College of Nursing

Silliman University
Dumaguete City
NCM 103

CASE ANALYSIS
A case study on a 12 year old pediatric patient who was diagnosed with Acute Rheumatic Fever

SUBMITTED BY:
Erica Rose Paalisbo
Ysabel Lianne Delloso

SUBMITTED TO:
Asst. Prof. Kathleah S. Caluscusans

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August 1, 2017

Asst. Prof. Kathleah S. Caluscusan, Clinical Instructor, Pediatric Rotation College of Nursing Silliman University Dumaguete City

Dear Maam:

Greetings!

We, Erica Rose Paalisbo and Ysabel Lianne Delloso level III students of Silliman University College of Nursing participating in the Pediatric rotation, would like to present our case study of our
patient, J.F 12 years old who was having Acute Rheumatic Fever and was admitted at Silliman University Medical Center Foundation Incorporated last 7 th day of July. In order for us to enhance
our skills and knowledge as student nurses of this university, we would like to ask for your authorization to present our case study. We promise to make sure to keep the patient’s data confidential
and shall only be used for educational purposes only. We would like to share our knowledge about the topic to our classmates in order to help them in understanding the said complication and in
order for us to develop our beginning skills while developing the desirable attitudes in providing care of clients with the same disease condition.

We are Thankful for your time and kind consideration.

Respectfully Yours,

__________________ __________________
Erica Rose S. Paalisbo Ysabel Lianne Delloso

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Vision
A leading Christian institution committed to total human development for the well-being of
society and environment.

Mission
 Infuse into the academic learning the Christian faith anchored on the gospel of Jesus Christ.
 Provide an environment where Christian fellowship and relationship can be nurtured and
promoted.
 Provide opportunities for growth and excellence in every dimension of the University life in
order to strengthen character, competence and faith.
 Instill in all members of the University community an enlightened social consciousness and a
deep sense of justice and compassion.
 Promote unity among peoples and contribute to national development

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PLACEMENT: 1st Semester Sy. 2017-2018 Level 3 NCM103
TIME ALLOTMENT: 1 hour
TOPIC DESCRIPTION: This is to present the case of JF, who was admitted Silliman
University Medical Center Foundation Incorporated last 7 th day of July who was diagnosed with
Acute Rheumatic Fever. This study will talk about the different aspects of Acute Rheumatic
Fever including the growth and development of the patient, the anatomy and physiology of the
related organs, pathophysiology, physical assessment, laboratory results, doctor’s and medication
orders, appropriate nursing interventions and nursing diagnosis, medical and family history of
the patient and more.

Specific Objectives:
Within 1 hour of our case presentation, the learners will:

1. Gain new information about the disease that is related to Nursing Care Management
103A- Medical Surgical Nursing.
2. Be familiar with all the medications given to the patient including their indications, side
effects and the nursing management needed.
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 3. Analyze critically the nursing care plans.
4. Participate in the open forum.

CASE PRESENTATION OBJECTIVES:

Our objectives of our case study are the following:
1. Expand our knowledge and skills on pediatric rotation.
2. Explain how the child acquired acute rheumatic fever.
3. Research more on the disease to supplement the knowledge we gained from our duty.
4. Discuss the anatomy and physiology of the systems organs involve.
5. Explain thoroughly the pathophysiology of the disease.
6. Analyze possible and actual problems and come up with relevant nursing interventions
and incorporate these into nursing care plans.

CENTRAL OBJECTIVES:
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 At the end of our case presentation the learners will acquire knowledge and skills by knowing
the concepts and how to manage a patient with acute rheumatic fever.

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 ACKNOWLEDGEMENT
First of all, we would like to thank God for making this case presentation possible and for guiding us in every
way. Second, to our beloved families, for the financial and moral support. For being our companion since the
beginning of our Silliman University College of Nursing journey. Third, to our friends for inspiring us to do our
best we could in making this case book done. Fourth, to our classmates who helped us understand few things.
Fifth, to our patient and his family for patiently answering our questions and cooperating with us. Sixth, to the
Medical Center Pediatric ward health care team who helped us to learn new things and make our job easier and
convenient. And last but never the least, to our ever loving and approachable clinical instructor, Asst. Prof.
Kathleah S. Caluscusan and the teachers of College of Nursing for molding us to be a better individuals and
nurses in the future. For simplifying what used to be incomprehensible, tricky and complicated concepts and for
assisting us in the various procedures we have performed, and for being kind to us despite of our immaturity

Thank you and May God bless us always!

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 Introduction
Acute rheumatic fever is an inflammatory disease caused by group A streptococcus. The
causative agent is spread by direct contact with oral or respiratory secretions. It can be developed
into further complication such as rheumatic heart disease if left untreated. It occurs mostly in
school-age children. Early treatment of “strep” throat with antibiotics can prevent the
development of rheumatic fever.
In the United States, the incidence of rheumatic fever is believed to have steadily decrease,
but the exact incidence is unknown due to difficulty in recognizing the infection, and people may
not seek for treatment. It is crucial for clinicians to keep a broad differential when presented
with clinical presentations suspicious for acute rheumatic fever.
This case study was done in order for us student nurses to have a better idea regarding this
rare condition. It will focus on establishing the diagnosis of Acute Rheumatic Fever. This study
also focuses on the clinical evaluation and treatment of patients with acute rheumatic fever by
offering a thorough review of the literature on diagnosis and recommendations on appropriate
treatment.
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 DEMOGRAPHIC
DATA

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Name: FJT
Age: 12 YEARS OLD
Address: STA. CATALINA NEGROS ORIENTAL
Religion: PENTICOSTAL
Educational attainment: HIGH SCHOOL STUDENT
Civil Status: SINGLE
Nationality: FILIPINO
Occupation: NA
Room & Bed No.: MPH R
Doctor in-charge: DR. MARY ANN CLAIRE A. MANN, MD
Date & time of admission: JULY 7, 2017 – 11:20 am
Chief complaints: HIGH FEVER, SKIN RASHES AND SWOLLEN RED TONGUE
Diagnosis: ACUTE RHEUMATIC FEVER
General Impression of client (appearance upon first contact): Received lying on bed, weak and
conscious. Oriented to time, place and person. Skin was pallor, nails well-groomed, hair was unkept.
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Hooked with IVF D5NM 1L running @ 32 gtts/min on right metacarpal vein, flowing well. IV site had no
signs of infiltration. Established good eye contact and responds properly during interview.

