Assessment and Care of Patients With Cardiovascular Conditions
Discussion Part I: Assessment and Care of Patients With Cardiovascular Conditions
Many cardiac disorders such as myocardial infarctions are a common problem in the acute care setting. Thus it is essential for you, as the advanced practice nurse caring for acute patients, to identify potential signs and symptoms of complications. Although some cardiac disorders require outpatient treatment and management, other procedures such as CABGs or valve replacements are more common and frequently require major interventions. In your role with acute cardiac patients, you must evaluate symptoms and determine how to treat patients. For this Discussion, consider potential diagnoses, treatment, and/or referral options for the patients in the following 1 case studies.Assessment and Care of Patients With Cardiovascular Conditions
Case Study 1
Tom is 56-year-old African American male who presented to the ED with chest pain radiating to his back. The pain has been continuous for 1 hour. The patient complains of shortness of breath. The pain has not been relieved with rest. The patient’s vitals are: 99.1-98-18-198/110. The patient’s cardiac enzymes are negative. Labs results are as follows:
• Na 134
• K 4.1
• Cr 1.8
• BUN 42
• Glucose 248
• WBC 13.1
• Hbg 14.1
• Hct 44.2
• Plt 236
• EKG sinus rhythm no ekg changes
Conduct an evidence-based drug search on the Vasopressin and post an explanation of any possible issues. Are there any drug interactions? Any black box warnings? To what type of patient would you prescribe this medication? Please writee in APA format within 5 years. Assessment and Care of Patients With Cardiovascular Conditions
Discussion Part I: Case Study Analysis
In this case, Tom, a 56-year-old African American presented with a continuous 1-hour chest pain which radiated to the back and was not relieved with rest, and shortness of breath. The patient’s vitals were as follows: temperature-99.1 Fahrenheit (37.30c)-normal, pulse rate-98bpm (normal), respiratory rate-18 breathes/min (normal), blood pressure- 198/110(hypertension). The patient’s cardiac enzymes were also negative, an indication that the patient’ heart had not suffered any form of injury. However, it could also be possible that the test was done too soon. This means that, the negative outcome does not necessarily imply that no injury was done to the heart. It is therefore recommendable that the cardiac enzyme test is redone after several hours for accurate results (Smith et al., 2015). According to the American Heart Association, it is mandatory for APNs and PCP to perform a cardiac enzyme test in clients whom they have a high index of suspicion to have a heart disease.
Cardiac enzyme tests are usually ordered in clinical scenarios where patients present with complaints of shortness of breath, chest pain or an abnormal ECG with an aim of finding out if there has been some injury to the heart. The clients laboratory results were as follows: Na 134(normal), K 4.1(normal), Cr 1.8(elevated), BUN 42(elevated), Glucose 248(elevated), WBC 13.1(elevated), Hbg 14.1(normal), Hct 44.2(normal), Plt 236(normal). Based on an EKG sinus rhythm that was done, there were no EKG changes. This was accurate enough to indicate that the client had at that time no signs of damage to the heart, a heart disease or a recent heart attack (Smith et al., 2015).
Potential Diagnosis
Although the patient’s presentation can be attributed to several differential diagnoses of cardiovascular disorders, the diagnosis with the highest probability given his presentation is acute coronary syndrome. This patient’s risk factors for acute coronary syndrome are: hypertension (BP-198/110mmhg) and diabetes (glucose 248) (Smith et al., 2015).
Treatment and Referral Options
Since the patient clearly explained that the chest pain was not being relieved with rest, it will immediately be essential to administer 300mg of aspirin orally and 800mcg of glyceryl trinitrate (GTN) sublingually. Insulin and fluid replacement should cautiously be administered for the management of hyperglycemia. However caution should be taken to prevent fluid overload (Smith et al., 2015). In order to improve his prognosis and reduce the likelihood of complications in the long-term, the following drugs should be prescribed for long term use: Atorvastatin 80mg PO, clopidogrel 300mcg, ramipril 2.5mg and GTN 500mcg, Metformin 500mg PO taken with a meal. Oxygen can only be administered if saturation is found to be below 95 % (Smith et al., 2015).Assessment and Care of Patients With Cardiovascular Conditions
In order for the patient to be closely monitored, it will be necessary to refer him for cardiac rehabilitation. Cardiac rehabilitation tends to bridge the gap which exists between a patient’s home and the hospital. This team comprises of different healthcare specialists with an aim of educating the patient about his cardiac condition with a purpose of adopting a lifestyle that is much healthier (Smith et al., 2015). This education will be about exercise, diet and the risk factors associated with his condition such as taking alcohol and smoking and the required medications. Research suggests that, adhering to cardiac rehabilitation programs helps to improve the rates of survival and decreased the risk of cardiovascular events in future.
