Critical Thinking Essay: Case Study of Mrs J

Mrs J is a 63 year-old woman with a past medical history of hypertension and chronic heart failure. She has been a heavy smoker for the last forty or so years and continues to smoke to date. Because of this habit she developed emphysema and chronic bronchitis over time and this is also present in her medical history as chronic obstructive pulmonary disease or COPD (GOLD, 2017). Mrs J is being treated for her chronic conditions. However, she does not take her medications regularly as she is required to. This paper discusses her symptoms, her medications, and health education needed for her to stop the habit of smoking.

The Symptoms or Clinical Presentation

By examining Mrs J’s symptoms or clinical manifestations closely, it is abundantly clear that what she is having is an increase in the severity of her COPD. There is also a possibility that her heart failure is getting worse. The reasons for this are that she is predominantly having dyspnea on exertion (she cannot perform her activities of daily living or ADLs), malaise, a cough, nausea, and a low-grade fever of 37.6°C. Tellingly, she has also been having symptoms that are suggestive of flu. In clinical critical thinking and given her medical history, this can only mean that the flu infection is what most probably triggered an exacerbation of the COPD. The chronic emphysema and bronchitis of COPD have impaired her gaseous exchange. This coupled with the inefficiency of the heart in pumping blood to the tissues make her suffer hypoxemia (low oxygen) in the blood and tissues (Hammer & McPhee, 2018). This shows as a low SpO₂ reading of just 82% which means that she requires supplemental oxygen. In COPD, the normal mucociliary clearance mechanism is altered and excessive sticky mucus accumulates in the airways. Additionally, the mucus glands hypertrophy and become hyperactive. This is the explanation for the productive cough that she has (Singh et al., 2018). Lastly, a plausible explanation for the nausea she has is that the vomiting center in the brain’s medulla may have been suffering irritation due to the hypoxemia leading to the nausea that she is experiencing. Critical Thinking Essay paper

Medications and Nursing Interventions for Mrs J

Mrs J is on the diuretic furosemide, inhaled corticosteroids, inhaled short-acting beta-agonists (SABA), the angiotensin-converting enzyme inhibitor (ACEI) enalapril, the opioid morphine, and the beta-blocking agent metoprolol (Rosenthal & Burchum, 2018). All these medications have a rationale behind their prescription for Mrs J. the SABA in the form of a drug such as albuterol reduces bronchospasms by acting locally and directly on the beta receptors in the respiratory airways. Inflammation that also increases the swelling of the airways is reduced – also directly and locally – by the inhaled corticosteroids. Morphine is known to relieve difficulty in breathing at therapeutic doses. The ACEI inhibitor and furosemide are there to control the hypertension and to manage the heart failure. The ACE inhibitor relaxes the blood vessels reducing blood pressure while the loop diuretic prevents reabsorption of water by the renal tubules thereby reducing intravascular volume and blood pressure. The fluid reduction also helps the failing heart to work more efficiently.

The nursing management of Mrs J on admission included several actions all of which were appropriate. The nurses took her vital signs, an action that is procedural as her baseline readings needed to be recorded. They then put her on supplemental oxygen by nasal cannula at 2 liter per minute after finding a low reading of the partial pressure of oxygen or SpO₂ in a dyspneic patient. Additionally, the nurses administered the prescribed medications as discussed above. Mrs J had not taken her medications in days due to poor compliance.

Four Heart-Failure-Causing Cardiovascular Conditions

According to the American Heart Association (AHA, 2017), valvular malfunction, a history of previous myocardial infarction (MI), hypertension, and coronary artery disease (CAD) are some of the conditions that can lead to the development of heart failure. Hypertension is increased resistance of the arterial walls to the pressure exerted by the heart’s left ventricle as it pumps oxygenated blood to the rest of the body. Left unmanaged, this prolonged resistance eventually makes the left ventricle hypertrophy as it strives to overcome this resistance. The result is that the heart fails (Hammer & McPhee, 2018; AHA, 2017). Coronary artery disease or CAD is caused by deposition of atherosclerotic material in the lining of coronary arteries. With time, the plaque becomes bigger and bigger occluding the lumen of the coronary artery. The heart is starved of oxygenated blood and begins to fail as the myocardium cannot work well (anaerobically) without oxygen. Cad eventually results to a MI in the event that cardiac catheterization is not done on time. This means that a part of the myocardium undergoes necrosis when the lumen of the coronary artery supplying it gets completely blocked. Lastly but not least, incompetence of any of the heart valves will also result in heart failure. An example is regurgitation of blood by the mitral valve due to its deformities caused by a childhood disease (group A beta-hemolytic streptococci) or a congenital malformation.

