NCLEX Review Endocarditis

Definition: Inflammation of the endocardium layer of the heart.

What is the endocardium layer? The endocardium is a membrane that lines the inside of the
heart chambers and the heart valves.

How many heart valves do you have? Four….Atrioventricular (tricuspid and mitral valve) and
Semilunar (pulmonic and aortic valves)

Endocarditis mainly affects the heart valves but it can affect the:

• interventricular septum: this separates the right and left ventricles (perforation)
• chordae tendineae: fibrous cords of tendons that connect papillary muscle to the tricuspid
and bicuspid valves (rupture)
Endocarditis is hard to treat because there is no blood flow to the valves so the body does NOT
respond properly to the pathogen present (hence, WBCs can NOT get to the valves to fight the
infection) and it is hard for antibiotics to get to it (so the patient will need weeks of IV antibiotics).

Types of Endocarditis:
• Infective (concentrated on in this lecture): bacteria, virus, or fungi gets into the bloodstream
and grows on the valve. The heart valves are more susceptible (especially defected heart
valves) to this because they don’t have a blood supply to help fight off infection (hence, white
blood cells). Therefore, the body doesn’t fight it properly.
• Patients who have weak heart valves due to defects on them are most at risk for this
(healthy valves are more resistant to the bacteria but can develop it as well).
• Examples of weak heart valves:
• Valve replacement (due to the increase risk of a thrombus forming on the valve is
the patient is not anticoagulated properly)
• Mitral valve prolapse
• Rheumatic heart disease
• History of IV drug use
• Invasive procedures: implanted device pacemaker, dental work surgery, central
line placement
• Congenital heart defects
Patients who have defective heart valves can experience complications of heart failure (valves are
leaking or have stenosis, embolic events (strokes), erosion of valve leaflets, and abscesses of the
heart tissue.

Non-effective: sterile platelets and fibrin (thrombus) form on the valve due to trauma or some
other issue (hypercoagulated blood) but it isn’t pathogenic. However, it is a site of origin for
possible infective endocarditis.

Patho of how a heart valve turns into Infective Endocarditis:

1. A defect on the valve allows platelets and fibrin (aka a thrombus…clotting ingredient) to stick
to the endothelial cells.
 2. A pathogen enters into the blood (from invasive procedure….dental work, central line
placement, implantable device) and the pathogen sticks to the platelets and fibrin
(thrombus).
3. The pathogen is able to grow.
4. As it grows, parts of the pathogen, platelets, and fibrin can break off. This can cause a
stroke.
Type of Infective Endocarditis:
• Acute IE: affects patient who have healthy heart valves (high death rate). The onset is fast
and symptoms are very severe.
• Subacute IE: affects people who have a pre-existing condition like rheumatic heart disease,
valve problem. The symptoms are subtle and onset slower (several weeks to months to
develop).
*IV drug uses are susceptible to both

Signs and Symptoms of Infective Endocarditis:

Remember the mnemonic: Pathogens

Petechiae (tiny purplish red spots on the skin….from emboli)

Anorexia (loss of appetite and enlarged spleen pushing on the stomach)

Tired and weak

High Fever & Heart Failure

Osler’s Nodes: tender, red lesions on the hands and feet

finGernail changes: splinter hemorrhages that are small, dark lines under the nails…like petechiae
but found under the nails

Embolic events, Erythematous, non-tender nodular lesions on the palms or soles of feet (Janeway
Lesions)…small, septic emboli that form abscesses

Night sweats, New cardiac heart murmur or worsening of one

Splenomegaly (helps fight infection so it becomes enlarged), Roth Spots (burst of blood vessels in
the retinas with white centers)

Diagnosed:
TEE (transesophageal echocardiogram): an ultrasound probe is placed down through the
patient throat and it looks at the back side of the heart which helps assess the heart valves.

Nursing Interventions for Infective Endocarditis:

Monitor:

• Embolic episodes of the spleen, renal, brain, pulmonary status:

• Spleen embolic: radiating abdominal pain that goes to the left shoulder
 • Renal: flank pain in the groin with possible pus or blood in the urine
• Brain (stroke): changes in neuro status…confusion, speech difficulty
• Pulmonary: chest pain, shortness of breath, dyspnea, decreased oxygen saturation
• Signs and symptoms of heart failure
• Monitor vital signs especially temperature, heart rate, blood pressure, oxygen saturation
Interventions:

• Collecting blood cultures to find out what type of microorganism is infecting the
patient…antibiotic treatment is based on this
• Administered IV antibiotics…type of antibiotics depends on the pathogen causing the
problem
• Example: Vancomycin or Rocephin (strong…usually need a central line because
patient will be on long term and go home on them…up to 4 weeks)
Educate the patient about:

• inform other healthcare practitioners about history of endocarditis because they are at risk
for it again and will need prophylactic antibiotics prior to invasive procedures
• how to take or administer antibiotics (complete all doses)
• monitor central line site and how to care for it
• good oral care