Nursing Care Plan (NCP) for Rheumatic Fever
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Outline
Lesson Objective for Rheumatic Fever
- Understanding Rheumatic Fever:
- Objective: Develop a comprehensive understanding of rheumatic fever, including its pathophysiology, etiology, and risk factors, to provide effective and informed nursing care.
- Identification of Signs and Symptoms:
- Objective: Learn to recognize the signs and symptoms of rheumatic fever, including those affecting the heart, joints, skin, and other organ systems, for early detection and intervention.
- Preventive Measures and Antibiotic Prophylaxis:
- Objective: Gain knowledge about preventive measures, including antibiotic prophylaxis, to reduce the risk of recurrent episodes and complications associated with rheumatic fever.
- Multidisciplinary Collaboration:
- Objective: Understand the importance of multidisciplinary collaboration with healthcare providers, including cardiologists, rheumatologists, and infectious disease specialists, to ensure comprehensive care for individuals with rheumatic fever.
- Patient Education and Empowerment:
- Objective: Develop skills in patient education to empower individuals and their families with information about rheumatic fever, its management, and the importance of adherence to prescribed treatments and follow-up care.
Pathophysiology of Rheumatic Fever
- Triggered by Streptococcal Infection:
- Rheumatic fever often follows an inadequately treated or untreated Group A Streptococcal infection, usually pharyngitis (strep throat) or less commonly, impetigo.
- Autoimmune Response:
- The body’s immune system, in response to the streptococcal infection, mistakenly attacks its own tissues, leading to an autoimmune response. This immune response primarily affects the heart, joints, skin, and other tissues.
- Inflammatory Cascade:
- The autoimmune response triggers a systemic inflammatory cascade, causing widespread inflammation in various organs and tissues. This inflammation is responsible for the clinical manifestations observed in rheumatic fever.
- Cardiac Involvement:
- The most severe and long-term consequences of rheumatic fever involve the heart, leading to rheumatic heart disease. Inflammatory damage to the heart valves, particularly the mitral valve, can result in valvular stenosis or regurgitation.
- Joint and Skin Manifestations:
- Rheumatic fever often presents with migratory arthritis, where joint pain shifts from one joint to another. Skin involvement includes the characteristic rash known as erythema marginatum, along with subcutaneous nodules.
Understanding the pathophysiology of rheumatic fever is crucial for providing targeted interventions, managing symptoms, and preventing complications, especially cardiac involvement.
Etiology of Rheumatic Fever
- Group A Streptococcal Infection:
- Rheumatic fever is primarily triggered by an infection with Group A Streptococcus (Streptococcus pyogenes). In particular, inadequately treated or untreated streptococcal pharyngitis (strep throat) is a common precursor.
- Genetic Predisposition:
- Genetic factors play a role in an individual’s susceptibility to rheumatic fever. Some people may have a genetic predisposition that makes them more prone to developing an autoimmune response after a streptococcal infection.
- Host Immune Response:
- The pathogenesis involves an aberrant immune response by the host. Certain individuals mount an immune response to the streptococcal infection that, instead of targeting only the bacteria, also attacks the body’s own tissues, leading to the characteristic manifestations of rheumatic fever.
- Environmental Factors:
- Environmental factors, such as overcrowded living conditions and limited access to healthcare, can contribute to the spread of streptococcal infections. These factors may increase the risk of exposure to the bacteria and subsequent development of rheumatic fever.
- Age and Geographic Location:
- Rheumatic fever is more common in children aged 5 to 15 years. The prevalence is also influenced by geographic location, with higher rates reported in low-income and developing regions where access to healthcare may be limited.
Understanding the etiological factors is crucial for prevention strategies, including early and effective treatment of streptococcal infections and addressing risk factors associated with the development of rheumatic fever.
Desired Outcome of Nursing Care for Rheumatic Fever
- Controlled Infection:
- Achievement of effective and timely antibiotic therapy to control and eliminate the Group A Streptococcus infection responsible for triggering rheumatic fever.
- Resolution of Symptoms:
- Alleviation and resolution of clinical symptoms associated with rheumatic fever, including joint pain, fever, and other systemic manifestations.
- Prevention of Cardiac Complications:
- Prevention or minimization of cardiac complications, such as rheumatic heart disease. Monitoring and managing cardiac symptoms to preserve cardiac function and prevent long-term damage.
- Prevention of Recurrence:
- Implementation of strategies to prevent the recurrence of rheumatic fever, including adherence to antibiotic prophylaxis regimens to avoid subsequent streptococcal infections and the development of recurrent episodes.
- Optimized Quality of Life:
- Improvement in the overall quality of life for the patient by addressing and managing symptoms, reducing the risk of complications, and promoting general well-being through a comprehensive and patient-centered care approach.
The desired outcomes focus on both the acute management of the current episode and the prevention of future occurrences, with a particular emphasis on protecting cardiac health and ensuring an improved quality of life for the individual affected by rheumatic fever.
