Nootan college of nursing

VISNAGAR

SUB:- child health nursing

TOPIC: - teaching practice ON “rheumatic heart DiSeaSe ”

SUBMITTED TO: SUBMITTED BY:

Mrs. Mahalakshmi. B. Mrs. Sayma Mansuri
Asso.Professor 2nd Year M.Sc. Nursing
NCN Roll no.- 03
INTRODUCTION :

Name of the Student: - Mrs. Sayma Mansuri

Name Of The Guide:- Mrs. Mahalakshmi. B.

Topic: - Rheumatic Heart Disease

Venue: - B.Sc. Nursing 3rd year classroom.

Class Taught: - Third year B.Sc. Nursing.

Method Of Teaching:- Lecture Cum Discussion.

Audio Visual Aids: - Power Point Presentation, Black Board.

GENERAL OBJECTIVE: -
At the end of the seminar group will be able to know about the definition, etiological factors, clinical manifestation and
management of the rheumatic heart disease, and apply this knowledge into the clinical setting.

SPECIFIC OBJECTIVES: -
At the end of the seminar group will be able to –

 Define Rheumatic Heart Disease.

 Explain etiological factor of rheumatic heart disease.
 Discuss the classification of the rheumatic heart disease in detail.
 Explain the Pathophysiology and manifestation.
 Describe the management of rheumatic heart disease.
SR. TIME SPECIFIC CONTENT TEACHING A.V. AIDS EVALUTION
NO. OBJECTIVE LEARNING
ACTIVITY
RHEUMATIC ENDOCARDITIS
(RHEUMATIC HEART DISEASE)

Introduction In the pediatric age group, the squeal of Lecture cum Powerpoint What is rheumatic
01 2 min about the rheumatic fever consist of mitral, aortic and discussion heart disease?
rheumatic heart tricuspid valve disease. The mitral valve
disease. involvement manifests predominantly as mitral
regurgitation and much less commonly as mitral
stenosis. The aortic valve and tricuspid valve
involvement presents exclusively as aortic and
tricuspid regurgitation respectively. Rheumatic
aortic stenosis has never been described below
the age of 15 years.
Rheumatic fever may have complications
as a valvular involvement resulting the disease of
mitral, aortic and tricuspid valves. The common
rheumatic heart disease includes mitral
regurgitation and mitral stenosis. Aortic valve
and tricuspid valvular disease include mainly
aortic and tricuspid regurgitation.
Mitral regurgitation Lecture cum Powerpoint What is mitral
Introduction
Mitral regurgitation is the back flow of discussion regurgitation?
02 3 min
about the mitral
regurgitation blood from the left ventricle into the left atrium
resulting from imperfect closure of the mitral
valve. It is the commonest complication of acute
recurrent rheumatic heart disease.
There is left ventricular dilation and
hypertrophy along with shortening and
thickening of the chorda tendinae. Back pressure
 into the pulmonary system results in right
ventricular hypertrophy and CCF. Left atrial
enlargement with atrial arrhythmias, pulmonary
edema and pulmonary hypertension may develop
in long term illness with this condition.
Patient present with easy fatigability,
Exertional dyspnea due to reduced cardiac output
and palpitation due to atrial arrhythmias.
Increased pulse rate, wide pulse pressure,
downward and outward shifting of apex beat are
important features.
Moderately low blowing pansyntonic
murmur at the apex. It may be transmitted to the
left axilla, to back and upwards. A systolic thrill
is usually felt at the mitral area.
List out the Diagnosis evaluation
03 1min
diagnosis  ECG,
evaluation of  Echocardiography
Mitral  Chest X-ray
regurgitation Medical management is for controlling of
CCF, penicillin prophylaxis against future
recurrence of rheumatic fever and prevention
against infective endocarditis.
Surgical management of mitral
regurgitation includes mitral valve repair or
replacement of it by prosthetic valve. Surgery is
indicated more than 55 percent cases with
refractory CCF, pulmonary hypertension and
progressive cardiomegaly.
Mitral stenosis
04 2min Introduction Is the narrowing of the mitral orifice Lecture cum Powerpoint What is mitral
about the mitral obstructing free flow of blood from the left discussion stenosis?
stenosis. atrium to the left ventricle. Mitral opening gets
tight due to progressive sclerosis of the base of
the mitral ring. It develops relatively late in
children with rheumatic carditis. It is less
common than mitral regurgitation and commonly
found in male children.
In moderate to severe cases, there is left
atrial dilation and hypertrophy which results in
back pressure in pulmonary system leading to
right ventricular hypertrophy and CCF.
The child with mitral stenosis presents
with dyspnea with exertion or even at rest or as
paroxysmal nocturnal dyspnea and palpitation,
tiredness, cough, hemoptysis and peripheral
cyanosis may present. Pulmonary edema, atrial
fibrillation and atypical angina may also develop
but in less frequency.
On examination, distended neck veins,
weak peripheral pulses, palpable RV impulse
and prominent precordium are found.
Diagnosis
 ECG
 Echocardiography
 Chest X-ray
Medical management of patient with
mitral stenosis is done with rest, digitalis,
diuretics, activity restriction, salt restriction in
diet, penicillin prophylaxis for recurrence of
rheumatic fever and prevention of infective
endocarditis.
Surgical management is performed as
closed mitral valvotomy (mitral
commissurotomy), if the heart failure does not
respond to medical management. Surgery is done
 in absence of carditis. Severely damaged valve
can be replaced by prosthesis. Mitral valve
replacement needs lifelong anticoagulant
therapy. Balloon mitral valvoplasty is another
surgical technique can be done for mitral
stenosis.
Post operative complications include
restenosis, CCF, bleeding disorder and atrial
embolization.
Aortic regurgitation or
incompetence Lecture cum Powerpoint What is aortic
Introduction Is the backflow of blood into the left discussion regurgitation ?
05 3min about the aortic ventricle due to an incompetent aortic valve. It is
regurgitation. less frequent than mitral regurgitation. It occurs
due to sclerosis of aortic valve resulting
shortening, distortion and retraction of the casps
leading to inadequate closure. Left ventricular
hypertrophy, pulmonary edema and CCF
developed as consequence of the condition.

