rheumatic heart disease

1. RHEUMATIC HEART DISEASE
Introduction
Rheumatic (roo-MAT-ik) heart disease was formerly one of the most
serious forms of heart disease of childhood and adolescence. Rheumatic heart
disease involves damage to the entire heart and its membranes.Rheumatic heart
disease is a complication of rheumatic fever and usually occurs after attacks of
rheumatic fever. The incidence of rheumatic heart disease has been greatly
reduced by widespread use of antibiotics effective against the streptococcal
bacterium that causes rheumatic fever.
Sign and Symptoms
Some of the most common symptoms of rheumatic heart disease are
breathlessness, fatigue, palpitations, chest pain, and fainting attacks.
Diagnosis
The first step in diagnosing rheumatic heart disease is establishing that your
child recently had a strep infection. The doctormayorder a throat culture, a blood
test, or both to check for the presence of strep antibodies. However, it is likely
that signs of the strep infection may be gone by the time you take your child to
the doctor. In that case, the doctorwill need you to try to remember if your child
recently had a sore throat or other symptoms of a strep infection.
The doctor will do a physical examination and check your child for signs
of rheumatic fever, including joint pain and inflammation. The doctor also will
listen to your child's heart to check for abnormal rhythms or murmurs that may
signify that the heart has been strained.

2. In addition, there are a couple of tests that may be used to check the heart
and assess damage, including:
Chest X-ray to check the size of the heart and to see if there is excess fluid
in the heart or lungs
Echocardiogram, a non-invasive test that uses sound waves to create a
moving image of the heart and to measure its size and shape
MedicalManagement
Medical therapy is directed toward eliminating the group A streptococcal
pharyngitis (if still present), suppressing inflammation from the autoimmune
response, and providing supportive treatment for congestive heart failure. But the
specific treatment for rheumatic heart disease will be determined by your
physician based on:
* Your overall health and medical history
* Extent of the disease
* Your tolerance for specific medications, procedures, ortherapies
* Expectations for the courseof the disease
* Your opinion or preference
Since rheumatic fever is the cause of rheumatic heart disease, the best
treatment is to prevent rheumatic fever from occurring. Oral penicillin V remains
the drug of choice for treatment of group A streptococcal pharyngitis. When oral
penicillin is not feasible ordependable, a single doseofintramuscular benzathine
penicillin G is therapeutic. For patients who are allergic to penicillin, administer
erythromycin or a first-generation cephalosporin.Other options include
clarithromycin for 10 days, azithromycin for 5 days, or a narrow-spectrum (first-
generation) cephalosporin for 10 days. To reduce inflammation, aspirin, steroids,

3. or non-steroidal medications may be given. Surgery may be necessary to repair
or replace the damaged valve
Nursing Management
*Monitor blood pressure, pulse apical and peripheral pulse
*Monitor cardiac rhythm and the frequency
*Sleeping position 450 semifowler
*Instruct the client to do stress management techniques (quiet environment,
meditation)
*Aids client activity as indicated when the client is able
BACTERIAL INFECTIVE ENDOCARDITIS
Infective endocarditis is a form of endocarditis, or inflammation of the
inner tissue of the heart, such as its valves, caused by infectious agents. The
agents are usually bacterial, but other organisms can also be responsible.
The valves of the heart do not receive any dedicated blood supply. As a
result, defensive immune mechanisms (suchas white blood cells) cannot directly
reach the valves via the bloodstream. If an organism (such as bacteria) attaches
to a valve surface and forms a vegetation, the host immune response is blunted.
The lack of blood supply to the valves also has implications on treatment, since
drugs also have difficulty reaching the infected valve.
Normally, blood flows smoothly through these valves. If they have been
damaged - from rheumatic fever, for example - the risk of bacterial attachment is
increased

