3 Valvulopatias

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23 Nursing Care of
Patients With Valvular,
Inflammatory, and
KEY TERMS Infectious Cardiac
or Venous Disorders
annuloplasty (AN-yoo-loh-PLAS-tee)
beta-hemolytic streptococci (BAY-tuh-HEE-moh-LIT-ick
STREP-toh-KOCK-eye)
cardiac tamponade (KAR-dee-yak TAM-pon-AYD)
cardiomegaly (KAR-dee-oh-MEG-ah-lee)
cardiomyopathy (KAR-dee-oh-my-AH-pah-thee) TERRI BLEVINS
chorea (core-REE-ah)
commissurotomy (KOM-ih-shur-AHT-oh-mee)
Dressler syndrome (DRESS-lers SIN-drohm) LEARNING OUTCOMES
emboli (EHM-boh-lye)
infective endocarditis (in-FEK-tive EN-doh-kar-DYE-tiss) 1. Explain the pathophysiology, etiology, signs and
insufficiency (IN-suh-FISH-en-see) symptoms, and diagnostic tests for each of the
international normalized ratio (IN-ter-NASH-uh-nul valvular disorders.
NOR-muh-lized RAY-she-oh)
murmur (MUR-mur) 2. Plan nursing care for a patient with a valvular disorder.
myectomy (my-EK-tuh-mee) 3. Compare and contrast the differences between commis-
myocarditis (MY-oh-kar-DYE-tiss) surotomy, annuloplasty, and valve replacement.
pericardial effusion (PEAR-ih-KAR-dee-uhl ee-FYOO-
zhun) 4. Identify postoperative complications that can occur for the
pericardial friction rub (PEAR-ih-KAR-dee-uhl FRICK- two types of cardiac valve replacements.
shun RUB)
5. Explain the pathophysiology, etiology, signs and symp-
pericardiectomy (PEAR-ih-kar-dee-EK-tuh-mee)
pericardiocentesis (PEAR-ih-KAR-dee-oh-sen-TEE-siss) toms, diagnostic tests, therapeutic measures, and nursing
pericarditis (PEAR-ih-kar-DYE-tiss) care for infective endocarditis, pericarditis, and
petechiae (peh-TEE-kee-eye) myocarditis.
regurgitation (ree-GUR-jih-TAY-shun)
rheumatic fever (roo-MAT-ick FEE-vur)
stenosis (steh-NOH-siss) toms, complications, diagnostic tests, therapeutic meas-
thrombophlebitis (THROM-boh-fleh-BYE-tiss) ures, and nursing care for dilated, hypertrophic, and
valvotomy (val-VAW-tuh-mee) restrictive cardiomyopathy.
valvuloplasty (VAL-vyoo-loh-PLASS-tee)
toms, complications, diagnostic tests, and therapeutic
measures for thrombophlebitis.
8. List risk factors and prevention measures for
thrombophlebitis.
9. Plan nursing care for thrombophlebitis.
432
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Chapter 23 Nursing Care for Valvular, Inflammatory, Infectious Cardiac or Venous Disorders 433
CARDIAC VALVULAR DISORDERS LEARNING TIP

Within the normal heart, blood flows in one direction because The opening of a stenosed valve and an insuffi-
of the presence of heart valves. There are four valves in the cient valve look very similar, and the results of
heart: mitral, tricuspid, pulmonic, and aortic (see Fig. 21.2). extra blood building up in a chamber are the same
The chordae tendineae and papillary muscles are attachment (see Fig. 23.1). However, the pathophysiology is
structures for both the mitral and tricuspid valves. They different. Think of what the defect is in each dis-
ensure that these valves close tightly. order to understand why the blood is building up
Damage to the valves or their surrounding structures can in that particular chamber.
result in abnormal valvular functioning (Fig. 23.1). The A stenosed valve does not open fully which
valves of the left side of the heart are most commonly does not allow the heart chamber to empty nor-
affected. Forward blood flow is hindered if the valve is mally causing blood to build up in that chamber.
narrowed, or stenosed, and does not open completely. If the Therefore, mitral stenosis does not allow the left
valve does not close completely, blood backs up; this is atrium to empty easily, so blood builds up in the
referred to as regurgitation or insufficiency. The abnormal left atrium.
blood flow increases the workload of the heart and increases An insufficient valve does not close fully, allow-
the pressures in the affected heart chamber. Valvular damage ing blood to flow back into the chamber that is
may result from congenital defects, rheumatic fever, or supposed to empty. Blood continues to build up
infections. in that chamber as a result. For example, mitral
Rheumatic fever occurs as an autoimmune reaction to an insufficiency allows blood to backflow from the
upper respiratory (sore throat) group A beta-hemolytic left ventricle into the left atrium after the left
streptococci infection. Two to 3 weeks after the streptococcal atrium has emptied, resulting in blood buildup in
infection, rheumatic fever occurs. Although rheumatic fever the left atrium.
can occur at any age, it typically occurs between ages 5
and 15. Rheumatic fever and subsequent rheumatic heart
disease and valvular damage can be prevented by detecting
and treating streptococcal infections promptly with penicillin. Mitral Valve Prolapse
A throat culture is used to diagnose a streptococcal infection Pathophysiology
at the time of the infection. It is a rare complication of strep During ventricular systole, as pressure in the left ventricle
throat in the United States. rises, the flaps of the mitral valve normally remain closed and
Signs and symptoms include polyarthritis, subcutaneous
nodules, chorea (brief, rapid, uncontrolled movements),
carditis, fever, arthralgia, and pneumonitis. Rheumatic heart • WORD • BUILDING •
disease may not be evident for years after rheumatic fever. regurgitation: re—again + gurgitare—to flood
Valvular disorders are summarized in Table 23.1 and insufficiency: in—not + sufficiens—sufficient
discussed in more detail in the following sections. stenosis: stenos—narrow
Fusion of cusps
Cusps preventing complete Cusps
opening and emptying
of heart chamber
Opening Opening Opening

of valve of valve of valve
Normal valve Stenosed valve Normal valve Insufficient valve

in open position in open position in closed position in closed position
allowing backflow
of blood through
the valve
FIGURE 23.1 Openings of stenosed and insufficient valves compared with a normal valve.
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434 UNIT FIVE Understanding the Cardiovascular System
TABLE 23.1 CARDIAC VALVULAR DISORDERS SUMMARY
Signs and Therapeutic Priority Nursing

Valve Disorder Symptoms Diagnostic Tests Complications Measures Diagnoses
Mitral valve None Echocardiography Emboli None Activity
prolapse Murmur Cardiac Infective Beta blockers Intolerance
Chest pain catheterization endocarditis Antidysrhythmics Decreased
Palpitations Valvuloplasty Cardiac Output
Dizziness Valve replacement
Syncope
Fatigue
Dyspnea
Mitral stenosis None ECG Emboli None Activity
Murmur Chest x-ray Heart failure PBV Intolerance
Chest pain Echocardiography Anticoagulants Valvuloplasty Decreased
Palpitations Doppler ultrasound Valve replacement Cardiac Output
Fatigue TEE
Exertional Cardiac
dyspnea catheterization
Cough
Hemoptysis
Mitral None ECG Emboli None Activity
regurgitation Murmur Chest x-ray Heart failure ACEI Intolerance
Chest pain Echocardiography Anticoagulants Decreased
Palpitations Doppler ultrasound Valvuloplasty Cardiac Output
Fatigue TEE Valve replacement
Exertional Cardiac MRI
dyspnea Cardiac
Cough catheterization
Hemoptysis
Acute:
Pulmonary
edema
Shock
Aortic stenosis None ECG Heart failure Valve replacement: Activity
Angina Chest x-ray surgical or Intolerance
Murmur Echocardiography transcatheter Decreased
Syncope Serial Cardiac Output
Heart echocardiogram
failure Cardiac
catheterization
Aortic None ECG Heart failure Valve replacement Activity
regurgitation Forceful Chest x-ray Digitalis (Lanoxin) Intolerance
pulse Echocardiography Diuretics Decreased
Murmur Cardiac Vasodilators Cardiac Output
Chest pain catheterization
Palpitations
Fatigue
Exertional
dyspnea
Corrigan’s
pulse
Diaphoresis
Note. ACEI = angiotensin-converting enzyme inhibitor; ECG = electrocardiogram; PBV = percutaneous balloon valvuloplasty; TEE = transesophageal
endoscopy.
4068_Ch23_432-461 18/11/14 4:42 PM Page 435
stay within the atrioventricular junction. In mitral valve pro- Therapeutic Measures
lapse (MVP), however, one or both flaps bulge backward into
Unless patients have severe mitral regurgitation, MVP is a
the left atrium (like a parachute) during systole. This can hap-
benign disorder. No treatment is needed unless symptoms are
pen when one flap is too large or if a defect occurs in the
present (Box 23-2). The severity of MVP and symptoms pro-
chordae tendineae that secure the valve to the heart wall. If
duced determine the treatment used. A healthy lifestyle, in-
the bulging flaps do not fit together, blood can leak backward
cluding a good diet, exercise, stress management, and
into the left atrium (mitral regurgitation). Increased pressure
avoidance of stimulants and caffeine, can be important to pre-
on the papillary muscles results in ischemia within the
vent symptoms. Beta blockers reduce the heart rate and may
muscle, causing further dysfunction of the mitral valve.
help relieve chest pain. Aspirin or anticoagulants may be or-
Etiology dered to help prevent formation of blood clots on the valve.
Surgical repair or replacement of the valve can be done for
MVP can be due to a hereditary collagen tissue disorder, with
severe cases of MVP. (See Box 23-2 and the surgical inter-
unknown etiology, an infection damaging the mitral valve,
ventions section later in the chapter.)
ischemic heart disease, or cardiomyopathy. MVP is the most
common form of valvular heart disease. It typically occurs in
women, mainly from ages 15 to 30, who are thin and have
slight chest deformities.
CRITICAL THINKING
Signs and Symptoms
Most patients with MVP do not have symptoms, and prognosis
Mrs. Tepley
is very good (see Table 23.1). MVP severity ranges from hav- ■ Mrs. Tepley, age 32, has MVP and reports palpitations
ing a murmur to chordae tendineae rupture with mitral regur- whenever she experiences stress. She drinks three cups
gitation. The murmur, which is best heard at the heart apex, of coffee daily.
begins midsystolic and becomes more intense until the end of
1. What might you hear when auscultating Mrs. Tepley’s
systole. Symptoms may include atypical chest pain not related
heart sounds?
to exertion, dysrhythmias causing palpitations, dizziness or
2. Why does Mrs. Tepley experience palpitations?
syncope, fatigue, dyspnea, or anxiety.
Would experiencing palpitations make you fearful?
Complications 3. What patient-centered information does Mrs. Tepley
need to manage her MVP?
Rare complications include mitral regurgitation, dysrhyth-
Suggested answers are at the end of the chapter.
mias, heart failure (HF), or infective endocarditis.
Diagnostic Tests
Auscultation for a click caused by the stress on the chordae
tendineae or valve leaflets when they prolapse, or a murmur
(if blood is leaking backward), is the first diagnostic step for Box 23-2 Therapeutic Measures
MVP. Other diagnostic tests are used when MVP is suspected
(Box 23-1). A normal electrocardiogram (ECG) is usually for Cardiac Valvular
seen with MVP, although inverted (downward) T waves Disorders
(indicating ischemia) may be seen (see Fig. 25.7). A two- • Rheumatic fever prophylaxis
dimensional echocardiogram with Doppler can show valve • Prophylactic antibiotic therapy per high-risk infective
abnormalities and identify mitral regurgitation from MVP. For endocarditis criteria
more severe cases, cardiac catheterization can show the • Anticoagulant therapy
bulging flaps of the mitral valve on a coronary angiogram. • Medication therapy
• Digitalis
• Diuretics
• Angiotensin-converting enzyme inhibitors
Box 23-1 Diagnostic Tests for • Beta blockers
Cardiac Valvular • Antidysrhythmics
• Percutaneous balloon valvuloplasty
Disorders • Surgery
• History and physical examination • Valvuloplasty
• Electrocardiogram • Closed commissurotomy
• Chest x-ray examination • Open commissurotomy
• Echocardiography • Annuloplasty
• Cardiac catheterization • Valve replacement
4068_Ch23_432-461 18/11/14 4:42 PM Page 436
Mitral Stenosis mitral valve opening and decreased motion of the valve.
Computed tomography (CT) scan and magnetic resonance
Pathophysiology
imaging (MRI) may be done. A cardiac catheterization is
Mitral stenosis results from thickening of the mitral valve typically done only if needed to validate unclear echocar-
flaps and shortening of the chordae tendineae, causing nar- diography results for preoperative evaluation or postproce-
rowing of the mitral valve opening. Older patients with mitral dure for symptom recurrence.
stenosis usually have calcification and fibrosis of the mitral
valve flaps. The narrowed opening obstructs blood flow from Therapeutic Measures
the left atrium into the left ventricle. The left atrium enlarges No treatment is needed if symptoms are not present. Moni-
to hold the extra blood volume caused by the obstruction. As toring of the stenosis is done to provide invasive treatment if
a result of this increased blood volume, pressure rises in the needed. Anticoagulants are given to patients at risk of devel-
left atrium. Pressures then rise in the pulmonary circulation opment of emboli from stasis of blood in the atrium. Atrial
and the right ventricle as blood volume backs up from the left fibrillation, an irregular heart rhythm, may develop and
atrium. The right ventricle dilates to handle the increased vol- require treatment. For HF, symptoms are treated with med-
ume. Eventually the right ventricle fails from this excessive ications (see Chapter 26).
workload, reducing the blood volume delivered to the left For less severe cases, percutaneous balloon valvuloplasty,
ventricle and subsequently decreasing cardiac output. which uses a balloon to dilate the stenosed heart valve, is done
Etiology in a cardiac catheterization lab (Fig. 23.2). Surgical treatment
can include valvular repair (valvuloplasty), but mitral valve
The major cause of mitral stenosis is rheumatic fever. It often
replacement is typically needed (Fig. 23.3; see Box 23-2).
takes two to four decades after the illness for symptoms to
appear. Because rheumatic fever is rare in developed nations, Mitral Regurgitation
less mitral stenosis is being seen except in older adults
who were exposed to rheumatic fever as children. Mitral Pathophysiology
stenosis is still a problem in underdeveloped areas where Mitral regurgitation, or insufficiency, is the incomplete clo-
rheumatic fever still occurs. Less common causes include sure of the mitral valve leaflets. It allows backflow of blood
congenital defects of the mitral valve, tumors, rheumatoid into the left atrium with each contraction of the left ventricle.
arthritis, systemic lupus erythematosus, and calcium deposits. This blood is then extra volume that is added to the incoming
blood from the lungs. With chronic mitral regurgitation, the
Signs and Symptoms increase in blood volume dilates and increases pressure in the
Patients may be asymptomatic (see Table 23.1). A click or left atrium. In response to the extra blood volume delivered
low-pitched murmur may be heard. This murmur is a rumbling by the left atrium, the left ventricle compensates by dilating.
sound over the heart apex during diastole and is more pro- If the compensatory mechanism of dilation is inadequate,
nounced right before systole. Pulmonary symptoms, such as pressures rise in the pulmonary circulation and then in the
exertional dyspnea, cough, hemoptysis (bloody sputum), and right ventricle as blood volume backs up from the left atrium.
respiratory infections can occur. Fatigue, intolerance to activ- The left ventricle and eventually the right ventricle may fail
ity, dizziness, or syncope result from decreased cardiac output. from this increased strain.
Edema of ankles and feet may be present. Palpitations from
atrial flutter or fibrillation caused by atrial enlargement and
chest pain from decreased cardiac output may be experienced.
Complications
Emboli can form from the stasis of blood in the left atrium
and may cause stroke and seizures. If the right ventricle fails,
symptoms related to HF are seen (see Chapter 26). Pulmonary
edema may develop from the backup of blood into the lungs.
Diagnostic Tests
Mitral stenosis is diagnosed with data from the patient his-
tory and physical examination and findings from diagnostic
tests (see Box 23-1). The ECG shows enlargement of the
left atrium and right ventricle and changes in the P wave-
form (see Fig. 25.2). Atrial flutter or fibrillation may be seen
(see Chapter 25). A chest x-ray examination confirms en-
largement of the affected heart chambers. Transthoracic
two-dimensional color flow Doppler echocardiography and
Doppler ultrasound are the noninvasive gold standard for
evaluation of valvular disease. They show the narrowed FIGURE 23.2 Percutaneous balloon valvuloplasty.
4068_Ch23_432-461 18/11/14 4:42 PM Page 437
and regurgitation of blood. Cardiac MRI may be used for

