Developing a Nursing Care Plan: Mr. Smith's Heart Failure Case Study

This document presents a nursing case study focusing on Mr. Smith, a 70-year-old male experiencing chronic chest pain and heart failure. The assignment analyzes Mr. Smith's condition, including vital signs and medical history, and utilizes the ABCDE framework to establish care priorities, specifically ineffective or impaired gas exchange and excess body fluid volume. The care plan details interventions such as sodium restriction, oxygen supply via nasal cannula, and deep breathing exercises. The document also addresses nursing considerations, rationales for interventions, and discharge planning, including patient education and referral to community resources. The assignment adheres to a structured format, including an introduction, body, conclusion, and proper Harvard referencing, as per the assignment brief's requirements for a NUR241 case study.

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author Note

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Introduction
Multiple attributes influence the framing of the nursing care plans for the older adults
who are suffering from chronic healthcare conditions. For a nursing professional, the clinical
priority must be set based on the needs of the patients. This is known as prioritization of
patient care that helps to increase the effectiveness of the overall outcome of patient’s health.
The following essay aims to analyse the two care priorities care on the basis of the critical
evaluation of the case study of Mr. Smith a 70 year old man suffering from chronic chest pain
(Cruz, Carvalho & Sousa 2014). The essay will use ABCDE framework to highlight the
primary priorities of care. The generation of two care priorities will be followed by three
nursing interventions to address the care priority followed by discharge planning.
Primary Priorities
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

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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.
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.
Interventions
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.

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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
When the haemoglobin of the red blood cells is devoid of oxygen the condition is
defined as hypoxia and is reflected by low level of oxygen saturation (SpO2). Mr. Smith’s
level of oxygen saturation is low. The low level of oxygen satiation is increasing the cardiac
heart rate and this is reflected in the high respiratory rate and heart rate. The decrease in the
oxygen saturation in the body leads generation of fatigue as reflected in Mr. Smith. Thus
management of the hypoxia will include oxygen therapy with the help of the nasal cannula
(Beasley et al., 2017).

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Apart from oxygen therapy, Mr. Smith should be positioned in a Fowler’s position. In
Fowler’s position the head of the patient is raised from the bed and thus promoting effective
breathing by increasing the surface area of the diaphragm. Diaphragmatic descent causes
maximum inhalation leading to increase in the flow of oxygen and at the same time decrease
the chance of laboured breathing (Ceylan et al., 2016).
Nursing consideration
The nursing professionals administering external oxygen must monitor the patients’
response. The monitoring of the patient’s response will be done with the help of the pulse
oxymetry. The regulation of the amount of the external oxygen supply will be as per the
physicians’’ advise and as per the vital signs. The oxygen tanks should be checked in a
periodic manner in order to ensure that there is adequate source of oxygen and ensuring that
there is no dent in the connecting tank in order to ensure steady flow. While maintaining the
Fowler position the bed must be positioned at an angle of 45 degree in order to ensure
adequate expansion of chest (Baird 2015).
Rationale and Evaluation of outcome
The external supply of oxygen will help to restore the oxygen saturation and
maintenance of the Fowler’s position will help to ease the process of breathing by providing
the required chest expansion. The evaluation of the outcome will be done based on the
oxygen saturation. The optimal limit is 97 to 98% of SpO2 (Baird 2015).
Intervention 3: Deep breathing and coughing techniques
Pathophysiology and Management
Deep breathing and coughing techniques help the patient to clear the airway
effectively while helping to maintain the oxygen saturation levels. Mr. Smith is suffering
from hacking cough with bilateral bibasal coarse crackles. Basal crackles is present in both of
the lungs of Mr. Smith. Crackles are mainly caused by the "popping open" of the small
airways. Under this condition, the alveoli remains collapsed by fluid, exudate, or due to the
lack of aeration during expiration leading to breathing problem. The breathing exercise and
coughing will help to promote cough clearance in the lungs and thus helping to breath in ease
(Westerdahl, 2015).

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Nursing consideration
The coughing and deep breathing must be educated by the execution of the effective
communication and showing empathy towards the patients. This will help in the development
of therapeutic relationships. The huffing technique is suitable to performing breathing
exercise ad coughing technique. This includes inhaling medium breath and then making
sound like “ha” to exhale the air fast while keeping the mouth slightly open. In order to keep
the buccal cavity hydrated, while breathing frequent sipping of water is recommended (Baird
2015).
Rationale and Evaluation of outcome
The clearance of the cough present in the chest will help to ensure proper breathing
and thereby helping to regain the normal oxygen saturation. The evaluation of the outcome
will be noted by increase in the oxygen saturation and decrease in the mucus deposition or
cough in the chest evaluated by chest X-ray (Baird 2015).
Discharge Planning
The five principle of social justice in the Australian Health Care is:
(i) Access to good healthcare services
(ii) Equity that is equal access of the healthcare for all irrespective of financial background
(iii) Equal legal rights for health
(iv) Patient participation in the decision making for informed consent
(Australian Nursing & Midwifery Federation, 2019)
The discharge planning for Mr. Smith will include active participation of the patient
along with patient education for informed decision making. The discharge will include proper
diet plan for Mr. Smith depending on his weight, age, gender and his present condition of the
blood glucose level. This will be included to proper medication for controlling high blood
pressure and drug treatment in order to reduce his congestion of lungs. Patient will be
educated about the mode of action, dosage and the time of administration of the medication.
Since Mr. Smith is 70 years old, the education will also be given to his primary care givers or
family members in the domain of medication management in order to increase the provision

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of healthcare. The discharge planning will also include the exact time for re-visit to the doctor
(Spatz, Krumholz & Moulton 2016)
Thus the main factors that must be taken into account in the discharge planning is
 Evaluation of the patient by doctor
 Discussion with the patient or his family members
 Planning for homecoming or shift to another care domain
 Determining whether training of caregiver is needed
 Referrals to a home care agency or community based healthcare access like
Commonwealth of Australia that provides Australian government funded home-based
assistance to the older adults
 Arranging follow-up for the next appointments with doctor
(Gonçalves‐Bradley et al. 2016)
The multidisciplinary team in the discharge planning of Mr. Smith will include
dietician or nutritionist in order to plan for sodium restricted and anti-diabetic diet plan.
Physiotherapists will be another member of the multidisciplinary team who will plan person-
centered physical exercise in order to reduce the BMI (Gonçalves‐Bradley et al. 2016).
Conclusion
Thus from the above discussion, it can be concluded that two main priorities of care
for Mr. Smith is management of the oxygen saturation by the use of the external oxygen
supply, maintain of the Fowler’s position and doing breathing exercise. Another clinical
priority will be management of hypervolemia by sodium restricted diet. In the domain of
discharge planning patient education along with education of the family member is important.
This will be followed by taking consent from the patient for informed decision making.

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References
Australian Nursing & Midwifery Federation. 2019. Social Justice. Access date: 3rd April
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