Patient Profile
Name: Mr JD (pseudonym) | Age: 74 | Gender: Male
Admission: Emergency admission via ambulance following acute dyspnoea and bilateral leg swelling
Relevant History: Ischaemic heart disease (IHD), hypertension, Type 2 diabetes mellitus, previous MI (2019)
Medications on Admission: Bisoprolol 5mg OD, Ramipril 10mg OD, Furosemide 40mg OD, Aspirin 75mg OD, Atorvastatin 80mg OD, Metformin 500mg BD
Presenting Complaint & Assessment
Subjective Data
Mr JD reported severe breathlessness at rest, worse when lying flat (orthopnoea), waking at night gasping for air (paroxysmal nocturnal dyspnoea), and progressive bilateral ankle swelling over five days. He rated his breathlessness as 9/10 on the Modified Borg Scale. He reported not taking his Furosemide for three days due to running out of his prescription.
Objective Data
Vital Signs: HR 110 bpm (irregularly irregular — AF confirmed on ECG), BP 158/96 mmHg, RR 28/min, SpO₂ 88% on air, Temp 36.8°C, NEWS2 score: 9 (high risk)
Physical Examination: Bilateral crackles at lung bases, raised JVP (+4cm), S3 gallop rhythm, 3+ bilateral pitting oedema to the knee, sacral oedema
Investigations: BNP 1,840 pg/mL (markedly elevated), Troponin I 38 ng/L, eGFR 44 ml/min, Na⁺ 133 mmol/L, K⁺ 3.2 mmol/L, CXR: cardiomegaly, bilateral pulmonary oedema, Kerley B lines
Nursing Diagnoses (NANDA-I)
Priority 1: Impaired Gas Exchange
Related to: Fluid accumulation in the alveolar spaces secondary to left ventricular failure
As evidenced by: SpO₂ 88%, RR 28/min, dyspnoea at rest, bilateral basal crackles on auscultation
Priority 2: Excess Fluid Volume
Related to: Compromised regulatory mechanisms secondary to heart failure and non-adherence to diuretic therapy
As evidenced by: BNP 1,840 pg/mL, 3+ bilateral pitting oedema, weight gain of 4.5 kg in 5 days, raised JVP
Priority 3: Decreased Cardiac Output
Related to: Altered cardiac rhythm (AF), reduced ventricular contractility, and increased afterload
As evidenced by: HR 110 bpm (irregular), BP 158/96 mmHg, S3 gallop, SpO₂ 88%
Nursing Care Plan — Priority 1: Impaired Gas Exchange
NOC Goal: Patient will maintain SpO₂ ≥ 95% within 4 hours of intervention commencement and report dyspnoea ≤ 4/10 within 24 hours.
NIC Interventions:
1. Administer controlled oxygen therapy via 28% Venturi mask, titrating to target SpO₂ 94–96%; reassess every 15 minutes. Rationale: Supplemental oxygen corrects hypoxaemia and reduces the work of breathing (O’Driscoll et al., 2017).
2. Position patient upright at 45–60° (high Fowler’s position) to reduce preload and maximise diaphragmatic excursion. Rationale: Orthopnoeic positioning redistributes pulmonary blood flow away from dependent lung zones (NICE, 2019).
3. Administer IV Furosemide 80mg as prescribed; monitor urine output hourly via urinary catheter. Rationale: Loop diuretics reduce ventricular preload within 30 minutes via venodilation and 2–4 hours via diuresis (Ponikowski et al., 2016).
4. Continuously monitor SpO₂, RR, HR, and BP; escalate immediately if NEWS2 worsens. Rationale: Early detection of clinical deterioration allows timely intervention (Royal College of Physicians, 2017).
Evaluation
After 6 hours: SpO₂ improved to 96% on 2L nasal cannula, RR reduced to 18/min, urine output 450ml/hour for first 2 hours then 120ml/hour. Patient reports dyspnoea 5/10. Goal partially met — continue current management and reassess in 4 hours. Potassium supplementation commenced due to K⁺ 3.2 mmol/L.
