Please respond to these posts to classmates in 125 words or more, by expanding upon what they have said or asking a probing question. Include one reference with each response.
1.
This patient presents with Stage 2 Hypertension, defined as systolic blood pressure greater than 140 or diastolic blood pressure greater than or equal to 90 (Norris & Ellinas, 2019) as well as a STEMI, more commonly known as a heart attack. Initial treatment for this patient should include cardiac angiography and reperfusion therapy within 90 minutes. If the patient needs to be transported, thrombolysis should be initiated and volume provided to assure adequate preload while other treatments may include aspirin load with 162 to 325 mg, unfractionated heparin, GP IIb/IIIa antagonist, and additional P2Y12 anti-platelets such as clopidogrel (Warner & Tivakaran, 2021) as well as oxygen, pain medications, and sometimes insulin (Norris & Ellinas, 2019). It is important to obtain more than one 12-lead ECG reading to confirm findings and because some changes may not show up until later (Norris & Ellinas, 2019).
Some complications post heart attack that may arise include cardiogenic shock, atrioventricular block, ventricular fibrillation, stroke, thromboemboli, and sudden death (Norris & Ellinas, 2019). The risk of stroke post-STEMI for this patient is greater due to her age and current diagnosis of hypertension (Norris & Ellinas, 2019). And even with proper follow-up and rehabilitation, a significant number of these patients need permanent pacing within 3 years (Warner & Tivakaran, 2021).
The patient and her family will need to be prepared for complete lifestyle changes to be made. Cardiac rehabilitation includes exercise, nutrition, smoking cessation, psychosocial management, and education (Norris & Ellinas, 2019) and there are programs available throughout the community. The patients goals should include lowering blood pressure, decreasing cholesterol and blood glucose, and maintaining a healthy body weight (Warner & Tivakaran, 2021). Because of her comorbidities such as diabetes mellitus, this patients goal blood pressure should be under 130/80 (Armstrong, 2018). She should be referred to a PCP to complete monthly blood pressure checks until goals are met, and due to her ethnic background she should be started on a thiazide diuretic or a calcium channel blocker. If her goals are not met within a month, a second medication may be added (Armstrong, 2018). The patient should focus on creating healthy, sustainable habits such as increasing activity and decreasing salt and alcohol.
2. According to JNC7 recommendations, a blood pressure of 160/90 would fall into the Stage 2 Hypertension category. The criteria for stage 2 are a systolic pressure greater than or equal to 160 or a diastolic pressure greater than or equal to 100 (Shrout et al., 2017). Since the patient is 54 years-old with pressures above 140/90, pharmacologic treatment should be initiated. Due to race and comorbidity of diabetes, calcium channel blockers or a thiazide diuretic would be the initial hypertensive drug to initiate. After a one-month trial, dosage should be increased or second medication added if the target blood pressure has not been achieved. (Ibanez et al., 2018)
The clinical management of this patient would begin with a prompt deployment of a medical team or expeditious transport to a higher level of care capable of initiating ST-segment elevation myocardial infarction (STEMI) evaluation and reperfusion therapy (Norris, 2018). Serial 12-lead electrocardiogram (ECG) should be obtained. Oxygen therapy may be indicted for SaO2 levels less than 90%. Since the patient was diagnosed with an inferior myocardial infarction with ST elevation in three leads, focus will be on pain management and reperfusion via primary percutaneous coronary intervention (PCI) or fibrinolysis. PCI reperfusion should be done within 12 hours of initial symptoms and within 120 min of STEMI diagnosis. Fibrinolysis should be done within 12 hours of onset of symptoms with the ultimate goal to inject fibrinolytics within 10 minutes of STEMI diagnosis. Periprocedural pharmacotherapy includes platelet inhibition and anticoagulation medication. A coronary artery bypass graft (CABG) can be considered if PCI cannot be performed and ischemia is ongoing. Once initially stabilized, there should be continuous monitoring of vital signs to include ECG. Frequent monitoring of glycemic status should also be initiated. (Ibanez et al., 2018)
Complications could include myocardial dysfunction of the ventricles, cardiogenic shock, and conduction disturbance arrythmias like supraventricular arrythmia, ventricular arrythmia, sinus bradycardia, and atrioventricular block (Ibanez et al., 2018). According to Norris, sudden death from STEMI is usually attributed to fatal arrythmias and occurs within one hour of onset of symptoms (2018). Other complications like sudden hypotension, recurrent chest pain, cardiac murmurs, pulmonary congestion, or pericarditis may also occur. (Ibanez et al., 2018)
According to the JNC guidelines, once discharged, the family and the patient would need to be educated on the importance of adherence to follow-up appointments, medication regimen, and other needed treatments. Compliance with the plan of care will allow assessment of current strategies, early detection of complications, and the need for further intervention like an implantable cardioverter-defibrillator. The patient and family would also need to be educated on lifestyle changes that will decrease risk of further damage to the heart or sudden death. (Ibanez et al., 2018)
Key lifestyle interventions include goals for optimal blood pressure, blood sugar, and cholesterol levels. These can be attained through implementation of diet changes and adherence to pharmacotherapy. The recommended diet would be one high in vegetables, fruits, legumes, nuts beans, grains, fish, and unsaturated fats. It would include a low intake of meat and dairy products. The patient would be encouraged to eliminate processed foods and limit alcohol. She should also participate in an exercise-based cardiac rehabilitation program tailored specifically to her condition. Increased activity and diet changes will contribute greatly to reducing abdominal fat and attaining a healthy weight and body mass index. Commitment to a heart healthy lifestyle and the plan of care can help prevent future recurrence and improve quality of life. (Ibanez et al., 2018)
3.
