Republic of the Philippines

ISABELA STATE UNIVERSIYY

Ilagan City, Isabela
COLLEGE OF NURSING

What is Rheumatic Fever?

Rheumatic fever is inflammatory disease that occurs following a Streptococcus

pyogenes infection, such as streptococcal pharyngitis. Believed to be caused by antibody cross-
reactivity that can involve the heart, joints, skin, and brain, the illness typically develops two to
three weeks after a streptococcal infection. Acute rheumatic fever commonly appears in children
between the age of 6 and 15, with only 20% of first-time attacks occurring in adult.

II. Epidemiology

In developing countries, the magnitude of ARF is enourmous. Recent estimates suggest

that 15. 6 million people worldwide have rheumatic heart disease and that 470, 000 new cases
of rheumatic fever (approximately 60% of whom will develop rheumatic heart disease) occur
annually, with 230, 000 death reulting from its complications. Almost all of this toll occurs in the
developing country.
The incedence rate of rheumatic fever is many as 50 cases per 100, 000 children in many
areas. Areas hyper endimicity (eg. Indigenous population of Australia and New Zeland) see an
300-500 cases per 100, 000 children, while the rates, are approximately 50 fold lower in their
nonindigenous compatriots. Rheumatics fever in the 21st century appears to be largely a
disease of crowding and poverty.

III. Diagnostics

Rheumatic Heart disease at autopsy with characteristic findings (thickened mitral vlave,
thickened chorda tendinae, hypertrophied left ventricular myocardium). Modified Jone criteria
were first published in1994 by T. Duckett Jone, MD. They have been periodically revised by the
American Heart Association in collaboration with other groups. According to revised Jones
criteria, the diagnosis of rheumatic fever can be made when:

 Two major criteria, or

 One major criterion plus two minor criteria, are present
 Along with evidence of streptococcal infection: elevated or rising antistreptolysin O titre
or DNAase.
 Exceptions are chorea and indoent carditis, each of which by itself can indicate
rheumatic fever. E & D studies have identified subclinical carditis in patients with acute
rheumatic fever, as well as in follow-ups of rheumatic heart disease patients who initially
presented as having isolated cases Sydenham’s chorea.

Major Criteria
1. Syndenham’s chorea (St. Vitus’ dance): When I immune system cross
react with the the tissue of the central nervous system causes basal
glangia (responsible for motore movement) to inflame. Due to the
inflamation of the basal glangia it causes the leak of water flouram. A
charactersitic series of rapid movement without purpose of the face and
arms is the effect of this (involuntary movement). This can occur very late
in the disease for at least three months from onset of the infection.

2. Polyanthritis: A temporary megrating inflamation od the large joints,

usually starting in the legs and migrating upwards.
3. Erythema marginatum. A long-lasting reddish rash that begins on the
trunk or arms as muscle, which spread outward and clear in the middle to
form rings, which continue to spread outward and clear in the middle to
form ringss, which continue to spread and coalesce with other rings,
ultimately taking on a snake-lile appaerance. The rash typhically spares
and face and is made worse with heat.

4. Subcuatneous nodules. Painless, firm collections of collagen fibers over

bones or tendons. They commonly appear on the back of the wrist, the
outside elbow, and the front of the knees.

5. Craditis. Inflamation of the heart muscle (myocarditis) which can

manifest as congestive heart failure with shortness of breath, pericarditis
with a rub, or new heart murmur.
 Manifested as pancarditis (endocarditis, myocarditis and pericarditis),
occurs in 40-50% of cases
 Carditis is the only manifestation of rheumatic fevertht leaves a squelae &
permanent damage organ
 Valvulitis occurs in acute phase
a. Rheumatic Pericardis
  Is one of the major manifestation of acute rheumatic fever ,
it occurs 5-10% of cases
 When immune response include the pericardium it can
cause inflamation, and development of endothilial gaps,
cuses leak of molecules called protien like fibrinogen
(produce by liver in a for of globular and soluble) present in
circulation.
 Chest pain (spicky, cutting like pain)
 Fibrous Peri Carditis/Butter Bread and butter peri carditis.
 Pericarditis Rub (scretchy sound) heard using stethoscope
b. Myocarditis

 Inflamation of the heart muscle when immune respose

cross react with the myocardium
 The heart become lose and flabby cause the heart not to
contract properly (Low cardiac output)
 Presence of aschoff body in the myocardium cause
inflamation of the heart
c. Endocarditis

 Immune system attack the inner line of the heart

especially the valvular tissue (when the valve become
inflame it is call Rheumatic Valvulitis)
 Formation of Vegataion is made due to the eruption of
epitlium layer and due to lots of fibrinogen formation and
platelets formation.
 Long term complication is due to acute rheumatic
endocarditis
 Cause permanent damege in the heart.

