NUR250 Assessment 1 S2 2018 Assignment Template

This document discusses patient assessment, care planning, and medication management for heart failure patients. It includes a nursing care plan for imbalanced fluid volume, impaired gas exchange, and activity intolerance. The medication management section covers the use of loop diuretics and cardiac glycosides in heart failure management.

NUR250 Assessment 1 S2 2018
Assignment template
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Task 1: Patient assessment
Patient assessment on admission to the ward should include cardiovascular
assessment inclusive of vital signs, respiratory assessment and pain assessment. These are the
priority assessments that will guide David’s management. From these assessments, crucial
information such as deterioration in his condition or improvement can be noted (Brunner,
2010). They can also be used to provide a basis for further intervention.
The cardiovascular assessment will involve the basic format of inspection, palpation,
and auscultation with measurement of vital signs and other cardiac markers of disease (Glynn,
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Drake, & Hutchison, 2012). The vital signs are the most accurate predictors of patient
deterioration in the hospital setting (Elliott & Coventry, 2012). David presented with heart
failure due to a previous myocardial infarction and failure of adherence to heart failure
therapy. Heart failure manifests as inadequate circulation and cardiogenic shock. The
expected vitals in heart failure include tachycardia and hypotension (Brunner, 2010). Vital
signs parameter will accurately monitor treatment, shows the signs of the underlying
pathology and show deterioration.
David has a blood pressure of 102/84, a heart rate of 118 beats per minute, and an
oxygen saturation of 92%. Tachycardia is a result of cardiogenic shock compensation as the
body activates sympathetic systems to try and maintain adequate perfusion. This, however,
comes at a cost as cardiac muscle metabolic needs increase due to increased workload leading
to further predisposition to ischemia. Patients whose vital signs are deranged have an
increased rate of mortality and morbidity (Böhm et al., 2010).
The respiratory examination follows the same sequence of inspection, palpation,
percussion, and auscultation (Douglas, Nicol, & Robertson, 2013). Increased effort of
breathing is noted on inspection. This could involve use of accessory muscles, increased
respiratory rate, cyanosis, nasal flaring and chest wall indrawing (Glynn, Drake, & Hutchison,
2012). Percussion is an important step as chest pathology can be picked by the percussion
note. David presents with heart failure that is a common cause of pulmonary edema and
infiltration of the lungs with fluid (Glynn, Drake, & Hutchison, 2012). This can be assessed on
percussion as fluid has a dull percussion note. The depth and character of breath sounds is
also a good indicator of respiratory pathology and deterioration.
David has an increased risk of recurrent myocardial infarction. Pain assessment is
therefore an important component of his assessment (Goodlin et al., 2012). The nature, site,
radiation, aggravating factors, relieving factors and character of any pain should be noted.
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Angina pain is usually crushing pain in the centre of the chest, usually very severe and
radiates to the shoulder (Turk & Melzack, 2011). This is characteristic and could point to an
impending infarction. Other pain rating tools can be used to assess his pain including verbal
rating scales that rate his pain on a scale of 1-10. Objective assessments combined with
patient accounts should be used. They include insomnia, restlessness, facial grimacing and
anxiety (Turk & Melzack, 2011).
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Task 2: Care planning
Nursing Care Plan: David
Note: Dot points recommended in care plan. Click and type in each cell, clickenter in a cell to make it longer. Do not remove text from the template.
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 odema.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
Decrease fluid volume
and maintain fluid
balance throughout the
shift.
 Monitor patient David’s urine output
by placing a urinary catheter.
 A 24-hour fluid chart should be
started and balanced for intake and
output.
 Heart failure is syndrome that
causes deranged fluid balance
through water and salt retention, a
function of the kidneys. Shock will
also reduce renal perfusion
reducing the urine output
(Marenzi et al., 2010). A urine
catheter allows for monitoring of
output and calculating a balanced
input.
 The patient’s delicate fluid
needs in the setting of heart
failure require close monitoring
(Katzung, Masters & Trevor,
2012). A fluid chart is the best
way of monitoring to avoid
overload or deficits.
