Nursing Care Plan For Ms. Martha Foley With Pulmonary Edema

Part 1: Observation chart and interpretation

Developing nursing care plan is a complex task involving correct identification of  patient’s problem and selecting appropriate intervention to address the problem. This process is facilitated by the use of several clinical assessment tools that gives an indication of improvement of deterioration in patient’s health status. Based on this evaluation of patient, standardised and evidenced-based holistic care plan can  be made (Ackley,  Ladwig, and Makic, 2016). This whole process of assessment planning care is discussed in this report by the analysis of the case scenario of Ms Martha Foley, a 35  year old lady with risk pulmonary oedema. The report analyse the patient’s scenario by means of observation chart and HHHS fluid balance chart. Based on the assessment of patients through this chart, effective care plan is provided for the recovery of patient and with support from evidence based rationales. The report also gives an explanation about the inter-professional model of  care required for Mrs. Foley.

Mr Martha Foley  has been admitted in the emergency department suffering multiple fractures in legs due to a car accident. The observation chart and the HHHS fluid balance chart of patient gives the following information:

Table: Fluid Balance Chart (HSSS)

Time	Oral/enteric intake Save Time On Research and Writing Hire a Pro to Write You a 100% Plagiarism-Free Paper. Get My Paper	IV fluids	mls/ IN	Program		Urine/mls
12:00:00 AM	NBM	compound		Total
1:00:00 AM		sodium	200	input		100
2:00:00 AM		intake	200
3:00:00 AM		1000mls	200
4:00:00 AM			200
5:00:00 AM			200
6:00:00 AM			200
7:00:00 AM			200
8:00:00 AM			200
9:00:00 AM
10:00:00 AM
11:00:00 AM
12:00:00 PM
1:00:00 PM
2:00:00 PM
3:00:00 PM
4:00:00 PM
5:00:00 PM
6:00:00 PM
7:00:00 PM
8:00:00 PM
9:00:00 PM
10:00:00 PM
11:00:00 PM
12:00:00 AM
total intake				1600	total	100
					output
Current Balance	Posiitve 1500mls
Pevious Balance	Positive 1900mls
Cumulative Balance	Positive 3400mls

                       

Table 2: Observation chart

                       

• 2/10 pain
• Shortness of breathing and greater work of breathing up to 25 respiratory rates per  minutes
• Oxygen saturation dropping to 80% on room temperature and return of oxygen saturation to  95% after using the four pillows
• Vital sign progressing towards hypotension with tachycardia
• No ooze or redness from wounds
• Ms Foley is dyspoenic and shows symptoms of cyanosis

Based on the vital sign assessment of Ms Foley, it can be said her vital sign are fluctuating consistently. After her multiple trips to theatre for fracture treatment and fixation of ankle, her breathing rate has been a major issue. The fluctuation in respiratory rate led to shortened of breath, tachycardia and dyspnea. This made her desperate for ar. This symptom was also seen because of the condition of pulmonary oedema where accumulation of fluids in the tissues and spaces of lungs created gas exchange problem and respiratory failure in patient (Vadász and Sznajder 2017). Hence, nursing intervention in this area is critical. Secondly, other areas where adequate nursing care plan is necessary for patients includes managing her orientation, pain, wound site on hip, fluid balance, adequate sleep and emotional problems in patient.

Pulmonary oedema is generally caused due to the increase in the capillary hydrostatic pressure secondary to the increased level of pulmonary venous pressure. Pulmonary oedema can be caused due to the damage in the alveolar capillary barrier, lymphatic obstruction. Increased pulmonary capillary pressure decreased plasma oncotic pressure and raised level of negative interstitial pressure (Inamasu et al., 2012). Pulmonary oedema can cause acute respiratory distress, which may lead to acute and decompensate heart failure. This is caused due to the left ventricular systolic or the dysfunction in the diastolic pressure. In an acute pulmonary oedema can be caused by the overload of the primary fluid in the lungs, hypertension and renal arterial stenosis. The alveolar space of the lungs gets filled up with fluids due to the absence of the elevated pulmonary capillary pressure (Vandse et al., 2012).  It has been noted in the above report that Ms Foley was diagnosed with pulmonary oedema after she was encountered with a serious accident of a car and a tree crash. A severe pulmonary oedema can be caused due to severe accidents which may lead to lung collapse giving rise to pulmonary oedema. Researches have found that a chronic lung collapse can cause thickening of the capillary endothelium by the release of interleukins. On expansion of the lung the microvessels are stretched which harms the endothelial cells. It has been reported that MS Foley was also a smoker. It has been found that smokers have an increased chance of developing pulmonary edema than those who are non smokers. The signs and symptoms shown by Ms Foley also align with the general symptoms that occur in an pulmonary oedema.

