Disorders of the heart: Coronary Atherosclerotic Disease Coronary Artery Disease (CAD) - term used to described Varity of conditions

that obstruct blood flow in the coronary arteries Atherosclerosis- (common arterial disorder characterized by yellowish plaques of : Cholesterol Lipids Cellular debris In the inner layers of the walls of large and medium sized arteries This the primary cause of atherosclerotic heart disease (ASHD) Lumen- ( cavity or channel within any organ of the body) the lumen of the vessel narrows as the disease progresses When it occurs in coronary arteries the blood flow to heart is obstructed

Obstructions exceeding 75% of the lumen of one or more of the three coronary arteries increases risk of death When myocardial oxygen demands exceeds the supply delivered by the coronary arteries, ischemia results Arteries become less elastic and less responsive to blood flow Angina Pectoris: Angina- spasmodic, cramp like, chocking feeling A-P used to denote paroxysmal (marked, usually episodic, increase in symptoms) thoracic pain and choking feeling caused by decreased oxygen or anoxia (lack of oxygen) of the myocardium Occurs when myocardium is deprived of oxygen Atherosclerosis in coronary arteries is the most common cause Ischemia- Decreased blood supply to a body organ or part often marked by pain and organ dysfunction

When myocardial oxygen demands exceeds the supply of the heart muscle occurs resulting in chest pain or angina

Typically occurs with an increased cardiac workload caused by: Intense Cold Exercise Heavy meals Emotional stress CAD #1 killer DX of unstable angina my save many lives Unstable Angina- unpredictable and transient episode of severe and prolonged discomfort that appears at rest, has never been experienced before or wore than previous episodes Mimic MI o Tightness or crushing of chest, arms, back, neck or jaw o For some indicates that an MI will occur Clinical Manifestations: Pain is outstanding characteristic Pain is Described as heaviness or tightness of chest o Often substernal or retrosternal (behind the sternum) o Pain usually radiates down inner arm to little finger and also upward to the shoulder and jaw o May be described as pressure or squeezing sensation but usually described as sharp pain o Other will only experience posterior thoracic pain

Other S&S: Dyspnea Anxiety Apprehension Diaphoresis Nausea Often relieved by rest or medication: Nitroglycerin-dilates coronary arteries and increases flow of oxygenated blood to myocardium

 Does not relieve pain from MI o This is used as a preliminary Diagnostic tool to quickly differentiate angina from an MI Assessment: Subjective data includes Noting patients statement regarding o Location o Intensity o Radiation o Duration Determine what relief measures have been used: Identify if there have been changes in frequency or severity of symptoms o Might indicate progressive worsening of ischemia Objective Data includes noting: Patients behavior o Such as rubbing left arm or pressing fist against sternum o Monitor V/S Diagnostic test: Mainly based on patients HX ECG may find ischemia and rhythm changes Holter monitoring used to correlate activities with precipitating factors Exercise stress test used to determine ischemic changes Thallium 201 scanning and PET are used to diagnose Ischemic heart disease Coronary angiography may be done to determine extent of CAD Medical Management: Goal is to control symptoms by reducing cardiac ischemia Identify possible cardiovascular risk factors and corrected if possible Avoid precipitating risk factors such as: o Intense cold o Strenuous exercise o Smoking

o Heavy meals o Emotional stress First line therapy is antiplatlet aggregation Aspirin drug of choice Ticlopidine (Ticlid) or clopidogrel (PLAVIX) used for those unable to tolerate aspirin Nitrates used to dilate coronary arteries and decrease workload include: Vasodilators (nitrates especially nitroglycerin) Beta- adrenergic blockers: Propranolol (Inderal) Metoprolol (lopressor) Nadolol (Corgard) Atenolol (Tenormin) Timolol (Blocadren) Calcium Channel Blockers: Nifedipine (Procardia) Verapmil (Calan, Isoptin) Diltiazem (Cardizem) Nicadipine (Cardene) For angina give one nitroglycerine tab If not relieved give another in 5min intervals for a total of three Surgical Interventions: for patients with ASHD of CAD CABG: after DX with cardiac cath Graft usually taken from saphenous vein or internal mammary artery When S-V is used one end is sutured to aorta and other to coronary artery distal to blockage When mammary artery one end is only sutured to coronary artery PTCA: another procedure for management of CAHD Percutaneous transluminal coronary angioplasty Catheter is guided through fluoroscopy from the femoral or brachial artery A balloon is inflated when in position

