endocarditis
what is endocarditis?
Endocardium damaged-> platelets
form “clot”-> infectious organism invades “clot”->
vegetation is formed-> vegetation erodes and encapsulates -> valvular insufficiencies/ HF occur
-you need to treat the cause of endocarditis. heparin will not treat
what is myocarditis?
Toxin/ virus/ inflammatory process causes
inflammatory reaction in myocardium-> necrosis-> collagen and elastin is destroyed -> may lead to DCM and HCM
• Usually Viral- Flu A, HIV, COVID, hepatitis, Coxsackie a and b
• bacterial, Rickettsial, fungal, parasitic, protazoal
• Immune-related
• Toxin/ pharmacological agents
what is pericarditis?
inflammatory process → influx of neutrophils → ↑ vascularity →↑ vasodilation/edema/ permeability → proteins/fibrinogen →fluid in Sac (norm is 20cc's).. Fluid in pericardial sac= Pericardial Effusion.. Increased pressure on heart-> Cardiac Tamponade!!! (complication!) leading to decreased CO and s/s of HF
stenosis vs regurgitation?
stenosis: valve does not OPEN completely-> limiting FORWARD flow
Regurgitation: valve does not CLOSE completely-> blood flows BACKWARDS
1. what is aortic stenosis?
2. causes?
opening problem... progressive narrowing of the valve, which can take years to develop, left ventricle tries to compensate, blood flow backs up into left atrium and pulmonary circulation
2.
• Degenerative calcifications in adults
• Risk factors common for other cardiac dx’s
• Congenital leaflet malformations
• Rheumatic endocarditis
what is a commissurotomy valvuloplasty?
-who is this surgery for?
-what are the 2 types? closed/open?
• Repair of Commissures
• Most common
• To open opening
-for mitral valve stenosis young pts or aortic valve stenosis in old pts
-Closed/Balloon (no anesthesia/ bypass needed)
-Open (contraindicated in LA or LV thrombus)
1. what is dilated cardiomyopathy?
2. complications?
heart muscle necrosis leading to impaired ventricle contraction...dilation of ventricle... which causes less blood flow to the body and fluid backup in lungs. can be genetic or ideopathic
2. Complications
• MV Regurgitation
• Pulmonary Congestion
• Thrombi
1. indications for a heart transplant?
2. within how many hours must a heart be transplanted after being removed
1. • Cardiomyopathy
• Ischemic heart disease
• Rejection of previously transplanted heart
• Congenital heart disease
2. 4 hours!
rheumatic endocarditis vs infective (bacterial)?
RHEUMATIC:
• Rheumatic Fever
• Group A Streptococcal pharyngitis
• Mitral Valve is most common
• Common in school aged kids
INFECTIVE:
• Staphylococcus
• Streptococcus pneumoniae
• Enterococci
• Chlamydia
• Fungus, viruses, parasites etc.
• Common in older people
myocarditis risk factors?
• Clients on Immunosuppressive therapy
• Prior or current HX on infectious endocarditis
• Crohn’s Disease, Lupus
types of pericarditis and etiology
• Acute, chronic, recurring
• Adhesive (constrictive)-fluid becomes sticky, cannot fill ventricle
• Serous, purulent, calcified, fibrinous, sanguinous, malignant
• Exudative and non-effusive
• Primary illness
• Idiopathic
• Usually viral, rarely bacterial/ fungal/parasitic
mitral valve prolapse: what is the first and only sign?
2. treatment?
mitral click
but could also have HF s/s like fatigue, SOB, dizziness, palpitations, CP
2. *Manage symptoms*
• Lifestyle changes- no caffeine, alcohol
• Antiarrhythmic meds
• Patient education
1. assessment findings of aortic stenosis?
2. complications?
1. • Asymptomatic-until heart gives out
• DOE
• Orthopnea, nocturnal dyspnea
• Pulmonary Edema (crackles, wheezing)
• Dizziness/syncope
• Angina
• BP can be normal or low
• Systolic murmur or S4
2. • Heart Failure
• Thromboembolism
• Atrial or Ventricular dysrhythmias
what is an annuloplasty valvuloplasty?
