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NUR241 Contexts Of Practice: Health Alteration

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Task description:

The goal of this case study is for you to identify the role of the Registered nurse in the appropriate assessment and management of an individual experiencing health alterations when access to healthcare is suboptimal or compromised.

Step 1: Consider the case study below:

Mr. Smith is a 70yr/old male who presented to his GP at 10am today with an exacerbation of his CHF. He was complaining of chest pain that is pleuritic in nature, SOB, weakness, fatigue, a hacking cough with bilateral bibasal coarse crackles.


A: penicillin

Meds: atorvastatin 20m Mane, frusemide 20 mg mane, Metoformin XR 1000mg BD

Past illnesses: hypercholesterolaemia, MI, angina, hypertension, Increased BMI 34, T2DM

Last meal: 7am (3hrs ago), bacon eggs, sausages toast and hash browns

Events leading up to presentation: walking/gardening on his farming property 3 hours away from the nearest hospital

His vital signs are a Temp 36.8, GCS 15, HR 105, NiBP- 170/90, Sp02- 92%, RR 24. Initial ECG displayed new abnormalities and initial bloods showed a negative troponin of TNI: 0.02. He was given his regular meds & 5mg IV morphine, 1gm paracetamol which reduced his pain to 2/10. PIVC insitu R) ACF- patent.  

Step 2: Based on your assessment of the case study, identify2 health care priorities for your patient. Refer to the ABCDE framework to justify your decision.

Step 3: Identify interventions (no more than 3 and at least one for each priority problem) to manage each priority. Provide a rationale for each intervention that refers to pathophysiology, as well as a discussion of related nursing care.

Monitoring such as completing vital signs, telemetry and fluid balance charting is not an intervention. An intervention needs to effect a pathophysiological change. These may be nursing considerations

Step 4: Outline and Discuss appropriate discharge planning for this patient that aligns with the social justice framework




This case study assesses patient Smith aged 70 years old presenting exacerbation of congestive heart failure. The patient indicative symptoms entail complains of chest pain, weakness, SOB, fatigue, hacking cough illustrating bilateral coarse crackles. The patient has a past illness of hypercholesterolemia, MI, angina, hypertension, increased BMI 34 and type II diabetes. This essay offers key primary priorities of the patient presentation. Further key nursing interventions which entail ineffective breathing restoration, ineffective airway clearance and fatigue management for the patient and discharge plan for the patient are presented.  The role of nurses in delivering appropriate nursing intervention for the patient is essential for the care process (Riley et al., 2016). As a form of care process continuity, enhancing the ability of the patient through an appropriate discharge plan is key in ensuring the prevention of patient readmission.

Primary Priorities

Nursing care priorities are essential for patient care management. Prioritizing patient management seeks to envision the implication of the patient overall state and improve the quality of care (Conway et al., 2017). The key health care nursing priority for the patient entails care for the acute respiratory syndrome and deteriorating state of congestive heart failure. Assessment using the ABCD framework for acute respiratory syndrome entails a review of airway depicted by the hacking cough with signs of bibasal coarse crackles. The occurrence of shortness of breath further the patient is depicting low oxygen saturation. The breathing assessment of the patient depicts severe shortness of breath and unusual labored breathing coupled up with tiredness. The blood circulation of the patient display anomalies as observed using the ECF negative troponin index.  The disability state of the patient reveals a general weakness with immense fatigue. Patient exposure levels as indicated by the temperature readings indicate hyperthermia, thus lowering of body temperature is beneficial for the patient.  

Congestive heart failure state of the patient reflects the lowered function of the respiratory function. The airway assessment of the patient depicts shortness of breath characterized by breath exertion (Benhase et al., 2018). The breathing status of the patent is lowered characterized by the increased heart rate levels and elevated respiratory rates. The blood circulation of the patient is lowered due to the occurrence of low heart rate and prehistory angina and low respiratory rate. The patient does not display any disability state while exposure levels indicated elevated temperature levels.



