Assessment 2: Advanced Pathophysiology Case Study – Chronic Heart Failure in Older Adults

Course and Assessment Overview

Course: MSN Advanced Pathophysiology

Assessment: Assessment 2 – Case-study essay

Length: 1,500-word individual written essay (±10%, excluding title page and references)

Weighting: 30–40% of final course grade (to be set by program)

Submission format: Word-processed document, double-spaced, 12-point font, current academic referencing style (e.g. APA or Harvard)

Case Scenario

Mr. J is a 78-year-old man who presents to the emergency department with worsening shortness of breath over three days, increasing fatigue over several weeks, and new-onset swelling of his ankles. He reports needing three pillows at night to sleep comfortably and waking up suddenly at night gasping for air. His medical history includes long-standing hypertension, type 2 diabetes mellitus, prior anterior wall myocardial infarction ten years ago, obesity, and hyperlipidemia. Medications include an ACE inhibitor, beta-blocker, loop diuretic taken inconsistently, statin, and metformin.

On examination, his blood pressure is 152/92 mmHg, heart rate 108 beats/min, respiratory rate 24 breaths/min, and oxygen saturation 92% on room air. Jugular venous distension is present at 45 degrees. Auscultation reveals bilateral basal crackles and a third heart sound (S3). There is bilateral pitting oedema to the mid-shins. Echocardiogram demonstrates a left ventricular ejection fraction of 30% with global hypokinesis. NT-proBNP is markedly elevated. A diagnosis of chronic heart failure with reduced ejection fraction (HFrEF) is made.

---

Assessment Task

You are required to write a 1,500-word case-study essay that critically explains the advanced pathophysiology of chronic heart failure in older adults, using Mr. J’s presentation as the organising framework.

Task Requirements

In your essay, you must:

• Characterise the heart failure phenotype:
  Identify and justify the classification of Mr. J’s heart failure using contemporary staging and ejection fraction categories (e.g. ACC/AHA stages, HFrEF/HFmrEF/HFpEF) and link these to his clinical findings.

• Explain core pathophysiological mechanisms:
  Analyse the underlying myocardial injury and ventricular remodelling processes, neurohormonal activation (including sympathetic nervous system and renin–angiotensin–aldosterone system), and haemodynamic changes that contribute to his signs and symptoms.

• Link signs and symptoms to mechanisms:
  Provide a mechanism-based explanation for each of the key features in the scenario, including dyspnoea on exertion, orthopnoea, paroxysmal nocturnal dyspnoea, peripheral oedema, jugular venous distension, basal crackles, S3 heart sound, and reduced ejection fraction.

• Discuss age-related and comorbidity influences:
  Critically discuss how ageing myocardium, multimorbidity (hypertension, diabetes, prior myocardial infarction, obesity), and polypharmacy shape the pathophysiology and progression of chronic heart failure in older adults.

• Integrate current guideline perspectives:
  Briefly summarise how contemporary heart failure guidelines conceptualise staging, risk, and disease trajectory in patients similar to Mr. J, and indicate the implications of this pathophysiology-focused understanding for advanced nursing assessment and monitoring.

Structure

Organise your essay using clear academic sections (use subheadings where appropriate):

1. Introduction: Briefly introduce chronic heart failure in older adults, state the purpose of the essay, and outline the structure.

2. Phenotype and classification of Mr. J’s heart failure.

3. Core pathophysiological mechanisms (myocardial injury, remodelling, neurohormonal activation, haemodynamics).

4. Mechanism-based explanation of Mr. J’s clinical manifestations.

5. Influence of ageing and comorbidities on disease trajectory.

6. Implications of guideline frameworks for advanced nursing assessment in heart failure.

7. Conclusion: Concise synthesis of key pathophysiological insights and their relevance to advanced nursing practice.

Academic and Presentation Requirements

• Word count: 1,500 words (±10%), excluding title page, headings, and reference list

• Use current, peer-reviewed sources and contemporary heart failure guidelines (2018–2026)

• Apply a consistent academic referencing style (e.g. APA 7th or Harvard) throughout

• Write in a formal, scholarly tone appropriate for an MSN-level advanced pathophysiology course

• Ensure logical flow, clear linkage between mechanisms and manifestations, and integration of evidence

Assessment 2 Marking Rubric – Case-Study Essay (Chronic Heart Failure in Older Adults)

Criterion 1: Heart Failure Classification and Clinical Framing (20%)

• High Distinction (85–100): Accurately classifies heart failure using up-to-date staging and ejection fraction categories, with precise justification supported by current guidelines; clearly integrates comorbidities and risk profile into the clinical framing.

• Distinction (75–84): Correctly classifies heart failure and provides clear justification with minor omissions; draws appropriate links to comorbidities and risk, supported by relevant sources.

• Credit (65–74): Provides generally accurate classification with basic justification; some elements of staging or phenotype may be underdeveloped or lack clear linkage to the case.

• Pass (50–64): Identifies heart failure type but justification is limited, partially inaccurate, or weakly linked to clinical findings.

• Fail (<50): Misclassifies heart failure, provides minimal or inaccurate justification, and shows limited awareness of guideline frameworks.

