Great Health History and Medication Information Case Study 1: Mrs. J.

Health History and Medication Information

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.

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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 and Medication 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). 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

  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

Health History and Medication Information
  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.


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

Critical Thinking Essay

Health History and Medication Information

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. 


 Subjective and objective clinical manifestations are detailed. The clinical manifestations are accurate and clearly report the observed and perceived  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. signs and symptoms. 

 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. 

 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. 

 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. 

 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. 

 All appropriate COPD triggers exacerbating return visits are clearly outlined. Strong options for smoking cessation are detailed and are highly relevant to the patient. 

 All appropriate COPD triggers exacerbating return visits are clearly outlined. Strong options for smoking cessation are detailed and are highly relevant to the patient. 

 Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear. 

 Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative. 

Submission Ide: 2d45bb31-11c9-48c9-ad0a-90ec4312d98c

61% SIMILARITY SCORE 6   CITATION ITEMS 19   GRAMMAR ISSUES 0   FEEDBACK COMMENT Internet Source   0% Institution   61%

Liliane Kouame



 925 Words  

Running head: CASE STUDY OF MRS. J. 1

Case Study of Mrs. J.

Liliane Kouame

Grand Canyon University



Clinical Manifestations

Health History and Medication Information

On account of Mrs. J for the case study being talked about, a few clinical signs exist. The

patient appears to be anxious and will, in general, ask if, at some point, she is going to die. Patients

patient notwithstanding a full set of vital signs and telemetry could help as well if different

innervations, for example, the administered prescriptions were of any significance to the Patient’s

wellbeing. To determine other significant nursing interventions, auscultation of Mrs. J’s heart, lung

fields, and the mid-region can be critical.

Heart Failure Prevention

An adherence to bodyweight management, having moderate exercises, adoption of a

healthy lifestyle by quitting smoking behaviors, and medication are examples of management and

prevention measures of the majority of cardiovascular disease. For patients to comply with

medication and treatment protocols, nurses are believed to play an essential role in providing case

management strategies as far as patient support is concerned through lifestyle modification and

education. Patients should draw a clear correlation between the increased risk of MI, HTN, and

CAD and physical activities. Hence, patients’ risk for heart disease and other comorbidities will

significantly decline when they incorporate physical exercise in their daily program as it will

improve the patient’s rate of blood pressure and reduction in body weight (Brown et al., 2011).

Polypharmacy: Nursing Implications

In the healthcare field, polypharmacy is a collateral application of different medications

prescribed and used by a patient (). Polypharmacy is linked with risks such as potential interactions

between different sets of drugs, non-compliance, as well as falls. Thus, healthcare practitioners are

responsible for preventing polypharmacy by first, ensuring an accurate medicine list, guaranteeing

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with cardiorespiratory and other interminable diseases, anxiety is one of the frequently dismissed

symptoms. Anxiety comes with side effects whereby the patient inhales factor that triggers

secondary effects such as chest pain, fear, and compounded symptoms of cardiovascular disease

(Bafadhel & Russell, 2016).

Subsequently, Mrs. J’s breathing problems roots from the anxiety she was undergoing. She

further complained of lacking sufficient air. Some of the most commonly detailed just as

weakening side effects of COPD and cardiovascular conditions include breathing shortness, also

referred to as dyspnea. As our case describes, breathing shortness is characterized by the patients

as breathlessness and routinely self-limiting activity based on the seriousness of the side effects.

Patients frequently describe dyspnea as shortness of breath, and patients routinely self-limit

activity because of the seriousness of symptoms (McCance & Huether, 2018). Mrs. J. further

complained of fever, malaise, nausea, and fatigue. In addition, fatigue is another common side

effect for patients with COPD and cardiovascular disease; the risk of becoming fatigued increases

by concurrent heart disease, a predicament that is probably going to increase the incidences of

COPD intensifications.

Nursing Interventions

As expressed in the case study of Mrs. J, some of the nursing interventions that have been

performed to help her in dealing with the wellbeing conditions she was experiencing include

oxygen at 2 LPM that was managed through the nasal cannula and several other different

prescriptions. Vital signs evaluation, for example, SPO2 and cardiac monitoring, were done on the


customary drug compromise, and facilitating patient education concerning clinical solutions under

which they have a place. Also, trying to prevent drug mistakes, diverse clinical intercessions can

be critical. Aiming to avoid possible medical errors among patients requires a follow-up from

physicians, and the emergency department is required and achieved using a routine medication

reconciliation intervention (Brown et al., 2011).

Health Promotion and Restoration

Looking at the health conditions of Mrs. J. in the case study, before and after her discharge

from the hospital, it is revealed that she requires health education and extensive support. The

primary focus of this education should be directed towards self-care: encourage patient disease

process understanding. In this setting, the health problem affecting Mrs. J., which is COPD, can

benefit from patient education, particularly in the use of inhalants and aspiratory hygiene. This

factor is used to optimize or boost the lungs (McCance & Huether, 2018). Evaluating Mrs. J’s

clinical needs at the point of discharge, there is a need for early involvement in the event that

management during the hour of her admission to the facility. This can aid the creation of a

discharge plan.

Medication Education

Nurses are the best practitioners in the facility that provide the best education about

medication adherence. When patients attend a medical education session, the nurse’s priority is to

evaluate their needs for education, readiness, and willingness to learn, specifically, if they are

cognitively, psychologically, and physically prepared to learn. Creating a successful education

program entirely depends on the patient’s health information the nurse has. Enhancing patient

education, in this case, will require the application of the teach-back method. This method is

commonly used across many health facilities because it allows patients to explain their concerns

to healthcare professionals in their language about what they understood in a given health

education program (Bafadhel & Russell, 2016). If patients can explain the care information earned

during the program, then it is believed that they are likely to implement.

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Bafadhel, M., & Russell, R. E. (2016). Are COPD and cardiovascular disease fundamentally


Brown, J. P., Clark, A. M., Dalal, H., Welch, K., & Taylor, R. S. (2011). Patient education in the

management of coronary heart disease. Cochrane Database of Systematic Reviews, (12).

McCance, K. L., & Huether, S. E. (2018). Pathophysiology-E-Book: The Biologic Basis for

Disease in Adults and Children. Elsevier Health Sciences.

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