Medical Problems as a Result of Chronic Cocaine Abuse and Alcoholism - Lab Report Example

ACUTE CARE NURSING ASSESSMENT DATA A. Patient’s chief health complaint: Carissa Smith, a 50 – year old female, was admitted at the Emergency Department (ED) because of chest pain and shortness of breathing. B. History of Present Illness: Four days prior to consultation, Carissa reported that she failed to refill and take her medications because she ran out of money until she got her disability check on a Friday, 21st of September. Twelve hours prior to consultation, Carissa Smith reportedly had onset of shortness of breathing (SOB) and chest pain after using cocaine. About 15 minutes of having chest pain, she began to have episodes of coughing and coughed out green/brown sputum. The client clarified that chest pain was not aggravated by coughing or taking deep breathing. She subsequently complained of shortness of breathing that prompted her to seek consult to the ED with her daughter at 8:00 o’clock in the morning. The client described the pain as constant and perceived as tightness at the substernal and midclavicular regions below the left side of the chest without radiation to the shoulder, arm, back and jaw. Initially, the client described the pain as stabbing rated 9/10; however, after administering 2 SL Nitro and ASA 325 mg, the pain gradually became “crampy” and is currently rated 1/10. In addition, the client was also given Lasix 40 mg IV. The client reported that she tried Excedrin PM and Tylenol PM at home to relieve the pain but was unsuccessful. A day prior to consult, the client related that she tried taking 100 mg of Toprol XL, which provided no pain relief. Carissa had a history of uncontrolled hypertension, and was diagnosed with congestive heart failure (CHF), dilated cardiomyopathy, and polysubstance abuse. C. Past Medical History: The client had a history of longstanding hypertension and polysubstance abuse. In March 2005, the client was diagnosed with stage II left intraductal breast carcinoma, metastatic with 1/14 left axillary lymph nodes. The client was S/P left mastectomy, chemotherapy, and XRT. She had a history of depression in the same year. In July 2006, the client was diagnosed with congestive heart failure and dilated cardiomyopathy D. Past Surgical/Hospitalization History/Intervention: On 11/7/2006 – 16/7/2006, the client was admitted in the ward for 5 days after presenting to the ED with complaints of chest pains and SOB. During her admission, the client’s cardiac enzymes, electrolytes, Mg++ levels are all WNL. Her EKG showed normal sinus rhythm with LA enlargement, LVH, and a prolonged QT interval (.514 sec) but no dynamic changes worrisome for cardiac ischemia. CXR showed marked cardiomegaly with some pulmonary vascular congestion. An ECHO was performed during this time revealing LA dilation (5.0 cm) with LV size at the upper limit of normal, severe impairment of LV systolic function with a calculated biplane EF of 14%. The LV diastolic filling pattern was felt to be “pseudonormal.” It was during this time that RT was started on an aggressive 5 drug regimen for heart failure and recommended to follow up with a cardiologist at the Myers Park Heart Failure clinic. She has followed up with the Heart Failure clinic two times since July. 8/8/2006-9/8/2006, Carissa was observed in the chest pain unit after presenting to the ED with complaints of chest pain and SOB. During her admission, the client’s cardiac enzymes were WNL, and no dynamic EKG changes concerning for cardiac ischemia were noted. POC BNP was 864. The client went on to have a pharmacologic stress test without evidence of inducible myocardial ischemia. There was an evidence of LV global hypokinesis with a calculated EF felt to be about 32%. In July 2005, the client was S/P mastectomy in the left breast. She was diagnosed with stage II left intraductal breast carcinoma, metastatic with 1/14 left axillary lymph nodes. The client was treated with surgery, chemotherapy, and XRT. In 1985, the client underwent a C - section E. Medications: 1) Toprol XL (100 mg po qday) 2) Digoxin .125 mg qday 3) Lasix 40 mg qday 4) Lisinopril 10 mg qday 5) Spironolactone 12.5 mg qday 6) Nicotine transdermal patch (21 mg/24 hours, 1 patch daily) 7) Lortab 5/500 1 tab po q6h prn pain 8) Excedrin PM (5 tablets/day) 9) Tylenol PM (5 tablets/day) 10) Protonix 40 mg po q day before meals E. Allergies: The client is hypersensitive with PCN, and is manifested as swelling of the throat F. Social History: The client started smoking when she was 15 years old and smokes roughly .5-1 ppd. She also started drinking when she was 15 years old and is currently on 56 drinking sessions per week. She drinks mostly liquor. Her heaviest bout of drinking was during her 20s – for 2 years straight. The client endorses that during this time, she was having 5 drinks per day. She has been doing cocaine for the past 20 years but denies IVDU. Carissa is presently unemployed which she says is due to her physical condition. She has two children, a 17 year old daughter with whom she lives with and a 26 year old son who visits her at home every now and then. Her financial situation is tight and she has no medical insurance. Carissa and her daughter are both currently collecting disability. G. Family History: The client’s mother died of stroke at age 60. Father died of stroke at age 40. HTN and DM run in her