RHEUMATIC FEVER

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A Case StudyPresented to

Tarlac State UniversityCollege of Nursing

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In Partial Fulfillmentof the Requirements for

NCM101

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By

BSN II-B4

Ryan Krisna Dela CruzJon Henry Ordoñez

Bridgitte OrtizMonica Pineda

Mark Alvin QuibuyenSarah Jane Quirante

Maryner RamosRon Mar RamosIsmael Rodriguez

Gladys Glen Santiago

INTRODUCTION

1. Description of the disease

Rheumatic fever is an inflammatory disease that may develop two to three

weeks after a Group A streptococcal infection (such as strep throat or scarlet fever). It is

believed to be caused by antibody cross-reactivity and can involve the heart, joints, skin,

and brain. Acute rheumatic fever commonly appears in children between ages 5 and 15,

with only 20% of first time attacks occurring in adults. Rheumatic fever is common

worldwide and responsible for many cases of damaged heart valves. In Western

countries, it became fairly rare since the 1960s, probably due to widespread use of

antibiotics to treat streptococcus infections. While it is far less common in the United

States since the beginning of the 20th century, there have been a few outbreaks since the

1980s. Although the disease seldom occurs, it is serious and has a mortality of 2–5%.

Rheumatic fever primarily affects children between ages 5 and 15 years and occurs

approximately 20 days after strep throat or scarlet fever. In up to a third of cases, the

underlying strep infection may not have caused any symptoms. The rate of development

of rheumatic fever in individuals with untreated strep infection is estimated to be 3%. The

incidence of recurrence with a subsequent untreated infection is substantially greater

(about 50%). The rate of development is far lower in individuals who have received

antibiotic treatment. Persons who have suffered a case of rheumatic fever have a

tendency to develop flare-ups with repeated strep infections.

Cardiovascular diseases (CVD) greatly threaten Filipinos today.   The

Filipino faces the risk of CVD throughout his life.  At birth, congenital heart diseases

(CHD) and vascular malformations are possible.   In early childhood, the risk of

rheumatic fever and rheumatic heart disease (RF/RHD) starts, peaking in adolescence. . 

Rheumatic fever arise from frequent streptococcal sore throat. Morbidity and mortality

trends for cardiovascular diseases have been rising for the past several decades.  The

morbidity rate is 206.3 cases per 100,000 population while the mortality rate is 73.7

deaths per 100,000 population is 1994.  CVD is now the number one cause of death and

the seventh leading cause of morbidity in the country.  The region with the highest

morbidity for CVD is Region 7, followed by Regions 1, CAR, 2 and 6.

We chose this case to be our subject for our study because primarily, it is

the best case we think we have handled while in the ward and as student nurses, we must

involve ourselves more in situations like this. We thought that the study of this disease

would further enhance our knowledge and skills when it comes to not only handling

patients but in gathering data about the patient and his/her disease.

2. Objectives:

Nurse –Centered:

To educate ourselves about rheumatic fever.

Specific Objectives:

Described and explained what a rheumatic fever is.

Identified the risk factors contributing to the occurrence of the disease.

Enumerated the different medications.

Formulated significant nursing diagnoses, with their significantly related

nursing care plans.

Patient-Centered:

To provide care to the patient who is experiencing this disease and to educate her

significant others about the disease and its treatment and methods of care

Specific Objectives:

Known facts about the disease

Known the medications used for the disease

Been taught about the different methods of care to be done to the client

II. NURSING HISTORY

1. Personal History

a. Demographic Data

Name of the Patient: Ms.16

Age: 12 y/o

Sex: Female

Civil Status: Single

Occupation: Student

Religious Affiliation: Roman Catholic

Role Position in the Family: Daughter

Address: Brgy. Mapalad Tarlac City

Date of Birth: April 17,1997

Place of Birth: Brgy. Mapalad Tarlac City

Nationality: Filipino

Health Care Financing: None

Admitting Diagnosis: UTI suspect, Rheumatic Fever

Date admitted: August 18, 2009

b. Lifestyles and Habits

Ms. 16 does not drink any alcoholic beverages or even smokes cigarette,

according to her mother. She usually sleeps at around 8pm-11pm if she were to watch her

daily soap operas and wakes up at around 6am since she is still a student. Since she was

diagnosed of rheumatic fever she became anxious of her condition. And due to her

swelling joints, she cannot to perform activities of daily living.