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 GENOGRAM

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 MN RN
RF 75
GF 63 73 Healthy
67 Healthy DM Technician
Hypertensive Housewife Midwife
Cashier

JF
RF RF 40 MN
32 41 Healthy 45
Healthy Healthy OFW Healthy
Teacher Family Driver Farmer
HNL
36
Healthy
Farmer
GFS
BF 37
26 Healthy
Healthy Farmer
Barista Healthy
JF
12 MSF
Diagnosed with Acute 17 LEGEND:
Rheumatic fever Healthy Female =
Student Student Male =

Patient=
deceased= X

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 Growth
and
Development

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Psychosocial Development
*industry vs. inferiority

If children are prevented from

achieving a sense of industry or do
not receive rewards for
accomplishment, they can develop a
feeling of inferiority or become
Our client is a 12 years old boy who enjoyed playing video games
convinced that they cannot do things
with his friends after school or during break time. He is living with
that
his 15 they
years old “bantay”actually can
and his older sister. Hisdo.
mother was an
OFW and his father was working in Manila as a family driver.
Adjusting
Parents communicate to and
them through achieving
phone call or video call. He in
asksschool
opinion/advice
arefrom two
her uncleof
whenever
theproblems
for major arose. Child
tasks
was able to answer our questions during interview.
the age group. An important part of
developing a sense of industry is
learning ow to solve problems.
Parents and teachers can help
children develop this skill by
encouraging practice.
Parents of a school-age child
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Cognitive development

*concrete operational
 This stage enables school-age children to
consider alternative solutions and solve Our patients was a Grade 7
problems student. He joined MTAP on
 however, school-age continue to rely on the previous years.
concrete experiences and materials to form
their thought content.
During the school-age years, the child learns the
concept of: he is slightly concerned with
1. CONSERVATION- no matter is not changed being absent from class. He
when its form is altered. his voice is
is also an Honor student.
2. DECENTERING- The ability to project the he does not slightly
our client's
self into other people’s situation and see the
question
world from their viewpoint rather than focusing height is he learned to playdeep.
guitar he is
on their own view. his
3. ACCOMMODATION- the ability to adapt 141 cm pastor. hewas
when he
sexuality tall
watching and
their
is also good with
thought process to fit what is perceived. other instruments suchthin.
as
4. CLASS INCLUSION- Necessary for learning
drums and organ.
mathematics and reading, systems that Psychosexual Development
categorize numbers and words
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  Preadolescence begins near the end of the
school age at which discrepancies in
growth and maturation between the
genders become appropriate
 A school-age child has acquired much her
knowledge of and many of his/her
attitudes towards sex at a very early age
 Puberty occurs during preadolescence
 Preadolescence is a period of rapid
growth for girls and boys
 The earliest age at which puberty begins
10 years in girls and 12 in boys.
 They evaluate themselves to determine
how their physical appearance, body
configuration and coordination compare
those of their peer.

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Moral Development
*conventional
Throughout the conventional level, a
child's sense of morality is tied to Patient was the chid was
personal and societal relationships.
respectful able to follow
Children continue to accept the rules of the rules and
authority figures, but this is now due to
and was regulations and
their belief that this is necessary to ensure stubborn do some
positive relationships and societal order. sometimes househld
chores in their
Adherence to rules and conventions is
house. The
somewhat rigid during these stages, and a child is
rule's appropriateness or fairness is friendly.
seldom questioned.

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Spiritual Development:
*Synthetic-Conventional Faith
Spiritual development invites reflections on the transcendental and the metaphysical, on
values that arise from fundamental propositions concerning human character and
existence, as well as on specific religious practices and symbols.
Faith is encompassed in a fairly uncritical, tacit acceptance of the conventional religious
values taught by others, centered on feelings of what is right and wrong, especially in
interpersonal relationships.
Religion of our patients is Pentecostal
- He goes to church every Wednesday, Friday and Sunday
- He serves in the church
- He joins youth service every Saturday
- He always prays to God before he went to sleep
- Believed that he will be discharged sooner since God is always guiding and watching
him
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 PATHOPHYSIOLOGY

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 .

Anatomy and physiology

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 The Cardiovascular System
The heart and circulatory system make up your cardiovascular system. Your heart works
as a pump that pushes blood to the organs, tissues, and cells of your body. Blood delivers
oxygen and nutrients to every cell and removes the carbon dioxide and waste products
made by those cells. Blood is carried from your heart to the rest of your body through a
complex network of arteries, arterioles, and capillaries. Blood is returned to your heart
through venules and veins.
The one-way system carries blood to all parts of your body. This process of blood flow
within your body is called circulation. Arteries carry oxygen-rich blood away from your
heart, and veins carry oxygen-poor blood back to your heart.
In pulmonary circulation, though, the roles are switched. It is the pulmonary artery that
brings oxygen-poor blood into your lungs and the pulmonary vein that brings oxygen-rich
blood back to your heart.
Twenty major arteries make a path through your tissues, where they branch into smaller
vessels called arterioles. Arterioles further branch into capillaries, the true deliverers of
oxygen and nutrients to your cells. Once the capillaries deliver oxygen and nutrients and
pick up carbon dioxide and other waste, they move the blood back through wider vessels
called venules. Venules eventually join to form veins, which deliver the blood back to
your heart to pick up oxygen.

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Heart
The heart is a muscular pumping organ located medial to the lungs along the
body’s midline in the thoracic region. The bottom tip of the heart, known as its
apex, is turned to the left, so that about 2/3 of the heart is located on the body’s
left side with the other 1/3 on right. The top of the heart, known as the heart’s
base, connects to the great blood vessels of the body: the aorta, vena cava,
pulmonary trunk, and pulmonary veins.
Circulatory Loops
There are 2 primary circulatory loops in the human body: the pulmonary
circulation loopand the systemic circulation loop.
Pulmonary circulation transports deoxygenated blood from the right side of the
heart to the lungs, where the blood picks up oxygen and returns to the left side
of the heart. The pumping chambers of the heart that support the pulmonary
circulation loop are the right atrium and right ventricle.
Systemic circulation carries highly oxygenated blood from the left side of the heart to all of the tissues of the body (with the
exception of the heart and lungs). Systemic circulation removes wastes from body tissues and returns deoxygenated blood to the
right side of the heart. The left atrium and left ventricle of the heart are the pumping chambers for the systemic circulation loop.

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Blood vessels Blood Vessels
Blood vessels are the body’s highways
that allow blood to flow quickly and
efficiently from the heart to every
region of the body and back again. The
size of blood vessels corresponds with
the amount of blood that passes
through the vessel. All blood vessels
contain a hollow area called the lumen
through which blood is able to flow.
Around the lumen is the wall of the
vessel, which may be thin in the case of
capillaries or very thick in the case of
arteries.
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Arteries and Arterioles:
Arteries are blood vessels that carry blood away from the heart. Blood carried by arteries is usually highly
oxygenated, having just left the lungs on its way to the body’s tissues. The pulmonary trunk and arteries
of the pulmonary circulation loop provide an exception to this rule – these arteries carry deoxygenated
blood from the heart to the lungs to be oxygenated.

