1. Cardiovascular Lecture II

8/6/2019 1. Cardiovascular Lecture II

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Cardiovascular Dysfunction I Lecture

INFECTIVE ENDOCARDITIS

-infection of the inner layer of the heart that usually AFFECTS the CARDIAC VALVES!

• Statistics:

-was almost ALWAYS fatal until development of Penicillin

-15,000 cases diagnosed in the US each year • Subacute Form:

-affects those with PREEXISTING VALVE DISEASE

-gradual onset of symptoms

-longer clinical course (harder to treat)

-caused by Enterococci

• Acute Form

-affects those with HEALTHY VALVES

-shorter clinical course

-rapid onset-caused by Strep, Staph

• Etiology

-MOST COMMON CAUSATIVE ORGANISMS Staph and Strep (both BACTERIAL)

-occurs when blood turbulence within heart allows causative agent to infect previously damaged valves

or other endothelial surfaces

>Turbulence Caused by valvular disorders, valve replacement

-you will hear a Heart Murmur most likely (b/c of the turbulent flow)• Risk Factors:

-Aging

-Intravenous Drug Abuse (IVDA)

-Prior Endocarditis

-Prosthetic Valves

-Acquired Valvular Disease

-Cardiac Lesions

-Renal Dialysis• Vegetation

-Fibrin, Leukocytes, Platelets, and Microbes

-Adhere to the valve or endocardium-Embolization of portions of Vegetation into Circulation

>can cause damage to other parts of the body (i.e. in brain = Stroke; spleen, liver, kidneys, etc)

-Left-Sided Emoblizations = go to the systemic (brain, limb, kidneys, livers, spleen)

-Right-Sided Embolizations = go to the lungs• 3 Things Needed to Know:

1. Identify it early

2. Treat it early

3. Monitor for Complications• Clinical Manifestations

-Nonspecific; Common Cold/Flu-like Symptoms

-Fever in 90%

-Chills-Weakness, Malaise, Fatigue

-Anorexia (no appetite)• Clinical Manifestations (Subacute Form)

-Arthralgias, Myalgias, Back Pain, Abdominal Discomfort

>may seem like kidney problems

-Weight Loss, Headache, Clubbing of Fingers (prolonged Hypoxemia)• Vascular Manifestations

-Splinter Hemorrhages in nail beds (IMPORTANT)



>lines underneath the nail bed, but don’t extend the entire length (1-2 mm in length at most)

-Petechiae (don’t see with Cold or Flu, so helps to point towards this disorder)

>cheek, face, or sclera, mostly

-Osler’s nodes on Fingers or Toes

>little bumps on the fingers or toes-Janeway’s lesions on palms or soles

>round form with another circle around it-Roth’s Spots

>specific for Infective Endocarditis• Clinical Manifestations (cont’d)

-Murmur in most patients

>new Murmur = BIG KEY that the patient has Infective Endocarditis

-Heart Failure in up to 80% with Aortic valve endocarditis• History

-Recent Dental, Urologic, Surgical, or Gynecological Procedures

-Hx of Heart Disease

-Recent Cardiac Catheterization (could have introduced pathogens)

-Skin, Respiratory, or urinary tract infection• Diagnostic Studies

-Lab Tests

>Blood Cultures>WBC w/Differential

-Echocardiography>looks at blood flow, and the heart valves

>one of the MOST IMPORTANT tests for this disorder

-Chest X-Ray• Collaborative Care

-Prophylactic treatment for patients having:

>Removal or Drainage of infected tissue

>Renal Dialysis

>Ventriculoatrial shunts-Prophylactic Treatment is mostly Antibiotics

• Antibiotic Administration

-prior to procedures, usually just oral (prophylactically)-monitor antibiotic serum levels

-subsequent blood cultures

>makes sure that whatever is in there is being killed by the drugs

-monitor renal function

>don’t want the drugs to affect Creatinine clearance (causing Renal Failure)>don’t want embolism to the kidneys

• Fungal and Prosthetic Valve Endocarditis

-responds poorly to antibiotics

-then, valve replacement is adjunct procedure• Subjective Data

-Hx of valvular, congenital, or syphilitic cardiac disease

-previous endocarditis

-Staph or Strep infection-Immunosuppressive Therapy

>Corticosteroids>Chemo & Radiation

-Recent surgeries and procedures• Functional Health Patterns

-IV drug abuse

-Alcohol abuse

-Unintentional Weight Changes (past 6 months)

-Chills, fever, etc.



• Nursing Assessment

-Diaphoresis

-Bloody Urine

>do they currently have a UTI??

>have they had a Kidney Infarct or Pyelnonephritis (or any condition that may cause bloody urine)-Exercise Intolerance or Dyspnea on Exertion

>can’t do activities they used to be able to-Generalized Weakness, Fatigue

-Cough

>pulmonary infection on top of it?

-Night Sweats

-Chest, Back or Abdominal Pain

• Objective Data

-Olser’s Node, Splinter Hemorrhages, Janeway’s Lesions, Petechiae

-Clubbing

-Tachypnea, Crackles

-Dysrhythmias, Tachycardia

-Leukocytosis (elevated WBC count)

-Anemia

-Increased ESR (Erythrocyte Sedimentation Rate inflammation) and Increased Cardiac Enzymes

-Positive Blood Cultures

-ECG showing chamber enlargement>right or left ventricle

• Planning

-Patient will:

>Have normal Cardiac Function

>Perform ADLs w/out fatigue

>Understand therapeutic regimen to prevent recurrence• Nursing Implementation

-Identify those at risk -Assessment of Hx and Understanding of disease process

-Teach importance of adherence to treatment regimen

>take Antibiotics until all is gone (don’t save some for the future)

