Clinical Reasoning Cycle for Congestive Heart Failure Patient

This study analyses a critical case study of an elderly female named M.G, age 68 years, using clinical reasoning cycle. The patient suffered congestive heart failure. The study focuses on the implementation of the cycle, identification of issues, and taking action. The two priority patient problems that require immediate and proper nursing intervention and care are breathlessness and fluid and salt imbalance. The study provides interventions and rationales for both issues.

NURSING ASSIGNMENT
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Table of Contents
Introduction........................................................................................................................ 3
Introduction to Clinical reasoning cycle....................................................................3
Implementation of Clinical reasoning cycle.............................................................4
Considering the patient situation........................................................................................ 4
Collecting cues/information................................................................................................. 4
Processing information.......................................................................................................... 6
Identification of issues............................................................................................................ 7
Establishing goals..................................................................................................................... 7
Taking action............................................................................................................................. 8
Expected outcomes................................................................................................................ 10
Reflecting on process and learning’s............................................................................... 10
Conclusion......................................................................................................................... 11
References......................................................................................................................... 12
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Introduction
The congestive heart failure (CHF) is a complicated heart disease that can
result due to many internal bodily conditions like hypertension, cardiac abnormalities,
valve diseases, cardiomyopathy etc. This (CHF) is the inability of the heart to
maintain adequate oxygen transportation in the body leading to defects in oxygenation
and perfusion that is again a risk to many other body parts (Stuart, 2014). In elderly
patients, heart failure occurs due to multiple comorbid bodily conditions like renal
dysfunctions, lung diseases, diabetes, hypertension etc., these comorbidities are
multifactorial, for example- renal dysfunction can occur due to factors like
depression, decreased perfusion, anemia and cachexia (Ackley et al. 2019).
In this study, a critical case study of an elderly female named M.G, age 68
years is analysed using clinical reasoning cycle. This clinical reasoning cycle helps to
understand patient condition followed by processing collected information from
physical history and examination to develop an effective care plan. This study
particularly focuses on the provided case study patient who suffered congestive heart
failure.
Introduction to Clinical reasoning cycle
Levett-Jones clinical reasoning cycle (2009) is a perfect process that can help
the nurse to manage patient information, study, collect cues, process information,
understanding patient issues and planning interventions. This is further followed by
the evaluation of outcomes and reflecting on new learning’s developed from the
complete process. Levett-Jones clinical reasoning cycle is considered perfect to
manage case study in nursing because it is a perfect blend of five clinical reasoning
rights that are cues, patient, action, time and reason. This clinical reasoning cycle
allows critical thinking alongside decision making in nursing practice (Forsberg,
Ziegert, Hult & Fors, 2016).
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Figure 1: Levett-Jones Clinical Reasoning Cycle
Implementation of Clinical reasoning cycle
Considering the patient situation
The case study patient M.G is an old-age lady who suffered congestive heart
failure (CHF) further facing critical consequences of CHF identified by her mentioned
symptoms like shortness of breathe and swelling in legs. According to Harjola et al.
(2016) studies shortness of breath and swelling in any body part are primary
symptoms of heart failure. The mentioned details indicate that the patient’s careless
attitude is the reason behind her critical condition as she was not following her salt
and fluid consumption instructions and was also not loyal to her medication schedule.
The case study information indicates that patient is in a very critical condition
because a major congestive heart failure at age of 68 years is already a serious
situation to handle followed by complication that can further harm her health. Further,
the patient is already a victim of other comorbidities of CHF like hypertension, renal
failure, hyperlipidaemia in past. She is also having a family inheritance of heart
condition and critical medical history.
Collecting cues/information
Reviewing current information
The provided information in case leaflet involves a past medical history,
family history, vital signs observation, laboratory results, and radiology result and
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prescribed medication details. As per the medical history details of the patient, she
suffered an acute myocardial infarction (heart attack) 4 years ago. She is also a victim
of hypertension, hyperlipidaemia and chronic renal failure. Harjola et al. (2016)
studies mention hypertension and renal failure as major factors that can provoke any
kind of heart failure in the future. According to Tham et al. (2015) studies,
hypertension and hyperlipidaemia are conditions’ that directly decrease perfusion and
oxygenation process by increasing blood pressure that can lead to any kind of
cardiovascular risk.
Further, the family history of the patient makes her clearly vulnerable to
serious heart condition because her father (myocardial infarction) and mother
(coronary artery disease) both were a victim of different cardiovascular conditions.
The nursing assessment details of patient indicate high blood pressure, high
respiratory rate and low oxygen saturation through vital sign’s examination. She is
identified with peripheral oedema, cardiomegaly, diaphoretic lungs, high pulse and
pinkish skin colour. The laboratory test results indicate high sodium (145 mEq/L),
potassium (5.3 mEq/L), creatinine (4.5 mg/dL) and blood urea nitrogen (BUN) (43
mg/dL). Lastly, her radiology result shows cardiomegaly and pulmonary congestion.
