Inflammatory and Valvular Heart Diseases

Inflammatory and Valvular Heart Diseases

Inflammatory and Valvular Heart Diseases

Rheumatic Fever and Heart Disease

• Rheumatic Fever - inflammatory disease of heart potentially involving all layers• Systemic• Abnormal immune response to group

A beta hemolytic strep (“strep throat”)• Transmission to heart via lymphatic

channelsMost common cause of valvular heart

disease

• Rheumatic Fever - inflammatory disease of heart potentially involving all layers• Systemic• Abnormal immune response to group

A beta hemolytic strep (“strep throat”)• Transmission to heart via lymphatic

channelsMost common cause of valvular heart

disease


• Rheumatic Heart Disease – chronic condition characterized by scarring and deformity of heart valves resulting from rheumatic fever

• Any or all layers of heart maybe affected

• Rheumatic Heart Disease – chronic condition characterized by scarring and deformity of heart valves resulting from rheumatic fever

• Any or all layers of heart maybe affected


• Rheumatic endocarditis (most serious)• Erosion and swelling of valves (thickening)• Vegetations• Stenosis/Regurgitation

• Rheumatic Myocarditis• Nodules and fibrin deposits loss of

contractile powerCHF

• Rheumatic Pericarditis• Fibrinous Exudate and pericardial

effusion

• Rheumatic endocarditis (most serious)• Erosion and swelling of valves (thickening)• Vegetations• Stenosis/Regurgitation

• Rheumatic Myocarditis• Nodules and fibrin deposits loss of

contractile powerCHF

• Rheumatic Pericarditis• Fibrinous Exudate and pericardial

effusion


• Nursing Assessment• Previous history of rheumatic fever

• Socioeconomic class

• Fever

• Cardiovascular (tachycardia; pericardial friction rub; distant heart sounds; murmurs)

• Neurological: chorea

• Skin: subcutaneous nodules and erythema marginatum

• Musculoskeletal: Polyarthritis

• Nursing Assessment• Previous history of rheumatic fever

• Socioeconomic class

• Fever

• Cardiovascular (tachycardia; pericardial friction rub; distant heart sounds; murmurs)

• Neurological: chorea

• Skin: subcutaneous nodules and erythema marginatum

• Musculoskeletal: Polyarthritis


•Primary Prevention•Detection and treatment of strep throat

•Secondary Prevention•Prophylactic antibiotics to prevent recurrent ARF

•Primary Prevention•Detection and treatment of strep throat

•Secondary Prevention•Prophylactic antibiotics to prevent recurrent ARF


Acute Intervention Antibiotics Rest Control Fever Anti-Inflammatories

Acute Intervention Antibiotics Rest Control Fever Anti-Inflammatories

Infective EndocarditisInfective Endocarditis

• Infection of the inner layer (endocardium) of the heart that usually affects the cardiac valves

• Was almost always fatal until development of penicillin

• 5,000-8,000 cases diagnosed in U.S. each year

• Infection of the inner layer (endocardium) of the heart that usually affects the cardiac valves

• Was almost always fatal until development of penicillin

• 5,000-8,000 cases diagnosed in U.S. each year

ClassificationClassification

• Subacute form• Longer clinical course

• Insidious onset

• Streptococcus bovis or viridians

• Staphylococcus epidermidis

• HACEK group

• Subacute form• Longer clinical course

• Insidious onset

• Streptococcus bovis or viridians

• Staphylococcus epidermidis

• HACEK group

Classification

• Acute form• Shorter clinical course

• Rapid onset

• Causative organism more virulent•Streptococcus pneumoniae•Staphylococcus aureus•Streptococcus groups A, B, C•Fungi

• Acute form• Shorter clinical course

• Rapid onset

• Causative organism more virulent•Streptococcus pneumoniae•Staphylococcus aureus•Streptococcus groups A, B, C•Fungi

Etiology and PathophysiologyEtiology and Pathophysiology

• Vegetations• Fibrin, leukocytes, and microbes• Adhere to the valve or endocardium• Embolization of portions of vegetations

into circulation

• Vegetations• Fibrin, leukocytes, and microbes• Adhere to the valve or endocardium• Embolization of portions of vegetations

into circulation

Bacterial Endocarditis of the Mitral Valve

Fig. 36-2


• Left-sided more common with bacterial infections and underlying heart disease

• Right-sided lesions usually caused by IV drug abuse

• Left-sided more common with bacterial infections and underlying heart disease

• Right-sided lesions usually caused by IV drug abuse


• Risk Factors:• Cardiac Conditions (blood flow turbulence

allows pathogen to infect previously damaged valves or other surfaces)

