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This case study describes
about Mr. X, a 76-year-old male patient who presented to emergency department
(ED) at 08:00 hours with complaints of two episodes of chest heaviness in
24-hour duration. He had self-administered glyceryl trinitrate pump spray twice
totaling 800mcg resulting a poor relief. Mr. X who on general assessment
appeared pale, diaphoretic and short of breath upon arrival to the ED was
allocated a bed. The vital signs were checked and recorded — core body temperature of 36.8C (tympanic),
Blood Pressure (BP) 172/86, irregular heart rate of 103 beats per minute (bpm),
respiratory rate of 24 breaths per minute (b/min), oxygen saturation (SPO2) of
97% in room air (RA), and a perfect Glasgow Coma Scale (GCS) score of 15/15
that is, Eye opening response = 4, Verbal response = 5, Motor response =6 (E4V5M6).

The paper attempts to
identify gaps, if any, in the management of the case aforementioned. It further
presents recommendations in accordance with evidence based care so that it will
ease in the process of speedy recovery. In totality, the case study imparts
light on the significance of a comprehensive assessment, appropriate care plan
and evidence based practice in nursing interventions.

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History
collection

The past medical
history of Angina, Non-ST Elevated Myocardial Infarction (NSTEMI), Hypertension
(HTN) and Hypercholesterolemia were documented along with the last intake of
toast and tea at 06:30 hours and 2 episodes of chest heaviness in 24 hours
preceding the admission to ED. Similarly, the case’s allergic reaction to
Amiodarone has been noted down. Amiodarone is classified as a Group III
Antiarrythmic agent.  (Broyles, Reiss,
Evans, Mickenzie, Pleunik, & Page, 2017, p. 443). It is indicated for
severe cases of tachyarrhythmias unresponsive to other treatment, the drug is
partially absorbed post-oral administration with a steady plasma level around
1-2 mcg/ml, is highly protein bound, accumulates in adipose tissue and richly
perfused organs. The first-pass metabolism takes place in the gut wall and/or
in the liver and most of the drug is excreted by biliary excretion. (eMIMS Sign In, 2017)

 Mr. X is reported to have
been on regular medications namely Aspirin 100mg PO OD, Metoprolol 50mg PO OD,
Rosuvastatin 10mg PO OD and Glyceryl Trinitrate pump spray PRN. Beside these
medications, he has also been prescribed administered Aspirin 300mg PO, Morphine
Sulphate IV 2.5mg on 4 occasions PRN, Low Molecular Weight (LMW) Heparin
infusion and Fentanyl 50mcg IV x2 STAT doses post-arrival to the ED. Bryant
& Knights (2017) describes Morphine as an opium alkaloid from natural
sources while Fentanyl as a synthetic product, both of these opioids have
morphine-like agonist effects on opioid (enkephalin) receptors.

Assessment and investigations

The vital signs (BP-172/86 mm of Hg, pulse-103 beats/minute, respiratory
rate-24/minute, core temperature-36.8 degree centigrade, oxygen saturation-97%)
were within normal limit except blood pressure (BP), which was slightly higher
(Systolic BP). The patient reported history of HTN also, that of NSTEMI, Hypercholesterolemia
and Angina. A perfect Glasgow Coma Scale (GCS) score of 15/15 was recorded at
the ED. General physical examination revealed pale appearance, diaphoresis and
shortness of breath. Interpreting Signs and Symptoms, 2018 suggests that MI is a fatal condition where
nausea, vomiting, shortness of breath and diaphoresis take place and, the skin
become cool and pale. The history reported and clinical manifestations
exhibited imply that the case most probably is an MI.

Pathophysiological
Changes

As per the past
history collected, assessments made and the presenting problems described, Mr.
X is shown to have been suffered from MI. The common conditions that affect
half a million Australians is heart attack  (Henry Krum, 2013).. Acute myocardial
infarction (AMI) is referred to the constant and irrevocable cell death in a
part of myocardium, which is due to the loss of blood flow and occurrence of a
severe ischemia in that part. (Mirian
NS, Sedehi M, Kheiri S,Ahmadi A: EBSCOhost,” n.d.)
MI is the most common cause of death in many communities .According to WHO
report, AMI is the leading cause of mortality in the world. (Mirian NS, Sedehi
M, Kheiri S, Ahmadi A: EBSCOhost,” n.d.).

