It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span.
Evaluate the Health History and Medical Information for Mrs. J., presented below.
Based on this information, formulate a conclusion based on your evaluation, and complete the Critical Thinking Essay assignment, as instructed below.
Health History and Medical Information
Mrs. J. is a 63-year-old married woman who has a history of hypertension, chronic heart failure, and chronic obstructive pulmonary disease (COPD). Despite requiring 2L of oxygen/nasal cannula at home during activity, she continues to smoke two packs of cigarettes a day and has done so for 40 years. Three days ago, she had sudden onset of flu-like symptoms including fever, productive cough, nausea, and malaise.
Over the past 3 days, she has been unable to perform ADLs and has required assistance in walking short distances. She has not taken her antihypertensive medications or medications to control her heart failure for 3 days. Today, she has been admitted to the hospital ICU with acute decompensated heart failure and acute exacerbation of COPD.
- Is very anxious and asks whether she is going to die.
- Denies pain but says she feels like she cannot get enough air.
- Says her heart feels like it is \”running away.\”
- Reports that she is exhausted and cannot eat or drink by herself.
- Height 175 cm; Weight 95.5kg.
- Vital signs: T 37.6C, HR 118 and irregular, RR 34, BP 90/58.
- Cardiovascular: Distant S1, S2, S3 present; PMI at sixth ICS and faint: all peripheral pulses are 1+; bilateral jugular vein distention; initial cardiac monitoring indicates a ventricular rate of 132 and atrial fibrillation.
- Respiratory: Pulmonary crackles; decreased breath sounds right lower lobe; coughing frothy blood-tinged sputum; SpO2 82%.
- Gastrointestinal: BS present: hepatomegaly 4cm below costal margin.
The following medications administered through drug therapy control her symptoms:
- IV furosemide (Lasix)
- Enalapril (Vasotec)
- Metoprolol (Lopressor)
- IV morphine sulphate (Morphine)
- Inhaled short-acting bronchodilator (ProAir HFA)
- Inhaled corticosteroid (Flovent HFA)
- Oxygen delivered at 2L/ NC
Critical Thinking Essay
In 750-1,000 words, critically evaluate Mrs. J.\’s situation. Include the following:
- Describe the clinical manifestations present in Mrs. J.
- Discuss whether the nursing interventions at the time of her admissions were appropriate for Mrs. J. and explain the rationale for each of the medications listed.
- Describe four cardiovascular conditions that may lead to heart failure and what can be done in the form of medical/nursing interventions to prevent the development of heart failure in each condition.
- Taking into consideration the fact that most mature adults take at least six prescription medications, discuss four nursing interventions that can help prevent problems caused by multiple drug interactions in older patients. Provide a rationale for each of the interventions you recommend.
- Provide a health promotion and restoration teaching plan for Mrs. J., including multidisciplinary resources for rehabilitation and any modifications that may be needed. Explain how the rehabilitation resources and modifications will assist the patients\’ transition to independence.
- Describe a method for providing education for Mrs. J. regarding medications that need to be maintained to prevent future hospital admission. Provide rationale.
- Outline COPD triggers that can increase exacerbation frequency, resulting in return visits. Considering Mrs. J.\’s current and long-term tobacco use, discuss what options for smoking cessation should be offered.
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Expert Answer and Explanation
Case Study of Mrs J
Heart diseases, also called cardiovascular disorders affect the functioning of almost every part of the body, which makes them high priority when presented to a healthcare facility. They happen mostly due to the presence of structural problems in the heart or blood vessels such as clotting problems or diseased blood vessels. In the US, 25% of the deaths are as a result of heart disorders, which makes them the leading causes of death (Benjamin et al., 2019).
The 63-y.o. female patient in question, Mrs. J., has acute COPD exacerbation, decompensated heart failure symptoms and other features that are characteristic of a dysfunctional heart. Different interventions on Mrs. J including but not limited to education, pharmaceutics, and rehabilitation resources could help her reduce the chances of COPD exacerbations as well as heart failure.
