endocarditis

Question 1

infective endocarditis

Answer 1

Is an infection of the innermost layer of the heart where the valves are.

Prognosis of IE has improved with use of antibiotics. Untreated will cause death.

15,000 cases are diagnosed per year.

Question 2

acute endocarditis

Answer 2

¨Affects those with healthy valves and is

rapidly progressive.

Question 3

sub acute endocarditis

Answer 3

¨Typically affects those with pre-

existing valve disease. Clinical course

       may extend over months.  Usually

              responds well to treatment.

Question 4

classified by cause of site (endocarditis)

Answer 4

Intravenous drug abuse infective

          endocarditis  (IE IVDA)

b. Fungal endocarditis
c. Prosthetic valve endocarditis (PVE)

Question 5

organisms that cause endocarditis

Answer 5

¨Bartonella quintana, Chlamydia
¨Coag. negative staphlococcus, enterococcus
¨MRSA, streptococcus, trophenyma whipple,
¨Rickettsiae, staph aureus, HACEK group
¨Viruses—coxsackie B virus
¨Fungi—Candida
¨
¨Most common cause is staph aureus and steptococcus viradans. Bartonella & trophenyma are new organisms that are difficult to cultivate. MRSA is hard to treat.

Question 6

predisposing cardiac conditions for endocarditis

Answer 6

¨Prior endocarditis, prosthetic valves
¨Acquired valve disease, cardiomyopathy
¨Pacemakers, Marfan’s syndrome
¨Asymmetrical septal hypertrophy
¨Rheumatic Heart Disease

Question 7

if you receive any procedure with endocarditis

Answer 7

any dental procedures or anything. Like murmurs

need to be on an antibiotcs

Question 8

non cardiac conditions that predispose you to endocarditis

Answer 8

¨IV drug abuse
¨Nosocomial infections

Question 9

procedures that predispose you to endocarditis

Answer 9

¨Intravascular devices, cardiac catherization
¨Oropharyngeal procedures
¨Bronchoscopy, esophageal dilation, endoscopy
¨Surgical procedures

Question 10

pathophysiology of endocarditis

Answer 10

¨Turbulent blood flow from damaged cardiac valves allows bacteria to settle on low pressure side of valve or defect.
¨Hallmark of IE is platelet-fibrin-bacteria mass on valve called vegetation. Organisms surround valve matrix, scarring and perforating leaflets.
¨Emboli can occur if vegetative growths break free and enter blood. 22% to 50% will experience systemic embolization with left sided vegetation. Right sided embolization goes to lungs.
¨Infection can spread from valve to supporting structures causing arrhythmias, valvular incompetence and possible heart failure.

Question 11

endocarditis in the mitral valve

Answer 11

affects organs

causes emboli to be pushed out into the system

Question 12

endocarditis in the tricuspid valve

Answer 12

causes emboli to go into the lungs

Question 13

symptoms of endocarditis

Answer 13

¨In acute type the onset is swift with septicemia and a fever over 38 degrees. The sub-acute is more insidious with vague complaints of malaise & aches & pains with low grade fever.
¨Chills, weakness, malaise, anorexia, fatigue.
¨Back pain, arthralgias, abdominal discomfort, headache, night sweats, and weight loss. May see clubbing of fingers in sub-acute.

Question 14

acute symptoms of endocarditis

Answer 14

come on strong. worst

Question 15

sub acute endocarditis symptoms

Answer 15

take longers to come on. not as stong. low grade fever

Question 16

vascular symptoms of endocarditis

Answer 16

¨Splinter hemorrhages on nail beds
¨Petechiae
¨Osler’s nodes-painful, tender, red or purple, pea size lesions on fingertips and toes
¨Janeway’s lesions-flat, painless, small red spots on palms and soles of feet.
¨Roth’s spots-hemorrhagic retinal lesions.
¨Onset of new or changing murmur is noted in most patients with aortic and mitral valve problems.

Question 17

embolization that comes of the left side (endocarditis)

Answer 17

¨Spleen—sharp LUQ pain and increased size of spleen
¨Kidneys—flank pain, hematuria, azotemia
¨Brain—neurological damage like ataxia, hemiplegia, aphasia, visual changes, changes in levels of consciousness.
¨Peripheral vessels to extremities–gangrene

Question 18

diagnostic studies for endocarditis

Answer 18

¨History of procedures in last 6months, IVDA(IV drug abuse), heart disease, intravascular devices, renal dialysis, infections.
¨Blood cultures
¨Elevated WBC, ESR, & C-reactive protein
¨Vegetative growth on echocardiogram
¨ECG
¨Chest Xray to check for cardiomegaly
¨Cardiac cath to evaluate valve.

Question 19

treatment for endocarditis

Answer 19

¨Long term antibiotic therapy
¨Valve replacement
¨Initially hospitalized for IV antibiotics . Then can get IV antibiotics on outpatient basis.
¨Will need prophylactic antibiotic therapy for any invasive procedures in the future.

