Case Study: Mrs. J.
Clinical Manifestations in Mrs. J.
COPD causes increasing airflow restriction accompanied by an aberrant inflammatory reaction to the lungs to irritating particles or gases. In this case, Mrs. J is a smoker and continues smoking. Inflammation occurs in the airways, lung parenchyma, and pulmonary vasculature. Inflammation in the pulmonary vasculature leads to the possible rupture of vessels and the bloody sputum she coughs.
Hinkle and Cheever (2018) explain that changes and constriction of the airways occur due to inflammatory processes and the body’s attempts to heal it. Changes in the proximal airways, trachea, and bronchi include an elevation in the number of goblet cells and an enlargement of the submucosal glands, both of which contribute to mucus hypersecretion. This can be shown by the bloody sputum she coughs. In the peripheral airways, the bronchioles, inflammation produces obstructive bronchiolitis.
This accounts for the fact that she says she feels like she cannot get enough air. This continuing injury-and-repair process leads to scar tissue development and constriction of the airway. The breakdown of the alveolar wall results in a reduction in elastic recoil (Hinkle & Cheever, 2018). The chronic inflammatory process affects the pulmonary vasculature, causing thickening of the artery lining, which leads to pulmonary hypertension.
Nursing Interventions for Mrs. J. And the Rationale For Each Of The Medications Listed
Furosemide treats edema caused by congestive heart failure exacerbation, liver failure, renal failure, and hypertension. According to Bertram (2018), it acts primarily by reducing electrolyte reabsorption from the kidneys and increasing water excretion from the body. In patients with profound congestive heart failure and poor clinical response to standard antihypertensive medications, enalapril therapy improves cardiac function as measured by a decrease in both preload and afterload, as well as long-term clinical status (Bertram, 2018).
In patients with congestive heart failure, enalapril enhances cardiac output and stroke volume while lowering pulmonary capillary wedge pressure. Metoprolol is used to treat heart failure and atrial fibrillation, and high blood pressure (Bertram, 2018). All of the indications for metoprolol are associated with cardiovascular disease.
Morphine sulfate is an opioid agonist used to relieve pain not relieved by non-narcotic analgesics. Salbutamol is prescribed to treat; bronchospasm, chronic bronchitis, obstructive airway ailments, and chronic bronchopulmonary disorders, wherein bronchospasm is a confounding factor. Fluticasone propionate is an inhaler that has been licensed for the treatment and prevention of asthma and therefore was not necessary.
According to Bertram (2018), in therapeutic settings, oxygen therapy is used to treat various forms of anoxia, hypoxia, or dyspnea, as well as any other disease states or situations that limit the efficiency of gas exchange and oxygen consumption, such as respiratory ailments. The goal of oxygen treatment is to achieve hyperoxia to lessen the level of hypoxia-induced tissue damage and dysfunction.
Cardiovascular Conditions That Cause Heart Failure
Heart failure can occur abruptly (acute) or gradually (chronic). It can damage either one or both sides of the heart. Heart failure is usually triggered by another medical issue that destroys the heart. A study by
Coronary heart disease occurs when the coronary arteries cannot supply enough oxygen to the heart. Coronary artery disease affects the bigger coronary arteries on the surface of the heart and is frequently caused by plaque formation inside the lining of the coronary arteries (Groenewegen et al., 2020). This accumulation can either partially or completely obstruct blood flow to the heart.
Cigarette smoking and elevated blood pressure are modifiable risk factors for coronary artery disease, as demonstrated by the patient. Intervention is to keep a steady ECG surveillance and monitor for arrhythmias and ST elevation. Nursing intervention to help the patient is positioning the patient and providing oxygen to improve myocardial oxygen delivery.
The body’s normal response to an infection or damage to the heart is cardiac inflammation (Hinkle & Cheever, 2018). Redness, swelling, and discomfort can be caused by white blood cells fighting infections. Inflammation can injure the heart’s lining or valves, the heart muscle, or the tissue around the heart. Heart inflammation can cause irregular heartbeats, heart failure, and coronary heart disease. Intervention is to monitor blood pressure, apical heart rate, and respirations every 5 minutes, especially in an anginal attack.
According to Hinkle and Cheever (2018), high blood pressure occurs when blood flows at higher-than-normal pressures through vessels. When the patient has a regular systolic pressure of 130 mm Hg and above or a diastolic pressure of 80 mm Hg or above, blood pressure is regarded as high. Because the patient has a history of hypertension, it is a probable cause of heart failure. Intervention is to administer anti-hypertensive medications as well as regular blood pressure monitoring.
Cardiomyopathy refers to heart muscle abnormalities that make it difficult for the heart to pump blood. Depending on the kind of cardiomyopathy, the heart muscle may thicken, stiffen, or become bigger than normal (Hinkle & Cheever, 2018). This can weaken the heart and lead to irregular heartbeats and heart failure. Intervention is the use of medications.
Nursing Interventions To Multiple Drug Interactions
When older persons take many prescriptions, drug interactions can be a major concern. a few strategies to avoid medication interactions: The nurse should keep note of side effects since new symptoms may be caused by the drug the patient is taking rather than by old age (Fialová et al., 2018). A nurse should also teach patients about their medications and warn them about potential drug interactions, how to correctly take any medication, and whether a less-priced generic pill is available.
Fialová et al. (2018) highlight the importance of the nurse examining the patients’ medications and encouraging them to bring all their medicine bottles, both prescription and over-the-counter, to their appointments. The nurse should advise the patient on what meals to eat with each medication. Some medications are better absorbed with particular meals, while others should not be taken with specific foods (Fialová et al., 2018).
