Planning Nursing in Medical Care - Report Example

Introduction This nursing care plan focuses on Mrs. Monica Claridge, who has been admitted to the medical ward with complaints of chest pain, nausea and shortness of breath, and diagnosed with acute pulmonary edema, secondary to heart failure. By identifying the needs/problems of the patient, by making clear cut goals and by using appropriate nursing interventions, the nursing care plan would be able to achieve an optimal outcome. The analysis section of this paper provides rationales for the interventions based on literature research and discusses the interventions as presented in the Nursing care plan. Nursing Care plan Needs / Problems Goals Interventions 1. Impaired gas exchange related to ventilation / perfusion imbalance. 2. Alteration in tissue perfusion related to decreased cardiac output. 3. Alteration in fluid/electrolyte balance related to decreased cardiac output. 4. Alteration in comfort related to decreased tissue perfusion: - chest pain - abdominal pain/fullness, nausea, and claudication. 5. Activity Intolerance related to fatigue, poor nutritional state and decreased CO. 6. Potential alteration in nutrition R/T: - fatigue - weakness - loss of appetite - abdominal fullness 7. Anxiety related to - fear of death, perceived or actual role changes, hospitalization, loss of control. 8. Knowledge deficit related to disease process, discharge plan. Achieve adequate oxygenation as evidenced by O2 sat. ≥ 93% from admission to within 2 days and prior to discharge, achieve adequate oxygenation as evidenced by normal breath sounds Maintain adequate tissue perfusion to all vital organs as evidenced by: -absence of mental status changes (Misasi and Keyes, 1994) -absence of angina symptoms (Ackley &Ladwig, 2005) -U/O ≥ 0.5 mL/Kg./hr (Ackley &Ladwig, 2005) -+ bowel sounds; absence of pain, abdominal fullness, nausea - liver enzymes WNL - Coags WNL - absence of bleeding - absence of skin breakdown (Ackley & Ladwig, 2005) Within 24 hours of admission, achieve adequate cardiac output as evidenced by:- CI ≥ 2 L/min - U/O ≥ 0.5 mL/Kg/hr. - SvO2 ≥ 60%: - absence of mental status changes . Within 3 days of admission, maintain adequate cardiac output as evidenced by: clear breath sounds, absence of peripheral edema, within +/- 2Kg of dry weigh Remain free of pain/discomfort as evidenced by: - improvement in pain severity scale/description - relaxed body posture - absence of ECG changes suggestive of ischaemia (Ackley &Ladwig, 2005) Inform staff of pain/discomfort at onset. Be able to perform ADL’s with minimal distress/hemodynamic compromise as evidenced by: - O2 sat > 93%, -HR change ≤ 20/minute, RR ≤ 28 per minute - maintain BP WNL for patient Patient statement of absence of shortness of breath, tolerance of activity Be able to pace self-care activities independently by the time of D/C home. Knows to stop activities when fatigued or short of breath. Maintain adequate nutrition as evidenced by: absence of unplanned weight loss ≤ 2 Kg from dry weight. Within 24 hours of admission, demonstrate tolerable anxiety level as evidenced by: patient statement, relaxed body posture. Before discharge home, acknowledge the chronic nature of illness CHF, and some understanding of process and potential lifestyle changes. Verbalize knowledge of discharge plans, home care, medications, follow-up. 1.Monitor oxygen saturation with pulse oximetry and maintain O2 sat. ≥ 93% (Berry and Pinard, 2002; Grap, 2002). 2.The client is assisted into a position, which they feel is comfortable. This promotes patient compliance (Brown & Edwards 2005). 3. The patient is instructed to report- increasing shortness of breath, increasing work of breathing, or coughing pink or bloody sputum (Ackley &Ladwig, 2005). 1.Implement skin integrity protocol (AACN, 2006.) 2.Implement chest pain protocol (Goldman, et al. 1982). 3.Assess GI system q shift; bowel sounds, pain, distension, N/V, bowel function. 4.Monitor I & O q shift. 5.Monitor results of liver enzymes/coagulation times. 1.Implement Cardiac Telemetry Monitoring (Upstate education). 2.Implement peripheral IV (PIV) catheter protocol (John Dempsey Hospital). 3.Monitor effects of medical & pharmaceutical interventions (Ackley &Ladwig, 2005;(Lessig and Lessig, 1998). 4.Observe for signs of hypovolemia and/or electrolyte imbalance (Clark and Kruse, 2003; Oliva and Cruz, 2003;Lessig and Lessig, 1998;Fuster et al, 2001) 5.Weigh patient on admission and daily (Ackley &Ladwig, 2005) 6.Assure patient receives a salt- restricted diet (Ackley &Ladwig, 2005). 