NUR250 Assessment 1 S2 2018 Assignment Template

This is a template for NUR250 Assessment 1 S2 2018. It includes patient assessment and care planning. The template is designed to meet the requirements of the assessment. The patient assessment includes cardiovascular assessment, respiratory assessment, and pain assessment. The care planning includes nursing problems such as imbalanced fluid volume, impaired gas exchange, and activity intolerance. The interventions and rationales are provided for each nursing problem.

NUR250 Assessment 1 S2 2018
Assignment template
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Task 1: Patient assessment
On admission to the ward, the nursing assessment for David should include
cardiovascular assessment with vital signs, respiratory assessment and pain assessment.
These assessments will ensure that the patient care is planned, the underlying cause is
monitored and arising problems identified, and further deterioration.
The cardiovascular assessment will involve a complete history and examination with
vital signs measurement (Talley & O'Connor, 2013). The cardiac history will try to grade the
level of dyspnoea, and confirm symptoms of heart failure. The patient will be examined for
signs of heart failure including ascites, distended veins, and peripheral pulse volume. The
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heart is auscultated noting any added murmurs that can point to a specific structural defect
(Talley & O'Connor, 2013).
In the cardiovascular assessment, vital signs monitoring is among the most accurate
measure of patient status in inpatient monitoring and in this case, cardiac instability (Elliott
& Coventry, 2012). Vital signs parameter will accurately show deterioration, monitor
treatment and shows signs of the underlying pathology. The patient has chronic heart
failure, meaning the heart is unable to adequately maintain perfusion needs of the body
(Morrissey, Czer, & Shah, 2011). This is attributed to the myocardial infarction David had
prior to the current admission. Myocardial infarction leads to the death of a portion of
cardiac tissue, rendering them non-functional. The remaining muscle is unable to maintain
adequate perfusion leading to a cardiogenic shock (Morrissey, Czer, & Shah, 2011).
The reduction in the cardiac function will manifest as increased heart rate, reduced
oxygen saturation and increased respiratory rate (Brunner, 2010). David has a tachycardia of
118 bpm, a tachypnoea of 24 and a low oxygen saturation of 92%. There is increased heart
rate as a reduction in perfusion leads to the heart pumping faster to meet previous oxygen
needs of the body. This, however, leads to further myocardial oxygen deficiency as the heart
is overworked and can lead to ischemia (Brunner, 2010). The blood pressure is reduced and
the respiratory rate and heart rate are increased owing to activation of the sympathetic
nervous system in response to the stress of cardiogenic shock. Patients who have deranged
vital signs have a higher mortality and morbidity (Böhm et al., 2010). Monitoring this vitals is
a good marker of deterioration and also monitors response to treatment. Continuous
monitoring of vital signs using a cardiac monitor is recommended as it shows the blood
pressure, pulse rate, rhythm, oxygen saturation and the respiratory rate. Continuous
monitoring has shown to be more effective in detecting deteriorating vital signs (Critchley,
Lee, & Ho, 2010).
The respiratory assessment involves taking a full history and examination of the
respiratory system (Chulay & Burns, 2010). On inspection, signs of respiratory distress
should be noted including use of accessory muscles, nasal flaring, cyanosis, rapid breathing
and chest indrawing. These signs point a worsening respiratory pathology. The respiratory
rate is taken at intervals with the other vital signs half hourly.
The lungs should be percussed to note the percussion notes. This are important
clues to the underlying respiratory pathology for example air is hype resonant while fluid is
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dull on percussion. The next step in assessment is auscultation over all lung fields. Listening
to the breath sounds and noting for any added sound including crackles, rales, wheeze,
stridor and basal crepitations.
Pain assessment is a crucial component of the assessment. Pain is a component of
cardiac disease manifesting as angina. The patient had a previous myocardial infarction and
the risk for another is substantially high hence assessment of pain is important. This involves
verbal rating of pain on a pain rating scale which asks the question “on a scale of 1-10 where
does your pain lie” (Turk & Melzack, 2011). This is a subjective measure of pain and when
combined with objective signs of pain such as restlessness, agitation, facial grimacing and
increased respiration.
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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, click enter 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 edema.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
Decrease fluid volume
and maintain fluid
balance throughout the
shift.
 Monitoring David’s urine output by
placing a urinary catheter, noting the
urine color and amount
 Fluid balance chart should be started
to calculate the 24-hour fluid intake
and output by David.
 Assess David for signs of fluid overload
including pitting edema, generalized
body edema, distended neck veins and
high-volume peripheral pulses.
