Assignment 1: Diagnostic and Pharmacontherapeutics Case Assignment Sample

Introduction: HFrEF Medication Errors and Discharge Planning Review

For patients with multiple comorbidities, such as heart failure, the problem of information interpretation, decision-making and management of medications is critical for successful treatment. The case of Mrs Gina Goddard, who is a 78-year-old female diagnosed with heart failure with reduced ejection fraction (HFrEF), supports these competencies. After being operated on for a fractured left femur, Mrs Goddard, the patient of interest, was readmitted to the hospital within 72 hours of discharge from the prior hospitalisation because of the new onset of heart failure. Although Mrs Goddard had previously been hospitalised for heart failure, she was discharged without adequate pain medication; instead, she was told to use over the counter, which is an NSAID that intensifies heart failure through renal retention of water.

This essay will appraise Mrs Goddard's case, specifically the clinical decision concerning medication management and highlight some of the major deficiencies made in the client’s planning. In addition, it will offer suggested measures to enhance patients’ safety and outcomes with special reference to the utilisation of research findings, planning, and implementation of discharge plans, as well as cooperation among practitioners. Analysing this case, it is possible to draw attention to registered nurses’ important activities in protecting patients with intricate conditions through accurate evaluation and clinical judgment.

Heart Failure with Reduced Ejection Fraction (HFrEF)

Pathophysiology and clinical manifestations of heart failure with reduced ejection fraction (HFrEF)

HFrEF implies, with reduced ejection fraction, as the name indicates, the heart is unable to pump adequate blood in circulation, hence qualifying for the standard of adequate perfusion of organs and tissues. For instance, Mrs Gina Goddard has HFrEF that resulted from a ‘silent’ anterior myocardial infarction that occurred one year back. This may have taken place during this event, when most of her myocardial damage in the left ventricle resulted in reduced /contractile function and ejection fraction.

The pathophysiology of HFrEF in Mrs Goddard includes several essential maladaptive processes, including her myocardial infarction would have caused a reduction in the ejection fraction of the left ventricle, which would have led to compensatory mechanisms such as activation of the RAAS and the sympathetic nervous system. Although the following mechanisms are designed at first to maintain and enhance cardiac output, they only worsen the condition of heart failure. RAAS activation is characterised by increased fluid retention and vasoconstriction; these actions would raise Mrs Goddard’s blood pressure while increasing preload in a heart that appears inherently weakened. These factors would, in the long term, cause ventricular remodelling which would decrease cardiac efficiency and aggravate her HFrEF.

Clinically, Mrs Goddard’s HFrEF is expressed by symptoms like breathlessness, orthopnea and symmetric pitting oedema as it arises from the pathophysiology. Her recent complaints of shortness of breath, which prevents her from sleeping in the supine position because of dyspnea, mean that she has altered pulmonary congestion that is pronounced in left heart failure. The oedema in the ankles and the patient’s inability to manage her walking frame are clear signs of systemic venous congestion, which is a result of right-sided heart failure; this is usually a complication of left-sided heart failure.

This clinical scenario also tries to reveal the effects of sub-optimal management of medications on her condition. Advising by ibuprofen, which belongs to the class of nonsteroidal anti-inflammatory drugs (NSAIDs), is prohibited in patients with heart failure as it causes an increase in fluid retention and worsening of the clinical picture of heart failure (Bindu et al., 2020). This probably led to her status post-acute exacerbation, manifested by her elevated blood pressure (190/110mmHg) and heart rate (120 bpm) at the time of admission, severe dyspnoea and pitting oedema. The current clinical guidelines regarding heart failure management in Australia focus on the fact that the use of NSAIDs in patients with HFrEF is contraindicated due to their impact on worsening the patient’s fluid status.

Medication Management for Heart Failure with Reduced Ejection Fraction (HFrEF)

 It is known that HFrEF is a chronic progressive condition that needs an individualised effective management of medications to increase survival, minimise symptoms and reduce the chances of readmission (Egbuche et al., 2019). Mrs Gina Goddard treats cardiovascular diseases with Enalapril, Bisoprolol, Spironolactone, Furosemide and Atorvastatin. All these drugs are useful in her treatment of her heart failure, but their interactions, particularly the drug-to-disease interactions and drug-to-drug interactions, are highlighted by her recent deterioration and hospitalisation.

Medication Overview

• Enalapril (20mg daily)

Enalapril belongs to the angiotensin-converting enzyme inhibitors and is one of the cardinal drugs used in treating HFrEF. RAAS activity is depressed, afterload and preload are decreased, and ventricular remodelling is prevented (Leancă et al., 2022). ACE inhibitors such as Enalapril are advised in the clinical guidelines of Australia for all patients with HFrEF unless they cannot tolerate them, and they do so because they improve symptoms and lower the mortality rate.

