Inflam Heart Disease.txt

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SP123
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9946
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Inflam Heart Disease.txt
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2010-03-11 00:15:29
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Med Surg I Inflam Heart Disease
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Med Surg I - Inflam Heart Disease
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  1. What is Endocarditis?
    • Inflammation of the lining of the heart and valves
    • Previously damaged valve surface seeded with bacteria released during invasive prodcedures
    • Infection (through bloodstream) causes valve damage; can infect myocardium and/or result in sepsis
    • Valve damage can lead to CHF
  2. What are vegetation?
    Clumps of bacteria, fibrin, platelets, and leukocytes that effects valvular function and can embolize to brain, kidneys, lungs, limbs, etc.
  3. Types of invasive procedures that can promote endocarditis
    • Dental procedures
    • Cystoscopy
    • Endoscopy
    • GYN procedures
    • Surgery
    • IV drug abuse
    • Cardiac cath
    • IV therapy
  4. Clinical manifestations of endocarditis
    • Fever, chills, weakness (immune response)
    • Myalgias, arthralgias (inflammatory cytokines released in reaction to infection)
    • New onset murmur (caused by valvular damage from infection and bacteria)
    • Splinter hemorrhage and petechiae (vegetations lodge in peripheral vessels)
    • Osler's Nodes (painful tender red or purple pea sized lesions on finger tips or toes)
    • Janeway's Lesions (bruising areas; flat painless small red spots on palms and soles)
    • Embolic complications (strokes, embolism in kidneys)
  5. Diagnosing endocarditis
    • CBC (elevated WBCs)
    • Blood cultures (want to know organism so know how to treat; usually strep, staph or enterococci)
    • 2D echo or TEE (to visualize valves; TEE better visualize vegetation)
  6. Treatment of endocarditis
    • IV antibiotics for weeks (usually PCN, cephalosporin, or vancomycin)
    • May be discharged with PICC
    • May require valve replacement (if damage is severe)
  7. Nursing care of endocarditis
    • Assessment (vitals, heart sounds, fever, lack of cardiac flow due to valve damage, skin lesions)
    • Cardiac monitoring
    • Draw labs and evaluate results (draw culture prior to 1st dose of antibiotics)
    • IV antibiotics (maintain IV access, review allergy history, observe for response to therapy and adverse reactions)
    • Acetaminophen for fever (control fever to decrease cardiac workload)
    • Patient education (explain diagnosis and treatment)
    • Psychosocial support
    • Discharge planning (home health follow up; PICC line; teach patient to do treatment themselves, maintenance of PICC line, signs and symptoms of infection, and what to do if there is a problem)
  8. Endocarditis prophylaxis
    • Patient's with pre-existing valve disease are more prone to endocarditis because they already have valves that are calcified
    • Required for patients with prosthetic heart valves, pacemakers, ICDs, some heart murmurs (does not include functional murmurs or MVP without regurgitation), rheumatic fever and prior history of endocarditis
    • Usually single dose of PCN or erythromycin 1 hour prior to procedure
    • Educate patient (inform dentist and other healthcare providers)
  9. What is pericarditis?
    • Inflammation of the pericardial sac
    • Inflammation results from infection, autoimmune responses, mechanical or biochemical sources
    • Results in chest pain and can cause increase in pericardial fluid which impedes cardiac function (normal is less than 50 ml)
    • Chest pain tends to be pleuritic, positional and sharp; auscultate rub (MI ischemia chest pain is more heavy and diffuse)
