Analysis of Mrs. Brown's Case: Heart Failure, Nursing, and Medications

This assignment analyzes the case of Mrs. Brown, who presented with symptoms indicative of acute exacerbation of chronic left-sided heart failure, including dyspnea and atrial fibrillation. The assignment begins by explaining the pathogenesis of heart failure, detailing how the condition leads to clinical manifestations, including pulmonary hypertension and the impact on the respiratory and cardiovascular systems. It then discusses two high-priority nursing strategies: providing patient education and careful monitoring of patients on diuretic medications. The core of the assignment focuses on the mechanisms of action of two drugs administered to Mrs. Brown, IV furosemide and sublingual glyceryl trinitrate, and relates these mechanisms to the underlying pathology. Furosemide's impact on preload and afterload, and glyceryl trinitrate's role in vasodilation are analyzed. Finally, the assignment describes the nursing implications, including monitoring and responding to adverse effects, and evaluating the therapeutic effects of these drugs in managing acute heart failure. The importance of patient positioning, maintaining adequate oxygenation, and continuous monitoring of vital signs are emphasized throughout the analysis. The assignment utilizes several research references to support the information presented.

Guided questions:
Question 1
Explain the pathogenesis causing the clinical manifestations with which Mrs. Brown presented.
Heart failure typically describes the condition of inability of the heart to function to provide the
necessary normal amount of blood to the organs [1]. Due to the characteristic inability of adequate
functionality of the heart, the primary functions of the human system are disarrayed [1]. Therefore,
failure of the heart collectively refers to a syndrome that leads to the weakness of the heart [1, 2]. Heart
failure may either affect the right or the left side of the heart [1, 2]. Failure of the left heart is a common
occurrence across the world [1, 2]. Oxygenated blood is pumped into the left side of the heart and this
blood is pumped to all the organs of the body [1, 2]. In left heart disease, the ability of the heart to
pump blood to all the organs is reduced [1, 2]. Due to the compromised capacity of the heart to pump
blood to all the body, the patient experiences severe fatigue [1, 2]. Mrs. Brown has been reported to
experience a severe case of dyspnoea or difficulty in breathing [1, 2]. This is primarily due to the lack of
oxygenated blood reaching the lungs from the left side of the heart [1, 2]. Mrs. Brown has been found to
have atrial fibrillation. Pulmonary hypertension is one of the most frequently occurring conditions in the
left heart disease [3, 4]. Pulmonary hypertension in left heart disease is a complex and partially-
understood phenomenon [3, 4]. It is regarded as being a heterogeneous phenomenon and is resulted
from the transmission of the filling pressure on the left side of the heart [3, 4]. The transmission is of a
passive nature and occurs in the backward direction [3, 4]. The filling pressures on the left side of the
heart are caused due to the dysfunction of systolic and diastolic pressures in the system in the left
ventricle [3, 4]. The left arterial pressure and the pulmonary arterial pressure are increased due to the
functional mitral regurgitation [3, 4]. The patient thus experiences this during exercise [3, 4]. In the
pathophysiology of left heart disease, a major event is the increase in the size of the left artery [3, 4].

The size of the left artery is a pathological marker for the morbidity of the disease along with indicating
the mortality index [3, 4]. Additionally, the pathological events include impairment of the contractility
and compliance of the left artery and stiffness in left artery [3, 4]. These events lead to several
pathological modifications in the right side of the heart and the pulmonary artery [3, 4]. The cardiac
filling and the output are affected by these pathological modifications in the properties of the left
arterial systolic and diastolic pressures [3, 4]. There is a sudden elevation in the left arterial pressure and
a failure of the alveolar-capillary stress. This results in oedema of the alveolar and the interstitial system
[3, 4]. The occurrence of severe dyspnoea, compromised in the rate of respiration, pulse, and heart rate
are all reduced [3, 4]. Chronic heart failure has high aetiology and the symptoms of disease and
respiratory system and exertional dyspnoea with poor prognosis leading to compromised functionality
in the activities of daily life, similar to the case of Mrs. Brown. The pathology of dyspnoea is mainly
caused due to cardiovascular factors. Additionally, dyspnoea depends on complex interactions in the
pulmonary and cardiac system [3, 4]. There is an abnormal increase in the restrictions on the expansion
of the tidal volume, ventilation, and critical cardiac output leading to dyspnoea [3, 4].
Question 2
Discuss two high priority nursing strategies to manage Mrs Brown and provide evidence-based
rationales for these strategies.
The symptoms of dyspnoea and limitations in breathing lead to several variations in the patient
symptoms [5, 6]. The primary method of determination of the link between the occurrence of dyspnoea
and left-sided heart disease is echocardiography [5, 6]. The intervention of the nurse is one of the most
essential aspects in providing medical care to patients, especially the elderly, for heart disease, chronic
heart failure, and connected pulmonary hypertension and respiratory compromise [5, 6]. The primary
objective of the nursing intervention and clinical manifestation is to maintain the stability of the clinical

