RHEUMATIC HEART DISEASE A RESEARCH STUDY PRESENTED TO THE FACULTY OF

THE COLLEGE OF

NURSING

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE SUBJECT INTENSIVE NURSING PRACTICUM

CHAPTER 1 THE PROBLEM AND ITS SETTING

INTRODUCTION Rheumatic heart disease describes a group of short-term (acute) and longterm (chronic) heart disorders that can occur as a result of rheumatic fever. One common result of rheumatic fever is heart valve damage. This damage to the heart valves may lead to a valve disorder. Rheumatic heart disease is permanent damage to the heart following rheumatic fever. It can lead to heart failure and sometimes the need for cardiac surgery. Rheumatic heart disease is the most common form of heart disease in children in the world.

A case of rheumatic fever can cause the heart to inflame and leave permanent damage to the heart, specifically the heart valve acts like a one-way door. It makes sure that blood pumped by the heart flows in one direction. When the heart is damaged, the heart valves are unable to function adequately. The heart has 4 sections, they are like rooms, also called chambers. the heart valves are the doors that stop the blood from flowing the wrong way. People who get rheumatic heart disease sometimes end up very sick because the blood stops flowing the right way, making them tired and short of breath. They may not be able to do the things they used to like hunting, playing sports, or even walking or going fishing. Rheumatic heart disease does not always cause symptoms. (www.medscape.com)

CLIENTS PROFILE
Clients Name : Patient X Birthday : October 18, 1959 Age : 54 years old Gender : Male Civil Status : Married Religion : Catholic Educational Attainment: High School Graduate Occupation : Tricycle Driver Address : Maligaya Street Brgy. Lusok Bongabon, Nueva Ecija Length of Residency : 30 years Hospitalization : December 2012 (check up) Final diagnosis : Rheumatic Heart Disease (RHD)

ASSESSMENT HEALTH PERCEPTION- HEALTH MANAGEMENT

Family History of Illness There are no known illnesses within the family. History of Present Illness Client was always complaining of having easy fatigability since October 2012. He also had some episodes of fever and breathlessness on exertion until he was not able to do his activities of daily living. So his family decided to bring him on Bongabon District Hospital for check-up that was on December 20, 2012. The doctor (Dr.Dauz) requested him to undergo ECG (Electrocardiograph), CBC (Complete Blood Count), and 2D echo (Two Dimensional Echocardiogram) the test revealed he has rheumatic heart disease. After this the doctor requested him to be confine on the hospital. He was observe there and given due medicines (propranolol and aspirin) for 3 days. Fortunately, up to this day the episodes of his discomforts are diminished.

Past History of Illness Patient X did not have any previous hospital stays. Nutrition and Metabolic Pattern At Breakfast, the client drinks coffee simultaneously with rice and egg or any leftover viand and about 2 glass of water before going to the terminal of tricycle. At Lunch, the client eats rice and mostly pork and sometimes vegetable with a glass of water, and at dinner he also eats rice and vegetable and sometimes fish. The client was restricted to eat salty and fatty food. The client does not have any food allergies. The client usual fluid intake is about 8-10 glasses of water per day. There are no problems with the client when it comes to his ability of eating. The client was taking Quantum plus as supplements/ vitamins.

Elimination Pattern The client usually defecates once a day. The client has frequent urination than the usual routine and his complaining of feeling of not emptying his bladder completely whenever he voids. Activity and Exercise Pattern The clients leave his house every morning at around 4am to go to the terminal of tricycle. His work serves as his daily exercise. Self care Ability 0- Independent 1- Assistive device 2- Assistance from others 3- Assistance from person and others 4- Dependent or unable

Table 1. Self-Care Ability

Activities Eating Bathing Dressing Toileting Bed mobility Transferring Ambulating 0 1 2 3 4 Remarks The client can eat by her own. He can support. bath independently without any

He can dress his self. The client can do toileting on his own. The client can do it independently. The client can transfer any heavy object. He is walking every morning as his exercise with the use of equipment.

Stairs

The client can do it without any support with others. He can go to the market. The client can cooked independently He can do other maintenance.