Epicardium/Pericardium: The
outer protective layer of the heart

Myocardium: Muscular middle

layer of the heart

Endocardium: The inner layer of

the heart
Minor Criteria

1. Fever of 38.2-38.9 ˚C
2. Arthralgia Joint pain without swelling (Cannot be included if polyarthritis is
present as a major syptom)
3. Raised erythrocyte sedimentation rate or CPR
4. Leukocytosis
5. ECG showing feature of heart block, such as a prolonged PR interval
(Cannot be included if carditis is present as major syptom)
6. Previous episode of rheumatic fever or inactive heart disease.
Other Signs and Syptoms
 1. Abdominal pain
2. Nose bleeds
3. Preceding streptococcal infection: recent scarlet fever, raised
antistreptolysis O or other streptococcal antibody titre, or positive throat
culture.

IV. Pathophysiology

Rheumatic fever is a systematic disease affecting the peri-arteriolar connective tissue

and can occur after an untreated Group A Beta hemolytic streptococcal pharyngeal infection. It
is believed to be caused be antibody cross-reactivity. This cross-reactivity is a Type II
hypersensitivity reaction and is termed molecular mimicry. Usually, self-reactive B cells remain
anergic (lymphocytes are said to be anergic when they fail to respond to their specific antigen)
in the periphery without T cell co-stimulation. During a streptococcus infection, mature antigen
presenting cells such as B cells present the bacterial antigen to CD4-T cells which differentiates
into helper T2 cells. Helper T2 cells subsequently activate the B cells to become plasma cells
and induce the production of antibodies against the cell wall of Streptococcus. However the
antibodies may also react against the myocardium and joints, producing the symptoms of
rheumatic fever.

Group A Streptococcus pyogenes has a cell wall composed of branched polymers which
sometimes contain M protein that are highly antigenic. The antibodies which the immune system
generates against the M protein may cross react with cardiac myofiber protein myosin, heart
muscle glycogen and smooth muscle cells of arteries, inducing cytokine release and tissue
destruction. However, the only proven cross reaction is with perivascular connective tissue. This
inflammation occurs through direct attachment of complement and Fc receptor-mediated
recruitment of neutrophils and macrophages.

V. Treatment

 Bed rest-2 to 6 weeks (till inflammation subsided)

 Supportive therapy-treatment of heart failure
  Eradication of Organism Anti-streptococcal therapy-Benzadthine penicillin (long
acting) 1.2 million units once (IM injection) or oral penicillin 10 days, if allergic to
penicillin erythromycin 10 days (antibiotic is given eve if throat culture is
negative)
 Anti-inflammatory agents-
 For Polyarthritis and mild carditis; anti-inflammatory therapy with salicylates;
Aspirin 100 mg/kg per day for arthritis and is absnce of carditis-for 4-6 weeks
to be tapered off
 For severe carditis with cardiogmegally: use steroid; Corticosteroids 1-2
mg/kg per day-for 4-6 weeks to be tapered off
VI. Drug Study

Drug Action Dosage Indication Contraindica Advers Nursing

Name tion e Managemen
Reactio t
n
1. Interferes Adult: General Concentration -Nausea Before
Generic with Indication s - Allergies
Name bacterial -Pharyngitis/ s to penicillins, - - Observe 15
Penicilli cell wall tonsillitis, group cephalosporin Vomitin rights of drug
nG synthesis A streptococci - Severe s, or other g administratio
Benzathi during (1.2 million units infections allergens n.
ne active IM x 1) caused by Precaution -Pain,
multiplicati Upper sensitive - Renal swelling - Reduce
Brand on, respiratory organisms disorders , lump, dosage with
Name: causing infection, group (streptoco bleeding hepatic or
Penadur cell wall A streptococci cci) - Pregnancy , or renal failure.
death and that are mild to bruising
resultant moderate and - URTI - Lactation in the - Assess for
bactericid are susceptible caused by Drug area hypersensitiv
al activity to low, sensitive interaction where ity to drug.
against prolonged streptococ Drug to drug the
susceptibl concentrations ci medicati - Assess for
e bacteria. of benzathine - - Decreased on was any
penicillin (1.2 Treatment effectiveness injected. contraindicati
million units of syphilis, with ons to the
intramuscularl bejel, tetracyclines drug.
y [IM] x 1) congenital
syphilis, - Inactivation - Educate
Pediatric: pinta, of parenteral about side
yaws aminoglycosi effects of
Pharyngitis/ des drug.
tonsillitis, group - (amikacin,
A streptococci: Prophylaxi gentamicin, During
Acute treatment s of kanamycin,
(less than 27 kg rheumatic neomycin, - Drug is not
= 600,000 units fever and tobramycin) for IV use.
IM x 1; greater chorea Do not inject
than 27 kg = 1.2 Drug to food or mix with
million units IM - none other IV
x 1); Chronic reported solutions.
carrier
treatment (less - Give IM
than 27 kg = injection in
600,000 units upper outer
IM x 1 in quadrant of
combination the buttock.
with oral
rifampin; greater - Avoid
than 27 kg = 1.2 contact with
million units IM the needle. -
x 1 in Withdraw
combination needle as
with oral quickly as
rifampin) possible to
avoid
discomfort.