Discussion Part 2: Vasopressin Drug Search
Indications of Vasopressin
Vasopressin is administered as an injection to patients with abdominal distension as a result of the buildup of fluid in the abdominal area. It is also administered to patients who present in emergent situations with no discernible heartbeat and in the management of diabetes insipidus which involves how the kidneys handle water and sodium. It regulates the loss of water and helps to maintain adequate levels of hydration (Christie & Hayes, 2016).
Vasopressin Mode of Action
Vasopressin has an antidiuretic action which increases the reabsorption of water in the renal tubules. It can constrict the smooth muscles of the GI tract and the entire vascular bed with very little or no effect on the smooth muscles of the large veins. Vasopressin is metabolized and destroyed in the kidney and the liver and excreted in urine unchanged in approximately 4 hours. Vasopressin’s half-life is 10-20 minutes (Bichet, 2016). Following administration, it also has a number of side effects. The most significant adverse effect of vasopressin therapy is a potential increase in liver enzymes, a high concentration of total bilirubin and a decrease in the count of platelets.Assessment and Care of Patients With Cardiovascular Conditions
Other side effects that are likely to occur are such as dizziness, headache, hives, excess sweating, labored breathing due to narrowing of the airways and frequently getting tired as a result of low levels of sodium. In patients who experience a reduced platelet count, this can be explained by vasopressin-induced aggregation of platelets. In other clinical settings, resultant cardiac complications have led to morbidities, mortalities and fatalities such as ventricular arrhythmias, severe hypertension and myocardial ischemia (Christie & Hayes, 2016). In case of peripheral constriction, patients are likely to get cutaneous gangrene with or without extravasation. In other instances, local irritation of the site of injection and venous thrombosis can also occur.
Drug Interactions
Vasopressin interacts with the following drugs which increase vasopressin effects through pharmacodynamics synergism: amitriptyline, amoxapine, chlorpropamide, carbamazepine, clomipramine, desipramine, doxepin, urea, trimipramine, trazodone, phenformin, lofepramine, imipramine and doxepin. It also interacts with the following drugs which reduce the effect of vasopressin through pharmacologic antagonism: lithium, epinephrine, ethanol and heparin (Lozić et al., 2018).
Black Box Warnings
In patients who have vascular disease especially that of the coronary arteries, the FDA makes it clear that vasopressin shouldn’t be used. Alternatively, it can be used with a lot of caution. This is attributed to the fact that vasopressin is likely to precipitate angina even in smaller doses and in higher doses, it may even cause myocardial infarction. In patients with gastrointestinal bleeding, vasopressin infusion needs to be continued for up to 12-24 hours after the bleeding and thereafter the dosage has to be tapered in 24-48 hours (Bichet, 2016). According to the FDA, continuous infusion of vasopressin should always be administered through a controlled infusion device. In patients with nitrogen retention and chronic nephritis, pre-operative and post-operative patients with polyuria, vasopressin should be used cautiously. In certain clinical scenarios, vasopressin can lead to water intoxication (Lozić et al., 2018). Early signs of water intoxication include: headaches and drowsiness. In order to prevent the occurrence of convulsions and terminal coma, these signs should be recognized early enough.Assessment and Care of Patients With Cardiovascular Conditions
References
Bichet, D. G. (2016). Vasopressin at central levels and consequences of dehydration. Annals of Nutrition and Metabolism, 68(Suppl. 2), 19-23.
Christie, L. E., & Hayes, M. A. (2016). Vasopressin to Reduce Mortality in Patients with Septic Shock and Acute Kidney Injury. In Reducing Mortality in Acute Kidney Injury (pp. 113-120). Springer, Cham.
Lozić, M., Šarenac, O., Murphy, D., & Japundžić-Žigon, N. (2018). Vasopressin, central autonomic control and blood pressure regulation. Current hypertension reports, 20(2), 11.
Smith, J. N., Negrelli, J. M., Manek, M. B., Hawes, E. M., & Viera, A. J. (2015). Diagnosis and management of acute coronary syndrome: an evidence-based update. The Journal of the American Board of Family Medicine, 28(2), 283-293.
Introduction
Regulating the balance of water in the body, a process also known as osmoregulation is a very complex mechanism where kidney and neural responses tend to adjust the concentration of urine as a form of response to alterations in the content of plasma water which can be assessed through osmolality. In the entire mechanism, any defects can easily impair the urine concentration process as it happens in patients with diabetes. The excretion of renal water is primarily regulated by vasopressin. It helps to facilitate adaptation to physiological responses with an aim of maintaining the osmolality and volume of plasma.
