Nursing Process Case Study: Acute Shortness of Breath and Heart Failure

Applying the Nursing Process in Clinical Nursing Education: Activity Overview

• Activity Format: This is a collaborative group activity where students are tasked with analyzing a patient scenario using the nursing process framework.

• Objective: To prepare a presentation lasting between $10$ and $15\,\text{minutes}$ based on a specific clinical case.

• Presentation Requirements: The presentation must comprehensively cover the following six components:

  • Patient assessment.

  • Priority nursing diagnoses.

  • Expected outcomes.

  • Nursing interventions accompanied by their professional rationales.

  • Evaluation of the care provided.

  • Reflection on pedagogical strategies: specifically, how the presenter would teach this specific case to undergraduate nursing students during clinical practice.

Group 1 Case Scenario: Mr. Johannes

• Patient Profile: Mr. Johannes is a $68\text{-year-old}$ male.

• Chief Complaint: He presented to the emergency department with severe shortness of breath ($\text{SOB}$) that had its onset early in the morning.

• Medical History: The patient has a documented history of chronic heart failure and hypertension.

• Clinical Examination Findings:

  • Respiratory Rate ($RR$): $34\,\text{breaths/min}$, indicating significant tachypnea.

  • Blood Pressure ($BP$): $168/96\,\text{mmHg}$, indicating hypertension.

  • Pulse Rate: $118\,\text{beats/min}$, indicating tachycardia.

  • Oxygen Saturation ($SpO_2$): $86\%$ on room air, indicating hypoxemia.

  • Body Temperature: $37.1^\circ\text{C}$, which is within the normal range.

  • Auscultation Findings: Bilateral crackles were detected in the lungs, suggesting fluid in the alveoli.

  • Peripheral Findings: Bilateral pitting oedema noted in both legs.

  • Interactions: The patient has difficulty speaking in full sentences due to respiratory distress.

  • Psychosocial Observation: The patient appears visibly anxious.

Analysis of Assessment Data

• Subjective Data Identification:

  • Patient's complaint of severe shortness of breath.

  • Self-reported onset time (early this morning).

  • Known history of hypertension and chronic heart failure.

• Objective Data Identification:

  • Measured vital signs: $RR = 34\,\text{breaths/min}$, $BP = 168/96\,\text{mmHg}$, Pulse = $118\,\text{beats/min}$, $SpO_2 = 86\%$, and Temperature = $37.1^\circ\text{C}$.

  • Physical signs: Bilateral crackles and bilateral pitting oedema.

  • Observable behaviors: Difficulty speaking and visible anxiety.

Priority Assessment Findings and Clinical Logic

• Priority Findings:

  • The most critical finding is the oxygen saturation level of $86\%$, which falls well below the standard target of $\ge 94\%$ (or $\ge 90\%$ depending on specific protocols), requiring immediate oxygen therapy.

  • The respiratory rate of $34\,\text{breaths/min}$ and the presence of bilateral crackles indicate acute pulmonary congestion.

  • Tachycardia and hypertension indicate the heart is under significant stress as it compensates for fluid overload and poor oxygenation.

• Additional Assessment Data to Collect:

  • Current weight compared to baseline (to quantify fluid retention).

  • Daily fluid intake and urinary output patterns.

  • Laboratory tests, specifically Brain Natriuretic Peptide ($\text{BNP}$) or $\text{N-terminal pro-BNP}$ levels for heart failure severity, and serum electrolytes.

  • Diagnostic imaging, such as a Chest X-ray, to confirm the extent of pulmonary oedema.

  • Electrocardiogram ($\text{ECG}$) to assess for potential cardiac rhythm disturbances.

The Strategic Importance of Assessment in Nursing

• Foundation of the Nursing Process: Assessment is considered the foundational stage because it provides the data upon which the entire care plan is built.

• Decision Making: Accurate assessment is essential for formulating correct nursing diagnoses. If the assessment is flawed, the subsequent goals, interventions, and evaluations will be misaligned with the patient's actual needs.

• Continuity of Care: It provides a baseline to monitor the patient’s progress or identify any neurological or physiological deterioration.

Educational Reflection: Student Mistakes and Teaching Strategies

• Common Student Mistakes During Assessment:

  • Overlooking subtle non-verbal cues (e.g., patient anxiety or slight changes in work of breathing).

  • Failing to link physiological pathophysiology with physical signs (e.g., not understanding that pitting oedema and crackles are both linked to heart failure fluid volume overload).

  • Prioritizing data collection inefficiently (e.g., spending too much time checking a temperature when the patient is in respiratory distress).

  • Poor validation: Accepting subjective reports without checking objective correlates.

• Teaching Reflection for Clinical Practice:

  • Educators should focus on helping students recognize the "ABCs" (Airway, Breathing, Circulation) priority in the context of heart failure.

  • Teaching should involve demonstrating how to effectively auscultate for crackles and identify different grades of pitting oedema in a live clinical setting.