•Rheumatic heart disease•Prosthetic valves

• Aging• IV drug abuse• Invasive Medical and Dental Procedures• UTI, skin/wound infections

• Risk Factors:• Cardiac Conditions (blood flow turbulence

allows pathogen to infect previously damaged valves or other surfaces)

•Rheumatic heart disease•Prosthetic valves

• Aging• IV drug abuse• Invasive Medical and Dental Procedures• UTI, skin/wound infections

Clinical ManifestationsClinical Manifestations

• Nonspecific

• Fever occurs in 90% of patients

• Chills

• Weakness

• Malaise, Fatigue

• Anorexia

• Nonspecific

• Fever occurs in 90% of patients

• Chills

• Weakness

• Malaise, Fatigue

• Anorexia


• Vascular manifestations• Splinter hemorrhages in nail beds

• Petechiae

• Osler’s nodes on fingers or toes

• Janeway’s lesions on palms or soles

• Vascular manifestations• Splinter hemorrhages in nail beds

• Petechiae

• Osler’s nodes on fingers or toes

• Janeway’s lesions on palms or soles

Clinical Manifestations


• Murmur in 80% of cases

• CHF • in up to 80% with aortic valve

endocarditis

• 50% with mitral valve endocarditis

• Manifestations secondary to embolism

• Murmur in 80% of cases

• CHF • in up to 80% with aortic valve

endocarditis

• 50% with mitral valve endocarditis

• Manifestations secondary to embolism

Sites of Embolization

HISTORYHISTORY

• Recent dental, urologic, surgical, or gynecologic procedures

• Heart disease

• Recent cardiac catheterization

• Skin, respiratory, or urinary tract infections

• Recent dental, urologic, surgical, or gynecologic procedures

• Heart disease

• Recent cardiac catheterization

• Skin, respiratory, or urinary tract infections

Diagnostic Studies

• Labs

• Blood cultures

• Echocardiography (detects valvular vegetations, abscesses)

• Chest x-ray

• Labs

• Blood cultures

• Echocardiography (detects valvular vegetations, abscesses)

• Chest x-ray

Collaborative CareCollaborative Care

• Prophylactic treatment for patients having:• Removal of drainage of infected

tissue

• Indwelling pacemakers

• Renal dialysis

• Ventriculoatrial shunts

• Prophylactic treatment for patients having:• Removal of drainage of infected

tissue

• Indwelling pacemakers

• Renal dialysis

• Ventriculoatrial shunts

Collaborative Care

• Antibiotic administration• Monitor antibiotic serum levels

• Antipyretics

• Subsequent blood cultures

• REST

• Valve repair/replacement

• Antibiotic administration• Monitor antibiotic serum levels

• Antipyretics

• Subsequent blood cultures

• REST

• Valve repair/replacement

Nursing AssessmentNursing Assessment

• Subjective• History of valvular, congenital, or

syphilitic cardiac diseases

• Previous endocarditis

• Staph or strep infection

• Immunosuppressive therapy

• Subjective• History of valvular, congenital, or

syphilitic cardiac diseases

• Previous endocarditis

• Staph or strep infection

• Immunosuppressive therapy


• Recent surgical procedures or invasive procedures

• IV drug abuse

• Weight changes

• Chills

• Diaphoresis

• Recent surgical procedures or invasive procedures

• IV drug abuse

• Weight changes

• Chills

• Diaphoresis


• Bloody urine

• Exercise intolerance

• Generalized weakness

• Fatigue

• Cough

• Dyspnea on exertion

• Night sweats

• Chest, back, abdominal pain

• Bloody urine

• Exercise intolerance

• Generalized weakness

• Fatigue

• Cough

• Dyspnea on exertion

• Night sweats

• Chest, back, abdominal pain


• Objective• Olser’s nodes

• Splinter hemorrhages

• Janeway’s lesions

• Petechiae

• Clubbing

• Objective• Olser’s nodes

• Splinter hemorrhages

• Janeway’s lesions

• Petechiae

• Clubbing


• Tachypnea

• Crackles

• Arrhythmias

• Leukocytosis

• Increased ESR and cardiac enzymes

• Positive cultures

• ECG showing chamber enlargement

• Tachypnea

• Crackles

• Arrhythmias

• Leukocytosis

• Increased ESR and cardiac enzymes

• Positive cultures

• ECG showing chamber enlargement

Nursing DiagnosesNursing Diagnoses

Decreased cardiac output

Activity intolerance

Ineffective health maintenance

Decreased cardiac output

Activity intolerance

Ineffective health maintenance

Acute Pericarditis• Caused by inflammation of pericardial sac• Etiologies: Infectious vs Non-Infectious• S&S: dyspnea, CP, pericardial friction rub• Complications• Pericardial effusion• Cardiac tamponade

