Senin, 16 Mei 2011
1. Definition
Rheumatic heart disease is the sequelae of rheumatic fever (DR) which is also an acute inflammatory disease that can accompany acute pharyngitis caused by Streptococcus group A beta-hemolyticusThese diseases tend to be repetitive and is seen as a cause of acquired heart disease in children and young adults worldwide.
2. Etiology
Streptococcus Infection of group A beta-hemolyticus the throat always precede the occurrence of rheumatic fever, both in the first attack and attack again.
It is known that in the event there are several predisposing rheumatic fever include:
a. There is a history of rheumatic fever in the family
b. Age
DR often occurs between the ages of 5-15 years and rarely at the age of less than 2 years.
c. Social Kedaan
Often occur in families with social and economic conditions less, bad housing with residents who crowded and humid air, and nutrition and ill health.
d. Season
In countries with 4 seasons, there is a high incidence in late winter and early spring (March-May) while the lowest incidence in August-September.
e. Dsitribusi area
f. Previous rheumatic fever attack.
DR after repeated attacks of reinfection with Streptococcus group A beta-hemolyticus is often in children who previously had received DR.
3. Pathophysiology
According to the hypothesis Kaplan et al (1960) and Zabriskie (1966), DR occurs because of the presence of an autoimmune process or antigenic similarity between human tissue and somatic antigen streptococcus. If the body is infected by Streptococcus group A beta-hemolyticus the foreign antigen is immediately formed immunologic reaction of antibody. Due to the nature of this antigen as the antibody component will also attack the tissues of the body in this case with myocardial sarcolemma due to the presence of antibodies against cardiac tissue in serum penderiat DR and damaged myocardial tissue. One toxin that may play a role in the incidence of DR is stretolysin titer of 0, a product extraseluler Streptococcus group A beta-hemolyticus known to be toxik of myocardial tissue.
Some of the various somatic streptococcal antigen settle for a short time and yet another for a long time. Serum imunologlobulin be elevated in patients with streptococcal sore especially after getting Ig G and A.
4. Clinical manifestations
Associated with diagnosis, clinical manifestations of acute DR differentiated into major and minor manifestations.
a. Major manifestations
• Karditis. Rheumatic Karditis an active inflammatory process of endokardium, myocardium, and pericardium. The initial symptoms are feeling tired, pale, and anorexia. Karditis clinical signs include tachycardia, dysrhythmias, noisy pathological, the kardiomegali in radiology that more and more enlarged, of heart failure, and signs of pericarditis.
• Arthritis. Arthritis occurs in approximately 70% of patients with rheumatic fever, a motion was not intentional and is not intended or inkoordinasi muscular, usually in the facial muscles and ektremitas.
• Erythema marginatum. Erythema marginatum was found in approximately 5% of patients. No itching, macular, with the edge of erythema that spread around the skin that looks normal.tersering of the trunk and proximal limbs, and does not involve the face.
• Nodulus subcutaneous. Found in approximately 5-10% of patients.Nodules measuring between 0.5 - 2 cm, no pain, and may be freely moved. Generally found in surface ekstendor joints, especially elbows, knuckles, knees, feet and joints.
b. Minor Manifestation
Minor manifestations of acute rheumatic fever may include fever is remittances, antralgia, abdominal pain, anorexia, nausea, and vomiting.
5. Inspection Diagnostic / peninjang
a. Blood tests
a. LED is very tall
b. Lekositosis
c. Low hemoglobin values may
b. Bacteriological examination
• remove throat cultures to prove existence of streptococcus.
• serological examination. Titer measured Asto, astistreptokinase, anti-hyaluronidase.
c. Radiological examination
Elektrokardoigrafi and echocardiography to assess cardiac abnormalities.
6. Diagnosis
Diagnosis of acute rheumatic fever diagnosis based on the revised Jones criteria. Because pathological clinical manifestations depend on the details of diagnosis should be referred to clinical manifestations, such as rheumatic fever with poliatritis only. The existence of two major criteria or one major and two minor criteria indicates the possibility of acute rheumatic fever, if supported by evidence of group A previous sterptokokus infection.
7. Complication
a. Cordis decompensation
Decompensation cordis events in infants and children describe the clinical syndrome due to the presence of myocardium is not able to meet the metabolic needs, including growth. This situation arose because of excessive heart muscle, usually due to cardiac structural abnormalities, abnormalities of the heart muscle itself, such as inflammatory process or a combination of both factors.
In general, bad heart in children treated with digitalis and classic drugs of diuretics. The aim of treatment is to relieve symptoms (symptomatic) and most importantly treat the primary disease.
b. Pericarditis
Inflammation in pericard visceralis and parietal inflammatory reactions varying from mild to tertimbunnnya fluid in the cavum pericard.
