ineffective_endocarditis_patho.doc.pdf

Running head: ROOM 555: PNEUMOTHORAX AND BACTERIAL INEFFECTIVE

ENDOCARDITIS

Room 555:

Pneumothorax and Ineffective Endocarditis

Keri Bennett

Liberty University

Running head: ROOM 555: PNEUMOTHORAX AND BACTERIAL INEFFECTIVE

ENDOCARDITIS

Student Name: Keri Bennett

1. Patient Profile Worksheet

A. Personal Information

Room #: 555 Gender: Female Ethnicity: White Age if < 90: 27

Place of Residence: Gladys, VA MD: Dr. Pittard

Emergency Contact: Mother Marital Status: Single

Admitting Diagnosis: Pneumothorax, acute and subacute ineffective endocarditis, bacterial

infection

Co-Morbidities: Suspected lumbar diskitis, chronic Hepatitis C

Date of Admission: 1/05/2018 Date of Surgery: 1/25/2018 Allergies: NKA

Code Status: Full code Mental Status: Single

B. Activity and Nutrition

Diet order: Normal Route/Rate: Self, oral Last Wt: 63kg

Level of Activity (bedrest, up ad lib, BRP, turning): Up ad lib

Level of self-care: Assist x1

C. Nursing Care:

Drainage devices (foley, NGT, JPs, T-tube, etc.): None

Wound care/Dressing (be specific): Surgical incision midsternum: liquid bandage. Incision

where chest tube was inserted: gauze and clear dressing, change Q72H.

IV access (peripheral, central, location, care): Single lumen PICC line: Cephalic IV placed

2/15/2018, 10ml saline flush Q12H

IVF: None Saline Lock? No

Frequency of vital signs (including pulse oximetry): Q12H

Frequency of Glucometer: None Supplemental oxygen: None OSA: No

Falls Risk: Low falls risk

Precautions: Contact precautions: MRSA; protect right shoulder

Room 555: Pneumothorax and bacterial ineffective endocarditis

Most Recent Labs (include date of labs):

Common Hematology/Chemistries/RFTs

Lab Normal range Patient value Date/time Out of range?

WBC 4-10 x 10^9/L 9.7 x 10^9/L 2/16/18 2117 WNL

Hb 13.5-17.5 g/dL 12.4 g/dL 2/16/18 2117 WNL

Hct 38.8-50% 36.3% 2/16/18 2117 WNL

Plts 50-400 x 10^9/L 241 x 10^9/L 2/16/18 2117 WNL

Na+ 135-145 mmol/L 138 mmol/L 2/16/18 2117 WNL

K+ 3.5-5 mmol/L 3.9 mmol/L 2/16/18 2117 WNL

Cl- 95-105 mmol/L 101 mmol/L 2/16/18 2117 WNL

HC03 18-22 mmol/L 20 mmol/L 2/16/18 2117 WNL

BUN 8-21 mg/dL 10 mmol/L 2/16/18 2117 WNL

Cr 0.6-1.2 mg/dL 1.1 mg/dL 2/16/18 2117 WNL

Glucose 70-100mg/dL 85 mg/dL 2/16/18 1157 WNL

Patient History Worksheet:

Chief Complaint: Back pain

History of Present Illness (discuss clinical course from admission until current date):

Per the patient’s report, her niece contracted the flu around 12/15/2017. The patient

developed flu-like symptoms a few days later and tested positive for the flu on 12/20/2017. She

self-medicated with OTC drugs, and her all of symptoms improved excepting the chest

discomfort, which increased. She came into the ED on 1/05/2018 after her chest pain and

dyspnea significantly worsened overnight. X-rays done at that time indicated a significant right

apical pneumothorax with no tension or midline shift noted. The patient denied any history of

Room 555: Pneumothorax and bacterial ineffective endocarditis

heavy lifting, trauma, or prior lung problems. The patient was admitted and a 14-French chest

tube was inserted, releasing a large volume of trapped air. That night the patient spiked a fever of

101.6, with lots of coughing, shortness of breath, and chest pain. Follow-up x-rays performed

on 1/06 showed the pneumothorax to be no longer present, and her lab samples were negative for

flu cultures. The patient has a history of IV drug abuse is felt to be a strong contributing factor in

the etiology of her pneumothorax. Cultures of urine and blood indicated colonization of a Gram-

negative bacterium and a MRSA infection in the blood. The patient was placed on IV

Daptomycin for 42 days per standard MRSA protocol and her blood cultures are negative for

bacterial growth since 1/15/2018. She does have some remaining infection which is affecting her

left shoulder and sacroiliac joint, however these are steadily responding to antibiotic treatment

and are expected to resolve fully by the end of the antibiotic regimen (2/28). The MRSA was

found to have colonized her tricuspid valve, causing a heart block and arrhythmias. A pacemaker

was placed on 1/30/2018, and the tricuspid valve was replaced with a porcine valve on 2/15. The

patient had no adverse effects to surgery and is recovering well. She is prescribed 325mg Aspirin

daily indefinitely post valve replacement.

Currently, the patient is afebrile, stable, and able to ambulate in her room without

assistance. Her biggest complaint at this time is pain, which she consistently rates to be between

5-8. She is prescribed opioids for pain management, but communication has been initiated with

the pharmacy about weaning off of this medication. She continues to be on DVT prophylaxis. If

there are no further complications, patient has an expected discharge date of 3/01/2018. She has

indicated interest in undergoing Suboxone treatment for her opioid addiction, but it is unclear at

this time whether that will be inpatient or from her home.

