NRS 455 Case Study: Mrs. R.
NRS 455 Case Study: Mrs. R. – Step-by-Step Guide
The first step before starting to write the NRS 455 Case Study: Mrs. R., it is essential to understand the requirements of the assignment. The first step is to read the assignment prompt carefully to identify the topic, the length and format requirements. You should go through the rubric provided so that you can understand what is needed to score the maximum points for each part of the assignment.
It is also important to identify the audience of the paper and its purpose so that it can help you determine the tone and style to use throughout. You can then create a timeline to help you complete each stage of the paper, such as conducting research, writing the paper, and revising it to avoid last-minute stress before the deadline. After identifying the formatting style to be applied to the paper, such as APA, you should review its use, such as writing citations and referencing the resources used. You should also review how to format the title page and the headings in the paper.
How to Research and Prepare for NRS 455 Case Study: Mrs. R.
The next step in preparing for your paper is to conduct research and identify the best sources to use to support your arguments. Identify the list of keywords from your topic using different combinations. The first step is to visit the university library and search through its database using the important keywords related to your topic. You can also find books, peer-reviewed articles, and credible sources for your topic from PubMed, JSTOR, ScienceDirect, SpringerLink, and Google Scholar. Ensure that you select the references that have been published in the last words and go through each to check for credibility. Ensure that you obtain the references in the required format, for example, in APA, so that you can save time when creating the final reference list.
You can also group the references according to their themes that align with the outline of the paper. Go through each reference for its content and summarize the key concepts, arguments and findings for each source. You can write down your reflections on how each reference connects to the topic you are researching about. After the above steps, you can develop a strong thesis that is clear, concise and arguable. Next you should create a detailed outline of the paper so that it can help you to create headings and subheadings to be used in the paper. Ensure that you plan what point will go into each paragraph.
How to Write the Introduction for NRS 455 Case Study: Mrs. R.
The introduction of the paper is the most crucial part as it helps to provide the context of your work, and will determine if the reader will be interested to read through to the end. You should start with a hook, which will help capture the reader’s attention. You should contextualize the topic by offering the reader a concise overview of the topic you are writing about so that they may understand its importance. You should state what you aim to achieve with the paper. The last part of the introduction should be your thesis statement, which provides the main argument of the paper.
How to Write the Body for NRS 455 Case Study: Mrs. R.
The body of the paper helps you to present your arguments and evidence to support your claims. You can use headings and subheadings developed in the paper’s outline to guide you on how to organize the body. Start each paragraph with a topic sentence to help the reader know what point you will be discussing in that paragraph. Support your claims using the evidence conducted from the research, ensure that you cite each source properly using in-text citations. You should analyze the evidence presented and explain its significance and how it connects to the thesis statement. You should maintain a logical flow between each paragraph by using transition words and a flow of ideas.
How to Write the In-text Citations for NRS 455 Case Study: Mrs. R.
In-text citations help the reader to give credit to the authors of the references they have used in their works. All ideas that have been borrowed from references, any statistics and direct quotes must be referenced properly. The name and date of publication of the paper should be included when writing an in-text citation. For example, in APA, after stating the information, you can put an in-text citation after the end of the sentence, such as (Smith, 2021). If you are quoting directly from a source, include the page number in the citation, for example (Smith, 2021, p. 15). Remember to also include a corresponding reference list at the end of your paper that provides full details of each source cited in your text. An example paragraph highlighting the use of in-text citations is as below:
The integration of technology in nursing practice has significantly transformed patient care and improved health outcomes. According to Smith (2021), the use of electronic health records (EHRs) has streamlined communication among healthcare providers, allowing for more coordinated and efficient care delivery. Furthermore, Johnson and Brown (2020) highlight that telehealth services have expanded access to care, particularly for patients in rural areas, thereby reducing barriers to treatment.
How to Write the Conclusion for NRS 455 Case Study: Mrs. R.
