RHEUMATIC HEART DISEASE

ANATOMY OF HEART

The heart is the organ that helps supply blood and oxygen to all parts of the body. It is divided by a partition or septum into two
halves, and the halves are in turn divided into four chambers. The heart is situated within the chest cavity and surrounded by a fluid
filled sac called the pericardium. This amazing muscle produces electrical impulses that cause the heart to contract, pumping blood
throughout the body. The heart and the circulatory system together form the cardiovascular system.

Chambers
  Atria - upper two chambers of the heart i.e. right atrium and left atrium
 Ventricles - lower two chambers of the heart i.e. right ventricle and left ventricle.

Heart Wall

The heart wall consists of three layers:

 Epicardium - the outer layer of the wall of the heart.

 Myocardium - the muscular middle layer of the wall of the heart.
 Endocardium - the inner layer of the heart.

Cardiac Conduction

Cardiac Conduction is the rate at which the heart conducts electrical impulses. Heart nodesand nerve fibers play an important role in
causing the heart to contract.

 Atrioventricular Bundle - bundle of fibers that carry cardiac impulses.

 Atrioventricular Node - a section of nodal tissue that delays and relays cardiac impulses.
 Purkinje Fibers - fiber branches that extend from the atrioventricular bundle.
 Sinoatrial Node - a section of nodal tissue that sets the rate of contraction for the heart.

Cardiac Cycle

The Cardiac Cycle is the sequence of events that occurs when the heart beats. Below are the two phases of the cardiac cycle:

 Diastole Phase - the heart ventricles are relaxed and the heart fills with blood.
 Systole Phase - the ventricles contract and pump blood to the arteries.

Heart Anatomy: Valves

Heart valves are flap-like structures that allow blood to flow in one direction. Below are the four valves of the heart:
  Aortic Valve - prevents the back flow of blood as it is pumped from the left ventricle to the aorta.
 Mitral Valve - prevents the back flow of blood as it is pumped from the left atrium to the left ventricle.
 Pulmonary Valve - prevents the back flow of blood as it is pumped from the right ventricle to the pulmonary artery.
 Tricuspid Valve - prevents the back flow of blood as it is pumped from the right atrium to the right ventricle.

Arteries:

 Aorta - the largest artery in the body of which most major arteries branch off from.
 Brachiocephalic Artery - carries oxygenated blood from the aorta to the head, neck and arm regions of the body.
 Carotid Arteries - supply oxygenated blood to the head and neck regions of the body.
 Common iliac Arteries - carry oxygenated blood from the abdominal aorta to the legs and feet.
 Coronary Arteries - carry oxygenated and nutrient filled blood to the heart muscle.
 Pulmonary Artery - carries de-oxygenated blood from the right ventricle to the lungs.
 Subclavian Arteries - supply oxygenated blood to the arms.

Veins:

 Brachiocephalic Veins - two large veins that join to form the superior vena cava.
 Common iliac Veins - veins that join to form the inferior vena cava.
 Pulmonary Veins - transport oxygenated blood from the lungs to the heart.
 Venae Cavae - transport de-oxygenated blood from various regions of the body to the heart

DISEASE CONDITION

INTRODUCTION

Rheumatic fever is a diffuse inflammatory disease characterized by a delayed response to an infection by group A beta-hemolytic
streptococci (GAS) in the tonsilopharyngeal area, affecting the heart, joints, central nervous system, skin and subcutaneous tissues.
DEFINITION

 Rheumatic heart disease is a chronic condition resulting from rheumatic fever which involves all the layers of the heart and is
characterized by scarring and deformity of the heart valves.
 The commonest valves affecting are the mitral, aortic and tricuspid valves are affected.

INCIDENCE

 Rheumatic fever is principally a disease of childhood, with a median age of 10 years, although it also occurs in adults (20% of
cases).

 Rheumatic fever occurs in equal numbers in males and females, but the prognosis is worse for females than for males.

 The disease is seen more commonly in poor socio-economic strata of the society living in damp and overcrowded place.

ETIOLOGY

 Group A beta-hemolytic streptococcus.

