Ward Class

An Online Resource Site For Student Nurses

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Ward Class is an online resource for student nurses. Created with the aim of helping student nurses cope with the demands of nursing school and clinicals, it offers free downloads, notes, sample NCPs, sample drug studies, study aids, news and updates, and practical tips to its users.

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Cardiovascular Disorders: Rheumatic Fever

Erythema marginatum in Rheumatic Fever
  • an autoimmune disease that occurs as a reaction to group-A beta-hemolytic streptococcus infection
  • a inflammatory disorder that may involve the heart, joints, connective tissues, and CNS
  • often follows an attack of pharyngitis, tonsillitis, 'strep throat', scarlet fever, or impetigo
  • occurs most commonly in children 6 to 15 years of age;peaks at 8 y.o.
  • most often seen in low-socioeconomic, crowded, urban areas
Assessment Findings
  • Major Symptoms (Jones' Criteria)
    • carditis-->seen in 50% of patients; presence of Aschoff nodules (inflamed areas around valves, pericardium, myocardium); cardiomegaly, valvular insufficiency, shortness of breath, hepatomegaly, edema)
    • polyarthritis-->transient, doesn't cause contractures; redness and inflammation most in large joints; sterile synovial fluid; no arthralgia
    • chorea (sydenham's chorea, st. vitus' dance)-->most striking symptom;sudden involuntary movements of the limbs;mostly seen in prepubertal girls; gradual in onset and lasts 1 to 3 months; increases with excitement
    • subcutaneous nodules-->a sign of severe disease; painless lumps on tendon sheaths by the joints; lasts for weeks; occurs with active carditis
    • erythema marginatum-->macular rash found predominantly on the trunk; non-pruritic (doesn't itch)
  • Minor symptoms:
    • reliable history of Rheumatic Fever
    • recent history of strep infection
    • ecg changes-->prolonged PR interval
    • diagnostic tests-->presence of antistreptococci-O titer, increased ESR (>20mm/hr for females, >13 mm/hr for males), increased C-reactive protein
Medical Management
  1. antibiotics-->penicillin (monthly injections of benzathine penicillin G) is commonly used to treat strep infection and to prevent recurrence; erythromycin is given to patients who are sensitive to penicillin
  2. oral salicylates-->reduces inflammation and pain
  3. corticosteroids-->give to patients who do not respond to salicylates alone
  4. phenobarbital--reduces purposeless movements in chorea
Nursing Management
  1. administer penicillin as ordered; given until age 20 or for 5 years after attack, whichever is longer
  2. promote bedrest until ESR returns to normal
  3. if administering salicylates, check for signs of aspirin toxicity such as tinnitus, nausea, vomiting, headache, and blurred vision; also watch out for purpura (reddish or purple discolorations under the skin) and other signs of bleeding
  4. ensure safety-->decrease stimulation, no forks during meals, assist during ambulation, padded side rails
  5. provide small, frequent meals-->to decrease cardiac workload
  6. provide diversionary activities that do not require fine coordination to avoid frustration
  7. provide client teaching on:
    • bedrest at home (use of call bell, commode)
    • prophylactic medication regimen (to prevent recurrence)
    • diet modifications
    • avoidance of reinfections
    • availability of community support systems
Prognosis

The prognosis for a child with Rheumatic Fever depends on the extent of myocardial involvement. The inflammation may cause so much to the heart muscle that it leads to heart failure. In some cases, a scarred heart valve may prevent adequate blood flow or not seal tightly, requiring valve replacement surgery.

Prevention

The only way to prevent rheumatic fever is to adequately treat streptococcus infections with appropriate antibiotics.

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