Vessel patency is established with angioplasty

Stent placement: Used to treat abrupt or threatened vessel closure following PTCA They are thrombogenic so patient must be kept on anticoagulants for at least 3 months Primary complication of stents are o Hemorrhage and vascular injury Nursing Interventions and patient Teaching N-I focus on achievement of five major patient outcomes: 1. Promoting comfort Reduce or remove known contributing factors to increased pain Assess for factors that contribute to decreased pain tolerance o Anxiety o Fatigue o Lack of knowledge Promote frequent rest periods Provide calm environment to reduce stress and anxiety Administer SL nitroglycerin as ordered O2 is given for high risk unstable angina or those with cyanosis or respiratory distress 2. Promoting Tissue Perfusion: Teach to avoid becoming overly fatigued and to stop activity immediately if these occur: o Chest pain o Dyspnea o Syncope o Vertigo These indicate low tissue perfusion 3. Promoting activity and rest: Augment patients activity tolerance by encouraging slower activity or shorter periods of activity with more rest periods Anginal pain occurs more easily in cold weather

4. Promoting relief of anxiety and feeling of wellbeing: Assist to reduce level of anxiety o Patient should minimize outburst, worry, and tension Provide support or family support Teach relaxation techniques Support groups and behavioral change programs Those who learn to live with limitations live out expected life span 5. Teaching patient and family: Delay teaching until patient is ready Promote positive attitude and active participation of patient and family to encourage compliance Teaching plan should include: o Info on meds o Minimizing events that trigger angina o Effects of exercise on myocardial needs o Stop smoking MYOCARDIAL INFARCTION: An occlusion of a major coronary artery or one of its branches with subsequent necrosis of myocardium caused by atherosclerosis or an embolus (a foreign object, a quantity of air or gas, a bit of tissue, or a piece of thrombus that circulates in the blood stream until it becomes lodged in a vessel) Coronary occlusion- an obstruction or closing off in a canal, vessel or passage of the body) Ischemia lasting more than 35-45 min produces cellular damage and necrosis The final extent of damage to the surrounding tissue depends on the ability to develop collateral circulation The bodies response to cell death is inflammatory process Enzymes are released from dead cardiac cells CLINICAL MANIFESTATIONS: An asymptomatic MI may occur AKA as silent MI

Many symptoms of MI are caused by irreversibly ischemia similar to ANGINA Pain often radiates to other sites o Described as vice like or crushing o Pain is retrosternal and in the heart region o Often radiates down left arm and to neck, jaws, teeth and epigastric area o May occur in conjunction with intense emotions, during exertion, or at rest o Not relieved with position changes, Nitro, Rest o Often DR. suggest take aspirin and report to ER

OTHER S&S: Nausea SOB Dizziness Weakness Diaphoresis Pallor Ashen color Sense of impending doom Subjective DATA: Pressure on chest Anxiety Dyspnea Weakness Faintness Nausea Objective data: Pallor Erratic behavior Hypotension, shock, cardiac rhythm changes Vomiting Fever diaphoresis

