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)
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
Health History and Medical Information Evaluation
Elder populations are often at a higher risk of chronic illnesses such as high blood pressure, obstructive pulmonary disease (COPD), diabetes and heart failure as well as other cardiovascular complications. Some behaviors and malnutrition may exacerbate most of these conditions. This paper examines health history of a 63-years old female patient who suffers from hypertension, chronic COPD and chronic heart failure. Despite these conditions, the patient smokes two packs of cigarettes each day. Upon sudden attack with some flu-like symptoms, malaise, nausea and productive cough, she was admitted at the hospital’s Intensive Care Unit (ICU) and prescribed various drugs and other medications. This paper will determine the appropriateness of the patient’s medications and a description of the present clinical manifestations.
Clinical Manifestations and Nursing Interventions
Based on the Mrs. J’s health history and current symptoms, it was very crucial to admit her at the ICU with acute exacerbation of COPD and acute decompensated heart failure. However, there are clinical manifestations of acute myocardial infarction or heart attack. The American Heart Association defines Myocardial infarction as the sudden and severe blockage of the artery of the heart. This condition is life-threatening and thus the need for intensive care unit service (Rusinowicz et al., 2017). The nursing interventions administered to the patient were appropriate in that the patient requires some drugs to address various cardiovascular challenges including blockage of the arteries, possible inflammation, high blood pressure, airway clearance and COPD as well as heart failure. Although the client denies pains, analgesic intervention is crucial.
Rational for the Interventions
IV furosemide (Lasix) – These drugs are important for the treatment of heart failure, high blood pressure and possible edema or excess fluid. It is highly effective when combined with other drugs.
Enalapril (Vasotec) – This is an ACE inhibitor for the treatment of high blood pressure and heart failure. It is a good combination with diuretics such as the furosemide listed above (Marushchak et al., 2019).
Metoprolol (Lopressor) – It is one of effective selective β1 receptor-blocker drugs for the treatment of hypertension.
IV morphine sulphate (Morphine) – Although the patient denied pain, this analgesic drug is important to relieve any chest pains among others.
Inhaled short-acting bronchodilator (ProAir HFA) – This inhaler intervention is important for the prevention of wheezing or shortness of breath, especially because of COPD.
Inhaled corticosteroid (Flovent HFA) – This intervention is critical for the treatment of nasal problems.
Oxygen delivered at 2L/ NC – The intervention of 2 liters of oxygen will increase the amount of oxygen in the body to ensure circulation of enough oxygenated blood.
Cardiovascular Conditions Leading to Heart Failure
There are various cardiovascular conditions that may lead to heart failure. Some of these conditions include the following:
- Coronary Artery Disease – Avoidance of smoking, reduction of LDL cholesterol and control of blood pressure are significant interventions to prevent this condition (American Heart Association, 2021)
- Hypertension– Some of nursing interventions include reduction of tension and stress, uninterrupted rest and healthy dietary as well as mobility therapy
- Blockage of an artery that supplies blood to the heart muscles– strict monitoring of arrhythmias and high blood pressure
- Heart muscle damage or Inflammation (myocarditis) – bed rest, strict monitoring of arrhythmias and Intravenous (IV) medication to enhance heart-pumping
Nursing Interventions for Multiple Drugs Interaction Problems
Although prescriptions of multiple drugs may influence undesirable problems on interactions, most of adult patients take a minimum of six prescriptions. However, there are effective nursing interventions to prevent these problems. These interventions include:
- Diet compliance – nurses will often advice the right diet to ensure that the patient will withstand the side effects of the polypharmacy.
- Accurate dosage – Nurses must ensure that the dosage of every drug in the prescription complement the other drugs in the prescription.
- Sleep pattern control – adequate sleep is a therapeutic remedy to health challenges.
- Mobility therapy – Nurses may provide the necessary information on how the patient should perform exercises and other movements to help in drugs functionality.
Health Promotion and Restoration Teaching Plan
A considerable health promotion and restoration plan begins with letting Mrs. J understand the importance of exercises despite the age. Exercises highly strengthens any muscle and that the heart is a muscle (Dharmarajan & Rich, 2017). Although the patient has smoked for over 40 years, she must understand the risk of smoking in blocking the arteries while influencing cardiovascular complications. As such, behavior change towards quitting smoking will be helpful to restore good health. It is also important for the patient to check on her Body Mass Index (BM1). Eating healthy foods, exercises and reducing stress causing activities would help to reduce weight. Excess cholesterol increases the risk of COPD, hypertension and other cardiovascular conditions that lead to heart failure (Pirina et al., 2017). In light of this, the patient should highly value all the medication and therapeutic remedy provided. All these rehabilitation resources and changes will help the patient to become independent.
The teach back method is one of the most effective methods for providing education for Mrs. J concerning interventions that must be maintained to prevent readmissions. The teach-back method is a strategy where the nurse would teach the patient and family members on various areas of care and then asks the patient to teach them. Nurses and other healthcare professionals will be convinced that the patient understood all the concepts and requirements for health improvement and reduction of hospital readmissions (Dharmarajan & Rich, 2017). For instance, the patient would tell the nurse all the symptoms at certain level and what to do when the symptoms are observed. The patient will also communicate the exercises, sleep pattern, quitting of smoking and mobility concerns.
COPD Triggers that Increase Exacerbation Frequency
Although COPD exacerbations are chiefly caused by bacterial or viral lung infections, other triggers include air pollution, exposure to smoke or the smoking behavior. Allergy-causing pollens, humid air, hot or cold air and strong perfumes also trigger COPD exacerbations (Pirina et al., 2017). Smoking cessation is thus helpful for Mrs. J. Options for smoking cessation include prescription of non-nicotine drugs such as varenicline and bupropion; prescription of nicotine nasal inhaler or spray, or over the counter nicotine lozenges and patches.
Patients with chronic illnesses such as high blood pressure, obstructive pulmonary disease (COPD), diabetes and heart failure as well as other cardiovascular complications must be watchful of their lifestyle including cigarette smoking and nutrition. Exercises are also significant to allow proper functioning of the heart and other body muscles.
American Heart Association. (2021). Causes of Heart Failure. https://www.heart.org/en/health-topics/heart-failure/causes-and-risks-for-heart-failure/causes-of-heart-failure
Dharmarajan, K., & Rich, M. W. (2017). Epidemiology, pathophysiology, and prognosis of heart failure in older adults. Heart failure clinics, 13(3), 417-426.
Marushchak, M., Maksiv, K., & Krynytska, I. (2019). ACE gene I/D polymorphism and arterial hypertension in patients with COPD. Pneumologia, 68(3), 114-119.
Pirina, P., Martinetti, M., Spada, C., Zinellu, E., Pes, R., Chessa, E., … & Corona, M. (2017). Prevalence and management of COPD and heart failure comorbidity in the general practitioner setting. Respiratory medicine, 131, 1-5.
Rusinowicz, T., Zielonka, T. M., & Zycinska, K. (2017). Cardiac arrhythmias in patients with exacerbation of COPD. In Clinical Management of Pulmonary Disorders and Diseases (pp. 53-62). Springer, Cham.