Bachelor of Nursing Case Study: Max Johnston's Nursing Care Plan

This case study focuses on the nursing care plan for Max Johnston, a patient admitted to the emergency department with chest pain, nausea, and breathlessness. The assignment details the patient's history, including smoking and alcohol consumption, and identifies a nursing diagnosis of acute chest pain potentially related to a heart attack. The study outlines a SMART goal aimed at increasing cardiac output and decreasing hypoxia. It further presents six nursing interventions with rationales, such as monitoring blood pressure, observing breath sounds, ensuring rest, monitoring cardiac output parameters, maintaining IV access, and providing information on activity restrictions. The conclusion emphasizes the importance of the nursing care plan in achieving positive patient outcomes, highlighting the assessment of pain, the implementation of interventions, and the continuous monitoring of vital parameters to understand and manage the patient's condition effectively. References to supporting literature are provided.

Running head: CASE STUDY
Case Study: Max Johnston
Student Name
University Name
Author Note

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Introduction
Nursing care plans are required for each patient as they help in better communicate
the diagnosis and the treatment to the patient, other healthcare specialists and the families of
the patients. The basic structure of the care plan for each patient remains the same; however,
the actions or the interventions for the patients are different. The following essay discusses a
patient named, Maxwell Johnston who was admitted to the emergency department for
complaining piercing chest pain which was often associated with nausea and breathlessness.
At the first instance, a pain assessment was conducted on him to understand the intensity of
the pain in the chest area of the patient and his pain score was 9/10. It is reported that the
patient consumes around 20 cigarettes per day and also 18 standard drinks per week. In the
following paragraphs, the nursing diagnosis, the SMART goal and the six interventions for
the patient with their relevant rationales will be presented.
Diagnosis
From the case study, it could be apprehended that Max was experiencing a piercing
chest pain which was detected to be a symptom of a heart attack and hence, requires
immediate nursing attention in the form of priority diagnosis. It is with the help of the
subjective cues that have been gathered from Max which led to believe that he may be
suffering from a heart attack. At the first instance, a pain assessment was conducted on him to
understand the intensity of the pain in the chest area of the patient and his pain score was
9/10. A coronary failure, or myocardial infarction (MI), happens when the surface covering
of a greasy plaque burst. Blood coagulation (thrombus) can frame on the plaque, which can in
part or obstruct the corridor. This blockage eases back or squares bloodstream to the territory
of heart muscle took care of by that artery. On the off chance that this proceeds for over 15
minutes, the muscle can get harmed or infarcted. During a coronary failure, it is likely that
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the patient may feel uneasiness in their chest region that is like a scene of ischemia, albeit
increasingly drawn-out and extraordinary. In this case, Max repeatedly complained to his
wife that he may faint from the extreme chest pain which is also making him breathless.
Troponin alludes to a bunch of proteins that help control the compressions of the skeletal
muscles and heart. High troponin levels can demonstrate an issue with the heart (Westwood
et al., 2015). The heart discharges troponin into the blood following a physical issue, for
example, a coronary attack or failure. Extremely high troponin levels normally imply that an
individual has as of late had a coronary failure or attack. On account of Max, his levels were
accounted for at 50.0 ng/L which is more than above the typical degree of <15 ng/L (Lipinski
et al., 2015). A specialist will not utilize raised troponin levels alone to analyze a heart
condition. They will likewise consider the individual's different side effects and may utilize
other analytic devices, for example, a physical assessment or an electrocardiogram (ECG).
Considering the blood pressure of Max being recorded at 88/65 mm hg reveals it to be
hypotensive. Excessive hypotension causes the blood pressure of the person to fall below the
range of 90/60 mm Hg and the individual experiences shortness of breathing with less
amount of oxygen being delivered to the heart or the body of the person (Sara et al., 2015).
