Kapi’olani Community College
Associate Degree Nursing Program
Nurs255 Nursing Care Plan
Student Name: Tori Ann Yatogo
Date of Care: 11-15-2013
Date Submitted: 11-19-2013
Nursing Diagnosis
Infection management related to bacterial endocarditis manifested by CHF with mitral valve repair and removal of vegetation, positive blood culture for streptococci, history of
rheumatic fever, chest x-ray showing cardiomegaly with pulmonary congestion and symptoms including difficulty breathing, tachycardia, tactile fevers, edema to lower extremities,
non-productive cough, muscle aches and diaphroesis.
Scientific Rationale:
Infective endocarditis is when there is damage to the endocardium from turbulent or high velocity blood flow. Bacteria that enters the bloodstream adheres to injured endocardium
and triggers the inflammatory process. Symptoms include fever, fatigue, joint and muscle aches, weight loss, headache and diaphoresis. As the bacteria grows and infects the tissue,
it can colonize, causing a vegetation that disrupts the closure of the valve. The ineffective valve closure leads to fluid build-up, increasing pressure in the ventricle and can lead to
cardiac hypertrophy and CHF.
Reference:
Ball, J., Bindler, R., & Cowen, K. (2012). Principles of pediatric nursing: caring for children, (5th ed.). Upper Saddle River, NJ: Pearson.
Gulanick, M. & Myers, J. (2011). Nursing care plans: Diagnosis, interventions, and outcomes, (7th ed.). St Louis: Mosby.
Measurable Outcomes:
Interventions:
Rationale (w/ references):
Evaluation:
Short Term Outcome:
Assess VS. Focused assessment on respiratory
& cardiovascular status. Provide antipyretics if
needed.
Most Pts have compensatory tachycardia in
response to low CO. Reduced BP from low CO
and vasodilating effects of meds are expected.
Rapid shallow respirations are characteristic of
reduced CO. (Gulanick, p. 257)
0800 oral temp was 97.8F. Pt remained afebrile, 1200
temporal temp was 98.8F. BP ran low, normal for Pt,
continued with BP medication. HR & RR also ran high
but normal for Pt. Lung sounds were clear on
auscultation w/no signs of distress. Vibratory murmur
noted, loudest n lower lobe of heart. VSS w/accordance
to Pt norms.
Monitor daily weight.
Body weight is a more sensitive indicator of fluid or
sodium retention than I&O. A 2-3 lb increase in
weight usually indicates retention of 1 liter of fluid
and a need to adjust diuretic drug therapy.
(Gulanick, p. 257)
Nurse stated she would take it later in the afternoon.
Assess for pain (type, location, intensity). Assess
incision site for signs of infection (redness,
swelling, drainage). Provide pain management
and reassess within 1 hour of administration.
Expected post-op pain. Sternum incision is
healing. Pain is an unpleasant sensory and
emotional experience associated with actual or
potential tissue damage. (Ball, p.371)
Incision sites were intact with no redness, swelling or
drainage. Pt reported pain in sternum area above
incision site. It looked slightly swollen and was tender
on palpation. Pt rated pain at 2 and declined PRN
Tylenol. Also noticed a red papule rash to left
subclavian area that Pt continued to scratch. Nurse
requested an order for hydrocortisone cream for it.
Administer prescribed antibiotics.
Evidence of infection through a positive blood
culture is a criterion for diagnosis. C&S reports
show which antibiotics will be effective against the
Administer Linezolid 306 mg IV over 1 hour. Pt tolerated
well. No signs of IV infiltration or pain at site.
Pt remains afebrile and incisions remain
intact with no signs of infection.
Long Term Outcome:
Pt has no signs or symptoms of
infection. Able to tolerate foods & fluids
adequately.
invading organism. (Gulanick, p.344)
Administer furosemide & captopril. Monitor I&Os
and for fluid and electrolyte imbalances.
Diuretics mobilize fluids & facilitate excretion.
Adequate output is a good indicator of renal
perfusion. Electrolyte imbalance is common when
diruetics are given. (Ball, p.626) ACE-inhibitors
decrease peripheral vascular resistance & venous
tone and suppress aldosertone output thus
reducing BP and demands on the heart. (Gulanick,
p.258)
Pt tolerated medications well. 0800 BP was 94/66 but
that was normal for Pt. Urine output during 7 hour shift
was 3.5 ml/kg/hr.
Assess GI function. Adhere to low tyramine diet.
Encourage food and fluids.
Children who have insufficient dietary intake
experience a higher rate of infectious disease due
to lowered immune response. (Ball, p.348) Low
tyramine diet because of reaction with Linezolid
drug including HA, chest pains, tachycardia, N&V.
Mother received handout on low tyramine diet teaching
and stated understanding. Pt ate egg whites, 3 large
spoon fulls of rice and 1/3 of sausage.