04.04 Endocarditis and Pericarditis

Overview

  1. Endocarditis – inflammation inner lining and valves of heart
  2. Pericarditis – inflammation outer lining, pericardial sac around heart

Nursing Points

General

  1. Causes
    1. Endocarditis
      1. IV Drug Use
      2. Valve Replacement
      3. Dental Procedures
      4. Tooth Abscesses
    2. Pericarditis
      1. Infection – viral, bacterial, fungal
        1. Coxsackie Virus
      2. Blunt Chest Trauma
  2. Complications
    1. Endocarditis
      1. Valve Disorders
      2. Vegetations on valves – can become embolic
        1. Stroke
        2. MI
    2. Pericarditis
      1. Inflammation and Fluid Buildup
      2. Pressure on heart → ↓ CO
        1. Heart Failure
        2. Cardiogenic Shock
      3. Cardiac Tamponade

Assessment

  1. Endocarditis
    1. Chest pain
    2. Heart murmurs
    3. ↑ Temp and WBC
    4. ↓SpO2
    5. S/S Heart Failure
    6. Embolic Complications
      1. Splinter hemorrhages in nail beds
      2. Janeway lesions
      3. Clubbing of fingers
  2. Pericarditis
    1. Chest pain
      1. Aggravated by breathing, coughing, swallowing, lying flat
    2. ↑ Temp and WBC
    3. Possible ST-Elevation
    4. S/S Heart Failure
    5. S/S Cardiac Tamponade
      1. Pulsus Paradoxus – SBP ↓ 15 mmHg during inspiration
      2. JVD with clear lungs
      3. Narrow Pulse Pressure
      4. ↓ CO
      5. Muffled heart sounds
      6. Beck’s Triad (distended neck veins, ↓ BP, muffled heart sounds)

Therapeutic Management

  1. Endocarditis
    1. IV Antibiotics
    2. Oral hygiene
    3. Antiembolic stockings or SCD’s
    4. Possible anticoagulation
  2. Pericarditis
    1. IV antibiotics
    2. Assess and treat pain
    3. Administer O2
    4. High-Fowler’s position
    5. Cardiac Tamponade → Pericardiocentesis

Patient Education

  1. Will need prophylactic antibiotics before any invasive procedure
  2. Oral hygiene is imperative
  3. No dental procedure for 6 months
  4. Monitor for s/s of infection and emboli

Reference Links

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Video Transcript

This lesson will cover endocarditis and pericarditis, both conditions that affect the heart.

If we dissect these words into their parts, like all medical terminology, we can easily figure out what they are. So you see they’re both ‘itis’ – so that means inflammation. They both have “card” which means “Cardiac” or heart. “Endo” means inside – so we’ll see endocarditis is inflammation inside the heart. “Peri” means “around” so you’ll see pericarditis is inflammation around the heart.

So let’s start with endocarditis. By definition, endocarditis is inflammation of the inner lining and valves of the heart. You can see here in this cross-section of the heart just how inflamed and red the inside is. You can also see this bacterial and vegetation buildup on the valves. That’s clumps of platelets, inflammatory cells, bacteria, etc. getting stuck to the valves. So already you can picture how difficult it’s going to be for this heart and these valve to work correctly, right? Some of the things that cause endocarditis are IV drug use – just think about these IV drug users on the street – that’s a lot of bacteria being introduced directly into the bloodstream. We talked in valve disorders about how patients who receive valve replacements are at risk – that foreign object is just asking for cells and bacteria to collect on it. Then what we see with endocarditis is this huge connection to oral health and dental procedures. It seems kind of silly, but the evidence has shown that bacteria travel from the mouth directly to the heart very easily. So people who have had dental procedures or have an abscessed tooth will come in with chest pain and it turns out to be endocarditis. And we actually teach our patients to avoid dental procedures for 6 months after this.

So, as you saw in that image, you can imagine that having all that inflammation and vegetation on the valves means they’re not going to work correctly. Sometimes they struggle to close all the way which causes regurgitation, and sometimes they don’t open all the way which causes stenosis. But the most important thing to note here is that those vegetations on the valves can actually break off and become embolic. That means they will move through the bloodstream and can get stuck somewhere – causing ischemia. So what’s the risk? Stroke, MI, PE. So we have to keep an eye out for these complications.

As far as symptoms, remember that this is an infectious process so you’ll see those signs of infection – fever, elevated WBCs. You may also hear heart murmurs because of the valve damage. And then, because it affects the heart’s ability to pump effectively, you may see signs of heart failure and decreased cardiac output. And then if those emboli travel down into the extremities we can see splinter hemorrhages, which look like little streaks of blood in the nail beds, janeway lesions which are small bruises on the hands and feet, and clubbing of fingers because of the lack of oxygen delivery. So we can see how this affects the whole body as well.

So what do we do for endocarditis? Well first and foremost we have to treat the infection, so they’ll receive IV antibiotics. They may even go home with a PICC line for a 6-week course. We stress oral hygiene because of that link we talked about between oral health and endocarditis. We will apply antiembolic stockings or SCD’s – the provider may even order anticoagulant medications to prevent further clotting. And then we’re going to prioritize infection control – both looking for s/s of infection and infection precautions, and educating the patient on both as well. As the nurse, we’ll also be monitoring for those complications and we want to see them responding to the antibiotics. So, that’s endocarditis.

