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Patient Background

Assessment: Nursing care of a person in a medical surgical setting

Meet David Parker.

You have cared for him previously when he was admitted to your ward following a myocardial infarction.

Source: pexels.com

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.

David’s regular medication, Ramipril, has been documented on his medication chart and he has also been commenced on new medications, frusemide and digoxin. The cardiologist has ordered a 1000ml per day fluid restriction for David.

Temperature

36.5oC

Heart rate

118 beats per min

Blood pressure

102/84 mmHg

Respiration

24 breaths per min

O2 saturations

92% on room air


David has been admitted to your ward and you will be caring for him today.

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.

And

For each assessment you have identified explain:

  • How specifically you will conduct the assessment
  • Why the assessment is specifically relevant to David’s care during your shift.

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

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:
  • Frusemide orally 40mg twice daily o Digoxin orally 62.5 mcg daily

o  Ramipril orally 5mg twice daily

And

  • Identify and explain
  • The specificnursing responsibilities associated with administering each medication
  • How you will monitor David for expected, side and adverse effects of each medication.

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:

  • Physical activity guidelines o Smoking cessation

o  Stress minimisation

o  Reducing excess fluid volume

Select one (1) of the topics above and, in grammatically correct sentences and topic paragraphs,

  • Identify thespecific information you will explain to David about the topic including recommendations on

what he needs to do.

And

  • Explain
  • Why the topic is an important aspect of David’s care
  • How you will ensure that David knows and understands why it is important and knows what he needs to do

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 writtenhandover that clearly and succinctly outlines the important information that staff need to know about David for continuation of nursing care.
Patient Background

Patient assessment on admission to the ward should include cardiovascular assessment inclusive of vital signs, respiratory assessment and pain assessment. These are the priority assessments that will guide David’s management. From these assessments, crucial information such as deterioration in his condition or improvement can be noted (Brunner, 2010). They can also be used to provide a basis for further intervention.

The cardiovascular assessment will involve the basic format of inspection, palpation, and auscultation with measurement of vital signs and other cardiac markers of disease (Glynn, Drake, & Hutchison, 2012). The vital signs are the most accurate predictors of patient deterioration in the hospital setting (Elliott & Coventry, 2012). David presented with heart failure due to a previous myocardial infarction and failure of adherence to heart failure therapy. Heart failure manifests as inadequate circulation and cardiogenic shock. The expected vitals in heart failure include tachycardia and hypotension (Brunner, 2010).  Vital signs parameter will accurately monitor treatment, shows the signs of the underlying pathology and show deterioration.

David has a blood pressure of 102/84, a heart rate of 118 beats per minute, and an oxygen saturation of 92%. Tachycardia is a result of cardiogenic shock compensation as the body activates sympathetic systems to try and maintain adequate perfusion. This, however, comes at a cost as cardiac muscle metabolic needs increase due to increased workload leading to further predisposition to ischemia. Patients whose vital signs are deranged have an increased rate of mortality and morbidity (Böhm et al., 2010).

The respiratory examination follows the same sequence of inspection, palpation, percussion, and auscultation (Douglas, Nicol, & Robertson, 2013). Increased effort of breathing is noted on inspection. This could involve use of accessory muscles, increased respiratory rate, cyanosis, nasal flaring and chest wall indrawing (Glynn, Drake, & Hutchison, 2012). Percussion is an important step as chest pathology can be picked by the percussion note. David presents with heart failure that is a common cause of pulmonary edema and infiltration of the lungs with fluid (Glynn, Drake, & Hutchison, 2012). This can be assessed on percussion as fluid has a dull percussion note. The depth and character of breath sounds is also a good indicator of respiratory pathology and deterioration.

David has an increased risk of recurrent myocardial infarction. Pain assessment is therefore an important component of his assessment (Goodlin et al., 2012). The nature, site, radiation, aggravating factors, relieving factors and character of any pain should be noted. Angina pain is usually crushing pain in the centre of the chest, usually very severe and radiates to the shoulder (Turk & Melzack, 2011). This is characteristic and could point to an impending infarction. Other pain rating tools can be used to assess his pain including verbal rating scales that rate his pain on a scale of 1-10. Objective assessments combined with patient accounts should be used. They include insomnia, restlessness, facial grimacing and anxiety (Turk & Melzack, 2011).

