Inflammatory Disorders

By Nancy Jenkins

Updated Spring 2010 by John Nation -

Overview of Today’s Lecture

A & P Review Endocarditis- infection of the endocardial surface

of the heart

Myocarditis- a focal or diffuse inflammation of the myocardium

Pericarditis- inflammation of the pericardial sac (the pericardium)

Layers of the Heart Muscle

Anatomy and Physiology!

How the heart works!

TISSUES SURROUNDING THE HEART

A- Aortic Valve

B- Mitral Valve

D- Tricuspid Valve

- Pulmonary Valve

Anatomy and Physiology Review

Blood enters the right atrium and moves through the _______ into the right ventricle.

Blood then moves from the right ventricle into the pulmonary artery via the _________.

A- Aortic Valve

B- Mitral Valve

C- Pulmonary Valve

D- Tricuspid Valve

Anatamy and Physiology Review (Cont’d)

After entering the left atrium via the pulmonary veins, blood moves through the _____ into the left ventricle.

Finally, it travels through the _____ and out of the heart.

A- Aortic Valve

B- Mitral Valve

C- Pulmonary Valve

D- Tricuspid Valve

Infective Endocarditis

• Infection of the inner layer of the heart

• Usually affects the cardiac valves

• Was almost always fatal until

development of penicillin

• Around 15,000 cases diagnosed

annually in the U.S.

Causative Organisms

Causative organisms Streptococcus viridans Staphylococcus aureus Viruses Fungi

Etiology and Pathophysiology

Vegetation – Fibrin, leukocytes, platelets, and microbes– Adhere to the valve or endocardium – Embolization of portions of vegetation into

circulation

Etiology and Pathophysiology

Occurs when blood turbulence within heart allows causative agent to infect previously damaged valves or other endothelial surfaces

Endocarditis

Infection of the innermost layers of the heart May occur in people with congenital and

valvular heart disease May occur in people with a history of

rheumatic heart disease May occur in people with normal valves with

increased amounts of bacteria

Etiology/Pathophysiology

Endocarditis– When valve damaged, blood is slowed down and

forms a clot– Bacteria get into blood stream – Bacterial or fungal vegetative growths deposit on

normal or abnormal heart valves

Classifications of Endocarditis

Acute Infective Endocarditis– Abrupt onset– Rapid course– Staph Aureus

Subacute Infective Endocarditis SBE– Gradual onset– Systemic manifestations

Prosthetic Valve Endocarditis

Bacterial Endocarditis of the Mitral Value

Fig. 37-2Fig. 37-2

Sequence of Events in Infective Endocarditis

Fig. 37-3Fig. 37-3

Risk Factors- endocarditis

Hx of rheumatic fever or damaged heart valve Prior history of endocarditis Invasive procedures- (introduce bacteria into blood

stream) (surgery, dental, etc) Recent Dental Surgery Permanent Central Venous Access IV drug users Valve replacements

Nursing Assessment

Subjective Data– History of valvular, congenital, or syphilitic cardiac

disease– Previous endocarditis – Staph or strep infection– Immunosuppressive therapy– Recent surgeries and procedures

Nursing Assessment

Functional health patterns– IV drug abuse– Alcohol abuse– Weight changes– Chills

Nursing Assessment

– Diaphoresis– Bloody urine– Exercise intolerance – Generalized weakness– Fatigue – Cough

Nursing Assessment

– Dyspnea on exertion – Night sweats – Chest, back, abdominal pain

Collaborative Care

Fungal and prosthetic valve endocarditis– Responds poorly to antibiotics– Valve replacement is adjunct procedure

Assesment endocarditis

Infection and emboli– Emboli-spleen most often affected (splenectomy)– Osler’s nodes- painful, red or purple pea-sized lesions on toes and fingertips

– Splinter hemorrhages- black longitudinal streaks on nail beds

– Janeway lesions- flat, painless, small, red spots on palms and soles

– Roth spots- hemorrhagic retinal lesions

– Murmur- 90% have murmurs– T above 101(blood cultures) and low-grade– Chills– Anorexia– Fatigue

Clinical Manifestations

Murmur in most patients Heart failure in up to 80% with aortic valve

endocarditis Manifestations secondary to embolism

Heart Sounds Assessment Video

Auscultating Heart Sounds

The aortic area or right sternal border (RSB) is at the right 2nd intercostal space, just under and to the right of the angle of Louis (sternal angle)

The pulmonic area or left upper sternal border (LUSB) is at the left 2 nd intercostal space

The tricuspid area or left lower sternal border (LLSB) is at the left fourth intercostal space

The mitral area or apex is at the PMI -- the 5 th intercostal space in midclavicular line

Splinter hemorrhage

• small areas of bleeding under the fingernails or toenails.

