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NRS 410 Case Study: Hypertension, CHF and Sleep Apnea

NRS 410 Case Study: Hypertension, CHF and Sleep Apnea

The case scenario discussed is of 63-year-old Mrs. J who has been in care for chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) and is now admitted due to their exacerbations. She reports a history of cigarette smoking, hypertension, poor compliance to medication, and a recent upper airway tract infection. This discussion aims to describe how she was managed, the reasons for exacerbation, and patient management plans.

Question 1

COPD that Mrs. J is characterized by an inflamed airway that impairs expiration of gases thus presenting with dyspnea. The limited expiration results in the accumulation of carbon (IV) oxide in the body which triggers anxiety (Choi & Rhee, 2020). On the other hand, CHF reduces the heart’s ability to pump blood thus irregular heartbeat occurs described as the heart running away (Schwinger, 2021). It also presents with fatigue due to impaired blood supply to the body tissues (Hajar, 2019).

Question 2

            Medications that have been administered to manage Mrs. J can be justified due to their effects. Furosemide and enalapril work through a different mechanisms of action to reduce the decompensation of the heart in CHF (Hajar, 2019). Although furosemide encourages diuresis by inhibiting the reabsorption of sodium in kidney tubules whereas enalapril inhibits the renin-angiotensin-aldosterone system (RAAS), they both lead to a decrease in preload and afterload (Lee et al., 2019). This reduces pressure against the heart and also corrects the reported edema especially due to furosemide use.

Metoprolol that was prescribed regulates the sympathetic system activation in heart failure thereby reducing the cardiac contractility and heart rate (Hajar, 2019). As such, it corrects the reported palpitations. Further, the inhaled bronchodilators and corticosteroids correct the bronchoconstriction due to COPD thus promoting expiration whereas morphine helped in reducing anxiety symptoms (Lief & McSparron, 2020). Due to Mrs. J’s low oxygen saturation, oxygen supplementation was also necessary to reverse the hypercapnia and promote oxygen delivery to tissues (Choi & Rhee, 2020). The prescribed drugs were therefore justified and appropriate for managing the exacerbations.

Question 3

            CHF results from most heart conditions whether they affect the valves, heart muscles, or the electrical conduction pathways. Some of these conditions include cardiomyopathy, valvular defects, coronary artery disease (CAD), and arrhythmias. Cardiomyopathy is where there is damage to the myocardium due to a myriad of factors including alcohol use and it consequently impairs the heart’s ability to pump blood (Hajar, 2019). Valvular defects whether resulting from infection of the valves, stenosis, or regurgitation are also implicated (Lee et al., 2019). CAD where there are narrowed coronary artery vessels with consequential cardiac ischemia as well as arrhythmias where the is uncoordinated heart beating such as atrial fibrillation are other risk factors for CHF (Schwinger, 2021). Most of these conditions can be prevented from resulting in CHF.

Different nursing interventions can help in preventing CHF from these cardiac conditions. Such measures include the adoption of physical exercise and dietary modification for CAD, reduced alcohol consumption for cardiomyopathy, and aggressive antibiotic therapy to prevent the advancement of valvular infection into CHF (Lee et al., 2019). Non-pharmacological vagal maneuvers may be applied to correct arrhythmias.

Question 4

            Nurses play important roles in preventing adverse reactions to polypharmacy. They achieve this through education, instruction,

NRS 410 Case Study Hypertension, CHF and Sleep Apnea

NRS 410 Case Study Hypertension, CHF and Sleep Apnea

information, and organization. Education involves highlighting the presentation of adverse reactions and warning the patient about drugs or food that possibly interact with their prescribed medications (Zabihi et al., 2018). By instruction, adherence to therapy is emphasized to prevent incidences of overdose which is an adverse reaction. During instruction, the nurse directs the patient to reliable sources of medicine to ensure continuity of therapy (Lief & McSparron, 2020). On the other hand, the organization is done by arranging the drug into daily pill packs that promote adherence and discourages overdose.