7.Obtain dietary consult (Palange et al, 1995) 8.Obtain orthostatic BP and pulse on admission and daily (Ackley &Ladwig, 2005). 1.Implement chest pain protocol. (Newberry, 2003). 2.Implement pain management protocol and instruct patient to notify staff immediately of any pain, nausea or discomfort at its onset. 1.Monitor and record the clients ability to tolerate activity (Wenger, 2001). 2.Space nursing care interventions/activities to minimize hemodynamic effects/distress (Prizant-Weston and Castiglia, 1992). 3.Question patient about fatigue/distress prior to, during, and after activities (Ackley &Ladwig, 2005). 4. Advance activities as tolerated if haemodynamically stable (Ackley &Ladwig, 2005); use bedside commode (Winslow, 1992), progress from sitting in bed to dangling, to standing, to ambulation (Fried and Fried, 2001) 5.Plan with patient/caregiver activities for home care (Campbell, 1998; Jaarsma, 1996). 1.Consult dietary to determine preference within prescribed diet (Peckenpaugh and Poleman, 1999). 2.Weigh daily 1.Assess contributing factors/cause of anxiety (Guzzetta, 1994; Gift, Moore, and Soeken, 1992) 2.Assist patient/caregiver to identify areas in which some control is possible (Ackley &Ladwig, 2005). 3.Encourage patient to express feelings regarding lifestyle changes. (Benson, 2000). 4.Implement spiritual distress protocol (Berggren-Thomas & Griggs, 1995; Newshan, 1998; Tuck, Wallace, & Pullen, 2001; Ackley &Ladwig, 2005). 1.Initiate cardiac rehabilitation program within 24 hours of admission (Ades, 1999). 2.Provide smoking cessation information/referral (Agency for Health Care Policy Research, 1996). 3.Consult heart failure nurse /continuity of care for assistance with discharge plan and referral to community support (Bosson, O, 2003). Client Case Analysis The normal oxygen saturation is 95% to 100%. The oxygen saturation should be monitored continuously using pulse oximetry and O2 saturation should be maintained ≥ 93%. The client, Mrs. Monica Claridge, has an O2 saturation of 91%. An O2 saturation of less than 90% or a partial pressure of oxygen of less than 80 mm Hg (normal: 80 to 100 mm Hg) indicates significant oxygenation problems (Berry and Pinard, 2002; Grap, 2002). The client in the case study, Mrs. Monica Claridge, has bilateral fine crepitations due to pulmonary edema. By positioning the client in either semi-Fowlers or a side-lying position, the oxygenation would be increased, as indicated by pulse oximetry (Ackley &Ladwig, 2005). The client should be turned every 2 hours. The mixed venous oxygen saturation has to be monitored closely after turning. If it drops below 10% or fails to return to baseline promptly, the client has to be turned back into the supine position and the oxygen status should be evaluated (Ackley & Ladwig, 2005). Thus, while turning is important to prevent complications of immobility, in critically ill clients with low hemoglobin levels or decreased cardiac output, turning on either side can result in desaturation (Winslow, 1992). Critically ill clients should be turned carefully and watched closely (Gawlinksi & Dracup, 1998). An increased respiratory rate, use of accessory muscles, nasal flaring, abdominal breathing, and a look of panic in the clients eyes may be seen with hypoxia (Ackley & Ladwig, 2005). The clients behavior and mental status is monitored for any restlessness, agitation, confusion, and extreme lethargy in the late stages (Ackley & Ladwig, 2005). Changes in behavior and mental status can be early signs of impaired gas exchange (Misasi and Keyes, 1994). The presence of any chest pain or discomfort is observed along with the location, radiation, severity, quality, duration, association with nausea, indigestion, and diaphoresis (Ackley & Ladwig, 2005). The precipitating and relieving factors are also noted. The presence of chest pain/discomfort may indicate an inadequate blood supply to the heart, which can compromise the cardiac output. Clients with heart failure can continue to have chest pain with angina or can reinfarct (Ackley & Ladwig, 2005). The urine output is measured hourly and any decrease in the output is noted. Decreased cardiac output results in decreased perfusion of the kidneys, with a resulting decrease in urine output (Ackley & Ladwig, 2005). The client has peripheral edema; therefore, it is important to follow a skin protocol to maintain skin integrity. The skin integrity and bony