Arteries face high levels of blood pressure as they carry blood being pushed from the heart under great
force. To withstand this pressure, the walls of the arteries are thicker, more elastic, and more muscular
than those of other vessels.

Smaller arteries are more muscular in the structure of their walls. The smooth muscles of the arterial walls
of these smaller arteries contract or expand to regulate the flow of blood through their lumen. In this way,
the body controls how much blood flows to different parts of the body under varying circumstances. The
regulation of blood flow also affects blood pressure, as smaller arteries give blood less area to flow
through and therefore increases the pressure of the blood on arterial walls.

Arterioles are narrower arteries that branch off from the ends of arteries and carry blood to capillaries.
They face much lower blood pressures than arteries due to their greater number, decreased blood volume,
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and distance from the direct pressure of the heart. Thus arteriole walls are much thinner than those of
arteries. Arterioles, like arteries, are able to use smooth muscle to control their aperture and regulate blood
flow and blood pressure.

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Capillaries:
Capillaries are the smallest and thinnest of the blood vessels in the body and also the most common. They can be found running
throughout almost every tissue of the body and border the edges of the body’s avascular tissues. Capillaries connect to arterioles
on one end and venules on the other.

Veins and Venules:

Veins are the large return vessels of the body and act as the blood return counterparts of arteries. Because the arteries, arterioles,
and capillaries absorb most of the force of the heart’s contractions, veins and venules are subjected to very low blood pressures.
This lack of pressure allows the walls of veins to be much thinner, less elastic, and less muscular than the walls of arteries.

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Integumentary system
SKIN
 EPIDERMIS- The epidermis is the most superficial
layer of the skin that covers almost the entire body
surface.
 DERMIS- the dermis is the deep layer of the skin
found under the epidermis. The dermis is mostly made
of dense irregular connective tissue along with
nervous tissue, blood, and blood vessels. The dermis
is much thicker than the epidermis and gives the skin
its strength and elasticity.
 HYPODERMIS- Deep to the dermis is a layer of

loose connective tissues known as the hypodermis,

subcutis, or subcutaneous tissue. The hypodermis
serves as the flexible connection between the skin and
the underlying muscles and bones as well as a fat
HAIR storage area.
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  Hair is an accessory organ of the skin made of columns of tightly packed dead
keratinocytes found in most regions of the body.
 Hair helps to protect the body from UV radiation by preventing sunlight from

striking the skin. Hair also insulates the body by trapping warm air around the
skin.

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NAILS
Nails are accessory organs of the skin made of sheets of hardened keratinocytes and
found on the distal ends of the fingers and toes. Fingernails and toenails reinforce and
protect the end of the digits and are used for scraping and manipulating small objects.
There are 3 main parts of a nail: the root, body, and free edge. The nail root is the portion
of the nail found under the surface of the skin. The nail body is the visible external
portion of the nail. The free edge is the distal end portion of the nail that has grown
beyond the end of the finger or toe.

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Digestive System
*Mouth
The mouth is a cavity formed
between the tongue at its base,
cheeks at the side, hard and soft
palate in its roof, and teeth at the
front. The teeth tear and grind food,
which is then churned through
movements of the jaws and tongue.
Breaking the food into smaller
pieces creates a larger surface area
for the action of enzymes in saliva;
these begin to digest the food

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 The pharynx, or throat, is the
passageway leading from the
mouth and nose to the
esophagus and larynx. The
pharynx permits the passage
of swallowed solids and
liquids into the esophagus, or
gullet, and conducts air to and
from the trachea, or windpipe,
during respiration.

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Central nervous system
SPINAL CORD Brain
A column of nerve tissue that runs from the base of
It skull
the processes
down theinformation that itbyreceives
back. It is surrounded three from
the senses
protective and body,
membranes, and isand sends
enclosed messages
within
the vertebrae
back to the(back bones). The spinal cord and
body.
the brain make up the central nervous system, and
spinal cord nerves carry most messages between the
brain and the rest of the body.

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 The skeletal system includes all of the
bones and joints in the body. Each bone is a
complex living organ that is made up of
many cells, protein fibers, and minerals. The
skeleton acts as a scaffold by providing
support and protection for the soft tissues
that make up the rest of the body. The
skeletal system also provides attachment
points for muscles to allow movements at
the joints. New blood cells are produced by
the red bone marrow inside of our bones.
Bones act as the body’s warehouse for
calcium, iron, and energy in the form of fat.
Finally, the skeleton grows throughout
childhood and provides a framework for the
rest of the body to grow along with it.

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 Laboratory examination

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 LABORATORY EXAMS RESULTS NORMAL VALUES SIGNIFICANCE

Iron-containing protein in the red blood

Hemoglobin 12.60 gm% 13-16 cells that transports oxygen through the
body. Decrease counts may cause
leukemia.
Fast way to determine the percentage of
Hematocrit 35.90 % 42-50 RBCs in the plasma. HCT is reported as a
percentage because it is the concentration
of RBCs in the blood.
Low RBC counts are indicative of anemia.
RBC 4.1 m/cumm 4.6-6.2 Higher than normal counts are indicative
of polycythemia.
Determines the number of circulating
WBC 7 900/cumm 4500-11000 WBCs per cubic mm of whole blood.
High WBC counts are often seen in the
presence of a bacterial infection. Low
counts indicate viral infection.
DIFFERENTIAL COUNT

Increased in acute suppurative infection,

Neutrophils decreased in overwhelming bacterial
infection.
Increased in chronic bacterial and viral
lymphocytes 32 % 20-35 infection, decreased in sepsis.

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 Increased in protozoal, ricketsial and
monocytes 13% 1-6 tuberculosis infection.

