CLINICAL SCENARIO ASSIGNMENT

CLINICAL SCENARIO ASSIGNMENT

Table of Contents

1. Rationale for ECG 3

2a. Pathophysiology of angina 3

2b. Risk factors for Betsy that can increase her risk of Acute Coronary Syndrome 4

3. ECG report analysis of Betsy 5
4. Central findings leading to Acute Coronary Syndrome diagnosis 6
5. Drug discussion 7
6. Use and mechanism of action of aspirin and ticagrelor in cardiac patients 10
7. Use of morphine in ACS 11
8. Current research evidence to link depression risks with chronic illness 11

References 13

1. Rationale for ECG

The rationale for ECG request in this case is owing to Betsy’s initial observations of nausea and breathing difficulties. As commented by Chen et al. (2018), ECG (electrocardiogram) is defined as the the clinical test to determine the reason for cardiac pain, shortness of breath, fatigue and dizziness. In case of Betsy, it can help the nursing personnel to identify the cause of her arrythmic conditions. Based on the past medical history of Betsy, it can be devised that she has been suffering from coronary heart ailment and chronic obstructive pulmonary disease (COPD). She has also undergone bypass grafting thrice with consistent presence of hypertension and type II diabetes mellitus. Another important jusitification for referring to ECG for Betsy is that it can help to deduce the drug mechanism rates for her medications (Azariadi et al. 2016). Hence, it can be justified that buddy nurse has insisted on doing an ECG to understand the efficiency of enoxaparin and diltiazem.

2a. Pathophysiology of angina

Agnina refers to a transient cardiac pain with chronic discomfort. This can result when cardiac requirement for oxygenated blood is more than its supply arising from coronary arteries. As commented by Zardavas et al. (2017), reduced oxygenated blood supply results from coronary artery spasm. Signs and symptoms of angina resemble distinct infarction. A significant angina attack can enable the experiences of acute pain in the chest with discomfort in sub-sternal location. Angina attack may occur during emotional or physical stress and can be resolved through due rest. According to the findings of Zhou et al. (2017), angina pectoris syndrome occurs from anger, exertion, fright, shock or violence. The pathophysiology of angina is owing to the imbalance in supply and demand ratio of myocardial oxygen. As stated by Wahab et al. (2017), narrowing of coronary arteries from arthrosclerosis can be caused by spasm or valvular complications. In case of Betsy, her systemic and pulmonary hypertension could be a cause for angina.

In other scenario, syphilis, aortic regurgitation, anaemia, infective endocarditis, or cardiomyopathy can be causative factors of angina. Clinical symptoms of angina that can be noted in a partient is acute pain in chest that lasts for a range of approximately 5 minutes. As stated by Müllerova et al. (2015), patients do not suffer from substernal pain, though it can be elaborated as a squeezing sensation. Betsy can be exposed to angina during exertion or exposure to thermal fluctuations due to vasospasm or enhanced oxygen demands. The pain can radiate to additional body parts like jaw, arms or back. As stated by Chen et al. (2018), diaphoresis or sweating can be due to enhanced work done by the body in order to meet primary physiologic needs. Tachycardia is another symptom that includes the heart pumping at a faster rate to for meeting oxygen demands. This leads to shortness of breathing or dyspnea as observed in Betsy and an enhanced oxygenation and respiratory rate. Anxiety is also prevalent when the body is not provided with ample oxygen to meet the denads of the cardiac muscles.

2b. Risk factors for Betsy that can increase her risk of Acute Coronary Syndrome

Prominent risk factors of ACS (Acute Coronary Syndrome) in case of Betsy is hypertension and type II Diabetes Mellitus. The first risk factor includes hypertension or high blood pressure that can multiple the ris of acute coronary syndrome by atleast three times (Müllerova et al. 2015). This is because, hypertension can cause further degradation to the arteries by depositing plaque or calcium in it. As opined by Al-Lamee et al. (2018), diabetes mellitus refers to inability of the body to develop appropriate amount of insulin in the pancreatic cells. Insulin is secreted by Islets of Langerhans in the pancreas to regulate glucose levels in the blood. Beta cells may cease to function during diabetes that can result in an enhancedrisk for coronary artery complications for Betsy. Diabetes can also lead to cardiac arrests through enhancing the rate of atherosclerosis by catalysing growth of cholesterol in the body.

