Nu 144-Inflammatory Valvular Heart Disease

Front 1

Patient admitted has CK-MB markedly elevated 12 hours after admission. Nurse interprets this finding as
a. lactic acidosis
b. thrombolytic therapy
c. deterioration of cardiac function
d. cellular necrosis

Back 1

d. cellular necrosis

Front 2

Mr. I is admitted with an inferior MI, essentially pain free – which of the following is not part of diagnosing an MI?
a. patient’s history
b. physical exam
c. enzyme studies
d. serial EKGs

Back 2

b. physical exam

Front 3

An inferior wall MI results from occlusion of which artery?
a. anterior descending
b. right coronary artery
c. circumflex
d. left main coronary artery

Back 3

b. right coronary artery

Front 4

Most common complication of an MI is
______________

Back 4

dysrhythmias

Front 5

Inferior MI in will show how indicative changes in the
a. V1 – V4
b. V1 – AVL
c. V5, V6
d. II, III, AVF

Back 5

d. II, III, AVF

Front 6

Review of layers of the heart
The outermost layer is called the _________
The inner layer is called the __________
The innermost layer is called the _______ – contiguous with valves of heart

Back 6

Review of layers of the heart
The outermost layer is called the epicardium
The inner layer is called the myocardium
The innermost layer is called the endocardium – contiguous with valves of heart

Front 7

Infective Endocarditis
Definition:
 ___________________
 Affects the valves of the heart (endocardium is continuous with valves of the heart)
 75% - caused by bacteria (Strep, Staph), but we now know it can be from virus, fungal

Back 7

Infective Endocarditis
Definition:
 Life-threatening infection of the endocardial (inner) surface of the heart
 Affects the valves of the heart (endocardium is continuous with valves of the heart)
 75% - caused by bacteria (Strep, Staph), but we now know it can be from virus, fungal

Front 8

Infective Endocarditis
Definition:
 Life-threatening infection of the endocardial (inner) surface of the heart
 Affects the ____________
 75% - caused by _______________, but we now know it can be from virus, fungal

Back 8

Infective Endocarditis
Definition:
 Life-threatening infection of the endocardial (inner) surface of the heart
 Affects the valves of the heart (endocardium is continuous with valves of the heart)
 75% - caused by bacteria (Strep, Staph), but we now know it can be from virus, fungal

Front 9

Infective Endocarditis
Classification:
 ___ vs. _______
 Acute- _________
 Subacute- _________
 infectious organism – what is causing it – now how we classify endocarditis
 site of involvement - – ex. prostatic valve endocarditis

Back 9

Classification:
 acute vs. subacute
 Acute- shorter course, virus was more virulent
 Subacute- long course, insidious onset
 infectious organism – what is causing it – now how we classify endocarditis
 site of involvement - – ex. prostatic valve endocarditis

Front 10

Infective Endocarditis
Classification:
 acute vs. subacute
 Acute- shorter course, virus was more virulent
 Subacute- long course, insidious onset
 _____________ – what is causing it – now how we classify endocarditis
 site of involvement - – _______________

Back 10

Classification:
 acute vs. subacute
 Acute- shorter course, virus was more virulent
 Subacute- long course, insidious onset
 infectious organism – what is causing it – now how we classify endocarditis
 site of involvement - – ex. prostatic valve endocarditis

Front 11

Infective Endocarditis
 Etiology
 Normally bacteria enter bloodstream, lodge in ________________
 Two components- _______ and damage to _________
 Enter from skin, GI, __________, GU tract, from ____________, surgical intervention
 Untreated can lead to _________ malfunction

Back 11

Infective Endocarditis
 Etiology
 Normally bacteria enter bloodstream, lodge in damaged valves/abnormal heart tissue
 Two components- Pathogen and damage to endocardial tissue
 Enter from skin, GI, Respiratory, GU tract, from nosocomial procedures, surgical intervention
 Untreated can lead to heart valve malfunction

