Lewis: Medical-Surgical Nursing, 8th Edition

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)
Thermoregulation
% Sweating when hot ___
% Shivering when cold ___
% Apical heart rate ___
% Radial pulse rate ___
% Reported thermal comfort
___
_____________________
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
Interventions (NIC) and
Rationales
Fever Treatment
% Monitor temperature as
appropriate to determine
effectiveness of therapy and
to prevent treatment-induced
hypothermia.
% Administer antipyretic
medication as appropriate or
as ordered to reduce fever.
% Administer medications as
appropriate to treat the cause
of the fever.
% Monitor white blood cell
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)
Activity Tolerance
% Ease of breathing with
activity ___
% Respiratory rate with
activity ___
% Systolic BP with activity ___ %
% Diastolic BP with activity ___
% Ease of performing activities
of daily living (ADLs) ___
_____________________
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
INTERVENTIONS (NIC) AND
RATIONALES
Energy Management
% Monitor cardiorespiratory
response to activity (e.g., vital
signs) to plan or alter
activities.
Monitor patient for
evidence of excess physical
(e.g., tachycardia,
hypertension, diaphoresis,
dyspnea) or emotional fatigue
to plan for changes in activity
level.
% Instruct patient/caregiver
to recognize signs and
symptoms of fatigue that
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)
Knowledge: Disease Process
% Description of specific
disease process ___
% Description of effects of
disease ___
% Descriptions of signs and
symptoms of complications ___
% Description of precautions
to prevent complications ___
_____________________
Measurement Scale
1 = None
2 = Limited
3 = Moderate
4 = Substantial
5 = Extensive
INTERVENTIONS (NIC) AND
RATIONALES
Teaching: Disease Process
% Review patients and
caregivers knowledge about
condition to identify teaching
needs.
% Discuss common signs and
symptoms of the disease
(e.g., fatigue, malaise, chills,
elevated temperature,
anorexia) so health care
provider can be notified and
treatment initiated promptly.
% Discuss lifestyle changes
that may be required to
prevent future complications
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.