• Treatment• Antibiotics• NSAIDS• Corticosteroids• Positioning head at 45 degree angle• Pericardiocentesis

• Caused by inflammation of pericardial sac• Etiologies: Infectious vs Non-Infectious• S&S: dyspnea, CP, pericardial friction rub• Complications• Pericardial effusion• Cardiac tamponade

• Treatment• Antibiotics• NSAIDS• Corticosteroids• Positioning head at 45 degree angle• Pericardiocentesis

Valvular Heart Disease

Valvular Heart Disease• Heart contains two atrioventricular

valves and two semilunar valves• Heart contains two atrioventricular

valves and two semilunar valves


• Types of valvular heart disease depends on:• Valve or valves affected

• Two types of functional alterations

• Stenosis • Regurgitation

• Types of valvular heart disease depends on:• Valve or valves affected

• Two types of functional alterations

• Stenosis • Regurgitation


• Stenosis • Valve orifice is restricted

• Impending forward blood flow

• Creates a pressure gradient across open valve

• Degree of stenosis reflected in pressure gradient differences

• Regurgitation • Incomplete closure of valve leaflets

• Results in backward flow of blood

• Stenosis • Valve orifice is restricted

• Impending forward blood flow

• Creates a pressure gradient across open valve

• Degree of stenosis reflected in pressure gradient differences

• Regurgitation • Incomplete closure of valve leaflets

• Results in backward flow of blood

Mitral Valve Stenosis

• Due to rheumatic heart disease• Causes scarring of valve leaflets and

chordae tendineae

• Contractures develop with adhesions between commissures of the leaflets

• Stenotic mitral valve assumes funnel shape due to thickening and shortening of valve structures

• Due to rheumatic heart disease• Causes scarring of valve leaflets and

chordae tendineae

• Contractures develop with adhesions between commissures of the leaflets

• Stenotic mitral valve assumes funnel shape due to thickening and shortening of valve structures

Mitral Valve Stenosis

• Pathophysiology:• Incomplete emptying of LA

Increased LA pressure LA dilatation and hypertrophy• Increased LA pressureElevated

pulmonary pressurepulmonary congestion• Incomplete emptying of

LAinsufficient volumes to ventricles decreased C.O.• Afib is common risk of embolism

• Pathophysiology:• Incomplete emptying of LA

Increased LA pressure LA dilatation and hypertrophy• Increased LA pressureElevated

pulmonary pressurepulmonary congestion• Incomplete emptying of

LAinsufficient volumes to ventricles decreased C.O.• Afib is common risk of embolism

Clinical Manifestations• Dyspnea• Occasionally accompanied by hemoptysis• Primary symptom because of reduced lung compliance

• Palpitations from atrial fibrillation• Fatigue• Opening snap• Low-pitched rumbling diastolic murmur• Chest pain• Seizures (from emboli)• Stroke• Emboli can arise from stagnant blood in left atrium

• Dyspnea• Occasionally accompanied by hemoptysis• Primary symptom because of reduced lung compliance

• Palpitations from atrial fibrillation• Fatigue• Opening snap• Low-pitched rumbling diastolic murmur• Chest pain• Seizures (from emboli)• Stroke• Emboli can arise from stagnant blood in left atrium

Mitral Valve Regurgitation• Mitral Valve fails to close properly

• LV ejects blood into aorta and back into LA

• Mitral Valve fails to close properly

• LV ejects blood into aorta and back into LA

Mitral Valve Regurgitation

• Majority of cases attributed to:• MI (MI with left ventricular failure places

patient at risk for rupture of chordae tendineae)

• Chronic rheumatic heart disease• Isolated rupture of chordae tendineae• Mitral valve prolapse• Ischemic papillary muscle dysfunction • Infectious endocarditis

• Majority of cases attributed to:• MI (MI with left ventricular failure places

patient at risk for rupture of chordae tendineae)

• Chronic rheumatic heart disease• Isolated rupture of chordae tendineae• Mitral valve prolapse• Ischemic papillary muscle dysfunction • Infectious endocarditis

