University Nursing Case Study: Pulmonary Oedema and Care Planning

This nursing case study analyzes the scenario of Ms. Martha Foley, a 35-year-old patient admitted with pulmonary oedema following a car accident. The report details the patient's observation and fluid balance charts, interpreting vital signs like respiratory rate, oxygen saturation, and fluid intake/output. It explores the pathophysiology of pulmonary oedema, discussing the impact of factors like smoking and lung injury. The core of the study lies in outlining a comprehensive nursing care plan that addresses gas exchange, fluid management, pain control, and wound care, with evidence-based rationales for each intervention. The report also emphasizes the interprofessional model of care, highlighting the roles of nurses, physicians, and other healthcare professionals in managing this complex case, including the use of oxygen therapy and medications such as diuretics and bronchodilators. The document also mentions the importance of monitoring the patient's condition, providing emotional support, and educating the patient and her family on the disease and its management.

0Running head: NURSING CASE STUDY
NURSING CASE STUDY
Name of the student:
Name of the University:
Author’s note

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Introduction:
Developing nursing care plan is a complex task involving correct
identification of patient’s problem and selecting appropriate intervention to
address the problem. This process is facilitated by the use of several clinical
assessment tools that gives an indication of improvement of deterioration in
patient’s health status. Based on this evaluation of patient, standardised and
evidenced-based holistic care plan can be made (Ackley, Ladwig, and Makic,
2016). This whole process of assessment planning care is discussed in this
report by the analysis of the case scenario of Ms Martha Foley, a 35 year old
lady with risk pulmonary oedema. The report analyse the patient’s scenario by
means of observation chart and HHHS fluid balance chart. Based on the
assessment of patients through this chart, effective care plan is provided for the
recovery of patient and with support from evidence based rationales. The report
also gives an explanation about the inter-professional model of care required
for Mrs. Foley.

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Part 1:
Observation chart and interpretation:
Mr Martha Foley has been admitted in the emergency department suffering
multiple fractures in legs due to a car accident. The observation chart and the
HHHS fluid balance chart of patient gives the following information:
Table: Fluid Balance Chart (HSSS)
Time
Oral/enteric
intake IV fluids
mls/
IN
Progra
m
Urine/
mls
12:00:00 AM NBM
compoun
d Total
1:00:00 AM sodium 200 input 100
2:00:00 AM intake 200
3:00:00 AM 1000mls 200
4:00:00 AM 200
5:00:00 AM 200
6:00:00 AM 200
7:00:00 AM 200
8:00:00 AM 200
9:00:00 AM
10:00:00 AM
11:00:00 AM
12:00:00 PM
1:00:00 PM
2:00:00 PM
3:00:00 PM
4:00:00 PM
5:00:00 PM
6:00:00 PM
7:00:00 PM
8:00:00 PM
9:00:00 PM
10:00:00 PM
11:00:00 PM

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12:00:00 AM
total intake 1600 total 100
output
Current
Balance Posiitve 1500mls
Pevious
Balance Positive 1900mls
Cumulative
Balance Positive 3400mls
Table 2: Observation chart

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 2/10 pain
 Shortness of breathing and greater work of breathing up to 25 respiratory
rates per minutes
 Oxygen saturation dropping to 80% on room temperature and return of
oxygen saturation to 95% after using the four pillows
 Vital sign progressing towards hypotension with tachycardia
 No ooze or redness from wounds
 Ms Foley is dyspoenic and shows symptoms of cyanosis
Based on the vital sign assessment of Ms Foley, it can be said her vital sign
are fluctuating consistently. After her multiple trips to theatre for fracture
treatment and fixation of ankle, her breathing rate has been a major issue. The
fluctuation in respiratory rate led to shortened of breath, tachycardia and
dyspnea. This made her desperate for ar. This symptom was also seen because

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of the condition of pulmonary oedema where accumulation of fluids in the
tissues and spaces of lungs created gas exchange problem and respiratory failure
in patient (Vadász and Sznajder 2017). Hence, nursing intervention in this area
is critical. Secondly, other areas where adequate nursing care plan is necessary
for patients includes managing her orientation, pain, wound site on hip, fluid
balance, adequate sleep and emotional problems in patient.
Pathophysiological knowledge related to the scenario:
Pulmonary oedema is generally caused due to the increase in the capillary
hydrostatic pressure secondary to the increased level of pulmonary venous
pressure. Pulmonary oedema can be caused due to the damage in the alveolar
capillary barrier, lymphatic obstruction. Increased pulmonary capillary pressure
decreased plasma oncotic pressure and raised level of negative interstitial
pressure (Inamasu et al., 2012). Pulmonary oedema can cause acute respiratory
distress, which may lead to acute and decompensate heart failure. This is caused
due to the left ventricular systolic or the dysfunction in the diastolic pressure. In
an acute pulmonary oedema can be caused by the overload of the primary fluid
in the lungs, hypertension and renal arterial stenosis. The alveolar space of the
lungs gets filled up with fluids due to the absence of the elevated pulmonary
capillary pressure (Vandse et al., 2012). It has been noted in the above report
that Ms Foley was diagnosed with pulmonary oedema after she was
encountered with a serious accident of a car and a tree crash. A severe

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pulmonary oedema can be caused due to severe accidents which may lead to
lung collapse giving rise to pulmonary oedema. Researches have found that a
chronic lung collapse can cause thickening of the capillary endothelium by the
release of interleukins. On expansion of the lung the microvessels are stretched
which harms the endothelial cells. It has been reported that MS Foley was also a
smoker. It has been found that smokers have an increased chance of developing
pulmonary edema than those who are non smokers. The signs and symptoms
shown by Ms Foley also align with the general symptoms that occur in an
pulmonary oedema.
Nursing care plan:
The following are the nursing care required for Ms. Foley:
1. Nursing intervention: Management of gas exchange and respiratory
failure in patient.
Nursing action:
To manage the respiratory function of Ms Foley, the nurse needs assess
the patient’s conditions and vital signs after every 30 minutes. This will help to
take immediate actions when breathing rate deteriorates. Patient can be made to
relax by promoting oxygenation and placing the patient in a Fowler’s position.
The nurse can ask patient to breath slowly if hyperventialing and teach them
breathing techniques to enhance strength and activity tolerance (Valenza et al.

