NUR250 Medical Surgical Nursing 1
Question:
Task 1: Patient assessment
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
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.
Task 2: Care planning
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
for the care plan (but not the other tasks) along with appropriate journal articles.
Online nursing care plans are NOT acceptable and will not be accepted as references.
Dot points may be used in the care plan template
Rationales must be appropriately referenced
Task 3: Medication management
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,
o Frusemide orally 40mg twice daily
o Digoxin orally 62.5 mcg daily
o Ramipril orally 5mg twice daily
Identify and explain
o The specific nursing responsibilities associated with administering each medication
o How you will monitor David for expected, side and adverse effects of each medication.
Task 4: Patient education
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.
maintaining his cardiac output:
o 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,
what he needs to do.
Explain
o Why the topic is an important aspect of David’s care
o How you will ensure that David knows and understands why it is important and knows what he
needs to do
Task 5: ISBAR handover
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:
know about David for continuation of nursing care.
Your handover must:
Adhere to the legal and professional nursing standards for documentation
Demonstrate person-centred care
Be in appropriate professional language
Contain NO abbreviations or nursing jargon
Answer:
Task 1: Patient assessment
The appropriate nursing assessment in this patient will include a complete cardiovascular assessment, pain assessment and assessment of risk factors (Brunner, 2010). These are the priority assessments in this patient presenting with features of heart failure in a previous myocardial infarction. They are at increased risk of recurrence of cardiovascular disease hence risk factors that precipitate heart failure or worsen morbidity need to be assessed (Elliott & Coventry, 2012). Pain is a vital component of cardiovascular ischemia and in-hospital stay hence assessment of pain is warranted.
The cardiovascular examination involves physical, functional and psychosocial assessment by collecting objective and subjective data. Physical assessment starts by measuring the blood pressure, heart rate, assessment of edema, peripheral circulation, followed by inspection, palpation, and auscultation of the precordium and a 12 lead ECG recording (Glynn, Drake, & Hutchison, 2012). Due to the profound effect and interrelation with the respiratory system, a respiratory assessment should be done.
Blood pressure measurement should be done with the patient seated, using the right size cuff and a working sphygmomanometer (Glynn et al., 2012). Automated machines do exist if the intervals between measurements are small. Normal blood pressure should be a systolic pressure of 130 to 90mmHg and diastolic of 90 to 60 mmHg with a pulse pressure of 30 to 50 mmHg. The patient’s BP was 102/84 which was within the normal range. In heart failure, hypotension is a major concern due to reduced cardiac output (Böhm et al., 2010).
The pulse rate should be measured by assessing the carotid, radial, femoral popliteal and dorsalis pedis pulses (Glynn et al., 2012). In cardiogenic shock, tachycardia is expected as sympathetic discharge in compensation tries to maintain perfusion. The normal pulse is 60 to 100 beats per minute. The patient has a tachycardia of 118 beats per minute.
Assessment of edema is also warranted. Pedal edema is measured at bony prominences such as sternum and malleoli by blanching and noting for pitting (Douglas, Nicol, & Robertson, 2013). Weight should measured at the same time daily to assess weight changes. Peripheral circulation is assessed by measuring the capillary refill, which should be less than 3 seconds.
Inspection for a hyperactive precordium, palpation of the apex beat and auscultation of heart sounds will show any abnormalities of cardiac function (Douglas et al., 2013). A respiratory assessment by auscultating for basal crepitations and rales may pick signs of pulmonary edema expected in this patient. A 12 lead ECG should be conducted to assess for abnormal rhythm, rate, and features of heart failure. It is usually indicated in ischemia and infarction as it categorizes infarction as STEMI or non-STEMI (Glynn et al., 2012).
Pain assessment is warranted in this patient. The assessment should include the site of pain, character, aggravating and relieving factors, radiation and associated factors (Goodlin et al., 2012). This patient is at an increased risk of recurrent myocardial infarction hence recognition of angina is paramount (Turk & Melzack, 2011).
The patient has several lifestyle risk factors for cardiovascular disease including physical inactivity, smoking, alcohol use and unhealthy diet. These should be assessed and the level of each quantified. These risk factors play a crucial role in clinical intervention and a baseline for each will guide such interventions.
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 edema.
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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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· Start a 24-hour intake and output chart to monitor the input and output.
· Monitor the patient’s urine output and note the amount, color and time of day when they urinate.
· Maintain the patient in a semi- Fowler’s position during bed rest or maintain chair rest.
· Weight the patient at the same time daily.
· Assess for signs of fluid overload including distended neck veins, ascites, pedal edema with or without pitting and anasarca.
