NRS 410 Case Study: Hypertension, CHF and Sleep Apnea
The case scenario discussed is of 63-year-old Mrs. J who has been in care for chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) and is now admitted due to their exacerbations. She reports a history of cigarette smoking, hypertension, poor compliance to medication, and a recent upper airway tract infection. This discussion aims to describe how she was managed, the reasons for exacerbation, and patient management plans.
COPD that Mrs. J is characterized by an inflamed airway that impairs expiration of gases thus presenting with dyspnea. The limited expiration results in the accumulation of carbon (IV) oxide in the body which triggers anxiety (Choi & Rhee, 2020). On the other hand, CHF reduces the heart’s ability to pump blood thus irregular heartbeat occurs described as the heart running away (Schwinger, 2021). It also presents with fatigue due to impaired blood supply to the body tissues (Hajar, 2019).
Medications that have been administered to manage Mrs. J can be justified due to their effects. Furosemide and enalapril work through a different mechanisms of action to reduce the decompensation of the heart in CHF (Hajar, 2019). Although furosemide encourages diuresis by inhibiting the reabsorption of sodium in kidney tubules whereas enalapril inhibits the renin-angiotensin-aldosterone system (RAAS), they both lead to a decrease in preload and afterload (Lee et al., 2019). This reduces pressure against the heart and also corrects the reported edema especially due to furosemide use.
Metoprolol that was prescribed regulates the sympathetic system activation in heart failure thereby reducing the cardiac contractility
and heart rate (Hajar, 2019). As such, it corrects the reported palpitations. Further, the inhaled bronchodilators and corticosteroids correct the bronchoconstriction due to COPD thus promoting expiration whereas morphine helped in reducing anxiety symptoms (Lief & McSparron, 2020). Due to Mrs. J’s low oxygen saturation, oxygen supplementation was also necessary to reverse the hypercapnia and promote oxygen delivery to tissues (Choi & Rhee, 2020). The prescribed drugs were therefore justified and appropriate for managing the exacerbations.
CHF results from most heart conditions whether they affect the valves, heart muscles, or the electrical conduction pathways. Some of these conditions include cardiomyopathy, valvular defects, coronary artery disease (CAD), and arrhythmias. Cardiomyopathy is where there is damage to the myocardium due to a myriad of factors including alcohol use and it consequently impairs the heart’s ability to pump blood (Hajar, 2019). Valvular defects whether resulting from infection of the valves, stenosis, or regurgitation are also implicated (Lee et al., 2019). CAD where there are narrowed coronary artery vessels with consequential cardiac ischemia as well as arrhythmias where the is uncoordinated heart beating such as atrial fibrillation are other risk factors for CHF (Schwinger, 2021). Most of these conditions can be prevented from resulting in CHF.
Different nursing interventions can help in preventing CHF from these cardiac conditions. Such measures include the adoption of physical exercise and dietary modification for CAD, reduced alcohol consumption for cardiomyopathy, and aggressive antibiotic therapy to prevent the advancement of valvular infection into CHF (Lee et al., 2019). Non-pharmacological vagal maneuvers may be applied to correct arrhythmias.
Nurses play important roles in preventing adverse reactions to polypharmacy. They achieve this through education, instruction, information, and organization. Education involves highlighting the presentation of adverse reactions and warning the patient about drugs or food that possibly interact with their prescribed medications (Zabihi et al., 2018). By instruction, adherence to therapy is emphasized to prevent incidences of overdose which is an adverse reaction. During instruction, the nurse directs the patient to reliable sources of medicine to ensure continuity of therapy (Lief & McSparron, 2020). On the other hand, the organization is done by arranging the drug into daily pill packs that promote adherence and discourages overdose.
Health promotion in a patient with COPD and CHF will aim at reducing readmission rates and facilitating recovery. To reduce the readmissions, the risk factors of exacerbation such as unhealthy diet, cigarette smoking, and obesity should be addressed. Mrs. J will therefore be encouraged to reduce her weight, adopt the DASH diet, and also engage in physical activity (Hajar, 2019). She will also be advised against cigarette smoking which may worsen COPD. In the promotion of her recovery, the patient will benefit from a multidisciplinary team comprised of pulmonologists and cardiologists who will educate her on pulmonary physiotherapy, cardiac rehabilitation, and adherence to medication (Schwinger, 2021). Homebased care can also be adopted to promote her well-being at home. These measures will enhance recovery and reduce the risks of readmission.