Importance of Medication Management for Nurses

Nursing Care Plan:  David 

Note:  Dot points recommended in care plan.   Click and type in each cell, clickenter in a cell to make it longer. Do not remove text from the template.

A reminder that all rationales must be referenced  

Nursing problem: Imbalanced fluid volume

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 odema.

Goal of care

Nursing interventions/actions

Rationale

Indicators your plan is working

Decrease fluid volume and maintain fluid balance throughout the shift.

· Monitor patient David’s urine output by placing a urinary catheter.

· A 24-hour fluid chart should be started and balanced for intake and output.

· Assess David for signs of fluid overload including pitting edema, generalized body edema, distended neck veins and high-volume peripheral pulses.

· Assess for David’s respiration including any added sounds and rate of respiration.

· Monitor David’s blood pressures and heart rate.

· Give David’s medication and fluid restriction as prescribed including:

o Furosemide

o 1000 ml fluid restriction

· Heart failure is syndrome that causes deranged fluid balance through water and salt retention, a function of the kidneys. Shock will also reduce renal perfusion reducing the urine output (Marenzi et al., 2010). A urine catheter allows for monitoring of output and calculating a balanced input.

· The patient’s delicate fluid needs in the setting of heart failure require close monitoring (Katzung, Masters & Trevor, 2012). A fluid chart is the best way of monitoring to avoid overload or deficits.

· Heart failure will lead to consequence offluid retention and this can lead to fluid overload evidenced by venous congestin such as high-volume pulses, distended neck veins and, leg edema and in some cases anasarca. Movement of fluid into the interstitial space gives rise to limb edema and anasarca (Glynn, Drake, & Hutchison, 2012).

· Pulmonary edema is a consequence of heart failure as fluid fills the airspaces. This can manifest as added sounds on assessment such as basal crepitations (Glynn, Drake, & Hutchison, 2012).

· Shock states will manifest as tachycardia and variations in blood pressure. Monitoring these vitals is crucial in assessing deterioration or improvement (Kim, Susan, Scott, & Heddwen, 2010).

· This is a diuretic that will increase sodium and water excretion reducing fluid overload (Katzung, Masters & Trevor, 2012).

· Fluid restriction is a means of ensuring fluid overload does not occur increasing the cardiac workload and worsening angina.

· By the end of the day David’s urine output should balance his input.  

· David’s fluid chart should show a balance in fluids as input and output should be relatively equal.

· David lacks signs of increased fluid volume.

· David’s chest is clear with a normal respiratory rate.

· David’s vitals are within normal range.

· David’s vital signs normalize to heart rate of less than 100 and a blood pressure of 90/60 to 130/90.

Nursing problem: Impaired gas exchange

Underlying cause or reason:

Heart failure causing increased accumulation of fluid in the alveolar spaces and increased airway inflammation.

Goal of care

Nursing interventions/actions

Rationale

Indicators your plan is working

Improvement in the gaseous exchange in 24 hours.

· Monitor David’s vital signs including David’s respiratory rate

· Assess signs of impaired ventilation including cyanosis on the mucous membranes, skin and nail beds

· Elevate David’s bed and encourage him to change positions frequently

· Encourage David to have adequate rest such as adequate sleep and bed rest.

Administer oxygen therapy as charted

· Impaired gaseous exchange will lead to increased respiratory rate as the body tries to overcome the reduced oxygen saturation in the body (Kim, Susan, Scott, & Heddwen, 2010).

· Hypoxia will lead to cyanosis, a sign of impaired systemic ventilation.  (Kim, Susan, Scott, & Heddwen, 2010).

· Elevation of the bed increases the inspiration capacity and allows for secretions to drain hence improving the gaseous exchange.

· This will lead to reduction in the metabolic needs of the body and also reduce the oxygen needs lowering fatigue.

· High flow, 100 % oxygen increases the gaseous exchange by increasing the partial pressure of oxygen within the alveoli (Kim, Susan, Scott, & Heddwen, 2010).

· The normal respiratory rate of 12-20 breaths per minute.

· The absence of cyanosis on David’s mucous membranes or nail beds.

· David shows normal respiration.

· David reports adequate rest with no fatigue

· David shows improved vital sign such as oxygen saturation.

