Exam 22 - Rheumatic Heart Disease / Inflammatory Heart Disease

Rheumatic Fever

• Inflammatory disease is caused by inadequately treated childhood pharyngeal or upper respiratory infections
• The infections are caused by Group A beta hemolytic streptococci

Rheumatic Fever Etiology/Pathophysiology

• Inadequately treated Group A beta hemolytic streptococci infections cause it
• Inflammation of cardiac tissues, the central nervous system, joints, skin, and subcutaneous tissues may occur
• All layers of the heart, including valves, are susceptible
• Necrosis and scar tissue can occur in valves, resulting in valvular stenosis and mitral valve insufficiency

Rheumatic Fever Clinical Manifestations

• Generalized signs and symptoms include fever, increased pulse, epistaxis, anemia, joint pain, nodules on joints, and inflammation of heart tissues
• Subjective symptoms include joint pain (polyarthritis), chest pain, lethargy, and fatigue
• Objective signs include erythema marginatum (small erythematous circles and wavy lines on the trunk and abdomen)
• Involuntary purposeless movement (Sydenham’s Chorea) can also occur
• A heart murmur may be present

Rheumatic Fever Diagnostic Testing

• Diagnosed based on signs, symptoms, and supported by lab results
• Echocardiogram determines damage to valves and myocardium
• ECG shown cardiac dysrhythmias
• Cardiac murmurs or friction rub may be auscultated
• Elevated ESR and leukocytes are present
• Elevated Antistreptolysin-O titer is observed
• C-Reactive Protein is also elevated

Rheumatic Fever Medical Management

• Rapid treatment of Group A strep pharyngitis with penicillin is the preventative measure
• Prescribe bed rest if carditis is present
• NSAIDs treat joint pain and inflammation
• A balanced diet with Vitamin B and C, along with high-volume fluid intake, is needed, unless heart failure is present
• Valve replacement or surgical commissurotomy are possible treatments

Rheumatic Fever Nursing Interventions

• Implement bed rest during the acute phase if carditis is present
• Minimize joint pain with proper positioning
• Minimize discomfort and avoid tiring the patient
• Emphasize emotional support and diversions

Rheumatic Fever Patient Teaching

• Explain the disease process, signs, and symptoms
• Reinforce the importance of a nutritional diet
• Make sure to keep follow-up appointments
• Prophylactic penicillin is needed for those with a history of rheumatic fever
• Prophylactic antibiotics are needed before surgery or dental procedures if there is valve damage

Pericarditis

• Pericarditis is the inflammation of the membranous sac surrounding the heart

Pericarditis Etiology/Pathophysiology

• Can be associated with bacterial, viral, or fungal infection
• Azotemia, acute MI, lung cancer, breast cancer, leukemia, scleroderma, trauma after thoracic surgery, systemic lupus erythematosus, radiation, or drug reactions can be a complication
• Chronic pericarditis involves fibrosis, constriction, and thickening of the pericardium, which prevents normal filling during diastole

Pericarditis Clinical Manifestations

• Debilitating pain, similar to MI, aggravated by lying supine, deep breathing, coughing, swallowing, and moving the trunk is experienced
• Patients feel relief by sitting up and leaning forward
• Dyspnea, fever, chills, diaphoresis, and leukocytosis may occur
• Pericardial friction rub can be auscultated
• A decrease in heart function is expected
• Subjective symptoms consist of muscle aches, fatigue, dyspnea, chest pain, and anxiety
• Objective signs consist of orthopneic positioning, facial grimacing, elevated temperature, chills, diaphoresis, nonproductive cough, rapid pulse, rapid shallow breathing, muffled heart sounds, and dysrhythmia

Pericarditis Diagnostic Tests

• ECG changes are present
• Echocardiogram shows pericardial effusion
• Elevated Leukocytosis and ESR
• Blood cultures identify the pathogen
• Elevated C-reactive protein is detected
• Chest radiograph may be normal or nonspecific

Pericarditis Medical Management

• Use analgesia for pain relief
• Administer oxygen
• Prescribe Parenteral fluids
• Administer antibiotics for bacterial pericarditis
• Rx salicylates for fever and indomethacin or corticosteroids for inflammation
• Possible Pericardiocentesis or pericardial window is a treatment option

Pericarditis Nursing Interventions

• Monitor vital signs every 2–4 hours and auscultate lung and heart sounds
• Provide supportive measures and observe for complications
• Maintain bed rest
• Elevate the head of the bed
• Hypothermia treatment
• Administer medications
• Restrict sodium
• Monitor I&O and daily weights

Endocarditis

• An infection or inflammation of the inner lining of the heart, especially the valves

