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Nursing Practice 3 - Pathophysiology and Pharmacology Applied to Nursing

Table of Contents

Case Study of Russell Medical Condition.

Introduction.

Case Scenario analysis.

Risk factors for developing heart failure.

Pathophysiology of right and left sided heart failure.

Acute exacerbation of chronic obstructive pulmonary disease.

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

Medications.

Non pharmacological recommendations for various conditions.

To prevent heart failure.

To prevent exacerbation of chronic obstructive pulmonary disease.

To prevent pneumonia.

To reduce cholesterol level

References.

Introduction to Russell's Medical Condition

In the study the case scenario of Russell, age 68 have been discussed. He is suffering from Chronic obstructive pulmonary disease (COPD) from past 30 years. He has got medical conditions like high blood pressure, diabetes and cholesterol. COPD is lung disease where the person experiences difficulty in breathing due to blockage of their air flow to the lungs. The patient also has a history of heart attack. After examining him the doctors have confirmed that Russell have developed heart failure. Here his health and the risk factors, pharmacological and no pharmacological approaches along with his medication have been analysed so that his condition can be improved.

Case Scenario Analysis of Russell's Medical Condition

Risk Factors for Developing Heart Failure

The heart failure involves risk factors such as high blood pressure, coronary artery disease and heart attack. Heart failure is most common in elderly people over age 65. Heart failure risk increases with advancing age so Russell age factor is also one of the causes. With increase in age heart loses its ability to pump blood and addition of the stress in such situation worsen it more. Males are at greater risk of heart failure than females. People with a family history of heart muscle damaging diseases have an increased risk of developing heart failure. Smoking, sedentary lifestyle, obesity, high-cholesterol and fat food, physical inactivity, alcohol and drug abuse can increase the risk of heart failure. Heart failure is a serious, long-term (chronic) condition and all the above factors cause wear and tear to the heart. Russell is having cholesterol problems which leads to deposition of cholesterol or fat on the arteries forming plaque. The plaque formation obstructs the blood flow in the arteries leading to chest pain and heart attack. Past heart attack history of Russell makes it clear that his heart muscles are already damaged. Another major risk factor for Russell is his high blood pressure. The pressure of blood more than the normal makes the heart to pump harder to keep on circulating the blood. The heart valves and chamber become weak due to the added work pressure on them. Abnormal opening and closing of valves add on more and heart failure takes place.Heart muscle disease like cardiomyopathy or inflammation (myocarditis) increases the risk of heart failure. Diabetes also raises the risk of heart failure. Diabetes patients continue to develop hypertension and atherosclerosis from elevated blood lipid levels. Hypertension and atherosclerosis both were associated with heart failure.

Pathophysiology of Right and Left Sided Heart Failure

Russell clinical observations showed the heart rate is 90 beats per minute which is normal. His blood pressure was observed to be 150/90 mm Hg. The respiratory rate of Russell was 26 breath per minute. His jugular venous pressure was slighted elevated. The doctor has examined him and confirmed that he has developed heart failure. He was asked to undergo various biochemical tests, chest x ray and echocardiogram. The chest X- ray showed an increase in cardiothoracic ratio and obliteration of cardiophernic and costophrenic angles in the lung fields. This conclude that Russell had pulmonary oedema and heart failure. The echocardiogram results proved that Russell left ventricle have dilated and 25% of severe systolic dysfunction has happened to the left side of the heart.

Left sided heart failure is caused by hypertension and Russell is suffering from it. The left heart ventricle is the main pumping chamber of the heart. Russell’s left ventricle are dilated that means the ventricle get stretched and do not efficiently pump blood. This abnormality of heart muscle is termed as cardiomyopathy. In this condition the heart valves do not get closed properly which leads to backflow of blood. The hypertension increases the workload of the heart and its cardiac output which leads to the hypertrophy of the left ventricle. The hypertrophy formation helps in maintaining the cardiac output. This condition needs to be checked in the patient as it will lead to disturbance in cardiac filling and the output from the left ventricle. Also, the condition cause fluid build-up in lungs, legs and feet, which was seen in case of Russell as well.

