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posts_to_answer.docxANSWER THE FIRST TWO QUESTIONS, THEY ARE QUESTIONS
POST 1
“Atrial fibrillation is the most common arrhythmia in patients visiting a primary care practice. Although many patients with atrial fibrillation experience relief of symptoms with control of the heart rate, some patients require restoration of sinus rhythm.” (Dell-Orfano) Since Mrs. J is in a-fib we can look at her medication list and realize that Metrolprolol is a medication that can help return her to sinus rhythm. Most medications have more than one use and Metroprolol is also used in chronic hypertension and is quite effective. Realizing that Mrs. J hasn’t eaten properly nor taken her medications properly, it is possible that her electrolytes are off and that too could put her into an arrhythmia. Which electrolyte imbalance do you think might cause the a-fib?
Reference:
POST 2
you mentioned that morphine is given to help relieve her pain, is that the only reason that morphine is used in the CHF patient?
POST 3
First of all, give patient emotional support, check her vital signs, elevate the head of her bed; it will help in her breathing. Then administer oxygen via non-rebreather mask or as per doctor’s order, place her on continuous cardiac monitor to see her cardiac activity and set the monitor for frequent vital signs with continue pulse oxymeter, about every 10-15 minutes. Then start an IV and draw stat blood work as ordered by the doctor.12 lead EKG and portable chest X-ray, calling the Respiratory Therapist to draw ABG and breathing treatment should be next. Then insert Foley’s catheter for strict output documentation. Get the list of home medicine or get the medicine if she brought from home. Then apply SCD to prevent her from thrombolytic embolism, as per hospital policy.
IV Furosemide (Lasix): It is a loop diuretic which means it inhibits NaCl reabsorption in the thick ascending limb of henle's loop. The thick ascending loop of henle is responsible for a large amount of NaCl reabsorption capacity. Furosamide is useful in treating heart failure, edema, and hypertension that the patient has. Lasix blocks the absorption of sodium and water and increase the urination so excessive fluid excreted from the body. Patient should be observed for hypotension. During heart failure, there is decreased perfusion to the kidneys which leads to renal retention of water and salt. This may partially restore the cardiac output but if the underlying disease causes cardiac output to decrease even further the kidneys will continue to retain salt and water. This will eventually result in interstitial or pulmonary edema. Diuretics such as furosemide cause reduced pulmonary vascular congestion and improve oxygenation and hence improve myocardial function. In hypertension diuretics such as thiazides are preferred over loop diuretics because of their mild vasodilator action in addition to improving blood flow but in patients with renal insufficiency or heart failure loop diuretics are used. Diuretics also enhance the efficacy of ACE inhibitors.
Enalapril (Vasotec): It is an orally active ACE inhibitor and they result in decreased vascular resistance without increasing heart rate and the also increase natriuresis. So they are effective in the treatment of hypertension and lessen the mortality and morbidity in heart failure as well. It helps in improving the ability of the heart to function and reduce symptoms. Unlike direct vasodilators these can be safely used in patients with ischemic heart disease.
Metoprolol (Lopressor): It is a beta-blocker used to treat for tachycardia and atrial fibrillation. It has high specificity for the Beta 1 receptors so it is safe to use in patients with bronchoconstriction which may aggravate if a non specific beta blocker like propanolol is used. The beta-blockers decrease incidence of anginal disease and also help to increase exercise tolerance. These drugs block cardiac beta receptors which results in decreased cardiac work and decreased cardiac demand. Lopressor is indicated in the treatment of definite or suspected acute myocardial infarction to reduce cardiovascular mortality.
IV Morphine sulphate (Morphine): Morphine is an opioid analgesic and hence reduces constant severe pain. The pulmonary edema results in dypsnea which is relieved by the use of morphine. Mechanism of action is reduced anxiety which decreases shortness of breath and reduces cardiac preload and after load. So in this case, morphine will help to reduce her anxiety, help her in breathing and relieve stress on her heart.
