University Affiliation Essay Example

  • Category:
    Nursing
  • Document type:
    Essay
  • Level:
    Undergraduate
  • Page:
    4
  • Words:
    2719

University Affiliation

  1. What is the mode of action for both Frieda’s drugs? (6 marks)

Both Friedas drug; losec and renetic mode of action is through enzyme inhibition. Losec reduces the secretion of gastric acid by irreversibly inhibiting the primary agent for gastric acid production, gastric enzyme H+ K+ -ATPase (proton pump) within the parietal cell of the stomach by binding itself to the enzyme altering its chemical makeup (MIMS, 2011).

Renetic acts by inhibiting angiotensin converting enzyme (AC E), a peptidyl dipeptidasse that catalyses the conversion of angiotensin 1 to the pressor substance angiotensin 11. This results to decreased plasma angitension 11 and an increase in plasma rennin activity due to removal of negative feedback of rennin release and decreased adosterone secretion. Blood pressure its believed is lowered by the suppression of rennin angitensin aldosterone, which plays a major role in regulating blood pressure .

  1. In your own words explain the desired effects of these medications for Frieda. (4 marks).

The desired effects of the drug Losec for Frieda in treatment of Gastroesophageal reflux disease (GORD) characterized by heartburn and irritation of oesophagus is blockage of final common pathway for gastric production thereby inhibiting basal and stimulated acid release(Lehne, p. 921). This action is supposed to lead to reduced acid secretion and prevention and relive from heartburn, besides enabling tissues that are eroded by gastric acid to heal thereby reducing formation of ulcers.

The desired effect of Renitine is to lower her blood pressure by surpressing rennin angitensin aldosteron, a component crucial in pressure regulation.

  1. Briefly outline two possible causes along with a rationale for what Frieda may be experiencing. (3 marks)

Friedas experience of inability to produce words (dysarthria) and vagueness (aphasia) could result from Transient Ischemic Attacks (TIA). This could be as a result of inadequate circulation of blood to an area of the brain resulting from a particular cerebral artery that is affected (Porth, p.1321 Ch. 51). Dysarthia may result from TIA affecting muscles of palate, pharysnx, mouth and lips. Aphasia is mostly produced by a stroke occurring in the territory of the middle cerebral artery (Porth,Ch 51 1322)

  1. Provide four (4) blood tests and discuss the relevance of each test and the data collected in assisting to provide a diagnosis for Frieda, not including CBE & U&E. (10 marks)

Troponin test — Measures the level of troponin T or troponin I proteins in a blood sample. These proteins are released when the heart muscles are damaged such as during a heart attack, blockage of lung artery, and abnormally high blood pressure. . The amount of troponin T and I in the blood will depend on the extent of damage. The order for troponin test for Frieda is based on her history of hypertension placing her at risk of heart attack (National Institute of Health, 2011)..

Coagulation studies — Usually a platelet count and prothrombin time ordered tests are used to screen blood coagulation. They aim at identifying clotting abnormalities. Relevant in Friedas case since possibility of stroke is increased with clotting abnormalities.

Blood lipids or cholesterol blood test — Measures all the cholesterol in the blood. Identifying the level and type of cholesterol (HDL and LDL) triglycerides and lipoprotein is crucial since high levels promote plaque formation and atherosclerosis in arteries and may contribute to hypertension and even clogging arteries increasing risk of heart disease and stroke (Pub Med, 2010).

Liver Function tests – These are common tests that evaluate how well the liver is functioning. The tests include albumin, ALP, ALT, AST,GGT, prothrombun time (PT), serum bilirubin and uine bilirubin. Relevant tests for diagnosis include prothrombin time, which tests presence of blood clotting disorder by measuring the presence of coagulation factor (special proteins involved n coagulation). Abnormal PT (shorter) may indicate increased risk of stroke.

  1. Contrast the two main types of CVA’s (10 marks).

Two main types of cerebovascular accident (stroke) are ischemic and hemorrhagic stroke.
Ischemic stroke results from diminished blood flow to a portion of the brain, which may be caused by thrombi or emboli blood flow (cerebral vessel) interruption resulting to cell death while Hemorrhagic stroke, on the other hand, result from bleeding into the brain tissue, usually after a blood vessel ruptures; caused by aneurysm, arteriovenous malformation, head injury or blood dyscrasias. Ischemic stroke is far more common (87%) and hemorrhagic stroke less common (15%). Ischemic stroke is potentially treatable with thrombolytic therapy and less fatal compared to Hemorrhagic stroke which is fatal (Porth, Ch 51, p. 1318)..

