Evidence based Nursing Research

This article discusses the primary health priorities of a patient with congestive heart failure, interventions to address these priorities, and discharge planning aligned with the social justice framework.

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Assessment Task 2
Title: Health Alterations (Case Study)
Student Name:
Student ID:
University:

Evidence based Nursing Research 2
Introduction
Mr.Smith is a 70 year old male reported to his GP for having exacerbation of Congestive Heart
Failure. He has pleuritic chest pain, SOB, fatigue and weakness with brief discontinuous popping
lung sound and cough. He is a patient with complex medical history of Type 2 Diabetes Mellitus,
Hypercholesterolaemia, Myocardial Infarction, Angina, Hyper tension and increased BMI. The
patient is highly conscious, has elevated heart rate and high BP. His initial ECG also displayed
abnormalities.
The essay will discuss the following points (a) two primary health priorities of Mr.Smith,
demonstrating the Pathophysiology in view of the assessment data; (b) three interventions to
address these primary priorities; (c) discharge planning for this patient that would align with the
social justice framework.
Primary Priorities
According to ABCDE framework, the two primary health care priorities of Mr. Smith are:
(1) Airway/ Breathing (reflected by pleuritic chest pain and coarse crackles sounds) and
(2) Circulation (depicted by high BP and abnormal ECG).
The lung assessments like slightly elevated Respiratory rate of 24 bpm, pleuritic chest pain and
bilateral bibasal coarse crackles, Shortness of breath show insufficient breathing pattern. The
coarse crackles sound reflects narrowed down airways in the lungs and retention of fluid in the
alveoli because of respiratory distress or heart failure. The probable mechanism of coarse crackle
sound is associated with sudden airway closure events during expiration and the sudden opening
events occurring during the inspiration (Sarkar, 2015). The bibasilar coarse crackles reflect the
presence of issues like airway obstruction in the base of the lungs. The presence of bibasilar
crackles signifies two issues: the presence of fluids or mucus in the lungs; and inefficiency of
lungs to inflate appropriately. These crackles are a sign of infection or illness. These crackles
may exhibit additional symptoms like trouble in breathing, fatigue, coughing and weakness (as
evident in the patient) (Pietro, 2018).

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The auscultation assessment of lungs can reveal the abnormal coarse crackles which are brief,
discontinuous and popping sounds. They are lower in pitch, louder and stay for longer. It shows
presence of excessive lungs inside the lungs. In this patient, the crackles are caused by transudate
like congestive heart failure and pulmonary edema.
Intense pleuritic chest pain occurs in the chest during inhale and exhale (Thim, Krarup, Grove,
Rohde and Løfgren, 2017). It occurs due to swelling of parietal pleura which causes pain in
cutaneous distributions of these nerves. The patient may have swelling in the membranes
surrounding the lungs and the linings of chest cavity. The nerves may disseminate the pain to the
shoulders and neck regions as well. In this patient the probable cause of pain can be Myocardial
Infarction (Sarkar, Madabhavi, Niranjan and Dogra, 2015). The symptoms of pain may be
accompanied with the other symptoms like SOB, faster Heart rate, shallow breathing and dry
cough. Another possible reason for the pleuritic chest pain is filling up of the space between the
pleurae with fluid. It causes SOB as the lungs need space for expanding during the breathing
(Thim et al., 2017).
The Circulatory problems are depicted by high BP, high heart rate, abnormal ECG, hypertension,
increased BMI, low level of SpO2 and hypercholesterolemia. Though he is fully conscious, his
low SpO2 reveals low level of hemoglobin carrying oxygen.
These care priorities can be addressed using Pharmacological Therapies, Non Pharmacological
Therapies and Use of Mechanical Circulatory Devices like Ventricular Assist Devices (VADs).
Interventions
The interventions for treatment and management of congestive heart failure may be aimed to
improve the cardiac function, breathing and symptom management. The treatment goals of the
pleuritic chest pain can be to provide relief from the symptoms, elimination of fluids, blood or air
from the pleural space, and the treatment of underlying symptoms.
Pharmacological Therapy

