Stephanie Dey

51 year old male patient. Patient admitted to ED with confusion. CT shows large stroke with hemorrhagic transformation. Blood cultures positive for streptococcus mitis. Patient also diagnosed with native mitral valve endocarditis. Transesophogeal echocardiography shows large vegetation with no valve ring abscess. Patient transferred to ICU after coding on 8/10/11 with acute respiratory failure. ICU assessment findings show acute respiratory failure, streptococcus mitis septicemia, native mitral valve endocarditis, pulmonary infiltrates bilaterally worsening on right lung, hemorrhagic stroke secondary to endocarditis and bradycardia. Past medical history includes hypertension and alcohol abuse.

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Medical Diagnosis: Native Mitral Valve Endocarditis Nursing Diagnosis: Risk for decreased cardiac output R/T decreased myocardial contractility secondary to infective endocarditis with vegetation and left ventricular wall surgery Ineffective cerebral tissue perfusion T/T interruption of blood flow due to hemorrhage AEB altered level of consciousness and memory loss. Risk for progression of septicemia/sepsis to septic shock R/T invasive procedures Ineffective airway clearance R/T artificial airway AEB changes in rate of respiration

Signs & Symptom Fever Chills Fatigue Aching muscles and joints Night sweats Headache Shortness of breath or persistent cough Skin paleness Small, painful red bumps under the skin on the fingers and toes Nausea and vomiting Swelling of the feet, legs or abdomen Blood in the urine A new heart murmur

Pathophysiology Mitral valve endocarditis is a bacterial or fungal infection of the mitral valve. This can damage or even destroy the valve by causing growths or holes on the valve or scarring of the valve tissue, most often causing the valve to leak. Can be

fatal Without treatment.

Past Medical History

Hypertension Alcohol Abuse

Diet NPO

Activity Bed Rest

Medications Ampicillin 2g Cardizem 100mg Gentamicin 60mg Coreg 12.5mg Propofol Titrate Furosemide 20mg Ambien 5mg Ativan 1mg Phenergan 12.5-25mg

Labs WBC – 22.4 HGB – 11.2 HCT – 35.1 PLT – 421

Glucose – 128 BUN – 12

Creatinine – 1.1 Na – 136 K – 4.4

Diagnostics

CT scan – Verified hemorrhages in brain and pulmonary infiltrates. Scan continues to monitor state of hemorrhagic stroke. TEE – Showed large vegetation on mitral valve.

Discharge needs

Not appropriate for this patient at this time

Manifested by

Improved by

confirm

confirm

Treated with

INTERVENTIONS RATIONALE

  1.Monitor trends in heart rate and BP. Attempt to keep heart rate

below 100bpm and systolic blood pressure above 90mm/hg         2.Monitor and document cardiac dysrhythmias and patient

response         3. Record skin temperature, and color as well as quality and

equality of peripheral pulses.     4.Measure and document I&O’s         5.Inspect for JVD, peripheral or dependent edema, lung

congestion, SOA, and changes in mental status    

  1. Tachycardia is a common response to discomfort, inadequate

fluid/blood replacement and surgical stress. SVT increases cardiac workload and decrease cardiac output. Hypertension places stress on suture lines changing blood flow/pressure across valves increasing risk of complications. Hypotension may result from fluid deficit, heart failure, shock and dysrhythmias.

  2. Life threatening dysrhythmias may be due to electrolyte

imbalance, myocardial ischemia, or conductivity alterations. A fib and A flutter are most common occurring 2-3 days post operative. Decreased cardiac output and hemodynamic compromise caused by dysrhythmias require prompt intervention.

  3. Warm, pink skin and strong, equal pulses indicate adequate

cardiac output.       4. Used to determine fluid needs or excess which can

compromise cardiac output         5.Indicative of acute or chronic heart failure    

INTERVENTIONS RATIONALE

  1. Review serial ECG’s monitoring for rhythm changes.       2.Administer IV fluids or blood transfusions as needed         3.Administer or maintain supplemental oxygen as

appropriate         4.Administer electrolytes and medications as indicated       5.Maintain surgically places pacing wires and initiate

pacing if indicated    

  1. Follows progress of normalization of electrical

conduction patterns or ventricular function after surgery or to identify complications.

