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A critical discussion paper related to the nursing management of Mr Ferguson’s

case study below:

The critical discussion paper should address the following issues:

  1. Describethe patient’s presenting problem focusing on the pathophysiological issues.
  2. Reviewand use of literature to explain the pharmacokinetics of the prescribed medications and their indicati
  3. Discussthe nursing management appropriate for the patient including management of the adverse effects of the medication(s)  using evidence-based literatur
  4. Describein detail the information you would share with the patient and how you will educate the patient about the interactions and long term effects of the medications prescribed in the ED?

Mr Ferguson is a 76 year old male who presented to your emergency department at 0800hrs complaining of a 2/24 history of chest heaviness. He has self administered x2 sprays of his glyceryl trinitrate pump spray totaling 800mcg with minimal relief. On arrival to your allocated bed Mr Ferguson appears pale, diaphoretic & short of breath.

Regular Medications

Medications Prescribed Administered in ED

Aspirin 100mg PO, OD

Aspirin 300mg Po

Metoprolol 50mg PO, OD

Morphine sulphate IV 2.5mg administered on four

(4) occasions PRN

Rosuvastatin 10mg, PO, OD

Low molecular weight (LMW) heparin infusion

glyceryl trinitrate pump spray- PRN

Fentanyl 50mcg IV, x2 STAT doses

Vitals Signs

Blood pressure

172/86

Heart rate

103bpm, irregular

Spo2

97% RA

Respiratory rate

24b/min

Temperature

36.8C tympanic

Glasgow Coma Scale

15/15 – E4V5M6


AMPLE

A llergies: Amiodarone

M edications: as stated above

P ast medical history: Angina

Non ST Elevated Myocardial Infarction (NSTEMI) (1998 & 2006) Hypertension

Hypercholesterolemia

L ast time the patient ate and drank: toast and tea at 0630hrs

E vents preceding admission: chest heaviness 2/24

Background

Chest heaviness is an indicator of breathing challenges by the patient as a result of blockage of arteries thus reducing blood circulation. Although the problem can be caused by indigestion or physical strain, it is important for one to understand how to manage the early signs of the condition and when to seek medical assistance. The case of Ferguson presents a situation where the patient failed to manage the signs of the problem.

The condition that Mr. Ferguson presents is chest heaviness which is the most characteristic of the symptoms of coronary artery disease. This is presented as the heaviness of the chest and shortness of breath which makes it impossible for the patient to breathe well. The disease is caused by the buildup of cholesterol deposits in arteries leading to thickening of walls thus narrowing the arterial space limiting the flow of blood to the heart (Grech, 2003). When the amount of blood reaching the heart muscles with oxygen is reduced which damages the endothelium thus leading to the accumulation of fats, cholesterol, and lipoproteins in the artery intima. This then leads to the formation of fatty streaks that eventually start to produce the extracellular matrix which forms atherosclerotic plague which turns into the fatty streak and starts narrowing the luminal space. Ambrose & Singh (2015) adds that once they have formed, they develop a cap whose edge leads to acute coronary disease.  It’s these narrowed arteries that lead to angina since heart muscles receive less oxygen. This process goes on as the plaque deposits grow larger thus making blood vessels narrowed which may lead to heart attack or myocardial infarction.

According to Ferreira & Mochly-Rosen (2012), glyceryl trinate is heart failure or blood pressure medication for treating and preventing chest heaviness due to lack of enough blood flow to the heart. Since it belongs in the nitrates family and is used to dilate blood vessels thus increasing blood circulation in the body which in turn reduces chest heaviness. This means that the drug decreases attacks by reversing angina through the endothelium-derived relaxing factor thus increasing blood circulation (Goldin & Malanga, 2013). The chemical mechanism of the drug is to produce nitric oxide which acts as an activator for guanlyl cyclace through heme-dependent mechanisms that result in the formation of cyclic guanosine monophosphate that is used to produce nitrogen which initiates relaxation of muscles in the blood cells thus reducing chest heaviness. Glyceryl is rapidly absorbed in the bucaal and sublingual mucosa which makes its effects to be realized within five minutes of administration.

