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Chapter 30 Coordinating Care for Patients With Cardiac Disorders
Evaluating Care Outcomes The primary goal is resolution of the underlying cause and reducing the symptoms of heart failure and risks of car- diomyopathy and sudden cardiac death. A well-managed patient is free of signs of infection and heart failure and is able to tolerate normal activity levels.
causative agent is needed when possible. Immunosuppres- sants such as corticosteroids, azathioprine, cyclosporine, and methotrexate and immunotherapies such as immuno- globulin G (IgG) may be used but have limited supporting evidence. Complications Myocarditis is the most frequent cause of dilated cardio- myopathy. Heart failure, cardiogenic shock, and dysrhyth- mias, including sudden cardiac death, especially in young persons, are also complications. Nursing Management Assessment and Analysis Clinical manifestations of myocarditis, such as SOB, chest pain, fatigue, and dysrhythmias typical of the manifesta- tions of heart failure, are due to the weakened or damaged heart muscle. Nursing Diagnoses/Problem List z Risk for decreased cardiac output related to myocar- dial dysfunction z Pain z Dysrhythmias Nursing Interventions ■ Assessments z Vital signs Hypotension, hypertension, tachycardia, tachypnea, and hypoxia are signs of heart failure. Fever is indicative of infection. z Cardiac rhythm Dysrhythmias are a common and dangerous clinical manifes- tation and must be identified and treated promptly. z Assess for crackles, edema, jugular vein distention (JVD), weight gain, and decreased urine output. These are evidence of the weakened heart muscle seen with heart failure. ■ Actions z Administer antivirals, antimicrobials, immunosuppres- sives, and immunoglobulins as ordered. Medications are administered depending on the cause of myocarditis. z Administer heart failure medications as needed. Heart failure is a common manifestation and must be treated to optimize cardiac output and tissue perfusion. z Provide emotional support. The diagnosis of myocarditis can cause fear and anxiety. ■ Teaching z Complete the full medication treatment regimen. Patients should continue to take medications as directed even if feeling better to ensure an effective/positive result. z Avoid strenuous activities. Athletes should not par- ticipate in competitive sports while inflammation is present and need to be reevaluated in no less than 3 to 6 months before resuming sport. Activity restrictions may reduce the risk of sudden cardiac death.
PERICARDITIS Epidemiology
Pericarditis , inflammation of the pericardium, is diag- nosed in about 0.2% of cardiovascular-related admissions and 5% of emergency department patients with chest pain not related to ischemia. About 80% of cases are idio- pathic (unknown etiology) or are presumed to occur after a viral infection. Acute pericarditis is common following MI, occurring in about 15% to 20% of post-MI patients. The true prevalence of pericarditis is difficult to deter- mine because persons with mild cases (subclinical) do not seek treatment. Some studies show that pericarditis occurs more in male individuals and young and middle-aged persons. Recurrence is common, with 20% to 30% of persons having an additional episode. Pericarditis can be categorized as infectious (viral, bacterial, fungal, or para- sitic), noninfectious (autoimmune, neoplastic, metabolic, trauma, drug or radiation related), and idiopathic. Peri- carditis can also be described as acute, chronic, or recur- rent. The prognosis is generally good, with an in-hospital mortality rate of 1.1%. Pathophysiology The heart is surrounded by the two-layered pericardium, which protects the heart, reduces friction with surrounding structures, and helps to determine chamber size and pres- sure. The tough, fibrous outer wall is the parietal pericar- dium; the inner is the visceral pericardium, or epicardium. The space between contains approximately 20 to 60 mL of pericardial fluid. This fluid acts as a lubricant to prevent friction between the two layers. When the pericardium becomes inflamed, it is termed pericarditis (Fig. 30.5). Clinical Manifestations The most common clinical manifestation of pericarditis is pleuritic chest pain. This occurs in 85% to 90% of cases and can be differentiated from MI chest pain because it tends to be relieved by sitting up and leaning forward and worsens with inspiration or coughing. Friction rubs , scratchy sounds that occur with each heartbeat, may be auscultated in 30% of cases. Box 30.1 describes how to assess for a friction rub. Other clinical manifestations include the following: z New or worsening pericardial effusion (60%) z ECG changes: diffuse ST-segment elevations or PR depression (60%) z Low-grade fever
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