some people to determine treatment approaches. Cardiac
catheterization further identifies regurgitation effects.
Therapeutic Measures
Without symptoms, there is no general medical treatment.
Angiotensin-converting enzyme (ACE) inhibitors are often used
to reduce afterload. If atrial fibrillation with rapid heart rate is
present, it can be controlled with digitalis, calcium channel
blockers, or beta blockers. Anticoagulants are used for emboli
prevention. Symptoms of HF are treated with therapies for HF
(see Chapter 26). When symptoms develop or surgery is indi-
Mechanical cated to prevent further left ventricular dysfunction, mitral valve
mitral valve repair or replacement is done. For acute mitral regurgitation,
emergency surgery may be needed (see Box 23-2).
Aortic Stenosis
Pathophysiology
Blood flow from the left ventricle into the aorta is obstructed
through the stenosed aortic valve. The opening of the aortic
valve may be narrowed from thickening, scarring, calcifica-
FIGURE 23.3 Mitral valve replacement with mechanical valve. tion, or fusing of the valve’s flaps. To compensate for the
difficulty in ejecting blood into the aorta, the left ventricle
contracts more forcefully. In chronic stenosis, the left ventri-
Etiology cle hypertrophies to maintain normal cardiac output. As nar-
Causes of mitral regurgitation include rheumatic heart dis- rowing increases, the compensatory mechanisms are unable
ease, endocarditis, rupture or dysfunction of the chordae to continue and the left ventricle fails to move blood forward,
tendineae or papillary muscle, MVP, hypertension, myocar- resulting in decreased cardiac output and HF.
dial infarction (MI), cardiomyopathy, annulus calcification,
aging, or congenital defects. Etiology
The major causes of aortic stenosis are congenital defects
Signs and Symptoms or rheumatic heart disease. Calcification of the aortic valve
Initially, patients may be asymptomatic; however, symptoms can be related to aging and occurs after age 60. Aortic steno-
may develop gradually and are similar to those of mitral sis is the most commonly acquired valvular heart disease in
stenosis (see Table 23.1). A murmur begins with S1 (first heart adults. As the population ages, it is expected to increase in
sound) and continues during systole up to S2 (second heart prevalence.
sound). Exertional dyspnea (shortness of breath), fatigue,
syncope (feeling faint), cough, and edema may occur. Palpi- Signs and Symptoms
tations and an irregular pulse due to atrial fibrillation may Many years or decades may pass before signs or symptoms
result. Weakness from decreased cardiac output occurs if of aortic stenosis are observed (see Table 23.1). When symp-
the left ventricle begins to fail. If acute mitral regurgitation toms do occur, evaluation is essential because the disease can
develops, as in papillary muscle rupture following MI, progress dramatically. If the mitral valve is also diseased,
pulmonary edema and shock symptoms will be exhibited. signs and symptoms can appear earlier.
Angina pectoris (chest pain) is the primary symptom that
Complications occurs as a result of a lack of oxygen to the myocardium. In
Atrial fibrillation may develop from the enlargement of the left the young patient, angina indicates severe obstruction.
atrium. Pulmonary hypertension or heart failure may occur (see Other signs and symptoms include a murmur, syncope
Chapter 26). Endocarditis is a risk due to the damaged valve. from dysrhythmias or decreased cardiac output, and HF signs
and symptoms. The murmur is a systolic murmur that begins
Diagnostic Tests just after the first heart sound, increasing in intensity till
A patient history and physical examination are done. The midsystole, then decreasing and ending right before the
ECG shows enlargement of the left atrium and left ventricle second heart sound. Orthopnea, dyspnea on exertion, and
and changes in the P waveform (see Fig. 25.2). Atrial flutter fatigue are indicators of left ventricular failure, resulting in
or fibrillation may be seen. A chest x-ray examination pulmonary edema and right sided heart failure.
confirms hypertrophy of the affected heart chambers. Two-
dimensional echocardiography with Doppler or trans- Complications
esophageal echocardiography shows left atrial enlargement HF, life-threatening dysrhythmias, or endocarditis can occur.
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Diagnostic Tests Aortic Regurgitation

ECG usually shows enlargement of the left ventricle and Pathophysiology
left atrium. A chest x-ray examination confirms hypertro- The aortic valve cusps may be scarred, thickened, or short-
phy of the left ventricle and calcification of the aortic valve. ened in chronic aortic regurgitation. A backflow of blood
Left atrial enlargement may be seen but occurs primarily from the aorta into the left ventricle occurs if the aortic valve
when mitral stenosis is also present. Two-dimensional and cusps do not close completely. The left ventricle’s blood vol-
Doppler echocardiography show thickening of the left ven- ume increases with this backflow of blood that is in addition
tricular wall, impaired movement of the aortic valve, and to the normal flow of blood from the left atrium. To handle
the severity of the disease. Cardiac catheterization will the increased volume, the left ventricle compensates with di-
show elevated left ventricular pressure and decreased car- lation and hypertrophy to deliver a stronger contraction. This
diac output. stronger contraction ejects more blood volume with each beat
to maintain cardiac output. Over time, the heart’s contraction
Therapeutic Measures
is not effective, and the left ventricle fails, causing a cardiac
Generally, the treatment of choice is valve replacement be- output drop and pulmonary edema.
cause of the risk of sudden death when severe symptoms are
present (see Box 23-2). If mechanical valves are used, they Etiology
require lifelong anticoagulation. For older adults, biological
Congenital defects, aging, rheumatic heart disease, syphilis,
valves are usually used because they do not require antico-
severe hypertension, and ankylosing spondylitis can cause
agulation therapy and last about 12 years. For those consid-
aortic regurgitation. An acute cause of aortic regurgitation
ered too high risk for traditional open-heart surgery, an aortic
may be endocarditis or aortic dissection.
valve implantation can be done with a catheter via the femoral
artery (visit www.medtronic.com to view this procedure— Signs and Symptoms
Medtronic CoreValve® system). Valvotomy (expansion of a
balloon to open the mitral valve) is used only for those who Symptoms may not become apparent for many years with
are unable to have valve replacement. chronic aortic regurgitation (see Table 23.1). Initially,
Symptoms of HF are treated. Medications that reduce the the patient may report feeling a forceful heartbeat that is
contractility of the heart and subsequently cardiac output are more pronounced when lying down. Also, palpitations and
avoided to prevent further HF. pounding in the head may be experienced. Then exertional
dyspnea, fatigue, and worsening levels of dyspnea (orthop-
nea, paroxysmal nocturnal dyspnea) occur after years
of progressive valvular dysfunction. A murmur is heard
during diastolic after the second heart sound. The palpated
CRITICAL THINKING pulse is forceful and then quickly collapses (Corrigan’s
pulse). The diastolic blood pressure decreases to widen the
Mrs. Pryor pulse pressure. This compensates for an increase in systolic
blood pressure. Angina pectoris may occur late. The angina
■ Mrs. Pryor, age 48, has aortic stenosis and is admit-
is atypical, often happening at rest or at night along with
ted to the hospital with angina. She had an episode
diaphoresis, when a lower pulse rate results in delivery
of syncope 2 days ago. She reports that she tires
of less oxygen to the myocardium. Eventually symptoms
easily.
of HF develop if the left ventricle fails. In acute dysfunc-
1. Mrs. Pryor asks what aortic stenosis is. What tion, profound symptoms of pulmonary distress, chest pain,
should the nurse tell her, and how should it be and shock symptoms occur.
documented?
2. Why might Mrs. Pryor be experiencing angina? Complications
3. What nursing care related to safety needs is impor- Endocarditis is a risk due to the damaged valve. HF may occur.
tant to include in Mrs. Pryor’s plan of care? Think
of how you would feel knowing you will continue Diagnostic Tests
to have episodes of syncope and fatigue. What con- The ECG shows left ventricle hypertrophy, ST-segment
cerns would you have regarding completing your depression (see Fig. 25.10), and T-wave inversion (see Fig.
activities of daily living? 25.7) in some leads. A chest x-ray confirms hypertrophy of
4. What nursing diagnoses and care are relevant for the left ventricle and aorta. With severe regurgitation, left atrial
Mrs. Pryor’s report of being tired? enlargement may also be seen. An echocardiogram, Doppler
5. Digoxin (Lanoxin) 0.25 mg is prescribed for echocardiography, or transesophageal echocardiography show
Mrs. Pryor. Digoxin is available in 0.125-mg an enlarged left ventricle and severity of the aortic regurgita-
tablets. How many tablets will the nurse give? tion. Cardiac catheterization reveals elevated left ventricular
Suggested answers are at the end of the chapter. diastolic pressure and, with contrast injection, shows the
regurgitation of blood into the left ventricle.
4068_Ch23_432-461 18/11/14 4:42 PM Page 439
Therapeutic Measures of complications, and early recognition of symptoms so that

medical care can be sought. For older adult patients, it is impor-
Treatment with vasodilator therapy may be useful for some
tant to include caregivers or family members in teaching sessions
patients to reduce systolic blood pressure and subsequently
to assist with understanding of the information being taught.
cardiac workload until surgery is needed. Occasionally, sur-
Teaching is provided for medications the patient is taking. If the
gical valve repair can be done, but valve replacement is typ-
patient is on anticoagulants for atrial fibrillation or mechanical
ically needed when symptoms develop (see Box 23-2).
valve replacement, medical identification should be used, and
Nursing Process for the Patient With a monthly appointments to check international normalized ratio
Cardiac Valvular Disorder (INR)/prothrombin time (PT) values should be kept.
Data Collection Information on endocarditis prevention is essential for
patients with most valvular problems. Damaged cardiac
A history is obtained that includes information presented in
valves are prone to developing infection from organisms such
Table 23.2. Vital signs are measured and recorded. Heart
as Streptococcus viridans or Staphylococcus epidermidis.
sounds are auscultated to detect murmurs. Any signs and
During invasive procedures in which bleeding is possible,
symptoms of HF are noted and reported (see Chapter 26).
these organisms can enter the circulation, attach to damaged
Nursing Diagnoses, Planning, Interventions, and valves, and multiply. Patients should discuss with their health
Evaluation care provider (HCP) the American Heart Association guide-
The major nursing diagnoses for all valvular disorders are the lines for prophylactic antibiotics to prevent endocarditis (see
same and include those for HF as well, if symptoms of HF the prevention section for endocarditis later in this chapter).
are present. See “Nursing Care Plan for the Patient With a
Cardiac Valvular Disorder.”
Cardiac Valve Repairs
A balloon valvotomy opens a stenosed heart valve. A balloon
Patient Education catheter is inserted through the diseased valve and then inflated
Education, an important nursing intervention, promotes under- to open the stenosed valve leaflets. For mitral valve valvoplasty,
standing of the valvular disorder, health maintenance, prevention the balloon catheter is inserted via the venous circulation into
TABLE 23.2 DATA COLLECTION FOR PATIENTS WITH CARDIAC

VALVULAR DISORDERS
Data Collection Subjective Data
Health History Infections (rheumatic fever, endocarditis, streptococcal or staphylococcal, syphilis)?

