1 Discuss the holistic care of the patient provided by the registered nurse. Critical thinking must be evident throughout the paper and discussion should cover the criteria/identification of arrhythmia, causative factors, presentation and relevant treatment modalities or options.
2.The use of Percutaneous Coronary Intervention (PCI) and thrombolytic has been shown to have benefits for patients being treated for ST Elevated Acute Myocardial Infarction (STEMI). Discuss the nursing care associated with thrombolytic drug therapy and PCI including rationale and evidence based practice.
3. Select a cardiac medication category (i.e. beta-blockers, calcium channel blockers, ACE inhibitors, etc.) and critically discuss the relevant nursing management of patients being treated with these medications. Discussion should involve medication action, adverse effects and relevant nursing care to ensure patient safety and effective treatment (desired effects).
4. Cardiac Rehabilitation has been shown to improve patient outcomes post cardiac event. Critically review and discuss the literature to support or refute this statement.
1. Arrhythmia can be defined as the disorder, which is characterized by the alteration of the normal sequence of electrical impulse that flows through the heart. Under normal condition this electrical impulse order to pump blood effectively to every organ of the body so that each works in a rhythm. When the impulses happen too fast or too slow or in abnormal motion, the heart also pumps fast or slow or also in abnormal manner ultimately affecting the blood flow to lungs, brain and different organs, resulting in complete shutdown of the organs or may lead to the damage (Daniels, 2014). Cardiac arrhythmia can be classified in different domains; atrial fibrillation is the condition that is characterized through rapid and irregular beating. Often this condition shows no or mild symptoms, making it difficult to be diagnosed.
As the diagnosis of this condition is difficult, proper monitoring and assessment is very important for identifying atrial fibrillation by a nurse to prevent any sort of organ damage and similar hazardous effects. A person having heart diseases need to be regularly monitored by healthcare nurse to determine the condition of the patient’s heart but those who do not have heart diseases should immediately report if they have symptoms like heart palpitations, fainting, breathing shortness, chest pain or lightheadness. There are many types of congenital disorders during births that can make one patient prone to arrhythmia or atrial fibrillation in his life. This can be explained by examples like there are many instances where babies are born with incompletely developed cardiac conduction systems, which may result in heart blocks or bradycardia. It is also seen that those people who are born with extra conduction pathways remains prone to a number of disorders where reentrant supraventricular tachycardia can be noted as the primary one. Other factors that may also lead to the occurrence of arrhythmia include different chemical agents that may result in high blood pressure. Moreover, tissue concentrations of a large number of minerals like calcium, magnesium and potassium can result in occurrence of the disorders. Often other substances of addiction like cigarettes and recreational drugs as well as alcohols can instigate the chance of occurrence of the arrhythmias or specifically atrial fibrillation (Vacca et al., 2014). Mutation of lamin AC gene is associated with the fibrosis of atria, thereby leading to atrial fibrillation. It leads to loss of atrial muscle mass as a result of RAAS activation, atrial remodeling and fibrosis. However, it is not limited to atrial muscle loss; rather it occurs in SA and AV node, correlating with sick sinus syndrome.
Once the registered nurse identifies the type of arrhythmia has been developed by the patient, i.e. atrial fibrillation, the nurse should assess the risks associated with the intensity of the disorder in that particular patient. She should try to restore the normal heart rhythm of the patient if possible by treating the actual area of the abnormal impulse generation. The nurse should try to prevent the advanced stage of the disorder and prognosis with any blood clots to reduce stroke risks. Controlling the heart rate to normal is the primary intervention followed by the treatment of the disease that is leading to arrhythmic conditions. Associated risk factors for stroke and other heart diseases should be prevented and proper monitoring of the patient’s vital signs and medications would be suggested to the patient (Nayak et al., 2016). Atrial fibrillation is the most common health condition that causes serious heart rhythm. Causes may be genetics or due to environmental risk factors. Inherited arrhythmic syndromes, familial and non-familial AF is associated with other genetic cardiac disorder like congenital long QT syndrome.
