RHEUMATIC FEVER

_________

A Case Study
Presented to
Tarlac State University
College of Nursing

___________

In Partial Fulfillment
of the Requirements for
NCM101

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By

BSN II-B4

Ryan Krisna Dela Cruz

Jon Henry Ordoñez
Bridgitte Ortiz
Monica Pineda
Mark Alvin Quibuyen
Sarah Jane Quirante
Maryner Ramos
Ron Mar Ramos
Ismael Rodriguez
Gladys Glen Santiago

INTRODUCTION
 1. Description of the disease
Rheumatic fever is an inflammatory disease that may develop two to three
weeks after a Group A streptococcal infection (such as strep throat or scarlet fever). It is
believed to be caused by antibody cross-reactivity and can involve the heart, joints, skin,
and brain. Acute rheumatic fever commonly appears in children between ages 5 and 15,
with only 20% of first time attacks occurring in adults. Rheumatic fever is common
worldwide and responsible for many cases of damaged heart valves. In Western
countries, it became fairly rare since the 1960s, probably due to widespread use of
antibiotics to treat streptococcus infections. While it is far less common in the United
States since the beginning of the 20th century, there have been a few outbreaks since the
1980s. Although the disease seldom occurs, it is serious and has a mortality of 2–5%.
Rheumatic fever primarily affects children between ages 5 and 15 years and occurs
approximately 20 days after strep throat or scarlet fever. In up to a third of cases, the
underlying strep infection may not have caused any symptoms. The rate of development
of rheumatic fever in individuals with untreated strep infection is estimated to be 3%. The
incidence of recurrence with a subsequent untreated infection is substantially greater
(about 50%). The rate of development is far lower in individuals who have received
antibiotic treatment. Persons who have suffered a case of rheumatic fever have a
tendency to develop flare-ups with repeated strep infections.
Cardiovascular diseases (CVD) greatly threaten Filipinos today. The
Filipino faces the risk of CVD throughout his life. At birth, congenital heart diseases
(CHD) and vascular malformations are possible. In early childhood, the risk of
rheumatic fever and rheumatic heart disease (RF/RHD) starts, peaking in adolescence. .
Rheumatic fever arise from frequent streptococcal sore throat. Morbidity and mortality
trends for cardiovascular diseases have been rising for the past several decades. The
morbidity rate is 206.3 cases per 100,000 population while the mortality rate is 73.7
deaths per 100,000 population is 1994. CVD is now the number one cause of death and
the seventh leading cause of morbidity in the country. The region with the highest
morbidity for CVD is Region 7, followed by Regions 1, CAR, 2 and 6.
We chose this case to be our subject for our study because primarily, it is
the best case we think we have handled while in the ward and as student nurses, we must
involve ourselves more in situations like this. We thought that the study of this disease
would further enhance our knowledge and skills when it comes to not only handling
patients but in gathering data about the patient and his/her disease.

2. Objectives:

Nurse –Centered:

To educate ourselves about rheumatic fever.

Specific Objectives:
➢ Described and explained what a rheumatic fever is.
➢ Identified the risk factors contributing to the occurrence of the disease.
➢ Enumerated the different medications.
➢ Formulated significant nursing diagnoses, with their significantly related
nursing care plans.

Patient-Centered:

To provide care to the patient who is experiencing this disease and to educate her
significant others about the disease and its treatment and methods of care

Specific Objectives:
➢ Known facts about the disease
➢ Known the medications used for the disease
➢ Been taught about the different methods of care to be done to the client
II. NURSING HISTORY
1. Personal History
a. Demographic Data
Name of the Patient: Ms.16
Age: 12 y/o
Sex: Female
Civil Status: Single
Occupation: Student
Religious Affiliation: Roman Catholic
Role Position in the Family: Daughter
Address: Brgy. Mapalad Tarlac City
Date of Birth: April 17,1997
Place of Birth: Brgy. Mapalad Tarlac City
Nationality: Filipino
Health Care Financing: None
Admitting Diagnosis: UTI suspect, Rheumatic Fever
Date admitted: August 18, 2009

b. Lifestyles and Habits

Ms. 16 does not drink any alcoholic beverages or even smokes cigarette,
according to her mother. She usually sleeps at around 8pm-11pm if she were to watch her
daily soap operas and wakes up at around 6am since she is still a student. Since she was
diagnosed of rheumatic fever she became anxious of her condition. And due to her
swelling joints, she cannot to perform activities of daily living.