Eosinophils 2% 1-4 Increased parasitic infection

Decrease level in the blood may cause
Basophils 0% 0.00-1.00 acute infection
Platelets are basic elements in the blood
Platelet 332 T/cumm 150-400 that promote coagulation

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 MCV is elevated or
decreased in accordance
MCV 87 fl 80-96 with average red cell size; ie,
low MCV indicates
microcytic (small average
RBC size),normal MCV
indicates normocytic(normal
average RBC size), and high
MCV indicates
macrocytic(large average
RBC size).
This test is therefore is used to
MCHgb 30.8 pq 27-31 determine the average amount
of hemoglobin per red blood
cell in the body
tests the level of hemoglobin
MCHC 35.2 % 33-36 in the blood

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IMMUNOLOGY

TEST RESULT UNITS RANGE

C-Reactive Protein 48 mg/dL <6.0

Anti-streptolysin 400 IU/mL <200

Hematology
ESR 31 Mm/Hr 0-15

Immunology
Salmonella typhi Antibody test
IgG NEGATIVE
IgM NEGATIVE

Urinalysis
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*Physical and Chemical Examnination

COLOR LIGHT YELLOW

Transparency CLEAR
Specific Gravity 1.015
Glucose NEGATIVE
Blood NEGATIVE
Urobilinogen NORMAL
Bilirubin NEGATIVE
pH 7.0
Nitrite NEGATIVE
Ketone NEGATIVE

Protein NEGATIVE
Leukocyte NEGATIVE

Urine Cytometry
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 PARAMETER S.I UNIT REF. RANGE CONV. UNIT REF. RANGE

RBC 1/uL 0-11 0/hpf 0-2

WBC 0/uL 0-11 0/hpf 0-2

EPITHELIAL
CELLS 0/uL 0-11 0/hpf 0-2

HYAKRE CAST 0/uL 0-1 o/hpf 0-3

BACTERIA 1/uL 0-111 0/hpf 0-20

Radiologic findings
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 Lung fields are clear
Heart valves are damaged
Aorta is not dilated
Sulci and diaphragm are intact
Bony thorax and visualized tissue are unremarkable

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 2-D
Echocardiography
Result

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*Left ventricle
test Normal range value
End diastolic dam 3.4-4.5 cms 4.1
End systolic diameter 2.7
End diastolic volume 27 cc
End systolic volume 27cc
Stroke volume 46 cc/beat
Cardiac output
Ejection fraction 55-77% 63
Fractional shortening 28-41% 34
Septal thickness 7-11 mm 9/10
Post wall thickness 7-11 mm 7/8

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*Right Ventricle

LEFT ATRIUM
A-P diameter 2.3-3.25 cms 2.9
AORTA
Diameter 2.15-2.75 cms 1.9

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Vital signs
At 8 am
T= 37.8 C AFEBRILE
PR= 132 bpm ABNORMAL
BP= 90/60 mmHg NORMAL
RR= 22 cpm SLIGHTLY INCREASED

At 12 noon
T= 37.7 C AFEBRILE, BUT LOWER THAN THE MORNING
TEMPERATURE.

PR= 124 BPM NORMAL

BP= 90/70 MMHG NORMAL
RR= 22 CPM SLIGHTLY INCREASED

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DOCTOR’S ORDER
ORDERS RATIONALE

1. Schedule 2Decho - This test allows your doctor to monitor how your heart and its
valves are functioning. The images can help them spot.
2. Montoux test - A test that is used to identify if the patient is positive for
tuberculosis.
3. To repeat CBC - To monitor the progress of the treatment

4. Return check up on 07/22/17 - To monitor the health condition of the patient

5. Continue medications - Not taking your medications us instructed by the doctor could
lead to worsening of your condition.
6. Give paracetamol every 4h if temperature is > than 37.5 - To lower body temperature
degrees C

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 PHYSICAL
ASSESSMENT

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 Physical Assessment Findings:
Physical Assessment
Vital signs:
At 8:00 am
BP = 90/60 mmhg
T= 37.8 c; febrile
PR= 134bpm palpable
RR=22 cpm effortless w/o use of accessory muscles
At 12 nn
BP= 90/70 mmHg
T= 37.7 C; Slightly afebrile
PR= 124bpm; strong and slightly palpable
RR= 22 cpm
Skin
• Temperature- hot and equal bilaterally

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• Moisture -smooth with no perspiration
• Texture- Smooth and soft
• Mobility and turgor- Lifts easily and snaps back immediately to its resting position
• Lesions- Presence of some lesions, no rashes noted

Nails

• Pinkish in color
• Nail plate are transparent and well-rounded
 prompt and capillary refill; > 3 seconds
 angle is 160 Degrees
 texture is firm

Head:
 There were no presence of nits, lesions, deformities and lumps noted
 No dandruff noted
 Quantity: Hair is thick, slightly brownish in color
 Distribution: hair is equally distributed
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  Texture: soft
 Scalp is inelastic and lighter than the face
 Hair was unkept

Face:
 Contour: Oval Shape, Color is white, same with the surrounding skin
 Symmetry: Symmetrical
 Involuntary movements: none
 Edema: none
 No masses and lumps
 No tenderness

Eyebrows:
 Quantity: Equally distributed
 Absence of masses nodules, lumps and scaliness

Eyes:

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  Conjunctiva and sclera: Conjunctiva is smooth and with minimal blood vessels visible on the left compared to
the right while sclera is china white in color.
 No presence of eye bags.
 Cornea and Lens: No opacities or cloudiness, clear, shiny and smooth.
 Eyelids intact with no discharges and discoloration. Closes symmetrically. approximately 15-20 involuntary
blinks per minute with bilateral blinking.
 No swelling or nodules.
 Eyeballs doesn’t protrude beyond frontal bone. Globe is firm and non-tender.
 Color of iris is black, shape is round and equal in size in both eyes.

Ears:
 Auricles are level with each other
 Color is white or same as that of the face
 Size is greater than 4 cm and smaller than 10 cm
 symmetrical
 No deformities.
 Position is almost vertical
 no presence of nodules, swelling and lesions
 soft and pliable
 there is no presence of yellow serumen
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Nose
 symmetrical with other facial features
 No presence of blackheads
 No deformities
 At the center of the face
 Absence of tenderness and nodules
 Internal mucosa is pink and moist with clear scant mucus
 No exudates, bleeding and swelling
 Nasal septum has no bleeding, deviation and perforation.

Mouth:
 Lips: pale, relatively dry
 Absence of lumps
 Gums: pale, moist, and firm in texture.
 Teeth: 30 with shiny tooth enamel
 Hard palate is whitish and dome-shaped
 Soft palate is light pink in color and smooth
 Tongue is symmetrical and swollen, strawberry red in color
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Neck:
 neck is symmetrical to body size
 no presence of scars, growths and enlargement of the parotid glands.
 Lymph nodes are slightly palpable
 Thyroid gland is not visible upon palpation

Posterior Chest:
 Upon inspection, the respiration was regular with no use of accessory muscles for breathing,
 There were no signs of tenderness or masses upon palpation.

