NURSING CARE PLAN

NAME OF PATIENT: Rey (8 years old) WARD: _______________________________________

DIAGNOSIS: Rheumatic Heart DATE: March 18, 2020

ASSESSMENT BACKGROUND NURSING OBJECTIVES NURSING RATIONALE EVALUATION

KNOWLEDGE DIAGNOSIS INTERVENTION

Subjective: Acute rheumatic Decreased 1. After 1hr of Independent: - Decrease cardiac 1. Patient is able to
- “naninikip dibdib heart disease is a Cardiac Output nursing intervention, - Keep patient on workload/provide sleep / verbalize
ko po minsan” complication of R/T Altered the patient will be bed rest/chair rest comfort feelings of comfort
- Joint pain rheumatic fever Contractility able to alleviate position of comfort or rest and report
in which the heart Secondary to feelings of chest that pain has been
Objective: valves are Acute Rheumatic pain and shortness - monitor vital - to note client’s reduced
- Temp 39 damaged. Heart Disease of breath and signs and cardiac current state or
degrees Celsius Rheumatic heart verbalize feelings of rhythms frequently response to activities 2. Patient is no
- BP 90/60 disease comfort / rest. as well as and interventions. longer in a febrile
- RR 21 chronically hemodynamic state and vital signs
- PR 90 manifests as 2. Within the shift, measurements as are within client’s
- Mitral Stenosis congestive heart patient’s vital signs indicated normal range
- increased failure from will return to normal
WBCs and APRs valvular range according to Dependent: 3. Patient and/or
involvement. client’s parameters - Administer - to increase oxygen family is able to
Most commonly oxygen via face available for cardiac verbalize
the mitral valve is 3. Patient and family mask or ventilator function / tissue understanding of
affected, will be aware of his as ordered perfusion client’s condition
resulting in mitral condition and are and is able to state
stenosis or mitral able to manage - Administer - Antibiotics are used at least 5
regurgitation disease after the medications as to treat the underlying statements
which reduces student nurse ordered streptococcal infection concerning
the blood that conducts health and prevent further information or
goes into the teachings damage. Analgesics management.
systemic are used to treat the
circulation. pain caused by RHD
 and antipyretics to
treat febrile state.
Collaborative:
- Instruct client and - this can cause
family to avoid / changes in cardiac
limit activities that pressures and impede
may stimulate the blood flow
Valsalva response
(e.g. bearing down
during bowel
movements)

NAME OF STUDENT: Jenny Juniora Ajoc CLINICAL INSTRUCTOR: Prof. Alvin Imperio RN, MAN
BLOCK & YEAR: BSN 210