Myocarditis, long-term careIntroduced: February 7, 2015

OverviewFocal or diffuse inflammation of the myocardium that's typically uncomplicated and self-limitingMay be acute or chronic

PathophysiologyAn infectious organism triggers an autoimmune, cellular, and humoral reaction.Inflammation may lead to hypertrophy, fibrosis, and inflammatory changes of the myocardium andconduction system. (See Tissue changes in myocarditis.) The heart muscle weakens and contractility is reduced.Left ventricular diastolic dysfunction leads to elevated left ventricular end-diastolic pressures,resulting in pulmonary venous and arterial hypertension; pulmonary edema is possible.

Tissue changes in myocarditis

The illustration below shows the inflamed myocardium in myocarditis.

CausesIdiopathicBacteriaChronic alcoholismHelminthic infections such as trichinosisHypersensitive immune reactions such as acute rheumatic feverParasitic infectionsRadiation therapyViruses (most common cause)Drugs such as cocaine or other toxinsDrugs such as cocaine, chemotherapeutic agents (eg, DOXOrubicin, cyclophosphamide [Cytoxan]),antibiotics (eg, penicillin, chloramphenicol), antihypertensives (eg, methyldopa, spironolactone[Aldactone])Enterotoxins associated with septic shockAutoimmune conditionsRadiationHeat stroke, hypothermiaSystemic inflammatory conditions

IncidenceMyocarditis can occur at any age but the average age is between 40 and 60 years.Men and women are affected equally.

ComplicationsLeft-sided heart failureCardiomyopathyChronic valvulitis (when it results from rheumatic fever)Arrhythmias

ThromboembolismIrreversible ventricular failure

Assessment

HistoryPossible recent upper respiratory tract infection with fever, viral pharyngitis, or tonsillitisNonspecific symptoms, such as fatigue, dyspnea, palpitations, persistent tachycardia, and persistentfeverChills, sweats, malaiseMild continuous pressure or soreness in the chest

Physical FindingsS3 and S4 gallops, muffled S1Pericardial friction rubTachypnea, retractionsJugular vein distensionArrhythmiasHepatomegalyWeak peripheral pulsesCool extremitiesPoor capillary refill

Diagnostic Test Results

LaboratoryLevels of cardiac enzymes, including creatine kinase (CK), CK-myocardial bound, aspartateaminotransferase, and lactate dehydrogenase are elevated; troponin T and I levels are elevated.White blood cell count, C-reactive protein, and erythrocyte sedimentation rate are elevated.Antibody titers, such as antistreptolysin-O titer in rheumatic fever, are elevated.Results of cultures of stools, throat or pharyngeal washings, or other body fluids show the causativebacteria or virus.

ImagingTwo-dimensional echocardiogram may reveal impaired systolic or diastolic ventricular function andhelps rule out other causes of heart failure.Chest X-ray may show cardiomegaly, pulmonary edema, and possible pleural effusions.Cardiac angiography helps rule out cardiac ischemia.Antimyosin scintigraphy identifies myocardial inflammation.Cardiac magnetic resonance imaging reveals the extent of inflammation and cellular edema.

Diagnostic ProceduresBiopsy of the endomyocardium may confirm myocarditis.Electrocardiogram is highly variable but may show sinus tachycardia, a diffuse ST-segment, and T-wave abnormalities, such as T-wave inversion, ST-segment elevations, and bundle-branch block;conduction defects (prolonged PR interval); and ventricular and supraventricular ectopic arrhythmias.