Causes and Symptoms of Chest Heaviness

However, the effectiveness of the medication becomes limited through tachyphylaxis within 2-3 weeks of sustained use. Further, this can lead to tolerance and limited usefulness of the agent after long-term use. To be more effective the patient is supposed to use it immediately after the onset of the symptoms rather than waiting long after the symptoms have occurred. Tolerance is developed after long-term use which reduces the effectiveness of the drug (Amsterdam, et al., 2010).  This leads to the need for higher doses for the effectiveness of the drug. Further, continued use is linked to vascular abnormalities thus worsening of patient prognosis which makes the patient develop endothelial dysfunction (Yasue, Nakagawa, Itoh, Harada, & Mizuno, 2014). Despite this, there are other side effects like plasma volume expansion, impaired transformation, counteraction of GTN and sometimes oxidative stress. In extreme cases, glyceryl trinates causes severe reflect tachycardia and hypotension. Other low side effects include severe headaches from time to time. Sometimes it leads to tadalafil, vardenafil and erectile dysfunction. This means that transdermal patches that develop with continued use need to be removed to reduce the risk of explosion.

According to Burman, Zakariassen & Hunskaar (2014) chest pain and heaviness patients are diagnosed and treated using specific guidelines that practitioners follow. The first step in the management of chest heaviness is for the practitioner to determine the nature of the problem before embarking on any management plan. Sometimes, chest heaviness or pain can be a result of indigestion or muscle strain or any other innocuous problem. The practitioner should begin by making a chest heaviness assessment to determine whether the problem is cardiac in nature (Herren & Mackway-Jones, 2001). This leads to reduced cardiac arrests which can make the situation more fatal or sometimes lead to death. The practitioner needs to apply the PQRST assessment which determining the provoking factor, quality of the heaviness, radiation of the heaviness, the severity of the problem and the duration that the patient has experienced the problem. This allows the practitioner to detect the high risk that the patient is in as a way developing early interventions. This means that if more than two risk factors are noted from analysis then the patient is may be at a high risk. For example in the case of Ferguson, persistent chest heaviness and failure to respond to prescribed attack medications is an indicator for the condition.  Further, the practitioner also needs to include the ample approach in the assessment to determine any allergies that the patient may be suffering from, previous medications, family history, last meal and the events that led to the attack. The AMPLE and PDRST tools are used to determine the underlying conditions that shape the management plan the practitioner uses.

Glyceryl Trinitrate Medication

From the analysis, if the patient presents an intermediate probability of serious cardiovascular complications, then the practitioner needs to initiate angina related medication to treat the cause of chest heaviness. The second stage is the management of the condition which begins by giving aspirin to inhibit cyclo-oxygenate-dependent platelet activity. This is then followed with supplementary oxygen and use of drugs like ECG and IVC 18g to manage the heaviness in the chest (Haasenritter, et al., 2015). This is followed by secondary management by ensuring the patient rests and observing for the changes in the heaviness of the chest. If there are no changes in the patient, then an x-ray is needed to determine the problem with the patient through consultation with other practitioners to determine the best approach for the condition. The patient needs to be observed for 6-12 hours allowing the chest condition to cool down before discharge. During discharge, management education needs to be given to the patient as a way of ensuring that they can manage the condition at home during such attacks before they seek medical assistance.

Information to be shared with the patient on managing the condition and long-term interaction with medication.

Brown, Clark, Dalal, Welch, & Taylor (2011) suggests that nursing education is used to assist patients to manage medical situations at home before seeking hospital admission while at the same time reducing the severity of the condition. This means that the patient needs to understand trigger situations and how to avoid them at all times. On the other hand, there is a need to ensure that the early signs and symptoms of the condition are detected to take precautionary measures in advance. The most important element that the patient needs to learn is dietary changes to reduce fats and sodium intake while at the same time increasing intake of fresh vegetables and fruits. The patient also needs to limit processed foods, greasy and fried foods, alcohol intake and only use low-fat dairy products. This is used to reduce the accumulation of fats in arteries which can complicate the condition.

The patient also needs to learn how to exercise to learn how to do simple exercises with some vigorous physical intensity lasting between 30-60 minutes to keep the body physically fit. Such exercises include brisk pace walking, running, hiking, riding of a bicycle and play games. The idea behind this is to increase blood circulation and weight management to keep the body mass index to normal (Berra, Fletcher, & Miller, 2007). The patient needs to work on his social life through learning ways of managing life situations like stress that can trigger anger and blood pressure.

