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Atrial fibrillation and its Pathophysiology

Discuss about the Objective Structured Clinical Examination Method.

Mr. Harry Jones is 68-year-old man and is admitted to the medical ward suffering from Rapid Atrial Fibrillation. He has allergy with penicillin , and has a past medical history of asthma and hypertension. Mr. Jones is currently on Salbutamol 5mg two puffs four times per day and, oral cardiprin 100mg once a day and oral enalapril 10mg daily. He has a known family history of acute myocardial infarction, migraines in mother , and cancer of the colon in his father.This report includes pathophysiology of atrial fibrillation, and the rationale of administrating amiodarone as his initial medical management, and action and the therapeutic benefits of both the drugs warfarin and dabigatran as well as the side effects to decide which drug most suitable for him.

Mr. Jones was prescribed aspirin to prevent the heart stroke, which can occur due atrial fibrillation since he has an age of 68 years. This drug was given because of low risk of bleeding, easy to use and monitoring is not required while giving this drug (Lip, 2013).The Mode of action of aspirin involves inhibiting the activation and aggregation of platelets and also the inhibition of enzyme cyclo xygenase that is platelet dependent. This leads to the inhibition of prostaglandin synthesis. The side effects of aspirin involves fever that lasts for 3 days, vomiting, pain in the stomach and nausea.

Cardiprin is used for thinning of blood during heart strokes and atrial fibrillation. It has an active ingredient as aspirin and functions by the suppression of the production of prostaglandins hormones. There are various side effects of Cardiprin such as nausea, vomiting (Ng & Ho, 2017). Asthma and problems related to digestion. Nursing interventions for administering Cardiprin involves proper knowledge about the current medicaments the patient is taking, allergic responses and any future surgery and pregnancy. The patient should inform the doctor about any issues of asthma, high blood pressure, heartburn or any other cardiac diseases. The nurse should give the medicine to the patient by checking on the outer packaging and as prescribed by the clinician. It can also lead to irritation in the stomach so it should be taken along with milk.

The pathophysiology of atrial fibrillation involves pathological changes such as fibrosis in the artria that is progressive in nature. The fibrosis occurs due to the ageing process, dilation of the chamber, genetic reasons and inflammation. Atria gets dilated due to various structural abnormalities in them heart such as high blood pressure, valvular heart disease or a congestive failure of the heart (Heitner, 2013).Atrial fibrosis can also occur due to the mutation in the lamin AC gene. The renin-aldosterone –angiotensin pathway is activated by the atrial dilatation due to stretch and this in turn increases the protein disintegrin and matrix metaproteinase in the walls of the atria. This pathway leads to the release of cytokines, oxidative stress and the formation of factors that lead to growth and promote fibrosis (Wakili, Voigt, Kääb, & Nattel, 2014). It also initiates various cell-signalling processes that increase the level of calcium inside the cells.

Drugs used in the management of AF

The Renin aldosterone angiotensin system (RAAS) includes various enzymes such as Angiotensin 2, aldosterone and angiotensin converting enzyme and they are increased during atrial fibrillation as they are synthesized on a local level in the atrial myocardium. The increase in the level of these enzymes leads to fibrosis and atrial remodeling and results in the loss of muscle mass of atria.There are two types of fibrosis that is Reactive interstitial fibrosis, which helps in the separation of muscle bundles, and Reparative fibrosis that helps in replacing the cardiomyocytes. Fibroblasts can be coupled to the cardiomyocytes in an electrical manner and help in promoting the ectopic activities when their number is increased (Dan & Camm, 2013).

Amiadarone is given to Mr Jones to prevent myocardial infarction since his mother had a past medical history of the same disease. Amiadarone is also used to help the heart to beat in a normal manner as he is suffering from atrial fibrillation. It  may lead to side effects if given to Mr Jones since he is allergic to pencillin and is suffering from  asthma and serious heart issues (Barber & Blundell, 2013).It should also be not given to patients suffering from thyroid diseases, implantation of pacemaker, eyesight issues, low balance of electrolyte and low or high blood pressure.  There are various side effects of amiodarone such that it can have a negative effect on the liver and lungs in Mr Jones. The nursing interventions include various measures after administering this drug to the patient such as continuous monitoring of ECG and rhythm and heart rate and keeping a check if the patient suffers from jaundice, pain in the chest and stomach breathing issues, dark coloured urine and blood in the cough (Schalij, 2014). Amiodarone should not be given to females who are pregnant as it can have a negative effect on the health of the baby because it passes to the mother’s milk.

Anticoagulants such as warfarin and dabigatran are used to reduce the risk of blood clotting and hence the heart stroke. The most common medicine is warfarin but it has a disadvantage that it can interact with foods, medicines and alcohol. But dabigatran has an advantage that it has a low interaction rate with medicaments, alcohol and food items .Warfarin requires regular blood tests to check the clotting time of blood in the body and dabigatran does not require regular blood tests (Wisløff & Klemp, 2014). According to, the National Institute for Health and Care Excellence (NICE), warfarin is used to decrease the risk of heart stroke. Its main disadvantage is heavy bleeding so to avoid it, a Vitamin K injection is given to stop the bleeding. Dabigatran blocks the effect of thrombin and helps in preventing the blood clots. Thrombin is a protein which is formed in the body for the formation of blood clots. Dabigatran gets collected in the blood of the patients who suffer from kidney problems as the kidney is not able to remove the drug from the body (Giugliano, Ruff, Braunwald, Murphy, Wiviott, & Ruzyllo, 2013).

