Nursing Assignment: Evaluation of Pharmacology and Pathophysiology

Question

Task

Nursing Assignment Case Scenario:

Deependra Sidhu (preferred name of “Deep”) is a 68 year old male of Indian descent. He immigrated to Melbourne at the age of 18. He became an Australian citizen at the age of 28.

Past medical history:

• Myocardial infarction (MI) 2017
• Stable Angina
• Hypertension
• Hypercholesterolemia

Type 2 Diabetes Mellitus (currently diet controlled, diagnosed 2016)

Current Medications:

• Asprin 100mg mane
• Atenolol 25mg mane
• Furosemide 40mg mane
• Pravastatin 40mg oral nocte (bedtime)
• GTN spray 1-2 sprays S/L PRN
• Sildenafil (Viagra) 50mg prn

Social History:

Deep tells you that he is trying to lose a bit of weight by having soup for lunch; he is particularly fond of hot and sour soup. His wife has bought him lunch and dinner every day he has been admitted. Deep has a very supportive family but they are currently studying. Deep work 3 days a week and would like to retire soon but “needs to support my family first”. He confides in you that he doesn’t like the side effects (“makes me go to the toilet too much”) of the Lasix tablet and sometimes doesn’t take it.

History of presenting complaint:

Deep has called for help after waking up at 2 am feeling breathless with pain in his chest (8/10 pain score). You sit him up in the bed and perform a set of observations while asking for assistance.

Your buddy nurse comes to assist and asks you to perform and ECG and prepares to take a troponin T and MKMB blood test. You prepare to give Deep GTM S/L as per the wards chest pain management. Your buddy nurse says to double check his PRN and OTC medication. You ask Deep if he has taken any medication in the last day, apart from his prescribed medication (Aspirin, Atenolol, Furosemide, Pravastatin). Deep says he has not and you administer the medication at 02:40 after performing your first set of observations.

Observations at 02:35

• HR 90, regular
• BP 145/85
• Skin- sweaty and pale, PR 26, regular
• SpO2 94% RA
• Temp. 36.7oC

Oedematous legs, moderate pitting oedema (2+)

Consider the above case scenario and answer the following questions:

1. Your buddy nurse asks for an ECG. Explain the rationale for the ECG request. Why would the nurse also ask you to prepare for a blood test? Why do both ECG and a blood test?
2. The medical team confirms the diagnosis of heart failure. Describe the pathophysiology of heart failure with reference to causes, progression and outcomes. Include links to how heart failure has progressed for Deep.
3. Systematically analyze the ECG, commenting on the: Rhythm – Rate – Presence and regularity of p waves – ST segment. What is your interpretation of this ECG?
4. Discuss about physiology of breathlessness and exacerbation of heart failure.
5. Discuss the pharmacodynamics of Viagra.
6. Provide a brief discussion on drugs with regards to the present case.

Answer

Introduction
The nursing assignment provides the analysis of the present situation to understand the evaluation of pharmacology and pathophysiology which are applied for Deependra Sidhu ("Deep"). Sidhu is a 68-year-old who hails from India and now he has become a citizen of Australia. Previously, Sidhu suffered from hypercholesteremia, myocardial infarction, T2DM, and stable angina. He has children in his family who are helping him at every step to lose weight. Currently, he is working for 3 days a week at this age and looking forward to getting retirement soon. But, it is difficult for him because his family needs some financial support from him. He found that sometimes he feels excruciating chest pain (pain score 8/10) and felt breathlessness. At present, he is taking the prescribed medicines by the doctors which are- Atenolol (25mg), Pravastatin (40 mg nocte before sleeping), Furosemide (40 mg mane), Aspirin (25 mg mane), Sildenafil (Viagra 50mg PRN) and GTN spray91-2 sprays S/L PRN). For a depth diagnosis, Deep was asked to undergo an ECG test, CKMB blood test, and he was also prepared to take Troponin T to establish links to heart failure. Necessary steps and preparation were taken to give the medicine- GTN S/L to Deep for the management of his chest pain. He said that he regularly took his prescribed medicines on time when he was asked about his medication on the last day. Review was done by the medical team which indicated a heart failure, and ECHO was scheduled for him the next day. A dosage of IV furosemide was given to him with 2L fluid and the output of his urine is regularly measured.

