Inflammatory Disorders

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Inflammatory Disorders

• By Nancy Jenkins
• Updated Spring 2010 by John Nation

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Overview of Todays 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)

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Layers of the Heart Muscle
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Anatomy and Physiology!

• How the heart works!

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TISSUES SURROUNDING THE HEART
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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
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Anatamy and Physiology Review (Contd)

• 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
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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.

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Causative Organisms

• Causative organisms
• Streptococcus viridans
• Staphylococcus aureus
• Viruses
• Fungi

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Etiology and Pathophysiology

• Vegetation
• Fibrin, leukocytes, platelets, and microbes
• Adhere to the valve or endocardium
• Embolization of portions of vegetation into
  circulation

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Etiology and Pathophysiology

• Occurs when blood turbulence within heart allows
  causative agent to infect previously damaged
  valves or other endothelial surfaces

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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

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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

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Classifications of Endocarditis

• Acute Infective Endocarditis
• Abrupt onset
• Rapid course
• Staph Aureus
• Subacute Infective Endocarditis SBE
• Gradual onset
• Systemic manifestations
• Prosthetic Valve Endocarditis

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Bacterial Endocarditis of the Mitral Value
Fig. 37-2
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Sequence of Events in Infective Endocarditis
Fig. 37-3
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Risk Factors- endocarditis

• 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

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Nursing Assessment

• Subjective Data
• History of valvular, congenital, or syphilitic
  cardiac disease
• Previous endocarditis
• Staph or strep infection
• Immunosuppressive therapy
• Recent surgeries and procedures

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Nursing Assessment

• Functional health patterns
• IV drug abuse
• Alcohol abuse
• Weight changes
• Chills

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Nursing Assessment

• Diaphoresis
• Bloody urine
• Exercise intolerance
• Generalized weakness
• Fatigue
• Cough

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Nursing Assessment

• Dyspnea on exertion
• Night sweats
• Chest, back, abdominal pain

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Collaborative Care

• Fungal and prosthetic valve endocarditis
• Responds poorly to antibiotics
• Valve replacement is adjunct procedure

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Assesment endocarditis

• Infection and emboli
• Emboli-spleen most often affected (splenectomy)
• Oslers 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

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Clinical Manifestations

• Murmur in most patients
• Heart failure in up to 80 with aortic valve
  endocarditis
• Manifestations secondary to embolism
• Heart Sounds Assessment Video

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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 fourth intercostal space
• The mitral area or apex is at the PMI -- the 5 th
  intercostal space in midclavicular line

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Splinter hemorrhage

• small areas of bleeding under the fingernails or
  toenails.
• due to damage to capillaries by small clots

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Janeway Lesions

• flat, painless red spots on palms and soles

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Oslers Nodes

• Painful, pea-size, red or purple lesions
• On finger tips or toes

Roth spots
Oslers nodes
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Roths Spots

• hemorrhagic retinal lesions

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Diagnostic Tests

• Blood Cultures-
• Echocardiogram-TEE best- see vegetations
• Other- WBC with differential, CBC,ESR, serum
  creatinine,CXR, and EKG

1) Vegetations on mitral valve 2) Vegetations on
aortic valve
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Diagnostic Criteria
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Diagnostic Criteria
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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

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Nursing Diagnoses

• Risk for Imbalanced Body Temperature
• Risk for Ineffective Tissue Perfusion-emboli
• Ineffective Health Maintenance

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Complications

• Emboli (50 incidence)
• Right side- pulmonary emboli (esp. with IV drug
  abuse- Why??)
• Left side-brain, spleen, heart, limbs,etc
• CHF-check edema, rales, VS
• Arrhythmias- A-fib
• Death
• .

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Prevention

• Eliminate risk factors
• Patient teaching

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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

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Collaborative Care

• Prophylactic treatment for patients having
• Removal or drainage of infected tissue
• Renal dialysis
• Ventriculoatrial shunts
• Dental, oral, or upper respiratory tract
  procedures

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Video Review- Endocarditis

• Livestrong Endocarditis Video

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To diagnose the causative organism in
endocarditis, the nurse should anticipate the
doctor ordering which test?

1. Chest x-ray
2. Echocardiogram
3. Blood cultures
4. CBC

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Which assessment finding is characteristic of
endocarditis?

