Chapter 24

Management of Patients With

Structural, Infectious, and
Inflammatory Cardiac Disorders
Learning Objectives
• The learner will be able to:
• Define valvular disorders of the heart and describe the
pathophysiology,
clinical manifestations, and management of patients with
mitral and aortic disorders.
• Describe types of cardiac valve repair and replacement
procedures used to treat valvular problems and care needed
by patients who undergo these procedures.
• Describe the pathophysiology, clinical manifestations, and
management of patients with cardiomyopathies.
• Describe the pathophysiology, clinical manifestations, and
management of
patients with infections of the heart.
• Use the nursing process as a framework of care for the
patient with a cardiomyopathy and the patient with
pericarditis.

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Valvular Disorders
• Regurgitation: The valve does not close properly, and
blood backflows through the valve.
• Stenosis: The valve does not open completely, and
blood
flow through the valve is reduced.
• Valve prolapse: The stretching of an atrioventricular
valve leaflet into the atrium during diastole

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Valves of the Heart

Valves of the heart (aortic or semilunar, tricuspid, and mitral)

in closed positions.

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Specific Valvular Disorders

• Mitral regurgitation
• Mitral stenosis
• In patients with mitral valve stenosis, the pulse is weak and
often irregular because of atrial fibrillation.
• The first symptom of mitral stenosis is often dyspnea on
exertion as a result of
pulmonary venous hypertension. Symptoms usually develop
after the valve opening is reduced by one-third to one-half
its usual size.
• Patients are likely to show progressive fatigue as a
result of low cardiac output. The enlarged left atrium may
create pressure on the left bronchial
tree, resulting in a dry cough or wheezing. Patients may
expectorate blood
(i.e., hemoptysis) or experience palpitations, orthopnea,
paroxysmal nocturnal
dyspnea (PND), and repeated respiratory infections

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Specific Valvular Disorders

• Aortic regurgitation
• Blood to flow back from the aorta to the left ventricle
• Aortic regurgitation eventually causes left ventricular
hypertrophy. In aortic regurgitation, blood from the aorta
returns to the left ventricle during diastole in addition to
the blood normally delivered by the left atrium. The left
ventricle dilates, trying to accommodate the increased
volume of blood.
• Aortic stenosis

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Nursing Management: Valvular Heart
Disorders #1
• Patient education
• Monitor VS trends
• Monitor for complications
– Heart failure
– Dysrhythmias
– Other symptoms
• Medication schedule: education
• Daily weights: monitor for weight gain

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 Nursing Management: Valvular Heart
Disorders #2

• Plan activity with rest periods

• Sleep with HOB elevated
• Patients with mitral stenosis are advised to avoid
strenuous activities, competitive sports, and pregnancy,
all of which increase heart rate.

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Question #1

The nurse is providing education for a client diagnosed with

mitral valve prolapse (MVP). What should be included in
the teaching plan? (Select all that apply.)
A. MVP is not hereditary.
B. Caffeine is tolerated in small amounts.
C. Avoid alcohol.
D. Stop use of tobacco products.
E. Prophylactic antibiotics are not prescribed before dental
procedures.

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Answer

C. Avoid alcohol.
D. Stop use of tobacco products.
E. Prophylactic antibiotics are not prescribed before dental
procedures.
Rationale: MVP is hereditary, and caffeine should be
avoided.

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Surgical Management:
Valvular Heart Disorders
• Valvuloplasty • Valve replacement
– Commissurotomy – Mechanical
– Balloon valvuloplasty
– Annuloplasty
– Leaflet repair
– Chordoplasty

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Balloon Valvuloplasty

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Annuloplasty Ring Insertion

• Annuloplasty ring insertion.

 A. Mitral valve regurgitation; leaflets do not close.
 B. Insertion of an annuloplasty ring.
 C. Completed valvuloplasty; leaflets close.

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Valve Leaflet Resection and Repair With
Ring Annuloplasty

• Valve leaflet resection and repair with a ring

annuloplasty.
 A. Mitral valve regurgitation; the section
indicated by dashed lines is excised.
 B. Approximation of edges and suturing.
 C. Completed valvuloplasty, leaflet repair,
and annuloplasty ring.
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Valve Replacement

• Valve replacement. A. The native valve is trimmed, and the prosthetic valve
is sutured in place. B. Once all sutures are placed through the ring, the
surgeon slides the prosthetic valve down the sutures and into the natural
orifice. Sutures are then tied off and trimmed.

