NRS 455 Case Study Mrs. R.

Sample Answer

Critical Thinking Table

Clinical Manifestations

Describe the clinical manifestations present in Mrs. R., focusing on the normal and abnormal findings and how this relates to his current condition.
Subjective Subjective manifestations refer to the patient’s expression of his/her experiences with a disease.

The abnormal subjective manifestations in Mr. R’s case study include anxiety, feeling that she cannot get enough air, feeling that her heart is running away, and feeling exhausted and unable to drink by herself. The above manifestations relate to Mr. R’s current condition. For example, he cannot get enough air because of pulmonary congestion.

He also feels exhausted because of inadequate gaseous exchange in the lungs (Irgashev, 2023). He is feeling that his heart is running away because of abnormal heart functions, which cause palpitations.

Objective

The abnormal objective manifestations in the case study include an irregular heart rate of 118 beats/minute, respiratory rate of 34, blood pressure of 90/58, presence of S3 heart sounds and distant S1 and S2 heart sounds, and decreased peripheral pulses.

They also include bilateral jugular vein distention, ventricular heart rate of 132, atrial fibrillation, pulmonary crackles, decreased breath sounds in the right lower lobe, coughing blood-stained sputum, SPO2 82%, and hepatomegaly.

These symptoms relate to Mr. R’s current condition. For example, decreased cardiovascular functioning results in blood buildup in the lungs, hence, crackles and bloodstained sputum (Schwinger, 2021). The decreased cardiovascular function also impairs cardiac filling, hence, jugular venous distention.

Cardiovascular Conditions Leading to Heart Failure

Describe cardiovascular conditions in which Mrs. R. is at risk.
Describe four cardiovascular conditions in which Mrs. R. is at risk and that may lead to heart failure. Mrs. R is at risk of cardiovascular conditions, including cardiomyopathy, coronary artery disease, myocarditis, and poorly controlled hypertension.

A failure in the heart muscle to pump blood will result in cardiomyopathy and worsening heart failure. Mrs. R is also at risk of coronary artery disease. Her history of smoking two packs of cigarettes daily places her at an increased risk of developing coronary artery disease. Myocarditis can also develop in Mrs. R. Myocarditis refers to the inflammation of the heart muscle.

Mrs. R has a history of hypertension, which can cause myocardial functional and structural changes. These changes can result in myocarditis and heart failure (Townsend et al., 2022). Mrs. R is at risk of poorly controlled hypertension and heart failure. She has not taken her antihypertensive medications for three days, which could worsen her hypertension.
Discuss any comorbidities Mrs. R. displays.

Mrs. R has COPD and congestive hepatomegaly as her comorbidities. Patients with a long history of heavy cigarette smoking have an increased risk of developing COPD. Statistics show that smoking contributes to 70% of all COPD cases in developed countries. Cigarettes contain chemicals that irritate the lung tissues and weaken their defense against infection.

The chemicals also stimulate inflammatory processes, airway narrowing, and air sac destruction, which lead to COPD. Mrs. R has developed congestive hepatomegaly as a complication of heart failure. Heart failure causes a buildup of blood in the liver.

This occurs from the pooling up of blood in the inferior vena cava, which affects other blood vessels, including the hepatic veins (Goel, 2021). Too much pressure on hepatic veins from blood buildup in the inferior vena cava causes congestive hepatomegaly.

How do these conditions increase her chance of heart failure?

Cardiomyopathy, coronary artery disease, myocarditis, and poorly controlled hypertension increase Mrs. R’s chances of heart failure. Cardiomyopathy affects the functioning of the heart muscles. This includes contraction and relaxation of the heart muscles.

Impaired functioning of the heart muscles will affect cardiovascular filling and emptying, hence, increasing the risk of heart failure. Coronary artery disease will cause narrowing of the arteries, which will increase vascular pressure and resistance.

These changes will cause increased cardiac workload, worsening Mrs. R’s risk of heart failure. Poorly controlled hypertension causes functional and structural changes in the heart muscles and tissue (Kario & Williams, 2021). For example, patients are at risk of myocarditis, which impairs normal cardiac filling and contraction, hence, heart failure.