3. ECG report analysis of Betsy

As provided in the above ECG report, the electrical impulses show certain aberrations in case of Betsy. According to Appleton et al. (2017), irregularities observerd in the cardiac environment of apatient with past medical history of COPD and hypertension can impose a significant amount of risks.

Rythm: Rythm between each trough and crest of the ECG graph shows distinct irregularities between the P and V waves. This may give rise to a considerable case of atrial flutter (Azariadi et al. 2016).

Rate: As it can be noted from the ECG chart, three large squares in graph sheet indicates cardiac rate in approximation of a 100 beats each minute.

P wave presence and regularity: The ECG graph shows that the P waves starts out to be a fractionally enhanced from normal levels. Each increment in the voltage incdicates enlarged or hypertrophied atria due to irregular data observed (Azariadi et al. 2016).

ST segment: A distinct depression is noted in the ST segment as clarified from the given ECG report.

Overall conclusion drawn from this report is that Betsy may be experiencing atrial flutter. Depression in the ST segment can amount to ischemia. However, medications like digitalis can cause depression in the ST segments.

4. Central findings leading to Acute Coronary Syndrome diagnosis

Primary symptoms noted in case of acute coronary syndrome can pertain to nausea, sweating, rise in body temperature, dizziness or difficulty in breathing. In order to diagnose ACS, three diagnostic variables can be checked that are angina, abnormal cardiac impulses and troponin levels. Angina is one of the important aymptoms observed in case of acute coronary syndromes (Al-Lamee et al. 2018). Angina can start from acute and recurring pain in the chest that gradually spreads to other parts of the body like back, neck, stomach or jaw. In addition to this electrocardiogram tests measure electrical activity in cardiac cavity through electrodes that are attached to skin.

Irregular or abnormal impulses can indicate a malfunctioning heart owing to insufficient oxygen levels. Certain patterns for electrical signal can indicate the confirmation of the diagnosis. Troponin acts as a biomarker that provides an efficient diagnosis in this case.High-sensitivity assays for cardiac troponin (hscTn) can diagnose the syndrome with enhanced sensitivity (Zardavas et al. 2017). Troponin assay is proposed if the patient complains about angina, diaphoresis, dyspnea and electrocardiographic complications. This assay can be market positive in case the threshold level corresponds to the concentration in 99th percentile.

5. Drug discussion

Generic name

GTN

Diltiazem

Pravastatin

Drug group

Glyceryl trinitrate belongs to the drug group of Nitrates.

Diltiazem belongs to the drug group of antianginal agent compounds. It is a

Nondihydropyridine based calcium channel blockers (Zhou et al. 2016).

Pravastatin belongs to the drug group of Reductase Inhibitors (HMG-CoA) or Statins.

Mechanism of action

The mechanism of action for glyceryl trinitrate can follow a circulation based pathway. This drug relaxes and widens the prominent cardiac blood vessels (coronary arteries). The drug can make the blood vessels relax in the body of the patients (Appleton et al. 2017). This can result in decrease considerable stress in cardiac capacities. As a result of this, blod flow can be normalised in the body.

Mechanism of action for Diltiazem involves inhibition of contractions dependent on calcium. These contractions take place in cardiac and peripheral smooth muscles. According to the findings of Teply et al. (2016), these contractions can result in vasodilation. Vasodilation can reduce the arrythmic condition of cardiac conductions and reduce stress on the cardiac muscles.

Mechanism of action for Pravastatin is through its reducing activity focused on lipoproteins. Effect of hydroxymethylglutaryl reductase (CoA) is blocked by the drug Pravastatin. In addition to this, the drug may prevent low density lipoprotein production in the body. This can enhance the amount of cellular LDL receptors in the body that reduces LDL and cholesterol levels.

