#nursing education. # Its for nursing students # study purpose only Heart infections occur when irritants such as bacteria, viruses and fungi infect your heart. The types of heart infections are endocarditis, myocarditis and pericarditis. Providers often treat heart infections with medication, though you may need surgery for serious infections

1. Rheumatic
fever &
Rheumatic
heart
disease

2. INTRODUCTION
Rheumatic fever is an immunological disorder
initiated by group A beta haemolytic
streptococci.

4. Etiology
The etiology of rheumatic fever is unknown
A strong association with beta hemolytic streptococci of group A is
indicated by a number of observations:
History of preceding sore throat is available in less than 50% patients
Epidemics of streptococcal infection are followed by higher incidence
of rheumatic fever

5. The seasonal variation of rheumatic fever and streptococcal infection are
identical
In patients with established RHD streptococcal infection is followed by
recurrence of acute rheumatic fever
Penicillin prophylaxis for streptococcal infection prevents recurrences of
rheumatic fever in those patients who have had it earlier
More than 85% of the patients with acute rheumatic fever show elevated
levels of anti-streptococcal antibody titer

6. Predisposing factors.
Poor socioeconomic conditions,
Unhygienic living conditions
Overcrowded households

8. CLINICAL MANIFESTATION
The clinical features of rheumatic fever consists of streptococcal sore
throat with fever followed 10 days to a few weeks later by recurrence of
fever and the various manifestations of acute rheumatic fever.
The history of sore throat is available in less than 50% of the patients.
Guidelines for the clinical diagnosis of acute rheumatic fever, originally
suggested by T. Duckett Jones have been revised by the American heart
association and WHO.
The guidelines consist of major, minor and essential criteria

9. CLINICAL FEATURES

10. Carditis
It is an early manifestation of rheumatic fever.
Studies utilizing echocardiography indicates that carditis occurs in
almost 90% patients.
In 60-70% it is clinically obvious whereas in the remaining, the
diagnosis is based on echocardiographic findings labelled as subclinical
carditis.

11. Rheumatic carditis is designated as a pancarditis involving the
pericardium, myocardium and endocardium, although studies indicate
limited myocardial component.
Almost 80% of those patients who develop carditis do so within the
first two weeks of onset of rheumatic fever.

12. Pericarditis results in precordial pain that may be quite severe.
On auscultation a friction rub is present.
Clinical pericarditis is seen in approximately 15% of those who have
carditis.
The electrocardiogram may show ST and T changes consistent with
pericarditis.

14. As a rule, the rheumatic pericarditis is associated with only small
effusions and does not result either in tamponade or constrictive
pericarditis.
A patient of rheumatic pericarditis always has additional mitral or
mitral and aortic regurgitation murmurs.

15. Other features of carditis are
Cardiac
enlargement
Soft first
sound
Protodiastolic
(S3) gallop,
Congestive
cardiac
failure
Carey
Coombs'
murmur.
The Carey Coombs
Murmur occurs
during acute
rheumatic fever.
Mitral valvulitis can
occur causing
thickening of the
leaflets. A murmur is
created by increased
blood flow across
the thickened mitral
valve. This can be
distinguished from
rheumatic mitral
valve stenosis by the
absence of an
opening snap.

16. Endocarditis is represented by a pansystolic murmur of mitral
regurgitation with or without an associated aortic regurgitation
murmur.
Pathologically mitral valve is involved in all cases of rheumatic fever
with carditis.
Clinically, however, 5-8% patients may present as pure aortic
regurgitation.
Thus almost 95% patients will have mitral regurgitation murmur, a
quarter of them also have an aortic regurgitation murmur and only 5%
present as pure aortic regurgitation

18. Tricuspid valvulitis resulting in tricuspid regurgitation occurs in 10-30%
of cases.
Isolated tricuspid valvulitis as a manifestation of acute rheumatic
endocarditis does not occur.
Clinical evidence of pulmonary valve involvement in acute rheumatic
fever is never seen.
The acute hemodynamic overload resulting from acute mitral
regurgitation and/ or aortic regurgitation leads to left ventricular failure
and is the main reason for the morbidity and mortality of rheumatic
fever and RHD.

