Management of Rheumatic Fever (2nd Year, Medical-Surgical)

# Management of Rheumatic Fever ## 2nd Year First Semester, Medical-Surgical ### Objectives: 1. Define Rheumatic fever & heart disease. 2. Identify etiology of Rheumatic fever. 3. Describe predisposing factors for Rheumatic fever. 4. List clinical manifestation of Rheumatic fever. 5. State all di...

# Management of Rheumatic Fever ## 2nd Year First Semester, Medical-Surgical ### Objectives: 1. Define Rheumatic fever & heart disease. 2. Identify etiology of Rheumatic fever. 3. Describe predisposing factors for Rheumatic fever. 4. List clinical manifestation of Rheumatic fever. 5. State all diagnostic measures of Rheumatic fever. 6. Explain medical and pharmacological management of Rheumatic fever. ### Rheumatic Fever #### Definition: Rheumatic fever is inflammatory disease of the heart involving all layers (endocardium, myocardium &pericardium). The resulting damage to the heart from rheumatic fever is called rheumatic heart disease. A chronic condition characterized by scarring & deformity of the heart valves. #### Etiology: Acute rheumatic fever is primarily a disease of childhood; most commonly occur between the age of 5 & 15 years. The attack rate of rheumatic fever following streptococcal pharyngitis. Rheumatic fever occurs to a group A beta – hemolytic streptococcal infection of the pharynx. ### Predisposing Factors 1. Socioeconomic factors 2. Familial history 3. Over crowding 4. Neglect or inadequate treatment of streptococcal sore throats 5. Poor nutrition & a lowered state of general health. ### Cardiac involvement: - In rheumatic fever all layers of the heart can be involved (endocardium, myocardium, and pericardium). - The valves may become necrotic & insufficient. - The mitral & aortic valves are most commonly affected. - Less commonly the tricuspid valve, & rarely the pulmonic valve. ### Extra cardiac involvement: The lesions of rheumatic fever are systemic, involving especially connective tissue. - The joints polyarthritis - Skin subcutaneous nodules - Central nervous systems chorea., and lungs fibrinous pleurisy & rheumatic pneumonitis. ### Clinical Manifestation: #### Common rheumatic fever symptoms include: - Swollen, tender and red joints, especially the large joints such as the knees, ankles and elbows. - Chest pain or abnormal heartbeat. - Feeling overly tired all the time (fatigue). - Fever, Flat, red rash with a jagged edge. - Unexplained or ongoing headaches, especially if the child has never complained of head pain before. - Jerky movements patient can't control in his/her hands, feet or other body parts. - Muscle aches or painful, tender joints. - Small bumps under the skin. - Swollen, red tonsils. If two major & one minor criteria or one major & two minor criteria are present, the diagnosis of rheumatic fever is usually made. - **Polyarthritis** is migratory, usually affecting joints, the joints are red, swollen, warm, & tender pain prevents the person from walking. - **Chorea** is a disorder of CNS characterized by weakness, ataxia, in coordination & sudden involuntary girts. - **Erythema marginatum:** is a pinkish red recurring rash originating on the trunk which may spread to other body parts. - **Subcutaneous nodules:** are small hard painless swellings found most commonly over body prominences (e.g. knee, elbows, spine, scapula). ### Diagnostic Measures: 1. Antistreptolysin-o titer (ASLO titer) 250 IU/ml. 2. Erythrocyte sedimentation rate 15mm / 1h 50mm / 2h. 3. C- reactive protein ----- positive. 4. Throat culture ----- may be positive for streptococcal most commonly is negative 5. White Blood Cell counts ----- Elevated. ### Complication of Rheumatic fever: - Chronic rheumatic heart disease as a complication that can result from acute rheumatic fever. - Changes in valvular structure which may occur month to years after an attack of acute rheumatic fever. ### Medical &pharmacological management: #### Diagnosis through: 1. History & physical examination 2. ASLO Titer 3. Throat culture. 4. Erythrocyte sedimentation rate 5. C- reactive protein. 6. White blood cell count. 7. Chest x- ray. 8. Echocardiography. #### Medical Management: 1. Bed rest 2. Benzathin penicillin 1.2 million units or procaine penicillin 600.000 units IM daily for 10 days. Penicillin is used to treat any residual beta hemolytic streptococcal infection. 3. Acetyl-salicylic acid (ASA) is used to treat the clinical manifestation of inflammation. 4. Corticosteroids are used as nonspecific anti -inflammatory agents if aspirin is not effective. ### Nursing Management: #### Health promotion &maintenance: Prevention of rheumatic fever is frequently classified as primary & secondary. #### Primary prevention involves: 1. Early detection & immediate treatment of group A beta- hemolytic streptococcal pharyngitis 2. Adequate treatment of streptococcal pharyngitis will prevent initial attacks of rheumatic fever. #### Secondary prevention: 1. The use of prophylactic antibiotic to prevent recurrent rheumatic fever. 