The objective data indicates the presence of an irregular heart rate, the presence of a bilateral jugular vein distention, arterial fibrillation, and decreased sounds of breath in the lower right lobe, pulmonary cackles, blood-tinged sputum, BS presence, and hepatomegaly. The subjective data shows anxiety in the client as she asks if she is going to die, shortness of breath, and fatigue.
She can barely perform the Activities of Daily Living for survival such as drinking or eating by herself. The vital signs (VS) are as follows: T 37.6C, HR 118 and irregular, RR 34, BP 90/58. She also has several cardiovascular signs such as initial cardiac monitoring indicating a ventricular rate (VR) of 132 and atrial fibrillation. Lastly, she constantly asks if she will die and this shows a high level of anxiety.
Are the Current Interventions Prescribed Appropriate?
Since the interventions given help in the reduction of the symptoms and fasten the recovery process of Mrs. J, they are appropriate. IV furosemide is often used to treat congestive heart failure, which is one of the reasons why the patient experiences problems in her cardiovascular system. Another intervention given is the inhaled short acting bronchodilator and oxygen, which is effective in helping Mrs. J to receive the right amount of oxygen that is necessary for the performance of other body functions (Sehgal et al., 2019).
Besides, the IV morphine sulphate given is effective in reduction of the symptoms of pain experienced as well as the anxiety that could otherwise lead to other further conditions (Sehgal et al., 2019). The Enalapril was useful in treating possible side effects of high blood pressure that would otherwise be realized after taking the other drugs. Metoprolol also helped to treat the high blood pressure as well as chest pains that could also arise in the course of medication.
Flovent HFA is a synthetic inhaled corticosteroid that was crucial for the client to prevent any symptoms of asthma that would be experienced. Lastly, the Oxygen delivered at 2L/ NC helped the patient when she could not efficiently utilize the room air to fulfil her respiratory functions.
Cardiovascular Conditions that could be Pre-determiners of Heart Failure
Coronary artery disease, myocardial infarction, hypertension, and endocarditis are the four primary diseases that could act as the pre-determiners of heart failure. Heart failure is the status in which the heart is unable to perform its basic function of pumping blood to the different muscles and organs of the body due to the presence of various weaknesses. With coronary artery disease, the blood vessels encounter fat deposits on their walls and result in restricting the flow of the blood to the heart.
The correction of the coronary artery disease could be done by reducing the blood concentration of low density lipoproteins (LDLs) or increasing the rate of emulsification of fats (Celano et al., 2018). In myocardial infarction, the muscles of the heart have little access to fresh blood that renders them weak, but can be corrected through various interventions such as vasodilation (Celano et al., 2018).
For hypertension, the heart encounters a rate of pumping blood that is higher than normal, and could be corrected through things such as taking laxative agents to reduce hypertension due to stress (Celano et al., 2018). Lastly, endocarditis is when the heart valves are unresponsive to the triggers of blood, and its correction is made through valve surgery.
Nursing Interventions to Prevent Problems of multiple drug interactions
The fact that the intervention of this patients consists the consumption of a total of seven drugs means that she is at risk of the problems associated with polypharmacy. One nursing intervention to help in this would be to educate the patient about the side effect of each of the drugs so that they could report in case anything beyond these side effects manifests, which could be most likely the interactions of the drugs (Kim & Parish, 2017).
Establishing proper timelines for the consumption of the drugs could also help reduce the chances of drug interactions (Kim & Parish, 2017). Another nursing intervention is performing follow-up on the patient using various telemedicine tools such as video calls. Lastly, the evaluation of the patient over various time periods could serve a suitable intervention.
Health Restoration and Promotion Teaching Plan
The health promotion for Mrs. J entails utilizing telemedicine tools to monitor her closely while she is away from the facility. Also, giving her life support tools such as walking sticks and wheel chairs could help her recover quickly. One of the key multidisciplinary resources for the health restoration plan would be assigning the patient to a certified pulmonologist who would help monitor the exact support that is offered by the people close to her at the time of need. This way, these tools would efficiently guide the patient through her independence as she would no longer need assistance when performing her activities of daily living.
