RN Expert Guides: Cardiovascular Care, 1st Edition (2008)

Chapter 7. Valvular Disorders

AORTIC INSUFFICIENCY

Aortic insufficiency by itself occurs most commonly in men. When associated with mitral valve disease, however, it's more common in women. This disorder may also be associated with Marfan syndrome, ankylosing spondylitis, syphilis, essential hypertension, and a ventricular septal defect, even after surgical closure.

Pathophysiology

In patients with aortic insufficiency (also called aortic regurgitation), blood flows back into the left ventricle during diastole. The ventricle becomes overloaded, dilated, and eventually hypertrophies. The excess fluid volume also overloads the left atrium and, eventually, the pulmonary system.

Aortic insufficiency results from rheumatic fever, syphilis, hypertension, endocarditis, or trauma. In some patients, it may be idiopathic.

Complications

·

Left-sided heart failure

·

Fatal pulmonary edema resulting from fever, infection, or cardiac arrhythmia

·

Myocardial ischemia (left ventricular dilation and elevated left ventricular systolic pressure alter myocardial oxygen requirements)

Assessment findings

·

A patient with chronic severe aortic insufficiency may report that he has an uncomfortable awareness of his heartbeat, especially when lying down on his left side.

·

He may report palpitations along with a pounding head.

 

·

The patient may experience exertional dyspnea and paroxysmal nocturnal dyspnea with diaphoresis, orthopnea, and cough.

·

 

·

He may also have a history of angina unrelieved by sublingual nitroglycerin.

·

On inspection, you may note that each heartbeat seems to jar the patient's entire body and that his head bobs with each systole.

·

Inspection of arterial pulsations shows a rapidly rising pulse that collapses suddenly as arterial pressure falls late in systole.

·

The patient's nail beds may appear to be pulsating. If you apply pressure at the nail tip, the root will alternately flush and pale.

·

Inspection of the chest may reveal a visible apical pulse.

·

If the patient has left-sided heart failure, he may have ankle edema and ascites.

·

When palpating the peripheral pulses, you may note rapidly rising and collapsing pulses (called pulsus biferiens). If the patient has cardiac arrhythmias, pulses may be irregular. You'll be able to feel the apical impulse. (The apex is displaced laterally and inferiorly.) A diastolic thrill probably is palpable along the left sternal border, and you may be able to feel a prominent systolic thrill in the jugular notch and along the carotid arteries.

·

Auscultation may reveal an S3, occasionally an S4, and a loud systolic ejection sound. A high-pitched, blowing, decrescendo diastolic murmur is best heard at the left sternal border, at the third intercostal space. Use the diaphragm of the stethoscope to hear it, and have the patient sit up, lean forward, and hold his breath in forced expiration. (See Identifying the murmur of aortic insufficiency.)

 

·

You may also hear a grade 5 or 6 midsystolic ejection murmur at the base of the heart, typically higher pitched, shorter, and less rasping than the murmur heard in aortic stenosis.

·

Another murmur that may occur is a soft, low-pitched, rumbling, middiastolic or presystolic bruit; this murmur is best heard at the base of the heart.

·

Place the stethoscope lightly over the femoral artery to hear a booming, pistol-shot sound and a to-and-fro murmur.

·

Arterial pulse pressure is widened.

·

Auscultating blood pressure may be difficult because you can hear the patient's pulse after you inflate the cuff. To determine systolic pressure, note when Korotkoff sounds begin to muffle.

A high-pitched, blowing decrescendo murmur that radiates from the aortic valve area to the left sternal border characterizes aortic insufficiency.

c7-tt1

Diagnostic test results

·

Cardiac catheterization shows reduced arterial diastolic pressures, aortic insufficiency, other valvular abnormalities, and increased left ventricular end-diastolic pressure.

·

Chest X-rays display left ventricular enlargement and pulmonary vein congestion.

·

Echocardiography reveals left ventricular enlargement, dilation of the aortic annulus and left atrium, and thickening of the aortic valve. It also reveals a rapid, high-frequency fluttering of the anterior mitral leaflet that results from the impact of aortic insufficiency.

·

Electrocardiography shows sinus tachycardia, left ventricular hypertrophy, and left atrial hypertrophy in patients with severe disease. ST-segment depressions and T-wave inversions appear in leads I, aVL, V5, and V6 and indicate left ventricular strain.

Treatment

Valve replacement is the treatment of choice and should be performed before significant ventricular dysfunction occurs. This may be impossible, however, because signs and symptoms seldom occur until after myocardial dysfunction develops.

A cardiac glycoside, a low-sodium diet, a diuretic, a vasodilator and, especially, an angiotensin-converting enzyme inhibitor are used to treat patients with left-sided heart failure. For acute episodes, supplemental oxygen may be necessary.

Nursing interventions

·

If the patient needs bed rest, stress its importance. Assist with bathing if necessary. Provide a bedside commode because using a

commode puts less stress on the heart than using a bedpan. Offer the patient diversionary, physically undemanding activities.

