BHARATI VIDYAPEETH (DEEMED TO BE UNIVERSITY)

COLLEGE OF NURSING, PUNE-43

F.Y.M.SC. NURSING
MEDICAL SURGICAL NURSING

NAME OF TOPIC: AGING

SUBJECT: MEDICAL SURGICAL NURSING
UNIT: UNIT 1

NAME OF PRESENTAOR: MS. LOMA R WAGHMARE

F.Y.MSC NURSING (MEDICAL SURGICAL NURSING
SPECIALITY) STUDENT,
BVDUCON, PUNE

NAME OF EVALUATOR: DR. KHURSHID JAMADAR

PROFESSOR, PRINCIPAL,
BVDU, PUNE

GROUP: F.Y.M.S.C NURSING

DATE: 07.12.2020

TIME: 2 PM
VENUE/ ONLINE ZOOM MEETING
MODE OF PRESENTATION:

AV AIDS: PPT/ VEDIO

GENERAL OBJECTIVE:
AT THE END OF THE SEMINAR, THE STUDENTS WILL BE ABLE TO GAIN KNOWLEDGE
ON INFLAMATORY DISEASE OF HEART AND WILL ABLE APPLY IN CLINICAL
PRACTICE

SPECIFIC OBJEVTIES:
At the end of the seminar, the group will be able to,
1. Review of normal anatomy of heart
2. Enumerate the types of inflammatory disease of heart
3. Enlist the causes of inflammatory disease of heart
4. Discuss the risk factors of inflammatory disease of heart
5. Discuss the pathophysiology of inflammatory disease of heart
6. Enlist the sign and symptoms of inflammatory disease of heart
7. Discuss different diagnostic test in inflammatory disease of heart
8. Enlist the complication of inflammatory disease of heart
9. Discuss the medical management of inflammatory disease of heart
10. Discuss the nursing management of inflammatory disease of heart
11. Verbalise the preventive measures of inflammatory disease
 OUTLINE FOR SEMINAR

1. Normal anatomy of heart

2. Types of inflammatory disease of heart
3. Causes of inflammatory disease of heart
4. Risk factors of inflammatory disease of heart
5. Pathophysiology of inflammatory disease of heart
6. Sign and symptoms of inflammatory disease of heart
7. Diagnosis of inflammatory disease of heart
8. Complications of inflammatory heart disease
9. Medical management of inflammatory disease of heart
10. Nursing management of inflammatory disease of heart
11. Preventive measures of inflammatory disease of heart
12. Current Researches
13. Summary
14. Conclusion
15. Bibliography
 INFLAMMATORY DISEASE OF HEART

INTRODUCTION:

Inflammation is your body’s response to infection or injury. It can affect many areas of the body and is a
cause of many major diseases, including cancer, ischemic heart disease, and autoimmune diseases.
Inflammation in the heart causes damage and can lead to serious health problems.

NORMAL ANATOMY OF HEART:

The heart has 4 chambers, 2 atria and 2 ventricles. De-oxygenated blood returns to the right side of the
heart via the venous circulation. It is pumped into the right ventricle and then to the lungs where carbon
dioxide is released and oxygen is absorbed. The oxygenated blood then travels back to the left side of the
heart into the left atria, then into the left ventricle from where it is pumped into the aorta and arterial
circulation.

Fig 1: Normal anatomy of heart

LAYERS OF HEART:

1. EPICARDIUM:
The epicardium is the outermost layer of the heart. It is actually the visceral layer of the
serous pericardium, which adheres to the myocardium of the heart. Histologically, it is made of mesothelial
cells, the same as the parietal pericardium. 
Below the mesothelial cells is a layer of adipose and connective tissue that binds the epicardium to the
myocardium and cushions the heart. Nerves and blood vessels that supply the heart are found in the
epicardium. At the roots of great vessels, the epicardium reflects back and continues as the parietal
pericardium, forming an enclosed pericardial sac. The sac is filled with serous pericardial fluid that
prevents friction during heart contractions.
2. MYOCARDIUM
The myocardium is functionally the main constituent of the heart and the thickest layer of all three heart
layers. It is a muscle layer that enables heart contractions. Histologically, the myocardium is comprised
of cardiomyocytes. Cardiomyocytes have a single nucleus in the center of the cell, which helps to
distinguish them from skeletal muscle cells that have multiple nuclei dispersed in the periphery of the cell.

