Cardiovascular Module:

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Adult Medical-Surgical Nursing

• Cardiovascular Module
• Cardiac Valvular Disorders

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Cardiac Valvular Disorders Description

• The cardiac valves are
  
• Aortic
• Pulmonary
• Mitral
• Tricuspid
• Disorders lead to poor blood flow through the
  heart, and may lead to ? cardiac output

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Cardiac Valvular Disorders Classification

• Stenosis
• Incompetence

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Cardiac Valve Stenosis

• Narrowing of the valve
• Increases demand on the myocardium to pump blood
  through the valve

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Cardiac Valve Incompetence

• Incompetence/ regurgitation
• A damaged valve which leaks and does not close
  properly
• Leads to
• Backflow of blood during systole and increased
  back pressure
• ? cardiac output

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Cardiac Valvular Disorder Aetiology

• Congenital
• Ageing wear and tear
• Rheumatic heart disease or bacterial
  endocarditis
• An auto-immune response following Rheumatic fever
  (less common now) or streptococcal throat
  infection
• ? endocarditis and chronic bacterial vegetation
  around valve/ valves

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Cardiac Valvular Disorder Diagnosis

• History and clinical findings
• Chest Xray
• ECG
• Echocardiography
• Cardiac catheterisation reveals degree of
  closure / incompetence

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Prevalent Conditions

• Mitral stenosis
• Mitral incompetence
• Aortic stenosis
• Aortic incompetence

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• Mitral Stenosis

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Mitral Stenosis Pathophysiology

• Narrowing of mitral valve
• This causes left atrium to force blood to left
  ventricle
• ? dilatation/ hypertrophy of left atrium
• Atrial fibrillation risk of thrombus/ emboli
• Backflow/ congestion in pulmonary circulation
  leads to
• Increased workload of right ventricle ?
• Right heart failure

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Mitral Stenosis Clinical Manifestations

• Fatigue/ dizziness (low cardiac output)
• Respiratory problems
• Dyspnoea, cough, frequent chest infections,
  haemoptysis
• Atrial fibrillation (dysrythmia) weak often
  irregular pulse (risk of emboli)
• Diastolic murmur on auscultation

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Mitral Stenosis Medical Management

• Treat congestive heart failure
• Diuretics, Digoxin, vasodilators (reduce
  afterload)
• Anti-dysrythmics
• Anticoagulants (longterm to prevent emboli)
• Antibiotics prior to dental or surgical
  procedures (to prevent endocarditis)

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Mitral Stenosis Surgery

• Valvotomy
• Valve replacement
• An animal or human valve
• An artificial valve (prosthesis)
• With an artificial valve long-term
  anticoagulants required (risk of thrombus)

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• Mitral Incompetence

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Mitral Incompetence Pathophysiology

• The mitral valve does not close and leaks
  causing
• Backflow of blood during systole from left
  ventricle to left atrium
• ? cardiac output is reduced
• ? increased pressure, dilatation and hypertrophy
  of left atrium
• Pulmonary congestion ?
• Right heart failure

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Mitral Incompetence Clinical Manifestations

• Maybe symptomless
• Fatigue and weakness
• Palpitations on exertion
• Dyspnoea and cough
• Systolic murmur at apex on auscultation

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Mitral Incompetence Surgery

• Surgical intervention is necessary as
  progressively cardiac output is reduced and
  pulmonary congestion increased
• Valvuloplasty (repair)
• Valve replacement
• Medical management of symptoms

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• Aortic Stenosis

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Aortic Stenosis Pathophysiology

• Narrowing of the aortic valve
• Causes increased filling and effort of the left
  ventricle (forcing blood through) ?
• Left ventricular hypertrophy
• Left ventricular failure (maybe acute pulmonary
  oedema)

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Aortic Stenosis Clinical Manifestations

• Faintness/ dizziness (low cardiac output)
• Angina
• O2 demand of hypertrophied left ventricle
• Slow forceful systole reduces diastole and
  filling time for coronary circulation
• Dyspnoea
• If LVF
• Copious blood-stained frothy sputum

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Aortic Stenosis Auscultation

• Loud systolic murmur over aortic area and
  vibration of turbulent blood felt by a hand over
  the apex

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Aortic Stenosis Management

• Medical
• Treat angina and symptoms of LVF
• Vasodilators, Digoxin, diuretics, anticoagulants
• Antibiotics prior to dental work or surgery to
  prevent endocarditis
• Surgery
• Valvotomy
• Valve replacement

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• Aortic Incompetence

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Aortic Incompetence Pathophysiology

• Aortic valve is damaged and leaking
• Blood regurgitates from aorta during diastole
  into left ventricle ? dilatation
• Left ventricle hypertrophies to force emptying
  into the aorta
• ? increased systolic BP
• Arterial vasodilatation to compensate
• (? peripheral resistance) ? diastolic BP
• (? pulse pressure) ? LVF

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Aortic Incompetence Clinical Manifestations

• Forceful heartbeat
• Dyspnoea on exertion and fatigue
• Paroxysmal nocturnal dyspnoea and orthopnoea (may
  lead to LVF)
• ? pulse pressure, water-hammer pulse (rapid
  strong pulse which then collapses)
• Diastolic murmur on auscultation

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Aortic Incompetence Management

• Medical management of LVF
• Antibiotic cover for dental or surgery to prevent
  endocarditis
• Surgery Aortic valve replacement
• (This is the preferred management)
• Anticoagulants long-term if artificial valve

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Nursing Responsibilities

• Physical examination
• ECG monitoring
• Weight, vital signs, fluid balance
• ICU nursing post-surgery
• Patient education on diet, degree of exercise and
  rest, medications
• Psychological/ emotional support