CHAPTER III
NURSING CARE
3.1 Assessment
Assessment
is the first step in the nursing process and basic overall
a. The main complaint
• Fever
•
Chest pain similar to angina pectoris and pericarditis
• Palpitations
• Shortness of breath
b. Important Signs
• Tachycardia
• Kardomegali (rapidly
occurring)
• weakened heart sound
•
Rhythm gallopTanda signs of heart failure, especially right heart failure.
Assessment
of patients myocarditis (Marilynn E. Doenges, 1999) include:
Activity / rest
Symptoms: fatigue,
weakness.
Signs:
tachycardia, decreased blood pressure, dyspnea with activity.
Breathing
Symptoms:
shortness of breath (chronic shortness of breath worse at night).
Signs:
DNP (paroxismal nocturnal dyspnea), coughing, wheezing inspiration; tachypnea,
krekels, and ronkhi; breathing shallow.
Circulation
Symptoms:
a history of rheumatic fever, congenital heart disease, cardiac surgery, heart
palpitations, fainting.
Signs:
tachycardia, dysrhythmias, perpindaha point of maximal impulse, cardiomegaly,
frivtion rub, murmur, gallop rhythm (S3 and S4), edema, DVJ, petechiae,
splinter hemorrhage, Osler nodes, Janeway lesions.
Elimination
Symptoms:
a history of renal disease / renal failure; decreased frequency / jumlsh urine.
Signs: dark concentrated urine.
Painful
Symptoms
such as pain struck and burned bert load
Signs:
distraction behavior, such as anxiety.
Security
Symptoms:
a history of viral, bacterial, fungal (myocarditis; chest trauma; malignancy /
irradiation thorakal; handling gear; sitem endoscopic examination of the GI /
GU), decreased immune system, SLE or other collagen diseases.
Signs: fever.
3.2 Special Examination
a. Examination
of ECG: Not a typical
• inferior ST-T changes
• cardiac conduction disorders
1. Thoracic
Photo: Not your typical
•
Enlarged heart or pleural effusion perikard.
1. Echocardiography:
• Enlargement of the left heart
•
Can be confused with hypertrophic cardiomyopathy and mitral stenosis.
3.3 Nursing Diagnosis
Nursing
diagnosis is a unification of the problem of real or potential patients based
on data that has been collected.
Nursing
diagnoses that appear in patients with myocarditis (Doenges, 1999) is
1. Pain
associated with myocardial inflammation, systemic effects of infection, tissue
ischemia.
2. High
risk for decreased cardiac output associated with heart muscle degeneration,
decreased / kontriksi ventricular function.
3. Infection
associated with the spread of infectious agents
4. Impaired
peripheral tissue perfusion related to penrunan cardiac output.
5. Activity
intolerance related to inflammation and degeneration of myocardial muscle
cells, decreased cardiac output.
6. Lack
of knowledge (learning need) regarding condition, treatment plan related to
lack of knowledge / memory, mis-interpretation of information, cognitive
limitations, deny the diagnosis.
3.4 Intervention
Intervention
is planning nursing actions that will be implemented to address the problem in
accordance with the nursing diagnoses.
Nursing
interventions and implementation occur in patients with myocarditis (Doenges,
1999).
1. Painful
Purpose: Pain is
lost or controlled.
Results
Criteria: - Pain is reduced or lost
- Clients look cool.
Intervention:
•
Collaboration of drugs as indicated (nonsteroidal agents: aspirin, indocin;
antipyretic; steroids).
R:
to relieve pain, reduce inflammation response, reduce fever; steroids given for
more severe symptoms.
•
Collaboration of oxygen supplementation as indicated.
R:
maximizing the availability of oxygen to reduce the workload of the heart
•
Provide a quiet environment and comfort measures eg change of position, rub
your back, use a warm compress / cold, emotional support.
R:
This action can reduce the physical and emotional discomfort of patients.
• Provide appropriate
distraction techniques
R:
redirect attention, provide distraction in individual activity levels.
•
Menitoring complaints of chest pain and a weighting factor or lowering. Note
the nonverbal cues of discomfort, for example; lay silent / anxiety, muscle tension,
crying.
R:
the pain is worse in the inspirations, move or lie down and disappear by
sitting upright / bent.
2. High risk for decreased
cardiac output
Objective:
Identify the behavior to decrease the heart's workload.
Criteria
Results -Melaporkan/menunjukkan period decreased dyspnea, angina, and
dysrhythmias.
-Shows stable
cardiac rhythm and frequency.
Intervention:
•
Maintain bed rest in a semi-Fowler position.
R:
decrease the heart's workload, maximize cardiac output.
•
Provide comfort measures eg change of position, rub his back, and entertainment
activities in tolerransi heart.
R:
increase relaxation and redirect the attention.
•
Collaboration of drugs as indicated, such as digitalis, diuretics.
R:
can be provided to increase myocardial contractility and cardiac workload
meurunkan.
•
Collaboration of antibiotic / antimicrobial intervena
R:
is given to address the identified pathogens and prevent further heart damage.
•
Monitor frequency / heart rhythm, blood pressure, and respiratory rate before
and after the activity and as long as necessary.
R:
help determine the degree of cardiac decompensation and pulmonary. Decrease
TD, tachycardia, dysrhythmias, and tachypnea are indicative of the damage
tolerance of the heart to the activity.
• Auscultation of heart
sounds. Note
the distance / muffled tone heart murmur, S3 and S4 gallops.