Cardiomyocytes are very rich in glycogen deposits and mitochondria. This has a great functional
significance since the myocardium is constantly contracting and needs a great amount of energy at all
times. Cardiomyocytes also contain yellow lipofuscin granules. They don’t have any particular functional
significance, but they are interesting since they are age markers for the cell. The older the cell, the more
lipofuscin it has. 

Cardiomyocytes communicate through special intercellular bridges called intercalated discs. The discs
comprise of three components: adherens junction (fascia adherens), desmosomes (maculae adherentes) and
gap junctions (communicating junctions). These three components enable mechanical unity of
cardiomyocytes and a direct pathway of spreading action potentials. Because of this, the myocardium is
observed as a form of syncytium, rather than a group of somewhat independent cells.

3. ENDOCARDIUM:
The endocardium is the innermost layer of the heart. It lines the inner surfaces of the heart chambers,
including the heart valves. The endocardium has two layers. The inner layer lines the heart chambers and is
made of endothelial cells. Superiorly, is the second layer: a subendocardial connective tissue which is
continuous with the connective tissue of the myocardium. Branches of the heart’s conduction system are
immersed into the subendocardial layer.

Fig 2: Layers of heart

TYPES OF INFLAMMATORY DISEASE OF HEART

There are three main types of heart inflammation: endocarditis, myocarditis, and pericarditis.
1. ENDOCARDITIS :
Endocarditis is inflammation of the inner lining of the heart chambers and valves, or endocardium.
Endocarditis is a rare but life-threatening disease. In endocarditis, clumps of bacteria or fungi,
along with blood cells, collect on the endocardium. These clumps occur more often on the heart
valves than on the heart chambers. Pieces of these clumps can break off and travel to different parts
of the body, blocking blood flow or spreading infection.
2. MYOCARDITIS:
Myocarditis is an uncommon disease marked by inflammation of the heart muscle, called the
myocardium, and other changes to the heart muscle cells that may be acute or chronic. Myocarditis
can affect small or large sections of the heart muscle, making it harder for the heart to pump blood,
which in turn can lead to heart failure.
3. PERICARDITIS:
Pericarditis is a condition in which the pericardium—the sac surrounding the heart—gets
inflamed. This sac is made of two thin layers of tissue with a small amount of fluid in between.
 The fluid keeps the layers from rubbing against each other and causing friction. The pericardium
holds the heart in its position in the chest and protects it from infection.

CAUSES OF INFLAMMATORY DISEASE OF HEART:

1. INFECTIONS
 Viral infections are the most common cause of myocarditis and pericarditis. These may include
adenovirus, coxsackievirus, herpes virus, influenza (flu) virus, and parvovirus B19. Viruses may
infect the heart muscle tissue, causing acute or chronic immune responses from the body. New
researches support that SARS-CoV-2, the virus responsible for COVID-19, may affect your
heart. 
 Bacteria are the most common cause of endocarditis, which occurs when bacteria and blood cells
form clumps, typically on the heart valves. In most developed countries Staphylococcus aureus is
the most common type of bacteria that causes endocarditis. Bacteria can enter the blood during
invasive medical procedures or intravenous drug use. Streptococcus bacteria can also cause
endocarditis, but this is more common in less developed countries. Pericarditis caused by bacteria
is rare in the United States and other developed countries. However, in developing countries, 70
percent of pericarditis cases are caused by Mycobacterium tuberculosis, the organism that causes
tuberculosis.
 Fungi are rare causes of myocarditis and pericarditis. Most commonly, fungal endocarditis is
caused by either Candida or Aspergillus. These infections are more common in
immunosuppressed patients, including those who have HIV.
 Other infections. Another infectious cause of myocarditis includes the parasite that
causes Chagas disease, which is a serious health problem in Latin America. The parasite can
specifically affect the heart at the time of infection and may lead to the need for a pacemaker.
2. AUTOIMMUNE DISEASES
Autoimmune diseases such as rheumatoid arthritis and lupus erythematous may cause pericarditis or
myocarditis. They can also damage the heart valves, which can lead to endocarditis.

