PRIORITIZED NURSING FOR PROBLEM FOR RHEUMATIC FEVER

Nursing Diagnosis Nursing Intervention Rationale

Decreased cardiac output Diagnostic:

related to altered  Assess potential for/  Early detection of
myocardial contractility type of developing changes promotes
evidenced by mitral shock states. timely intervention to
stenosis/accumulation of limit degree of cardiac
fibrin on mitral valve dysfunction.

 To determine degree
 Monitor vital signs of assistance needed
frequently. by the patient and
note response to
activities/intervention.

 Monitor intake and  To decrease oxygen

output. consumption and risk
of decompensation.

THERAPEUTIC:
 To determine
 Keep patient on bed
alterations on fluid
rest/chair rest position
and electrolyte
of comfort.
balance.
 Administer oxygen
 To increase oxygen
supplement.
available for cardiac
function and tissue
 Assist with or perform perfusion for both
self-care activities for mother and the baby.
the client.
 Decrease cardiac
 Provide fluid and workload/provide
electrolytes as comfort
indicated.
 To minimize
dehydration and
dysrhythmias.
EDUCATIVE:
 Encourage Deep  Provide oxygenation.
breathing exercise.

 Instruct client to avoid  Can cause changes in

stressful activities. cardiac pressures and
or impede blood flow.

 To monitor condition
 Reiterate importance
and prevent
of regular pre-natal
complication
check-ups
especially on the fetal
side.
 Instruct to elevate legs
when on sitting
position.  To enhance venous
return.
PATHOPHYSIOLOGY of Rheumatic Fever