Treatment

GeneralSupportive careHospitalization until stabilized in patient with signs and symptoms of heart failureMechanical ventilation in patients with severe respiratory failure secondary to myocardial failureMechanical cardiac support, such as ventricular assist devicesWithdrawal of offending agent, if indicatedCardioversion to convert supraventricular arrhythmias if presentExtracorporeal membrane oxygenation for short-term circulatory support

DietAvoidance of alcoholLow-sodium

ActivityModified bed rest during acute phaseAs tolerated

MedicationsAnti-infectives to treat underlying infection as indicatedAntiarrhythmics to treat hemodynamically significant arrhythmiasAnticoagulants, such as heparin for acute condition or warfarin sodium for chronic conditioninvolving severe myocardial depression or ventricular dilationAngiotensin-converting enzyme (ACE) inhibitors, such as enalapril, to treat heart failureDiuretics, such as furosemide, to treat heart failureNitroglycerin or sodium nitroprusside to reduce systemic vascular resistanceInotropic agents, such as milrinone lactate, DOPamine hydrochloride, or DOBUTamine hydrochlorideBeta-adrenergic blocker with or without digitalisHigh-dose I.V. gamma globulin during acute phaseVasopressors (if heart failure is present)Anticoagulants such as warfarin if atrial fibrillation is presentOxygen if indicated

SurgeryPacemaker implantationVentricular assist device implantationHeart transplantation

Nursing Considerations for Long-Term Care

Nursing DiagnosesActivity intoleranceAnxietyDecreased cardiac outputDeficient knowledgeExcess fluid volumeFatigueImpaired gas exchangeRisk for decreased cardiac perfusionRisk for electrolyte imbalance

Risk for ineffective peripheral tissue perfusionRisk for infection

Expected OutcomesThe resident will:

carry out activities of daily living without weakness or fatiguecope with his medical condition without demonstrating severe signs of anxietymaintain hemodynamic stability and adequate cardiac output without arrhythmiaverbalize an understanding of the condition and its causesidentify the planned treatment regimenget adequate rest and will verbalize baseline energy levelsmaintain adequate ventilation and oxygenationexpress feelings about his diminished capacity to perform usual rolesmaintain adequate fluid and electrolyte balance.

Nursing InterventionsStress the importance of bed rest, especially during the acute phase, to minimize myocardial oxygendemands. Provide a bedside commode.Allow the resident to express his concerns about the effects of activity restrictions on hisresponsibilities and routines, assist in identifying positive coping strategies, and assist withrelaxation techniques. Model positive coping strategies.Auscultate heart and lung sounds for changes and maintain a patent airway.Obtain the resident's daily to weekly weight, check his lower extremities for edema, and note anypitting.Allow for frequent rest periods; cluster care activities to provide for rest and minimize energyexpenditure. Implement energy conservation measures.Give prescribed oxygen based on oxygen saturation levels.Give prescribed medications, such as ACE inhibitors, anti-infective agents, beta-adrenergic blockers,or diuretics.Provide small frequent meals with rest periods to minimize energy expenditure related to eating.Obtain a physical therapy consult for energy conservation techniques.

MonitoringVital signsCardiovascular status including cardiac rate and rhythmHemodynamic statusRespiratory and pulmonary statusFluid balance; intake and outputSigns and symptoms of heart failureWeightResponse to treatmentEdemaActivity toleranceAnxiety level; coping strategiesOxygen levelsCondition changesPeripheral pulsesLaboratory monitoring

Associated Nursing ProceduresAdmission, long-term careAdvance directives, long-term careAssessment differences in the older adult, long-term care

Care plan preparation, long term careChange in status, identifying and communicating, long-term careHealth history interview and physical assessment, long term careOral drug administrationPulse assessment, long-term carePulse oximetry12-lead electrocardiogram (ECG)Venipuncture

Nursing Considerations for Acute Care

Nursing DiagnosesActivity intoleranceAnxietyDecreased cardiac outputDeficient diversional activityDeficient knowledge: Disease processDeficient knowledge: TreatmentImpaired gas exchangeIneffective copingIneffective role performance

Expected OutcomesThe patient will:

carry out activities of daily living without weakness or fatiguecope with his medical condition without demonstrating severe signs of anxietymaintain hemodynamic stability and adequate cardiac output without arrhythmiaexpress interest in using his leisure time meaningfullyverbalize an understanding of the condition and its causesidentify the planned treatment regimenmaintain adequate ventilation and oxygenationdemonstrate positive coping strategiesexpress feelings about his diminished capacity to perform usual roles.