3. MEDICINES
Medicines can cause side effects that may lead to myocarditis, pericarditis, or both. These medicines
include:
- Antibiotics, such as penicillin
- Antidepressants, such as tricyclic antidepressants
- Benzodiazepines, known as tranquilizers, such as lorazepam and diazepam
- Diuretics, which are medicines, such as furosemide and hydrochlorothiazide, that help your body
get rid of fluid
- Cardiac medicines, such as amiodarone, hydralazine, methyldopa, and procainamide
- Psychiatric medicines, such as clozapine and lithium
- Seizure medicines, such as phenytoin
- Vaccines, which may cause allergic reactions leading to myocarditis, although this is rare
- Weight-loss medicines, such as phentermine-fenfluramine or phen-fen

4. ENVIRONMENTAL FACTORS
Environmental factors that may cause myocarditis include: Heavy metals, such as copper and lead &
Radiation
RISK FACTOR ASSOCIATED WITH INFLAMMATORY DISEASE OF
HEART:
A. AGE:
Different age groups are at risk for different types of heart inflammation:
- Although they can affect all ages, myocarditis and pericarditis occur more often in young adults.
Pericarditis also commonly affects middle-aged adults.
- Older adults are more at risk for endocarditis caused by bacteria. In recent years, age-related heart
valve infections have been on the rise.
B. SEX:
- Heart inflammation from endocarditis, myocarditis, and pericarditis is more common in men than
in women, except when caused by autoimmune diseases, such as lupus and rheumatoid arthritis,
which are more common in women.
- Endocarditis and pericarditis occur twice as often in men as in women.
C. GENETICS:
- Genetics play a role in the risk of developing all three types of heart inflammation. The
genes may be partly responsible for how the body responds to infection and inflammation and
whether one develops myocarditis or pericarditis.
- People who have structural or congenital heart defects, such as problems with the heart valves,
may be at higher risk for infection that can cause endocarditis.
- Certain inherited conditions can affect your risk for heart inflammation. For example, one may be
at higher risk for myocarditis and pericarditis if have familial Mediterranean fever or tumor
necrosis factor receptor-associated periodic syndrome (TRAPS). These rare conditions affect how
the body controls inflammation.
D. ENVIRONMENTAL:
Chagas disease, common in Latin America, can cause acute and chronic myocarditis. It is caused
by a parasite that is spread by certain types of insects. Endocarditis caused
by Streptococcus bacteria is more common in less developed countries.
E. LIFESTYLE:
Certain lifestyle choices raise the risk for endocarditis or myocarditis. These include:
- Drinking too much alcohol, which may cause inflammation of the myocardium and could lead to
reduced heart function and heart failure
- Drug use such as cocaine and amphetamines and intravenous drug use with endocarditis
- Poor dental health, which increases the risk for bacterial endocarditis
F. MEDICAL CONDITIONS:
Some medical conditions can increase the risk of endocarditis, myocarditis, or pericarditis. These
include:
- Cancers, such as advanced lung and breast cancer or lymphoma. Medicines used to treat these
types of cancer can cause myocarditis or pericarditis.
- Diabetes, which can make you more likely to develop infections
- Eating disorders such as anorexia
- End-stage kidney disease, which can result from the buildup of waste products in the blood
- HIV/AID Sexternal link, which may lead to myocarditis from a number of causes, including
viral, bacterial, or fungal infection; treatment; and nutritional deficiencies. People who have
HIV/AIDS may be at higher risk for fungal infection.
- Skin disorders, such as burns or recurrent infections
- Trauma or injury to the chest or esophagus, or indirect injury to the chest wall
 G. MEDICAL PROCEDURES:
Certain medical procedures can increase the risk of endocarditis, myocarditis, or pericarditis, including:
- Central venous line, which is an intravenous catheter that goes into a larger central vein in your
body
- Devices in the heart, such as artificial heart valves, pacemakers, and implantable
cardioverter defibrillators
- Hemodialysis for end-stage kidney disease. Infection may result from access to blood vessels
needed for hemodialysis.
- Medical procedures, such as having a central venous line, which is an intravenous catheter that
goes into a larger central vein in your body; heart ablation for abnormal heart rhythm; or
treatments for coronary heart disease
- Radiation therapy to treat cancers such as lung and breast cancer and lymphoma. This may
cause myocarditis or pericarditis.
- Treatments for ischemic heart disease

PATHOPHYSIOLOGY OF INFLAMMATORY DISEASE OF HEART:

Causative organism like virus, bacteria and fungus may infect the cells of the heart tissue. Once the
causative organism is in the cell, it multiplies and activates the body’s immune system, leading to
damage in the heart tissue. This initial phase of infection can last weeks to months.

