MYOCARDITIS; 3RD DEGREE AV BLOCK

8/10/2019 MYOCARDITIS; 3RD DEGREE AV BLOCK

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EMERGENCY ROOM COMPLEX: MYOCARDITIS 1

PLEASE BE CAREFUL WITH MYHEART

MYCARDITIS, VIRAL; 3RDDEGREE AV BLOCK

BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER

EMERGENCY ROOM COMPLEX

CHIQUI M. BUENO, RN, EMT-B

KIANA MAE W. DIWAG, RN, MAN


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I. ABSTRACT

23 year old, male patient sought consultation at the Emergency Room

Complex for dizziness, palpitations, chest heaviness, choking sensation.

Initial ECG shows 3rd degree AV block. Nursing and medical interventions

were started at the ER and continued at the Coronary Care Unit. Temporary

pace maker insertion was done the next day. Nursing priorities were to

prevent and treat life-threatening dysrhythmias, support patient and significant

others in dealing with anxiety and fear of potentially life-threatening situation,

assist in identification of cause and precipitating factors, review information

regarding condition, prognosis and treatment regimen. Discharge goals were

the following: for the patient to be free of life-threatening dysrhythmias and

complications of impaired cardiac output and tissue perfusion, for his anxiety

to be reduced and managed, that the patient will understand disease process,

therapy needs, and prevention of complications. Viral myocarditis remains an

uncommon but challenging illness. Its precise characterization and natural

history have been limited by the extraordinary variability of its clinical

presentations, laboratory findings, and the diversity of etiologies. ECG,

echocardiography, troponin I are warranted for initial diagnostic evaluation.

Currently, the standard of care remains hemodynamic and cardiovascular

support. Pharmacological therapy should consist of a cardiovascular regimen

demonstrated to improve hemodynamics and symptoms. After 12 hospital

days, patient was discharged in an improved condition.


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II. MAIN BODY

A. INTRODUCTION

Myocarditis is an inflammatory disorder of the myocardium with necrosis

of the myocytes and associated inflammatory infiltrate.

Myocarditis usually manifests in an otherwise healthy person and can

result in rapidly progressive (and often fatal) heart failure and arrhythmia.

When diagnosis is suspected and severe cardiovascular compromise follows,

it requires admission to Coronary Care Unit.

Potential causes may include toxins, medications, physical agents, and,

most importantly, infections. Viruses, bacteria, protozoa, and even worms

have been implicated as infectious agents. The most common forms appear

to be post viral in origin. These mostly include adenovirus and enteroviruses

such as the coxsackieviruses.

Unfortunately, the clinical features of myocarditis can vary widely, and

often no cardiac signs or symptoms occur, complicating its recognition. Its

clinical manifestations widely vary in mild forms to few or no symptoms are

noted.

In viral myocarditis, there is usually unexplained heart failure or

arrhythmias occur in the setting of systemic febrile illness, after symptoms of

an upper respiratory tract infection, gastroenteritis, and systemic afebrile

illness which precedes myocarditis followed by an abrupt onset of

hemodynamic collapse. Sometimes patient cant even remember having a


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febrile illness because it can be mild. Other symptoms may include fatigue,

decrease exercise intolerance, palpitations, chest pain and syncope.

In severe cases, patient may present with acute cardiac decomposition

and may progress to death. Sign of diminished cardiac output, such as

tachycardia, weak pulse, cool extremities, decreased capillary refill, and pale

or mottled skin maybe present.

Medical care is aimed at minimizing hemodynamic demands of the body.

No specific proven therapy is available to prevent the myocardial damage, but

maintenance of tissue perfusion is the goal to avoid further complications.

The incidence of myocarditis is estimated to be 1 to 10 cases per 100,000

persons. The rate may be higher because the variety of clinical presentations

may cause underreporting (Tang, 2001). Mortality varies with the severity of

symptoms. Most patients with mild symptoms recover completely. Other

patients may develop cardiomyopathy and heart failure. Patients with

symptomatic heart failure and an ejection fraction of less than 45% had a 1-

year mortality rate of 20% and a 4-year mortality rate of 56% (Tang, 2001).

A. DEMOGRAPHICAL DATA

-This is the case of C.D.R., a 22 year old, male, Filipino, Roman

Catholic, born on April 17, 1992, presently residing in Agpaoa

Camp 7, Baguio City, Benguet, who was admitted in this institution

on October 02, 2014 due to dizziness, palpitations, chest

heaviness, choking sensation and vomiting.

B. HISTORY


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1. HISTORY OF PRESENT ILLNESS

-Patient had 3 days history of dizziness with palpitations, chest

heaviness, choking sensation but spontaneously resolves. No

medications taken. No consult done.

-Few hours PTA, patient experienced the same sensation which

was persistent, now associated with vomiting. Condition

prompted consult and was admitted.

2. PAST MEDICAL HISTORY

- (+) HPN, (+) Heart Disease, (+) Sore Throat 2X/year

3. HEREDOFAMILIAL HISTORY

- (+) HPN, (+) Heart Disease(-) Cancer (-) DM (-) Asthma

- (-) Goiter (-) PTB exposure

4. SOCIOENVIRONMENTAL HISTORY

Occupation: student

Marital Status: Single

Smoking: none

Illicit Drug Use: none

Alcohol: none

Sexual History: none

Travel History: none

Exposure: none


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C. COURSE OF CONFINEMENT

1stHospital DayOctober 02, 2014

-At around 5:42 am, patient C.D.R was rushed at the emergency

room complex with chief complaints of dizziness, palpitations, chest

heaviness, choking sensation and vomiting.

