Nursing Care Plan for Endocarditis
1. Acute pain related to systemic effects of infection.
Interventions :
Independent
- Assess the complaint of chest pain. Pay attention to nonverbal cues of discomfort.
- Provide a quiet environment and comfort measures, such as: changes in position, back rub, use a warm compress / cold.
- Give proper entertainment activities.
- Give medications as indicated.
- Give O2 supplementation as indicated.
Rationale :
- Chest pain may and may not accompany the presence or absence of ischemia depends endocarditis.
- This action can reduce the patient's physical and emotional discomfort.
- Redirecting attention, provide distraction in the level of individual activities.
- Can relieve pain, decrease the inflammatory response.
- Maximize the availability of O2 to reduce the workload of the heart and prevent ischemia.
2. Risk for decreased cardiac output related to disorders of the heart valves and the endothelium.
Interventions :
Independent
- Monitor frequency / rhythm, heart sounds.
- Provide comfort measures, for example; back rub, semi-Fowler's position and entertainment.
- Give medications as indicated.
- Tachycardia and distritmia can occur when the heart is working to increase, rising to fever, hypoxia and ischemia.
- Increase relaxation and redirecting attention.
- Increase ventricular contraction.
3. Altered body temperature related to the infection process.
Interventions :
Independent
- Assess for dehydration, diaphoresis, poor skin turgor, dry mucous membranes.
- Measure the body temperature 4-8 hours.
- Monitor the input and output of fluids every 8 hours.
- Monitor the IV presence of redness and swelling, change places every 24 hours.
- Give antibiotics antipyretic to order, make sure the drug is administered according to the time.
- Increased heat causes the discharge through evaporation.
- Further support the diagnosis.
- Knowing the fluid balance while an increase in temperature.
- Prevent the occurrence of phlebitis.
4. Risk for Ineffective tissue perfusion related to embolization
Interventions :
Independent
- Assess for signs of embolization, report any signs of embolization to the doctor immediately.
- Perform a neurological examination or according client's condition.
- Instruct the client about the need to continue anticoagulation, if ordered for further prevent embolic period.
- Encourage active with range of motion exercises as tolerated.
- Give anticoagulant therapy.
- The presence of emboli causing blockage of blood flow resulting in tissue hypoxia.
- Help enforce the subsequent diagnosis.
- Reduce the formation of embolism due to freezing blood cells.
- Improves peripheral circulation and venous return to reduce thrombus formation and embolism.
EVALUATION
1. Acute pain related to systemic effects of infection.
- Reported pain gone / controlled.
- Demonstrate the use of the skills of relaxation and diversion activities as indicated for individual situation.
- Identify methods that give disappearance.
2. Risk for decreased cardiac output related to disorders of the heart valves and the endothelium.
- Nutritional status is maintained / repaired.
- Achievement fixes weight according to age, gender.
- Clients revealed increased appetite.
3. Altered body temperature related to the infection process.
- Inflammatory process has been lost.
- Moist and dry skin.
- Cerebral tissue perfusion is maintained.
- Clients conscious and oriented.
- No signs of embolization.
(reference: Marilynn E. Doenges)