•  Bisoprolol (10mg daily)

Bisoprolol is a major drug class in beta-blockers, and bisoprolol, in particular, is the drug used in the treatment of HFrEF. Bisoprolol slows the heart rate, decreases myocardial oxygen demand and prevents arrhythmias, which in the long run, decrease the risk of sudden cardiac death (Bazroon & Alrashidi, 2022). Thus, beta-blockers are also advocated in various clinical guidelines for all patients with HFrEF.

•  Spironolactone (25mg daily)

Spironolactone is also an aldosterone antagonist, but it also blocks additional components of the RAAS to limit fluid buildup and promote potassium conservation (Patibandla et al., 2023). AmRenTHR has been demonstrated to decrease mortality and hospitalisation of HFrEF patients who have had continued HF symptoms despite ACE inhibition and beta-blockade.

•  Furosemide (40mg daily)

Furosemide belongs to the loop category of diuretics that are used to treat fluid overload by encouraging diuresis and improving congestion signs like oedema and dyspnoea. Litres are used for the relief of symptoms but do not alter the natural history of the illness.

•  Atorvastatin (40mg daily)

Atorvastatin is administered as a statin used for the prevention of hypercholesterolemia and cardiovascular disease (McIver & Siddique, 2024). Although statins are not direct therapies for heart failure, they are central in treating cardiovascular risk factors such as hyperlipidaemia that cause atherosclerosis.

Probable Drug-to-Disease and Drug-to-Drug Interactions

From the clinical scenario shown above for Mrs Goddard, this paper will argue that her heart failure deterioration and subsequent readmission were possibly due to a drug-to-disease interaction arising from Ibuprofen, which is an NSAID recommended and taken by the patient for pain relief. Some of the side effects of NSAIDs include sodium and water retention, increasing blood pressure and reducing the effectiveness of diuretics and RAAS drugs such as Enalapril. These effects are deleterious in patients with HFrEF since they worsen the problem of fluid retention and increase cardiac workload, thus worsening the patient’s heart failure. This interaction is quite well described in the recent clinical guidelines for managing heart failure in Australia, where the use of NSAIDs is contraindicated because of the potential risk of harm.

Person-Centred Nursing Care

HFrEF is a complex condition that should be managed not only from the medical standpoint but also from several aspects, such as patient and relatives’ education and effective discharge organisation.HFrEF is a complex disease that worsens morbidity and also mortality compared to cancer (Sharma et al., 2022). Nurses have a major part in this process of delivering person-centred care to the patients, including Mrs Gina Goddard and making sure that they are not readmitted to the hospital again.

Patient Education

•  Medication Adherence

Another area that nurses must pay attention to is educating patients about the significance and necessity of taking medications as prescribed. For Mrs Goddard, this entails teaching her about the purpose of Enalapril, Bisoprolol, Spironolactone, Furosemide and Atorvastatin in the treatment of heart failure and the prevention of complications. She should also discuss with the nurse the possible side effects and the need to avoid missing doses, as this will worsen her situation.

•  Lifestyle Modifications

 Education should embrace the changes that can be incorporated into lifestyle to manage HFrEF. Moderate restriction of salt is a better option compared to strict reduction, and cardiac rehabilitation and exercise are also beneficial in HFrEF (Camafort et al., 2023). Nurses should also encourage intake of fluids and adequate, moderate exercise, and weight changes as signs of worsening heart failure.

Discharge Planning

• Medication Review

There is no advocating for Nurses to review all discharge medications and look for any interactions and contraindications. As seen in Mrs Goddard's case, where she was readmitted because the care provider did not review her use of Ibuprofen, this marks this as significant. The nurse planning the discharge should consult with a preliminary intervention the pharmacy and the physician who prescribed the discharge medication.

• Clear Instructions and Follow-up

The most important thing to do is give the patient clear written instructions regarding what should be done after they are discharged. This entails the record of the medications given, lifestyle changes to be made, and the subsequent appointments to be made. The nurse must assess if indeed Mrs Goddard comprehends the need to attend follow-up GP appointments and the orthopaedic surgeon, as well as what each appointment entails.

Contributing Factors to Exacerbation and Readmission

•  Inappropriate Medication Advice

It is now considered a major medical malpractice that the doctor recommended taking Ibuprofen to her due to her HFrEF condition. They also do not recommend the use of NSAIDs in patients with heart failure, as the drugs may lead to fluid retention that precipitates the worsening of their symptoms, as witnessed with Mrs Goddard.

