Activity intolerance related to inflammation and degeneration of muscle cells myocarditis, cardiac filling restriction (cardiac output).
Characterized by:
Outcomes:
Interventions and Rationale :
1. Assess the patient's response activities. Note the presence / emergence and change of complaints like weakness, fatigue and shortness of breath during activity.
R/ : Myocarditis causing inflammation and allow disruption in muscle cells that can lead to CHF.
Decreased cardiac filling / cardiac output will cause the liquid to collect in the pericardial cavity (if any pericarditis), which in turn can cause endocarditis and valvular dysfunction trend decline in cardiac output.
2.Monitor rate or rhythm of the heart / pulse, blood pressure and respiration amount, before / after and during activities as needed.
R/ : Help illustrate the level of the heart and pulmonary decompensation. Decreased blood pressure, tachycardia, and tachypnea are indicative of heart activity disorders.
3. Maintain bedrest during periods of fever and as indicated.
R/ : Control changes infection, during the acute phase of pericarditis / endocarditis.
Note: Fever increases oxygen demand, thereby increasing the ability of the heart and reduces the activity.
4. Plan of care by setting the rest / sleep period.
R /: Maintaining balance the needs of cardiac activity, enhancing the healing process and emotional coping skills.
5. Evaluation of emotional response to the situation / administration support.
R/ : R /: Anxiety will arise due to infection and cardiac responses (psychological). The level of anxiety and emotional needs of the patient will be a good coping posed by the possibility of life-threatening illness. Support is needed to face the possibility of frustration due to long hospitalization / healing period.
6. Collaboration: Provide oxygen therapy as indicated.
R /: Improved oxygenation ability to myocarditis, offset the increase in oxygen consumption. Can be seen in the activity.
Acute pain related to inflammation of the myocardium and pericardium, systemic effects of the infection, and ischemic tissue (myocardium).
Characterized by:
Interventions and Rationale :
1. Observe for chest pain, record the time, factors complicate / originator, record the non-verbal signs of discomfort such as weakness, muscle tension and tears.
R /: Location of pain of pericarditis in the substernal radiating to the neck and back. But in contrast to myocardial ischemic pain / infarction. The pain will increase as the inspiration, position changes, and reduced the time to sit / lean forward.
Note: Chest pain is the presence or absence of endocarditis / myocarditis depends on the presence of ischemia.
2. Maintain or create a peaceful environment and a fun action such as changes in position, put a cold compress or warm, mental support, and so on.
R /: These measures can reduce the patient's physical and emotional discomfort.
3. Give the medication as indicated.
R /: To prevent the onset of pain or reduce the inflammatory response.
Source : http://nandacareplan.blogspot.com/2014/10/acute-pain-and-activity-intolerance-ncp.html
Characterized by:
- Complaints of weakness / fatigue / tightness during activity.
- Changes in vital signs while the activity.
- Signs of CHF.
Outcomes:
- Increased activity capabilities.
- Reduction of physiological signs that do not fit.
- Reveals the importance of limited activity.
Interventions and Rationale :
1. Assess the patient's response activities. Note the presence / emergence and change of complaints like weakness, fatigue and shortness of breath during activity.
R/ : Myocarditis causing inflammation and allow disruption in muscle cells that can lead to CHF.
Decreased cardiac filling / cardiac output will cause the liquid to collect in the pericardial cavity (if any pericarditis), which in turn can cause endocarditis and valvular dysfunction trend decline in cardiac output.
2.Monitor rate or rhythm of the heart / pulse, blood pressure and respiration amount, before / after and during activities as needed.
R/ : Help illustrate the level of the heart and pulmonary decompensation. Decreased blood pressure, tachycardia, and tachypnea are indicative of heart activity disorders.
3. Maintain bedrest during periods of fever and as indicated.
R/ : Control changes infection, during the acute phase of pericarditis / endocarditis.
Note: Fever increases oxygen demand, thereby increasing the ability of the heart and reduces the activity.
4. Plan of care by setting the rest / sleep period.
R /: Maintaining balance the needs of cardiac activity, enhancing the healing process and emotional coping skills.
5. Evaluation of emotional response to the situation / administration support.
R/ : R /: Anxiety will arise due to infection and cardiac responses (psychological). The level of anxiety and emotional needs of the patient will be a good coping posed by the possibility of life-threatening illness. Support is needed to face the possibility of frustration due to long hospitalization / healing period.
6. Collaboration: Provide oxygen therapy as indicated.
R /: Improved oxygenation ability to myocarditis, offset the increase in oxygen consumption. Can be seen in the activity.
Acute pain related to inflammation of the myocardium and pericardium, systemic effects of the infection, and ischemic tissue (myocardium).
Characterized by:
- Chest pain radiating to the neck or back.
- Joint pain.
- Increased pain on deep inspiration, activity, and change the position.
- Fever or chills.
- Clients can identify ways to prevent pain.
- Clients can control and report pain arising.
- Clients can demonstrate relaxation techniques and a variety of activities that are indicated for individual circumstances.
Interventions and Rationale :
1. Observe for chest pain, record the time, factors complicate / originator, record the non-verbal signs of discomfort such as weakness, muscle tension and tears.
R /: Location of pain of pericarditis in the substernal radiating to the neck and back. But in contrast to myocardial ischemic pain / infarction. The pain will increase as the inspiration, position changes, and reduced the time to sit / lean forward.
Note: Chest pain is the presence or absence of endocarditis / myocarditis depends on the presence of ischemia.
2. Maintain or create a peaceful environment and a fun action such as changes in position, put a cold compress or warm, mental support, and so on.
R /: These measures can reduce the patient's physical and emotional discomfort.
3. Give the medication as indicated.
R /: To prevent the onset of pain or reduce the inflammatory response.
Source : http://nandacareplan.blogspot.com/2014/10/acute-pain-and-activity-intolerance-ncp.html
