Question

Brief Patient History

Mr. K is a 58-year-old white man admitted to the cardiac unit from the medical unit after cardiac arrest (VF). He was successfully defibrillated after one shock (biphasic at 200 joules). He has a history of hypertension, myocardial infarction, mitral valve regurgitation, atrial fibrillation, and hyperlipidemia. Mr. K was scheduled for mitral valve replacement and the maze procedure. Mr. K is a school administrator, is married, and has two daughters who live out of state.

Clinical Assessment

Mr. K is awake; follows commands; and is oriented to person, place, and time; however, he complains of weakness and severe shortness of breath despite sitting upright in bed.

Diagnostic Procedures

Mr. K’s vital signs include blood pressure of 142/82 mm Hg, pulse of 168 beats/min that is irregular and bounding, respiratory rate of 28 breaths/min, temperature of 98.2°F, and SpO2 of 92% on O2 at 2 L per nasal cannula. Further assessment reveals bilateral breath sounds with coarse crackles in the bases, S3, and a loud pansystolic murmur. Cardiac rhythm is atrial fibrillation. Chest radiograph shows cardiomegaly and bilateral congestion. Echocardiogram indicates left ventricular hypertrophy with an EF of 25%. He has negative serum cardiac enzymes; serum B–type natriuretic peptide (BNP), 1100 pg/mL; serum potassium, 3.8 mEq/dL; cholesterol, 250 mg/dL; triglycerides, 200 mg/dL; and high-density lipoprotein, 30 mg/dL.

Medical Diagnosis

• Atrial fibrillation with a rapid ventricular rate • Heart failure • Mitral valve regurgitation

Questions

1. What major outcomes do you expect to achieve for this patient?

2. What problems or risks must be managed to achieve these outcomes?

3. What interventions must be initiated to monitor, prevent, manage, or eliminate the problems and risks identified?

a. Atrial fibrillation with a rapid ventricular response of 186 beats/min. Interventions to control the ventricular rate include the administration of which medications ? Name all meds including the dosages

b. Prevention of thromboembolism from atrial fibrillation. Name all meds including dosing. Should Pradaxa) be used in this situation as for Mr. K given that he has mitral valve regurgitation – why ?. Should we consider The maze procedure for Mr. K ? What is the maze procedure ?

c. Conversion of atrial fibrillation to sinus rhythm. What medications are used for conversion to SR or If Cardioversion (synchronized countershock), what process must be considered for prevention of thromboembolism prior to cardioversion.

d. What is the evidence of Left ventricular failure or acute heart failure in this patient ? What are the Goals of pharmacologic treatment of heart failure include alleviating symptoms and slowing the progression of the disease. Consider the following in your answers: Nesiritide (Natrecor) - Effects on PAOP, CVP, SVR, PVR, and urine output. Compared Natrecor with traditional vasodilator therapy for acute heart failure. What are other types of pharmacologic management of acute heart failure (examples of several meds) Because Mr. K’s EF is 35%, what administration of meds should be considered to prevent further left ventricular remodeling. Because of Mr. K’s acute heart failure should betablockers be used cautiously? why?

e. Risk of sudden cardia death because of a history of VF and left ventricular failure (EF less than 35%). How would you monitor Mr. K’s cardiac ? (rhythm, meds, activity, potential for ICD). 4. What interventions should be initiated to promote optimal functioning, safety, and well-being of the patient?

5. What possible learning needs would you anticipate for this patient? a. psychologic b. education of the patient and family c. risk factor modification, diet, and prescribed medications. d. lipid e. Preoperative teaching related to the maze procedure and mitral valve replacement is needed. Patient education after mitral valve replacement and medication management, safety, diet…

6. What cultural and age-related factors may have a bearing on the patient’s plan of care?

Answer 1

Atrial fibrillation a disorder of heart that results in irregular and abnormal heart beat. During contractions the heart muscle ability to relax reduced.

Heart failure refers to inability to pump blood to the vital organs. It is classified into acute or chronic , right sided and left sided heart failure. The etiology includes predisposing heart conditions, congenital heart defect, heart attack, high blood pressure, hIV, anemia of chronic form.

The outcomes of the treatment are to improve symptoms and underlying ventricular dysfunction. The ways to handle the risks includes improving compliance of patients towards the treatment. Starting supportive drugs ACE inhibitors, to treat systolic dysfunction.

Atrial fibrillation treatments includes beta blockers esmolol,metoprolol,propanolol to control heart rate. Clacium channel blockers diltiazem,verapamil helps to slower the heart and reduce contractions strength of the ventricles.

Electrical cardioversion is initiating a shock to control abnormal firing of impulses. Non pharmacological management includes surgical ablation also known as maze procedure. Catheter ablation involves in reducing the risk of reappearance of atrial fibrillation. Treatment strategies to reduce the risk of thromboembolism occurs secondary to AF.

Maze procedure is a treatment option for atrial fibrillation. A maze of scar tissue is created in the heart that helps to control the abnormal firing of impulses from the atria to the ventricles. It is done for patients with heart attack, bleeding disorders, infection, arrhythmias of new origin.

Cardiac monitors are used to monitor abnormal heart rhythms. Electrocardiogram, Holter monitors, Echocardiography can helps to detect abnormality.