OM HEALTH CAMPUS

AFFILIATED TO PURBANCHAL UNIVERSITY

GOPIKRISHNANAGAR, KATHMANDU

LESSON PLAN ON RHEUMATIC HEART DISEASE

SUBMITTED TO: SUBMITTED BY:

Ms. Sita Devi Kunwar Ms. Gita Tamang

College principal Roll no.: 09

PBBN 2ND Year

SUBMISSION DATE

2076/10/16

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 LESSON PLAN

Subject: Child Health Nursing

Unit no. and name:

Topic: Rheumatic heart disease

Level of learners: BSC 3rd year

No of learners: 29

Date and time: 2076/10/16 and 9 am-11 am

Duration: 2 hours

Venue: Om Health Campus, BSC 3rd year

Name of student teacher: Gita Tamang

Level of student teacher: PBBN, 2nd year

Name of supervisor: Ms Rija Acharya

General objectives:

At the end of the classroom teaching, BSC 3rd year student will be able to explain about
Rheumatic heart disease.

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S.N Specific objective Content Time TL method TL media Evaluation
Introduction
Topic
Announcement
Statement of 5 min Brainstorming White board What do you mean by Rheumatic
objectives heart disease?
Revision
At the end of Pretest
classroom teaching,
BSC 3rd year student
will be able to
1. introduce Rheumatic Introduction of 5 min Interactive Power point How will you introduce
heart disease Rheumatic heart lecture Rheumatic heart disease?
disease
2. state the incidences State the incidences 5 min Illustrative Power point What are the incidences of RHD?
of RHD of RHD talks
3. list the etiology of Etiology of RHD 10 Discussion + Power point What are the etiology of RHD?
RHD min Interactive
lecture
4. enlist the risk factors Risk factors of 10 Discussion + Power point What are the risk factors of RHD?
of RHD incubator min Interactive
lecture
5. explain the Pathophysiology of 10 Discussion + Power point What are pathophysiology of
pathophysiology of RHD min Interactive RHD?
RHD lecture
6. State the clinical Clinical 15 Interactive Power point What are the clinical manifestation
manifestation of manifestation of min lecture + of RHD?
RHD RHD Discussion
7. Identify the Diagnosis of RHD 15 Interactive Power point How RHD can be diagnosed?
diagnosis of RHD min lecture +
Discussion
8. Explain the Management of 20 Discussion + Power point What are management of RHD?

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 management of RHD min Interactive
RHD lecture
9. Describe the Prevention of RHD 10 Discussion+ Power point How RHD can be prevented?
prevention of RHD min Interactive
lecture
10. Summarize session Summary 10 Discussion+ How will you define RHD?
Assignment: min Interactive What are main roles and
(Write about the lecture responsibilities of nurses in caring
JONES criteria. rheumatic heart diseased child?
Submission date:
10/19).
References

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RHEUMATIC HEART DISEASE

Definition:

RHD is a chronic condition resulting from rheumatic fever which involves all the layers of the heart i.e. pancarditis and is
characterised by scarring and deformity of the heart valves.

The commonest valves affecting are the mitral and aortic in that order. However, all fourth valves can be affected.

Incidence

 Rheumatic fever occurs in equal number in male and female but the prognosis is a worse for females than for males.
 The disease is seemed more commonly in poor socioeconomic status of the society living in damp and overcrowded places.
 It is thought that 40-60% of patient with ARF will go on to developing RHD.
 It is common in developing countries like India, Pakistan, Nepal etc.

Etiology
 The exact cause is unknown
 Group A beta-haemolytic streptococcus
 Rheumatic fever

Risk factors

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  Poor socioeconomic status
 Overcrowding
 Age: most commonly in children between 5 to 15 yrs
 Climate and season: It occurs more in rainy season and cold climate.

 Upper respiratory tract infection: Rheumatic fever is an outcome of upper respiratory tract infection with group A beta-
haemolytic streptococcus.

