NUR250 Assessment 1 S2 2018 Assignment Template

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
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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 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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