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. What nursing interventions are appropriate for Mrs. J. at the time of her admission? Based on Mrs. J’s diagnosis of acute decompensated heart failure the nursing priorities would be to enhance myocardial contractility/systemic perfusion, decrease fluid volume overload, and prevent complications. In the acute phase it is important for the nurse to plan and implement (Hogan & Madayag, 2004):
- Monitor and record BP, HR, RR, EKG, and CVP to distinguish fluctuations in cardiac output.
- Mrs. J should be placed and maintained in a sitting position to reduce pulmonary congestion and enable better-quality gas exchange.
- Auscultate heart and lung sounds often: augmenting crackles and dyspnea, diminishing breath sounds suggest deteriorating failure.
- Administer o2 as ordered to enhance gas exchange and amplify existing o2 for myocardial uptake to resist outcomes on hypoxia/ischemia. Monitor SO2 and ABG as ordered to evaluate oxygenation. Set up bipap or cpap at bedtime.
- Administer prescribed medications on exact schedule (Lasix, enalapril, metoprolol, & morphine).
- Monitor serum electrolytes to notice hypokalemia secondary to Lasix.
- Check exact I & O (Mrs. J may require a foley catheter to permit for exact measurement of urine output) to assess fluid standing.
- If fluid restriction is in place, distribute the fluid throughout the day to decrease thirst.
- Promote physical rest and organized activities with repeated rest intervals to decrease myocardial o2 demand/consumption and work overload.
- Offer a calm and comforting setting to reduce Mrs. J’s anxiety; this reduces o2 utilization and reduces requirements of the heart.
2. 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) – Patients with ADHF and evidence of volume overload, regardless of etiology, should be treated with intravenous diuretics as part of their initial therapy. Fluid removal with intravenous diuretics can relieve symptoms and improve oxygenation. Intravenous rather than oral administration is recommended because of greater and more consistent drug bioavailability (Hogan & Madayag, 2004).
- Enalapril (Vasotec) – ACE inhibitors decrease afterload and therefore raise cardiac output (Hogan & Madayag, 2004).
- Metoprolol (Lopressor) – Blocks the cardiac effects of chronic adrenergic stimulation. Assist in decreasing tachycardia & regulating heart rhythm (Hogan & Madayag, 2004).
- IV morphine sulphate (Morphine) – Morphine reduces patient anxiety and decreases the work of breathing. These effects diminish central sympathetic outflow, leading to arteriolar and venous dilatation with a resultant fall in cardiac filling pressures
3. 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.
Four cardiovascular conditions that may lead to heart failure (American Heart Association, 2016):
- Coronary Artery Disease (CAD)- When cholesterol and fatty accumulations develop in the heart’s arteries, a smaller amount of blood is able to arrive at the heart muscle. This accumulation is identified as atherosclerosis. The outcome can be chest pain (angina) or, if blood flow becomes completely blocked, a heart attack. Coronary artery disease may also play a factor to having high blood pressure which, over time, can lead to heart failure.
- Myocardial Infarction (MI) – An MI happens when an artery that delivers blood to the heart muscle gets obstructed. The lack of oxygen and nutrients injure the heart’s muscle tissue – a portion of it eventually “dies.” The injured heart tissue does not contract to its capacity, which debilitates the heart’s capacity to pump blood.
- Hypertension (HTN) – Unmanaged HBP raises the chance of forming heart failure by two to three times. When pressure in the blood vessels is too elevated, the heart has to pump harder than usual to maintain the blood circulating. This takes a toll on the heart, and over a while the chambers get bigger and frailer.
- Abnormal heart valves – Heart valve issues can be an outcome from disease, infection (endocarditis) or a defect existing at birth. When the valves don’t open or close entirely throughout each heartbeat, the heart muscle has to pump harder to keep the blood moving. If the workload becomes too great, heart failure results.
Medical/nursing interventions to prevent the development of heart failure in each condition (American Heart Association, 2016):
CAD & MI
- Have cholesterol tested often, and treat high blood levels.
- Manage high blood pressure and diabetes.
- Take the medications prescribed to correct the function of the heart and prevent additional injury.
- Follow up with PCP for ordered follow-up visits. Consult a cardiologist in addition to your PCP for the reason of including preventive medications.
- Contemplate coronary artery bypass surgery, or an interventional procedure (angioplasty and stent placement) to treat stenosis of blood vessels, if suggested by a cardiologist.
- Consume foods low in fat and salt, and rich in fruits, vegetables, and low-fat dairy products
- Take high blood pressure medicine as prescribed. Various types of medications for treating high blood pressure are available. The physician will base therapy on blood pressure readings and other medical conditions present. Medications must be taken regularly and in the correct dosage.
Abnormal heart valves
- Valve repair—preserves the patient’s valve and leaflets. Sometimes repairs demand a minimal surgery procedure and other times repairs need a more extensive surgery. Repair is most often possible for mitral valve regurgitation and tricuspid valve regurgitation.
- Valve replacement — which can involve transcatheter aortic valve replacement (TAVR) or other minimally invasive procedure. In many cases, the best long-term solution can demand a more extensive operation such as the Ross procedure or the insertion of a new tissue or manufactured valve.
4. 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.
- Adequate monitoring – monitoring for complications, effectiveness, or both is essential in preventing multiple drug interactions. Close examination can determine if the medication may be discontinued if the medical problem is resolved or causing complications. Insufficient careful monitoring, particularly after new drugs are prescribed, raises the risk of adverse effects and ineffectiveness.
- Provide effective communication between the patient’s various health providers- it is important that all healthcare providers be aware and be on the same page of all medications patients are taking so that multiple prescriptions are not being doubled.
- Assess all medications patient currently prescribed and taking- Most elderly patients may not know or be aware of the medications they are taking and may be taking a medication for no medically legitimate reason.
- Be aware of dietary supplements the patient may be taking- Medicinal herbs can interact with prescribed drugs and lead to adverse effects. For example, ginkgo biloba extract taken with warfarin can increase risk of bleeding, and St.John’s wort taken with an SSRI can increase risk of serotonin syndrome.