An understanding of the cardiovascular and respiratory systems is a critically important component

An understanding of the cardiovascular and respiratory systems is a critically
important component of disease diagnosis and treatment. This importance is
magnified by the fact that these two systems work so closely together. A variety
of factors and circumstances that impact the emergence and severity of issues in
one system can have a role in the performance of the other.
Effective disease analysis often requires an understanding that goes beyond
these systems and their capacity to work together. The impact of patient
characteristics, as well as racial and ethnic variables, can also have an important
impact.
Photo Credit: yodiyim / Adobe Stock

An understanding of the symptoms of alterations in cardiovascular and respiratory
systems is a critical step in diagnosis and treatment of many diseases. For APRNs this
understanding can also help educate patients and guide them through their treatment
plans.
In this Assignment, you examine a case study and analyze the symptoms presented.
You identify the elements that may be factors in the diagnosis, and you explain the
implications to patient health.
Assignment (1- to 2-page case study analysis)
In your Case Study Analysis related to the scenario provided, explain the following
 The cardiovascular and cardiopulmonary pathophysiologic processes that result
in the patient presenting these symptoms.
 Any racial/ethnic variables that may impact physiological functioning.
 How these processes interact to affect the patient.

Module 2: Week 4: Case Study
76-year-old female patient complains of weight gain, shortness of breath, peripheral
edema, and abdominal swelling. She has a history of congestive heart failure and
admits to not taking her diuretic, as it makes her “have to get up every couple hours to
go to the bathroom.” She now has to sleep on two pillows in order to get enough air.
Clinical Insight for Hypertension
Posted on:
CC and AHA recommend thiazide diuretics, ACE inhibitors or ARBs, or CCBs as
first-line drug therapy of hypertension. Guidelines from the American College of
Cardiology (ACC) and the American Heart Association (AHA) recommend antihypertensive
medications shown to reduce the risk of CVD events—thiazide diuretics, ACE inhibitors,

angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs). ACC/AHA
recommends initiating therapy with two drugs from these classes in patients who have stage 2
hypertension (BP ≥ 140/90 mm Hg) or an average BP > 20/10 mm Hg above their target. For
patients with stage 1 hypertension (SBP 130-139 mm Hg or DBP 80-89 mm Hg), the guidelines
suggest that it is reasonable to start with one recommended drug with dose titration and add-on
therapy as necessary to achieve the goal BP. Due to an increased risk of harm, medications that
have the same mechanism of action and those with similar therapeutic targets should not be used
together. This includes dual inhibition of the renin-angiotensin system with any combination of
ACE inhibitors, ARBs, and/or aliskiren (Whelton PK. Hypertension. 2017 Nov 13; published
ahead of print). NOTE: These recommendations agree with those from the panel members
appointed to the Eight Joint National Committee (JNC-8).

ACC and AHA recommend a lower BP goal (≤130/80 mm Hg) in hypertensive
adults. Guidelines from the American College of Cardiology (ACC) and the American Heart
Association (AHA) suggest greater benefit associated with a lower BP target in hypertensive
patients at significant CVD risk. The guidelines recommend that patients with known CVD or a
10-year risk ≥ 10% be treated to a BP of < 130/80 mm Hg. This lower goal is considered
“reasonable” for those without increased risk of CVD events. While results of randomized
controlled trials of lower BP targets report inconsistent results relating to the risk of CVD events,
ACC/AHA point out that systematic reviews report a reduced risk of CVD with lower BP targets
(Whelton PK. Hypertension. 2017 Nov 13; published ahead of print). NOTE: In 2014, the panel
members appointed to the Eight Joint National Committee (JNC-8) recommended a goal BP of <
140/90 mm Hg (< 150/90 mm Hg in healthy adults ≥ 60 years of age) based on an absence of
RCT evidence supporting lower thresholds.

ACC and AHA recommend antihypertensive therapy at a BP ≥ 130/80 in high-risk
patients and ≥ 140/90 in lower-risk patients.
Guidelines from the American College of Cardiology (ACC) and the American Heart
Association (AHA) recommend initiating antihypertensive medications based on BP level, the
presence or absence of clinical CVD, and 10-year CVD risk. Individuals who have known CVD
(defined as coronary disease, heart failure, or stroke) and those without CVD, but a 10-year risk
≥ 10% should have lifestyle modifications plus antihypertensive therapy initiated at an average
BP ≥ 130/80 mm Hg. Patients at lower risk should be managed with lifestyle modifications first
and receive antihypertensive medications if their BP remains ≥ 140/90 mm Hg. The ACC/AHA
panel members emphasize that white coat hypertension should be excluded in patients at low risk
prior to initiating therapy (Whelton PK. Hypertension. 2017 Nov 13; published ahead of
print). NOTE: The lower BP threshold for treatment differs from guidelines published by the
panel members appointed to Eighth Joint National Committee (JNC-8) in 2014, which
recommend treatment at or above a BP of 140/90 mm Hg in most patients and a higher BP
threshold of ≥ 150/90 in adults 60 years and older without diabetes or CKD.

