Rhuematic Heart Disease

UNIVERSITY OF SAINT ANTHONY
(Dr. Santiago G. Ortega Memorial)

City of Iriga
HEALTH CARE EDUCATION DEPARTMENT
CASE ANALYSIS:
RHUEMATIC HEART DISEASE
Prepared by:
GROUP 5
Members:
Marasigan, Peter
Meniano, Xyra Shaine
Nang, Mary Mae C.
Nava, Patrick
Navales, Hillary Ross
Santillan, Mary Joyce
Sapinoso, Aprille Zellene D.
Sarahan, Keith Sherry
Sergio, Melfie Erin D.

City of Iriga
Introduction
According to World Health Organization Rheumatic heart disease starts as a sore

throat from a bacterium called Streptococcus pyogenes (group A streptococcus) which
can pass easily from person to person in the same way as other upper respiratory tract
infections. Strep infections are most common in childhood. In some people, repeated
strep infections cause the immune system to react against the tissues of the body
including inflaming and scarring the heart valves. This is what is referred to as
rheumatic fever. Rheumatic heart disease results then from the inflammation and
scarring of heart valves caused by rheumatic fever.
Rheumatic fever mostly affects children and adolescents in low- and middle-
income countries, especially where poverty is widespread and access to health services
is limited. People who live in overcrowded and poor conditions are at greatest risk of
developing the disease. Where rheumatic fever and rheumatic heart disease are
endemic, rheumatic heart disease is the principal heart disease seen in pregnant
women, causing significant maternal and perinatal morbidity and mortality. Pregnant
women with rheumatic heart disease are at risk of adverse outcomes, including heart
arrythmias and heart failure due to increased blood volume putting more pressure on
the heart valves. It is not uncommon for women to be unaware that they have
rheumatic heart disease until pregnancy.
In accordance with WHO it most commonly occurs in childhood, and can lead to
death or life-long disability. Every year, the disease claims 288,348 lives worldwide. It
also accounts for about 2% of deaths from cardiovascular diseases—the number one
cause of death globally. According to the latest WHO data published in 2020 Rheumatic
Heart Disease Deaths in Philippines reached 1,807 or 0.27% of total deaths. The age
adjusted Death Rate is 1.81 per 100,000 of population ranks Philippines #75 in the
City of Iriga
world. Review other causes of death by clicking the links below or choose the full health
profile.
PHILHEALTH Circular no. 2019 / 0005 “Outpatient Benefit Package for

the Secondary Prevention of Rheumatic Fever / Rheumatic Heart Disease”
City of Iriga
Learning Objectives:
At the end of the discussion, students will be able to:
 To define and understand the Rheumatic Heart Disease.

 To Identify the Anatomic structures and Pathophysiology responses of Rheumatic
Heart Disease.
 To Identify and differentiate the signs and symptoms of Rheumatic Heart
Disease.
 Know the basic concepts about the interventions and treatment for a patient with
Rheumatic Heart Disease.
 Know the pharmacological and surgical interventions for Rheumatic Heart
Disease.
 Formulate an appropriate nursing care plan (NCP) for a patient with Rheumatic
Heart Disease.
 Give recommendations and suggestions on the management of a person with
Rheumatic Heart Disease.
Patient Data & Brief History
Patient Data
Patient Nicanor, 56-year-old man, was admitted in the hospital because of chest
pain. " Sumasakit ang dibdib ko kaya punta na kami dito sa ospital, dati na rin kasi na
sabi ng Doctor na may sakit ako sa puso" as verbalized by the patient. "Nahihirapan din
ako matulog dahil sa sakit, maya't maya ako nagigising" he added. During the
City of Iriga
interview, patient Nicanor mention that he is experiencing difficulty in urination. The

nurse observed that the patient is experiencing discomfort and looks restlessness. Upon
admission, vital sign was taken as BP:100/80 mmHg, CR: 89 bpm, RR: 20 cpm, OSAT:
97%, T: 36.7 C and Pain Scale of 6/10.
Patient Data:
Name: Nicanor, V.
Age: 56 y/o
Gender: Male
Religion: Roman Catholic
Patient History:
 There are no stated family inherited diseases but Patient Nicanor stated his signs
and symptoms.
 He is diagnosed with Rheumatic Heart Disease way back 2019.
Brief History:
 Patient Nicanor stated that he experience chest pain, sleep deprivation and
difficulty in urination.
Background
Gordon's 11 Typology of Functional Health Pattern
1. Health Perception/Health management

