Mrs. J. is a 63-year-old woman who has a history of hypertension, chronic heart failure, and sleep apnea.
Question: System Admin
Max Points: 20.0
Use the following Case Scenario, Subjective Data, and Objective Data to answer the Critical Thinking Questions.
Mrs. J. is a 63-year-old woman who has a history of hypertension, chronic heart failure, and sleep apnea. She has been smoking two packs of cigarettes a day for 40 years and has refused to quit. Three days ago, she had an onset of flu with fever, pharyngitis, and malaise. She has not taken her antihypertensive medications or her medications to control her heart failure for 4 days. Today, she has been admitted to the hospital ICU with acute decompensated heart failure.
1. Is very anxious and asks whether she is going to die.
2. Denies pain but says she feels like she cannot get enough air.
3. Says her heart feels like it is “running away.”
4. Reports that she is so exhausted she cannot eat or drink by herself.
1. Height 175 cm; Weight 95.5 kg
2. Vital signs: T 37.6 C, HR 118 and irregular, RR 34, BP 90/58
3. 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
4. Respiratory: Pulmonary crackles; decreased breath sounds right lower lobe; coughing frothy blood-tinged sputum; SpO2 82%
5. Gastrointestinal: BS present: hepatomegaly 4 cm below costal margin
Critical Thinking Questions
What nursing interventions are appropriate for Mrs. J. at the time of her admission? Drug therapy is started for Mrs. J. to control her symptoms. What is the rationale for the administration of each of the following medications?
1. IV furosemide (Lasix)
2. Enalapril (Vasotec)
3. Metoprolol (Lopressor)
4. IV morphine sulphate (Morphine)
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 rationale for each of the interventions you recommend.
WHAT IS THE NURSING INTERVENTION.
I will use Abraham Masclow ABC’s
First, I need to address respiratory issue by keeping her in upright position to helps in air exchange, higher concentration of oxygen using non-breaher face mask and ventilation.
She might be going through heart failure with signs and symptoms of tachycardia irregular, low Sp02, edema to lower extremeties, bilateral jugular vein distention, hungry for air.
Mrs. J. will have to be admitted to the hospital immediately, with vital signs monitoring and telemetry monitoring to assess heart rate and rhythm.
Monitor weight daily and fluid and electrolyte balance is very crucial.
Lab work should be order and done e.g. BMP, CBC, Liver profile, D-dimer is recommended.
RATIONALE FOR USING THESE MEDICATION
1. IV furosemide (Lasix): is a diuretic. Lasix can be used to treat fluid overload (hypervolaemia) thus an elevation of the extracellular fluid volume produces circulatory overload and subsequently, an abnormally amplified cardiac contractility, increased mean artery pressure (MAP), and an elevated capillary hydrostatic pressure. The latter, therefore, causes shifts of fluids to the interstitial space, and hence, producing edema. Lasix is used to reduce workload on the heart by giving through intravenous to patient with ADHF classically results in a rapid diuretic effects leading to a decrease in ventricular filling pressures and improvement in symptoms. (“▷ Hypervolemia – Definition, Symptoms, Diagnosis, Treatment – (2018 – Updated),” n.d.)
2. Enalapril (Vasotec): Enalapril is an ACE Inhibitor. the reason for giving this medication to Miss J, would be to dilate the blood vessels, which would then improve blood flow and oxygenation to heart. Cordonnier, Zaoui, & Halimi, 2001, stated ACE inhibitors have been reported to improve kidney, heart, and to a lesser extent, eye and peripheral nerve function of patients with diabetes mellitus.
3. Metoprolol (Lopressor): Metoprolol is a beta blocker. Reduce heart rate and inhibition of isoproterenol-induced tachycardia. In case of Mrs. J condition. (“Metoprolol – FDA prescribing information, side effects and uses,” n.d.)
4. IV morphine sulphate (Morphine): opioid (narcotic) analgesics commonly use to treat pain. It is use to improve vasodilation, bring respiratory relaxation and use for a calming effect on Mrs. J. condition.
