RHEUMATIC HEART DISEASE Clinical Manifestations: 1. Symptoms of streptococcal pharyngitis may precede rheumatic symptoms.

a) Sudden onset of sore throat; throat reddened with exudates. b) Swollen tender lymph nodes at angle of jaw c) Headache and fever 101 to 104F (38.9 to 40C) d) Abdominal pain (children) e) Some cases of streptococcal throat infection are relatively asymptomatic 2. Warm and swollen joints (polyarthritis) 3. Chorea (irregular, jerky, involuntary, unpredictable muscular movements) 4. Erythema marginatum (transient meshlike macular rash on trunk and extremities in about 10% of patients) 5. Subcutaneous nodules (hard, painless nodules over extensor surfaces of extremities; rare) 6. Fever 7. prolonged PR interval demonstrated by ECG 8. heart murmurs; pleural and pericardial rubs Diagnostic Evaluation: 1. Throat Culture- to determine presence of streptococcal organisms 2. Sedimentation rate, WBC count and differential, and CRPincreased during acute phase of infection 3. Elevated Antistreptolysin- O (ASO) titer 4. ECG prolonged PR interval or heart block Management: 1. Antimicrobial therapy- penicillin is the drug of choice a) Note that missed doses of antibiotics due to the patients unavailability while off the unit for diagnostic tests are given after return to the unit. b) Missed antibiotic doses may have irreversible deleterious consequences. c) Notify health care provider if doses will be missed to make sure that appropriate alternative measures are taken. 2. Rest- to maintain optimal cardiac fuction 3. Salicylates or NSAIDs- to control fever and pain 4. Prevention of recurrent episodes through long-term pernicillin therapy for 5 years after initial attack in most adults; periodic prophylaxis throughout life if valvular damage.

Nursing Interventions Reducing Fever 1. Administer penicillin therapy as prescribed to eradicate hemolytic streptococcus. 2. Give salicylates or NSAIDs as prescribed to suppress rheumatic activity by controlling toxic manifestations, to reduce fever, and to relieve joint pain. 3. Perform TSB to lower patients body temperature. 4. Encourage increase in fluid intake as tolerated unless contraindicated. 5. Assess for effectiveness of drug therapy a. Take and record temperature at regular intervals b. Evaluate patients comfort level. Maintaining Adequate Cardiac Output 1. Assess for signs and symptoms of acute rheumatic carditis. a. Be alert to patients complaints of chest pain, palpitations, and/or precordial tightness b. Monitor for tachycardia (usually persistent when patient sleeps) or bradycardia c. Be alert to development of second-degree heart block or Wenckebachs disease (acute rheumatic carditis causes PR interval prolongation) 2. Auscultate heart sounds a regular interval. a. document presence of murmur or pericardial friction rub b. Document extra heart sounds (S3 gallop, S4 gallop) 3. Monitor for development of chronic rheumatic endocarditis, which may include vulvar disease and heart failure. Maintaining Activity 1. Maintain bed rest for duration of fever or if signs of active carditis are present. 2. Provide ROM exercise program 3. Provide diversional activities that prevent exertion Patient Education and Health Maintenance 1. Counsel to patient to maintain good nutrition. 2. . Counsel patient on hygienic practices. a. Discuss proper hand washing, disposal of tissues, laundering of handkerchiefs (decrease risk of exposure to microbes) b. Discuss importance of using patients own toothbrush, soap, and washcloths when living in group situations. 3. Counsel patient on importance in receiving adequate rest.

4. Instruct patient to seek treatment immediately should sore throat occur 5. Support patient in long-term antibiotic therapy to prevent relapse 6. Instruct patient with vulvar disease to use prophylactic penicillin therapy before certain procedures and surgery