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The pharmacological therapies for this patient may involve use of medications like statins,
vasodilators, beta blockers and anti coagulants (Dumitru, 2018).
The respiratory distress and circulatory problems can be relieved through administration of these
medications. The statins like Atorvastatin will reduce the blood cholesterol levels, vasodilators
will dilate the blood vessels (arteries) in the lungs to prevent the symptoms of pulmonary
hypertension (Reamy and Williams, 2017). It will relax the smooth muscles thereby lowering
down the blood pressure. It will facilitate easier transport of blood to the rest of the organs in the
body.
The loop diuretics medications like frusemide will also help lower down the blood pressure by
treating the fluid retention in lungs during congestive heart failure (Royal Children’s Hospital,
2019). The medicine will eliminate the extra fluid developed in the lungs and will relieve the
patient from shortness of breath, high blood pressure, hypertension and probable edema (Burns,
2017). This class of medications will increase the volume of urine thereby eliminating the extra
fluids from the body. It will help reduce the fluid retention. The morphine and paracetamol have
already reduced the patient’s pain level to 2/10.
To remove the excessive fluids from the lungs the surgical procedures can also be performed. It
includes insertion of a chest tube from the chest wall, to suction out the fluid. The medications
can be given to relieve the pleuritic symptoms and control the cough.
The Registered Nurse will give medications on time and will ensure that the patient is compliant
with the medication routine as per his plan of care. It will reduce the readmissions. RN needs to
educate the patient about his medicines, their side effects and use before discharge from hospital.
The initiation of medications is done at the lowest possible dose to eliminate the possibility of
excessive dilation. The RN need to monitor the Blood pressure regularly during the treatment.
The RN plays a central role in administration of drugs according to existing recommendations
for drug therapy, its adverse effects, precautions, mechanism of action and correct dosing
schedule. They collaborate with the GPs about the patients’ care plan. They increase awareness
of patients and their families, and provide effective vigilance. They make sure that the care is
provided to meet the desired outcomes.
Non Pharmacological Therapy

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The non pharmacological therapies may include appropriate physical activity, fluid restrictions
and weight reduction measures (Shah, Pellicori, Cuthbert and Clark, 2017). The salt intake can
be restricted to less than 2000 mg and the fluids consumption can be reduced to a level of 2000
ml (Burns, 2017). The life style of the patient may nutritional changes as he has high BMI. He is
also having medical history of diabetes so his lifestyle should involve a comprehensive
management of all the diseases. The patient should not be recommended to do exertive exercises
to prevent worsening of symptoms. He may be advised to carry out his daily regular active
routine with appropriate rest. He should cut down his high cholesterol levels and fat in the diet.
The patient needs to be counseled for stress reduction or management of hypertension. Other
than these therapies, the patient may be given ventilator support if his condition does not
improve after medication. He may be given ultrafiltration to eliminate excessive salt and fluids
from the body (Shah et al., 2017). Additionally non invasive positive pressure ventilation can be
provided to lower down the heart rate.
The lifestyle changes like lying on the painful side of the body, coughing to eject out the mucus,
breathing deeply and taking adequate rest can be helpful in relieving the symptoms of pleuritic
pain.
The Registered Nurse will assist the old age patient in maintaining compliance with the non
pharmacological interventions. The RN will educate the patient about possible life style changes
to effectively address the obesity and diabetes together. The patient will be educated about the
drugs he needs to avoid like non steroidal inflammatory drugs. He also needs to restrict his
alcohol intake or the other fluids. The RN will help in self caring supportive strategies and will
implement effective surveillance and management of clinical symptoms.
Use of Mechanical Circulatory Devices
The cardiac assistive devices like VAD can be used to improve the cardiac function by
maintaining a consistent blood pressure and regulating the recovery. The assistive devices can
improve the health conditions like mechanical dysfunction, frequent adverse events and
operational difficulties (La-Franca, Iacona, Ajello and Sansone, 2013). As the patient is feeling
weakness and fatigue, he has faced the chest pain while he was walking and gardening in his

