Complex nursing care Assignment PDF

Running head: COMPLEX NURSING CARE
Complex nursing care
Name of thee Student
Name of the University
Author Note

1COMPLEX NURSING CARE
Table of Contents
Background..........................................................................................................................2
Patient health problems........................................................................................................3
1. Chest pain........................................................................................................................3
Assessment data...................................................................................................................3
Interventions........................................................................................................................4
Evaluation............................................................................................................................5
2. Breathing..........................................................................................................................5
Assessment data...................................................................................................................5
Intervention..........................................................................................................................6
Evaluation............................................................................................................................7
References............................................................................................................................9

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CASE STUDY
Background
Mr Anthony Khoury, 67(M) presented at emergency department of the UTS hospital.
Complain includes shortness of breath and chest pain. The patient was reported by the eldest
daughter at 1000 hrs. On collection of the medical history, the patient was found to be diagnosed
with type 2 diabetes 12 years ago. The patient was administered with oral medication. The
diabetes complications of the patient include symptomatic neuropathy and Peripheral vascular
diseases. The patient underwent coronary angioplasty and stents for myocardial infarction. He is
also under regular cardiology care. Other medical history also involves hypertension,
dyslipidaemia, and Angina also managed by oral medication. Recently the hypertension has
exacerbated. The person is non-drinker but previously was involved in smoking. No allergies
were reported in the patient. He was administered perindopril for hypertension and Atarvostatin
for hyperlipidemia.
On admission Mr Khoury was observed with the following-
HR 130
tachycardia
BP Sitting: 152/92
standing: 130/64
Resp. 28
non-productive cough;
speaks in short phrases
auscultation- coarse crackles
Reports-orthopnoea
fatigue with exercise
O2 Sat. 91% RA
Elevated to 95% with O2 (6L/min)
Temp. 36.5oC
LOC Alert
orientated to person
slight confusion with time and place (GCS 14/15)

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feels light headed after quick wake up
Pupils Equal
reactive to light
Pain 4/10
focused upper chest area (left)
Decreased with O2 suppky
Airway Patent
Peripheries oedema in both ankles
BGL 7 mmols/l
Patient health problems
1. Chest pain
Assessment data
Mr Khoury while arguing with his sons experienced sudden chest pain and
breathlessness. His pain is exacerbating due to high level of anxiety and stress. His cardiac
condition is weak with history of the Angina and Myocardial infarction. Chest pain together with
shortness of breath is risk factor blockage in blood vessels and reduces supply of oxygen to the
heart muscles, characteristics of the coronary artery disease. It is the condition of the inactive
tissue perfusion and activity intolerance (Miller et al., 2015). There is a risk of coronary heart
failure as the patient has high fluid accumulation in ankles, tachycardia, high anxiety, state of
confusion and orthopnea. Orthopnea is the symptom of the left ventricular heart failure or and
pulmonary edema (Gazewood & Turner, 2017). The patient was observed with fatigue. It is
caused by decreased cardiac output and impaired skeletal muscle blood supply, which is causing

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fatigue. According to Sheldon et al. (2015) abnormal heart rhythms, supraventricular
tachycardia increases the level of anxiety in patients with previous cardiac problems. This
triggers the symptoms of the light-headedness, discomfort and shortness of breath.
Interventions
The nursing goal for the patient is to reduce the chest pain scores and other contributing
factors. The intervention to achieve this goal are-
 Monitoring of the vital signs- as per clinical review mandated by NSW policy.
The patient blood pressure, heart rate are below the normal range therefore,
regular monitoring of vital signs will help improve the condition. Clinical review
is important till the patient is out of the BTF (between the flags)(Azzolin et al.,
2013).
 Provide oxygen supply to achieve 99% saturation to improve ventricular function
by increasing CO2 release (Martin & Grocott, 2013).
 Perform ECG- helps determine the pain quality, and mange the chest pain. With
the help of the PQRST assessment the radiation of the pain can be detected. There
is also need of additional information on the ventricular function, valve function,
and thickness of the chest wall. EKG may be 12 lead or 24 lead. Patient with
chronic heart failure should have low voltage ECG after resolving the peripheral
oedema, the ECH again gains the voltage and looks normal (AlGhatrif &
Lindsay, 2012).
 Medication- the patient can be treated with opioid analgesics by PCA system to
relief pain. The patient may also be administered with the Nonopioids

