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Risk for Impaired Gas Exchange - Nursing Diagnosis for Rheumatic Heart Disease

Rheumatic heart disease is a condition in which permanent damage to heart valves is caused by rheumatic fever. The heart valve is damaged by a disease process that generally begins with a strep throat caused by bacteria called Streptococcus, and may eventually cause rheumatic fever.

Symptoms may include:
  • Joint inflammation - including swelling, tenderness, and redness over multiple joints. The joints affected are usually the larger joints in the knees or ankles. The inflammation "moves" from one joint to another over several days.
  • Small nodules or hard, round bumps under the skin.
  • A change in your child's neuromuscular movements (this is usually noted by a change in your child's handwriting and may also include jerky movements).
  • Rash (a pink rash with odd edges that is usually seen on the trunk of the body or arms and legs).
  • Fever.
  • Weight loss.
  • Fatigue.
  • Stomach pains.

Nursing Diagnosis and Interventions for Rheumatic Heart Disease

Risk for Impaired Gas Exchange related to the accumulation of blood in the lungs due to increased atrial filling

Goal: risk for impaired gas does not occur

Expected outcomes:
  • Demonstrating adequate ventilation and oxygenation of the tissue, indicated by blood gas analysis / oximetry in the normal range and free of symptoms of respiratory distress.
  • Participate in a treatment program within the ability / situation.

Intervention and rationale:

1. Auscultation of breath sounds, note: crackles, mengii.
2. Instruct the patient to cough effectively, breathing deeply.
3. Maintain a semi-Fowler position, chock the hand with a pillow if possible
4. Collaboration in the provision of supplemental oxygen as indicated.
5. Collaboration for the examination of blood gas analysis.
6. Collaboration for the administration of diuretics.
7. Collaboration for the administration of bronchodilator drugs.


1. Stating pulmonary congestion / collecting secretions indicate the need for further intervention.
2. Clearing the airway and facilitate the flow of oxygen.
3. Lowering the oxygen consumption / needs and enhance maximum lung expansion.
4. Increasing alveolar oxygen concentration, which can improve / lower tissue hypoxemia.
5. Can be severe hypoxemia during pulmonary edema.
6. Lowers alveolar congestion, improve gas exchange.
7. Increasing the flow of oxygen to dilate small airways and emit a mild diuretic effect to reduce pulmonary congestion.

Acute Pain - NCP Atherosclerosis

Nursing Care Plan for Atherosclerosis

Atherosclerosis is a slow disease in which your arteries become clogged and hardened. Fat, cholesterol, calcium, and other substances form plaque, which builds up in arteries.

Signs and Symptoms:

Many times, people with atherosclerosis don't have any symptoms until an artery is 40% clogged with plaque. Symptoms vary depending upon which arteries are affected.

Nursing Diagnosis for Atherosclerosis : Acute Pain related to an impaired ability of blood vessels to supply oxygen to the tissues.

Goal: reduced pain

Expected outcomes: patient states chest pain disappear, or can be controlled, the patient did not seem grimace, demonstrate relaxation techniques.

Intervention and Rational:

1. Monitor characteristics of pain through verbal and hemodynamic responses (crying, pain, grimacing, can not rest, respiratory rhythm, blood pressure and changes in heat rate).
Rationale: Each patient has a different response to pain, verbal and hemodynamic changes in response to detecting a change in comfort.

2. Assess the description of pain experienced by patients include: place, intensity, duration, quality, and distribution.
Rationale: Pain is a subjective feeling that is experienced and is described by the patient and should be compared with other symptoms to obtain accurate data.

3. Provide a comfortable environment, reduce the activity, limit visitors.
Rationale: Helps reduce external stimuli that can add to the tranquility so patients can rest in peace and the power of the heart is not too hard.

4. Teach relaxation techniques with a sigh
Rationale: Helps relieve pain experienced by patients psychologically which can distract the patient that is not focused on the pain experienced.

5. Observation of vital signs before and after drug administration.
Rationale: Knowing the patient's progress, after being given the drug.

Ineffective Tissue Perfusion: Peripheral related to impaired circulation

Ineffective Tissue Perfusion: Peripheral related to impaired circulation

Nursing Diagnosis for Atherosclerosis : Ineffective Tissue Perfusion: Peripheral related to impaired circulation

Goal: clients show improvement perfusion with

Expected outcomes: a peripheral pulse / same, normal skin color and temperature, an increase in behaviors that increase tissue perfusion.

Intervention and Rational:

1. Observation of skin color on the sick.
Rationale: The skin color typically occurs when cyanosis, cold skin. During the color change, the sick to be cool then throbbing and tingling sensations.

2. Note the decrease in pulse; traffic change skin (no color, glossy / tense).
Rationale: This change indicates progress or chronic process.

3. View and examine the skin for ulceration, lesions, gangrene area.
Rationale: Lesions may occur from the size of a pin needle to involve all the fingertips and can lead to infection or damage / loss of tissue seriously.

4. Advise for the proper nutrients and vitamins.
Rationale: The balance of a good diet includes protein and adequate hydration, necessary for healing of the sick.

5. Monitor signs of tissue perfusion adequacy.
Rationale: To identify the early signs of impaired perfusion.

6. Encourage patients perform the exercises or exercises gradually extremities.
Rationale: For circulation.

Risk for Impaired Skin Integrity NCP Heart Failure

Nursing Diagnosis Risk for impaired skin integrity related to pitting edema.

Expected outcomes:
clients can demonstrate behaviors / techniques to prevent skin damage.
Maintaining the integrity of the skin.


1. Change position often in bed / chair, assistive range of motion exercises passive / active.
2. Provide frequent skin care, minimizing the moisture / excretion.
3. Check narrow shoes / sandals and change as needed.
4. Monitor skin, bone protrusion noted, edema, impaired circulation area / pigmentation or overweight / underweight.
5. Massage the area red or white.


1. Improving circulation / lowering an area that interfere with blood flow.
2. Too dry or moist skin damage and accelerating damage.
3. Dependent edema can cause the shoe is too narrow, increasing the risk of stress and damage to the skin on the feet.
4. Lowering the pressure on the skin, improve circulation.
5. Skin disorders are at risk due to the peripheral circulation, physical immobilization and impaired nutritional status. Increase blood flow, minimizing tissue hypoxia.

NANDA Nursing