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Question 5

            Health promotion in a patient with COPD and CHF will aim at reducing readmission rates and facilitating recovery. To reduce the readmissions, the risk factors of exacerbation such as unhealthy diet, cigarette smoking, and obesity should be addressed. Mrs. J will therefore be encouraged to reduce her weight, adopt the DASH diet, and also engage in physical activity (Hajar, 2019). She will also be advised against cigarette smoking which may worsen COPD. In the promotion of her recovery, the patient will benefit from a multidisciplinary team comprised of pulmonologists and cardiologists who will educate her on pulmonary physiotherapy, cardiac rehabilitation, and adherence to medication (Schwinger, 2021). Homebased care can also be adopted to promote her well-being at home. These measures will enhance recovery and reduce the risks of readmission.

Question 6

Mrs. J is a geriatric patient who will benefit from proper education on her condition. Given most geriatric patients have poor literacy that may enable the comprehension of complex medical information during education, an effective education would involve the use of diagrams and charts for illustrations (Lee et al., 2019). This not only promotes comprehension but also encourages memorability. Adoption of family education can also be encouraged to promote the involvement of family members in patient care (Toledano-Toledano & Luna, 2020).

Question 7

            Some of the factors that may have exacerbated the COPD in this patient would include the history of cigarette smoking and the recent flu-like illness that is reported. These triggers cause airway hyperresponsive and worsen bronchoconstriction, especially in COPD and asthma patients (Lief & McSparron, 2020). Other possible causes of the exacerbation may include exposure to cold, air pollution, and non-adherence to medications. Smoke cessation would therefore be encouraged for patients with COPD who smoke a cigarette. The options to encourage cessation of smoking include nicotine replacement therapy, use of bupropion, as well as psychotherapy such as group therapy (Choi & Rhee, 2020). These methods help in reducing cravings for smoking thus promoting recovery.


            Chronic illnesses such as COPD and CHF have underlying organ dysfunctions that are responsible for their presentation. Understanding these dysfunctions as well as their causes and triggers helps in the formulation of effective strategies for managing patients against these conditions. The use of medications should be aimed at addressing the dysfunction or patient symptoms. In the course of treatment, adherence to therapy should be encouraged as the incidences of adverse drug reactions are reduced. Further, the specific risk factors of the conditions should also be addressed by encouraging health promotion strategies such as a healthy diet, smoke cessation, and physical exercise. This would reduce incidences of readmission for these patients and promote patient recovery.




Choi, J. Y., & Rhee, C. K. (2020). Diagnosis and treatment of early chronic obstructive lung disease (COPD). Journal of Clinical Medicine9(11), 3426. https://doi.org/10.3390/jcm9113426

Hajar, R. (2019). Congestive heart failure: A history. Heart Views: The Official Journal of the Gulf Heart Association20(3), 129–132. https://doi.org/10.4103/HEARTVIEWS.HEARTVIEWS_77_19

Lee, J. H., Kim, M. S., Yoo, B. S., Park, S. J., Park, J. J., Shin, M. S., Youn, J. C., Lee, S. E., Jang, S. Y., Choi, S., Cho, H. J., Kang, S. M., & Choi, D. J. (2019). KSHF guidelines for the management of acute heart failure: Part II. Treatment of acute heart failure. Korean Circulation Journal49(1), 22–45. https://doi.org/10.4070/kcj.2018.0349

Lief, L., & McSparron, J. (2020). Acute Exacerbation of COPD. In Evidence-Based Critical Care (pp. 169–173). Springer International Publishing.

Schwinger, R. H. G. (2021). Pathophysiology of heart failure. Cardiovascular Diagnosis and Therapy11(1), 263–276. https://doi.org/10.21037/cdt-20-302

Toledano-Toledano, F., & Luna, D. (2020). The psychosocial profile of family caregivers of children with chronic diseases: a cross-sectional study. BioPsychoSocial Medicine14(1), 29. https://doi.org/10.1186/s13030-020-00201-y

Zabihi, A., Hosseini, S., Jafarian Amiri, S., & Bijani, A. (2018). Polypharmacy among the elderly. Journal of Mid-Life Health9(2), 97. https://doi.org/10.4103/jmh.jmh_87_17

Case Scenario for Hypertension, CHF and Sleep Apnea

Mrs. 3. is a 63-year-old woman who has a history of hypertension, chronic heart failure, and sleep apnea. She has been smoking two packs of cigarettes a day for 40 years and has refused to quit. Three days ago, she had an onset of flu with fever, pharyngitis, and malaise. She has not taken her antihypertensive medications or her medications to control her heart failure for 4 days. Today, she has been admitted to the hospital ICU with acute decompensated heart failure.