Question 20

nursing care for endocarditis

Answer 20

¨Assess for history and subjective/objective symptoms of endocarditis.
¨Possible nursing diagnoses:

a. Decreased cardiac output
b. Hyperthermia
c. Activity intolerance
d. Knowledge deficit

Question 21

nursing interventions for endocarditis

Answer 21

¨Monitor vital signs, cardiovascular status, respiratory status and for complications
¨Administer medications as ordered
¨Give oxygen as needed, I&O, daily weight, keep HOB elevated.
¨Monitor labs/diagnostic procedures
¨Evaluate activity tolerance. Encourage balance between rest and activity to decrease cardiac workload.

Question 22

teaching a patient with endocarditis

Answer 22

¨Review patient’s knowledge about this condition
¨Review signs & symptoms of the disease and when to notify doctor.
¨Patient should avoid contact with people who have infections.
¨Patient should take prophylactic antibiotics prior to any invasive procedure.
¨Action of medications
¨Need for medical follow-up.
¨Avoid excessive fatigue.

Question 23

pericarditis

Answer 23

¨Is an inflammatory process of the visceral or parietal layer of the pericardium (membranous sac that encloses the heart)
¨Can be acute or chronic.
¨Acute pericarditis is commonly associated with:
¡Infective organisms ( bacteria, viruses, fungi)
¡Malignant neoplasms
¡Post MI syndrome ( Dressler’s Syndrome )
¡Post-pericardiotomy syndrome after cardiac surgery
¡Systemic connective tissue disease like Lupus
¡Renal disease with uremia

Question 24

acute pericarditis

Answer 24

¡Infective organisms ( bacteria, viruses, fungi)
¡Malignant neoplasms
¡Post MI syndrome ( Dressler’s Syndrome )
¡Post-pericardiotomy syndrome after cardiac surgery
¡Systemic connective tissue disease like Lupus
¡Renal disease with uremia

Question 25

pathology of pericarditis

Answer 25

¨Membranes around heart become inflamed and rub against each other causing a friction rub that persists through systole and diastole.

Question 26

symptoms of pericarditis

Answer 26

¨Patient complains of severe precordial chest pain that resembles MI pain. Pain intensifies in supine position and when the patient breathes deeply. May radiate to the trapezius muscle.
¨Pain is often relieved by sitting up and leaning forward.

hurts more on inspiration than expiration

¨Patient’s with acute pericarditis may also have a fever with an elevated WBC and SED rate.
¨May have malaise, myalgias, tachycardias.
¨If bacterial get high fevers, chills , shaking, and night sweats.

¨Patients with chronic constrictive pericarditis have signs of right sided heart failure, elevated venous pressure with jugular vein distention, hepatic engorgement, and dependent edema.
¨Exertional fatigue and dyspnea are common complications.

Question 27

diagnostics for pericarditis

Answer 27

¨ECG usually shows ST-T spiking with onst of Atrial Fibrillation. May also show pr depression.
¨CT, MRI, and Echocardiogram help to diagnosis this. May see thickening and calcification of the pericardium.

Question 28

pericardial effusion

Answer 28

¨Acute inflammation causes an accumulation of fluid within the pericardial sac. Can be serous. Purulent or hemorrhagic.
¨Puts patient at risk for cardiac tamponade. This restricts diastolic ventricular filling and cardiac output drops. Leads to cardiac failure, shock and death.

Question 29

symptoms of cardiac tamponade

Answer 29

Jugular vein distention

Hypotension

muffled heart sounds

Pulsus paradoxus ( SBP 10 mm Hg or more on

  expiration than on inspiration.

Narrowed pulse pressure

Question 30

collaborative care for pericarditis

Answer 30

¨Need to make sure it’s pericarditis and not an MI.
¨If effusion is small, treatment may be supportive. May use NSAIDS and sometimes corticosteroids. With larger effusions a pericardiocentesis is performed.
¨If cardiac tamponade is suspected it is an emergency. Have to manage low cardiac output and remove excessive fluid accumulation with pericardiocentesis. May need pericardial drain placement.
¨A portion of the pericardium may have to be removed if tamponade reoccurs.

Question 31

care of a patient with pericarditis

Answer 31

¨Assess the nature of the patient’s pain. Usually substernal and worse on inspiration and when the patient is supine.
¨Auscultate for a friction rub. Assist patient into position of comfort.
¨Provide anti-inflammatory agents as prescribed. Avoid use of ASA and anticoagulants since they may increase the risk of tamponade.
¨Assess for signs of tamponade and notify physician if it is suspected.

Question 32

calculation of pulsus paradoxus

Answer 32

¨Auscultate BP carefully to detect paradoxical blood pressure.
¨Palpate the blood pressure and inflate the cuff above SBP.
¨Deflate the cuff slowly and note when the sounds are first audible on expiration.
¨Identify when sounds are audible on inspiration.
¨Subtract the inspiratory pressure from the expiratory pressure. Greater than 10 mm hg is an indication of tamponade.

Question 33

treatment of chronic adhesive pericarditis

Answer 33

¨May need to remove pericardium (pericardiectomy) to restore cardiac function.
¨Will need to be monitored closely in ICU following surgery.