NURSING PROCESS WORKSHEET The following content for your client requires a research component to ensure an adequate assessment. This needs to include peer reviewed articles, research databases, etc. All information must relate to your client during this admission. References need to be listed on a correctly formatted APA reference page, as well as cited within your answers using correct APA in-text referencing format. 1. Based on the collected data of your assigned client, identify and briefly explain their primary pathophysiology [related to their primary diagnosis] for this admission. This client’s primary diagnosis was new onset of congestive heart failure (CHF). Congestive heart failure occurs when the myocardium can’t pump effectively enough to meet the body’s metabolic needs (Hinkle et al., 2022). Heart failure may be classified in different ways according to its pathophysiology. The different classifications include right sided or left sided, systolic or diastolic, and acute or chronic. According to Reber et al. (2019), left-sided heart failure is a result of ineffective left ventricular contractile function, which can sometimes lead to pulmonary congestion or pulmonary edema and decreased cardiac output. Typically, left-sided heart failure develops first. Systolic heart failure involves the left ventricle of the heart not contracting effectively and is usually indicated by an ejection fraction of <40% (Hinkle et al., 2022). Diastolic heart failure refers to the left ventricle of the hearts inability to relax and fill properly during diastole, so it is not being pumped with as much blood that needs to be there. This means that there is less blood being pumped by your heart. Acute and chronic refers the timing of the onset of symptoms, i.e., over a period of time versus recently. 2. According to Erickson’s Stages of Psychosocial Development, identify the expected developmental level and tasks appropriate for the developmental level; also state whether or not the client has achieved these tasks with documented examples. At what level is the client now functioning? What factors may contribute to present developmental level? Based on Erikson’s Stages of Psychosocial Development, the client is in the Generativity versus stagnation stage. During this stage, an individual can express “generativity” which is a desire for impacting the world around them. This can be seen through an individual “developing relationships with family” and “contributing to the next generation”. On the contrast, an individual may express “stagnation”, which would be an individual’s inability to impact the world. This can be due to an individual’s selfishness and/or lack of self-improvement, or an individual’s failure to create meaningful relationship (Cherry, 2021). This is evidenced by the client’s relationship to their daughter. They expressed their pride and admiration in their daughter’s accomplishments, by showing pictures of their daughter’s work and talking about how they just helped her move to her new school. The client also stated how proud they were of their daughter and how much they loved her. Even with the client’s recent loss of his father, the client stated that they went back home to see family. This support system illustrates the connection he has with others, which also supports that the client expresses “generativity”. 3. How does the client’s past medical and social history contribute to the primary admitting medical diagnosis? If your client has no medical history or the medical history does not contribute, include a complete sentence that identifies the lack of connections. NURS 3313 Page 1 While the client’s primary diagnosis was new onset of congestive heart failure, the client had other medical conditions such as hypertension (HTN), hyperlipidemia, a recent myocardial infarction (MI), and is a current smoker. These comorbidities placed the client at an increased risk of developing heart failure. Of note, the client’s father recently passed away from a MI. This genetic predisposition to heart disease placed the client at an even higher risk of developing heart disease. 4. How do the client’s co-morbidities and medical history impact the treatment and recovery? If your client has no comorbidities, or they do not contribute to the treatment plan or client recovery, include a complete sentence that identifies the lack of connections. The client was diagnosed with new onset of CHF, two weeks after they had experienced a MI. The diagnosis of heart failure may have been exacerbated by the combination of smoking paired with the client’s pre-existing HTN and hyperlipidemia diagnoses. The progression of new onset congestive heart failure occurred due to the damage imposed on the client’s heart after the MI. This damage was evidenced by an ejection fraction of 25%. After the recent MI, the client continued to smoke. Smoking causes vasoconstriction which may counteract the treatment of reducing peripheral resistance and improving cardiac output. The continuation of smoking, lack of diet modifications, and compliance with medication therapy created an environment within this client’s body that promoted deterioration rather than recovery. 