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Chapter 30 Coordinating Care for Patients With Cardiac Disorders
cases, aortic stenosis typically produces a systolic murmur described as turbulent or harsh. Most clinical manifestations of valvular disease resem- ble those of HF due to decreased cardiac output. They include the following: z SOB, dyspnea, orthopnea z Crackles z Angina z Syncope, dizziness z Dysrhythmias z Palpitations z Fatigue z Weight gain z Edema z Cool, pale extremities with weak pulses Interprofessional Management Medical Management Diagnosis Diagnostic Tests Diagnostic tests used to diagnose valvular disease include the following: z Echocardiogram (transesophageal or transthoracic) to identify valve abnormalities and ejection fraction z Chest x-ray to identify left or right heart hypertrophy and pulmonary edema z Electrocardiogram (ECG) for rhythm identification and conduction system assessment z Stress testing to identify functional capacity z Heart catheterization for hemodynamic assessment
Table 30.3 Types of Valvular Disease
Type
Description
Stenosis
Stiffening and thickening of the valve leaflets, caused by calcium deposits or scarring, narrow the opening and obstruct flow. Blood flows or leaks backward—ventricle to atria, aorta to the left ventricle, pulmonic circulation to the right ventricle—because of incomplete closing of the valve. Valve leaflets bulge backward and do not close, causing regurgitation.
Regurgitation or insufficiency
Prolapse
or continuous on the basis of where in the cardiac cycle it is best heard. Systolic murmurs can be heard during S1 or “lub” when the ventricles are contracting. During this time, the aortic and pulmonic valves should be open, and the mitral and tricuspid valves should be closed. Diastolic murmurs can be heard during S2 or “dub” when the ven- tricles are relaxing, and the heart is filling. The mitral and tricuspid valves should be open to allow for ventricular fill- ing, and the aortic and pulmonic valves should be closed. Therefore, a systolic murmur can be heard with aortic or pulmonic stenosis or mitral or tricuspid regurgitation. In contrast, a diastolic murmur can be heard with aortic or pulmonic valve regurgitation or mitral or tricuspid steno- sis. Another factor used to identify murmurs is the location of where the murmur is best heard based on the heart’s aus- cultatory sites. Mitral valve murmurs are best heard at the apex of the heart. Table 30.4 identifies valve murmurs and their defining characteristics. Murmurs can be described in terms of sound qualities, but practice is needed to develop this skill. For instance, although it is not true in all
z CT or MRI Medications
Medication management for valvular disease is dependent on the etiology and degree of the disease. Valvular diseases
Table 30.4 Valvular Disease Characteristics
Valve Disease
Auscultation Location
Manifestations
Mitral regurgitation
Systolic, 5th ICS left mid-clavicular line Left-sided HF, palpitations
Mitral stenosis
Diastolic, ICS left mid-clavicular line
Left-sided HF
Mitral prolapse
Systolic, 5th ICS left mid-clavicular line Chest pain, palpitations, syncope, anxiety, left-sided HF
Aortic regurgitation
Diastolic, 3rd ICS left sternal border
Left-sided HF, palpitations, widened pulse pressure
Aortic stenosis
Systolic, 2nd ICS, right sternal border
Left-sided HF, chest pain, syncope, narrowed pulse pressure
Pulmonary regurgitation
Diastolic, 3rd ICS left sternal border
Right-sided HF
Pulmonary stenosis
Systolic, 2nd ICS, left sternal border
Asymptomatic until severe, then right-sided HF
Tricuspid regurgitation
Systolic, 4th ICS left sternal border
Right-sided HF, atrial fibrillation
Tricuspid stenosis
Diastolic, 4th ICS left sternal border
Right-sided HF
HF, Heart failure; ICS, intercostal space.
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