Managing Chest Heaviness In Elderly Patients: A Case Study Discussion

Pathophysiology of chest heaviness in elderly male patients

Write about the Case Study Assessment for Pharmacokinetics and Nursing Strategies.

Chest heaviness is a common symptom among the adult population which can turn into emergency situations (Ambrose & Singh, 2015). The following assignment aims to highlight critical discussion of the case study of 76 year old male who is brought to the emergency department with chest heaviness. The assignment will focus on the pathophysiology problems based on the symptoms expressed by the patient followed by pharmacokinetics, nursing strategies, effective patient’s education and clinical considerations that should be followed in order manage the adverse effects.

The 76-year-old male patient has high blood pressure and heart rate, but the oxygen saturation seems to be normal all of which indicate the possibility of non-ST myocardial infarction (NSETMI). The patient has a tympanic temperature of 36.86, which is quite low and is sweating. It is common in NSETMI patients, as the internal organs take away excess oxygen form the body to maintain their optimal temperature. The patient is suffering from difficulty in breathing but the oxygen saturation is normal. The patient seems pale suggesting lack of blood circulation due to MI and pain shock (Ambrose & Singh, 2015). The blood pressure of the patient is very high 172/86 mmHg, which suggests cardiac workload. The heart rate seems irregular which can indicate the symptoms of non-ST myocardial infarction and unstable angina. The breathing rate of the patient is quite high of about 24beats per minute which could be due to lack of oxygen supply. The patient came into the emergency with dyspnea, shortness of breath and visibly seems pale and diaphoretic state. These symptoms suggest that the patient is undergoing a heart attack. Given the history of the patient of having angina, hypertension, cholesterolemia and two times of NSETMI, it is presumable that the patient is undergoing a third heart attack (Rønhovde, 2017). 

The patient was prescribed dose of 300 mg of aspirin, 2.5 mg of Morphine administered on four different occasions as required for the situation intravenously. The patient was infused with low molecular weight heparin and 50mcg Fentanyl twice with immediate effect. The pharmacokinetics of these drugs are described in the following-

Aspirin 300mg: The analgesic aspirin is used to treat moderate to severe depending on the situation but it is also sometimes used as an anticoagulant for prevention of myocardial infection and other heart related abnormalities (Saxena et al., 2013). Inactive form of aspirin is readily observed in the acidic environment of the stomach where it is broken down into acetyl group and salicylate which further is observed why the small intestine. Acetylsalicylic inhibits platelet aggregation which is why it is used as an anticoagulant. The acetyl group of the drug binds to cyclo-oxygenase (COX 1 and 2) enzymes, which inhibit prostaglandin and thromboxane production from arachidonic acid. The acetylsalicylate portion facilitates antipyresis, thermal induction and vasodilatation (Thorat & Cuzick, 2013).

Pharmacokinetics of aspirin, morphine, heparin and fentanyl

Morphine sulphate IV 2.5mg: Morphine is another drug which is used to reduce severe pain related to angina surgery or trauma. The gastrointestinal mucosal lining readily absorbs morphine and rapidly circulated throughout the body. morphine hypothesized to bind and inhibit to GABA inhibitory mediator neurons, which reduce the transmission of pain signals (Kubica et al., 2015).

Low Molecular weight Heparin (LMWH) infusion: Low molecular weight heparin is a very common form of anticoagulant drug that prevents blood coagulation clots as well as thrombo-embolism in deep vein as well as in pulmonary conditions. It is mainly used to treat myocardial infarction. Serine protease inhibitor called anti-thrombin is majorly responsible for coagulation inhibition. LMWH inhibits the process by binding to anti-thrombin and prevents the conformational change that activates factor X. heparin binds to anti-thrombin III and inactivates blood coagulation reaction by inactivating the cascade factors (Xu et al., 2014).

Fentanyl 50mg IV: Fentanyl converts to morphine in the system and close N-type voltage gated ion channels and open the Ca²⁺ dependant in fluxing K⁺ channels which reduce the action potential of pain neurons.

