Clinical Research Template

Client: Lesley George Room #: XXX Primary Diagnosis: CHF exacerbation Medications Lab values:
Not given Not given
Age: 77 Gender: Female

Allergies: Codiene Health History: HTN, Dyslipidemia, OA - bilateral

knees
Universal Precautions: Code status: Full Code
None

Diet: Healthy Heart Activity: AAT Health Assessment Data

MMSE (if given in report)

Concept(s) related to the Exemplar/Primary

Condition
Perfusion, Gas Exchange, Mobility, Nutrition

Readings and Resources

Here’s where you document the resources you accessed when
completing the research for your assigned client
Giddens, J.F. Concepts for nursing practice. St. Louis, Missouri: Mosby-Elsevier.
Paul, P., Day, R. A., & Williams, B. (Eds.). (2016). Brunner & Suddarth's Canadian textbook of medical-surgical nursing. Wolters Kluwer.
Perry, A.G. & Potter, P.A. (Eds.). Clinical nursing skills and techniques. Elsevier. 4. Potter, P. A., Perry, A.G., Stockert, P.A., & Hall, A.M. Canadian
fundamentals of nursing (J. C. Ross-Kerr, M. J. Wood, B. J. Astle & W. Duggleby,
Cdn. Eds.). Elsevier Canada.
Wilson, S.F. & Giddens, J. Health assessment for nursing practice. Mosby-Elsevier. 6. Karch, A. M. Focus on nursing pharmacology . Wolters Kluwer.

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 Exploring the Exemplar/Primary Diagnosis
Here is where you include relevant NK notes. Summarize and keep it brief for
quick access to support clinical judgment.

A&P: Summarize the main organ system(s) or physiological Pathophysiology: Summarize the pathophysiology of the exemplar/condition
processes affected by the exemplar/condition (or other in your own words.
relevant A&P). Include optimal/normal and
impaired/abnormal function and include a diagram for quick
reference in clinical.

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 basic function of the heart is to pump blood ability to pump is
evaluated by cardiac output - amount of blood pumped per
minute
CO is determined by measuring heart rate x stroke volume
stroke volume is the amount of blood pumped out of the
ventricle
with each contraction
HR is controlled by ANS (sympathetic and parasympathetic)
when sympathetic NS is stimulated, HR and SV increase
when parasympathetic NS is stimulated, HR and SV decrease
SV depends on three factors: preload, afterload and
contractility
preload - amount of blood within ventricle before systole
(contraction)
increases pressure in the ventricle - stretched ventricular wall
ventricular muscles need to be stretched to produce optimal
blood ejection
too little or too much stretch decreases volume of blood
ejected
ventricular compliance
elasticity/amount of ‘give’ when blood enters the ventricle
elasticity is decreased when the muscle thickens or when there
is increased fibrotic tissue - little compliance
given same amount of blood, a noncompliant ventricle has a
higher pressure
higher pressure increases workload and can lead to HF if
sustained
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Definition
a clinical syndrome resulting from structural or functional cardiac
disorders that impair the ability of the ventricles to fill with or eject
blood
Left side HF
• pulmonary congestion occurs when the left ventricle cannot
effectively pump blood out of the ventricle into the aorta and the
systemic circulation
• increased left ventricle end-diastolic blood volume increases left
ventricle end diastolic pressure
◦ decreases blood flow from left atrium into the left
ventricle during diastole
◦ blood volume and pressure in the left atrium increases -
decreases blood flow from pulmonary vessels into the left
atrium
◦ pulmonary venous blood volume and pressure increase in
the lungs, forces fluid from pulmonary capillaries into
pulmonary tissues and alveoli - causes pulmonary
interstitial edema and impaired gas exchange
Right side HF
• congestion in peripheral tissues and viscera predominates - right
side of heart cannot eject blood and cannot accommodate all of
the blood that normally returns to it from the venous circulation
◦ increased venous pressure leads to increased jugular
venous pressure (JVP) and increased hydrostatic pressure
throughout the venous system
Main S&S
• Congestion
◦ dyspnea - difficulty breathing
◦ orthopnea - difficulty breathing when laying flat
◦ paroxysmal nocturnal dyspnea - sudden attacks of
dyspnea at night
 afterload - amount of resistance to the ejection of blood from
the ventricle (amount of blood in aorta and surrounding vessels
after systole)
to eject blood, the ventricle must overcome the resistance
caused by tension in the aorta and systemic vessels
after load is inversely related to SV increase in afterload
causes the ventricle to work harder and may decrease amount
of blood ejected
major factors that determine afterload:
diameter and distensibility of the aorta and pulmonary artery
if a patient has vasoconstriction, hypertension or
a narrowed valvular opening, resistance afterload increases
opening and competence of semilunar valves (pulmonary and
aortic valves)
when valves open easily, resistance is lower
if afterload increases, the workload of the heart must increase
to overcome the resistance and eject blood
contractility
- the force of contraction is related to the status of the
myocardium
Catecholamines - released by sympathetic stimulation
increases contractility and SV
an MI causes necrosis and subsequent fibrosis of some
myocardial cells
shifts the workload to remaining cells
significant loss of myocardial cells can decrease
contractility and cause HF
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◦ cough - dry and non-productive
▪ can become moist - large quantities of frothy
sputum (sometimes pink/blood tinged)
◦ pulmonary crackles that do not clear with cough
• Poor perfusion/Cardiac Output
◦ difficulty sleeping
◦ oliguria (reduced urine output)
◦ nocturia (frequent urination at night)
◦ altered digestion
◦ dizziness/lightheadedness/confusion/restlessness/anxiety
◦ pale or ashen skin/cool and clammy
◦ cyanosis
◦ tachycardia and dysrhythmias
◦ weak and thready peripheral pulses
◦ fatigue and decreased activity tolerance
Right Sided Heart Failure
• Increased Venous Pressure
◦ increased jugular venous pressure (JVP)
◦ edema of the lower extremities (dependent edema)
◦ hepatomelagy (enlargement of liver)
◦ pleural effusion (fluid accumulation in the pleural space)
◦ ascites (accumulation of fluid in the peritoneal cavity)
◦ anorexia (loss of appetite) and nausea (congestion in the
gut)
◦ weakness
◦ weight gain
Risk factor
CAD, HTN, Cardiomyopathy, valvular disorders, renal dysfunction
(with volume overload), atherosclerosis, diabetes, metabolic syndrome,
hyperlipidemia, smoking,
2-3 most relevant potential complications
Blood clots - can lead to pulmonary embolism signs and symptoms:
 bloody productive cough, chest pain, cyanosis
Impaired kidney function, Signs and symptoms: increased/decreased
urine production, shortness of breath, oedema
Tests
• assessment of ventricular function
• echocardiogram (ECG/EKG)
• chest XRay
• Laboratory studies (blood tests)
◦ serum electrolytes
◦ blood urea nitrogen (BUN)
◦ createnine
◦ thyroid-stimulating hormone (TSH)
◦ CBC
◦ BNP - key diagnostic factor
◦ liver function tests
◦ routine urinalysis
Treatments
• relieve patient symptoms, improve functional status and quality
of life
◦ eliminate or reduce contributory factors (HTN, ischemia,
AFib, excessive alcohol use)
◦ Reduce workload of the heart by reducing afterload and
preload
▪ improvement of cardiac function with
pharmacologic management (oral or IV)
▪ ACE inhibitors (angiotensin-converting
enzyme inhibitors)
▪ promote vasodilation and diuresis -
decreases afterload and preload
▪ ARB’s (angiotensin II receptor blockers)
▪ decrease activation of angiotensin
II - decreased BP, decreased SVR
(systemic vascular resistance) and
improved CO

