Atrial fibrillation

Length: 2000 words

This academic paper requires students to articulate in writing the patient presented at their Clinical Case Conference. It should be submitted as a report. There must be analysis of the patient’s medical condition(s) demonstrating the ability to apply theoretical concepts including (but not limited too) pharmacology; patho-physiology; anatomy and physiology. There must be presentation and evaluation of nursing and medical management of the patient. Sound clinical rationales must be provided that support the care afforded the patient. Appropriate evidence sources must be used and Harvard referencing used throughout.

Please according to the patient’s case study.

Follow the structure and marking rubic.
The requirement and structure of this essay:

Introduction: (200 words)
1.Introduces patient student presented at Case Conference
2.Presents biographical data
3.Presents current medical history of this patient
4.Presents past medical history of this Patient

Discussion: (1200words)
1.Demonstrates understanding of patient’s medical condition(s),
including relevant anatomy and physiology and in ‐ depth pathophysiology discussion.
2.Nursing management Included ‐ clinical assessment presented
using ISBAR(Introduction, Situation, Background, Assessment, Recommend), explanation of how nursing management relates to
medical management with clear clinical rationales provided, role
of interdisciplinary team involvement explained and primary health care strategies evident.
3.Medical management and Treatments described including
all relevant pharmacological, non– pharmacological treatments,
pain management explained and clear clinical rationales provided
4.Relevant Laboratory results / Diagnostic tests included (put in appendix if word count is high)
5.Evidence of ability to make clinical inferences based upon the data available.
6.Psychosocial / Environmental / Economic aspects of the case discussed
7.Ethical and legal aspects included if relevant
8.Education of patient / family
9.Discharge Planning

Article Discussion: (500 words)(Please find a article for me, must less than 5 years, talk about Type 2 Diabetes management and self-care)
1.Description of how this literature findings/recent evidence is related to the case
2.Comparison and critique of the management / nursing care of
the case against the literature.
3.Suggestions of alternative management / nursing care

Summary and conclusion: (100 words)
1.Summary of the case
2.Education needs of the patient
3.Short and long term outcomes
4.Other relevant comments

reference for this essay and must less than 5 years. The article should mention about Type 2 Diabetes management and self-care.

In this essay, just following the requirement of the numbers, mention all of the essay requirement and structure.

Patient’s Case Conference

1. Patient Data
Name: Pendini Vincenzo Gender: Male Age: 84 yrs

2. Psychosocial / economic background
He’s Independent with ADL’s. His wife died 2 years ago. He was born in Italy, He came to Australia in 1945. He speaks English. He worked at Car factory. He retired for a long time ago.
He has 1 daughter and 2 sons. They live in Adelaide. Now he lives in a house with his daughter. His daughter and son-in-law take care of him.
He has medical insurance.
He has quit smoking when he was 35-year-old. Drug free. Before he came to the hospital, he drinks 2 glasses of wine a day.
He can drive, and shopping by himself.

3. Date and reason for admission/Current medical history

This patient admitted with left pleural effusion on 3/10/2014.
He was admitted with Pneumonia in Ashford Hospital, for 3 weeks last month.

Left pleural effusion – is excess fluid that accumulates in the pleural cavity, the fluid-filled space that surrounds the lungs. Excessive amounts of such fluid can impair breathing by mass effect, limiting the expansion of the lungs during ventilation( hydrothorax).
Pathophysiology — Pleural fluid is secreted by parietal layer of the pleura and reabsorbed by the lymphatics[lɪm’fætɪks] in the most dependent parts of the parietal pleura, primarily the diaphragmatic and mediastinal regions.

On the admission day, pt is A + O. coughing and shortness of breath. No chest pain. Ankles more swollen. He has low BP. Systolic pressure between 90-110mmHg(millimetre(s) of mercury). Diastolic pressure between 50-60. Other Obs stable. Cough improved at night.

4 Past medical history
Type 2 Diabetes(T2DM), Arial Fibrillation(AF), Left Ventricle Failure(LVF), Congestive Heart Failure(CCF), Pneumonia, Gout, Osteoporosis, Low Blood Pressure, High Cholesterol, Constipation

Pt had T2DM for 4 years.
— a metabolic disorder
is insulin resistance.
Damaged secretion of insulin by the pancreatic beta cells
Increased glucose production by the liver.

T2DM, initially stimulates an increased in insulin secretion, often to a level of modest hyperinsulinemia, as beta cells attempt to maintain in a normal blood glucose level. In time, the increase demand for insulin secretion leads to beta cells failure.

