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NURS20024 – Applied Nursing Practice 4:
Written assessment task-Patient case scenario
Completing this written task
- Read the following case study and provide answers within the WHITE boxes below the question number on the ANSWER TEMPLATE PROVIDED ON MOODLE. The space will get bigger as you type. Do not change the formatting or edit boxes that are not white.
- Allocated marks for each question are indicated to the right of each question.
- The total score to be gained is up to 100 marks which will contribute to 35% of your unit grade.
- Where poor grammar and spelling detract from the graders/markers’ ability to understand your answer you are unlikely to receive full marks for this question.
- Check that you have used the correct template, format, and referencing style.
- For question 11 upload the chosen FULL-TEXT article along with this answer sheet (using the link provided). Marks have been allocated for loading the required paper.
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The answer you have given for this question will receive no marks. Penalties may apply for plagiarism |
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Where evidence of collusion and/or plagiarism exists, penalties will be applied according to the Academic Integrity policy.
| Question 1a: | /3 marks |
| Upon conducting a cardiopulmonary assessment on Mrs. Banks, the nurse might notice signs of pulmonary edema and dyspnoea. The ECG results may display atrial or ventricular hypertrophy, ischemia, and axis deviation. The S1 and S2 heart sounds may also be weak due to decreased pumping action (Padua et al., 2022). The patient may also present with defects in the respiratory system including crackles or wheezes. | |
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| Question 1b: | /3 marks |
| Other than dyspnoea, the patient may also complain of fatigue, edema of the lower extremities, and pulmonary congestion or crackles. These are the common indicating signs and symptoms of heart failure, among others that required further assessment like liver enlargement and inadequate tissue perfusion (Long et al., 2019). | |
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| Question 2: | /5 marks |
| Answer: Heart failure (HF), also known as congestive heart failure (CHF) can be defined as a physiologic state where the patient’s heart is unable to pump an adequate amount of blood to meet the metabolic demands of the patient’s body due to any functional or structural impairment of ejection of blood or ventricular filling. Based on the cause, heart failure can be classified into two, left-sided and right-sided HF. Left-sided heart failure is further divided into two, systolic and diastolic HF (Choi et al., 2019). Systolic failure occurs when the heart’s left side is unable to pump an adequate amount of blood with enough force required in pushing the blood to other body parts (Savarese et al., 2019). Diastolic failure on the other hand occurs when the heart is unable to rest between the heartbeats. Right-sided heart failure usually occurs when the heart’s right side is unable to pump an adequate amount of blood to the lungs. | |
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| Question 3: | /5 marks |
| Answer: Heart failure is characterized by increased venous pressure and reduced cardiac output (CO) due to underlying molecular alterations and consequent damage to the cardiac muscle cells, and their death. The pathophysiology of chronic heart failure is associated with several structural damages including apoptosis, loss of myofilaments, cytoskeleton disorganization, collagen synthesis, signal transduction, alteration in the density of receptors, and Ca2+ homeostasis disturbances (Brennan, 2018). As chronic heart failure develops, neurohormonal compensatory mechanisms are normally activated where the sympathetic nervous system is stimulated to release norepinephrine and epinephrine. A decrease in renal perfusion in HF normally leads to renin release promoting angiotensin 1 formation which is then converted to angiotensin II by angiotensin-converting enzymes, leading to blood vessel constriction and stimulation of aldosterone release causing fluid and sodium retention. To compensate for the increased workload, the heart muscles will increase in thickness. | |
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| Question 4a: | /2 marks |
| Answer:
· Left ventricular ejection fraction of less than 35% and a QRS duration of less than 120 ms, in addition to the New York Heart Association (NYHA) functional class III or class IV with ideal medical therapy (Padua et al., 2022). · Left ventricular ejection fraction of less than 35% and prolonged duration of QRS · Left ventricular ejection fraction of less than 35% in addition to the NYHA functional class I or class II among patients undergoing insertion of the pacemaker or implantable cardioverter defibrillator and may depend on frequent cardiac pacing. |
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| Question 4b: | / 5 marks |
| Answer: The pre-operative preparation of a patient for insertion of a BIV is like that of other procedures for cardiac catheterization. First, the patient will be assessed for the procedure and adequately informed regarding the benefits risks, and complications of the procedure. Blood tests will then be done followed by an assessment of the coagulation profile which is crucial among patients taking anticoagulants (Ferreira et al., 2019). The patient will then be required to fast for not less than 6 hours before the procedure. Maintaining the intravenous cannulas is necessary with the administration of antibiotics especially anti-staphylococcal as prophylaxis for infections. Upon arriving at the catheterization lab, the access site will be cleaned with an antiseptic solution before draping the patient. Finally, the patient will be sedated through the intravenous route before the procedure. | |
