Reyes, Christine Mae

BSN 2-B RHEUMATIC FEVER

I. Overview

Rheumatic fever is an inflammatory disease that can develop when strep throat or

scarlet fever isn't properly treated. Strep throat and scarlet fever are caused by an

infection with streptococcus bacteria.

Rheumatic fever most often affects children who are between 5 and 15 years old,

though it can develop in younger children and adults. Although strep throat is common,

rheumatic fever is rare in the United States and other developed countries. However,

rheumatic fever remains common in many developing nations.

It can cause permanent damage to the heart, including damaged heart valves and

heart failure. Treatments can reduce damage from inflammation, lessen pain and other

symptoms, and prevent the recurrence of rheumatic fever.

II. Signs and Symptoms

Rheumatic fever is caused by a reaction to the bacterium that causes strep throat.

Although not all cases of strep throat result in rheumatic fever, this serious complication

may be prevented with a doctor’s diagnosis and treatment of strep throat.

If your or your child have a sore throat along with any of the following symptoms,

see your doctor for an evaluation:

 Tender and swollen lymph nodes

 Red rash
  Difficulty of swallowing

 Thick, bloody discharge from nose

 Temperature of 101°F (38.3°C) or above

 Tonsils that are red and swollen

 Tonsils with white patches or pus

 Small, red spots on the roof of the mouth

 Headache

 Nausea and Vomiting

A wide variety of symptoms are associated with rheumatic fever. A person with the

illness could experience a few, some, or most of the following symptoms. Symptoms

usually appear two to four weeks after your child has a strep infection.

Common symptoms of rheumatic fever include:

 Small, painless nodules under the skin

 Chest pain

 Rapid fluttering or pounding chest palpitations

 Lethargy or Fatigue

 Nosebleed

 Stomach pain

 Painful or sore joints in the wrists, elbows, knees, and ankles

 Pain in one joint that moves to another joint

 Red, hot, swollen joints

  Shortness of breath

 Fever

 Sweating

 Vomiting

 A flat, slightly raised, ragged rash

 Jerky, uncontrollable movements of the hands, feet, and face

 A decrease in attention span

 Outbursts of crying or inappropriate laughter

If your child has a fever, they might require immediate care. Seek immediate medical

care for your child in the following situations:

 For newborns to 6-week-old infants: more than a 100°F (37.8°C) temperature

 For babies 6 weeks to 6 months old: a 101°F (38.3°C) or higher temperature

 For a child of any age: a fever that lasts more than three days

III. Causes

Rheumatic fever is caused by a bacterium called group A Streptococcus. This

bacterium causes strep throat or, in a small percentage of people, scarlet fever. It’s an

inflammatory disorder.

Rheumatic fever causes the body to attack its own tissues. This reaction causes

widespread inflammation throughout the body, which is the basis for all symptoms of

rheumatic fever.

IV. Risk Factors

 Factors that increase your child’s chances of developing rheumatic fever include:

 Family history. Certain genes make you more likely to develop rheumatic fever.

 Type of strep bacteria present. Certain strains are more likely than others to

lead to rheumatic fever.

 Environmental factors present in developing countries, such as overcrowding.

V. Complications

Once they develop, the symptoms of rheumatic fever can last for months or even

years. Rheumatic fever can cause long-term complications in certain situations. One of

the most prevalent complications is rheumatic heart disease. Other heart conditions

include:

 Aortic valve stenosis. This is a narrowing of the aortic valve in the heart.

 Aortic regurgitation. This is a leak in the aortic valve that causes blood to

flow in the wrong direction.

 Heart muscle damage. This is inflammation that can weaken the heart

muscle and decrease the heart’s ability to pump blood effectively.

 Atrial fibrillation. This is an irregular heartbeat in the upper chambers of the

heart.

 Heart failure. This occurs when the heart can no longer pump blood to all

parts of the body.

If left untreated, rheumatic fever can lead to:

 Stroke

 Permanent damage to your heart

  Death

VI. Diagnostic Tests

Although there's no single test for rheumatic fever, diagnosis is based on medical

history, a physical exam and certain test results.

