04.03 Nursing Care and Pathophysiology for Valve Disorders

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Outline

Overview

  1. Valves do not open fully (stenosis)
  2. Valves do not close fully (regurgitation)
  3. Blood flow / Cardiac output is jeopardized
Pathophysiology: There are different valvular disorders. The vales might not fully open, which means the blood can not get through the valve fully to continue moving forward. Valves might not close completely, which causes blood to regurge and move back instead of forward.

Nursing Points

General

  1. Valve Disorders
    1. Mitral Valve Stenosis
      1. Doesn’t open completely
      2. Diastolic murmur
    2. Mitral Valve Regurgitation
      1. Doesn’t close completely
      2. Systolic murmur
    3. Aortic Valve Stenosis
      1. Doesn’t open completely
      2. Systolic murmur
    4. Aortic Valve Regurgitation
      1. Doesn’t close completely
      2. Diastolic murmur
  2. Identifying Murmurs
    1. Mnemonic = TPMA (Toilet Paper My Ass)
      1. T= Tricuspid Valve
        1. Closed during Systole (S1)
        2. Open during Diastole (S2)
      2. P= Pulmonic Valve
        1. Open during Systole (S1)
        2. Closed during Diastole (S2)
      3. M= Mitral Valve
        1. Closed during Systole (S1)
        2. Open during Diastole (S2)
      4. A= Aortic Valve
        1. Open during Systole (S1)
        2. Closed during Diastole (S2)
    2. Hear a murmur?
      1. Identify location
      2. Is it S1 or S2?
      3. Should it be closed or open?
        1. Should be closed = regurgitation
        2. Should be opened = Stenosis
  3. Causes
    1. Rheumatic Fever
    2. Endocarditis
      1. Vegetation / Damage
    3. Congenital
    4. Cardiomyopathy
      1. Pulls papillary muscles
    5. Trauma

Assessment

  1. Identifying murmurs
    1. Is it Systolic (S1) or Diastolic (S2)?
    2. Which valve is it?
      1. Aortic – 2nd ICS RSB
      2. Pulmonic – 2nd ICS LSB
      3. Tricuspid – 3rd ICS LSB
      4. Mitral – 5th ICS MCL
    3. What should the valve be doing?
      1. If should be open – stenosis
      2. If should be closed – regurgitation
  2. Sudden Onset New Murmur
    1. Mitral Valve Prolapse (regurgitation)
    2. Papillary Muscle Rupture (mitral or tricuspid regurgitation)

Therapeutic Management

  1. Balloon valvuloplasty – repair for stenosis
  2. Valve repair – prolapse or papillary muscle rupture
  3. Valve replacement
    1. Mechanical: lifetime anticoagulant therapy indicated
    2. Biological: valve from other species
    3. Post-Op
      1. Monitor hemodynamics
      2. Monitor for s/s bleeding

Patient Education

  1. Post-Op Valve Replacement
    1. Maintain good oral hygiene with soft bristle toothbrush
    2. Prophylactic antibiotics required prior to invasive procedures
    3. Instruct client on anticoagulant therapy
    4. Avoid dental procedures for 6 months
      1. High risk endocarditis
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Transcript

Hey guys, my name is Brad, and welcome to nursing.com. And in today’s video, what we’re going to be discussing are valve disorders. We’re going to go over some of the different types of valve disorders, as well as how these may change what you hear whenever you auscultate heart sounds as well as some of the causes, treatments and patient education associated. Without further ado, let’s dive in. 

Now, whenever we’re talking about valve disorders, we’re pretty much looking at one of two types of valve disorders, right? Valves can either become stenotic, which is another way of saying stiff. The valves can become stiff.  Or the valves can become regurgitant, which is another way of saying loose or leaky. 

So the way that I like to try and think about this is I’d like to draw this little heart, right? And we’re going to split it down the middle. We know up top, we have to atrium and down low, we have two ventricles.  And in between the right atrium and the right ventricle, we had this little tricuspid valve. So let’s take, like a little cross section of this tricuspid valve. And let’s see what this might look like. Now, in a nice normal homeostatic valve we’re going to be looking at something like this, right? Blood is going to be passing from this right atrium down through this tricuspid valve, into this right ventricle and in a homeostatic environment, everything’s working just fine, no problems.  But what would happen if instead, we had this little calcium molecules, right? These little calcium deposits within the valve itself. Well, what happens is whenever calcium gets deposited into the valve itself, the valve becomes stiff, more stenotic and much more difficult for blood to be able to flow from that right atrium down through that thicker stiffer valve into the right ventricle. 

