J.F. is a 50-year-old married homemaker with a genetic autoimmune ...

[acc299]

J.F. is a 50-year-old married homemaker with a genetic autoimmune deficiency; she has had recurrent infective endocarditis.
 
  The most recent episodes were a Staphylococcus aureus infection of the mitral valve 16 months ago and a Streptococcus viridans infection of the aortic valve 1 month ago. During the
  latter hospitalization, an echocardiogram showed moderate aortic stenosis, moderate aortic insufficiency,
  chronic valvular vegetations, and moderate left atrial enlargement. Two years ago, J.F. received
  an 18-month course of total parenteral nutrition (TPN) for malnutrition caused by idiopathic, relentless
  nausea and vomiting (N/V). She has had coronary artery disease for several years and, 2 years ago had an
  acute anterior wall myocardial infarction (MI). In addition, she has a history of chronic joint pain.
  Now, after having been home for only a week, J.F. has been readmitted to your floor with endocarditis,
  N/V, and renal failure. Since yesterday, she has been vomiting and retching constantly; she also has had
 
  Admission Orders
  STAT blood cultures (aerobic and anaerobic)  2 30 minutes apart
  STAT CMP & CBC
  Begin TPN at 85 mL/hr
  Penicillin G potassium (Pfizerpen) 2 million units IVPB q4h
  Vancomycin (Vancocin), renal dosing per pharmacy, IVPB q12h
  Furosemide (Lasix) 80 mg/day PO
  Amlodipine (Norvasc) 5 mg/day PO
  Potassium chloride (K-Dur) 40 mEq/day PO
  Metoprolol (Lopressor) 25 mg PO bid
  Ondansetron (Zofran) 4 mg IV every 4-6 hours for N/V
  Transesophageal echocardiogram ASAP
  Admission Assessment
  Blood pressure 152/48 (supine) and 100/40 (sitting)
  Pulse rate 116 beats/min
  Respiratory rate 22 breaths/min
  Temperature 100.2  F (37.9  C)
  Oriented  3 but drowsy
  Grade II/VI holosystolic murmur and a grade III/VI diastolic murmur noted on auscultation
  Lungs clear bilaterally Abdomen soft with slight left upper quadrant (LUQ) tenderness
  Multiple petechiae on skin of arms, legs, and chest; splinter hemorrhages under the fingernails;
  hematuria noted in voided urine chills, fever, fatigue, joint pain, and headache. As you go through the admission process with her, you note that she wears glasses and has a dental bridge. Intravenous (IV) access is obtained with a double lumen
  peripherally inserted central catheter (PICC) line. Other orders and your assessment are shown in the box.
 
  What is the significance of the orthostatic hypotension and tachycardia?
 
  What is the significance of the abdominal tenderness, hematuria, joint pain, and petechiae?
 
  What are splinter hemorrhages and what is their significance?

Question 2

Mrs. W. has been with her husband since he arrived at the emergency department and is worried about his condition and his care.
 
  List five things you might do to make her more comfortable while her husband is in the MICU.

[TINA]

Answer to Question 1

These findings might indicate hypovolemia secondary to the intractable N/V and furosemide.

Embolization of vegetations from damaged heart valves, with resulting infarction of various organs,
is a common complication of endocarditis. Infarction of the spleen can manifest as abdominal
tenderness. Infarction of the kidneys causes hematuria and reduced urinary output. Petechiae result
from microembolization to small skin vessels, and arthritis from embolization to joints.

Splinter hemorrhages are red-brown linear streaks located under the fingernails. They are embolic
lesions and often occur with infectious endocarditis, although they also appear with trauma to the nails.

Answer to Question 2

 Explain to her that a nurse is watching her husband closely and that his heart rhythm is being
monitored at all times.
 Explain the equipment (monitoring devices, tubes, wires, alarms) used for his care. Familiarity with
them might make them seem less intimidating.
 Explain all procedures and treatments before they are performed.
 Report her husband's condition to her regularly. This demonstrates caring if the report is
unsolicited. It also engenders trust.
 Encourage her to take care of herself while her husband is in the hospital by eating well and
getting enough rest.
 Let her know that if she goes home for brief periods, she can call the MICU at any time to inquire
about her husband.
 Encourage her to seek support from friends, family, or clergy.
 Let her know it is OK to ask questions. Ask her if she has any questions, and encourage her to write
them down for future reference in talking with nurses and physicians.