NURSING CARE PLAN

(Medical Ward)

I.

Demographic Profile :

Name: R.A.S.
Sex: Female
Age: 17
Civil Status: Single
Birthdate: July 2, 1997
Birthplace: Baguio City
Address (1): 126 Hamada Subdivision, Baguio City
Religion: Roman Catholic
Address (2): 09301888728
Nationality: Filipino
Next of kin: Rosemarie Salenga
Relationship: Mother
Admitting Physician: Dr. Bartolo
Date and time admitted: May 3, 2015/ 8:30 pm.
Attending Physician: Dr. Adrian Calera
Chief Complaint: Generalized body pain
Diagnosis:
II.

Room: 221-1, Medical ward

A. History of present illness

1 week prior to admission patient experience generalized body pain, rated as 3/10 but was tolerable.
She just continued her maintenance medications, Methylprednisolone and Arcoxia which provided relief of the
condition. No consults was done.
5 hours prior to admission, she was just resting when she suddenly felt pain in her whole body and
noticed that her fingers were swollen. She rates the pain as 9/10 which is aggravated by movement. Her
mother gave her maintenance medications but no relief was noted. Hence, she was brought in for
consultation with a private physician and was advised admission.

B. Past Medical History

The mother claims that the patient had been diagnosed of rheumatic heart disease in her childhood
years. In September 2014, the patient had dental extraction. The mother also claimed that she had a rheumatic
heart fever and was given Salphen via IV. She was also admitted in BGH, at an unrecalled date for kidney problems
secondary to her tonsillitis. The mother claims that she had an average of 3 incidence of tonsillitis in a month. On
March 15, 2015, she was diagnosed of rheumatoid arthritis but she was negative for rheumatoid factor. She
currently takes Arcoxia 120 mg OD and Methylprednisolone 16 mg OD for her maintenance medications. She also
had been given Clenza 10 mg OD for 3 Days. The mother claimed that the patient is 100% compliant with her
medications. No known allergies to food and drugs. No other history of surgery or trauma. The mother claimed the
she have received complete immunization when she was a child.
C. Family History

There is no known maternal history of cerebrovascular disease. The patient had a history on both sides
of coronary artery disease, diabetes mellitus and hypertension. There was no known history of pulmonary
tuberculosis, cancer, dementia and depression.
D. Social and Environmental History
The patient is a non-smoker, non-alcohol drinker, non-caffeinated beverage drinker. She lies an active
lifestyle until the beginning of March when she started to have problems with her boy. The family lives in a wellventilated, non-congested, two-story house with 3 bedrooms and 6 occupants. She used to stay upstairs but now
she was limited to the ground level due to her body pains. She is a 3 rd year college student. The familys drinking
water comes from a water refilling stations and the water for domestic purposes comes from the Baguio water
district. She doesnt practice fad diets and any restrictions on her foods. They have 1 dog living in their backyard.
The toilet is of manual flushed-type. Garbage is collected weekly.
Diagnostic/ Laboratory Results:
X-ray: Hands: reveals swelling are note overlying the proximal interphalangeal joints and
metacarpophalangeal joints
Chest: Mild Cardiomegaly
Doppler Ultrasound: Dilated left atrium with left atrial volume index of 29 cc/m3

Pathophysiology of Rheumatic heart disease and SLE

Predisposing factors:
-history of rheumatic heart fever
in her childhood, female, age: 17
years old

Precipitating:
-3 incidence of tonsillitis
every month

Streptococcal Infection

Antibiotic Therapy
X-ray:
Hands:
reveals
swelling are
note
overlying
the
proximal
interphalan
geal joints

Bind to receptors
in the synovial
joints
Autoimmune
response
Antigens are similar
to bodys own cell
that may result to
attack of healthy
body cells by

Increase production of
antigen (streptococci)
Antigen circulates to system

Attacks the heart valves

Inflammation of the layers of
the heart
Difficulty of heart to pump
Increase cardiac workload

Inflammation

Colchicin
e,
Arcoxia,
Methylpr
ednisolo

(+) Joint pains

Scarring of the heart valves

that damages the (mitral or
aortic valve)

Acute Pain related to

ongoing
inflammatory
process
-Impaired comfort

Decreased cardiac supply of

blood in different parts of the
body
Generalized body
weakness

Decrease immune
defense reaction
Paracetam
ol 500 mg
Prn for feer

Risk for imbalanced body

temperature
related
to
Increase
risk of
infection
infection
Fever may occur

-Activity Intolerance
related to generalized
body weakness
-Fatigue related poor
physical condition
-Risk for fall
-Risk for injury

