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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
  • Endocarditis

    1. 1. www.hi-dentfinishingschool.blogspot.com
    2. 2. Case Study <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
    3. 3. What is going on? <ul><li>Significance of orthostatic hypotension, wide pulse pressure and tachycardia? </li></ul><ul><ul><li>Decreased cardiac output, aortic insufficiency </li></ul></ul><ul><li>Significance of abdominal tenderness, hematuria, joint pain, and petechia? </li></ul><ul><ul><li>Indicates embolization. </li></ul></ul>
    4. 4. Endocarditis <ul><li>Infection of the endocardial surface of the heart. </li></ul><ul><li>The endocardium is contiguous with the valves and therefore inflammation from infective endocarditis (IE) affects cardiac valves. </li></ul><ul><li>Two types: </li></ul><ul><ul><li>Sub acute </li></ul></ul><ul><ul><li>Acute </li></ul></ul>
    5. 5. Etiology <ul><li>Staphylococcus aureus; MRSA </li></ul><ul><li>Streptococcus viridans </li></ul><ul><li>Bartonella quintana </li></ul><ul><li>Enteroc0cci </li></ul><ul><li>Fungi- Candida Albicans </li></ul><ul><li>Viruses </li></ul>
    6. 6. Staphylococcus aureus Bacteremia <ul><li>A study was conducted trying to identify the leading risk factors for S. aureus infective endocarditis. The risk factors identified were: </li></ul><ul><ul><li>Presence of a valvular prosthesis, persistent fever, and persistent bacteremia </li></ul></ul><ul><ul><li>MRSA and preexisiting valvular disorder were not associated with S. aureus infective endocarditis (SAIE). </li></ul></ul><ul><ul><li>However, MRSA can increase the mortality rate of SAIE. (Hill et al., 2007) </li></ul></ul>
    7. 7. Pathophysiology <ul><li>Occurs when blood flow turbulence within the heart allows the causative organism to infect previously damaged valves or other endothelial surfaces </li></ul><ul><li>Vegetations adhere to valve surface or endocardium </li></ul><ul><ul><li>Can break into circulation and result in embolization. </li></ul></ul>
    8. 8. Right versus Left sided Infective Endocarditis <ul><li>According to Thalme, Westling, Julander (2006): </li></ul><ul><ul><li>Treatment for Left sided IE was longer than Right sided (34 d vs. 28 d) </li></ul></ul><ul><ul><li>Left-sided IE hospital mortality is significant (13%) whereas in the study there were no mortalities with right sided IE. </li></ul></ul><ul><ul><li>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. </li></ul></ul>
    9. 9. Risk Factors for Endocarditis <ul><li>Prior endocarditis </li></ul><ul><li>Prosthetic valves </li></ul><ul><li>Acquired valve disease </li></ul><ul><li>Cardiac lesions </li></ul><ul><li>Rheumatic Heart Disease </li></ul><ul><li>Congenital Heart Disease </li></ul><ul><li>Pacemakers </li></ul><ul><li>IV Drug Abuse (IVDA) </li></ul><ul><li>Nosocomial bacteremia </li></ul><ul><li>Intravascular devices (PICCs, pulmonary artery catheter </li></ul><ul><li>Cardiac catheters </li></ul>
    10. 10. Pacemakers and Endocarditis <ul><li>In an article titled: </li></ul><ul><ul><ul><li>Pacemaker Endocarditis: Clinical Features and Management of 60 consecutive cases </li></ul></ul></ul><ul><li>“ This study shows that a majority of patients from an endocarditis during the first year after implantation of a pacemaker.” (Massoure, 2007) </li></ul><ul><li>“ Antibiotic prophylaxis should be recommended at the time of pacemaker implantation as most infections occur within the first year after implantation.” (Massoure, 2007) </li></ul>
    11. 11. Clinical Manifestations in relation to J.F. <ul><li>Primary manifestations </li></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Chills </li></ul></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><li>Malaise </li></ul></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>Anorexia </li></ul></ul><ul><ul><li>Arthralgia </li></ul></ul><ul><ul><li>Myalgia </li></ul></ul><ul><ul><li>Back pain </li></ul></ul><ul><ul><li>Abdominal discomfort </li></ul></ul><ul><ul><li>Weight loss </li></ul></ul><ul><ul><li>HA </li></ul></ul><ul><ul><li>Clubbing </li></ul></ul><ul><ul><li>Oslers Nodes </li></ul></ul><ul><ul><li>Janeway’s lesions </li></ul></ul><ul><ul><li>Petechiae </li></ul></ul><ul><li>Secondary due to embolization </li></ul><ul><ul><li>LUQ pain </li></ul></ul><ul><ul><li>Splenomegaly </li></ul></ul><ul><ul><li>Local tenderness and abdominal rigidity </li></ul></ul><ul><ul><li>Flank pain </li></ul></ul><ul><ul><li>Hematuria </li></ul></ul><ul><ul><li>Azotemia </li></ul></ul><ul><ul><li>*Gangrene </li></ul></ul><ul><ul><li>Hemiplegia </li></ul></ul><ul><ul><li>Ataxia </li></ul></ul><ul><ul><li>Aphasia </li></ul></ul><ul><ul><li>Visual changes </li></ul></ul><ul><ul><li>Change In level of consciousness </li></ul></ul><ul><ul><li>Pulmonary emboli (Right side) </li></ul></ul>
    12. 12. Osler’s Nodes and Janeway’s Lesions http://www.childrenshospital.org/cfapps/mml/viewBLOB.cfm?MEDIA_ID=1887
    13. 13. http://gsbs.utmb.edu/microbook/images/fig94_3.JPG