Mitral Valve Regurgitation• Acute Onset (e.g. papillary

dysfunction due to M.I.)• Backward flow increased LA

pressure Increased Pulmonary Pressure Pulmonary Edema

• Chronic Onset• Backward flow LA dilates and

hypertrophies Increased pulmonary pressures pulmonary congestion right sided failure

• Acute Onset (e.g. papillary dysfunction due to M.I.)• Backward flow increased LA

pressure Increased Pulmonary Pressure Pulmonary Edema

• Chronic Onset• Backward flow LA dilates and

hypertrophies Increased pulmonary pressures pulmonary congestion right sided failure

Mitral Valve RegurgitationClinical Manifestations

• Asymptomatic for years until development of some degree of left ventricular failure

• Initial symptoms include:• Weakness• Fatigue• Dyspnea that gradually progress to

orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema

• Asymptomatic for years until development of some degree of left ventricular failure

• Initial symptoms include:• Weakness• Fatigue• Dyspnea that gradually progress to

orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema

Aortic Valve Stenosis

• Usually discovered in childhood, adolescence, or young adulthood

• Those seen later in life usually have aortic stenosis from rheumatic fever or senile fibrocalcific degeneration of a normal valve

• Usually discovered in childhood, adolescence, or young adulthood

• Those seen later in life usually have aortic stenosis from rheumatic fever or senile fibrocalcific degeneration of a normal valve

Aortic Valve Stenosis

• Results in obstruction of flow from LV to aorta during systole

• Effect is left ventricular hypertrophy and increased myocardial oxygen consumption because of increased myocardial mass

• Leads to reduced CO and pulmonary hypertension

• Results in obstruction of flow from LV to aorta during systole

• Effect is left ventricular hypertrophy and increased myocardial oxygen consumption because of increased myocardial mass

• Leads to reduced CO and pulmonary hypertension

Aortic Valve StenosisClinical Manifestations

• Symptoms of angina pectoris

• Syncope

• Heart failure • Occurs when valve orifice is 1/3 normal

size

• Symptoms of angina pectoris

• Syncope

• Heart failure • Occurs when valve orifice is 1/3 normal

size

Aortic Valve Stenosis• Poor prognosis when experiencing

symptoms and valve obstruction is not relieved

• Why would Nitroglycerine be contraindicated with aortic valve stenosis?

• Poor prognosis when experiencing symptoms and valve obstruction is not relieved

• Why would Nitroglycerine be contraindicated with aortic valve stenosis?

Aortic Valve Regurgitation

• May result from disease of aortic valve leaflets, aortic root, or both

• Caused by:• Bacterial endocarditis• Trauma• Aortic dissection

• Constitutes life-threatening emergency

• Chronic aortic regurgitation results from:• Rheumatic heart disease• Congenital bicuspid aortic valve• Syphilis• Chronic rheumatic heart conditions

• May result from disease of aortic valve leaflets, aortic root, or both

• Caused by:• Bacterial endocarditis• Trauma• Aortic dissection

• Constitutes life-threatening emergency

• Chronic aortic regurgitation results from:• Rheumatic heart disease• Congenital bicuspid aortic valve• Syphilis• Chronic rheumatic heart conditions

Aortic Valve Regurgitation

• Physiologic consequence: • Retrograde blood flow from ascending

aorta to left ventricle• Elevated LV pressures• LV dilatation and hypertrophy

•Results in volume overload

• Physiologic consequence: • Retrograde blood flow from ascending

aorta to left ventricle• Elevated LV pressures• LV dilatation and hypertrophy

•Results in volume overload

Tricuspid Valve Disease

• Tricuspid valve stenosis

• Seen in IV drug users

• Right atrial output is obstructed

• Results in right atrial enlargement and elevated systemic venous pressure

• Tricuspid valve stenosis

• Seen in IV drug users

• Right atrial output is obstructed

• Results in right atrial enlargement and elevated systemic venous pressure

Tricuspid Valve DiseaseClinical Manifestations

• Peripheral edema

• Ascites

• Hepatomegaly

• Murmur

• Peripheral edema

• Ascites

• Hepatomegaly

• Murmur

Collaborative Care

• Drug therapy

• Digitalis

• Diuretics

• Antiarrhythmics blockers

• Anticoagulants

• Low-sodium diet

• Drug therapy

• Digitalis

• Diuretics

• Antiarrhythmics blockers

• Anticoagulants

• Low-sodium diet

Collaborative Care

• Percutaneous transluminal balloon valvuloplasty to split open fused commissures

• Surgical therapy for valve repair • Annuloplasty• Valvuloplasty• Commissurotomy