In chronic and severe cases, the clinical

presentations include palpitations, exercise
intolerance, Exertional dyspnea, even
paroxysmal nocturnal dyspnea and angina pain.
Characteristics rapid water hammer pulse, wide
pulse pressure, early diastolic murmur and
cardiac enlargement are important features
present in case of illness help in diagnosis.
Medical management
Explain about  Diuretics,
the medical  Digoxin
management of  Salt restriction in diet
aortic  Vasodilators like ACE inhibitors and
 regurgitation. antiarrhythmic agents.
Surgical management is done in the form
of aortic valvotomy or aortic valve replacement
by prosthetic valve and hemograft. Valve
replacement should be planned before the child
develops CCF.
Tricuspid regurgitation Lecture cum Powerpoint What is tricuspid
It Is the backflow of blood from the right discussion regurgitation ?
Introduction ventricle into the right atrium. It is found in
06 3min about the about 20 to 50 percent cases of rheumatic heart
tricuspid disease. There are no specific symptoms of this
regurgitation. condition. It is common accompaniment of
mitral stenosis and mitral incompetence.
Physical signs related to tricuspid
regurgitation include prominent “V” waves in
jugular veins in neck, systolic pulsation of liver
and a pansystolic murmur in lower left sterna
border. On examination signs of mitral stenosis
and pulmonary hypertension are usually found.
Management is done with decongestive
therapy (digitalis, diuretics) and treatment of
associated problems. Surgery is done with
various procedures. Mitral valve replacement is
required when tricuspid regurgitation is
associated with mitral incompetence. Balloon
mitral valvoplasty can be done when the
condition is associated with mitral stenosis.
Tricuspid annuloplasty or repair may also be
performed.
Endocarditis
Rheumatic endocarditis is an acute, Lecture cum Powerpoint What is
07 1min Introduction recurrent inflammatory disease that causes discussion endocarditis?
about the damage to the heart as a sequel to group A beta-
 endocarditis. hemolytic streptococcal infection, particularly
the valves, resulting in valve leakage
(insufficiency) and/or obstruction (narrowing or
stenosis). There are associated compensatory
changes in the size of the heart's chambers and
the thickness of chamber walls.
Pathophysiology and Etiology
 Rheumatic fever is a sequela to group A Lecture cum Powerpoint What is
08 2min Details about streptococcal infection that occurs in discussion pathophysiology
the about 3% of untreated infections. It is a and etiology of
pathophysiology preventable disease through the detection RHD?
and etiology of and adequate treatment of streptococcal
RHD. pharyngitis.
 Connective tissue of the heart, blood
vessels, joints, and subcutaneous tissues
can be affected.
 Lesions in connective tissue are known as
Aschoff bodies, which are localized areas
of tissue necrosis surrounded by immune
cells.
 Heart valves are affected, resulting in
valve leakage and narrowing.
 Compensatory changes in the chamber
sizes and thickness of chamber walls
occur.
 Heart involvement (carditis) also includes
pericarditis, myocarditis, and
endocarditis.
Clinical Manifestations Lecture cum Powerpoint What are the
09 2min Classify the  Symptoms of streptococcal pharyngitis discussion clinical
clinical may precede rheumatic symptoms manifestation of
manifestation of o Sudden onset of sore throat; RHD?
RHD. throat reddened with exudate
 o Swollen, tender lymph nodes at
angle of jaw
o Headache and fever 101° to
104° F (38.9° to 40° C)
o Abdominal pain (children)
o Some cases of streptococcal
throat infection are relatively
asymptomatic
 Warm and swollen joints (polyarthritis)
 Chorea (irregular, jerky, involuntary,
unpredictable muscular movements)
 Erythema marginatum (transient mesh
like macular rash on trunk and
extremities in about 10% of patients)
 Subcutaneous nodules (hard, painless
nodules over extensor surfaces of
extremities; rare)
 Fever
 Prolonged PR interval demonstrated by
ECG
 Heart murmurs; pleural and pericardial
rubs

