Rheumatic Heart Disease

Streptococcal (strep) infections are communicable diseases that develop when Streptococcus bacteria normally found on the skin or in the intestines, mouth, nose, reproductive tract, or urinary tract invade other
parts of the body and contaminate blood or tissue.





Rheumatic Fever

—is an inflammatory disease which may develop two to three weeks after a Group A
Streptococcal Infection (such as strep throat or scarlet fever)
Streptococci are a part of normal animal flora!

—It is believed to be caused by antibody cross-reactivity and can involve the heart, joints, skin, and brain

The capsule of Streptococcus pyogenes is chemically similar to that of it's host's
connective tissue, and therefore, is nonantigenic, and it's cytoplasmic membrane has antigens similar to human cardiac, skeletal and smooth muscle.



Epidemiology

—2 – 3 % of people with untreated Group A beta-hemolytic streptococcal infection.
—470,000 new cases and 233,000 deaths each year.
—Mostly in developing countries, among indigenous groups.
—over 15 million people are estimated to have rheumatic heart disease.
—In the US and other developed countries the incidence is low (hygiene and routine antibiotic use)

Predisposing Factors


—AGE – 90% occur between the ages of 5 – 15 y.o.
- Also the AGED, severe cardiac disability and death.
—SOCIOECONOMIC FACTORS – slum, city dweller more than the farmer.
— GENETICS – may appear to develop in household members.



Etiology
—Exact cause remains uncertain!
- bacteria do not grow within the heart and joints.

—2 Theories:

—The body undergoes anallergic response to invading streptococci.
—The host develop an autoimmune response in which streptococcal antibodies attack the host tissue.

—Basis of the theories:

1. RF develops following an URTI by streptococci

2. The devl’p of RF is between 1 - 5weeks, with an average of 18 days. The time our body needs to sensitized an organism and undergo immune response.

3. Since only 2 -3 % devl’p RF after strep. throat, it has been
hypothesized that these people have a greater immunological reaction.




Pathophysiology


[CLICK THE PICTURE TO ENLARGE]


Assessment

—Almost always follows a streptococcal infection of the nasopharynx.

Did you experience sore throat lately? How often?


Signs and Symptom

1.Polyarthritis – prominent finding; last hours to days

2.Carditis – common manifestation

3.Relapsing fever – 38o C and episode of normal temp.

4.Subcutaneous nodules – small, painless firm

nodules (knees, knuckles, and elbows); usually in

children; only in first week.

5.Erythema Marginatum – crescent shape lesion with

clear centers “chicken-wire rash”

6.Abdominal pain – may be related to liver

engorgement

7.Sydenham’s chorea – “St. Vitus’ dance”; late stages,

usually in girls; Involuntary grimacing and jerky,

purposeless movements.

8.Malaise, weakness, weight loss, and anorexia – As a

result of fever, pain, and the general debilitation



















Diagnostic Measures


—There is no single diagnostic feature identifies rheumatic fever.

JONES CRITERIA


- gauges the probability of the presence of rheumatic fever in an individual.


Premise:



1. Diagnosis requires two major manifestation

2. One major manifestation and two minor manifestation





Major criteria

Joints
O [imagine heart-shaped O] (carditis)
N: Nodules
Erythema marginatum
Sydenham’s chorea (St. Vitus' dance)

C: Carditis
A: Arthritis
N: Nodules
C: Chorea
ER:ERythema Marginatum


Minor criteria

Fever
Arthralgia

Laboratory abnormalities: increased ESR, increased C reactive Protein, leukocytosis
Electrocardiogram abnormalities: a prolonged PR interval
Evidence of Group A Strep infection: elevated or rising Antistreptolysin O titre, or DNAase, though by the time clinical illness begins, cultures for the streptococci bacterium will be negative.

Previous rheumatic fever or inactive heart disease

Other signs and symptoms
Abdominal Pain
Nosebleeds

Medical Intervention


—Control and alleviate infecting streptococci if still present.
—Protect the heart against the damaging effects of carditis.
—Relieve joint pain, fever, and other symptoms.

—Typical intervention:

1. Chemotherapy with penicillin, salicylates, and steriods
2. Bed rest
3. Proper diet


Pharmacologic Intervention


—PENICILLIN – for 10 days ff. the onset of rheumatic fever.
—ERYTHROMYCIN – if allergic to penicillin
—Prophylactic doses of same med is given to prevent further attacks
—Monthly injections of Longacting Penicillin must be given for a period of 5 years in patients having one attack of Rheumatic fever
—SALICYLATES – to control fever and to relieve joint pain.
—Aspirin – give with food to reduce gastric irritation
—STERIODS – relieve inflammatory symptoms; prevent further scarring of tissue and may prevent development of sequelae such as Mitral stenosis
—CARDIAC GLYCOSIDES (‘digitalis’) and DIURETICS

Nursing Management

NURSING ASSESSMENT

* Cardiac function

* Tolerance to activity and feelings towards restriction

* Support Systems

* Coping Strategies

* Nutritional Status

* Level of Discomfort

* Knowledge with RF

NURSING GOALS

1. Person will demonstrate progression toward an optimal level of physical activity tolerance.

2. Person will use adaptive coping strategies.

3. Person will experience increased comfort.

4. Person will show fewer behavioral and physical symptoms of anxiety.

5. Person will maintain or restore proper nutritional balance.

6. The person will restore or maintain hemodynamic status – lungs, Urine output, weight,

7. Person and SO will demonstrate adequate knowledge f rheumatic fever.





Nursing Dx and Interaction



—Alteration in Comfort
—Activity Intolerance – Bed rest (reduces strain on the heart and reduces metabolic needs)

* Temp is normal without salicylates

* Resting pulse (adults) <100>

Prognosis and Complication

—With antibiotic therapy, the prognosis is generally good. (only 1 – 2 % die from initial attack; acute myocarditis)
—Laboratory and clinical signs subsides within one to two months following therapy.
—Some develop residual heart damage:

MITRAL REGURGITATION and/or STENOSIS AORTIC REGURGITATION





SOURCE: Mr. Euno Carlo Raymundo D. Arreola, RN

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