Monday, September 20, 2010


    1. Pericarditis is inflammation (swelling) of the pericardium, which is the fluid-filled sac that surrounds your heart.
                                 1.  Definition and related terms
a.                  in pericarditis, an infection (from a bacterium, a fungus, Systemic Lupus Erythematosus (SLE), etc.) inflames the pericardium.
b.                 There may or may not be pericardial effusion or constrictive pericarditis.
c.                  dressler's Syndrome, also called postmyocardial infarction syndrome, is a combination of pericarditis, pericardial effusion and constrictive pericarditis. It occurs several weeks to months after a myocardial infarction. Etiology unclear.
                                 2.            Epidemiology
a.       may be acute or chronic and may occur at any age.
b.       pericarditis occurs in up to 15% of persons with a transmural infarction.
                                 3.            Findings  
a.    sharp chest pain often relieved by leaning forward
b.    pericardial friction rub
c.     dyspnea
d.    fever, sweating, chills
e.     dysrhythmias
f.     pulsus paradoxus
g.     client cannot lie flat without pain or dyspnea
                                 4.            Management
a.              antibiotics to treat underlying infection
b.              corticosteroids: usually reserved for clients with pericarditis due to SLE, or clients who do not respond to NSAID
c.              NSAIDS/Asprin for pain and inflammation
d.              oxygen: to prevent tissue hypoxia
e.              surgical
                                                                                      i.   emergency pericardiocentesis if cardiac tamponade develops
                                                                                   ii.   for recurrent constrictive pericarditis, partial pericardiectomy (pericardial window) or total pericardiectomy
                                 5.            Nursing interventions
a.   manage pain and anxiety
b.   the cardio-care six 
c.    maintain a pericardiocentesis set at the bedside in case of cardiac tamponade.
d.   assess respiratory, cardiovascular, and renal status often.
e.   observe for findings of infiltration or inflammation at the venipuncture site, a possible complication of long-term IV administration. Rotate the IV sites often.
f.     client and family teaching - teach the cardio five 
                                 6.            Diagnostic studies
a.              EKG changes, arrythmias
b.              echocardiography to determine pericardial efusion or cardiac tamponade
c.              history and physical exam

