Chapter 4: Cardiovascular Disorders

Topic: Endocarditis

Presented By
Christofar Joshi Soren
Roll:212620
2nd Year 2nd Semester
Session:2021-22
Department of Nursing & Health Science
Jashore University of Science & Technology
 Endocarditis/ Infective Endocarditis

Concept:
Microorganisms, usually bacteria, enter the blood stream and attach to the inner lining of the
heart (endocardium) and heart valves, resulting in inflammation. Ulceration and necrosis occur
when microorganisms cover the heart valves. This usually occurs in patients with rheumatic
heart disease or degenerative heart disease; those with recent instrumentation (IV, GU, and
respiratory procedures) or dental procedures; and IV drug users.
Definition:
Infective endocarditis (formerly called bacterial endocarditis) is inflammation of the inner layer
of heart tissue as a result of an infectious microorganism.
Or,
Endocarditis disease is an inflammation of the inner lining of the heart chambers and heart
valves (Endocardium).

Or,
Endocarditis disease is an inflammation of the inner lining of the heart chambers
and heart valves (Endocardiac)
Types:
There are two types of endocarditis-
1. Non-infective Endocarditis: Non infective endocarditis develops when sterile
fibrous vegetations form on the heart valves. (Sterile vegetations form on heart
valves in response to factors such as trauma, circulating immune complexes,
vasculitis, or a hypercoagulable state).
2. Infective Endocarditis: Infective endocarditis is caused by a pathogen either
bacterial, viral, or fungi. The microbes come from another body part, such as the
mouth (strep throat), skin, intestines, or the urinary tract, and can spread through
the bloodstream and reach the damaged cardiac tissues.
Risk Factors of Infective Endocarditis:
1. Prosthetic cardiac valves or prosthetic material used for cardiac valve repair.
2. History of bacterial endocarditis (even without heart disease).
3. Congenital heart disease.
4. Unrepaired cyanotic congenital disease, including patients with palliative shunts and
conduits. heart
5. Repaired congenital heart disease with prosthetic material or device either by surgery or
catheter intervention during the first 6 months after the procedure.
6. Repaired congenital heart disease with residual defects at the site or adjacent to the site of
a prosthetic patch or device.
7. Cardiac transplant valvulopathy
 Microorganisms that Cause Endocarditis:
1. Streptococci: Account for 55% of cases of endocarditis.
 Group A beta-hemolytic: Attack normal or damaged heart valves and may cause rapid
destruction.
 S. bovis: Related to I malignancy.
 S. viridans: Tend to affect previously damaged heart valves.

2. Staphylococci: Cause 30% of cases of endocarditis.

 S. aureus: Virulent strain with high mortality rate
 S. epidermidis: Associated with dental procedures and valve replacements.
 S. faecalis: Cause both acute and subacute infections. Associated with urologic instrumentation in men,
bacteremia, respiratory tract infections, pneumonia, sinusitis, otitis media, and epiglottitis.

3. Enterococci: Normal inhabitants of the GI tract, anterior urethra, and occasionally the mouth.
• E. faecalis and E. faecium: Relatively resistant to single antibiotics; require combination of antibiotic therapy for
a minimum of 4 weeks.
4. HACEK Group: Slow-growing gram- negative bacilli.
 Haemophilus parainfluenzae: Require culture for 2 weeks or longer when initial culture is negative. And,
 H aphrophilus: subacute presentations. Cause
 Aggregabactor actinomycestemcomi- tans: Associated with very large vegetations.
 Cardiobacterium hominis
 Eikenella corrodens
 Kingella kingae
5. Gram-negative bacteria: May travel from GI or genitourinary tract.
 Escherichia coli: Increased risk in older adults.
 Klebsiella species
 Pseudomonas species

6. Fungi: Increased incidence in IV drug users.

 Candida: Risk increased with improper use of antibiotics and steroids.
Cause
 1.Bacterial Cause
 2.Poor Oral Health
 3.Other Medical conditions
 4.Certain dental Problems
 5.Existing heart Problems
 6.Marfan's heart problems
 7.Strep throat
 8.Contaminated needles for IV drug Use
Signs and Symptoms:
Common signs and symptoms of endocarditis include:
1. Low-grade fever. It occurs in more than 90% of patients.
2. Chills
3. Heart murmur (new or changed)
4. Weakness
5. Fatigue
6. Anorexia
7. Aching (pain) joints and muscles
8. Night sweats
9. Shortness of breath
10. Chest pain when breathe
11. Peripheral Edema or Swelling in the feet and legs
12. Ascites of the abdomen
13.Dyspnea.
14.Petechiae.
15.Changing murmur.
16.Dental caries.
17.Hepatosplenomegaly.
18.Congestive heart failure
19. Fever.
Severe endocarditis signs and symptoms may also cause:
1. Unexplained weight loss
2. Hematuria or blood in the urine
3. Tenderness in the spleen
4. Splinter hemorrhages (thin, red to reddish- brown lines of blood under the nail plate)
5. Roth spots (retinal hemorrhages in the eye)
6. Small purplish or reddish spots on the skin, oral mucosa or whites of the eyes (Petechiae)
7. Red spots on the palms or soles of the feet (Janeway lesions)
8. Red tender spots on the toes or fingers (Osler's nodes)
Diagnostic Evaluations:
1. Blood Tests
 A complete blood count (CBC) may show anemia. WBC count with differential identifies elevation.
 Blood culture will show the specific causative agent of the infection. A series of three blood cultures collected over 1 to 24 hours usually
identifies the microorganism circulating in the blood.
 The erythrocyte sedimentation rate (ESR) may be elevated.
o C-reactive protein (CRP) levels may be elevated.

