WHICH NURSING DIAGNOSIS WOULD BEST APPLY TO A CHILD WITH RHEUMATIC FEVER?

Introduction

Rheumatic fever is a serious, immune-mediated disease that most commonly develops after an untreated or inadequately treated Group A streptococcal infection. In pediatrics, it can lead to painful arthritis, carditis, and even long-term valvular damage. As nurses, selecting the most appropriate nursing diagnosis guides our interventions, ensures patient safety, and supports optimal recovery. In this post, we’ll explore the pathophysiology of pediatric rheumatic fever, review common assessment findings, and identify the top nursing diagnoses, culminating in the one that best captures the child’s primary risk.

Understanding Pediatric Rheumatic Fever

Before we choose a nursing diagnosis, let’s quickly review key features of rheumatic fever in children:
• Onset follows 2–4 weeks after a strep throat.
• Major manifestations include migratory polyarthritis, carditis (murmurs, tachycardia, heart failure), Sydenham’s chorea, erythema marginatum, and subcutaneous nodules.
• Minor criteria: fever, arthralgia, elevated acute-phase reactants (ESR, CRP), prolonged PR interval.
• Complications: rheumatic heart disease, valve scarring, heart failure.

Assessment Cues and Clues

When admitting a child with suspected or confirmed rheumatic fever, you might observe or collect:
• Vital signs: fever, tachycardia, possible hypotension if carditis is severe.
• Activity level: reports of fatigue, shortness of breath on exertion.
• Pain complaints: joint pain (knees, ankles, wrists).
• Heart sounds: new murmur, gallop rhythm.
• Lab results: elevated ESR/CRP, positive ASO titer.
• Parent/patient knowledge: understanding of disease, medications, follow-up.

Top Nursing Diagnoses for Rheumatic Fever

1. Activity Intolerance
   Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities.
   Rationale: Myocardial inflammation compromises cardiac output, making even simple tasks exhausting.
2. Acute Pain
   Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage.
   Rationale: Migratory arthritis causes significant joint pain, limiting mobility and self-care.
3. Risk for Decreased Cardiac Output
   Definition: At risk for an inadequate volume of blood pumped by the heart to meet metabolic demands.
   Rationale: Carditis and valvular involvement can acutely impair contractility and circulatory efficiency.
4. Knowledge Deficit (Disease Process)
   Definition: Lack of cognitive information related to a specific topic.
   Rationale: Parents and children often need education on antibiotic compliance, activity restrictions, and long-term follow-up.
5. Risk for Infection
   Definition: At risk for being invaded by pathogenic organisms.
   Rationale: Frequent injections (e.g., penicillin prophylaxis), hospitalization, and joint aspirations may introduce infection risk.

Selecting the Best Nursing Diagnosis

While all of the above diagnoses are relevant, “Risk for Decreased Cardiac Output related to impaired myocardial function” often takes priority in a child with rheumatic fever, especially if carditis is present. Why?

• Cardiac involvement can be life-threatening.
• Early recognition and intervention prevent acute decompensation.
• Interventions directly influence hemodynamic stability.

Nursing Interventions for Risk for Decreased Cardiac Output

1. Monitor Cardiovascular Status
   – Check vital signs every 2–4 hours, including orthostatic blood pressures.
   – Auscultate heart sounds for new or changing murmurs, gallops.
2. Optimize Oxygenation
   – Administer supplemental oxygen per protocol if tachycardia or dyspnea occurs.
   – Elevate head of bed to reduce preload and ease breathing.
3. Balance Activity and Rest
   – Implement scheduled rest periods; cluster care activities to minimize exertion.
   – Encourage age-appropriate diversion (reading, storytelling) while on bed rest.
4. Administer Medications
   – Provide anti-inflammatories (aspirin or NSAIDs) to reduce myocardial inflammation.
   – Give cardiac support drugs (e.g., diuretics, ACE inhibitors) as ordered.
   – Ensure adherence to antibiotic prophylaxis to stave off recurrent strep infections.
5. Educate Family and Patient
   – Explain signs of worsening cardiac output (edema, fatigue, pallor).
   – Teach parents how to monitor daily weights and intake/output.
   – Stress the importance of follow-up echocardiograms and cardiology visits.

Additional Considerations

• Collaborate with physical therapy for gentle range-of-motion exercises once pain is controlled.
• Involve child life specialists to maintain normalcy and reduce anxiety.
• Coordinate a multidisciplinary care conference if severe carditis or recurrent episodes occur.

Conclusion

In pediatric rheumatic fever, prompt recognition of the child’s altered cardiac function is critical. Although pain management and patient education are essential, prioritizing “Risk for Decreased Cardiac Output” lays the foundation for safe, effective care. By closely monitoring cardiovascular status, optimizing oxygenation, tailoring activity, and ensuring medication adherence, nurses play a pivotal role in steering the child toward a full recovery and preventing long-term heart damage. Empowered with these insights and interventions, you’ll be well-equipped to support children and families through the challenges of rheumatic fever.