The patient’s condition suggests that the unstable angina has induced the third non-ST myocardial infarction along with hypertension and shortness of breath. The goal of the nursing management for Mr. Ferguson should be reduction of pain, decreasing the blood pressure, increase the fluid volume intake in the heart and temperature control.

Pain management: It is important for the patient to minimize his pain as the patient is elderly and feeble which will induce the pain shock quickly, called pain catastrophysing. The best method is to provide medications that will reduce the pain risk like aspirins and morphine or other opoid based drugs (Montalescot et al., 2014).

Blood Pressure management: the patient has a blood pressure of 172/86 mmHg, which needs to be controlled to reduce the myocardial workload. This can be done by administering bronchodilators, which will relax the respiratory vessels and allow easy flow of blood. The heart muscles can also be relaxed to decrease the blood load on the vessels. administration of beta-blockers can will inhibit the stimulation of cardiac myocytes and control heart rate. The drugs bind and inhibit the receptors for adrenaline secretion. This makes sure that the heart rate is lowered and the person can be relived from hypertension.

Temperature control: the patient seemed to have body temperature of 36.86, which is quite low. This could be resultant of the non-ST myocardial infarction along with sweating. Pyretic medicines need to be administered to control the temperature of the patient and regulate the temperature of the room to warm him properly (Gardner et al., 2014).

Nursing strategies for management of chest heaviness

Angina treatment: the patient takes nitroglyverine spray as required due to his unstable angina, which did not work the time before hospitalization. alternative for nitroglycerine should be administered like mononitrate or isosorbide dinitrate, which will help reduce the angina condition. Administration of morphine can be encouraged if the nitroglycerine does not work. Morphines are known to be good analgesic as well as anti-angenic.

Fluid Volume maintenance: the fluid volume intake can be maintained to reduce the cardiac load and administration of diuretics, which will remove the extracellular fluid through urination. This will ensure that the cardiac chamber is able to reduce the fluid intake and excrete through the urine and reduce the blood pressure. 

It is common for practitioners to prescribe aspirin to patients show suffer from unstable angina or other cardiac or respiratory diseases that cause pain (Saxena et al., 2013). Nevertheless, the long term effects of aspirin are quite adverse, especially for adults over 65 years of age, as in case of Ferguson. He is 76 years old and has a condition of hypertension. People with consistent high blood pressure are not supposed to take aspirin for long. Prolonged use of aspirin causes digestive disorder and aching stomachs if taken before meal. The people who take aspirin daily are commonly susceptible to bleeding as it dilutes the blood. The patient is administered with heparin which is a known anticoagulant which will dilute the blood even more and causes serious issue. Aspirin also interacts with diuretics and increase the fluid excretion. More studies have shown that aspirins induce the risk of colon cancer (Douiri et al., 2013). The patient is also prescribed morphine, which can interact with pain medications and cause dizziness, which will enhance the risk of falling in the patient. Morphine is considered a narcotic and any form of dependence cannot be encouraged. The side effects of morphine are nausea, dizziness, irritable bowel and constipation (Samarghandian et al., 2014). The patient was administered with heparin, which is a known anti-coagulant. Heparin can interact with aspirin and other non-steroidal anti-inflammatory drugs (NSAID) like ibuprofen, which the patient is needed to be taught about.  Ferguson needs to be taught about the addictive effects of fentanyl. It is a dorm of opoid, which lead to death if being overdosed. Fentanyl causes respiratory troubles, which will cause serious health issues. Fentanyls react with other cough relievers and medications for hypertension and anxiety. (Von Korff et al., 2011). Muscle relaxers also affected by the fentanyl, which needs to be told to Mr. Ferguson

