Rheumatic Heart Disease.

Acute Rheumatic Heart Disease (RHD) is an acute inflammatory reaction. It may involve the endocardium, including the valves, resulting in scarring, distortion and stenosis of the valves. It may also involve the myocardium where necrosis occurs and on healing, leaves scars, or the pericardium where it may cause adhesions to surrounding tissues. The development of symptoms of chronic RHD in later life depends on the location and severity of the damage and other factors.

This type of heart disease, which usually occurs in children, has its origin in rheumatic fever. The fever is associated with haemolytic streptococcal infection of the throat, mainly tonsillitis and pharyngitis, experienced two to three weeks before the onset of the fever. About 90% of first fever attacks occur among persons aged five to fifteen years of age.

Pathophysiology.

All the three layers of the heart gradually become affected, especially the endocardium.

This is known as endocarditis of the left side of the heart. The infection may also progress to affect the mitral valve or other valves in the heart. The flaps, which form the valve, become swollen and oedematous with small and firmly attached vegetable like deposits.

In the acute stage, the valve becomes incompetent, resulting in subsequent fibrosis and thickening. The tendonous cords (cordae tendineae) become shortened. This causes stenosis, with or without incompetence.

Clinical Features.

Now you will look at the clinical features of rheumatic fever. When the child arrives at your health facility, you should observe for some or all of the following features, in attempting to make your diagnosis:

•       The child complains of headache, vomiting, moderate fever of 37.2 degrees Celsius to 37.8 degrees Celsius but can be higher, fur tongue, sweating and occasionally constipation. These are signs of emerging toxaemia.

•       Pulse rate is elevated, corresponding to temperature.

•       On examination, the patient has a severely painful moveable joint, which begins with one and spreads to others. Normally the knees, elbows, wrists, ankles are affected.

•       Occasionally these joints are reddened, swollen and warm to the touch. There may be nodules over these joints.

•       When the child has been ill for a prolonged period of time, anaemia will develop, indicating danger of permanent heart damage.

•       Some patients may occasionally faint and develop slightly pinkish rash appearing on the chest. This may occur intermittently for several months.

Nursing Care.

The following procedures should be followed when providing care to a child with rheumatic fever:

•       Nurse the child in recumbent position in a well ventilated room, with minimal disturbances.

•       Vital signs observations of temperature, pulse and respiration should be taken and recorded every two hours, and any abnormalities immediately reported to the doctor.

•       Take particular interest in the painful joints. Small soft pillows should be used to support the affected limb providing comfort. You should ensure that bed cradle is in place to keep beddings off the lower limbs.

•       The child should be on complete bed rest with all activities carried out by the nurses. You should explain to older children and their parents why such steps are being taken.

•       The child should be given light well balanced meals, you should assign one nurse to feed them if they are too ill to do it for themself or if they are in pain.

•       Slowly progressive passive exercise in bed and occupational therapy is advised. As the child’s condition improves, they will be mobilized within the ward.

•       Involve the family in the child’s care, as this care will have to continue at home. Reassure the parents that the child with rheumatic heart disease should be encouraged to continue with normal activities as far as possible and emphasize that over protection will not facilitate recovery.

Medical Treatment.
Good nursing care is the most significant remedy for this patient. However, several drugs may be given, mainly to control pain and for prophylaxis. Antibiotics, such as penicillin V, or Amoxil as prophylactic, are commonly used. Analgesics, such as aspirin or brufen, may be the alternative choice. The doses depend on the age and individual patient’s needs

Complications.
One or more complications may occur. These include heart failure, mitral stenosis, aortic valve incompetence and pericarditis. You should be on the lookout for the onset of these. 

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