-Oxygen was administered and 12 lead ECG was made.

-Troponin I reveals positive

-Patient was initially diagnosed as ACS, NSTEMI, High Lateral

Wall, 3rd Degree AV Block.

-Aspirin 4 tabs were given as loading dose

-Dobutamine 250mg drip was initiated due to un-appreciated blood

pressure.

-Further history reveals sore throat 2x a year and flu symptoms 2

days prior to admission; viral myocarditis was suspected

-Routine Blood works were done: CBC with platelet, Na, K,

creatinine, magnesium, phosphorus, SGOT, SGPT, PTPA, APTT,

and ABG

-CRP, ASO titer and ESRwas also made to rule out myocarditis

-CXR PA was made as a routine work up and to rule out congestion

or cardiomegaly.

-Patient was admitted and brought to CCU with blood pressure of

90/70 and with the same symptoms.


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-At CCU, patient was hooked to cardiac monitor revealing

bradycardia (CR-40-50s); Atropine Sulfate 1mg amp was given,

one dose.

-2D Echowas done at the same day revealing hypokinetic of the

anterolateral left ventricular free wall; with ejection fraction of 72%

-Potassium reveals 4.6 (Normal: 3.39-4.14).

2nd HospitalDay- October 03, 2014

- Still with chest pain, nitrates was started (ISDN tab now SL

then PRN for pain.

- Able to maintain a BP of > 90/60 but with episodes of

hypotension, maintained on Dobutamine drip; with a cardiac rate

ranging from 98-155

- Arrhythmias were noted: Cardiac monitor shows different

readings such as ST-elevation, bradycardia, SVT, PACs, and

ventricular asystole.

- CPR was done 2x during ventricular asystole

- Morphine 2mg IV was started due to severe chest pain

- Verapamil 2.5 mg IV was given for SVTs

- Temporary pacemaker insert ionwas done at the right femoral

area by Dr, Aswat at the x-ray department; with episode of

ventricular fibrillation during insertion; CPR one cycle was done,

defibrillated once

- Amiodarone drip (D5W 250 + 300mg Amiodarone) was started.


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- Post TPI insertion, CR 120-130s, no chest pain

3rd Hospital Day- October 04, 2014

- With episodes of low grade fever (Temp 37.8)

- Paracetamol 300mg IV was started

- Sulbactam-Ampicillin 1.5 gm. IV was started

- Cardiac monitor shows alternate SVTs to sinus tachycardia (CR

110-130s), no chest pains, BP 100/70

- Metoprolol 50mg was started

4th Hospital Day- October 05, 2014

- No chest pain noted, CR 83-105, BP 110/70-120/60

- Oxygen was discontinued

- KCl tabs 3 x a day started, Potassium with 3.2mmol/L (Normal:

3.39-4.14)


-With decreased breath sounds at the right, CXR PA was done

-BP 100/60, still maintained on Dobutamine drip

-no chest pains, no difficulty of breathing

-with privilege to sit up on bed and dangle legs



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-No chest pains and difficulty of breathing

-BP 110/80-120/80, CR 78-117

-Discontinued Dobutamine drip

7thHospital Day- October 08, 2014

-With episodes of bradycardia (CR 53-104), BP 80/40-100/60

-ECG reveals inverted T-waves

-ASA 80mg once a day was started

-Temporary Pacemaker removed


-BP 90/50-110/60, CR 70-93

-Sulbactam-Ampicillin completed, shifted to Co-Amoxiclav 625mg

-Advised to ambulate; with bathroom privileges


-BP 90/50-105/60, CR 59-81

-Captopril 25/tab, tab 2 x a day started with BP precaution

-Potassium: 4mmol/L (Normal: 3.39-4.14)


-ECG: sinus rhythm, diffuse ischemia


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-BP 80/40-110/70 CR 64-104

-No chest pains, no palpitations, no difficulty of breathing


-BP 90/70-110/80 CR 67-83

-Trans-out to Private Room


-BP 90/70-110/70 CR 64-93

-Repeat 2D echo done


-BP 90/50-110/70 CR 98-142

-For possible discharge


-2Decho - hypokinetic of the anterolateral left ventricular free wall;

with ejection fraction of 72%

-Discharged; Follow-up at Notre Dame Hospital on October

27,2014

-Home Medications: Perindopril 5mg, tab OD

Trimetazidine 35 mg BID


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ISMN 20mg OD

Aspirin 80mg OD

D. ASSESSMENT

Neurological System

- GCS = 15 (M6V5E4)

- (+) dizziness

- conscious, oriented to 3 spheres

- no motor or sensory deficit

Respiratory System

- (+) cough (-) crackles (-) wheezes (-) dyspnea (-) retractions

Cardiovascular

- (+) chest pain/heaviness (+) palpitations

- CR= 46, regular

- Weak pulses at lower extremities

- No BP in all extremities

- Pale in color

- (+) easy fatigability

- (-) edema


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- (-) murmurs

- Capillary refill time


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- (-) fever (-) rashes

- Skin cold touch, temp 35.1

- Pale in color

- With good skin turgor

Eye

- Pink palpebral conjunctiva

ENT

- (-) cervical lymph node adenopathy

- With choking sensation

Mental Health

- (-) confusion

- (-) mental health disorder (-) depression

- (-) alcohol abuse

E. DIAGNOSTIC STUDIES

12 Lead ECG

October 2, 2014 5:45 am

- 3

rd

degree AV block

In this type of heart block, none of the electrical signals reach the

ventricles. When complete heart block occurs, special areas in the

ventricles may create electrical signals to cause the ventricles to


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contract. This natural backup system is slow and isn't coordinated

with thecontraction of the atria. On an EKG, the normal pattern is

disrupted. The P waves occur at a faster rate than the QRS waves.

