RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS / Mrs. N. SAVITHA
GOUTHAM COLLEGE OF NURSING
MANJUNATH NAGAR,
WEST OF CHORD ROAD, RAJAJINAGAR,
BANGALORE – 560 010
2. / NAME OF THE INSTITUTION / GOUTHAM COLLEGE OF NURSING
MANJUNATH NAGAR,
WEST OF CHORD ROAD, RAJAJINAGAR,
BANGALORE – 560 010
3. / COURSE OF THE STUDY AND SUBJECT / M.Sc. NURSING I YEAR
PEDIATRIC NURSING
4. / DATE OF ADMISSION TO THE COURSE / 23.08.2008
5. / TITLE OF THE TOPIC / A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAM ON “CARE OF THE CHILDREN WITH RHEUMATIC HEART DISEASE” REGARDING KNOWLEDGE AND ATTITUDE AMONG MOTHERS IN A SELECTED GOVERNMENT HOSPITAL AT BANGALORE.
6. / BRIEF RESUME OF THE INTENDED WORK.
6.1 / NEED FOR THE STUDY:
“The child of today is citizen of tomorrow”
Children in the age group of 0-14 years constitute 40% of the population. The well being of these children are the responsibility of parents as well as health personals. As they are the most vulnerable section which under go various types of health problems. The risk is connected to growth, development and survival. The primary health cane in children aims at prevention and promotion of health.
Rheumatic heart disease is a condition in which the heart valves are damaged by rheumatic fever. Rheumatic fever begins with a strep throat from streptococcal infection. Rheumatic fever is an inflammatory disease it can affect many of the body’s connective issues especially those of the heart, Joints, brain or skin1. If the heart valve damaged they will fail to open and close properly. When this damage is permanent the condition is called as Rheumatic heart disease. 2 Rheumatic heart disease usually occurs in children age between 5-15 years. 3 Both male and female children are equally affected. Rheumatic disease is primarily associated with poverty, illiteracy and low socio economic status. 4
The Rheumatic heart disease that results can last for life. Rheumatic heart disease places a heavy economic burden on health care system in low and middle income countries because of the cost of the medical treatment and heart valve surgery and also because it is a disease of young adults, who are most economically active group of any population. 5
Developed countries have experienced a dramatic decline in the incidence and prevalence of Rheumatic fever and Rheumatic heart diseases caused by streptococcal throat infections. This is thought to have occurred as result of improved living conditions and the wide spread use of penicillin for the treatment of streptococcal pharyngitis.
However Rheumatic Fever / Rheumatic Heart Disease remain major global problem in developing countries. Despite the wide spread availability of effective antibiotic treatment of prophylaxis to prevent Rheumatic Fever and cardiology services for those, with established Rheumatic Heart Disease as a sequel to Rheumatic Fever in these developing countries, which represent 80% of the world population.
WORLDWIDE INCIDENCE: The prevalence of rheumatic fever was 0.75 per 1000 (rural 1.20, urban 0.42). cases of rheumatic heart disease were distributed equally between the ages of 7 – 11 years and 12 to 15 years and male female ratio 1:0.6. Recent research estimates that Rheumatic Fever Rheumatic Heart Disease affects about 15.6 million people world wide, 2.4 million of whom are children between five and fourteen year old living in developing countries. Half a million new cases are declared every year Rheumatic Fever / Rheumatic Heart Disease leads to an estimated 3,50,000 deaths annually, and hundreds and thousands of survivors left disabled without asses to the expensive medical and surgical care that the disease requires.