4. Sign and Symptoms
Fever, i.e. fever of unknown origin occurs in 97% of people; malaise and
endurance fatigue in 90% of people.
A new orchanging heart murmur, weight loss, and coughing occurs in 35%
of people
Vascular phenomena: septic embolism (causing thromboembolic
problems such as stroke in the parietal lobe of the brain or gangrene of
fingers), Janeway lesions (painless hemorrhagic cutaneous lesions on the palms
and soles), intracranial hemorrhage, conjunctivalhemorrhage, splinter
hemorrhages, Renal Infarcts, and Infarct Spleen.
Immunologic phenomena: Glomerulonephritis which allows for blood and
albumin to enter the urine,[1] Osler's nodes (painful subcutaneouslesions in the
distal fingers), Roth's spots onthe retina, positive serum rheumatoid factor
Other signs may include; night sweats, rigors, anemia, splenomegaly,
clubbing
Diagnosis
Blood Tests - Blood cultures are the most important blood tests used to
diagnose IE. Blood is drawn several times over a24-hour period. It's putin special
culture bottles that allow bacteria to grow.
Echocardiography - Echocardiography (echo) is a painless test that uses
sound waves to create pictures of your heart. Two types of echo are useful in
diagnosing IE.

5. Transthoracic (tranz-thor-AS-ik) echo. For this painless test, gel is applied
to the skin on your chest. A device called a transducer is moved around on the
outside of your chest.
This device sends sound waves called ultrasound through your chest. As
the ultrasound waves bounce off your heart, a computer converts them into
pictures on a screen.
Your doctor uses the pictures to look for vegetations, areas of infected
tissue (such as an abscess), and signs of heart damage.
Because the sound waves have to pass through skin, muscle, tissue, bone,
and lungs, the pictures may not have enough detail. Thus, your doctor may
recommend transesophageal (tranz-ih-sof-uh-JEE-ul) echo (TEE).
Transesophageal echo. For TEE, a much smaller transducer is attached to
the end of a long, narrow, flexible tube. The tube is passed down your throat.
Before the procedure, you're given medicine to help you relax, and your throat is
sprayed with numbing medicine.
The doctor then passes the transducer down your esophagus (the passage
from your mouth to your stomach). Because this passageis right behind the heart,
the transducer can get detailed pictures of the heart's structures.
EKG - An EKG is a simple, painless test that detects your heart's electrical
activity. The testshows how fast your heart is beating, whether your heart rhythm
is steady or irregular, and the strength and timing of electrical signals as they pass
through your heart.
An EKG typically isn't used to diagnose IE. However, it may be done to
see whether IE is affecting your heart's electrical activity.

6. For this test, soft, sticky patches called electrodes are attached to your
chest, arms, and legs. You lie still while the electrodes detect your heart's
electrical signals. A machine records these signals on graph paper or shows them
on a computer screen. The entire test usually takes about 10 minute
MedicalManagement
High doseantibiotics are administered by the intravenous route to
maximize diffusion of antibiotic molecules into vegetation(s) from the blood
filling the chambers of the heart. Antibiotics are continued for a long time,
typically two to six weeks.
High doseIV crystalline penicillin every 4hrs for 2 weeks is recommended
and still remains the drug of choice.
2 week treatment regimen of benzyl penicillin IV
Nursing Management
During the acute phase of the disease, provide adequate rest by assisting
the patient with daily hygiene. Provide a bedside commode to reduce the
physiological stress that occurs with the use of a bedpan. Space all nursing care
activities and diagnostic tests to provide the patient with adequate rest. During
the first few days of hospital admission, encourage the family to limit visitation.
Emphasize patient education. Individualize a standardized plan ofcare, and
adapt it to meet the patient's needs. Areas for discussion include the cause of the
disease and its course, medication regimens, technique for administering IV
antibiotics, and practices that help avoid and identify future infections.
If the patient is to continue parenteral antibiotic therapy at home, make sure
that, before he or she is discharged from the hospital, the patient has all the

