45A CASE STUDY

Atrial FibrillationMaria ArroyoLong Beach City CollegeADN 45A/ALAmy Blanks, RN, BSNFebruary 26, 2020Atrial FibrillationThe telemetry unit provides care to patients that have been transferred from the Intensive care unit (ICU), surgery or from the emergency department that require continuous cardiac monitoring. Most of the patients on the telemetry unit have a predisposing history that involves the cardiovascular system therefore require close monitoring. The telemetry unit has a monitor technician that will monitor, recognize any abnormality and report cardiac arrhythmias to the registered nurse caring for the patient. The case study was completed on a 74-year-old male who came to the emergency room after experiencing shortness of breath and palpitations that started about two days ago. On the day that he decided to come to the emergency room he also experienced chest pain. After laboratory and diagnostic testing was completed a diagnosis of atrial fibrillation which is a cardiac arrhythmia that if not treated correctly can lead to serious complications. This case study will discuss the signs and symptoms that a person will experience and that frequently require urgent or emergent medical intervention. Other points that will be discussed in this case study is the immediate treatment of atrial fibrillation while in the hospital. And the outpatient management once patient is discharged home (Timby & Smith, 2014).Basic Conditioning FactorsF.R. is a 74-year-old Hispanic male that presented to the emergency room on February 7th, 2020 after experiencing chest pain. The other symptoms that the patient also experienced were dizziness, shortness of breath and palpitations that started a few days before being admitted to the hospital. Echocardiogram showed an ejection fraction of 20-25%. F.R. is a full code and his adult son lives with patient. He is divorced. F.R.’s admission weight was 77 kilograms. F.R. has no allergies to any medication or food. F.R. has a history of hypertension (HTN), hyperlipidemia, and coarctation of the aorta. After all studies were completed, the patient was found to be in atrial fibrillation and eventually was admitted for treatment and cardiac monitoring. After all tests were completed, F.R. was also diagnosed with new diagnosis of congestive heart failure (CHF). On Erikson’s developmental level F.R. was found to be in the integrity versus despair category. During the integrity versus despair level, a person may look back at their life and evaluate the success and meaning of it or they may focus on regrets and disappointments they might have had. The student nurse believes the patient has achieved the Erikson’s integrity developmental level because his son was at bedside and seemed very caring toward the patient. Son also seemed very involved in patients care and health status. The patient also stated to the student nurse that he is very proud of his son since he is attending the university and works part-time and still finds time to come visit him to the hospital. Patient feels satisfied that his son is getting an education. Patient stated that all his hard work has paid off.Anatomy and Physiology of the Involved OrgansF.R.’s diagnosis of atrial fibrillation along with a new diagnosis of congestive heart failure which are processes that involve the cardiac system. The heart, blood, blood vessels and the spleen are vital parts of the cardiovascular system. The heart pumps oxygenated blood to the rest of the body’s organs and tissues. It defends the body against foreign organisms, clot the blood, regulate temperature, and transport hormones. The heart lies between the lungs and pericardium, which is within the thoracic cavity. The heart is made up three layers of muscle tissue, which are the epicardium, middle layer and the endocardium. The pericardial fluid lubricates the cavity to help prevent friction rub against the cavity, holds the heart in place, and assists in reducing over expansion of the heart. The right and left atria, as well as the right and left ventricle make up the four chambers of the heart. The first two valves in the heart are the atrioventricular valves. The mitral valve, which lies on the right and the tricuspid valve which lies on the left separate the atria from the ventricles. The aortic valve is a large tube-like valve that sits between the left ventricle and the pulmonic valve and separates the right ventricle and pulmonary artery. Coronary arteries extend from the aorta and supply the hear with oxygen throughout the blood (Hinkle & Cheever, 2014).PathophysiologyF.R. has a