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2014). In severe case, cough also impairs respiratory exchange, so teaching
patient effective breathing technique will be important to provide relied to her.
Rationale:
As Ms Foley has been admitted to the hospital after a car accident, she is
at high risk of pulmonary oedema due to the injury to the lungs. As the
accumulation of fluid in lung tissues impairs gas exchange in patients,
improving respiratory function of patient is a vital nursing intervention.
Changing the position of patients also help a lot to provide relief to patients with
poor respiratory status (Kubota et al. 2017). The prone and upright position
helps to enhance the oxygenation rate. Another advantage of placing the patient
in a fowler’s position is that improves patient’s tolerance for enteral feeding too
(Richard and Lefebvre 2011).
Evaluation:
The stability in the normal breathing rate and pulse rate of patients will gives
the idea that breathing rate of patient has improved. In such case, oxygen
saturation rate will also improve and oxygen requirements may be discontinued.
2. Nursing intervention: Manage fluid, nutrition intake and medications of
patients
Nursing action:

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 Ms Foley is a heavy smoker, so she needs to discontinue smoking to
prevent extra complications.
 To decrease the accumulation of fluids in lungs, the nurse needs to
provide diuretics to patients
 Other fluids given to her must be balanced to reduce the symptoms of
pulmonary edema
 The nurse also needs to monitor urine output in patient to assess fluid
overload
Rationale:
For patients like Foley, quitting smoking is important because it increases
the likelihood of mucus production, damage of bronchial walls and leads to
reduction in oxygen availability (Varol et al. 2015).
Management of fluid is specifically important for Ms Foley because she had
a past medical history of congenital heart failure. Hence, for such patients, fluid
overload results in adverse outcomes. Although diuretics are the main treatment
for fluid balance, monitoring other fluid and enteral intake in patient is critical
for recovery. Patients with heart failure are at high rate of peripheral edema
because renal perfusion decreases in such patient (Kelm et al. 2015).
Evaluation:

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The success of the intervention can be evaluated on the basis of balanced
intake and stable weight in patient. Assessment of lung sounds can also assist
nurse in managing symptoms of patients. Secondly, assessment of weight in
relation to nutritional status helps to identify whether fluid intake is balanced or
retained in patients
3. Nursing intervention: Management of pain and wound in patient
Nursing actions:
 Monitor the size, depth, odour and drainage from wounds
 Promoting the integrity of wounds by regular dressing and infection
control
 Evaluate the characteristics of pain
 Assess vital signs of tachycardia and hypertension in patient
 Regularly identify the cause of discomfort in patient
 Identify additional comfort measures in patients
Rationale:
As Ms Foley has had a ankle resection and other surgeries on hip,
regularly monitoring her wound and addressing pain is critical for recovery.
Vital signs assessment is also an important indicator for managing pain because
it gives an indication of level of discomfort in patient (Ross, 2017). Certain

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comfort measures like position change, relaxation techniques and oral care
reduces pain and stress and anxiety (Mahler 2017).
Evaluation:
Stability in vital signs and decrease in discomfort of patient is an
indicator for effective pain management.
Oxygen requirements:
The case study provides with the idea that Ms. Foley was suffering from
respiratory distress. She was suffering from shortness of breath and greater
work of breathing (WOB), her respiratory rate was increased up to 25Rpm and
her oxygen saturation is dropping to 80%. The initial management of the
pulmonary oedema should involve the ABCs of resuscitation which is - airway,
breathing and circulation. Methods of oxygen delivery that can be used are the
provision of a face mask, non invasive pressure support ventilation, mechanical
ventilation and intubation (Lenglet et al., 2012).
Oxygen saturation level below 80% refers that the pressure of the oxygen
in the blood is too low to penetrate the walls of the red blood cells. In case of
persistent hypoxemia, acidosis, intubation or mechanical ventilation can be
required (Sztrymf et al., 2012). A patient with severe pulmonary oedema would
require non-invasive pressure support ventilation. Intra aortic balloon pumping
can be given to improve the coronary blood flow. It has been reported that she

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was desperate for air and is dyspnoeic (Matthay, Ware and Zimmerman, 2012).
In order to treat the dyspnea, it is required to use bronchodialators to open the
airway. Steroids can be provided to reduce the swellings in the lungs.
Broncodialators can be introduced by subcutaneous injections (Lenglet et al.,
2012). Albuterol sulphate and ipratropium bromide are normally used in the
treatment of dyspnea.
Part 2: interprofessional model of care:
Interprofessional models of care, refers to the involvement of a group of
professionals from different specialisation to cater to provide care to a specific
patient (Davison et al., 2012). The diagnosis of the pulmonary oedema relies on
the medical examination, appropriate investigations and on medical history. In
this case history it can be clearly seen that Ms Foley had been suffering from
respiratory distress, therefore the specialised clinicians should focus on the
procedures to treat the respiratory problems. Giving oxygen should be the first
step to treat pulmonary oedema (Thille et al., 2013). Medications like Preload
reducers. Morphines , afterload reducers and medications for maintaining the
blood pressure is usually given (Davison et al., 2012). The registered nurse
standards should follow the given standards:-
 She should be able to think critically and analyse the nursing practice.