DOMINICA STATE COLLEGE

Faculty of Health Sciences

NURSING PROCESS

BNUR212

NURSING PLAN OF CARE WITH CONCEPT MAP

Presented to
Mrs. Beverley Fontaine
by

Ms. Kimon Augustine

ID# 24-1981

NOVEMBER 16th 2024.

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 Table of Contents

INTRODUCTION...................................................................................................3

DEMOGRAPHIC DATA.........................................................................................5

PATHOPHYSIOLOGY OF CONGESTIVE HEART FAILURE...............................5

MEDICAL MANAGEMENT OF CONGESTIVE HEART FAILURE........................7

SYNOPSIS OF THE FRAMEWORK/MODEL USED.............................................9

ASSESSMENT DATA......................................................................................... 10

ANALYSIS AND SYNTHESIS OF DATA............................................................12

NURSING DIAGNOSIS.......................................................................................13

ALTERATION OF BASIC NEEDS.......................................................................15

RELEVANCE OF BASIC NEEDS IN LIGHT OF CONDITION............................16

EXPECTED GOALS............................................................................................17

NURSING INTERVENTIONS..............................................................................19

EVALUATION OF OUTCOMES..........................................................................21

CONCLUSION.................................................................................................... 23

BIBLIOGRAPHY AND FORMAT.........................................................................25

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 INTRODUCTION

Congestive Heart Failure (CHF) is a progressive, disabling condition in which the

heart cannot adequately pump blood, and therefore lacks tissue perfusion and

fluid retention. This syndrome has millions of cases in the world and is more

prevalent among the elderly. Mrs. J was a schoolteacher aged 62, who was

admitted to the hospital with severe headache, dizziness, weakness, shortness

of breath on exertion, intermittent cough and loss of appetite. Her background of

chronic hypertension (sometimes uncontrolled due to medication non-medication

lapses) most likely paved the way for her heart failure.

Having high blood pressure leads to CHF, where the heart must work harder for

long periods, the heart muscle is stiffened over time. Mrs. J has new-onset CHF,

but her sedentary condition is accompanied by a high blood pressure (180/110

mmHg) and clinical symptoms including pulmonary congestion (i.e., wheezing

and shortness of breath) and peripheral edema. The combination of these

symptoms, as well as her fast heartbeat and mild swelling of her lower

extremities, would suggest that her heart’s capacity to carry blood is

compromised.

In this article, one will learn the pathophysiology of congestive heart failure and

the mechanisms that cause the disease. Also, discussions on the systematically

medical treatment options such as medication, changes in lifestyle, and fluid

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management. With this clinical case analysis, we shall explore some important

nursing diagnoses, an appropriate nursing care plan, and some key nursing

interventions for improving Mrs. J’s health. My intention with this paper is to give

emphasis on early diagnosis, targeted therapy and patient education in the

treatment of heart failure, and ongoing research to improve treatment.

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 DEMOGRAPHIC DATA

Clients Initials: Mrs. J

Age: 62 years

Sex: Female

Occupation: School Teacher

Diagnosis: New onset congestive heart failure

Marital Status: Married

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 PATHOPHYSIOLOGY OF CONGESTIVE HEART FAILURE

Newly diagnosed congestive heart failure is a physiological condition in which the

heart cannot pump enough blood to meet the metabolic needs of the body. This

clinically complex disease can be caused by a number of problems, including

excessive peripheral demands such as elevated blood pressure, fluid overload,

primary muscle disease, or high-output disorders. While the contractility of the

heart muscle is reduced in the typical form of heart failure, congestive heart

failure can be caused by functional or structural heart disorders that impair the

ability of the ventricles to fill or eject blood. Reduced cardiac output is produced,

which is insufficient to meet the peripheral needs of the body.

There are four major determinants of left ventricular (LV) performance which are

generally diverse: (i.) There is an intrinsic decrease in muscle contractility, which

means that the myocardial cells have an intrinsic contractile capacity, indicating

the pumping capacity of the heart muscle. (ii.) Left atrial preload or filling

pressure increases, leading to pulmonary congestion and dyspnea. (iii.) Systemic

blood pressure is often reduced, but systemic vascular resistance (afterload)

increases, which may further reduce cardiac output. (iv.) Heart rate usually

increases as part of a compensatory mechanism related to increased

sympathetic tone and circulating catecholamines.