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(acetaminophen), which stimulate the nociceptor. As this angina pain Sublingual
Glyceryl trinitrate would be effective. PRN medication can be given if the pain is
unmanageable with regular medicine (Collinsbet al., 2013). The patient may be
educated about the side effects and observed for signs of complications as well as
respiratory distress.
 Nonpharmacological intervention- Rest- the patient may be positioned with the
flower or semi-flower position for maximum chest expansion. The patient may be
kept in calm environment and reduce the environmental stimuli (Authors/Task et
al., 2012).
Evaluation
The patient must be monitored for decrease in chest pain score, oxygen saturation and
other vital signs to evaluate the desired outcome. If the observations are between the flags,
immediate interventions will be taken and modify the previous nursing strategies. Monitoring
can be discontinued if signs are in normal range. The patient must be evaluated for the decrease n
anxiety and confusion. Effective feedback must be collected from the patent to rate the pain and
satisfaction after intervention. The patient may demonstrate improved well being with the base
line levels of Blood pressure, pulse, improved breathing. Pressure care shall be determined in
nose and ear. The patient may be asked to verbalise his feelings of illness (Innovation, 2016).

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2. Breathing
Assessment data
Shortness of breath is the other major complain of Mr Khoury. His initial oxygen
saturation level was 91% in RA. After administrating the oxygen, it elevated to the 95%. The
patient could utter only few short sentences. The patient has oedema in both ankles. It is the sign
of the venous congestion. Tachycardia leads to decreased cardiac output, increased sodium
retention, increased osmotic pressure, increased ADH, increased water reabsopption and fluid
overload oedma (Belen et al., 2015). Breathlessness is caused by the raised left ventricular filling
pressure to maintain the decreased cardiac output. It increases pulmonary diffusion, and
breathlessness. Extreme shortness of breath is the sign of the pulmonary edema also
accompanied with the anxiety. The patient may be at risk of the pulmonary oedema owing to the
symptoms of chest discomfort, irregular heart, headaches, non productive cough (Vital et al.,
2013). Pulmonary oedema and heart failure are interlinked. Fluid accumulation in lungs impairs
the gaseous exchange. The heart failure prevents the adequate removal of blood from the
pulmonary circulation. In this condition the respiratory distress is to hypoxia (Platz et al., 2015).
Intervention
The nursing goal for Mr Khoury is to achieve the oxygen saturation of 99% and relive of
respiratory distress.
 Oxygen supply- nurse collaboration with the oxygen to improve the ventricular
function. It is the life saving drug. It will help heart muscles to survive and reduce
pain. It will improve the oxygen saturation to 99% as it previously got elevated to

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95%. Since ages it has been the standard treatment for myocardial ischemia and
chest pain. While giving oxygen the patient to be positioned in the Fowler’s
position. It will expand both the accessory and primary muscle. Oxygen delivery
is important for maintaing the homeostasis (Lenglet et al., 2012).
 Patient education- on effective coughing and deep breathing. He must be educated
about frequent changes in the position. It will help clear airway and facilitates
oxygen delivery. Further educate the patient about the relaxation technique t
decrease the work of breathing (Gulanick & Myers, 2013).
 Medication- diuretics (Thiazide) can be administered to reduce the alveolar
congestion and improve the exchange of gases. Administration of the
bronchodilators will allow increased oxygen delivery. It will help dilates small
airways and reduces pulmonary congestion (Vandse et al., 2012). In addition to
the diuretics the vasodilators are also administered to minimise the risk of the
fluid overload. After administration of the vasodilators the nurse must regularly
monitor the urine output to avoid hypovolemia (Gulanick & Myers, 2013).
 Monitor- the nurse must observe the breathing pattern for SOB. Further the
nasal flaring pursued lip breathing and increases the accessory muscles. It will
help identify increased breathing work. the nurse must measure the Vital capacity
and tidal volume. The nurse must maintain the fluid balance chart to monitor the
oedema. The patient may be advocated to take 2 liters of fluid per day (Granado
& Mehta 2016). The nurse must monitor the level of confusion of the patient
using the AVPU assessment. Headache and confusion are common in the

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hypoxia. Further any risk of deterioration may be monitored by the clinical
review.
 The nurse must use the compression stockings to minimise oedema and improve
circulation. There is need of regular monitoring of the odema by pressing over the
bony surface and categorise as mild indent or moderate or deep (Cooper, 2013).
Evaluation
The patient may be monitored if the respiratory pattern is effective without fatigue. The
oxygen saturation if achieved till 99%. Further, the input and output must be carefully regulated.
If the input and the output is not appropriate then it must be followed by the clinical review. The
patent may be monitored for mobility issue and risk of fall through fall risk assessment. If the
patient has clear airway, without coarse crackles and deceased leg oedema, then the nursing
goals are said to be achieved. The patient should be carefully monitored for any other
complications (Powell et al., 2016).

