Emergency Nursing Care Plan For INVECTIVE ENDOCARDITIS

Bacterial endocarditis is now referred to as infective endocarditis due to the presence of other organisms besides bacteria being the causative agent. It is an infection of the cardiac valves and inner lining of the heart that is characterized as a systemic illness. Endocarditis may be misdiagnosed as other infections in the early stages if signs and symptoms of cardiac involvement are not present, Common complaints range from fever with temperature less than 102 degrees, chills, arthralgia, lethargy, and anorexia. Acute endocarditis may result in death within a matter of hours if not treated. Antimicrobial therapy can decrease mortality to 15%, but heart failure secondary to valvular scarring and damage can occur after the infection is resolved.
Almost any organism can cause endocarditis but the most common ones noted have been Streptococcus viridans, Staphylococcus aureus, Enterococci, Staphylococcus epidermidis, Streptococcus pneumoniae, Pseudomonas aeruginosa, Candida albicans, and Aspergillus fumigatus.
Endocarditis may be subdivided into the acute and subacute classes, depending on the virulence of the organism involved and the length of duration. Acute infective endocarditis (AIE) has less than one-month duration whereas subacute infective endocarditis (SIE) is usually greater than one month in duration, SIE usually involves congenitally-deformed or damaged heart valves, and AIE usually involves normal heart valves. Trauma in many forms can occur to the epithelial layer of the valves/endocardium causing injury and deposits of platelets and fibrin to adhere to this surface. This is known as nonbacterial thrombotic endocarditis (NBTE). After this stage, the heart is then set up for vegetation to colonize from bacteria from other areas of the body during transient episodes of bacteremia. As these organisms grow, more platelets and fibrin adhere and eventually valves are destroyed, vegetation breaks off and embolizes to other areas of the body, and a systemic immune response occurs.
Patients who are at risk for endocarditis include those with rheumatic heart disease, open-heart surgery, congenital heart defects, prosthetic valve replacements, dental procedures, gynecological surgery or procedures, genitourinary surgery or procedures, invasive tests or lines, infected peripheral or central venous lines, IUDs, AV shunts or fistulas, skin abnormalities in preexisting cardiac disease, immunosuppressive therapy, and IV drug use.
Patients who have had prosthetic valves placed and who develop endocarditis are divided into early (occurring less than two months postoperatively) and late (occurring greater than two months post- operatively) classes, and develop chills, fever, leukocytosis, and/or a new murmur. Mortality is higher in early prosthetic valve endocarditis and is a serious problem.