The Nurse should closely monitor the symptoms of the patient to make a correct diagnosis. She can confirm the diagnosis by conducting electrocardiogram known as ECGS that help to identify the electrical impulse of the heart (Daniels, 2014). In addition, transthoracic echocardiogram, complete blood count and serum thyroid stimulating hormone level test can be used for specific diagnosis of AF. The nurse can identify different forms of Arrhythmia and it would be only possible for her if she has a good knowledge, a keen eye and good theoretical knowledge (Liu, Cheng & Lin, 2013). AF shows narrowed QRS complex in ECG, which in turn help the nurses to identify which part of the heart is facing an issue due to abnormal impulse generation. This helps the nurse to take necessary steps accordingly. Echocardiography, chest X-ray, exercise stress testing are also significant diagnostic tests.
2. Formation of thrombi is important for major as well as minor injuries in the vascular system and usually remains confined to those particular injured areas. Under normal condition it does not obstruct any blood flow and does not interfere with the circulation of blood to different important tissues and organs. However, thrombolysis process works in a better way in thrombi that are formed recently but fail to act on the older thrombi because they have extensive polymerization of the fibrin. As a result, they get resistant to thrombolysis and hence need the requirement of thrombolytic drug therapy. This condition results in the formation of artherosclerotic plaque which when rupture causes blood clot formation in the artery that may ultimately result in partial or complete occlusion of the arteries. This gives rise to a situation when heart attack or myocardial infarction takes place. These problems are assessed from the ST segment of the ECG and hence the name.
Thrombolytic agents in the thrombolytic drug therapy mainly include the serine prtoteases that mainly work by conversion of the plasminogen into the naturally occurring fibrinolytic agent plasmin. This compound is essential for lysing the clots. This mainly helps in restarting the blood flow to the heart and thereby prevents further damage to the heart muscles. In this way thrombolytic agents may help in the stoppage of the heart attack, which may otherwise could have lead to the death of a particular patient. The blood flow that has been restarted may not be completely out of danger. Therefore, further therapies like cardiac catheterization with angioplasty and stenting needs to be followed after thrombolytic drug therapy. They can be both Fibrin-specific agents and Non–fibrin-specific agents. The former contains alteplase (tPA), reteplase (recombinant plasminogen activator [r-PA]), and tenecteplase that helps in limited production of the plasminogen conversion in the absence of fibrin and the latter contains streptokinase that helps in catalyzing systemic fibrinolysis (Nonnenmacher et al., 2016). However, this therapy should be conducted within the first 30 minutes after the arrival of the patient at hospital.
In nursing interventions, at first the nurse should evaluate the contraindications like whether the patient had a recent surgery or trauma, cerebral vascular accident and many others. This may be because it can result in precipitation intracranial, internal, or peripheral bleeding. Proper discussion should be made with the patient or with his family members about the purpose of the therapy. It should be also instructed that the patient should completely maintain his position during and after the infusion. Vital signs should be continuously monitored during the infusion with gradual increase in time duration of the interval of checks until intravenous catheter is moved. Cardiac monitoring should be continued and emergency preparations for prevention of Ventricular dyrhythmias should be ready (Nonnenmacher et al., 2016). After post infusion, proper assessment of the vital signs, distal pulses and infusion site should be conducted as the client remains at a risk of bleeding after the therapy. Proper evaluation of the responses should be made like ST segment, relief of chest pain, reperfusion dysrhythmias, early peaking of the CK and CK-MB band and similar other things. Position of the patient should be maintained with head kept below 15 Degree. Peripheral bleeding may occur at puncture sites and hence proper dressing is to be made. Body fluids should also be checked regularly along with proper administration of the platelet modifying drugs (Meyer et al., 2016).
In Percutaneous Coronary Intervention (PCI), a catheter is inserted and threaded through blood vessels at the site of narrowed blood vessels where a stent with a balloon tip cover is inflated which helps in the compression of the plaque. Once accomplished, the stent stays in artery holding it open allowing proper blood flow.
Nurses should be aware of the various risks associated with during or after this treatment. The antithrombotic agents used before the therapy increases the risk of vascular access complications that may include hematoma arterial occlusion, arteriovenous fistula that may harm the patient leading to morbidity and mortality. Therefore, nurses need to be knowledgeable about the complications that may arise from this situation and handle them efficiently (Middleton, Gromley & Alexandrov, 2015). Therefore after receiving the patient from the cath lab after the treatment, nurses should have a comprehensive monitoring of the medication administration during the process, correct location placement of the stents, different types of vital signs should be assessed and assessment of the pedal pulses are to be made. The registered nurse should be properly experienced with the sheath pulling activity, as it requires extensive training (Bates et al., 2015).
