Mississippi University for Women

Etiology and Pathophysiology

An infection of the endocardial surface with the presence of microorganisms. Since this is the tissue lining the inside of the heart, the ______________are usually affected as well. Most common causative organisms: S. aureus, Streptococcus pyrogenes, and Streptococcus pneumoniae. These organisms are introduced into the blood by several possible routes of entry, such as _____________________________________________. Once in the blood, the organisms tend to lodge on damaged areas in the heart: damaged valves, artificial valves, damaged endocardial tisse. The primary lesions are known as areas of _________________. These areas consist of fibrin, leukocytes, platelets, and microbes. The loss of these growths results in __________________. The infection may cause further damage to the valves and/or supporting tissue resulting in congestive heart failure, generalized myocardial dysfunction, and sepsis.
 

Clinical Manifestations

Findings are nonspecific:

- _______________

- _______________

- _______________

- _______________

- _______________

- _______________
 

Vascular manifestations:

- splinter ________________ in the nailbeds

- _____________in the conjunctivae, lips, buccal mucosa, palate, and ankles

- Osler's nodes (tender lesions on the finger or toe tips)

- Janeway's lesions (painless red spots on the palms and soles of feet)

- Roth's spots (lesions on the retina)
 

Murmurs

- new onset

- most common in aortic and mitral valves

- CHF is common (80% of aortic valve and 50% of mitral valve)
 

Embolization

- Spleen:_______________________

- Kidney:_______________________

- peripheral blood vessels:____________________

- brain:__________

- pulmonary embolus if on R side heart valves
 

Diagnostic studies

- History - recent _____________________ or _________________.

- Lab data - _____________________are primary diagnostic tool and are positive in 90% to 95% of pts. with infective endocarditis. Also will have mild leukocytosis and elevated ESR. May also have proteinuria and pos. rheumatoid factor.

- Echocardiogram - can detect _______________ and ____________on valves
 

Prophylactic Treatment

See Lewis p. 950: Table 35-4 and 35-5
 

Collaborative Care

Key to treatment is accurate identification of the offending ________________. Treatment usually takes several weeks and relapses are common. Treat fever with antipyretics. Bedrest only if in ____________ _________________. In pts. with an infection of a prosthetic valve, replacement of the valve is necessary in over 25% of cases.
 

Nursing Management

Complete H&P, to include a careful assessment of heart sounds. Also check for arthralgia, which is common and may involve multiple joints. Also assess oral mucosa and skin for petchiae
 

Goals

Are to have:

- ___________________________

- ___________________________

- ___________________________

- ___________________________
 

Health Promotion

Identify pts. at risk. and teach them to:

- avoid those with _________________________

- avoid __________________________________

- perform ________________________________

- inform all health care providers _____________

- understand significance of __________________________________________

Acute Intervention

- antibiotic therapy usually for ________________________________________

- fever is a common early sign and is monitored during treatment. If stays elevated is indication of ______________ _________________.

- May need bedrest if has persistent fever or signs of heart damage. (CT/DB, TED hose to prevent complications)

- Freq. lab test (Bld C&S, WBC) to determine adequacy of __________________
 
 
 

Acute Pericarditis
 

An acute inflammation of the pericardial sac surrounding the heart. This sac is composed of two membranes, the inner (visceral) layer and the outer (parietal) layer. The space in between is called the pericardial space and holds about 50 ml of serous fluid in a normal state. It's serves the heart by reducing friction and preventing excessive dilation during diastole.
 

Causes of pericarditis are usually idiopathic with a variety of suspected viral causes. See p. 955, Table 35-8 for a list of causes. It can occur immediately after an MI, or within 2 to 4 weeks, which is _______________ syndrome.
 