The disorder that is described in prompt A is endocarditis. Endocarditis is an infection of the inner surface of the heart (Norris, 2019). The infection is caused when a bacterial agent enters the blood stream, most commonly Staphylococcus epidermis, that can be either from a blood stream infection, injection from a contaminated needed (intravenous drug users) or from a source in the mouth from a dental or surgical procedure (Norris, 2019).the infectious process from the endothelial injury, bacteremia, and changes in hemodynamic can activate the formation of fibrin-platelet thrombus along the endothelial lining (Norris, 2019). When there is thrombus formation the risk of bacterial seeding increases and leads to the inflammation and enlargement of valular vegetations (Norris, 2019). The most common areas of the heart that are infected include the mitral and aortic valves and can also infect the right side of the heart. Infection may also be systemic when the vegetations dislodges and travels as an emboli throughout the body (Norris, 2019). Diagnosis is obtained through transesophageal echocardiogram (TEE). Treatment includes intravenous antibiotics usually vancomycin.The disorder that is described in prompt C is left sided heart failure also known as congested heart failure. Left sided heart failure causes a decrease in the cardiac output which results in blood back up in the left ventricle, left atrium and in the pulmonary circulation which elevates the pulmonary venous pressure (Norris, 2019). This increase in pressure causes the capillaries to shift intravascular fluid into the intersitium of the lung resulting in pulmonary edema (Norris, 2019). Causes of left sided heart failure include hypertension which increases afterload which makes the heart work harder to pump (Chahine & Alvey, 2021). The heart is a muscle so when it has to pump harder it increases in size which leads to the ventricles being enlarged and having to work harder to circulate blood. These results in a low ejection fraction which can be classified preserved that is above 50%, mid range 41-49%, or reduced below 40% (Chahine & Alvey, 2021). Other causes of left sided heart failure include coronary heart disease, past myocardial infarction, obesity, diabetes, smoking and drinking alcohol (Fairview. org, n.d.).
4.I nfective Carditis or acute bacterial carditis is caused by damage to the endocardium of the heart followed by bacterial colonization that leads to infection. McDonald (2009) mentions that the most common site of endocardial injury is the atrial valve and infections are mostly caused by staphylococcal infections and those of the HACEK group. The bacterias portal of entry into the bloodstream is from contaminated surfaces such as an oral cavity. Dental work creates holes and lesions within the oral cavity making it easy for bacterial to enter the blood. The bacteria then attach to the surface of the damaged endocardium tissue and buries itself within the blood clot. Inflammation at the site releases tissue factor and cytokines, which attracts platelets to the site and becomes activated, causing vegetation or growths (Holland, 2016). The bacteria attach itself within the fibrin strands of the blood clot, which is composed to fibrin, platelets, and bacteria. Overtime, the clot grows and continuously releases bacteria into the bloodstream due to its loose composition. As the clot grows, valve damage is caused, which can lead to valvular regurgitation, abscess, heart blocks, pericarditis, aneurysm, and valve perforation (Norris, 2018). Norris (2018) mentions that the incubation period can be 2 weeks for infective carditis. Signs and symptoms include fever chills, anorexia, malaise, lethargy, and dyspnea. Diagnostics include blood cultures, echocardiography, CT, MRI, and tests that meet DUKES criteria. Treatment includes preventative measures for a PE, antibiotics, and prophylactic antibiotics for dental work. Tricuspid valve regurgitation falls under heart valve disease where the valves between the ventricle and atrium do no close properly causing blood to leak backwards into the atrium (Norris, 2018). Primary causes of tricuspid valve regurgitation are direct valve injury from either trauma or an implantable device, congenital heart disease, infective carditis, rheumatic valve disease, carcinoid syndrome, tricuspid valve prolapse, connective tissue disorder, inflammatory and autoimmune disorders myxomatous degeneration and other valve disorders (Mulla, 2021). Structure abnormalities causes the backflow of blood from the right ventricle to the right atrium during systole. The valves are unable to close properly, allowing blood to leak and back up. Rana, Robinson, Francis, et. al (2019) explains that left sides heart failure causes an increase of left atrial pressure which leads to pulmonary hypertension. This overload strains t he right ventricle which cause it to become enlarged in size. This enlargement makes the tricuspid annulus dysfunctional and unable to properly close. Since the heart cannot pump blood efficiently, there is a built up in pressure in the circulatory system that forces fluid into the lungs and other parts of body. This creates pulmonary edema as well as peripheral edema. This also reduces oxygen movement into the lungs which causes shortness or breath due to hypoxia (Mulla, 2021). Other clinical manifestations are fatigue, arrhythmias, distended and pulsatile neck veins, S3 gallops and murmur. The back up of the pulmonary system causes overload which is pushing fluid into other spaces which can cause distended veins and edema in peripheral spaces. Due to less oxygen perfusion, the patient will feel short of breath and tired. The improper closing of the valves a turbulent flow, resulting in a murmur and/or extra heart sounds. Diagnostics for tricuspid valve regurgitation include ECHO, physical exam, chest x ray, and cardiac catherizations. Management includes diuretics, antiarrhythmics and surgery.
