Assignment Case Study: Mrs. J

Assignment Case Study: Mrs. J

Assignment Case Study: Mrs. J

In 750-1,000 words, critically evaluate Mrs. J.’s situation. Include the following:

Describe the subjective and objective clinical manifestations present in Mrs. J.

Describe four cardiovascular conditions in which Mrs. J is at risk, and that may lead to heart failure. What can be done in the form of medical/nursing interventions to prevent the development of heart failure in each of the presented conditions?

By following the nursing process, were the interventions at the time of admissions beneficial for Mrs. J? Would you change any of the interventions to ensure patient independence and prevent readmission?

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Explain each of the seven medications listed in the scenario above. Include the classification, the action, and the rationale for each of these. 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, including maintenance of medications. Explain how the rehabilitation resources and modifications will assist the patients’ transition to independence and prevent readmission.

Considering Mrs. J.’s current and long-term tobacco use, discuss what options for smoking cessation should be offered. Outline COPD triggers that can increase exacerbation frequency, resulting in return visits.

Health History

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.

Subjective Data

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.

Objective Data

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.

Intervention

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

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Case Study: Mrs. J

Mrs. J, a 63-year-old female, has a history of hypertension, chronic heart failure, and COPD. She smokes 2PPD even though she requires 2L of oxygen at home during activity. She presented with an abrupt onset of flu-like symptoms three days ago and has difficulties carrying out ADLs.  The purpose of this assignment is to analyze the patient’s case and the provided interventions.

Subjective and Objective Clinical Manifestations

The patient’s subjective findings include anxiety, shortness of breath, palpitations, fatigue, and limitations in performing ADLs. Objective findings include obesity with a BMI of 31.2, and the vital signs reveal a low-grade fever, tachycardia, tachypnea, and hypotension. Cardiovascular findings include abnormal heart sounds (S gallop), bilateral neck vein distention, faint peripheral pulses, and PMI at the 6^th ICS. Respiratory findings include diminished breath sounds unilaterally, pulmonary crackles, cough with frothy blood-tinged sputum, and low oxygen saturation levels. The patient also has hepatomegaly.

Cardiovascular Conditions That May Lead To Heart Failure

Mrs. J is at risk of Coronary Artery Disease (CAD), Arrhythmia, cardiomyopathy, and Aortic stenosis that can contribute to heart failure (HF). Obesity is a risk factor for CAD, which occurs following the accumulation of cholesterol and fatty deposits in the heart’s arteries. The development of HF secondary to CAD can be prevented by educating patients on lifestyle modification (Groenewegen et al., 2020). Arrhythmia can be prevented from causing HF by prescribing Antiarrhythmic agents like sodium-channel blockers,  beta-blockers, potassium-channel blockers, and calcium-channel blockers. Mrs. J is at risk of Cardiomyopathy due to her history of hypertension. It is vital to prescribe beta blockers due to their negative chronotropic and inotropic effects to prevent cardiomyopathy from causing HF (Groenewegen et al., 2020). The patient’s hypertension is also a risk factor for Aortic stenosis, which impedes left ventricular outflow causing hypertrophy and HF. Aortic valve replacement through surgery is necessary to avoid patients with aortic stenosis from having HF.

Interventions at the Time of Admission

Some interventions were appropriate, while others were inappropriate. The appropriate interventions include administering Furosemide, Inhaled ProAir HFA, and administering oxygen 2L via nasal cannula.  Furosemide is recommended in patients with signs of congestive heart failure. Inhaled ProAir HFA is indicated in COPD exacerbation and thus was appropriate (Nici et al., 2020). Oxygen was also necessary to improve the patient’s oxygen saturation levels. I would change the inappropriate interventions, like administering Enalapril, Metoprolol, Morphine, and the inhaled corticosteroid.

Medications Administered

Furosemide is a loop diuretic that acts at the proximal and distal renal tubules to inhibit the reabsorption of sodium and chloride. This alters water and sodium balance leading to decreased blood volume and preload (Oparil et al., 2018). It is indicated in congestive heart failure and HTN. Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that inhibits the activity of ACE. ACE is an enzyme that converts angiotensin I into angiotensin II (a potent vasoconstrictor) and is recommended to lower BP. Metoprolol is a selective Beta-1 blocker that reduces cardiac output thus lowering BP and is indicated in HTN and HF (Oparil et al., 2018). Morphine is an opioid analgesic that inhibits the ascending pain pathways. It is indicated for sedation respiratory depression, and cough suppression. ProAir HFA is a short-acting Beta2 agonist that relaxes bronchial smooth muscles and is indicated for acute bronchospasms. Flovent HFA is an anti-inflammatory corticosteroid that suppresses the immune system and alleviates inflammation (Nici et al., 2020). It is used in the long-term treatment of COPD to prevent bronchospasms.

