Nursing Interventions Associated With Amiodarone Therapy in Atrial Fibrillation in a Cardiac Patient - Essay Example

? Nursing Interventions Associated With Amiodarone Therapy in Atrial Fibrillation in a Cardiac Patient By of [Word Count] [Date] Case Report The name of the patient in this case report has been changed to Mr. Patel for confidentiality reasons. The patient is 67 years old transferred from theatre to the Intensive Care Unit (ICU) after an uncomplicated CABG X3. The patient has a history of HTN, type 2 diabetes mellitus and hypercholesterolaemia. Mr. Patel is paced at AAI100bpm and has his underlying rhythm checked. In addition, the patient has ectopics. Importantly, an ECG done on the patient indicates arterial fibrillation. A day after his surgery, Mr. Patel’s blood pressure is found to be unstable. The other features identified with the patient one day after the operation are Good CO, Good CI, is normal ABG, 4.3 potassium, on inotropic support, sedated, ventilated , PICCO inserted . The 4.3 potassium was replaced with 20mmol of KCL. Lab results indicated magnesium levels of 0.98, which was replaced with 10mmol of magnesium. After carrying out TOE, it was revealed that the patient had heart muscle edematous. Hence, Cardioversion was forgone. Consequently, a 300mg loading dose of Amiodarone was started on the patient, followed by a 900mg maintenance dosage. The patient was back to SR the following day. This case study highlights the importance and effectiveness of using Amiodarone as medication against Mr. Patel’s arterial fibrillation, outlining and emphasizing the NICE guidelines observed during Mr. Patel’s treatment and management. In addition, the use of the NICE-recommended nursing observation, strategies and intervention practices on Mr. Patel are outlined. In the United Kingdom, it is reported that atrial fibrillation (AF), one of the most common class of arrhythmia managed in clinical practice, affects about 5% of the population aged 65 years and above. The condition is found in both genders with men reporting higher prevalence. As in the case of Mr. Patel, the disease is characterised by lack of synchronisation of rhythm between the ventricles and atria, thus disturbing his regular rhythm of the heart. AF is general regarded as an electrical energy disruption that causes the upper chambers of the heart to vibrate at an approximate rate of between 300 and 600 times a minute (NCC-CC, 2006). Although the overall mortality rate for atrial fibrillation has recently risen to the hitherto unseen levels of up to 90%, many doctors and nurses continue to disregard the potential of modifying the cardiovascular risk factors associated with this disease to reverse the situation (NCC-CC, 2006). As a matter of fact, it has been established that nurses have a great potential to positively contribute to the detection, prevention and management of this progressively common condition (Flegel, 1995). It has also been noted that people aged above 65 years old such as Mr. Patel, are the most affected by this condition. Interestingly, this age group account for huge portion of people under nursing care (NCC-CC, 2005). The role of nurses in Mr. Patel’s case is quite clear since his condition, and the fact that he is aged require that he is placed under intensive treatment and nursing care. For instance, that Mr. Patel just has just undergone surgical procedures and has his cardiac and metabolic systems’’ stability impaired makes his case rather care-intensive. Since most of AF’s signs and symptoms are asymptotic, it is recommended that nurses suspect the disease in patients with irregular pulses (Flegel, 1995). It is not enough to merely suspect the disease in such patients; nurses should do more by informing physicians and recommending referral to an electrocardiogram. The objectives of nursing observations and activities on Mr. Patel, after his surgery includes the following: to alleviate the signs and symptoms of AF and to prevent other related complications he might contract. Among the procedures that are likely to be applied should be suffer these complications include but are not limited to ablation therapy, antiarrhythmics, cardioversion and antithrombotics (AHA, 2006). Awareness of the traditional antiarrhythmic drugs, which are only slightly effective on AF but have high potential for serious adverse effects is quite vital in providing Mr. Patel’s care. Luckily for Mr. Patel, the recently developed AF medications at the disposal of the facility will see him enjoy treatment with improved safety and efficacy. Amiodarone as Rhythm Control Medication for Atrial Fibrillation In many instances, physicians often settle on medication as the first action in the management and treatment of arterial fibrillation. First among the intentions of physicians is to give medicines that would make the heart rate to slow (Wyse & Waldo, 2002). If such strategies fail, many a doctor goes for rhythm control medications. These medications function by attempting to restore patient’s heart rate to the regular sinus pace (Lee & Lam, 2009). The other terms used to refer to rhythm control medication are drug cardioversion or chemical cardioversion. For Mr. Patel, the choice of the rhythm control medication will be determined by the specific type of arterial fibrillation from which he suffers (Roy & Nattel, 2008). The other factor that will be considered in the choice of rhythm medication for Mr. Patel is his history. For an illustration, it will first be