Patent Ductus Arteriosus
DUCTUS ARTERIOSUS
-temporary fetal blood vessel that connects the
aorta and the pulmonary artery before birth
-allows blood to bypass the deflated lungs and
go straight out to the body.
-closure usually occurs quickly, within days up
to 2 weeks after birth as levels of certain
chemicals, called prostaglandins change, and the
lungs fill with air.
PATENT DUCTUS ARTERIOSUS
- the ductus arteriosus remains open allowing
some oxygenated blood, intended for the body,
to return to the lungs
- the blood vessels in the lungs may be
overloaded and the body may not receive
enough oxygenated blood
-In most cases, a small PDA does not result in
TREATMENTS
physical symptoms. If the PDA is larger, health
Medical Management
complications may occur.
1. Conservative Management
Etiology: A patent ductus arteriosus can be
idiopathic (i.e. without an identifiable cause), or
secondary to another condition. Some common
contributing factors in humans include:
 Preterm birth
2. Drugs
 Congenital rubella syndrome
 Chromosomal abnormalities such
as Down syndrome
PATHOPHYSIOLOGY
DIAGNOSIS
 Echocardiogram
-evaluates the structure and function of
the heart by using sound waves to
produce a moving picture of the heart
and heart valves
-shows the pattern of blood flow through
the PDA, determines the size of the opening and
how much blood is passing through it.
 Chest X-ray
With a PDA, the heart may be enlarged
due to excess blood flowing through the
lungs. The extra blood flow may also
cause changes in the lungs that can be
seen on an X-ray.
 Electrocardiogram (ECG)
-records the electrical activity of the
heart, detects abnormal rhythms and
detects heart muscle stress.
 Cardiac catheterization
-gives detailed information about the
structures inside the heart. A small, thin,
flexible tube (catheter) is inserted into a
blood vessel in the groin, and guided to
the inside of the heart. Blood pressure
and oxygen levels in the four chambers
of the heart are measured, as well as in
the pulmonary (lung) artery and aorta.
Contrast dye is used to clearly visualize
the structures inside the heart.
a. fluid restriction
b. diuretic therapy
c. adequate calorie
d. ventilator support
a. Indomethacin
b. Ibuprofen
 Indomethacin
 Prostaglandins, especially E-type
prostaglandins, maintain the patency of
the ductus. Thus, inhibition of
prostaglandin synthesis by indomethacin
results in constriction of the ductus
arteriosus.
 Ibuprofen
 The mechanism of action that results in
PDA closure in neonates is not known;
however, ibuprofen is an inhibitor of
prostaglandin synthesis
 Catheter-based procedures
 Timing: usually done after neonatal
period
 Indications:
-small PDA with intra vascular coils
-moderate to large PDA with a catheter
introduced sac into which several coils are
released or with umbrella-like device
 Catheter Procedure:
 the child is sedated
 a small, thin, flexible tube is inserted into
a blood vessel in the groin and guided to
the inside of the heart
 cardiologist will pass a special device,
called a coil or occluder, into the open
PDA preventing blood from flowing
through it
 Devices used:
Amplatzer Duct Occluder- a percutaneous,
transcatheter occlusion device, intended for the
non-surgical closure of PDA
Flipper detachable embolization coil- used for
arterial and venous embolization in the
peripheral vasculature
 Surgery
Indications:
1. A premature or full-term infant with
symptomatic heart failure from PDA in
whom medical treatment has failed or
contraindicated to use of drugs
2. PDA isn’t successfully closed by a
catheter-based procedure
3. Surgery is planned for treatment of
related congenital heart defects
Timing: -usually after 6 months of age
Procedure: Ligation and division of ductus via a
thoracotomy
 Surgical repair: Ligation of PDA,
Division and oversewing of PDA
Nursing Management
PDA necessitates careful monitoring, patient and
family teaching, and emotional support.
 Watch carefully for signs of PDA in all
premature neonates.
 Be alert for respiratory distress
symptoms resulting from heart failure,
which may develop rapidly in a
premature neonate. Frequently assess
 vital signs, ECG, electrolyte levels, and
intake and output. Record response to
diuretics and other therapy.
 If the infant receives indomethacin,
watch for possible adverse effects, such
as diarrhea, jaundice, bleeding, and renal
dysfunction.
 Immediately after surgery, carefully
assess vital signs, intake and output, and
arterial and venous pressures. Provide
pain relief as needed.
 Before discharge, review instructions to
the parents about activity restrictions
based on the child’s tolerance and
energy levels.
 Stress the need for regular follow-up
examinations.