1. Peripheral edema
2. Jaundice
3. Bradycardia
4. Heart Murmur

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A common complication of endocarditis of the
mitral valve is pulmonary embolism.

1. True
2. False

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Layers of the Heart Muscle
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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.

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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
  cardiomyopathy- heart transplant or death

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• 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.

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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

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Multiple Causes of Myocarditis
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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 myocarditis-
  check friction rub

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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 Resonance
• A safe and sensitive noninvasive diagnostic test
  to confirm the diagnosis is not available

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Chest X-Ray in Myocarditis
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MRI in Acute Myocarditis
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Endomyocardial Biopsy
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Biopsy Video

• Heart Biopsy Video

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Possible Medications

• Antibiotics (rarely)
• Antiviral with interferon-a
• IVIG- experimental trials
• Corticosteroids or immunosuppressents
• HF drugs- ACE, diuretics, beta blockers etc
• Antiarrhythmics
• Anticoagulants-

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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
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Nursing Diagnoses

• Activity Intolerance
• Decreased CO
• Anxiety
• Excess fluid Volume

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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.

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Etiology/Pathophysiology

• Pericarditis
• bacterial, fungal or viral infection
• Heart loses natural lubrication(10-30ccs) and
  layers roughen and rub
• Inflammatory process causes lymphatic fluid
  build-up- if sudden may have cardiac tamponade
• Pericardial Effusion- usually 250 ccs before
  show up on x-ray. Can have 1000ccs.

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Risk Factors/pericarditis

• Post MI (Dresslers syndrome)
• Radiation
• Infection
• Trauma
• Cancer
• Drugs and toxins
• Rheumatic diseases
• Trauma or cardiac surgery
• Can be chronic disorder-pericardium becomes rigid

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Assessment pericarditis

• Inflammation and pain
• Pericardial friction rub-
• diaphragm at LL sternal
• border in knee chest
• position
• Fever
• Substernal, sharp, pleuritic chest pain
• Inc. with coughing, breathing,turning,lying flat
• Decreases with sitting up and leaning forward
• Referred to trapezius muscle
• Dyspnea

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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

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ECG in Pericarditis
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Medications

• ASA or tylenol
• NSAIDS- ibuprofen
• Corticosteroids

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Pericarditis Video Review

• Livestrong Pericarditis Video

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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

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Pericardial Effusion

• Can occur rapidly or slowly
• Pulmonary compression-cough, dyspnea, and
  tachypnea
• Phrenic nerve involvement- hiccups
• Laryngeal nerve- hoarseness

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Pericardial Effusion- EKGElectrical 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.

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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 decreased CO,
  NVD (neck vein distention) and pulsus paradoxus
  present
• With slow onset dyspnea may be only symptom

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PERICARDIUM
CARDIAC TAMPONADE

Original heart size
Excess pericardial fluid
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Definition- a decrease in systolic BP with
inspirations that is exaggerated in cardiac
tamponade
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Determination of Pulsus Paradoxus

• Place the patient in a position of comfort and
  take their systolic blood pressure during
  baseline respiration.
• Raise sphygmomanometer pressure until Korotkoff
  sounds disappear.
• Lower pressure slowly until first Korotkoff
  sounds are heard during early expiration with
  their disappearance during inspiration
• Record this pressure.
• Very slowly lower pressure (1mm at a time) until
  Korotkoff sounds are heard throughout the
  respiratory cycle with even intensity.
• Record this pressure.
• The difference between the two recorded pressures
  is the Pulsus Paradox.
• 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.

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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)

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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.
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Cardiac Tamponade and treatment
You tube- Cardiac Tamponade
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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

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Nursing Diagnoses for Pericarditis

• Acute Pain
• Ineffective Breathing Pattern
• Risk for Decreased Cardiac Output
• Activity Intolerance

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Specific Nursing Assessment

• Paradoxical pulse
• Murmur
• Pericardial friction rub
• Emboli
• Chest pain
• CHF

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Comfort Measures

• O2
• Bedrest
• Positioning
• Prevent complications of immobility
• Psychological support

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Case study

• http//www.austincc.edu/adnlev4/rnsg2331online/mod
  ule06/mr_a_case_study.htm
• http//intmedweb.wfubmc.edu/grand_rounds/1999/tamp
  onade.html - CASE20PRESENTATION

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The End!