Myocarditis, long-term care

Introduced: February 7, 2015

Overview
Focal or diffuse inflammation of the myocardium that's typically uncomplicated and self-limiting
May be acute or chronic

Pathophysiology
An infectious organism triggers an autoimmune, cellular, and humoral reaction.
Inflammation may lead to hypertrophy, fibrosis, and inflammatory changes of the myocardium and
conduction 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.

Causes
Idiopathic
Bacteria
Chronic alcoholism
Helminthic infections such as trichinosis
Hypersensitive immune reactions such as acute rheumatic fever
Parasitic infections
Radiation therapy
Viruses (most common cause)
Drugs such as cocaine or other toxins
Drugs such as cocaine, chemotherapeutic agents (eg, DOXOrubicin, cyclophosphamide [Cytoxan]),
antibiotics (eg, penicillin, chloramphenicol), antihypertensives (eg, methyldopa, spironolactone
[Aldactone])
Enterotoxins associated with septic shock
Autoimmune conditions
Radiation
Heat stroke, hypothermia
Systemic inflammatory conditions

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

Complications
Left-sided heart failure
Cardiomyopathy
Chronic valvulitis (when it results from rheumatic fever)
Arrhythmias

Thromboembolism
Irreversible ventricular failure

Assessment
History
Possible recent upper respiratory tract infection with fever, viral pharyngitis, or tonsillitis
Nonspecific symptoms, such as fatigue, dyspnea, palpitations, persistent tachycardia, and persistent
fever
Chills, sweats, malaise
Mild continuous pressure or soreness in the chest

Physical Findings
S3 and S4 gallops, muffled S1
Pericardial friction rub
Tachypnea, retractions
Jugular vein distension
Arrhythmias
Hepatomegaly
Weak peripheral pulses
Cool extremities
Poor capillary refill

Diagnostic Test Results

Laboratory
Levels of cardiac enzymes, including creatine kinase (CK), CK-myocardial bound, aspartate
aminotransferase, 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 causative
bacteria or virus.

Imaging
Two-dimensional echocardiogram may reveal impaired systolic or diastolic ventricular function and
helps 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 Procedures
Biopsy of the endomyocardium may confirm myocarditis.
Electrocardiogram is highly variable but may show sinus tachycardia, a diffuse ST-segment, and Twave 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

General
Supportive care
Hospitalization until stabilized in patient with signs and symptoms of heart failure
Mechanical ventilation in patients with severe respiratory failure secondary to myocardial failure
Mechanical cardiac support, such as ventricular assist devices
Withdrawal of offending agent, if indicated
Cardioversion to convert supraventricular arrhythmias if present
Extracorporeal membrane oxygenation for short-term circulatory support

Diet
Avoidance of alcohol
Low-sodium

Activity
Modified bed rest during acute phase
As tolerated

Medications
Anti-infectives to treat underlying infection as indicated
Antiarrhythmics to treat hemodynamically significant arrhythmias
Anticoagulants, such as heparin for acute condition or warfarin sodium for chronic condition
involving severe myocardial depression or ventricular dilation
Angiotensin-converting enzyme (ACE) inhibitors, such as enalapril, to treat heart failure
Diuretics, such as furosemide, to treat heart failure
Nitroglycerin or sodium nitroprusside to reduce systemic vascular resistance
Inotropic agents, such as milrinone lactate, DOPamine hydrochloride, or DOBUTamine hydrochloride
Beta-adrenergic blocker with or without digitalis
High-dose I.V. gamma globulin during acute phase
Vasopressors (if heart failure is present)
Anticoagulants such as warfarin if atrial fibrillation is present
Oxygen if indicated

Surgery
Pacemaker implantation
Ventricular assist device implantation
Heart transplantation

Nursing Considerations for Long-Term Care

Nursing Diagnoses
Activity intolerance
Anxiety
Decreased cardiac output
Deficient knowledge
Excess fluid volume
Fatigue
Impaired gas exchange
Risk for decreased cardiac perfusion
Risk for electrolyte imbalance

Risk for ineffective peripheral tissue perfusion

Risk for infection

Expected Outcomes
The resident will:
carry out activities of daily living without weakness or fatigue
cope with his medical condition without demonstrating severe signs of anxiety
maintain hemodynamic stability and adequate cardiac output without arrhythmia
verbalize an understanding of the condition and its causes
identify the planned treatment regimen
get adequate rest and will verbalize baseline energy levels
maintain adequate ventilation and oxygenation
express feelings about his diminished capacity to perform usual roles
maintain adequate fluid and electrolyte balance.

Nursing Interventions
Stress the importance of bed rest, especially during the acute phase, to minimize myocardial oxygen
demands. Provide a bedside commode.
Allow the resident to express his concerns about the effects of activity restrictions on his
responsibilities and routines, assist in identifying positive coping strategies, and assist with
relaxation 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 any
pitting.
Allow for frequent rest periods; cluster care activities to provide for rest and minimize energy
expenditure. 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.