Shopping Cooking Home maintenance

Client can do all the activities independently. His

Gait and posture is normal and he can move into motion with his reflexes in proportion. There are no deformities found. And he lives normally with his family. Table II. Head To Toe Assessment
Body Part Skull Hair Scalp Actual Findings Round with the prominence in the frontal and occipital. Evaluation Normal

Evenly distributed hair, thick hair silky, resilient hair, Normal no infection or infestation variable. Can be moist or oily No scars noted Free from lice, nits and dandruff Shape maybe oval or rounded Face is symmetrical No exopthalmus, strabismus or nystagmus. No ptosis, edema or lesions of lids. No lid lags conjunctivae. Normal

Face Eyes

Normal

Normal

Ears

Symmetrical, parallel, lobes are bean-shaped. Skin is the same color as in the complexion No discharges and lesions noted.

Normal

Heari No hearing loss ng Nose No discharges Both nares are patent Symmetrical

Normal Normal

Neck

Normal Normal

Chest Symmetrical Abdom Skin color is uniform en No lesions Soft when palpated and symmetric upon palpation

Normal

Extre Equal size on both sides of the body mitie No contractures s No tremors No swelling Joints move smoothly.

normal

Cardiovascular The clients radial pulse was measured and revealed 88 beats per minute. He has a regular and strong pulse. He is slightly warm to touch with the temperature of 37.0. His capillary refill is within the normal time of about 2 seconds. Respiratory The clients chest is symmetrical in shape with a respiratory rate of 19 cycles per minute. Usual sleep pattern Client usually sleeps for seven hours every night. He usually sleeps at around 8:00 pm and wake up early to go to the farm. And after doing his work, he takes a nap in the afternoon.

Cognitive and Perceptual Pattern The client was alert upon assessment and interview. He is oriented in his environment particularly the people living with him. His pupil reacted to light accommodation. His reflexes are normal. His visual acuity is within normal limit, he can identify objects easily. He has a normal hearing senses and able to respond at stimuli. Able to communicate through speaking, gestures and actions. Self Perception and Self Concept During interview, the client was in his well state and does not feel any pain. The client stated that whenever he feels the difficulty of breathing he just chooses to stay at home and not go to the terminal. Usually he just sleeps to ease the fatigue until he feels well.

Roles and Relationship Client together with his wife. He plays the father role for their only daughter. It seems that he has a good relationship with his family, they support him with his present condition and he is also well taking care of.
Sexuality and Reproductive The client is 54 years old. Before, he can do his usual sexual activity. But due to his condition, it lessens his activity. Coping and Stress Tolerance Client copes up effectively condition, he manages his fatigue enough rest until he gets well.

with his by taking

Table 2. Vital Signs The table shows the daily vital signs of the client from the day of the first to the last home visit.
Home Visit Blood pressure Temp. Pulse Rate Respiratory Rate
19 cpm 21 cpm 20 cpm

Jan 13,2014 Jan 14,2014 Jan 15,2014

120/90 mmHg 36.4 C 88 bpm 120/90 mmHg 36.7 C 84 bpm 110/80 mmHg 36.5C 85 bpm

Jan 16,2014
Jan 17,2014

120/80 mmHg 36.4C

120/80 mmHg 36.4C

80 bpm
82 bpm

19 cpm
20 cpm

Body Mass Index Height and Weight As of January 13, 2014 the clients weights 60 kilograms and his height is 5 feet and 2 inches.
Basis of Interpretation BMI of less than 18.5 is classified underweight. BMI of 18.5- 24.9 is classified Normal. BMI of 25- 29.9 is classified Overweight. BMI of 30-39 is classified as obese. Final Computation BMI= Weight in kilograms (Height in meters)2 = 60kg (1.57m)2 = 19.10kgs

as

Interpretation The clients weight and Height is based on the computation above, the clients Body Mass Index is 19.10 kilograms which means the client is classified normal.

CHAPTER 2 CASE DISCUSSION AND PRESENTATION

Overview This chapter contains the case discussion and presentation of the case study.

REVIEW OF ANATOMY AND PHYSIOLOGY

Figure I. The Heart.

The pericardium is the membrane that surrounds and protects the heart. It is composed of two layers separated by a narrow cavity. The inner layer is firmly attached to the heart wall and is known as the visceral layer or epicardium. The outer layer is composed of relatively inelastic connective tissue and is termed the parietal layer. This fibrous layer prevents distension of the heart, thus preventing excessive stretching of the heart muscle fibres. The cavity between the two layers contains a small volume of fluid which serves as a lubricant, facilitating the movement of the heart by minimising friction. The sternopericardiac ligament connects the parietal layer to the sternum and the phrenopericardiac ligament joins the parietal layer to the diaphragm. The latter is present only in the canine.

