Nursing Practice 3: Pathophysiology & Pharmacology Applied to Nursing

Introduction to Heart Failure

Heart failure is a complex health condition that occurs when the heart is unable to pump blood effectively to meet the metabolic needs of the body (Chahine & Alvey,2019). The given document presents a case of Mr. Russel who is aged 68 and works as a truck driver. He also possesses a history of COPD, diabetes, hypertension, high cholesterol, and heart attack. This paper identifies the risks of heart failure that are associated with the health condition of Russel and also explains the pathophysiology of the condition. The exacerbation of COPD and the identified risks for Russel associated with the same have also been discussed. A concise table that explains the mechanism of action, side effects, and nursing consideration of few drugs prescribed for Russel has also been included. Further, this paper also proposes suitable noon-pharmacological interventions that can help in the overall improvement of the health of Russel. 

Risks that Caused Heart Failure

The major risks that have contributed to the heart failure in Russel include his present comorbid conditions like COPD, diabetes, history of chronic smoking, high cholesterol, alcohol consumption, diabetes, hypertension, and history of a heart attack. In high blood pressure, the vessels are narrowed and this hinders the passage of blood. As the blood flow is restricted, there are higher chances of developing heart failure. Further, Russel also presents with a history of chronic smoking. Smoking results in atherosclerosis and blocks the passage of blood (Chahine & Alvey,2019). This is also a major contributor that can enhance the chances of heart failure. The oxidative stress is generated due to insufficient blood supply that can result in myocardial infarction and impacts both systolic and diastolic functions of the heart. COPD in the patient also acts as a contributor to this oxidative stress and serves as a risk factor for the development of cardiac failure (Ohiomomba et al., 2019).

As Russel has also been exposed to alcohol for long. Long term alcohol abuse has been associated with the weakening of the cardiac muscles that impact the ability of the body to pump blood. When the heart faces problems in pumping blood throughout the body, the vital organs and body functions are disrupted. Another essential health condition that has impacted the health condition of Russel is his diabetes. People with high blood glucose levels tend to weaken blood vessels (Khadanga et al., 2019). This damage of arteries results in atherosclerosis and further enhances the risk of cardiac failure in the patients. Russel also reports that he had a heart attack 15 years ago. History of heart attack is intricately linked with cardiac failure. People who suffer from a heart attack have higher risks of heart failure as there are chances of damage in the cardiac muscle that can impact the blood supply and limit the body of heart to pump blood efficiently(Ohiomomba et al., 2019). 

Pathophysiology of Left-Sided and Right-Sided Heart Failure

Heart failure can occur impacting the left-sided cardiac muscles or the right-side cardiac muscles categorizing them into left-sided and right-sided heart failure. (Zaher et al., 2017) The heart failure in the patients can either be systolic or diastolic, that is, when the ventricle fails to push enough blood to meet the metabolic demands of the body and when the ventricular filling is hindered due to stiffness or problems in contractibility, respectively (Arrigo et al., 2019). 

Pathophysiology Right-Side Heart Failure 

Right-sided heart failure occurs when the right chamber of the heart fails to pump blood adequately. This condition occurs when the ventricle in the heart fails to collect blood and pump it in the veins. The right ventricle is responsible for the venous return and the pulmonary circulation (Arrigo et al., 2019). The right ventricle is much thinner than the left ventricle in its physiology and is liable for the damage. Heart failure of the right-sided ventricle results in edema and renal problems in the body. The primary pathophysiology behind the failure is increased afterload. The function of the right ventricle involves preload, contractility, afterload, and heart rhythm (Thomompoulos & Zanchetti, 2019). The failure largely occurs due to a pre-existing cardiac condition that impacts the contractibility of the ventricle and this impacts the cardiac output (Figure 1). The other causes of the right-side heart failure involve reduced contractibility, abnormal preload, altered rhythm, and altered independence that can occur due to abnormal heart rhythms, hypovolemia or hypervolemia, and other cardiomyopathies (Thomompoulos & Zanchetti, 2019). 

Left-Sided Heart Failure 

The left-sided heart failure occurs when the left ventricle of the heart struggles to pump out the blood. This occurs due to the weakening of the left ventricular muscle (Chahine & Alvey,2019). As the ventricular contraction is limited, there is an observed decrease in the ejection fraction in the system due to the presence of decreased pressure and volume. Changes in the calcium ion concentrations and signaling are also observed that impacts the muscle contraction and blood supply (Bellumkonda et al., 2017). The ventricular contraction is an active process, that is, it requires ATP for its completion, and hence changes in the electrophysiology and ATP utilization are also observed. People with left-sided heart failure may also report pulmonary problems like edema and dyspnea (Chahine & Alvey,2019).