·

Alternate periods of activity with periods of rest to prevent extreme fatigue and dyspnea.

·

To reduce anxiety, allow the patient to express his concerns about the effects of activity restrictions on his responsibilities and routines. Reassure him that the restrictions are temporary.

·

Keep the patient's legs elevated while he sits in a chair to improve venous return to the heart.

·

Place the patient in an upright position to relieve dyspnea, if necessary, and administer oxygen to prevent tissue hypoxia.

·

Keep the patient on a low-sodium diet. Consult a dietitian to ensure that the patient receives foods that he likes while adhering to diet restrictions. (See Teaching the patient with aortic insufficiency.)

·

Monitor the patient for signs of heart failure, pulmonary edema, and adverse reactions to drug therapy.

·

Monitor his vital signs, arterial blood gas level, intake and output, daily weight, blood chemistry results, chest X-ray, and pulmonary artery catheter readings.

DISCHARGE TEACHING

ff3-b01382759TEACHING THE PATIENT WITH AORTIC INSUFFICIENCY

·

Advise the patient to plan for periodic rest in his daily routine to prevent undue fatigue.

·

Teach the patient about diet restrictions, drugs, signs and symptoms that should be reported, and the importance of consistent follow-up care.

·

Tell the patient to elevate his legs whenever he sits.

ff2-b01382759RED FLAG

If the patient undergoes surgery, watch for hypotension, arrhythmias, and thrombus formation.

Aortic stenosis is hardening of the aortic valve or of the aorta itself. About 80% of patients with aortic stenosis are male.

ff1-b01382759AGE AWARE

Signs and symptoms of aortic stenosis may not appear until the patient reaches ages 50 to 70, even though the lesion has been present since childhood. Incidence increases with age. Aortic stenosis is the most significant valvular lesion seen among elderly people.

Pathophysiology

In aortic stenosis, the opening of the aortic valve narrows, and the left ventricle exerts increased pressure to drive blood through the opening. The added workload increases the demand for oxygen, and diminished cardiac output reduces coronary artery perfusion, causes ischemia of the left ventricle, and leads to heart failure.

Aortic stenosis may result from congenital aortic bicuspid valve (from coarctation of the aorta), congenital stenosis of pulmonic valve cusps, rheumatic fever or, in elderly patients, atherosclerosis.

Complications

·

Left-sided heart failure, usually after age 70, within 4 years after the onset of signs and symptoms; fatal in up to two-thirds of patients

·

Sudden death, usually around age 60, in 20% of patients, possibly caused by an arrhythmia

Assessment findings

·

Even with severe aortic stenosis (narrowing to about one-third of the normal opening), the patient may be asymptomatic.

·

The patient may complain of exertional dyspnea, fatigue, exertional syncope, angina, and palpitations.

·

If left-sided heart failure develops, the patient may complain of orthopnea and paroxysmal nocturnal dyspnea.

·

Inspection may reveal peripheral edema if the patient has left-sided heart failure.

·

Palpation may detect diminished carotid pulses and alternating pulses. If the patient has left-sided heart failure, the apex of the heart may be displaced inferiorly and laterally. If the patient has pulmonary hypertension, you may be able to palpate a systolic thrill at the base of the heart, at the jugular notch, and along the carotid arteries. Occasionally, it may be palpable only during expiration and when the patient leans forward.

·

Auscultation may uncover an early systolic ejection murmur in children and adolescents who have noncalcified valves. The murmur begins shortly after S1Identifying the murmur of aortic stenosis.)

 

·

The murmur is low-pitched, rough, and rasping and is loudest at the base at the second intercostal space. In patients with stenosis, the murmur is at least grade 3 or 4. It disappears when the valve calcifies. A split S2 develops as aortic stenosis becomes more severe. An S4 reflects left ventricular hypertrophy and may be heard at the apex in patients with severe aortic stenosis.

IDENTIFYING THE MURMUR OF AORTIC STENOSIS

A low-pitched, harsh crescendo-decrescendo murmur that radiates from the aortic valve area to the carotid artery characterizes aortic stenosis.

c7-tt2

Diagnostic test results

·

Cardiac catheterization reveals the pressure gradient across the valve (indicating the severity of the obstruction), increased left ventricular end-diastolic pressures (indicating left ventricular function), and the location of the left ventricular outflow obstruction.

·

 

·

Echocardiography demonstrates a thickened aortic valve and left ventricular wall and, possibly, coexistent mitral valve stenosis.

·

Electrocardiography reveals left ventricular hypertrophy. In advanced stages, the patient exhibits ST-segment depression and T-wave inversion in standard leads I and aVLand in the left precordial leads. Up to 10% of patients have atrioventricular and intraventricular conduction defects.