Risk factor: elder people, overweight, Smoke, Alcohol

The classic sign & symptoms are excess thirst, frequent urination, and constant hunger.

Arial Fibrillation- Atrial fibrillation is a type of arrhythmia, which means abnormal heart beats.
–Atrial do not contract.
— SA node is not working properly.
It is often associated with chest pain. But this pt has no chest pain. AF can be confirmed with ECG. No P Wave.
The primary pathologic change seen in atrial fibrillation is the progressive fibrosis of the atria. This fibrosis is due primarily to atrial dilation, Dilation of the atria can be due to almost any structural abnormality of the heart that can cause a rise in the pressure within the heart.

LVF & CCF
CCF is a condition in which the heart’s function as a pump is inadequate to deliver oxygen rich blood to the body. Congestive heart failure can be caused by:
1. diseases that weaken the heart muscle
2. diseases that cause stiffening of the heart muscles
3. diseases that increase oxygen demand by the body tissue beyond the capability of the heart to deliver adequate oxygen-rich blood
In a person with CCF, The left ventricle does not empty properly. This leads to increased pressure in the atria(upper chambers) and the nearby veins. This backlog of blood triggers fluid retention (oedema) in the lungs, abdominal organs and legs. This affects the kidneys, interferes with their function and leads to retention of salt and water, causing oedema.

In some people with HF, rather than failed pumping of the blood from the left ventricle, there is failed relaxation of the left ventricle. This also leads to blood pooling under back-pressure.

Pneumonia
Lung Infection—bacteria or viruses
Pneumococcal pneumonia and Mycoplasma pneumonia
A pleural effusion is a fluid collection around the inflamed lung. This often results when the pneumonia is close to the chest wall and causes inflammation in the pleurae surrounding the lung
Symptoms – cough, chest pain, fever, difficulty breathing

Gout — Gout is characterized by sudden, severe attacks of pain, redness and tenderness in joints, often the joint at the base of the big toe. It is caused by elevated levels of uric acid in the blood.

Osteoporosis — is a progressive bone disease that is characterized by a decrease in bone mass and density which can lead to an increased risk of fracture.

5 Diagnosis (Testing/confirmation & pathology results)

ECG — Showed AF (No P Wave)
Troponin — positive (Troponin is a complex of three regulatory proteins (troponin C, troponin I, and troponin T) that is integral to muscle contraction[2] in skeletal muscle and cardiac muscle, but not smooth muscle.)

Chest X-Ray — small bilateral pleural effusions

Echo – heart size is generally enlarged.

Blood test – high Urea & Creatinine— Kidney Dysfunction

INR – Result 1.1 (because using Warfarin)
The target is 2-3.5

6 Treatment

Pharmacological treatment

Pt had Pleura fluid tap on 5/10/14. It is the thoracentesis. The drainage of fluid for therapeutic or diagnostic purposes from the pleural space. This is procedure to remove fluid from the Pleura Space. A cannula or hollow needle, is carefully introduced into the thorax, generally after administration of local anesthesia.

Complication – Haemorrhage
Infection
Post – Rest in Bed
Record Obs every 30mins for 2 hrs
Check wound intact and dry. No bleeding
Held Warfarin for the tap, but still need Keep an eye for the wound—bleeding problem, he has high risk on bleeding.

Medication:
Metformin SR(Slow release) 500mg — For his T2DM
– for T2DM
– is an oral anti-diabetic drug (first line drug of choice for treatment of type 2 diabetes)
– can make insulin working well
– mainly to counteract the most common GI side effects.
His BGL 7.7mmol/L @ 2100 with good controlled– Always between 6-7.9mm/L

Bisoprolol 2.5mg – Beta-Blockers – Hypertension, —For his CCF
— works by relaxing blood vessels and slowing heart rate to improve and decrease blood pressure

Amiodarone 200mg BD — For his AF & CCF
— Anti-arrhythmic medication
— Amiodarone is used to help keep the heart beating normally. in people with life-threatening heart rhythm disorders of the ventricles
— Amiodarone is used to treat ventricular tachycardia or ventricular fibrillation.
Amiodarone is for use only in life-threatening situations. This medication has the potential to cause side effects that could be fatal, and you will receive your first few doses in a hospital setting. Initial dose (PO): Loading doses of 800 to 1600 mg/day are required for 1 to 3 weeks until initial therapeutic response occurs. When adequate arrhythmia control is achieved, the dose should be reduced to 600 to 800 mg/day for one month and then to the maintenance dose, usually 400 mg/day.

