Rheumatic heart disease, nursing prespective

1. Rheumatic Heart Disease
Moderator Presenter
Mr. L Gopichandran Esther Mary Mathew
Lecturer, M.Sc Nursing 1st yr
CON, AIIMS. CON, AIIMS.

2. OBJECTIVES
Define rheumatic fever and rheumatic heart disease.
Describe the aetiology, risk factors, clinical manifestations,
diagnostic criteria and management of RF
Explain the pathophysiology and symptoms in RHD.
Explain the management of RHD.
Describe the nursing management.
Describe about preventive methods.

3. INTRODUCTION
• Rheumatic heart disease (RHD) is the most common
acquired heart disease in children, especially in
developing countries.
• RHD is a chronic heart condition caused by rheumatic
fever that can be prevented and controlled.

4. WHAT IS
RHEUMATIC FEVER ?

5. RHEUMATIC FEVER
• Rheumatic fever is an immunologically mediated
inflammatory disorder, which occurs as a sequel to
group A streptococcal pharyngeal infection.
• Multisystem disease affecting connective tissue
particularly of the heart, joints, brain, cutaneous and
subcutaneous tissues
• RF – not a communicable disease but results from a
communicable disease (streptococcal pharyngitis).

6. • RF  RHD (rheumatic heart disease);
a crippling disease.
• Epidemiological point of view these cannot be
separated.
[WHO CHRONICLE 1969]
• RF and RHD  diseases of the poor most prevalent
in underdeveloped and developing countries.
• The clinical course of rheumatic fever involves a
childhood infection with complications in adulthood
(cardiac defect).

7. EPIDEMIOLOGY
• RF and RHD is the most common cause of heart
disease in 5-30 age groups throughout the world.
• It accounts for 12-65% of hospital admissions related
to CVD in developing countries.

8. IN INDIA
• RHD is prevalent in range of 5-7/1000 in 5-15 age
groups.
• About 1 million cases of RHD
• RHD constitutes 20-30% hospital admissions due to
CVD.
• Streptococcal infections common in children living in
under –privileged conditions and RF accounts for 1-
3% of the cases.

9. • Age: 6-15 years
• Untreated streptococcal infection
• Familial predisposition
• Over crowding
• Poverty ,Poor hygiene
• Lack of access to medical care
RISK FACTOR

10. CAUSES
• Everyday oral activities. Activities such as brushing your
teeth or chewing food can allow bacteria to enter your
bloodstream
• An infection or other medical condition. From an
infected area, such as a skin sore. Gum disease, a
sexually transmitted infection.
• Weakened immune system
• Certain dental procedures. Some dental procedures
that can cut your gums may allow bacteria to enter your
bloodstream.

11. PATHOGEN
• S. Pyogenes also known as Group A Streptococcus
(GAS) is the causative agent in Group A Streptococcal
infections including Streptococcal pharyngitis, acute
rheuamtic fever , scatlet fever, and acute
glomerulonephritis.

12. PATHOPHYSIOLOGY

13. • Based on currently based evidence, RF is caused
by group A streptococcal (GAS) pharyngeal
infection.
• Postulated that series of preceding streptococcal
infection is needed to prime the immune system
prior to final infection that directly causes the
disease.
• Group A strep pharyngeal infection
precedes clinical manifestations of
ARF by 2 - 6 weeks.
PATHOPHYSIOLOGY

14. • Body produce antibodies against streptococci .
• These antibodies cross react with human tissues
because of the antigenic similarity between
streptococcal components and human connective
tissues (molecular mimicry) [there is certain
amino acid sequence that is similar btw GAS and human tissue]
• Immunologically mediated inflammation & damage
(autoimmune) to human tissues which have antigenic
similarity with streptococcal components- like heart,
joint, brain connective tissues
PATHOPHYSIOLOGY

15. CLINICAL FEATURES

16. STREPTOCOCCUS SORE THROAT
• Tender lymph nodes
• Strawberry tounge
• Excoriated nares( crusted lesions) in infants
• Tonsillar exudates in older children
• Abdominal pain
• More common in winter/ rainy season.

17. Clinical features of RF
• Streptococcal sore throat with
fever
• Recurrence of fever with
manifestation of acute rheumatic
fever
• Shortness of breath

18. FEATURES
Following upper airway infection with GAS
Silent period of 2 - 6 weeks
Sudden onset of fever, pallor, malaise, fatigue.
Commonly GAS streptococcal infection is
subclinical; such cases confirmed using streptococcal
antibody testing .