    1. Myocarditis
                                 2.            Definition - an inflammatory condition of the myocardium caused by
a.       viral infection
b.       bacterial infection
c.        fungal infection
d.       serum sickness
e.        rheumatic fever
f.        chemical agent
g.        as a complication of a collagen disease, i.e. SLE
                                 3.            Epidemiology
a.    may be acute or chronic and may occur at any age.
b.    usually an acute virus and self-limited, but it may lead to acute heart failure.
                                 4.            Findings
a.    depends on the type of infection, degree of myocardial damage, capacity of myocardium to recover, and host resistance
b.    may be minor or unnoticed: fatigue and dyspnea, palpitations, occasional precordial discomfort manifested as a mild chest soreness and persistent fever
c.     recent upper-respiratory infection with fever, viral pharyngitis, or tonsillitis
d.    cardiac enlargement
e.     abnormal heart sounds:  murmur, S3 or S4 or friction rub
f.     possibly findings of congestive heart failure such as pulsus alternans, dyspnea, and crackles
g.     tachycardia disproportionate to the degree of fever
                                 5.            Diagnostic studies
a. EKG for changes and arrythmias
b. labs
I.                    increases ESR
II.                  increases myocardial enzymes such as:
                                                                                                    i.      AST
                                                                                                 ii.      CK
                                                                                               iii.      LDH
c.  endomyocardial biopsy (EMB)
d. myocardial imaging
                                 6.            Management
a.              antibiotics to treat underlying infection
b.              corticosteroids to decrease inflammation
c.              analgesics for pain
d.              oxygen to prevent tissue hypoxia
                                 7.            Nursing interventions
a.              the cardio-care six  with modified bedrest and less help with ADLs
b.              assess for edema;  weigh daily; record intake and output
c.              assess cardiovascular status frequently
d.              observe for findings of left-sided heart failure (dyspnea, hypotension and tachycardia)
e.              check often for changes in cardiac rhythm  or conduction; auscultate heart sounds
f.               evaluate arterial blood gas levels as needed to ensure adequate oxygenation
g.              client and family teaching
I.        physical activity may be slowly increased to sitting in chair, walking in room, then outdoors.
II.      avoid pregnancy, alcohol, and competitive sports.
III.   immunize against infections.
IV.    teach client about anti-infective drugs. Stress importance of taking drugs as ordered.
V.      teach clients taking digitalis at home to:
                                                                                                  i.         check pulse for one full minute before taking the dose, and withhold the drug if heart rate falls below 60 beats/minute.
                                                                                               ii.         observe for findings of digitalis toxicity (anorexia, nausea, vomiting, blurred vision, cardiac arrhythmias) and for factors that may increase toxicity, such as electrolyte imbalance and hypoxia.
                                                                       VI.            teach client to report rapidly beating heart.
    1. Endocarditis
                                 2.            Definition and related terms
a.       an infection of the endocardium, heart valves, or cardiac prosthesis resulting from bacterial or fungal invasion.
b.       endocarditis can be classified as
I.        native valve endocarditis
II.      endocarditis in I.V. drug users
III.   prosthetic valve endocarditis
                                 3.            Epidemiology
a. with proper treatment about 70% of clients recover.
b. the prognosis is worse when endocarditis damages valves severely or involves a prosthetic valve.
c.  infective endocarditis occurs in 50 to 60% of clients with previous valvular disorders.
d. systemic lupus erythematosus (SLE) often leads to nonbacterial endocarditis.
e.  in 12% to 35% of clients with subacute endocarditis, lesions produce clots that show the findings of splenic, renal, cerebral or pulmonary infarction, or peripheral vascular occlusion.
                                 4.            Findings of endocarditis
a.              cardiac murmurs in 85 to 90% of clients 
b.              fever
c.              especially, a murmur that changes suddenly, or a new murmur that develops in the presence of a fever
d.              pericardial friction rub
e.              anorexia
f.               malaise
g.              clubbing of fingers
h.              neurologic sequelae of embolus
i.                petechiae of the skin (especially on the chest)
j.               splinter hemorrhage under the nails
k.              infarction of spleen: pain in the upper left quadrant, radiating to the left shoulder, and abdominal rigidity
l.                infarction in kidney: hematuria, pyuria, flank pain, and decreased urine output
m.            infarction in brain: hemiparesis, aphasia, and other neurologic deficits
n.              infarction in lung: cough, pleuritic pain, pleural friction rub, dyspnea and hemoptysis
o.              peripheral vascular occlusion:  numbness and tingling in an arm, leg, finger, or toe, or signs of impending peripheral gangrene
                                 5.            Management - clients at risk for prosthetic valves
a.              prophylaxis - to prevent endocarditis; i.e. MVP, cardiac lesions
b.              antibiotics - to treat underlying infection
c.              antipyretics - to control fever
d.              anticoagulants - to prevent embolization
e.              oxygen - to prevent tissue hypoxia
f.               surgical - possible valve replacement
                                 6.            Nursing interventions
a.    the cardio-care six 
b.    observe for findings of infiltration or inflammation at venipuncture site; rotate sites often.
c.     client and family teaching
I.               explain all procedures in a simple and culturally sensitive manner.
II.             involve the client and family in scheduling the daily routine activities. Allow client and family to participate in care.
III.          teach client relaxation techniques (meditation, visualization, or guided imagery) to cope with stress, pain, or insomnia.
IV.           explain endocarditis and the need for long-term therapy.
V.             explain the need for prophylactic antibiotics before dental work and other invasive procedures.
                                                                       VI.            teach client to report fever, tachycardia, dyspnea and shortness of breath.
                                 7.            Diagnostic studies
a.              health history
b.              lab data
I.               CBC
II.             blood cultures
III.          ESR
c.              CXR - to detect CHF
d.              EKG - transesophageal echocardiogram to detect vegetation and abscess on valves
    1. Rheumatic heart disease (rheumatic endocarditis)
                                 2.            Definition and related terms
a.       rheumatic heart disease is damage to the heart by one or more episodes of rheumatic fever. Pathogen is a group A streptococci.
b.       rheumatic endocarditis is damage to the heart, particularly the valves, resulting in valve leakage (regurgitation) and/or stenosis. To compensate, the heart's chambers enlarge and walls thicken.
                                 3.            Epidemiology
a.              worldwide, 15 to 20 million new cases of rheumatic fever are reported each year.
b.              rheumatic fever follows a group A streptococcal infection. We could prevent it by finding and treating streptococcal pharyngitis.
c.              where malnutrition and crowded living are common, rheumatic fever is commonest in children between ages 5 and 15.
d.              rheumatic fever strikes most often during cool, damp weather. In the U.S., it is most common in the northern states.
e.              it is unknown how and why group A streptococcal infections cause the lesions called Aschoff bodies.
f.               damage depends on site of infection: most often the mitral valve in females and the aortic valve in males.
g.              malfunction of these valves leads to severe pericarditis, and sometimes pericardial effusion and fatal heart failure. Of those who survive this complication, about 20% die within ten years.
                                 4.            Findings
a.              streptococcal pharyngitis
I.               sudden sore throat
II.             throat reddened with exudate
III.          swollen, tender lymph nodes at angle of jaw
IV.           headache and fever to 104 degrees Fahrenheit
b.              polyarthritis manifested by warm and swollen joints
c.              carditis
d.              chorea
e.              erythema marginatum (wavy, thin red-line rash on trunk and extremities)
f.               subcutaneous nodules
g.              fever to 104 degrees Fahrenheit
h.              heart murmurs  pericardial friction rub and pericardial rub
i.                no lab test confirms rheumatic fever, but some support the diagnosis.
                                 5.            Management
a. give antibiotics steadily to maintain level in blood.
b. provide analgesics - for pain/inflammation
c.  oxygen to prevent tissue hypoxia.
d. surgical - commissurotomy, valvuloplasty, prosthetic heart valve
                                 6.            Nursing interventions
a.              the cardio-care six 
b.              help the client with chorea to grasp objects; prevent falls.
c.              encourage family and friends to spend time with client and fight boredom during the long, tedious convalescence.
d.              client and family teaching
I.               explain all tests and treatments
II.             nutrition
III.          hygienic practices
IV.           to resume ADLs slowly and schedule rest periods
V.             to report penicillin reaction: rash, fever, chills
VI.           to report findings of streptococcal infection
                                                                                                    i.      sudden sore throat
                                                                                                 ii.      diffuse throat redness and oropharyngeal exudate
                                                                                               iii.      swollen and tender cervical lymph glands
                                                                                                iv.      pain on swallowing
                                                                                                  v.      temperature of 101 to 104 degree Fahrenheit
                                                                                                vi.      headache
                                                                                             vii.      nausea
II.             keep client away from people with respiratory infections
III.          explain necessity of long-term antibiotics
IV.           arrange for a visiting nurse if necessary
V.             help the family and client cope with temporary chorea
                                 7.            Diagnostic studies
a.              antistreptolysin 0 titer - increased
b.              ESR - increased
c.              throat culture - positive for streptococci
d.              WBC count - increased
e.              RBC parameters - normocytic, normochromic anemia
f.               C-reactive protein - positive for streptococci 


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