NUR250 Medical Surgical Nursing | Patient Assessment
You met David Parker last month when he was admitted to the medical ward you are working on following a myocardial infarction. David initially recovered and was discharged with referrals to an outpatient cardiac rehabilitation program. David did not attend the rehabilitation program as he had too much work on the farm and driving into town takes up too much of his time
David now experiences breathlessness which is no longer relieved by rest and gets worse when he lies down. He has also developed a cough and is becoming increasingly fatigued. David has continued to smoke 10 cigarettes per day as he states this assists him to cope with the stress. He also states he still has the occasional alcoholic drink but admitted he has “a few drinks with the boys at the local pub” every Friday night. David’s wife, Sophie, now provides David with low fat, low salt meals but he often refuses to eat them. He states his appetite has decreased over the past few weeks and he often feels nauseous however he has put on 6 kilograms during the past month.
David visited the cardiologist clinic today for his regular follow up cardiac appointment. The cardiologist has diagnosed David with Chronic Heart Failure (CHF) and has admitted David to hospital for further investigation of his cardiac function and symptom management.
Task 1: Patient assessment
On admission to the ward, the nurse focuses on collecting specific cues and information relevant to the person’s condition at the time. This second step in the Clinical Reasoning Cycle assists the nurse to recognise patient deterioration and assists the nurse in planning care and to facilitate mutually established goals. The nurse will continually assess and re-assess the patient throughout the continuity of care
In grammatically correct sentences and topic paragraphs and using current, reliable evidence for practice
Identify 3 specific nursing assessments that you would conduct as a priority on David’s admission to your ward to assist with planning his nursing care and identify potential problems and further deterioration of his cardiac function.
Task 2: Care planning
Based solely on the handover you have received and using the template provided, develop a care plan for three (3)
nursing problems identified and included in the template. These nursing problems cannot be changed and a care
plan needs to be developed for each.
Your task is to identify for each of the 3 nursing problems:
The underlying cause or what the nursing problem is related to
Goal of care
Specific bedside nursing interventions you will do
The rationales for your nursing interventions and actions
Indicators that your plan is working
Task 3: Medication management
Three important aspects of medication management by registered nurses is for the nurse to understand why a
patient has been prescribed specific medications, understanding the nursing responsibilities and how to monitor the
patient to ensure they are responding to prescribed medications as they should.
In grammatically correct sentences and topic paragraphs and using current, reliable evidence for practice,
Briefly explain why David has been prescribed:
a.Frusemide orally 40mg twice daily
b.Digoxin orally 62.5 mcg daily
c.Ramipril orally 5mg twice daily
Task 4: Patient education
Patient education starts on admission and continues throughout care. Patient education should be aimed at; improving or increasing the patient’s knowledge; influencing their attitude to alter their behaviours or attitudes; and/or to prepare the patient for discharge. Health education should be focused on the individual patient and individual strategies to improve the patient’s health and wellbeing
When caring for David you recognise David may need further education on the following topics in relation to
maintaining his cardiac output:
a.Physical activity guidelines
b.Smoking cessation
c.Stress minimisation
d.Reducing excess fluid volume
Select one (1) of the topics above and, in grammatically correct sentences and topic paragraphs,
Identify the specific information you will explain to David about the topic including recommendations on what he needs to do.
Task 5: ISBAR handover
An important legal requirement of nursing practice is to effectively and succinctly communicate relevant information, actions and outcomes related to patient care and provide an accurate reflection of the health status of the patient, their responses to care and the patient’s perspective.
Using the ISBAR format and information from the handover:
Provide a written handover that clearly and succinctly outlines the important information that staff need to know about David for continuation of nursing care
Answer:
Task 1: Patient assessment
In this case study, David had a medical history of Myocardial infarction and came to the cardio logical department to assess his increased health complications. Case study mentions the client, David Parker to be diagnosed with a risk of developing chronic heart failure. It further states that the client in the case study has been recently treated with the complications of cardiac arrest and had been asked to participate in the rehabilitation program. The client on account of the busy schedule at the farm, and the major distance to reach the town had avoided the rehabilitation program. On consulting a cardiologist, the cardiologist states that David is at an increased risk of developing chronic heart disease and that he needs immediate cardiac care. Therefore assessments which are relevant for David are congestive heart related risk assessment, observation of vital signs and dietary assessment.
