NURSING CARE PREPARATION

Student Name: Diana Millan

Unit/Room Number: IMCU 243
Age: 62
Gender: Male
Eriksons Developmental Level: Generativity vs.
Stagnation

Date of Care: 5/13/14

Date of Admission: 5/12/14
Ethnic/Cultural Preferences: Unknown
Allergies: NKA
Code Status: Full Code

Primary Diagnosis:
Rheumatic Fever

Co-morbidities:
Chest pain, anal or rectal pain possible hemorrhoids, joint pain pelvis left hip pain
No further medical hx

Discharge Plan (add day of clinical):

Patient is to be discharged today May 13, 2014, following one day of observation. Before discharge, teach the
patient about disease process and expected prognosis. Teach the patient regarding antibiotic therapy and
importance of adhering to regimen. Teach the patient about preventing congestive heart failure as a result of
rheumatic fever. Patient will need to make lifestyle modifications, including heart healthy diet and exercise and
should consider finding a different job with less exposure to disease-causing bacteria that may further affect his
immune system. Refer patient to community resources. Assess need for help upon return home.
Preliminary Integrated Pathophysiology primary diagnosis (what is going on with your client at the cellular
level for the health condition). Explain how your clients primary diagnosis, co-morbidities, medications and
labs interrelate. 1-3 page APA formatted.

Data Collection (Record exactly what is writtenA on the personal information sheet [aka Kardex]. Any
assessment/elaboration should be made on the assessment sheet):
Diet (Type):
IV (Fluid type, rate, access type): IV lock right arm,
AHA
no fluids running, NaCl flush PRN
I&O (MD order/Nursing Order/Frequency):
CBG (Yes/No, frequency): NO
Yes
Fall Risk/Safety Precautions (Yes/No):
Activity (What is the patient activity level): Encourage
NO
early ambulation; up ad lib
Wound Care (Yes/No): NO
Oxygen (Yes/No, Delivery method, how much): No
Drains (Yes/No, Type): NO
Other Tubes: N/A

Last BM: May 13, 2014 ~0900

ASSESSMENTS
(Include Subjective & Objective Data)
Integumentary:
Braden score 22- No risk
Skin pink, warm, dry
Feet-dry, nails are thin
Skin color appropriate for ethnicity
No tenting
Localized rash on back, no itching
Peripheral IV on right arm-saline lock: clean, dry,
intact, no signs of swelling or inflammation
Eyes/Ear/Nose/Throat:
Ears, nose: symmetrical, no drainage or discharge, no
tenderness
Eyes: uses glasses
Pupils: PEARRLA
No lesions or redness of eyes, ears, nose
Not able to hear on left ear patient states it is r/t ear
tube/drum removal
No difficulty swallowing
Oral mucosa, tongue: pink, moist
Non-productive cough
Cardiac:
Apical pulse: 83 regular
Skin pink, warm, dry,
Radial pulse: strong and regular, equally bilateral
Pedal pulses: weak, equally bilateral
Capillary refill: less than 3 sec upper and lower
extremities
No JVD
No edema
BP: 106/74
Cardiac monitoring
- Regular rhythm
- HR 88
- QR interval: 0.08
- PR interval: 0.16
- QT interval: 0.36
- Normal sinus rhythm
Genitourinary:
Continent- pt gets up to use the bathroom-output not
being measured
No GU hx
No burning/pain with urination
Intake: 1600 mL
Neurological/Psychosocial
Awake, alert, oriented X4
Clear speech
Pupils: PEARRLA
Strong bilateral grips

Head and Neck:

Head: round, soft
Alopecia
Moderate headache 5/10 on scale of 0-10; worsens
during cough, patient describes it as an explosion
Neck: no masses, swelling, no tenderness on
palpation, trachea midline

Thorax/Lungs:
Chest symmetrical
Equal chest rise and fall
Lung sounds: all lobes clear to auscultation
RR 16, regular pattern and depth
No dyspnea
No pain with inspiration/expiration
SaO2: 95 % room air

Musculoskeletal:
Hx: bilateral knee surgery
Up as tolerated; ambulated by self
Morse fall risk: 20- low risk
Posture: erect
No ROM deficits in upper or lower extremities; no
muscle strength deficits
Pain, tenderness in left hip r/t worsening of bursitis r/t
rheumatic fever
Dorsi/plantar flexion strongno deficits