ASSESSMENT: SUBJECTIVE DATA: onset, location, quality, duration, and radiation of pain SOB, dizziness, weakness, and anxiety or fear may be expressed Identify precipitating factors Inquires about pain relief measures used OBJECTIVE DATA: Observation of patients behavior, to determine apprehension and anxiety V/S reveal hypotension Pulse o Tachycardic o Barley perceptible o Early temp elevation o Presence of diaphoresis o Vomiting o Ashen color o Cool clammy skin o Labored respirations o Cardiac dysrhytmia DIAGNOSTIC TEST: SERUM TEST: Serum cardiac markers (CK-MB, myoglobin, Troponin I) Troponin I- proven useful in detecting ischemic myocardial injury o Cardiac specific Elevated WBC count of 12,000- 15,000/mm3 is associated with severe infarcts o Increase begins within a few hours after onset of pain and lasts for 3-7 days ESR elevated during first week and may remain elevated for several weeks 12 lead ECG indicates that MI include ST segment elevation and development of Q and T wave inverts o In time ST returns to normal and T wave inverts o ECG changes important in Diagnosing MI X-RAY to note size and shape of heart

Other test that may be done: cardiac fluoroscopy myocardial imaging PET Multigated angiogram (MUGA) scanning o Done to diagnose MI an to see extent of CAD MEDICAL MANAGEMENT Focus of Medical management is to prevent further tissue injury and limit size of the infarct Intervention is designed to facilitate cardiac tissue perfusion and reduce workload of the heart Promote tissue oxygenation, relieving pain, preventing further tissue damage MEDICATION: Morphine and valium are given to alleviate pain and anxiety Continuous amiodarone (Cordarone) may b given to patient with frequent PVCs which may precede ventricular fibrillation Lidocain may be used in a patient with sustained ventricular tachycardia or ventricular fibrillation Beta-Adrenergic blockers: Atenolol (Tenormin) or Metoprolol (Lopressor) early in the acute phase of MI and during a 1yr follow up regimen can decrease morbidity ACE may be used following an MI: Can prevent or slow progression of heart failure O2 to facilitate tissue perfusion Fibrinolytic agents: Streptokinase (Sterptase) Anistreplase Tissue plasminogen Activator (TPA) o Alteplase To be effective reperfusion must be attained within 3-5 hrs

 may take 4-6 hrs for entire thickness of muscle to become necrosed reperfusion most effective in the first 30 min to 1hr before a thrombolytic agent is given a thorough HX must be obtained o contraindicated in active internal bleeding suspected aortic dissecting aneurysm recent head trauma HX of hemorrhagic stroke within past yr Surgery within past 10 days PTCA may be used for some CABG may be used when other TX has failed NURSING INTERVENTIONS AND PATIENT TEACHING: Administer O2 per protocol for 24-48hrs and longer if pain, hypotension, dyspnea, or dysrhythmias persist Administer medication as prescribed: IV morphine sulfate for relief of pain and apprehension and to produce vasodilation o Morphine also decreases myocardial oxygen demands, reduces contractility, and slows heart rate Heparin therapy or unfractionated or low- molecular-weight heparin such as enoxaprin (Lovenox) or dalteparin (Fragmin) will inhibit further clotting and prevent coronary artery occlusion after the thrombolytic therapy opens vessel Antiplatelet agents such as aspirin and ticlopidine (Ticlid) decreases platelet release of thromboxane, which causes vasoconstriction and platelet aggregation o Ticlopidine can be used for patients allergic to ASA Nitroglycerin can be used for patients with Left ventricular infarctions when given IV Reduces cardiac oxygen demand by relaxing vascular smooth muscle and dilating peripheral vessels it also dilates coronary vessels Beta Blockers to inhibit cardiotoxicity of catecholamines Zocor, Lipitor, Crestor to prevent elevated cholesterol levels Stool softener as prescribed prevents straining o Valsalvas maneuver may cause changes in heart rate

