RHEUMATIC HEART DISEASE Rheumatic (roo-MAT-ik) heart disease was formerly one of the most serious forms of heart

disease of childhood and adolescence. Rheumatic heart disease involves damage to the entire heart and its membranes.Rheumatic heart disease is a complication of rheumatic fever and usually occurs after attacks of rheumatic fever. The incidence of rheumatic heart disease has been greatly reduced by widespread use of antibiotics effective against the streptococcal bacterium that causes rheumatic fever. Sign and Symptoms Some of the most common symptoms of rheumatic heart disease are breathlessness, fatigue, palpitations, chest pain, and fainting attacks.

Diagnosis The first step in diagnosing rheumatic heart disease is establishing that your child recently had a strep infection. The doctor may order a throat culture, a blood test, or both to check for the presence of strep antibodies. However, it is likely that signs of the strep infection may be gone by the time you take your child to the doctor. In that case, the doctor will need you to try to remember if your child recently had a sore throat or other symptoms of a strep infection. The doctor will do a physical examination and check your child for signs of rheumatic fever, including joint pain and inflammation. The doctor also will listen to your child's heart to check for abnormal rhythms or murmurs that may signify that the heart has been strained. In addition, there are a couple of tests that may be used to check the heart and assess damage, including: Chest X-ray to check the size of the heart and to see if there is excess fluid in the heart or lungs Echocardiogram, a non-invasive test that uses sound waves to create a moving image of the heart and to measure its size and shape

Medical Management Medical therapy is directed toward eliminating the group A streptococcal pharyngitis (if still present), suppressing inflammation from the autoimmune response, and providing supportive treatment for congestive heart failure. But the specific treatment for rheumatic heart disease will be determined by your physician based on: * Your overall health and medical history * Extent of the disease * Your tolerance for specific medications, procedures, or therapies * Expectations for the course of the disease * Your opinion or preference Since rheumatic fever is the cause of rheumatic heart disease, the best treatment is to prevent rheumatic fever from occurring. Oral penicillin V remains the drug of choice for treatment of group A streptococcal pharyngitis. When oral penicillin is not feasible or dependable, a single dose of intramuscular benzathine penicillin G is therapeutic. For patients who are allergic to penicillin, administer erythromycin or a first-generation cephalosporin.Other options include clarithromycin for 10 days, azithromycin for 5 days, or a narrow-spectrum (first-generation) cephalosporin for 10 days. To reduce inflammation, aspirin, steroids, or non-steroidal medications may be given. Surgery may be necessary to repair or replace the damaged valve

Nursing Management *Monitor blood pressure, pulse apical and peripheral pulse *Monitor cardiac rhythm and the frequency *Sleeping position 450 semifowler *Instruct the client to do stress management techniques (quiet environment, meditation) *Aids client activity as indicated when the client is able

BACTERIAL INFECTIVE ENDOCARDITIS Infective endocarditis is a form of endocarditis, or inflammation of the inner tissue of the heart, such as its valves, caused by infectious agents. The agents are usually bacterial, but other organisms can also be responsible. The valves of the heart do not receive any dedicated blood supply. As a result, defensive immune mechanisms (such as white blood cells) cannot directly reach the valves via the bloodstream. If an organism (such as bacteria) attaches to a valve surface and forms a vegetation, the host immune response is blunted. The lack of blood supply to the valves also has implications on treatment, since drugs also have difficulty reaching the infected valve. Normally, blood flows smoothly through these valves. If they have been damaged from rheumatic fever, for example - the risk of bacterial attachment is increased

Sign and Symptoms Fever, i.e. fever of unknown origin occurs in 97% of people; malaise and endurance fatigue in 90% of people. A new or changing heart murmur, weight loss, and coughing occurs in 35% of people Vascular phenomena: septic embolism (causing thromboembolic problems such as stroke in the parietal lobe of the brain or gangrene of fingers), Janeway lesions (painless hemorrhagic cutaneous lesions on the palms and soles), intracranial hemorrhage, conjunctivalhemorrhage, splinter hemorrhages, Renal Infarcts, and Infarct Spleen. Immunologic phenomena: Glomerulonephritis which allows for blood and albumin to enter the urine,[1] Osler's nodes (painful subcutaneouslesions in the distal fingers), Roth's spots on the retina, positive serum rheumatoid factor Other signs may include; night sweats, rigors, anemia, splenomegaly, clubbing