Prior: Aware of his condition but doesn't exactly understand it.
City of Iriga
During Hospitalization: Coherent, willing to accept and listen to health

teachings, and practices healthy lifestyle.
2. Nutritional-Metabolic Pattern
Prior: Eating unhealthy foods
During Hospitalization: Low Salt, Low fat with SAP
3. Elimination Pattern
Prior: having difficulty in urination.
During Hospitalization: Normal urination and bowel movement.
4. Activity-Exercise Pattern
Prior: He lives in unhealthy lifestyle
During Hospitalization: Upon admission his vital signs taken as Bp:100/80 T:
36.7 CR: 89 RR: 20 OSAT: 97%
5. Sleep-Rest Pattern
Prior: Experiencing sleep deprivation
During Hospitalization: able to sleeps for at least 8 hrs.
6. Cognitive-Perception Pattern
Prior: No sensory deficits, oriented to people, time, and place
During Hospitalization: All senses were all responsive to medical procedures.
7. Self-Perception/Self-Concept Pattern
Prior: Patient is willing to know more about his medical condition and is ready to
undergo treatment
City of Iriga
During Hospitalization: Patient is open and can express his thoughts and
feelings, and willing to cooperate with all the treatment and interventions needed
to be done.
8. Role Relationship Pattern

Prior: Married, has healthy relationship with his family and friends.
During Hospitalization: He is supported by his family.
9. Sexually-Reproductive Pattern
Prior: Patient has no history of reproductive trauma and any disease affecting
his genitals.
During Hospitalization: He has a healthy reproductive organ.
10. Coping-Stress Tolerance Pattern

Prior: Patient is anxious about his experience of chest pain, chest pain, sleep
deprivation and difficulty in urination.
During Hospitalization: He verbalized desire to recover, and able to accept
situation by cooperating with the medical advice and procedures.
11. Value/Belief Pattern

Prior: Roman Catholic, not a religious person.
During Hospitalization: No restriction in the procedures brought by religion,
and the admission does not interfere with spiritual practice
Anatomy and Physiology
Anatomy of the Heart

City of Iriga
(Michigan Medicine (2019) Anatomy of a Human Heart Retrieved from https://healthblog.uofmhealth.org/heart-

health/anatomy-of-a-human-heart )
Functions of the Heart
1. Generating Blood Pressure

2. Routing Blood
3. Ensuring One-way blood flow
4. Regulating Blood Supply
Heart Chambers
(Cleveland Clinic (2022) Chambers of the Heart

Retrieved from
https://my.clevelandclinic.org/health/body/23074-
heart-chambers)
City of Iriga
Heart Valves
(Heart and Stroke Foundation. Valvular

heart diseases from
https://www.heartandstroke.ca/heart-
disease/conditions/valvular-heart-
disease )
(Adam Pick (2020) Rheumatic Fever & Heart Valve

Disease: 8 Important Facts for Patients from
https://www.heart-valve-surgery.com/rheumatic-
fever.php)
(Dr. Nabi Darya Vali (2018) Rheumatic Heart Disease from

https://www.myupchar.com/en/disease/rheumatic-heart-
disease)
Pathophysiology
City of Iriga
Rheumatic heart disease is the result of valvular damage caused by an abnormal

immune response to Streptococcus pyogenes infection, which is classified as a group A
streptococcus that causes acute rheumatic fever. Acute rheumatic fever occurs around
three weeks after group A streptococcal pharyngitis and can affect joints, skin, brain,
and heart. After multiple episodes of rheumatic fever, progressive fibrosis of heart
valves can occur, which can lead to rheumatic valvular heart disease. If valvular heart
disease remains untreated, then heart failure or death may occur. The precise
pathophysiology is not well known. Rheumatic carditis is characterized by Aschoff
nodules and MacCallum plaques. Aschoff bodies are seen in nodules in the hearts
affected with rheumatic fever. They result from inflammation in the heart muscle.
MacCallum plaques are seen on the valves and the subendocardium in the left atrium
Manifestations and Rationale
A recent history of strep infection or rheumatic fever is key to the diagnosis of

