Understanding Cardiovascular Diseases

This assignment delves into the complexities of cardiovascular diseases. It examines the pathophysiology of conditions like hypertension and explores various pharmacological interventions for their treatment. The discussion encompasses diuretics, beta-blockers, metformin, and other drugs commonly used in managing these ailments. Case studies illustrate real-world applications of these treatments.

Running head: NURSING CASE STUDY
NURSING ASSIGNMENT- Case study of Joylene Sims
Name of the Student
Name of the University
Author Note

1NURSING CASE STUDY
INTRODUCTION
The purpose of this paper is the case study of Ms. X, name not mentioned to protect
confidentiality, to understand her medical history, events leading to her admission, health
risks, Pathophysiology of the clinical conditions experienced by the patient, pharmacological
interventions that might be applicable (including the outcomes, side effects, contradictions
and nursing considerations), assessment of the diagnoses and provide recommendations
based on the findings.
The patient is a 66-year-old lady, residing in SA Housing with her son and primary
care giver, Matthew. She previously was able to live independently with little assistance,
needed 4WW for walking, and was able to manage her own medication, finances, toileting,
and personal care.
She was admitted to Finder’s Medical Centre on 02/05/2017 after her son found her
collapsed on the floor. The patient also had a medical history of Diabetes Mellitus (type 2),
Hypertension, Migraine, Fatty Liver, Depression, Right Sub Arachnoid Cyst, Recurrent pain
of lower back, Left Shoulder Bursitis and Anxiety disorder. A drastic drop in blood sugar
levels caused by Diabetes Mellitus can cause loss of consciousness (Fainting diabetes2017).
She was subsequently diagnosed with chest infection and right leg cellulitis with
septicemia. She was administered with intravenous antibiotics immediately.
Her condition worsened, and developed rapid Arterial Defibrillation, Acute Kidney
Injury, pneumonia and edema in her legs and arms. Her urine tested positive for APMC
(multi resistant gram-positive bacterium). She has also admitted to the Intensive Care Unit
twice for respiratory failure, which along with her present medical condition caused
significant deconditioning and a loss of functional abilities.

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Consent was obtained as per the healthcare policy guidelines to access her
information, for ethical concerns (Nursing and Midwifery Board of Australia – Policies,
2017).
The health risk was aggravated by the history of diabetes, which could have had
stressful effects on the other organs (Matsuda and Shimomura 2013). Hypertension, and
arterial fibrillation further complicated the condition, and a damage of the kidneys could be
attributed to it, which can also explain the onset of edema (Bonde et al. 2014). Depression
and Anxiety may also be the effect of her clinical condition.She is also suffering from
Obesity and Deconditioning.
PATHOPHYSIOLOGY/ PHARMACOLOGY
During the shift the patient experienced a plethora of signs and symptoms that
worsened his condition. The primary concern in the patient was diabetes. Type 2 Diabetes
occurs due to an insufficient production of insulin by the pancreas or an insulin resistance
(which causes the failure of cells of muscles, liver and fatty tissues to respond to insulin, even
if they exist in high levels in the blood). This resulted in a rise in blood glucose level, and a
depletion of the stored glycogen. Insulin resistance can be caused due to obesity and lack of
physical activity (Mandal, 2017).
Type 2 diabetes represents about 90% of all reported diabetes cases, and can lead to
other complications like cardiac arrest, problems with vision and foot ulcer
(Diabetesaustralia.com.au, 2017). The risk factors include family history, age more than 45
years with obesity or High Blood Pressure, and certain ethnic groups. Typical symptoms
include: excessive thirst, frequent urination, lethargy, persistent hunger, slow healing of
wounds, skin infection and itching, blurry vision, obesity, mood swings, headache, dizziness,
leg cramps (Kirk et al. 2015).

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Study of the patient’s clinical condition shows a clear association with diabetes
related complications. Her diagnosis of septicemic infection of the leg, Hypertension,
Migraine, Fatty Liver, Depression and Anxiety can be attributed to Diabetes.
Pharmacological intervention should involve administration of Metformin HCL (1g) daily
(Mujeeb and Mutha 2015). This medicine will help in improving her sensitivity to insulin,
and will result in a lowered glycogenesis in the liver. However, lifestyle changes like weight
reduction and exercise is needed for the medicine to be effective in reducing blood sugar
levels. Side effects include nausea and diarrhea.
The patient also reported signs of hypertension, evidenced by blood flow through the
vessels with a higher pressure than normal. This requires attention as the condition can create
stress on the heart, damage blood vessels, and can also heighten chances of cardiac arrest or
myocardial infarction, cerebrovascular accident, renal dysfunction. It can even lead to death
(PubMed Health, 2017).
The physiological mechanisms underlying hypertension includes a decrease in
peripheral resistance and elevated cardiac output; low levels of rennin and angiotensin II;
interaction between the autonomous nervous system and renin-angiotensin system;
endothelial dysfunction and genetic factors (ncbi.nlm.nih.gov, 2017). These will lead to
headaches, dizziness and anxiety.
The history of migraine headache and anxiety can be attributed to hypertension,
which in turn could be related to her obesity (Ahmad et al. 2016).
Pharmacological intervention should include administration of Nebivolol (5mg) once
daily and Frusemide (40mg) thrice daily. Nebivolol is a beta receptor blocker and vasodilator
(Perros et al. 2015), and Frusemide helps in the treatment of the buildup of fluid caused by
cardiac failure, liver scarring and kidney dysfunctions (Tamargo, Segura and Ruilope. 2014).

