122 | a g e

123 | a g e

NURSING CARE: 1st Nursing Care PIan
Date
and
Time
Cues Need Nursing Diagnosis Objective of Care Nursing Intervention EvaIuation


D
E
C
E
M
B
E
R

S: "Lisudan ko ug
ginhawa
O:
-Temp of 36
-CR of 102 bpm
-PR of 100bpm
-RR of 23cpm
-BP of 100/80
- with crackles noted
-pinkish nailbeds

A
C
T

V

T
Y


mpaired Gas
Exchange related to
alveolar-capillary
membrane changes.
: Having ventricular
failure causes
pulmonary venous
blood volume and
pressure increases
forcing fluid from the
pulmonary
capillaries into the
pulmonary tissues
and alveoli. The
fluid-filled alveoli

Within my 8 hrs
span of care,
patient will be
able to improve
ventilation as
manifested by:

1. VS within
normal
range;
2. Have
pinkish
nailbeds
and
capillary

1. Monitor Vital Signs.
: To serve as a baseline
data
2. Assess level of
consciousness and
mentation changes.
: Altered LOC may
indicate inadequate
ventilation and oxygenation
3. Assess for cyanosis
and decreased
capillary refill.

December 10,
2010
@ 3pm
Goal Partially Met
At the end of 8 hrs
span of care, our
patient was able to
improve ventilation
as evidenced by:
1. VS of:
Temp of 35.8
124 | a g e


10,

2
0
1
0

7-3 shift

@ 7am


noted
-capillary refill of
2sec
-dyspnea with
exertion such as
rising up and
standing

ABG result:
pH of 7.485
PCO2 of 23.7
PO2 of 132.4
HCO3 of 17.7
mpression:
Respiratory Alkalosis
E
X
E
R
C

S
E

P
A
T
T
cannot exchange
oxygen and carbon
dioxide causing
impaired gas
exchange.
refill of 2-3
sec
3. Absence of
respiratory
distress
such as
shortness of
breath,
restlessnes
s, and use
of
accessory
respiratory
muscles;
4. Perform
behaviors to
improve
ventilation
and
adequate
oxygenation
: This may indicate
inadequate ventilation and
oxygenation
4. Elavate head of bed/
position on Semi-
Fowler.
: To promote better lung
expansion; maintain
airway/breathing
5. Perform Deep
Breathing Exercise
: To promote secretion
clearance, volume
expansion and ventilation
6. Encourage adequate
rest and sleep
: To conserve energy and
promotes adequate
CR of 96bpm
PR of 90bpm
RR of 20cpm
BP of 100/90
2. Have
pinkish
nailbeds
and
capillary
refill of 2sec
3. Absence of
respiratory
distress but
was still on
Oxygen
Therapy
4. Performed
behaviors
to improve
123 | a g e

E
R
N

oxygenation and ventilation.
7. nstruct to limit
activities to within
patient tolerance.
: To prevent oxygen
demand and conserve
energy
8. Perform relaxation
and stress reduction
techniques.
: To promote oxygenation
and ventilation.
9. Provide oxygen
therapy as ordered.
: To promote adequate
oxygenation.
ventilation
such as
performing
deep
breathing
exercise,
on Semi-
Fowler's
postion and
use of
relaxation
technique


126 | a g e

NURSING CARE: 2nd Nursing Care PIan
Date &
Time
Cues Need Nursing
Diagnosis
Objective of
care
Nursing Interventions EvaIuation

D
E
C
E
M
B
E
R

10


Subjective:
" nagalisud jud
ko ug ginhawa
nurse
as verbalized by
the patient

Objective:
CR 102

RR 23

Extra heart
sounds

A
C
T

V

T
Y

E
X

Decreased
cardiac Output
Related to
Structural
Changes;
valvular defects

:Presence of
valve defect
causes an
increase volume
of blood which
increases the
pressure of

After 6 hours
span of care
patient will be
able to prevent
further
complication as
evidence by:

a. Vital
signs
within
normal
range

b. Decreas

1.Auscultate apical pulse;
asses heart rate, rhythm.
Tachycardia is usually
present to compensate for
decreased ventricular
contractility.

