Chapter 24 Management of Patients w/Structural, Infectious, & Inflammatory Cardiac Disorders

Question 1

Functions of the Heart

Answer 1

Pumping
-Pumping oxygenated blood to the other body parts
- Pump hormones and other vital substances to different parts of the body

Receiving deoxygenated blood and carrying metabolic waste products from the body

Maintain BP

Question 2

Heart Failure (HF)

Answer 2

A clinical syndrome resulting from structural or functional cardiac disorders that impair the ability of a ventricle to fill or eject blood
-The heart is unable to pump enough blood to meet the body’s metabolic demands or needs

Question 3

Heart Failure Risk Factors

Answer 3

Cigarette smoking, obesity, poorly managed diabetes,
and metabolic syndrome

Question 4

The onset of HF is typically a …

Answer 4

…morbid consequence of another disease
- CAD, HTN, cardiomyopathy, valvular disorders, and renal dysfunction

Question 5

What is the primary cause of heart failure?

Answer 5

Atherosclerosis

Question 6

Pathophysiology of HF

Answer 6

Significant myocardial dysfunction occurs before the patient experiences signs/symptoms of HF such as SOB, edema, or fatigue.
- Ischemic Heart Disease
- Hyperthyroidism
- MI
- Valve disease
- Alcohol, cocaine use
- HTN
-> Leads to decreased CO, decreased systemic BP, and decreased kidney perfusion

As HF develops the body compensates to cope with the HF and are responsible for the signs/symptoms.
-Baroreceptor activation
->Stimulation of vasomotor regulatory centers in medulla
-> SNS activation
-> Increased secretion of epinephrine & norepinephrine
- RAAS system activation
* Increased aldosterone secretion
-> Na+ & water reabsorption
Both lead to vasoconstriction
- Increased afterload
- Increased BP & HR

The most common type of HF is systolic HF, also HF w/reduced Ejection Fracture (EF).

Question 7

LT Sided Heart Failure

Answer 7

Occurs when the LV, the heart’s main pumping power source is gradually weakened
- The heart is unable to pump
O2-rich blood from the lungs to heart’s LT atrium, into the LV and on through the body and the heart must work harder

Question 8

Clinical Manifestations of LT-sided HF

Answer 8

Pulmonary Congestion
-Dyspnea & cough
-Crackles & decreased O2 sat
-S3 gallop & orthopnea
-Paraoxysmal nocturnal dyspnea (PND)

Decreased Tissue Perfusion
- Decreased CO
- Decreased EF
- Decreased SV
- Increased Catecholamines (impedes perfusion over time)

Progressive Symptoms
- Decreased GI perfusion
- Decreased brain perfusion (lightheadedness, confusion, restlessness, & anxiety)
- Pale, ashen, cool, & clammy skin
- Tachycardia, palpitations, fatigue, nocturia

Question 9

S3 Sound

Answer 9

Early diastolic sound

Low pitched

Suggest poor systolic function and/or volume overload

Occurs when mitral valve opens & blood enters overfilled ventricle

Question 10

Paraoxysmal Nocturnal Dyspnea

Answer 10

Shortness of breath that occurs suddenly during sleep

Question 11

RT-Sided Heart Failure

Answer 11

Inability of the RT ventricle to fill or eject sufficient blood into pulmonary circulation

Question 12

Pathophysiology of RT-sided HF

Answer 12

Increased venous pressure leads to JVD and ↑ capillary hydrostatic pressure throughout the venous system → systemic clinical manifestations.
* Right-sided failure can occur as a result of left-sided failure

Question 13

Clinical Manifestations of RT-sided HF

Answer 13

Jugular vein distension (JVD) - From increased venous pressure

Dependent edema of the lower extremities

Hepatomegaly: Results from enlargement of the liver from venous
engorgement

Ascites due to fluid in the peritoneal cavity

Loss of appetite from nausea & pain

Generalized weakness: Decreased CO & impaired circulation

Question 14

Ascites

Answer 14

Accumulation of serous fluid in the peritoneal cavity

Question 15

Acute Decompensated Heart Failure (ADHF) Early Clinical Manifestations

Answer 15

1) Increase in RR

2) Decrease in PaO2

Question 16

Acute Decompensated Heart Failure (ADHF) Later Clinical Manifestations

Answer 16

1) Interstitial edema

2) Tachypnea

Question 17

Acute Decompensated Heart Failure (ADHF) Further Progression Clinical Manifestations

