1- We need to reassure Mrs. J to decrease her anxiety.  Lab work, chest x-ray and ECHO will be needed.  She will need a septic work-up and qualifies for a sepsis alert, however with signs and symptoms of congestive heart failure she may need an inotropic infusion instead of fluid bolus to correct her hypotension.  She may have developed pneumonia from the flu virus and could possibly have a pleural effusion.  The rationale for each of the medications ordered are as follows (U.S. National Library of Medicine, 2015) Lasix      -for pulmonary edema – frothy blood-tinged sputum Enalapril      – an ACE inhibitor is given for heart failure; it works by decreasing      vascular resistance – watch for further hypotension Metoprolol      – a betablocker is for hypertension and heart failure; it slows the heart      rate and relaxes veins – again watch for hypotension IV      morphine is usually for pain, but in this case, it is for the anxiolytic      properties and vasodilation (Naito, Kohno, & Fukuda, 2017).        Four cardiovascular conditions that cause heart failure are coronary artery disease, myocardial infarction, myocarditis, and congenital heart defects (American Heart Association [AHA], 2017).  One condition is coronary artery disease caused by fatty deposits and cholesterol that clog arteries.  This can lead to the arteries that feed heart muscle becoming closed off resulting in heart muscle damage.  Second, a myocardial infarction happens when an artery that feeds the heart muscle is blocked causing lack of oxygen.  This ultimately results in death of the muscle and pump failure.  The blockage can be from a blood clot that traveled to the heart or from arteriosclerosis.  Another condition is myocarditis.  It is caused by an infection that attacks the heart muscle resulting in pump failure.  Finally, congenital heart defects can result in heart failure because the heart is malformed.  The malformation makes the heart work harder and the blood may not flow in an efficient manner (AHA, 2017).      For the most part, being active and eating a healthy diet are important factors to reduce the risks of developing heart failure.  Taking prescribed medications are very important to help improve heart function and reduce the heart’s work load.  For congenital heart defects, the patient may need surgery to correct the malformation; or sometimes, a heart transplant may be required.     For medication safety, Develop      an accurate medication list for your patient.  This medication list      should be in words the patient can understand and include the name, dose,      time for administration and the reason for each medication.       Encourage the patient to take ownership of her medications and keep the      list up to date.  Take it to every appointment no matter who the      doctor is.  Also, include any over the counter medications and check      for interactions with prescription medications. Have      the patient use only one phar ...

1. 1- We need to reassure Mrs. J to decrease her anxiety. Lab
work, chest x-ray and ECHO will be needed. She will need a
septic work-up and qualifies for a sepsis alert, however with
signs and symptoms of congestive heart failure she may need an
inotropic infusion instead of fluid bolus to correct her
hypotension. She may have developed pneumonia from the flu
virus and could possibly have a pleural effusion. The rationale
for each of the medications ordered are as follows (U.S.
National Library of Medicine, 2015)
Lasix -for pulmonary edema – frothy blood-tinged sputum
Enalapril – an ACE inhibitor is given for heart failure; it
works by decreasing vascular resistance – watch for further
hypotension
Metoprolol – a betablocker is for hypertension and heart
failure; it slows the heart rate and relaxes veins – again
watch for hypotension
IV morphine is usually for pain, but in this case, it is for the
anxiolytic properties and vasodilation (Naito, Kohno, &
Fukuda, 2017).
Four cardiovascular conditions that cause heart failure are
coronary artery disease, myocardial infarction, myocarditis, and
congenital heart defects (American Heart Association [AHA],
2017). One condition is coronary artery disease caused by fatty