-need to Avoid Infectious People-Avoidance of Stress and Fatigue

-Rest, Hygiene, Nutrition

-Assessment of nonspecific manifestations

>tiredness, weakness, muscle aches, headache, cold/flu-like symptoms

-monitor lab data

-monitor patency of IV>IV antibiotics will be given

>make sure to give them on time

-Compression Stockings w/immobility

-ROM

-Turn, Cough, Deep Breathe (prevent pneumonia)

>will be on complete bed-rest, b/c we don’t want those Vegetations on the Valves to break off

• Teach-S&S of Infection-Reduction Measures for risk for Infection

>Hand Washing, and Proper Hygiene

-Stress Follow-Up Care• Evaluation

-Vital Signs WNL

-Absence of chills, diaphoresis, headache

-Sufficient Cardiac Output

>monitored by looking at Kidney Function and proper Urinary Output (look at Creatinine levels)



>want a normal BP (something above a 90 Systolic)

>don’t want them SOB, have Chest Pain, or any complaints of leg pain (DVT)

-Completion of ADLs w/no fatigue or physiologic distress

-Increased understanding of disease process and self-care management

ACUTE PERICARDITIS

-inflammation of the outer portion of the heart (the Pericardium)-usually Viral

-usually a complication of an infection somewhere else in the body• Statistics

-usually Men <50

1. Non-Infectious Pericarditis

-Post Trauma or Post Procesure

-Post Acute MI

-Uremia

-Cancer

-Radiation

-Myxedema (deposit of Muco-Proteins)

-Dissective Aneurysm

• Autoimmune and Hypersensitivity

- Dressler’s Syndrome – 1-4 weeks

>type of inflammatory syndrome>Type of Pericarditis Secondary to MI or Traumatic Injury

-Post-Pericardiotomy Syndrome

-Lupus and other Rheumatoid Diseases

-Medications dilantin, pronestyl, hydralazine

• Clinical Manifestations of Acute Pericarditis

-Chest Pain

>P (pain) worse w/motion or deep breath and better when sitting forward

>Q (quality) sharp pain, that can radiate; once pain starts, it does not go away

>R (region) usually Anterior, but can go to Shoulder and Neck

>S (severity) can be quite severe

>T (timing) always present (never goes away)

-Fever

>often Low-Grade (below 101) from inflammatory response

-Pericardial Friction Rub (HALLMARK FINDING!)

>have the patient hold their breath while auscultation (so you don’t mix up Pleural Friction Rub)

>can be creaking or grating sound

>can be absent or so low that it is inaudible

-Other S&S Non-Specific Fatigue, Dyspnea, Tachycardia, Tachypnea, Anxiety• Diagnostic Tests

-CBC, EKG, Cardiac Enzymes, Sedimentation Rate (C-Reactive Protein), Chest X-Ray,

ECHOcardiogram, CT or MRI

>the same as Infective Endocarditis

- Pericardiocentesis – removing fluid in the Pericardial Sac

>different from Infective Endocarditis

>involves sticking a big, long needle into the Pericardial sac

>can be done at the bed-side• Pericardial Effusion – lots of fluid build-up in the Pericardial Sac

- Acute Effusion – as little as 80-100 cc will cause a Tamponade

-Chronic Effusion – as much as 1-2 Liters can build and the sac will slowly stretch to the change

>Will see S&S from constriction of adjoining structures:

LUNGS – cough, dyspnea, increased Resp. Rate

LARYNGEAL NERVE – hoarseness



PHRENIC NERVE – hiccups

HEART SOUNDS – increasingly muffled (MOST PREVALENT)

• EMERGENCY! Pericardial Tamponade

- Beck’s Triad (TEST QUESTION!)

1. Muffled Heart Tones2. Jugular Venous Distension (JVD)

3. Hypotension-Other S&S are from Low Flow State

>Anxiety, chest pain, decreased LOC, tachycardia, tachypnea, low-voltage EKG

-Immediate Pericardiocentesis is required

• Chronic Complications

-Chronic Restrictive Pericarditis

>Sac scars, thickens, and shrinks>TREATMENT is pericardectomy (surgical removal of the sac)

-Chronic or Recurrent Effusion

>Effusion won’t decrease or it reoccurs

>TREATMENT is pericardial window (surgical hole in the sac)• Therapeutic Management/Treatment

-Identify and Treat the Cause

- Infectious

>Bacterial – Antibiotic

>Fungal – Antifungals

>Viral – no direct treatment; may use Anti-Virals but of minimal assistance>Autoimmune – Prednisone in tapering dose

- Non-Infectious

>Simple Inflammatory Cause - NSAIDs and Rest

>Uremic – increase dialysis and rest

>Medication Reaction – Stop medication and rest

• Nursing Management of Acute Pericarditis (mostly treatment of symptoms; not curative)

-Pain NSAIDs, Occasional Narcotics, but NSAIDs usually better; lean forward on over bed table

-Fever NSAIDs or Tylenol or Both; comfort measures including dry sheets, cool cloth*Tylenol is better if already using NSAIDs for the Inflammation

-Monitor for Complications

>VS q4h, w/heart and lung sounds

>Signs of decreasing Cardiac Output

>Monitor breathing patterns

>Oxygen as needed

>Monitor pain pattern for changes to more angina pattern

-Activity Intolerance HOB up, bedrest, assist as needed

-Anxiety Need reassurance, esp. those w/Dressler’s

-Medication Precautions NSAIDs and Steroids w/food (prevents Gastric Ulcers)

>Monitor Na+, K+, Glucose; and fluids in those on Steroids• Home Teaching for Pericarditis

-S&S of Complications and Recurrence

-Continue NSAIDs and how to take them

-Wean off Steroids

>need to be tapered down

-Gradual Increase in Activity

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1. Cardiovascular Lecture II