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 Nursing Management: Valvuloplasty and
Valve Replacement #1
• Balloon valvuloplasty
-For some patients, valvuloplasty can be done in a cardiac
catheterization laboratory.”
– Monitor for heart failure and emboli
– Assess heart sounds every 4 hours
– Same care as after cardiac catheterization
– After undergoing percutaneous balloon valvuloplasty, the patient
usually remains in the hospital for 24 to 48 hours.
• Surgical valvuloplasty or valve replacements
– Focus is hemodynamic stability and recovery from anesthesia
– Frequent assessments with attention to neurologic,
respiratory, and cardiovascular systems

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Nursing Management: Valvuloplasty and
Valve Replacement #2
• Patient education
– Mechanical valves necessitate long-term use of
required anticoagulants.
– Prevention of infective endocarditis
– Follow up
– Repeat echocardiograms
– Following mechanical valve replacement, antibiotic
prophylaxis is necessary before dental procedures
involving manipulation of gingival tissue, the
periapical area of the teeth or perforation of the oral
mucosa

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 Nursing Management: Valvuloplasty and
Valve Replacement #3
• Patients who take warfarin (Coumadin) after valve
replacement have individualized target INRs; usually
between 2 and 3.5 for mitral valve replacement and 1.8
and 2.2 for aortic valve replacement.
• Possible complications of a balloon valvuloplasty include
aortic regurgitation, emboli, ventricular perforation,
rupture of the aortic valve annulus, ventricular
dysrhythmia, mitral valve damage, and bleeding
from the
catheter insertion sites.

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Patient education

• In general, valves that undergo valvuloplasty function

longer than prosthetic valve replacements and patients
do not require continuous anticoagulation.
• Valvuloplasty carries a risk of infection, like all surgical
procedures, and it is not performed in a physician's
office.
• Antirejection drugs are unnecessary because foreign
tissue is not introduced.

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Cardiomyopathy
• Cardiomyopathy is a series of progressive events that
culminates in impaired cardiac output and can lead to
heart failure, sudden death, or dysrhythmias.
• Types
– Dilated Cardiomyopathy(Dilated ventricles without
hypertrophy of the ventricles)
– The ventricles have elevated systolic and diastolic
volumes, but a decreased ejection fraction.
– Restrictive cardiomyopathy
– Hypertrophic cardiomyopathy (With HCM, cardiac arrest
(i.e.,
sudden cardiac death) may be the initial manifestation in
young
people, including athletes).

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Cardiomyopathies That Lead to
Congestive Heart Failure

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diagnostic tool for cardiomyopathy
• diagnostic tool would be most helpful in diagnosing
cardiomyopathy is the echocardiogram
• the echocardiogram is one of the most helpful diagnostic
tools because the structure and function of the ventricles
can be observed easily

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Question #2

What is the main electrolyte involved in cardiomyopathy?

A. Calcium
B. Phosphorus
C. Potassium
D. Sodium

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Answer

D. Sodium
Rationale: Sodium is the major electrolyte involved with
cardiomyopathy. Cardiomyopathy often leads to heart
failure, which develops, in part, from fluid overload.
Fluid
overload is often associated with elevated sodium
levels.

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 Nursing Process: The Patient With
Cardiomyopathy (Assessment)

• History (predisposing factors, family history)

• Chest pain
• Review of diet (Na reduction, vitamin supplements)
• Psychosocial history: impact on family, stressors,
depression
• Physical assessment: VS pulse pressure; pulsus
paradoxus; weight gain or loss; PMI; murmurs; S3 or S4;
pulmonary auscultation for crackles, JVD, and edema

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Nursing Process: The Patient with
Cardiomyopathy (Nursing Diagnosis)

• Decreased cardiac output

• Risk for ineffective cardiac, cerebral, peripheral, and
renal tissue perfusion
• Impaired gas exchange
• Activity intolerance
• Anxiety
• Powerlessness
• Noncompliance with medication and diet therapies

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Collaborative Problems and Potential
Complications
• Heart failure
• Ventricular dysrhythmias
• Atrial dysrhythmias
• Cardiac conduction defects
• Pulmonary or cerebral embolism
• Valvular dysfunction

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Nursing Process: The Patient With
Cardiomyopathy (Planning and Goals)

Goals
– Improvement or maintenance of cardiac output
– Increased activity tolerance
– Reduction of anxiety
– Adherence to the self-care program
– Increased sense of power with decision making
– Absence of complications

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Nursing Process: The Patient With
Cardiomyopathy (Nursing Interventions) #1

• Improve cardiac output and peripheral blood flow

– The priority nursing diagnosis of a patient with
cardiomyopathy would include improved or maintained
cardiac output
– Rest, positioning (legs down), supplemental O2,
– medications, low Na diet, avoid dehydration
• Increase activity tolerance and improving gas exchange
– Cycle rest and activity, ensure patient recognizes
symptoms that indicate the need for rest
• Reduce anxiety
– Eradicate or alleviate perceived stressors, educate family
about diagnosis, assist with anticipatory grieving

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Nursing Process: The Patient With
Cardiomyopathy (Nursing Interventions) #2

• Decrease the sense of powerlessness

– Assist patients in identifying things that have been
lost (i.e., ability to play sports), assist patients in
identifying amount of control they still have left
• Promote home- and community-based care
– Educate patients about ways to balance lifestyle and
work while accomplishing therapeutic activities
– Assess patient and family and their adjustment to
lifestyle changes, educate family about CPR and
AEDs, establish trust