What if instead, our valve looked like this, okay. It’s a lot more loose, a lot more leaky, right? A regurgitant valve. What’s going to occur is blood is going to pump from that right atrium into that right ventricle, right? Some of the blood is going to get delivered to the right ventricle. However, some of the blood is going to go through and actually just regurgitate right back up into the right atrium. This is an instance where we have a regurgitant valve. Now, whether what we’re experiencing, what we’re seeing in a patient is a stenotic or a regurgitant valve, either way, you’re going to be able to hear this and identify it whenever you’re auscultating heart tones. 

So as far as the assessment is concerned, whenever we’re actually auscultating heart tones, and we’re listening for murmurs, we’re going to take a little something into account here, okay? What I’d like to do is bring your attention to the fact that we have S1 and S2.  Interchangeably, this correlates to systole and S2 correlates to diastole. Also, you can think this is contract versus relaxed. This is S1 is systole, whenever the ventricles contract.  S2 is diastole, whenever the ventricles relax.  All of these are used interchangeably. So, S1 murmurs versus S2 murmurs. Systolic murmurs versus diastolic murmurs. These are the ways that I like to break it down. Systolic murmurs are going to be heard during S1 and diastolic murmurs are going to be auscultated during S2. So one thing that you have to keep in mind is whenever we’re listening for murmurs, there’s three different things that you have to keep in mind whenever you’re trying to identify a murmur, right? What kind of murmur am I hearing? 

The first thing is the location. It’s very important to know what is the location of this murmur that I’m actually hearing. I want you guys to make sure that you go check on our heart sounds video, that we’ve done here on nursing.com, if you’re fuzzy about the anatomical locations associated with auscultating heart tones.  The second thing is, are we hearing it during S1 or are we hearing it during S2? Is it an S1 murmur or is it an S2 murmur? And that’s going to help us better identify whether we’re dealing with a stenotic or regurgitant valve. And the third component that’s going to help us identify is, what is the valve supposed to be doing? What is this valve, at this location that we’re hearing this murmur, supposed to be doing during either S1 or S2.  

To give you an example of what the heck we’re even talking about, right, let’s say we’re auscultating the aortic valve. The aortic valve can be heard, if we’ll recall, right, from our heart tones video, it’s the right sternal border, second intercostal space. Okay. So we’re auscultating the aortic valve. Now that’s the first thing, the location. And we notice during our auscultation, we’re hearing a murmur. Now, you might ask yourself, how the heck do we actually hear a murmur? So remember during systole, during diastole, what do we actually hear? Right? We actually hear lub, and then we hear dub.  Lub, during systole, during ventricular contraction. Dub, diastole, during ventricular relaxation. Okay. So we’re listening to the aortic valve and we hear a murmur. Now, systolic murmurs are going to be presented as a whooshing sound. Really all murmurs are, is basically just a stenotic valve. You’re hearing a whooshing sound because there’s a turbulent flow of blood through that thick and stiff valve. And during a regurgitant valve, you’re hearing a whooshing sound because blood is not all completely passing through that valve. It is whooshing and regurgitating back into the previous chamber. I hope that made sense. 

So for systolic murmurs, instead of lub dub, we’re going to hear whoosh dub and for diastolic murmurs, instead of lub dub, we’re going to hear a lub whoosh. Okay. We’re listening to the aortic valve and we hear a murmur. And we hear the murmur, it’s an S1 murmur. We’re hearing whoosh dub, whoosh dub. First thing, the location we’re listening to the aortic valve. Second thing is this an S1 or an S2 murmur.  But what we’re hearing is woosh dub, but what we’re hearing is a S1, a murmur is systolic murmur. That’s the second thing. We now know the location of our murmur. And S1 and S2, we know that this is an S1 murmur.  It’s occurring during systole. The last thing that we have to ask is what is the aortic valve supposed to be doing during systole? Well, again, you’ll know, from our cardiac anatomy video, the way in which blood flows throughout the heart, during systole ventricular contraction occurs, and this actually opens the aortic valve, allowing blood to pass through up to the aorta. So if our valve is supposed to be open during systole, and what we’re hearing is whoosh dub, we’re hearing a systolic murmur. Then what we know is, is as that valve is supposed to be opening to allow blood to pass through. Instead, we’re actually pumping against the stenotic valve. 

