NRS 410 CASE STUDY MRS. J

Sample Answer

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 reviews, 4(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. Jama, 325(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 pharmacology, 12, 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 medicine, 201(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 therapy, 11(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 quarterly, 44(1), 121–127. https //doi.org/10.1097/CNQ.0000000000000345