Mandatory Discussion Question
Mrs. J is having some serious symptoms at the time of her admission and the appropriate nursing interventions for her will be taking her vital signs, performing a systematic assessment to prioritize care in an appropriate manner, finding the cause of her current symptoms, and initiating an appropriate treatment. In addition, patients presenting with acute dyspnea from acute decompensated heart failure (ADHF) should be rapidly assessed and stabilized (Colucci, 2017). Some of initial laboratory testing’s that must be completed are CBC, UA, serum electrolyte levels, liver function tests, BNP, NT-proBNP, ECG, chest radiography, cardiac troponin T and I, TSH and lipid profile. Managing her low oxygen saturation of 82% will be the first priority based on the airway, breathing, and circulation rule used by medical professionals. To control her shortness of breath and oxygen saturation of 82%, Mrs. J will require a non-rebreather facemask to deliver high-flow percent oxygen. Also, she will need to be in a seated posture to help her with her breathing and the volume overload based on her symptoms of all peripheral pulses of 1+, bilateral jugular distention, pulmonary crackles, and coughing. As presented in the scenario, Mrs. J is having many organ system complications. She is having respiratory, cardiovascular, and gastrointestinal problems that are causing her current health condition. She is experiencing acute decompensated heart failure that requires rapid care in the ICU where she will be continuously monitored. For this, Mrs. J will require continuous cardiac monitoring to prevent further threatening conditions. Also, administration of multiple drugs to control her symptoms will be required. Mrs. J needs supplemental oxygen to manage her shortness of breath, ionotropic agents to increase the strength of muscular contraction of her heart, diuretics to reduce edema and volume overload, and vasodilators to improve cardiac output, hemodynamics, and symptoms.
Drug therapy of IV furosemide, enalapril, metoprolol, and morphine sulphate was started for Mrs. J to control her symptoms.
The rationale for administration of IV furosemide (Lasix) is to reduce the volume overload and produce better outcomes by relieving symptoms and improving oxygenation. In addition, furosemide is a loop diuretic (water pill) that prevents one’s body from absorbing too much salt and allows the salt to instead be passed in urine. It is used to treat fluid retention (edema) in people with congestive heart failure, liver disease, or a kidney disorder such as nephrotic syndrome.
The rationale for Enalapril (Vasotec) is to relax blood vessels so blood can flow easily and decreases the amount of work the heart has to do. It also blocks a substance in the blood called angiotensin that is made as a result of heart failure.
The rationale for Metoprolol ( Lopressor) is to control symptoms of heart failure that are made worse by certain hormones called catecholamines. They also work by slowing the heart rate and slowing the progression of heart failure. Beta-blockers are also used together with other medicines that are usually used to treat heart failure, such as angiotensin-converting enzyme (ACE) inhibitors or diuretics.
The rationale for IV morphine sulphate (Morphine) is reduce anxiety and decrease the work of breathing. Morphine is thought to produce mild vasodilatation, induce respiratory relaxation and exert a calming effect on those with agitated dyspnea. Despite empiric use, there is limited evidence in support of morphine in acute HF and several small trials suggesting potential harm. Moreover, in ADHERE (Acute Decompensated Heart Failure Registry), morphine use was found to be an independent predictor of in-hospital mortality (Levy & Bellou, 2013).
Coronary artery disease is a cardiovascular condition in which cholesterol and fatty deposits build up in the heart’s arteries that causes less blood to reach the heart muscle. This build up is knows an atherosclerosis. This can cause chest pain or heart attack. CAD also can contribute to having high blood pressure over time that may lead to heart failure. Interventions to prevent development of heart failure due to CAD can be done by making some lifestyle changes. High blood pressure, high blood levels of lipids (LDL, total cholesterol, and triglycerides), diabetes, smoking, and obesity are risk factors for coronary artery disease. Eating a diet low in fat, losing weight if overweight, exercising on most days, quitting smoking, controlling high blood pressure and diabetes, getting cholesterol checked regularly and seeing doctor for regular follow-up visits can have a major effect on reducing the chances of having a heart failure.
Hypertension is another cardiovascular condition that may lead to heart failure. When pressure in the blood vessels is too high, the heart has to pump harder than normal to keep the blood circulating. This takes a toll on the heart, and over time the chambers get larger and weaker. People who are at risk of developing heart failure, may need to get a prescription for a medication to keep their blood pressure below 130/80 mm Hg. Untreated high blood pressure, or hypertension, can lead to an enlarged heart and heart failure. To prevent heart failure due to hypertension, it is important that people with hypertension eat food low in fat and salt, eat more vegetables and low-fat dairy products, lose weight if overweight, limit alcohol intake, exercise regularly, quit smoking, and take high blood pressure medications as prescribed by their physician.
Myocardial infarction is also a cardiovascular condition that may lead to heart failure. It is when an artery that supplies to the heart muscle gets blocked and the loss of oxygen and nutrients damages the heart’s muscle tissue and some part of it essentially dies. This damaged heart tissues then does not contract as well which weakens the heart’s ability to pump blood. Patients who had MI in the past must follow-up with their physician and be compliant with their prescribed medications.
Lastly, abnormal heart valve is another cardiovascular condition that may lead to heart failure. It may results from disease, infection(endocarditis) or a defect present at birth. When the valves don’t open or close completely during each heartbeat, the heart muscle has to pump harder to keep the blood moving. If the workload becomes too great, heart failure results. To prevent heart failure people who have abnormal heart valve must follow-up with their physician for any early symptoms that they may be experiencing so their physician can prescribe treatment before it gets worse.
Older adults are at risk for polypharmacy. This is when they take multiple medications concurrently to manage their coexisting health problems such as hypertension or diabetes. This becomes problematic when multiple healthcare providers working independently of each other prescribe different medications for the older patient. This can cause drug interactions if those health care providers are not aware of the older adults complete medication list. To prevent this from happening it is important that these patients get educated on importance of taking their medications with them when they visit another healthcare provider. It is important for them to keep an accurate list of all medications, including generic and brand names, dosages, dosing frequency, and reason for taking the drug. Nursing interventions that can help prevent problems caused by multiple drug interactions in older patients are by reviewing older patients medications to ensure medications prescribed are appropriate to the patients and that there is no drug interactions, verifying that the patient understands and agrees to the regimen which can reduce changes of double dosing. Patient education is a key intervention to assist older adults with medication management. When patients have knowledge of their drugs it is positively associated with adherence. Also, advising to use a medication pill box to organize medications have found to increase medication adherence and prevent missing or double dosing. Medication schedules and calendars are helpful, especially in combination with education and use of a pill box. Therefore, monitoring medications and patients adherence to their medication is an ongoing process and health care professionals can educate patients and their family members on the medications patient is taking and reporting of any abnormal side effects or ask any questions they may have regarding their medications.