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The drug will inhibit the absorption of sodium and chlorine in the proximal and distal
convoluted tubules of the nephrons. Thus, both these medications can be used as effective
interventions to treat hypertension in the patient.
The side effects of Nebivolol may result in hypersensitivity, low blood sugar,
dizziness, breathlessness, gain in weight, and swelling of arms or legs, slowing of heartbeat,
headache and fatigue (Velasco et al. 2016). Therefore, the drug should be administered with
or before food, at a single time without missing any doses (however, double doses/extra doses
should be avoided, if timely administration is missed). Frusemide may also lead to increased
urination, weakness, muscle cramps, thirst, rashes, dizziness, diarrhea/ constipation, stomach
pain, fever, nausea and dehydration. However, it should be noted that the medication can
increase nephrotoxicity of cephalosporin and aminoglycosides, and should not be
administered with phenytoin and indomethacin.
The presence of atrial fibrillation in the patient is another concern. It is caused by irregular
beating of the atrium of heart, causing irregular or rapid heartbeat. This increases the risk of
strokes, heart attack and other cardiac dysfunctions (January 2014). The irregularity can be
due to chaotic electrical signals to the Aurio-Ventricular (AV) node, and increase the heart
rate to 100 to 175 beats per minutes, and can also cause ventricular fibrillation (Andrade
2014).
Previous history of hypertension, lung disease, heart attack, congenital heart defects,
coronary arterial disease, and abnormal valves of heart, thyroid dysfunction and viral
infections might have contributed to the incidence of atrial fibrillation in the patient.
Common symptoms include weakness, palpitation, fatigue, dizziness, short breath, confusion,
chest pain and light headedness (Heart.org. 2017).

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Based on the symptoms being manifested by the patient, her pharmacological
interventions should include daily administration of Amiodarone (200mg). The drug will
block electrical signals to the heart that causes irregular heartbeats (Roy et al. 2000).
However, she may suffer from some side effects such as, nausea, constipation, appetite loss,
fatigue and shakiness (Drugs.com.2017). Her allergic and medical history (liver/ lung
/thyroid dysfunction) should be checked before administering the drug.
The patient also exhibited signs and symptoms of obesity, following her admission.
This condition is principally characterized by an excessive accumulation of body fats,
causing adverse health conditions. A body weight that is 20% more than the normal weight
and a Body Mass Index above 30 is considered as obese (WHO, 2017). Excessive calorie
intake, sedentary lifestyle, lack of sleep, endocrine disruption (like food that interferes with
lipid metabolism) and genetic conditions (like a faulty FTO gene or family history) might
have contributed to the excess increase in weight in the patient (Healthdirect.gov.au. 2017).
This condition is dangerous for the patient as it aggravates the chances of type 2
diabetes, cardiac disease, hypertension, arthritis, stroke and sleep apnea (Esser et al. 2014).
The effects on health can be due to an increased mass of fat (causing arthritis, sleep apnea) or
increase in the number of fat cells that can cause insulin resistance, proinflammatory and
prothrombotic states.
Since the patient was already obese, it can be concluded that diabetes, hypertension,
fatty liver and back pain could have been a clinical repercussion. An effective approach
would be a change in diet, and usage of laxatives like Docusate (50mg x2) and Sennoside
(8mg), twice a day. Reducing the reward value for food is a good strategy to reduce weight
(Hiesler. 2016).

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Side effects of Docusate include rectal bleeding/ irritation, rashes around rectum,
diarrhea, stomach cramps, constipation, and allergic reaction. Sennoside administration can
also lead to nausea, vomiting, diarrhea, weakness, muscle cramp, dizziness, cardiac
arrhythmia, decreased urine output, mood changes and allergic reactions. Therefore, there is a
need to check for drug interactions for both the medications, before administering them to the
patient (Drugs.com. 2017).
The patient also reported signs of deconditioning that might have occurred due to lack
of physical activity or due to disuse of body parts, and can have severe effect in older patients
(Narici. 2017). A sedentary lifestyle or complete bed or chair rest during an illness might
have contributed to this condition in the patient. Deconditioning is characterized by a decline
in muscle tone, mass and strength. Aging can result in a reduction in the number of muscle
fibers, and thus a loss of the bulk. Additionally, disuse of muscles can have similar effects on
muscle strength and mass. Since the patient was completely bed ridden, it seemed possible
that it resulted in her deconditioning due to the lack of use of her legs. An exercise plan
should be formulated with the help of a physical therapist that would keep the patient in good
spirits.
INVESTIGATION
Investigations on the patient’s medical condition revealed the following problems: she
developed cellulitis on the right leg, and a subsequent septicemia. It can be attributed to the
slowed healing of wounds typical in diabetes. Nurses play an essential role in conducting
assessments and identifying worsening conditions in a patient. However, evidences suggest
that they often miss reporting patient’s exacerbating conditions due to delayed management
that leads to adverse consequences (Chua et al. 2013). Strict monitoring of her blood pressure
was required to reduce health complications. If her increased blood pressure was left