The four cardiovascular conditions that may lead to heart failure are hypertension, stroke, arrhythmias, and coronary artery disease.
Hypertension: Hypertension is the excessive force of blood pumping through the blood vessels. It is a common form of cardiovascular disease. Hypertension is one of the most preventable and treatable types of cardiovascular disease. High blood pressure needs to be controlled; otherwise it will lead to heart failure. Hypertension can be controlled by weight control, regular exercise, low salt diet and stay stress free by using different stress relief techniques. The patient should see the doctor regularly to monitor BP and taking prescribed medicines. By using all the preventive measures it helps to control blood pressure and prevent heart failure.
Stroke: A stroke occurs when blood flow to the brain is interrupted or when a blood vessel in the brain ruptures. It can cause the death of brain cells in the affected areas. Stroke is also a neurological disorder because of the many complications it causes. Other forms of cardiovascular diseases, such as high blood pressure, increase the risk of stroke. It also leads to heart failure. It can be prevented by controlling blood pressure and taking other preventive measures such as regular checkup, daily exercise, weight control, staying stress free by using different techniques.
Arrhythmias: Arrhythmias occur when the electrical impulses in the heart that coordinates the heartbeats do not function properly; causing the heart to beat too fast, too slow meaning irregularly. It can also lead to heart failure. It can be prevented or keep under control by using heart healthy diet, regular excises, taking prescribed anti arrhythmic medicines.
Coronary artery disease: This is a common form of cardiovascular disease. Coronary artery diseases are diseases of the arteries that supply the heart muscle with blood. Coronary artery disease is the leading cause of heart attacks. It generally means that blood flow through the coronary arteries has become obstructed, reducing blood flow to the heart muscle. It can lead to heart failure. It can be prevented by taking cardiac medication to reduce the cardiac work load, diuretics to avoid extra fluids, and eating a heart healthy diet and getting regular exercise.
Taking multiple drugs together is called polypharmacy. There are so many interventions that can be used to prevent problems caused by polypharmacy and multiple drug interactions in older patients.
Medicine information: Older patients should have an accurate list of all the medicine, doses, frequency, route and reason for taking medicine, contact information and the name of the pharmacy the patient using. This information will help the care providers to see the whole picture.
Using one pharmacy: Suggest the patient to always go to one pharmacy, it prevents confusion. Pharmacists get used to the patient and they always have a list of the medicine in the computer. The pharmacist should be able to verify the list of medicines, when needed. This way the patient always gets the right medicine and the right dosage.
Medication instructions: It is very important to give instructions to the patient, especially an older patient. They need written instructions, such as the purpose of each medication, reason for why the medicine is prescribed, frequency of taking the medicine, side effects of the medicine, and when to seek emergency care.
Organization in pill dispenser: Daily or weekly pill dispensers are a good intervention to prevent polypharmacy confusion. Suggest the patient to use a pill box to avoid overdose.
References
Drugs.com. (2014). Cardiovascular agents. Retrieved from http://www.drugs.com/drug-class/cardiovascular-agents.html
Mayo Clinic. (2013). Heart failure. Retrieved from http://www.mayoclinic.com/health/heart-failure/DS00061/DSECTION=symptoms Woodruff, Kathleen . (2010). Preventing
Polypharmacy in Older Adults. Retrieved from http://www.americannursetoday.com/article.aspx?id=7132&fid=6852
POST 4
Nursing interventions appropriate for Mrs. J who is a 63 year old admitted to ICU in heart failure with a past medical history of hypertension, chronic heart failure, sleep apnea, and chronic two pack a day cigarette smoking for 40 years; include a complete head to toe assessment with vital signs, obtain history of routine medications taken at home, both prescribed and OTC; ask about any known allergies, including drug allergies.
