What nursing interventions are appropriate for Mrs. J. at the time of her admission?

Mrs.  J. is being admitted to the ICU due to acute decompensated heart failure. The subjective and objective data obtained is the following: Mrs. J is overweight based on her height and weight (5 feet 9 inches and weighs 210.5 pounds). For three days she has been experiencing a low grade fever (99.68), pharyngitis, and malaise. She denies pain but feels that she cannot breathe due to dyspnea. She claims that her heart is running away which indicates tachycardia (HR 118 and irregular). Her heart rate is working harder to compensate for the low blood pressure of 90/58. Her peripheral pulses are +1, demonstrating jugular distention, and ventricular rate of 132 with atrial fibrillation. She has crackles at auscultation, decreased breath sounds on right lower lobe, coughing frothy blood-tinged sputum, with and a very low oxygen saturation level of 82%. This patient is having left sided heart failure based on the subjective and objective data obtained.

Intervention: Place patient on continuous oxygen 2-4 LPM via n/c.

Rationale: To alleviate dyspnea symptoms and allow patient not to work as hard breathing

Intervention: Establish guidelines and goals of daily activity.

Rationale: Patient will most likely be more willing to cooperate if she is included in the goals being set.

Intervention:  Assess patient’s mentation regularly.

Rationale: This is to determine if the patient is becoming more severe. Anxiety and confusion are late signs when a patient is having decreased cardiac output.

Intervention: Keep patient semi to high-fowlers position.

Rationale: This will help alleviate some of the shortness of breath.

Intervention: Asses heart rate and blood pressure frequently.

Rationale: Sinus tachycardia and increased arterial blood pressure are in the early stages and the blood pressure decreases as the condition worsens.

Intervention: Assess peripheral pulses frequently.

Rationale: weak pulses are indicators of low cardiac output.

Intervention: Assess skin color and temperature.

Rationale: Cold and clammy skin is an indicator of low cardiac output and desaturation.

Intervention: Assess fluid balance and weight gain.

Rationale: A compromised regulatory system can result in sodium and fluid retention.

Intervention: Continuous assessment of lung sounds.

Rationale:  Crackles are indicative of fluid accumulation and secondary to left ventricular failure.

Intervention: Asses urine input and output.

Rationale: Decreased urine output is an indicator of lack of renal perfusion.

Intervention: Assess for chest pain.

Rationale: Indicates lack of oxygen supply. (Ackley & Ladwig, 2011).


What is the rationale for the administration of each of the following medications?

  1. IV furosemide (Lasix) – Furosemide is a loop diuretic and used to decrease fluid volume (pre-load). Patient is demonstrating. It is also used as an adjunct therapy. Mrs. J has crackles and coughing frothy blood-tinged sputum that is indicative of pulmonary edema. Nurse must check patient’s urine input and output and electrolytes due to possible dehydration, depletion of potassium, and metabolic alkalosis.
  2. Enalapril (Vasotec) – is an angiotensin-converting enzyme (ACE) inhibitor. Enalapril is used for congestive heart failure which is a weakness of the heart that leads to buildup of fluid in the lungs and the surrounding tissues. Patient has crackles, and she is coughing frothy blood-tinged sputum (McKenry, 2006).
  3. Metoprolol (Lopressor) – Lopressor is a beta blocker and the standard use for heart failure. Beta blockers are used in patients with heart failure because it helps improve the hearts ability to relax, decrease the production of harmful substances produced by the body in response to heart failure, and slows down the heart rate. Mrs. J has a ventricular rate of 132 and atrial fibrillation (WebMD, 2015).
  4. IV morphine sulphate (Morphine)- Morphine is an opioid and it is used to alleviate Mrs. J’s dyspnea. Morphine lowers the breathing rate in the brains respiratory center. This will help Mrs. J’s heart not work so hard. Morphine does this by widening the blood vessels in the extremities which will allow the heart not to work hard and use less oxygen. It is also great use for anxiety. Mrs. J is experiencing anxiety due to dyspnea and fear of complications (McKenry, 2006).

Describe four cardiovascular conditions that may lead to heart failure

Obesity – Mrs. J is overweight (210.5 lb). Obesity can cause congestive heart failure. Left Ventricular hypertrophy is very common in patients with obesity.

High Blood Pressure – Mrs. J has a history of high blood pressure. The history of years of high blood pressure probably caused damage to the artery walls. The constant pushing on the walls of the arteries probably weakened her heart.

Atrial Fibrillation – Mrs. J is currently having atrial fibrillation. This means that the heart is not pumping enough blood to meet the needs of the body. This can lead to heart failure because the heart is beating so fast and working so hard that the heart doesn’t fill-up properly to pump blood to the body. The blood then can back up in the pulmonary veins which cause fluid buildup which Mrs. J is currently experiencing. Mrs. J is also has fatigue and dyspnea due to lack of rich oxygenated blood that is not being delivered to her body and brain (American Heart Association, 2015).

