Assessment Diagnostics and Pharmacotherapeutics

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Nov 24, 2024

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1 Assessment Diagnostics and Pharmacotherapeutics Student's Name Instructor's Name Institution Affiliation Course Date

2 Introduction Registered nurses must understand pharmacology and evidence-based clinical practice to deliver safe and thorough nursing care. The evaluation helps develop evidence evaluation, introspection, and clinical reasoning skills. The assessment requires practitioners to apply knowledge of assessment, clinical reasoning, and pharmacotherapeutics to evaluate a scenario comprising a patient diagnosed with heart failure. Moreover, the evaluation consists of event series resulting in heart failure exacerbation and readmission to care facilities. The patient, Lynda Wicks, is an 82-year-old woman who underwent open reduction and internal fixation (ORIF) for a left hip fracture after a fall at home. She has a history of heart failure with reduced ejection fraction (HRrEF) following a previous "silent" anterior myocardial infarction, hypertension, and hypercholesterolemia. The main issues arising from Lynda Wicks' clinical scenario involve medication-related factors, heart failure exacerbation, inadequate pain management, poor symptom monitoring, and managing her hypertension and edema. Prompt assessment, appropriate treatment, and close follow-up with her healthcare providers are crucial to address these issues effectively and improve her overall health outcomes (Berliner, Hänselmann, & Bauersachs, 2020). Before her recent hospital admission, Lynda lived independently at home, managing her daily activities and medications. After her surgery, she was discharged with a blister pack of medications, excluding pain relief. She was advised to buy OTC painkillers and administer Frusemide 400mg thrice daily (Greene et al., 2018). She left with Enalapril, Bisoprolol, Spironolactone, Frusemide, and Atorvastatin. Two days after discharge, Lynda experienced breathlessness and ankle swelling, which she managed with the painkillers provided by the hospital (Sotomi et al., 2021). She also reported feeling increasingly breathless and had difficulty using her walking frame. Due to the worsening symptoms, her daughter brought her to the emergency department on a Sunday.

3 Heart Failure with Reduced Ejection Fraction (HFrEF) [500 words] Pathophysiology Manifestations Clinical guidelines, such as those from the American College of Cardiology (ACC) and the American Heart Association (AHA), have extensively discussed the pathophysiology of HFrEF. For example, the ACC/AHA guidelines on heart failure management (last updated in 2017) provide insights into the mechanisms and contributing factors of HFrEF (Uijl et al., 2021). Lynda's HFrEF is attributed to a previous "silent" anterior myocardial infarction, which means she experienced a heart attack without the typical symptoms. In the case of myocardial infarction, a blocked coronary artery reduces blood supply to part of the heart muscle, damaging it (Smiseth et al., 2022). The damage impairs the heart's ability to contract effectively, reducing its pumping function (Beldhuis et al., 2022). In HFrEF, the left ventricle becomes weakened and loses its ability to contract forcefully, leading to a decreased ejection fraction (Uijl et al., 2021). Thus, each heartbeat pumps less blood into the body. The sympathetic nervous and renin-angiotensin-aldosterone systems activate to compensate for diminished pumping capacity (Smiseth et al., 2022). Increase heart rate, blood pressure, and fluid retention to sustain cardiac output. These compensatory mechanisms eventually become maladaptive and worsen heart failure (Packer et al., 2021). Clinical Manifestations The clinical scenario of Lynda Wicks illustrates some of these manifestations, such as her breathlessness, ankle edema, elevated blood pressure, rapid heart rate, and the presence of crackles in her lung fields. The scenario highlights the typical presentation of HFrEF (Uijl et al., 2021). Lynda experienced breathlessness, especially with exertion, due to the reduced pumping capacity of her heart. In HFrEF, the blood may go back into the lungs, causing pulmonary congestion, leading to dyspnea (shortness of breath) and fatigue (Smiseth et al.,