Diagnosis Blood Tests - Blood cultures are the most important blood tests used to diagnose IE. Blood is drawn several times over a 24-hour period. It's put in special culture bottles that allow bacteria to grow. Echocardiography - Echocardiography (echo) is a painless test that uses sound waves to create pictures of your heart. Two types of echo are useful in diagnosing IE. Transthoracic (tranz-thor-AS-ik) echo. For this painless test, gel is applied to the skin on your chest. A device called a transducer is moved around on the outside of your chest. This device sends sound waves called ultrasound through your chest. As the ultrasound waves bounce off your heart, a computer converts them into pictures on a screen. Your doctor uses the pictures to look for vegetations, areas of infected tissue (such as an abscess), and signs of heart damage. Because the sound waves have to pass through skin, muscle, tissue, bone, and lungs, the pictures may not have enough detail. Thus, your doctor may recommend transesophageal (tranz-ih-sof-uh-JEE-ul) echo (TEE). Transesophageal echo. For TEE, a much smaller transducer is attached to the end of a long, narrow, flexible tube. The tube is passed down your throat. Before the procedure, you're given medicine to help you relax, and your throat is sprayed with numbing medicine. The doctor then passes the transducer down your esophagus (the passage from your mouth to your stomach). Because this passage is right behind the heart, the transducer can get detailed pictures of the heart's structures. EKG - An EKG is a simple, painless test that detects your heart's electrical activity. The test shows how fast your heart is beating, whether your heart rhythm is steady or irregular, and the strength and timing of electrical signals as they pass through your heart. An EKG typically isn't used to diagnose IE. However, it may be done to see whether IE is affecting your heart's electrical activity. For this test, soft, sticky patches called electrodes are attached to your chest, arms, and legs. You lie still while the electrodes detect your heart's electrical signals. A machine records these signals on graph paper or shows them on a computer screen. The entire test usually takes about 10 minute 4

Medical Management High dose antibiotics are administered by the intravenous route to maximize diffusion of antibiotic molecules into vegetation(s) from the blood filling the chambers of the heart. Antibiotics are continued for a long time, typically two to six weeks. High dose IV crystalline penicillin every 4hrs for 2 weeks is recommended and still remains the drug of choice. 2 week treatment regimen of benzyl penicillin IV

Nursing Management During the acute phase of the disease, provide adequate rest by assisting the patient with daily hygiene. Provide a bedside commode to reduce the physiological stress that occurs with the use of a bedpan. Space all nursing care activities and diagnostic tests to provide the patient with adequate rest. During the first few days of hospital admission, encourage the family to limit visitation. Emphasize patient education. Individualize a standardized plan of care, and adapt it to meet the patient's needs. Areas for discussion include the cause of the disease and its course, medication regimens, technique for administering IV antibiotics, and practices that help avoid and identify future infections. If the patient is to continue parenteral antibiotic therapy at home, make sure that, before he or she is discharged from the hospital, the patient has all the appropriate equipment and supplies that will be needed. Make a referral to a home health nurse as needed, and provide the patient and family with a list of information that describes when to notify the primary healthcare provider about complications.

KAWASAKI DISEASE Kawasaki (KAH-wah-SAH-ke) disease is a rare childhood disease. It's a form of a disease called vasculitis (vas-kyu-LI-tis).In Kawasaki disease, the walls of the blood vessels throughout the body become inflamed. The disease can affect any type of blood vessel in the body, including the arteries, veins, and capillaries.In some cases, Kawasaki disease affects the coronary arteries, which carry oxygen-rich blood to the heart. As a result, a small number of children who have Kawasaki disease may develop serious heart problems. Sign and Symptoms Major Signs and Symptoms One of the main symptoms during the early part of Kawasaki disease, called the acute phase, is fever. The fever lasts longer than 5 days. It remains high even after treatment with standard childhood fever medicines. Other classic signs of the disease are: Swollen lymph nodes in the neck,A rash on the mid-section of the body and in the genital area,Red, dry, cracked lips and a red, swollen tongue,Red, swollen palms of the hands and soles of the feet,Redness of the eyes During the acute phase, your child also may be irritable and have a sore throat, joint pain, diarrhea, vomiting, and stomach pain.Within 2 to 3 weeks of the start of the first symptoms, the skin of your child's fingers and toes may peel, sometimes in large sheets. Diagnosis Blood tests. These tests can show whether the body's blood vessels are inflamed. Chest x ray. This test can help show whether Kawasaki disease has affected the heart EKG (electrocardiogram). This simple test detects and records the heart's electrical activity. EKG can show whether Kawasaki disease has affected the heart.
Medical Management The medical management of Kawasaki disease primarily involves the use of gamma globulin. Although some have suggested that aspirin is no longer needed, most use high-dose aspirin for a variable period of time, followed by lower-dose aspirin for its antiplatelet effects. Of note, a 2008 Cochrane Database of Systematic Reviews article concluded that "there is insufficient evidence to indicate whether children with Kawasaki disease should continue to receive salicylate as part of their treatment regimen."Some controversy exists about the ideal timing to begin gamma globulin, but this is not an issue that concerns emergency physicians. It is given most often from days 5-7.Although data are 6

limited, authors of several case reports have suggested a possible role for thrombolysis in those with acute MI as a consequence of thrombus formation in aneurysms. At this time, it seems unlikely that the emergency physician will administer this therapy.Some have suggested that there is, or may be, a role for corticosteroids. Most have pointed out that not only is there no good data to support a benefit in terms of outcome but also that current therapy with IVIG and aspirin is safe and effective. In a metaanalysis of 4 studies and 447 patients, Athappan et al concluded that the addition of steroids to standard therapy (IVIG + aspirin) decreased the rate of re-treatment but did not decrease the incidence of coronary aneurysms or adverse events.Ibuprofen antagonizes aspirin's antiplatelet activity and should be avoided.Because these children will take aspirin for a variable period of time, vaccination against influenza and varicella must be ensured.Studies that involved plasma exchange or cyclophosphamide have shown variable results. Both are used in cases of refractory disease. In a small series of 24 children, infliximab was reported to be as effective as a second IVIG infusion in resistant cases.