Nursing Management of Chest Heaviness

The practitioner also needs to educate the patient on how to manage the medicines by keeping track of the episodes that occur and sharing them with the practitioner. One way of keeping the episodes from occurring is taking the medications exactly as directed. The practitioner needs to develop a medication plan with Ferguson based on his lifestyle so that the medication program can fit within his daily activities. This reduces the chances of skipping medication thus improving effectiveness.  By understanding the way episodes occur, the practitioner can be able to develop management plans for the patient (Kluwer & Williams, 2014). Since chest episodes can occur anywhere, the patient needs to learn how to walk with glyceryl trinitrate pump spray all times so that the drug can be taken immediately when the episode occurs to increase effectiveness.

Lastly, Amsterdam, et al. (2010) add that the patient needs to know the signs and symptoms that make him seek assistance. The common signs and symptoms that indicate the first aid is not working are a severe headache, dizziness or fainting, nausea, fats heartbeat higher than 100 beats per minute, weakness, angina arrests that last longer and those that occur during rest.

Conclusion

Chest heaviness can be managed at home if the patient is able to detect early signs and symptoms of the condition and taking early medication. The effectiveness of glyceryl trinitrate pump spray depends on the time taken after the beginning of the episode. Since it works to control the challenge by increasing circulation, then it means that it has to be taken immediately the episode starts. Patients need to learn how to manage the condition and call their doctor to avoid complications of the condition. By managing the condition, Ferguson can lead a normal life and reduce the number the number of episodes that occur or their severity. Patients who adhere to the medical education from their doctors have higher chances of leading normal lives since the condition only requires management.

References

Ambrose, J. A., & Singh, M. (2015). Ambrose, J. A., & Singh, M. (2015). Pathophysiology of coronary artery disease leading to acute coronary syndromes. F1000Primw Reports, 7(108).

Amsterdam, E. A., Kirk, J. D., Bluemke, D. A., Diercks, D., Farkouh, M. E., Garvey, J. L., . . . Thompson, P. D. (2010). Testing of Low-Risk Patients Presenting to the Emergency Department With Chest Pain A Scientific Statement From the American Heart Association. Circulation, 122(17), 1756-1776.

Berra, K., Fletcher, B., & Miller, N. H. (2007). Chronic stable angina: Addressing the needs of patients through risk reduction, education and support. 5th Québec International Symposium on Cardiopulmonary Prevention/Rehabilitation,, (pp. 13-15). Québec City.

Brown, J., Clark, A., Dalal, H., Welch, K., & Taylor, R. (2011). Patient education in the management of coronary heart disease (Review). London: Wiley.

Burman, R. A., Zakariassen, E., & Hunskaar, S. (2014). Management of chest pain: a prospective study from Norwegian out-of-hours primary care. BMC Family Practice, 15(51).

Ferreira, J., & Mochly-Rosen, D. (2012). Nitroglycerin Use in Myocardial Infarction Patients: Risks and Benefits. Circulation Journal, 76(1), 15-21.

Goldin, M., & Malanga, G. (2013). Tendinopathy: a review of the pathophysiology and evidence for treatment. The Physician and Sportsmedicine, 41(3), 36-49.

Grech, E. D. (2003). Pathophysiology and investigation of coronary artery disease. BMJ, 326(1027).

Haasenritter, J., Biroga, T., Keunecke, C., Becker, A., Donner-Banzhoff, N., Dornieden, K., . . . Bösner, S. (2015). Causes of chest pain in primary care – a systematic review and meta-analysis. Croatian Medical Journal, 56(5), 422-430.

Herren, K., & Mackway-Jones, K. (2001). Emergency management of cardiac chest pain: a review. Emergency Medicine Journal, 18, 6-10.

Kluwer, W., & Williams, L. (2014). Angina. Nursing, 44(9).

Yasue, H., Nakagawa, H., Itoh, T., Harada, E., & Mizuno, Y. (2014). Coronary artery spasm--clinical features, diagnosis, pathogenesis, and treatment. Journal of Cardiology, 51(1), 2-17.

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