Congenital defects? Cardiac disease (myocardial infarction, cardiomyopathy)?
Respiratory Dyspnea at rest, on exertion, when lying, or that awakens patient?
Cough or hemoptysis?
Cardiovascular Chest pain—when does it occur?
Palpitations, dizziness, fatigue, activity intolerance?
Medications What medications are you taking?
Knowledge of Condition What is the reason that you are here today?
What does your diagnosis mean to you?
Coping Skills How does patient normally cope with stressors?
Support system?
Adaptations in lifestyle and/or environment?
Objective Data
Respiratory Crackles, wheezes, tachypnea

Cardiovascular Murmurs, extra heart sounds, dysrhythmias, edema, jugular venous distention,
Corrigan’s pulse, increased or decreased pulse pressure
Integumentary Clubbing; cyanosis; diaphoresis; cold, clammy skin; pallor
Diagnostic Test Findings Review ordered test results.
4068_Ch23_432-461 18/11/14 4:42 PM Page 440
the right atrium. Then the catheter is threaded through a small A commissurotomy repairs a stenosed valve. The valve
hole pierced into the right atrial septum that emerges into the flaps that have adhered to each other and thus closed the
left atrium. The catheter is passed through the mitral valve, and opening between them, known as the commissure, are sep-
the inflation of the balloon within the mitral valve opens the arated to enlarge the valve opening. The patient is placed
stenosed valve flaps. Complications may include dysrhyth- on cardiopulmonary bypass (CPB; see Chapter 21), and an
mias, emboli, hemorrhage, and cardiac tamponade. A balloon
valvuloplasty results in fewer complications than traditional • WORD • BUILDING •
open-heart surgery. commissurotomy: commissura—joining together + tome—incision
NURSING CARE PLAN for the Patient with a Cardiac Valvular Disorder
Nursing Diagnosis: Decreased Cardiac Output related to valvular stenosis or insufficiency or heart failure
Expected Outcome: The patient will have adequate cardiac output as evidenced by vital signs within normal lim-
its (WNL), no dyspnea, and minimal fatigue.
Evaluation of Outcome: Are patient’s vital signs WNL with no dyspnea or fatigue?
Intervention Assess vital signs, oxygen saturation, chest pain, and fatigue. Rationale Vital signs, chest pain,
and fatigue are indicators of cardiac output decline. Evaluation Are vital signs WNL with no chest pain?
Intervention Give oxygen as ordered. Rationale Supplemental oxygen provides more oxygen to the heart by
increasing the oxygen saturation in the blood. Evaluation Is oxygen saturation WNL?
Intervention Provide bedrest or rest periods as ordered. Rationale Cardiac workload and oxygen needs are
reduced with rest. Evaluation Are vital signs WNL and no fatigue reported?
Intervention Elevate head of bed 45 degrees. Rationale Venous return to heart is reduced and chest expansion
improved, which increases the amount of oxygen coming into the lungs. Evaluation Are vital signs WNL
without use of accessory muscles of respiration?
GERIATRIC
Intervention Note cardiac medication side effects and teach patient side effects to report. Rationale Toxic side
effects are more common owing to altered metabolism and excretion of medications in the older adult.
Evaluation Are side effects present for medications patient is taking? Does patient understand side effects to report?
Nursing Diagnosis: Activity Intolerance related to decreased oxygen delivery from decreased cardiac output
Expected Outcome: The patient will show normal changes in vital signs with less fatigue in response to activity.
Evaluation of Outcome: Does patient have normal changes in vital signs with activity? Does patient report
decreased fatigue with activity?
Intervention Assist as needed with activities of daily living (ADLs). Rationale Conserve energy with ADL
assistance. Evaluation Are all ADLs completed? Are vital signs WNL with activity?
Intervention Provide rest between activities. Rationale Cardiac workload and oxygen needs are reduced with
rest. Evaluation Is patient able to perform activities when allowed extra time?
GERIATRIC
Intervention Slow pace of care and allow patient extra time to perform activities. Rationale Patients can often
perform activities if allowed time to slowly perform them and rest at intervals. Evaluation Does blood pressure
remain WNL when changing position?
Intervention Ensure safety when mobilizing older patient. Rationale Orthostatic hypertension is common in the
older adult. Evaluation Does patient ambulate without injury?
4068_Ch23_432-461 18/11/14 4:42 PM Page 441
atriotomy (incision into the atrium) is made to expose the

valve. The valve cusps are either incised with a knife or
broken apart with a dilator. The atrium is sewn closed,
CPB is discontinued, and surgery continues as described in
Chapter 21. Commissurotomy is most commonly performed
on the mitral valve.
Annuloplasty is the repair or reconstruction of the valve
flaps or annulus. It may involve the use of prosthetic rings.
The mitral valve is the most common valve repaired in this
way. Sutures or a ring may be placed in the valve annulus to
improve closure of the leaflets. Similar procedures are used
on the tricuspid valve; however, the aortic valve is not readily
repaired in this manner.
Heart Valve Replacement
Valves used for cardiac valve replacement may be either
mechanical or biological. Research is ongoing to develop
tissue engineered heart valves. Biological (tissue) valves
come from xenograft (porcine [pig] and bovine [cow]) or
allograft (human donor) (see “Cultural Considerations”).
Allografts are available in limited numbers because they rely FIGURE 23.4 Mechanical valve prosthesis. An SJM Masters
on donors. An autograft (Ross procedure) uses the patient’s Series valve. Courtesy of St. Jude Medical, Inc., St. Paul, MN.
own pulmonary valve to replace the removed aortic valve; an
allograft (human donor) pulmonary valve then replaces the growths can make valves incompetent or break off to be-
patient’s pulmonary valve. Visit www.lifenet.org for more come emboli.
information on allografts.
For mitral valve replacement, a left atriotomy is made Nursing Process for the Preoperative Cardiac
after the patient is on CPB. For an aortic valve replacement, Surgery Patient
an incision is made above the right coronary artery in DATA COLLECTION. Baseline data collection is important for
the aorta. Then in either valvular procedure, the diseased postoperative comparison and to begin discharge planning.
valve is excised and the new valve sutured in place. The in- Pain control needs and circulatory status are essential items.
cision is closed, and surgery then continues as described Results of diagnostic laboratory tests, x-ray examinations,
in Chapter 21. and other studies are also significant. Typing and crossmatch-
Complications of Valve Replacement ing for ordered units of blood is done.
Tissue valves have a low incidence of thrombus formation NURSING DIAGNOSES, PLANNING, INTERVENTIONS, AND
and do not require lifelong anticoagulant therapy, but they EVALUATION. See the “Nursing Process for Preoperative
do not last as long as mechanical valves because of de- Patients” in Chapter 12.
generative changes and calcification. Mechanical valves Nursing Process for the Postoperative Cardiac
are durable (lasting 20–30 years) but create turbulent Surgery Patient
blood flow, requiring lifelong anticoagulant therapy to
After cardiac surgery, the patient goes to an intensive care
prevent blood clots (Fig. 23.4). Anemia from hemolysis
unit (ICU) or cardiac universal bed unit (CUB). In the ICU,
of red blood cells (RBCs) as they come in contact with
mechanical valve structures can occur. Also endocarditis
can occur due to micro-organisms growing on the valve • WORD • BUILDING •
leaflets or the sewing ring of mechanical valves. These annuloplasty: annulus—ring + plasty—formed
Cultural Considerations
Cardiac Valves
Because the pig is considered a forbidden animal to religious Jews and Muslims, only bovine, synthetic, or human
valves should be used for these patients. Because the cow is sacred among Hindus, only porcine, synthetic, or human
valves should be used for Hindu patients.
4068_Ch23_432-461 18/11/14 4:42 PM Page 442
the patient is monitored for 1 to 2 days. As recovery pro- electrolytes, coagulation studies, and arterial blood gases
gresses, the patient is transferred to a step-down or general (ABGs) are monitored.
surgical unit for continued cardiac monitoring. In the CUB After the initial transfer assessment, vital signs, oxygen
unit, the patient recovers in the same room until discharge, saturation, and cardiac pressures are monitored and recorded
which avoids transfers to other units and increases continu- every 15 to 30 minutes, with decreasing frequency as the pa-
ity of care. tient stabilizes. Input and output (I&O) is measured. A 12-
lead ECG is done to detect perioperative MI. A chest x-ray
DATA COLLECTION. The patient is accompanied to ICU/CUB
examination is done to check central line and endotracheal
by the anesthesiologist, who gives the nurse a report of the
tube placement and to detect a pneumothorax or hemothorax,
procedure, complications, and hemodynamic and ventilatory
diaphragm elevation, or mediastinal widening from bleeding.
management of the patient. The patient is connected to a car-
At this point, the family can see the patient.
diac monitor and mechanical ventilator for up to 24 hours.
Awakening with many questions, strange auditory and tac-
The patient is placed under a warming device, such as a
tile sensations, and the inability to speak are frightening and
forced air blanket, as needed.
frustrating to the patient. Give explanations regarding proce-
A head-to-toe assessment of the patient, including dress-
dures in simple terms. Keeping eye contact with the patient and
ings, tubes (chest and, nasogastric tube, urinary catheter)
using touch appropriately can be soothing to the patient. If lip
and intravenous (IV) lines, is performed. Of importance
reading is unsuccessful, use simple closed-ended questions,
are signs of awakening, shivering, pain, lung and heart
nonverbal gestures, communication boards, or magic slates.
sounds, and palpation of the entire chest and neck to detect
After cardiac surgery, pain is monitored in relation to the
crepitus (air in the subcutaneous tissue from opening the
patient’s preoperative anginal or infarction-associated pain.
chest). Trends in cardiac output are monitored. Body tem-
Chest pain after surgery can be frightening. Knowing that
perature is continuously monitored if warming measures
chest pain can occur from the surgical incision rather than
are used. Warming is discontinued when the core body tem-
from anginal or MI pain is comforting to the patient.
perature nears 98.6°F (37°C). Warming should occur
slowly to avoid peripheral vasodilation, which can result NURSING DIAGNOSES, PLANNING, INTERVENTIONS, AND
in shock. While being rewarmed, patients are assessed EVALUATION. Nursing diagnoses for postoperative cardiac
for shivering, which may be felt as a fine vibration at the surgery are discussed in the “Nursing Care Plan for the
mandibular angle of the jaw. Shivering greatly increases Postoperative Patient Undergoing Cardiac Surgery.” Addi-
cardiac oxygen needs. Paralyzing agents given with nar- tional general postoperative nursing care is discussed in
cotics eliminate shivering. Complete blood count (CBC), Chapter 12.
NURSING CARE PLAN for the Postoperative Patient Undergoing

Cardiac Surgery
Nursing Diagnosis: Pain related to sternotomy or pericarditis
Expected Outcomes: The patient will state that pain is relieved or tolerable. Patient will be able to rest and
perform respiratory treatments.
Evaluation of Outcomes: Does patient state pain is within acceptable levels? Is patient able to rest and perform
respiratory therapies?
Intervention Ask about characteristics of pain with each episode. Rationale A thorough description is needed
to determine cause and plan actions. Evaluation Does patient describe pain on scale of 0 to 10?
Intervention Splint chest incision with all movement, including coughing and deep breathing.
Rationale Stabilizes sternum and incision to increase comfort. Evaluation Can patient splint chest
incision independently?
Intervention Encourage patient to report pain even when it is mild. Rationale It is easier to keep pain under
control when mild. Evaluation Does patient report pain when mild?
Intervention Turn, reposition every 2 hours. Rationale Changes muscle position, relieving stiffness.
Evaluation Is patient comfortable without stiffness?
4068_Ch23_432-461 18/11/14 4:42 PM Page 443

Cardiac Surgery
Intervention Offer back rubs frequently. Rationale Relaxes tense muscles retracted during operation.
Evaluation Is patient able to rest comfortably?
Intervention Instruct patient to take a deep breath before movement and exhale slowly during movement.
Rationale Keeps muscles relaxed, minimizing tension with guarding and pain. Evaluation Can patient perform
coughing and deep-breathing techniques as instructed?
Nursing Diagnosis: Decreased Cardiac Output related to myocardial depression, hypothermia, bleeding, unsta-
ble dysrhythmias, or hypoxemia
Expected Outcomes: The patient will remain free of major side effects of pharmacological support. The patient will
maintain vital signs WNL, palpable peripheral pulses, urine output greater than 30 mL/hr, and normal sinus rhythm.
Evaluation of Outcomes: Is patient free of major side effects? Are vital signs WNL?
Intervention Monitor vital signs. Rationale Trends reflect problems. Evaluation Are vital signs WNL?
Intervention Monitor peripheral circulation. Rationale Mottling or weak pulses may indicate poor cardiac out-
put (CO). Evaluation Do peripheral pulses remain strong with normal skin color, temperature, capillary refill?
Intervention Monitor intake and output. Rationale Fluid deficit or excess can alter CO. Evaluation Does total
intake equal output?
Intervention Listen to lung sounds and note character of sputum. Rationale Wet lung sounds may indicate HF
or pulmonary edema. Evaluation Are lungs clear?
Intervention Monitor temperature closely while rewarming the patient. Rationale Febrile state increases heart
rate and myocardial oxygen consumption. Evaluation Does temperature remain less than or equal
to 98.6°F (37°C)?
Intervention Monitor for shivering. Rationale Shivering increases the blood pressure, decreasing CO and
increasing risk for bleeding. Evaluation Is patient’s shivering controlled?
Intervention Monitor chest tube drainage for increase or sudden decrease. Rationale Drainage greater than
200 mL/hr may lead to hypovolemia and decreased CO. Evaluation Is patient free from cardiac tamponade and
hypovolemia?
Intervention Monitor ECG. Rationale Premature ventricular contractions and atrial fibrillation decrease CO.
Evaluation Does patient remain in normal sinus rhythm or controlled dysrhythmia?
Intervention Monitor electrolytes. Rationale Low calcium and magnesium and high potassium decrease
contractility and CO. Evaluation Are electrolytes WNL?
Intervention Monitor arterial blood gases (ABGs). Rationale Acidosis decreases heart function, and a low CO
may lead to further acidosis. Evaluation Are ABGs WNL?
Nursing Diagnosis: Risk for Infection related to inadequate primary defenses from surgical wound
Expected Outcome: The patient will remain free from infection.
Evaluation of Outcome: Does patient remain free from infection?
Continued
4068_Ch23_432-461 18/11/14 4:42 PM Page 444