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References
AlGhatrif, M., & Lindsay, J. (2012). A brief review: history to understand fundamentals of
electrocardiography. Journal of community hospital internal medicine perspectives, 2(1),
14383.
Authors/Task Force Members, McMurray, J. J., Adamopoulos, S., Anker, S. D., Auricchio, A.,
Böhm, M., ... & Gomez-Sanchez, M. A. (2012). ESC Guidelines for the diagnosis and
treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and
Treatment of Acute and Chronic Heart Failure 2012 of the European Society of
Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the
ESC. European heart journal, 33(14), 1787-1847.
Azzolin, K., Mussi, C. M., Ruschel, K. B., de Souza, E. N., de Fátima Lucena, A., & Rabelo-
Silva, E. R. (2013). Effectiveness of nursing interventions in heart failure patients in
home care using NANDA-I, NIC, and NOC. Applied Nursing Research, 26(4), 239-244.
Belen, E., Tipi, F. F., Helvaci, A., & Bayyigit, A. (2015). Concurrent early-onset peripartum
cardiomyopathy in a preeclampsia patient with acute pulmonary edema. Internal
Medicine, 54(8), 925-927.
Collins, S. P., Pang, P. S., Fonarow, G. C., Yancy, C. W., Bonow, R. O., & Gheorghiade, M.
(2013). Is hospital admission for heart failure really necessary?: the role of the emergency
department and observation unit in preventing hospitalization and
rehospitalization. Journal of the American College of Cardiology, 61(2), 121-126.

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Cooper, G. (2013). Compression therapy in chronic oedema and lymphoedema. Nursing &
Residential Care, 15(3), 134-139..
Gazewood, J. D., & Turner, P. L. (2017). Heart Failure with Preserved Ejection Fraction:
Diagnosis and Management. American family physician, 96(9).
Granado, R.C. & amp; Mehta, R.L. (2016). Fluid overload in the ICU: evaluation and
management', BMC Nephrology, vol. 17, no. 109, pp. 1-9
Gulanick, M., & Myers, J. L. (2013). Nursing Care Plans-E-Book: Nursing Diagnosis and
Intervention. Elsevier Health Sciences.
Innovation, A.f.C. (2016), Cardiac Monitoring of Adult Cardiac Patients in NSW Public
Hospitals, viewed 11th April 2018,
<http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2016_019.pdf>.
Lenglet, H., Sztrymf, B., Leroy, C., Brun, P., Dreyfuss, D., & Ricard, J. D. (2012). Humidified
high flow nasal oxygen during respiratory failure in the emergency department:
feasibility and efficacy. Respiratory Care, 57(11), 1873-1878.
Martin, D. S., & Grocott, M. P. W. (2013). Oxygen therapy in critical illness: precise control of
arterial oxygenation and permissive hypoxemia. Critical care medicine, 41(2), 423-432.
Miller, A. H., Carreras, M. T. C., Miller, S. A., Miller, H. E., & Page, V. D. (2015). Is there
coronary artery disease in the cancer patient who manifests with chest pain, shortness of
breath and/or tachycardia? A retrospective observational cohort. Supportive Care in
Cancer, 23(2), 419-426.

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Platz, E., Jhund, P. S., Campbell, R. T., & McMurray, J. J. (2015). Assessment and prevalence of
pulmonary oedema in contemporary acute heart failure trials: a systematic
review. European journal of heart failure, 17(9), 906-916.
Powell, J., Graham, D., O’Reilly, S. & Punton, G. (2016). Acute pulmonary oedema, Nursing
Standard (2014+), vol. 30, no. 23, pp. 51-4.
Sheldon, R. S., Grubb, B. P., Olshansky, B., Shen, W. K., Calkins, H., Brignole, M., ... & Sutton,
R. (2015). 2015 Heart Rhythm Society expert consensus statement on the diagnosis and
treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and
vasovagal syncope. Heart rhythm, 12(6), e41-e63.
Vandse, R., Kothari, D. S., Tripathi, R. S., Lopez, L., Stawicki, S. P., & Papadimos, T. J. (2012).
Negative pressure pulmonary edema with laryngeal mask airway use: Recognition,
pathophysiology and treatment modalities. International journal of critical illness and
injury science, 2(2), 98.
Vital, F. M., Ladeira, M. T., & Atallah, Á. N. (2013). Non‐invasive positive pressure ventilation
(CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. The Cochrane Library.