NUR250 Assessment 1 S2 2018 Assignment template

This assignment template covers patient assessment, care planning, and medication management for NUR250. It includes interventions for imbalanced fluid volume, impaired gas exchange, and activity intolerance.

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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dry.
 The body areas should be checked and
assessed for any oedema.
 Auscultation of the breath sounds.
 Increased dyspnoea or tachypnoea
should be recorded.
 Frequent monitoring of the creatinine,
serum potassium and the sodium
levels.
 Regular monitoring of the central
venous pressure and B.P.
 Administration of medicines like
diuretics, potassium supplements,
maintenance of fluid and sodium
restrictions
(Tawalbeh, &Tubaishat, 2013).
 Proper positioning of the patient
increases the rate of glomerular
filtration (Wakefield, Boren, Groves
& Conn, 2013).
 Skin integrity can be affected by the
formation of oedema, prolonged
immobilisation and altered
nutritional status (Lambrinou,
Kalogirou, Lamnisos, &Sourtzi,
2012).
 Fluid retention can be manifested
by the formation of the body
oedema (Kemp & Conte, 2012).
 High volume of fluid may cause
pulmonary congestion (Redon et
al.,2016).
 Dyspnoea, orthopnoea or cough
may display right sided heart (Kemp
& Conte, 2012)
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 Application of various medications
may lead to electrolytic imbalance
(Lee et al., 2012).
 High CVP and BP indicates fluid
volume excess (Wakefield, Boren,
Groves & Conn, 2013).
 This would prevent the
accumulation of excess water in the
body (Wakefield, Boren, Groves &
Conn, 2013).
Nursing problem:Impaired gas exchange
Underlying cause or reason: The gas exchange is impaired due to the obstruction caused due to the accumulation of fluid in the alveoli, such that enough
oxygen is not diffused.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
The gas exchange is
restored in the patient
 Monitoring of the vital signs
 Observing the colour of the skin,
presence of peripheral cyanosis, nail
beds and mucous membrane.
 For obtaining the baseline data
 Cyanosis may indicate
vasoconstriction (Wakefield, Boren,
Groves & Conn, 2013).
 Subjective outcome- David admitted
that he is able to breathe properly
 Objective outcome- Patient displayed an
increased oxygen saturation level and
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 Elevation of the level of bed.
 Keeping an allergen free ambience
 Administration of oxygen therapy as
and when required.
 Provision of adequate rest
 Provision of suction secretions.
 Improved tissue perfusion
 Keeping the back dry.
 Bed should be elevated for
providing maximum inspiration and
improve ventilation (Ahmed, Jones,
& Hays, 2008).
 Keeping allergen out to reduce the
irritation of the airways (Saguil, &
Fargo, 2012).
 Oxygen therapy can be provided to
increase the oxygen saturation
level (Martin &Grocott, 2013).
 Adequate amount of rest helps to
reduce fatigue, thus decreasing the
demand for oxygen (Martin
&Grocott, 2013).
 Suction of the secretions are
necessary to clear the airways (Lee
et al., 2012).
 For avoiding excessive cough (Lee
et al., 2012).
the respiratory distress was also found
to be relieved.
 The patient showed an improved
breathing pattern and improved
ventilation.
Nursing problem: Activity intolerance
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Underlying cause or reason:The imbalance between the demand and the supply of oxygen causes weakness and fatigue or insufficient physiological capacity
to complete a desired activity.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To restore the
functional capacity of
the patient to carry out
the desired activities
 The vital signs should be checked
immediately after the activity,
especially if the patient is under
diuretics, vasodilators or the beta
blockers.
 It is necessary to note presence of
tachycardia, diaphoresis, pallor and
dyspnoea (LeMone et al., 2015).
 Assessment of the causes of
weakness
 Evaluation of the activity
intolerance
 Provision of assistance in the self-
care activities.