• due to damage to capillaries by small clots

Janeway Lesions

• flat, painless red spots on palms and soles

Osler’s Nodes

Painful, pea-size, red or purple lesions On finger tips or toes

Roth spotsOsler’s nodes

Roth’s Spots

• hemorrhagic retinal lesions

Diagnostic Tests

Blood Cultures- Echocardiogram-TEE best- see vegetations Other- WBC with differential, CBC,ESR,

serum creatinine,CXR, and EKG

1) Vegetations on mitral valve

2) Vegetations on aortic valve

Diagnostic Criteria

Diagnostic Criteria

Medications

Antibiotics– IV for 2-8 weeks– Monitor peaks and troughs of certain drugs– Monitor BUN and Creat.– Unclear success of oral antibiotics if not a good candidate

for IV. Oral antibiotics are considered when dealing with endocarditis:

– Of the tricuspid valve– With a causative organism sensitive to oral agents– Long-term IV therapy difficult or impossible– Outpatient f/u can be arranged

Nursing Diagnoses

Risk for Imbalanced Body Temperature Risk for Ineffective Tissue Perfusion-emboli Ineffective Health Maintenance

Complications

Emboli (50% incidence)– Right side- pulmonary emboli (esp. with IV drug abuse-

Why??)– Left side-brain, spleen, heart, limbs,etc

CHF-check edema, rales, VS Arrhythmias- A-fib Death

.

Prevention

Eliminate risk factors Patient teaching

Risk Stratisfication for IE

High Risk- – Mechanical prosthetic heart valve– Natural prosthetic heart valve– Prior infective endocardititis– Valve repair with prosthetic material– Most congenital heart diseases

Moderate Risk- – Valve repair without prosthetic material– Hypertrophic cardiomyopathy– Mitral valve prolapse with regurgitation– Acquired valvular dysfunction

Low Risk-– Innocent heart murmurs– Mitral valve prolapse without regurgitation– Coronary artery disease– People with pacemakers/ defibrillators

• Prophylactic antibiotics are generally recommended only for people in the “High Risk” category

Collaborative Care

Prophylactic treatment for patients having– Removal or drainage of infected tissue– Renal dialysis– Ventriculoatrial shunts– Dental, oral, or upper respiratory tract procedures

Video Review- Endocarditis

Livestrong Endocarditis Video

To diagnose the causative organism in endocarditis, the nurse

should anticipate the doctor ordering which test?

Ches

t x-ra

y

Ech

ocard

iogra

m

Blo

od cultu

res

CBC

25% 25%25%25%

1. Chest x-ray

2. Echocardiogram

3. Blood cultures

4. CBC

Which assessment finding is characteristic of endocarditis?

Per

ipher

al e

dema

Jau

ndice

Bra

dycar

dia

Hea

rt M

urmur

25% 25%25%25%

1. Peripheral edema

2. Jaundice

3. Bradycardia

4. Heart Murmur

A common complication of endocarditis of the mitral valve is pulmonary embolism.

Tru

e

Fal

se

50%50%

1. True

2. False

Layers of the Heart Muscle

Myocarditis

Myocarditis is an uncommon inflammation of the heart muscle (myocardium). This inflammation can be caused by infectious agents, toxins, drugs or for unknown reasons. It may be localized to one area of the heart, or it may affect the entire heart.

Etiology/Pathophysiology

Myocarditis– Virus, toxin or autoimmune response causes necrosis of the

myocardium– Most often caused by viral infection– Frequently caused by Coxsackie B virus– Frequently follows an upper respiratory infection or viral

illness– Get decreased contractility– Can become chronic and lead to dilated cardiomyopathy-

heart transplant or death

•This is an infection in the muscles of the heart, most commonly caused by the Coxsackie B virus that follows upon a respiratory or viral illness, bacteria and other infectious agents.

