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Health, Medicine, Nursing
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Case Study: Mrs. J. Health History and Medical Information (Essay Sample)


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). 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
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.
Respiratory: Pulmonary crackles; decreased breath sounds right lower lobe; coughing frothy blood-tinged sputum; SpO2 82%.
Gastrointestinal: BS present: hepatomegaly 4cm below costal margin.
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.
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.


Case Study of Mrs. J
Author Name
Institution Affiliation
Clinical Manifestations Present in Mrs. J
From this case study, it is evident that Mrs. J had a history of chronic heart failure, COPD (chronic obstructive pulmonary disease), and hypertension. Her body temperature used to increase significantly, resulting in a high fever. In addition, she had complained about productive cough, malaise, and nausea. In the last few days, she was not able to perform ADLs and needed someone’s help to walk short distances. She seemed to have developed feelings of restlessness, which is why she kept asking whether she was about to die. Though Mrs. J had always denied pain, she felt like she was unable to get air which clearly indicates that she had asthma. Furthermore, the patient used to get tired of things easily and this kept her from eating and drinking whatever she liked. These facts make us understand that Mrs. J may suffer from nosebleed, headache, and dizziness in the coming days. Fatigue, weakness and swelling in the legs, feet, and ankles may also occur.
Most Suitable Nursing Interventions for Mrs. J
At the time of admission, it was good if Mrs. J was assessed properly as this is the very first step to determining what actually the problem is and how to cure the illness (Josephson, 2013). Before planning care or interventions for a person with heart failure, it is mandatory for the medical expert to conduct a systematic assessment which consists of steps like identification of the actual cause of the heart failure, potential risk factors, the current clinical status, aggravating factors, and Mrs. J’s quality of life. Three of the most important things that should be taken care of are assessing the patient, planning appropriate and effective care and educating the patient regarding the seriousness of the issue.
Mrs. J should be assessed from the head to toe, and changes in her physical structure have to be observed. Any sign of abnormality has to be noticed. Some of the most effective management strategies for the patient are checking the status of her pulmonary crackles and trying to evaluate why her breath sounds strange. I would like to say that she should be given oxygen using a non-rebreather mask in order to help Mrs. J increase the SpO2 level. For this purpose, a high concentration of oxygen should be delivered for several hours

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