20. Arthritis
Rheumatic arthritis is a polyarthritis
involving large joints that include knees,
ankles and elbows.
Uncommonly smaller joints may also be
involved.
It is a migratory polyarthritis with the
affected joints showing redness, warmth,
swelling, pain and limitation of movement.
It is an early manifestation and occurs in
70-75% of cases according to western
literature.

22. However, the figures from India indicate that arthritis is seen in 30 to
50% of patients.
The pain and swelling appear rather quickly, last 3 to 7 days and
subside spontaneously to appear in some other joint.
There is no residual damage to the joint.
Arthritis tends to be commoner in older patients

23. Subcutaneous nodules
Subcutaneous nodules
appear on bony
prominences like elbows,
shins, occiput and spine.
They vary in size from
pinhead to an almond.

24. They are non-tender.
Subcutaneous nodules are a late manifestation and appear around 6
weeks after the onset of rheumatic fever though they have been
described as early as 3 weeks from the onset.
They occur in about 3 to 20% of cases of rheumatic fever in India.
Patients who have subcutaneous nodules almost always have carditis.
They last from a few days to weeks but have been known to last for
almost a year.

25. Chorea.
Sydenham's chorea is also a late manifestation
occurring about three months after the onset of
acute rheumatic fever.
Generally by the time a patient manifests
chorea, the signs of inflammation usually subside
Chorea consists of semi-purposeful, jerky
movements resulting in deranged speech,
muscular incoordination, awkward gait and
weakness.

26. The affected child is emotionally disturbed and drops things she or he
is carrying.
It is three to four times more common in females as compared to
males.
Untreated, it has a self-limiting course of two to six weeks.

27. Erythema marginatum
It is an early manifestation, predominantly seen over the trunk.
The rash is faintly reddish, not raised above the skin and non-itching.
It starts as a red spot with a pale center, increasing in size to coalesce
with adjacent spots to form a serpiginous outline.
We believe that the inability to recognize erythema marginatum is not
because it does not occur but because of the dark complexion of the
skin.

28. Minor criteria
Clinical
criteria
Laboratory
manifestation

29. Clinical criteria
Fever
Arthralgia
Previous History

30. Fever. Rheumatic fever
is almost always
associated with fever.
The temperature rarely
goes above 39.5°C.

31. Arthralgia.
Arthralgia is defined as
subjective pain whereas
arthritis means subjective
symptoms as well as
objective signs of joint
inflammation.
Whereas arthritis is a major
manifestation, arthralgia is
a minor manifestation.
Figures from India indicate
that arthritis and arthralgia
together occur in about
90% of the patients

32. Previous rheumatic fever or rheumatic heart disease.
This minor criterion is applicable only for a second attack of
rheumatic fever.

33. Laboratory Manifestations
Acute phase
reactants
Prolonged PR
interval

34. a) Acute phase reactants
Acute phase reactants consist of polymorphonuclear leukocytosis,
increased sedimentation rate and C-reactive protein.
The leukocyte count usually lies between 10,000 to 15,000/cu mm.
The sedimentation rate is elevated during acute rheumatic fever and
remains so for 4 to 10 weeks in almost 80% of patients.
In a small proportion of patients it may remain elevated even beyond
12 weeks.

35. Although congestive cardiac failure tends to bring the sedimentation
rate down toward normal, it is unlikely that a patient of acute rheumatic
fever in congestive cardiac failure will have a normal sedimentation
rate.
C-reactive protein is increased in all patients of acute rheumatic fever.
It subsides rapidly if the patient is on steroids. While absence of C-
reactive protein is strongly against the diagnosis of acute rheumatic
fever, its presence is non-specific.

36. (b) Prolonged PR interval in the
electrocardiogram
Prolonged PR interval is a non-diagnostic criterion since it can get
prolonged in many infections.
It is also not diagnostic of carditis.
Higher grades of block like second degree atrioventricular block
specially of the Wenckebach type may also be seen.
Complete atrioventricular block is extremely rare.

