Pathophysiology is the study of the deranged physiological processes that result from or associated with an injury or disease. Pharmacology is the study of the effects, use and action of the drugs. Thus pharmacology plays an important role in human health and has a significant impact on the pathophysiology. The nurses must have the knowledge of pathophysiology of the disease and the related pharmacology to develop the clinical reasoning and critical thinking that results in correct clinical judgements (Rischer, 2018). However the therapeutic success largely depends on the ability of the nurses to analyse the psychosocial needs of the patient. The clinical report will describe the implementation of these facts in nursing practice. The detail understanding of the clinical scenario will help to integrate the pathophysiological, psychosocial and pharmacological aspects in nursing practice.
Russell has a past history of heart attack 15 years ago due to coronary heart disease for which coronary artery stent was placed. Heart attack causes damage to the cardiac muscles thus decreasing the efficiency of cardiac muscles to pump the blood. After his first heart attack, he did not address the contributing factors such as high blood pressure, high cholesterol and being overweight. Heart failure is a complex condition that results from multiple risk factors such as individual, environmental, clinical, pathophysiological mechanism and increased exposure to risk factors (Lawson et al., 2020). He has a history of COPD for 30 years, hypertension, diabetes and cholesterol. Systemic hypertension is the potential risk factor for the heart failure as it leads to left ventricular hypertrophy thus causing heart failure. High cholesterol causes plaque deposition on the walls of the arteries resulting in the development and progression of coronary artery disease. LDL is also known as the bad cholesterol because increased LDL levels leads to accumulation of cholesterol in the arteries resulting in atherosclerosis (Pinto et al., 2019). People who are overweight have high risk of developing heart failure. Lung disease such as COPD causes pulmonary hypertension that leads to heart failure (Konstam et al., 2018). Diabetes increases the risk of hypertension and subsequently the coronary artery disease.
When the heart cannot pump sufficient blood around the body, it results in a heart failure. The myocardial muscles become too weak to pump blood. Heart failure either affects the left or the right side of the heart or both the sides resulting in 3 types of heart failure.
Left Sided Heart Failure – When the left ventricle of the heart is not able to pump sufficient blood around the body, results in accumulation of blood in the pulmonary veins. This leads to shortness of blood, difficult breathing specially while exertion (Lawson et al., 2020). This type of heart failure is commonly caused by CAD (Coronary Artery Disease).
Right sided heart failure - When the right ventricle of the heart is not able to pump sufficient blood to the lungs, results in accumulation of blood in the veins. This leads to increased pressure inside the veins as a result of which the fluid can come out of the veins in the surrounding tissues. This leads to edema in legs, genital area or other organs. Right sided heart failure develops from advanced left sided heart failure. It can also result from pulmonary hypertension, pulmonary embolism or other lung disease such as COPD (Arrigo et al., 2019).
Left sided heart failure presents with shortness of breath while lying flat or during physical exercise, chronic wheezing, fluid retention causing edema in legs, ankle or feet, rapid heartbeat, lack of appetite. These symptoms cause heart to pump harder thus resulting in enlarged heart and less blood flowing to the extremities. Russell has had progressive dyspnoea for the past 3 months and now days he is more comfortable sleeping in his raised head position for the past one week is suggestive of his breathing difficulty in flat lying position.
Chronic Right heart failure is clinically manifested by reduced exercise in tolerance, fatigue, decreased cardiac output, end organ damage and cachexia (Konstam et al., 2018). Signs and symptoms include elevated Jugular venous pressure, peripheral edema, abdominal discomfort, ascites, hepatomegaly and pleural effusion. While doing clinical examination of Russell, his jugular venous pressure is found raised which is suggestive of RHF and he has slight edema in his legs. Peripheral edema is the prominent sign of RHF.
