eNursing Care Plan 36-1

Patient with Infective Endocarditis

Nursing Diagnosis*
Impaired Cardiac Output
Etiology: Altered rhythm, valvular insufficiency, fluid overload
Supporting data: Heart murmur, S3, tachycardia, diminished peripheral pulses,
adventitious breath sounds, decreased urine output, unexplained weight gain, restlessness

(Outcomes and Interventions for this Nursing Diagnosis are presented in eNursing Care
Plan 36-2: Nursing Care Plan for the Patient with Valvular Heart Disease.)

Nursing Diagnosis
Activity Intolerance
Etiology: Insufficient oxygenation from decreased cardiac output
Supporting data: Fatigue, malaise, weakness, painful joints, myalgia, dyspnea,
dysrhythmias

(Outcomes and Interventions for this Nursing Diagnosis are presented in eNursing Care
Plan 36-2: Nursing Care Plan for the Patient with Valvular Heart Disease.)

Nursing Diagnosis
Hyperthermia
Etiology: Infection of heart tissue
Supporting data: Fever, diaphoresis, chills, malaise, tachycardia, tachypnea

Patient Goal
Maintains normal body temperature

Outcomes (NOC) Interventions (NIC) and Rationales

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
Fever Treatment
 Monitor temperature and other vital signs, as
appropriate, to determine effectiveness of therapy and
to prevent complications.
 Administer medications or IV fluids (e.g.,
antipyretics, antibacterial agents, and anti-shivering
agents) to reduce fever and treat cause.
 Monitor intake and output and be aware of changes in
insensible fluid loss to monitor for signs and
symptoms of dehydration.
 Encourage fluid consumption to replace fluids lost as
a result of fever.
 Monitor for fever-related complications and signs and

*
Nursing diagnoses listed in order of priority.

Copyright © 2020 by Elsevier, Inc. All rights reserved.

eNursing Care Plan 36-2

Outcomes (NOC) Interventions (NIC) and Rationales

5 = Not compromised symptoms of fever-causing condition (e.g., seizure,
decreased level of consciousness, abnormal
electrolyte status, acid-base imbalance, dysrhythmia,
and abnormal cellular changes) to identify and treat
complications.
 Avoid unnecessary exposure, drafts, overheating, or
chilling to control fever symptoms.

Nursing Diagnosis
Acute Pain
Etiology: Infection of heart tissue, embolization
Supporting data: Malaise, painful joints, myalgia, back pain, abdominal discomfort,
headache, backache

Patient Goal
Reports relief of pain

Outcomes (NOC) Interventions (NIC) and Rationales

Pain Control Pain Management
 Uses preventive  Perform a comprehensive assessment of pain to include
measures ___ location, characteristics, onset/duration, intensity/severity
 Uses analgesics of pain, and precipitating factors to plan appropriate
appropriately ___ interventions.
 Reports uncontrolled  Provide optimal pain relief with prescribed analgesics
symptoms to health care because pain exacerbates tachycardia and increases BP.
professional ___  Position patient (e.g., using principles of body alignment,
 Reports pain controlled support with pillows, support joints during movement,
_____ splint over incisions and immobilize painful body parts to
facilitate comfort.
Measurement Scale  Teach the use of nonpharmacologic techniques (e.g.,
1 = Never demonstrated relaxation, guided imagery, hot/cold application, and
2 = Rarely demonstrated massage) and along with other pain relief measures to
3 = Sometimes promote comfort.
demonstrated  Encourage patient to monitor own pain and intervene
4 = Often demonstrated
appropriately to increase patient’s control over pain
5 = Consistently
demonstrated management.
 Facilitate hygiene measures (e.g., wiping brow, applying
skin creams, or cleaning body, hair, and oral cavity) to
keep the patient comfortable.
 Evaluate effectiveness of pain control measures through
ongoing assessment of pain experience to ensure effective
pain managemen and facilitate comfort.