Following the provided case study of Russel, left-sided-systolic heart failure is being observed, this is evidenced by the dilatation of the left ventricle that has an extraction fraction below 25% which should ideally be 40% (Bellumkonda et al., 2017). The observed dilatation in the ventricles of Russel is known as cardiomyopathy and is a classified cause of left-sided heart failure. Further, ECG of Russel also indicates this dilatation in the left ventricle and also reports the presence of severe systolic dysfunction. 

Acute Exacerbation of COPD

Chronic obstructive pulmonary disease (COPD) is identified as a chronic pulmonary health condition that primarily occurs due to damage in the respiratory pathway and alveoli (Ko et al., 2016). The essential characteristics of the disease include the abnormal inflammatory response in the lungs along with poorly reversible airflow. Exacerbation of the health condition has been a major burden on healthcare systems globally (Hashmi et al., 2014). The pathophysiology of the condition is associated with the proinflammatory and the prothrombotic states in the respiratory system. The ciliary function of the respiratory tract is impaired in the health condition that results in chronic inflammation and hyper mucus secretion in the respiratory pathway. As a consequence, the airflow in the lungs is obstructed and the patient develops dyspnea. COPD is also characterized by inflammation in the skeletal muscles and therefore the patient develops severe complications associated with breathlessness and hypoxia (Flattet et al., 2017). Exacerbation in the condition is associated with the immunogenic response that is triggered by an irritant that incites a reaction by the neutrophils and the eosinophils of the body. As the inflammation increases further, the gas exchange is compromised and muscle fatigue in the oxygen-deprived condition is observed (Landis et al., 2019). Further, bronchoconstriction and edema are also observed in the patient eventually causing respiratory failure. Fibrosis of the airways is also observed that results in narrowing of the respiratory pathway hindering airflow (Flattet et al., 2017). 

In the case of Russel, multiple factors are responsible for the occurrence of COPD and the observed exacerbation. The primary factor that is responsible for the development of COPD in Russel is his history of smoking. Inflammation is persistent in patients that possess a history of smoking contributing to a weak respiratory system susceptible to frequent inflammations in the presence of an irritant (Hashmi et al., 2014). The other factor that is responsible for the exacerbation of COPD in Russel is his occupation. Russel works as a truck driver where he is constantly exposed to the fumes of fuel and other pollutants that can act as an irritant and trigger an exacerbation. The pathophysiology of exacerbation involves the action of proteases and antiproteases in the body that trigger the destruction of the alveolar wall and cause emphysema (Landis et al., 2019). Further, they are also involved in the secretion of chemotactic factors that regulate hypersecretion of the mucus in the bronchi further leading to oxidative stress in the patient (Hashmi et al., 2014). 

Information on Drugs Prescribed to Russel

Generic name of the drug

Perindopril

Spironolactone

Budesonide/ formoterol fumarate dihydrate puffs

Drug class

The drug belongs to the class of ACE inhibitors (Angiotensin converting enzyme)

(Laurent et al., 2018)

The drug belongs to the class of diuretics (Guerra et al., 2018)

The drug Budesonide acts as a corticosteroid and formoterol fumarate as an adrenergic antagonist (Kerwin et al., 2018)

Mechanism of action

The drug prevents the conversion of ATI to ATII by competitively binding to the receptor. The ACE receptor has two functional domains at its N and C termini, the drug acts as a competitive inhibitor and prevents binding of ATI. This competitive inhibition prevents the conversion to ATII and helps in reducing the blood pressure (Bertrand et al., 2016).

The drug functions by acting as a competitive inhibitor of the sodium potassium channels in the distal convoluted tubules. This binding results in suppression of sodium potassium exchange in the cells. This assists in improving the water and mineral balance in the body and enhances potassium retention (Velagapudi et al., 2018).

The primary action of this medication is to act as a bronchodilator. The drug reduces the inflammatory response in the respiratory tract and enhances the air passage. The drug also functions by inducing relaxation in the respiratory muscles that promotes dilatation in the respiratory pathway and minimizes the hindrance in the airflow (Ferguson et al., 2018)

Side effects or complications associated with drug intake

The inconsiderate consumption of this drug can lead to hypotension, problems in digestion, cough, dizziness, etc.

