Rheumatic fever small group discussion

1. Mariano Marcos State University
Republic of the Philippines
Batac, Ilocos Norte
College of Health and Sciences
Department of Nursing
Rheumatic Fever
NCM 109b
BSN II-D Group 1
Abadilla, Michaela Therese D.
Acosta, Jemy Armyn B.
Agcaoili, Annah Mikaela L.
Agnir, John Harvey A.
Alquiza, Yves Anne Joie F.
Ansagay, Mc Lein A.
Antolin, Chloe Rosette B.
Asuncion, Keziah Claire D.
Asuncion, Mary Joyce R.
Aurelio, Lyca Mae M.
PROF. JOSEPHINE D. CERIA, M.A.N.
Clinical Instructor
February 20, 2021

2. I. Description
 It is a bacterial infection affecting joints, heart and blood vessels;
 This is a febrile disease occurring as a delayed consequence of infection with group A
hemolytic streptococci and characterized by multiple focal inflammatory lesions of the
connective tissue structures, especially of the heart, blood vessels and joints
(polyarthritis) and by the presence of Aschoff bodies in the myocardium and skin;
 A severe disease chiefly of children and characterized by painful inflammation of the
joints and frequently damage to the heart valves.
II. Incidence
Although the incidence of rheumatic fever has declined greatly in recent years, the disease
has not been eradicated, and in some inner cities the incidence is rising. It occurs most often
in children 6 to 15 years of age, with a peak incidence at 8 years. It is seen most often in poor,
crowded areas. Because children do not develop immunity to streptococcal infections,
streptococcal infections recur, rheumatic fever also recurs.
III. Risk Factors
Certain factors than can increase the risk of getting rheumatic fever:
Place: Most people with rheumatic fever live in places that have limited medical resources,
such as resource-poor countries. Living in an area where it’s difficult to get medication or
medical care may also put them at risk in developing rheumatic fever.
Age: Rheumatic fever mostly affects children or teenagers between 5 and 15.
Overall health: Having a weakened immune system can also increase risk. Children who
frequently get strep infections may be more likely to get rheumatic fever.
Family history: If someone in their family has had rheumatic fever, other family members
may be more likely to get it.
Environmental factors. A greater risk of rheumatic fever is associated with overcrowding,
poor sanitation and other conditions that can easily result in the rapid transmission or
multiple exposures to strep bacteria.
Type of strep bacteria. Certain strains of strep bacteria are more likely to contribute to
rheumatic fever than are other strains such as the Group A streptococcus.
IV. Etiology or Cause
 Occur after a throat infection from a bacteria called Group A Streptococcus (GAS).

3.  Group A Streptococcus (GAS) is a bacteria that can cause infections such as strep
throat with or without scarlet fever and skin infections like impetigo, and cellulitis. If
left untreated, this can trigger rheumatic fever.
 Rheumatic fever causes the body to attack its own tissues. The body produces
antibodies to fight the bacteria, but instead the antibodies attack the body’s own
tissues. The tissues that they attack are those of the heart, joints, central nervous
system (CNS) and skin. These tissues react by becoming inflamed
 Because only a small fraction (fewer than 0.3%) of people with strep throat ever
contract rheumatic fever, medical experts say that other factors, such as a weakened
immune system, must also be involved in the development of the disease
V. Pathophysiology
The pathophysiology of Rheumatic Fever are the untreated strep throat infection caused
by the bacteria Group A Streptococcus (GAS). These bacteria spread by direct contact with
droplets of the discharges from an ill individual to the nose and throat of an individual or
those with skin lesions.
There are two types of Group A Strep, and these are; Invasive and non-invasives. The most
common GAS infection are non invasive like Strep throat, scarlet fever, and impetigo, these
are less severe and more contagious.
Invasive GAS infections are more aggressive and severe. Although Rheumatic Fever is
technically non contagious but it is the immune response to the bacteria or the infection.The
strep has the similar protein found in certain tissues of the body causing the immune system
to target its own tissues like the heart, joints, skin, and central nervous system.
VI. Manifestations
Rheumatic fever can affect people in different ways. Sometimes, people experience such
mild strep symptoms that they don’t realize they had a strep infection until rheumatic fever
develops later on.
Rheumatic fever symptoms look similar to many other health issues. Most of these
other problems are routine and not dangerous. Symptoms can vary widely, depending on
what part of the body the disease impacts.
Because rheumatic fever can be serious, always call your healthcare provider if you
suspect you or your child may have this condition. Common rheumatic fever symptoms
include:
 Swollen, tender and red joints, especially the large joints such as the knees, ankles and
elbows

