Adult heart failure nursing case study and care plan

Assessment 2: Adult Health Nursing Case Study and Focused Care Plan

(Individual Written Assignment)

Unit / Course

NUR Adult Health Nursing / Medical–Surgical Nursing II (BSN level)

Weighting and Length

Weight: 30% of final grade

Length: 1,500–2,000-word written case study analysis and nursing care plan (excluding title page and reference list), or an equivalent 4–6 page paper if your institution uses page counts for written assignments.

Due Date and Submission

• Due: End of Week 6 (Sunday, 23:59 local campus time).

• Submission: Via the Learning Management System (LMS) in Word or PDF format only.

• Academic integrity check: All submissions will be screened using similarity detection software in accordance with university policy.

Assessment Type and Level

Assessment type: Individual written case study analysis and nursing care plan.

Course level: Undergraduate BSN (Year 2–3), mapped to program learning outcomes related to clinical reasoning, evidence-based practice, and professional communication.

Assessment Overview

In this assessment, you will analyse an adult medical–surgical patient scenario, apply the nursing process to identify priority problems, and develop an evidence-based, person-centred nursing care plan. The task is designed to strengthen clinical reasoning skills, particularly the ability to link assessment data to nursing diagnoses and to justify planned interventions using contemporary research and clinical guidelines.

The assignment also assesses your written communication skills and your ability to reference scholarly sources accurately using the citation style specified by your program, such as APA 7th edition or Harvard.

Learning Outcomes

On successful completion of this assessment, you should be able to:

• Collect and interpret relevant subjective and objective data from an adult patient case to identify actual and potential health problems.

• Formulate at least two priority nursing diagnoses or nursing problems and justify their selection using clinical reasoning and current evidence.

• Develop a focused, patient-centred nursing care plan that includes measurable goals, rationales, and evaluation criteria for each intervention.

• Integrate recent, peer-reviewed literature and current clinical guidelines to support nursing assessments and interventions.

• Communicate clinical reasoning in clear, structured academic writing that meets professional and ethical standards in nursing practice.

Case Study Scenario

You are working as a registered nurse on a general medical ward caring for Mr. Daniel Carter, a 64-year-old man admitted with an acute exacerbation of chronic heart failure, type 2 diabetes mellitus, and long-standing hypertension. Mr. Carter lives alone and reports increasing shortness of breath on exertion over the past week. He has gained 3 kilograms in the last five days.

On admission, he has bilateral pitting oedema to the knees, orthopnoea requiring two pillows, and appears visibly fatigued.

Clinical information on admission:

• Vital signs: Blood pressure 168/94 mmHg, heart rate 104 bpm (irregular), respiratory rate 24 breaths per minute, oxygen saturation 90% on room air, temperature 37.6°C.

• Current medications (selected): Oral furosemide, ACE inhibitor, beta-blocker, metformin, and PRN short-acting insulin.

• Social history: Former smoker, limited family support, occasionally misses medication doses, and expresses concern about “being a burden on anyone.”

You have been allocated to care for Mr. Carter during the first 24 hours of his hospital admission.

Task Description

Using the case of Mr. Carter, complete the following components in a structured academic paper. Use clear headings that align with the sections outlined below.

1. Focused Nursing Assessment (approximately 400–500 words)

• Summarise the key subjective and objective assessment data relevant to Mr. Carter’s current presentation, including cardiovascular, respiratory, metabolic, and psychosocial domains.

• Identify and briefly discuss at least three abnormal findings, explaining why each is clinically significant in the context of his comorbid conditions.

2. Priority Nursing Problems or Diagnoses (approximately 300–400 words)

• Identify two priority nursing problems or NANDA-I nursing diagnoses that require focused intervention during the first 24 hours of care.

• Provide a concise justification for each priority, drawing on assessment findings and evidence related to deterioration risks in heart failure and diabetes.

3. Evidence-Based Nursing Care Plan (approximately 600–800 words)

• For each priority nursing problem, develop one short-term and one medium-term patient-centred goal written in SMART format (Specific, Measurable, Achievable, Relevant, Time-bound).

• For each goal, outline three to five specific nursing interventions to be implemented over the next 24–48 hours, including:

  • Clearly described nursing actions.

  • Evidence-based or scientific rationales linked to pathophysiology or best practice guidelines.

  • Explicit criteria for evaluating whether each goal has been achieved.

• Integrate a minimum of five recent peer-reviewed sources published between 2018 and 2026 to support your care plan.

4. Patient Education and Self-Management (approximately 200–300 words)

• Describe two key patient education priorities to be addressed before discharge to support Mr. Carter’s self-management of heart failure and diabetes.

• Explain how these education strategies would be tailored to his social situation, limited support network, and expressed concerns about being a burden.

