ALMOETE, ABEGAIL C.

NR – 23

NURSING CARE PLAN - RHEUMATIC HEART DISEASE

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective cues: Decreased Cardiac Rheumatic heart Goal: - Monitor BP, - Clinical indicators of After 8 hours of the
- Reports shortness Output related to a disease is a After 8 hours of the apical pulse, the adequacy of nursing intervention,
of breath (especially disturbance in the condition in which nursing intervention peripheral pulses cardiac output. the goal is met.
with activity or closure of the permanent damage the client will be Monitoring enables Because the client was
when lying down) mitral valve (valve to heart valves is able to alleviate early able to alleviate
- “Naninikip at ang stenosis). caused by feelings of chest detection/treatment feelings of chest pain,
bilis po ng tibok ng rheumatic fever. pain, palpitations, of decompensation palpitations, and
puso ko,” verbalized The heart valve is and shortness of shortness of breath.
by the patient. damaged by a breath. - Monitor - Routine blood work
- Reports previous disease process that laboratory tests can provide insight - The patient
history of rheumatic generally begins such as complete into the etiology of verbalized,
fever with a strep throat Objectives: blood count, heart failure and “Maginhawa na po
caused by bacteria 1. Verbalizations of sodium level, and extent of ang paghinga ko
Objective cues: called decreased serum creatinine. decompensation. tuwing nakahiga
- Trouble breathing Streptococcus, and episode of man o nakayuko 'di
- General malaise may eventually dyspnea and po tulad nang dati"
feeling rested Maintain adequate
- Swollen joints cause rheumatic - The capillary refill
2. Capillary refill ventilation and
- Prolonged capillary fever. The damage time came back to
time will come perfusion as in the
refill can cause valve normal
back to normal following:
- V/S taken as stenosis, valve - The patient was
follows: regurgitation 3. Display vital able to display
- Position patient - Upright position is
PR: 86 bpm and/or damage to signs within vital signs within
in semi-Fowler’s recommended to
RR: 12 bpm the heart muscle. acceptable limits acceptable limits
to high-Fowler’s reduce preload and
Temp: 37°C 4. The presence - The presence
ventricular filling
BP: 90/60 mmHg swollen joints swollen joints
when fluid overload
will be is the cause. were minimized
minimized
- Ensure patient - In severe heart
remains on bed failure, restriction of
rest or maintains activity often
activity level that facilitates
does not temporary
compromise decompensation.
cardiac output.

- Reposition - To prevent
patient every 2 occurrence of bed
hours sores

- Check for calf - Reduced cardiac

tenderness, output, venous
diminished pedal pooling, and
pulses, swelling, enforced bed rest
local redness, or increases risk
pallor of of thrombophlebitis.
extremity.

- Administer - Increases available

supplemental oxygen for
oxygen as myocardial uptake
indicated. to combat effects of
hypoxia.

- Administer - Depending on
medications as etiological factors,
prescribed, common
noting side medications include
effects and digitalis therapy,
toxicity. diuretics,
vasodilator therapy,
antidysrhythmic,
angiotensin-
converting enzyme
inhibitors, and
inotropic agents.