Anterior Chest:
 Upon palpation, no masses noted.
Axilla:
 color: white
 no presence of hair noted
 no masses

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Abdomen
• no presence of lesions noted

Breast

• Nipples are everted

 breast is flat
• Symmetrical
• No lesions
• No dimpling or retraction

Extremities
 symmetrical
 no lesions noted

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 MEDICATIONS

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  GENERIC NAME: Paracetamol
 BRAND NAME: Tempra
 CLASSIFICATION: Acetaminophen
 DOSAGE: 250 g/ml 7 ml of 4H PRN for fever
 ACTION: Blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain
receptors to stimulation

 INDICATIONS:
1. Mild pain for fever

 CONTRAINDICATION
1. Contraindicated in patients hypersensitive to drug or any ingredients of the drug.
2. Use cautiously in patients with long term alcohol use because therapeutic doses causes hepatotoxicity in these patients

 ADVERSE REACTIONS
1. HEMATOLOGIC: hemolytic anemia, leukopenia, neutropenia, and pancytopenia
2. HEPATIC: Jaundice
3. METABOLIC: Hypoglycemia
4. SKIN: rash, urticarial

 NURSING CONSIDERATIONS

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 1. Use liquid form for children and patients who have difficulty swallowing.
2. Many OTC and prescription products contain acetaminophen; be aware of this when calculating daily dose.

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  GENERIC NAME: Penicillin G^
 BRAND NAME: Pfizerpen
 CLASSIFICATION: Penicillin
 DOSAGE: 1 million units IV
 ACTION: inhibits cell wall synthesis during bacterial multiplication (half-life 30-60 minutes)

 INDICATION:
1. Adults and children age 12 and older: highly individualized; 1 to 30 million units IM or IV daily in divided doses q 2 to 6 hours
or via continuous IV infusion
2. Pneumonia
3. Streptococcal infections
4. Bacterial endocarditis
5. Syphilis
6. Anthrax
7. Diphtheria

 CONTRAINDICATIONS
1. Contraindicated in patients hypersensitive to drug or other penicillins
2. Use cautiously in patients with other drug allergies, especially to cephalosporins, because of possible cross-sensitivity

 ADVERSE REACTIONS
1. CNS: seizures, neuropathy, lethargy, hallucinations, anxiety, confusion, agitation, depression, dizziness, fatigue
2. GI: pseudomembranous colitis, nausea, vomiting, enterocolitis
3. GU: interstitial nephritis, nephropathy
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 4. HEMATOLOGIC: leukopenia, thrombocytopenia, eosinophilia, anemia
5. SKIN: maculopapular rash

 NURSING CONSIDERATIONS
1. Before giving drug, ask patient or S.O about allergic reactions to penicillin.
2. Obtain specimen for culture and sensitivity tests before giving first dose. Therapy may begin pending results.
3. Shake well before injection if IM.
4. Give drug at least 1 hour before a bacteriostatic antibiotic
5. Drug’s extremely slow absorption time makes allergic reactions difficult to treat.
6. Tell patients to report adverse reactions

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  GENERIC NAME: Multivitamis + Iron
 BRAND NAME: Sangobion
 CLASSIFICATION: Vitamins
 DOSAGE: 5 ml OD

 INDICATION
1. Used to treat or prevent low levels of vitamins and iron in the body

 CONTRAINDICATIONS
*check with your physician if you have any of the following:

1. Ulcer from stomach acid

2. Iron metabolism disorder
3. Ulcerated colon

 SIDE EFFECTS
1. constipation, diarrhea
2. nausea, vomiting, heart burn
3. Stomach pain
4. Dark-colored stool urine
5. Temporary staining of the teeth
6. Headache
7. Unpleasant taste in your mouth
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  NURSING RESPONSIBILITIES
1. Assess patients for signs of nutritional deficiency before and throughout therapy
2. Encourage patent and family to comply with recommendations of health care professionals
3. Advise parents not to refer to chewable multivitamins as candy.

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  GENERIC NAME: Ascorbic Acid
 BRAND NAME: Ceelin Syrup
 CLASSIFICATION: Vitamin supplement
 DOSAGE: 5ml OD
 ACTION: Water-soluble vitamin essential for synthesis and maintenance of collagen and intercellular ground substance of
body tissue cells, blood vessels, cartilage, bones, teeth, skin, and tendons. Unlike most mammals, humans are unable to
synthesize ascorbic acid in the body; therefore it must be consumed daily.

 INDICATION
1. Used for the prevention and treatment of vitamin C deficiency in infants and children
2. Used to treat scurvy
3. Dietary supplements

 CONTRAINDICATIONS
1. Hypersensitivity to Ceelin Syrup
2. Use of sodium ascorbate in patients on sodium restriction
3. use of calcium ascorbate in patients receiving digitalis.

 SIDE EFFECTS
1. Temporary faintness
2. Dizziness
3. Injection site soreness

 NURSING CONSIDERATIONS

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High doses of vitamin C are not recommended during pregnancy.
Instruct client to Take large doses of vitamin C in divided amounts because the body uses only what is needed at a particular time and excretes the
rest in urine.
Megadoses can interfere with absorption of vitamin B12.
Note: Vitamin C increases the absorption of iron when taken at the same time as iron-rich foods.
Tell patient if mother, sDo not breast feed while taking this drug without consulting physician

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Generic Name: Clarithromycin
Brand Name: Clarithronatrapharm
Classification: Macrolide

Indications: Treatment of upper & lower resp. tract infections including otitis media; skin & soft tissue infections. Clarithro-
Natrapharm Tab/Susp: Eradication of H. pylori in treatment regimen for PUD. Susp: Prophylaxis & treatment of opportunistic mycobacterial
infections. Treatment of leprosy & protozoal infections including toxoplasmosis.
Contraindications:

Hypersensitivity to macrolides. Concomitant use w/ astemizole, cisapride, pimozide, terfenadine, ergotamine or dihydroergotamine.

Side Effects / Adverse Reactions:

Headache, taste perversion; diarrhea, nausea, abdominal pain, dyspepsia, vomiting; increased hepatic enzyme.
Administration:
Filmtab/Oral susp: May be taken with or without food:
Oral susp may be taken w/ milk.
OD tab: Should be taken with food: Swallow whole, do not chew/crush.

Nursing Considerations:

 Inquire about previous hypersensitivity to other macrolides (e.g., erythromycin) before treatment.

 Withhold drug and notify physician, if hypersensitivity occurs (e.g., rash, urticaria).

 Monitor for and report loose stools or diarrhea, since pseudomembranous colitis must be ruled out.
68 | P a g e
  When clarithromycin is given concurrently with anticoagulants, digoxin, or theophylline, blood levels of these drugs may be elevated.
Monitor appropriate serum levels and assess for S&S of drug toxicity.

