Pathophysiology

This is a case of Mr. Ferguson, a 75-year-old man who presents to an emergency department at 0800hrs. He was complaining of two chest heaviness in the last 24 hours. He however had self-administered 800mcg of glyceryl trinitrate pump spray which is equivalent. Mr. Ferguson seems pale, short of breath and diaphoretic. He has a past medical of Angina, non ST elevated myocardial infarction (1998&2006), hypertension and hypocholestoremia. The following discussion presents Mr. Ferguson’s presenting problem and related pathophysiology, prescribed medication and their pharmacokinetics, the nursing management and educational points regarding the interactions and long term effects of the medications prescribed in the Emergency department.

This will describe Mr. Ferguson presenting problem with focus on the various changes that occurs in his mechanical, biochemical, and physical functions of the body as a result of this condition. The presenting problem of Mr. Ferguson is heaviness. Therefore, the following description will major on the pathophysiological changes related to it.

Chest heaviness is the most common symptom of coronary heart disease under angina (Lilly, & Braunwald, 2012). According to healthcentral, Angina is described as squeezing, pressure, aching, heaviness and painful feeling in one’s chest. It may also be felt in arm, shoulder, neck, arm and back. Heusch (2016) states that angina pectoris is caused by imbalance between the oxygen demand and blood supply to the myocardium. This mismatch causes restriction of myocardial blood flow which eventually results to atherosclerotic narrowing of the surface of coronary artery, this leads to vasoconstriction due to impaired endothelial function. A study by Chandala, Bindhu, & Revathi, (2016) shows that fatty deposits or other cellular waste products blocks the coronary artery and if it ruptures, platelets clump and clogs the artery this decreases blood flow to the heart and causes shortness of breath. Paleness is due to reduced blood flow and oxygen to body parts (Mehta, 2017). It can be seen all over the skin or localized region like the limb. Diaphoresis is excessive or absurd sweating (Longmore, Wilkinson, Baldwin, & Wallin, 2014), it affects the whole of one’s body or one part like hands and feet. It’s a symptom of underlying health condition like heart attack or myocardial infarction resulting to oxygen-rich blood cannot reach the heart. This is a medical emergency (Hickman, Alfes, & Fitzpatrick, 2018).

Mr. Ferguson should therefore be attended to promptly since her conditions may worsen more if actions are delayed

Pharmacokinetics

Pharmacokinetics basically refer to the study of drug movement within the body. This involves the absorption, distribution, metabolism, and elimination of the drug (Hamidi, Azadi, Rafiei, & Ashrafi, 2013). The following passage will therefore review and use literature to support how various drugs that was prescribed to Mr. Ferguson move into, through and out of his body.  

Aspirin has short half-life, its rapidly absorbed from the stomach and intestine by the process of passive diffusion (Whalen, 2018). It is a prodrug which is changed to salicylate. This transformation takes place in the stomach, intestinal mucosa and in the liver. The active metabolite has analgesic and anti-inflammatory effect (Satoskar, Rege, & Bhandarkar, 2015). Acetylsalicylate is an active moiety which has antiplatelet-aggregating effect. Salicylate distributes rapidly into compartments of body fluid and binds with albumin in plasma. It can cross the placental barrier and be found in breast milk. It’s absorbed by liver; this metabolism occurs by heparin conjugation with glucuronic acid in different metabolic pathways. The most common pathway is conjugation with glycine and its saturates. 10% of unchanged salicylate is eliminated through urinary excretion. This is dependent on PH from 5 to 8, ionized salicylate are excreted increases from 3% of the total salicylate also it’s metabolites are excreted through urine (Schrör, & Voelker, 2016). It’s indications include to ease pain, fever and swelling. Used to treat arthritis, rheumatic fever, to protect the bypass grafts in the heart and also used to treat heart attack or stroke (Antonopoulos, Papanikolaou, Vogiatzi, Oikonomou, & Tousoulis, 2018).