Cardiac Surgery—cont’d
Intervention Practice excellent hand hygiene, and always cleanse stethoscope with ethanol-based cleanser or
alcohol between patients. Rationale Hands and stethoscopes carry infectious agents. Evaluation Are infectious
preventive techniques used? Does patient remain free from infection?
Intervention Observe incision for signs and symptoms of infection, which are redness, warmth, fever, and/or
edema. Rationale Redness, warmth, fever, and swelling indicate the body’s response to an invading pathogen.
Evaluation Are signs and symptoms of infection present?
Intervention Monitor drainage and maintain drains. Rationale Drains remove fluid from the surgical site to
prevent infection development. Evaluation Are drainage amount and color normal for procedure? Are drains
functioning?
Intervention Maintain sterile technique for dressing changes. Rationale Sterile technique reduces infection
development. Evaluation Is incision free of signs and symptoms of infection?
Intervention Monitor and report abnormal findings for temperature, lung sounds, sputum, and urine
consistency. Rationale Low-grade (immunosuppressed) or high-grade fever, crackles, yellow-green sputum
color, or cloudy urine can indicate infection. Evaluation Is the patient’s temperature WNL, and are lung sounds,
sputum, and urine clear?
INFLAMMATORY AND INFECTIOUS infected, leading to endocarditis, pericarditis, and my-

CARDIAC DISORDERS ocarditis, respectively.
Infective Endocarditis
The layers of the heart—the endocardium, pericardium,
and myocardium (Fig. 23.5)—can become inflamed or Infective endocarditis (IE) is an infection of the endo-
cardium that mostly occurs in hearts with artificial or dam-
aged valves. Men develop IE more often than women, as do
older adults compared with younger.
Pathophysiology
Cardiac defects result in turbulent blood flow that erodes
the normally infection-resistant endocardium. IE begins
when the invading organism (most commonly a bacteria
but possibly a fungi or other organism) attaches to eroded
endocardium where platelets and fibrin deposits have
formed a vegetative lesion. Then more platelets and fibrin
cover the multiplying organism. This covering protects the
microbes, reducing the ability to destroy them. Damage to
valve leaflets occurs as the vegetations grow. As blood
flows through the heart, these vegetations may break off
and become emboli.
Damaged valves from conditions such as MVP with re-
gurgitation, rheumatic heart disease, congenital defects, and
valve replacements are especially prone to bacterial invasion.
The mitral valve is the valve most commonly infected, with
the aortic valve being second. HF may result from valve dam-
age, especially of the aortic valve.
Etiology
Risk factors include the following:
• Compromised immune system
FIGURE 23.5 Layers of the heart. • Artificial heart valve
4068_Ch23_432-461 18/11/14 4:42 PM Page 445
• Congenital or valvular heart disease

• History of endocarditis TABLE 23.3 INFECTIVE ENDOCARDITIS
• IV drug use SUMMARY
• Gingival gum disease.
Signs and Fever
Prevention Symptoms Chills
Dental disease may be a contributing factor to IE, so daily Heart murmur
oral care and regular dental care is an important preventive Night sweats
measure. Antibiotic prophylaxis guidelines have been up- Fatigue
dated. Before a dental procedure, the American Heart Weight loss
Association (2014) now recommends that only individuals Weakness
with an artificial heart valve or a valve repaired with Aching in abdomen, joints,
artificial material, a history of endocarditis, a heart trans- muscles, back
plant with abnormal valve function, or specific congenital Nailbed splinter hemorrhages
heart defects receive antibiotics. Prophylaxis for proce- Petechiae
dures on the genitourinary or gastrointestinal (GI) tract or
Diagnostic Tests Blood cultures
for most people who have orthopedic implants is no longer
and Findings Transesophageal echocardiography
recommended.
CBC
Signs and Symptoms Chest x-ray
ECG
The onset of symptoms can be rapid or slow. Fever (99°–
103°F [37.2°–39.4°C]) is a common sign, although the older Therapeutic Acute therapy:
adult may be afebrile (Table 23.3). Chills, aching muscles Measures IV antimicrobial medications such
and joints, fatigue, dyspnea, cough, edema, and hematuria as penicillin, vancomycin,
may occur. A new or different murmur is heard with valvu- amphotericin B
lar damage. Splinter hemorrhages may be seen in the distal Antipyretics
nailbed (black or red-brown longitudinal short lines). Rest
Petechiae (tiny red or purple flat spots) resulting from Valve replacement
microembolization of the vegetation may occur on mucous Prophylactic antibiotic therapy per
membranes, conjunctivae, or skin (Fig. 23.6). Janeway le- high-risk infective endocarditis
sions (small, painless red-blue lesions on palms and soles) criteria
are an acute finding. Osler’s nodes (small, painful nodes on
Complications Emboli
fingers and toes) from cardiac emboli are a late finding
Heart failure
(Fig. 23.7). Have you ever seen petechiae or palpated an
Abscesses
Osler’s node? Look for the opportunity in clinical to see
petechiae, Janeway lesions, or an Osler’s node. Priority Nursing Activity Intolerance related to
Diagnoses reduced oxygen delivery from
Complications decreased cardiac output
Vegetative emboli can be a major complication of IE. If Decreased Cardiac Output related
organ embolization occurs, signs and symptoms that reflect to impaired valvular function or
the organ that was affected by the emboli are seen. Brain em- heart failure
boli may produce changes in level of consciousness or Ineffective Tissue Perfusion related
stroke. Kidney emboli cause pain in the flank area, hema- to emboli
turia, or renal failure. Emboli in the spleen cause abdominal
pain. Emboli in the small blood vessels can impair circula- Note. CBC = complete blood count; ECG = electrocardiogram.
tion in the extremities. Pulmonary emboli result in sudden
dyspnea, cough, and chest pain.
Heart structures can be damaged or destroyed by IE. Therapeutic Measures
Stenosis (narrowing) or regurgitation (leakage) of a heart
Initial treatment begins with hospitalization. An antimicro-
valve may also result. As the infection progresses and causes
bial drug is selected that will destroy the organism identi-
more damage to heart structures, HF may occur. Abscesses
fied by the blood culture. For bacterial infections, penicillin
may also develop in the heart or other parts of the body.
(or vancomycin for those allergic to penicillin) is com-
monly used. These medications are given IV over a period
Diagnostic Tests
Table 23.3 lists diagnostic tests for IE. Positive blood cultures
identify the causative organism, and echocardiography shows • WORD • BUILDING •
cardiac effects. petechiae: petecchia—skin spot
4068_Ch23_432-461 18/11/14 4:42 PM Page 446
Nursing Process for the Patient With Infectious

Endocarditis
DATA COLLECTION. A patient history is obtained that in-
cludes risk factors for IE and recent infections or invasive
procedures (Table 23.4). Vital signs are recorded, and heart
sounds are auscultated for murmurs. Signs of HF and emboli
are noted. Notify the HCP immediately if circulatory impair-
ment, such as cold skin, decreased capillary refill, cyanosis,
or absent peripheral pulses in an extremity, or symptoms of
organ-related emboli are detected.
NURSING DIAGNOSES, PLANNING, IMPLEMENTATION, AND
EVALUATION. See “Nursing Care Plan for the Patient With
Infective Endocarditis.” Teaching provides patients and
families with the ability to provide IV antibiotics at home
and promotes health maintenance to prevent future IE. Good
hygiene including dental care is essential. Skin care in-
FIGURE 23.6 Petechiae. From Goldsmith, L. (1997). Adult & cludes bathing, using proper hand-washing technique with
pediatric dermatology (p. 61). Philadelphia: F.A. Davis. soap, avoiding nail biting, not popping pimples or lancing
boils, and washing and applying antibiotic ointment to cuts.
Brushing with a soft-bristle toothbrush (to prevent gum
trauma) twice a day reduces the formation of plaque (which
traps bacteria). Biannual dental cleaning (with prophylactic
antibiotics as specified) is important. Recognition of symp-
toms (e.g., fever, chills, sweats), seeking prompt medical
care, and having blood cultures drawn before antibiotics are
started, along with the patient’s statement of understanding
and a willingness to follow lifestyle changes, support goal
achievement.
CRITICAL THINKING
Mrs. Jones
■ Mrs. Jones, age 28, is admitted to the hospital with a
fever of 100°F (37°C), chills, fatigue, anorexia, and pain
in her joints. A physical assessment reveals splinter hem-
orrhages in the left index finger nailbed and petechiae
on her chest. She is diagnosed with a heart murmur and
infective endocarditis.
FIGURE 23.7 Osler’s nodes. From Goldsmith, L. (1997). Adult
& pediatric dermatology (p. 188). Philadelphia: F.A. Davis. 1. Why is a heart murmur heard with endocarditis?
2. What do splinter hemorrhages look like?
3. What do petechiae indicate?
4. How would Mrs. Jones’s data collection findings be
of 4 to 6 weeks, often once a day. A lengthy course of high- documented?
dose antibiotics is needed to penetrate the vegetations 5. What type of medication would the nurse expect to
to reach all of the microbes inside to kill them. Rest be ordered to treat the infection?
and supportive symptom care are also used. If afebrile 6. Why does Mrs. Jones have chills if her temperature
and without complications, the patient is discharged to con- is elevated?
tinue IV antibiotic therapy at home. Response to the 7. What signs and symptoms might occur if the
drug is monitored by the home care nurse and laboratory complications of heart failure develop?
testing. 8. Tylenol 650 mg every 6 hours for pain is ordered. It
Surgical replacement or repair of valves is done for se- comes as 325-mg tablets. How many tablets would
verely damaged heart valves, prosthetic valve infection, re- be given per dose?
current infection, multiple emboli from damaged valves, or Suggested answers are at the end of the chapter.
HF. Antimicrobial therapy continues after surgery.
4068_Ch23_432-461 18/11/14 4:42 PM Page 447
TABLE 23.4 DATA COLLECTION FOR PATIENTS WITH INFECTIVE ENDOCARDITIS
Subjective Data
Health History Infections (rheumatic fever, scarlet fever, previous endocarditis, streptococcal or staphylococcal,
syphilis)?
Cardiac disease (valvular surgery, congenital)?
Childbirth?
Invasive procedures (surgery, dental, catheterization, IV therapy, cystoscopy, gynecological)?
Malaise?
Anorexia?
Medications Steroids, immunosuppressants, prolonged antibiotic therapy, IV drug use, alcohol use?
Respiratory Dyspnea on exertion or orthopnea (when lying down)?
Cough?
Cardiovascular Palpitations, chest pain, fatigue, or activity intolerance?
Musculoskeletal Weakness, arthralgia, myalgia?
Knowledge of Patient’s understanding
Condition
Objective Data
Body Temperature Fever, diaphoresis

Respiratory Crackles, tachypnea
Cardiovascular Murmurs, tachycardia, dysrhythmias, edema
Integumentary Nailbed splinter hemorrhages; petechiae on lips, mouth, conjunctivae, feet, or antecubital area;
paleness
Renal Hematuria
Diagnostic Test Positive blood cultures, anemia, elevated WBC count, elevated ESR, ECG showing conduction
Findings problems, echocardiogram showing valvular dysfunction and vegetations, chest x-ray exam
showing heart enlargement (cardiomegaly) and lung congestion
Note. ECG = electrocardiogram; ESR = erythrocyte sedimentation rate; IV = intravenous; WBC = white blood cell.
NURSING CARE PLAN for the Patient With Infective Endocarditis

Nursing Diagnosis: Decreased Cardiac Output related to impaired valvular function or heart failure as
manifested by activity intolerance
Expected Outcome: The patient will have adequate cardiac output as evidenced by vital signs WNL, no
dyspnea, and minimal fatigue in response to activity.
Evaluation of Outcome: Are patient’s vital signs WNL with no dyspnea and minimal fatigue? Can patient
participate in desired activities?
Intervention Assess vital signs, murmurs, dyspnea, and fatigue. Rationale Abnormal vital signs, dyspnea, and
fatigue are indicators of cardiac output decline. Evaluation Are vital signs WNL with no dyspnea or fatigue?
Intervention Give oxygen as ordered. Measure oxygen saturation. Rationale Supplemental oxygen will increase
oxygen level in the blood. Evaluation Is oxygen saturation WNL?
4068_Ch23_432-461 18/11/14 4:42 PM Page 448
NURSING CARE PLAN for the Patient With Infective Endocarditis

