High Dependency and Emergency

Question-1- (a) The above-mentioned ECG strip represents atrial fibrillation. It is a common form of observed cardiac arrhythmia, which is represented by a loss of “P-wave” in the ECG strip. It is marked by an irregular and rapid heartbeat or heart rate (Freedman, 2016). This condition can increase the chances of development of stroke in an individual and can also cause further heart-related complications. The cardiac arrhythmia in atrial fibrillation is found to be caused by irregularity in the flow of atriums or upper chambers of the heart. These chambers do not attain pumping action in sync with the lower chambers or ventricles of the heart and thus, creating an emergent situation for the patient. Missed or rapid conduction in the upper chambers of the heart, brings about an added pressure on the heart vessels and thus, repetition of this phenomenon can cause life-threatening condition for the patient as well (Staerk, 2017). If atrial fibrillation goes untreated, it can lead to clot formation in the upper chambers of heart, which is well-connected with some of the major arteries in the body. This can cause blood flow obstruction and ischemia in various organs of the body.

(b) There are multiple reasons for development of atrial fibrillation. Three of the main attributing reasons can be as enlisted below:

  • Age- As the age of the person progresses the chances of development of atrial fibrillation. In older patients, the chances of getting atrial fibrillation also increases by multiple folds, as the underlying risk factors increases (Chao, 2018). The patient in the given case study is 69-years-old, thus, the risk of developing atrial fibrillation in this case is quite obvious.
  • Having a history of coronary artery disease or any heart-related condition- Various heart conditions have been directly found to be associated with developing atrial fibrillation. Some of the common heart conditions attributing to formation of atrial fibrillation include history of heart attack, history of heart surgery, medical history of congenital heart disease, medical history of congestive heart failure, heart problems related to valvular disorders as well (Ramkumar, 2017). All of these conditions cumulatively attribute to increasing the risk of atrial fibrillation.
  • Chronic conditions- Chronic conditions are found to have an overall detrimental effect on the individuals suffering from the same. These chronic conditions are also found to have a direct impact on the life-expectancy of a person. Various chronic conditions have been found to be directly associated with increasing the risk of development of atrial fibrillation in the people suffering from the same. These few conditions include thyroid problems, metabolic syndromes, chronic kidney diseases, lung diseases, diabetes and so on (Choi, 2019).

(c) The treatment options of atrial fibrillation can be in multiple forms. Some of the commonly used methods are as mentioned-below:

  • Cardioversion- For managing atrial fibrillation, two methods can be used to deliver cardioversion to the patient. in this procedure and electric shock is given to the heart to stop its activity for a short period. Cardioversion can be given through an electric stimulation as well as through the medium of drugs. The medication can be administered either through IV method or via oral route (Plitt, 2016).
  • Medical management- Various medications can also be used to regularize the heart beat in atrial fibrillation. Some of the commonly used drugs include digoxin, beta-blockers and calcium channel blockers. Digoxin is used to maintain the heart rate of the patient, which mainly rises during any activity (Lopes, 2018). Beta blockers are used to lower the resting as well as activity heart rate of the person. However, the patient has to be dully monitored for signs such as hypotension (lowered blood pressure). Calcium channel blockers help in regulating heart rate by preventing any chances of heart failure to the patient.
  • Surgical intervention- It can be a primary choice of treatment for patients who are severely affected by this condition and are experiencing rapid episodic event of atrial fibrillation quite often. Some of these procedures include Catheter ablation, Maze procedure and Atrioventricular node ablation. Catheter ablation is mainly carried out by the means of inserting a thin tube in the effected artery and destroying the hampered tissue area responsible for causing atrial fibrillation. Maze procedure can be considered as another type of ablation procedure. Generally, a surgeon prepares a mesh work and places it over the defective area. The success rate of this procedure is found to be highest in patients, set aside from all other surgical interventions. AV node ablation is done mainly targeting the AV node, which is responsible for ensuring rhythmic conduction of heart rate in a person (Romero, 2017).

