Nursing Case Study: Mrs J
Mrs. J. is a 63-year-old female patient with has a history of hypertension, chronic heart failure, and chronic obstructive pulmonary disease. Despite needing 2L of oxygen/nasal cannula at home during activity, she still smokes two packs of cigarettes daily as she has done for the last four decades. Three days ago, the patient had a sudden onset of flu-like symptoms comprising fever, malaise, productive cough, and nausea. Thus, she has not performed ADLs and requires assistance in walking a short distance. At the same time, Mrs. J has not taken her antihypertensive medications and medications for regulating her heart failure. She has been admitted to the hospital ICU with acute decompensated heart failure (ADHF) and acute exacerbation of COPD. This essay presents the clinical manifestations, the rationale for nursing interventions, cardiovascular conditions that lead to heart failure,
Part One: Clinical Manifestations
The clinical manifestations of ADHF are the sudden onset of dyspnea, fluid retention, fatigue and altered mental status. The fluid retention usually results in pulmonary congestion and peripheral edema. The patient may also present with lower extremity edema, progressive weight gain, increasing dyspnea upon exertion, or dyspnea while resting. She may report paroxysmal nocturnal dyspnea and orthopnea (Dunphy, et al., 2019). The clinical manifestations of the acute exacerbation of COPD are worsening dyspnea, increased sputum volume, and sputum purulence. She may also present with fever, coughing and thick and coloured (yellowish, brownish, grayish, or greenish) sputum.
Part Two: Nursing Interventions
The medications administered through drug therapy to control Mrs. J.’s symptoms were IV furosemide (Lasix), Enalapril (Vasotec), Metoprolol (Lopressor), IV morphine sulphate (Morphine), Inhaled short-acting bronchodilator (ProAir HFA), an inhaled corticosteroid (Flovent HFA), and oxygen delivered at 2L/ NC. First, IV furosemide is a loop diuretic that was used to prevents Mrs. J’s body from the absorption of excessive salt by passing it in the urine. In this case, furosemide was used in treating edema in a patient with congestive heart failure and high blood pressure. Secondly, enalapril is an angiotensin-converting enzyme inhibitor that was used in the treatment of high blood pressure. Enalapril was used to lower blood pressure by preventing the formation of angiotensin II; thus, relaxing the blood vessels and arteries. Thus, the medication was used to enhance the heart’s effectiveness since Mrs. J has heart failure by decreasing the blood pressure maintained by the heart.
Next, metoprolol is a beta-blocker that blocks the action of some natural chemicals in the body on the blood vessels and heart. Metoprolol was used to lower the blood pressure heart rate, and strain the patient’s heart to enhance survival after the heart attack. IV morphine sulphate is an opioid analgesic, the most potent form of medication used to treat severe pain. ProAir HFA is a fast-acting bronchodilator that was used to offer quick relief and treat COPD. The medicine was used to rapidly relax muscles tightening around the airways to ease breathing, clearing mucus from lungs, and relieving acute dyspnea. In this case, Flovent HFA was used in preventing breathing difficulties, coughing, chest tightness, and wheezing caused by COPD. The medication works by lessening swelling and irritation in the airways to ease breathing. Finally, the oxygen delivered at 2L/ NC was administering oxygen at a concentration greater than ambient air to treat manifestations and symptoms of hypoxia.
Cardiovascular Conditions and Heart Failure
There are various cardiovascular conditions, which might lead to heart failure since the heart cannot pump adequate blood for the body to get the needed oxygen. Heart failure rarely occurs alone, as it can result from other conditions that strain the heart. The common condition that may lead to heart failure is coronary artery disease that clogs the arteries with cholesterol and different kinds of fats (Dunphy, et al., 2019). The heart is forced to work hard to push the blood through constricted blood vessels, leading to high blood pressure and heart failure. The pharmacological agents are used in controlling the symptoms of angina and preventing subsequent events. A clinician can recommend low-dose daily Aspirin (81 mg–325 mg) together with beta-blockers, ranolazine, calcium channel blockers, and nitroglycerin. Other treatments comprise lifestyle changes, angioplasty, coronary artery bypass graft surgery, and enhanced external counterpulsation. Secondly, heart attacks occur when blocked arteries block blood from being pumped to the heart. With no immediate treatment, some parts of the heart start dying. Heart failure happens if the tissue is damaged, and the heart cannot pump blood. The treatment can range from lifestyle changes, cardiac rehabilitation, stents, bypass surgery and medications like Aspirin, thrombolytics, antiplatelet agents, nitroglycerin, and ACE inhibitors.