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 so exhausted she cannot eat or drink by herself.

Objective Data

  • Height 175 cm; Weight 95.5 kg
  • Vital signs: T 37.6 C, HR 118 and irregular, RR 34, BP 90/58
  • Cardiovascular: Distant S1, 52, 53, 54 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; 5p02 82%
  • Gastrointestinal: BS present: hepatomegaly 4 cm below costal margin

Replies to Barb McGraw

In the hospital where I work, atrial fibrillation is one of the most frequently encountered cardiac arrhythmias that we diagnose and treat. Having atrial fibrillation can put a person at an increased risk of having a stroke, particularly if the condition is not treated or diagnosed in a timely manner. Because of the irregular heart rate, atrial fibrillation can also lead to heart failure. More than 5 million people in the United States are currently living with atrial fibrillation, and it is anticipated that the number of people affected will rise to 12.1 million by the year 2030 (Streur, 2019). According to Streur (2019), the risk of developing atrial fibrillation is increased by a number of comorbid conditions and lifestyle factors. These factors include hypertension, coronary artery disease, heart failure, diabetes mellitus, obesity, hyperlipidemia, sleep apnea, hyperthyroidism, moderate to heavy alcohol consumption, smoking, and excessive exposure to ultraviolet light. There are things in this list that a person can change and things that one cannot change.

“The plan of care prioritizes the management of comorbid conditions in order to shorten the duration of atrial fibrillation and prevent its recurrence. It also emphasizes the control of heart rate in order to minimize symptoms and the prevention of thromboembolism and stroke” (Little, 2022). Age, gender, genetics, and ethnicity are examples of inborn predispositions that cannot be changed. People have the ability to reduce some of the risks by deciding to stop smoking, reduce their weight, and improve their diet. People who make the conscious decision not to change aspects of their lives that they have the ability to change have options, such as medication. To assist in maintaining a healthy heart rate, your doctor may recommend taking a medication known as a beta blocker. In addition, there are medications that can treat diabetes, high cholesterol, and hypertension. Education regarding each of these medications is of the utmost importance, as is the management of the diseases that put patients at risk for atrial fibrillation or for developing this disease.


Little, K. (2022). Atrial fibrillation: Recognition and management to improve quality of life: Keep patients at the center of decision making. American Nurse Today17(4), 10–16.

Streur, M. (2019). Atrial Fibrillation Symptom Perception. The Journal for Nurse Practitioners15(1), 60–64.


Sara Habib

replied toMarise Guillaume Charles

Jul 22, 2022, 3:10 PM

Replies to Marise Guillaume Charles


Where I use to work, we saw a lot of diagnosis of Atrial Fibrillation as well. Often after an Afib diagnosis, a cardiologist would order a transesophageal echocardiogram (TEE). A TEE is performed by putting a probe down the esophagus to record ultrasound images to evaluate for blood clots (Johnson, 2018). The TEE images can also diagnose things like heart failure, atrial fibrillation, atrial flutter, and abnormal heart valves (Johnson, 2018). A TEE is a valuable tool that a cardiologist can use to help diagnose a patient.

Johnson, A. (2018). Pathophysiology Clinical Applications for Client Health (Chapter 1). Grand Canyon University (Ed). https://lc.gcumedia.com/nrs410v/pathophysiology-clinical-applications-for-client-health/v1.1/#/chapter/1

Critical Thinking Questions

What nursing interventions are appropriate for Mrs. 3 at the time of her admission? Drug therapy is started for Mrs. 3. to control her symptoms. What is the rationale for the administration of each of the following medications?

  • IV furosemide (Lasix)
  • Enalapril (Vasotec)
  • Metoprolol (Lopressor)
  • IV morphine sulphate (Morphine)

Describe four cardiovascular conditions that may lead to heart failure and what can be done in the form of medical/nursing interventions to prevent the development of heart failure in each condition.
Taking into consideration the fact that most mature adults take at least six prescription medications, discuss four nursing interventions that can help prevent problems caused by multiple drug interactions in older patients. Provide rationale for each of the interventions you recommend.

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