Use The Following Case Scenario, Subjective Data, And Object ✓ Solved

Use the following Case Scenario, Subjective Data, and Object

Use the following Case Scenario, Subjective Data, and Objective Data to answer the Critical Thinking Questions.

Case Scenario: 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: 1. She is very anxious and asks whether she is going to die. 2. Denies pain but says she feels like she cannot get enough air. 3. Says her heart feels like it is "running away." 4. Reports that she is so exhausted she cannot eat or drink by herself.

Objective Data: 1. Height 175 cm; Weight 95.5 kg 2. Vital signs: T 37.6 C, HR 118 and irregular, RR 34, BP 90/58 3. Cardiovascular: Distant S1, S2, S3 present; PMI at sixth ICS and faint; all peripheral pulses 1+; bilateral jugular vein distention; initial cardiac monitoring indicates a ventricular rate of 132 and atrial fibrillation 4. Respiratory: Pulmonary crackles; decreased breath sounds right lower lobe; coughing frothy blood-tinged sputum; SpO2 82% 5. 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? 1. IV furosemide (Lasix) 2. Enalapril (Vasotec) 3. Metoprolol (Lopressor) 4. 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.

Paper For Above Instructions

Introduction and Assessment at Admission

Nursing Interventions for Symptom Control and Stabilization

Rationale for Each Medication

1) IV furosemide (Lasix): Furosemide rapidly reduces preload by diuresis, relieving pulmonary edema and improving dyspnea and oxygenation. It also decreases systemic venous pressures, which can lessen JVD and hepatic congestion. Monitoring includes urine output, electrolyte balance (notably potassium and magnesium), kidney function, and blood pressure to avoid intravascular depletion. In ADHF with volume overload, loop diuretics are foundational therapy (Yancy et al., 2017; Ponikowski et al., 2016). (Yancy et al., 2017; Ponikowski et al., 2016)

2) Enalapril (Vasotec): An ACE inhibitor, enalapril reduces afterload and preload indirectly by vasodilation, which improves forward cardiac output, decreases myocardial oxygen demand, and may limit adverse remodeling. ACE inhibitors have mortality and hospitalization benefits in chronic HF and can be initiated in the setting of stable or improving hemodynamics when renal function and potassium levels are acceptable. Monitor for hypotension, renal function, and hyperkalemia. (Yancy et al., 2017; Ponikowski et al., 2016)

3) Metoprolol (Lopressor): Beta-blockade in chronic HF reduces mortality and adverse remodeling, and can improve long-term outcomes by limiting sympathetic overactivity. Initiation or continuation requires careful assessment of hemodynamics: acute decompensation with hypotension or shock generally argues for delaying uptitration until stabilization; once stabilized, low-dose initiation or cautious uptitration is recommended to achieve a target heart rate and improve EF over time. (Yancy et al., 2017; Ponikowski et al., 2016)

4) IV morphine sulphate (Morphine): Morphine historically served to relieve dyspnea and anxiety in severe pulmonary edema. However, current guidelines and evidence indicate limited or no mortality benefit and potential adverse effects such as respiratory depression, hypotension, and sedation. Its routine use is discouraged; it may be considered in select patients with severe distress after weighing risks versus benefits and in settings where other measures have failed. This reflects evolving guidance on morphine use in ADHF (Beers Criteria and contemporary HF practices) (American Geriatrics Society, 2019; NHLBI, 2020). (Beers Criteria 2019; NHLBI 2020)

Four Cardiovascular Conditions That May Lead to Heart Failure and Preventive Interventions

1) Chronic Hypertension: Prolonged elevated blood pressure leads to left ventricular hypertrophy and eventual systolic/diastolic dysfunction. Prevention includes aggressive BP control with antihypertensives (ACE inhibitors, ARBs, thiazide diuretics, CCBs as appropriate), weight management, exercise, sodium restriction, and smoking cessation. Regular surveillance to ensure adherence and detect early HF signs is essential (Ponikowski et al., 2016; Yancy et al., 2017). (Ponikowski et al., 2016; Yancy et al., 2017)

2) Coronary Artery Disease and Myocardial Infarction: Ischemic injury can weaken myocardial contractility and precipitate HF. Preventive strategies include lipid management with statins, antiplatelet therapy, smoking cessation, effective risk-factor modification, and revascularization when indicated. Early CAD management reduces HF risk and improves survival (Yancy et al., 2017; Benjamin et al., 2019). (Yancy et al., 2017; Benjamin et al., 2019)