2. Family History of Health and Illness

65

HC 59DHN

35 38 A&W A&W

12 2 Mos RF A&W

LEGEND

- Deceased male -Pertains to patient, living female child -Deceased female - living male child

-Living mother HC -Heart ComplicationDHN – Dehydration

RF – Rheumatic Fever -Living father A&W – Alive and Well

X X

X

X

3. History of Past Illness

Ms.16 had a history of relapsing fever for a month. According to her mother, she

usually has this fever at night and is given paracetamol for the fever to subside and let her

rest. She was first hospitalized with a diagnosis of UTI for a week and then it developed

to rheumatic fever. She was not involved in any accidents and has no known allergies to

medicines, animals or foods, according to her mother. She also had completed her

immunizations.

4. History of Present Illness

Ms. 16 was admitted on August 18, 2009 at TPH due to her relapsing fever for a

month. She first experienced fever with her neck aching then next is her joints swelling,

she also complained of difficulty of swallowing. She also experienced vomiting. She was

first suspected of UTI which then developed to Rheumatic Fever. At present, she is now

confined in TPH for a month now.

5. Physical Assessment

Date Performed

Area/Region Techniques of Assessment

Standard Findings Normal Findings Interpretation

09/10/09 Skin InspectionPalpation

Light to brown in colorTemperature is 36.5ºCWhen pinched, skin springs back to previous stateTexture not uniform, some areas are thick and some are roughNo unusual marksNo presence of lesions and rushesNo pressure sores foundNo edema

Color should be light to deep brownTemperature should be uniform and within normal rangeskin should spring back to place when pinchedtexture should not be uniform; some areas should be thick like the palms and soles.

Normal

09/10/09 Hair InspectionPalpation

Hair is thick and shinyHair is equally distributed and has no presence of alopecia.No foul odor

Should be silky,resilientShould be thick and hair should be evenly distributed

Normal

09/10/09 Nails InspectionPalpation

Angle between finger nail and base is about 160º Blanch test is normal.When palpated base is

Should be pinkish in color.Convex curvature: angle between nail and nail bed should

Normal

firm.Dirty nails

be at about 160ºAfter pinching, pink color in the nail bed should return within 3sec.

09/10/09 Head InspectionPalpation

Rounded and symmetrical.No unusual swelling

Should be rounded and symmetrical, Normocephalic Should have smooth skull contour

Normal

09/10/09 Eyes Inspection Eyes are symmetricalTransparent, shiny and smooth cornea.Pupil is 3mm in size, black in color.Pupil dilates when without the presence of light and constricts on the presence of light.Visual acuity is normal and able to read letters within 36cm of range

The eyes should be symmetrically aligned.Cornea should be transparent, shiny and smooth.Illuminated pupil constrict (direct response), non illuminated pupil dilates (consensual response)Visual acuity should be able to read news print.

Normal

09/10/09 Ear Inspection The location and alignment is normal, symmetrical with upper attachment at eye corner level (lateral cantus)

Pinna should be aligned with the eyes.The color of the pinna should be the

Normal

Pinna is brown in color; canal has presence of ear wax.No presence of discharge and odor.Able to hear instructions and responds quickly

same with the color of the face.Should have no presence of discharge and odor.Sounds should be heard in both ears or is localized with the center of the head.

09/10/09 Nose InspectionPalpation

Normal in shape.Located symmetrically.Each nostril is patent.Sinuses are not tender, air-filled cavities and resonant to percussion.

Should be symmetric and straight.Should have no discharge or flaring.Should not be tender

Normal

09/10/09 Lips Inspection Normal integrity.Normal symmetry.Light pink in color.