Mrs. J is a geriatric patient who will benefit from proper education on her condition. Given most geriatric patients have poor literacy that may enable the comprehension of complex medical information during education, an effective education would involve the use of diagrams and charts for illustrations (Lee et al., 2019). This not only promotes comprehension but also encourages memorability. Adoption of family education can also be encouraged to promote the involvement of family members in patient care (Toledano-Toledano & Luna, 2020).
Some of the factors that may have exacerbated the COPD in this patient would include the history of cigarette smoking and the recent flu-like illness that is reported. These triggers cause airway hyperresponsive and worsen bronchoconstriction, especially in COPD and asthma patients (Lief & McSparron, 2020). Other possible causes of the exacerbation may include exposure to cold, air pollution, and non-adherence to medications. Smoke cessation would therefore be encouraged for patients with COPD who smoke a cigarette. The options to encourage cessation of smoking include nicotine replacement therapy, use of bupropion, as well as psychotherapy such as group therapy (Choi & Rhee, 2020). These methods help in reducing cravings for smoking thus promoting recovery.
Chronic illnesses such as COPD and CHF have underlying organ dysfunctions that are responsible for their presentation. Understanding these dysfunctions as well as their causes and triggers helps in the formulation of effective strategies for managing patients against these conditions. The use of medications should be aimed at addressing the dysfunction or patient symptoms. In the course of treatment, adherence to therapy should be encouraged as the incidences of adverse drug reactions are reduced. Further, the specific risk factors of the conditions should also be addressed by encouraging health promotion strategies such as a healthy diet, smoke cessation, and physical exercise. This would reduce incidences of readmission for these patients and promote patient recovery.
Choi, J. Y., & Rhee, C. K. (2020). Diagnosis and treatment of early chronic obstructive lung disease (COPD). Journal of Clinical Medicine, 9(11), 3426. https://doi.org/10.3390/jcm9113426
Hajar, R. (2019). Congestive heart failure: A history. Heart Views: The Official Journal of the Gulf Heart Association, 20(3), 129–132. https://doi.org/10.4103/HEARTVIEWS.HEARTVIEWS_77_19
Lee, J. H., Kim, M. S., Yoo, B. S., Park, S. J., Park, J. J., Shin, M. S., Youn, J. C., Lee, S. E., Jang, S. Y., Choi, S., Cho, H. J., Kang, S. M., & Choi, D. J. (2019). KSHF guidelines for the management of acute heart failure: Part II. Treatment of acute heart failure. Korean Circulation Journal, 49(1), 22–45. https://doi.org/10.4070/kcj.2018.0349
Lief, L., & McSparron, J. (2020). Acute Exacerbation of COPD. In Evidence-Based Critical Care (pp. 169–173). Springer International Publishing.
Schwinger, R. H. G. (2021). Pathophysiology of heart failure. Cardiovascular Diagnosis and Therapy, 11(1), 263–276. https://doi.org/10.21037/cdt-20-302
Toledano-Toledano, F., & Luna, D. (2020). The psychosocial profile of family caregivers of children with chronic diseases: a cross-sectional study. BioPsychoSocial Medicine, 14(1), 29. https://doi.org/10.1186/s13030-020-00201-y
Zabihi, A., Hosseini, S., Jafarian Amiri, S., & Bijani, A. (2018). Polypharmacy among the elderly. Journal of Mid-Life Health, 9(2), 97. https://doi.org/10.4103/jmh.jmh_87_17
Case Scenario for Hypertension, CHF and Sleep Apnea
Mrs. 3. 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.
- 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 so exhausted she cannot eat or drink by herself.