Question 1: Justification for ECG and blood test
ECG is a simple diagnostic tool that helps detect the changes in the congestive heart failure which was detected in the health condition of Deep. Moreover, an advanced computer system will enhance the diagnostic reliability and effectiveness of ECG which is required for understanding the complexities of CHF among heart patients (Almahmoud et al., 2015). The ECG signals are assessed visually to detect any changes or irregularities in signals. There needs to be appropriate measures and evaluation of evidences as well as procedures for detection of heart failure and ECG provides one of the appropriate methodologies (Yancy et al., 2013). This article also suggests that ECG need to be performed on patients diagnosed with heart failure.

The rationale for blood test troponin T and CKMB blood test is that dduring serious conditions of heart failure, the Troponin can circulate at a very low level. These are also detected in coronary artery disease and myocardial infarction as well. The increase in the level of troponin in the blood is also helpful to analyze serious effects among patients. As suggested by Yancy et al., (2013) troponin T is useful for establishment of prognosis and determining severity of the disease in acute conditions of heart failure. The major role of Troponin T and Creatine Kinase- Myocardial (CK-MB) for heart failure. CK-MB is a typical signifier of myocardial injury. It can be regarded as the traditional criteria for diagnosis and can be used in patients for accurate details of heart failure, which has been suggested for this patient case.

Question 2: Pathophysiology of heart failure and signs of progression
The nursing staff detected heart failure of Deep supported by some of the major underlying causes, there are major signs of progression of the disease also as seen in him. Hypertension is asymptomatic and can also increase the risk of heart failure in the future. Both heart failure and T2DM can affect clinical governance and progress as well. It was found that the patients without T2DM have a low rate of mortality due to cardiovascular complications as compared to the patients with T2DM. Moreover, the pathophysiology and several causes which are observed in the patients may have occurred due to the detrimental effects of T2DM upon the myocardium, because it is one of the major reasons that cause HF also obesity of Deep has acted as one of the major causes of heart failure for Deep (Borlaug, 2014).

The integration of HF and T2DM causes higher pervasiveness of HF in comparison with the patients who do not have T2DM along with obesity. The common problems faced by the patients due to pathophysiology along with TDM also include CAD and hypertension (which was detected in Deep). The medical processes related to TDM cause HF which has a direct impact on the regular functioning of the heart. Other factors that contribute to dysfunction of the myocardial in T2DM are insulin resistance or glucose intolerance or hyperinsulinemia. Harmful impacts from insulins can further cause various metabolic deviations, for example, lipotoxicity, microvascular rarefication, and collection of glycosylation end products. Substantial and injurious interconnections between the pathophysiologic mechanisms are harmful and can cause various maladaptive responses that lead to myocyte altercation. Insulin resistance is responsible forreleasing fatty acids that are chained to HF-linked dysregulation that forms neuroendocrine. It can be considered an as aetiological cause that develops in the left ventricular hypertrophy. There are various effects of hyperglycaemia due to cardiovascular changes in the T2DM that might cause cardiomyocyte contractile dysfunction along with the disintegration of the mitochondrial network and less activity of protein kinase C (Riehle, &Abel, 2016). As pointed out rightly in this article insulin resistance is seen associated as a reason for HF with T2DM and obesity being major risks factors. This can also cause the reactive oxygen to activate with a collection of AGEs in endothelial across the smooth muscle cells which predispose at the left ventricular remodeling that escalates diastolic stiffness. Some reasonable proofs are also found which elevates the concern regarding the T2DM drugs which raises the risk of HF. Also, the patient is already given T2DM drugs that can cause serious risks. Long-lasting effects of hypertension eventually cause HF. The HF escalates with diastolic dysfunction after a fraction of ejection develops. These complications are very common among cardiac patients which are caused by hypertension. The pathophysiological function in the right ventricle can have adverse effects on Heart Failure. Because the functioning of the right ventricle has a notable significance which is the outcome of pulmonary hypertension that largely affects the complication of the disease.