o Teach mouth breathing o Instruct to avoid excessive fatigue and stop activity in presence of chest pain, dyspnea, or faintness o Promote rest o Once MI patients are able to climb two flights of stairs they are ready for sexual activity CARDIAC REHABILITATION: A monitored exercise program and continuing education are provided o Designed to help patients recover faster and return to full productive lives o C-R has to major parts exercise training education TEACHING: Teach associated risk between associated risk Identify nonmodifiable risks Identify modifiable risks Dietary restrictions CAD < 2g Na+ o 1500 calorie low cholesterol diets o Fluid restrictions o Limit fat intake 25-35% Eat 20-30 g of fiber Warn against anal sex HEART FAILURE: When heart is no longer able to pump enough blood to sustain the bodys metabolic needs HF or cardiac insufficiency HF- is characterized by circulatory congestion as a result of the hearts inability to act as an effective pump o once called CHF because many patients experienced pulmonary or systemic congestion o Heart failure should be viewed as a nuerohormonal problem in which heart failure progresses as a result of chronic release of catecholamines (epinephrine and norepinephrine)

o Are of the sympathetic nervous system and produce negative effects on ailing heart o HF may occur after MI, prolonged HTN, DM, or valvular heart disease o Other factors infection, stress, hyperthyroidism, anemia, and fluid replacement therapy o Left ventricle most commonly affected by coronary atherosclerosis and hypertension, HF usually begins there o Left sided failure usually progresses to right sided failure S&S of HF are: o Decreased cardiac output o Pulmonary congestion peripheral Left ventricular failure: o First sign is deceased cardiac output o Second is pulmonary congestion Pulmonary effusion: an abnormal accumulation of fluid in the thoracic cavity between visceral and parietal pleura o S&S of this condition includes dyspnea, orthopnea, pulmonary crackles, hemoptysis, and cough RIGHT VENTRICUALR FAILURE: o Occurs when left ventricle is unable to pump against increased pulmonary circulation o Most often pressure is because of blood backing up in left ventricle o Inability of right ventricle to pump blood forward into lungs results in peripheral congestion o Pitting edema may result o If depression does not fill almost immediately pitting edema is present o One liter of fluid equals 1kg o Liver can become congested and accumulate in abdomen (ascites) o DJV may be observed Assessment:

Subjective Data: o Complaints of dyspnea, orthopnea (abnormal condition in which a person must sit or stand in order to breath deeply or comfortably) o Paroxysmal nocturnal dyspnea (PND) (sudden awaking because of shortness of breath), cough, o Also listen for complaints of fatigue, anxiety, weight gain, from fluid retention and edema Objective Data: Noting presence of: o Dyspnea o Orthopnea o Edema o Abdominal distention o Weight gain o Adventitious breath sounds o Abnormal heart sounds (gallop and murmurs) o Activity intolerance o JVD o Blood flow to kidneys diminishes resulting in oliguria Diagnostic Tests: Diagnosis made on presenting signs &symptoms o X-ray shows pulmonary vascular congestion, pleural effusion, and cardiomegaly o ECG reveals cardiac dysrhythmia o Echocardiography to determine valvular heart disease, pericardial fluid and HF o Echocardiogram to determine ejection fraction o o Exercise stress test to determine activity tolerance o Cardiac CATH to detect cardiac abnormalities and underlying cardiovascular disease Multiple gated acquisitions scanning are ordered to evaluate: o cardiac function o determine ejection fraction o detect abnormal wall motion

LABS: o sodium o calcium o magnesium o potassium o BUN and Cretonne levels elevated B type natriuretic peptide (BNP): neurohormone released by the heart in response to expanded ventricular volume and pressure overload o Normal BNP level less than 100pg/ml suggest no HF

MEDICAL MANAGEMENT: Increasing cardiac efficiency with digitalis and vasodilators (NITRO, ISOSORBIDE) ACE inhibitors such as o Catopril (Capoten) o Enalapril (Vasotec) o Rampril (Altace) o Benzapril (Lotensen) o Lisinopril (Prinivil) (Zestril) o Quinapril (Accupril) o Fosinopril (Monopril) Decrease peripheral vascular resistance and improves cardiac output Cardiac remodeling occurs when left ventricle: Dilates Hypertrophies Develops a more spherical shape Prevented with Beta Blocker only one approved is Carvedilol (Coreg)