Past Medical History: Unremarkable PMH

Room 555: Pneumothorax and bacterial ineffective endocarditis

Past Surgical History: No PSH

Family History: Unremarkable FH

Tobacco: ½ pack/ day Alcohol: Abuse Illegal Drugs: IV drug abuse, current opioid addiction

Occupational Status: Unemployed

Religious Preference: Not listed

Cultural Support Needs: The patient has two young children who are currently being cared for by

patient’s mother. The patient is addicted to opioid drugs.

Room 555: Pneumothorax and bacterial ineffective endocarditis

II. Medications

Student should also have medication cards or book available on clinical.

Include PRNs that have been administered with the last 24 hours.

Medication

Generic &

Trade

Route Dosage &

Fre

que

ncy

Category/Mechanis

m of Action

Contraindications / Cautions Side Effects

Use for

this

patient

Acetaminophen

(Tylenol)

Oral 650mg

Q4HP

Subclass: Other

Analgesics

Mechanism of Action

analgesic mechanism

of action unknown;

antipyretic effect via

direct action on the

hypothalamic heat-

regulating center

Serious Reactions

hypersensitivity rxn;

anaphylaxis/anaphylactoid rx; skin

rxn, severe; hepatotoxicity; renal

tubular necrosis, acute; analgesic-

assoc. nephropathy (chronic use);

anemia; thrombocytopenia

Common Reactions

Nausea; rash; headache

hypersens. to

drug/class/compon.; caution

if hepatic impairment;

caution if renal impairment

(long-term use); caution if

hypovolemia, severe;

caution if PKU

(phenylalanine-containing

forms); caution if

malnutrition, chronic;

caution if chronic alcohol

use

Relief of

mild to

moderate

pain

Alprazolam

(Zoloft)

Oral 0.25mg

TIDP

Subclass: Benzodiaze

pines (BZDs) 1:

Short-acting

Mechanism of Action

binds to

benzodiazepine

receptors; enhances

GABA effects

hypersens. to drug/class/compon.;

avoid abrupt withdrawal; caution if

pulmonary impairment; caution if

sleep apnea; caution if CNS

depression; caution if alcohol use;

caution if alcohol or drug abuse hx;

caution if seizure hx; caution if renal

impairment; caution if hepatic

impairment; caution in elderly or

debilitated pts; caution if depression;

caution if smoking habit changes;

caution if elevated gastric pH (ODT

form); caution if salivary flow decr.

(ODT form); caution if PKU

(phenylalanine-containing forms)

Serious Reactions

respiratory depression;

dependency, abuse; seizures;

suicidality; tachycardia;

hypotension; syncope; CNS

stimulation, paradoxical;

hepatotoxicity; Stevens-

Johnson syndrome;

angioedema; withdrawal sx

if abrupt D/C

Common Reactions

Drowsiness; fatigue;

impaired coordination;

irritability; amnesia; appetite

Treatmen

t of

depressio

Room 555: Pneumothorax and bacterial ineffective endocarditis

changes; confusion;

dysarthria; dizziness;

impaired concentration;

xerostomia; libido changes;

urinary retention; menstrual

irregularities; sialorrhea;

hypotension; rash; diplopia;

LFTs elevated; disinhibition;

incontinence

Chlorohexidine

oral solution

Swish 15ml BID Subclass: Gingivitis/P

eriodontitis

Mechanism of Action

bacteriostatic or

bactericidal,

depending on

susceptibility and

concentration;

penetrates cell wall,

disrupting integrity of

cell membrane

hypersens. to drug/class/compon. Serious Reactions

hypersensitivity rxn;

anaphylaxis

Common Reactions

tooth staining; dental

depositsl taste changes;

local irritation

Treatmen

t of

gingivitis

Cyclobenzapine

(Flexoril)

Oral 5mg BID Centrally-acting

muscle relaxant

elderly pts (ER form); hepatic

impairment (ER form); MI, acute

recovery; cardiac conduction

disturbance; arrhythmias; heart

block; CHF; hyperthyroidism; avoid

abrupt withdrawal (long-term use);

caution in elderly pts (IR form);

caution if hepatic impairment (IR

form); caution if urinary retention;

caution if glaucoma, angle-closure;

caution if IOP incr.; caution if CNS

depressant use; caution if alcohol

use; caution if smoking habit

changes; caution if high

environmental temperature

Serious Reactions

seizures; cardiac conduction

disturbance; arrhythmias;

MI; stroke; heat stroke;

hypersensitivity rxn;

anaphylaxis; psychosis

Common Reactions

drowsiness; xerostomia;

dizziness; fatigue; headache;

constipation; nausea;

dyspepsia; taste changes;

blurred vision; nervousness;

confusion; photosensitivity

Muscle

relaxer to

help

reduce

additional

pain

associate

d with

tense

muscles

Room 555: Pneumothorax and bacterial ineffective endocarditis

Senna-

Docusate SOD

oral 50mg (2

tablets)

BID

Subclass:

Constipation 5: Stool

Softeners

Mechanism of Action

facilitates mixture of

stool fat and water

hypersens. to drug/class/compon.;

fecal impaction; mineral oil use;

appendicitis; acute abdomen; GI

obstruction; caution if

nausea/vomiting

Serious Reactions

may occur but none reported

Common Reactions

diarrhea; abdominal cramps;

throat irritation; rash;

electrolyte disorders; bitter

taste (PO liquid forms)

