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  • Discuss how heart is tachy due to trying to compensate for decrease cardiac out put and aortic insufficiency Embolization – left sided IE embolization abd. Tenderness = possible splenomegaly hematuria = kidney joint pain = joint petechia = limbs
  • Subacute - pt. has preexisiting valve disease, has a clincal cause that may extend over months Acute – pt. with healthy valves and presents as a rapidly progressive illness
  • Explain Vegetation Explain Left side vs. right side vegetation
  • Mention #4 in case study – diagnostic criteria for IE = anemia, fever, and cardiac murmurs and explain cause murmur = valve insufficiency, aortic stenosis fever = infection spreading systematically from heart anemia = of chronic disease – inflammatory process release cytokines that causes inc. uptake and retention of iron within macrophage that leads to diversion of iron from circulation into storage sites.
  • Can mention that BUN occurs due to infection
  • Transcript

    • 1.
    • 2. Case Study
      • J.F. is a 50 year-old married homemaker with a genetic autoimmune deficiency; she has suffered from recurrent bacterial endocarditis. The most recent episodes were a Staphylococcus aureus infection of the mitral valve 16 months ago and a Streptococcus mutans infection of the aortic valve 1 month ago. During this latter hospitalization, an ECG showed moderate aortic stenosis, moderate aortic insufficiency, chronic valvular vegetations, and moderate left atrial enlargement. Two years ago J..F. received an 18-month course of TPN for malnutrition caused by idiopathic, relentless N/V. she has also had CAD for several years, and 2 years ago suffered an acute anterior wall MI. In addition, she has a history of chronic joint pain.
      • Now, after being home for only a week, J.F. has been readmitted to your floor with endocarditis, N/V, and renal failure. Since yesterday she has been vomiting and retching constantly; she also has had chills, fever, fatigue, joint pain, and headache. As you go through the admission process with her, you note that she wears glasses and has a dental bridge. She is immediately started on TPN at 125 ml/hr and on penicillin 2 million units IV q4h, to be continued for 4 weeks. Other medications are furosemide 80 mg PO qd, amlodipine 5 mg PO qd, K-Dur 40 mEq PO qd (dose adjusted according to laboratory results), metoprolol 25 mg PO bid, and prochlorperazine (Compazine) 2.5 to 5 mg IVP prn for N/V.
      • Admission VS are 152/48 (supine) and 100/40 (sitting), 116, 22, 37.9 degrees Celsius. When you assess her, you find a grade II/VI holosystolic murmur and a grade III/VI diastolic murmur; 2+ pitting tibial edema but no peripheral cyanosis; clear lungs; orientation x3 but drowsy; soft abdomen with slight left upper quadrant (LUQ) tenderness; hematuria; and multiple petechiae on skin of arms, legs, and chest.
    • 3. What is going on?
      • Significance of orthostatic hypotension, wide pulse pressure and tachycardia?
        • Decreased cardiac output, aortic insufficiency
      • Significance of abdominal tenderness, hematuria, joint pain, and petechia?
        • Indicates embolization.
    • 4. Endocarditis
      • Infection of the endocardial surface of the heart.
      • The endocardium is contiguous with the valves and therefore inflammation from infective endocarditis (IE) affects cardiac valves.
      • Two types:
        • Sub acute
        • Acute
    • 5. Etiology
      • Staphylococcus aureus; MRSA
      • Streptococcus viridans
      • Bartonella quintana
      • Enteroc0cci
      • Fungi- Candida Albicans
      • Viruses
    • 6. Staphylococcus aureus Bacteremia
      • A study was conducted trying to identify the leading risk factors for S. aureus infective endocarditis. The risk factors identified were:
        • Presence of a valvular prosthesis, persistent fever, and persistent bacteremia
        • MRSA and preexisiting valvular disorder were not associated with S. aureus infective endocarditis (SAIE).
        • However, MRSA can increase the mortality rate of SAIE. (Hill et al., 2007)
    • 7. Pathophysiology
      • Occurs when blood flow turbulence within the heart allows the causative organism to infect previously damaged valves or other endothelial surfaces
      • Vegetations adhere to valve surface or endocardium
        • Can break into circulation and result in embolization.