If the organism infection lasts for a long time, it can damage the structure and function of the heart
muscle, valves leading to complications 

SIGN AND SYMPTOMS OF INFLAMMATORY DISEASE OF HEART:

If a virus causes heart inflammation, it may have a cough, runny nose, or gastrointestinal symptoms a
few weeks before symptoms of the heart inflammation. The signs and symptoms of heart inflammation
are different depending on the type of heart inflammation

ENDOCARDITIS
 Fever and chills
 New or worsening heart murmur
 Hematuria
 Splenomegaly
 Abdominal pain
 Chest pain
 Cough, with or without the presence of blood
 Loss of appetite and weight loss
 Muscle, joint, and back pain
 Night sweats
 Pain where an infected cardiac device is located
 Shortness of breath
 Skin changes, which can occur with endocarditis. These may be painful red or purple bumps, or
painless flat red spots on places such as the palms of your hands or soles of your feet, or tiny
reddish purple spots from broken blood vessels.
MYOCARDITIS
 Chest pain and discomfort
 Heart palpitations
 Fainting
 Shortness of breath
 Fatigue
 Abdominal pain
 Exercise intolerance, or no longer being able to exercise
 Fever
 Loss of appetite
 Swelling of feet or legs
 Weakness

PERICARDITIS
 Chest pain from pericarditis typically feels sharp, gets worse with breathing, and feels better with
sitting up and leaning forward.
 Tachycardia
 Fever
 Shortness of breath

DIAGNOSIS:
MEDICAL HISTORY:
Assess for
- History of endocarditis, myocarditis, or pericarditis in the past
- History of recent illness or injury to the chest
- Any symptoms, such as fever, chest pain, or shortness of breath?
- Any other medical conditions or any other risk factors for heart inflammation, including exposure
to certain medicines or toxins or a travel history that may be significant?
PHYSICAL EXAMINATION:
- Assess lower extremities for swelling, a sign of heart failure
- Assess skin for any changes, as may be seen in cases of endocarditis
- Vital signs
- Palpation- for a spleen that is larger than normal,
- Auscultation- heart murmur that may be heard with endocarditis, a pericardial rub that may be
heard with pericarditis, or an abnormal heart rhythm

TESTS AND PROCEDURES:

Echocardiography (echo) to look for heart valve problems, problems in the structure or function of the
heart, or a thickening of the pericardium
Electrocardiogram (ECG or EKG) to look for changes in your heart’s electrical activity, which do not
necessarily indicate myocarditis, endocarditis, or pericarditis. It may help distinguish a MI from
pericarditis
Cardiac magnetic resonance imaging (MRI) to detect inflammation and swelling of the myocardium
and pericardium. MRI can also be done to look for complications of endocarditis in other parts of the
body, such as the brain, which may indicate stroke
Cardiac computed tomography (CT) to help diagnose pericarditis, as well as the complications of
endocarditis and pericarditis
Endomyocardial biopsy (EMB) to test very small pieces of the heart to look for myocarditis
Heart valve tissue testing to identify the microbes from the heart valve or its vegetation that may be
causing endocarditis
Pericardiocentesis to remove excess fluid in the pericardium, called a pericardial effusion.
Positron emission tomography (PET) scan or nuclear medicine scan to diagnose endocarditis,
myocarditis, or pericarditis. In both types of imaging studies, a small amount of a radioactive substance
is given to see where the body takes it up. This may indicate infection, cancer, or other conditions in the
places where it shows up on imaging.

BLOOD TEST
- Blood cultures to identify and treat the exact bacterium, virus, or fungus that is causing the
infection in endocarditis or pericarditis
- Cardiac troponins or creatine kinase-MB, which are blood markers that increase when there is
damage to your heart. Since there are no specific blood tests for myocarditis, these markers are
useful to show injury to the heart muscle. However, they are also increased with heart attack or
heart failure and do not necessarily mean you have myocarditis. They are often normal in cases of
subacute or chronic myocarditis.
- C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR), which may indicate
inflammation in the body if higher than normal
- Complete blood count to look for higher levels of white blood cells, which might indicate
infection
- Serum cardiac autoantibodies (AAbs), which are antibodies that your body may start to make if
you have myocarditis. These antibodies recognize your own heart muscle.
- Testing for specific organisms, such as Borrelia burgdorferi, which causes Lyme
disease; Mycobacterium tuberculosis, which causes tuberculosis; HIV; or hepatitis C