Additional nursing interventions include explaining to Mrs. J what the nurse will be doing to care for her, and maintaining privacy and confidentiality which can help to relieve anxiety. Position her in upright comfortable position enhancing her ability to breathe easy. Apply cardiac monitor, get 12 lead ECG to monitor cardiac arrhythmia. Listen to her breath sounds bilaterally in bases and upper lobes anterior and posterior. Assess skin color and temperature. Looking and listening for signs of respiratory distress. Explain to patient the physician ordered plan for her care. Based on the respiratory assessment, I would give her 2 LPM oxygen via nasal canula because her SpO2 is 82%. Due to signs of pulmonary edema, SOB, cough with frothy, bloody sputum, crackles in base of lung, administer medications as ordered.Lasix IV – Diuretic, given to lower intravascular volume, and enhance excretion of fluid. Used to reduce pulmonary and peripheral edema. (Copstead-Kirkhom, 2013)
Vasotec - Blood pressure medication that causes vasodilatation, relaxing and expanding of the blood vessel, Used to make it easier for the heart to pump blood. (AHA, 2014)
Lopressor – Beta Blocker medication lowers blood pressure, lowers heart rate, decreases heart palpitations, and increases heart muscle contractility. Should not be used on very low blood pressure. (AHA, 2014) (Lect. 3, 2013)
Morphine IV- Reduces cardiac workload, reduces congestive symptoms, lowering cardiac preload and after load. (Copstead-Kirkhom, 2013)
Conditions that can lead to congestive heart failure include: hypertension- change lifestyle and take medication, cardiomyopathy- maintain regular health screenings, lifestyle changes, follow doctors recommendations, lung disease- lifestyle changes, do not smoke, follow doctor recommendation, diabetes- life style changes, take medications, lose weight, eat properly and heart valve disease- lifestyle change, follow doctor recommendations. Lifestyle changes include (healthy diet, exercise, no drug and alcohol use, weight loss) (Copstead-Kirkhom, 2013)
Interventions to reduce drug interactions include teach patient to become familiar with medication use, teach patient to follow prescription direction, demonstrate to patient safe medication administration at home, and instruct patient to take medicine 1-2 hours apart from other medications and seek support from pharmacist. In addition, teach patient to use pill organizer and if there is concern that patient is unable to self medicate safely at home seek family support or social services.
POST 5
Mrs. J. is a 63 year old obese female with a history that includes many problems such as heart failure, HTN, and sleep apnea. She is also a heavy smoker who smokes 2 packs per day x 40 years. Upon admission and institution of droplet precautions, the nurse must first begin reassuring and calming the patient, explaining the plan of care and act fast with other interventions. The nurse would immediately place on cardiac monitor, with frequent vitals, O2 as ordered by physician and contact respiratory therapy immediately since patient has sleep apnea and most likely utilizes a CPAP at home. The patient may require CPAP or BIPAP to help stabilize her breathing. The nurse knows that getting her medications on board and stabilizing her heart failure will help with other problems including the hepatomegally which can result from heart failure. This patient would have to be semi-fowlers to high fowler’s position depending on her and where she feels most comfortable. Other interventions would be finding a family member or friend if available to be with the patient during this time to add comfort and calm her down. The nurse will need to advocate for other medications such as Tylenol for fever or perhaps something to combat the nicotine withdrawal she will eventually have to deal with that could cause more anxiety and agitation in the patient. SCD’s can also be placed on the patient to help with circulation. These should be utilized in patients who are not mobile. The patient will also need strict I & O’s so IV’s should be on a pump and a foley catheter should be placed.
1) Lasix – diuretic utilized to rid the body of excess fluid in the lungs caused from heart failure. This will hopefully help Mrs. J’s breathing.
2) Vasotec: Used in heart failure and should be used with a diuretic ie: Lasix. It is used if the patient is symptomatic and can help to stabilize blood pressures caused by chronic hypertension.
3) Metroprolol: is an anti-hypertensive used also to treat a-fib which the patient is currently in this rhythm.
4) IV Morphine – helps this patient in many ways by decreasing her respirations which allows her heart and lungs to rest because her heart doesn’t have to pump as hard. It decreases anxiety and helps her to relax.