Treatment

A cardiac glycoside, a low-sodium diet, a diuretic and, for acute cases, oxygen are used to treat patients with heart failure. Nitroglycerin helps to relieve angina.

ff1-b01382759AGE AWARE

For children who don't have calcified valves, simple commissurotomy under direct visualization is usually effective.

Adults with calcified valves need valve replacement when they become symptomatic or are at risk for developing left-sided heart failure.

Percutaneous balloon aortic valvuloplasty is useful in a child or young adult with congenital aortic stenosis and in an elderly patient with severe calcifications. This procedure may improve left ventricular function so the patient can tolerate valve replacement surgery.

A Ross procedure is usually performed in patients younger than age 55. During this procedure, the pulmonic valve is used to replace the aortic valve, and the pulmonic valve of a cadaver is inserted. This allows longer valve life and makes anticoagulant therapy unnecessary.

Nursing interventions

·

If the patient needs bed rest, stress its importance. Assist the patient with bathing if necessary; provide a bedside commode because using a commode puts less stress on the heart than using a bedpan. Offer the patient diversionary, physically undemanding activities.

·

Alternate periods of activity with periods of rest to prevent extreme fatigue and dyspnea.

·

To reduce anxiety, allow the patient to express his concerns about the effects of activity restrictions on his responsibilities and routines. Reassure him that the restrictions are temporary.

·

Keep the patient's legs elevated while he sits in a chair to improve venous return to the heart.

·

Place the patient in an upright position to relieve dyspnea, if needed. Administer oxygen to prevent tissue hypoxia, as needed.

·

Keep the patient on a low-sodium diet. Consult with a dietitian to ensure that the patient receives foods that he likes while adhering to diet restrictions. (See Teaching the patient with aortic stenosis.)

·

Monitor the patient for signs of heart failure, pulmonary edema, and adverse reactions to drug therapy.

·

Allow the patient to express his fears and concerns about the disorder, its impact on his life, and any upcoming surgery. Reassure him as needed.

·

After cardiac catheterization, apply firm pressure to the catheter insertion site, usually in the groin. Monitor the site every 15 minutes for at least 6 hours for signs of bleeding. If the site bleeds, remove the pressure dressing and apply firm pressure.

 

·

Notify the practitioner of any changes in peripheral pulses distal to the insertion site, changes in cardiac rhythm and vital signs, and complaints of chest pain.

·

Monitor vital signs, arterial blood gas levels, intake and output, daily weight, blood chemistry results, chest X-rays, and pulmonary artery catheter readings.

DISCHARGE TEACHING

ff3-b01382759TEACHING THE PATIENT WITH AORTIC STENOSIS

·

Advise the patient to plan for periodic rest in his daily routine to prevent undue fatigue.

·

Teach the patient about diet restrictions, drugs, signs and symptoms that should be reported, and the importance of consistent follow-up care.

·

Tell the patient to elevate his legs whenever he sits.

ff2-b01382759RED FLAG

If the patient has surgery, watch for hypotension, arrhythmias, and thrombus formation.

MITRAL INSUFFICIENCY

Mitral insufficiency—also known as mitral regurgitation—occurs when a damaged mitral valve allows blood from the left ventricle to flow back into the left atrium during systole.

Pathophysiology

In mitral insufficiency, blood from the left ventricle flows back into the left atrium during systole. As a result, the atrium enlarges to accommodate the backflow. The left ventricle also dilates to accommodate the increased volume of blood from the atrium and to compensate for diminishing cardiac output.

Mitral insufficiency tends to be progressive because left ventricular dilation increases the insufficiency, which further enlarges the left atrium and ventricle, which further increases the insufficiency.

Damage to the mitral valve can result from rheumatic fever, hypertrophic cardiomyopathy, mitral valve prolapse, a myocardial infarction, severe left-sided heart failure, or ruptured chordae tendineae.

In older patients, mitral insufficiency may occur because the mitral annulus has become calcified. The cause is unknown, but it may be linked to a degenerative process. Mitral insufficiency is sometimes associated with congenital anomalies such as transposition of the great arteries.

IDENTIFYING THE MURMUR OF MITRAL INSUFFICIENCY

A high-pitched, rumbling pansystolic murmur that radiates from the mitral area to the left axillary line characterizes mitral insufficiency.

c7-tt3

Complications

·

Left- and right-sided heart failure with pulmonary edema and cardiovascular collapse, resulting from ventricular hypertrophy and increased end-diastolic pressure

Assessment findings

·

Depending on the severity of the disorder, the patient may be asymptomatic or complain of orthopnea, exertional dyspnea, fatigue, weakness, weight loss, chest pain, and palpitations.

·

Inspection may reveal jugular vein distention with an abnormally prominent a wave. You may also note peripheral edema.

·

Auscultation may detect a soft S1 that may be buried in the systolic murmur. A grade 3 to 6 or louder holosystolic murmur, most characteristic of mitral insufficiency, is best heard at the apex.

