NRSG257 Assignment: Analyzing the Case of Sue and ARF in Pediatrics

This case study assignment focuses on a 14-year-old girl named Sue who was diagnosed with Acute Rheumatic Fever (ARF) after a history of streptococcal pharyngitis and impetigo. The paper delves into the pathophysiology of ARF, explaining how the initial infections progressed to the current condition. It also explores the crucial role of the nurse in providing comprehensive care, including assessing the patient's developmental stage, communicating effectively, and considering cultural and linguistic factors, given Sue's indigenous background. The assignment emphasizes the importance of family-centered care, detailing how the nurse should educate and support the family, especially considering their remote location and potential barriers to accessing care. The paper discusses the need for patient education on cardiac complications, medication adherence, and lifestyle modifications, ensuring the patient's well-being and preventing further health issues. Overall, the assignment provides a detailed overview of the nursing care required for a patient with ARF, highlighting the significance of holistic approaches that consider both the patient's physical and emotional needs, as well as their family's involvement.

Running head: NRSG257
NRSG257
Name of the Student
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Author note

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The paper deals with the discussion of case study of Sue. She is a 14-yar-old girl treated
for streptococcal pharyngitis and impetigo over last two years. She was advised to take
secondary prophylaxis program to reduce risk for Acute Rheumatic Fever (ARF). As she is an
indigenous girl residing in a remote area, she failed to attend the clinic and receive her
antibiotics. After this, she presented with acute joint pain, sore throat with body temperature of
38°C. Finally, she was diagnosed with ARF and need cardiology review and echocardiogram.
Therefore, the following essay discusses the pathophysiology of her present condition and role of
nurse in the development of nursing care and in providing family centered care.
Pathophysiology
Streptococcal pharyngitis is the infection or irritation of tonsils or pharynx and of viral
origin. Streptococcus pyogenes is the significant bacterial agent that causes pharyngitis in
children called GAS infection (Hoffman, 2014). Viruses or bacteria invade the pharyngeal
mucosa directly and causes a local inflammation. After invasion, they release extracellular
proteases and toxins and caused by group A beta-hemolytic streptococcus (GAS). It is the most
common pharyngitis causes 15-20% of the infections (Fierro et al., 2014). It is contagious in
nature and spread through contact. In the given case study, Sue was treated for repeated
streptococcal pharyngitis and impetigo episodes over the last two years.
The virulent factor of GAS is M protein. The protein is located peripherally over the cell
wall and causes invasive infection. Cells are exposed to the M protein that causes cross-reaction
with epitopes of laminin and cardiac myosin that contribute to impetigo and acute rheumatic
disease. Impetigo being the most common bacterial infection infects children on the superficial
layers of epidermis by Staphylococcus aureus or Streptococcus pyogenes. This secondary skin

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infection infected Sue that caused impetigo or scarlet fever or school sores due to GAS infection
(O'Meara et al., 2015).
As she lives in a remote area, she failed to turn for the second prophylactic program to
prevent ARF risk or Rheumatic Heart Disease (RHD). This aggravated to cause ARF in her that
required echocardiogram and cardiology review. RHD is a post infection systemic complication
caused by S. Pyogenes, although exact pathophysiology is not known. It developed in Sue post
pharyngitis where the organism is attached to the epithelium of upper respiratory tract and
initiates a cascade of enzymatic reactions that help them to invade and damage human cells and
tissues (Lee et al., 2016). After the three to four days incubation period, the organism invades
and triggers acute inflammatory response causing acute joint pain, sore throat that migrated to
knees and ankles with elevated body temperature. This shows that Streptococcus impetigo causes
predisposition to ARF or RHD. This was witnessed in Sue where she reported sore throat, acute
joint pain radiating to ankles and knees indicating ARF.
Evaluation of nursing role and care
For the proper diagnosis and care for Sue, the nurse should be aware of the growth and
development expected at her age. Sue is 14 year-old-girl and expected developmental milestones
at her age is formal operational stage as stated by Jean Piaget’s theory of adolescent
development. At Sue’s age, they learn to think in an abstract manner in solving problems and
think symbolically about things that are not concrete according to them. At the age of 14 years,
they are able to think in a complex manner and express their feelings in a better way by talking.
They have a strong sense of right and wrong as compared to children and towards gaining

