Acute Rheumatic Fever: Pathophysiology And Nurses’ Role In Delivering Developmentally Appropriate Care

Pathophysiology of Acute Rheumatic Fever

The paper intends to analyse Sue case. She is suspected to be suffering from acute rheumatic fever. The purpose of the paper is to focus on how nurses should intervene. The paper is divided into two sections. The first section will focus on the pathophysiology of acute rheumatic fever and the second section will focus on the elements to consider during the management of the acute rheumatic fever.

Acute rheumatic fever (ARF) is the consequence of an autoimmune reaction that occurs after pharyngeal Streptococcus pyogenes infection. The antigenic mimicry between certain bacterial surface proteins – specific epitopes – and the cells of the host is at the origin of a cross-immunological reaction occurring on a genetically predisposed terrain. In other words, Streptococcus M proteins share epitopes (antigenic determinants recognized by Ac) with synovial proteins, cardiac muscle, heart valves, indicating that molecular mimicry contributes to the occurrence of arthritis, carditis, lesions valvular (Lennon, 2018). The role of genetic factors is evidenced by the higher prevalence of acute rheumatic fever and chronic rheumatic heart diseases (including rheumatic heart diseases) in individual families. In 75-100% of patients and only 15% of healthy people on B-lymphocytes, there is a specific alloantigen 883 (D8 / 17), detected with the help of special monoclonal antibodies (Zühlke, et al 2017). The joints, the heart, the skin and the central nervous system are most often involved. The pathology varies according to the site.

Concerning the joint, it is important to note that joint involvement resembles nonspecific inflammation on a synovial biopsy specimen, sometimes with small foci suggestive of Aschoff bodies (nodules found in the hearts of individuals with rheumatic fever) (Lennon et al 2017).

Concerning the heart, cardiac involvement is manifested as carditis, which usually affects the heart from the inside to the outside, i.e. valves and endocardium, then the myocardium and finally the pericardium. Characteristic and potentially dangerous valvular abnormalities may occur. Acute interstitial valvulitis can cause valve edema. If left untreated, it can lead to edema, thickening, retraction or other destruction of valves and cusps causing stenosis or valve insufficiency (Kostopoulou, Gkentzi, Karatza & Dimitriou, 2018). Similarly, tendinous cordage may shorten, thicken or weld, which may increase the insufficiency of damaged valves or cause valve failure even in the absence of injury (Hanson-Manful, et al 2018). The dilatation of the valvular rings may also cause regurgitant insufficiency. The mitral valves are most often affected then the aortic, tricuspid and pulmonary valves in order of decreasing frequency. Valvar insufficiency and narrowing usually result from mitral and tricuspid valve lesions (Umapathy & Saxena, 2018).

Nurse’s Role in Delivering Developmentally Appropriate Care

Concerning the skin, the subcutaneous nodules are indistinguishable from those of rheumatoid arthritis, but on the biopsy they look like Aschoff nodules (Bozabali, Bayraktar & Kocaba?, 2017). The erythema marginé differs histologically from other skin lesions of similar macroscopic appearance e. g, juvenile idiopathic arthritis rash, Henoch-Schönlein purpura, chronic erythema migrans (manifestation of the onset of Lyme disease), and erythema multiforme (Sato, Uejima, Suganuma, Takano & Kawano, 2017). At the level of the dermis, perivascular infiltrates of neutrophils and mononuclear are found.

Initial symptoms usually occur nearly 2 to 4 weeks after streptococcal infection. The manifestations typically involve an association of the joints, the heart, the skin and the central nervous system. The migratory arthritis is the most common symptom, seen in about 70% of children; it is often accompanied by fever. Sometimes, a monoarthritis is observed. The joints are painful, sensitive, red, hot and accompanied by edema (Khanna & Liu, 2016). The ankles, knees, elbows and wrists are the joints most frequently affected. The shoulders, hips and small joints of the hands and feet can also be reached, but almost never in isolation. In case of spine injury, another condition should be suspected.

The ultimate role of nurses would be to treat the disease and prevent recurrence. The main objectives are the suppression of inflammation and the control of acute symptoms, the eradication of group A streptococcal infections and the prophylaxis of a future infection, in order to avoid recurrent cardiopathy.

Firstly, nurses would be expected to treat streptococcal pharyngitis. Treatment of streptococcal pharyngitis would decrease the incidence of ARF. The treatment recommended by WHO (World Health Organization) is based on oral or intramuscular penicillin. Nurses also have the role to put in place preventing measures. Some teams assign a major role to primary prophylaxis to control rheumatic heart disease. Evidence of the effectiveness and value of the cost / benefit of such a strategy remains controversial (Oliver, Foster, Williamson, Pierse & Baker, 2018). Indeed, streptococcal carriage is frequently asymptomatic and the existence of potential non-pharyngeal portal of entry, such as the skin, limits the effectiveness of primary prevention. Nurses should also administer secondary prophylaxis. Secondary prophylaxis is based on the prevention of ARF relapses (Kevat, Reeves, Ruben & Gunnarsson, 2017). Regular long-term antibiotic therapy aims to limit the carriage of the pathogen. It is recommended to administer penicillin intramuscularly (and not orally) every 3 to 4 weeks by adjusting the dosages to the patient’s weight. Duration of treatment depends on the date of the most recent ARF attack, the age of the patient and the severity of the valvular lesions (Ralph, et al 2017). Secondary prophylaxis has been shown to be particularly effective when monitored with specific registers. These regional or national registers have made it possible to improve treatment compliance and to deal with severe cases early. Nurses should also offer education. Education of health and population actors, combined with primary and secondary prophylaxis, is an effective strategy for controlling the disease and significantly reducing the economic costs of advanced forms of ARF. Unlike primary prevention, secondary prevention has proved its effectiveness with an interesting cost / benefit ratio

