GROUP ONE MEMBERS:

(1).Mhango,Julius wesley (2).Mpalabwazi Benjamin(3).Mtike Doreen(4).Majiga,Dunda Sabina(5).Lukhere Christine(6).Chitsokwe Evelyn

GROUP 1 MEMBERS,PRESENTS:

RHEUMATIC HEART DISEASE (RHD)

LEARNING OBJECTIVES

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 assessment 6) State the nursing diagnoses7) Explain the nursing management and interventions8) Medical management9) Health education10) State complications of RHD

What is Rheumatic Heart Disease?

0According to Lewis et al, RHD is the chronic condition/disease resulting from rheumatic fever that is characterised by swelling and deformity of valves.

0RHD 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).

DEFINITION contd/:

0RHD Is the a chronic condition characterised by scarring and deformity of the heart valves following rheumatic fever infection.

0Rheumatic fever is an inflammatory disease of the heart potentially involving all the layers of the heart ie endocardium ,myocardium and pericardium

ETIOLOGY

Streptococcal infectionso Gram-positive non motile spherical bacteria

occurring in chains.oMost species are saprophytes and some are pathogenicoMany pathogenic species are haemolytic

o They have the ability to destroy red blood cells

LET US LOOK HOW THE HEART WORKS! VIDEO CLIP

ARTICLE PUBLISHED ON N.º 240 OF JOURNAL OF GENERAL HOSPITAL ROCHESTER

INTERNET:WWW. www.interscience.wiley.com)---21/01/2013

PATHOPHYSIOLOGY

0Rheumatic 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.

0Connective tissue of the heart, blood vessels, joints, and subcutaneous tissues are affected.

0Lesions in connective tissue are known as Aschoff bodies, which are localized areas of tissue necrosis surrounded by immune cells.

PATHOPHYSIOLOGY contd/:

0Heart valves are affected, resulting in valve leakage and narrowing.

0Compensatory changes in the chamber sizes and thickness of chamber walls occur.

0Heart involvement (carditis) also includes pericarditis, myocarditis, and endocarditis

SUMMARY OF RHD PATHOPHYSIOLGY

Streptococcal infections inflammation of the heart’s tissues & fever affects the heart’s valves resulting in valve leakage and narrowing as a Compensatory mechanism changes in the chamber sizes and thickness of chamber walls occur.

CLINICAL MANIFESTATIONS

0Symptoms of streptococcal pharyngitis may precede rheumatic symptoms e.g.Sudden onset of sore throat; throat reddened with

exudateSwollen, tender lymph nodes at angle of jawHeadache and fever >38 degrees celsiusAbdominal pain (children)Some cases of streptococcal throat infection are

relatively asymptomatic0Warm and swollen joints (polyarthritis)

CLINICAL MANIFESTATIONS 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 extremities

0 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.

DIAGNOSTIC EVALUATION

0Throat culture-to determine presence of streptococcal organisms

0Sedimentation rate, WBC count and differential, and CRP increased during acute phase of infection

0Elevated antistreptolysin-O (ASO) titer0ECG-prolonged Pulse Rate interval or heart block

NURSING ASSESSMENT

SUBJECTIVE DATAPast health history:

Recent streptococcal infectionPrevious history of RHD/RF

Health perception-health management:Family history of rheumatic fever

Nutritional-metabolic:Anorexia and weight loss

Activity-exercise:Palpitations, generalized weakness,fatigue,ataxia etc

SUBJECTIVE DATA contd

Cognitive –perceptual:Chest painMigratory joint painTenderness (especially large joints)

OBJECTIVE DATAGeneral

fever

Integumentary:Subcutaneous nodulesErythema marginatum

CardiovascularTachycardia,pericardial friction rubMuffed heart soundsGallop rhythmMurmurs &Peripheral edema

Neurologic:Chorea-involuntary, purposeless,rapid motions,facial

grimaces.oMusculoskeletal:

Signs of mono or polyarthritis including swelling ,heat,redness,limitation of motion (especially,knees,ankles,elbows,shoulders,wrists etc)

NURSING DIAGNOSIS

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

NURSING DIAGNOSIS

4)Altered comfort pain(joint pain) related to swollen joint as evidenced by patient’s verbalisation and inability to stretch joints well.5)Activity intolerance related to arthralgia secondary to joint pain, pain from pericarditis and heart failure as manifested by facial expression6)Ineffective therapeutic regimen management related to lack of knowledge concerning the need for long-term prophylactic antibiotic therapy and possible disease sequelae as manifested by patient asking a lot of questions.

complications

0Heart failure0Atrial fibrillation0 Infective endocarditis0Atrial and ventricular arrhythmias

NURSING INTERVENTIONS

Ineffective breathing pattern0 Observe for cyanosis, dyspnoea, hypoxia, and

confusion, indicating worsening condition.0Place 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.

0Administer oxygen at concentration to maintain Pao2 at acceptable level i.e. 4 to 6 litres per minute which will relieve the tissue hypoxia.

.

0Avoid 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 patient's only remaining ventilatory drive. If high concentrations of oxygen are given, monitor alertness and Pao2 and Paco2 levels for signs of CO2 retention.

0Follow 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 patient's comfort level every 3 hours

NURSING INTERVENTIONS contd

Maintaining Adequate Cardiac Output0Assess for signs and symptoms of acute rheumatic

carditis.0 Be alert to patient's 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

Wenckebach's disease (acute rheumatic carditis causes Pulse Rate interval prolongation).

NURSING INTERVENTIONS contd

0Auscultate heart sounds every 4 hours.0 Document presence of murmur or pericardial friction

rub.0 Document extra heart sounds (S3 gallop, S4 gallop).

0Monitor 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 maintenance

0Counsel patient to maintain good nutrition.0Counsel 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 patient's own toothbrush, soap, and washcloths when living in group situations.

0Counsel patient on importance of receiving adequate rest.

0 Instruct patient to seek treatment immediately should sore throat occur.

0Support 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 surgery

0Explore 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 Outcomes

0Afebrile0Denies chest pain; normal sinus rhythm0Maintains bed rest while febrile

COMMENT/CONCLUSION

0Tell as many other people as possible about this disease (rheumatic heart disease).

0 It could save their lives !!! 0DON'T 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 ABOUT THIS DISEASE OF RHEUMATIC HEART DISEASE (RHD)IT COULD SAVE THEIR LIVES !!! REMEMBER HEART IS THE ENGINE OF THE BODY. ANY CONDITION WHICH CAN 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

THANK YOU!!!!!!!!!!!!