37. Essent
ial
Criteri
a
Evidences of recent
streptococcal infection
Scarlet fever
Positive throat culture
for streptococci

38. Evidences of recent streptococcal
infection.
The commonest in use is the antistreptolysin 'O' titer (ASO).
Elevated levels of ASO only indicate previous streptococcal infection
and not rheumatic fever.
Although generally the higher the level the more likely one can
conclude a recent streptococcal infection, lower levels considered
"normal" do not necessarily exclude a recent streptococcal infection.

39. If the basal ASO titer of an individual is 50 units and it goes up to 250
units, it is indicative of recent streptococcal infection.
Rising titer of ASO is a strong evidence for a recent streptococcal
infection

40. Positive throat culture for
streptococci
Positive throat culture for streptococci is relatively uncommon, when
a patient presents with acute rheumatic fever.
Positive throat culture can also not be equated with the diagnosis of
rheumatic fever.
Positive throat culture means that streptococci are present in the
throat.
The patient may or may not have rheumatic fever.

41. Scarlet fever
The third feature suggestive for the diagnosis of recent streptococcal
infection is the presence of residua of scarlet fever.
The desquamation of skin of palms and soles indicates that the patient
has had scarlet fever within the previous two weeks.
Scarlet fever is rare in India.

42. DIAGNOSTIC EVALUATION
 Diagnosed clinically through use of the Jones criteria from the American
Heart Association presence of two major manifestations or one major and
two minor manifestations (as listed above), with supporting evidence of a
recent streptococcal infection.
 ECG done to evaluate PR interval and other changes.
Laboratory tests listed above. In addition, group A streptococcal culture
and/or antistreptolysin-O titer to detect streptococcal antibodies from
recent infection.
Chest X-ray for cardiomegaly, pulmonary congestion, or edema.

43. MANAGEMENT
Disorders is symptomatic of Cardiovascular combined System with
suppressive - therapy.

44. BED REST
Bed rest is generally recommended for
acute rheumatic fever. Patients who do
not have cardiac involvement can be
ambulant in two to three weeks whereas
when carditis is present, immobilization
may have to be continued for one to
three months specially in the presence
of congestive failure.

45. DIET
In the absence of cardiac
involvement there should be no
restriction in salt intake.
Even in the presence of cardiac
involvement, salt restriction is not
necessary unless congestive cardiac
failure is present and not responding
well to treatment.

46. PENICILLIN
After obtaining throat cultures the patient should be put on penicillin.
A single injection of benzathine penicillin can be administered when
the diagnosis of rheumatic fever is made.
Penicillin V (250 mg four times a day for 10 days) is another
alternative; erythromycin (250 mg qid for 10 days) can be administered
for those with penicillin allergy.

47. SUPPRESSIVE THERAPY
Aspirin or steroids are given as suppressive therapy. Since untreated
rheumatic fever subsides in 12 weeks in 80% of the patients, either of
the two suppressive agents is given for 12 weeks
Steroids are a more potent suppressive agent as compared to aspirin.
However, there is no proof that the use of steroids results in less cardiac
damage as compared to aspirin. A number of observations indicate that
steroids act faster and are superior at least in the initial phases.

48. Pericardial friction rub tends to disappear within three to five days
after starting the steroids and a new friction rub does not appear.
Despite adequate doses of aspirin having been given, a new friction
rub may still make its appearance. Subcutaneous nodules tend to
disappear faster with the use of steroids as compared to aspirin.
Patients who have carditis with congestive cardiac failure have a higher
mortality if aspirin is used compared to steroids.

49. Surgical
 Surgical replacement of the mitral and/or aortic valve is indicated if
the patient is deteriorating despite aggressive decongestive measures.
 Acute hemodynamic overload due to mitral or aortic regurgitation is
the main cause of mortality due to rheumatic fever.

51. Management of chorea
The patient as well as the parents should be reassured and told about
the self-limiting course of the disease.
The signs and symptoms of chorea do not respond well to anti-
inflammatory agents or steroids.
Supportive measures such as rest in a quiet room and medications
such as haloperidol, diazepam and carbamazepine are effective.