  1. Explain why each of these medications have been ordered/given? (12 marks)

Enalapril acts by inhibiting angiotensin converting enzyme (ACE), a peptidyl dipeptidasse that catalyses the conversion of angiotensin 1 to the pressor substance angiotensin 11. This results to decreased plasma angitension 11 and an increase in plasma rennin activity due to removal of negative feedback of rennin release and decreased adosterone secretion consequently lowering blood pressure. Frishman et al (2005, p. 20) assert that ACE inhibitors offer an important therapeutic option for hypertension as they serve as a first line of treatment especially when compelling conditions such as recurrent stroke prevention exists.

Paracetamol 1gm IV TDS

Paracetemol is given for reduction of body temperature. The patient’s body temperature at 38.2 is a low grade fever and fever is a strong predictor of outcome in outcome in stroke (Dippel et al, 2001). Studies have indicated that small but potentially beneficial decreases in body temperature follow the treatment with paracetemol.

Aspirin medication ordered is based on the fact that its beneficial in stroke patients as there is substantial platelet activation in acute stroke and aspirin assists by preventing platelet aggregation and reducing the release of thromboxane and other thrombogenic eicosanoids in the circulation (Elvine and Peter, 2009). After a stroke, aspirin thus prevents serious vascular events such as vascular death and recurrent stroke. Aspirin suppresses or halts ongoing thrombotic process, which may reduce the volume of infracted cerebral tissue thus reducing the risk of death(Elvine and Peter, 2009).

Currently Frieda’s observations include –

  • P 122, BP 161/72, R 19, T 38.2, GCS 13, BGL 13.6mmol/l

  1. Highlight 3 (three) concerns with a rationale in relation to Frieda’s observations. (6 marks)

BP 161/72 indicates that the patient has a moderately high blood pressure. The patient is therefore at an increased risk for heart attack, stroke, death, kidney disease and cardiovascular disease and should be put on treatment.

The pulse at 122 is also high than normal and these may indicate a risk of heart disease or stimulation of drugs (Thresymma, 2010, p. 207).

The third observation is that patients temperature at 38.2 is high, an indication of a mild fever. Considering that fever is a factor that affects outcome in treatment suggests that temperature control is crucial step that should be undertaken by the nurse.

  1. Discuss why the neurological observations have been ordered. (4 marks)

Neurologic observations entails assessment of functioning of motor and sensory skills, speech, hearing, balance and coordination, mental status and they are beneficial in diagnosis of brain tumors, stroke and neurological disorders. Neurological observations ordered for include structural, chemical, pathophysiological changes assessed through cerebral blood volume (CBV), cerebral blood flow (CBF) and cerebral perfusion pressure (CPP) are crucial as they highlight the general health condition of the patient. Part of the observations involve scanning and this may be done using a CT to detect blood clots and intracranial bleeding in patients with stroke thus assisting in proper diagnosis through differentiating the area of the brain that is affected (National Institute of Neurological Disorders and Stroke, 2011). Since there is diagnosis of stroke, these observations will assist to identify how well the patient is responding to medication. For instance, following an ischemic lesion, a dissociation occurs between blood flow and brain metabolism and neurological assessment may assist in evaluation of ischemic penumbra and effects of treatment (Adams, 2006 p.142 ). Observations such as cerebral blood flow changes, mean transient time and intravascular volume observed through perfusion imaging can assist in detection of area of hypo perfusion and identifying the area of ischemic penumbra (Adams,2006 p. 147)

  1. Frieda’s daughter asks you the following question – My Uncle had a CVA and he was able to talk and swallow why can’t mum do this? Respond to this question (2 marks).

There is a direct relationship between brain lesion location and swallowing disturbance patterns and speech patterns (Steinhagen et al, 2009). Swallowing disturbance related parameters include attention deficit, buccofacial apraxia, gag reflex, orofacial paresis, and delay of pharyngeal swallow, larynx elevation, pharyngeal contraction and upper oesophageal sphincter (UES). Buccofacial apraxia is affected by left sided parietotemporal infarction, orofacial paresis by infarction encompassing upper motor neuron of cranial nerves, and impaired UES opening by lateral medullary infraction (Steinhagen et al, 2009). The ability to talk may also be dependent on brain area lesion and in her mothers case, anterior cerebral artery or middle cerebral affecting frontal lobe area and most lateral hemisphere of the brain respectively is likely to have been involved in the stroke (Porth, p. 1321, ch. 51).