Relief of

constipati

Daptomycin IV 8 mg/kg

IV q24h

x2-6wk

Subclass: Other

Antibacterials

Mechanism of Action

bactericidal; binds to

and depolarizes

bacterial membranes,

inhibiting protein,

DNA and RNA

synthesis

(polypeptide)

hypersens. to drug/class/compon.;

CK >10x ULN; CK >5x ULN w/

myopathy; pts <1 yo; pneumonia;

caution in elderly pts; caution if renal

impairment, mod-severe; caution if

recent abx-assoc. colitis hx

Serious Reactions

C. difficile-assoc. diarrhea;

superinfection’ pneumonia,

eosinophilic;

hypersensitivity rxn;

anaphylaxis; drug rxn w/

eosinophilia and systemic

sx; skin rxn, severe;

thrombocytopenia;

myopathy; rhabdomyolysis’

peripheral neuropathy

Common Reactions

Insomnia;

pharyngolaryngeal pain; CK

elevated; chest pain; edema;

abdominal pain; pruritus;

HTN; headache; diarrhea;

diaphoresis; rash; abnormal

LFTs; UTI; hypotension;

dizziness; dyspnea;

infection, fungal; fever

(peds pts); vomiting (peds

pts)

Antibioti

treatment

of MRSA

infection

Pantoprazole

sodium

Oral 40mg 0600 Subclass: Proton

Pump Inhibitors

(PPIs); H. pylori

hypersens. to drug/class/ compon.;

caution if long-term use; caution if

high dose tx; caution if

hypomagnesemia; caution in pts 50

Serious Reactions

hypersensitivity rxn;

anaphylaxis; erythema

Stress

ulcer

prophyla

xis

Room 555: Pneumothorax and bacterial ineffective endocarditis

Mechanism of Action

inhibits gastric

parietal cell hydrogen-

potassium ATPase

(proton pump

inhibitor)

yo and older (high dose or long-term

use)

multiforme; Stevens-

Johnson syndrome; toxic

epidermal necrolysis;

interstitial nephritis; renal

impairment; pancreatitis;

rhabdomyolysis; fractures;

hyponatremia;

hypomagnesemia (long-

term use); lupus

erythematosus; C. difficile-

assoc. diarrhea; blood

dyscrasias; hepatic

impairment

Common Reactions

headache; diarrhea;

thrombophlebitis (IV use);

abdominal pain;

nausea/vomiting; URI sx

(peds pts); fever (peds pts);

rash (peds pts); dizziness;

flatulence; arthralgia; ALT,

AST elevated; vitamin B12

deficiency (long-term use)

Enoxaparin

sodium

SubQ 40mg 1600 Subclass:

Anticoagulants

Mechanism of Action

binds to antithrombin

III and accelerates

activity, inhibiting

thrombin and factor

Xa (low-molecular

weight heparin)

hypersens. to drug/class/compon.,

hypersens. to pork products, active

major bleeding, thrombocytopenia

hx, enoxaparin-assoc., neonates or

infants (benzyl alcohol-containing

INJ forms), caution in elderly pts,

caution in pregnancy (benzyl

alcohol-containing INJ forms),

caution in pregnant pts w/

mechanical heart valve, caution if wt

<45 kg (female pts) or <57 kg (male

Serious Reactions

hemorrhage, major,

epidural/spinal hematoma,

prosthetic heart valve

thrombosis, anemia,

thrombocytopenia,

thrombocytopenia w/

thrombosis, thrombocytosis,

anaphylactoid rxn,

hypersensitivity rxn, skin

necrosis, hyperkalemia,

Preventio

n of

blood

clots

Room 555: Pneumothorax and bacterial ineffective endocarditis

pts), caution if BMI >30 kg/m^2,

caution if hepatic impairment,

caution if renal impairment, caution

if coagulation disorder, caution if

heparin-induced thrombocytopenia,

caution if bleeding risk, caution if

recent surgery or trauma, caution if

GI bleeding or ulcer hx, caution if

active GI ulcer or dz, caution if HTN,

uncontrolled, caution if hemorrhagic

stroke, caution if diabetic

retinopathy, caution if endocarditis,

acute, caution if epidural or spinal

anesthesia, caution if spinal puncture

hepatotoxicity, neonatal

gasping syndrome (benzyl

alcohol-containing INJ

forms)

Common Reactions

anemia, hemorrhage, fever,

peripheral edema, local

injection site rxn, hematuri,

ALT, AST elevated, nausea,

thrombocytopenia, diarrhea,

osteoporosis (long-term use)

Oxycotin Oral 15mg

Q4HP

Subclass: Opioids

Mechanism of Action

binds to various

opioid receptors,

producing analgesia

and sedation (opioid

agonist)

hypersens. to drug/class/ compon.;

