REPUBLIC OF THE PHILIPPINES

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
LUCINDA CAMPUS, BRGY. UNGOT, TARLAC CITY
__________________________________________

NCM-118 LABORATORY:
CASE ANALYSIS
(ENDOCARDITIS)

Submitted by:
Jia Laurice P. Barandino
Aleckza Jade S. Melendez
Rosemarie B. Sebastian
BSN 4-2

Submitted to:
Mrs. Anne Myrtle M. Lorenzo, RN, MAN
Clinical Instructor
Case Scenario:

A 56 year old male with a history of hypertension presented with a 2 month history of fevers,
chills, anorexia, and weight loss with a 2 week history of worsening dyspnea and pedal edema.
At the time of presentation, he had a blood pressure of 90/27 mmHg, with a heart rate of 80 beats
per min, temperature of 38.0 °C, and required 8 L/ min of oxygen to maintain an oxygen
saturation of 94%. On exam, his jugular venous pressure was 7 cm above the sternal angle. He
had bilateral crackles, a grade III/VI decrescendo diastolic murmur along the left lower sternal
border, and bilateral pitting edema. His white blood cell count was 14,000 cells/μL. Two sets of
blood cultures were drawn, and empiric vancomycin, gentamicin, and ciprofloxacin were
initiated. At 9 h, blood cultures were positive for pansensitive Streptococcus oralis and his
antimicrobial therapy was changed to ceftriaxone. A transthoracic echocardiogram reported a
mildly dilated left ventricle with normal systolic function, a trileaflet aortic valve with severe
aortic insufficiency, and a 15 mm aortic valve vegetation (Fig. 19.1, Videos 19.1 and 19.2). A
computed tomography (CT) scan of his head reported a left frontal subacute infarction with
associated petechial hemorrhage.

All patients with IE should be initiated on early empiric guideline-recommended antibiotic

therapy, and antimicrobials should be further guided by culture and sensitivities. Patients with
severe mitral or aortic insufficiency causing congestive heart failure should be referred for early
cardiac surgery to repair or replace the incompetent valve. Prior to surgery, this patient
underwent a coronary CT scan, which reported a calcium score of 0. This test was done instead
of a coronary angiogram to reduce the risk of dislodging the vegetation. A dental consultation
excluded an oral abscess source. On postadmission day 2, he developed shock (blood pressure
70/20 mmHg) and flash pulmonary edema (Fig.  19.2). The patient was stabilized with non-
invasive mechanical ventilation and vasopressors. Dopamine was selected to increase his blood
pressure and his heart rate, with the intent of shortening diastolic filling time. He underwent an
emergent aortic valve replacement with a bioprosthetic valve. He was extubated and transferred
to the surgical ward on post-operative day 2, and discharged home on post-operative day 6. An
echocardiogram prior to discharge showed a normally functioning aortic bioprosthesis with no
signs of infective endocarditis. Ceftriaxone was continued for a total of 6 weeks.
DIADNOSTIC FINDINGS:
II. Nursing Process

A. Assessment

 Personal Data

Name: Patient X
Age: 56 years old
Height: 5’5
Weight: 50 kg
Address: San Agustin, Concepcion Tarlac
Gender: Male
Date of Birth: November 2, 1964
Birth Place: Tarlac City
Civil Status: Married
Occupation: Business man
Nationality: Filipino
Chief Complaint: Fever, Dyspnea, Pedal Edema
Final Diagnosis: ENDOCARDITIS

B. ENVIRONMENTAL STATUS

Patient X is presently living in Conception, Tarlac together with his wife. Their house is
bungalow-type made up of concrete. Their house is near the highway, few trees were
planted around their house and water from a deep well is their main source of water.
Garbage and waste disposal are observed, garbage-collecting truck collects their waste
making sure that their surrounding are free from it. As their mode of transportation, they
use tricycle, jeepneys, and also buses to go to other places. Based on the data gathered,
there are no significant factors that may influence to his disease.