 Previous history of rheumatic fever

 Genetic predisposition

Pathophysiology
RF and RHD are an antigen antibody reaction. The patient produces antibodies against streptococcal cell membrane protein. The
streptococci bacterial antigen and human cardiac (heart valve) glycoprotein appear to be an identical. These antibodies attack to
human connective tissue especially cardiac muscle. Especially, endocardium is more affected.

Infection with group A beta-haemolytic streptococcal bacterial

Antibodies formed against these bacteria

These antibodies cross react with antigen in different connective and endothelial tissue like heart, joint, CNS, sub-cutaneous tissue etc.

Production of inflammation in these tissues

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When the heart is involved, it is called carditis followed by;
 Edema and inflammation of heart tissue
 Formation of fibrin like plaque: Aschoff body on the heart valve and endocardium
Due to recurrent inflammation of the endocardium and healing fibres and scar tissues are formed. Valve leaflets are fused resulting
stenosis and fibrosis of the valves insufficiency. Mitral and aortic valves are affected most.

Clinical features:
Major manifestations

 Carditis: Rheumatic carditis is pancarditis involving pericardium, myocardium and endocardium. It is an early manifestation
of RF in about 50-60 % cases. It includes tachycardia, cardiomegaly, murmur heart sounds, pericardial friction rub, chest pain
and pericardial effusion, etc.

 Polyarthritis: It is a migratory type of joint inflammation characterised by pain decreased active movements, warm,
tenderness, redness and swelling. Two or more joints are affected.

 Sydenham chorea: Charaterised by sudden aimless, irregular movements of the extremitis involuntary facial grimace, speech
disturbance, muscle weakness. Symptoms increased with stress and decreased with rest.

 Sub-cutaneous nodules: are non tendered located over bony prominents like elbow, occiput.

 Erythema marginatum: consists of pink macular not itching rash found mainly over trunk but never on face.

Minor criteria:

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  High fever with chills and rigor 104 F.
 Arthralgia
 Weakness, Malaise, weight loss, Anorexia
 Elevated ESR or presence of C reactive protein
 ECG changes with prolonged PR interval
Essential criteria:
 Elevated antistreptolysin –O (ASO) titer indicates previous streptococcal infection (normal 200 IU/ml).
 Throat swab culture shows streptococcal positive

Diagnosis:
 History of tonsillitis, pharyngitis or streptococcal infection
 Physical examination: Sub cutaneous nodules, murmur heart sound
 Laboratory investigation:
1. CBC: increased WBC, anaemia and increased ESR
2. Throat swab culture: positive for streptococcal infection
3. Elevated C reactive protein, ASO titer positive within 2 months
 Chest X-ray: Cardiac enlargement
 ECG: Prolonged PR interval
 Echo: to rule out cardiac involvement
 Jones criteria: 2 majors or one major and two minors

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Management:
There is no specific treatment. Management includes symptomatic and suppressive management.

 Bed rest: Bed rest is important management for children with rheumatic fever especially for child with carditis.
 Antibiotic therapy: Penicilin is the drug of choice with cephalosporins as substitute of penicillin sensitivity. Initial therapy
includes a full 10 days course of penicillin or alternative antibiotics. Benezathine penicillin 0.4 million unit deep intramuscular
twice a day or oral penicillin (penicillin V). 0.4 milion units (250 mg) 4 times a day for 10-14 days can be given or
Erythromycin 20-40 mg/kg/day 2-4 times a day orally.
 Diet: nutritious normal diet and salt restriction if CCF presents.
 Aspirin (80-110 mg/kg/day) given in divided dose therapy to control pain and inflammation of joints. It may be needed for 12
weeks.
 Steroid (prednisolone) is used only if there is acute onset of CCF associated with carditis.
 Digoxin if carditis with CCF.
 Oxygen therapy according to need.

Duration of Secondary Rheumatic Fever Prophylaxis

Category
1. RF with carditis and residual heart
disease (valvular disease)
2. RF with carditis but no residual heart
disease
3. RF without carditis
Duration
1. At least 10 years since last episode or at least
until age 40 years or lifelong may be needed
2. 10 years or well into adulthood, whichever is
longer.
3. 5 years or until age 21 years whichever is longer.