MAO inhibitor use w/in 14 days;

respiratory depression, severe;

asthma, acute or severe; GI

obstruction, known or suspected;

paralytic ileus; coma or impaired

consciousness; circulatory shock;

avoid abrupt withdrawal (prolonged

or long-term use); caution in elderly

or debilitated pts; caution if renal

impairment; caution if hepatic

impairment; caution if pulmonary

impairment; caution if sleep apnea

(long- term use); caution if CNS

depression; caution if concurrent

CNS depressant use; caution if

alcohol use; caution if alcohol or

drug abuse hx; caution if mental

illness hx; caution if ICP incr.;

caution if head injury; caution if

seizure disorder; caution if

hypovolemia; caution if

cardiovascular dz; caution if

Serious Reactions

hypersensitivity rxn;

anaphylaxis; respiratory

depression; respiratory

arrest; apnea; cardiac arrest;

shock; ICP incr.; circulatory

depression; hypotension,

severe; seizures; paralytic

ileus; biliary spasm; adrenal

insufficiency; opioid-

induced androgen deficiency

(long-term use);

dependency, abuse;

withdrawal sx if abrupt D/C

(prolonged or long-term

use)

Common Reactions

constipation; nausea;

somnolence; dizziness;

pruritus; vomiting;

Relief of

moderate

to severe

pain

Room 555: Pneumothorax and bacterial ineffective endocarditis

difficulty swallowing (ER form);

caution if GI stricture risk (ER form);

caution if GI motility disorder;

caution if acute pancreatitis or biliary

dz; caution if GU obstruction;

caution if hypothyroidism; caution in

pts trying to conceive (long-term use)

headache; insomnia;

xerostomia; asthenia;

diaphoresis; anorexia;

nervousness; fever/ rigors;

confusion; diarrhea;

abdominal pain; dyspepsia;

rash; anxiety; dysphoria/

euphoria

Asprin

Oral 325mg

daily

Subclass:

Antiplatelets;

Salicylates; Stroke

Mechanism of Action

non-selectively and

irreversibly inhibits

cyclooxygenase,

reducing

prostaglandin and

thromboxane A2

synthesis, producing

analgesic, anti-

inflammatory, and

antipyretic effects and

reducing platelet

aggregation

hypersens. to drug/class/compon.,

ASA or NSAID-induced asthma or

urticaria, aspirin triad, GI bleeding,

coagulation disorder, G6PD

deficiency, HTN, uncontrolled,

influenza, varicella, or febrile viral

infection (pts <20 yo), avoid alcohol

use (3 or more drinks/day), caution in

pts 60 yo and older, caution if

thrombocytopenia, caution if surgery

or trauma, caution if intracranial

lesion, caution if ICP incr., caution if

PUD, caution if GI bleeding hx,

caution if GERD, caution if gout

(high-dose ASA use), caution if renal

impairment, caution if hepatic

impairment, caution if sodium

restriction (buffered ASA forms)

Serious Reactions

anaphylaxis/anaphylactoid

rxn, angioedema,

bronchospasm, bleeding, GI

perforation/ulcer, DIC,

pancytopenia,

thrombocytopenia,

agranulocytosis, aplastic

anemia,

hypoprothrombinemia,

nephrotoxicity,

hepatotoxicity (high-dose

ASA use), salicylism, Reye

syndrome

Common Reactions

dyspepsia, nausea, vomiting,

abdominal pain, tinnitus,

dizziness, hyperuricemia,

bleeding, ecchymosis,

constipation, diarrhea

Antiplatle

aggregate

Oxycodone 20mg QAM,

Bedtime

Subclass: Opioids

Mechanism of Action

binds to various

opioid receptors,

producing analgesia

and sedation (opioid

hypersens. to drug/class/compon.,

MAO inhibitor use w/in 14 days,

respiratory depression, severe,

asthma, acute or severe, GI

obstruction, known or suspected,

paralytic ileus, coma or impaired

Serious Reactions

hypersensitivity rxn,

anaphylaxis, respiratory

depression, respiratory

arrest, apnea, cardiac arrest,

shock, ICP incr., circulatory

Pain

reduction

Room 555: Pneumothorax and bacterial ineffective endocarditis

agonist) consciousness, circulatory shock,

avoid abrupt withdrawal (prolonged

or long-term use), caution in elderly

or debilitated pts, caution if renal

impairment, caution if hepatic

impairment, caution if pulmonary

impairment, caution if sleep apnea

(long-term use), caution if CNS

depression, caution if concurrent

CNS depressant use, caution if

alcohol use, caution if alcohol or

drug abuse hx, caution if mental

illness hx, caution if ICP incr.,

caution if head injury, caution if

seizure disorder, caution if

hypovolemia, caution if

cardiovascular dz, caution if

difficulty swallowing (ER form),

caution if GI stricture risk (ER form),

caution if GI motility disorder,

caution if acute pancreatitis or biliary

dz, caution if GU obstruction, caution

if hypothyroidism, caution in pts

trying to conceive (long-term use)

depression, hypotension,

severe, seizures, paralytic

ileus, biliary spasm, adrenal

insufficiency, opioid-

induced androgen deficiency

(long-term use),

dependency, abuse,

withdrawal sx if abrupt D/C

(prolonged or long-term

use)

Common Reactions

constipation, nausea,

somnolence, dizziness,

pruritus, vomiting,

headache, insomnia,

xerostomia, asthenia,

diaphoresis, anorexia,

nervousness, fever/rigors,

confusion, diarrhea,

abdominal pain, dyspepsia,

rash, anxiety,

dysphoria/euphoria

V. Top Three Prioritized Medical and Nursing Diagnosis

1. Bacterial endocarditis: (actual) infection r/t MRSA colonization AEB cultures on 1/10/2018 indicating MRSA infection, prescription of 42

day IV Doxycycline antibiotic regimen, fever with a high of 101.8*F on 1/08/2018, and pain, erythema, and swelling of left shoulder and

sacroiliac joints consistent with expected findings for bacterial infection.

