Acute rheumatic fever is an inflammatory disease that can affect the heart, joints, brain, and skin. It occurs as a complication of untreated strep throat infection. Major symptoms include heart inflammation, arthritis, abnormal movements, skin nodules, and rashes. It is diagnosed based on symptoms and evidence of prior strep infection. Treatment involves antibiotics to treat strep, aspirin or steroids to reduce inflammation, and lifelong antibiotics to prevent recurrence. Nursing care focuses on reducing fever, monitoring the heart for damage, maintaining activity, and educating patients about prevention and management of the disease.

1. Presented by : Ms. Avelin
D’Souza

2. DEFINITION:
2
 Acute rheumatic fever is a systemic disease of
childhood ,often recurrent that follows group A
beta hemolytic streptococcal infection
 It is a diffuse inflammatory disease of connective
tissue primarily involving heart, blood vessels,
joints, subcut.tissue and CNS
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3. Incidence
3
 In developing areas of the world, severe disease
caused by group A Streptococcus (e.g., ARF,
rheumatic heart disease, glomerulonephritis, and
invasive infections) is estimated to affect nearly
20 million people and is the leading cause of
cardiovascular death during the first five decades
of life. ARF can occur at any age, although most
cases occur in children 5 to 15 years of age.
Worldwide, there are 470,000 new cases of ARF
and 233,000 deaths attributable to ARF or
rheumatic heart disease each year. Most cases
occur in developing countries and among 5/30/2016

4. Etiology
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 Group A Beta hemolytic Streptococcus
pyogenes
 Malnutrition
 Poverty
 overcrowding.
 Incidence more during fall ,winter &
early spring

5. Pathophysiology
5
 Rheumatic fever is a sequela to
group A beta- hemolytic
streptococcal infection that
occurs in about 3% of untreated
infections. It is a preventable
disease through detection and
adequate treatment of
streptococcal pharyngitis.
 Connective tissue of the heart,
blood vessels, joints and
subcutaneous tissues can be
affected.
 Lesions in connective tissue are
known as Aschoff bodies, which
are localized areas of tissue
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6. Cont.…
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 Heart valves, mainly the
mitral valve, are affected
resulting in valve leakage
and narrowing.
 Compensatory changes
in the chamber sizes and
thickness of chamber
walls occur.
 Heart involvement
(pancarditis) also
includes pericarditis,
myocarditis, epicarditis
and endocarditis.

7. Pathologic Lesions
7
 Fibrinoid degeneration of connective tissue,
inflammatory edema, inflammatory cell infiltration
& proliferation of specific cells resulting in
formation of Ashcoff nodules, resulting in-
 Pancarditis in the heart
 Arthritis in the joints
 Ashcoff nodules in the subcutaneous tissue
 Basal gangliar lesions resulting in chorea
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8. Clinical manifestations
8
Criteria was established by
T.D. Jones in 1944 revised
by the American Heart
Association and modified by
WHO to provide a basis for
diagnosis, the presence of
two major criteria or one
major and two minor criteria
plus evidence of a
preceding group A
streptococcal infection
indicates a high probability
of ARF. 5/30/2016

9. Cont.…
9
Major criteria
 Carditis
 Mono or polyarthritis
 Chorea
 Erythema Marginatum lesion
 Subcutaneous nodules
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10. Cont.…
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Minor criteria
 Fever
 Polyarthralgia Joint pain without swelling
 Raised erythrocyte sedimentation rate or C reactive protein
 Leukocytosis
 ECG showing features of heart block, such as a prolonged
PR interval
 Previous episode of rheumatic fever or inactive heart
disease

11. Cont.…
11
Evidence of infection
 Fever (38.9 to 40 C [101 to 104 F])
 Chills
 Sore throat (sudden in onset)
 Diffuse redness of throat with exudate on oropharynx
(may not appear until after the first day)
 Enlarged and tender lymph nodes
 Abdominal pain (more common in children)
 Acute sinusitis and acute otitis media
 Increased antistreptolysin O titre
 Positive throat culture
 Positive rapid antigen test for group A streptococci
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12. 12
Jones Criteria (Revised) for Guidance in the
Diagnosis of Rheumatic Fever*
Major Manifestation Minor
Manifestations
Supporting Evidence
of Streptococal Infection
Carditis
Polyarthritis
Chorea
Erythema Marginatum
Subcutaneous Nodules
Clinical Laboratory
Increased Titer of Anti-Streptococcal
Antibodies ASO
(anti-streptolysin O),
others
Positive Throat Culture
for Group A Streptococcus
Recent Scarlet Fever
Previous
rheumatic fever
or rheumatic
heart disease
Arthralgia
Fever
Acute phase
reactants:
Erythrocyte
sedimentation
rate,
C-reactive
protein,
leukocytosis
Prolonged P-R
interval
*The presence of two major criteria, or of one major and two minor criteria, indicates a
high probability of acute rheumatic fever, if supported by evidence of Group A
streptococcal nfection.
Recommendations of the American Heart Association
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13. Complications
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 Chronic rheumatic carditis.
 Valvular heart disease
 Cardiomyopathy
 Heart failure
 Atrial arrhythmias
 Pulmonary and systemic embolism

14. Medical management
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 Anti-microbial therapy—penicillin is the drug of
choice
 Rest to maintain optimal cardiac function.
 Salicylates or NSAIDS or corticosteroids
 Periodic prophylaxis throughout life
 Beta blockers, ACE inhibitors, digoxin, diuretics,
supplemental oxygen, rest, sodium and fluid
restrictions to manage heart failure
 Phenobarbital and diazepam to manage chorea