- 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, 52, 53, 54 present; PMI at sixth ICS and faint; all peripheral pulses are 1+; bilateral jugular vein distention; initial cardiac monitoring indicates a ventricular rate of 132 and atrial fibrillation
- Respiratory: Pulmonary crackles; decreased breath sounds right lower lobe; coughing frothy blood-tinged sputum; 5p02 82%
- Gastrointestinal: BS present: hepatomegaly 4 cm below costal margin
Most of time atrial fibrillation is a chronic condition caused by damage to the heart through varying disease processes. What I learned years ago is that atrial fibrillation can be episodic and completely reverse itself. My grandma who in her 70’s developed aspiration pneumonia after 50+ years of smoking. I was sure this was the final time we would see her alive. She was ventilated and her suction canister was filled with black fluid from years of tar filled lungs. While she lay in the hospital ICU her heart converted into atrial fibrillation and plans were made for her to take long-term anticoagulants upon discharge. However, as the days past and her infection died her a-fib rhythm converted back into sinus rhythm. The irony of this is that she soon quit smoking just in time for a lung cancer diagnosis that finally took her life a few more years later. The point of my story is that pneumonia can trigger atrial fibrillation but is one of the few triggers that a-fib can be reversed from if treated, (Nichols, 2017). I saw this firsthand.
Nichols L. (2017). Pneumonia as a trigger for atrial fibrillation. Journal of rural medicine: JRM, 12(2), 146–148. https://doi.org/0.2185/jrm.2937
- Elizabeth Mateo Gonzalez
replied toMarise Guillaume Charles
Jul 22, 2022, 5:37 PM
- Replies to Marise Guillaume Charles
Atrial fibrillation is among the most experienced cardiac arrhythmias. It is a condition that places one at a risk of suffering from a stroke if not diagnosed and treated early. Notably, this condition has the capabilities of causing heart failure due to the irregular heart rates. Research has shown that approximately 5 million people in the United States are living with atrial fibrillation at the current times and the number is predicted to rise to 12.1 million by 2030 (Gramlich, 2018). Atrial fibrillation is majorly linked to lifestyle factors.
Gramlich, M. (2018). Prognostic Value of Atrial Fibrillation Inducibility in Patients Without History of Clinical Atrial Fibrillation. Journal Of Atrial Fibrillation, 11(1). https://doi.org/10.4022/jafib.1837
- Chizoba Njoku
replied toMarise Guillaume Charles
Jul 22, 2022, 7:18 PM
- Replies to Marise Guillaume Charles
Good topic, and nicely described. Atrial fibrillation is characterized by high frequency excitation of the atrium that results in both dyssynchronous atrial contraction and irregularity of ventricular excitation. Whereas atrial fibrillation may occur in the absence of known structural or electrophysiological abnormalities, epidemiological association studies are increasingly identifying comorbid conditions, many of which have been shown to cause structural and histopathological changes that form a unique atrial fibrillation substrate or atrial cardiomyopathy. ( Straek, et al). Atrial fibrillation is really a serious cardiac issue, which could be caused by an untreated hypertension or coronary artery disease and that has somehow damaged the electrical connections within the heart and so many other factors. However, the etiology of atrial fibrillation is sometimes unknown.
Straek, L., Sherer, J., & Helm, R (2017). Atrial Fibrillation: Epidemiology, Pathophysiology, and Clinical Outcomes. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC550874/#_ffn_sectitle
- Grace Ochulor
replied toMarise Guillaume Charles
Jul 24, 2022, 2:41 AM
- Replies to Marise Guillaume Charles
Marise, nice post. Atrial fibrillation, often called AFib or AF, is the most common type of treated heart arrhythmia. An arrhythmia is when the heart beats too slowly, too fast, or in an irregular way. When a person has AFib, the normal beating in the upper chambers of the heart (the two atria) is irregular, and blood doesn’t flow as well as it should from the atria to the lower chambers of the heart (the two ventricles). AFib may happen in brief episodes, or it may be a permanent condition, symptoms include Irregular heartbeat, Heart palpitations (rapid, fluttering, or pounding). Light headedness,Extreme fatigue, Shortness of breath, Chest pain. Treatment for AFib can include, Medicines to control the heart’s rhythm and rate, Blood-thinning medicine to prevent blood clots from forming and reduce stroke risk, Surgery, Medicine and healthy lifestyle changes to manage AFib risk factors.
Heart Rhythm Society. (2019). Complications from Atrial Fibrillation. Accessed May 9, 2019.
Critical Thinking Questions
What nursing interventions are appropriate for Mrs. 3 at the time of her admission? Drug therapy is started for Mrs. 3. to control her symptoms. What is the rationale for the administration of each of the following medications?
- IV furosemide (Lasix)
- Enalapril (Vasotec)
- Metoprolol (Lopressor)
- 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.