Nursing Diagnosis and Nursing Interventions

Nursing Diagnosis and Nursing Intervention for Myocarditis

Myocarditis is inflammation of heart muscle. Inflammation of the myocardium.

Myocarditis is most often due to infection by common viruses, such as parvovirus B19, less commonly nonviral pathogens such as Borrelia burgdorferi (Lyme disease) or Trypanosoma cruzi, or as a hypersensitivity response to drugs.

Symptoms do develop they can include:
  • Chest pain
  • Fever (raised temperature)
  • A fast heartbeat - faster than usual for a normal high temperature (fever)
  • An irregular heartbeat
  • Tiredness
  • Shortness of breath

Nursing Diagnosis and Nursing Intervention for Myocarditis


Activity Intolerance

Related to :
  • generalized weakness;
  • reduced energy stores,
  • increased metabolic rate from massive production of leukocytes,
  • imbalance between oxygen supply and demand (anemia and hypoxia),
  • therapeutic restrictions—isolation,
  • bedrest;
  • effect of drug therapy

Can be evidenced by
  • Verbal report of fatigue or weakness
  • Exertional discomfort or dyspnea
  • Abnormal heart rate or BP response

Expected Result / criteria for evaluation of patients will :
  • Endurance
  • Report a measurable increase in activity tolerance.
  • Participate in ADLs to level of ability.
  • Demonstrate a decrease in physiological signs of intolerance—pulse, respiration, and BP remain within client’s normal range.

Nursing intervention and Rationale for Myocarditis :
  1. Assess patient's response to the activity. Watch for changes and complaints of weakness, fatigue, and dyspnea related to activity.
    R: myocarditis causing inflammation and possible damage to the function of myocardial cells.
  2. Monitor frequency / heart rhythm, BP, and respiratory frequency before and after activity and as long as necessary.
    R: helps determine the degree of cardiac and pulmonary decompensation. Decrease in blood pressure, tachycardia, dysrhythmias, and tachypnea is indicative of damage to the heart of activity tolerance.
  3. Maintain bed rest during febrile period and according to indications.
    R: improving the resolution of inflammation during the acute phase.
  4. Plan of care, with periods of rest / sleep without interruption.
    R: provide balance in the needs which the activity relies on the heart.
  5. Assist patients in gradually progressive exercise program as soon as possible to get out of bed, noting the response of vital signs and patient tolerance to the increase in activity.
    R: when inflammatory / basic condition is resolved, the patient may be able to perform the desired activity, except for permanent myocardial damage / complications.
  6. Collaboration supplemental oxygen administration as indicated.
    R: maximizing the availability of oxygen to reduce the heart's workload.

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Nursing Diagnosis - Nursing Interventions

NANDA NURSING

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