HF increases the complexities of myocardial infarction (MI) which is regular among the patients. Moreover, there is an intense connection between HF and MI. In this, the proper management and care of patients are mandatory. The patients who are identified with beta-blockers for a long period may have lesser chances of reinfarction and can also lead to death. Though, the capability of beta-blockers still needs further evaluation. Various studies signify the appearance and its complications of HF after MI (Gerber et al., 2016).The other substantial causes of overflow in the arteries can cause heart failure which is not just the outcome of myocardial disease. The analysis of the ventricular pressure-volume loop is the main issue to understand Heart failure.

Question 3: ECG Interpretation
The analysis of Electrocardiography or ECG helps to give necessary and accurate advice to take care of patients. ECG analysis of Deep was done when he complained of having breathing difficulty or dyspnea which can help in understanding these below-mentioned points:

Rate: The HR of the patient is indicated 100 regulars which is a harmful rhythm, also called tachycardia.

ST-segment: This also indicates the irregularity of the rhythm of the heartbeat.

Rhythm: The segments of QRS represent the dissimilation in ventricles which indicates the irregularity.

Presence and regularity of p waves: It means analysis of the depolarization of the atria. They remain upright in the Lead II which shows on the cardiac monitor which is also followed by segments of QRS. The above indications reflects that Deep might be have a heart failure.

Question 4: Physiology of breathlessness and exacerbation of heart failure
Heart failure in adults is primarily interlinked with the number of various causes of distressing symptoms. It is found that several symptoms include swollen ankles, breathlessness, fatigue, etc. Moreover, it is very important to understand that the diagnosis of these conditions is dependent upon the patient when they feel any uneasiness or until they realize something is wrong. The symptoms vary from person to person but are easily recognizable as it is connected to the pathology. It is also mentioned in the study that symptoms of shortness of breath are the major cause of heart failure (Dekker, 2014). It is also interlinked with the symptoms related to ageing or other various medical conditions and even side-effects of medications and it was accepted that they will pass through time.

Heart failure can be a particular condition when the heart is not able to do its regular work which is filling or pumping the blood in the body and that is a dangerous chronic illness. Chronic breathlessness is a symptom that affects patients who suffer from HF. The pathophysiology of breathlessness is caused due to various reasons such as intense pain, unpleasantness, the person's emotional and functional purpose (Ponikowski et al., 2014). The aetiology of breathlessness is associated with the physiological, environmental, pathological, and other spheres. Shortness of breath can cause due to the problem in the respiratory and the cardiovascular symptoms which are also linked to the physiological, neuromuscular and physiological disorders.

Question 5: Pharmacodynamics of Viagra
Improper endearment of the prescribed medications is also a major cause that leads to heart failure. Due to fewer facilities and other inadequacies the rate of heart failure increases, such as risks of hospitalization, less physical functions, and it also causes death. Viagra (sildenafil) has occurred as an effective measure to reduce the cardiac modelling with its capabilities of anti-hypertrophic and anti-fibrotic impacts can act as a protection for the heart to fight against any possible injuries (Hutchings et al., 2018). Sildenafil played a valuable role in contributing to the treatment of cardiovascular disease. It may have happened that Deep would have consumed 'Viagra' which prevented heart failure.

The pharmacodynamics of Glyceryl Trinitrate and found a significant decrease in the blood pressure which is traceable to the Viagra (sildenafil) after reducing the pressure. This means, that if Deep would have taken Viagra, then his heart failure can be avoided to a certain extent.

