2. At the end of the practice teaching the students will be
able to gain in depth knowledge regarding Rheumatic
Fever and appreciate and develop positive attitude and
practice this knowledge in clinical settings.
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3. At the end of the Class students will be able to,
o Define the Rheumatic fever.
o Enlist the predisposing factor of acute rheumatic
fever.
o Explain the etiology of Rheumatic fever.
o Describe the pathophysiology of Rheumatic fever
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4. o Enumerate the clinical manifestation of Rheumatic
fever.
o Describe the diagnostic evaluation of Rheumatic
fever.
o Explain the medical management of Rheumatic fever.
o Explain the nursing management of Rheumatic fever.
o Explain the prevention of Rheumatic fever.
o Enlist complication of Rheumatic fever.
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5. Rheumatic fever is a serious complication that can
develop following an untreated throat infection (by a
type of bacteria called group A streptococcus).
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6. Rheumatic fever is an acute illness characterized by
lesions in the connective tissues of the joints, heart,
blood vessels less frequently affecting the central
nervous system, skin and sub cutaneous tissue.
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7. Rheumatic fever is an acute autoimmune collagen
disease occurs as a hypersensitivity reaction to group
A beta haemolytic streptococcal infection.
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8. Genetic predisposition
Temperate climate
Winter season
Unhygienic living condition
Overcrowding in family
Poor dietary intake
Increasing immunological response.
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9. 30/06/2020Rheumatic Fever by Hina R 9
Rheumatic fever is not clear but there is strong
association with Group A, beta haemolytic
streptococcal sore throat.
10. post pharyngeal infection (3 weeks)
Causes
(group A beta haemolytic streptococcal cell
pharyngitis)
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11. Antigen and antibody reactions rheumatic fever with
cardiac damage and other problems like polyarthritis,
chorea etc.
production of antibodies against streptococcal cell
antigen, connective tissue of the heart, blood vessels,
joints and subcutaneous tissues have antigen similar to
streptococcal cell antigen
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12. The clinical features of acute rheumatic fever can be
grouped as major, minor and essential
manifestation or criteria, as described in modified
Jones criteria (Revised) for diagnosis of rheumatic
fever.
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13. Carditis:
It is early manifestation of rheumatic fever as
pancarditis i.e. pericarditis, myocarditis and
endocarditis
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16. It is evidenced as presence of significant tachycardia,
murmur, ECG changes, cardiac enlargement, friction
rub, pericardial effusion and features of heart failure.
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17. Two or more joints are affected.
It is usually flitting or migratory type of:
1. joint inflammation with pain
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18. 2. decreased active movements
3. warm
4. Tenderness
5. redness and swelling
6. Commonly knees, ankles and elbows are involved
but sometimes smaller joint may also be affected.
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20. It is purposeless involuntary, rapid movements
usually associated with muscle weakness,
incoordination, and involuntary facial grimace,
speech disturbance, awkward gait and emotional
disturbances.
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21. It is found as firm painless nodule over the extensor
surface of certain joints (elbow, knees and wrists),
occiput and vertebral column.
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22. A transient erythematous rash i.e. Erythema
marginatum.
It is pink macular nonitching rash, found mainly over
trunk, sometimes on the extremities but never on face.
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23. It is transient and brought out only by heat and
migrates from place-to-place.
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24. ESSENTIAL CRITERIA
Fever: Is common findings. It rarely goes above 39.5
degree Celsius. (103.1 degree F).
Arthralgia: Pain in the joints occurs in about 90 % of
cases. It presents along with arthritis
Previous attack of rheumatic fever or rheumatic heart
disease. This is applicable for a second attack of rheumatic
fever.
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26. ECG changes with prolonged P-R interval is
considered as minor criteria. It is not diagnostic of
carditis.
Elevated ESR or presence of C- reactive protein may
be considered as minor criteria.
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27. OTHER MANIFESTATIONS
Elevated antistreptolysin-O (ASO) titre indicates
previous streptococcal infection (normal 200 IU/mL).
Positive throat swab culture may show streptococcal
infection (sore throat, scarlet fever etc.)
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28. 30/06/2020Rheumatic Fever by Hina R 28
The diagnosis is made on the basis of Duckett Jones
essential, major and minor criteria listed.
Two major or one major and two minor criteria
should be present along with presence of essential
criteria for making the diagnosis of acute rheumatic
fever.
29. Leukocytosis
Raised ESR (Erythrocytes sedimentation rate)
Raised CRP (C- reactive protein)
Elevation of ASO titer (Anti streptolising O titer) or
antideoxyribonuclease-beta (anti-DNase-B) titers in
response to preceding streptococcal infection are
mandatory before making diagnosis of acute
rheumatic fever.