 Blood Tests

 Electrocardiogram (ECG or EKG)

 Echocardiogram
 Cardiovascular System

VII. Pathophysiology
 Predisposing Factors: Risk Factors:

 Family History  Sore throat

 Environmental Factors  Non compliance to
 Age from 5-15 years old medications

Causative Agent
Group A Beta-hemolytic
streptococci

Streptococcal Infection Increased WBC

Increased production of antigen

(streptococci)
Binds to receptor in
synovial joint
Antigen circulates to the system

Autoimmune response
Autoimmune response attack
the heart valves
Antigen are similar to body’s
own cell that may result to
attack of healthy body cells by Inflammation of the layer of the
mistake heart

Increased ESR
Difficulty of heart to pump
Collection of
Subcutaneous Inflammation
collagen fibers over
Nodules (+) Joint Pains
the bones and
Increased Cardiac Workload
tendons
Decreased cardiac supply of Scarring of the heart valves that
blood in different organs damages Mitral or Aortic
Valves
 Decreased blood in the bone
marrow

Decreased RBC production Blood cell production slows

down

Decreased in hemoglobin and

iron rich protein WBC production
Decreased

Shortness of
breath and Decreased immune defense
Tachycardia reaction

Systemic infection still

Decreased oxygen in the Increased risk for infection occurs
body

FEVER Rashes
(Erythema Nodosum &
Generalized body Maculopapular Rash)
weakness
VIII. Prevention
The most effective way to make sure your child doesn’t develop rheumatic fever is to
start treating their strep throat infection within several days and to treat it thoroughly.
This means ensuring your child completes all prescribed doses of medication.
Practicing proper hygiene methods can help prevent strep throat:
 Cover your mouth when coughing or sneezing.
 Wash your hands.
 Avoid contact with people who are sick.
 Avoid sharing personal items with people who are sick.

IX. Treatment

 Antibiotics
Your child’s doctor will prescribe antibiotics and might prescribe a long-term
treatment to prevent it from occurring again. In rare cases, your child may receive
lifelong antibiotic treatment.
 Anti-inflammatory treatment
Anti-inflammatory treatments include pain medications that are also anti-
inflammatory, such as aspirin (Bayer) or naproxen (Aleve, Naprosyn). Though aspirin
use in children with certain illnesses has been associated with Reye’s Syndrome, the
benefits of using it in treating rheumatic fever may outweigh the risks. Doctors may also
prescribe a corticosteroid to reduce inflammation.
  Anticonvulsant medications
Your child’s doctor might prescribe an anticonvulsant if involuntary movements
become too severe.
 Bed rest
Your child’s doctor will also recommend bed rest and restricted activities until the
major symptoms — such as pain and inflammation — have passed. Strict bed rest will be
recommended for a few weeks to a few months if the fever has caused heart problems.

X. Nursing Management
Nursing care of a child with rheumatic fever include:
 Nursing Assessment
Nursing assessment for a child with rheumatic fever are as follows:
 History. Obtain a complete up-to-date history from the child and the caregiver;
ask about a recent sore throat or upper respiratory infection; find out when the
symptoms began, the extent of the illness, and what if any treatment was obtained.
 Physical exam. Begin with a careful review of all systems, and note the child’s
physical condition; observe for any signs that may be classified as major or minor
manifestations; in the physical exam, observe for elevated temperature and pulse,
and carefully examine for erythema marginatum, subcutaneous nodules, swollen
or painful joints, or signs of chorea.
RHEUMATOID ARTHRITIS
I. Overview
Rheumatoid arthritis is a chronic inflammatory disorder that can affect more than
just your joints. In some people, the condition can damage a wide variety of body
systems, including the skin, eyes, lungs, heart and blood vessels.
An autoimmune disorder, rheumatoid arthritis occurs when your immune system
mistakenly attacks your own body's tissues.
Unlike the wear-and-tear damage of osteoarthritis, rheumatoid arthritis affects the
lining of your joints, causing a painful swelling that can eventually result in bone
erosion and joint deformity.
The inflammation associated with rheumatoid arthritis is what can damage other
parts of the body as well. While new types of medications have improved treatment
options dramatically, severe rheumatoid arthritis can still cause physical disabilities.