When writing the conclusion of the paper, start by restarting your thesis, which helps remind the reader what your paper is about. Summarize the key points of the paper, by restating them. Discuss the implications of your findings and your arguments. End with a call to action that leaves a lasting impact on the reader or recommendations.
How to Format the Reference List for NRS 455 Case Study: Mrs. R.
The reference helps provide the reader with the complete details of the sources you cited in the paper. The reference list should start with the title “References” on a new page. It should be aligned center and bolded, in sentence sentence care. The references should be organized in an ascending order alphabetically and each should have a hanging indent. If a source has no author, it should be alphabetized by the title of the work, ignoring any initial articles such as “A,” “An,” or “The.” If you have multiple works by the same author, list them in chronological order, starting with the earliest publication.
Each reference entry should include specific elements depending on the type of source. For books, include the author’s last name, first initial, publication year in parentheses, the title of the book in italics, the edition (if applicable), and the publisher’s name. For journal articles, include the author’s last name, first initial, publication year in parentheses, the title of the article (not italicized), the title of the journal in italics, the volume number in italics, the issue number in parentheses (if applicable), and the page range of the article. For online sources, include the DOI (Digital Object Identifier) or the URL at the end of the reference. An example reference list is as follows:
References
Johnson, L. M., & Brown, R. T. (2020). The role of telehealth in improving patient outcomes. Journal of Nursing Care Quality, 35(2), 123-130. https://doi.org/10.1097/NCQ.0000000000000456Smith, J. A. (2021). The impact of technology on nursing practice. Health Press.
NRS 455 Case Study: Mrs. R.
Use the “Case Study: Mrs. R.” template to complete the assignment.
Case Study: Mrs. R. has indirect care experience requirements. The “NRS-455 – Case Studies: Indirect Care Experience Hours” form, found in the Topic 1 Resources, will be used to document the indirect care experience hours completed in the case study. As progress is made on the case study, update this form indicating the date(s) each section is completed. This form will be submitted in Topic 3. Read the next task NRS 455 Topic 2 DQ 1 Identify a common perceptual, neurological, or cognitive issue and discuss contributing factors.
You are required to cite a minimum of three sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.
American Association of Colleges of Nursing Core Competencies for Professional Nursing Education
This assignment aligns to AACN Core Competencies 2.5, 2.7, and 8.2.
NRS 455 Case Study: Mrs. R. Example
Directions: Read the case study below. Evaluate the information and formulate a
conclusion based on your evaluation. Complete the critical thinking table and submit this
completed template to the assignment dropbox.
Case Study: Mrs. R.
It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the
pathophysiological processes of disease, the clinical manifestations and treatment protocols, and
how they affect clients across the life span.
Evaluate the Health History and Medical Information for Mrs. R., presented below.
Health History and Medical Information
Mrs. R. is a 68-year-old married woman who has a history of hypertension, chronic heart failure,
and chronic obstructive pulmonary disease (COPD). Despite requiring 2L of oxygen/nasal
cannula at home during activity, she continues to smoke two packs of cigarettes a day and has
done so for 40 years. Three days ago, she had sudden onset of flu-like symptoms, including
fever, productive cough, nausea, and malaise. Over the past 3 days, she has been unable to
perform ADLs and has required assistance in walking short distances. She has not taken her
antihypertensive medications or medications to control her heart failure for 3 days. Today, she
has been admitted to the hospital ICU with acute decompensated heart failure and acute
exacerbation of COPD.
Subjective Data
- Is very anxious and asks whether she is going to die.
- Denies pain but says she feels like she cannot get enough air.
- Says her heart feels like it is “running away.”
- Reports that she is exhausted and cannot eat or drink by herself.
Objective Data - Height 175 cm; Weight 95.5kg.
- Vital signs: T 37.6C, HR 118 and irregular, RR 34, BP 90/58.
- Cardiovascular: Distant S1, S2, S3 present; PMI at sixth ICS and faint: all peripheral
pulses are 1+; bilateral jugular vein distention; initial cardiac monitoring indicates a
ventricular rate of 132 and atrial fibrillation. - Respiratory: Pulmonary crackles; decreased breath sounds right lower lobe; coughing
frothy blood-tinged sputum; SpO2 82%. - Gastrointestinal: BS present: hepatomegaly 4cm below costal margin.