COMPLICATIONS:
ENDOCARDITIS
An embolus. In endocarditis, a clump of bacteria or fungi, along with blood cells, forms on the
damaged heart valves. A piece of this clump can break off, forming a type of embolus that travels
through the blood to different parts of the body, blocking blood flow and spreading infection. An
embolus that travels to the brain can cause stroke, meningitis, or an infection called a brain
abscess. An embolus that travels to the lung can cause lung damage or a lung abscess. An
embolus may also travel to the kidney or spleen, blocking blood flow to those organs.
Arrhythmia or heart conduction disorders
Heart failure
Sepsis, a life-threatening blood infection

MYOCARDITIS
Arrhythmia or heart conduction disorders
Cardiomyopathy
Heart failure and cardiogenic shock
Lung complications, such as fluid in the lungs or effusions between the layers covering the lungs
that may occur with heart failure
Syncope

PERICARDITIS
Pericardial effusion, in which fluid collects in the sac around the heart
 Cardiac tamponade, in which too much fluid collects in the pericardium, or the sac around the
heart. This complication of pericarditis prevents the heart from properly filling with blood,
causing a sharp drop in blood pressure that can lead to decreased blood flow to your body.
Constrictive pericarditis, in which scar-like tissue forms through the pericardium. The sac
becomes stiff and cannot move properly. The scarred tissue prevents the heart from filling with
blood properly.

MEDICAL MANAGEMENT OF INFLAMMATORY DISEASE OF HEART:

ENDOCARDITIS
- Antibiotics to treat bacterial infections. Side effects of antibiotics depend on which antibiotic is
used but may include diarrhea; problems with hearing, balance, and kidneys; and decreased white
blood cell counts. Some of these side effects may not happen until treatment is finished.
- Antifungal medicines to treat fungal infections. Sometimes doctor may recommend lifelong oral
antifungal treatment to prevent the infection to reoccour. Possible side effects of antifungal
medicines include allergic reactions, such as diarrhea, dizziness, itching, blisters or hives,
difficulty breathing, weight loss, and jaundice.
- Anticoagulants are used in some types of endocarditis

MYOCARDITIS
- Corticosteroids to lower the activity of the body’s immune system. Corticosteroids may be used
to treat myocarditis caused by autoimmune diseases, such as lupus.
- Heart failure medicines to decrease the work of the heart when heart failure is a complication.
Your doctor may recommend medicines such as beta blockers and angiotensin-converting
enzyme (ACE) inhibitors.
- Intravenous immunoglobulin (IVIG) helps control the body’s immune and inflammatory
response.

PERICARDITIS
- Anti-inflammatory medicines to treat pericarditis. These include colchicine, aspirin, and non-
steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and indomethacin. Side effects are
mainly gastrointestinal and include abdominal pain, nausea, vomiting, and diarrhea.
- Corticosteroids to lower the activity of the body’s immune system. With pericarditis,
corticosteroids are used only in patients who are not responding to or cannot take NSAIDs.
- Intravenous immunoglobulin (IVIG) to help control the body’s immune and inflammatory
response. This may be used when there is an autoimmune disorder, such as lupus.

