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NURSING CARE PLAN

Medical Diagnosis: Acute Myocarditis


Nursing Diagnosis: Activcity Intolerance related to imbalance between oxygen supply (delivery) and demand

Cues Nursing Diagnosis Scientific OBJECTI VES INTERVENTIONS RATIONALE EVALUATION


Explanation
Subjective: Activity Influenza Virus Short term Goal: Independent: Short term:
¨ “Nanghihina intolerance After 8 hours of Goal met
ako,kadalasan related to Entry to the heart nursing 1. Assess • Influences After 8 hours of
hindi ko imbalance interventions patient’s choice of nursing
matapos ang between oxygen Entry & Replication the patient will: ability to perform interventions or interventions
mga gawain ko” as supply (delivery) inside the myocytes normal task or needed assistance. the patient had:
verbalized by the and demand. • Report an activities of daily
client Activation of increase in living. • Report an
Macrophages activity tolerance increase in
Objective: including activity tolerance
activities of daily 2. Note • May indicate including
• Fatigue. Lysis of noninfected living. changes in neurological activities of daily
and infected balance/ gait changes associated living.
• Greater need myocytes • Demonstrate a disturbance, muscle with vitamin B12
for sleep and decrease in weakness. deficiency, affecting• Demonstrate a
rest. Myocardial physiological patient safety or risk
decrease in
inflammation signs of of injury. physiological
intolerance. signs of
• Enhances rest to intolerance.
decreased • Display 3. Recommend lower body’s oxygen
myocardial laboratory quiet requirements, and • Display
contractility values within atmosphere, bed reduces strain on laboratory
acceptable range. rest the heart and lungs. values within
Imbalance between if indicated. acceptable range.
oxygen supply Long term Goal:
delivery and After 1 week of Long term:
demand nursing 4. Elevate the • Enhances lung Goal met
interventions, head of expansion to After 1 week of
the patient: the bed as maximize nursing
will be free form tolerated. oxygenation for interventions,
weakness and cellular uptake. the patient:
risk for Is free form
complications has weakness and
been prevented. 5. Provide or • Although help risk for
recommend may complications has
assistance with be necessary, self been prevented
activities or esteem is enhanced
ambulation as when patient does
necessary, allowing some things for self.
patient to do as
much as possible.

Plan activity
progression with
patient, including
activities that the
patient views
essential. Increase
levels of activities
as
tolerated.

6. Identify or
implement
energy
saving
technique
like sitting
while doing a
task.

Collaborative:

• Monitor
laboratory
studies. Hb or Hct
and
RBC count, arterial
blood gases
(ABGs).
NURSING CARE PLAN
Medical Diagnosis: Acute Myocarditis
Nursing Diagnosis: Risk for Decreased Cardiac Output

Cues Nursing Diagnosis Scientific OBJECTI VES INTERVEN-TIONS RATIONALE EVALUATION


Explanation
Risk for Influenza Virus Short term Goal: Independent: Short term Goal:
DecreasedCardiac Afte 4 hours of Goal met
Output related to Entry to the heart effective nursing 1. Monitor for 1. As these Afte 4 hours of
insufficient preload intervention the symptoms of symptoms of effective nursing
and afterload Entry & Replication client will be able to heart failure and heart failure intervention the client
inside the myocytes explains actions and decreased progress, had able to explains
precautions to take cardiac output, cardiac output actions and
Activation of for cardiac disease including declines. precautions to take for
Macrophages diminished cardiac disease
quality of
peripheral
Lysis of noninfected Long term Goal pulses, cool skin
and infected After 8 hours of and extremities, Long term Goal
myocytes effective nursing increased Goal Met
intervention the respiratory rate, After 8 hours of
Myocardial client will presence of effective nursing
inflammation demonstrates paroxysmal intervention the client
adequate cardiac nocturnal haddemonstrates
Decrease space for output as evidenced dyspnea or adequate cardiac
the heart by blood orthopnea, output as evidenced
pressure and pulse increased heart by blood
Risk for rate and rhythm rate, neck vein pressure and pulse
DecreasedCardiac within normal distention, rate and rhythm
Output related to parameters for decreased level within normal
insufficient preload client; strong of parameters for client;
and afterload peripheral pulses; consciousness, strong peripheral
and an ability to and presence of pulses; and an ability
tolerate activity edema. to tolerate activity
without symptoms without symptoms of
of dyspnea, dyspnea, syncope, or
syncope, or chest 2. Monitor chest pain
pain hemodynamic
parameters for 2. Hemodynami
an increase in c parameters
pulmonary give a good
wedge pressure, indication of
an increase in cardiac function.
systemic
vascular
resistance, or a
decrease in
cardiac output
and index.

