COMPLICATIONS

vegetations can become dislodged resulting in emboli

left-sided heart embolizations
-brain:
hemiplegia, ataxia, aphasia, visual changes & changes in LOC

-liver:
sharp RUQ pain, local tenderness, abdominal rigidity

-spleen:
sharp LUQ pain, local tenderness, abdominal rigidity & splenomegaly

-kidneys:
flank pain, hematuria, & renal faliure

-extremities:
ischemia & gangrene

right-sided heart embolizations
-lungs:
dyspnea, chest pain, hemoptysis & respiratory arrest

NURSING MANAGEMENT

Health Promotion
-identifying those individuals at risk for developing IE
-teach:
-about risk factors & disease process
-importance of prophylactic antibiotic therapy & adherence to tx
-to avoid others with infection
-to report cold, flu, & cough symptoms
-to avoid excessive fatigue & to plan rest periods
-importance of good oral health & routine dental check-ups
-patient to inform other HCPs about hx of IE if undergoing certain invasive procedures
-referral to drug rehabilitation for those patients w/ hx of IVDA

Ambulatory & Home Care
-home nursing care for patients receiving outpatient IV antibiotics or those that are hemodynamically stable & adhering to treatment:
-assess IV site for patency & signs of complications
-administering ABX on time & monitoring for side effects
-teach:
-to monitor temperature & that persistent fever could indicate ineffective drug therapy
-s/s of stoke, pulmonary edema & HF due to increased risk of developing these complications
-ambulation & moderate activity if tolerated
-to plan adequate rest periods & bedrest if fever or complications arise
-to wear compression stockings; perform ROM exercises & deep breathe and cough q2h if on bedrest
-coping & stress reduction strategies due to anxiety & fear from illness
-routine lab work to monitor effectiveness of ABX tx
-patient about follow-up care, good nutrition & early tx of common infections to prevent relapses

ETIOLOGY

idiopathic w/ suspected viral cause (most common)
-coxsackie B virus

Drug Therapy

-accurate identification of the infecting organism is the key to successful treatment
-long term tx is necessary to kill dormant bacteria within the valvular vegetations
-complete elimination can take weeks
-relapses are common
-patients are initially hospitalized w/ IV ABX based on blood cultures

-subsequent blood cultures are later assessed for effectiveness of tx:
positive cultures indicate inadequate antibiotic, aortic root or myocardial abscess, or the wrong diagnosis

-fungal endocarditis & prosthetic valve endocarditis:
respond poorly to ABX tx when used alone
early valve replacement & prolonged (6 wks or more) ABX tx is recommended tx

-endocarditis w/ heart failure:
responds poorly to drug therapy & valve replacement
often life-threatening

-fever may persist for several days after starting drug therapy:
aspirin
acetaminophen
ibuprofen
fluids
rest (complete bedrest only indicated if those patients w/ continued fever or s/s of heart failure)

Criteria for Diagnosis

need at least two of the following:

-positive blood cultures
-presence of new or changed murmur
-presence of intracardiac mass or vegetation on echocardiogram

NURSING MANAGEMENT

manage patient's pain & anxiety:
-put pt on bedrest w/ HOB at 45 degrees
-anti-inflammatory meds to be given w/ food or milk & to avoid alcohol
-pantoprazole to reduce stomach acid
-to decrease anxiety, explain procedures & tx to pt

assess pain to distinguish from MI:
-left trapezius muscle
-sharp pleuritic quality that increases w/ inspiration
-relieved when pt sits up or leans forward
-worst when lying supine

monitor pt for s/s of cardiac tamponade:
-sharp chest pain
-confusion (anxious & restlessness)
-decreased cardiac output
-muffled heart sounds
-narrowed pulse pressure
-tachypnea
-tachycardia
-increased JVD
-pulsus parodoxus

prepare pt for possible pericardiocentesis

Pathophysiology

Myocardium infected ~> Agents invade myocytes ~>Cellular damage & necrosis ~>Immune response activated ~>Release of cytokines & oxygen free radicals ~>Autoimmune response activated as further infection progresses ~>Further destruction of myocytes~>Myocarditis ~> Cardiac dysfunction ~>Dilated Cardiomyopathy

Diagnositcs

-EKG
May show evidence of pericardial involvement
Diffuse ST Segment changes
Dysrhythmias & conduction disturbances may be present

Labs (may be inconclusive)
Mild - Moderate Elevated WBC's
Atypical lymphocytes
Elevated ESR
Elevated CRP
Elevated Troponin
Elevated Viral Titers

Virus may be present in tissue and pericardial fluids samples only during initial 8-10 days of illness

Endomyocardial Biopsy
Done during 1st 6 weeks of acute illness because period of lymphocytic infiltrateand myocyte damage are present

Assessment of Cardiac Function
Nuclear Scan
MRI
Echocardiography

Nursing Management

Manage signs and symptoms of HF
Decrease cardiac workload:
Semi-Fowler's
Spacing activities
Rest periods
Provide quiet environment

Carefully monitor meds that increases heart contractility and decreases preload, afterload or both

Assess level of anxiety
Keep patient and caregiver informed about therapeutic regimen to help decrease the level of anxiety

If taking immunosuppressive agents:
Monitor for signs of infection
Provide proper infection control procedures

Most patients with myocarditis recover spontaneously

Some develop Dilated Cardiomyopathy

If severe HF occurs: May need ❤ transplant

Drug Therapy

antibiotics
-for bacterial pericarditis

NSAIDS
-control pain & inflammation

corticosteroids
-pericarditis 2ndary to SLE
-colchicine (Colsalide) can be used for recurrent pericarditis (originally used for gout)

COLLABORATIVE CARE

pericardiectomy
-complete resection of the pericardium by a median sternotomy