Gastrointestinal:
Abdomen: soft no palpable masses
No tenderness on palpation
Last BM May 13, 14
No constipation or diarrhea
Normal bowel sounds all quadrants
Adequate nutrition: eats 100% of meals
Other (Include vital signs, weight):
Apical Pulse: 83; 84 regular
BP: 106/74; 104/68left arm, sitting up
RR: 16; 18 regular rhythm and depth
Temp: 99.0 , 98.0 F oral

Stronger dorsi/plantar flexion equally bilateral

No dizziness or vertigo
No numbness or tingling sensation in extremities
States Im ready to go home
Works nightshift as maintenance man for department
store

SaO2: 95%; 98% room air

Pain (chronic or acute) Acute; headache 5/10 sharp,
stabbing like a band around my head
Pain management: Acetaminophen

CURRENT MEDICATIONS
List ALL regularly scheduled and prn medications scheduled on your client.
(Due morning of clinical)
Generic &
Trade Name

Classification

Dose/Route/
Rate if IV

Onset/Peak

Pantoprazole
(Protonix)

Proton
pump
inhibitor;
antisecretor
y
Beta-lactam
antibiotic;
natural
penicillin
Analgesic/a
ntitussive

40 mg=1 tab
PO daily or
10 ml IV
daily

Onset PO:
UK
2.4 H

500 mg=2
tab PO Q8H

Onset:
Unknown
Peak: 30-60
min
Onset: 30-45
min
Peak: 1-2 H
Onset: 0.5-1
H
Peak: 0.5-2
H

Penicillin V

Acetaminoph
en/codeine
Acetaminoph
en

Nonnarcotic
analgesic ;
antipyretic

Bisacodyl
(Dulcolax)

Stimulant,
laxative

Docusate
sodium
(Colace)

Stool
softener

300/30 mg 1
tab PO Q4H
PRN
650 mg=2
tab PO Q4H
PRN

10 mg= 1
suppository
rectal daily
PRN
200 mg=2
cap PO
daily PRN

Intended
Action/Therape
utic use. Why is
this client taking
med?
Anti-ulcer

Adverse
reactions (1
major side
effect)

Nursing Implications for this client.

(No more than one)

Diarrhea

Monitor for S&S of angioedema (Red

welts near eyes, lips, hands, feet,
inside of throat; burning, painful
swollen areas)

Streptococci
infection

Diarrhea

Asses patient allergies; report onset of

fever, chills

Pain

Constipation

Minor pain/HA

Rash; negligible
with
recommended
dosage

Onset: 15- 60
min
Peak: varies

Constipation

Fluid and
electrolyte
imbalances

Monitor for pain relief; supervise

ambulation- may cause dizziness and
light-headedness; monitor for nausea
Monitor for effectiveness of pain
relief; Monitor for S&S of angioedema
(Red welts near eyes, lips, hands, feet,
inside of throat; burning, painful
swollen areas) Dose should not exceed
3000mg
Assess patients need for continued
use; Monitor BM

Onset: 6-12
H
Peak: 2-3
days

Constipation

Diarrhea

Monitor BM, withhold if diarrhea

develops and notify prescriber

Magnesium
Hydroxide/A
luminum
hydroxide/Si
methicone
(Mag-Al
Plus)
Magnesium
Hydroxide
(milk of
magnesia)

Saline
catharticantacid/
adsorbent

30 mL PO
Q4H
PRN

Onset: UK
Peak: UK

Gas/GI upset/
Minor dyspepsia

Impacted stool

Note number and consistency of stoolconstipation is common with

aluminum hydroxide; max
recommended dose is 60 ml in 24H

Saline
Cathartic;
antacid

30 mL PO
daily PRN

Onset: 3-6 H
Peak: UK

Constipation

Hypotension

O.4 mg=1
tab SL
Q5min PRN
4 mg=2mL
IV Q4H
PRN

Onset: 3-5
min
Peak: 10 min
Onset: rapid
Peak: 1-1.5
H

Chest pain

Headache,
postural
hypotension
Diarrhea

Evaluate patients continued need for

drug. Prolonged and frequent use of
laxative doses may lead to
dependence. Monitor serum Mg
levels
Monitor BP before and after
administration; Do not give if systolic
BP is less than 100
Monitor fluid and electrolyte status;
monitor for effectiveness

