Inflammatory & Structural Heart Disorders

Layers of the Heart

Infective Endocarditis (IE)

• Disease of the endocardial layer of the heart, including the heart valves

• IE most often affects the aortic and mitral valves

Infective Endocarditis (IE): Principal risk factors

• Prosthetic valves

• Hemodialysis

• IV drug abuse (IVDA)

Infective Endocarditis (IE): Causative Organism:

• Bacterial

IE Etiology and Pathophysiology

• Occurs in three stages

• Bacteremia (bacteria in the blood)

• Adhesion

• Vegetation

IE Etiology and Pathophysiology

• vegetation

• Fibrin, leukocytes, platelets, and microbes

• Stick to the valve or endocardium 

• Parts break off and enter circulation (embolization)

  • Left-sided vegetation can move to brain, kidneys, spleen

  • Right-sided vegetation can move to lungs (PE)

IE Clinical Manifestations

• Nonspecific 

• Fever, Chills

• Weakness, Fatigue

• Abdominal discomfort, Anorexia 

• Diaphoresis

• Systolic murmur (worse)

• Septic embolism (worse)

• Heart Failure (worse)

• Arthralgias (joints)

• Myalgias (muscles)

• Clubbing of fingers

• Vascular manifestations

Vascular manifestations

• Splinter hemorrhages in nail beds

• Petechiae

• Osler’s nodes pea–sized, erythematous, tender nodules on fingertips or toes

• Janeway’s lesions on pads of the fingers and toes. Irregular, nontender hemorrhagic macules (mostly flat)

• Roth spots: retinal hemorrhage

IE Diagnostic Studies

• History

• Laboratory tests

• Echocardiography: check valve vegetation and flow

• Chest x-ray: enlarged heart

• ECG: blocks

• Duke criteria:

lab tests

• Blood cultures (3 cultures from 3 different sites)* Always cultures before beginning antibiotics

• CBC with differential

• ESR, C-reactive protein (CRP): Inflammation

duke criteria:

clinical criteria set for the diagnosis re: blood cultures, pt history, microorganisms, endocardial involvement, new vegetation, etc.

IE Collaborative Care

• Accurate identification of organism

• IV antibiotics (long-term-4 to 6 weeks)

• Repeat blood cultures

• Valve replacement, if needed

• Antipyretics

• Fluids

• Rest

• Home Care with meds

• Meds for pain (ASA) and inflammation (corticosteroids)

IE Collaborative Care: Prophylactic antibiotic treatment for patients having:

• Certain dental procedures

• Respiratory tract incisions

• Tonsillectomy and adenoidectomy

• Surgical procedures involving infected skin, skin structures, or musculoskeletal tissue

IE Patient Teaching

• Stress need to avoid infectious people

• Avoidance of stress and fatigue

• Plan rest periods 

• Good oral hygiene

• Prophylactic antibiotics

• Drug rehabilitation, if needed

• Signs and symptoms of complications

• Nature of disease and how to reduce risk  of reinfection

• Stress follow-up care, good nutrition

• Signs and symptoms of infection and prompt tx

Acute Pericarditis (Pericarditis)

• Inflammation of pericardial sac (pericardium)

Acute Pericarditis (Pericarditis) common causes

•  infectious agents (coxsackie B virus most common), noninfectious, hypersensitive, or autoimmune

Pericarditis Clinical Manifestations

• Progressive, severe, sharp chest pain worsening with deep inspiration and lying flat

• Pericardial friction rub*

pericardial friction rub

• Best heard lower left sternal border with the pt leaning forward

• Pt holds breath.  If you still hear rub, it is cardiac related (rather than a pleural friction rub)

• Muffled heart sounds

Pericarditis complications

• Pericardial Effusion (pericardium fluid build up)

• Cardiac tamponade (heart constricted, then decreased CO)

  • Chest pain, narrow pulse pressure (Sys-Dias = pressure arteries under—norm 40mmHg), tachypnea, tachycardia, neck vein distention, pulsus paradoxus (BP dec when breathing in), dyspnea

Pericarditis

• Diagnostics

• ECG (watch for ST segment changes), Echo, CT, MRI, CXR, CRP, ESR

Pericarditis

• treatment

• Identify underlying cause

• Bed rest with HOB at least 45° or Sitting up and leaning forward relieves pain

• Antibiotics, NSAIDS, Corticosteroids

• Always observe for signs of decreased CO—low urine output, decreased LOC, decreased BP

• Pericardiocentesis (to remove fluid)

  • Complication: Dysrhythmia

Myocarditis

• Inflammation of myocardium 

• Causes – infectious virus, radiation therapy, chemical, drugs, autoimmune disorders

Myocarditis tx

• Rest

• Heart transplant

• Medications include diuretics, ACE inhibitors, and beta-blockers for heart failure symptoms, while immunosuppressants are used for specific inflammatory types of myocarditis.

