NURS 370 MED SURG: Module 4: Cardiac One B: Inflammatory, Infectious, Structural Disorders. Endocarditis and Valve Disorders

Endocarditis

An infection of the inner lining of the heart (endocardium), usually involving the heart valves.

Endocarditis Cause

Most often bacterial (Staphylococcus aureus, Streptococcus viridans), but can also be fungal.

Endocarditis Risk factors

IV drug use, prosthetic heart valves, congenital heart disease, previous endocarditis, invasive procedures (dental, surgical, IV lines).

Endocarditis Pathophysiology

Bacteria (or fungi) enter the bloodstream → attach to damaged endocardium/valves → form infected vegetations (clumps of organisms + fibrin).

Endocarditis Infected Vegetations

These vegetations can:

1. Damage valves → regurgitation/heart failure.

2. Break off → cause emboli → stroke, pulmonary embolism, kidney infarct, splinter hemorrhages.

Endocarditis Signs & Symptoms: General infection signs

fever, chills, malaise, fatigue, anorexia.

Endocarditis Signs & Symptoms: Cardiac signs

new or changing murmur, signs of HF.

Endocarditis Signs & Symptoms: Peripheral signs (classic NCLEX material)

1. Splinter hemorrhages (under fingernails).

2. Janeway lesions (painless, flat red spots on palms/soles).

3. Osler's nodes (painful, raised lesions on fingers/toes).

4. Roth spots (retinal hemorrhages with pale center).

Endocarditis Signs & Symptoms: Embolic complications

sudden neuro changes, flank pain, respiratory distress.

Endocarditis Diagnostic Workup: Blood cultures

positive for causative organism.

Endocarditis Diagnostic Workup: Echocardiogram (TEE)

visualize vegetations.

Endocarditis Diagnostic Workup: Labs

elevated WBC, ESR, CRP.

Endocarditis Nursing Interventions: Monitor

1. Vital signs, cardiac sounds (new/changed murmur).

2. Signs of emboli (neuro, lungs, kidneys, extremities).

Endocarditis Nursing Interventions: Medications

1. IV antibiotics (long course, often 4-6 weeks).

2. Antipyretics, rest, fluids.

Endocarditis Nursing Interventions: Patient education

1. Prophylactic antibiotics before dental or invasive procedures (high-risk patients).

2. Importance of finishing antibiotics.

3. Report symptoms of HF or emboli immediately.

Endocarditis Nursing Interventions: Surgical

valve replacement if infection is severe or valve destroyed.

Endocarditis NCLEX Pearls

1. Endocarditis = infection + vegetation + emboli risk.

2. Nursing priority: monitor for heart failure and embolic events, administer IV antibiotics, and teach about prophylaxis.

The Endocardium

1. The innermost layer of the heart wall.

2. It lines the chambers of the heart and covers the heart valves.

Endocardium is Made of

a thin, smooth layer of endothelial cells (similar to the inside lining of blood vessels).

Functions of the Endocardium: Smooth surface

Prevents blood clots by allowing blood to flow easily without turbulence.

Functions of the Endocardium: Valve coverage

Forms the surface of the atrioventricular (mitral, tricuspid) and semilunar (aortic, pulmonic) valves.

Functions of the Endocardium: Barrier function

Separates blood in the chambers from the heart muscle tissue.

Functions of the Endocardium: Clinical link

Because it's in direct contact with blood, it is the layer most affected by infective endocarditis.

Clinical Relevance for Nursing: Endocarditis

Infection/inflammation of the endocardium (often involving valves).

Clinical Relevance for Nursing: Valve disease

Many valve disorders originate in or affect the endocardial lining.

Clinical Relevance for Nursing: Thrombus risk

Damage to the endocardium (e.g., from turbulent flow in atrial fibrillation) increases clot risk.

Endocarditis: Aortic Valve

is a common site for endocarditis, especially in people with underlying valve disease, artificial valves, structural valve defects, or increased exposure to bloodborne pathogens.

Endocarditis: Chordae Tendineae

1. are string-like structures connecting the heart valves (especially the mitral and tricuspid valves) to the papillary muscles in the ventricles.