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| Question 5a: | /2 marks |
| Answer: Captopril is an ACE inhibitor that inhibits the conversion of angiotensin I to angiotensin II by blocking the renin-angiotensin-aldosterone-system (RAAS) (Sabanayagam et al., 2018). The drug also decreases the amount of aldosterone released and suppresses kinin degradation. As a result, cardiac hemodynamic are improved with favourable cardiac remodelling (Schichtel et al., 2019). The drugs help reduce morbidity, hospitalization, symptoms, and mortality of patients with heart failure. | |
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| Question 5b: | /2 marks |
| Answer: Bisoprolol is a beta-adrenergic receptor antagonist which directly blocks the negative impact of the sympathetic nervous system on HF (Brennan, 2018). The drug improves the health of the patient by improving LV ejection fraction, slowing HF progression, increasing exercise tolerance, and lowering the need for hospitalization (Schichtel et al., 2019). | |
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| Question 5c: | /2 marks |
| Answer: Spironolactone is a potassium-sparing diuretic that is normally given to counteract the loss of potassium arising from loop and thiazide diuretics (Sabanayagam et al., 2018). It reduces the risks of drug-induced dysrhythmias. | |
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| Question 6a: (NO REFERENCE REQUIRED FOR 6a) | /1 mark |
| Answer: 88 bpm | |
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| Question 6b: | /1 mark |
| Answer:
Rate = 300/R-R interval in large squires 300/3.4= 88 bpm (Savarese et al., 2019) |
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| Question 6c: (NO REFERENCE REQUIRED FOR 6c)
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/1 mark |
| Answer: The ECG rhythm is regular. | |
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| Question 6d:
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/1 mark |
| Answer: The rhythm strip displays a heart rate that falls within the normal range and a regular rhythm. The nurse is required to closely monitor the patient blood pressure and heart rate regularly for any changes (Jahmunah et al., 2019). | |
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| Question 7a: | /4 marks |
| Answer: Furosemide is a loop diuretic that promotes loss of fluid to reduce peripheral oedema. The drug can cause hypokalaemia, hence the need to administer potassium supplements (Savarese et al., 2019). | |
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| Question 7b: | /3 marks |
| Answer: To determine the effectiveness of the administered furosemide and potassium supplements, it will be necessary to assess the patient’s fluid status. Monitoring the patient’s daily weight will also be required in addition to the amount and location of oedema, skin turgor, and lung sounds (Long et al., 2019). The patient’s pulse and BP should also be taken before and during the administration of these drugs. Evaluating the electrolyte panel will also be necessary for changes in potassium levels. | |
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| Question 7c: | /10 marks |
| Answer: The patient should be educated on the causes and presentation of heart failure in addition to the therapeutic regimen. For instance, the patient should be acknowledged that her condition may have resulted from lifestyle factors or underlying conditions. However, it can be managed by relieving the presenting symptoms such as dyspnoea, weight gain, and oedema of the lower extremities (Awoke et al., 2019). Since these symptoms result from fluid retention, it was necessary to administer furosemide to help promote loss of fluids. However, the drug is also associated with side effects such as dehydration and electrolyte imbalance that can lead to hypokalaemia. To reduce the risks of hypokalaemia, it was necessary to administer potassium supplements. Consequently, it will be important to also point out the need of taking the medication as prescribed and report back to the clinic in case of adverse effects such as fainting, drowsiness, confusion, and muscle cramps among others. | |
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| Question 8a: | /3 marks |
| Answer:
· Weight: The patient’s body weight has increased from 86kg to 90.8 which might be because of the accumulation of fluids (Schichtel et al., 2019). · BP: The diastolic blood pressure is low indicating signs of bradycardia · HR: The patient’s heart rhythm is irregular with increased heart rate. |
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| Question 8b: | /2 mark |
| Answer: The patient’s increased body weight may be due to the accumulation of fluids which will be managed using diuretics like furosemide (Long et al., 2019). For low blood pressure and irregular heart rhythm, a beta blocker such as bisoprolol and an ACE inhibitor such as captopril will be considered. | |
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| Question 9a: | /2 marks |
| Answer:
· Potassium: levels are lower indicating signs of hypokalaemia (Schichtel et al., 2019). |
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| Question 9b: | /1 mark |