Chronic heart failure: while attending a regular cardiac follow up routine The Cardiologist diagnosed David with Chronic heart failure and admitted him to the healthcare facility. It was important so that his cardiac failure related symptoms and interventions can be managed. Further it was observed that he has gained 6 kg of weight despite of the fact that he has lost his appetite and is unable to consume food properly. Hence, his cardiac failure related symptoms were important to assess as he increased his water and salt retention capacity.
Vital sign assessment: Vital sign observation is an important aspect for David, which includes temperature, respiratory rate, blood pressure, and oxygen saturation and pulse rate. In case of David, his heart rate, and respiratory rate showed elevated levels and due to this his chronic heart related condition was identified. His oxygen saturation and blood
pressure was also not normal as both showed steep decrease due to which, the helathcare professionals were able to identify the congestive heart related condition.
Dietary assessment: dietary assessment is an important step that should be assessed in case of David as due to decreased cardiac output and compensatory mechanisms, his water and salt retention has been increased. He is unable to have food due to decreased appetite however, due to water and salt retention, his weight has been increased by 6 kilograms. Therefore, it is important to control his dietary input and track both input and output of calories so that a track of his weight related disparity can be recorded. Further, he has mentioned of being fatigue and nauseous. Therefore in case of congestive heart failure, it is important to reduce the sodium intake and besides this exercise and stress management should be implied on David.
Task 2: Care planning
Nursing Care Plan: David
Note: Dot points recommended in care plan. Click and type in each cell, click enter in a cell to make it longer. Do not remove text from the template.
A reminder that all rationales must be referenced
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Nursing problem: Imbalanced fluid volume | |||
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Underlying cause or reason: Decreased cardiac output and compensatory mechanisms causing salt and water retention. Use of diuretics may reduce circulating blood volume causing hypovolemia despite peripheral oedema.
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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Decrease fluid volume and maintain fluid balance throughout the shift.
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· For this purpose, the medicine Frusemide will be given to the patient. · Further, the patient will be weighted daily · A close observation of input and output of the liquid will be monitored. · Besides this the 1000ml per day fluid restriction will be continued · the patient will be provided with balanced food so that the weight gain can be managed and controlled
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· The medicine Frusemide is a loop diuretic medicine that helps to prevent body from absorbing salts and helps the salts to be excreted outside the body with urine (Taylor, Fonte & Min, 2013). · This will help in maintaining a log of patient weight · This will help in monitoring patient’s input and output of calories (Hur et al., 2013) · this will prevent the patient from consuming excess water or fluid which can increase his salt intake · This helps in preventing water retention, which can be life-threatening condition for people with congestive heart failure (Hur et al., 2013). |
The patient will be weighted daily so that the change in mass can be identified and the effectiveness of the intervention can be identified. Besides this, the input and output of liquid will be monitored and calculated in every shift so that the interventions can be strictly managed (Hur et al., 2013). |
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Nursing problem: Impaired gas exchange | |||
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Underlying cause or reason: impaired gas exchange can be a reason for congestive heart failure as alveolar and capillary as well as lung functions contribute heart failure related condition and can also lead to respiratory co-morbidities | |||
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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To create a balance between gaseous exchange through alveoli and capillary
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· Patient will be observed for respiratory rate, depth, and effort while breathing and in this situation; · Abdominal breathing, increased respiratory rate and oxygen saturation level will be assessed. · Further the medication with Digoxin will continue. · oxygen will be provided to the patient so that ample amount of oxygen could reach to his lungs · His smoking and alcohol related habits will be prevented as it also affects the lung capacity of the patient |
· This is an important intervention, as it will help to observe the patients oxygen saturation level · Vestbo et al. (2013) mentions that during impaired gas exchange a sharp decrease in blood pressure and oxygen level as well as an increase in respiratory rate is witnessed. · These observations will be helpful in maintaining a balanced gas exchange. · Further, the medicine Digoxin will help in maintaining the heart rate and pump ample amount of oxygen so that gaseous exchange can be controlled (Kemp & Conte, 2012). · controlling his smoking condition will help to increase his lung health and lung capacity (Hur et al., 2013) |
Evaluation of oxygen saturation level will done after every 6 hours so that the level of oxygen can be observed. Further with this assessment,. The respiratory rate, heart rate will also be evaluated to that the effectiveness of the intervention could be understood (Connolly et al., 2012). |
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Nursing problem: Activity intolerance | |||
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Underlying cause or reason: It can be caused by the compromised oxygen transport (due to impaired gas exchange), increased respiratory rate and abnormal changes in the blood pressure
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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To make the able to perform the daily activity by increasing his activity tolerance level.
