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NURSING CARE PLAN 1 HRP NURSING DIAGNOSIS Ineffective Airway clearance r/t increase secretions in the bronchi CUES PATHOPHYSIOLOGY CLIENT OUTCOME At the end of the 80 duty, the patient will be to expectorate secretions as manifested by RR of 20 bpm. NURSING INTERVENTION Vital signs monitored and recorded. Encouraged deep breathing exercise Assisted in semi-fowlers position RATIONALE To get baseline of the pt. for comparison. This will promote proper lung expansion Proper positioning helps in draining secretions Increase fluid will soften secretions and making it easier to expel. Adequate rest prevents fatigue. EVALUATION

E X C H A N G I N G

SUBJECTIVE Opo naga ubo ako,may plema medyo green pa as verbalize by the patient. OBJECTIVE productive Cough noted RR=31bpm crackles heared upon auscultation. mucus secretions noted (+) use of accessory muscleswhe n breathing

Patient has rheumatoid heart disease. It develops another complication (pneumonia).In pneumonia There is inflammation it increases production of secretion that cause the narrowing of the airway making it ineffective.

GOAL PARTIALLYM ET. -the patient expectorated secretions and decrease RR from 31bpm to 27bpm.

Encouraged patient to increase fluid intake.

Encouraged patient to have adequate rest

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NURSING CARE PLAN 2 HRP NURSING DIAGNOSIS Hyperthermia r/t increase metabolic rate 20 inflammation of the heart valves. CUES PATHOPHYSIOLOGY CLIENT OUTCOME NURSING INTERVENTION RATIONALE To get baseline of the pt Room temperature should be altered to maintain near-normal body temperature May help reduce fever. Use of ice water/alcohol may cause chills, actually elevating temp. In addition, alcohol is very drying to skin Used to reduce fever by its central action on the hypothalamus. To provide adequate water in the body. EVALUATION

E X C H A N G I N G

SUBJECTIVE

The patient has rheumatic heart disease "Opo cause by kaninang Streptococcus bacteria umaga lang It affects the heart nag start ba causing it to inflame mag init ako (carditis) and increase as verbalize metabolic rate The by the increased metabolic rate patient. will produce additional heat in the body, thus OB JECTIVE increases the bodys thermoregulation. T = 38.2 0C RR=31bpm Warm to touch body weakness noted

At the end of 80 Assessed vital signs and duty, the patient record temperature will be to decrease Monitored environmental from 38.2C to temperature 37.5C. provided tepid sponge bath,

GOAL MET. -The pt temperature lowered. From 38.2C to 37.1C.

Administered antipyretics as ordered. Encouraged to increase fluid intake.

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NURSING CARE PLAN 3 HRP NURSING DIAGNOSIS CUES PATHOPHYSIOLOGY CLIENT OUTCOME After 80 of duty, the pt will be able to have a decrease in blood pressure from 140/100 mmhg to 120/90 mmhg. NURSING INTERVENTION Monitor vital signs specially blood pressure. Administered antihypertensive drug as ordered. Rationale To get baseline of the patient and compare. To control the BP and to avoid other complications Rest alleviates stress which aids the heart from proper functioning. To note for abnormalities and other sign and symptoms. Semi fowlers position can reduce cardiac workload. Evaluation

E X C H A N G I N G

Ineffective SUBJECTIVE Peripheral Tissue Ang last Perfusion r/t BP ko nag pressure abot po ng exerted in the 140/100 blood mmhg as vessels. verbalize by the patient. OBJECTIVE BP=140/90 mmhg PR=75 bpm weak shallow pulse noted.

The patient has rheumatoid heart disease. In RHD there is narrowing of the valves of the heart(Mitral stenosis) that increases blood flow as compensation causing an increase pressure exerted in blood vessels.

GOAL MET: >patient Blood pressure decreased from 140/q00 mmhg to 120/70 mmhg.

Instructed to have enough rest

Encouraged patient to verbalize feeling and concerns. Position patient in semi fowlers.

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NURSING CARE PLAN 4 HRP NURSING DIAGNOSIS Impaired skin integrity r/t Inflammation of the skin and subcutaneous tissue 20 Edema CUES PATHOPHYSIO LOGY The patient has rheumatic heart disease.In rheumatic heart disease there will be an increase in the left atrial pressures .Pressures in this level cause an imbalance between the hydrostatic pressure and the oncotic pressure, leading to extravasation of fluid from the vascular tree and pooling of fluid leading to Edema. CLIENT OUTCOME After 8 hours of nursing intervention Patient will maintain an intact skin. NURSING INTERVENTION inspect skin for changes in colour, turgor, vascularity, note redness monitor fluid intake and hydration of skin and mucous membranes RATIONALE indicates areas of poor circulation/breakdown that may lead to infection detects presence of dehydration or over hydration that affect circulation and tissue integrity at the cellular level Elevation promotes venous return, limiting venous stasis, edema formation prevents direct dermal irritation and promotes evaporation of moisture on the skin To obtain baseline data and compare if theres improvement. EVALUATION

E X C H A N G I N G

SUBJECTIVE Grabi po ang maga niya kaya naisipan napo nmin na e admit nalang , as verbalized by watcher. OBJECTIVE swelling noted at the lower extremities + 2 pitting edema poor skin turgor Shiny skin noted weakness noted

GOAL MET The patient maintains an intact skin.

Elevate legs of the patient

Suggest wearing loose fitting cotton garments. Compare current weight gain with admission or previous stated weigh

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