prominences are inspected daily for any signs of redness, scaling, breaks, or ulcerations (AACN, 2006). The client has to be turned/repositioned every 2 hours when on bed rest. Any pressure and friction has to be prevented and eliminated (AACN, 2006). Pillows or other supports are positioned between pressure areas to avoid two skin areas from touching (AACN, 2006). If the skin integrity is maintained well, the skin will be of normal color and be intact, warm and dry (AACN, 2006.) The Goldman chest pain protocol (Goldman, et al. 1982) is a computer derived decision aid designed to improve triage to CCU. A recursive partitioning is used to divide subjects into subgroups correlating with high or low risk of MI. The bowel function is monitored regularly. The client is provided stool softeners and is cautioned not to strain when defecating (Ackley & Ladwig, 2005). Straining results in the Valsalva maneuver and can lead to dysrhythmia, decreased cardiac function, and even death (Ackley & Ladwig, 2005). Cardiac telemetry is used to monitor the heart rhythm on a continuous basis. It is helpful for patients who have chest pain or angina, and other cardiac problems (Upstate education). The objectives of the peripheral IV (PIV) protocol are: to maintain skin integrity around the IV catheter site and cause minimal or no complications to patient like infiltration, phlebitis. The protocol includes: appropriate hand cleaning, aseptic technique, use of sterile products, and gloves; change of IV bags/bottles every 24 hours; change of IV administration sets/tubing no more frequently than every 72 hours and no later than 96 hours; change of IV site no more frequently than every 72 hours and no later than 96 hours; dressing for all IV sites with appropriate changing; assessing the IV site at least every 8 hours; flushing the peripheral lines not being used for continuous fluid administration with normal saline solution every 8 hours; and reporting immediately of infiltration of a blood component, irritant, or vesicant (John Dempsey Hospital ) It is important to monitor the effects of medical and pharmaceutical interventions. The inotropic and vasoactive medications have to be titrated within defined parameters to maintain contractility, preload, and afterload (Ackley & Ladwig, 2005). By following parameters, the nurse ensures maintenance of a delicate balance of medications that stimulate the heart to increase contractility, while maintaining adequate perfusion of the body (Ackley & Ladwig, 2005). Any signs of hypovolemia and/or electrolyte imbalance have to be observed. Fluids should be provided within the clients cardiac and renal reserve. The fluid intake (including intravenous lines) is closely monitored, and fluids are restricted, if ordered (Ackley & Ladwig, 2005). Since the client has a decreased cardiac output, the poorly functioning ventricles may not tolerate increased fluid volumes. Cardiogenic shock is a state of circulatory failure from loss from cardiac function associated with inadequate organ perfusion (Clark and Kruse, 2003). The symptoms of cardiogenic shock including impaired mentation, hypotension, decreased peripheral pulses, cold clammy skin, signs of pulmonary congestion and decreased organ function. The client has hypokalemia. Hypokalemia is common in heart clients due to diuretic use (Lessig & Lessig, 1998). A low serum sodium level often is seen with advanced heart failure and is a poor prognostic sign (Fuster et al, 2001). The patient has to be weighed on admission and daily. Weighing should be done at the same time daily (after voiding) (Ackley & Ladwig, 2005). An accurate daily weight is a good indicator of fluid balance. Increased weight and severity of symptoms can signal decreased cardiac function with fluid retention (Ackley & Ladwig, 2005). The client has to be served small, sodium-restricted, low-cholesterol meals. Sodium-restricted diets help by decreasing any excess fluid volume (Ackley & Ladwig, 2005). The client has a past history of dyslipidaemia; therefore, a low-cholesterol diet helps to decrease atherosclerosis, which can cause coronary artery disease (Ackley &Ladwig, 2005). Clients with cardiac disease tolerate smaller meals better because they require less cardiac output to digest (Ackley & Ladwig, 2005). The client has to be referred for a dietary consultation. Improved nutrition helps to increase muscle aerobic capacity and exercise tolerance (Palange et al, 1995). It is important to check the blood pressure