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 pharmacy for all of her prescriptions.  The      pharmacist will be able to identify any 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

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 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 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  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
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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.

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 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 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