19. • There is no definitive test.
• Diagnosis of ARF relies on presence of combination of
typical clinical features together with evidence of the
precipitating GAS infection .
• This uncertainty led Dr.T.Duckett Jones in 1944 to
develop a set of criteria Jones Criteria to aid
diagnosis.
• Now Diagnosis based on MODIFIED JONES
CRITERIA .

20. Major criteria: oint
• Migratory polyarthritis of large joint
• Usually >5 joints affected and mainly large joints
Knees, ankles, wrists, elbows, shoulders
• Redness, warmth, swelling, pain , movement limitation
• Quick to appear, lasts 3- 7 days, subside and appear
in other joint.
• Respond to salicylates and NSAIDS
• Commoner in older patients.
• Small joints and cervical spine less commonly
involved.

21. Major criteria: Carditis
• Early manifestation 90% (within 2 weeks of onset)
• Pancarditis
▫ Pericarditis : precordial pain, friction rub, ST and T
changes
▫ Endocarditis: pansystolic murmur of MR w/wo AR
murmur
▫ Others : cardiac enlargement, soft S1, S3 gallop,
congestive cardiac failure,
Carditis is the only manifestation of rheumatic fever
that leaves a sequelae & permanent damage to the
organ

22. Major criteria: odules
• Late manifestation 3- 20% ( 6 weeks after onset of
RF)
• Non- tender subcutaneous nodules on bony
prominence
• Small, painless, mobile hard lumps beneath skin.
• Most common along -
extensor surfaces of joint-Knees, elbows, wrists
• Also: on bony prominences, tendons, dorsi of feet,
occiput or cervical spine.
• Pinhead to almond size
in

23. Nodules -Firm, non-tender, isolated or
in clusters

24. Major criteria:
rythema marginatum
• Early manifestation <3%
• Erythematous, serpiginous, non-pruritic, macular
lesions with pale centre.
• Pink macules - Clear centrally ,serpiginous spreading
edge. (has slightly elevated red margins)
• More on trunks & limbs, Almost never on face.
• Worsens with application of heat.
• Often associated with chronic carditis.

26. Major criteria :
ydenham’s Chorea
• Neurological manifestation of rheumatic fever
• Late manifestation 10-15% ( 3 months after onset)
• Semi- purposeful , jerky movements  deranged
speech, muscular incoordination, facial grimacing
▫ Exacerbated by stress and disappears with sleep
• More common in females
• Clinical maneuvers to elicit chorea:
▫ Demostrate milkmaid’s grip
▫ Handwriting examination
• Self- limiting ( 2-6 weeks)

27. • FEVER
• Present at onset of acute illness
• High grade fever >39ºC
• Lasts for about 12 weeks, tends to
recur.
• Alternates with normal temperature.
• Weakness ,malaise , weight loss ,
anorexia
MINOR CRITERIAS

28. MINOR CRITERIAS
Arthralgia
• Pain in one or more joints
• Without the presence of arthritis
• Epistaxis
• Abdominal pain

29. LAB DIAGNOSIS
• High ESR
• Anemia, leucocytosis
• Elevated C-reactive protien
• Elevated ASO or other streptococcal antibody titer
• Anti-DNase B test
• Throat culture-GABH streptococci
• ECG: prolonged PR interval

30. DIAGNOSIS- YOU SHOULD HAVE
• 2 Major + Essential criteria
OR
• 1 Major+2 Minor + Essential criteria
Along with evidence of streptococcal infection

31. OTHER FEATURES
• Aschoff bodies are nodules found in the hearts of
individuals with rheumatic fever. They result from
inflammation in the heart muscle .
•
Aschoff cells

32. Diagnostic Categories Criteria
Primary episode of rheumatic fever Two major or one major and two minor
manifestations plus evidence of preceding
group A streptococcal infection
Recurrent attack of rheumatic fever in a
patient without established rheumatic heart
disease
Two major or one major and two minor
manifestations plus evidence of preceding
group A streptococcal infection
Recurrent attack of rheumatic fever in a
patient with established rheumatic heart
disease
Two minor manifestations plus evidence of
preceding group A streptococcal infectionc
Rheumatic chorea Other major manifestations or evidence of
group A streptococcal infection not requiredInsidious onset rheumatic carditis
Chronic valve lesions of rheumatic heart
disease (patients presenting for the first
time with pure mitral stenosis or mixed
mitral valve disease and/or aortic valve
Do not require any other criteria to be
diagnosed as having rheumatic heart disease
2002–2003 World Health Organization Criteria for the Diagnosis
of Rheumatic Fever and Rheumatic Heart Disease (Based on the
1992 Revised Jones Criteria)