Front 12

Infective Endocarditis
 _______________ – mainly effects tricuspid valve
 Incidence and Prevalence – Commonly in elderly (after _________, occurs 2 x in men)

Back 12

 Pathophysiology – mainly effects tricuspid valve
 Incidence and Prevalence – Commonly in elderly (after 50, occurs 2 x in men)

Front 13

Infective Endocarditis
Predisposing Conditions:
 _____________ or an acquired heart conditions - occur in children/young adults – _____% due to congenital heart defects. As folks live longer, valves deteriorate along the way, so will see it in older due to that
 IV Drug use – _____________ patient. Affects, for some reason, the _________ valve – leads you in the direction that it might be associated with IV drug use – this is a generalization
 RHD - – rheumatic heart disease – in the past, most common cause.

Back 13

Infective Endocarditis
Predisposing Conditions:
 Congenital or an acquired heart conditions - occur in children/young adults – 75% due to congenital heart defects. As folks live longer, valves deteriorate along the way, so will see it in older due to that
 IV Drug use – younger adult patient. Affects, for some reason, the tricuspid valve – leads you in the direction that it might be associated with IV drug use – this is a generalization
 RHD - – rheumatic heart disease – in the past, most common cause.

Front 14

Infective Endocarditis
Predisposing Conditions:
 Congenital or an acquired heart conditions - occur in children/young adults – 75% due to congenital heart defects. As folks live longer, valves deteriorate along the way, so will see it in older due to that
 IV Drug use – younger adult patient. Affects, for some reason, the tricuspid valve – leads you in the direction that it might be associated with IV drug use – this is a generalization
 RHD - – _________________ – in the past, most common cause.

Back 14

Infective Endocarditis
Predisposing Conditions:
 Congenital or an acquired heart conditions - occur in children/young adults – 75% due to congenital heart defects. As folks live longer, valves deteriorate along the way, so will see it in older due to that
 IV Drug use – younger adult patient. Affects, for some reason, the tricuspid valve – leads you in the direction that it might be associated with IV drug use – this is a generalization
 RHD - – rheumatic heart disease – in the past, most common cause.

Front 15

Infective Endocarditis
Predisposing Conditions:
 ______________ – 1 out of 6 of those patients will develop endocarditis
 Prior history of endocarditis
 ASD – ____________
 MVP with murmur - – ___________

Back 15

 Prosthetic heart valves – 1 out of 6 of those patients will develop endocarditis
 Prior history of endocarditis
 ASD – atrial septal defect
 MVP with murmur - – mitral valve prolapse

Front 16

Infective Endocarditis
High Risk Procedures:
 Professional dental cleaning – take ________ as prevention- potential for bleeding/infection – high risk procedure
 Endoscopic examination or surgery of
a. _______
b. ___
c. ______

Back 16

Infective Endocarditis
High Risk Procedures:
 Professional dental cleaning – take antibiotics as prevention- potential for bleeding/infection – high risk procedure
 Endoscopic examination or surgery of
a. respiratory
b. GI
c. Urinary tract

Front 17

Infective Endocarditis
Clinical Manifestations - presents like flu – very generalized symptoms – need to assess for risk factors (ex. recent cleaning)
 ________
 _____
 ______
 _______
 Muscle aches and joint pain
 Sweating
 Anorexia, Weight loss

Back 17

Infective Endocarditis
Clinical Manifestations - presents like flu – very generalized symptoms – need to assess for risk factors (ex. recent cleaning)
 Fever and Chills
 Cough
 Fatigue, weakness
 Loss of appetite
 Muscle aches and joint pain
 Sweating
 Anorexia, Weight loss

Front 18

Infective Endocarditis
Clinical Manifestations - presents like flu – very generalized symptoms – need to assess for risk factors (ex. recent cleaning)
 Fever and Chills
 Cough
 Fatigue, weakness
 Loss of appetite
 _________
 __________
 __________

