| Course | NUR 616 Primary Care of Adults and Gerontological Patients |
|---|---|
| Module | Module 3 |
| Paper type | Milestone case study: heart failure with reduced ejection fraction |
| Length | About 1,070 words, 6 pages |
| Format | APA 7 student paper |
| School | Southern New Hampshire University |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NUR 616 Module 3
Milestone One: Starting Guideline-Directed Therapy in a 67-Year-Old Woman Newly Diagnosed With Heart Failure and an Ejection Fraction of 30%
[Student Name]
Southern New Hampshire University
NUR 616: Primary Care of Adults and Gerontological Patients
Milestone One
[Instructor Name]
[Date]
The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.
Milestone One: Starting Guideline-Directed Therapy in a 67-Year-Old Woman Newly Diagnosed With Heart Failure and an Ejection Fraction of 30%
Heart failure with reduced ejection fraction has seen its treatment change more in one decade than almost any other condition in primary care. Where a clinician once started an ACE inhibitor and a beta blocker and added drugs slowly over months, current guidance calls for four drug classes, each shown to reduce death, started within weeks. The difficulty is doing so safely in an older adult whose blood pressure, kidney function and potassium must be watched. This milestone presents a new diagnosis of heart failure in a woman in her late sixties and argues that a planned sequence, with each step tied to monitoring, allows all four classes to be started quickly without harm.
Presentation
Mrs. H. is a 67-year-old retired postal worker who has noticed for three months that a single flight of stairs leaves her winded, which she used to manage without stopping, and swelling of both ankles by evening. She sleeps on two pillows and once woke breathless and sat up to recover. She denies chest pain, palpitations and fainting. She had a viral illness with fever and body aches about five months ago. She has hypertension, treated with amlodipine 10 mg daily, and no known coronary disease, diabetes or kidney disease. She never smoked and drinks rarely. Her mother had a heart attack at 70.
Examination: blood pressure 128/78 mm Hg, pulse 88 and regular, respiratory rate 18, oxygen saturation 95%, weight 76 kg. Jugular venous pressure 9 cm above the right atrium. Fine crackles at both lung bases. Regular rhythm with an S3; no murmur. Pitting edema 2+ to the mid-shin bilaterally. She has NYHA class II to III symptoms.
Workup: B-type natriuretic peptide 820 pg/mL. ECG: sinus rhythm at 86, left bundle branch block with QRS duration of 138 ms. Chest radiograph: cardiomegaly and mild interstitial edema. Transthoracic echocardiogram: left ventricular ejection fraction 30% with global hypokinesis, left ventricular end-diastolic diameter 6.1 cm, no significant valve disease. Labs: creatinine 0.9 mg/dL, eGFR 68, potassium 4.4 mmol/L, sodium 138, hemoglobin 13.1, TSH normal, A1c 5.6%, ferritin 62 ng/mL with transferrin saturation 16%.
Assessment
Heart failure with reduced ejection fraction, stage C, NYHA class II to III, newly diagnosed, with volume overload. The cause is not yet established. Global hypokinesis after a recent viral illness raises the possibility of a post-viral cardiomyopathy, but ischemic disease must be excluded because of her age, hypertension and family history; the guideline recommends noninvasive or invasive evaluation for coronary disease in new heart failure when there is no clear alternative cause (Heidenreich et al., 2022). Additional findings are left bundle branch block, iron deficiency by the guideline's definition of ferritin below 100 ng/mL or ferritin of 100 to 299 with transferrin saturation below 20%, and hypertension treated with a drug, amlodipine, that offers no benefit in heart failure.
The Evidence for Four Drug Classes
Each of the four classes reduced death in a large trial. In PARADIGM-HF, 8,442 patients with reduced ejection fraction were randomized to sacubitril-valsartan or enalapril; the angiotensin receptor-neprilysin inhibitor reduced the composite of cardiovascular death or heart failure hospitalization by 20%, with a hazard ratio of 0.80, and reduced death from any cause (McMurray et al., 2014). In DAPA-HF, dapagliflozin added to standard therapy reduced worsening heart failure or cardiovascular death, with a hazard ratio of 0.74, in patients with and without diabetes (McMurray et al., 2019). Evidence-based beta blockers and mineralocorticoid receptor antagonists had shown mortality benefits in earlier trials. The 2022 guideline gives all four classes its strongest recommendation for patients with reduced ejection fraction and prefers an angiotensin receptor-neprilysin inhibitor over an ACE inhibitor where feasible (Heidenreich et al., 2022).
