Evaluate the Health History and Medical Information Essay.

Posted: December 28th, 2022

Evaluate the Health History and Medical Information Essay.



It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span. Evaluate the Health History and Medical Information for Mrs. J., presented below. Based on this information, formulate a conclusion based on your evaluation, and complete the Critical Thinking Essay assignment, as instructed below. Health History and Medical Information 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).

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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.Evaluate the Health History and Medical Information Essay. 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 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 exhausted and cannot eat or drink by herself. Objective Data Height 175 cm; Weight 95.5kg. Vital signs: T 37.6C, HR 118 and irregular, RR 34, BP 90/58. 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. Evaluate the Health History and Medical Information Essay.Respiratory: Pulmonary crackles; decreased breath sounds right lower lobe; coughing frothy blood-tinged sputum; SpO2 82%. Gastrointestinal: BS present: hepatomegaly 4cm below costal margin. Intervention The following medications administered through drug therapy control her symptoms: IV furosemide (Lasix) Enalapril (Vasotec) Metoprolol (Lopressor) IV morphine sulphate (Morphine) Inhaled short-acting bronchodilator (ProAir HFA) Inhaled corticosteroid (Flovent HFA) Oxygen delivered at 2L/ NC Critical Thinking Essay In 750-1,000 words, critically evaluate Mrs. J.’s situation. Include the following: Describe the clinical manifestations present in Mrs. J. 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. 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 a rationale for each of the interventions you recommend. 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. Describe a method for providing education for Mrs. J. regarding medications that need to be maintained to prevent future hospital admission. Provide rationale. Evaluate the Health History and Medical Information Essay.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. You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance.Evaluate the Health History and Medical Information Essay.


The understanding of pathophysiological processes of diseases is important in formulating effective treatment plans for patients. This paper explores the case study of a 63-year-old married woman, Mrs. J., who presents with a history of chronic obstructive pulmonary disease (COPD), chronic heart failure and hypertension. She demonstrates risk behaviors such as smoking which have affected her walking abilities and complicating her health resulting in admission at the ICU with acute decompensated heart failure and acute exacerbation of COPD.

Clinical manifestations

The patient presents multiple clinical manifestations of heart failure, COPD and hypertension. These include the fever, productive cough, nausea, and malaise. She also complains of tiredness, shortness of breath, energy loss, walking difficulties which suggest the presences of COPD (Hillas et al., 2015). She also complains of irregular heartbeat and anxiety and breathing difficulties associated with hypertension. Her clinical manifestations are generally related to flu-like symptoms which have onset within the last 3 days.

The medical therapy used to treat Mrs. J present an appropriateness of the nursing intervention. For instance, IV furosemide (Lasix) is important in managing the extra body fluid caused by heart failure which helps in the reduction of swelling legs which limit mobility of the client as well as prevent her shortness of breath. Enalapril (Vasotec) is an angiotensin converting enzyme inhibitor that is effective in the treatment of the congestive heart failure (CHF) while Metoprolol (Lopressor) is a beta blocker that lowers treats hypertension by lowering the heart rate and blood pressure. On the other hand, morphine is used to manage pain in patients with chronic illnesses and thus is appropriate treatment for the client. However, the patient expresses no feelings of pain and thus can be withdrawn from the treatment plan. Inhaled short-acting bronchodilator (ProAir HFA) help the client in treating her breathing problems and COPD together with Inhaled corticosteroid (Flovent HFA) (Bonini & Usmani, 2015). The delivery of oxygen at Oxygen delivered at 2L/ NC is also essential in increasing airflow of the patient.Evaluate the Health History and Medical Information Essay.

The four cardiovascular conditions that may lead to heart failure include heart attack, hypertension, coronary artery disease and Arrhythmia. Heart attack describes the severe reduction of blood flow to due to narrowed blood vessels. Hypertension is the increase of blood pressure exerted against the walls of the blood vessels. Consequently, Arrhythmia is the change in the normal sequence of the heartbeat of an individual while coronary artery disease describes the blockage of the blood vessels thus restricting the flow of blood. These conditions can cause a reduced functioning of the heart which results in heart failure. The management of each condition through medication can prevent the development of heart failure as the drugs restore the normal heart functions.Evaluate the Health History and Medical Information Essay.

Drug interactions can be prevented through knowing the reason why the patient is taking each medication. This will help determine a safe combination of drugs for the patient. Another intervention is to develop an appropriate schedule for drug administration stating whether the medicine is taken with or without food and what diet should be given with the drugs. Moreover, the nurse should ensure the filling of the prescriptions at the pharmacy. Updated lists of medications are essential during emergency situations. Nurses can also advice the patient on the use of supplements to prevent interactions with the drugs. These interventions will reduce the chances of drug interactions particularly since the patient is on multiple pharmacological therapies.Evaluate the Health History and Medical Information Essay.

Health promotion and restoration teaching plan for the client will involve rehabilitation. Here the patient will remain in the healthcare facility while receiving therapy services that will enable his recovery. This will include managing his tobacco smoking addiction through behavioral changes and modifications to improve the quality of her life. Comorbidities increase the morbidity, disability and dependence of the patients and therefore, rehabilitation employs multidisciplinary disease-management approach to reduce the hospital readmissions and symptoms of the client thus improving their outcomes. The patient also learns self-care and therefore she will be able to independently care for herself after discharge.

Mrs. J will be educated through socialization with the staff who are versed with his health condition. This will help her gain insights on her health as well as the risk factors of tobacco smoking. In addition, the patient will be involved in learning sessions with other patients where demonstrations will be made to facilitate understanding. Individual sessions with the family will also promote creation of awareness and health. Since the patient is literate, handouts with health related literature will be given to her to familiarize with the preventive and treatment interventions.

COPD exacerbations can be caused by environmental and personal factors. These include the changes in weather that influence diseases of the lungs and the cardiovascular system. Smoking is the most common trigger for COPD and this is the major cause of Mrs. J’s hospital revisits as well as frequent exacerbations. As such, engaging the patient in a six months smoking cessation program will help her to successfully quit smoking. The use of varenicline (Chantix) drug will help control her cravings for smoking and decrease the pleasurable effects associated with it (Gaballa, Drowos & Hennekens, 2017).


Evaluate the Health History and Medical Information Essay.

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