Specific objective Time Content Teachers Learners Av aids Evaluation

activity activity
Introduce the 1mt Introduction Lecture cum Learning PPT What is
topic discussion rheumatic heart
Rheumatic heart disease describes a group disease?
of short-term (acute) and long-term
(chronic) heart disorders that can occur as a
result of rheumatic fever. One common
result of rheumatic fever is heart valve
damage. Every part of the heart, including
the outer sac (the pericardium), the inner
lining (the endocardium) and the valves may
be damaged by inflammation caused by
acute rheumatic fever. It usually occurs in
children between the ages of 5 and 15 years.

Anatomy and physiology of heart

Explain anatomy Lecture cum learning PPT Explain anatomy
and physiology of The heart is a muscular organ roughly the discussion and physiology of
heart size of a closed fist. It sits in the chest, heart?
slightly to the left of center.As the heart
contracts, it pumps blood around the body. It
carries deoxygenated blood to the lungs
where it loads up with oxygen and unloads
carbon dioxide, a waste product of
metabolism.The heart, blood, and blood
vessels combined are referred to as the
circulatory system. An average human has
around 5 liters (8 pints) of blood, which is
constantly pumped throughout the body.
The heart consists of four chambers

Atria: the two upper chambers (they receive

blood).
Ventricles: the two lower chambers (they
discharge blood).
The left atria and left ventricle are separated
from the right atria and right ventricle by a
wall of muscle called the septum.
.
The heart has four valves that help ensure
that blood only flows in one direction:
Aortic valve: between the left ventricle and
the aorta.
Mitral valve: between the left atrium and the
left ventricle.
Pulmonary valve: between the right
ventricle and the pulmonary artery.
Tricuspid valve: between the right atrium
and right ventricle.
Define rheumatic 2mts Definition Lecture cum Listening PPT Define rheumatic
heart disease and discussion heart disease and
rheumatic fever According to Lewis et al, RHD is the rheumatic fever?
chronic condition/disease resulting from
rheumatic fever that is characterised by
swelling and deformity of valves.

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).

RHD is a chronic condition characterised by

scarring and deformity of the heart valves
following rheumatic fever infection.

Rheumatic fever is an inflammatory disease

of the heart potentially involving all the
layers of the heart i.e. ,endocardium
,myocardium and pericardium

Risk factors
Enlist the risk 1mt It includes. Lecture cum Listening PPT Enlist the risk
factors of • 5-15 years old discussion factors of
rheumatic heart • Family history of Rheumatic Fever rheumatic heart
disease • Low socioeconomic status (poverty, poor disease?
hygiene, medical deprivation)
• Untreated strep throat
Enlist the 1mt Etiology Lecture cum Listening PPT Enlist the
etiology of Streptococcal infections discussion etiology of
rheumatic heart  gram-positive non motile spherical rheumatic heart
disease bacteria occurring in chains disease?
 many pathogenic species are
haemolytic
 most common subtypes are 1,3,5
Rheumatic fever

Explain the patho Pathophysiology Lecture cum Listening PPT Explain the patho
physiology of 5mts discussion physiology of
RHD Streptococcal infection RHD?

Cross immune response between host and

streptococcal antigens(antigenic mimicry)

Abnormal reaction- auto immunity disease

Rheumatic pan carditis and endocarditis in

valves

Erosion of valve leaflets

Fibrous thickening and thickened valves

Stenosis and regurgitation

Enlist clinical 4mts Clinical manifestations of RHD Lecture cum Listening PPT Enlist clinical
manifestations of  Chorea discussion manifestations of
RHD  Pancarditis RHD?
 Polyarthritis
 Erythema marginatum
 Subcutaneous nodules
 chest pain
 heart palpitation
 breathlessness on exertion
 breathing problems when lying
down (orthopnoea)
 waking from sleep with the need to
sit or stand up (paroxysmal
nocturnal dyspnoea)
 swelling (oedema) fainting
(syncope)
 stroke
 fever associated with infection of
damaged heart valves.
Explain
Explain 3mts Diagnostic evaluation Lecture cum Listening PPT diagnostic
diagnostic discussion evaluation of
evaluation of Diagnosis may include RHD?
RHD  History collection – including evidence
of past acute rheumatic fever or strep
infection
•Physical examination – while a heart
murmur may suggest RHD, many patients
with RHD do not have a murmur( pleural
and pericardial rubs)

• Chest x-ray – to check for enlargement of

 the heart or fluid on the lungs
• Electrocardiogram (ECG) – to check if
the chambers of the heart have enlarged or
if there is an abnormal heart rhythm
(arrhythmia)
Echocardiogram – to check the heart
valves for any damage or infection and
assessing if there is heart failure. This is
the most useful test for finding out if RHD
is present.

Explain 2mts Prevention Lecture cum Listening PPT Explain

prevention of Primary prevention discussion prevention of
RHD Early treatment of streptococcal RHD?
pharyngitis
Penicillin or erythromycin
Secondary prevention
To prevent recurrence of rheumatic
activity
Long-acting penicillin (benzathine
penicillin) 1.2 million units IM, every
4 weeks Sulfonamides or erythromycin
may be substituted
Explain 15mts Management Lecture cum Listening PPT Explain
management of discussion management of
RHD Medical management RHD?