Question-2 (a) The arterial blood gas analysis of the patient indicates respiratory acidosis. Respiratory acidosis is marked by respiratory insufficiency in the patient. This insufficiency brings about a hampered potential of the patient to evacuate out carbon dioxide from the lings. The increase in the value of partial level of carbon dioxide in blood and low pH indicates an acidic nature of blood developing in the body. The pH of the blood is supposed to be maintained at a neutral value so that proper gaseous exchange can be executed by the lungs and thus, maintaining a normal inspiration and expiration ratio. Acidosis in blood in indicated in blood with a pH value below 7.35. Respiratory acidosis can lead to the patient developing a ventilatory failure (González, 2018). Due to increased value of carbon dioxide, they can get mixed in the lungs through ventilation process and not get adequately flushed out of the system, leading to carbon dioxide toxicity. Pulmonary edema in the lungs is marked by fluid filled in air passages of lungs due to gaseous exchange abnormality. This condition can be both acute and chronic. The condition of pulmonary edema can be directly associated with respiratory acidosis as there is a major imbalance in the gaseous exchange. With respiratory failure occurring in respiratory acidosis, the patient can develop acute pulmonary edema as well (Belenguer, 2017).

(b) Acute pulmonary edema in the lungs can be marked by a rapid fluid buildup in the lungs. This fluid is generally filled in lower passages such as alveoli and interstitium. This further hampers with the pulmonary circulation in the lungs (Bhattacharya, 2016). With the slow progressive building up of fluid the air passages further constrict and thus, decreasing the lungs’ capacity for adequate gaseous exchange and reduced lung compliance as well. This can also accumulate in the patient causing symptoms such as hypoxia and dyspnoea. Acute pulmonary edema can be cardiogenic in nature or non-cardiogenic. Cardiogenic acute pulmonary edema can be reflected in the patient in terms of reduced cardiac output, whereas, non-cardiogenic acute pulmonary edema can be reflected as the patient having reduced vascular permeability.

(c) The treatment of patient having acute pulmonary edema can be as follow:

  • Medical management- The condition can be treated with various drug class. Some of the drug classes that can be considered in this case are as mentioned below with the define rationale:
  1. Morphine- The patient is having severe shortness of breath; however, the percentage of oxygen saturation is not that alarmingly low. The patient can be provided with morphine, as it helps in relieving shortness of breath and anxiety of the patient (Gil, 2019). This will be helpful in restoring a sense of calmness in the patient. The same will also be helpful in lowering his heart rate.
  2. Diuretics- The diuretics medications will be helpful in lowering the accumulated excess fluid in the lungs and pulmonary spaces. This will help with smooth facilitation and promotion of proper ventilation in the air spaces. This group of medication can be directly helpful in lowering the impact of episode of acute pulmonary edema in the patient (Agrawal, 2016).
  3. Medications for managing blood pressure- The patient in the given case study is having a high blood pressure reading of 170/80mm Hg. These group of medications include medications such as calcium channel blockers, beta-blockers and so on. These medications help in reducing the preload on the heart and thus, lowers the implications of high blood pressure on the heart and bodily functions as well (Pascual, 2016). This will evidently be helpful in reducing the pulmonary edema as well.

Nursing interventions- The nurses can cater to the medical needs of this patient in the following ways:

  1. Provide patient with supplement oxygen as and when indicated. The oxygen can also be provided to the patient for managing his shortness of breath and reducing his anxiety and stress.
  2. Maintaining the supply of diuretics, till the fluid accumulation in the body lowers down.
  3. Monitoring the fluid and electrolyte imbalance in the patient (Assaad, 2018).
  4. Managing preload and afterload, to manage the anxiety and stress.
  5. Vitals monitoring of the patient, every hourly should be done to note for any fluctuation in the same. These vitals can be heart rate, blood pressure, respiratory rate, urine output and so on.

Question-3 (a) A secondary survey of the patient is generally conducted when all potential life-threatening conditions are avoided. A composite assessment of the patient is carried out in this method. The various aspects that are covered in this condition include the following:

  • Vital signs- The vital monitoring of the patient gives a very clear picture of the current medical condition the patient might be in. main vitals to be noted in this case scenario, include, heart rate, blood pressure, respiratory rate, urine analysis, arterial blood gas analysis etc. (Cardona, 2016).
  • Providing comfort- It can be given in the form of reassurance to the patient, helping him with his stress and anxiety. Medications also play a vital role in this process. However, the nurse is required to have a good clinical judgement and decision-making to make sure that wrong medication is not administered to the patient (Lee, 2020). This can increase the already established adversity of the condition. The nurse should be cautious about any potential drug interaction.
  • History taking- This process involves taking detailed history of the patient from head to toe, covering all of the major body parts. In the given case study, head/neck can be assessed for the use of accessory muscles as a compensation for managing shortness of breath. Chest can be noted for any abnormal breathing pattern or deformity, such as pigeon-chest, barrel-chest, formed in compensation for respiratory loss. Extremities and skin can be evaluated for abnormal discoloration and capillary filling (Moinzadeh, 2018). The extremities can also be palpated for presence and absence of peripheral pulses, which can be due to increased swelling caused in the extremities due to underlying pulmonary edema. The temperature of the extremities can also be monitored to keep a close watch on the hampered circulation in the body.