| Answer: Since the potassium levels dropped, it will be necessary to add a potassium-sparing diuretic like spironolactone to the patient’s treatment regimen (Schichtel et al., 2019). | |
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| Question 10a: (NO REFERENCE REQUIRED FOR Q 10a) | /2 marks |
| Answer: Mrs. Banks’ rhythm is irregular. I measured the distance between consecutive P values (P-P interval) and r waves (R-R intervals) and found out that they were not consistent. | |
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| Question 10b: (NO REFERENCE REQUIRED FOR Q 10b) | /2 marks |
| Answer:
· Irregular heart rhythm: Auscultate heart sounds to assess for S3 and S4 gallop sounds. The presence of S3 will indicate HF which will require improvement of myocardial contractility and systemic perfusion by administration of antihypertensives as prescribed. · Excess fluid volume: Elevate the patient’s feet when sitting and inspect the skin surface and provide padding as indicated. Maintain sodium and fluid restriction and administer medication as prescribed. |
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| Question 10c: | /5 marks |
| Answer: Irregular heart rhythm has significant hemodynamic consequences for the patient. For instance, it increases the risks of bradycardia, with decreased cardiac output hence decreasing arterial pressure (Lindenfeld et al., 2019). The stroke volume may also be reduced increasing the risks of tachycardia. Minor hemodynamic consequences may also be experienced by the patient at rest, but with risks of significantly reduced ventricular stroke volume and cardiac output especially when exercising (Jahmunah et al., 2019). This may lead to shortness of breath. | |
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| Question 10d: | /2 marks |
| Answer: Iron replacement therapy, administered intravenously may be necessary to reduce the patient’s risks of hospitalization and improve exercise capacity and peak oxygen consumption. Hormone replacement therapy may also be considered given the patient’s female gender and advanced age, to improve survival (Awoke et al., 2019). | |
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| Question 11a: | 2/ marks |
| Answer: Amakali, K. (2015). Clinical Care for the Patient with Heart Failure: A Nursing Care Perspective. Cardiovascular Pharmacology: Open Access, 04(02). https://doi.org/10.4172/2329-6607.1000142 | |
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| Question 11b: | /15 marks |
| Answer: In the provided article, Amakali (2015) provides clinical nursing care to heart disease patients with great application of knowledge regarding the disease contributing to the nursing interventions needed. The author has conducted comprehensive research and presented a thorough discussion on some of the priorities in the clinical care of heart failure patients from a nurse’s perspective. The article provides comprehensive discussions on the heart failure disease process and its relevance in identifying the health needs of the patient. As demonstrated by the author, the nursing care plan is usually based on the nursing diagnosis which promotes appropriate determination of the nursing care plan goals. The nursing care intervention is based on the patient’s needs outlined in the care plan goals. The priority aspects in nursing care for patients with heart failure have also been illustrated in this article with 7 themes presenting the nursing intervention to be implemented. The application of ethical principles in the care for Heart failure patients by nurses has also been discussed in this article. | |
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| Question 11c: | /4 marks |
| Answer: Just as demonstrated in the article by Amakali (2015) the patient in the provided case study was diagnosed with heart failure with priority health concerns of arrhythmias, dyspnea, and peripheral edema. The article provided information on how to monitor such a patient’s vitals, and manage the presenting symptoms with both pharmacological and non-pharmacological interventions (Savarese et al., 2019). The required diagnostic examinations for such a patient, in addition to counseling and patient education have also been illustrated. | |
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| Question 12: | /5 marks |
| Answer: The provided observation of the vital signs and laboratory results, in addition to the ECG, support the NMBA standard which requires RNs to comprehensively conduct assessments (Savarese et al., 2019). The 0600 hr vital signs and lab results also support the standard that requires evaluation of outcomes to inform nursing practice. | |
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| Question 13: | /2.5 mark |
| Answer: The nurse should exhibit a high level of professionalism in treating the patient and evaluating the treatment outcome to ensure that they do not harm the patient (Hill et al., 2020). | |
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| Question 14:
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/2.5 mark |
| Answer: The nurse should uphold the patient’s autonomy by respecting decisions made by the patient regarding treatment choice (Hill et al., 2020). | |
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| Total Marks /100 |
| Overall Marker Comments:
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References
Amakali, K. (2015). Clinical Care for the Patient with Heart Failure: A Nursing Care Perspective. Cardiovascular Pharmacology: Open Access, 04(02).