Vasopressin, also known as antidiuretic hormone (ADH), is synthesized in the hypothalamus. It plays a vital role in controlling the osmotic balance of the body, regulating blood pressure and proper functioning of the kidneys. Based on its significant role in the aforementioned functions, it is for this reason that vasopressin is of essence. Primarily, ADH affects the kidney’s ability in the reabsorption of water.Assessment and Care of Patients With Cardiovascular Conditions
When sufficient, it induces proteins that transport water in the collecting duct and distal tubule to increase the reabsorption of water. However, there are disease states when the body does not have control over the secretion of ADH and cannot respond to its presence. To serve this purpose, vasopressin is also available as an injection that causes blood vessels to constrict, to prevent excessive water loss through urination. This paper discusses the indications and mode of action of vasopressin. A description of the drugs which vasopressin interacts with and the black box warnings according to the FDA will also be provided.
Indications of Vasopressin
Vasopressin is administered as an injection to patients with abdominal distension as a result of the buildup of fluid in the abdominal area. It is also administered to patients who present in emergent situations with no discernible heartbeat and in the management of diabetes insipidus which involves how the kidneys handle water and sodium. It regulates the loss of water and helps to maintain adequate levels of hydration (Christie & Hayes, 2016).
Vasopressin Mode of Action
Vasopressin has an antidiuretic action which increases the reabsorption of water in the renal tubules. It can constrict the smooth muscles of the GI tract and the entire vascular bed with very little or no effect on the smooth muscles of the large veins. Vasopressin is metabolized and destroyed in the kidney and the liver and excreted in urine unchanged in approximately 4 hours. Vasopressin’s half-life is 10-20 minutes (Bichet, 2016). Following administration, it also has a number of side effects. The most significant adverse effect of vasopressin therapy is a potential increase in liver enzymes, a high concentration of total bilirubin and a decrease in the count of platelets.
Other side effects that are likely to occur are such as dizziness, headache, hives, excess sweating, labored breathing due to narrowing of the airways and frequently getting tired as a result of low levels of sodium. In patients who experience a reduced platelet count, this can be explained by vasopressin-induced aggregation of platelets. In other clinical settings, resultant cardiac complications have led to morbidities, mortalities and fatalities such as ventricular arrhythmias, severe hypertension and myocardial ischemia (Christie & Hayes, 2016). In case of peripheral constriction, patients are likely to get cutaneous gangrene with or without extravasation. In other instances, local irritation of the site of injection and venous thrombosis can also occur.Assessment and Care of Patients With Cardiovascular Conditions
Drug Interactions
Vasopressin interacts with the following drugs which increase vasopressin effects through pharmacodynamics synergism: amitriptyline, amoxapine, chlorpropamide, carbamazepine, clomipramine, desipramine, doxepin, urea, trimipramine, trazodone, phenformin, lofepramine, imipramine and doxepin. It also interacts with the following drugs which reduce the effect of vasopressin through pharmacologic antagonism: lithium, epinephrine, ethanol and heparin (Lozić et al., 2018).
Black Box Warnings
In patients who have vascular disease especially that of the coronary arteries, the FDA makes it clear that vasopressin shouldn’t be used. Alternatively, it can be used with a lot of caution. This is attributed to the fact that vasopressin is likely to precipitate angina even in smaller doses and in higher doses, it may even cause myocardial infarction. In patients with gastrointestinal bleeding, vasopressin infusion needs to be continued for up to 12-24 hours after the bleeding and thereafter the dosage has to be tapered in 24-48 hours (Bichet, 2016). According to the FDA, continuous infusion of vasopressin should always be administered through a controlled infusion device. In patients with nitrogen retention and chronic nephritis, pre-operative and post-operative patients with polyuria, vasopressin should be used cautiously. In certain clinical scenarios, vasopressin can lead to water intoxication (Lozić et al., 2018). Early signs of water intoxication include: headaches and drowsiness. In order to prevent the occurrence of convulsions and terminal coma, these signs should be recognized early enough.
Conclusion
Vasopressin is a drug with a lot of clinical significance which is administered in for of an intramuscular or subcutaneous injection to manage different conditions. However, when not administered appropriately, it can lead to significant effects and poor clinical outcomes as initially discussed. Knowledge on the indications, mode of action, adverse effects, drug interactions and black box warnings of vasopressin is paramount for nurse practitioners, as this will help them in clinical decision making and when administering medications.Assessment and Care of Patients With Cardiovascular Conditions
References
Bichet, D. G. (2016). Vasopressin at central levels and consequences of dehydration. Annals of Nutrition and Metabolism, 68(Suppl. 2), 19-23.
Christie, L. E., & Hayes, M. A. (2016). Vasopressin to Reduce Mortality in Patients with Septic Shock and Acute Kidney Injury. In Reducing Mortality in Acute Kidney Injury (pp. 113-120). Springer, Cham.
Lozić, M., Šarenac, O., Murphy, D., & Japundžić-Žigon, N. (2018). Vasopressin, central autonomic control and blood pressure regulation. Current hypertension reports, 20(2), 11.Assessment and Care of Patients With Cardiovascular Conditions