Case Study: Mrs. J

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

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
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.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

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Solution

Case Study: Mrs. J.  

            The case study provided for this discussion presents a 63-year-old married female patient with a history of chronic obstructive pulmonary disease (COPD), chronic heart failure, and hypertension. The patient has been using 2L of oxygen/nasal cannula for respiratory aid during activity and still smokes about 2 packs of cigarettes every day for the past 40 years. However, her present flu-like symptoms such as malaise, nausea, productive cough, and fever started about 3 days ago. During this time, the patient reports defaulting from her antihypertensives. She reports difficulties in performing routine daily activities and even requires assistance to move around the house. Her current admission to the hospital ICU is a result of acute exacerbation of COPD and acute decompensated heart failure. This discussion evaluates the case of this patient from clinical manifestations, nursing interventions, and care plans to appropriate preventive measures.

Clinical Manifestations of Mrs. J.

Mrs. J reports that she started having flu-like symptoms such as malaise, nausea, productive cough, and fever about 3 days ago. She also needs assistance to move around the house, with difficulties in carrying out routine daily activities. The subjective portion of information reveals symptoms such as anxiety, lack of air, fatigue, shortness of breath, palpitations. Upon conducting a physical examination, it is noted that the patient is obese with increased heart rate, irregular heartbeats, bradycardia, presence of S3 sound with diminished S1 and S2, and atrial fibrillations. The patient also displays the presence of respiratory crackles, productive cough, bloody sputum, diminished right lower lobe breathing sound, and hepatomegaly.

 

Evaluation of Nursing Interventions at Admissions

The patient was admitted to the ICU with an acute exacerbation of COPD and acute decompensated heart failure. The recommended nursing interventions are thus aimed at improving the patient’s heart pump function and maintaining normal blood pressure in addition to relieving respiratory symptoms such as shortness of breath (Doenges et al., 2019). It was necessary to administer furosemide given that the patient was admitted as a result of acute decompensated heart failure which is associated with leg or foot swelling that is managed by diuretics. Enalapril was administered to help manage and prevent atrial fibrillation, which is demonstrated by the patient’s irregular and elevated heart rate of 118.

Metoprolol is effective in maintaining sinus rhythm and preventing atrial fibrillation but was not necessary at the point of admission given the patient’s low blood pressure (Doenges et al., 2019). Morphine was also not necessary given that the patient was not in any kind of pain.Inhaled short-acting bronchodilator (ProAir HFA) on the other hand was necessary for quick relief of the patient’s shortness of breath and prevent COPD complications. Lastly Inhaled corticosteroid (Flovent HFA) was not appropriate, given that this drug can only be considered in long-term therapy for patients with asthma, especially when a short-acting bronchodilator has already been used.

Cardiovascular Conditions Leading to Heart Failure and Interventions

Conditions such as hypertension, myocardial infarction, coronary artery disease, and abnormal heart valves. Hypertension is the main risk factor for heart failure as a result of overworking the heart to promote normal blood circulation. In such a condition, the recommended nursing intervention is to regularly monitor the patient’s blood pressure and ensure great compliance with antihypertensives. Coronary artery disease is associated with cholesterol and fatty deposits in the heart arteries (Inciardi et al., 2020). Monitoring the patient’s cholesterol level and lipid profile in addition to the use of dietary control is necessary to prevent the development of heart failure. For patients who have had a history of heart attack the nursing care plan will involve monitoring the patient’s vitals regularly and administration of antianginals to prevent heart attack (Mahmud et al., 2020). Lastly, abnormal heart valves can also lead to overworking of the heart which can eventually lead to heart failure. This can be prevented by the use of blood thinners and lifestyle modifications.

Nursing Interventions for Older Patients to Prevent Problems Caused by Multiple Drug Interactions

            Given that most elderly patients present with comorbidities, there isa high possibility of polypharmacy. To prevent problems associated with multiple drug interactions, it is necessary to eliminate duplicate medication during care transition to avoid toxic doses which promote adverse drug reaction (Unlu et al., 2020). Assessment of the treatment plan is crucial to prevent drug-drug interaction and avoid the associated adverse effects. Nurses should conduct medical reconciliation to avoid instances of prescription errors (Unlu et al., 2020). Lastly drug dosage review should be conducted to ensure that administered drugs are safe, with reduced incidences of adverse events.

Health Promotion and Restoration Teaching Plan

The patient must be educated on the pathophysiology of his health condition and the importance of taking the prescribed medication (Inciardi et al., 2020). She should also adopt a healthy diet low on sodium, fats, and calories, and frequent physical exercise to promote her health (Mahmud et al., 2020). The patient should also be advised to stop smoking through the adoption of appropriate smoking cessation programs, to prevent the effects of tobacco smoke in worsening COPD symptoms. Consequently, she needs to frequently monitor her vitals to evaluate the treatment outcome. It is also necessary for the patient to sign up for cardiac rehabilitation which is crucial in improving the quality of life and even prolonging the patient’s life expectancy (Mahmud et al., 2020). Additional resources which will help the patient identify life modification strategies to promote health and independent living include ‘American Heart Association’, ‘Centers for Disease Control and Prevention’ and ‘National Heart, Lung, and Blood Institute’ among others.

Method for Providing Education to Prevent Hospital Readmissions

            To promote the patient’s recovery and prevent possibilities of readmission, it is necessary to advise the patients on the importance of complying with the medications prescribed at the indicated dose, frequency, and duration (Unlu et al., 2020). The patient must also be educated about the side effects to avoid unexpected symptoms which would otherwise make the patient stop using the drug.

COPD Triggers and Options for Smoking Cessation

Cigarette smoking is the leading cause of COPD, whereas tobacco smoke is also associated with increased increase exacerbation frequency. To help the patient stop smoking, and promote their quality of life it is necessary to consider referral to a smoking cessation counselor (Inciardi et al., 2020). The counselor will be able to evaluate the patients extend of addiction and develop the most effective cessation program to help the patient quit smoking.

Conclusion

The provided case study illustrates a patient with cardiorespiratory problems, which can lead to heart failure. The patient however received adequate care in the ICU, upon admission. It is however necessary to educate the patient on appropriate life modifications such as exercise and a healthy diet to promote well-being and prevent complications associated with these disorders.

 

References

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span. FA Davis.

Inciardi, R. M., Lupi, L., Zaccone, G., Italia, L., Raffo, M., Tomasoni, D., … & Metra, M. (2020). Cardiac involvement in a patient with coronavirus disease 2019 (COVID-19). JAMA cardiology5(7), 819-824. https://doi.org/10.1001/jamacardio.2020.1096.

Mahmud, E., Dauerman, H. L., Welt, F. G., Messenger, J. C., Rao, S. V., Grines, C., … & Henry, T. D. (2020). Management of acute myocardial infarction during the COVID-19 pandemic: a position statement from the Society for Cardiovascular Angiography and Interventions (SCAI), the American College of Cardiology (ACC), and the American College of Emergency Physicians (ACEP). Journal of the American College of Cardiology76(11), 1375-1384. https://doi.org/10.1016/j.jacc.2020.04.039.

Unlu, O., Levitan, E. B., Reshetnyak, E., Kneifati-Hayek, J., Diaz, I., Archambault, A., … & Goyal, P. (2020). Polypharmacy in older adults hospitalized for heart failure. Circulation: Heart Failure13(11), e006977. https://doi.org/10.1161/CIRCHEARTFAILURE.120.006977

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