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Atheroma formation in Blood Vessels

Discuss about the Nursing Case Study for Blood Vessels and Inflammatory.

1. Physical and chemical action on the endothelial barrier of the arteries are mainly responsible for atheroma formation in an individual. Free radicals generated from smoking & environmental pollution, high level of low density lipoproteins (LDL) & glucose and trauma to blood vessels can cause injury to the endothelia barrier. Leukocytes or white blood cells (WBCs) are dormant in normal state, however, in case of injury to the blood vessels, WBCs get triggered in the wall of blood vessels and produces inflammatory response by releasing inflammatory mediators. In the inflammatory state, endothelium of the blood vessels generates adhesion molecules such as vascular cell adhesion molecule 1 (VCAM-1) and secretes monocyte chemoattractant protein (MPC-1). Increased level of LDL stimulates   VCAM-1 and MPC-1 to attract monocytes and T-lymphocytes at the site on injury under due to chemokines. These monocytes get converted into the macrophases. Macrophases express scavenger receptors on their surface and bind to the modified LDL and as a result, form of the macrophages changed to foamy and which is called as macrophage foam cells. In cases of atheroma formation, there is low level of high density lipoprotein (HDL). High level of HDL prevent atherosclerosis by eliminating cholesterol and inflammatory cells from foam cells (Hao and Friedman, 2014; Libby, 2002).     

2. Neurovascular assessment of wrist injury can be evaluated by assessing pain, swelling sensation, temperature, and motor function.

If the existing pain in an individual is not proportionate to the injury of the person, it indicates neurovascular problem of the person. Pain in case Mr Marconi is occurred as a result of passive extension and flexion movement of wrist. This pain designate neurovascular problem in Mr Marconi.

One of the prominent complications of neurovascular problem is swelling. It has been observed that there is swelling on the left wrist of Mr Marconi. Vascular complications like inadequate arterial supply and to inadequate venous return are responsible for  hollow or prune like swelling and distended or tense swelling respectively.

In case of injury, there are the possibilities of nerve obstruction and injury to the peripheral nerve. Due to this nerve obstruction and injury to the peripheral nerve, there is reduced or loss of sensation, deadness, dysaesthesia and burning sensation.

Due to injury, detected neurovascular problem is reduced venous return. Due to the reduced venous return, there is the increase temperature in the affected area and in case of Mr Marconi temperature is increased.

Neurovascular Assessment

In neurovascular disease, there is the disturbance in the motor function. It is observed that, there is the difficulty in movement of wrist in Mr Marconi due to injury radial nerve and median Nerve. (Nuber, et al., 1998).

3. a. Request/consent form should be there with information containing Mr Marconi name, date of birth, age, full address, clinical history and medications. 

Following are the vital signs recorded at 06:30

List the vital sign

Respiratory Rate

21-30

O2 Saturation

≥ 93 %

O2 Flow Rate

> 5  (L / min)

Systolic BP

120

Heart Rate

90

Temperature

≥ 38.6°C

4 Hour Urine Output

450 mL

Consciousness

Alert

Following are the abnormal signs observed: (Barfod, et al., 2012)

List the vital sign

O2 Saturation

≥ 93

Slightly hypoxemia

O2 Flow Rate

> 5

Hypo

Systolic BP

120

Prehypertension

Temperature

≥ 38.6°C

Hyper

ADDS Score for Mr. Marconi :

ADDS Score

Respiratory Rate

1

O2 Saturation

0

O2 Flow Rate

2

Systolic BP

0

Heart Rate

0

Temperature

2

4 Hour Urine Output

0

Consciousness

0

Total ADDS

5

Nurse should accompany Mr Marconi when he leaves the ward to go to the X-ray department.

4. One of the major reasons for fall in elderly patients is polypharmacy. Mr Marconi is consuming medicines like atenolol, ramipril, lantus and lipitor. Most of these medicines are for the cardiovascular and related indications and it is reported that medicines for these indications can cause fall in the elderly patients. Mr Marconi is suffering from diabetes mellitus and cardiovascular disease. Moreover, his vital signs like pulse rate (105) and respiratory rate (28 bpm) are deviating from normal range. As , Mr Marconi is not taking proper meals, he is going through malnutrition and it is responsible for rise in temperature of Mr Marconi. In case of Mr Marconi, fall occurs when he was using bathroom. It is well established that fall in the bathroom is one of the main reasons for fall in the elderly patients.    These were the reasons for fall of Mr Marconi. (Chester and Rudolph, 2011; Fialova et al., 2005).

