Myocarditis (Nursing)

00:00 Hi, I'm Professor Lawes. And I want to welcome you to this part of our video series on myocarditis.

00:07 So, let's get started. Here you see an image of the heart.

00:10 Now, there's two things I want to draw your attention to - First, the pericardium, which is that sac around the heart, and next, the myocardium.

00:20 That when we're talking about myocarditis, it's an inflammatory disease of the myocardium.

00:26 That's why you see the letters itis after myocardial.

00:30 So, myocarditis means we've got an inflammatory disease of the heart muscle.

00:36 Now, the cause can sometimes be idiopathic, meaning we just don't know.

00:40 Or it might be caused by a virus, like you see there on the screen.

00:44 And there's also several immune- mediated causes of myocarditis.

00:49 Now, these are not likely things that you have to memorize, but just be aware that these can also be causes of myocarditis.

00:56 Now, some people have a genetic predisposition, or they have like this susceptibility to the myocytes being damaged.

01:02 So some of the causes can just you have a genetic predisposition to develop myocarditis.

01:08 There's also some drugs that we use to treat one thing, and we end up giving you myocarditis.

01:14 Drugs like doxorubicin, cyclophosphamide, and street drugs like cocaine.

01:21 Now, here's the NCSBN Clinical Judgment Measurement Model.

01:25 This is just a really fancy way of kind of writing out how nurses think, in safe clinical decision makings.

01:32 This is a way you think about how you make good sound effective clinical judgments.

01:38 Now, where most of the questions are going to come from on your exams, and even on the NCLEX are going to be right here in Layer 3.

01:45 So, you need to recognize cues, right? Analyze cues, prioritize hypothesis.

01:50 You've seen all six of those steps.

01:53 But what I'm going to focus on now is what are the cues that you should recognize? What are you looking for? So, here are the cues that I want you to be thinking about watching for in your patients and looking for on your exam questions.

02:07 Now, I'm going to kind of start at the top and go all the way down.

02:10 This is thinking about a heart that's inflamed, so it can't pump effectively.

02:16 The clearest way for you to do that is remember what the heart does when it is working, then these will be signs of, wow, this patient is getting into trouble.

02:24 First one, dyspnea.

02:26 They're going to feel like they're not getting enough oxygen, because they're not.

02:31 A heart that is not strong enough to pump because of the inflammation is not going to be able to deliver enough oxygen to the rest of the body, including the lungs.

02:42 The patient may have chest pain.

02:44 You may see that their heart rate is starting to go faster, because the body's trying to compensate.

02:50 You can also see different dysrhythmia.

02:53 So shorter breath because the heart can't move enough oxygen.

02:57 Fast heart rate, because the heart can't move enough oxygen.

03:00 So it's trying to move around what it has even faster.

03:03 They end up with fluid being in the wrong places.

03:07 When heart is no longer an adequate pump, fluid starts backing up and building up.

03:12 Now, where are the places you can see that? We can see jugular vein distension.

03:17 I have to have a patient and the appropriate position to assess this, but you'll see this vein kind of bulging out of their neck.

03:24 That's called jugular vein venous distension.

03:27 And that's a sign of fluid volume overload.

03:29 In this case, because the heart has been inflamed, and it can't pump adequately enough.

03:35 Now, another place you're going to see them is right here in the abdomen.

03:39 They may also have some weird kind of abdominal pain, and you'll note peripheral edema, particularly in their lower extremities.

03:46 Okay, so put that picture all together.

03:48 Someone's heart, their myocardium, it's inflamed.

03:52 What I want you to do is pause the video, and you look through each one of these cues.

03:58 And I want you to explain why you're having these particular problems and what to look for if you're in a patient's room.

04:12 Okay, welcome back.

04:14 I hope you took the time to do that. Because I promise you taking in some information, pausing and then practicing with it, that's the best way to make it stick.

04:23 So, parts of myocarditis seems like other diagnoses we looked at.

04:27 When the heart has trouble, patient has difficulty breathing.

04:30 Might have chest pain. Fluids going to be inappropriate places.

04:33 These are all similar symptoms, but they have different causes, and therefore different treatments.

04:39 So, when you do a physical exam, you're going to hear some really cool things.

04:44 You're going to hear a murmur.

04:45 Well, it's only cool if you pick it up.

04:47 Not cool if you're the patient who has the murmur.

04:50 [Murmur sound] You're also can hear an S3 and an S4 gallop.