In summary, ventricular dysfunction can occur for two reasons: 1. Systolic

contraction failure (systolic dysfunction), the left ventricle cannot contract

properly during systole. This occurs due to myocardial disease or damage, such

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as myocardial infarction or cardiomyopathy. 2. Diastolic relaxation disorder

(diastolic dysfunction), when the ventricles do not relax properly during diastole,

the myocardium becomes ventricular hypertrophy or restrictive cardiomyopathy

due to abnormal relaxation or stiffness.

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 MEDICAL MANAGEMENT OF CONGESTIVE HEART FAILURE

The medical management of Congestive heart failure includes:

Diuretics (e.g., Furosemide) - to reduce fluid overload and relieve symptoms of

congestion

ACE Inhibitors or ARBS (e.g. Lisinopril) - to lower blood pressure and decrease

heart workload

Beta Blockers (e.g., metoprolol) - to control the heart rate

Close monitoring of weight and symptoms

Lifestyle modifications such as sodium restriction and increased physical activity.

Cardiac Glycosides

Surgical

Revascularization

Angioplasty, CABG

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Valve Repair/ Replacement

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 SYNOPSIS OF THE FRAMEWORK/MODEL USED

The nursing process framework, which includes assessment, diagnosis,

planning, implementation, and evaluation, will be applied. This systematic

approach ensures comprehensive care is tailored to Mrs. J's specific needs. The

Roy Adaptation Model can be applied, because it focuses on helping patients

adapt to changes in health, by modifying their environment, supporting

physiological and psychological needs, and promoting overall health.

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 ASSESSMENT DATA

Subjective data:

 Severe headache

 Dizziness

 Weakness,

 Shortness of breath when lying down

 Loss of appetite

 Non-adherence to her medication due to forgetfulness

 Throbbing headache and light-headedness

 Works as a school teacher and lives with her husband

 62 years

 Patient name is Mrs J

 Lives a sedentary lifestyle

 coughing

Objective Data:

 Vital Signs: BP 180/110 mmHg (hypertensive crisis), HR 120 bpm

(tachycardia), RR 24 breaths/min (Elevated), Oxygen Saturation 93%

(Mild hypoxia), Temperature 98.6°F (normal), Blood glucose 135 mg/dl

(slightly elevated)

 Physical Findings: Warm, dry skin, moderate swelling in legs, ankles and

feet, wheezing, irregular heart rate

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 Medical history and family history of hypertension and heart disease

ANALYSIS AND SYNTHESIS OF DATA

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Mrs J’s symptoms of shortness of breath, dizziness, fatigue, edema, and

hypertension, combined with the objective data of wheezing and an irregular

heart rate, suggest acute congestive heart failure (CHF) with potential pulmonary

and systemic congestion. Her sedentary lifestyle and occasional non-adherence

to medications may have contributed significantly to her condition. History alone

is insufficient to make the diagnosis of heart failure but often provides clues to

the cause (myocardial infarction or uncontrolled hypertension), the

noncompliance with diet or medications, and the severity. The symptoms of heart

failure can be related to either the reduction of cardiac

output (fatigue, weakness) or excess fluid retention (dyspnea, and cardiac

wheezing). Fluid retention also results in peripheral edema and occasionally

increases abdominal girth secondary to ascites. A comprehensive assessment of

the heart muscles, including the evaluation of its pumping action is necessary to

know the thickness of the walls. Imaging can help by performing

echocardiography to evaluate chamber dimensions, valve function, and more.

NURSING DIAGNOSIS

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Actual Nursing Diagnosis

 Impaired Gas Exchange related to pulmonary congestion as evidenced by

wheezing, shortness of breath, and oxygen saturation of 93%.