Complete heart block can be fatal. It can result in sudden cardiac

arrest and death. This type of heart block needs emergency

treatment. A temporary pacemaker may be used to keep the heart

beating until you get a permanent pacemaker.

October 2, 2014 6:40 pm

- ST elevation

The ST segment corresponds to a period of ventricle systolic

depolarization,when the cardiac muscle is contracted. Subsequent

relaxation occurs during the diastolic repolarization phase. The

normal course of ST segment reflects a certain sequence of

muscular layers undergoing repolarization and certain timing of this

activity. When the cardiac muscle is damaged or undergoes a

pathological process (e.g. inflammation), its contractile and

electrical properties change. Usually, this leads to early

repolarization, or premature ending of thesystole.

October 3, 2014 2:30 pm

Supraventricular tachycardia, ventricular asystole

Supraventricular tachycardia is a rapid rhythm of the heart

originating at or above theatrioventricular node.

October 4, 2014 8 am, October 6, 2014 5:35 am
http://www.nhlbi.nih.gov/health/dci/Diseases/scda/scda_whatis.htmlhttp://www.nhlbi.nih.gov/health/dci/Diseases/scda/scda_whatis.htmlhttp://en.wikipedia.org/wiki/ST_segmenthttp://en.wikipedia.org/wiki/Systole_%28medicine%29http://en.wikipedia.org/wiki/Depolarizationhttp://en.wikipedia.org/wiki/Diastolehttp://en.wikipedia.org/wiki/Repolarizationhttp://en.wikipedia.org/wiki/ST_segmenthttp://en.wikipedia.org/wiki/Inflammationhttp://en.wikipedia.org/wiki/Systole_%28medicine%29http://en.wikipedia.org/wiki/Atrioventricular_nodehttp://en.wikipedia.org/wiki/Atrioventricular_nodehttp://en.wikipedia.org/wiki/Systole_%28medicine%29http://en.wikipedia.org/wiki/Inflammationhttp://en.wikipedia.org/wiki/ST_segmenthttp://en.wikipedia.org/wiki/Repolarizationhttp://en.wikipedia.org/wiki/Diastolehttp://en.wikipedia.org/wiki/Depolarizationhttp://en.wikipedia.org/wiki/Systole_%28medicine%29http://en.wikipedia.org/wiki/ST_segmenthttp://www.nhlbi.nih.gov/health/dci/Diseases/scda/scda_whatis.htmlhttp://www.nhlbi.nih.gov/health/dci/Diseases/scda/scda_whatis.html


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Sinus tachycardia

Rapid heartbeat may be the body's response to heart muscle

damage

October 8, 2014 3:50 pm

Inverted T waves

T-wave inversions may result from myocardial ischemia

2D Echo - October 2, 2014,

Normal left ventricular dimension and wall thickness with normal

LVMI of 98 g/m2

normal RWT of 0.39 cm with hypokinesis of the

anterolateral left ventricular free wall from the base to apex. The

rest of the left ventricular segments are contracting adequately.

Ejection fraction is 72%.

Dilated left atrium with volume index of 27.4 mL/m2

Normal right ventricular dimension with normal wall motion,

contractility and systolic function (TAPSE of 2.3 cm, RVFAC of

27%)

Normal right atrium, main pulmonary artery and aortic root

dimensions

Structurally normal aortic valve, mitral valve, tricuspid valve and

pulmonic valve

No intracardiac thrombus


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Normal pericardium with no significant pericardial effusion

There is greater than 50% inferior vena caval collapse on deep

inspiration

COLOR FLOW AND SPECTRAL DOPPLER STUDIES

Mosaic color flow display across the mitral valve

Pulmonary artery pressure is normal by acceleration time

CONCLUSION

Normal left ventricular dimension with segmental hypokinesis but

with adequate global systolic function

Ejection fraction is 72%

Tissue Doppler/mitral Doppler indices are normal

Dilated left atrium with normal volume index

Mild mitral regurgitation

Normal pulmonary artery pressure

SUMMARY OF LABORATORY RESULTS

Diagnostics October 2,2014

October 3,2014

October 4,2014

October 10,2014

CBC

Hgb 172 155 128 160

Hct 0.494 0.451 0.375 0.472

WBC 9.63 12.36 9.54 8.14

Neutrophils 0.756 0.765 0.738 0.679Lymphocytes 0.172 0.147 0.179 0.219

Platelet 238 235 187 357

* White blood cells (WBCs) constitute the bodys primary defense system against

foreign organisms, tissues, and other substances. Increase in WBC is most


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commonly associated with an infectious process.

October 2, 2014 October 3, 2014

Prothrombin Time 13.44 13.59% Activity 79.24 % 78.28 %

APTT 24.33 31.56

SerumElectrolytes

October 2,2014

October 3,2014

October 4,2014

October 5,2014

October10, 2014

Na 131 136 132 130 130

K 4.6 4.4 3.8 3.2 4.8

Cl 95

Ca 2.31 2 2 2

Mg 1.21 0.78P 0.88

Creatinine 96.9 79.1 74.9 72.5

BUN 4.1 4.1

SGOT 140

SGPT 34

TotalCholesterol 3.10

Triglyceride 1.00

LDL 1.84

HDL 0.84

* Potassium deficiency can be caused by an inadequate intake of dietary

potassium.

