How heart valve disorders occur and caring for heart valve disorders (Nursing Care Plan)
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HEART VALVE DISORDERS...NURSING CARE PLAN
Pathophysiology
Mitral Regurgitation – mitral valve cannot close completely, therefore blood back-flows into the LA
Mitral Stenosis – mitral valve cannot open fully or is narrowed, therefore blood can’t go into the LV
Aortic Regurgitation – aortic valve cannot close completely, therefore blood back-flows into the LV
Aortic Stenosis – aortic valve cannot open fully or is narrowed, therefore blood can’t get out of LV
When the blood can’t flow the direction it’s supposed to flow, cardiac output is compromised.
Etiology
The most common cause of valve disorders is rheumatic fever or endocarditis which cause damage, vegetation, or thickening and scarring of the heart valves. An acute, emergent situation could be caused by mitral valve prolapse or papillary muscle rupture.
Desired Outcome
Preserve cardiac output where possible, and proceed to valve repair or replacement if cardiac output is compromised. Prevent post-op complications from valve repair or replacement.
Subjective Data:
May be asymptomatic except heart murmur. If cardiac output is compromised, may see these symptoms:
Chest pain
Shortness of breath
Weakness
Fatigue
Objective Data:
Heart Murmur
Systolic Murmur – Aortic Stenosis or Mitral Regurgitation
Diastolic Murmur – Aortic Regurgitation or Mitral Stenosis
May be asymptomatic except heart murmur. If cardiac output is compromised, may see these signs:
↓ BP
↑ HR
Skin – cool, diaphoretic, pale, dusky
Weak pulses
Slow cap refill
Nursing Interventions and Rationales
Assess Heart SoundsTo identify murmur:
Is it an S1 or S2 murmur?
Which valve are you listening to?
What should the valve be doing at that time?
The easiest way for a nurse to determine the presence of a valve disorder is to listen for murmurs. A murmur indicates abnormal or turbulent blood flow through the valve.
If the valve should be open, but doesn’t open fully – stenosis
If the valve should be closed, but doesn’t close fully – regurgitation
Assess and Monitor CV status
Pulses
Capillary refill
Skin color, temperature
Heart rate
Blood Pressure
Arrhythmias (ECG)
Valve disorders can compromise cardiac output. Assess cardiovascular status to determine if there is decreased perfusion to the tissues. If BP is dropping, HR may increase to compensate.
Assess respiratory status
Lung sounds
SpO2
Shortness of Breath
Sputum
If blood is not going forward or backing up, it can cause pulmonary congestion leading to pulmonary edema. This would cause decreased SpO2, crackles in the lungs, and possibly even pink-frothy sputum
Notify provider of new or sudden onset or murmurs, especially if accompanied by signs of poor perfusion or pulmonary edema
Papillary muscle rupture and mitral valve prolapse may occur suddenly. They are most often accompanied by chest pain, shortness of breath, or other signs of heart failure. This is an emergency that requires surgical intervention immediately. Don’t hesitate to call for help.
Educate patient about post-op requirements after valve replacement surgery
Prophylactic antibiotics prior to any invasive procedures
Bleeding Precautions (anticoagulant therapy)
Use soft bristle toothbrush
Maintain good oral hygiene
Avoid dental procedures for 6 months post-op
Patients who receive artificial valve replacements will require lifelong anticoagulant therapy. They need to be taught precautions for anticoagulant therapy, including using electric razors and soft bristle toothbrushes and how often they will require monitoring, if at all.
Patients with artificial heart valves are at high risk of developing endocarditis. They need to be taught about preventative measures, including receiving prophylactic antibiotics prior to any invasive procedures.
Oral hygiene is imperative to prevention of endocarditis after valve repair. This may seem silly but it is a HUGE deal. The evidence has shown that bacteria from the oral cavity are highly likely to translocate (move) to the heart and become lodged in/on the valves. This is also why patients should avoid dental procedures for 6 months after valve surgery. It is so important that you, as the nurse, educate them on why this is so important.
Visit us at https://nursing.com/medical-disclaimer/ for disclaimer information.
NCLEX®, NCLEX-RN® are registered trademarks of the National Council of State Boards of Nursing, INC. and hold no affiliation with NURSING.
Welcome to the NURSING Family, we call it the most supportive nursing cohort on the planet.