5. Major Changes observed in pneumonia patients are accumulation of fluid and edema formation in the alveoli. Due to the edema formation in the alveoli results in the blocking of air flow in the alveoli and reduced external respiration. In external respiration, air from the environment is inhaled into the body to provide oxygen to the lungs and air is expelled from the body to the outside to eliminate carbon dioxide from the body. In usual gas transport there is diffusion of oxygen from lung alveoli to the blood in the blood vessels and removal of carbon dioxide from the blood in blood vessels to the alveoli. In case of pneumonia there is the reduced external respiration and impaired gas exchange.  This impaired gas exchange in Mr Marconi leads to the alteration in the O2:CO2 and reduced level of oxygen in the blood. As a final consequence, there is the decreased carbon dioxide level in the blood. (Lahiri et al., 1978; Brunner, et al., 1982).  

Vital Signs Recording


6.
a. O2 and CO2 are the two gases detected in the blood.

O2 and CO2 gases are detected at peripheral chemoreceptors through innervation of glossopharyngeal (IX) nerve b in the carotid arteries and vagus (X) nerve in the aortic arch. O2 and CO2 gases are also detected at baroreceptors at the walls of blood vessel.

Control centre for these receptors is respiratory rhythmicity centre and it is located in the medulla oblongata which comprises a dorsal respiratory group (DRG) and a ventral respiratory group (VRG). In Mr Marconi SaPO2 is 91%, which is less than normal range. This reduced SaPO2 leads to the altered O2:CO2 ratio. In this case of Mr Marconi, it exhibits decreased level of O2 and increased level of CO2 in the blood. It is well established that fever raises the level of CO2 as compared to the O2 in the body. To neutralize the increased level of CO2 in the blood, person needs to breathe at faster rate. CO2 is exchanged in the form of bicarbonate ion between alveoli and blood. Increased level of CO2 results in anaerobic respiration which leads to increased rate of respiration. Chemical control of breathing is specially depends on the carbon dioxidein the blood. This respiratory rate in a person can  can be measured using spirometer (Lahiri and Forster, 2003; Brendan, et al., 2000).    

7. First step in the analysis of sputum sample is to identify type of gram stain such as gram positive and gram negative stain. This is called culture method in which sputum sample is incubated on the culture media and this culture media allowed the growth of bacteria. These bacteria may be either pathogenic or non-pathogenic. In this testing, if pathogenic bacteria are identified, antimicrobial susceptibility testing should be carried out. Antimicrobial susceptibility testing should be carried out to identify the antibiotic resistance to identified bacteria. Identification of the susceptibility of bacteria to antibiotic helps in the prescription of antibiotic that are susceptible to the identified bacteria. Methods available for susceptibility testing are broth micro dilution or rapid automated instrument method (Jorgensen and Ferraro., 2009).

8. a. Factors responsible for release of renin are : sympathetic nerve stimulation through β1-adrenoceptors on the juxtaglomerular (JG) cells present in kidney, reduced level of tubular NaCl and reduced afferent arteriole pressure. .

Target for the action of renin is angiotensinogen in the liver. Angiotensinogen facilitates conversion of angiotensinogen into angiotensin I.

Reasons for the Fall in Elderly Patients

Angiotensin-converting enzyme (ACE) facilitates conversion of angiotensin I to angiotensin II. ACE is found in the lung and epithelial cells of endothelial and kidney.

Angiotensin II acts on the adrenal gland to secret aldosterone which aids tubular Na+ Cl- reabsorption and K+ excretion, consequently there is the increase in the blood pressure. Angiotensin II acts on the Angiotensin I (AT1) receptor which releases Ca++, this results in the reduced level of cAMP and increased blood pressure.

Ramipril acts by inhibiting angiotensin-converting enzyme (ACE) and it is used for treatment of indications like hypertension and congestive heart failure. (Paul et al., 2006; Kumar et al., 2008; Frampton and Peters, 1995)

9. Insulin binds to the extracellular portion of cell membrane-bound insulin receptors. In the presence of insulin molecule, insulin and its receptor gets converted into tyrosine kinase. Tyrosine kinase phosphorylates insulin receptor substrate 1 (IRS-1) and IRS-1 bound to the activated insulin receptor. As a result, there is incorporation of glucose transporter type 4 (GLUT4) into the cell membranes of adipose tissue and skeletal muscle. GLUT4 promotes uptake of glucose in the tissues from the blood. Insulin stimulates storage of glucose in liver and skeletal muscle as glycogen as a reservoir by activating glycogen synthase enzyme. Insulin aid dephosphorylation of phosphofructokinase which facilitate glycolysis i.e. breakdown of glucose (Sonksen and Sonksen 2000; Wilcox, 2005).

10.