Right ventricular failure is determined by a systemic congestion which is due to backward failure. The right heart dilates and there is compromise in left ventricle filling. This reduces the left ventricle performance and causes a forward failure. Once the systemic congestion happens because of the heart failure there is association between failures of hepatic, renal and gastrointestinal functions. The right ventricle failure also causes respiratory distress. Most of the time the right ventricle failure follows existing or the new pulmonary diseases or cardiac diseases.

Acute Exacerbation of Chronic Obstructive Pulmonary Disease

 This is a condition where sudden worsening of symptoms of pulmonary disease occur and chances of rupture of airways of lungs. There is marked inflammation in the airways and obstruction in the airflow. Since the condition become very severe and intense in terms of patient health status so the term Acute exacerbation of chronic obstructive pulmonary disease is given. The symptoms of COPD including uneasiness and shortness of breath. The patient experiences increase severe frequent coughing with change in appearance of sputum. When the situation worsens the patient experiences congestion, discomfort and wheezing or a squeaky sound while sleeping. The infection can be caused by bacteria or viruses or also it can be due to environment pollutants. lungs are the most vulnerable organs, exposure of the lungs to harmful particles can cause an exacerbation of COPD. Allergens like pollen and smoking can aggravate the situation further in the patient. During the exacerbation, airway inflammation increases, the expiration air flow decreases and hence it leads to reduced exchange of gases. The half of COPD exacerbations are due to respiratory infections (National Heart, Lung, and Blood Institute, 2020).

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

Russell current condition have many risk factors which makes him on high risk for developing acute exacerbation of chronic obstructive pulmonary disorder. Any pulmonary infections do not get reversed even if the patient quit smoking or any other habit related to the increase in infection. Russell is a truck driver and his occupation makes him get exposed to the pollutants, allergens and dust. Pollutants and any chemical exposure can cause inflammation of the pulmonary tract, leading generation of mucus due to inflammation (American Lung Association, 2020). The inflammation of the pulmonary tract makes it more prone in catching other types of infections. Russell have other health problems like high cholesterol and diabetes. Diabetes is a chronic condition and it can be an obstacle in healing of inflammation in the pulmonary disorder. Russell condition should be studied and he should be counselled on the trigger factors of acute COPD.

Medications 

Generic name

Perindopril

Spironolactone

Budesonide/Fumarate dehydrate puffs

Drug group

 It belongs to the class of Angiotensin converting enzyme inhibitors

It belongs to the class of Aldosterone receptor antagonists.

Budesonide is a corticosteroids. Formoterol belongs to the class of drugs known as long-acting beta agonists.

Mechanism of action

This drug relaxes and widens the blood vessels. It lowers the blood pressure and helps heart to pump blood to body smoothly. It is mainly responsible for the conversion of angiotensin I (ATI) to angiotensin II (ATII). ATII regulates blood pressure. It is a key component of the renin-angiotensin-aldosterone system (RAAS).

Spironolactone competitively inhibits aldosterone dependant sodium potassium exchange channels in the distal convoluted tubule. This action leads to increased sodium and water excretion, but more potassium retention. The increased excretion of water leads to diuretic and also antihypertensive effects.

Budesonide is an inhaled corticosteroid (ICS) that works by reducing and preventing respiratory tract inflammation, while formoterol is a long-acting beta2-agonist bronchodilator (LABA) that decreases resistance in the respiratory airway and increases airflow to the lungs.

Complications/side effects

The most likely symptom of this drug is severe hypotension. The other common side effects could be difficulty in breathing and joint pains.

The side effect in case of Russell could be
drowsiness, mental confusion, kidney and liver dysfunction.

· The side effect of this drug can lead to stuffy nose, muscle or joint pain, or changes in your voice.

Nursing considerations

The consideration for Russell with this drug is to keep a check on his breathing pattern and if required oxygen has to be provided externally.

Russell have to be carefully checked for his edema, and mobilization of edema fluid.

