NUR250 Assessment 1 S2 2018 Assignment template

NUR250 Assessment 1 S2 2018 Assignment template
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Task 1: Patient assessment
A careful and a detailed clinical assessment is necessary to assess the likely causes
and the severity of the symptoms. The most important symptoms that should be checked
are tightness of chest, shortness of breath, palpitation and chest pain. This initial physical
examination should be followed by a cardiac assessment (Glozier, 2013).
 Cardiac assessment involves chest inspection, palpation and percussion of the heart. The
patient should be examined for any chest deformities (King, Kingery, & Casey, 2012).
Palpation should include inspection and assessment of the nail beds. Palpation of the
skin should be done to identify the presence of oedema. The carotid artery should be
palpated and inspected (King, Kingery, & Casey, 2012). Physical examination of the veins
has been found to be one of the important physical assessment to understand the
volume status of the patient with a heart failure. The internal jugular vein can be
examined to assess the jugular venous distention (JVD). David has normal blood
pressure but the heart rate is 118 beats per minute, which higher than the standard
value. According to Huikuri & Stein (2013), any increase in the heart rate of 5 b.p.m from
the normal value causes a 9% increase of mortality due to cardiac failure (Kemp &
Conte, 2012). Due to the tachycardia in the patient, the blood might not be pumped
effectively to the rest of the body that can deprive the organs and the tissues of oxygen
giving rise to symptoms like chest tightness, heart palpitations (Lee et al., 2012).
 The second assessment is the respiratory assessment. David has been assessed with
acute breathlessness, which worsens on lying down. This condition is due to pulmonary
oedema caused by the fluid accumulation in the alveoli of the lungs, which might
interfere with the oxygen from getting in to the blood, giving rise to dyspnoea (Glozier,
2013).The normal oxygen saturation level read on a pulse oximeter is from 95- 100
percent. Low oxygen saturation levels in chronic heart failure in this patient indicate the
inability of the heart to receive oxygen rich blood from the lungs (Saguil, & Fargo, 2012).
The final assessment for the patient with chronic heart failure is the pain
assessment. Pain assessment should be initiated by identifying the source of the pain.
Repositioning of the patient would not improve patient with HF. 70-80 % of the pain related
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to HF is reported in the middle or the upper sub-sternal region and the pain can often be
described as a "crushing" and heavy sensation (Alemzadeh-Ansari, Ansari-Ramandi, &
Naderi, 2017). Further it is important to note that the pain is radiating or not. Furthermore
the severity of the pain can be identified by facial grimacing or by a pain rating scale.
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Task 2: Care planning
Nursing Care Plan: David
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A reminder that all rationales must be referenced
Nursing problem:Imbalanced fluid volume
Underlying cause or reason: Decreased cardiac output and compensatory mechanisms causing salt and water retention. Use of diuretics may reduce
circulating blood volume causing hypovolemia despite peripheral oedema.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
Decrease fluid volume
and maintain fluid
balance throughout
the shift.
 Monitoring the urine output
 Monitoring the 24- intake and the
output
 The patient should be kept in semi
fowler position
 The position should be changed
frequently. The skin should be kept
 Urine output can be less due to less
renal perfusion (Lambrinou,
Kalogirou, Lamnisos, &Sourtzi,
2012).
 Monitoring of I & O balance is
necessary as application of
diuretics can cause hypovolemia
 Subjective outcome-David reported that
he was not having any problem
regarding skin integrity and urine
retention.
 Objective outcome- The arterial blood
gas results demonstrated I &O balance.
Hypovolemia was removed.
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