Nursing Care Plan Assignment Case Study –

Nursing Care Plan Assignment Case Study – Left-Sided Heart Failure Irma Jacobs is a 78-year-old woman who lives by herself in her own home. In the past week she has started to feel tired and unwell. She has always had a good appetite and the energy to live her life but she has been feeling increasingly short of breath and tired and has been unable to go to her social activities. Her friends had been visiting and dropping off food and encouraging her to seek medical attention. When she awoke this morning, she felt so short of breath and tired that she finally called and asked her daughter to take her to the doctor. The physician admitted her to the hospital for treatment of acute left sided heart failure. Irma was admitted to the medical unit on September 25, 2022, with a diagnosis of left sided heart failure and you are her nurse. Irma has a history of osteoporosis, hypertension and constipation. She has no known allergies and no surgical history. She is a full code status and states her religion is Presbyterian. Irma’s medications include Alendronate 70 mg PO weekly; Bisoprolol 5 mg PO daily; Docusate Sodium 100mg PO, BID, Acetaminophen 500mg, 2 tabs PO, q 4-6 h prn pain. She has a IV in her left hand with 2/3 & 1/3 at TKVO. On examination Irma’s vital signs are temp: 37.3 degrees Celsius; Pulse 102 bpm (radial); RR 32 breaths/min; blood pressure: 142/96 mm Hg and O2 sat 92% on 2.5L O2 via nasal prongs. She denies any pain. Her lung sounds are diminished and she has crackles throughout. Irma reports that she has been coughing in the past couple of days and has pink coloured sputum. She is pale and slightly cyanotic and her skin feels cold and clammy. Irma states her shortness of breath is scaring her and she is quite anxious. She is afraid to lie down as this makes it worse. Irma states she has been suffering from constipation for a long time, only going to have a BM every 2-3 days. Her abdomen is firm and slightly distended with hypoactive bowel sounds. She is 5’4″ tall and weighs 115 pounds. Her daughter states that she weighed 137 pounds at the physician’s office 6 months ago and that her appetite has decreased particularly over the past week. She reports that she has only eaten very small amounts of soft food and some fluids because of her shortness of breath. She is able to communicate well despite having bilateral hearing aids, however has recently had poor memory and concentration. Irma is continent of urine and feces and walks independently however she currently needs assistance with ADLs such as hygiene, transferring and mobilizing due to her severe fatigue and dyspnea. She says she has not been sleeping well for the past few weeks. Irma lives in a 2 storey home with the laundry on the first floor and her bedroom on the third floor. She reports she has been struggling due to her fatigue and dyspnea and has had to stop to catch her breath whenever she uses the stairs. She and her husband owned a restaurant when they were younger and until recently she has enjoyed cooking and eating, but now she has no energy. She lost her husband 10 years ago and her only daughter lives 45 minutes away but calls once a week to check in on her and accompanies her to medical appointments. Her CXR today shows pulmonary edema. Bloodwork is unremarkable except BNP (B-type natriuretic peptide) is elevated at 4100, PaO2 – 74 and serum albumin is 31 g/L. Nursing Care Plan Assignment: Nursing Diagnosis/Problem, Goal, Interventions, Evaluation (10%) Nursing Care Plan – 10% In this assignment students will develop a nursing care plan by building on work completed in the classroom. The assignment includes: 1. Identification of a Priority Problem Area. Look back at the clusters of assessment data you collected from the case study in-class, and rank them from 1-4 (highest to lowest) order of priority. When ranking your clusters your priority cluster will include significant abnormal assessment data. Remember your ABCs – airway, breathing, circulation, Maslow’s hierarchy of needs etc., to identify the first priority problem area for your patient. 2. One Nursing Diagnosis/Nursing Problem Statement. Select a priority problem from the priority problem area identified from the case study and write one nursing diagnosis/nursing problem statement. The nursing diagnosis/nursing problem statement must be written as a Problem, Etiology, Signs & Symptoms (PES) statement. This List five signs and symptoms that support your choice of priority problem. These signs & symptoms are to be included in the Assessment part of the Nursing Care Plan Template. 2. One Short Term SMART Goal/Expected Outcome. Write one SMART nursing goal/expected outcome for the nursing problem. This is a measurable statement of accomplishment that may be related to physical health or areas that need improvement for your client. 3. Four Nursing Interventions with Cited Rationale. Write 4 appropriate priority nursing interventions to help address the problem. The interventions are nursing actions (treatments, behaviours, activities and therapies) that nurses perform independently on behalf of clients or in collaboration with other health care professionals. These are individual steps to help achieve the client outcome (goal). Provide ‘evidence based’ rationale to support and validate each intervention chosen. Use APA format for all evidence-based rationale supporting the chosen intervention. 4. Evaluation Reflect on the effectiveness of interventions and the client’s progress to achieve the outcome. Do believe the interventions would be effective in achieving the client outcome? Because you cannot truly evaluate the outcome it will be important to provide an explanation about what, when and how would you evaluate the nursing interventions? You can use the worksheet below to complete the assignment and then complete your final care plan on the “Nursing Care Plan” template attached. A rubric is also provided in Appendix A of the Course Outline to guide completion. Nursing Care Plan Worksheet (10%) Nursing diagnosis/problem 1 Short term goal 4 nursing interventions with cited rationale Evaluation Nursing Diagnosis/Problem: Review the priority cluster and select the priority nursing diagnosis/problem. 2. List the signs and symptoms from your data collection that support the chosen diagnosis/problem. 1. 2. 3. 4. 5. Priority Nursing Diagnosis/Problem Statement: Short Term SMART Goal/Expected Outcome: Nursing Interventions: Identify four appropriate Nursing Interventions with cited rationale. Nursing Intervention Research-Based Rationale Evaluation: Because you cannot truly evaluate the outcomes it will be important to provide an explanation about what, when and how would you evaluate the nursing interventions. Assessment Data Nursing Diagnosis/Problem Short Term Goal/Outcome Nursing Interventions Rationale Evaluation 1. 2. 3. 4. 5. SCIENCE HEALTH SCIENCE NURSING PNC 121

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