Nitroglycerin Antianginal;
vasodilator
Ondansetron
(Zofran)

5-HT3
Antagonist;
antiemetic

Nausea/vomitin
g

DIAGNOSTIC TESTING
Include pertinent labs [ABGs, INRs, cultures, etc] & other diagnostic reports [X-rays, CT, MRI, U/S, etc.]
NOTE: Adult values indicated. If client is newborn or elder, normal value range may be different.
Date
Lab Test
Patient Values/
Interpretation as related to Pathophysiology cite
Normal Values
Date of care
reference & pg #
5/12 Sodium
136
/14 135 145 mEq/L
Potassium
3.6
3.5 5.0 mEq/L
Chloride
97-107 mEq/L
Co2
23-29 mEq/L
Glucose
75 110 mg/dL

BUN
8-21 mg/dL
Creatinine
0.5 1.2 mg/dL
Uric Acid Plasma
4.4-7.6 mg/dL
Calcium
8.2-10.2 mg/dL
Phosphorus
2.5-4.5 mg/dL
Total Bilirubin
0.3-1.2 mg/dL
Total Protein
6.0-8.0 gm/dL
Albumin
3.4-4.8gm/dL
Cholesterol
<200-240 mg/dL
Alk Phos
25-142 IU/L
SGOT or AST
10 48 IU/L
LDH
70-185 IU/L
CPK
38-174 IU/L
WBC
4.5 11.0
RBC
male: 4.7-5.14 x 10
female: 4.2-4.87 x 10
HGB
male: 12.6-17.4 g/dL
female: 11.7-16.1 g/dL
HCT
male: 43-49%
female: 38-44%
MCV
85-95 fL

MCH
28 32 Pg

101
27
118

May be stress related due to illness

Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and diagnostic
procedures: With nursing diagnoses (pp.
190). New Jersey: Pearson.

16
1.27

8.6

1.0
7.5
4.2

61
31

8.9
4.82
15.2
46.2
96

31.6

May be nutritional Vitamin B12 deficiency

Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and diagnostic
procedures: With nursing diagnoses (pp.
34). New Jersey: Pearson.

MCHC
33-35 g/dL
RDW
11.6-14.8%
Platelet
150-450
Other: Troponin T
0.1-0.2

Band Cell 0-5%

33.0
13.4
163
0.83

May be r/t to rheumatic fever or possible

NTEMI
Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and diagnostic procedures:
With nursing diagnoses (pp. 286-287). New
Jersey: Pearson.
May be r/t bacterial infection
Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and diagnostic
procedures: With nursing diagnoses (pp.
48). New Jersey: Pearson.

14

DIAGNOSTIC TESTING
Date

UA

Normal
Range

Results

Interpretation as related to
Pathophysiology cite reference & pg
#

Color/Appearance
pH
Spec Gravity
Protein
Glucose
Ketones
Blood
Date

5/12/14
5/12/14

Date

Other
(PT, PTT, INR,
ABGs, Cultures,
etc)
Strep A Rapid AG
test
Sreptolysin O
antibody

Radiology

Normal
Range

Results

Interpretation as related to
Pathophysiology cite reference & pg
#

Neg
Significant
if more
than
200IU/ml

92

Results

Antibodies present r/t streptococcal

infection
Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and
diagnostic procedures: With
nursing diagnoses (pp. 357).
New Jersey: Pearson.

Interpretation as related to
Pathophysiology cite reference & pg

#
X-Rays
Scans CT
EKG-12 lead
Telemetry
Other

DAR NURSING PROGRESS NOTE

Include the same note that was written in the client record for the priority nursing diagnostic statement.
Include the date/time/signature.