 Rheumatic fever

RISK FACTORS

 Poor socio-economic status

 Over-crowding
 Age (5 to 15 years)
 Climate and season ( rainy season and in the cold climate)
 Upper respiratory tract infection ( group A beta- hemolytic streptococcus)
PATHOPHYSIOLOGY
 Causative agent (Group A Beta-hemolytic streptococci)

Untreated Sore throat

Rheumatic fever

All layers of the heart and the mitral valve become inflamed

Vegetation forms

Valvular regurgitations and stenosis

Heart failure

CLINICAL MANIFESTATIONS

s.no Book ’s picture Patient’s picture Inference

.
I.  Polyarthritis Absent Present since 1 month
 Carditis Present
 Subcutaneous nodules Absent
 Erythema marginatum Absent
 Sydenham’s chorea Absent

II.  Chest pain Present Present since 15 days

 Heart palpitations Absent
Present
  Breathlessness on exertion Absent
 Breathing problems when lying
down (orthopnoea) Absent
 Waking from sleep with the
need to sit or stand up
(paroxysmal nocturnal
dyspnoea)
 Swelling (oedema) Present
 Fainting (syncope) Absent
 Stroke Absent
Absent
 Fever associated with infection
of damaged heart

DIAGNOSTIC EVALUATION

S. Patient picture Book picture Inference

no
.
Diagnosis may include:
1. Physical examination – while a Done Murmur sound resent
heart murmur may suggest
RHD, many patients with RHD do
not have a murmur
2. Medical history – including Done Present
evidence of past ARF or strep
infection
3. Chest x-ray – to check for Done Swelling present
enlargement of the heart or fluid on
the lungs
4. Electrocardiogram (ECG) – to Done Prolonged PR interval present
check if the chambers of the heart
have enlarged or if there is an
abnormal heart rhythm (arrhythmia)
 5. Echocardiogram – to check the Done
heart valves for any damage or It suggest that right atrium and
infection and assessing if there is ventricle dilated and mild mitral
heart failure. This is the most useful regurgitation present
test for finding out if RHD is present.
6. Other test
• High ESR Done Increased
• Anemia, leucocytosis
• Elevated C-reactive protien

CARDIAC PROBLEMS AND ITS MANAGEMENT

IN BOOK

1.Mitral regurgitation

It results in systolic leak of blood to left atrium, which passes back into the ventricles on diastole. The blood flowing out of the
ventricles becomes insufficient duing exertion. This reduction in systemic output results in fatigue.

Treatment
  The medical management consist of using digitalis, diuretics and vasodilators besides prophylactic penicillin for preventing
recurrence of rheumatic fever.
 In severe MR, mitral valve repair is indicated.

2.Mitral stenosis

It is less common than mitral regurgitation. It results in obstruction to the flow of blood across mitral valve, during left ventricular
diastole. The left atrium compensates for this obstruction by increasing its pressure. This increase in pressure results in hypertrophy of
left atrial wall.

Treatment

Medical management is digitalis and diuretics. Surgical management is closed mitral vavotomy. Also done mitral vavoplasty in few
patients, using a balloon catheter.

3.Aortic regurgitation

In this, the semi lunar cups of aortic valve are deformed and shortened, due to which aortic ring gets dilated. The defect leads to back
flow of blood aorta to left ventricles. Due to back flow, volume overload occurs in left ventricle leading to left ventricular
hypertrophy.

Treatment

Digitalis and vasodilators are commonly used.

4.Tricuspid regurgitation

It is associated with mitral stenosis and mitral regurgitation. There are no specific symptoms of tricuspid regurgitation. Specific
features of tricuspid regurgitation are:

 Prominent V waves in jugular venous pulse

 Systolic pulsation of liver
 Systolic murmur at lower left sterna border, increasing in intensity with inspiration
Treatment

The common drug used are digoxin and diuretics.

IN PATIENT

The patient was having condition of mitral regurgitation and she is getting the medical treatment such as tab. Digitalis, inj. Lasix. Tab.
Omnacortil etc

NURSING DIAGNOSIS
 Decreased cardiac output related to disturbance on the closure of the mitral valve as evidenced by altered hear rate.

 Ineffective tissue perfusion related to decrease in peripheral blood circulation as evidenced by impaired vital signs.

 Ineffective breathing pattern related to musculoskeletal fatigue as evidenced by irregular breathing patterns.

 Impaired body comfort related to pain as evidenced by verbalization of the patient.

 Activity intolerance related to pain in joints as evidenced limited activity of the patient.

 Fear & anxiety of parents related to baby’s disease conditions as evidenced by facial expression of parents.