Pathophysiological knowledge related to the scenario

The following are the nursing care required for Ms. Foley:

Nursing action:

To manage the respiratory function of Ms Foley, the nurse needs assess the patient’s conditions and vital signs after every 30 minutes. This will help to take immediate actions when breathing rate deteriorates. Patient can be made to relax by promoting oxygenation and placing the patient in a Fowler’s position. The nurse can ask patient to breath slowly if hyperventialing and teach them breathing techniques to enhance strength and activity tolerance (Valenza et al. 2014). In severe case, cough also impairs respiratory exchange, so teaching patient effective breathing technique will be important to provide relied to her.

Rationale:

 As Ms Foley has been admitted to the hospital after a car accident, she is at high risk of pulmonary oedema due to the injury to the lungs. As the accumulation of fluid in lung tissues impairs gas exchange in patients, improving respiratory function of patient is a vital nursing intervention. Changing the position of patients also help a lot to provide relief to patients with poor respiratory status (Kubota et al. 2017). The prone and upright position helps to enhance the oxygenation rate. Another advantage of placing the patient in a fowler’s position is that improves patient’s tolerance for enteral feeding too (Richard and Lefebvre 2011).

Evaluation:

The stability in the normal breathing rate and pulse rate of patients will gives the idea that breathing rate of patient has improved. In such case, oxygen saturation rate will also improve and oxygen requirements may be discontinued.

Nursing  action:

• Ms Foley is a heavy smoker, so she needs to discontinue smoking to prevent extra complications.
• To decrease the accumulation of fluids in lungs, the nurse needs to provide diuretics to patients
• Other fluids given to her must be balanced to reduce the symptoms of  pulmonary edema
• The nurse also needs to monitor urine output in patient to assess fluid overload

Rationale:

For patients like Foley, quitting smoking is important because it increases the likelihood of mucus production, damage of bronchial walls and leads to reduction in oxygen availability (Varol et al. 2015).

Management of fluid is specifically important for Ms Foley because she had a past medical history of congenital heart failure. Hence, for such patients, fluid overload results in adverse outcomes. Although diuretics are the main treatment for fluid balance, monitoring other fluid and enteral intake in patient is critical for recovery. Patients with heart failure are at high rate of peripheral edema because renal perfusion decreases in such patient (Kelm et al. 2015).

Evaluation:

The success of the intervention can be evaluated on the basis of balanced intake and stable weight in patient. Assessment of lung sounds can also assist nurse in managing symptoms of patients. Secondly, assessment of weight in relation to nutritional status helps to identify whether fluid intake is balanced or retained in patients

Nursing care plan

Nursing actions:

• Monitor the size, depth, odour and drainage from wounds
• Promoting the integrity of wounds by regular dressing and infection control
• Evaluate the characteristics of pain
• Assess vital signs of tachycardia and hypertension in patient
• Regularly identify the cause of discomfort in patient
• Identify additional comfort measures in patients

Rationale:

As Ms Foley has had a ankle resection and other surgeries on hip, regularly monitoring her wound and addressing pain is critical for recovery. Vital signs assessment is also an important indicator for managing pain because it gives an indication of level of discomfort in patient (Ross, 2017). Certain comfort measures like position change, relaxation techniques and oral care reduces pain and stress and anxiety (Mahler 2017).

Evaluation:

Stability in vital signs and decrease in discomfort of patient is an indicator for effective pain management.

