NURS20024: Applied Nursing - Managing Infective Endocarditis Patient

This assignment comprehensively addresses the management of a patient with infective endocarditis. It identifies the etiology, pathophysiology, and risk factors associated with the condition, detailing various types such as native valve, prosthetic valve, IV drug-related, healthcare-associated, and fundal endocarditis. Diagnostic tests, including echocardiography, renal and liver function tests, and blood cultures, are described along with their expected results. The assignment also explores complications like heart failure and myocardial damage, and formulates appropriate nursing diagnoses such as acute pain, activity intolerance, and risk for infective tissue perfusion, along with corresponding nursing goals. Furthermore, it analyzes a rhythm strip, discusses antiarrhythmic medications like Digoxin, their mechanisms, contraindications, and side effects, and considers alternative treatments like electrical cardioversion. The solution also addresses potential stroke risks, electrolyte imbalances, and the management of underwater seal drain systems, concluding with an ISBAR report to communicate the patient's condition effectively. Desklib offers more solved assignments for students.

Management of a Patient with Infective Endocarditis
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Questions
1. Identify and describe the aetiology, pathophysiology and risk factors for infective
endocarditis.
a. Aetiology of Infective Endocarditis
Definition: Infective endocarditis is seen to be e a microbial infection of the endothelial
surface of the heart. It significantly affects the valves that are present in the heart. It is
prone to occur due to infection by microorganisms. These microorganisms come from the
classes of staphylococci, enterococci, streptococci, chlamydia or pneumococci which
invade the endocardium (Ashley, E. A., & Niebauer, J., 2004; Surrena, H., 2010).
There are varied types of infective endocarditis which are associated with different
microorganisms as their cause. These types include:
(i.) Native valve endocarditis: Native valve endocarditis is caused by rheumatic valvular
disease in thirty percent of cases, congenital heart disease in fifteen percent of cases,
mitral valve prolapse and degenerative heart disease. Infectious organisms that are
attributed to native valve endocarditis include Streptococcus virdans and
Streptococcus bovis.
(ii.) Prosthetic valve endocarditis: Prosthetic valve endocarditis is caused by nosocomial
acquired organism. In most cases it is caused S epidermidis and S aureus.
(iii.) IV drug infective endocarditis: IV drug infective endocarditis is common in patients
who are receiving IV drugs. Methicillin Resistant Staphylococcus Aureus consist
the common culprit in the case of infection. S. aureus is the common causative
agent. The streptococci and enterococci are also common causative organisms.

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(iv.) Healthcare Associated Infective Endocarditis: These includes the subset of patients
who have central line catheters, those who have cardiac rhythm devices inserted
onto them and those who have peripheral line catheters. The causative organism in
these cases is mostly S. aureus.
(v.) Fundal endocarditis: Mostly common in patients who are in intensive care units and
intravenous drug users who receive broad spectrum antibiotics. Diagnosis for this
subset of patients is often performed by performing microscopic examinations. In
most cases emboli will be identified within the patient’s circulatory system.
b. Pathophysiology of Infective Endocarditis
A microbe gains access to the endocardium. The infectious process results due to these
microbes which include the enterococci, the pneumococci or the staphylococci. Vegetation
composing of fibrin, platelets, infectious microorganism are compounded together by the
antibodies that are released by the infectious microorganisms. The process of inflammation,
ulceration and subsequent damage of the valves and leaflets of the heart results. As a result, the
valve leaflets of the heart are interfered with. The cardiac structures such as the chordae
tendainea can also be affected. Other causative microbes such as the fungi or the rickettsia can
also lead to these pathology (Hinkle, J. L., & Cheever, K. H., 2013)
c. Risk factors for infective endocarditis
Risk factors for the development of infective endocarditis include:
(i.) Age: the aged individuals are more likely to have a weaker immune system,
possess metabolic derangements that are associated with aging and are more
likely to have a calcified heart valve.

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(ii.)Intravenous drug use (IV drugs): Staphylococcal infection is very common in
among the IV drug users.
(iii.) Hospitalization: Those patients with indwelling catheters and those who
are on hemodialysis or those receiving prolonged doses of IV fluids and
therapies of antibiotics are at higher risk.
(iv.) Immunosuppression: Those patients who are on medication that
suppresses the immune system and those on corticosteroids are even more
likely to develop fungal endocarditis.
(v.)Prosthetic heart valves or possession of structural heart or cardiac defects: The
presence of valve disorders significantly increases the risk of infective
endocarditis (DeWit , Stromberg & Dallred, 2016).
2. Describe three (3) diagnostic tests and results needed to make a diagnosis of infective
endocarditis.
Diagnostic tests for infective endocarditis and the associated results include:
I. Echocardiography: A mobile or moving mass on the surface of the valves that is
the prosthetic valve or its supporting structures and results displaying vegetation
or abscess can be identified or new regurgitation can be identified. An
echocardiogram may also display the process of development of heart failure.
II. Renal and liver function tests: Urea and creatinine levels may be raised. The
levels of liver enzymes will also be notable raised.
III. Blood cultures: Blood cultures are the main or primary diagnostic method in cases
whereby patients are suspected or have infective endocarditis. Blood cultures will
show several causative microorganisms within the blood stream of the patient.