X-ray: Mild Cardiomegaly

Doppler Utz: Dilated left
atrium with left atrial volume
index of 29 cc/m3
Increase
production of
lactic acid
Chest pain/
Tachycardia
Ineffective peripheral
tissue perfusion
related to decreased
blood supply

Arcoxi
a

References:
Chin, T.K. (2001). Rheumatic Heart Disease. eMedicine Journal. 2 (9). Retrived by www.emedicine.com
Doenges, M.E. et.al. (2010). Nurses pocket guide: Diagnoses, prioritized interventions and rationales. F.A.
Davis Company. Philadelphia.
12th Edition. Pp. 586-591, 608-614, 333-337.
Smeltzer, S. et.al. (2010). Brunner and Suddarths textbook of Medical-Surgical Nursing. 10 th Edition. Pp. 795801.
LIST OF PRIORITIZATION:

PRIORITIZATION
1. Acute pain related to ongoing inflammatory
disease
1.1 Impaired comfort

JUSTIFICATION
This is the first prioritized problem because this is what
the patient complains about and it is an actual problem
existing that may result to further complications if not
resolved first. According to Maslows hierarchy of needs
under physiologic needs rest is needed and should be
met firs before moving to the level of hierarchy.

2. Ineffective peripheral tissue perfusion related to

decreased blood flow

This is the second priority because according to the

ABCs of life circulation should be prioritized first and to
prevent possible or further complications of decreased
blood flow.

3. Activity Intolerance related to generalized body

weakness/pain
3.1. Fatigue related poor physical condition
3.2 Risk for fall
3.3. Risk for injury

This is the third priority because this can be solved if the

above problems will be solved. And also according to
Maslows hierarchy of needs this falls under Safety which
needs to be met before going to the next level of
hierarchy. And I clustered the other 3 problems into this
since they will have the same or similar nursing
interventions and the risks will not occur if given
appropriate interventions.

4. Risk for imbalanced body temperature related to

infection/inflammation

This is my last prioritized problem since it is a potential

problem that may arise if the above problems will not be
resolved and also it can be corrected immediately with

paracetamol or drug administration.

NCP 1
ASSESSMENT

BRIEF
EXPLANATION OF
THE PROBLEM

S> .

LTO/STO

LTO: After 72
hours of nursing
interventions the
client will be able
:

O:

NURSING
INTERVENTIONS
Dx:

TX

. (Doenges,
M.E.et.al.,2014)

(Creditor, 1994).
(Prizant-Weston,
Castiglia, 1992).
Ed:

Reference:
Doenges, M.E.
et.al.(2010).
Nurses Pocket

With references
per rationale
. (Doenges,
M.E.et.al.,2014)

(Eliopoulous,
1998).

STO: After 8
hours of nursing
interventions the
client will be able
to:
a.

A> Ineffective
peripheral
tissue
perfusion
related to
decreased
blood flow

RATIONALE

CRITERIA FOR
EVALUATION/
EALUATION
After 72 hours of
nursing
interventions
LTO:
Fully met if
Partially met if
Not met if:

STO :After 8
hours of nursing
interventions the
client will be able
to:
Fully met if: able
to:
Partially met if:
Not met if:

Guide:
Diagnoses,
Prioritized
interventions and
rationale. F.A
Davis Company.
12th Edition. Pp.
69-73.
NCP 2
ASSESSMENT

S> Nahihirapan
pong maglakad,
tsaka mabagal
po.
O:- With
functional level of
2.
- Muscle strength
of both left and
right upper
extremities: 3/5,
both lower
extremities: 4/5.
-Needs
assistance in
doing ADLS such
as toileting or
transferring from

BRIEF
EXPLANATION OF
THE PROBLEM
Since my patient
is diagnosed of
having
Rheumatic heart
disease which
means it is
caused by
streptococcus
infection in which
my patient has
sensitivity to the
antibodies that
were formed in
response to the
invading
bacteria. Since
there is an
increase
production of

Goals and
Objectives

NURSING
INTERVENTIONS

LTO: After 72
hours of nursing
interventions the
client will be able
to

Dx:
1.Assessed
functional level of
assistance

a. have a muscle
strength of 5/5 in
all extremeties
with no pain and
discomforts
a.Walk on her
own without
assistance.
c. Will not
develop any
complications