Africa, which contains 10% of the world population has a disproportionately high share of people living with RHD / RF of the 2.4 million children with the RF / RHD living in developing countries, nearly half (> 1 million) live in sub Saharan Africa a recent systematic review of prevalence studies found exceptionally high rates of RHD in sub Saharan Africa. With the high level in Kinshasa DRC at 14/1000. In school– aged children.6 There is a high prevalence of rheumatic heart this case in the pacific sub continent, Asian Mediterranean, Latin American, the Indian sub continent. The incident in the middle east (Lebanon) is high. 7
INCIDENCE IN INDIA: Approximately 1to1.25million cases of R.H.D are present in India. In Delhi in 1999, out of 191 children below 12 years of age with definite acute R/F 7.9% were below 5 years, 31.4% between 5 & 9 years and 60% above 9 years. 378 patients from Orissa below 19 years, the mean age was 15.1 I 4.4 years. In 2000 the school survey involving 3963 children from the district of Kanpur, the prevalence of RHD was 4.54 per 1000 (urban 2.56 and rural 7.42).8
A study was conducted in North Western Indian town to determine influence of socio economic status. 3292 school children age range 5 – 14 years in two private school ten middle socio economic status Govt. school and six low socio economic status government school were participated. 3002 were clinically examined of which 1042 were in private schools, 1002 in middle socio economic status schools and 958 in low socio economic status schools. Prevalence of cardiac murmur and rheumatic heart disease clinical diagnosis was determined. Those with a murmur were further evaluated by Doppler – echocardiography in hospital. Results were, a significant murmur was observed in 55 subjects with similar prevalence in boys & girls. The prevalence of murmur was greater in children belonging to low socio economic schools (29.12/1000) as compared to middle (18.9/1000) & higher socio economic status schools (7.6/1000). 9
A prevalence of rheumatic heart disease of 3.9/1000 in the last school study in primary school children 6 – 10 years of age is unexpectedly high. Further proof of the continuing large reservoir of rheumatic heart disease cases is the large number of patients in their teens and twenties coming in for the new modality of balloon mitral valvotomy, pediatrics clinics in large hospitals from various parts of India have reported several cases with acute manifestations of rheumatic heart disease such as carditis, chorea, nodules and poly arthritis. 10
A study was conducted by Department of pediatrics, king Faisal, specialist hospital & research centre, Riyadh, kingdom of Saudi Arabia. To investigate parental knowledge of pediatric Rheumatic diseases in general, and in particular information regarding their children’s diseases. Majority of parents have wrong beliefs, regarding rheumatic diseases. The treating physician is the main source of parental information and in the majority of the parents, their in formation was satisfactory. The questionnaire was simple and easy to test to investigate parental knowledge regarding pediatric Rheumatic diseases. The survey shows the need for health education programs and a future general public health education plan to improve awareness of pediatric Rheumatic diseases. 11
There is a lack of knowledge and awareness among parents and care givers about so streptococcal infection, Rheumatic fever, and its complications which makes the children to lead a miserable life and it is the responsibility of the health personnel to make them accept and understand the consequences and how to mange. Mothers consistently reported a lack of knowledge and they expressed stress full life style. So, the parents and care givers should be provided adequate importance of treating sore throat, streptococcal infection, Rheumatic Fever and prevention of complications and the availability of treatment. Psychological and emotional support for children as well as parents which in turn helps to improve the health and to live a healthy lives by controlling complications. Hence the researcher is interested to take up the study in this aspect to provide knowledge and try to develop positive attitude among mothers in caring Rheumatic heart diseased children.
6.2 / REVIEW OF LITERATURE:
A.  Literature related to incidence of Rheumatic heart disease
A study was conducted in rural area Rajasthan among the school children regarding Rheumatic heart disease prevalence. Thirty for of 10168 school going children were found to have Rheumatic heart disease in a school survey in the rural areas of charu district the prevalence rate was 3.34 per 1000. A high prevalence of Rheumatic Heart Disease was found in 11 to 15 years age group. Maximum was in low socio economic group. Out of these 34 cases of RHD isolated Mitral stenosis was present in sixteen, isolated Mitral regurgitation in four, combined Mitral stenosis and Mitral regurgitation in ten patients. 12
An echo cardiograph study was conducted in Bikaner Urban School. 3292 eligible children 3002 children examined. 1555 children were in between the age group of 5-9 years and 1447 in age group of 10-14 years. A significant cardiac murmur was observed in patients diagnosed with acute rheumatic fever in both studies were treated with salycylates and antibiotics. Conclusion was “Systemic screening with echo cardiography, as compared with clinical screening, reveals a much higher prevalence of Rheumatic heart disease. 13
A cross sectional study to determine the prevelance of rheumatic heart disease was conducted in rural block in Gandubal, Srinagar in 2003 Out of 4125 children from 54 schools selected randomly 21 children male - 10 female – 11 had evidence of R.H.D giving overall prevalence rate of 5.09/1000children of parents belonging to low economic group were more effected. The prevalence was least in high socio economic condition private school. The greater prevalence was in low socio economic govt. school. 14
B.  Literature related to complication of Rheumatic heart disease
A study conducted to determine the cardiac sequel of rheumatic fever and rheumatic heart disease pre completed case protocol of patients with rheumatic fever and rheumatic heart disease were analyzed to record the demographic data clinical features on admissions/presentation recurrence cardiac valvular affection and outcome. The study included 550 patients, mean age of presentation was 9.62 years and sex ration was 1.15:1. Average duration of follow up was 3.19 years, 74.72% of cases lost to follow up Benzathine pencillin prophylaxis was regular in 42.18% cases. Positive family history of rheumatic heart disease was present in 2% of cases. 23 patients died. Conclusion – Arthritis was most common in patients presenting manifestation in the initial attack of rheumatic fever while carditis most common with pre existing RHD and mitral regurgitation was most common valuvlar leision. Rate of patient dropout from pencillin prophylaxis was high. 15