Intervention
The following medications administered through drug therapy control her symptoms:
- IV furosemide (Lasix)
- Enalapril (Vasotec)
- Metoprolol (Lopressor)
- IV morphine sulphate (Morphine)
- Inhaled short-acting bronchodilator (ProAir HFA)
- Inhaled corticosteroid (Flovent HFA)
- Oxygen delivered at 2L/ NC
Subjective data are symptoms felt by the patient while objective data is not felt by the patient.
Critical Thinking Table
| Clinical Manifestations Describe the clinical manifestations present in Mrs. R., focusing on the normal and abnormal findings and how this relates to his current condition. | |
| Subjective | She is asking if she is going to die, this tells us that she is feeling anxious which is a sign that she is not getting enough oxygen. This is because she has rapid accumulation of fluid that fills her lungs interstitial and alveolar spaces. (UpToDate, 2024) This happens because of cardiogenic pulmonary edema. Which is the accumulation of fluid in the lungs because of the pressure in the heart. She is reporting that she is exhausted and unable to eat or drink on her own, as well as though her heart is running away. This is because her compensatory mechanisms are overwhelmed. (Njoroge & Teerlink, 2021) Filling pressures of the ventricular are causing these symptoms that she is experiencing. Cardiogenic pulmonary edema is |
| Objective | She is overweight we do not know her weight prior this could be an indication of fluid retention, but it is not clear. Weight would be good to review. And then monitor going forward to see if therapies are working. Her blood pressure is low this is because her overaction of sympathetic system. Her left |
| ventricular dysfunction is leading to decreased blood pressure that in return leads to decreased renal perfusion. (Acute Decompensated Heart Failure, 2019). Crackles in her lungs are indication that she has pulmonary edema with pleural effusions. She is not able to perfuse oxygen appropriately due to the pulmonary edema frothy blood-tinged sputum is a sign and symptom of this. (Njoroge & Teerlink, 2021) This is why we are seeing decreased spO2 stats. Hepatomegaly that is heard as well as the jugular venous distention indicates that she has right ventricular malfunctions. (Khalid et al., 2021) Her ventricular pressures and neurohormonal compensatory mechanisms increase chronotropy and inotropy trigger the tachycardia and arrhythmias this will increase strain on her heart and ischemia. (Njoroge & Teerlink, 2021) | |
| Cardiovascular Conditions Leading to Heart Failure Describe cardiovascular conditions in which Mrs. R. is at risk. | |
| Describe four cardiovascular conditions in which Mrs. R. is at risk and that may lead to heart failure. | |
| without increase in the ejection fraction during exercise it associated with obesity. Smoking– Smoking decreases good cholesterol, and increases bad cholesterol, this produces plaque in the arteries that damage the blood vessels. (Villines, 2022) Smoking can also cause hypertension. The pulmonary artery pressure will increase because of poor-oxygenated blood from the heart to the lungs. Smoking also causes more carbon monoxide this damages the kidneys and causes oxidative stress. All these comorbid diseases lead to heart failure. Because she has multiple comorbidities her risk of heart failure is great. | |
| Discuss any comorbidities Mrs. R. displays. | Hypertension – She is also overweight, so she might be sedentary, and her diet might not be good, taking in high salt. She is also not compliant with her medications. All of this increases her blood pressure, which is putting a lot of strain on her heart and stretching and weakening her left ventricle. COPD- Is due to her smoking history. This probably has contributed to her hypertension as well. Her organs are not getting enough oxygen due to her lungs not being able to exchange oxygen as it should. Atrial fibrillation- When in afib the heart beats quickly and irregular. Because of this the atria does not fill completely or pump it out properly. This makes the heart work harder and weakens the muscle in the heart, which will lead to heart failure. (Atrial Fibrillation Complications and Risks, 2024) |
| How do these conditions increase her chance of heart failure? | Hypertension is hard on the heart and puts a lot of strain on it. The high blood flow will cause the left ventricular to stretch and weaken and because of this her heart is not able to pump blood efficiently leading to decreased output of the heart. (Oh & Cho, 2020). COPD reduces the amount of oxygen in the heart and so if the oxygen leaving the heart with the reduced ejection fraction causes poor oxygenation of all other organs. |
| COPD is the result of her smoking, smoking damages the bronchi and increases her blood pressure. The body is trying to compensate for the low oxygen and get more oxygen to her organs. | |