pathway endocarditis

Penicillin is the treatment of choice for Streptococcus viridans, with cephalothin or vancomycin being alternate choices; penicillin plus gentamicin is the treatment of choice for Streptococcus faecalis; synthetic penicillin’s, such as oxacillin or nafcillin, cephalothin and/or gentamicin are used in Staphylococcus epidermidis
A series of blood cultures is done to isolate the causative organism and sensitivity to antimicrobial agents; CBC is used to assess for anemia that may occur in up to 70% of patients, to monitor leukocyte levels, and to assess platelet counts; sedimentation rates may increase; immune titers show antigen-antibody response
Shows alterations in conduction, dysrhythmias, ischemia
Used to establish diagnosis, to determine underlying cardiac disease, to estimate myocardial contractility, and demonstrate early mitral valve closure and aortic insufficiency
Nuclear cardiologic testing:
Technetium-99 scans and gallium-67 imaging used to evaluate the extent of the infective process and to evaluate potential as a surgical candidate
Valve replacement is necessary if patient develops intractable congestive heart failure with hemodynamic compromise, persistent bacteremia despite antimicrobial treatment, prosthetic valve endocarditis, major systemic emboli, gram negative or fungal infection; drainage of abscesses or empyema; repair of peripheral or cerebral mycotic aneurysms
Prophylactic antibiotic therapy must be prescribed prior to dental procedures, urethral or gynecological procedures, or surgery
Risk for altered tissue perfussion: cardiopulmonary, cerebral, renal, gastrointestinal, and peripheral
Related to: valvular vegetation emboli, platelet- fibrin emboli, and immunologic responses causing allergic vasculitis; embolus
Defining characteristics: petechiae, arthritis, arthralgia, myalgias, decreased peripheral pulses, Janeway’s lesions, Roth‘s spots, Osler’s nodes, lower back pain, splinter hemorrhages to subungual areas, hematuria, oliguria, anuria, chest pain, shortness of breath, dyspnea, confusion, weakness, convulsions, coma, hemiplegia, aphasia, hemiparesis, cardiac tamponade, pericardial friction rub, murmur, dysrhythmias, conduction defects, cold clammy skin, cyanosis, mental status changes, hypotension, tachycardia, decreased urinary output, increased BUN
Outcome Criteria
Patient will achieve and maintain adequate tissue perfusion to all body systems.
Determine mental status and level of consciousness. Observe
for hemiparesis, paralysis, aphasia, convulsions, visual field defects, or coma, and notify MD.
Symptoms may indicate embolization to cerebrum which may re- quire emergency treatment.
Monitor EKG for conduction abnormalities, especially prolonged PR interval, new left bundle branch block, new right bundle branch block with or without left anterior hemiblock. Treat as indicated per protocol.
Due to the close proximity of aortic valve cusps to the conduction system, bacterial invasion and proliferation may extend the infection process into the myocardium and cause dysrhythmias. Extension of the infection from the mitral valve to the Bundle of His and AV node may result in junctional tachycardia, Mobitz I, second degree or third degree AV blocks.
Observe for sudden shortness of breath, tachypnea, pleurisy-type pain, pallor or cyanosis.
Arterial emboli may affect the heart and other vital organs. Venous congestion may result in thrombus formation in deep veins and cause embolization to lungs, or embolization of vegetation thrombi may result in pulmonary embolus.
Evaluate chest pain, tachycardia, decreased blood pressure. Auscultate heart sounds for new or changed murmurs, pericardial friction rubs, or abnormal lung sounds (crackles, rales).
Arterial emboli may affect the heart and cause myocardial infarction. New murmurs may occur as a result of valve scarring and distortion, valve aneurysm, septal rupture, papillary muscle rupture, or myocardial abscess rupture. Rupture into the pericardial sac can cause cardiac tamponade, in which heart tones will be muffled. Pericardial friction rubs may indicate pericarditis. Abnormal lung sounds may indicate impending congestive heart failure.
Observe extremities for swelling, erythema, tenderness, pain, positive Homans’ sign, positive Pratt’s sign. Observe for decreased peripheral pulses, pallor, coldness, cyanosis.
Bedrest promotes venous stasis which can increase the risk of thromboembolus formation. Actual vegetation emboli can migrate and occlude peripheral arteries, leading to tissue ischemia and necrosis.
Monitor for complaints of abdominal pain to left upper abdomen with radiation to left shoulder, abdominal rigidity, tenderness, nausea, or vomiting.
May indicate embolization to spleen. Vegetative emboli may occlude mesenteric artery and cause bowel infarction. Splenomegaly may be caused by anti- gen stimulation and allergic vasculitis.
Observe urine for hematuria, oliguria, anuria, complaints of flank or back pain.
Allergic vasculitis from endocarditis can result in focal, acute, or chronic glomerulonephritis and progress to renal insufficiency, renal failure, and uremia.
Observe for petechiae on mucous membranes, conjunctiva, neck, wrists, and ankles. Observe for splinter hemorrhages in subungual areas, Osler’s nodes to distal fingers and toes, sides of fingers, palms or thighs, and for Janeway’s lesions to the palms, soles of feet, arms and legs.
Petechiae is one of the classic symptoms of endocarditis as a result of allergic vasculitis.
Petechiae are usually 1-2 mm in diameter, flat, red with white or gray centers, non-tender, and groups fade within a few days. Petechiae may be noted in other diagnoses and they should be ruled our. Hemorrhages to the subungual areas may be seen in early infective endocarditis but may be seen in trauma, with hemo  or peritoneal dialysis, or in mitral stenosis. Osler‘s nodes are nodules that range from 1-10 mm in diameter, red with white centers, overtly tender, and are usually a late sign of endocarditis, typically found in subacute endocarditis infections. Jane- way’s lesions are non-tender reddened or pink macular lesions, 1-5 mm in diameter, and usually change to tan and fade within 2 weeks. These are usually an early sign of endocarditis.
Evaluate complaints of arthritis, arthralgia, and severe lower back pain. Medicate as needed.
Occur in endocarditis due to localized immune responses or in decreased perfusion.
Monitor blood culture and sensitivity reports.
Usually 3-6 blood cultures are done in a series to assess for sustained bacteremia because bacteria are continually released into the system in endocarditis. The series prevents the possibility of false readings. Cultures determine the specific organism responsible for the bacteremia, and sensitivity results enable the choice of antimicrobials to be suited to the specific infection.
Administer antimicrobials as ordered.
Antibiotics should not be started until culture series is completed in subacute IE, but with acute IE, empiric antibiotics are given until cultures are available. In some instances, early negative results may indicate only that the culture could not be grown due to low levels of bacteria or an unusual organism being present. Obtaining cultures after antibiotics have been started do not give accurate information.