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4 2022). The compromised pumping function of the heart can lead to fluid accumulation in the lower extremities, resulting in ankle edema, as observed in Lynda's case. Lynda's elevated blood pressure on arrival at the emergency department may be attributed to the activation of the sympathetic nervous system and the renin-angiotensin-aldosterone system in response to reduced cardiac output (Sotomi et al., 2021). The diverse crackles auscultated in Lynda's bilateral lung fields indicate pulmonary congestion, common in HFrEF due to fluid accumulation in the lungs (Roh et al., 2022). Lynda's 120-bpm heart rate indicates increased sympathetic activity to compensate for the lower cardiac output. Lynda's legs have pitting edema because her heart can't pump blood and fluid efficiently. Lifestyle changes, medication, and surgery can treat HFrEF (Uijl et al., 2021). ACE inhibitors, beta-blockers, diuretics, and aldosterone antagonists can reduce symptoms, fluid retention, and disease progression (Greene et al., 2018). Regular follow-up with healthcare providers, medication adherence, and a heart-healthy lifestyle is crucial for managing HFrEF effectively (Beldhuis et al., 2022). Spironolactone blocks aldosterone, increasing salt, water retention, and cardiac strain. Spironolactone helps block the effects of aldosterone, reducing fluid retention and potentially improving heart function. It is prescribed at a daily dose of 25mg. Beta-blocker bisoprolol selectively blocks beta-1 adrenergic receptors to lower heart rate and myocardial contractility, lowering cardiac oxygen consumption (Berliner, Hänselmann, & Bauersachs, 2020). The medications have improved heart function and reduced mortality in patients with HFrEF (Smiseth et al., 2022). Bisoprolol is usually recommended at 10mg daily, and Enalapril inhibits ACE. ACE inhibitors are a cornerstone of HFrEF treatment (Smiseth et al., 2022). Moreover, the medications block the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, leading to vasodilation and reduced afterload on the heart (Roh et al., 2022). The approach helps improve cardiac function and

5 decrease the workload on the heart. Enalapril is typically prescribed at a daily dose of 20mg in divided doses. Medication Management for Heart Failure with Reduced Ejection Fraction (HFrEF) Enalapril, Frusemide, Bisoprolol, Spironolactone, and Atorvastatin are prescribed for Lynda's heart failure with reduced ejection fraction (HFrEF). Medication management for heart failure is complex and tailored to each patient's medical history, co-morbidities, and tolerance to treatment (Uijl et al., 2021). Heart failure with decreased ejection fraction management requires regular doctor visits and drug adherence. Dosage and drugs might be modified (Packer et al., 2021). After hip fracture surgery, Lynda was prescribed 400mg of Frrusemide thrice daily for pain to optimize patient outcomes. Frusemide, an NSAID, can promote fluid retention and aggravate heart failure symptoms in heart failure patients. Heart failure patients should avoid NSAIDs (Pfeffer, Shah, & Borlaug, 2019). Heart failure exacerbation is typically complicated, and patient considerations are crucial (Sotomi et al., 2021). Healthcare practitioners should tackle and mitigate these issues to improve patient outcomes and prevent hospital readmission (Smiseth et al., 2022). Patients with heart failure need pharmaceutical management, lifestyle changes, and regular follow-up. Atorvastatin constitutes a statin drug used to reduce cholesterol levels. Hypercholesterolemia increases heart failure risk. Statins decrease cholesterol, lowering cardiovascular risk (Pieske et al., 2019). Atorvastatin is usually administered at 40mg daily. Frusemide is a loop diuretic commonly used to relieve symptoms of fluid overload in heart failure. It helps increase urine output and reduce fluid retention, alleviating edema and pulmonary congestion (Packer et al., 2021). The emergency department administered 80mg intravenously; maintenance medication is normally prescribed at a lesser dose. After Lynda's hip fracture surgery, she used Frusemide, an over-the-counter NSAID, for discomfort. The