5. Reflection on Professional Practice (approximately 150–250 words)

• Provide a brief reflective discussion on what this case has taught you about delivering safe, person-centred care for adults with multiple chronic conditions in acute care settings.

• Use a simple reflective framework, such as description, analysis, and future action, to structure this section.

Formatting and Referencing Requirements

• Use academic essay format with clear section headings.

• Double-spaced text using an 11- or 12-point readable font and standard margins.

• Cite a minimum of five scholarly, peer-reviewed sources published between 2018 and 2026, in addition to any prescribed textbooks or clinical guidelines.

• Use the referencing style specified by your program, such as APA 7th edition or Harvard, and apply it consistently throughout the paper.

• Write in clear, formal academic English appropriate for an upper-division undergraduate nursing course. Avoid colloquial or informal language.

Assessment and Marking Criteria (Scoring Rubric)

Criterion 1: Clinical Assessment and Data Interpretation (20%)

• High Distinction (85–100%): Comprehensive synthesis of assessment data with accurate identification and explanation of all key abnormal findings, supported by strong pathophysiological reasoning and current evidence.

• Distinction (75–84%): Thorough assessment with most key data addressed and well-reasoned interpretation.

• Credit (65–74%): Adequate assessment summary with correct identification of main abnormalities but limited depth of explanation.

• Pass (50–64%): Basic assessment with some omissions or superficial explanations.

• Fail (<50%): Incomplete or inaccurate assessment with major omissions or misunderstanding of clinical data.

Criterion 2: Identification and Justification of Priority Nursing Problems (20%)

• High Distinction: Priority problems are highly appropriate and justified with strong clinical reasoning and up-to-date evidence.

• Distinction: Priorities are appropriate and well supported, with minor gaps in justification.

• Credit: Priorities are generally appropriate but justification lacks depth.

• Pass: Priorities are partially appropriate with vague or incomplete justification.

• Fail: Priorities are inappropriate, missing, or incorrectly justified.

Criterion 3: Quality of Nursing Care Plan (30%)

• High Distinction: Goals are clearly patient-centred and written in precise SMART format; interventions are specific, safe, evidence-based, and supported by detailed rationales and evaluation criteria.

• Distinction: Goals and interventions are appropriate and mostly SMART, with strong rationales.

• Credit: Goals and interventions are generally appropriate but lack specificity or detailed evaluation criteria.

• Pass: Goals and interventions are present but generic or underdeveloped.

• Fail: Care plan is incomplete, unsafe, or not linked to identified nursing problems.

Criterion 4: Patient Education and Reflection (15%)

• High Distinction: Education strategies are realistic, individualised, and clearly linked to patient needs; reflection demonstrates strong insight and application to future practice.

• Distinction: Education and reflection are appropriate and show good insight.

• Credit: Education and reflection are present but somewhat generic or descriptive.

• Pass: Education and reflection are basic with minimal critical thought.

• Fail: Education strategies or reflection are missing or inappropriate.

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Criterion 5: Academic Writing and Referencing (15%)

• High Distinction: Writing is clear, coherent, and professional, with accurate and consistent referencing using more than the minimum required sources.

• Distinction: Well-organised writing with minor language or referencing errors.

• Credit: Writing is generally clear with some structural or referencing issues.

• Pass: Writing is understandable but inconsistently organised, with noticeable referencing errors.

• Fail: Writing is difficult to follow with major language and referencing problems.

Mr. Carter’s rapid weight gain, worsening dyspnoea, and peripheral oedema indicate fluid volume excess associated with acute decompensated heart failure, placing him at high risk of respiratory compromise if not managed promptly. A priority short-term goal is that within 24 hours, he will maintain oxygen saturation at or above 94% on prescribed oxygen therapy while reporting reduced breathlessness at rest. Nursing interventions to support this goal include positioning in high Fowler’s to optimise lung expansion, close monitoring of respiratory status and daily weights, titration of oxygen therapy as prescribed, and collaboration with the interprofessional team to optimise diuretic therapy in line with current heart failure guidelines.

 Scholarly References

Ponikowski, P., Voors, A.A., Anker, S.D., Bueno, H., Cleland, J.G.F., Coats, A.J.S. et al. (2021). 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal, 42(36), 3599–3726.

Artioli, G., Foà, C. and Taffurelli, C. (2021). Reflective thinking in nursing practice: A concept analysis. Nursing Open, 8(3), 1608–1617.

McDonagh, T.A., Metra, M., Adamo, M., Gardner, R.S., Baumbach, A., Böhm, M. et al. (2021). Heart failure: Epidemiology, pathophysiology, and clinical management. The Lancet, 398(10311), 785–802.

American Diabetes Association (2022). Standards of medical care in diabetes—2022. Diabetes Care, 45(Suppl. 1), S1–S264.

Nursing and Midwifery Council (2018). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. London: NMC.