Instruction, Information, Demonstration
Instruct patient in signs/ symptoms to report to MD.
Promotes knowledge and compliance with regimen.

Discharge or Maintenance Evaluation
·        Patient will have adequate tissue perfusion to all body systems.
·        Patient will be mentally lucid, with no confusion or neurological deficits.
·        Patient will have adequate urinary output with no hematuria, and renal function studies will be within normal limits.
·        Patient will be able to recall accurately the information instructed.

Decreased cardiac output
[See MI]
Related to: complications with infected heart valves, potential for cardiac tamponade because of effusion, damaged myocardium, decreased contractility, dysrhythmias, conduction defects, alteration in preload, alteration in afterload, vasoconstriction, myocardial ischemia, ventricular hypertrophy
Defining characteristics: decreased blood pressure, tachycardia, pulsus paradoxus greater than 10 mmHg, distended neck veins, increased central venous pressure, dysrhythmias, decreased QRS voltage or electrical alternans, diminished heart sounds, dyspnea, friction rub, cardiac output less than 5 L/min, cardiac index less than 2.5 L/min/m2, change in mental status, change or new cardiac murmur, arterial emboli, decreased urine output, cyanosis, cold clammy skin

Related to: bacteremia, allergic vasculitis, arterial occlusion/infarction, abscess
Defining characteristics: body temperature greater than normal range, flushed warm skin, chills, increased heart rate, increased respiratory rate
Outcome Criteria
Patient will maintain body temperature within normal limits and be free of infection.

Monitor temperature every 2-4
hours and prn. Observe for chills and diaphoresis.
Endocarditis usually results in temperatures less than 102 degrees; temperatures greater than this indicate an acute
infective process. Chills frequently precede a temperature spike.
Monitor environment temperature and limit or add blankets as warranted. Change linens as needed.
Room temperature may be altered to assist with maintenance of normal body temperature.
Monitor input and output; provide adequate fluids.
Diaphoresis and increased metabolic rate from temperature elevations increase fluid loss and may cause dehydration.
Give tepid sponge baths prn.
May assist in lowering temperature by means of evaporation. Using cooler water or alcohol may cause chilling and thus increase body temperature.
Place on cooling blanket as warranted.
Cooling blankets are usually only used for severe fever greater than 104 degrees when risk of brain damage or seizures is imminent.
Administer antipyretic medications as warranted.
Reduces fever by action on the hypothalamus. Low grade temperatures may be beneficial to the body’s immune system and ability to retard the growth of organisms.

Information, Instruction, Demonstration
Instruct on procedures for decreasing temperature.
Provides knowledge and reduces Fear and enhances compliance.
Instruct to take temperature frequently and to notify MD for elevations immediately.
Temperature elevations indicate infection and prompt notification will allow for prompt treatment.
Instruct on medications, effects, side effects, contraindications, symptoms to report.
Promotes knowledge and compliance

Discharge or Maintenance Evaluation
Patient will be normothermic with no overt signs/symptoms of infection.