and pulse, daily, before administering cardiac medications such as angiotensin-converting enzyme (ACE) inhibitors, digoxin, and beta-blockers (Ackley &Ladwig, 2005). An electrocardiogram can reveal previous MI, or evidence of left ventricular hypertrophy, indicating aortic stenosis or chronic systemic hypertension (Ackley &Ladwig, 2005). Radiography may provide information on pulmonary edema or a large pericardial effusion (Fuster et al, 2001). The echocardiogram is the most important imaging tool for evaluating clients with symptoms of heart failure (Ackley &Ladwig, 2005). If chest pain is present, the client is made to lie down. The cardiac rhythm is monitored, oxygen is given, vital signs are checked, pain medication given, and the physician is notified. A prompt assessment of the client with acute coronary symptoms is important, since the incidence of ventricular fibrillation is 15 times greater during the first hour after symptoms of an acute myocardial infection (Newberry, 2003). The clients ability to tolerate activity is monitored and recorded. The pulse rate, blood pressure, any dyspnoea, use of accessory muscles, and skin color are noted before and after activity (Wenger, 2001). If the following signs and symptoms of cardiac decompensation like onset of chest discomfort, dyspnoea, palpitations, excessive fatigue, lightheadedness, confusion, ataxia, pallor, cyanosis, nausea, or any peripheral circulatory insufficiency, dysrhythmia, exercise hypotension or excessive rise in blood pressure (180 /110 mm Hg or more) develops, then activity should be stopped immediately (Wenger, 2001). Symptoms typically last for minutes. If symptoms last longer than 5 to 10 minutes, a physician should evaluate the client before resuming any activity (Ackley &Ladwig, 2005). In order to minimize hemodynamic effects/distress, it is necessary to allow periods of rest before and after planned exertion periods such as meals, baths, treatments, and physical activity. Rest periods decrease oxygen consumption (Prizant-Weston & Castiglia, 1992). During acute events, it should be ensured that the client remains on short-term bed rest or maintains an activity level that does not compromise cardiac output (Ackley & Ladwig, 2005). In severe heart failure, the restriction of activity reduces the workload of the heart (Braunwald et al, 2001). After the clients condition has stabilized, activity can be gradually increased by slower paced activities or shorter periods of activity with frequent rest periods. The client can use a commode or urinal and avoid the use of a bedpan. Getting out of bed to use a commode or urinal does not stress the heart much (Winslow, 1992). In addition, getting the client out of bed minimizes complications of immobility (Winslow, 1992). Exercise can help the client. Whereas earlier, rest was commonly recommended, it has become clear now that inactivity can worsen the skeletal muscle myopathy (Ackley & Ladwig, 2005). A carefully monitored exercise program can improve both functional capacity (Bellardinelli et al, 1999) and left ventricular function (Giannuzzi et al, 1997). In order to evaluate for postural hypotension, the client can always dangle the legs at the bedside before trying to stand (Ackley & Ladwig, 2005). The client is watched closely for dizziness during increased activity. Discharge planning is started as soon as possible. The case manager or social worker needs to assess the client’s home support systems and the need for community or home health services (Ackley & Ladwig, 2005). According to Jaarsma (1996) being discharged to home without adequate support may result in the readmission of elderly clients. The client in the case study lives with a female friend in a retirement village unit and has a supportive son who lives nearby. She, therefore, mainly needs support services for personal care and transportation to doctor visits. The case manager or social worker can evaluate the client’s ability to pay for prescriptions. According to Campbell (1998), the cost of drugs may be a factor in filling prescriptions and adhering to a treatment plan. The client has to be continued being monitored at home for any exacerbation of heart failure. The client and her son can be instructed about the disease process, complications of the disease process, information on medications, need for weighing daily, and when the doctor should be called (Ackley & Ladwig, 2005). The dietitian can be consulted and the importance of a sodium-restricted