52. COMPLICATIONS
CHF.
Pericarditis,
pericardial effusion.
Permanent damage to the aortic or mitral valve, possibly requiring
valve replacement.

53. Nursing Assessment
Assess for signs of cardiac involvement by auscultation of the heart for
murmur and cardiac monitoring for prolonged PR interval.
Monitor pulse for 1 full minute to determine heart rate.
Assess temperature for elevation.
Observe for involuntary movements: stick out tongue or smile; garbled
or hesitant speech when asked to recite numbers or the ABCs;
hyperextension of the wrists and fingers when trying to extend arms.

54. Assess child's ability to feed self, dress, and do other activities if
chorea or arthritis present.
Assess pain level using scale appropriate for child's age.
Assess parents' ability to cope with illness and care for child.
Assess need for home schooling while patient is on bed rest.

55. Nursing Diagnoses
Decreased Cardiac Output related to carditis
Acute and Chronic Pain related to arthritis
Risk for Injury related to chorea

56. Nursing Interventions

57. Goal:Improving Cardiac Output
Explain to the child and family the need for bed rest during the acute
phase (approximately 2 weeks) and as long as CHF is present. In milder
cases, light indoor activity is allowed.
In severe cases, organize care so that the child will not have to exert self
and will have hours of uninterrupted rest.
Maintain cardiac monitoring if indicated.
Administer course of antibiotics as directed. Be alert to adverse effects,
such as nausea, vomiting, and GI distress.
Administer medications for CHF as directed. Monitor BP, intake and
output, and heart rate.

58. Relieving Pain
Administer anti-inflammatory medication, analgesics, and antipyretics
as directed.
◦ Monitor for signs of aspirin toxicity, such as tinnitus, nausea and vomiting,
and headache.
◦ Monitor for signs of corticosteroid use—GI distress, acne, weight gain,
emotional disturbances—or long-term effects, such as rounded face, ulcer
formation, and decreased resistance to infection.
◦ Administer all anti-inflammatory medications with food to reduce GI injury.
◦ Be aware that anti-inflammatories may not alter the course of myocardial
injury.

59. Teach family the importance of maintaining dosage schedule,
continuing medication until all signs and symptoms of the ARF have
gone, and tapering the dose as directed by health care provider.
Assist child with positioning for comfort and protecting inflamed joints.
Suggest diversional activities that do not require use of painful joints.

60. Protecting the Child with
Chorea
Use padded side rails if chorea is severe.
Assist with feeding and other fine-motor activities as needed.
Assist with ambulation if weak.
Avoid the use of straws and sharp utensils if chorea involves the face.
Make sure that child consumes nutritious diet with recommended
vitamins, protein, and calories.
Be patient if speech is affected, and offer emotional support.
Protect the child from stress.
Administer phenobarbital or other medication for chorea as directed.
Observe for drowsiness.

61. Family Education and Health
Maintenance
Teach the appropriate administration of all medications, including
prophylactic antibiotic.
Encourage all family and household members to be screened for
streptococcus and receive the appropriate treatment.
Instruct on additional prophylaxis for endocarditis with dental procedures
and surgery as indicated.
Encourage following activity restrictions, resuming activity gradually, and
resting whenever tired.

62. Encourage keeping appointments for follow-up evaluation by
cardiologist and other health care providers.
Advise the parents that child cannot return to school until health care
provider assesses that all disease activity is gone. Parents may need to
discuss with teachers how the child can catch up with schoolwork.

63. Instruct on follow-up with usual health care provider for immunizations,
well-child evaluations, hearing and vision screening, and other health
maintenance needs.
Provide general health education about early identification and
treatment seeking for any possible streptococcal infection (fever, sore
throat). Compliance with 10 to 14 days of antibiotics can greatly reduce
the risk of ARF and other poststreptococcal sequelae.

64. Prevention of Rheumatic Fever
 Primary prevention requires identification of streptococcal sore throat
and its treatment with penicillin.
Secondary prevention consists in giving long-acting benzathine
penicillin