 Reduced urine output is a sign of
renal hypoperfusion owing to
cardiogenic shock causing salt and
water retention (Marenzi et al.,
2010). It also allows for the
calculation of fluid replacement to
avoid fluid overload.
 The patient is on an antidiuretic
which may result in a sudden
increase in fluid losses causing a
hypovolemia (Katzung, Masters &
Trevor, 2012). A fluid chart would
adequately account for such
losses.
 Fluid overload is a complication of
cardiac failure due to renal salt
and water retention. It will
manifest as venous congestion
seen peripherally as distended
 David’s urine amount is commensurate
to his fluid intake.
 David’s fluid chart shows a balanced
intake and output.
 David does not show edema, anasarca
or distended veins.
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 Assess for David’s breath sounds
noting any added sounds such as basal
crepitations.
 Monitor David’s blood pressures and
heart rate.
 Administer David’s medication and
fluid restriction as charted including:
o Furosemide
neck veins and increased volume
peripheral pulses. The increased
intravascular volume leads to
reduced oncotic pressure and
movement of fluid into the
interstitial space manifested by
edema beginning in the lower
limbs (Glynn, Drake, & Hutchison,
2012). Generalized body edema
implies a more systematic failure
such as right heart failure.
 Fluid overload leads to pulmonary
congestion which will manifest as
crepitation and crackles (Glynn,
Drake, & Hutchison, 2012).
 The fluid imbalance will cause
fluctuations in blood pressure and
heart rate. Fluid overload
increases the cardiac output which
will increase the blood pressure
which is a product of cardiac
output and peripheral resistance
(Kim, Susan, Scott, & Heddwen,
2010).
 Furosemide is a diuretic that
enhances fluid and sodium
excretion and reduces the cardiac
output hence cardiac workload
 David’s breathing is normal with no
crackles, basal crepitations or increased
rate.
 David’s vitals are within normal range.
 David shows a balanced fluid output,
normalizing of blood pressure and pulse
rate.
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o 1000 ml fluid restriction
(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:
Airway inflammation and accumulation of fluid in the alveoli.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
Improvement in the
gaseous exchange.
 Monitor 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
 The respiratory rate is a good
indicator of increased work of
oxygenation due to impaired
gaseous exchange (Kim, Susan,
Scott, & Heddwen, 2010).
 Cyanosis is a sign of impaired
oxygenation, especially central
cyanosis. Peripheral cyanosis at
the nail beds is a sign of peripheral
vasoconstriction (Kim, Susan,
Scott, & Heddwen, 2010).
 This promotes inspiration to the
maximum and also the position
change encourages removal of
secretions hence improving
ventilation.
 Rest prevents fatigue, reduces
 The normal respiratory rate of 12-20
breaths per minute.
 The absence of cyanosis on David’s
mucous membranes or nail beds.
 David displaying normal respiration
pattern.
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 Encourage David to have adequate
rest for example bed rest.
 Administer oxygen therapy as charted
oxygen demands and lowers the
metabolic rate.
 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:
Activity imbalance is probably due to the imbalance in oxygen supply and demands secondary to decreased perfusion.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
David will be able to note
improvement in activity
tolerance
 Access David’s daily activities and the
level of activity intolerance.
 Encourage David to adjust the level
and intensity of daily activities. He
should also have adequate bed rest
and sleep.
 Assist David with ambulation if he is
unable to.
 Monitor David’s response to activity
and recognize signs and symptoms of
 Assessment of daily activity
provides a baseline knowledge of
the activity level of the patient
(Kemps et al., 2010)
 Reducing overexertion and fatigue
lower the cardiac workload and
improves outcomes (Kemps et al.,
2010)
 This reduces his risk of falling and
causing more harm.
 David reports improvement in exercise
tolerance and can carry out prescribed
exercise without symptoms.
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intolerance. Encourage him to
verbalize symptoms.
 Refer David to a physiotherapist to
enhance his improvement and to help
him with exercise.
 Administer medications as charted
including digoxin.
 Provides a continuous assessment
of activity intolerance and need to
change the activity level (Kemps et
al., 2010).
 Treatment of this condition
involves a multidisciplinary team
to enhance recovery and best care.
 Treatment of the cardiac anomaly
causes an improvement in the
perfusion. Digoxin increases
cardiac output and perfusion to
distal tissues (Katzung, Masters &
Trevor, 2012).