2. Pneumothorax: (actual) impaired comfort r/t MRSA colonization AEB the patient reports pain as being 5-8 on a 10 point scale, prescription

of opioid pain medications, swelling and erythema of left shoulder and sacroiliac joints consistent with findings for bacterial infection, patient

complains of difficulty walking, patient complains of pain when walking.

Room 555: Pneumothorax and bacterial ineffective endocarditis

3. Pneumothorax: (actual) impaired tissue integrity r/t surgical incisions AEB midsternal surgical incision for tricuspid valve replacement,

surgical incision in right upper rib cage for placement of chest tube, patient’s complain of pain and soreness at incisions sites, redness and

swelling at incision sites.

Care Plan

Medical & Nursing Dx Nursing Outcomes

(NOC)

Nursing Interventions (NIC) Evaluation

Bacterial endocarditis: (actual) infection

r/t MRSA colonization AEB cultures on

1/10/2018 indicating MRSA infection,

prescription of 42 day IV Doxycycline

antibiotic regimen, fever with a high of

101.8*F on 1/08/2018, and pain,

erythema, and swelling of left shoulder

and sacroiliac joints consistent with

expected findings for bacterial infection.

1A. During the nurse’s 8

hour shift, the patient

will exhibit continued

recovery from septic

infection AEB continued

afebrile state.

1B. During the nurse’s 8

hour shift, the patient

will display continued

healing by increased

ability to ambulate

without pain and stated

by the patient.

1C. During the nurse’s 8

hour shift, the patient

will demonstrate verbal

understanding of the

infectious risks

associated with use of IV

drugs.

1A-1. The nurse will administer antibiotics as prescribed in order to

continue combatting the septic infection.

1A-2. The nurse will provide excellent wound care as prescribed in

order to keep the area clean, reduce the risk of further infection, and

continue to combat the current septic infection.

1A-3. The nurse will encourage the patient to consume an adequate

amount of fluids based on the doctors prescription and the patient’s

idea fluid intake as per her body mass in order to encourage kidney

function, good circulation, and eradication of septic infection.

1B-1. The nurse will medicate the patient prior to ambulation to

lessen pain during ambulation.

1B-2. The nurse will encourage the patient to ambulate as much as

possible to aid in the healing process.

1B-3. The nurse will set specific, attainable goals ambulation goals

for the patient to meet during the nurse’s shift.

1C-1. The nurse will provide patient education regarding the

infectious risks of illegal drug use.

1C-2. The nurse will encourage the patient to enroll in a drug

addiction recovery program.

1C-3. The nurse will help the patient to identify acceptable coping

mechanisms for the stressors in her life.

(Include Goal

Statement)

1A. During the nurse’s 8

hour shift, the patient

continued to exhibit

recovery from septic

infection AEB a

continued afebrile state.

1B. During the nurse’s 8

hour shift, the patient

displayed continued

healing by increased

ability to ambulate

without pain as reported

by the patient.

1C. During the nurse’s 8

hour shift, the patient

demonstrated verbal

understanding of the

infectious risks

associated with the use

of IV drugs and stated

willingness to participate

in an addiction recovery

program.

Room 555: Pneumothorax and bacterial ineffective endocarditis

Pathophysiology

The Ms. G is a 27 year old Caucasian female who was admitted to LGH from the ED on 1/05 with a

spontaneous pneumothorax. The following is a discussion of her past medical history, diagnosis, and

treatment.

The patient has a history of substance abuse, including alcohol abuse and illegal drug use which she

has stated to primarily consist of IV opioids. The patient also states that she smokes ½ pack of cigarettes

daily. It is unclear how reliable the patient’s testimony is as she has changed her story many times over the

course of hospitalization, initially claiming that she had no history of drug, alcohol, or tobacco use. A multi-

substance abuse history is common with illegal drug users, and it is likely the Ms. G is also abusing other

substances in addition to those already listed (Ackley, 2017).

Opiates are central nervous system (CNS) depressants and analgesics. They are useful in a medical

setting as pain killers, but when abused they can cause physical and psychological dependence (Skidmore-

Roth, 2018). Opioids exert their psychological effects by binding to the μ, δ, and κ receptors of the body,

mimicking the actions of the endogenous opioid peptides endorphins, endomorphins, encephalin, and

dynorphins (Al-Hashimi, 2017). The majority of their activity is centered on the μ-Opioid receptors (MOP-

r), where they significantly increase dopamine levels in the synaptic clefts of the ventral tegmental area

(VTA) of the brain. Opiates may also bind to Gamma-amino butyric acid receptors (GABA), a

neurotransmitter which inhibits the action of dopamine. Hyperpolarization of these GABA-interneurons in

the VTA prevent the dispersion of GABA, delaying dopamine degradation. Opioids are therefore powerful

pleasure-stimulating drugs as they both increase the release of dopamine and potentiate its affects (Liang,

2016).

Not only does opioid medication stimulate the release of dopamine, it also desensitizes dopamine

receptors to natural release triggers, meaning that in the absence of opioids, dopamine is released in very

low quantities or not at all (Roy, 2011). This absence of dopamine can trigger depression, anxiety, and other

mood disorders in addicts who do not have access to the drug. Tolerance to the effects of opioids also

Room 555: Pneumothorax and bacterial ineffective endocarditis

increases over time, meaning that an increased dose of the drug is needed to achieve the same effect (Porth,

2013).

