Notes mod #6 Inflammatory Endocarditis/Myocarditis/Pericarditis (6/30/05) Inflammatory Disease affecting the Heart Etiology/Pathophysiology



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NOTES Mod #6 Inflammatory

Endocarditis/Myocarditis/Pericarditis (6/30/05)
Inflammatory Disease affecting the Heart

Etiology/Pathophysiology (general)
A. Pathophysiology

1. Various causes of inflammatory disease affecting heart (bacteria, fungus) * Review rheumatic fever and RHD management)




  1. Endocarditis: precipitated by bacteria/fungal infection; untreated lead to death from emboli and valvular disturbance

  2. Myocarditis: virus, toxin or autoimmune response damaging heart muscle: may lead to cardiomyopathy and death!

  3. Pericarditis: Bacterial, fungal or viral infection affecting visceral and parietal pericardium; restricts heart pumping action, can lead to cardiac tamponade and death!



Endocarditis (Infective)



  1. Etiology/Pathophysiology:

1. Pathogens enter bloodstream through dental work, invasive procedures and vegetation forms on damaged endothelium

a. Organisms colonize the vegetations and become covered with platelets and fibrin

b. Friable vegetations break off and* embolize and travel through blood stream to other organ systems

c. Emboli lodge in small vessels causing hemorrhages, infarcts, abscesses

d. *Vegetation scars and deforms valves and causes turbulent blood flow through the heart

2. Classifications (See p. 891, Tab 30-5)

a) Acute infective endocarditis

1) Abrupt onset, rapidly progressive severe disease

2) Staphylococcus aureus most common infective organism (associated usually with IV drug use)

b) Subacute infective endocarditis

1) Gradual onset with systemic manifestation

2) Occurs with preexisting heart disease

3) Organisms include Streptococcus viridans, enterococci, yeasts, fungi

c) Prosthetic valve endocarditis (PVE) (generally 2 mo after surgery; esp aortic valve)

1) Early onset is usually due to contamination during surgery or preoperative bacteremia and has high mortality rate

2) Late onset is similar to subacute endocarditis

3. Risk factors

a. Previous heart damage such as deformed valves, valve prostheses, areas of heart damaged by congenital or ischemic disease (left sided valves, especially mitral); history rheumatic fever!

b. *Intravenous illicit drug use (right sided valves usually affected): why? Due to IV site injection and travel to rt side of heart)

c. Invasive catheters (central venous lines, indwelling urinary catheters)

d. Dental procedures, poor dental health

e. Recent heart surgery


B. Common Manifestation/Complications

1. Temperature above 101.5o F. (39.4o C) with flulike symptoms (cough, shortness of breath, joint pain); esp acute endocarditis; blood cultures required!

2. Acute staphylococcal endocarditis may present with sudden onset of chills and high fever

3. Heart murmurs occur (new or worsening)

4. *Embolic complications

a. Splenomegaly with chronic disease

b. Peripheral manifestations

1) Petechiae

2) Splinter hemorrhages (hemorrhagic streaks under finger or toenails)

3) Osler’s nodes: small, reddened painful raised growths on finger and toe pads

4) Janeway lesions: small nontender purplish red macular lesions on palms of hands or soles of feet

5) Roth’s spots, small whitish spots seen on retina










  1. Complications include heart failure, organ infarction

    1. RT emboli (50% break off and have septic clots

1) Right sided endocarditis develop pulmonary emboli

2) Left sided emboli affect brain, spleen ,heart and limbs



    1. CHF

    2. Arrhythmia (afib most common)

    3. Death

    4. Cardiac tamponade



C. Therapeutic Interventions/Collaborative Care

    1. Diagnostic tests: * Identify and eradication infected organism with antibiotics; minimizing valve damage and complications

a. Blood cultures: considered positive if infecting organism is identified from 2 or more separate blood cultures (different sites, different times); temp above 101 drawn from different sites, different times)

b. WBC, ESR for elevations and decreased HCT and HGB

c. Echocardiography: visualization of vegetations and evaluation of valve function and TEE for best visualization of vegetation

d. Serologic immune testing: test for circulating antigens to infective organisms

e. Monitor Bun creatinine with use of antibiotics necessary to treat infection!!
2. Medications

a. *Antibiotic prophylaxis for pre-existing valve damage or heart disease prior to high risk procedures

b. *Infective endocarditis involves extended course of multiple intravenous antibiotics (2 – 8 weeks); repeat blood cultures

c. *Prosthetic valve endocarditis includes extended treatment (6 – 8 weeks) with combination of antibiotics