So what are some of the causes of valve disorders? But one of the big ones here is endocarditis, right? Endocarditis is caused by IV drug use as well as, and this is a big one to know, poor dental hygiene or associated with dental procedures. What is endocarditis? It’s basically a, it’s a result of a bacterial infection getting into the bloodstream . Dental procedures, a big one, poor dental hygiene, a big one. There’s an associated link of poor dental hygiene and bacteria going from the gums through the bloodstream, up to the heart and this bacterial infection actually attacking not only the heart muscle, but, as well as, the delicate valve.  You can also see rheumatic fever, this is another infectious process that can lead to diseased valves.  Congenital as well as papillary muscle rupture. You recall from our cardiac anatomy video that we actually have down here in the beds of these ventricles, these little papillary muscles and attached to them here are these delicate chordae tendineae, which essentially act as tethers holding that valve closed preventing retrograde blood flow from that valve back into the previous chambers, you can kind of think about this, like a little fishing line, right? You’ve got the water here. The cute little fish is swimming. And as you’ve got tight tethered here on your fishing line, you’re pulling that fish in no problem. But what happens if that line were to snap, you’re going to lose all slack on that fishing line. And basically you’re losing all slack here on this delicate chordae tendineae, allowing blood to flow backwards back into the previous chamber. 

What are some different ways in which we treat patients with valve disorders? Well there’s a lot of invasive means that we can do this. You can actually see things such as valve replacements over here on the right. These are usually done with the replacement of valves using either biological or mechanical valves, biological being, oftentimes, pig valves. They usually would have to be replaced every so many years.  And then mechanical valves as well. When actually using these, usually, requires lifelong anticoagulation. 

You could also see valvular repair itself in instances, such as papillary muscle rupture, where those chordae tendineae have lost all of their slack. And now that valve is prolapsing. Then you can also see an intervention such as something like balloon valvuloplasty, which is, essentially, you have this usually used for stenotic valves, right? Like I’ve said, we’ve had all this calcium deposition into this valve. And now this valve has become super stiff, very thick and hard for blood to flow through it. So what they do is they essentially thread a very small catheter up through and across that valve and what resides right here within that, across that valve membrane, is a balloon and they blow this balloon up, which essentially pushes out onto this diseased valve, crushing and breaking up all of this calcium deposits so that the calcium falls away.  You basically lose this hard rigid armor, if you will, on top of these valves. And now that that calcium has been crushed, the valve can open and close, nice and easy. 

And what are some of the things that we’re going to educate our patients on who have had valve disorders or have undergone some sort of valvular intervention? Of course, good oral hygiene. Like we said, whenever we’re talking about endocarditis, the known associated link between poor dental hygiene and the development of bacterial endocarditis, destroying those valves. It’s also important that we make sure that we educate patients on avoiding dental procedures for six months post procedure. And if they’ve received a mechanical valve, sometimes I think with biological valves as well, the importance of anticoagulant adherence, because now that we have a new valve in the heart, our brain or our body basically interprets this as a foreign body. So we want to make sure that we prevent any kind of platelet aggregation to this new valve. 

And so to summarize our valve disorders lecture here, let’s recall valve disorders are from either stiff or stenotic valves or leaky, loose, and regurgitant valves. We’re going to be able to auscultate these heart murmurs. And what we’re going to hear is the whooshing sound due to either a stenotic valve, that turbulent flow of blood, trying to get through that stiff valve, or a whooshing sound due to that regurgitate and loose and leaky valve, allowing blood to flow backwards into the previous chamber. And also knowing that we’re going to be able to identify murmurs on exams for exam purposes, using three things. One, what is the location of the murmur that we’re hearing? Two, is it an S1 or S2 murmur? And three, what should that valve be doing during this S1 or S2? What are the different kinds of causes that we’re going to go over that we’re going to see, leading to valve disorders that, as we’ve already discussed, endocarditis, rheumatic fever, et cetera. The kinds of therapeutic management, the types of surgical interventions, that invasive interventions that we may see for patients to try and repair poorly diseased valve. And the patient education that we just went over. 

Go out there and be your best selves today, guys. And as always happy nursing.

 

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