       Metaprolol is a beta adrenergic receptor antagonist (Frishman, 2016). It’s well absorbed on oral administration and its peak concentration occurs 1-3 hours after ingestion. Ii has short half-life of 3-7 hours so it can be given as slow release preparation.it is metabolized by alpha hydroxylation and as a substrate of cytochrome liver enzymes CYPD2D6 and a percentage by CYP3A4 resulting in inactive metabolites. It crosses the blood brain barrier and cerebral spinal fluid. Only small fraction of drug is bound to serum albumin. Increase in dose is not affected by food taken. It is indicated for patients with angina pectoris, heart failure and hypertension.

Morphine sulfate a is an opioid analgesic which is absorbed well subcutaneously and orally also through rectal mucosa is possible. The effect of this drug when given orally is less than that given parenterally due to first pass metabolism in liver. Bioavailability is 25% when given orally so much dose should be given. It crosses blood brain barrier at a lower rate. It does get retained in tissue for longer time, it undergoes conjugation with glucuronic acid to morphine -3-glucoronide and morphine -6- glucuronide. These metabolites are excreted through urine and very little is excreted unchanged and eliminated through glomerular filtrate as morphine -3- glucuronide. Used for severe pain and pulmonary edema.

Nursing Management

       Fentanyl is also a strong opioid analgesic used to relieve severe pain (Dowell, Haegerich, & Chou, 2016). It is absorbed well intravenously and orally (Fischer BD 2005). Low molecular weight heparin binds to plasma protein it’s an antithrombin which inhibits clotting factor thrombin by forming complexes. It has high bioavailability in subcutaneous injection and less frequent dosing requirements. Used in treating thromboembolic disorders and it’s effective.

According to Hockenberry & Wilson, (2018), nurses play a major role in the management of a patient right from admission to discharge. Nowadays a patient-centered approach is applied in order to appropriately manage each patient with a better focus on his needs. Moreover, most medications have some adverse effects which need to be properly smanaged in order to prevent complications that may arise. This passage will therefore discuss the nursing management which is appropriate for M. Ferguson and how the adverse effects of his medications can be appropriately managed for effectiveness.

The nurse should encourage Mr. Ferguson to have a bed rest and ensured that he is in Semi Fowler’s position. This will work to decrease the demand of oxygen and requirements of myocardium which is ischemic (DiGiulio, 2015). A nurse should also administer oxygen therapy through nasal prongs and monitor oxygen saturation and respiratory rate. His vital signs should also be monitored after every for hours. This include the blood pressure, temperature, pulse and respiratory rate.

The nurse should also aim to manage him psychologically. This can be done through emotional support. Reduce anxiety if present by explaining to the patient about his conditions, medication and side effects of his drugs especially morphine, fentanyl and metoprolol. Anxiety can also be alleviated by ensuring that all the patient’s questions and concerns are well addressed.

The nurse to also focus on enhancing comfort for Mr. Ferguson. Ensure that you assess the findings, scale of pain and the level of activity. A nurse should ensure that the patient takes right drugs as prescribed to avoid complications. It’s a nurse role to make sure that the right patient takes the right drug, right dose and at the right time (Vallerand, 2018). Ensure that the drugs administered are effective to the patient and watch out for any adverse effects. Turn the patient 2 hourly to reduce chances of bed sores being formed at bone protuberance. Bed sore are usually difficult to manage and may create more complications.

Encourage the patient to take small meals at a time and monitor the amount of food he takes. This will enhance better elimination pattern. Advise the patient to change position on bed and breathe deeply to prevent accumulation of fluid in lungs.

Mr. Ferguson environment should be quiet without distractions or irritable noise. This help to reduce stress. As a nurse you should teach him relaxation techniques to reduce anxiety.

Health information and Education on drug interactions and long term effects

Most patients get anxious when admitted in a hospital since they do not have adequate knowledge concerning their conditions. It is therefore necessary to teach them and share appropriate information concerning their problem. Some drugs also have long term effects and it is necessary to educate the patient concerning those effects. The following passage will describe the health information I can share with Mr. Ferguson and how I will educate him concerning the interactions and long term effects of the drugs that has been prescribed to him in the emergency department.