Natrector for IV first new drug called human B-Type natriuretic peptides Reduces pulmonary capillary pressure helps improve breathing and cardiac output LOWER OXYGEN DEMANDS: HOB elevated @45 Provided O2 if patient is hypoxic Diuretics, sodium restriction, restrict fluids Daily weights

Medications HF

Cardiac Glycosides Digitalis digoxin (Lanoxin)

Strengthen cardiac force Slow rate, increase circulation, dieresis

Monitor apical pulse Monitor toxicity: N/V Anorexia Dysrhythmia Bradycardia HA Fatigue Blurred vision or colored Monitor electrolytes, QD weights

Diuretics: Thiazides: Cholorothiazide (diuril) Hydrochlorothiazide (Esidrix, Hydrodiuril)

Increase output of Na+ Block Na+ and O2 absorption

Sulfonamides (Loop Diuretics): Furosemide (Lasix) Bumetadine (Bumex) Aldosterone antagonist (potassium sparing) Spironolactone (Aldactone)

Act rapidly for less responsive edema Relieves ascites that do not respond to usual diuretics

Administer in Am Consider sulfa allergies Monitor GI Monitor hyperkalemia

Potassium supplements For electrolyte imbalance K-Lyte

Monitor K+ levels

Sedatives :

Promotes rest and

Temazepane (Restoril) Morphine

comfort Relieves chest and abdominal pain Reduces anxiety and decreases myocardial O2 demand Dilates arteries Reduced B/P Monitor for hypotension Monitor HA and flushing

Nitrates: Nitroglycerin (Cardabid)

ACE Inhibitors Catopril (capoten) Enalapril (vasotec) Fosinopril (monopril) Lisinopril (zestril, Prinivil) Benzapril (Lotensen) Beta Adrenergic Blockers: Carvedilol (Coreg) Act as antihypertensive Monitor B/P for drop in pressure within 3hrs

Blocks sympathetic NS effects on failing heart

Increase gradually

Nursing Interventions:

 Monitor V/S for changes Note signs of respiratory distress Low output Edema elevate legs Note abdominal girth and total body weight as indicators of fluid retention Auscultator lungs note crackles and wheezes, coughing, and dyspnea Activity intolerance ,extreme fatigue and anxiety Guide lines for Nursing Interventions: Provide oxygen Semi-fowlers or high fowlers Conserve energy Encourage activity within restrictions monitor for intolerance Assist with ADL encourage independence within patients limitation Provide activities that will help conserve energy Monitor for signs of fluid and K+ imbalance daily weight Provide skin care over areas of edema Help maintain adequate nutrition intake Monitor for constipation Meds PATIENT TEACHING: Monitor for S&S of recurring HF and report S&S: o Weight gain of 2-3lbs over a short period (about 2days) o SOB o Orthopnea o Swelling of ankles and feet or abdomen o Persistent cough o Frequent nocturia Avoid fatigue and plan for activities Sodium restrictions Maintain low fat diet fat intake < 30% of total calories Meds Diuretics Check own apical pulse before taking DIGITALIS

 Weight self Eat food high in K+ Report Hypotension PULMONARY EDEMA: Etiology/ Pathophysiology: Etiology/ Pathophysiology: accumulation of extravascular fluid in lung tissue and alveoli, caused mostly by HF (LEFT sided) Clinical Manifestations: Respiratory distress Frothy sputum Assessment: Restlessness Value uneasiness Agitation Disorientation Diaphoresis Sever dyspnea Tachypnea Tachycardia Pallor or cyanosis Cough production of large quantities of blood tinged, frothy sputum Audible wheezing, crackles Cold extremities Diagnostic Test: S&S Supported with X-RAY ABGs PaO2 and Paco2 may reveal respiratory alkalosis or acidosis Medical Management: Interventions to promote oxygenation Improve cardiac output Reduce pulmonary congestions