Enabling and initiating nursing intervention for the patient is essential as it is critical in managing exacerbating patient’s conditions and improves the overall disease state of the patient (Rice, Say & Betihavas, 2018). There is a need to focus on the following key three interventions; ineffective breathing patterns, fatigue management and clearance of breathing pathway. Developing a comprehensive care intervention plan is essential to improve the overall patient ability and to help in various nursing interventions and identification of other complications which might arise from the patient assessment.

Intervention 1: Ineffective breathing pattern restoration

Ineffective breathing pattern for the patterns reveals changes and occurrence of shortness of breath with activity, further utilization of accessory muscles has declined. The oxygen saturation levels indicate 92%, while the heartbeat rates have high of 105 indicating an increased burden on the heart breathing mechanism.

The occurrence of the abdominal wall excursion during the inspiration and expiration process needs to be maintained to optimum levels for the patient. The ineffective breathing pattern is often one of the key issues for intervention among patients with acute respiratory distress (Kelley & Ferreira et al., 2017). This intervention assesses the depth, rate, timing and the rhythm pattern of breathing. The ineffective breathing pattern is correlated with variation respiratory rate, abdominal and thoracic pattern. Breathing rate can further alter various circumstances such as heart failure, hypoxia, airway obstruction, infection and trauma (Rutledge et al., 2018).

Enhancing clear pathways for effective airway processes in patient care is essential. There is a need for appropriate management having difficulties in oxygenation in order to sustain ventilation for the pulmonary. The need for promoting comfort and easing breathing pathways improvement and the ability to engage in physical excises and prevention of oxygenation problem such as tissue breakdown and skin (Borge et al., 2015).

Expected nursing outcomes for the patient entail improvement of patient saturation level to be between 90%-100% per minute during the hospitalization period. Key assessment to be monitored by the nurse entail the respiratory rates periodically in order to assess trends in the first 8 hours of admission and beginning usage of verbalization which demonstrate the breathing techniques for the patient. The nursing outcome goals aim at achieving effective breathing pattern as evident by breathing relaxation to normal rates and reduction of dyspnoea (Payne et al., 2017).

Continuous nursing assessment for the patient will be crucial in order to determine possible problems for prevention of ineffective breathing patterns. The key assessment entails period assessments of respiratory rate after every 4 hours. The key rationale for this assessment is for maintenance of the average respiratory rate of 10-20 breaths per minute. This is key so that preventive action measures are undertaken due to compromise of respiratory state.

Further, assessment of breathing patterns is vital for the patient so as to assess the underlying disease as the patient has the previous history of various diagnoses, which is crucial in order to provide targeted care plan. Assessment of breathing sounds such as crackle sounds is key in assessing the function of the lungs. Pulse oximetry assessment to measure the oxygenation status is key. The aim is to lower the level of oxygenation for the patient (Vainshelboim et al., 2016).


Intervention 2 Ineffective airway clearance

Patient history of congestive heart failure reflects changes in the systolic and diastolic function of the left ventricle. The functionality of the heart fails due to intrinsic and structural functions which can handle normal blood volume, thus not able to tolerate blood volume expansion. The heart failure state reflects clinical syndrome underlying manifestations of volume overload, limited tissue perfusion, and poor tolerance on exercise. The fluid back located in the heart fails to perform its functions and to pump effectively. This can occur on either the left or right-hand side. This leads to pump failure resulting in hypoperfusion in tissues. Functioning hearts have over 50% ejection fractions which lower than this indicates heart failure. Changes or alterations of the cardiovascular system such as myocardial infarction, coronary heart disease, diabetes, hypertension, and heart arrhythmias and comorbid diseases contribute to heart failure occurrence (Pascoal et al., 2016).

The nursing care plan is geared towards ensuring support and improvement to the heart pump sign various nursing interventions and identification of complications arising from the disease state.

The exacerbating chest pain that is pleuritic in nature is indicative of a prior history of myocardial infection for the patient. The feelings of chest pains are associated with anterior infarction due to the left ventricular impairment developed from prior diagnosis.

Ineffective airway clearance emanates from the accumulation of secretions causing obstructions in the respiratory tract thus hindering clean airway maintained. The mucosal production at the lining of air passages forms on the walls. During inflammation, the membranes are irritated and excess mucus is produced and retained in the tracheobronchial tree. The inflammation leads to an increase in the level of secretion blocking the airways making it difficult to maintain a clear pathway. In this case, it leads to an increase in the respiratory rate tact as a compensatory mechanism of the body based on the obstructed airways, thus depicting breathing difficulty as observed from the patient state (Beltrão et al., 2015).