Copyright © 2020 by Elsevier, Inc. All rights reserved.

eNursing Care Plan 36-3

Nursing Diagnosis
Lack of Knowledge
Etiology: Lack of experience and exposure to information about disease and treatment
process
Supporting data: Questions about desired or prescribed health behaviors, requests
information

Patient Goal
Describes disease process, appropriate treatments, and measures to prevent recurrence of
disease

Outcomes (NOC) Interventions (NIC) and Rationales

Knowledge: Disease Process
 Characteristics of specific
disease _____
 Cause and contributing
factors _____
 Physiologic effects of
disease _____
 Usual course of disease
process _____
 Signs and symptoms of
disease complications _____
 Precautions to prevent
complications _____
Measurement Scale
1 = No knowledge
2 = Limited knowledge
3 = Moderate knowledge
4 = Substantial knowledge
5 = Extensive knowledge
Teaching: Disease Process
 Assess the patient’s current level of knowledge
related to specific disease process to identify teaching
needs.
 Describe common signs and symptoms of the disease
so patient will notify health care provider and
treatment can be initiated promptly.
 Discuss lifestyle changes that may be required to
prevent future complications and/or control the
disease process to reduce the risk of recurrent
infective endocarditis.
Teaching: Prescribed Medication
 Provide the patient and caregiver with written
information about the action, purpose, and side effects
of the medications to promote safe medication
therapy.

Copyright © 2020 by Elsevier, Inc. All rights reserved.

eNursing Care Plan 36-4

eNursing Care Plan 36-2

Patient with Valvular Heart Disease

Nursing Diagnosis*
Impaired Cardiac Output
Etiology: Valvular incompetence
Supporting data: Murmurs, dyspnea, dysrhythmias, peripheral edema

Patient Goal
Maintains adequate tissue and organ perfusion

Outcomes (NOC) Interventions (NIC) and Rationales

Cardiac Pump Effectiveness Cardiac Care
 Dysrhythmia ___  Monitor vital signs, cardiovascular status, and
 Abnormal heart sounds ___ respiratory status to assess for manifestations of
 Peripheral edema ___ decreased cardiac output (e.g., fatigue, malaise,
 Dyspnea ___ shortness of breath, dyspnea on exertion, palpitations,
 Pulmonary edema ___ angina, widened pulse pressure).
 Monitor for dysrhythmias, including disturbances of
Measurement Scale both rhythm and conduction, to identify and treat
1 = Severe significant dysrhythmias.
2 = Substantial
3 = Moderate Hemodynamic Regulation
4 = Mild  Administer positive inotropic and contractility
5 = None medications to increase myocardial contractility.
 Elevate the head of the bed to reduce venous return
and optimize breathing.

Energy Management
 Promote bedrest/activity limitation to decrease
cardiac workload and O2 demand.

Nursing Diagnosis
Fluid Imbalance
Etiology: Fluid retention from valvular-induced heart failure
Supporting data: Peripheral edema, weight gain, adventitious breath sounds, neck vein
distention

Patient Goal
Achieves fluid and electrolyte balance

Outcomes (NOC) Interventions (NIC) and Rationales

*Nursing diagnoses listed in order of priority.

Copyright © 2020 by Elsevier, Inc. All rights reserved.

eNursing Care Plan 36-5

Outcomes (NOC) Interventions (NIC) and Rationales

Fluid Balance Hypervolemia Management
 Adventitious breath sounds  Monitor for peripheral edema to detect hypervolemia
___ causing third spacing.
 Neck vein distention ___  Monitor respiratory pattern for symptoms of
 Peripheral edema ___ pulmonary edema (e.g., anxiety, air hunger,
orthopnea, dyspnea, tachypnea, cough, frothy sputum
Measurement Scale production, and shortness of breath) to assess for fluid
1 = Severe congestion in the lungs.
2 = Substantial  Monitor hemodynamic status, including HR, BP,
3 = Moderate MAP, CVP, PAP, PCWP, CO, and CI, if available, to
4 = Mild assess hemodynamic response to and effectiveness of
5 = None
interventions.
 Weigh daily at consistent times (e.g., after voiding,
before breakfast) and monitor trends to monitor for
signs of hypervolemia.
 Administer prescribed medications to reduce preload
(e.g., furosemide, spironolactone, morphine, and
nitroglycerin) to assist with removal of fluid.
 Monitor for laboratory test results of
hemoconcentration (e.g., sodium, BUN, hematocrit,
urine specific gravity), if available, to assess for signs
of hypervolemia.