Rationale: CHF leads to fluid accumulation in the lungs, impairing gas exchange

and causing symptoms like dyspnea and low oxygen levels.

 Decreased Cardiac Output related to impaired myocardial function as

evidenced by signs of fatigue, dyspnea, abnormal heart rate and blood

pressure

Rationale: Decreased cardiac output in CHF leads to poor oxygen delivery to

tissues, causing fatigue.

 Imbalanced Nutrition; less than body requirements related to loss of

appetite as evidenced by patient verbalization.

Rationale: Congestive heart failure risk factors include altered metabolism

and decreased appetite.

Potential Nursing Diagnosis

 Risk for Decreased Activity Tolerance related to weakness and shortness

of breath

Rationale: Congestive heart failure significantly limits physical capacity

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 Risk for Impaired Skin Integrity related to edema and dry skin.

Rationale: Swelling can lead to skin breakdown and ulcers

ALTERATION OF BASIC NEEDS

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Mrs. J's basic needs which include oxygenation, nutrition, and safety, are

altered due to her heart failure. In accordance to Maslow’s hierarchy of

needs, Mrs J experiences difficulty breathing most critical for living which is

considered a Physiological need. Her inadequate nutritional intake and

increased risk for falls due to dizziness and weakness are needs that are also

altered.

Low oxygen saturation results from impaired oxygenation brought on by the

congestion of the lungs.

Nutrition: Modified as a result of decreased appetite, which may lead to

dehydration or malnutrition.

Elimination: Possible risk because of gastrointestinal issues and fluid

retention.

RELEVANCE OF BASIC NEEDS IN LIGHT OF CONDITION

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 Physiological Needs is of major priority due to the immediate concerns of

impaired oxygenation, fluid overload, and the risk of further cardiac

decline.

 Safety becomes critical as Mrs. J's irregular heart rate, weakness and

dizziness could lead to falls or accidents.

 Social and Emotional Support will help address Mrs J’s possible non-

compliance and provide the emotional resources needed to manage her

chronic illness.

EXPECTED GOALS

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 1. Goal: The patient will improve oxygen saturation within the normal 95%-

100% range in 8 hrs.

Rationale: Adequate oxygenation is critical for reducing symptoms of hypoxia

and improving overall comfort and energy levels.

2. Goal: Reduce peripheral edema in the next 48 hrs.

Rationale: Diuretic therapy can help reduce fluid overload and decrease swelling,

improving comfort and decreasing the workload on the heart.

3. Goal: The patient will achieve blood pressure control by at least less than

140/90 mmHg within 24 hours.

Rationale: Managing high blood pressure can prevent further cardiac damage

and reduce the strain on the heart.

4. Goal: Increase patient medication adherence by setting up a reminder

system (alarm).

Rationale: Noncompliance can worsen congestive heart failure symptoms, so

increasing adherence can improve disease control.

5. Goal: The patient will maintain a heart rate of less than 100 BPM within 24

hours.

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Rationale: Reducing tachycardia improves cardiac efficiency and reduces the risk

of arrhythmias.

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 NURSING INTERVENTIONS

 Initiate interventions to decrease cardiac output (e.g., palpate peripheral

pulses, auscultate apical pulse, comprehensive health history focusing on

signs and symptoms of worsening heart failure, etc...)

Rationale: this can help prevent the progression of the disease and decrease the

risk of complications. Early recognition and management of decreased cardiac

output can improve patient outcomes and quality of life.

 Maintaining and improving respiratory functions by administering oxygen

therapy as instructed

Rationale: To improve oxygen saturation and reduce symptoms of hypoxia. As

heart failure progresses it may lead to fluid accumulation in the lungs causing

respiratory symptoms and compromised breathing.

 Administer prescribed medications (e.g., Furosemide) and monitor for side

effects as well as monitor for serum potassium levels regularly and report

any abnormalities (e.g., hypotension, electrolyte imbalances).

Rationale: Diuretics are essential for reducing blood volume, therefore,

decreasing venous pressure, arterial pressure, pulmonary edema and improved

breathing.

