• Internal Code :
  • Subject Code : NURBN 2012
  • University : Federation University
  • Subject Name : Nursing

Table of Contents

Introduction.

Risk factors in the case of Russell for heart failure.

Pathophysiology of right and left-sided heart failure.

Acute exacerbation of the chronic obstructive pulmonary disease.

Factors in case of Russell for acute exacerbation of chronic obstructive pulmonary disorder

Drugs.

Non-pharmacological recommendations.

Conclusion.

References.

Introduction

A 68-year-old truck driver Mr Russell was admitted to Monash health with breathlessness. He gives the history that he has progressive dyspnea for last three months and is breathless while trying to do activities of daily living. He has a past medical history of suffering from hypertension, diabetes, hypercholesterolemia and chronic obstructive pulmonary disorder and is taking medications for the same. He has a history of a heart attack 15 years ago leading to stent placement and the patient is positive that there is no chest pain. He has a history of smoking but he is not a current smoker and takes less amount of alcohol.

Risk Factors in The Case of Russell for Heart Failure

The first risk factor that is associated with the development of heart failure in Russell is that he has a history of hypertension and hyperlipidemia. Heart failure is a pathophysiologic condition which affects the heart in such a way that the heart is not able to fulfil the metabolic needs of the body (Bertero & Maack, 2018). Systemic venous hypertension is one such risk factor which reduces the afterload to the heart which reduces the cardiac output. In Russell, the hypertension is attributed to two reasons one is that he was a chronic smoker and the other one is that he has a high level of blood cholesterol. In case of hypertension, there are changes in the blood vessels which make them constricted and less flexible causing reduced blood flow to the heart further reducing the cardiac output (Ledley et al., 2017).

He has a high level of blood cholesterol which is another risk factor for heart failure. Presence of a high level of high-density lipoprotein causes the formation of atherosclerotic plaque which causes vasoconstriction (Hurtubise et al., 2016). Russell is suffering from the chronic obstructive pulmonary disorder and one of the complications is the development of heart failure. The chronic obstructive pulmonary disorder causes pulmonary hypertension, edema, and reduces the preload to the heart (Sato et al., 2019). This increases the work that is done by heart to fulfil the oxygen and metabolic needs and remove the waste from the body effectively. As the chronic obstructive pulmonary disease is a progressive condition failure of the heart is a progressive condition as well.

Pathophysiology of Right and Left-Sided Heart Failure

Form the clinical examination of the Russell it is seen that the heart rate is regular with 90 beats per minute and his blood pressure is 150/90 mmHg and there is a slight elevation in the jugular venous pressure. It can be seen that there is peripheral pooling of the blood with an increase in respiratory rate of 26 breaths per minute. Radiograph of the chest reflected that there was increased cardiothoracic ratio which showed that there is dilatation of heart suggestive of right-sided heart failure. Obliteration of cardiophrenic and costophrenic angles which is suggestive of pulmonary oedema and right-sided heart failure. The echocardiogram shows that there was dilation of the left ventricle and severe systolic dysfunction of 25% which is suggestive of left-sided heart failure.

Left-sided heart failure is succeeded by right-sided heart failure. Left-sided heart failure is caused by poorly controlled hypertension which can be seen in the case of Russell. This causes an increase in afterload further increasing the cardiac workload leading to hypertrophy of the left ventricle (Bosch et al., 2017). Formation of hypertrophy acts as a compensatory mechanism so that cardiac output is maintained which needs intervention for rectification otherwise in long-term it can cause impaired cardiac filling and output from the left ventricle is reduced.

Coronary heart disease can cause heart failure in which there is ischemic damage to myocardium which reduces contractility and cardiac output (Bosch et al., 2017). Though arrhythmia is not seen in the present case it is one of the reasons for decreased ventricular filling and reduced ventricular relaxation, in turn, reducing the cardiac output. A physical examination that is seen in patients with left ventricular failure is dilatation of the heart and jugular venous distension which is seen in Russell.