2. Infective Endocarditis can seriously affect these tendons.

3. Endocarditis can lead to infection and weakening of the chordae tendineae, especially when vegetations (infected clumps) form on valves.

4. Continued infection may cause these tendons to become fragile or rupture.

Peripheral Signs of Infective Endocarditis

1. Osler's Nodes

2. Janeway Lesions

3. Roth's Spots

4. Splinter Hemorrhage

Osler's Nodes: Appearance

Painful, red-purple, raised nodules commonly found on the tips of fingers or toes. Tender to touch; pain often precedes the lesion by up to 24 hours.

Osler's Nodes: Cause

Immune complex deposition (immunologic phenomenon).

Janeway Lesions

Reflect acute infective endocarditis and vascular phenomena.

Janeway Lesions: Appearance

Painless, flat, red-brown or purple macules on the palms or soles.

Janeway Lesions: Cause

associated with Microembolic Septic Events.

Roth's Spots: Appearance

Retinal hemorrhages with pale or clear centers seen on fundoscopic eye exam.

Roth's Spots: Cause

Caused by emboli or localized immune-mediated vasculitis.

Splinter Hemorrhages: Appearance

Linear, reddish-brown streaks under the nail beds, usually in the proximal portion.

Splinter Hemorrhages: Cause

Associated with microemboli or damaged small blood vessels.

Petechiae: Appearance

Small, pinpoint, red or purple spots on the skin, mouth, eyes, or other mucous membranes.

Petechiae: Cause

Represent tiny areas of bleeding due to emboli or vasculitis. Evidence of end tissue hypoxia due to emboli, similar to fat embolus syndrome breaks off and disrupts O2 delivery at tissue level

Endocarditis Cause

Inflammation/infection of the heart's inner lining (endocardium), most often from bacteria but sometimes fungi.

Endocarditis Common Risk Factors

1. History of rheumatic heart disease or prior endocarditis

2. Prosthetic (artificial) heart valves

3. IV drug abuse

4. Use of contaminated invasive devices (catheters, pacemakers, etc.)

5. Hemodialysis

6. Immunosuppression (e.g., cancer therapy, HIV)

7. Poor dental hygiene or oral infections

Endocarditis Pathophysiology

1. Infection forms vegetations/thrombi on valve leaflets and heart tissue; fragments can embolize and cause organ dysfunction.

2. Progressive damage leads to valve/wall/chordae tendineae destruction and impaired ventricular filling → decreased cardiac output and perfusion.

3. Risk of pulmonary congestion, heart failure, and systemic emboli

Endocarditis Assessment: Central & Peripheral Perfusion

1. Monitor vital signs

2. Capillary refill time

3. Peripheral pulses

4. Urine output

5. Skin color/temperature for signs of decreased perfusion.

Endocarditis Assessment: Temperature

Watch for fever spikes (>38.9°C/102°F), chills, and night sweats

Endocarditis Assessment: Breath Sounds

Assess for crackles; possible pulmonary vascular congestion (heart failure).

Endocarditis Assessment: Cardiac Rhythm

Look for arrhythmias (afib, heart blocks), inflammation may affect conduction system

Endocarditis Assessment: Laboratory Tests

CBC with WBC differential (shift to left), elevated ESR, blood cultures (essential for diagnosis), BUN/Cr (renal dysfunction), coagulation studies.

Endocarditis Assessment: Imaging

Echocardiogram for wall motion/valve dysfunction (diagnostic)

Endocarditis Assessment: Physical Findings

1. New/changed murmurs (high prevalence)

2. Signs of systemic emboli

3. Anorexia, weight loss, headache, malaise, arthralgia

Endocarditis Assessment: Physical Findings: Classic signs

Osler's nodes, Janeway lesions, Roth spots, splinter hemorrhages, petechiae, splenomegaly.