R:
provide early detection of serious complications such as: GJK, cardiac
tamponade.
3. The risk of the spread of
infectious agents b.d infection
Objective: Do not
spread the infection occurs
Expected
outcomes are:-normal body temperature, 36.5 to 37 C
Normal WBC values
3800-9800/mcl
Intervention:
• Collaboration of
antibiotics
R /
antibiotics to reduce infectious agents
•
Perform complete blood tests to monitor the value of granulocytes and WBC
R
/ to find out the value of WBC and granlosit as an indicator of infection
• Observation of vital signs
R
/ Monitor the patient's condition and progress further action
4. Activity
intolerance
Objective:
the patient has enough energy to move.
Criteria
results: - Behavior reveal the ability to provide for ourselves.
-
Patients expressed able to do some activities without assistance.
-Coordination
of muscle, bone and other limbs either.
Intervention:
•
Assist patients in gradually progressive exercise program as soon as possible
to get out of bed, take vital signs and responses of patients at increased
activity tolerance.
R:
when inflammation / basic condition is resolved, the patient may be able to
perform the desired activity, except for permanent myocardial damage /
complications occur.
• Assess the
patient's response to the activity. Watch
for changes and complaints of weakness, keletiahan, and dyspnea with respect to
activity.
R:
myocarditis causing inflammation and possible damage to the function of
myocardial cells.
•
Maintain bed rest during periods of fever, and as indicated.
R:
improving the resolution of inflammation during the acute phase.
•
Collaboration of oxygen supplementation as indicated.
R:
menmgimbangi maximize the availability of oxygen to oxygen consumption that
occurs with activity
•
Meantau frequency / heart rhythm, blood pressure, and respiratory rate before
and after the activity and as long as necessary.
R:
help determine the degree of cardiac decompensation and pulmonal.Penurunan TD,
tachycardia, dysrhythmias, and tachypnea are indicative of the damage tolerance
of the heart to the activity.
5. Impaired tissue
perfusion bd decreased cardiac output.
Objective:
Impaired tissue perfusion resolved within 3x24 hours.
Results Criteria: - RR
30-60 x / mnt
-Nadi 120-140 x / mnt.
-Temperature 36.5 to 37 C
-Cyanosis (-)
Warm-Extremity
Intervention:
• Give oxygen as needed
R / Help increase
cardiac output
• Observation
frequency and heart sounds
R
/ frequency heart sounds were normal and indicates the blood flow smoothly,
which means back to normal tissue perfusion.
• Observe for cyanosis.
R
/ presence of cyanosis or bluish indicate impaired tissue perfusion.
• Observation TTV.
R / Monitor
development of the condition of patients
•
Collaboration with physicians for the provision of therapy.
R / Increase cardiac output
6. Lack of
knowledge
Objective:
To express understanding of the disease process and treatment regimen.
Expected
outcomes:-Identify the side effects and possible complications to consider.
-Memperlihatan
behavior change to prevent complications.
Intervention:
•
Assess readiness and barriers to learning, including people nearby.
R:
A feeling of well-being has long enjoyed affect the interests of patients /
significant other to study the disease.
•
Explain the effects of inflammation on the heart, the patient individually. Ajarakkn
to pay attention to the symptoms associated with complication / recurrence and
symptoms reported immediately to the caregiver, for example fever, increased
chest pain that is not normal, weight gain, increased tolerance to activity.
R:
to take responsibility for their own health, patients need to understand the
specific causes, treatment and long-term effects are expected from inflammatory
conditions, according to the signs / symptoms that indicate recurrence /
complications.
•
Instruct the patient / significant other about the dosage, purpose and side
effects of medication; dietary needs; special considerations; activity is
allowed / restricted.
R:
the information necessary to improve self-care, increased involvement in the
therapeutic program, prevent complications.
•
Review the need for long-term antibiotic / antimicrobial terapy.
R:
length of hospitalization / giving IV antibiotic / antimicrobial necessary
until blood culture negative / other blood results showed no infection.
3.5 Evaluation
Evaluation
addalah stadium on the nursing process in which the degree of success in
achieving the goals of nursing assessed and the need to modify or nursing
intervention defined purpose.
The
evaluation is expected in patients with myocarditis (Doenges, 1999) are:
1. Lost
or uncontrolled pain
2. Identify
behaviors to reduce the heart's workload.
3. No
systemic infection
4. Peripheral tissue perfusion returns
to normal
5. Patients have enough
energy to move.
6. Stating
understanding of the disease process and treatment regimen.
CHAPTER IV
CLOSING
4.1 Conclusion
Myocarditis
is rarely obtained at the peak of the infection because the disease will be
covered by the systemic manifestations of the disease and new infections clear
on the recovery phase. This
form is generally heal by itself, but most continue to be a form of
cardiomyopathy, and there is also a cause of arrhythmias, conduction disorders
or heart trouble which is structurally considered normal.
Most
of the clients are not the typical complaints, may be obtained weakness,
palpitations, shortness of breath, and chest discomfort. Chest pain is
usually there when accompanied by pericarditis. Sometimes
resembling obtained pain of angina pectoris. The
most common symptoms are tachycardia that does not conform to the temperature
rise. Sometimes
hypotension obtained with a small pulse or the pulse interference.
4.2 Suggestion
As
a nurse should always alert in the management of myocarditis as it would be
fatal if too late to handle it. Besides
nurses also provide health education to clients and their families to
understand with myocarditis and how its treatment.
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