NRS 410V Case Scenario

8 Oct No Comments

Mrs. J. is a 63-year-old woman who has a history of hypertension, chronic heart failure, and sleep apnea. She has been smoking two packs of cigarettes a day for 40 years and has refused to quit. Three days ago, she had an onset of flu with fever, pharyngitis, and malaise. She has not taken her antihypertensive medications or her medications to control her heart failure for 4 days. Today, she has been admitted to the hospital ICU with acute decompensated heart failure.

Subjective Data

Is very anxious and asks whether she is going to die.

Denies pain but says she feels like she cannot get enough air.

Says her heart feels like it is “running away.”

Reports that she is so exhausted she cannot eat or drink by herself.

Objective Data

Height 175 cm; Weight 95.5 kg

Vital signs: T 37.6 C, HR 118 and irregular, RR 34, BP 90/58

Cardiovascular: Distant S1, S2, S3 present; PMI at sixth ICS and faint; all peripheral pulses are 1+; bilateral jugular vein distention; initial cardiac monitoring indicates a ventricular rate of 132 and atrial fibrillation

Respiratory: Pulmonary crackles; decreased breath sounds right lower lobe; coughing frothy blood-tinged sputum; SpO2 82%

Gastrointestinal: BS present: hepatomegaly 4 cm below costal margin

Critical Thinking Questions

What nursing interventions are appropriate for Mrs. J. at the time of her admission?

The nurse should reassure the patient that the problem is under control. Calm her anxiety. The patient to be provided a container to empty the sputum. The first task is to monitor basic observations such as serial ECGs, urinary output, oxygenation, blood pressure, heart rate, respiratory rate, volume status and temperature. The information obtained is to be monitored through the cause of treatment and will be used to prioritize treatment needs and identifying the primary underlying cause. Placement of a central venous line is done to allow administration of any intravenous fluids and medication. An invasive monitoring system is also needed to prevent infections as well as maintain the line patency by flushing the system hourly. The patient oxygen saturation in blood should be monitored and if possible, supplemental oxygen be administered to achieve a target of > 95% saturation. If ineffective, non-invasive ventilation may be done based on local guidelines. Reduce patient movements to conserve oxygen. Most importantly, administer the prescribed medication, while monitoring for the side effects. Place fluid restriction on the patient and monitor fluid input and output. Monitoring the symptoms from time of admission is vital as pharmacological intervention is ongoing. In addition, determination of the electrolytes, BUN and creatinine is important, during diuresis. The nurse must also evaluate the patient for implantable cardioverter defibrillator.

Drug therapy is started for Mrs. J. to control her symptoms. What is the rationale for the administration of each of the following medications?

IV furosemide (Lasix)

To relieve congestion through diuresis. The furosemide is a high ceiling loop diuretic that enhances fluid loss thus easing fluid retention. This rapidly reduces the right and left ventricular filling pressures. Subsequently, the pulmonary congestion and hepatomegaly are expected to ease. It also relieves blood pressure.

Enalapril (Vasotec)

Reduces blood pressure, by blocking the angiotensin converting enzyme, with subsequent effects of preventing narrowing of arteries. It improves heart function and reduces congestion.

Metoprolol (Lopressor)

It is a beta blocker. Improves the hearts ability to relax, slows heart rate, improves hearts pumping ability and decreases production of harmful substances that are produced in response to heart failure.

IV morphine sulphate (Morphine)

Used as an adjunctive therapy, producing mild venodilation and preload reductions. It reduces anxiety and also removes the catecholamine effects.

Describe four cardiovascular conditions that may lead to heart failure and what can be done in the form of medical/nursing interventions to prevent the development of heart failure in each condition.

Cardiac arrhythmias

The ineffective contractions mean that blood is not moving into arteries, depriving the heart effective perfusion to sustain the pumping heart. Too fast pumping will ultimately overwork the heart, leading to symptoms of heart failure. Treatment involves use of a pace maker device, implanted on the chest to help normalize heart rhythms. Other options include, vagal maneuvers and cardioversion.

Myocarditis

My condition results in damage to heart valves and muscles, leading to cell death and poor pumping of the blood. When valves are damaged, blood is not pumped effectively, and the resulting ischemia leads to increased heart rate, leading to heart failure. Infective myocarditis requires antimicrobial therapy. Especially, bacterial endocarditis, is treated by I.V broad spectrum antibacterial agents.

Hypertension

Causes tiredness of the heart, as well as increased heart muscle size, which makes it less effective in pumping blood. It is treated using the antihypertensive drugs such as beta blockers.

Faulty heart valves

This means, the pumping is not effective thus, the heart dose, a lot of work with no important oxygenation taking place. The heart tires, and grows in size to try to compensate, becoming progressively ineffective in what we call heart failure. The intervention involves surgical replacement of the valves with artificial ones.

Taking into consideration the fact that most mature adults take at least six prescription medications, discuss four nursing interventions that can help prevent problems caused by multiple drug interactions in older patients. Provide rationale for each of the interventions you recommend.

Give the patient relevant information. The nurse discusses the patient the importance of, keeping an accurate list of the medication there are taking, dose frequency and their purpose. The list of the medicine provider and their contacts. Thus, there will be no room for confusion.

Organization. Here, the patient is taught how to manage the drugs they are on. They should store the medication at the appropriate conditions, avoid sharing them, dispose them appropriately, and link their daily chores to drug taking. This will help them stick to the directions of the clinician.

Instructions. The patient must be given not too much and not too little information. The most important information must be delivered. This includes, how to take the drugs, what time, dose frequency, and storage conditions. The expected side effects may be discussed to prepare the patient. The patient having the right information will take the drug the right way.

Reference material. The patient can have a point of quick reference, in order to clear up any forgotten issue concerning their medication. This may include a relevant website or a leaflet. The patient is thus in a position to clear and doublt.




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