Nonpharmacological management

Strict bed rest

Pharmacological management
1. Control streptococcal infection
Penicillin is of choice benzathine
penicillin, 1.2 million units IM once or
procaine penicillin, 600,000 units IM
daily, 10 days If allergic to penicillin,
erythromycin be given
2. Antirheumatic therapy
a. Salicylates Of choice in patients
with little or no cardiac
involvement; Particularly
effective in reducing fever and
relieving joint pain and swelling
Aspirin 0.6~0.9 g / 4h in adults;
lower doses in children
b. Corticosteroids Used in patients
who do not respond well to
adequate doses of salicylates
Prednisone 40~60 mg orally daily,
tapering over 2 weeks
3, Treatment of symptoms and
complications
If heart failure is present, digitalis
preparations should be used cautiously
because cardiac toxicity may occur with
conventional dosages

Surgical management

 Percutaneous balloon valvuloplasty

Percutaneous balloon valvuloplasty is

 a procedure to improve a heart valve.
A balloon will help to open a stiff heart
valve. A blood vessel in your groin or
arm will be prepared. A wire will be
placed through your skin to the blood
vessel. It will be passed through the
blood vessel until it reaches the heart
valve. The doctor can watch the
progress of wire with the x-rays. A
tube with a balloon tip will be passed
over the wire. A dye may be injected
through the device. This will help the
doctor see the area and make sure the
device is in the right place. The
balloon will then be inflated and
deflated. The inflation may need to be
repeated. The device will then be
removed from the blood vessel. A
dressing will be placed over the
puncture site.
 Valvulotomy
The surgical cutting of a constricted
cardiac valve to relieve obstruction.

 Closed mitral valvotomy; minimally

invasive valvulotomy surgery, using
mini sternotomy or parasternal
approach.
 Open mitral valvotomy

 Mitral valve replacement

 Mechanical valve; these are
 manufactured from man-made
materials and consist of combinations
of metal alloys, pyrolite carbon and
Dacron
 Bio prosthesis; These are constructed
from bovine,procine,and human
cardiac tissue and usually contains
some man-made materials
Nursing management

Nursing diagnosis

1) Ineffective breathing pattern related to

musculoskeletal fatigue ,low level of
consciousness as evidenced by irregular
breathing patterns and use of accessory
muscles.
2) Hyperthermia related to
microorganism invasion as evidenced 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)Acute chest pain related to pericarditis
as evidenced by patient’s verbalisation.
5)Activity intolerance related to joint
pain from polyarthritis as evidenced by
facial expression

Nursing interventions
Ineffective breathing pattern
 Observe for cyanosis, dyspnoea,
hypoxia, and confusion, indicating
worsening condition.
 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.
 Administer oxygen at concentration to
maintain Pao2 at acceptable level i.e. 4
to 6 litres per minute which will relieve
the tissue
 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 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.
 Follow ABG levels/Sao2 to determine
oxygen need and response to oxygen
therapy

Reducing fever
 Do tepid sponging to reduce fever
through conduction and evaporation
and administer antipyretic e.g. ASA.
 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.
 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. Take and record temperature
every 3 hours.
 Evaluate patient's comfort level every
3 hours

Maintaining Adequate Cardiac Output

 Assess for signs and symptoms of
acute rheumatic carditis.
 Be alert to patient's complaints of chest
pain, palpitations, and/or precordial
tightness.
 Monitor for tachycardia (usually
persistent when patient sleeps) or
bradycardia.
 Be alert to development of second-
degree heart block or Wenckebach's
 Disease (acute rheumatic carditis
causes Pulse Rate interval
prolongation).
 Auscultate heart sounds every 4 hours.
Document presence of murmur or
pericardial friction rub.
 Document extra heart sounds (S3
gallop, S4 gallop).
 Monitor for development of chronic
rheumatic endocarditis, which may
include valvular disease and heart
failure

Pain management

 Total bed rest /quiet environment for

the comfortability of the patient.
 Patient sleep to the side which is less
painful
 Administer prescribed analgesic
Eg PCM 1g tds/24hrs
 Diversion therapy-avoid the patient’s
mind concentrating on his/her pain.

Maintaining activity

 Maintain bed rest for duration of fever

or if signs of active carditis are present.
 Allow the patient to do the physical
exercises which he/she can manage to
do due to his/her easily fatigue.
 •Provide diversional activities that prevent
exertion.
•Discuss need for tutorial services with
parents to help child keep up with
schoolwork.
Patient education and health
maintenance
Explain health 3mts  Counsel patient to maintain good Lecture cum Listening PPT Explain health
education for nutrition. discussion education for
patients with  Counsel patient on hygienic patients with
RHD practices. RHD?
 Discuss proper handwashing,
disposal of tissues, laundering of
handkerchiefs (decrease risk of
exposure to microbes).
 Discuss importance of using
patient's own toothbrush, soap, and
wash cloths 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
•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.)

Enlist the 1mt Complications Lecture cum Listening Chart Enlist the
complications of discussion complications of
RHD  Heart failure RHD?
 Atrial fibrillation
 Infective endocarditis
 Atrial and ventricular arrhythmias
 Ruptured heart valve
What is RHD?
Conclude the 1mt Conclusion Lecture cum Listening PPT
topic discussion
Rheumatic heart disease (RHD) is a
consequence of acute rheumatic fever
(ARF). While ARF usually occurs
between 5 and 15 years of age, it can also
occasionally occur in adulthood. RHD is
particularly associated with damage to
the valves of the heart. ARF is caused by
infection with the Group A Streptococcus
bacterium.
Assignment

Write an assignment on nursing careplan

of patients with RHD?
Bibliography

 S. Lewis, M. Heitkemper, S. Dirksen, P. Obrien and L. Bucher (2007) Medical Surgical Nursing; Assessment and Management of

Clinical problems (7th edition)St Louis Mosby. Page no-870-878

 A.D. LINTON (2007) Introduction to medical Surgical Nursing, (4th edition), St Louis Mosby. Page no-700-774

 Phipps’ (2007) Medical Surgical Nursing. Health and Illness Perspectives (8th edition) St Louis; page no-886-889

 www.slideshare.com

 www.wikepedia.com

 www.myoclinic.com