On examination his BP is 150/90 mm Hg, BMI 26 m2/kg and LDL 5.0 mmol/L. These findings suggest that his BP is uncontrolled even after taking Tab.Perindopril and Atenolol, BMI 26 suggests that he is overweight. The chest X-Ray reveals high CTR (Cardiothoracic Ratio) and pulmonary embolism. Systemic hypertension is a silent killer as it is the potential risk factor for the hypertensive heart disease and hypertensive heart failure hence resulting in high CTR on a chest X-Ray (Halilu et al., 2017). Chest X-Ray shows pleural effusion or pulmonary edema in the lung fields which suggests heart failure. Pleural effusion is caused due to a number of conditions such as heart failure, pneumonia, liver cirrhosis and kidney disease. (Lababede, 2017)
His ECG shows a dilated left ventricle which suggests the left ventricular hypertrophy due to left heart failure.
COPD is also known as chronic obstructive pulmonary disease. COPD is a chronic inflammatory lung disease characterized by respiratory symptoms such as breathing difficulty, mucous production, cough and wheezing due to the airflow obstruction from the lungs (Aldabayan et al., 2017). It usually results from long term exposure to particulate matter or irritating gases such as cigarette smoke. Sudden worsening of COPD symptoms such as shortness of breath, and color of phlegm that lasts for several day is Acute exacerbation of COPD. Smoking, viral or bacterial infections lead to exacerbation of COPD, resulting in airway inflammation. Therefore smokers should adopt self management practice to quit smoking (Watson et al., 2017). Acute exacerbation is associated with severity of coughing, chest congestion and discomfort accompanied by increased sputum production.
Patients with COPD are at high risk of developing lung cancer, heart disease etc. Chest X-ray reveals obliteration of the costophrenic angle in the lung fields which suggests the chronic lung disease. Comorbidities of Russel such as Hyperglycemia, hypertension, atherosclerosis, dyslipidemia have a negative impact on exacerbation frequency. (Viniol & Vogelmeier, 2017)
Budesonide/Formoterol fumarate dehydrate puffs
Angiotensin converting enzyme (ACE) inhibitors
Corticosteroid/ long acting beta agonist(LABA)
Mechanism of action
Perindopril prevents the formation of Angiotensin2 by inhibiting a chemical known as angiotensin converting enzyme (ACE). This dilates the blood vessels and thus helps to decrease the quantity of water put back by the kidneys. This action helps to decrease the blood pressure (Stewart, 2017).
It inhibits the activity of the hormone aldosterone in the renal distal tubules, vasculature and myocardium. This inhibition prevents the formation of aldosterone induced proteins and decreases the sodium reabsorption in the cells therefore decreasing the potassium excretion ( Papich, 2016).
Corticosteroids have inhibitory action against many cells ( lymphocytes, neutrophils, eosinophils, macrophages) . they inhibit the mediators (such as cytokines, histamine , leukotrienes) of allergic and non-allergic inflammation. They increase the synthesis of proteins such as IL-10, lipocortin-1 and secretory leukocyte protease inhibitor. Formoterol is a long-acting bronchodilator that relaxes muscles in the airways to improve breathing.
Complication/ side effects
· Dizziness while standing up (orthostatic hypotension)
· Dry irritating cough
· Tinnitus, shortness of breath
· Dry mouth and thirst
· Dizziness and headache
· Gynaecomastia in men and breast pain in women
· Irregular menstrual periods
· Errectile dysfunction
· Abdominal cramps and vomiting
· Breathing problems or Asthma immediately after use
· Sneezing or running nose
· Sores inside mouth or lips
· Oral Thrush
· Serious allergic reactions such as swelling of mouth, face ,tongue and breathing problems
· Blurred vision, tunnel vision, eye pain, halos formation
· Fever, chills, nausea or vomiting
· Symptoms of low adrenal gland hormones such as muscle weakness, feeling of light headed ( Multum, 2019)
· Vital signs, WBC count and serum electrolytes must be monitored peridically to avoid hyperkalemia and pancytopenia.
· Patient should be advised to change positions slowly to avoid orthostatic hypotension (Zheng & et al., 2016).
· Potassium sparing diuretics should be given cautiously.
· Serum electrolyte should be monitored regularly.
· Daily doses of diuretics should be administered early so that sleep is not disturbed due to increased urination.
· Regular weight assessment should be done to monitor edema fluid mobilisation.
· If breathing problems get worsened while giving the inhalation, nurses should immediately inform the doctor.
· Any allergies should be immediately monitored.