history of essential hypertension which can lead to atrial fibrillation if not treated or managed correctly. F.R.’s only risk factor is hyperlipidemia. Essential hypertension is idiopathic which means there is no known cause for the elevation of blood pressure. Hypertension is characterized by an increase of the systolic blood pressure of 120mm Hg or higher and a diastolic blood pressure of 89 mm Hg or higher. The kidneys release the renin into the blood which that will help with converting angiotensin to angiotensin I in the liver. Angiotensin I will be converted to angiotensin II (which works as a vasoconstrictor) in the lungs. Angiotensin II causes constriction in the arterioles and aldosterone is secreted which in turn there is retention of water and sodium. Blood volume increases due to sodium and water retention which then will cause peripheral vascular resistance and fluid volume will increase causing hypertension (Hinkle & Cheever, 2014).In atrial fibrillation, what usually is seen is that the atria beat very fast and irregular. It is sometimes described as a “quiver”. Because of the irregularity of the pattern, the atria do not work in coordination with the ventricle like they should. Atrial fibrillation occurs when the electrical signals begin in the wrong place instead of at the sinoatrial (SA) node and miscarry the appropriate signal. The defective signals make the atria quiver very rapidly therefore, not allowing them to contract completely. Usually the electrocardiogram waves appear more chaotic and random. When the atria and ventricles fail to contract in coordinated way, blood is not able to empty efficiently into the ventricles and begins to pull into the atria. This pulling of blood can form clots which increases the risk of an ischemic stroke if a clot dislodges and travel to the brain (Hinkle & Cheever, 2014)Medical OrdersActivity F.R. was on bed rest when admitted but after his initial physical and occupational therapy evaluations he was cleared to get out of bed and ambulate independently in his room. He required a one person assist to ambulate in the hallways. The patient tolerated his physical therapy session without any signs of oxygen desaturation.DietF.R was NPO in the morning since he was scheduled for a coronary computed tomography angiogram (CTA). After the test was completed patient was able to have a cardiac low sodium diet. No fluid restriction.Intake/OutputF.R. had was placed on strict intake and output. He had an output of about 600 milliliters by the end of student nurse’s shift. His last bowel movement was on February 10th, 2020.Labs/Diagnostic TestsTest Name Admission Results2/7/20 Resultsfor assigned day2/12/20 Clinical Implications Possible Causes of any abnormal valuesWBC 10.3 7.8 To monitor for infectionHbg 15.0 17.2H CoagulationHct 44.4 52 ThrombusPlatelets 175 210 Pt on blood thinners K+ 3.9 4.2 Monitor d/t being on K wasting diureticNa+ 139 136 Monitor d/t being on K wasting diureticMg++ 2.3 2.3 Monitor d/t being on K wasting diureticCa++ 8.6 8.7 Monitor d/t being on K wasting diureticGlucose 110H 95 Stress from hospitalizationBUN 19H 28H Monitor for renal functionCreatinine 0.90 0.93 Monitor for renal functionINR 1.21H N/A Monitor d/t anticoagulantAPTT 31.2H N/A Monitor d/t anticoagulantPT 15.5H N/A Monitor d/t anticoagulantChest Xray Clear N/A Heart size, fluid in lungs and pleural spacesEchocardiogram EF 20-25% N/A Heart rhythm and blood movement through heart(Pagana, Pagana, & Pagana, 2017)MedicationsDRUG (generic/brand) Drug classification Reason Drug Prescribed to this patientNursing interventionsDigoxin (Lanoxin) 250mg daily Cardiac glycoside A-fib with RVR Assess AP, hold if <60 or >110, monitor for hypokalemia and dig toxicityGuaifenesin (Mucinex) 600mg BIDExpectorant Cough Monitor for rash, itching or swellingFurosemide (Lasix) 40mg daily Diuretic Fluid overload K+ wasting, monitor electrolytes, urine output, weight, I&OLosartan Angiotensin II Receptor Blocker HTN Monitor BP & HRMetoprolol (Lopressor) 75mg TID Beta Blocker HTN Hold for HR <60 or SBP <100Pantoprazole (Protonix) proton pump inhibitor prevents stomach ulcers, protects lining of stomach do not crush, chew, or split, give IV routeEnoxaparin (Lovenox) Lower molecular weight heparin. Bind to anti thrombin factors Prevent of thrombus formation Monitor for signs of bleeding, CBC, platelets.