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NURSING CARE PLAN

(Medical Ward)

I.

Demographic Profile :

On March 15. Medical ward A. she was diagnosed of rheumatoid arthritis but she was negative for rheumatoid factor.A. rated as 3/10 but was tolerable. Attending Physician: Dr. No known allergies to food and drugs.Name: R. she was just resting when she suddenly felt pain in her whole body and noticed that her fingers were swollen. 5 hours prior to admission. Baguio City Religion: Roman Catholic Address (2): 09301888728 Nationality: Filipino Next of kin: Rosemarie Salenga Relationship: Mother Admitting Physician: Dr. Methylprednisolone and Arcoxia which provided relief of the condition. 2015/ 8:30 pm. She rates the pain as 9/10 which is aggravated by movement. No other history of surgery or trauma. the patient had dental extraction. She also had been given Clenza 10 mg OD for 3 Days. She just continued her maintenance medications. In September 2014. The mother claimed the she have received complete immunization when she was a child. 2015. C. Family History . No consults was done. 1997 Birthplace: Baguio City Address (1): 126 Hamada Subdivision. B. The mother also claimed that she had a rheumatic heart fever and was given Salphen via IV.S. Room: 221-1. Sex: Female Age: 17 Civil Status: Single Birthdate: July 2. The mother claimed that the patient is 100% compliant with her medications. Bartolo Date and time admitted: May 3. She currently takes Arcoxia 120 mg OD and Methylprednisolone 16 mg OD for her maintenance medications. Her mother gave her maintenance medications but no relief was noted. History of present illness 1 week prior to admission patient experience generalized body pain. Hence. She was also admitted in BGH. at an unrecalled date for kidney problems secondary to her tonsillitis. she was brought in for consultation with a private physician and was advised admission. Past Medical History The mother claims that the patient had been diagnosed of rheumatic heart disease in her childhood years. Adrian Calera Chief Complaint: Generalized body pain Diagnosis: II. The mother claims that she had an average of 3 incidence of tonsillitis in a month.

cancer. dementia and depression. She used to stay upstairs but now she was limited to the ground level due to her body pains. non-alcohol drinker. The patient had a history on both sides of coronary artery disease. There was no known history of pulmonary tuberculosis. The family’s drinking water comes from a water refilling stations and the water for domestic purposes comes from the Baguio water district. diabetes mellitus and hypertension. female. The family lives in a wellventilated. The toilet is of manual flushed-type. Garbage is collected weekly. non-congested. age: 17 years old Precipitating: -3 incidence of tonsillitis every month . She is a 3 rd year college student. D. non-caffeinated beverage drinker. She doesn’t practice fad diets and any restrictions on her foods. Diagnostic/ Laboratory Results:  X-ray: Hands: reveals swelling are note overlying the proximal interphalangeal joints and metacarpophalangeal joints Chest: Mild Cardiomegaly  Doppler Ultrasound: Dilated left atrium with left atrial volume index of 29 cc/m3 Pathophysiology of Rheumatic heart disease and SLE Predisposing factors: -history of rheumatic heart fever in her childhood. Social and Environmental History The patient is a non-smoker.There is no known maternal history of cerebrovascular disease. They have 1 dog living in their backyard. two-story house with 3 bedrooms and 6 occupants. She lies an active lifestyle until the beginning of March when she started to have problems with her boy.

Arcoxia. Methylpr ednisolo (+) Joint pains Scarring of the heart valves that damages the (mitral or aortic valve) Acute Pain related to ongoing inflammatory process -Impaired comfort Decreased cardiac supply of blood in different parts of the body Generalized body weakness Decrease immune defense reaction Paracetam ol 500 mg Prn for feer Risk for imbalanced body temperature related to Increase risk of infection infection Fever may occur -Activity Intolerance related to generalized body weakness -Fatigue related poor physical condition -Risk for fall -Risk for injury X-ray: Mild Cardiomegaly Doppler Utz: Dilated left atrium with left atrial volume index of 29 cc/m3 Increase production of lactic acid Chest pain/ Tachycardia Ineffective peripheral tissue perfusion related to decreased blood supply Arcoxi a .Streptococcal Infection Antibiotic Therapy X-ray: Hands: reveals swelling are note overlying the proximal interphalan geal joints Bind to receptors in the synovial joints Autoimmune response Antigens are similar to body’s own cell that may result to attack of healthy body cells by Increase production of antigen (streptococci) Antigen circulates to system Attacks the heart valves Inflammation of the layers of the heart Difficulty of heart to pump Increase cardiac workload Inflammation Colchicin e.

