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Unit VI Promoting Health in Patients With Circulatory or Perfusion Disorders
MYOCARDITIS Epidemiology
z Provide social support during prolonged hospitalization. Social isolation due to hospitalization may contribute to depression, anxiety, and anger. z Refer patient to addiction counseling services if sub- stance use has caused the disease. Stopping recreational IV drug use may help limit the reoc- currence of IE and lead to a better quality of life. ■ Teaching z Maintain oral health through regular professional den- tal care, regular tooth brushing with manual powered or ultrasonic toothbrushes, and using dental floss. Poor dental hygiene may increase the recurrence of IE due to bacterial seeding from the mouth. z Inform healthcare provider about IE history before any dental or invasive procedure. Prophylactic antibiotics may be prescribed to decrease the risk of IE in patients with a history of IE or other major risks such as immunosuppression or transplant. z Completion of prolonged antibiotic regimen Completing the full course of antibiotics is critical to eradicat- ing the infection and preventing recurrence and complications. Evaluating Care Outcomes Goals of care for patients with IE are control of the infec- tious process through antibiotic administration and min- imizing complications. Patient education should focus on risk control, early detection, and prevention. A well- managed patient is free from infection and understands the signs of IE and when the healthcare provider should be contacted. (See Geriatric/Gerontological Considerations: Infective Endocarditis.) Infective Endocarditis Older people are at higher risk for infective endocarditis (IE) due to comorbidities, increasing numbers of invasive procedures, and greater use of implanted cardiac devices such as pacemakers and artificial valves. The required prolonged hospitalization and treatment can contrib- ute to rapid functional decline. Evaluation for early dis- charge and home infusion therapy should be considered to maintain functional capabilities. An increase in fat mass, reduced renal function, and lower albumin levels require careful antimicrobial adjustments to optimize outcomes and reduce adverse effects. Serum medication levels, renal function, and culture reports should be rou- tinely monitored. Confusion and agitation can challenge the maintenance of continuous IV access. Alternate med- ication routes may need to be considered. Aging is not a contraindication for surgery, but comorbidities and clinical status should be evaluated. Geriatric/Gerontological Considerations
Myocarditis is an inflammatory disease of the myocar- dium that is most commonly triggered by viral infection, autoimmune diseases, or exposure to toxic substances. Men and young persons are most affected. It is a leading cause of dilated cardiomyopathy (discussed in Chapter 32) and a leading cause of sudden cardiac death in young persons. It is estimated that 22 in 100,000 patients have some form of myocarditis. About 1% to 5% of persons with viral ill- nesses may exhibit a form of myocarditis, including those with COVID-19. Pathophysiology Viruses are the infectious agent in most cases of myocar- ditis. Coxsackie virus, adenovirus, parvovirus, and herpes- virus are frequent pathogens. Bacteria, parasites, and fungi can be the etiology. Autoimmune hypersensitivity reac- tions and toxin exposure can also cause myocarditis. Some toxins noted to cause myocarditis are clozapine, cocaine, and anticancer agents. Viral infection can directly damage the myocardium, and the patient’s own immune responses can cause secondary damage. Myocardial inflammation and injury result, affecting the entire myocardium or local- ized areas of tissue. Clinical Manifestations Myocarditis can be classified as acute, subacute, or chronic. Symptoms vary widely from asymptomatic and mild cases to acute heart failure and cardiogenic shock. Common pre- senting symptoms are chest pain, dysrhythmias, dyspnea, palpitations, syncope, fatigue, and heart failure. In the case of viral illness, sequelae such as fever, fatigue, loss of appe- tite, and myalgia may also be experienced. Patient history, C-reactive protein, erythrocyte sedimen- tation rate, troponin, brain natriuretic peptide (BNP) or pro-BNP, ECG, echocardiography, and CMR imaging are used in the diagnostic process. Myocardial biopsy, also called endomyocardial biopsy (EMB), is the definitive test but is reserved for more acute cases. Treatment Some cases of myocarditis resolve within days, whereas oth- ers progress to heart failure and acute dilated cardiomyopa- thy that require significant intervention, which may include heart transplantation, implanted cardiac defibrillators, or mechanical circulatory support (see Chapter 32). Medical treatment focuses on the management of heart failure, dys- rhythmias, and dilated cardiomyopathy. Withdrawal of the Interprofessional Management Medical Management Diagnosis Diagnostic Tests
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