2. Note heart sounds
S1 and S2 may be
weak because of diminish
Pumping action. Murmurs
may reflect valvular
incopetences/ stenosis
December 10 @ 2
pm

" GOAL PARTALLY
MET


After 6 hours span of
care patient was
able to prevent
further complication
as evidence by:

a. Decreased
127 | a g e

2010

@
8 am

7-3
Shift


Dyspnic

Orthopnea

Crackles

JVD



ABG result
of
Respiratory
Alkalosis

CRT of 3
sec


E
R
C

S
E

P
A
T
T
E
R
N
pumping of the
heart to force or
eject the blood.
ncreased
pressure causes
the heart to
dilate and
decreases the
heart's
contractility to
pump out blood
which soon
causes
decreased
cardiac output.
e
recurrenc
e of
dyspnea

c. Maintain
level of
consciou
sness.



.

3. Palpate peripheral
pulses.
decreased cardiac
output may be reflect in
diminished radial,
popliteal, dorsalis pedis.
Pulses may be fleeting or
irregular to palpation and
pulses alternans.

4. nspect skin for pallor,
cyanosis
Pallor is indicative of
diminished peripheral
perfusion secondary to
inadequate cardiac
output.

recurrence of
dyspnea

b. Maintain level
of
consciousnes
s
However, vital sign
still not within yhe
normal range.

128 | a g e





5. Monitor urine output,
noting decreasing output
and dark consentrated
urine.
Kidneys respond to
reduced cardiac output by
retaining water and
sodium. Urine output is
usually decreased during
day because of fluids
shifts into tissues but may
be increased at night
because fluid returns to
circulation when client is
recumbent.

6. Note changes in
sensorium.
May indicate
inadequate cerebral
129 | a g e

perfusion secondary to
decreased cardiac output.

7. Encourage rest,
semirecumbent in bed or
chair.
Physical rest should be
maintained to improve
efficiency of cardiac
contraction and to
decrease myocardial
oxygen demand,
consumption and
workload.

8. Provide bedside
commode.
Commode use
decreases work of getting
130 | a g e

to bathroom or struggling
to use bedpan

9. Administer
supplemental oxygen as
indicated
ncreases available
oxygen for myocardial
uptake to combat effects
of hypoxia.





131 | a g e

NURSING CARE: 3rd Nursing Care PIan

Date
&
Time

Cues

Need

Nursing
Diagnosis

Objective of
care

Nursing nterventions

Evaluation

DEC.
10,
2
0
1
0

@

7am



S:
"usahay mag-lisod
ko ug ginhawa as
verbalized by the
patient.

O:
- Presence of
crackles
heard upon
asculation
- VS:
T 36.0
PR - 100

A
C
T

V

T
Y

&

E

neffective
airway clearance
r/t pulmonary
edema
Due to the
pulmonary
edema; there is
an obstruction in
the respiratory
tract that leads
to difficulty in
breathing.



Within our 8
hour span of
care, our patient
will be able to
improve airway
patency as
manifested by:

1. RR within
normal
range
(12-20
cpm)

2. Minimize
presence
of
crakles

1. Established rapport.
To facilitate trust and
cooperation.
2. Monitor RR.
Serve as a baseline data
3. Auscultate for
breath sounds.
To ascertain status and
note progress
4. Positioned head
midline with flexion
appropriate for

"GOAL PARTALY
MET
Dec. 10, 2010
@ 3pm

At the end of our 8
hours span of care
our patient was able
to improve airway
clearance as
evidenced by:
1. RR of: 20
cpm

2. Still had
presence
of
132 | a g e

CR 102
RR- 23
BP- 100/80
- With ABG
result of:
Partially
compensat
ed
respiratory
alkalosis
with
hyperoxia
d/t
hyperventila
tion

- With x-ray
result of:
Pulmonary
vascular
marking
remain
prominent
attributed to
X
E
R
C

S
E

P
A
T
T
E
R
N
3. Participat
e in
treatment
regimen






.
condition.
To help or maintain open
airway.
5. Encourage patient to
drink more water (should
be warm.)
To liquefy secretions.
Using warm liquids may
decrease bronchospasm.
6. Teach patient to do
deep breathing exercise.
To mobilize secretions
so that patient may be able
to more easily expectorate
mucous secretions.
7. Position patient to High-
fowler's position/ Elevation
of head.
To promote lung
crackles

3. Patient
was
assertive
in the
treatment






133 | a g e

pulmonary
congestion.