One week later Frieda has been ordered Warfarin 2mg orally, mane.

  1. Frieda’s daughter Ruth asks why her mum is on Warfarin and needs to see her doctor every second day following discharge, can you explain this to her? (4 marks).

Frieda is on Warfarin, which is an anticoagulant that acts by inhibition of synthesis of vitamin K dependent coagulation factors VII, IX, X and 111synthesis since while they do not reverse ischemic tissue damage or treat thrombosis; they prevent extension of formed clot and potentially fatal secondary thromboembolic complications (MIMS, 2011). Warfarin is used in blood thinning and reduces chances of formation of clots. Frieda is required to see her doctor every second day after discharge to monitor prothrombin time (PT) levels, identifying clotting status, and thus effectiveness of drug dosage in preventing complication of thrombosis and side effects of warfarin (Medline, 2011).

Scenario 2 (total 29 marks)

George Small now retired from his profession as a builder has suffered from osteoarthritis in his knees for several years.

  1. Explain the pathophysiology of osteoarthritis. (6 marks)

Osteoarthritis pathophysiology revolves around contributions of metabolic and biomechanical factors altering the articular cartilage tissue homeostasis and subchondral bone. Cell/extra-cellular matrix (ECM) interactions play major role in pathophysiology of articular cartilage in a process mediated by cell surface integrins. Growth, differentiation and maintenance of cartilage homeostasis are modulated by cell/ECM, modulated by integrins. Osteoarthritis occurs when through abnormal integrin expression, cell/ECM signaling is altered leading to modification of chondrocyte synthesis resulting to an imbalance of destructive cytokines over regulatory factors (Porth, ch 59, 1533). Without the benefit of a counterbalance through adequate synthesis of inhibitors, IL-1, TNF-alpha and other pro-catabolic cytokines activate the enzymatic degradation of cartilage matrix. Growth factors such as TGF-beta, BMP, IFG and NFG play a role in osteoarthritis pathogenesis by failing to repair damaged tissues induced by catabolic factors (Iannone & Lapadula, 2003).

  1. Compare osteoarthritis and rheumatoid arthritis (10 marks)

Osteoarthritis and rheumatoid arthritis have various differences. Pathogenesis of rheumatoid Arthritis is viewed as an aberrant immune response leading to synovial inflammation and joint architecture destruction (Porth ch 59, p. 50). Osteoarthritis on the other hand can present itself as a primary disease of unknown etiology or as a secondary disorder related to congenial or acquired defects that affect the distribution of joint stress (Porth, ch 59, p. 1532). Osteoarthritis includes the progressive disruption of the smooth surface of the articular cartilage with development of surface cracks that deepen to involve the subchondral bone, followed by complete erosion of the articular cartilage with exposure of ivory-like polished subchondral bone, dislodgement of fragments of free floating osteocartilaginous bodies, development of bone cysts and abnormal bony spurs formation at the joint margins (Porth, ch 54, 1532). Rheumatoid arthritis on the other hand is a systematic inflammatory disease initiated by the activation of helper T cells, release of cytokines such as interleukin, tumor necrosis factor and antibody factor and while the role of autoimmune remains obscure, at cellular level, lymphocytes, neutrophils and macrophage are attracted to the joint areas and through the immune complexes process, cause the release of lysosomal enzymes that are capable of causing destructive changes in the joint cartilage (Porth, ch 59, 1520). Rheumatoid arthritis has more pronounced changes occurring in the synovium compared to osteoarthritis (Porth, ch 59, p. 1533).

Other differences include, osteoarthritis which is also known as “wear and tear” arthritis often developing slowly over a long period of time unlike rheumatoid arthritis that often develops suddenly, sometimes within weeks or months. While osteoarthritis usually begins after age 40, rheumatoid arthritis usually begins between the ages of 25 and 50. Osteoarthritis is usually more common among men up to the age of 45 and more common in women after 54 while rheumatoid arthritis women outnumber men in a ratio of 3 to 1. Additionally, osteoarthritis often affects joints on only one side of the body while rheumatoid arthritis affects the same joint on both sides of the body (Porth, ch 59, 1520). Rheumatoid arthritis is manifested through anorexia, weight loss, and stiffness and generalized aching, while this symptoms are not manifested in osteoarthritis (Porth, ch 59, 1521).