    2. Replacement may be needed to restore or maintain

adequate circulating volume and increase oxygen carrying capacity.

     

3.Promotes maximum oxygenation reducing cardiac workload and aid in resolving myocardial ischemia and dysrhythmias

   

  4.Electrolytes, antidysrhythmics, and other heart

medications may be needed short term or long term to maximize cardiac contractility or cardiac output

  5.Supports cardiac output if severe dysrhythmias

compromise cardiac function    

INTERVENTIONS RATIONALE

  1.Compare BP readings in both arms and arterial lines         2.Auscultate heart sounds for murmurs monitoring rate and rhythm     3.Monitor respirations noting pattern and rhythm       4.Evaluate pupils noting size, shape, equality, reactivity           5. Determine factors related to individual situation or cause for

decreased cerebral perfusion and potential for increased ICP.       EVALUATION of Short Term Goal #1: Goal partially met. Patient vital

signs were stable except for heart rate prior to mitral valve replacement and patient was displaying stable vital signs post operative

  1. Fluctuations in pressure may occur because of cerebral

pressure or injury. Hypotension may occur due to shock. ICP increases may occur due to tissue edema or clot formation. Subclavian artery blockage may be seen by difference in BP reading between arms.

  2. Dysrhythmias and murmurs may reflect cardiac disease

precipitating CVA after MI or valvular dysfunction.   3. Irregularities can suggest location of cerebral insult or

increasing ICP and need for further intervention and possible respiratory support.

    4. Reactions are regulated by cranial nerve III and are useful in

determining if brainstem is intact. Pupil size and equality is determined by balance of parasympathetic and sympathetic enervation. Response to light reflects combined function of cranial nerves II and III

    5. Determine if deterioration neurological signs or symptoms

or failure to improve after initial insult may reflect decreased intracranial adaptive capacity. Evolving patients can deteriorate quickly and require repeated assessment and progressive treatment. If stroke is complete deficit is non progressive and treatment is geared towards rehabilitation and preventing recurrence.

   

INTERVENTIONS RATIONALE

  1. Document changes in vision. Patient may experience hallucinations,

and changes in pupils. Pupils may become uneven, dilation changes, light reactivity, and accommodation

  2. Maintain bed rest, provide quiet environment, and restrict visitors and

activities as indicated. Provide rest periods between care activities, limit duration of procedures.

      3Talk directly to client speaking slowly and distinctly. Use yes/no

questions to begin         4. Speak with normal volume and talk slowly giving patient time to

respond.         5.Respect client’s preinjury capabilities avoid speaking down to patient

or making patronizing remarks   EVALUATION of Long Term Goal #1: Goal met. Patient did not display

any further deficits resulting from stroke and was able to use hand and head movements to communicate as well as mouthing words. Patient was able to follow commands wiggling toes, squeezing hands, and moving fingers.

 

  1. Specific visual alterations reflect area of brain involved, indicate

safety concerns, and influence choice of interventions.     2. Continual stimulation and activity can increase IP. Absolute rest and

quiet may be needed to prevent rebleeding in the case of hemorrhage       3. Reduces confusion and anxiety at having to process and respond to

large amounts of information at one time.       4. Patient may not have hearing impairment and loud voices/sounds may

irritate or anger. Forcing responses can result in frustration and patient may resort to “automatic speech”

    5.Enables client to feel esteemed because intellectual abilities often

remain intact        

INTERVENTIONS RATIONALE

  1. Inspect wounds and sites of invasive devices daily. Pay special

attention to PPN and TPN lines as they are a great medium for bacterial growth. Document signs of local inflammation/infection, changes in character of wound drainage, sputum, or urine.

      2.Note temperature trends and observe for shaking chills and profuse

diaphoresis         3.Understand the nurse’s role in identifying client at risk and preventive

interventions (hand disinfection, early removal of invasive tubes and catheters, 30-degree head elevation for client on ventilator, and early nutrition)

      4. Maintain sterile technique when changing dressings, suctions,

providing site care.     5. Wear gloves and gowns when caring for open wounds or anticipating

direct contact with secretions or excretions.        