Left minimal
pleural effusion
remains
unchanged.






expansion
8. Encourage patient to
rest.
To prevent fatigue.
9. Keep environmental
pollution to a minimum (ex.
Dust, smoke, and feather
pillows), according to
individual situation.
Precipitators of allergic
type of respiratory
reactions that can trigger
or exacerbate onset of
acute episodes
10. Change of Position
every 2 hours.
To take advantage of
gravity decreasing
pressure on the diaphragm
134 | a g e

and enhancing drainage of
ventilation to different lung
segment
11. nstruct patient/family
to notify nurse/physician of
sputum color changes,
increase work of breathing
or onset of chest pain.
To monitor signal of
worsening of condition that
requires immediate
medical intervention to
prevent further
complications.
12. Maintain a relaxed,
calm, non-stimulating
environment.
To assist client to
establish optimal sleep/
rest.
133 | a g e

NURSING CARE: 4th Nursing Care PIan
Date &
time
Cues Need Nursing
Diagnosis
Objective of care Nursing Interventions EvaIuation
7
3
shift
D
E
C
E
M
B
E
R

1
0
S: "Dali lang
ko kapuyon,
miski pagadto
lang sa CR.

"Miski maligo
lang ko,
maglisod na
ko ug
ginahawa.

"Miaki
maglakaw ko
gamay lang,
maglisod na
A
C
T

V

T
Y
-
E
X
E
Activity
intolerance r/t
imbalance
between
oxygen
supply

R: Due to the
inability of the
right ventricle
to pump
deoxygenated
blood to the
left lung
which
oxygenates
At the end of 8-hour
span of care,
patient will achieve
measurable
increase in activity
tolerance as
evidenced by:
a) Participation
in desired
activities such
as going to
the bathroom;

b) Reduced
fatigue and
weakness;
1. Check vital signs
before and
immediately after
activity, especially if
patient is receiving
vasodilators,
diuretics, or -
blockers.

R: Orthostatic
hypotension can
occur with activity
because of
medication effect
(vasodilation), fluid
shifts (diuresis), or
compromised cardiac
At the end of 8-hour
span of care, patient
achieved measurable
increase in activity
tolerance as
evidenced by:
a) Participation in
desired
activities such
as going to the
bathroom;

b) Reduced
fatigue and
weakness; and

136 | a g e


2010
ko mag
ginhawa.

O:
O Lethargic
O Upon
standing
up, she
would
lean her
hand to
the wall
O nitial VS
prior to
standing
up:
O T =
36.7C
O CR = 102
O PR = 100
R
C

S
E
pattern
the blood;
there is
imbalance in
the oxygen
supply of the
patient.
Because of
the increased
oxygen
demand
during the
activity and
decrease in
oxygen
supply, there
would be
activity
intolerance.


and
c) Vital signs:
T: 35.5
37.5C
P: 60 100
BPM
R: 12 20
CPM
BP: 90/60
130/90 mmHg.


pumping function.

2. Document
cardiopulmonary
response to activity.
Note tachycardia,
dysrhythmias,
dyspnea,
diaphoresis, pallor.


R: Compromised
myocardium /
inability to increase
stroke volume during
activity may cause an
immediate increase
in heart rate and
oxygen demand,
thereby aggravating

c) Vital signs:
T: 35.8C
P: 90 BPM
R: 20 CPM
BP: 100/90
mmHg.

137 | a g e

O RR = 23
O BP =
100/80
mmhg
O VS after
standing
up:
O T = 36.9
C
O CR = 107
BPM
O PR = 103
BPM
O RR = 27
CPM
O BP =
120/90
mmhg

















weakness and
fatigue.

3. Assess for other
precipitators / causes
of fatigue such as
treatments, pain,
medications.

R: Fatigue is a side
effect of some
medications such as
-blockers,
tranquilizers, and
sedatives). Pain and
stressful regimens
also extract energy
and produce fatigue.

4. Evaluate accelerating
138 | a g e
















activity intolerance.

R: May denote
increasing cardiac
decompensation
rather than over
activity.