Mr Ferguson
caseis that the gradual development of atherosclerosis formation in the vessels
has increased which leads to obstruction in the blood flow through the vessels.
(Farrell, 2017) . Atherosclerotic plaque rupture promotes atherothrombosis,
vessel occlusion and consequent ischaemic organ damage. This pathophysiological
sequence is the primary cause of acute cardiovascular events (such as
myocardial infarction MI. (Federico Carbone1; Alessio Nencioni1; François Mach; icolas Vuilleumier;
Fabrizio Montecucco, 2013). This obstruction is
leading to decrease in blood supply to the heart muscles. (Farrell, 2017) This
decrease in blood flow causes hypoxia and reduced oxygen demand leads to Angina
(Farrell, 2017). Due to hypoxia Mr ferguson was looking pale and he had
shortness of breath. The moving clot in vessels causes the unstable angina
which gets thrombus permanently later on (due to this reason he had chest
heaviness twice in a day). This leads to necrosis of the organ ending with
myocardial infarction. (Farrell, 2017).  

Pharmacological
Interventions and Nursing Consideration

Aspirin

Aspirin
(acetylsalicylic acid) is a pharmaceutical drug used to reduce pain or
inflammation. It is classified as a non-steroidal anti-inflammatory drug
(NSAID). (“Alcohol &Drug Foundation (ADF) – Drug Facts –
Asprin,” n.d.)

Indications: used in the prevention of blood clots, heart
attacks, strokes and bowel cancer. (“Alcohol &Drug Foundation (ADF) – Drug
Facts – Asprin,” n.d.) Headache with upset stomach; body aches and pain;
neuralgia; sore throat.(“Alka-Seltzer – Full PI,” n.d.)

Pharmacokinetics: Aspirin taken orally is rapidly absorbed, partly
from thestomach,and also from intestine. peak serum levels is reached within
20-40 minutes. Rapid metabolism by tissue and blood esterases occurs ,
hydrolysing aspirin to acetic acid and salicylate;the peak level is reached in
2-4 hours. (Bronwen Bryant,
Kathleen Knights, 2017)Salicylate
is distributed throughout most body tissues and fluids, including synovial
fluid and cerebrospinal fluid, and is 50-90% bound to plasma proteins. It then
undergoes hepatic metabolism to inactive metabolities. The plasma salicylate
level require 100mg/l for anti-inflammatory effects.( this is why mrferguson
was on regular medication as 100mg). higher doses is needed for more
anti-inflammatory effects(Bronwen Bryant,
Kathleen Knights, 2017).(so
he was administered 300mg in emergency department). Diane Brown. (2015)

Adverse
effect:  Rarely, hypersensitivity reactions
(bronchospasm, skin reactions). Very rarely, thrombocytopenia (“Alka-Seltzer –
Full PI,” n.d.).  There is no safe level
of drug use. Use of any drug always carries some risk – even medications can
produce unwanted side effects. It’s important to be careful when taking any
type of drug. (ADF – Drug Facts – Asprin, n.d.) Aspirin affects everyone differently,
based on: Size, weight and health whether the person is used to taking it, whether
other drugs are taken around the same time, the amount taken (ADF – Drug Facts
– Asprin, n.d.)

Nursing
consideration: The effect of
severe overdose of a aspirin can be fatal which can be treated by gastric
lavage and forced alkaline diuresis, with close monitoring of vital functions (Bronwen
Bryant, Kathleen Knights, 2017).
Fluid, electrolyte and acid-base imbalances must be corrected and hyperthermia,
hyperglycemias and hypoglycaemia treated (as Mr. was administered 300mg, he
should be under consideration as mentioned above) (Bronwen Bryant,
Kathleen Knights, 2017)

Metoprolol

Metoprolol
is practically devoid of membrane stabilising activity and does not display
partial agonist activity (i.e. intrinsic sympathomimetic activity = ISA) at
doses required to produce ?-blockade.(“Metrol-XL – Full PI,” n.d.)
?-Adrenergic blockade of the smooth muscle of bronchi
and bronchioles may result in an increased airways resistance.