Rehabilitation Resources for Independence
Rehabilitation resources would help to eradicate some bad behaviors that Mrs. J may be having such as smoking or drinking too much alcohol. Mentally, they would help Mrs. J. increase her ability to live and sustain an independent life. Physically, they would increase her stability by allowing her being more aware of her condition and making the necessary adjustments in her daily life, which would include but would not be limited to adjusting her diet.
Education Style to Help Reduce Readmission Chances
There are many ways that could be used to educate Mrs. J but since her stability depends on her ability to stay independent, she should be allowed to experience an uncontrolled environment such as a loosely monitored nursing home (Werchan et al., 2019). After learning about the plight of the patients who are not committed to improvement, she would be more driven to undertake various practices that could lead to absolute growth and hence reduced chances of readmission.
Triggers of COPD that could Increase Frequency of Exacerbations
Lung infections could trigger COPD, where the lungs would become less responsive to the normal functions. Also, dangerous habits such as smoking and increased exposure to air pollution could trigger COPD. (Viniol & Vogelmeier, 2018). For the smoking session, the client could be given some FDA-approved drugs such as Varenicline Tartrate (Chantix) and also behavioral therapy administered by a certified pulmonologist.
To efficiently manage Mrs. J’s condition, the nurse in charge needs to educate her about the most suitable lifestyle adjustments and also monitor her closely to avoid common risks such as problems of polypharmacy. Various life tools and rehabilitation resources would also help to increase the independence of the patient and hence prevent readmissions. Most importantly, the patient should avoid common COPD triggers such as smoking and lung infections.
Benjamin, E. J., Muntner, P., Alonso, A., Bittencourt, M. S., Callaway, C. W., Carson, A. P., … & American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. (2019). Heart disease and stroke statistics—2019 update: a report from the American Heart Association. Circulation, 139(10), e56-e528. https://doi.org/10.1161/CIR.0000000000000659
Celano, C. M., Villegas, A. C., Albanese, A. M., Gaggin, H. K., & Huffman, J. C. (2018). Depression and anxiety in heart failure: a review. Harvard review of psychiatry, 26(4), 175. DOI: 10.1097/HRP.0000000000000162
Kim, J., & Parish, A. L. (2017). Polypharmacy and medication management in older adults. Nursing Clinics, 52(3), 457-468. DOI: 10.1016/j.cnur.2017.04.007
Sehgal, I. S., Agarwal, R., Dhooria, S., Prasad, K. T., Kalpakam, H., & Aggarwal, A. N. (2019). Adaptive Support Ventilation During Non-Invasive Ventilation in Acute Exacerbation of COPD: In Statu Nascendi. COPD, 16(3-4), 305-305. DOI: 10.1080/15412555.2019.1640192
Viniol, C., & Vogelmeier, C. F. (2018). Exacerbations of COPD. European Respiratory Review, 27(147). DOI: 10.1183/16000617.0103-2017
Werchan, C. A., Steele, A. M., Janssens, T., Millard, M. W., & Ritz, T. (2019). Towards an assessment of perceived COPD exacerbation triggers: Initial development and validation of a questionnaire. Respirology, 24(1), 48-54. DOI: 10.1111/resp.13368
Alternative Expert Answer and Explanation
Mrs. J’s Case Study
The case study is about Mrs. J, a 63-year-old married woman with a history of chronic heart failure, hypertension, and chronic obstructive pulmonary disease (COPD). The patient smokes two packs of cigarettes a day, yet she requires 2L of oxygen/nasal cannula at home during activity. The patient complained of sudden onset of flu-like symptoms including malaise, nausea, fever, and productive cough. The patient has been unable to engage in ADLs and needs help in walking short distances.
The patient notes that she has not taken medications for controlling her blood pressure and her heart failure for 3 days. The patient has admitted to the hospital ICU with acute exacerbation of COPD and acute decompensated heart failure. The purpose of this assignment is to analyze the case study and answer the questions below.