5. Provide assistance
with self-care
activities as
indicated. ntersperse
activity periods with
rest periods.

R: Meets patient's
personal care needs
without undue
myocardial stress /
excessive oxygen
139 | a g e











demand.

6. Assist patient to
prioritize ADLs /
desired activities.

R: Promotes
adequate rest,
maintains energy
level, and alleviates
strain on the cardiac
and respiratory
systems.

7. Provide quiet
atmosphere; bedrest
if indicated. Stress
need to monitor and
limit visitors, phone
calls, and repeated
140 | a g e

unplanned
interruptions.

R: Enhances rest to
lower body's oxygen
requirements, and
reduces strain on the
heart and lungs.

8. Elevate the head of
the bed as tolerated.

R: Enhances lung
expansion to
maximize
oxygenation

9. Suggest patient to
change position
141 | a g e

slowly.

R: Minimizes
occurrence of
Orthostatic
hypotension,
dizziness, and
fainting

10. dentify / implement
energy-saving
techniques such as
using a shower
chair, sitting to
perform tasks.

R: Encourages
patient to do as
much as possible,
while conserving
142 | a g e

limited energy and
preventing fatigue.

11. Provide
supplemental
oxygen as indicated.

R: Maximizing
oxygen transport to
tissues improves
ability to function.



143 | a g e

NURSING CARE: Discharge PIanning

edication
1. Furosemide (Lasix) 40 mg 1 tab OD 6 am
2. AIdactone 50 mg 1 tab OD 6 am
3. Lanoxin 0.25 mg 1 tab OD 6 am
HeaIth Teachings (Furosemide) RationaIe
1. Take one tablet of Furosemide
(Lasix) 40 mg once a day every
6 AM.
So that diuresis does not interfere with
the patient's night-time rest
2. Change positions slowly. To minimize orthostatic hypotension
3. Avoid alcohol, exercise during
hot weather and standing for
long periods.
May enhance orthostatic hypotension
during therapy
4. Consult health care professional
before taking OTC medication or
herbal products concurrently
with this therapy.
Unprescribed medications may have
unsure actions that may possibly harm
the health of the client.
5. Use sunscreen and protective
clothing.
To prevent photosensitivity reactions

HeaIth Teachings (AIdactone) RationaIe
1. Take one tablet of Spironolactone
(Aldactone) 50 mg once a day
every 6 AM.
Promotes progression of the patient's
health status and avoid error
2. Emphasize the importance of
continuing to take this medication,
even if feeling well. Take missed
To avoid under dosage or over dosage
of the drug
144 | a g e

doses as soon as remembered
unless almost time for next dose.
Do not double dose.
3. Avoid exposure to direct sunlight Drug can cause photosensitivity
4. Avoid activities requiring alertness
until response to medication is
known.
May cause dizziness
5. Consult with health care
professional before taking any
OTC decongestants, cough or
cold preparations concurrently
with this medication.
Because of potential for increased
blood pressure

HeaIth Teachings (Lanoxin) RationaIe
1. Take one tablet of Digoxin
(Lanoxin) 0.25 mg once a day
every 6 AM.
Promotes progression of the patient's
health status and avoid error
2. Take missed doses within 12 hour
of scheduled dose or not taken at
all. Do not double dose. Consult
health care professional if doses
for 2 or more days are missed. Do
not discontinue medication without
consulting health care
professional.
To avoid under dosage or over
dosage of the drug
3. Take pulse and to contact health
care professional before taking
medication if pulse rate is <60 or
>100.
Taking the drug may further
decrease or increase the heart rate
of the patient
4. Stress importance of reporting Early recognition of developing
143 | a g e

signs / symptoms of digitalis
toxicity such as:
O Development of G and
visual disturbances
O Changes in pulse rate /
rhythm
complications may prevent toxicity /
hospitalization
5. Do not take OTC drugs without
consulting the health care
provider.
To avoid adverse drug interactions


