Health History and Medical Information Mrs. R. is a 68-year-old married woman who has a history of hypertension, chronic heart failure, and chronic obstructive pulmonary disease (COPD). Despite requiring 2L of oxygen/nasal cannula at home during activity, she continues to smoke two 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 antihypertensive medications or medications to control her 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
Clinical Manifestations Present in Mrs. J.
As Mrs. J.’s case description demonstrates, the patient was admitted to the hospital with flu-like symptoms. The clinical manifestation or the symptomatic indications of a disease or deterioration in bodily systems present in the patient include nausea, malaise, cough, and fever. The patient indicates diminished walking capacity, requires assistance, and experiences acute decompensated heart failure and acute exacerbation of chronic obstructive pulmonary disease (COPD). These clinical manifestations, in combination with the chronic conditions present in Mrs. J., namely hypertension, chronic heart failure, and COPD, serve as the basis for referring to the hospital.
Appropriateness of the Nursing Interventions at the time of Admissions and Medication Rationale
The nursing interventions at the time of admission addressed the patient’s chronic conditions. In particular, Mrs. J. had not taken her prescription medication for three days before admission. Therefore, administering the medications and oxygen to address the daily requirements under chronic conditions is essential. Moreover, the patient’s vital signs play a crucial role in deciding what nursing interventions are appropriate and the most required. At the time of admission, Mrs. J.’s oxygen saturation is low and decreased to the point of 82%; her heart rate is high with 118 beats per minute, and her blood pressure is low at 90/58. Therefore, the interventions and medications are appropriate since they were aimed at stabilizing the vital signs of the patient.
In particular, Mrs. J. was administered IV furosemide, enalapril, metoprolol, IV morphine sulphate, inhaled short-acting bronchodilator, inhaled corticosteroid, and oxygen delivered at 2L/ NC. Furosemide administered intravenously helps regulate fluid accumulation caused by heart failure. Enalapril is commonly used with furosemide to address hypertension. Metoprolol stimulates blood flow and is aimed to help with blood pressure. IV morphine sulphate is administered to manage pain in the patient. As for the oxygen, bronchodilator and corticosteroid administered for inhalation are aimed at regulating lung function, normalize oxygen saturation, and cure inflammatory processes in the respiratory system.