Acute Bilogocal Crises( Tissue Repair)

INDIVIDUAL REQUIREMENTS MECHANICAL AND TISSUE (BIOLOGICAL) VALVE REPLACEMENT: Mechanical Valve Replacement: • Ball-and-cage or disk design • More durable than tissue prosthetic • Often used for younger patients • Used for patients with renal failure, hypercalcaemia, endocarditis or sepsis who require valve replacement. • Do not deteriorate or become infected as the tissue valves used for patients with this condition (renal failure, hypercalcemia, endocarditis or sepsis) • Significant complication associated with mechanical valve replacement:  Thromboemboli requiring long-term use of anticoagulants  Some amount of hemolysis also occurs with mechanical valves (usually it is not clinically significant) Tissue (biological) Valve Replacement: • 3 types;  Xenografts (e.g bioprosthesis, heterografts) – used for all tricuspid valve replacement. - They are used for women of childbearing age because the potential complications of long-term anticoagulation associated with menses, placental transfer to a fetus, and delivery of a child do not exist. - Used also for patients with a history of peptic ulcer disease, and others who cannot tolerate long-term anticoagulation. - Most xenografts are from pigs (porcine), but valves from cows (bovine) may also be used. - Viability is 7 to 10 years. - Xenografts do not generate thrombi, thereby eliminating the need for long-term anticoagulation.  Homogratfs or Allografts (e.g human valves) - Obtain from cadaver tissue donations - Used for aortic and pulmonic valve and a portion of the pulmonary artery are harvested and are stored cryogenically. - Always available and are very expensive - Last about 10 to 15 years, somewhat longer than xenogratfs - Not thrombogenic and are resistant to sub-acute bacterial endocarditis.  Autografts (e.g autologous valves) - Obtain by excising the patient’s own pulmonic valve and a portion of the pulmonary artery for use as aortic valve. - Anti-coagulation is unnecessary because the valve is the patient’s own tissue and it is not thrombogenic

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Alternative for children , women of childbearing age, young adults, patient with history of peptic ulcer disease, and people who cannot tolerate anticoagulation. Aortic valve autografts have remained viable for more than 20 years Most aortic valve autograft procedures are double valve procedures; a homograft also is performed for pulmonic valve replacement. If the pulmonary vascular pressures are normal, some surgeons elect not to replace the pulmonic valve Patients can recover without a valve between the right ventricle and the pulmonic artery

Your choices are: Get a mechanical replacement valve. Get a tissue replacement valve.

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The decision about whether to get a mechanical or tissue valve takes into account your personal feelings and the medical facts. Deciding about a mechanical valve or tissue valve Reasons to get a mechanical valve • •

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A mechanical valve lasts 20 to 30 years. The durability of a mechanical valve makes it less likely that you will need another replacement valve in your lifetime. You are younger than 60 and are likely to outlive a tissue valve and require another valve replacement. You already are taking anticoagulants for another condition.

Are there other reasons you might want to get a mechanical replacement valve?

Reasons to get a tissue valve •

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You are older than 65 or have a health problem that makes it unlikely that you will outlive a tissue valve. You are less likely to develop blood clots. You do not want to take anticoagulants permanently. You are worried about the increased risks of bleeding associated with anticoagulants. Tissue valves tend to last longer in older people.

Are there other reasons you might want to get a tissue valve?

NURSING DIAGNOSIS AND INTERVENTIONS AFTER CARDIAC SURGERY: 1. Decrease cardiac output R/T blood loss, compromised myocardial function, and dysrhytmias