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Task 3: Medication management
Furosemide 40mg PO twice daily
Furosemide is a loop diuretic used in the management of fluid overload in heart
failure. It is a diuretic that acts by promoting salt and water excretion in the kidney (Katzung,
Masters & Trevor, 2012). Adverse effects due to furosemide include dose-dependent
hearing loss, dizziness, fatigue, and bleeding. The nurse should explain these symptoms to
the patient to make sure that he is looking out for them. the drug should not be
administered if the patient has an allergy to it as it can be rapidly fatal (Katzung, Masters &
Trevor, 2012). This medication is contraindicated in those who have a urinary obstruction,
kidney disease, liver disease or metabolic derangements. It Is the responsibility of the nurse
to make sure that contraindications are sought and alternative medications sought.
Digoxin 62.5mcg PO daily
Heart failure is characterized by the inadequacy of the heart to maintain adequate
perfusion due to and can be due to a primary cardiac pathology (Kim, Susan, Scott, &
Heddwen, 2010). Digoxin is a cardiac glycoside with a positive inotropic effect on the heart.
It acts to improve cardiac output by increasing the force of contraction which in turn
improves perfusion to distal organs (Katzung, Masters & Trevor, 2012). Digoxin is a drug
requiring close nursing monitoring as digoxin toxicity is fatal. The nurse should make sure
that the patient has no allergy to digoxin or any of the contraindications to digoxin use
including liver and kidney failure, ventricular fibrillation and a recent myocardial infarction.
Adverse effects include uneven heart rate, nausea, vomiting, blurred vision, headache,
dizziness, 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. It works by blocking synthesis of
angiotensin ii, a potent vasoconstrictor, hence causing vasodilation. This action occurs in the
peripheral circulation improving the perfusion of the organs and also in the coronary organs
improving oxygen supply to the myocardium (Katzung, Masters & Trevor, 2012). The
nursing responsibility includes ensuring that the patient has no allergy to the medication,
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ensuring adequate dosing and administration of the prescribed drug and monitoring for any
side effects.
Task 4: Patient education
Stress minimization
Acute myocardial infarction is a life-threatening cardiac event that should be
prevented at all times. David already had a previous myocardial infarction and his risk for
undergoing another is increased. Stress reduction is one of the management strategies for
him (Schneider et al., 2012). It has been shown to reduce mortality, myocardial infarction,
stroke in patients with coronary syndromes. The nurse would make sure that David can
verbalize these correlations to assess understanding. The nurse should also ensure adequate
education by monitoring David’s body language and providing written forms of the message
included in pamphlets or audio-visual forms (Gruman et al, 2010). The stress reduction
initiative should be a combined venture and should involve David’s family.
Task 5: ISBAR handover
Introduction
I am ----------, a registered nurse, handing over, Mr. David Parker, a patient who presented
with dyspnoea at rest. He is a referral from the cardiology clinic where he was attending
under Dr.------------- and a working diagnosis of Chronic Heart Failure was made.
Situation
He was attended to at the cardiology and admitted fairly stable.
Background
He is a patient who had been seen a month prior due to myocardial infarction and
discharged to a rehabilitation center but has not been attending. He also refuses to take
low-fat food made by his wife, Sophie. He still smokes and drinks alcohol. She is on ramipril,
digoxin, and furosemide.
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Assessment
He has dyspnoea at rest and has a cough and is increasingly fatigued. Her respiratory rate
was 24 breaths per minute, her blood pressure 102/84, her heart rate at 118, oxygen
saturation was 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. Monitoring of fluids and vitals every half hourly is recommended.
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References
Böhm, M., Swedberg, K., Komajda, M., Borer, J. S., Ford, I., Dubost-Brama, A., ... & SHIFT
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Brunner, L. S. (2010). Brunner & Suddarth's textbook of medical-surgical nursing (Vol. 1).
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Critchley, L. A., Lee, A., & Ho, A. M. H. (2010). A critical review of the ability of continuous
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approach to clinical practice. Edinburgh: W.B. Saunders
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Gruman, J., Rovner, M. H., French, M. E., Jeffress, D., Sofaer, S., Shaller, D., & Prager, D. J.
(2010). From patient education to patient engagement: implications for the field of
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medicine, 38(2), 438-444. doi: 10.1097/CCM.0b013e3181b9eb3b
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Morrissey, R. P., Czer, L., & Shah, P. K. (2011). Chronic heart failure. American Journal of
Cardiovascular Drugs, 11(3), 153-171. Doi: https://doi.org/10.2165/11592090-
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diagnosis. Elsevier Health Sciences.
Turk, D. C., & Melzack, R. (Eds.). (2011). Handbook of pain assessment. Guilford Press.
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