Health Care Delivery and Evidence-Based Nursing Practice, Chapter 1-19

CASE STUDY, Chapter 1, Health Care Delivery and Evidence-Based Nursing Practice

Q1 Suzanne Jones, 76-year-old patient with COPD is admitted to the ICU. Mrs. Jones is placed on mechanical ventilation to assist with her breathing. After 2 days on the ventilator, Mrs. Jones is extubated and then transferred to a medical-surgical unit. The medication regimen is adjusted during the hospitalization. Mrs. Jones is discharged home after 6 days. She and her family are pleased with the care she receive in the hospital. (Learning Objectives 3 and 6)

(a) Describe the quality performance tools that may be used to demonstrate that the care and treatment rendered are both cost-efficient and of high quality.


COPD is a chronic obstructive pulmonary disease in which bronchitis is blocked by the accumulation of mucus and causes the problem in the airflow and make difficulty in breathing. The symptoms which are mainly observe in the patients, include shortness of breath and cough with sputum production. The treatment can help in ease of symptoms, prevent complications, and generally slow-down the disease progression.


Bronchodilators are medications that help in relaxing the muscles of the airways so the patient can breathe easily. These are usually taken through an inhaler. Glucocorticosteroids can be added to reduce inflammation in the airways. There are mainly two major types, agonists and anticholinergics. Both exist in long-acting and short-acting forms. They reduce shortness of breath, wheeze, and exercise limitation, resulting in an improved quality of life.

Phosphodiesterase-4 inhibitors:

The newly developed medication in pill form reduces inflammation and changes mucus production.


This medicine eases chest tightness and shortness of breath. It may help prevent flare-ups. It’s available in pill form.

Awareness of COPD conditions among patients is very important and communication between patients and health care providers is also important. The strengthening of the role of the nurse practitioner in management of COPD could be an important strategy to improve patient education and communication. The handling patient concerns about safety and tolerability, which is an important aspect of the nurse practitioner’s responsibilities, and may help to improve adherence to treatment. Nurses provide advice and support to patients and their families and, at the same time, they educate and encourage patients to manage their disease pro-actively.



Q2. The registered nurse working in the cardiac care clinic is tasked with implementing quality improvement measures. To educate the clinic staff, the nurse plans an in-service program to introduce concepts of quality improvement and evidence-based practice. Additionally, the role of the case manager will be included in the presentation. The nurse plans on using care of the patient with Congestive Heart Failure as a template, and prepares sample critical pathways, care maps, and multidisciplinary action plans. (Learning Objective 3). 

[2A]  Describe how clinical pathways are used to coordinate care of caseloads of patients. 

Clinical pathways are management plans that display goals for patients and provide the sequence and timing of actions necessary to achieve these goals with optimal efficiency. As competition in the healthcare industry has increased, managers have embraced clinical pathway as a method to reduce variation in care, decrease resource utilization, and potentially improve healthcare quality. Cardiovascular medicine in particular is an area in which critical pathways have been embraced. This is due in part to the high volume and high cost associated with cardiovascular diseases and procedures. In addition, the relatively mature guideline process has also contributed to the growth in use of clinical pathways in cardiology. Although anchored in clinical guidelines, the critical pathways involve a distinct tool that details processes of care and highlights inefficiencies regardless of whether there is evidence to warrant changes in those processes. Clinical guidelines, on the other hand, are consensus statements that are systematically developed to assist practitioners in making patient management decisions related to specific clinical circumstances. Although clinical guidelines can and should be used in critical pathways development, the majority of processes included in clinical pathways has not been rigorously tested and are generally not addressed in guidelines. Another term that should also be distinguished from critical pathways is clinical protocols. Protocols are treatment recommendations that are often based on guidelines. Like the clinical  pathways, the goal of the clinical protocol may be to decrease treatment variation. However, protocols are most often focused on guideline compliance rather than the identification of rate-limiting steps in the patient care process. In further contrast to critical pathways, protocols may or may not include a continuous monitoring and data-evaluation component…..


