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Concept Map - Ned Flanders - Coggle Diagram
Concept Map - Ned Flanders
Introduction
Referred to A&E by GP
Worsening shortness of breath
Shortness of breath on exertion
Struggling to breath at rest
Struggles/worsening when lying flat
Reduced swelling when exercising
Bilateral oedema to both legs
Reduced appetite
Fatigue/previously active
Nursing assessment/diagnosis
Hand Hygiene, introduction to patient.
Vital signs- HR, BP, SPO2, RR, Temp.
cardiovascular assessment-
ECG and Echo.
Blood tests.
Findings from assessment:
Ned has raised jugular venous pressure.
On listening to chest: crackles on ausculation. Bilateral oedema to both legs, SOB, fatigued.
NANDA- I-
Ned jugular venous pressure could be slightly increased as he has pulmonary hypertension.
Diagnosis: From neds findings, sign & symptoms- Due to the sounds heard on auscultation- we query Pericardial disease.
A lot of Ned's signs & symptoms correlate with the same signs and symptoms of Pericardial disease.
NANDA-I- Early warning signs of health failure. In a echo, 40-55% = below normal heart function. Less than 40% may confirm heart failure. Signs & symptoms also indicate for heart failure include- SOB, with activity and lying down as stated. Fatigued, swelling in the leg, irregular heartbeat (Atrial fibrillation).
High BNP- 800pg/ml- indicates your heart is not functioning properly. BNP higher than 100pg can indicate heart failure. The higher the BNP the more likely heart failure is present and the more severe it is. In this case Ned's is 800.
Nurse-sensitive outcomes
A skin assesment bundle for his bilateral oedema and his age
Appropriate care adhered to reduce swelling and discomfort
Has breathlessness so appropriate medication eg nebulisers/inhalers/steroids
Reduced appetite so administration of suplements might be needed
Patient feels like a burden so nurse might talk with him or call the social worker for a chat or organise a meeting in the family room with his wife
Encouraging/assisting with meal times because of lack of appetite
Taking note of his medication and making sure no medication counteracts with another
Monitoring his alcohol intake
Taking note of his position and repositioning on bed
making sure patient is upright to prevent breathlessness
Educating patient about bed exercises due to reduced mobility
Educating patient about an active and healthy lifestyle and motivating the patient
Reflection on teamwork
Team work was achieved overall throughout this group assignment. Together, we made a group chat in order to discuss the work in which each person in the group would do. We evenly shared the group work and we all agreed to do our assigned parts. Communication was achieved by effectively communicating within the group chat when we needed help or a problem occurred. Each group member actively played a role in their part and we were all very happy with the teamwork and work put in.
Nursing Interventions
Care Plan -
Managing acute pain and discomfort (raising head of the bed as Ned is short of breath lying down flat). Maintaining skin integrity and preventing pressure ulcers (fatigued easily, may be in bed a lot,).
Reducing anxiety, fear and improving coping (new diagnosis for Ned, may be overwhelming and anxious due to change in lifestyle).
Initiating health teaching and patient education
Administering medication and providing pharmacological interventions (Ned already has a list of regular medication and may require additional meds now).
(Vera, 2019).
References
Vera, M. (2019). Heart failure nursing care plans: 15 nursing diagnosis. [online] Nurseslabs. Available at:
https://nurseslabs.com/heart-failure-nursing-care-plans/
.
Conclusion
In conclusion, we feel as though Ned's signs and symptoms indicate to him nearing heart failure. As a group we came to this decision based off of the information in our lectures, our Stage one practice and our clinical skills labs. We then planned our care plans and nursing interventions based off all of the knowledge in order to care for the patient appropriately.