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Inflammatory Disorders By John Nation [email protected] Updated Spring 2012 From the notes of Nancy Jenkins 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! 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 organism more virulent 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 – – – Subacute Infective Endocarditis SBE – – Abrupt onset Rapid course Staph Aureus Gradual onset Systemic manifestations Prosthetic Valve Endocarditis Bacterial Endocarditis of the Mitral Value Fig. 37-2 Sequence of Events in Infective Endocarditis Fig. 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 fifth 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 Osler’s nodes Roth spots Roth’s Spots • hemorrhagic retinal lesions Diagnostic Tests Blood CulturesEchocardiogram-TEE best- see vegetations Other- WBC with differential, CBC,ESR, serum creatinine,CXR, and EKG Echocardiogram- 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 abuseWhy??) 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 To diagnose the causative organism in endocarditis, the nurse should anticipate the doctor ordering which test? 95% C B C ltu re s 0% cu d lo o B ca r ho Ec 0% di og ra m y 5% xra 4. st 3. he 2. Chest x-ray Echocardiogram Blood cultures CBC C 1. Which assessment finding is characteristic of endocarditis? 100% di c ea H B ra d yc un Ja rt M ur m ur 0% ar di a 0% e em a 0% ed 4. ra l 3. rip he 2. Peripheral edema Jaundice Bradycardia Heart Murmur Pe 1. A common complication of endocarditis of the mitral valve is pulmonary embolism. 86% ls e 14% Fa 2. True False Tr ue 1. 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 cardiomyopathyheart 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 myocarditischeck 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 Resonace 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 Medications Antibiotics 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? 21% e IV IV si x ro n m io da A La si no pr il divided by 3 Li MAP = Systolic BP + 2 (DiastolicBP) IV 5% 0% in e 4. ut am 3. ob 2. Lisinopril Lasix IV Dobutamine IV Amiodarone IV D 1. 74% In the United States, myocarditis is usually caused by: 91% 9% IV oi so H B A lc o ho lp ie sa ck 0% ni ng 0% vi ru s s re u ox C 4. au 3. h 2. Staph aureus Coxsackie B virus HIV Alcohol poisoning St ap 1. 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 rubdiaphragm at LL sternal border in knee chest position – Fever – Substernal, sharp, pleuritic chest pain – Inc. with coughing, breathing,turning,lying flat Dec. 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- EKG Electrical 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 dec. CO, NVD and pulsus paradoxus present With slow onset dyspnea may be only symptom PERICARDIUM CARDIAC TAMPONADE Original heart size Excess pericardial fluid Cardiac tamponade Definition- a decrease in systolic BP with inspirations that is exaggerated in 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 Determination of Pulsus Paradoxus 1.Place the patient in a position of comfort and take their systolic blood pressure during baseline respiration. 2.Raise sphygmomanometer pressure until Korotkoff sounds disappear. 3.Lower pressure slowly until first Korotkoff sounds are heard during early expiration with their disappearance during inspiration 4.Record this pressure. 5.Very slowly lower pressure (1mm at a time) until Korotkoff sounds are heard throughout the respiratory cycle with even intensity. 6.Record this pressure. 7.The difference between the two recorded pressures is the Pulsus Paradox. 8.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) Pericardial Window 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. Cardiac Tamponade and treatment 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 Studies http://intmedweb.wfubmc.edu/grand_rounds/19 99/tamponade.html CASE%20PRESENTATION Morphine is the drug of choice for pericarditis. 100% ls e 0% Fa 2. True False Tr ue 1.