1.Identify, prioritize, and describe at least four problems.
2.Provide substantiating evidence (assessment data) for each problem identified.
3.Identify and describe at least four medical and/or nursing interventions.
4.Discuss your rationale for the interventions identified.
Collaborative Learning Community: Home Visit with Sallie Mae Fisher
Identify, Prioritize, and Describe At Least Four Problems
Ms. Fisher has chronic congestive heart failure (CHF) history. She has been
experiencing CHF exacerbation. She has history of hypertension and atrial fibrillation. From
the review of system, the patient has the following problems (Albert, 2012);
a) Decreased cardiac output: this is attributable to the fact that the patient heart has reduced
capacity to meet her body`s metabolic requirements. The decrease in blood flow that supplies
the heart results into reduced cardiac output, which the causes the insufficient blood fail to
circulate to all the other body parts. This causes altered heart rate, weakness, and paleness.
CLC: HOME VISIT WITH SALLIE MAE FISHER 2
This problem is clinically manifested by irregular pulse rhythm, tachycardia and generalized
b) Fluid and electrolyte imbalance: the patient has not been taking a lot of fluids. The
imbalances are related to low fluid intake and use of diuretics.
c) Dyspnea episodes had been indicated in the discharge report, but the patient declined the
proposed intervention of using oxygen supplement.
d) Risk for imbalanced nutrition: associated with poor dietary intake.
Provide Substantiating Evidence (Assessment Data) For Each Problem Identified
The decreased cardiac output is indicated by the blood pressure of 90/56. The
insufficient blood circulation to the other parts of the body is the main cause of tachycardia.
The fluid and electrolyte imbalance is indicated by the patient’s skin condition. The patient
skin is tenting and coarse. This is an indicator that the patient’s body is not well hydrated.
When pinched, a hydrated skin goes back to the original state immediately. The assessment
also indicated that the mucous membranes are dry. The hypoactive bowel movement bowel
movement sounds, low blood pressure and her complaints that her mind is cloudy are
indicator for fluid and electrolyte imbalance (Hughes, 2013).
The episodes of dyspnea are evident by the fact that the patient discharge report had
requested for oxygen gas supplementation but the patient declined the treatment. This
indicates that the condition is still persistent as it was not managed. The patient risk for
imbalanced nutrition is indicated by the fact that the patient has lost 14 pounds within a span
of one week. This indicates that the patient has not been able to cook or she has no caregiver
to help her with her daily routine activities such as hygiene or feeding. She says that she has
no appetite and is still undergoing grief due to loss of her husband (Apostolo et al. 2012)
Identify and describe At Least Four Medical and/or Nursing Interventions and Their
CLC: HOME VISIT WITH SALLIE MAE FISHER 3
Nursing diagnosis Nursing intervention Rationale
Decreased cardiac output Abnormal heart lungs and
sounds will be assessed
Assess patient consciousness
and mental status
Assess skin temperature as
well as the peripheral pulses
This facilitates the detection
of renal failure associated with
fluid and electrolytes
This can be caused by
toxicity due to accumulation
of waste products caused by
impaired blood circulation.
This is manifested by the
patient condition of legarthy,
altered consciousness and
Reduced perfusion of oxygen
to the secondary tissue could
lead to decreased temperature
and diminished peripheral
Fluid and electrolyte
Monitor diagnostic tests and
Implement strategies to manage
fluid and electrolyte imbalances
Administer cardiac glycoside
agents as indicated, the nurse
should monitor toxicity
Assess risk for skin integrity
complication such as bed sores
Important as they provide
clues on patients response to
medication and statues of the
This helps reduce risks
associated with decreased
Digitalis is associated with
positive isotropic effect on the
myocardium. It also
strengthens contractility which
improves cardia output
Patient skin is at risk of
developing skin complication.
The patient should remain
hydrated reposition every two
hours to prevent bed sores
Episodes of dyspnea Oxygen saturation and ABGs
should be monitored
Patient should be given oxygen
as indicated by oxygen
saturation and ABGs report
This provides insights of
hearts ability to circulate and
perfuse the distal tissues with
This will provide the patient
with enough gas for gaseous
exchange. This will help
alleviate hypoxia and activity
CLC: HOME VISIT WITH SALLIE MAE FISHER 4
Patient is encouraged to make
This facilitates reduction of
cardiac overload, which
reduces myocardial oxygen
Imbalanced nutrition Assess patient ability to carry
out daily living activities such
as cooking, taking medication
right dosage and appropriate
time, shopping from the
groceries, cleaning the house
This will help check if the
patient has the capacity to take
care of herself, or there is
need to have a care giver with
her. This will also help
identify if there is medication
CLC: HOME VISIT WITH SALLIE MAE FISHER 5
Part B: SCRIPTED DIALOGUE PORTION
A: Health care: quality of life
Nurse: Good morning Salle Mae, I am Myre from Mt view Hospital. I am your nurse today.
