Case Study: Mrs. J
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.
You are required to cite to a minimum of two sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
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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