Case Study Namen

RHEUMATIC FEVER _________ A Case Study Presented to Tarlac State University College of Nursing ___________

In Partial Fulfillment of the Requirements for NCM101 ___________ By BSN II-B4 Ryan Krisna Dela Cruz Jon Henry Ordoñez Bridgitte Ortiz Monica Pineda Mark Alvin Quibuyen Sarah Jane Quirante Maryner Ramos Ron Mar Ramos Ismael 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: Admitting Diagnosis: Date admitted:

None UTI suspect, Rheumatic Fever 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

X

X 65 HC

59 DHN

35 A&W

38 A&W

12 RF

2 Mos A&W

LEGEND X X

- Deceased male

-Pertains to patient, living female child

-Deceased female

- living male child

-Living mother

HC -Heart Complication DHN – Dehydration RF – Rheumatic Fever A&W – Alive and Well

-Living father

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 Skin Inspection Palpation

Standard Findings

Normal Findings

Light to brown in color Temperature is 36.5ºC When pinched, skin springs back to previous state Texture not uniform, some areas are thick and some are rough No unusual marks No presence of lesions and rushes No pressure sores found No edema

09/10/09

Hair

Inspection Palpation

09/10/09

Nails

Inspection Palpation

Hair is thick and shiny Hair is equally distributed and has no presence of alopecia. No foul odor Angle between finger nail and base is about 160º Blanch test is normal. When palpated base is firm.

Color should be Normal light to deep brown Temperature should be uniform and within normal range skin should spring back to place when pinched texture should not be uniform; some areas should be thick like the palms and soles. Should be silky, Normal resilient Should be thick and hair should be evenly distributed Should be pinkish Normal in color. Convex curvature: angle between nail and nail bed should be at about 160º

09/10/09

Interpretation

Dirty nails

09/10/09

Head

Inspection Palpation

Rounded and symmetrical. No unusual swelling

09/10/09

Eyes

Inspection

Eyes are symmetrical Transparent, 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

09/10/09

Ear

Inspection

The location and alignment is normal, symmetrical with upper attachment at eye corner level (lateral cantus) Pinna is brown in color; canal has presence of

After pinching, pink color in the nail bed should return within 3sec. Should be rounded and symmetrical, Normocephalic Should have smooth skull contour 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. Pinna should be aligned with the eyes. The color of the pinna should be the same with the color of the face.

Normal

Normal

Normal

ear wax. No presence of discharge and odor. Able to hear instructions and responds quickly

09/10/09

Nose

Inspection Palpation

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

09/10/09

Lips

Inspection

09/10/09

Mouth

Inspection

Normal integrity. Normal symmetry. Light pink in color. Number and condition of the teeth is normal, properly aligned Gums 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. Parotid gland is smooth, moist and has no swelling and reddening.

Should have no presence of discharge and odor. Sounds should be heard in both ears or is localized with the center of the head. Should be Normal symmetric and straight. Should have no discharge or flaring. Should not be tender Should be uniform, Normal and pink in color Should have 32 Normal 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 rough, thin whitish coating. Soft palate should

09/10/09

Neck

Inspection Palpation

09/10/09

Extremities

Inspection Palpation

be light pink and smooth. Uvula should be position in the midline of soft palate. Muscles are Muscles should be symmetrical with the equal in size and head and able to move head centered. without discomfort. Trachea should be Trachea is in the midline at the center of the position. neck, spaces are Thyroid is smooth, soft, equal on both sides. not enlarges and has no Thyroid should not presence of mass and be visible on bruises. inspection No discolorations Should have no No lesions, masses discolorations No Tenderness Should have no No presence of edema masses, lesions Uniform in temperature Should have no and within normal range tenderness Joints are swollen Should be uniform Client complains of pain in temperature when joints are touched

Normal

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

VI. Nursing Care Plan Assessment

Diagnosis

Subjective >“Nahihirapan siya gumalaw..”, as stated by mother.

Analysis:

Objective >Discomfort >Immobility >Palor >Body >Weakness V/S: BP: 110/70 RR:19 CR:102 Temp:37.3C

Planning

Intervention

Rationale

Expected Outcome

After 2 hours of >Monitor Vital >To be of help After 2 proper nursing signs for direct hours of Activity intervention, >Observe and appropriate proper intolerance r/t the patient will document skin intervention nursing imbalance be able to integrity. >Activity intervention, between *maintain >Assist in intolerance may the patient oxygen supply normal skin proper position lead to pressure should be and demand color and skin >Assist in ulcers able to: would be warm performing >Inactivity Insufficient to dry ROM exercises rapidly *maintain physiological or *Able to >Demonstrate contributes t normal skin psychological perform activity proper muscle color and energy to without breathing shortening and skin would endure or discomfort pattern changes in be warm to complete *Understand >Determine periarticular dry required or need for cause of and *Able to desired daily balanced rest activity cartilaginous perform activities and activity intolerance and joint structure activity determine >Inappropriate without whether cause prolonged bed discomfort is physical, rest orders may *Understand psychological t contribute need for or motivational. activity balanced rest >Assess the intolerance and activity client daily for 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

Subjective >”Nilalagnat siya”, as verbalized by client’s mother

Hyperthermia r/t infection

Short term: After 1 hour of proper nursing intervention, the patient’s temperature will decrease from 38.7°C to 37C

Objective: >Febrile >Pale >Skin warm to touch >Inflammed joints >Incoherent >Weakness V/S >BP:100/60 >RR:18 cpm >CR:106 bpm Temp:38.7 °C

Assessment

Increased of temperature is a chemical response of the body to infections that causes inflamed joints of the patient

Diagnosis

Long term: After proper nursing intervention, the patient’s condition will improve and there would be no more swelling of joints.

Planning

Intervention

Rationale

Expected Outcome

>Monitor Vital >To limit Short term: After 1 signs fatigue hour of proper >Performed nursing continuous TSB >To promote intervention, the > Checked well-being and patient’s temperature energy temperature every 15 production should decreased minutes >>To promote from 38.7°C to >Encouraged optimal level of 37°C Patient to rest function and >Provide dry prevent clothing and complications. Long term: bed linens Patient’s joints >Encouraged >To determine should continue to adequate intake progress of swell but should of fluids and interventions now state that nutritious foods pain is reduced. >Encourage >To reduce participation in temperature in self care the body >Note >To relax emotional or patient’s body behavioral response to problems of fever 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 10/10 V/S: PR: 106 bpm Temp: 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