Patients with Structural, Inflammatory, and Infectious Cardiac Disorders

Question 1

patho of rheumatic fever and heart disease

Answer 1

Strep throat that was never treated
Immune system attacking the heart
* Systemic inflammatory condition from a complication of Group A beta-hemolytic streptococcal pharyngitis (rheumatic fever)
* Can affect pericardium, myocardium, and endocardium
* Produces lesions in the heart and damage to connective tissues
* Rheumatic heart disease develops later in life if not treated

Question 2

s/s of rheumatic fever and heart disease

Answer 2

• Sore throat, fever, swollen glands (early)
• Headache, weakness, diaphoresis, irritability
• Nausea
• Erythema marginatum – non-itchy macular rash on trunk and extremities that blanches and does not scar

Question 3

medical and nursing management for preventing rheumatic fever and heart disease

Answer 3

• Throat cultures - swab back of throat - need for diagnosis
• PCN* for treatment; clarithromycin or clindamycin if allergic
• Echo for diagnosis - valve and ventricular function
• Long-term prophylaxis antibiotics
• Once had it, more succeptible
• Annual cardiac evaluation
• Monitor for s/s of valvular disease, heart failure, thromboembolism, and arrhythmias - sign of reoccurance
• Treat strep as a prevention!!

Question 4

patho of infective endocarditis

Answer 4

Serious infection of endocardium; can be systemic or pathogens enter through surgical or dental procedures or direct contamination
Vegetations = formation of platelets, fibrin, blood cells, and pathogens - clump together and grow on valves
–Can break off and cause emboli
Rapid onset

Question 5

common risk factors of infective endocarditis

Answer 5

Body piercing
Degenerative valve disease
IV drug use (IVDA)
Nosocomial endocarditis - central line gets infected
IV lines
Prosthetic cardiac valves - replacements
History of endocarditis

Question 6

clinical manifestations of infective endocarditis

Answer 6

Anorexia, myalgia, (fever and chills**), weight loss, back and joint pain, night sweats
Heart murmur
Osler nodes = painful, red nodules on pads of fingers and toes
Janeway lesions = painless, red or purple macules on palms and soles
Roth spots = oval retinal hemorrhages in eye with pale centers
Splinter hemorrhages - line up and down nail
Petechiae
CNS: headache, strokes
Cardiac: cardiomegaly, heart failure, splenomegaly, tachycardia
Abdominal discomfort

Question 7

assessment of infective endocarditis

Answer 7

Positive blood cultures - never off existing IV line
–Three sets 24 hours apart before administration of antimicrobial (Vancomycin)
Echo
–Presence of vegetation or abscess or regurg
Elevated WBC
Anemia - decreased production of RBC or destroyed
Elevated ESR and C-reactive protein - from increased inflammation
ECG
–Heart Blocks

Question 8

3 diagnostic criteria for infective endocarditis

Answer 8

Physical exam findings
Blood culture results
Echo findings

Question 9

goal of infective endocarditis

Answer 9

eliminating the infection and preventing complications

Question 10

medical and nursing management of infective endocarditis

Answer 10

Long-term IV antibiotics for 6 weeks
–Prevent complications of long-term IV therapy
–Take as prescribed and full course
–PICC line placement
Do not discharge pt with IV drug use history
Occasional blood cultures
Monitor for persistent infection, heart failure, kidney failure, or emboli
Valve replacement (if cause)
Recognize s/s of endocarditis and seek medical attention
Emotional support with coping strategies
Daily dental hygiene
Prophylactic before dental procedures

Question 11

patho of pericarditis

Answer 11

Inflammation of the pericardium (sac around the heart)
Develops rapidly when the pericardial sac is inflamed
Can lead to pericardial effusion = accumulation of fluid in pericardium  increased pressure on the heart (cardiac tamponade)

Question 12

causes of pericarditis

Answer 12

Acute MI
Bacterial, fungal, viral infection
Cancer and radiation therapy
Chest trauma
Disorders of adjacent structures (aneurysm, pneumonia)
Meds (isoniazid, hydralazine, procainamide)
Flu, mono, chicken pocks

