Mrs. J. is a 63-year-old woman who has a history of hypertension, chronic heart
ID: 121980 • Letter: M
Question
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.
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 so exhausted she cannot eat or drink by herself.
Objective Data
Height 175 cm; Weight 95.5 kg
Vital signs: T 37.6 C, 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 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?
IV furosemide (Lasix)
Enalapril (Vasotec)
Metoprolol (Lopressor)
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.
Explanation / Answer
NURSING INTERVENTIONS :
Initially, respiratory problems need to be controlled. For that she has to be given oxygen and nonrebreather mask. Telometry monitoring is to be followed for 24-48 hours after administration. A combination of vasodilators and inotropic support is to be given to her. Monitoring of vitals such as weight, fluid balance, electrolyte levels, serum creatinine levels, signs and symptoms of congestion is essential.
Rationale for administration of the following drugs :
IV furosemide : It is used to reduce pulmonary edema
Loop diuretic : decreases absorption of water in kidneys, increases urine production, decreases intravascular volume.
Enalapril : It is an ACE inhibitor which decreases afterload and raises cardiac output.
Metoprolol : It is a cardioselectibe beta blocker which decreases BP and heart rate.
Controls hypertension
Decreases cardiac workload
IV morphine sulphate : Relieves pulmonary congestion by venodilation
Lowers myocardial oxygen demand and reduces anxiety.
Four cardiovascular conditions that may lead to heart failure are :
Coronary artery disease : When arteries of heart are deposited with cholesterol, less blood reach the heart muscles, this results in atherosclerosis. It causes chest pain and if there is total obstruction of blood flow, it leads to heart failure.
Interventions : Having heart healthy diet that is low in saturated fat, trans fat, cholesterol, sodium.
High blood pressure ; When there is high pressure in the blood vessels, heart has to pump harder and it makes chambers larger and weaker.
Interventions : Blood pressure increases with each puff of nicotine from tobacco smoke. Therefore, people has to quit smoking.
Sleep apnea : It is a life threatening sleep disorder which causes high blood pressure, heart failure.
Interventions : Adequate rest is needed which includes sleep at night or a nap after lunch.
Obesity : It causes heart to work much harder and also results in cardiomyopathy.
Interventions : Weight has to be maintained. This can be done by following appropriate diet, avoiding alcohol, limiting caffeine.
Nursing interventions that can help prevent problems caused by multiple drug interactions in older patients are :
a. An accurate lists of all medications, along with dosages, dosing frequency is to be kept.
Ratinale : This would avoid confusions over previously discontinued drugs or incorrect dosages.
b. Patients should know the adverse affects of medicines ,including when to call the clinic.
Rationale : This would avoid confusions about look-alike or sound-alike drug names.
c. A complete list of medical providers and their contact information has to be kept.
Rationale : This would help the patient to contact the medical providers when needed.
d. Patients must be aware of not to stop taking a drug without consulting healthcare provider and they must be asked about their adherence to the medication regimen.
Rationale : A strong relationship has to be maintained between a nurse and a patient to find out how patient is intaking medicines.
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