II. Signs and Symptoms

In most patients with RA, onset is insidious, often beginning with fever, malaise,
arthralgias, and weakness before progressing to joint inflammation and swelling.
Signs and symptoms of RA may include the following:
  Persistent symmetric polyarthritis (synovitis) of hands and feet (hallmark
feature)
 Progressive articular deterioration
 Extra-articular involvement
 Difficulty performing activities of daily living (ADLs)
 Constitutional symptoms
The physical examination should address the following:
 Upper extremities (metacarpophalangeal joints, wrists, elbows, shoulders)
 Lower extremities (ankles, feet, knees, hips)
 Cervical spine
During the physical examination, it is important to assess the following:
 Stiffness
 Tenderness
 Pain on motion
 Swelling
 Deformity
 Limitation of motion
 Extra-articular manifestations
 Rheumatoid nodules

III. Causes
Rheumatoid arthritis occurs when your immune system attacks the synovium —
the lining of the membranes that surround your joints.
The resulting inflammation thickens the synovium, which can eventually destroy
the cartilage and bone within the joint. The tendons and ligaments that hold the joint
together weaken and stretch. Gradually, the joint loses its shape and alignment.
Doctors don't know what starts this process, although a genetic component
appears likely. While your genes don't actually cause rheumatoid arthritis, they can
make you more susceptible to environmental factors — such as infection with certain
viruses and bacteria — that may trigger the disease.

IV. Risk Factors

Factors that may increase your risk of rheumatoid arthritis include:
 Your sex. Women are more likely than men to develop rheumatoid arthritis.
  Age. Rheumatoid arthritis can occur at any age, but it most commonly begins
in middle age.
 Family history. If a member of your family has rheumatoid arthritis, you may
have an increased risk of the disease.
 Smoking. Cigarette smoking increases your risk of developing rheumatoid
arthritis, particularly if you have a genetic predisposition for developing the
disease. Smoking also appears to be associated with greater disease severity.
 Environmental exposures. Although poorly understood, some exposures
such as asbestos or silica may increase the risk of developing rheumatoid
arthritis. Emergency workers exposed to dust from the collapse of the World
Trade Center are at higher risk of autoimmune diseases such as rheumatoid
arthritis.
 Obesity. People — especially women age 55 and younger — who are
overweight or obese appear to be at a somewhat higher risk of developing
rheumatoid arthritis.

V. Complications
Rheumatoid arthritis increases your risk of developing:
1. Osteoporosis
2. Rheumatoid Nodules
3. Dry eyes and Mouth
4. Infections
5. Abnormal Body Composition
6. Carpal Tunnel Syndrome
7. Heart Problems
8. Lung Disease
9. Lymphoma

VI. Diagnostic Tests

 Blood Tests
People with rheumatoid arthritis often have an elevated erythrocyte sedimentation
rate (ESR, or sed rate) or C-reactive protein (CRP), which may indicate the presence
 of an inflammatory process in the body. Other common blood tests look for
rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies.
 Imaging Tests
Your doctor may recommend X-rays to help track the progression of rheumatoid
arthritis in your joints over time. MRI and ultrasound tests can help your doctor judge
the severity of the disease in your body.
 Synovial Membrane Biopsy
 Radionuclide scans
 Direct arthroscopy

VII. Pathophysiology

Predisposing Factors:
Risk Factors:
 Family History
 Smoking
 Age
 Obesity
 Gender
 Environmental Exposure
 Genetics
 Etiology Unknown

Antigen presenting cell in

Synovium

T-Helper cell

Macrophages

Cytokines

IL-1, IL-6, TNFa

Effects on bone remodeling

Increased RANKL (osteoblast),

Decreased OPG
RANKL binds to RANK
(prosteoclast)
 Osteoclast

Erosion of Bone
 Stiffness
 Pain
 Swelling
 Redness
Synovial Inflammation Rheumatoid Nodule
 Warmth

Immobilization Pannus Formation

Contractures Cartilage Damage

Bone Damage
Deformity

Joint Dysfunction
VIII. Prevention

1. Stop smoking.
2. Lose weight.
3. Limit exposure to pollutants.
4. Get help early.
5. Takeaway.

IX. Treatment

There is no cure for rheumatoid arthritis. But clinical studies indicate that
remission of symptoms is more likely when treatment begins early with
medications known as disease-modifying antirheumatic drugs (DMARDs).

The types of medications recommended by your doctor will depend on the

severity of your symptoms and how long you've had rheumatoid arthritis.