3. Epinephrine and nor epinephrine are the neurotransmitters which usually bind with the the betareceptors 1 of the heart, eye and kidneys and with the Beta 2 receptors of the lungs, liver and others. Beta blockers are those drugs which when bond with the beta-receptors inhibits the binding of the neurotransmitters with that of the beta receptors and as a result they help in reduction of heart rate and reduce the blood pressure. These are mainly done by diluting the blood vessels (Flather & Gollop, 2016). Therefore, in a way it can be said that the flight and fight activities conducted by the activity of the neurotransmitters are prevented. They reduce the workload of the heart and are useful in treatment of angina pectoris or chest pain (Reinstra et al., 2013).
Beta cell blockers result in fatigued condition of the body along with drowsiness, dizziness and even weakness. Patients also experience dry mouth, dry skin, dry eyes nausea and even vomiting. Nurses also notice a feeling of coldness in hands and feet in patients. Shortness of breath, sleep disturbances and reduced sex drive are also been reported. Therefore, they are not provided to asthma patients. By blocking the effects of the nor-epinephrine and nor epinephrine, they may constrict the air passage. This is mainly due to the contraction of the muscles surrounding the air passage and thereby causes difficulty in breathing. Other side effects include toxic epidermal necrolysis, raynaud’s phenomenon, Lupus erythematosus and Bronchospasm. Serious allergic reactions, Erythema multiform, Steven Johnson Syndrome, Toxic epidermal necrolysis also take place. (Morales et al., 2014).
Before administering the beta-blockers the nurse should check whether the patient is suffering from allergies. It should be also known what kind of drugs the patient uses including the herbs if taken to ensure that any other medicines of similar effect are taken or not. The nurse should also check the current BP and the apical pulse rate before the administration. After administration of the drug the nurse should observe the intended effect of the dose. The side effects should be monitored especially like orthostatic hypotension. Older patients should be checked for mental confusion and changes in LOC. Diabetic patients should be handled carefully because there is a chance of hypoglycemic condition that may arise from such disorders and therefore they should be monitored regularly. COPD patient should be handled carefully especially asthma patients for respiratory issues like wheezing and difficulty in breathing (Bolton et al., 2016). Proper information to be also given to the patients about the side effects so it would help them to be aware of their physical health
4. Cardiac rehabilitation in a post cardiac event in case of patients have been highly supported by different researchers where they have specifically mentioned cardiac exercise to be a major factor that had decreased the number of morbidity and also mortality in various hospitals and centers. Rise in heart rate during exercise due to parasympathetic withdrawal and sympathetic activation and subsequent fall in heart rate due to parasympathetic activation takes place in individuals who undergo exercise treatments in rehabilitations. Researchers have identified that failure in the decrease of the heart rate rapidly during exercise is linked with all cause mortality. Exercise training in the rehabilitations improves heart rate variability in the patients along with baroflex sensitivity for patients who suffered coronary artery diseases (Anderson et al., 2016). Altogether, it showed positive impacts on the heart rate recovery improvement of the patients who faced cardiac events (Rutledge et al., 2013).
Researchers have shown that cardiopulmonary rehabilitation has not only helped patients to obtain excellent treatment after vascularisation but has also taught patients with benefits of proper secondary prevention (Griffo et al., 2013). When patients underwent good lifestyle and medical adherence taught in the rehabilitations, risks of further harm from cardiac events were found to decrease along with decreased mortality. In case of artial fibrillation, exercise for muscle strengthening, endurance and a range of motions can be helpful. In rehabilitation centre, walking is being focused as an aerobic and safe exercise. In the later phase, jogging is recommended for increasing HDL or “good” cholesterol. Cycling can be helpful to AF patients for managing stress of blood pumping by heart. In addition, swimming, yoga and strength based training can be helpful with a alternative day schedule, as these can help to prevent the risk of blood clot and stroke rate (Dunlay et al., 2014).
