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Curu, Lorelyn June P.

BSN III-1 Page 1



ANGELES UNIVERSITY FOUNDATION
Angeles City

College of Nursing
Nursing Care Management 103

Handout for Management of Clients with Structural Cardiac Disorders

VALVULAR HEART DISEASE
Stenosed valve
Insufficient (incompetent)

Incidence
Decreasing steadily
One of the most common cardiac abnormalities mitral valve prolapsed
5% of the population is affected
Women > men

I. MITRAL VALVE DISEASE

Etiology and Risk Factors
Rheumatic Heart Disease
Infectious Endocarditis
Connective Tissue Abnormality
Myocardial Ischemia - blood flow in the heart

A. Mitral Stenosis
- Valve becomes calcified and immobile
- Valvular orifice narrows (normally 4 6 cm
2
)

Pathophysiology:



























Blood is not adequately pumped
from LA to LV during diastole
Inadequate filling of LV
(preload)
Pressure in LA elevates
Cardiac Output
Back pressure elevates Pulmonary
Venous & Pulmonary Capillary
Pressures
Pulmonary HTN
RV hypertrophy as it needs to pump
blood harder
MITRAL STENOSIS
Right-Side Heart Failure
RV failure can result
Hypertrophy
Curu, Lorelyn June P. BSN III-1 Page 2

Manifestations
Dyspnea, orthopnea, exercise tolerance, PND
Hemoptysis
Diastolic murmur
Systemic congestion
Opening snap is heard (apex) diaphragm
Atrial fibrillation common in mitral stenosis
Mural thrombi
Irregular pulse

Diet
Na restricted diet

Surgical Management
Percutaneous Balloon Valvuloplasty
Temporarily redues backflow by enhancing forward blood flow into the aorta

Note:
Mechanical mostly prescribed for children
- after 10 years it becomes 30% inefficient
- need anti-coagulant therapy

Tissue for adults
- less durable
- for clients with bleeding tendency
- for pregnant women
- no anti-coagulant therapy needed

B. Mitral Regurgitation

Pathophysiology



























Backflow of blood from
LV to LA
Reduced amount of
blood flow to LV
Large amount of blood received
by the LA during systole
LV must pump harder
to pressure CO
LA hypertrophy/
LA pressure LV hypertrophy
Pulomonary
congestion
LV failure
RV hypertrophy since it has to pump
against a higher resistance
CO pulmonary
congestion
Right-side Heart
Failure
Systemic congestion
Curu, Lorelyn June P. BSN III-1 Page 3

Manifestation
Symptoms of CO
Fatigue, dyspnea, orthopnea, PND
Systolic murmur: blowing & high pitched, heard immediately after S
1

Changes in the mean capillary pressure
S
3
gallop: rapid in flow rate across mitral orifice
Manifestations of right-sided heart failure
Atrial fibrillation: irregular heart beat

Management
Pharmacologic Management
Diuretic
To decrease cardiac workload

Digitalis
Nitrates tx of angina
ACE inhibitors

Diet
Na restricted diet

Activity
Restriction of physical activities that produce fatigue and dyspnea

C. Mitral Valve Prolapse
Barlow Syndrome
Systolic Click Murmur Syndrome
Floppy Valve Syndrome

Pathophysiology


















Manifestations
Asymptomatic
Regurgitant murmur with med systolic click
Tachycardia, palpitation r/t dysrhythmias
Lightheadedness, syncope, fatigue, weakness, dyspnea
Anxiety
Dyspnea & chest discomfort



Anterior & posterior cusps of mitral valve billow
upward into the atrium during systolic contraction
Chordae tendineae lengthen allowing the valve cusps
to stretch upward
Cusps enlarges & thickens
Regurgitation
Curu, Lorelyn June P. BSN III-1 Page 4

Management
Beta blockers
Aspirin
Antibiotics

Diet
Eliminate caffeine & alcohol from the diet

Surgical Mgt
Mitral valve replacement


II. AORTIC VALVE DISEASE
In aortic stenosis the orifice of the aortic valve becomes narrowed
Aortic regurgitation (insuffient) allows blood to leak back from the aorta to the
left ventricle
Both aortic stenosis and regurgitation overwork the left ventricle ventricle
hypertrophy

Etiology and Risk Factors
Congenital defects of the aortic valve
Calcification of the valve
Rheumatic Fever

A. Aortic Stenosis

Pathophysiology



























Note:
Systole contraction
Diastole relaxation

Narrowed aortic valve
Blood not adequately pumped
from LV to aorta
Pressure in LV elevates during
systole
LV hypertrophy/Dilation
Elevated End-Diastolic Pressure
Decreased CO/LV Failure
Left-Side Heart Failure/
Pulmonary Congestion
Curu, Lorelyn June P. BSN III-1 Page 5