Hypoxemia is beneath the ordinary degree of oxygen in the blood of the patient, explicitly in
arteries. Hypoxemia is an indication of an issue identified with breathing or course and may
bring about different side effects, for example, shortness of breath. A typical healthy
individual ought to have the option to accomplish ordinary blood oxygen immersion levels
(SpO2) of 94% to 99% (Payne et al., 2015). In any case, on account of Max, his SpO2 levels
were recorded to be beneath 94% and at 91% which is disturbing and should be a nursing
care concern.
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Expected Health Outcome
The SMART goal specifically for the patient is needed for the appropriate health
outcome to be established for the patient. After analyzing the condition of the patient, the
specific goal for the medical improvement of the patient requires to increase the cardiac
output and decrease the onset of hypoxia. In addition, it is also necessary to ensure the
delivery of oxygen by the pulse oximetry for the detection of the oxygen saturation level of
the patient. One of the methods by which this is measures is the continuous level monitoring
of the hormone concentration, body temperature and heart rate are some of measuring factors
which will be monitored by the nursing professionals to understand the graph of the
improvement in the condition of the patient. To achieve this, it is important to note that the
heart is efficient enough to transport oxygen to the body. If the heart is able to pump enough
blood with oxygen to and from the body, then it could be understood that the condition of the
patient is improving and the goal is achieved. The body temperature, changing heart rate,
stroke volume and hormone concentration are some of the factors which show the
development or the improvement in the condition of the patient. The goal that is set for the
improvement in the medical condition of the patient, it is critical to understand whether it is
relevant to the situation of the patient. Analyzing the condition of the patient, the blood
pressure level of the patient and the oxygen saturation level of the patient is to be monitored
continuously such that further escalation in the health condition of the patient is not observed.
Hence, it could be deduced that the goal that has been set for the patient is relevant as per the
condition of the patient. For the goal to be achieved and the condition of the patient to be
improved, it is important to keep in mind about the required time frame of the achievement.
The time frame required for the hypotension of the patient to be reduced and the oxygen
saturation level to be stabilized, 1 week time is required for the nurses to continuously
monitor the medical situation of the patient and report any sign of improvement to the doctor.
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Interventions for Max
Intervention 1:
Compare and monitor the blood pressure obtained from both arms in the sitting, lying and
standing postures of the patient.
Rationale: The hypoperfusion in the myocardium of the patient is likely with hypotension
and can cause pain the chest (Pereira et al., 2015).
Intervention 2:
Observe the breath sounds of the patient.
Rationale: Depressed function of the myocardium is responsible for the development of
congestion in the pulmonary and reflecting with crackles (Ferreira et al., 2016). Considering
the case of the patient, the decreased inability of the patient to deliver oxygen can lead to
pulmonary sepsis and infection which could be detected by observing the breathing sounds of
the patient.
Intervention 3:
It is important to note that amount of activity that is done by the patient and ensure complete
rest.
Rationale: It is generally observed that overexertion in the form of everyday activities for the
patient may lead to higher consumption of already less available oxygen and hence, should be
restricted (Baird, 2015). It can also compromise the optimum functionality of the
myocardium.
Intervention 4:
Regularly monitor the parameters that are responsible for the action of cardiac output like the
cardiac index, cardiac work and contractility as and when found appropriate by the physician.
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Rationale: The above-mentioned parameters for the measurement of cardiac output could be
measured with thoracic electrical bioimpedance technique noninvasively (da Costa, da Costa
Linch & Nogueira de Souza, 2016). It can help the nursing professionals to understand the
sudden change in the medical condition of the patient and identify the need for emergency or
aggressive care.
Intervention 5:
Maintain the intravenous supply as and when indicated by the physician
Rationale: The patent line of the patient is critical to be established such that in an event of
an emergency, medicines could be administered intravenously (Ma et al., 2015). In addition,
because Max is experiencing chest pain, it is all the more important to ensure the injection of
drugs by intravenous methods.
Intervention 6:
Share the information of no arms positioned above the level of head and restriction against
the isometric activity.
