Caring for Valvular Disorders of the Heart

1
Caring for Valvular Disorders of the Heart

• CHAPTER 30

2
Overview

• Each structure of the heart helps to maintain
  normal cardiac function.
• The valves promote the forward circulation of
  blood to sustain an adequate cardiac output.

3
Aortic Stenosis Pg 455

• Narrowing of the opening thru the aortic valve
  that occurs when the valve cusps become stiff and
  rigid
• Aortic insufficiency can result from damage of
  the valve cusps and is usually the result of
  rheumatic fever or calcium deposits in the elderly

4
Aortic Stenosis

• Stiff valve cant open properly and more force is
  needed to push blood thru
• Left ventricle thickens (hypertrophy) and blood
  flow eventually becomes insufficient to nourish
  the myocardium and other organs.

5
Signs and Symptoms of Aortic Stenosis

• Initially dyspnea and fatique are experienced
  during activity
• Dizziness, fainting, anginal pain due to low
  cardiac output
• point of maximum impulse is displaced laterally
  or distally
• carotid pulse may feel weak because of low stroke
  volume

6
Medical Management

• Digitalis, antiarrhythmics and diuretics given to
  support the hearts pumping activity.
• Antibiotics given to prevent endocarditis
• Na restricted
• Nitroglycerin is beneficial for relieving chest
  pain.

7
Nursing

• Report dyspnea, irregular heart rhythm, chest
  pain, fainting and confusion as inadequate
  cardiac output
• bedrest while symptoms present
• Assess apical pulse before giving cardiotonics
  -hold if below 60
• I O , daily weight

8
Aortic Insufficiency (Aortic Regurgitation) Pg 457

• Aortic valve does not close tightly
  enough--called valvular incompetence
• Results from damage to valve cusps or papillary
  muscles from rheumatic fever, endocarditis,
  syphillis or age related stretching of proximal
  aorta
• Some blood leaks backward (regurgitation) into
  left ventricle

9
Aortic Insufficiency

• Backflow reduces cardiac output and causes fluid
  overload in the left ventricle.
• Left ventricle becomes stretched so does not pump
  as well. Increases hearts need for O2
• High fluid pressure in left ventricle causes
  mitral valve to close early so left atria cant
  empty and blood backs up in lungs

10
Aortic Insufficiency

• Angina, dizziness and confusion occurs
• Left ventricular failure may develop.
• asymptomatic as long as left ventricle can
  sustain circulation
• When valve damage affects left ventricle will
  have palpitations when lying flat or on left
  side. Later will have dyspnea and chest pain

11
Signs Symptoms

• Skin may be flushed and moist, especially in
  upper regions
• Radial pulse feels strong with quick sharp beats
  followed by by a sudden collapse of the force (
  called water-hammer pulse or Corrigans pulse)
• Wide pulse pressure as systolic is extremely high
  but diastolic stays low or normal

12
Signs and Symptoms

• Enlargement of heart displaces the PMI. Chest may
  heave or rock from forceful contractions or
  enlarged ventricle.
• Heart murmur caused by turbulence of blood
  falling back thru the dilated aortic valve may
  also be heard.

13
Nursing Care

• Same as for other valvular conditions
• Antibiotics before dental or other invasive
  procedures. Teach ways to reduce B/P
• Avoid strenuous exercise and emotional stress

14
Mitral Stenosis Pg. 462

• Narrowing of the valve between the left atrium
  and left ventrilce
• Usually caused by rheumatic fever. Gets worse
  with each recurrence of endocarditis.
  Inflammation causes cusps to stick together and
  form a thick, rigid scar called a commissure. The
  chordae tendineae fuse and shorten

15
Mitral Stenosis

• Unable to open completely so left atria does not
  empty completely. Clots form. Left atrium
  enlarges.
• Pressure from overfilling causes back pressure
  and creates pulmonary hypertension. Right
  ventricle will eventually enlarge too as having
  to pump against high pressure. Liver enlarges,
  edema occurs

16
Mitral Stenosis

• May take several years to develop
• One of the earliest indications is an extremely
  loud S1 heart sound
• Symptoms become worse when unusual demands are
  put on the heart. (pregnancy, fever)
• Later will have palpitations and tachyarrythmias