Atrial Septal Defect
 It is a hole in the wall between the two
upper chambers of the heart (interatrial
septum)
 It is a condition present from birth
(congenital heart disease)
 It is a defect with increased pulmonary
blood flow (hemodynamic classification)
 Septum – means “dividing wall”
 Ostium – means “opening”
Anatomy of the Heart
 Interatrial septum
– divides the right and left atria into separate
chambers
– arises from four structures:
1. septum primum
2. septum secundum
3. sinus venosus
4. endocardial cushion tissue
Types of Atrial Septal Defect
 Ostium Primum (ASD I) – opening at
lower end of septum, associated with
mitral valve abnormalities (20%);
incomplete closure of septum primum
and endocardial cushion tissues at 5
weeks gestation
 Ostium Secundum (ASD II) –
opening near center of septum
(70%); incomplete closure of septum
primum and septum secundum at birth
(foramen ovale)
 Sinus venosus defect – opening near
junction of superior (more common) or
inferior vena cava and right atrium; may
be associated with partial anomalous
pulmonary venous connection (10%);
incomplete closure of the right horn of
sinus venosus with the superior and
inferior vena cava
Hemodynamics
 Vascular Resistance - resistance to
flow that must be overcome to push
blood through the circulatory system
Systemic circulation > Pulmonary
circulation
thus, the left ventricle must pump harder to
create a greater pressure gradient
Pressure in left side > Pressure in
right side
Prognosis
• ASDs less than 2 millimeters - has a
high probability that it will close on its
own
• ASDs that are 3-9 millimeters -
patients are asymptomatic but may
experience symptoms of complications
beginning the third decade of life
• ASDs greater than 9 millimeters –
considered large and patients are quite
symptomatic
• Prognosis after ASD closure during
childhood is excellent with a very low
operative mortality of less than 1%
Clinical Manifestations
 fixed splitting of S2 at upper left sternal
border of children
 ejection systolic murmur (pulmonic
valve)
 shortness of breath
 palpitations (cardiac dysrhythmia)
PATHOPHYSIOLOGY
RISK FACTORS
When the following conditions occur during
pregnancy, they can increase the risk of having a
baby with a heart defect:
 Rubella infection. Becoming infected
with rubella (German measles) while
pregnant can increase the risk of fetal
heart defects
 Drug or alcohol use or exposure to
certain substances. Use of certain
medications, alcohol or drugs such as
cocaine during pregnancy can harm the
developing fetus.
↓In the case of ASDs >9mm, higher pressures
from the right atrium causes a remarkable left-
to-right shunt, a significant amount of blood
shunts from the left to the right atrium
↓Extra volume of blood from the left atrium
causes volume overload of both the right atrium
and the right ventricle (fixed splitting of S2)
↓Enlargement of the right side of the heart,
particularly the right ventricle
↓Stretching of conduction fibers
↓Abnormal conduction of heart causes
changes in cardiac rhythm (atrial
dysrhythmias)
↓Volume overload in the whole pulmonary
vasculature
↓Pulmonary vasculature constricts
developing pulmonary hypertension to
divert the extra volume of blood away from
lungs (SOB)
↓Pulmonary hypertension causes increased
afterload forcing the right ventricle to generate
higher pressures (ejection systolic murmur)
↓If right ventricle is unable to tolerate, it
weakens due to increasing workload
↓ Right ventricular failure (complication)
 Shortness of breath
  Swelling of feet and ankles  Cardiac Catheterization - for CHF and significant mitral
 Urinating more frequently at night Medical Management regurgitation
 Pronounced neck veins Cardiac Catheterization (Interventional)  captopril (Capoten)
 Palpitations (sensation of feeling the -indicated only for ASD II  enalapril (Vasotec)
heart beat) - a guidewire is advanced through a vein Nursing ALERT
into the right side of the heart and through Because ACE Inhibitors also block the action
 Irregular fast heartbeat
the septaldefect of aldosterone, the addition of potassium
 Fatigue
- a special catheter is placed over the supplements or spironolactone (Aldactone)
 Weakness
guidewire and positioned across the septal to the drug regimen of patients taking
 Fainting diuretics is usually not needed and may
defect
↓If the right ventricle is able to tolerate cause hyperkalemia.