Intervention Provide bedrest or rest periods as ordered. Rationale Cardiac workload and oxygen needs are
reduced with rest. Evaluation Are vital signs WNL and no fatigue reported?
Intervention Elevate head of bed 45 degrees. Rationale Venous return to heart is reduced and chest expansion
improved. Evaluation Are vital signs WNL and respirations easy with no reported dyspnea or use of accessory
respiratory muscles?
Intervention Assist with activities of daily living (ADLs) as needed, providing rest periods. Rationale Assis-
tance conserves energy. Cardiac workload and oxygen needs are reduced with rest. Evaluation Are ADLs
completed? Does patient report less fatigue?
Nursing Diagnosis: Deficient Diversional Activity related to restricted mobility from prolonged IV therapy
Expected Outcome: The patient will state diversional activities are satisfying.
Evaluation of Outcome: Does patient participate in diversional activities? Does patient state satisfaction with
activities?
Intervention Assess patient’s preferred activities and hobbies. Rationale Activity preference should be known
to plan satisfactory diversional activities. Evaluation Are patient’s preferred activities known?
Intervention Plan patient’s schedule around relaxing and fun activities, using the patient’s input. Rationale Self-
esteem is fostered with increased patient control. Evaluation Does patient offer input into scheduled care? Is
input followed?
Intervention Use pet therapy. Rationale Individuals who interact with pets live longer and are healthier.
Evaluation Does patient state enjoyment of pet therapy?
Intervention Provide a mix of physical, mental, and social activities on a rotating schedule. Rationale Rotating
stimulating activities and visitors will keep patient interested and avoid fatigue. Evaluation Does patient state
satisfaction in activities with no fatigue?
Pericarditis There are several forms of chronic pericarditis. Chronic

constrictive pericarditis is the result of fibrous scarring of the
Pathophysiology and Etiology
pericardium. The heart becomes surrounded by a thickened,
Pericarditis is an acute or chronic inflammation of the peri- stiff sac that limits the stretching ability of the heart’s cham-
cardium (the sac surrounding the heart). The inflammation cre- bers for filling, which may result in HF. Chronic constrictive
ates a problem for the heart as it tries to expand and fill. As a pericarditis results from neoplastic disease and metastasis,
result, ventricular filling is reduced, which then decreases cardiac radiation, or tuberculosis.
output and blood pressure. Acute pericarditis usually resolves in
less than 6 weeks. Recurrence is possible. Acute pericarditis can Signs and Symptoms
be caused by a variety of factors, including the following:
Chest pain is the most common symptom of acute peri-
• Infections: viruses, bacteria, fungi, or Lyme disease carditis (Table 23.5). The pain is located substernally and
• Drug reactions over the heart and may radiate to the clavicle, neck, left
• Connective tissue disorders: systemic lupus erythemato- scapula, or epigastric area. Typically there is an intense,
sus, rheumatic fever, or rheumatoid arthritis sharp, creaky, grating pain that increases with deep inspi-
• Neoplastic disease ration, coughing, moving of the trunk, or lying flat. For
• Postpericardiotomy (e.g., after cardiac surgery) some the pain is not as intense and is instead a dull ache.
• Postmyocardial infarction The pain may be relieved by sitting up and leaning forward.
• Dressler syndrome (autoimmune response) Other symptoms depend on the cause of the pericarditis and
• Renal disease or uremia may include orthopnea, low-grade fever, fatigue, cough,
• Trauma from chest injury or invasive thoracic procedures and edema.
4068_Ch23_432-461 18/11/14 4:42 PM Page 449
Diagnostic Tests
TABLE 23.5 PERICARDITIS SUMMARY Table 23.5 lists diagnostic tests for pericarditis. The ECG
reveals ST-T wave elevation in all leads (see Fig. 25.11),
Signs and Chest pain which indicates cardiac injury. Echocardiogram results
Symptoms Dyspnea show pericardial effusions (buildup of fluid in pericardial
Low-grade fever space). Serum laboratory tests focus on causes of the peri-
Cough carditis, such as an elevated white blood cell (WBC) count,
Pericardial friction rub indicating a bacterial or viral infection, or elevated blood
Diagnostic Tests CBC urea nitrogen or creatinine levels, indicating uremia. Fluid
ECG obtained during pericardiocentesis (aspiration of fluid
Echocardiogram from pericardial sac) is examined to diagnose the cause. In
MRI chronic constrictive pericarditis, a CT scan or MRI may
CT show a thickened pericardium.
Therapeutic Anti-inflammatory medication Therapeutic Measures

Measures Corticosteroids Mild acute cases may resolve without treatment. The cause
Pericardiocentesis is determined so that appropriate treatment can be admin-
Pericardial window istered, such as antibiotics for bacterial infections. Bed rest
Complications Pericardial effusion is used to reduce the heart’s workload during acute symp-
Cardiac tamponade toms. Nonsteroidal anti-inflammatory drugs (NSAIDs)
or aspirin are given along with colchicine (Colsalide) to
Priority Nursing Acute Pain related to inflammation resolve inflammation and reduce pain. Corticosteroids are
Diagnoses of pericardium used if initial treatment is not effective. Hemodialysis
Anxiety related to disease process is used to treat uremic pericarditis. If the patient is unstable,
Decreased Cardiac Output related prompt intervention is required, such as an emergency
to cardiac constriction pericardiocentesis.
Chronic effusive pericarditis can be treated with a peri-
Note. CBC = complete blood count; CT = computed tomography; cardial window to allow continuous drainage of pericardial
ECG = electrocardiogram; MRI = magnetic resonance imaging.
fluid into the pleural space. A pericardial window is created
surgically by removing a portion of the outer pericardial
layer.
A pericardial friction rub—a grating, scratchy, high- Chronic constrictive pericarditis is treated with peri-
pitched sound—may be heard. The rub is a result of friction cardiectomy, which is the surgical removal of the entire
from the inflamed pericardial and epicardial layers rubbing tough, calcified pericardium. Pericardiectomy relieves con-
together as the heart fills and contracts. Depending on the striction of the heart and allows normal filling of the
severity of the pericarditis, the rub may be faint when aus- ventricles.
cultated or loud enough to be audible without auscultation.
The rub may be heard intermittently or continuously. It is Complications
usually heard over the lower left sternal border of the chest A pericardial effusion is the most common complication of
during each heartbeat. It is present in about 50% of those pericarditis. A rapidly developing effusion, such as one oc-
with pericarditis. curring from trauma, can produce symptoms with smaller
Chronic constrictive pericarditis produces dyspnea and amounts of fluid than slowly developing effusions, such as
signs and symptoms of right-sided HF and may also cause pericarditis from tuberculosis, with larger amounts of fluid.
atrial fibrillation. The increasing fluid presses on nearby tissue. Pressure on
lung tissue can produce dyspnea, cough, and tachypnea. The
heartbeat sounds distant. The body’s compensatory mecha-
nisms attempt to maintain blood pressure.
As the fluid accumulation grows, cardiac tamponade,
LEARNING TIP another complication of pericarditis, can occur. Cardiac
To simulate the sound of a pericardial friction tamponade is a life-threatening compression of the heart
rub, hold the diaphragm of a stethoscope
against the palm of one hand; listen through
the stethoscope as you rub the index finger
of the opposite hand over the knuckles of the • WORD • BUILDING •
hand holding the diaphragm. The sound you hear pericardiocentesis: peri—around + kardia—heart + centesis—
is similar to that of a pericardial friction rub. puncture
cardiac tamponade: kardia—heart + tamponade—plug
4068_Ch23_432-461 18/11/14 4:42 PM Page 450
by fluid accumulated in the pericardial sac. Cardiac output relieves pain. Teaching the patient about pericarditis and
drops and, to compensate, the heart rate increases. Then its treatment relieves anxiety and allows a feeling of control
blood pressure falls as compensatory mechanisms fail. The by allowing the patient to make knowledgeable health care
patient shows symptoms of decreased cardiac output, such decisions.
as restlessness, confusion, tachycardia, and tachypnea.
Jugular venous distention is present from increased venous Myocarditis
pressure, and heart sounds are distant. Pathophysiology and Etiology
Cardiac tamponade requires immediate treatment with peri- In myocarditis, inflammation of the myocardium occurs. The
cardiocentesis. The pericardium is punctured with a 16-gauge amount of muscle destruction and necrosis that occurs as a
needle, and excess fluid in the pericardial sac is removed result of myocarditis determines the extent of damage to the
(Fig. 23.8). After the procedure, the patient is monitored for heart. The heart may enlarge in response to the damaged mus-
complications, such as dysrhythmias, laceration of a coronary cle fibers, although most cases of myocarditis are benign,
artery, or laceration of the myocardium or pneumothorax. with few signs or symptoms.
Nursing Care Myocarditis is a rare condition that most commonly de-
velops after a viral infection. Other causes are bacteria, par-
A patient history is obtained that includes any cardiac disease, asites, fungi, rickettsiae, spirochetes, medications, lead
recent infections, and current medications. Vital signs are toxicity, autoimmune factors, human immunodeficiency virus
documented, noting fever, tachycardia, as well as chest pain, (HIV), rheumatic fever, systemic lupus erythematosus (SLE),
pericardial friction rub, and signs of HF. pericarditis or IE, or cardiac transplant rejection.
Nursing care focuses on relieving the patient’s pain and
anxiety and maintaining normal cardiac function. Pain is Signs and Symptoms
rated and treated as ordered. Allowing the patient to assume Signs and symptoms of myocarditis vary from none to
a position of comfort by sitting up and leaning forward also severe cardiac manifestations. Fatigue, fever, pharyngitis,
malaise, dyspnea, palpitations, muscle aches, GI discom-
fort, and enlarged lymph nodes may occur early from a viral
Heart monitor infection. Cardiac manifestations such as chest pain or
tachycardia may occur about 2 weeks after a viral infection.
Occasionally, sudden death may occur.
Diagnostic Tests
A myocardial biopsy during the first 6 weeks of inflamma-
tion is the preferred diagnostic test for myocarditis, al-
though it is positive only about 30% of the time.
Echocardiogram and MRI are helpful. An ECG shows dys-
rhythmias, commonly sinus tachycardia. Blood tests are
Pericardium
done, including CBC, viral antibodies, and enzyme levels
Attached to
Xyphoid that look for heart damage.
pressure Heart
monitor Therapeutic Measures
Treatment is aimed at the cause, if known, such as antibi-
Excessive otics for bacterial infections. Interventions to reduce the
fluid-filled
Three-way pericardial heart’s workload during recovery are essential and include
Syringe stopcock sac bed rest and limited activity. Exercise increases myocardial
inflammation and mortality and should be avoided until
symptoms improve and inflammation is gone. The use of
Heart after pericardiocentesis alcohol and tobacco should be avoided. Symptoms of HF
are treated with medications such as beta blockers, ACE in-
hibitors, diuretics, or digoxin to reduce the heart’s work-
load and oxygen needs. With myocarditis, the heart is
sensitive to digoxin. The patient should be monitored
closely for signs of digoxin toxicity, which may include
Heart
anorexia, nausea, vomiting, bradycardia, dysrhythmias, or
Pericardium malaise.
Pericardial sac
• WORD • BUILDING •
FIGURE 23.8 Pericardiocentesis. myocarditis: myo—muscle + kardia—heart + itis—inflammation
4068_Ch23_432-461 18/11/14 4:42 PM Page 451
Nursing Care Normal
Recent illnesses, toxin exposure, cardiac diseases, activity

tolerance, and current medications are documented. Vital Comparison to normal
signs and signs of heart failure, such as jugular venous dis- Note normal size of chambers
tention, peripheral edema, crackles, and dyspnea are noted. and thickness of ventricle walls
Nursing care is aimed at maintaining normal cardiac func- for comparison with cardiomyopic
heart changes.
tion by monitoring vital signs, symptoms, and administering
medications as ordered. Interventions to reduce fatigue in-
clude providing assistance as needed, having frequent rest pe- Dilated or (congestive)
riods, and teaching energy conservation methods. Reducing
the patient’s anxiety and increasing his or her knowledge can
be achieved by teaching about the disease. Determining di-
versional activities with the patient for times when activity is Chambers greatly enlarged
restricted further reduces patient anxiety.
Cardiac Trauma Ventricle walls are thinner
Two types of cardiac trauma can occur: nonpenetrating and Hypertrophic

penetrating. Nonpenetrating injuries, or contusions, occur from
blunt trauma such as motor vehicle accidents or contact sports
in which direct compression or force is applied to the upper
torso. Contusions may vary from small bruises to hemorrhage. Smaller filling areas
There may be few or no external injuries indicating
traumatic cardiac injury. The patient may be asymptomatic
or exhibit signs and symptoms identical to a MI. In severe Ventricle walls greatly
contusions, laboratory results may show elevated creatine thickened
kinase MB (CK-MB, an enzyme) or troponin I (a protein) Restrictive
levels.
If bleeding into the pericardial sac occurs, cardiac tam-
ponade can occur. If signs of shock are present, a pericardio-
centesis must be performed. With its own pressure, the
tamponade may seal the area of bleeding, so no cardiac de-
Muscle layers are stiff and
compensation occurs. In this case, only bed rest and obser- resist stretching for filling.
vation are required. There are no long-term effects with most
contusions. With severe contusions, however, scarring and
FIGURE 23.9 Comparison of the normal heart structure with
necrosis of the myocardium may decrease cardiac output and each type of cardiomyopic heart structure.
increase the risk for cardiac rupture.
Penetrating traumas include an external injury to the
chest, such as a stab or gunshot wound, or an internal injury, mutations that cause these diseases and are leading to better
such as invasive lines that penetrate the cardiac muscle. diagnosis and treatment.
Complications vary depending on the size, location, and Dilated Cardiomyopathy
cause of injury. Tamponade occurs from bleeding into the
pericardial sac if the pericardium is sealed off by clot for- In dilated cardiomyopathy, the size of the ventricular cavity
mation. A hemothorax develops if blood drains into the enlarges with reduced cardiac output. Contractile function
pleural space in the chest. A pneumothorax occurs if air col- decreases as the myocardial tissue is destroyed. Blood moves
lects in the pleural space. Signs and symptoms of hemor- more slowly from the left ventricle, which often results in
rhage and myocardial ischemia can be noted. Surgical repair blood clot formation. Dilated cardiomyopathy is the most
may be indicated. frequent type of cardiomyopathy and one of the most frequent
causes of HF. Dilated cardiomyopathy may be caused by
Cardiomyopathy genetics, infectious myocarditis, hypertension, heart valve
Cardiomyopathy is an enlargement of the heart muscle. disorders, myocardial infarction, chronic alcohol or cocaine
There are three types of cardiac structure and function ab- use, metals such as lead, elevated iron levels, HIV, thiamine
normalities in cardiomyopathy: dilated, hypertrophic, and or zinc deficiencies, cardiac infections, chemotherapy, neu-
restrictive (Fig. 23.9). A consequence of each type of car- romuscular disorders, or other causes.
diomyopathy can be HF (Fig. 23.10), myocardial ischemia,
or MI due to reduced cardiac output. There is currently no • WORD • BUILDING •
cure. The greatest advancement for the cardiomyopathies cardiomyopathy: kardia—heart + myo—muscle + pathy—
has been in genetic research, which has identified genetic disease
4068_Ch23_432-461 18/11/14 4:42 PM Page 452
Dilated
cardiomyopathy
TABLE 23.6 CARDIOMYOPATHY
SUMMARY
Signs and Angina