Subjective and Objective Clinical Manifestations
Clinical manifestations include sudden onset of flu-like symptoms (malaise, nausea, fever, and productive cough), inability to engage in ADLs, needing help in walking short distances, and complaints of breathing problems with no pain. She also reports that she feels as if her heart is pumping faster. She reports that she feels tired and cannot drink or eat on her own. She is anxious and wonders if she will make it.
Her respiratory results show decreased breath sounds right lower lobe, pulmonary crackles, SpO2 82%, and coughing frothy blood-tinged sputum. Gastrointestinal tests show hepatomegaly 4cm below the costal margin and BS.
The patient is at risk of many cardiovascular conditions. One of the conditions is coronary heart disease. Some of the risk factors for coronary heart disease include smoking, age, high blood pressure, obesity, and age (Li et al., 2019). The is obese, smokes twice a week, has high blood pressure, and is an older adult increasing her risk of suffering coronary heart disease.
Coronary heart disease can cause a heart attack. The disease can be treated using statins. Li et al. (2019) statins are beneficial in the treatment of coronary heart disease. The patient can also be educated to stop smoking. The second cardiovascular condition is cardiomyopathy. The risk factors of cardiomyopathy. The risk factors for cardiomyopathy include obesity, prolonged high blood pressure, and a family history of the disease (Mustafa et al., 2022).
The patient risk suffering from cardiomyopathy because she is obese and has hypertension. The disease can be treated using Sacubitril, a medicine for improving blood pressure (Mustafa et al., 2022). The third cardiovascular complication is arrhythmia. The patient has high blood pressure increasing her risk of developing arrhythmia. The disease depends on the type of arrhythmia.
For instance, if one has atrial fibrillation, cardioversion can be recommended. The last condition is heart valve disease. Heart valve disease occurs when one or more heart valves do not work properly. Old age and high blood pressure are risk factors for the disease. The disease can be treated by educating the patient to adopt a healthy lifestyle.
Appropriateness of the Nursing Interventions
The interventions provided to the patient at the time of admission were all appropriate. For instance, it was appropriate to prescribe the patient IV furosemide. The patient has the symptoms of heart failure, which include shortness of breath, irregular heartbeat, fatigue and weakness, persistent cough, and nausea (Ahmed et al., 2021). IV furosemide stops the body from absorbing a lot of salt and prevents heart failure (Ahmed et al., 2021).
Enalapril is vital because it helps prevent stroke as a result of health failure (American Heart Association, 2017). Metoprolol was appropriate because it improved the patient’s breathing. Oxygen delivered at 2L/ NC and Flovent HFA, and ProAir HFA were important because they helped solve her breathing issues (Gulick & Flexner, 2019). Providing the patient with morphine helped relieve pain caused by heart failure. I would educate the patient to take her medication as prescribed and engage in physical exercise to reduce readmission.
Multiple Drug Interactions
IV furosemide belongs to a class of drugs known as diuretics. It works by preventing electrolyte reabsorption from the kidneys and improving water excretion. It is used to treat edema in heart failure. The medication prevented heart failure (Ahmed et al., 2021). Enalapril belongs to angiotensin-converting enzyme (ACE) inhibitors it works by reducing certain chemicals that tighten the blood vessels to improve blood flow. It was prescribed to prevent stroke in a patient with heart failure. Metoprolol is a beta-blocker.
It works by slowing heart rate and relaxing blood vessels. It is significant because it helps in decreasing blood pressure and improving heart rate. Morphine belongs to opiate (narcotic) analgesics. It is vital because it helps reduce pain experienced during heart failure. ProAir HFA belongs to the Beta-2 agonist class. It works by improving airways muscles to improve breathing (Wouters et al., 2022). Flovent HFA belongs to the Corticosteroids, Inhalants class. It works by improving inflammation of the airways, and as a result improves breathing (Wouters et al., 2022).