3. Watch laboratory
data closely,
especially
arterial blood
gases and 3. Client may
electrolytes, be receiving
including cardiac
potassium. glycosides and
the potential for
toxicity is greater
with
hypokalemia;
hypokalemia is
common in heart
clients because
4. Administer of diuretic use.
oxygen as
needed per
physician's order

5. Gradually
increase activity
when client's 4. Increases
condition is oxygen level in
stabilized by the body
encouraging
slower paced
activities or
shorter periods
of activity with
frequent rest
periods following
exercise
prescription;

Collaborative:

1. Collaborate with
the dietitian to 1. Sodium-
serve small restricted diets
sodium- help decrease
restricted, low- fluid volume
cholesterol excess. Low-
meals. Give only cholesterol diets
small amounts of help decrease
caffeine- atherosclerosis,
containing which causes
beverages, if no coronary artery
resulting) disease.
NURSING CARE PLAN
Medical Diagnosis: Acute Myocarditis
Nursing Diagnosis: Knowledge Deficit related to

Cues Nursing Diagnosis Scientific OBJECTI VES INTERVEN-TIONS RATIONALE EVALUATION


Explanation
Subjective Cues Knowledge Deficit Influenza Virus Short term Goal: Independent: Short term Goal:
related to New
“Hindi ko alam kung condition, procedure Entry to the heart After 4 hours of 1. Provide a 1. This allows Goal Met
pano ako and treatment effective nursing quiet patient to
nagkasakit ng Entry & Replication intervention the atmosphere concentrate After 4 hours of
ganito” as inside the myocytes client will be able to without more effective nursing
verbalized by the demonstrates interruption. completely. intervention the
client” Activation of motivation to learn client had able to
Macrophages such as asking demonstrates
Objective cues question to the 2. Focus 2. This allows the motivation to learn
health care teaching learner to such as asking
Expressing Lysis of noninfected member. sessions on a concentrate question to the
frustration or and infected single concept or more completely health care
confusion when myocytes Long term Goal: idea. on material member.
performing task being discussed.
Myocardial After 8 hours of Long term Goal:
inflammation effective nursing
intervention the 3. To add Goal Met
Signs and client will verbalizes knowledge
Symptoms understanding of 3. Teach After 8 hours of
desired content, symptoms of effective nursing
and/or performs heart failure and intervention the
Percieved as a desired skill. appropriate client will verbalizes
change in health actions to take if understanding of
status client becomes desired content,
symptomatic. and/or performs
Knowldege deficit desired skill.
about condition 4. Clients who
procedure and continue to
treament 4. Teach smoke increase
importance of their chance of
smoking dying by at least
cessation and 50%, and
avoidance of alcohol
alcohol intake.. depresses heart
contractility

5. Sodium
retentiion
5. Explain leading to fluid
necessary overload is a
restrictions, common cause
including of hospital
consumption of readmission.
a sodium-
restricted diet,
guidelines on
fluid intake, and
the avoidance of
Valsalva's
maneuver.

6. to prevent
becoming overly
6. Teach the fatigued
importance of
pacing activities,
work
simplification
techniques, and
the need to rest
between
activities.
7. Medications can
prolong the lives
7. Teach client of heart failure
actions, side clients but often
effects, and are not taken,
importance of resulting in
consistently hospital
taking readmissions
cardiovascular
medications..

8. To have a
written material
8. Provide
specific written
materials and
self care plan for
client/caregivers
to use for
reference.

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