• Repair to Annulus
• To narrow the diameter of valve
-for regurgitation pts because they're valves don't close all the way
-open procedure-Ring placed/ sutured
-Tucking/Stapling of the leaflets
1. what is hypertrophic cardiomyopathy?
2. complications?
heart wall increases, thickens, which decreases the size of the ventricles meaning they cant fill properly, so the atrium has to work harder leading to decreased CO, ischemia, necrosis. can be genetic or ideopathic, typically detected after puberty
2. complications- ventricular dysrhythmias (vfib or vtach)...
what is a Orthotopic Transplantation?
*Remove recipient’s heart but leave a portion of the atria, vena cava, and pulmonary veins in place*
• Prior endocarditis
• Gingival manipulation
• Anatomic cardiac defects / devices/ HCM
• Indwelling catheters, Hemodialysis
• Prolonged IV fluid or antibiotic use
• ↓ Immunological response
• Metabolic alterations due to age
• IV drug use, Body piercings, Tattoos
what are some assessment findings that you'd see withyocarditis?
• Most Common c/o:
FLU-like symptoms
-Could be asymptomatic
-Mild/Moderate fatigue, dyspnea, syncope, palpitations, discomfort in chest or upper abdomen, tachycardia
- Faint Heart sounds (S1), gallop or systolic murmur (s3, s4)
some risk factors for pericarditis?
• Primary illness
• Post MI-dresslers syndrome
• s/p pericardectomy
• Connective tissue disorders
• Decreased immune response
• Hypersensitivities to meds
• Neoplastic disease
• Radiation to chest
• Trauma/ surgery
• Renal failure/ uremia
1. what is mitral valve stenosis?
2. what can this be cause by?
chordae tendineae gradually thicken-> Valve can’t open properly....causing blood flow obstruction, decreased CO, right-sided HF
2. • Rheumatic fever
• Endocarditis
• Recurrent Strep
• Radiation to chest
diagnostics of aortic stenosis?
• Echo- every 1-5 years unless they're symptomatic, then 6-12 months
• CMR
• Cardiac Cath-severity
• Exercise Stress Test-BUT NOT IF THEY HAVE DYSRHYTHMIAS.tests are not performed on unstable patients.
what is a chordoplasty valvuloplasty?
• Repair the Tendineae
• Fix short leaflets
-most always for MV
-open procedure
1. what is restrictive cardiomyopathy?
2. assessment findings?
1. ventricle walls are rigid limiting its stretch, blood backs up into left atrium leading to increased PAP and CVP. causes: ideopathic or amyloidsis
2. -dyspnea, non productive cough, CP
1. what meds are used to minimize rejection
2. what kinds of strict regimens do heart transplant pts include?
• Corticosteroids-decrease immune response
• Calcineurin inhibitors-decrease immune response
• Antiproliferative agents
2. • Diet control
• Medications
• Activity restrictions
• Follow up labs
• Biopsies
• Clinic visits
assessment findings for endocarditis?
-Fever, chills, malaise, murmur OR asymptomatic
-progression: S+S from toxic effects of infection- tachycardia/ palpable thrills
-Complications: cardiomegaly, S+S HF, S+S embolization (pulmonic or systemic), stroke s/s if clot travels to brain, decreased urine output if clot travels to kidneys
skin: assess for petechia, pink lesions, Oclers nodes (painful lesions on fingers or toes), janeways lesions (small painless spots on palms or soles), roths spots (retinal hemorrhages)
whats a big complication of myocarditis?
• Sudden cardiac death
• Severe CHF
assessment findings for pericarditis?
2. Complications?
• Asymptomatic
• CHEST PAIN-worsens with deep inspiration, laying down, turning
• Friction rub-Left sternal border 5th ICS
• Mild fever
• Nonproductive cough or hiccup
• Dyspnea
• Tachycardia
• Malaise, fatigue, weakness, anorexia
2. HF, pericardial effusion, cardiac tamponade
assessment findings of mitral valve stenosis? what is the first symptom?
2. complications that can arise?
• 1st symptom: DOE
• Progressive fatigue
• Decreased exercise tolerance
• Dry cough of wheezing
• Diastolic murmur
• Atrial dysrhythmias
• Weak pulse, palpitations
2. • Heart failure
• Atrial arrhythmias
• Thromboembolisms
• Endocarditis
• Pulmonary HTN
• Pulmonary edema
1. medical management of aortic stenosis?