·

You also hear a split S2 and a low-pitched S3. The S3 may be followed by a short, rumbling diastolic murmur. An S4 may be evident in patients who have experienced a recent onset of severe mitral insufficiency and who are in normal sinus rhythm. (See Identifying the murmur of mitral insufficiency.)

·

Auscultation of the lungs may reveal crackles if the patient has pulmonary edema.

·

Palpation of the chest may disclose a regular pulse rate with a sharp upstroke. You can probably palpate a systolic thrill at the apex. In

patients with marked pulmonary hypertension, you may be able to palpate a right ventricular tap and the shock of the pulmonic valve closing. When the left atrium is markedly enlarged, it may be palpable along the sternal border late during ventricular systole. It resembles a right ventricular lift.

·

Abdominal palpation may reveal hepatomegaly if the patient has right-sided heart failure.

Diagnostic test results

·

Cardiac catheterization is used to detect mitral insufficiency with increased left ventricular end-diastolic volume and pressure, increased left atrial and pulmonary artery wedge pressures, and decreased cardiac output.

·

Chest X-rays demonstrate left atrial and ventricular enlargement, pulmonary vein congestion, and calcification of the mitral leaflets in patients with long-standing mitral insufficiency and stenosis.

·

Echocardiography reveals abnormal motion of the valve leaflets, left atrial enlargement, and a hyperdynamic left ventricle.

·

Electrocardiography may show left atrial and ventricular hypertrophy, sinus tachycardia, and atrial fibrillation.

Treatment

The nature and severity of associated symptoms determine treatment for a patient with valvular heart disease. For example, he may need to restrict activities to avoid extreme fatigue and dyspnea.

Heart failure requires digoxin (Lanoxin), a diuretic, a sodium-restricted diet and, for acute cases, oxygen. Other appropriate measures include anticoagulant therapy to prevent thrombus formation around diseased or replaced valves and a prophylactic antibiotic before and after surgery or dental care.

If the patient has severe signs and symptoms that can't be managed medically, he may need open-heart surgery with cardiopulmonary bypass for valve replacement.

ff1-b01382759AGE AWARE

Valvuloplasty may be used for elderly patients who have end-stage disease and can't tolerate general anesthesia.

Nursing interventions

·

Provide rest periods between periods of activity to prevent excessive fatigue.

·

To reduce anxiety, allow the patient to express his concerns about the effects of activity restrictions on his responsibilities and routines. Reassure him that the restrictions are temporary.

 

·

Keep the patient on a low-sodium diet; consult with the dietitian to ensure that the patient receives as many favorite foods as possible during diet restrictions. (SeeTeaching the patient with mitral insufficiency.)

·

Monitor the patient for left-sided heart failure, pulmonary edema, and adverse reactions to drug therapy. Provide oxygen to prevent tissue hypoxia, as needed.

·

If the patient has surgery, monitor him postoperatively for hypotension, arrhythmias, and thrombus formation.

·

Monitor the patient's vital signs, arterial blood gas level, intake and output, daily weight, blood chemistry results, chest X-ray, and pulmonary artery catheter readings.

ff3-b01382759TEACHING THE PATIENT WITH MITRAL INSUFFICIENCY

·

Teach the patient about diet restrictions, drugs, signs and symptoms that should be reported, and the importance of consistent follow-up care.

·

Explain all tests and treatments.

·

Make sure the patient and his family understand the need to comply with prolonged antibiotic therapy and follow-up care, and the need for an additional antibiotic during dental procedures.

·

Tell the parents or patient to stop the drug and call the practitioner immediately if the patient develops a rash, fever, chills, or other signs or symptoms of allergy at any time during penicillin therapy.

·

Instruct the patient and his family to watch for and report early signs and symptoms of heart failure, such as dyspnea and a hacking, unproductive cough.

ff2-b01382759RED FLAG

Before giving penicillin, ask the patient or his parents if he has ever had a hypersensitivity reaction to it. Even if he hasn't, warn that such a reaction is possible. Give the ordered antibiotic on time to maintain a consistent drug level in the blood.

MITRAL STENOSIS

Mitral stenosis is the hardening of the mitral valve. Two-thirds of all patients with mitral stenosis are women.

Pathophysiology

In patients with mitral stenosis, valve leaflets become diffusely thickened by fibrosis and calcification. The mitral commissures fuse, the chordae tendineae fuse and shorten, the valvular cusps become rigid, and the apex of the valve becomes narrowed, obstructing blood flow from the left atrium to the left ventricle.

As a result of these changes, left atrial volume and pressure increase and the atrial chamber dilates. The increased resistance to blood flow causes pulmonary hypertension, right ventricular hypertrophy and, eventually, right-sided heart failure. Also, inadequate filling of the left ventricle reduces cardiac output.

Mitral stenosis most commonly results from rheumatic fever. It may also be associated with congenital anomalies.