The wall of the heart consists of three layers: the epicardium (external layer), the myocardium (middle layer) and the endocardium (inner layer). The epicardium is the thin, transparent outer layer of the wall and is composed of delicate connective tissue. The myocardium, comprised of cardiac muscle tissue, makes up the majority of the cardiac wall and is responsible for its pumping action. The thickness of the myocardium mirrors the load to which each specific region of the heart is subjected. The endocardium is a thin layer of endothelium overlying a thin layer of connective tissue. It provides a smooth lining for the chambers of the heart and covers the valves. The endocardium is continuous with the endothelial lining of the large blood vessels attached to the heart.

Cardiac muscle fibres are shorter in length and larger in diameter than skeletal muscle fibres. They also exhibit branching, which gives an individual fibre a Y-shaped appearance. A typical cardiac muscle fibre is 50-100m long and has a diameter of about 14m. Normally, there is only one centrally located nucleus, although occasionally a cell may have two nuclei. The sarcoplasm of cardiac muscle is more abundant than that of skeletal muscle and the mitochondria are larger and more numerous. Cardiac muscle fibres have actin and myosin filaments arranged in the same way as skeletal muscle fibres and possess a well-developed Ttubule system. In contrast to skeletal muscle, cardiac muscle does not fatigue, cannot be repaired when damaged and is regulated by the autonomic nervous system.

Although cardiac muscle fibres branch and interconnect with each other, they form two separate functional syncytia, one for the atria and another for the ventricles. The ends of each fibre in a network connect to its neighbours by irregular transverse thickenings of the sarcolemma called intercalated discs. The discs contain desmosomes, which hold the fibres together, and gap junctions, which allow ions to travel between cells and permit the rapid propagation of action potentials. Consequently, excitement of a single fibre of either network results in stimulation of all the other fibres in the network. As a result, each network contracts as a functional unit.

In addition to cardiac muscle tissue, the heart wall also contains dense connective tissue that forms the fibrous skeleton of the heart. The fibrous skeleton is composed of dense connective tissue rings that surround the four heart orifices. The skeleton contains fibrocartilage in which nodules of bones (ossa cordis) may develop in some species. Although these bones occur most commonly in cattle, they are not restricted to this species. The skeleton performs several functions: It serves as a point of attachment for the heart valves The cardiac muscle bundles insert onto the fibrous skeleton. It prevents the valves from overstretching as blood passes through them. It acts as an electrical insulator thereby preventing the direct spread of action potentials from the atria to the ventricles.

The heart contains four chambers. The two upper chambers are the atria and the two lower chambers are the ventricles. On the cranial surface of each atrium is a pouch-like appendage called an auricle which is thought to increase the capacity of the atrium slightly. The thickness of the myocardium of the four chambers varies according to function. The atria are thin-walled because they deliver blood into the adjacent ventricles and the ventricles are equipped with thick muscular walls because they pump blood over greater distances. Even though the right and left ventricles act as two separate pumps that simultaneously eject equal volumes of blood, the right side has a much smaller workload. This is because the right ventricle only pumps blood into the lungs, which are close by and present little resistance to blood flow. On the other hand, the left ventricle pumps blood to the rest of the body, where the resistance to blood flow is considerably higher. Consequently, the left ventricle works harder than the right ventricle to maintain the same blood flow rate. This difference in workload affects the anatomy of the ventricular walls; the muscular wall of the left ventricle being significantly thicker than that of the right.

The right atrium forms the dorsocranial section of the base of the heart and receives blood from the cranial vena cava, caudal vena cava and coronary sinus. The interatrial septum is a thin partition dividing the right and left atria and possesses a characteristic oval depression called the fossa ovalis which is a remnant of the foetal foramen ovalis. The right atrium also houses the sinoatrial node. Blood flows from the right atrium to the right ventricle through the tricuspid valve (also know as the right atrioventricular valve).