(Vallerand & Sanoski, 2015)Health DeviationsBalance Between Solitude and Social InteractionHealth deviations brought on by the atrial fibrillation. The patient was in atrial fibrillation and very short of breath that he was placed on oxygen, on a cardiac monitor and on bed rest which may have interrupted the patient’s normal social interaction and now was unable to get out of bed on his ownHealth deviations brought on by diagnostic tests and/or treatments. Echocardiogram was performed indicating patient has an ejection fraction of 20-25% leading patient to be placed on bed rest.Maintenance of Sufficient Intake of AirHealth deviations brought on by the atrial fibrillation. The patient was put on two liters of oxygen due to the dyspnea and hypoxia. He maintained an oxygen saturation level of 98% while on two liters of oxygen via nasal canula.Health deviations brought on by diagnostic tests and/or treatments. A chest x-ray was completed to make sure there was not another underlying problem in the lungs or heart. The x-ray was normal.Maintenance of Sufficient Intake of Food and WaterHealth deviations brought on by the atrial fibrillation. The patient was made nothing by mouth (NPO) for possible further testing. After some testing was completed, patient was allowed to have liquids only, no food.Health deviations brought on by diagnostic tests and/or treatments. The patient was only permitted to drink water and apple juice, no food until the CTA was completed.Maintenance of Sufficient Elimination ProcessHealth deviations brought on by the atrial fibrillation. The patient was on bed rest due to the atrial fibrillation and shortness of breath. He was unable to get out of bed to void, therefore he had to use the urinal. Health deviations brought on by diagnostic tests and/or treatments. Due to patient having an order to be NPO he required a peripheral intravenous line on his left hand which was running with lactated ringer’s solution. The patient was also placed on a strict intake and output.Maintenance of Balance Between Activity and RestHealth deviations brought on by the atrial fibrillation. Being in the telemetry unit with constant monitoring, alarms going off and bed rest can be a very stressful situation for the patient. Health deviations brought on by diagnostic tests and/or treatments. No health deviations brought on by diagnostic tests or treatments. Promotion of NormalcyHealth deviations brought on by the atrial fibrillation. F.R.’s daily life was interrupted by his hospital admission, medical diagnoses and current health status. Being placed on bed rest is extremely difficult for patient since he was previously independent.Health deviations brought on by diagnostic tests and/or treatments. Due to certain diagnostic test and treatments, patient had to be placed on bed rest and on NPO which caused a significant impact on his independence and socialization.Nursing DiagnosisThe student nurse diagnosed the patient with a nursing diagnosis of decreased cardiac output related to decreased preload as evidenced by an abnormal electrocardiogram, echocardiogram showing an ejection fraction of 20-25% and an irregular heart rate. The student nurse’s goal was for the patient to remain free of signs and symptoms of dyspnea by maintaining an oxygen saturation level above 96% on room air. Nursing interventions included to monitor heart rate, oxygen saturation and electrocardiogram for any changes. The patient maintained an oxygen saturation level of 98% on room air by end of shift. The student nurse diagnosed the patient with a second nursing diagnosis of risk for constipation related to lack of physical activity as evidenced by last bowel movement on February 10th, 2020, bowel sound hypoactive and decreased mobility. The goal was for the patient to have one normal bowel movement during the student nurse’s shift. The nursing interventions were to encourage patient to ambulate in the room or hallway, encourage fluid and fiber intake after NPO order is discontinued, and administer laxative as needed. The patient was able to tolerate a walk in the hallway with the physical therapist (Ladwig & Ackley, 2014). A potential complication of atrial fibrillation is the formation of blood clots. Because the heart is not pumping the blood effectively through the heart and through the rest of body the clots may develop. These clots can develop in the heart, lungs and brain. Some of the sign and symptoms of a stroke are mental confusion, numbness or weakness on one side of body or face, headache, dyspnea, oxygen saturation below 95%, vital sign changes. The primary goal is to return the heart rate to normal. The nursing interventions are to administer anticoagulants and blood thinners as ordered, monitor electrocardiogram, monitor heart rate, oxygen saturation. A second potential complication