P.B.B.Sc.

DEGREE COURSE IN
NURSING
Child Health Nursing
VII.Common Disorders of Children
Δ CARDIAC DIORDERS
: RHEUMATIC FEVER

Presented by,
Abinaya R Tutor
Dep. Of. psychiatric
SBCN
 LEARNING OBJECTIVES

The students will be able to

• define rheumatic fever
• list down the predisposing factors of
rheumatic fever
• enumerate the causes of rheumatic fever
• explain the pathophysiology of rheumatic fever
• describe the management of rheumatic fever
 INTRODUCTION

Rheumatic fever is a rare but potentially life-threatening

disease, is a complication of untreated strep throat
caused by bacteria called group A streptococcus.
Rheumatic fever causes inflammation, especially of the
heart, blood vessels and joints. Symptoms include fever
and painful, tender joints.
 DEFINITION

Acute rheumatic fever[ARF]is an autoimmune

collagen disease occurs as a hypersensitivity reaction
to group-A beta hemolytic streptococcal infection . It
is characterized by inflammatory lesions of
connective tissue and endothelial tissue . It affects
heart ,joint .blood vessels and other connective
tissues.
 INCIDENCE

It is the most important acquired heart disease in

children and commonly found in 4 to 15 years of age
with incidence rate 5.0/1000 approximately
 PREDISPOSING FACTORS
• Genetic predisposition

• Temperature, climate

• Winter season

• Unhygienic living conditions

• Overcrowding in the family

• Poor dietary intake

• Increasing immunological response

 ETIOLOGY

• An untreated Group- A beta hemolytic

streptococcal infection is the commonest
antecedent event that precipitates an attack
of Acute Rheumatic fever.

• It is a delayed non-suppurative sequelae

to URTI with GABH streptococci
 PATHOPHYSIOLOGY

The exact etiopathogenesis of ARF is not well

understood. Preceding streptococcal infection is
may not always clinically manifest. It is considered
as a sort of hypersensitivity reaction.
 PATHOPHYSIOLOGY

streptococcal sore throat

Antigen antibody reaction

Anti-streptococcal antibody titre is elevated

Antibodies attack the myocardium, pericardium and

cardiac valves (especially the mitral valves)
 PATHOPHYSIOLOGY cont..

aschoff’s bodies (fibrin deposits) develop on the valves

Permanent valve dysfunction

Severe myocarditis

Dilation of the heart

Heart failure
 PATHOPHYSIOLOGY cont..

The antibodies may react with striated muscle,

vascular smooth muscle and nervous tissue

Joint inflammation

Involuntary movements as chorea

Lesions in blood vessels and other connective

tissues.
 CLINICAL
MANIFESTATIONS
The clinical features of acute rheumatic fever can
be grouped as major, minor and essential
manifestations or criteria s described in modified
Jones criteria
 CLINICAL MANIFESTATIONS cont..

Major manifestations or criteria

Carditis
• It is an early manifestations of rheumatic fever as
• Pancarditis (pericarditis, myocarditis and
endocarditis)
 CLINICAL MANIFESTATIONS cont..

• It is evidenced as presence of significant

murmur
• ECG changes
• Cardiac enlargement
• Friction rub
• Pericardial effusion
• Features of heart failure
 CLINICAL MANIFESTATIONS cont..

Polyarthritis
• It is usually flitting or migratory type of
joint
• Inflammation with pain
• Decreased active movements

• Warm, tenderness, redness and swelling

 CLINICAL MANIFESTATIONS cont..

• Two or more joints are affected

• Commonly knees, ankles and elbows are

involved
• But sometimes smaller joints may also be
affected.
 CLINICAL MANIFESTATIONS cont..

Chorea
• It is purposeless involuntary, rapid movements usually
associated with
• muscle weakness
• incordination
• Involuntary facial grimace
• Speech disturbance
• Awkward gait
• Emotional disturbances
 CLINICAL MANIFESTATIONS cont..

Subcutaneous Nodules
• It is found as firm painless nodule over the extensor
surface of certain joints (elbow, knees and wrists)
• Occiput

• Vertebral column
 CLINICAL MANIFESTATIONS cont..

Erythema marginatum
• It is pink macular non-itching rash

• Found mainly over the trunk

• Sometimes on the extremities but never on the face.

• It is transient and brought only by heat and migrates

from place to place
 CLINICAL MANIFESTATIONS cont..

MINOR MANIFESTATIONS OR CRITERIA

Fever
• Increase in body temperature is common
findings. It rarely goes above 39.5 ˚C
 CLINICAL MANIFESTATIONS cont..

Arthralgia
• Pain in the joints occurs in about 90 percent
cases. It presents along with arthritis.
 CLINICAL MANIFESTATIONS cont..

Previous attack of rheumatic fever or rheumatic

heart disease. This is applicable for a second attack
of rheumatic fever.
 CLINICAL MANIFESTATIONS cont..

ECG changes

prolonged P-R interval is considered as minor

criterion. It is diagnostic of carditis.
 CLINICAL MANIFESTATIONS cont..