What can be done by way of medical/nursing interventions to prevent the development of heart failure in each of the presented conditions? The patient should be administered IV furosemide, enalapril, and metoprolol for cardiomyopathy.

These drugs will reduce fluid volume overload, and cardiac volume, and maintain normal blood pressure. Mrs. R should be administered furosemide, angiotensin-converting enzyme inhibitors, and beta-blockers for myocarditis. Mrs. R should be administered furosemide and beta-blockers for poorly controlled hypertension.

She should also be administered aspirin, diuretics such as furosemide, blood thinning medications such as enoxaparin, statins, and antihypertensive drugs such as beta-blockers, calcium channel blockers, or angiotensin-converting enzyme inhibitors (Sindone et al., 2022). Some of the nursing interventions include daily weighing Mrs. R to detect fluid volume overload, health education on lifestyle and behavioral modifications, respiratory support, and educating on self-management of her comorbidities.

Evaluation of Nursing Interventions at Admissions

Discuss the initial assessments and interventions provided to Mrs. R.
According to the nursing process, were the initial assessments and interventions at the time of admission beneficial for Mrs. R? The initial assessments and interventions were beneficial for Mrs. R. Subjective data provided insights into Mrs. R’s experience with her health problems and their severity.

The data also provided baseline information to determine her health needs. The objective assessment confirmed the subjective data. It also informed the body systems involved in Mrs. R’s problems. Interventions such as the administration of IV furosemide were appropriate to increase excessive fluid loss through the kidneys.

Enalapril and metoprolol were appropriate to decrease cardiac workload through increased vasodilation and decreased cardiac contractility. Morphine was appropriate for pain reliever, anxiolytic, and inhibition of the sympathetic nervous system to lower afterload and preload.

Inhaled corticosteroids and short-acting bronchodilators were appropriate to open the airways and improve respiratory function. Oxygen delivered 2L/NC was appropriate to increase body tissue oxygenation since the patient has a saturation of 82% and respiratory difficulties due to the disease process.

Discuss changes to any of the initial assessments or interventions you would make to ensure patient independence and prevent readmission. Mrs. R has congestive hepatomegaly. She is at risk of developing hepatic encephalopathy. Therefore, I would prescribe oral lactulose 15-30 ml thrice daily to prevent ammonia buildup (Goel, 2021).

Medications and Prevention of Problems Caused by Multiple Drug Interactions
Explain each of the seven medications listed in the case study and increase the incidence of polypharmacy.

Explain each of the seven medications listed in the case study. Include the classification, action, and rationale for each of these medications as they stem from the pathophysiology of this patient’s condition (e.g., consider morphine use outside of pain management).

Furosemide is a diuretic that works by inhibiting sodium and chloride reabsorption in the ascending loop of Henle, hence, increasing fluid loss with sodium and chloride. Furosemide was prescribed to treat fluid volume excess from heart failure. Enalapril is an angiotensin-converting enzyme inhibitor that blocks the conversion of angiotensin 1 to angiotensin II.

The inhibition prevents vasoconstriction. It was prescribed to cause vasodilation, creased cardiac preload, and increased blood and oxygen supply to the heart. Metoprolol is a beta-1-receptor blocker that inhibits beta-1-receptors to cause decreased cardiac output from its negative chronotropic and inotropic effects.

Metoprolol was prescribed to lower cardiac workload by inhibiting increased excitation of the cardiac muscles. IV morphine sulfate was prescribed as an anxiolytic and a depressant of the sympathetic nervous system. The suppression of the sympathetic nervous system would lower cardiac preload and afterload. ProAir HFA is a short-acting bronchodilator that acts on beta-2-adrenergic receptors to cause bronchial smooth muscle relaxation.

ProAir HFA was prescribed to treat airway inflammation and to increase airflow to the lungs. Floven HFA is a corticosteroid that was prescribed to inhibit anti-inflammatory and vasoconstriction activity in the respiratory system (Remien & Bowman, 2024). It works by inhibiting inflammatory cells such as mast cells, monocytes, and eosinophils in the respiratory system.