Rheumatic Fever Nursing Care Plan
Subjective Data:
- Painful or tender joints
- Chest pain
- Fatigue
- Unusual behaviors or outbursts
Objective Data:
- Fever
- Red, swollen joints
- Rash
- Subcutaneous nodules
- Heart murmur
- Uncontrollable body movements (hands, feet, face)
Nursing Assessment for Rheumatic Fever
- Medical History:
- Obtain a detailed medical history, with a focus on recent or recurrent streptococcal infections, prior episodes of rheumatic fever, and any cardiac history.
- Symptom Assessment:
- Assess for common symptoms, including joint pain, swelling, and tenderness, fever, skin rash (erythema marginatum), and manifestations of carditis, such as chest pain and breathlessness.
- Cardiac Monitoring:
- Perform regular cardiac monitoring, including auscultation for murmurs, assessment of heart rate and rhythm, and monitoring for signs of heart failure.
- Joint Examination:
- Conduct a thorough joint examination to assess the extent of joint involvement, documenting the number, location, and severity of affected joints.
- Skin Inspection:
- Inspect the skin for erythema marginatum, a characteristic rash associated with rheumatic fever, and other skin manifestations.
- Laboratory Tests:
- Order and review laboratory tests, including complete blood count (CBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and antistreptolysin O (ASO) titers to confirm the diagnosis and monitor disease activity.
- Throat Culture:
- Obtain a throat culture to identify the presence of Group A Streptococcus, which may be instrumental in confirming the infectious trigger for rheumatic fever.
- Functional Assessment:
- Assess the patient’s functional status, including mobility, activities of daily living, and any limitations imposed by joint pain or cardiac symptoms.
Regular and comprehensive assessments are crucial for identifying the extent of involvement, monitoring disease progression, and tailoring the nursing care plan to address the specific needs of the patient with rheumatic fever.
Implementation for Rheumatic Fever
- Administer Antibiotics:
- Administer prescribed antibiotics, such as penicillin or alternative agents, to eliminate the causative Group A Streptococcus infection and prevent recurrent streptococcal infections.
- Manage Pain and Inflammation:
- Provide analgesics and anti-inflammatory medications to manage joint pain and inflammation. Consider nonsteroidal anti-inflammatory drugs (NSAIDs) and other pain relief strategies.
- Cardiac Monitoring and Support:
- Implement continuous cardiac monitoring for patients with carditis, and collaborate with the healthcare team to manage cardiac symptoms. Supportive measures may include diuretics for fluid management and medications to maintain cardiac function.
- Patient Education:
- Educate the patient and their family about the importance of completing the full course of antibiotics, recognizing symptoms of recurrent streptococcal infections, and adhering to prescribed medications and follow-up appointments.
- Joint Care and Physical Therapy:
- Collaborate with physical therapists to develop a joint care plan, including range-of-motion exercises and activities to maintain mobility. Encourage and support the patient in participating in physical therapy sessions.
Implementation strategies aim to address the underlying infection, manage symptoms, and promote overall health and well-being. Close collaboration with the healthcare team is essential for coordinating care and ensuring a comprehensive approach to the treatment of rheumatic fever.
Nursing Interventions and Rationales
- Assess and monitor vital signs
Get a baseline to determine effectiveness of interventions. Fever is a primary symptom. Blood pressure and heart rate may be elevated from fever or from involvement of the heart.
- Perform complete physical assessment
Provides baseline. Note redness of the skin or rash, swelling of the joints, or presence of subcutaneous nodules.
- Assess motor and neurologic function
Patients often have chorea (irregular movements may be noted in the face or extremities and may cause changes in speech)
- Assess pain with appropriate pain scale and manage with non-pharmacological routes
FACES and FLACC scales may be used.
Joint pain is most common and may be relieved by applying cool compresses or heat, repositioning or relaxation techniques.
- Monitor lab tests
Blood tests may be run, such as C-reactive protein or ESR to determine inflammation.
Monitor for presence of strep antibodies or cardiac enzymes as appropriate.
- Obtain ECG and echocardiogram
These tests are used to determine amount of cardiac involvement of the disease. They can detect electrical or functional abnormalities such as faulty valves and help determine course of treatment.
- Administer medications appropriately
- Antibiotics
- Anti-inflammatories
- Anticonvulsants
- Primary goal is to effectively treat the infection and reduce symptoms.
- Antibiotics – given to treat remaining strep infection, may be given orally or IM.
- Anti-inflammatories – given to relieve pain, treat fever and reduce inflammation.
- Anticonvulsants- given to treat involuntary movements (chorea)
- Provide patient and parent education regarding home care and prevention of future disease or complication
- The best way to prevent rheumatic fever is to fully treat strep infections as they occur. Incomplete or no treatment can lead to rheumatic fever.