33. Major manifestations Carditis
Polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodules
Minor manifestations Clinical: fever, polyarthralgia
Laboratory: elevated erythrocyte
sedimentation rate or leukocyte counte
Electrocardiogram: prolonged P-R interval
Supporting evidence of a preceding
streptococcal infection within the last 45
days
Elevated or rising anti-streptolysin O or
other streptococcal antibody, or
A positive throat culture, or
Rapid antigen test for group A
streptococcus, or
Recent scarlet fevere

34. Antibiotic therapy:-
Oral penicillin 500 mg BD x 10 days OR
 A single dose of Benzathine penicillin 1.2 million
units I/M
 Tab. Erythromycin 250 mg BD x 10 days(in case
of penicillin allergy)
(the patient should be started on long-term antibiotic
prophylaxis)

35. Contd…
• Arthritis , arthralgia : Salicylates or NSAIDS (eg: aspirin)
80-100 mg/kg/day in 4-5 divided doses x 3-5wks
• Severe carditis :- Corticosteroids ( prednisolone 1-2 mg
/kg/day ;max 60 mg x 4-6 wks, then taper20-25 mg/wk)
• Sydenham’s Chorea :-
▫ Haloperidol -0.5mg/kg/day
▫ Carbamazepine or sodium valproate -15-20
mg/kg/day x1-2 wks

36. • Rheumatic fever can recur whenever the individual
experience new GABH streptococcal infection, If not
on prophylactic medicines.
• Good prognosis for older age group & if no carditis
during the initial attack
• Bad prognosis for younger children & those with
carditis with valvar lesions
PROGNOSIS

37. RHEUMATIC HEART
DISEASE
• Rheumatic heart disease is an immunologic disease
characterized by valvular damage or dysfunction followed
by one or more episodes of rheumatic fever caused by
pharyngeal infection with GAB hemolytic streptococci.
• Rheumatic Heart Disease is the permanent heart valve
damage resulting from one or more attacks of ARF.
• It is thought that 40-60% of patients with ARF will go on to
developing RHD.
• Sadly, RHD can go undetected with the result that
patients present with debilitating heart failure.

38. RHEUMATIC HEART DISEASE
• RHD is the result of damage to the heart valves which
occur after repeated episodes of ARF
• The order of frequency of involvement depends on the
hemodynamic stress placed on the various chambers
• Thus the order is mitral> aortic > tricuspid> pulmonic
• Valve incompetence is more common than stenosis
65-70% 20-25% 10% Rarely

39. The extent of the damage
depends on the heart area that
the disease strikes

40. PATHOPHYSIOLOGY
Causative agent
Group A Beta-hemolytic streptococci
Untreated strep throat
Rheumatic fever
All layers of the heart and the mitral valve become inflammed
Vegetation forms
Valvular Regurgitation
and stenosis
Heart Failure

41. Normal valve is
Transparent,
avascular, thin
flexible membrane.
RHD: Thick, fibrous
scarred stenotic &
fixed (MS/MR) with
Blood Vessels.
THE DIFFERENCE

42. High pulse
rate
Murmur
mitral or aortic regurgitation-endocardium
involved
Cardiomegaly myocardium involvement
Pericardial
friction rub Pericarditis
Prolonged
PR interval
Myocardial inflammation affecting
electrical conduction
Cardiac
failure

43. VALVE INVOLVEMENT IN RHD

44. VALVE CHANGES
• Leaflet thickeninig
• Commissural fusion
• Shortening and thickening of chordae
• Orifice is narrowed

45. VALVE INVOLVEMENT IN RHD
• MITRAL Valve is affected in 60 – 70% of cases
 Mitral regurgitation most commonly found in
children and adolescent.
 Mitral stenosis represent longer term chronic
disease, commonly in adults.
 Most common complication in mitral stenosis is
atrial fibrillation.

46. MITRAL STENOSIS

47. VALVE INVOLVEMENT IN RHD
• AORTIC Valve next most commonly affected
 Generally associated with diseases of the mitral
valve.
 Aortic stenosis is one of the most common and
most serious valve disease problems in elderly
population.
• Tricuspid and pulmonary valves re much less
commonly affected
 Usually affected in very severs RHD when all
valves are affected.

