NUR241 Contexts Of Practice: Health Alteration

NUR241 Contexts Of Practice: Health Alteration

NUR241 Contexts Of Practice: Health Alteration


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. NUR241 Contexts Of Practice: Health Alteration

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).