I comprehend that you have not been feeling fatigued and shortness of breath. In general,
how would you describe your health?
Patient: In comparison to my health status a week ago, I would say my health fairly good.
But I am extremely weak and cannot do anything without losing of breath.
Nurse: I will read a list of activities that you would normally do on any typical day. After I
read each of them, please state if your current health limit’s them a little or more?’
Patient: Nurse, lately I have not been doing any activity other than resting on this couch.
Nurse: Why is so? Is that because of your health status?
Patient: Yes, I can barely manage to get myself a glass of water. Cooking has also become
an issue and I am relying on frozen foods.
Nurse: Okay, Salle, how do you feel? How things have things been with you since you were
discharged from hospital?
Patient: I feel helpless. I have not known peace for the last two weeks especially because I
am depending on other people for help. I am overburdening them. They would so much
better if I was not alive.
Nurse: What is some of the things do enjoy doing? How often do you get to do them
nowadays? What do you do on the weekends?
Patient: I love golfing. Normally, I would spend the weekends with my friend Penny playing
golf. However, since the regular hospitalization incidences, I am unable to join her and all I
do during the weekend is sleep.
CLC: HOME VISIT WITH SALLIE MAE FISHER 6
Nurse: I have noticed that you have been to the hospital a lot lately. How does this make you
feel? Would you like to tell me what else has been going on with your health?
Patient: This has made me loose energy. I am unable to understand why life has been this
tough. (She is acute distress). My energy levels are low and I seem to be very forgetful
Nurse: Salle, how has the heart failure affected you and how it kept you from living life the
way you have always wanted?
Patient: I am no longer able to do things the way I have always wanted because I have to sit
and rest a lot during the day. I lose breath even when walking for short distances like from
the bed room to the toilet. The shortness of breath has makes it difficult to sleep at night. I
feel tired and fatigued throughout the day.
Nurse: Salle, I would like to make you understand your symptoms. You have a health
condition which makes your heart fail to function properly. This makes it difficult to propel
enough blood to the other body organs of the body. This is explains why you have been
experiencing shortness of breath, activity intolerance and fatigue.
Patient: Is this why I have all these medications. They are just too many and sometimes I
forget to take some.
Nurse: Salle, the medications will help reduce your signs and symptoms. You must adhere to
medication. To ensure that you take medication all the time, you can put an alarm for
Patient: My mind is cloudy, what can I do to have a peaceful life?
Nurse: Salle, you need to have adequate rest. You must also adhere to medication. Try as
much as possible to maintain an active lifestyle such as talking a walk around the
neighbourhood. Importantly avoid prescribed medication alcohol or cigarettes.
Salle, do you feel sad living alone?
CLC: HOME VISIT WITH SALLIE MAE FISHER 7
Patient: Ever since Eddy left me (her eyes tears), I feel depressed.
Nurse: You really loved your husband, tell me more about him
Patient: He is the best thing that has ever happened to me. He was the funniest person ever
and kept very happy. He was hardworking and my best friend.
Nurse: Are there members of the family or community who regularly check on you? Whom
can you call for help when you are not feeling okay?
Patient: My daughter and best friend Penny. She lives few blocks down the street. Penny is
always checking on me and would prepare dinner for me when she visits.
Nurse: What about social workers and case managers? Do you mind if I contacted them to
discuss ways they can help you?
Patient: I do not really think that I am that needy, but it is okay, may be they too have
additional instructions of benefit to me
Nurse: that is okay, I will reach a social worker; she could be having ample solutions to that
will help you manage your health condition and obtain the appropriate social support.
Patient: Thank you so much.
Nurse: Meanwhile Salle, I would encourage you to remain active in church and prayer
groups. This will help you have improved sense of belonging. I will also enrol you to a
cardiac rehabilitation program at a health facility that targets the elderly population diagnosed
with CHF; it is a community where you meet with other people experiencing the same
I will see in five days. I want you to take the medication as requested, eat nutritious food to
help the body retain it energy. Try to remain active to avoid other complications associated
with congestive heart failure.
Patient: Alright nurse; thanks for checking on me.
CLC: HOME VISIT WITH SALLIE MAE FISHER 8
Albert, N. (2012). Fluid Management Strategies in Heart Failure. Critical Care Nurse, 32(2),
Apostolo, A., Giusti, G., Gargiulo, P., Bussotti, M., and Agostoni, P. (2012) Lungs in Heart
Failure. Pulmonary Medicine Volume 2012, Article ID 952741,
Hughes, R. (2013). Treatments to achieve fluid balance in heart failure. Br J Cardiac
Nursing, 8(11), 537-540.