5. Identify one surgical or interventional procedure that your client has received during this admission that will impact your client’s recovery. If your client has not yet received a surgical or interventional procedure, identify one that would be appropriate to use for the client’s primary diagnosis. Once identified, please explain the impact this would have on the client’s overall recovery. There were no surgical interventions at the time of this client’s stay. However, an additional cardiac catherization to identify any new blockages and/or to evaluate ejection fraction could be beneficial to the care of this client. The client already suffers from HTN, hyperlipidemia, and is a smoker, all of which increase the risk for new plaque and clot formations. The new information obtained from this procedure could provide guidance in the treatment plan and/or medication regimen. 6. Briefly explain any related abnormal lab values, including drug levels or microbiology cultures. as they relate to your client’s pathophysiology. Please provide the necessary intervention/treatment that would address the abnormal value; if your client had any of these abnormal findings during this admission, please provide the intervention that was provided to address the abnormal value specific to your client instead of providing a general response. On the admission, the client’s blood work showed elevated levels of troponin and brain natriuretic peptide (BNP). The troponin was recorded as 0.06ng/ml and the BNP was 2656 ng/ml. Elevated levels of troponin indicate recent myocardial damage, which is supported by the client’s recent MI approximately two weeks prior. According to Hinkle et al. (2022), troponin levels may remain elevated up to two weeks post MI. There were no interventions implemented based on this level. The elevated BNP level is used to determine the presence and severity of heart failure. This is supported by the client’s admitting diagnosis of new onset of CHF. Treatment included anti-hypertensive medications, diuretics, and preventative clot formation medications. NURS 3313 Page 2 7. Based on the fall risk screening tool utilized at your clinical facility, identify your client’s fall score/rating, and provide one nursing intervention (specific to your client) that could be implemented to help prevent a fall. Based on the Morse falls risk assessment, the client scored a 60 which is considered a high fall risk. A nursing intervention implemented based on this score is to assist patient with ambulation using a gait belt. Using a gait belt with ambulation will help to provide the client with more stability and can assist the nursing staff to support the client safely. 8. Identify at least one teaching need for the client and/or family. Explain the impact this education would have on the overall plan of care for this client. According to Hinkle et al. (2022), some of the goals of treatment for heart failure includes improving cardiac function, stabilizing the client’s condition, reducing symptoms, delaying progression, and promoting a healthy cardiac lifestyle. Given that the client was newly diagnosed with heart failure, the client needs to be educated on signs and symptoms of worsening heart failure, monitoring daily weights, as well as the importance of taking medications as prescribed. Additionally, education should be provided on the importance of diet modifications and smoking cessation. Improving the client’s knowledge regarding disease process, treatment regimen, and medication can increase compliance and participation in adequate self-care. Being able to communicate about one’s body will help the client and doctor make the most effective personalized treatment plan (Mayo Clinic, ND). 9. Identify the Joint Commission Safety Goal that is most applicable to your client during this shift, and explain why it is appropriate for your client. (Please state the entire goal and not just the reference number) Please use the Joint Commission Accreditation Program: Hospital National Client Safety Goals http://www.jointcommission.org/assets/1/6/2014_HAP_NPSG_E.pdf https://www.jointcommission.org/-/media/tjc/documents/standards/national-client-safetygoals/2022/simple_2022-hap-npsg-goals-101921.pdf NPSG.03.06.01: Maintain and communicate accurate client medication information. This goal is important as the client has a new diagnosis of HF. It is important for the client to understand the indications for the new medication to ensure that his heart condition was not exacerbated. NPSG.09.02.01: Reduce the risk of falls. The client scored a high falls risk on the Morse falls risk assessment. It is important to implement fall risk protocol to prevent client harm associated with falls during the hospital admission. 