Patient & Family Education

 Complete prescribed course of therapy.

 Report rash or other signs of hypersensitivity immediately.

 Report loose stools or diarrhea even after completion of drug therapy.

 Do not breast feed without consulting physician.

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Functional
Health Pattern
& NURSING CARE PLANS

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 USUAL FUNCTIONAL PATTERN
1.) Health-Perception-Health Management
 “Sa balay ra ko gipanganak” as stated by
the patient
 health status for the past years has been
good, as claimed
 he was admitted when he was a baby
due to dehydration
 does not visit hospital when sick; takes
paracetamol instead
 no allergies, as claimed
 no problems in following drug regimen
 his father is a smoker but does not
smoke around him due to long-distance
rel.
 Heredofamilial disease: Hypertension
 No immunizations, as claimed
INITIAL APPRAISAL
 Tested for TB skin test
 Had a high fever when admitted in
Bayawan District Hospital (39.9 C)
 “has symptoms of Kawasaki Disease
according to its doctor” As verbalized by
his uncle
 Had presence of skin rashes, swollen red
tongue, and high fever for 3 days before
admitted to SUMC
 Diagnosed with Acute Rheumatic fever
by Dr. Mann
ONGOING APPRAISAL
 Received sitting on bed, wearing patients
gown
 Skin is light brown in color, texture is rough
with no lesions & slightly moist
 No of teeth= 30, with no missing & decay
 Both pupils are equal in size, iris is brown in
color with no signs of redness
 Hair was unkept and scalp had no masses and
lesions
 Negative results for Kawasaki disease
 Tepid sponge bath done
 Skin was hot, pallor
 Had slight fever (37.8C)
 VS Taken @ 8am: T=37.8, P= 96 bpm, RR= 22
cpm, BP= 100/70mmHg
 Client was weak
 No rashes, as observed
 VS @ 12pm: T= 37.7C, P= 116 bpm, RR=
24cpm, BP= 90/60

2.)Nutritional-Metabolic Pattern
Breakfast: Breakfast:
 Has a high appetite
Rice (1 cup) Rice (1 cup)
 Rarely drinks water
Fried Chicken (1 pc.) Sinigang ( 1 bowl)
 Takes Celine as his vitamins
Water (1 glass/ small cup) Water (1 glass)
 Current weight: 37kg
 Demands for sinigang for every meal - Hooked with new bottle of IV D5NM 1L @
 Breastfed by his mother when he was
 No food allergies 32gtts/min
still a baby
 Oral fluid= 150ml for 8 hours - PO Meds and IV were given
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  Breakfast:  Urine vol.= 250 ml for 8 hours 1) Penicillin G^ aqueous 1million units IV
Rice (1-2cups)  “Di man ni sha muinom kayo og tubig 2) Clarithromycin (Clarithronatrapharm) 250
Corned beef (1 cup) mao ng usa sa rason ngano gi admit ni mg/5m
Milo (1 glass) siya karon”, as verbalized by his uncle - Diet as tolerated
Lunch:  Full course treatment - Was not able to take his celine vitamins
Rice (2-3 cups)  IVF D5NM 1L @ 32gtts/min. - Doesn’t like to eat banana
Fried chicken (1 pc.)  Medications:
Dinner: 1) Paracetamol (tempra) 250g/5ml, 7ml q
Rice (2-3 cups) 4H PRN for fever
Meat (2-3 pcs.) 2) Penicillin G^ aqueous 1million units
 Favorite food is sinigang, ginataang  He likes the hospital food/meals except
pork and fish for fruits
 Does not drink the required amount of
fluids a day

3.)Elimination Pattern
- Defecated once a day: brown in color
and texture is soft
- No difficulty in defecation
- No problems with urinating, yellow in
color
- No skin problems
- Perspires but does not have any odor, as
claimed
4.) Activity-Exercise Pattern
- Plays with friends in school
- Plays computer/tablet during spare time
or if there are no classes
- passed stool only once, after 3 days upon
admission
- stool was brown in color & slightly hard,
as claimed
- urinated 6 times today & it was clear
white in color with no unusual odor
- does not perspire a lot due to cold
evironment
- plays minecraft on hospital bed
- watches youtube videos
- often sleeps in the morning
- Defecated once, in small amount
- Urinated 2 times with a clear white in color
- No unusual odors noted
- Played with his tablet
- Seated on chair most of the time
- Slightly able to ambulate
Self-care ability:
Bathing: II dressing: II