2. deposits and cholesterol that clog arteries. This can lead to the
arteries that feed heart muscle becoming closed off resulting in
heart muscle damage. Second, a myocardial infarction happens
when an artery that feeds the heart muscle is blocked causing
lack of oxygen. This ultimately results in death of the muscle
and pump failure. The blockage can be from a blood clot that
traveled to the heart or from arteriosclerosis. Another condition
is myocarditis. It is caused by an infection that attacks the
heart muscle resulting in pump failure. Finally, congenital
heart defects can result in heart failure because the heart is
malformed. The malformation makes the heart work harder and
the blood may not flow in an efficient manner (AHA, 2017).
For the most part, being active and eating a healthy diet are
important factors to reduce the risks of developing heart failure.
Taking prescribed medications are very important to help
improve heart function and reduce the heart’s work load. For
congenital heart defects, the patient may need surgery to correct
the malformation; or sometimes, a heart transplant may be
required.
For medication safety,
Develop an accurate medication list for your patient. This
medication list should be in words the patient can
understand and include the name, dose, time for
administration and the reason for each medication.
Encourage the patient to take ownership of her medications
and keep the list up to date. Take it to every appointment no
matter who the doctor is. Also, include any over the counter
medications and check for interactions with prescription
medications.
Have the patient use only one pharmacy for all of her
prescriptions. The pharmacist will be able to identify any

3. risks or issues with contraindications or double medications
for the same disease.
Have your patient use a pill dispenser or other reminder
system. The pill dispenser will not only keep the
medications straight but will help the patient know whether
she took her medications for the day.
Ask your patient to bring her medications (the actual bottles)
at least once a year for evaluations. This will allow for
evaluation of dosages, expired medications, etc. This will
also allow you to help the patient dispose of medications
that are no longer used or needed. This will prevent the
patient from accidentally taking the wrong pills.
References
American Heart Association. (2017). Causes of heart failure.
Retrieved from https://www.heart.org/en/health-topics/heart-
failure/causes-and-risks-for-heart-failure/causes-of-heart-failure
Naito, K., Kohno, T., & Fukuda, K. (2017, July). Harmful
impact of morphine use in acute heart failure.
Journal of Thoracic Disease
,
9
(7), 1831-1834. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5542994/
U.S. National Library of Medicine. (2015). Medline plus-
trusted health information for you. Retrieved from
https://medlineplus.gov/druginformation.html

4. 2-Your post is very knowledgeable and in thorough detail. As
you have mentioned in your post about Morphine , is a
vasodilator and reduces the workload on the heart and
improving blood flow to the heart. Morphine can help to slow
the respirations and alleviate dyspnea and anxiety (WebMD,
2019 ). Morphine can be used for pulmonary edema, heart
failure and in Myocardial infarction as well. I still remember
MONA from nursing school stands for Morphine, Oxygen,
Nitroglycerin and Aspirin treatments for Myocardial Infarction.
3-
Yes ! that is right, polypharmacy is a very serious problem in
elderly patients. They get easily confused over their
medications. Even with a little stress whether physical or
mental, they easily get confused and start missing their meds or
can consume too much to relieve their symptoms. Which will
leads them to very critical health issues. So it is health care
professionals responsibility to educate them about all the
medications they are taking. They should always have all the
written information about all their medications and an
emergency call number for help.
4-Ms. J is showing the symptoms of Acute bilateral ventricular
heart failure and pulmonary edema (Copstead & Banasik ,
2013). Clinical signs of heart failure are an S3 heart sound and
the PMI at the 6th Intercostal space, as normal is at the 5th and
this indicates a shift with the enlarged heart. Crackles in the
lungs, + cough, frothy blood tinged sputum, hypoxemia, and
dyspnea are signs of pulmonary edema and left sided failure.
The bilateral jugular vein distention and hepatomegaly are two
signs of right sided failure. This patient is very critical but