Effective patient’s education for chest heaviness management

Administration of heparin for long periods lowers the platelet count of the patient and causes blood clotting inside the veins. Bleeding risks are also associated with heparin administration. The patient needs to be under constant care and monitoring will be required so as to minimize the risk of prolonged bleeding (Choudhry et al., 2011). Emergency care contacts need to be provided to the family members of Mr. Fergusson incase of severe conditions. Symptoms like bleeding nose, gums or dark urine and stools can be reflective of internal bleeding. The aspirin side effects can be addressed by checking the intake and making sure that the patient is not consuming medication only after meal. Morphine or fentanyl dependence need to be controlled and made sure that the patient does not develop any sort of dependence for it as over dose will cause fatality.  The patient should be monitored for not taking the drugs which he used to before like metoprolol, rosuvastatin and nitroglycerine spray. These medications will react with the current medication which needs to be checked.

Thus from the above discussion it can be concluded that pain management, blood pressure management, angina control, fluid volume management and temperature control are most effective nursing interventions for Mr. Ferguson. However, there are certain limitations in the domain of drug administration. In order to prevent harmful allergic reactions of the drug, effective medication plan must be framed based of Mr. Ferguson’s medication allergy traits.

References

Ambrose, J. A., & Singh, M. (2015). Pathophysiology of coronary artery disease leading to acute coronary syndromes. F1000prime reports, 7.

Choudhry, N. K., Avorn, J., Glynn, R. J., Antman, E. M., Schneeweiss, S., Toscano, M., … & Levin, R. (2011). Full coverage for preventive medications after myocardial infarction. New England Journal of Medicine, 365(22), 2088-2097.

Douiri, A., McKevitt, C., Emmett, E. S., Rudd, A. G., & Wolfe, C. D. (2013). Long-term effects of secondary prevention on cognitive function in stroke patients. Circulation, CIRCULATIONAHA-113.

Gardner, B., Ling, F., Hopke, P. K., Frampton, M. W., Utell, M. J., Zareba, W., … & Topf, M. C. (2014). Ambient fine particulate air pollution triggers ST-elevation myocardial infarction, but not non-ST elevation myocardial infarction: a case-crossover study. Particle and fibre toxicology, 11(1), 1.

Kubica, J., Adamski, P., Ostrowska, M., Sikora, J., Kubica, J. M., Sroka, W. D., … & Siller-Matula, J. M. (2015). Morphine delays and attenuates ticagrelor exposure and action in patients with myocardial infarction: the randomized, double-blind, placebo-controlled IMPRESSION trial. European heart journal, 37(3), 245-252.

Montalescot, G., Van’t Hof, A. W., Lapostolle, F., Silvain, J., Lassen, J. F., Bolognese, L., … & Hammett, C. J. (2014). Prehospital ticagrelor in ST-segment elevation myocardial infarction. New England Journal of Medicine, 371(11), 1016-1027.

Rønhovde, H. A. I. (2017). Modeling Cardiovascular Patient Pathways in an Accident and Emergency Department from a System Dynamic Perspective Using a Patient Oriented Modeling Approach (Master’s thesis, The University of Bergen).

Samarghandian, S., Afshari, R., & Farkhondeh, T. (2014). Effect of long-term treatment of morphine on enzymes, oxidative stress indices and antioxidant status in male rat liver. International journal of clinical and experimental medicine, 7(5), 1449.

Saxena, A., Balaramnavar, V. M., Hohlfeld, T., & Saxena, A. K. (2013). Drug/drug interaction of common NSAIDs with antiplatelet effect of aspirin in human platelets. European journal of pharmacology, 721(1-3), 215-224.

Thorat, M. A., & Cuzick, J. (2013). Role of aspirin in cancer prevention. Current oncology reports, 15(6), 533-540.

Von Korff, M., Kolodny, A., Deyo, R. A., & Chou, R. (2011). Long-term opioid therapy reconsidered. Annals of internal medicine, 155(5), 325-328.

Xu, Y., Cai, C., Chandarajoti, K., Hsieh, P. H., Li, L., Pham, T. Q., … & Harris, E. N. (2014). Homogeneous low-molecular-weight heparins with reversible anticoagulant activity. Nature chemical biology, 10(4), 248.