The right ventricle forms most of the anterior surface of the heart and is crescent-shaped in cross-section. The cusps of the tricuspid valve are connected to tendon-like cords, the chordae tendinae, which, in turn, are connected to cone-shaped papillary muscles within the ventricular wall. The right ventricle is separated from the left by a partition called the interventricular septum. The trabecula septomarginalis is a muscular band that traverses the lumen of the right ventricle. Deoxygenated blood passes from the right ventricle through the pulmonary semi-lunar valve to the pulmonary trunk, which conveys the blood to the lungs.

The left atrium forms the dorsocaudal section of the base of the heart and is similar to the right atrium in structure and shape. It receives oxygenated blood from the lungs via the pulmonary veins. Blood passes from the left atrium to the left ventricle through the bicuspid or left atrioventricular valve. The left atrium lies under the tracheal bifurcation and enlargement of this area of the heart can cause breathing difficulties. The left ventricle forms the apex of the heart and is conical in shape. Blood passes from the left ventricle to the ascending aorta through the aortic semi-lunar valve. From here some of the blood flows into the coronary arteries, which branch from the ascending aorta and carry blood to the heart wall. The remainder of the blood travels throughout the body.(www.medscape.com)

Signs and Symptoms The signs and symptoms that may be observed to the client with RHD are easy fatigability and heart palpitations. The client wasnt able to finish half of his work due to his easy fatigability.
Book Based

Client Based Easy fatigability Heart Palpitations

Chest pain Heart palpitations Breathlessness on exertion Breathing problems when lying down (orthopnea) Walking from sleep with the need to sit or stand up (paroxysmal nocturnal dyspnea) Swelling (edema) Fainting (syncope) Stroke Fever associated with infection of damage heart valves

RISK FACTORS
Risk Factors (Book Risk Factors Based) (Client Based) Reduced access to Smoking medical care. Poverty Overcrowding High Cholesterol Diet

DIAGNOSTIC TEST (BOOK BASED)

You may notice the signs of RHD and decide to visit your doctor. The earlier the condition is diagnosed the lower the risk of complications. If a doctor suspects the patient has RHD they may refer them to a specialist cardiologist. Tests will be carried out to reach a diagnosis and determine the appropriate course of treatment. The doctor may order Physical examination while a heart murmur may suggest RHD, many patients with RHD do not have a murmur; Medical history including evidence of past ARF or strep infection; Chest x-ray to check for enlargement of the heart or fluid on the lungs; Electrocardiogram (ECG) to check if the chambers of the heart have enlarged or if there is an abnormal heart rhythm (arrhythmia); Echocardiogram to check the heart valves for any damage or infection and assessing if there is heart failure. This is the most useful test for finding out if RHD is present. (www.medscape.com)

DIAGNOSTIC TEST (CLIENT BASED)

There are diagnostic tests that are needed to determine the final diagnosis of the client. The client had undergone diagnostic test which is Chest x-ray to check for enlargement of the heart. Electrocardiogram to check if the chambers of the heart have enlarged or if there is an abnormal heart rhythm and Echocardiogram to check the heart valves for any damage or infection and assessing if there is heart failure. This is the most useful test for finding out if RHD is present

COMPLICATION (BOOK BASED)

Rheumative Heart Failure (RHD) rarely has complications. When it does, these complications include: Arrhythmia (An irregular heartbeat is an arrhythmia (also called dysrhythmia). Heart rates can also be irregular), Infective endocarditis ( an infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium, or a septal defect, Congestive heart failure ( blood moves through the heart and body at a slower rate, and pressure in the heart increases. As a result, the heart cannot pump enough oxygen and nutrients to meet the body's needs. The chambers of the heart may respond by stretching to hold more blood to pump through the body or by becoming stiff and thickened), Recurrent pulmonary infections (restraining of certain organism in the respiratory system) ,Death (the cessation of all biological functions that sustain a living organism).(www.medicalcare.com)

Prevention (Client Based)

Rheumatic heart disease can be prevented. Some people believe: Regular check-up with a cardiologist to monitor the heart; Up-to-date flu (influenza and pneumococcal) vaccinations; Regular (preventive) antibiotic to prevent group A streptococcus throat infection and recurring ARF; Early presentation, diagnosis, and where appropriate, antibiotic treatment of sore throats; Good dental hygiene (tooth brushing and flossing, dental check-ups)as oral bacteria entering the bloodstream can increase the risk of complications such as inflammation of the inner lining of the heart; Antibiotics- may be given to some people before some dental or surgical procedures to prevent bacterial infection of the damaged areas of the heart; Good prenatal care, as pregnancy can make rheumatic heart disease worse (www.emedicinehealth.com)

Prevention (Book Based)

The client have some preventive measures like eating a balance diet composed of fruits and vegetables, exercise daily 10-15 mins., complying in his drug regimen, daily monitoring of his blood pressure and not engaging in vigorous activities.