Enhancing airway clearance is desired to enhance the ability of the patient to establish and have maintained airway patency. Key assessments relevant are the assessment of the respiratory process and paroxysmal dyspnoea assessment. Ensuring accurate sitting position for the patient through upright support in ¾ pillows is essential for acute shortness of breath. Further administration of oxygen therapy can be administered as the airway is being cleared to resume normal breathing patterns.


Intervention 3: Fatigue

Fatigue represents a state of overwhelming sustained exhaustion and reduced capacity for physical and mental work activity. An occurrence of heart failure indicates the physiologic state of the heart having the inability to pump blood to meet the metabolic demands of the body due to inadequate cardiac output restoration. This can leads to a hypoxic state with a lowered rate of metabolic waste removal which cases the patent to tire easily (Lainsamputty & Chen, 2018).

The patient manifestation depicts general weakness and limited motion of activities. The desired outcome care entails improving the sense of energy on the patient. Various activities are initiated at this stage. The medication regime of the patient is reviewed with key rational aimed to assessng how certain medications cause fatigue and exacerbation. Assessment of vital signs entails an evaluation of the fluid status of the patient in response to cardiopulmonary response. The patient further is inquired on the rate of fatigue so as to aid in determining the degree of fatigability aiding care process plan care (Ranitya, 2015).

Key nursing actions for the patient in managing this diagnosis entail establishing realistic goals with the patient which encourages forward movement activities. This enhances commitment and optimizes on the optimal outcome of care. Teaching the patient on various ways of monitoring responses and activity levels and to identify significant signs and symptoms is vital as it will aid in alterations of activity level.


Discharge Planning

The occurrence of heart failure signifies the inability to pump enough oxygen and other key nutrients to the body. Occurrence fluid and poor tissue perfusion lead to acute syndrome status of the patient. The recurrence of heart failure could occur on the patient with signs of volume overload. The patient status indicates an exacerbation of chronic heart failure with previous history hypertension, angina and increased BMI.

Entrenchment of the social justice framework is essential in ensuring that the patient is actively involved in the care process. Further enhancing rights and self-determination to achieve the expected nursing outcomes is key. The objective of enhancing teaching plan is to manage signs and symptoms for the patient. Enhancing the discharge teaching plan is essential. This will be initiated prior during the admission so as the patient has adequate time for questions and probing. Early discharge plan intervention is key. Having more time with the patient enables a clear understanding of the overall pathophysiology of the disease and its mechanism (Hawkley et al., 2018).

Preparation of discharge plan on diet management will entail teaching the patient on the benefits of recommended dietary requirements based on her state. There is a need for offering support and encouraging her to always consult with the dietitian while she is a hospital on an appropriate diet plan upon discharge. Avoidance of fats foods and high sodium food is essential for the patient. Weight monitoring for the patient is essential. The previous history of heart failure indicates the risks of developing other weight-related complications such as diabetes for the patient. Teaching the patient to always consider weight management is critical in ensuring that appropriate weight range is maintained for an improved state of the disease. Encouraging the patient in the teaching on the importance of activity levels for cardiac rehabilitation is key in ensuring that exacerbation symptoms of congestive heart failure are managed effectively for the patent (Rutherford et al., 2017).


Patient Smith assessment offers an incisive care process in entrenching appropriate nursing intervention to the patient. The patient is suffering from an exacerbation of chronic heart failure occasioned with various symptoms depicting readmission state. In order to address the symptoms of the patient and restore the patient state; appropriate key interventions aiming at ineffective airway clearance, ineffective breathing pattern restoration, and fatigue intervention management have been highlighted as the key avenues to improve the state of the patient. The role of the registered nurse in ensuring that this intervention achieves target objective is essential. Discharge plan protocol developed aims at improving the ability for the patient to conduct self-assessment and to regulate fluid and dietary management and often assess vital status symptoms. This seeks at improving the overall patient status on the congestive heart failure. 



