ADRIAN G. MALLARBSN 2FOCUS: CHEST PAIN

NURSING CARE PLAN – RHEUMATIC HEART DISEASEASSESSMENT SCIENTIFIC

BACKGROUNDDIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:“naninikip ang dibdib ko,” verbalized by the patient.

Complaints of palpitations

fatigue

OBJECTIVE: dyspnea Restless edema Pallor clammy skin Prolonged

capillary refill

oliguria Vital signs:

BP: 90/60 mmhgPR: 86 bpmRR: 12 bpmTemp: 36 oC

Inadequate blood pumped by the heart to meet the metabolic demands of the body.

Decreased cardiac output related to altered myocardial contractility evidenced by mitral stenosis/accumulation of fibrin on mitral valve.

STO>After 15 minutes of nursing intervention, the patient will be able to alleviate feelings of chest pain and shortness of breath.

LTO>After 3-4 days of continuous nursing intervention, the patient will be able to decrease episodes of dyspnea, angina and dysrhythmias through proper intervention.

Diagnostic: Assess

potential for/ type of developing shock states.

Monitor vital signs frequently.

Monitor intake and output.

THERAPEUTIC:

Keep patient on bed rest/chair rest

Early detection of changes promotes timely intervention to limit degree of cardiac dysfunction.

To determine degree of assistance needed by the patient and note response to activities/intervention.

To decrease oxygen consumption and risk of decompensation.

To determine alterations on fluid and

STO: goal met: patient was able to breathe within normal range and decrease feelings of chest pain.

LTO: goal met the patient was able to demonstrate improved breathing pattern and decreased episodes of chest pain.

position of comfort.

Administer oxygen supplement.

Assist with or perform self-care activities for the client.

Provide fluid and electrolytes as indicated.

EDUCATIVE: Encourage

Deep breathing exercise.

Instruct client to avoid stressful activities.

Reiterate importance of regular pre-natal check-

electrolyte balance.

To increase oxygen available for cardiac function and tissue perfusion for both mother and the baby.

Decrease cardiac workload/provide comfort

To minimize dehydration and dysrrhythmias.

Provide oxygenation.

Can cause changes in cardiac pressures and or impede blood flow.

To monitor condition and prevent complication

ups

Instruct to elevate legs when on sitting position.

especially on the fetal side.

To enhance venous return.