case study namen
DESCRIPTION
case studyTRANSCRIPT
RHEUMATIC FEVER
_________
A Case StudyPresented to
Tarlac State UniversityCollege of Nursing
___________
In Partial Fulfillmentof the Requirements for
NCM101
___________
By
BSN II-B4
Ryan Krisna Dela CruzJon Henry Ordoñez
Bridgitte OrtizMonica Pineda
Mark Alvin QuibuyenSarah Jane Quirante
Maryner RamosRon Mar RamosIsmael 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: None
Admitting Diagnosis: UTI suspect, Rheumatic Fever
Date admitted: 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
65
HC 59DHN
35 38 A&W A&W
12 2 Mos RF A&W
LEGEND
- Deceased male -Pertains to patient, living female child -Deceased female - living male child
-Living mother HC -Heart ComplicationDHN – Dehydration
RF – Rheumatic Fever -Living father A&W – Alive and Well
X X
X
X
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
Standard Findings Normal Findings Interpretation
09/10/09 Skin InspectionPalpation
Light to brown in colorTemperature is 36.5ºCWhen pinched, skin springs back to previous stateTexture not uniform, some areas are thick and some are roughNo unusual marksNo presence of lesions and rushesNo pressure sores foundNo edema
Color should be light to deep brownTemperature should be uniform and within normal rangeskin should spring back to place when pinchedtexture should not be uniform; some areas should be thick like the palms and soles.
Normal
09/10/09 Hair InspectionPalpation
Hair is thick and shinyHair is equally distributed and has no presence of alopecia.No foul odor
Should be silky,resilientShould be thick and hair should be evenly distributed
Normal
09/10/09 Nails InspectionPalpation
Angle between finger nail and base is about 160º Blanch test is normal.When palpated base is
Should be pinkish in color.Convex curvature: angle between nail and nail bed should
Normal
firm.Dirty nails
be at about 160ºAfter pinching, pink color in the nail bed should return within 3sec.
09/10/09 Head InspectionPalpation
Rounded and symmetrical.No unusual swelling
Should be rounded and symmetrical, Normocephalic Should have smooth skull contour
Normal
09/10/09 Eyes Inspection Eyes are symmetricalTransparent, 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
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.
Normal
09/10/09 Ear Inspection The location and alignment is normal, symmetrical with upper attachment at eye corner level (lateral cantus)
Pinna should be aligned with the eyes.The color of the pinna should be the
Normal
Pinna is brown in color; canal has presence of ear wax.No presence of discharge and odor.Able to hear instructions and responds quickly
same with the color of the face.Should have no presence of discharge and odor.Sounds should be heard in both ears or is localized with the center of the head.
09/10/09 Nose InspectionPalpation
Normal in shape.Located symmetrically.Each nostril is patent.Sinuses are not tender, air-filled cavities and resonant to percussion.
Should be symmetric and straight.Should have no discharge or flaring.Should not be tender
Normal
09/10/09 Lips Inspection Normal integrity.Normal symmetry.Light pink in color.
Should be uniform, and pink in color
Normal
09/10/09 Mouth Inspection Number and condition of the teeth is normal, properly alignedGums 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.
Should have 32 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
Normal
Parotid gland is smooth, moist and has no swelling and reddening.
rough, thin whitish coating.Soft palate should be light pink and smooth.Uvula should be position in the midline of soft palate.
09/10/09 Neck InspectionPalpation
Muscles are symmetrical with the head and able to move without discomfort.Trachea is in the midline position.Thyroid is smooth, soft, not enlarges and has no presence of mass and bruises.
Muscles should be equal in size and head centered.Trachea should be at the center of the neck, spaces are equal on both sides.Thyroid should not be visible on inspection
Normal
09/10/09 Extremities InspectionPalpation
No discolorationsNo lesions, massesNo TendernessNo presence of edemaUniform in temperature and within normal rangeJoints are swollenClient complains of pain when joints are touched
Should have no discolorationsShould have no masses, lesionsShould have no tendernessShould be uniform in temperature
Abnormal, Joints are swollen, client complains of pain when joints are touched
VI. Nursing Care Plan
Assessment Diagnosis Planning Intervention Rationale Expected Outcome
Subjective>“Nahihirapan
siya gumalaw..”, as
stated by mother.
Objective>Discomfort>Immobility
>Palor>Body
>WeaknessV/S:
BP: 110/70RR:19CR:102
Temp:37.3C
Analysis:
Activity intolerance r/t
imbalance between
oxygen supply and demand
Insufficient physiological or psychological
energy to endure or complete
required or desired daily
activities
After 2 hours of proper nursing intervention,
the patient will be able to *maintain
normal skin color and skin
would be warm to dry
*Able to perform activity
without discomfort
*Understand need for
balanced rest and activity
>Monitor Vital signs
>Observe and document skin
integrity.>Assist in
proper position>Assist in performing
ROM exercises >Demonstrate
proper breathing pattern
>Determine cause of activity
intolerance and determine
whether cause is physical,
psychological or motivational.
>Assess the client daily for
>To be of help for direct
appropriate intervention>Activity
intolerance may lead to pressure
ulcers>Inactivity
rapidly contributes t
muscle shortening and
changes in periarticular
and cartilaginous joint structure>Inappropriate prolonged bed rest orders may
t contribute activity
intolerance
After 2 hours of proper nursing
intervention, the patient should be able to:
*maintain normal skin color and
skin would be warm to
dry*Able to perform activity without
discomfort*Understand
need for balanced rest and activity
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 Intervention Rationale Expected Outcome
Subjective>”Nilalagnat
siya”, as verbalized by
client’s mother
Objective:>Febrile
>Pale>Skin warm to
touch>Inflammed
joints>Incoherent>Weakness
V/S>BP:100/60>RR:18 cpm
>CR:106 bpmTemp:38.7 °C
Hyperthermia r/t infection
Increased of temperature is a
chemical response of the
body to infections that
causes inflamed joints of the
patient
Short term: After 1 hour of proper nursing intervention, the patient’s temperature will decrease
from 38.7°C to 37C
Long term: After proper
nursing intervention, the patient’s
condition will improve and
there would be no more
swelling of joints.
>Monitor Vital signs
>Performed continuous TSB
> Checked temperature
every 15 minutes
>Encouraged Patient to rest>Provide dry clothing and bed linens
>Encouraged adequate intake
of fluids and nutritious foods
>Encourage participation in
self care>Note
emotional or behavioral response to problems of
fever
>To limit fatigue
>To promote well-being and
energy production
>>To promote optimal level of
function and prevent
complications.
>To determine progress of
interventions
>To reduce temperature in
the body>To relax
patient’s body
Short term: After 1 hour of proper
nursing intervention, the
patient’s temperature
should decreased from 38.7°C to
37°C
Long term: Patient’s joints
should continue to swell but should now state that
pain is reduced.
Assessment Diagnosis Planning 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 10/10V/S:
PR: 106 bpmTemp: 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