Complications

·

 

·

Fibrosis in the alveoli and pulmonary capillaries resulting from increased transudation of fluid from pulmonary capillaries and reduced vital capacity, total lung capacity, maximal breathing capacity, and oxygen uptake per unit of ventilation

·

Thrombi in the left atrium, embolizing and traveling to the brain, kidneys, spleen, and extremities, possibly causing infarction; most common in patients with arrhythmias

Assessment findings

·

Patients with mild mitral stenosis may have no symptoms.

·

Those with moderate to severe mitral stenosis may have a history of exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, weakness, fatigue, and palpitations.

·

A dry cough and dysphagia may occur because of an enlarged left atrium or bronchus.

·

Hemoptysis suggests rupture of pulmonary-bronchial venous connections.

·

Inspection may reveal peripheral and facial cyanosis, particularly in severe cases. The patient's face may appear pinched and blue, and she may have a malar rash. You may note jugular vein distention and ascites in the patient with severe pulmonary hypertension or associated tricuspid stenosis.

·

Palpation may reveal peripheral edema, hepatomegaly, and a diastolic thrill at the cardiac apex.

 

·

Auscultation may reveal a loud S1 or opening snap and a diastolic murmur at the apex, along the left sternal border or at the base of the heart. (See .)

·

In patients with pulmonary hypertension, the S2 is commonly accentuated, and the two components of the S2 are closely split. A pulmonary systolic ejection click may be heard in patients with severe pulmonary hypertension. Crackles may be heard when the lungs are auscultated.

·

Because mitral insufficiency is a form of heart disease, the practitioner may need to differentiate it from other forms of valvular heart disease.

IDENTIFYING THE MURMUR OF MITRAL STENOSIS

A low, rumbling crescendodecrescendo murmur in the mitral valve area characterizes mitral stenosis.

c7-tt4

Diagnostic test results

·

Cardiac catheterization shows a diastolic pressure gradient across the valve. It also shows elevated pulmonary artery wedge pressure (greater than 15 mm Hg) and pulmonary artery pressure in the left atrium with severe pulmonary hypertension. It detects elevated right ventricular pressure, decreased cardiac output, and abnormal contraction of the left ventricle. However, this test may not be indicated for patients who have isolated mitral stenosis with mild symptoms.

·

Chest X-rays show left atrial and ventricular enlargement (in patients with severe mitral stenosis), straightening of the left border of the cardiac silhouette, enlarged pulmonary arteries, dilation of the upper lobe pulmonary veins, and mitral valve calcification.

·

Echocardiography discloses thickened mitral valve leaflets and left atrial enlargement.

·

Electrocardiography reveals left atrial enlargement, right ventricular hypertrophy, right axis deviation and, in about half of cases, atrial fibrillation.

Treatment

Treatment for patients with valvular heart disease depends on the nature and severity of associated symptoms. In a young patient with asymptomatic mitral stenosis, penicillin is an important prophylactic.

If the patient is symptomatic, treatment varies. Heart failure requires bed rest, digoxin (Lanoxin), a diuretic, a sodium-restricted diet and, for acute cases, oxygen. Small doses of a beta-adrenergic receptor blocker may also be used to slow the ventricular rate when digoxin fails to control atrial fibrillation or flutter. Synchronized cardioversion may be used to correct atrial fibrillation in a patient whose status is unstable.

If hemoptysis develops, the patient requires bed rest, a sodium-restricted diet, and a diuretic to decrease pulmonary venous pressure. Embolization mandates an anticoagulant along with symptomatic treatments.

A patient with severe, medically uncontrollable symptoms may need open-heart surgery with cardiopulmonary bypass for commissurotomy or valve replacement.

Percutaneous balloon valvuloplasty may be used in young patients who have no calcification or subvalvular deformity, in symptomatic pregnant women, and in elderly patients with end-stage disease who can't tolerate general anesthesia. This procedure is performed in the cardiac catheterization laboratory.

Nursing interventions

·

Before giving penicillin, ask the patient if she has ever had a hypersensitivity reaction to it. Even if she hasn't, warn her that such a reaction is possible.

·

If the patient needs bed rest, stress its importance. Assist with bathing as necessary. Provide a bedside commode because using a commode puts less stress on the heart than using a bedpan. Offer the patient diversionary, physically undemanding activities.

·

To reduce anxiety, allow the patient to express concerns over her inability to meet her responsibilities because of activity restrictions. Give reassurance that activity limitations are temporary.

·

Watch closely for signs of heart failure, pulmonary edema, and adverse reactions to drug therapy.

P.370

·

Place the patient in an upright position to relieve dyspnea, if needed. Administer oxygen to prevent tissue hypoxia as needed.

·

If the patient has had surgery, watch for hypotension, arrhythmias, and thrombus formation. Monitor her vital signs, arterial blood gas level, intake and output, daily weight, blood chemistry results, chest X-ray, and pulmonary artery catheter readings.