Risk factor-myocarditis

Hx of upper respiratory infection Toxic or chemical effects (radiation, alcohol) Autoimmune or immunosuppresents- 10%

HIV develop it Metabolic-lupus Heat stroke or hypothermia

Multiple Causes of Myocarditis

Assessment myocarditis

Infection and CHF– Fatigue,DOE– Tachycardia– Arrhythmias- PVCs, PACs, Atrial Tachycardias, – Chest pain– Signs of heart failure (S3, etc.) – Pericarditis frequently occurs with myocarditis-

check friction rub

Diagnostic Tests

EKG- Non-specific T-wave abnormalities CK-MB and Troponin may be elevated Endomyocardial biopsy- there are risks and not used

for every case but is definitive for myocarditis Chest X-Ray- Variable (Normal to Cardiomegaly) Echocardiogram Cardiovascular Magnetic Resonance A safe and sensitive noninvasive diagnostic test to

confirm the diagnosis is not available

Chest X-Ray in Myocarditis

MRI in Acute Myocarditis

Endomyocardial Biopsy

Biopsy Video

Heart Biopsy Video

Possible Medications

Antibiotics (rarely) Antiviral with interferon-a IVIG- experimental trials Corticosteroids or immunosuppressents HF drugs- ACE, diuretics, beta blockers etc Antiarrhythmics Anticoagulants- Why??

Other Treatments

Bedrest and activity restrictions- Why important??

**Activities may be limited for 6 months- 1 yr. O2

GOAL- Decrease workload of the heart so it can heal

Nursing Diagnoses

Activity Intolerance Decreased CO Anxiety Excess fluid Volume

Your client with myocarditis develops heart failure; his BP is 80/40; (MAP is 53.3).Which of the following medications should the nurse anticipate administering to improve myocardial contractility?

Lis

inop

ril

Las

ix IV

Dobut

amin

e IV

Am

iodar

one IV

25% 25%25%25%

MAP = Systolic BP + 2 (Diastolic BP)  

    divided by 3

1. Lisinopril

2. Lasix IV

3. Dobutamine IV

4. Amiodarone IV

In the United States, myocarditis is usually caused by:

Sta

ph aure

us

Coxs

acki

e B v

irus

HIV

Alc

ohol pois

oning

25% 25%25%25%

1. Staph aureus

2. Coxsackie B virus

3. HIV

4. Alcohol poisoning

Break!

!

Pericarditis

Pericarditis is an inflammation of the pericardium, the thin, fluid-filled sac surrounding the heart. It can cause severe chest pain (especially upon taking a deep breath) and shortness of breath.

Etiology/Pathophysiology

Pericarditis– bacterial, fungal or viral infection– Heart loses natural lubrication(10-30cc’s) and

layers roughen and rub– Inflammatory process causes lymphatic fluid

build-up- if sudden may have cardiac tamponade– Pericardial Effusion- usually 250 cc’s before show

up on x-ray. Can have 1000cc’s.

Risk Factors/pericarditis

Post MI (Dressler’s syndrome) Radiation Infection Trauma Cancer Drugs and toxins Rheumatic diseases Trauma or cardiac surgery Can be chronic disorder-pericardium becomes rigid

Assessment pericarditis

Inflammation and pain– Pericardial friction rub- diaphragm at LL sternal border in knee chest position – Fever– Substernal, sharp, pleuritic chest pain

Inc. with coughing, breathing,turning,lying flat Decreases with sitting up and leaning forward Referred to trapezius muscle Dyspnea

Diagnostic Tests- to R/O

CBC-inc. WBC, ESR, and CRP Cardiac Enzymes- elevated but not as much as with

MI EKG- ST elevation, PR changes Echo- for wall movement CXR CT or MRI- for pericardial effusion Pericardiocentesis fluid for analysis- attempt to

determine cause

ECG in Pericarditis

Medications

ASA or tylenol NSAIDS- ibuprofen Corticosteroids

Pericarditis Video Review

Livestrong Pericarditis Video

Complications of Pericarditis

Pericardial Effusion- an accumulation of excess fluid in the pericardium

Cardiac Tamponade- an increase in intracardial pressure caused by pericardial effusion that results in compession of the heart

Pericardial Effusion

Can occur rapidly or slowly Pulmonary compression-cough, dyspnea,

and tachypnea Phrenic nerve involvement- hiccups Laryngeal nerve- hoarseness

Pericardial Effusion- EKGElectrical Alternans

Pericardial effusion with electrical alternans

•The QRS axis alternates between beats. In this example it is best seen in the chest leads where the QRS points in different directions!

