Rheumatic heart disease is a chronic condition that results from damage to the heart valves from rheumatic fever, which occurs as a sequela to group A streptococcal infection. The pathophysiology involves inflammation of the heart tissues from the infection that affects the heart valves and causes valve leakage and narrowing. Nursing assessment focuses on signs of carditis, joint pain, and fever, while management includes bed rest, antipyretics, antibiotics, pain medications, maintaining activity levels and cardiac output, and educating patients on prevention.

3. 1) Define Rheumatic Heart disease
2) Explain the pathophysiology and Aetiology of Rheumatic
Heart Disease
3) Explain the clinical manifestation of Rheumatic Heart
Disease
4) State the diagnostic evaluation/studies of RHD
5) Explain the Nursing assessment
6) State the nursing diagnoses
7) Explain the nursing management and interventions
8) Medical management
9) Health education
10) State complications of RHD

4. 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).

5. 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

6.  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

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8. 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.

9. 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

10.  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.

11. 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 asymptomatic
0 Warm and swollen joints (polyarthritis)

12. 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.

13. 0 Throat culture-to determine presence of
streptococcal organisms
0 Sedimentation rate, WBC count and differential,
and CRP increased during acute phase of infection
0 Elevated antistreptolysin-O (ASO) titer
0 ECG-prolonged Pulse Rate interval or heart block

14. SUBJECTIVE DATA
Past health history:
 Recent streptococcal infection
 Previous 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

15. contd
Cognitive –perceptual:
 Chest pain
 Migratory joint pain
 Tenderness (especially large joints)
OBJECTIVE DATA
General
 fever

16. Integumentary:
 Subcutaneous nodules
 Erythema marginatum
Cardiovascular
 Tachycardia,
 pericardial friction rub
 Muffed heart sounds
 Gallop rhythm
 Murmurs &
 Peripheral edema

17.  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)

18. 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

19. 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 expression
6)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.

20. 0 Heart failure
0 Atrial fibrillation
0 Infective endocarditis
0 Atrial and ventricular arrhythmias

21. Ineffective breathing pattern
0 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

22. 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 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.

23. 0 Follow ABG levels/Sao2 to determine oxygen need and
response to oxygen therapy

24. REDUCING FEVER
0 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

25. contd
Maintaining Adequate Cardiac Output
0 Assess 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).

26. contd
0 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

27. 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 drugs eg PCM 1g
tds/24hrs
Diversion therapy- avoid the patient’s mind
concentrating on his/her pain

28. NURSING INTERVENTIONS
contd
MAINTAINING ACTIVITY
0 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.

29. patient education and health
maintenance
0 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 patient's own toothbrush,
soap, and washcloths when living in group situations.

30. 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).

31. 0 Instruct patient with valvular disease to use
prophylactic penicillin therapy before certain
procedures and surgery
0 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.)

32. Evaluation: Expected Outcomes
0 Afebrile
0 Denies chest pain; normal sinus rhythm
0 Maintains bed rest while febrile

33. COMMENT/CONCLUSION
0 Tell as many other people as possible about this
disease (rheumatic heart disease).
0 It could save their lives !!!
0 DON'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.

34. 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!!!

35. REFERENCES
1) 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