3898111058100 NUR535 Assessment 2 S2 2024
3898111058100 NUR535 Assessment 2 S2 2024
Assessment Two Nursing Care Plan
Case study 1:Mr. Harinder Kumar
The clinical reasoning cycle is a structured approach for nurses to patient care, involving several steps to ensure comprehensive assessment and management (Ericsson, Whyte and Ward, 2007).
Task 1: Review and Synthesis of the Case Scenario
Patients Condition
Mr. Harinder Kumar, 60 Male, referred to the cardiology for decompensated heart failure (HF) with severe left ventricular systolic impairment due to ischemic heart disease.
Past Medical History:
Type 2 diabetes (T2DM)
Peripheral neuropathy
Peripheral edemaCollect Cues
Objective data:
Extensive peripheral edema.
Weight gain: 12 kg in 2months (87 KG from 75 KG)
BP: sitting 122/58 mmHg, standing 112/55 mmHg
Heart Rate: 70 bpm
SpO2: 97% RA
Temperature: 36.2C.
Subjective Data:
Fatigue and breathlessness with ordinary activities; no shortness of breath at rest, orthopnea, chest pain, or palpitations.
Confirm allergies and identify next-of-kin for care planning (Dougherty et al., 2020; Khknen et al., 2019).
Ensure referral notes and current prescriptions (Toney-Butler & Unison-Pace, 2023).
Process Information
Pathophysiology of the Disease
Ischemic Heart Disease (IHD): IHD occurs when coronary arteries narrow reduces blood flow causing myocardial ischemia (Advocate Health Care, 2023). This can lead to myocardial infarction and weaken the hearts pumping ability (Sangha et al., 2023).
Left Ventricular Systolic Dysfunction: The damage in left ventricles have led in systolic heart failure reducing cardiac output. This activates compensatory mechanisms Renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system, causing fluid retention (Advocate Health Care, 2023).
Decompensated Heart Failure: It refers to inefficient pumping that leads to fluid accumulation in tissues (edema) and lungs (pulmonary congestion) (Advocate Health Care, 2023).
Peripheral Neuropathy in Diabetes: Prolonged high blood glucose damages nerves, reducing mobility and exacerbating heart failure symptoms (Bodman & Varacallo, 2023). It increased venous congestion contributing to breathlessness and fatigue.
Relation of Current Presentation to Past Medical History:
Mr. Kumar's left ventricular impairment results from IHD, with recent weight gain and peripheral edema indicating worsening heart failure (Malik et al., 2023).
Type 2 Diabetes Mellitus (T2DM) accelerates cardiovascular disease through elevated blood sugar levels, worsening heart failure despite insulin treatment (Bodman & Varacallo, 2023).
Diabetic peripheral neuropathy may impair his ability to detect worsening heart failure symptoms. (Bodman & Varacallo, 2023).
Diuretics and RAAS inhibitors, while managing fluid retention, may increase the risk of postural hypotension and electrolyte imbalance.
Identify Problems
Worsening fluid retention and decompensated heart failure.
Fatigue and breathlessness indicate reduced activity tolerance.
Increased risk of pressure ulcers due to reduced mobility and edema (Goyal et al., 2023).
Fall risk from medication side effects and neuropathy.
Risk of hypo/hyperglycemia due to insulin therapy.
Establish Goals
Develop SMART (Specific, Measurable, Achievable, Relevant, Time-bound) goals to focus on what is important (White, 2022).
Reduce fluid overload and stabilize weight.
Gradually improve symptoms and functional capacity.
Maintain skin integrity to prevent pressure injuries.
Minimize fall risk with mobility aids and monitoring.
Stabilize blood glucose levels and prevent further decompensation.
Take ActionPerform ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach and head-to-toe examination, including skin integrity, respiratory effort, and signs of infection. Auscultate for pulmonary congestion (Kleber & Rn, 2024; Ernstmeyer & Christman, 2021).
Assess neurological status using AVPU scale (Alert, Voice, Pain, Unresponsive), Glasgow Coma Scale, and pupillary assessment. Evaluate cognitive function with Mini-Mental State Examination (Toney-Butler & Unison-Pace, 2023; Kleber & Rn, 2024).