2. Family History of Health and Illness

 X
X
65
HC 59
DHN

35 38
A&W A&W

12 2 Mos
RF A&W

LEGEND

X
- Deceased male -Pertains to patient, living female child

X -Deceased female - living male child

-Living mother HC -Heart Complication

DHN – Dehydration
RF – Rheumatic Fever
-Living father A&W – Alive and Well

3. History of Past Illness

 Ms.16 had a history of relapsing fever for a month. According to her mother, she
usually has this fever at night and is given paracetamol for the fever to subside and let her
rest. She was first hospitalized with a diagnosis of UTI for a week and then it developed
to rheumatic fever. She was not involved in any accidents and has no known allergies to
medicines, animals or foods, according to her mother. She also had completed her
immunizations.

4. History of Present Illness

Ms. 16 was admitted on August 18, 2009 at TPH due to her relapsing fever for a
month. She first experienced fever with her neck aching then next is her joints swelling,
she also complained of difficulty of swallowing. She also experienced vomiting. She was
first suspected of UTI which then developed to Rheumatic Fever. At present, she is now
confined in TPH for a month now.
5. Physical Assessment

Date Area/Region Techniques Standard Findings Normal Findings Interpretation

Performed of
Assessment
09/10/09 Skin Inspection Light to brown in color Color should be Normal
Palpation Temperature is 36.5ºC light to deep brown
When pinched, skin Temperature should
springs back to previous be uniform and
state within normal
Texture not uniform, range
some areas are thick and skin should spring
some are rough back to place when
No unusual marks pinched
No presence of lesions texture should not
and rushes be uniform; some
No pressure sores found areas should be
No edema thick like the palms
and soles.
09/10/09 Hair Inspection Hair is thick and shiny Should be silky, Normal
Palpation Hair is equally resilient
distributed and has no Should be thick and
presence of alopecia. hair should be
No foul odor evenly distributed
09/10/09 Nails Inspection Angle between finger Should be pinkish Normal
Palpation nail and base is about in color.
160º Convex curvature:
Blanch test is normal. angle between nail
When palpated base is and nail bed should
firm. be at about 160º
 Dirty nails After pinching,
pink color in the
nail bed should
return within 3sec.
09/10/09 Head Inspection Rounded and Should be rounded Normal
Palpation symmetrical. and symmetrical,
No unusual swelling Normocephalic
Should have
smooth skull
contour
09/10/09 Eyes Inspection Eyes are symmetrical The eyes should be Normal
Transparent, shiny and symmetrically
smooth cornea. aligned.
Pupil is 3mm in size, Cornea should be
black in color. transparent, shiny
Pupil dilates when and smooth.
without the presence of Illuminated pupil
light and constricts on constrict (direct
the presence of light. response), non
Visual acuity is normal illuminated pupil
and able to read letters dilates (consensual
within 36cm of range response)
Visual acuity
should be able to
read news print.
09/10/09 Ear Inspection The location and Pinna should be Normal
alignment is normal, aligned with the
symmetrical with upper eyes.
attachment at eye corner The color of the
level (lateral cantus) pinna should be the
Pinna is brown in color; same with the color
canal has presence of of the face.
 ear wax. Should have no
No presence of presence of
discharge and odor. discharge and odor.
Able to hear instructions Sounds should be
and responds quickly heard in both ears
or is localized with
the center of the
head.
09/10/09 Nose Inspection Normal in shape. Should be Normal
Palpation Located symmetrically. symmetric and
Each nostril is patent. straight.
Sinuses are not tender, Should have no
air-filled cavities and discharge or flaring.
resonant to percussion. Should not be
tender
09/10/09 Lips Inspection Normal integrity. Should be uniform, Normal
Normal symmetry. and pink in color
Light pink in color.
09/10/09 Mouth Inspection Number and condition Should have 32 Normal
of the teeth is normal, teeth for adult and
properly aligned 28 teeth for
Gums are pink, smooth, children.
moist and firmed. Gums should be
Tongue lies midline, pink.
pink in color, moist, has The gums should be
free mobility and free of moist and firm
lesions. texture.
Palate is concave and Tongue should be
pink in color. pink, moist, slightly
Parotid gland is smooth, rough, thin whitish
moist and has no coating.
swelling and reddening. Soft palate should
 be light pink and
smooth.
Uvula should be
position in the
midline of soft
palate.
09/10/09 Neck Inspection Muscles are Muscles should be Normal
Palpation symmetrical with the equal in size and
head and able to move head centered.
without discomfort. Trachea should be
Trachea is in the midline at the center of the
position. neck, spaces are
Thyroid is smooth, soft, equal on both sides.
not enlarges and has no Thyroid should not
presence of mass and be visible on
bruises. inspection
09/10/09 Extremities Inspection No discolorations Should have no Abnormal,
Palpation No lesions, masses discolorations Joints are
No Tenderness Should have no swollen, client
No presence of edema masses, lesions complains of
Uniform in temperature Should have no pain when
and within normal range tenderness joints are
Joints are swollen Should be uniform touched
Client complains of pain in temperature
when joints are touched
VI. Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Expected

