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Case Study: Mr. J. NRS 410

Case Study: Mr. J. NRS 410

Case Study: Mr. J. NRS 410

This paper is an analysis of Mrs. J’s case study. Mrs. J is a 63-year-old woman with history of chronic heart failure, hypertension, and chronic obstructive pulmonary disease. Mrs. J is an active smoker despite being on oxygen. She was admitted due to sudden onset of flu-like symptoms, productive cough, fever, nausea and malaise. She has found it difficult to engage in activities of the daily living and needs assistance. Therefore, aspects of the case study such as clinical manifestations, appropriateness of the interventions, conditions leading to heart failure, and health promotion interventions are explored in this paper.

Mr. M is an elderly male who presents with memory problems for the past 2months with reports of trouble in recalling names of people and even objects such as things he read or his room number. This is associated with aggressive behaviors and has rendered him dependent on others to help with activities of daily living. The urinalysis done on the patient showed that his urine was cloudy in appearance with a considerable amount of leukocytes detected. The patient’s forgetfulness may be diagnosed as dementia which accounts for most of these cases, especially in old patients (Arvanitakis et al., 2019). Due to the forgetfulness in dementia, the patient may be frustrated at his inability to remember information thus the agitation and aggression that is reported by Mr. M. The agitation and aggression may also relate to deterioration in personality that usually results from dementia (Gale et al., 2018).

Clinical Manifestations

Mrs. J has several clinical manifestations that brought her to the hospital. They include productive cough, nausea, fever, and malaise. Mrs. J has history of obstructive pulmonary disease, hypertension and chronic heart failure. She has difficulties in engaging in activities of the daily living and requires assistance in walking short distances. She also has difficulties in breathing and appears anxious.

Whether the Interventions were Appropriate

The nursing interventions utilized in managing the patient at the point of admission were appropriate. The healthcare provider undertook subjective and objective assessments to determine the cause of Mrs. J’s problems. Subjective assessment relied on the information the client gave concerning her problems while the healthcare provider obtained objective data. The nurse needed to perform additional interventions such as minimizing physical activity by the patient, nursing her in semi-fowlers position, ensuring airway patency, and administering oxygen to ensure optimum tissue perfusion (Barber & Robertson, 2020).

Mrs. J has been started on Lasix, an antidiuretic that works by lowering the renal re-absorption of chloride and sodium for increased fluid loss. She has also been prescribed vasotect, which produces its effect by blocking the action of angiotensin converting enzyme. The client has also been started on metoprolol that works by blocking the beta-receptors to reduce cardiac contractility and overstimulation. Mrs. J has also been initiated on morphine to minimize pain through its action on mu and kappa receptors. Flovent has been administered to reduce the release of inflammatory biomarkers while oxygen has been used to ensure adequate tissue perfusion (Barber & Robertson, 2020).

Conditions that Can Lead to Heart Failure

The first condition that can cause heart failure is a previous history of heart failure. Patients with history of heart failure are increasingly at a risk of developing it in the future. The second condition is hypertension. Hypertension initiates cascades of events that cause damage to heart muscles and physiological functioning, hence, heart failure. Cardiomyopathy is the other condition that causes heart failure. Diseases that affect the heart muscles may lead to poor heart contractility and inadequate filling, hence, heart failure. The last condition is myocardial infarction. Myocardial infarction may lead to loss of tissue functioning, hence heart failure. Myocardial infarction is associated with risk factors such as atherosclerosis and coronary artery disease. The nursing interventions that can be adopted include educating about the need for reducing dietary intake of sodium, alcohol abuse, smoking, and engaging in regular physical activity (Ashraf & Rosenthal, 2020). There is also the need for the regular monitoring of blood pressure and medication adherence.

Nursing Interventions for Multiple Drug Interactions

One of the nursing interventions to minimize the effects of multiple drug interactions is avoiding contraindicated medications in patient treatments. Nurses should perform comprehensive history taking to identify the relevant drug allergies that patients have. The second intervention is avoiding drugs with similar therapeutic indexes. Drugs with closely related mechanism of actions or interactions may increase the risk of adverse events. The third intervention is health education on the importance of medication adherence and need for reporting any adverse effects of medication if experienced. The last intervention is educating the patients about the risks of self-medication and over-the-counter medications (Ryu et al., 2018). Self-medication and use of over the counter medications increase the risk of multiple drug interactions and adverse events.