4.  Chest pain or abnormal Heartbeat
 Feeling overly tired all the time (fatigue)
 Fever especially one over 100.4 degrees Fahrenheit. (38C)
 Flat, red rash with a jagged edge.
 Unexplained or ongoing headaches, especially if your child has never complained of
head pain before.
 Jerky movements you can’t control in your hands, feet or other body parts.
 Muscle aches or painful, tender joints.
 Small bumps under the skin.
 Swollen, red tonsils.
VII. Laboratory and Diagnostic Tests
There is no single test used to diagnose rheumatic fever. Instead, doctors can look for signs
of illness, check the patient’s medical history, and use many tests, including:
1. A throat swab to look for a group A strep infection
The appropriate technique includes vigorous swabbing of both tonsils and the
posterior pharynx. The sample is grown on sheep blood agar to demonstrate the presence of
beta-hemolytic streptococci infection. Colonies that grow on the agar can be tested with latex
agglutination, fluorescent antibody assay, coagglutination, or precipitation techniques to
demonstrate group A beta hemolytic streptococci (GABHS) infection.
Nursing Responsibilities
a. Always observe proper hand hygiene and gloving prior to the test.
b. Have the patient sit comfortably either on bed or chair while explaining the procedure.
c. Allow the patient to tilt his head back and ask him to say “Ahhh.” Antiseptic
mouthwash should be avoided before this test.
d. Make use of the flashlight to light up the back of the throat and check for presence of
inflammation using the tongue depressor.
e. Swab the tonsillar areas from side to side and make sure to include any inflamed or
purulent sites. The test may cause momentary gagging because the back of the throat
is a sensitive area, but it should not be painful.
f. Refrain from touching the tongue, cheeks, or teeth with the applicator, due to possible
contamination with oral bacteria.
g. Place the cotton-tipped applicator into the culture tube immediately.
h. Label the culture tube with the patient’s name, SSN, and ward number if applicable.
i. Fill out the request form completely with the personal information (date and time,
patient’s name, room #, etc.)

5. 2. Rapid antigen detection test
This test allows rapid detection of group A streptococci (GAS) antigen, allowing the
diagnosis of streptococcal pharyngitis to be made and antibiotic therapy to be initiated.
This test reportedly has a specificity of greater than 95% but a sensitivity of only 60-90%.
Thus, obtain a throat swab in conjunction with the rapid antigen detection test.
3. Blood tests
A blood test that can detect antibodies to the strep bacteria in the blood is done. The
actual bacteria might no longer be detectable in your child's throat tissues or blood.
To test for rheumatic fever, your doctor is also likely to check for inflammation by
measuring inflammatory markers in your child's blood, which include C-reactive protein and
the erythrocyte sedimentation rate.
 Acute-phase reactants: C-reactive protein and erythrocyte sedimentation rate are
elevated in individuals with rheumatic fever due to the inflammatory nature of the
disease. Both tests have high sensitivity but low specificity for rheumatic fever.
 Heart reactive antibodies: Tropomyosin is elevated in persons with acute rheumatic
fever.
Nursing Responsibilities
The role of nurses in collecting, labeling, and ensuring the timely and proper delivery of
specimens to the laboratory plays a very important thing in the hospital setting. With this,
nurses should be knowledgeable enough about the hospital’s policy and procedures for
specimen collection. However, nurses should not only possess the right knowledge, but as
well as the skill and understanding in performing necessary procedures in accordance with
the organization’s protocols, policies, and guidelines.
4. Electrocardiogram (ECG or EKG)
This test records electrical signals as they travel through your child's heart. The results can tell
if the electrical activity of the heart is abnormal and can help your doctor determine if parts
of the heart may be enlarged.
Nursing Responsibilities
Patient Preparation for Electrocardiography (ECG)
a. Explain to the patient the need to lie still, relax, and breathe normally during the
procedure.
b. Note current cardiac drug therapy on the test request form as well as any other
pertinent clinical information, such as chest pain or pacemaker.
c. Explain that the test is painless and takes 5 to 10 minutes.