- two connected mesh disks (one on each
workload, and there is continuing pulmonary Diuretics - to relieve volume overload and
side of the septum) are then used to close
hypertension, pressure in the right side pulmonary congestion in patients with CHF
the septal defect
increases  furosemide (Lasix)
 Open heart surgery
↓Pressure gradient between the two atrias
- mainstay treatment for ASD I and sinus  thiazides (chlorothiazide suspension or
diminishes as pressure in the right atria
venosus hydrochlorothiazide tablets)
increases and levels with the left atria
- require cardiopulmonary bypass and  spironolactone (Aldactone)
↓If left untreated, pressure in the right side of
general anesthesia Nursing ALERT
the heart increases and becomes greater than
- small defects may be closed with simple A fall in the serum potassium level enhances the
the left side of the heart
sutures using a monofilament thread made effects of digitalis, increasing the risk of digoxin
↓A reverse in the pressure gradient across the
of Prolene or Polypropylene. toxicity. Therefore, serum potassium levels must
two atrias occurs, and the shunt will also reverse
- larger defects may be covered with patches be carefully monitored.
causing a right-to-left shunt
made of pieces of pericardium or of silk or a Antibiotics
↓A portion of the deoxygenated blood will shunt
synthetic material such as Dacron or Teflon - for bacterial endocarditis prophylaxis at
to the left side of the heart and will eject to the
Pharmacologic Management a duration of 6 months after surgery
systemic circulation
Inotropic agents - to combat respiratory infections
↓Eisenmenger’s syndrome (complication)
- increase the force of contraction of the Nursing Management CHF
 Arrhythmia
myocardium  Restrict fluids only (sodium is less often
 Cyanosis
- used to treat CHF restricted in children)
 Chest pain
 digoxin (Lanoxin) – 0.8 to 2.0  Bed rest
 Coughing up blood micrograms/L  Elevate HOB (semi or high-fowler’s)
 Dizziness  dopamine (Intropin)  Preserve body temperature (TSBs)
 Fainting Nursing ALERT
 Provide supplemental cool, humidified
 Feeling tired  Digoxin is not given if the pulse is below O2
 Shortness of breath 90 to 100 bpm in infants and young
 Shirts and diapers are pinned loosely
 Stroke children or below 70 bpm in older children
 Encourage good hand washing before
 Swelling in the joints caused by too  Infants rarely receive more than 1 mL
and after caring
much uric acid (gout) (0.05 mg) in one dose; a higher dose is an
Nursing Management Cardiac
Diagnostic Procedures immediate warning of a dosage error
catheterization
Angiotensin-converting enzyme inhibitors
 Chest X-Ray • Preoperative care
- decreases blood pressure and systemic
 MRI  assess history of allergic reactions
arteriolar resistance thus decreasing
 Echocardiogram
afterload  assess for severe diaper rash
 Electrocardiogram
 assess, mark and document pedal
pulses
 clearly describe the catheterization room
especially the x-ray machine
 explain to the child that:
o the groin is cleansed with a special
brown solution
o a medicine will be given so that the
skin will sleep
o a tube will be inserted (femoral
vein) and this will cause a pushing
sensation
 explain to the child that:
o a special medicine will be given, the
child may feel warm for a few
seconds
o the lights will then go off and a
machine will take pictures
 NPO for 4 to 6 hours or more before
the procedure
• Postoperative care
 observe for signs of complications;
assess for:
o pulses below the catheterization
site
o temperature and color of
extremity (arterial obstruction)
o vital signs every 15 min especially
heart rate (bradycardia and
dysrhythmias)
o blood pressure especially
hypotension (bleeding)
o dressing (bleeding)
o fluid intake (hypovolemia and
dehydration)
o Hypoglycemia
 keep affected extremity straight for 4
to 6 hours
 child‘s usual diet is resumed, beginning
with sips of clear liquids
 encourage child to void and drink
fluids
 cover dressing with plastic film and
seal edges with tape to keep it dry if
child is using diaper
Nursing Management Surgery
• Preoperative care
 introduce child and family to the
environment (ICU or RR)
o sounds of ECG monitors, oxygen
tents, and placement of the bed
o allow child to ask questions
o emphasize all positive aspects, such
as the play area, visitors’ section,
pictures, mobiles, or TV
Preoperative care
 familiarize child and family with
equipment and procedures
o tell the child about placement of the
BP cuff and the sensor for the pulse
oximetry
o demonstrate location of each tubing
on the child or on a doll (oxygen
mask, suction, chest tubes, ETT,
incentive spirometers, NGT and IV
tubing
o assure the child that his or her
parents will be there when he or she
wakes up
• Postoperative care
 observe vital signs
o monitor every 15 minutes until
stable, then hourly for 4 hours; count
HR and RR for 1 full minute
o check cardiac rhythm
(dysrhythmias)
o auscultate lungs hourly
(atelectasis)
o keep the child warm, infants may
be placed under radiant heat
warmers
o monitor for elevated temperature
after 48 hours (infection)
 maintain respiratory status
o encourage child to turn and deep
breath hourly
o encourage splinting at operative
site
o suctioning is performed only as
needed and maintained for no more
than 5 seconds at a time
 monitor fluids
o NPO for the first 24 hours
 provide rest and progressive activity
o plan a progressive schedule for
ambulation and rest based on child’s
preoperative activity patterns
o ambulation is initiated at 2nd
postoperative day
o carefully monitor heart rate and
respirations
 provide comfort and emotional support
o provide IV analgesics during the
immediate postoperative period
(opioids, NSAIDs)
 provide comfort and emotional support
o encourage use of firm pillow or
favorite stuffed animal against chest
incision
o encourage child’s expression of
feelings especially anger, and may
direct this toward parents; reassure
parents that this is normal
o stress importance of parent’s
presence (security)
TETRALOGY OF FALLOT
• is a congenital heart defect which involves
four anatomical deformities: pulmonary
stenosis, ventricular septal defect, overriding
aorta, ventricular hypertrophy
Pulmonary Stenosis - This defect is a
narrowing of the pulmonary valve and the
passage through which blood flows from the
right ventricle to the pulmonary artery.
