Nursing Care Report: Mrs. Walesa's Case Study Assessment and Plan

This nursing care report provides a comprehensive analysis of Mrs. Walesa's case, detailing her health assessment, including vital signs, physical and psychological variables, and laboratory test results. Mrs. Walesa is diagnosed with multiple conditions including type 2 diabetes, left-sided heart failure, and osteoarthritis. The report identifies health priorities such as chronic conditions and the promotion of physical activities. It outlines two primary nursing diagnoses: decreased cardiac output and urinary stress incontinence. The care plan includes specific interventions, rationales, and expected outcomes for each diagnosis, such as assessing heart rhythm and encouraging rest to manage decreased cardiac output and interventions to increase pelvic floor muscle tone to address urinary incontinence. The report emphasizes the importance of a multidisciplinary approach to improve Mrs. Walesa's quality of life and manage her complex health needs, including the use of medications like furosemide, metoprolol, and metformin. The report highlights the interconnectedness of her conditions and the need for continuous monitoring and care.

Running head: NURSING CARE 1
Nursing Care
Name
Institution

NURSING CARE 2
Nursing Assessment
Client Assessment
This is a case of a patient named Mrs. Walesa who before being admitted at a care facility had
failed to thrive and had been medically diagnosed with type 2 diabetes, a left-sided heart failure,
and osteoarthritis. She does not have any reported case of any allergic reactions according to the
provided case study. Some of the medications she is taking for her condition include furosemide,
metformin, metoprolol, docusate sodium, lansoprazole, and acetylsalicylic acid. According to the
case study, Mrs. Walesa is on a diet of soft 1800 CDA and diabetic snacks. Her vital signs
include a temperature of 37.4℃, a pulse rate of 88 bpm, shallow respiration at 25 breaths per
minute, blood pressure of 130/94 mmHg, and Saturation of oxygen measured at 86% and rises to
88% after addition of 2 liters of oxygen via nasal prongs.
Health Assessment
Psychological Variable
General Appearance/Mental State
Mrs. Walesa appears tired and is not oriented
to place or time. This implies that she has no
idea what time it is and she cannot also identify
where she is. This is an indication that her
mental health status has been affected by her
deteriorating condition. She also appears shaky
and irritable when being given her
lansoprazole. The irritability may also be an
Gastrointestinal System
She is on a diet of soft 1800 CDA that she
manages to consume 75% consistently. She is
required to take her diabetic snacks between
meals but she is reluctant in doing so. The
findings of the assessment also revealed that
Mrs. Walesa is continent of stool and daily
passes brown stool. She additionally takes
docusate sodium, a medication that is

NURSING CARE 3
indication of anxiety. sometimes used to treat constipation. This
medication is used as a stool softener to
prevent the patient from straining to have a
bowel movement (Ruston, Hunter, Cummings
& Lazarescu, 2013). This explains why she
passes medium-soft stool. She also takes
lansoprazole, a medication that is normally
used to reduce the acidity of the stomach and
treat conditions such as frequent heartburns.
Lab tests show that she has a below-average
creatinine which could be an indication of
excess fluid intake.
Respiratory System
On the assessment of the patient’s respiratory
system, it is discovered that she has shallow
respirations at 25bpm. Given that the normal
respiratory rate for an adult at rest ranges
between 12-20bpm, this could be an indication
of tachypnea which may be due to her left-
sided heart failure (Park, & Khattar, 2019).
Further assessment of her respiratory system
reveals fine crackles from the lungs which
could be an indication of lung failure.
Nervous System
She appears confused and disoriented as she
seems not to know the time or the place she is.
Her cognitive ability enables her to request to
be taken back to bed because she feels tired. It
is also visible that she is experiencing some
acute pain on her left knee that feels warm
when touched and the patella is red. She is also
able to describe the pain as she states that the
pain has significantly increased as compared to
the previous day. She additionally takes

NURSING CARE 4
Laboratory tests reveal that her hemoglobin
concentration of 90mmol/l is abnormally high
which could be an indication of an impaired
gaseous exchange in the lungs.
Acetylsalicylic acid daily during breakfast.
This medication is used in pain reduction
(Schrör, 2016).
Cardiovascular System
Assessment of Mrs. Walesa’s circulatory
system reveals that her pulse rate is 88. Her
heartbeat is irregular; however, she has clear
S1 and S2. Her blood pressure is measured to
be 130/94 mmHg which is very high and may
be considered as stage 1 hypertension. Mrs.
Walesa takes metoprolol to treat her
hypertension and possible chest pains. She also
shows signs of oxygen deprivation because her
SaO2 is just 86% and rises to 88% when she is
given oxygen via nasal prongs. She also takes
furosemide that helps in preventing her body
from absorbing too much salt thus helping in
treating edema. According to Segar (2012), this
medication prevents fluid retention by allowing
the excess salt to be passed in the urine.
Urinary System
She passes foul-smelling urine that appears to
be very concentrated. She has urine
incontinence and uses Attends to help with the
problem. Laboratory tests reveal that her
albumin, sodium, and potassium levels are
within normal ranges which could be an
indication that her kidneys are in good
condition.
Musculoskeletal System
Mrs. Walesa’s ischial tuberosity region turns
Integumentary System
Her body temperature is 37.4℃ which is

