Use the following Case Scenario, Subjective Data, and Objective Data to answer t

Question

Use the following Case Scenario, Subjective Data, and Objective Data to answer the Critical Thinking Questions.

Case Scenario

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 at the time of admission;

1)Connecting the client to a continuous monitoring system to understand her vital parameters and getting ready with all emergency cart and equipments like Defibrillator and ventilator at bedside to tackle any Medical Emergency.

2) Oxygenation via mask and Fowler's position can be more helpful to deliver adequate oxygen, to decrease load on heart and activate the respiratory system.

3) Emergency drugs as advised by the Doctor as her heart rate was irregular need of anti arrhythmics and inotropic support to boost the blood pressure as she presented with lower BP. Some sedatives to calm her down which can help in relaxation of muscles.

4) Urinary catheterization to monitor the output as she will require diuretics to drain out excess fluid and prevent further fluid overload.

5) Parenteral Nutrition in the form Intravenous or Rules tube feeding as there is nutritional deprivation

6) Strict monitoring of Intake Output to understand the reversal of heart failure or any further deterioration.

7) To comfort the client emotionally is one of the most important factor

8) Collecting Blood samples for necessary investigations, taking 12 lead ECG and securing Intravenous line

9) Correct documentation of each event is necessary .

Rationale for administration of following medications:

1) IV FUROSEMIDE(LASIX)- It is a drug belongs to loop diuretic category. It inhibits the reabsorption of sodium and chloride ions at the proximal, distal loops as well as loop of Henle by interfering with chloride binding vittan sport system. Thus , it reduces the water build up in the body.

2)ENALAPRIL(VASOTEC)- It comes under the class of Angiotensin converting enzyme inhibitors(ACE). ACE is an enzyme in the body which produces Angiotensin II which leads to narrowing of arteries resulting in increased blood pressure. ENALAPRIL acts on preventing the formation Angiotensin II, thus helps in controlling the blood pressure.

3) METOPROLOL (LOPTESSOR) - It is in a group of drugs called Beta Blockers. It affect the heart and blood circulation through arteries and veins. It is a beta1 selective(Cardioselective) adrenergic receptor blocker. Thus it acts on the beta 2 adrenergic receptors chiefly located inbronchial and vascular areas. Hence, it reduces and stabilizes the irregular heart rate and variations in blood pressure and pulmonary functions.

4) IV MORPHINE SULPHATE (MORPHINE)- It is an opioid pain medication. It is also known as narcotic drugs. Morphine appears to mimic endorphins which are naturally available sources in the human body for analgesia that is controlling pain. IV administration can help the client for relaxation and better absorption of oxygen towards heart and pulmonary system.

Four cardiac conditions that may lead to congestive heart failure are coronary artery disease, hypertension, myocarditis, congenital heart defects.

Possible medical /nursing interventions for the above mentioned four conditions are;

1)Coronary Artery Disease -

- To keep nitroglycerine for immediate use

- To monitor vital parameters like heart rate, rhythm, respiratory counts, oxygen saturation, ECG findings on a continuous monitoring system.

- To monitor intake output and if possible weight check on daily basis

- To grade pain as per the severity

- To maintain sufficient nutrition by adequate food and water intake

- To cope with stress and control of emotions

-To perform some physical activity which is to be monitored carefully for pain

2) Hypertension -

- To monitor vital parameters

- To take regular anti hypertensive drugs

-To reduce the intake of sodium and avoid foods high in salt content

3) Myocarditis -

- Monitor ECG,Heart sounds and vital signs

- Antibiotic coverage as per doctors order

- Semi Fowler's position

- Oxygenation if needed via mask

- Administration of pain medications

- Nutritious and protein rich diet easy to digest.

4) Congenital heart defect-

- Monitor ECG

- Monitor vital parameters

- Oxygenation

- Fowler's or semi Fowler's position

- Monitor intake output

- Watch for Cyanosis

-Prepare client for surgical interventions if advised

Nursing interventions on prevention of problems caused by multiple drugs in older adults.

1) Teaching about drugs, this will help the patient's and their family about the drugs and their usage. To ensure that the family is being taught to keep the list of drugs ready with their prescribed time schedule.

2) Lifestyle changes - This can help in removing or reducing the dosage of drugs. These changes includes modifying food habits, avoid intake of self prescribed drugs, keeping oneself active and engaged.

3) Non pharmacological interventions such as modified behaviours through counselling, art, music , pet instead of loading older patients with numerous drugs.

4) Careful monitoring on drugs usage from the medicine cupboard, having organised medication cupboard with a separate lock and key to avoid unnecessary usage of drugs . Certain conditions where the patient forgets to take the drugs or over use the drugs.

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