Pulmonary Atresia- a complete obstruction
Ventricular Septal Defect - a hole in the part
of the septum that separates the ventricles, the
lower chambers of the heart. The hole allows
oxygen-rich blood from the left ventricle to mix
with oxygen-poor blood from the right ventricle.
Overriding Aorta - the aorta is between the left
and right ventricles, directly over the VSD. As a
result, oxygen-poor blood from the right ventricle
flows directly into the aorta instead of into the
pulmonary artery to the lungs.
Ventricular Hypertrophy - This defect occurs
if the right ventricle thickens because the heart
has to pump harder than it should to move blood
through the narrowed pulmonary valve.
Pathophysiology
• Maternal Predisposing Factors
• Age (>40y.o)
• With a history of TOF
• Viral Illnesses (German Measles)
• Maternal Precipitating Factors
• Poor Nutrition
• Overuse of Alcohol
• Sedentary Lifestyle
Signs & symptoms
• Cyanosis ( lips, mucous membranes,
skin)
• Retarded growth and development
• Tires easily
• Clubbing of toes and fingers
• Shortness of breath
• Irritability
• Loss of consciousness
• Heart murmur
• Polycythemia
• “tet spells”-marked increase in cyanosis
followed by syncope, and may result in
hypoxic brain injury and death
-Is caused by a sudden drop of oxygen in
the blood
• Hypercyanosis
• Have a hard time breathing
• Become very tired and limp
• Not respond to a parent's voice or touch
• Become very fussy
• Loss of consciousness
DIAGNOSTIC TESTS
• Echocardiography
– Is a painless test that uses sound waves
to create a moving picture of the heart.
During the test, the sound waves (called
UTZ) bounce off yhe structures of the
heart. A computer converts the sound
waves into pictures on screen.
– It is an important for diagnosing TOF
because it shows the four heart defects
and how the heart is responding to
them. This test helps the cardiologist
decide when to repair these defects and
what type of surgery is needed.
• ECG ( Electrocardiogram)
– A simple, painless test that records the
heart’s electrical activity. The test
shows how fast the heart is beating and
its rhythm ( steady or irregular).
– It also records the strength and timing
of electrical signals as they pass
through each part of the heart.
– It also can help the doctor determine
whether the right ventricle is enlarged
( ventricular hypertrophy)
• Cardiac Catheterization
– a thin, flexible tube called a catheter is
put into a vein in the arm , groin or
neck threaded into the heart.
– special dye is injected through the
catheter into a blood vessel or a
chamber of the heart. The dye allows
the doctor to see the flow of blood
vessel on an x-ray image.
– This can also be use to measure the
pressure and oxygen level inside the
heart chambers and blood vessels. This
can help the doctor determine wehether
blood is mixing between the two sides
of the heart.
• Chest X-ray
– A painless test that creates pictures of
the structures in the chest, such as the
heart and lungs. This test can show
whether the heart is enlarged or
whether the lungs have extra blood flow
or extra fluid, a sign of a heart failure.
• Pulse Oximetry
– a small sensor is atteched to a finger or
toe which gives an estimate of how
much oxygen is in the blood.
MANAGEMENTS
• SURGICAL
– Shunt Operation ( Blalock- Taussig
Procedure) may be done first to provide
more blood flow to the lungs. This is not
open-heart surgery and doesn’t fix the
inside of the heart. it places a tube to
allow blood to leave the aorta and enter
the pulmonary artery, oxygenate in the
lungs, and return to the left side of the
heart, the aorta and the body parts.
Usually, subclavian artery is used in
this procedure
– Complete Repair - the surgeon
closes the ventricular septal defect
with a patch and relieves the
obstruction to blood flow going to the
lungs. This may be done by removing
some thickened muscle below the
pulmonary valve, repairing or
removing the obstructed pulmonary
valve and if needed, enlarging the
pulmonary artery branches that go
to each lung.