Endocarditis Etiology/Pathophysiology

• Bacterial is most common
• Can be acquired traumatically, mainly after cardiac surgery
• Organisms embed in tissue, leading to vegetative growth
• At-risk populations include patients with rheumatic, congestive, and degenerative heart disease, unhealthy teeth and gums, and those who use needles for tattoos or IV drugs

Endocarditis Clinical Manifestations

• Endocarditis can occur in acute or subacute forms
• Subjective symptoms include flu-like symptoms with recurrent fever, undue fatigue, chest pain, headaches, joint pain, and chills
• Objective signs include petechiae, splinter hemorrhages, and non-tender macular lesions

Endocarditis Diagnostic Testing

• ECG changes and chest radiographic examination are present
• Transesophageal echocardiogram is performed
• Laboratory findings indicate leukocytosis, increased ESR, anemia, and hyperglobulinemia
• Blood cultures determine the causative organism

Endocarditis Medical Management

• Support cardiac function and destroy the pathogen
• Anticoagulation is generally not recommended
• Rest to decrease the heart’s workload
• Administer massive doses of antibiotics
• Prophylactic antibiotic treatment is recommended for individuals who are at high risk
• Surgical repair of the valve or valve replacement may be necessary

Endocarditis Nursing Interventions

• Observe for petechiae, location of pain, vomiting, and fever
• Maintain decreased activity and provide a calm, quiet environment
• Take vital signs, including apical pulse, every 4 hours
• Ensure adequate nutrition
• Promote rest and comfort

Endocarditis Patient Teaching

• Discuss causes, precautions, and dietary requirements
• Make sure you describe the need for prophylactic antibiotics before any invasive procedure if the patient has preexisting valvular heart disease
• Educate on reporting any signs and symptoms that may indicate recurrent infections

Myocarditis

• Myocarditis is inflammation of the myocardium

Myocarditis Etiology/Pathophysiology

• May originate from rheumatic heart disease, viral, bacterial, or fungal infection, or endocarditis or pericarditis
• Most significant cases are caused by coxsackie virus type B in the United States

Myocarditis Clinical Manifestations

• Upper respiratory tract symptoms such as fever, chills, and sore throat are present
• Abdominal pain and nausea
• Vomiting, diarrhea, and myalgia
• Chest pain and heart failure with dyspnea
• Cardiac enlargement, murmur, gallop, and tachycardia

Myocarditis Diagnostic Tests

• Check X-ray
• ECG
• Echocardiography
• MRI
• Cardiac catheterization with endomyocardial biopsy

Myocarditis Medical Management

• Therapy is symptomatic and primarily follows the same approach as that of endocarditis
• Prescribe bed rest, oxygen, antibiotics, anti-inflammatory agents to correct dysrhythmias

Cardiomyopathy

• Cardiomyopathy is a group of heart muscle diseases that primarily affect the structure and functional ability of the heart muscle

Cardiomyopathy Etiology/Pathophysiology

• Primary cardiomyopathy consists of heart muscle disease of unknown cause, classified as dilated, hypertrophic, or restrictive
• Secondary cardiomyopathy has a number of causes, including infective, metabolic, nutritional, alcoholism, peripartum, prescribed drugs, radiation therapy, systemic lupus erythematosus, rheumatoid arthritis, and cocaine abuse

Cardiomyopathy Clinical Manifestations

• Angina
• Syncope
• Fatigue
• Dyspnea on exertion
• Severe exercise intolerance
• Right and Left heart failure

Cardiomyopathy Diagnostic Studies

• Diagnosis is made using the patient’s signs and symptoms
• ECG determines if there are changes in rhythm which may lead to a functional problem
• Echocardiogram determines if there is a structural or functional problem
• CT scan determines if there is a structural problem
• Nuclear Studies determine structural and functional problems
• MUGA Scan creates a video of the blood pumping through the lower chambers, or ventricles, of the heart
• Cardiac Catheterization determines structural and functional problems
• Endomyocardial biopsy determines the damage to the heart’s muscle cells

Cardiomyopathy Medical Management

• Administer Medications to treat the heart failure
• Cardiac glycosides help with contractility (digoxin)
• Diuretics help remove some fluid and decrease pre-load and after load
• ACE Inhibitors help with decreasing the workload of the heart by decreasing BP
• Anti-dysrhythmic medication will help the heart pump more effectively improving cardiac output
• Beta-adrenergic blockers slow down the rate of the heart giving the ventricles more time to fill thus during contraction they will move more volume
• Internal defibrillator can be placed to prevent sudden cardiac death
• Cardiac transplant should be considered

Cardiomyopathy Nursing Implications

• Focus on relieving symptoms, observing for and preventing complications, and providing emotional and psychological support
• Monitor response to medications and monitor for dysrhythmias

Cardiomyopathy Patient Teaching

• Adjust their lifestyle to avoid strenuous activity and dehydration
• Space activities and allow for rest periods