05:00 Now we have other videos that will walk you through exactly what those sounds like.

05:04 But just want you to know the heart sounds could likely be abnormal.

05:09 You might hear a rub too.

05:11 You might have a pericardial friction rub, and that's from pericarditis.

05:16 That means an inflammation of that pericardial sac.

05:19 So, we know you're going to look different, shorter breath.

05:22 You're going to be kind of swollen, you might have right jugular vein distension. Right? You might be able to really uncomfortable, you might hear weird heart tones, where you hear a rub or an S3 or an S4 or a gallop.

05:36 So far, you've got a long list of cues that you want to be keeping in mind, so that you can recognize the possibility of myocarditis.

05:45 Now, lab work. This lines up with the other cardiac things we've talked about. Elevated troponin will tell us, "Oh, the heart is suffering. There's been some damage to the heart." So,lab work as a cue would be elevated troponin levels above normal.

06:00 Also, you might see some mild to moderate leukocytes or some atypical lymphocytes.

06:05 That's that whole inflammatory response going on in the myocarditis. We talked about rhythms.

06:11 You could look at a strip and see sinus tachycardia.

06:14 You can also see some other types of dysrhythmias as you're going through.

06:19 We've got some strips up there for you to watch You want to watch particularly at the ST and T wave changes.

06:25 Those could be a possibility.

06:26 You might see just any number of arrhythmias.

06:29 Remember, the myocardium is irritated, right? It's inflamed.

06:33 And when that happens, you can have some problems with the electro conduction system in the heart.

06:39 Now, one way to diagnose this is to do an endomyocardial biopsy.

06:45 Take a look at that picture. How do they get that? They're taking a tissue sample, right through the right atrium, right ventricle, where they can snatch some tissue from there.

06:56 Pretty radical, but it'll give you excellent information to know if the heart is inflamed.

07:01 Now, you've recognized cues, you've analyzed cues.

07:04 Now, we're moving over to that next column, and the NCSBN Clinical Judgment Measurement Model.

07:10 See right there, we're going to prioritize hypothesis and generate solutions, then take actions.

07:16 Now, when you're collaborative care with the healthcare provider, These are some of the things that your healthcare provider might order.

07:23 So, as a nurse, caring for this client, observing them and monitoring them, these are the type of treatments you might experience.

07:30 Our main overall goal is to manage the patient's symptoms.

07:34 So we've got a couple of medications I want to talk about that are direct cardiac medications.

07:39 Usually, you've seen these for blood pressure medications, but they have a use in myocarditis.

07:43 ACE inhibitors, pretty universal that these would be used.

07:47 Beta blockers on the other hand, you want to use with caution, because remember, a patient with myocarditis, that heart is kind of already inflamed, and it's really prone to having dysrhythmias and beta-blockers have a direct rate of decreasing the heart rate.

08:02 So, you want to make sure that you monitor these patients very closely.

08:07 Now two other groups of drugs by the diuretics like furosemide, and another drug that is particularly effective on the heart.

08:15 In fact, it can improve heart contractility, and reduce heart rate. That's called Digoxin.

08:21 Now, I also want to use digoxin with caution and care in patients with myocarditis, because it also could increase the risk of dysrhythmias.

08:31 So what else can I do for my patient that might not even require a physician's order? Well, Semi-Fowler's position is the go to position for anyone who's having respiratory difficulty.

08:41 Remember, someone in myocarditis has this fluid volume excess and often has dyspnea or difficult breathing.

08:49 Healthcare providers play a really active role in helping the patient space their activity with rest periods.

08:55 So, we want everyone to be active in someone with myocarditis is no exception.

08:59 But help them kind of space that activity with a rest period before they have a another time of activity.

09:06 Quiet environment will help decrease the stimuli allow the person to be calm and peaceful as they are healing and recovering.

09:14 Now, as a nurse, you are pivotal and actively monitoring the effects of the treatment.

09:19 You're listening to their lungs to see if lung sounds are clear.

09:23 You're monitoring for edema.

09:24 Make sure that that is resolving the diuretic is effective.

09:28 They're not having any really weird dysrhythmias That is your roles in nurse to actively monitor the treatments to make sure they are effective.

09:36 And remember, throughout the entire experience, our role is to keep the patient the center and the focus of our care.

09:43 So, keep them informed about the therapeutic plan and make sure they have as much choice as possible.

09:49 And that's it. That's our overview of myocarditis.

09:53 See in the next video.