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.