Answer 17

1) Alveolar edema

2) Resp Acidemia

Question 18

Nursing Process for Heart Failure

Answer 18

Assessment – effective of therapy, self-care strategies, explore emotional status

Health History – focus on the signs/symptoms of HF, ask about # of pillows used for sleeping (compensation for orthopnea), edema, abdominal symptoms, AMS, ADLs, and understanding of HF

Physical Examination
 LOC (↓ O2 to the brain)
 Respirations and lungs fields are auscultated to detect crackles and wheezes
 Evaluate BP for hypotension or hypertension
 Auscultated heart for S3 heart sound which is an early sign of ↑ blood volume in the ventricles
 Document HR and rhythm; patient may be placed on continuous ECG if hospitalized
 Assess JVD with the patient sitting at at 45-degree angle (distended > 4cm above sternal angle → Right HF
 Assess pulses, skin, lower legs for edema, abdomen for hepatomegaly, monitor I/O’s, and daily weight

Question 19

Planning & Goals for the Patient w/ HF

Answer 19

Promote activity and reduce fatigue

Relieve fluid overload symptoms

Decrease anxiety or increase the patient’s ability to manage anxiety

Encourage the patient to verbalize his or her ability to make decisions and influence outcomes

Educate the patient and family about management of the therapeutic regimen

Question 20

Diagnostic Testing for Heart Failure

Answer 20

Echocardiogram- determines ejection fraction (EF) and confirms dx of HF. An expected EF is 55%-65% of the
ventricular volume. EF is a measure of ventricular contractility

CXR

12-lead ECG

Serum electrolytes & CBC

BUN & Creatinine

Liver function tests

BNP test (Brain natriuretic peptide)- key indicator of HF; high levels are signs of high cardiac filling pressure and
aids in diagnosis and management of HF.

Question 21

Which test is the key indicator for heart failure?

Answer 21

BNP test

Question 22

Normal BNP Level

Answer 22

Less than 100

Question 23

What does a high BNP level indicate?

Answer 23

A high BNP level indicates high cardiac filling pressure & the presence of HF
-The higher the BNP, the worse the HF gets

Question 24

Select Medications for the Patient w/HF

Answer 24

Diuretics: ↓ fluid volume overload; observe for electrolyte abnormalities ↑ K+ (spironolactone), ↓ Na, ↓ BP

ACE inhibitors: ↓ BP, ↓ afterload; observe for cough and worsening renal function, ↓ BP, ↑ K+ (critical in the Tx for
CHF

Beta Blockers: dilates blood vessels, ↓ afterload, and improves exercise capacity; observe for ↓ HR, dizziness, fatigue, and symptomatic ↓ BP

Digitalis: Improves cardiac contractility; observe for ↓ HR and digitalis toxicity

Question 25

Adjunct Therapies for Heart Failure

Answer 25

Nutritional Therapy: Low Na+2 diet (no more than 2 g/day) to prevent fluid overload -Omega-3 supplements are recommended to reduce fatal CV events Supplemental Oxygen: Oxygen therapy may become necessary as HF progresses based on degree congestion and hypoxia - Some patients require supplemental oxygen during periods of activity Management of Sleep Disorders: Sleep apnea is common in HF patients - Continuous positive airway pressure (CPAP) is suggested to reduce apneic episodes and improve sleep

Question 26

Nursing Process for HF: Health History

Answer 26

Focus on the signs/symptoms of HF Ask about # of pillows used for sleeping -Assess for paraoxysmal nocturnal Dyspnea Edema Abdominal symptoms AMS ADLs Understanding of HF