(Laurent et al., 2018)

The inconsiderate consumption of this drug can lead to nausea in the patients. It is also possible for the patients to present with drowsiness and confusion (Velagapudi et al., 2018). 

The inconsiderate consumption of this drug can lead to development of anxiety in the patient. The patient can also report chest pain and sleep apnea (Kerwin et al., 2018).

Nursing considerations associated with the medication

The nursing considerations that are associated with intake of this medication include comprehensive assessment of patient medical history to check for existing allergies. It is also crucial for the nurses to assert the need of regular blood pressure check ups to monitor the action of the drug.

(Bertrand et al., 2016)

The nursing considerations that are associated with intake of this medication include proper assessment and recording of medical history of the patient. It is also important to screen the patient for allergies and to screen regularly for edema (Guerra et al., 2018).

The nursing considerations that are associated with intake of this medication include effective recording and analysis of medical history of the patient. It is essential to screen patient for any infections as the drug can act as an immunosuppressant. It is also important to record and monitor the respiratory rate of the patient regularly (Ferguson et al., 2018).

Non-Pharmacological Interventions Suitable for Russel

Heart Failure (Thomompoulos & Zanchetti, 2019)

  1. Weight loss
  2. Staying away from irritants like passive smoke and toxic fumes
  3. Limit consumption of alcohol
  4. Inclusion of exercise and physical activity
  5. Management of diet.

Prevention of Exacerbation of COPD (Ko et al., 2016)

  1. Staying away from irritants like passive smoke and toxic fumes
  2. Wear a mask while driving or when in places with excess dust or risk of irritants
  3. Breathing exercises
  4. Pulmonary rehabilitation
  5. Positioning in times of respiratory distress

Prevention of Pneumonia (Hua et al., 2016)

  1. Perform breathing exercise
  2. Prevent exposure to irritants
  3. Have regular checkups at the hospital for a focused respiratory system assessment.
  4. Pulmonary rehabilitation
  5. Maintenance of oral hygiene

Reduction of Cholesterol Level (Chen et al., 2018)

  1. Diet management
  2. Weight loss
  3. Increase in water intake
  4. Perform physical exercise
  5. Regular examination of cholesterol levels

Conclusion on Heart Failure

This paper provides a concise analysis of the case study of Russel and discusses the risk factors and pathophysiology of his heart failure diagnosed by the clinician. Further, pathophysiology and cause of exacerbation of his underlying health problem, COPD has also been discussed. Some essential information about the medication prescribed to Russel along with possible non-pharmacological interventions for the identified health conditions has also been provided.

References for Heart Failure

Arrigo, M., Huber, L. C., Winnik, S., Mikulicic, F., Guidetti, F., Frank, M., ... & Ruschitzka, F. (2019). Right ventricular failure: Pathophysiology, diagnosis and treatment. Cardiac Failure review, 5(3), 140.https://www.cfrjournal.com/articles/Right-Ventricular-Failure

Bellumkonda, L., Tyrrell, D., Hummel, S. L., & Goldstein, D. R. (2017). Pathophysiology of heart failure and frailty: a common inflammatory origin?. Aging cell, 16(3), 444-450.

Bertrand, M. E., Vlachopoulos, C., & Mourad, J. J. (2016). Triple combination therapy for global cardiovascular risk: atorvastatin, perindopril, and amlodipine. American Journal of Cardiovascular Drugs, 16(4), 241-253.https://link.springer.com/article/10.1007/s40256-016-0175-2

Chahine, J., & Alvey, H. (2019). Left Ventricular Failure. In StatPearls [Internet]. StatPearls Publishing.https://www.ncbi.nlm.nih.gov/books/NBK537098/

Chen, G., Farris, M. S., Cowling, T., Colgan, S., Xiang, P., Pericleous, L., ... & Anderson, T. J. (2018). Atherosclerotic Cardiovascular Diseases and Low-Density Lipoprotein Cholesterol Management in Alberta, Canada. Circulation, 138(1), 14272-14272.https://www.ahajournals.org/doi/abs/10.1161/circ.138.suppl_1.14272

Ferguson, G. T., Rabe, K. F., Martinez, F. J., Fabbri, L. M., Wang, C., Ichinose, M., ... & Aurivillius, M. (2018). Triple therapy with budesonide/glycopyrrolate/formoterol fumarate with co-suspension delivery technology versus dual therapies in chronic obstructive pulmonary disease (KRONOS): a double-blind, parallel-group, multicentre, phase 3 randomised controlled trial. The Lancet Respiratory Medicine, 6(10), 747-758.https://www.sciencedirect.com/science/article/abs/pii/S2213260018303278

