Tutor Blog Post


03 Jul 2021 228 Views Sarah


Care Planning Template

Problem 1 Nursing Diagnostic Statement: Decreased cardiac output R/T

Hemodynamic Regulation

It is evident as Brian Edwards has heart sounds S1 S2 and S3 with systolic murmur grade 3 prominent over left apex area (defining criteria for structural heart disease), hypoxia, exertional dyspnoea (admission complaint) with 28 respiration rate, central cyanosis at room air decreased activity tolerance as has to top after 5 meters of walk, weight gain of 4kgs in last week, pitting oedema in lower limbs, capillary refill 3 seconds for all limbs, and clammy to touch. The reduced cardiac output also potentially impairs kidney function that is also contributing to Brian’s pitting edema (Dempsey, Hillege, & Hill, 2016).

Expected Outcome – Brian demonstrates adequate cardiac output to have all vital signs in normal parameters, reduced cardiac workload and exhibits dry and warm skin (Gulanick & Myers, 2016).

Nursing Intervention 1 – To measure Brian’s blood pressure in both arms and thighs. It is necessary to take three readings at the interval of 5 minutes while standing, sitting and resting with the clinically recommended cuff size and technique. The fluctuations can be evaluated through the systolic and diastolic readings.

Rationale 1- With the serial readings, the registered nurse gets right guidance of diagnosing vascular involvement and problem scope (DeLaune et al., 2016).

Nursing Intervention 2- To record the intake and output on timely basis. If Brain’s condition deteriorates, hourly urine output must be measures and reduction in output must be notified.

Rationale 2- The reduced cardiac output causes reduced perfusion of kidneys along with the reduction in urine output (Gulanick, &Myers, 2018).

Nursing Intervention 3- To auscultate heart sounds noting the rhythm, rate, lung sounds and presence of S3, S4.

Rationale 3- It is because the new onset of the gallop rhythm, fine crackles in the lung bases and tachycardia can be the indication of heart failure. In case Brain develops pulmonary edema, this will present coarse crackles on having inspiration with severe dyspnoea (Urden, Stacy & Lough, 2017).

Nursing Intervention 4- If there is increase in preload, Brian’s sodium and fluids must be limited as per clinical orders.

Rationale 4- The fluid restriction reduces the fluid volume and also decreases the demands over the heart (Phelps, 2019).


Problem 2 Nursing Diagnostic Statement: Impaired gas exchangeR/T

It is evident as Brian has high breathing rate at 28 bpm and dysponoea on exertion, hypoxia on room air with SpO2 86%, breathlessness even at rest, is able to speak only in short sentences, central cyanosis at room air, accessory muscles of respiration including sternocleidomastoid and scalene muscles noted to be in use, and blood pressure is little elevated and fluctuating (Urden et al., 2017). The obesity and the effect of excessive fat mass over the lung function contribute to the risk of hypoxia. Congestive heart failure results in structural changes in lungs well accompanied by pulmonary edema. This is directly responsible for impacting the gas exchange efficacy. In Brian’s case, the causal factors responsible for impaired gas exchange are interstitial edema, changed alveolar fluid clearance and alveolar-capillary membrane hydrostatic injury (Levett-Jones, 2018).

Expected Outcome – Brian will maintain optimal gas exchange through the evidence of unlaboured respirations at 12-20 bpm, SpO2 95% or above, reduced or absence respiratory distress visible, and in complete regimen of his own capability and condition (DeLaune et al., 2016).

Nursing Intervention 1- To position Brian with the head of bed elevated defining the semi-Fowler’s position (that means head of bed to be positioned at 45 degrees when Brian is supine), but as per Brian’s toleration.

Rationale 1- The upright position or the semi-Fowler’s position permits raised thoracic capacity, raised lung expansion and complete descent of diaphragm that helps in preventing the crowding of the abdominal contents (Paliadelis, 2018).

Nursing Intervention 2- To turn Brian every 2 hours and monitor the mixed venous oxygen saturation with closed observation after turning. In case it drops less than 10% or actually fails to get back to baseline promptly, Brian must be turned back into the supine position with consistent evaluation of his oxygen status.

Rationale 2- The process of turning is necessary and imperative for preventing complications in immobility, but in the critically ill patients having decreased cardiac output or low hemoglobin levels, turning needs to be very well-managed or restricted as it can cause desaturation (Paliadelis, 2018).

Nursing Intervention 3- To have strict monitoring of Brian’s intake and output with strict restriction of his sodium and fluid intake.

Rationale 3- It is because maladaptive compensatory mechanisms being secondary to decreased cardiac output can result in excess of fluid volume and raise the intra-alveolar fluid that compromises gas exchange (DeLaune et al., 2016).

Nursing Intervention 4- To help Brian deep breath as tolerated and perform controlled coughing with demonstration.

Rationale 4- This technique assists in raising sputum clearance and reducing cough spasms. Controlled coughing makes use of diaphragmatic muscles to make cough more effective and forceful (Paliadelis, 2018).


