ENDOCARDITIS

Definition:
Infective endocarditis
previously referred to as
bacterial endocarditis is an
infection of the valves and
endothelial surface of the heart.
3 categories:
Native valve endocarditis (acute and
subacute)
An infection of a previously normal or
damaged valve.
ACUTE: develops over days or weeks
with an erratic course and earlier
development of complications; commonly
caused by Staphylococcus aureus, which is
capable of infecting other body tissues.
Staphylococcus aureus in mouth
SUBACUTE: develops gradually
over several weeks or months; usually
caused by organisms of low virulence,
such as Streptococcus viridans and
enterococci, which as limited ability
to infect other body tissues.
Prosthetic valve endocarditis (early and
late)
Infection of a prosthetic valve
Early prosthetic valve endocarditis occurs
within 60 days of valve implantation.
Late prosthetic valve endocarditis occurs
60 days or more after valve implantation.
Endocarditis related to intravenous
drug use
Endocarditis in intravenous drug
abusers commonly involves the
tricuspid valve. Staphylococcus
aureus is the most common causative
organism.
Clinical epidemiology
endocarditis is more common in
older people; mostly 50 years and
above

The male-to-female ratio is

approximately 2:1
Clinical manifestations
Influenza like symptoms:
Intermittent fever
Chills
Excessive sweating
Weakness
Anorexia
Weight loss
Pallor
Cough
Back and joint pain
Paleness
Osler’s nodes
Roth’s spots
Janeway’s lesion
Osler’s nodes- painful, red, raised
lesions found on the hands and feet
Roth’s spot - retinal hemorrhages with
white or pale centers composed of
coagulated fibrin
Janeway’s lesion – flat, small, non-tender red
spots on the palms of hands and soles of the feet.
Cardiac Manifestation
Heart murmur
Vegetation of the valve
Stenosis
Embolization
Diagnostics
Blood culture – most
confirmatory
Echocardiogram
Pathophysiology
 Pathophysiology
Endocardial
Damage Precipitating factor:
Predisposing factor: Stress, deposition
Age, sex, Development of thrombi
congenital(turbulent of immune
blood flow), complex
RHD(turbulent Nonbacterial thrombotic endocarditis
blood flow)

Genitourinary instrumentation Hemodialysis

Intravenous drug abuse

Dental procedure

Skin infection Cardiac

surgery
Gastrointestinal procedures Prosthetic heart valves

Pathogen entry into the blood stream

Failure of platelet inhibition Failure of mechanism of self-defense

causing platelet deposition (serum complement, antibodies)

Bacteremia

Colonization on endocardial surfaces

Adherence of more platelet Formation of more

fibrin
Growth of vegetation

INFECTIVE ENDOCARDITIS
Medical Management
Antibiotic therapy is usually
administered parenterally in a
continuous intravenous infusion for
2 to 6 weeks.
Penicillins (drug of choice) and
Gentamicin
Ampicillin
(Anti-infectives, Penicillins)
 Mechanism of Action
 Penicillins kill bacteria by disrupting their cell walls. Many bacterial cell walls contain a
substance called penicillin-binding protein that serves as a receptor for penicillin. Penicillin
weakens the cell wall and allows water to enter thus killing the organisms. Human cells do not
contain cells walls; therefore, the action of penicillins are specific to bacterial cells.
 Indication
 To prevent endocarditis in patients having dental, GI, GU procedures
 Adverse Reaction
 GI upset, nausea, vomiting, diarrhea; blood dyscrasias; urticaria, exfoliative dermatitis, rash;
fever, seizures; interstitial nephritis.
Potentially Fatal: Anaphylactic shock; pseudomembranous colitis; neuromuscular
hypersensitivity; electrolyte imbalance.
 Nsg. Responsibility
 Assess previous drug reaction to penicillin prior to administration
 Monitor for hyperkalemia and hypernatremia prior to and during therapy
 Tell patient to take entire quantity of drug exactly as prescribed, even after he feels better.
 Instruct patient to take oral form on an empty stomach 1 hour before or 2 hours after meals
 Inform patient to notify prescriber if rash, fever, or chills develop. A rash is the most common
allergic reaction, especially if allopurinol also is being taken.
 Advise patient to report discomfort at I.V. injection site.
Gentamicin
(Anti-infectives , Aminoglycosides)
Mechanism of Action
Interferes with bacterial protein synthesis and causing the synthesis of abnormal
proteins
Indication
Serious infection ; to prevent endocarditis before GI or GU procedure.
Adverse Reaction
Nephrotoxicity & neurotoxicity.
Nsg. Responsibility
Obtain specimen for culture and sensitivity tests before giving first dose
Watch for signs and symptoms of superinfection
Monitor for ototoxicity and nephrotoxicity
Encourage patient to drink plenty of fluids.
Instruct to complete the full course of treatment
Surgical Management
Surgical valve replacement
Mitral valve replacement
Aortic valve replacement

Types of prosthetic heart valve

Tissue (bioprosthetic) valves
Mechanical valves
Tissue ( Bioprosthetic )
valves
Mechanical valves
Nursing Management
Assessment
Gather data about the client’s hemodynamic
stability
Assess level of comfort, coping ability, support
for significant others and potential for self care.
Assess for signs and symptoms of organ damage
Assess for rapid pulse, easy fatigability, dyspnea,
restlessness, manifestations of heart failure and
embolic manifestation.
Assess for heart sounds
Diagnosis
Anxiety related to critical illness and prolonged
hospitalization
Acute pain related to generalized inflammatory
process and effects of embolic phenomena
Risk for activity intolerance related to alteration
in oxygen supply secondary to valvular
dysfunction
Hyperthermia related to infectious process
Nursing interventions:
Anxiety related to change in health status and threat of
death
Determine ability to manage own self-care
Observe behavior indicate of the level of anxiety present
Provide open and trusting relationshjp
Encourage expression of feelings
Provide information about normalcy of feelings and individual
grief reaction
Provide calm, peaceful setting, and privacy as appropriate.
The nurse provides the patient and family with emotional
support and facilitates coping strategies during prolonged
course of the infection and antibiotic treatment required.
Develop individual plan using client’s locus of control.
Acute pain related to generalized inflammatory process and effects of
embolic phenomena

Monitor vital signs

Monitor for signs and symptoms of systemic embolization,
pulmonary infarction and infiltrates.
Perform a comprehensive assessment of pain
Note clients attitude toward pain and use of specific pain medication
Provide quiet environment, calm activities
Encourage use of relaxation
Encourage adequate rest periods
Administer analgesic as prescribed
Administer antibiotic as prescribed for discomfort
Risk for activity intolerance related to the
presence of debilitating condition
Monitor the client’s physical response to
exercise , as activity increases
Promote conditioning program and support
inclusion in exercise
Patients and their families are instructed about
any activity restrictions, medications, and signs
and symptoms of infection.
Hyperthermia related to infectious process
Monitor vital signs, report temperature spikes
Administer antipyretics and/or sedatives as ordered.
Reduce physical activity
Increase oral fluid intake
Administer antibiotics as prescribed
Monitor blood cultures, WBC count.
Wash client with cool water
Cover client with light blankets to prevent shivering
Expected outcome
The client will identify and express feelings and will
able to formulate a plan dealing with individual
concerns.
The client will report pain is controlled and
demonstrate use of relaxation skills and diversional
activities.
The client will be able to participate in conditioning
program to enhance ability to perform and identify
alternative ways to maintain desired activity level.
The client will be able to maintain his normal vital
signs and report the absence of chills, diaphoresis
and headache.