Assignment: Health History and Medical Information Essay

Health History

Mrs. J. is a 63-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. Assignment: Health History and Medical Information Essay

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Subjective Data

1. Is very anxious and asks whether she is going to die.
2. Denies pain but says she feels like she cannot get enough air.
3. Says her heart feels like it is \”running away.\”
4. Reports that she is exhausted and cannot eat or drink by herself.
Objective Data
1. Height 175 cm; Weight 95.5kg.
2. Vital signs: T 37.6C, HR 118 and irregular, RR 34, BP 90/58.
3. Cardiovascular: Distant S1, S2, S3 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.
4. Respiratory: Pulmonary crackles; decreased breath sounds right lower lobe; coughing frothy blood-tinged sputum; SpO2 82%.
5. Gastrointestinal: BS present: hepatomegaly 4cm below costal margin.

Intervention

The following medications administered through drug therapy control her symptoms:
1. IV furosemide (Lasix)
2. Enalapril (Vasotec)
3. Metoprolol (Lopressor)
4. IV morphine sulphate (Morphine)
5. Inhaled short-acting bronchodilator (ProAir HFA)
6. Inhaled corticosteroid (Flovent HFA)
7. Oxygen delivered at 2L/ NC. Assignment: Health History and Medical Information Essay

Critical Thinking Essay

In 750-1,000 words, critically evaluate Mrs. J.\’s situation. Include the following:
1. Describe the clinical manifestations present in Mrs. J.
2. Discuss whether the nursing interventions at the time of her admissions were appropriate for Mrs. J. and explain the rationale for each of the medications listed.
3. 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.
4. 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 a rationale for each of the interventions you recommend.
5. Provide a health promotion and restoration teaching plan for Mrs. J., including multidisciplinary resources for rehabilitation and any modifications that may be needed. Explain how the rehabilitation resources and modifications will assist the patients\’ transition to independence.
6. Describe a method for providing education for Mrs. J. regarding medications that need to be maintained to prevent future hospital admission. Provide rationale.
7. Outline COPD triggers that can increase exacerbation frequency, resulting in return visits. Considering Mrs. J.\’s current and long-term tobacco use, discuss what options for smoking cessation should be offered.

You are required to cite to a minimum of two sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. Assignment: Health History and Medical Information Essay.

Content

1. Clinical Manifestations of Mrs. J.
a. Subjective and objective clinical manifestations are detailed. The clinical manifestations are accurate and clearly report the observed and perceived signs and symptoms.
b. The patient, Mrs. J, is a 63-year-old female presenting to the ICU department with acute onset shortness of breath. Her past medical histories are hypertension, chronic heart failure, and chronic obstructive pulmonary disease (COPD). Symptoms began approximately 3 days ago with sudden flu-like symptoms such as fever, malaise, and productive cough. She had progressively worsened with no associated, aggravating, or relieving factors noted. She is smoking over 40 years despite using 2 liters of oxygen per nasal canula at home. Mrs. J is also not adherent with medications and didn’t take her antihypertensive and heart failure medications for past 3 days. Currently she reported feeling anxious and concerned to die. She feels that her heart is “running away” and needs assistance with daily activities. She denies pain but reported not getting enough air. The initial assessment indicated that patient is tachycardic ( with irregular heart rhythm. Her blood pressure is …

2. Evaluation of Nursing Interventions at Admissions
a. Evaluation of appropriateness of nursing interventions at the time of admission is thoroughly discussed. A well-supported explanation for each of the medications listed is presented. Strong and compelling rationale is provided.

3. Cardiovascular Conditions Leading to Heart Failure and Interventions
a. Four cardiovascular conditions that may lead to heart failure are clearly described. Medical and nursing interventions to prevent the development of heart failure in each condition are discussed. Overall, the discussion demonstrates insight into medical and nursing interventions used to prevent heart failure.

4. Nursing Interventions for Older Patients to Prevent Problems Caused by Multiple Drug Interactions
a. Four nursing interventions that can help prevent problems caused by multiple drug interactions in older patients are discussed. The discussion fulfills the assignment criteria and strong rationale for the interventions is provided. Assignment: Health History and Medical Information Essay

5. Health Promotion and Restoration Teaching Plan
a. A well-developed health promotion and restoration teaching plan for the patient is presented. Multidisciplinary resources for rehabilitation and any modifications that may be needed are clearly discussed. An strong explanation for how rehabilitation resources and modifications assist patient transition to independence is presented. The overall discussion is well-supported.

6. Method for Providing Education to Prevent Hospital Readmissions
a. A method for providing education to the patient for the maintenance of prescribed medications that prevents future hospital admissions is thoroughly described. The method is clearly appropriate for the client and prevents readmission. Strong rationale is provided for support.

7. COPD Triggers and Options for Smoking Cessation
a. All appropriate COPD triggers exacerbating return visits are clearly outlined. Strong options for smoking cessation are detailed and are highly relevant to the patient.

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Organization, Effectiveness, and Format

1. Thesis Development and Purpose
a. Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.
2. Argument Logic and Construction
a. Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative.
3. Mechanics of Writing (includes spelling, punctuation, grammar, language use)
a. Writer is clearly in command of standard, written, academic English.
4. Paper Format (use of appropriate style for the major and assignment)
a. All format elements are correct. Assignment: Health History and Medical Information Essay
5. Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)
a. Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.

Assignment: Health History and Medical Information Essay