 Monitor cardiovascular status. Serial readings of blood pressure (arterial, pulmonary artery wedge pressure [PAWP], central venous pressure [CVP], cardiac output/index, systemic and pulmonary vascular resistance, and cardiac rhythm and rate are obtained, recorded, and tolerated with the patient’s condition  Observe for persistent bleeding; steady, continuous drainage of blood; hypotension, low CVP; tachycardia. Prepare to administer blood products, IV solutions  Observe for cardiac tamponade: hypotension; rising PAWP, PAD, CVP, or pulsus paradoxus; muffled heart sounds; weak thready pulse; jugular vein distention, decreasing urinary output. Check for diminished amount of blood in chest drainage collection system. Prepare reoperation.  Observe for cardiac failure; hypotension, rising PAWP, PAD, CVP, tachycardia, restlessness, agitation, cyanosis, venous distention, dyspnea, moist crackles, ascites. Prepare to administer diuretics, digoxin, IV inotropic agents  Observe for myocardial infarction: ST-segment elevations, T-wave changes, decreased cardiac output in the presence of normal circulating volume and filling pressures. Monitor serial ECGs and cardiac biomarkers. Differentiate myocardial pain from incisional pain. 2. Impaired gas exchanged R/T the trauma of the chest surgery  Maintain mechanical ventilation until the patient is able to breathe independently  Monitor arterial blood gases, tidal volume, peak inspiratory pressure and extubation parameters.  Auscultate chest for breath sounds  Sedate patient adequately, as prescribed, and monitor respiratory rate and depth if ventilations are not “controlled” by ventilator.  Assist in weaning and endotracheal tube removal  After extubation, promote deep breathing, coughing, and turning. Encourage use of the incentives spirometer and compliance with breathing treatments. Teach incisional splinting with a “cough pillow” to decrease discomfort. 3. Risk for imbalanced fluid volume (and electrolyte imbalance) R/T alteration in circulating blood volume  Maintain fluid and electrolyte balance  Be alert to changes in serum electrolyte levels 4. Disturbed sensory perception (visual or auditory) R/T excessive environmental stimuli (critical care environment, surgical experience), insufficient sleep, psychological stress, altered sensory integration, and electrolyte imbalances  Use measures to prevent postcardiotomy delirium o Explain all procedures and the need for patient cooperation o Plan nursing care to provide for periods of uninterrupted sleep with patient’s normal day-night pattern o Decrease sleep-preventing environmental stimuli as much as possible o Promote continuity of care

Orient to time and place frequently. Encourage family to visit Assess for medications that may contribute to delirium Teach relaxation techniques and diversions Encourage self-care as much as tolerated to enhance self-control. Assess support systems and coping mechanisms  Observe for perceptual distortions, hallucinations, disorientation, and paranoid delusions o o o o

5. Acute pain R/T surgical trauma and pleural irritation caused by chest tubes  Record nature, type, location, intensity and duration of pain  Assist patient to differentiate between surgical pain and angina pain  Encourage routine pain medication dosing for the first 24 to 72 hours and observe for side effects of lethargy, hypotension, tachycardia, respiratory depression. 6. Ineffective tissue perfusion (renal, cerebral, cardiopulmonary, gastrointestinal, peripheral) R/T decreased cardiac output, hemolysis, vasopressor, drug therapy, embolizaiton, underlying atherosclerotic disease, or coagulation problems  Assess renal function  Prepare to administer rapid-acting diuretics or inotropic drugs (i.e dobutamine)  Prepare patient for dialysis or continuous renal replacement therapy if indicated 7. Ineffective thermoregulation R/T infection or postpericardiotomy syndrome  Assess temperature every hour  Use aseptic technique when changing dressings, suctioning endotracheal tube; maintain closed systems for all intravenous and arterial lines and for indwelling urinary catheter  Observe for symptoms of postcardiotomy syndrome; fever, malaise, pericardial friction rub, arthralgia  Obtain cultures and other lab work (CBC, ESR); administer antibiotics as prescribed  Administer anti-inflammatory agents as directed 8. Deficient knowledge about self-care activities.  Develop teaching plan for patient and family. Provide specific instructions for the following: o Diet and daily weighs o Activity progression o Exercise o Deep breathing, coughing, lung expansion exercises o Temperature monitoring o Medication regimen o Pulse taking o Access to the emergency medical system o Need for medic alert identification

 Provide verbal and written instructions; provide several teaching sessions for reinforcement and answering questions  Involve family in teaching sessions  Provide contact information for surgeon and cardiologist and instructions about follow check-up visit with the surgeon  Make appropriate referrals; home care agency, cardiac rehabilitation program, community support groups, mended hearts club. CAUSE AND SIGNIFICANCE OF ‘GALLOP SOUNDS” • If the blood filling the ventricle is impeded during diastole, as occurs in certain disease states, then a temporary vibrations may occur in diastole that is similar to, although usually softer than, S1 and S2. The heart sounds then come in triplets and have the acoustic effect of a galloping horse; they are called GALLOPS. This may occur early in diastole, during the rapid-filling phase of the cardiac cycle, or later at the time of arterial contraction. • Gallop sounds are very low-frequency sounds and may be heard only with the bell of the stethoscope placed against the chest. • Best heard at the apex, although occasionally, when emanating from the right ventricle, they may be heard to the left of the sternum • A gallop sound that occurs during rapid ventricular filling is called a THIRD HEART SOUND (S3). Normal finding in children and young adults. • Such a sounds is heard in patients who have myocardial disease or in those who have HF and whose ventricles fail to eject all of their blood during diastole. • An S3 gallop – BEST HEARD WITH THE PATIENT LYING ON THE LEFT SIDE • Gallop sound that occurs during arterial contraction is called FOURTH HEART SOUND (S4) – often heard when the ventricle is enlarged or hypertrophied and therefore resistant to filling. • Such circumstances may associated with CAD, HTN, or stenosis of the aortic valve. • On rare occasions, all four heart sounds are heard within single period of cardiac contraction, ejection refilling, and resting, referred to as cardiac cycle, giving rise to what is called a QUADRUPLE RHYTHM ATHEROSCLEROSIS AS DAMAGING PROCESS Atherosclerosis is a disease in which plaque builds up on the insides of your arteries. Arteries are blood vessels that carry oxygen-rich blood to your heart and other parts of your body. Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood. Over time, plaque hardens and narrows your arteries. The flow of oxygen-rich blood to your organs and other parts of your body is reduced. This can lead to serious problems, including heart attack, stroke, or even death. WEB ASSIGNMENT: CARDIOMYOPATHY