2.Assessed
muscle strength

RATIONALE

>to be able to
give the
appropriate
assistance
needed.
(Doenges,
M.E.et.al.,2014)
>to determine
current status
and needs
associated with
participation in
needed/desired
activities. Serves
as a basis for
determining the
effectiveness of

CRITERIA FOR
EVALUATION/
EALUATION
After 72 hours of
nursing
interventions
LTO:
Fully met if:
the client will be
able to
a.walk on her
own without
assistance
b.have a muscle
strength of 5/5 in
all extremeties
with no pain and
discomforts
c.Will not develop
any

one place to
another.
A :Activity
intolerance
related to
generalized
body
weakness/pai
n
3.1. Fatigue
related poor
physical
condition
3.2 Risk for fall
3.3. Risk for
injury

antigen it
circulates in her
system attacking
the valves of her
heart causing
inflammation.
Which makes the
heart difficult to
pump
blood.Because of
decrease cardiac
workload
,scarring of heart
valves
:mitral/aortic
valve is damage
which therefore
decreases
cardiac supply in
different parts of
her body ,in
which she
complain of body
weakness .
Activity
intolerance
according to
NANDA, is an
insufficient
physiological or
psychological

such as fall and

injury.
STO: After 8
hours of nursing
interventions the
client will be able
to:
a.Have a
muscle
strength of
4/5 on both
upper
extremities
b.Verbalize
needs for
assistance
c.Able to
change
position (from
left to right or
vice versa)
frequently

TX
3. Gradually
increase activity,
allowing client to
assist with
positioning,
transferring, and
self-care as
possible.
Progress from
sitting in bed to
dangling, to chair
sitting, to
standing, to
ambulation
4. Perform rangeof-motion exercis
es if client is
unable to tolerate
activity.

5. Allow for
periods of
rest before and

nursing
interventions.
(Doenges,
M.E.et.al.,2014)
>Increasing
activity helps to
maintain muscle
strength, tone,
and endurance.
Allowing the
client to
participate
decreases the
perception of the
client as
incapable and
frail (Eliopoulous,
1998).

>Inactivity
rapidly
contributes to
muscle
shortening and
changes in
periarticular and
cartilaginous
joint structure.
These factors
contribute to

complications
such as fall and
injury.
Partially met if:
needs minimal
assistance when
ambulating,5/5 in
all extremities
with pain or
discomforts
Not met if: Not
able not walk or
ambulate
And did not have
a muscle strength
of 5/5 in all
extremities.
STO :After 8
hours of nursing
interventions the
client will be able
to:
Fully met if: able
to:
a. Have a
muscle
strength of
4/5 on both
upper

energy to endure
or complete
required or
desired daily
activities.

Reference:
Doenges, M.E.
et.al.(2010).
Nurses Pocket
Guide:
Diagnoses,
Prioritized
interventions and
rationale. F.A
Davis Company.
12th Edition. Pp.
69-73.

after planned
exertion periods
such as meals,
baths,
treatments, and
physical activity.
6.Administer
Colchicine a
ordered

Ed:
7.Encourage to
ambulate and do
exercise as
tolerated

contracture and
limitation of
motion (Creditor,
1994).
>Rest periods
decrease oxygen
consumption
(Prizant-Weston,
Castiglia, 1992).

>The exact
mechanism of
action
of colchicine in go
ut is not
completely
known, but it
involves (1) a
reduction in lactic
acid production
by leukocytes,
which results in a
decrease in
uric acid
deposition, and
(2) a reduction
inphagocytosis,
with abatement o
f

extremities
b. Verbalize
needs for
assistance
c. Able to
change
position
(from left
to right or
vice versa)
frequently
Partially met if:
a. Ambulate
with
minimal
assistance
b. Still have a
muscle
strength of
3/5 on both
upper
extremities
c. Verbalize
needs for
assistance
d. Able to
change
position
(from left
to right or
vice versa)
frequently
Not met if:

the inflammatory
response.
8. Instructed to
call for SO for
assistance when
needed

>Both activity
tolerance and
health status
improves with
progressive and
appropriate
activity and
exercise
>to prevent fall
and injury, helps
move from one
place to another

a. Cant
Ambulate
without
assistance
b. Have a
muscle
strength of
3/5 on both
upper
extremities
c. Unable to
verbalize
needs for
assistance
d. Unable to
change
position (from
left to right or
vice versa)
frequently