ACC and AHA suggest that accurate office measurement of BP and exclusion of
white coat hypertension are critical before making the diagnosis of
hypertension. Guidelines from the American College of Cardiology (ACC) and the American
Heart Association (AHA) suggest that errors are common in the ascertainment of a patient’s true
BP. Many measurement errors can be avoided by using proper 1) preparation (e.g., sitting quietly

for 5 minutes before and throughout measurement, supporting the limb at heart level), 2)
equipment (e.g., validated and calibrated device, proper cuff size and placement), 3) technique
(e.g., deflate cuff at 2 mm Hg/second, take multiple measurements separated by 1-2 minutes),
and 4) estimation of true BP (averaging 2-3 readings obtained on 2-3 separate occasions). Based
on evidence that BP measured outside of the office may be superior to in-office BP measurement
in predicting CVD outcomes, ACC/AHA also recommends home BP monitoring or  ambulatory
BP monitoring to confirm the diagnosis of hypertension and titrate medications (Whelton
PK. Hypertension. 2017 Nov 13; published ahead of print.

ACC and AHA more aggressively define hypertension as a SBP ≥ 130 mm Hg and
DBP ≥ 80 mm Hg. Guidelines from the American College of Cardiology (ACC) and the
American Heart Association (AHA) recommend classifying patients with a SBP 120-129 mm Hg
and a DBP < 80 mm Hg as having “elevated BP” and SBP ≥ 130 mm Hg or DBP ≥ 80 mm Hg as
having “hypertension”. In contrast to the Seventh Joint National Committee (JNC-7) guidelines,
the committee lowered the range that defines stage 1 hypertension to a BP of 130-139/80-89 mm
Hg and now defines stage 2 hypertension as a BP ≥ 140/90 mm Hg. These changes are based on
observational data suggesting a consistent association between rising BP and CVD risk as well as
RCT data from interventional trials of lifestyle modifications and pharmacotherapy. Estimates
based on the NHANES data suggest a potentially large increase in the prevalence of
hypertension between the new definition compared to the old (46% vs. 32%) with larger
proportional changes among younger patients (Whelton PK. Hypertension. 2017 Nov 13;
published ahead of print). NOTE: These recommendations differ from the 2014 guidelines
published by the panel members appointed to JNC-8, which define hypertension as a BP ≥
140/90 mm Hg.

Learning Resources

Required Readings (click to expand/reduce)
McCance, K. L. & Huether, S. E. (2019). Pathophysiology: The
biologic basis for disease in adults and children (8th ed.). St. Louis,
MO: Mosby/Elsevier.
 Chapter 32: Structure and Function of the Cardiovascular and
Lymphatic Systems; Summary Review
 Chapter 33: Alterations of Cardiovascular Function (stop at
Dysrhythmias); Summary Review
 Chapter 35: Structure and Function of the Pulmonary System;
Summary Review
 Chapter 36: Alterations of Pulmonary Function (stop at
Disorders of the chest wall and pleura); (obstructive
pulmonary diseases) (stop at Pulmonary artery hypertension);
Summary Review
Note: The above chapters were first presented in the Week 3 resources. If
you read them previously you are encouraged to review them this week.

Inamdar, A. A. & Inamdar, A. C. (2016). Heart failure: Diagnosis,
management, and utilization, 5(7). doi:10.3390/jcm5070062

Note: The above article was first presented in the Week 3
resources. If you read it previously you are encouraged to
review it this week.
Required Media (click to expand/reduce)
Alterations in the Cardiovascular and Respiratory Systems – Week

4 (15m)

Accessible player
Pneumonia
MedCram. (2015, September 14). Pneumonia explained clearly by
MedCram [Video file]. Retrieved from

Note: The approximate length of the media program is 13 minutes.
(Previously reviewed in Week 3)
Online Media from Pathophysiology: The Biologic Basis for Disease in
Adults and Children
In addition to this week's media, it is highly recommended that you access and
view the resources included with the course text, Pathophysiology: The Biologic
Basis for Disease in Adults and Children. Focus on the videos and animations in
Chapters 32, 33, 35, and 36 that relate to cardiorespiratory systems and
alteration in cardiorespiratory systems. Refer to the Learning Resources in Week
1 for registration instructions. If you have already registered, you may access the
resources at https://evolve.elsevier.com/
Rubric Detail