rheumatic heart disease. Symptoms of rheumatic fever vary and typically begin 1 to 6
City of Iriga
weeks after a bout of strep throat. In some cases, the infection may have been too mild
to have been recognized, or it may be gone by the time the person sees a doctor.
These are the most common symptoms of rheumatic fever:
 Fever
 Swollen, tender, red and extremely painful joints — particularly the knees and
ankles
 Nodules (lumps under the skin)
 Red, raised, lattice-like rash, usually on the chest, back, and abdomen
 Shortness of breath and chest discomfort
 Heart murmur
 Uncontrolled movements of arms, legs, or facial muscles
 Weakness
Symptoms of rheumatic heart disease depend on the degree of valve damage

and may include:
 Shortness of breath (especially with activity or when lying down)

 Chest pain
 Swelling
 Irregular or rapid heartbeats (heart palpitations)
 Shortness of breath
 Fatigue or weakness
 Light-headedness, dizziness or near fainting
 Swelling of the stomach, feet, or ankles
When to see a doctor:

City of Iriga
Contact your healthcare provider if you experience new or worsened symptoms,

including:
 Confusion.
 Difficulty breathing.
 Chest pain.
 Swelling or pain in your lower body.
Diagnostic Studies
 Echocardiogram- This test uses sound waves to check the heart's chambers
and valves. The echo sound waves create a picture on a screen as an ultrasound
transducer is passed over the skin overlying the heart. Echo can show damage to
the valve flaps, backflow of blood through a leaky valve, fluid around the heart,
and heart enlargement. It’s the most useful test for diagnosing heart valve
problems.
 Electrocardiogram-This test records the strength and timing of the electrical
activity of the heart. It shows abnormal rhythms (arrhythmias or dysrhythmias)
and can sometimes detect heart muscle damage. Small sensors are taped to
your skin to pick up the electrical activity.
 Chest X-ray- May be done to check your lungs and see if your heart is
enlarged.
 Cardiac MRI- This is an imaging test that takes detailed pictures of the heart. It
may be used to get a more precise look at the heart valves and heart muscle.
 Blood tests- Certain blood tests may be used to look for infection and
inflammation.
City of Iriga
Interventions and Treatments
There is no cure for rheumatic heart disease and the damage to the heart valves
are permanent. Patients with severe rheumatic heart disease will often require surgery
to replace or repair the damaged valve or valves.
Surgery for rheumatic heart disease:
 Closed mitral valvotomy

 Mitral valve repair
 Replacement with mechanical, bioprosthetic, and autograft valves
Heart valve repair
The Doctor will recommend heart valve repair to preserve heart valve. To repair
a heart valve, surgeons might:
 Patch holes in a valve

 Separate valve leaflets that have fused
 Replace the cords that support the valve
 Remove excess valve tissue so that the valve can close tightly
Surgeons often tighten or reinforce the ring around a valve (annulus) by

implanting an artificial ring. In some cases, doctors use less invasive procedures to
repair certain valves using long, thin tubes (catheters). These procedures can involve
the use of clips, plugs or other devices.
Heart valve replacement
If the valve can't be repaired, surgeons might remove the damaged valve and
replace it with a mechanical valve or a valve made from cow, pig or human heart tissue
(biological or tissue valve).
City of Iriga
If the patient had valve replacement with a mechanical valve, the patient will
need to take blood thinners for the rest of his/her life to prevent blood clots. Biological
tissue valves break down over time and usually need to be replaced.
A minimally invasive procedure called transcatheter aortic valve

replacement (TAVR) may be used to replace a damaged aortic valve. In this
procedure, the doctor inserts a long, thin tube (catheter) into an artery in the patient’s
leg or chest and guides it to the heart valve. A replacement valve is moved through this
catheter to the correct position.
Pig Valve Replacements
Interestingly, a pig’s heart is similar in size, weight, and structure to a human’s