October 2, 2014

Troponin Ipositive* Troponin I is a protein in the striated cells of cardiac tissue and therefore

provides a unique marker for myocardial cardiac damage.

CRPpositive

*C-reactive protein (CRP) is a glycoprotein produced by the liver in response to

acute inflammation. The CRP assay is a nonspecific test that determines the


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presence (not the cause) of inflammation; it is often ordered in conjunction with

erythrocyte sedimentation rate (ESR).

ESR - 2 mm/hr

ASOT - < 200 IU/ml

ABGs

pH 7.425 Respiratory alkalosis, partial compensation, adequate O2pCO2 20.9

HCO3 13.4

pO2 90

DRUG STUDY

1. Fondaparinux 2.5 g SQ now then OD

Therapeutic class: Anticoagulant

INDICATIONS

- To prevent deep vein thrombosis (DVT), which may lead to pulmonary

embolism, in patients undergoing surgery for hip fracture, hip replacement,

knee replacement, or abdominal surgery

ACTION

- Binds to antithrombin III (AT-III) and potentiate the neutralization of factor

Xa by AT-III, which interrupts coagulation and inhibits formation of

thrombin and blood clots.

ADVERSE REACTIONS

CNS: fever, insomnia, dizziness, confusion, headache, pain.

CV: hypotension, edema.


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GI: nausea, constipation, vomiting, diarrhea, dyspepsia.

GU: UTI, urine retention.

Hematologic: hemorrhage, anemia, hematoma, postoperative

hemorrhage, thrombocytopenia.

Metabolic: hypokalemia.

Skin: mild local irritation (injection site bleeding, rash, pruritus), bullous

eruption, purpura, rash, increased wound drainage.

NURSING CONSIDERATIONS

- Monitor these patients closely for neurologic impairment.

- Monitor renal function periodically and stop drug in patients who develop

unstable renal function or severe renal impairment while receiving therapy.

- Routinely assess patient for signs and symptoms of bleeding, and

regularly monitor CBC, platelet count, creatinine level, and stool occult

blood test results. Stop use if platelet count is less than 100,000/mm3.

PATIENT TEACHING

- Tell patient to report signs and symptoms of bleeding.

3. Dobutamine 250 mg drip to start at 5 mkd to achieve BP > 90/60

Therapeutic class: Inotrope

INDICATIONS

- Increased cardiac output in short term treatment of cardiac decompensation

caused by depressed contractility, such as during refractory heart failure;

adjunctive therapy in cardiac surgery.


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ACTION

- Stimulates hearts beta 1 receptors to increase myocardial contractility and

stroke volume. At therapeutic dosages, drug increases cardiac output by

decreasing peripheral vascular resistance, reducing ventricular filling pressure,

and facilitating AV node conduction.

ADVERSE REACTIONS

CNS: headache.

CV: hypertension, increased heart rate, angina, PVCs, phlebitis, nonspecific

chest pain, palpitations, ventricular ectopy, hypotension.

GI: nausea, vomiting.

Respiratory: asthma attack, shortness of breath.

Other: anaphylaxis, hypersensitivity reactions.


Alert: Because drug increases AV node conduction, patients with atrial fibrillation

may develop a rapid ventricular rate.

- Continuously monitor ECG, blood pressure, pulmonary artery wedge pressure,

cardiac output, and urine output.

- Monitor electrolyte levels. Drug may lower potassium level.

PATIENT TEACHING

- Tell patient to report adverse reactions promptly, especially labored breathing

and drug-induced headache.

- Instruct patient to report discomfort at I.V. insertion site.

2. Alprazolam 250 mcg at bedtime


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Therapeutic class:Anxiolytic

INDICATIONS

Anxiety

ACTION

- Unknown. Probably potentiates the effects of GABA,

depresses the CNS, and suppresses the spread of seizure

activity.

ADVERSE REACTIONS

CNS: insomnia, irritability, dizziness, headache, anxiety,

confusion, drowsiness, light-headedness, sedation,

somnolence, difficulty speaking, impaired coordination,

memory impairment, fatigue, depression, suicide, mental

impairment, ataxia, paresthesia, dyskinesia, hypoesthesia,

lethargy, vertigo, malaise, tremor, nervousness,

restlessness, agitation, nightmare, syncope, akathisia,

mania.

CV: palpitations, chest pain, hypotension.

EENT: allergic rhinitis, blurred vision, nasal congestion.

GI: diarrhea, dry mouth, constipation, nausea, increased or

decreased appetite, anorexia, vomiting, dyspepsia,

abdominalpain.


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GU: dysmenorrhea, sexual dysfunction, premenstrual

syndrome, difficulty urinating.

Metabolic: increased or decreased weight.

Musculoskeletal: arthralgia, myalgia, arm or leg pain, back

pain, muscle rigidity, muscle cramps, muscle twitch.

Respiratory: upper respiratory tract infection, dyspnea,

hyperventilation.

Skin: pruritus, increased sweating, dermatitis.

Other: influenza, injury, emergence of anxiety between

doses, dependence, feeling warm, increased or decreased

libido.


Alert: Dont withdraw drug abruptly; withdrawal symptoms,

including seizures, may occur. Abuse or addiction is

possible.

Monitor hepatic, renal, and hematopoietic function

periodically in patients receiving repeated or prolonged

therapy.

Closely monitor addiction-prone patients.

