Rheumatic Heart Disease - Essay Example

Running head:   RHEUMATIC HEART DISEASE.          Rheumatic heart disease     Name:       Institution:                                 Date:   Table of Contents Table of Contents 2 Rheumatic heart disease 3 Introduction 3 Rheumatic heart disease 3 Link between Rheumatic heart disease (RHD) and pregnancy 4 Role of nurses in adolescent patients with Rheumatic Heart Disease 5 Nurses in the Control of symptoms of rheumatic heart disease 6 Management of ARF 7 Heather’s health status, health education and health promotion activities 8 Secondary prevention and rheumatic heart disease control 8 Conclusion 10 References 13 Rheumatic heart disease Introduction Heather, the 16 year old indigenous girl in our case has pregnancy which worsens the rheumatic heart disease. She is equally traumatized and emotionally affected after her boyfriend abandons her. Normally, pregnancy worsens the conditions or effects of an already existing valvular disease. Predictors of raised maternal and foetal risk are minimized. LV systolic function, significant aotic or mitral stenosis, moderate or acute pulmonary hypertension, a history of heart failure and symptomatic valvular disease should be considered before getting pregnant. Her condition is a threat to her life since pregnancy can lead to heart failure especially when the blood volume and cardiac output are at the maximum. She can also experience a heart failure due to stress now that she has been abandoned by her boyfriend. In case she delivers, heart failure may also occur due to overworking of the circulation by the blood. Sub-acute bacterial endocarditis can also occur in the puerperium (Abbas, 2004). Rheumatic heart disease Rheumatic heart disease (RHD) is still a common health problem especially in the developing nations where it results to morbidity and mortality both to the children and the adults. Although comprehensive data is not available to substantiate the claim, evidence reveals that there has been little or no decline at all, of the occurrence of rheumatic heart disease in the recent past. Recent reports  from the developing countries have recorded rheumatic fever (RE) occurrence rates as high as 206/100 000 and RHD frequency rates as high as 18.6/1000. The high occurrence of RHD in the developing nations calls for an aggressive prevention and control measures to combat the menace. The main interventions measures for prevention and control of RHD include: minimization of the exposure to group A streptococci, primary prophylaxis to reduce the initial episodes of RE and secondary prophylaxis to avert recurrent episodes of RE. Since recurrent episodes of RE result to heightened severe cardiac complications, secondary prophylaxis is the most important aspect of a successful RHD program (Abbas, 2004). In some impoverished nations, secondary prophylaxis may be the only viable control and prevention measure that can be implemented. Financial and human resources can be invested and integrated with the existing primary health care systems to fight the disease. Since RHD has persistently been a regular health problem particularly in the developing nations, greater emphasis should be granted to the simple and cost-effective prevention and control strategies that are at the moment available to fight the disease (Abbas, 2004). There is a significant regional variation of the preference of RHD within nations. In Australia, ARF and RHD are highly widespread among the Aboriginal and Torres Strait Islander communities where it commonly affects the youth. Aboriginal and Torres Strait Islander individuals have eight times higher chances of being affected by the ARF and RHD than the non-Aboriginal and Torres Strait Islanders. Link between Rheumatic heart disease (RHD) and pregnancy   Heather, the 16 year old indigenous girl in our case is already pregnant which worsens her situation. She is equally traumatized and emotionally affected after her boyfriend abandons her. Normally, pregnancy worsens the conditions or effects of an already existing valvular disease. Predictors of raised maternal and foetal risk are minimized. LV systolic function, significant aotic or mitral stenosis, moderate or acute pulmonary hypertension, a history of heart failure and symptomatic valvular disease should be considered before getting pregnant. Under normal circumstances, patients with rheumatic valvular disease are properly assessed before pregnancy occurs. In case they are already symptomatic as a result of high levels of RHD, serious intervention measures should be applied before the pregnancy occurs (Saxena, 2000). In patients with moderate levels or acute mitral stenosis, percutaneous ballon mitral valvuloplasty should be taken into account due to the increased risk of maternal and foetal complications in the course of the pregnancy. Patients having mechanical valves and already in warfarin should be given suitable contraceptive advice and should be enlightened on the risks to mother and foetus with pregnancy. Though warfarin crosses the placenta, heparin usually does not. However theris a raised threat of prosthetic thrmbosis with heparin and a threat of embryopathy with warfarin particularly in the first trimester. The choise for antithrombotic treatment in the course of pregnancy are low molecular weight heparin during the first trimester and then warfarin (Saxena, 2000). Role of nurses in adolescent patients with Rheumatic Heart Disease Nurses come in hardy especially in the management of rheumatic heart disease in the adolescence. Heather’s condition is severe and requires close monitoring by nurses considering that she has been abandoned by her boyfriend and she is