7. appropriate equipment and supplies that will beneeded. Make a referral to a home
health nurse as needed, and provide the patient and family with a list of
information that describes when to notify the primary healthcare provider about
complications.
KAWASAKI DISEASE
Kawasaki (KAH-wah-SAH-ke) disease is a rare childhood disease. It's a
form ofa disease called vasculitis (vas-kyu-LI-tis).In Kawasaki disease, the walls
ofthe blood vessels throughout the body become inflamed. The disease can affect
any type of blood vessel in the body, including the arteries, veins, and
capillaries.In some cases, Kawasaki disease affects the coronary arteries, which
carry oxygen-rich blood to the heart. As a result, a small number of children who
have Kawasaki disease may develop serious heart problems.
Sign and Symptoms
MajorSigns and Symptoms
One of the main symptoms during the early part of Kawasaki disease,
called the acute phase, is fever. The fever lasts longer than 5 days. It remains high
even after treatment with standard childhood fever medicines.
Other classic signs ofthe disease are:
Swollen lymph nodes in the neck,A rash on the mid-section of the body
and in the genital area,Red, dry, cracked lips and a red, swollen tongue,Red,
swollen palms of the hands and soles of the feet,Redness of the eyes
During the acute phase, your child also may be irritable and have a sore
throat, joint pain, diarrhea, vomiting, and stomach pain.Within 2 to 3 weeks of

8. the start of the first symptoms, the skin of your child's fingers and toes may peel,
sometimes in large sheets.
Diagnosis
Blood tests. These tests can show whether the body's blood vessels are
inflamed.
Chestx ray. This test can help show whether Kawasaki diseasehas affected
the heart
EKG (electrocardiogram). This simple test detects and records the heart's
electrical activity. EKG can show whether Kawasaki disease has affected the
heart.
MedicalManagement
The medical management of Kawasaki disease primarily involves the use
of gamma globulin. Although some have suggested that aspirin is no longer
needed, most use high-dose aspirin for a variable period of time, followed by
lower-dose aspirin forits antiplatelet effects. Of note, a 2008 CochraneDatabase
of Systematic Reviews article concluded that "there is insufficient evidence to
indicate whether children with Kawasaki disease should continue to receive
salicylate as part of their treatment regimen."Some controversy exists about the
ideal timing to begin gamma globulin, but this is not an issue that concerns
emergency physicians. It is given most often from days 5-7.Although data are
limited, authors of several case reports have suggested a possible role for
thrombolysis in those with acute MI as a consequence of thrombus formation in
aneurysms. At this time, it seems unlikely that the emergency physician will
administer this therapy.Some have suggested that there is, or may be, a role for
corticosteroids. Most have pointed out that not only is there no good data to
supporta benefit in terms of outcome but also that current therapy with IVIG and
aspirin is safe and effective. In a meta-analysis of 4 studies and 447 patients,
Athappan et al concluded that the addition of steroids to standard therapy (IVIG

9. + aspirin) decreased the rate of re-treatment but did not decreasethe incidence of
coronaryaneurysms oradverse events.Ibuprofenantagonizes aspirin's antiplatelet
activity and should be avoided.Because these children will take aspirin for a
variable period of time, vaccination against influenza and varicella must be
ensured.Studies that involved plasma exchange or cyclophosphamide have
shown variable results. Both are used in cases of refractory disease. In a small
series of 24 children, infliximab was reported to be as effective as a second IVIG
infusion in resistant cases.
Nursing Management
Monitoring
1. Monitor pain level and child’s responseto analgesics.
2. Institute continual cardiac monitoring and assessment for complications;
report arrhythmias.
3. Closely monitor intake and output, and administer oral and I.V fluids as
ordered.
4. Monitor hydration status by checking skin turgor, weight, urinary output,
specific gravity, and presence of tears.
5. Observe mouth and skin frequently for signs of infection.
Supportive care
1. Allow the child periods of uninterrupted rest. Offer pain medication routinely
rather than as needed during stage I. Avoid NSAIDS if the child is in aspirin
therapy.
2. Perform comfort measures related to the eyes.
 Conjunctivities can cause photosensitivity, so darken the room, offer
sunglasses.
 Apply coolcompress.