Side effects or complications

Side effects involve nausea, allergic patches on skin. Furthermore, Chen et al. (2018) comment the patient can also experience cetain episodes of dizziness, atrial flutter, arrythmia and migraine as complications.

Complications of this drug can result in the form of constipation, bloating, nausea, fatigue, shortness of breath and malaise. Side effects in severe events can give rise to the patient losing their consciousness and developing yellowed skin or eyes. Betsy can also feel abdominal pain after ingestion of this drug (Wada et al. 2016).

In mild cases, the paitent may experiecne side effects of this drug in the form of nausea or persistent malaise, dizziness, or rashes (Chauvet-Gelinier & Bonin, 2017).

Complications of Pravastatin intake involve problems in muscle and diabetic health. Primary side effects of the drug is creation of mild cause confusion or mild memory problems. In case of Betsy, it may show complications like hepatic, gastric or renal pain.

2 major nursing considerations

1. GTNsSprays often comprise of flammable materials as their secondary or tertiary ingredients (Wahab et al. 2017). Hence, as a professional nursing practitioner, these sprays must be stored in cool and dark places that do not subject them to naked flame.
2. GTN medications cannot be provided to the patients who are pregnant or are suffering with complications from renal failure, hypothyroidism,, low blood pressure and glaucoma.
3. The traces of diltiazem is not eady to be flushed out by simple hemodialysis method. Hence, Zhou et al. (2017) opine patients suffering from renal or hepatic impairment requires trace amount of diltiazem dose.
4. Professional nurses must responsibly store diltiazem in places dry and dark places in room temperature.

The patients who are suffering from elevations in the levels of hepatic transaminase or are diagnosed with one or the other form of hepatic complications must not be given Pravastatin.

As per the recommendations of (Carney & Freedland, 2017), Pravastatin dose must be regulated in case of paediatric and eriatric patients owing to their fragile metabolism immunity.

6. Use and mechanism of action of aspirin and ticagrelor in cardiac patients

Ticagrelor can be mixed with aspirin in reduced dose to treat patients who are suffering from COPD. According to the findings of Valkenburg et al. (2016), this drug brings specific benefits for patients who suffer from atrial flutter by reducing the risk of a stroke. In case of Betsy, major cardiac events can reduce the risk of further attacks. It is also seen that Betsy has undergone three bypass graft surgery with a medical history of COPD, hypertension, diabetes and coronary cardiac ailment Hence, a blend of ticagrelor and aspirin can aid in platelet-driven clot prevention in the arteries (). This is due to the fact that ticagrelor is an antiplatelet drug that renders smoother blood flow in the body.

7. Use of morphine in ACS

Morphines can create adverse impact in the patients who are suffering from Acute Coronary Syndrome or a myocardial infarction. The enhanced mortality value of morphine during its administration to the patients can create complications in its incorporation in the care plan. As opined by Valkenburg et al. (2016), morphine can be beneficial due to its analgesic actions that relieves moderate to severe pain in the patients. In case the morphine disage is elongated in terms of time or concentration, the patient may develop an unhealthy addiction. This is further supported by Chen et al. (2018), who state repetitive application in care plan may bring deterioration in the health of the patient.

8. Current research evidence to link depression risks with chronic illness

As commented by Chauvet-Gelinier & Bonin (2017), patients suffering from chronic cardiac events can develop a pthological depression as a comorbidity. This is further supported by the evidence of Teply et al. (2016), who show that almost 46.7% of patients suffering from coronary ailments in the age group of 50 to 80 years are diagnosed with clinical depression. In addition to this, almost 75.8% of these patients in the given age group suffer from non-clinical depression. As per the research evidence gathered from Carney & Freedland (2017), depression is developed as a comorbidity to life-threatning and chronic illnesses. In this case, Betsy has shown a long medical history of suffering from chronic diseases. This has exposed her to depressive disorders owing to prolonged hospital stay and general malaise owing to the complications. Simultaneous occurences of coronary diseases and depression is also common in almost two-third of the cases occuring worldwide.