Four conditions that can lead to heart failure include:
1) Arrhythmias: While hospitalized the nurse can monitor closely the rhythm of the heart either by heart monitor or by listening to all heart sounds and recognizing if there is an arrhythmia. Then the nurse needs to advocate for the patient by contacting the physician for medical intervention with anti-arrhythmia drugs, cardioversion, ablation, or defibrillation.
2) Hypertension: By closely monitoring a patient’s blood pressure and ensuring it is being done correctly the nurse can educate the patient regarding diet and exercise as well as when and how to take their blood pressure medication and giving them resources on how to decrease stress in their lives.
3) Diabetes: Patient’s who are diagnosed with diabetes often time has poor eating habits, little exercise and don’t monitor their blood sugars. Nurses can educate and resource the patient with information and websites who will help them to keep their sugars lower which will help to decrease their weight and keep them exercising. Assessing the patient’s willingness to learn is critical.
4) Hypercholesterolemia: This can quickly lead to heart failure in some patients. Education and resourcing again is top priority for the nurse to help the patient. Proper diet, exercise and even cholesterol lowering vitamins such as Red Yeast Rice or prescribed drugs can significantly reduce the patient’s cholesterol which will lead to decrease risk of heart failure.
Proper drug regimen in any patient is a struggle. Especially in older patients who have multiple physicians it’s not uncommon to see what’s called “polypharmacy”. “Polypharmacy (ie, the use of multiple medications and/or the administration of more medications than are clinically indicated, representing unnecessary drug use) is common among the elderly.” (Hajjar, pg. 1) Another issue in the elderly is that there kidney’s don’t excrete the drugs. Much research has been done in this area. “The kidney is exposed to many potential toxins because of its anatomy and physiology. Prerenal factors affecting cardiac output, drugs altering intrarenal haemodynamics and those directly toxic to the renal parenchyma may cause life-threatening renal impairment. Comorbidities and pre-existing renal disease increase the risks. Careful assessment before prescribing commonly used drugs, dosage adjustment when indicated and close follow-up are required to avoid the potential iatrogenic pitfalls.” (Saker) Careful monitoring of renal function tests are critical to any elderly patient on numerous medications. Teaching the patient how to take their medications, organizing them properly, updating their lists and keeping it with them at all times is critical. The nurse may have to teach a family member how to organize the patient’s pills if the patient is unable to do it.
References:
Hajjar ER, Cafiero AC, Hanlon JT. “Polypharmacy in the Elderly”. Retrieved from: ncbi.nlm.nih.gov/pubmed/18179993
B. M. Saker, Department of Nephrology, RoyalPerthHospital, Perth. Everyday Drug Therapies Effecting Kidney’s”.ncbi.nlm.nih.gov – retrieved January 21, 2014
POST 6
Ms. J. is a 63 years old female, who had history of HTN, heart failure and sleep apnea. She was a heavy smoker for 40 years. Upon admission to the ICU, the first thing done is placing her in high Fowlers position which enhances lung expansion and helps Ms. J to breathe easier. Since the SPo2 is 82%, we need to start an oxygen administration either through nasal cannula, CPAP, or BPAP, according to doctor’s order. Because the patient had history of sleep apnea, she must be using CPAP or BIPAP at home. Next I would place the patient in a continuous cardiac monitor and check the 12 lead EKG so we can find out if any heart muscles are affected. Then I would start an IV access in order to give any intravenous medication. I would be closely monitoring the vital signs, cardiac arrhythmias, and maintaining the O2 saturation above 90% is very important in her case. To reduce anxiety, we need to give mental and psychological comfort for the patient’s family or friends who can stay with the patient. Maintaining bed rest or activity restriction can reduce the cardiac work load. Chest X-rays are also important in this case to find out the pulmonary and heart function. Strict intake and output is very important in heart failure case especially when using diuretics. Since the patient arrived with a fever and flu symptoms, she should be isolated for droplet precaution according to the hospital policy. Applying SCD can prevent thrombolytic embolism and improve the circulation when patients are in bed rest.