Discuss four nursing interventions that can help prevent problems caused by multiple drug interactions in older patients. Provide a rationale for each of the interventions you recommend. One of the nursing interventions that can help prevent problems caused by multiple drug interactions is patient education.

Mrs. R should be educated on the appropriate use of the prescribed medications and avoiding over-the-counter medications to prevent multiple drug interactions. The other nursing intervention is implementing the use of screening tools to identify and address polypharmacy in older patients. Tools such as NO TEARS can be used in healthcare settings to help identify and eliminate any drug with an increased risk of adverse outcomes if prescribed for older patients.

The other strategy is encouraging interprofessional collaboration in drug prescribing, dispensing, and use by elderly patients. Interprofessional strategies such as involving pharmacists in patient education on drug safety reduce the risk of polypharmacy among older patients (Drenth-van Maanen et al., 2020; Hailu et al., 2020).

The last strategy is adopting deprescribing. Deprescribing entails identifying and discontinuing any medication whose harm is more than its benefits and those having unclear patient benefits.

Health Promotion and Restoration Teaching Plan

Develop a multidisciplinary health promotion and restoration teaching plan for Mrs. R.
Discuss the steps needed to move the patient from acute care to subacute care, before discharging home and beginning a rehabilitation process. Qualified providers should assess and make decisions related to Mrs. R’s movement from acute care to subacute care before their discharge home and the start of the rehabilitation process.

The assessment determines Mrs. R’s health status, needs, and functioning ability. The second step would be discussing and involving Mrs. R in the decision-making process. The third step is planning for the patient transfer and determining any need for support such as caregiver training.

The fourth step entails planning for follow-up appointments. Providers should also determine whom the patient should contact should they require any assistance.

Discuss alternative discharge options and qualifications to facilitate a smooth transition to the next level of care. The alternative discharge options for Mrs. R include respite care, rehabilitation facilities, and home healthcare facilities.

Mrs. R can be discharged for home healthcare if she has a caregiver who can meet her health needs at home. This includes a skilled provider who will administer intravenous medications at home should she be discharged with such medications. Mrs. R can be discharged to rehabilitation facilities to help her overcome her substance use problem.

She can be discharged from the hospital to respite care should she have difficulties in meeting their daily needs due to her illness. The qualifications for a smooth transition to the next level of care include care coordination, multidisciplinary collaboration, active patient involvement, and ready access to patient data for different providers involved in Mrs. R’s care.

Explain how the rehabilitation resources, including medication management, and modifications will assist the patient’s transition to promote independence and prevent readmission. Rehabilitation resources such as medication management promote optimum disease management and improved treatment adherence.

Treatment adherence would reduce the risk of adverse outcomes in Mrs. R’s management, hence, reducing the hospitalization rate and emergency department visits. Resources such as telehealth would ensure Mrs. R’s timely access to specialized care and support, which would lower the risk of adverse events (Kitzman et al., 2021). Telehealth facilitates virtual patient-provider interaction, assessment, treatment, monitoring, and evaluation.

Pathophysiological Changes

Discuss the pathophysiological changes that come with Mrs. R.’s long-term tobacco use. Long-term tobacco use is associated with significant adverse health effects. Studies have shown that long-term tobacco use causes endothelial dysfunction. It also predisposes individuals to thrombotic and atherogenic problems that are associated with ischemic conditions such as stroke and coronary syndrome.

Long-term tobacco use also affects the blood-brain barrier. Evidence shows that tobacco smoke causes leaky brain micro-vessels and altered blood-brain barrier integrity. This leads to an increased risk of silent cerebral infarction and stroke.

The additional effects of long-term tobacco use include insulin resistance, hemodynamic alterations, alterations in the lipid profile, and hypercoagulable state in the affected patients (El-Mahdy et al., 2021).

COPD Triggers and Options for Smoking Cessation

Discuss options for smoking cessation education.

What options for smoking cessation should be offered to Mrs. R? Several options for smoking cessation exist for Mrs. R. They include nicotine replacement therapy, bupropion, varenicline, or behavioral therapies.
Explain the COPD triggers that can increase exacerbation frequency, resulting in readmission.