8. Treatment / management
Because rheumatic fever is closely related to inflammation of Streptococcus group A beta-hemolyticus, the eradication and prevention directed at these inflammation. This can be:
a. Germ eradication of Streptococcus group A beta-hemolyticus
Adequate treatment should be started immediately in the DR and continue with prevention. Erythromycin given to those who are allergic to penicillin.
b. Anti-rheumatic drug
Both cortocisteroid or salicylate is known as a useful drug to reduce / eliminate the symptoms of acute inflammation in the DR.
c. Diet
Foods that enough calories, protein and vitamins.
d. Break
Rest is recommended until the signs of inflammation disappeared and smaller heart shape on kardiomegali cases. Usually 7-14 days in the case of DR minus carditis. In the case of plus carditis, long break an average of 3 weeks - 3 months depending on the severity of abnormalities that exist and the progress of the disease.
e. Other Drugs
Given according to need. In cases with cardiac decompensation given digitalis, diuretics and sedatives. If there chorea given largactil and others.
NURSING CONCEPTS
1. Assessment
Perform routine physical assessment
Get medical history, especially regarding the evidence antesenden streptococcal infection.
Observation of the manifestation of rheumatic fever.
2. Nursing Diagnosis
a. High risk associated with decreased cardiac dysfunction myocardium
b. Increased body temperature (hyperthermia) associated with the process of disease infection.
c. Nutrition is less than the needs associated with nausea, vomiting, anorexia.
d. Pain associated with inflammation.
3. Nursing Plan
a. High risk associated with decreased cardiac dysfunction myocardium
Objective: Patients can indicate cardiac repair.
Rational Interventions
Give digoxin as instructed, using the precautions that have been determined to prevent toxicity.
Review signs of digoxin toxicity (nausea, vomiting, anorexia, bradycardia, dysrhythmias)
Often taken an EKG rhythm strip
Ensure adequate potassium input
Observation of signs of hypokalemia
Give drugs to reduce afterload according to instructions can improve cardiac output
To prevent the occurrence of toxicity
Assessing cardiovascular status
Decrease in serum potassium levels will increase digoxin toxicity
b. Increased body temperature (hyperthermia) associated with the process of disease infection.
Objectives: Normal body temperature (36-37 'C)
Rational Interventions
Assess current fever
Observation of vital signs: temperature, pulse, BP, breathing every 3 hours
Give an explanation of the causes of fever or increased body temperature
Give an explanation to the client and family about the things done
Explain the importance of bed rest for the client and the consequences if it is not done
Encourage clients to drink lots of approximately 2.5 to 3 liters / day and explain its benefits
Give a warm compress and recommend wearing thin clothing
Give antipyretic can be identified in accordance with the instructions of the pattern / level of fever
Vital signs are a reference to determine the client's general objec
An explanation of the conditions dilami clients can help reduce the anxiety of clients and families
To overcome the fever and encourage clients and families to more cooperative
Family involvement is very significant in the healing process in the RS client
Increased body temperatures cause increased evaporation of body fluids that need to be balanced with a lot of fluid intake
Compress will be able to help lower body temperature, thin clothing can help to increase the body heat of vaporization
Antipiretika that have receptors in the hypothalamus to regulate body temperature so that the body temperature near normal temperature strived
c. Nutrition is less than the needs associated with nausea, vomiting, anorexia.
Objectives:
Client's nutritional needs are met, clients are able to spend the food that has been provided.
Rational Interventions
Review the causative factors
Explain the importance of adequate nutrition
Encourage clients to eat in small portions and frequent, if not vomiting continue
Perform good oral care after vomiting
Measure BB every day
Record amount spent serving clients
Determination of factors, will determine the intervention / follow-up
Increasing knowledge of the client and family so that clients are motivated to consume food
Avoid nausea and vomiting and excessive abdominal distension
An unpleasant smell in the mouth increases the likelihood of vomiting
BB is an indicator of whether or not nutritional needs are met
Knowing the amount of intake / nutrition fulfillment clients
d. Pain associated with inflammation.
Objectives: Pain is reduced or lost
Rational Interventions
Assess the level of pain experienced by the client by providing a range of pain (1-10), specify the type of pain and response to pain experienced by patients
Assess the factors that influence the patient's reaction to pain
Provide a comfortable position, keep the situation quiet room
Give a happy atmosphere for patients, pasian divert attention from pain (involve family)
Provide opportunities for clients to communicate with friends / people closest
Give appropriate analgesic drugs instructions To know how many levels of pain experienced
Patient reaction to pain can be influenced by various factors as are also different individual response to pain varies dab
Reducing the pain caused excitatory external stimulus
By doing other activities, clients can forget little attention to pain experienced by
Stay in touch with the people closest / friends making the patient happy / unhappy and turned his attention to pain dapaty
Reducing pain with pharmacologic effects
REFERENCES
Arief Mansjoer, et al. 2000. Capita Selekta Medicine. Ed. 3. Media Publisher
Aesculapius FKUI. Jakarta.
Bare Smeltzer, et al. 2000. Medical Surgical Nursing. EGC. Jakarta.
Donna L. Wong 2004. Pediatric Nursing. EGC. Jakarta
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