IV furosemide (Lasix): Lasix is a diuretic which helps to reduce fluid retention (edema) which is caused by congestive heart failure. Lasix increases the urine output and helps the patient breathe easy. When patients are taking Lasix, should be instructed to take high potassium diet because medication can cause lower potassium level
Enalapril (Vasotec): Vasotec is a antihypertensive medication. This medication is act as ACE inhibitor which reduces vascular resistance without increase the heart rate. ACE inhibitors prevent an enzyme in your body from producing angiotensin II, a substance in your body that affects your cardiovascular system by narrowing your blood vessels and releasing hormones that can raise your blood pressure. This lower the blood pressure, increases the blood and oxygen to the heart and helps to decrease the cardiac workload (Mayo Clinic, 2010).
Metoprolol (Lopressor): Metoprolol is a beta blocker that helps to reduce the blood pressure. This medicine is a beta-blocker. It works by affecting the response to nerve impulses in certain parts of the body, like the heart. As a result, the heart beats slower and decreases the blood pressure. When the blood pressure is lowered, the amount of blood and oxygen is increased to the heart (Mayo Clinic, 2010).
IV Morphine Sulphate (Morphine): Morphine reduces the sympathetic nervous system activity, alleviates the anxiety and reduces the pain. It reduces preload and to a lesser extent afterload. This can decrease the myocardial oxygen demand and workload (Cotter, 2010).
The four cardiovascular conditions that can lead into heart failure is hypertension, coronary artery diseases, cardiomyopathy, and diabetes.
Hypertension: Uncontrolled high blood pressure can cause for heart failure. When there is a high blood pressure, the heart is working hard to circulate the blood throughout the body. Over time, the heart muscle becomes weaker, thicker and stiff to pump blood effectively and lead to heart failure (Mayo Clinic, 2010). Maintaining the blood pressure within the acceptable range through proper medication, life style changes, healthy eating habit, no smoking, limited alcohol, and improved physical exercise can avoid the complication like heart failure.
Coronary Artery Disease: Coronary artery disease is another main cause of heart failure. When coronary artery is deposit with plaque, heart muscles are not getting enough oxygen and blood circulation which can lead to MI and heart failure. This can be prevented by healthy diets, regular exercise, no smoking, eating a low-fat low-salt diet that's rich in fruits, vegetables and whole grains, maintaining a healthy weight, reducing and managing stress, and controlled high blood pressure, high cholesterol and diabetes (Mayo Clinic,2010).
Cardiomyopathy is the heart muscle that becomes enlarged, thick, or rigid. In rare cases, the muscle tissue in the heart is replaced with scar tissue. As cardiomyopathy worsens, the heart becomes weaker. It's less able to pump blood through the body and maintain a normal electrical rhythm. This can lead to heart failure or arrhythmia (Mayo Clinic, 2010). This can be prevented and maintained by the life style changes.Choose foods that are low in saturated fat, trans fat, and cholesterol. Healthy choices include lean meats, poultry without skin, fish, beans, and fat-free or low-fat milk and milk products. Choose and prepare foods with little sodium (Cleveland Clinic, 2014).
Diabetes: Diabetic cardiomyopathy is a disease that damages the structure and function of the heart. This disease can lead to heart failure and arrhythmias, even in people who have diabetes but don't have CHD. People who have type 1 or type 2 diabetes can develop DHD. The higher a person's blood sugar level is, the higher his or her risk of DHD. This can be prevented by following a healthy diet, maintaining a healthy weight, being physically active, quitting smoking, and managing stress level.
Polypharmacy is a common problem in older adults. Currently, 44% of men and 57% of women older than age 65 take five or more medications per week; about 12% of both men and women take 10 or more medications per week (American Nurses Today, 2010). To help this problem, patients need to maintain and accurate list of the medication list that they are currently taking. This list should have generic and brand names of the medicine, dosage, route, frequency and reason for taking the medication. Keep a complete list of medical providers and their contact information. Keep the telephone and the information about the local pharmacy. Health care professional should be teaching the patient and family regarding the medication and side effects associated with medication. Medication organizers or pill boxes can be helpful for the patient or the care giver to comply with drug regimen ( American Nurses Today, 2010).