NURSING CARE 5
red when she lies down; an indication of
inflammation in this region, a condition that
may be described as ischial bursitis. She is
unable to put any pressure on her left leg due to
the extreme pain she feels in her left knee. Her
knee movements indicate 100 degrees flexion
and 110 degrees extension in her left knee as
compared to 120 degrees flexion and extension
on her right knee. This is an indication that she
has a limited range of movement on her left
knee. It is also revealed in the case study that
she uses a pressure reduction mattress which
could be due to pressure ulcers when she lies
down in bed. She manages to walk daily with
the help of a walker from the nursing station to
the dining room. She also suffers from
osteoarthritis.
considered normal. She can feel pain implying
that there is a presence od sensation in her skin.
There are no notable findings in her
integumentary system apart from the once
mentioned above.
Endocrine System
Mrs. Walesa has type 2 diabetes implying that
her blood glucose is too high due to the body’s
inability to appropriately utilize insulin.
Additionally, it could also mean that the
pancreas is not producing enough insulin thus
Senses
She can see as it is stated that she walks daily
from the nursing station to the dining room
only requiring the help of a walker. She eats
her food and is reluctant to eat her diabetic
snacks in between meals. This is an indication

NURSING CARE 6
causing an increase in blood glucose level thus
leading to insulin resistance. Laboratory tests
reveal that her random blood glucose is
6.3mmol/L which is higher than the required
normal blood glucose that ranges between 4
and 5.9mmol/L (Plis, Bunescu, Marling,
Shubrook & Schwartz, 2014). She is on
medication for metformin to treat her diabetic
condition.
Further laboratory tests reveal that her TSH
level is 8mcU/L which is higher than the
normal range. This is an indication of
underactive thyroid; a condition known as
hypothyroidism.
that her sense of taste is still good.
Reproductive System
Her reproductive system is healthy given the
fact that she was able to bear 8 children.
Environmental Factors
She seems to have a happy family having been
blessed with 8 children before the death of her
husband. She has type 2 diabetes that probably
increased her chances of left-sided heart
failure. Additionally, her age might have
contributed to these medical conditions
including osteoarthritis. She also has a
condition of hypothyroidism that is believed to

NURSING CARE 7
increase the risk of left-sided heart failure. Her
mental health is normally okay until when she
became disoriented one morning.
Nursing Care Plan
Health Priorities
Mrs. Walesa has type 2 diabetes, left-sided heart failure, and osteoarthritis. According to studies,
patients who have type 2 diabetes are at an increased risk of developing heart failure.
Consequently, heart failure also increases the risk of developing diabetes. Often, these two
conditions occur together thus deteriorating the state of a patient even further and lowering their
quality of life (Seferović et al., 2018). Studies have also revealed that they share a lot of risk
factors. Additionally, type 2 diabetes increases the risk of developing osteoarthritis which is a
joint disorder that affects the cartilages. But this risk of osteoarthritis due to diabetes arises
mostly from obesity which is a known risk factor for type 2 diabetes. Osteoarthritis then
increases the risk of cardiovascular diseases such as left-sided heart failure (Rahman et al.,
2013)S. The risk increases when the affected joint is the knee joint as is the case with the client
in the case study. Aging also increases the risk of both osteoarthritis and heart failure. This is
because old age leads to thickened arteries thus leading to conditions such as high blood pressure
and eventually heart failure. Additionally, with age, the joints wear out and degenerate thus
increasing the risk of developing osteoarthritis.
Mrs. Walesa also has a condition of hypothyroidism that is believed to be prevalent among
diabetic patients. Having a thyroid disease affects the metabolism of the body and this includes

NURSING CARE 8
the regulation of blood sugar (Swamy et al., 2012). As a result, it becomes difficult for a diabetic
patient to manage their blood sugar levels like in the provided case study.
One of the health priorities in this case study is chronic conditions. They include diabetes,
arthritis, and cardiovascular diseases such as heart failure among others. Primary health care
should be improved to ensure there is an increase in support systems and multi-disciplinary care
models. This will help in improving the quality of life.
Another health priority, in this case, is the promotion of lifelong physical activities. Physical
activities help in managing blood sugar levels and help the body to appropriately utilize insulin.
Research has also shown that physical activities help patients with cardiovascular diseases such
as heart failure in staying active and relieving symptoms (Taylor et al., 2014). Exercise therapy is
also believed to be very beneficial to patients with osteoarthritis because it relieves pain and
increases joint movement.
Nursing Diagnosis
One of the nursing diagnoses from the provided case study is decreased cardiac output. This is a
situation that is characterized by the heart’s inability to pump sufficient blood all through the
body to meet metabolic demands. This may be caused by left-sided heart failure as is the case
with Mrs. Walesa (Rojas Sanchez et al., 2017). The heart tries to compensate for this decreased
cardiac output by trying to pump blood faster and harder which may lead to hypertension. Other
characteristics of this diagnosis may include chest pains which she uses metoprolol to treat.
Crackles are another characteristic associated with this diagnosis. Some of the related factors
associated with decreased cardiac output include general body weakness, poor cardiac reverse,
and inotropic changes among others ("Heart Failure Nursing Care Plans: 15 Nursing Diagnosis -
Nurseslabs", 2020).

