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Nursing interventions that would be appropriate for Ms J during her admission to the ICU would include the following:

• Continuous monitoring of VS and oxygen saturation after nasal O2 is applied - if saturations do not improve change to mask and do not rule out possible intubation - elevate HOB to a semi-fowlers position to facilitate easier effort of breathing 
• Assess for changes in her alertness or signs of confusion or hypoxia
•  Observe rhythm for increased ventricular rate with atrial fib and deterioration in cardiac status with ectopy or onset of chest pain
• Provide an environment that allows for rest and decreased anxiety – organize nursing care to facilitate rest periods
• Monitor intake and output for cardiac stability as well as dehydration from the onset of the flu
• Auscultate chest more frequently for  breath sounds to determine improvement or deterioration in status
• Administer medications as ordered and  assess for prn meds to facilitate reduction in fever, generalized achiness from flu, decrease anxiety and promote rest

Rationale for the following meds (“Heart Failure Treatments and Drugs”, 2017): 

•  LASIX IV – Produces diuresis in the kidneys and dilation in the venous system to promote a preload reducing effect that is seen within minutes once administered.  Promotes excretion of water from the body and decreases fluid in the lungs to improve breathing 
• VASOTEC – an Angiotensin-Converting Enzyme (ACE) inhibitor is a vasodilator that increases the blood vessels to lower blood pressure, improve blood flow and decrease the workload on the heart.
• LOPRESSOR – A beta blocker that reduces the symptoms of oxygen demand and myocardial ischemia of heart failure, improves the pumping action, and lowers the heart rate and blood pressure. Also increases diastolic relaxation to allow for the heart to fill properly due to wall motion stiffness.  
• MORPHINE IV – Induces vasodilation and increases venous return to the heart, acts as a mild arterial dilator, decreases myocardial oxygen consumption, centrally suppresses symptoms of breathlessness, decreases anxiety and reduces pain.

Four CV conditions that may lead to heart failure; what medical/nursing interventions can prevent the development of heart failure in each condition:

• Coronary Artery Disease/and MI is the most common cause of heart failure in which the arteries to the heart that supplies blood become narrowed or blocked.  When blood flow is completely blocked the heart muscle suffers damage and blood supply is reduced and the area around the muscle and blockage dies or suffers loss of blood flow.  If the damage affects the pumping ability, heart failure develops.  Preventative measures to avoid CAD/MI are the lifestyle changes that slow the progression of atherosclerosis or avoided – patient teaching and education regarding a balance diet, exercise, smoking cessation, controlling BP and cholesterol levels.  Patients that have developed CAD should consider the regime of taking an ASA daily, beta blockers to reduce the workload of the heart, routine follow-ups with MD to prevent further advancement of heart failure. Proactive with testing for cardiac catheterization for stent placement and evaluation of coronaries/heart function (Copstead& Banasik, 2012).  
• Cardiomyopathy  is a general term describing disease of the heart muscle.  Even though it can be caused by other heart related issues the heart muscle cannot withstand the workload and heart failure develops. Management normally is the treatment with beta blockers and calcium antagonists; both reduce oxygen consumption and slow the heart rate.  Patients with cardiomyopathy are at risk for atrial fib in which treatment and education involves the patient understanding the rhythm, the incidence of stroke with a.fib, and treatment such as cardioversion and medications, other preventative measures focused on reducing symptoms include following a weight loss program, reducing alcohol intake andmoderate exercise.
•  Heart Valve Disease  forces your heart to work harder to keep blood flowing in the correct direction.   The valves open and close during diastole and systole and prevent backflow of leakage of blood back into the chambers.  A damaged valve can be due to a heart defect, CAD, or a previous MI that involved the valve areas such as papillary muscles or chordae tendineae. Infection known as endocarditis can cause vegetation and damage the valves.  Treatment with antibiotics and preventative measures such as good personal hygiene – dental care is important. 
• Hypertension  is another common cause of heart failure.  High blood pressure causes the heart to work harder to pump blood even at rest and the muscle becomes stiff with the inability to pump effectively.   Eventually the heart cannot keep up and symptoms of heart failure over time develop.  Education is important to teach patient about medications – Diet with foods low in sodium, healthy choices from the food groups, and exercise program for maintaining weight. Medical tx may include the use of thiazide diuretics, beta blockers, ACE inhibitors or other meds per the MD’s prescribing (Riley, J. 2015). 

Four nursing interventions that can prevent problems caused by multiple drug interactions in older patients – provide rationale

• Avoiding what is known as “polypharmacy” in which multiple meds are taken to manage coexisting health issues by multiple healthcare providers. It is important to review each visit the current list of prescribed meds, OTC and supplements for possible duplicates, adverse reactions, or over-dosing (ANA, 2010). 
• Proper medication reconciliation at time of admission to hospital and at discharge for any changes.  Upon admission many times physicians are unaware of all medications the patient is taking when admitted; at discharge the list should be updated in the discharge papers and reviewed with patients/ family members taking note the correct med, dosage is understood.
•  Practice habits using the OTC pill organizers that list the 7 days, am and pm for dispensing meds.  This routine will assist in keeping the patient compliant in taking correct medication and an easy tool to identify the meds has been taken as prescribed.  Keep pill box in place that is easily visible. Keep as simple as possible (ANA, 2010).
• Avoid doctor shopping and using multiple pharmacies.  Many primary care physicians hand off patients to specialty practices in which further medications are prescribed or the patient may request an additional med that he no longer takes  and is given.  Patients may have several pharmacies they use for shopping or who may home deliver. A monthly visit by home health is an option or follow up with a family member that oversees family care for evaluation.

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