J.F.

is a 50-year-old married homemaker with a genetic autoimmune deficiency; she has

suffered from recurrent infective endocarditis. The most recent episodes were a
Staphylococcus aureus infection of the mitral valve 16 months ago and a Streptococcus viridans
infection of the aortic valve 1 month ago. During this latter hospitalization, an echocardiogram
showed moderate aortic stenosis, moderate aortic insufficiency, chronic valvular vegetations,
and moderate left atrial enlargement. Two years ago, J.F. received an 18-month course of
parenteral nutrition for malnutrition caused by idiopathic, relentless nausea and vomiting
(N/V). She has also had coronary artery disease for several years and, 2 years ago, suffered an
acute anterior wall myocardial infarction (MI). In addition, she has a history of chronic joint
pain. Now, after being home for only a week, J.F. has been readmitted to your floor with
endocarditis, N/V, and renal failure. Since yesterday, she has been vomiting and retching
constantly; she also has had chills, fever, fatigue, joint pain, and headache. As you go through
the admission process with her, you note that she wears glasses and has a dental bridge.
Intravenous access is obtained with a double lumen peripherally inserted central catheter
(PICC) line, and other orders are written below. Your assessment is also documented.

Admission Orders

STAT blood cultures (aerobic and anaerobic) × 2

STAT electrolytes & CBC

Begin parenteral nutrition (PN) at 85 mL/hr

Penicillin 2 million units IV piggyback q4h

Furosemide (Lasix) 80 mg/day PO

Amlodipine (Norvasc) 5 mg/day PO

Potassium chloride (K-Dur) 40 mEq/day PO

Metoprolol (Lopressor) 25 mg PO bid

Prochlorperazine (Compazine) 5 mg IV push prn for N/V

Transesophageal echocardiogram ASAP

Admission Assessment

Blood pressure 152/48 (supine) and 100/40 (sitting)

Pulse rate 116 beats/min

Respiratory rate 22 breaths/min

Temperature 100.2° F (37.9° C)

Oriented × 3 but drowsy

Grade II/VI holosystolic murmur and a grade III/VI diastolic murmur noted on auscultation

Lungs clear bilaterally

Abdomen soft with slight left upper quadrant (LUQ) tenderness

Multiple petechiae on skin of arms, legs, and chest; and splinter hemorrhages under the fingernails

Hematuria noted in voided urine

The next day, you review J.F.'s laboratory test results:

Laboratory Test Results

Na 138 mEq/L

K 3.9 mEq/L

Cl 103 mEq/L

BUN 85 mg/dL

Creatinine 3.9 mg/dL

Glucose 165 mg/dL

WBC 6700/mm 3

Hct 27%

Hgb 9.0 g/dL

As you admitted J.F., you were aware that as soon as she became stable, she would be going home in a
few days on PN and IV antibiotics. The home care agency that will be supervising her care is contacted to
coordinate discharge preparations and teaching.

Fortunately, J.F. has a supportive husband and two daughters who live nearby who can function as
caregivers when J.F. is discharged. They, along with the patient, will need teaching about endocarditis.
Although J.F. has been ill for several years, you discover that she and her family have received little
education about the disease. You prepare a teaching plan for the family. The home care agency has a
parenteralenteral nutrition team to address her nutritional needs, which will also include vitamins,
minerals, and lipids. PN formulations require complex calculations. The parenteral-enteral nutrition
team takes care of the formulation of the PN through the pharmacy or dietary staff (depending on local
arrangements). Your hospital discharge planner facilitates J.F.'s transition to home care.
Instruction:

Based on the above case scenario, discuss each questions comprehensively in not less than 10
sentences. Please see the attached rubrics, this will be the guide of your teacher in checking your
output.

Set A. Questions:

1. What is the significance of the abdominal tenderness, hematuria, joint pain, and petechiae?

Abdominal tenderness: the result from the formation of intra-abdominal mycotic aneurysm and
deposition of immune complexes.

Hematuria: the heart is not working correctly so it could impact the kidneys and lead to renal failure.
Blood would pass the kidneys and go into the urine.

Joint pain: because the heart is not working properly, it is harder to ambulate the body and perform
ADLs.

Petechiae: the thrombi have made the vessels weak and narrow leaving the blood to leak outside of the
blood vessels/ rupture the vessels collecting throughout the body.

These are the indications of embolization.

2. What is the significance of the orthostatic hypotension and the tachycardia?

Orthostatic hypotension and tachycardia signify cardiac insufficiency. Tachycardia is present because to
counteract decreased blood pressure.

Orthostatic hypotension: Her blood vessels were already narrowed from thrombi so any fast change in
posture would cause her to fall out. Her blood pressure wouldn’t be able to stabilize fast enough with
small thrombi in the vessels.