· Blood pressure should be monitored periodically as this may increase the blood pressure.
a) To prevent heart failure:
Non Pharmacological recommendations to prevent heart failure are exercise, reducing sodium in the diet, managing stress and losing weight. Managing stress by a number of techniques such as meditation, deep breathing exercises result in relaxation of mind which increases muscle relaxation and strengthen the immune system. Russel is advised to watch funny videos and laugh during the day because laughter is a natural stress buster and it decreases blood pressure thereby reducing stress.
b) To prevent exacerbation of COPD:
Adherence to non-pharmacological recommendations is important for patients suffering from chronic disease. Mr. Russell should adopt self management practice and participate in rehabilitation programs. Patients of COPD have high chances to improve from exercise-based interventions such as pulmonary rehabilitation ( Brighton et al., 2020). He should adopt regular exercise and physical activity to improve the outcomes and prevent the exacerbation.
c) To prevent Pneumonia :
Pulmonary rehabilitation should be employed by doing exercise and muscle training. Physiotherapy is helpful to clean bronchial secretions. Various techniques such as forced expiration and postural drainage should be carried out regularly at home. Oxygen therapy at home to over come hypoxemia is also beneficial in curing breathlessness.
d) To reduce high cholesterol level:
Dietery strategy is effective in lowering the blood cholesterol levels. Healthy diet is shown to be effective in reducing the risk of cardio vascular disease (Mahmood, 2015). Consuming cholesterol lowering foods such as almond and nuts, avocado, fish, green vegetables and fruits will help maintain low cholesterol. Physical activity will also help in maintaining the cholesterol levels.
Upon evaluating the questions raised in clinical scenario, nurses must follow an integrated approach. Nurses should include all the aspects of pathophysiology, pharmacology and psychology to provide the quality care.
Aldabayan,Y. S., Alrajeh, A.M., Lemson, A. & Hurst, J. (2017). Pulmonary rehabilitation and cardiovascular risk in COPD: a systematic review. COPD Research and Practice, 7(3). DOI: https://doi.org/10.1186/s40749-017-0026-9
Arrigo, M., Huber, L.C., Winnik, S., Mikulicic, F., Guidetti, F., Frank, M., Flammer, A.J. & Ruschitzka, F. (2019). Right Ventricular Failure: Pathophysiology, Diagnosis and Treatment. Card Fail Rev, 5(3), 140–146. DOI: 10.15420/cfr.2019.15.2
Brighton, L. J., Evans, C. J., Man, W. D. C. & Maddocks, M. (2020). Improving Exercise-Based Interventions for People Living with Both COPD and Frailty: A Realist Review. International Journal of Chronic Obstructive Pulmonary Disease, 15, 841-855.
Pinto,R,D., Grassi,D., Properzi, G., Desideri,G. & Ferri,C.(2019). Low Density Lipoprotein (LDL) Cholesterol as a Causal Role for Atherosclerotic Disease: Potential Role of PCSK9 Inhibitors. US National Library of Medicine National Institutes of Health, 199-207. DOI: 10.1007/s40292-019-00323-7
Halilu, S.D., Aiyekomogbon, J.O., Igashi, J.B., Ahmed, H.M, & Aliyu, Y.S (2017). Cardiothoracic Ratio on Chest Radiographs as a Predictor of Hypertensive Heart Disease Among Adults with Systemic Hypertension. Archives of International Surgery, 7(3), 82-88. DOI: 10.4103/ais.ais_46_17
Hayes-Watson, C., Nuss, H., & Tseng, T.S. (2017). Self-management Practices of Smokers with Asthma and/or Chronic Obstructive Pulmonary Disease: A Cross-sectional Survey. COPD Research and Practice, 3(3). DOI: https://doi.org/10.1186/s40749-017-0022-0
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Lawson, C,A., Zaccardi, F., Squire, I., Okhai, H., Davies, M., Huang, W., Mamas, M., Lam, C.S.P.,
Khunti, K. & Kadam, U.T. (2020). Risk Factors for Heart Failure. AHA Journals,13 (2), e006472.
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Viniol , C. & Vogelmeier CF. (2018) Exacerbations of COPD. NCBI US National Library of Medicine National Institutes of Health, 27 (147), 170103. DOI: 10.1183/16000617.0103-2017
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