Inflammatory Disorders

1. Inflammatory Disorders

2. TISSUES SURROUNDING THE HEART

3. Layers of the Heart Muscle

4. 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

5. Classifications of Endocarditis • Acute Infective Endocarditis • Abrupt onset • Rapid course • Staph Aureus • Subacute Infective Endocarditis SBE • Gradual onset • Systemic manifestations • Prosthetic Valve Endocarditis • Occurs within 2 months after OR

9. Risk Factors- endocarditis • Hx of rheumatic fever or damaged heart valve • Invasive procedures- dental,gyne, etc. • IV drug users • Valve replacements

10. Assesment endocarditis • Infection and emboli • Emboli-spleen most often affected • Osler’s nodes • Splinter hemorrhages • Janeway lesions • Murmur • T above 101(blood cultures),chills • Anorexia • Fatigue • Roth spots

12. Osler’s nodes Janeway lesions Splinter hemmorrhages Roth spots

13. Diagnostic Tests • Blood Cultures- for temp >101 • Echocardiogram-TEE best- see vegetations • Other- CBC,ESR, serum creatinine,CXR, and EKG

14. Medications • Antibiotics • IV for 2-8 weeks • Monitor peaks and troughs of certain drugs • Monitor BUN and Creat.

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

16. Complications • Emboli(50% incidence) • Right side- pulmonary emboli • Left side-brain, spleen, heart, limbs,etc • CHF-check edema, rales, VS • Arrhythmias-Afib most common • Death • Cardiac Tamponade .

19. Prevention • Eliminate risk factors • Patient teaching • Penicillin prophylaxis

20. Etiology/Pathophysiology • Myocarditis • Virus, toxin or autoimmune response causes necrosis of the myocardium • Frequently caused by Coxsackie B virus • Get dec. contractility • Can become chronic and lead to dilated cardiomyopathy

21. 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.

22. Risk factor-myocarditis • Hx of URI • Toxic or chemical effects(radiation, alcohol) • Autoimmune • Metabolic-lupus • Heat stroke or hypothermia

23. Assessment myocarditis • Infection and CHF • Fatigue,DOE • Tachycardia • Arrhythmias • Chest pain- maybe an MI • Signs of CHF

24. Diagnostic Tests • EKG- ST segment and T wave changes • CK-MB and Troponin may be elevated • Endomyocardial biopsy

26. Medications • Antibiotics • Antiviral with interferon-a • Corticosteroids or immunosuppressents • HF drugs-ACE, diuretics, beta blockers etc • Antiarrhythmics • Anticoagulants

27. Other Treatments • Bedrest and activity restrictions • **Activities may be limited for 6 months- 1 yr. GOAL- Decrease workload of the heart

28. Nursing Diagnoses • Activity Intolerance • Decreased CO • Anxiety • Excess fluid Volume

29. A 42 year old West African man was admitted unconscious to the intensive care unit, after an out of hospital cardiac arrest and resuscitation by a friend. He had little medical history of note other than that he had had a recent upper respiratory tract infection. There were no risk factors for HIV infection. While on intensive care he had recurrent episodes of ventricular fibrillation requiring multiple dc shocks, but ultimately settled on treatment with intravenous lignocaine (lidocaine), amiodarone, and overdrive pacing. His resting ECG showed non-specific T wave changes (fig 1) and he intermittently had non-sustained episodes of a broad complex, irregular tachycardia (fig 2). Full blood count, urea and electrolytes, and liver function tests were normal. Transthoracic echocardiography showed normal left ventricular function and size. He gradually recovered

30. without any sequelae. Electrophysiological testing revealed inducible non-sustained polymorphic ventricular tachycardia. Coronary angiography was entirely normal. A right ventricular biopsy was taken which subsequently showed healing myocarditis (fig 3). The patient declined to have an implantable cardioverter/defibrillator and was discharged on oral amiodarone.

31. Normal Pericardium Pericarditis • slit like opening between two layers • contains pericardial fluid • film of serous fluid • lubricant that reduces friction between the beating heart and pericardial sac

32. Etiology/Pathophysiology • Pericarditis • bacterial, fungal or viral infection • Heart loses natural lubrication(15-50cc’s)and layers roughen and rub • Inflammatory process causes lymphatic fluid build-up • Pericardial Effusion- usually 250 cc’s before show up on x-ray

34. PERICARDIUM CARDIAC TAMPONADE Original heart size Excess pericardial fluid

36. 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 atime) 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% of the pressure at which all Korotkoff sounds are heard with even intensity. • ______________________________________________________________________________________

38. Risk Factors/pericarditis • Post MI (Dressler’s syndrome) • Secondary to chemo and cancer • Secondary to uremia in renal failure-40-50% of ESRD Pts. Develop this • Trauma or cardiac surgery • Can be chronic disorder-pericardium becomes rigid

39. Assessment pericarditis • Inflammation and pain • Friction rub-LLsternal border in knee chest position Cardiac Resources • Fever • Substernal, pleuritic chest pain • Inc. with coughing, breathing,turning,lying flat • Dec. with sitting up and leaning forward

40. Diagnostic Tests- to R/O • CBC-inc. WBC and ESR • Cardiac Enzymes- inc. but not as much as with MI • EKG • Echo- for wall movement • CXR • CT or MRI- for pericardial effusion

41. Medications • ASA or tylenol • NSAIDS • Corticosteroids

42. Surgical/invasive Interventions for all • Pericardiocentesis • Hook needle to V lead • Look for ST elevation • Withdraw fluid • Afterward watch for cardiac tamponade(PP) Valve Replacement Heart Transplant Pericardial window

44. 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.

45. Nursing Diagnoses for Pericarditis • Acute Pain • Ineffective Breathing Pattern • Risk for Decreased Cardiac Output • Activity Intolerance

46. Specific Nursing Assessment • Paradoxical pulse • Murmurhttp://www.music.mcgill.ca/auscultation/heart_tables.html • Pericardial rub • Emboli • Chest pain • CHF

47. Comfort Measures • O2 • Bedrest • Positioning • Space Activities • Prevent complications of immobility • Psychological support

48. Case Studies • http://www.indegene.com/Car/ClinRound/indCarCase2.html myocarditis • Vascular Infections Case 7-endocarditis • http://www.med.unsw.edu.au/pathology/Pathmus/m1004089.htm-endocarditis http://intmedweb.wfubmc.edu/grand_rounds/1999/tamponade.html - CASE%20PRESENTATION Johns Hopkins Arthritis Case report on rheumatoid pericarditis