Ch.36 Inflammatory & Valvular Heart Disease

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INFECTIVE ENDOCARDITIS
overview

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infection of the endocardial surface of the heart that affects the cardiac valves. was always fatal, until it is treated with
penicillin. Usually affects cardiac valves.

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INFECTIVE ENDOCARDITIS
classification

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Two forms include the subacute form, insidous onset & causitive organism of low virulence(typically affecting those with preexisting valve disease and the acute form, shorter clinical course & rapid onset(typically affecting those with healthy valves).

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INFECTIVE ENDOCARDITIS
etiology

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The most common causative organisms of IE are Staphylococcus aureus and Streptococcus viridans.Vegetations, the primary lesions of IE, adhere to the valve surface or endocardium and can embolize to various organs (particularly the lungs, brain, kidneys, and spleen) and to the extremities, causing limb infarction. occurs when blood flow turbulence w/i heart akkiws causative organism to infect previously damages valves or endothelial surfaces. Main contributors:1)aging 2)IV drug abuse 3)increased survival rat eof kids w/ congential heart dis.

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INFECTIVE ENDOCARDITIS
CM

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The infection may spread locally to cause damage to the valves or to their supporting structures resulting in dysrhythmias, valvular incompetence, and eventual invasion of the myocardium, leading to heart failure (HF), sepsis, and heart block.Clinical findings in IE are nonspecific & can involve multiple organ sys. Low-grade fever, chills, weakness, malaise, fatigue, and anorexia (90%),Splinter hemorrhages (black longitudinal streaks) in the nail beds, Petechiae (a result of fragmentation and microembolization of vegetative lesions) in the conjunctivae, the lips, the buccal mucosa, and the palate and over the ankles, the feet, and the antecubital and popliteal areas, Hemorrhagic retinal lesions= Roth’s spots, A new or changing murmur in the aortic or mitral valve(80%), HF

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subacute infective endocarditis
CM

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Arthralgias, myalgias, back pain, abdominal discomfort, weight loss, headache, and clubbing of fingers

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INFECTIVE ENDOCARDITIS
CM

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Osler’s nodes (painful, tender, red or purple, pea-size lesions) on the fingertips or toes and Janeway’s lesions (flat, painless, small, red spots) on the palms and soles. Embolization to spleen= sharp, LUQ pain & splenomegaly. Tenderness & ABD rigidity. Kidneys may cause pain in flank, hematuria, & azotemi. Emboli may lodge in small peripheral blood vessels of arms/legs= gangrene. Nuerologic problems= hemiplegia, ataxia, aphasia, visual changes, LOC change. Pulmonary emboli= rt. sided endocarditis

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INFECTIVE ENDOCARDITIS
diagnostic studies

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blood culture primary. echocardiography, good when blood cul. are neg., chest x-ray, ECG+ 1st or 2nd blk of AV b/c cardiac valves lie close to conductive tissue. Catherterization, vlave functioning= for surgical interven.

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INFECTIVE ENDOCARDITIS
collab. care

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antibiotic prophylaxis for patients with specific cardiac conditions before dental, respiratory tract, gastrointestinal (GI), and genitourinary (GU)procedures and for high-risk patients who (1) are to undergo removal or drainage of infected tissue, (2) receive renal dialysis, or (3) have ventriculoatrial shunts for management of hydrocephalus.

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INFECTIVE ENDOCARDITIS
collab. care
-drugs

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I.D. ofo infecting organism is key to success. Drug therapy consists of long-term treatment with IV antibiotic therapy with subsequent blood cultures to evaluate the effectiveness of antibiotic therapy. antibotic serum levels monitored. Renal monitor b/c of emboli.Early valve replacement followed by prolonged (6 weeks or longer) drug therapy is recommended for patients with fungal infection and prosthetic valve endocarditis
Fever is treated with aspirin, acetaminophen(Tylenol), ibuprofe(Motrin), fluids, and rest.

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INFECTIVE ENDOCARDITIS
RN management

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Heart sounds assessed w/ VS to detect murmur or extradiastolic sound. Assessed for jt. tenderness, decreased ROM & musc. tenderness, oral mucosa, conjunctivae, upper chest, lower extrem checked for petechiae.

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Infec. Endo
RN implementation, goal

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Overall goals for the patient with IE include (1) normal or baseline cardiac function, (2) performance of activities of daily living (ADLs) without fatigue, and (3) knowledge of the therapeutic regimen to prevent recurrence of endocarditis.

