NSG2101 Nursing Management

Answers:

Introduction

Clinical reasoning is the process by which the care providers are to collect cues or patient information, process the collected information, point out the patient problems or situation, plan and correspondingly implement appropriate interventions, assess the outcomes, and successively reflect on the entire nursing process. The clinical reasoning cycle is a notable framework that allows nurses to demonstrate problem solving, clinical judgment, clinical reasoning and decision making skills. The present paper is based on the case study of M.G, a 68-year-old female patient whose chief diagnosis is congestive heart failure (CCF). A concept map is provided for the case study and each of steps 1-3 of the clinical reasoning cycle is explained. The purpose is to highlight the physiology presented in the case study.

Concept map

Clinical reasoning cycle applied to the case study

Collect cue/ information

The patient in the present case study is M.G, a 68-year-old female patient who presented to the setting upon diagnosis of congestive heart failure (CHF). The patient had been discharged from the hospital 11 days back, and at present is complaining of shortness of breath and poor mobility due to enlargement of legs. The patient has been found not to adhere to the fluid and salt intake restrictions, and to the medication regime outlined previously. She has gained considerable weight since her discharge. The patient has a family history of her parents dying due to CVA and AMI. While her sister does not have any condition of the cardiovascular system, her brother has coronary artery disease, type II diabetes and HTN.

The patient’s medical history includes hypertension, acute myocardial infarction 4 years ago, chronic renal failure, type 2 diabetes, hyperlipidaemia. In addition, the patient has undergone cholecystectomy and hysterectomy previously. The present vital signs of the patient are P 122 irregular; BP 160/100, RR 26, T 37.3 C, O2 Sats 93% on room air. Chest examination shows widespread consolidation and cardiomegaly. Widespread crepitations are found on chest auscultation. The patient is newly diagnosed with Atrial Fibrillation. Oedema is present with pink skin colour. Further, apical pulse is thready and fast. Radiology results indicate pulmonary congestion. The laboratory test results report potassium 5.3 mEq/L, sodium 145 mEq/L, chloride 100 mEq/L, bicarbonate 27 mEq/L, glucose 11.2 mmol, creatinine 4.5 mg/dL, BUN 4.3 mg/dL, magnesium 1.9 mEq/L.

Process information

The patient’s primary diagnosis in the present case is congestive heart failure (CHF) which is a chronic progressive condition affecting the pumping action of the heart muscles. In CHF there is accumulation of fluid around the heart due to the underlying causes. CHF develops when the ventricles are incapable of pumping blood to the body in sufficient volume. The blood supply coming from the venous system is not met, and eventually, there is an accumulation of blood and other fluids in the lungs, abdomen, liver and parts of lower body (Oikonomou, Tousoulis, Siasos, Zaromitidou, Papavassiliou, & Stefanadis, 2011). The patient has been complaining of shortness of breath and enlarged legs. In case of left-sided CHF, the main symptoms are pulmonary edema and fluid accumulation in the lungs, and shortness of breath due to the fluid accumulation. Increase of weight by 5 kg is indicative of body swelling due to fluid accumulation.

The patient has a medical history of type II diabetes, coronary artery disease that is acute myocardial infarction, and HTN, all of which are important risk factors of CHF. When the patient’s blood pressure is higher than the normal value, CHF is common. Coronary artery diseases are also a contributor to CHF. Cholesterol and other fatty substances block the coronary arteries, leading to narrowing of the same. As a result, blood flow is restricted in the body. While CHF is mostly due to heart-related conditions, other conditions, such as diabetes and obesity, can lead to CHF (Horwich & Fonarow, 2010). Further, the patient has not adhered to the fluid and salt intake restrictions following her previous hospital admission. This has aggravated the symptoms related to CHF. Salt and fluid restriction is recommended for those individuals living with CHF in global guidelines, since a pool of scientific evidence supporting it is strong (Fabrício, Gentil, Amato, Marques, & Schwartzmann, 2016). Restrictions of dietary sodium are a common and modifiable precipitant of admissions due to HF. High consumption of sodium is a primary modifiable factor for promotion of hypertension. Excess salt consumption leads retention of water, worsening the fluid buildup that happens in case of heart failure (Doukky, et al., 2016).