    14. 14. What do J.F.’s lab values mean? <ul><li>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. </li></ul><ul><li>Her abnormal values and their indication: </li></ul><ul><ul><li>BUN & Creatinine = renal failure </li></ul></ul><ul><ul><li>Glucose = stress from hospitalization and from TPN </li></ul></ul><ul><ul><li>Hct &Hgb = anemia </li></ul></ul>
    15. 15. Diagnostic Studies <ul><li>Blood culture </li></ul><ul><li>H&P </li></ul><ul><li>Echocardiography </li></ul><ul><li>ECG </li></ul><ul><li>CXR </li></ul><ul><li>Cardiac catheterization </li></ul>
    16. 16. Nursing Diagnoses <ul><li>Decreased cardiac output related to valvular insufficiency as evidenced by heart murmurs, peripheral edema, and tachycardia. </li></ul><ul><li>Risk for imbalanced nutrition related to nausea and vomiting, use of TPN, and prior history of malnutrition </li></ul>
    17. 17. Decreased cardiac output related to valvular insufficiency as evidenced by heart murmurs, peripheral edema, and tachycardia. <ul><li>Maintains adequate tissue and organ perfusion throughout length of stay </li></ul><ul><ul><li>Assess heart rate and blood pressure to assess for manifestations of decreased cardiac output </li></ul></ul><ul><ul><li>Assess skin color and temperature. Cold, clammy skin is secondary to compensatory increase in sympathetic nervous system stimulation and low cardiac output and desaturation. </li></ul></ul><ul><ul><li>Elevate head of bed to reduce O2 demand </li></ul></ul><ul><ul><li>Monitor intake and output hourly </li></ul></ul><ul><ul><li>Monitor lab values closely to detect any irregular values . </li></ul></ul><ul><li>Maintains normal cardiac output throughout length of stay and at home </li></ul><ul><ul><li>Administer stool softeners as needed. Straining for a bowel movement further impairs cardiac output. </li></ul></ul><ul><ul><li>Promote bed rest/activity limitaiton to decrease cardiac workland and O2 demand </li></ul></ul><ul><ul><li>Administer antiobiotics prescribed to fight underlying cause of impaired cardiac function </li></ul></ul><ul><ul><li>Collaborate with home health nurse to set up IV therapy for patient at home. Home health will have technical knowledge of IV maintenance. </li></ul></ul>
    18. 18. Risk for imbalanced nutrition related to nausea and vomiting, use of TPN, and prior history of malnutrition <ul><li>Patient weighs within 10% of ideal body weight. </li></ul><ul><ul><li>Monitor recorded intake for nutritional content and calories to evaluate nutritional status </li></ul></ul><ul><ul><li>Encourage exercise as tolerated. Metabolism and utilization of nutrients are enhanced by activity. </li></ul></ul><ul><ul><li>Weigh patient weekly. During aggressive nutritional support, patient can gain up to 0.5 pound/day. </li></ul></ul><ul><li>Maintains lab values within normal limits </li></ul><ul><ul><li>Monitor laboratory values that indicate nutritional well-being/deterioration </li></ul></ul><ul><li>Patient will be free of signs of malnutrition while in the hospital. </li></ul><ul><ul><li>Monitor for signs of malnutrition such as: brittle hair, bruises, dry skin, pale skin and conjunctiva, smooth red tongue. </li></ul></ul><ul><ul><li>Watch for signs of infection because pts who are malnourished are at an increased risk for infection. </li></ul></ul>
    19. 19. Treatment for IE <ul><li>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 </li></ul><ul><li>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. </li></ul><ul><li>Acetaminophen, ibuprofen, fluid and rest are recommended to treat the fever that accompanies IE </li></ul>
    20. 20. Prevention of Infective Endocarditis <ul><li>Interesting article on American Heart Association website regarding prevention of IE </li></ul><ul><li>“ 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)” (americanheart.org) </li></ul><ul><li>Patients at highest risk and therefore should be given prophylaxis antibiotics are those who have: </li></ul><ul><ul><li>Prosthetic cardiac valve </li></ul></ul><ul><ul><li>Previous endocarditis </li></ul></ul><ul><ul><li>Congenital heart disease </li></ul></ul><ul><ul><li>Cardiac transplant recipient with cardiac valvular disease </li></ul></ul>
    21. 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. 22. References <ul><ul><ul><li>American Heart Association. (2008). Endocarditis Prophylaxis Information . Retrieved September 28, 2008, from http://www.americanheart.org/presenter.jhtml?identifier=11086 </li></ul></ul></ul><ul><ul><ul><li>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. </li></ul></ul></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>Ackley, B.J. & Ladwig, G.B. Nursing Diagnosis Handbook: a guide to planning care ( 7 th ed.). St. Louis: Mosby Elsevier. </li></ul><ul><li>Huether, S.E. & McCance, K.L. (2004). Understanding Pathophysiology (3 rd ed.) St. Louis: Mosby Elsevier. . </li></ul><ul><li>Deglin, J.H. & Vallerand, A.H. (2007). Davis’s Durg Guide for Nurses (10 th ed.). Philadelphia: F.A. Davis Company </li></ul>