2. surgical management of aortic stenosis?
goal: prevention!!!!
1. • HF Treatment
Digoxin
ACE inhibitors
Diuretics
Beta Blockers *use with caution*
Antidysrhythmics
• Restrict activity
• Low sodium diet
2. • Valve replacement
• Percutaneous balloon valvuloplasty
mechanical vs prosthetic valves for valve replacement: name some key points pls
• Bileaflet, tilting disc, ball-and- cage
• More durable
• Younger, renal, endocarditis, and sepsis patients
• Require long term anticoag’s- increases risk for bleeding!
• Complications: thromboemboli
• Bioprostheses, homografts, autografts
• Not as durable
• Less likely to generate emboli-so only anticoags for the first 6 months
1. what is arrhythmogenic right ventricular cardiomyopathy?
2. assessment findings?
1. myocardium is replaced with scar tissue, progresses to entire heart, right ventricle dilates leading to poor contractility, and dysrhythmias. uncommon, inherited, often unrecognized.
2. palpitations, dysrhythmias, ankle swelling, s/s of right sided HF
complications of heart transplant?
• Rejection-can happen literally anytime ever
• Infection
• Accelerated atherosclerosis
• Injury/inflammation of coronary arteries
• HTN
• Osteoporosis
• Cancer
• Organ affects R/T corticosteroids
diagnostics for endocarditis?
• Positive blood cultures (takes like 3 days)
1. get blood
2. start on broad-spectrum
3. once culture comes,more specific antibiotics
• CBC
• Rheumatoid Factor (+)
• ESR / CRP (+)
• Urinalysis (proteins in urine, hematuria)
• CXR
• Echocardiogram / TEE (ASAP NO ROCKY!)
• EKG
• Throat Culture (strep)
• Cardiac Enzymes (troponin, CPK)
*Rheumatic: mostly by symptoms and EKG changes*
diagnostics for myocarditis?
Cardiac Catheterization (shows normal CA and heart pressures)
CMR is better diagnostic and non-invasive
EKG
CBC & ESR (+)
CXR
Enzymes
-WBC elevated
What major complication can pericarditis lead to?
2. first signs of this?
3. late signs of this?
4. how much fluid does it take to have this?
cardiac tamponade!!!!! a medical emergency!
-Extra fluid in pericardial sac -> significant compression
First signs:
• SOB
• Chest tightness
• Dizziness
• Increased restlessness
Late signs:
• Pulsus paradoxes (on inspiration, SBP decreased by 10)
• Narrowing pulse pressure (normal 30-40, narrow 10-20)
• Muffled heart sounds
• JVD
• Increased CVP and PAWP
• Hypotension
• Tachycardia
4. only 50-100cc's
1. diagnostics of mitral valve stenosis?
1. • Echo
• EKG (to see hypertrophy)
• Exercise testing/ Stress test
• Cardiac cath (severity)
• CXR
1. what is aortic regurgitation?
2. causes?
1. closing problem...aortic insufficiency...valve cant close properly,, blood flows from aorta to left ventricle so it dilates to compensate leading to hypertrophy. widening pulse pressure.
2. • Infective or rheumatic endocarditis
• Congenital abnormalities
• Dissecting aneurysm
• Blunt chest trauma
• Deterioration of a surgically replaced valve
1. mechanical types of valves vs prosthetic typs?
2. whats important to remember about prosthetic types?
1. bileaflet, tilting-disc, ball-n-cage
2. bioprostheses: • From pigs
• Aortic, mitral and tricuspid
• For patients who shouldn’t have long-term anticoag tx
• Last 7-15 yrs
homografts: from cadaver
autografts: patients own pulm. valv and artery because their aortic valve.
2. REMEMBER Cultural contraindications because some people don't want piggy valves
common assessment findings of cardiomyopathy disorders?
-asymptomatic until it progresses
-1st signs look like bronchitis or pneumonia, so its often misdiagnosed.
• S/S HF—Dyspnea and Cough
• Fluid retention, peripheral edema
• Chest pain /Dizziness / Syncope / JVD
• Crackles/rales
• Murmurs & tachycardia, S3, S4 sounds
• Enlarged liver
• Nausea
• Dysrhythmias
• Death (HCM- might be first indication)
nursing management for heart transplant?
