Nursing Practice Pathophysiolgy And Pharmacology

Introduction:

Kevin is diagnosed with Atrial Fibrillation (AF). AF is a disease of the cardiovascular system and is associated with the increase in the heart beat and irregular heart rhythm. AF is classified into first detected, paroxysmal, persistent and permanent based on the frequency of episodes of AF. In AF, pathological changes occur both in heart and blood vessels. Thromboembolism and cardiovascular accident are closely associated with AF. Different types of medications like medications for heart rate and thromboembolism required for AF patients. Lifestyle changes also required for AF patients to maintain a healthy life. In this essay,all these aspects related to AF are discussed.    

Discussion:

AF can be classified into four categories like first detected, paroxysmal, persistent and permanent. First detected AF patients have only one diagnosed episode. These patients may or may not have earlier unnoticed AF episode. If the episodes continue for less than seven days and stop on its own, it is classified as Paroxysmal. From the literature, it is evident that these Paroxysmal episodes stop within 24 hours. If these episodes continue for more than seven days, then there are no chances of stopping these episodes on their own. These AF episodes which continue more than seven days are termed as persistent episodes. These persistent episodes can be stopped by cardioversion. Cardioversion is the procedure by which heart rate and rhythm can be controlled by using drugs or electric shock (Natale and Jalife, 2008).

Main goals of treatment of AF in Kevin should be the prevention of cardiomyopathy and improvement in symptoms mainly occurred due to stroke and tachycardia. Kevin should also be provided with an anticoagulant. Kevin should be provided with treatment for normalization of heart rate (Kingma et a., 2012).

Main pathologic alteration occurs in AF is progressive fibrosis of atria. This fibrosis mainly occurs due to the dilation of atria, however, is some cases it may occur due to genetic factors and inflammation (Anumonwo and Kalifa, 2014). Structural alteration of the heart is responsible for the dilation of atria, and it leads to the augmented pressure in the heart. Increased pressure may lead heart problems like valvular heart disease, hypertension and congestive heart disease in Kevin. Inflammation and followed by fibrosis may occur in Kevin due to sarcoidosis and autoantibodies against myosis heavy chains. Lamin AC gene mutation is also responsible for the fibrosis of atria. Atrial dilation is responsible for the activation of the rennin-aldosterone angiotensin system (RAAS). Activation of RAAS leads to the release of matrix metalloproteinases and disintegrin. This lead to the atrial remodeling comprising of fibrosis and loss of atrial muscle mass. Along with fibrosis of muscle mass, fibrosis might occurr in sinus node (SA node) and atrioventricular node (AV node) in Kevin. Alteration in the normal functioning of the SA node can be well correlated with the progressive episodes of AF. Alteration in heart rate and rhythm occurs due to overwhelmed response to impulse generated by the SA node (Iwasaki, et al., 2011).           

In Kevin, due to AF, there is the unorganized atrial contraction. Atrial contraction lead to the dormant blood in the left atrium (LA) or left atrial appendage (LAA). This accumulated blood without movement might lead to thrombus formation in Kevin. If this accumulated blood is carried by circulating blood, it is called as an embolus. This embolus proceeds through the small arteries and prevents the supply of nutrient and oxygen to the organs (Watson et al., 2009). Cerebrovascular accident (CVA) mainly occur due to the embolus in the artery to the brain. In CVA embolus plugs in the artery to the brain and prevents blood flow to the brain. This is called as an embolic stroke. As there is embolus formation in Kevin, it might lead to ischemic CVA. Ischemic CVA occurs due obstruction in the blood vessels supplying blood to the brain. Hemorrhagic CVA occurs due to weak blood vessels. Weak blood vessels ruptures and hemorrhage occurs. In Transient ischemic attack (TIA) blood flow to the brain stops for short duration. This happens for the duration of fewer than 24 hours. This TIA doesn’t produce permanent brain damage. However, it gives danger signal of stroke (Kishore et al., 2014; Asirvatham, 2014).

Rate control medications are used in AF patients to reduce the rate of breathing. Rhythm management medications are used in case of AF patients to normalize rhythm of the heart beat. Rate control medications act by increasing extent of the block of AV node. This block results in the decrease in number of impulses to be conducted to the ventricles. β blockers are used as first- line therapy for rate control in AF patients. Examples of cardioselective beta blockers are metoprolol, atenolol, bisoprolol, and  nebivolol. Epinephrine and norepinephrine stimulate β1 receptors. This lead to the positive chronotropic and inotropic effect, which increase cardiac conduction velocity. Blockade of the β1 receptors can reduce cardiac conduction velocity and heart rate (Nguyen et a., 2013). For normalization Heart Rhythm, cardioconversion can be used in patients with AF. DC electrical shock can be used for the normalization of cardiac rhythm in AF patients. Amiodarone and dronedarone are the first line drugs, which can be used for the cardiac rhythm in AF patients. These drugs act by decreasing calcium permeability and increasing potassium permeability. By this, these drugs lower conduction rate and increase the duration of the refractory period of SA and AV node (Oishi and Xing, 2013; Al-Khatib, 2014). Novel oral anticoagulants (NOACs) are preferred for nonvalvular AF patients. Warfarin is a preferred treatment for AF patients. NOACs includes dabigatran and rivaroxaban. These NOACs act by competitively inhibiting thrombin. This thrombin plays a role in the conversion of fibrinogen into fibrin in the coagulation cascade. By this thrombus formation can be prevented. Mechanism of action of warfarin is to inhibit synthesis of vitamin K-dependent clotting factors such as Factors II, VII, IX, and X. Vitamin K is mainly responsible for the post ribosomal synthesis of vitamin k dependent clotting factors (Shenasa and Camm, 2015).