Awoke, M. S., Baptiste, D.-L., Davidson, P., Roberts, A., & Dennison-Himmelfarb, C. (2019). A quasi-experimental study examining a nurse-led education program to improve knowledge, and self-care, and reduce readmission for individuals with heart failure. Contemporary Nurse, 55(1), 15–26.
Brennan, E. J. (2018). Chronic heart failure nursing: integrated multidisciplinary care. British Journal of Nursing, 27(12), 681–688.
Choi, H.-M., Park, M.-S., & Youn, J.-C. (2019). Update on heart failure management and future directions. The Korean Journal of Internal Medicine, 34(1), 11–43.
Ferreira, J. P., Kraus, S., Mitchell, S., Perel, P., Piñeiro, D., Chioncel, O., Colque, R., de Boer, R. A., Gomez-Mesa, J. E., Grancelli, H., Lam, C. S., Martinez-Rubio, A., McMurray, J. J., Mebazaa, A., Panjrath, G., Piña, I. L., Sani, M., Sim, D., Walsh, M., & Yancy, C. (2019). World Heart Federation Roadmap for Heart Failure. GLOBAL HEART, 14(3), 197–214.
Hill, L., Prager Geller, T., Baruah, R., Beattie, J. M., Boyne, J., Stoutz, N., Di Stolfo, G., Lambrinou, E., Skibelund, A. K., Uchmanowicz, I., Rutten, F. H., Čelutkienė, J., Piepoli, M. F., Jankowska, E. A., Chioncel, O., Ben Gal, T., Seferovic, P. M., Ruschitzka, F., Coats, A. J. S., & Strömberg, A. (2020). Integration of a palliative approach into heart failure care: a European Society of Cardiology Heart Failure Association position paper. European Journal of Heart Failure, 22(12), 2327–2339.
Jahmunah, V., Oh, S. L., Wei, J. K. E., Ciaccio, E. J., Chua, K., San, T. R., & Acharya, U. R. (2019). Computer-aided diagnosis of congestive heart failure using ECG signals – A review. Physica Medica, 62, 95–104.
Lindenfeld, J., Abraham, W. T., Maisel, A., Zile, M., Smart, F., Costanzo, M. R., Mehra, M. R., Ducharme, A., Sears, S. F., Desai, A. S., Paul, S., Sood, P., Johnson, N., Ginn, G., & Adamson, P. B. (2019). Hemodynamic-GUIDEd management of Heart Failure (GUIDE-HF). American Heart Journal, 214, 18–27.
Long, B., Koyfman, A., & Gottlieb, M. (2019). Diagnosis of Acute Heart Failure in the Emergency Department: An Evidence-Based Review. Western Journal of Emergency Medicine, 20(6), 875–884.
Padua, B. L. R. de, Tinoco, J. de M. V. P., Dias, B. F., Carmo, T. G. do, Flores, P. V. P., & Cavalcanti, A. C. D. (2022). Cross-mapping of nursing diagnoses and interventions in decompensated heart failure. Revista Gaúcha de Enfermagem, 43.
Sabanayagam, A., Cavus, O., Williams, J., & Bradley, E. (2018). Management of Heart Failure in Adult Congenital Heart Disease. Heart Failure Clinics, 14(4), 569–577.
Savarese, G., Lund, L. H., Dahlström, U., & Strömberg, A. (2019). Nurse‐Led Heart Failure Clinics Are Associated With Reduced Mortality but Not Heart Failure Hospitalization. Journal of the American Heart Association, 8(10).
Schichtel, M., Wee, B., Perera, R., & Onakpoya, I. (2019). The Effect of Advance Care Planning on Heart Failure: a Systematic Review and Meta-analysis. Journal of General Internal Medicine, 35(3), 874–884. https://doi.org/10.1007/s11606-019-05482-w
