coursework-banner

Case Study: Mrs. J. NRS 410V

NRS 410V Case Study: Mrs. J.

Case Study: Mrs. J. 

            The case study provided for this discussion presents a 63-year-old married female patient with a history of chronic obstructive pulmonary disease (COPD), chronic heart failure, and hypertension. The patient has been using 2L of oxygen/nasal cannula for respiratory aid during activity and still smokes about 2 packs of cigarettes every day for the past 40 years. However, her present flu-like symptoms such as malaise, nausea, productive cough, and fever started about 3 days ago. During this time, the patient reports defaulting from her antihypertensives. She reports difficulties in performing routine daily activities and even requires assistance to move around the house. Her current admission to the hospital ICU is a result of acute exacerbation of COPD and acute decompensated heart failure. This discussion evaluates the case of this patient from clinical manifestations, nursing interventions, and care plans to appropriate preventive measures.

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.

Clinical Manifestations of Mrs. J.

Mrs. J reports that she started having flu-like symptoms such as malaise, nausea, productive cough, and fever about 3 days ago. She also needs assistance to move around the house, with difficulties in carrying out routine daily activities. The subjective portion of information reveals symptoms such as anxiety, lack of air, fatigue, shortness of breath, palpitations. Upon conducting a physical examination, it is noted that the patient is obese with increased heart rate, irregular heartbeats, bradycardia, presence of S3 sound with diminished S1 and S2, and atrial fibrillations. The patient also displays the presence of respiratory crackles, productive cough, bloody sputum, diminished right lower lobe breathing sound, and hepatomegaly.

Evaluation of Nursing Interventions at Admissions

The patient was admitted to the ICU with an acute exacerbation of COPD and acute decompensated heart failure. The recommended nursing interventions are thus aimed at improving the patient’s heart pump function and maintaining normal blood pressure in addition to relieving respiratory symptoms such as shortness of breath (Doenges et al., 2019). It was necessary to administer furosemide given that the patient was admitted as a result of acute decompensated heart failure which is associated with leg or foot swelling that is managed by diuretics. Enalapril was administered to help manage and prevent atrial fibrillation, which is demonstrated by the patient’s irregular and elevated heart rate of 118.

Metoprolol is effective in maintaining sinus rhythm and preventing atrial fibrillation but was not necessary at the point of admission given the patient’s low blood pressure (Doenges et al., 2019). Morphine was also not necessary given that the patient was not in any kind of pain.Inhaled short-acting bronchodilator (ProAir HFA) on the other hand was necessary for quick relief of the patient’s shortness of breath and prevent COPD complications. Lastly Inhaled corticosteroid (Flovent HFA) was not appropriate, given that this drug can only be considered in long-term therapy for patients with asthma, especially when a short-acting bronchodilator has already been used.

Cardiovascular Conditions Leading to Heart Failure and Interventions

Conditions such as hypertension, myocardial infarction, coronary artery disease, and abnormal heart valves. Hypertension is the main

Case Study Mrs. J. NRS 410V
Case Study Mrs. J. NRS 410V

risk factor for heart failure as a result of overworking the heart to promote normal blood circulation. In such a condition, the recommended nursing intervention is to regularly monitor the patient’s blood pressure and ensure great compliance with antihypertensives. Coronary artery disease is associated with cholesterol and fatty deposits in the heart arteries (Inciardi et al., 2020). Monitoring the patient’s cholesterol level and lipid profile in addition to the use of dietary control is necessary to prevent the development of heart failure. For patients who have had a history of heart attack the nursing care plan will involve monitoring the patient’s vitals regularly and administration of antianginals to prevent heart attack (Mahmud et al., 2020). Lastly, abnormal heart valves can also lead to overworking of the heart which can eventually lead to heart failure. This can be prevented by the use of blood thinners and lifestyle modifications.

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

            Given that most elderly patients present with comorbidities, there isa high possibility of polypharmacy. To prevent problems associated with multiple drug interactions, it is necessary to eliminate duplicate medication during care transition to avoid toxic doses which promote adverse drug reaction (Unlu et al., 2020). Assessment of the treatment plan is crucial to prevent drug-drug interaction and avoid the associated adverse effects. Nurses should conduct medical reconciliation to avoid instances of prescription errors (Unlu et al., 2020). Lastly drug dosage review should be conducted to ensure that administered drugs are safe, with reduced incidences of adverse events.

Click here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS: Case Study: Mrs. J. NRS 410V

Health Promotion and Restoration Teaching Plan

The patient must be educated on the pathophysiology of his health condition and the importance of taking the prescribed medication (Inciardi et al., 2020). She should also adopt a healthy diet low on sodium, fats, and calories, and frequent physical exercise to promote her health (Mahmud et al., 2020). The patient should also be advised to stop smoking through the adoption of appropriate smoking cessation programs, to prevent the effects of tobacco smoke in worsening COPD symptoms. Consequently, she needs to frequently monitor her vitals to evaluate the treatment outcome. It is also necessary for the patient to sign up for cardiac rehabilitation which is crucial in improving the quality of life and even prolonging the patient’s life expectancy (Mahmud et al., 2020). Additional resources which will help the patient identify life modification strategies to promote health and independent living include ‘American Heart Association’, ‘Centers for Disease Control and Prevention’ and ‘National Heart, Lung, and Blood Institute’ among others.

Method for Providing Education to Prevent Hospital Readmissions

            To promote the patient’s recovery and prevent possibilities of readmission, it is necessary to advise the patients on the importance of complying with the medications prescribed at the indicated dose, frequency, and duration (Unlu et al., 2020). The patient must also be educated about the side effects to avoid unexpected symptoms which would otherwise make the patient stop using the drug.

COPD Triggers and Options for Smoking Cessation

Cigarette smoking is the leading cause of COPD, whereas tobacco smoke is also associated with increased increase exacerbation frequency. To help the patient stop smoking, and promote their quality of life it is necessary to consider referral to a smoking cessation counselor (Inciardi et al., 2020). The counselor will be able to evaluate the patient’s extend of addiction and develop the most effective cessation program to help the patient quit smoking.

Conclusion

The provided case study illustrates a patient with cardiorespiratory problems, which can lead to heart failure. The patient however received adequate care in the ICU, upon admission. It is however necessary to educate the patient on appropriate life modifications such as exercise and a healthy diet to promote well-being and prevent complications associated with these disorders.

References

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span. FA Davis.

Inciardi, R. M., Lupi, L., Zaccone, G., Italia, L., Raffo, M., Tomasoni, D., … & Metra, M. (2020). Cardiac involvement in a patient with coronavirus disease 2019 (COVID-19). JAMA cardiology5(7), 819-824. https://doi.org/10.1001/jamacardio.2020.1096.

Mahmud, E., Dauerman, H. L., Welt, F. G., Messenger, J. C., Rao, S. V., Grines, C., … & Henry, T. D. (2020). Management of acute myocardial infarction during the COVID-19 pandemic: a position statement from the Society for Cardiovascular Angiography and Interventions (SCAI), the American College of Cardiology (ACC), and the American College of Emergency Physicians (ACEP). Journal of the American College of Cardiology76(11), 1375-1384. https://doi.org/10.1016/j.jacc.2020.04.039.

Unlu, O., Levitan, E. B., Reshetnyak, E., Kneifati-Hayek, J., Diaz, I., Archambault, A., … & Goyal, P. (2020). Polypharmacy in older adults hospitalized for heart failure. Circulation: Heart Failure13(11), e006977. https://doi.org/10.1161/CIRCHEARTFAILURE.120.006977

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