NOACs protect AF patient in a better way as compared to the vitamin k dependent clotting factors. However, the risk of bleeding is more in NOACs as compared to the vitamin k dependent clotting factors. There is the possibility of skin necrosis with the use of vitamin k dependent clotting factors. Skin necrosis risk is not there in the patients with NOACs. Dietary restriction required in patients with warfarin. Dietary restriction not required in patients with NOACs. Hence, there is no much effect on the lifestyle of patient with NOACs. There are less drug-drug interactions in patients with NOACs as compared to the warfarin treatment (Gidwani et al., 2013).

The uurse should make sure that Kevin consumes medications on a regular basis. The nurse should ask him knowledge about medication and give him knowledge about medication. By this, Kevin understands importance of the medication. As a result, he may consume medication on a regular basis. The nurse should tell him about the negative impact of non-consumption of medicine. The nurse should prepare schedule for his medicines. The nurse should involve Kevin for the preparation of medication schedule. By this way, he can remember time to take medicine. Information about medications increases the faith of Kevin in medications. His involvement in discussion regarding medication and the schedule preparation gives him feeling of dignity. The nurse should check his heart beat on a regular basis during the treatment period and inform Kevin about improvement in his condition due to consumption of medicine. This information may increase the interest of Kevin in medication consumption. After his discharge, the nurse should take follow-up of his medication consumption through phone (Brown, et al., 2015; Gulanick and Myers, 2016).   

The nurse should provide education to Kevin about signs and symptoms of CVA. The nurse should tell Kevin about symptoms of CVA like the weakness of arm and limb, slurred speech, vision trouble, overall fatigue, fainting, difficulty in breathing, irritation and trouble in walking. These are very common symptoms, and these can be identified by common man also. Hence, the nurse can make sure that Kevin can identify danger signals of CVA. The nurse should advise Kevin to take food each day on same time. The nurse should also advise him to take a small amount of food at regular small intervals. The nurse should advise him to avoid more amount salt and fat containing food. The nurse should advise him to take food rich in vegetable, grains, and fruits. The nurse should advise him not to consume alcohol and coffee. The nurse should advise him to avoid smoking. Excessive weight is a risk factor for AF. Hence, the nurse should advise him to keep regular check on his body weight. Alcohol and coffee can exaggerate episodes in AF. Nurse should advise Kevin to perform slight exercise on the regular basis. Exercise is useful in improving condition of AF. Also it is useful in reducing anxiety and fear. AF patients are at risk of developing anxiety and risk. The nurse should advise Kevin to take the regular breaks in his regular activities. The nurse should advise him to prepare his time table for food, daily activities, and medications. The nurse should ask him to follow relaxation procedure along with medications to reduce episodes of AF (Brown, et al., 2015; Gulanick and Myers, 2016).

Conclusion:

AF is a very complex disease. This disease is more common in elder patients and is associated with wide variety of symptoms. In AF, both anatomical and electrical changes occur. This is due to alteration in the functioning of the atria and ventricles. There should be multiple goals for the management of AF. The therapeutic strategy should be decided based on the severity of the disease. Selection of food and medication is very important for AF patient because food also has a prominent impact on the AF. Along with medication management, lifestyle changes are very important for the management of AF. Prevention of CAV is most challenging in patients with AF. Hence, special emphasis should be given to cure CAV and AF in Kevin. Nursing interventions comprising of medication and lifestyle aspects would be helpful for Kevin to recover from AF.  

References:

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Anumonwo, J.M., and Kalifa, J. (2014). Risk Factors and Genetics of Atrial Fibrillation.  Cardiology clinics, 32(4), 485–494.

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Gulanick, M., and Myers, J. L. (2016). Nursing Care Plans: Nursing Diagnosis and Intervention. Elsevier Health Sciences.

Iwasaki, Y.K., Nishida, K., Kato, T., and Nattel, S. (2011). Atrial Fibrillation Pathophysiology. Implications for Management. Circulation, 24, 2264-2274

Kingma, J.H., van Hemel, N.M., and Lie, K.J. (2012).  Atrial Fibrillation, a Treatable Disease?

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Nguyen, T.N., Hilmer, S.N; Cumming, R.G. (2013). Review of epidemiology and management of atrial fibrillation in developing countries. International Journal of Cardiology, 167(6), 2412–20.

Shenasa, M., and Camm, A. J. (2015). Management of Atrial Fibrillation. Oxford University Press.

Watson, T., Shantsila, E., and Lip, G.Y. (2009). Mechanisms of thrombogenesis in atrial fibrillation: Virchow's triad revisited. Lancet, 373(9658), 155–66.