· Assess the patients breathing by auscultating the breath sounds noting any added sounds such as wheeze, crackles, rales or decreased air entry. Note for dyspnoea, orthopnoea, cough and paroxysmal nocturnal dyspnoea.
· Monitor the patient’s blood pressure or if available the central venous pressure.
· Palpate the patient’s abdomen noting the presence of abdominal distension, right upper quadrant pain or abdominal tenderness.
· Administer the patient’s medication as indicated including furosemide.
· Maintain the patient’s fluid and sodium restriction as indicated.
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· Monitoring helps calculate balanced input accordingly. Close monitoring is also warranted since diuretic therapy in heart failure causes rapid fluid losses with hypovolemia despite signs of overload such as edema and ascites (Glynn et al., 2012).
· Reduced urine volume and concentrated urine represent reduced glomerular filtration usually seen in renal hypoperfusion due to heart failure. The amount may increase during the night due to laying recumbent and increase during the day (Marenzi et al., 2010). · Laying recumbent usually increases the glomerular filtration rate and is thought to decrease ADH production. This enhances urine production and reduces fluid overload (Marenzi et al., 2010).
· This helps in monitoring changes in edema. Diuretics can also cause sudden shifts in fluid status (Glynn et al., 2012).
· Heart failure causes salt and water causing fluid overload that will manifest venous engorgement and the formation of edema. With increased congestion associated right heart failure causes systemic edema that manifests as anasarca (Glynn et al., 2012).
· These represent signs of pulmonary edema and congestion and represent left heart failure. They may be slow in onset in right heart failure (Glynn et al., 2012).
· Hypotension represents cardiogenic shock with a reduction in cardiac output. Hypertension may set in in the event of fluid overload (Kim, Susan, Scott, & Heddwen, 2010) · Fluid overload with venous congestion may lead to hepatomegaly and pain with ascites (Glynn et al., 2012).
· Diuretics such as furosemide inhibit sodium and water retention hence improving fluid overload status (Katzung, Masters & Trevor, 2012).
· This reduces the fluid overload and prevents the reaccumulation of fluid.
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· Balanced input and output chart throughout the day
· Improved urine output that can be explained by intake.
· Improved urine output throughout the day.
· Constant weight without sudden shifts in the figures.
· Resolution of edema, distended veins, and ascites.
· Normal breathing without adventitious sounds.
· Blood pressure within the normal range
· Soft not distended or tender abdomen with normal values of liver function tests.
· Normalization of vital sign and resolution of signs of fluid overload with balanced fluid status.
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Nursing problem: Impaired gas exchange |
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Underlying cause or reason: alveolar membrane changes due to a collection of fluid into the alveoli or into the interstitial.
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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Demonstrate an improvement in gaseous exchange by the end of the shift
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· Assess the respiration by auscultating the breath sounds noting any added sounds such as wheeze or crackles.
· Instruct the patient in the proper means of coughing and also on deep breathing.
· Encourage the patient to change position frequently.
· Encourage bed rest with the bed elevated at 20 to 30 degrees.
· Monitor the values of pulse oximetry and arterial blood gases.
· Administer oxygen as prescribed.
· Administer medication as indicated for example furosemide. |
· These represent signs of pulmonary edema and congestion and represent left heart failure. They may be slow in onset in right heart failure (Kim et al., 2010).
· Coughing clears the airway while deep breathing helps with oxygen delivery to the alveoli (Kim et al., 2010).
· This helps in the removal of secretions which is important in preventing pneumonia and atelectasis (Kim et al., 2010).
· This facilitates maximum air entry into the lungs and the bed rest reduces the metabolic need and subsequent oxygen consumption (Kim et al., 2010). · These values show hypoxemia which can be marked by heart failure and pulmonary edema. ABGs will also show respiratory compensation in metabolic derangements (Kim et al., 2010).
· Increasing the concentration of oxygen at the alveoli membrane increases the diffusion gradient and help in correcting the hypoxemia (Kim et al., 2010). · Diuretics such as furosemide inhibit sodium and water retention hence improving fluid overload status. This also has an effect on pulmonary edema (Katzung et al., 2012).
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· Patient demonstrates normal breath sounds with no adventitious sounds.
· Patient demonstrates proper deep breathing exercises and coughing.
· patient exhibits normal breathing with no added sounds.
· Patient values show no hypoxemia such as pulse oximetry of 97% and above.
· Patient values show no hypoxemia such as pulse oximetry of 97% and above
· Patient values show no hypoxemia such as pulse oximetry of 97% and above
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Nursing problem: Activity intolerance |
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Underlying cause or reason: The imbalance between the supply of oxygen and the delivery or prolonged bed rest.
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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The patient will be able to participate in his desired activities and meet self-care needs. |
· Assess the patient’s vital signs immediately after a period of activity
· Assess the patient’s level of fatigue and activity intolerance. Also, document his daily activities.