- Stay with
patient
throughout
whole
duration of
administratio
n.

After

- Monitor
client for at
least 30
minutes.

- Arrange for
regular
follow-up,
including
blood tests,
to evaluate
effects.

- Instruct to
report
difficulty
breathing,
rashes, and
severe pain
at injection
 site, mouth
sores,
unusual
bleeding or
bruising.

- Instruct to
take
medication
as directed
for the full
course of
therapy,
even if
feeling
better.

- Do proper
documentati
on.

Drug Action Dosag Indication Contraindica Adverse Nursing

Name e tion Reaction Managem
ent
1. Generic Exhibits Aspirin For pain on Hypersensitiv GI: -Assess for
Name antipyretic, 100mg/t integument ity to dyspepsia, pain: type,
Aspirin antiinflamma ab 1 tab ary salicylates, heartburn, location
(acetylsalic tory and p lunch structures, severe anorexia, and pattern
ylic acid) analgesic PO OD myalgia, anemia, nausea,
effect neuralgia, history of epigastric -Note for
Brand headache, blood discomfort, asthma
Name: dysmenorr coagulation potentiation of
Antipyretic
Aspergum hea, gout. defects, peptic ulcer
effect is due -Monitor
vitamin K
to an action Arthritis, deficiency, 1 Allergic: renal, LFTs
on the SLE, acute week before Bronchospas and CBC
hypothalamu rheumatic and after m, asthma-
s, resulting in fever surgery, like -Determine
heat loss by pregnancy in symptoms, history of
vasodilation the last anaphylaxis, peptic
of peripheral trimester skin rashes, ulcers or
blood vessels urticaria bleeding
tendencies.
Antiinflamma Hematologic:
tory effects prolongation Precaution
are mediated of bleeding s:
by a decrease time, -Do not use
in thrombocytop in children
enia,
prostaglandi with
leucopenia,
 n synthesis. chicken
Other: Thirst, pox or flu
fever, symptoms
dimness of
vision -Lactation
Mild
diabetes,
erosive
gastritis,
bleeding
tendencies,
liver or
kidney
disease.

VII. Nursing Care Plan

Case Scenario

In a local hospital a 7-year-old boy presents with his father. The patient’s father reports
that he has noticed his son fidgeting constantly and making jerky movements with her arms and
legs. He also has a low-grade fever (38.3 ˚C) and has been experiencing aches in her knees
and ankles that seem to come and go. On history taking it reveals that the patient is a healthy
boy with an unremarkable medical history, although he did complain of a sore throat about a
month ago. And during performing a physical exam. On inspection, erythema marginatum was
seen on his abdomen.

Assessment Nursing Nursing Nursing Rationale Evaluation

Diagnosis Planning Intervention
Subjective: Involuntary After 8 hours 1. Monitor 1. Harmful After 8 hours
“I noticed that movement s of nursing patient for incident s of nursing
my son is of the left intervention, self-harm can intervention,
fidgeting extremities the client (sleeping, contribute the client
constantly related to should be home safety) and give partially met
and making impaired able to : possible and achieved
jerky mobility. recurrences the following:
movements -maintain of the
with her arms functional impairment >maintained
and legs” as ability to the client. functional
verbalized by 2. Keep ability
the patient -prevent patient away 2. Involuntary
father. additional from sharp movements >prevented
impairment of objects. of the client additional
Objective: physical might lead impairment of
 -Low grade activity her to harm physical
fever (38.3 herself. activity
˚C) -ensure a 3. Feed
safe patient slowly 3. Patient >ensured a
environment. with few but might be at safe
frequent risk of environment
-Perform aspiration
activities of 4. Encourage >performed
daily living independent 4. Can help activities of
with minimal ambulation regain daily living
assistance as long as mobility and without
possible. can do discomfort
activities of and with
daily living minimal
without assistance.
assistance