 Cardiomyopathy is a weakening of the heart muscle or a change in heart muscle structure. It is often associated with inadequate heart pumping or other heart function problems.  TYPES: 1. Dilated Cardiomyopathy o Most common form of cardiomyopathy o 5 to 8 case per 100,000 people per year and increasing o Occurs most often in men and AfricansAmericans o Distinguished by significant dilation of the ventricles without simultaneous hypertrophy o Ventricles have elevated fraction o Formerly name Congestive Cadiomyopathy, but it may exist without signs and symptoms of congestion 2. Hypertropic Cardiomyopathy o Rare autosomal dominant condition, occurring in men, women , and children (often detected after puberty) o The heart muscle asymmetrically increases in size and mass, especially along the septum. o Often affects nonadjacent areas of the ventricle. o May be non-obstructive or obstructive o Has been called idiopathic hypertrophic sub-aortic stenosis and asymmetric septal hypertrophy. 3. Restrictive Cardiomyopathy o Characterized by diastolic dysfunction caused by rigid ventricular walls that impair diastolic filling and ventricular stretch. o Least common cardiomyopathy o 5% of cases of pediatric cardiomyopathies, is pathogenesis is the least understood. o May be associated with amyloidosis and other infiltrative diseases. 4. Arrythmogenic Right Ventricular Cardiomyopathy o Occurs when the myocardium of the right ventricle is progressively infiltrated and replaced by fibrous scar and adipose tissue. o Initially, only localized areas of the right ventricle are affected, but as the disease progresses, the entire heart is affected. Eventually, the right ventricular dilates and develops poorly contractility, right ventricular wall abnormalities and dysrythmias. o Prevalence is unknown because many causes are not recognized. o Palpitations or syncope may develop between 15 and 40 years of age 5. Unclassified Cardiomyopahties o Different from or have characteristics of more than one of the previously described types. o Examples include fibroelastosis, noncompacted myocardium, systolic dysfunction with minimal dilation, and mitochondrial involvement. TREATMENT STRATEGIES:

While all types of cardiomyopathy can cause heart failure, each case requires specific strategies for recovery. Treatment involves a combination of patient education, dietary changes, and medications. Possible medications include: • •

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ACE-inhibitors and angiotensin receptor blockers (ARBs): These drugs have been shown to improve survival and reduce heart-related complications. Aldosterone blockers: These drugs help balance electrolytes in the body. Studies have shown that aldosterone blockers can improve survival in patients who have a heart attacked complicated by cardiomyopathy. Beta blockers: Beta blockers are widely used for congestive heart failure. They improve survival in patients with cardiomyopathy and are important parts of therapy. Beta blockers slow the heart rate. Diuretics: Often called "water pills," diuretics help relieve the fluid overloads in heart failure. Positive inotropic medications: These medicines help the heart contract. They include dopamine, dobutamine, and milrinone. Vasodilators: These drugs dilate blood vessels at several levels in the body, reducing the workload for the heart.

Other drugs that correct irregular heart rhythms and blood thinners may also be used. Certain individuals with severely weak pumping function of the heart and severe heart failure may need a biventricular pacemaker. It works on the right and left chambers (ventricles) of the heart and keeps them pumping together. In very specific cases, this special pacemaker may also have a defibrillation function, which means it can quickly detect a life-threatening, rapid heartbeat and convert it back to normal. See: Defibrillation. In severe cases, surgery may be performed to help the patient live longer until a donated heart is available. However, surgery does not cure the disease. Surgical procedures include: •

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Left ventricular assist device (LVAD): LVADs are the most common type of heart pump. They help the left side of the heart push blood to the aorta, the body’s main blood vessel. Dynamic cardiomyoplasty: A procedure in which a flap created from a patient's chest muscle is trained to contract often and "wrapped around" the heart to help it contract.

Patients with advanced, severe heart failure need a heart transplant.