Endocarditis Nursing Implications

Endocarditis is inflammation of the endocardium, which is the innermost layer of the heart and also includes the valves. It is often a result of infection, but can also be a complication of rheumatic fever and systemic lupus erythematosus. When it’s caused by an infection, you’ll see it referred to as “infective endocarditis” or IE. Infective endocarditis is the most common form and is very difficult to treat, with a mortality rate of just over 35%. It is often due to staphylococcus aureus infection related to IV drug use or infection related to prosthetic valves.

Infective endocarditis occurs when bacteria in the bloodstream attach to platelet-fibrin adhesions that have developed at damaged areas of the endocardium or valves. The result is the formation of vegetations that further damage heart function and can break off to cause embolism elsewhere in the body. The infection can further infiltrate the heart resulting in heart failure, dysrhythmias, heart block and sepsis.

Let’s go through the endocarditis nursing implications using the Straight A Nursing LATTE method.

L: How does the patient LOOK? What signs/symptoms are present?

• Most patients with endocarditis will have a fever, but note that in older patients or those who are immunocompromised, they could actually have a lower-than-normal body temperature. With fever also come associated symptoms such as chills, fatigue, malaise, headache, bone and muscle aches.
• Splinter hemorrhages are black streaks on the nail beds caused by vessel damage related to inflammation and/or tiny clots in the small capillaries.
• Petechiae may be present in the sclera, lips/mouth, on the feet and in elbow/knee creases. 
• Janeway lesions are red, nontender lesions on the palms and soles. 
• Osler’s nodes are pea-sized subcutaneous nodules in the fingertips and toes.
• Roth spots are retinal hemorrhages that have a pale center.
• Most patients will have a systolic murmur. 
• Signs of heart failure will also likely be present. 
• Stroke symptoms may be present since embolic events occur in over half of patients with IE. Though the brain is the most commonly affected organ, emboli can lodge anywhere in the body.

A: How do you ASSESS the patient with endocarditis?

• It’s important to obtain a thorough health history to identify risk factors and previous occurrence of IE. Risk factors for IE are IV drug use, prosthetic valves, any valve or congenital heart disease, immunosuppressant therapy, recent surgery or other invasive procedures.
• Get a full set of vital signs, knowing that patients with endocarditis can develop sepsis (with severe sepsis you’d expect to see fever, tachypnea, tachycardia and hypotension). Pulmonary edema secondary to heart failure will result in low oxygen saturation levels and possible tachypnea.
• 12-lead EKG to determine if any dysrhythmias are present.
• Listen to the heart (systolic murmurs are common). 
• Assess lung sounds. Heart failure can lead to pulmonary edema which you’ll hear as crackles or coarse lung sounds. 
• Daily weights assess for sudden weight gain secondary to fluid retention and heart failure
• Assess the patient for bone and muscle pain.

T: What TESTS will be ordered? 

• Echocardiogram (ECHO) will show vegetations, valve disruption and ineffective ventricular action. If heart failure is present, an ECHO will calculate the “ejection fraction” which is reduced in individuals with heart failure. A normal ejection fraction is typically between 55 and 70%.
• Blood cultures will show the presence of systemic infection.
• ESR and C-reactive protein can be increased in inflammatory states.

As the MD works the patient up for a diagnosis of endocarditis, he or she will likely use The Duke Criteria. For IE to be present, the patient must meet either: 

• Two major criteria
• One major criteria + three minor criteria, or
• Five minor criteria

The major criteria are: 

• Positive blood cultures from at least two separate cultures drawn 12 hours apart
• Evidence of IE on echocardiogram (vegetation, abscesses, or valve perforation)
• New regurgitant murmur

The minor criteria are: 

• Predisposing heart condition such as mitral valve prolapse, rheumatic or congenital heart disease; or IV drug abuse
• Temperature greater than 100.4°F (38°C)
• Presence of embolic disease or hemorrhage
• Presence of immunological phenomena, such as glomerulonephritis, Osler’s nodes, Roth spots, or rheumatoid factor
• Positive blood culture that does not meet the major criteria
• Positive echocardiogram that does not meet the major criteria
• Chest x-ray showing cardiomegaly and/or ECG showing first or second-degree AV block. 

T: What TREATMENTS will be provided?

The treatment for endocarditis will be dependent on what is causing the infection. Antibiotics are used for bacterial infection and are typically needed for several weeks. If a valve is infected, the valve will be replaced as early as possible with follow-up antibiotics or antifungals as needed. Some individuals who are at high risk for endocarditis may receive prophylactic antibiotics when undergoing surgery or dental procedures. These high risk individuals are those with prosthetic valves, a history of IE, individuals with congenital heart defects, or heart transplant recipients.

E: How do you EDUCATE the patient/family?

• Teaching those patients who are at high risk about avoiding people with infections, getting adequate rest, and informing their dentist or health care practitioner before any invasive procedures. 
• If a patient is an IV drug user, educate them on the importance of quitting and offer referrals for drug rehabilitation. A social work consult may be helpful.
• Since these patients are on antibiotics for several weeks at a time, it will be important to teach the importance of medication adherence and any expected side effects.
• Educate patients to notify their health care provider if a fever persists after starting antibiotics. This may indicate the antibiotic is ineffective.
• Teach the warning signs of possible complications from embolism, such as sudden dyspnea, mental status changes, signs of stroke, or chest pain.

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References

Capriotti, T., & Frizzell, J. P. (2016). Pathophysiology: Introductory concepts and clinical perspectives. F.A. Davis Company.

Lewis’s medical-surgical nursing: Assessment and management of clinical problems. (2019). Elsevier health sciences.

Medline Plus. (n.d.). Splinter hemorrhages: MedlinePlus Medical Encyclopedia. Retrieved December 1, 2021, from https://medlineplus.gov/ency/article/003283.htm