1) Define Rheumatic Heart disease2) Explain the pathophysiology and Aetiology of Rheumatic Heart Disease3) Explain the clinical manifestation of Rheumatic Heart Disease4) State the diagnostic evaluation/studies of RHD5) Explain the Nursing assessment6) State the nursing diagnoses7) Explain the nursing management and interventions8) Medical management9) Health education10) State complications of RHD
0 According to Lewis et al, RHD is the chronic condition/disease resulting from rheumatic fever that is characterised by swelling and deformity of valves.0 RHD is an acute, recurrent inflammatory disease that causes damage to the heart as a sequela to group A beta-hemolytic streptococcal infection, particularly the valves, resulting in valve leakage (insufficiency) and/or obstruction (narrowing or stenosis).
contd/:0 RHD Is the a chronic condition characterised by scarring and deformity of the heart valves following rheumatic fever infection.0 Rheumatic fever is an inflammatory disease of the heart potentially involving all the layers of the heart ie endocardium ,myocardium and pericardium
Streptococcal infections o Gram-positive non motile spherical bacteria occurring in chains. o Most species are saprophytes and some are pathogenic o Many pathogenic species are haemolytic o They have the ability to destroy red blood cells
ARTICLE PUBLISHED ON N.º 240 OF JOURNAL OF GENERAL HOSPITAL ROCHESTERINTERNET:WWW. www.interscience.wiley.com)---21/01/2013
0 Rheumatic fever is a sequela to group A streptococcal infection that occurs in about 3% of untreated infections. (Nettina S.M et al,2006)0 It is a preventable disease through the detection and adequate treatment of streptococcal pharyngitis.0 Connective tissue of the heart, blood vessels, joints, and subcutaneous tissues are affected.0 Lesions in connective tissue are known as Aschoff bodies, which are localized areas of tissue necrosis surrounded by immune cells.
contd/:0 Heart valves are affected, resulting in valve leakage and narrowing.0 Compensatory changes in the chamber sizes and thickness of chamber walls occur.0 Heart involvement (carditis) also includes pericarditis, myocarditis, and endocarditis
Streptococcal infections inflammationof the heart’s tissues & fever affects the heart’s valves resulting in valve leakageand narrowing as a Compensatory mechanism changes in the chamber sizes andthickness of chamber walls occur.
0 Symptoms of streptococcal pharyngitis may precede rheumatic symptoms e.g. Sudden onset of sore throat; throat reddened with exudate Swollen, tender lymph nodes at angle of jaw Headache and fever >38 degrees celsius Abdominal pain (children) Some cases of streptococcal throat infection are relatively asymptomatic0 Warm and swollen joints (polyarthritis)
contd/:0 Chorea -(irregular, jerky, involuntary, unpredictable muscular movements especially affecting the head, face or limbs)0 Erythema marginatum -(transient meshlike macular rash on trunk and extremities0 Subcutaneous nodules (hard, painless nodules over extensor surfaces of extremities; rare)0 Fever >38 degrees celsius.0 Prolonged Pulse Rate (heart beat) interval demonstrated by ECG.0 Heart murmurs; pleural and pericardial rubs.
0 Throat culture-to determine presence of streptococcal organisms0 Sedimentation rate, WBC count and differential, and CRP increased during acute phase of infection0 Elevated antistreptolysin-O (ASO) titer0 ECG-prolonged Pulse Rate interval or heart block
SUBJECTIVE DATAPast health history: Recent streptococcal infection Previous history of RHD/RFHealth perception-health management: Family history of rheumatic feverNutritional-metabolic: Anorexia and weight lossActivity-exercise: Palpitations, generalized weakness,fatigue,ataxia etc
Neurologic: Chorea-involuntary, purposeless,rapid motions,facial grimaces.o Musculoskeletal: Signs of mono or polyarthritis including swelling ,heat,redness,limitation of motion (especially,knees,ankles,elbows,shoulders,wrists etc)
1) Ineffective breathing pattern related to musculoskeletal fatigue ,low level of consciousness as manifested by irregular breathing patterns and use of accessory muscles.2) Altered thermoregulation (Hyperthermia) related to micro organisms invasion as manifested by high temperature of 38 degrees Celsius.3) Decreased cardiac output related to valve dysfunction of heart failure as evidenced by low blood pressure
4)Altered comfort pain(joint pain) related to swollenjoint as evidenced by patient’s verbalisation andinability to stretch joints well.5)Activity intolerance related to arthralgia secondary tojoint pain, pain from pericarditis and heart failure asmanifested by facial expression6)Ineffective therapeutic regimen management relatedto lack of knowledge concerning the need for long-termprophylactic antibiotic therapy and possible diseasesequelae as manifested by patient asking a lot ofquestions.