An often-overlooked aspect of drug addiction are the metabolic and nutritional impacts. Beta cell

dysfunction and insulin resistance has been associated with opioid addiction, resulting in fasting blood

glucose levels four times higher than control subjects in one study. Acute insulin response in heroin addicts

were found 42% lower than control subjects, accompanied by an 80% lower glucose disappearance rate,

when they were given intravenous glucose (Sacerdote, 2011). The lifestyle of opiate dependents is typically

not conducive to healthy eating practices and as a result most are undernourished. While some of the poor

food choices typical of opioid addiction can be ascribed to poor financial status as a result of being unable

to maintain employment and the majority of funds being allocated to the purchase of drugs, the drugs

themselves also predispose users to unhealthy nutritional choices. Morphine, for example, has been shown

to increase an individual’s desire for sugary foods, and other drugs are known to have a similar deleterious

effect on healthy dietary choices (Nabipour, 2014).

The nutritional status of drug addicts is concerning for two reasons. First, malnourishment may

have a significant impact on the body’s ability to recover from drug addiction (Nabipour, 2014). Studies

performed by Larson et al. suggest that because of the major deficiencies and absorption problems typical

of drug addicts, proper eating behavior is not sufficient to overcome the depletion of nutrients in the

beginning of a detoxification program (2015). For example, pantothenic acid administered orally to

alcoholic patients has been found to be excreted through the kidneys and not absorbed in appreciable

amounts. The same can be proven to be true of other ingested nutrients. Problems arising from poor

absorption can be corrected, but an increased dietary intake of the under-absorbed nutrients is necessary to

correct the imbalance (Ackley, 2017). Many opioid addicts also have carbohydrate metabolism problems.

By increasing the dietary intake of protein, vegetables, and whole grains and reducing simple

carbohydrates, this imbalance can be corrected. These metabolic malfunctions influence not only the body’s

ability to absorb and maintain nutrient status, but also affect treatment strategies. It has been shown that

Room 555: Pneumothorax and bacterial ineffective endocarditis

methadone maintenance treatment is not a favorable approach until is coupled with proper diet due to

negative role of vitamins and minerals deficiencies in withdrawal process. Treatment of drug addicts should

include a dietary component that is specifically tailored to the individual patient’s need (Nabipour, 2014).

In addition to proteins and key vitamins, trace minerals such as zinc, iron, calcium, chromium,

magnesium, potassium and other essential nutrients should be prescribed in detoxification programs to

recovering addicts. Zinc can help to improve immune system and proper brain function, both of which are

inhibited in opiate addicts (Porth, 2013). Many opiate and alcohol addicts have shown calcium and

magnesium deficiencies due to poor diet and inadequate intake of calcium. Calcium and magnesium

deficiencies are the major factors of pain and nervous/muscular disorders among addicts and alcohol

consumers during detoxification programs (Liang, 2016). Ms. G was previously enrolled in a program to

help her overcome her addiction, with unsatisfactory results. Although at 170cm and 63kg Ms. G is within

a healthy BMI (21.8), it is possible that her nutritional status may have played some role in her inability to

recover from her addiction (Ackley, 2017).

Secondly, nutritional deficiencies can hinder the recovery process for those seeking to escape

addiction, and places drug users at increased risk for infection by lowering the body’s ability to maintain

immune status and fight off invading pathogens (Al-Hashimi, 2014). The use of opioid drugs has a direct

impact on the immune system. Opioids have recently been recognized to interfere with the immune

response, negatively interfering with a wide variety of functions of both natural and adaptive immunity, and

significantly reducing cellular immunity. Adaptive immunity is influenced in the form of decreased T-cell

viability and proliferative response, decreased T-helper cell function, decreased Th1/Th2 ratio of T-helper

cell population (PBMCs), decreased B cells mitogenic response to bacterial LPS, decreased CD4/CD8

population in vivo, decreased IL1β, IL-2, TNF-α and IFN-γ, decreased NK cell activity, decreased primary

antibody response (B cells), decreased macrophage activity, increased TFG-β1 and IL-10 (anti-

inflammatory cytokines), and inhibition of CD3/28 mAb induced IL-2 transcripts (Sacerdote, 2011). Innate

immunity is also negatively impacted in the decreased number of macrophages available to fight infections,

Room 555: Pneumothorax and bacterial ineffective endocarditis

decreased ability of leucocytes to migrate to the site of infection, decreased peritoneal macrophage

phagocytosis, decreased respiratory burst activity and chemotaxis, inhibition of Fc γ receptor mediated

phagocytosis, decreased superoxide production from neutrophils and macrophages, alteration of IL-8

induced neutrophil chemotaxis, decreased number of neutrophil cytokines involved in wound healing,

decreased ability of leucocytes to adhere to endothelial tissue, and increased apoptosis of macrophages

impairing host defense barrier (Roy, 2011). While different opioids affect the immune system to different

degrees when used in therapeutic doses in a controlled setting (recent studies indicate that buphrenorphine,

for example, has a more favorable profile than traditional morphine after surgery, being a potent analgesic

devoid of intrinsic immunosuppressive activity) all opioids have the ability to produce undesirable effects

on immune function if abused (Skidmore-Roth, 2018). Ms. G’s current illness began when she contracted

the flu, it is likely that drug abuse lowered her ability to fight infection, predisposing her to contracting the

virus.