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 - Loves to play basketball and soccer
- Enjoyed playing tartanilla woth friends
- Loves to play guitar and drums
- loves to draw
5.) Sleep-Rest Pattern
- onset: 8pm awakening: 6am
- no difficulty with sleeping
- has not tried sedative medications
- has not experience nightmares
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- slightly able to ambulate
- could not feed himself
- plays fidget spinner when hands don’t
hurt, as claimed
- onset: 12am awakening: 5am
- had difficulty with sleeping
- felt restless on bed, as observed
- no use of sleeping aids
- woke up early in the morning to take his
medications
Feeding: II grooming: II
Toileting: II
-was not able to brush his teeth since the day of
admission
- Onset: 8:05pm Awakening: 6:40am
- No difficulty sleeping in the hospital
- No use of sleeping aids
- No nightmares, as claimed
- Prone position while sleeping
- Slept beside his bantay
- Lethargic feeling, as observed
- Took a nap @ 11:43 after VS taking
6.) Cognitive-Perceptual Pattern
- No family history of deafness
- Able to respond properly to people
- Eyesight is good, as claimed
- Favorite color is black
- Learned to play guitar while watching
their pastor
- Good in drawing, as claimed
- Consistent class honor, as claimed by his
uncle
7.) Self-Perception-self Concept Pattern
- Dependent in terms of financial
purposes
- Smiles most of the time, as claimed
- Is afraid of sharp objects that gets near
his eyes (pencil/needle)
- Wants to become an architect
8.) Coping Stress
- Sleeps when tired
- When he needs help, he asks his elder
brother and uncle
- Plays basketball or the instruments
when stress is present
9.)Role-Relationship Pattern
- Interact with friends in school
74 | P a g e
 Feels chest and joint pains: 6/10
 Grade 7 student
 No visual problems
 No hearing problems
 Felt dizzy from time to time
- Verbalized that he misses his mom and
dad
- Was able to joke with the people around
him
- Not fluent in speaking bisaya
- Spoke in Filipino language most of the
time
- Posture: lying on a supine position
- Able to answer questions
- Has a good eye contact
- He liked being in the hospital because he
cannot go to school yet which lessens his
stress
- Enjoyed watching youtube videos with
his uncles
 Is concerned with being absent from the class
 No problems with his senses
 Complained of the noise inside the hospital
(loud cry of babies)
 Comfortable with sitting position
 Pain felt on the joints: 4/10
- Able to establish good eye contact
- Speaks in bisaya/ Filipino
- Speech is good, as observed
- Claimed that he has no friends in the hospital
since most of the patients were infants or
preschool children
- Most of the his where spent in playing his
tablet
- Still afraid of sharp objects
- Played with his tablet to avoid boredom
- Minimal dark circles noted around eyes d/t
stress
 Cues & Evidences Nursing Objectives Interventions Rationale Evaluation
Diagnosis
Subjective: Impaired physical At the end of our 5 hours 1. Consider reports of 1) Favorable in determining GOAL WAS
-unwillingness to Mobility r/t of care, our patient: pain, noting location pain management needs and PARTIALLY
move; prefers to stay alteration in bone 1) Report pain is and intensity (scale of effectiveness of program. MET as evidenced
in bed and use the structure relieved/controlled. 0–10). Note by:
tablet integrity; precipitating factors
musculoskeletal 2) Appear relaxed, and nonverbal pain 2) Prevents general fatigue and 1. Patient
“Sakit mu gimok jud able to sleep/rest cues. joint stiffness. Stabilizes reports if
panagsa nya and participate in joint, decreasing joint there is any
kapoy”as verbalized activities 2. Encourage frequent movement and associated pain felt
appropriately. changes of position. pain.
Objective: Assist patient to move 2. Able to sleep
-decrease in fine or 3) Follow prescribed in bed, supporting 3) Promotes relaxation and properly
gross motor skills, as pharmacological affected joints above reduces muscle tension.
observed regimen. and below, avoiding 3. Was able to
jerky movements. 4) Refocuses attention, take the
4) Incorporate provides stimulation, and ordered
-Decrease in range of
relaxation skills and enhances self-esteem and medications
motion; difficulty in
diversional 3. Provide gentle massage. feelings of general well-
turning, as observed
activities into pain being. 4. Not able to
control program. 4. Involve in diversional incorporate
Self-care ability:
activities appropriate relaxation
Bathing: II
for individual situation. skills
dressing: II
Feeding: II
grooming: II
Toileting: II

75 | P a g e
 Cues and Evidences Nursing Objectives Interventions Rationale Evaluation
Diagnosis
Subjective: Decreased At the end of our 5 hours 1) Record intake and output. 1) Reduced cardiac output results GOAL WAS
-feels anxious, as Cardiac of care, our patient should: If patient is acutely ill, in reduced perfusion of the PARTIALLY
claimed by the bantay Output: Inadequat measure kidneys, with a resulting MET as evidenced
e blood pumped 1. Patient demonstrates hourly urine output and decrease in urine output. by:
-decreased urine output by the heart to adequate cardiac note decreases in output. 2) The new onset of a gallop
meet the output as evidenced rhythm, tachycardia, and fine 1) Patient
-decreased activity metabolic by blood 2) Auscultate heart sounds; crackles in lung bases can demonstrates
intolerance demands of the pressure and pulse note rate, rhythm, indicate onset of heart failure. adequate
body rate and rhythm presence of S3, S4, and 3) Chest pain/discomfort is cardiac
-slight pain felt on within normal lung sounds generally suggestive of an output
chest, as verbalized parameters for patient; inadequate blood supply to the 2) Patient was
strong peripheral 3) Note chest pain. Identify heart, which can compromise free of any
Objective: pulses; and an ability location, radiation, cardiac output. side &
-cold skin & delayed to tolerate activity severity, quality, duration, 4) Depending on etiological adverse
capillary refill without symptoms of associated manifestations factors, common medications effects of the
dyspnea, or such as nausea, and include digitalis therapy, diuret medications
-tachycardia chest pain. precipitating and ics, vasodilator therapy, anti- administered
2. Patient remains free of relieving factors dysrhythmics, angiotensin-
--there is a change of side effects from the converting enzyme inhibitors, 3) Patient was
level of consciousness; 4) Administer medications not able to
medications used to and inotropic agents.
from alert to lethargic, as prescribed, noting side explain the
achieve adequate 5) Psycho educational programs
as observed effects and toxicity. precautions
cardiac output including information
3. Patient explains on stress management and to take for
5) Educate patient the need cardiac
VS taken: July 11, actions and health education have been
for and how to disease
12pm precautions to take for shown to reduce long term
incorporate lifestyle
T=36.9C PR=134bpm cardiac disease mortality and recurrence
changes.
RR= 13cpm of myocardial infarction in
BP=95/50mmHg heart patients.

76 | P a g e
 Cues & Evidences Nursing DX Objectives Interventions Rationale Evaluation
Subjective: Ineffective After 5 hours of our 1. Assist with 1.) This will give us the clue of GOALS WERE
-had a high fever when Thermoregulation r/t care, our patient should: measures to identify what are the causes of sudden rise NOT MET as
admitted @ Bayawan fluctuating body temp 1) Maintain body underlying of temp. evidenced by:
district Hospital temp. within conditions by
(39.9C) normal limits obtaining history 2.) to restore or maintain body/ 1.) His temp.
-“Taas mana shag 2) Verbalize concerning present organ function reduced but still
hilanat tung wala pa understanding of symptoms on a febrile level
siya diri pero pag appropriate 2. Administer fluids, 3.) to promote heat loss by
admit niya, on & Off interventions electrolytes and evaporation 2.) Did not follow/
nalang..”, as 3) Manifest normal medications, as was not able to
verbalized by client’s color of the skin indicated 4.) to promote heat loss by drink the moderate
uncle and texture 3. Perform Tepid radiation and conduction amount of fluids
4) Be able to consume sponge bath
Objectives: nutritious meals 4. Promote surface 5.) to keep the patient hydrated 3.) skin was still
VS: July 10 and adequate coding by means of pallor in color
T= 37.5 amount of fluids to undressing
July 11 @ 7:45am improve immune 5. Encourage him to 4.) able to
T=37.6C system maintain/drink the verbalize
@ 12pm adequate amount of understanding of
T=36.9C water & fluids appropriate
July 12 @ 8:00am interventions
T=37.8C

