Infective

Endocarditis
Chapter 37

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Infective Endocarditis
(IE)
Infection of the inner layer
of heart, including the
cardiac valves
Improved prognosis with
antibiotic therapy
10,00015,000 new cases
diagnosed in the U.S. each
year

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Layers of the Heart

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Classification

Subacute form
Preexisting valve disease
Longer clinical course

Acute form
Healthy valves
Rapidly progressive

Also classified by cause or

site of involvement
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Causative Organisms

Bacterial most common

Streptococcus viridans
Staphylococcus aureus

Viruses
Fungi

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Etiology and
Pathophysiology

Occurs when blood

turbulence within heart
allows causative organism
to infect previously
damaged valves or other
endothelial surfaces

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Case Study
E.F. is a 72-year-old man

who comes to the clinic

with flulike symptoms.
He has a history of
hypertension, past MRSA
infection, and a recently
implanted pacemaker.
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

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Case Study
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What risk factors for IE

does E.F. have?

What other risk factors

would you assess E.F. for?

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Risk Factors
Cardiac, noncardiac,
procedural
Principal risk factors

Age
IV drug abuse (IVDA)
Prosthetic valves
Use of intravascular devices
Renal dialysis
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Etiology and
Pathophysiology

Vegetation
Fibrin, leukocytes, platelets,
and microbes
Adhere to the valve or
endocardium
Parts break off and enter
circulation (embolization)

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Bacterial Endocarditis of
Mitral Value

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Pathogenesis of IE

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Case Study
What clinical

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manifestations of IE does
E.F. present with?
What other clinical

manifestations of IE would
you assess him for?
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Clinical Manifestations
Nonspecific
Low-grade fever occurs in
90% of patients
Chills
Weakness
Malaise
Fatigue
Anorexia

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Clinical Manifestations

Subacute form

Arthralgias
Myalgias
Back pain
Abdominal discomfort
Weight loss
Headache
Clubbing of fingers
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Clinical Manifestations

Vascular manifestations

Splinter hemorrhages in nail

beds
Petechiae
Oslers nodes on fingers or
toes
Janeways lesions on palms
or soles
Roths spots
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Oslers Nodes

From: Marrie, T. J., (2008). Oslers Nodes and Janeway Lesions .

American Journal of Medicine, 121(2),105-106.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Janeway Lesion
From: Marrie, T. J., (2008). Oslers Nodes and
Janeway Lesions . American Journal
of Medicine, 121(2),105-106.

From: Zitelli, Basil, et al. (2007).

Zitelli and Davis' Atlas of Pediatric Physical
Diagnosis. Mosby.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Roth Spots

From: Swartz, M. H..

Textbook of Physical
Diagnosis: History and
Examination, 6th
Edition. W.B. Saunders
Company

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Clinical Manifestations
Murmur in most patients
Heart failure
Manifestations secondary to
embolism

Spleen
Kidneys
Limbs
Brain
Lungs
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Case Study
E.F. has petechiae in the
conjunctivae and splinter
hemorrhages in his nail beds.

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His blood pressure is 138/64,

heart rate 80, respiratory rate 18,
and temperature 99.5 F (37.5 C).

A heart murmur is noted.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Case Study
The health care provider

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suspects infective
endocarditis.
E.F. is sent to the hospital for
further workup and treatment.
What diagnostic studies would
you expect the admitting
health care provider to order
for E.F.?
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies
History
Laboratory tests

Blood cultures
CBC with differential
ESR, C-reactive protein (CRP)

Echocardiography
Chest x-ray
ECG
Cardiac catheterization

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Collaborative Care

Prophylactic antibiotic
treatment for select
patients having

Certain dental procedures

Respiratory tract incisions
Tonsillectomy and
adenoidectomy
GI wound infection
Urinary tract infection
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Case Study
E.F.s blood culture results

are positive for

Staphylococcus aureus
Echocardiogram
demonstrates vegetations
on his mitral valve.
What treatment would you
expect the health care
provider to order for E.F.?
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

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Collaborative Care
Accurate identification of
organism
IV antibiotics (long-term)
Repeat blood cultures
Valve replacement if
needed
Antipyretics
Fluids

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Assessment

Subjective data

Health history
Valvular, congenital, or
syphilitic cardiac disease
Previous endocarditis
Staph or strep infection

Drugs
Recent surgeries and
procedures

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Nursing Assessment

Subjective data: functional health

patterns
IVDA
Alcohol abuse
Weight changes
Chills
Hematuria
Exercise intolerance, weakness, fatigue
Cough, DOE, orthopnea, palpitations
Night sweats
Pain, headache, joint or muscle tenderness

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Assessment

Objective data

Fever
Oslers nodes
Splinter hemorrhage
Janeways lesions
Petechiae, purpura
Peripheral edema, clubbing
Tachypnea, crackles
Dysrhythmia, tachycardia, murmurs,
S3, S 4
Retinal hemorrhages
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Case Study
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E.F. is started on IV

antibiotics and seems to

be resting comfortably.
He occasionally requests

PRN drugs for achiness

and continues to have a
low-grade fever.
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Case Study
He is not demonstrating

any symptoms of heart

failure at this time.
Identify appropriate

nursing diagnoses and

goals for E.F.
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

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Nursing Diagnoses
Decreased cardiac output
Hyperthermia
Impaired comfort
Activity intolerance
Deficient knowledge

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Planning

Patient will
Have normal cardiac
function
Perform ADLs without
fatigue
Understand therapeutic
regimen to prevent
recurrence

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation

Health promotion
Identify those at risk
Assess history and
understanding of disease
process
Teach importance of
adherence to treatment
regimen

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation
Health promotion
Patient teaching

Stress need to avoid

infectious people
Avoidance of stress and
fatigue
Rest
Hygiene
Prophylactic antibiotics
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Nursing Implementation

Ambulatory and home care

Antibiotic therapy for 46

weeks
Assess home setting
Monitor laboratory data,
including blood cultures
Assess IV lines
Coping strategies
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation

Ambulatory and home care

Adequate rest
Moderate activity
Compression stockings
ROM exercises
Deep breath and cough
every 2 hours

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Case Study
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E.F. has completed a week

of IV antibiotic therapy in
the hospital setting.
He is afebrile and feeling

better.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Case Study
Social service has arranged

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home IV antibiotic therapy in

anticipation of discharge to
home.
What important patient and

caregiver teaching should

you provide E.F. and his
family?
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation

Patient teaching

Monitor body temperature

Signs and symptoms of complications
Nature of disease and reducing risk of
reinfection
Stress follow-up care, good nutrition,
early treatment of common infections
Signs and symptoms of infection
Need for prophylactic antibiotic
therapy
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Evaluation
Adequate tissue and organ
perfusion
Normal body temperature
Activity tolerance
Comfort
Verbalizes understanding

Copyright 2014 by Mosby, an imprint of Elsevier Inc.