• Elevated ESR or presence of C-reactive protein

may be considered as minor criteria.
 CLINICAL MANIFESTATIONS cont..

Essential criteria
• Elevated antistreptolysin-O (ASO) titre indicates
previous streptococcal infection (normal 200 IU/ml)
• Positive throat swab culture may show streptococcal
infection (sore throat, scarlet fever)
 CLINICAL MANIFESTATIONS cont..
Other manifestations
• Precordial pain
• Abdominal pain
• Head ache
• Easy fatigability
• General weakness
• Tachycardia
• Malaise
• Sweating
 CLINICAL MANIFESTATIONS cont..

• Vomiting
• Skin rash
• Erythema nodosum
• Epistaxis
• Anemia
• Pleuritis
• Weight loss
 DIAGNOSIS

• The presence of two major or one major and two

minor criteria plus evidence of a preceding
streptococcal infection is essential for labelling
a case a rheumatic fever.
 DIAGNOSIS cont..

• Doppler echocardiography

• Artificial subcutaneous nodule test

 DIAGNOSIS cont..

• Endomyocardial biopsy showing Aschoff’s

nodules or histocytes confirms the

diagnosis.
 DIAGNOSIS cont..

• Chest X-ray shows cardiomeagly and heart

failure
• electrocardiography
 DIAGNOSIS cont..
• Blood test for ESR, ASO titre, WBC counts
 MANAGEMEN
T
Antibiotic therapy
• Pencillin is administered after skin test
• Initially procaine pencillin 4 lacks units deep
IM, twice a day is given for 10 to 14 days
 MANAGEMENT cont..

• Long acting benzanthine pencillin 1.2 megaunits

every 21 days or 0.6 mega unit every 15 days to be
given
• Oral pencillin 4 lacks units (250 mg) every 4 to 6
hours for 10 to 14 days can also be given.
• Erythromycin can be used in pencillin sensitive
patients.
 MANAGEMENT cont..
• Aspirin is administered as suppressive therapy to control pain
and inflammation of joints.
• The dose of aspirin is 90 to 120 mg/kg/day in 4 divided
doses.
• It may be needed for 12 weeks.

• Aspirin should not be given in empty stomach.

• Antacid to be given just prior to or with aspirin.

 MANAGEMENT cont..
• Steroid (prednisolone) therapy is given as suppressive
therapy along with aspirin.
• The initial dose is 40 to 60 mg/day or 2 mg/kg/day in 4
divided doses for 7 to 10 days.
• Then the dose is reduced to 1 mg/kg/day.

• It should be tapered off gradually over 12 weeks period and

used for patients having carditis with or without CCF.
 MANAGEMENT cont..

Mangement of chorea can be done with

diazepam or phenobarbitone
 MANAGEMENT cont..

• Bed rest is important in management of children

with rheumatic fever. It is needed for at least 6 to 8
weeks.
 MANAGEMENT cont..

• Nutritious diet to be provided with sufficient amount of

protein, vitamins and micro nutrients.
• Salt restriction is not necessary unless CCF is present

• Avoid rich spicy food.

 NURSING MANAGEMENT
• Providing rest as long as rheumatic activity and heart
failure persist.
• Maintaining normal body temperature by managing
fever.
• Providing bland diet with adequate nutrition and fluid
intake with salt restriction in case of CCF.
• Monitoring cardiac output

• Maintain intake-output chart

 NURSING MANAGEMENT

• Assist the child in feeding, ambulation and

other fine motor activities
• Administer drugs to control chorea.

• Remove hard and sharp objects from the child’s

reach.
 PREVENTION
• Primary prevention can be achieved by educating the people
to avoid streptococcal sore throat and elimination of
predisposing factors of the disease.

• Treatment of streptococcal pharyngitis with pencillin or other

medications to prevent primary attack of rheumatic fever.
 PREVENTION
• Secondary prevention of the disease can be done by early
detection, adequate treatment and prevention of
recurrences of rheumatic fever.
• Long acting pencillin therapy should be continued every 15
days or 21 days for at least 5 years from the last attack of
rheumatic fever or up to 18 th birthday.
• Parents should be made aware about the continuation of
treatment, medical help and follow up.
 NURSING DIAGNOSIS
• Decreased cardiac output related to carditis

• Pain related to polyarthritis

• Risk for injury related to involuntary movements in

chorea
• Anxiety related to disease process

• Knowledge deficit related to long term treatment and

prognosis of the acquired heart disease.
 SUMMARY

Rheumatic fever (RF) is an inflammatory disease

that can involve the heart, joints, skin, and brain. The
disease typically develops two to four weeks after a
streptococcal throat infection.
 REFERENCES

• Hockenberry- Wong's nursing care of infants and

children,2007,Elsevier.
• Marlow –Text book of pediatric nursing
1996,Elsevier.
• Potts- Pediatric nursing 2007,Thomas
learning.
• Nelson –Textbook of pediatrics
2007,Elsevier.
• Ghai- Essential pediatrics 2009,CBS.