77 | P a g e
 Related
articles

78 | P a g e
ACUTE RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE
Acute rheumatic fever (ARF) is the result of an autoimmune response to pharyngitis caused by
infection with group A Streptococcus. The long-term damagse to cardiac valves caused by ARF,
which can result from a single severe episode or from multiple recurrent episodes of the illness,
is known as rheumatic heart disease (RHD) and is a notable cause of morbidity and mortality in
resource-poor settings around the world. Although our understanding of disease pathogenesis has
advanced in recent years, this has not led to dramatic improvements in diagnostic approaches,
which are still reliant on clinical features using the Jones Criteria, or treatment practices. Indeed,
penicillin has been the mainstay of treatment for decades and there is no other treatment that has
been proven to alter the likelihood or the severity of RHD after ans episode of ARF. Recent
advances — including the use of echocardiographic diagnosis in those with ARF and in
screening for early detection of RHD, progress in developing group A streptococcal vaccines and
an increased focus on the lived experience of those with RHD and the need to improve quality of
life — give cause for optimism that progress will be made in coming years against this neglected
disease that affects populations around the world, but is a particular issue for those living in
poverty.
79 | P a g e
Acute Rheumatic Fever with Erythema Marginatum

A previously healthy 36-year-old man presented with a 1-month history of fever and pain in both
shoulders and knees, which had been preceded by a sore throat 2 weeks before the onset of fever.
Laboratory studies were notable for a white-cell count of 13,800 per cubic millimeter (85% neutrophils),
a C-reactive protein level of 26 mg per deciliter (reference value, ≤0.3), and an antistreptolysin O titer of
1478 IU per milliliter (reference value, <241). Transthoracic echocardiography revealed mild aortic
regurgitation. His fever and arthralgias abated after the administration of a nonsteroidal antiinflammatory
drug. One week later, painless, nonpruritic, red annular macules appeared on the upper limbs and
abdomen (Panel A shows the right forearm; black ink dots indicate the diameter of one lesion 10 hours
before the time that the photograph was taken). The rash migrated within hours and then faded over the course of a few days while new lesions
appeared (Fig. S1 in the Supplementary Appendix, available at NEJM.org). Skin biopsy revealed perivascular infiltration of lymphocytes and
neutrophils in the dermis (Panel B, hematoxylin and eosin). Acute rheumatic fever with erythema marginatum was diagnosed. Erythema
marginatum, an evanescent nonpruritic macular rash, is one of the major Jones criteria for the diagnosis of acute rheumatic fever. The patient
began taking amoxicillin for secondary prophylaxis of rheumatic heart disease. The rash disappeared completely 4 months after presentation, and
the antistreptolysin O titer decreased to 246 IU per milliliter 12 months after presentation.
Global first for rheumatic fever research

80 | P a g e
The first robust evidence that supports community initiatives to prevent acute rheumatic fever has come from researchers at the University of
Auckland.
In a paper published online in the latest Pediatric Infectious Disease Journal, lead researcher and clinician, Professor Diana Lennon says until
now, treatment to prevent rheumatic fever in children was derived from studies in adults in the American armed forces.
Rheumatic fever in New Zealand affects mostly Māori and Pacific Island children in low-socioeconomic areas in the North Island, particularly in
Northland and south Auckland. It affects mainly primary age children and peaks in 9-10 years olds.
Globally, it is a disease of poverty in developing countries, and untreated episodes can lead to the disabling effects of rheumatic heart disease in
children.
“In New Zealand, rheumatic fever has continued at an unacceptably high rate with hospitalization from this disease affecting about one in 150
Māori or Pacific Island children, aged under 13 years,” she says.
“Life span in Māori adults with heart damage from rheumatic fever is reduced by more than 10 years.”
Research using data collected, from providing access to sore throat management to more than 25,000 children/year in 61 south Auckland primary
schools between 2010 and 2016, was led by Professor Lennon.
The programme itself is delivered by an alliance of health providers led by the National Hauora Coalition. The research aspect was funded by a
partnership grant arising from a joint venture between the Health Research Council of New Zealand, the Ministry of Health, Te Puni Kōkiri,
CureKids and the Heart Foundation.
The prevention model uses a team of school-based nurses with a whānau support worker, based at school clinics five days per week operating
sore throat clinics with daily assessment and treatment of group A streptococcal sore throats in the children.

81 | P a g e
This model was first developed as a new model of healthcare delivery to improve access in an earlier published trial (in 2009) funded by the
Health Research Council of New Zealand, the Ministry of Health and the Heart Foundation.
“In the latest study, we were able to demonstrate for the first time using robust methodology, that first presentation of acute rheumatic fever is
preventable in a community setting and using oral amoxicillin,” says Professor Lennon.
“The sore throat programme in schools resulted in a significant decrease in acute rheumatic fever rates among primary children,” she says.
Over two years of running the sore throat clinics, the rates of rheumatic fever dropped 58 percent, from 88 in 100,000 children to 37 in 100,000
children.
A parallel decline in Strep A from throats was found in cross sectional surveys once the prevention programme was begun.
“We have demonstrated this ‘proof of principle’ - the first both nationally and internationally - supporting prevention of first presentation
rheumatic fever through sore throat management delivered in school clinics,” says Professor Lennon.
“This supports the continuation of school clinics already underway in Northland, Auckland, the Bay of Plenty, Hawkes Bay and other regions
around New Zealand,” she says.
“This has been a 30 year journey, based on community advocacy and partnership, empowerment, and knowledge sharing that began with
participation from the Māori Women’s Welfare League,” says Professor Lennon.

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 Bibliography

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 1. Nursing2008 drug handbook. (2008). Philadelphia, PA: Lippincott Williams & Wilkins.
2. McCance, K. L., Huether, S. E., & Felver, L. (2015). Study guide for Pathophysiology: the biologic basis for disease in adults and children.

St. Louis: Mosby.

3. Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology. St. Louis, MO: Elsevier
4. Brunner, L. S., Suddarth, D. S., & Smeltzer, S. C. (2008). Brunner & Suddarth’s textbook of medical-surgical nursing / Suzanne C. Smeltzer

... Philadelphia: Lippincott Williams & Wilkins

5. http://www.innerbody.com/image/cardov.htmls
6. Maternal & Child Health Nursing Care of the Childbearing & Childrearing Family. (2015). Lippincott Williams & Wilkins
7. Berman, A., & Smith, S. F. (2009). Nursing skills for a concept-based approach to learning. New York: Learning Solutions
8. https://www.nature.com/articles/nrdp201584
9. http://www.nejm.org/doi/full/10.1056/NEJMicm1601782#t=article
10. (2014, December 05). Rheumatoid Arthritis | Nucleus Health. Retrieved August 02, 2017, from https://www.youtube.com/watch?v=Yc-9dfem3lM
11. Rheumatic fever & heart disease - causes, symptoms, treatment & pathology. (2016, June 29). Retrieved August 02, 2017, from

https://www.youtube.com/watch?v=cXPtewa5PJc
12. JF

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