Tachycardia: The heart rate is higher because it has to compensate for the low blood pressure

3. As you monitor J.F. throughout the day, what other signs and symptoms (S/S) of embolization will
you watch for?

Other signs and symptoms of embolization will I watch are cold arms/legs, numbness / tingling in arms /
legs, lack of movement in limbs, muscle spasm, muscle pain in the affected area, tachycardia, edema,
neurological deterioration like paresis, etc.
4. Explain the diagnostic criteria for infectious endocarditis.

1. Onset of anemia: Anemia occurs as a response to the physiological stress due to the infection.
Infection results in iron deficiency by the sequestration of iron by the pathogens, increased
sedimentation of the erythrocytes, disrupted recycling hemoglobin from dead erythrocytes and
decreased production of erythrocytes.

2. Onset of fever: Fever and chills are typical features indicating infective endocarditis.

3. Presence of cardiac murmur: Cardiac murmurs is referred to as abdominal sound originated within
the heart due to defective valve function. These are typical of infective endocarditis.

5. What is the greatest risk for J.F. during the process of rehydration, and what would you monitor to
detect its development?

The risk factors associated during the rehydration therapy include the seizures, electrolyte and acid-base
imbalance and failure of the rehydration therapy.

6. During the initial home visit, the home health nurse evaluates J.F.'s IV site for implementation of
the IV therapy program. The nurse interviews the family members to determine their willingness to
be caregivers and their level of understanding and enlists the patient's and family's assistance to
identify 10 teaching goals. What topics would be included on this list?

1. The planner should consider whether caregiver would be comfortable doing tasks like parenteral-
enteral nutrition to the patient and activities of daily living assistance (ADLs)

2. The caregiver needs to be able to accurately calculate the dose of antibiotics that are to be
administered to the patient routinely.

3. Blood thinner drugs are very important for thinning the blood, which prevents the formation of clots.
These clots are the main reason for strokes and heart attacks. It is important to take care for bleeding
and bruising. When giving blood thinner like warfarin are sensitive to the food and medicines. They must
be taken with proper diet. It works best with diet rich with vitamin K. Diet consisting of vitamin K should
be taken every day.

4. Physical activities should be adjusted accordingly. While on medication any strenuous physical
activities should be avoided. Perform exercises recommended by the physical health practician only.

5. The diet of the patient should include fruits, vegetables, fish, soybean oils, nuts, and canola. High fiber
foods are also good for the heart.

6. Salt intake should be reduced, and low cholesterol food should be included. A nutritionist made
proper food chart should be followed.

7. The weight loss plan is also important. An increase in the weight may cause the low-density lipids to
increase in the blood. This would result in other heart disease.

8. A cardiologist should be contacted if J.F. gets the fever or a lost of appetite. If she has an increased
weakness of fatigue, she should be taken to emergency. Trouble in breathing, discomfort or pain in the
neck, stomach, jaws or arms, chest pain, or nausea, and vomiting like symptoms should be reported
immediately.

9. Oral care at home should begin from morning to night. It begins with proper brushing and flossing in
the morning. Tooth brushing should be done with soft bristle toothbrush. Since J.F. is on blood thinners
and prone to vessel eruptions due to edema, it is mandatory to brush softly.

10. The caregiver’s willingness to provide adequate emotional support and encouragement to the
patient.

7. Identify the values that are not within normal ranges and explain the reason for each abnormality.
(Based on laboratory results)

• J.F has a very high level of blood urea nitrogen (BUN) of 85 mg/dL. The test is
done to check kidney function. The increase in the levels of BUN might be caused
due to her cardiac abnormalities. Dehydration, which caused due to the increased
water loss from the body, also causes the BUN levels to rise.

• J.F has a high level of 3.9 mg/dL of creatinine in her blood. Since her BUN is
increased, her creatinine levels have greater chances to be high. Kidney non-
functioning is the main cause of the elevated levels of creatinine. Edema,
dehydration, shortness of breath is its common symptoms.

• J.F has a high glucose level of 165 mg/dL, this means she is diabetic. The high
level of glucose in J.F. found associated with the cardiac decompositions as two
years ago she had a myocardial infarction.

• J.F has 27% hematocrit value, which is very low. This can be caused due to the
intake of blood thinner medication. These medications often cause anemia,
bleeding, and destruction of red blood cells.

• J.F has a low hemoglobin level of 9.0 g/dL, and the low hematocrit value are co-
related due to anemia.

8. What are splinter hemorrhages, and what is their significance?

Splinter hemorrhages are small bleeding below the fingernails or toenails. They signify damage to
capillaries by small clots.
Set B. Questions:

1. Identify three (3) nursing diagnoses applicable in the case. Prioritize according to Maslow’s hierarchy
of need. Make an NCP for each nursing diagnoses and list at least 5 nursing interventions with rationale.

2. Identify 3 medications for your patient and make a drug study in each medications.