Indications: Stable, chronic heart failure as an adjunct to other
heart failure therapy.

Pharmacokinetics: rapid disintegration within the gastrointestinal
tract, metoprolol is continuously released for approximately 20 hours, and a
stable metoprolol plasma concentration is achieved over a dosage interval of 24
hours. Approximately 12% of metoprolol is bound to human serum proteins.
Metoprolol undergoes oxidative metabolism in the liver. Over 95% of an oral
dose can be recovered in the urine. Only approximately 5% of the administered
dose is excreted unchanged (“Metrol-XL – Full PI,” n.d.)

Contraindication: ?-blockers are contraindicated in any patient with a
history of airways obstruction or a tendency to bronchospasm. Use of
cardioselective ?-blockers can also result in severe bronchospasm. If such
therapy must be used, great caution should be exercised. Alternative therapy
should be considered. ?-Blockers should not be used in patients with
unstabilised heart failure, severe peripheral arterial circulatory disorders, suspected
acute myocardial infarction with a heart rate of <45 beats/minute, a PR interval of  >0.24 seconds or a
systolic blood pressure of <100 mmHg, and/or moderate to severe noncompensated heart failure and Hypotension. Adverse effect: cold hands and feet, bradycardia, postural disorders, Palpitations, fatigue, dizziness, headache, dyspnoea. Nursing consideration: Tell patient to change position slowly to avoid sudden hypotension. Educate not to discontinue medication so as to avoid precipitate life-threatening arrhythmias, hypertension, or myocardial ischemia, notify if the patient is having adverse reaction signs and educate all the contraindication to the patient and patient relatives as well to prevent from further damage to the body. 3.      Rosuvastatin Rosuvastatin is in a class of medications called HMG-CoA reductase inhibitors (statins). It works by slowing the production of cholesterol in the body to decrease the amount of cholesterol that may build up on the walls of the arteries and block blood flow to the heart, brain, and other parts of the body. Lowering  blood level of cholesterol and fats with rosuvastatin has been shown to prevent heart disease, angina (chest pain), strokes, and heart attacks. Rosuvastatin is also used to decrease the amount of cholesterol such as low-density lipoprotein (LDL) cholesterol ('bad cholesterol') and triglycerides in the blood and to increase the amount of high-density lipoprotein (HDL) cholesterol (also known as good cholesterol) in the blood. Indication: Rosuvastatin is indicated to: reduce the risk of nonfatal myocardial infarction; reduce the risk of nonfatal stroke; reduce the risk of coronary artery revascularisation procedures. Rosuvastatin is indicated for the treatment of hypercholesterolaemia. Contraindication: Known hypersensitivity to any of the ingredients. Patients with active liver disease including unexplained, persistent elevations of serum transaminases, severe renal impairment (APO-Rosuvastatin - Full PI, n.d.) Adverse effects: dizziness, constipation, nausea, abdominal pain. Rarely pancreatitis, myalgia, asthenia Rarely myopathy (including myositis), pruritus, rash, urticarial,  headache.  Some side effects can be serious like muscle pain, tenderness, or weakness, lack of energy, fever, chest pain, yellowing of the skin or eyes, dark coloured urine, pain in the upper right part of the abdomen, nausea, extreme tiredness, weakness, unusual bleeding or bruising, loss of appetite, flu-like symptoms, rash, hives, itching, difficulty breathing or swallowing, swelling (of the face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs), hoarseness.("APO-Rosuvastatin - Full PI," n.d.) Nursing consideration: ask for medical history of allergies .explain the adverse effects of the medication to the patient. If patient have any of the above effects educate to consult the doctors or any health personnel. Explain the patient to take medication as prescribed. 4.      Glyceryl Trinitrate Pump Spray Glyceryl trinitrate, an organic nitrate, is a vasodilator which has effects on both arteries and veins. Nitrolingual Pumpspray is a metered dose spray. Each metered dose of Nitrolingual Pumpspray delivers 400 microgram of glyceryl trinitrate per spray emission. This product delivers glyceryl trinitrate in the form of spray droplets beneath the tongue.