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.
- 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.
- 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? 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)
- Enalapril (Vasotec)
- Metoprolol (Lopressor)
- IV morphine sulphate (Morphine)
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.
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.
Question Guide (Order for Complete Paper)
Nursing Interventions at the Time of Admission:
- Assessment and Monitoring:
- Conduct a thorough assessment of Mrs. J.’s condition, including a detailed history, vital signs, and physical examination. Monitor her vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, frequently due to her critical condition.
- Assess her oxygenation status continuously using pulse oximetry.
- Monitor cardiac rhythm and ECG to evaluate arrhythmias.
- Oxygen Therapy:
- Administer supplemental oxygen to maintain oxygen saturation above 90% and alleviate her respiratory distress.
- Intravenous Access:
- Establish and maintain intravenous access to administer medications and fluids promptly.
- Fluid Management:
- Administer intravenous fluids cautiously to optimize Mrs. J.’s hemodynamic status, taking care not to exacerbate her heart failure.
- Medication Administration:
- Administer medications as prescribed to manage her symptoms and stabilize her condition.
Rationale for Medication Administration:
- IV Furosemide (Lasix): Furosemide is a loop diuretic used to relieve pulmonary congestion and reduce fluid overload in acute heart failure. It promotes diuresis by inhibiting reabsorption of sodium and water in the renal tubules, reducing preload on the heart and relieving symptoms of congestion.
- Enalapril (Vasotec): Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that helps improve cardiac function and reduce afterload. It dilates blood vessels, reduces blood pressure, and decreases the workload on the heart.
- Metoprolol (Lopressor): Metoprolol is a beta-blocker that can slow the heart rate and reduce myocardial oxygen consumption. In atrial fibrillation with rapid ventricular response, it can help control heart rate and rhythm.
- IV Morphine Sulphate (Morphine): Morphine is administered for its vasodilatory and analgesic effects. It can relieve anxiety and dyspnea associated with acute heart failure. By reducing preload and afterload, it can help alleviate symptoms.
Four Cardiovascular Conditions Leading to Heart Failure and Preventive Interventions:
- Hypertension: Uncontrolled high blood pressure can lead to left ventricular hypertrophy and heart failure. Nursing interventions include regular blood pressure monitoring, medication adherence promotion, lifestyle modifications (e.g., diet, exercise, stress reduction), and patient education on hypertension management.
- Coronary Artery Disease (CAD): CAD can lead to myocardial infarction and subsequent heart failure. Preventive measures include cardiac rehabilitation, lifestyle modifications, antiplatelet therapy, and the use of statins to manage cholesterol levels.
- Valvular Heart Disease: Conditions like aortic stenosis or mitral regurgitation can lead to heart failure. Preventive interventions include regular cardiac evaluations, timely valve repair/replacement, and prophylactic antibiotics for high-risk patients before dental or surgical procedures.
- Diabetes Mellitus: Poorly managed diabetes can cause microvascular and macrovascular complications, including heart failure. Preventive measures include glycemic control, blood pressure management, lipid control, and patient education on diabetes self-care.
Nursing Interventions to Prevent Drug Interaction Problems in Older Patients:
- Medication Reconciliation: Regularly review and update the patient’s medication list, including over-the-counter drugs and supplements, to identify potential interactions. This helps ensure that all healthcare providers have an accurate medication history.
- Patient Education: Educate the patient and their caregivers about the importance of adhering to medication schedules, reporting any side effects, and avoiding alcohol or other substances that may interact with their medications.
- Communication: Foster communication between healthcare providers, including pharmacists, to share information about prescribed medications and potential interactions. This interprofessional collaboration can help avoid prescribing conflicting drugs.
- Regular Monitoring: Continuously assess the patient for signs of adverse drug reactions or interactions and promptly report any concerning findings to the healthcare team. This allows for timely intervention or medication adjustments if needed.