• Monitor and assess:
Vital signs/ hemodynamics (compare/trend)
Heart and lung sounds
For S+S of HF
Cardiac monitoring
I+O/ Fluid restriction
• Administer meds
• Limit Activity
• Low Na Diet
• Psychological Support
• Patient Education-meds, monitor weight, what to report
1. medical management for endocarditis?
2. Surgical management for endocarditis?
goal: eradicate invading organism
MEDICAL
• IV antibiotics x 2- 6 weeks,get blood cultures regularly until negative
• PCN is the drug of choice, IV Q4H or daily,
based on dose
SURGICAL
• Valve debridement/excision of vegetation or area of destroyed tissue/ closure of abscesses
• Valve replacement
1. medical management for myocarditis?
2. Surgical management for myocarditis?
goal: Resolution of tachycardia/fever etc
1. • Prevention: immunizations
• Early treatment (Treat the cause)
• Bed rest (to decrease workload)
• Management of dysrhythmias and/or HF
-*Avoid NSAIDS for inflammation- may worsen/ are ineffective*
2. none
diagnostics of pericarditis?
• Made on Hx/ S+S
• Echo/TEE to confirm
• CT, CXR
• CMR
• Video-assisted pericardioscope (guided biopsy/ tissue sample)
• EKG (ST elevation/depression, T wave inversion)
• Chemistry, CBC, BUN, Cr
• SED rate/ C-Reactive protein
1. medical management of mitral valve stenosis?
2. surgical management of mitral valve stenosis?
1. • HF Treatment- meds
• HR control
• Anticoagulants
• Control of atrial arrhythmias
• Avoid strenuous activities!!!
2. • Valvuloplasty
• Commissurotomy-removes scar tissue
• Percutaneous Transluminal Valvuloplasty
• Valve replacement
1. assessment findings of aortic regurgitation?
2. complications?
1. • Asymptomatic- mostly!
• Forceful heartbeat- you can see it
• Exertional dyspnea and fatigue
• Diastolic murmur- 3rd/4th ICS left sternal border!!!
• Widened pulse pressure
2. • Heart Failure
• Ventricular arrhythmias
• Pulmonary Edema
• MI
• Endocarditis
nursing management post op? what are priority assessments? what do you want to teach your pt?
• Focus: Recovery from anesthesia & hemodynamic stability
• Assess neuro, cardiac, respiratory systems often
• Assess for S+S of HF and emboli
• Anticoagulant therapy-check PT and INR
• Medication education-prophylactic abx (dentist)
• Infective endocarditis prevention
• Echo 3-4 weeks following discharge
diagnostics to get for cardiomyopathy?
• ECHO-EF? (above 65 is normal)
• CMR (esp for HCM)
• EKG
• CXR-can show cardioyopathy
• Endomyocardial biopsy
nursing management for endocarditis?
goals: prevention
• Prophylactic antibiotics for before an event (dentist)
• Increased vigilance
• Fever monitoring/management
• Assessment
• Patient Education- report fever, SOB, syncope, palpitations, CP, incr. HR, prevention)
• Emotional support
nursing management for myocarditis?
• Antipyretics
• Assess: Head-to-toe cardiac- more pronoe toDig tox
• Continuous cardiac monitoring
• Anti-embolism stockings, ROM, bed rest, prophylaxis,
• Patient education-explain management, s/s to report
• Emotional support
1. medical management of pericarditis?
2. surgical management of pericarditis?
goal: ID cause and treat, symptom relief, detect tamponade
1. • Bed rest
• Analgesics, NSAIDs
• Colchicine (prevention of uremia, prevent scarring, prevent pericarditis again)
• Corticosteroids
• Antibiotics/ antifungal ONLY if needed
2. • Pericardiocentesis
• Pericardial window (drain fluid into lymph system)
• Pericardectomy (removes pericardium)
what is mitral regurgitation?
2. causes?
closing problem, leaflets cant close completely causing backward blood flow into the left atrium leading to pulmonary congestion. The right ventricle has strain leading to right heart failure.
2. • Degenerative changes
• Myxomatous changes
• Ischemic Left Ventricle
• Infective endocarditis
• Collagen vascular diseases
• Cardiomyopathy
1. diagnostics for aortic regurgitation?