5. manageable and already admitted in Intensive care settings. My
priorities would be oxygenate her ASAP and resume all stat
medications to make her comfortable. As she is on room air and
her SPO2 is 82% only. I will get an order from MD to put her
on “Non Invasive Ventilation” OR BIPAP and call RRT to
initiate it right away. Initiating NIV, is a non-pharmacological
approach may improve outcomes for patients with heart failure .
With this NIV she needs to be sitting in high fowler position
and complete bed rest until stable, cardiac monitor, foley’s
catheter insertion to monitor I & O strictly. She also needs to
send all her initial blood work for instance, elytes, CBC,
cardiac enzymes and liver enzymes with blood culture.
Medically, she is given morphine and lasix which are perfect
treatment for CHF and pulmonary edema. Lasix is a loop
diuretic will increase her U/O which will decreases the preload
or workload on the heart. She already has foley catheter to
monitor her output. Morphine is a vasodilator and reduces the
workload on the heart and improving blood flow to the heart.
Morphine can help to slow the respirations and alleviate
dyspnea and anxiety (WebMD, 2019 ). She is getting Enalapril,
is an ace inhibitor which works by relaxing blood vessels and
decreasing blood volume which results in lowering the blood
pressure and oxygen demand. Metoprolol is a beta blocker and
improves the heart's ability to relax, decreases heart rate and
blocks stress hormones that can cause the heart to enlarge and
weaken over time. If metoprolol does not help with her Afib,
physician can also prescribe her an Antiarrhythmic such as
amiodarone 150 mgs bolus IV following with infusion as per
standard protocol.Which is very effective for Afib. However,
her BP is a kind of border line needs to be monitored. While she
is on beta blocker or Antiarrhythmic. As she is on strict bed rest
and she is already in uncontrolled Afib HR 132/ mnt she is at
high risk of developing DVT. She needs Low molecular heparin,
dose according to her weight as DVT prophylaxis. For being on
BIPAP she needs to be NPO so that she does not aspirat her

6. gastric contents. She also needs gastric prophylaxis to reduce
gastric acid production such as ranitidine or pantoprazole.
Four cardiovascular conditions that may lead to congestive
heart failure are Coronary Artery Disease, Hypertension,
previous myocardial infarction, and valvular disorders.
Coronary artery disease results primarily from atherosclerosis
which causes a narrowing in the arterial lumen. This causes the
heart to work harder and can result in risk for thrombus or
myocardial infarction (American Heart Association, n.d.).
Hypertension will cause an increase in pressure to the heart
over time if uncontrolled and eventually the heart will weaken
and not function (American heart Association, n.d.). These
conditions can be improved by educating patients on risk
factors and lifestyle changes and by talking their prescribed
medications on regular basis. Educating them on smoking
cessation programs, healthy diet and maintain daily regular
activity and maintain normal weight makes a difference in their
treatment . People needs to learn that, being overweight can
cause the heart to work harder than normal and cause sleep
apnea too. People needs to be Educated on the long term effects
of obesity and some ways to help with their weight loss.
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 rationale for each of
the interventions you recommend.
1. Help and teach the patient on keeping an exact record or a
list of all over the counter and herbal medications as well as all
the vitamins and minerals that the patient is taking. So as to
lessen the opportunity of MD’s requesting prescription that may
have drug interaction.
2. Teach the patient on the significance of picking one primary

7. doctor so as to lessen polypharmacy.
3. Help and instruct the patient on guaranteeing appropriate
dosage and recurrence are trailed by utilizing a medicine
organizer.
4. Guarantee the patient is taught on every single new
medications, indications, potential reactions and potential
collaborations.
Reference :
American Heart Association (n.d.). Causes and risk for heart
failure. Retrieved from https://www.heart.org
Copstead , L., & Banasik , J.L. (2013). Pathophysiology (5 th
ed.). St. Louis, MO: Saunders
WebMD (2019). Heart failure questions and answers.
Retrieved from https://www.webmd.com
Reply | Quote & Reply
Feb 18, 2019 06:45 PM0 Like
5-
Strong work mentioning, strict i & o's. This is an a really
important aspect in heart failure patients to prevent further
fluild overload. Mrs. J will also need to be taught what her dry
weight is, and the importance of taking her weight everyday
upon discharge.