15. Treatment
15
 Step I - primary prevention
(eradication of streptococci)
 Step II - anti inflammatory treatment
(aspirin, steroids, NSAIDS)
 Step III- supportive management &
management of complications
 Step IV- secondary prevention
(prevention of recurrent attacks)
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16. 16
STEP I: Primary Prevention of Rheumatic Fever
(Treatment of Streptococcal Tonsillopharyngitis)
Agent Dose Mode Duration
Benzathine penicillin G 600 000 U for patients Intramuscular Once
27 kg (60 lb)
1 200 000 U for patients >27 kg
or
Penicillin V Children: 250 mg 2-3 times daily Oral 10 d
(phenoxymethyl penicillin) Adolescents and adults:
500 mg 2-3 times daily
For individuals allergic to penicillin
Erythromycin: 20-40 mg/kg/d 2-4 times daily Oral 10 d
Estolate (maximum 1 g/d)
or
Ethylsuccinate 40 mg/kg/d 2-4 times daily Oral 10 d
(maximum 1 g/d)
Recommendations of American Heart Association 5/30/2016

17. 17
Arthritis only Aspirin 75-100
mg/kg/day,give as 4
divided doses for 6
weeks
(Attain a blood level 20-
30 mg/dl)
Carditis Prednisolone 2-2.5
mg/kg/day, give as two
divided doses for 2
weeks
Taper over 2 weeks &
while tapering add
Aspirin 75 mg/kg/day
for 2 weeks.
Continue aspirin alone
100 mg/kg/day for
another 4 weeks
Step II: Anti inflammatory treatment
Clinical condition Drugs
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18. 18
 Bed rest
 Treatment of congestive cardiac failure: -digitalis,
diuretics
 Treatment of chorea:
-diazepam or haloperidol
 Rest to joints & supportive splinting
3.Step III: Supportive management &
management of complications
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19. 19
STEP IV : Secondary Prevention of Rheumatic
fever (Prevention of Recurrent Attacks)
Agent Dose Mode
Benzathine penicillin G 1 200 000 U every 4 weeks* Intramuscular
or
Penicillin V 250 mg twice daily Oral
or
Sulfadiazine 0.5 g once daily for patients 27 kg (60 lb Oral
1.0 g once daily for patients >27 kg (60 lb)
For individuals allergic to penicillin and sulfadiazine
Erythromycin 250 mg twice daily Oral
*In high-risk situations, administration every 3 weeks is justified and
recommended
Recommendations of American Heart Association 5/30/2016

20. 20
Duration of Secondary Rheumatic Fever
Prophylaxis
Category Duration
Rheumatic fever with carditis and At least 10 y since last
residual heart disease episode and at least until
(persistent valvar disease*) age 40 y, sometimes lifelong
prophylaxis
Rheumatic fever with carditis 10 y or well into adulthood, but
no residual heart disease whichever is longer
Rheumatic fever without carditis 5 y or until age 21 y,
whichever is longer
*Clinical or echocardiographic evidence.
Recommendations of American Heart Association
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21. Nursing management
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Nursing assessment
Subjective data:
 Important health information
 Functional health patterns
Objective data:
 General
 Integumentary
 Cardiovascular
 Neurologic
 Musculoskeletal

22. Cont.…
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Nursing diagnosis:
 Hyperthermia related to disease process
 Decreased cardiac output related to decreased
cardiac contractility
 Activity intolerance related to joint pain and easy
fatigability

23. Nursing interventions
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Reducing fever
 Administer penicillin therapy to eradicate
the hemolytic streptococcus.
 Give salicylates or NSAIDS as prescribed
to suppress the rheumatic activity
controlling toxic manifestations to reduce
fever and relieve joint pain.
 Assess for effectiveness of drug therapy

24. Cont.…
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Maintaining adequate cardiac output
 Assess for signs and symtoms of ARF
 Auscultate the heart sounds every 4 hours
document the presence of murmur or
pericardial effusion
 Monitor for development of chronic
rheumatic endocarditis which may include
valvular disease and heart failure

25. Cont.…
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Maintaining activity
 Maintains bed rest for duration of fever or if
signs of active carditis is present
 Provide ROM exercise program
 Provide diversional activities that prevent
exertion

26. Patient education and health maintenance
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 Counsel about need for good nutrition,
 Counsel on hygiene practices ( hand washing)
 Counsel about importance of adequate rest
 Instruct patient to seek treatment immediately
should sore throat or fever occur
 Support patient in long term antibiotic therapy to
prevent relapse
 Instruct patient with valvular disease to use
prophylaxis penicillin therapy before certain
procedures and surgery
 Patient with previous history of ARF should be
taught about the disease process, possible
sequelae and continues need for prophylactic
therapy.
 Teach about monthly injections of penicillin or

27. Summary
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28. Reference
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 Brunner & Siddharth, ‘Textbook of Medical surgical
nursing’, Volume 1, 11th edition, Wolters Kluwer
publication, New Delhi 2009, pg. 794 - 796.
 Lewis et al, ‘Medical Surgical Nursing’,7th edition,
Elsevier publication 2007 New Delhi, pg. 875- 878
 Linda et al, ‘Understanding Medical Surgical Nursing’,
4th edition, Jaypee brothers’ publication, pg. 740 - 742
 Lippincott, ‘Manual of Nursing Practise’, 10th edition,
Wolters Kluwer publication, New Delhi 2010, pg. 405-
406.
 www.mayoclinic.org/diseases-conditions/rheumatic
fever/basics/.../con-20031399

29. Cont.…
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 www.uptodate.com/.../acute-rheumatic-fever-
clinical-manifestations-and-diagnosis
 emedicine.medscape.com/article/333103-
overview
 https://en.wikipedia.org/wiki/Rheumatic_fever
 www.healthline.com › Reference Library
 www.medicinenet.com/rheumatic_fever/article.ht
m

30. 5/30/201630

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THANK YOU
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