Diagnostic Evaluation Lecture cum Powerpoint What are the

10 2min List out the  Throat culture to determine presence of discussion diagnostic
diagnostic streptococcal organisms evaluation of
evalution of  Sedimentation rate, WBC count and RHD?
RHD. differential, and CRP increased during
acute phase of infection
 Elevated antistreptolysin-O (ASO) titer
 ECG-prolonged PR interval or heart
block
Management
  Antimicrobial therapy penicillin is the
drug of choice
o Note that missed doses of
antibiotics due to the patient's
unavailability while off the unit
for diagnostic tests are given after
return to the unit.
o Missed antibiotic doses may have
irreversible deleterious
consequences.
o Notify health care provider if
doses will be missed to make sure
that appropriate alternative
measures are taken.
 Rest to maintain optimal cardiac function
 Salicylates or NSAIDs to control fever
and pain
 Prevention of recurrent episodes through
long-term penicillin therapy for 5 years
after initial attack in most adults; periodic
prophylaxis throughout life if valvular
damage
Find out the Complications Powerpoint What are
11 0.5min
complication of  Valvular heart disease Lecture cum complication of
RHD.  Cardiomyopathy discussion RHD?
 Heart failure
Nursing Assessment
 Ask patient about symptoms of fever or
throat or joint pain.
 Ask patient about chest pain, dyspnea,
and fatigue.
 Observe for skin lesions or rash on trunk
and extremities.
  Palpate for firm, nontender movable
nodules near tendons or joints.
 Auscultate heart sounds for murmurs
and/or rubs.
List out the Powerpoint What are find the
Nursing Diagnoses
12 2min nursing  Hyperthermia related to disease process Lecture cum nursing diagnosis
diagnosis of  Decreased Cardiac Output related to discussion for RHD?
RHD. decreased cardiac contractility
 Activity Intolerance related to joint pain
and easy fatigability

Detail about the Nursing Interventions Powerpoint What are the

nursing Reducing Fever Lecture cum nursing
13 3min intervention of  Administer penicillin therapy as discussion intervention for
RHD. prescribed to eradicate hemolytic RHD?
streptococcus; an alternative drug may be
prescribed if patient is allergic to
penicillin, or sensitivity testing and
desensitization may be done.
 Give Salicylates or NSAIDs as
prescribed to suppress rheumatic activity
by controlling toxic manifestations, to
reduce fever, and to relieve joint pain.
 Assess for effectiveness of drug therapy.
o Take and record temperature
every 3 hours.
o Evaluate patient's comfort level
every 3 hours.

Maintaining Adequate Cardiac Output

 Assess for signs and symptoms of acute Powerpoint What are the
rheumatic carditis. Lecture cum maintaining the
 o Be alert to patient's complaints of discussion adequate cardiac
chest pain, palpitations, and/or output?
precordial tightness.•
o Monitor for tachycardia (usually
persistent when patient sleeps) or
bradycardia.
o Be alert to development of
second-degree heart block or
Wenckebach's disease (acute
rheumatic carditis causes PR
interval prolongation).
 Auscultate heart sounds every 4 hours.
o Document presence of murmur or
pericardial friction rubs.
o Document extra heart sounds (S3
gallop, S4 gallops).
 Monitor for development of chronic
rheumatic endocarditis, which may
include valvular disease and heart failure.
Maintaining Activity
Explain about Powerpoint What are the
14 2min  Maintain bed rest for duration of fever or
the maintain the Lecture cum maintain acvtivity
if signs of active carditis are present.
activity of discussion for RHD?
 Provide ROM exercise program.
RHD.
 Provide diversional activities that prevent
exertion.
 Discuss need for tutorial services with
parents to help child keep up with school
work.
Patient Education and Health Maintenance
 Counsel patient to maintain good
nutrition.
 Counsel patient on hygienic practices.
 o Discuss proper handwashing,
disposal of tissues, laundering of
handkerchiefs (decrease risk of
exposure to microbes).
o Discuss importance of using
patient's own toothbrush, soap,
and washcloths when living in
group situations.
 Counsel patient on importance of
receiving adequate rest.
 Instruct patient to seek treatment
immediately should sore throat occur.
 Support patients in long-term antibiotic
therapy to prevent relapse (5 years for
most adults).
 Instruct patient with valvular disease to
use prophylactic penicillin therapy before
certain procedures and surgery (see pages
403 and 404).
 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.)
Research Article:

High prevalence of rheumatic heart disease detected by echocardiography in school children. (Bhaya M, Panwar S, Beniwal R, Panwar RB.)