Smeltzer. S.A.K. 12th Edition. Pp.al.com Doenges.emedicine. Retrived by www. eMedicine Journal.al. (2010). 608-614. 333-337. (2001). Philadelphia. M. 795801. 10 th Edition. T. et. Pp. prioritized interventions and rationales. LIST OF PRIORITIZATION: . Nurse’s pocket guide: Diagnoses. Brunner and Suddarth’s textbook of Medical-Surgical Nursing.E. et. 2 (9). F. Davis Company. 586-591.References: Chin. (2010). Rheumatic Heart Disease.

Fatigue related poor physical condition 3. Activity Intolerance related to generalized body weakness/pain 3. 4. And I clustered the other 3 problems into this since they will have the same or similar nursing interventions and the risks will not occur if given appropriate interventions. Ineffective peripheral tissue perfusion related to decreased blood flow This is the second priority because according to the ABC’s of life circulation should be prioritized first and to prevent possible or further complications of decreased blood flow.1 Impaired comfort JUSTIFICATION This is the first prioritized problem because this is what the patient complains about and it is an actual problem existing that may result to further complications if not resolved first. Acute pain related to ongoing inflammatory disease 1. According to Maslow’s hierarchy of needs under physiologic needs rest is needed and should be met firs before moving to the level of hierarchy.1.PRIORITIZATION 1. Risk for imbalanced body temperature related to infection/inflammation This is my last prioritized problem since it is a potential problem that may arise if the above problems will not be resolved and also it can be corrected immediately with .2 Risk for fall 3. And also according to Maslow’s hierarchy of needs this falls under Safety which needs to be met before going to the next level of hierarchy.3. 2. 3. Risk for injury This is the third priority because this can be solved if the above problems will be solved.

. M.” LTO/STO LTO: After 72 hours of nursing interventions the client will be able : O: NURSING INTERVENTIONS Dx: TX .paracetamol or drug administration. Ed: Reference: Doenges.2014) (Eliopoulous. 1998). (Doenges.(2010). (Doenges. Nurse’s Pocket With references per rationale .. 1994). Castiglia.al. M.E.2014) (Creditor. et.al.et. (Prizant-Weston. STO: After 8 hours of nursing interventions the client will be able to: a. M. A> Ineffective peripheral tissue perfusion related to decreased blood flow RATIONALE CRITERIA FOR EVALUATION/ EALUATION After 72 hours of nursing interventions LTO: Fully met if Partially met if Not met if: STO :After 8 hours of nursing interventions the client will be able to: Fully met if: able to: Partially met if: Not met if: .E.al.et.E. NCP 1 ASSESSMENT BRIEF EXPLANATION OF THE PROBLEM S> “. 1992).

