MELE
Setting:
Mele tells you how hard it is with so many people living in the house. She also tells you
about her six year old grandchild Fai, who has very sore joints and appears to be lethargic
and unwell.
Action point
What are your main concerns about this information?
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Issue of overcrowding
Grandchild Fai- how long has he been having sore joints
Anyone else in the family with the same symptoms as Fai
Are there any associated symptoms?
Hygiene
Is grandchild Fai up to date with all his immunisations
Fai might be at risk of strep throat because his age falls in between 3-14 years, one of
the strep throat risk factors
Has he been seen by any doctor for further assessment
Action point
Knowing that money is short in this household, how are you going to ensure that this child
accesses appropriate medical care?
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Arrange with Fai’s medical centre to check on him and ask to make arrangements in
paying for his medications.
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Work and Income could be contacted to see whether they are able to assist in paying
with their medications.
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Fai and grandmother can also access the nearest medical centre or ring and ask if
doctors can do home visits.
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Ensure that he can be seen by the school nurse’s when he is at school and get him and
other family members in a throat swab programme
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Arrange for a public health nurse to do a home visit if they cannot access appropriate
medical care
Setting:
During a discussion with Siu, she tells you that she wants to start looking for a job. She asks
if you can offer any advice around preparing a cover letter and CV.
Action point
Find a reliable information source that offers helpful tips and/or templates for cover letters
and CV’s. Share this information by discussing it with your team.
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Work and Income NZ- case managers
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Citizen Advice Bureau
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Libraries-community
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Careers NZ - http://www2.careers.govt.nz/how-to-get-a-job/cvs-and-coverletters/templates/ or on Phone number - 0800 222 733
Setting:
Several weeks later, you revisit the family with a referral from Kidz 1st for follow up as Fai
(Mele’s 6 year-old granddaughter) has Rheumatic Fever and needs ongoing medication.
Action point
What is Rheumatic Fever and how does it develop?
Rheumatic Fever is a serious preventable disease that can cause permanent heart damage. It is
an inflammatory disease that may develop after a streptococcal infection such as a sore throat
(‘strep’ throat).
Rheumatic fever occurs when the body produces a strong immune response to a throat
infection caused by a particular type of bacteria - Group A Streptococcus (“Strep throat”).
Most “strep” throat infections get better without developing into rheumatic fever. However,
in a small proportion of people, an untreated sore throat can cause the body’s defence
mechanism (the immune system) to react very strongly, causing the heart, joints, brain and
skin to become inflamed and swollen.
The usual symptoms are:
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a warm, swollen painful joint (or joints)
fever
tiredness
stomach pain
sometimes a skin rash or lumps under the skin that aren’t itchy or painful
sometimes jerky uncoordinated movements of hands, feet, tongue and
face.
If this inflammation causes scarring on the heart valves the affected person can develop a
condition known as rheumatic heart disease. Rheumatic heart disease can require heart valve
replacement surgery, or even cause premature death.
What is the ongoing medication and for how long will she need it? Why?
1. antibiotics - the immediate goal is to treat the streptococcus infection with
antibiotics, Fai will continue to receive monthly doses of antibiotics after the
initial treatment to help prevent further complications
Penicillin injections:
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must be given every 28 days
are given in your child's thigh or bottom
can be painful at first but children quickly get used to them
are given by your Community Nurse, District Nurse or Public Health Nurse. They
will come to your home or your child's school and give the injection.
According to the New Zealand Guidelines for rheumatic fever, Fai requires benzathine
pencillin via the intramuscular for 10 years or until she is 21 years old. This is the best
secondary prophylaxis to prevent reoccurrence of another rheumatic fever attack.
2. anti-inflammatory medications - depending on the severity of Fai’s
condition, the doctor may prescribe medication to help decrease swelling that
occurs in the heart muscle, as well as to relieve joint pain
3. bed rest - the length of bed rest will be determined by Fai’s doctor, based on
Action point
Discuss the demographics and epidemiology of Rheumatic Fever.
Pacific peoples have the highest rate of rheumatic fever in New Zealand and one of the
highest rates in the world. In 2009, there were 53 notified cases of rheumatic fever among
Pacific peoples in New Zealand, a rate of 23 per 100 000. This is over six times the overall
rate for all New Zealanders of 3.5 per 100 000 (a total of 140 cases).1New Zealand stands out
from most other developed countries in continuing to have high rates of acute rheumatic fever
(ARF) and rheumatic heart disease (RHD).
It is estimated that 97% of cases of RHD worldwide occur in developing countries and in the
indigenous populations of countries such as New Zealand and Australia.
Since 1984, ARF has been a notifiable disease in New Zealand. However, it continues to be
under-notified despite increasing rates each year.There is significant geographical variation in
the rates of ARF in New Zealand, with the highest rates in the NorthIsland, e.g. Tairawhiti,
Hawke’s Bay and Northland.1,5. However, clusters of cases occur in a number of
communities across New Zealand.
Action point
Define best practice in relation to administering intramuscular antibiotics. (Include reference
to Z tracking).
Z-track injection is a method of injecting medication into a large muscle using a needle and
syringe. This method seals the medication deeply within the muscle and allows no exit path
back into the subcutaneous tissue and skin. This is accomplished by displacing the skin and
subcutaneous tissue 1–1.5 inches (2.5–3.75 cm), laterally, prior to injection and releasing the
tissue immediately after the injection.
Purpose
The Z-track method of intra-muscular (I.M.) injection is used primarily when giving dark-u
medication solutions, such as iron solutions, that can stain the subcutaneous tissue or skin.
To give a Z-track injection, use the non-dominant hand to move and hold the skin and
subcutaneous tissue about 1–1.5 in (2.5–3.75 cm) laterally from the injection site. Alert
patients when the medication is about to be injected. Ask them to breathe through their mouth
and to try to relax the muscle to avoid muscle resistance. Continue holding the displaced skin
and tissue until after the needle is removed. Dart the syringe rapidly into the site at a 90°
angle. Aspirate on the syringe to be sure that a blood vessel has not been penetrated. Inject
the medication slowly into the muscle. Be sure that the syringe is completely empty,
including the air, before withdrawing the syringe. Withdraw the syringe and immediately
release the skin and subcutaneous tissue.
The complications of a Z-track injection are not common, but include tissue staining,
bruising, abscess formation at the injection site, and severe pain at the injection site. Notify
the physician if any of these conditions are noted.
Medication administered by Z-track injection is absorbed rapidly from the muscle into the
bloodstream. The effects are seen over hours to days, depending upon the medication given.
Setting
Appropriate treatment of sore throats in high risk populations will eliminate group A
streptococcus in most cases and prevent individual cases of Acute Rheumatic Fever.
Action Point
Outline management of household contacts
Refer to pdf please-guide for sore throat management
Action point
Discuss Primary and Secondary prevention of Acute Rheumatic Fever and Rheumatic Heart
Disease
Refer to pdf please- a summary of the New Zealand Guidelines
References
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Floyd, S & Meyer, A. (2007). Injections – what’s best practice?. Kai Tiaki Nursing
New Zealand. 13(6), 20-22.
 Malkin, B. (2008). Are techniques for intramuscular injection based on research
evidence?. Nursing Times, 104(50-51), 48-51
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www.heartfoundation.org.nz - The National Heart Foundation of New Zealand