• NURSING
– Administer oxygen as prescribed
– Position the child in a squatting
position (knee-chest position)
– For the baby, place the baby
over your shoulder (just like
 when burping the baby) with the
knees curled toward the chest
– Perform CPR if the child may stop
breathing.
– monitor closely vital signs
• PHARMACOLOGIC
– Beta blockers:
• Propanolol
– Vasopressor:
• Morphine
• Epinephrine
• Phenylephrine
• Norepinephrine
Ventricular Septal Defect
 most common type of congenital heart
defect
 describes one or more holes in the
interventricular septum (wall that
separates the right and left ventricles of
the heart) causing extra blood in the
pulmonary arteries and lungs and in
the left atrium and left ventricle
 Cause is unknown
 Symptomless at birth; acyanotic
Classifications of VSD:
Size of the defect.
• small VSD -restrictive - do not cause
symptoms in infants and children, rarely
need surgery
• moderate VSD – medium-sized - may
cause symptoms in infants and children,
less likely than small defects to close on
their own, require surgery to close
• Large VSD- non-restrictive - is less
likely to close completely on its own, but
it may get smaller, surgery is usually
needed
Location of the defect
• Membranous VSDs- located near
the heart valves.
• Muscular VSDs - found in the lower • In children with moderate or large
part of the septum. They are ventricular septal defects therapies may
surrounded by muscle, and most include:
close on their own during early • Increased caloric density of
childhood. feedings to ensure adequate weight
• Inlet VSDs - located close to where gain. Occasionally, oral feeds must be
blood enters the heart. They are less supplemented with tube feeds because a
common than membranous and baby in CHF may be unable to consume
muscular VSDs. adequate calories for appropriate weight
gain.
• Outlet VSDs -found in the part of
Medications:
the ventricle where the blood leaves
• Diuretics (eg, furosemide)
the heart. This is the rarest type of
o to eliminate excess water and
VSD.
salt to prevent reaccumulation
o used to relieve pulmonary
PATHOPHYSIOLOGY
Modifiable Risk Factors: Non- congestion
Modifiable: o N.C: - monitor serum potassium
Maternal Factors > Family Hx of level(3.5-5.1 meq/L), monitor for
VSD signs and symptoms of
- maternal alcohol > Genetics hypokalemia (serum K less than
consumption and > Race (Asian) than normal range), encourage
FAS > Sex ( slightly foods high in potassium/ give
more potassium supplements
-use of antiseizure in females) • ACE inhibitors (captopril and
medicines depakote enalapril)
and dilantin
o to reduce both the systemic and
pulmonary pressures (more so
the latter), and this results in
reducing the left to right shunt
o inhibits the normal fxn. Of RAS in
the kidney, vasodilation occurs
Exams and Tests
 Chest x-ray
• Digoxin- indicated if diuresis
and afterload reduction do not relieve
 ECG
adequately symptoms.
 Echocardiogram
o increases CO, increase heart
 Cardic catheterization
contractility, decrease HR
 MRI of the Heart o normal level - 0.5 -2.0 mg/dl
Medical Managements:
o N.I: - count apical pulse for 1 full
• Children with small ventricular septal minute before giving drug,
defects (VSDs) are asymptomatic and withhold medication and notify
have an excellent long-term prognosis. practitioner if pulse rate is less
Neither medical therapy nor surgical than 90-110 bpm (infants) or 75-
therapy is indicated 85 bpm (older children),
 depending on previous readings,
serum potassium level should be
monitored, recognize signs of
digoxin toxicity
Signs of Digoxin toxicity:
 Nausea
 Vomiting
 Anorexia
 Bradycardia
 Dysrhythmias
- administer it 1 hour before feedings or 1-
2 hrs. after feeding
- if a dose is missed and more than 4 hrs.
Has elapsed , do not administer a second
dose
- if more than 2 consecutive dose have
been missed , notify the physician; do
not double the dose for missed doses
- if the child vomits , do not administer a
second dose
Surgical Managements:
 Surgical Repair: surgical repair is
recommended if child’s VSD: is large, is
causing symptoms, causes enlarged
heart chamber, affects aortic valve
• Small defects- repaired with a purse
string approach, a patch of synthetic
material is utilized and is secured with
interrupted matress sutures
• Large Defects- require a knitted Dacron
patch sewn over the opening
Open heart surgery- may be done if the
opening is large, scheduled before 2yrs. of age
to prevent pulmonary hypertension
Pulmonary Artery Banding - narrows the
pulmonary artery to reduce the blood flow to the
lungs
Post-op Interventions:
 Monitor arrythmias
 Children may receive prophylactic
antibiotics to prevent bacterial
endocarditis for 6 months afterward and
before receiving any dental work.