·

Keep the patient on a low-sodium diet; provide as many favorite foods as possible. (See Teaching the patient with mitral stenosis

DISCHARGE TEACHING

ff3-b01382759TEACHING THE PATIENT WITH MITRAL STENOSIS

·

Explain all tests and treatments to the patient.

·

Advise the patient to plan for periodic rest in her daily routine to prevent undue fatigue.

·

 

·

Make sure the patient and her family understand the need to comply with prolonged antibiotic therapy and follow-up care, and the need for an additional antibiotic during dental or other surgical procedures.

PULMONIC INSUFFICIENCY

Pulmonic insufficiency is the leaking of the pulmonic valve, which lets blood flow back into the right ventricle.

Pathophysiology

In patients with pulmonic insufficiency, blood ejected into the pulmonary artery during systole flows back into the right ventricle during diastole, causing fluid overload in the ventricle, ventricular hypertrophy, and eventual right-sided heart failure.

Pulmonic insufficiency may be congenital or may result from pulmonary hypertension. The most common acquired cause is dilation of the pulmonic valve ring from severe pulmonary hypertension.

Rarely, pulmonic insufficiency may result from prolonged use of a pressure-monitoring catheter in the pulmonary artery.

Complications

·

 

IDENTIFYING THE MURMUR OF PULMONIC INSUFFICIENCY

A high-pitched, blowing decrescendo murmur at Erb's point characterizes pulmonic insufficiency.

c7-tt5

Assessment findings

·

The patient may complain of exertional dyspnea, fatigue, chest pain, and syncope.

·

Peripheral edema may cause him discomfort.

·

A patient with severe insufficiency that progresses to right-sided heart failure may appear jaundiced with severe peripheral edema and ascites. He may also appear malnourished.

·

Auscultation may reveal a high-pitched, decrescendo, diastolic blowing murmur along the left sternal border. This murmur may be difficult to distinguish from the murmur of aortic insufficiency. (See Identifying the murmur of pulmonic insufficiency.)

·

Palpation may disclose hepatomegaly if the patient has right-sided heart failure.

Diagnostic test results

·

Cardiac catheterization shows pulmonic insufficiency, increased right ventricular pressure, and associated cardiac defects.

·

Chest X-rays show right ventricular and pulmonary arterial enlargement.

·

Echocardiography can be used to visualize the pulmonic valve abnormality.

·

Electrocardiography findings may be normal in mild cases or reveal right ventricular hypertrophy.

Treatment

Treatment is based on the patient's symptoms. A low-sodium diet and a diuretic helps to reduce hepatic congestion before surgery. Valvulotomy or valve replacement may be required in severe cases.

DISCHARGE TEACHING

ff3-b01382759

·

Teach the patient about diet restrictions, drugs, signs and symptoms that should be reported, and the importance of consistent follow-up care.

·

Tell the patient to elevate his legs whenever he sits.

Nursing interventions

·

Alternate periods of activity and rest to prevent extreme fatigue and dyspnea.

·

Keep the patient's legs elevated while he sits in a chair to improve venous return to the heart.

·

Elevate the head of the bed to improve ventilation.

·

Keep the patient on a low-sodium diet. Consult with a dietitian to ensure that the patient receives foods that he likes while adhering to diet restrictions. (See Teaching the patient with pulmonic insufficiency.)

·

Monitor the patient for signs of heart failure, pulmonary edema, and adverse reactions to drug therapy.

·

To reduce anxiety, allow the patient to express his concerns about the effects of activity restrictions on his responsibilities and routines. Reassure him that the restrictions are temporary.

·

If the patient has surgery, watch for hypotension, arrhythmias, and thrombus formation. Monitor his vital signs, arterial blood gas level, intake and output, daily weight, blood chemistry results, chest X-ray, and pulmonary artery catheter readings.

PULMONIC STENOSIS

Pulmonic stenosis is a hardening or narrowing of the opening between the pulmonary artery and right ventricle. A congenital defect, pulmonic stenosis is associated with other congenital heart defects such as tetralogy of Fallot. It's rare among elderly patients.

IDENTIFYING THE MURMUR OF PULMONIC STENOSIS

A medium-pitched, harsh crescendo-decrescendo murmur in the area of the pulmonic valve characterizes pulmonic stenosis.

c7-tt6

Pathophysiology

In patients with pulmonic stenosis, obstructed right ventricular outflow causes right ventricular hypertrophy as the right ventricle attempts to overcome resistance to the narrow valvular opening.

Pulmonic stenosis results from congenital stenosis of the pulmonic valve cusp or, infrequently, from rheumatic heart disease or cancer.

Complications

·

Right-sided heart failure resulting from untreated pulmonic stenosis

Assessment findings

·

Depending on the severity of the obstruction, the patient with mild stenosis may be asymptomatic.

·

A patient with moderate to severe stenosis may complain of exertional dyspnea, fatigue, chest pain, and syncope. Accompanying peripheral edema may cause him discomfort.

·

Inspection may reveal a prominent a wave in the jugular venous pulse.