Criterion 2: Explanation of Core Pathophysiological Mechanisms (30%)

• High Distinction (85–100): Provides a sophisticated, integrated explanation of myocardial injury, ventricular remodelling, neurohormonal activation, and haemodynamic alterations; demonstrates advanced understanding of how these processes interact over time in older adults with chronic heart failure.

• Distinction (75–84): Explains key mechanisms accurately with good detail; integration across mechanisms is mostly clear, with only minor gaps or oversimplifications.

• Credit (65–74): Describes most core mechanisms with reasonable accuracy; explanation may be compartmentalised or somewhat descriptive rather than integrative.

• Pass (50–64): Provides basic, predominantly descriptive coverage of mechanisms; key concepts are present but with limited depth or integration.

• Fail (<50): Mechanistic explanations are superficial, inaccurate, or missing substantial components.

Criterion 3: Mechanism-Based Explanation of Clinical Manifestations (25%)

• High Distinction (85–100): Systematically links each major sign and symptom in the case (e.g. dyspnoea, orthopnoea, PND, oedema, JVD, S3, reduced EF) to specific cellular, neurohormonal, and haemodynamic mechanisms; demonstrates nuanced understanding of cause–effect relationships.

• Distinction (75–84): Provides clear and mostly detailed mechanistic explanations for most clinical manifestations; a small number of links may lack depth or precision.

• Credit (65–74): Relates manifestations to underlying mechanisms in a broadly correct way; may rely on general descriptions with limited detail.

• Pass (50–64): Offers basic, partially correct links between some signs/symptoms and underlying processes; important features may be omitted or weakly explained.

• Fail (<50): Explanations are largely descriptive of symptoms with minimal or inaccurate discussion of mechanisms.

Criterion 4: Ageing, Comorbidities, and Disease Trajectory (15%)

• High Distinction (85–100): Critically analyses how ageing myocardium, multimorbidity (e.g. hypertension, diabetes, prior MI, obesity), and treatment patterns influence structural disease, neurohumoral activation, and progression of chronic heart failure in older adults, supported by contemporary evidence.

• Distinction (75–84): Provides clear discussion of ageing and comorbidity influences with relevant evidence; analysis is sound though slightly less critical or comprehensive.

• Credit (65–74): Describes influences of ageing and comorbidities in general terms; some evidence cited but limited depth of analysis.

• Pass (50–64): Mentions relevant factors but discussion is brief, descriptive, or poorly integrated with the case.

• Fail (<50): Minimal or absent consideration of ageing and comorbidity influences.

Criterion 5: Use of Evidence, Structure, and Academic Writing (10%)

• High Distinction (85–100): Integrates high-quality, recent peer-reviewed and guideline sources throughout; essay is logically structured, clearly written, and adheres fully to academic conventions and referencing style.

• Distinction (75–84): Uses appropriate and mostly recent sources with minor gaps; structure and academic style are strong with only minor issues.

• Credit (65–74): Draws on a mix of sources including some older or non-peer-reviewed references; structure is adequate with some lapses in flow or referencing.

• Pass (50–64): Limited use of evidence and/or reliance on textbooks or general websites; academic writing and referencing are inconsistent.

• Fail (<50): Minimal or inappropriate use of sources; significant problems with structure, clarity, or academic integrity.

Heart failure with reduced ejection fraction in older adults reflects a chronic, progressive syndrome in which previous myocardial injury and persistent haemodynamic stress drive adverse ventricular remodelling, neurohormonal activation, and systemic congestion. In Mr. J’s case, longstanding hypertension, type 2 diabetes, and a prior myocardial infarction have produced structural left ventricular damage that now limits contractility and lowers his ejection fraction, which is evident in his echocardiographic EF of 30% and global hypokinesis. Elevated left-sided filling pressures contribute to pulmonary venous congestion, which explains his exertional dyspnoea, orthopnoea, and paroxysmal nocturnal dyspnoea, while chronic activation of the renin–angiotensin–aldosterone system and sympathetic nervous system promotes sodium and water retention, peripheral oedema, and jugular venous distension. Recognition of these tightly linked mechanisms is central to advanced nursing assessment because it anchors clinical decision-making in an understanding of how structural heart disease, neurohormonal pathways, and age-related vulnerability intersect in patients like Mr. J.

 Recent References

• Heidenreich, P.A., Bozkurt, B., Aguilar, D. et al. (2022) ‘2022 AHA/ACC/HFSA guideline for the management of heart failure’, Circulation, 145(18), pp. e895–e1032.

• McDonagh, T.A., Metra, M., Adamo, M. et al. (2021) ‘2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure’, European Heart Journal, 42(36), pp. 3599–3726.

• Kazmi, S., Riaz, H., Ali, M. et al. (2023) ‘The pathophysiology and new advancements in the management of heart failure with reduced ejection fraction’, Cureus, 15(9), e45178.

• StatPearls Publishing (2025) ‘Heart failure (congestive heart failure)’, StatPearls.

• Beghini, S., Paulus, W.J. and Pieske, B. (2025) ‘2024 update in heart failure’, ESC Heart Failure, 12(1).