17
Mitral Stenosis

• Pulmonary hypertension causes more dyspnea at
  night and must sleep in a sitting position
• Cough productive of pink, frothy sputum may
  develop
• Loud S1 sound may be earliest sign. Later may not
  have any S1 sound as cusps can not move

18
Mitral Stenosis

• A murmur described as a rumbling underground
  train can be heard at the hearts apex.especially
  when lying on left side
• Systolic pressure low from reduced cardiac output
• face flushed, neck vein distention, liver
  enlargement, edema and crackles in lung bases are
  signs of pulmonary congestion

19
Medical Management

• Daily Asa, Persantine and anticoagulants usually
  ordered..
• Cardiotonic drugs or cardioversion done to treat
  atrial fibrillation
• Nursing same as other valvular conditions

20
Mitral Insufficiency ( Mitral Regurgitation) Pg
464

• Mitral valve does not close completely
• Associated with rheumatic heart and mitral valve
  prolapse, connective tissue disorders, stretching
  of the valve opening from enlarged left ventricle
  and malfunction of a replaced valve.
• Blood flows backward into left atrium during
  ventricular systole.

21
Mitral Insufficiency

• Heart can compensate for a small volume. If
  regurgitation affects papillary muscles, or is
  damaged from MI or rupture of a prosthetic valve,
  heart cant compensate and pulmonary congestion
  occurs.
• The regurgitated blood plus the normal amount are
  pushed into left ventricle. It enlarges and
  weakens and heart failure develops. Left atrium
  also affected.

22
Signs and Symptoms

• Dyspnea on exertion and fatigue
• If pulmonary congestion, will have shortness of
  breath and moist lung sounds
• palpitations, tachycardia, hypertension if
  cardiac output inadequate
• A loud blowing murmur often heard thru-out
  ventricular systole at the apex. S1 diminished
  because of incomplete closure of mitral valve. S3
  early sign of heart failure

23
Nursing Care

• Monitor vitals
• Weigh to determine changes in fluid balance
• Teach about low Na diet
• Teach need for prophylactic antibiotics

24
Nursing Care

• Monitor vitals, heart and lung sounds.
• Signs of right or left heart failure reported
  stat
• Review Nursing care for the client with a
  valvular disorder on Page 458--460

25
Mitral Valve Prolapse Pg 464

• The valve cusps enlarge, become floppy and bulge
  backward into left atrium
• associated with connective tissue disorders and
  CAD but not completely understood.
• Affects young women more
• Changes in mitral valve tissue layers cause cusps
  to distend and stretch papillary muscle and
  causes local ischemia and chest pain

26
Mitral Valve Prolapse

• May also have increased levels of catecholamines
  (epinephrine and norepinephrine) which cause
  symptoms that mimic severe anxiety or panic(
  tachycardia, palpitations, breathlessness,light-he
  adedness, difficulty concentrating and fear of
  impending death. May have chest pain,
  palpitations and fatigue
• Many are asymptomatic

27
Mitral Valve Prolapse

• Chest pain is different from angina its onset
  does not correlate with physical exertion, its
  duration is prolonged, and it is not easily
  relieved
• Auscultation of heart sounds reveals a
  characteristic click during ventricular systole
  and may have a systolic murmur.

28
Nursing management of Mitral Prolapse

• Chest pain relieved by lying flat with legs
  elevated and supported against a wall or couch at
  a 90 degree angle for 3 to 5 min. to facillitate
  volume changes in heart.
• Increasing activity when tachycardia occurs to
  eliminate the initiation of extra ineffective
  beats to make up for reduced cardiac output and
  to lower catecholamines.
• Breathe deeply slowly thru pursed lips

29
Nursing management

• Avoid caffeine, over-the -counter drugs that have
  stimulants.
• If hypertension not a problem, increase fluids
  and moderate amount of Na to maintain
  intravascular volume
• No alcohol
• Do not stop tranquilizers abruptly as causes
  withdrawal symptoms and makes cond. worse

30
Recap

• Review nutritional considerations, pharmacology,
  and geriatric considerations for test
• Review anatomy