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Chapter 30 Coordinating Care for Patients With Cardiac Disorders
right-sided versus left-sided IE, native versus prosthetic valve involvement, patient comorbidity, and other factors. Infectious disease specialists are often consulted. Penicillin G, ceftriaxone, vancomycin, ampicillin, daptomycin, and gentamicin may be considered in various combinations for the treatment of IE. Supportive treatment for the common complications of IE, especially HF, is also indicated to optimize cardiac output and tissue perfusion.
typically seen in the hands and feet, are due to infection. Sepsis can occur in conjunction with IE. Septic emboli can alter CNS and systemic perfusion. The damage to the heart valves can cause a new murmur and heart failure. Nursing Diagnoses/Problem List z Infection related to an invading organism secondary to IE z Ineffective tissue perfusion related to emboli z Decreased cardiac output related to valve dysfunc- tion, altered rhythm, and/or altered stroke volume z Fever z Fatigue Nursing Interventions ■ Assessments z Vital signs Fever is indicative of ongoing acute infection. Hypotension, tachycardia, tachypnea, and low SpO 2 can be signs of sepsis or heart failure. z Auscultate breath sounds. Crackles may be a sign of heart failure related to valve dysfunction. z Auscultate heart sounds. A new or worsening murmur may occur due to valve damage. z Assess neurological function. Neurological changes or deficits in pupils, grips, foot pushes, facial droop, and speech may be signs of CNS embolization. z Assess extremities. Cyanosis or pallor, delayed capillary refill, and decreased peripheral pulses may indicate peripheral embolization. Edema could be a sign of heart failure related to valve dysfunction. z Skin assessment Osler’s nodes, Janeway lesions, and splinter hemorrhages are indicative of IE. z Monitor diagnostic test results. Repeated culture reports are used to evaluate the effective treatment of IE. White blood cell (WBC) counts can indicate responsiveness to infection. Echocardiograms can evaluate the size of vegetation and valve function and can be used to predict the risk of complications. z History of drug use, invasive procedures, implanted vascular or cardiac devices, or valve replacement surgery Common risk factors for IE ■ Actions z Administer antibiotics as prescribed. Treatment for IE is long-term IV antibiotic treatment. z Maintain IV access for antibiotic administrations. Intravenous access is essential for antibiotic administration. Long-term venous access, such as a peripherally inserted central catheter (PICC), may be considered. z Administer heart failure medications as needed. Heart failure treatment optimizes cardiac output and tissue perfusion.
Safety Alert
Routine antibiotic prophylaxis is no longer recommended for patients who
have mechanical or bioprosthetic valves for the pre- vention of IE because this contributes to antimicrobial resistance and has not been proven to reduce infection risk. Prophylactic antibiotics are recommended before genitourinary procedures or in high-risk patients such as those with active infections or who may be immunosup- pressed. Meticulous oral hygiene should be encouraged for patients at highest risk, such as those with a history of IE, intracardiac prosthetic material such as valves and defect closure devices, cardiac transplant, and congenital heart disease. Surgical Management The surgical treatment options for IE include valve repair or replacement. Surgery can remove infected tissue and reduce mortality and complications, but it also has sig- nificant risk. Recent evidence suggests that early surgery within the first 7 days has reduced mortality, embolisms, and recurrence when compared to delayed surgery. Complications Embolic events are the major complication of IE and occur in 22% to 50% of cases. Embolization occurs when frag- ments of vegetation break free from the valve and travel to other parts of the body through the bloodstream. Embolic events are often a complication of left-sided IE and are rarely seen in right-sided IE. The emboli can travel ran- domly to any organ or tissue, resulting in obstructed blood flow and potential spreading of infection. Emboli from left-sided IE typically travel to the central nervous system (CNS; 65%) but can also affect the kidneys, spleen, bowel, and extremities. Emboli traveling to the CNS cause tran- sient ischemic attacks or strokes. Right-sided IE is associ- ated with pulmonary emboli. Heart failure and dysrhythmias can also occur due to valvular dysfunction and abscesses in the conduction sys- tem. Strokes, heart failure, and dysrhythmias can be a part of the presenting symptoms of IE because they compel
patients to seek treatment. Nursing Management Assessment and Analysis
The clinical manifestations of IE, such as positive blood cultures combined with fever, fatigue, and the lesions
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