146 | a g e

Exercise
HeaIth Teaching RationaIe
1. Avoid prolonged bed rest. Prolonged bed rest has
deconditioning effects and risks such
as pressure ulcers (especially in
edematous patients), venous
thrombosis, and pulmonary embolism.
2. A total of 30 minutes of physical
activity every day should be
encouraged such as:
O Daily walking regimen for
30 minutes.
Exercise training has many favourable
effects for HF, including increasing
functional capacity and decreasing
dyspnea.
3. Before undertaking physical
activity, the patient should be
given the following safety
guidelines:
O Begin with a few minutes
of warm-up activities.
O Wait 2 hours after eating a
meal before performing the
physical activity.
O Stop the activity if severe
shortness of breath, pain,
or dizziness develops.
O End with cool down
activities and a cool-down
period.
To promote wellness during the
activity and to prevent fatigue after the
activity
4. The degree of fatigue felt after the
activity can be used to assess the
response.
f the patient tolerates the activity,
short-term and long-term goals can be
developed to gradually increase the
147 | a g e

intensity, duration, and frequency of
the activity.
5. ncrease walking and other
activities gradually.
To increase functional capacity
without causing unusual fatigue or
dyspnea.
6. Balance activity with rest periods. Excessive physical activity or
overexertion can further weaken the
heart, exacerbating failure, and
necessitates adjustment of exercise
program.

Prevents fatigue, conserves energy,
and facilitates recovery
7. Avoid performing physical
activities outside in extreme hot,
cold, or humid weather.
t increases the cardiac workload
8. Encourage patient to have
frequent changes of position and
leg exercises.
Helps prevent pressure ulcers


148 | a g e

Treatment
HeaIth Teaching RationaIe
1. nstruct and receive return
demonstration of ability to take
and record daily pulse and blood
pressure and when to notify
healthcare provider.
Promotes self-monitoring of condition /
drug effect. Early detection of changes
allows for timely intervention and may
prevent complications such as digitalis
toxicity
2. Review signs / symptoms that
require immediate medical
attention such as: rapid /
significant weight gain, edema,
shortness of breath, increased
fatigue, cough, hemoptysis and
fever.
Self-monitoring increases client
responsibility in health maintenance
and aids in prevention of complications
such as pulmonary edema and
pneumonia.


3. Client should weigh self daily in
morning without clothing, after
voiding and before eating.
Weight gain of more than 3 lbs in a
week requires medical evaluation of
diuretic therapy.
4. Discuss general health risks
such as infection, recommending
avoidance of crowds and
individuals with respiratory
infections, obtaining yearly
influenza immunization and one-
tine pneumonia immunization.
This population is at increased risk for
infection because of circulatory
compromise.
5. Encourage patient to assume a
position that facilitates breathing.
The number of pillows may be
increased, the head of the bed
may be elevated, or the patient
may sit in a comfortable
n these positions, the venous return to
the heart (preload) is reduced,
pulmonary congestion is alleviated,
and pressure on the diaphragm is
minimized.
149 | a g e

armchair.
6. Support lower arms with pillows. To eliminate fatigue caused by the pull
of the patient's weight on the shoulder
muscles.
7. Encourage patient to control
identify factors that contribute to
anxiety and how to use
relaxation techniques to control
anxious feelings.

Encourage family members to provide
psychological support.
Emotional stress stimulates the
sympathetic nervous system which
causes vasoconstriction, elevated
arterial pressure, and increased heart
rate. This sympathetic response
increases cardiac workload.

By decreasing anxiety, the patient's
cardiac workload also is decreased.
Cardiac function may improve and
symptoms of HF may decrease.
8. Engage in diversional activities,
meditation, guided imagery, or
music therapy.
Promotes relaxation and decreases
anxiety
9. Advise patient who gets out of
bed at night to seat comfortably
in an armchair.
As cerebral and systemic circulation
improves, the degree of anxiety
decreases and the quality of sleep
improves.



130 | a g e

Hygiene
HeaIth Teaching RationaIe
1. Have a good oral hygiene
through visiting a dentist at least
once a year and by using a soft
toothbrush and toothpaste to
brush the teeth, gums, tongue,
and oral mucosa at least twice a
day, as well as rinsing the mouth
with an antiseptic mouthwash for
30 seconds intermittently
between tooth brushing.
Poor dental hygiene can lead to
bacteremia, particularly in the setting of
a dental procedure. The severity of oral
inflammation and infection is a
significant factor in the incidence and
degree of bacteremia.

