The document provides a nursing care plan for a patient with infective endocarditis. It includes three nursing diagnoses: 1) Decreased cardiac output related to altered heart rhythm and valvular issues; 2) Hyperthermia related to infection of cardiac tissue; and 3) Activity intolerance related to generalized weakness. For each diagnosis, it lists patient goals, outcomes, and interventions to address thermoregulation, energy management, and teaching about the disease process and prescribed medications.
The document provides a nursing care plan for a patient with infective endocarditis. It includes three nursing diagnoses: 1) Decreased cardiac output related to altered heart rhythm and valvular issues; 2) Hyperthermia related to infection of cardiac tissue; and 3) Activity intolerance related to generalized weakness. For each diagnosis, it lists patient goals, outcomes, and interventions to address thermoregulation, energy management, and teaching about the disease process and prescribed medications.
The document provides a nursing care plan for a patient with infective endocarditis. It includes three nursing diagnoses: 1) Decreased cardiac output related to altered heart rhythm and valvular issues; 2) Hyperthermia related to infection of cardiac tissue; and 3) Activity intolerance related to generalized weakness. For each diagnosis, it lists patient goals, outcomes, and interventions to address thermoregulation, energy management, and teaching about the disease process and prescribed medications.
Chapter 37: Nursing Management: Inflammatory and Structural
Heart Disorders
Care Plans - Customizable
eNCP 37-1: Nursing Care Plan
Patient with Infective Endocarditis
Nursing Diagnosis: Decreased cardiac output related to altered
rhythm, valvular insufficiency, and fluid overload as evidenced by heart murmur, S3, tachycardia, diminished peripheral pulses, adventitious breath sounds, decreased urine output, and restlessness (Outcomes and Interventions for this Nursing Diagnosis are presented in the Nursing Care Plan for Valvular Heart Disease on pp. to .) Nursing Diagnosis: Hyperthermia related to infection of cardiac tissue as evidenced by temperature elevation, diaphoresis, chills, malaise, tachycardia, and tachypnea
Patient Goal Maintains normal
body temperature Outcomes (NOC) Interventions (NIC) and Rationales Thermoregulation Fever Treatment % Sweating when hot ___ % Monitor temperature as % Shivering when cold ___ appropriate to determine % Apical heart rate ___ effectiveness of therapy and % Radial pulse rate ___ to prevent treatment-induced % Reported thermal comfort hypothermia. ___ % Administer antipyretic _____________________ medication as appropriate or Measurement Scale as ordered to reduce fever. 1 = Severely compromised % Administer medications as 2 = Substantially compromised appropriate to treat the cause 3 = Moderately compromised of the fever. 4 = Mildly compromised % Monitor white blood cell 5 = Not compromised count to evaluate patients response to treatment. % Monitor vital signs to assess cardiorespiratory response to fever. % Encourage intake of oral fluids to replace fluids lost as a result of fever. Nursing Diagnosis: Activity intolerance related to generalized weakness, arthralgia, and alteration in oxygen transport secondary to valvular dysfunction as evidenced by fatigue, malaise, weakness, painful joints, dyspnea, increased or decreased respiratory rate, and blood pressure (BP) changes
PATIENT GOAL Performs
activities of living with minimal fatigue or weakness OUTCOMES (NOC) INTERVENTIONS (NIC) AND RATIONALES Activity Tolerance Energy Management % Ease of breathing with % Monitor cardiorespiratory activity ___ response to activity (e.g., vital % Respiratory rate with signs) to plan or alter activity ___ activities. % Systolic BP with activity ___ % Monitor patient for % Diastolic BP with activity ___ evidence of excess physical % Ease of performing activities (e.g., tachycardia, of daily living (ADLs) ___ hypertension, diaphoresis, _____________________ dyspnea) or emotional fatigue Measurement Scale to plan for changes in activity 1 = Severely compromised level. 2 = Substantially compromised % Instruct patient/caregiver 3 = Moderately compromised to recognize signs and 4 = Mildly compromised symptoms of fatigue that 5 = Not compromised require reduction in activity (e.g., pulse increases >20 beats/min; no increase in activity if resting pulse >100 beats/min) since these signs indicate excessive cardiac effort. % Encourage alternate rest and activity periods to reduce cardiac workload.
Nursing Diagnosis: Deficient knowledge related to lack of
experience and exposure to information about disease and treatment process as evidenced by verbalization of misconceptions about desired or prescribed health behaviors as well as requests for information
PATIENT GOAL Describes disease
process, appropriate treatments, and measures to prevent recurrence of disease OUTCOMES (NOC) INTERVENTIONS (NIC) AND RATIONALES Knowledge: Disease Process Teaching: Disease Process % Description of specific % Review patients and disease process ___ caregivers knowledge about % Description of effects of condition to identify teaching disease ___ needs. % Descriptions of signs and % Discuss common signs and symptoms of complications ___ symptoms of the disease % Description of precautions (e.g., fatigue, malaise, chills, to prevent complications ___ elevated temperature, _____________________ anorexia) so health care Measurement Scale provider can be notified and 1 = None treatment initiated promptly. 2 = Limited % Discuss lifestyle changes 3 = Moderate that may be required to 4 = Substantial prevent future complications 5 = Extensive and/or control the disease process (e.g., avoiding persons with infection, taking prophylactic antibiotics before dental procedures) to reduce the risk of recurrent infective endocarditis. % Teaching: Prescribed Medication % Provide the patient and caregiver with information about the action, purpose, and side effects of the medications to promote safe medication therapy.
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