UNIVERSITY OF EASTERN AFRICA, BARATON.

SCHOOOL OF NURSING.

DEPARTMENT OF NURSING.

AN ASSIGNMENT DONE IN PARTIAL FULFILMENT OF THE COURSE

CHILD HEALTH CARE NRSG328.

STUDENTS DETAILS:
1. WILL OKOTH SOKOAC2111
2. ROBERT MORAA SRAERO1941
3. BONICE KIPCHUMBA SKIPJE2116
 RHEUMATIC FEVER.
It is an Autoimmune inflammatory disease that occur as a reaction to GABHS and affects the connective
tissues involving the heart, brain, joints and skin.
This disease is a complication of streptococcal pharyngitis.
RHEUMATIC HEART DISEASE.
It is a condition of the heart that is caused by an abnormal immune response to GABHS bacteria and
occur as a complication of rheumatic fever.
The immune response causes inflammation of the heart tissues resulting in injury of the heart valves,
leading to the onset of rheumatic heart disease.

ETIOLOGY.
The most important factor in the etiology of rheumatic fever is group A hemolytic streptococcus. Upper
respiratory tract infection with group A beta-hemolytic streptococci (GABHS) leads to subsequent
development of Rheumatic fever and appearance of clinical features usually within 2 to 6 weeks.
When the immune system tries to fight off the bacteria, it can also attack the tissues resulting in
inflammation and injury making the body susceptible to rheumatic fever.
The source of streptococcal infection is often an incident of Pharyngitis, tonsillitis, Scarlets fever, Strep
throat, and Impetigo.
Risk factors.
1. Age
The age of onset is usually between five and ten years, but some cases start at the age of 2, 3 or 4.
However it is not uncommon to have the onset under five years of age.
This is because their immune system is still developing and may not be fully equipped to handle
abnormal immune response that can occur.
2. Genetics
Certain genetic factors may make some people more susceptible to developing rheumatic fever after a
strep infection.
Some of the genetic factors include Epigenetic factors in that there are changes to gene expression that are
caused by environmental factors, such as diet, stress and exposure to toxins can cause influence of
developing rheumatic fever.
3. Environmental factors.
Living in crowded conditions, poor sanitation, and lack of access to medical care can increase the risk of
strep infections and subsequent rheumatic factors.
Crowded living areas and poor sanitation is likely to expose one to group A streptococcus hemolytic
bacteria while lack of accessible medical care makes it less easily for early detection and treatment of
strep infection thereby it graduates to rheumatic fever.
4. Previous history of rheumatic fever.
The previously damaged tissue is vulnerable to damage from subsequent strep infections. In addition, the
antibodies that are produced in response to the initial strep infection may cross-react (ability of an
antibody to bind with multiple different antigens) with the tissue leading to further inflammation and
tissue injury.

PATHOPHYSIOLOGY OF RHEUMATIC FEVER

Inoculation of Group A beta-hemolytic streptococcus antigens on the upper respiratory tract triggers the
body to produce antibodies against the streptococci. The antibodies produced normally target proteins
within the skin, brain, heart and joints. In the heart, the pericardium bacteria damages the tissues
triggering an inflammatory reaction leading to pericarditis causing the layers rub against each other
producing pericardial friction rub heard during auscultation and there's also stubbing chest pain .In the
myocardium, there is formation of Aschoff bodies/lesions. In the endocardium, The valves become
inflammed and swollen, and endocarditis results .Inflammation of the valves lead to stenosis (narrowing
of blood vessels)and regurgitation (valves don't close properly leading to backflow of blood ).This
manifests as heart murmurs and increased heart rate. In the Central nervous system, it results in
Sydenham’s chorea that is characterized by Uncontrolled, rapid ,jerky movements of the face, tongue
and upper limbs. In the Joint,it results in Polyarthritis, which is inflammation of the synovial joints , The
affected joint is swollen ,hot ,red and painful. Polyarthritis is migratory. In the skin, erythematous
macule is formed called erythema marginatum.One may develop collagen deposits around the are of the
subcutaneous tissues called subcutaneous nodules that appear over bony prominences such as the elbow,
ankles,knuckles,feet,knees and back of wrist.
MANIFESTATION.

1. MAJOR MANIFESTATIONS
 Carditis- inflammation of the heart muscles, valves, and lining
 Polyarthritis- a type of arthritis that involves inflammation of multiple joints in the body.
 Erythema marginatum- skin rash that is associated with rheumatic fever.
 Chorea- movement disorder characterized by involuntary, brief, and irregular muscle
contractions that occur at a random and unpredicted manner.
2. MINOR MANIFESTATIONS
a) Clinical manifestations
 Arthralgia ( joint pain)
 Fever
 Swelling, stiffness
 Chest pain
  Shortness of breath
 Fatigue
 Heart murmur
b) Laboratory features
 Elevated erythrocyte sedimentation rate
 Elevated c- protein
 Prolonged P-R interval

DIAGNOSIS.
1. Physical examination.