Growth and Developmental Theories

Nurses also has the role of monitoring the dosage and ensuring that the dosage is adhered to. For example, aspirin is used for controls the fever and pain of arthritis and carditis. The dose is administered with increasing dosage until clinical efficacy or signs of toxicity are observed. The initial dosage in children and adolescents is 15 mg / kg 4 times a day. If the effect of this dose is not maintained the next day, it will be increased to 22.5 mg / kg 4 times a day the following day and to 30 mg / kg 4 times a day. The systemic toxicity of salicylates is manifested by tinnitus, headache, or hyperpnea, and may not appear until after 1 week. Salicylate levels are only measured to manage toxicity and should not be measured until the patient has received aspirin for 5 days. If no therapeutic effect occurs after the 4th day, which sometimes occurs when carditis or arthritis are severe, nonsteroidal anti-inflammatory drugs (NSAIDs) should be replaced by a corticosteroid. This clearly shows that nurses should be always there to monitor dosage and compliance.

It is important to note that the prevalence of rheumatic heart disease increases with age due to cumulative exposures to infection during childhood and adolescence, with a female predominance whose reasons are still unknown. The highest figures are for sub-Saharan Africa and the indigenous populations of Australia (prevalence reaches 50 per 1,000).

Family care is very important as far as acute rheumatic fever is concerned. The acute rheumatic fever is primarily related to living conditions: while it has been practically eradicated from industrialized countries for more than thirty years, its incidence reaches up to 250 per 100,000 inhabitants in Australia’s aboriginal populations. Rheumatic heart disease still affects between 15 and 20 million people worldwide, mostly children and young adults living in developing countries. Undernutrition, overcrowding and a low socio-economic level predispose to streptococcal infections and the resulting episodes of rheumatic fever.  Family-centred care should focus on providing ideal environment to Sue. The family-centred care should focus on dietary practices and physical activity. It should be noted that the acute patient with arthritis, chorea or symptomatic heart failure usually has to reduce his activity. In the absence of carditis, no limitation of the physical activities is necessary after the disappearance of the initial thrust. In the asymptomatic patient, strict bed rest has no proven benefit in case of carditis

Family-Centered Care

Hospitalization will have positive effects on child because it will enable nurses monitor the condition and intervene on the right time. It should be noted that acute rheumatic fever. Considering the treatment plan, it would be better to hospitalize sue. The antibiotic treatment, lasting 10 days, is based on penicillin G (Benzylpenicillin) at the dose of 2 million units divided into 2 intramuscular injections per day, or penicillin V (Phenoxymethylpenicillin) at a dose of 2 million units divided into 3 doses oral. Intramuscular injections are contraindicated in patients taking anticoagulants.  In case of allergy to penicillin, erythromycin is used at the dose of 50 mg / kg / day in 3 taken orally for 10 days.  Anti-inflammatory treatment It is based on corticosteroids or aspirin. Prednisone is administered at the dose of 2 mg / kg / day without exceeding 80 mg / day. This attack dose is maintained until the normalization of the SV, which usually occurs on the 10th day, then gradually decreases the dosage of corticosteroids in steps every 5 days to have a total duration of treatment of 6 weeks in the absence of heart disease and 3-4 months in case of carditis. SV is performed weekly and must remain normal. If it increases, we must mention a resumption of the inflammatory process. For aspirin, the initial dose is 100 mg / kg / day without exceeding 6g / day in 4 oral doses. This dose is maintained until the normalization of SV. The maintenance dose is 60 mg / kg / day maintained for 6 weeks in the absence of carditis and for 3 months in case of cardiac involvement. Bed rest is part of the treatment of ARF crisis as well as measures related to corticosteroids (deodized diet, potassium supplementation, calcium and gastric bandages). Consequently, the treatment plan will expect Sue to be admitted so that she can get adequate medical attention.

ARF poses a major disease burden among disadvantaged populations globally (Coffey, Ralph & Krause, 2018). Hospitalization will have negative effects on the family because the case shows that the hospital offering the services is located 800km away. This means that it will cost the family a lot of money to meet the transport and hospitalization fee.

Conclusion

Acute rheumatic fever remains a major public health problem in developing countries, even though effective prevention strategies exist. Ultrasound is able to identify early rheumatic heart valve lesions and could play a key role in screening for and expanding secondary ARF prevention measures in areas where the disease is still endemic.

Effects of Hospitalization on the Child and Family

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