6 approach may have worsened her heart failure and required hospitalization (Pieske et al., 2019). NSAIDs inhibit prostaglandin synthesis, prompting salt and water retention, decreased diuresis, and vasoconstriction. The effects can exacerbate heart failure symptoms, especially in patients with HFrEF (Gevaert et al., 2022). Lynda's blister pack of medications lacked painkillers after her left hip fracture surgery. She was recommended to get over-the-counter Frusemide 40mg thrice daily from the drugstore. Lynda utilized the provided medicines to manage her pain. The drug’s side effects —fluid retention and vasoconstriction—may have worsened Lynda's heart failure symptoms. Breathlessness, ankle swelling, and lung field crackles indicate heart failure exacerbation (Sotomi et al., 2021). NSAIDs, including NSAIDs can cause fluid retention, aggravate heart failure, and increase hospital readmission in heart failure patients, especially those with low ejection fraction (Rosch et al., 2022). Thus, heart failure patients should avoid NSAIDs unless prescribed by a doctor and monitored. The prescribed medications may have caused Lynda's clinical worsening and hospital readmission. Medication management improves heart failure patients' symptoms, hospitalizations, and outcomes, especially HFrEF (Uijl et al., 2021). The guidelines recommend ACE inhibitors, beta-blockers, and aldosterone antagonists for heart failure therapy. HFrEF or HFpEF, co-morbidities, and treatment response should guide medication selection and use (Roh et al., 2022). Lynda's heart failure exacerbation and hospital readmission may have been caused by factors other than Enalapril and Bisoprolol use; thus, it's important to cautiously evaluate the clinical scenario (Uijl et al., 2021). Lynda's complete medical history, medication list, and clinical data are needed to evaluate her medication management and drug interactions, which are outside the scope of the scenario (Armstrong et al., 2020). Thus, healthcare providers must carefully evaluate and treat heart failure drugs using evidence- based guidelines and the patient's clinical circumstances (Solomon et al., 2021).

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7 Person-Centered Nursing Care Upon reviewing the clinical scenario provided for Lynda Wicks, there was no specific mention of Frusemide and Atorvastatin being used for pain relief after her hip fracture surgery. Since there is no specific clinical information about medicines used in Lynda's case, I cannot provide direct clinical evidence or guidelines related to the drugs impact on her exacerbation of heart failure (Greene et al., 2018). Therefore, I can offer general information about using NSAIDs in heart failure patients based on existing evidence and guidelines up to my last update in September 2021 (Paulus & Zile, 2021). According to clinical trials, NSAIDs can harm heart failure patients, especially those with HFrEF (Beldhuis et al., 2022). NSAIDs suppress prostaglandin synthesis, which can cause sodium and water retention, diminished diuresis, and increased systemic vascular resistance, worsening heart failure symptoms (Solomon et al., 2021). NSAIDs can enhance fluid retention and heart failure decompensation in heart failure patients, according to AHA and HFSA clinical guidelines. HFrEF is a well-described condition in which the heart's pumping capacity is reduced, leading to inadequate blood circulation (Rosch et al., 2022). The reduction in pumping function often results from underlying heart muscle damage, as seen in Lynda's case, with a history of a "silent" anterior myocardial infarction. The damage to the heart muscle impairs its contractility, which, in turn, decreases the ejection fraction (Roh et al., 2022). Lynda's hospital readmission within 72 hours of discharge was likely due to the management of her medications. She was discharged without adequate analgesia for pain relief after her surgery, which may have led her to self-administer the painkillers, possibly inappropriately, exacerbating her heart failure (Gevaert et al., 2022). Lynda presented with symptoms suggesting an exacerbation of her heart failure, including breathlessness, ankle swelling, and crackles in the lung fields on auscultation (Smiseth et al., 2022). Her elevated blood pressure and heart rate also indicate possible decompensation of her heart condition. The lack of

8 appropriate pain relief following her hip fracture surgery may have contributed to her self- administration of painkillers and potentially inappropriate use of medications, which can adversely affect her heart failure (Gevaert et al., 2022). Medication management improves heart failure patients' symptoms, hospitalizations, and outcomes, especially HFrEF (Rosch et al., 2022). The guidelines recommend ACE inhibitors, beta-blockers, and aldosterone antagonists for heart failure therapy. HFrEF or HFpEF, co-morbidities, and treatment response should guide medication selection and use (Uijl et al., 2021). Given that the mention of the prescribed drugs used for Lynda was not present in the provided clinical scenario, it is essential to interpret the information cautiously and consider that other factors may have contributed to her heart failure exacerbation and hospital readmission (Pieske et al., 2019). Safe and effective discharge planning ensures that patients like Lynda receive comprehensive care after leaving the hospital. Patient education, clinical reasoning, and medication management by nurses help people manage their diseases, recognize warning signs, and seek medical assistance when needed (Gevaert et al., 2022). Nurses reduce readmissions, improve patient outcomes, and improve the quality of life for chronic disease patients like HFrEF by motivating patients to participate in positive treatment plans (Smiseth et al., 2022). For a comprehensive evaluation of Lynda's medication management and potential drug interactions, it would be essential to have access to her complete medical history, medication list, and clinical details, which are beyond the scope of the given scenario (Paulus & Zile, 2021). Therefore, it is crucial for healthcare providers to thoroughly assess and manage medications for heart failure patients while considering the specific evidence- based guidelines and the patient's unique clinical circumstances. The nurse plays a crucial role in patient education and discharge planning to ensure safe and person-centered nursing care for individuals living with Heart Failure with Reduced Ejection Fraction (HFrEF). Practitioners teach patients and their families about HFrEF, its