HISTORY OF PRESENT ILLNESS

Prior to admission, the patient had a history of hypertension and presented with a two-
month history of fevers, chills, anorexia, and weight loss, as well as a two-week history
of worsening dyspnea and pedal edema. His initial vital signs show a blood pressure of
90/27 mmHg, a heart rate of 80 beats per minute, a temperature of 38.0 °C, and a need for
8 L/min of oxygen to maintain an oxygen saturation of 94%. His jugular venous pressure
 was 7 cm above the sternal angle on physical examination. He had bilateral crackles
heard and a bilateral pitting edema.
HISTORY OF PAST ILLNESS
According to the patient he has no previous confinement even though he has a 2 months
of recurring fever and chills and had significant weight-loss of 5 kg. Several check-ups
were done for his hypertension. He has no known allergies to foods and medications and
has no previous surgical treatment.

GENOGRAM
 Poor dental IV drug use (mostly Invasive
hygiene/recent dental because R sided procedure/indwelling BOOK BASED PATHOPHYSIOLOGY OF
procedure endocarditis) device
ENDOCARDITIS

Bacteria (see microbiology note) enter

LEGENDS:
the blood stream
Positive blood PATHOPHYSIOLOGY
Thrombus forms on culture
Bacteria adhere to thrombi on MECHANISM
the surface of a
the cardiac valve endothelium
cardiac valve Activation of SIGNS AND SYMPTOMS
Fever
immune system RISK FACTORS
Infection of the thrombus In subacute cases, valvular abnormality
usually present beforehand Mitral regurgitation, aortic stenosis,
typically produces a vegetation aortic insufficiency
on the flow surface of a valve
In all cases, vegetation forms
an affected valve Vegetation seen on ultrasound

Formation of immune Immune complexes deposit in kidney Glomerulonephriti

complexes (complexes s
of antibody bound to Immune complexes causevasculitis in retinal
antigen) secondary to vessels Roth’s Spots
infection
Immune complexes deposit
subcutaneously
Osler Nodes

Parts of vegetation embolize Bloodflow to organs perfused by the obstructied

arteries Organ infarction
systemically, obstructing arteries

Smaller emboli block smaller Splinter hemorrhages

vessels on hands/ feet-
macroinfarction Janeway lesions
Infection destroys
infected valve \Valve unable to fulfil normal functions
Cardiac valve insufficiency, regurgitation
PATIENT BASED
PATHOPHYSIOLOGY OF
ENDOCARDITIS
Diagnostic/Labo Date Indication/ Result Normal values Analysis and Nursing
ratory ordered/ Purpose interpretation responsibilities prior
Procedure Date done of result to, during, and after
the procedure

CBC (Complete Date ordered: A blood test WBC: WBC: WBC is Before:
Blood Count) Sept. 21 ,2021 used to evaluate 14,000/mm3 4,500 to 11,000 elevated. High  Explain test
and count cells cells per white blood procedure.
Date done: that circulate in microliter cell count, also Explain that slight
Sept. 21, 2021 the blood. (cells/mcL) known as discomfort may
leucocytosis, be felt when the
can indicate skin is punctured.
a range of
conditions  Encourage to
including avoid stress if
infections, possible because
inflammation, altered
and bodily physiologic status
injury and influences and
immune changes normal
system hematologic
disorders. values.

During:
 Instruct the
patient to remain
still.

After:
 Apply manual
pressure and
dressings over
 puncture site.
 Monitor the
puncture site for
oozing or
hematoma
formation.

Transthoracic Date ordered: Echocardiogram  Mildly dilated  Left Abnormal. Before:

Echocardiogram Sept. 21 ,2021 is done for left ventricle ventricular Presence of  Inform the patient
(ECG) structural imaging with normal cavity ventricular that
Date done: of the systolic normally an dilation is the echocardiography
Sept. 21, 2021 pericardium, function echo-free initial is used to evaluate
imaging of the space between compensatory the size, shape,
left or right the interventri response of the and motion of
ventricle and their cular septum failing heart various cardiac
cavities, imaging and the that restores structures.
of the valves, posterior left stroke volume.  Advise the patient
imaging of the ventricular that he doesn’t
great vessels and wall. need to restrict
imaging of atria food and fluids for
and septa between the test.
cardiac chambers.  Trileaflet  Aortic valve  Instruct patient to
aortic valve cusps moving Abnormal. Due void prior and to
with aortic anteriorly to presence of change into a
insufficiency during systole Streptococcus gown.
 15 mm aortic and Oralis,  Advise the patient
valve posteriorly vegetation to remain still
vegetation during occurred. during the test
diastole and because movement
no presence of may distort results.
lesions.  The room may be
darkened slightly
to aid visualization
 on the monitor
screen, and that
other procedure
(ECG and
phonocardiograph
y) may be
performed
simultaneously to
time events in the
cardiac cycles.
During:
 Warn patient that
he may feel minor
discomfort
because pressure is
exerted to keep the
transducer in
contact with the
skin.
 Explain that
transducer is
angled to observe
different areas of
the heart and that
he may be
repositioned on his
left side during the
procedure.
After:
 Remove the gel
from the patient’s
chest wall.
 Inform the patient
 that the study will
be interpreted by
the physician. 
 Instruct patient to
resume regular diet
and activities. 
BLOOD Date ordered: It is performed to  (+) Pan  No presence Abnormal. Before:
CULTURE Sept. 21 ,2021 isolate and aid in sensitive of any Pathogen is the  Confirm the
the identification Streptococcus pathogens. cause of patient’s identity
Date done: of the pathogens Oralis existing using two patient
Sept. 21, 2021 in bacteraemia inflammation identifiers
(bacterial and infection according to
invasion of the which is the facility policy.
bloodstream) and presence of  Explain to the
septicaemia Streptococcus patient that the
(systemic spread Oralis. blood culture
of such infection). procedure is used
It requires to help identify the
inoculating a organism causing
culture medium his symptoms.
with a blood  Inform the patient
sample and that he doesn’t
incubating it. need to restrict
Blood cultures food and fluids.
can identify about  Advise the patient
67% of pathogens that he may
within 24 hours experience slight
and up to 90% discomfort from
within 72 hours. the tourniquet and
needle punctures.
During:
 Put on gloves.
 Clean the
 venepuncture site
with an alcohol
swab and then
with an iodine
swab, working in a
circular motion
from the site
outward.
 Apply the
tourniquet.
 Perform a
venepuncture;
draw 10 to 20 mL
of blood for an
adult.
 Send each sample
to the laboratory
immediately after
collection.
After:
 Assess the
venepuncture site
for hematoma
formation; if one
develops, apply
direct pressure.
 Prepare to initiate
antimicrobial
therapy, as
ordered.

COMPUTED Date ordered: This procedure is  Left frontal  No infarction Abnormal. Before:
TOMOGRAPH Sept. 21 ,2021 done to pinpoint sub-acute and There are tiny  Obtain an
Y (CT) SCAN the location of a infarction with haemorrhage punctate informed consent
Date done: associated must be regions of properly signed.
tumor, infection
Sept. 21, 2021 petechial present. haemorrhage.  Assess for any
or blood clot, haemorrhage history of allergies
guide procedures  Calcium score:  Score: 0 Normal: No to iodinated dye or
such as surgery, 0 plaque is shellfish if contrast
biopsy and present. media is to be
used.
radiation therapy
 Instruct the patient
an detect and to not to eat or
monitor diseases drink for a period
and conditions amount of time
such as cancer, especially if a
contrast material
heart disease, will be used.
lung nodules and  Instruct the patient
liver masses to wear
comfortable,
loose-fitting
clothing during the
exam.
 Tell the patient
that a mild
transient pain from
the needle
puncture and a
flushed sensation
from an I.V.
contrast medium
will be
experienced.
 Inform about the
duration of the
 procedure. 
During:
 Instruct the patient
to remain still. 
After:
 Instruct the patient
to resume the
usual diet and
activities unless
otherwise ordered.
 Encourage the
patient to increase
fluid intake (if
a contrast is
given).
 NURSING CARE PLAN