established if Mr. Patel is suffering from other heart conditions, which may result in adverse effects for him if certain types of medications are applied (Sweeney & Bank, 2007). Besides, Amiodarone, the other drugs normally used for rhythm control are quinidine, sotalol (Betapace®), dronedarone (Multaq®) and propafenone (Rythmol®). However, from order and prescription history, Amiodarone is considered the most effective among these drugs for treating patients with conditions similar to Mr. Patel’s. In fact, many doctors use and attest to the effectiveness of this medication in maintaining and achieving normal sinus rhythm. Nonetheless, Amiodarone is normally used as last resort, given its toxicity to the lings. Additionally, the drug also has a high potential for long-term adverse side effects. To counter the toxic effects of Amiodarone on Mr. Patel, an amiodarone-derivative but iodine-free drug called, dronedarone (Multaq®) will be used. Although it is less effective than amiodarone, dronedarone is not likely to have the adverse side effects associated with amiodarone on Mr. Patel. Additionally, Mr. Patel will benefit from dronedarone’s beta-blocking abilities for rate control. Regrettably, many patients report that while rhythm control drugs work well and fast at the initial stages of treatment, these drugs just make patients feel bad and often tired (Saffitz, 2006). In fact, some rhythm control drugs work for years before eventually stopping to work. Hence, it is recommended that when these medications fail on Mr. Patel, physicians should apply catheter ablation or surgical ablation. Physicians are advised to accompany rhythm control medications such as amiodarone with anticoagulation (Lau & Crystal, 2007). The reason for this advice is that though doctors traditionally believed that the risk of stroke is greatly reduced in patients with normal sinus rhythm so that anticoagulation is not important, latest scientific evidences show that patients withdrawing from anticoagulants after restoration of normal sinus rhythm are at greater risk of stroke (Thrall et al., 2006). Therefore, besides making a decision on the applicability of rate control or rhythm control medication, physicians should make a decision on the implementation of an anticoagulant medication. Dosage and Administration Since Mr. Patel received an oral administration of amiodarone therapy, it may delay up to two or more weeks for the antiarrhythmic effects to be noted in him. However, to shorten this period, a loading regimen of relatively high dosage is recommended. Since dosages that fall below 300mg are often associated with decreased cases of adverse effects on the pulmonary system, for Mr. Patel’s case, a dosage of 200mg per day will be implemented. After the amiodarone treatment, Mr. Patel will be constantly and regularly be monitored to assess the need for amiodarone, its efficacy, appropriate dosage, adverse effects and possibilities of drug interactions. The critical follow up areas that should be emphasised are history and physical examination, heart failure, prothrombin time, international normalized ratio, pulmonary function test and diffusing capacity of lung for carbon monoxide. The other aspect of Mr. Patel’s condition that will be keenly observed is his electrolyte balance, which is quite important for cardiac function. First, any changes in Mr. Patel’s electrolyte concentration and balance would have dire effects on the generation and propagation of his cardiac signals. As identified in the patient, the main electrolytes that are constantly being monitored in Mr. Patel’s system are sodium, calcium, potassium, magnesium and chloride. First, sodium is quite necessary for automaticity, associated with the heart’s capacity to generate impulsive and repetitive contraction stimuli. Calcium, on the other hand, helps in cardiac contractions and automaticity. Potassium has a role in assisting the heart to reset the heart’s repetitive firing system, helping the organ to get active quickly after the generation of an electrical stimulus. Low levels of mg and cl in the patient will be associated with an impaired functioning and replacement of electrolytes. For Mr. Patel, the importance of electrolyte concentration and balance cannot be overemphasised since the balance of the concentrations of electrolytes would change the function of the heart, whether a decrease or an increase in the electrolyte levels. For instance, if Mr. Patel suffers excess calcium or hypercalcaemia, he will likely suffer from increased cardiac contractility whereas hypocalcemia would depress the contractility of the heart, resulting in electrical irritability. Hyperkalemia, excess potassium, would decrease the automaticity and conduction of Mr. Patel’s heart while hypokalemia would increase electrical irritability of the heart. Nursing Observation, Interventions, Strategies and Practices Health care for Mr. Patel is thus not a preserve of his physicians; nurses have equally important roles in ensuring he gets the best care possible and recover in the shortest period. The importance of nurses in caring for patients such as Mr. Patel is highlighted by the initiative taken by the National Institute for Health and Clinical Excellence (NICE) to establish guidelines on the management of the condition. These evidence-based guidelines were released by NICE in 2006, for use by health care givers to manage atrial fibrillation patients. In fact, these guidelines were the first national guidelines to be