2. Echocardiogram: Echocardiogram is used to detect vegetation on valves or heart valves damaged by the microorganism, and also to determine
which valves are involved.
3. Transesophageal echocardiogram: It offers a view to detect vegetation on heart valves or view heart valves damaged by a microorganism.
4. Electrocardiogram
5. Imaging: Chest X-ray, CT scan, or MRI may show enlargement of the heart and/or infection in the lungs, as well as possible spread in other
organs.
Medical-Surgical Management:
A. Surgical
1. If the endocarditis is related to faulty or damaged heart valves, surgery may be required. Heart valve repair or replacement with
artificial valve is the particular surgical associated with endocarditis. intervention
B. Pharmacological
1. Patients are treated with antimicrobial drugs and intravenous antibiotics.
 The antibiotics are usually continued for 2 to 6 weeks.
 Broad-spectrum antibiotics are given if there is a delay in obtaining blood culture results, and then changed to treat the
specific pathogen.
 The most commonly used antibiotics
 are penicillin V potassium (V-Cillin K), vancomycin hydrochloride (Vancocin), gentamicin sulfate (Garamycin), ampicillin
(Principen), amoxicillin (Amoxil), and ciprofloxacin (Cipro).
 Oxacillin-resistant strains of Staphylococcus aureus are treated with vancomycin and rifampin (Rifadin) for at least 6 weeks
and gentamicin for the first 2 weeks.
 Nafcillin (Nafcil) is used for non- oxacillin-resistant S. aureus.
Amphotericin B (Amphocin) alone or with fluconazole (Diflucan) is given for at least 6 weeks for a fungal infection.
C. Diet
 Provide the patient with a well-balanced nutritious diet, with between-meal snacks.
 An adequate intake of protein, zinc, iron, phosphate, and vitamins A, B, C, D, and E is important for the immune
system and wound healing.
 Vitamin K intake is kept at a consistent level if the patient is on warfarin (Coumadin).
D. Activity
 The patient is on bed rest to decrease the workload of the heart.
 Provide a calm, quiet environment
Nursing Management
A. Nursing Assessment
 A patient history is obtained that includes risk factors for IE and recent infections or invasive procedures.
 Vital signs are measured and recorded, and heart sounds are auscultated to detect murmurs.
 Signs of heart failure and emboli are noted.
 The physician is notified immediately if circulatory impairment, such as cold skin, decreased capillary refill,
cyanosis, or absent peripheral pulses in an extremity. or symptoms of organ-related emboli are detected.

B. Nursing Diagnosis
 Decreased cardiac output related to impaired valvular function or heart failure.
Activity intolerance related to reduced oxygen delivery from decreased cardiac output.
 Deficient diversional activity related to restricted mobility from prolonged intravenous therapy.
C. Nursing Planning and Goals
 To maintain adequate cardiac output.
 To manage activity level.
 To assist patient in participate diversional activities.
 D. Nursing Intervention
 Maintaining Cardiac Output

D.Nursing Intervension
 Assess vital signs, murmurs, dyspnea, and fatigue.
 Give oxygen as ordered.
 Provide rest as ordered.
 Elevate head of bed 45 degrees.
Managing Activity Level
 Assist with activities of daily living (ADLs) prn.
 Provide rest and space activities.
 Assisting Patient in Participate Diversional Activities
 Assess patient's preferred activities and hobbies.
 Plan patient's schedule around relaxing and fun activities.
 Use pet therapy.
Provide a mix of physical, mental, and social activities on a rotating schedule.
E. Evaluation
 Patient has adequate cardiac output.
 Patient state less fatigue in response to activity.

Patient Teaching:
 Teaching about the disease and its treatment
 provides patients and families with the prolity to provide IV antibiotics at home and
 promotes health maintenance to prevent IE. Drood hygiene including dental care is essential
 Skin care includes bathing, using proper hand washing technique with soap, avoiding nail
biting, not popping pimples or lancing boils, and washing and applying antibiotic ointment to
cuts.
 Brushing with a soft-bristle toothbrush (prevents gum trauma) twice a day reduces plaque
formation, which traps bacteria.
 Twice yearly dental cleaning using prophylactic antibiotics, if indicated, is important.
 It is essential that patients understand the need to request and take prophylactic antibiotics as
needed before invasive procedures.
 Patients are also taught symptom recognition (e.g., fever, chills, sweats) and seeking of
prompt medical care.
 The patient is educated on the importance of having blood cultures drawn before antibiotics
are started.
 The patient's statement of understanding and a willingness to follow lifestyle changes
supports goal achievement.
Prevention:
Although rare, bacterial endocarditis may be life-threatening. A key strategy is primaryprevention in high-risk
patients (e.g., those withprevious infective endocarditis, prosthetic heartvalves).Antibiotic prophylaxis recommende
for is high-risk patients immediately before and sometimes after the following procedures:
 Dental procedures that involve manipulation of gingival tissue or the periapical area of the teeth or perforation of
the oral mucosa (except routine anesthetic injections through noninfected tissue, placement of orthodontic
brackets, loss of deciduous teeth, bleeding from trauma to the lips or oral mucosa, dental x-rays, adjustment of
orthodontic appliances, and placement of removable prosthodontic or orthodontic appliances).
 Tonsillectomy or adenoidectomy.
 Surgical procedures that involve respiratory mucosa.
 Bronchoscopy with biopsy or incision of respiratory tract mucosa.
 Cystoscopy or urinary tract manipulation for patients with enterococcal urinary tract infections or colonization.
 Surgery involving infected skin musculoskeletal tissue. or
Complications:
1. Paralysis - unable to move a part of the body or all of it
2. Pulmonary embolism - the clump of bacteria blocks an artery of the lung
3. Seizure attacks
4. Stroke
5. Enlarged spleen
6. Kidney disorder
7. Brain abscess
8. Heart failure