| What can be done by way of medical/nursing interventions to prevent the development of heart failure in each of the presented conditions. | The best nursing intervention is to educate the patient and help the patient to make modifications in lifestyle to reduce their risk of heart failure. Providing education on smoking sensation, increasing activity as well as modifications in diet to reduce the risk of heart failure. Providing resources for the patients can have a huge impact. Providing information to a dietician, as well as support groups to quit smoking are all great ways to help the patient make the changes, they need to reduce their risk of heart failure. According to our book, showing Mrs. R on how to breath with pursed lips will help her to feel more in control of COPD. (Falkner et al., n.d.) This will decrease the carbon dioxide provide more oxygen to the blood and this will decrease Mrs. R anxiety that she is experiencing. |
| Evaluation of Nursing Interventions at Admissions Discuss the initial assessments and interventions provided to Mrs. R. | |
| According to the nursing process, were the initial assessments and interventions at the time of admission beneficial for Mrs. R? | Yes, the objective and subjective collection of data is important to know what is happening to Mrs. R. Helping to determine what is exacerbated. All this data that was collected is important to figure out what needs to be done to help her and get her comorbidities under control to decrease the progression of her heart failure. Because she is not compliant with her medications this has made her situation much worse. She needs more education regarding her medications and what they do for her. I think that if she had a better understanding of how important her medications are to slow the progression of her heart failure, she may be more compliant. |
| Discuss changes to any of the initial assessments or interventions you would make to ensure patient independence and prevent readmission. | To educate patients about HF and ultimately improve outcomes and reduce readmissions. (Vuckovic et al., 2020) The only thing that I would add health is to have a mental evaluation done. She is older and has many health conditions that are chronic, this can lead to depression, this could be why she is not taking care of her health. If she is depressed, she is less likely to adhere to medications regiments and lifestyle recommendations. She may need her living situation evaluated; she might need more support at home to help her with her ADLs. |
| Medications and Prevention of Problems Caused by Multiple Drug Interactions Explain each of the seven medications listed in the case study and increase the incidence of polypharmacy. | |
| Explain each of the seven medications listed in the case study. Include the classification, action, and | IV furosemide (Lasix)- Is a loop diuretic the stops the body from absorbing too much salt, the salt will pass in the urine. |
| rationale for each of these medications as they stem from pathophysiology for this patient’s condition (e.g., consider morphine use outside of pain management). | This will reduce the fluid in the body, allowing her to breathe easier. (DrugGuide.com, n.d.) It inhibits sodium and chloride from being reabsorbed from the loop of Henle and distal renal tubule. The decrease in fluids will also decrease blood pressure, thus taking some of the pressure off the heart. Enalapril (Vasotec)-Ace inhibitor (Angiotensin-converting enzyme) that blocks the conversion of angiotensin 1 to angiotensin 2. This will increase the plasma renin levels and decrease aldosterone to create vasodilation. Increasing vasodilation will decrease the blood pressure and decrease the preload on the heart. Metoprolol (Lopressor)-Beta blocker, which is what it says blocks the adrenergic receptors the beta 1. This will decrease the blood pressure and heart rate. Decreasing the workload on the heart. IV morphine sulphate (Morphine)-opioid agonists, it reduces the vascular tone, causing vasodilatory by increasing the histamine release. This will depress the brainstem respiratory rhythm pattern generation. It has a vasodilator response which will decrease blood pressure. (Caspi & Aronson, 2020) Inhaled short-acting bronchodilator (ProAir HFA)- adrenergic, it binds to beta2 adrenergic receptors in the smooth muscle in the airways. This will relax the air ways. This will help with her COPD Inhaled corticosteroid (Flovent HFA)-Is an anti- inflammatory considering a corticosteroid. This will decrease the inflammation in the bronchi to help relieve her COPD |
| symptoms, allowing her to get more oxygen to her body. Oxygen delivered at 2L/ NC-Increasing her oxygen will help her to not work so hard to get oxygen to her lungs. It will reduce the amount of breathing and reduce venous return. (Ramachandran et al., 2022) | |
