Pathophysiology, Nursing Care, And Effects Of Hospitalization In Acute Rheumatic Fever: A Case Study Essay.

1.Describe the pathophysiology of the presenting complaint in the case study

2.Evaluate the nurse’s role in delivering developmentally appropriate nursing care in relation to your chosen case study.

3.Effects of hospitalization of the child on the child and family.

1.Pathophysilogy

Acute rheumatic fever is an inflammatory disease of the connective tissue and endothelial tissue which is common in children aged 6-15 years (Webb 2015). It affects the mitral valve either making them loose or sternose hence reducing cardiac output. It is caused by immunologic reaction that is a delay sequel of group A hemolytic streptococcal infection of the pharynx with cardiac tissue antigen. It is diagnosed using the revised jones criteria which consist of either two major criteria or one major and two minor criteria with a supportive evidence of increased titer of streptococcal antibodies or positive throat culture of group A beta hemolytic streptococcus. Prevention and treatment   penicillin is used (Seckeler 2011).

Acute rheumatic fever is an inflammatory disease of the connective and endothelial tissues especially of the brain, joints, hearth and skin. It is a primary type of acquired heart disease which can be prevented. It occurs due to cross reactivity between cardiac tissue antigens and group A beta hemolytic streptococcal cell wall components .Usually occurs after  untreated streptococcal infection of the throat or upper respiratory tract which may still be present of may have cleared off but presence of streptococcal autoantibodies attacks ones heart especially the myocardium, pericardium or the heart valves (Burke 2014). Most common in children 6-15 years. This leads to a unique pathological lesion of rheumatic fever called the Asch off body which is a collection of reticuloendothelial cells surrounding a neurotic center on some structure of heart, The inflammatory process mainly affect the brain, skin, heart and joints thus manifestations such as carditis, polyarthritis, Sydenham chorea, erythema marginatum and subcutaneous nodules. Also arthralgia, fever, elevated erythrocyte sedimentation rate, leukocytosis and ECG changes may occur (Gewitz 2015). Carditis mainly manifest by significant murmurs, tachycardia, signs of pericarditis, cardiac enlargement and congestive heart failure. Polyarthritis manifest by swelling, heat, redness and pain of the large joints and is usually migratory. Chorea is a central nervous system disorder which presents by purposeless involuntary rapid movements often associated with muscle weakness involuntary facial grimace, speech disturbance and emotional liability. Erythema marginatum presents as erythematous areas with pale centers and weary margins varying in sizes. Erythema is usually transient and migratory from place to place and heat is a predisposing factor. Subcutaneous nodules present as painless nodules seen on the surface of certain joints particularly elbow, knees and wrist. Also at the occipital regions the spinous processes of the thoracic vertebrae. The skin overlying them moves freely and is not inflamed.  The inflammation may also involve the leaflets or chordae tendinae of the heart valves most frequently the mitral or aortic valves resulting in sclerosis and fusion on valve margins. This leads to valvular incompetence. The recurrence rate is high and 75% of acute rheumatic fever progresses to rheumatic heart disease in adulthood. This condition is usually preventable by penicillin treatment of the primary infection or the throat infection or erythromycin for those with penicillin sensitivity (Barash 2008).

Growth and developmental theories

Sue is a teenager. Most teenagers understand about their condition if education is provided properly but they may have difficulty in decision making. According to Sigmund freud developmental stages Sue falls in the category of genital phase and they have high libido. At this stage their superego has developed and therefore they can be able to think and make decisions when provided with a friendly environment (Cicchetti 2013). The role of a nurse is to gather for the needs of Sue. Pain management is an important aspect. The pain related to inflammatory response in the joints is managed by providing bed rest to her administering analgesics such as paracetamol depending on pain severity as verbalized by the patient. Also diversional therapy such as psychological support can also help. Also as the heart if affected there is reduced cardiac output related to valve dysfunction or cardiac failure. The intervention by the nurse is to assess the symptoms of heart failure including diminished quantity of peripheral pulses, cold skin and distended neck veins. Then monitor intake and output of fluids, provide bed rest, give cardiac glycosides as prescribed. Also encourage the client not to engage in strenuous activities that can lead to fatigue but to exercise just enough. Third nursing diagnosis is anxiety related to disease condition and heart failure. The nurse should ensure that the client shows maximum reduction of anxiety by clarifying the doubts of the client by using non-medical terms, calm and low speech. Also   explain all the procedures to be performed on the client and explain about the disease condition and the course together with possible outcomes. Anxiolytics can be provided if the level of anxiety is too high. Fourth diagnosis is knowledge deficit related to disease condition and long term treatment. It is evident that Sue and her family lacked enough knowledge about her condition basing in the fact that she was not able to complete her dosage of IM penicillin injection as prescribed and this has led to her developing acute rheumatic fever. The role of a nurse is to ensure that the patient gains adequate knowledge such that the client is able to understand and explain the disease process recognizing need for medication and understanding treatment by explaining to the patient about the disease condition and prophylactic treatment of antibiotic (Ball 2013).

