Infective endocarditis (IE) is an inflammatory process that typically affects a deformed or previously damaged valve, which is usually the focus of the infection. Typically, endocarditis occurs when an invading organism enters the bloodstream and attaches to the leaflets of the valves or the endocardium. Bacteria multiply and sometimes form a projection of tissue that includes bacteria, fibrin, red blood cells, and white blood cells on the valves of the heart. This clump of material, called vegetation, may eventually cover the entire valve surface, leading to ulceration and tissue necrosis. Vegetation may even extend to the chordae tendineae, causing them to rupture and the valve to become incompetent. Most commonly, the mitral or aortic valve is involved. The tricuspid valve is mainly involved in intravenous drug abusers but is otherwise rarely infected. Infections of the pulmonary valve are rare. Infective endocarditis can occur as an acute or a subacute condition. Generally, acute infective endocarditis is a rapidly progressing infection, whereas subacute infective endocarditis progresses more slowly. Acute endocarditis usually occurs on a normal heart valve and is rapidly destructive and fatal in 6 weeks if it is left untreated. Subacute endocarditis usually occurs in a heart already damaged by congenital or acquired heart disease, on damaged valves, and takes up to a year to cause death if it is left untreated.
Since the 1960s the most common causes of infective endocarditis are nosocomial infections from intravenous (IV) catheters, IV drug abuse, and prosthetic valve endocarditis. The etiology of acute infective endocarditis is predominantly bacterial. The two most common causes of bacterial endocarditis are staphylococcal and streptococcal infections, and Staphyloccus aureus is the primary pathogen of endocarditis. Subacute infective endocarditis occurs in people with acquired cardiac lesions. Possible ports of entry for the infecting organism include lesions or abscesses of the skin and genitourinary (GU) or gastrointestinal (GI) infections. Surgical or invasive procedures such as tooth extraction, tonsillectomy, bronchoscopy, endoscopy, cystoscopy, and prosthetic valve replacement also place the patient at risk.
Nursing care plan assessment and physical examination
A common finding of patients with preexisting cardiac abnormalities is a recent history (3 to 6 months) of dental procedures. Question the patient about the type of procedure performed and if bleeding of the gums occurred. Patients with infective endocarditis may have complaints of continuous fever (103°F to 104°F) in acute infective endocarditis, whereas in the subacute form, temperatures are generally in the range of 99°F to 102°F. Other symptoms include chills (limited to acute IE), fatigue, malaise, joint pain, weight loss, anorexia, and night sweats.
The patient appears acutely ill. Observe for signs of temperature elevation, such as warm skin, dry mucous membranes, and alternating chills and diaphoresis. Inspect the conjunctivae, upper extremities, and mucous membranes of the mouth for the presence of petechiae, splinter hemorrhages in nail beds, Osler nodes (painful red nodes on pads of fingers and toes), and joint tenderness. Palpate the abdomen for splenomegaly, which is present in approximately 30% of patients with infective endocarditis. Auscultate the heart for the presence of tachycardia and murmurs. Approximately 95% of those with subacute infective endocarditis have a heart murmur (most commonly mitral and aortic regurgitation murmurs), which is typically absent in patients with acute infective endocarditis.
Lengthy interventions such as prophylactic antibiotic treatment are generally required. Therefore, determine the patient’s ability to understand the disease, as well as to comply with prescribed long-term treatments.
Nursing care plan primary nursing diagnosis: Infection related to the causative organism (streptococci, pneumococci, staphylococci, gramnegative bacilli, fungi).
Nursing care plan intervention and treatment plan
For persons at high risk for contracting infective endocarditis, most physicians prescribe antibiotic therapy to prevent episodes of bacteremia before, during, and after invasive procedures. Procedures that are particularly associated with endocarditis are manipulation of the teeth and gums or GU and GI systems, and surgical procedures or biopsies that involve respiratory mucosa.
If the patient has developed endocarditis as a result of IV drug abuse, an addiction consultation is essential, with a possible referral to an appropriate treatment program. Surgical replacement of the infected valve is needed in those patients who have an infecting microorganism that does not respond to available antibiotic therapy and for patients who have developed infectious
endocarditis in a prosthetic heart valve.
During the acute phase of the disease, provide adequate rest by assisting the patient with daily hygiene. Provide a bedside commode to reduce the physiological stress that occurs with the use of a bedpan. Space all nursing care activities and diagnostic tests to provide the patient with adequate rest. During the first few days of hospital admission, encourage the family to limit visitation.
Emphasize patient education. Individualize a standardized plan of care, and adapt it to meet the patient’s needs. Areas for discussion include the cause of the disease and its course, medication regimens, technique for administering antibiotics intravenously, and practices that help avoid and identify future infections.
If the patient is to continue parenteral antibiotic therapy at home, make sure that, before he or she is discharged from the hospital, the patient has all the appropriate equipment and supplies that will be needed. Make a referral to a home health nurse as needed, and provide the patient and family with a list of information that describes when to notify the primary healthcare
provider about complications.
Nursing care plan discharge and home health care guidelines
To prevent infective endocarditis, provide patients in the high-risk category with the needed information for early detection and prevention of the disease. Instruct recovering patients to inform their healthcare providers, including dentists, of their endocarditis history, since they may need future prophylactic antibiotic therapy to prevent subsequent episodes.
Be sure the patient understands all medications, including the dosage, route, action, and adverse effects. Encourage the patient to seek prompt medical attention if side effects occur. Make sure the patient or significant others can demonstrate the appropriate method of antibiotic administration. Instruct the patient on proper IVs catheter site care, as well as the signs of infiltration. Encourage good oral hygiene, and advise the patient to use a soft toothbrush and to brush at least twice a day. Teach patients to avoid irrigation devices and flossing. Teach the patient to monitor and record the temperature daily at the same time. Encourage the patient to take antipyretics according to physician orders. Instruct the patient to report signs of heart failure and embolization, as well as continued fever, chills, fatigue, malaise, or weight loss.