Patient’s Name: Patient X Age: 56-year-old male patient

ASSESSMENT NURSING PLANNING NURSING EVALUATION

DIAGNOSIS INTERVENTION
Subjective: Decreased cardiac Within 48-72hrs of Independent After 48-72hrs of rendering
output related to rendering appropriate nursing intervention,
Patient was in decreased appropriate nursing Monitor heart rate and blood the patient was able to
an ventricular filling intervention, the pressure; For baseline data demonstrate adequate cardiac
uncomfortable patient will: and for monitoring output as evidenced by normal
state, blood pressure and pulse rate and
experiencing demonstrate Assess neurologic status; to rhythm.
difficulty; adequate cardiac detect if there’s an alteration
having output as evidenced due to surgery
decreased BP by blood pressure
and presence of and pulse rate and Keep patient on bed rest,
crackles in the rhythm within semi-fowlers position;
lungs. normal parameters Maintain the patient's airway
and circulation 
Objective:
- Restlessness Evaluate Jugular vein
- Weakness distention; to evaluate sign of
noted increased central venous
- Hypotension pressure (CVP).
(with blood
pressure of
90/27 Record intake and output:
- Dyspneic; 10 to prevent dehydration/fluid
- Temperature retention
of 38.0 °C
- O2 Sat of 94%
Dependent
Maintain adequate ventilation
and perfusion; Administer
oxygen therapy as
prescribed.;  to correct
alveolar and/or tissue hypoxia

Maintain fluid restriction if

ordered; to correctly balance
fluid

Collaborative
Administer medications as
prescribed (ceftriaxone,
dopamine, noting side effects
and toxicity.
 DRUG STUDY

NAME OF ROUTE & INDICATION MECHANISM CONTRAINDICATION SIDE EFFECTS NURSING

DRUG DOSAGE OF ACTION RESPONSIBILITY
Generic
name: 500 mg  indicated for Inhibits cell Contraindicated to Black, tarry stools.
Vancomycin intravenously the treatment of wall synthesis people who have: blood in the urine - Monitor signs
every 6 hours serious or by binding to or stools. of hypersensitivity
or 1 g severe the D-Ala-D- hypersensitivity to this continuing ringing reactions and
Brand name: intravenously infections Ala terminal of antibiotic. or buzzing or other anaphylaxis
- Monitor signs of 
N/A every 12 caused by the growing Systemic mastocytosis. unexplained noise
Pulmonary
hours susceptible peptide low levels of a type of in the ears. symptoms
strains of chain during white blood cell called cough or (tightness in the
Drug class: methicillin- cell wall neutrophils. hoarseness. throat and chest,
Glycopeptides resistant (beta- synthesis, hearing loss. dizziness or wheezing, cough
lactam- resulting in kidney disease with lightheadedness. dyspnea)
resistant) inhibition of likely reduction in feeling of fullness - Monitor signs of 
staphylococci.) the kidney function. in the ears. Skin reactions
transpeptidase, fever with or (rash, pruritus,
which prevents without chills. urticaria). Notify
further general feeling of physician or
nursing staff
elongation and tiredness or
immediately if
cross-linking of weakness. these reactions
the occur.
peptidoglycan
matrix (see
glycopeptide
 pharm).