NURSING MANAGEMENT (BOOK BASED)

Teaching patients of Self-care. Instruct patient and family about medication side effects and toxicity. Ineffective breathing pattern: Observe for cyanosis, dyspnea, hypoxia and confusion indicating worsening condition; place patient in an upright position to obtain greater lung expansion and improve aeration. Frequent turning and increased activity (up in chair, ambulate as tolerated) should be employed. Do tepid sponging to reduce fever through conduction and evaporation and administer antipyretic. Maintaining cardiac output: assess for signs and symptoms of acute rheumatic carditis; be alert to patients complains of chest pain, palpitations, and/or precordial tightness; monitor for tachycardia (usually persistent when patient sleeps) or bradycardia, be alert to development of second-degree heart block or wenckebachs disease (acute rheumatic carditis causes pulse rate interval prolongation), auscultate heart sounds every 4 hours.

MEDICAL MANAGEMENT (BOOK BASED)

Treatment of acute rheumatic fever includes antibiotics to treat the strep infection and additional medications to ease the inflammation of the heart and other symptoms. Usually aspirin is given in large doses until the joint inflammation goes away; rarely, steroids are needed. Once the acute illness has gone away, patients need to take penicillin, or an equivalent antibiotic, for many years to prevent recurrences. This is a very important treatment because the risk of heart valve damage increases if rheumatic fever recurs.(www.emedicine.com)

MEDICAL MANAGEMENT (CLIENT BASED)

The client has prescribed propranolol (beta-blocker) and aspirin (thrombolytic). Propranolol was prescribed for high blood pressure and chest pain. It is also used to prevent migraine and recurrent attacks. Aspirin was prescribed for pain, heart attack and fever. The drug decreases the substances that cause pain and inflammation. They are both taken once a day per orem.

SURGICAL MANAGEMENT (BOOK BASED)

Most often the valve leak caused by the disease is mild and does not need treatment. If the leak is severe enough to strain and enlarge the heart, surgery may be needed to eliminate the leak. This surgery may involve repair of the damaged valve. Sometimes the valve is too badly damaged to repair, in which case it must be replaced by artificial valves.(www.medicalworld.com)

Drug Classificati Indication on This medication is a Propan Beta beta-blocker, olol blocker prescribed for high blood pressure and chest pain. It is also used to prevent migraine headaches and recurrence of heart attacks. It works by relaxing blood vessels.

Contraindication Contraindicated in patients with shock due to heart problems, heart failure, asthma, and very low blood pressure, children with congenital heart disease, asthma and hypersensitivity

Mechanism Of Action A widely used noncardioselective betaadrenergic antagonist. Propranolol is used in the treatment or prevention of many disorders including acute myocardial infarction, arrhythmias, angina pectoris, hypertension, hypertensive emergencies, hyperthyroidism, migraine, pheochromocytoma, menopause, and anxiety.

Adverse Reaction Aggravated congestive heart failure Bradyarrhythmia Hypotension

Nursing Considerations You may take propranolol with or without food, but take it the same way each time.Take the medicine at the same time each day.

Decreased exercise tolerance Do not crush, chew, break, or Raynaud phenomenon open an extended-release capsule. Swallow it whole.

Potential increase in Breaking or opening the pill insulin resistance may cause too much of the Depression Fatigue InsomniaParesthesi a Psychotic disorder drug to be released at one time.

Drug

Classification

Indication

Contraindication

Mechanism Of Action

Adverse Reaction

Nursing Considerations

Aspirin

Thrombolytics

This medication is Contraindicated in an analgesic and patients with blood antipyretic, disorder, liver or prescribed for kidney impairment pain, heart attack and and fever. The hypersensitivity. drug decreases the substances that cause pain and inflammation.

