1.

Ineffective Breathing Pattern related to muscoskeletal fatigue as manifested by irregular

breathing patterns and use of accessory muscles.

INTERVENTIONS

1. Auscultate breath sounds and presence of adventitious sounds.

2. Observe chest excursion and decreased expansion of lack of symmetry.

3. Encourage client participation for deep breathing exercise and coughing.

4. Reinforce splinting of chest with pillows during deep breathing and coughing.

Rationale

1. Loss of active breath sounds ma reflect collapse of the lung segment.

2. This indicate further assessment of ventilation status.

3. Aids in lung re expansion and maintaining patency.

4. Reduces incisional tension, promote maximal lung expansion and enhance effectiveness of cough
effort.

5. Rate and effort may be increased by pain.

2. Decreased cardiac output related to prolapse of tricuspid valve secondary to RHD as evidenced
by bounding of pulse distended jugular vein, heart rate of 48 beats/ min.

INTERVENTIONS

1. Monitor vital signs such as blood pressure and pulses.

2. Monitor cardiac rhythm and frequency.

3. Encourage patient to stress management techniques such as quiet environment and ventilation.

4. Explain the need to rest

5. Assist the patient to resume activity very gradually

6. Provide safe and supportive environment

7. Restrict sodium and fluids then obtain daily weights.

Rationale:

1. For baseline data and monitor changes for complications

2. To determine irregular rhythm

3. Helps to facilitate relaxation and rest

4. To let the patient know the importance of rest especially the case of RHD.

3. Ineffective tissue perfusion related to decrease in peripheral blood circulation secondary to RHD
as evidence by delayed capillary refill than 2 seconds, pale and skin cold and respiratory rate of 25
cycles per minute.

INTERVENTIONS:

1. Monitor changes or continuous mental disorder like fainting.

2. Observe for pale, skin cold/humid and strength of peripheral pulses.

3. Monitor input and changes in urine output.

4. Assess for edema

5. Assess GI function, nausea/vomiting, abdominal distension, constipation

4. Activity intolerance related to decreased cardiac output and imbalance between myocardial
oxygen supply and needs secondary to rheumatic heart disease as characterized by cold/ humid
skin and decreased cardiac activity

INTERVENTIONS:
1. Assess the patients tolerance of activity for weakness and cold clummy skin.

2. Limit activity that are heavy advice patient to avoid strenuous activity.

3. Advice patient to avoid increase pressure during defecation

4. Dangle legs from bed side for 10 to 15 minutes orthostatic.

RATIONALE:

1. To prevent possible weakness and fainting during the activity.

2. It could worsen the patient when doing heavy activity.

3. Pressure during defecation provides pain in the chest / heart area.

4. To prevent orthostatic hypotension

5. Imbalanced Nutrition: less than body requirements related to increased metabolic needs caused
by disease process and limited intake of food secondary to rheumatic heart disease as characterized
by poor skin turgor, underweight, and thin appearance with a BMI of 17.3604

INTERVENTIONS:

1. Evaluate client’s weight and body size or mass.

2. Determine client’s ability to chew and swallow

3. Provide insight into dietary interventions.

4. Encourage to eat nutritious food such as food such as food rich in Omega 3

5. Encourage a rest period of 1 hour before and after meals and provide small frequent feedings.

RATIONALE:

1. To be able to plan and interventions on how to improve lifestyle and appropriate weight.

2. Difficult in chewing or swallowing decreased fluid intake

3. To have a nutritional plan and better food choices.

4. To increase weight and maximal nutrients.

5. This could help reduces fatigue during mealtime, and provides opportunity to increase total caloric
intake.