Pt awake, alert, oriented X4. Pt states he is still shocked regarding suspected diagnosis of rheumatic fever.
Taught patient about illness process. Pt states he is experiencing hot flashes, sore throat, and headache 5/10 that
feels like a band around his head. Temperature 99.0F. Administered acetaminophen/codeine (See Mac). Pt
standing by bedside table, states I think Ill stand for a while. No dizziness or lightheadedness present. Call
light within reach. 5/13/14 @ 0814----------------------------------------------------------------D. Millan, SN
Patient resting in bed, watching television. Temperature 98 F. Patient denies pain at the moment. States he
would like to go home. Patient had requested information earlier today regarding a healthy diet, taught
patient/provided handout on low cholesterol diet. No further needs at the moment. Bed in lowest position. Call
light in reach. 5/13/14 @ 1230--------------------------------------------------------------------D. Millan, SN

PATIENT CARE PLAN

Patient Information:
62 year old patient
Rheumatic fever
Allergies: NKA
Code Status: Full Code
Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as evidenced by
(AEB).
Problem #1 Acute pain r/t inflammation of major joints AEB patient reports of left hip pain
Desired Outcome: Pain will remain at tolerable level during shift
Nursing Interventions
Client Response to Intervention
1.
1.
Assess pain level and joints for inflammationeffects on
Joint pain not significant no effect on ADLs.
mobility/ADLs
Major pain/priority is headache/sore throat and
cough
2.
2.
Teach patient alternative ways to decrease joint pain
Pt. states he walks a lot during work
(avoiding excessive stress on the joints; appropriate
(maintenance job). Constantly walking back and
exercise: walking, stretching)
forth
3.
3.
Administer pain medication if needed
Headache/cough gone following
acetaminophen/codeine administration
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed):
Joint pain was not a significant problem in this patient. His primary complaint was a headache r/t rheumatic
fever as well as a cough that worsens his headache. My goal and interventions werent exactly correct but the
patient did have pain (headache). In this situation, I modified my goal and intervention in order to address the
headache and cough which in this patient, I believe medication (Acetaminophen/codeine) was the best most
effective treatment. The patient was also having hot flashes and his temperature was 99F which Tylenol took
care of the headache and mildly elevated temperature and the codeine addressed the cough which in turn also
decreased the headache.

Problem #2 Fatigue r/t elevated body temperature, pain, and stress AEB reports of felling tired & increased rest
requirements
Desired Outcome: Pt activity and rest will be remain balanced during shift
Nursing Interventions
Client Response to Intervention
1.
1.
Assess fatigue/energy level and whether patient is getting
Pt states he is well rested; he is walking around
sufficient rest
in his room. No dizziness/lightheadedness
present
2.
2.
Instruct patient on balancing energy and rest during illness
Pt verbalized understanding, states it is
sometimes difficult since he works night shifts
and illness affected his sleep/rest cycle
3.
3.
Reduce physical/environmental discomforts, limit
No physical/ environmental discomforts. Pt
environmental stimuli
states he enjoys the view from his window. Is
comfortable
Evaluation:
Patient remained comfortable during shift, no fatigue present except when patient was experiencing hot flashes
which were gone following acetaminophen administration. Stated he felt great, ready to go home. Signs and

symptoms were minimal or nonexistent. Patient is to be discharged today.

Problem #3 Risk for imbalanced body temperature r/t immune response to infection AEB fever & chills X3days
Desired Outcome: Thermoregulation will be maintained during shift
Nursing Interventions
Client Response to Intervention
1.
1.
Assess temperature/vital signs, signs of dehydration
No signs of dehydration, temp 99F, decreased to
98 following acetaminophen administration
2.
2.
Teach patient non-pharmacological ways to reduce fever
Verbalized understanding, able to teach back
3.
3.
Teach patient interventions during fever-(removing excess
Receptive to teaching, teaches back and willing
clothing, maintaining adequate fluid intake, maintaining
to learn more
stable environment temperature)
Evaluation:
Patient was experiencing hot flashes, temperature was mildly elevated. Though acetaminophen was
administered for pain, its antipyretic effect also worked to bring temperature down, remained stable, no
complaints throughout shift. Patient is really receptive to learning, asking multiple questions, willing to do what
he can to improve his health and lifestyle habits.