Question 27

Nursing Process for HF: Physical Examination

Answer 27

LOC (↓ O2 to the brain) Respirations and lungs fields are auscultated to detect crackles and wheezes Evaluate BP for hypotension or HTN Auscultated heart for S3 heart sound which is an early sign of ↑ blood volume in the ventricles Document HR and rhythm; patient may be placed on continuous ECG if hospitalized Assess JVD with the patient sitting at at 45-degree angle (distended > 4cm above sternal angle → Right HF Assess pulses, skin, lower legs for edema, abdomen for hepatomegaly, monitor I/O’s, and daily weight

Question 28

Nursing Interventions for the Patient w/ HF: Promote Activity Tolerance

Answer 28

Bed rest for acute exacerbations Encourage regular physical activity; build up to about 30 minutes daily Exercise training Pacing of activities; wait 2 hours after eating for physical activity Avoid activities in extreme hot, cold, or humid weather Modify activities to conserve energy Positioning; elevation of the head of bed to facilitate breathing and rest, support of arms

Question 29

Nursing Interventions for the Patient w/ HF: Manage Fluid Volume

Answer 29

Assess for symptoms of fluid overload Daily weight I&O Diuretic therapy; timing of meds Fluid intake; fluid restriction Maintenance of sodium restriction

Question 30

Treatment of Acute Decompensated HF: Reduce Volume Overload

Answer 30

Diuretics (Furosemide)

Question 31

Treatment of Acute Decompensated HF: Improve Ventricular Function

Answer 31

Vasodilators (IV Nitroprusside, NTG), continuous monitoring

Question 32

Treatment of Acute Decompensated HF: Increase the force of Myocardial Contraction

Answer 32

IV inotropes (Milrinone, Dobutamine)

Question 33

Pulmonary Edema

Answer 33

Pathologic accumulation of fluid in the interstitial spaces & alveoli of the lungs causing severe respiratory distress - This situation demands EMERGENT action to prevent O2 and perfusion from becoming critical!!!

Question 34

Pathophysiology of Pulmonary Edema

Answer 34

It’s triggered when the LV fail and blood backs up quickly into the pulmonary circulation causing edema; PE can also develop slowly when caused by noncardiac disorders such as kidney injury The LV can’t handle the fluid overload → ↑ pulmonary pressure which forces fluid into the capillaries, interstitial spaces, and alveoli

Question 35

Pulmonary Edema Clinical Manifestations

Answer 35

Anxious, pale, cyanotic Cool and clammy skin Dyspnea Orthopnea Tachypnea Use of accessory muscles Incessant coughing w/ frothy, blood-tinged sputum Crackles and wheezes Tachycardia Hypotension or HTN Abnormal S3 or S4

Question 36

Medical Management of Pulmonary Edema

Answer 36

Easier to prevent than to treat Early recognition: monitor lung sounds and for signs of decreased activity tolerance and increased fluid retention Minimize exertion and stress Oxygen; nonrebreather Medications -Diuretics (furosemide) -Vasodilators(nitroglycerin)

Question 37

Nursing Management of Pulmonary Edema

Answer 37

Positioning the patient to promote circulation -Positioned upright w/ legs dangling Providing psychological support Reassure patient and provide anticipatory care Monitoring medications -I&O

Question 38

Which classification of meds play a pivotal role in the management of HF caused by systolic dysfunction? A) ACE inhibitors B) Beta-Blockers C) Diuretics D) Digitalis

Answer 38

A) ACE inhibitors

Question 39

Which of the following is NOT an appropriate recommendation for an exercise program for the patient with HF? A) Follow the exercise period with a cool-down activity B) High-intensity training will provide the most benefit C) Wait 2 hours after eating a meal before performing the physical activity D) Begin with low-impact activities such as walking

Answer 39

B) High-intensity training

Question 40

Cardiomyopathy

Answer 40

The heart can’t efficiently pump blood to the rest of the body due to a series of progressive events that culminates in impaired cardiac output

Question 41

What is major electrolyte involved with cardiomyopathy?

