Presenting Case: Esther Brown is a 68-year-old Caucasian female who… Presenting Case: Est

Presenting Case: Esther Brown is a 68-year-old Caucasian female who… Presenting Case: Esther Brown is a 68-year-old Caucasian female who presents to the Emergency Room with the complaint of shortness of breath and chest discomfort a few days after a large family BBQ 2 weeks ago. She reports that she can’t sleep well lying in bed, wakes up short of breath, and has needed to sleep in the recliner over the past week. She also complains because she had to make her belt bigger and her legs look “fat and puffy” despite having a decreased appetite over the last 1 1/2 weeks and not eating much.  She has been more fatigued lately so has not been getting her usual walk in.PMH:Myocardial Infarction 5 years ago with a 2-vessel coronary artery bypass graftHyperlipidemia- diagnosed 9 years agoBMI 40OsteoarthritisCurrent Medications:Atorvastatin 80 mg qdLisinopril 10mg qdCelecoxib 200 mg qdAspirin 81 mg qdAllergies: Atenolol -hives, Cats- itchy noseExam findings: BP 158/92, P 110 regular, R 24, T 98.4F, O2 sat 91% on RA, Pain 1 out of 10Restless, sitting upright in bed, appears anxious  Breath sounds – breathing labored, coarse crackles on inspiration and expiration scattered throughout both lung fields anterior/posteriorForehead diaphoretic, 3+ pitting edema bilateral lower extremities in feet, ankles, 3+ up to knees bilaterally, S3 gallop most prominent over apex, no jugular venous distention (JVD) noted sitting up at 45 degreesAbdomen, pale, symmetric, soft, and non-tender, bowel sounds present in all four quadrants- normoactiveEchocardiogram done 6 months ago showed ejection fraction of 25%Section 1Identify the Relevant Subjective Data from the Present Problem and Explain Clinical SignificanceRelevant Subjective Data from the Presenting ProblemClinical Significance Unable to sleep flat & has to sleep on a reclinerOrthopnea: the clinical significance of orthopnea is an increase of pressure in the lungs due to fluid backing up in the lungs. When the heart fails or doesn’t work optimally. The patient will have difficulty breathing in supine position. Fowler or semi-fowler positions bring relief and ease breathing (Capriotti, 2020, p.417).She has to make her belt bigger and her legs look “fat and puffy”Unexplained weight gain due to edema resulting heart failure (left ventricular failure). The body’s system that maintains blood volume and blood pressure.  Water and sodium are retained in response to decreased cardiac output  and increased peripheral resistance (Capriotti, 2020, p.121).Unable to do her normal walkdecreased appetiteFatigue due to decreased exercise tolerance Section 2 Connect the Relationship between Client PMH and Medications (why is the client taking the meds)Relationship between Client PMHMedicationsHyperlipidemiaAtorvastatin 80 mg qd – Client is taking to lower her cholesterolMyocardial Infarction 5 years ago with a 2-vessel coronary artery bypass graft Lisinopril 10mg qdAspirin 81 mg qd- Client is taking Lisinopril to lower her blood pressure due HTN and history of the MI and CABG. Client is taking aspirin to prevent blood clots due to her history of MI as well as a precaution against recurrence of MI.OsteoarthritisCelecoxib 200 mg qd – Client is taking to reduce pain due to osteoarthritisDescribe the Drug Class and Mechanism of Action Drug ClassMechanism of ActionAtorvastatinCompetitively inhibits HMG-CoA reductase. By preventing conversion of HMG-CoA to mevalonate, statin medications decrease cholesterol production in the liver.Lisinoprilinhibits renin angiotensin-converting enzyme (ACE). ACE is a peptidyl dipeptidase that catalyzes the conversion of angiotensin I to vasoconstrictor substances, angiotensin II.   