Abnormal signs

O2 Saturation

85-89 %

O2 Flow Rate

> 5  (L / min)

Systolic BP

190

Heart Rate

120

Consciousness

To Voice

Mr Marconi is feeling sleepy and he is refusing to eat. This indicates there is the reduced level of consciousness in Mr Marconi. This leads to the decrease alert, voice, pain, unresponsive (AVPU) scale. Also doctor diagnosed Mr Marconi with pneumonia. In pneumonia, there is the accumulation of fluid in the respiratory tract and this leads to the increased rate of breathing in Mr Marconi. This increase rate of breathing reduced AVPU scale, which is indicator of reduced consciousness in Mr Marconi. Decreased consciousness level is associated with both impaired glycaemic control. In case Mr Marconi, there is hypoglycaemic condition is evident and this hypoglycaemic condition also plays role in decreasing AVPU scale. Mr Marconi consuming four drugs and as a result there is the possibility of drug-drug interaction within these drugs. These drugs can negatively affect  treatment of other drugs and can exaggerate adverse effects of other drugs. Hence consumption of atenolol, ramipril, lantus and lipitor together is responsible for deterioration of the condition of Mr Marconi (Sprague and Arbeláez, 2011; Golden et al., 1997).

References:

Barfod, C. (2012). Abnormal vital signs are strong predictors for intensive care unit admission and in-hospital mortality in adults triaged in the emergency department - a prospective cohort study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 20,  28. doi:  10.1186/1757-7241-20-28.  

Brendan, C., Kevin, G., & Cliffoed, W.Z. (2000).The control of breathing in clinical practice.  Chest, 117(1), 205-225.

Brunner, M.J., Sussman, M.S., Greene, A.S, Kallman, C.H., & Shoukas, A.A (1982). Carotid sinus baroreceptor reflex control respiration. Circulation Research , 51(5), 624- 636. 

Chester, J.G., & Rudolph, J.L. (2011). Vital signs in older patients: Age-related changes. Journal of the American Medical Directors Association, 12(5), 337–343.

Fialova, D., Topinkova, E., Gambassi, G., Finne-Soveri, H., Jonsson, P., Carpenter, I., et al.  (2005). Potentially inappropriate medication use among elderly home care patients in Europe. Journal of the American Medical Association, 293, 1348–1358.

Frampton, J.E, & Peters, D.H. (1995). Ramipril. An updated review of its therapeutic use in essential hypertension and heart failure. Drugs, 49(3), 440–66.

Golden, F.S.C., Tipton, M.J. & Scott, R.C. (1997). Immersion, near-drowning and drowning. British Journal of Anaesthesia, 79, 214-225.

Hao, W., & Friedman, A. (2014). The LDL-HDL profile determines the risk of atherosclerosis: a mathematical model. PLoS One, 9(3), e90497. doi: 10.1371/journal.pone.0090497.

Jorgensen, J.H., and Ferraro, M.J. (2009). Antimicrobial susceptibility testing: A review of general principles and contemporary practices. Clinical Infectious Diseases, 49(11), 1749-1755.

Lahiri, S., & Forster, R.E. (2003). CO2/H(+) sensing: Peripheral and central chemoreception. International Journal of Biochemistry and Cell Biology , 35(10), 1413-1435.

Lahiri, S., Mokashi, A., Delaney, R.G., & Fishman, A.P. (1978). Arterial PO2 and PCO2 stimulus threshold for carotid chemoreceptors and breathing. Respiration Physiology, 34(3), 359-375.

Libby, P. (2002). Inflammation in atherosclerosis. Nature, 420(6917), 868-74.

Kumar, R., Singh, V.P., & Baker, K.M. (2008). The intracellular renin-angiotensin system: implications in cardiovascular remodeling. Current opinion in nephrology and hypertension, 17 (2), 168–73.

Nuber, G.W., Assenmacher, J., & Bowen, M.K. (1998). Neurovascular problems in the forearm, wrist, and hand. Clinics in Sports Medicine, 17(3), 585-610.

Paul, M., Poyan Mehr, A., & Kreutz, R. (2006). Physiology of local renin-angiotensin systems. Physiological Reviews, 86(3), 747–803.

Sonksen, P., & Sonksen, J. (2000). Insulin: understanding its action in health and disease. British Journal of Anaesthesia. 85(1), 69–79.

Sprague, J.E. & Arbeláez, A. M. (2011). Glucose Counterregulatory Responses to Hypoglycemia. Pediatric Endocrinology Reviews, 9(1), 463–475.

Wilcox, G. (2005). Insulin and Insulin Resistance.  Clinical Biochemist Reviews, 26(2), 19–39.

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