Should be uniform, and pink in color

Normal

09/10/09 Mouth Inspection Number and condition of the teeth is normal, properly alignedGums are pink, smooth, moist and firmed.Tongue lies midline, pink in color, moist, has free mobility and free of lesions.Palate is concave and pink in color.

Should have 32 teeth for adult and 28 teeth for children.Gums should be pink.The gums should be moist and firm texture.Tongue should be pink, moist, slightly

Normal

Parotid gland is smooth, moist and has no swelling and reddening.

rough, thin whitish coating.Soft palate should be light pink and smooth.Uvula should be position in the midline of soft palate.

09/10/09 Neck InspectionPalpation

Muscles are symmetrical with the head and able to move without discomfort.Trachea is in the midline position.Thyroid is smooth, soft, not enlarges and has no presence of mass and bruises.

Muscles should be equal in size and head centered.Trachea should be at the center of the neck, spaces are equal on both sides.Thyroid should not be visible on inspection

Normal

09/10/09 Extremities InspectionPalpation

No discolorationsNo lesions, massesNo TendernessNo presence of edemaUniform in temperature and within normal rangeJoints are swollenClient complains of pain when joints are touched

Should have no discolorationsShould have no masses, lesionsShould have no tendernessShould be uniform in temperature

Abnormal, Joints are swollen, client complains of pain when joints are touched

VI. Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Expected Outcome

Subjective>“Nahihirapan

siya gumalaw..”, as

stated by mother.

Objective>Discomfort>Immobility

>Palor>Body

>WeaknessV/S:

BP: 110/70RR:19CR:102

Temp:37.3C

Analysis:

Activity intolerance r/t

imbalance between

oxygen supply and demand

Insufficient physiological or psychological

energy to endure or complete

required or desired daily

activities

After 2 hours of proper nursing intervention,

the patient will be able to *maintain

normal skin color and skin

would be warm to dry

*Able to perform activity

without discomfort

*Understand need for

balanced rest and activity

>Monitor Vital signs

>Observe and document skin

integrity.>Assist in

proper position>Assist in performing

ROM exercises >Demonstrate

proper breathing pattern

>Determine cause of activity

intolerance and determine

whether cause is physical,

psychological or motivational.

>Assess the client daily for

>To be of help for direct

appropriate intervention>Activity

intolerance may lead to pressure

ulcers>Inactivity

rapidly contributes t

muscle shortening and

changes in periarticular

and cartilaginous joint structure>Inappropriate prolonged bed rest orders may

t contribute activity

intolerance

After 2 hours of proper nursing

intervention, the patient should be able to:

*maintain normal skin color and

skin would be warm to

dry*Able to perform activity without

discomfort*Understand

need for balanced rest and activity

appropriateness of activity and bed rest orders.>Instructed the

client on rationale and techniques for

avoiding activity

intolerance.>Taught client the importance

of nutrition>Instructed the client in the use

of relaxation techniques

during activity

Assessment Diagnosis Planning Intervention Rationale Expected Outcome

Subjective>”Nilalagnat

siya”, as verbalized by

client’s mother

Objective:>Febrile

>Pale>Skin warm to

touch>Inflammed

joints>Incoherent>Weakness

V/S>BP:100/60>RR:18 cpm

>CR:106 bpmTemp:38.7 °C

Hyperthermia r/t infection

Increased of temperature is a

chemical response of the

body to infections that

causes inflamed joints of the

patient

Short term: After 1 hour of proper nursing intervention, the patient’s temperature will decrease

from 38.7°C to 37C

Long term: After proper

nursing intervention, the patient’s

condition will improve and

there would be no more

swelling of joints.

>Monitor Vital signs

>Performed continuous TSB

> Checked temperature

every 15 minutes

>Encouraged Patient to rest>Provide dry clothing and bed linens

>Encouraged adequate intake

of fluids and nutritious foods

>Encourage participation in

self care>Note

emotional or behavioral response to problems of

fever

>To limit fatigue

>To promote well-being and

energy production

>>To promote optimal level of

function and prevent

complications.