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field, it shows the patient is unable to do heavy exercises also in view of his old age and obesity.
In this condition, the assistive devices can be effectively helpful in providing his airway passage
and blood circulation.
The respiratory care therapy may involve Oxygen therapy, Aerosol Therapy, and Airway
clearance therapy. The symptoms if left untreated, may prove difficult to cure leading to several
complications. The person may develop inflammation of legs and arms, resulting into cardiac
failure. Adequate diagnosis and early treatment may promote complete recovery. The guidance
and care of a learned pulmonologist may help identify the underlying cause and may lead to
faster post illness rehabilitation.
The registered nurse can identify the need of use of assistive devices, if the patient’s condition
does not improve with medications and physical therapy. The RN can install the devices and can
monitor the outcomes and improvements in his health due to assistive therapy. RN must ensure
that the therapy is not administered in excessive levels than intended.
Discharge Planning
The discharge planning involves evaluation of patient’s medical condition, ventilator or
respiratory support provided, details of all the interventions and assistive devices. The physical
and functional ability of the patient is assessed during discharge planning, the patient’s
psychosocial condition, the goals of care from patient’s perspective and improvements in his
health. Training and education of the patient about clear demonstration of medicines their
dosage, disease management, lifestyle changes, precautions and follow up visits. The satisfaction
level of the patient and his family is ensured before the discharge.
The discharge planning of the patient need to follow completion of discharge checklist, holistic
education for the patients, and conducting a telephonic follow up about the patient’s health at
home after discharge (Chen, Zhu, Xu and Chen, 2016).
According to social justice framework, the discharge planning should support the self
determination, should respect the patient rights, provide equity of care, access to resources, and
facilitate his maximum participation in his own care plan (Nelson and Creagh, 2013).

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Patient needs to be educated before discharge to facilitate reduced readmissions, early
identification of symptoms and promote self care. The patient should be taken as an active
partner in the care plan. The Registered nurses should identify the barriers in implementing the
care plan and should help the patient minimize these barriers (Paul, 2019). The patient also needs
to understand all the measures to identify the deteriorating symptoms and to seek medical help
whenever he depicts the need for it.
The patient should be given written instructions at the time of discharge addressing the discharge
medications, the activity level of the patient at the time of discharge, his follow up appointments,
his weight monitoring, diet, precautions to take, and the things to do if the condition worsens.
Generally the patients do not comply with the discharge plan due to their lack of understanding
(Paul, 2019). Thus, the Registered Nurses and the care planning teams need to be ensured that
the patient and his family have understood the instructions given to them during discharge.
Effective discharge planning is related to enhanced patient outcomes. It is possible through
effective communication between the patient and the care providers.
Conclusion
Thus we can conclude that the patient requires a holistic care plan that will involve medication
and non pharmacological interventions along with the use of assistive devices if he needs. The
patient is already receiving medications for his hypertension, elevated BP, high cholesterol levels
and Diabetes. The primary care priorities of the patient are improving the breathing and
respiratory pattern and improving the cardiac responsiveness to enhance blood circulation. The
discharge planning of the patient will require written instructions to be given with clear
education about the necessary things to monitor during self management of his symptoms at
home.

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References
Burns, A.D.,(2017). Critical Care Nursing Quarterly: Pharmacological Treatment of Heart
Failure. 30(4). pp. 299-306. Available from : https://www.nursingcenter.com/journalarticle?
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Chen, Y., Zhu,L., Xu, F., and Chen,J.(2016). Discharge planning for heart failure patients in a
tertiary hospital in Shanghai: a best practice implementation project. JBI Database of Systematic
Reviews and Implementation Reports. 14(2). pp.322–336. doi: 10.11124/jbisrir-2016-2510

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Dumitru,I.(2018). Heart Failure Treatment and Management. Available from
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