Clinical Manifestations

1. _________ ___________(usually sharp and radiates to back, neck, abd. causing difficult dx; may think angina or abd. condition)

- worse when supine, deep breath, cough, swallow, or movement

- better when sitting up and leaning forward

4. _____________

- caused by pain with breathing

- aggravated by fever and anxiety

7. ___________________

- scratching, grating, high-pitched sound (friction between inflamed surfaces)

- heard best over the lower left sternal border

- equal to heart beat (this will distinguish it from pleural rub during resp)
 

Complications

Two major complications that may result from pericarditis:

1. _________________ _____________________- accumulation of excess pericardial fluid (can occur slowly or rapidly depending on the cause, usually not a problem unless it becomes severe and constricts the heart, decreasing CO)

2. _______________ _______________________ - fluid accumulation to the degree it constricts the normal movement and function of the heart
 

Diagnostic Studies

- ECG changes are usually seen and indicative of superficial myocardial inflammation

- Chest x-ray is usually normal unless effusion is significant

- Echocardiograms are most specific

- Lab data useful in determining cause (Creat. in renal failure and Pos. TB test in tuberculin pericarditis)

- Fluid obtained during pericardiocentesis may also be used to determine cause.
 

Collaborative Care

- Management is aimed at treating the ______________ _____________.

- Antibiotics if thought to be bacterial in origin.

- NSAIDS are used to treat the pain and inflammation, steroids are reserved certain conditions and those not responding to the NSAIDS.

- Pericardiocentesis may be performed if _____________________ has dropped BP 30 mm Hg or greater.
 

Pericardiocentesis - 16 to 18 gauge needle is inserted in pericardial space to relieve pressure and for diagnostic purposes. Usually done in CCU or cath. lab under sterile technique in conjunction with ECG, hemodynamic monitoring, and sometimes under echo. Complications include arrhythmias, pneumomediastinum, pneumothorax, myocardial laceration, and tamponade.
 

Nursing Management

Assessment and management of _____________ is primary nursing considerations. Must be able to distinguish from angina quickly.

Pain relief :

- keep HOB @ 45 degress and provide table to lean over

- provide NSAIDS - with food or milk and avoid alcohol

- reduce anxiety - explain all procedures and diagnosis

- monitor for complications like tamponade

- assist with procedures like pericardiocentesis
 
 
 

Chronic Constrictive Pericarditis
 

Begins with a prolonged acute episode, in which the pericardial sac becomes fibrous and thickened with eventual obliteration of the pericardial space. The thickened sac encases the heart, impairing its _______________ and _____________ ________________. Signs and symptoms are similar to heart failure. Auscultatory findings include a pericardial knock heard on the left sternal border. ECG will show low QRS voltage and a________ _______________ is common. Echo. May detect this, but heart cath. is more specific. CT and MRI may also confirm diagnosis.
 

Treatment of choice is pericardiectomy. This involves complete resection of the pericardium in an open heart surgical procedure.
 
 
 

Myocarditis
 

Is a focal or diffuse inflammation of the ____________________. Is usually idiopathic or has a viral cause. Frequently associated with pericarditis. Usually a period of several weeks before signs are evident. The majority of cases are benign and self-limiting

Early systemic s/s: fever, malaise, pharyngitis, dyspnea, lymphadenopathy, and GI symptoms

Early cardiac s/s: pericardial chest pain, friction rub, progressing to s/s of CHF
 

Management

.

Nursing care: Assessment for s/s associated with CHF. Care consists of supportive care associated with cardiac decompensation and measures to ______________ _____________ __________________; such as placement in semi-fowlers position, bedrest, restricted activity, and usually O2 therapy and Digoxin, along with other agents to increase contractility while decreasing preload, afterload, or both. Occasionally immunosuppressents are used, in which case measures to prevent infection and exposure to infection is needed.
 
 
 

Rheumatic Fever and Heart Disease
 

Acute Rheumatic fever (ARF) - Inflammation of the heart potentially involving all layers of the myocardium.

Rheumatic heart disease - Chronic condition that is caused by rheumatic fever and is characterized by scarring and deformity of heart valves.
 