3. Paracetamol 500 mg tab q 8 hours

Therapeutic class:Analgesic


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INDICATIONS

Mild pain or fever

ACTION

- Thought to produce analgesia by inhibiting prostaglandin

and other substances that sensitize pain receptors. Drug

may relieve fever through central action in the hypothalamic

heat-regulating center.

ADVERSE REACTIONS

Hematologic: hemolytic anemia, leukopenia, neutropenia,

pancytopenia.

Hepatic: jaundice.

Metabolic: hypoglycemia.

Skin: rash, urticaria.


Alert: Many OTC and prescription products contain

acetaminophen; be aware of this when calculating total daily

dose.

.

PATIENT TEACHING

Advise parents that drug is only for short term use; urge

them to consult prescriber if giving to children for longer than

5 days or adults for longer than 10 days.


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Alert: Advise patient or caregiver that many OTC products

contain acetaminophen and should be counted when

calculating total daily dose.

Tell patient not to use for marked fever (temperature higher

than 39.5 C, fever persisting longer than 3 days, or

recurrent fever unless directed by prescriber.

Alert: Warn patient that high doses or unsupervised long-

term use can cause liver damage. Excessive alcohol use

may increase the risk of liver damage. Caution long-term

alcoholics to limit drug to 2 g/day or less.

4. ISMN 20 mg/tab 1 tab BID with BP preacautions

Isoket Drip for persistent chest pain

Therapeutic class:Antianginal

INDICATIONS

Acute anginal attacks to prevent situations that may cause

anginal attacks

ACTION

- Thought to reduce cardiac oxygen demand by decreasing

preload and afterload. Drug also may increase blood flow

through the collateral coronary vessels.


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ADVERSE REACTIONS

CNS: headache, dizziness, weakness.

CV: orthostatic hypotension, tachycardia, palpitations, ankle

edema, flushing, fainting.

EENT: sublingual burning.

GI: nausea, vomiting.

Skin: cutaneous vasodilation, rash.


Monitor blood pressure and heart rate and intensity and

duration of drug response.

Drug may cause headaches, especially at beginning of

therapy. Dosage may be reduced temporarily, but tolerance

usually develops. Treat headache with aspirin or

acetaminophen.

PATIENT TEACHING

Caution patient to take drug regularly, as prescribed, and to

keep it accessible at all times.

Alert: Advise patient that stopping drug abruptly may cause

spasm of the coronary arteries with increased angina

symptoms and potential risk of heart attack.

Warn patient not to confuse S.L. with P.O. form.


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Tell patient to minimize dizziness upon changing to upright

position slowly. Advise him to go up and down stair to lie

down at first sign of dizziness.

5. Atropine 1g IV now, amp

Therapeutic class:Antiarrhythmic

INDICATIONS

Symptomatic bradycardia, bradyarrhythmia (junctional or

escape rhythm)

ACTION

- Inhibits acetylcholine at parasympathetic neuroeffector

junction, blocking vagal effects on SA and AV nodes,

enhancing conduction through AV node and increasing heart

rate.

ADVERSE REACTIONS

CNS: headache, restlessness, insomnia, dizziness, ataxia,

disorientation, hallucinations,delirium, excitement, agitation,

confusion.

CV: bradycardia, palpitations, tachycardia.

EENT: blurred vision, mydriasis, photophobia, cycloplegia,

increased intraocular pressure.

GI: dry mouth, constipation, thirst, nausea, vomiting.


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GU: urine retention, impotence.

Other: anaphylaxis.


Aler t : Watch for tachycardia in cardiac patients because

it may lead to ventricular fibrillation.

Many adverse reactions (such as dry mouth and

constipation) vary with dose.

Monitor fluid intake and urine output. Drug causes urine

retention and urinary hesitancy.

PATIENT TEACHING

Instruct patient to report serious or persistent adverse

reactions promptly.

.

6. Morphine 2 mg IV now then q 4 hours for severe chest

pain

Therapeutic class: Opioid analgesic

INDICATIONS

Moderate to severe pain

ACTION

- Unknown. Binds with opioid receptors in the CNS, altering

perception of and emotional response to pain.


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ADVERSE REACTIONS

CNS: dizziness, euphoria, lightheadedness, nightmares,

sedation, somnolence, seizures, depression, hallucinations,

nervousness, physical dependence, syncope.

CV: bradycardia, cardiac arrest, shock, hypertension,

hypotension, tachycardia.

GI: constipation, nausea, vomiting, anorexia, biliary tract

spasms, dry mouth,ileus.

GU: urine retention.

Hematologic: thrombocytopenia.

Respiratory: apnea, respiratory arrest, respiratory

depression.

Skin: diaphoresis, edema, pruritus, skin flushing.

Other: decreased libido.


Reassess patients level of pain at least 15 and 30 minutes

after giving parenterally.

Keep opioid antagonist (naloxone) and resuscitation

equipment available.


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Monitor circulatory, respiratory, bladder, and bowel

functions carefully. Drug may cause respiratory depression,

hypotension, urine retention, nausea, vomiting, ileus, or

altered level of consciousness regardless of the route. If

respirations drop below 12 breaths/minute, withhold dose

and notify prescriber. Morphine has an abuse liability similar

to other opioid analgesics and may be misused, abused, or

diverted.

7. Diltiazem 30 mg BID

Therapeutic class:Antihypertensive

INDICATION:

Atrial fibrillation or flutter; paroxysmalsupraventricular

tachycardia

ACTION

- A calcium channel blocker that inhibits calcium ion influx

across cardiac and smooth muscle cells, decreasing

myocardial contractility and oxygen demand. Drug also

dilates coronary arteries and arterioles.

