Myocarditis 3RD Degree Av Block

EMERGENCY ROOM COMPLEX: MYOCARDITIS
PLEASE BE CAREFUL WITH MY HEART

MYCARDITIS, VIRAL; 3RD DEGREE AV BLOCK
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER

EMERGENCY ROOM COMPLEX
CHIQUI M. BUENO, RN, EMT-B

KIANA MAE W. DIWAG, RN, MAN
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.
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
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 1year 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
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
C. COURSE OF CONFINEMENT
1st Hospital Day October 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 ESR was 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.
-At CCU, patient was hooked to cardiac monitor revealing

bradycardia (CR-40-50s); Atropine Sulfate 1mg amp was given,
one dose.
-2D Echo was 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 Hospital Day- 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 insertion was 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.
- 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

-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
-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

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

-
(-) murmurs
Capillary refill time <2 seconds
Gastrointestinal
-
(-) nausea (+) vomiting (-)diarrhea (-) hematemesis (-) melena

(-) hematochezia
Abdomen: flat and soft, non-tender
Renal
-
(-) dysuria (-) hematuria (-) frequency (-) flank pain (-) tea
colored
Hematology/Oncology
-
(-) bleeding (-) bruising
Endocrine
-
(-) polyuria (-) polydipsia (-) polyphagia
Musculoskeletal
-
(-) joint pains
(-) muscle cramps
Skin

-
(-) 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
- 3rd 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
contract. This natural backup system is slow and isn't coordinated

with the contraction 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 the systole.

October 3, 2014 2:30 pm
Supraventricular tachycardia, ventricular asystole
Supraventricular tachycardia is a rapid rhythm of the heart
originating at or above the atrioventricular node.
October 4, 2014 8 am, October 6, 2014 5:35 am
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
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
0.679
Lymphocytes
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
commonly associated with an infectious process.
Prothrombin Time
% Activity
APTT
October 2, 2014
13.44
79.24 %
24.33
October 3, 2014
13.59
78.28 %
31.56
Serum
October 2, October 3, October 4, October 5,
October
Electrolytes
2014
2014
2014
2014
10, 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
0.78
P
0.88
Creatinine
96.9
79.1
74.9
72.5
BUN
4.1
4.1
SGOT
140
SGPT
34
Total
Cholesterol
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 I positive
* Troponin I is a protein in the striated cells of cardiac tissue and therefore
provides a unique marker for myocardial cardiac damage.
CRP positive
*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
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 O2
pCO2
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.
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.
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
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,
restlessness,
malaise,
agitation,
tremor,
nightmare,
nervousness,
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,
abdominal pain.
anorexia,
vomiting,
dyspepsia,

GU:
dysmenorrhea,
sexual
1
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
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.
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 longterm 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.
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.
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.
GU: urine retention, impotence.

Other: anaphylaxis.
Alert: 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.
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.
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.
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

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, upper respiratory infection.

Skin: rash.
Monitor blood pressure at the start of therapy and during
dosage adjustments. Assist patient with walking because
dizziness may occur.
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.
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
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,
coordination, weight change, heat or cold intolerance, or

neck swelling.
poor
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
nonsusceptible organisms.
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.
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.
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.
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
- 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
INDICATIONS
Lower respiratory tract infections, community-acquired
pneumonia
ACTION
Prevents bacterial cell-wall synthesis during replication.
increases amoxicillins effectiveness by inactivating betalactamases, which destroy amoxicillin.
ADVERSE REACTIONS
CNS: agitation, anxiety, behavioral changes, confusion,
dizziness, insomnia.
GI:
nausea,
stomatitis,
vomiting,
glossitis,
diarrhea,
black
hairy
indigestion,
tongue,
gastritis,
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
hepatically impaired patients, and monitor the hepatic

function of these 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

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
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.
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, selfcare, 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
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
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
survival rates <50%. Ongoing clinical trials should help to clarify

whether immune-modulating strategies can improve this prognosis.
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. Davis
Company.
4. Doenges, M. et al., (2006). Nursing care plans: guidelines for
individualizing client care across the life span (7th ed.). Philadelphia
: F. A. Davis Company.
5. Porth, C. (2011). Essentials of pathophysiology: concepts of altered health

states (2nd ed.). 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 laboratory
and diagnostic tests with nursing implications (2nd ed.). Philadelphia: F. A.
Davis Company.
Journals:
1. Feldman, A. et al., (2001) Myocarditis. The New England Journal of
Medicine. 343:1388-1398.
2. Uhl, T. (2008) Viral Myocarditis in Children. Critical Care Nurse. 28 no.

142-63.
3. Magnani, J. et al., (2006) Myocarditis: Current Trends in Diagnosis and

Treatment. Circulation.113:876-890.

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EMERGENCY ROOM COMPLEX: MYOCARDITIS

PLEASE BE CAREFUL WITH MY HEART

BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER

CHIQUI M. BUENO, RN, EMT-B

EMERGENCY ROOM COMPLEX: MYOCARDITIS

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

EMERGENCY ROOM COMPLEX: MYOCARDITIS

EMERGENCY ROOM COMPLEX: MYOCARDITIS

EMERGENCY ROOM COMPLEX: MYOCARDITIS

1. HISTORY OF PRESENT ILLNESS

(-) Goiter (-) PTB exposure

EMERGENCY ROOM COMPLEX: MYOCARDITIS

EMERGENCY ROOM COMPLEX: MYOCARDITIS

-At CCU, patient was hooked to cardiac monitor revealing

Cardiac monitor shows different

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

EMERGENCY ROOM COMPLEX: MYOCARDITIS

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

3rd Hospital Day- October 04, 2014

4th Hospital Day- October 05, 2014

5th Hospital Day- October 06, 2014

6th Hospital Day- October 07, 2014

EMERGENCY ROOM COMPLEX: MYOCARDITIS

7thHospital Day- October 08, 2014

8thHospital Day- October 09, 2014

9thHospital Day- October 10, 2014

10thHospital Day- October 11, 2014

EMERGENCY ROOM COMPLEX: MYOCARDITIS

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

11th Hospital Day- October 12, 2014

12th Hospital Day- October 13, 2014

13th Hospital Day- October 14, 2014

14th Hospital Day- October 15, 2014

EMERGENCY ROOM COMPLEX: MYOCARDITIS

conscious, oriented to 3 spheres

no motor or sensory deficit

(+) chest pain/heaviness (+) palpitations

CR= 46, regular

Weak pulses at lower extremities

(+) easy fatigability

EMERGENCY ROOM COMPLEX: MYOCARDITIS

Capillary refill time <2 seconds

(-) nausea (+) vomiting (-)diarrhea (-) hematemesis (-) melena

Abdomen: flat and soft, non-tender

(-) bleeding (-) bruising

(-) polyuria (-) polydipsia (-) polyphagia

(-) joint pains

(-) muscle cramps

EMERGENCY ROOM COMPLEX: MYOCARDITIS

(-) fever (-) rashes

Skin cold touch, temp 35.1

With good skin turgor

Pink palpebral conjunctiva

(-) cervical lymph node adenopathy

With choking sensation

(-) mental health disorder (-) depression

(-) alcohol abuse

EMERGENCY ROOM COMPLEX: MYOCARDITIS

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

depolarization, when the cardiac muscle is contracted. Subsequent

repolarization, or premature ending of the systole.

EMERGENCY ROOM COMPLEX: MYOCARDITIS

2D Echo - October 2, 2014,