Perform urinalysis for proteinuria and kidney issues. Monitor bowel movements and urinary output (Marsden & Pickering, 2015; Toney-Butler & Unison-Pace, 2023).
Request chest X-ray for pulmonary congestion and heart enlargement. Perform Electrocardiogram (ECG) for arrhythmias or ischemic changes (Kleber & Rn, 2024).
Conduct Mini Nutritional Assessment (MNA) and note last oral intake. Assess edema severity using Edema assessment scale (MTG, 2023).
Conduct FRAT (Fall Risk Assessment Tool), pressure ulcer risk (Waterlow scale), and pain (Abbey Pain scale).
Management Plan
Implement ISBAR (Introduction,Situation,Background,Assessment,Recommendation) for structured communication (Clinical Governance Hunter New England Health, 2019).
Plan fluid restriction, dietary changes, and medication review in collaboration with the physiotherapist, doctor, and dietician. Monitor daily weight, urine output, bowel movements, blood glucose levels, and heart failure symptoms.
Refer to physiotherapy for mobility assessment and cardiac rehabilitation. Assess patient's adherence to foot care regimen.
Administer medications as per guidelines, ensuring patient awareness of side effects and symptoms requiring immediate attention.
Involve next of kin in critical care plan discussions and ongoing management.
Evaluate Outcomes
Monitor for decreased edema and stable weight following fluid management and diuretic administration (MTG, 2023).
Assess increased exercise capacity and reduced breathlessness.
Regularly check for skin breakdown and pressure ulcers using the Waterlow scale.
Evaluate improvements in AVPU scale, Glasgow Coma Scale, and cognitive assessments.
Review ECG results for signs of improvement in pulmonary congestion and cardiac function.
Assess nutritional intake and edema using the Mini Nutritional Assessment and Edema assessment scale.
7. Reflect on Process and LearningDiscuss outcomes with the healthcare team to identify areas for improvement. Use reflective models like Gibbs Reflective Cycle to enhance the reflection process (Gibbs Reflective Cycle, 2020).
Task 2 Nursing Care Plan: Mr. Harinder Kumar
Nursing problem: Peripheral oedema
Related to: Decompensated heart failure and fluid retention
Goal of care Nursing interventions Rationale Evaluation
Reduce peripheral edema and stabilize weight within 7 days
Administer diuretics as prescribed
Monitor daily weights, fluid intake/output and sign of electrolyte imbalance. Implement restriction on fluid and sodium intake.
Elevate affected limbs when at rest
Assess for postural hypotension when changing positions
Eliminates excess fluid and reduces oedema (Penn Medicine, 2022).
Helps assess fluid status and effectiveness of treatment. Diuretic therapy can lead to imbalance (Goyal et al., 2023).
Promotes venous return and reduces swelling (Krause, 2014)
Fluid imbalance can lead to postural hypotension, increasing fall risk (Heart Foundation, 2018) Monitor reduction in peripheral oedema, weight, and improvement in mobility and comfort.
Nursing problem: Decreased Activity Tolerance
Related to: Heart failure and fatigue
Goal of care Nursing interventions Rationale Evaluation
Improve cardiac function and exercise tolerance within 14 days
Monitor vitals and fluid status
Administer prescribed ACE inhibitors and beta-blockers
Assess baseline activity tolerance and initiate referral to cardiac rehabilitation program
Provide guidance on safe exercise levels and gradually increase activity as tolerated.
Implement balance training. Use of a walking aid if necessary.
Assesses fluid balance and cardiac function.
Improves heart function and reduces workload (Penn Medicine, 2022).
Establish starting point for care and Improve quality of life and cardiac health (Heart Foundation, 2018).
Ensures safe physical activity and avoid overexertion (Mair et al., 2013)
Improves postural stability and gait, reducing fall risk. It can enhance stability and confidence (Toney-Butler & Unison-Pace, 2023).
Improvement in breathlessness, stabilization of vital signs, and increased activity tolerance
Nursing problem: Risk of HypoglycemiaRelated to: Insulin therapy and limited physical activity
Goal of care Nursing interventions Rationale Evaluation
Maintain blood glucose within target range
Monitor blood glucose levels regularly before meal and insulin administration
Educate on signs and symptoms of hypoglycaemia
Teach proper management of hypoglycaemia
Educate on proper foot care and regular sensation monitoring Allows timely intervention. Synchronizing meals and insulin minimizes the risk of hypoglycemia (World Health Organization, 2023)
Enables early recognition and treatment (Herman et al., 2015)
Empowers patient in self-care.