So now let’s look at Pericarditis. Remember we said it’s inflammation around the heart – by definition it is inflammation of the lining around the heart and the pericardial sac. So you can see the heart sits in the pericardial sac, like a little baggie. It’s nice and flexible with a little fluid cushion and the heart is protected. When that baggie gets inflamed, it starts to fill with fluid and swell up. It stops being so flexible and that fluid cushion actually starts to put pressure on the heart itself. The more pressure, the harder it is for the heart to fully relax and contract effectively. Pericarditis is also caused by infectious source – fungal (which is the least common), bacterial, and viral. One virus that we see causing pericarditis is the Coxsackie virus – which mostly affects children. But really anyone susceptible to infection can get pericarditis.

Now, I mentioned that the more pressure the inflamed pericardium and fluid build-up put on the heart, the harder it will be for it to pump – so you may see the patient develop heart failure, or even cardiogenic shock, which we’ll talk about in a later lesson. Then there’s another condition where the pressure has become so great that the heart can’t really pump at all – it’s called cardiac tamponade – and it’s a medical emergency. So what might you see in a patient with pericarditis? Well just like endocarditis we’ll see those signs of infection, increased temp and increased WBCs, we’ll also see those signs of heart failure and low cardiac output. But also they’re going to be in a lot of pain because of the inflammation. It will be worse with breathing, coughing, swallowing, laying down etc, because that all increases the pressure on the heart. Then, we may also end up seeing Cardiac Tamponade. There’s a classic triad of symptoms, called Beck’s triad. Because of the pressure around their heart, it backs up into the body so you’ll see distended neck veins. Remember JVD looks like this – that vein is popping out of their neck. You’ll see their blood pressure drop because the heart can’t pump, and you’ll hear muffled heart sounds because of all the fluid surrounding the heart. You may also see Pulsus Paradoxus which is the blood pressure dropping when they take a deep breath, and you may see the pulse pressure narrow. Remember pulse pressure is SBP – DBP – those numbers get closer and closer together because their heart can’t relax and contract fully.

So what do we do for pericarditis – well if it’s bacterial we’re going to give IV antibiotics, but of course if it’s viral we just have to support the symptoms – so we may see anti-inflammatory medications given as well. We’re going to manage their pain because they’re definitely going to have some. We see that their oxygenation suffers and their chest pain is worse with breathing or lying flat so we’re gonna give O2 and put them in a high-fowler’s position for comfort. Then, if they do experience cardiac tamponade, we have to prep them for what’s called a pericardiocentesis. A surgeon will usually come with a large long needle, he’ll use ultrasound to guide him and he’ll go right into the pericardial sac to drain off the fluid. Remember that the heart is now in this swollen, inflamed baggie full of fluid, we’ve got to drain the fluid so it can pump more freely. A lot of times you’ll see almost immediate relief of symptoms when this fluid gets drained.

There’s a care plan for each of these conditions attached to this lesson, but the major nursing concepts are the same. Perfusion because we could see how both conditions could cause decreased cardiac output. Infection control to treat and prevent infection. And health promotion – they need to know what behaviors to avoid, including avoiding dental procedures for 6 months. They need to know signs of infection or emboli and what to report to their providers. And overall how to prevent it from happening again.

So let’s recap – endocarditis is inflammation of the inner lining and valves of the heart. Pericarditis is inflammation of the outer lining and sac around the heart. Both will have symptoms of infection and decreased cardiac output because the heart can’t beat correctly. We need to treat the cause and address the infection and inflammation but we also need to prevent complications. This means prophylactic antibiotics before invasive procedures, anticoagulants or SCD’s, and possibly a pericardiocentesis if there’s tamponade. And then remember that Health Promotion is a priority – patients need to know what signs of infection or emboli to report to their providers and need to know what precautions to take.

These conditions are relatively similar so I hope we’ve been able to show you the differences. Be sure to check out the case study attached to this lesson – it’s based on a patient of mine and is a great way for you to learn more about endocarditis. We love you guys! Go out and be your best selves today, and, as always, happy nursing!

Read more

  • Question 1 of 6

A nurse is on the cardiac floor and is describing to a new nurse which signs and symptoms to be looking for to recognize cardiac tamponade. Which signs and symptoms are a part of Beck’s triad?

  • Question 2 of 6

A 50 year-old male with a history of endocarditis reports he is having a hard time breathing and it feels like an elephant is sitting on his chest. As the nurse, what is your first priority?

  • Question 3 of 6

A patient with pericarditis is being evaluated for dizziness and shortness of breath. His heart rate on the monitor demonstrates supraventricular tachycardia. Which of the following interventions is most appropriate in this situation?

  • Question 4 of 6

A nurse is caring for a 49-year-old client who is recovering from valve replacement surgery. Three days after the surgery, the nurse suspects that the client has developed infective endocarditis. Which of the following signs or symptoms would indicate that this condition has developed in the client?

  • Question 5 of 6

Your patient is experiencing chest pain and the patients inflammatory markers are elevated. You are worried about the patient having pericarditis. What heart sound would you expect to hear if your patient had pericarditis?

  • Question 6 of 6

A 50 year-old male with a history of endocarditis reports he is having a hard time breathing and it feels like an elephant is sitting on his chest. Which interventions are an emergent priority? Select all that apply.