Endocarditis Assessment: Monitor for heart failure

Evidence of impaired body perfusion and pulmonary congestion

Endocarditis Interventions & Rationale: Rapid Recognition & Response

1. Frequent monitoring of vital signs and ECG for dysrhythmias

2. Watch for symptoms of heart failure due to drops in cardiac output/body perfusion

Endocarditis Interventions & Rationale: Maintain Gas Exchange

1. Monitor breath sounds for crackles

2. Provide oxygen, titrate to keep O₂ saturation >94%

Endocarditis Interventions & Rationale: Monitor Labs and Renal Function

1. Check WBC for leukocytosis, anemia

2. BUN/Cr for renal toxicity, especially during long-term IV antibiotics

Endocarditis Interventions & Rationale: Manage Vascular Access

Assess/maintain central venous catheter (CVC) for extended antibiotic therapy; monitor for irritation or infection

Endocarditis Interventions & Rationale: Antibiotic Therapy

Ensure antibiotics are administered on schedule (4-6 weeks to maintain therapeutic levels).

Endocarditis Interventions & Rationale: Symptom Management

1. Support for headache, fever, anorexia, nausea

2. Comfort positioning and activity modification as needed

Endocarditis Interventions & Rationale: Monitor

Fluid, Electrolyte, and Nutrition (FEN) status

Endocarditis Interventions & Rationale: Education

Stress importance of medication adherence and monitoring for symptoms of embolism and heart failure

Cardiac Valve Disorders

1. Mitral Stenosis

2. Mitral Insufficiency

3. Aortic Stenosis

4. Aortic Insufficiency

The Hearts Four Valves

Separated into

1. Atrioventricular Valves (AV):

A) Tricuspid (Right)

B) Mitral (Left) 2. Semilunar Valves:

A) Pulmonic (Right)

B) Aortic (Left)

3. Valves ensure unidirectional blood flow.

4. Problems occur when valves don't open or don't close properly.

Types of Valve Disorders

1. Stenosis

2. Regurgitation

3. Prolapse

Stenosis

Valve does not open fully → narrowed opening → blood flow obstructed. Results: increased pressure behind the valve, hypertrophy of the chamber.

Regurgitation (Insufficiency)

Valve does not close completely → blood leaks backward. Results: volume overload, dilation of the chamber.

Prolapse (specific to mitral valve)

Valve flaps bulge backward into the left atrium during systole. Usually benign, but can lead to regurgitation.

Blood Flow Order Through Valves

1. Tricuspid

2. Pulmonic

3. Mitral

4. Aortic MNEMONIC: Top Performance More Action

Why Valves Fail

(Mechanical Damage)

1. Infections (Endocarditis, Rheumatic Fever, Syphilis)

2. Congenital Heart Defects

3. Genetic Disorders (Marfan Syndrome)

4. Autoimmune Disorders (Lupus)

5. Atherosclerosis

6. Hypertension

7. Heart Failure

8. Calcifications (Tissue Aging)

9. Radiation Therapy to Chest

Chambers of the Heart

1. Right Atrium

2. Right Ventricle

3. Left Atrium

4. Left Ventricle

Right Atrium

Receives oxygen-poor blood from the body through the vena cava.

Right Ventricle

Pumps oxygen-poor blood to the lungs through the pulmonary artery.

Left Atrium

Receives oxygen-rich blood from the lungs through the pulmonary vein.

Left Ventricle

Pumps oxygen-rich blood to the body through the aorta.

Mitral Stenosis Cause

1. Rheumatic Fever (Most Common)

2. Calcification

3. Obstruction to forward flow from left atrium to left ventricle.

Mitral Stenosis Patho

Narrowed Mitral Valve --> Obstructed flow of Left Atrial = Pressure Increase --> Pulmonary Congestion.

1. Lack of Forward Flow causes Reduced LV filling ⇒ decreased cardiac output (↓ C.O.).

2. Pressure Build Up causes Backup into lungs ⇒ pulmonary congestion.

Mitral Stenosis Classic Murmur

Diastolic rumbling murmur (apex) with opening SNAP.