Nursing InterventionsStress the importance of bed rest, especially during the acute phase, to minimize myocardial oxygendemands. Provide a bedside commode.Allow the patient to express his concerns about the effects of activity restrictions on hisresponsibilities and routines, assist in identifying positive coping strategies, and assist withrelaxation techniques. Model positive coping strategies.Institute continuous cardiac monitoring or hemodynamic monitoring as ordered.Auscultate heart and lung sounds for changes, maintain a patent airway, and provide mechanicalventilator support if the patient develops respiratory failure.Obtain the patient's daily weight, check his lower extremities for edema, and note any pitting.Allow for frequent rest periods; cluster nursing care activities to provide for rest and minimize energyexpenditure. Implement energy conservation measures.Give prescribed oxygen based on oxygen saturation levels or arterial blood gas results.Give prescribed medications, such as ACE inhibitors, anti-infective agents, beta-adrenergic blockers,or diuretics.Provide small frequent meals with rest periods to minimize energy expenditure related to eating.Prepare the patient and family for possible surgical intervention, such as insertion of a ventricularassist device or pacemaker or cardiac transplant.

MonitoringVital signsCardiovascular status including cardiac rate and rhythmHemodynamic statusRespiratory and pulmonary statusFluid balance; intake and outputSigns and symptoms of heart failureDaily weightResponse to treatmentActivity toleranceAnxiety level; coping strategiesPostoperative status as appropriateVentricular assist device function

Associated Nursing ProceduresBlood pressure assessmentCalculating and setting an IV drip rateCardiac monitoringHealth history interview and physical assessmentIntake and output assessmentIntra-aortic balloon insertion, assistingIntra-aortic balloon managementIV bag preparationIV bolus injectionIV catheter insertionNutritional screeningOral drug administrationPulse assessmentRespiration assessmentTemperature assessment12-lead electrocardiogram (ECG)Venipuncture

Patient Teaching

GeneralBe sure to cover:

disorder, diagnosis, possible underlying causes, and treatment, including the condition's effect oncardiac function, medications, and assistive devices for respiratory and cardiac functionprescribed medications, including drug name, dosage, frequency of administration, and duration oftherapypotential adverse reactions of prescribed medications, such as fluid and electrolyte imbalances withdiuretic therapy, possible dizziness or light-headedness, and GI upset with ACE inhibitorssigns and symptoms of heart failure, including shortness of breath, dyspnea, and swelling of theextremitieshow to monitor pulse rate and rhythm if indicated, how to monitor daily weight, and the need to reportany sudden weight gaindangerous signs and symptoms and the need to notify the practitioner if any occurimportance of continued follow-up care, including laboratory testing and visits to the practitionerevery 1 to 3 months to evaluate therapy effectivenesspostoperative care measures, including care of the surgical site, device use and function, and signsand symptoms of complications that need to be reported immediatelyimportance of adhering to follow-up, including laboratory testing as appropriate.

Discharge PlanningRefer the patient who has had surgery to a cardiac rehabilitation program as appropriate.Refer the patient who has had a cardiac transplant to social services for evaluation and follow-upcare.Refer the patient to home health care services if indicated.

ResourcesAmerican Heart Association: www.americanheart.orgMayo Clinic: www.mayoclinic.comNational Heart, Lung, and Blood Institute: www.nhlbi.nih.gov

Selected References(Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions)

1. Andrews, T. D., et al. (2010). Sudden killer: Arrhythmogenic right ventricular cardiomyopathy. Nursing,40 (11), S7–S11.