Objective Structured Clinical Examination Method

There are various precautions while taking the drug dabigatran such as the capsule should not be opened before giving then dose to the patient that will lead to an increase in the concentration of drug in the body of the patient and hence lead to an increase in the risk of bleeding. Another disadvantage of this drug is that it is degraded when comes in contact with moisture and hence precautionary measures should be followed to keep the bottle closely tight. It should be used within 30 days after the bottle is opened. A side effect of dabigatran is that it leads to indigestion and stomach upset in patients if it is discontinued because the drug needs an acidic environment to get absorbed in the body (Mooney, 2013).It can also lead to heart stroke or heart attack if this medicine is stopped from taking. The side effects of warfarin are fever, bleeding from the gums, pain and swelling, irritation and diarrhea. Warfarin is more effective and safer than dabigatran and dabigatran should not be taken by patient suffering from kidney and liver problems as it lead to increase in bleeding.

Salbutamol is used in the treatment of asthma by providing relaxation to the muscles in the walls of airways present in the lungs. The normal dose for patients is 1-2 inhalations those who are adults and one puff for children in the age group of 6-11 years. It should be used only after prescribed by the doctor. (Salvi, 2013). Mr Jones will be instructed to remove the cover from the mouthpiece and shake the inhaler profusely then hold the inhaler and breathe out in a gentle manner. Then the mouthpiece should be immediately kept on the mouth. He will be advised to seal the mouthpiece totally with lips and start to breathe slowly with the mouth. After breathing slowly, press the inhaler firmly to release the medication and continued to breathe in (Zhang, Liu, Hu, & Tan, 2015).

If the patient misses the dose he should continue with the regular dosage schedule. It should be store at a room temperature and kept out of reach from children. It should be kept away from hot devices such as stove and heater. The patients who are allergic to salbutamol and milk proteins such as lactose should not take salbutamol puffers. Side effects of this medication include drowsiness, dizziness, fatigue, coughing and faster rate of heartbeat (Lahiri, 2017).

It can be concluded that Mr Jones has a high risk of heart stroke since he is an elderly person. He should take proper care of himself and follow the medicaments prescribed by his clinician properly. He should take a well balanced diet and exercise daily that will decrease the chances of heart stroke. He should take warfarin that will help to decrease the risk of heart stroke and it is more effective and safer as compared to other drugs such as dabigatran. He should follow proper nursing interventions and follow precautionary measures to recover from Rapid Atrial Fibrillation.

Barber, & Blundell, P. &. (2013). Further Esstentials of Pharmocology For Nurses. Maidenhead: McGraw-Hill Education .

Dan, & Camm, B. d. (2013). Atrial fibrillation therapy. .

Giugliano, Ruff, Braunwald, Murphy, Wiviott, & Ruzyllo, H. &. (2013). Edoxaban versus warfarin in patients with atrial fibrillation. New England Journal of Medicine , 369(22), 2093-2104.

Heitner, H. &. (2013). Cardiology in Family Practice. A practical guide .

Lahiri. (2017). vidence behind use of levosalbutamol over salbutamol to prevent cardiac side effects. . International Journal of Contemporary Pediatrics , 4(3), 674-678.

Lip, &. L. (2013). Stroke prevention with oral anticoagulation therapy. Circulation Journal, Volume 77(6), pp1380-1388. .

Mooney. (2013). Use of dabigatran to prevent stroke in patients with atrial fibrillation. .Nursing standard, Volume 27(27), , pp 35-41.

Ng, & Ho, C. &. (2017). Comprehension by older people of medication information with or without supplementary pharmaceutical pictograms. Applied Ergonomics , 58, 167-175.

Salvi, B. &. (2013). Aspirin and asthma. CHEST Journal Volume118 (5 , p1470-1476.doi:10.1378/chest.118.5.1470.

Schalij, V. E. (2014). Amiodarone: an effective antiarrhythmic drug with unusual side effects. Heart, Volume , 96(19).

Use of dabigatran to prevent stroke in patients with atrial fibrillation. (2013). Nursing standard, , Volume 27(27), pp 35-41.41.

Van Erven, L., & Schalij, M. J. (2010)Amiodarone: an effective antiarrhythmic drug with unusual side effects. . (2013). Heart, Volume 96(19) , 96(19).

Wakili, Voigt, Kääb, & Nattel, D. (2014). Reccent advances in the molecular pathophysiology of atrial fibrillation. Journal of clinical investigation , p2955-2968.

Wisløff, & Klemp, H. &. (2014). conomic evaluation of warfarin, dabigatran, rivaroxaban, and apixaban for stroke prevention in atrial fibrillation. . Pharmacoeconomics , 32(6), 601-612.

Zhang, Liu, Hu, & Tan, X. (2015). An aerosol formulation of R-salbutamol sulfate for pulmonary inhalation., . Acta Pharmaceutica Sinica B , 4(1), 79-85.

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