Answer 41

Sodium

Question 42

Pathophysiology of Cardiomyopathy

Answer 42

Decreased SV stimulates the SNS & the RAAS-> Increased systemic vascular resistance & increased Na+ & fluid retention -> Places an increased workload on the heart The decrease in CO can be seen on the echocardiogram as a decrease in ejection fraction -> can lead to HF

Question 43

Hypertrophic Cardiomyopathy

Answer 43

An autosomal genetic disorder that leads to ↑ heart muscle size and mass -The heart muscle becomes abnormally thick  The thickened muscle impairs the pumping action of the heart  Thickness of the heart reduces the size of the ventricles  Leads to ventricular hypertrophy & diastolic failure

Question 44

Dilated Cardiomyopathy

Answer 44

The heart muscle begins to dilate, stretch, and become thin → enlarged LV - Most common form of cardiomyopathy - Impaired contractility causes the heart to weaken → HF - Poor blood flow through the ventricle may → ventricular or atrial thrombi, which may embolize to other parts of the body

Question 45

Which type of cardiomyopathy is the most common?

Answer 45

Dilated cardiomyopathy

Question 46

Ischemic Cardiomyopathy

Answer 46

Term frequently used to describe an enlarged heart caused by CAD -Usually accompanied by HF

Question 47

Clinical Manifestations of Cardiomyopathy

Answer 47

Patients may remain stable and w/out symptoms for many years. As the disease progress, patients present with:  Dyspnea on exertion (DOE)  Syncope and Fatigue  Paroxysmal nocturnal dyspnea (PND)  Cough, Orthopnea, Peripheral edema  Early satiety, chest pain, palpitations

Question 48

Assessments & Diagnostic Findings Associated w/ Cardiomyopathy

Answer 48

History (predisposing factors, family history) Chest pain Review of systems: presence of orthopnea, syncope Review of diet (Na reduction, vitamin supplements) Psychosocial history: impact on family, stressors, depression Physical assessment: VS, pulse pressure; pulsus paradoxus; weight gain or loss; PMI; murmurs; S3 or S4; pulmonary auscultation for crackles, JVD, and edema

Question 49

Nursing Interventions for the Patient with Cardiomyopathy

Answer 49

Improve cardiac output and peripheral blood flow -Rest, positioning (legs down), supplemental O2, medications, low Na diet, avoid dehydration Increase activity tolerance and improve gas exchange -Cycle rest and activity, ensure patient recognizes symptoms that indicate the need for rest Reduce anxiety -Eradicate or alleviate perceived stressors, educate family about diagnosis, assist with anticipatory grieving Decrease the sense of powerlessness -Assist patients in identifying things that have been lost (i.e., ability to play sports), assist patients in identifying amount of control they still have left Promote home and community-based care -Educate patients about ways to balance lifestyle and work while accomplishing therapeutic activities -Assess patient and family and their adjustment to lifestyle changes, educate family about CPR and AEDs, establish trust

Question 50

The nurse is providing education to a client newly diagnosed with cardiomyopathy. Which statement should the nurse use to best describe cardiomyopathy to the client? A) Cardiomyopathy is another term for high blood pressure. B) Cardiomyopathy is an abnormal heart rate. C) Cardiomyopathy causes ineffective pumping of the heart. D) Cardiomyopathy develops when the kidneys cannot regulate blood pressure.

Answer 50

C) Cardiomyopathy causes ineffective pumping of the heart Rationale: Cardiomyopathy is a disease process in which the heart is weakened, which interferes with its ability to pump blood through the body. The other statements do not accurately describe cardiomyopathy.