| Discuss four nursing interventions that can help prevent problems caused by multiple drug interactions in older patients. Provide a rationale for each of the interventions you recommend. | A nursing intervention to help prevent problems with drug interactions for older adults is to teach the patient and their caregivers about the medication, purpose of the drug and the effects it has on them. (Preventing Polypharmacy in Older Adults, 2020) Educate them on the side effects and what may interact with the medications. Education on importance of taking the medication as directed. This education will help the patient understand what medications they are taking and why they are taking them. Another nursing intervention that can be beneficial is helping the patient to organize and manage their medications. Utilizing a pill dispenser or organizer for all 7 days can decrease confusion and make it easier for them to take them. This can increase medication compliance. Teaching precautions about the medications is important as well. Taking blood pressure medications can cause dizziness, teaching them to rise slowly will prevent falls. Also teaching about precautions to take when on so many medications and when to call their doctor. Teaching about complications will help the patient to recognize when there is a serious side effect and when to seek help can save them from life threating complications to the medications. |
| Health Promotion and Restoration Teaching Plan Develop a multidisciplinary health promotion and restoration teaching plan for Mrs. R. | |
| Discuss the steps needed to move the patient from acute care to subacute care, before discharging home and beginning a rehabilitation process. | For this patient to step down into acute care the patient would need to show improvement in her breathing, oxygen stats should be over 90%. She should have decreased fluid from her lungs and jugular distension lesson. Her blood pressure should be within normal limits as well as her heartbeat. Her Afib should be resolved and her heart workload decreased. |
| Discuss alternative discharge options and qualifications to facilitate a smooth transition to the next level of care. | Involving a case worker for her discharge will help facilitate any care and assistance she may need when she goes home. Making sure she has enough oxygen supplies. The case worker will make sure she has followed up appointments set up. Making sure that Mrs. R has the support she needs at home will significantly improve her outcome. She might need a home health nurse to visit with her, or physical therapy to increase her exercise to strengthen her lungs. |
| Explain how the rehabilitation resources, including medication management, and modifications will assist the patient’s transition to promote independence and prevent readmission. | Rehabilitation services would benefit Mrs. R significantly. She may be lacking understanding of her medical condition as well as not understanding why she is taking her medications. Because we can’t see what the medications are doing, we may think we are healed. I see a lot where patients believe that these conditions go away magically. Or they chose to ignore it because they are overwhelmed. Teaching her how to manage her conditions and medications would help her to manage her health. This would give her control over her health when she is educated about how to care for herself as well as understanding that not managing these conditions will lead to heart failure. If she is more engaged in her self-care this will help reduce the hospitalizations and improve her quality of life. (Vuckovic et al., 2020) |
| Pathophysiological Changes Discuss the pathophysiological changes that come with Mrs. R.’s long-term tobacco use. | |
| COPD Triggers and Options for Smoking Cessation Discuss options for smoking cessation education. | |
| What options for smoking cessation should be offered to Mrs. R? | Some options for Mrs. R, are Chantix (varenicline) Or nicotine patches and gum could be helpful for her to help her quit smoking. (Falkner et al., n.d.) According to our book Medicaid plans help pay for smoking cessation in full to make this feasible for patients to stop smoking. |
| Explain the COPD triggers that can increase exacerbation frequency, resulting in readmission. | Triggers for COPD include continued smoking. As well as getting sick. Respiratory infections are the most common triggers. Protecting herself by washing her hands, staying away from others that are sick as well as getting a flu vaccine will help minimize her COPD exacerbation frequency. (American Lung Association, n.d.) |
References
Acute decompensated heart failure. (2019, April 26). https://www.emra.org/emresident/article/adhf
American Lung Association. (n.d.). Preventing Flare-Ups. https://www.lung.org/lung-health- diseases/lung-disease-lookup/copd/living-with-copd/prevent-flare-ups
Arrigo, M., Jessup, M., Mullens, W., Reza, N., Shah, A. M., Sliwa, K., & Mebazaa, A. (2020).