Cardiac symptoms and hypertension have to be monitored in Russell. A regular monitor of blood pressure and ECG is required.

Non Pharmacological Recommendations for Various Conditions

Non-pharmacological therapy provides symptomatic improvement and better quality of life as there is no medication or surgical procedures required.

To prevent heart failure.

Russell suffers from heart failure so he has to follow the pharmacological and non-pharmacological recommendations religiously. Dietary habits have to regulated like consumption of the amount of salt in the diet. The amount less than 2,000mg is relevant in patients with heart failure (Konerman &  Hummel, 2015). Alcohol consumption must be prohibited in high risk patients as Russell has become now after the second heart attack encounter. He cannot have moderate levels of alcohol now. Nutritional advice for heart failure patients includes reduction of weight if they are obese and avoid malnourishment. The patients with heart failure are advised not to exercise and exert as this can lead to deterioration. If the heart failure patient is in stable condition, the patient should be encouraged to conduct routine activities and can do mild physical activities in their free time. Smoking is always discouraged. Patients are advised to keep a check on their weight and if sudden unexpected gain in weight is observed they needs to consult a doctor.

To prevent exacerbation of chronic obstructive pulmonary disease.

Non-pharmacological approaches like cessation of smoking and oxygen administration will extend the life expectancy. Administration of oxygen can be done for the patient at the time of sleeping so as to reduce the cardiac workload. In patients with very severe illness, Exercise is unwarranted and everyday life tasks are designed in such a way that they reduce the energy expenditure. For example, patients can stay in single storey house, avoid climbing on stairs. Several small meals can be taken instead of few large meals. (Pleguezuelos et al, 2017).

To prevent pneumonia.

Vaccines are known to prevent infectious disease and there are vaccines available for treatment of pneumonia. Hand hygiene is also very important in prevention of the disease. Another big risk factor responsible for spread of pneumococcal infections is smoking. Russell was a chain smoker before his heart attack so he has to avoid smoking in future as well. There are studies which shows the consumption of vitamin C through diet also decrease the risk of pneumonia (Hemilä & Louhiala, 2013) Russell also needs to be careful during his hospital visits as he has chance of getting hospital acquired pneumococcal infections.

To reduce cholesterol level

Dietary modification is considered a powerful non-pharmacological approach to improve blood lipids, since Russell has high cholesterol. If required Russell can also consult a nutritionist or dietician. In addition to diet management, physical exercise can either actively boost lipid profiles by lowering body weight or indirectly by decreasing body weight. Physical activity has also been shown to help reduce LDL cholesterol levels by 15-20 percent. Both dietary and exercise regimens can therefore help to regulate LDL cholesterol (Singh & Devi, 2017).

References for Russell's Medical Condition Case Study

Pleguezuelos, E. & Miravitlles M. (2017). Prescription of physical activity in chronic obstructive pulmonary disease… and beyond. Medicina Clinica (Barc). 149(1), 24-25. doi: 10.1016/j.medcli.2016.12.014.

Singh, M. M. & Devi, R. (2017). Intensive cholesterol control in high risk patients can reduce cardiovascular events by 20%. BMJ , 358 doi: https://doi.org/10.1136/bmj.j4040

Hemilä, H. & Louhiala P (2013). Vitamin C for preventing and treating pneumonia. The Cochrane Database of Systematic Reviews (8): CD005532. doi:10.1002/14651858.CD005532.pub3

 Konerman, M. C. &  Hummel, S. L. (2014). Sodium Restriction in Heart Failure: Benefit or Harm? Current Treatment Options in Cardiovascular Medicine. 16(2), 286. doi: 10.1007/s11936-013-0286-x

American Lung Association, (2020). COPD Causes and Risk Factors. Retrieved from https://www.lung.org/lung-health-diseases/lung-disease-lookup/copd/what-causes-copd

(National Heart, Lung, and Blood Institute, 2020). COPD. Retrieved from https://www.nhlbi.nih.gov/health-topics/copd

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.

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