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Health Promotion and Restoration Teaching Plan

Mrs. J should be educated about the importance of lifestyle and behavioral modifications to promote her health. She needs health education on avoiding cigarette smoking, as it precipitates cardiovascular and respiratory complications. The patient also requires health education on dietary modification to minimize renal and cardiovascular complications of her health problems. She also needs education on the importance of moderate physical activity to reduce her risk of comorbid conditions (Toback & Clark, 2017).

Method for Providing Education and COPD Triggers

Patient-centered education should be utilized in addressing the needs of Mrs. J. Patient-centered education individualizes the health needs of the patients. It also strengthens the utilization of interventions that take into consideration patient needs, values and preferences. Patient-centered education is associated with benefits that include patient empowerment, satisfaction, and improved experiences with care (Toback & Clark, 2017). The most notable triggers of COPD include cigarette smoking, stress, exposure to environmental allergens, and persistent or frequent upper respiratory tract infections (Zhao et al., 2020).

Conclusion

In summary, Mrs. J has complex comorbid conditions that have affected health quality of life significantly. The interventions that were used in treating the patient at the time of admission were appropriate. Mrs. J requires health education on ways of minimizing the risk of adverse events related to her health. Therefore, patient-centered health education should be utilized.

 

 

References

Ashraf, H., & Rosenthal, J. L. (2020). Right Heart Failure: Causes and Clinical Epidemiology. Cardiology Clinics, 38(2), 175–183. https://doi.org/10.1016/j.ccl.2020.01.008

Barber, P., & Robertson, D. (2020). Essentials of Pharmacology for Nurses, 4e. McGraw-Hill Education (UK).

Ryu, J. Y., Kim, H. U., & Lee, S. Y. (2018). Deep learning improves prediction of drug–drug and drug–food interactions. Proceedings of the National Academy of Sciences, 115(18), E4304–E4311. https://doi.org/10.1073/pnas.1803294115

Toback, M., & Clark, N. (2017). Strategies to improve self-management in heart failure patients. Contemporary Nurse, 53(1), 105–120. https://doi.org/10.1080/10376178.2017.1290537

Zhao, Q., Meng, M., Kumar, R., Wu, Y., Huang, J., Lian, N., Deng, Y., & Lin, S. (2020). The impact of COPD and smoking history on the severity of COVID-19: A systemic review and meta-analysis. Journal of Medical Virology, 92(10), 1915–1921. https://doi.org/10.1002/jmv.25889

The case scenario concerns Mrs. J., a 63-year-old female with hypertension, chronic heart failure, and COPD. She usually uses 2L of oxygen at home during activity but has persisted in smoking cigarettes 2PPD for the last 40 years. The purpose of this paper is to analyze the patient’s condition.

Clinical Manifestations of Patient

The patient’s subjective findings include fever, nausea, productive cough, malaise, inability to perform ADLs, anxiety, palpitations, dyspnea, and fatigue. Objective findings include obesity (BMI-31.2), mild fever, low blood pressure, tachypnea, and tachycardia with irregular heart rhythm. In addition, the patient has jugular vein distention, distant heart sounds, S gallop, faint PMI at sixth ICS, and atrial fibrillation. Respiratory findings include frothy blood-tinged sputum, reduced breath sounds, pulmonary crackles, and SpO2 82%. GI findings include hepatomegaly.