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· The patient will be involved in specific activities so that active range of motion can be achieved and · will be refrain for several non-essential activities · daily exercise will be included in his routine · he will be provided with educational sessions so that he can understand the actions which can increase his activity tolerance · on the other hand, while each activity, his energy consumption will be assessed using his cardiac output so that his physical strain can be assessed.
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· Involving patient in the goal setting and asking for coordinated effort will affect the patient situation positively (Billinger et al., 2014). · Further, conserving energy will help in increasing the patient’s ability to gain tolerance for activities for daily life (Billinger et al., 2014). · providing educational classes to the patient will increase his knowledge about such activities and he will be able to contribute in his helathcare interventions (Kemp & Conte, 2012) |
The patient will be observed for all the activities and after that after every 2 days, the progress of the patient in achieving short-term goals will be monitored (Anderson et al., 2013). |
Task 3: Medication management
In case of David Parker, three medications were used such as Frusemide orally 40mg twice daily, Digoxin orally 62.5 mcg daily and Ramipril orally 5mg twice daily.
The medicine Frusemide was used in case of David as it helps in the management of high fluid
Retention related condition. Due to increased cardiac output and different compensatory mechanism, it was observed that David increased the salt and water retention and due to which, his body fluid level was increased. Therefore, Frusemide medicine was provided 40 mg twice daily so that the water and salt retention can be reduced and excess salt and water can be excreted outside the body through urine (Andreucci, Solomon & Tasanarong, 2013).
The second medication Digoxin was provided to the patient to treat imbalanced cardiac conditions, and congestive heart failure so that his elevated heart rate increased respiratory rate could be controlled. Therefore providing the patient with Digoxin 62.5 mcg daily will help the patient to control his heart rate (Garg et al., 2012). On the other hand, Ramipril was provided orally 5mg twice daily to David so that his elevated blood pressure and congestive heart failure related condition could be controlled. This medicine helps in the arterial muscle relaxation and helps the blood to flow thoroughly through the cavity. Hence, the specific nursing responsibility will be providing the patient with all the medicine on time so that effective result could be achieved. Besides this, monitoring of positive and negative effects of each medication will also be evaluated. Assessment of Ramprill will involve dryness, cough, cold and nausea whereas for Frusemide will be stomach cramping, constipation and body ache. Hence, these signs will be assessed using frequent observation and close monitoring if the patient (Wharton et al., 2012).
Task 4: Patient education
Excess fluid volume related patient education
Patient education is an important aspect of nursing intervention due to which involvement of the patient in nursing intervention and focused contribution of the patient within the care process is achieved. In case of David, he was not aware of his healthcare concern in which his ignorance and lack of health education were primary factors. It was observed that after being discharged from the healthcare facility he did not attended the rehabilitation program and hence, were not aware of the activities that could affect his health. Therefore, a nursing education will be provided to David on excess fluid volume, its causes, and preventive actions (Shepherd, Lomer & Gibson, 2013). These educational sessions will be arranged every week and David will be provided with interesting handouts and presentations so that he could easily understand the causes and consequences of congestive heart failure (Verbalis et al., 2013).
To ensure that David is attentive to the session and uses all the preventive measures, which he is able to in the healthcare activity, in his daily life, daily, weekly assessment will be carried out so that his understanding and loopholes can be assessed. The assessment can be a questionnaire filling or oral session with the educator nurse (Leung et al., 2012).
Task 5: ISBAR handover
ISBAR handover tool is used as a clinical handover tool so that at the time of handover, a minimum information can be provided to the nurse appointed as care in charge. It comprises Introduction, Situation, Background, Assessment and Recommendation.
Introduction: the name of the patient is David Parker who was admitted to the healthcare facility after visiting the cardiologist. He has been diagnosed with congestive heart failure.
Situation: In cardiac investigation besides his congestive heart failure, he reported breathlessness, developing cough and increasing fatigue, which is indicating towards decreased activity tolerance.
Background: the patient was admitted to the healthcare facility prior to this scenario; due to myocardial infarction however, he was recovered from the situation and was asked to take part in an outpatient rehabilitation program, which he did not attended due to work related pressure.
Assessment: due to his congestive heart failure, his impaired gas exchange could become sever and due to his cardiac output and other physiological factor associated with such situation, his fluid balance could be hampered leading to increased or decreased fluid balance.