ADVERSE REACTIONS

CNS: headache, dizziness, asthenia, somnolence.


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CV: edema, arrhythmias, AV block, bradycardia, heart

failure, flushing, hypotension, conduction abnormalities,

abnormal ECG.

GI: nausea, constipation, abdominal discomfort.

Hepatic: acute hepatic injury.

Skin: rash.


Monitor blood pressure and heart rate when starting

therapy and during dosage adjustments.

Maximal antihypertensive effect may not be seen for 14

days.

If systolic blood pressure is below 90 mmHg or heart rate is

below 60 beats/minute, withhold dose and notify prescriber.

.

PATIENT TEACHING

Instruct patient to take drug as prescribed, even when he

feels better.

If nitrate therapy is prescribed during dosage adjustment,

stress patient compliance.

8. Verapamil 2.5 g IV now



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INDICATIONS

To prevent paroxysmal supraventricular tachycardia

ACTION

- Not clearly defined. A calcium channel blocker that inhibits

calcium ion influx across cardiac and smooth-muscle cells,

thus decreasing myocardial contractility and oxygen

demand; it also dilates coronary arteries and arterioles.

ADVERSE REACTIONS

CNS: dizziness, headache, asthenia, fatigue, sleep

disturbances.

CV: transient hypotension, heart failure, bradycardia, AV

block, ventricular asystole, ventricular fibrillation, peripheral

edema.

GI: constipation, nausea, diarrhea, dyspepsia.

Respiratory: dyspnea, pharyngitis, pulmonary edema,

rhinitis, sinusitis, upperrespiratory infection.

Skin: rash.


Monitor blood pressure at the start of therapy and during

dosage adjustments. Assist patient with walking because

dizziness may occur.


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If signs and symptoms of heart failure occur, such as

swelling of hands and feet and shortness of breath, notify

prescriber.

PATIENT TEACHING

Encourage patient to increase fluid and fiber intake to

combat constipation. Give a stool softener.

9. Amiodarone drip 300 mg in D5W250 cc x 24 hours

Therapeutic class:Antiarrhythmic

INDICATIONS

- Amiodarone is intended for use only in patients with life

threatening recurrent ventricular fibrillation or recurrent

hemodynamically unstable ventricular tachycardia

unresponsive to adequate doses of other antiarrhythmics or

when alternative drugs cant be tolerated.

ACTION

- Effects result from blockade of potassium chloride leading

to a prolongation of action potential duration.

ADVERSE REACTIONS

CNS: fatigue, malaise, tremor, peripheral neuropathy, ataxia,

paresthesia, insomnia, sleep disturbances, headache.


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CV: hypotension, bradycardia, arrhythmias, heart failure,

heart block, sinus arrest, edema.

EENT: asymptomatic corneal microdeposits, visual

disturbances, optic neuropathy or neuritis resulting in visual

impairment, abnormal smell.

GI: nausea, vomiting, abnormal taste, anorexia, constipation,

abdominal pain.

Hematologic: coagulation abnormalities.

Hepatic: hepatic failure, hepatic dysfunction.

Metabolic: hypothyroidism, hyperthyroidism.

Respiratory: acute respiratory distress

syndrome, SEVERE PULMONARY TOXICITY.

Skin:photosensitivity, solar dermatitis, blue-gray skin.


Be aware of the high risk of adverse reactions.

Obtain baseline pulmonary, liver, and thyroid function test

results and baseline chest X-ray. Give loading doses in a

hospital setting and with continuous ECG monitoring

because of the slow onset of antiarrhythmic effect and the

risk of life-threatening arrhythmias. Drug may pose life

threatening management problems in patients at risk for


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sudden death. Use only in patients with life-threatening,

recurrent ventricular arrhythmias unresponsive to or

intolerant of other antiarrhythmics or alternative drugs.

Amiodarone can cause fatal toxicities, including hepatic and

pulmonary toxicity. Drug is highly toxic. Watch carefully for

pulmonary toxicity. Risk increases in patients receiving

doses over 400 mg/day.

Watch for evidence of pneumonitis, exertional dyspnea,

nonproductive cough, and pleuritic chest pain. Monitor

pulmonary function tests and chest X-ray.

Monitor liver and thyroid function test results and electrolyte

levels, particularly potassium and magnesium.

Monitor blood pressure and heart rate and rhythm

frequently. Perform continuous ECG monitoring when

starting or changing dosage. Notify prescriber of significant

change in assessment results.

PATIENT TEACHING

Tell patient to contact prescriber if he has vision changes,

weakness, pins and needles or numbness, poor

coordination, weight change, heat or cold intolerance, or

neck swelling.


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10. Sulbactam Ampicillin 1.5 g IV q 8 ANST (-)

Therapeutic class:Antibiotic

INDICATIONS

- infections caused by susceptible strains, community-acquired

pneumonia

ACTION

- Inhibits cell-wall synthesis during bacterial multiplication.

ADVERSE REACTIONS

GI: diarrhea, nausea, pseudomembranous colitis, black hairy

tongue, enterocolitis,gastritis, glossitis, stomatitis, vomiting.

Hematologic: agranulocytosis, leukopenia, thrombocytopenia,

thrombocytopenic purpura, anemia, eosinophilia.

Skin:pain at injection site.

Other: hypersensitivity reactions, anaphylaxis, overgrowth of

nonsusceptibleorganisms.


