RNSG 2332: ADULT HEALTH NURSING ASSESSMENT TEST
• Nursing Management
o Nursing Assessment
▪ Subjective Data
• Important Health Information
o Past health history:
▪ Rheumatic fever
▪ Infective endocarditis
▪ Congenital defects
▪ Heart attach
▪ Chest trauma
▪ Cardiomyopathy
▪ Syphilis
▪ Marfan’s syndrome
▪ Streptococcal infections
• Functional Health Patterns
o Health perception-health management:
▪ IV drug abuse
▪ Fatigue
o Activity-exercise:
▪ Palpitations
▪ Generalized weakness
▪ Activity intolerance
, ▪ Dizziness
▪ Fainting
▪ Dyspnea on exertion
▪ Cough
▪ Hemoptysis
▪ Orthopnea
o Sleep-rest:
▪ Paroxysmal nocturnal dyspnea
o Cognitive-perceptual:
▪ Angina or atypical chest pain
▪ Objective Data
• General
o Fever
• Integumentary
o Diaphoresis
o Flushing
, o Cyanosis
o Clubbing
o Peripheral edema
• Cardiovascular
o Abnormal heart sounds, including –
▪ Murmurs
▪ S₃
▪ S₄
o Dysrhythmias, including –
▪ Atrial fibrillation
▪ Premature ventricular contractions
o Tachycardia
o Increased or decreased pulse pressure
o Hypotension
o Water-hammer or thread peripheral pulse
• Gastrointestinal
o Ascites
o Hepatomegaly
o Unexplained weight
gain
• Possible Diagnostic Findings
o Cardiomegaly on chest x-ray
o ECG abnormalities specific to involved valve
o Echocardiogram (valve disorders and chamber dilation)
o Heart catheterization (abnormal valves, chamber pressures, cardiac output, and
, blood flow depending on involved valve)
o Nursing Diagnoses
▪ Decreased CO related to valvular incompetence
▪ Excess fluid volume related to fluid retention secondary to valvular-induced HF
▪ Activity intolerance related to insufficient oxygenation secondary to decreased CO and
pulmonary congestion
o Planning
▪ Overall goals –
• Normal heart function
• Improved activity tolerance
• An understanding of the disease process and health maintenance measures
o Nursing Implementation
▪ Health Promotion
• Pts must adhere to ordered therapies
▪ Acute Care and Ambulatory Care
• Implement therapeutic intervention and evaluate their effects
• Perform ongoing cardiac assessments
o Evaluation
▪ Expected outcomes –
• Maintain adequate tissue and organ perfusion
• Achieve fluid and electrolyte balance
• Achieve optimal level of activity
• Describe disease process and appropriate measures to prevent complications
A. Mitral Valve Stenosis
a. Etiology and Pathophysiology
• Nursing Management
o Nursing Assessment
▪ Subjective Data
• Important Health Information
o Past health history:
▪ Rheumatic fever
▪ Infective endocarditis
▪ Congenital defects
▪ Heart attach
▪ Chest trauma
▪ Cardiomyopathy
▪ Syphilis
▪ Marfan’s syndrome
▪ Streptococcal infections
• Functional Health Patterns
o Health perception-health management:
▪ IV drug abuse
▪ Fatigue
o Activity-exercise:
▪ Palpitations
▪ Generalized weakness
▪ Activity intolerance
, ▪ Dizziness
▪ Fainting
▪ Dyspnea on exertion
▪ Cough
▪ Hemoptysis
▪ Orthopnea
o Sleep-rest:
▪ Paroxysmal nocturnal dyspnea
o Cognitive-perceptual:
▪ Angina or atypical chest pain
▪ Objective Data
• General
o Fever
• Integumentary
o Diaphoresis
o Flushing
, o Cyanosis
o Clubbing
o Peripheral edema
• Cardiovascular
o Abnormal heart sounds, including –
▪ Murmurs
▪ S₃
▪ S₄
o Dysrhythmias, including –
▪ Atrial fibrillation
▪ Premature ventricular contractions
o Tachycardia
o Increased or decreased pulse pressure
o Hypotension
o Water-hammer or thread peripheral pulse
• Gastrointestinal
o Ascites
o Hepatomegaly
o Unexplained weight
gain
• Possible Diagnostic Findings
o Cardiomegaly on chest x-ray
o ECG abnormalities specific to involved valve
o Echocardiogram (valve disorders and chamber dilation)
o Heart catheterization (abnormal valves, chamber pressures, cardiac output, and
, blood flow depending on involved valve)
o Nursing Diagnoses
▪ Decreased CO related to valvular incompetence
▪ Excess fluid volume related to fluid retention secondary to valvular-induced HF
▪ Activity intolerance related to insufficient oxygenation secondary to decreased CO and
pulmonary congestion
o Planning
▪ Overall goals –
• Normal heart function
• Improved activity tolerance
• An understanding of the disease process and health maintenance measures
o Nursing Implementation
▪ Health Promotion
• Pts must adhere to ordered therapies
▪ Acute Care and Ambulatory Care
• Implement therapeutic intervention and evaluate their effects
• Perform ongoing cardiac assessments
o Evaluation
▪ Expected outcomes –
• Maintain adequate tissue and organ perfusion
• Achieve fluid and electrolyte balance
• Achieve optimal level of activity
• Describe disease process and appropriate measures to prevent complications
A. Mitral Valve Stenosis
a. Etiology and Pathophysiology