2. Cooper, L. T. Clinical manifestations and diagnosis of myocarditis in adults. (2013). In: UpToDate,McKenna, W. J. (Ed.). Retrieved from: www.uptodate.com

3. Cooper, L. T. Etiology and pathogenesis of myocarditis . (2013). In: UpToDate, McKenna, W. J. (Ed.).Retrieved from: www.uptodate.com

4. Cooper, L. T. Natural history and therapy of myocarditis in adults. (2013). In: UpToDate, McKenna, W. J.(Ed.). Retrieved from: www.uptodate.com

5. Holmvang, G., & Dec, G. W., (2012). CMR in myocarditis : Valuable tool, room for improvement. JACCCardiovascular Imaging, 5 (5), 525–527. Abstract | Complete Reference

6. Hsiao, J. F., et al. (2013). Speckle tracking echocardiography in acute myocarditis . International Journalof Cardiovascular Imaging, 29 (2), 275–284. Abstract | Complete Reference

7. Hussein, A. A., et al. (2013). Inflammation and sudden cardiac death in a community-based populationof older adults: The Cardiovascular Health Study. Heart Rhythm, 10 (10), 1425–1432. (Level IV) Abstract | Complete Reference

8. Lindenfeld, J., et al. (2010). HFSA 2010 Comprehensive Heart Failure Practice Guideline. Journal ofCardiac Failure, 16 (6), e1–e194. Abstract | Complete Reference

9. Liu, Z. L., et al. (2012). Herbal medicines for viral myocarditis . Cochrane Database of SystematicReviews, 2012(11), CD003711. (Level I)

10. Nettina, S. (2014). Lippincott manual of nursing practice (10th ed.) . Philadelphia, PA: Wolters Kluwer.11. Nursing Diagnoses: Definitions and Classification 2012–2014 © 2012, 1994–2012 NANDA International.

Used by arrangement with Blackwell Publishing Limited, a company of John Wiley & Sons, Inc.12. Sagar, S., Liu, P. P., & Cooper, Jr. L. (2012). Myocarditis . The Lancet, 379 (9817), 738–747.13. Tang, W. H. (2013)“Myocarditis ” [Online]. Accessed November 2014 via the Web at

http://emedicine.medscape.com/article/156330-overview14. Tinetti, M. E., et al. (2012). Contribution of individual diseases to death in older adults with multiple

diseases. Journal of the American Geriatrics Society, 60 (8), 1448–1456. Abstract | Complete Reference | Full Text | Ovid Full Text

  Rating System for the Hierarchy of Evidence for Intervention/Treatment QuestionsThe following leveling system is from Evidence-Based Practice in Nursing and Healthcare: A Guide to Best

Practice (2nd ed.) by Bernadette Mazurek Melnyk and Ellen Fineout-Overholt.

Level I: Evidence from a systematic review or meta-analysis of all relevant randomizedcontrolled trials (RCTs)

Level II: Evidence obtained from well-designed RCTs

Level III: Evidence obtained from well-designed controlled trials without randomization

Level IV: Evidence from well-designed case-control and cohort studies

Level V: Evidence from systematic reviews of descriptive and qualitative studies

Level VI: Evidence from single descriptive or qualitative studies

Level VII: Evidence from the opinion of authorities and/or reports of expert committees

Modified from Guyatt, G. & Rennie, D. (2002). Users' Guides to the Medical Literature. Chicago, IL: AmericanMedical Association; Harris, R.P., Hefland, M., Woolf, S.H., Lohr, K.N., Mulrow, C.D., Teutsch, S.M., et al.(2001). Current Methods of the U.S. Preventive Services Task Force: A Review of the Process. AmericanJournal of Preventive Medicine, 20, 21-35.

To make safe and effective judgments using NANDA-I nursing diagnoses, it is essential that nursesrefer to the definitions and defining characteristics of the diagnoses listed in Nursing Diagnoses:Definitions and Classification 2012-2014 © 2012, 1994-2012 NANDA International (ISBN 987-0-4706-5482-8).Copyright NANDA International, www.nanda.org Nursing Diagnoses - Definitions and Classification 2012-2014 © 2012, 1994-2012 NANDA International. Used by arrangement with Blackwell Publishing Limited,a company of John Wiley & Sons, Inc.