NURSING CARE 9
Another nursing diagnosis in Mrs. Walesa’s case is urinary stress incontinence. This situation is
characterized by urine suddenly leaking due to increased pressure in the intra-abdominal region
(Cervigni & Gambacciani, 2015). Some of the factors that are related to urinary stress
incontinence aging, trauma to the pelvic region, menopause, and diabetic neuropathy among
others.
Planning
Client Goals:
Decreased cardiac output- controlled
dysrhythmias after a period of 6 months.
Expected Outcomes:
 Mrs. Walesa will report a reduction in
angina episodes.
 Mrs. Walesa will take part in activities
that help in reducing cardiac workload.
 Mrs. Walesa will report adequate
cardiac output. This will be
characterized by controlled
dysrhythmias.
Urinary stress incontinence- increase pelvic
floor and abdominal muscle tone after a period
of 6months.
 Mrs. Walesa will have no episodes
of incontinence.
Interventions
Diagnosis
Decreased Cardiac
Output
Intervention
Assess the rate of heart
rhythm and document
dysrhythmias.
Rationale
Even when a patient is at rest, tachycardia may
still be present. This helps in compensating for
the reduction in ventricular contractility ("Heart

NURSING CARE 10
Failure Nursing Care Plans: 15 Nursing
Diagnosis - Nurseslabs", 2020).
Take note of the heart
sounds.
Due to a decreased cardiac output, the pumping
action may be diminished thus producing weak
S1 and S2 (Chen et al., 2016). It is also important
to note that as blood flows to non-compliant
chambers gallop rhythms may be common. This
intervention may also help in identifying
murmurs that characterize valvular
incompetence.
Encourage the patient
to rest and assist her
with all activities.
This intervention is important because it will
help in reducing the cardiac workload as well as
reducing the rate of myocardial consumption of
oxygen (Capuana, Dywan, Tays & Segalowitz,
2012).
Monitoring the pulse
of the patient and her
blood pressure.
This intervention is important because patients
with left-sided heart failure may be hypertensive
due to the heart trying to compensate for the
decreased cardiac output ("Heart Failure
Nursing Care Plans: 15 Nursing Diagnosis -
Nurseslabs", 2020).
Administer medication
such as metoprolol as
This helps in treating chest pains thus reducing
episodes of angina (Divchev & Stöckl, 2017).

NURSING CARE 11
required.
Urinary stress
incontinence.
Encouraging the
patient to ensure they
consume adequate
amounts of fluids.
Patients are usually embarrassed with their
incontinence and they may limit fluid intake to
try and reduce the episodes associated with
incontinence. This limited intake of water or
other fluids may increase the risk of UTI and
kidney stones (Lotan et al., 2013). Additionally,
it affects the mental and physical performance
of a client.
Encourage medication
use as required.
Medication such as vaginal estrogen and
Pseudoephedrine help in improving the pelvic
muscle tone (Hersh & Salzman, 2013).
Evaluation
Achievement of Expected
Outcomes:
The patient reported a
reduction in angina and a
significant increase in cardiac
output. However, the level of
engagement in physical
activities was not achieved as
required. A new plan to
increase the level of exercise
Client Response and
Findings:
Episodes of angina were
significantly reduced because
the patient adhered to the
metroprolol medication that
she took daily during
breakfast. This medication is
used in reducing chest pains
and treating hypertension that
Further Nursing Actions:
Mediation administration for
pain before any exercise
therapy is important to relieve
pain. It is important to note that
exercise is essential for the
mobility of the knee joint but
exercises may be impossible
when the patient is

NURSING CARE 12
therapy was initiated. may be associated with left-
sided heart failure.
Additionally, there was an
increase in cardiac output
because heart rate, heart
sounds, and blood pressure
were monitored to ensure that
the patient was posting good
results. The level of
engagement to physical
exercises was, however, not
attained as required because
the patient had an issue with
her left knee that limited her
range of motion and knee joint
movement.
The above-mentioned nursing
interventions were mostly
successful.
experiencing excessive pain.
Urinary continence was not
achieved as required.
Total urinary continence was
not achieved because of the
patient’s age. This is because
as one gets older their body
Advise the patient to adopt the
use of insert pads that are
reusable or disposable to help
in absorbing urine due to

NURSING CARE 13
structure changes and they
become weaker. In post-
menopausal women, muscle
atrophy in the pelvic region
makes it difficult for the
bladder to hold urine thus
causing incontinence.
incontinence.
References
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inhibitory control in younger and older adults. Biological psychology, 90(1), 60-70.
Cervigni, M., & Gambacciani, M. (2015). Female urinary stress
incontinence. Climacteric, 18(sup1), 30-36.
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(2016). S1 and S2 heart sound recognition using deep neural networks. IEEE
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of ivabradine and metoprolol: effectiveness and tolerability in routine clinical
practice. Cardiology and therapy, 6(2), 239-249.

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