Autoimmune Disorders

Streptococcus Infections/Sequelae

Introduction: Group A beta-hemolytic streptococcus is a common infectious organism that causes illness in children and is highly contagious. In themselves, the diseases caused by streptococcus do not seem very serious: strep throat, otitis media, impetigo, or scarlet fever. The most common treatment for strep is a full course of antibiotic therapy: 10 days of penicillin (or, if allergic, erythromycin). With adequate therapy, generally no sequelae are seen. If the strep is not treated, or is only partially treated, the sequelae include serious systemic diseases, with potentially long-term effects. If the effect is manifested primarily in the heart (carditis), it is acute rheumatic fever. If the effect is manifested primarily in the kidneys, it is acute glomerulonephritis

1. Rheumatic fever

1. Introduction:Introduction: Rheumatic fever is an acute, systemic, inflammatory disease affecting multiple organs and systems: heart, joints, CNS, collagenous tissue, etc. Thought to be autoimmune in nature, it most commonly follows a streptococcus infection and occurs primarily in school-age children. In addition, it tends to recur, and the risk of permanent heart damage increases with each subsequent attack of rheumatic fever.

2. Assessment:

   1. Major manifestations (modified Jones criteria)

   1. Carditis: tachycardia, cardiomegaly, murmur, congestive heart failure (CHF).
   2. Migratory polyarthritis: swollen, hot, red, and excruciatingly painful large joints; migratory and reversible.
   3. Sydenham chorea (St. Vitus Dance): sudden, aimless, irregular movements of the extremities; involuntary facial grimaces, speech disturbances, emotional lability, muscle weakness; completely reversible.
   4. Erythema marginatum: reddish pink rash most commonly found on the trunk; nonpruritic, macular, clear center, wavy but clearly marked border; transient.
   5. Subcutaneous nodules: small, round, freely movable, and painless swellings usually found over the extensor surfaces of the hands/feet or bony prominences; resolve without any permanent damage.
   2. Minor manifestations
      1. Clinical
         1. Previous history of rheumatic fever.
         2. Arthralgia.
         3. Fever-normal in morning, rises in mid-afternoon, normal at night.
      2. Laboratory
         1. Increased erythrocyte sedimentation rate (ESR).
         2. Positive C-reactive protein.
         3. Leukocytosis.
         4. Anemia.
         5. Prolonged P-R/Q-T intervals on ECG.
   3. Supportive evidence
      1. Recent history of streptococcus infection:
         1. Strep throat/tonsilitis.
         2. Otitis media.
         3. Impetigo.
         4. Scarlet fever.
      2. Positive throat culture for streptococcus.
      3. Increased ASO titer: indicates presence of streptococcus antibodies; begins to rise in 7 days, reaches maximum level in 4-6 weeks.
3. Analysis/nursing diagnosis:
   1. Decreased cardiac output related to carditis.
   2. Pain related to migratory polyarthritis.
   3. Risk for injury related to chorea.
   4. Diversional activity deficit related to lengthy hospitalization and recuperation.
   5. Knowledge deficit related to preventing cardiac damage, relieving discomfort, and preventing injury.
   6. Ineffective management of therapeutic regimen with long-term antibiotic therapy and follow-up care.
4. Nursing care plan/implementation:
   1. Goal: prevent cardiac damage.
      1. Hospitalization, with strict bed rest.
      2. Monitor apical pulse for changes in rate, rhythm, murmurs.
      3. Evaluate tolerance of increased activity by apical rate: if heart rate increases by more than 20 beats/min over resting rate, child should return to bed.
      4. Offer low-sodium diet to prevent fluid retention.
      5. Administer oxygen, digoxin/L«six as ordered (if CHF develops).
   2. Goal: relieve discomfort.
      1. Use bed cradle to keep linens from resting on painful joints.
      2. Administer aspirin as ordered to relieve pain.
      3. Move child carefully, minimally-support joints.
      4. Do not massage; do not perform ROM exercises; do not apply splints; do not apply heat/cold. All these treatments will cause increased pain and are not needed, because no permanent deformities will result from this type of arthritis.
   3. Goal: promote safety and prevent injury related to chorea.
      1. Use side rails: elevated, padded.
      2. Restrain in bed if necessary.
      3. No oral temperatures-child may bite thermometer.
      4. Spoon-feed-no forks or knives, to prevent injury to oral cavity.
      5. Assist with all aspects of ADL until child can care for own needs.
   4. Goal: provide diversion as tolerated.
      1. Encourage quiet diversional activities: hobbies, reading, puzzles.
      2. Get homework, books; provide tutor as condition permits.
      3. Encourage contact with peers: telephone calls, letters, cards.
   5. Goal: encourage child and family to comply with long-term antibiotic therapy.
      1. Begin antibiotics immediately, to eradicate any lingering streptococcus infection.
      2. Prepare child/family for minimum of 5 years of IM injections of penicillin.
      3. Stress need for exact schedule: every 4 weeks.
      4. Enlist child’s cooperation with therapy, “hero” badge.
   6. Goal: health teaching.
      1. To encourage compliance with prolonged bed rest-stress that ultimate prognosis depends on amount of cardiac damage.
      2. Teach necessity for long-term prophylactic therapy for 5 years initially (with lifelong follow-up), during dental work, childbirth, surgery (to prevent subacute bacterial endocarditis [SBE]). Instruct adolescents to avoid body piercing and tattooing for same rationale.
      3. Teach rationale: permanent cardiac damage is more likely to occur with subsequent attacks of rheumatic fever.
5. Evaluation/outcome criteria:
   1. No permanent cardiac damage occurs.
   2. Child is free from discomfort or is able to tolerate discomfort.
   3. Injuries are avoided.
   4. Child’s need for diversional activity is met.
   5. Child/family comply with long-term antibiotic therapy/prophylactic therapy.