Question 13

clinical manifestations of pericarditis

Answer 13

Chest pain that is persistent, sharp, pleuritic (deep breaths), and retrosternal (internal)
–Can radiate to neck, shoulders, arms
–Aggravated by deep inspiration, coughing, lying down, or turning
–Relief of pain when sitting forward
Friction rub
Mild fever, increased WBC
Anemia, elevated ESR and C-reactive protein (inflammation)
Nonproductive cough
Dyspnea
SOB

Question 14

assessment/diagnosis of pericarditis

Answer 14

Diagnosis (2 out of 4 to diagnose)
–Pleuritic chest pain
–Pericardial friction rub
–ECG with widespread ST elevation without T-wave inversion
–Pericardial effusion (new or increased)
Echo - looking for effusion - cardiac tamponade?

Question 15

goal of treating pericarditis

Answer 15

symptom relief and detect s/s of cardiac tamponade

Question 16

medical and nursing management of pericarditis

Answer 16

Treat underlying cause if known
NSAIDs and aspirin for inflammation
Pain management
Colchicine in combo with anti-inflammatories to reduce inflammation for recurrent
Sit upright and leaning forward to reduce pressure on pericardium
Restrict activity until pain resides
Psychological support, education, and reassurance

Question 17

treatment for pericarditis

Answer 17

C - Colchicine
U - underlying cause
P - Pain relief (NSAIDs, aspirin and PPI)
S - steroids

Question 18

patho of pericardial effusion

Answer 18

Accumulation of fluid in the pericardial sac

Question 19

side effects of pericardial effusion

Answer 19

Raises pressure within pericardial sac  compression of the heart
Can accumulate slowly and heart can stretch to accommodate
Can accumulate rapidly –> cardiac tamponade*
Can lead to shock and death if not treatedcaus

Question 20

causes of pericardial effusion

Answer 20

pericarditis,
HF,
metastatic carcinoma,
chemo,
cardiac surgery,
trauma

Question 21

clinical manifestations and assessment of pericardial effusion

Answer 21

chest pain
SOB
compression of near structures
Feeling of fullness within chest; ill-defined pain
Engorged neck veins with inspiration (Kussmaul sign)
Dyspnea, cough, and labile or low BP
Pulses paradoxus
–Difference in SBP heard during inhalation and exhalation
–Exceeds 10 mm Hg is abnormal
Pericardial friction rub
Cardinal signs of tamponade: falling SBP, narrowing pulse pressure, JVD, muffled heart sounds
CXR and Echo confirms diagnosis

Question 22

what is happening in pulses paradoxus

Answer 22

Difference in SBP heard during inhalation and exhalation
Exceeds 10 mm Hg is abnormal

Narrowing pulse pressure - difference between systolic and dyastolic

Question 23

Beck’s triad

Answer 23

falling SBP
JVD
muffled heart sounds

Question 24

cardinal signs of cardiac tamponade

Answer 24

falling SBP
narrowing pulse pressure
JVD
muffled heart sounds

Question 25

medical and nursing management with pericardiocentesis

Answer 25

Puncture of pericardial sac to aspirate fluid
Have emergency resus equipment at bedside
Elevate HOB to 45-60 degrees
Initiate peripheral line with IV infusion
Ultrasound guided needle to aspirate fluid
Feels immediate relief -
Fluid immediately sent to lab
Monitor for coronary artery puncture, arrythmias, pleural laceration, gastric puncture, myocardial trauma

Question 26

medical and nursing management of pericardiotomy

Answer 26

AKA pericardial window
Portion of pericardium is excised to allow fluid to drain into mediastinum and reabsorbed in lymphatic system
Care for cardiac surgical client
–like the CABG tx

Question 27

patho of acute pericardial tamponade

Answer 27

• sudden fluid accumulation
• pericardium cannot adjust
  –dramatic increase in pressure inside pericardial sac

Question 28

causes of acute pericardial tamponade

Answer 28

chest trauma
ruptured aorta
ruptured of ventricle after a heart attack