Health Promotion And Restoration
Vitacca and Paneroni (2018) advise the nurse to instruct patients to sustain a healthy weight and a well-balanced diet as part of their COPD education strategy. During the day, the patient needs to drink at least 6-8 glasses of water. Eating 4-6 small meals per day helps the diaphragm to move more freely and allows patients to breathe more effortlessly. The nurse needs to encourage the patient to consume complex carbs, protein, and mono- and poly-unsaturated fats.
According to Vitacca and Paneroni (2018), pulmonary rehabilitation improves exercise capacity and wellbeing, as well as reduces hospitalization, unplanned health care visits, and symptoms. Exercise training improves peak oxygen uptake and cardiac autonomic function during exercise while decreasing ventilatory demand and dyspnea in COPD patients.
Furthermore, exercise training lowers the degree of dynamic lung hyperinflation in COPD patients, resulting in enhanced arterial oxygen concentration and central hemodynamic responses, hence enhancing systemic muscle oxygen availability (Vitacca & Paneroni, 2018). Pulmonary rehabilitation reduces chest wall volumes during exercise by reducing stomach volumes, and it improves exercise performance.
Suggestions for Improving Patient Education
Nurses must continually enhance patient education before discharge to achieve this. Some of the things nurses may do to help patients learn more include: Begin teaching patients as soon as they are admitted. According to Hinkle and Cheever, 2018), teaching patients in simpler words as much as possible and utilizing visual aids as much as possible aids in patient education.
Inquiring about their understanding of the care and preparing the next lesson is a teaching strategy. The nurse needs to use a return presentation and include the patient from the start while providing treatment. Make sure the patient understands the medications when you hand them out. Finally, the nurse should inform patients about their illness’s clinical signs that demand quick attention.
COPD Triggers That Can Increase Exacerbation Frequency
According to the case scenario, Smoking is one of the COPD triggers that might increase the frequency of exacerbations. According to the American Lung Association, breathing cigarette smoke might aggravate pre-existing COPD symptomsSmoking can irritate the airways, raise the risk of lung infection, and hasten the course of COPD. Options for quitting smoking should include a Pharmaceutical nicotine inhaler or nasal spray. nicotine patches, gum, and lozenges (Viniol & Vogelmeier, 2018). Prescription of non-nicotine smoking cessation medications includes bupropion and aids in smoking cessation.
Bertram, G. (2018). Basic & clinical pharmacology. Edu.Zm:8080. http://elibrary.mukuba.edu.zm:8080/jspui/handle/123456789/477
Fialová, D., Kummer I., Držaić M., & & Leppee, M. (2018). Ageism in medication use in older patients. In Contemporary Perspectives On Ageism (pp. 213-240). Springer, Cham.
Groenewegen, A., Rutten, F. H., Mosterd, A., & Hoes, A. W. (2020). Epidemiology of heart failure. European Journal of Heart Failure, 22(8), 1342–1356. https://doi.org/10.1002/ejhf.1858
Hinkle, J. L., & Cheever, K. H. (2018). Brunner and suddarth’s textbook of medical-Surgical Nursing. Wolters Kluwer.
Viniol, C., & Vogelmeier, C. F. (2018). Exacerbations of COPD. European Respiratory Review: An Official Journal of the European Respiratory Society, 27(147), 170103. https://doi.org/10.1183/16000617.0103-2017
Vitacca, M., & Paneroni, M. (2018). Rehabilitation of patients with coexisting COPD and heart failure. COPD Journal of Chronic Obstructive Pulmonary Disease, 15(3), 231–237. https://doi.org/10.1080/15412555.2018.1468427
Case Study Instructions: Mrs. J.
It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span.
Evaluate the Health History and Medical Information for Mrs. J., presented below.
Based on this information, formulate a conclusion based on your evaluation, and complete the Critical Thinking Essay assignment, as instructed below.
Health History and Medical Information
Mrs. J. is a 63-year-old married woman who has a history of hypertension, chronic heart failure, and chronic obstructive pulmonary disease (COPD). Despite requiring 2L of oxygen/nasal cannula at home during activity, she continues to smoke two packs of cigarettes a day and has done so for 40 years. Three days ago, she had sudden onset of flu-like symptoms including fever, productive cough, nausea, and malaise. Over the past 3 days, she has been unable to perform ADLs and has required assistance in walking short distances. She has not taken her antihypertensive medications or medications to control her heart failure for 3 days. Today, she has been admitted to the hospital ICU with acute decompensated heart failure and acute exacerbation of COPD.
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 exhausted and cannot eat or drink by herself.
Height 175 cm; Weight 95.5kg.
Vital signs: T 37.6C, 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 4cm below costal margin.
The following medications administered through drug therapy control her symptoms:
IV furosemide (Lasix)
IV morphine sulphate (Morphine)
Inhaled short-acting bronchodilator (ProAir HFA)
Inhaled corticosteroid (Flovent HFA)
Oxygen delivered at 2L/ NC
Critical Thinking Essay
In 750-1,000 words, critically evaluate Mrs. J.\'s situation. Include the following:
Describe the clinical manifestations present in Mrs. J.
Discuss whether the nursing interventions at the time of her admissions were appropriate for Mrs. J. and explain the rationale for each of the medications listed.
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 a rationale for each of the interventions you recommend.
Provide a health promotion and restoration teaching plan for Mrs. J., including multidisciplinary resources for rehabilitation and any modifications that may be needed. Explain how the rehabilitation resources and modifications will assist the patients\' transition to independence.
Describe a method for providing education for Mrs. J. regarding medications that need to be maintained to prevent future hospital admission. Provide rationale.
Outline COPD triggers that can increase exacerbation frequency, resulting in return visits. Considering Mrs. J.\'s current and long-term tobacco use, discuss what options for smoking cessation should be offered.
You are required to cite to a minimum of two sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.