Rationale: These behaviors have been reported to cause adverse effects of the optimum
function of the cardiac muscle and influence the recovery and rising of complications in the
medical condition of the patient (Rogers & Bush, 2015).
Conclusion
In concluding remarks, it can be understood that to achieve a positive health outcome
for the patient, it is critical for the nursing professionals to use the nursing care plan as a
directive for the appropriate care for the patient. From the information of the case study of
Maxwell Johnson, acute chest pain had been identified as the nursing diagnosis which
requires immediate nursing attention. It is because of this that a SMART goal was established
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such that the medical condition of the patient could be subsequently improved. It is with the
administration of the interventions encircling around the goal that the condition of the patient
is expected to improve. For a critical understanding of the chest pain, it is crucial for the
nursing and medical professional to assess the type of pain that is being experienced by the
patient and help in providing suitable treatment. Decreased cardiac output is one of the
reasons why the patient may be experiencing breathless and subsequent chest pain. Hence,
regular monitoring of the vital parameters related to cardiac output can help in understanding
the underlying cause and implementation of the care.
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References
Baird, M. S. (2015). Manual of Critical Care Nursing-E-Book: Nursing Interventions and
Collaborative Management. Elsevier Health Sciences.
da Costa, C., da Costa Linch, G. F., & Nogueira de Souza, E. (2016). Nursing diagnosis
based on signs and symptoms of patients with heart disease. International journal of
nursing knowledge, 27(4), 210-214.
Ferreira, A. M., da Rocha, E. D. N., Lopes, C. T., Bachion, M. M., de Lima Lopes, J., & de
Barros, A. L. B. L. (2016). Nursing diagnoses in intensive care: cross-mapping and
NANDA-I taxonomy. Revista brasileira de enfermagem, 69(2), 285.
Lipinski, M. J., Baker, N. C., Escárcega, R. O., Torguson, R., Chen, F., Aldous, S. J., ... &
Inoue, K. (2015). Comparison of conventional and high-sensitivity troponin in
patients with chest pain: a collaborative meta-analysis. American heart
journal, 169(1), 6-16.
Ma, M., Noori, S., Maarek, J. M., Holschneider, D. P., Rubinstein, E. H., & Seri, I. (2015).
Prone positioning decreases cardiac output and increases systemic vascular resistance
in neonates. Journal of Perinatology, 35(6), 424-427.
Payne, B. A., Hutcheon, J. A., Dunsmuir, D., Cloete, G., Dumont, G., Hall, D., ... & van
Papendorp, E. (2015). Assessing the incremental value of blood oxygen saturation
(SpO2) in the miniPIERS (Pre-eclampsia Integrated Estimate of RiSk) risk prediction
model. Journal of Obstetrics and Gynaecology Canada, 37(1), 16-24.
Pereira, J. D. M. V., Dantas Cavalcanti, A. C., Lopes, M. V. D. O., da Silva, V. G., de Souza,
R. O., & Gonçalves, L. C. (2015). Accuracy in inference of nursing diagnoses in heart
failure patients. Revista brasileira de enfermagem, 68(4).
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Rogers, C., & Bush, N. (2015). Heart failure: pathophysiology, diagnosis, medical treatment
guidelines, and nursing management. Nursing Clinics, 50(4), 787-799.
Sara, J. D., Widmer, R. J., Matsuzawa, Y., Lennon, R. J., Lerman, L. O., & Lerman, A.
(2015). Prevalence of coronary microvascular dysfunction among patients with chest
pain and nonobstructive coronary artery disease. JACC: Cardiovascular
Interventions, 8(11), 1445-1453.
Westwood, M., van Asselt, T., Ramaekers, B., Whiting, P., Thokala, P., Joore, M., ... &
Kleijnen, J. (2015). High-sensitivity troponin assays for the early rule-out or diagnosis
of acute myocardial infarction in people with acute chest pain: a systematic review
and cost-effectiveness analysis. Health technology assessment, 19(44).
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