Nursing Management Monitoring 1. Monitor pain level and childs response to analgesics. 2. Institute continual cardiac monitoring and assessment for complications; report arrhythmias. 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 1. Allow the child periods of uninterrupted rest. Offer pain medication routinely rather than as needed during stage I. Avoid NSAIDS if the child is in aspirin therapy. 2. 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. 3. Monitor temperature every 4 hours. Provide sponge bath if temperature above normal. 4. Perform passive range of motion exercises every 4 hours while the child is awake because movement may be restricted. 5. Provide quiet and peaceful environment with diversional activities. 6. Provide care measures for oral mucous membrane.  Offer cool liquids like ice chips and ice pops. 7

CARDIAC CATHETERIZATION Cardiac catheterization involves passing a thin flexible tube (catheter) into the right or left side of the heart, usually from the groin or the arm. How the Test is Performed You will be given a mild sedative before the test to help you relax. An intravenous (IV) line is inserted into one of the blood vessels in your arm, neck, or groin after the site has been cleansed and numbed with a local numbing medicine (anesthetic). A catheter is then inserted through the IV and into your blood vessel. The catheter is carefully threaded into the heart using an x-ray machine that produces real-time pictures (fluoroscopy). Once the catheter is in place, your doctor may:
y y

y y

Collect blood samples from the heart Measure pressure and blood flow in the heart's chambers and in the large arteries around the heart Measure the oxygen in different parts of your heart Examine the arteries of the heart with an x-ray technique called fluoroscopy (which gives immediate, "real-time" pictures of the x-ray images on a screen and provides a permanent record of the procedure) Perform a biopsy on the heart muscle

How to Prepare for the Test If possible, you will be asked not to eat or drink for 6 - 8 hours before the test. The test takes place in a hospital and you will be asked to wear a hospital gown. Sometimes, you will need to spend the night before the test in the hospital. Otherwise, you will be admitted as an outpatient or an inpatient the morning of the procedure. Tell your doctor if you:
y y y y

Are allergic to seafood Have had a bad reaction to contrast material or iodine in the past Are taking Viagra Might be pregnant 8

How the Test Will Feel The study is done by trained cardiologists with the assistance of trained technicians and nurses. You will be awake and able to follow instructions during the test. You will usually get a mild sedative 30 minutes before the test to help you relax. The test may last 30 - 60 minutes. You may feel some discomfort at the site where the catheter is placed. Local anesthesia will be used to numb the site, so the only sensation should be one of pressure at the site. You may experience some discomfort from having to remain still for a long time. After the test, the catheter is removed. You might feel a firm pressure, used to prevent bleeding at the insertion site. If the catheter is placed in your groin, you will usually be asked to lie flat on your back for a few hours after the test to avoid bleeding. This may cause some mild back discomfort. Why the Test is Performed In general, this procedure is done to get information about the heart or its blood vessels or to provide treatment in certain types of heart conditions. It may also be used to determine the need for heart surgery. Your doctor may perform cardiac catheterization to:
y y y y

Diagnose or evaluate coronary artery disease Diagnose or evaluate congenital heart defects Diagnose or evaluate problems with the heart valves Diagnose causes of heart failure or cardiomyopathy

The following may also be performed using cardiac catheterization:

y y y

Repair of certain types of heart defects Repair of a stuck (stenotic) heart valve Opening of blocked arteries or grafts in the heart

The procedure can identify heart defects or disease, such as:

y y y y

Coronary artery disease Valve problems Ventricular aneurysms Heart enlargement

The procedure also may be performed for the following:

y y

y y

Primary pulmonary hypertension Heart valve defects, such as pulmonary valve stenosis, mitral valve regurgitation, aortic stenosis, and others Pulmonary embolism Birth defects, such as Tetralogy of Fallot, transposition of the great vessels, ventricular septal defect,coarctation of the aorta, and others Cardiac amyloidosis

Risks Cardiac catheterization carries a slightly higher risk than other heart tests, but is very safe when performed by an experienced team. Generally, the risks include the following:
y y y y y y

Cardiac arrhythmias ,Cardiac tamponade Heart attack Bleeding Low blood pressure Reaction to the contrast medium Trauma to the artery caused by hematoma

Possible complications of any type of catheterization include the following:

y y y

A risk of bleeding, infection, and pain at the IV site A very small risk that the soft plastic catheters could damage the blood vessels Blood clots could form on the catheters and later block blood vessels elsewhere in the body. The contrast material could damage the kidneys (particularly in patients with diabetes).

Our Lady of Fatima University College of Nursing Quezon City

Pediatric Nursing

Rheumatic Heart Disease Bacterial Infective Endocarditis Kawasaki Disease Cardiac Catheterization

Name : Caisa Enrica M. Abesamis Section : BSN 4A1-5

LONG QUIZ # 2