Rheumatic Fever and Rheumatic Heart Diseases

Rheumatic Fever and Rheumatic Heart Diseases-

Rheumatic fever is an inflammatory disease of the heart potentially involving all layers of the heart. The resulting damage to the heart form rheumatic fever is called rheumatic heart disease (RHD). Most common in 6-15 years of ages.

Rheumatic heart disease is a chronic condition result from rheumatic fever which involves all the layer of the heart ( i.e- pancarditis- is the inflammation of the entire heart) and characterized by scarring and deformity of the heart valves.

Causes -

Rheumatic fever occurs as a delayed Sequela of a group A Beta -hemolytic streptococcal infection of the upper respiratory system.

Predisposing Factors -

  • Socio-economic factors - Poor socio-economic status. Incidence of rheumatic fever and RHD is higher in low socio-economic groups.
  • Over- crowded living conditions-People who are living in a slum or damp area are more prone to get.
  • Poor nutrition and inadequate treatment.
  • Age-Most commonly in children between the ages 5 to 15 years.
  • Familial Factors -Related to abnormal immunological responses in the family.
  • Previous history of Rheumatic fever-The client with previous history of Rheumatic fever are at high to develop.
  • Climate and Season-It occurs more in the rainy season and in the cold climate.

Pathophysiology-

Causative agent (Group A Beta- hemolytic streptococci)    ­číć Untreated Strep throat­číćRheumatic fever  ­číć  All layer of the heart and the mitral valve become inflamed­číćVegetation forms ­číć  Valvular regurgitation and stenosis ­číć  Heart  Failure

Clinical Manifestations -

They are grouped into Jones major and minor criteria for diagnosis. Presence of two major criteria or one major and two minor criteria indicate rheumatic fever, but with evidence of existing streptococcal infection (Jon's criteria).

  • Carditis - Indicated by-heart murmur from mitral of aortic regurgitation of mitral stenosis, cardiomegaly and congestive heart failure and pericrditis.
  • Polyarthritis -Most common finding in rheumatic fever, Swelling, redness, heart, tenderness, pain and limitation of the larger joints, Arthralgia-affecting one joint and then moving to another .More dominant feature in adults.
  • Sydenham 3 Chorea - Characterized by weakness, ataxia and spontaneous, rapid and purposeless choric movements. Female under 18 years of age are primarily affected.
  • Erythema Marginatum - Less common feature-transitory bright-pink map-like lesions occur mainly on trunks, inner aspects of upper arm and thigh.
  • Subcutaneous Nodules Firm, small, hard painless swelling found over the body prominences of knees, elbows, spine and scapulae.

Laboratory Findings -

  • Antistreptolysin 0 titre (ASLO) -More than 250 IU/ml. (most specific test)
  • ESR  >15 mm/hr in male, > 20 rnm/hr in female
  • C-reactive protein - Positive
  • Throat Culture - Positive for Beta-Hemolytic streptococci
  • WBC count -Increased

Diagnosis -

  • History and Physical examination.
  • John's criteria.-Provide guidelines for the diagnosis of rheumatic fever. (2 major or 1 major and 2 minor)

Major manifestation-

  1. Carditis
  2. Polyarthritis
  3. Chorea
  4. Erythema marginatum
  5. Subcutaneous nodules

Minor Findings-

Clinical findings-

  1. Previous rheumatic fever or rheumatic heart disease.
  2. Arthralgia
  3. Fever associated with weakness, malaise weight loss and anorexia.

Laboratory findings-

  1. Elevated ESR, C-reactive protein and Leukocytosis.
  2. ECG and Echocardiogram to confirm rhythm problem and structural change.
  3. Chest X- ray show enlargement heart.

Evidence of Group A- streptococcal infection-

  1. Positive throat culture for strep A
  2. Elevated or rising anti-streptococcal antibody titer
  3. Recent scarlet fever
  • Echocardiogram show valvular insufficiency.
  • Chest X-ray cardiomegaly if CHF present.
  • ECG-prolonged PR interval.
  • Laboratory findings.

Treatment -

  • No specific treatment to cure rheumatic fever.
  • Antibiotics and administered to control infection.
  • Procaine penicillin 600,000 units IM for lodays, Benzathine penicillin.
  • 1.2 million unit IM every two or three weeks.
  • Acetylsalicylic acid-in case of arthritis.
  • Corticosteroids-if carditis is present.
  • Promote comfort-Client with arthritic manifestation obtain relief with salicylates.
  • Bed rest is usually prescribed to reduce cardiac effort until evidence of inflammation has subsided.

Surgical Managements-  

  • Commissurotomy - A commissurotomy is a surgical incision of a commissure in the body, as one made in the heart at the edges of the commissure formed by cardiac valves, or one made in the brain to treat certain psychiatric disorders.
  • In patient with critical stenosis, Mitral valvulotomy, Percutaneous balloon Valvuloplasty, or mitral valve replacement.

Nursing Management-

The overall goals are that patient with RH fever will resume daily activities without Joint pain, reduce the risk of residual cardiac disease, and plan and implement primary prgventive measures through health education and prophylaxis.

Long acting penicillin or its substitute to be continued for life in individuals who had rheumatic carditis. Individuals with repeated throat infection need to I continue prophylactic penicillin up to 30 years of age.

Assessment-

  • Assess the past and present history of illness, sore throat, rheumatic fever and treatment received previously. '
  • Family history of rheumatic fever.
  • Socio-economic status.
  • Physical examination-kystem-wise, signs and symptoms.
  • Rewrds and Reports.

Nursing Interventions-

  • Primary goals in acute rheumatic fever are:
  • Control and eradication of the infecting organism.
  • Prevent cardiac complications.
  • Relieve joint pain, fever and other symptoms.
  • Support patient psychologically and emotionally.

Care of Patient -

  • Administer antibiotics as prescribed.
  • Care of the IV line maintained for medicine administration.
  • Provide optimal rest to reduce the cardiac workload and diminish metabolic needs of the body.
  • Tepid sponge and antipyretics to relieve fever.
  • Monitor vital signs regularly.
  • Oral fluids, monitor intake output.
  • Ambulate patient after acute symptoms have subsided, if'without carditis. If patient has carditis with CHF, bed rest till anti-inflammatory therapy is completed. Gradual ambulation.
  • Relief of joint pain. Position the painful joints with comfort and proper alignment. May use a bed cradle to take the weight off the joints, of the top bed clothes. Disprin is administered to relieve pain.
  • Safety measures.
  • Psychological and emotional support because children and young adults are the patients.

Preventive Measure -

Primary prevention

Early detection and treatment of group "A" b-hemolytic streptococcal pharyngitis. Penicillin is the commonly prescribed drug. Educate the patient about the consequences of untreated sore throat and the need for appropriate treatment.

Secondary prevention

Focuses on the use of prophylactic antibiotics to prevent recurrent rheumatic fever, usually with long acting penicillin IM every 21 days. This has to be continued indefinitely for patient with carditis. Teach about the importance of hygienic and healthy living.

 

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