Ineffective breathing pattern0 Observe for cyanosis, dyspnoea, hypoxia, and confusion, indicating worsening condition.0 Place patient in an upright position to obtain greater lung expansion and improve aeration. Frequent turning and increased activity (up in chair, ambulate as tolerated) should be employed.0 Administer oxygen at concentration to maintain Pao2 at acceptable level i.e. 4 to 6
0 Avoid high concentrations of oxygen in patients with COPD, particularly with evidence of CO2 retention; use of high oxygen concentrations may worsen alveolar ventilation by depressing the patients only remaining ventilatory drive. If high concentrations of oxygen are given, monitor alertness and Pao2 and Paco2 levels for signs of CO2 retention.
0 Follow ABG levels/Sao2 to determine oxygen need and response to oxygen therapy
REDUCING FEVER0 Do tepid sponging to reduce fever through conduction and evaporation and administer antipyretic e.g. ASA.0 Administer penicillin therapy as prescribed to eradicate hemolytic streptococcus; an alternative drug may be prescribed if patient is allergic to penicillin, or sensitivity testing and desensitization may be done.0 Give salicylates or NSAIDs as prescribed to suppress rheumatic activity by controlling toxic manifestations, to reduce fever, and to relieve joint pain.0 Assess for effectiveness of drug therapy. 0 Take and record temperature every 3 hours.0 Evaluate patients comfort level every 3 hours
contd Maintaining Adequate Cardiac Output0 Assess for signs and symptoms of acute rheumatic carditis. 0 Be alert to patients complaints of chest pain, palpitations, and/or precordial tightness. 0 Monitor for tachycardia (usually persistent when patient sleeps) or bradycardia. 0 Be alert to development of second-degree heart block or Wenckebachs disease (acute rheumatic carditis causes Pulse Rate interval prolongation).
contd0 Auscultate heart sounds every 4 hours. 0 Document presence of murmur or pericardial friction rub. 0 Document extra heart sounds (S3 gallop, S4 gallop).0 Monitor for development of chronic rheumatic endocarditis, which may include valvular disease and heart failure
PAIN MANAGEMENTTotal bed rest /quiet environment for the comfortability of the patient.Patient sleep to the side which is less painfulAdminister prescribed analgesic drugs eg PCM 1g tds/24hrsDiversion therapy- avoid the patient’s mind concentrating on his/her pain
NURSING INTERVENTIONS contd MAINTAINING ACTIVITY0 Maintain bed rest for duration of fever or if signs of active carditis are present.0 Allow the patient to do the physical exercises which he/she can manage to do due to his/her easily fatigue.0 Provide diversional activities that prevent exertion.0 Discuss need for tutorial services with parents to help child keep up with school work.
patient education and health maintenance0 Counsel patient to maintain good nutrition.0 Counsel patient on hygienic practices. 0 Discuss proper handwashing, disposal of tissues, laundering of handkerchiefs (decrease risk of exposure to microbes). 0 Discuss importance of using patients own toothbrush, soap, and washcloths when living in group situations.
0 Counsel patient on importance of receiving adequate rest.0 Instruct patient to seek treatment immediately should sore throat occur.0 Support patients in long-term antibiotic therapy to prevent relapse (5 years for most adults).
0 Instruct patient with valvular disease to use prophylactic penicillin therapy before certain procedures and surgery0 Explore with patient his ability to pay for medical treatment. If appropriate, contact social services for patient. (Financial difficulties may inhibit patient from seeking early treatment of symptoms.)
Evaluation: Expected Outcomes0 Afebrile0 Denies chest pain; normal sinus rhythm0 Maintains bed rest while febrile
COMMENT/CONCLUSION0 Tell as many other people as possible about this disease (rheumatic heart disease).0 It could save their lives !!!0 DONT ever think that you are not prone to rheumatic heart disease as your age is less than 25 or 30. Nowadays due to the change in the life style, rheumatic heart disease is found among people of all age groups.
AS NURSES,TELL AS MANY OTHER PEOPLE AS POSSIBLE ABOUTTHIS DISEASE OF RHEUMATIC HEART DISEASE (RHD)IT COULD SAVE THEIR LIVES !!! REMEMBER HEART ISTHE ENGINE OF THE BODY. ANY CONDITION WHICHCAN AFFECT THE HEART CAN LEAD TO DEATH!!!
REFERENCES1) LEWIS ,HEITKEMPER,DIRKSEN,O’BRIEN & BUCHER,(2007) MEDICAL -SURGICAL NURSING,ASSESSMENT AND MANAGEMENT OF CLITICAL PROBLEMS.7TH EDITION.MOSBY ELSEVIER.2) JOYCE M.BLACK AND JANE HOKANSON HAWKS,(2009) MEDICAL-SURGICAL NURSING CLINICAL MANAGEMENT FOR POSITIVE OUTCOMES.8TH EDITION.MOSBY ELSEVIER.3) NETTINA,SANDRA M,MILLS ELIZABETH JACQUUELINE,(2006) LIPPINCOTT MANUAL OF NURSING PRACTICE.8TH EDITION.WILLIAMS & WILKINS.4) INTERNET: Wiley (http://www.interscience.wiley.com)--- 21/01/2013