References:
Anderson, L., Oldridge, N., Thompson, D. R., Zwisler, A. D., Rees, K., Martin, N., & Taylor, R. S. (2016). Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. Journal of the American College of Cardiology, 67(1), 1-12.
Bates, E. R., Blankenship, J. C., Ellis, S. G., Moussa, I. D., Guyton, R. A., Mukherjee, D., & Kushner, F. G. (2015). 2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction.
Bolton, N. (2016). Perioperative beta-blockers for preventing surgery-related mortality and morbidity. Journal of perioperative practice, 26(3), 30-31.
Daniels, D. (2014). Role of the Clinical Nurse Specialist in Multidisciplinary Care Planning for an Obstetric Patient with Cardiac Arrhythmia. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 43(S1), S93-S93.
Dunlay, S. M., Pack, Q. R., Thomas, R. J., Killian, J. M., & Roger, V. L. (2014). Participation in cardiac rehabilitation, readmissions, and death after acute myocardial infarction. The American journal of medicine, 127(6), 538-546.
Flather, M. D., & Gollop, N. D. (2016). Understanding Mechanisms of Action of Beta-Blockers in Heart Failure With Reduced and Preserved Ejection Fraction. JACC: Heart Failure, 4(2), 150-151.
Griffo, R., Ambrosetti, M., Tramarin, R., Fattirolli, F., Temporelli, P. L., Vestri, A. R., … & Tavazzi, L. (2013). Effective secondary prevention through cardiac rehabilitation after coronary revascularization and predictors of poor adherence to lifestyle modification and medication. Results of the ICAROS Survey. International journal of cardiology, 167(4), 1390-1395.
Liu, S. H., Cheng, D. C., & Lin, C. M. (2013). Arrhythmia identification with two-lead electrocardiograms using artificial neural networks and support vector machines for a portable ECG monitor system. Sensors, 13(1), 813-828.
Meyer, G., Vicaut, E., Danays, T., Agnelli, G., Becattini, C., Beyer-Westendorf, J., … & Dellas, C. (2014). Fibrinolysis for patients with intermediate-risk pulmonary embolism. New England Journal of Medicine, 370(15), 1402-1411.
Middleton, S., Grimley, R., & Alexandrov, A. W. (2015). Triage, Treatment, and Transfer Evidence-Based Clinical Practice Recommendations and Models of Nursing Care for the First 72 Hours of Admission to Hospital for Acute Stroke. Stroke, 46(2), e18-e25.
Morales, D. R., Jackson, C., Lipworth, B. J., Donnan, P. T., & Guthrie, B. (2014). Adverse respiratory effect of acute β-blocker exposure in asthma: a systematic review and meta-analysis of randomized controlled trials. CHEST Journal, 145(4), 779-786.
NAYAK, C. G., Seshikala, G., Desai, U., & Nayak, S. G. (2016). Identification of Arrhythmia Classes Using Machine-Learning Techniques. International Journal of Biology and Biomedicine, 1, 48-53.
Nonnenmacher, C. L., Ávila, C. W., Mantovani, V. M., Vargas, M. A., Echer, I. C., & Lucena, A. (2016). Cross Mapping Between the Priority Nursing Care for Stroke Patients Treated With Thrombolytic Therapy and the Nursing Interventions Classification (NIC). International Journal of Nursing Knowledge.
Rienstra, M., Damman, K., Mulder, B. A., Van Gelder, I. C., McMurray, J. J., & Van Veldhuisen, D. J. (2013). Beta-blockers and outcome in heart failure and atrial fibrillation: a meta-analysis. JACC: Heart Failure, 1(1), 21-28.
Rutledge, T., Redwine, L. S., Linke, S. E., & Mills, P. J. (2013). A meta-analysis of mental health treatments and cardiac rehabilitation for improving clinical outcomes and depression among patients with coronary heart disease. Psychosomatic medicine, 75(4), 335-349.
Vacca, A., Meune, C., Gordon, J., Chung, L., Proudman, S., Assassi, S., … & Matucci-Cerinic, M. (2014). Cardiac arrhythmias and conduction defects in systemic sclerosis. Rheumatology, 53(7), 1172-1177.
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