Promotes early detection of neuropathy progression, which can affect balance and increase fall risk (Diabetes Australia, 2020) Stable blood glucose levels, no hypoglycemics episodes.
Nursing problem: Knowledge Deficit
Related to: Multiple chronic conditions requiring complex management
Goal of care Nursing interventions Rationale Evaluation
Enhance understanding of complex care regimen within hospital stay
Educate on heart failure management
Teach diabetes self-management
Instruct on medication regimen and educate on signs/symptoms requiring medical attention
Teach environmental safety measures to reduce fall risk at home Improves self-management of heart failure (Legg, 2019).
Enhances diabetes control (Diabetes Australia, 2020)
Ensures proper medication adherence and timely seeking of medical help (Australian Commission on Safety and Quality in Health Care, 2024).
Reduces environmental hazards and empowers patient to create a safer living space (Toney-Butler & Unison-Pace, 2023). Patient demonstrates understanding of care regimen and performs proper s
Task 3:Create Patient education strategies and a discharge plan
Discharge Plan
Aspect Details
Transportation Mr Kumar can be transferred by non-medical emergency transport or private vehicle depending on his mobility and fatigue levels accompanied by next to kin or designated caregiver.
Electronic Discharge Summary Complete and send an electronic discharge summary to Mr. Kumar's assigned doctor. Add it to Mr. Kumar's My Health Record, ensuring confidentiality. The summary should include:
Patient identification (Name, DOB, MRN)
Admission and discharge dates
Diagnoses (including discharge diagnosis)
Pathology tests and reports
Current medications and discontinued medications
Allergies and adverse reactions
Hospital/facility information
Primary Care Physician and Consultant Cardiologist details
Author of the discharge summary
Functional Status Assess Mr. Kumar's functional mobility, ADLs, and IADLs. An occupational therapist and physiotherapist should evaluate and recommend appropriate assistive devices (e.g., walker, grab bars) and home modifications. (Toney-Butler & Unison-Pace, 2023).
Financial Confirm insurance covers medications and services. Ensure Mr. Kumar understands any out-of-pocket expenses.
Medications and Instructions Provide a list of medications with dosages and timings (Australia, 2024). Educate on diuretics, insulin, dietary instructions, and fluid limitations.
Follow-up and Referrals Schedule appointments with a cardiologist and GP. Refer to occupational therapy, cardiac rehab, nutritionist, and diabetes education. Arrange home health nurse visits to monitor vital signs and medication compliance. Explanation of fall prevention strategies.
Documentation Obtain acknowledgment of discharge information and address concerns (Toney-Butler & Unison-Pace, 2023). .
Patient Education
1. Medication Management
Strategy:Use the Teach-Back Method
Show Mr. Kumar how to properly take his diuretics and insulin. Include timing, dosage, and any specific instructions.
Ask Mr. Kumar to repeat the steps back to you to confirm understanding.
Provide written instructions and diagrams for clarity.
Rationale:
Ensures Mr. Kumar understands his medication regimen, which is crucial for managing heart failure and diabetes effectively.
Reduces the risk of medication errors.
Evaluation:
Mr. Kumar accurately demonstrates and explains his medication routine.
Follow-up to assess competency and address any questions.
2. Lifestyle Modifications
Strategy:Encourage Self-Monitoring
Provide a template logbook for tracking weight, blood glucose levels, and symptoms.
Discuss the importance of monitoring these parameters.
Plan regular check-ins to review and adjust the care plan as needed.
Rationale:
Empowers Mr. Kumar to take an active role in managing his health.
Helps identify trends allowing for timely interventions.
Evaluation:
Mr. Kumar maintains a consistent log and can communicate changes.
Improved health outcomes through proactive management.
Task 4:Review the patients current medications
Mr. Kumar is prescribed several medications to manage his complex health conditions, including heart failure, ischemic heart disease, and type 2 diabetes. Based on Mr. Harinder Kumar's medication list I have discussed two of it in detail:
Bumetanide
Bumetanide is a loop diuretic that works by acting on the kidneys to increase urine production. It inhibits the reabsorption of sodium and chloride in the ascending loop of Henle and distal renal tubule, leading to increased excretion of water, sodium, chloride, potassium, and hydrogen ions (MIMS Australia, n.d.).