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Infec. Endo
RN implementation

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Patients and families must be taught(health promo) to recognize signs and symptoms of life-threatening complications of IE, such as cerebral emboli (e.g., change in mental status), pulmonary edema (e.g., dyspnea), and HF (e.g., chest pain).Fever is a common early sign that the drug therapy is ineffective. acute inter= bed rest needed when fever .Laboratory data and blood cultures are monitored to determine the effectiveness of the antibiotic therapy, IV lines monitored, perform ROM exer., TCDB Q2, help reduce pt's. anxiety/fear.

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ACUTE PERICARDITIS

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inflammation of the pericardial sac (the pericardium). serves as an anchor, lubrication=decrease of friction during sys/dias, prevents excess dialation during dias

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ACUTE PERICARDITIetiology/patho

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Acute pericarditis most often is idiopathic but can be caused by uremia, viral or bacterial infection, acute MI, TB, neoplasm, and trauma.

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ACUTE PERICARDITIS
Pericarditis in the acute MI

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described as two distinct syndromes: (1) acute pericarditis (occurs within the initial 48 to 72 hours after an MI), and (2) Dressler syndrome (late pericarditis which appears 4 to 6 weeks after an MI). Inflammatory response is the characterisitc patho finding in acute peridarditis.

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ACUTE PERICARDITIS
CM

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Progressive, frequently severe chest pain that is sharp and pleuritic in nature and worse with deep inspiration and when lying supine. The pain is relieved by sitting. Pain can be referred to the trapezius muscle (shoulder, upper back).The hallmark finding in acute pericarditis is the pericardial friction rub.(heard, Lower Lt. strenal border)

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ACUTE PERICARDITIS
Complications

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pericardial effusion= accumulation of excess fluid in pericardium, can occur rapidly(chest trauma) or slowly(TB peri). LArge effusions can cause pulmonary tissue compression=cough, dyspnea, tachypnea. cardiac tamponade= b/c increased pressure inside small space. compression of heart, cm w// CArdiac Tamp.= confused, agitated, & restless. slow onset cm may only be dyspnea Pulsus paradox= inspiratory drop in sys.<10.

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ACUTE PERICARDITIS
Collaborative care

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i.d. what caused it and trt. that cause. Antibiotics for bacterial. Corticosteroids for pericarditis secondary to systemic lupus erythematosus, pt's already on corticosteroids for a rheumatologic or immune system condition, or pt's who do not respond to NSAIDs.
Pain and inflammation are usually treated with NSAIDs or high-dose salicylates (e.g., aspirin). Pericardiocentesis is usually performed for pericardial effusion with acute cardiac tamponade(change in sys.<30 from baseline), purulent pericarditis, and a high suspicion of a neoplasm. sterile W/ECG, echocardiogram, & hemodynamic measurements, 16-18 g to remove fluid & relieve cardiac pressure.

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ACUTE PERICARDITIS
RN management

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pt's pain and anxiety during acute pericarditis is a primary nursing. Amt, quality, location of pain. Re: ischemic chest pain, gen located retrosternal in lt. shoulder/arm w/ pressure, burning like & unaffected by posture, unlike pericar pain= in pericordium, lt.t rapezius, sharp, pleirtic quality change w/ respiration. Releif= leaning forward, no no lying back. Pain relief HOB 45%, padded table for leaning forward, antiinflam. meds. w/ food or milk.

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ACUTE PERICARDITIS
RN management

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ECG monitoring can aid in distinguishing ischemic pain from pericardial pain as ischemia involves localized ST-segment changes, as compared to the diffuse ST-segment changes present in acute pericarditis. co is real potential w/ acute peric b/c of possible card. tamponade.

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CHRONIC CONSTRICTIVE PERICARDITIS

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scarring with consequent loss of elasticity of the pericardial sac and begins with an initial episode of acute pericarditis followed by fibrous scarring, thickening of the pericardium from calcium deposition, and eventual obliteration of the pericardial space. cm= mimic HF cor pulmonale & include dyspnea on exertion, peripheral edema, ascites, fatigue, anorexia, and weight loss, prominent finding=elevated jugular venous pressure. Trtmnt of choice for chronic constrictive pericarditis is a pericardiectomy. complete resection of the pericardium through a median sternotomy with the use of cardiopulmonary bypass.

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MYOCARDITIS

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focal or diffuse inflammation of the myocardium caused by viruses, bacteria, fungi, radiation therapy,& pharmacologic & chemical factors. Myocarditis is frequently a/w acute pericarditis.