Nursing problem: Activity intolerance

Underlying cause or reason:

Heart failure causing an imbalance between the oxygen supply and the demand because of the decreased cardiac output.

Goal of care

Nursing interventions/actions

Rationale

Indicators your plan is working

There will be improvement in David’s activity tolerance in 24 hours

· Note David’s level f activity and activity tolerance.

· Encourage reduction in activity and attaining of adequate sleep and rest.

· Encourage David to perform activities and ambulation but if unable assist him with ambulation

· Assess David’s response to activity look out for any symptoms of intolerance. Also encourage him to speak up about symptoms if they occur.

· Refer David to a professional such as a physiotherapist to help him with exercise intolerance.

· Administer medications as charted including digoxin.

· This will provide baseline data on his tolerance and activity level and guide interventions (Kemps et al., 2010)

· Reducing activity lowers the metabolic rate and cardiac workload hence improving outcomes (Kemps et al., 2010)

· This will reduce adverse events such as falls that cause more harm.

· This provides a good monitor for improvement or worsening of symptoms. (Kemps et al., 2010).

· This approach is multidisciplinary and improves outcomes and David will receive the best care possible.

· Treatment of heart failure will improve perfusion and reduce his activity intolerance.  (Katzung, Masters & Trevor, 2012).

David reports improvement in exercise tolerance and can carry out prescribed exercise without symptoms.


Furosemide 40mg PO twice daily

Loop diuretics such as furosemide have a recognized role in heart failure management. They act by enhancing salt and water excretion hence reducing fluid overload in heart failure patients (Katzung, Masters & Trevor, 2012). The drug is fairly well tolerated but side effects such as dizziness, nausea, vomiting, headache and bleeding can occur. It is the duty of the nurse to make sure the patient is aware of such side effects. The nurse should also make sure furosemide is not administered to any patient who has an allergy to it (Katzung, Masters & Trevor, 2012). Contraindicatin to furosemide use include liver disease, renal failure or metabolic derangements.

Digoxin 62.5mcg PO daily

Digoxin is a cardiac glycoside that improves cardiac output by increasing the force of contraction of the heart (Katzung, Masters & Trevor, 2012). This is beneficial in a patient with heart failure as perfusion is improved and distal organ damage due hypoperfusion id reversed. (Kim, Susan, Scott, & Heddwen, 2010). Close monitoring is required in digoxin use as toxicity due to it is fatal. It is the responsibility of the nurse to titrate the correct dose, make sure no allergies to digoxin exist and monitor therapy. Contraindications to digoxin use include recent myocardial infarction, liver disease and kidney failure. The side effects that the patient needs to be aware of include dizziness, tachycardia, nausea, vomiting, blurred vison and confusion (Katzung, Masters & Trevor, 2012). The nurse should make sure the patient is well informed about these effects and to verbalize any complaints.

Ramipril 5mg PO twice daily.

Ramipril is an angiotensin-converting enzyme inhibitor used for the treatment of heart failure, hypertension, and coronary syndromes. Its mechanism of action includes the inhibition of synthesis of angiotensin II by blocking the enzyme responsible which is angiotensin-converting enzyme. Angiotensin II is a strong vasoconstrictor hence this drug will cause vasodilation improving the peripheral resistance and thus tissue perfusion and coronary perfusion. (Katzung, Masters & Trevor, 2012).  The nurse should be responsible for dosing titration and teaching the patient about drug allergy and side effects.

Smoking cessation

Smoking is one of the most common modifiable risk factors for cardiovascular disease (Thomas, 2012). Apart from its effects in the cardiovascular system, it is leading risk factors for most cancers especially respiratory and gastrointestinal cancers (US Department of Health and Human Services, 2014). David should be made aware of the added benefits of quitting smoking, as cardiovascular disease is among the leading causes death and morbidity worldwide. David will be provided with information on help centres where smoking addiction is treated (Stead et al., 2013).

Care Plan for Nursing Problems

Multiple media formats will be used to pass information to him to make sure that this aspect of risk management is understood by David, including video presentations, pamphlets, news articles and real examples of the benefits accrued. David will then be instructed to verbalize what he has learned and if the information appealed to him. This will help him in behaviour modification.