Flattet, Y., Garin, N., Serratrice, J., Perrier, A., Stirnemann, J., & Carballo, S. (2017). Determining prognosis in acute exacerbation of COPD. International Journal of Chronic Obstructive Pulmonary Disease, 12, 467.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5293360/

Guerra, R. A., Silva, M. P., Silva, T. C., Salvadori, M. C., Teixeira, F. S., de Oliveira, R. N., ... & de Moraes, J. (2019). In vitro and in vivo studies of spironolactone as an antischistosomal drug capable of clinical repurposing. Antimicrobial Agents and Chemotherapy, 63(3), e01722-18.https://aac.asm.org/content/early/2018/12/14/AAC.01722-18?versioned=true

https://onlinelibrary.wiley.com/doi/full/10.1111/acel.12581

Hua, F., Xie, H., Worthington, H. V., Furness, S., Zhang, Q., & Li, C. (2016). Oral hygiene care for critically ill patients to prevent ventilator‐associated pneumonia. Cochrane Database of Systematic Reviews, (10).https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008367.pub3/abstract

Kerwin, E. M., Siler, T. M., Arora, S., Darken, P., & Rose, E. (2018). Efficacy, safety, and pharmacokinetics of budesonide/formoterol fumarate delivered via metered dose inhaler using innovative co-suspension delivery technology in patients with moderate-to-severe COPD. International Journal of Chronic Obstructive Pulmonary Disease, 13, 1483.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5947839/

Khadanga, S., Savage, P., Rengo, J., Ades, P., & Gaalema, D. (2019). Expired Carbon Monoxide: A Novel Approach to Assess Smoking Status in Cardiac Rehabilitation. Circulation, 140(1), 10667-10667.https://www.ahajournals.org/doi/abs/10.1161/circ.140.suppl_1.10667

Ko, F. W., Chan, K. P., Hui, D. S., Goddard, J. R., Shaw, J. G., Reid, D. W., & Yang, I. A. (2016). Acute exacerbation of COPD. Respirology, 21(7), 1152-1165.https://onlinelibrary.wiley.com/doi/full/10.1111/resp.12780

Landis, S. H., Pimenta, J. M., Yang, S., Compton, C., Barnes, N., & Brusselle, G. (2019). Association between blood eosinophils and acute exacerbation of COPD risk in patients with COPD in primary care. Respiratory Medicine: X, 1, 100011.https://www.sciencedirect.com/science/article/pii/S2590143519300119

Laurent, S., Mancia, G., & Poulter, N. (2018). Perindopril 3.5 mg/amlodipine 2.5 mg versus renin–angiotensin system inhibitor monotherapy as first-line treatment in hypertension: a combined analysis. Journal of Hypertension, 36(9), 1915-1920.https://journals.lww.com/transplantjournal/00004872-201809000-00022.fulltext

Ohiomoba, R., Youmans, Q. R., Ezema, A., Anderson, A. S., Jackson, K., Mandieka, E., ... & Okwuosa, I. S. (2019). History of cigarette smoking and heart transplant outcomes. Journal of Cardiac Failure, 25(8), S169.https://www.onlinejcf.com/article/S1071-9164(19)31291-6/abstract

Qureshi, H., Sharafkhaneh, A., & Hanania, N. A. (2014). Chronic obstructive pulmonary disease exacerbations: latest evidence and clinical implications. Therapeutic Advances in Chronic Disease, 5(5), 212-227.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4131503/

Thomopoulos, C., & Zanchetti, A. (2019). Blood Pressure-Lowering Treatment and the Prevention of Heart Failure: Differences and Similarities of Antihypertensive Drug Classes. In Hypertension and Heart Failure (pp. 285-298). Springer, Cham.https://link.springer.com/chapter/10.1007/978-3-319-93320-7_18

Velagapudi, C., Bansal, S., Munoz, K., Brune, S., & Prasad, A. (2018). Safety and efficacy of high dose spironolactone in loop diuretic resistant acute decompensated heart failure. Circulation, 138(1), 12572-12572.https://www.ahajournals.org/doi/abs/10.1161/circ.138.suppl_1.12572

Zaher, A. M. E., & Ali, S. M. R. (2017). Angiotensin II Contributes to the Pathophysiology of Heart Failure. Heart Failure, 2(4)

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