Factors which may have an adverse effect on an individual who is suffering from heart failure, without any significant information are similar to the psychological effects and the cooperation from the patient's side (Swearingen et al., 2013). In several cases, the patients have a negative feeling and may not cooperate with clinical assistance required for his health.

Question 6: Discussion of drugs

Question 7: Reason for non-adherence to furosemide
The usage of furosemide leads to an increase in net fluid and losing weight due to increasing cases of serum creatinine in heart failure. Furosemide has been observed that it some poor outcomes in heart failure too.

Furosemide is also linked to mortality. However, it is a pharmacological intervention in heart failure because it reduces the water content in the lungs and influences oxygenation to increase diuresis. It is very important to know that diuretics can cause renal impairment, hemodynamic instability, and electrolyte imbalance (Mentz et al., 2016). The diuretic agents help provide the main treatment for heart failure. Although, they are also linked to worsening the condition of edema of the gut through oral consumption.

Deep require adequate medication and clinical assistance to improve his health, supported by all the assessment results. Nursing care plan will be aimed at assisted by interaction and engaging in conversation to take his medications. Primary interaction will include explaining to him the various medications and the impact they will cause on his body along with an explanation of each of their side effects.

Conclusion
In conclusion, the present condition of pharmacological intervention along with adequate nursing and health facilities can help to improve the condition of patients. According to the current condition of the patient he is experiencing a heart failure and requires pharmacological with nursing support. He is already diagnosed for HF and has been provided appropriate interventions such as 2L fluids with furosemide and measurement of urine output. With continuous intervention once he recovers, he will require an appropriate nursing care plan that he can follow back when at home.

References
Almahmoud, M. F., O'Neal, W. T., Qureshi, W., & Soliman, E. Z. (2015). Electrocardiographic versus echocardiographic left ventricular hypertrophy in prediction of congestive heart failure in the elderly. Clinical cardiology, 38(6), 365-370.https://doi.org/10.1002/clc.22402

Borlaug, B. A. (2014). The pathophysiology of heart failure with preserved ejection fraction. Nature Reviews Cardiology, 11(9), 507-515.

Dekker, R. L. (2014). Patient perspectives about depressive symptoms in heart failure: a review of the qualitative literature. The Journal of cardiovascular nursing, 29(1).

Gerber, Y., Weston, S. A., Enriquez-Sarano, M., Berardi, C., Chamberlain, A. M., Manemann, S. M., ... & Roger, V. L. (2016). Nursing Assignment Mortality associated with heart failure after myocardial infarction: a contemporary community perspective. Circulation: Heart Failure, 9(1), e002460.

Hutchings, D. C., Anderson, S. G., Caldwell, J. L., & Trafford, A. W. (2018). Phosphodiesterase-5 inhibitors and the heart: compound cardioprotection?. Heart, 104(15), 1244-1250.

Mentz, R. J., Hasselblad, V., DeVore, A. D., Metra, M., Voors, A. A., Armstrong, P. W., ... & O'Connor, C. M. (2016). Torsemide versus furosemide in patients with acute heart failure (from the ASCEND-HF Trial). The American journal of cardiology, 117(3), 404-411.

Ponikowski, P., Anker, S. D., AlHabib, K. F., Cowie, M. R., Force, T. L., Hu, S., ... &Filippatos, G. (2014). Heart failure: preventing disease and death worldwide. ESC heart failure, 1(1), 4-25.

Riehle, C., & Abel, E. D. (2016). Insulin signaling and heart failure. Circulation research, 118(7), 1151-1169.

Swearingen, D., Nehra, A., Morelos, S., & Peterson, C. A. (2013). Hemodynamic effect of avanafil and glyceryl trinitrate coadministration. Drugs in context, 2013.

Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Drazner, M. H., ... &Wilkoff, B. L. (2013). 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 62(16), e147-e239.