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732 PA R T I V / Pathophysiology and Management of Heart Disease
Pathophysiology The nurse is also in the best position to monitor the patient for
Myocarditis is the result of both myocardial infections and au- worsening of symptoms and for response to medical treatments.
toimmunity that results in active inflammatory destruction of my- Evaluation of heart sounds, lung sounds, vital signs, and periph-
ocytes. Inflammation of the myocardium affects its function, and eral perfusion, as well as interpretation of laboratory results are
heart failure can result. key nursing responsibilities. Signs of congestion and decreased
CO must be detected and reported early to ensure the most effec-
Assessment Findings tive treatment. This assessment involves accurate hemodynamic
The clinical appearance of myocarditis is varied; the features range measurements and assessments, which guide therapy. The nurse
from systemic symptoms of fever, myalgias, palpitations, and dys- titrates medications and fluids to improve cardiac function, mon-
pnea, to arrhythmia, syncope, sudden death, acute right or left itoring the effects and side effects. Patients with poor perfusion, as
ventricular failure, cardiogenic shock, or DCM. 44,81 Myocarditis is seen in cardiac disease, are at increased risk for skin breakdown.
may resolve, or result in relapse, DCM requiring heart transplan- The nurse is responsible for assessment and prevention of this
tation, or death. complication. The nurse optimizes the patient’s oxygenation
Endomyocardial biopsy has been the gold standard for the di- through position changes, pulmonary toilet, monitoring and in-
agnosis of myocarditis, but this technique is fraught with difficul- terpretation of arterial blood gases, and oxygen administration or
ties. 80 Other diagnostic criteria have been proposed that incorpo- ventilator management. Infection control is also critical. Because
rate molecular techniques applied to the examination of the lethal arrhythmias can occur, emergency equipment should be
myocardium. 81 Contrast-enhanced MRI may become a valuable readily available.
diagnostic tool. 81,83 If a ventricular assist device is used in the course of treatment
ECG, echocardiography, and measurement of serum troponin for cardiomyopathy or myocarditis, the nurse monitors the effects
are additional required tests when myocarditis is suspected. 81 In of this therapy. When the patient is to have surgery, preoperative
myocarditis, the ECG can show low-voltage QRS complexes, ST education can allay many fears if the patient and family have an
segment elevation, or heart block. Nonsustained atrial or ventric- opportunity to ask questions and are prepared for the postopera-
ular arrhythmias are common. An S 4 and systolic ejection mur- tive course. Teaching needs to be individualized, with determina-
murs may be heard on auscultation. tion of the best method for the patient and family. After surgery,
the nurse is responsible for postoperative hemodynamic monitor-
Medical Management ing, pain control, and respiratory care. Recognition of symptoms
Supportive care is the first line of treatment in myocarditis. Man- of excess use of drugs or alcohol or withdrawal from these sub-
agement includes treatment of heart failure, with the goal of im- stances is necessary. 90 Complications need to be prevented or de-
proving symptoms and hemodynamic status. 81 Many researchers tected immediately. Patients with HCM who have undergone sep-
have evaluated the use of immunosuppression in myocarditis, but tal ablation must be monitored closely for conduction defects.
the efficacy of routine use has not been established. 81,84,85 Intra- The temporary pacemaker is employed as needed. Patients are also
venous (IV) immunoglobulin has also been given to treat viral monitored for enzymes and ECG changes.
myocarditis, but evidence does not support its use. 86 Emotional support and education are key components of
nursing care of patients with cardiomyopathy and myocarditis.
Nursing Management in In a familial disease, a patient may be grieving for a family
Cardiomyopathies and Myocarditis member while coping with his or her own new diagnosis. They
may need assistance coping with this stressful crisis. Emotional
The nurse can help in identifying the cause of cardiomyopathy needs are particularly important in cardiomyopathy because of
or myocarditis through a careful and detailed nursing history. its wide-ranging impact on the lives of both the patient and
Advances in understanding of causes of cardiomyopathies make family. Individual counseling, support groups, or both can be
genetic counseling and screening strategies even more critical. 87 effective.
Advanced practice nurses are in a unique position to detect, ed- The patient and his or her family must be educated about car-
ucate, and treat familial diseases. As expert clinicians, they assess diomyopathy and myocarditis, its treatments and possible com-
disorders from a holistic perspective using comprehensive phys- plications. To make the diagnosis, the patient undergoes many
ical examination and detailed history, including assessment of tests, such as echocardiography and cardiac catheterization. Each
family history, psychosocial influences, and functional abili- test that is done should be explained to the patient. The plan of
ties. 66 The nurse must be attentive to family history so identifi- care needs to be discussed and agreed on. If anticoagulants are
cation of a familial disease can be made and other family mem- used, side effects and their symptoms, as well as dietary interac-
bers might be screened. Young family members should be tions, need to be explained. Other dietary considerations must be
screened prior to participation in sports. 63 Genetic testing may addressed, such as fluid and salt restriction, and the nurse as a
identify those likely to develop the disease, although this testing leader of the multidisciplinary team can ensure that the patient’s
is not a readily available option in most laboratories. Guidelines multiple needs are met.
have been published recently for genetic testing in families Research has shown the addition of a 1-hour, nurse educator-
where sudden cardiac death has occurred. 88 The nurse must delivered teaching session at the time of hospital discharge re-
probe to find out the concerns of the patient and the family, and sulted in improved clinical outcomes, increased self-care measure
try to address each of them. adherence, and reduced cost of care in patients with systolic heart
It is crucial that the patient with a disease such as cardiomy- failure. 91 As a leader of the health care team, the nurse can alert
opathy at high risk for sudden death wear a medical alert bracelet social workers, chaplains, mental health professionals, dieticians
in case of emergency and that family members be trained in basic and others to the needs of the patient and coordinate the multi-
life support techniques. 89 disciplinary care.