10. List all references in APA format on a separate sheet at the end of this document. See next page… NURS 3313 Page 3 References Burke, A. (2021, Oct 22). Hemodynamics: NCLEX-RN. https://www.registerednursing.org/nclex/hemodynamics/ Cherry, K. (2021). Erik Erikson’s stages of psychosocial development. Retrieved December 6, 2021 from https://www.verywellmind.com/erik-eriksons-stages-of-psychosocial-development-2795740 Doenges, M., Moorhouse, M., & Murr, A. (2019). Decreased cardiac output. In Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales (15th edition, pp. 113-121). Hinkle, J.L., Cheever, K.H., & Overbaugh, K.J. (2022). Brunner & suddarth's textbook of medical-surgical nursing (15th ed.). Wolters Kluwer. Mayo Clinic. (ND). Heart failure – Diagnosis and treatment. Retrieved on 12/2/21, from https://www.mayoclinic.org/diseases-conditions/heart-failure/diagnosis-treatment/drc-20373148 McLeod, S. (2020, Dec 29). Maslow’s hierarchy of needs. Retrieved on 12/2/21, from https://www.simplypsychology.org/maslow.html Medline (2021). Elevating patient safety with gait belts. Retrieved on December 10, 2012, from https://www.medline.com/strategies/safe-mobility/elevating-patient-safety-gait-belts/ National Client Safety Goals - Joint Commission. (n.d.). Retrieved December 6, 2021, from https://www.jointcommission.org/standards/national-client-safety-goals//media/b35ba0b4b9754c6dbafdb1f86e152e5c.ashx Reber, C.R., Heimgartner, N.M., Gersch, C.J. (2019). Pathophysiology made incredibly easy! (6th ed.). Wolters Kluwer. NURS 3313 Page 4 Medication Documentation Tool - complete the chart below with your client’s medications Medications Dose Route PO Frequency Lisinopril (Zestril) 20mg Daily Milrinone (Primacor) 0.375mg IV Continuous Furosemide (Lasix) 40mg PO Daily Atorvastatin 20mg PO Daily Enoxaparin (Lovenox) 40mg SQ Every 24 hours daily K-Dur (Potassium supplement) 20meq PO Daily (Lipitor) Reason for Your Client’s Use of the Medication (State information in your own words but include APA reference for drug guide/source) Lisinopril is an ACE Inhibitor. ACE inhibitors promote vasodilation and diuresis, which ultimately decreases afterload and preload (Hinkle et al., 2022). Lisinopril relieves signs and symptoms of HF and prevents progression. Milrinone works to increase the heart’s contractility and decrease pulmonary vascular resistance (Mayo Clinic, ND). Furosemide is classified as a loop diuretic. Diuretics are prescribed to remove excess extracellular fluid by increasing diuresis in clients with signs and symptoms of fluid overload (Hinkle et al., 2022). Atorvastatin is a statin. This drug is used to treat high cholesterol and triglyceride levels. (Hinkle et al., 2022). Statins are prescribed to lower the risk of stroke, heart attack, and other heart complications such as HF. Lovenox is classified as an anticoagulant. The main purpose of Lovenox is to prevent and treat blood clot formation. (Hinkle et al., 2022). Potassium is a supplement to replenish potassium depleted during diuresis from Lasix (Hinkle et al., 2022). All information must relate to your client during this admission and must be cited using APA format, both in-text and on your attached reference page. NURS 3313 Page 5 Diagnosis #1 Provide rationale for Nursing Diagnosis AND rationale for prioritization: This diagnosis was chosen because excess fluid volume can impact preload, afterload and contractility. All of these changes can lead to serious complications and side effects (Burke, A., 2021). This is a priority diagnosis because in Maslow’s hierarchy of needs the physiological needs for human survival are the highest priority. Ensuring life-sustaining cardiac function is essential for survival (McLeod, 2020). *Include APA referencing both in-text and on reference page ASSESSMENT r/t THIS Nursing Diagnosis Subjective: “I have gained 15 pounds just in the past week.” “I have only been to the bathroom once today.” “I feel short of breath.” PLANNING GOAL STATEMENT (Broad Statement) PRIORITY NURSING INTERVENTIONS (Interventions you implemented; minimum of 3 required) 1. The client will regain a balanced fluid volume. Objective: Client has 4+ pitting edema in BLE, UOP of 250ml and intake of 1200ml in a 24hr period. Elevated BUN/Creatinine levels 36/2, HR 115 at rest. Crackles in bilateral lower lobes; BNP = 2656 2. Desired Outcome NURSING DIAGNOSIS NANDA RATIONALE EVALUATION (For each intervention) Goal Met/Partially met/Not met 1. Monitor urine output, noting amount and color, as well as time of day when diuresis occurs. Maintain fluid/sodium restrictions as indicated. 