2.

Acquired Heart Disease

Luz B. Ubana, RN, MAN

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Acquired Heart Disease
• A. Rheumatic Fever
• B. Kawasaki Disease
• C. Bacterial Endocarditis

Luz B. Ubana, RN, MAN

2
Rheumatic Fever
• Description
• Rheumatic fever is an autoimmune
disease that occurs as a reaction to a
group A beta-hemolytic streptococcus
• infection.
• Inflammation from the immune response
leads to fibrin deposits on the
endocardium & valves, in particular the
mitral valve, & the major body joints.
*** LUZ B. UBANA, R.N., M.A.N. *** 3
• It often follows an attack of pharyngitis,
tonsillitis, scarlet fever, strep throat or
impetigo because the organism common
to these infections is a group A beta-
hemolytic streptococcus.

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• It occurs most often in children 6 to 15
years of age, with a peak incidence at 8
years.
• Because streptococcal infections recur,
rheumatic fever can also recur.
• It is seen most often in socioeconomically
• Depressed urban areas.
• The course of rheumatic fever is 6 to 8
weeks.
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• Assessment Findings
• Major:
• Carditis with systolic murmur & prolonged
P-R & QT intervals on electrocardiogram.
• Chorea (involuntary limb movement) along
with dysfunctional speech, weak or
spasmodic hand grasp, & facial
expression changes
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• Subcutaneous nodules by the joints
• Polyarthritis with swollen & tender joints
• Erythema marginatum(macular rash
primarily on trunk)
Minor
• Fever
• Arthralgia

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• History of previous rheumatic fever
• Elevated sedimentation rate(ESR) & C-
reactive protein levels
• Prolonged PR Interval

• Nursing Implications
• Maintain bed rest during the acute phase of
illness until the erythrocyte sedimentation
rate decreases & C-reactive

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• Protein level & pulse rate return to normal.
• Frequently assess the child’s vital signs,
including apical pulse while awake &
sleeping, for changes.
• Administer penicillin as prescribed to treat
the infection; give as a single
intramuscular injection of benzathine
penicillin; use erythromycin in children

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• Who are sensitive to penicillin.
• Administer oral salicylates to reduce
inflammation & pain; monitor for symptoms
of aspirin toxicity that may result from the
high dosage, including tinnitus, nausea,
vomiting, headache, & blurred vision.
• Be alert for petechiae if the aspirin dosage

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• Interferes with prothrombin synthesis.
• Anticipate administering corticosteroids as
prescribed for the child who is not
responding to salicylate therapy, & monitor
for possible side effects of corticosteroid
therapy.
• Administer phenobarbital as prescribed to
reduce the purposeless movements of

*** LUZ B. UBANA, R.N., M.A.N. *** 11

• Chorea.
• Keep in mind that the prognosis depends
on the extent of myocardial involvement ;
permanent valve destruction, especially of
the mitral valve, may occur; there are no
after effects of joint or chorea involvement.
• Offer support & guidance to the parents &
child to help alleviate their fears &
anxieties.

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• If chorea is present, provide toys & games
for children that do not require fine
coordination to minimize the frustrations of
not being able to use the hands
meaningfully; assist with feeding as
necessary ; pad the bed rails as necessary
to prevent injury from thrashing
movements.

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• Emphasize that chorea is transitory & the
lack of coordination will pass without
permanent effects.
• Administer appropriate antibiotic treatment
as prescribed for streptococcal infections
to help prevent the occurrence of
rheumatic fever.
• Inform parents to bring the child with an

*** LUZ B. UBANA, R.N., M.A.N. *** 14

• Upper respiratory infection to see the
physician to evaluate for the possibility of
a streptococcal infection & ensure prompt
treatment.
• Instruct parents of a child with
streptococcal infection receiving antibiotic
• Therapy in all aspects of the medication
regimen, including the dosage, frequency

*** LUZ B. UBANA, R.N., M.A.N. *** 15

• & duration, & to continue the course of
therapy for the full 10 to 14 days as
prescribed.
• For the child who has had rheumatic fever,
instruct parents in need to maintain
prophylactic antibiotics therapy for at least
5 years after the initial attack, or until the
• child is 18 years old, or as long as the

*** LUZ B. UBANA, R.N., M.A.N. *** 16

• the physician may prescribed.
• Educate the child & parents about extra
prophylactic measures when dental or
tonsillar surgery is planned; because most
children have streptococci in their throats,
an open incision in the mouth increases
the risk of streptococcal invasion into the
blood stream.

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• Nursing diagnosis
• Risk for non compliance with drug therapy
related to knowledge deficit about
importance of long-term therapy.
• Outcome identification
• Child will maintain prophylaxis against
reinfection for prescribed interval.

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• Outcome Evaluation
• Child takes oral penicillin daily; absence of
symptoms of throat infection; vital signs
within age-acceptable parameters.
• Nursing Diagnosis
• Situational low self-esteem related to
choreal movements secondary to
rheumatic fever.

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• Outcome identification
• Child will express confidence in self &
transitory nature of the chorea; will
continue with major part of self during the
course of illness.
• Outcome Evaluation
• Child expresses frustration with inability to
control movements; continues to feed &
dress self with help as needed.
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Kawasaki Disease
• Description
• Kawasaki disease (mucocutaneous lymph
node syndrome) is a febrile, multisystem
disorder that occurs almost exclusively in
children before the age of puberty.
• Peak incidence is in boys under 4 years of
age , with Asian Pacific children being the
most at risk.