F. (Doenges. Serves as a basis for determining the effectiveness of CRITERIA FOR EVALUATION/ EALUATION After 72 hours of nursing interventions LTO: Fully met if: the client will be able to a.E. Since there is an increase production of Goals and Objectives NURSING INTERVENTIONS LTO: After 72 hours of nursing interventions the client will be able to Dx: 1.Walk on her own without assistance.Guide: Diagnoses. M. NCP 2 ASSESSMENT S> “Nahihirapan pong maglakad. c. Prioritized interventions and rationale. 69-73.With functional level of 2.have a muscle strength of 5/5 in all extremeties with no pain and discomforts c.Will not develop any .walk on her own without assistance b.Assessed functional level of assistance a..2014) >to determine current status and needs associated with participation in needed/desired activities. Will not develop any complications 2. tsaka mabagal po. both lower extremities: 4/5.” O:. Pp.al.Assessed muscle strength RATIONALE >to be able to give the appropriate assistance needed. -Needs assistance in doing ADL’S such as toileting or transferring from BRIEF EXPLANATION OF THE PROBLEM Since my patient is diagnosed of having Rheumatic heart disease which means it is caused by streptococcus infection in which my patient has sensitivity to the antibodies that were formed in response to the invading bacteria. have a muscle strength of 5/5 in all extremeties with no pain and discomforts a. .Muscle strength of both left and right upper extremities: 3/5. 12th Edition.A Davis Company.et.

3.Because of decrease cardiac workload . Perform rangeof-motion exercis es if client is unable to tolerate activity. to chair sitting. and endurance. allowing client to assist with positioning.2 Risk for fall 3..Verbalize needs for assistance c.scarring of heart valves :mitral/aortic valve is damage which therefore decreases cardiac supply in different parts of her body . These factors contribute to complications such as fall and injury. Which makes the heart difficult to pump blood. Have a muscle strength of 4/5 on both upper . Gradually increase activity.et. Risk for injury antigen it circulates in her system attacking the valves of her heart causing inflammation. and self-care as possible.E. STO: After 8 hours of nursing interventions the client will be able to: a.al.Able to change position (from left to right or vice versa) frequently TX 3. Partially met if: needs minimal assistance when ambulating. M. Activity intolerance according to NANDA. is an insufficient physiological or psychological such as fall and injury. Progress from sitting in bed to dangling.1.Have a muscle strength of 4/5 on both upper extremities b. (Doenges.one place to another. to standing. to ambulation 4. STO :After 8 hours of nursing interventions the client will be able to: Fully met if: able to: a. A :Activity intolerance related to generalized body weakness/pai n 3.in which she complain of body weakness .5/5 in all extremities with pain or discomforts Not met if: Not able not walk or ambulate And did not have a muscle strength of 5/5 in all extremities.2014) >Increasing activity helps to maintain muscle strength. Fatigue related poor physical condition 3. 5. transferring. 1998). tone. >Inactivity rapidly contributes to muscle shortening and changes in periarticular and cartilaginous joint structure. Allow for periods of rest before and nursing interventions. Allowing the client to participate decreases the perception of the client as incapable and frail (Eliopoulous.

1992). >Rest periods decrease oxygen consumption (Prizant-Weston. and (2) a reduction inphagocytosis.(2010). 1994). M. and physical activity. baths. >The exact mechanism of action of colchicine in go ut is not completely known. F. Nurse’s Pocket Guide: Diagnoses. Ambulate with minimal assistance b. Able to change position (from left to right or vice versa) frequently Not met if: . Prioritized interventions and rationale.energy to endure or complete required or desired daily activities.Administer Colchicine a ordered Ed: 7. 6. which results in a decrease in uric acid deposition. but it involves (1) a reduction in lactic acid production by leukocytes. 69-73. Still have a muscle strength of 3/5 on both upper extremities c.A Davis Company. treatments. Able to change position (from left to right or vice versa) frequently Partially met if: a. Verbalize needs for assistance d. Pp. after planned exertion periods such as meals. 12th Edition.Encourage to ambulate and do exercise as tolerated contracture and limitation of motion (Creditor. Verbalize needs for assistance c. with abatement o f extremities b. et. Reference: Doenges.al.E. Castiglia.

the inflammatory response. 8. Unable to verbalize needs for assistance d. helps move from one place to another a. Have a muscle strength of 3/5 on both upper extremities c. Unable to change position (from left to right or vice versa) frequently . Instructed to call for SO for assistance when needed >Both activity tolerance and health status improves with progressive and appropriate activity and exercise >to prevent fall and injury. Can’t Ambulate without assistance b.