Acute heart failure. Nature Reviews Disease Primers, 6(1). https://doi.org/10.1038/s41572-020-0151-7
Atrial fibrillation complications and risks. (2024, July 11). Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/atrial-fibrillation/afib- complications
Caspi, O., & Aronson, D. (2020). Morphine in the setting of acute heart failure: Do the risks outweigh the benefits? Cardiac Failure Review, 6. https://doi.org/10.15420/cfr.2019.22
Davis’s Drug Guide Online + App | DrugGuide.com. (n.d.). https://www.drugguide.com/ddo? svar=a%7cub&svar=c%7crc
Falkner, A., Green, S., Johnson, A., Randall, J., Whitney, S., & Grand Canyon University. (n.d.). Pathophysiology: Clinical Applications for Client Health. https://bibliu.com/app/? bibliuMagicToken=pXDObeilxX0gRuMVJVgB9HYQl9fox8KW#/view/books/ 1000000000590/epub/AuthorBios.html#page_5
Khalid, K., Padda, J., Komissarov, A., Colaco, L. B., Padda, S., Khan, A. S., Campos, V. M., & Jean-Charles, G. (2021). The coexistence of chronic obstructive pulmonary disease and heart failure. Cureus. https://doi.org/10.7759/cureus.17387
Malik, A., Brito, D., Vaqar, S., Chhabra, L., & Doerr, C. (2023, November 5). Congestive heart failure (NuRSing). StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK574497/
Njoroge, J. N., & Teerlink, J. R. (2021). Pathophysiology and therapeutic approaches to acute decompensated heart failure. Circulation Research, 128(10), 1468–1486. https://doi.org/10.1161/circresaha.121.318186
Oh, G. C., & Cho, H. (2020). Blood pressure and heart failure. Clinical Hypertension, 26(1). https://doi.org/10.1186/s40885-019-0132-x
Preventing polypharmacy in older adults. (2020). American Nursing Association. https://www.myamericannurse.com/preventing-polypharmacy-in-older-adults/ #:~:text=As%20a%20nurse,%20you%20can%20be%20pivotal%20in%20helping
Ramachandran, G., Prasad, C. H. R. K., Garre, S., & Sundar, A. S. (2022). Oxygen management in heart failure patients. Indian Journal of Clinical Cardiology, 3(3), 150–156. https://doi.org/10.1177/26324636221081585
Renal system | Pharmacology Education Project. (n.d.). https://pharmacologyeducation.org/drugs/renal-system
Shen, Q., Hiebert, J. B., Rahman, F. K., Krueger, K. J., Gupta, B., & Pierce, J. D. (2021). Understanding Obesity-Related High Output heart Failure and its implications. International Journal of Heart Failure, 3(3), 160. https://doi.org/10.36628/ijhf.2020.0047
UpToDate. (2024, August). UpToDate. https://www.uptodate.com/contents/treatment-of-acute- decompensated-heart-failure-specific-therapies
Villines, Z. (2022, November 22). Can smoking cause heart failure? https://www.medicalnewstoday.com/articles/smoking-and-heart-failure
Vuckovic, K. M., Bierle, R., & Ryan, C. J. (2020). Navigating symptom management in heart Failure: The crucial role of the Critical care nurse. Critical Care Nurse, 40(2), 55–63. https://doi.org/10.4037/ccn2020685