As opined by Teply et al. (2016), 85% of the depressive episodes occur following a massive cardiac event, such as a stroke. This can also be connected in a reverse mechanism by stating that chronic depresison can also give rise to adverse cardiac events. Hence, based on these evaluation it can be deduced that Betsy is exposed to the enhanced risk of contracting depression owing to her age and frail health. Furthermore, her list of comorbidities may add to the malaise that leads to the formation of multiple emotional disorders like anxiety and depression. She has been earlier diagnosed with hypertension, a condition commonly paired with anxiety for its patients.

References

Al-Lamee, R., Thompson, D., Dehbi, H. M., Sen, S., Tang, K., Davies, J., … & Nijjer, S. S. (2018). Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial. The Lancet, 391(10115), 31-40.

Appleton, J. P., Sprigg, N., & Bath, P. M. (2017). Therapeutic potential of transdermal glyceryl trinitrate in the management of acute stroke. CNS drugs, 31(1), 1-9.

Azariadi, D., Tsoutsouras, V., Xydis, S., & Soudris, D. (2016, May). ECG signal analysis and arrhythmia detection on IoT wearable medical devices. In 2016 5th International conference on modern circuits and systems technologies (MOCAST), 1-4.

Carney, R. M., & Freedland, K. E. (2017). Depression and coronary heart disease. Nature Reviews Cardiology, 14(3), 145.

Chauvet-Gelinier, J. C., & Bonin, B. (2017). Stress, anxiety and depression in heart disease patients: A major challenge for cardiac rehabilitation. Annals of physical and rehabilitation medicine, 60(1), 6-12.

Chen, Z., Liu, R., Niu, Q., Wang, H., Yang, Z., & Bao, Y. (2018). Morphine Postconditioning alleviates autophage in ischemia-reperfusion induced cardiac injury through up-regulating lncRNA UCA1. Biomedicine & Pharmacotherapy, 108, 1357-1364.

Müllerova, H., Maselli, D. J., Locantore, N., Vestbo, J., Hurst, J. R., Wedzicha, J. A., … & Anzueto, A. (2015). Hospitalized exacerbations of COPD: risk factors and outcomes in the ECLIPSE cohort. Chest, 147(4), 999-1007.

Teply, R. M., Packard, K. A., White, N. D., Hilleman, D. E., & DiNicolantonio, J. J. (2016). Treatment of depression in patients with concomitant cardiac disease. Progress in cardiovascular diseases, 58(5), 514-528.

Valkenburg, A. J., Calvier, E. A., van Dijk, M., Krekels, E. H., O’hare, B. P., Casey, W. F., … & Breatnach, C. V. (2016). Pharmacodynamics and pharmacokinetics of morphine after cardiac surgery in children with and without Down syndrome. Pediatric Critical Care Medicine, 17(10), 930-938.

Wada, A., Matsumoto, T., Taniguchi, A., Fujii, M., Hara, M., Kinoshita, M., & Horie, M. (2016). High-Throughput Transcriptome Analysis Reveals Therapeutic Effects of Statin on Alternations of Cardiac Gene Expression in Heart Failure. Journal of Cardiac Failure, 22(9), S167.

Wahab, M. A. K. A., Saad, M. M., & Baraka, K. A. G. (2017). Microalbuminuria is a late event in patients with hypertension: Do we need a lower threshold?. Journal of the Heart Association, 29(1), 30-36.

Zardavas, D., Suter, T. M., Van Veldhuisen, D. J., Steinseifer, J., Noe, J., Lauer, S., … & de Azambuja, E. (2017). Role of troponins I and T and N-terminal prohormone of brain natriuretic peptide in monitoring cardiac safety of patients with early-stage human epidermal growth factor receptor 2–positive breast cancer receiving trastuzumab: a herceptin adjuvant study cardiac marker substudy. J Clin Oncol, 35(8), 878-84.

Zhou, Y., Zhang, M. L., Yuan, B. J., Yuan, J. Q., Zhao, X. F., Zhao, L., & Ren, H. Q. (2017). Herbal carrier-based floating microparticles of diltiazem hydrochloride for improved cardiac activity. Tropical Journal of Pharmaceutical Research, 16(6), 1239-1244.