diet is stressed on the patient (Ackley & Ladwig, 2005). The client can be provided alternatives for salt such as spices, herbs, lemon juice, or vinegar. Although the initial elimination of salt from the diet might be difficult for the client, the taste of salt can be unlearned (Peckenpaugh & Poleman, 1999). The client is instructed to take the weight daily and keep a weight log. A scale is necessary; if the client does not have one at home, she is assisted in getting one (Campbell, 1998). Anxiety about the disease is common any contributing factors/cause of anxiety is assessed (Ackley & Ladwig, 2005). Music has been shown to reduce the heart rate, blood pressure, anxiety, and cardiac complications (Guzzetta, 1994). Relaxation therapy can help reduce dyspnoea and anxiety (Gift, Moore, Soeken, 1992). The client in the case study is usually independent with ADLs but recently it has become more limited due to increasing shortness of breath. The client is explained the necessary restrictions, including consumption of a sodium-restricted diet, guidelines on fluid intake, and the avoidance of Valsalvas maneuver (Ackley &Ladwig, 2005). The client is taught the importance of pacing activities, work simplification techniques, and the need to rest between activities to prevent becoming overly fatigued (Ackley &Ladwig, 2005). The client is encouraged to express any feelings regarding lifestyle changes. Social workers can assist the client and family with acceptance of life changes. Psychoeducational programs including information on stress management and health education have been shown to reduce long-term mortality and recurrence of myocardial infarction in heart patients (Benson, 2000). Spiritual distress is defined as an impaired ability to experience and integrate meaning and purpose in life through the individuals connectedness with self, others, art, music, literature, nature, or a power greater than oneself (Ackley & Ladwig, 2005). Listening attentively to the client and being physically present can be spiritually nourishing (Berggren-Thomas & Griggs, 1995). Meditation, guided imagery, therapeutic touch, journaling, relaxation, and involvement in art, music, or poetry promote spiritual well-being (Newshan, 1998). Touch supports clients spiritually (Tuck, Wallace, & Pullen, 2001). Cardiac rehabilitation program is initiated within 24 hours of admission. Cardiac rehabilitation safely increases aerobic capacity, muscular strength, and endurance in older clients (Ades, 1999). Specialized cardiac care programs have addressed the needs to CABG clients discharged from the hospital early (Frantz and Walters, 2001). Exercise-based cardiac rehabilitation is effective in reducing the number of cardiac deaths (Joliffe et al, 2002). The client has given up smoking. This is a good sign. Giving up smoking can slow the course of disease, and some clients may even regain some lung function (Anthonisen et al, 1994). The heart failure specialist nurse (SN) can assess the signs and symptoms of cardiac destabilization, provide education, emotional support, counsel, develop behavior modification techniques, monitor therapy compliance and also act as the healthcare liaison for the patient and their family. The aim is to prevent rehospitalisation, increase functional ability, and improve the quality of life (Bosson, 2003) Conclusion A well-structured and planned nursing care plan can help achieve optimal health results and improve the health care outcome of a patient. This nursing care plan has outlined the nursing diagnoses, goals, and nursing interventions in a patient with reduced cardiac output. A detailed literature research was performed with supporting rationale for the outlined nursing interventions. An analysis of the discharge planning of the patient was also discussed. References Ackley, BJ, Ladwig, GB, 2005. Nursing Diagnosis Handbook: A Guide to Planning Care, 6th Edition. Elsevier Health Sciences. Ades PA, 1999. Cardiac rehabilitation in older coronary patients, J Am Geriatr Soc 47:98. Anthonisen NR et al, 1994. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study, JAMA 272:1497. AACN (American Association of Critical Care Nurses), 2006. Patient Care Standards for Progressive Care Units. Agency for Health Care Policy and Research (AHCPR), 1994. Guidelines for patients with heart failure, AHCPR Publication No 942, US Department of Health and Human Services. Brown, D & Edwards, H 2005. 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