Aspirin causes several different effects in the body, mainly the reduction of inflammation, analgesia (relief of pain), the prevention of clotting, and the reduction of fever.

Large doses of You should not use salicylate, a aspirin if you have metabolite of a bleeding disorder aspirin, have been such as proposed to cause hemophilia, a tinnitus (ringing in recent history of the ears) based on stomach or experiments in rats, intestinal bleeding, via the action on or if you are allergic arachidonic acid to an NSAID (nonand NMDA steroidal antireceptors cascade. inflammatory drug) such as Advil, Motrin, Aleve, Orudis, Indocin, Lodine, Voltaren, Toradol, Mobic, Relafen, Feldene, and others.

Assessment Subjective: Hindi ko na kayang gawin yung mga dati kong ginagawa mabilis ako mapagod as verbalized by the patient. Objective: Easy fatigability Unable to walk long period of time

Diagnosis Activity Intolerance related to decreased cardiac output, oxygen supply and demand imbalance.

Planning Intervention Rationale After 8 days Energy saving To conserve energy during the of duty, the acute patients. patient will be able to To conserve energy Maintain bed rest until the results optimal of laboratory patient can and clinical status of tolerate the patients activity does. improved.
In line with the good general To monitor how many condition, energy he has monitor the used gradual increase in the level of activity undertaken. Teach to participate in activities of daily To bring back the necessities functions of his body

Evaluation After 8 hours of nursing intervention, the patient was able to tolerate the activity.

Assessm ent Subjective Data: Nag manas yung paa ko verbalize d by the patient Objective Data: >Edema

Diagnosis

Planning

Intervention Rationale

Evaluation

Excess fluid volume related to increased ADH production and sodium/water reten tion

After 8hrs of nursing intervention the patient will be able to reduce recurrence of fluid excess.

Monitor VS. Note presence of underlying condition that potentia l fluid excess Note presence of edema and calculate its grade Note pattern of urination

Establish baselin e data for further compari son To assess precipitating factorand to evaluate degree of edema To know if there is fluid retention in the body To reduce tissue pressure and decrease risk of skin breakdown

After 8 hours Goal partially met after 8hrs of nursing intervention, patien t was able to reduce recurrence of fluid excess and decreased edema.

Assessment Subjective: "I can't breathe well because of my chest pain," as verbalized by the patient. Objective: Difficulty of breathing Nasal flaring VS T: 35.7 C BP: 120/80 mmHg RR: 23 cpm PR: 110 bpm

Diagnosis Ineffective breathing pattern related to difficulty of breathing as manifested by prolonged expiration phases than inspiration

Planning

Intervention

Rationale To evaluate pressure and character of breath sounds To promote physiologic ease of maximal inspiration To assist client in taking control of the situation

Evaluation After 4 hours of nursing intervention, the patient did the coping mechanisms to improve his breathing pattern

After 4 hours of nursing Auscultate chest intervention, the patient will able to do coping mechanisms to improve his breathing pattern Elevate HOB or have client sit up in chair

Encourage slower/deeper respirations, use purse lip technique

CHAPTER 4 FINDINGS, CONCLUSION AND RECOMMENDATION

Overview This chapter presents the summary of findings, its conclusions and recommendations offered by the researchers.

SUMMARY OF FINDINGS
The following are the summary of the study based on the general survey and assessment of the client. 1. The name of the client was not allowed to reveal due to right of privacy, the client live at Zone 4, Barangay Lusok, Bongabon, Nueva Ecija. 2. He lived in Zone 4 Barangay Lusok for almost 30 years, which classified the client as permanently living in the area. 3. The client family structure is Nuclear and the stage of family development is Launching family. 4. The client is working as a farmer and tricycle driver. 5. He was fan of eating salty and fatty foods.

CONCLUSIONS
Based on the findings, it is safe to conclude that: 1. Rheumatic heart disease is permanent damage to the heart following rheumatic fever. 2. A case of rheumatic fever can cause the heart to inflame and leave permanent damage to the heart, specifically the heart valve acts like a one-way door.

RECOMMENDATIONS
The Researchers, therefore recommend: 1. Regular check-up with a cardiologist to monitor the heart. 2. To visit the health professional during the early experience of symptoms. 3. To conduct information dissemination to the community about the condition, to widened their knowledge. 4. Live in a healthy lifestyle.