*** LUZ B. UBANA, R.N., M.A.N. *** 28

• Vasculitis is the principal & life-threatening
finding, leading to formation of aneurysm
& myocardial infarction.
• The cause is unknown, but it apparently
develops in genetically predisposed
individuals after exposure to an
unidentified infectious agent resulting in
altered immune function.

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• Assessment Findings- the child must
manifest fever & four of the typical
symptoms listed below:
• Fever of 5 or more days (38.9 to 41.4C)
that does not respond to antipyretics.
• Bilateral congestion of ocular conjunctiva
• Changes of the mucous membrane of the
upper respiratory tract, such as reddened

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• Pharynx; red, dry, fissured lips; or
protuberance of tongue papillae (
strawberry tongue)
• Changes of the peripheral extremities,
such as peripheral edema, desquamation
of the palms & soles.
• Rashes, primarily truncal & polymorphous
• Cervical lymph node swelling

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• Nursing Implication
• Perform a detailed history & physical
assessment..
• Administer salicylic acid(aspirin) to
decrease inflammation & block platelet
agglutination.
• Arrange for sequential echocardiograms to
monitor if aneurysms are developing.

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• Obtain necessary laboratory specimens,
as prescribed.
• Administer dipyridamole, as prescribed, to
increase coronary vasodilatation &
decrease platelet accumulation.
• Administer intravenous gamma globulin as
prescribed, to reduce the antigen-antibody
reaction & the possibility of coronary

*** LUZ B. UBANA, R.N., M.A.N. *** 35

• Artery disease.
• Administer warfarin (Coumadin) or heparin
or fibrinolytic therapy, such as
streptokinase, urokinase or tissue
plasminogen activator as prescribed.
• Provide emotional support to the parents
during this disease.
• Provide the parents with ongoing informa-

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• Tion about the status of their child; allow
parents to verbalize their feelings & fears.
• Nursing Diagnosis
• Risk for ineffective peripheral tissue
perfusion related to inflammation of blood
vessels.
• Outcome Identification
• Child will maintain adequate tissue
*** LUZ B. UBANA, R.N., M.A.N. *** 37
• Perfusion during the course of illness.
• Outcome Evaluation
• Child’s pulse, blood pressure , &
respiratory rate are within age-acceptable
parameters; capillary filling time is less
than 5 seconds.

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• Observe the child for signs of heart failure
such as tachycardia, dyspnea, crackles, &
edema.
• Inspect the extremities for color & palpate
• For warmth & capillary filling in toes &
fingers to evaluate peripheral tissue
perfusion.
• If developing myocarditis, be alert for

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• Chest pain, arrhythmias, & ECG changes.
• Nursing Diagnosis
• Pain related to swelling of lymph nodes &
inflammation of joints.
• Outcome Identification
• Child will experience a tolerable level of
pain during the course of illness.

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• Outcome Evaluation
• Child states that level of pain is tolerable.

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Bacterial Endocarditis
• Description
• Endocarditis is the inflammation & infection of
the endocardium or valves of the heart.
• This may occur with any child; however, it is
more common as a complication of
congenital heart disease such as TOF, VSD,
or Coarctation of the Aorta.
• The infection associated with endocarditis is
usually streptococcal, staphylococcal,
*** LUZ B. UBANA, R.N., M.A.N. *** 43
• Or fungal in origin.
• The streptococcal infection can occur with
dental work or urinary tract infection.
• Progression of the disease leads to
valvular vegetation.
• Eventually the lining of the heart is
destroyed, including underlying muscle &
valves.

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• The onset of endocarditis is typically
insidious.
• Treatment is aimed at identification &
treatment of the invading organism with
antibiotics & supportive measures to
reduce congestive heart failure.
• Prognosis is good.

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• Assessment Findings
• Pallor
• Anorexia weight loss
• Arthralgia
• Malaise
• Chills
• Heart murmurs

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• Congestive heart failure
• Petechiae of the conjunctiva or oral
mucosa
• Hemorrhages of the fingernails or toenails
• Left upper quadrant pain secondary to
spleen infarction
• Splenomegaly

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• Proteinuria
• Hematuria
• Leukocytosis
• Increased sedimentation rate
• Positive blood culture of invading
organism
• Echocardiogram revealing vegetative
• Growth on the heart valves

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• Nursing Implications
• Evaluate all children with a known
congenital heart defect.
• Prevent the incidents of endocarditis in
this population with prophylactic use of

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• Antibiotics before invasive procedures,
including dental work.
• Be alert to signs & symptoms of
endocarditis in this population.
• Evaluate for any signs & symptoms, &
refer to physician for further workup.
• Prepare the parent & child for the hospital
experience, & support them in better

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• Understanding the disease process.
• Administer intravenous penicillin as
prescribed to treat streptococcal infection.
• Discover & appropriately treat the invading
organism.
• Monitor for serious congestive heart
failure, & administer diuretics as
prescribed.

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• Maintain the child on bed rest during the
acute stages to help rest the heart.
• Prepare the child for continued medical &
possibly surgical intervention depending
on the severity of damage caused by the
endocarditis.
• Provide long-term follow-up care to be
certain that the invading organism is

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• Completely eliminated & the disease is
halted.
• Provide continued follow-up care to
monitor the functional heart muscle.
• Support the parents & child throughout this
difficult disorder & with the potential
complications.

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