1. NSAIDs (Nonsteroidal Anti-inflammatory Drugs)

2. Steroids
3. Disease-modifying antirheumatic drugs (DMARDs)
4. Biologic agents.

X. Nursing Management
Nursing care of the patient with RA should follow a basic plan of care.
Nursing Assessment
The assessment of a patient with RA can contribute to its diagnosis.
 History and physical exam. The history and physical examination address
manifestations such as bilateral and symmetric stiffness, tenderness, swelling,
and temperature changes in the joints.
 Extra-articular changes. The patient is also assessed for extra-articular
changes and these include weight loss, sensory changes, lymph node
enlargement, and fatigue.
COARCTATION OF AORTA
I. Overview
Coarctation of the aorta — or aortic coarctation — is a narrowing of the aorta, the
large blood vessel that branches off your heart and delivers oxygen-rich blood to your
body. When this occurs, your heart must pump harder to force blood through the
narrowed part of your aorta.
Coarctation of the aorta is generally present at birth (congenital). The condition
can range from mild to severe, and might not be detected until adulthood, depending
on how much the aorta is narrowed.
Coarctation of the aorta often occurs along with other heart defects. While
treatment is usually successful, the condition requires careful lifelong follow-up.

II. Signs and Symptoms

Coarctation of the aorta symptoms depend on the severity of the condition. Most
people don't have symptoms. Children with serious aortic narrowing may show signs
and symptoms earlier in life, but mild cases with no symptoms might not be
diagnosed until adulthood. People may also have signs or symptoms of other heart
defects that they have along with coarctation of the aorta.
Babies with severe coarctation of the aorta may begin having signs and symptoms
shortly after birth. These include:
 Pale skin
 Irritability
 Heavy sweating
 Difficulty breathing
 Difficulty feeding
 Left untreated, aortic coarctation in babies might lead to heart failure or death.
Older children and adults with coarctation of the aorta often don't have symptoms
because their narrowing may be less severe. If you have signs or symptoms that
appear after infancy, you most commonly will have high blood pressure
(hypertension) measured in your arms. However, your blood pressure is likely to be
lower in your legs. Signs and symptoms might include:
 High blood pressure
 Headache
 Muscle weakness
 Leg cramps or cold feet
 Nosebleeds
 Chest pain
Seek medical help if you or your child has the following signs or symptoms:
 Severe chest pain
 Fainting
 Sudden shortness of breath
 Unexplained high blood pressure

III. Causes
Doctors aren't certain what causes coarctation of the aorta (aortic coarctation). For
unknown reasons, mild to severe narrowing develops in part of the aorta. Although
aortic coarctation can occur anywhere along the aorta, the coarctation is most often
located near a blood vessel called the ductus arteriosus. The condition generally
begins before birth (congenital). Congenital heart defects are the most common of all
birth defects.
Rarely, coarctation of the aorta develops later in life. Traumatic injury might lead
to coarctation of the aorta. Rarely, severe hardening of the arteries (atherosclerosis) or
a condition causing inflamed arteries (Takayasu's arteritis) can narrow the aorta,
leading to aortic coarctation.
Coarctation of the aorta usually occurs beyond the blood vessels that branch off to
your upper body and before the blood vessels that lead to your lower body. This can
often lead to high blood pressure in your arms but low blood pressure in your legs and
ankles.
With coarctation of the aorta, the lower left heart chamber (left ventricle) of your
heart works harder to pump blood through the narrowed aorta, and blood pressure
increases in the left ventricle. This may cause the wall of the left ventricle to thicken
(hypertrophy).

IV. Risk Factors

Coarctation of the aorta often occurs along with other congenital heart defects,
although doctors don't know what causes multiple heart defects to form
together. The condition is more common in males than in females. You or
your child may be more likely to have aortic coarctation if certain heart
conditions exist, including:

 Bicuspid Aortic Valve

 Patent Ductus Arteriosus
 Holes in the wall between the left and right sides of the heart
  Aortic valve stenosis
 Aortic valve regurgitation
 Mitral valve stenosis
 Mitral valve regurgitation