3. Surgery

a. Surgery may be part of treatment

1) To replace damaged valve

2) To remove large vegetation

3) To remove valve that is source of infection not responding to antibiotics

b. Surgery usually indicated for clients with valvular regurgitation causing heart failure that does not respond to antibiotic therapy; also fungal endocarditis


4. Nursing Diagnoses

a. Risk for Imbalanced Body Temperature

b. Risk for Ineffective Tissue Perfusion

c. Ineffective Health Maintenance

d. Knowledge deficit include: use of medications and need to complete therapy, need to notifying health practitioners of need for *prophylaxis with all invasive procedures (penicillin) ; need for dental care and hygiene and follow-up with physician;


Myocarditis
A. Etiology/Pathophysiology:

1. Inflammation of heart muscle from infectious process, immunologic response to radiation, toxins, medications

2. In US most myocarditis is viral due to Coxsakie B virus

3. More common in clients with altered immunity

4. Get decreased contractitility

5. Viral myocarditis usually self-limiting, but can become chronic and lead to *dilated cardiomyopathy

6. Myocardial cells damaged by inflammation and invading pathogens

7. Extent of damage determines outcome*

8. Risk factors include: URI, toxic or chemical effects (radiation, alcohol); autoimmune; metabolic disturbance-lupus; heat stroke or hypothermia









  1. Common Manifestation/Complications

1. Dependent on degree of myocardial damage; range from asymptomatic to heart failure

2. Non-specific: fever, fatigue, general malaise, dyspnea, palpitations, arthralgias (may be preceded by nonspecific febrile illness or upper respiratory infection)

3. Heart sounds: muffled S1, S3, murmur, pericardial friction rub, tachycardia

4. Manifestations of heart failure, chest pain, maybe MI, signs CHF, arrhythmia


C. Therapeutic Interventions/Collaborative Care

1. Diagnostic tests:

a. Electrocardiography: may show ST segment and T wave changes, dysrhythmias, possible heart block

b. Cardiac markers (Creatinine kinase, troponin T and I) may be elevated

c. Endomyocardial biopsy for definitive diagnosis




  1. Medications

a. Medications to eradicate infecting organism, including interferon-alpha for virus (antibiotics, antiviral with interferon-a)

b. Immunosuppressive therapy may be instituted with corticosteroids

c. Other medications may include: (heart failure drugs including ACE inhibitors, beta blockers, antiarrhythmics if indicated; anticoagulants, to prevent emboli

d. Bedrest and restricted activity during the acute inflammatory process; may be limited 3- 6 months

3. Nursing diagnosis/Nursing Care

a. Nursing Care focus: decreasing myocardial work and maintaining cardiac output

b. Nursing Diagnoses

1) Activity Intolerance

2) Decreased Cardiac Output

3) Fatigue

4) Anxiety

5) Excess Fluid Volume

6) Knowledge Deficit

a) Home Care teaching includes activity restriction; recognition of early manifestations of heart failure; medications, diet modifications; continue follow-up with medical care




Pericarditis and Cardic Tamponade
A. Etiology/Pathophysiology:

1. Inflammation of pericardium

2. Types include acute, which is usually viral in nature, can be bacterial or fungal

3. *Can result from end-stage renal disease and uremia, post-MI, post open heart surgery