Right-sided heart failure is a consequence of left ventricular failure. The action of the heart is to pump deoxygenated blood which returns to the heart through superior vena cava is poured into right ventricle by right atrium (Miike et al., 2018). Right atrium by the action of pumping transfers this deoxygenated blood to the lung for gaseous exchange. When there is left-sided heart failure there is increased fluid pressure which is passed to the lungs causing pressure on the right side of the heart to fail (Miike et al., 2018). This usually causes oedema in the legs which were seen in the case of Russell and reason for the same is that it is due to the fact that heart failure causes dysfunction of kidneys causing retention of fluid.

Acute Exacerbation of The Chronic Obstructive Pulmonary Disease

In patients who are suffering from the chronic obstructive pulmonary disease may suffer from acute worsening of respiratory symptoms which requires immediate intervention in form of additional therapy and hospitalization is termed as an acute exacerbation of chronic obstructive pulmonary disease (Crisafulli et al., 2018). There has been no exact definition of the term acute exacerbation of chronic obstructive pulmonary disease which has caused implications for the healthcare professionals inappropriate decision-making.

The symptoms of acute exacerbation of chronic obstructive pulmonary disease can include an increase in breathlessness, increased productive cough with characteristics of infection, fever, sleeplessness and edema of feet (Torres et al., 2018). Due to the general compromised state of the patient acute exacerbation of chronic obstructive pulmonary disease has high mortality as there is a rapid decline which is seen. There are less positive health outcomes of the acute exacerbation and treatment modality is mainly aimed towards preventative measures for the patient so that relapse and readmission can be avoided (Crisafulli et al., 2018).

Factors in Case of Russell for Acute Exacerbation of Chronic Obstructive Pulmonary Disorder

In the case of Russell, there are a few factors that can cause acute exacerbation of his respiratory condition. Chronic obstructive pulmonary disease is a progressive condition which does not get reversed after the patient quits the habit (Bragadottir et al., 2018). This alters the functioning and structure of the respiratory mucosa in such a way that it is more prone to infections. This can be attributed to environmental conditions where there can be the presence of allergens, dust or smoke which can trigger acute exacerbation (Colarusso et al., 2017).

Russell has other chronic conditions like hypertension and diabetes. Diabetes is a chronic condition which alters the healing and inflammatory process of the body (Ackerman et al., 2017). The changes in inflammation and healing process can cause an exaggerated reaction to infection which can be seen due to the presence of bacteria or smoke (Rao et al., 2019). The care process changes as the trigger factor are to be identified and appropriate intervention should be provided immediately.

Drugs

Generic name

Perindopril

Spironolactone

Budesonide/ fumarate dehydrate puffs

Drug group

It belongs to the group of drug called angiotensin-converting enzymes inhibitors. It is indicated for the treatment of mild to moderate hypertension and mild to moderate congestive heart failure.

Spironolactone belongs to the group of drug called potassium-sparing diuretic which inhibits the receptors of mineralocorticoids in the distal convoluted tubule. This helps in the promotion of sodium and water removal from the body while doing potassium retention. It is indicated in case of heart failure for the management of edema.

Fumarate dehydrate belongs to the group of drug which is beta2 agonist. It is indicated for the treatment of breathlessness due to asthma and chronic obstructive pulmonary disorder.

Mechanism of action

Angiotensin-converting enzymes have two isoforms which have two domains N and C. N domain is related to hematopoietic stem cell, its differentiation and proliferation while the C domain regulates blood pressure (Ramirez, Sanchez & Sanchez, 2019). The drug binds has more affinity towards the second domain and binds to it which inhibits the conversion of angiotensin one to angiotensin two thereby reduction of blood pressure. The other mechanism is that plasma renin is activated by loss of feedback inhibition mediated by angiotensin two which affects the reflex mechanism by the means of baroreceptors.

Spironolactone acts by inhibiting the action of receptors which are of mineralocorticoids in the distal convoluted tubules. This is accomplished by the promotion of sodium and water removal and potassium retention (Patibandla, Heaton & Kyaw, 2020). The inhibition of the receptors causes an increase in the level of renin and aldosterone in the blood. It acts by inhibiting the aldosterone dependent channels which regulate the exchange of sodium and potassium which are present in the distal convoluted tubule.

There is an abundance of beta2 agonist in bronchial smooth muscles. The drug acts as agonist which stimulates adenylyl cyclase which is responsible for the conversion of ATP to cyclic AMP (Wolthers, 2016). This relaxes the bronchial smooth muscles which help in easing the breathing.