V. Complications
Untreated coarctation of the aorta frequently leads to complications. Some
complications may be a result of long-standing high blood pressure caused by the
aortic coarctation. Complications are also possible after treatment for coarctation
of the aorta.
Complications of coarctation of the aorta may include:
 Narrowing of the aortic valve (aortic stenosis)
 High blood pressure
 Stroke
 Enlargement in a section of the wall of the aorta (aneurysm)
 Aortic rupture or tear (dissection)
 Premature coronary artery disease — narrowing of the blood vessels that
supply the heart
 Heart failure
 A weakened or bulging artery in the brain (brain aneurysm) or bleeding in
the brain (hemorrhage)
In addition, if the coarctation of the aorta is severe, your heart might not be
able to pump enough blood to your other organs. This can cause damage to your
heart and also can result in kidney failure or other organ failure.
If your coarctation of the aorta was treated when you were young, you have a
risk of the aorta re-narrowing (re-coarctation) over time. You also have a higher
risk of developing high blood pressure. You will need lifelong follow-up for
coarctation of the aorta, and you may require additional treatments.

VI. Diagnostic Tests

1. Echocardiogram
2. Electrocardiogram
3. Chest X-ray
4. MRI
5. Computerized tomography (CT) scan
6. Cardiac catheterization
VII. Pathophysiology
Coarctation of the aorta usually occurs at the proximal thoracic aorta just beyond
the left subclavian artery and just across from the opening of the ductus arteriosus.
Coarctation rarely involves the abdominal aorta. Thus, in utero and before the patent
ductus arteriosus (PDA) closes, much of the cardiac output bypasses the coarctation
via the PDA. Coarctation may occur alone or with various other congenital anomalies
(eg, bicuspid aortic valve, ventricular septal defect, aortic stenosis, patent ductus
arteriosus, mitral valve disorders, intracerebral aneurysms).
Physiologic consequences involve 2 phenomena:
 Pressure overload in the arterial circulation proximal to the coarctation
 Hypoperfusion distal to the coarctation
Pressure overload causes left ventricular hypertrophy and hypertension in the
upper part of the body, including the brain.
Hypoperfusion affects the abdominal organs and lower extremities. Malperfusion
of the intestine increases the risk of sepsis due to enteric organisms.
Ultimately, the pressure gradient increases collateral circulation to the abdomen
and lower extremities via intercostal, internal mammary, scapular, and other arteries.
Untreated coarctation may result in left ventricular hypertrophy, heart failure,
collateral vessel formation, bacterial endocarditis, intracranial hemorrhage,
hypertensive encephalopathy, and hypertensive cardiovascular disease during
adulthood. Patients with untreated coarctation are at increased risk of aortic dissection
or rupture later in life or in association with pregnancy. The ascending aorta is the
area most frequently involved in dissection or rupture. Current data suggest that this
risk is less likely a direct consequence of the coarctation and more likely related to a
bicuspid aortic valve and associated aortopathy.
 VIII. Prevention
Coarctation of the aorta can't be prevented, because it's usually present at birth
(congenital). However, if you or your child has a condition that increases the risk of
aortic coarctation, such as Turner syndrome, bicuspid aortic valve or another heart
defect, or a family history of congenital heart disease, early detection can help.
Discuss the risk of aortic coarctation with your doctor.
IX. Treatment
Treatment options for coarctation of the aorta depend on your age at the time of
diagnosis and the severity of your condition. Other heart defects might be repaired at
the same time as aortic coarctation.
Treatment approaches usually consist of surgery or a procedure called balloon
angioplasty or stent placement. A doctor trained in congenital heart conditions will
evaluate you and determine the most appropriate treatment for your condition.
X. Nursing Management

Monitoring for signs and symptoms of heart failure (decrease cardiac output or fluid
volume overload): fluid in lungs with crackles, difficulty breathing, increased respiratory
rate, fatigue, trouble feeding
Monitoring and reporting blood pressure and pulse differences in upper and lower
extremities
Mild cases…may go undetected until later in childhood when abnormal blood
pressures or pulses are detected in the upper vs. lower extremities…sometimes a heart
murmur may be present (systolic) that is located on the back on the left side near the
shoulder blades “interscapular”
If CoA is severe in a newborn, the patient may be started on a prostaglandin
infusion to keep the ductus arteriosus open until surgery. This will help:

 Decrease the work load on the left ventricle

 Help blood to flow to the lower extremities