Next, heart failure and coronary artery disease may cause arrhythmias. The damaged heart tissue could lead to problems with the electrical system of the heart, which makes the heartbeat either slowly, quickly, or changing speeds. Also, some of the drugs used in treating heart failure may lead to arrhythmias. The treatment plan includes antiarrhythmic drugs such as antiarrhythmic agents, calcium channel blockers, beta-blockers, and dietary supplements. Also, cardioversion, cardiac ablation, and implantable devices can be used to prevent the development of heart failure. Finally, vascular disease diffuses the atherosclerosis of arteries, including carotids, heart and legs. Patients with vascular disease have twice the likelihood of developing heart failure. Lifestyle modifications, medications, angioplasty, angioplasty with stent placement or atherectomy are treatments available for vascular disease.
Multiple Drug Interactions in Older Patients
As age progresses, more diseases develop resultant in the usage of more medications. The physiological changes, homeostatic regulation alterations and diseases modify the drug response and pharmacokinetics among older patients. There are risks for drug interactions and problems that increase with the use of multiple medications. The risks can be alleviated by the periodic evaluation of the drug regimen to minimalize polytherapy (Gujjarlamudi, 2016). Secondly, complete patient history should be obtained to perform medication reconciliation. In this case, a brown bag approach is an effective way of reviewing all the medications. Another strategy is being vigilant and checking the usage of dietary and herbal supplements as they are predisposed to drug-drug interactions. Oral and written information on any new medicine prescribed: name, rationale, how to take it, possible adverse reactions, and problems should be provided. Finally, the clinician should promote the adherence to medication regimen by teaching the tools and strategies for supporting compliance like pill dispenser boxes, colour-coded containers, or alarms.
Patient Education
The education of both the patient and her family is important for effective therapy. Mrs J and her family need to understand that even though COPD is not disease, proper management coupled with smoking cessation can control the symptoms and enhance the quality of life. It is important to seek collaborative partnerships in caring for the patient due to the various problems that can be experienced with the patient. Smoking cessation will improve declining lung function. The patients should be urged to stop smoking and the family members can be encouraged to offer support and stop smoking too.
COPD Triggers
Some factors cause COPD symptoms to become more severe and increase the exacerbation frequency, resultant in return visits. They include cigarette smoke, extreme weather, hot, cold, humid conditions, inhaled irritants, fumes, dust, air pollution, and respiratory infections. Considering the patient’s present and long-term tobacco use, there are various possible options for smoking cessation. Effective smoking cessation will require behaviour modification by recognizing triggers and substituting healthy alternative behaviours to overcome the urge to smoke. Also, hypnosis in smoking cessation can enable a smoker to attain an altered state of consciousness, enhancing the aptitude to quit. The pharmacological approaches are antidepressants or anxiolytics like bupropion as both an antidepressant and a smoking deterrent. Finally, nicotine replacement therapies can assist n smoking cessation. They include the nicotine patches, lozenges, and gums are available over the counter as well as nicotine nasal sprays and inhalers can be prescribed.
References
- Dunphy, L. M. H., In Winland-Brown, J. E., In Porter, B. O., & In Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing – an interprofessional approach. Philadelphia, PA: F.A. Davis Company.
- Gujjarlamudi H. B. (2016). Polytherapy and drug interactions in elderly. Journal of mid-life health, 7(3), 105–107. https://doi.org/10.4103/0976-7800.191021.
- Nici, L., & ZuWallack, R. L. (2012). Chronic obstructive pulmonary disease: Co-morbidities and systemic consequences. New York: Humana Press.