Chapter 23 Nursing Care of Patients with Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders

Answers CHAPTER 23 NURSING CARE OF PATIENTS WITH VALVULAR, INFLAMMATORY, AND INFECTIOUS CARDIAC OR VENOUS DISORDERS AUDIO CASE STUDY Mrs. Bell: Mitral Regurgitation and Anticoagulants 1. Shortness of breath when exercising, fatigue, coughing, some swelling in the ankles, and palpitations. 2. Heart murmur, enlargement of left ventricle, atrial fibrillation, hypertrophy of the left atrium, and regurgitation of blood. 3. Mitral valve leaflets of the valve are not closing properly, which lets blood flow backward into the left atrium each time the heart contracts. This backflow creates extra volume that the heart must then pump in addition to the new blood that comes with each heartbeat. Over time, this increased blood volume dilates and increases pressure in the left atrium and the left ventricle. Eventually, the ventricles may not be able to pump blood effectively, and they could fail from the increased strain. 4. Have blood coagulation level checked monthly, so your blood isn’t “thinned” too much. Wear medical information jewelry and carry a card, so medical personnel know you take warfarin (Coumadin) and that you have a mechanical heart valve. Certain foods (e.g., broccoli, spinach, and other dark green leafy vegetables) contain vitamin K, which can reduce the effects of warfarin (Coumadin). Eat them in consistent amounts; don’t eat a large amount one time and a little bit another time. Keep the amount and frequency steady, so you can get established on a warfarin (Coumadin) dosage and keep your blood level of it steady. Promptly seek medical attention if injured or bleeding, as it may be difficult to stop any bleeding, which can become life-threatening. VOCABULARY 1. annuloplasty 2. commissurotomy 3. insufficiency 4. regurgitation 5. stenosed 6. valvuloplasty 7. chorea 8. pericarditis 9. myocarditis 10. petechiae 11. pericardiocentesis 12. cardiac tamponade 13. cardiomyopathy 14. cardiomegaly 15. myectomy 16. thrombophlebitis MITRAL VALVE PROLAPSE Corrections are in boldface. During ventricular systole, when pressures in the left ventricle rise, the leaflets of the mitral valve normally remain closed. In mitral valve prolapse (MVP), however, the leaflets bulge backward into the left atrium during systole. Often there are no functional problems seen with MVP. However, if the leaflets do not fit together, mitral regurgitation can occur with varying degrees of severity. MVP tends to be hereditary, and the cause is unknown. Infections that damage the mitral valve may be a contributing factor. It is the most common form of valvular heart disease and typically occurs in women aged 20 to 55. Most patients with MVP have no symptoms. Symptoms that may occur include chest pain, arrhythmias, palpitations, dizziness, and syncope. No treatment is needed unless symptoms are present. Stimulants and caffeine should be avoided to prevent symptoms. VALVULAR DISORDERS 1. False. Narrowing. 2. True 3. True 4. False. Allows. 5. True 6. False. Mitral and aortic valves. 7. True 8. False. Occur late. 9. True 10. True 11. True 12. True 1 2 Chapter 23 Answers 13. False. Enlarges. 14. True 15. False. Current guidelines consider antibiotics only for those at high risk before certain invasive procedures. 3. (3) 4. (2) 5. (5) RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE CRITICAL THINKING—MRS. MURPHY 1. Aging. 2. Ask if there is a history of rheumatic fever. 3. The left ventricle contracts more forcefully and over time hypertrophies to increase contractility. 4. Left ventricular failure. 5. Decreased coronary artery blood flow results from the reduced cardiac output at the same time that the left ventricular workload is increased. This imbalance in oxygen supply and demand results in angina. 6. “Hypertrophy is a compensatory mechanism.” Mrs. Murphy’s heart, like any muscle in the body, has enlarged due to the increased workload of pumping blood through the narrowed aortic opening. This is how her heart has been compensating for the narrowed aorta. 