The case study provides with the idea that Ms. Foley was suffering from respiratory distress. She was suffering from shortness of breath and greater work of breathing (WOB), her respiratory rate was increased up to 25Rpm and her oxygen saturation is dropping to 80%. The initial management of the pulmonary oedema should involve the ABCs of resuscitation which is – airway, breathing and circulation. Methods of oxygen delivery that can be used are the provision of a face mask, non invasive pressure support ventilation, mechanical ventilation and intubation (Lenglet et al., 2012).

 Oxygen saturation level below 80% refers that the pressure of the oxygen in the blood is too low to penetrate the walls of the red blood cells. In case of persistent hypoxemia, acidosis, intubation or mechanical ventilation can be required (Sztrymf et al., 2012). A patient with severe pulmonary oedema would require non-invasive pressure support ventilation. Intra aortic balloon pumping can be given to improve the coronary blood flow. It has been reported that she was desperate for air and is dyspnoeic (Matthay, Ware and Zimmerman, 2012). In order to treat the dyspnea, it is required to use bronchodialators to open the airway. Steroids can be provided to reduce the swellings in the lungs. Broncodialators can be introduced by subcutaneous injections (Lenglet et al., 2012). Albuterol sulphate and ipratropium bromide are normally used in the treatment of dyspnea.

Interprofessional models of care, refers to the involvement of a group of professionals from different specialisation to cater to provide care to a specific patient (Davison et al., 2012). The diagnosis of the pulmonary oedema relies on the medical examination, appropriate investigations and on medical history. In this case history it can be clearly seen that Ms Foley had been suffering from respiratory distress, therefore the specialised clinicians should focus on the procedures to treat the respiratory problems. Giving oxygen should be the first step to treat pulmonary oedema (Thille et al., 2013). Medications like Preload reducers. Morphines , afterload reducers and medications for maintaining the blood pressure is usually given (Davison et al., 2012).  The registered nurse standards should follow the given standards:-

• She should be able to think critically and analyse the nursing practice.

In this report it can be seen that throughout the course of the illness she had been suffering from respiratory distress. So oxygen should be administered accordingly. The patient should be kept in a fowler position to increase the lung expansion (Morrow et al., 2012).

• Nurses should engage in therapeutics and professional relationships.
• Should conduct assessment.

A registered nurse should carefully assess the patient’s condition and monitor the improvement or any further deterioration, complications should be watched for like electrolyte depletion. The vital signs should be monitored every 15 to 30 minutes (Morrow et al., 2012).

• Chalking out specific nursing plans-

A registered nurse should urge the patient to adhere to the prescribed medication.

• Should explain the whole scenario to Ms Foley’s family.
• Should emphasize on the early signs of the fluid upload.
• Should provide mental support to the patient, since this can lead to deterioration of the conditions. All the prescribed medications should be reviewed.

Acute pulmonary oedema can cause mortality and morbidity if not properly treated. It has been reported that current treatment of pulmonary oedema focuses in the symptomatic treatment, but also focuses on preventing the transition of pulmonary oedema to a complete heart failure (Villar,  Kacmarek  and Guérin, 2014). Recent studies have found that pharmacological treatment has not much improved the high mortality and the morbidity rate. A holistic care of approach is required to deal with the patients having acute pulmonary oedema.

Conclusion:

From the case  analysis of Ms Foley, the complications and risk present in patient with pulmonary oedema can be easily identified. As she was a smoker and had sustained injuries due to car accident, the risk for pulmonary edema was high in patient. Her clinical presentation and vital sign assessment also revealed complications related to pulmonary oedema such as poor breathing rate and impaired gas exchange. Hence, nursing care plan mainly focused on improving breathing rate of patient, managing fluid uptake and managing pain and integrity of wounds. Such comprehensive nursing care plan are vital for routine care and recovery of patients with pulmonary edema.

Reference:

Ackley, B.J., Ladwig, G.B. and Makic, M.B.F., 2016. Nursing Diagnosis Handbook-E-Book: An Evidence-Based Guide to Planning Care. Elsevier Health Sciences.

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