The lifetime risk for development of CFH doubles with blood pressure more than 160/100 (Ettehad, et al., 2016). In the present case, the patient is having BP of 160/100 and P 122. Rapid and irregular heartbeat is a common condition associated with CHF. The weakened heart tries to beat faster for sending more blood through your system, leading to irregular heartbeat (Morton, Fontaine, & Hudak, 2017). The patient’s RR 26 is also abnormal, and researchered, patients CHF often develop breathing abnormalities (Garde, Sörnmo, Jané, & Giraldo, 2010). Chest examination of the patient indicates Cardiomegaly, a condition of the heart in which it is enlarged. This condition has a strong association with CHF, and the risk factors for the same include diabetes and hypertension. Examining the blood serum chemistry report it can be stated that the glucose level at11.2 mmol and creatinine level at 4.5 mg/dL are above reference range. While the normal value of creatinine is 1.0-2.0 mg/dL, the normal value for glucose is 4.0 to 6.0mmol/L for fasting state (Lindblad, Eickhoff, Forslund, Isaksson, & Gustafsson, 2015). This indicates chronic renal failure and poorly managed diabetes.

The patient has recently been diagnosed with Atrial fibrillation which is the irregular and rapid heart rate in individuals, increasing the risk of heart failure stroke, and other heart-related complications (Kirchhof, Benussi, Kotecha, Ahlsson, & Atar, 2016). Atrial fibrillation and congestive heart failure are known to be morbid conditions sharing common risk factors and these two conditions frequently coexist. Research indicates that each of the two conditions predisposes to the other, increasing the risk for mortality.

Identify problems

Processing of the collected information about the patient has helped in highlighting the patient problems aligned to which nursing interventions are to be given. In the present case, the main patient problems/issues are shortness of breath, poorly managed diabetes, hypertension, renal failure and improper salt and fluid intake.

Bibliography

Doukky, R., Avery, E., Mangla, A., Collado, F. M., Ibrahim, Z., Poulin, M. F., et al. (2016). Impact of dietary sodium restriction on heart failure outcomes. . JACC: Heart Failure , 4 (1), 24-35.

Ettehad, D., Emdin, C. A., Kiran, A., Anderson, S. G., Callender, T., Emberson, J., et al. (2016). Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. The Lancet , 387 (10022), 957-967.

Fabrício, C. G., Gentil, J. R., Amato, C. A., Marques, F., & Schwartzmann, P. V. (2016). Prospective, Randomised and Blinded Clinical Study Testing Two Levels of Dietary Sodium Intake in Patients with Acute Decompensated Heart Failure. Journal of Cardiac Failure , 22 (8), 55.

Garde, A., Sörnmo, L., Jané, R., & Giraldo, B. F. (2010). Breathing Pattern Characterization in Chronic Heart Failure Patients Using the Respiratory Flow Signal. Annals of biomedical engineering , 3572-3580.

Horwich, T. B., & Fonarow, G. C. (2010). Glucose, obesity, metabolic syndrome, and diabetes: relevance to incidence of heart failure. Journal of the American College of Cardiology , 283-293.

Kirchhof, P., Benussi, S., Kotecha, D., Ahlsson, A., & Atar, D. .. (2016). ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.  EP Europace , 18 (11), 1609-1678.

Lindblad, F., Eickhoff, M., Forslund, A. H., Isaksson, J., & Gustafsson. (2015). Fasting blood glucose and HbA1c in children with ADHD. Psychiatry research , 226 (2), 515-516.

Morton, P. G., Fontaine, D., & Hudak, C. M. (2017). Critical care nursing: a holistic approach. Lippincott Williams & Wilkins.

Oikonomou, E., Tousoulis, D., Siasos, G., Zaromitidou, M. A., Papavassiliou, A. G., & Stefanadis, C. H. (2011). The role of inflammation in heart failure: new therapeutic approaches. . Hellenic J Cardiol , 30-40.