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Name:  _Module2_Case Study_Assignment_Rubric

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Show Descriptions
Develop a 1- to 2-page case study analysis, examing the patient symptoms
presented in the case study. Be sure to address the following:
Explain both the cardiovascular and cardiopulmonary pathophysiologic
processes of why the patient presents these symptoms.–

Excellent 28 (28%) – 30 (30%)
The response accurately and thoroughly describes the patient symptoms.
The response includes accurate, clear, and detailed reasons, with explanation for
both the cardiovascular and cardiopulmonary pathophysiologic processes
supported by evidence and/or research, as appropriate, to support the explanation.
Good 25 (25%) – 27 (27%)
The response describes the patient symptoms.
The response includes accurate reasons, with explanation for both the
cardiovascular and cardiopulmonary pathophysiologic processes supported by
evidence and/or research, as appropriate, to support the explanation.
Fair 23 (23%) – 24 (24%)
The response describes the patient symptoms in a manner that is vague or
inaccurate.
The response includes reasons for the cardiovascular and/or cardiopulmonary
pathophysiologic processes, with explanations that are vague or based on
inappropriate evidence/research.
Poor 0 (0%) – 22 (22%)
The response describes the patient symptoms in a manner that is vague and
inaccurate, or the description is missing.
The response does not include reasons for either the cardiovascular or
cardiopulmonary pathophysiologic processes, or the explanations are vague or
based on inappropriate or no evidence/research.
Explain how the cardiovascular and cardiopulmonary pathophysiologic
processes interact to affect the patient.–
Excellent 28 (28%) – 30 (30%)
The response includes an accurate, complete, detailed, and specific explanation of
how the cardiovascular and cardiopulmonary pathophysiologic processes interact
to affect the patient.
Good 25 (25%) – 27 (27%)
The response includes an accurate explanation of how the cardiovascular and
cardiopulmonary pathophysiologic processes interact to affect the patient.
Fair 23 (23%) – 24 (24%)
The response includes a vague or inaccurate explanation of how the cardiovascular
and cardiopulmonary pathophysiologic processes interact to affect the patient.

Poor 0 (0%) – 22 (22%)
The response includes a vague or inaccurate explanation of how the cardiovascular
and cardiopulmonary pathophysiologic processes interact to affect the patient.
Explain any racial/ethnic variables that may impact physiological functioning.–
Excellent 23 (23%) – 25 (25%)
The response includes an accurate, complete, detailed, and specific explanation of
racial/ethnic variables that may impact physiological functioning supported by
evidence and/or research, as appropriate, to support the explanation.
Good 20 (20%) – 22 (22%)
The response includes an accurate explanation of racial/ethnic variables that may
impact physiological functioning supported by evidence and/or research, as
appropriate, to support the explanation.
Fair 18 (18%) – 19 (19%)
The response includes a vague or inaccurate explanation of racial/ethnic variables
that may impact physiological functioning, and/or explanations based on
inappropriate evidence/research.
Poor 0 (0%) – 17 (17%)
The response includes a vague or inaccurate explanation of racial/ethnic variables
that may impact physiological functioning, or the explanations are based on
inappropriate or no evidence/research.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically,
and demonstrate continuity of ideas. Sentences are carefully focused—neither
long and rambling nor short and lacking substance. A clear and comprehensive
purpose statement and introduction are provided that delineate all required
criteria.–
Excellent 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.
A clear and comprehensive purpose statement, introduction, and conclusion are
provided that delineate all required criteria.
Good 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity
80% of the time.
Purpose, introduction, and conclusion of the assignment are stated, yet are brief
and not descriptive.
Fair 3 (3%) – 3 (3%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity
60%–79% of the time.
Purpose, introduction, and conclusion of the assignment are vague or off topic.
Poor 0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity <
60% of the time.
No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English Writing Standards:
Correct grammar, mechanics, and proper punctuation–
Excellent 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
Good 4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
Fair 3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
Poor 0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with
the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for
title page, headings, font, spacing, margins, indentations, page numbers, running
heads, parenthetical/in-text citations, and reference list.–
Excellent 5 (5%) – 5 (5%)
Uses correct APA format with no errors.
Good 4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors.
Fair 3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors.
Poor 0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors.
Total Points: 100