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Microorganisms such as Brucella, Candida and Chlamydia are likely to be
identified. Blood should however, not be drawn from the central line and should
be drawn before the administration of antibiotics or one hour after the
administration of antibiotics. Samples bottles for gram negative and gram positive
bacteria should be collected separately.
3. List and explain two (2) complications of acute infective endocarditis.
(i.) Heart failure: from the destruction of valve leaflets and heart structures, and blood flow
obstruction due to the presence of vegetation.
(ii.)Myocardial damage: Due to the effects of inflammation and scaring caused by the
infectious process.
4. (a) List three (3) appropriate nursing diagnoses that you might expect for a patient like
Mr Johnson.
(i.) Acute pain related to inflammation of the myocardium as evidenced by chest pain
(ii.)Activity intolerance related to reduced cardiac output as evidenced by complains
of fatigue and generalized body weakness
(iii.) Risk for infective tissue perfusion related to vegetation on valve surface
(b) List the appropriate nursing goals related to these diagnoses.
(i.) Improve tissue perfusion.
(ii.)Relieve pain.
(iii.) Improve physical activity and reduce likelihood of immobility
(iv.) Maintain the cardiac output within optimal levels

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5. Consider the above rhythm strip
a. What is the rate of this rhythm?
The rate is 100 bpm (Heart rate)
b. Explain how you determined this rate.
By identifying the beginning and end of one QRS complex. I then divided the
number of big boxes between this QRS complexes by 300.
c. Identify the rhythm.
There is no P wave and there are irregular QRS complexes which represents a
patient with atrial fibrillation.
d. How does the above rhythm explain the patient’s most recent blood pressure?
Explain the underlying pathophysiology. Over time the presence of an atrial
fibrillation can lead to a problem with the functioning of the heart which is
secondary to the effects of infective endocarditis. The patient’s blood will then be
pooled down to the atria. As a result the patient will experience a low blood
pressure. The patient will also have increased risks of having blood clotting.
e. Considering the current rhythm that the patient is in, what intravenous
antiarrhythmic medication (commonly used in Australia) is the doctor likely to
order to facilitate conversion to sinus rhythm? (List 1) Digoxin
f. For the selected anti-arrhythmic agent, describe the mechanism of action
(minimum of three).
(i.) Acts by regulating the cytosolic calcium concentration: calcium concentrations
have to be lowered at the end of each contraction to enable the heart to contract.

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The movement of Sodium ions out of the cell is inhibited and thus the efficiency
and activity of the Sodium-calcium exchange is promoted.
(ii.)The increase the contractility of the heart: The digoxin increases the force of the
heart to contracts to an extent that it represents that of a normal heart. The result
increase in efficiency in contraction leads to a cumulative decrease in end-
diastolic volume and promotes circulation of blood throughout the body.
g. For the selected anti-arrhythmic agent, describe a minimum of three (3)
contraindications and five (5) side effects of the medication.
Contraindications of digoxin include:
(i.) Patients with hypersensitive carotid sinus syndrome: to avoid
complications
(ii.)Patients with a history of digitalis toxicity: digoxin can lead to toxicity,
patients should not receive more doses if they had a history of digoxin
toxicity.
(iii.) Digoxin hypersensitivity: hypersensitive reactions can lead to
death.
Side effects of digoxin include:
(i.) Electrolyte imbalance: digoxin interferes with the electrolyte levels
within the body.
(ii.)Confusion may result.
(iii.) Drowsiness and headache may occur.
(iv.) Abdominal discomfort and pain may result
(v.)Diarrhea is also likely to occur

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h. List one other method (aside from drug therapy) used to convert this rhythm to
sinus rhythm.
Electrical cardioversion (Currie, M. P., Karwatowski, S. P., Perera, J., &
Langford, E. J., 2004)
i. Discuss five (5) nursing considerations when preparing a patient for this treatment
(listed in question 6h).
(i.) Emotional and psychological readiness: the client should be educated on
the procedure and associated risks before the procedure.
(ii.)Consent on the procedure: due to the risk of stroke and death and prior
written consent should be signed to ensure the autonomy of the patient is
maintained.
(iii.) Identify whether the patient has a pacemaker as the procedure may
interfere with its activity. The positioning of electrodes will be changed if
the patient has a pacemaker.
(iv.) Administration of an antiarrhythmic drug should be performed
either 24 or 48 hours before the procedure is performed. In case the
antiarrhythmic drug does not prove effective it will be ok since it will
reduce the energy that will be needed before the cardioversion is
performed.
(v.)Preparation of anticoagulants before the procedure because of the risk of
stroke when emboli travel to the brain or other vital organs of the body.