 The activity periods should be
 Medications may give rise to
orthostatic hypotension or
compromised functioning of the
cardiac pumping (LeMone et al.,
2015)
 Compromised stroke volume at the
time of the activity can increase the
heart rate and the oxygen demands
(LeMone et al., 2015)
 Factors like pain, stress,
medications can cause weakness
and fatigue in patients (Ahmed,
Jones, & Hays, 2008).
 Acceleration of the activity
intolerance can indicate towards
 Subjective outcome-David could
verbalise easily and admitted that he
can move or sit up without any help.
 Objective outcome- The patient
demonstrated an achievable level of
activity tolerance and reduced fatigue.
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interspaced with rest periods.
 Implementation of cardiac
rehabilitation program
 Providing assistance to the patient
with the ROM exercises.
 The patient should be assessed
regularly for the tenderness or pain
in the calf.
increased cardiac decompensation
(Lambrinou, Kalogirou, Lamnisos,
&Sourtzi, 2012).
 Assistance would reduce
myocardial stress and high oxygen
demand for activities (Lambrinou,
Kalogirou, Lamnisos, &Sourtzi,
2012).
 Cardiac rehabilitation program
would strengthen and improve the
function of the cardiovascular
system. If the activities are
increased gradually then then
excess myocardial workload is
avoided (Huikuri & Stein, 2013).
 Pain and tenderness should be
checked to prevent deep vein
thrombosis because of vascular
congestion (Panizzolo et al., 2014).
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Task 3: Medication management
Frusemide orally 40mg twice daily
Frusemide is given to David for inhibiting the sodium and water reabsorption causing
excess water to get rid of the body, so that there is a proper functioning of the heart. It does
so by inhibiting the Na-K-Cl cotransproter in the Henle'sloop, causing to get rid of excess
sodium through urine (Kemp & Conte, 2012). A nurse should be careful about the dosages
of the medicine and should enquire for any allergic reactions like itching, or ringing in ears,
loss of appetite, dizziness or dark urine (Tiziani, 2017). The nurse should make sure that
David does not have sulphonamide allergies It should be noted that frusemide is a strong
diuretic and can cause electrolytic imbalance, the hence potassium rich food should be
consumed (Bikdeli et al., 2013). The nurse should make sure that the patient does not
continue to alcohol as that would exacerbate the side effects.
Digoxin orally 62.5 mcg daily
Digoxin has been prescribed to David due to is chronic heart failure, as it increases
the efficiency and the strength of the heart contraction by inhibiting the action of ATPase for
increasing the calcium content in the heart muscles and thus increasing the force of
contraction of the heart muscles (Freeman et al., 2016). A nurse should look for the side
effects such as nausea, vomiting, diarrhoea, skin rashes or dizziness or some serious side
effects like bradycardia (Tiziani, 2017). Hence it is essential to measure the pulse before the
administration. If digoxin starts working well then it will improve symptoms like shortness of
breath and would also help to mitigate problems with arterial fibrillation (Freeman et al.,
2016).
Ramipril orally 5mg twice daily
Ramipril is an angiotensin-converting enzyme (ACE) inhibitor that has been given to
the David to reduce high blood pressure by the relaxation of the blood vessels and thus
reducing the chance of heart failure. Before the administration of the medicines the nurse
should check whether the patient is on any other ACE inhibitor as that might cause
hypersensitivity to other ACE inhibitors (Redon et al., 2012). The patient should be
examined for any renal condition complications, as the medicine should not be given to
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patients with renal impairment (Rohde, Bertoldi, Goldraich, & Polanczyk, 2013). The nurse
would ask the patient for any signs of allergic reactions or troubled breathing, stomach pain
or breathing, right after the administration of the medicines.
Task 4: Patient education
Smoking is an important contributor of cardiovascular diseases that includes stroke
and heart failure. Smoking damages the lining of the arteries building up deposits of fatty
materials or atheroma on the inner linings of the arteries that can cause a heart failure.
