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Case Study Worksheet Name of Disease: Endocarditis PATHOPHYSIOLOGY Incidence/prevalence of the disease/what age range is most susceptible?

Ineffective endocarditis occurs primarily in patients who abuse IV drugs, have had valve replacements, have experience systemic infection, or have structural cardiac defects. Endocarditis is more common in older people. About 50% of all cases occur in patients over the age of 50. Endocarditis is twice as common in men of any age and is 8 times as common in elderly men as in elderly women. In children and young adults, most cases (about 75%) of endocarditis occur in those with congenital (i.e., present at birth) heart defects (Swierzewski, S.J., 2011). Your name/date:

Pathophysiology (describe what happens in the body initially and what happens as the condition worsens) 1. Caused by Streptococcus viridians or Staphylococcus aureus. Bacteremia (nosocomial or spontaneous) that delivers the organisms to the surface of the valve 2. Adherence of the organisms 3. Eventual invasion of the valvular leaflets with cardiac defect, blood may flow rapidly from a high-pressure area to a low-pressure zone, eroding a section of endocardium. Platelets and fibrin adhere to the denuded endocardium, forming a vegetative lesion. During bacteremia, bacteria become trapped in the low-pressure sinkhole and are deposited in the vegetation. Additional platelets and fibrin are deposited, which causes the vegetative lesion to grow. The endocardium and valve are destroyed. Valvular insufficiency may result when the lesion interferes with normal alignment of the valve. If vegetations become so large that blood flow through the valve is obstructed, the valve appears stenotic and then is very likely to embolize. What causes the condition? Streptococcus viridians or Staphylococcus aureus entering and infecting the endocardium. A healthy, defective, or prosthetic valve can be affected, but infections may occur also in apparently healthy endocardium or in septal defects. Endocarditis occurs when germs enter your bloodstream, travel to your heart, and attach to abnormal heart valves or damaged heart tissue. Bacteria cause most cases, but fungi or other microorganisms also may be responsible. What other conditions are related to this disease and how are they related? Possible ports of entry for infecting organisms include the oral cavity (especially dental procedures), skin rashes, lesions, or abscesses, infection (cutaneous, genitourinary, GI,

systemic), surgery or invasive procedures, including IV line placement. There is s development of heart murmurs (S3 or S4 heard), heart failures is the most common complication of infective endocarditis, arterial embolism (1/2 patients have), splenic infarction with sudden abdominal pain and radiation to the left shoulder can occur, rebound tenderness, 1/3 of patients have neurologic changes (confusion, reduced concentration, dyspnea, and cough are symptoms of pulmonary infarction related to embolization, petechiae, and splinter hemorrhages in the nail bed. Chart 37-9 fever associated with chills, night sweats, malaise, and fatigue, anorexia and weight loss, cardiac murmur, development of heart failure, evidence of systemic embolization, petechiae, splinter hemorrhages, Oslers nodes (on hand and soles of feet), Janeways lesions (flat reddened maculas on hands and feet), and positive blood cultures.renal infarction is flank pain that radiates to the groin and is accompanied by hematuria or pyuria. GENETICS What genetic component is associated with this condition? There is no true evidence that endocarditis has a genetic component. It is more of a communicable disease. HEALTH PROMOTION AND MAINTENANCE What risk factors are related to this disease? Artificial heart valves. Germs are more likely to attach to an artificial (prosthetic) heart valve than to a normal heart valve. The risk of infection is highest in the first year after implantation. Congenital heart defects. If you were born with certain types of heart defects, your heart may be more susceptible to infection. A history of endocarditis. An episode of endocarditis damages heart tissue and valves, increasing the risk of a future heart infection. Damaged heart valves. Certain medical conditions such as rheumatic fever or infection can damage or scar one or more of your heart valves, making them more prone to endocarditis. History of intravenous (IV) illegal drug use. People who use illegal drugs by injecting them are at a greater risk of endocarditis. The needles used to inject drugs are often contaminated with the bacteria that can cause endocarditis. If you have a known heart defect or heart valve problem, ask your doctor about your risk of developing endocarditis. Even if your heart condition has been repaired or hasn't caused symptoms, you may be at risk.

Describe the physical assessment findings related to this disease Recurrent fever of 99-103F (37.2-39.4C) Many older adults remain afebrile due to aging. Cardiovascular status: murmurs, S3 or S4. Heart failure is the most common complication of infective endocarditis. o Assess for right-sided HF (peripheral edema, weight gain, anorexia) o Left-sided HF (fatigue, shortness of breath, crackles on auscultation of breath sounds) Arterial embolization is major complication in up to half of patients. o Fragments of vegetation break loose and travel randomly to circulation Splenic infarction w/sudden abdominal pain and radiation to left shoulder can also occur. o Rebound tenderness on palpation of abdomen Renal infarction o Flank pain that radiates to groin is accompanied by hematuria or pyuria Mesenteric emboli o Diffuse abdominal pain, often after eating, and abdominal distention Neurologic changes o Confusion o Reduced concentration o Aphasia or dysphagia Signs/symptoms of pulmonary problems symptoms of pulmonary infarction r/t embolization o Pleuritic chest pain o Dyspnea o Cough Petechiae o Pinpoint red spots o Examine mucous membranes, palate, conjunctivae, skin above clavicles for small, red, flat lesions. Splinter hemorrhages o Assess distal third of nail bed. o Appear as black longitudinal lines/small red streaks. Other key features o Fever associated with chills, night sweats, malaise, fatigue o Anorexia, weight loss o Oslers nodes (on palms of hands and soles of feet) o Janeways lesions (flat, reddened maculas on hands and feet) o Positive blood cultures

Describe the psychosocial and cultural assessment related to this disease Rest balanced with activity. Supportive therapy for heart failure. Patients and family need to be motivated and have the knowledge, physical ability, and resources to administer IV antibiotics at home. Proper hygiene, especially oral hygiene. Teach patients to request prophylactic antibiotics for every invasive procedure, especially dental care.