> limit from playing rough contact sports
> if a synthetic patch was used to close
the VSD, some medicines may need to
be taken for the first few weeks after
operation
Nursing Managements:
• Decrease Cardiac Output
o administer Digoxin as ordered, using
established precautions to prevent
toxicity
o Monitor serum potassium level
• Ineffective Breathing Pattern
o place in inclined posture of 30-45
degrees, tilt mattress support of
incubator
o avoid any constricting clothing or
restraints around abdomen and chest
o administer humidified oxygen as
prescribed
o assess RR, ease of respiration, color and
oxygen saturation
• Anxiety
o handle child gently
o hold and comfort client
o encourage family to provide comfort and
solace
• Fluid Volume Excess
o administer diuretics as prescribed
o maintain accurate intake and output
o weigh daily at the same time and on
same scale , weigh diapers.
o provide skin care for children with edema
o change position frequently to prevent
skin breakdown associated with edema
• Activity Intolerance
o Maintain neutral thermal environment
o Feed small volumes at frequent intervals
using soft nipple with moderately large
opening
o time nursing activities to disturb child as
little as possible
o respond promptly to crying or other
expressions of distress
RHEUMATIC FEVER
• Is an inflammatory autoimmune
disease that affects connective tissues of
the heart, joints, subcutaneous tissues and
blood vessels of the central nervous
system
• Clinically, the affected individual
has an acute arthritis affecting multiple
joints (which is why the disease is called
“rheumatic” fever).
• Causative Agent: Group A beta
Hemolytic Streptococcus/ Streptococcus
pyogenes
• Most serious complication:
Rheumatic Heart Disease, which affects
the cardiac valves, particularly the mitral
valve
• Rheumatic fever is not a
bacterial infection but a type of
hypersensitivity reaction induced by
various antigens present in the
streptococcus. This reaction develops
several weeks after initial
streptococcal infection. It is uncertain
exactly how the streptococcus
induces the development of rheumatic
fever.
Pathophysiology
There is no specific test for RF; therefore a
combination of clinical manifestations and
laboratory findings is used as a basis for
diagnosis.
DIAGNOSTIC EVALUATION
Jones’ Criteria
Cardiology Criteria for diagnosing acute
rheumatic fever, first proposed by TD Jones in
1944, later revised and updated by the American
Heart Association.
Presence of 2 major manifestations or one major
plus 2 minor manifestations with supportive
evidence of recent streptococcal infections
indicate a high probability of RF
Major Manifestations
• Carditis
• Polyarthritis
• Chorea (Sydenham's chorea)
• Eythema marginatum
• Subcutaneous nodules
Minor Manifestations
• Arthralgia
• History of previous RF or RHD
• Fever
Laboratory findings
• Leukocytosis
• Anemia
• ↑ Erythrocyte sedimentation rate
• C-reactive protein
• Prolonged PR interval on ECG
Evidence of previous group A streptococcal
infection
+ Throat culture or rapid streptococcal antigen
test
↑ (or rising) streptococcal antibody titer
The most reliable and best standard test is an
elevated or rising antistreptolysin-O (ASO) titer,
which occurs in 80% of children with RF.
PATHOGNOMONIC SIGN OF RF:
Aschoff bodies:
Areas of inflammation of the connective tissue
of the heart.
MEDICAL MANAGEMENT
The goals of medical management are to:
• eradicate group A beta-hemolytic
streptococci
• prevent permanent cardiac damage
• palliate other symptoms
• prevent recurrence of the disease
PHARMACOLOGIC MANAGEMENT
PENICILLIN in sufficient dosage to eradicate the
streptococci is the drug of choice for treatment
with erythromycin as a substitute in penicillin-
sensitive children.
Hospitalization is advised and bed rest is
recommended, the length determined by the
severity and duration of the illness
Manifestations are managed appropriately.
Anti-inflammatory drugs, principally salicylates,
are used to suppress acute joint inflammation
when multiple joints are involved.
Acetaminophen may be prescribed when only
one joint is involved and diagnosis is uncertain.
Corticosteroids are administered to suppress
severe myocardial inflammation.
Mild sedation is often helpful in alleviating some
of the anxiety and restlessness caused by
chorea.
In some cases, the anticonvulsive clonazepam
(Clonopin) is prescribed for more distressing
symptoms.
Prevention:
Prevention of first attacks (primary prevention) is
accomplished by identification and adequate
treatment of streptococcal upper respiratory
tract infection. Because children who have
suffered a previous attack of RF are highly
susceptible to recurrent attacks following
streptococcus upper respiratory infections, they
need continuous protection to prevent
recurrences (secondary prevention).