Mechanism of action (Bumetanide, 2024) :
Inhibits the Na-K-2Cl symporter in the thick ascending limb of the loop of Henle.
Prevents the reabsorption of sodium, chloride, and potassium to increase excretion of these electrolytes and water in the urine.
Reduces fluid overload and edema.
Why has Mr. Kumar been prescribed bumetanide?
Bumetanide has been prescribed to treat edema which relieves symptoms like peripheral edema and shortness of breath in heart failure patients.
Side effects (Side Effects of Bumetanide, 2022):
Electrolyte imbalances may lead to hypokalaemia and hyponatremia.
Dehydration and hypotension can cause dizziness especially in older patients.
Bumetanide may raise blood glucose levels, significant for Mr. Kumar's diabetes.
Rarely, ototoxicity can cause hearing impairment in older adults.
Hyperuricemia may worsen gout if Mr. Kumar is prone to it.
Bumetanide can affect kidney function, requiring careful monitoring.
Ramipril
Ramipril is an Angiotensin-Converting Enzyme (ACE) inhibitor that dilates blood vessels, reducing blood pressure and heart workload (MIMS Australia, n.d.).
Mechanism of Action (Chauhan et al., 2023):
Inhibiting the enzyme angiotensin-converting enzyme (ACE) which prevents the conversion of angiotensin I to angiotensin II
Reducing levels of angiotensin II, a potent vasoconstrictor
Decreasing the production of aldosterone, leading to decreased sodium and water retention
Increasing levels of bradykinin, a vasodilator
Causing vasodilation and reducing blood pressure
Decreasing cardiac workload and improving cardiac output
Why has the patient been prescribed this medication?
Ramipril has been prescribed to manage his heart failure and hypertension, which are complications of his ischemic heart disease.
Side effects (Chauhan et al., 2023):
Hypotension may cause dizziness especially when standing up.
A dry cough is a common side effect of ACE inhibitors.
Hyperkalemia is more likely in patients with diabetes or kidney disease.
Although rare - Angioedema can cause serious swelling of the face, lips or tongue.
Kidney function may worsen, particularly for Mr. Kumar with diuretics medicines.
First-dose hypotension can lead to headache or fatigue.
The combined use of diuretics and ACE inhibitors increases the risk of postural hypotension, which, coupled with his peripheral neuropathy, elevates his fall risk.
Suggest a medication that can be used to reduce Mr Kumars peripheral oedema. - Furosemide (Lasix): Loop Diuretic
Mechanism of action (Khan et al., 2023)
Inhibits the Na-K-2Cl symporter in the thick ascending limb of the loop of Henle
Increases sodium and water excretion through reabsorption of sodium and chloride.
Reduces fluid overload and plasma volume decreasing workload of the heart and lower peripheral edema.
Rationale (Khan et al., 2023)
Furosemide is a potent loop diuretic for managing severe fluid retention in heart failure.
Its rapid onset makes it suitable for acute decompensated heart failure.
It may offer better control of Mr. Kumar's extensive peripheral edema than bumetanide.
Furosemide can be administered orally or intravenously, allowing flexible dosing.
Suggestion for temporary withdrawal: Spironolactone (Aldactone)
Rationale (Patibandla et al., 2023):
Spironolactone is a potassium-sparing diuretic and aldosterone antagonist that reduces sodium reabsorption and promotes potassium retention.
For Mr. Kumar's acute fluid retention, a potent loop diuretic (furosemide or bumetanide) would be sufficient.
Spironolactone increases hyperkalemia risk during acute decompensation and potential renal impairment.
Withdrawing spironolactone may improve renal function by reducing electrolyte imbalance risks, particularly hyperkalemia.
While beneficial for long-term heart failure management, spironolactone may be temporarily held until renal function stabilizes and fluid overload is controlled.
Any changes to Mr. Kumar's medication regimen should be made under close medical supervision. Regular monitoring of renal function, electrolytes (especially potassium), and overall clinical status is essential. Decisions should be made in consultation with the treating physician, considering the patient's condition and treatment response.
References
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