3) Valvular Heart Disease (e.g., aortic stenosis or significant mitral regurgitation): Valve dysfunction increases cardiac workload and promotes HF over time. Prevention involves timely surgical or transcatheter valve repair/replacement when indicated, along with medical optimization (afterload reduction, rate control in concomitant AF). Regular monitoring for progression is key (Ponikowski et al., 2016; McMurray et al.). (Ponikowski et al., 2016; McMurray et al., 2012)

4) Arrhythmias and Tachyarrhythmias (e.g., atrial fibrillation with rapid ventricular response): AF diminishes atrial contribution to ventricular filling and can reduce EF, accelerate HF progression, and contribute to thromboembolism. Preventive measures include rate control with appropriate medications, rhythm control strategies when suitable, anticoagulation for stroke prevention, and consideration of ablation in selected patients. Early rhythm management and anticoagulation reduce HF progression and mortality (Yancy et al., 2017; Ponikowski et al., 2016). (Yancy et al., 2017; Ponikowski et al., 2016)

Nursing Interventions to Prevent Problems from Multiple Drug Interactions in Older Adults

1) Comprehensive medication reconciliation at each transition of care (admission, transfer, discharge) to identify potential interactions and duplications. Involve the patient and caregivers, verify prescriptions with the pharmacy, and ensure updated lists are accessible to all providers. Rationale: polypharmacy increases the risk of adverse drug events; reconciliation reduces error and improves safety (Beers Criteria 2019; AGS). (Beers Criteria 2019; American Geriatrics Society, 2019)

2) Regular use of Beers Criteria and age-related pharmacology review to guide prescribing and monitoring of high-risk medications in older adults; avoid or adjust combinations with known interaction risks (e.g., combining NSAIDs with ACE inhibitors or diuretics). Rationale: reduces harm from inappropriate medications and highlights safer alternatives (Beers Criteria 2019). (Beers Criteria 2019)

3) Simplify regimens and optimize dosing schedules to reduce confusion and nonadherence; evaluate renal/hepatic function and adjust dosages accordingly; prefer once-daily dosing when possible. Rationale: simplified regimens decrease errors and interactions in patients taking multiple drugs daily (AGS/polypharmacy literature). (American Geriatrics Society, 2019)

4) Engage interprofessional team-based approaches including pharmacists for medication therapy management and patient education; provide clear discharge instructions, use pill organizers or electronic reminders, and encourage medication review visits. Rationale: pharmacotherapy optimization in older adults requires collaborative care to minimize interactions and ensure safe deprescribing where appropriate (AGS Beers Criteria, 2019; NHLBI). (Beers Criteria 2019; NHLBI 2020)

Discussion and Conclusion

The case of Mrs. J. underscores the complexity of managing acute decompensated heart failure in an older patient with significant comorbidities and polypharmacy. Early and targeted nursing interventions guided by HF guidelines can stabilize the patient and reduce complications. Pharmacologic therapy must be individualized, balancing hemodynamic status, renal function, and electrolyte balance while remaining mindful of evolving evidence about morphine use in acute pulmonary edema. Long-term strategies to prevent HF progression involve addressing modifiable risk factors, surgical or percutaneous interventions for valvular disease when appropriate, and polydrug safety through systematic reconciliation and geriatric pharmacology principles. (Yancy et al., 2017; Ponikowski et al., 2016; Beers Criteria 2019)

References

1. Yancy CW, Jessup M, Bozkurt B, et al. 2017. 2017 ACC/AHA/HFSA Focused Update of the 2013 Guideline for the Management of Heart Failure. Circulation. 136(6): e137-e161.
2. Ponikowski P, Voors AA, Anker SD, et al. 2016. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 37(27): 2129-2200.
3. Mozaffarian D, Benjamin EJ, Go AS, et al. 2015. Heart disease and stroke statistics—2015 update. Circulation. 131(4): e29-e322.
4. Benjamin EJ, Muntner P, Alonso A, et al. 2019. Heart disease and stroke statistics—2019 update. Circulation. 139(3): e56-e528.
5. American Heart Association. 2020. Heart Failure Fact Sheet. Retrieved from https://www.heart.org/en/health-topics/heart-failure
6. National Heart, Lung, and Blood Institute. 2020. What is Heart Failure? Retrieved from https://www.nhlbi.nih.gov/health-topics/heart-failure
7. American College of Cardiology. 2020. Heart Failure Overview. Retrieved from https://www.acc.org
8. American Geriatrics Society. 2019. Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 67(4): 1489-1501.
9. Hajjar ER, Hanlon JT, Schmitz SC. 2007. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 5(4): 345-351.
10. NHLBI. 2020. Polypharmacy and Older Adults. Retrieved from https://www.nhlbi.nih.gov