Source

Sardar Patel Medical College & Associated Group of Hospitals, Department of Cardiology, Bikaner, Rajasthan, India. maneeshabhaya@gmail.com

Abstract

OBJECTIVES:

It is fairly easy to detect advanced valve lesions of established rheumatic heart disease by echocardiography in the clinically identified cases of
rheumatic heart disease. However, to diagnose a subclinical case of rheumatic heart disease, no uniform set of echocardiographic criteria exist.
Moderate thickening of valve leaflets is considered an indicator of established rheumatic heart disease. World Health Organization criteria for
diagnosing probable rheumatic heart disease are more sensitive and are based on the detection of significant regurgitation of mitral and/or aortic
valves by color Doppler. We attempted diagnosing RHD in school children in Bikaner city by cardiac ultrasound.

METHODS:

The stratified cluster sampling technique was employed to identify 31 random clusters in the coeducational schools of Bikaner city. We selected 1059
school children aged 6-15 years from these schools. An experienced operator did careful cardiac auscultation and echocardiographic study. A second
expert confirmed the echocardiographic findings.
FINDINGS:

The prevalence of lesions suggestive of rheumatic heart disease by echocardiography was 51 per 1,000 (denominator = 1059; 95% CI: 38-64 per
1,000). We were able to clinically diagnose RHD in one child. None of these children or their parents having echocardiographic evidence of RHD
could provide a positive history of acute rheumatic fever.

CONCLUSIONS:

By echocardiographic screening, we found a high prevalence of rheumatic heart disease in the surveyed population. Clinical auscultation had much
lower diagnostic efficacy.

Valve repair in rheumatic heart disease in pediatric age group. (Reddy PK, Dharmapuram AK, Swain SK, Ramdoss N, Raghavan SS, Murthy
KS.)

Source

Department of Pediatric Cardiac Surgery Apollo Children's Heart Hospital Hyderabad, India.

Abstract

Valve repair in children is technically demanding but more desirable than valve replacement. From April 2004 to September 2005, 1 boy and 8 girls
with rheumatic heart disease, aged 2-13 years (median, 9 years), underwent valve repair for isolated mitral regurgitation in 5, combined mitral and
aortic regurgitation in 2, mitral stenosis in 1, and mitral regurgitation associated with atrial septal defect in 1. Chordal shortening in 7, annular
plication in 6, commissurotomy in 1, reconstruction of commissural leaflets in 7 were performed for mitral valve disease. Plication and reattachment
of the aortic cusps was carried out in 2 patients. Annuloplasty rings were not used. All patients survived the operation, 8 had trivial or mild residual
mitral regurgitation, and 1 had trivial aortic regurgitation. Mean left atrial pressure decreased from 14 to 7 mm Hg postoperatively. During follow-up
of 3-18 months, all children were asymptomatic and enjoyed normal activity. None required reoperation. In addition to chordal shortening and
annular plication, reconstruction of the commissural leaflets is considered the most important aspect of valve repair. It can be achieved without
annuloplasty rings, giving good early and midterm results.

Comment in Asian Cardiovasc Thorac Ann. 2008 Dec;16(6):515-6.

PMID: 18381871 [Pub Med - indexed for MEDLINE]

 BIBLIOGRAPHY:-

I. Hockenberry & Wilson David, “Wong’s essentials of pediatric nursing”, 8th edt.2009, Mosby Elsevier, St. Louis, Missouri. Page no.893-894.

II. Marlow R, Dorothy& Redding A. Barbara, “Text book of pediatric nursing”, 6th edt.2007, Saunders Company, Philadelphia, Pennsylvania.

III. Ghai O.P., Gupta piyush et al, “essential pediatrics”, 6th edt.2006, CBS publishers & Distributers, New-Delhi, page no.-384-389.

IV. Gupte suraj “The short textbook of pediatrics” 11th edition (2004) jaypee brother medical publishers p. ltd. Page no.382-386.

V. Bhat Swarna Rekha, “Achar’s textbook of pediatrics”, 4th edt.2009, universities press (India) private limited, Hyderabad, page no.-

VI. Datta parul, “pediatric nursing”, 2nd edt.2009, Jaypee brothers medical publishers (p) ltd. New-Delhi, page no.331-335.

VII. Mrs.Tambulwadkar R.S., “Pediatric nursing”, 2nd edt.2005, Vora medical publications, Bombay, page no.180-182.

VIII. Internet Sources- www.google.com