Coronary Artery Disease – Coronary artery disease is the most common form of heart disease and heart failure. It is the accumulation of fatty deposits buildup that causes reduction in blood flow, weakening the heart, and causing permanent damage to the heart. 

And what can be done in the form of medical/nursing interventions to prevent the development of heart failure in each condition.

Obesity Intervention – Establish short and long term goals, encourage calorie intake appropriate for body type and lifestyle, encourage Mrs. J to keep a daily log of food and liquid consumption. Encourage Mrs. J to be more aware of nutritional habits that may contribute to weight gain. Encourage Mrs. J to exercise and encourage consultation of a dietician for further assessment and recommendations regarding a weight loss program. Educate Mrs. J of the importance of routine follow-up MD visits.

High Blood Pressure – Mrs. J has been smoking two packs of cigarettes daily for the last forty years. Smoking cause’s blood pressure to rise but the chemicals in the tobacco causes damage to the lining of the artery walls causing arteries to narrow, increasing the blood pressure. Educating the patient with the outcome of smoking is beneficial. Mrs. J needs to be educated on the importance of taking her blood pressure on daily and keeping a log of the blood pressure reading. Mrs. J should be placed on a low sodium cardiac diet. Educating Mrs. J on the importance of taking her medication on a daily basis as prescribed to prevent organ damage. Informing Mrs. J that lifestyle adjustment must be made to reduce the risk of cardiovascular morbidity. This is not a short term goal and it will take time for patients to get use to the lifestyle change and nursing follow is important for the patient to feel supported and follow the program.

Atrial Fibrillation – Atrial fibrillation is the loss of synchrony between the atria and ventricles. The goal is to maintain adequate cardiac output and tissue perfusion to make sure Mrs. J does not develop a thromboembolism. Monitoring the heart rate is very important and making sure that the systolic rate does not go below 90mmHg. Mrs. J should be educated on reporting any chest discomfort in which oxygen therapy would be beneficial. Continuous cardiac monitoring is imperative. Also making sure Mrs. J receives education on medications such as Amiodarone or Digoxin to control the atrial fibrillation. Educate Mrs. J how to obtain her own pulse and recognize symptoms of toxicity.

Coronary Artery Disease – is the accumulation of plaque buildup on the coronary arteries which leads to blockage. The heart is deprived of oxygen due to the blockage and is unable to pump efficiently. Very important to access patient level of consciousness, evaluate for chest pain, assess heart rate, blood pressure, peripheral pulses, and evaluate skin color and temperature. Provide oxygen in conjunction with medication therapy. Monitor fluid volume to prevent overloading the heart and lungs Reduce anxiety by providing Mrs. J to share her fears or concerns. Provide a quiet environment and uninterrupted sleep.

Discuss four nursing interventions that can help prevent problems caused by multiple drug interactions in older patients.

Intervention: Interview Mrs. J to obtain a complete drug history that includes prescribed, OTC, home remedies, herbals, vitamins, and any drug allergies (Ackley & Ladwig, 2011).

Rationale: This will help the healthcare provider identify any potential side effects that might occur with the medications, OTC, home remedies, herbals, vitamins, or drug allergies (Ackley & Ladwig, 2011).

Intervention: Teach Mrs. J how to make a list of each medication, including the name, strength, appearance, purpose, and effects (Ackley & Ladwig, 2011).

Rationale: Educates the patient on the reason for taking the medication and what to look for(Ackley & Ladwig, 2011).

Intervention: Question Mrs. J on her self-medication practices. How does Mrs. J remember to take her medication? Does she forget to take her medication and what does she do when she remembers (Ackley & Ladwig, 2011).

Rationale: This allows the healthcare provider know if Mrs. J is over or under medicating herself (Ackley & Ladwig, 2011).

Intervention: Determine if Mrs. J is capable of administering medications (Ackley & Ladwig, 2011).

Rationale: There might be a physical impairment, memory loss, health, cultural beliefs, financial constraints, or social support lacking (Ackley & Ladwig, 2011).




Ackley, B., & Ladwig, G. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis: Mosby, Elsevier.


American Heart Associatio. (2015). Why atrial fibrillation (af or afib) matters. Retrieved from


Kozier, B. (2012). Kozier & Erb’s fundamentals of nursing: Concepts, process, and practice(9th ed.).

  Boston: Pearson.


McKenry, L., & Tessier, E. (2006). Mosby’s pharmacology in nursing (22nd ed.). St. Louis, Mo.: Elsevier



WedMD. (2015). Heart failure health center. Retrieved from

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