C.  Literature related to influence of rheumatic heart disease on growth and development of children.
A study to determine the effect of left ventricular and endocrine functions on linear growth in children with RHD. 100 children & adolescents were studied with RHD over a period of 1 year. Growth was assessed by determining both height standard deviation scores & growth velocity standard deviation scores every 4 months & sexual maturity was assessed according to Tanner’s criteria. 200 age matched normal children were control group. The height standard & growth standard of children with RHD were significantly lower than the normal group. They had high evidence of delayed sexual development secondary to delayed maturation of their hypothalamic pitutary gonadal axis. 16
D.  Literature related to secondary prophylaxis for controlling rheumatic fever and rheumatic heart disease in a rural area of northern India.
A study was conducted in a community development block of a district in Haryana to evaluate the compliance of secondary prophylaxis for controlling rheumatic fever and rheumatic heart disease. The patients were interviewed using a semi – structured schedule at home. Currently 110 patients are registered in rheumatic fever/rheumatic heart disease registry of which 53(48.2%) are males. Mean age of patients was 18.4 + / - 8.6 years, ranging from 6 to 50 years with majority (48, 43.7%) of patients in the age group of 6 – 15 and 16 – 25 years. Out of 110 patients, more than 90 percent had taken 11 out of the 12 due doses of secondary prophylaxis every year in the last eight years in the program except in 1995 when 92 (83.6%) patients took the prophylactic doses. Only one patient reported recurrent attacks of rheumatic fever after irregular secondary prophylaxis. Eighteen (16.4%) patients are defaulters at the time of interview and were motivated to take secondary prophylaxis regularly. Ninety – seven (88.2%) patients were satisfied with the ongoing program. In developing countries, it is possible to successfully apply a secondary prevention program for control of RF/RHD by using existing health infrastructure. 17
E.  Literature related to diagnosis of rheumatic heart disease
A study was carried out to assess the accuracy of clinical evaluation of valvular hear disease and compare it with that of an echocardiography evaluation. 50 children between the age of 5 – 16 years, attending the out patient department or admitted in a large teaching hospital, satisfying the criteria of RHD, were included in the study. Each patient underwent detailed clinical evaluation and relevant investigations including echocardiography. Results was mitral valve was involved most often both by echocardiography and clinically. Isolated aortic valve involvement was rare. The most common lesion was mitral regurgitation both by auscultation and by echo. Mixed lesions were seen more often than pure lesions. Mitral stenosis had the highest sensitivity while tricuspid regurgitation had the highest specificity. Mitral regurgitation had the highest positive predictive value and mitral stenosis the highest negative predictive value. Sensitivity and specificity of aortic regurgitation was very low when compared to earlier studies. There was a statistically significant difference between echo diagnosis and clinical diagnosis (p< 0.05). Conclusion was recommended that echocardiography be done routinely for the diagnosis of cardiac lesions in patients of RHD as clinical examination alone can miss various lesions, especially when the lesions are mild or when multiple lesions are present. 18
F.  Literature related to need for awareness regarding prevention of complication in parents of children with heart disease :
A prospective survey of parents of children with heart diseases conducted to determine their awareness as regards to importance of oral prophylaxis against infective endocarditis. The results of this study demonstrated that only 8% of parents of children of heart diseases were aware of need for infective endocarditis prophylaxis. Hence a serious attempts has to be made by health care professionals to educate the parents on importance of good oral hygiene the need for prophylaxis in children with heart disease. 19