Transcript Pericarditis and endocarditis

PERICARDITIS
Pericarditis is
the inflammation
of the
membranous
sac surrounding
the heart. It may
be manifested
as an acute or
chronic
condition.
ACUTE PERICARDITIS
Infectious forms of acute pericarditis include….
-bacterial
-viral
-fungal
-tubercular
Noninfectious forms of acute pericarditis are….
-azotemia-presence or increase of nitrogenous waste
products, especially urea, in the blood.
-acute MI
-lung cancer
-breast cancer
-leukemia
-Hodgkin’s disease
-lymphoma
-scleroderma
-trauma after thoracic surgery
-systemic lupus erythematosus
-radiation
-drug reactions
BACTERIAL PERICARDITIS
Pericardial sac
The
pericardial
sac has
been opened
to reveal an
abundant
amount of
fibrin that is
coating the
heart’s
surface.
VIRAL PERICARDITIS
This is an
example of
severe viral
pericarditis.
Here, the
pericardial sac
surrounding the
heart has been
opened to show
the amount of
pus and fibrin
that has
accumulated
around the heart.
FUNGAL PERICARDITIS
This is an example
of purulent fungal
pericarditis. Note
the yellowish
exudate that has
pooled in the lower
pericardial sac.
Fibrosis of the pericardial sac develops in the chronic form
causing….
-fibrous constriction of the pericardium
-thickening of the pericardium
-severe compression of the pericardium due to the fibrous
growth
-prevents normal filling during diastole-because of the
fibrous constriction, the heart is not about to fill and
pump effectively
A window of adherent
pericardium has been
opened to reveal the
surface of the heart.
There are thin strands of
fibrous exudate that
extend from the
epicardial surface to the
pericardial sac. This is
typical for a fibrous
pericarditis.
This is an example
of a fibrous
pericarditis. The
surface appears
roughened from
the normal
glistening
appearance by the
stands of pink and
tan firbin.
The pericarditis here
not only has fibrin, but
also hemorrhage.
Thus, this is called a
“hemorrhagic
pericarditis”. Without
inflammation, blood in
the pericardial sac
would be called
“hemopericardium”.
Surgical removal of the pericardium may be
necessary to restore normal cardiac output
The white stuff that you see on
the pericardium is calcified,
scar tissue that is filled with
fibrous material. The cause of
why it’s there is unknown. In
this specific case they think
that it was caused by a
childhood virus….
Pericarditis differs clinically from other inflammatory
conditions of the heart in that the presentation of
debilitating pain-much like that of an MI-is common.
The pain is aggravated by…
-lying supine
-deep breathing
-coughing
-swallowing
-moving the trunk of the body
The pain is alleviated by…
-sitting up
-leaning forward
The hallmark
finding in acute
pericarditis is a
pericardial friction
rub due to an
accumulation of
fluid in the
pericardial space,
this produces….
-grating
-scratching
-leathery sounds
on auscultation
-dysrhythmias
Other findings in pericarditis include….
-dypnea
-fever
-chills
-diaphoresis
-leukocytosis
-muscle aches
-fatigue
-excruciating chest pain
radiating to the neck and
shoulders with severe and
sudden onset.
-nonproductive cough
-anxiety
-rapid pulse
-shallow breaths
The most serious
complication of
pericarditis is a
cardiac tamponade…
This is when a
pericardial effusion is
so large that it
restricts heart
movement and
pumping
An EKG will note changes or dysrhythmias
Electrocardiogram obtained in 17-year-old adolescent with chest pain
caused by acute pericarditis. The ST segments are elevated in multiple
leads. This represents the first stage of acute pericarditis.
Echocardiography will show the presence of a pericardial
effusion or a cardiac tamponade by ultrasound.
Visualization of the heart with an echocardiography device. The pericarditis is
signaled by the arrow and corresponds to a removal of the two leaflets of the
pericardium that is “the heart envelope”.
Chest radiographic findings are generally normal or
nonspecific in acute pericarditis unless the patient has a
large pericardial effusion .
This chest x-ray
shows viral
pericarditis with
a massive
pericardial
effusion.
A CT scan gives you a
picture of the body in a
cross-section and it is
as if you are looking
down at the section.
The red arrow in the
picture is showing
pericarditis.
Some medical management includes….
-analgesics for pain
-oxygen
-parenteral fluids
-antibiotics if bacterial
-salicylates for an elevated temperature
-corticosteroids for the inflammatory process
Some surgical interventions are….
-pericardial fenestration (pericardial window)-a surgical
drainage portal through the pericardium into the
peritoneum to drain fluid from the pericardial space.
-pericardiocentesis
A pericardiocentesis is an invasive procedure in
which the physician removes fluid from the
pericardial sac. The procedure involves the
insertion of a needle into the pericardium to
withdraw fluid. A catheter may be inserted to
allow further drainage. If necessary, the catheter
will remain in place for several days for
continuous drainage.
Complications of a pericardiocentesis include….