Running head: RHEUMATIC FEVER

Rheumatic Fever
Diana Millan
Southwestern Oregon Community College
5/13/14

RHEUMATIC FEVER

Rheumatic Fever
Sixty-two year old male was admitted to Bay Area Hospital after developing sore throat
for three weeks and fever and chills for approximately three days. The patient then developed a
rash and was complaining of arthralgias in the large joints with some noted swelling. Troponin
and CRP were increased indicating possible rheumatic fever. The patient has developed a
continuous headache since the rash began. The patient is currently in observation in IMCU
because there is a concern with elevated troponin which on admission was 1.19 and may indicate
a non ST elevation myocardial infarction. The patient is currently being treated for possible
rheumatic fever.
Rheumatic fever is caused by a delayed and exaggerated immune response to group A hemolytic streptococcus (Huether & McCance, 2012). Inflammation of the joints, skin, nervous
system, and heart can occur which may result in rheumatic heart disease if left untreated
(Huether & McCance, 2012). Acute rheumatic fever results from an abnormal humoral and cellmediated response to streptococcal cell membrane antigens referred to as M proteins (Huether &
McCance, 2012). This response reacts with similar self-antigens in the heart, muscle, brain, and
joints, inducing and autoimmune response that causes inflammatory lesions which can damage
the heart valves (Huether & McCance, 2012). Carditis from rheumatic fever primarily affects the
endocardium but if it penetrates the myocardium, localized fibrin deposits surrounded by areas of
necrosis occurs (Huether & McCance, 2012). Signs and symptoms include, fever,
lymphadenopathy, arthralgia, nausea, vomiting, epistaxis, abdominal pain, and tachycardia
(Huether & McCance, 2012).
As mentioned rheumatic fever causes inflammation, especially of the major joints which
can then lead to pain. In this patient it is presented as pelvic joint pain of the left hip. The heart

RHEUMATIC FEVER

may have become affected in this patient through carditis which presents as sharp or stabbing
chest pain. The most important of the lab values to monitor is troponin, which is mainly used as a
cardiac marker to indicate myocardial infarction. Elevated troponin and chest pain leave the
possibility of the patient having had a myocardial infarction. The diagnosis appears to lean more
towards rheumatic fever in which CRP is also elevated (Huether & McCance, 2012). That and
the patients signs and symptoms, increased band cell count and positive streptolysin O antibody
test indicate a streptococcal infection. The most important medication for this patient is
penicillin. The main goal of treating rheumatic fever is to treat the streptococcal infection which
involves a ten day regimen of oral penicillin or erythromycin. Though not used in this patient,
nonsteroidal anti-inflammatory drugs can also be used for rheumatic carditis and arthritis.
As mentioned, my patient was in IMCU for observation. During my shift, he remained
stable with no complaints other than a moderate headache and hot flashes that were relieved with
acetaminophen. Upon assessment, the generalized rash that the patient had been admitted to the
ER with was more localized on his back. The patient was mobile, had no difficulty ambulating
or needed assistance with ADLs. The day went by a little slow with not much going on but I
did get multiple opportunities to teach my patient. I began with teaching about rheumatic fever
and myocarditis, including how, why, and when it happens. The next teaching session was on a
low cholesterol, low salt diet. Besides the myocarditis, the patient had no other health issues. He
was overall a healthy person presenting with no risk factors for cardiovascular problems. I
decided to teach the patient about a healthy diet mainly because I was in the patients room when
the physician stated there was a possibility of his illness being cardiac related and the paint was
wondering if there was anything he could do to be healthier. I found some informational
handouts and went over them with the patient. I later found out the patient will need education on

RHEUMATIC FEVER

preventing heart failure from rheumatic fever. The physician stated he was highly likely of
developing it in the future. I then reinforced some teaching and education on a heart healthy diet
and then taught about congestive heart failure. From there, I taught about antibiotic therapy for
streptococcal infection. The patient will have to take antibiotics for one to two years. From there,
it will be decided if he is to receive lifetime antibiotics. The patient was really receptive to
teaching. He was able to teach back and was constantly asking questions. He was willing to learn
and comply with treatment regimen. I always have something to teach my patients but Ive never
had to teach complicated topics in too much depth. This was definitely a good teaching
opportunity and experience.

PATHOPHYSIOLOGY AT A CELLULAR LEVEL

References
Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology (5th ed.). St. Louis,
MO: Mosby/Elsevier.

PATHOPHYSIOLOGY AT A CELLULAR LEVEL