Prevention of the above four conditions is best achieved through primary prevention. This means timely health education to those at risk of suffering these diseases such as those who are overweight or obese (Hammer & McPhee, 2018). This involves lifestyle changes in diet and habits. The person must eat enough fresh fruits and vegetables with every meal. They must also engage in physical activity regularly in the form of exercise. This can take the form of either resistance training or simply isotonic aerobic exercise such as walking (MacDonald & Pescatello, 2018). These measures will prevent hypertension, CAD, and MI through actions such as prevention of accumulation in the blood of low-density lipoprotein cholesterol or LDL cholesterol. Secondary prevention is the key to valvular incompetence through thorough and complete antibiotic treatment of all childhood sore throat cases. Screening of pregnant women antenatally will also be beneficial in recognizing congenital abnormalities in utero. If all fails, tertiary prevention through cardiac surgery is undertaken to correct the valvular anomalies or insert an artificial prosthetic valve.

Nursing Interventions to Prevent the Consequences of Multiple Medications Prescribed for the Elderly

The elderly are already frail and have failing physiological systems. They also suffer from multiple comorbidities. By default, they usually find themselves having to take multiple medications at any given time. This predisposes them to adverse drug reactions and interactions. Some of the nursing interventions that can prevent this eventuality are (i) pre-packing the medications in doses and placing them in specially designed compartments in a drug container. These are labelled with the time the medication dose is to be taken. (ii) Education on drug compliance in order to enter remission and remove the need for the other medications; and (iii) education on signs of medication interactions or side effects. The rationale for all these is that the patent needs to be responsible for their own care as much as possible to prevent unwanted hospital readmissions. Critical Thinking Essay paper

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Smoking Cessation Health Promotion, Rehabilitation and Restoration

Mrs J will have to start reducing and tapering off the number of cigarettes she smokes per day. Having smoked almost all her adult life, this will not be easy as the craving will be enormous. For this reason, she can be given nicotine patches to help with the craving as she tapers off the number of sticks per day. A physiotherapist may have to help her with measured exercises even as she starts eating a diet richer in fresh fruits and vegetables. She will also have to avoid other respiratory irritants and allergens apart from cigarette smoke. These are dangerous triggers of COPD exacerbation.  Critical Thinking Essay paper

References

American Heart Association [AHA] (May 31, 2017). Causes of heart failure. https://www.heart.org/en/health-topics/heart-failure/causes-and-risks-for-heart-failure/causes-of-heart-failure

Global Initiative for Chronic Obstructive Lung Disease [GOLD] (2017). Pocket guide to COPD diagnosis, management, and prevention: A guide for health care professionals. https://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

MacDonald, H.V. & Pescatello, L.S. (2018). Exercise prescription for hypertension: New advances for optimizing blood pressure benefits. Lifestyle in Heart Health and Disease, 115-136. https://doi.org/10.1016/B978-0-12-811279-3.00009-4

Rosenthal, L.D., & Burchum, J.R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.

Singh, D., Barnes, P.J., Stockley, R., Valera, M.V.L., Vogelmeier, C. & Agusti, A. (2018). Pharmacological treatment of COPD: The devil is always in the detail. European Respiratory Journal, 51(4), https://doi.org/10.1183/13993003.00263-2018

Instructions for Case Study: Mrs. J
-Evaluate the health history and medical information for Mrs. J presented below:
Health History
-Mrs. J is 63-year-old married women who has a history of hypertension, CHF and COPD
-Despite requiring 2 liters of oxygen nasal cannula at home during activity, she continues to smoke 2 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 anti-hypertensive medications, or medications to control heart failure for 3 days
-Today, she has been admitted to the hospital ICU with acute decompensated heart failure and acute exacerbation of COPD
Subjective Data
-She 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
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 p
-all peripheral pulses are 1+, bilateral jugular vein distention
-initial cardiac monitoring indicates a ventricular rate of 132 and atrial fib
-Respiratory: Pulmonary crackles: decreased breath sounds right lower lobe, coughing frothy blood-tinged sputum, spo2 82%
-Gastrointestinal: BS present: hepatomegaly 4cm below costal margin

Interventions
The following medications were administered through drug therapy to control her symptoms:
-IV furosemide (Lasix)
-Enalapril (Vasotec)
-Metoprolol (Lopressor)
-IV morphine sulfate
-Inhaled short-acting bronchodilator (ProAir HFA)
-Inhaled corticosteroid (Flovent HFA)
-Oxygen delivered at 2L/NC
Critical Thinking Essay
-In 1000 words, critically evaluate Mrs. J’s situation include the following:
1. Describe the clinical manifestations present in Mrs. J.
2. Discuss whether the nursing interventions at the time of her admission were appropriate for Mrs. J and the rationale for each of the medications listed
3. Describe 4 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
4. Taking into consideration the fact that most mature adults take at least 6 prescription medications, discuss 4 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
5. 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 patient’s transition to independence
6. Describe a method for providing education for Mrs. J regarding medication that needs to be maintained to prevent future hospital admission
7. Outline COPD triggers that can increase exacerbation frequency resulting in result visits. Considering Mrs. J’s current and long-term tobacco use, what options for smoking cessation should be offered
-You are required to cite a minimum of 2 sources
-Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice    Critical Thinking Essay paper

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