Some of the COPD triggers that can increase exacerbation frequency and result in readmission include cigarette smoking, illnesses such as pneumonia, exposure to dust or fumes, allergens, and extreme temperature changes (Ji et al., 2022). These triggers are stressors that cause inflammatory processes that are associated with COPD development and symptoms.

References

• Drenth-van Maanen, A. C., Wilting, I., & Jansen, P. A. F. (2020). Prescribing medicines to older people—How to consider the impact of ageing on human organ and body functions. British Journal of Clinical Pharmacology, 86(10), 1921–1930. https //doi.org/10.1111/bcp.14094
  
• El-Mahdy, M. A., Mahgoup, E. M., Ewees, M. G., Eid, M. S., Abdelghany, T. M., & Zweier, J. L. (2021). Long-term electronic cigarette exposure induces cardiovascular dysfunction similar to tobacco cigarettes Role of nicotine and exposure duration. American Journal of Physiology-Heart and Circulatory Physiology, 320(5), H2112–H2129. https //doi.org/10.1152/ajpheart.00997.2020
  
• Goel, S. K. (2021). Hepatic parameters in congestive heart failure patients A prospective study. Journal of Advanced Medical and Dental Sciences Research, 9(4). http //jamdsr.com/uploadfiles/37vol9issue4pp162-166.20211215042656.pdf
  
• Hailu, B. Y., Berhe, D. F., Gudina, E. K., Gidey, K., & Getachew, M. (2020). Drug related problems in admitted geriatric patients The impact of clinical pharmacist interventions. BMC Geriatrics, 20(1), 13. https //doi.org/10.1186/s12877-020-1413-7
  
• Irgashev, I. E. (2023). “Pathological Physiology of Heart Failure.” American Journal of Pediatric Medicine and Health Sciences (2993-2149), 1(8), Article 8.
  Ji, S., Dai, M.-Y., Huang, Y., Ren, X.-C., Jiang, M.-L., Qiao, J.-P., Zhang, W.-Y., Xu, Y.-H., Shen, J.-L., Zhang, R.-Q., & Fei, G.-H. (2022). Influenza a virus triggers acute exacerbation of chronic obstructive pulmonary disease by increasing proinflammatory cytokines secretion via NLRP3 inflammasome activation. Journal of Inflammation, 19(1), 8. https //doi.org/10.1186/s12950-022-00305-y
  
• Kario, K., & Williams, B. (2021). Nocturnal Hypertension and Heart Failure Mechanisms, Evidence, and New Treatments. Hypertension, 78(3), 564–577. https //doi.org/10.1161/HYPERTENSIONAHA.121.17440
  
• Kitzman, D. W., Whellan, D. J., Duncan, P., Pastva, A. M., Mentz, R. J., Reeves, G. R., Nelson, M. B., Chen, H., Upadhya, B., Reed, S. D., Espeland, M. A., Hewston, L., & O’Connor, C. M. (2021). Physical Rehabilitation for Older Patients Hospitalized for Heart Failure. New England Journal of Medicine, 385(3), 203–216. https //doi.org/10.1056/NEJMoa2026141
  
• Remien, K., & Bowman, A. (2024). Fluticasone. In StatPearls. StatPearls Publishing. http //www.ncbi.nlm.nih.gov/books/NBK542161/
  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
  
• Sindone, A. P., De Pasquale, C., Amerena, J., Burdeniuk, C., Chan, A., Coats, A., Hare, D. L., Macdonald, P., Sverdlov, A., & Atherton, J. J. (2022). Consensus statement on the current pharmacological prevention and management of heart failure. Medical Journal of Australia, 217(4), 212–217. https //doi.org/10.5694/mja2.51656
  
• Townsend, N., Kazakiewicz, D., Lucy Wright, F., Timmis, A., Huculeci, R., Torbica, A., Gale, C. P., Achenbach, S., Weidinger, F., & Vardas, P. (2022). Epidemiology of cardiovascular disease in Europe. Nature Reviews Cardiology, 19(2), 133–143. https //doi.org/10.1038/s41569-021-00607-3