Infectious

1
Infectious Inflammatory Disorders of Heart
Blood Vessels

• CHAPTER 29

2
Rheumatic Fever Rheumatic Carditis

• Rheumatic fever is a systemic inflammatory
  disease that occurs as a result of a group A
  streptococcal infection of the throat
• Rheumatic Carditis refers to the cardiac
  manisfestations of rheumatic fever

3
Rheumatic Carditis

• An autoimmune disorder because it occurs after
  the body is exposed to a bacterial toxin that is
  similar to antigens within the bodys own
  tissues.
• Antibodies mistakenly identify the normal cells
  in the heart and joints and attacks them

4
Rheumatic Carditis S/S pg 438

• Involves heart, joints and nervous system.
• Occurs more often in children 2 to 3 weeks after
  streptococcal infection. (strept throat)
• Carditis (inflam. of the layers of heart),
  polyarthritis, rash, subq nodules, and chorea
  (involuntary muscle twitching) are the classic
  symptoms
• Adults do not have same degree of symptoms as
  children

5

• Polyarthritis

• Strep Throat

6
RheumaticCarditis S/S

• A mild fever, if untreated, continues for several
  weeks. Tachycardia and arrhythmias occur r/t the
  fever.
• A red, spotty rash appears on the trunk but
  disappears rapidly, leaving irregular circles on
  the skin
• Several joints (knees, ankles, hips and
  shoulders) become swollen, red, warm
  painful---migrates from joint to joint

7
Rheumatic Carditis S/S

• Sometimes marble size nodules appear around the
  joints.
• Motor disturbances cause involuntary grimacing
  and an inability to use skeletal muscles in a
  coordinated manner.
• Heart murmur suggests valve damage, a paricardial
  friction rub is indictive of pericarditis

8
Treatment

• Iv penicillin is drug of choice
• Bed rest
• Asa to prevent blood clots
• Steroidsto suppress the inflammatory response
• Tx depends on extent of damageif arrhythmias or
  heart failure require extensive Tx If mild
  symptoms may not require Tx.
• May require surgery to fix valves

9
Nursing Care

• Focused cardiac assessments
• diversions for weeks of bed rest (reading,
  puzzles and minimal activity)
• Must take prophylactic antibiotics before any
  invasive procedure , including dental to prevent
  endocarditis
• Susceptible to endocarditis

10
Infective Endocarditis (Bacterial
Endocarditis)

• Inflammation of the inner layer of heart
• Caused by bacteria and fungi--strept and staph
  most often as found normally on skin, mucous
  membranes of mouth, nose, throat and other
  cavities.
• Considered an autoimmune responsenot an
  infection.

11
Infective Endocarditis

• Most pathogens find their way into the blood
  stream through a cut or break in the skin or
  mucous membrane.
• Prolonged IV, insertion of pacemaker, cardiac
  cath, tracheal intubation, cardiac surg, foley
  cath and IV drug use are portal of entry

12
Endocarditis

• Once heart is infected, micros congregate around
  heart valves, chordae tendineae and papillary
  muscles.
• Fibrin, platelets, and blood cells stick to
  injured cells forming vegetations. The micros
  bury themselves in the vegetative mass so
  difficult for antibiotics to destroy.
• Mitral valve most common location of vegetation
  blood leaks between chambers

13
Endocarditis

• Can cause heart failure.
• Vegetations can break off and form emboli (mobile
  masses of tissue that circulate in the blood
  stream)
• Emboli may occlude small blood vessels and
  interfere with an organs blood supply.

14
Assessment Findings

• May have insidious onset with slight fever,
  headache, malaise, and fatigue.
• As it gets worse, purplish, painful nodules may
  be on pads of finger and toes. Black longitudinal
  lines (splinter hemorrhages) seen in nails.
• Spleen may be enlarged and abd. palpation causes
  pain

15
Assessment Findings

• May have heart murmur
• Petechiae (tiny reddish hemorrhagic spots on the
  skin and mucous membranes) are a sign of
  embolization
• Pronounced weakness, anorexia and weight loss are
  common
• Emboli can cause stroke, renal failure, and
  pulmonary emboli

16
Medical Management

• High doses of IV antibiotics given 2 to 6 weeks
  or longer.
• Bed rest Initially. As he improves may have
  bathroom privileges
• May need valve replacement

17
Nursing Management

• Will have to take periodic antibiotics for life
  as prone to recurrence
• Changes in weight, pulse rate and rhythm and
  appearance of new symptoms reported

18
Myocarditis Pg 441

• An inflammation of the myocardium-- muscle layer
  surrounding the heart
• A viral, bacterial, fungal or parasitic infection
  causes.
• Myocardium can become inflamed from the toxins
  of microorganisms, chronic alcohol abuse,
  radiation therapy or autoimmune disorders

19
Myocarditis

• Most cases in the US are caused by viral
• An inflammatory response causes the muscle tissue
  to swell and interferes with ability to stretch
  and recoil.