(b) The three common respiratory signs that can be observed in the patient in the given case scenario include:

  • Shortness of breath- This is caused by airflow obstruction, brought by progressive inflammation of the air passages over the due course of time. this obstruction of airflow is caused by pulmonary edema (Kumar, 2019). If the same progresses to an advanced stage, the condition can cause irreversible damages to the patient. It can also hamper the overall functioning of the body systems.
  • Increased blood pressure- The rise in blood pressure can exert and additional pressure on the smaller arteries of the body. The situation can be alarming for the patient, is left untreated.
  • Increased respiratory rate- The increased respiratory rate can be due to a compensatory mechanism for the stress and anxiety experienced by the patient. The increased respiratory rate can also be observed, to compensate for the shortness of breath experienced by the patient (Benke, 2017).

The patient in the given case study should be monitored on an hourly basis for vitals such as heart rate, respiratory rate, blood pressure, blood oxygen saturation etc. The lab test of arterial blood gas analysis should also be done, to keep a close vigil on the gaseous abnormality (Fanari, 2019). This will be helpful in altering the dose of medication and oxygen supplement to be provided to the patient. Blood pressure readings are to be monitored specifically to this case, as the readings will be helpful in altering the dosage of diuretics in the patient, used for managing acute pulmonary edema.

References for Mr. Curtis Case Study

Agrawal, N., Kumar, A., Aggarwal, P., & Jamshed, N. (2016). Sympathetic crashing acute pulmonary edema. Indian Journal of Critical Care Medicine: Peer-Reviewed, Official Publication of Indian Society of Critical Care Medicine20(12), 719. https://dx.doi.org/10.4103%2F0972-5229.195710

Assaad, S., Kratzert, W. B., Shelley, B., Friedman, M. B., & Perrino Jr, A. (2018). Assessment of pulmonary edema: Principles and practice. Journal of Cardiothoracic and Vascular Anesthesia32(2), 901-914. https://doi.org/10.1053/j.jvca.2017.08.028

Belenguer-Muncharaz, A., Mateu-Campos, L., González-Luís, R., Vidal-Tegedor, B., Ferrándiz-Sellés, A., Árguedas-Cervera, J., ... & Moreno-Clarí, E. (2017). Non-invasive mechanical ventilation versus continuous positive airway pressure relating to cardiogenic pulmonary edema in an intensive care unit. Archivos De Bronconeumología53(10), 561-567. https://doi.org/10.1016/j.arbres.2017.02.005

Benke, C., Hamm, A. O., & Pané‐Farré, C. A. (2017). When dyspnea gets worse: Suffocation fear and the dynamics of defensive respiratory responses to increasing interoceptive threat. Psychophysiology54(9), 1266-1283. https://doi.org/10.1111/psyp.12881

Bhattacharya, M., Kallet, R. H., Ware, L. B., & Matthay, M. A. (2016). Negative-pressure pulmonary edema. Chest150(4), 927-933. https://doi.org/10.1016/j.chest.2016.03.043

Cardona-Morrell, M., Prgomet, M., Lake, R., Nicholson, M., Harrison, R., Long, J., ... & Hillman, K. (2016). Vital signs monitoring and nurse–patient interaction: A qualitative observational study of hospital practice. International Journal of Nursing Studies56, 9-16. https://doi.org/10.1016/j.ijnurstu.2015.12.007

Chao, T. F., Lip, G. Y., Liu, C. J., Lin, Y. J., Chang, S. L., Lo, L. W., ... & Chen, T. J. (2018). Relationship of aging and incident comorbidities to stroke risk in patients with atrial fibrillation. Journal of the American College of Cardiology71(2), 122-132. https://doi.org/10.1016/j.jacc.2017.10.085.