Ms. G reports that she tested positive for the flu virus on 12/20/2017, a few days after her niece

developed flu-like symptoms. Ms. G experienced typical flu symptoms of fever, chills, muscle aches,

cough, congestion, runny nose, headaches, and fatigue, which she was able to treat successfully using OTC

medication. Around 1/02/2018 she began to develop severe chest pain and mild dyspnea, which worsened

on 1/05 to the extent that she visited the local Emergency Department. X-rays were performed, confirming

that she had developed a primary spontaneous pneumothorax. Spontaneous pneumothoraxes occur when

the lining of the lungs ruptures with no identifiable external trauma to the lung tissue. The punctured lung

allows air to escape into the thoracic cavity on inspiration, filling the closed compartment and putting

pressure on the external surface of the lung, causing it to collapse. There are several factors which may

have contributed to Ms. G’s pneumothorax (Porth, 2013).

Physically, Ms. G is tall and slender. Although more common in men, pneumothorax typically

occurs tall patients due to the distribution of force as air moves through the lung fields (Ackley, 2017). The

gradient of negative pleural pressure increases from the lung base to the apex, subjecting the superior

Room 555: Pneumothorax and bacterial ineffective endocarditis

alveoli of taller individuals to significantly greater distending pressure than those at the base of the lung. In

taller individuals, increased lung volume exponentially increases the amount of force exerted on the upper

alveoli, with no appreciable increase in pleural tissue thickness (Sulam, 1985). Additionally, Ms. G smokes

½ pack of cigarettes daily. Cigarette smoke irritates the lining of the lungs, causing bronchiolitis and

increasing one’s risk of pneumothorax by 120%. Smoke residue also builds up on the epithelial cells,

reducing alveolar elasticity (Gotway, 2012). These combined factors reduce the ability of the alveoli to

withstand the pressures of respiration, predisposing them to bursting. Drug use also contributes to increased

thoracic pressure and decreased alveolar resilience. IV use of opioids is thought to cause acute

inflammation and endothelial abnormalities in the bronchoalveolar tissue, as indicated by increased protein

concentration in pulmonary lavage fluid (Suzuki, 2016). Central nervous system depression secondary to

opiate usage may further exacerbate the issue by causing further neurogenic pulmonary edema. Respiratory

side effects of the flu virus, namely: coughing, increased mucus secretions, and inflammation of the airway

tissues, all contribute to place further stress on the lung tissue (Erbas, 2011). Given her extensive risk

factors and history of pulmonary stressors, is not surprising that Ms. G developed a PCP.

Ms. G’s pneumothorax was treated with the insertion of a 14-French chest tube to release the air

trapped in the pleural space, standard practice for relief of pneumothorax. Although there is risk for repeat

pneumothorax in the days following the initial injury, further treatment is not commonly indicated for

primary spontaneous pneumothoraxes as the collapsing of the lung tissue allows the break to re-adhere

sufficiently to allow the lung to re-inflate normally once the thoracic cavity is decompressed (Suzuki,

2016). Prophylactic antibiotics were given at the time of chest tube insertion. Although current research is

indicating that prophylactic antibiotics are unnecessary and even contradicted in routine chest tube given

the unnecessary risk for furthering the development of antibiotic resistant bacterial strains, because of Ms.

G’s compromised immune state, the physicians decided to proceed with the antibiotic dose (Olgac, 2006).

Ms. G’s lung re-inflated with no complications and she was admitted to the pulmonary floor for observation

overnight.

Room 555: Pneumothorax and bacterial ineffective endocarditis

During the night, the patient spiked a fever of 101.6*F. Her white blood cell count was also elevated

to 11.8 x 10^9 u/dL, which is consistent with expected findings for her diagnosis. Cultures of urine and

blood indicated colonization of a MRSA infection in the blood. As discussed above, the impact of Ms. G’s

lifestyle on her immune system places her at increased susceptibility for infection. The route of her drug

use further compounds her risk for infection, as it is unlikely that IV injections of illicit substances were

performed using aseptic technique. Given the timing of the onset of her symptoms, it seems unlikely that

the patient acquired a septic infection during the procedure performed in the hospital; it is more likely that

she became infected with community-acquired MRSA prior to her admission and became symptomatic

while on the hospital floor (Ackley, 2017).

The patient was placed on IV Daptomycin for 42 days per standard MRSA protocol. Daptomycin is

a lipopeptide antibiotic active against Gram-positive organisms. It inserts into the cell membrane in a

phosphatidylglyerol-dependent fashion where it then aggregates, disrupting the curvature and continuity of

the membrane. Rapid depolarization then occurs due to the leakage of ions through the plasma membrane,

resulting in a loss of membrane potential. Without membrane potential to aid in transport of molecules

necessary for the synthesis of proteins, DNA, and RNA, the bacteria cell is unable to sustain life and dies

(Skidmore-Roth, 2018).

One of the primary concerns associated with bacteremia is the colonization and necrosis of vital

organs. Of primary concern are the heart, lungs, and meningeal tissues (Rinewalt, 2014). These concerns

came to fruition in the case of Ms. G, as the MRSA was found to have colonized the bone of her left

shoulder and sacroiliac joint, as well as her tricuspid valve, the latter causing a heart block and arrhythmias.