Hypertrophic Left ventricular Restrictive Symptoms Arrhythmias
cardiomyopathy function impaired cardiomyopathy
Dyspnea
Fatigue
Syncope
Blood stasis in
Diagnostic Tests Electrocardiogram
heart chambers Chest x-ray
Cardiac catheterization
Cardiac magnetic resonance
imaging
Echocardiography
Heart failure
Therapeutic Anticoagulants
FIGURE 23.10 Each type of cardiomyopathy can lead to heart
Measures Antidysrhythmics
failure.
Dilated cardiomyopathy: vasodila-
tors, cardiac glycosides, biven-
tricular pacing, ventricular assist
Hypertrophic Cardiomyopathy device, heart transplant
Hypertrophic cardiomyopathy is enlargement of the cardiac Hypertrophic cardiomyopathy: beta
muscle wall, often of the septum and left ventricle. The hy- blockers, calcium channel blockers,
pertrophy may occur asymmetrically. It can be a hereditary myectomy, septal ablation
disorder that is transmitted as a dominant trait. Hypertrophic Restrictive cardiomyopathy:
cardiomyopathy causes the ventricular wall to be rigid, which vasodilators, heart transplant
decreases ventricular filling. If an enlarged septum obstructs
Complications Heart failure
the outflow of blood through the aortic valve, it is known as
obstructive hypertrophic cardiomyopathy. Death can occur Priority Nursing Decreased Cardiac Output related
suddenly and is likely due to an abnormal heart rhythm. Diagnoses to impaired myocardial function
Activity Intolerance related to
Restrictive Cardiomyopathy cardiac insufficiency
Restrictive cardiomyopathy impairs ventricular stretch and Anxiety related to disease process
limits ventricular filling. Cardiac muscle stiffness is present
with no ventricular dilation, although systolic emptying of
the ventricle remains normal. Restrictive cardiomyopathy is
the rarest form of cardiomyopathy. It may be caused by infil- Diagnostic Tests
trative diseases such as amyloidosis that deposit the protein Cardiomegaly is visible on a chest x-ray examination.
amyloid within the myocardial cells, making the muscle stiff Echocardiography shows muscle thickness and chamber size
and resistant to stretching for easy ventricular filling. Treating to differentiate between the types of cardiomyopathy. Changes
the underlying cause may help reduce heart damage. related to enlarged chamber size, tachycardia, and dysrhyth-
Signs and Symptoms mias can be seen on the ECG. Cardiac catheterization and
biopsy may be useful as well as cardiovascular magnetic
Manifestations of cardiomyopathy depend on the type of ab- resonance. Blood tests may be done to identify infections or
normality. Most patients show varying degrees of signs and elevated metal or iron levels.
symptoms of heart failure (Table 23.6). With dilated car-
diomyopathy, left ventricular and then right-sided heart fail- Therapeutic Measures
ure with a poor prognosis are seen. Dyspnea on exertion, Treatment for both dilated and restrictive cardiomyopathies
orthopnea, fatigue, and sometimes atrial fibrillation occur. In is palliative, aimed at managing HF and the underlying
hypertrophic cardiomyopathy, exertional dyspnea related to cause, if known (see Chapter 26). For dilated cardiomyopa-
the obstruction of cardiac output is the most common symp- thy, treatment focuses on the symptoms of HF. ACE in-
tom. Angina is not common, but atypical chest pain that oc- hibitors, angiotensin II receptor blockers, beta blockers,
curs at rest and is not relieved with nitrates may occur. With
restrictive cardiomyopathy, heart failure symptoms result
from the ventricles’ inability to fill during diastole. Syncope, • WORD • BUILDING •
arrhythmias, and thrombi may occur. cardiomegaly: kardia—heart + mega—large
4068_Ch23_432-461 18/11/14 4:42 PM Page 453
diuretics, aldosterone antagonists, and digoxin may be Reducing anxiety is important and can be accomplished
given. Biventricular pacing and implantable defibrillators by providing education regarding procedures, as well as ed-
may be used. Therapy is not very useful for restrictive car- ucating the patient about the disease and its treatment. This
diomyopathy. Diuretics or nitrates may be used to relieve should provide patients with a greater sense of control and
venous congestion that occurs because of HF. However, a help them to make informed decisions. These patients and
fine balance is needed when using these drugs so that pre- their families have a great need for emotional support because
load is not reduced too greatly, which would worsen symp- of the chronic nature of the disease (see Box 23-3).
toms. Anticoagulants are given to prevent emboli formation
in patients with atrial fibrillation. Antidysrhythmics or car-
dioversion is used for dysrhythmias.
VENOUS DISORDERS
For obstructive hypertrophic cardiomyopathy, beta blockers
and calcium channel blockers are given to slow the heart rate
Thrombophlebitis
to allow more filling time and lessen the strength of the heart’s Thrombophlebitis is the formation of a clot, followed by in-
contraction. An antiarrhythmic agent might be used. Patients flammation within a vein. Thrombophlebitis is the most com-
must remain hydrated at all times to maintain cardiac output. mon disorder of veins, with the legs being most often
In obstructive hypertrophic cardiomyopathy, digoxin and affected. Any superficial or deep vein in the body can be in-
vasodilators are avoided because they can increase the ob- volved. Deep venous thrombosis (DVT) is the most serious
struction. Strenuous exercise and athletic sports are restricted form of thrombophlebitis because pulmonary emboli can
to prevent sudden death. Lower levels of exercise may be al- result if the thrombus detaches (see Chapter 28).
lowed. For patients in whom medical therapy is not effective,
Pathophysiology
atrioventricular (AV) sequential pacemakers, implantable au-
tomatic defibrillators, or invasive procedures are considered. A venous thrombus is made up of platelets, RBCs, WBCs,
For those without obstruction, fewer treatment options exist. and fibrin. Platelets attach to a vein wall, and then a tail forms
Diuretics are used to reduce elevated pressures along with as more blood cells and fibrin collect. As the tail grows, it
beta blockers and calcium channel blockers. drifts in the blood flowing past it. The turbulence of the blood
If medical therapy is not successful, surgery is considered. flow can cause parts of the drifting thrombus to break off and
For hypertrophied muscle, surgery to remove part of the ven- become emboli that travel to the lungs.
tricular septum (myectomy) is done to allow greater outflow
Etiology
of blood. Another option especially for those who are not can-
didates for surgery is septal ablation. In septal ablation, alco- Three factors, referred to collectively as Virchow’s triangle,
hol is delivered via a catheter to necrose and reduce septal are involved in the formation of a thrombus: stasis of blood
heart wall thickness. flow, damage to the lining of the vein wall, and increased
For severe HF, primarily in those with dilated cardiomy- blood coagulation (Table 23.7). Venous stasis occurs when
opathy, a heart transplant may be the only hope for survival. blood flow is reduced, veins are dilated, muscle contrac-
A ventricular assist device may be used until a donor is found. tions are decreased, or vein valves are faulty. When the wall
Many patients die while waiting for a donor heart because
donated organs are limited.
• WORD • BUILDING •
Nursing Care myectomy: myo—muscle + ectomy—cutting out

thrombophlebitis: thromb—lump (clot) + phleb—vein + itis—
A patient history is obtained that includes signs and symptoms inflammation
and data collection related to family support systems because
of the chronic nature of the disease. A physical assessment is
done, noting vital signs and any signs or symptoms of HF.
Nursing care focuses on maintaining normal cardiac func-
tion, increasing activity tolerance, relieving anxiety, and ed- Box 23-3 Patient Education
ucating the patient about the disease and its treatment.
Cardiomyopathy
Patients with cardiomyopathy can be very ill. Careful mon-
itoring is done to detect complications, such as HF, emboli, Patients and families should understand the importance
or dysrhythmias. The HCP is immediately notified of prob- of the following:
lems. Home health care is often used for these patients to • Adherence to medication regimen to prevent heart
maintain their functional ability and reduce hospitalizations. failure
Maintenance of normal cardiac function includes increasing • Having emergency telephone numbers readily available
activity tolerance, planning rest periods, scheduling activities • Cardiopulmonary resuscitation (CPR) training for
in small amounts, avoiding tiring activities, and providing family members
small meals that require less energy to digest than large meals. • The availability of hospice care and emotional
Patients are encouraged to avoid alcohol because it decreases support for families during the grieving process
cardiac function.
4068_Ch23_432-461 18/11/14 4:42 PM Page 454
TABLE 23.7 PREDISPOSING CONDITIONS FOR THROMBOPHLEBITIS (VIRCHOW’S

TRIANGLE)
Condition Type Example

Venous stasis Reduction of blood flow Shock, heart failure, myocardial infarction, atrial fibrillation
Dilated veins Vasodilators
Decreased muscle Immobility, sitting for long periods as in traveling, fractured hip,
contractions paralysis, anesthesia, surgery, obesity, advanced age
Faulty valves Varicose veins, venous insufficiency
Venous wall injury Venipuncture, venous cannulation at same site for >48 hours,
venous catheterization, surgery, trauma, burns, fractures, dislo-
cation, intravenous (IV) medications (potassium, chemotherapy
drugs, antibiotics, IV hypertonic solutions), contrast agents,
diabetes, cerebrovascular disease
Increased Anemia, malignancy, antithrombin III deficiency, oral
coagulation contraceptives, estrogen therapy, smoking, discontinuance of
of blood anticoagulant therapy, dehydration, malnutrition, polycythemia,
leukocytosis, thrombocytosis, sepsis, pregnancy
of a vein is damaged, it provides a site for a thrombus to breathing aids in improving blood flow in the large thoracic
form. IV therapy and venipuncture cause trauma to the veins. Smoking should be avoided because nicotine causes
vein, and IV catheters in place longer than 48 to 72 hours vasoconstriction.
increase the risk of inflammation and thrombus. Increased
coagulation of the blood promotes thrombus formation.
Patients on oral anticoagulants that are abruptly stopped
experience increased clotting of the blood. Smoking, oral EVIDENCE-BASED PRACTICE
contraceptive use, and estrogen therapy also increase Clinical Question
blood coagulation. Hematologic disorders can also lead to Are statins effective in preventing venous throm-
altered blood coagulation and increased risk of thrombus boembolism?
formation. Evidence
A large randomized controlled trial involving
Prevention 17,802 participants aged 50 years or older for
Identification of risk factors for thrombosis (see Table 23.7) men and 60 years or older for women, without a
and patient education promote the use of interventions (dis- history of cardiovascular disease, a low-density
cussed later) to prevent thrombosis (see “Evidence-Based lipoprotein (LDL) cholesterol level of less than
Practice”). Because older adults are at increased risk for 3.4 mmol/L and a high-sensitivity C-reactive
thrombus formation, a family member should also be in- protein level of 2.0 mg/L or more found that ro-
structed in techniques that may be difficult for the older suvastatin (Crestor), a statin, did reduce the
person to perform. Dehydration should be avoided to reduce incidence of venous thrombosis, especially in the
thrombus risk. presence of cancer, recent trauma, hospitaliza-
tion, or surgery. However, the drug did not reduce
IMMOBILITY. People with sedentary jobs that require long complications that occurred after diagnosis of
periods of sitting, standing, or traveling long distances venous thrombosis.
should change positions, perform knee and ankle flexion
Implications for Nursing Practice
exercises, or walk at regular intervals to prevent stasis
It has been shown that statins are effective in
of blood. Patients on bed rest should have legs elevated
reducing venous thromboembolism.
above the level of the heart, if possible, and turn every
2 hours to prevent pooling of blood. Postoperatively or in REFERENCE
times of bed rest, active or passive range-of-motion (ROM) Li, L., Sun, T., Zhang, P., Tian, J., Tian, J., & Yang, K. (2011).
exercises should be done to increase blood flow. Postoper- Statins for primary prevention of venous thromboem-
atively, early ambulation is a major preventive technique bolism. Cochrane Database of Systematic Reviews, 12,
for thrombosis. Patients’ pain should be controlled to facil- CD008203.
itate their ability to participate in early ambulation. Deep
4068_Ch23_432-461 18/11/14 4:42 PM Page 455
under the stockings as ordered. Intermittent pneumatic com-