Nurses can prevent problems caused by multiple drug interactions by taking a detailed medication history to identify a patient’s current and previous medications. This can help identify the drugs that may cause interactions.  Nurses can also maintain an accurate list of all the patient’s medications, including dose, frequency, and indication. This can help identify unnecessary medications and reduce polypharmacy (Rankin et al., 2018). In addition, nurses can use screening tools that identify potential drug interactions, duplicate medications, and inappropriate prescription medication use (Rankin et al., 2018). Lastly, nurses can propose non-pharmacological interventions that can substitute medications like cold/hot therapies and Yoga for pain.  

Health Promotion and Restoration Teaching Plan for Mrs. J.

Mrs. J’s health promotion and teaching plan will comprise lifestyle modification strategies. The patient will be educated on healthy dietary habits to promote weight loss and lower BP, like eliminating high-caloric foods and drinks. She will be recommended to increase her physical activity to a level she can manage to improve cardiovascular and respiratory function and promote weight loss (Ambrosino & Bertella, 2018).  Smoking cessation will be recommended and she will be educated on the effects of smoking in causing airway inflammation. Multidisciplinary rehabilitation care will include physicians, nurses, social workers, exercise specialists, and dieticians. Pulmonary rehabilitation will be included to improve airflow limitation, prevent and manage secondary complications, and improve respiratory symptoms and quality of life (Zhang et al., 2022). A nutritional assessment focusing on dietary practices will be conducted to help the patient in weight management.

Options for Smoking Cessation

Options to quit smoking include nicotine replacement therapy (NRT) like nicotine gum, patches, and lozenges. The patient can also be prescribed non-nicotine treatment like Bupropion, Nortriptyline, Varenicline, and Clonidine (Pajai et al., 2023). Furthermore, the patient can be referred for individualized or group psychotherapy. COPD triggers include smoke, dust, and carbon monoxide.

Conclusion

The patient is at risk of CAD, Arrhythmia, Cardiomyopathy, and Aortic stenosis, which can lead to heart failure. Lifestyle interventions and appropriate medications can help prevent HF. Health promotion for Mrs. J should include lifestyle modification in diet, physical activity, and smoking to promote weight loss, prevent COPD exacerbations, and improve cardiovascular and respiratory functioning. NRT, non-nicotine treatment, and counseling can help Mrs. J in smoking cessation.

References

Ambrosino, N., & Bertella, E. (2018). Lifestyle interventions in prevention and comprehensive management of COPD. Breathe (Sheffield, England), 14(3), 186–194. https://doi.org/10.1183/20734735.018618

Groenewegen, A., Rutten, F. H., Mosterd, A., & Hoes, A. W. (2020). Epidemiology of heart failure. European journal of heart failure, 22(8), 1342-1356. https://doi.org/10.1002/ejhf.1858

Nici, L., Mammen, M. J., Charbek, E., Alexander, P. E., Au, D. H., Boyd, C. M., … & Aaron, S. D. (2020). Pharmacologic management of chronic obstructive pulmonary disease. An official American Thoracic Society clinical practice guideline. American Journal of respiratory and critical care medicine, 201(9), e56-e69. https://doi.org/10.1164/rccm.202003-0625ST

Oparil, S., Acelajado, M. C., Bakris, G. L., Berlowitz, D. R., Cífková, R., Dominiczak, A. F., Grassi, G., Jordan, J., Poulter, N. R., Rodgers, A., & Whelton, P. K. (2018). Hypertension. Nature reviews. Disease primers, 4, 18014. https://doi.org/10.1038/nrdp.2018.14

 Pajai, D. D., Paul, P., & Reche, A. (2023). Pharmacotherapy in Tobacco Cessation: A Narrative Review. Cureus, 15(2), e35086. https://doi.org/10.7759/cureus.35086

Rankin, A., Cadogan, C. A., Patterson, S. M., Kerse, N., Cardwell, C. R., Bradley, M. C., Ryan, C., & Hughes, C. (2018). Interventions to improve the appropriate use of polypharmacy for older people. The Cochrane database of systematic reviews, 9(9), CD008165. https://doi.org/10.1002/14651858.CD008165.pub4

 Zhang, H., Hu, D., Xu, Y., Wu, L., & Lou, L. (2022). Effect of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis of randomized controlled trials. Annals of Medicine, 54(1), 262–273. https://doi.org/10.1080/07853890.2021.1999494