 By the end of the day David’s urine
output should balance his input.
 David’s fluid chart should show a
balance in fluids as input and output
should be relatively equal.
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 Assess David for signs of fluid overload
including pitting edema, generalized
body edema, distended neck veins and
high-volume peripheral pulses.
 Assess for David’s respiration including
any added sounds and rate of
respiration.
 Monitor David’s blood pressures and
heart rate.
 Heart failure will lead to
consequence offluid retention and
this can lead to fluid overload
evidenced by venous congestin
such as high-volume pulses,
distended neck veins and, leg
edema and in some cases
anasarca. Movement of fluid into
the interstitial space gives rise to
limb edema and anasarca (Glynn,
Drake, & Hutchison, 2012).
 Pulmonary edema is a
consequence of heart failure as
fluid fills the airspaces. This can
manifest as added sounds on
assessment such as basal
crepitations (Glynn, Drake, &
Hutchison, 2012).
 Shock states will manifest as
tachycardia and variations in blood
pressure. Monitoring these vitals is
crucial in assessing deterioration
or improvement (Kim, Susan,
Scott, & Heddwen, 2010).
 David lacks signs of increased fluid
volume.
 David’s chest is clear with a normal
respiratory rate.
 David’s vitals are within normal range.
 David’s vital signs normalize to heart
rate of less than 100 and a blood
pressure of 90/60 to 130/90.
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 Give David’s medication and fluid
restriction as prescribed including:
o Furosemide
o 1000 ml fluid restriction
 This is a diuretic that will increase
sodium and water excretion
reducing fluid overload (Katzung,
Masters & Trevor, 2012).
 Fluid restriction is a means of
ensuring fluid overload does not
occur increasing the cardiac
workload and worsening angina.
Nursing problem: Impaired gas exchange
Underlying cause or reason:
Heart failure causing increased accumulation of fluid in the alveolar spaces and increased airway inflammation.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
Improvement in the
gaseous exchange in 24
hours.
 Monitor David’s vital signs including
David’s respiratory rate
 Assess signs of impaired ventilation
including cyanosis on the mucous
membranes, skin and nail beds
 Elevate David’s bed and encourage
him to change positions frequently
 Impaired gaseous exchange will
lead to increased respiratory rate
as the body tries to overcome the
reduced oxygen saturation in the
body (Kim, Susan, Scott, &
Heddwen, 2010).
 Hypoxia will lead to cyanosis, a
sign of impaired systemic
ventilation. (Kim, Susan, Scott, &
Heddwen, 2010).
 Elevation of the bed increases the
inspiration capacity and allows for
secretions to drain hence
improving the gaseous exchange.
 The normal respiratory rate of 12-20
breaths per minute.
 The absence of cyanosis on David’s
mucous membranes or nail beds.
 David shows normal respiration.
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 Encourage David to have adequate
rest such as adequate sleep and bed
rest.
Administer oxygen therapy as charted
 This will lead to reduction in the
metabolic needs of the body and
also reduce the oxygen needs
lowering fatigue.
 High flow, 100 % oxygen increases
the gaseous exchange by
increasing the partial pressure of
oxygen within the alveoli (Kim,
Susan, Scott, & Heddwen, 2010).
 David reports adequate rest with no
fatigue
 David shows improved vital sign such as
oxygen saturation.
Nursing problem: Activity intolerance
Underlying cause or reason:
Heart failure causing an imbalance between the oxygen supply and the demand because of the decreased cardiac output.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
There will be
improvement in David’s
activity tolerance in 24
hours
 Note David’s level f activity and
activity tolerance.
 Encourage reduction in activity and
attaining of adequate sleep and rest.
 Encourage David to perform activities
and ambulation but if unable assist
him with ambulation
 This will provide baseline data on
his tolerance and activity level and
guide interventions (Kemps et al.,
2010)
 Reducing activity lowers the
metabolic rate and cardiac
workload hence improving
outcomes (Kemps et al., 2010)
 This will reduce adverse events
such as falls that cause more harm.
David reports improvement in exercise
tolerance and can carry out prescribed exercise
without symptoms.