 Monitor vital signs repeatedly, including heart rate and blood pressure.
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Rationale: Frequent monitoring helps track the effectiveness of interventions and

detect any severe fluctuations in blood pressure or heart rate.

 Implement a medication alarm system and provide education on the

importance of complying.

Rationale: To improve medication compliance in order to prevent the

aggravation of chronic heart failure due to missed doses.

 Provide comfort actions for pain and discomfort, such as positioning the

leg to reduce edema and using cool compresses for headaches.

Rationale: Comfort measures help improve overall well-being and patient

satisfaction.

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 EVALUATION OF OUTCOMES

 Oxygen saturation improved to 95% after 4 hours of oxygen therapy.

 Peripheral edema reduced by 1 kg within 48 hrs. of diuretic therapy.

 Blood pressure decreased to 150/90 mmHg after 12 hours and maintained

below 140/90 mmHg in 24 hours.

 Patient reported improved compliance after using the alarm system.

 Heart rate reduced to 95 BPM within 16 hours.

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 CONCLUSION

Congestive heart failure (CHF) remains a serious clinical problem, particularly in

patients like Mrs. J, whose underlying hypertension progressively weakens the

heart’s ability to pump blood effectively. Mrs. J’s case highlights the critical role of

early detection, comprehensive treatment, and patient education in improving

outcomes in patients with heart failure.

The pathophysiological mechanisms that drive CHF, including fluid retention,

impaired gas exchange, and cardiac remodeling, requires a multifaceted

approach to treatment that combines pharmacological interventions, lifestyle

changes, and careful monitoring. The nursing intervention and management plan

developed for Mrs. J is based on evidence-based practices that aim to alleviate

symptoms, improve medication adherence, manage fluid overload, and improve

overall quality of life.

By addressing both the physical and psychosocial aspects of CHF, healthcare

providers can help patients manage their condition more effectively, ultimately

reducing hospitalizations and preventing further deterioration of cardiac function.

By carefully integrating medical and nursing care, promoting self-management,

and focusing on preventing complications, patients like Mrs. J can achieve better

symptom control and a higher quality of life. This case also reinforces the need

for continued research and individualized treatment approaches that meet the

unique needs of each patient.

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In conclusion, while CHF poses serious challenges, a holistic, patient-centered

approach to treatment, can lead to better outcomes and longer life expectancy

for those afflicted.

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 BIBLIOGRAPHY AND FORMAT

1. Bolger, A. P., Coats, A. J., & Gatzoulis, M. A. (2003). Congenital heart

disease: the original heart failure syndrome. European Heart Journal,

24(10), 970-976.

2. Krämer, B. K., Schweda, F., & Riegger, G. A. (1999). Diuretic treatment

and diuretic resistance in heart failure. The American journal of medicine,

106(1), 90-96.

3. Brennan, E. J. (2018). Chronic heart failure nursing: integrated

multidisciplinary care. British Journal of Nursing, 27(12), 681-688.

4. Cowie, M. R., & Mendez, G. F. (2002). BNP and congestive heart failure.

Progress in cardiovascular diseases, 44(4), 293-321.

5. Jaarsma, T., Strömberg, A., De Geest, S., Fridlund, B., Heikkila, J.,

Mårtensson, J., & Thompson, D. R. (2006). Heart failure management

programmes in Europe. European Journal of Cardiovascular Nursing,

5(3), 197-205.

6. Kemp, C. D., & Conte, J. V. (2012). The pathophysiology of heart failure.

Cardiovascular Pathology, 21(5), 365-371.

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7. Krämer, B. K., Schweda, F., & Riegger, G. A. (1999). Diuretic treatment

and diuretic resistance in heart failure. The American journal of medicine,

106(1), 90-96.

8. Maisel, W. H., & Stevenson, L. W. (2003). Atrial fibrillation in heart failure:

epidemiology, pathophysiology, and rationale for therapy. The American

journal of cardiology, 91(6), 2-8.

9. Nurses labs. (2010). Nursing care plans and nursing diagnosis guide.

Nurses labs. https://nurseslabs.com/nursing-care-plans/.

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