The question is pace. In STRONG-HF, patients discharged after acute heart failure who had their therapies increased to full doses within two weeks, with close follow-up, had fewer deaths or readmissions at 180 days than those treated with usual care (Mebazaa et al., 2022). Although Mrs. H. is an outpatient, the trial supports rapid, monitored titration rather than months of waiting between steps.
Plan
Week 0: stop amlodipine. Start furosemide 20 mg daily for congestion, with a target weight loss of 0.5 to 1 kg a day until her ankles and lungs are clear. Start sacubitril-valsartan 24/26 mg twice daily; she is not on an ACE inhibitor, so no washout period is needed. Start dapagliflozin 10 mg daily, which has little effect on blood pressure or potassium and can be added from the start. Week 1 to 2: basic metabolic panel; if potassium is below 5.0 mmol/L and eGFR above 30, start spironolactone 12.5 mg daily. Week 2 to 3: once she is less congested and her heart rate remains above 70, start metoprolol succinate 12.5 mg daily. Weeks 4 to 8: increase sacubitril-valsartan and metoprolol toward target doses of 97/103 mg twice daily and 200 mg daily at two-week intervals as blood pressure, heart rate and potassium allow, with laboratory tests one to two weeks after each change. Iron: intravenous iron to improve symptoms and function. Cause: referral for coronary evaluation. After three months on optimized therapy, repeat echocardiogram; if the ejection fraction remains at or below 35% with left bundle branch block and a QRS of 130 ms or more, refer to cardiology for cardiac resynchronization therapy with or without a defibrillator.
Education and Follow-Up
Mrs. H. will weigh herself each morning after urinating and before breakfast and call if the scale climbs by over 1 kg overnight or by over 2 kg across any seven days, if her breathing worsens or if she becomes dizzy on standing. She will limit sodium, not add salt at the table and avoid NSAIDs, which cause fluid retention. She was taught to pause dapagliflozin and furosemide on days she cannot eat or drink because of illness. A nurse phone call at one week and clinic visits every two weeks during titration are scheduled, with referral to cardiac rehabilitation once she is stable.
Conclusion
Mrs. H. has new heart failure with reduced ejection fraction and signs of congestion. Relieving congestion and starting all four mortality-reducing drug classes within weeks, in a planned order with a monitoring rule for each step, gives her the treatment the evidence supports without exposing her to avoidable harm. Milestone Two will evaluate her response and address the remaining questions about cause and devices.
References
Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., . . . Yancy, C. W. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 145(18), e895-e1032. https://doi.org/10.1161/CIR.0000000000001063
McMurray, J. J. V., Packer, M., Desai, A. S., Gong, J., Lefkowitz, M. P., Rizkala, A. R., Rouleau, J. L., Shi, V. C., Solomon, S. D., Swedberg, K., & Zile, M. R. (2014). Angiotensin-neprilysin inhibition versus enalapril in heart failure. New England Journal of Medicine, 371(11), 993-1004. https://doi.org/10.1056/NEJMoa1409077
McMurray, J. J. V., Solomon, S. D., Inzucchi, S. E., Kober, L., Kosiborod, M. N., Martinez, F. A., Ponikowski, P., Sabatine, M. S., Anand, I. S., Belohlavek, J., Bohm, M., Chiang, C.-E., Chopra, V. K., de Boer, R. A., Desai, A. S., Diez, M., Drozdz, J., Dukat, A., Ge, J., . . . Langkilde, A.-M. (2019). Dapagliflozin in patients with heart failure and reduced ejection fraction. New England Journal of Medicine, 381(21), 1995-2008. https://doi.org/10.1056/NEJMoa1911303
Mebazaa, A., Davison, B., Chioncel, O., Cohen-Solal, A., Diaz, R., Filippatos, G., Metra, M., Ponikowski, P., Sliwa, K., Voors, A. A., Edwards, C., Novosadova, M., Takagi, K., Damasceno, A., Saidu, H., Gayat, E., Pang, P. S., Celutkiene, J., & Cotter, G. (2022). Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): A multinational, open-label, randomised, trial. The Lancet, 400(10367), 1938-1952. https://doi.org/10.1016/S0140-6736(22)02076-1
What the NUR 616 Module 3 instructions ask for
Milestone One in NUR 616 usually asks you to present an adult or older adult case, document the history, examination and diagnostic findings, state the diagnosis with its classification and develop an initial evidence-based management plan. Later milestones then evaluate the response and refine the plan. Four to six pages in APA 7, drawing on current guidelines and primary trials, is a common length. Classify the condition with the terms the guideline uses, such as stage and functional class, explain the evidence for each major drug with effect sizes and describe the order and pace of starting therapy with a monitoring rule for each step, since the milestone is graded on whether the plan is safe as well as current. Include target doses.