Describe the laboratory findings and other diagnostic procedures related to this disease Blood culture: prime diagnostic test o most definitive diagnostic procedure and essential to guide treatment. o Use of antibiotics made identifying the causative organism much more difficult o Negative blood cultures up to 30% of cases of IE, delaying diagnosis and treatment and having profound effect on outcome o BC causative organisms are slow growing, require special culture media, or are not readily cultured Echocardiography is primary technique for detection of vegetations and cardiac complications resulting from IE and is important tool in diagnosis and management of disease. o Transesophageal echocardiography (TEE) allows visualization of cardiac structures that are difficult to see with transthoracic echocardiography (TTE). o Good resolution and very sensitive for discovering valvular abnormalities o Can diagnose IE more accurately Most reliable criteria: o Positive blood cultures, a new regurgitant murmur, and evidence of endocardial involvement by echocardiography.

What screening can be done to detect this disease in an early stage? Screen for recurrent fevers, cardiovascular status, and for the signs/symptoms above. Report fever, chills, malaise, weight loss, increased fatigue, sudden weight gain, or dyspnea to primary care provider.

What interventions will alleviate this disease? Antimicrobials o Main treatment, which choice of drug depending on specific organism involved. o IV, about 4-6 weeks o Ideal penicillins or cephalosporins Prophylaxis for invasive procedures like dental work. Anticoagulants o No value in preventing embolization from vegetations. Bc they may result in bleeding, avoid unless required to prevent thrombus formation on prosthetic valve Rest balanced with activity Proper oral and general body hygiene Supportive therapy for heart failure o Monitor for signs of HF: rapid pulse, fatigue, cough, dyspnea Surgical management o If antibiotic therapy is ineffective in sterilizing valve, if large valvular vegetations are present, or if multiple embolic events occur. o Removing the infected valve (either biologic or prosthetic) o Repairing or removing congenital shunts

o o

Repairing injured valves and chordae tendineae Draining abscesses in the heart or elsewhere.

Nutritional considerations A well-balanced, nutritious diet, combined with appropriate rest and activity as recommended by the physician. What drug therapy is effective? Antimicrobials are the main treatment, and the appropriate antibiotic depends on the infective organism involved in infection. High doses are usually administered in order to completely destruct any vegetations that are surrounding the infective organism. Patients may be hospitalized for several days in order to institute IV antibiotic therapy, with continuing IV therapy taking place at home for potentially several weeks. What complementary or alternative therapies are associated with this disease? Patients activities are balanced with a suitable amount of rest. Proper oral care and general body hygiene are important considerations for patients with endocarditis. COMMUNITY BASED CARE Describe the home management for this condition Home management for includes proper IV administration of antibiotics at home. A come care nurse and the pharmacist should collaborate to arrange for supplies: prepared antibiotic, IV pump with tubing, alcohol wipes, IV access device, NS solution, saline flush solution in syringes, a saline lock, a PICC line or central catheter is positioned at an accessible site for the patient and the family Describe the health teaching for this condition Teach the patient and the family how to administer the antibiotic and care for the infusion site and maintenance of asceptic technique. Nurses should ensure proper teaching by requiring a return demonstration by the patient or family members before discharge. Reinforcing the importance of proper scheduling and administration of antibiotics in order to maintain therapeutic drug levels. Teaching the patient proper hygiene, especially oral hygiene is of critical importance. Patients should be advised to use a soft toothbrush, and to brush their teeth at least twice per day and to rinse their mouths with water after brushing. Patients should not use irrigation devices or floss their teeth because of the risk for bacteremia. Patients should also be taught to clean any open skin areas, and to apply antibiotic ointment. Patients should also be advised to inform all of their health care providers of their condition, especially dentists. Teach patients to request prophylactic antibiotics for any invasive procedure.

Patients should be taught to monitor and record their temperatures daily for up to six weeks and to report and fever. They should also report any chills, malaise, weight loss/gain, increased fatigue or dyspnea.

ANALYSIS Name at least one nursing diagnosis and expected outcome for this disease EVALUATION - How will you know the patient is getting better? NURSING DIAGNOSIS: Risk for infection related to: 1. spread of infecting organism into the blood and to other sites associated with inadequate host defenses and resistance to antimicrobial agents; 2. interruption in the balance of usual endogenous microbial flora associated with the administration of antimicrobial agents. Patient will demonstrate absence of infection, characterized by: return of vital signs to normal, normal mental status, absence of a pericardial friction rub, precordial pain, and a pathologic murmur, absence of joint pain and swelling, absence of unusual drainage from any body cavity, absence of white patches and ulcerations in mouth, absence of stiff neck and headache, and WBC and differential counts returning toward normal range for client.