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 Assess David’s response to activity
look out for any symptoms of
intolerance. Also encourage him to
speak up about symptoms if they
occur.
 Refer David to a professional such as a
physiotherapist to help him with
exercise intolerance.
 Administer medications as charted
including digoxin.
 This provides a good monitor for
improvement or worsening of
symptoms. (Kemps et al., 2010).
 This approach is multidisciplinary
and improves outcomes and David
will receive the best care possible.
 Treatment of heart failure will
improve perfusion and reduce his
activity intolerance. (Katzung,
Masters & Trevor, 2012).
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Task 3: Medication management
Furosemide 40mg PO twice daily
Loop diuretics such as furosemide have a recognized role in heart failure
management. They act by enhancing salt and water excretion hence reducing fluid overload
in heart failure patients (Katzung, Masters & Trevor, 2012). The drug is fairly well tolerated
but side effects such as dizziness, nausea, vomiting, headache and bleeding can occur. It is
the duty of the nurse to make sure the patient is aware of such side effects. The nurse
should also make sure furosemide is not administered to any patient who has an allergy to it
(Katzung, Masters & Trevor, 2012). Contraindicatin to furosemide use include liver disease,
renal failure or metabolic derangements.
Digoxin 62.5mcg PO daily
Digoxin is a cardiac glycoside that improves cardiac output by increasing the force of
contraction of the heart (Katzung, Masters & Trevor, 2012). This is beneficial in a patient
with heart failure as perfusion is improved and distal organ damage due hypoperfusion id
reversed. (Kim, Susan, Scott, & Heddwen, 2010). Close monitoring is required in digoxin use
as toxicity due to it is fatal. It is the responsibility of the nurse to titrate the correct dose,
make sure no allergies to digoxin exist and monitor therapy. Contraindications to digoxin
use include recent myocardial infarction, liver disease and kidney failure. The side effects
that the patient needs to be aware of include dizziness, tachycardia, nausea, vomiting,
blurred vison and confusion (Katzung, Masters & Trevor, 2012). The nurse should make sure
the patient is well informed about these effects and to verbalize any complaints.
Ramipril 5mg PO twice daily.
Ramipril is an angiotensin-converting enzyme inhibitor used for the treatment of heart
failure, hypertension, and coronary syndromes. Its mechanism of action includes the
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inhibition of synthesis of angiotensin II by blocking the enzyme responsible which is
angiotensin-converting enzyme. Angiotensin II is a strong vasoconstrictor hence this drug
will cause vasodilation improving the peripheral resistance and thus tissue perfusion and
coronary perfusion. (Katzung, Masters & Trevor, 2012). The nurse should be responsible for
dosing titration and teaching the patient about drug allergy and side effects.
Task 4: Patient education
Smoking cessation
Smoking is one of the most common modifiable risk factors for cardiovascular
disease (Thomas, 2012). Apart from its effects in the cardiovascular system, it is leading risk
factors for most cancers especially respiratory and gastrointestinal cancers (US Department
of Health and Human Services, 2014). David should be made aware of the added benefits of
quitting smoking, as cardiovascular disease is among the leading causes death and morbidity
worldwide. David will be provided with information on help centres where smoking
addiction is treated (Stead et al., 2013).
Multiple media formats will be used to pass information to him to make sure that
this aspect of risk management is understood by David, including video presentations,
pamphlets, news articles and real examples of the benefits accrued. David will then be
instructed to verbalize what he has learned and if the information appealed to him. This will
help him in behaviour modification.
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Task 5: ISBAR handover
Introduction
I am ----------, a registered nurse, handing over, Mr. David Parker, a patient we are managing
for chronic heart failure. He is a referral from the cardiology clinic where he was attending
under Dr.------------- presenting with dyspnoea at rest.
Situation
He was admitted stable from the clinic to the ward.
Background
He had been seen a few months prior for myocardial infarction and discharged to a heart
failure centre. He however is non-compliant to that directive and also refuses to take low-
fat food made by his wife, Sophie. He still smokes and drinks alcohol. His medication include
furosemide, ramipril, and digoxin.