9 origins, symptoms, and the significance of the following treatment (Solomon et al., 2021). The intervention includes explaining the role of medications, lifestyle modifications, and regular follow-up appointments (Berliner, Hänselmann, & Bauersachs, 2020). Practitioners also explain each medication's purpose, dose, and negative effects. Medication compliance is stressed (Roh et al., 2022). The nurse also warns regarding self-medicating with over-the- counter drugs. Safe and person-centered nursing care for heart failure with reduced ejection fraction (HFrEF) patients depends on nurses' patient education and discharge planning (Pfeffer, Shah, & Borlaug, 2019). Nurses teach patients and families how to treat HFrEF. Explaining the ailment, its causes, and the significance of following recommended drugs and lifestyle changes. Nurses educate patients about drugs and their adverse effects (Paulus & Zile, 2021). Dietary advice, symptom monitoring, and activity suggestions improve wellness. Nurses also encourage people to recognize exacerbation symptoms and seek medical assistance (Packer et al., 2021). Nurses create personalized discharge plans with the healthcare team to ensure a smooth hospital-to-home transition. They provide emotional support, psychosocial care, and resource referrals (Paulus & Zile, 2021). Nurses can improve patient outcomes and quality of life by educating and discharging patients. The nurse's involvement in patient education and discharge planning empowers HFrEF patients to be proactive in their care, make well-informed choices, and take responsibility for their health to improve outcomes and quality of life (Roh et al., 2022). For instance, they take a holistic approach to patient education and discharge planning, considering the patient's preferences, cultural background, and socioeconomic factors to ensure the care plan is person-centered and achievable (Paulus & Zile, 2021). Nurses educate patients' families and carers because they provide ongoing support and help manage the condition. Practitioners also create a patient-specific discharge plan with the healthcare team (Smiseth et al., 2022). The strategy might entail scheduling follow-up appointments with the

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10 primary care provider or cardiologist, organizing home health services, and ensuring the patient gets the necessary drugs and supplies. Conclusion Several factors may have contributed to the exacerbation of heart failure and hospital readmission for Lynda Wicks. Heart failure exacerbation is typically complicated, and patient considerations are crucial. Healthcare practitioners should tackle and mitigate these issues to improve patient outcomes and prevent hospital readmission. Patients with heart failure need pharmaceutical management, lifestyle changes, and regular follow-up. Lynda Wicks had a history of HFrEF following a "silent" anterior myocardial infarction. She underwent hip fracture surgery and was discharged with inadequate pain relief, which may have contributed to the self-administration of over-the-counter drugs. Two days' post-discharge, she developed an exacerbation of heart failure symptoms, leading to hospital readmission. The nurse is crucial in patient education and discharge planning for individuals with HFrEF. The approach involves educating patients and their families about the condition, medication management, dietary restrictions, monitoring symptoms, recognizing warning signs, and promoting self- care. The clinical scenario will also improve my nursing care by emphasizing patient education, discharge planning, medication management awareness, and early detection and intervention. The goal is to enhance patient outcomes, satisfaction, and hospital readmissions for patients with heart failure and other chronic diseases.