Angiotensin II also stimulates aldosterone secretion by adrenal cortex.AspirinAcetylsalicylic acid disrupts the production of prostaglandins throughout the body by targeting cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) CelecoxibThe mechanism of action of celecoxib is due to selective inhibition of cyclooxygenase-2 (COX-2), which is responsible for prostaglandin synthesis, an integral part of the pain and inflammation pathway. [3] This pharmacologic activity gives celecoxib its analgesic, anti-inflammatory, and antipyretic effects.Section 3 Identify the Abnormal Vital Signs and Provide Rationale for Findings Supported by a Reputable SourceAbnormal Vital SignsRationale for FindingsReputable SourceBP 158-92Uncontrolled blood pressure. The narrowing of the blood vessels due to atherosclerosis causes an increase in BP due to increased peripheral resistance.American Heart Associationwww.heart.orgAmerican College of Cardiology.www.acc.orgP110The heart beats faster to pump enough blood to the body. This can cause a rapid or irregular heartbeat. The ventricles fail to relax and fill properly or might be too stiff from hypertrophy. Both the filling and pumping ability of the ventricles are affected (Capriotti, 2020, p.415).Davis advantage for pathophysiology textbook, chapter 17 Heart failure.R 24 and O2 sat 91%Fluid backup in the lungs can cause shortness of breath with exercise or difficulty breathing at rest or when lying flat in bed Section 4 Identify the Abnormal Assessment Findings and Provide Pathophysiologic Reason for Findings supported by a Reputable SourceAbnormal Assessment FindingsProvide Pathophysiologic ReasonReputable SourceBreath sounds – breathing labored, coarse crackles on inspiration and expiration scattered throughout both lung fields anterior/posterior In heart failure, the ventricles may become stiff and not fill properly between beats. In some cases of heart failure, the heart muscle may become damaged and weakened, and the ventricles dilate to the point that the heart can’t pump blood efficiently throughout the body. The lungs are not able to receive and distribute oxygen well, thus causing labored breathing. The crackling in lung sounds is a result of fluid accumulation in the pulmonary interstitial spaces seen in the clinical manifestation of orthopnea, a patient’s inability to lay flat (Capriotti, 2020, p.417).Davis advantage for pathophysiology textbook, chapter 17 Heart failure.Forehead diaphoretic, 3+ pitting edema bilateral lower extremities in feet, ankles, 3+ up to knees bilaterally, S3 gallop most prominent over apex, no jugular venous distention (JVD) noted sitting up at 45 degrees Fluid and water retention are caused by the reabsorption of sodium and water from RAAS as by lesser blood getting to the kidneys resulting in swelling ankles and legs, and even weight gain. The continuous activation of the RAAS system is detrimental to the failing heart especially the effect of Angiotensin II which is a powerful vasoconstrictor causes widespread peripheral resistance increasing the afterload of the weakened heart (Capriotti, 2020, p.415). Davis advantage for pathophysiology textbook, chapter 17 Heart failure.Echocardiogram done 6 months ago showed ejection fraction of 25% Ejection fraction (EF) refers to how well your left ventricle (or right ventricle) pumps blood with each heartbeat. The normal range is between 55-70%. 25% is extremely below normal. This is caused by the inability of the heart to completely pump out blood due to enlargement and clogged blood vessels.Mayo ClinicSection 5: Interpret the Primary Problem Using the Clinical Data Provided (what do you think the diagnosis is?)The clinical manifestation of orthopnea, hyperlipidemia and low ejection fraction of 25% point to ventricular heart failure in particular left ventricular failure. The clinical findings associated with left ventricular heart failure are high heart rate, pulmonary congestion (edema)  and widespread bibasilar crackles, dyspnea and orthopnea. Explain the Pathophysiology in Own Words The pathophysiology of left ventricular failure has two outcomes, a forward effect where the heart is unable to pump blood to the body and a backward effect which causes fluid buildup in the lungs resulting in pulmonary edema. The forward effect of LVF is propelled by the kidney’s sensing low blood circulation and activating the RAAS system which responds to low blood volume and pressure by causing sodium and water to be retained; this increases the heart’s workload. Identify the Priority Body System(s) to continue to Assess and methods to collect data (techniques- i.e.: inspection…) cardiovascular system: Assess changes in mental status or level of consciousness that could result from decreased tissue perfusion.  