Patient is identified as Mr. Reggie Simpson, 42, an indigenous Australian.

He was diagnosed with

rheumatic heart disease and compensated heart failure then after. He is married with three children and the
breadwinner of the family. He was admitted with heart failure acute decompensation. (Focus) This essay will
discuss the pathophysiology of and rationale of identified priority nursing problems and will evaluate the
interventions provided.

There are two priority nursing problems identified in this essay. The first refers to the ineffective
breathing pattern related to decreased lung volume capacity as evidenced by crackles on both lung fields and
compromised breathing. Another identified problem is the fluid volume excess related to decreased cardiac
output, sodium and water retention evidenced by bilateral pitting oedema, coarse crackles and ascites.

The first problem can be remedied by proper positioning and oxygen administration as prescribed, in
order to alleviate the signs and symptoms of respiratory distress while the second can be managed by
administering medication as indicated and by collaborating with dietician to modify the patient’s dietary intake to
reduce fluid retention.

The first priority problem, ineffective breathing pattern, relates to a decreased lung volume capacity as
evidenced by coarse crackles and low oxygen saturation. Since the patient has heart failure (HF) and is showing
signs of altered oxygen supply there is an inability to provide adequate ventilation during inspiration and
expiration. As HF progresses, left ventricular pressure increases, causing enlargement of both ventricle and atrium
(Brahmbhatt, & Cowie 2018 p. 588). This will then result to increased back-pressure to the pulmonary veins leading
to pulmonary oedema (ref). Fluid overload causes inability of the lungs to expand when breathing, hence affects
the normal breathing pattern and oxygen distribution in the body (ref).

Since the patient has below normal oxygen saturation at 92%, this indicates that there is low oxygen
supply from the lungs. Coarse crackles sound is evident upon auscultation that likewise indicates presence of fluid
in the lungs (ref). Moreover, high respiratory rate which at 28bpm shows that the body is compensating to breath
more rapidly to increase the oxygen supply in the blood.

The application of the first intervention called proper repositioning is to maximise lung expansion and aid
in breathing. It is an independent nursing action that does not need collaboration with other allied health care
professionals. Positioning the patient in Semi Fowlers position with the head and upper body inclined to 15 to 45
degrees as tolerated will promote maximum oxygenation because it allows maximum chest expansion (ref). It also
facilitates the relaxation of tense abdominal muscle that will facilitate improvement of breathing. When
performing this intervention, nurses should determine if the patient can tolerate this position and identify any
circumstances where it is not permitted for instance, during post-operative and patients with COPD (ref).

Positioning to Semi Fowlers may have advantages and disadvantages to patients. Firstly, it can facilitate
breathing and lung expansion. It is also a standard position applied when feeding patients. Although this
intervention facilitates patient’s breathing, (ref) claims that semi Fowlers position may bring a change in the blood
pressure and cardiac output of the patient. Moreover in a study conducted by (ref) it could have a same tendency
among hypertensive patients. A slight difference in posture may have an effect in the heamodynamic and
cardiovascular regulation.

Overall, it is still beneficial for Mr. Simpson as he has compromised breathing and positioning him in Semi
Fowler’s will improve his oxygenation.

The second identified intervention for ineffective breathing pattern is administration of supplemental
oxygen as ordered. This is to maximise oxygen available for cellular uptake (ref). This is a collaborative
intervention, as oxygen administration can be implemented by nurses once prescribed by the physician. When
giving oxygen to the patient, nurses should secure an order from the physician, follow the prescription, dose and
use the appropriate device (ref). Oxygen supplementation is recommended to manage hypoxemia for patients
with less than 90-94 percent of oxygen saturation. Since Mr. Simpson has 92% oxygen saturation, oxygen
supplementation is therefore recommended to benefit him. His diagnosis being heart failure is also indicative that
it is necessary for him to have supplemental oxygen as oxygen therapy has been prescribed in management of
patients with cardiac problem. This can improve his oxygen saturation and respiratory rate thus improve the
overall health of the patient.

Oxygen administration can be prescribed for patients experiencing respiratory distress. However, there
are some precautions and consequences that require consideration. It is advantageous since the therapy improves
the oxygen supply in the body, tissue perfusion up to peripheral area, and relieves respiratory distress hence,
reduces anxiety resulting to improved breathing pattern. On the contrary, it becomes disadvantageous during long
term use (ref). Prolonged oxygen administration provides risk for oxygen toxicity where there is an excess oxygen
administered to the patient(ref). Accessories used for oxygen therapy such as masks may place the patient to risk
for pressure sore (ref).

Proper positioning and administering oxygen to patient with Acute Decompensated Heart Failure is
beneficial. It helps to improve their prognosis. The patient is manifesting signs of respiratory distress. The goal is to
increase the oxygen saturation from 92 percent to normal range which is 95 to 100 percent(ref). Those nursing
intervention can also facilitate the improvement of his respiratory rate and breathing. As the patient is fatigued,
improved oxygenation and proper posture will help him to minimize energy consumption (ref).

Fluid Volume Excess related to altered cardiac output (Increased isotonic fluid retention related to
increased antidiuretic hormone (ADH) production, and sodium and water retention evidenced by weight gain,
abnormal breath sounds, hypertension and signs of respiratory distress.

Pathophysiology – Heart Failure results to decrease blood flow to the renal artery. This stimulates the
baroreceptor reflex and the release of renin in the bloodstream will be initiated. Renin interacts with angiotensin
and will stimulate the production of Angiotensin 1. When Angiotensin 1 reacts with Aniotensin Converting Enzyme
it will be converted to Angiotensin II. Angiotensin II then increases the arterial vasoconstriction that promotes the
release of norepinephrine of sympathetic nerve endings and stimulates adrenal medulla which secretes
aldosterone that enhances sodium and water retention. Thus the activation of Renin Angiotensin System (RAS)
causes overload of plasma volume resulting to oedema, sudden weight gain, and respiratory distress (ref).