·

If severe stenosis has progressed to right-sided heart failure, the patient may appear jaundiced with severe peripheral edema and ascites. He may also appear malnourished.

·

, a thrill at the upper left sternal border, a harsh systolic ejection murmur, and a holosystolic decrescendo murmur of tricuspid insufficiency, particularly if the patient has heart failure. (See Identifying the murmur of pulmonic stenosis.)

 

·

Palpation may detect hepatomegaly if the patient has right-sided heart failure, presystolic pulsations of the liver, and a right parasternal lift.

DISCHARGE TEACHING

ff3-b01382759TEACHING THE PATIENT WITH PULMONIC STENOSIS

·

Teach the patient about diet restrictions, drugs, signs and symptoms that should be reported, and the importance of consistent follow-up care.

·

Teach the patient to elevate his legs when sitting.

Diagnostic test results

·

Chest X-rays usually show normal heart size and lung vascularity, although the pulmonary arteries may be evident. With severe obstruction and right-sided heart failure, the right atrium and ventricle typically appear enlarged.

·

Echocardiography can be used to visualize the pulmonic valve abnormality.

·

Electrocardiography results may be normal in mild cases, or they may show right-axis deviation and right ventricular hypertrophy. High-amplitude P waves in leads II and VI indicate right atrial enlargement.

Treatment

A low-sodium diet and a diuretic help reduce hepatic congestion before surgery. Also, cardiac catheter balloon valvuloplasty is usually effective, even with moderate to severe obstruction.

·

Alternate periods of activity with periods of rest to prevent extreme fatigue and dyspnea.

·

Keep the patient's legs elevated while he sits in a chair to improve venous return to the heart.

·

Elevate the head of the bed to improve ventilation.

·

Keep the patient on a low-sodium diet. Consult with a dietitian to ensure that the patient receives foods that he likes while adhering to diet restrictions. (See Teaching the patient with pulmonic stenosis.)

·

Monitor the patient for signs of heart failure, pulmonary edema, and adverse reactions to drug therapy.

 

·

To reduce anxiety, allow the patient to express his concerns about the effects of activity restrictions on his responsibilities and routines. Reassure him that the restrictions are temporary.

·

After cardiac catheterization, apply firm pressure to the catheter insertion site, usually in the groin. Monitor the site for signs of bleeding every 15 minutes for at least 6 hours. If the site bleeds, remove the pressure dressing and manually apply firm pressure to the site.

·

Notify the practitioner of changes in peripheral pulses distal to the insertion site, changes in cardiac rhythm and vital signs, and complaints of chest pain.

TRICUSPID INSUFFICIENCY

Tricuspid insufficiency occurs when the tricuspid valve doesn't close completely, allowing blood to flow back into the right atrium.

Pathophysiology

In patients with tricuspid insufficiency (also known as tricuspid regurgitation), an incompetent tricuspid valve allows blood to flow back into the right atrium during systole, decreasing blood flow to the lungs and left side of the heart. Cardiac output also decreases.

Tricuspid insufficiency results from marked dilation of the right ventricle and tricuspid valve ring. It most commonly occurs in the late stages of heart failure because of rheumatic or congenital heart disease.

Less commonly, it results from congenitally deformed tricuspid valves, atrioventricular canal defects, or Ebstein's malformation of the tricuspid valve. Other causes include infarction of the right ventricular papillary muscles, tricuspid valve prolapse, carcinoid heart disease, endomyocardial fibrosis, infective endocarditis, and trauma.

Complications

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Right-sided heart failure possible if fluid overload in right side of heart

Assessment findings

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The patient may have a history of a disorder that can cause tricuspid insufficiency.

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The patient may complain of dyspnea, fatigue, weakness, and syncope.

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Peripheral edema may cause him discomfort.

 

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Inspection may reveal jugular vein distention with prominent v waves in a patient with normal sinus rhythm.

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A patient with severe tricuspid insufficiency that has progressed to right-sided heart failure may appear jaundiced, with severe peripheral edema and ascites.

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Auscultation may disclose a blowing holosystolic murmur at the lower left sternal border that increases with inspiration and decreases with expiration and Valsalva's maneuver. (See Identifying the murmur of tricuspid insufficiency.

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Palpation may reveal hepatomegaly when the patient has right-sided heart failure, systolic pulsations of the liver, and a positive hepatojugular reflex. You may also feel a prominent right ventricular pulsation along the left parasternal region.

IDENTIFYING THE MURMUR OF TRICUSPID INSUFFICIENCY

A high-pitched, blowing holosystolic murmur in the tricuspid area characterizes tricuspid insufficiency.

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Diagnostic test results

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x descent during early systole, but instead a prominent c-v wave with a rapid y

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Chest X-rays show right atrial and ventricular enlargement.

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Echocardiography reveals right ventricular dilation and prolapse or flailing of the tricuspid leaflets.