At NURSING.com, we want to help you remove the stress and overwhelm of nursing school so that you can focus on becoming an amazing nurse.
Check out our freebies and learn more at: https://nursing.com/?utm_medium=socia...
HEART VALVE DISORDERS...NURSING CARE PLAN
Pathophysiology
Mitral Regurgitation – mitral valve cannot close completely, therefore blood back-flows into the LA
Mitral Stenosis – mitral valve cannot open fully or is narrowed, therefore blood can’t go into the LV
Aortic Regurgitation – aortic valve cannot close completely, therefore blood back-flows into the LV
Aortic Stenosis – aortic valve cannot open fully or is narrowed, therefore blood can’t get out of LV
When the blood can’t flow the direction it’s supposed to flow, cardiac output is compromised.
Etiology
The most common cause of valve disorders is rheumatic fever or endocarditis which cause damage, vegetation, or thickening and scarring of the heart valves. An acute, emergent situation could be caused by mitral valve prolapse or papillary muscle rupture.
Desired Outcome
Preserve cardiac output where possible, and proceed to valve repair or replacement if cardiac output is compromised. Prevent post-op complications from valve repair or replacement.
Subjective Data:
May be asymptomatic except heart murmur. If cardiac output is compromised, may see these symptoms:
Chest pain
Shortness of breath
Weakness
Fatigue
Objective Data:
Heart Murmur
Systolic Murmur – Aortic Stenosis or Mitral Regurgitation
Diastolic Murmur – Aortic Regurgitation or Mitral Stenosis
May be asymptomatic except heart murmur. If cardiac output is compromised, may see these signs:
↓ BP
↑ HR
Skin – cool, diaphoretic, pale, dusky
Weak pulses
Slow cap refill
Nursing Interventions and Rationales
Assess Heart SoundsTo identify murmur:
Is it an S1 or S2 murmur?
Which valve are you listening to?
What should the valve be doing at that time?
The easiest way for a nurse to determine the presence of a valve disorder is to listen for murmurs. A murmur indicates abnormal or turbulent blood flow through the valve.
If the valve should be open, but doesn’t open fully – stenosis
If the valve should be closed, but doesn’t close fully – regurgitation
Assess and Monitor CV status
Pulses
Capillary refill
Skin color, temperature
Heart rate
Blood Pressure
Arrhythmias (ECG)
Valve disorders can compromise cardiac output. Assess cardiovascular status to determine if there is decreased perfusion to the tissues. If BP is dropping, HR may increase to compensate.
Assess respiratory status
Lung sounds
SpO2
Shortness of Breath
Sputum
If blood is not going forward or backing up, it can cause pulmonary congestion leading to pulmonary edema. This would cause decreased SpO2, crackles in the lungs, and possibly even pink-frothy sputum
Notify provider of new or sudden onset or murmurs, especially if accompanied by signs of poor perfusion or pulmonary edema
Papillary muscle rupture and mitral valve prolapse may occur suddenly. They are most often accompanied by chest pain, shortness of breath, or other signs of heart failure. This is an emergency that requires surgical intervention immediately. Don’t hesitate to call for help.
Educate patient about post-op requirements after valve replacement surgery
Prophylactic antibiotics prior to any invasive procedures
Bleeding Precautions (anticoagulant therapy)
Use soft bristle toothbrush
Maintain good oral hygiene
Avoid dental procedures for 6 months post-op
Patients who receive artificial valve replacements will require lifelong anticoagulant therapy. They need to be taught precautions for anticoagulant therapy, including using electric razors and soft bristle toothbrushes and how often they will require monitoring, if at all.
Patients with artificial heart valves are at high risk of developing endocarditis. They need to be taught about preventative measures, including receiving prophylactic antibiotics prior to any invasive procedures.
Oral hygiene is imperative to prevention of endocarditis after valve repair. This may seem silly but it is a HUGE deal. The evidence has shown that bacteria from the oral cavity are highly likely to translocate (move) to the heart and become lodged in/on the valves. This is also why patients should avoid dental procedures for 6 months after valve surgery. It is so important that you, as the nurse, educate them on why this is so important.
Visit us at https://nursing.com/medical-disclaimer/ for disclaimer information.
NCLEX®, NCLEX-RN® are registered trademarks of the National Council of State Boards of Nursing, INC. and hold no affiliation with NURSING.
4 سال پیش
در تاریخ 1399/04/18 منتشر شده
است.
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