Inflammatory Disorders

1. Inflammatory Disorders By John Nation jnation@austincc.edu

2. 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)

3. Layers of the Heart Muscle

4. Anatomy and Physiology!

6. TISSUES SURROUNDING THE HEART

9. 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

10. 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

11. 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.

12. Causative Organisms • Causative organism more virulent • Streptococcus viridans • Staphylococcus aureus • Viruses • Fungi

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

14. 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

15. 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

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

17. Bacterial Endocarditis of the Mitral Value Fig. 37-2

19. Sequence of Events in Infective Endocarditis Fig. 37-3

20. 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

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

22. Nursing Assessment • Functional health patterns • IV drug abuse • Weight changes • Chills

23. Nursing Assessment • Diaphoresis • Bloody urine • Exercise intolerance • Generalized weakness • Fatigue • Cough

24. Nursing Assessment • Dyspnea on exertion • Night sweats • Chest, back, abdominal pain

25. Collaborative Care • Fungal and prosthetic valve endocarditis • Responds poorly to antibiotics • Valve replacement is adjunct procedure

26. 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

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

28. 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

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

31. Janeway Lesions • flat, painless red spots on palms and soles

32. Osler’s Nodes • Painful, pea-size, red or purple lesions • On finger tips or toes Roth spots Osler’s nodes

33. Roth’s Spots • hemorrhagic retinal lesions

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

35. Echocardiogram- • http://www.youtube.com/watch?v=y53Y7vr31V8

36. Diagnostic Criteria

37. Diagnostic Criteria

38. Medications • Antibiotics • IV for 6-8 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 only 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

39. Nursing Diagnoses • Risk for Imbalanced Body Temperature • Risk for Ineffective Tissue Perfusion-emboli • Ineffective Health Maintenance

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

41. Prevention • Eliminate risk factors • Patient teaching

42. 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

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

44. To diagnose the causative organism in endocarditis, the nurse should anticipate the doctor ordering which test? • Chest x-ray • Echocardiogram • Blood cultures • CBC

45. Which assessment finding is characteristic of endocarditis? • Peripheral edema • Jaundice • Bradycardia • Heart Murmur

46. A common complication of endocarditis of the mitral valve is pulmonary embolism. • True • False

47. Layers of the Heart Muscle

48. 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.

49. 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

50. 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.