produced and published despite the fact that other such guidelines and systematic reviews had been produced earlier. Although designed and developed in response to a well-defined scope, the NICE guidelines cannot be said to address all the aspects of investigating and managing atrial fibrillation. Among the core features of this guideline is the importance of the active involvement of patient?carer representatives (NICE, 2006). This individual should be experienced in atrial fibrillation and its consequences. These carers are really helpful in identifying patients’ choices and preferences and acknowledging these choices. In fact, this provision is one of the main strengths of the NICE guidelines on atrial fibrillation (NICE, 2006). The other provision is that of inclusion, which recommends that nurses and other health care givers should discuss with patients and their loved ones the pros and cons of every possible medication available for use. According to NICE (2004), atrial fibrillation is perhaps the most common sustained cardiac conditions that affect sinus rhythm. If not treated in time, atrial fibrillation could be a considerable risk factor for stroke, not to mention other associated morbidities. Due to the serious nature of the condition, NICE developed a guideline that contains evidence-based guidance not only on the diagnosis but also on the management of the condition. The guideline targets atrial all types of fibrillation including those occurring as emergencies. It also covers primary, post-operative and secondary care for atrial fibrillation (McKeown & Gutterman, 2005). One strong point emphasized by NICE in these guidelines is its recommendations for referral to specialist services. The core components of the guideline that nurses should use to guide their practices, observations and strategies are the management of atrial fibrillation, tests for atrial fibrillation diagnosis, the treatments offered for various types of the condition such as acute-onset AF, persistent AF, permanent AF and stroke-associated AF(NICE, 2006). The NICE guidelines particularly emphasise the role of nurses in the management of atrial fibrillation after a cardiac surgery, as is the case with Mr. Patel. For Mr. Patel, it is required that all the vital signs and symptoms associated with atrial fibrillation are monitored on a regular basis (Snow & Weiss, 2003). In particular, nursing strategies for Mr. Patel should focus on the heart rhythm and rate. In addition, the requirement that nurses differentiate among chronic AF, controlled and uncontrolled AFs makes it necessary that Mr. Patel gets enough attention with regards to the likelihood of his AF converting from one type to another. The other activity that will accompany Mr. Patel’s treatment is educating his family on the medications under which he has been placed and the available options in case of adverse side effects or poor response from the patient (Russo, 2006). Still in the same line of education, nurses may educate patients and their caretakers on the diagnostic tools used such as EKG and Echo. It is also of the essence that Mr. Patel’s nurses are aware of the various signs and symptoms associated with the toxicity of the medications applied (Russo, 2006). The following are the recommended goals that will be emphasised during Mr. Patel’s treatment after the cardiac surgery. They include the reduction of hemodynamic symptoms and focusing on rate control and prevention of thrombi development (Singer et al., 2003). Ensuring and assessing patient stability is the other goal that the treatment will focus on, especially if the patient has indications of decreased consciousness, short breath, uncontrolled ventricular rate and low blood pressure. From these recommendations, it is clear that assessment is one of the critical nursing activities that will benefit Mr. Patel and similar type of patients (Wyse & George, 2006). Potentially adjustable causes, anemia, electrolyte imbalance, Ischemia, sepsis, alcohol intoxication and comorbidities are some of the issues that should be assessed on a regular basis (NICE, 2004). Conclusion That atrial fibrillation is one of the most common arrhythmias is not debatable. In the United Kingdom, as is the case in other regions, those aged 65 years and above are the mostly affected age bracket. Coincidentally, this age group is massively represented in nursing homes and suffers from most of the conditions for which nursing care is crucial. Hence, the role and importance of nursing interventions and observation for AF patients cannot be overemphasised (Greener, 2010). For this reason, NICE developed a guideline for nursing AF patients. These guidelines are really useful for AF patients who have had cardiac surgery and are placed under rhythm control medications such as amiodarone. Astute and observant nursing is highly recommended since these medications have adverse effects, especially after long-term use (Fuster et al., 2001). The other treatment options that nurses should be aware of and equip themselves with the appropriate nursing skills and knowledge include oral antiarrhythmic medications, direct current electric cardioversion, radiofrequency ablation, and pharmacological cardioversion (Klabunde, 2005). It is vital that the treatment adopted suits the specific needs, choices and preference of a patient, efficacy, costs and safety, clinical symptoms and response to previous treatment, if any (Fox, 2004). 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