Question 51

Valvular Regurgitation

Answer 51

The valve does not close properly, and blood backflows through the valve

Question 52

Valvular Stenosis

Answer 52

The valve does not open completely, and blood flow through the valve is reduced

Question 53

Valvular Prolapse

Answer 53

The stretching of the valve leaflet into the atrium during systole

Question 54

Mitral Valve Regurgitation

Answer 54

Blood flows from the LV back into the left atrium due to valve not closing properly

Question 55

Clinical Manifestations of Mitral Valve Regurgitation

Answer 55

SOB with exertion/SOB lying flat Fatigue Reduced ability to exercise Palpitations Swelling in legs, abdomen, and neck veins Chest pain (less common) A blowing systolic murmur heard at the apex * Confirmed w/ Echocardiography

Question 56

Treatment for Mitral Valve Regurgitation w/ HF

Answer 56

ACE Inhibitors, Beta Blockers and Valve Replacement

Question 57

Aortic Regurgitation

Answer 57

This is a back flow of blood into the LV from the aorta due to the aortic valve not closing tightly

Question 58

Clinical Manifestations of Aortic Regurgitation

Answer 58

SOB with exertion/SOB lying flat Fatigue Palpitations Swelling in legs, abdomen, and neck veins Chest pain or tightness with exertion High pitched, blowing diastolic murmur at the 3rd or 4th ICS at the left sternal border

Question 59

Treatment for Aortic Regurgitation

Answer 59

ACE Inhibitors & Ca Channel blockers for HTN management, and Aortic Valve replacement or Valvuloplasty

Question 60

How is mitral valve and aortic regurgitation confirmed?

Answer 60

ECHOcardiography

Question 61

Nursing Management: Valvular Heart Disorders

Answer 61

Educate the patient about the diagnosis and treatment Teach to report new symptoms or changes to the provider Explain that bacterium can easily adhere to a diseased heart valve more readily→ Endocarditis and further damage to the valve Measure VS and compare results with previous data Assess heart/lung sounds and peripheral pulses Assess signs/symptoms of HF, arrhythmias, symptoms of syncope, and chest pain Educate patient to relieve chest pain (angina) with rest before taking nitroglycerin

Question 62

Nursing Management of Patients with Valvular Heart Disorders

Answer 62

Patient education Monitor VS trends, heart and lung sounds, peripheral pulses Monitor for complications -Heart failure -Arrhythmias -Other symptoms: dizziness, syncope, angina pectoris Medication schedule: plan and education Daily weights: monitor for weight gain Plan activities with rest periods

Question 63

Valvuloplasty

Answer 63

Cardiac valve repair

Question 64

Annuloplasty

Answer 64

Repair of annulus of heart valve

Question 65

Annulus

Answer 65

Junction at which valve leaflets connect to the heart wall

Question 66

Leaflet Repair

Answer 66

Repair of cardiac valves movable "flaps" leaflets"

Question 67

Candidates for Valve Replacement

Answer 67

Patients w/: -Valves w/extensive calcification -Severely fibrotic or fused leaflets, chordae tendineae, or papillary muscles

Question 68

Bioprostheses

Answer 68

Valves made from animal tissues (heterograft) -Used for aortic, mitral, & tricuspid valve replacement Less risk of thromboembolism Shorter life than mechanical valves Long-term anticoagulation is not required -However, patients with biologic valves and atrial fibrillation must be on long-term anticoagulation

Question 69

Homografts

Answer 69

AKA "Allografts" Obtained from cadaver tissue donations used for aortic & pulmonic valve replacement Not always available-> highly expensive Lasts for 10-15 yrs

Question 70

Autografts

Answer 70

AKA "Autologous Valves" Obtained by excising the patient's own pulmonic valve & a portion of the pulmonary artery for use as the aortic valve

Question 71

Mechanical Valves

Answer 71

Last longer than biologic Higher risk of thromboembolism Require long-term anticoagulation  INR values of 2.5-3.5 considered therapeutic

Question 72

The nurse is caring for a client with mitral valve regurgitation. Which of the following is an expected assessment finding for this disorder? A. A High pitched, blowing diastolic murmur B. A blowing systolic murmur heard at the apex C. A loud, harsh systolic murmur is heard over the aortic area D. A low-pitched, rumbling diastolic murmur