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30. Throat culture
In patients suspected to have carditis, ECG,
echocardiography and X-ray chest should be taken.
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31. o Bed rest is important in the management of children
with rheumatic fever. It is needed for at least 6 to 8
weeks till the rheumatic activity is disappeared.
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32. Diet
o Nutrition diet to be provided with protein, vitamins and
micronutrients.
o Salt restriction is not necessary unless CCF is present.
o Avoid rich spicy food.
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33. o Penicillin is administered after test to eradicate
streptococcal infection.
o Initially, Procaine Penicillin 4 lacks units deep IM,
twice a day is given for 10 to 14 days.
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34. o Then the long-acting Benzathine Penicillin 1.2 mega
units every 21 days or 0.6 mega unit every 15 days
to be given.
o Oral Penicillin 4 lakhs units (250 mg), every 4 to 6
hours for 10 to 14 days can be also given.
o Erythromycin or Tetracycline can be used in patients
who are sensitive to Penicillin.
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35. Aspirin is administered as suppressive therapy to
control pain and inflammation of joints.
The dose of Aspirin is 90 to 120 mg/kg/day in 4
divided doses.
It may be needed for 12 weeks.
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36. The dose can be modified for the individual patients.
Aspirin should not be given in empty stomach.
Antacid to be given just prior to or with the aspirin.
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37. o Steroid (Prednisolone) therapy is given as
suppressive therapy along with Aspirin.
o The initial dose is 40 to 60 mg/day or 2 mg/kg/day in
4 doses, for 7 to 10 days.
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38. o Then the dose is reduced to 1mg/kg/day.
o It should be tapered off gradually over 12 weeks
period and used for patients having carditis with or
without CCF.
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39. Management of chorea can be done with Diazepam
or Phenobarbitone.
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40. o Treatment of complications, if present, especially for
CCF. Symptomatic care to be provided accordingly.
o Good nursing care with emotional support to the child
and parents is as important as the medicated.
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41. o Nursing assessment is vital for care the child with
rheumatic fever.
o It should include special attention to vital signs,
cardiac monitoring (ECG, heart sound), pain
assessment and other associated problem.
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42. The patient with chorea should be provided with
padded railings in the bed to prevent any injury.
Handwriting of the patient should be monitored to
assess the progress of disease.
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43. a) Decreased cardiac output related to carditis.
b) Pain related to polyarthritis
c) risk of injury related to involuntary movement in
chorea
d) anxiety related to disease condition
e) Knowledge deficit related to long-term treatment and
prognosis of the acquired heart disease.
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44. 30/06/2020Rheumatic Fever by Hina R 44
Primary prevention can be achieved by educating the
people to avoid streptococcal sore throat and
elimination of predisposing factors of the disease.
Treatment of streptococcal pharyngitis with penicillin
or other medication (erythromycin, amoxicillin,
cephalexin, clindamycin, nafcillin) can be useful
measure to prevent primary attack of rheumatic fever.
45. Secondary prevention of the disease can be done by early
detection, adequate treatment and prevention of
recurrences of rheumatic fever. Long acting penicillin
therapy should be continued every 15 days or 21 days for
at least 5 years from the last attack of rheumatic fever or
up to 18th birth day, whichever comes earlier. In patients
with carditis or rheumatic heart disease, pencillin
prophylaxis is continued lifelong or at least up to the age
of 40 years. Parents should be made aware about the
continuation of treatment, medical help and follow-up.
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46. Chronic rheumatic heart disease is the most
common complication
Heart failure
Infective endocarditis
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47. Pericardial effusion
Permanent cardiac damage are also common
complication of rheumatic fever.
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48. Rheumatic fever is an acute autoimmune collagen
disease occurs as a hypersensitivity reaction to group-
A beta haemolytic streptococcal infection. It is an
important cause of acquired heart disease in children.
Good prognosis for older age group & if no carditis
during initial attack.
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49. Bad prognosis for younger children and those with
carditis with valvar lesions.
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50. Assuma Beevi. T.M. Textbook of Paediatric Nursing.
1st Edition. Noida: Reed Elsevier India Private
limited; 2009. P. 278-280.
Parul Datta. Textbook of Pediatric Nursing. 3rd
Edition. New Delhi; Jaypee Brothers Medical
Publication; 2014. P.313-314.
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51. Singh Meharban. Essential Pediatric for Nurses.
Fourth Edition. New Delhi: CBS Publishers &
Distributors Pvt Ltd; 2017. P. 321,353.
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