NAME OF ROUTE & INDICATION MECHANISM OF CONTRAINDICATION SIDE EFFECTS NURSING

DRUG DOSAGE ACTION RESPONSIBILITY
Generic
name: 1g Susceptible Ceftriaxone Contraindicated to Black, tarry
Ceftriaxone intravenousl bacterial works by people who have: stools. Monitor signs of
y (IV) every infections of the inhibiting the chest pain. pseudomembranous
12 hours for lower mucopeptide Diarrhea from an shortness of colitis
7-14 days  respiratory tract, synthesis in the infection with breath. Monitor diarrhea,
Brand name: skin and skin bacterial cell wall. Clostridium difficile sore throat. abdominal pain,
Rocephin structure, bone The beta-lactam bacteria. sores, ulcers, or fever, pus or mucus
and joint, acute moiety of A type of blood disorder white spots on the in stools, and other
otitis media, ceftriaxone binds where the red blood lips or in the severe or prolonged
Drug class: UTIs, to cells burst called mouth. GI problems
cephalosporin septicemia, carboxypeptidases hemolytic anemia. swollen glands. (nausea, vomiting,
antibiotics pelvic , endopeptidases, Liver problems. unusual tiredness heartburn). Notify
inflammatory and Disease of the or weakness. physician or nursing
disease (PID), transpeptidases in gallbladder. staff immediately of
intraabdominal the bacterial Severe renal these signs.
infections, cytoplasmic impairment.
meningitis, membrane. These Yellowing of the skin in
uncomplicated enzymes are a newborn child.
gonorrhea. involved in cell-
wall synthesis and
cell division.
NAME OF DRUG ROUTE & INDICATION MECHANISM CONTRAINDICATION SIDE EFFECTS NURSING
DOSAGE OF ACTION RESPONSIBILITY
Generic name:
Ciprofloxacin 800 mg IV It is used to Ciprofloxacin is Contraindicated to - nausea.
q24h in 2 treat serious a bactericidal people who have: - vomiting. - Report tendon
divided doses infections, or antibiotic of the - stomach pain. inflammation
infections fluoroquinolone - diarrhea from an or pain. Drug
- heartburn.
Brand name: when other drug class. infection with should be
Cipro XR anitbiotics It inhibits DNA Clostridium - diarrhea. discontinued.
have not replication by difficile bacteria. - vaginal - Lab tests:
worked. It's inhibiting - diabetes. itching and/or Culture and
Drug class: used to treat bacterial DNA discharge. sensitivity tests
Fluoroquinolones bacterial topoisomerase - low blood sugar.
- pale skin. should be done
infections, and DNA- - glucose-6- prior to initial
- unusual
such as: chest gyrase. It works phosphate dose.
tiredness.
infections by killing dehydrogenase Treatment may
(including bacteria that (G6PD) deficiency. be
pneumonia) cause - low amount of implemented
skin and bone infections. magnesium in the pending results.
infections. Antibiotics blood. - Monitor urine
such as - low amount of pH; it should
ciprofloxacin be less than
potassium in the
will not work 6.8, especially
blood.
for colds, flu, or in the older
other viral - a low seizure
adult and
infections. threshold.
patients
- receiving high
 dosages of
ciprofloxacin,
to reduce the
risk of
crystalluria.
- Monitor I&O
ratio and
patterns:
Patients should
be well
hydrated;
assess for S&S
of crystalluria.
- Monitor plasma
theophylline
concentrations,
since drug may
interfere with
half-life.
- Administration
with
theophylline
derivatives or
caffeine can
cause CNS
stimulation.
- Assess for S&S
of GI irritation
(e.g., nausea,
diarrhea,
vomiting,
abdominal
discomfort) in
 clients
receiving high
dosages and in
older adults.
- Monitor PT
and INR in
patients
receiving
coumarin
therapy.
- Assess for S&S
of
superinfections.
SURGICAL MANAGEMENT

Name of Date Brief Indication/purpos Client’s Nursing responsibilities

procedure performed description e response prior to, during, and
to surgical
operation procedure(actual)
Bioprosthetic September Bioprosthetic For the Patient's Pre-op
valve 2021 valve fracture replacement of condition
procedure (BVF) is an malfunctioning is good Secure consent
emerging native or which Explain procedure to
novel prosthetic aortic means the patient
technique for valves with the his Monitor vital signs to
patients with option of aortic recovery patient safety prior to
small root replacement.  is doing operation
surgical well Instruct patient for
bioprostheses Remove if patient
who are having a nail polish for
undergoing a easy access for
VIV monitoring cyanosis
procedure.
The Intra op
technique Ensure sterility
includes Perform surgery safety
positioning checklist
of a
noncompliant Post-op
valvuloplasty 1.Respiratory status is
balloon assessed by monitoring
within the rate, depth, and pattern
surgical of respiration. A patient
bioprosthesis airway is maintained
, followed by 2. Vital signs
a high- monitoring
pressure 3. Arterial and central
balloon venous pressure CVP
inflation to are monitored
fracture the 4. Pharmacological
surgical agents may be
sewing ring prescribed
of the 5. Incisional and
surgical headache pain may be
valve.  controlled with mild
analgesics