Recommendations: He has been recommended with Frusemide orally 40mg twice daily, Digoxin orally 62.5 mcg daily, Ramipril orally 5mg twice daily so that his elevated blood pressure, elevated respiratory rate, impaired gas exchange and fluid balance can be controlled as well as his activity tolerance can be increased.
References
Anderson, T. J., Grégoire, J., Hegele, R. A., Couture, P., Mancini, G. J., McPherson, R., ... & Genest Jr, J. (2013). 2012 update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia for the prevention of cardiovascular disease in the adult. Canadian Journal of Cardiology, 29(2), 151-167. DOI: https://doi.org/10.1016/j.cjca.2012.11.032
Andreucci, M., Solomon, R., & Tasanarong, A. (2014). Side effects of radiographic contrast media: pathogenesis, risk factors, and prevention. BioMed research international, 2014. DOI: https://dx.doi.org/10.1155/2014/741018
Billinger, S. A., Arena, R., Bernhardt, J., Eng, J. J., Franklin, B. A., Johnson, C. M., ... & Shaughnessy, M. (2014). Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 45(8), 2532-2553. DOI: https://doi.org/10.1161/STR.0000000000000022
Connolly Jr, E. S., Rabinstein, A. A., Carhuapoma, J. R., Derdeyn, C. P., Dion, J., Higashida, R. T., ... & Patel, A. B. (2012). Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 43(6), 1711-1737. DOI: https://doi.org/10.1161/STR.0b013e3182587839
Garg, V., Chandorkar, G., Farmer, H. F., Smith, F., Alves, K., & Heeswijk, R. P. (2012). Effect of telaprevir on the pharmacokinetics of midazolam and digoxin. The Journal of Clinical Pharmacology, 52(10), 1566-1573. DOI: https://doi.org/10.1177/0091270011419850
Hur, E., Usta, M., Toz, H., Asci, G., Wabel, P., Kahvecioglu, S., ... & Ok, E. (2013). Effect of fluid management guided by bioimpedance spectroscopy on cardiovascular parameters in hemodialysis patients: a randomized controlled trial. American Journal of Kidney Diseases, 61(6), 957-965. DOI: https://doi.org/10.1053/j.ajkd.2012.12.017
Kemp, C. D., & Conte, J. V. (2012). The pathophysiology of heart failure. Cardiovascular Pathology, 21(5), 365-371.DOI: https://doi.org/10.1016/j.carpath.2011.11.007
Leung, F. W., Amato, A., Ell, C., Friedland, S., Harker, J. O., Hsieh, Y. H., ... & Radaelli, F. (2012). Water-aided colonoscopy: a systematic review. Gastrointestinal endoscopy, 76(3), 657-666. DOI: https://doi.org/10.1016/j.gie.2012.04.467
Shepherd, S. J., Lomer, M. C., & Gibson, P. R. (2013). Short-chain carbohydrates and functional gastrointestinal disorders. The American journal of gastroenterology, 108(5), 707. DOI
https://doi.org/10.1038/ajg.2013.96
Taylor, C. A., Fonte, T. A., & Min, J. K. (2013). Computational fluid dynamics applied to cardiac computed tomography for noninvasive quantification of fractional flow reserve: scientific basis. Journal of the American College of Cardiology, 61(22), 2233-2241. DOI: 10.1016/j.jacc.2012.11.083
Verbalis, J. G., Goldsmith, S. R., Greenberg, A., Korzelius, C., Schrier, R. W., Sterns, R. H., & Thompson, C. J. (2013). Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. The American journal of medicine, 126(10), S1-S42. DOI: https://doi.org/10.1016/j.amjmed.2013.07.006
Vestbo, J., Hurd, S. S., Agustí, A. G., Jones, P. W., Vogelmeier, C., Anzueto, A., ... & Stockley, R. A. (2013). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. American journal of respiratory and critical care medicine, 187(4), 347-365. DOI: https://doi.org/10.1164/rccm.201204-0596PP
Wharton, W., Stein, J. H., Korcarz, C., Sachs, J., Olson, S. R., Zetterberg, H., ... & Jacobson, L. E. (2012). The effects of ramipril in individuals at risk for Alzheimer's disease: results of a pilot clinical trial. Journal of Alzheimer's Disease, 32(1), 147-156. DOI: 10.3233/JAD-2012-120763
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