6. Implementation
a. Place the patient in a supine or semi-Fowler’s position.
b. Expose the chest, ankles, and wrists.
c. Place electrodes on the inner aspect of the wrists, on the medical aspect of the lower
legs, and on the chest.
d. After all electrodes are in place, connect the lead wires.
Procedure
a. Press the START button and input any required information.
b. Make sure that all leads are represented in the tracing. If not, determine which
electrode has come loose, reattach it, and restart the tracing.
c. All recording and other nearby electrical equipment should be properly grounded.
d. Make sure that the electrodes are firmly attached.
Nursing Interventions after EKG
a. Disconnect the equipment, remove the electrodes, and remove the gel with a moist
cloth towel.
b. If the patient is having recurrent chest pain or if serial ECG’s are ordered, leave the
electrode patches in place.
5. Echocardiogram
Sound waves are used to create live-action images of the heart, which can help your doctor
to detect heart problems.
Nursing Responsibilities
a) Explain the procedure to the patient. Inform the patient that echocardiography is used
to evaluate the size, shape, and motion of various cardiac structures. Tell who will
perform the test, where it will take place, and that it’s safe, painless, and is
noninvasive.
b) No special preparation is needed. Advise the patient that he doesn’t need to restrict
food and fluids for the test.
c) Ensure to empty the bladder. Instruct patient to void prior and to change into a gown.
d) Encourage the patient to cooperate. Advise the patient to remain still during the test
because movement may distort results. He may also be asked to breathe in or out or
to briefly hold his breath during the exam.
e) Explain the need to darkened the examination field. The room may be darkened
slightly to aid visualization on the monitor screen, and that other procedure (ECG and
phonocardiography) may be performed simultaneously to time events in the cardiac
cycles.

7. f) Explain that a vasodilator (amyl nitrate) may be given. The patient may be asked to
inhale a gas with a slightly sweet odor while changes in heart functions are recorded.
The following are the nursing considerations during echocardiogram:
 Inform that a conductive gel is applied to the chest area. A conductive gel will be
applied to his chest and that a quarter-sized transducer will be placed over it. Warn
him that he may feel minor discomfort because pressure is exerted to keep the
transducer in contact with the skin.
 Position the patient on his left side. Explain that transducer is angled to observe
different areas of the heart and that he may be repositioned on his left side during the
procedure.
After the procedure
The nurse should be aware of these post-procedure nursing interventions after an
echocardiogram, they are as follows:
 Remove the conductive gel from the patient’s skin. When the procedure is completed,
remove the gel from the patient’s chest wall.
 Inform the patient that the study will be interpreted by the physician. An official report
will be sent to the requesting physician, who will discuss the findings with the patient.
 Instruct patient to resume regular diet and activities. There is no special type of care
given following the test.
Major Criteria: JONES
Joint Involvement
In Rheumatic Fever, there is painful and tender joints — most often in the knees,
ankles, elbows and wrists. Pain in one joint that migrates to another joint.

8. O looks like a Heart = MYOCARDITIS
Myocarditis is an inflammation of the heart muscle (myocardium). Myocarditis can
affect your heart muscle and your heart's electrical system, reducing your heart's ability to
pump and causing rapid or abnormal heart rhythms (arrhythmias).
In severe cases, Rheumatic heart disease is a condition in which the heart valves have
been permanently damaged by rheumatic fever.
Nodules, Subcutaneous
The painless nodules are found over joints (such as the elbows, knees, ankles, and
knuckles), the back of the scalp, and the vertebrae (backbone). The nodules are firm, round,
mobile, and range from 0.5-2 cm in size. The nodules are usually only found when severe
carditis is present.
Erythema Marginatum
A rare skin rash that spreads on the trunk and limbs. The rash is round, with a pale-
pink center, surrounded by a slightly raised red outline. The rash can appear in rings or have
less regular, larger, or elongated shapes.
Sydenham Chorea
Sydenham chorea (SC) is a neurological disorder of childhood resulting from infection
via Group A beta-hemolytic streptococcus (GABHS), the bacterium that causes rheumatic
fever. SC is characterized by rapid, irregular, and aimless involuntary movements of the arms
and legs, trunk, and facial muscles. It affects girls more often than boys and typically occurs
between 5 and 15 years of age.
Minor Criteria: CAFE PAL
CRP increase
 C-reactive protein (CRP) is a blood test marker for inflammation in the body. CRP is
produced in the liver and its level is measured by testing the blood.
 CRP is classified as an acute phase reactant, which means that its levels will rise in
response to inflammation.
 CRP measurement is made using a blood sample from a vein. The sample is then taken
to a laboratory and analyzed.
 Greater than 10 mg/L is a sign of serious infection, trauma or chronic disease,
Arthralgia
JOINT PAIN. Pain can also be a symptom of inflammation, infection, or an allergic response.