Nursing Interventions: O2 Place patient in upright position with legs in dependent position to decrease venous blood return t o heart Relieving pulmonary congestion and dyspnea Monitor ABGs and give meds Ausculate lung frequently Monitor V/S and I&O Medical Management: Intervention Diuretics: or over side of bed High fowlers furosemide (Lasix) wit Bumetanide on bed side arms supported (Bumex) table Inotropic Agents: Morphine 10-15mg IV titrated Dobutamine (Dobutrex) O2 Amrinone (Incor) @ 40%-100% nonrebreather mask Nitroprusside (Nitropress) Nitroglycerin Rational Decreases pulmonary edema and increases excretion Increase myocardial contractility Decrease pain , anxiety, slows RR, without increasing oxygen dilates pulmonary and systemic consumption blood vessels Increases peripheral vasodilatation Increase cardiac output potent vasodilator Increase myocardial blood flow

VALVULAR DISEASE: Etiology/ Pathophysiology: occurs when heart valves are compromised and do not open and close properly Two problems can occur: Stenos is: thickening of the valve tissue causing the valve to become narrow Insufficiency: occurs when the valve is unable to close completely

Another prominent factor in valvular disease is a HX of rheumatic fever Because the blood volume and workload of the heart are greater on the left than on the right, the valves affected more frequently are the mitral and aortic o Clinical symptoms tend to occur 10-40 yrs after rheumatic fever o Valvular heart disorder includes Mitral stenosis Mitral insufficiency Aortic stenosis Tricuspid insufficiency Tricuspid stenosis Pulmonary insufficiency Pulmonary stenosis Clinical Manifestation: S&S seen in Valvular disorder are related to decreased cardiac output ASSESSMENT: SUBJECTIVE DATA: Noting HX of rheumatic fever and inability to perform ADLs with fatigue or weakness HX of chest pain noting o Quality o Duration o Onset o Precipitating factors o Measures used to provide comfort o Verbalized having feelings of lightheadedness, dizziness, or fainting o May be HX of weight gain and nocturnal dyspnea OBJECTIVE DATA: Heart mummer Adventitious breath sounds Edema pitting or non MEDICAL MANGMENT:

Activity restrictions Na+ restricted diet Diuretics Digoxin Antidysrhythmic

Surgical repair usual when life style is severely disrupted there are two types of surgeries: Open Mitral commissurotomy: A surgical splitting of the fused Mitral valve leaflet for treating stenosis of the mitral valve Valve replacement: replacement of the stenosed or incompetent valve with a bioprostetic or mechanical valve commonly used valve are: o Tilting disks o PIG o Heterografts o Homografts o Ball in cage valves NURSING INTERVENTIONS AND TEACHING: Focused on assisting to perform ADLs, relieving specific symptoms, associated wit decreased cardiac output and promoting comfort Meds o Diuretics o DIGoxin o Antiysrhythmics o Recording I&O, RR, auscultation of breath sounds, heart sounds, and B/P o Capillary refill o Pedal pulses o Na+ restricted diet o Oxygen as prescribed o Plan for rest periods and identify ADLs that cause fatigue o Antibiotic prophylaxis to prevent infectious endocarditis INFLAMMATORY HEART DISORDERS Rheumatic heart disease ETIOLOGY /PATHOPHYSIOLOGY