Cardiovascular Conditions in Which Mrs. J Is At Risk

            The patient’s obesity increases the risk of Coronary Artery Disease (CAD), which causes heart failure (HF) when cholesterol and fat deposits accumulate along the arteries obstructing myocardial blood flow. HF can be prevented in patients with CAD by administering lipid-lowering agents and lifestyle modification to lower cholesterol levels. Atrial fibrillation (AF) causes increased resting heart rate and an exaggerated heart rate response to exercise, causing a reduced diastolic filling time and eventually reduced cardiac output that causes HF (Schwinger, 2021). Lifestyle modification and maintaining optimal blood pressure can prevent the progression of AF to HF. Stroke induces cardiac damage like ventricular wall motion defects that increase the risk of HF. Cardiac damage can be prevented by controlling BP through antihypertensives and lifestyle modification. Myocardial infarction (MI) causes myocardial damage, stunning, and necrosis that impairs the heart’s contractility resulting in heart failure (Schwinger, 2021). HF in patients with MI can be mitigated by administering ACE inhibitors to decrease cardiac output and avoiding high-intense activities that increase oxygen demand.

Evaluation of Nursing Interventions at Admissions

The interventions during the admission of Mrs. J. included the administration of IV Lasix, Vasotec, Lopressor, IV Morphine, inhaled ProAir HFA, Flovent HFA, and oxygen via nasal cannula. The appropriate interventions included IV Lasix, ProAir HFA, and oxygen therapy. Lasix was appropriate because it alleviates symptoms of pulmonary congestion like cough, frothy sputum, palpitations, pulmonary crackles, and jugular vein distention (Oparil et al., 2019). ProAir HFA was also appropriate because it relieves COPD exacerbations, which would increase perfusion and alleviate dyspnea.

Oxygen therapy was ideal for improving the oxygen saturation levels to above 95%. Vasotec and Lopressor were inappropriate because they lower BP, which would worsen the patient’s low BP (Oparil et al., 2019). Furthermore, Morphine was unsuitable because it causes respiratory depression, which would worsen the patient’s breathing difficulties. Flovent HFA was inappropriate during admission since it is indicated for long-term COP maintenance to prevent exacerbations.

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

Lasix is a loop diuretic that facilitates water and sodium excretion by interfering with the chloride-binding cotransport system. This hinders the reabsorption of sodium and chloride in the ascending loop of Henle, and distal renal tubule, and lower preload in CHF (Oparil et al., 2019). Vasotec hinders the conversion of angiotensin I to angiotensin II, causing elevated plasma renin levels and reduced aldosterone secretion. This lowers blood pressure and improves HF symptoms. Lopressor is a selective beta-1-adrenergic blocker that competitively blocks beta1-receptors at low doses and blocks beta2-receptors at higher doses (Oparil et al., 2019). It is used in HF because it lowers cardiac output through negative inotropic and chronotropic effects.

Morphine is an opioid analgesic that blocks the ascending pain pathways altering pain response. It produces analgesia, sedation, and respiratory depression. ProAir HFA is a Beta 2 Agonist that relaxes bronchial smooth muscles and is indicated to alleviate acute bronchospasms (Nici et al., 2020). Flovent HFA is an inhalant corticosteroid with an anti-inflammatory effect on eosinophils, neutrophils, macrophages, lymphocytes, mast cells, and mediators

Older adults are significantly affected by multiple drug interactions due to polypharmacy since they have comorbid health conditions. Nursing interventions to prevent drug interactions include medication reconciliation, which entails identifying and documenting all drugs a patient takes and comparing the list with the physician’s orders (Kurczewska-Michalak et al., 2021). The nurse can also note a patient’s coexisting conditions and medications and assess the possibility of resulting in adverse drug effects. In addition, the nurse should educate the patient on how to take the medications, including the medications, generic and brand names, indications, and potential side effects, and explain how long the medication will likely be taken (Kurczewska-Michalak et al., 2021). Furthermore, the nurse can regularly reevaluate the patient for the need to continue prescribed medications and inform the physician to stop those that are no longer necessary or medications with higher possible risks than benefits.

Health Promotion and Restoration Teaching Plan

The health promotion and restoration education plan for Mrs. J will focus on lifestyle modification to control BP, maintain a healthy weight, delay COPD progression, and prevent COPD exacerbations. Regarding COPD, Mrs. J will be educated on the benefits of smoking cessation and avoiding environmental pollutants to delay disease progression and prevent exacerbations. Physical exercises will further be emphasized to improve lung function (Burge et al., 2020). Health education to control BP will include engaging in moderate aerobic exercises at least 40 minutes daily to improve cardiovascular functioning, lower BP, and promote weight loss. In addition, she will be educated on a healthy diet and reducing caloric intake for weight loss and to lower BP.