49. RESEARCH INPUT
Screening for rheumatic heart disease: quality and
agreement of focused cardiac ultrasound by briefly
trained health workers.
BMC cardiovascular disorders 2016
AIM: to evaluate the quality and agreement of FoCUS for valvular
regurgitation by briefly trained health workers.
Methods: Seven nurses participated in an eight week training
program in Fiji. Nurses performed FoCUS on 2018 children
aged 5 to 15 years, and assessed any valvular regurgitation.
An experienced pediatric cardiologist assessed the quality of
ultrasound images and measured any recorded regurgitation.
The assessment of the presence of regurgitation and
measurement of the longest jet by the nurse and cardiologist
was compared.

50. RESEARCH INPUT
Results: The quality of FoCUS overall was adequate for
diagnosis in 96.6 %. There was substantial agreement between
the cardiologist and the nurses overall on the presence of mitral
regurgitation (κ = 0.75) and aortic regurgitation (κ = 0.61) seen
in two views. Measurements of mitral regurgitation by nurses
and the cardiologist were similar (mean bias 0.01 cm; 95 %
limits of agreement −0.64 to 0.66 cm).
Conclusions: After brief training, health workers with no prior
experience in echocardiography can obtain adequate quality
images and make a reliable assessment on the presence and
extent of valvular regurgitation

51. • Congestive heart failure
• Infective endocarditis
• Arrhythmias mainly atrial fibrillation
• Embolic episodes
• cardiomegaly
COMPLICATIONS

52. MEDICAL- digoxin, diuretics, antibiotic prophylaxis,
control arrythmias.
SURGICAL- closed mitral commisurotomy, percutaneous
transluminal ballon valvuloplasty,
OTHERS –Ross procedure, bentalls procedure
TREATMENT for VALVULAR
HEART DISEASE

53. Balloon
Valvuloplasty
MITRAL
COMMISSUROTOMY

54. • Elongated leaflets
▫ Leaflet plication
▫ Leaflet resection
• Holes in the leaflets
▫ Pericardial patch repair
• Short leaflets
▫ Most often repaired by chordoplasty

55. • Repair of the chordae tendinae
• Mostly used for mitral valve
• Gore-Tex can be used to create chordae tendinae.

56. ROSS PROCEDURE

58. • Performed when valvuloplasty is not suitable
• Approached through a median sternotomy or mitral
valve (at times) – right thoracotomy incision

59. • Two types of prosthetic valves :-
▫ Mechanical valves
▫ Tissue(biologic) valves

60. ▫ Caged ball valve (Starr-Edwards)
▫ Tilting disc valve (Medtrionic-Hall)
▫ Bileaflet valve(St. Jude Medical)
▫ Trileaflet valve
Caged ball valve Bileaflet valveTilting disc valve

62. NEXT GENERATION OF
MECHANICAL VALVE: TRILEAFLET
VALVE  More
physiological
 Better
hemodynamic
s ‘central
blood flow’
 Reduced
thrombosis
risk

63. • These are animal tissue valves: pigs(porcine),
cows(bovine).
• Viability is 7-10 yrs.
• Do not generate thrombi. So no need for long term
anticoagulation.
Indications :
• Women of child bearing age
• Others who cannot tolerate long term
anticoagulation.
- patients older than 70yrs
- patients with H/O peptic ulcer disease

64. • Obtained from cadaver tissue donations
• Used for aortic and pulmonic valve replacement
• Aortic valve and a portion of the aorta / pulmonic valve
and a portion of the pulmonary artery are harvested from
the cadaver and stored cryogenically
• Non thrombogenic
• Viability – 10 to 15 years

65. • Patient’s own pulmonic valve and a portion of the
pulmonary artery excised for use as the aortic valve
(aortic valve autograft) –Ross procedure
• Anticoagulation not required as non-thrombogenic
• Viability – more than 20 years
• Most aortic valve auto grafts are double valve replacement
procedures
▫ Where pulmonic valve is replaced with a homograft

66. • More durable
• Can be used if the patient
has hypercalcemia,
endocarditis or sepsis.
• Do not deteriorate or
become infected as easily
as the tissue valves.
•Life long anticoagulation with
warfarin required.
•Increased risk of thrombo
embolism.
•Not suitable for women of
child bearing age.