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Nursing Process: The Patient With
Cardiomyopathy (Evaluation) #1

• Maintain or improve cardiac function

– HR and RR WNL, decreased dyspnea and increased
comfort, maintain or improve gas exchange, absence
of weight gain, maintain or improve peripheral blood
flow
• Maintain or increase activity tolerance
– Carry out activities of daily living (e.g., brush teeth,
feed self), reports increased tolerance to activity

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Nursing Process: The Patient With
Cardiomyopathy (Evaluation) #2

• Reduce anxiety
– Discusses prognosis, verbalizes fears and concerns,
participates in support groups, demonstrates
appropriate coping mechanisms
• Decrease sense of powerlessness
– Identifies emotional response to diagnosis, discusses
control that he or she has
• Adhere to self-care program
– Takes medications as prescribed, modifies diet to
accommodate sodium and fluid recommendations,
modifies lifestyle, identifies S&S to be reported

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Cardiomyopathy

• When heart failure progresses and medical treatment is

no longer effective, surgical intervention, including heart
transplantation, is considered.

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Infectious Diseases of the Heart

• Any of the layers of the heart may be affected by an

infectious process.
• Diseases are named by the layer of the heart that is
affected.
• Diagnosis is made by patient symptoms and
echocardiogram.
• Blood cultures may be used to identify the infectious
agent and to monitor therapy.
• Treatment is with appropriate antimicrobial therapy.
Patients require teaching to complete the course of
appropriate antimicrobial therapy and require teaching
for infection prevention and health promotion.
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Types of Infectious Disease of the Heart
• Rheumatic endocarditis
– Occurs most often in school-age children after group A beta-hemolytic
streptococcal pharyngitis; need to promptly recognize and treat “strep”
throat to prevent rheumatic fever
• Infective endocarditis
– Usually develops in people with prosthetic heart valves or structural
cardiac defects; also occurs in patients who are IV drug abusers and in
those with debilitating diseases, indwelling catheters, or prolonged IV
therapy
– The physician's choice of antibiotics would be primarily based on Blood
cultures
– Group A streptococcus can cause rheumatic heart fever, resulting in
rheumatic endocarditis. Being aware of signs and symptoms of
streptococcal infections, identifying them quickly, and treating them
promptly, are the best preventative techniques for rheumatic
endocarditis

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Types of Infectious Disease of the Heart

• Pericarditis
– Inflammation of the pericardium; many causes; potential complications:
pericardial effusion and cardiac tamponade
– The most characteristic symptom of pericarditis is chest pain, although
pain also may be located beneath the clavicle, in the neck, or in the left
trapezius (scapula) region. The pain or discomfort usually remains fairly
constant, but it may worsen with deep inspiration and when lying down
or turning. A pericardial friction rub is diagnostic of pericarditis
• Myocarditis
– An inflammatory process involving the myocardium; most common
pathogens involved in myocarditis tend to be viral; in endocarditis, they
tend to be bacterial; complications: cardiomyopathy and heart failure
– The most common symptoms of myocarditis are flulike symptoms

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Clinical Manifestations: Infectious
Diseases of the Heart

 Fever
 New heart murmur, friction rub at left lower sternal
 border (pericarditis)
 Osler nodes, Janeway lesions, Roth spots, and splinter
hemorrhages in nailbeds (Rheumatic)
 Cardiomegaly, heart failure, tachycardia, splenomegaly
 Fatigue, dyspnea, syncope, palpitations, chest pain
(myocarditis)
 Diagnostic tools: blood cultures, echocardiogram, CBC,
rheumatoid factor, ESR, CRP, urinalysis, ECG, cardiac
catheterization, TEE, CT scan

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Prevention
• Antibiotic prophylaxis before certain procedures .
Amoxicillin is the drug of choice.
• Ongoing oral hygiene
• Female patients are advised NOT to use IUDs
• Meticulous care should be taken in patients “at risk”
who have catheters
• Catheters should be removed as soon as they are no
longer needed
• Immunizations

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Question #3

A patient with restrictive cardiomyopathy taking digoxin

presents with symptoms of anorexia, nausea, vomiting,
headache, and malaise. What should the nurse expect to
be included in the plan of care for this patient?
A. The patient’s digoxin will be changed to nifedipine.
B. The patient’s digoxin dose will be decreased.
C. Nothing; these are signs of restrictive cardiomyopathy
that are expected.
D. The patient will be admitted to an ICU.

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 Answer

B. The patient’s digoxin dose will be

decreased.
Rationale: Patients with restrictive cardiomyopathy are
sensitive to digitalis. Nurses must closely monitor these
patients for digitalis toxicity, which is evidenced by
dysrhythmia, anorexia, nausea, vomiting, headache,
and
malaise. This patient presents with symptoms of digoxin
toxicity, so a decrease in dosage should be anticipated.
These patients should avoid nifedipine, and they do not
need to be admitted to the ICU.

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