7NURSING CASE STUDY
uncontrolled several complications such as, transient ischemic attacks, dementia, cognitive
impairment, kidney failure, heart failure might have occurred. Therefore, her blood pressure
was continuously checked. She also developed chest infection which can be related to the
fluid buildup and edema caused by diabetes. She was consequently administered antibiotics
via intravenous channel. However, her condition became worse, and she developed acute
kidney infection, due to the systemic spread of the disease. A positive urine test for AMPC
indicated the presence of urine infection in the patient. There was a need to periodically
monitor her blood glucose levels before and after meals as this would provide an accurate
representation of her glycemic index. This should be strictly monitored unless the levels get
normalized. Significant associations exist between cardiovascular complications and high
glycemic index. Therefore, there is a need to control her blood sugar levels in order to reduce
predisposition to further complications.
An X-ray analysis showed the presence of chest infection in the patient. Her lung
infection seemed to have quickly worsened, and she even faced respiratory failures, twice,
while in the intensive care unit. Because of these multiple complications, she was put to
complete bed rest, and it result in a significant deconditioning of her muscle’s strength and
tone. The patient was considered for an ACAT assessment. This aged care assessment team
provided her assistance as she was obsess and was unable to move (Boltz et al. 2016). ACAT
assessment showed that the patient was no longer able to stand transfer, and hence she needed
more care than what can be provided at home. Sling assistance for bed transfers, and 2-3
assists were provided.
RECCOMENDATION
Firstly, the patient requires a round the clock nursing supervision or a permanent
residential care. Both physical and social health care must be provided to the patient in order

8NURSING CASE STUDY
to help her achieve optimal health and wellbeing. Secondly, her diet should be properly
formulated to ensure prevent excess calorie intake. Thirdly, it is also important to address the
effect of the diseases on her mental health condition. Her medical history of depression and
anxiety predisposes her of acute mental stress, which can adversely affect the treatment
outcome. It can therefore be suggested that she be administered 4 tablets of Doxepin (50mg)
or 1 tablet of Duloxetine (30mg), daily to manage depression (Werner and Covenas. 2017).
Furthermore, social healthcare workers should be involved in providing long term care, and
to assist the primary caregiver (patient’s son). As it is understood, that the patient might be on
prolonged bed rest, with only the minimal movement, regular checkups are needed to ensure
she does not suffer from bed sores, muscle fatigue and further deconditioning.
Additional recommendations can a psychological counseling or evaluation would be
helpful for the patient to deal with her condition. Since a comprehensive care might not be
feasible in the house, she was recommended to opt for permanent residential care.
REFLECTION
Working as a nurse involves a list of responsibilities like observing behavior of
patients; coordination between the healthcare professionals; creating and evaluating care
plan; emotional and psychological support; analyze patient’s symptoms and taking any action
needed for recovery; maintain report, medical history, and change in condition; administering
or changing medication; checking the stock of medicine, to ensure it does not run out;
maintain safe and hygienic environment; researching effective nursing practices; providing
emergency care; discussion of treatment plan with doctors or healthcare professionals;
providing guidelines disease prevention and health maintenance (Nursing and Midwifery
Board of Australia – Policies. 2017).

9NURSING CASE STUDY
Feedbacks are essential tools for developing competencies in the field of evidence
based nursing (Boltz, Capezuti, Fulmer and Zwicker. 2016). The feedback by my PEP
facilitator during my VIVA VOCE placement suggested that I had demonstrated sufficient
knowledge on the case scenario that was presented. I was able to identify the gaps that were
associated with the pathophysiology of the several complications presented by the patient.
However, my placement facilitator suggested that there was lack of cohesion in my VIVA
VOCE assessment. Moreover, I did not demonstrate adequate flow of information during the
assessment. My facilitator suggested that I had demonstrated great efforts to present the case.
I felt that registered nurses should provide frequent feedbacks to the nursing
students to help them develop their nursing practice. The substandard 1.2 of the Nursing and
Midwifery Board of Australia(NMBA) (2016, p. 3) points out that nurses are supposed to
critically think and analyse the nursing practice. Furthermore, the sub standard 3.5 states that
a nurse should maintain the practice capability to ensure continuous professional
development. Using the reflection provided, I will implement a better strategy in analyzing
and writing the article. I will follow the protocols and marking criterion, create a mental
checklist, and work towards achieving my objective. Utilizing the knowledge gathered from
the feedback, and the learning processes, allowed me to better understand the subject and
national standards. Thus, the clinical placement and VIVA VOCE assessment helped me
enhance my clinical skills.

10NURSING CASE STUDY
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