Answer 72

B) A blowing systolic murmur heard at the apex

Question 73

Infective Endocarditis

Answer 73

Infection of endocardial layer of heart Endocardial layer continuous with heart valves Heart valves continuous with endocardium Valves commonly affected Vegetations form on valves or endocardial surface -May become emboli

Question 74

Most Common Cause for Infective Endocarditis

Answer 74

Streptococcus viridans and Staph aureus

Question 75

Risk Factors for Endocarditis

Answer 75

IV Drug Use Prosthetic heart valves Prior endocarditis Certain heart disorders:  Cardiomyopathies  Congenital heart disease  Acquired valve disease  Existing cardiac lesions Implanted Cardiac Devices  Pacemaker/Cardioverter Defib Hemodialysis

Question 76

Clinical Manifestations of Infective Endocarditis

Answer 76

Onset is usually insidious Often non-specific Fever, malaise, weakness, anorexia Arthralgia, myalgia Abdominal discomfort Cutaneous signs  Splinter hemorrhages: Reddish-brown lines & streaks that may be seen under half of fingernails & toenails  Osler’s nodes: Small painful nodules  Roth’s spots: Hemorrhages w/ pale centers caused by emboli (may be observed in fundi of eyes)  Janeway lesions: Irregular, red or purple, painless flat macules that may be present on palms, fingers, hands, soles, and toes

Question 77

Pathophysiology of Infective Endocarditis

Answer 77

1) Clot Formation: Deformity/injury of the endocardium leads to accumulation of fibrin & platelets on the endocardium 2) Infectious organisms invade the clot & endocardial lesion 3) Infection results in platelets, fibrin, blood cells, & microorganisms that clusters as vegetations on the endocardium -Vegetations may embolize to other vessels throughout the body 4) As the clot on the endocardium continues to expand, the infecting organism is covered by the new clot & concealed from the body's normal defenses 5) Infection may erode through the endocardium into underlying structures (valve structures) -> causes tears or other deformities of valve leaflets, dehisence of prosthetic valves, deformity of chordae tendineae, or mural abscesses

Question 78

Diagnostic Findings Associated w/ Infective Endocarditis

Answer 78

Blood Cultures x2 (aerobic/anaerobic) Echocardiogram (show vegetation) Labs: CBC (elevated WBC), Rheumatoid Factor (positive), ESR (elevated), CRP (elevated) Transesophageal Echo (TEE)-superior in assessing vegetations

Question 79

Prevention of Infective Endocarditis

Answer 79

Antibiotic prophylaxis: For those w/previous infective endocarditis, prosthetic heart valves, patients w/ heart transplant & valve regurgitation - Done before dental procedures Good Oral hygiene  Regular dental visits, brushing, flossing, and using plaque removal devices Increased vigilance required in patients with IV catheters and during invasive procedures  Nurses must perform meticulous hand hygiene  All catheters, drains, tubes should be removed when no longer needed

Question 80

Medical Management of Infective Endocarditis

Answer 80

Objective of Treatment: Eradicate invading organisms through adequate doses of an appropriate antibiotic Antibiotic therapy IV for 2 to 6 weeks  Serum levels of antibiotics and blood cultures are monitored to gauge effectiveness of therapy Patients may require psychosocial support Confined to home or hospital with restrictive IV therapy

Question 81

Nursing Management of Infective Endocarditis

Answer 81

The nurse monitors the patient’s temperature and administers antibiotics as prescribed Ensure planned rest periods and space activities due to fever→ fatigue Practice good infection control by nurse, patient, and family members NSAIDS prescribed for fever and discomfort Assess heart sounds for new or worsening murmur Assess all invasive lines and wounds daily redness, warmth, swelling, drainage, and tenderness Educate the patient and family members on activity restrictions, medications, and signs/symptoms of infection

Question 82

Pericarditis

Answer 82

Inflammation of pericardium, which is the sac enveloping the heart

Question 83

Clinical Manifestations of Pericarditis

Answer 83

May be asymptomatic Chest pain- most characteristic symptom; constant and worsens with inspiration/relieved by sitting forward Pericardial friction rub- most characteristic clinical manifestation Diffuse ST segment elevation Mild fever, elevated WBC, ESR, CRP, anemia Non-productive cough or hiccup/SOB