67. SELECTION OF AN ARTIFICIAL
VALVE
• RISK BENEFIT RATIO
• MULTIFACTORIAL
▫ Age
▫ Site of involvement
▫ Special situation(Pregnancy, Associated cardiac
abnormalities)
▫ Patient’s preference(Anticoagulation, regular
follow up)

68. FACTORS
• Age
>65 years : bioprosthesis
<65 years : mechanical
• Anticoagulation
Ready : mechanical
No / contraindication : bioprosthesis
• Prosthesis
mechanical at other site : mechanical
Reoperation / Infective endocarditis : bioprosthesis

69. FACTORS
oSpecial
women of child bearing age : bioprosthesis
Small aortic annulus : stentless bioprosthetic

71. PREVENTION

72. PREVENTION
PRIMARY-10 days
course of penicillin
therapy;
SECONDARY-
Secondary prevention
is directed at
preventing acute
GABHS pharyngitis in
patients at substantial
risk of recurrent
acute rheumatic fever

73. PRIMARY PREVENTION
 Detection and Mx. of streptococcal throat infection.
 Antibiotic prophylaxis in highly prevalent areas with
Benzathine penicillin.
 Promote health :-improve living conditions, hygiene,
avoid over crowding, access to medical facilities,
education

74. PRIMARY PREVENTION
• AIM ; Prevent the first attack of RF, by identifying all patients
with streptococcal throat infection and treating them with
pencillin.
• Theoretically simple , in practise its difficult, not feasible.
• Many infections are in apparent or if apparent are not brought
to attention of health services.
• VIABLE APPROACH; concentrate on high risk groups ie
school age children.

75. Secondary Prevention of Rheumatic Fever
(Prevention of Recurrent Attacks)
Agent Dose Mode
Benzathine penicillin G 1 200 000 U every 3 weeks* Intramuscular
or
Penicillin V 250 mg twice daily Oral
For individuals allergic to penicillin and sulfadiazine
Erythromycin 250 mg twice daily Oral
Recommendations of American Heart Association

76. Duration of Secondary Rheumatic Fever
Prophylaxis
Recommendations of Am erican Heart Association
Category Duration
Rheumatic fever without carditis At least 5 y or until age 18 y,(whichever
is longer)
Rheumatic fever with carditis and
heart disease (persistent valvular
disease*)
At least 10 y since last residual
episode and at least until age 40 y
sometimes lifelong prophylaxis
RF with carditis disease but no residual
heart disease (no valvular disease*)
Rheumatic fever 10 y or well into
adulthood (whichever is longer )
More severe valvular disease Post-
valve surgery cases
*Clinical or echocardiographic
evidence.
Lifelong
Recommendations of American Heart Association

77. Supportive management &
management of complications
• Bed rest
• Treatment of congestive cardiac failure:
-digitalis, diuretics
• Treatment of chorea:-diazepam or haloperidol
• Rest to joints & supportive splinting

78. PENICILLIN PROPHYLAXIS IS
NOT EASY!!!!
• Give the test dose of penicillin injection every time
the patient comes for the injection. Give the
injection deep I/M.
• The most serious adverse effect of penicillin is
anaphylaxis.
• The most common side effects are diarrhea,
maculopapular rash, urticarial rash, fever,
bronchospasm, vasculitis, , and exfoliative
dermatitis.

79. PATIENT MONITORING
• Keep epinephrine and emergency equipment at hand
in case of anaphylaxis.
• Watch closely for anaphylaxis and serum sickness.
• In long-term therapy, monitor electrolyte levels and
CBC.
• Assess neurologic status, especially for seizures and
decreasing level of consciousness.
• Watch for evidence of super infection

80. PATIENT TEACHING
• Teach patient to recognize anaphylaxis
symptoms and to contact emergency
medical services immediately.
• Tell patient drug may cause diarrhoea.
• Tell female patient that drug may make
hormonal contraceptives ineffective.
Advise her to use barrier birth control if
she wishes to avoid pregnancy.

81. NON- MEDICATED MEASURES
• Improvement of living standards.
• Breaking the poverty –disease –poverty cycle.
• Improvements in socio-economic conditions.

83. Ineffective breathing pattern R/T
altered hemodynamics
• Assess the alteration in lung function like hypoxemia,
atelectasis, abnormal lung sounds, work of breathing etc..
• Monitor ABG
• Position properly for maximum lung expansion.
• Administer O2 therapy.
• Teach deep breathing and coughing.
• Schedule activities to conserve energy.
• Medications for pain to prevent tachypnea

84. Fluid volume excess R/T CHF
• Observe and assess clinical signs that indicate
impending or present heart failure.
• Monitor patient’s intake and output.
• Weigh the patient daily.
• Take abdominal girth measurements if abdominal
distention or ascitis is present.