A multidisciplinary approach will be needed for rehabilitation and will include pulmonary rehabilitation, nutritional counseling, education, and self-management. Pulmonary rehabilitation is a multidisciplinary intervention for COPD established to improve exercise tolerance, dyspnea, and health-related QoL (Young et al., 2021). Nutritional counseling by a dietitian is vital for COPD patients who are underweight or overweight. Education and self-management are vital aspects of the multidisciplinary approach. They involve educational sessions educating patients on the nature and course of COPD and how to live with the impact of the disease.

COPD Triggers and Options for Smoking Cessation

Mrs. J can be provided individual psychotherapy to help with smoking cessation and group-based behavioral counseling. Pharmacotherapy intervention for smoking cessation includes Nicotine replacement therapy (NRT). The patient can be administered nicotine transdermal patches, gum, lozenges, inhalers, or nasal spray (Krist et al., 2021). COPD triggers that can cause exacerbations and readmission include tobacco smoke, exposure to dust, and environmental pollutants like carbon monoxide, which cause bronchoconstriction.

Conclusion

Mrs. J has a risk of cardiovascular conditions like Coronary Artery Disease, Atrial fibrillation, Stroke, and Myocardial infarction. IV Lasix, ProAir HFA, and oxygen therapy were appropriate since they improve symptoms of pulmonary congestion and COPD exacerbations. However, Vasotec and Lopressor lower BP, which is unsuitable for the patient due to the low BP. Morphine would have caused respiratory depression, while Flovent HFA is indicated for long-term COPD maintenance and thus was inappropriate. The health education plan for Mrs. J focuses on lifestyle modification to control BP, promote weight loss, delay COPD progression, and prevent COPD exacerbations.

 

 

References

Burge, A. T., Cox, N. S., Abramson, M. J., & Holland, A. E. (2020). Interventions for promoting physical activity in people with chronic obstructive pulmonary disease (COPD). The Cochrane database of systematic reviews4(4), CD012626. https://doi.org/10.1002/14651858.CD012626.pub2

Krist, A. H., Davidson, K. W., Mangione, C. M., Barry, M. J., Cabana, M., Caughey, A. B., … & US Preventive Services Task Force. (2021). Interventions for tobacco smoking cessation in adults, including pregnant persons: US Preventive Services Task Force recommendation statement. Jama325(3), 265-279. doi:10.1001/jama.2020.25019

Kurczewska-Michalak, M., Lewek, P., Jankowska-Polańska, B., Giardini, A., Granata, N., Maffoni, M., Costa, E., Midão, L., & Kardas, P. (2021). Polypharmacy Management in the Older Adults: A Scoping Review of Available Interventions. Frontiers in pharmacology12, 734045. https://doi.org/10.3389/fphar.2021.734045

Nici, L., Mammen, M. J., Charbek, E., Alexander, P. E., Au, D. H., Boyd, C. M., … & Aaron, S. D. (2020). Pharmacologic management of chronic obstructive pulmonary disease. An official American Thoracic Society clinical practice guideline. American journal of respiratory and critical care medicine201(9), e56-e69. DOI: 10.1164/rccm.202003-0625ST

Oparil, S., Acelajado, M. C., Bakris, G. L., Berlowitz, D. R., Cífková, R., Dominiczak, A. F., Grassi, G., Jordan, J., Poulter, N. R., Rodgers, A., & Whelton, P. K. (2019). Hypertension. Nature reviews. Disease primers, p. 4, 18014. https://doi.org/10.1038/nrdp.2018.14

Schwinger, R. H. G. (2021). Pathophysiology of heart failure. Cardiovascular diagnosis and therapy11(1), 263–276. https://doi.org/10.21037/cdt-20-302

Young, M., Villgran, V., Ledgerwood, C., Schmetzer, A., & Cheema, T. (2021). Developing a Multidisciplinary Approach to the COPD Care Pathway. Critical care nursing quarterly44(1), 121–127. https://doi.org/10.1097/CNQ.0000000000000345