Clexane (Subcutaneous Injection) 50mg BD—For his CCF. Prevent Blood Clots due to prevent stroke.
(His on the treatment dose, Because his Warfarin was stopped for the Pleura fluid tap)
— Clexane injection contains the active ingredient enoxaparin, which is a type of medicine called a low molecular weight heparin. It is used to stop blood clots forming within the blood vessels
— Treating blood clots in the coronary arteries in unstable angina and heart attack, MI
— need regular blood tests to monitor the numbers of blood cells called platelet in blood
Side effect — bleeding — contact with Dr straight away

Frusemide 120mg Oral BD — For his oedema
— is a loop diuretic — treat for High Blood Pressure, CCF and oedema.
Side effect – electrolyte imbalance

Spironolactone 12.5mg — For his Oedema
— potassium Sparing Diuretic — CCF
— In patients with heart failure, increased levels of a hormone produced by the adrenal glands, called aldosterone, causes salt and fluid to be retained by the kidneys. The body then becomes overloaded with salt and water, and this worsens the heart failure.
Spironolactone inhibits the action of aldosterone thereby causing the kidneys to excrete salt and fluid in the urine while retaining potassium. Therefore, spironolactone is classified as a potassium-sparing diuretic, a drug that promotes the output of urine (diuretic) while allowing the kidneys to retain potassium.

Digoxin 125mg (5 days MAX)
— helps Keep regular heart rhythm.
is used to treat heart failure & AF
Before give this med, should check pulse. If less than 60bpm, should not give.

Simvastatin — ‘Statins’ 80mg PO
— Lower cholesterol
— is used to lower the risk of stroke, heart attack

Movicol — bowels — constipation
Coloxyl & Senna— bowels — constipation

Panadol Osteo — pain relief

Allopurinol 150mg PO
— treat Gout
— treat hyperuricemia (excess uric acid in blood plasma)

Assessment

Baseline
Cognition : A + O

Obs
QID BGL (6-7.9 mmol/L) Make sure before and after meal check BGL
Metformin at night
Side effect: Hypoglucemia – ask pt any dizziness or polydipsia.
Could give high sugar drink or food, if pt is conscious and able to swallow.

If BGL over 20-25 — check ketone, monitor diabetic ketoacidosis
If BGL less than 3.5-4 — caused by too much insulin, less intake,
S&S — pale, moist, cool skin, drowsiness, sweaty

100mls Carbotest — 15 mins recheck — if less than 4 — repeat
100mls Carbotest — modification, recheck in 1hr
If Unconscious — MET CALL / IM(intramuscular injection) Glucagon

Vital Signs
Admit Day for 4 hrsly Obs, if stable, TID Obs.
RR + O2 — Airway problem
Pulse — AF,
BP – low BP
Pain (Pleural Tap site)— Factors(coughing & Movement)
-Intensity – Pain scale
-Quality
-Onset + duration
-Location
If chest pain – ECG & GTN Spray(PRN)
Type of Eating – soft diet for constipation

1.5L Fluid Restriction FBC & Daily Weight — CCF
Fluid overload – increase heart workload
Encouraged Volid in Bottle due to meansure output
Frusemide & Fluid restriction with good effect – 79Kg on admission day 3/10/14
75 Kg on 7/10/14

Skin – Intact & Dry
He has legs oedema problem. See the legs color, and pitting. Ask about the shoes become small or not. Elevating the legs for good circulation.

Fall – nil Fall history, poor bone strength(Osteoporosis), still has risk on fall.

Psychological – Upset before he came to FMC. Because pt complain about Ashford Hospital didn’t solve his problem and sent him home.
Good relationship with families.
Still sad for his wife died

CCF Nursing Interventions
1. Assess for abnormal heart and lung sounds.
2. Monitor blood pressure and pulse.
3. Assess mental status and level of consciousness.
4. Assess patient’s skin temperature and peripheral pulses.
5. Monitor results of laboratory and diagnostic tests.
6. Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs.
7. Implement strategies to treat fluid and electrolyte imbalances.
8. Encourage periods of rest and assist with all activities.

Recommendation
Monitoring BGL Regularly—educate T2DM, tell him about hypoglycemia & hyperglycemia, avoid these problems

Medication – educate all meds and tell him how to take them.

Chest pain – lay flat, have a rest, GTN Spray, or call ambulance

Constipation – stool check daily. Should be aware if bowels not open over 2-3 days, taking bowels medication regularly

Diet – – High Fiber
Low Fat, Low salt, Low Sugar, soft diet

Encourage cut drink after go home, educate alcohol damage to the heart failure.

Exercise – Regular activity—Refer to Physio

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