85. Cont…
• Evaluate the patients heart sound for a changed
or a new murmur.
• Evaluate patients lung sound for presence of
rales.
• Provide rest periods, administer prescribed
medications

86. Decreased CO R/T altered hemodynamics as
manifested by fatigue, dizziness or syncope
• Assess, document and report signs of decreased CO such
as decreased systolic BP, increased HR, presence of
murmurs, decrease urine out put, cool clammy skin etc..
• Position the patient properly.
• Administer medications as prescribed.
• Explain the need to limit activities.

87. Potential for impaired skin integrity R/T
edema, immobility etc..
• Observe the condition of the skin.
• provide pressure relieving mattresses.
• Frequent position changes.
• Provide skin care.
• Encourage adequate hydration and nutrition.
• Encourage ambulation if patient is able.

88. Potential for bleeding R/T
anticoagulant therapy
• Assess s/s of bleeding.
• Assess the patient for high risk for bleeding conditions like
liver disease, kidney disease, severe HTN.
• Obtain coagulation profile-PTT, aPTT, INR etc..
• Institute safety precautions.
• Avoid injury, I/M injections.

89. Anxiety R/T change in health condition,
increase in respiratory difficulty, fear of
death etc..
• Assess the level of anxiety.
• Encourage patient to ventilate feelings of anxiety.
• Assess the patient’s normal coping mechanisms.
• Support previously effective coping mechanisms.
• Give information to the patients regarding their health
status, plan of Mx, prognosis etc..

90. Knowledge deficit R/T anticoagulant therapy,
continuing care at home and follow up
• Explain the patient the importance of compliance to
medications such as anticoagulants.
• Advice the patient to report immediately if bleeding
occurs.
• Advice the patient to refrain from any activities that
can cause trauma.
• In case of young females who are on anticoagulant
therapy, tell them to report to physician if they are
planning pregnancy or if pregnancy is suspected.

91. Cont….
• Diet- do not take vitamin k rich food(green leafy
vegetables).
• Tell the patients the importance of checking PT and INR
frequently.
• Explain the importance of antibiotic prophylaxis for RF and
also IE.
• Explain the patient the importance of follow up visits.

92. Cont….
• Patient should report to physician in case of any recurring
symptoms or if any s/s of infection develops.
• Patients with mechanical valves should be told to listen to
the sound produced by the valves and report in case of
any absent sounds or abnormal sounds.

93. RESEARCH INPUT
Awareness of rheumatic heart disease in patients
suffering from rheumatic heart disease
OBJECTIVE: To determine the degree of awareness about
the different aspects of rheumatic heart disease in patients
STUDY DESIGN AND DURATION: Questionnaire based
survey.
METHODS: A total of 200 commutative patients of either
sex between 12-80 years of age, suffering from Rheumatic
Heart Disease coming to Faisalabad Institute of
Cardiology were included in the study.

94. RESEARCH INPUT
RESULTS: Out of 200 patients included in the survey, Majority of
the patients (78%) belonged to villages whereas 22% patients
belonged to cities.
Only 5% of the patients were aware that sore throat is a
precipitating factor for Rheumatic Heart Disease. 58% of the
patients were aware of prolonged oral anticoagulation and
antibiotic prophylaxis after undergoing surgery.
CONCLUSIONS: The patient population is lacking awareness
about Rheumatic Heart Disease and treatment options
available which has a profound effect on the incidence,
morbidity and mortality of the disease.

95. Ensuring that patients
understand their disease, are
informed regarding their
future and receive secondary
prophylaxis
EDUCATION
Health education is critical at all levels
Lack of parental awareness of the causes and
consequences of ARF/RHD is a key contributor
to poor adherence amongst children on long-term
prophylaxis

96. KEY MESSAGE

97. SUMMARY
• Rheumatic fever
• Different risk factors
• Diagnostic Criteria for Rheumatic fever
• Treatment for Rheumatic fever
• Rheumatic disease
• Pathophysiology of RHD
• Clinical manifestations of RHD
• Medical management RHD
• Nursing management of RHD
• Prevention of RHD

98. REFERENCES
• Suzanne C , Brenda G. Textbook of medical surgical
nursing,2003;9
• Black J M, Hawks J H . Medical surgical
nursing,2005;7
• Woods S L .Cardiac nursing,1995;3;847-850
• www.medicalcriteria.com
• www.wikipedia.com
• www.emedicine.medscape.com