Drug users are especially at risk for endocarditis for many reasons in addition to their increased chances of

pathogenic introduction, as the pathophysiology requires several abnormalities of the vascular and immune

system for bacterial colonization to occur (Gotway, 2002). Bacteria do not readily adhere to normal

endothelial surfaces. Damage to the endothelial surface causes deposition of platelets of fibrin, rendering

the valve surface susceptible to bacterial colonization. There are certain virulence factors which promote

Room 555: Pneumothorax and bacterial ineffective endocarditis

adherence to endothelial surfaces. Dextran, an extracellular polysaccharide, is thought to be one of these

factors. Staphylococci bacteria are thought to adhere more readily to the fibrin-platelet more readily than

other types of bacteria, both due to the presence of dextran and resistance to antibacterial activities of

compliment and phagocytosis by white blood cells (Porth, 2013). Vegetation propagation also requires

activation of the clotting cascade. Perturbation of the valvar cells by staphylococci triggers the production

of thromboplastin, resulting in the deposition and growth of a fibrin-platelet clot over the proliferating

bacteria colonies. This fibrin-platelet clot protects the growing bacterial colony from destruction by

leukocytes and provides surface area for the adherence and growth of further bacterial colonies. Not only

do these plaques interfere with the normal functioning of the heart by impairing blood flow, but the plaques

can break off sending emboli to the brain or lungs and cause death (Suzuki, 2016). Inflammation of the

vascular tissue due to high doses IV injection of medication and changes in blood pressure can trigger the

endothelial trauma which allows for bacterial adherence (Seeley, 2017). This is likely the causative agent

behind Ms. G’s endocarditis.

The colonization of MRSA on Ms. G’s tricuspid valve inhibited the transfer of electrical signals

though the heart, causing heart block and arrhythmia. It also impaired the normal functioning of the

tricuspid valve, preventing it from blocking blood regurgitation during contraction. If left untreated,

tricuspid valve dysfunction can lead to cardiac enlargement and right sided heart failure. The endocarditis

failed to respond well to antibiotic treatment, and the placement of a pacemaker was performed on

1/30/2018 to rectify the cardiac arrhythmias. The tricuspid valve was necrotic to the point of being

unsalvageable and was replaced with a porcine valve on 2/15. The patient had no adverse effects to surgery

and is recovering well. She is prescribed 325mg Aspirin daily indefinitely post valve replacement to

prevent blood clots. Ms. G’s blood cultures are negative for bacterial growth since 1/15/2018. She still

suffers from some discomfort due to the bacterial infection in her shoulder and iliosacral joint; however,

these are steadily responding to antibiotic treatment and are expected to resolve fully by the end of the

antibiotic regimen on 2/28/2018.

Room 555: Pneumothorax and bacterial ineffective endocarditis

In addition to bacterial infection, Ms. G is also suffering from chronic Hepatitis C. It is estimated

that 60% to 90% of injection users are infected with the Hepatitis C virus (HCV). The mechanism of

HCV’s entry and infection of cells is not well understood due to the lack of a productive cell culture

system. Weak response from CD4+ and CD8+ T-cells failing to prevent viral proliferation during the initial

infection stage seem to play a role in the development of persistent infection (Pawlotsky, 2004).

Interestingly, once established, HCV does not appear to by cytopathic. The hepatic lesions associated with

hepatitis C appear to be due, not to the cellular toxicity of the viral infection, but rather the local

inflammatory response triggering fibrogenesis in local stellate cells. Cirrhosis is facilitated by external

factors such as chronic alcohol consumption (Edlin, 2007). Ms. G has admitted to excessive alcohol

consumption, which places her at increased risk for developing hepatocellular carcinoma. Excessive

alcohol consumption also reduces the body’s immune function, which also contributes to Ms. G’s risk for

contracting HCV, bacterial infection, and carcinomas (Porth, 2013). Because of the systemic effects of

antiviral medication, its use is avoided in all but the most severe cases. Depending on the severity of the

HCV infection, treatment may consist of immune system support to assist the body in naturally eradicating

the viral infection ((Edlin, 2007). This is the approach being taken by the physicians in the case of Ms. G.

The hope is that, once the extenuating factors of her alcohol and drug abuse are resolved, a healthy diet and

lifestyle will allow her immune system to recover to the point that she is able to resolve the remaining

health issues without the assistance of medication.

Current nursing priorities include ensuring that the antibiotic regimen is completed as prescribed,

and that the bacterial infection is eliminated before discharge. Pain management for Ms. G’s shoulder and

iliosacral joints are also a concern. Although she is currently prescribed opioids for the management of

pain, as her pain levels become more manageable, discourse has begun with pharmacy about changing to a

non-opioid pain medication. Discourse has also been initiated with the patient regarding enrollment in an

addiction-recovery program. Due to the significant psychological impact of opioids, the opiate addict’s

brain can take months or even years to restructure its receptor organization patterns and regain its normal

Room 555: Pneumothorax and bacterial ineffective endocarditis

functioning. Symptoms of withdrawal during this time can include fatigue, depression, increased sensitivity

to pain, and lack of motivation. As discussed above, nutritional therapy can help with the severity and

length of unpleasant withdrawal symptoms. The patient is responding well to current treatment and is

expected to make a full recovery from her bacterial infection and suffer no significant loss of function in

her cardiac output.

Room 555: Pneumothorax and bacterial ineffective endocarditis

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