  10. What are some complications of pericarditis?
    • Cardiac tamponade (fluid accumulation due to inflammation)
    • Chronic constrictive pericarditis
    • Myocarditis
  11. Etiology of pericarditis
    • Viral (treat by symptom management)
    • MI (inflammatory response after infarction can produce pericarditis)
    • Dressler's syndrome (2 weeks after MI; autoimmune pericarditis)
    • Bacterial
    • Trauma
    • Neoplasm
    • Radiation
    • Tuberculosis
    • Uremia
  12. Clinical manifestations of pericarditis
    • Chest pain (sharp, pleuritic; worse with coughing, swallowing, movement or lying down; relieved by sitting up or leaning forward)
    • Fever
    • Pericardial friction rub
    • EKG changes (diffuse ST segment elevation across all 12 leads; if is an MI, will correlate with leads that correspond to a certain artery and not across all 12 leads)
  13. Diagnosing pericarditis
    • EKG and cardiac enzymes (to rule out MI)
    • Echo (to look for inflammation, effusion, or tamponade)
    • Pericardiocentesis (pull fluid from sac) or pericardial biopsy (to determine etiology)
  14. Treatment of pericarditis
    • NSAIDs or corticosteroids
    • Treat underlying cause if not viral
    • Rest
  15. Nursing care for pericarditis
    • Assess pain
    • Observe for medication effects (NSAIDs: GI bleed, kidney problems; corticosteroids: incr risk for infection, catabolism, incr blood sugar)
    • Observe for signs or symptoms of tamponade
    • Assist to position of comfort
    • Provide emotional support
  16. Cardiac tamponade
    • Rapid accumulation of fluid compresses the heart impeding its ability to fill
    • Results in severely compromised cardiac output (impaired preload)
    • Can occur from trauma
    • Severity depends on how rapidly it develops
    • Hypotension, tachycardia, tachypnea, dyspnea, anxiety, confusion, JVD, muffled heart sounds, poor perfusion peripherally (low voltage EKG)
    • Pulsus paradoxus - inspiratory drop in SBP of >10mmHg (related to shifts in thoracic pressure)
  17. Treatment of cardiac tamponade
    • Emergent pericardiocentesis
    • Risks of pericardiocentesis: arrhythmias, pneumomediastinum, pneumothorax, myocardial laceration, coronary artery laceration, puncture of ventricle
    • Pericardial window: removal of part of pericardium in patient's who have chronic pericardial effusions (keep re-accumulating fluid)
  18. What is myocarditis?
    • Impaired contractility due to inflammation of myocardium
    • Etiology: viral, SLE, idiopathic
    • Clinical manifestations: similar to pericarditis with CHF, crackles, S3, JVD, edema
    • Contraindication to perform any type of exertion (can go into a lethal arrhythmia)
  19. Treatment of myocarditis
    • No specific treament
    • Rest and treat underlying CHF
    • Most will resolve
    • Some will progress to dilated cardiomyopathy
  20. What is rheumatic fever?
    • Inflammation of the heart resulting from an immune reaction to an infection with group A beta hemolytic strep
    • Occurs 2 to 3 weeks after infection
    • Inflammation can occur throughout the heart but primarily affects the valves
    • Complications: permanent valve damage (usually mitral or aortic), stenosis, regurgitation
  21. Clinical manifestations of rheumatic fever
    • Fever (immune response)
    • Cardiac effects (new onset murmur, CHF, pericardial effusion, pericarditis)
    • Migratory polyarthritis (inflammatory arthritis; joints are red, swollen, tender)
    • Subcutaneous nodules (Firm, small, round, painless swellings over bony prominences)
    • Sydenham's chorea (nervous system inflammation; spastic movements that worsen with voluntary activity; delayed sign; weakness, ataxia)
    • Erythema marginatum (less common; bright red macular lesions on trunk, upper arms, and thighs)
  22. Diagnosing rheumatic fever
    • History and exam (recent infections, sore throat, assess pharynx, lymph nodes, CV exam)
    • ASO titer (indicates immune response to strep; tests for antibodies)
    • Throat culture (identify strep source)
    • Echo (assess heart valves)
  23. Treatment of rheumatic fever
    • Antibiotics (treat with PCN or macrolide to eradicate underlying strep infection; will require antibiotic prophylaxis for 5 years to life because attacks will recur if re-infected with strep)
    • Anti-inflammatiories (salicylates or corticosteroids)
    • Course (95% resolve in 6 months)
    • Valve damage (may require on-going evaluation and treatment)
    • Prevention
  24. What are the differences between endocarditis and rheumatic fever?
    • The bacteria that cause them (endocarditis: usually staph)
    • Different antibodies (rheumatic rever: antibodies are causing problem, not bacteria; endocarditis: bacteria causes problem, bacteria is attacking the heart)
    • Etiology (endocarditis: bacteria gets into blood stream; can get rheumatic fever without septicemia)

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