PENICILLIN is the drug of choice for primary
prevention. The drug may be given IM in single
dose or orally for a full 10 days.
SURGICAL PROCEDURES
In some patients, rheumatic fever damages a
heart valve. Repairing this problem can often be
delayed for many years. The physician may
recommend expanding the narrowed mitral
valve with a balloon catheter procedure or
replacing it with another valve in surgery.
NURSING MANAGEMENT
The objectives of nursing care of the child with
RF are to:
• Facilitate recovery from illness
• Encourage compliance with drug
regimen
• Provide emotional support
• Prevent primary and secondary disease
The child with carditis may be hospitalized for an
extended period depending on the severity of
the disorder and placed on limited activity
following discharge. Slow convalescence requires
home care and home tutoring, and any athletic
activities are usually restricted for some time.
The family may need help in coping with the
child’s enforced inactivity. Therefore,
encouraging the child to become involved in
quiet activities of interest and to maintain
contact with friends are important aspects of
nursing care.
The nurse can be helpful by explaining the
disturbing, although temporary nature of the
manifestations and protecting the child from
stressful situations.
Nurses need to stress to families the importance
of compliance with the oral penicillin regimen. If
compliance is in doubt this should be reported to
the physician so that long-acting penicillin can
be administered. If parenteral medication is
instituted the child needs preparation for and
support during the monthly injections.
OTHER NURSING RESPONSIBILITIES
>> Initiate seizure precautions if the child is
experiencing chorea.
>>Instruct parents about the importance of
follow up and the need of antibiotic prophylaxis
for dental work, infection and invasive
procedures.
>> advise the child to inform the parents if
anyone in school develops a streptococcal throat
infection
KAWASAKI DISEASE
(mucocutaneous lymph node syndrome
 is an acute self-limited systemic
vasculitis of unknown cause.
  first described in Japan by the size and shape of the heart, its pumping capacity After fever subsided: aspirin is continued at an
paediatrician, Tomisaku Kawasaki in and the location and extent of any damage to its antiplatelet dose (3 to 5 mg/kg/day).
1967. tissues. Low-dose aspirin is continued in patients
without echocardiographic evidence of
 VASCULITIS is the principal (and life-
Electrocardiogram (ECG) - this device records the coronary abnormalities until platelet count has
threatening) finding – can lead to
electrical activity and rhythms of the patient's returned to normal (6 to 8 wks)
formation of aneurysm and myocardial
heart. 3. Abciximab => platelet receptor inhibitor
infarction.
specific for KD
 The pathologic hallmark of Kawasaki MEDICAL MANAGEMENT
disease is a generalized vasculitis SURGICAL MANAGEMENT
1. The fist echocardiogram is usually
performed 10-14 days into the illness 1. Coronary Artery Bypass Grafts
DIAGNOSTIC CRITERIA FOR KAWASAKI
A ff-up echocardiogram is done 4-6 weeks later => Arteries or veins from elsewhere in the
DISEASE
If both test are normal = coronary arteries are body are grafted to coronary arteries to bypass
The child must exhibit 5 of the ff. 6 criteria,
considered normal atherosclerotic narrowing.
including fever:
If persistent coronary changes => coronary Consideration:
1. Fever (5 days or more) that is unresponsive to
arteries will be watched overtime, the child will > Reversible ischemia is present
antibiotics and antipyretics
typically remain in a low-dose aspirin therapy > The myocardium to be perfused through the
2. Bilateral conjunctival injection (inflammation)
and will need a longer ff-up with cardiologist graft is still viable
without exudation
2. Plasma exchange (plasmapheresis) has been >No appreciable lesions are present in the
3. Changes in the oral mucous membranes, such
reported as effective in patients who were not artery distal to planned graft site.
as erythema, dryness, and fissuring of the lips;
responding to aspirin and gamma globulin. 2. Coronary artery angioplasty
oropharyngeal reddening, or “strawberry
=> opens up an artery that has narrowed by
tongue” (large papillae are exposed)
PHARMALOGICAL MANAGEMENT inflating a small balloon inside the artery.
4. Changes in the extremities, such as peripheral
1. Intravenous immunoglobulin (IVIG) 3. Stent
edema, erythema of the palms and soles,
Intravenous immunoglobulin (IVIG) is the => A stent may be placed in the clogged
periungual desquamation (peeling) of the hands
standard treatment for Kawasaki disease artery to help prop it open.
and feet
5. Polymorphous rash
(Gamma globulin has been demonstrated to be NURSING MANAGEMENT
6. Cervical lymphadenopathy (one lymph node
effective at reducing the incidence of coronary Monitoring
>1.5 cm)
artery abnormalities when given w/in the first >Monitor pain level and child’s response to
10 days of the illness.) analgesics.