-atelectasis
-introduction to infectious agents
Pericardiocentesis
Nursing interventions….
-carefully evaluate vitals every two to four hours
-auscultate lungs and heart sounds
-administer meds as ordered
-provide physical and emotional support
-observe for further complications
-bed rest
-HOB elevated 45 degrees to decrease dyspnea
-hypothermia therapy may be necessary
-explain all procedures thoroughly
-monitor I&O and restrict sodium intake
Some nursing diagnoses….
-decreased cardiac output, related to inflammatory process
-pain, related to inflammatory process
-excess fluid volume, related to ineffective myocardial
pumping action.
Prognosis….
The prognosis is fair in early stages but extremely poor if
purulent and fibrous stages develop. Also, depending on
the underlying cause, pericarditis usually subsides in one
month or less. However, if pericarditis is caused by a
disease like lupus or rheumatoid arthritis, it can persist
for longer periods of time.
ENDOCARDITIS
Endocarditis
is an infection
or
inflammation
of the inner
lining of the
heart,
particularly
the heart
valves.
It is termed infective endocarditis, causative
organisms include….
-fungi
-chlamydiae
-rickettsiae
-viruses
-bacteria
Most common organisms….
-streptococcus viridans
-streptococcus pyogenes
-staphylococcus aureus
-staphylococcus epidermidis
Endocarditis may result from….
-invasion of an organism into the endocardium
-injury to the lining of the endocardium
-after cardiac surgery
Who’s at risk?
-rheumatic heart disease
-congestive heart disease
-degenerative heart disease
-street drugs-due to the possibility of bacterium from
contaminated needles
-following intrusive procedures
-dental procedure
-minor surgery
-gynecological exams
-insertion of indwelling urinary catheters
As organisms embed into the tissues, a vegetative (morbid outgrowth, wartlike projections made of fibrin, RBC’s, and WBC’s) growth perforates the
chambers or valve leaflets. Fibrin and calciferous growths may ulcerate
and scar the valves.
If the vegetations break away from the valves they could
cause an embolus, which it turn could cause an infection
or abscess in the organs where they lodge….
Systemic embolization
-occurs from left side heart vegetation that breaks loose
and travels to the peripheral circulation
-progresses to organs
-brain
-kidneys
-spleen
-limb infarction
Lung embolization
-occurs from right side heart vegetation that break off and
travels to the lungs
Some signs and symptoms of endocarditis….
-flu like symptoms
-splinter hemorrhages in nailbed
-fatigue
-weight loss
-chest pain
-rapid pulse
-headaches
-onset of a murmur
-joint pain
-aortic and mitral valves most
-chills
commonly affected
-petechiae
-conjuntiva
-oral mucosa
-neck
-anterior chest
-abdomen
-legs
Roth spots-small
white spots in the
retina close to the
optic disk, often
surrounded by a
systemic infection.
Osler nodes-small,
tender cutaneous
nodes, usually
present in the fingers
and toes. They are
due to infected emboli
from the heart.
DIAGNOSTICS….
-EKG-will show changes
and dysrhythmias
-Chest x-ray
-TEE-transesophageal
echocardiography (An
ultrasonographic
transducer is introduced
into the esophagus. This
test detects cardiac
sources of emboli,
prosthetic heart valve
malfunction, endocarditis,
aortic dissection, cardiac
tumors, and valvular and
congenital heart disease.
Labs would indicate….
-leukocytosis-elevated WBC count
-increased erythrocyte sedimentation rate
(ESR)-test of the speed at which RBC’s
settle out of un-clotted blood
-anemia-reduction in the amount of
circulating red blood cells
-hyperglobulinemia-excess amount of globin
(a plasma protein) in the blood.
-sensitivity tests for antibiotics
Medical management may include….
-rest to decrease cardiac output
-massive doses of antibiotics-usually parenterally-to kill the
organism
-supporting cardiac function
-prevention of complications, such as emboli and heart
failure
-prophylactic antibiotics for individuals who at high risk for
developing infective endocarditis
-previous valve surgery
-preexisting valvular heart disease
-congenital abnormalities
-surgical repair of valves
-surgical replacement of valves
Gross anatomy of aortic valve endocarditis. The left-sided image displays a
quadricuspid aortic valve with prominent nodules of Arantii (arrow). The rightsided image displays a vegetation on the aortic valve (arrow). The pulmonary
valve is on the left side of this image and is bicuspid.
Nursing interventions….
-based on the signs and symptoms
-observe for petechiae
-location of pain
-vomiting
-fever
-decreased activity
-calm, quiet environment
-vitals every 4 hours, including apical pulse
-adequate nutrition
-give attractive meals to stimulate appetite and supplements in
between meals
-promote rest and comfort
-preventing further inflammation and infection
Prognosis….
Before the advent of antibiotics, patients with infective
endocarditis could be expected to live approximately one
year; prompt treatment with intensive antibiotic therapy
will now cure about 90% of patients with this condition.