>To determine progress of

interventions

>To reduce temperature in

the body>To relax

patient’s body

Short term: After 1 hour of proper

nursing intervention, the

patient’s temperature

should decreased from 38.7°C to

37°C

Long term: Patient’s joints

should continue to swell but should now state that

pain is reduced.

Assessment Diagnosis Planning Intervention Rationale Expected Outcome

Subjective>”Masakit ang

mga kasukasuhan

niya”.as stated by client’s

mother.

Objective>Swollen joints

>Febrile>Weak in

appearance>Grimace

>Pain scale of 10/10V/S:

PR: 106 bpmTemp: 38.7 °C

Pain r/t swollen and inflamed

joints

Pain is whatever the experiencing

person says. It is existing

whenever the person says it

does, unpleasant sensory and emotional experience

arising from actual or

potential tissue damage or

described in terms of such

damage.

After 2 hours of proper nursing intervention, the patient’s pain scale of 10/10 will be decrease to 6/10 and the

temperature of 38.7C will

decrease to 37C

>Monitor vital signs

>Move the patient

carefully.>Performed

TSB>Assess pain using a self

report zero to ten numerical

pain scale>Teach the

client to use the pain rating

scale to rate the intensity of past or current pain.

>Administer antibiotics as prescribed by

physician

>So that pain in the joints and

other parts would lessen

>single item ratings of pain intensity are

valid and reliable as

measures of pain intensity

After 2 hours of nursing

intervention, client should state of pain scale being

6/10

VII. Discharge Planning

M > Almg OH 2tbsp, 30 min before/after meal

Paracetamol 320mg every 4 hours if temperature is 37.8

Cefuroxime 750mg IVP every q 8 ANST (-)

Aspirin 500mg 3 tabs 3x a day with full stomach

E > Advise to: Do gradual walking and breathing exercises.

Have assistance and support as tolerated when ambulating.

Perform ADLs involving hygiene and self-care, with support if needed

T > Instructed to Comply with the medications prescribed

H > Demonstrate to: Place pillows on bed when asleep to prevent injury and other

accident precautions.

Provide adequate rest periods. Make up activities that increase the

well being.

O > Return for check-ups and further treatments of the disease

D > Nutritious diet. Increase fluid, fruit and vegetable intake.

VIII. Conclusion

The group concluded that Rheumatic fever is common worldwide and

responsible for many cases of damaged heart valves Rheumatic fever is an inflammatory

disease that may develop two to three weeks after a Group A streptococcal infection

(such as strep throat or scarlet fever. The rate of development of rheumatic fever in

individuals with untreated strep infection is estimated to be 3%. The incidence of

recurrence with a subsequent untreated infection is substantially greater (about 50%). The

rate of development is far lower in individuals who have received antibiotic treatment.

Persons who have suffered a case of rheumatic fever have a tendency to develop flare-ups

with repeated strep.

The group also observed, that a patient with rheumatic fever suffer s from

frequent vomiting, inflamed joints and relapsing fever. The patient also cannot perform

ADLs such as eating grooming or even going to the bathroom with out assisstance due to

pain cause by the inflamed joints

IX. RECOMMENDATION

Recommendations

            Based on the findings and conclusions presented, the following recommendations

are presented:

 

 Research

 

1.   Improvement of interaction between nurse and patient, especially when the

patient is a child because they cannot easily express themselves

2.   Research may be conducted to find out the level of difficulty of the client or

patient so that necessary adjustments and sound decisions can be made as to

which should be included or not.

3.   Further research may be undertaken to use other forms of testing other than

the Laboratory Examination tests to indicate the level of the disease.

4.   Additional research may be conducted to determine other factors that would

contribute to the disease being worsen.

5.   Studies may be made to identify the specific disease of the client which is best

suited for the students.

X. BIBLIOGRAPHY

Internet:

* http://en.wikipedia.org/wiki/Rheumatic fever

*Medscape

*Nursing Crib.com

Books:

*Clinical Nursing Techniques from basic to advance skills

*Understanding the Nursing Process