    • 8. Right versus Left sided Infective Endocarditis
      • According to Thalme, Westling, Julander (2006):
        • Treatment for Left sided IE was longer than Right sided (34 d vs. 28 d)
        • Left-sided IE hospital mortality is significant (13%) whereas in the study there were no mortalities with right sided IE.
        • Was thought that IVDA caused right sided IE however, the study found that IV drug use patient often with suspected IE suffers from left-sided IE which has a worse prognosis.
    • 9. Risk Factors for Endocarditis
      • Prior endocarditis
      • Prosthetic valves
      • Acquired valve disease
      • Cardiac lesions
      • Rheumatic Heart Disease
      • Congenital Heart Disease
      • Pacemakers
      • IV Drug Abuse (IVDA)
      • Nosocomial bacteremia
      • Intravascular devices (PICCs, pulmonary artery catheter
      • Cardiac catheters
    • 10. Pacemakers and Endocarditis
      • In an article titled:
          • Pacemaker Endocarditis: Clinical Features and Management of 60 consecutive cases
      • “ This study shows that a majority of patients from an endocarditis during the first year after implantation of a pacemaker.” (Massoure, 2007)
      • “ Antibiotic prophylaxis should be recommended at the time of pacemaker implantation as most infections occur within the first year after implantation.” (Massoure, 2007)
    • 11. Clinical Manifestations in relation to J.F.
      • Primary manifestations
        • Fever
        • Chills
        • Weakness
        • Malaise
        • Fatigue
        • Anorexia
        • Arthralgia
        • Myalgia
        • Back pain
        • Abdominal discomfort
        • Weight loss
        • HA
        • Clubbing
        • Oslers Nodes
        • Janeway’s lesions
        • Petechiae
      • Secondary due to embolization
        • LUQ pain
        • Splenomegaly
        • Local tenderness and abdominal rigidity
        • Flank pain
        • Hematuria
        • Azotemia
        • *Gangrene
        • Hemiplegia
        • Ataxia
        • Aphasia
        • Visual changes
        • Change In level of consciousness
        • Pulmonary emboli (Right side)
    • 12. Osler’s Nodes and Janeway’s Lesions
    • 13.
    • 14. What do J.F.’s lab values mean?
      • J.F.’s lab values: Na 138, K 3.9, Cl 103, BUN 85, Creatinine 3.9, glucose 185, WBC 6.7, Hct 27%, Hgb 9.0.
      • Her abnormal values and their indication:
        • BUN & Creatinine = renal failure
        • Glucose = stress from hospitalization and from TPN
        • Hct &Hgb = anemia
    • 15. Diagnostic Studies
      • Blood culture
      • H&P
      • Echocardiography
      • ECG
      • CXR
      • Cardiac catheterization
    • 16. Nursing Diagnoses
      • Decreased cardiac output related to valvular insufficiency as evidenced by heart murmurs, peripheral edema, and tachycardia.
      • Risk for imbalanced nutrition related to nausea and vomiting, use of TPN, and prior history of malnutrition
    • 17. Decreased cardiac output related to valvular insufficiency as evidenced by heart murmurs, peripheral edema, and tachycardia.
      • Maintains adequate tissue and organ perfusion throughout length of stay
        • Assess heart rate and blood pressure to assess for manifestations of decreased cardiac output
        • Assess skin color and temperature. Cold, clammy skin is secondary to compensatory increase in sympathetic nervous system stimulation and low cardiac output and desaturation.
        • Elevate head of bed to reduce O2 demand
        • Monitor intake and output hourly
        • Monitor lab values closely to detect any irregular values .
      • Maintains normal cardiac output throughout length of stay and at home
        • Administer stool softeners as needed. Straining for a bowel movement further impairs cardiac output.
        • Promote bed rest/activity limitaiton to decrease cardiac workland and O2 demand
        • Administer antiobiotics prescribed to fight underlying cause of impaired cardiac function
        • Collaborate with home health nurse to set up IV therapy for patient at home. Home health will have technical knowledge of IV maintenance.