Gathering new information
The current information about case study patient indicates a critically serious
risk to the heart where a patient is suffering pulmonary congestion, cardiomegaly,
hypertension and history of heart diseases. Begum, Barua, Filla & Ahmed (2014)
indicated that pulmonary congestion is a condition where lungs get filled with fluid
where the body struggles for oxygen causing breathe shortness. This creates a direct
impact on cardiovascular by affecting normal oxygenation and perfusion process in
the body. Further, increased level of sodium, potassium, BUN and creatinine indicates
a risk to normal urinary function. The patient is already having a history of renal
failure indicating that her health really needs a proper care plan and medication for
survival.
Recalling knowledge (pathophysiology)
Heart failure is a condition where heart efficiency is reduced due to overload
or damage. CHF is either directly or indirectly caused by other bodily conditions like
pulmonary dysfunction (abnormal oxygenation), hypertension, amyloidosis and renal
dysfunction (Figueroa & Peters, 2016). These conditions in the body increase
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workload in heart muscle causing heart failure (Yancy et al. 2016). In the present
case, the patient is identified with pulmonary congestion and renal abnormalities as
per information collected from the study of symptoms, laboratory results and nursing
assessment. In CHF condition, heart muscle reduces its contractility resulting in
reduced cardiac output becoming incapable to meet body demand and supply rule
(Hunter & Arthur, 2016). According to Figueroa & Peters (2016) studies, CHF patient
has an imbalance between myocardial oxygen supply and demand leading to
disturbance in perfusion and oxygenation harming other body organs.
According to Caplan (2015) studies, CHF pathophysiology involves structural
abnormalities as well as cardiovascular response to poor perfusion in the body. This
poor perfusion activates the neurohumoral system that increases preload by
stimulating fluid and salt retention. Thus, this increases vasoconstriction afterload that
causes damage to myocytes and extracellular matrix also affecting other body organs
like lungs, kidneys, blood vessels etc. This pathophysiology clearly demonstrates
present case study patient condition because the CHF of the patient has affected her
kidney (renal dysfunction) and lungs (pulmonary oedema). Further, Ter Maaten et al.
(2015) indicated that abnormal diastolic function of the heart causes loss of normal
left-ventricular function that results in exercise intolerance where pulmonary-venous
pressure and left-atrial pressure causes pulmonary congestion. Further, inadequate
cardiac output leads to poor perfusion while performing exercise in the leg and other
accessory muscles of respiration.
Processing information
By understanding the provided information about the patient situation, sign’s
and symptoms, pathophysiology and gathering new information it can be interpreted
that patient is suffering serious health issue related to her heart, renal organs and
respiratory system. The complete laboratory results showing high salt content in the
body indicates renal dysfunction (Figueroa & Peters, 2016). Further, the
pathophysiology of CHF suffered by the patient and relating it to the patient’s current
signs and symptoms it can be interpreted that cardiovascular and respiratory system of
the patient is highly disturbed requiring proper attention.
The provided case study information is critical to handle because all the
provided vital symptoms and other laboratory results are critically linked with each
other. It is difficult to find the core reason for such serious disturbance in the patient’s
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body because of the past medical condition indicates the occurrence of similar
cardiovascular and renal dysfunction. However, presently patient is a victim of heart
failure consequences that are shortness of breathe and swelling in the body part that
requires major attention. According to Guazzi & Naeije (2017) studies, eating too
much of salt or not managing salt (sodium) intake develop fluid retention in the body
that leads to shortening of breathe and swelling in the heart failure condition. Further,
the laboratory finding indicates a critical fluid disturbance in the body. The presence
of swelled legs, cardiomegaly and pulmonary congestion issues indicate disturbed
oxygenation and perfusion in the body of the patient.
The prescribed medication for case study patient are proper to handle the issue
of hypertension and renal dysfunction but one medicine, potassium chloride, cannot
be considered as suitable medication because patient is detected with high potassium
content (5.3 mEq/L) in laboratory result which is above normal potassium content
range for adult human (3.0-5.0 mEq/L). The data indicate that health consequences of
CHF faced by the patient in the current situation are due to careless behaviour adopted
by the patient (not taking prescribed medication, fluid and salt restriction). Therefore,
the patient needs a proper care diagnosis, plan, observation and care to overcome
these life-threatening issues at this old age.