 Knowledge deficit related to disease condition as evidenced by asking questions of parents of the baby.
s. Assessment Nursing Goal Implementation Rationale Evaluation
n Diagnosis
o.
1. Subjective data: Decreased To maintain Assess pulse, To obtain baseline After 24 hours
cardiac the normal respiration, blood pressure data of the nursing
Patient’s says that she output related cardiac regularly every 4 hours. intervention
is having to output  To assess the the patient was
breathlessness disturbance  Monitor the heart abnormal heart sounds able to meet
on the sounds. the goal
closure of the  To identify further partially.
mitral valve  complications
as evidenced  Assess changes in
by low blood skin color towards cyanosis
pressure. and pallor. To know the
 nutritional status of
Objective data: the patient

By checking the vital
signs it was found that  Monitor intake and
To prevent discomfort
blood pressure is output every 24 hours.
of the child
80/50 mm.hg 
 Limit activities of the To decrease the
patient adequately. anxiety of the patient

 Give psychological To make comfortable
support to the patient to the patient

 Provide calm and To facilitate blood
quiet environment to the circulation in the body
 patient

Change the position of the

patient (semi fowler position)

s. Assessment Nursing Goal Implementation Rationale Evaluation

n diagnosis
o
3. Subjective data: Ineffective After the 24 Help in distinguishing The patient
Assess the rate, depth of
The patient breathing hours of normal breathing and partially meet
respirations & chest
complaints that she is pattern nursing apnea the goal
movement
having breathing related to intervention
difficulty musculoskele , the normal
tal fatigue as breathing
evidenced by pattern of Checked the vital signs of the To know the
irregular the patient baby i.e. temp-37.6°c. HR- fluctuations in vital
breathing will 96beats/min, R- parameters
patterns. establish 20breaths/min, Spo2-88%,
BP. 90/60 mm.Hg
Observe for cyanosis,
Objective data: dyspnea, hypoxia and To prevent worsening
The baby looks confusion of condition
restless and
respiratory rate is 16 Place patient in upright To obtain greater lung
breaths/min position expansion

Avoid high concentration of To prevent

oxygen to the patient at a complications of the
time patient

Provided oxygen as indicated. To facilitate normal

 breathing pattern

s. Assessment Nursing Goal Implementation Rationale Evaluation

n diagnosis
o.
4. Subjective data- Impaired To provide Assess the duration, site and To know the severity of The patient’s
The patient says that body comfort to intensity of pain of the pain pain is
she is having pain in comfort the patient patient partially
the body especially related to To decrease the pain of decreased.
joints pain as Provide range of motion the patient
evidenced exercise to the patient
by
Objective data- verbalizati Observe the patient for
I observed that ; there on of the complications such as To prevent further
is tenderness present patient. swelling on the joints and damage of the patient
on the joints erythema marginatum and
subcutaneous nodules

Provide complete bed rest to To prevent further

the patient complications of the
patient
Provide calm and quite
environment to the patient To provide rest to the
when she is sleeping patient

Changed the position of the To make comfortable to

 the patient
patient frequently
To decrease pain of the
Administered analgesic drug patient
as per as doctor’s order

s. Assessment Nursing Goal Implementation Rationale Evaluation

no. diagnosis
5. Subjective data- Activity To patient  Assess the patient's To determine the The patient is
Patient’s complaints intoleranc can work tolerance for activity using problems occurring able to perform
that she is having e related within the the following parameters: during performing some activities
difficulty during to pain in noted an increase in blood activities
limit of
performing activities joints as pressure, dyspnoea, chest
evidenced activities pain, severe fatigue,
limited with weakness, sweating,
activity of tolerance dizziness or fainting.
the  To prevent further
patient.  Increase breaks, complication of the
limit activity on the basis of patient
pain
Objective data-  To make comfortable to
I observed that the  Provide leisure the patient
patient is having activities that are not heavy.
fainting during  To prevent discomfort of
perform the the patient
 Limit visitors or
activities
visits by patients.
Helps to know the

problems during
 Assess readiness to performing activities
increase activities eg
decrease weakness / fatigue,
 stable blood pressure / pulse
rate, increased attention on
the activities and self-care. To increase the self
 esteem of the patient
 Promote activities of
self care to the patient To fulfill the need of
 selfcare
 Provide assistance as
needed (eating, bathing,
dressing, elimination)

s. Assessment Nursing Goal Implementation Rationale Evaluation

no. diagnosis
2. Subjective data: Ineffective To maintain Monitor changes To know the effect on The patient
tissue normal suddenly or continuous the mental status of the maintains
Patient complaint perfusion circulation mental disorders (anxiety, patient optimum
that the she is related to confusion, lethargy, circulation
of the
having breathing decrease fainting). after 24 hours
difficulty in patient To know the changes in
 Observation of pale,
peripheral cyanosis and cold skin of skin of the patient
blood patient
circulation 
as  Assess Homan's sign To know the severity of
evidenced (pain in the calf with the disease in patient
Objective data: by dorsiflexion), erythema,
impaired edema.
I observed that the vital signs. 
patient looks restless  Encourage leg To maintain normal
exercises active / passive. circulation of the patient

To protect the child from
 Monitor breathing
dyspnea
pattern of the patient
 
 Assess GI function,
record anorexia, decreased
bowel sounds, nausea /
vomiting, abdominal
distension, constipation.