Manifestation
Gradually and late in the course of the disease
Angina pectoris in 66% (similar with CAD), dysrhythmias
Syncope during exertion due to fixed CO during periods of increased demand
Symptoms of left-sided heart failure
In severe AS: palpitation, fatigue, and visual disturbances
Systolic murmur
Early ejection click & systolic thrill

Management
Pharmacologic Mgt
Antibiotics
Diuretics
Digitalis

Activity
Avoid vigorous activity

Surgical Mgt
Aortic Valve Replacement
Percutaneous Balloon Valvuloplasty


B. Aortic Regurgitation

Pathophysiology





















Manifestation
Even with severe AR, pts may be asymptomatic for a long time
Palpitation, fatigue
Prominent carotid artery pulsation and head-bobbing with each heartbeat (de
Musset sign)
Widening Pulse Pressure: high systolic in LV and low diastolic pressure in aorta
Diastolic murmur
Corrigans or water hammer pulse (sharp pulse then sudden collapse in diastolic
pressure)
Blood in the aorta flows back in the
LV through an incompetent valve
Volume overload in the LV
Increased left ventricular end
diastolic volume
Hypertrophy & dilation of left ventricle
Progression of condition leads to decline in contractility
Curu, Lorelyn June P. BSN III-1 Page 6

Management
Antibiotics
Diuretics
Digitalis
Beta blockers

Diet
Na restricted diet

Surgical Mgt
Aortic Valve replacement

III. TRICUSPID VALVE DISEASE
Tricuspid stenosis & regurgitation
Usually develops from rheumatic fever or in combination with other structural
disorders of the heart
right atrial pressure

A. Tricuspid Stenosis

Pathophysiology














Manifestation
Dyspnea, fatigue, jugular vein distention, peripheral edema & weight loss
Pulsation in the neck with prominent waves
Diastolic murmur is heard best along the left lower sterna border

Management
Diuretics
Digitalis
Beta blockers

B. Tricuspid Regurgitation

Pathophysiology










Inability of RA to propel blood
across the stenosed valve
RA
Pressure/Systemic Venous
Congestion
Cardiac Output
Backflow of blood from the RV back into the RA during systole
RA pressure
Systemic venous congestion
Curu, Lorelyn June P. BSN III-1 Page 7

Manifestation
Decreased CO
Right-side Heart Failure
- hepatic congestion
- peripheral edema
Atrial Fibrillation
Systolic murmur/S
3
gallop

Management
Anti-dysrythmic drugs
Digitalis


IV. PULMONIC VALVE DISEASE
Usually a congenital defiect
May be caused by RHD
Caused by mitral stenosis, pulmonary emboli & chronic lung disease
Pulmonic stenosis and regurgitation lead to in CO

A. Pulmonary Stenosis

Pathophysiology











Manifestation
Murmur
Right sided heart failure


B. Pulmonic Regurgitation
Allows blood to flow back from the PA to the RV during diastole
Most common cause: dilatation of the pulmonic valve ring due to pulmonary
hypertension
Charac. Murmur: GRAHAM STEELL MURMUR: begins after S
2
and the sound is
accentuated with inspiration
Tap is heard & palpable systolic pulsation on the left parasternal area

Manifestation
SOB, fatigue, cyanosis, fainting
Chest pain
Poor weight gain & failure to thrive in infants
Heart murmur

Management
Diuretics
Digitalis
ACE inhibitors
Vasodilators

Narrowing of the entrance of the pulmonary artery
Interferring with the blood flow out of the right side of the
heart
CO
Curu, Lorelyn June P. BSN III-1 Page 8

Nursing Diagnosis
1. Decreased Cardiac Output (Valvular Dse) r/t reduced ventricular filling and/or emptying
Assess VS
Monitor I & O
Restrict fluids as ordered
Elevate the head of the bed
Provide physical, emotional & mental rest
Administer prescribed medications to reduce cardiac workload

2. Activity Intolerance r/t imbalance between O
2
supply and demand
Monitor VS before, during and after exercise
Encourage adequate rest
Encourage self care
activity levels gradually
Assist with ADLs as needed
Formulate a schedule with alternating rest and activities

3. Risk for Infetion r/t Inadequate primary defense
Assess wounds and catheter sites for signs of infection
Use antiseptic techniques for all invasive procedures
Provide proper wound care

4. Risk for Fluid Volume Excess r/t Na and fluid retention
5. Anxiety r/t change in health status
6. Knowledge deficit regarding preventive measures against endocarditis
7. Risk for Non-compliance