Patient education is one of the interventions that can prevent multiple drug interactions. Zazzara et al. (2021) noted that drug interaction can be prevented by educating patients to take medications as prescribed. The second intervention is working with the patient’s family. The patient’s family can help by ensuring that the patient does not overdose (Zazzara et al., 2021). The third intervention is labeling the drugs properly to prevent confusion. The fourth intervention is advising the patient to refill her prescriptions once to avoid confusion (Zazzara et al., 2021).
Promotion and Restoration Teaching Plan
The teaching plan should involve identifying the goals of the plan, determining the needs of patients, identifying teaching resources, and the patient’s readiness to learn. During teaching, the patient should be engaged and the lesson evaluated to ensure that they achieve its aims. Rehabilitation resources include nicotine patches, education materials, gum, lozenges, and inhalers. Gums, inhalers, and nicotine patches will be used in nicotine replacement therapy to help the patient recover (Colarusso et al., 2017). Education materials will improve the patient’s knowledge about heart failure and smoking and its consequences.
The patient can be offered nicotine patches instead of tobacco. Lindson et al. (2019) noted that nicotine patches can provide a steady level of nicotine in the body to reduce the urge to take tobacco products. The patient can also be given lozenge and gum to reduce cravings for cigarettes as they happen (Lindson et al., 2019). COPD can be triggered using smoking, respiratory infections, humid weather, or hot or cold weather. However, smoking is the main trigger of COPD and thus the patient should be educated to avoid it.
The medications provided to help improve the patient’s symptoms are appropriate. The drugs will help reduce the patient’s risk of suffering heart failure. The patient should be advised to stop smoking because it increases the risk of readmission due to COPD. The patient should also be advised to engage in physical exercise to reduce her weight.
Ahmed, F. Z., Taylor, J. K., John, A. V., Khan, M. A., Zaidi, A. M., Mamas, M. A., & Cunnington, C. (2021). Ambulatory intravenous furosemide for decompensated heart failure: Safe, feasible, and effective. ESC Heart Failure, 8(5), 3906-3916. https://doi.org/10.1002/ehf2.13368
American Heart Association. (2017). What Is High Blood Pressure? South Carolina State Documents Depository. https://dc.statelibrary.sc.gov/bitstream/handle/10827/25131/DHEC_What_is_High_Blood_Pressure_2017-07.pdf?sequence=1
Colarusso, C., Terlizzi, M., Molino, A., Pinto, A., & Sorrentino, R. (2017). Role of the inflammasome in chronic obstructive pulmonary disease (COPD). Oncotarget, 8(47), 81813. doi: 10.18632/oncotarget.17850
Gulick, R. M., & Flexner, C. (2019). Long-acting HIV drugs for treatment and prevention. Annual review of medicine, 70, 137-150. https://www.annualreviews.org/doi/abs/10.1146/annurev-med-041217-013717
Li, M., Wang, X., Li, X., Chen, H., Hu, Y., Zhang, X., … & Shang, H. (2019). Statins for the primary prevention of coronary heart disease. BioMed Research International, 2019. https://doi.org/10.1155/2019/4870350
Lindson, N., Chepkin, S. C., Ye, W., Fanshawe, T. R., Bullen, C., & Hartmann‐Boyce, J. (2019). Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews, (4). https://doi.org/10.1002/14651858.CD013308
Mustafa, N. H., Jalil, J., Zainalabidin, S., Saleh, M. S., Asmadi, A. Y., & Kamisah, Y. (2022). Molecular mechanisms of sacubitril/valsartan in cardiac remodeling. Frontiers in Pharmacology, 13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9393311/
Wouters, O. J., Feldman, W. B., & Tu, S. S. (2022). Product hopping in the drug industry—lessons from Albuterol. New England Journal of Medicine, 387(13), 1153-1156. https://eprints.lse.ac.uk/116986/1/WoutersP_dm1clean.pdf
Zazzara, M. B., Palmer, K., Vetrano, D. L., Carfì, A., & Onder, G. (2021). Adverse drug reactions in older adults: A narrative review of the literature. European Geriatric Medicine, 12(3), 463-473. https://link.springer.com/article/10.1007/s41999-021-00481-9
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