•This is rarely seen and is due to the heart moving in the effusion.

Cardiac Tamponade

Compression of the heart Can occur acutely (trauma) or sub-acutely

(malignancy) Symptoms- chest pain, confusion, anxious and

restless Later- tachypnea, tachycardia, and decreased CO,

NVD (neck vein distention) and pulsus paradoxus present

With slow onset dyspnea may be only symptom

PERICARDIUMCARDIAC TAMPONADE

Original heart size

Excess pericardial fluid

Cardiac tamponade

Physiology- Paradoxical pulse is a pulse that markedly decreases in amplitude during inspiration. On inspiration, more blood is pooled in the lungs and so decreases the return to the left side of the heart; this affects the consequent stroke volume.

Definition- a decrease in systolic BP with inspirations that is exaggerated in cardiac tamponade

Determination of Pulsus Paradoxus

•Place the patient in a position of comfort and take their systolic blood pressure during baseline respiration. •Raise sphygmomanometer pressure until Korotkoff sounds disappear. •Lower pressure slowly until first Korotkoff sounds are heard during early expiration with their disappearance during inspiration •Record this pressure. •Very slowly lower pressure (1mm at a time) until Korotkoff sounds are heard throughout the respiratory cycle with even intensity. •Record this pressure. •The difference between the two recorded pressures is the Pulsus Paradox. •Hemodynamically significant pulsus paradox is greater than or equal to 10 but we look at trends. People with COPD may have a paradox due to increased thoracic pressures.

Surgical/invasive Interventions

Pericardiocentesis– Hook needle to V lead- guided by EKG and echo– Look for ST elevation– Withdraw fluid– Afterward watch for cardiac tamponade (PP), arrhythmias,

and pneumothorax

Pericardiectomy Pericardial window Sclerosing agent- tetracycline (Bonds layers

together)

A procedure in which an opening is made in the pericardium to drain fluid that has accumulated around the heart. A pericardial window can be made via a small incision below the end of the breastbone (sternum) or via a small incision between the ribs on the left side of the chest.

Pericardial Window

Cardiac Tamponade and treatment

You tube- Cardiac Tamponade

Chronic Constrictive Pericarditis

Starts with acute then scarring and fibrosis occur

See signs of HF and cor pulmonale; most relate to decreased cardiac output

Most prominent finding is jugular vein distention (JVD)

Treatment of choice pericardectomy- with use of cardiopulmonary bypass

Nursing Diagnoses for Pericarditis

Acute Pain Ineffective Breathing Pattern Risk for Decreased Cardiac Output Activity Intolerance

Specific Nursing Assessment

Paradoxical pulse Murmur Pericardial friction rub Emboli Chest pain CHF

Comfort Measures

O2 Bedrest Positioning Prevent complications of immobility Psychological support

Case study

http://www.austincc.edu/adnlev4/rnsg2331online/module06/mr_a_case_study.htm

Case Studies

http://intmedweb.wfubmc.edu/grand_rounds/1999/tamponade.html - CASE%20PRESENTATION

Morphine is the drug of choice for pericarditis.

Tru

e

Fal

se

50%50%

1. True

2. False

You have just received change of shift report about these clients on the coronary step-down unit. Which one will you assess first?

1. A 26 year old with heart failure caused by congenital mitral stenosis who is scheduled for balloon valvuloplasty later today.

2. A 45 year old with constrictive cardiomyopathy who has developed acute dyspnea and agitation.

3. A 56 year old who had a coronary angioplasty and stent placement yesterday and has complained of occasional chest pain since the procedure.

4. A 77 year old who transferred from intensive care 2 days ago after coronary artery bypass grafting and has a temperature of 100.6F.

Which of the following clients would be the lowest priority to see after shift change?

A 1

9 ye

ar o

ld w

ith rh

...

A 3

3 ye

ar o

ld a

dmitt

e...

A 5

0 ye

ar o

ld w

ith n

ew..

A 7

5 ye

ar o

ld w

ho ha

s...

25% 25%25%25%

1. A 19 year old with rheumatic fever who needs discharge teaching prior to going home with a roommate today.

2. A 33 year old admitted a week ago with endocarditis who will be receiving Cefizol 2gm IV.

3. A 50 year old with newly diagnosed stable angina who has many questions about medications and nursing care.

4. A 75 year old who has just been transferred to the unit after having coronary artery bypass grafting yesterday.

The End!