Results from rheumatic fever - an inflammatory disease that results from a delayed childhood reaction to inadequately treated pharyngeal or upper respiratory tract infection (group B-hemolytic streptococci) Inadequate TX can result in inflammation of o Cardiac tissue o CNS o Joints o Skin o Subcutaneous tissue Onset is usually 1-5wks after recovery of pharyngitis or from scarlet fever Can affect : o Pericardium o Myocardium o Endocardium Affected tissue develops small areas of necrosis, which heal leaving scar tissue Heart valves are typically affected by Aschoffs nodules (vegetative growth) that becomes fibrous and incompetent o With healing valves become thick and deformed CLINICAL MANIFESTATIONS: Fever Increased pulse Epistaxis Anemia Joint involvement Nodules on joints and subcutaneous tissue Carditis may develop ASSESSMENT: SUBJECTIVE DATA: Joint pain (Polyarthritis) Abdominal pain Lethargy and fatigue OBJECTIVE DATA:

 Skin manifestations of erythmatous circles and wavy lines on the trunk of abdomen that appear and disappear rapidly (Erythema marginatum) Involuntary purposeless movements of the muscles if Sydenhams chorea (St.Vitus dance) a disorder of the CNS is present Murmur if cordites with valve involvement DIAGNOSTIC TEST S&S SUPPORTED BY LABS Echocardiogram to determine extent of damage to valves and myocardium ECG shows dysrhythmias Cardiac murmurs or friction rubs can be heard ESR and leukocytes will be elevated

MEDICAL MANGMENT: Preventative prompt TX of pharyngeal infections Penicillin drug of choice Patient with carditis can be ambulatory as soon as inflammation is gone and HF is controlled NSAIDS for joint pain and inflammation along with gentle heat Balanced diet NURSING INTERVERNTIONS& TEACHING S&S determine interventions Bed rest with initial attack when carditis is present With polyarthritis proper positioning to minimize pain Teach on: disease course S&S Activity gradually increased Prophylactic use of antibiotics Patients wit HX of rheumatic fever should receive daily penicillin (PO) or monthly IM injections to prevent streptococcal infections o At lest during childhood and adolescence

o Patients with deformed heart valves should be given antibiotics

before surgery or dental work PERICARDITIS: Inflammation of the membranous sac surrounding the heart May be acute or chronic Acute carditis associated with: Bacterial Fungal Viral May occur with noninfectious conditions: MI Azotemia Neoplasms such as: o lung cancer o Breast cancer o Leukemia o Hodgkins disease o Lymphoma o Scleroderma Trauma after thoracic surgery Lupus Radiation Drug reactions: Procainamide (procan SR) Hydralazine (Apresoline) Fibrosis on sac in chronic form Fibrous constriction and thickening of pericardium occurs gradually causing compression severe enough to prevent normal filling during systole Remove of pericardium may be necessary CLINCAL MAINFESTATIONS: Differs from other inflammatory conditions in that there is severe pain o Aggravated by lying supine o Deep breathing o Coughing

o o o o o o o

Swallowing Moving the trunk Alleviated by sitting and leaning forward Dyspnea Chills Diaphoresis Leukocytosis

Hallmark finding in acute pericarditis is Pericardial friction rub Grating Scratching Leathery sounds Dysrhythmias HF can occur due to fluid compression in sac As much as 150-200ml or more may accumulate Cardiac Tamponade- when pericardial effusion restricts heart movement Pericardiocentisis- pericardial tap to remove excess fluid and restore normal heart function ASSESSMENT: SUBJECTIVE DATA: Patients description of muscle aches, fatigue, and dyspnea Excruciating chest pain said to originate pericordial and radiate to the neck and shoulders with severe rapid onset OBJECTIVE DATA Noting expressed substernal pain radiating to the shoulders and neck o Obvious by orthopneic positioning and facial grimace on inspiration o Elevated temp with chills o Nonproductive cough o V/S- forcible pulse and rapid, shallow breathing o Pericardial friction rub DIAGNOSTIC TEST:

ECG-dysrhythmia Echocardiography= pericardial effusion or cardiac tamponade Leukocytes= 10,000-20,000/mm ESR elevated