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j. This patient may be at risk for a stroke due to his arrhythmia. Which oral anti-
coagulant medication is he likely to be commenced on? Warfarin
k. Consider the above electrolyte results. Identify which of these results are not
within normal range. Describe the impact on cardiac function. Describe what
action is needed.
(i.) There are low Potassium and Chloride levels within the patients’ blood stream.
(ii.)Low potassium levels within are responsible for irregular heartbeats due to poor
myocardial contractility and repolarization. Administration of potassium chloride
infusions is necessary to maintain the patient’s normal functioning of the heart.
6. The following picture shows an underwater seal drain system. Label the components of
the system using the letters provided.
A: Tube from patient
B: Drainage chamber or collection chamber
C: Water seal chamber or air leak chamber
D: Suction control chamber
E: To suction
7. Describe three (3) reasons why the fluid in the tubing may not swing/oscillate.
(i.) Proper insertion of the tube.
(ii.)Presence of negative and positive pressures that ensure no fluid flows in the
wrong place
(iii.) There is no leakage in the tubing
8. Describe two (2) reasons for the water-seal chamber to show ‘bubbling’.

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(i.) In cases of an air leak in the system: continuous bubbling is indicative of a
leakage within the underwater seal drainage system and should be assessed.
(ii.)Bubbling is also visible wen respirations occur, however, it should cease on
expiration.
9. Describe three (3) possible complications at the chest tube insertion site. Explain signs
and/or symptoms that would indicate each of these complications.
(i.) Penetration of other organs: there may be intense bleeding after placing of the
chest tube that may be a hallmark sign.
(ii.)Dislodgement of the tube: the tube may be stuck out of the body or no fluid is
being released
(iii.) Pulmonary edema is another possible risk: in this case, oedema may
significantly lead to cardiovascular symptoms of right sided hear failure.
10. Do any of the vital sign or UWSD observations at 1400hrs concern you? Why?
Yes. There is no suction, no drainage for the last four hours and no bubbling. The air
entry on the left lung is more than that on the right lung.
11. Describe the underlying pathophysiology that would relate to the most obvious cause of
Mr Johnson’s change in condition at 1400hr.
There is a pneumothorax. Fluid is flowing into the lungs and thus the decrease in
secretion. In addition, there is a significant increase in the amount of air that is getting in
the left than in the right lung, this is a warning sign.
12. Using ISBAR, how would you report this patient’s condition to the team leader on this
shift?

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Situation: This is Mr Johnson. He is married and is 62 years old. His gender is male.
Background: He was diagnosed with acute infective endocarditis and has a history of
COPD. He has recently quit smoking. He was admitted and has since received care.
During the insertion of an intravenous catheter He developed a puncture of the right ling
and was, therefore, placed on an underwater chest drain.
Assessment: On assessment of the underwater seal drainage observations at 1400hrs, I
was able to identify that no suctioning occurred, there was no air leak, the drainage at the
time was 0/290, and there was no drainage at the time. On further assessment, I found out
that the air entry ratio between the left and right lung gave even more data. The air entry
on the left lung was more than the right lung which had the underwater seal drainage.
Recommendation: I recommend that the patient undergoes a chest x-ray and ultrasound to
identify if anything was wrong or if the patient is ok.
13. List six (6) nursing actions that would be appropriate at this time based on these most
recent observations
(i.) Asses if the underwater seal drainage was working properly.
(ii.)Advocate for the patient to go for chest X-ray.
(iii.) Take vital signs of the patient continuously to assess any anormalies.
(iv.) Identifying if the tube for suctioning in the underwater seal drainage was
properly placed
(v.)Document any findings present.
(vi.) Report findings to other members of the healthcare team for further
management.

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14. Discuss five (5) appropriate discharge education needs for Mr. Johnson to ensure a
positive outcome.
(i.) Advice on the importance of feeding to maintain fluid and electrolyte balance. He
should drink enough fluids to restore the fluids and electrolytes lost.
(ii.)Positioning: Mr Johnson should sleep on the upright position to avoid
complications.
(iii.) Access to an emergency healthcare personnel: considering the likelihood
of a heart attack, he should ensure timely and fast access to a healthcare personnel
or hospital for appropriate and timely care.
(iv.) Activity pattern: Mr Johnson should ensure that he does not engage
intense activity due to the compromise on his cardiac function caused by
infectious endocarditis.
(v.)Avoiding stress and high adrenaline activities: Stress is likely to increase the heart
rate of his already compromised hear which is likely going to lead to a heart
attack pending to his compromised heart.
(vi.) Maintaining hygiene: He should maintain appropriate hygiene to avoid the
occurrence of sepsis on the puncture site. In case of any gangrene on the site, he
should immediately seek medical assistance.
15. Consider the case study and which of the NMBA standards (2016) are applicable to this
case. Give examples of three (3) relevant RN Standards for Practice and discuss how
they could be applied to this case study.