Venous Insufficiency ◦ Varicose Veins ◦ Recurrent Deep Vein Thrombosis Diagnostic Tests ◦ ◦ ◦ ◦ ◦ Duplex Ultrasound Impedance Plethysmography Magnetic Resonance Imaging (MRI) Venography d-dimer and Coagulation Tests Therapeutic Interventions ◦ Superficial Veins Warm, Moist Heat Analgesics NSAIDs Compression Stockings Therapeutic Interventions (cont’d) ◦ Deep Veins Low-molecular Weight Heparin/Heparin Warfarin (Coumadin) Bedrest (Elevate Extremity) Warm, Moist Heat Compression Stocking Therapy Therapeutic Interventions (cont’d) ◦ Deep Veins (cont’d) Thrombolytic Therapy Thrombectomy Vena Cava Filter Nursing Diagnoses ◦ ◦ ◦ ◦ Acute Pain Impaired Skin Integrity Anxiety Deficient Knowledge Identify Risk Factors Monitor Those at Risk for Signs Administer Meds per INR/PT Relieve Pain Monitor for Pulmonary Embolism Educate