Question

Group 2 Scenario: Valvular Heart Disease/Infective Endocarditis

J.F. is a 50-year-old married homemaker that has suffered from recurrent infective endocarditis. The most recent episodes were a Staphylococcus aureus infection of the mitral valve 16 months ago and a Streptococcus viridans infection of the aortic valve 1 month ago. During this latter hospitalization, an echocardiogram showed moderate aortic stenosis, moderate aortic insufficiency, chronic valvular vegetations, and moderate left atrial enlargement. Two years ago, J.F. received an 18-month course of parenteral nutrition for malnutrition caused by idiopathic, relentless nausea and vomiting (N/V). She has also had coronary artery disease for several years and, 2 years ago, suffered an acute anterior wall myocardial infarction (MI). In addition, she has a history of chronic joint pain. Now, after being home for only a week, J.F. has been readmitted to your floor with endocarditis, N/V, and renal failure. Since yesterday, she has been vomiting and retching constantly; she also has had chills, fever, fatigue, joint pain, and headache. As you go through the admission process with her, you note that she wears glasses and has a dental bridge. Intravenous access is obtained with a double lumen peripherally inserted central catheter (PICC) line, and other orders are written below. Your assessment is also documented.

Admission Orders

STAT blood cultures (aerobic and anaerobic) × 2

STAT electrolytes & CBC

Begin parenteral nutrition (PN) at 85 mL/hr

Penicillin 2 million units IV piggyback q4h

Furosemide (Lasix) 80 mg/day PO

Amlodipine (Norvasc) 5 mg/day PO

Potassium chloride (K-Dur) 40 mEq/day PO

Metoprolol (Lopressor) 25 mg PO bid

Prochlorperazine (Compazine) 5 mg IV push prn for N/V

Transesophageal echocardiogram ASAP

Admission Assessment

Blood pressure 152/48 (supine) and 100/40 (sitting)

Pulse rate 116 beats/min

Respiratory rate 22 breaths/min

Temperature 100.2° F (37.9° C)

Oriented × 3 but drowsy

Grade II/VI systolic murmur and a grade III/VI diastolic murmur noted on auscultation

Lungs clear bilaterally

Abdomen soft with slight left upper quadrant (LUQ) tenderness

Multiple petechiae on skin of arms, legs, and chest; and splinter hemorrhages under the fingernails

Hematuria noted in voided urine

Scenario Questions:

1. Explain the diagnostic criteria for infectious endocarditis.

2. What is the significance of the orthostatic hypotension and the tachycardia?

3. What is the significance of the abdominal tenderness, hematuria, and petechiae?

4. As you monitor J.F. throughout the day, what other signs and symptoms (S/S) of embolization will you watch for?

5. What is the greatest risk for J.F. during the process of rehydration, and what would you monitor to detect its development?

PLEASE ANSWER ALL QUESTIONS

Answer 1

1, Diagnostic criteria of infective endocarditis:
- ECHO cardiogram- regurgitant jets on the path, prosthetic valve regurgitation
-Positive blood culture with the organism enterococcus
2, Orthostatic hypotension: when the blood vessels are narrowed due to emboli or thrombi or dehydration there will be low blood volume cause decrease cardiac output. there will be vasoconstriction and diastolic blood pressure will be higher when the person standing up comparing to lying position.
Tachycardia: this is due to infective organisms destroy the valve and make heart failure. so there will be rapid heartbeat due to a preexisting heart murmur.
3, Abdominal tenderness: There will be the rupture of mycotic aneurysm and embolism in liver, spleen, kidney, and intestine there will be abdominal tenderness and pain.
Hematuria: There will be kidney involvement in case of infective endocarditis make glomerular lesions, interstitial lesions. so there is hematuria when in case of infective endocarditis.
Petechiae: It is embolic or vasculitic small red or purple spots (due to bleeding into the skin )composed of blood(petechiae)cover the skin of the upper trunk.
4, We have to monitor for fever, chilling, dyspnea and cough. when emboli travel into the lungs patient there may be construction in the tiny blood vessels make interfere with blood supply to the lungs. so due to the insuffiecient o2 supply, there will be cough and dyspnea.