11 References Armstrong, P. W., Pieske, B., Anstrom, K. J., Ezekowitz, J., Hernandez, A. F., Butler, J., & O'Connor, C. M. (2020). Vericiguat in patients with heart failure and reduced ejection fraction. New England Journal of Medicine , 382 (20), 1883-1893. Beldhuis, I. E., Lam, C. S., Testani, J. M., Voors, A. A., Van Spall, H. G., Ter Maaten, J. M., & Damman, K. (2022). Evidence-based medical therapy in patients with heart failure with reduced ejection fraction and chronic kidney disease. Circulation , 145 (9), 693- 712. Berliner, D., Hänselmann, A., & Bauersachs, J. (2020). The treatment of heart failure with reduced ejection fraction. Deutsches Ärzteblatt International , 117 (21), 376. Gevaert, A. B., Kataria, R., Zannad, F., Sauer, A. J., Damman, K., Sharma, K., & Van Spall, H. G. (2022). Heart failure with preserved ejection fraction: recent concepts in diagnosis, mechanisms, and management. Heart , 108 (17), 1342-1350. Greene, S. J., Butler, J., Albert, N. M., DeVore, A. D., Sharma, P. P., Duffy, C. I., & Fonarow, G. C. (2018). Medical therapy for heart failure with reduced ejection fraction: the CHAMP-HF registry. Journal of the American College of Cardiology , 72 (4), 351-366. Packer, M., Butler, J., Zannad, F., Filippatos, G., Ferreira, J. P., Pocock, S. J., & EMPEROR- Preserved Trial Study Group. (2021). Effect of empagliflozin on worsening heart failure events in patients with heart failure and preserved ejection fraction: EMPEROR-preserved trial. Circulation , 144 (16), 1284-1294. Paulus, W. J., & Zile, M. R. (2021). From systemic inflammation to myocardial fibrosis: the heart failure with preserved ejection fraction paradigm revisited. Circulation Research , 128 (10), 1451-1467.

12 Pfeffer, M. A., Shah, A. M., & Borlaug, B. A. (2019). Heart failure with preserved ejection fraction in perspective. Circulation Research , 124 (11), 1598-1617. Pieske, B., Tschöpe, C., De Boer, R. A., Fraser, A. G., Anker, S. D., Donal, E., & Filippatos, G. (2019). How to diagnose heart failure with preserved ejection fraction: the HFA– PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). European heart journal , 40 (40), 3297-3317. Roh, J., Hill, J. A., Singh, A., Valero-Muñoz, M., & Sam, F. (2022). Heart failure with preserved ejection fraction: heterogeneous syndrome, diverse preclinical models. Circulation Research , 130 (12), 1906-1925. Rosch, S., Kresoja, K. P., Besler, C., Fengler, K., Schöber, A. R., von Roeder, M., & Lurz, P. (2022). Characteristics of heart failure with preserved ejection fraction across the range of left ventricular ejection fraction. Circulation , 146 (7), 506-518. Smiseth, O. A., Morris, D. A., Cardim, N., Cikes, M., Delgado, V., Donal, E., & Reviewers: This document was reviewed by members of the 2018–2020 EACVI Scientific Documents Committee Bertrand Philippe B Dweck Marc Haugaa Kristina H Sade Leyla Elif Stankovic Ivan Ha Jong-Won Nagueh Sherif Oh Jae K Ohte Nobuyuki Cosyns Bernard. (2022). Multimodality imaging in patients with heart failure and preserved ejection fraction: an expert consensus document of the European Association of Cardiovascular Imaging. European Heart Journal-Cardiovascular Imaging , 23 (2), e34-e61. Solomon, S. D., de Boer, R. A., DeMets, D., Hernandez, A. F., Inzucchi, S. E., Kosiborod, M. N., & McMurray, J. J. (2021). Dapagliflozin in heart failure with preserved and mildly

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13 reduced ejection fraction: rationale and design of the DELIVER trial. European journal of heart failure , 23 (7), 1217-1225. Sotomi, Y., Hikoso, S., Nakatani, D., Mizuno, H., Okada, K., Dohi, T., & PURSUIT‐HFpEF Investigators. (2021). Sex differences in heart failure with preserved ejection fraction. Journal of the American Heart Association , 10 (5), e018574. Uijl, A., Savarese, G., Vaartjes, I., Dahlström, U., Brugts, J. J., Linssen, G. C., & Koudstaal, S. (2021). Identification of distinct phenotypic clusters in heart failure with preserved ejection fraction. European journal of heart failure , 23 (6), 973-982.

Assessment Diagnostics and Pharmacotherapeutics

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