ATI Chapter 35: Inflammatory Disorder

Myocarditis-Patient Education

1. Patients are given specific treatment for the underlying cause if it is known (Ex; Penicillin for hemolytic streptococci) 2. Patients are placed on bedrest to decrease cardiac workload 3. Bed rest also helps decreased myocardial damage and the complications of myocarditis 4. In young patients with myocarditis (activities especially athletics) should be limited for a 6 month period or at least until heart size and function have returned to normal. 5. Physical activity is increased slowly and the patient is instructed to report any Sx that occur with increasing activity such as a rapidly beating heart. 6. NSAIDs should not be used for pain control; they have been implicated in increased cardiac injury and viral replication

Cardiac Tamponade Nursing Actions

1. Notify PCP immediately 2. Administer IV fluids to combat hypotension 3. Obtain a chest x ray or echocardiogram to confirm DX 4. Prepare the client for pericardiocentesis - Informed consent - Gather materials - Administer meds as prescribed 5. Monitor hemodynamic pressures to ensure they normalize 6. Monitor heart rhtythm as changes indicate improper positioning of the needle 7. Monitor for reoccurence of manifestations after the procedure

Side note: Patients with myocarditis are sensitive to digitalis

1. Nurses must closely monitor these patients for digitalis toxicity AEB by a new onset of arrhythmias, anorexia, N/V, headache and malaise -The PCP should be notified immediately if this is suspected.

Pericarditis Treatment:

1. Objectives of treatment: Determine the cause, administer therapy for treatment and symptom relief. 2. Pericardiocentesis: removal of pericardial fluid. 3. Surgical removal of tough encasing pericardium may be needed to release both ventricles from constrictive and restrictive inflammation and scarring. 4. Pericardial window: Allows for continuous drainage into the chest cavity by making an opening into the pericardium

What is Myocarditis?

Inflammatory process involving the myocardium.

Ibuprofen

NSAIDs are given to treat fever and inflammation associated with pericarditis (No longer used for treatment of pain and inflammation with myocarditis) 1. Do not use with clients who have peptic ucler diseae 2. Watch for indications of GI distres 3. Monitor platelets and liver and kidney function levels Client Education: 1. Medication can cause GI distress (take with food) 2. Avoid alcohol when taking

Rheumatic Endocarditis Causes:

1. An infection of the endocardium due to a complication of rheumatic fever 2. Preceded by Group A-beta streptococcal pharyngitis 3. Produces lesions in the heart

LAB Test

1. Blood cultures can detect a bacterial infection 2. Elevated WBC count can indicative of bacterial infection 3. Cardiac enzymes can be elevated with pericarditis 4. Elevated ESR and CRP indicate inflammation in the body 5. Throat cultures can detect a strep infection which can lead to rheumatic fever

ECG

1. Can detect heart block associated with - Rheumatic fever 2. Demonstrates ST segment elevation in almost all leads in the case of pericarditis

Echocardiography

1. Can reveal inflamed heart layers or pericardial effusion

Interprofessional Care

1. Cardiology services are consulted to manage cardiac dysfunction 2. Infectious disease can be consulted to manage infection 3. PT can be consulted to increase the clients level of activity once prescribed

Cardiac Tamponade

1. Considered a medical emergency as a result from fluid accumulation in the pericardial sac

Cardiac Tamponade Manifestations

1. Dyspnea 2. Dizziness 3. Chest tightening 4. Increased restlessness 5. Pulsus paradoxus (a decrease of 10 mm Hg) or more in systolic BP during inspiration 6. Tachycardia 7. Muffled heart sounds 8. JVD

Pericarditis Assessment Findings:

1. Echocardiogram: May detect inflammation, pericardial effusion or tamponade, and heart failure. 2. CT: best for determining size, shape, and location of pericardial effusions. 3. MRI: May detect inflammation and adhesions. 4. 12 Lead ECG: May show concave ST elevations in many, or all, leads and may show depressed PR segments or atrial arrhythmias.

Bacterial Endocarditis S/S:

1. Fever 2. Roth spots 3. Osler nodes 4. Murmr 5. Janeway lesions 6. Anemia 7. Nail bed hemorrhages 8. Emboli FROM JANE

Myocarditis can Cause:

1. Heart dilation 2. Thrombi on the heart wall (aka mural thrombi) 3. Infiltration of the circulating blood cells around the coronary vessels and between the muscle fibers.

Care after discharge

1. Home health services can be indicated if the client had surgery 2. IV antibiotic therapy can be given by home health service 3. Pharmaceutical services can be indicated for IV supplies and meds 4. Rehav services can be indicated to help the client decrease the level of activity

Endocarditis Treatment

1. IV antibiotic therapy - They will use a broad-spectrum antibiotic therapy to cover as many bacterial species as possible - As soon as they know which type they will adjust the antibiotics to target it - They will be on antibiotics for at least 6 weeks

Infective Endocarditis

1. Infection of the endocardium due to staphylococci, fungi, or other infectious organisms 2. Most common in clients who have cardiac devices, prosthetic heart valves, or have IV substance use disorder 3. Infective procedures such as dental procedures

Pericarditis Causes

1. Infection: most commonly cause is virus like enterovirus, herpes, adenovirus, parvovirus. 2. Bacterial: rare but if bacterial cause, it is typically mycobacterium tuberculosis. 3. Fungal: rare but histoplasma, aspergillus, candida. 4. Parasitic: rare but Echinococcus, toxoplasma.