10.  Discourage rubbing the eyes.
 Instill artificial tears to soothe conjunctiva.
3. Monitor temperature every 4 hours. Provide spongebath if temperature above
normal.
4. Perform passive range of motion exercises every 4 hours while the child is
awake because movement may be restricted.
5. Provide quiet and peaceful environment with diversional activities.
6. Provide care measures for oral mucous membrane.
 Offer coolliquids like ice chips and ice pops.
CARDIAC CATHETERIZATION
Cardiac catheterization involves passing a thin flexible tube (catheter) into
the right or left side of the heart, usually from the groin or the arm.
How the Test is Performed
You will be given a mild sedative before the test to help you relax. An
intravenous (IV) line is inserted into one of the blood vessels in your arm, neck,
or groin after the site has been cleansed and numbed with a local numbing
medicine (anesthetic).
A catheter is then inserted through the IV and into your blood vessel. The
catheter is carefully threaded into the heart using an x-ray machine that produces
real-time pictures (fluoroscopy). Once the catheter is in place, your doctormay:
 Collect blood samples from the heart
 Measure pressure and blood flow in the heart's chambers and in the large
arteries around the heart
 Measure the oxygen in different parts of your heart

11.  Examine the arteries of the heart with an x-ray technique called
fluoroscopy (which gives immediate, "real-time" pictures of the x-ray
images on a screen and provides a permanent record of the procedure)
 Perform a biopsyon the heart muscle
How to Prepare for the Test
If possible, you will be asked not to eat or drink for 6 - 8 hours before the test.
The test takes place in a hospital and you will be asked to wear a hospital gown.
Sometimes, you will need to spend the night before the test in the hospital.
Otherwise, you will be admitted as an outpatient or an inpatient the morning of
the procedure.
Tell your doctorif you:
 Are allergic to seafood
 Have had a bad reaction to contrast material or iodine in the past
 Are taking Viagra
 Might be pregnant
How the TestWill Feel
The study is done by trained cardiologists with the assistance of trained
technicians and nurses.
You will be awake and able to follow instructions during the test. You will
usually get a mild sedative 30 minutes before the test to help you relax. The test
may last 30 - 60 minutes.
You may feel some discomfort at the site where the catheter is placed.
Local anesthesia will be used to numb the site, so the only sensation should be

12. one of pressure at the site. You may experience some discomfort from having to
remain still for a long time.
After the test, the catheter is removed. You might feel a firm pressure, used
to prevent bleeding at the insertion site. If the catheter is placed in your groin,
you will usually be asked to lie flat on your back for a few hours after the test to
avoid bleeding. This may cause some mild back discomfort.
Why the Testis Performed
In general, this procedure is done to get information about the heart or its
blood vessels or to provide treatment in certain types of heart conditions. It may
also be used to determine the need for heart surgery.
Your doctor may perform cardiac catheterizationto:
 Diagnose or evaluate coronary artery disease
 Diagnose or evaluate congenital heart defects
 Diagnose or evaluate problems with the heart valves
 Diagnose causes of heart failure or cardiomyopathy
The following may also be performed using cardiac catheterization:
 Repair of certain types of heart defects
 Repair of a stuck (stenotic) heart valve
 Opening of blocked arteries or grafts in the heart
The procedure can identify heart defects or disease, suchas:
 Coronary artery disease
 Valve problems
 Ventricular aneurysms
 Heart enlargement

13. The procedure also may be performed for the following:
 Primary pulmonary hypertension
 Heart valve defects, such as pulmonary valve stenosis, mitral valve
regurgitation, aortic stenosis, and others
 Pulmonary embolism
 Birth defects, such as Tetralogy of Fallot, transposition of the great
vessels, ventricular septal defect,coarctation of the aorta, and others
 Cardiac amyloidosis
Risks
Cardiac catheterization carries a slightly higher risk than other heart tests,
but is very safe when performed by an experienced team.
Generally, the risks include the following:
 Cardiac arrhythmias ,Cardiac tamponade
 Heart attack
 Bleeding
 Low blood pressure
 Reaction to the contrast medium
 Trauma to the artery caused by hematoma
Possible complications ofany type of catheterizationinclude the following:
 A risk of bleeding, infection, and pain at the IV site
 A very small risk that the soft plastic catheters could damage the blood
vessels
 Blood clots could form on the catheters and later block blood vessels
elsewhere in the body.

14.  The contrast material could damage the kidneys (particularly in patients
with diabetes).