(Nitrolingual Pumpspray - Full PI, n.d.) Indication: Treatment of acute angina pectoris, as well as relieving the pain of an acute attack, Nitrolingual Pumpspray may be used prophylactically five to ten minutes prior to engaging in activities which may precipitate an acute attack.(Nitrolingual Pumpspray - Full PI, n.d.) Pharmacokinetics: When administered sublingually, glyceryl trinitrate is rapidly absorbed from the mucosa of the mouth and reaches the vascular system, bypassing the liver. Glyceryl trinitrate is metabolized in the liver. After sublingual administration, a wide range of intraindividual and interindividual variations are observed for the plasma concentration. Plasma protein binding is approximately 60%. Glyceryl trinitrate and its metabolites are principally renally eliminated and less than 1% is excreted unchanged.(Nitrolingual Pumpspray - Full PI, n.d.) Adverse effect: particularly headache and hypotension are generally dose related. Headache is the most commonly reported side effect, but usually subsides with continued use. It may be severe and persistent. Uncommon cases of hypotension, sometimes severe, and/or orthostatic hypotension, possibly associated with reflex tachycardia or paradoxical reflex bradycardia, have been reported when glyceryl trinitrate was used for the first time or the dose was increased. This may  accompanied by a reflex increase in heart rate, somnolence, dizziness and weakness especially on standing.(Nitrolingual Pumpspray - Full PI,  n.d.) Nursing consideration: instruct the patient to use the spray below the tongue. Explain the adverse effect to the patient. Explain the adverse effect for the first time users separately and see if they havr any adverse effects. If the reaction is seen stop the medication and alternative management must be done. 5.      Morphine sulphate Morphine is the principal alkaloid of opium. Morphine acts as an agonist, binding to receptors in the brain, spinal cord and other tissues. Morphine exerts its primary effects in the central nervous system and organs containing smooth muscle. Indications: morphine sulfate is indicated for the relief of moderate to severe pain not responsive to nonopioid analgesics. It may also be used as a preoperative medication and as an analgesic adjunct in general anaesthesia.("DBL Morphine Sulfate Injection BP - Full PI," n.d.) Pharmacokinetics: Peak analgesia occurs within 20 minutes after intravenous administration. Morphine is distributed throughout the body, but particularly to parenchymatous tissue such as kidney, lung, liver and spleen. About 35% is protein bound, mainly to albumin. Morphine is metabolised principally in the liver by conjugation with glucuronic acid. Elimination half-life from serum is approximately 1.5 to 2 hours in healthy subjects and 90% of the dose is recovered in urine within 24 hours. Approximately 7 to 10% of the dose is recovered in faeces, the majority after conjugation and excretion via bile.(DBL Morphine Sulfate Injection BP - Full PI, n.d.) Adverse effect: Constipation, light headedness, dizziness, sedation, nausea, vomiting, sweating, dysphoria and euphoria are the common adverse effects. (DBL Morphine Sulfate Injection BP - Full PI, n.d.) Interaction:  Morphine may increase the activity of anticoagulant medication. The combination of morphine and propranolol is potentially lethal as it increases the acute CNS toxicity of morphine. Since Mr. X is under different medication that interact with morphine like metoprolol, while administering medication all the cautions should be maintained (DBL Morphine Sulfate Injection BP - Full PI, n.d.) Nursing consideration: Morphine must not be administered in empty stomach to minimize any gastric irritation. Discontinuation of the drug should be done gradually to prevent withdrawal symptom after long-term use. Patient must be advised to increase their fluid intake so as to avoid and manage constipation. Any sign and symptoms of adverse effects must be notified by the patient or nurses should observe the patient carefully. 6.      