Case study of a patient with heart failure

13 Case study of a patient with heart failure








Martha’s nursing care plans




1. Problem: Martha is breathless.


Goal: To restore normal breathing pattern.



















Nursing action Rationale
Assess Martha’s breathing, respiratory rate and keep oxygen saturation > 95%
Observe for signs of cyanosis
Administer prescribed oxygen
Inform the nurse in charge of any changes to Martha’s condition
To observe for any signs of deterioration
To ensure that Martha does not become hypoxic
Oxygen is a drug and must be prescribed
Encourage Martha to sit upright supported by pillows To maximise lung expansion and gaseous exchange
To increase comfort
Administer any medication as prescribed and ensure that Martha is fully informed about the medication and any side effects
For example, explain to Martha why she needs to keep her oxygen mask on
Martha is much more likely to comply with her medication if she understands why she needs to have it
Refer Martha to the physiotherapist and liaise To maximise gaseous exchange
To prevent complications from immobility
To ensure consistent treatment from nurses and physiotherapists

2. Problem: Martha is cardiovascularly unstable due to her condition.


Goal : To stabilise Martha.













Nursing action Rationale
Martha needs continuous cardiac monitoring of her condition until it has stabilised
Ensure that alarm limits are set within appropriate limits
Hourly observations of pulse and blood pressure
Inform the nurse in charge and doctor regarding any changes in observations and discuss the frequency of observations required
To detect any change in Martha’s condition as soon as possible
To be able to respond to these changes and for the team to be informed
To check blood urea and electolytes Abnormal potassium levels will increase the risk cardiovascular instability

3. Problem: Martha is frightened and distressed.


Goal : To try to relieve Martha’s distress.
















Nursing action Rationale
Spend time with Martha using verbal and non-verbal communication to reassure her Being alone will increase Martha’s distress
Always introduce Martha to the nurse who is relieving you or taking over your shift
If you need to go to another area, explain to Martha who will be looking after her
Explain to Martha how the call bell system works and make sure that it is in easy reach
Knowing who is looking after her will help Martha to relax
Knowing where her nurse is is important as Martha will know that there is someone identified who is looking after her needs
If Martha cannot see her nurse she will understand how to summon help
Communicate with Martha’s family and significant others with her permisssion Family and friends may find the environment and equipment daunting
Information will help them to understand about Martha’s condition
Nurses should never presume that a patient wants her family to know about their condition and it is important to respect Martha’s wishes

4. Problem: Martha has a urinary catheter.


Goal: To monitor fluid balance accurately and to prevent infection.



















Nursing action Rationale
Explain to Martha why she requires urinary catheter.  
Hourly measurements of urine: if below 30 mL/h or above 200 mL/h, report to the nurse in charge and liaise with the doctors when reducing the frequency of the urine output measurements
Document urine output on a fluid balance chart
To accurately monitor Martha’s fluid balance. Martha is at risk of fluid overload due to her cardiac condition
Provide catheter care and hygiene
Check the colour of the urine each shift
Report any changes to the nurse in charge
Provide privacy when providing catheter care
To prevent infection
To detect any signs of infection or trauma
To ensure that Martha’s privacy and dignity needs are met
Monitor temperature, pulse and blood pressure and respirations four times a day while Martha has an indwelling urinary catheter
Take a catheter specimen of urine for microscopy, culture and sensitivity testing if Martha’s temperature is > 37.5°C and inform the nurse/doctor
To detect any infection and treat as soon as possible

5. Problem: Martha is unable to eat or drink adequately due to her condition.


Goal: For Martha to have adequate fluid and dietary intake.

























Nursing action Rationale
Ensure a malnutrition risk assessment is undertaken in the first 24 hours (see Ch. 9) To determine Martha’s nutritional status
Maintain strict food and fluid balance monitoring
Martha may be on fluid restriction
Inform Martha about this and provide her with rationale
Inform the nurse in charge or doctor if Martha’s diet or fluid intake are below the normal limits
Due to her cardiac failure, Martha is at risk of fluid overload
To ensure that Martha receives adequate fluids and nutrition
To prevent complications of dehydration
To ensure that there is effective communication within the multidisciplinary team
Ensure that nutritional supplements are explained to Martha and encourage her to drink them To keep Martha fully informed
Monitor and document observations of her vital signs (see Ch. 7) To detect any deterioration/improvement
Administer intravenous therapy as prescribed and ensure that a cannula care plan is in place for this (see Ch. 9) To reduce the risk of cannula-associated infection/complications
Keep Martha informed of her condition To promote and enhance communication

6. Problem: Martha is a life-long smoker and cannot smoke in hospital.


Goal: To help Martha deal with any cravings or withdrawal symptoms.













Nursing action Rationale
To discuss with Martha how she is feeling and discuss prescribing nicotine supplements with the medical team To prevent Martha from suffering from nicotine withdrawal symptoms
Once Martha is feeling better, discuss how she feels about smoking after discharge and whether she would accept a referral to the cardiac rehabilitation/heart failure team or smoking cessation team
Provide verbal and written information for Martha and her husband
To provide health education and promotion to Martha and her family

Stay updated, free articles. Join our Telegram channel

Feb 25, 2017 | Posted by in NURSING | Comments Off on Case study of a patient with heart failure

Full access? Get Clinical Tree

Get Clinical Tree app for offline access