On physical exam, one can observe for skin rash and measure temperature for fever.

2. Blood tests.
A blood sample is taken to detect elevated proteins like c- protein and check the erythrocyte
sedimentation rate, these are markers of inflammation in the body.
3. Standard Throat culture
To check for the presence of streptococcus bacteria which causes rheumatic fever.
4. Electrocardiogram (ECG)
To check for any abnormalities in the heart’s electrical activity in that with the inflammation there could
be changes in the heart rhythm and conduction.
5. Echocardiogram
It is an ultrasound of the heart thereby checking for any damages to the heart valves as a result of
rheumatic fever.
6. Jones Criteria- a set of guidelines used to diagnose rheumatic fever based on the presence of
certain symptoms such as joint pain, fever, and rash.
In order to us this criteria, it should include one major criteria and two minor criteria
Diagnosed using the standard Jones criteria:
1. Major criteria
 Carditis
 Polyarthritis
 Erythema maginatum
 Subcutaneous nodules
 Chorea
2. Minor criteria
Clinical findings.

 fever (38.2-38.9°C)
 Arthralgia (joint pain without swelling
 Previous rheumatic fever
 MEDICAL MANAGEMENT.

The goals of Medical Management are.

 To eradicate hemolytic streptococci.
 Prevention of permanent Cardiac damage.
 Palliation of other symptoms.
 Prevention of recurrence of rheumatic fever.

1. Administration of antibiotics; treats the underlying streptococcal infection that cause rheumatic
fever.
Benzathine Penicillin G (long acting) 1.2 million units OD IM OR Oral penicillin V 250mg OD
for 10 days.
In children allergic to penicillin Erythromycin 250mg OD is given for 10 days. Antibiotics is
given if throat culture is negative.

2. Administration of anti-inflammatory medications; helps reduce inflammation.

For polyarthritis and mild carditis:
Salicylate such as aspirin 75-100mg/kg per day for arthritis and in the absence of carditis for 4-6
weeks to be tapered off.

For severe carditis with cardiomegaly:

Steroid: Corticosteroids 1-2mg /kg per day for 4-6 weeks to be tapered off.

Secondary prevention of recurrent attacks:

Benzathine penicillin G 1.2 million units IM every 4 weeks OR penicillin V 250 mg PO BD.
If allergic to both give Erythromycin 250mg BD daily orally

3. Administration of corticosteroids; helps reduce inflammation.

 Prednisolone
 Methylprednisolone

NURSING MANAGEMENT.
These activities are done in collaboration with the family to ensure maximization of family-centered
care.
1. Administration of medications as per treatment sheet and monitor for any adverse effects.
2. Assessing and managing symptoms such as using non-pharmacological methods of relieving pain
and providing comfort.
3. Providing rest and activity in that the patients need enough rest during the periods of acute illness
and also should engage in regular physical activity to maintain mobility and prevent emergence
of complications like deep venous thrombosis.
4. Providing emotional support to both the child and family. The child could be experiencing
anxiety and uneasiness with help of available family members create an environment of easiness
and encourage reassuring communication amongst each other.
 5. Educate the family on the condition, medications used and lifestyle modifications to prevent
complications.

3 NURSING DIAGNOSIS.
1. Acute pain related to joint inflammation as evidenced by patient grimacing, patient
verbalizing a pain of 9/10 and increase in pulse rate of 170 bmin
2. Impaired mobility related to joint pain as evidenced by patient wobbling, muscle weakness
and joint stiffness.
3. Knowledge deficit related to disease condition and long term treatment as evidenced by
mother asking many questions and child wondering why he is always in hospital.
4. Risk for infection related to immunosuppression.

COMPLICATIONS
Possible complications of rheumatic fever and rheumatic heart disease include destruction of the
mitral and aortic valves, pan carditis and heart failure.

Conclusion
In conclusion rheumatic fever is a disease that can occur following an untreated streptococcus
bacterial infection. Without treatment it leads to rheumatic heart disease.

REFERENCES.
1.Jane W Balletal, Child health nursing, 2nd edition, London,2010.
2.Frank H. Netter, Netters pediatrics, 5th edition, Philadelphia, 2010.
3) . Hockenberry, M.J, Wilson, D, & Rodgers, C.C. (2016). Wong’s Essential of Pediatric
Nursing. (10THED). Mosby.