NUR241 - Case Study: Heart Failure Patient Care Plan Development

This case study focuses on a 70-year-old male patient presenting with chest pain, shortness of breath, and other symptoms indicative of heart failure. The assignment requires the student to utilize the clinical reasoning cycle to develop a comprehensive nursing care plan. The plan addresses key issues like impaired gas exchange and excess fluid volume, detailing interventions such as oxygen administration and sodium restriction. The student considers the patient's history, vital signs, and medications to formulate appropriate nursing diagnoses, goals, and interventions. The plan also highlights the importance of patient education and discharge planning, considering the patient's family. The document also includes detailed pathophysiology, nursing considerations, and evaluation of outcomes, using references to support the care plan's rationale. The student is also asked to reflect on the assessment and planning processes.

NUR 241 Student Worksheet
Case StudyHeart failure
Revisit pathophysiological concepts:
Group work developing a plan of care:
You are a Registered Nurse on a medical ward when a patient is handed over to you from the morning staff.
You are provided with this handover:

Work through the clinical reasoning cycle and develop a care plan for this patient
I Mr. Smith is a 70yr/old male who presented to his GP at 10am today
S He was c/o chest pain that is pleuritic in nature, SOB, weakness, fatigue a hacking cough with
bilateral bibasal course crackles.
B History:
Ax: penicillin
Meds: atorvastatin 20m Mane, frusemide 20 mg mane
Past illnesses: hypercholesterolaemia, MI, angina, hypertension, Increased BMI 34, T2DM
Last meal: 7am (3hrs ago), bacon eggs, sausages toast and hash browns
Events leading up to presentation: walking/gardening
A His vital signs are a Temp 36.8, GCS 15, HR 105, NiBP- 170/90, Sp02- 92%, RR 24. Initial ECG
displayed t wave inversion and initial bloods showed a negative troponin of TNI: 0.02
R He was given his regular meds & 5mg IV morphine, 1gm paracetamol which reduced his pain to
2/10. PIVC insitu R) ACF- patent.

Please complete the nursing process:
Consider
the patient
Situation
Assessment
Head to toe assessment:
CNS:gcs-15
RESP: tachychardia, spo2 of 92%, sob shortness of breath
CVS:heart rate- 105, tachycardic, bp- 170/90 systolic is high, bilateral bibasal course
crackles.( we can hear during
GIT: had a proper meal, bmi is high 34
RENAL: increase urine output(polyuria
Other: weak,fatigue, chaestvpain
Collect
informatio
n and cues
Process
informatio
n
Diagnosis
According to Grin et al. (2016), ABCDE framework deals with Airway, Breathing,
Circulation, Disability and Exposure. It is a systematic approach for immediate assessment
and treatment of critically ill patients and is applicable in the clinical emergencies.
Airway of Mr. Smith is experiencing obstruction as be is experiencing exacerbation
of his CHF (Chronic Health Failure). The airway of Mr. Smith indicates bibasal coarse
crackle. According to Pocock, Richards and Richards (2013), basal crackles are present on
both side of the lungs and are caused by "popping open" of the small airways or fluid
collapsed alveoli or lack of aeration at the time of expiration.
In breathing, it can be said that Mr. Smith has general signs of respiratory distress.
The respiratory rate of Mr. Smith is 24. Normal respiratory rate is 12 to 20 beats per
minute and rate higher than this shows visible sign of respiratory distress. This high
respiratory rate might be due to his high non-invasive blood pressure (170/90 mg/Hg)
(Shier, Butler & Lewis 2015). Moreover Mr. Smith is also experiencing shortness of breath
(SOB) and thus it can be said that he is suffering from in-effective gas exchange.
Circulation is accessed by the body temperature of the patient. Body temperature
is slightly decreased. The body temperature of Mr Smith is 36.8 degree Centigrade. Normal
body temperature range for adults is 37 degree. Her heart rate is slightly increased: 105
beats per minute (normal: 60 to 100 beats per minute) (Shier, Butler & Lewis 2015). He is
also experiencing hacking cough with bibasal course crackles. His past history indicated
that she has oedema as she is on Frusemide medication. Thus it indicates he is suffering
from excess fluid volume.
Disability is reflected in the domain of hypoxia. Mr. Smith might be suffering from
mild hypoxia as his oxygen saturation (Sp02- 92%) (Grin et al. 2016). Normal oxygen
saturation is 98% at room temperature (Shier, Butler & Lewis 2015).
There is no significant information in the domain of Exposure.
Identify
problems