I will inform the patient more about his condition. This include how the presenting problem develops and the risk factors. I will also teach him on how he may prevent it in the near future from happening. I will teach him about his medication both regular and the ones prescribed in the emergency department. I will clearly describe to him the dosage, frequency and how each drug should be taken. The adverse effects of those drugs should also be explained and how they present. I will advise him to immediately inform the nurse or any health staff whenever he experienced any side effect. I will also encourage Mr. Ferguson to eat a healthy diet. For example, eating plenty fruits and low-fat dairy products, avoiding foods that have high levels of sodium.

I will educate the patient concerning the possible drug interactions that may occur and also the long terms effects which may result from the use of the prescribed drugs. I will do this by teaching him first the reasons as to why such interactions usually occurs and how they occur. I will further explain to him how such interactions will alter various physiological functions of the and how that may affect his health.

The health messages and educational points discussed above will be very useful in enhances the healing process of Mr. Ferguson. This is because it will help in alleviating anxiety and moreover it will encourage him to cooperate throughout his management as he understand his condition and the future effects of drugs.

References

Antonopoulos, A. S., Papanikolaou, E., Vogiatzi, G., Oikonomou, E., & Tousoulis, D. (2018). Anti-inflammatory agents in peripheral arterial disease. Current opinion in pharmacology, 39, 1-8.

Chandala, M., Bindhu, V., & Revathi, V. (2016). A Study on Nutritional Status, Behaviour and Life Style Management among Coronary Heart Disease Patients Aged 40-60 Years. International Journal of Innovative Research and Development, 5(9).

DiGiulio, M. (2015). Medical-Surgical Nursing Demystified. e-BOOK STIKES-POLTEKKES MAJAPAHIT.

Frishman, W. H. (2016). Beta-adrenergic receptor blockers in hypertension: alive and well. Progress in cardiovascular diseases, 59(3), 247-252.

Hamidi, M., Azadi, A., Rafiei, P., & Ashrafi, H. (2013). A pharmacokinetic overview of nanotechnology-based drug delivery systems: an ADME-oriented approach. Critical Reviews™ in Therapeutic Drug Carrier Systems, 30(5).

Heusch, G. (2016). Myocardial ischemia: lack of coronary blood flow or myocardial oxygen supply/demand imbalance?. Circulation research, 119(2), 194-196.

Hickman, R., Alfes, C. M., & Fitzpatrick, J. (Eds.). (2018). Handbook of Clinical Nursing: Critical and Emergency Care Nursing: Critical Care. Springer Publishing Company.

Hockenberry, M. J., & Wilson, D. (2018). Wong’s nursing care of infants and children-E-book. Elsevier Health Sciences.

Lilly, L. S., & Braunwald, E. (2012). Braunwald’s heart disease: a textbook of cardiovascular medicine (Vol. 2). Elsevier Health Sciences.

Longmore, M., Wilkinson, I., Baldwin, A., & Wallin, E. (2014). Oxford Handbook of Clinical Medicine-Mini Edition. OUP Oxford.

Mehta, S. (2017). Unit-4 Introduction to Health Conditions Related to Heart, Blood vessels and Lungs. IGNOU.

Satoskar, R. S., Rege, N., & Bhandarkar, S. D. (2015). Pharmacology and Pharmacotherapeutics-E-Book. Elsevier Health Sciences.

Schrör, K., & Voelker, M. (2016). NSAIDS and Aspirin: Recent Advances and Implications for Clinical Management. In NSAIDs and Aspirin (pp. 107-122). Springer, Cham.

Symptoms of  Coronary heart Disease Healthcental https://www.healthcentral.com/…/symptoms-of-coronary-heart-disease ( accessed on November 2, 2018)

Vallerand, A. H. (2018). Davis’s drug guide for nurses. FA Davis.

Whalen, K. (2018). Lippincott illustrated reviews: pharmacology. Lippincott Williams & Wilkins.