Choi, E. K., Han, K. D., Lee, E. J., Lee, S. R., Cha, M. J., & Oh, S. (2019). Association of metabolic syndrome and chronic kidney disease with atrial fibrillation: a nationwide population-based study in Korea. Diabetes Research and Clinical Practice148, 14-22. https://doi.org/10.1016/j.diabres.2018.12.004

Fanari, Z., Mohammed, A. A., Bathina, J. D., Hodges, D. T., Doorey, K., Gagliano, N., ... & Doorey, A. J. (2019). Inadequacy of pulse oximetry in the catheterization laboratory. An exploratory study monitoring respiratory status using arterial blood gases during cardiac catheterization with conscious sedation. Cardiovascular Revascularization Medicine20(6), 461-467. https://doi.org/10.1016/j.carrev.2018.07.027.

Freedman, B., Potpara, T. S., & Lip, G. Y. (2016). Stroke prevention in atrial fibrillation. The Lancet388(10046), 806-817. https://doi.org/10.1016/S0140-6736(16)31257-0

Gil, V., Domínguez-Rodríguez, A., Masip, J., Peacock, W. F., & Miró, Ò. (2019). Morphine use in the treatment of acute cardiogenic pulmonary edema and its effects on patient outcome: A systematic review. Current Heart Failure Reports16(4), 81-88. https://doi.org/10.1007/s11897-019-00427-0

González, S. B., Menga, G., Raimondi, G. A., Tighiouart, H., Adrogué, H. J., & Madias, N. E. (2018). Secondary response to chronic respiratory acidosis in humans: a prospective study. Kidney International Reports3(5), 1163-1170. https://doi.org/10.1016/j.ekir.2018.06.001

Kumar, M., & Thompson, P. D. (2019). A literature review of immersion pulmonary edema. The Physician and Sports Medicine47(2), 148-151. https://doi.org/10.1080/00913847.2018.1546104

Lee, K., & Kim, S. H. (2020). Patients' and nurses' perceptions of what constitutes good nursing care: An integrative review. Research and Theory for Nursing Practice34(2), 144-169. https://doi.org/10.1891/RTNP-D-19-00070

Lopes, R. D., Rordorf, R., De Ferrari, G. M., Leonardi, S., Thomas, L., Wojdyla, D. M., ... & Hanna, M. (2018). Digoxin and mortality in patients with atrial fibrillation. Journal of the American College of Cardiology71(10), 1063-1074. https://doi.org/10.1016/j.jacc.2017.12.060

Moinzadeh, A. T., De Moor, R. J., & De Bruyne, M. A. (2018). Influence of a calcium hydroxide-based intracanal dressing on the quality of the root canal filling assessed by capillary flow porometry. Clinical Oral Investigations22(4), 1733-1739. https://doi.org/10.1007/s00784-017-2267-z

Pascual, I., Moris, C., & Avanzas, P. (2016). Beta-blockers and calcium channel blockers: first line agents. Cardiovascular Drugs and Therapy30(4), 357-365. https://doi.org/10.1007/s10557-016-6682-1

Plitt, A., Ezekowitz, M. D., De Caterina, R., Nordio, F., Peterson, N., Giugliano, R. P., & ENGAGE AF‐TIMI 48 Investigators. (2016). Cardioversion of atrial fibrillation in ENGAGE AF‐TIMI 48. Clinical Cardiology39(6), 345. https://dx.doi.org/10.1002%2Fclc.22537

Ramkumar, S., Yang, H., Wang, Y., Nolan, M., Negishi, K., Sanders, P., & Marwick, T. H. (2017). Relation of functional status to risk of development of atrial fibrillation. The American Journal of Cardiology119(4), 572-578. https://doi.org/10.1016/j.amjcard.2016.10.043

Romero, J., Kumar, S., Akira, F., Briceño, D. F., Tedrow, U. B., Epstein, L., ... & Michaud, G. F. (2017). Emergence of atrioventricular nodal reentry tachycardia after surgical or catheter ablation for atrial fibrillation: Are we creating the arrhythmia substrate?. Heart Rhythm14(11), 1637-1646. https://doi.org/10.1016/j.hrthm.2017.08.002

Staerk, L., Sherer, J. A., Ko, D., Benjamin, E. J., & Helm, R. H. (2017). Atrial fibrillation: epidemiology, pathophysiology, and clinical outcomes. Circulation Research120(9), 1501-1517. https://doi.org/10.1161/CIRCRESAHA.117.309732

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