NURSING MANAGEMENT OF INFLAMMATORY DISEASE OF HEART

 The nurse monitors the temperature of the patient as the patient may have fever for weeks
 Heart sounds are assessed: a new heart murmur may indicate involvement of valves in
endocarditis
 Monitoring the sign and symptoms of systemic embolization, pulmonary infarction and
infiltration, heart failure, stroke etc
 All invasive lines if present should be assessed for the signs of infection like redness, tenderness,
warmth or pain at insertion site
 Patient with acute pericarditis may require pain management with analgesics, positioning nad
psychological support
 NURSING PROCESS
1. ASSESSMENT:
It includes history taking like
 Subjective data: past medical history: patient asked of signs of the disease and the onset of
the disease and review with patient history of risk factors like cardiac failure, shock
 Medication history: has the pt ever taken any medication, what happened afterwards
 Family history: ask of any case at home of the similar condition
 Social history: social behaviors that can trigger the problem
 Surgical history: if ever operated on
 Objective data: assess for temperature elevations, heart mummer, evidence of cough ,
peripheral edema and embolism, auscultate for heart sound, monitor arterial blood gas, rapid
purse rate, dyspnea, restlessness and manifestation of heart failure
2. DIAGNOSIS:
 Infective breathing pattern related to inflammation of heart muscle as evidenced by use of
accessory muscle, dyspnea.
 Impaired gaseous exchange related to fluid accumulation in the lungs as evidenced by shortness
of breath
 Decreased cardiac output related to valvular dysfunction as evidenced by poor tissue perfusion
 Imbalanced nutrition less than body requirement related to anorexia as evidenced by loss of
weight.
3. NURSING INTERVENTION:
 Position the patient at semi fowlers position to help in infective breathing through providing
enough room for lung expansion as abdominal contents goes down
 Administer oxygen therapy 4-6 l/min to help pt in breathing effectively through supplementing
oxygen
 Monitor arterial blood gas , carbon dioxide, oxygen saturation hourly and document to monitor
signs of respiratory acidosis
 Encourage and provide small frequent meals reach in proteins helping in repairing worn-out
tissues
 Monitor vital signs , heart and lung sound, level of consciousness to evaluate how effectively the
organs like the heart and the lungs are working
 Schedule nursing activities to allow rest
 Encourage and assist pt to cough and deep breath to promote chest expansion
 provide tepid sponging to reduce raised body temperature by evaporation and conduction
 Encourage patient on exercises in order to improve patients mobility through making the body
physically fit
 Make yourself available to the patient and nurse with love and respond well to his/her questions
to array pain and anxiety
 Educate the patient on disease process to make patient cope up with therapy and the condition

PREVENTIVE MEASURES OF INFLAMMATORY DISEASE OF HEART:

Avoid using illegal intravenous (IV) drugs.

Practice careful skin hygiene, such as regularly washing your skin and immediately washing any
cuts or scrapes to prevent infection.
Practice good dental hygiene, including daily brushing and flossing and regular visits to the
dentist.
Take antibiotics before some medical procedures, but only as directed by your doctor. Many
causes of myocarditis and pericarditis are difficult or impossible to avoid or prevent. Controlling
 risk factors for diseases such as HIV and avoiding substances such as amphetamines and cocaine
may decrease your risk for myocarditis.

CLINICAL STUDIES:

- Two-dimensional echocardiographic studies were performed in 293 patients with rheumatic heart
disease who underwent open-heart mitral valve surgery during an 18-month period. Diagnostic
confirmation of a left atrial thrombus was based on direct inspection of the left atrium during
surgery and histopathologic examination. Two- dimensional echocardiographic recordings were
reviewed. Of the 293
- This diagnosis was confirmed at surgery and histopathologic study in 30 (specificity 98.8%). A
thrombus was not found in three patients. In 21 other patients, left atrial thrombi were present but
were not detected by two-dimensional echocardiography (sensitivity 58.8%). Ten of these 21 had
thrombi in the left atrial cavity. In 11 patients, thrombi were located in the left atrial appendage,
all of which were missed by two-dimensional echocardiography. Excluding these 11 left atrial
appendage thrombi, the sensitivity of two-dimensional echocardiography for detecting left atrial
cavity thrombi was 75.0 %.

SUMMARY:
To summarize there are mainly three types of inflammatory heart disease namely endocarditis,
myocarditis and pericarditis. Major causes include viral, bacterial and fungal infection. Diagnostic test
such as EKG, Echo, MRI, CT and blood culture can diagnose the condition. They can be prevented and
cured with antibiotics, antiviral and antifungal drugs.

CONCLUSION
To conclude inflammatory heart disease are major cause by infection which can be prevented.
Awareness among society can help prevent and reduce the disease.

BIBLIOGRAPHY
1) Suzanne C Smelter , Brenda Bare. Brunner & Suddarth's Textbook of Medical-Surgical
Nursing. (10th edition ed.). Philadelphia: Brunner & Suddarth; 2004.
2) Mary A Miller, Debohra C. Wirwicz, ‘You Can Teach Med- Surg Nursing’, Springer Publishing
Company, NewYork, 2015
3) Linta S Williams,Paula D Hopper, Understanding Medical Surgical Nursing(3rd Edition), F.A Davis
Company, Philadephia,2007
4) Black JM,Hawks JH medical surgical nursing 7th ed.elsevier ; Missouri, 2005 vol:2; 1612- 24.
5) https://www.nhlbi.nih.gov/health-topics/heart-inflammation#:~:text=There%20are%20three
%20main%20types,a%20sac%20around%20the%20heart.