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Electrocardiography discloses right atrial hypertrophy, right or left ventricular hypertrophy, atrial fibrillation, and incomplete right bundle-branch block.

ff3-b01382759TEACHING THE PATIENT WITH TRICUSPID INSUFFICIENCY

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Teach the patient about diet restrictions, drugs, signs and symptoms that should be reported, and the importance of consistent follow-up care.

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Tell the patient to elevate his legs whenever he's sitting.

Treatment

A sodium-restricted diet and a diuretic help reduce hepatic congestion before surgery. When rheumatic fever has deformed the tricuspid valve, resulting in severe insufficiency, the patient usually needs open-heart surgery for tricuspid annuloplasty or tricuspid valve replacement.

Nursing interventions

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Alternate periods of activity with rest periods to prevent extreme fatigue and dyspnea.

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Keep the patient's legs elevated while he's sitting to improve venous return to the heart.

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Elevate the head of the bed to improve ventilation.

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Maintain a low-sodium diet. Consult with a dietitian to ensure that the patient receives foods that he likes while adhering to diet restrictions. (See Teaching the patient with tricuspid insufficiency.)

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Monitor the patient for signs of heart failure, pulmonary edema, and adverse reactions to drug therapy.

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To reduce anxiety, allow the patient to express his concerns about the effects of activity restrictions on his responsibilities and routines. Reassure him that the restrictions are temporary.

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If the patient has surgery, watch for hypotension, arrhythmias, and thrombus formation. Monitor his vital signs, arterial blood gas level, intake and output, daily weight, blood chemistry results, chest X-ray, and pulmonary artery catheter readings.

TRICUSPID STENOSIS

Tricuspid stenosis is a relatively uncommon disorder in which the tricuspid valve is hardened, resulting in increased blood in the right atrium.

IDENTIFYING THE MURMUR OF TRICUSPID STENOSIS

A low, rumbling crescendodecrescendo murmur in the tricuspid area characterizes tricuspid stenosis.

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Pathophysiology

In tricuspid stenosis, blood flow is obstructed from the right atrium to the right ventricle, causing the right atrium to dilate and hypertrophy. Eventually, this leads to right-sided heart failure and increases pressure in the vena cava.

Although tricuspid stenosis is usually caused by rheumatic fever, it may also be congenital.

Complications

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Right-sided heart failure possible with untreated tricuspid stenosis

Assessment findings

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Inspection may reveal jugular vein distention with giant a waves in a patient who has normal sinus rhythm.

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A patient with severe tricuspid stenosis that has progressed to right-sided heart failure may appear jaundiced, with severe peripheral edema and ascites; she may also appear malnourished.

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Auscultation may reveal a diastolic murmur at the lower left sternal border and over the xiphoid process. It's most prominent during presystole in sinus rhythm. The murmur increases with inspiration and decreases with expiration and during Valsalva's maneuver. (See Identifying the murmur of tricuspid stenosis.)

 

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Palpation may reveal hepatomegaly when the patient has right-sided heart failure.

Diagnostic test results

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Cardiac catheterization shows an increased pressure gradient across the valve, increased right atrial pressure, and decreased cardiac output.

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Chest X-rays demonstrate right atrial and superior vena cava enlargement.

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Echocardiography indicates a thick tricuspid valve and right atrial enlargement.

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Electrocardiography reveals right atrial hypertrophy, right or left ventricular hypertrophy, and atrial fibrillation. Tall, peaked P waves appear in lead II; prominent, upright P waves appear in lead V1.

Treatment

Treatment for tricuspid stenosis is based on the patient's symptoms. A sodium-restricted diet and a diuretic can help to reduce hepatic congestion before surgery.

A patient with moderate to severe stenosis probably requires open-heart surgery for valvulotomy or valve replacement.

ff1-b01382759AGE AWARE

Nursing interventions

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Alternate periods of activity and rest to prevent extreme fatigue and dyspnea.

·

When the patient sits in a chair, elevate her legs to improve venous return to the heart.

·

Elevate the head of the bed to improve ventilation.

·

Keep the patient on a low-sodium diet. Consult with a dietitian to ensure that the patient receives foods that she likes while adhering to diet restrictions. (See Teaching the patient with tricuspid stenosis, page 380.)

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Monitor the patient for signs of heart failure, pulmonary edema, and adverse reactions to drug therapy.

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Allow the patient to express her fears and concerns about the disorder, its impact on her life, and upcoming surgery. Reassure her as needed.

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If the patient has surgery, watch for hypotension, arrhythmias, and thrombus formation. Monitor her vital signs, arterial blood gas level,

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intake and output, daily weight, blood chemistry results, chest X-ray, and pulmonary artery catheter readings.

DISCHARGE TEACHING

ff3-b01382759TEACHING THE PATIENT WITH TRICUSPID STENOSIS

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Teach the patient about diet restrictions, drugs, signs and symptoms that should be reported, and the importance of consistent follow-up care.

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Tell the patient to elevate her legs whenever she sits.