7. Sudden death may occur from aortic stenosis, so the valve is replaced. INFLAMMATORY AND INFECTIOUS CARDIOVASCULAR DISORDERS Corrections are in boldface. Rheumatic fever is a complication of a streptococcal infection such as a sore throat. Rheumatic fever signs and symptoms include polyarthritis, subcutaneous nodules, chorea with rapid and uncontrolled movements, carditis, fever, arthralgia, and pneumonitis. A throat culture diagnoses a streptococcal infection during the infection. The heart valves and their structures can be scarred and damaged. Rheumatic fever can be prevented by detecting and treating streptococcal infections promptly with penicillin. DIAGNOSTIC TESTS FOR INFECTIVE ENDOCARDITIS 1. (3) 2. (5) 3. (2) 4. (4) 5. (1) 1. (1) 2. (4) THROMBOPHLEBITIS NURSING DIAGNOSIS Acute Pain related to inflammation of vein Intervention Monitor pain using a rating scale, such as 0 to 10. Rationale Self-report is the most reliable indicator of pain. Evaluation Does patient report pain using rating scale? Provide analgesics and NSAIDs as ordered. Analgesics relieve pain. Pain is reduced when inflammation is decreased, which is the action of NSAIDS. Is patient’s rating of pain lower after medication? Apply warm, moist compresses as ordered. Moist heat penetrates deeply to relieve pain and increase circulation to aid comfort. Does patient report increased comfort with warm, moist soaks? Chapter 23 Answers 3 NURSING DIAGNOSIS Impaired Skin Integrity related to venous stasis Intervention Observe skin for edema, skin color changes, and ulcers. Measure both extremities’ circumference at the same site in each extremity daily or as ordered. Rationale Monitoring will detect signs of skin integrity impairment. Edematous skin breaks down more easily. Evaluation Is there a change in edema or skin integrity? Elevate feet above heart level. Elevation decreases swelling by increasing venous return to heart. Is swelling reduced? Fit and apply elastic compression stockings after edema is reduced, as ordered. Elastic compression stockings, fitted after edema is reduced to avoid constriction, increase venous return to heart to reduce swelling. Is swelling reduced? Teach patient to avoid crossing legs or wearing constrictive clothes. Crossing legs and constrictive clothes impair venous return. Does patient demonstrate understanding of teaching? CRITICAL THINKING—MR. EVANS REVIEW QUESTIONS—CONTENT REVIEW 1. Enlargement of the heart muscle, especially along the septum without dilation of the ventricle, which does not relax or fill easily. 2. Smaller ventricular size, reduced ventricular filling because of decreased relaxation and size. 3. Chest x-ray. 4. It would increase contractility in a heart that already does not relax easily, so filling of the heart chambers with blood would be decreased even more as a result of even less relaxation. 5. (a) Because cardiac output is reduced, dehydration must be avoided to prevent a further decrease in cardiac output. (b) Exertion is avoided so that an increase in cardiac output, which the compromised heart is unable to provide, is not required. 6.The family will have a useful role and feel included in the patient’s care if they are taught cardiopulmonary resuscitation (CPR). They will feel a sense of control and purpose in the event that CPR is required. The correct answers are in boldface. CRITICAL THINKING—MRS. STRECKER 1. (4) 2. (2, 6, 7) 3. (4, 5) 1. (2) is correct. Impaired emptying of blood from the left ventricle occurs because the blood cannot easily leave the left ventricle through the narrowed aortic valve. (1) is incorrect. The aortic valve is narrowed. (3) is incorrect. Backflow of blood into the left atrium occurs with mitral regurgitation. (4) is incorrect. Impaired emptying of the left atrium occurs with mitral stenosis. 2. (1) is correct. Backflow of blood into the left atrium occurs through the mitral valve, which does not close tightly. (2) is incorrect. Backflow of blood into the right atrium occurs with tricuspid regurgitation. (3) is incorrect. Impaired emptying of blood from the right ventricle occurs because of pulmonic stenosis. (4) is incorrect. Impaired emptying of blood from the left ventricle occurs because of aortic stenosis. 3. (3) is correct. Ventricular hypertrophy occurs to increase contractility to help maintain cardiac output. (1, 2, 4) are incorrect. 4. (2) is correct. Left ventricular failure results in decreased cardiac output, which reduces oxygen to the tissues and causes fatigue. (1, 3, 4) are incorrect. 5. (4) is correct. Cardiac catheterization measures chamber pressures. (1, 2, 3) are incorrect. 4 Chapter 23 Answers 6. (4) is correct. A beta-hemolytic streptococcal infection can precede rheumatic fever. (1, 2, 3) are incorrect. 7. (3) is correct. Chest pain is the most common symptom, especially with deep inspiration. (1, 2, 4) are incorrect. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 8. (3) is correct. The patient’s outcome would be to be able to verbalize knowledge of the disorder. (1) is incorrect. It would be an outcome for Decreased Cardiac Output. (2) is incorrect. It would be an outcome for Activity Intolerance. (4) is incorrect. It would be an outcome for Fear. 9. (1, 6) are correct. Furosemide (Lasix), a potassiumwasting diuretic, helps prevent pulmonary edema, a complication of decreased cardiac output and heart failure. A potassium supplement is often needed with furosemide. (2, 3, 4, 5) help prevent complications that are not related to decreased cardiac output. 10. (1) is correct. Determining the patient’s and family’s learning priorities helps ensure that the patient is motivated to learn because the patient’s needs and not the nurses’ needs are being met. (2, 4) do not promote learning and may hinder it. (3) is not correct. 11. (1, 3, 5, 6) are correct. Wearing medical identification is essential in case of a bleeding problem or loss of consciousness; blood test appointments are monthly to ensure warfarin level is therapeutic; to establish a therapeutic level of warfarin, consistency in the amount of green leafy vegetables in the diet is required to prevent inconsistent levels of vitamin K, which is contained in the vegetables; signs and symptoms to report to the HCP are important to prevent life-threatening complications. (2) is incorrect. Green leafy vegetables do not have to be avoided. They can be eaten in a consistent amount so they do not counteract the effects of warfarin (Coumadin) because they contain vitamin K. (4) is incorrect. An electric razor is to be used when shaving. 12. (1, 2, 3, 5) are correct. Elastic stockings, early ambulation, sequential compression devices, and leg exercises help prevent thrombophlebitis. (4) is not preventive and could contribute to development of thrombophlebitis, so pain should be managed to promote early ambulation. 13. (4) is correct. Heart failure can occur because of fluid congestion in the lungs, so lung sounds are auscultated to see if crackles, indicating fluid congestion, are present. (1, 2, 3) are not the current priority. 14. (1) is correct. Prevention of infective endocarditis is the goal because of increased risk from previous heart damage. (2) is not the reason they are given. (3, 4) are not prevented by antibiotics. 15. (4) is correct. Pericardial friction rub indicates inflamed pericardial tissue and would be the highest priority for this patient. (1) is incorrect. Bronchovesicular sounds over the major airways are a normal finding. (2, 3) are incorrect. Chest soreness and tenderness and sternal bruising are expected with chest trauma and are not the highest priority. 16. (3) is correct. Partial thromboplastin time is monitored for heparin. (1, 2, 4) are not monitored for heparin; (2) and (4) are monitored for warfarin (Coumadin) therapy. 17. (2) is correct. Vitamin K is the antidote. (1, 3, 4) are incorrect; (4) is the antidote for heparin. 18. (2) is correct. The desired outcome for pain is that it is satisfactorily relieved according to the patient. (1) is the outcome for anxiety. (3, 4) would not be appropriate for a patient with acute deep vein thrombosis because bedrest is ordered. 19. (2) is correct. A throat culture must be done to rule out a streptococcal infection, which can lead to complications. (1, 3, 4) are not as essential to prevent complications. 20. (2) is correct. The health care provider should be informed now for orders because the international normalized ratio monitors warfarin (Coumadin) effects, and it is above the therapeutic range. (1) is incorrect. An unscheduled dose of warfarin is not needed since the international normalized ratio is elevated and bleeding could occur. (3, 4) are incorrect because the health care provider must provide orders regarding warfarin administration. 21. (1, 4, 6) are correct. Leg elevation to reduce swelling may be ordered. Apply stocking(s) as ordered. Heat provides pain relief and increases circulation. (2, 3, 5) are incorrect. Ambulation must be ordered for an acute thrombophlebitis episode; leg exercises and massage could encourage emboli development. 22. (2) is above therapeutic range. (3) measures heparin effects. (1) does not measure warfarin effects. (4) is therapeutic. 23. (4) is correct. The patient is experiencing paroxysmal nocturnal dyspnea, which occurs from increased fluid returning to the heart from the release of gravity on the legs when in a reclining position; the fluid then builds up in the lungs. (1, 2, 3) are incorrect. 24. (1) is correct. Anorexia is a side effect of digoxin (Lanoxin). (2, 3, 4) are incorrect. 25. (2) is correct. (1, 3, 4) are incorrect. 45 mg 2 mL = 1.5 mL 60 mg Chapter 23 26. The nurse palpates pedal pulses in the feet for a patient who has peripheral arterial disease. Answers 5