I am ----------, a registered nurse, handing over, Mr. David Parker, a patient we are managing for chronic heart failure. He is a referral from the cardiology clinic where he was attending under Dr.------------- presenting with dyspnoea at rest.

Situation

He was admitted stable from the clinic to the ward.

He had been seen a few months prior for myocardial infarction and discharged to a heart failure centre. He however is non-compliant to that directive and also refuses to take low-fat food made by his wife, Sophie. He still smokes and drinks alcohol. His medication include furosemide, ramipril, and digoxin.

He has dyspnoea at rest and has a cough and is increasingly fatigued. His blood pressure was 102/84, respiratory rate 24 breaths per minute, her heart rate at 118, oxygen saturation of 92% and a temperature of 36.50c.

David is on treatment with ramipril, digoxin, and furosemide for chronic heart failure with 1000ml fluid restriction. Monitor his fluid intake and output and make sure he takes his medication.

References

Böhm, M., Swedberg, K., Komajda, M., Borer, J. S., Ford, I., Dubost-Brama, A., ... & SHIFT Investigators. (2010). Heart rate as a risk factor in chronic heart failure (SHIFT): the association between heart rate and outcomes in a randomized placebo-controlled trial. The Lancet, 376(9744), 886-894.

Brunner, L. S. (2010). Brunner & Suddarth's textbook of medical-surgical nursing (Vol. 1). Lippincott Williams & Wilkins.

Douglas, G., Nicol, F., & Robertson, C. (Eds.). (2013). Macleod's Clinical Examination E-Book. Elsevier Health Sciences.

Elliott, M., & Coventry, A. (2012). Critical care: the eight vital signs of patient monitoring. British Journal of Nursing, 21(10), 621-625.

Glynn, M., Drake, W. M., & Hutchison, R. (2012). Hutchison's clinical methods: an integrated approach to clinical practice. Edinburgh: W.B. Saunder

Goodlin, S. J., Wingate, S., Albert, N. M., Pressler, S. J., Houser, J., Kwon, J., ... & PAIN-HF Investigators. (2012). Investigating pain in heart failure patients: the pain assessment, incidence, and nature in heart failure (PAIN-HF) study. Journal of cardiac failure, 18(10), 776-783.

Hands, C., Reid, E., Meredith, P., Smith, G. B., Prytherch, D. R., Schmidt, P. E., & Featherstone, P. I. (2013). Patterns in the recording of vital signs and early warning scores: compliance with a clinical escalation protocol. BMJ Qual Saf, bmjqs-2013.

Katzung, B. G., Masters, S. B., & Trevor, A. J. (2012). Basic and Clinical Pharmacology (LANGE Basic Science). McGraw-Hill Education.

Kemps, H. M., de Vries, W. R., Schmikli, S. L., Zonderland, M. L., Hoogeveen, A. R., Thijssen, E. J., & Schep, G. (2010). Assessment of the effects of physical training in patients with chronic heart failure: the utility of effort-independent exercise variables. European journal of applied physiology, 108(3), 469-476.

Kemps, H. M., Schep, G., Zonderland, M. L., Thijssen, E. J., De Vries, W. R., Wessels, B., ... & Wijn, P. F. (2010). Are oxygen uptake kinetics in chronic heart failure limited by oxygen delivery or oxygen utilization? International journal of cardiology, 142(2), 138-144.

Kim, E. B., Susan, M. B., Scott, B., & Heddwen, L. B. (2010). Ganong’s review of medical physiology.

Marenzi, G., Assanelli, E., Campodonico, J., De Metrio, M., Lauri, G., Marana, I., ... & Bartorelli, A. L. (2010). Acute kidney injury in ST-segment elevation acute myocardial infarction complicated by cardiogenic shock at admission. Critical care medicine, 38(2), 438-444

Stead, L. F., Buitrago, D., Preciado, N., Sanchez, G., Hartmann-Boyce, J., & Lancaster, T. (2013). Physician advice for smoking cessation.

Thomas, D. (2012). Smoking and cardiovascular diseases. La Revue du praticien, 62(3), 339-343.

Turk, D. C., & Melzack, R. (Eds.). (2011). Handbook of pain assessment. Guilford Press.

US Department of Health and Human Services. (2014). The health consequences of smoking—50 years of progress: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 17.

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