20
Myocarditis

• Cardiac output is reduced and circulation is
  impaired. Myocardium becomes ischemic causing
  tachycardia and arrhythmias
• Hypertrophic cardiomyopathy (enlarged thicker
  heart) is a complication of myocarditis.

21
Signs Symptoms of Myocarditis

• General chest discomfort relieved by sitting up,
• low grade fever, tachycardia, arrhythmias
• dyspnea, malaise, fatigue and anorexia
• pale or cyanotic skin, neck vein distention
• ascites and peripheral edema (right failure
• crackles (left failure), S3 gallop rhythm or
  pericardial friction rub

22
Medical Management

• Antibiotics if bacterial
• bedrest
• Na restricted diet
• cardiotonic drugs (digitalis related drugs)
• May need heart transplant

23
Nursing Management

• Monitor cardiopulmonary status
• daily weights, recording I O
• assess lung sounds and monitor for edema
• Maintain bed rest to reduce cardiac workload and
  promote healing

24
Cardiomyopathy pg 443

• Cardiomyopathy is a chronic condition
  characterized by structural changes in the heart
  muscles.
• Various types and treatments
• See nursing management pg 445

25
Pericarditis Pg 445

• Inflammation of the pericardium, (sac like
  structure that surrounds and supports the
  heart)-- can occur as a primary condition (one
  that develops independently of any other
  condition) or as a secondary condition (one that
  develops because of another condition).

26
Pericarditis

• Can occur with or without effusion ( the
  accumulation of fluid within two layers of
  tissue)
• Usually occurs secondary to endocarditis, chest
  trauma, MI,or cardiac surgery
• TB, malignant tumors, uremia and connective
  tissue disorders also cause

27
Pericarditis

• Intracellular fluid leaks into interstitial
  spaces. Fig 29-5 pg 446
• The exudate or effusion can be serous, resembling
  clear serum fibrinous, like thick, congealed
  liquid or purulent or sanguinous containing
  blood.

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Pericarditis

• Causes acute compression of heart or cardiac
  tamponade.
• The fluid takes up space the heart needs to
  expand or fill. This causes pulsus paradoxus or a
  drop in systolic BP on inspiration

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Pericarditis

• As cardiac tamponade progresses, stroke volume is
  diminished, reducing cardiac output and resulting
  in death if uncorrected.
• Pericardiocenteses, needle aspiration of fluid
  may be done and small cath. left in place so
  fluid will continue draining

30
Signs Symptoms of Pericarditis

• fever and malaise, dyspnea or chest feels heavy
• Precordial pain--pain in anterior chest overlying
  the heart (classic symptom)
• Pain can be mistaken for esophagitis,
  indigestion, pleurisy or MI
• Moving and deep breathing worsen the pain (MI
  pain does not change with movement)
  

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Pericarditis

• Sitting upright and leaning forward relieve pain
• Pain in MI remains unchanged regardless of
  position, movement or breathing
• A pericardial friction rub, a scratchy, high
  pitched sound, helps diagnose. Heart sounds
  muffled by fluid. Resp are rapid and labored,
  severe hypotension weak pulse

32
Medical Management

• Rest
• Analgesics
• Antipyretics
• Nonsteroidal anti-inflammatory drugs
• Sometimes corticosteroids

33
Nursing Assessment

• Assess for pericardial friction rub by asking him
  to briefly hold breath while auscultating heart
  sounds. A pericardial friction rub will not
  disappear when breath is held.
• Assess for cardiac tamponade and cardiac output.
  Assess for dyspnea, muffled heart sounds,
  Syncope, cough due to compression, pain and
  anxiety of trachea bronchi, neck vein
  distention

34
Nursing Care

• Assess lung sounds q 8 hrs.
• Assess peripherial pulses, level of consciousness
  and anxiety level
• Assess for signs of cardiac tamponade--tachycardia
  , pulsus paradoxus (drop in systolic with
  inspiration), restlessness and distended neck
  veins.
• Give O2 and have emergency pericardiocentesis
  tray available

35
Pericardiocentesis

• Consent form signed, baseline vitals, measure
  amt. of fluid and describe before sending to
  lab. Site covered with sterile dsg and reinforced
  PRN. Assess for bleeding or leakage of fluid.
  Significant changes in breathing, heart rate or
  rhythm and BP reported stat. Should see improved
  vitals, increased Ua output

