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734 PA R T I V / Pathophysiology and Management of Heart Disease
in almost all patients with IE, the exceptions are those with CHF, evidence-based guidelines are controversial, and are substantially
renal failure, or disseminated intravascular coagulation. different that from past recommendations. 106
The association gave additional advice against body piercing
Medical Management for high-risk patients. Finally, the guidelines state that there
The cornerstone of treatment of IE is early recognition and elim- should be greater emphasis placed on improving access to dental
ination of the infecting organism. Timely surgical intervention care and oral health in patients at risk for IE. 97
and anticipation and treatment of complications are also key con-
cepts in the care of these patients. Antibiotics are usually bacteri- Nursing Management in
cidal (versus ineffective bacteriostatic agents). 103 Antibiotic ther- Infectious Endocarditis
apy is usually of a long duration. Published guidelines such as Nurses need to be knowledgeable about IE and its symptoms and
those from the American Heart Association and the European So- complications, the difficulty in making the diagnosis, and its far-
ciety of Cardiology are valuable resources on the specifics of man- reaching effects. A detailed history reveals risk factors, symptoms,
agement of IE. 93,104 prodromal illness, recent antibiotic therapy, and pre-existing renal
All patients with IE should have an initial evaluation of cardiac disease. This information aids in the medical diagnosis. Determi-
function. Careful history and physical examination is paramount. nation of body piercing or tattooing is necessary. A careful physi-
Echocardiography is used to evaluate ejection fraction and valvular cal examination may reveal the signs of IE, such as a murmur sec-
function. The most frequent complication of IE is congestive heart ondary to new-onset regurgitation. Patients that develop heart
failure, usually the result of valvular insufficiency. 92 Valvular de- failure during IE may be managed with diuretics, and afterload re-
struction is caused by the infection. Heart failure is the most com- duction with nitroglycerin and ACE inhibitors. 107 The nurse
mon cause of death in IE, and is an indication for surgery. 103 Con- manages the administration and monitoring of these medications.
tinuous close monitoring for symptoms of hemodynamic Once the patient is diagnosed, the plan of care should be dis-
decompensation and heart failure is important as the aortic valve can cussed with the patient and family. Management of the patient
sudden fail and pulmonary edema can abruptly develop. Left-sided with IE is complex and requires a team of experts on infectious dis-
IE involving the mitral valve frequently requires surgery as well. 103 eases, cardiology, cardiac surgery, respiratory therapy, nutritional
Valvular and perivalvular abscess, an extension of the infection, medicine, social services, and nursing. Nurses can be effective lead-
also requires surgical intervention. 92 Cardiac conduction prob- ers on this team, ensuring all the needs of the patient are met.
lems may develop secondary to the abscess or infection, making A lengthy hospitalization is likely, and patients need assistance
cardiac rhythm monitoring essential. 103 with coping with hospitalization and the illness. IE is potentially
Vegetation emboli can cause stroke, especially from the mitral life threatening, so information and emotional support are crucial.
valve. Mycotic aneurysms result from septic embolization to an If it is indicated, a referral for drug addiction treatment should be
arterial intraluminal space or the vasa vasorum of the cerebral ves- completed. Drug addiction and alcohol abuse frequently engen-
sels. These aneurysms can have few symptoms, or may cause ma- der strong negative feelings among nurses and physicians. The
jor neurological complications such as intracranial hemorrhage. 92 nurse must make care decisions in an ethical, professional manner,
Angiography is valuable in assessing mycotic aneurysms. Place- even when caring for patients who use IV drugs, do not follow
ment of coils or neurosurgery to ligate or clip the aneurysm may recommendations, or do not take the prescribed medications. 108
be indicated. 103 Renal dysfunction is another commonly seen In a recent study, it was found that consideration of drug abuse is-
complication, and occurs due to localized infarctions and immune sues was frequently not incorporated into the plan of care in the
complex glomerlunephritis. 92 intensive care unit. 109 Other issues in this population are an in-
creased tolerance to analgesia, potential drug withdrawal, and be-
Prevention havior and adherence problems, and poly-substance abuse. 110,111
There has not been a placebo-controlled, multicenter, randomized, The nurse manages oxygen therapy, ventilator care, and va-
double-blinded study to evaluate the efficacy of IE prophylaxis in soactive medications and monitors fluid balance and ECGs. The
patients who undergo potentially risky dental, gastrointestinal, or nurse often obtains the blood for laboratory tests and blood cul-
genitourinary tract procedures. 97 There is no evidence about tures, and then interprets the results. The nurse is responsible for
whether prophylaxis is effective or not against IE in patients under- proper administration of antibiotics and monitoring for thera-
going dental procedures. 105 The American Heart Association has peutic levels and side effects. The nurse also manages the IV lines
published new evidence-based guidelines for antimicrobial prophy- for the long course of antibiotics. If a pulmonary artery catheter is
97
laxis for IE. The guidelines have radically changed regarding the in place, accurate measurements and interpretations guide med-
recommendations for antibiotic prophylaxis in dental and other ical care. Meticulous handwashing, infection control, and early re-
procedures. IE prophylaxis is now recommended only for those pa- moval of invasive lines help to prevent nosocomial IE. The Cen-
tients with underlying cardiac conditions associated with highest ter for Disease Control and the American Association of
risk of adverse outcome from IE. These conditions include pros- Critical-Care Nurses have both published guidelines to prevent
thetic cardiac valve, previous IE, specific forms of congenital heart catheter-related infections. 112,113
disease, and cardiac transplantation with cardiac valvulopathy. 97 Careful assessment facilitates early detection of complications.
This prophylaxis for these select patients is recommended for all The nurse must know the symptoms of complications to facilitate
dental procedures that involve manipulation of gingival tissue or the rapid intervention. Preoperative teaching is necessary to prepare
periapical region of teeth or perforation of oral mucosa. 97 Prophy- the patient undergoing surgery. During surgery, it is desirable to
laxis is also “reasonable” for procedures on respiratory tract or in- keep the family informed of the progress. After surgery, pulmonary
fected skin, skin structures, or musculoskeletal tissue, for the same hygiene and close hemodynamic monitoring are crucial. Idemoto
high-risk patients. Antibiotic prophylaxis is no longer recom- and Kresevic 114 recently reviewed evidence-based practice, includ-
mended for gastrointestinal or genitourinal procedures. These new ing pain management, infections, and patient education, and