Hence smoking cessation is an important part of the management of heart failure
(Wakefield, Boren, Groves & Conn, 2013). David should be informed that the carbon
monoxide present in the tobacco reduces the amount of oxygen in the blood as a result, the
heart have to overwork, thus increasing the cardiac output. It is necessary to teach David
that the nicotine present in the cigarettes stimulates the body to produce adrenaline, which
in turn can cause bradycardia and cause hypertension (Rice, Hartmann-Boyce, & Stead,
2013).
David should be provided with psychosocial support for motivating him to quit
smoking and build coping skills to avoid relapse of the habit. Pharmacotherapy can also be
suggested such as bupropion, and varenicline. Nicotine free chewing gums or oral spray can
also be suggested (Rice, Hartmann-Boyce, & Stead, 2013). Although medicines has been
found to be useful for reducing the symptoms of nicotine withdrawal,
pharmacotherapeutics can be avoided for David, since he is comorbid with other health care
conditions and in under several medications. Nicotine replacement therapies such as gums,
lozenge, and mouth spray are not associated with an increased risk of cardiovascular
diseases (Rigotti & Clair, 2013).
Patient education can be evaluated by cross questioning the patient, assessing his
body language. The information should be given in a simple and comprehensive language,
without any medical jargon. David can be provided with referrals to antismoking community
programs.Moreover it can be said that it is the nurses that can influence the smoking
behaviour of the patients by prompting the smokers to adopt a quit attempt in a cost
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effective way. This is because diagnosis of a heart failure make the health issues related to
smoking suddenly salient.
Task 5: ISBAR handover
Introduction
David Parker is a patient who has been diagnosed with a chronic heart failure and is
under the care of Dr X. I Miss Y is giving a clinical handover for the transition of the patient
from the ED to the medical ward.
Situation:
David has visited the cardiac department with a report of increasing breathlessness,
development of cough and increased fatigue. He has been diagnosed with a chronic cardiac
failure.
Back ground
David has a previous history of myocardial infarction. He was discharged with a
referral to an outpatient cardiac care rehabilitation program which he did not attend due to
his workload. He has continued to smoke 10 cigarettes a day and have also not refrained
him from smoking. He eats low sodium food. His appetite has decreased and feels nauseous.
He has also put on 6 kilograms of weight. His acute breathlessness is increasing day by day.
David was on Ramipril and furosemide and digoxin were also newly added to his medication
charts. Fluid restrictions of 1000ml per day has been ordered for David by the physician.
Assessment
David had an acute respiratory distress and his vital signs on admission were:-
Temperature -36.5℃, Heart rate- 118 beats per min, Blood pressure- 102/84 mmHg,
Respiration- 24 breaths per min, O2 saturations- 92% on room air.
Recommendations
David should be transferred to the coronary care unit on further deterioration.
Currently he is on an hourly check-up of the BP, RR, Spo2 and HR and medicines -Frusemide
orally 40mg twice daily , Digoxin orally 62.5 mcg daily , Ramipril orally 5mg twice daily. The
doctor in charge should be notified for any concern.
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References
Alemzadeh-Ansari, M. J., Ansari-Ramandi, M. M., & Naderi, N. (2017). Chronic Pain in
Chronic Heart Failure: A Review Article. The Journal of Tehran University Heart
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Bikdeli, B., Strait, K. M., Dharmarajan, K., Partovian, C., Coca, S. G., Kim, N., ... & Krumholz,
H. M. (2013). Dominance of furosemide for loop diuretic therapy in heart failure:
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Freeman, J. V., Yang, J., Sung, S. H., Hlatky, M. A., & Go, A. S. (2013). Effectiveness and safety
of digoxin among contemporary adults with incident systolic heart failure.
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internal medicine, 156(11), 767-775.DOI: 10.7326/0003-4819-156-11-201206050-
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352-358.https://europepmc.org/abstract/med/22335314
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Tawalbeh, L. I., &Tubaishat, A. (2013). Effect of simulation on knowledge of advanced
cardiac life support, knowledge retention, and confidence of nursing students in
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19.10.1097/JCN.0b013e318239f9e1
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