What is Pericarditis?

1. Inflammation of the membranous sac around the heart called the pericardium. 2. May be acute, chronic, or recurrent. 3. May be infectious or noninfectious.

Pericardiocentesis for Pericarditis

1. Insertion of a needle into the pericardium to aspirate percardial fluid 2. Can be done in ED or a procedure room

Cardiac Tamponade Hemodynamic Monitoring Reveals

1. Intracardiac and pulmonary artery pressures similar and elevated (plateau pressures)

Pericarditis Education

1. Major goal may be to relieve pain. 2. Take medications as prescribed. 3. Avoid exercise and strenuous activity unless approved by physician. 4. Rest

Pericarditis Signs and Symtoms

1. May be asymptomatic. 2. Chest pain (most characteristic). 3. Pain may also be located beneath the clavicle, in the neck, or left trapezius(scapula) region. 4. Creaky or scratchy friction rub heard clearly at the left lower sternal border. 5. Mild fever 6. Increased WBC 7. Anemia 8. Elevated ESR or C-reactive protein level.

Myocarditis Pathophysiology:

1. May begin in one small area of the myocardium and then spread throughout the myocardium 2. The degree of myocardial inflammation and necrosis determine the degree of interstitial collagen and elastin destruction. 3. The greater the destruction, the greater is the hemodynamic effect and resulting signs/symptoms 4. It is thought that dilated cardiomyopathy and hypertrophic myopathy are latent manifestations of myocarditis.

Myocarditis Mortality varies depending on the severity of SX:

1. Most patients with mild symptoms recover completely 2. However, some patients develop cardiomyopathy and heart failure

What causes Myocarditis?

1. Myocarditis usually results from an infectious source (can be due to a viral, fungal, or bacterial infection) 2. Or can be from an autoimmune disorder 3. COVID-19 might also increase the risk for myocarditis 4. May also result from an inflammatory reaction to toxins such as pharmacologic agents

Myocarditis - Assessment/Diagnostic Findings

1. Patients may be tachycardic or may report chest pain 2. An endomyocardial biopsy can provide the definitive diagnosis 3. Cardiac MRI's are being used as a more diagnostic tool because of its noninvasive approach 4. Monitoring EKG's - Patients without any abnormal heart structures (at least initially) may suddenly develop arrhythmias or ST and T wave changes. 5. If the patient has strucutral heart abnormalities (ex; systolic dysfunction), a clinical assessment may disclose cardiac enlargement, faint heart sounds (especially s1), pericardial friction rub, a gallop rhythm or a systolic murmur. 6. The WBC count, C-Reactive protein, leukocyte count and ESR (erythrocyte sedimentation rate) may be elevated

Pericardiocentesis for Pericarditis Nursing Actions

1. Pericardial fluid can be sent to the lab for culture and sensitivity 2. Monitor for reoccurrence of cardiac tamponade

Duke minor criteria for Endocarditis

1. Predisposing condition 2. Fever 3. Immunologic signs 4. One positive blood culture

What are the clinical manifestations of Myocarditis?

1. Tachycardia 2. Murmurs 3. Friction rub ascultated in the lungs 4. Fatigue 5. Dyspnea 6. Syncope (fainting or passing out) 7. Palpitations 8. Cardiomegaly 9. Dysrhthmias 10. Occasional discomfort/pain in the chest and upper abdomen 11. Most common symptoms are flulike *** 12. Patients may also sustain sudden cardiac death or quickly develop severe congestive heart failure in fulminant myocarditis.

Client Education

1. Take rest periods PRN 2. Wash hands to prevent infection 3. Avoid crowds to reduce risk of infection 4. Good oral hygiene and prevention of infection 5. Take meds as prescribed 6. Demonstrate administration of IV antibiotics and management before discharge 7. Participiate in cessation of tobacco use 8. Understand illness, and express any feelings 9. Advise all providers, including dentists, of Hx of endocarditis so that antibiotic therapy prophylaxis is prescribed if needed

Myocarditis Nursing Management:

1. The nurse assess for resolution of tachycardia, fever, and any other clinical manifestations 2. The cardiovascular assessment focuses on s/s of HF and arrhythmias 3. Patients with arrhythmias should have continuous cardiac monitoring with personnel and equipment readily available to treat life threatening arrhythmias 4. Anti embolism stockings and passive and active exercises should be used because embolization from venous thrombosis and mural thrombi can occur especially those on bed rest

Duke major criteria for Endocarditis

1. Two positive blood cultures 2. Positive echo 3. New regurgitant murmur

Penicilin

Antibiotic given to treat infection 1. Monitor for skin rahs and hives 2. Monitor electrolyte and kidney levels Client Education: 1. Report skin rash or hives 2. The medication can use GI distress

Amphortericin B

Antifungal cream given to treat fungal infection 1. Monitory liver and kidney function levels Client Education: 1. Can cause GI distress

Inflammated r/t to the heart is an

Extended inflammatory response that often leads to the destruction of healthy tissue Primarily includes the layers of the heart: - Epicardium - Myocardium - Endocardium

For Duke Criteria (Endocarditis)

For diagnosis you need either 2 major 1 major and 3 minor 5 minor

Prednisone

Glucocorticosteroids given to treat inflammation 1. Use in low doses 2. Monitor BP 3. Monitor electrolytes and blood glucose levels 4. Monitro for impaired healing in clients taking this med Client Education: 1. Take with food 2. Do not stop med abruptly 3. Report unexpected weight gain