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 ▪ Beta blockers
▪ block adverse effects of the SNS -
relax blood vessels, lower BP,
decrease afterload and decrease
cardiac workload
▪ Diuretics
▪ remove excess extracellular fluid
by increasing the rate of urine
production
▪ Vasodilators
▪ reduction of symptoms and improvement
functional status
▪ stabilization of patient condition and lowering of
the risk of hospitalization
▪ delay of the progressing of HF and extension of
life expectancy
▪ promotion of a lifestyle conductive to cardiac
health
▪ supplemental oxygen
▪ implantation of assistive devices
▪ surgical approaches - cardiac transplant
Concept map

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 Exploring the Health History
Here’s where you consider additional health history and medical diagnoses
(comorbidities) affecting your client’s health.

Health issue (comorbidity): Hypertension Related Concept(s): Perfusion

Brief pathophysiology (include definition, risk factors, main treatments and complications): blood pressure that repeatedly exceed 140/90
mmHg. risk factors include age, gender, race, family history, genetics, increased sodium intake, dyslipidemia, tobacco, excessive alcohol use, low
fitness levels, obesity, diabetes, sleep apnea, secondary hypertension, renal hypertension, increased adreno-cortical hormones,
pheochromocytoma, coarctation of aorta, oral contraceptive drugs. Treatments: lifestyle and behaviour modification, medication therapy.
Consequences: angina, MI, HF, stroke or TIA, CKD or KF, PAD, retinopathy, SD
Anticipated assessment data (signs and symptoms): blood pressure above 140/90, typically asymptomatic - until target-organ damage happens

Link to primary diagnosis (if applicable): HTN - causes stress on the heart - leads to myocardial dysfunction

Health issue (comorbidity): Dyslipidemia Related Concept(s): Nutrition, Perfusion

Brief pathophysiology: imbalance of the lipid components of the blood. Risk factors include nutrition, genetics, medications, comorbid
conditions and metabolic diseases. Treatments: diet (high in fruits, vegetables, whole grains, dairy, chicken, fish, legumes and nuts, low intake of
red meats and sweets) Consequences: CAD, PAD, atherosclerosis, stroke, MI, HF