heart. Hearts are harvested from freshly killed pigs. This is done under clean conditions
and the porcine tissue is refrigerated right away.
The pig valve is typically mounted to a stent (frame) that can be reinforced with
Dacron cloth and sutures.
After mounting, the valve is checked microscopically and cultures are taken.
Cotton can be used to maintain proper structure (geometry) and the valve is placed in a
sterile cup. To preserve the tissue, the valve is often placed in glutaraldehyde to reduce
possible failure or rejection of the valve by the recipient.
Pharmacological Interventions
Warfarin
This medication is used to treat blood clots (such as in deep vein thrombosis-
DVT or pulmonary embolus-PE) and/or to prevent new clots from forming in your body.
Preventing harmful blood clots helps to reduce the risk of a stroke or heart attack.
City of Iriga
Conditions that increase your risk of developing blood clots include a certain type of
irregular heart rhythm (atrial fibrillation), heart valve replacement, recent heart attack,
and certain surgeries (such as hip/knee replacement).
Warfarin is commonly called a “blood thinner”, but the more correct term is
"anticoagulant." It helps to keep blood flowing smoothly in your body by decreasing the
amount of certain substances (clotting proteins) in your blood.
Metolazone
Metolazone is a "water pill" (diuretic) that increases the amount of urine you
make, which causes your body to get rid of excess water. This drug is used to treat
high blood pressure. Lowering high blood pressure helps prevent strokes, heart attacks,
and kidney problems. This medication also reduces swelling/fluid retention (edema)
which can result from conditions such as congestive heart failure or kidney disease. This
can help to improve symptoms such as trouble breathing.
Drug Study 1
DRUG NAME MECHANISM OF ACTION ADVERSE/SIDE EFFECT NURSING

CONSIDERATIONS
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Generic Name:   
Brand Name:
CONTRA-INDICATIONS
Classification: 
Dosage
Forms:
Route:
Indications:
Drug Study 2
DRUG NAME MECHANISM OF ACTION ADVERSE/SIDE EFFECT NURSING

CONSIDERATIONS
City of Iriga
Generic Name:   
Brand Name:
CONTRA-INDICATIONS
Classification: 
Dosage
Forms:
Route:
Indications:
Prognosis
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Rheumatic heart disease has no permanent cure, and the damage to the heart
valves is irreversible. Depending on the disease severity, medications are needed to
treat symptoms of heart failure or heart rhythm abnormalities. In the case of serious
diseases, the long-term prognosis is highly variable. surgical repair or replacement of
diseased valves has greatly improved the outlook for patients with RHD.
The prognosis of RHD may be stated to be more dependent on the infection at

work in the heart than on the actual structural change in this organ. it is a continued or
frequently repeated active infection in the heart which eventually eripples the patient.
Rheumatic Heart Disease can ensue in adults with single or recurrent attacks of RF.
Nursing Care Plan 1
Name of the patient: Patient N.V Age: 57 y/o

Address: Chief Complaint: Chest Pain/ discomfort
ASSESSME NURSIN INFERE PLANNING INTERVENTI RATIONALE EVALUATION
NT G DX NCE ON
SUBJECTIV Acute At the end of 8 hrs INDEPENDEN  Useful in At the end of 8 hrs
E DATA: Pain of Nsg. Intervention T: evaluatin of Nsg. Intervention
"Sumasakit r/t the patient will be  Assess g pain, the patient was
ang dibdib ko inflammati able to: verbal and choice of able to:
kaya punta on of the nonverbal interventi  Describes
na kami dito synovial  Report pain is reports of ons, the satisfactory
sa ospital, membran relieved or pain, effectiven pain control at
dati na rin e as controlled. noting ess of a level.
kasi na sabi evidenced  follow the location, therapy  demonstrates
ng Doctor na by verbal intensity  Vital the use of
prescribed
may sakit ako report of pharmacologic (0–10 signs can appropriate
sa puso" as pain 6/10. scale), and be diversional
al regimen.
verbalized by duration. altered in activities and
 verbalize
the patient.  Monitor acute relaxation
nonpharmacol
ogical methods the client's pain, it is skills.
Pain Scale: that provide vital Signs. necessary  Displays
6/10 relief.  Encourage to have improved well-
(+) chest  demonstrate the patient baseline being such as
pain the use of to use data r/t baseline levels
relaxation the for pulse, BP,
relaxation
skills and techniques client's respirations,
OBJECTIVE : guided current and relaxed
DATA: diversional
activities, as imagery, condition. muscle tone or
indicated, for soft music,  Help body posture.
and refocus  Displays
City of Iriga
Vital Signs the individual progressiv attention improvement