Problem 3 Nursing Diagnostic Statement: Ineffective self-health management R/T

It is evident in the case from the poor regulation of blood pressure, taking diclofenac 25mg BD prn from last one week for lower back pain without consulting doctor that resulted in exacerbation of chronic heart failure, lack of knowledge about health management, poor weight management and low self-esteem. These behaviours can impact his heart failure prognosis as he also has the problems of overweight, type-2 diabetes and low level of physical activity that are greater contributing factors to cardiovascular diseases (Levett-Jones, 2018).

Expected Outcome 3 – Brian will verbalize the aim to have proper follow-up of defined regimen and presents the needed competencies and develop self-esteem with positive hope in life (Ingham-Broomfield, 2018).

Nursing Intervention 1- To permit Brian in planning the treatment regimen with short term goal preparation.

Rationale 1- Patients who are involved in the caring procedures have higher chance of attaining positive result. This will also help Brian to set realistic goals and overcome his fears (Luxford, 2018).

Nursing Intervention 2- To initiate referral to the support group in case Brian lacks enough support system in following the defined treatment regimen.

Rationale 2- The involvement in groups assure the patient that they have come together for a common support as well as knowledge to be helpful, certainly for patients who suffer from chronic illnesses (Luxford, 2018).

Nursing Intervention 3- To explain the regimen in an accurate way and in an easy way to be acknowledged best by Brian. The focus must be on suggesting long-acting mediations and elimination of unnecessary medicines.

Rationale 3- Patients have been found to disregard medications being taken multiple times a day and get frustrated with ongoing treatment process (Ladwig, Ackley & Makic, 2019).   

Nursing Intervention 4- To develop a method of rewards with Brian following a successful follow-through with key focus on behavioural change. This must be implemented with motivational interviewing.

Rationale 4- The rewards can consist of verbal recognition, special privileges like early appointments or addition of patient liking in the plan of care. With motivational interviewing, patient learns about one’s issues with a clear focus and develops solution also (Ladwig et al., 2019).


Problem 4 Nursing Diagnostic Statement: Risk for unstable blood glucose level R/T?

It is evident as Brian’s usual bBGL is 5.5-6.9 mmol/L (pre-prandial) and 8-10 mmol/L (post-prandial) with current results showing random BGL at 15 mmol/L at 1000 hours. This is a major risk for deteriorating his heart health. Moreover, lack of diet and exercise adherence and taking medications at one’s own level without clinical consultation are added dangers to his life and fluctuation of BGL. He also has stress about his health and life due to heart fafiure disease and this is adding more to imbalance BGL (Luxford, 2018).

Expected Outcome – Brian will have fasting BGL to be <5.5 mmol/L and the post-prandial BGL to be <11 mmol/L with haemoglobin A1C level <7% (Luxford, 2018).

Nursing Intervention 1- Brian needs to be assisted in identifying his eating patterns that need modification.

Rationale 1- This data defines the base for individualized dietary needs and instructions associated with the condition contributing to BGL fluctuation (Ladwig et al., 2019).  

Nursing Intervention 2- Brian should be counselled and educated about the importance of following defined diet plan and exercise plan.

Rationale 2- The prescribed plan assists patient in maintaining and being focused on assuring stable blood glucose levels (Dempsey et al., 2016).

Nursing Intervention 3- Brian needs to be referred to a registered diabetes dietician to assure individualized diet instruction.

Rationale 3- The individualized diet plan relies over patient’s BGL, weight, body type, activity patterns, and other present clinical conditions. When there is change in the patient’s food intake, it makes contribution to stabilized blood glucose levels (Luxford, 2018).

Nursing Intervention 4- To refer Brian to community nursing team for daily visit and updates about his health post-discharge and better health at home.

Rationale 4- Community nurses are the best and most experienced professionals to support patient at home with timely help, interventions and follow-up (Doenges, Moorhouse & Murr, 2016) 1291

Handover of care (use iSoBAR format)



Patient – Mr. Brian Edwards, Gender – M, Age – 67 years.

Marital Status- Married (40 years), Ethnicity- Anglo-Australian, Occupation- Retail Manager, Education:TAFE, Certificate IV Retail Management, Primary Language: English. Usual Health Practitioner: Dr.AdulKamar, Mary Street Practice, Yokine




Diagnosed with exacerbation of reduced ejection fraction (28%) Heart Failure “Class II - Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity. Diagnosis of Cardiomyopathy due to hypertension and subsequent development of Heart Failure

Current Diagnosis includes - Decreased cardiac output, Impaired gas exchange, Ineffective health management, Risk for an unstable blood glucose level.




Objective Assessment Data: - Random Blood Glucose Level 15 mmol/L, Weight 85 kg (4 kg more than usual weight),

Height 184 cm, Afebrile –temperature 36.5oC tympanic, Respirations: 28bpm, SPO2 on room air 86% and 94%, Pulse: 105bpm regular, Blood pressure: 145/85 mmHg, Heart Sounds S1 S2 and S3, systolic murmur grade 3 prominent over left apex area, 

Subjective Data: Diclofenac reaction Fluid restriction of 1200mls per day,

+3 pitting edema of lower legs to just below the knee and +3 sacral edema noted, Clammy to touch, Capillary refill 3 seconds all limbs.