References:
Heart failure. (n.d.). MayoClinic. Retrieved January 21, 2014, from http://www.mayoclinic.org/diseases-conditions/heart-failure/basics/definition/con-20029801
Preventing polypharmacy in older adults. (n.d.). American Nurse Today. Retrieved January 21, 2014, from http://www.americannursetoday.com/article.aspx?id=7132
What is Cardiomyopathy?. (n.d.). Cleveland Clinic. Retrieved January 21, 2014, from http://my.clevelandclinic.org/disorders/cardiomyopathy/hic_what_is_cardiomyopathy.aspx
POST 7
Mrs J is a very anxious woman concerned she is dying that has been admitted to the ICU with heart failure. The nursing interventions most appropriate for her admit include both psychosocial interventions as well as medical interventions. First, Mrs J. needs to be spoken to using therapeutic communication to try and calm her down and to help ease her fears. This can include fully explaining what is occurring and the treatments or plan for her hospital stay. Another nursing intervention would be to apply oxygen to help her breathe as well as monitoring her oxygen saturations, vital sounds, and heart rhythm with a cardiac monitor. She may also need to be placed on a blood thinner or compression devices to keep blood flow going since she is immobile and too exhausted to eat or drink. Her fluid and electrolyte status will need to be monitored as well with replacement given as needed, this will need to documented using strict intake and outtake. The main thing is to calm the patient down and get her as comfortable as possible including changing position and consulting the physician for medications.
Medications:
1. Lasix- Furosemide will be used to help decrease the amount of fluid in the body and lungs to help with breathing, heart failure leads to a build up of fluid in the lungs especially and depending on which side is failing can lead to overall edema and fluid overload.
2. Enalapril- Vasotec is usually used in conjunction with Lasix to help hypertension and to help keep blood pressure under control if fluid overload occurs. This will also take some of the stress off of the heart during heart failure symptoms.
3. Metoprolol- Another blood pressure medication, a beta blocker, that will help regulate her tachycardia and also relieve some stress on the heart, allowing it to pump more efficiently.
4. Morphine- Morphine will not only help if there is any pain involved, but witll get oxygen to the heart, morphine can also help decrease anxiety and calm Mrs. J down.
Conditions Leading To Heart Failure
1. Hypertension can lead to heart failure by causing stress on the heart and not allowing blood to flow properly, this can be controlled by diet and medication.
2. Hyperlipidemia can lead to hypertension by causing atherosclerosis; this can also be controlled by medication and diet.
3. Smoking causing vasoconstriction and decreased intake of oxygen in the body, anti smoking medications can be administered such as the patch or Chantix.
4. Arrhythmias also cause stress on the heart and decrease blood flow. In Mrs. J’s case she has a fib, which means there is a higher risk of a clot forming and traveling through her body causing possible harm. Drugs are given to help this condition and to help the heart efficiently pump blood through the body and fulfill the metabolic and oxygen needs of the body.
Unfortunately many older individuals see numerous doctors and the doctors prescribe medications that should not be taken together or can cause adverse effects, called polypharmacy. Many times one physician that orders medications does not know that a patient is on another medication and these patients do not have the knowledge base nor assistance to know they should not take all these medications together. Nursing interventions for this include discussing all medications that the patient is taking, educating the patient on how important it is to have an accurate medication list at all times, monitoring labs, and alerting the patient of the risks of the medications they are on. It is important with older adults to make sure they have some sort of adequate support system to help them keep track of all of their medications, this is where most of the problems occur. Monitoring is important because older individuals also tend to excrete drugs more slowly making them more toxic in the body and allowing more adverse drug reactions to occur.
Mettina, S. M. (2010). Lippincott: Manual of Nursing Practice (9th ed.). Philadelphia: Wolters Kluwer Health Lippincott Williams & Wilkins.