Assessment
He has dyspnoea at rest and has a cough and is increasingly fatigued. His blood pressure was
102/84, respiratory rate 24 breaths per minute, her heart rate at 118, oxygen saturation of
92% and a temperature of 36.50c.
Recommendation/plan
David is on treatment with ramipril, digoxin, and furosemide for chronic heart failure with
1000ml fluid restriction. Monitor his fluid intake and output and make sure he takes his
medication.
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References
Böhm, M., Swedberg, K., Komajda, M., Borer, J. S., Ford, I., Dubost-Brama, A., ... & SHIFT
Investigators. (2010). Heart rate as a risk factor in chronic heart failure (SHIFT): the
association between heart rate and outcomes in a randomized placebo-controlled
trial. The Lancet, 376(9744), 886-894.
Brunner, L. S. (2010). Brunner & Suddarth's textbook of medical-surgical nursing (Vol. 1).
Lippincott Williams & Wilkins.
Douglas, G., Nicol, F., & Robertson, C. (Eds.). (2013). Macleod's Clinical Examination E-Book.
Elsevier Health Sciences.
Elliott, M., & Coventry, A. (2012). Critical care: the eight vital signs of patient
monitoring. British Journal of Nursing, 21(10), 621-625.
Glynn, M., Drake, W. M., & Hutchison, R. (2012). Hutchison's clinical methods: an integrated
approach to clinical practice. Edinburgh: W.B. Saunder
Goodlin, S. J., Wingate, S., Albert, N. M., Pressler, S. J., Houser, J., Kwon, J., ... & PAIN-HF
Investigators. (2012). Investigating pain in heart failure patients: the pain
assessment, incidence, and nature in heart failure (PAIN-HF) study. Journal of cardiac
failure, 18(10), 776-783.
Hands, C., Reid, E., Meredith, P., Smith, G. B., Prytherch, D. R., Schmidt, P. E., &
Featherstone, P. I. (2013). Patterns in the recording of vital signs and early warning
scores: compliance with a clinical escalation protocol. BMJ Qual Saf, bmjqs-2013.
Katzung, B. G., Masters, S. B., & Trevor, A. J. (2012). Basic and Clinical Pharmacology (LANGE
Basic Science). McGraw-Hill Education.
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Kemps, H. M., de Vries, W. R., Schmikli, S. L., Zonderland, M. L., Hoogeveen, A. R., Thijssen,
E. J., & Schep, G. (2010). Assessment of the effects of physical training in patients
with chronic heart failure: the utility of effort-independent exercise
variables. European journal of applied physiology, 108(3), 469-476.
Kemps, H. M., Schep, G., Zonderland, M. L., Thijssen, E. J., De Vries, W. R., Wessels, B., ... &
Wijn, P. F. (2010). Are oxygen uptake kinetics in chronic heart failure limited by
oxygen delivery or oxygen utilization? International journal of cardiology, 142(2),
138-144.
Kim, E. B., Susan, M. B., Scott, B., & Heddwen, L. B. (2010). Ganong’s review of medical
physiology.
Marenzi, G., Assanelli, E., Campodonico, J., De Metrio, M., Lauri, G., Marana, I., ... &
Bartorelli, A. L. (2010). Acute kidney injury in ST-segment elevation acute myocardial
infarction complicated by cardiogenic shock at admission. Critical care
medicine, 38(2), 438-444
Stead, L. F., Buitrago, D., Preciado, N., Sanchez, G., Hartmann-Boyce, J., & Lancaster, T.
(2013). Physician advice for smoking cessation.
Thomas, D. (2012). Smoking and cardiovascular diseases. La Revue du praticien, 62(3), 339-
343.
Turk, D. C., & Melzack, R. (Eds.). (2011). Handbook of pain assessment. Guilford Press.
US Department of Health and Human Services. (2014). The health consequences of smoking
—50 years of progress: a report of the Surgeon General. Atlanta, GA: US Department
of Health and Human Services, Centers for Disease Control and Prevention, National
Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and
Health, 17.
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