Outcome

Subjective Analysis: After 2 hours of >Monitor Vital >To be of help After 2

>“Nahihirapan proper nursing signs for direct hours of
siya Activity intervention, >Observe and appropriate proper
gumalaw..”, as intolerance r/t the patient will document skin intervention nursing
stated by imbalance be able to integrity. >Activity intervention,
mother. between *maintain >Assist in intolerance may the patient
oxygen supply normal skin proper position lead to pressure should be
Objective and demand color and skin >Assist in ulcers able to:
>Discomfort would be warm performing >Inactivity
>Immobility Insufficient to dry ROM exercises rapidly *maintain
>Palor physiological or *Able to >Demonstrate contributes t normal skin
>Body psychological perform activity proper muscle color and
>Weakness energy to without breathing shortening and skin would
V/S: endure or discomfort pattern changes in be warm to
BP: 110/70 complete *Understand >Determine periarticular dry
RR:19 required or need for cause of and *Able to
CR:102 desired daily balanced rest activity cartilaginous perform
Temp:37.3C activities and activity intolerance and joint structure activity
determine >Inappropriate without
whether cause prolonged bed discomfort
is physical, rest orders may *Understand
psychological t contribute need for
or motivational. activity balanced rest
>Assess the intolerance and activity
client daily for
appropriateness
 of activity and
bed rest orders.
>Instructed the
client on
rationale and
techniques for
avoiding
activity
intolerance.
>Taught client
the importance
of nutrition
>Instructed the
client in the use
of relaxation
techniques
during activity
 Assessment Diagnosis Planning Intervention Rationale Expected
Outcome