presentations of the patient with left-sided heart disease and to improve the quality of life and aid them
in the performance of activities of daily life [5, 6]. The nursing strategies that are of high importance
include:
(i) The provision of education to the patients and to provide prognosis to the patient; the symptoms of
ischemia, hypertension, and atrial fibrillation are common amongst patients [5, 6]. The important
treatment option for dyspnoea is the use of diuretics; however, it does not improve the prognosis of the
patient [5, 6]. Tachycardia is resulted from serious injury to the heart and myocardial infarction [5, 6].
Exercise increases tachycardia and nurses are required to take care that patients remain at rest [5, 6].
(ii) The second nursing intervention involves the care given to patients of chronic left-sided heart failure
who are on diuretic medication, in order to maintain the state of rest and accomplish activities of daily
life [7, 8]. The shortness of breath and dyspnoea is mainly caused by congestion of the pulmonary
venocapillary. Nurses need to ensure that the patients remain in the sitting position while sleeping [5, 6].
The strategies of nursing are predominantly dependent on the care for patients based on the rationale
of compromised daily activity. Research evidence suggests that nursing interventions that aim to
control/restrict activity in the patient, enhance the mechanics of respiration, function of the peripheral
muscle, and exercise capacity [5, 6]. Thus, the rationale for providing nursing care to the heart failure
population is to control pulmonary hypertensive and respiratory impairment and to improve the quality
of life of the patient.
Question 3
Two of the drugs that were given to Mrs Brown were IV furosemide and sublingual glyceryl trinitrate.
a. Discuss the mechanism of action of these two drugs, and relate to the underlying pathogenesis of
an acute exacerbation of chronic left-sided heart failure.

a) Furosemide IV: Diuretics are known for the effective treatment of the retention of sodium and water
in symptoms of chronic heart failure [7, 8]. Furosemide (frusemide) is a diuretic that provides immediate
systemic relief to patients upon administration [7, 8]. Furosemide has direct and indirect implications on
veins and causes venodilation that leads to the release of prostaglandins in the veins [7, 8]. Furosemide
produces a vascular effect in the peripheral system apart from the dieresis occurring through sweat
glands in patients of heart failure [7, 8]. The capacitance and the rate of flow of blood are increased
upon the administration of furosemide [7, 8]. Furosemide causes acute reduction of preload, prior to
dieresis, and had affected haemodynamics [7, 8]. However, furosemide has been found to have an acute
vasoconstricting effect on the arteries as found in Mrs. Brown [7, 8]. This vasoconstricting effect leads to
the elevation of heart rate, filling pressures in the right atrium and the left ventricle, and lowering of the
volume of stroke according to the ECG reports of Mrs. Brown [7, 8]. The following are the important
events that occur upon the administration of furosemide: (i) consistent increase in the activity of plasma
rennin irrespective of venodilation or artertial constriction (ii) formation of angiotensin II (iii) activation
of rennin-angiotensin system and (iv) acute hemodynamic response [7, 8].
b) glyceryl trinitrate: The continuous administration of glyceryl trinitrate (IV) leads to an immediate and
stable therapeutic concentration of nitrates in the blood [7, 8]. Glyceryl trinitrate causes venodilation at
small doses and dilation of both arteries and veins at higher concentrations [7, 8]. It reduces the filling
pressure in the left ventricle and in the oxygen demand of the myocardial system [7, 8]. It is a well-
tolerated drug and produces favourable hemodynamic effects in a majority of the heart failure
population [7, 8].
b. Describe the nursing implications (monitoring for and responding to adverse effects, and evaluating
therapeutic effect) when administering these two drugs to a patient with an acute exacerbation of
chronic left-sided heart failure.

Furosemide: Since Mrs. Brown has atrial fibrillation and severe dyspnoea, during the administration of
furosemide, the blood pressure and pulse have to be constantly monitored. An oxygen mask and
respiratory aids may need to be kept handy for emergencies. Since furosemide leads to atrial
constriction at higher doses, the continuous titration of venodilating dosage has to be maintained.
Glyceryl trinitrate: Monitored titrations of doses need to be infused intravenously to Mrs. Brown. In case
of adverse effects such as respiratory challenges or short breaths, oxygen masks need to be kept
available. The patient has to be positioned in a comfortable and resting manner in order to ensure
controlled cardiac output, pulse, and blood flow rate [7, 8]. Since tachycardia is a common occurrence
during administration of diuretics IV, it is important to maintain a resting position for the patient.
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