SISTER NIVEDITA GOVERNMENT

NURSING COLLEGE
IGMC, SHIMLA

SUBJECT: MEDICAL SURGICAL NURSING

NURSING CARE PLAN
ON
Rheumatic Heart Disease

IDENTIFICATION DATA

 Name Gudi Devi

 Age 25 years
 Sex Female
 CR No. 202111089341
 Marital Status Married
 Ward/Bed No 45
  Address VPO Sundla distt. Chamba H.P.
 Religion Hindu
 Education 12th
 Occupation Housewife
 Date of Admission 12-8-2021
 Date of Discharge Not planned
 Consultant Dr. Sudhir Sharma
 Diagnosis Rheumatic Heart Disease

CHIEF COMPLAINTS:
On Admission: Patient was admitted in the hospital with chief complaints of:
 Fever × 3 days
 Difficulty in breathing since morning
 Weakness in all extremities ×2 months
 Restless on doing activities of daily living × 2 months
 Fatiguability× 1 year

On Assessment: (19/11/2019) On assessment patient is having

 Hypotension (B.P. 90/70 mm of Hg)
 Tachycardia
 Restless on doing activities of daily living

History of Present illness: The patient was apparently well 1year back and there were no signs
and symptoms present in patient. But patient had weakness in extremities, fatiguability, and
restlessness few months back but had no any checkup. On 19/11/2019 in morning patient had
shortness of breath, restlessness and brought to Medanta for management. At that time patient
vitals are checked and patient is having tachycardia, hypotension and dyspnea her
echocardiography was done and she was diagnosed with the RHD with MR.

Present surgical history: Mitral valve replacement surgery is planned for patient on
25/11/2019.
History of Past illness: Patient had history of on and off fever and sore throat from past 4 years
but not had any checkup because symptoms were relieved by taking tab. paracetamol 650mg.
Past surgical history: The patient had no any past surgical history.
Family History: In the family there is
No history of pharyngitis
No history of diabetes
No history of hypertension
No history of hypothyroidis
Family tree:

Sudesh kumar Guddi Devi

 Age 32 years Age 25 years

Rahul Anshu
Age 4 years Age 2 years

Type of family: Joint family KEY

No. of family members: 05
Male
Female
Married
Patient
Death

Sr. Name Age Relationship Education Occupatio Marital Health

no. with patient n status status
1 Kanta devi 60 Mother in law Uneducated Housewife Widow Healthy
2 Sudesh 32 Husband Graduation Private job Married Healthy
kumar
3 Guddi 25 Self 12th Housewife Married Unhealthy
devi
4 Rahul 4 Son Graduate - Unmarried Healthy
5 Anshu 2 Daughter Pursuing - Unmarried Healthy
graduation

Personal and Social History:-

 Health Facility Near home: Civil Hospital, Chamba

Type: Government
Distance from home: 3 kms
Transportation facility: Yes
 Housing: Owned
Type: Pucca
 No. of Rooms: 5
Toilet: Indian
Electricity: Yes
Drinking water source: Tap Water
 Personal Hygiene: Maintained
Oral Hygiene: Maintained
Diet: Non-Vegetarian
Sleep and rest: Patient used to sleep 8 hours/day.
Elimination: Normal pattern
 Mobility and Exercise: No any regular walking habits
 Substance Use:
Alcohol: No alcohol intake
Drugs: No drug abuse
Addictions: No addiction of alcohol and tobacco
 Sexual & Marital History: Spouse: General Health: Good
Relationship: Satisfactory
Staying: Together

PHYSICAL EXAMINATION
General status
 Nourishment: Patient is under-nourished.
 Body build: Patient body build is average.
 Look: Patient looks anxious and worried.
 Health: Patient is unhealthy.
 Activity: Patient activity level is reduced
 Gait: Normal
 Foul body odour: Not present
 Weight: 49 kg
 Height: 5’2

Mental status:
 Consciousness: Patient is conscious

Vital signs:
 Temperature: 98.70 F
 Radial pulse: 110 b/min
 Respiration: 10 b/min
 Blood pressure: 90/70 mm of Hg

Skin:
 Color: Patient looks cyanosed and pallor skin.
  Lesions: Not present
 Scars: Not present
 Bruises: Not present
 Edema: Edema present over all extremities.