Monitoring
Vital signs
Cardiovascular status including cardiac rate and rhythm
Hemodynamic status
Respiratory and pulmonary status
Fluid balance; intake and output
Signs and symptoms of heart failure
Weight
Response to treatment
Edema
Activity tolerance
Anxiety level; coping strategies
Oxygen levels
Condition changes
Peripheral pulses
Laboratory monitoring

Associated Nursing Procedures

Admission, long-term care
Advance directives, long-term care
Assessment differences in the older adult, long-term care

Care plan preparation, long term care

Change in status, identifying and communicating, long-term care
Health history interview and physical assessment, long term care
Oral drug administration
Pulse assessment, long-term care
Pulse oximetry
12-lead electrocardiogram (ECG)
Venipuncture

Nursing Considerations for Acute Care

Nursing Diagnoses
Activity intolerance
Anxiety
Decreased cardiac output
Deficient diversional activity
Deficient knowledge: Disease process
Deficient knowledge: Treatment
Impaired gas exchange
Ineffective coping
Ineffective role performance

Expected Outcomes
The patient will:
carry out activities of daily living without weakness or fatigue
cope with his medical condition without demonstrating severe signs of anxiety
maintain hemodynamic stability and adequate cardiac output without arrhythmia
express interest in using his leisure time meaningfully
verbalize an understanding of the condition and its causes
identify the planned treatment regimen
maintain adequate ventilation and oxygenation
demonstrate positive coping strategies
express feelings about his diminished capacity to perform usual roles.

Nursing Interventions
Stress the importance of bed rest, especially during the acute phase, to minimize myocardial oxygen
demands. Provide a bedside commode.
Allow the patient to express his concerns about the effects of activity restrictions on his
responsibilities and routines, assist in identifying positive coping strategies, and assist with
relaxation 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 mechanical
ventilator 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 energy
expenditure. 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 ventricular
assist device or pacemaker or cardiac transplant.

Monitoring
Vital signs
Cardiovascular status including cardiac rate and rhythm
Hemodynamic status
Respiratory and pulmonary status
Fluid balance; intake and output
Signs and symptoms of heart failure
Daily weight
Response to treatment
Activity tolerance
Anxiety level; coping strategies
Postoperative status as appropriate
Ventricular assist device function

Associated Nursing Procedures

Blood pressure assessment
Calculating and setting an IV drip rate
Cardiac monitoring
Health history interview and physical assessment
Intake and output assessment
Intra-aortic balloon insertion, assisting
Intra-aortic balloon management
IV bag preparation
IV bolus injection
IV catheter insertion
Nutritional screening
Oral drug administration
Pulse assessment
Respiration assessment
Temperature assessment
12-lead electrocardiogram (ECG)
Venipuncture

Patient Teaching
General
Be sure to cover:
disorder, diagnosis, possible underlying causes, and treatment, including the condition's effect on
cardiac function, medications, and assistive devices for respiratory and cardiac function
prescribed medications, including drug name, dosage, frequency of administration, and duration of
therapy
potential adverse reactions of prescribed medications, such as fluid and electrolyte imbalances with
diuretic therapy, possible dizziness or light-headedness, and GI upset with ACE inhibitors
signs and symptoms of heart failure, including shortness of breath, dyspnea, and swelling of the
extremities
how to monitor pulse rate and rhythm if indicated, how to monitor daily weight, and the need to report
any sudden weight gain
dangerous signs and symptoms and the need to notify the practitioner if any occur
importance of continued follow-up care, including laboratory testing and visits to the practitioner
every 1 to 3 months to evaluate therapy effectiveness
postoperative care measures, including care of the surgical site, device use and function, and signs
and symptoms of complications that need to be reported immediately
importance of adhering to follow-up, including laboratory testing as appropriate.

Discharge Planning
Refer 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-up
care.
Refer the patient to home health care services if indicated.

Resources
American Heart Association: www.americanheart.org
Mayo Clinic: www.mayoclinic.com
National 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), S7S11.
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. JACC
Cardiovascular Imaging, 5 (5), 525527.
Abstract | Complete Reference
6. Hsiao, J. F., et al. (2013). Speckle tracking echocardiography in acute myocarditis . International Journal
of Cardiovascular Imaging, 29 (2), 275284.
Abstract | Complete Reference
7. Hussein, A. A., et al. (2013). Inflammation and sudden cardiac death in a community-based population
of older adults: The Cardiovascular Health Study. Heart Rhythm, 10 (10), 14251432. (Level IV)
Abstract | Complete Reference
8. Lindenfeld, J., et al. (2010). HFSA 2010 Comprehensive Heart Failure Practice Guideline. Journal of
Cardiac Failure, 16 (6), e1e194.
Abstract | Complete Reference
9. Liu, Z. L., et al. (2012). Herbal medicines for viral myocarditis . Cochrane Database of Systematic
Reviews, 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 20122014 2012, 19942012 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), 738747.
13. Tang, W. H. (2013)Myocarditis [Online]. Accessed November 2014 via the Web at
http://emedicine.medscape.com/article/156330-overview
14. 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), 14481456.
Abstract | Complete Reference | Full Text | Ovid Full Text

Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions

The 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 randomized

controlled 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: American
Medical 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. American
Journal of Preventive Medicine, 20, 21-35.
To make safe and effective judgments using NANDA-I nursing diagnoses, it is essential that nurses
refer to the definitions and defining characteristics of the diagnoses listed in Nursing Diagnoses:
Definitions and Classification 2012-2014 2012, 1994-2012 NANDA International (ISBN 987-0-47065482-8).
Copyright NANDA International, www.nanda.org Nursing Diagnoses - Definitions and Classification 20122014 2012, 1994-2012 NANDA International. Used by arrangement with Blackwell Publishing Limited,
a company of John Wiley & Sons, Inc.