Diabetes: People with insulin resistance are at greater risk of developing type 2 diabetes and cardiovascular disease. They also are more likely to have a history of being obese and physically inactive and to have other cardiovascular risk factors such as dyslipidemia (too much) LDL (“bad”) cholesterol, not enough HDL (“good”) cholesterol, or high triglycerides, hypertension, and other factors that can increase cardiovascular risk. Untreated diabetes can lead to many serious medical problems, including heart disease and stroke. That’s why it’s important to be aware of the symptoms as well as the risk factors and to take appropriate steps to prevent and treat insulin resistance and diabetes.
Atherosclerosis – Narrowing and hardening of the blood vessels of the body, which can be caused by diabetes, high cholesterol, and smoking. The sclerosis can cause hypertension and poor blood flow to heart increasing the work of heart, which may lead to heart failure. Nursing education on diet like intake of low fat, sodium containing food. Exercise, explaining patient about benefit of controlling weight gain, stress management techniques, Quit smoking helps to control the worsening of disease condition.
Sleep apnea: Is a condition in which the person may experience pauses in breathing five to 30 times per hour or more during sleep. Obstructive sleep apnea (OSA) is associated with obesity, which is also a major risk factor for heart disease and stroke. Besides obesity contributing to sleep apnea, sleep deprivation caused by sleep apnea can, in an ongoing unhealthy cycle, lead to further obesity, Dr. Arnett explained. In OSA the upper airway closes off because the muscles that hold it open lose tone – the more weight, the more loss of tone and the more severe the sleep apnea. Each time the airway closes, there is a pause in breathing. It can lead to cardiovascular problems and can be a life-threatening situation.
It is a condition in which a waxy substance called plaque builds up inside the coronary arteries., which reduces the blood flow to heart. Educating patients on exercising, Dietary modification like reducing salt in diet, stress management techniques and weight loss can help in prevention of CAD.
ROLE OF NURSES AND RATIONALE.
My role as a nurse is to discuss with the patient the reasons to keep the list of medications they are taking currently either prescription or over – the – counter. By writing down the name of the medicine, dosage, frequency and the reason they are taking the medicine, by doing this it will eliminate problems caused by multiple drug interactions in older patients.
Maintaining effective communication is another way to prevent problems caused by multiple drug interactions in older patient. Advise patients to use only one pharmacy to obtain medications; this adds another level of review to help ensure appropriate dosage and reduce the risk of adverse drugs effects and interactions and teach them side effects of the medications.
Instruct patients to take medications as instructed and to inform their providers if health changes occur, especially after starting a new medication. Proper warning should be given to older patients not to stop taking their medicine without informing their provider.
Organizing their medication is important too, I will teach older, or impaired cognitive patients to store medications in a secure, dry location away from direct sunlight or to refrigerate them if needed. As appropriate, recommend use of 7-day pill boxes, daily pill boxes, or blister packs to help patients adhere to their regimen. Color-coded charts can help elderly patients set up pill boxes. Or I will schedule a phone call reminder or connect their dosing schedule with their ADL’s care for example after brushing their teeth to remind them to take their medicine.
American Heart Association [AHA]. (November 29,2017). Medications used to treat heart failure. Retrieved from: http://www.heart.org/HEARTORG/Conditions/HeartFailure/TreatmentOptionsForHeartFailure/Medications-Used-to-Treat-Heart-Failure
Preventing polypharmacy in older adults – American Nurse Today. (2017, September 19). Retrieved from https://www.americannursetoday.com/preventing-polypharmacy-in-older-adults/
Cordonnier, D. J., Zaoui, P., & Halimi, S. (2001). Role of ACE Inhibitors in Patients with Diabetes Mellitus. Drugs, 61(13), 1883-1892. doi:10.2165/00003495-200161130-00001
Metoprolol – FDA prescribing information, side effects and uses. (n.d.). Retrieved from https://www.drugs.com/pro/metoprolol.html
Hypervolemia – Definition, Symptoms, Diagnosis, Treatment – (2018 – Updated). (n.d.). Retrieved from https://www.ihealthblogger.com/hypervolemia-definition-symptoms-diagnosis-and-treatment/
Maslow’s Hierarchy of Needs. (2007, February 5). Retrieved from https://simplypsychology.org/maslow.html