pregnant. Rheumatic heart disease is an auto-immune reaction to bacterial attacks by group A streptococcus (GAS). Recurrences of ARF may result to additional valve damage, and consequently worsening the RHD. Though the specific causal pathway is still unknown, it appears that some strains of GAS are rheumatogenic and that a little fraction of individuals in the population have an inbuilt vulnerability to ARF. Individuals with acute rheumatic fever are usually in great pain and need hospitalization. Through hospitalization, the nurses will have an opportunity to be actively involved in the monitoring of the patients. Irrespective of the dramatic nature of the severe episode, ARF does not leave permanent damage to the brain, joints or skin. RHD however may persist. Individuals who have had ARF formerly are much more likely than the general community to have successive episodes (Pittilleri, 2007). While it is usually thought that only upper respiratory tract infectivity with GAS can result to ARF. GAS skin infections also come in play in particular populations like the Aboriginal and Torres Strait Islander Australians. ARF is principally a disease of children aged 5-14 years of age though individuals can have persistent episodes even in their forties. The occurrence of RHD peaks in the third and fourth decades. Thus, though ARF is a disease associated with the young, its effects can be felt in the entire adulthood of an individual, particularly in the young adult years when individuals are highly productive (Saxena, 2000). Nurses in the Control of symptoms of rheumatic heart disease Since ARF has no accurate diagnostic criteria, the nurses who are close enough to the patients are involved in the diagnosis of the ARF and Rheumatic heart disease. Nurse are involved in the diagnosis of the symptoms of the infection and also in the control of the symptoms that accompany rheumatic heart disease. Some of the symptoms that the nurses focus in controlling include: fever, weight loss, fatigue, stomach pains and joint inflamation. Joint inflamation is accompanied by swelling, tenderness and rednes on the multiple joints. These inflamations moe from one joint to another over a number of days. Nurses are directly involved in the control of the complications brought about by these symptoms. The symptoms are clear indicators of the presence of rheumatic heart disease It is important that an accurate diagnosis of ARF be made. Over-diagnosis leads to unnecessary treatment over long periods while under diagnosis results to further attacks of ARF, cardiac damage and in extreme cases premature death. Diagnosis is usually a clinical decision since specific laboratory tests have not been devised.  The diagnosis of ARF is normally controlled by the ones criteria and the more recent World Health Organization (WHO) approach. Most of the clinical aspects of ARF are non-specific and thus a broad range of differential diagnosis should be taken into account. In an area with high preference of ARF, an individual with fever and arthritis has more chances of having ARF. Some post- streptococcal conditions may be confused with ARF. All the people with suspected or confirmed ARF should be subjected to echocardiography to ascertain of refute the possibility of RHD (Saxena, 2000).   Management of ARF Just like the diagnosis of the disease, the nurses are equally involved in the management of the disease in adolescence. During the first days of infection, the main priority is confirming the diagnosis. Safe for the heart failure management, none of the other treatments offered to the patients have been able to change the outcome of severe episodes or the extent of damage to heart valves. Nurses are involved in the management of complicated cases like Heather’s. The nurses are also involved in counseling the youths who might be heart broken and not willing to co-operate in the treatment of the disease.  Therefore there is no hurry to start definitive treatment. Non-steroidal anti-inflammatory medications minimize the pain of arthritis arthralgia and fever of ARF but can misdirect the diagnosis.  Paracetamol and codeine are usually suggested to minimize pain until the diagnosis is completed. Corticosteroids are at times used for acute carditis (Saxena, 2000). Heather’s health status, health education and health promotion activities Heather’ health status forces her to engage in activities that she would otherwise not be involved in. since her condition is serious due to the pregnancy she has to be subjected to the whole procedure of secondary treatment to avert the recurrence of the disease after treatment. She has to undergo a complete guiding and counseling session to control and mange stress in order to prevent the possibility of a heart attack. Other activities that he will be involved in include:  Secondary prevention and rheumatic heart disease control Secondary prevention describes the early detection of disease and implementation of strategies to avert recurrent and worsening of the menace. This also involves the nurses who are directly involved in the admistration of drugs. The nurses are also involved in the monitoring the progress of the patients and the effects of the drugs in patiens. Secondary prophylaxis with benzathine penicillin G (BPG) is the most effective and economic means of controlling the disease both at society as well as population stages. Pilot controlled trials have revealed that regular administration is necessary to avert the recurrent of ARF. Secondary prophylaxis with BPG is the most effective remedy for patients with a history of either ARF or RHD.  