Regular professional care combined
with personal oral care may reduce risk
of bacteremia.
2. Avoid nail biting. Bacteria may lodge into the nails and
nail biting transmits bacteria to the
patient.
3. Wash hands frequently. To avoid the spread of pathogenic
microorganisms
4. Have a good skin care by
applying ample amount of
moisturizer.
Excessive dryness or moisture
damages skin and hastens breakdown


131 | a g e

Out-Patient
HeaIth Teaching RationaIe
1. Keep regular appointments with
physician or clinic.
To evaluate the health status and the
effectiveness of treatment regimen
2. Report immediately to the
physician or clinic any of the
following:
O Gain in weight of 2-3 lbs (0.9
1.4 kg) in 1 day, or 5 lb (2.3
kg) in 1 week.
O Loss of appetite
O Unusual shortness of breath
with activity
O Swelling of ankles, feet, or
abdomen
O Persistent cough
O Development of restless
sleep; increase in number of
pillows needed to sleep
To prevent complications and to have
a prompt intervention


132 | a g e

Diet
HeaIth Teaching RationaIe
1. Have the patient eat small,
frequent meals.
t decreases the amount of energy
needed for digestion while providing
adequate nutrition.
2. Patient should adhere to a low-
sodium diet by reading food
labels and avoiding high-sodium
foods such as canned,
processed, and convenience
foods. Restrict sodium intake to
2000-3000 mg daily.
Sodium promotes fluid retention in the
body. Having a low-sodium diet
prevents fluid retention in different
parts of the body.

Dietary sodium intake of more than
3g/day can offset effect of diuretic
3. Minimize intake of sweets such
as chocolates, cakes, soft drinks,
etc.
Glucose serves as a medium of growth
for streptococcus. t may trigger an
episode of rheumatic fever which
makes her condition worse.
4. Eat vitamin C rich fruits and
vegetables such as papaya,
orange, melon and cauliflower
Strengthens the immune system
5. Eat potassium and magnesium
rich fruits and vegetables such
as banana, raisins and spinach.
Diuretics may cause depletion of these
nutrients.

n patients receiving digoxin,
hypokalemia can lead to digitalis
toxicity. Patients with HF may also
develop low levels of magnesium
which can add to the risk of
dysrhythmias.


133 | a g e

134 | a g e

PROGNOSIS

Rheumatic Heart Disease is a complication of Rheumatic Heart Fever.
According to the book of Joyce M. Black and Jane Hukanson Hawks, "Medical
Surgical Nursing for management for positive outcomes 8
th
edition (2009), t
says that RHF can be curable and by antibiotics in an early stage before it leads
to Rheumatic Heart Disease. RHD patient can also have a good prognosis if
early detection and early management can implement.
However, in the case of our patient where there are already visible
obvious signs and symptoms of severe complications of RHD, we rank it as Poor
Prognosis.




133 | a g e




136 | a g e

REFERENCES
BibIiography:
Black, J. and Hawks, J. Medical-Surgical Nursing: Clinical Management
for Positive Outcomes. 7
th
Edition. 2005. By Elsevier.
Bullock, B. and Henze, R. Focus on Pathophysiology. 2000. By
Lippincott Williams & Wilkins.
Deglin, J. and Vallerand, A. Davis's Drug Guide For Nurses. 10
th
Edition.
2007. By F.A. Davis Company
Doenges, M. et.al. Nursing Care Plans. Edition 7. 2006. By F.A. Davis
Company
Greyson, C. Critical care medicine. Pathophysiology of right ventricular
failure. January 2, 2008.
Gulanick, et.al. Nursing Care Plan. 6
th
Edition. 2007. By Elsevier
gnitavicius, D. and Workman, L. Medical- Surgical Nursing: Patient-
Centered Collaborative Care. 6
th
Edition. 2010. By Saunders, an imprint
of Elsevier nc
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ebIiography:
http://en.wikipedia.org/wiki/Mitral_stenosis
http://www.nlm.nih.gov/medlineplus/ency/article/000175.htm
http://www.cardiologychannel.com/aorticstenosis/index.shtml
http://www.merckmanuals.com/home/sec03/ch028/ch028f.html
http://rheumaticheartdisease.net/
http://heartdisease.about.com/od/heartvalvedisease/a/rheumatic_heart_di
sease.htm
http://www.wrongdiagnosis.com/medical/right_ventricular_failure.htm
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