Assessment Nursing Nursing Nursing Rationale Evaluation

Diagnosis Planning Intervention
Subjective Acute pain After 8 hours Assess the -Provides After 8 hours
Data: related to of nursing child’s pain information of nursing
migratory intervention, perception about pain intervention,
“He has been polyarthritis the client using an level of child. the client
experiencing as should be appropriate partially met
aches in her manifested able to : scale every 2- and achieved
knees and by patient 3 hours. the following:
ankles that complain of -Child will be
seem to aches in his able to -Examine -Provides -Child will be
come and go” knees and verbalize less affected joints, data about able to
as verbalized ankle that pain by using degree of joint pathologic verbalize less
by the patient seem to a scale 1 to pain, level of changes in pain by using
father. come and go. 10. movement joints; a scale 1 to
reversible join 10.
Objective -Child will involvement
Data: appear usually -Child will
relaxed affecting appear
-Low grade without large joints, relaxed
fever (38.3 guarding such as without
˚C) knees, hips, guarding
-Child’s join wrists, elbow;
will not an increase in -Child’s join
become numbers of will not
inflamed, red affected joints become
or warm. occurs over inflamed, red
period of or warm.
time.

-Relieves
-Administer pain,
 salicylates inflammation
and anti- in joins and
inflammatory provide rest
medications and comfort
as prescribed,
and advise
that the
medication will
decrease the
pain
-Avoid
-Apply bed pressure of
cradle under painful parts.
outside covers
over painful
joints.
-Provides
-Encourage additional
the use of measures to
non- decrease
pharmacologic pain
interventions perception.
such as
imaginary,
relaxation.
-Promotes
-Educate comfort and
parents in avoids pain
proper body contractures
positioning during bed
and handling rest.
of affected
parts.

Different case with the other 2 NCP

Assessment Nursing Nursing Nursing Rationale Evaluation

Diagnosis Planning Intervention
SUBJECTIV Decreased STO: Diagnostic: STO:
E DATA: cardiac
output After 15 -Assess -Early detection Goal met:
“naninikip related to minutes of potential for/ of changes patient was
ang dibdib altered nursing type of promotes timely able to
ko,” myocardial intervention, developing intervention to breathe
verbalized by contractility the patient shock states. limit degree of within
the patient. evidenced will be able cardiac normal
Complaints by mitral to alleviate dysfunction. range and
of stenosis/ feelings of decrease
palpitations accumulatio chest pain feelings of
fatigue n of fibrin on and -Monitor vital -To determine chest pain.
OBJECTIVE mitral valve. shortness of signs degree of
DATA : breath. frequently. assistance LTO:
-dyspnea needed by the
LTO: patient and note Goal met
-Restless After 3-4 response to the patient
-edema days of activities/ was able to
continuous Intervention. demonstrat
-Pallor nursing e improved
intervention, -Monitor intake -To decrease breathing
-clammy skin the patient and output. oxygen pattern and
will be able consumption decreased
-Prolonged to decrease and risk of episodes of
capillary refill episodes of decompensation chest pain.
dyspnea, .
-oliguria angina and
dysrhythmia THERAPEUTI
-Vital signs: s C
BP: 90/60
mmhg PR: -Keep patient
86 bpm RR: on bed -To determine
12 bpm rest/chair rest alterations on
Temp: 36 o C position of fluid and
comfort. Electrolyte
balance.
-Administer
oxygen -To increase
supplement. oxygen available
for cardiac
function and
tissue perfusion
for both mother
and the baby.

-Assist with or -Decrease

perform cardiac
selfcare workload/
activities for the provide comfort
client.

-Provide fluid -To minimize

and dehydration and
electrolytes as dysrhythmias.
indicated.
EDUCATIVE:

-Encourage -Provide
Deep breathing oxygenation.
exercise.

-Instruct client -Can cause

to avoid changes in
stressful cardiac
activities. pressures and or
impede blood
flow.

-Reiterate -To monitor

importance of condition and
regular prevent
prenatal complication
checkups especially on the
fetal side.

-To enhance
-Instruct to venous return.
elevate legs
when on sitting
position.
-Complication
especially on the
fetal side.

-To enhance
venous return.