BE SAFE! pression (IPC) devices fill intermittently with air to move ve-
nous blood in the legs by simulating contraction of the leg
For prevention of thrombophlebitis: muscles. They may be used in combination with elastic com-
• Teach and encourage leg exercises if pression stockings. Research that compares the various pre-
patient is immobilized in bed. ventive measures for DVT and rates of DVT in surgical patients
• Ambulate as early as possible. has shown that the lowest incidence of DVT occurs with elastic
• Change IV sites every 48 to 72 hours. compression stockings and IPC devices used together.
PROPHYLACTIC MEDICATION. Low molecular weight heparin

(LMWH) is given postoperatively to prevent thrombosis
PROPHYLACTIC ANTIEMBOLISM DEVICES. Patients with periph- (Table 23.8). Anticoagulation tests are not monitored with
eral vascular disease, those on bed rest, and those who have LMWH because of the predictability of its dose-related
had surgery or trauma may use antiembolism devices to im- response. Subcutaneous heparin may also be used postopera-
prove blood flow. Knee- or thigh-length elastic compression tively to prevent thrombosis. Platelet counts must be moni-
stockings apply pressure to the leg. They must be applied tored with either LMWH or heparin to detect heparin-induced
correctly to avoid a tourniquet effect. Older patients with de- thrombocytopenia.
creased manual dexterity may need assistance. The skin should Oral anticoagulants such as warfarin (Coumadin) can be
be inspected, cleansed, and moisturized daily for irritation used in the high-risk patient to decrease thrombosis. The
TABLE 23.8 ANTICOAGULANT MEDICATIONS
Medication Class/Action Examples Nursing Implications
Coumarin
Inhibits liver synthesis of vitamin K warfarin (Coumadin) Monitor INR/PT regularly.
dependent clotting factors: II, XII, Monitor for bleeding, and teach patient to report
IX, X. bleeding.
Acetaminophen (Tylenol) used instead of aspirin
during therapy.
Antidote: Vitamin K.
Heparins
Bind to antithrombin III, which then heparin sodium Do not give intramuscularly because of pain and
inhibits fibrin formation. hematoma.
Monitor heparin antifactor Xa or PTT: 1.5–
2 times control.
Monitor platelet count for decrease.
Monitor for bleeding, and teach patient to report
bleeding.
Antidote: Protamine sulfate.
Low Molecular Weight Heparins
(LMWHs)
Bind with antithrombin III, inhibiting dalteparin sodium Bleeding rare.
making of factor Xa and the (Fragmin) Contraindicated with renal failure due to
formation of thrombin. enoxaparin (Lovenox) increased bleeding risk. Teach patient to
fondaparinux (Arixtra) give injection subcutaneously (with prefilled
syringes, do not remove air bubble).
Thrombolytics
Promote fibrinolysis to break down rPA (Retavase, reteplase) Minimize blood draws for 24 hours. Monitor for
fibrin in blood clot. TNK (TNKase, tenecteplase) bleeding.
tissue plasminogen activa- Avoid acetylsalicylic acid, nonsteroidal anti-
tor (t-PA, alteplase) inflammatory drugs.
Note. INR = international normalized ratio; PT = prothrombin time; PTT = partial thromboplastin time.
4068_Ch23_432-461 18/11/14 4:42 PM Page 456
international normalized ratio (INR) measures the effec- Signs and Symptoms
tiveness of warfarin therapy using a standardized testing
There are two locations for thrombophlebitis: superficial
reagent. This means that INR can be used around the world
veins and deep veins. Up to 50% of patients have no symp-
with no variation in results as occurs with prothrombin time
toms with thrombophlebitis in the legs. For others, the symp-
(PT) from lab to lab. INR is reported along with the PT.
toms vary according to the size and location of the thrombus,
INR should be used; however, a discussion of how to in-
and for some the thrombus becomes an embolus (Table 23.9).
terpret the PT is presented in the following “Learning Tip”
If adequate collateral circulation is present near the involved
for your understanding.
area, symptoms are reduced.
IV THERAPY. Monitoring of IV sites should be performed ac- SUPERFICIAL VEINS. Thrombophlebitis in a superficial vein
cording to institutional policy time frames to detect signs of may produce redness, warmth, swelling, and tenderness in
thrombophlebitis. Venous cannula sites should be changed the area around the site of the thrombus. The vein feels like
regularly according to institutional guidelines (e.g., every a firm cord, which is referred to as induration. The saphenous
48–72 hours) to prevent thrombus formation. vein is the most commonly affected vein in the leg. Varicosity
of the vein is usually the cause. In the arm, IV therapy is the
most common cause.
LEARNING TIP DEEP VEINS. In a DVT in the leg (femoral vein), swelling,
edema, pain, warmth, venous distention, and tenderness with
Before administering anticoagulants, laboratory
palpation of the calf may be present in the affected leg. Ob-
values must be assessed to ensure patient safety.
struction of blood flow from the leg causes edema and varies
• Normal and desired therapeutic INR values with the location of the thrombus. An elevated temperature
for the patient’s disorder are provided on the
laboratory report. These INR values do not
require calculation of a therapeutic range be-
cause the values are given on the report. TABLE 23.9 THROMBOPHLEBITIS
• Compare the patient’s INR value with the SUMMARY
desired INR value to determine if it is safe
to give the warfarin. Signs and Superficial veins: redness, warmth,
• Although INR is the preferred test for war- Symptoms swelling, and tenderness
farin effectiveness, you might still want to Deep veins: swelling, edema, pain,
know how to calculate a therapeutic range warmth, venous distention, and
for PT. PT is measured in seconds. The nor- tenderness
mal value range gives the seconds required Diagnostic Venous duplex ultrasound
for a fibrin clot to form during the test. If Tests Magnetic resonance venography
a patient is on warfarin, the purpose is to
increase the time (seconds) it takes the Therapeutic Superficial veins: warm, moist heat;
blood to clot. Measures analgesics; NSAIDs; compression
• Because a therapy, warfarin, is being given, a stockings
PT range that safely considers the expected Deep veins: low molecular weight he-
effects of the warfarin is needed. This is parin; heparin; warfarin; bedrest
called the therapeutic range (i.e., a low and a with extremity elevation above the
high value). Warfarin’s therapeutic range is 1.5 level of the heart for 5–7 days;
to 2 times the normal PT range. To monitor warm, moist heat; compression
the patient’s therapeutic PT, compare the stocking therapy; thrombolytic ther-
patient’s result with the therapeutic range apy; thrombectomy; vena cava filter
that you calculate. For example: patient’s Complications Pulmonary embolism
value on warfarin: 16 seconds (sec) Chronic venous insufficiency
• Normal PT range: 9 to 12 seconds Varicose veins
To calculate therapeutic range, Recurrent deep venous thrombosis
multiply: 1.5 2
Priority Acute Pain related to inflammation
⫻ 9 sec ⫻ 12 sec
Nursing of vein
Therapeutic range: 13.5 sec to 24 sec Diagnoses Impaired Skin Integrity related to ve-
Compare the patient’s value of 16 seconds with nous stasis
the therapeutic range of 13.5 to 24 seconds to Anxiety related to uncertain prognosis
determine that the patient’s PT value is safely of disease
within the therapeutic range.
NSAID = nonsteroidal anti-inflammatory drugs.
4068_Ch23_432-461 18/11/14 4:42 PM Page 457
may also be present. Pain in the calf with sharp dorsiflexion An endovascular procedure using the Trellis™ peripheral in-
of the foot, a classic indication known as a positive Homans’ fusion system is used to remove new-onset proximal (high in
sign, is present in less than 50% of those with throm- leg) blood clots within 2 weeks of symptom onset. A catheter
bophlebitis and is not specific to DVT. Once a DVT is posi- with two balloons is inserted into the vein and through the clot.
tively diagnosed, it is important to avoid performing Homans’ The balloons are inflated. Then a thrombolytic medication is
sign because it may cause the clot to become dislodged. instilled into the clot through holes along the catheter between
Cyanosis and edema may occur if the large veins such as the the two balloons. The balloons prevent the medication from
vena cava are involved. being systemically absorbed and keep the clot material con-
tained as it dissolves. A motor oscillates (moves) the catheter
Complications to disperse the medication along the clot to help dissolve it. Any
The most serious complication of DVT is pulmonary em- clot material that remains is aspirated out of the vein through
bolism, which is a life-threatening emergency (see Chapter 28). the catheter. Patients usually go home in 24 hours and return to
Another complication, chronic venous insufficiency, results normal activity as ordered. To see this procedure, visit www
from damage to the valves in the vein and causes venous stasis. .bacchusvascular.com/products/trellis/animation.html. Early
Signs and symptoms from venous insufficiency that may removal of the clot with this combined mechanical and phar-
appear years after a thrombus include edema, pain, brownish macological approach improves quality of life and reduces post-
discoloration and ulceration of the medial ankle, venous dis- phlebitic syndrome (PPS), which occurs in up to 50% of DVT
tention, and dependent cyanosis of the leg. This condition can patients within 1 year. PPS occurs after a DVT from damage to
be difficult to treat. the vein valves and results in pain, swelling, and leg ulcers,
which reduce quality of life. Little can be done for PPS, and
treatment aims to prevent leg ulcers.
Diagnostic Tests Other approaches are surgical treatment to prevent pul-
Diagnostic tests are done to guide treatment, with venous du- monary emboli or chronic venous insufficiency when antico-
plex ultrasound being the primary test used (see Table 23.9). agulant therapy cannot be used or the risk of pulmonary
emboli is great. Venous thrombectomy removes the clot
Therapeutic Measures through a venous incision. In some cases, a vena cava filter
The goals of treatment are to relieve pain and to prevent pul- is placed into the vena cava through the femoral or right
monary emboli, thrombus enlargement, and further thrombus internal jugular vein (Fig. 23.11). Once in place, it is opened
development. Superficial thrombophlebitis is treated with and attaches to the vein wall. The filter traps clots traveling
warm, moist heat; analgesics; NSAIDs; and elastic compres- toward the lungs without hindering blood flow.
sion stockings.
Patients with a proximal DVT may be treated at home Nursing Process for the Patient
if they do not have pulmonary embolism, cardiovascular or With Thrombophlebitis
pulmonary disease, obesity, or renal failure and are able to DATA COLLECTION. A patient history is obtained that includes
adhere to follow-up care. LMWH is given subcutaneously questions regarding recent IV therapy or use of contrast
daily or twice a day, and oral warfarin is started (see Table
23.8). Both are taken until the INR is within therapeutic range
(about 5 days), then the LMWH is stopped.
Traditional medical care for some DVTs involves a hos-
pital stay with bed rest, elevating the leg above heart level for
5 to 7 days; warm, moist heat; elastic compression stocking
(initially on unaffected leg only until acute symptoms are
gone on affected leg); and anticoagulants. An initial IV bolus
of heparin and then a continuous heparin IV infusion is usu-
ally started and continued for up to 10 days to prevent further
enlargement of the thrombus and development of new
thrombi; it has no effect on the existing clot, which the body
dissolves over time. Daily heparin antifactor Xa or partial
thromboplastin times (PTTs) are monitored to maintain ther-
apeutic heparin levels. Warfarin is begun 4 to 5 days before
the heparin is stopped because it requires 3 to 5 days to reach
a therapeutic level. To monitor warfarin’s effects, INRs and
PTs are done daily, and adjustments in warfarin doses are
made based on the results. When the therapeutic INR goal is
reached, the heparin is stopped. Warfarin is continued for sev-
eral months, which necessitates regular monitoring of INR
levels to ensure the drug’s level is within therapeutic range. FIGURE 23.11 Vena cava filter placed in the inferior vena
For second DVT episodes, lifelong warfarin therapy is used. cava to prevent emboli from reaching the lungs.
4068_Ch23_432-461 18/11/14 4:42 PM Page 458
media, surgery, extremity trauma, childbirth, bed rest, recent

long trips, cardiac disease, recent infections, and current med-
ications that can put the patient at high risk of thrombus. Home Health Hints
Physical assessment is done noting pain, fever, tenderness,
positive Homans’ sign, redness, warmth, swelling, edema, • On admission, measure the patient’s midcalf area
and a firm, cordlike vein in the affected extremity. Daily so you have a baseline size. Reassess measure-
measurements are taken of bilateral thighs and calves and ments during each visit. Subtle changes in measure-
recorded to monitor swelling. Coagulation tests are moni- ment can indicate a potential problem.
tored. Signs of a pulmonary embolism, such as dyspnea, • Note whether pressure is being applied on the
tachycardia, tachypnea, blood-tinged sputum, chest pain, or popliteal area or calf muscle when a patient with
changes in level of consciousness are immediately reported venous circulation problems is sitting in a recliner with
to the HCP. the leg rest up. The angle of the recliner and the
patient’s height affect the position of the pressure. A
NURSING DIAGNOSES, PLANNING, INTERVENTIONS, AND small, flat pillow is placed underneath the knees and
EVALUATION. See “Nursing Care Plan for the Patient With lower legs to open the angle and relieve the pressure.
Thrombophlebitis” for specific nursing interventions. • Report any abnormal findings following cardiovascu-
Teaching the patient about the disease and treatment is lar surgeries because patients are at a high risk for
important to reduce anxiety about complications and to thrombophlebitis. They also are at risk for incisional
enhance adherence to treatment to prevent complications infection, pneumonia, and pulmonary emboli.
(see Box 23-4). • Encourage the patient to move often because im-
mobility can contribute to thrombophlebitis.
• If the patient is bed bound, instruct both the patient
and caregiver on simple active and passive ROM
exercises. If necessary, consider involving occupa-
tional and physical therapists. Working collabora-
Box 23-4 Patient Education tively with therapy, an appropriate activity program
can be planned.
Anticoagulant Therapy • Assist patients to develop energy-conserving tech-
Anticoagulants prolong the time it takes blood to clot, niques by being observant of their lifestyles. For
so it is important to prevent injury and to recognize and instance, notice the room and chair in which the
report signs of bleeding to the HCP. patient spends most of the day. Trays and baskets
can be used to hold items the patient may need
To Prevent Injury or want, such as water, cup, medicines, tissues, a
• Wear shoes or slippers; avoid going barefoot. phone book, telephone, snacks, TV remote, read-
• Use an electric razor to shave. ing material, paper, and pen. Other techniques to
• Use a soft toothbrush. conserve energy are putting a carrying pouch on
the front bar of a walker to carry items such as a
Signs of Bleeding to Report to Physician portable phone or tissues and, if the house has
• Easy bruising stairs, putting a chair at the top and bottom of the
• Nosebleeds stairs so the patient can rest.
• Bleeding that does not stop • The caregiver should be the one to answer the door.
• Blood in urine When the patient is alone, a note can be placed on
• Blood in sputum the door with instructions; however, the instructions
• Blood in stools or black stools should not convey that the patient is alone.
• Patients on oral anticoagulants should be instructed
Additional Instructions on dietary guidelines, adherence to follow-up labs,
• Avoid use of aspirin/NSAIDs because they further and potential complications. Many times, these
prolong the time it takes for a clot to form. patients are discharged with a booklet outlining his
• Have lab work done as prescribed by HCP to monitor or her new medication. Spend time to review this
clotting time and medication dosage. information with the patient and family.
4068_Ch23_432-461 18/11/14 4:42 PM Page 459
NURSING CARE PLAN for the Patient With Thrombophlebitis