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Case Study, Chapter 4, Health Education and Health Promotion

Q1. Mr. Smith, a 57-year-old patient, presents at a health fair asking questions about the age-appropriate health maintenance and promotion considerations he should be concerned about. He stated that he only goes to his physician when he is sick and the last time he saw his physician was 2 years ago when he had a sinus infection. (Learning Objectives 7 to 9)

(a) What further assessment does the nurse need to make before designing a teaching plan?


Assessment is the first step in patient education. Evaluate your patient’s skills and knowledge in important areas. Consider the patient’s reading level, ability to learn, ability to understand English, and resources. Use the assessment findings to develop a unique plan for the patient.

Consider the following before designing a teaching plan :

  • Maintain a positive and patient attitude.
  • Take a few minutes to talk and problem-solve before starting to teach.
  • Identify significant cultural or social factors that may affect the teaching learning process.
  • Include the patient in setting learning goals. Keep the material relevant to the learner’s needs.
  • Identify and try to accommodate any disability that may affect the learning process.
  • Slow the pace of instruction and gear teaching to the patient’s rate of absorption. Stop teaching if the patient appears tired or stressed.
  • Break each topic into small parts. Repeat sessions when necessary. Give pertinent, positive feedback.
  • Assess responses carefully to make sure the information was understood correctly. Gear the frequency and duration of your teaching to match your patient’s learning ability and need to know.
  • Middle-aged adults experience changes of aging to varying degrees depending upon the individual. For some individuals these changes are very stressful.
  • Assess to detect risk for: Skin breakdown due to dryness and decreased subcutaneous tissue, Hypertension and hyperlipidemia, Sleep apnea, Skeletal injury due to diminished bone density and osteoporosis.
  • Assess and address nutritional needs.

(b) What topics does the nurse need to include for Mr. Smith based on current medical recommendations?


The nurse needs to include the following topics:

He should be made aware about the need to make important lifestyle changes now, as time is of the essence before they get a chronic illness. This may include important topics such as weight loss and strategies for accomplishing weight loss goals.

He should be made aware that as they age they become more and more vulnerable to all sorts of illnesses and injuries. This includes pneumonia, cancer and chronic endocrine diseases. Besides learning about appropriate lifestyle modification involving nutrition and exercises, also need to learn about stress management, as well as key warning signs of possible impending illnesses. For example, they may need to learn about how to spot memory problems, signs of cancer like a change in the color of a mole, or an endocrine disease, such as sudden weight gain, so that all can be caught and treated earlier.

(c) Design a teaching plan that covers the topics.


Teaching plan includes –


He should consume a well-balanced diet based on the food pyramid and recommended daily allowances of nutrients. Some changes in caloric intake and protein and vitamin needs appear to be desirable with aging.


Regular exercise should be a part of any daily plan for Mr. smith. Exercise can help keep the joints flexible, maintain muscle mass, control blood glucose levels and weight, and promote a sense of well-being. Exercise such as Walking, swimming, golfing, housekeeping, and active lawn work or gardening are all advised. To be of most benefit, exercise should consist of at least 30 minutes of continuous activity. The type, level, and amount of exercise that is most beneficial differ for each person and should be based on physician recommendations.

Tobacco and Alcohol

It is never too late to stop smoking. Cessation may be difficult when smoking has been a long-standing habit, but various aids are now available to help smokers quit. Before using any of these aids, older adults should seek guidance from their physicians because they may need to follow some special precautions related to existing health problems.

Excessive consumption of alcoholic beverages is never recommended. Alcoholism is an all too common problem in the older adult population—both men and women—because alcohol may be used as a means of coping with depression, sleep disorders, or other problems. Occasional or moderate alcohol consumption usually is not prohibited or restricted unless some medical condition or medication precludes its use. Some physicians even recommend a glass of wine or beer as an appetite enhancer in certain situations.