 Monitor input and
changes in urine output
To assess the nutritional
status of the patient
because adequate
nutrition is essential for
increase o2 concentration
To prevent fluid overload
in the patient

s. Assessment Nursing Goal Implementation Rationale Evaluation

no. diagnosis
6. Subjective data: Fear & To reduced Recognized the parent’s To identify the needs of The parents
anxiety of the anxiety level of fear and anxiety the parents anxiety level is
The parents ask that parents level of the reduced
what happened to related to baby Orient the parents about the partially
her daughter. baby’s Helps to decrease the
environment and
disease anxiety level of parents
conditions equipments using on the
as child
Objective data: evidenced
I observed that the by facial Identified the needs of the Helps to prioritize their
parents looks expressio parents of the baby need
anxious about her n of
daughter parents Clarified their doubts about Helps to understand
their child’s condition parents about the
problems of the child
Provided psychological
To decrease the anxiety
support to the patient and level
family members
 Helps to understand the
Educated the mother about condition of the child
the pattern of disease and
its complication
To create some
awareness into the
Educated the mode of
parents regarding the
transmission and spread of disease
the disease and its
prevention

PROGRESS NOTE

DAY- 1ST – The patient admitted in the pediatric medicine ward with the complaints of whole body pain, breathlessness, abdominal
distension and dry cough . The child condition was poor at that time. The oxygen therapy and IV fluids was started immediately.
Blood sample had taken for the investigations. The vital signs also checked.

Pulse rate- 64beats/ min

Temperature - 100.2° F

Respiration - 18breaths/min

Spo2- 87%

To relieve patient we provide medication as prescribed by the doctor. After 5 hours of medication and nursing intervention patient’s
vital signs become normal

DAY-2nd - On the day second, the condition of the baby was better than the previous one. The IV fluid and medication had also given
to the child. The bowel and bladder pattern of the patient was normal. Blood samples collected for the further investigations. Weight
of the patient checked. ECG of the patient was also done. The intake and output chart has been maintained. The vital signs also
checked

Vital signs:

Pulse 82beats/min

Temperature 99.5 F

Respiration 20breath/min

SPO2 92%

DAY-3rd – On the third day the baby looks better from the previous days; the child looks conscious. The patient’s intake and output is
normal. The medication is given to the baby such as tab. Digitalis, omnacartil, inj. Ceftriaxone, metrogyl etc. The vital signs have been
checked. The IV fluid was also given to the baby to prevent dehydration.

Vital signs:

Pulse 156beats/min

Temperature 96.2 F

Respiration 42breaths/min

Spo2 94%

HEALTH EDUCATION

Diet
  Asked the mother to provide healthy and nutritious diet to fulfill the feeding requirement of the baby.
 Educated the parents to provide balanced diet to the child which is rich in protein vitamins and minerals
 Educated the mother to avoid oily and spicy food which are harmful for the baby
 Educated her to use clean water for preparation of food and use clean utensils for making food.
 Educated the mother to do hand wash and also her child before and after eating food.

Exercise

 Educated the parents to provide range of motion exercise to the child frequently to prevent swelling on the joints.
 Educated the parents do not force the child to do strenuous activities eg. Heavy bucket lifting, running etc.

Personal hygiene

 Educated the parents about hand washing techniques and hand wash after going to the toilet.
 Educated the parents about importance of bathing, eye care, skin care etc.

Medication and follow-up

 Educated the parents about the importance of medication for the early recovery of the child.
 Asked her to weight the baby periodically to know the progress of the baby even after discharge.
 Educated the mother about signs of complication to the child occur, immediately go for the doctor.
 Educated the parents if the child is having fever again then immediately go for the doctor.
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 “Sharma Rimple, Essentials of Pediatric Nursing, First Edition, Jaypee Brothers Medical Publishers LTD, 2013,Page
No. 481-485”

 “TM Beevi Assuma, Pediatric Nursing care Plans, First Edition, Jaypee Brothers Medical Publishers LTD, 2012,Page
No. 212-236”

 “Dutta Parul, Pediatric Nursing, Third Edition, Jaypee Brothers Medical Publishers LTD,2014, Page No. 361-366”

 “Wongs, Essentials of Pediatric Nursing, Eighth Edition, Reed Elsevier India Private LTD,2012,Page NO.846-848”

 “Ghai OP, Essentials of Pediatric Nursing, Eighth Edition, CBS Publishers Private LTD, 2012, Page NO. 289-292”

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