  1. George currently takes Paracetamol Osteo and Celecoxib; explain the mode of action for each of these drugs along with recommended dosages. (6 marks)

Celecoxib blocks the production of prostanoids (prostaglandin E2) through inhibition of COX-2 thereby producing its anti inflammatory effect and thus its use in treatment of pain joints in patients with osteoarthritis (MIMS, 2010). Treatment for Osteorthritis celebrex dosage that has been found to be effective in pain reduction should be a daily dosage of 200 mg administered either as 100mg twice daily (bd) or 200 mg once daily (od) (MIMS, 2010).

Paracetemol osteo inhibits prostanglandin sythenis thus exhibiting analgesic and anti-pyretic acitivity. Mechanism for pain reduction involves its modulating and inhibiting uptake of cannabinoid anandamine, which activates main pain receptor of the body. In patients with osteoarthritis, the dosage is 2 tablet taken three times daily (GlaxoSmithKline Consumer Healthcare, 2005).

George has been complaining of heartburn for the past two weeks and in order to manage this he has been taking Mylanta 20mls three times a day.

  1. Explain if this affects George’s medications. (4 marks)

Mylanta may affect George’s medication since celecoxib absorption is affected by magnesium and aluminum containing drugs. Mylanta, which is a magnesium and aluminum containing antacid may reduce the absorption rate of celecoxib.Coadministration of celecoxin and Mylantha may results to up to 37% reduced plasma concentration of celecoxin thus reducing its effectiveness ( MIMS, 2010). There is no known interaction with paracetemol.

  1. What is the possible causative agent for George’s pain? (3 marks)

Progressive loss of articular cartilage and synovitis leading to friction in joint movement associated with Ostearthritis results from attempts by tissue to self-repair creating spurs or osteophytes (Porth, ch 59, p. 1532). The inflammatory stimuli induce cyclooxygenase-2 (COX-2) production, leading to synthesis and accumulation of prostanoids, specifically prostaglandin E2 that result to inflammation, pain and oedema (MIMS, 2010).

References

PubMed Health. 2010. A.D.A.M Medical Encyclopedia. U.S National Library of Medicine

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0003963/

MIMS. 2011. MIMS Full prescribing information. Warfarin (Coumadin).

National Institute of Health . 2011. Troponin test. Medline Plus. U.S National Library of Medicine.

Medline Plus. 2011. Prothrombin time (PT). National Institute of Health.

National Institute of Neurological Disorders and Stroke. 2011. Neurological Diagnostic Tests and procedures. National Institute of Health. U.S National Library of Medicine.
http://www.ninds.nih.gov/disorders/misc/diagnostic_tests.htm

Thresyamma. (2010). Fundamentals of Nursing.

Porth. Ch 51. Disorders of brain functions stroke.

MIMS Full Prescribing Information. 2010. Celecoxib.

2115Australia Pty Ltd ,82 Hughes Avenue, Ermington NSWPRODUCT INFORMATION :PANADOL Osteo Tablets GlaxoSmithKline Consumer Healthcare.

Porth, ch 59. Disorders of musculoskeletol function osteoarthritis. P1532-1535.

Dippel, D.W., Breda, v.E., M.A.van Germet. 2001. Effect of pracetemol (Acetaminophen) on body temperature in acute ischemic stroke: A double-blind, randomized phase 11 clinical trial. Stroke. 32:1607-1612.

Frishman, H.W.,& Angela, C.,& James, N. 2005. Current cardiovascular drugs. Springer.

Elvine B & Peter, S. (Ed. Julien, B.,& Werner, H). Thrombolytic and antithrombotic therapy for stroke. Taylor and Francis.

Steinhagen, V., & Grossman, A.,& Reiner, B., & Uwe, W. (2009). Swallowing disturbance patterns relates to brain lesion location in acute stroke patients. . Stroke. 2009;40:1903-1906

Iannone F & Lapadula, G. 2003. The pathophysiology of osteoarthritis. Aging clinical and experimental research .15(5):364-72.

Adams, H. (2006). Principles of cerebovascular disease. McGraw-Hill Professional.