Acute rheumatic fever is an autoimmune disorder that follows an upper respiratory infection with group A beta-hemolytic streptococci. Rheumatic fever affects the heart, central nervous system, skin, and musculoskeletal system. In addition to an initial insult, recurrences are common. Only 3% of people who have a pharyngeal streptococcal infection actually develop rheumatic fever.
Acute rheumatic fever is most destructive to the heart. Rheumatic heart disease (RHD) occurs in up to 50% of patients with acute rheumatic fever and may affect any of the layers of the heart during the acute phase. Endocarditis leads to leaflet swelling of the valves, leaflet erosion, and deposits of blood and fibrin on the valves; these deposits are called vegetation. Myocarditis causes cellular swelling, damage to collagen, and formation of fibrosis and scarring. Pericarditis can occur as well, which can lead to pericardial effusion. In addition to valvular disease, acute rheumatic fever can lead to severe carditis and life-threatening heart failure. Complications lead to a 20% death rate within the first 10 years after the initial illness.
Acute rheumatic fever is caused by a prior streptococcal infection and is often associated with nasopharyngitis, or upper respiratory infections. The group A beta-hemolytic streptococcus infection, which may have been mild and even unnoticed and untreated, usually occurred 2 to 6 weeks before the development of symptoms of acute rheumatic fever. Experts suspect that rheumatic fever is an autoimmune response triggered by antibodies that are produced in response to the streptococcal infection. The antibodies react with the body’s cells and produce characteristic lesions in the target organs.
Nursing care plan assessment and physical examination
Usually, the patient has a sore throat and a fever of at least 100.4°F a few days to several weeks before the onset. The patient either may have been treated with antibiotics or may not have completed a full course of treatment. Determine if the patient has experienced migratory joint tenderness (polyarthritis), chest pain, fever, and fatigue. Some patients describe unexplained nosebleeds as well. Patients with pericarditis may describe sharp pain over the shoulder that radiates to the neck, back, and arms. The pain may increase with inspiration and decrease when the patient leans forward from a sitting position. Patients with heart failure may describe shortness of breath, cough, and right upper quadrant abdominal pain. In addition, the patient may describe fatigue or activity intolerance, along with periorbital, abdominal, or pedal edema.
The patient may have a distinctive red rash, referred to as erythema marginatum. This nonpruritic rash appears primarily on the trunk of the body, the buttocks, and the extremities; it appears on the face in only rare instances. In addition, subcutaneous nodules of less than 1 cm in diameter form on the skin. Painless and movable, they usually appear over bony prominences: the hands, wrists, elbows, knuckles, feet, and vertebrae. If the patient has heart failure, there may be peripheral edema. The patient may also demonstrate chorea (previously referred to as St. Vitus’ dance). Mild chorea produces hyperirritability, problems concentrating, and illegible handwriting. Severe chorea causes purposeless, uncontrollable, jerky movements and muscle spasms, speech disturbances, muscle fatigue, and incoordination. Transient chorea may not appear until several months after the initial streptococcal infection.
When the joints are palpated, the patient may have migratory polyarticular arthritis (more than four joints are progressively involved). The most frequently involved joints include the knees, elbows, hips, shoulders, and wrists. These joints are extremely warm and tender to the touch, and even a light palpation can cause pain. The pain usually subsides after the patient becomes afebrile.
Heart murmurs serve as an indicator that carditis has occurred. The aortic and mitral valves are particularly involved as a result of the Aschoff bodies (small nodules of cells and leukocytes) that form on the tissues of the heart. You are more likely to hear the murmurs at the third intercostal space right of the sternum for the aortic valve and at the apex of the heart if the mitral valve is involved. When you palpate peripheral pulses, you may note a rapid heart rate.
The disease is likely to occur at an age when children are active and industrious. Those that require extended bedrest may have trouble coping with the limitations placed on them.
Nursing care plan primary nursing diagnosis: Pain (acute) related to tissue swelling.
Nursing care plan intervention and treatment plan
The goal of management is to end the infection, relieve the symptoms, and prevent recurrence. Complete eradication of the streptococcal infection is necessary so that the heart and kidneys are not damaged. The physician may prescribe antibiotic therapy, intramuscular benzathine penicillin G, if the patient has no known history of allergy to penicillin. Reinforce the need for the patient to complete all medications and to watch for potential side effects, such as rash, hives, wheezing, or anaphylaxis. Activity restrictions are required to ensure full recovery. In patients with active carditis, strict bedrest may be needed for approximately 5 weeks. The physician then prescribes a progressive increase in activity. If valvular dysfunction leads to persistent heart failure, the patient may need surgery to correct the deficit in heart function.
Explain to the child and the family the need to take all antibiotics until they are completed. This information needs to be conveyed in such a manner so as to promote compliance, not communicate guilt. Remind the parents that failure to seek treatment for a streptococcal infection is common because the symptoms are so mild. The patient is likely to remain on oral antibiotics indefinitely through his or her life.
Managing activity restrictions is a challenging goal in working with a young person of school age who is on bedrest. As the chorea decreases, the child needs to participate in therapeutic play activities that promote a sense of industry and minimize any feelings of inferiority activities
such as reading, board games, and video game play. Encourage the parents to obtain a tutor so the patient can keep up with schoolwork during her or his convalescence. To protect the patient who develops chorea and has an unsteady gait, make sure that all obstructions are cleared out of the way during ambulation to reduce the risk of injury.
Nursing care plan discharge and home health care guidelines
Teach the patient or parents to prevent any further streptococcal infections by good hand washing and avoiding people with sore throats. Encourage the patient or parents to contact the primary healthcare provider if a sore throat occurs. Explain all medications, including dosage,
action, route, and side effects. Encourage the patient to resume activity gradually and to use an elevator, if one is available, at school. Teach the patient to return to physical education classes or extracurricular sports gradually, with the guidance of the physician. Encourage the patient to
take frequent naps and rest periods.