Facts and Etiology

A complication of group A B-hemolytic streptococci pharyngitis (_________ ________)

- occurs in _____ of all cases

- most common initial infection in ____ to ____ yr. olds

- most common recurrence in ____ to _____ yr. olds

- rapid decline in developed countries since introduction of _______________ (needs to be given within 9 days; continues to be big problem in undeveloped countries today)

- will see about 2 - 3 weeks after strep throat
 

Those at greatest risk:

- _________________________

- _________________________

- _________________________
 

Pathophysiology

- It is thought the body may have an allergic response in which the antibodies that attack the strep, attack the host tissues as well. This immune reaction to the organism sets off chain of events leading to this disease. (sometimes will see in very mild cases, usually never sought treatment). The abnormal humoral and cell-mediated immune response to the group A strep, is probably the cause of the widespread reaction observed in patients with ARF. In addition to affecting the heart, the disease may also affect the joints, skin, and CNS. It is possible these antigens bind to receptors at these sites triggering an immune and inflammatory response. This concept is widely believed but remains unproven.
 

Cardiac and Valve Lesions

- found in ____________ of all cases of ARF

- _____________ and _________ found primarily on the heart valves

- vegetation on valve leaflets - start with deposits of fibrin and blood cells at areas of erosion, then these areas become thick and fibrous. This results in inadequate valve function and causes stenosis and regurgitation of blood which leads to the _________ ____________.

- Aschoff's bodies - nodules found in the myocardium as a result of inflammation and later form scar tissue; also contributes to the heart failure
 

Clinical Manifestations

Criteria for diagnosis is divided into major and minor criteria. Evidence of an existing ________ ________________, in addition to having either two major criteria or one major and two minor indicates a high probability of having ARF.
 
 

Carditis - most important finding: includes cardiac enlargement, murmurs, and pericarditis

________________________________- most common finding

Chorea (weakness and spontaneous, purposeless movements)- major CNS manifestation

Erythema marginatum (pink macular rash lasting a few hours) - less common manifes.

Subcutaneous nodules - small, hard painless swellings found over boney prominences.
 
 

Fever

Previous ARF

Arthralgia

Prolonged PR interval on ECG

Lab findings (talk to in a minute)
 

Complications

Is a short lived disease in that <5% of s/s remain for over 6 months. It will not recur without a new strep infection and no ___________ ________________ with future attacks if it does not occur with the first attack.

Major complication is chronic rheumatoid carditis and can occur months to years after the initial episode.
 

Diagnostics

- no single test

- throat cultures usually ___________________by the time ARF s/s occur

- antistreptolysin O (ASO) is most specific to confirm a recent group A strep. infection

- ESR and CRP are nonspecific indicators of systemic inflammation

- Echo - may show problems with valves

- ECG - may show prolonged PR interval

- CXR - may show cardiac enlargement
 

Management

- No specific ___________ or _______

- _______________eliminates Strep, but does not alter the course of the disease once it has begun

- ____________________ agents control fever, joint inflammation, and carditis.

- Restricted _______________ until CHF controlled, otherwise are fully mobile.
 

Nursing Considerations

ARF is one of the only ___________________ cardiac diseases (need to educate public to seek treatment for sore throats)

____________ ____________________- Early detection and treatment of strep throat (MUST EDUCATE!)

- PCN G: 0.6 to 1.2 million units IM x one dose

- PCN G: x 10 days po

- If allergic: clindamycin, vancomycin, or gentamicin

____________ ___________________ - Prophylactic treatment to prevent recurrence

- PCN G: IM monthly

- PCN G: daily

- How long depends on age at onset and associated complications

- Does not take the place of antibiotic administration before invasive or dental procedures
 

Primary goals

- control and eradicate the organism

- prevent cardiac complications

- relieve joint pain and fever

- encourage po fluids

- prevent spread to others (resp. precautions for 24 hrs after treatment)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Valvular Heart Disease
 

Two atrioventricular valves:

- mitral - left heart

- tricuspid - right heart

Two semilunar valves:

- aortic

- pulmonic

Two types of functional alterations: (Lewis p. 965 for picture)

- stenosis - valves fails to open properly, impeding blood flow through it

- regurgitation - incomplete closure results in backflow of blood

Two common causes:

- congenital heart disease in children

- Rheumatic heart disease in adults
 

Mitral Stenosis

_________________ ____________ _________________most common cause, which causes scarring of the valve leaflets and cordae tendineae. The valve becomes thick and funnel shaped creating a difference in the pressure gradient between the left atrium and ventricle during diastole. (pressure should be equal during diastole) The pressure in the left atrium rises, which in turn increases the pressure of the pulmonary vasculature. This is what causes the two primary manifestations; ____________ and ________________.

Clinical manifestations:

- dyspnea - primary manifestation

- hemoptysis -

- palpitations from a.fib

- fatigue

- hoarseness (from atrial enlargement)

- chest pain (from decreased CO)

- seizures or CVA's from emboli

- heart sounds - opening snap and a low-pitched rumbling diastolic murmur (will have a murmur with any of the valve diseases)
 

Mitral Regurgitation

Valve patency is dependent on several structures that support the mitral valve. Abnormalities of any of these can result in regurgitation. Causes may be inflammatory, degenerative, infective, structural, or congenital. Volume overload of the left atrium, left ventricle, and pulmonary bed is the result of a backflow of blood. Over time, this causes a varying degree of chamber enlargement. Signs of heart failure will develop, but are chronic in nature. With __________ mitral regurgitation, there is no heart enlargement. Without this enlargement to accommodate the increased volume, _______________ _____________ rapidly develops.
 
 
 
 
 

Clinical Manifestation:

Chronic

- _____________

- _____________

- _____________

- _____________ _________

- heart sounds - S3; loud systolic murmur at apex

Acute

- _______________________________

- _______________

- _______________________________
 

Mitral Valve Prolapse

The ______ _________________ valve disease in U.S. Is caused by failure of leaflets to come together properly. Etiology unknown, but may be familial tendency and occurs more often in young women, ages 14 to 30. Is benign in many cases but may cause serious complications.
 

Clinical Manifestation:

- ________________

- ________________

- ________________

- ________________

- ___________________________________
 

Patient teaching guide in Lewis on pg. 968.
 

Aortic Stenosis

Most found in childhood, if found later in life is usually due to:

- rheumatic fever - mitral stenosis also accompanies it; if only aortic valve involved, almost always nonrheumatic in origin

- senile fibrocalcific degeneration - incidence due to this expected to rise with aging population
 

Impedes flow of blood leaving left ventricle. Causes LV enlargement eventually leading

to heart failure
 

Aortic Regurgitation

Acute cases may be caused by bacterial endocarditis, trauma, or aortic dissection and is a life-threatening emergency. Chronic cases may be due to rheumatic heart disease, a congenital disorder or syphilis. Blood backflows into the left ventricle and heart failure eventually develops.
 

Clinical Manifestation:

Chronic

- fatigue

- dyspnea

- LV heave

- diastolic rumble, systolic click

Acute

- abrupt onset of severe dyspnea

- transient chest pain

- quick progression to shock
 

Tricuspid Valve Disease

Tricuspid stenosis is rarely seen outside of rheumatic mitral stenosis and IV drug users. Tricuspid regurgitation is seen as a result of pulmonary HTN and right ventricular dysfunction. Both result in right sided heart failure with the development of ascites, peripheral edema, and hepatomegaly.
 

Pulmonic Valve Disease

Very uncommon

Stenosis - almost always congenital

Regurg - usually benign and asso. with diseases of other valves
 
 
 

Diagnostic Studies of Valve Disease

- H & P

- CXR

- ECG

- Echo

- Cardiac cath.
 

