By:ZAIRRABASIG

RHEUMATIC FEVER infection) → the onset of rheumatic fever

symptoms can begin.

ASSESSMENT

➢ signs and symptoms are divided into

major and minor symptoms according
to the Jones criteria

➢ an autoimmune disease that occurs as a

reaction to a group A beta-hemolytic
streptococcal infection
➢ Inflammation from the immune response
→ deposits on the endocardium and valves,
in particular the mitral valve, as well as in
the major body joints
➢ often follows an attack of:
✓ pharyngitis
✓ tonsillitis
✓ scarlet fever
✓ “strep throat”
✓ impetigo ➢ heart involvement is the most serious
➢ child usually has a systolic murmur from
CAUSATIVE AGENT → group A beta-hemolytic
mitral insufficiency and prolonged P-R and
streptococcus
Q-T intervals on the ECG that reflect
➢ In 95% of children with acute rheumatic inflammation and slowing of impulse
fever, an elevation of one or more conduction.
antistreptococcal antibodies, an indication ➢ Sydenham’s chorea (sudden involuntary
of a recent streptococcal infection, can be movement of the limbs) is a striking
documented. symptom
➢ occurs most often in children 6 to 15 years ➢ loss of voluntary muscle control due to
of age, with a peak incidence at 8 years inflammation of basal ganglia occurs most
➢ seen most often in poor, crowded urban often in children between 7 and 14 years of
areas age
➢ Because children do not develop immunity ➢ occurs more frequently in girls than boys
to streptococcal infections, streptococcal ➢ Dysfunctional speech from chorea may be
infections recur; rheumatic fever also demonstrated by asking the child to count
recurs. rapidly
➢ symptoms of the original streptococcal ➢ Children with chorea begin with clear
infection subside in a few days with or speech, but then suddenly the sounds
without antimicrobial therapy become garbled or they cannot speak for
➢ Children appear well again → After 1 to 3 several seconds
weeks, (if the child was not treated with an ➢ If asked to protrude the tongue, children
appropriate antibiotic for the original cannot keep from making undulating, jerky
movements.
 By:ZAIRRABASIG
➢ If asked to extend their arms in front of ✓ used to eliminate group A beta-
them, they soon hyperextend their wrists hemolytic streptococci completely
and fingers. from the child’s body
➢ Hand grasp may be weak or may consist of ➢ Oral ibuprofen
spasmodic contractions and relaxation. ✓ to reduce inflammation and joint
➢ If asked to smile, the facial expression may pain
change rapidly from a “Cheshire cat” grin ➢ Corticosteroids
to a flat, expressionless affect or grimace. ✓ to reduce inflammation in children
➢ Additional manifestations: who are not responding to ibuprofen
✓ Erythema marginatum, a macular therapy alone
rash found predominantly on the ➢ Possible side effects of corticosteroid
trunk therapy include:
✓ subcutaneous nodules or painless ✓ Hirsutism
lumps on tendon sheaths by the ✓ round moon face (Cushing’s
joints syndrome)
✓ and tender swollen large joints ✓ increased susceptibility to infection
(polyarthritis) ➢ Phenobarbital and diazepam are both
➢ Important laboratory findings: effective in reducing the purposeless
✓ presence of an antibody movements of chorea.
antistreptococcal titer (ASO) ➢ If heart failure is present, measures to
✓ an increased ESR and C-reactive reduce heart failure such as digoxin and
protein levels diuretics will be prescribed.
➢ The prognosis for the child with rheumatic
fever depends on the extent of myocardial
THERAPEUTIC MANAGEMENT involvement.
➢ formation of Aschoff’s bodies (fibrin
➢ full course of rheumatic fever is 6 to 8
deposits) → Valve destruction → may
weeks
result in permanent valve dysfunction, esp.
➢ Children are maintained on bedrest only
of the mitral valve
during the acute phase of illness or until
➢ severe myocarditis → heart dilates, but
✓ congestive heart disease is not present
when it cannot maintain this compensation
✓ the ESR decreases
→ fails to contract effectively.
✓ the C-reactive protein level and pulse
➢ Children may be left with mitral valve
rate return to normal
insufficiency, which is especially hazardous
➢ monitoring vital signs is essential during
for girls, because this may lead to heart
the acute phase
failure during pregnancy.
✓ pulse rate is a valuable sign of
➢ Some children need mitral valve
improvement
replacement to restore heart function.
➢ Obtaining an apical pulse for a full minute
➢ Usually, there are no residual effects from
is preferred. It may be ordered when the
joint or chorea involvement.
child is asleep as well as when the child is
awake to measure the effect of activity on
the pulse rate.
➢ penicillin therapy or a single intramuscular
injection of benzathine penicillin
 By:ZAIRRABASIG
2. Situational low self-esteem related to
NURSING DIAGNOSES AND chorea movements secondary to rheumatic

RELATED INTERVENTIONS fever

➢ Provide toys and games that do not require
fine coordination
1. Risk for nonadherence to drug therapy
✓ because it may be frustrating to try
related to knowledge deficit about
to do something such as move
importance of long-term therapy
checkers or chessmen on a board (a
➢ Therapy for Initial Attack
typical low-activity game)
✓ amoxicillin or penicillin
➢ Children with chorea who are on bedrest
To eliminate the bacteria from the
may need to have the bedrails padded so
upper respiratory tract
they do not injure themselves from
a drug level must be maintained for
thrashing movements.
10 to 14 days
✓ Erythromycin
used in children sensitive to
penicillin
must be continued for at least 10
days
✓ One intramuscular injection of a long-
acting penicillin, such as benzathine
penicillin (Bicillin)
Can be used with children if there is
a question whether the parent will
give, or the child will take, the full
course of oral penicillin

➢ Prevent Recurrent Attacks

✓ Prophylactic antibiotic therapy
for at least 5 years after the initial
attack or until they are 18 years of
age
➢ If some valve involvement is present,
many physicians advocate maintaining the
child on penicillin indefinitely.
➢ Penicillin may be prescribed as monthly
injections of benzathine penicillin G or daily
oral doses of aqueous penicillin (penicillin
V).
➢ Additional prophylactic measures should be
instituted when dental or tonsillar surgery
is planned, because most children have
streptococci in their throats
➢ With an open incision in the mouth, the risk
of streptococcal invasion of the
bloodstream increases.