Risk for infection
Related to: inhibition of antibodies due to immunological system action, inflammatory processes due to vegetation growth, predisposition to bacteremia, septic emboli, myocardial abscess, occlusion of arteries leading to necrosis of body systems, invasive procedures and lines, dental procedures, nosocomial infections, lack of recognition of infection, lack of prophylactic treatment, suprainfection.
Defining characteristics: elevated temperature, ele- vated WBC count, positive blood cultures, reddened, draining IV sites
Outcome Criteria
Patient will be free of infection, afebrile, with no over symptoms of infection or infective process noted.
Monitor temperature trends.
Decreases in body temperature below 96 degrees may indicate advanced shock states and is a critical indicator of decreased tissue perfusion and lack of the body’s ability to muster enough defense to raise the temperature. Temperatures greater than 101 degrees are due to the effect of endotoxins on the hypothalamus and of pyrogen released endorphins.
Monitor for signs/symptoms of deterioration of patient and failure to improve within a timely manner.
May indicate ineffective antibiotic therapy or abundance of resistant organisms.
Observe mouth for patches of white plaque and perineal areas for vaginal drainage or itching, and notify MD.
Thrush or yeast infections may occur as a secondary infection when normal flora is killed by massive antibiotic therapy.
inspect wounds, IV sites, catheter sites, invasive devices and lines, changes in drainage or body fluids.
May indicate local secondary infection or inflammation.
Maintain aseptic or sterile technique as warranted.
Reduces the risk of opportunistic infection and chances of cross-contamination.
Obtain urine, blood, sputum, wound, and invasive catheter specimens for culture and sensitivity and Gram stain as warranted.
Assists with identification of source of infection, causative organism, and antibiotic of choice to enable prompt and effective treatment.
Reposition patient every 2 hours; encourage coughing and deep breathing.
Frequent changes in position and breathing exercises enhance pulmonary toilet and may help to prevent pneumonia.
Administer antibiotics as ordered.

Antibiotics may be started prior to receiving final culture reports based on the likelihood of the infective organism. Specific antibiotics are determined by the culture information.

Information, Instruction, Demonstration
Instruct patient to cover mouth and nose during coughing/sneezing.
Instruct in handwashing and disposal of contaminated materials.
from airborne organisms. Good Prevents spread of infection handwashing reduces spread of infection. Infection control procedures limit contamination and spread of infective materials.
Instruct patient in good dental hygiene to use soft toothbrush; to avoid water pik and toothpicks; to obtain regular dental exams.
Avoids trauma to gums which may promote reinfection. Water pik and toothpicks may cause bleeding and promote infection.
Instruct patient to take temperature every day for 1 month post discharge.
Temperature elevations may indicate infection/reinfection.
Prepare patient for surgery as warranted.
Surgery may be required to remove necrotic tissue or limbs and to remove purulent material in order to enhance healing.
Surgery may be required to replace damaged heart valves due to vegetative infection.
Instruct patient in obtaining prophylactic antibiotic therapy prior to procedures.
Prophylaxis will be required for any invasive procedure due to likelihood of reinfection.

Discharge or Maintenance Evaluation
·        Patient will have normal temperature and vital signs.
·        Patient will exhibit no overt symptoms or signs of infection.
·        Patient will be able to recall instructions accurately.
·        Patient will seek prophylactic antibiotic therapy prior to any procedure and will have no evidence of reinfection.

[See MI]
Related to: change in health status, fear of death, threat to body image, threat to role functioning, pain
Defining characteristics: restlessness, insomnia, anorexia, increased respirations, increased heart rate, increased blood pressure, difficulty concentrating, dry mouth, poor eye contact, decreased energy, irritability, crying, feelings of helplessness.

Knowledge deficit
[See MI]
Related to: lack of understanding, lack of under- standing of medical condition, lack of recall

Defining characteristics: questions regarding problems, inadequate follow-up on instructions given, misconceptions, lack of improvement of previous regimen, development of preventable complications.  

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