LABORATORY RESULTS AND DIAGNOSTIC
A single, large infusion of 2g/kg over 10-12 hrs. >Institute continual cardiac monitoring and
TESTS
is recommended. children who have had assessment for complications; report
Laboratory Results:
immune globulin should wait 11 months before arrhythmias.
Platelet count > 150,000 – 400,000/mm3
having the measles and chicken pox vaccines. ..Take vital signs as directed by condition;
Erythrocyte Sedimentation Rate (ESR) > 1-13
2. Aspirin (Acetylsalicylic acid) report abnormalities.
mm/hr (male) / 1-20 mm/hr (female)
..Assess signs of CHF (congestive heart failure)
= inflammatory condition C Reactive Protein Aspirin (Acetylsalicylic acid) => given initially including decreased urine output, gallop rhythm
(CRP) Test > 3.0 mg/L in an anti-inflammatory dose (80 to (additional eart sound), tachycardia, respiratory
= inflammatory condition 100mg/kg/day in divided doses q 6h) to control distress
= high risk for cardiovascular disease fever and symptoms of inflammation ..Monitor for heart failure (dyspnea, nasal flaring,
Aspirin is used to decrease inflammation and grunting, retractions, cyanosis, orthopnea,
Echocardiogram - this is an ultrasound scan that lower fever, as well as prevents blood clots. crackles, moist respirations, distended
checks the pumping action of the patient's heart.
jugular veins, edema).
It can provide helpful information, including the
>Closely monitor intake and output, and
administer oral and I.V fluids as ordered.
>Monitor hydration status by checking skin
turgor, weight, urinary output, specific gravity,
and presence of tears.
>Observe mouth and skin frequently for signs of
infection
Supportive care
>Allow the child periods of uninterrupted rest.s
Offer pain medication routinely rather than as
needed during stage I Avoid NSAIDS if the child
is in aspirin therapy.
>Perform comfort measures related to the eyes.
>Conjunctivities can cause photosensitivity, so
darken the room, offer sunglasses.
>Apply cool compress.
>Discourage rubbing the eyes.
>Instill artificial tears to soothe conjunctiva.
>Monitor temperature every 4 hours. Provide
sponge bath if temperature above normal.
>Perform passive range of motion exercises
every 4 hours while the child is awake because
movement may be restricted
> Provide quiet and peaceful environment with
diversional activities.
>Provide care measures for oral mucous
membrane.
..Offer cool clear liquids like ice chips and ice
pops.
..Encourage the older child to suck on ice chips,
the younger child may suck on a cool, moist
washcloth.
.. Soft foods can be offered.
..Use soft toothbrush only.
..Apply petroleum jelly or any lubricating
ointment to dried, cracked lips.
>Provide skin measures to improve skin
integrity.
..Avoid use of soap because it tends to dry skin
and make it more likely to breakdown.
..Elevate edematous extremities.
..Use smooth sheets.
..Apply unscented emollients to skin as ordered.
..Protect peeling of skin, observe for signs of >Any live immunizations (e.g. MMR, varicella)
infection. should be deferred for 11 months after
..Encourage wearing soft, loose clothing administration of gamma globulin (because the
>Offer clear liquids every hour when the child is body might not produce the appropriate amount
awake. of antibodies).
>Encourage the child to eat meals and snack >Temperature should be recorded after
with adequate protein. discharge
>Infuse I.V fluids through a volume control
device if dehydration is present, and check the
site and amount hourly.
>Administration of gamma globulin should follow
same guidelines as for any blood product, (with
frequent monitoring of vital signs).
>Explain all procedures to the child and family.
>Encourage the parents and child to verbalize
their concerns, fears, and questions.
>Practice relaxation techniques with child, such
as relaxation breathing, guided imagery, and
distraction.
>Prepare the child for cardiac surgery or
thrombolytic therapy if complications develop.
>Keep the family informed about progress and
reinforce stages and prognosis.
Discharge Teaching: things to consider
>Provide accurate information about the
progression of KD,
>Continue monitor the child’s temperature after
discharge until the child has been afebrile for 7
days.
>Irritability is likely to persist up to 2 months
after initial diagnosis.
 Importance of follow-up monitoring
 When to contact their practitioner.
> Toxic effects of aspirin therapy such as
headache, confusion, dizziness or tinnitus should
be reported to the primary care provider
>Peeling of the hands and feet is painless (2nd or
3rd weeks)
>Children are typically more stiff in the
mornings, during cold weather, and after naps.
>Passive ROM in the bathtub – helps increase
flexibility