Mitral Stenosis Nursing Priorities

1. Monitor for AFib & HF symptoms

2. Anticoagulation often needed due to A-fib risk.

3. Possible valve repair/replacement

Mitral Stenosis S/SX

1. Dyspnea

2. Hemoptysis

3. Orthopnea

4. Atrial fibrillation Risk

5. Diastolic murmur.

6. Fatigue

Mitral Insufficiency (Regurgitation) Cause

1. MI

2. Rheumatic Heart Disease

3. Mitral Valve Prolapse

Mitral Insufficiency (Regurgitation) Patho

1. Valve doesn't close completely ⇒ blood flows backward into LA (Causing Dilation) as well as forward into LV.

2. Reduced net forward LV filling ⇒ ↓ cardiac output.

3. Backup into lungs ⇒ pulmonary congestion.

Mitral Insufficiency (Regurgitation) S/SX

1. Fatigue

2. Dyspnea

3. Palpitations

4. Pulmonary Congestion

5. HF

Mitral Insufficiency (Regurgitation) Classic Murmur

Holosystolic murmur (apex, radiates to axilla)

Mitral Insufficiency (Regurgitation) Nursing Priorities

1. Monitor HF

2. Give diuretics/ACE inhibitors

3. Anticoagulation if AFib

4. Surgical repair/replace

Aortic Stenosis Cause

1. Age-related calcification

2. Congenital bicuspid valve.

Aortic Stenosis Patho

Narrowed Aortic Valve --> LV pressure increases causing LV Hypertrophy that Reduces Cardiac Output.

1. Obstruction to forward flow from left ventricle into aorta.

2. Reduced LV ejection ⇒ ↓ cardiac output, Coronary Artery Perfusion, Central & Peripheral Perfusion.

3. Back up into Left Atrium and then Lungs: Pressure build up due to the lack of forward flow causes Backup and lung congestion.

4. Left ventricular hypertrophy develops due to increased pressure required to maintain cardiac output over time.

Aortic Stenosis Classic Murmur

Harsh systolic crescendo-decrescendo murmur (Best Heard at Right 2nd Intercostal Space, radiates to carotids)

Aortic Stenosis Nursing Priorities

Avoid strenuous activity, monitor for HF; valve replacement if severe

Aortic Stenosis S/SX

SAD:

1. Syncope: on exertion

2. Angina

3. Dyspnea

4. Harsh Systolic Murmur

Aortic Insufficiency (Regurgitation) Cause

1. Endocarditis

2. Rheumatic Disease

3. Congenital

4. Syphilis

Aortic Insufficiency (Regurgitation) Patho

Incomplete Closure --> Backflow into LV during diastole causes volume overload and LV Dilation:

1. Valve doesn't close completely ⇒ blood regurgitates back into LV.

2. Reduced net forward flow ⇒ ↓ cardiac output.

3. Backup into lungs ⇒ pulmonary congestion.

Aortic Insufficiency (Regurgitation) S/SX

1. Dyspnea

2. Palpitations

3. Bounding "water hammer" pulse

4. Widend pulse pressure

Aortic Insufficiency (Regurgitation) Classic Murmur

High-pitched blowing diastolic murmur (L sternal border)

Aortic Insufficiency (Regurgitation) Nursing Priorities

1. Monitor for Left Sided HF s/sx (dyspnea, orthopnea)

2. Diuretics/vasodilators

3. Surgical replacement if severe

Mitral Valve Prolapse Cause

1. Congenital

2. Connective Tissue Disorders

3. More Common in Women

Mitral Valve Prolapse Patho

Valve leaflets bulge into LA during systole; may cause regurgitation

Mitral Valve Prolapse S/SX

1. Often asymptomatic; may have palpitations

2. Chest pain

3. Anxiety

Mitral Valve Prolapse Classic Murmur

Mid-systolic click + late systolic murmur

Mitral Valve Prolapse Nursing Priorities

Reassure if mild; beta blockers for palpitations; avoid stimulants; monitor for worsening regurgitation

Cardiac Valve Disorders General: Diagnostics

1. Echocardiogram: gold standard (assess structure and function).

2. Chest X-ray: may show cardiomegaly.

3. ECG: arrhythmias (esp. AFib).

4. Cardiac catheterization: if surgery considered.

Cardiac Valve Disorders General: Nursing Management: Monitor

heart sounds (murmurs), VS, signs of HF, arrhythmias.