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competency in adult-type thinking as stated by Piaget theory of cognitive development (Piaget,
2015).
This shows that they have the ability for complex thinking and rapid cognitive skill
development with good language development. Therefore, while communicating with Sue, the
nurse must assess that her cognitive development and ability to converse is same as others if her
age and if her pattern of speech is near to adult style. This would help the nurse to assess her
joint pain and sore throat effectively by locating and communicating with Sue. There can be
better adjustment and management of medications according to her changing pain levels. The
explanation of the medial procedures like echo cardiology and cardiology review techniques
through simple drawings and video clips. Although she is an adolescent, use of simple terms is
still important while communicating with her (Scanlon et al., 2016).
According to Piaget’s theory of cognitive development in children of age 11-14 years,
they have the ability for abstract thinking and complete the last stage of Piaget theory of
developmental milestones. The formal operation period states that adolescents of 14 years
display logical thinking, seriate and conserve mass, number and volume. They also develop
reasoning abilities, better executive function of brain and improved memory. This is the reason
when the children are able to formulate values based on analysis and thinking and opposes
experiences or feeling (Modgil, Modgil & Brown, 2013). Therefore, in case of Sue, the nurse
might be able to provide appropriate information to her about her medical condition and the
further diagnosis process. This will reduce the anxiety and pain she is going through and provide
emotional and mental support. Nurse might be able to make her understand the clinical
manifestations exhibiting the particular signs and symptoms like joint pain and sore throat. She is

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at that age where the nurse can explain to her the body parameters like body temperature, blood
pressure, respiratory and cardiac frequency.
The assessment of the mental status of Sue is also important to assess by the nurse for
preparing her for the hospital admission and in reduction of anxiety and emotional distress. As
she is an adolescent, she has the intelligence, patience and maturity to understand the care and
management process. Keeping Sue’s age in mind, she should be involved in her care process and
medical procedure that would affect her. It is important for the nurse to assess her cognitive and
mental development and deviations from the normal development pertaining her age and
involvement of her mother and six younger brothers and sisters. In this case, informed consent is
important illustrating respect for autonomy and greater good for the diagnostic tests, medical
conditions and care process. Sue should be given full opportunity to express her feelings and
views and nursing considerations regarding ethical principles. The nurse should comply with
these principles that includes, respect for autonomy, non-maleficence, beneficence and social
justice. The care plan should benefit Sue and her family.
Nursing in the podiatric management should provide family centred care model
(Hockenberry & Wilson, 2014). The nurse should educate Sue’s family members about the
diagnosis process, care plan, side effects and care after discharge. Nurse should inform Sue and
her family members that she should not attend school and stay away from infection to prevent
further infection and worsening of situation. Nurse should also inform her family about activity
restriction and cardiac complications that might happen in absence of proper care. She should be
kept clean with regular dressing, maintenance of proper hygiene to avoid risk for injury that is
related to Streptococcal infection. The nurse should notify and inform her family about the
cardiac complications like shortness of breath, consciousness, body temperature, joint pain and

