04.03 Valve Disorders

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Overview

  1. Valves do not open fully (stenosis)
  2. Valves do not close fully (regurgitation)
  3. Blood flow / Cardiac output is jeopardized

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. 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

Reference Links

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Video Transcript

Okay, we’re going to talk about Valve disorders and how we identify and treat them.

So there are two main types of valve disorders that is regurgitation and stenosis. So what happens in regurgitation is that the valve should be closed but for whatever reason it doesn’t close fully. Because the valve doesn’t close all the way blood is able to back up or regurgitate backwards through the valve. A good example here is mitral valve regurgitation. The mitral valve should be closed during systole, so when the left ventricle contracts to push blood out of the heart some of that blood also goes backwards through the mitral valve back into the left atrium. The second type of valve disorder is stenosis. What happens in stenosis is that the valve should be open but for whatever reason can’t open fully. Now stenosis means narrowing so essentially the hole that the blood is supposed to push through is narrow. This makes it harder for the blood to get where it needs to go. So let’s use the left heart for example again, when the left ventricle contracts the aortic valve should be open. If you have aortic stenosis, then the left ventricle is pushing blood through a smaller hole and that makes it difficult to get all of the blood out of the heart. Ultimately, both of these conditions can impair cardiac output because the blood can’t move forward appropriately. So you may see symptoms of poor perfusion or even pulmonary edema as the blood backs up into the lungs.

The blood trying to force through a smaller opening or moving backwards through a partially closed valve causes turbulence which presents as a murmur. So if we can identify the murmur, we can identify the problem with the valve.

We talked briefly in the heart sounds lecture about identifying murmurs, but let’s review again and we’re gonna give you a super simple 3 step process to Identify murmurs every time!

You can remember the order of the valves with the mnemonic Toilet Paper My Ass. Tricuspid, Pulmonic, Mitral, Aortic. Okay, so…three steps to identifying a murmur correctly every time. Step 1 is to ask yourself which valve you’re listening to. Review the heart sounds lecture if you need to review those landmarks. But let’s say for example, you’re listening over the 2nd intercostal space, right sternal border, you know you’re listening to the aortic valve. If you’re listening to the 5th intercostal space mid-clavicular line, you know you’re hearing the mitral valve. Make sense? So that’s step 1. Step 2 is to ask whether the murmur you’re hearing is Systolic or on your S1 beat or Diastolic on your S2 beat. Then, ask yourself what should the valve be doing during that phase of the cardiac cycle. If it should be open but isn’t opening fully – that’s stenosis. If it should be closed but isn’t closing fully – that’s regurgitation. So let’s review what these valves should be doing during each phase. Tricuspid valve, during systole when the ventricles contract, it should be Closed so the blood can move forward. So during diastole it’s open to allow filling. Pulmonic valve is open during systole so blood can go to the lungs, and closed during diastole. The Mitral valve, same as the tricuspid valve – closed during systole and open during diastole. And the aortic valve is the same as the pulmonic – open during systole to allow blood to the body and closed during diastole. So anywhere you see closed, you know that if it’s a murmur then it isn’t closed all the way – that’s gonna be regurgitation. And if you see open, you know that a murmur there means it’s not open all the way so it’s stenosis. I hope that makes sense, that three step process will get you there every time. If you know what the valves should be doing, you can figure out what’s going wrong.

Really quick I want to address the main causes of valve disorders. The top two causes of every possible valve disorder are 1) Rheumatic Fever and 2) Endocarditis. Now we’ll talk more about endocarditis in the next lesson, but what you NEED to know is that both of these conditions will cause damage and scarring of the valves and can even cause bacterial vegetation to build up around the valves. So anything that affects the integrity of the valves can cause these problems.

Also I want you to be aware of something called a papillary muscle rupture. These muscles here are connected to the valves by tendons and when the muscles contract, the valve opens. If these muscles rupture, the valve will just flop there – it can’t function at all. What you’ll see is that all of a sudden your patient will complain of chest pain, shortness of breath – they will have signs of poor perfusion and congestion in the lungs – pale skin, maybe crackles. Because you’re an awesome nurse and you understand cardiac physiology, you listen to their heart and suddenly they have a murmur that wasn’t there before. This is a medical emergency and requires surgical intervention immediately so make sure you get the provider on the phone right away.

Now, for everyone else who just has damaged valves chronically, they may not have this sudden problem. But once cardiac output is impaired, we need to intervene. So let’s look at some of those options really quick.

One of the ways we can do that is through a balloon valvuloplasty. As you can see a catheter is inserted through the valve and a balloon is inflated to open up the valve. So this is used for stenotic valves or ones with vegetation. The goal is to increase that opening so we can have better forward motion of blood.

Now, for patients whose valves can’t be repaired, they have to be replaced. The replacement valves can be mechanical like the ones you see here or biological – like from a pig. The mechanical ones are much more common these days. They replace the valve with this device that has a little ball in it and when the ventricles contract it pushes the ball up to block the hole. Now these patients will need to be on anticoagulants for the rest of their lives to keep clots from forming around the artificial valves. But also – the most important thing to note here is that they’re at HIGH risk for infectious endocarditis because bacteria collect on the valves. So patient education is a top priority. Two big things – they should receive prophylactic antibiotics before any invasive procedure and they should avoid dental procedures for at least 6 months. Oral hygiene is a huge deal for these patients – it seems silly but studies have shown that bacteria from the mouth tend to move to the heart easily and cause a lot of problems. We’ll talk about that more in the endocarditis lesson.

If you want more details on specific nursing interventions, check out the nursing care plan attached to this lesson. But just know our top 3 priorities for this patient are perfusion because their hearts will struggle to get the blood where it needs to go, infection control because of the high risk of endocarditis, and clinical judgment because we, as nurses, need to be assessing and identifying those murmurs!

So let’s recap – there are two main types of valve disorders that can affect all four major valves – regurgitation and stenosis. Being able to identify the murmur can help identify the valve problem. Remember that sudden onset of a murmur with signs of poor perfusion or lung congestion may signify a papillary muscle rupture, which is an emergency. Once the patient’s cardiac output is impaired, they will need a valve repair or replacement. And again, make sure you prioritize patient education for anticoagulant and infection control precautions.

We want you to feel super confident identifying these valve disorders and caring for a patient with them. Make sure you check out the care plan and other resources attached to this lesson to learn more. Now, go out and be your best self today! And, as always, happy nursing!

Read more

  • Question 1 of 2

A nurse is reviewing a client’s history and notes that the client has aortic stenosis. What heart sound would the nurse expect to hear?

  • Question 2 of 2

A nurse is assessing for murmurs in a client with aortic stenosis. At which location is the nurse most likely to hear a murmur in this client?