Health History and Medical Information




Health History and Medical Information






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Health History and Medical Information

            The assigned case study demonstrates a 63-year-old female patient, Mrs. J., with a history of chronic heart failure, chronic obstructive pulmonary disease (COPD), and hypertension. She claims to be using 2L of oxygen/nasal cannula to help with her respiration, and still reports smoking 2 packs of cigarettes daily for the last 40 years. However, three days ago, she started experiencing flu-like symptoms like productive cough, nausea, malaise, and fever. She reports stopping taking her antihypertensive medication during this time. She also experiences difficulties in independently going through her daily routine and moving around the house. Currently, she has been admitted to the ICU for acute decompensated heart failure and acute exacerbation of COPD. The purpose of this discussion is to evaluate Mrs. J.’s case and come up with the most appropriate interventions to help manage her symptoms.

Clinical Manifestations of Mrs. J.

            The patient reports flu-like symptoms for the past three days such as productive cough, nausea, malaise, and fever. She also presents with limited ability for independent living. Looking at the subjective data, the patient presents with symptoms of anxiety, dyspnea, palpitations, and lack of air. The physical examination findings reveal that the patient is obese, with symptoms of elevated heart rate, bradycardia, S3 present while S1 and d S2 diminished, fibrillation, and irregular heartbeats. Respiratory crackles, bloody sputum, productive cough, hepatomegaly, and diminished breathing sounds in the right lower lobe were also noted

Evaluation of Nursing Interventions at Admissions assessment

Recommended nursing interventions for the patient are mainly focused on relieving the patient’s respiratory symptoms like dyspnea and improving her heat pump function to maintain normal blood pressure. At admission, it was necessary to give furosemide to prevent edema of the lower limb associated with the reported acute decompensated heart failure. The patient was also administered enalapril for management of atrial fibrillation (Tinè et al., 2020). Metoprolol, on the other hand, is effective in preventing atrial fibrillation and maintaining the patient’s sinus rhythm but was not necessary to be administered during admission of the patient given her low blood pressure (Terraneo et al., 2021). It was also not necessary to give the patient morphine, since she reported symptoms of pain. For quick relief of the patient’s dyspnea and to avoid complications associated with COPD, it was necessary to give the patient inhaled short-acting bronchodilator (ProAir HFA). Nevertheless, it was not wise to give inhaled corticosteroid (Flovent HFA) as this medication is only considered for an asthmatic patient who requires long-term therapy after short-acting bronchodilators have already been used which is not the care with Mrs. J.

Cardiovascular Conditions Leading to Heart Failure and Interventions

            Heart failure is normally precipitated by several cardiovascular conditions like myocardial infarction, hypertension, abnormal heart valve, and coronary artery disease. To avoid such complications, it is necessary to promote regular monitoring of the patient’s blood pressure and heart rate and make sure that she sticks to the treatment regimen. To prevent coronary artery disease, it is important to regularly monitor the patient’s lipid profile and cholesterol levels in addition to encouraging a heart-healthy diet and regular exercise (Tinè et al., 2020). Heart failure resulting from a previous heart attack can also be prevented by regularly monitoring the patient’s vitals and being given antianginal agents. Finally, an abnormal heart valve usually leads to overworking the heart, which can be prevented by administering blood thinners in addition to appropriate healthy lifestyle modifications.

Nursing Interventions for Older Patients to Prevent Problems Caused by Multiple Drug Interactions

Given the patient’s advanced age, there are usually high possibilities of developing comorbidities that promote polypharmacy. This can lead to multiple drug interactions harming the patient’s health. However, multiple drug interactions can be avoided by making sure that only synergistic drugs with a proven desirable safety profile when combined can be used by the patient (Scrutinio et al, 2019). Every drug must also be assessed for possibilities of interactions and dose regulated appropriately, especially for those that are metabolized by the same liver enzyme. The clinician must also avoid prescription errors and review the drug list and dosages before issuing the prescription to ensure that administered drugs are safe, with limited possibilities of adverse events.

Health Promotion and Restoration Teaching Plan

            Mrs. J’s teaching plan will comprise patient education on the pathophysiology of COPD and associated conditions as reported in the patient’s history, in addition to an appropriate treatment approach to manage each condition/symptom. The patient will also be advised on health promotion practices such as consuming a healthy diet low in sodium, calories, and fats, and frequently engaging in physical activity (Tinè et al., 2020). She should also be educated on the best strategies to help her quit smoking, and prevent associated COPD complications. several resources have been provided to help promote the health of COPD patients with comorbid heart disease such as ‘The American Heart Association’, ‘The Centers for Disease Control and Prevention, and ‘The National Heart, Lung, and Blood Institute’ among others.



Method for Providing Education to Prevent Hospital Readmissions

            Promoting the patient’s recovery process and preventing the likelihood of readmission requires the clinician to utilize appropriate communication skills and use easy language to promote patient education. The patient will be educated on the importance of being compliant with the treatment regimen to promote a positive outcome (Scrutinio et al, 2019). The patient will also be educated on the benefits and side effects of all the prescribed medication to avoid unexpected symptoms which might make her stop using a certain drug.

COPD Triggers and Options for Smoking Cessation

            One of the leading causes of COPD is cigarette smoking. Tobacco is also associated with increased risks of increased exacerbation frequency. As a result, the patient needs to be referred to a smoking cessation counselor to help her quit smoking (Terraneo et al., 2021). The counselor, will evaluate the patient’s addiction, and come up with patient-specific smoking cessation programs for a positive outcome. Support groups can also help the patient quit smoking to promote her health and avoid severe health complications.


            The elderly patient in the case study provided demonstrates cardiorespiratory health problems which can trigger heart failure. However, Mrs. J receives adequate care after being admitted to the ICU. Other than complying with the treatment regimen, adopting lifestyle modifications such as a healthy diet and physical activity can help promote the health of the patient, and prevent associated complications.




Scrutinio, D., Guida, P., Passantino, A., Ammirati, E., Oliva, F., Lagioia, R., … & Frigerio, M. (2019). Acutely decompensated heart failure with chronic obstructive pulmonary disease: Clinical characteristics and long-term survival. European Journal of Internal Medicine60, 31-38.

Terraneo, S., Rinaldo, R. F., Sferrazza Papa, G. F., Ribolla, F., Gulotta, C., Maugeri, L., … & Di Marco, F. (2021). Distinct mechanical properties of the respiratory system evaluated by forced oscillation technique in acute exacerbation of COPD and acute decompensated heart failure. Diagnostics11(3), 554.

Tinè, M., Bazzan, E., Semenzato, U., Biondini, D., Cocconcelli, E., Balestro, E., … & Saetta, M. (2020). Heart failure is highly prevalent and difficult to diagnose in severe exacerbations of COPD presenting to the emergency department. Journal of clinical medicine9(8), 2644.

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