Identification of issues
The two priority patient problem in the provided case that requires immediate and
proper nursing intervention and care are: -
 Breathlessness (decreased cardiac output, disturbed oxygenation and
perfusion)
 Fluid and salt imbalance (heart and urinary dysfunction)
Establishing goals
Priority Issue 1 - Breathlessness
Short term goals Timefram
e
Long term goals Timeframe
The patient will
ensure proper air
exchange and clear
2weeks The patient will remain free from
respiratory distress
6months
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breathe
The patient will feel
relaxed and
comfortable
breathing
2weeks
The patient will
properly understand
and learn therapeutic
methods to manage
breathlessness
1week
Priority Issue 2 - Fluid and salt imbalance
Short term goals Timefram
e
Long term goals Timeframe
The patient will
maintain a properly
functional fluid
balance in the body
2weeks The patient will display normal
laboratory values
3 months
The patient will feel
hydrated and
balanced with a
stable physical and
mental condition.
2 weeks The patient will demonstrate
behaviour to prevent
reoccurrence of condition as well
as monitoring fluid status.
3 months
The patient will
understand and learn
dietary patterns and
fluid restrictions
2weeks
Taking action
Priority Issue 1 - Breathlessness (decreased cardiac output, disturbed
oxygenation and perfusion)
Intervention Rationale
Maintaining proper body alignment and
position for the patient.
A proper sitting position maximises chest
expansion and lung excursion
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(Christensen & Kockrow, 2014).
Encouraging breathing exercises (slow
inhalation and passive exhalation),
relaxation exercises and appropriate
muscle training (diaphragmatic
breathing).
The breathing exercises increase
oxygenation and manage perfusion
issues. Further, controlled breathing help
to aid slow respirations in the patient.
Further, relaxation exercises and muscle
training helps to overcome respiratory
distress (Higginson et al. 2014).
Ensuring patient consultation regarding
dietary modifications with the dietician
The proper support and good nutrition
help to strengthen respiratory muscles
(Thomas, Kern, Hughes & Chen, 2016).
Helping and supporting the patient in
daily activities as well as acute
respiratory distress episode.
This shall work to manage patient anxiety
by ensuring proper support and care as a
professional (Christensen & Kockrow,
2014).
Providing education regarding
medications, breathing patterns,
relaxation, exercises and other possible
measures to manage shortness of breathe.
This promotes safe and effective disease
management for long-term even in the
absence of professional care (Higginson
et al. 2014).
Priority Issue 2 - Fluid and salt imbalance
Intervention Rationale
Daily monitoring of vital signs, body
weight, physical examination and fluid
I&O followed by periodic monitoring of
laboratory studies (sodium, BUN,
potassium and arterial blood gases.
This shall help to observe fluid shifts,
water restriction and renal functionality.
By daily and periodic monitoring
professional eliminate emergency
conditions like cardiac arrest (Stuart,
2014).
Encourage patient to drink the prescribed
amount of fluids (replacement therapy).
The oral fluid replacement can be
considered the most effective
replacement therapy to overcome
fluid/salt imbalance (Christensen &
Kockrow, 2014). According to Higginson
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et al. (2014) studies, old age patient has a
low sense of thirst, therefore, the need for
drinking reminders and other fluid
management strategies to meet their body
hydration demands.
Ensuring consultation with a dietician for
proper food and fluid balanced diet for
the patient (low sodium diet, balanced
protein and required/restricted fluids).
This shall further help to strengthen the
body by proper nutrition and manage
fluid imbalance (Stuart, 2014).
Ensure safety measures like low bed
position, soft restraints, frequent
observations, 24-hour support services
and using side rails.
Fluid shifts or imbalance is a serious
issue that can risk to severe accidents like
falls, hallucinations, unconsciousness etc.
Such safety measures shall help to avoid
these emergency situations (Christensen
& Kockrow, 2014).
Educating patient about possible causes,
effects of fluid losses as well as the
importance of fluid management in their
body.
This shall enhance patient knowledge to
develop self-care behaviour and maintain
a regular balanced state of hydration in
the body (Urden, Stacy & Lough, 2017).
Expected outcomes
The proper implementation of provided nursing care plan should ensure a
balanced fluid and salt quantity in the patient’s body that shall minimise their risk to
further cardiovascular arrest or renal dysfunction. Further, managing shortness of
breath shall eliminate the risk of emergency (cardiac arrest) as well as help to
maintain oxygenation and perfusion in the patient’s body.
Reflecting on process and learning’s
This study involves detailed and structured management of provided case
study using clinical reasoning cycle that has helped to enhance professional
knowledge and learning regarding nursing practice and patient management. The
study helped to gain theoretical as well as practically applicable knowledge on
analysing the patient situation, detecting problem and providing nursing management
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for specific issues. Such study clearly works to enhance professional knowledge,
skills and practice as a nursing professional.
Conclusion
The case of M.G patient in clearly analysed in this study using Levett-Jones
clinical reasoning cycle to understand patient condition and develop a proper nursing
intervention for getting control over identified issues. The expected outcomes are also
mentioned to ensure achievement of targeted goals. Lastly, the study particularly
focuses on pathophysiology and care plan development for the case study patient
specifically.
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