2.Nursing care

From the case study the Sue is a 14 year old girl with other six younger brothers and sisters and her mother living in rural Australia. The main cause of acute rheumatic fever is throat infection by group A beta hemolytic streptococcus infection. The streptococcus is transmitted through droplets which are greatly contributed by overcrowding and poor hygiene a common thing in rural areas (Jaine. 2011). The chances of her transmitting the infection to her younger siblings are very high as young children have low immunity. The role of a nurse at the family level is to ensure that there is minimal or no spread of the infection to other family members and reduce the progress and severity of those already affected. This can be prevented by Prophylactic antibiotics to those at high risk and adherence to the drug therapy. The nurse can promote this by educating the family on importance of completing antibiotic therapy as prescribed to avoid resistance to the drug and avoid recurrence of the streptococcal infection. Also educate and counsel on good hygiene. For those already affected like Sue explain to her the course of the disease and possible recurrence and importance of her adhering to the medication as chances of developing a rheumatic heat disease is high. Also counsel on the long term treatment as she has to be on IM penicillin every 28 days to prevent recurrence of acute rheumatic fever and cardiac damage. Considering cardiology review of Sue encourage the mother on ways off obtaining support especially on funds as early recognition of cardiac damage involvement is important to prevent further heart  damage (Potts 2012).

Acute rheumatic heart disease can develop to a serious heart damage if not treated promptly. Hospitalization of an adolescent brings more anxiety to the client. I also affects bonding with the fellow siblings and family at large. Sue has lives with her mother and siblings and her being I  hospital deprive her of parental and sibling bonding. It can also affect the patients nutritional status. The role of a nurse in this is to reassure the client on the situation give her enough knowledge in the reasons for her hospitalization and encourage the family members to visit her in hospital (Milne 2012). Hospitalization of a child also affects the family. Funds needs to be provided for the care of her child in hospital and thus the family has to give out. Sue live with her mother in a rural area with health facilities being at a long distance of 800 Km. This may be a challenge for her mother as most rural areas are poverty stricken. Also parent-child bonding is affected with hospitalization. This makes the family not to  be stable and happy (Pfoh 2008).

Conclusion

Acute rheumatic fever is a preventable disease if primary throat infection is treated early. Completing antibiotic dosage as prescribed is an important factor in the recurrence of the infection.  If left untreated it can lead to complications such as chronic heart failure and aortic mitral regurgitation. Treatment and hospitalization has much impact on the patient and the family members at large as it is a long term condition and requires long term therapy.

References

Ball, J. W., DrPH, R. N., Bindler, R. C., & Cowen, K. J. (2013). Child health nursing. Prentice Hall.

Barash, J., Mashiach, E., Navon-Elkan, P., Berkun, Y., Harel, L., Tauber, T., ... & Pediatric Rheumatology Study Group of Israel. (2008). Differentation of post-streptococcal reactive arthritis from acute rheumatic fever. The Journal of pediatrics, 153(5), 696-699.

Burke, R. J., & Chang, C. (2014). Diagnostic criteria of acute rheumatic fever. Autoimmunity reviews, 13(4-5), 503-507.

Cicchetti, D. (2013). Developmental psychopathology: Past, present, and future. In The emergence of a discipline (pp. 15-26). Psychology Press.

Coleman, K., Austin, B. T., Brach, C., & Wagner, E. H. (2009). Evidence on the chronic care model in the new millennium. Health affairs, 28(1), 75-85.

Gewitz, M. H., Baltimore, R. S., Tani, L. Y., Sable, C. A., Shulman, S. T., Carapetis, J., ... & Mayosi, B. M. (2015). Revision of the Jones Criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography: a scientific statement from the American Heart Association. Circulation, CIR-0000000000000205.

Jaine, R., Baker, M., & Venugopal, K. (2011). Acute rheumatic fever associated with household crowding in a developed country. The Pediatric infectious disease journal, 30(4), 315-319.

Milne, R. J., Lennon, D. R., Stewart, J. M., Vander Hoorn, S., & Scuffham, P. A. (2012). Incidence of acute rheumatic fever in New Zealand children and youth. Journal of paediatrics and child health, 48(8), 685-691.

Pfoh, E., Wessels, M. R., Goldmann, D., & Lee, G. M. (2008). Burden and economic cost of group A streptococcal pharyngitis. Pediatrics, 121(2), 229-234.

Potts, N. L., & Mandleco, B. L. (2012). Pediatric nursing: Caring for children and their families. Cengage Learning.

Seckeler, M. D., & Hoke, T. R. (2011). The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease. Clinical epidemiology, 3, 67.

Webb, R. H., Grant, C., & Harnden, A. (2015). Acute rheumatic fever. Bmj, 351, h3443.