36
Client Family Teaching

• Pg 447---review on own

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Thrombophlebitis pg 449

• Inflammation of a vein accompanied by clot
  formation
• Venous stasis(slowed circulation), altered blood
  coagulation and trauma to the vein predispose
  thrombophlebitis
• Venous stasis is most common cause
• Inactivity, reduced cardiac output, compression
  of veins in pelvis or legs and injury contribute
  to clot formation

38
Thrombophlebitis

• Some drugs and chemicals given IV irritate vein
• Oral contraceptives increase risk, especially if
  smokers
• Platelets clump together forming a clot when vein
  is irritated or injured
• Symptoms include pain, heat, redness and swelling

39
Thrombophlebitis

• Positive Homans sign (dorsiflexion)
• Capillary refill takes less than 2 seconds
  because of venous congestion
• may have fever, malaise, fatigue and anorexia
• Complains of discomfort in affected extremity
• Will have an elevated platelet count

40
Medical Management

• Complete rest of affected extremity essential to
  prevent the thrombus from becoming an embolus.
  Nurse should instruct him to maintain complete
  bedrest and do not massage area. warm compresses
  may be ordered
• Heparin and Coumadin ordered. Must watch for
  hematuria and other signs of bleeding

41
Nursing

• Prevent venous stasis by promoting activity and
  exercise for high risk patients.
• Ankle pumping exercises, TED stockings or
  pneumatic venous compression device that inflates
  and deflates.
• Change position frequently. Avoid prolonged
  sitting or gatching of bed. Do not put pillows
  under popliteal area...teach leg exercises page
  451

42
Teaching

• Avoid prolonged sitting and crossing legs
• elevate legs periodically
• wear support hose
• increase fluids
• nosebleeds, bleeding gums, rectal bleeding, easy
  bruising and prolonged oozing from minor cuts
  should be reported as impaired clotting

43
Thromboangitis Obliterans (Buergers Disease) pg
453

• Inflammation of blood vessels that is associated
  with clot formation and fibrosis of blood vessel
  wall. Affects small arteries and veins of legs
  more.
• Cause not known but smoking makes it worse.
• Affected arteries spasm and inflammatory lesions
  occlude the blood flow

44
Buergers Disease

• Skin and soft tissue have hypoxia and anoxia and
  some cells die and causes ulcerations. gangrene
  can occur.

45
Assessment Findings

• One or both feet are always cold and may have
  numbness, burning, tingling
• Intermittent claudication (cramps in legs after
  exercise) common.
• Intermittent claudication indicates peripheral
  vascular disease. Pain may occur at rest also.

46
Assessment Findings

• Cyanosis and redness of feet and legs may occur.
• Skin is mottled purplish red and appears thin and
  shiny with sparse hair growth
• Shallow, dry leg ulcers may be seen

47
Assessment Findings

• Black gangrenous areas on toes and heels
• Nails are thick. Capillary refill prolonged
• Peripheral pulses may be present at rest but
  disappear with activity
• Capillary refill is prolonged.

48
Buerger-Allen Exercises

• Teach Buerger-Allen Exercises on page 453
• Lie flat legs up for 2 min. or until blanching
• Place legs in dependent position, until
  cyanotic/red
• Lie in horizontal position for 1 min.
• Repeat exercise 4x 3x daily

49
Buerger-Allen Exercises

• Purpose of Buerger-Allen exercises is to improve
  circulation of the lower extremities.
• Lie flat legs up for 2 min. or until blanching
• Place legs in dependent position, until
  cyanotic/red
• Lie in horizontal position for 1 min.
• Repeat exercise 4x 3x daily

50
Medical Managment

• Tobacco in any form is restricted.
• Analgesics to ease pain
• Exercises

51
Nursing Management

• Affected areas are examined for redness,
  swelling, and other color changes, such as
  cyanosis and mottling.
• The nails and skin are inspected for changes, and
  the skin temperature above and below the affected
  area is noted.
• The presence and quality of peripheral pulses are
  monitored. Capillary refill assessed.

52
Nursing Management

• When the client is not performing exercises, the
  legs are kept horizontal or dependent.
• Elevating the legs increases ischemia and
  therefore, contributes to pain.
• The nurse carries out meticulous wound care if
  leg or foot ulcers exists.

53
Pt Family Teaching

• Avoid caffeine, tobacco products, OTC drugs
  that cause vasoconstriction, such as nasal
  decongestants.
• Inspect fingernails, toenails, and skin on arms
  and legs daily
• Wear properly fitting shoes and stockings or
  socks
• avoid prolonged exposure to cold
• When cold weather teach to wear thick socks or
  insulated boots and gloves