8. 6-Ms. J i s showing signs of biventricular heart failure
(Copstead & Banasik , 2013). Crackles in the lungs, + cough,
frothy blood tinged sputum, hypoxemia, and dyspnea are signs
of pulmonary edema and left sided failure. The bilateral jugular
vein distention and hepatomegaly are two signs of right sided
failure. Additional clinical signs of heart failure are an S3 heart
sound and the PMI at the 6 th Intercostal space, as normal is at
the 5 th and this indicates a shift with the enlarged heart.
This patient is unstable which requires an Intensive care setting.
Initial interventions would require addressing her hypoxia and
dyspnea. Initiate oxygen due to her hypoxia per the physician
order and adjust as needed to get her oximetry >90%. Place her
in upright position in bed to help alleviate dyspnea. Administer
ordered meds (IV Lasix and IV morphine) would be a priority.
Cardiac monitoring is critical to monitor her hemodynamic
status. Assess for cardiac output by assessing skin for
temperature and color, mental status, urine output, and
peripheral perfusion. Assess for clinical signs of improvement
in her heart failure by auscultating lungs and heart and checking
for any peripheral edema or jugular distention (Riley, 2015).
Assessing this patient’s response to medications given and if
her anxiety is reduced by the interventions. If not, then it would
be important to discuss with the physician to order an
antianxiety medication as well.
Lasix, enalapril, metoprolol, and morphine are all used on this
patient and are common for heart failure. Lasix is a diuretic and
works to remove excess fluid from the body by increasing renal
blood flow and blocking sodium and chloride reabsorption. This
decreases the preload or workload on the heart. Enalapril is an
ace inhibitor which works by relaxing blood vessels and
decreasing blood volume which results in lowering the blood
pressure and oxygen demand. Metoprolol is a beta blocker and
improves the hearts ability to relax, decreases heart rate and

9. blocks stress hormones that can cause the heart to enlarge and
weaken over time. Morphine is a vasodilator and reduces the
workload on the heart and improving blood flow to the heart.
Morphine can help to slow the respirations and alleviate
dyspnea and anxiety (WebMD, 2019 ) .
Four cardiovascular conditions that may lead to congestive
heart failure are Coronary Artery Disease, Hypertension,
previous myocardial infarction, and valvular disorders.
Coronary artery disease results primarily from atherosclerosis
which causes a narrowing in the arterial lumen. This causes the
heart to work harder and can result in risk for thrombus or
myocardial infarction (American Heart Association, n.d.).
Hypertension will cause an increase in pressure to the heart
over time if uncontrolled and eventually the heart will weaken
and not function as well (American heart Association, n.d.).
Inteventio s n to both of these conditions include educating
on risk factors and lifestyle changes. Educate on smoking
cessation programs, healthy diet and activity and taking meds
such as antihypertensives and cholesterol lowering meds as
prescribed. Myocardial infarctions ( MI) are caused by a
sudden blockage to the myocardium which can cause scarring
and lead to poor functioning and result in ineffective pumping.
Valvular disorders result from stenosis which is a decrease in
blood flow or regurgitation when the valve fails to close
properly. Educating people on the signs/symptoms of an MI and
valve disorders are important for early detection and treatment.
There are many risks to the elderly for taking multiple
medications. The following are interventions I would suggest.
Instruct patient to carry a list of medications including over
the counter to all physicians. Consulting physicians may not
be aware of all the meds that are prescribed by the other

10. physicians.
Instruct patient on all meds and side effects. Write out
generic and brand name and include dosage, frequency and
reason to take.
Teach patients or a family member to use a pill caddy to
prefill weekly meds to encourage compliance and that are
correctly taking meds
Instruct patients and families on risk to falls. Patient taking
multiple meds are at a higher risk to fall.
Reference
American Heart Association (n.d.). Causes and risk for heart
failure. Retrieved from https://www.heart.org
Copstead , L., & Banasik , J.L. (2013). Pathophysiology (5 th
ed.). St. Louis, MO: Saunders
Riley, J. (2015). Cardiac failure review. The Key Roles for the
Nurse in Acute Heart Failure Management, 1 (2), Retrieved
from https://www.cfrjournal.com/article
WebMD (2019). Heart failure questions and answers.
Retrieved from https://www.webmd.com