Safe for patients regarded to be at a relatively high risk, the commonly recommended treatment is a four-weekly dose of BPG. Patients at a high risk are given a 3-weekly treatment. Recurrences rarely occur in patients who take the four-weekly BPG treatment. Some patients may not be willing to follow the secondary treatment criteria to the later which calls for the services of the nurses. The nurses will enforce the treatment procedures to avert the recurrence of the diseases in the adolescence (Saxena, 2000).          There are alternatives to the BPG, although they are less effective and cal for careful monitoring. In patients who do not wish to take the intramuscular BPG are often given the oral penicillin which is normally less effective than BPG in averting GAS infections and the resultant recurrences of ARF. For patients using the oral penicillin, the consequences of lacking the full doses should be taken into account which calls for a careful monitoring program. Some patients may also be allergic to penicillin which will then call for the services of an allergist. Although the levels of allergic and anaphylactic reactions to monthly BPG are not significant and fatal reactions a rare phenomenon, effective monitoring is necessary in case a need arises. For patients with confirmed, immediate and severe allergic reaction to penicillin a non-beta-lactam antimicrobial such as erythromycin is recommended. In pregnant patients, like the case of Heather, penicillin prophylaxis is recommended in the course of the entire pregnancy period to avert recurrent ARF. There is though no confirmation of teratogenicity. Erythromycin is also regarded as a safe measure during pregnancy though monitored trials have not been carried out. In anticoagulated patients, treatment using the BPG injections is still applicable unless the patient suffers from uncontrolled bleeding or the international accepted standard are outside the described therapeutic window. Intramolecular bleeding is not common when BPG injections are incorporated with anti-coagulation therapy.        The appropriate period of time of the secondary prophylaxis is determined by several factors including age, time since the last occurrence of ARF, and the possible harm from recurrent ARF. All individuals should however proceed with secondary prophylaxis for a minimum of ten years after the last occurrence of ARF or until the patient attain the age of 21. Those with mild or severe RHD should proceed with secondary prophylaxis until they attain the age of 35-40 years (Kumar et al, 2007).  Infective endocarditis is a risky complication of RHD and a regular unfavorable event especially after replacement in Aboriginal and Torres Strait Islander individuals. Individuals with confirmed RHD or prosthetic valves should antibiotic prophylaxis before any strategy to produce bacteraemia such as dental procedures, surgical strategies where infection is detected.        Persistent high levels of recurrent ARF in Australia bring about the consistent failure of secondary prevention. Several factors including sociological factors integrate to limit the success of secondary prophylaxis. The main causes for poor follow up in individual among the Aboriginal and Torres Strait Islanders are the accessibility and suitability of health services as opposed to personal factors like injection rejection due to pain of the injection or failure to understand ARF and RHD. Adherence is enhanced when patients have a feeling of personalized care in regard to the health facility and when follow up systems extend outside the barriers of the community (Kumar et al, 2007). Conclusion        Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are prevalent at very high rates among the Aboriginal and Torres Strait Islander individuals. These ailments mostly affect the young people and significant causes of premature mortality. Almost all the RHD infections and the resultant deaths are preventable (Fae et al 2006).        The National Heart Foundation of Australia (NHFA) together with Cardiac Society of Australia and New Zealand (CSANZ) has spotted various factors that result to inadequate prevention and management of RHD. Strategies to combat the ailments are inadequately implemented in the communities at highest risk of contracting the ailments though they are cheap, simple and easy to execute. Majority of health officials including the clinicians have scanty first hand experience in regard to the diseases since ARF and RHD are rare in the metropolitan areas where they are trained.  The variability of the management of the diseases is thus large due to lack of first hand experience and the latest training in the management of the same. The populations living in highly prevalent areas of RHD have little or limited access to health facilities which is a big blow to the management of the disease (Porth, 2004).  References Abbas, L. (2004). Basic Immunology: Functions and Disorders of the Immune System. New York: Elsevier Inc.   Faé KC. et al. (2006).  "Mimicry in recognition of cardiac myosin peptides by heart- intralesional T cell clones from rheumatic heart disease". J. Immunol. 176 (9):  Kumar, V. et al. (2007). Robbins Basic Pathology (8th ed.). New York: Saunders Elsevier. pp. 403-406  Pittilleri, A. (2007) Maternal & Child Health Nursing: Care of the Chilbearing Family. Philadelphia: Lippincott Williams & Wilkins. Porth, C. (2007). Essentials of pathophysiology: concepts of altered health states. Hagerstown, MD: Lippincott Williams & Wilkins.  "Rheumatic Heart Disease/Rheumatic Fever". American Heart Association. March 27,  2010,   Saxena, A.(2000). "Diagnosis of rheumatic fever: Current status of Jones criteria and role of echocardiography". Indian Journal of Pediatrics 67 (4): 283–6. Read More