Subjective Hyperthermia Short term: >Monitor Vital >To limit Short term: After 1
>”Nilalagnat r/t infection After 1 hour of signs fatigue hour of proper
siya”, as proper nursing >Performed nursing
verbalized by Increased of intervention, continuous TSB >To promote intervention, the
client’s mother temperature is a the patient’s > Checked well-being and patient’s
chemical temperature temperature energy temperature
Objective: response of the will decrease every 15 production should decreased
>Febrile body to from 38.7°C to minutes >>To promote from 38.7°C to
>Pale infections that 37C >Encouraged optimal level of 37°C
>Skin warm to causes inflamed Patient to rest function and
touch joints of the Long term: >Provide dry prevent
>Inflammed patient After proper clothing and complications. Long term:
joints nursing bed linens Patient’s joints
>Incoherent intervention, >Encouraged >To determine should continue to
>Weakness the patient’s adequate intake progress of swell but should
V/S condition will of fluids and interventions now state that
>BP:100/60 improve and nutritious foods pain is reduced.
>RR:18 cpm there would be >Encourage >To reduce
>CR:106 bpm no more participation in temperature in
Temp:38.7 °C swelling of self care the body
joints. >Note >To relax
emotional or patient’s body
behavioral
response to
problems of
fever
Assessment Diagnosis Planning Intervention Rationale Expected
Outcome
 Subjective Pain r/t swollen After 2 hours of >Monitor vital >So that pain in After 2 hours of
>”Masakit ang and inflamed proper nursing signs the joints and nursing
mga joints intervention, >Move the other parts intervention, client
kasukasuhan the patient’s patient would lessen should state of
niya”.as stated Pain is pain scale of carefully. pain scale being
by client’s whatever the 10/10 will be >Performed >single item 6/10
mother. experiencing decrease to TSB ratings of pain
person says. It 6/10 and the >Assess pain intensity are
Objective is existing temperature of using a self valid and
>Swollen joints whenever the 38.7C will report zero to reliable as
>Febrile person says it decrease to 37C ten numerical measures of
>Weak in does, pain scale pain intensity
appearance unpleasant >Teach the
>Grimace sensory and client to use the
>Pain scale of emotional pain rating
10/10 experience scale to rate the
V/S: arising from intensity of past
PR: 106 bpm actual or or current pain.
Temp: 38.7 °C potential tissue >Administer
damage or antibiotics as
described in prescribed by
terms of such physician
damage.
VII. Discharge Planning

M > Almg OH 2tbsp, 30 min before/after meal

Paracetamol 320mg every 4 hours if temperature is 37.8
Cefuroxime 750mg IVP every q 8 ANST (-)
Aspirin 500mg 3 tabs 3x a day with full stomach

E > Advise to: Do gradual walking and breathing exercises.

Have assistance and support as tolerated when ambulating.
Perform ADLs involving hygiene and self-care, with support if needed

T > Instructed to Comply with the medications prescribed

H > Demonstrate to: Place pillows on bed when asleep to prevent injury and other
accident precautions.
Provide adequate rest periods. Make up activities that increase the
well being.

O > Return for check-ups and further treatments of the disease

D > Nutritious diet. Increase fluid, fruit and vegetable intake.

 VIII. Conclusion

The group concluded that Rheumatic fever is common worldwide and

responsible for many cases of damaged heart valves Rheumatic fever is an inflammatory
disease that may develop two to three weeks after a Group A streptococcal infection
(such as strep throat or scarlet fever. The rate of development of rheumatic fever in
individuals with untreated strep infection is estimated to be 3%. The incidence of
recurrence with a subsequent untreated infection is substantially greater (about 50%). The
rate of development is far lower in individuals who have received antibiotic treatment.
Persons who have suffered a case of rheumatic fever have a tendency to develop flare-ups
with repeated strep.
The group also observed, that a patient with rheumatic fever suffer s from
frequent vomiting, inflamed joints and relapsing fever. The patient also cannot perform
ADLs such as eating grooming or even going to the bathroom with out assisstance due to
pain cause by the inflamed joints

IX. RECOMMENDATION
 Recommendations
Based on the findings and conclusions presented, the following recommendations
are presented:

Research

1. Improvement of interaction between nurse and patient, especially when the

patient is a child because they cannot easily express themselves

2. Research may be conducted to find out the level of difficulty of the client or
patient so that necessary adjustments and sound decisions can be made as to
which should be included or not.

3. Further research may be undertaken to use other forms of testing other than
the Laboratory Examination tests to indicate the level of the disease.

4. Additional research may be conducted to determine other factors that would

contribute to the disease being worsen.

5. Studies may be made to identify the specific disease of the client which is best
suited for the students.

X. BIBLIOGRAPHY
Internet:

* http://en.wikipedia.org/wiki/Rheumatic fever
*Medscape
*Nursing Crib.com

Books:

*Clinical Nursing Techniques from basic to advance skills

*Understanding the Nursing Process