    • 18. Risk for imbalanced nutrition related to nausea and vomiting, use of TPN, and prior history of malnutrition
      • Patient weighs within 10% of ideal body weight.
        • Monitor recorded intake for nutritional content and calories to evaluate nutritional status
        • Encourage exercise as tolerated. Metabolism and utilization of nutrients are enhanced by activity.
        • Weigh patient weekly. During aggressive nutritional support, patient can gain up to 0.5 pound/day.
      • Maintains lab values within normal limits
        • Monitor laboratory values that indicate nutritional well-being/deterioration
      • Patient will be free of signs of malnutrition while in the hospital.
        • Monitor for signs of malnutrition such as: brittle hair, bruises, dry skin, pale skin and conjunctiva, smooth red tongue.
        • Watch for signs of infection because pts who are malnourished are at an increased risk for infection.
    • 19. Treatment for IE
      • Antibiotic prophylaxis – used for high risk patients before they undergo certain procedures such as : dental, GI, and GU procedures or who are undergoing drainage/removal of infected tissue, renal dialysis, or have ventriculoatrial shunts for hydrocephalus
      • Long-term antibiotic – regimens dependent on organism that it is eradicating. Penicillin is a common antibiotic used unless there are allergies. The regimen can take weeks to complete.
      • Acetaminophen, ibuprofen, fluid and rest are recommended to treat the fever that accompanies IE
    • 20. Prevention of Infective Endocarditis
      • Interesting article on American Heart Association website regarding prevention of IE
      • “ The current practice of giving patients antibiotics prior to a dental procedure is no longer recommended EXCEPT for patients with the highest risk of adverse outcomes resulting from BE (bacterial endocarditis)” (
      • Patients at highest risk and therefore should be given prophylaxis antibiotics are those who have:
        • Prosthetic cardiac valve
        • Previous endocarditis
        • Congenital heart disease
        • Cardiac transplant recipient with cardiac valvular disease
    • 21. PREVENTION OF BACTERIAL ENDOCARDITIS Wallet Card This wallet card is to be given to patients (or parents) by their physician. Healthcare professionals: Please see back of card for reference to the complete statement. Name:__________________________________________________________________________ Needs protection from BACTERIAL ENDOCARDITIS because of an existing heart condition. Diagnosis:_______________________________________________________________________ Prescribed by:____________________________________________________________________ Date:___________________________________________________________________________
    • 22. References
          • American Heart Association. (2008). Endocarditis Prophylaxis Information . Retrieved September 28, 2008, from
          • Hill, E.E., Vanderschueren, S., Verhaegen, J., Herugers, P., Claus, P., Herreods, M.C. and et al. (2007). Risk factors for Infective Endocarditis and outcome of patients with Staphylococcus aureus Bacteremia. Mayo Clinic Proc., 82(10), 1163-1169.
      • Massoure, P., Reuter, S., Lafitte, S., Laborderie, J., Bordachard, P., Clementy, J., et al. (2007). Pacemaker endocarditis: clinical features and management of 60 consecutive cases. Pacing & Clinical Electrophysiology , 30 (1), 12-19.
      • Thalme, A., Westling, K., Julander, I. (2007). In-hospital and long-term mortality in infective endocarditis in injecting drug users compared to non-drug users: A retrospective study of 192 episodes. Scandinavian Journal of Infectious Diseases, 39, 197-204.
      • Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O’Brien, P.G., and Bucher, L. (2007). Medical-Surgical Nursing ( 7 th ed.). St. Louis: Mosby Elsevier.
      • Ackley, B.J. & Ladwig, G.B. Nursing Diagnosis Handbook: a guide to planning care ( 7 th ed.). St. Louis: Mosby Elsevier.
      • Huether, S.E. & McCance, K.L. (2004). Understanding Pathophysiology (3 rd ed.) St. Louis: Mosby Elsevier. .
      • Deglin, J.H. & Vallerand, A.H. (2007). Davis’s Durg Guide for Nurses (10 th ed.). Philadelphia: F.A. Davis Company