taken as: situation. e and assist in mood, and
relaxation. the coping. patient
BP:100/80 patient to uses
CR: 89 bpm DEPENDENT: manage pharmacologic
RR: 20 cpm  Administer pain al and
T: 36.7 C medication and/or nonpharmacol
OSAT: 97% s such as discomfor ogical pain-
analgesics, t more relief
as effectivel strategies.
indicated. y.
 Evaluate  To
and maintain
document an
the client's "acceptab
response le" level
to of pain.
medication notify the
s physician
(analgesia) if the
and assist regimen
in is
transitionin inadequat
g or e to meet
altering the pain
the drug control
regimen, goal.
based on  Increasin
individual g or
needs and decreasin
protocols. g dosage,
stepped
program
COLLABORAT helps in
IVE: self-
 Collaborat managem
e in the ent pain.
treatment  To easily
of manage
underlying the pain
conditions and
or disease discomfor
processes t of the
causing patient.
pain.  Promotes
 Provide active,
individualiz rather
ed physical than
therapy or passive,
exercise role and
programs enhances
that can the sense
be of
continued control.
by the
client after
the
discharge.
City of Iriga
4/4 GOALS MET

Nursing Care Plan 2

ASSESSME NURSI INFEREN PLANNING INTERVENTI RATIONAL EVALUATION
NT NG DX CE ON E
SUBJECTIVE Decrease At the end of 8 INDEPENDEN  Persons At the end of 8 hrs
DATA: d Cardiac hrs of Nsg. T: with of Nsg. Intervention
"Sumasakit Output r/t Intervention the  Review acute or the patient was able
ang dibdib ko a patient will be clients at acute to:
kaya punta na disturban able to: risk as chronic  Describes
kami dito sa ce in the noted in condition satisfactory
ospital, dati closure of  Display related s may pain control at
na rin kasi na the mitral hemodynami factors and comprom a level.
sabi ng valve c stability. defining ise  demonstrates
Doctor na (valve (e.g., Blood characterist circulatio the use of
may sakit ako stenosis) pressure, ics, as well n and appropriate
sa puso" as dysfunctio cardiac as place diversional
verbalized by n due to output, renal individuals excessive activities and
the patient. establishe perfusion/Uri with demands relaxation
d nary Output, conditions on the skills.
rheumatic and that stress heart.  Displays
heart peripheral the heart.  To assess improved well-
OBJECTIVE disease as  Evaluate for signs being such as
DATA: pulses.
manifeste  Report/ client of poor baseline levels
d by a demonstrate reports and ventricula for pulse, BP,
Vital Signs decreased evidence of r function respirations,
decreased
taken as: in blood episodes of extreme and/or and relaxed
pressure, fatigue, impendin muscle tone or
angina and
and dysrhythmias and g cardiac body posture.
BP:100/80
fatigue intolerance failure.  Displays
CR: 89 bpm .
 Demonstrate for activity.  To improvement in
RR: 20 cpm
an increase  Monitor the establish mood, and
T: 36.7 C
in activity Vital Signs baseline coping. patient
OSAT: 97%
tolerance. of the data uses
 Verbalize client. related to pharmacologica
knowledge of Auscultatio the l and
the disease n of heart client’s nonpharmacolo
process, sounds current gical pain-relief
individual note the condition strategies.
risk factors, extra heart .
and sounds, a
treatment gallop  To
plan rhythm, determin
and a
City of Iriga
systolic e the
murmur therapeut
ic,
DEPENDENT: adverse,
 Administer or toxic
blood or effects of
fluid therapy.
replacemen  To
t, prevent
antibiotics, bolus/
diuretics, overdose.
and
vasopresso  Helps
rs, as determin
indicated. e the
 Monitor the underlyin
rate of IV g cause.
drugs  which
.
closely, may
using indicate
infusion deteriorat
pumps, as ing
appropriate cardiac
. function.
COLLABORATI
VE:
 Review
laboratory
data and
diagnostic
studies.
 Review
"danger"
signs
requiring
immediate
physician
notification
.
4/4 GOALS MET
Nursing Care Plan 3