Beltrão, B.A., Herdman, T.H., Pascoal, L.M., Chaves, D.B.R., da Silva, V.M. and de Oliveira Lopes, M.V., 2015. Ineffective breathing pattern in children and adolescents with congenital heart disease: accuracy of defining characteristics. Journal of clinical nursing, 24(17-18), pp.2505-2513.

Benhase, C., Faulkner, T.J., Hendricks, K. and Sublett, J., 2018. Nursing Aspects of Heart Failure. In Heart Failure in the Child and Young Adult (pp. 481-492). Academic Press.

Borge, C.R., Mengshoel, A.M., Omenaas, E., Moum, T., Ekman, I., Lein, M.P., Mack, U. and Wahl, A.K., 2015. Effects of guided deep breathing on breathlessness and the breathing pattern in chronic obstructive pulmonary disease: A double-blind randomized control study. Patient education and counseling, 98(2), pp.182-190.

Conway, A., O’Donnell, C. and Yates, P., 2017. The effectiveness of the nurse care coordinator role on patient-reported and health service outcomes: A systematic review. Evaluation & the health professions, p.0163278717734610.

Hawkley, L.C., Long, M., Kostas, T., Levine, S., Molony, J. and Thompson, K., 2018. Geriatrics training for nurses in a skilled nursing facility: a GWEP feasibility study. Geriatric Nursing, 39(3), pp.318-322.

Kelley, R.C. and Ferreira, L.F., 2017. Diaphragm abnormalities in heart failure and aging: mechanisms and integration of cardiovascular and respiratory pathophysiology. Heart failure reviews, 22(2), pp.191-207.

Lainsamputty, F. and Chen, H.M., 2018. The Correlation Between Fatigue and Sleep Quality among Patients with Heart Failure. NurseLine Journal, 3(2), pp.100-114.

Pascoal, L.M., de Carvalho, J.P.A., de Sousa, V.E.C., Santos, F.D.R.P., Neto, P.M.L., Nunes, S.F.L. and de Oliveira Lopes, M.V., 2016. Ineffective airway clearance in adult patients after thoracic and upper abdominal surgery. Applied Nursing Research, 31, pp.24-28.

Payne, P., Fiering, S., Leiter, J.C., Zava, D.T. and Crane-Godreau, M.A., 2017. Effectiveness of a novel qigong meditative movement practice for impaired health in flight attendants exposed to second-hand cigarette smoke. Frontiers in human neuroscience, 11, p.67.

Ranitya, R., 2015. Enhanced External Counterpulsation in Chronic Heart Failure: Where Do We Stand?. Acta Medica Indonesiana, 47(4).

Rice, H., Say, R. and Betihavas, V., 2018. The effect of nurse-led education on hospitalisation, readmission, quality of life and cost in adults with heart failure. A systematic review. Patient education and counseling, 101(3), pp.363-374.

Riley, J.P., Astin, F., Crespo?Leiro, M.G., Deaton, C.M., Kienhorst, J., Lambrinou, E., McDonagh, T.A., Rushton, C.A., Stromberg, A., Filippatos, G. and Anker, S.D., 2016. Heart Failure Association of the European Society of Cardiology heart failure nurse curriculum. European journal of heart failure, 18(7), pp.736-743.

Rutherford, M. M. 2017. Enhanced RN role in behavioral health care: an untapped resource. Nursing Economics, 35(2), pp. 88-95.

Rutledge, T., Atkinson, J.H., Holloway, R., Chircop-Rollick, T., D'Andrea, J., Garfin, S.R., Patel, S., Penzien, D.B., Wallace, M., Weickgenant, A.L. and Slater, M., 2018. Randomized Controlled Trial of Nurse-Delivered Cognitive-Behavioral Therapy Versus Supportive Psychotherapy Telehealth Interventions for Chronic Back Pain. The Journal of Pain, 19(9), pp.1033-1039.

Vainshelboim, B., Oliveira, J., Fox, B.D. and Kramer, M.R., 2016. The prognostic role of ventilatory inefficiency and exercise capacity in idiopathic pulmonary fibrosis. Respiratory care, 61(8), pp.1100-1109

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