• Valve Replacement• Mechanical Vs. Biological

• Percutaneous transluminal balloon valvuloplasty to split open fused commissures

• Surgical therapy for valve repair • Annuloplasty• Valvuloplasty• Commissurotomy

• Valve Replacement• Mechanical Vs. Biological

Nursing Assessment

• Objective• Fever• Diaphoresis• Peripheral edema• Crackles• Wheezes• Abnormal heart sounds• Ascites• Hepatomegaly• Cardiomegaly• Valve calcification• Pulmonary congestion on x-ray

• Objective• Fever• Diaphoresis• Peripheral edema• Crackles• Wheezes• Abnormal heart sounds• Ascites• Hepatomegaly• Cardiomegaly• Valve calcification• Pulmonary congestion on x-ray

Nursing Assessment

• Diagnostic Tests:

• Calcification or vegetation of leaflets or prolapse

• Chamber enlargement• Arrhythmias• Conduction deficits on ECG

• Diagnostic Tests:

• Calcification or vegetation of leaflets or prolapse

• Chamber enlargement• Arrhythmias• Conduction deficits on ECG

Nursing Implementation

• Prevention of rheumatic valvular disease by diagnosing and treating streptococcal infection and providing prophylactic antibiotics for patients with history

• Patient with history of endocarditis must also be treated with prophylactic antibiotics

• Prevention of rheumatic valvular disease by diagnosing and treating streptococcal infection and providing prophylactic antibiotics for patients with history

• Patient with history of endocarditis must also be treated with prophylactic antibiotics


• Teach when to seek medical treatment

• Design activity to patient’s limitations

• Discourage smoking

• Avoid strenuous activity

• Nursing assessment to monitor effectiveness of medications

• Teach when to seek medical treatment

• Design activity to patient’s limitations

• Discourage smoking

• Avoid strenuous activity

• Nursing assessment to monitor effectiveness of medications


• Medic Alert bracelet

• Teach importance of completing antibiotic regimen

• Teach drug side effects

• INR for anticoagualtion therapy

• Follow-up care

• Medic Alert bracelet

• Teach importance of completing antibiotic regimen

• Teach drug side effects

• INR for anticoagualtion therapy

• Follow-up care

Case Study• Patient Profile:

• Mrs. S., a 54-year-old Hispanic woman, is admitted to the hospital for valvular heart disease.

• Subjective Data• Was told she had streptococcal throat infection as a child• Was diagnosed 10 years ago with rheumatic heart disease• Has shortness of breath at rest; cannot get out of bed

without becoming dyspneic• Takes digoxin (0.25 mg once a day)

• Objective Data• Physical Examination

• Ankle edema• Irregular pulse• Crackles at lung bases• Murmurs of mitral stenosis, mitral insufficiency, and aortic

insufficiency• Diagnostic Studies• Chest x-ray and ECG indicate enlarged left atrium

• Patient Profile:• Mrs. S., a 54-year-old Hispanic woman, is admitted to the

hospital for valvular heart disease.• Subjective Data

• Was told she had streptococcal throat infection as a child• Was diagnosed 10 years ago with rheumatic heart disease• Has shortness of breath at rest; cannot get out of bed

without becoming dyspneic• Takes digoxin (0.25 mg once a day)

• Objective Data• Physical Examination

• Ankle edema• Irregular pulse• Crackles at lung bases• Murmurs of mitral stenosis, mitral insufficiency, and aortic

insufficiency• Diagnostic Studies• Chest x-ray and ECG indicate enlarged left atrium

Case Study: Question #1• Explain the cause of Mrs. S.’s

valvular heart disease. What valves are most likely to become involved with rheumatic heart disease?

• Explain the cause of Mrs. S.’s valvular heart disease. What valves are most likely to become involved with rheumatic heart disease?

Case Study: Question #2• Differentiate between the

characteristics of mitral stenosis and mitral regurgitation.

• Differentiate between the characteristics of mitral stenosis and mitral regurgitation.

Case Study: Question #3

• What other conservative treatment measures might be initiated for Mrs. S. (in addition to digoxin?)

• What other conservative treatment measures might be initiated for Mrs. S. (in addition to digoxin?)

Case Study: Question #4• On the basis of the assessment

data provided, write one or more nursing diagnoses.

• On the basis of the assessment data provided, write one or more nursing diagnoses.

Case Study: Question #5• What are important nursing

measures for Mrs. S.?• What are important nursing

measures for Mrs. S.?

Inflammatory and Valvular Heart Diseases

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