•  Lack of Symptom Monitoring

It becomes apparent that Mrs Goddard could have been provided with educational sessions before she was discharged, and thus she should have continued to weigh herself and check her symptoms more closely. This would suggest that perhaps she did not fully appreciate the function of these self-monitoring strategies.

• Inadequate Discharge Planning

Failure in the discharge planning, especially the absence of a review of the medications she required and overall instruction that could have been given to her, were major causes of the worsening of her condition. This means that it is vital to ensure that such aspects are all in place to avoid occasions of such events.

• Reflection On Learning

Therefore, while undertaking this essay, I have improved my understanding of the challenges of handling patients with HFrEF. Analysing this case of poor discharge planning with the help of a specific structured reflective model like Gibbs’ Reflective Cycle has enabled me to consider the various aspects of the situation and think about the significance of safe and efficient nursing assessments, the use of clinical reasoning potential, and proper medication administration in the process of developing a safe and effective discharge plan. In this manner, this reflection will look at what has been learned, how the lessons were implemented and in what way these shall be used in a clinical context.

• Description

This clinical case showed the problems of treating HFrEF, particularly concerning the key areas of medication administration and discharge planning that contributed to Mrs Gina Goddard’s readmission. My work involved assessing these phenomena and making suggestions on mechanisms to enhance the welfare and safeguarding of individuals in their contact with health services. As a result of this, I came to learn that nurses have several functions in guaranteeing that patients are educated and encouraged to take the right medications and receive adequate preparation for discharge to avert poor results or complications.

• Feelings

At the beginning of the episode, I experienced several feelings, including confusion due to the severity of Mrs Goddard's condition and the number of aspects that led to the readmission. However, as I read the details of the clinical guidelines and the evidence-based literature involved, I got a feeling of understanding the crucial role of the nurse in terms of coordination of care and teaching. A new responsibility of try to come up with different mechanisms to minimise the risks that may arise when practising as a nurse.

• Evaluation

Reflecting on Mrs Goddard’s case has been a very fruitful experience in terms of improving my knowledge of the fundamental aspects of nursing; more specifically, it has provided me with a deeper appreciation of the significance of nursing assessments, clinical judgment and decision-making, as well as medication administration. It was possible to understand that individual nursing assessments form the basis of an effective nursing care plan. For example, if a multivalued assessment had been done towards the end of Mrs Goddard’s discharge, perhaps the contraindication of Ibuprofen would have been forestalled. Further, this case highlighted the role of clinical judgement in assessing drug-drug and drug-disease interactions needed for avoiding worsening of chronic states, as may be the case with the HFrEF patient herein.

• Analysis

This case scenario was relevant in refreshing the fact that nursing is not merely the implementation of orders, but it also involves the provision of critical thinking to avoid the worst. For any disease treatment, medication management is central, and this is even more demanding in chronic diseases such as HFrEF; this arises from needing to appreciate pharmacology and the possibility of an adverse interaction. It could have been avoided by nurses making sure that they understand the medications their patients are taking and make changes when they have to to safer drugs, as happened when Flan only vociferously prescribed Mrs Goddard Ibuprofen instead of the safer acetaminophen. It also pointed out the problem of patient knowledge in terms of the management of their medications and possible side effects or complications.

Conclusion

 It is crucial to admit that the management of HFrEF involves medical therapy, education of the patient and an appropriate discharge plan. The case of Mrs Gina Goddard shows important aspects of her care that were in question when her heart failure worsened, and she had to be readmitted. Some of the negligence, which contributed to the worsening of her health and situation, was the staff’s suggestion of Ibuprofen consumption contrary to the heart failure patients. This has a bearing on compliance with clinical standard operating procedures and the review of all medications to eliminate potential toxic drug-disease interactions.

The key intervention by the nurse on assessment, implementation, and evaluation includes; The nurse needs to do the following; Explain to Mrs Goddard her medications and what she needs to look out for as symptoms of worsening heart failure Inform Mrs Goddard of the effects of over-the-counter medications Moreover, a proper and effective process of developing a plan for discharging and issuing specific directives, setting up the subsequent appointments and coordinating with other carers is crucial for the continuity of the care and for avoiding rupture. Thus, complications may be prevented by improving these areas, focusing on person-centred care and enhancing patient-related outcomes and the quality of life of HFrEF. Balancing both medication and patient directions’ prescription and delivery is key to managing such conditions as heart failure.