How this NUR 616 Module 3 milestone one example is built
This sample presents a composite 67-year-old retired postal worker with three months of exertional breathlessness, orthopnea and edema. It documents jugular venous distension, crackles, an S3 and edema, then a BNP of 820, left bundle branch block and an ejection fraction of 30% with global hypokinesis. The assessment classifies stage C, NYHA II to III heart failure, weighs post-viral and ischemic causes and notes iron deficiency and an unhelpful amlodipine. The evidence section cites PARADIGM-HF, DAPA-HF, STRONG-HF and the 2022 guideline. The plan stops amlodipine and starts diuresis and the four drug classes week by week, with laboratory checks, target doses and device reassessment at three months.
Where the NUR 616 Module 3 rubric puts the points
Milestone rubrics in this course typically weigh the case presentation, interpretation of diagnostic data, the diagnosis and classification, evidence-based pharmacologic management, safety monitoring, patient education and APA 7 writing. The top band usually requires a plan that follows current guidelines precisely, gives starting and target doses and explains the sequence of initiation with laboratory monitoring. Graders also tend to reward attention to comorbidities that change management, such as iron deficiency or a drug that should be stopped, and to evaluation of cause. Education with specific thresholds, such as daily weight limits, often earns full credit under patient teaching when it is written for the patient in plain language.
NUR 616 Module 3 help: the mistakes that cost points
Heart failure milestones lose points when they list the four drug classes without an order or pace, when doses are missing, when potassium and kidney monitoring are not planned or when an ACE inhibitor and sacubitril-valsartan are overlapped without the required washout. A frequent gap is leaving a non-beneficial drug in place. Classify the heart failure, cite the trials with effect sizes, sequence initiation with a monitoring rule for each step, give target doses, address comorbidities and cause and teach daily weights with thresholds. If your case involves preserved ejection fraction, COPD or chronic kidney disease, send the case and milestone guidelines for a plan built on those findings.
Get NUR 616 Module 3 written to your instructions
Send the case, the milestone guidelines and your rubric. A plan that classifies the condition, cites the key trials with effect sizes, sequences therapy with a monitoring rule for each step and gives target doses will be drafted in 24 to 48 hours, and your first draft is free. The paper above is an original model document written by our desk, not a submitted student paper and not an official Southern New Hampshire University document.
More NUR 616 papers and related MSN samples
- NUR 616 Module 1 Discussion: Daily Aspirin After Sixty
- NUR 616 Module 2 SOAP Note: Diabetes With Albuminuria: Adding an SGLT2
- NUR 601 Module 9 Final Project: Cirrhosis From Compensated to Decompensated
- NUR 530 Module 3 Milestone One: A Clinical Microsystem Assessment of a Medical Unit
- NUR 557 Module 8 Case Paper: Asymptomatic Bacteriuria in Pregnancy and a Fetus-Safe Antibiotic
- NUR 607 Module 8 Focused Neurologic Note: A New Headache at 56
NUR 616 Module 3 questions, answered
Where can I find a free NUR 616 Module 3 Milestone One sample?
A complete milestone is on this page: new heart failure with reduced ejection fraction in a 67-year-old woman, with the four drug classes sequenced week by week, monitoring and APA 7 references.
What are the four pillars of HFrEF therapy?
Sacubitril-valsartan (or an ACE inhibitor or ARB when it cannot be used), one of the three proven beta blockers, spironolactone or eplerenone and an SGLT2 inhibitor, each shown to reduce death or hospitalization.
In what order should heart failure drugs be started?
Guidelines allow flexibility. A common approach relieves congestion first, starts sacubitril-valsartan and an SGLT2 inhibitor early, adds a mineralocorticoid antagonist when potassium and kidney function allow and adds a beta blocker once congestion improves.
What did PARADIGM-HF show?
Sacubitril-valsartan reduced cardiovascular death or heart failure hospitalization by 20% compared with enalapril in 8,442 patients with reduced ejection fraction, and it lowered death from any cause.
When should a heart failure patient call the clinic about weight?
Typical call-in rules use a rise of over 1 kg overnight or over 2 kg within a week, or any worsening breathlessness or swelling, since these can signal fluid buildup.