NURSING CARE PLAN (NCP)

CUES NURSING DIAGNOSIS

Decreased cardiac output related to structural factors secondary to valvular dysfunction from infective process.

BACKGROUND KNOWLEDGE
Endocarditis is an inflammation of the endocardium; it is usually limited to the memrane lining and the valves. The cause of endocarditis may be viral, fungal, or most commonly, bacterial. The most common organism is Streptococcus viridans. Vegetations (growths or lesion) may cause vulvular dysfunction.

NURSING OBJECTIVES
After my 8hours of nursing care and interventions, the patient BP will be stable

NURSING INTERVENTIONS
Independent Monitor BP and Pulse a. Note presence of pulse alternans ( indicative of left sided heart failure) b. Evaluate pulse pressure (30-40 mmHg indicates adequate CO) Auscultate heart sound Keep client on bed, promote bed rest, semi fowlers position is preferred Evaluate Jugular vein distention Record intake and output Record daily weight Provide supplemental oxygen at 2 to 4 L/min. Auscultate lung fields for evidence of crackles(rales) Dependent: Administer multi-I.V antibiotic regimen antipyretics as ordered and as needed.

RATIONALE

EVALUATION

Subjective: Naglisod ko ginhawa ug sakit ako dughan day as verbalized by the patient. Objective: -received pt. per stretcher -shortness of breath/ dyspnea noted -cyanotic -weakness noted -cough noted -tachycardia noted - with the ff vls: T PRRRBP-

-provide baseline data for comparison to follow trends and to evaluate respond to intervention

Goal met, patients BP is stable

-detect new murmur or change in existing murmur and presence of gallop -decrease oxygen consumption and promote venous return -to measure the exact fluid retention of the body -for baseline purposes - to maintain or improve oxygenation

Source: http://nursingcrib.com/cr itical-care-andemergencynursing/endocarditis/