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

Answer 1

1. The greatest risk for J.F. is renal failure during the process of rehydration because in renal failure acute care has to be taken while providing hydration as any increase in the daily volume of fluids in the form of parental and oral will cause severe renal complications .

To monitor this :-

- assess the vital signs of the patient

- assess the wieght of the patient daily at same time

- assess the input and output of the patient

- assess for any edema , breathing difficulty high blood pressure etc as these are the early signs of renal complications .