Head:
 Hair color: Black in color
 Scalp: Clean

Eyes:
 Vision: Normal
 Eyebrows: Symmetrical
 Cornea, sclera, conjunctiva are dry
 Papillary response: Pupils are 2mm reacting bilaterally

Ears:
 Symmetry: Symmetrical
 Auditory acuity: Normal
 Abnormal discharge: Not present
Nose:
 Shape: Normal
 No any blockage, polyps, abnormal discharge is present.
 DNS: No septal deviation

Mouth:
 Lips: Lips are dry
 Buccal mucosa: Buccal mucosa is dry
 Teeth: No discoloration, no dental caries
 Dentures: Absent
 Gums: Swallon
 Tongue: Tongue is dry

Neck:
 Range of motion: Limited range of motion
 Glands: Not enlarged

Cardiovascular System:
 Inspection: capillary refill: > 3seconds
 Percussion: Pericardial Effusion: Absent
 Palpation: No any swelling
 Auscultation: Heart sounds: Murmur sound present
 Any dysrhythmias: patient is having sinus tachycardia

Respiratory System:
 Inspection: Chest shape: Normal
 Symmetry: Symmetrical
 Breathing pattern: Dyspnea and shortness of breath
 Percussion: Pleural effusion: No sign of pleural effusion is present
  Auscultation: Diminished breath sounds

Lymphatic System:
 Inspection: No visible lymph node enlargement
 Palpation: No lymphadenopathy

Gastrointestinal System:
 Inspection: Shape: Normal
 Abdominal girth: Normal
 Scar: No visible scar on abdomen
 Distention: Absent
 Auscultation: Bowel sounds: Normal
 Percussion: Ascites: Absent
 Palpation: No any lump is palpated
 Organomegaly: Spleenomegaly: Absent
 Other complaints: Bowel per day: Normal bowel pattern.

Genitourinary System:
 Inspection: Patient is having urinary catheter
 Urine colour and amount: Pale urine
 Palpation: Bladder distention: Present

Musculoskeletal System:
 Inspection: Edema over both upper and lower extremities
 Range of motion of upper and lower extremity: Limited range of movement in both upper
and lower extremities.
 Muscle tone: Normal
 Palpation: Joint tenderness: Present

Nervous system:
 Level of consciousness: GCS: E4VTM6
 Memory: Intact
 Attention span: Normal
 Reflexes: Normal
 Motor functions: Intact
 Sensory functions: Intact

Integumentary system:
 Complexion: Pale
 Skin turgor: Decreased
 Leisons: Not present
 Edema: Absent
 Temperature: patient skin is cold to touch
 INVESTIGATION/ DIAGNOSTIC EVALUATION

GENERAL INVESTIGATIONS:

 Complete blood count:

Sr.No. Investigations Normal Patient’s Patient’s Remarks

value value value
(Units) 12-11-19 19-1-2019
1 Hemoglobin gm/dl 13-14 11.0 11.1 Decreased

2 Platelet counts per 150- 231 233 Normal

microliter
400×109
3 TLC cells/cumm 4000- 20000 15000 Increased
11000
4 PT(seconds) 9-12 12.2 - Increased
5 INR <1.1 0.89 - Normal
6 APTT(seconds) 30-40 27.4 - Decreased

 Renal function test:

Sr. Investigations Normal Patient’s Patient’s Remarks

No. value value value
(Units) 12-11-2019 19-11-2019
1 Potassium (mEq/L) 3.5-4.5 3.8 4.2 Normal
2 Sodium (mEq/L) 135-145 143 142 Normal
3 Chloride (mEq/L) 96-110 108 105 Normal
4 Calcium (mg/dl) 8.2-10 6.6 8.0 Decreased
5 Phosphorus(mg/dl) 2.5-4.5 mg/dl 3.5 3.5 Normal
6 Urea (mg/dl) 7-20mg/dl 13 13 Normal
7 Creatinine (mg/dl) 0.6-1.2 mg/dl 0.9 0.6 Normal