Dosage is expressed as total drug. Each 1.5-g vial contains 1

g ampicillin sodium and 0.5 g sulbactam sodium.

In patients with impaired renal function, decrease dosage.


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Monitor liver function test results during therapy, especially in

patients with impaired liver function.

.

PATIENT TEACHING

Tell patient to report rash, fever, or chills. A rash is the most

common allergic reaction.

Warn patient that I.M. injection may cause pain at injection site.

11. Metoprolol 50 mg tab now then BID


INDICATIONS

- Early intervention in acute MI, angina pectoris

ACTION

- Unknown. A selective beta blocker that selectively blocks

beta 1 receptors; decreases cardiac output, peripheral

resistance, and cardiac oxygen consumption; and depresses

renin secretion.

ADVERSE REACTIONS

CNS: fatigue, dizziness, depression.

CV: hypotension, bradycardia, heart failure, AV block, edema.

GI: nausea, diarrhea, constipation, heartburn.

Respiratory: dyspnea, wheezing.


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Skin: rash.


Always check patients apical pulse rate before giving drug. If

its slower than 60 beats/minute, withhold drug and call

prescriber immediately.

Monitor blood pressure frequently; drug masks common signs

and symptoms of shock.

PATIENT TEACHING

Instruct patient to take drug exactly as prescribed and with

meals.

Tell patient to alert prescriber if shortness of breath occurs.

Instruct patient not to stop drug suddenly but to notify

prescriber about unpleasant adverse reactions. Inform him that

drug must be withdrawn gradually over 1 or 2 weeks.

12. KCl tabs, 1 tab TID

Therapeutic class: Potassium supplement

INDICATIONS

To prevent hypokalemia

ACTION

Replaces potassium and maintains potassium level.


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ADVERSE REACTIONS

CNS: paresthesia of limbs, listlessness, confusion,

weakness or heaviness of limbs, flaccid paralysis.

CV: postinfusion phlebitis, arrhythmias, heart block, cardiac

arrest, ECG changes,hypotension.

GI: nausea, vomiting, abdominal pain, diarrhea.

Metabolic: hyperkalemia.

Respiratory: respiratory paralysis.


Monitor ECG and electrolyte levels during therapy.

Monitor renal function.

PATIENT TEACHING

Teach patient signs and symptoms of hyperkalemia, and

tell patient to notify prescriber if they occur.

13. Lactulose 15 cc HS

Therapeutic class: Laxative

INDICATIONS

Constipation

ACTION


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- Produces an osmotic effect in colon; resulting distention

promotes peristalsis. Also decreases ammonia, probably as

a result of bacterial degradation, which lowers the pH of

colon contents.

ADVERSE REACTIONS

GI: abdominal cramps, belching, diarrhea, flatulence,

gaseous distention, nausea,vomiting.

NURSING CONSIDERATIONS.

Monitor mental status and potassium levels.

Replace fluid loss.

.

PATIENT TEACHING

Inform patient about adverse reactions and tell him to notify

prescriber if reactions become bothersome or if diarrhea

occurs.

Instruct patient not to take other laxatives during lactulose

therapy.

14. Co-amoxiclav 625 mg 1 tab TID

Therapeutic class:Antibiotic


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INDICATIONS

Lower respiratory tract infections, community-acquired

pneumonia

ACTION

Prevents bacterial cell-wall synthesis during replication.

increases amoxicillins effectiveness by inactivating beta-

lactamases, which destroy amoxicillin.

ADVERSE REACTIONS

CNS: agitation, anxiety, behavioral changes, confusion,

dizziness, insomnia.

GI: nausea, vomiting, diarrhea, indigestion, gastritis,

stomatitis, glossitis, black hairy tongue, enterocolitis,

pseudomembranous colitis, mucocutaneous candidiasis,

abdominal pain.

GU: vaginal candidiasis, vaginitis.

Hematologic: anemia, thrombocytopenia, thrombocytopenic

purpura, eosinophilia,leukopenia, agranulocytosis.

Other: hypersensitivity reactions, anaphylaxis, pruritus, rash,

urticaria, angioedema, overgrowth of nonsusceptible

organisms, serum sicknesslike reaction. Use cautiously in


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hepatically impaired patients, and monitor the hepatic

function ofthese patients.


Alert: Both 250- and 500-mg film-coated tablets contain the

same amount of clavulanic acid (125 mg). Therefore, two

250-mg tablets arent equivalent to one 500-mg tablet.

Regular tablets arent equivalent to Augmentin XR.

PATIENT TEACHING

Tell patient to take entire quantity of drug exactly as

prescribed, even after feeling better.

Instruct patient to take drug with food to prevent GI upset. If

hes taking the oral suspension, tell him to keep drug

refrigerated, to shake it well before taking it, and to discard

remaining drug after 10 days.

Tell patient to call prescriber if a rash occurs because rash

is a sign of an allergic reaction.

15. Captopril 25 mg/tab tab BID



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INDICATIONS

Hypertension, left ventricular dysfunction after acute MI

ACTION

- Inhibits ACE, preventing conversion of angiotensin I to

angiotensin II, a potent vasoconstrictor. Less angiotensin II

decreases peripheral arterial resistance, decreasing

aldosterone secretion, which reduces sodium and water

retention and lowers blood pressure.

ADVERSE REACTIONS

CNS: dizziness, fainting, headache, malaise, fatigue, fever.

CV: tachycardia, hypotension, angina pectoris.

GI: abdominal pain, anorexia, constipation, diarrhea, dry

mouth, dysgeusia, nausea, vomiting.