2. The best prophylactic treatment should continue for life in individuals who developed rheumatic carditis as children 3. The best prophylactic treatment is monthly injections of benzathine penicillin G. 4. If a person with known rheumatic heart is having any dental procedures or surgical procedures of the upper respiratory, gastrointestinal or genitourinary tract, prophlaxis is necessary. ### Acute Intervention: 1. Provide &encourage optimal rest. 2. Avoid over activities 3. Painful joints should be positioned for comfort & good alignment. It may be necessary to remove the weight of covers from painful joints by using bed cradle 4. Heat may be applied to the joist pain relief. 5. Psychological& emotional care can be more important than physical care. ### Chronic Management: 1. The patients' needs to be taught about the disease process, the possible sequel of rheumatic fever & the continual needed for prophylactic antibiotics 2. The patient needs to be aware of the possibility of developing valvular heart disease. 3. The patient should be taught to seek medical attention if symptoms appear such as excessive fatigue, dizziness, palpitations, or dyspnea on exertion develops. # Heart Failure ## 2nd Year First Semester, Medical-Surgical Heart failure is a clinical syndrome that results from the progressive process of alteration, in which mechanical and biochemical forces alter the size, shape, and function of the ventricle's ability to fill and pump enough oxygenated blood to meet the metabolic demands of the body. ### Left-Sided Heart Failure: Altering the filling and pumping function of left ventricle, congestion occurs mainly in the lungs from blood backing up into pulmonary veins and capillaries. * Shortness of breath, dyspnea on exertion, tachypnea, orthopnea, cyanosis, pulmonary edema, and hemoptysis. * Cough-may be dry, unproductive; usually occurs at night. * Fatigability from low CO, nocturia, insomnia, dyspnea, catabolic effect of chronic failure. * Insomnia, restlessness. * Tachycardia. ### Right-Sided Heart Failure Altering the pumping function of right ventricle, there are signs and symptoms of elevated pressures and congestion in systemic veins and capillaries. * Edema of ankles; unexplained weight gain (pitting edema is obvious only after retention of at least [4.5 kg] of fluid) * Liver congestion—may produce upper abdominal pain * Distended jugular veins, increased CVP, pulmonary hypertension * Abnormal fluid in body cavities (pleural space, abdominal cavity), splenomegaly * Anorexia and nausea—from hepatic and visceral engorgement * Nocturia: diuresis occurs at night with supine position. * Weakness ### Does Left-Sided Heart Failure Lead To Right-Sided Heart Failure? * Left-sided heart failure occurs when the left ventricle of the heart is weakened and cannot as efficiently pump blood into the body. As a result of the diminished ejection fraction, fluid can flow back into the lungs and put additional stress on the right side of the heart. This can lead to right-sided heart failure. ### What Causes of Heart Failure? Heart failure often occurs after another condition has weakend the heart. Any of the below conditions can weaken the heart and cause heart failure: * Coronary artery disease and heart attack * High blood pressure * Faulty heart valves * Damage to the heart muscle * Inflammation of the heart muscle (myocarditis) * Congenital heart defect (a heart problem you're born with) * Abnormal heart rhythms (arrhythmia) * Diabetes * HIV * Over- or underactive thyroid ### Management #### Nursing Interventions * Place patient at physical and emotional rest to reduce work of heart. * Evaluate frequently for progression of left-sided heart failure. Take frequent blood pressure readings. * Auscultate heart sounds frequently and monitor cardiac rhythm. * Observe for signs and symptoms of reduced peripheral tissue perfusion: cool temperature of skin, facial pallor, and poor capillary refill of nailbeds. * Administer pharmacotherapy as directed. * Auscultate lung fields at least every 4 hours for crackles and wheezes in dependent lung fields * Position the patient every 2 hours to help prevent atelectasis and pneumonia. * Encourage deep-breathing exercises every 1 to 2 hours to avoid atelectasis. * Offer small, frequent feedings * Administer oxygen as directed. * Give diuretic early in the morning-nighttime diuresis disturbs sleep. * Keep input and output record. Weigh patient daily. The image included a graphical representation of Left sided heart failure and right sided heart failure. The left side of the image showcased the left sided heart failure with different symptoms and the right side of the image highlighted the right sided heart failure with its symptoms. The image had two stick figures, one for each heart failure, depicting the affected areas of the body.