St.

Paul College of Ilocos Sur

(Member: St. Paul University System)
St. Paul Avenue, 2727 Bantay, Ilocos Sur
DEPARTMENT OF NURSING
NOVILYN C. PATARAY BSN – II
RHEUMATIC DISEASE
ASSESSMENT DIAGNOSI PATHOPHYSIOLOG PLANNING INTEREVENTION RATIONALE EVALUATION
S Y
Subjective: Decreased Inadequate blood pumped After 1 hour of 1. Assess potential 1. Early detection After 1 hour of nursing
“maririgatan nga cardiac output by the heart to meet the nursing for type of of changes intervention, the patient
umanges etoy anak ko related to metabolic demands of the interventions, the developing promotes timely was able to breathe
ken nadagsen ti altered body. patient will be able to shock states intervention to within normal range and
barukong na” as myocardial alleviate feelings of limit degree of decrease feeling of chest
verbalized by the contractility chest pain and cardiac pain.
mother. evidenced by shortness of breath. dysfunction
mitral stenosis/ 2. To determine
Objective: accumulation degree of
 Restlessness of fibrin on 2. Monitor vital assistance
 Dyspnea mitral valve signs frequently needed by the
 Edema patient and note
 Pallor response to
 Clammy skin activities
 Prolonged 3. To decrease
capillary refill oxygen
3. Monitor intake consumption
 V/S taken as
and output and risk for
follows:
decompensatio
T- 36
n
PR-86
RR-12
BP-90/60