Hematologic: leukopenia, agranulocytosis,

thrombocytopenia, pancytopenia, anemia.

Metabolic: hyperkalemia.

Respiratory: dry, persistent, nonproductive cough, dyspnea.

Skin: urticarial rash, maculopapular rash, pruritus, alopecia.

Other: angioedema.therapy, and periodically thereafter.

PATIENT TEACHING


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Instruct patient to take drug 1 hour before meals; food in

the GI tract may reduce absorption.

Inform patient that light-headedness is possible, especially

during first few days of therapy. Tell him to rise slowly to

minimize this effect and to report occurrence to prescriber.

If fainting occurs, he should stop drug and call prescriber

immediately.

Tell patient to use caution in hot weather and during

exercise. Lack of fluids, vomiting, diarrhea, and excessive

perspiration can lead to light-headedness and syncope.

Advise patient to report signs and symptoms of infection,

such as fever and sore throat.

Tell women to notify prescriber if pregnancy occurs. Drug

will need to be stopped.

Urge patient to promptly report swelling of the face, lips, or

mouth; or difficulty breathing.


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PRIORITIZATION AND LIST OF NURSING DIAGNOSIS

The following nursing diagnoses were prioritized based on Maslows Hierarchy of

Needs and ABCs:

1. Decreased Cardiac Output related to reduced mechanical function of the heart

and altered electrical conduction as evidenced by changes in rate, rhythm,

electrical conduction

2. Tissue Perfusion, ineffective related to reduction of blood flow secondary to

decreased cardiac output as evidenced by BP = mmHg, CR = 46 bpm

3Acute pain related to ischemia of myocardial tissue as evidenced by verbal

report of chest pain rated as 7-8, 10 as the highest, 1 as the lowest.

2. Activity intolerance related to imbalance between myocardial oxygen

supply and demand presence of ischemia of myocardial tissues as

evidenced by easy fatigability

3. Infection related to spread of infectious agents

4. Risk for sedentary lifestyle related to safety concerns, fear of injury

5. Anxiety related to deficient knowledge regarding cause, treatment, self-

care, and discharge needs related to lack of information of medical

condition as evidenced by questions

6. Therapeutic regimen: ineffective management related to complexity of

therapeutic regimen decisional conflicts

7. Grieving, anticipatory related to perceived loss of general well-being,

required changes in lifestyle, confronting mortality


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8. Family Processes, interrupted related to situational transition and crisis

9. Home Management, impaired related to altered ability to perform tasks,

inadequate support systems, reluctance to request assistance.

10. Decisional Conflict (treatment) related to multiple/divergent sources of

information, perceived threat to value system, support system


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K. CONCLUSION AND RELEVANCE OF THE STUDY

Myocarditis is the end result of both myocardial infection and

autoimmunity that results in active inflammatory destruction of

myocytes. Its precise characterization and natural history have been

limited by the extraordinary variability of its clinical presentations,

laboratory findings, and the diversity of etiologies. The relatively low

incidence and difficulties in unequivocally establishing a diagnosis

have limited the conduct of large-scale, randomized clinical trials to

evaluate treatment strategies.

ECG, echocardiography, measurement of serum troponin, and

noninvasive cardiac MRI are warranted for initial diagnostic evaluation.

Myocarditis should be considered in patients who lack evidence of

coronary atherosclerosis or other pathophysiological etiologies such as

stress-induced cardiomyopathy (takotsubo syndrome).

Treatment of myocarditis remains largely supportive. Currently, the

standard of care remains hemodynamic and cardiovascular support,

including use of ventricular assist devices and transplantation when

necessary. Pharmacological therapy should consist of a heart failure

regimen demonstrated to improve hemodynamics and symptoms.

Although the high rate of spontaneous improvement in acute

myocarditis and cardiomyopathy provides some optimism, patients

who progress to chronic dilated cardiomyopathy experience 5-year


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survival rates


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REFERENCES

Books

1. Brunner, L. S., Suddarth, D. S., & Smeltzer, S. C. O. (2008). Brunner &Suddarth's textbook of medical-surgical nursing (11th ed.). Philadelphia:Lippincott Williams & Wilkins.

2. Davis, F. (2010). Nursing diagnosis manual: planning, individualizing and

documenting client care (3rd ed.). Philadelphia

: F. A. Davis Company.

3. Davis, F. (2012). Nursing drug handbook (32nd ed.). China: F. A. DavisCompany.

4. Doenges, M. et al., (2006). Nursing care plans: guidelines forindividualizing client care across the life span (7th ed.). Philadelphia: F. A. Davis Company.

5. Porth, C. (2011). Essentials of pathophysiology: concepts of altered healthstates (2

nded.). Philadelphia: Lippincott Williams and Wilkins.

6. Robinson, J. (2012) Pathophysiology made incredibly visual (2nd

ed.).China: Lippincott Williams and Wilkins.

7. Van Leeuwen, A. (2006) Daviss comprehensive handbook of laboratoryand diagnostic tests with nursing implications(2

nded.). Philadelphia:F. A.

Davis Company.

Journals:

1. Feldman, A. et al., (2001) Myocarditis. The New England Journal ofMedicine. 343:1388-1398.

2. Uhl, T. (2008) Viral Myocarditis in Children. Critical Care Nurse. 28 no.142-63.


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3. Magnani, J. et al., (2006) Myocarditis: Current Trends in Diagnosis and

Treatment. Circulation.113:876-890.

MYOCARDITIS; 3RD DEGREE AV BLOCK

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