Back 18

Infective Endocarditis
Clinical Manifestations - presents like flu – very generalized symptoms – need to assess for risk factors (ex. recent cleaning)
 Fever and Chills
 Cough
 Fatigue, weakness
 Loss of appetite
 Muscle aches and joint pain
 Sweating
 Anorexia, Weight loss

Front 19

Infective Endocarditis
Possible assessment findings
 Onset of a new murmur
 -___% of new cases have a regurgitate murmur (blood backflow into left atrium) in the ______ valve – have blood going back into left atrium
 Symptoms associated with heart failure
 -__, __, crackles, _____, hypotensive (low CO)

Back 19

Infective Endocarditis
Possible assessment findings
 Onset of a new murmur
 80% of new cases have a regurgitate murmur (blood backflow into left atrium) in the aortic/mitral valve – have blood going back into left atrium
 Symptoms associated with heart failure
 SOB, edema, crackles, tachycardia, hypotensive (low CO)

Front 20

Infective Endocarditis
Possible assessment findings
Vascular manifestations
 Assess skin for __________ (brown streaks in fingernails and sometimes in toenails)
 ____________- small red spots in palm of hand, sometimes seen in feet
 _________
 ________ syndrome- cold extremites

Back 20

 Vascular manifestations
 Assess skin for splinter hemorrhages (brown streaks in fingernails and sometimes in toenails)
 Janeway lesions- small red spots in palm of hand, sometimes seen in feet
 Petechiae
 Blue toe syndrome- cold extremites

Front 21

Infective Endocarditis
Possible assessment findings
Other organ embolization
 Can occur just about anywhere- clots to brain (stroke, altered level of consciousness or TIA), neurological changes (___________), ________ to the kidney (flank pain, proteinuria), ________ (sharp increase left upper quadrant abdominal pain)

Back 21

 Other organ embolization
 Can occur just about anywhere- clots to brain (stroke, altered level of consciousness or TIA), neurological changes (aphasia), embolization to the kidney (flank pain, proteinuria), spleen (sharp increase left upper quadrant abdominal pain)

Front 22

Diagnostic Studies of Infectious Endocarditis
Patient History:
 recent procedures in the last ___-_____months? Dental, neurological, surgical, gynecological
 previous history of ________, especially _______ disease?
 history of ____use
 __________ – skin, urinary

Back 22

Diagnostic Studies of Infectious Endocarditis
Patient History:
 recent procedures in the last 3-6 months? Dental, neurological, surgical, gynecological
 previous history of heart disease, especially rheumatic heart disease?
 history of IV drug use
 recent infection – skin, urinary

Front 23

Diagnostic Studies of Infectious Endocarditis

 What is the single most important diagnostic test for Infectious Endocarditis. Positive in 90 - 95% of the patients (may be negative if the source is not bacterial – might be fungal). Need to get three sets of _________ within 24 hours. This is a priority before antibiotics

Back 23

 Blood cultures

Front 24

Diagnostic Studies of Infectious Endocarditis
 Other lab findings
a. mild ________ in about 30% of the patients
b. elevated ESR (___________ - marker for inflammation
positive rheumatoid factors are found in 50% of patients
c. _______ and __________ - – get a UA – found in 50% of patients

Back 24

 Other lab findings
a. mild leukocytosis in about 30% of the patients
b. elevated ESR (Erthrocyte sedimentation rate - marker for inflammation
positive rheumatoid factors are found in 50% of patients
c. proteinuria and hematuria - – get a UA – found in 50% of patients

Front 25

Diagnostic Studies of Infectious Endocarditis
Echocardiography
 _______ Echocardiography done first – detects vegetation in about 50% patients that you think may have endocarditis.
 If negative, do a TEE (___________). This is an invasive test, which is more sensitive, small risk for false negative (only is vegetation is very small). Even if negative, patient still might be treated. Can have fast negative in about __% of patients