Nursing Diagnosis: Acute Pain related to inflammation of vein
Expected Outcome: The patient will report satisfactory pain relief within 30 minutes of pain report.
Evaluation of Outcome: Does patient report satisfactory pain relief?
Intervention Assess pain using rating scale such as 0 to 10. Rationale Self-report is the most reliable indicator
of pain. Evaluation Does patient report pain using scale?
Intervention Provide analgesics and NSAIDs as ordered. Rationale Pain is reduced when inflammation is
decreased. Evaluation Is patient’s rating of pain lower after medication?
Intervention Apply warm, moist soaks. Rationale Heat relieves pain and vasodilates, which increases circulation
to aid comfort. Moist heat penetrates more deeply. Evaluation Does patient report increased comfort with warm,
moist soaks?
Intervention Maintain bedrest with leg elevation above heart level. Rationale Elevation above heart level de-
creases swelling by aiding venous blood flow back to the heart. Evaluation Is swelling reduced, documented by
measuring extremities?
Nursing Diagnosis: Impaired Skin Integrity related to venous stasis
Expected Outcome: The patient’s skin will remain intact.
Evaluation of Outcome: Does patient’s skin remain intact?
Intervention Observe skin for edema, skin color changes, and ulcers. Measure extremities, bilaterally at same
location in each extremity. Rationale Monitoring will detect signs of skin integrity impairment and extremity
swelling. Edematous skin breaks down more easily. Evaluation Are skin changes seen? Do daily measurements
show a change in swelling?
Intervention Elevate feet above heart level. Rationale Elevation decreases swelling by increasing blood flow
to heart. Evaluation Is swelling reduced?
Intervention Fit and apply elastic compression stockings after edema is reduced, as ordered. Rationale Elastic
compression stockings are fitted after edema is reduced to avoid constriction. The compression of elastic
stockings increases blood flow to reduce swelling. Evaluation Is swelling reduced?
Intervention Teach patient to avoid crossing legs or wearing constricting clothes. Rationale Crossing legs and
constrictive clothes impair venous return. Evaluation Does patient state understanding of teaching?
SUGGESTED ANSWERS TO
CRITICAL THINKING she should reduce caffeine intake (e.g., drink decaf-
feinated coffee), and to understand symptoms of
■ Mrs. Tepley endocarditis to report to her HCP.
1. You might hear a murmur.
■ Mrs. Pryor
2. Stress and caffeine increase the occurrence of
1. In aortic stenosis, the valve is narrowed, which makes
palpitations.
it more difficult for blood to leave the left ventricle
3. To help manage her condition, Mrs. Tepley needs a def- and go into the aorta. This means there can be less
inition of MVP, stress management techniques, to know
4068_Ch23_432-461 18/11/14 4:42 PM Page 460
SUGGESTED ANSWERS TO
blood flow to the body, which is most likely why Mrs. ■ Mrs. Jones
Pryor is feeling tired. 1. A heart murmur is heard from damaged heart valves.
Documentation using the SOAP method: S: “What 2. Splinter hemorrhages appear as black or red lines in
is aortic stenosis?” O: Listened attentively during the nails.
explanation that in aortic stenosis the valve is nar-
rowed making it more difficult for blood to leave 3. Petechiae indicate that tiny pieces of a lesion on the
left ventricle to go to aorta. This means there can be endocardium or valves have broken off and become
less blood flow to the body. A: Interested in learn- microemboli.
ing more about diagnosis. P: Provide more informa- 4. Subjective data collection findings might include patient
tion written and verbal. statements such as, “I have pain in my joints and am
2. Angina results if the heart is not getting enough oxygen- chilled” or “I am fatigued and have no appetite.” Objec-
rich blood. tive findings are as follows: temperature 100°F (37°C),
red splinter hemorrhages in left index finger nailbed,
3. Nursing care should include fall precautions due to many petechiae on chest.
syncope and fatigue. Teaching should be based on
Mrs. Pryor’s need for safety at home, assistance with 5. Expected medications include IV antibiotics.
ADLs, and her questions and concerns. 6. Chilling is muscular work that raises the body’s tempera-
4. Diagnoses and care include the following: Self-Care ture. Raising the body’s temperature is part of the inflam-
Deficits related to fatigue, so plan for meeting ADL matory process and is the body’s attempt at developing
needs. Activity Intolerance related to fatigue, so plan an unfavorable environment for the pathogen. Removing
rest periods between activity and monitor vital signs blankets to decrease fever results in chills and shivering,
with activity. which further increases body temperature from the heat
generated by muscular activity during shivering. There-
5. You should give two tablets. Here is an example of fore, Mrs. Jones should be kept covered to prevent chills.
how to solve this problem using the unit analysis
method: 7. For left-sided HF, crackles, wheezes, cough, or dyspnea
might be present. In right-sided HF, peripheral edema or
0.25 mg 1 tablet jugular venous distention may be present.
= 2 tablets
0.125 mg 8. Two tablets.
REVIEW QUESTIONS
1. The nurse is caring for a team of patients. After complet- 3. The nurse is evaluating a patient’s preoperative teaching
ing morning rounds, which of the following patients for a commissurotomy. The patient shows understanding
require priority care? of the purpose of this procedure by stating which of the
1. A patient who is 2 days postsurgery reporting following?
severe constipation. 1. “Fused valve flaps are separated to enlarge the
2. A patient with a DVT has peripheral edema. valve opening.”
3. A patient with aortic stenosis who is reporting 2. “A mechanical valve is inserted to replace a valve.”
chest pain. 3. “The valve flaps are repaired or reconstructed.”
4. A patient with mitral valve prolapsed has lost 4. “A biological valve is inserted to replace a valve.”
2 pounds of weight this morning.
4. The nurse is evaluating understanding after a teaching
2. The nurse is evaluating patient teaching for mitral valve session for mechanical cardiac valve replacement
prolapse. The patient shows understanding of the surgery. Which statement by the patient indicates
prognosis of MVP by stating which of the following? understanding of teaching?
1. “The prognosis is poor.” 1. “You will need anticoagulants for the first month
2. “There are often no symptoms.” after surgery.”
3. “Heart failure often occurs.” 2. “You will not need to be on anticoagulant therapy.”
4. “Symptoms quickly progress.” 3. “You will need anticoagulant therapy for the first
year after valve replacement.”
4. “You will need anticoagulant therapy for life.”
4068_Ch23_432-461 18/11/14 4:42 PM Page 461
5. The nurse evaluates the patient as understanding how to 8. The nurse reviews medication orders and is to give war-
prevent rheumatic fever if the patient states that rheu- farin (Coumadin). Which of the following actions should
matic fever can be prevented by treating streptococcal the nurse take first?
infections with which of the following? 1. Obtain a glass of water.
1. Penicillin 2. Prepare the medication for administration.
2. Prednisone 3. Review international normalized ratio result.
3. Cortisone 4. Document the medication administration.
4. Cyclosporine
Answers can be found in Appendix C.
6. The nurse is caring for a patient with cardiomyopathy.
Which of the following symptoms, if reported by the
patient, require priority action by the nurse?
1. Left great toe pain
2. Dyspnea
3. Headache
4. Decreased appetite
7. The nurse is collecting data on a patient who had surgery.

Which of the following signs and symptoms indicate
to the nurse the possible presence of a deep venous
thrombus in the patient’s leg? Select all that apply.
1. Calf swelling
2. Crackles
3. Jugular venous distention
4. Positive Homans’ sign
5. Warmth
6. Redness
Reference For additional resources and infor-

mation visit davispl.us/medsurg5
American Heart Association. (2014). Infective endocarditis. Re-
trieved February 16, 2014, from www.heart.org/HEARTORG
/Conditions/CongenitalHeartDefects/TheImpactofCongenital
HeartDefects/Infective-Endocarditis_UCM_307108_Article.jsp
Copyright of Understanding Medical-Surgical Nursing, 5th Edition is the property of F.A.
Davis Company/Publishers and its content may not be copied or emailed to multiple sites or
posted to a listserv without the copyright holder's express written permission. However, users
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4068_Ch23_432-461 18/11/14 4:42 PM Page 432

CARDIAC VALVULAR DISORDERS LEARNING TIP

Opening Opening Opening

Normal valve Stenosed valve Normal valve Insufficient valve

434 UNIT FIVE Understanding the Cardiovascular System

TABLE 23.1 CARDIAC VALVULAR DISORDERS SUMMARY

Signs and Therapeutic Priority Nursing

436 UNIT FIVE Understanding the Cardiovascular System

and regurgitation of blood. Cardiac MRI may be used for

438 UNIT FIVE Understanding the Cardiovascular System

Diagnostic Tests Aortic Regurgitation

Therapeutic Measures of complications, and early recognition of symptoms so that

TABLE 23.2 DATA COLLECTION FOR PATIENTS WITH CARDIAC

Data Collection Subjective Data

Health History Infections (rheumatic fever, endocarditis, streptococcal or staphylococcal, syphilis)?

Respiratory Crackles, wheezes, tachypnea

440 UNIT FIVE Understanding the Cardiovascular System

atriotomy (incision into the atrium) is made to expose the

442 UNIT FIVE Understanding the Cardiovascular System

NURSING CARE PLAN for the Postoperative Patient Undergoing

Nursing Diagnosis: Pain related to sternotomy or pericarditis

NURSING CARE PLAN for the Postoperative Patient Undergoing

Expected Outcome: The patient will remain free from infection.

Evaluation of Outcome: Does patient remain free from infection?

444 UNIT FIVE Understanding the Cardiovascular System

NURSING CARE PLAN for the Postoperative Patient Undergoing

INFLAMMATORY AND INFECTIOUS infected, leading to endocarditis, pericarditis, and my-

• Congenital or valvular heart disease

446 UNIT FIVE Understanding the Cardiovascular System

Nursing Process for the Patient With Infectious

TABLE 23.4 DATA COLLECTION FOR PATIENTS WITH INFECTIVE ENDOCARDITIS

Body Temperature Fever, diaphoresis

NURSING CARE PLAN for the Patient With Infective Endocarditis

448 UNIT FIVE Understanding the Cardiovascular System

NURSING CARE PLAN for the Patient With Infective Endocarditis

Pericarditis There are several forms of chronic pericarditis. Chronic

Therapeutic Anti-inflammatory medication Therapeutic Measures

450 UNIT FIVE Understanding the Cardiovascular System

Nursing Care Normal

Recent illnesses, toxin exposure, cardiac diseases, activity

Cardiac Trauma Ventricle walls are thinner

Two types of cardiac trauma can occur: nonpenetrating and Hypertrophic

452 UNIT FIVE Understanding the Cardiovascular System

Signs and Angina

Nursing Care myectomy: myo—muscle + ectomy—cutting out

454 UNIT FIVE Understanding the Cardiovascular System

TABLE 23.7 PREDISPOSING CONDITIONS FOR THROMBOPHLEBITIS (VIRCHOW’S

Condition Type Example

under the stockings as ordered. Intermittent pneumatic com-

PROPHYLACTIC MEDICATION. Low molecular weight heparin

TABLE 23.8 ANTICOAGULANT MEDICATIONS

Medication Class/Action Examples Nursing Implications

456 UNIT FIVE Understanding the Cardiovascular System

458 UNIT FIVE Understanding the Cardiovascular System

media, surgery, extremity trauma, childbirth, bed rest, recent

NURSING CARE PLAN for the Patient With Thrombophlebitis

Evaluation of Outcome: Does patient report satisfactory pain relief?

Nursing Diagnosis: Impaired Skin Integrity related to venous stasis

Expected Outcome: The patient’s skin will remain intact.

Evaluation of Outcome: Does patient’s skin remain intact?

460 UNIT FIVE Understanding the Cardiovascular System

7. The nurse is collecting data on a patient who had surgery.

Reference For additional resources and infor-

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