2. (Specific Criteria) Fluid Volume Excess R/T (cause) Decreased cardiac output, compromised regulatory mechanisms, and decreased left ventricular function AEB (s/s) 4+ pitting edema in BLE, elevated BUN/Creatinine levels, low UOP, and weight gain, crackles in BLL and dyspnea; BNP = 2656 NURS 3313 Page 6 The client will adhere to fluid restrictions of 2000ml daily, diet modification of decreased sodium intake, and prescribed medication regimen before discharge. 3. Administer medications as indicated: Diuretics, e.g., furosemide (Lasix) Potassium supplements, e.g., K-Dur. 3. Urine output may be scanty and concentrated (especially during the day) because of reduced renal perfusion. Recumbency favors diuresis; therefore, urine output may be increased at night/during bedrest. (Doenges, M., et al, 2019). Reduces total body water/prevents fluid from reaccumulating. Increases rate of urine flow and may inhibit reabsorption of sodium/chloride in the renal tubules (Mayo Clinic, ND). Promotes diuresis without excessive potassium losses (Mayo Clinic, ND). Replaces potassium that is lost as a common side effect of diuretic therapy, which can adversely affect cardiac function (Mayo Clinic, ND). AEB Decrease in pitting edema to 3+, UOP 3200ml and intake of 1500ml; BUN/Creatinine level remain elevated; HR 88. Should your interventions be continued? Why or why not? Yes, to continue the process of diuresis and improve fluid volume balance. List new interventions appropriate as identified by you or the client: Weigh daily; Assess for distended neck and peripheral vessels. Inspect dependent body areas for edema with/without pitting; note presence of generalized body edema (anasarca); Change position frequently. Elevate feet when sitting. Inspect skin surface, keep dry, and provide padding as indicated. Diagnosis #2 Provide rationale for Nursing Diagnosis AND rationale for prioritization: This diagnosis was chosen because decreased cardiac output can impact the heart rate and rhythm, as well as preload, afterload, and contractility. All these changes can lead to serious complications and side effects (Burke, A., 2021). This is a priority diagnosis because in Maslow’s hierarchy of needs the physiological needs for human survival are the highest priority. Ensuring life-sustaining cardiac function is essential for survival (McLeod, 2020). *Include APA referencing both in-text and on reference page ASSESSMENT r/t THIS Nursing Diagnosis PLANNING PRIORITY NURSING INTERVENTIONS (3 required) GOAL STATEMENT Subjective: Client complaints of shortness of breath and fatigue with activity Objective: EF 25% on echo; 4+ pitting edema on lower extremities, recent weight gain of 15 lbs; BP 80/50; weak peripheral pulses (Broad Statement) Client will display hemodynamic stability (stable vitals and normal pulses) Reassess blood pressure and pulses q4h and PRN Desired Outcome (Specific Criteria) Client will verbalize signs and symptoms of NURS 3313 Page 7 1. 2. Administer diuretic and inotropic medications as ordered by MD RATIONALE EVALUATION (1 for each intervention) Goal 1. Frequent assessment allows for comparison of date to the baseline and identification of trends (improvement or deterioration); this will also allow the nurse to identify client responses to medication and other interventions (Doenges, M., et al, 2019). Met/Partially met/Not met 2. Diuretic medications will decrease cardiac workload by removing AEB: BP remained low during my shift; last measurement was 79/55. No change to pulses, pedal pulses were +1 on palpation. Should your interventions be continued? Why or why not? Yes, because the client will still be in the hospital. The assessment should continue until the client is stable for discharge. This will allow the nurses NURSING DIAGNOSIS NANDA Decreased Cardiac Output R/T (cause) impaired left ventricular function AEB (s/s) BP 80/50, weak pulses, client complaint of shortness of breath, and EF of 25% on echocardiogram NURS 3313 Page 8 cardiac decompensation specific for their condition (changes in BP, increase in swelling, changes in energy level) by the time of discharge. 3. Educate client about heart failure and potential signs and symptoms they may experience excess volume in circulation, inotropic medications will help the heart pump more effectively (Mayo Clinic, ND). and doctors to determine effectiveness of the current medications and treatments. The client should continue to be educated to help prevent future readmission after they are stable enough for discharge. 3. Proper treatment can help symptoms improve, being able to communicate about one’s body will help the client and doctor make the most effective personalized treatment plan (Mayo Clinic, ND). List new interventions appropriate as identified by you or the client: As BP becomes more stable, the nurse should begin assisting the client with more out of bed activity to help improve activity tolerance and regain ADL abilities.