4. Heart loses natural lubrication (15-50cc’s) and layers roughen and rub

5. Damage occurs to pericardial tissue leading to inflammation

6. Increased capillary permeability and plasma proteins seep into pericardial space forming exudates

7. Scar tissue or adhesions may form between pericardial layers

8. Chronic inflammation may cause pericardium to become rigid: chronic disorder* as pericardium becomes rigid

9. Risk factors: Post MI (Dressler’s syndrome); secondary to chemo and cancer; secondary to uremia in renal failure-40-50% of ESRD pts. develop this; trauma or cardiac surgery


B. Common Manifestation/Complications

1. Chest pain: aggravated by respiratory movement, changes in body position; sitting upright and leaning forward may reduce the pain

2. Pericardial friction rub: leathery grating sound produced by inflamed layers rubbing together; heard most clearly at left lower sternal border with client sitting and leaning forward during expiration
Pericardial Friction Rub (Go to this web site to hear a pericardial friction rub)



3. Fever (low grade) with dyspnea and tachycardia
4. Complications


  1. Pericardial effusion


1) Abnormal collection of fluid in pericardial space that threatens normal cardiac function

2) Fluid may be pus, blood, serum, lymph or combination

3) Rate at which effusion develops effects manifestations:

a) Slow build up causes no immediate effects

b) Rapid buildup can compress heart interfering with myocardial function (tamponade)

c) May have distant or muffled heart sounds, cough, mild dyspnea
b. Cardiac tamponade

1) Medical emergency; rapid collection of fluid interferes with ventricular filling and pumping, reducing cardiac output

2) Manifestations

a) Paradoxical pulse (pulsus paradoxus): pulse has marked decrease in amplitude during inspiration

b) Paradoxical pulse indicated by drop in systolic blood pressure of more than 10 mm HG during inspiration

c) Muffled heart sounds

d) Dyspnea and tachypnea

e) Narrowed pulse pressure

f) Distended neck veins
c. Chronic Constrictive Pericarditis

1) Scar tissue forms between pericardial layers and restricts heart movement and filling

2) May follow viral infection, radiation therapy, heart surgery

3) Manifestations: dyspnea; fatigue, weakness; ascites; neck vein distension during inspiration (Kussmaul’s sign)
C. Therapeutic Interventions/Collaborative Care (relieve symptoms; prevent complications)
1. Diagnostic tests:

a. Differentiate from MI: CBC and ESR: Elevated WBC and ESR reflect acute inflammation

b. Cardiac enzymes: elevation is lower than with MI

c. Electrocardiography: diffuse ST segment elevation in all leads which resolves more quickly than as with MI; Q waves and T wave changes associated with MI do not occur

d. Echocardiography: assesses heart motion, pericardial effusion and any restricted movement

e. Hemodynamic monitoring: assesses pressures and cardiac output

f. Chest xray: cardiac enlargement if pericardial effusion is present

g. CT scan or MRI to identify effusion or constrictive pericarditis


2. Medications

a. Aspirin or acetaminophen to reduce fever

b. NSAIDS for comfort

c. Corticosteroids for severe or recurrent pericarditis


3. Surgery/Other

a. Pericardiocentesis: Removal of fluid from pericardial sac for diagnostic or therapeutic purposes; involves needle insertion into pericardial sac and withdrawal of fluid; emergency procedure for cardiac tamponade

Cardiac monitoring during procedure; catheter to V lead

b. Surgery

1) Pericardial Window: excision of rectangular piece of pericardium to allow fluid to drain into pleural space with recurrent pericarditis or effusion




2) Partial or total pericardectomy with constrictive pericarditis
4. Nursing Care/Nursing Diagnoses Pericardidits

a. Acute Pain

b. Ineffective Breathing Pattern

c. Risk for Decreased Cardiac Output

d. Activity Intolerance

e. Knowledge deficit: regarding anti-inflammatory medications; activity restriction; manifestations of recurrent pericarditis and seeking treatment


___________________________________________________


Summary
Inflammatoru conditions of the heart can be life threatening, cause death

Management will depend upon etiology and disease manifestation

Surgery and in some cases, even transplant of the heart may be required.
General nursing (during acute phase) care includes:

O2

Bedrest



Positioning

Space Activities

Prevent complications of immobility

Psychological support



RNSG 2331 


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