City of Iriga

ASSESSME NURSIN INFEREN PLANNING INTERVENTI RATIONALE EVALUATION
NT G DX CE ON
SUBJECTIVE Disturbed At the end of INDEPENDENT  Sleep At the end of 8 hrs
DATA: Sleep 8 hrs of Nsg. : problems of Nsg. Intervention
"Nahihirapan Pattern r/t Intervention  Identify can arise the patient was able
din ako chest the patient will presence of from to:
matulog dahil discomfort be able to: factors internal  Identify
sa sakit, as known to factors individually
maya't maya evidenced  Identify interfere and may appropriate
ako by individuall with sleep require interventions to
nagigising" as unintentio y including assessme promote sleep.
verbalized by nal appropriat current nt over  Report
the patient. awakening e illness time to Improved
due to interventi (RHD). differentia Sleep.
OBJECTIVE discomfort ons to  Note te specific  Report
DATA: promote nursing cause (s). increased sense
sleep. observation  To of well-being
 Report s of monitor and feeling
(+) sleeping patient's rested.
Restlessness Improved
Sleep. and wakeful sleep
(+) behaviors. patterns.
Discomfort  Report
increased Record  This
sense of number of regimen
Vital Signs: well-being sleep hours. may help
Bp:100/80 and Note to
CR: 89 bpm feeling physical soothes
RR: 20 cpm rested circumstanc and
T: 36.7 C es (chest relaxes
OSAT: 97% discomfort) the pt.
that  Pharmaco
interrupt logical
sleep. regimen
 Provide may help
non- to relieve
pharmacolo pain and
gical to provide
regimen patient to
(e.g., calm sleep
environmen during
t & comfort night
measures). time.
  For
DEPENDENT: specific
 Administer interventi
medications ons
such as and/or
sedatives therapies,
. including
and pain
relief medicatio
medications ns,
, as biofeedba
prescribed ck.
the the
physician
City of Iriga
before
bedtime.
COLLABORATI
VE:
 Refer to
physician or
sleep
specialist as
indicated.
3/3 GOALS MET
RECOMMENDATION
 Eating a heart-healthy diet.

 Maintaining a healthy weight.
 Getting regular physical activity
 Managing stress
 Avoiding tobacco
 Take medications as prescribed
REFERENCES:
 WHO, (2020 ). PHILIPPINES: RHEUMATIC HEART DISEASE, Retrieved January

11, 2023, from https://www.worldlifeexpectancy.com/philippines-rheumatic-
heart-disease
 Ballelos, P. & Balderas J. , (2019). RHD Action Small Grant Supports Efforts for
National Roll-Out of RHD Care in the Philippines, Retrieved January 11, 2023,
from https://rhdaction.org/news/rhd-action-small-grant-supports-efforts-
national-roll-out-rhd-care-philippines
City of Iriga
 WHO, (2023).Rheumatic Heart Disease, Retrieved January 11, 2023, from

https://www.who.int/health-topics/rheumatic-heart-disease#tab=tab_1
 Philhealth,( 2019). Phihealth Circular no. 2019 / 0005, Retrieved January 11,
2023, from https://www.philhealth.gov.ph/circulars/2019/circ2019-0005.pdf
 Johns Hopkins,(2023). Rheumatic Heart Disease, Retrieved January 11, 2023,
from ,
https://www.hopkinsmedicine.org/health/conditions-and-diseases/rheumatic-
heart-disease#:~:text=Symptoms%20of%20rheumatic%20heart%20disease
%20depend%20on%20the%20degree%20of,Swelling Cleveland Clinic, (2023).
 Rheumatic Heart Disease: Definition, Causes, Prevention & Treatment, January
11, 2023, from https://my.clevelandclinic.org/health/diseases/21485-rheumatic-
heart-disease

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UNIVERSITY OF SAINT ANTHONY

(Dr. Santiago G. Ortega Memorial)

HEALTH CARE EDUCATION DEPARTMENT