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Surgical management:
 When heart failure persists or worsens after aggressive medical therapy for acute rheumatic heart disease, surgery to decrease
valve insufficiency may be life-saving.
 Forty percent of patients with acute rheumatic heart disease subsequently develop mitral stenosis as adults.
 Cummisurotomy can be done to widen the valve.
 In patient with critical stenosis, mitral valvulotomy, percutaneous balloon valvuloplasty, or mitral valve replacement may be
indicated.
 Due to high rates of recurrent symptoms after annuloplasty or other repair procedures, valve replacement appears to be the
preferred surgical option.

Nursing management:

Nursing care of a child with rheumatic fever include;

Nursing Assessment:

Nursing assessment for a child with rheumatic fever are as follows:

 History: Obtain a complete up-to-date history from the child and the caregiver; ask about a recent store throat or upper
respiratory infection; find out when the symptoms began, the extent of the illness, and what if any treatment was obtained.
 Physical exam: Begin with a careful review of all systems and note the child’s physical condition; observe for any signs that
may be classified as major or minor manifestations; in the physical exam, observe for elevated temperature and pulse, and
carefully examine for erythema marginatum, subcutaneous nodules, swollen or painful joints, or signs of chorea.

Nursing diagnosis:

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Based on the assessment data, the major nursing diagnoses are:

 Acute pain related to joint pain when extremities are touched or moved.
 Deficient diversional acitivity related to prescribed bed rest.
 Activity intolerance related to carditis or arthralgia.
 Risk for injury related to chorea.
 Risk for noncompliance with prophylactic drug therapy related to financial or emotional burden of lifelong therapy.
 Deficient knowledge of caregiver related to the condition, need for long-term therapy, and risk factors.

Nursing intervention:

Nursing intervention for a child with rheumatic fever includes:

 Provide comfort and reduce pain: Position the child to reduce joint pain; warm baths and gentle range-of-motion exercises
help to alleviate some of the joitn discomforts; use pain indicators scales with children so they are able to express the level of
their pain.
 Provide divisional activities and sensory stimulation: for those who donot feel very ill, bed rest can cause distress or
resentment; be creative in finding diversional activities that allow bed rest but prevent restlessness and boredom, such as a
good book; quiet games can provide some entertainment, and plan all activities with the child’s developmental stage in mind.
 Provide energy conservation: Provide rest periods between activities to help pace the child’s energies and provide maximum
comfort; if the child has chorea, inform visitors that the child cannot control these movements, which are as upsetting to the
child as they are to others.
 Prevent injury: protect the child from injury by keeping the side rails up and padding them; do not leave a child with chorea
unattended in a wheelchair; and use all appropriate safety measures.

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Evaluation:

Goals are met as evidenced by:

 Reducing pain
 Providing diversional activities and sensory stimulation
 Conserving energy
 Preventing injury

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Prevention

Susceptible host

Primordial prevention

Housing

Hygiene

Group A streptococcal infection

Primary prevention

Sore throat treatment

Vaccine (not currently available)

Acute rheumatic fever

Secondary prevention
No rheumatic heart disease
Regular penicilin

Rheumatic heart disease

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 Rheumatic heart disease morbidity
(congestive cardiac failure, atrial
fibrillation, infective endocarditis, stroke

Clinical management

Heart failure medication

Surgery

Anti-coagulation

Death

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References
 Black JM, Hawks JH. Medical surgical nursing. 8th ed. Vol-2. Elsevier; p. 1396-1401
 Lewis, Heitkemper, Dirksen O’Brien, Bucher. Medical surgical nursing. 7th ed. New Delhi. Elsevier; p. 875-882
 URL: https://en.wikipedia.org/wiki/Rheumatic fever
 URL: http://www.slideshare.net/miel9156/rheumatic-heart-disease-3264045
 URL: http://www.powershow.com/view/3d4797-MWIOM/Rheumatic heart disease RHD Powerpoint ppt presentation
 URL:http://gmch.gov.in/estudy/e%20lectures/Pathology/cvs5%20RF.pdf

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