2. can stress tests be performed on these pts?
1. • Echo
• TEE- q 6 months if unstable
• CMR
• CXR
• EKG
2. NO STRESS TESTS BECAUSE IT WILL WORSEN THE CONDITION
medical management for cardiomyopathy?
goal: treat the cause!!!
• Mostly HF Treatment
• HF Drugs: Diuretics, ACE Inhibitors, ARBs, Dig, antiarrhythmics, BB’s/ CCB’s
• Anticoagulants
• Bed rest, limit activity or exercise regimen
• AICD or Pacemaker-cardioversion
• 2L/day Fluid Restriction (ONLY IF pulmonary congestion)
• Low Sodium Diets
• Not recommended: Nitrates, Vasodilators because they decrease CO
nursing management of pericarditis?
goal: relieve pain
• Analgesics
• Monitor fever
• Activity- position- sit up
• Assess cardio: HF and/ or tamponade
• Psychological Support
• Patient education
1. assessment findings for mitral regurgitation?
2. complications?
3. diagnostics?
1. • Chronic- asymptomatic
• Acute- Severe HF (sudden volume overload), HF S+S
• Systolic murmur
• Atrial dysrhythmias
2. • Heart Failure
• Pulmonary Edema
• Thromboembolism
• Endocarditis
3. • Echo
• TEE- to see mitral valve
• EKG
• CXR
1. medical management for aortic regurgitation?
2. surgical management for aortic regurgitation?
goal: prevention/treat bacterial infections!!!
1. • Avoid physical exertion
• HF monitoring/ Tx
Vasodilators-procardia
CCB’s
Antidysrhythmias -amiodarone
2. • Valve replacement in unstable patients
assistive devices for cardiomyopathy?
1. intra-aortic balloon pump-used for pts who need bypass, short term support to decrease workload
2. Ventricular assistive devices- this actually pumps the heart for the ventricles, used for a bridge for pts who need a transplant or who have ventricular failure.
what is pericardiocentesis? 2. what is the nurses role in this? 3. complications of this procedure?
4. how do you know if it worked?
-gets fluid out of the pericardium.
Nurse’s Role
• Equipment setup- emergency equipment
• Position
• EKG monitoring- for adverse effects
• IVF at KVO (Keep Vein Open)- slow IV fluid
• Monitoring- q15 min neuro checks
3. Complications
• CA puncture
• Myocardial trauma
• Dysrhythmias
• Pleural lacerations
• Gastric puncture
4. increased BP, decreased pain and SOB, normal SR, decreased HR
1. medical management for mitral regurgitation?
2. surgical management for mitral regurgitation?
goal: prevention!!!
1. • HF Treatment
• Drugs: to reduce afterload, decrease resistance, promote arterial dilation
ACE inhibitors (prils)
ARB’s (losartan)
Beta Blockers (lols)
Vasodilators (hydrolazine)
• Restrict activity
• Low sodium diet
2. • Valvuloplasty
• Valve replacement (if the repair doesnt work)
1. nursing management for valve disorder patients???****************************
2. what do you want to teach these patients?
• Monitor and assess
• Vital sign trends
• Auscultate heart and lungs
• Palpate pulses
• Cardiac monitor
• Assess for S+S of HF
• Psychological support
• Administer cardiac/ heart failure meds
• Monitor and limit activity
• Cardiac diet (low Na, low fat)
2. • Diagnosis
• Procedures
• Medications
• Progressive S+S- know what to report
• Daily weights- 3+lbs/day or 5+lbs/week=REPORT
• To report chest pain/ increased SOB
• Activity limitations
1. complications for assistive devices?
2. nursing management?
1. • Bleeding disorders/ hemorrhage
• Thromboembolism
• Hemolysis
• Infection
• Kidney injury
• Right-sided HF
• Mechanical Failure
2.• Frequent assessments:
Cardiac
Pulmonary
Neuro
Renal
• Recovery from anesthesia
• Hemodynamic Stability
• Obtain and monitor lab values
• Provide psychological support
• Patient education- procedure, meds, infection prevention, what to report
education for IABP= tell pt they ned to lay flat for duration that they have the pump, keep the legs straight, and they have q1hr neuro checks