Nursing Care Plan for Rheumatic Fever in Children


Nursing Care Assessment

Based on the information Nelson (2000), the data could focus on assessment of nursing care, among others:

1. Focus data :
  • Increased body temperature usually occur in the afternoon.
  • A history of respiratory tract infection.
  • Decreased blood pressure, increased pulse rate, respiration increases.
  • Non-productive cough.
  • Epistaxis.
  • Abdominal pain.
  • Arthralgia.
  • Loss of appetite.
  • Losing weight.

2. Specific manifestations:

Carditis:
  • tachycardia
  • cardiomegaly
  • voice murmurs
  • changes in heart sound
  • ECG changes (PR lengthwise)
  • precordial pain
  • pericardial friction rub
Polyarthritis
  • joint swelling, heat, redness, tenderness.
  • spread on the knee joint, elbow, shoulder, arm.

Subcutaneous nodules:
  • swelling of the skin, soft palpable.
  • coming shortly, in general readily absorbed.
  • found on the extensor surfaces of the joints

Chorea:
  • irregular movements of the extremities, involuntary.
  • involuntary facial expressions
  • speech disorders
  • emotional lability
  • muscle weakness
  • muscle tension when anxious, lost when the break.
Erythema marginatum:
  • reddish macular common on the torso and palms.
  • the macula can not be permanently relocates à
  • the macula is non pruritus

Nursing Diagnosis for Rheumatic Fever in Children

1. Knowledge Deficit : parents / child related to treatment, the activity restriction, the risk of cardiac complications.

Goal: complications did not occur and parents understand the child's disease.

Interventions:
  • Auscultation of heart sounds to detect changes in rhythm.
  • Give antibiotics according to the program.
  • Restriction of activity to the clinical manifestations of rheumatic fever does not exist, and provide rest periods.
  • Provide play therapy is appropriate and does not make patients tired.
  • Give knowledge on mother and child about the disease and treatment procedures.


2. Ineffective individual coping related to disease conditions.

Goal: child understands about treatment procedures and can be cooperative, individual kooping effective.

Interventions:
  • Assess the desire to play according to the age and condition.
  • Create a schedule of activity and rest.
  • Teach for participation in activities of daily necessities.
  • Teach children / parents do not realize that the movement is associated with chorea and temporary.

4. Pain related to polyartritis.

Goal: lost and diminished pain.

Expected outcomes: child can control pain and mild pain scale of 2-3.

Interventions:
  • Assess pain scale (1-10).
  • Giving analgeik, anti-inflammatory and antipyretic according to the program.
  • Repositioning to reduce joint stress.
  • Give warm and cold treatment on a sore joint.
  • Teach technique of distraction / relaxation for example; relaxation techniques and fantasy.

5. Risk for injury related to streptococcal infection.

Goal injury did not occur.

Interventions:
  • Monitor the temperature every 4 hours during treatment.
  • Give antibiotics according to the program.
  • See also in discharge planning.
  • Rest patients of activities that can make you tired.

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