Low molecular weight Heparin (LMWH) infusion LMWH is the anticoagulant as well as antithrombotic agent. It has several actions on the coagulation pathway through binding to antithrombin III. The antithrombotic activity is related to inhibition of thrombin generation and inhibition of two main coagulation factors: factor Xa and thrombin (Clexane and Clexane Forte - Full PI, n.d.) Pharmacokinetics: the drug in subcutaneous (SC) injection is rapidly and completely absorbed with the bioavailability over 90%. The maximum plasma activity is observed after 3 hours. Metabolic breakdown is slight and takes place mainly in the liver. However, the kidneys may slightly eliminate the product in an intact or slightly degraded form. (Clexane and Clexane Forte - Full PI, n.d.) Interactions: Does not show adverse reaction when infused with thrombolytic agents. (Clexane and Clexane Forte - Full PI, n.d.) Adverse effect: most common one is thrombocytopenia. Other adverse reactions may include anaemia, asymptomatic and reversible increases in the levels of liver enzymes erythema, hematoma and pain in the injection site. (Clexane and Clexane Forte - Full PI, n.d.) Nursing consideration: As bleeding is common side effects of LMWH the signs of bleeding must be watched very carefully. Patient must be advised the importance for frequent laboratory monitoring. Advise patient regarding diet, particularly for foods that contain vitamin K. The patient does not need to avoid foods rich in vitamin K, but the patient must be consistent with consumption habits. (Clexane and Clexane Forte - Full PI, n.d.) 7.      Fentanyl Fentanyl is an opioid analgesic. The principal actions of therapeutic value are analgesia and sedation (Aspen Fentanyl - Full PI, n.d.) Pharmacokinetics: The onset of action is almost immediate when the drug is given intravenously; however, the maximal analgesic and respiratory depressant effect may not be noted for several minutes. The usual duration of action of the analgesic effect is 30 to 60 minutes after a single intravenous dose of up to 100 microgram (Mr. X had start dose of 50mcg the duration of action for him will be half an hour to an hour). It accumulates in skeletal muscle and fat, and is released slowly into the blood (Aspen Fentanyl - Full PI, n.d.). Almost 75% secrets in urine and 9% in faeces (Aspen Fentanyl - Full PI, n.d.) Interaction: Central nervous system (CNS) depressants (barbiturates, tranquilizers) will have an additive or potentiating effects when given with fentanyl. Fentanyl decreases pulmonary arterial pressure when used with neuroleptic (droperidol) drugs. (Aspen Fentanyl - Full PI, n.d.) Adverse effects: Respiratory depression, apnoea, muscular rigidity, myoclonic movements and bradycardia. If these remain untreated, respiratory arrest, circulatory depression or cardiac arrest could occur (Aspen Fentanyl - Full PI, n.d.) Nursing considerations: Monitoring vital signs and observing patient for signs of skeletal and thoracic muscle (depressed respirations) rigidity and weakness. Report immediately if signs of respiratory depression and for movements of various groups of skeletal muscle in extremities, external eye, and neck during postoperative period (Aspen Fentanyl - Full PI, n.d.) Nursing management  According to Diane Brown, 2015 nursing management strategies for MI cases include obtaining frequent vital signs along with continuous monitoring and use of 12-leads Electrocardiogram (ECG), auscultation of heart and breath sounds to check if they are normal and regular, assessment of the oxygenation status and saturation level. Similarly, the patient needs to be asked to describe pain and rate it on a pain scale of 0-10. And, sources of worry (anxiety) have to be ruled out and minimized accordingly.   Reflection and Recommendations There are few gaps in the case of Mr. X: a) duplication of opioid analgesics (Morphine sulphate and Fentanyl) for which one of these two can be administered as elaborated earlier. b) Health education must be an integral part of any care plan which must involve the family members and patient both for better understanding and management. Ghisi, Abdallah, Grace, Thomas & Oh, 2018 supports that educational interventions are helpful in the people with heart diseases through a rise in patient's knowledge level and behavioral modification. Patient education, therefore, must be included in the hospital care plan in hospital. Brørs, Norekvål, Skotnes, Romild & Fridlund, 2018 emphasizes on the cumulative effect on self-care behavior as a result of counseling from a nurse coupled with usual care of MI. The behavior changes in self-management as stated can be observed during the follow ups. Hence, it recommends counseling as well along with the usual care strategies for MI cases.  A heedful monitoring of the cases with MI, and their management through programs focused on preventive strategies is recommended, especially for high-risk of recurrent ischemic attacks. (Jernberg et al., 2018) 

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