Establish
Goals
Planning
Goals:
The two main clinical priorities will be in-effective or impaired gas exchange and
excess body fluid volume. The reduction in the excess body fluid volume can be done
by restriction of sodium intake in diet and control of fluid intake. The improving in-
effective or impaired gas exchange can be done with the help of Fowler’s posture and
deep breathing and coughing technique.

Priority 1: Management of Excess Fluid Volume
Intervention 1: Limitation of Sodium (Na) Intake
Pathophysiology
Mr. Smith is showing slightly reduced body temperature and hacking cough with
bibasal course crackles which is an indicator of excess fluid volume. According to Baird
(2015), excess fluid volume or hypervolemia is defined as increased volume of body fluid.
This increased fluid volume increases central venous pressure and this increases right atrial
pressure, right ventricular end-diastolic pressure. This is the reason why NiBP of Mr. Smith
is high. In order to compensate for impaired cardiac output, there occurs an increase in
the heart rate along with an increase in the systemic vascular resistance (SVR) (Vincent et
al. 2016). As per the case study, Mr. Smith is experiencing high heart rate (105) along with
high respiratory rate (24 beats per minute) and this is the reason why Mr. Smith is
experiencing high level of fatigue. Mr. Smith is on metformin (artificial insulin). Baird
(2015) stated that excess insulin shifts the equilibrium of the metabolism towards
anabolism, converting dietary sugar and fat into stored fat and thus leading to weight gain.
It leads to production of extra cholesterol at unhealthy levels that retain kidneys to store
sodium causing water retention, high blood pressure.
Management
Management of the hypervolemia can be done with the help of sodium restricted
diet. Low sodium-diet or salt restricted diet is useful to reduce or prevent fluid retention in
the body. Sodium helps to regulate the balance of fluid in the body. During water build up
in the tissues, reduction of sodium in the diet causes the kidneys to retain potassium. This
leads to increase in the urine production and thereby helping to decrease the excess body
fluid (Butcher et al. 2018). Restriction of diet includes restriction processed cheese, salted
or canned meats, commercially frozen meats. In fruits the restriction includes canned
fruits and vegetables like salted vegetables (Butcher et al. 2018). Smith had bacon eggs,
sausages toast and hash browns in his breakfast that is high sodium diet and is not
permissible at his current physiological state .
Nursing Consideration
The main nursing consideration includes monitoring of the urine-out in
comparison to the fluid intake. Increase in the urine output in comparison to the fluid
intake will help to monitor the elimination of the excess body fluid. Intake of water or fluid
must also be limited in order to maintain the fluid balance (Romøren, Gjelstad & Lindbæk
2017).
Importance of intervention and evaluation of outcome
The intravenous injection of Na restricted diet will help to restore the fluid balance
in Mr. Smith and thereby helping to reduce heart rate along with increase in the body
temperature at the optimal level. It will also help to reduce the level of fatigue (Miller
2015).
Priority 2: Impaired or ineffective gas exchange
Intervention 2: External supply of oxygen through nasal cannula
Pathophysiology and Management

Evaluate
Outcomes
Evaluation Check/ maintain spo02 / – looking to see the decrease in crackles (respiratory
assessment and absence of cough and increased body temperature
Reflect
Key learning points:
Patient education is an important part of nursing care and the discharge planning must be
done under the presence of the family members.

Assessment Planning: Please open the assessment booklet and spend the remainder of the tutorial
developing a template for your essay. This is your opportunity to ask questions of and receive
assistance from the teaching team.