Mrs. J is a 63-year-old married woman who has a history of hypertension, chronic heart failure, and chronic obstructive pulmonary disease (COPD)
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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EXPERT ANSWER AND EXPLANATION
Patient Assessment and Treatment
One’s physiological wellbeing depends on a wide range of factors including lifestyle behaviors. The prolonged use of the psychotic substances, for example, can expose one to the risk of developing health problems, and the nature of the medical condition one develops depends on the substance they use. For instance, smoking tobacco exposes smokers to the risk of developing respiratory issues.
Equally, the type of food one eats and their levels of physical activity can have a certain level of impact on their physiological wellbeing. It is imperative to explore the case of patient with COPD, in terms of the effectiveness of the intervention she receives, and examine the contributors to the heart failure.
Mrs. J’s Clinical Manifestations
Based on the Mrs. J’s medical history and subjective data, she exhibits a number of clinical manifestations. One of these manifestations is the acute exacerbation of the chronic obstructive pulmonary disease (COPD). Another clinical manifestation present in the patient is acute decompensated heart failure. These two conditions explain the reason why she experiences difficulties breathing, and her heart rate is irregular. She has Congestive Heart Failure (CHF).
Mrs. J also shows sign of hypertension considering that her blood pressure level is 90/58, and this is more than the 120/80 average (Lin et al., 2016). Additionally, the patient has fever, and besides this fever, she cannot perform Activities of Daily Living (ADLs). She coughs blood-tinged sputum, and this indicates a possible respiratory problem.
Assessment of the Effectiveness of the Nursing Interventions
Mrs. J takes a number of medications to help promote her recovery, and while these medications are effective, some may not be necessary in her case. She takes IV furosemide, and this intervention is appropriate based on her case. This is because this medication would help relieve her heart failure problem by helping improve the heart’s blood-pumping capacity. Given the patient’s history with CHF and hypertension, the use of the Enalapril would help manage these two conditions (Wiysonge et al., 2017).
Still, the use of Metoprolol is effective in helping improve the performance of the heart and limit the effects of hypertension (Akbar & Alorainy, 2014). While administering IV morphine is important, the risk of addiction for this patient can be high if the nurse administers it for prolonged duration of time or in large amount.
Mrs. J has a history of experiencing shortness of breath, and for her, the inhalation of the short-acting bronchodilator can help aerate her lungs. The same applies with 2L/NC oxygen supply. By inhaling the corticosteroid, her COPD problem will reduce given that the medication limits the inflammation in the lungs.
Possible Cardiovascular Issues which can Cause Heart Failure
The heart failure can result from a number of cardiovascular-linked conditions. The atherosclerosis is one of these conditions, and it results when clogs form in the arteries. When these clogs occur, the heart’s capacity to pump reduces, and this can lead to the eventual failure of the heart. One can also attribute this failure to the hypertension given that this condition increases the workload of the heart.
The thickening of the left ventricle is a possible implication associated with increased heart workload. Thrombosis, in addition, to the arrhythmias can cause this failure (Ziaeian & Fonarow, 2016). Intervention may entail recommending to the patient physical activity and dietary change given that diet and exercise can affect one’s health. Patients with advanced cardiovascular conditions may have to undergo a surgical intervention to promote their cardiac health.
Nursing Interventions to Prevent Drug Reactions
The possibility of the patient experiencing drug reactions can be high in the case of the elderly, and certain interventions can help limit these adverse drug reactions. The correct documentation of the details related to the medication treatment, for instance, can help lessen cases of errors. By using this intervention, the nurse administers the right medication to the appropriate patient. Still, they can limit the interactions by prescribing to patients medications with limited side effects.
Patients may refuse medications with adverse side effects, and switch to using other drugs, and this may raise the possibility of the occurrence of the drug interaction. Another intervention is using the correct prescription drug labels for drugs, and this is vital in the sense that the patient understands the type of medications they use. Furthermore, it is important to educate the patient to adhere to the medication regimen given that some patients may not use the drugs correctly because of lack of understanding of the benefits of adherence.
Health Promotion and Restoration Plan
The health promotion for Mrs. J focuses on helping improve her physiological and physiological health. Part of this plan is an objective, which in this case entails empowering Mrs. J to know how she can manage her own health. Given the patient’s lifestyle behaviors, the education should focus on training her to cease smoking because if she continues with this behavior, her health may worsen.
The education will also have to focus on helping her understand the importance of eating healthy foods and engaging in regular physical activity. When educating the patient, it is important to recommend to them resources with cardiovascular topics so that they can understand the relationship between lifestyle behaviors and the cardiac conditions (Ziaeian & Fonarow, 2016). When working with the patient, it is important to involve nurses, nutritionists, physiotherapists and psychotherapists to help provide her with holistic care.
Methods of Patient Education
A nurse can adopt different approaches when educating the patient. The nurse, for example, may have a phone conversation with the patient to her gain insights into the process of managing her health. The nurse may, still, use posters with details which explain the type of foods the patient should eat. Part of the approach to education may entail recommending resources on heart health to the patient (Tuso, 2015).
Certain factors constitute the COPD triggers. Smoking of the tobacco is one of these triggers given that it interfere with the heart performance. Dusts can also contribute the trigger given that it irritates the lungs causing one to cough. Indoor pollution can additionally contribute to this irritation.
In overview, Mrs. J’s lifestyle decisions seems to cause her ill health, and if the patient continues with her behaviors, her cardiovascular problems including hypertension may cause her heart to fail. Although the nursing intervention in the patient’s context can result to her recovery, the intervening nurse has to take caution when prescribing medication to the patient. This is necessary to prevent adverse drug reactions which may cause harm to the patient. However, the intervention should also focus on limiting the COPD triggers by encouraging the patient to cease smoking.
Akbar, S., & Alorainy, M. S. (2014). The current status of beta blockers’ use in the management of hypertension. Saudi medical journal, 35(11), 1307–1317. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4362137/.
Lin, J. D., Chen, Y. L., Wu, C. Z., Hsieh, C. H., Pei, D., Liang, Y. J., & Chang, J. B. (2016). Identification of Normal Blood Pressure in Different Age Group. Medicine, 95(14), e3188. Doi: https://doi.org/10.1097/MD.0000000000003188.
Tuso P. (2015). Strategies to Increase Physical Activity. The Permanente journal, 19(4), 84–88. Doi: https://doi.org/10.7812/TPP/14-242.
Wiysonge, C. S., Bradley, H. A., Volmink, J., Mayosi, B. M., & Opie, L. H. (2017). Beta-blockers for hypertension. The Cochrane database of systematic reviews, 1(1). Doi: https://doi.org/10.1002/14651858.CD002003.pub5.
Ziaeian, B., & Fonarow, G. C. (2016). Epidemiology and aetiology of heart failure. Nature reviews. Cardiology, 13(6), 368–378. Doi: https://doi.org/10.1038/nrcardio.2016.25.
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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