Complications or side effects

In the case of Russell, the most common side effect that can be seen is that there can be difficulty in breathing and joint pains.

The side effect of the drug which is to be considered in case of Russell is that it can cause kidney and liver dysfunction.

The main side effect that can be seen in Russell is the development of cardiac symptoms like hypotension and arrhythmia.

Nursing considerations

The most important nursing consideration is that Russell should be continuously monitored for strained breathing and if required oxygen is administered to the patient.

Nursing consideration is that Russell already has oedema of feet and kidney failure can be exaggerated by the use of spironolactone.

Russell should be continuously monitored by cardiac symptoms like hypotension and arrhythmia by monitoring blood pressure and ECG.

Non-Pharmacological Recommendations

  1. Heart failure- in case of Russell he is suffering from heart failure which is a progressive condition and has a poor prognosis. The main important non-pharmacological intervention is to make sure that the patient is comfortable. The patient is instructed to consume a healthy and well-balanced diet with fluid restriction. The patient is instructed that he should rest more and not undertake any strenuous exercises (Gomes, Pagan & Okoshi, 2019). Administration of oxygen can be done for the patient at the time of sleeping so as to reduce the cardiac workload.

  2. Prevention of exacerbation of chronic obstructive pulmonary disease- one of the main intervention for the prevention of acute exacerbation it is required that the patient is appropriately educated and provide by pulmonary rehabilitation (Safka & McIvor, 2015). Physical activity of the patients suffering from the chronic obstructive pulmonary disease is restricted and as the disease progresses the activity is reduced. The patients are educated regarding the maintenance of muscular patency of respiratory muscles is maintained so that pharmacotherapy is effective (Safka & McIvor, 2015).

  3. Prevention of pneumonia- the patient can be educated regarding the development of pneumonia by the education of patient as well as the patient can be given pneumococcal vaccination. The vaccination contains polysaccharide of 23 subtypes of Streptococcus pneumonia (Currie, 2017). The vaccination is given in the dose of 0.5 ml and is administered intramuscularly. It should be instructed to the patient that there can be redness, inflammation and induration at the site of injection. It is effective in preventing the bacteremia related to pneumococcal pneumonia. Pneumonia can occur due to influenza as well and the patient can be administered vaccination for the same as well (Currie, 2017).

  4. To reduce high cholesterol level- the main non-pharmacological intervention that is seen in the case of Russell is diet alteration. The patient is advised to consume food that has less content of high-density lipoprotein and free fatty acid. If required the patient is referred to dietician and nutritionist (Zhang et al., 2017).

Conclusion

The present report discusses the case of Russell who is an elderly person suffering whose diagnosis is heart failure and he has a medical history of chronic obstructive pulmonary disease. The clinical examination is in consistence with right and left ventricular heart failure wherein the cardiac output is reduced and workload is increased because the heart is working more to meet the metabolic needs of the body. The report also discusses the drugs that are given to the patient in response to his condition and also non-pharmacological management.

References

Ackerman, J. E., Geary, M. B., Orner, C. A., Bawany, F., & Loiselle, A. E. (2017). Obesity/Type II diabetes alters macrophage polarization resulting in a fibrotic tendon healing response. PloS One, 12(7). DOI: 10.1371/journal.pone.0181127.

Bertero, E., & Maack, C. (2018). Metabolic remodelling in heart failure. Nature Reviews Cardiology, 15(8), 457-470. DOI: 10.1038/s41569-018-0044-6.

Bosch, L., Lam, C. S., Gong, L., Chan, S. P., Sim, D., Yeo, D., ... & Richards, A. M. (2017). Right ventricular dysfunction in left‐sided heart failure with preserved versus reduced ejection fraction. European Journal of Heart Failure, 19(12), 1664-1671. DOI: 10.1002/ejhf.873.

Bragadottir, G. H., Halldorsdottir, B. S., Ingadottir, T. S., & Jonsdottir, H. (2018). Patients and families realising their future with chronic obstructive pulmonary disease—A qualitative study. Journal of Clinical Nursing, 27(1-2), 57-64. DOI: 10.1111/jocn.13843.