Assess the skin the entire body for proper pallor, oxygenation and perfusion. Palpate the carotid artery for rate and rhythm. Inspect the jugular vein for distention. Auscultate the carotid arteries and the 5 cardiac landmarks using both the diaphragm and the bell of the stethoscope. Listen for heart sounds and murmurs indicated by swooshing sounds. Palpate and auscultate the apical pulse. Respiratory system: assess by inspecting the breathing pattern and oxygen saturation should be above 95, observe chest symmetry and expansion. Inspect chest for pallor or cyanosis. Auscultate anterior chest and posterior chest and compare the lung sounds left and right side, note lung sounds. Percuss the lungs for fluid. Skin, Lower and upper body: Inspect the face, fingertips and lips for discoloration or cyanosis. Inspect the extremities for edema. Inspect the toes, feet and legs bilaterally. Palpate the extremities for edema, tenderness and pain around the calves for possible deep vein thrombosis. Note the temperature of extremities. Check capillary refill and note if less than 3 seconds.Section 6: Create 3 Subjective Questions to Effectively Assist in the Plan of Care for Chest Pain/SOB When you experience pain, how long does it last? Is it intermittent or constant pain? Have you ever woken up from sleeping unable to suddenly breath? How long does it take you to recover from chest pain or shortness of breath? Section 7:Identify 3 Education Topics/Lifestyle Suggestions with Rationale to Promote Health for the ClientDiet changes: Diet intervention or restrictions can have a positive impact and have been shown to improve the management of heart disease (Wickman et al., 2021). A low sodium diet will be key to managing the patient’s weight due to edema. Salt causes fluid retention thus restricting the amount of sodium the patient consumes will be key to reducing the swelling in the body. A low sodium diet will also help lower blood pressure. In addition to the statins the patient is taking for cholesterol, it will be important to add a low-fat diet to the plan.Balance daily activities and rest and incorporate stress management strategies: It’s important for the patient to find the right balance to do physical activity and get rest to prevent excess stress on the heart. Due to her health status, she considers doing a few exercises that will not result in shortness of breath and chest pain. Physical activity will help with blood circulation and edema whereas prolonged inactivity increases exercise intolerance. Teach the patient to do ROM exercises if unable to do physical exercises. Heart failure is a life-threatening disease, it could cause anxiety and depression. Acknowledge patient’s concerns and anxieties and teach them how to cope with the diagnosis. Facilitate positive communication. Empathy demonstrates support and caring. Don’t smoke and avoid exposure to secondhand smoking: If patient uses tobacco, encourage them to quit smoking. Chemicals in cigarettes are harmful to the body, they can enter the bloodstream causing inflammation and clots.  Section 8:     References American College of Cardiology. 2017 Guideline for high blood pressure in adults.  https://www.acc.org/Latest-in-Cardiology/ten-points-to-remember/2017/11/09/11/41/2017-Gu ideline-for-High-Blood-Pressure-in-Adults American Heart Association. High blood pressure. https://www.heart.org/en/health-topics/high-blood-pressureCapriotti, T. (2020). Davis advantage for pathophysiology: Introductory concepts and clinical perspectives(2nd edition). F.A. Davis.Dietary management of heart failure: Dash Diet and precision nutrition perspectives. Nutrients, 13(12), 4424. https://doi.org/10.3390/nu13124424Jones & Bartlett Learning. (2021). 2021 Nurse’s drug handbook. Sudbury, MA: Jones & Bartlett Learning.Manjad, R. (2021). What does the term “ejection fraction” mean? What does it measure? Mayo Clinic.https://www.mayoclinic.org/tests-procedures/ekg/expert-answers/ejection-fraction/faq-200586Swearingen, P.L., & Wright, J. (2019). All-in-one nursing care planning resource: Medical-surgical, pediatric, maternity, psychiatric nursing care plans (5th edition). Els  Was this done correctly  Health Science Science Nursing NUR 380 Share QuestionEmailCopy link Comments (0)

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