Nursing Care Plan | NCP Myocarditis

Myocarditis describes the infiltration of myocardial cells by various forms of bacteria or viruses that damage the myocardium by inciting an inflammatory response. The actual incidence of myocarditis is unknown; many people are asymptomatic or have symptoms that may not be attributed to myocarditis. For this reason, a significant number of otherwise unexplained sudden deaths in young people and following childbirth may actually be due to the condition.

Myocarditis results in white blood cell (WBC) infiltration and necrosis of myocytes (heart muscle cells). Although myocarditis commonly is self-limiting, mild, and asymptomatic, it sometimes induces myofibril degeneration, which leads to right- and left-sided heart failure. When myocarditis recurs, it can produce chronic valvulitis (usually when it results from rheumatic fever), dysrhythmias, thromboembolism, or cardiomyopathy.

Myocarditis generally occurs as a result of an infectious agent, but it also can be caused by radiation or other toxic physical agents, such as lead. A variety of drugs, including phenothiazines, lithium and chronic use of cocaine, may also lead to myocarditis. In the United States, the most common cause of myocarditis is viral infection (e.g., coxsackie, Group B, ECHO), but a variety of bacterial, protozoal, parasitic, helminthic (such as trichinosis), and rickettsial infections can produce inflammation of the heart.

Nursing care plan assessment and physical examination

Establish a history of malaise, fatigue, dyspnea, palpitations, myalgias, and fever. Ask the patient to describe any chest pain or soreness, including the onset, location, intensity, and duration of the pain. Determine if the patient has experienced excessive tachycardia, both at rest and with effort. Elicit a history of medication use, particularly the use of phenothiazines, lithium, or cocaine. Ask if the patient has been exposed to radiation or lead or has undergone radiation therapy for lung or breast cancer. Determine if the patient has been previously diagnosed with rheumatic fever, infectious mononucleosis, polio, mumps, trichinosis, sarcoidosis, or typhoid. Develop a history of recent upper respiratory tract infections, including viral pharyngitis and tonsillitis. Ask if the patient has recently traveled to South America.

Although myocarditis is generally uncomplicated and self-limiting, it may induce myofibril degeneration that results in right and left heart failure. When heart failure progresses, a number of changes can occur. Inspect the patient for signs of cardiomegaly, neck vein distension, dyspnea, resting or exertional tachycardia that is disproportionate to the degree of fever, and supraventricular and ventricular dysrhythmias. Palpation may reveal a left ventricular heave. Auscultate for pericardal friction rub and, with heart failure, crackles in the lungs and an S3 heart sound. Auscultate breath sounds and heart sounds one to two times every 8 hours. Assess for signs and symptoms of decreased cardiac output (decreased urine output, delayed capillary refill, dizziness, syncope).

The patent is likely to be experiencing severe anxiety, even fear, since the condition involves his or her heart. Determine the patient’s knowledge of heart disease and the meaning that the diagnosis represents in his or her life. Assess the patient’s emotional, financial, and social resources to manage the disease.

Nursing care plan primary nursing diagnosis: Decreased cardiac output related to a reduced mechanical function of the heart muscle or valvular dysfunction.

Nursing care plan intervention and treatment plan

The primary goal of treatment of myocarditis is to eliminate the underlying cause. Patients admitted to the hospital are placed in a coronary care unit where their cardiac status can be observed via cardiac monitor. Oxygenation and rest are prescribed in order to prevent dysrhythmias and further damage to the myocardium. Apply intermittent compression boots, as prescribed, to prevent the complications of thrombophlebitis.

Congestive heart failure responds to routine management, including digitalization and diuresis, although patients with myocarditis appear to be particularly sensitive to digitalis. Observe for signs of digitalis toxicity such as anorexia, nausea, vomiting, blurred vision, and cardiac dysrhythmias. Patients with a low cardiac output state, which is commonly associated with severe congestive heart failure, require serial monitoring of cardiac filling pressures; a flow-directed pulmonary artery catheter has the capability of measuring cardiac output. With severe heart failure, dobutamine appears valuable because of its inotropic effects with limited vasoconstrictor and arrhythmogenic properties. Intractable congestive cardiac failure or shock, or both, in a patient with acute myocarditis may indicate the need for temporary partial or total cardiopulmonary bypass and eventual cardiac transplantation.

Focus on maximizing oxygen delivery and minimizing oxygen consumption. Encourage the patient to maintain bedrest with the head of the bed elevated. Stress the importance of bedrest by assisting with bathing, as necessary, and providing a bedside commode to reduce stress on the heart. For patients with enough mobility, encourage active range-of-motion activities to prevent blood stasis. For patients who are acutely ill, extremely weak, or in cardiac failure, perform passive rangeof- motion exercises. Provide regular skin care for the patient on bedrest to maintain skin integrity.

In addition to any prescribed analgesics, assist the patient with pain management by teaching relaxation techniques, guided imagery, and distractions. Encourage the patient to sit upright, leaning slightly forward, rather than lying supine. Use pillows to increase the patient’s comfort.

Before discharge, be sure to teach the patient about the pathophysiology of myocarditis. Explain the prescribed medications, any potential complications, and lifestyle limitations. Reassure the patient that activity limitations are temporary and that myocarditis is generally a selflimiting condition.

Nursing care plan discharge and home health care guidelines

Be sure the patient and family understand any medication prescribed, including dosage, route, action, and side effects. If the patient is on immunosuppression therapy, review the medications and strategies to limit infection. Review with the patient all follow-up appointments that are scheduled. Review the need to check with the physician before resuming physical activities. Caution the patient to avoid active physical exercise during and after viral or bacterial infection. Review the nature of the disease process and signs and symptoms to report to the physician.