- Patient will need routine follow up with cardiology as symptoms of valve damage may not fully appear until later in life.
- Encourage good hygiene as studies have shown higher occurrence in areas of overcrowding and poor sanitation.
Evaluation for Rheumatic Fever
- Resolution of Acute Symptoms:
- Evaluate the patient’s response to treatment by assessing the resolution of acute symptoms associated with rheumatic fever, such as joint pain, fever, and carditis. A reduction in symptom severity indicates a positive response to interventions.
- Normalization of Inflammatory Markers:
- Monitor inflammatory markers, such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), to assess the degree of inflammation in the body. A decrease in these markers indicates a reduction in the inflammatory response and can be used as an objective measure of treatment effectiveness.
- Prevention of Cardiac Complications:
- Assess the cardiac status of the patient, particularly monitoring for the development or progression of cardiac complications such as valvular damage. Prevention or mitigation of cardiac sequelae is a key indicator of successful management.
- Adherence to Antibiotic Prophylaxis:
- Evaluate the patient’s adherence to antibiotic prophylaxis, which is crucial in preventing recurrent episodes of rheumatic fever. Regular administration of prescribed antibiotics as recommended by healthcare providers is essential for long-term management.
- Patient Education and Empowerment:
- Assess the patient’s understanding of rheumatic fever, its complications, and the importance of adherence to prescribed medications and preventive measures. Evaluation should focus on the patient’s ability to actively participate in self-management and lifestyle modifications.
References
- https://www.merckmanuals.com/home/children-s-health-issues/bacterial-infections-in-infants-and-children/rheumatic-fever
- https://www.mayoclinic.org/diseases-conditions/rheumatic-fever/diagnosis-treatment/drc-20354594
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Transcript
Okay, let’s get into this nursing care plan for rheumatic fever. So rheumatic fever occurs when a strep throat infection is untreated or not completed. Uh, it can result in an autoimmune condition such as rheumatic fever that has an immune response that causes the inflammation in the body, in the text or joints, the heart, the skin, and the central nervous system. Some risk factors that may increase the chance of developing rheumatic fever include a genetic predisposition, certain strains of group A strep bacteria and poor sanitation. Some nursing considerations that we want to keep in mind are that we want to manage these people’s pain. These patients have a lot of pain, especially in the joints. We want to monitor their vital signs. There are a couple of labs that we want to draw. We want to get an EKG for cardiac involvement, and we want to administer any medications that are ordered. The desired outcome from this patient is that the patient is going to be free from infection. The patient’s going to be free from pain and the patient will not have any permanent tissue damage.
So this patient with rheumatic fever comes in and they’re going to say, the first thing is pain. These patients have painful joints. The other subjective data that is going to present with the patient is chest pain. And that’s in the case of cardiac involvement and then also unusual behaviors or outbursts. Some things that we’re going to observe here is this patient can present with a fever, red, swollen joints, a rash, the subcutaneous nodules, a heart murmur, and also uncontrollable body movements. That’s going to include the hands, feet and face. So nursing considerations and interventions, we want to start by assessing and monitoring their vital signs because with a rheumatic fever, they are going to have a fever. That’s the primary symptom. They also are going to have increased BP and increased heart rate, and that’s going to come from the fever or if there’s any cardiac involvement.
The next thing we want to do after assessing those vital signs is we want to do a head to toe complete physical assessment. This is going to give us our baseline. Be sure that you note on the patient and your documentation any redness or rash that may appear also noting any swelling of joints or presence of subcutaneous nodules. We’re going to look at their lab tests and the results, because we’re going to have to run blood such as C-reactive protein or ESR. This is going to determine inflammation. So we’re going to be on top of that as well. Any medications that we need to administer? So we are going to help with med management, okay. That’s going to include antibiotics, anti-inflammatories and anticonvulsants. The primary goal of this is to effectively treat the infection and reduce the symptoms.
Finally, we are going to assess their motor and neurological function. Patients with this often have chorea, which is irregular movements. They may be noted in the face or extremities, and it may cause changes with speech. The reason why we want to assess this. And so that way we can stop it and keep the disease process from progressing. Now onto the key points, the pathophysiology behind a rheumatic fever; it’s strep throat infection that is not completely treated. It can result in this autoimmune condition, subjective data that the patient will provide us is they’re going to complain of painful or tender joints. They’re going to have some chest pain, and they may also complain of fatigue. Objective, we’re going to note fever, rash, and we may hear a heart murmur where we also take some of the things that we want to be mindful of is to know when there’s some inflammation, as we are going to draw the CRP and the ESR laboratory to determine inflammation and some home care and very important for this patient to make sure that they fully treat strep infections. They’re going to follow up with the cardiologists in the case of any cardiac involvement. They want to make sure that they have some good oral hygiene, because that is also somewhere, where the source of infection can lead to. We love you guys, and we want you to go out and be your best self today. As always, happy nursing.
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