Anticipated assessment data: low HDL, high LDL, hypertension

Link to primary diagnosis (if applicable): can cause plaques to build up on the walls of arteries, increases end diastolic blood pressure - stress on
the heart (one of the causes of HF)

Health issue (comorbidity): Osteoarthritis Related Concept(s): Mobility

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 Brief pathophysiology: a non inflammatory degenerative disorder of the joints. Risk factors include over age, female, menopause, obesity, high
labour occupation, engaging in sports activities, history of previous injuries, muscle weakness, genetic predisposition. Treatments: exercise (CV
aerobic exercise and lower extremity strength training, weight loss, wedged insoles, knee braces, orthotic devices and mobility aids, massage,
yoga, TENS, NSAIDs, COX-2 enzyme blockers, opioids, intra-auricular corticosteroids, topical analgesic agents, glucosamine, joint replacements.
Consequences: loss of mobility/function, severe pain.

Anticipated assessment data: tender and enlarged joints, loss of joint cartilage on X-ray, pain

Link to primary diagnosis (if applicable): loss of mobility can contribute to exercise reduction and inability to perform ADL’s - can increase chance
of high fat/sodium diet - easier to do than cook

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 Quality & Safety
Safety Concerns
Given your client information, what safety concerns do you anticipate? Consider any precautions, diet, activity, etc… (Example: risk of harm or falls,
allergies, on oxygen or requiring suction, bed alarm, ability to use call bell).

Safety risk and rationale Nursing Interventions

Falls risk Assess LOC/LOO, check tripping hazards, mobility, pain, mobility aids
Cognitive impairment Assess LOC/LOO
High blood pressure Monitor blood pressure, make sure they are getting the right diet
Low oxygen saturation Monitor o2 sat, check if oxygen is working

Priority Patient Problems/ Area of Focus?

3 priority health risks, actual or potential client nursing problems based on your research. Make sure to consider all the patient data (past medical history,
diet, activity levels etc.) when identifying your 3 priority problems. May also include complications from treatments or procedures. See relevant course
resources for guidance and consider ‘strategies for client prioritization’ and ‘lifespan considerations’.

1. Impaired perfusion and gas exchange related/to HF

2. Impaired mobility r/t osteoarthritis in bilateral knees

3. Potential impaired nutrition r/t hyperlipidemia

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 Priority Problem: Impaired mobility related to osteoarthritis in bilateral knees
Nursing problem, not diagnosis

Primary Concept identified Mobility, Safety

Brief summary of the A degenerative joint disease associated with the gradual loss of cartilage between joints and the formation of bony growths at the
pathophysiology of the margins of the joints.
health risk/problem

Indicate why this concept is a Impaired mobility is a falls risk. Potential problems: falls, fractures/breaks, loss of function, loss of independence, loss of ability to
priority for the patient. perform ADL’s

What are the potential

outcomes if this health risk
/problem is not addressed?

Risk factors related to this Osteoarthritis, Dyslipidemia, HF

nursing problem (particular
to the patient)
(Health Promotion and
Maintenance/Reduction of
Risk Potential)

Identify top 3 psychosocial Frustration, overwhelm, anxiety

concerns for the problem
(Psychosocial Integrity)

Identify 3 priority nursing Assess pain, looking for hesitancy to move joints, diaphoresis, facial grimacing
assessments for the problem Assess inflammation, looking for redness, swelling
Assess impaired physical mobility, looking for restricted joint movement, bone deformities
(Physiological Adaptation-
Assess deficient knowledge, looking for inadequate awareness of resources, interest in learning and participation in care planning
acute, chronic, life-
threatening)

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 Identify 3 Priority Labs and
Diagnostics for the problem
(Reduction of Risk
Potential)
IF APPLICABLE

Identify 3 Priority NSAIDs, opioids, corticosteroids

Medications for the
problem (Pharmacological
and Parenteral Therapies)
IF APPLICABLE

Identify 3 priority nursing Promote comfort by administering pain relief to decrease pain, increase mobility and provide relief
Promote use of assistive devices by teaching the correct use to promote patients mobility, safety and reduce risk of injury
interventions for the Reinforce patient education through frequent repetition and follow-up sessions
problem
(Basic Care and
Comfort/Safety & Infection
Control)

Identify 1 Priority Refer patient to physical therapy to help formulate an exercise program to address immobility and joint pain
Collaborative Goals for the
problem
(Health Promotion &
Maintenance/Safety &
Infection Control/
Management of Care)

Identify 1 Priority Educate patient on how proper supplement, medication and mobility aid use can make everyday life easier.
Teaching/Self-Manageme
nt Goals for the problem
(Health Promotion &
Maintenance/Safety &
Infection Control/
Management of Care)

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