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Upon admission there are many appropriate interventions to be executed. An accurate weight should be obtained to provide necessary weight based medications as well as to monitor for fluid retention/loss. Vital signs to include blood pressure, pulse, respirations, oxygen saturations and temperature give the nurse a baseline measure for future monitoring of the patients’ condition. Oxygen should be initiated if not already on, since room air O2 saturation levels are 82% and oxygen is needed for adequate cellular growth and adaption. Baseline assessment should include lung and heart sounds as well as any peripheral edema present. Given the dyspnea and productive sputum, initial bedrest would be appropriate. Riley (2015), concludes that the nurses’ utmost important tasks are to monitor the effectiveness of treatment and alert physicians of changes to obtain best outcomes for patients. Sharp assessment skills upon admission are vital to how later outcomes are obtained. Medications will need to be verified by pharmacy asap to use in providing relief for Mrs. J. Along with prescribed medications, I would also look into obtaining a nicotine patch given her smoking history. Accurate I & O recordings will be essential as well in monitoring medication effectiveness. Depending on the severity, a Foley catheter may be placed for hourly monitoring of output. Essential labs to obtain given admission information would be a Troponin, CPK, BNP, CMP, CBC, and a NT-proBNP. Given the irregular heart rhythm I would anticipate cardiac monitoring in the form of a halter monitor and a baseline EKG to be obtained.

Rationale for:

• · IV furosemide (Lasix)- Lasix given in the IV route acts differently than an oral route. IV administration has an effect of pulling fluid from the lungs that oral Lasix does not achieve. This medication alone will help rid the body of excess fluid and eases the dyspnea that is currently present. Serum potassium will need to be especially monitored as this created a large amount of urine output. As fluid is removed this med is also known to lower blood pressure. Careful monitoring is essential.
• · Enalapril (Vasotec)- This is an ACE Inhibitor which can lower the blood pressure but also rids the body of excess fluid while strengthening the overload hearts ability to contract. Blood pressure will need to be closely monitored as well as electrolytes as this medication both lowers pressure and increases output creating the possibility of electrolyte imbalances.
• · Metoprolol (Lopressor)- This is a beta blocker that also reduces blood pressure and is typically used to control heart rate and dysrhythmias such as atrial fibrillation. The action of this reduces the amount of work the heart has to pump in order to function, generally reducing chest pain and uncontrolled rhythm. Blood pressure will need to be closely monitored as this patient already presents with a low pressure.
• · IV Morphine Sulphate (Morphine)- IV morphine acts as a multi-tool in that it relaxes smooth muscle to allow blood flow to and from the heart more easily, as well as acting as an anti-anxiety for the patient. Allowing her to relax will ease respiration workload while allowing for more blood flow to vital organs.

Four Cardiac conditions that may lead to heart failure/ interventions to prevent development of heart failure:

According to the National Institutes of Health (2016), the most common cause of heart failure is Coronary artery disease or (CAD). This occurs when cholesterol builds up on the most inner parts of the arteries narrowing the available pathway of blood flow to and from the heart. When this occurs, the arteries suppling the heart with blood pump inefficiently decreasing the required volume of blood and oxygen needed to sustain healthy cardiac function. Over time this leads to weakened cardiac muscles and damage that results in failure of the organ (NIH, 2016).

• · Prevention includes implementing a healthy low sodium diet, increasing exercise frequency, maintaining a healthy weight, reducing stress, smoking cessation, and possible use of statin medications such as Lipitor or Zocor. In extreme cases, surgical intervention may be necessary to open or bypass the blocked areas.

High blood pressure is another common cause of heart failure. Many times this is a result of the increased force needed to contract blood through the body due to CAD. Hardened veins and arteries require a harder force thus increasing the pressure needed to get blood through. Another possibility is genetics in which we cannot prevent but can be controlled. This harder force eventually weakens the heart creating enlarged areas of the heart leading to heart failure.

• · Prevention is education! Monitor your pressure, live a healthy lifestyle free from high fats, fried foods, no smoking, get out there and move!! If it is genetic then acknowledge it and treat as you need to (American Heart Association, 2015). Decreasing stress levels, taking medication as prescribed and treating yourself with the respect your body deserves are all ways in which you can prevent high blood pressure from leading to a failing heart.

Abnormal heart valves are another reason that the AMA describes. Whether it is a result of a birth defect or from an infection improper working valves in the heart causes the workload of the heart to be extreme. The heart cannot tolerate the extra workload demand for long before the heart muscle begins to enlarge and weaken, decreasing the contractibility of each beat. Not only does the heart weaken but the valve doesn’t fully shut allowing blood to backflow into previous chambers. Most commonly is the backflow of right sided heart failure to the lung.

• · Prevention depends on the cause of the valve failure. If it was a birth defect diligent monitoring is essential vs surgical intervention to replace the valve if needed. If acquired by infection, medication will need to completed as ordered and followed for progression of the valve recovery or damage. Surgical intervention is also a possibility in this case as well. Maintaining a healthy lifestyle and intermittent monitoring of the condition will be essential in prevention of progression of failure occurring (AMA, 2015).

Previous heart attack is another main cause in failure of the heart. When a portion of the cardiac tissue is derived from oxygen the muscle will no longer function as the organ requires (AMA, 2015). The remaining tissue picks up the pace for the part of non-working tissue increasing the workload. The harder working areas bulk up thus decreasing contractibility and eventually tires out leaving the heart to fail.

• · Fast action is required with an active heart attack to prevent tissue damage. Medications will need to be taken as directed and cardiac rehab followed through for best results. Depending on the amount of damage received will impact the amount of rehab needed. Lifestyle changes are crucial in preventing further damage.

Four Interventions to prevent problems caused by multiple drug interactions/ Rational:

In a study conducted by Farrell, Shamji, Monahan and French Merkley (2013), showed that by using multiple interventions such as identifying the drug problem, prioritizing the significance of the interaction, tapering the medication and monitoring for withdrawal can significantly reduce the burden of drug interactions and actually improve the overall wellbeing of the patient. Identifying which drugs may be interacting is essential in changing the interaction of problem. Deciding which of the medications is creating the greatest negative impact and slowly tapering the doses will allow for less interaction. Many times it was found that some of the drug were really not needed and some patients actually showed mental clarity (Farrell et. el…, 2013). If the drugs were tapered slowly then prevention of withdrawal could be detoured. With decreasing the overall amount of medications can reduce potential side effects and interactions that are unnecessary. Another intervention is using a computerized system to ensure that polypharmacy is decreased. Current systems allow the pharmacy to see if duplicate scripts are being written and flag potential interactions. Having a written form of medications taken can be informative to all physicians involved so all players in the care are informed of each other’s doings as well.