Question 84

Diagnostic Findings Associated w/ Pericarditis

Answer 84

Echocardiogram- detect inflammation TEE CT imaging: determine size, shape, and location of effusions MRI: detect inflammation and adhesions 12-lead ECG: may show ST elevations

Question 85

Medical Management of Pericarditis

Answer 85

If CO is impaired-> Pt is placed on bed rest until, fever, chest pain, and friction rub have subsided Analgesics & NSAIDS: Aspirin, indomethacin, or ibuprofen may be prescribed for pain relief during the acute phase -Corticosteroids (prednisone) can be used as an alternative when NSAIDS are contraindicated

Question 86

Objective of Medical Management of Pericarditis

Answer 86

Objective: Determine the cause, administer therapy for treatment & symptom relief & detect signs & symptoms of cardiac tamponade

Question 87

Key Point of Nursing Management of Pericarditis

Answer 87

BE ALERT for signs/symptoms of cardiac tamponade

Question 88

The nurse identifies that a patient has a characteristic symptom of pericarditis. Which symptom does the nurse recognize as significant for this diagnosis? a) Dyspnea b) Constant chest pain c) Fatigue lasting more than 1 month d) Uncontrolled restlessness

Answer 88

b) Constant chest pain

Question 89

Myocarditis

Answer 89

An inflammatory process involving the middle layer of the heart, the myocardium Can Cause: - Heart dilation - Thrombi on the heart wall (mural thrombi) - Infiltration of circulating blood cells around the coronary vessels & between muscle fibers - Degeneration of muscle fibers

Question 90

Pathophysiology of Myocarditis

Answer 90

Usually from an infectious source (viral: HIV, influenza A) - Can also be autoimmune-related (rheumatic fever or autoimmune disease) May begin in 1 small area then spread to the rest of the myocardium - Degree of myocardial inflammation & necrosis determines the degree of interstitial collagen & elastin destruction

Question 91

Clinical Manifestations of Myocarditis

Answer 91

May be asymptomatic as infection resolves May develop mild-moderate symptoms & seek medical attention (most are flu-like) - Fatigue - Dyspnea - Syncope - Palpitations - Occasional discomfort in the upper abdomen & chest

Question 92

Assessment & Diagnostic Findings Associated w/ Myocarditis

Answer 92

May reveal no detectable abnormalities (may go undiagnosed) Tachycardic & complain of chest pain Endomyocardial biopsy is the most definitive diagnosis - Cardiac MRI is used more often since it's non-invasive Patients w/out initial heart structure abnormalities may suddenly develop arrhythmias/ ST--T wave changes If the patient has structural abnormalities (systolic dysfunction): - Cardiac enlargement - Faint heart sounds (especially S1) - Pericardial friction rub - Gallop rhythm or systolic murmur Labs: WBC- elevated C-reactive protein- elevated Leukocyte count - elevated ESR - elevated

Question 93

Medical Management of Myocarditis

Answer 93

Given specific treatment if underlying cause is known (ex: antibiotics) Bed rest to decrease cardiac workload Activities should be limited for a 6 month period or until heart size & function have returned to normal - Should be increased slowly - Notify the clinician immediately of any symptoms w/increasing activity (rapidly beating heart) DO NOT USE NSAIDS FOR PAIN CONTROL!!! - Implication of increased cardiac injury & viral replication

Question 94

Nursing Management for Myocarditis

Answer 94

Assess for resolution of tachycardia, fever, & other clinical manifestations Focus on signs & symptoms of HF & arrhythmias Patients w/arrhythmias are to be put on continuous cardiac monitoring w/ emergent equipment ready Sensitive to digitalis Watch for signs of toxicity! Notify provider immediately if these symptoms are observed: - New onset of arrhythmia - Headache - Anorexia - N/V - Malaise