NUR250 Assessment 1 S2 2018 Assignment Template

NUR250 Assessment 1 S2 2018
Assignment template
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Task 1: Patient assessment
The appropriate nursing assessment in this patient will include a complete cardiovascular
assessment, pain assessment and assessment of risk factors (Brunner, 2010). These are the priority
assessments in this patient presenting with features of heart failure in a previous myocardial
infarction. They are at increased risk of recurrence of cardiovascular disease hence risk factors that
precipitate heart failure or worsen morbidity need to be assessed (Elliott & Coventry, 2012). Pain
is a vital component of cardiovascular ischemia and in-hospital stay hence assessment of pain is
warranted.
The cardiovascular examination involves physical, functional and psychosocial assessment by
collecting objective and subjective data. Physical assessment starts by measuring the blood pressure,
heart rate, assessment of edema, peripheral circulation, followed by inspection, palpation, and
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auscultation of the precordium and a 12 lead ECG recording (Glynn, Drake, & Hutchison, 2012).
Due to the profound effect and interrelation with the respiratory system, a respiratory assessment
should be done.
Blood pressure measurement should be done with the patient seated, using the right size
cuff and a working sphygmomanometer (Glynn et al., 2012). Automated machines do exist if the
intervals between measurements are small. Normal blood pressure should be a systolic pressure of
130 to 90mmHg and diastolic of 90 to 60 mmHg with a pulse pressure of 30 to 50 mmHg. The
patient’s BP was 102/84 which was within the normal range. In heart failure, hypotension is a major
concern due to reduced cardiac output (Böhm et al., 2010).
The pulse rate should be measured by assessing the carotid, radial, femoral popliteal and
dorsalis pedis pulses (Glynn et al., 2012). In cardiogenic shock, tachycardia is expected as
sympathetic discharge in compensation tries to maintain perfusion. The normal pulse is 60 to 100
beats per minute. The patient has a tachycardia of 118 beats per minute.
Assessment of edema is also warranted. Pedal edema is measured at bony prominences
such as sternum and malleoli by blanching and noting for pitting (Douglas, Nicol, & Robertson,
2013). Weight should measured at the same time daily to assess weight changes. Peripheral
circulation is assessed by measuring the capillary refill, which should be less than 3 seconds.
Inspection for a hyperactive precordium, palpation of the apex beat and auscultation of
heart sounds will show any abnormalities of cardiac function (Douglas et al., 2013). A respiratory
assessment by auscultating for basal crepitations and rales may pick signs of pulmonary edema
expected in this patient. A 12 lead ECG should be conducted to assess for abnormal rhythm, rate,
and features of heart failure. It is usually indicated in ischemia and infarction as it categorizes
infarction as STEMI or non-STEMI (Glynn et al., 2012).
Pain assessment is warranted in this patient. The assessment should include the site of pain,
character, aggravating and relieving factors, radiation and associated factors (Goodlin et al., 2012).
This patient is at an increased risk of recurrent myocardial infarction hence recognition of angina is
paramount (Turk & Melzack, 2011).
The patient has several lifestyle risk factors for cardiovascular disease including physical
inactivity, smoking, alcohol use and unhealthy diet. These should be assessed and the level of each
quantified. These risk factors play a crucial role in clinical intervention and a baseline for each will
guide such interventions.
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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.
 Start a 24-hour intake and output
chart to monitor the input and
output.
 Monitor the patient’s urine output
and note the amount, color and time
of day when they urinate.
 Monitoring helps calculate
balanced input accordingly. Close
monitoring is also warranted since
diuretic therapy in heart failure
causes rapid fluid losses with
hypovolemia despite signs of
overload such as edema and ascites
(Glynn et al., 2012).
 Reduced urine volume and
concentrated urine represent
reduced glomerular filtration
usually seen in renal hypoperfusion
due to heart failure. The amount
may increase during the night due
to laying recumbent and increase
during the day (Marenzi et al.,
2010).
 Balanced input and output chart
throughout the day
 Improved urine output that can be
explained by intake.
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