is CHF and as seen in this case study, the patient was diagnosed with CHF. Some of the signs and symptoms of CHF are fluid overload, fatigue, dyspnea, edema, crackles, and hypoxia. Some of the student nurse interventions should be to check weight daily at the same time, monitor oxygen saturation, administer diuretic if ordered, head of the bed at 30-45-degree angle, low sodium diet and fluid restriction if ordered. Teaching PlanF.R. was admitted after being diagnosed with atrial fibrillation. After an echocardiogram was completed, the patient was also diagnosed with congestive heart failure (CHF). CHF is a complication of atrial fibrillation. Some of the important points that were discussed with the patient were about medication therapy, diet, activity and most important disease management. Some of the instructions that the student nurse went over with patient was for him to adhere to a low sodium diet, to take his antihypertension medications and any blood thinning medications along with any new medications prescribed while in the hospital and that now need to be taken as outpatient. The student nurse also educated the patient on the importance of weighing himself daily at the same time. Any weight change of three pounds or more in one to two days should be report to his physician. The student nurse also emphasized to not stop any medications without first consulting with his Cardiologist. The student nurse explained to patient that if he goes home with a blood thinner, he needs to look for signs of bleeding (for example, gums bleeding out of the ordinary when brushing his teeth) and needs to be careful with falls or head injuries. Patient understood and was able to explain back to the student nurse his understanding. He understood that before leaving the hospital follow up appointments will be scheduled with his primary care physician, Cardiology and with the Cardiology Thoracic surgeon. ConclusionAtrial fibrillation has become one of the most common cardiac dysrhythmias and is one of the leading medical diagnosis for admission to a hospital for treatment. But as mentioned in this article, with proper management of the risk factors and aggressive medical management of atrial fibrillation in nurse-led clinics has demonstrated to lower costs for the patient and prevent hospitalizations all while promoting and improving patient’s health. What is key in the management of AF is for patient to seek regular follow up with medical doctors, laboratory/diagnostic testing, and adherence to the medication therapy. Article Synopsis/SummaryJacob conducted a research study to describe how nurse-led clinics can minimize complications of atrial fibrillation by aggressive risk factor prevention and management. The article discussed how the risk factors like diabetes mellitus, hypertension, hyperlipidemia play a major role in attributing to atrial fibrillation. The study emphasizes how nurse-led clinics for risk factor management can prevent further complications of atrial fibrillations like stroke, heart failure, and sudden death. The study looked into how managing both patient’s weight and the risk factor mentioned above can reduce the incidence of AF complications. A large population-based cohort study by Staszewsky et al (2015), who tested the hypothesis that diabetes was an independent risk factor for AF hospitalization by following the cohorts for nine years, concluded that diabetic patients with AF had the highest risk for stroke or mortality. The study proved that nurse-led clinics can improve AF prevention and management by focusing on patient centered care. Through proper and effective management AF, these nurse-led clinics can prevent hospitalizations and further potential complications of AF (Jacob et al. 2017)ReferencesHinkle, J., & Cheever, K. (2014). Brunner & Suddarth’s textbook of medical-surgical nursing, (13th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.Jacob, Liril. 2017. “Nurse-Led Clinics for Atrial Fibrillation: Managing Risk Factors.” BritishJournal of Nursing 26 (22): 1245-48. doi:10.12968/bjon.2017.26.22.1245.Ladwig, G.B., & Ackley, B.J. (2014). Mosby’s guide to nursing diagnosis. Maryland heights, MO: Mosby/Elsevier.Timby, B.K., & Smith, N.E. (2014). Introductory Medical-Surgical Nursing. Philadelphia: Wolters Kluwer.Pagana, K., Pagana,T., & Pagana, T. (2017). Diagnostic & laboratory test reference(13th ed.). St. Louis, MO: Elsevier Mosby.Vallerand, A.H., Sanoski, Ca. A., & Deglin, J.H. (2013). Davis’s drug guide for nurses (13th ed.).Philadelphia: F.A. Davis.

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