 Liver function test:

Sr.No. Investigations Normal value Patient’s value Remarks

15-1-2019
(Units)
1 SGOT/AST 10-40IU/L 31 Normal
2 SGPT/ALT 10-40IU/L 39 Normal
3 ALP 40-112U/L 61 Normal
 4 Protein total (gm/dl) 6-8.5g/dl 6.7 Normal
5 Albumin (gm/dl) 3.5-5g/dl 4.2 Normal
6 Bilirubin total (U/lt) 0-1mg/dl 0.42 Normal
7 Bilirubin Direct 0-0.35mg/dl 0.12 Normal
(U/lt)
8 Bilirubin Indirect 0.2-0.65mg/dl 0.30 Normal
(U/lt)

 Thyroid function test:

Sr.No. Investigations Normal value Patient’s value Remarks
15-11-2019
(Units)
1 T3 (ng/dl) 80-180 110 Normal

2 T4 (ng/dl) 0.7-1.9 0.8 Normal

3 TSH (mIU/L) 0.4-4.0 2.8 Normal

SPECIFIC INVESTIGATION:
 ECG: ECG findings showed prolonged PR interval.
 ECHO: EF is 40%
 Antistreptolysin-O titer: Increased Antistreptolysin-O titer i.e. 300 IU
 Throat culture: Positive throat culture for group A streptococci.

MEDICATIONS

Sr. DRUG NAME DOSE ROUTE FREQU ACTION NURSING

No -ENCY RESPONSIBILITIES

1 Tab. Metolar XL 25 mg P.O. O.D. Beta- Obtain current BP and

Blockers apical pulse rate; if
below 90 systolic or 60
beats per minute hold
the drug and notify
physician.
2 Tab.Digoxin 0.25 P.O. O.D. Cardiac Monitor vitals before
mg Glycosides administration and if
heart rate is less than
60b/min. then withhold
the drug and inform to
 physician.
3 Tab. Dytor 10 mg P.O. B.D. Diuretics Monitor I&O with
daily weights. Assess
for improvement in
edema.

4 Inj. Meropeneum 1.2 I.M. B.D. Antibiotics Observe IV site closely

mEq for extravasation.
Observe for skin
rashes.

5 Inj. Vitamin K 10 mg I.M O.D. Coagulants Educate patient to

avoid taking food rich
in vit. K e.g. broccoli,
cabbage, tomatoes etc.
till drug regimen is
stabilized.

6 Tab. Thyroxine 125 P.O. B.B.F. To treat Give this medicine in

mg hypothyroid empty stomach.
-ism Advice patient to not
take anything after
taking thyroxin till half
an hour.
7 Tab. Pantop 40 mg OD Orally Protein Give medication in
empty pump empty stomach.
stomach inhibitor Assess GI symptoms
such as epigastric pain,
bleeding and anorexia.
Monitor for possible
drug induced adverse
reactions.

NURSING MANAGEMENT:
Nursing Assessment:
 Assess the general condition of patient.
 Vitals of patient are monitored.
 Breathing pattern of patient is assessed i.e. patient is having shortness of breath.
 Assess the pain level, intensity, location.
 Assess the mobility level of patient.
 Assess the urinary pattern of patient.
 Assess the nutritional status of patient

GOALS:
Short term goals:
 To maintain adequate cardiac output.
  To maintain adequate tissue perfusion.
 To maintain fluid and electrolyte balance.
 To restore patient ability to perform daily activities.

Long term goals:

 To prevent further complications of disease condition.
 To provide psychological support to patient and family members.
 To provide health education to patient and family regarding patient condition, treatment
and prognosis.
 To encourage patient for regular follow up.