9. Fever
elevated body temperature
Elevated ESR (erythrocyte sedimentation rate)
Children should have an ESR between 0 and 10 mm/hr (normal). Erythrocyte
sedimentation rate (ESR or sed rate) is a test that indirectly measures the degree of
inflammation present in the body. The test actually measures the rate of fall (sedimentation)
of erythrocytes (red blood cells) in a sample of blood that has been placed into a tall, thin,
vertical tube
PR Interval Increased
Normal ECG values for waves and intervals are as follows: RR interval: 0.6-1.2 seconds. P
wave: 80 milliseconds. PR interval: 120-200 milliseconds.
The PR interval incorporates the time from the depolarization of the sinus node to the onset
of ventricular depolarization. The measurement starts from the beginning of the P wave to
the first part of the QRS complex, with a normal duration between 0.12 to 0.20 seconds.
Anamnesis of Rheumatism
Anamnesis = medical history
While Rheumatism isn't hereditary, your genetics can increase your chances of developing
this autoimmune disorder. Researchers have established a number of the genetic markers
that increase this risk. These genes are associated with the immune system, chronic
inflammation, and with Rheumatism in particular.
Leukocytosis
NORMAL WBC VALUES
 Newborn = 9000 – 30000 mcL
 Children under = 6200 – 17000 mcL
 Children over 2 and adults = 5000-10000 mcL
Leukocytosis is a condition in which the white cell (leukocyte count) is above the normal range
in the blood. It is frequently a sign of an inflammatory response, most commonly the result
of infection.
VIII. Medical/Surgical Management
1. Anti-inflammatory. Treatment of the acute inflammatory manifestations of acute
rheumatic fever consists of salicylates and steroids; aspirin in anti-inflammatory doses

10. effectively reduces all manifestations of the disease except chorea, and the response typically
is dramatic.
2. Corticosteroids. If moderate to severe carditis is present as indicated by cardiomegaly,
third-degree heart block, or CHF, add PO prednisone to salicylate therapy.
3. Anticonvulsant medications. For severe involuntary movements caused by Sydenham
chorea, your doctor might prescribe an anticonvulsant, such as valproic acid (Depakene) or
carbamazepine (Carbatrol, Tegretol, others).
4. Antibiotics. Your child’s doctor will prescribe penicillin or another antibiotic to eliminate
remaining strep bacteria.
5. Surgical care. When heart failure persists or worsens after aggressive medical therapy for
acute RHD, surgery to decrease valve insufficiency may be lifesaving; approximately 40% of
patients with acute rheumatic fever subsequently develop mitral stenosis as adults.
6. Diet. Advise nutritious diet without restrictions except in patients with CHF, who should
follow a fluid-restricted and sodium-restricted diet; potassium supplementation may be
necessary because of the mineralocorticoid effect of corticosteroid and the diuretics if used.
7. Activity. Initially, place patients on bed rest, followed by a period of indoor activity before
they are permitted to return to school; do not allow full activity until the APRs have returned
to normal; patients with chorea may require a wheelchair and should be on homebound
instruction until the abnormal movements resolve.
IX. Nursing Management
1. Provide comfort and reduce pain. Position the child to reduce joint pain; warm baths and
gentle range-of-motion exercises help to alleviate some of the joint discomforts; use pain
indicator scales with children so they are able to express the level of their pain.
2. Provide diversional activities and sensory stimulation. For those who do not feel very ill,
bed rest can cause distress or resentment; be creative in finding diversional activities that
allow bed rest but prevent restlessness and boredom, such as a good book; quiet games can
provide some entertainment, and plan all activities with the child’s developmental stage in
mind.
3. Promote energy conservation. Provide rest periods between activities to help pace the
child’s energies and provide for maximum comfort; if the child has chorea, inform visitors that
the child cannot control these movements, which are as upsetting to the child as they are to
others.