Mild abdominal distension noted, liver margin palpated at the right costal margin, spleen not palpable, unable to participate in an exercise program in the last four days, Breathlessness at rest –able to currently walk ~ 5 metres before having to stop. Able to speak in short sentences only, accessory muscles of respiration including sternocleidomastoid and scalene muscles noted to be in use, Moist, not productive cough. Central cyanosis noted when on room air, breath sounds of fine inspiratory crackles heard bilaterally to mid-zone, No complaints of chest pain, sleeping difficulty, fear, & frustration regarding dietary restrictions and potential future danger associated with heart failure, poor medication knowledge.




Medical History- Type 2 Diabetes, Hypertension, Heart Disease. Previous Illness- Measles, Mumps, Chickenpox. Immunisations –Diphtheria, Tetanus, Smallpox, Tuberculin, Pneumonia, Previous Hospitalisation – Heart Failure in 2018.

Medication Reactions – Rashes due to Penicillin reaction allergies- Dust and Mite led conjunctivitis.

Dietary Habits- Diabetic diet, reduced-sodium in diet 2.3 grams per day, pre-prandial mane (usually 5.5 to 6.9 mmol/L), and postprandial morning (usually 8 to 10 mmol/L), Bodyweight usual 81 kg.

Skin: skin thinning, multiple solar keratotic lesions noted over arms and face, pitting edema of lower legs.

Physical activity – Usually participate in exercise for 30 minutes or resistive exercise per day.

Pulmonary Function: - Breathlessness noted on heavy exertion. Non-smoker.

Cardio-vascular function - Heart sounds S1 S2 with grade 1 systolic murmur prominent over the left apex area.
Musculoskeletal function - Bilateral range of movement in upper limbs and lower limbs.

Sleep Pattern – Usually takes 8-9 hours of sleep.

Sensory Perception- No issues with sensory perception.

Self- Concept – Patient is usually fearful and anxiety-prone

Coping Pattern – Exercise and Tai chi to manage stress.

No issues with the gastrointestinal, urinary, and reproductive system, no neurological issues noted.


Agreed Plan

Weight to be taken prior to breakfast. BD IV Frusemide as indicated, Blood pathology to be conducted as indicated in the care plan, Blood glucose level (BGL) monitoring QID and to contact the medical team via Shift Coordinator if BGL <5mmol/L or > 15 mmol/L, Oxygen therapy to maintain SPO2> 94% (vary between 0.5 to 4 LPM via Nasal prongs or 6 to 10 LPM via Hudson Mask), No diclofenac, communicate with the client to assess discomfort, needs and worries.



Read Back

Medication for heart failure to be administered as indicated, Oxygen supplementation to be strictly followed for Oxygen saturation level of 94% at room air, Semi-Fowler’s position to assist in respiratory distress, Monitoring of blood glucose level at frequent intervals as indicated, administration of medication for blood glucose level as indicated.




Discharge instructions: Guidelines to Follow at Home.


CHF Education is given & discussed. (Yes/No).

Sudden Cardiac Arrest teaching is given and discussed (Yes/No).

Lab Results: ProBNP-

                      Blood Urea Nitrogen (BUN)




                      Ejection Fraction-

Vital Signs: Heart Rate 65, Blood pressure 125/85, Respiratory Rate 16, SpO2 at room air 96%

Date: -



Blood glucose level: -Morning pre-prandial 6.5 mmol/L and postprandial 7 to 9 mmol/L nil change in diabetes medications.

Cardiac medications to be continued.

Heart failure medications: ceased IV Frusemide and oral Frusemide 40mg tab prescribed for daily prn if the weight goes up by 2Kg above usual weight (i.e., if it goes above 83 Kg).

The list of medications has been listed, prescribed, and the patient has been educated on medication administration and associated precautions to be taken.


Activity to be continued as instructed and demonstrated by the physiotherapist.

Exertion must be avoided and breaks during exercise are advocated.

Stop exercise if you feel shortness of breath and/or chest pain.

Breathe deeply in between the activities to promote better respiration and to avoid exertion.

Noted: Successful stair climbing test with the physiotherapist. No hypoxia noted or supplemental oxygenation required.


Refer dietician/ nutritionist as prescribed within 48 hours.

Adhere to physician-recommended diet and maintain the daily diet chart.

Low sodium diet and fluid restrictions as prescribed by the physician.


Continuous monitoring of Weight pre-breakfast.

Keep a log of weight details.

Notify doctor regularly about the weight changes.


No specific instructions for treatment or types of equipment mentioned.


§  If shortness of breath or difficulty in breathing observed.

§  Weight gain, excessive sweating, breaking out in the cold, feeling nauseated, light-headedness.

§  Clamminess or feeling cold.

§  Swelling of feet, hands, or abdomen.

§  Limited activity, feeling exhausted or tired, troubled sleeping, coughing, chest discomfort.

§  Feeling breathless even at rest.

§  Rapid Weight gain

Call 000 in case of emergency and do not wait more than five minutes if you get signs of heart failure.

RN Signature                                          Discharge Physician                               Patient