NUR 241 Student Worksheet - Case Study on Heart Failure

NUR 241 Student Worksheet
Case StudyHeart failure
Revisit pathophysiological concepts:
Group work developing a plan of care:
You are a Registered Nurse on a medical ward when a patient is handed over to you from the morning staff.
You are provided with this handover:

Work through the clinical reasoning cycle and develop a care plan for this patient
I Mr. Smith is a 70yr/old male who presented to his GP at 10am today
S He was c/o chest pain that is pleuritic in nature, SOB, weakness, fatigue a hacking cough with
bilateral bibasal course crackles.
B History:
Ax: penicillin
Meds: atorvastatin 20m Mane, frusemide 20 mg mane
Past illnesses: hypercholesterolaemia, MI, angina, hypertension, Increased BMI 34, T2DM
Last meal: 7am (3hrs ago), bacon eggs, sausages toast and hash browns
Events leading up to presentation: walking/gardening
A His vital signs are a Temp 36.8, GCS 15, HR 105, NiBP- 170/90, Sp02- 92%, RR 24. Initial ECG
displayed t wave inversion and initial bloods showed a negative troponin of TNI: 0.02
R He was given his regular meds & 5mg IV morphine, 1gm paracetamol which reduced his pain to
2/10. PIVC insitu R) ACF- patent.

Please complete the nursing process:
Consider
the patient
Situation
Assessment
Head to toe assessment:
CNS:gcs-15
RESP: tachychardia, spo2 of 92%, sob shortness of breath
CVS:heart rate- 105, tachycardic, bp- 170/90 systolic is high, bilateral bibasal course
crackles.( we can hear during
GIT: had a proper meal, bmi is high 34
RENAL: increase urine output(polyuria
Other: weak,fatigue, chaestvpain
Collect
informatio
n and cues
Process
informatio
n
Diagnosis
According to Grin et al. (2016), ABCDE framework deals with Airway, Breathing,
Circulation, Disability and Exposure. It is a systematic approach for immediate assessment
and treatment of critically ill patients and is applicable in the clinical emergencies.
Airway of Mr. Smith is experiencing obstruction as be is experiencing exacerbation
of his CHF (Chronic Health Failure). The airway of Mr. Smith indicates bibasal coarse
crackle. According to Pocock, Richards and Richards (2013), basal crackles are present on
both side of the lungs and are caused by "popping open" of the small airways or fluid
collapsed alveoli or lack of aeration at the time of expiration.
In breathing, it can be said that Mr. Smith has general signs of respiratory distress.
The respiratory rate of Mr. Smith is 24. Normal respiratory rate is 12 to 20 beats per
minute and rate higher than this shows visible sign of respiratory distress. This high
respiratory rate might be due to his high non-invasive blood pressure (170/90 mg/Hg)
(Shier, Butler & Lewis 2015). Moreover Mr. Smith is also experiencing shortness of breath
(SOB) and thus it can be said that he is suffering from in-effective gas exchange.
Circulation is accessed by the body temperature of the patient. Body temperature
is slightly decreased. The body temperature of Mr Smith is 36.8 degree Centigrade. Normal
body temperature range for adults is 37 degree. Her heart rate is slightly increased: 105
beats per minute (normal: 60 to 100 beats per minute) (Shier, Butler & Lewis 2015). He is
also experiencing hacking cough with bibasal course crackles. His past history indicated
that she has oedema as she is on Frusemide medication. Thus it indicates he is suffering
from excess fluid volume.
Disability is reflected in the domain of hypoxia. Mr. Smith might be suffering from
mild hypoxia as his oxygen saturation (Sp02- 92%) (Grin et al. 2016). Normal oxygen
saturation is 98% at room temperature (Shier, Butler & Lewis 2015).
There is no significant information in the domain of Exposure.
Identify
problems