Fluid/Electrolyte Management
 Provide prescribed diet as appropriate for specific
fluid or electrolyte imbalance (e.g., low-sodium, fluid-
restricted, and no added salt) to prevent fluid
retention.

Nursing Diagnosis
Activity Intolerance
Etiology: Insufficient oxygenation from decreased cardiac output and pulmonary
congestion
Supporting data: Weakness, fatigue, shortness of breath, increase or decrease in pulse
rate, BP changes

Patient Goal
Achieves optimal level of activity

Outcomes (NOC) Interventions (NIC) and Rationales

Activity Tolerance Energy Management
 Pulse rate with activity ___  Monitor cardiorespiratory response to activity
 Ease of breathing with activity (e.g., tachycardia, other dysrhythmias, dyspnea,
___ diaphoresis, pallor, hemodynamic pressures,

Copyright © 2020 by Elsevier, Inc. All rights reserved.

eNursing Care Plan 36-6

Outcomes (NOC) Interventions (NIC) and Rationales

 Systolic BP with activity ___
 Diastolic BP with activity ___
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
respiratory rate) to plan appropriate interventions.
 Encourage alternate rest and activity periods to
conserve energy and decrease cardiac demands.
 Encourage patient to choose activities that
gradually build endurance to increase cardiac
tolerance.
 Assist the patient/caregiver to establish realistic
activity goals to promote feelings of
accomplishment.

Nursing Diagnosis
Lack of Knowledge
Etiology: Lack of experience and exposure to information about disease and treatment
process
Supporting data: Questions about measures to prevent complications, requests for
information

Patient Goal
Describes disease process and appropriate measures to prevent complications

Outcomes (NOC) Interventions (NIC) and Rationales

Knowledge: Disease Process
 Characteristics of specific
disease ___
 Physiologic effects of disease
___
 Signs and symptoms of disease
___
 Strategies to minimize disease
progression ___
Knowledge: Medication
 Medication therapeutic effects
___
 Medication side effects ___
 Medication adverse effects ___
 Potential medication
interactions ___
 Correct use of prescribed
medication ___
Teaching: Disease Process
 Assess the patient’s current level of knowledge
related to specific disease to develop teaching
plan.
 Explain pathophysiology of the disease and how it
relates to anatomy and physiology to ensure
knowledge base.
 Describe common signs and symptoms of the
disease.
 Describe disease process. Instruct the patient on
measures to control/minimize symptoms to
manage disease.
 Discuss lifestyle changes that may be required to
prevent complications and/or control the disease
process (e.g., smoking cessation) to decrease
cardiac workload and promote oxygenation.
 Teach patient and caregiver signs and symptoms to
report to health care provider to ensure
appropriate interventions.

Measurement Scale Teaching: Prescribed Medication

1 = No knowledge  Teach patient and/or caregiver purpose and action
2 = Limited knowledge

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eNursing Care Plan
Outcomes (NOC)
3 = Moderate knowledge
4 = Substantial knowledge
5 = Extensive knowledge
Copyright © 2020 by Elsevier, Inc. All rights reserved.
36-7
Interventions (NIC) and Rationales
of each medication.
 Provide patient and/or caregiver with written
information about action, purpose, and side effects
of each medication.
 Teach the patient appropriate actions to take if side
effects occur to prevent complications and ensure
appropriate actions are taken.