MEDICAL MANGMENT: Analgesics O2 Antibiotics to treat bacterial pericarditis Salicylates for temp Indomethacin for inflammation Corticosteroids- for persistent inflammatory Surgical interventions: Pericardial fenestration (Pericardial window) Pericadiocentisis (Pericardial Tap)

NURSING INTERVENTIONS Bed rest is maintained to promote healing and decrease cardiac workload HOD @ 45

ENDOCARDITIS: Infection or inflammation of the inner lining of the heart particularly heart valves Classified by cause: Infective endocarditis (formerly bacterial endocarditis) May also be as a result of injury to the lining o Endocarditis may result after heart surgery People @ risk include: Patients with rheumatic fever

 Congestive heart disease Degenerative heart disease With valve replacement the incidence of prosthetic valve endocarditis has risen For some endocarditis has been a result of intrusive procedures: o Dental work o Minor surgery o Gynecological exams o Indwelling FC o Other @ high risk needle drug users CAUSATIVE ORGANISMS INCLUDE: Fungi Bacteria Virus Chlamydia Rickettsiae Most common: Streptococcus viridans Streptococcus pyogens Staphylococcus aureus Staphylococcus epidermidis Enterococci As organism embeds itself in the heart tissue in produces vegetative growth and perforates valve leaflets and chambers Vegetative growth scars tissue or may breakaway and cause emboli, infection or abscess in organs where they lodge Systemic embolization may occur fro left sided heart vegetation, progressing to organs particularly : o Brain o Kidneys o Spleen o Limb infarction Right sided embolize in lungs

CLINICAL MANIFESTAIONS: Occurring acute or subacute S&S occur rapidly in acute phase or gradually ASSESSMENT: SUBJECTIVE DATA: Noting patients complaints of flulike symptoms with recurrent fever Undue fatigue Chest pain HA Joint pain Chills OBJECTIVE DATA: Petechiae in conjunctive, anterior chest ,neck, abdomen, oral mucosa, legs and anemia Splinter hemorrhage (black longitudinal streaks in nail beds) Rapid pulse Onset of new murmurs with infective endocarditis commonly affecting aortic and mitral valve DIAGNOSTIC TEST: ECG and chest X-RAY show evidence of HF and heart enlargement Transesophageal echocardiography and digital imagery to see vegetative growth and abscess on valves LABS: Leukocytosis ESR increased Anemia MEDICAL MANGMENT: Relies on bed rest to decrease workload on heart Complete bed rest is not indicated unless there are signs of increased fever and signs of HF o Priorities are include : Supporting cardiac function

 Preventing complications such as emboli and HF Prophylactic antibiotic therapy for those at high risk of developing infective endocarditis Prior valve surgery Preexisting valvular disease NURSING INTERVENTIONS AND TEACHING: Observe for petechiae Location of pain Fever o If S&S are present report During acute phase patient must have limited activity and provide calm quirt environment V/S q4hrs with apical pulse With ambulation or activity assess pulse before and after to determine effects on heart muscle Take antibiotics prophylactic with surgery Teach S&S of infection o Fever, chills, fatigue, malaise

MYOCARDITIS: Inflammation of the myocardium may originate from rheumatic heart disease: Viral Bacterial Fungal Or endocarditis or pericarditis S&S: vary with site of infection Patient may have upper respiratory symptoms o Fever o Chills o Sore throat Other S&S o Abdominal pain

o o o o

Nausea Vomiting Diarrhea Myalgia

Occurs 6wks before S&S of myocarditis such as: o Chest pain o N/V o Over heart failure with dyspnea Commonly seen in myocarditis o Cardiomegaly o Murmur o Gallop and tachycardia o Enlargement may develop into dysrhythmia Therapy is symptomatic and follows same as endocarditis: o Bed rest o Oxygen o Antibiotics o Anti-inflammatory drugs o Correction of dysrhythmia Cardiomyopathy may occur