  1. Catheter related blood stream infections are on the increase while

central venous catheters are used in both acute and chronic care settings. Monitoring TPN and PPN lines is needed due to excellent medium for bacterial growth.

      2. Chills often precede temperature spikes in presence of generalized

infection. Hypothermia is a grave sign reflecting advanced shock or the failure of the body to mount a febrile response, or decreased tissue perfusion.

    3. The nurse is crucial in preventing the spread of severe sepsis is crucial

because they are in the position to identify clients at the first signs of developing sepsis.

        4. Prevents and limits introduction of bacteria, reducing risk of

nosocomial infection.     5.Prevents spread of infection and cross contamination          

INTERVENTIONS RATIONALE

  1.Monitor laboratory studies           2.Administer medications as indicated           3.Monitor for signs of deterioration     4.Obtain specimens of urine, blood, sputum, wound,

invasive lines or tubes as indicated for gram stain, culture, and sensitivity

  5.Inspect oral cavity for white plaques      

  1. The normal ratio of neutrophils to total WBC’s is at least 50% but when

WBC count is markedly decreased calculating the absolute neutrophil count is more pertinent to evaluating immune status. While an initial elevation of band cells reflects the body’s attempt to mount a response to the infection, but a decline indicates decompensation.

 

  2. Specific antibiotics are determined by culture and sensitivity results,

but therapy is usually initiated before obtaining results. Using broad spectrum antibiotics based on most likely infecting organisms. Concomitant use of antimicrobials is often beneficial, but dosage must be balanced against renal function and clearance.

    3. May reflect inappropriate or inadequate antibiotic therapy or

overgrowth of resistant or opportunistic organisms.  

  4. Identification of portal of entry and organism causing the septicemia is

crucial to effective treatment based on susceptibility to specific medications.

 

5. Depression of the immune system and use of antibiotics increase risk of secondary infections particularly yeast.

     

INTERVENTIONS RATIONALE

  1.Evaluate for chest movement and auscultate for

bilateral breath sounds       2. Reposition every 2 hours or as needed for patient

comfort.

    3. Encourage or provide fluids within individual

capability     4. Use inline catheter suction when available       5.Assess for airway patency          

  1. Symmetrical chest movement with breath sounds

throughout lung fields indicates proper placement and unobstructive airflow.

    2. Promotes drainage of secretions and ventilation to all

lung segments reducing the risk of atelactasis.     3. Helps to liquefy secretions enhancing expectoration     4. Reduces the risk of infection for healthcare workers

and helps maintain oxygen saturation and PEEP when used.

    5. Obstruction may be caused by accumulation of

secretions, mucous plugs, hemorrhage, bronchospasms, and /or problems with the position of the tracheostomy or ET tube.

       

INTERVENTIONS RATIONALE

  1.Monitor ET tube placement noting lip line marking and

compare with desired placement securing carefully with tape or tube holder

      2.Note excessive coughing, or increased dyspnea       3. Assess ventilator settings assessing set respiratory

frequency and compare with client’s respirations.       4.Administer IV and or aerosol bronchodilators as indicated         5. Monitor serial ABG’s and pulse oximetry for changes.     

  1. The ET tube may slip into the right main stem bronchus

obstructing airflow to the left lung and putting the client at risk for tension pneumothorax

      2. The intubated client often has an ineffective cough

reflex or neuromuscular and neurosensory impairment altering ability to cough.

    3. Rapid client respirations can produce respiratory

alkalosis and prevent volume from being delivered from the ventilator.

      4. Promotes ventilation and removal of secretions by

relaxation of smooth muscle and brochospasms.       5. Adjustments to ventilator settings may be required

depending on the client’s response and trends in gas exchange parameters.

 

Ignatavicius, Donna D., and M. Linda. Workman. Medical-surgical Nursing: Patient-centered Collaborative Care. St. Louis, MO: Saunders/Elsevier, 2010. Print.

 Doenges, Marilynn E., Mary Frances Moorhouse, and Alice C. Murr. Nursing Care Plans:

Guidelines for Individualizing Client Care across the Life Span. Philadelphia: F.A. Davis, 2006. Print.

 Venes, Donald, and Clarence Wilbur Taber. Taber's Cyclopedic Medical Dictionary. Philadelphia:

F. A. Davis, 2009. Print.