Back 25

 Echocardiography
 Transthoracic Echocardiography done first – detects vegetation in about 50% patients that you think may have endocarditis.
 If negative, do a TEE (TransioEsophageal Echo). This is an invasive test, which is more sensitive, small risk for false negative (only is vegetation is very small). Even if negative, patient still might be treated. Can have fast negative in about 10% of patients

Front 26

Diagnostic Studies of Infectious Endocarditis
 C_____

Back 26

 CXR

Front 27

Infectious Endocarditis
Treatment aimed at prevention
 Identifying _____ patients
 __________ for the prevention of endocarditis for patients undergoing _____procedures
(mitral valve relapse with murmur, IV drug users, history of rheumatic heart disease)

Back 27

Treatment aimed at prevention
 Identifying high risk patients
 Antibiotic prophylaxis for the prevention of endocarditis for patients undergoing high risk procedures
(mitral valve relapse with murmur, IV drug users, history of rheumatic heart disease)

Front 28

Infectious Endocarditis
Treatment aimed at prevention
Antibiotics for treatment related to causative agent
 Depends on _, ____, _______, _______, site, susceptibility to ______, complications. ___% will have a relapse
 Treatment is no less than 6 weeks of IV antibiotics. Patients don’t have to stay in hospital (can have a home health nurse visit). Some may have a relapse

Back 28

Infectious Endocarditis
Treatment aimed at prevention
 Antibiotics for treatment related to causative agent
 Depends on age, condition, duration, severity, site, susceptibility to antibiotics, complications. 5% will have a relapse
 Treatment is no less than 6 weeks of IV antibiotics. Patients don’t have to stay in hospital (can have a home health nurse visit). Some may have a relapse

Front 29

Infectious Endocarditis
Treatment aimed at prevention
 Antibiotics for treatment related to causative agent
 Depends on age, condition, duration, severity, site, susceptibility to antibiotics, complications. 5% will have a relapse
 Treatment is no less than 6 weeks of _______. Patients don’t have to stay in hospital (can have a home health nurse visit). Some may have a _____

Back 29

Infectious Endocarditis
Treatment aimed at prevention
 Antibiotics for treatment related to causative agent
 Depends on age, condition, duration, severity, site, susceptibility to antibiotics, complications. 5% will have a relapse
 Treatment is no less than 6 weeks of IV antibiotics. Patients don’t have to stay in hospital (can have a home health nurse visit). Some may have a relapse

Front 30

Infectious Endocarditis
Treatment aimed at prevention
Antibiotics for treatment related to causative agent
 Untreated = ______, 100% fatal if you have the _________. If treated, mortality depends upon age, condition, duration of infection before it was treated, severity of underlying disease, how severely the valve was affected, the site of infection, how susceptible microorganism is to antibiotics, potential for complications
 Right side responds better to ______ and has better _________ than left

Back 30

Infectious Endocarditis
 Untreated = fatal, 100% fatal if you have the Aspirgillis fungus. If treated, mortality depends upon age, condition, duration of infection before it was treated, severity of underlying disease, how severely the valve was affected, the site of infection, how susceptible microorganism is to antibiotics, potential for complications
 Right side responds better to antibiotics and has better prognosis than left

Front 31

Infectious Endocarditis
Treatment aimed at prevention Surgical intervention
 – _______ valve replacement are difficult to treat. Surgical intervention might be needed to replace valve
 about ___% of patients diagnosed with endocarditis have valve surgery in the next couple of years
Remember, before you treat with antibiotics, get your ________ – they are your priority

Back 31

 Surgical intervention
 – fungal/prostatic valve replacement are difficult to treat. Surgical intervention might be needed to replace valve
 about 45% of patients diagnosed with endocarditis have valve surgery in the next couple of years

Remember, before you treat with antibiotics, get your blood cultures – they are your priority