Colarusso, C., Terlizzi, M., Molino, A., Pinto, A., & Sorrentino, R. (2017). Role of the inflammasome in chronic obstructive pulmonary disease (COPD). Oncotarget, 8(47), 81813. DOI: DOI: 10.18632/oncotarget.17850.

Crisafulli, E., Barbeta, E., Ielpo, A., & Torres, A. (2018). Management of severe acute exacerbations of COPD: an updated narrative review. Multidisciplinary Respiratory Medicine, 13(1), 36. DOI: 10.1186/s40248-018-0149-0.

Currie, G. P. (Ed.). (2017). ABC of COPD. John Wiley & Sons.

Gomes, M. J., Pagan, L. U., & Okoshi, M. P. (2019). Non-Pharmacological Treatment of Cardiovascular Disease| Importance of Physical Exercise. Arquivos Brasileiros De Cardiologia, 113(1), 9-10. DOI: 10.5935/abc.20190118.

Hurtubise, J., McLellan, K., Durr, K., Onasanya, O., Nwabuko, D., & Ndisang, J. F. (2016). The different facets of dyslipidemia and hypertension in atherosclerosis. Current Atherosclerosis Reports, 18(12), 82. DOI: 10.1007/s11883-016-0632-z.

Khachian, A., Seyedoshohadaee, M., Haghani, H., & Aghamohammadi, F. (2016). Family-centered education and self-care behaviors of patients with chronic Heart Failure. Journal of Client-Centered Nursing Care, 2(3), 177-183.

Ledley, G. S., Ahmed, S., Jones, H., Rough, S. J., & Kurnik, P. (2017). Hemodynamics and Heart Failure. In Heart Failure (pp. 27-48). Springer, London. DOI: 10.1007/978-1-4471-4219-5_2.

Miike, H., Ohuchi, H., Suzuki, D., Toyoshima, Y., Morimoto, Y., Negishi, J., ... & Kurosaki, K. (2018). Association of Circulating Blood Volume With Right-Sided Heart Failure Pathophysiology in Adults With Congenital Heart Disease. Circulation, 138(Suppl_1), A12944-A12944.

Patibandla, S., Heaton, J., & Kyaw, H. (2020). Spironolactone. In StatPearls [Internet]. StatPearls Publishing.

Ramirez, A. J., Sanchez, M. J., & Sanchez, R. A. (2019). Diabetic patients with essential hypertension treated with amlodipine: blood pressure and arterial stiffness effects of canagliflozin or perindopril. Journal of Hypertension, 37(3), 636-642. DOI: 10.1097/HJH.0000000000001907.

Rao, D. M., Phan, D. T., Choo, M. J., Weaver, M. R., Oberley-Deegan, R. E., Bowler, R. P., & Gally, F. (2019). Impact of fatty acid binding protein 5-deficiency on COPD exacerbations and cigarette smoke-induced inflammatory response to bacterial infection. Clinical and Translational Medicine, 8(1), 1-11. DOI: 10.1186/s40169-019-0227-8.

Safka, K. A., & McIvor, R. A. (2015). Non-pharmacological management of chronic obstructive pulmonary disease. The Ulster Medical Journal, 84(1), 13.

Sato, Y., Yoshihisa, A., Oikawa, M., Nagai, T., Yoshikawa, T., Saito, Y., ... & Anzai, T. (2019). Prognostic impact of chronic obstructive pulmonary disease on adverse prognosis in hospitalized heart failure patients with preserved ejection fraction–A report from the JASPER registry. Journal of cardiology, 73(6), 459-465. DOI: 10.1016/j.jjcc.2019.01.005.

Torres, A., Crisafulli, E., Barbeta, E., & Ielpo, A. (2018). Management of severe acute exacerbations of COPD: an updated narrative review. Multidisciplinary Respiratory Medicine, 13. DOI: 10.4081/mrm.2018.188.

Wolthers, O. D. (2016). Budesonide+ formoterol fumarate dihydrate for the treatment of asthma. Expert Opinion on Pharmacotherapy, 17(7), 1023-1030. DOI: 10.1517/14656566.2016.1165207.

Zhang, W., Zhang, Y., Li, C. W., Jones, P., Wang, C., & Fan, Y. (2017). Effect of statins on COPD: A meta-analysis of randomized controlled trials. Chest, 152(6), 1159-1168.

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