NURSING DIAGNOSIS:

1) Diagnosis: Decreased cardiac output related to valvular incompetence as evidenced by

murmur, dsyrhythmias, dyspnea and peripheral edema
Expected outcomes: Cardiac output will be maintained to some extend as evidenced by normal
breathing pattern and normal heart rhythm.
2) Diagnosis: Ineffective tissue perfusion related to interruption of blood flow as evidenced by
cyanosis, pallor skin.
Expected outcome: Tissue perfusion will be maintained to some extend as evidenced by
reduction in pallor and cyanosis.
3) Diagnosis: Excess fluid volume related to incompetent valves as evidenced by peripheral
edema, neck vein distension, weight gain.
Expected outcome: Fluid volume will be maintained to some extend as evidenced by
monitoring weight and reduction in edema over patient body.
4) Diagnosis: Activity intolerance related to insufficient oxygenation secondary to decreased
cardiac output and as evidenced by weakness, fatigue, shortness of breath, pulse and BP changes.
Expected outcome: Activity level of patient is maintained to some extend as evidenced by
monitoring vital signs.
5) Diagnosis: Knowledge deficit related to disease condition, treatment and its prognosis and
evidenced by frequent questioning by patient and family members of patient.
Expected outcomes: knowledge level of patient and family will be improved to some extend as
evidenced by asking question regarding disease condition.

HEALTH EDUCATION
DIET:

 Patient is educated to avoid consuming alcohol.

 Patient is educated to take low-salt and low-fat diet e.g limit butter, red meat, fried foods.
 Patient is educated to eat high-fibre foods such as fruits and vegetables such as beans,
legumes.
  Patient is educated to take diet rich in whole grains to maintain proper weight.
 Patient is advice to take adequate water and fluids to maintain hydration.
 Patient is educated to maintain adequate weight.

EXERCISE:
 Patient is educated to DO NOT stand or sit in the same spot for too long. Move around a
little bit.
 Walking is a good exercise for the lungs and heart. Take it slowly at first.
 Patient is advised to climb stairs carefully because balance may be a problem. Hold onto
the railing. Rest part way up the stairs if you need to. Begin with someone walking with
you.
 Patient is educated to stop activity if she feels shortness of breath, dizzy, or have any pain
in your chest.
 Patient is educated to DO NOT do any activity or exercise that causes pulling or pain
across chest, (such as using a rowing machine, twisting, or lifting weights.

PERSONAL HYGIENE:
 Patient is educated to limit contact with people after with colds or viruses to prevent
further chances of infection.
 Patient is educated to wash hands properly and maintain personal hygiene to reduce risk
of infection.

REST AND SLEEP:

 Patient is educated to take proper rest and sleep.
 Patient is educated to follow alternative rest and activity period.

FOLLOW UP:
 Patient is educated to report immediately to physician about any complication after
surgery.
 Education regarding wound care is given.
 Patient is encouraged for regular follow up.
 Health education regarding prescribed medicine with rational and common side effects is
given to patient and family members.
 Health education regarding patient disease condition, treatment and prognosis is given to
patient and his family.

NURSING RECORDS:
Patient Mrs. Guddi Devi admitted in hospital on 12-11-2019 with chief complaints of

 Fever × 3 days
 Difficulty in breathing since morning
 Weakness in all extremities ×2 months
 Restless on doing activities of daily living × 2 months
 Fatiguability× 1 year.
Patient is diagnosed as Rheumatic Heart Disease with mild MR. Patient is admitted in Super
Speciality Ward and mitral valve replacement surgery is planned for patient on 25-11-2019.
On 19-11-2019: General condition of patient is assessed.
 History collection is done
 Physical examination is done.
 Vitals of patient are monitored.
 Intake output is strictly monitored.
 Back care is given.
 Catheter care, eye care, oral care is given.
 Medicine given as per chart.
 Investigation reports are collected and analyzed and informed to physician.
 Health education regarding surgery is given to patient to reduce anxiety level.
 Psychological support is provided to patient.
 Health education is given to patient and family regarding patient condition, treatment and
prognosis.