11. 4. Prevent injury. Protect the child from injury by keeping the side rails up and padding them;
do not leave a child with chorea unattended in a wheelchair, and use all appropriate safety
measures.
X. Nursing Care Plan
Nursing Care Plan #1
Nursing Diagnosis
Acute pain related to inflammation of the joints (knees and ankles) as evidenced by a
guarding behavior, redness, and warmth at the affected joints, with a pain scale rate of 8/10
in the Wong-Baker FACES pain rating scale. With a verbalization of “Nasakit toy tumeng ko kn
palay-palay ko”.
Nursing Inference
The body's immune system, which normally targets infection-causing bacteria, attacks
its own tissue, particularly tissues of the heart, joints, skin, and central nervous system. This
immune system reaction results in swelling of the tissues (inflammation).
Nursing Goal
After 10-12 hrs of effective nursing intervention, the redness of the affected joints and
guarding behavior will decrease, a pain scale rate of 4/10 in the wong baker faces pain rating
scale and verbalization of " Haan unay nasakit detuy tumeng ken lpalay palay kon."
Nursing Intervention Rationale
Elevate involved extremities above heart
level when the patient is at lying position.
Improves circulation to the heart to alleviate
edema.
Maintain bed rest during the acute stage
of the disease.
Promotes relief of joint pain caused by
movement.
Advise positional changes every 2 hours
while maintaining body alignment.
Prevents contractures and promotes
comfort.
Apply bed cradle or joint support. Avoids pressure on painful parts.
Assist in gentle handling and supporting of
body parts.
Prevents extra pain to affected parts.
Encourage the use of nonpharmacologic
interventions such as imagery, relaxation,
distraction, cutaneous stimulation, heat
application
Provides additional measures to decrease
pain perception.
Provide mechanical support such as cane or
walker support.
Supports patients when he moves around
(e.i walk to the bathroom)

12. Apply alternate cold and warm compress for
inflamed joints.
Cold compress numbs the joints and
decrease pain, while warm compress
relieves pain and increase circulation in the
area.
Allow patient to listen to music. Releases endorphins- a natural pain reliever
released by the brain.
Loosen the clothing of the patient. To make the patient comfortable.
Provide psychomedical and spiritual support
to the client.
This will help the patient tolerate pain and
provide hope of healing through clinging to
divine powers.
Administer salicylates and anti-
inflammatory medications as prescribed.
Relieves pain, inflammation in joints and
provides rest and comfort.
Nursing Evaluation
After 10-12 hrs of effective nursing intervention, the redness of the affected joints and
guarding behavior is decreased, has a pain scale rate of 4/10 in the Wong baker faces pain
rating scale and verbalization of " Haan unay nasakit detuy tumeng ken palay palay kon."
Nursing Care Plan #2
Nursing Diagnosis
Hyperthermia related to illness or inflammatory disease evidenced by body
temperature of 38.5o
C, skin warm to touch, chills, tachycardia, tachypnea, loss of appetite
and verbalization of “Nakabarbara tuy riknak”
Nursing Inference
Hyperthermia is a reaction to group A beta-hemolytic streptococcal infection related
to stimulation of the body's immune response. It support the immune system's attempt to
gain advantage over the infectious agents and it makes the body less favorable as a host for
replicating bacteria, which are temperature sensitive.
Nursing Goal
Within 4 hours of nursing interventions, the child will be able to have a body
temperature within normal range (36.5o
C-37.5O
C), be free from chills and verbalize “Haan nak
agguriguren”.

13. Nursing Intervention Rationale
Administer nonsteroidal anti-inflammatory
drug (NSAIDs) as prescribed; Observe for
any untoward effects of NSAIDs.
Reduces inflammation and pain
Administer paracetamol every 4 hours as
prescribed
Reduces elevated body temperature
Administer a course of penicillin therapy or
intramuscular benzathine penicillin as
prescribed.
A complete antibiotic treatment of penicillin
eliminates group A streptococcus infection.
Provide a tepid sponge bath. Helps reduce the occurrence of fever
Modify the child’s environment such as
room temperature and bed linens as
indicated.
Room temperature may be accustomed to
near normal body temperature and blankets
and linens may be adjusted as indicated to
regulate the temperature of the client.
Eliminate excess clothing and covers. Exposing skin to room air decreases warmth
and increases evaporative cooling.
Maintain bed rest especially during the
acute febrile phase.
Conserves energy and reduces metabolic
rate.
Encourage increase fluid intake Extra fluids increase insensible fluid losses
from fever and respiratory tract
evaporation, correcting dehydration from
reduced intake, and reducing the viscosity of
mucus.
Teach the parents or significant others
about the signs and symptoms of
hyperthermia and help in identifying factors
related to the occurrence of fever.
Providing health teachings to the patient
and family aids in coping with disease
condition and could help prevent further
complications of hyperthermia.
Nursing Evaluation
Within 4 hours of nursing interventions, the child was be able to have a body
temperature within normal range (36.5o
C-37.5o
C), be free from chills and verbalize “Haan nak
agguriguren”.