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sore throat that explains the risk for injury related to the infection. This would help her family to
contact the medical team in case of injury as they live in a remote area.
Communication is the most essential component that determines the medical diagnosis,
treatment and management of a disease (Hockenberry, Wilson & Rodgers, 2016). In the given
case study, while conversing with Sue’s family members, nurse should be careful about her way
of communication. She has six younger brothers and sisters who are minor and her mother can
only understand, however, she belongs to the indigenous population and require culture-centred
communication via a qualified medical interpreter to make her understand the diagnosis,
treatment and care plan of Sue. Nurse should use lucid language and value and respect her
choices, preferences and beliefs in providing Sue patient-centred care. As Sue is an indigenous
girl living with her family in a remote area, there is requirement of a qualified medical interpreter
who help to overcome the language barrier. The religious and cultural preferences are important
as she is from a diverse linguistic and cultural background. While providing patient-centred care,
nurse need to take into consideration her cultural and religious needs of Sue and her family foe
their active participation and decision-making related to her illness (Giger, 2016).
Patient education is also important to teach her to keep a check on the cardiac
complications and compliance to medications and lifestyle modifications after her discharge
from hospital (Peter et al., 2015). Apart from this, assessment of the psychological and emotional
needs is also important for the patient and her family. Her family will undergo anxiety and stress
by seeing her in pain and agony. Due to lack of awareness about the illness, health literacy,
understanding of medical terms and low socio-economic status also contribute to anxiety and
stress. Every child is different and have different coping mechanism depending on their
temperament and intelligence. Therefore, nurse should encourage Sue with a positive attitude

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and involve her family in the coping mechanism. An intimate and close attachment with the
family helps to maintain a secured and safe environment as stated by Bowlby's Attachment
Theory with family involvement (Goldberg, Muir & Kerr, 2013).
From the above discussion, it can be concluded that Streptococcal pharyngitis is a
bacterial and viral disease caused by S. pyogenes and gives rise to systemic post-infection
complications like ARF. There is sore throat and joint pain radiating to knees and ankles which
is clearly explained through pathophysiology of streptococcal pharyngitis and impetigo
progressing to ARF. Due to the illness, there is significant impact on Sue and her family
members and so family centered care is important in this case. Concisely, this assignment helped
to gain a deep insight on nursing role in a pediatric setting.

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References
Fierro, J. L., Prasad, P. A., Localio, A. R., Grundmeier, R. W., Wasserman, R. C., Zaoutis, T. E.,
& Gerber, J. S. (2014). Variability in the diagnosis and treatment of group a streptococcal
pharyngitis by primary care pediatricians. Infection Control & Hospital
Epidemiology, 35(S3), S79-S85.
Giger, J. N. (2016). Transcultural Nursing-E-Book: Assessment and Intervention. Elsevier
Health Sciences.
Goldberg, S., Muir, R., & Kerr, J. (Eds.). (2013). Attachment theory: Social, developmental, and
clinical perspectives. Routledge.
Hockenberry, M. J., & Wilson, D. (2014). Wong's Nursing Care of Infants and Children-E-Book.
Elsevier Health Sciences.
Hockenberry, M. J., Wilson, D., & Rodgers, C. C. (2016). Wong's Essentials of Pediatric
Nursing-E-Book. Elsevier Health Sciences.
Hoffman, L. (2014). UPDATED Feb. 27: All You Ever Wanted to Know about Group A
Streptococcal Pharyngitis But Were Afraid to Ask. Emergency Medicine News.
Lee, C. J., Wright, M. H., Arnold, M. S. J., Greene, A. C., & Cock, I. E. (2016). Inhibition of
Streptococcus pyogenes growth by native Australian plants: New approaches towards the
management of impetigo, pharyngitis and rheumatic heart disease. Pharmacognosy
Communications, 6(3), 164.
Modgil, S., Modgil, C., & Brown, G. (Eds.). (2013). Jean Piaget. Routledge.

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O'Meara, W. P., Mott, J. A., Laktabai, J., Wamburu, K., Fields, B., Armstrong, J., ... & Pan, W.
(2015). Etiology of pediatric fever in western Kenya: a case–control study of falciparum
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Piaget, J. (2015). Structuralism (Psychology Revivals). Psychology Press.
Scanlon, A., Cashin, A., Bryce, J., Kelly, J. G., & Buckely, T. (2016). The complexities of
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