Conservative Treatment

Of primary importance is to prevent recurrence of rheumatic fever and endocarditis. Treatment depends on the valve and the severity of the disease and is focused on managing the complications, such as heart failure, arrhythmias, and embolization.
 

Percutaneous transluminal balloon valvuloplasty (PTBV): (Lewis p. 970 for picture)

An alternative to surgery for older, debilitated patients and is used for pulmonic aortic, and mitral stenosis. A balloon is inserted into the heart and inflated in the diseased valve in an attempt to open up and separate the valve leaflets.
 

Surgical Therapy

Decision is based on patient's status as generally appraised by the New York Association classification system for disability (Lewis p. 892). Type of surgery depends on: 1)valves involved; 2) valve pathology; 3) severity of disease; 4) status of patient.
 

Repair of the valve, as opposed to replacement, has a lower mortality and has become the treatment of choice. This may be the treatment f choice, for example, for a woman of child bearing age who can not take ___________________.
 

Two types of prosthetic valves:

1. mechanical - metalpyrolite, and Dacron (better than valves from 1950's). These have more complications with ________________________ that biologic (long term anticoagulants), but they last longer.

2. biologic (tissue) - bovine, porcine, human. Don't have the problems with thromboembolism, but are prone to develop disease.
 

Nursing Care

- quit smoking

- limit strenuous activity

- use of prophylactic antibiotics

- instruct on care of CHF (CHF is the most common complication and long-term health consideration. Teach daily wts, check edema, report dyspnea, low Na diet)

- INR _____________ if on anticoagulant

- Seek medical care: s/s infection, CHF, bleeding, planned invasive or dental procedures.
 
 
 
 
 

Cardiomyopathy

Definition - a group of heart muscle diseases of unknown etiology that affect the functional or structural ability of the heart.
 

It is diagnosed by s/s and on the ruling out of other disease processes
 

Two classifications:

1. primary - etiology of heart disease is unknown

2. secondary - a result of another disease process, such as ischemia, viral infections, alcohol or drug abuse, and pregnancy
 

Three types:

1. _____________________

2. _____________________

3. ______________________
 

Dilated Cardiomyopathy

- most common; >90% of cases

- cardiomegaly with ventricular dilation, atrial enlargment, impaired systolic function, and blood stasis in LV

- clinical picture similar to CHF, but no hypertrophy of LV

- 20% to 50% die within a year of diagnosis

- often follows myocarditis

- rapid degeneration and acute inflammation of myocardial fibers that decrease contractility
 
 
 

Management:

- similar to CHF; enhance contractility and decrease afterload

- treat underlying disease process (ie, alcohol induced )

- Dobutrex and Primacor help symptoms temporarily

- Heart Transplant an option for some, but very poor prognosis.
 

Hypertropic Cardiomyopathy

- also known as Idiopathic Hypertrophic Subaortic Stenosis (IHSS)

- asymmetric myocardial hypertrophy w/o dilation

- possibly an autosomal dominant genetic disease

- more common in ____________, ____________ men

- Four characteristics: vent. hypertrophy; rapid, forceful contraction of LV; impaired relaxation; obstruction to aortic outflow

- Thick wall is noncompliant and ____________, allowing for poor filling during diastole. This combine with impaired aortic outflow decreases CO. Particularly noticeable during exertion. ____________________are a common complication as is syncope due to a decreased cerebral flow
 

Management

- treat with beta-blockers or calcium channel blockers

- CHF doesn't occur until very late

- Can perform ventriculomyotomy, an incision of the thickened heart muscle

- Nursing intervention aimed at teaching to avoid strenuous activities.

-

Restrictive Cardiomyopathy

- the least common

- impairs diastolic volume and stretch

- etiology unknown

- primary characteristic is a cardiac muscle stiffness, which results in poor filling and decreased CO

- primary symptom is exercise intolerance (HR can't tolerate it)

- s/s of CHF are common
 

Management

- similar to CHF

- avoid exercise

- no specific treatment

- heart transplant may be an option