RHD

• Inflammatory disease that can affect all heart layers

• Scarring, vegetation, and deformity of heart valves, resulting from rheumatic fever. Creates Stenosis and Regurgitation (mitral and aortic valves most affected).

RHD complication of

•  Strep A pharyngitis, affects heart, also skin, joints, and CNS

• Primarily affects young adults

RHD Clinical Manifestations

• Carditis

  • Heart murmur of mitral/aortic regurgitation or stenosis

  • Cardiomegaly and heart failure

  • Pericarditis

    • Muffled heart sounds, chest pain, friction rub

• Monoarthritis or polyarthritis-joints

• Sydenham’s chorea: involuntary movement face, limbs

• Erythema marginatum lesions: pink macular (flat) lesions

• Subcutaneous nodules: knees, wrist, elbows

RHD complications

• chronic rheumatic carditis, mitral valve stenosis

RHD diagnosis

•  History, Lab Studies, CXR, Echo, ECG

RHD tx

• Rest

• Antibiotic, NSAIDS, salicylates, corticosteroids

• Prophylactic antibiotics when necessary

Valvular Heart Disease

• Mitral stenosis

• Mitral regurgitation

• Mitral valve prolapse 

• Aortic stenosis

• Aortic regurgitation

• Tricuspid and Pulmonic stenosis

Valvular Heart Disease…Clinical Manifestations

• Stenosis

• Exertional dyspnea

• Diastolic murmur (apex)

• Chest pain

• Hemoptysis

• Syncope

Valvular Heart Disease…Clinical Manifestations

• regurgitation

• Low CO

• Thready pulses

• Cool, clammy extremities

• Systolic murmur (apex)

• Weakness, fatigue

• Palpitations

• Dyspnea

• Crackles (higher up = worse)

Valvular Heart Disease…Prolapse (bulge)

• Asymptomatic

• Systolic Murmur

• Dysrhythmia

• Chest pain

• Dyspnea

• Palpitation

Valvular Heart Disease- diagnostic

Valvular Heart Disease tx

• Surgical Tx: Valve repair or replacement

• Prophylactic ATBs (dental)

• NA restriction diet

• Drug Therapy

• O2

valvular heart disease drug therapy

• Vasodilators, Positive Inotropes, Diuretics, β Blockers, Anticoagulants (until replacement, then 90 days after replacement valve), Antidysrhythmic

Valvular Heart Disease…Prosthetic Valves

• Types of prosthetic heart valves. (A) Starr-Edwards caged ball valve. (B) St. Jude bi-leaflet valve. (C) Carpentier-Edwards porcine valve. (D) CoreValve transcatheter aortic valve 

A patient is diagnosed with mitral stenosis and new-onset atrial fibrillation. Which interventions could the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

a. Obtain and record daily weight

b. Assess severity of pain level on 0 to 10 scale

c. Observe for overt signs of bleeding

d. Teach the patient how to get a Medic Alert device

e. Obtain and record vital signs, including pulse oximetry

While collecting a patient history, the nurse identifies which of the following risk factors as an increased risk for development of infective endocarditis?

a. Alcoholism

b. IV drug abuse

c. Glomerulonephritis

d. Atherosclerosis

In managing the care of a patient with acute pericarditis, the nurse ensures monitoring with which diagnostic procedure occurs daily?

a. Chest X-ray

b. ECG

c. CT scan

d. Blood cultures

After receiving change-of-shift report about these four clients, which client should the nurse assess first?

a. The 46-year-old with aortic stenosis who takes digoxin and has increasing dyspnea and new-onset, frequent premature ventricular (PVC) complexes

b. The 55-year-old admitted with pulmonary edema who just received furosemide and whose current O2 saturation is 94%

c. The 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths

d. The 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, rate 104

The nurse is assessing the client with a cardiac issue. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis?

a. Friction rub auscultated at the left lower sternal border

b. Pain aggravated by breathing, coughing, and swallowing

c. Splinter hemorrhages

d. Muffled heart sounds

The nurse is caring for a patient admitted with heart failure secondary to infective endocarditis. Which intervention would be the priority?

a. Encourage caregivers to learn CPR

b. Consider a consultation with hospice for palliative care

c. Monitor the patient’s response to prescribed medications

d. Arrange for the patient to enter a cardiac rehabilitation program.

A 72-year-old woman comes to the clinic with “flulike” symptoms. She has a history of hypertension, past MRSA infection, and a recently implanted pacemaker. 

What risk factors for infective endocarditis does she have?

What other symptoms might  the nurse assess for?

Make a nursing plan for this person.