· Encourage adequate bed rest and plenty of sleep.
· Assist the patient with ambulation and self-care activities whenever he is unable to.
· Refer the patient to a proper physiotherapist to assist with his appropriate exercises.
· Implement the patient’s graded cardiac rehabilitation and activity program.
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· Circulatory failure in a compromised myocardium may be evidenced by the inability to increase the stroke volume according to requirements which may manifest as tachycardia and increased oxygen demands (Kemps et al., 2010).
· Level of fatigue can be commensurate with the hemodynamic instability. Assessing activity level provides a baseline for intervention (Kemps et al., 2010).
· Rest reduces myocardial oxygen requirements, metabolic requirements and reduces fatigue (Kemps et al., 2010).
· This support prevents overexertion which might worsen the intolerance and also prevents adverse events such as falls.
· Multidisciplinary approach enhances best care and recovery.
· These programs strengthen and improve the cardiac function and are tailored to patient needs.
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· The normalization of vital signs on activity.
· Improved activity tolerance as the patient can carry out desired activities and self-care needs without restriction.
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Task 3: Medication management
The patient is on anti-failure medication with ramipril, digoxin, and furosemide. These are among the drugs recommended for management of heart failure.
Furosemide 40mg PO twice daily
Furosemide is a loop-diuretic that functions to reduce fluid overload in heat failure. It functions as a diuretic at the kidney to enhance salt and water excretion thus reducing fluid accumulation (Katzung et al., 2012). Nursing responsibility during medication with furosemide should include assessment of fluid balance and appropriate dosing. Drug allergy should be asked for and any contraindications such as kidney disease and liver disease noted. Side effects include nausea, vomiting, dizziness, and bleeding.
Digoxin 62.5mcg PO daily
Cardiac glycosides have been used in heart failure for years, with digoxin being one of them. It is a positive inotrope that improves cardiac contractility thus improving cardiac output and perfusion in heart failure (Katzung et al., 2012). Digitalis toxicity is a recognized adverse effect when using this drug and can be fatal. Monitoring of dosage and adverse effects is an important nursing responsibility. They include a headache, dizziness, arrhythmias, blurred vision and confusion. The patient should be instructed to verbalize any of these side effects if they occur.
Ramipril 5mg PO twice daily
Ramipril is an angiotensin-converting enzyme blocker with profound action on smooth muscle causing vasodilation. It inhibits the formation of angiotensin II which is a vasoconstrictor thus causing vasodilation (Katzung et al., 2012). It has a role in heart failure as it improves perfusion by eliminating reflex vasoconstriction. The nurse should ensure no drug allergies in the patient exist and no contraindication are present in the patient. Dosage and monitoring of therapy should also be done.
Task 4: Patient education
Smoking is among the modifiable risk factors for most cardiovascular diseases. Smoking cessation should be considered in any patient with or without cardiovascular disease as it is unhealthy and has been implicated in many systemic diseases and cancers (US Department of Health and Human Services, 2014). The patient could enroll in a rehabilitation program that is equipped with support and medication to ensure smoking cessation, combating of withdrawal and positive behavior modification (Thomas, 2012; Stead et al., 2013). To make sure David understand the teaching, a teach-back method of patient education should be employed (Tamura-Lis, 2013). In this method, the patient is taught the health effects of smoking, complications, and hazards and given alternatives and options. They are then instructed to teach the health professional what they have learned. Effective understanding is considered to be achieved if David can correctly teach the nurse what he learned.
Task 5: ISBAR handover
Introduction
I am —————— a registered nurse in this department handing over Mr. David Parker, a patient who was referred from the cardiology clinic under Dr——————– with a diagnosis of chronic heart failure after presenting with dyspnoea at rest.
Situation
The patient was received unstable in the ward following the referral from cardiology.
Background
He is a patient who had been in our cared before due to a myocardial infarction. He had been discharged through a rehabilitation facility. However, he refused to attend the program and also refused diet guidelines as he did not eat the low-fat diet prepared by his wife. Other directives which he ignored included cessation of smoking and alcohol use. His medication included ramipril, digoxin and furosemide.
Assessment
His vitals were as follows: tachycardia of 118 beats per minute, tachypnoea of 24 breaths per minute with a low oxygen saturation of 92%. His other vitals were within normal with a blood pressure of 102/84 and temperature of 36.5oC. He had dyspnoea at rest, a cough and was fatigued.
Recommendation and plan
The patient was put on 1000 ml fluid restriction which should be maintained. Monitor input and output and administer medication as charted
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.
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.
Tamura-Lis, W. (2013). Teach-back for quality education and patient safety. Urologic Nursing, 33(6), 267.
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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