family. Carissa has four siblings, two sisters and two brothers. At least one of her brothers and one of her sisters has both HTN and DM. Carissa says that she is the only person in her family to ever have cancer. H. Review of System: General: (+) night sweats and fatigue, (-) denies weight loss, fever. Eyes: Denies eye pain, acute visual loss, or significant visual changes. Ears, Nose, Mouth, and Throat: + Rhinorrhea, denies allergies, epistaxis, sore hroat, neck stiffness or tenderness. Cardiovascular: (+) occasional palpitations, denies oedema Respiratory: (+) wheezing, hemoptysis, asthma, PNA, TB, or emphysema. GIT: (+) nausea, vomiting (nonbloody, nonbilious), occasional diarrhea. (-) indigestion, heartburn, or abdominal pain. GUT: (-) itching, burning, or pain with urination. No hematuria. MSK: (+) Low back pain Neurologic: No H/A, dizziness, loss of sensation, loss of function, numbness, tingling, or weakness Endocrine: (-) history of thyroid problems, anemia, or DM Psychiatric: (+) Depression and denies history of anxiety or suicidal ideation. I. Physical Exam: Vital Signs: T 97° F, HR 104, BP 160/108 mmHg, RR 24 , O2 Sats 94% on 2L oxygen General: NAD, somewhat SOB but able to speak in full sentences Psych: Patient is appears anxious HEENT: Head is normocephalic PERRLA, EOMs intact, eyes anicteric, Nares patent, oral mucosa normal appearing with good dental hygiene, and her mucous membranes are moist and pink. Neck: (-) thyromegaly, normal ROM, no LAD Pulmonary: Chest wall symmetric, large mastectomy scar on the left chest wall with some tenderness to palpation over the scar. Bilateral bibasilar crackles, more prominent over the right lung. No wheezing or rhonchi appreciated. Cardiac: Sinus tachycardia, NL S1, S2 with S3 gallop. No murmurs or rubs. No JVD. No cyanosis, clubbing, or edema, 2+ pulses bilaterally at the carotid artery, 1+ pulses bilaterally at radial, DP, and PT arteries. Skin: Acanthosis nigricans noted on posterior aspect of neck and Portacath still in place in the right upper chest wall. No other skin abnormalities appreciated. Neuro: Mental Status: A, A, and O x 3; CNs II and XII are grossly intact. Breast: No lumps or fixed masses appreciated in the right breast, no nipple discharge or skin discoloration noted. Lymph: No cervical, supraclavicular, axillary, or inguinal LAD. J. Laboratory Data (1) POC results at 8:00 o’clock in the morning dated 9/16/2007: Na 142, Cl 109, BUN 16, Glc 101, K 3.8, CO2 23, Cr .8, POC Troponin I .01, POC CkMB 2.2 (2) CXR: Significant cardiomegaly >2/3 the width of the chest wall. Increased pulmonary vascular congestion. Costophrenic angles are difficult to see. The size of the heart obliterates the left costophrenic angle. There appears to be increased opacity over the right costophrenic angle as compared to last CXR in August 2007; this may be c/w pulmonary edema. There is no evidence of lobar infiltrates, effusions, masses, or pneumothorax. (3) EKG: Rate 104, Sinus Rhythm with Tachycardia, Intervals PR .162 sec, QRS .086 sec, QT .465 sec, Axis + 3045°, Hypertrophy LVH (V2 + V6 > 35 mm), Infarcts – No ST segment elevation or depression, no evidence of Q waves or TWI, nonspecific T wave abnormalities (some ST flattening in leads AVL, V1, and I). II. Body of Report A. Pathophysiology of Patient’s Complaints and Co-morbidities 1. Chest pain resulting from inadequate oxygenation of the myocardium The client, Carissa, is known for being an alcoholic beverage drinker since her young age, and addicted to cocaine for approximately 20 years. The following are the facts gathered explaining why the client exhibit complaints of chest pain. Burnett (2010), Arkangel (2005), and Weber, et al., (2003) stated that chronic cocaine addiction and alcoholism best explains the client’s complaint of chest pain and shortness of breathing. Burnette (2010) stated that users who combined cocaine with alcohol are observed in about 30% and 60% individuals. Concurrent alcohol and cocaine use is linked in a clinical data with mortality and morbidity increase secondary to complications involving cardiovascular system as well as hepatoxicity, and behaviors that lead to personal injury (Burnett, 2010). The aforementioned information is proven in clinical data. Brunett related that in the United States, 74% of fatalities related with cocaine use have been associated with co – ingestion of ethanol, and a 25 – fold increase of sudden death is linked with addition of alcohol. Burnett (2010) added that cocaine – related nontraumatic deaths are commonly caused by tachydysrhythmias. Additionally, acute vasospasm, dysrhythmia, or chronic accelerated atherogenic disease results to myocardial infarction. McCord, et al (2008) and Burnett (2010) explained the pathophysiology behind cocaine and myocardial infarction. McCord, et al (2008) and Burnett (2010) stated that a cardiovascular and hematologic effect of cocaine that contributes likely to myocardial infarction development is due to the effect of cocaine. At presynaptic adrenergic terminals, cocaine blocks norepinephrine and dopamine reuptake that causes catecholamine accumulation at the postsynaptic receptor that thereby acts as a “powerful sympathomimetic agent.” McCord added that in a dose – dependent fashion, cocaine causes an increase in heart rate and blood pressure. In the setting of alcohol use, the cocaine’s chronotropic effect is reportedly intensified. Furthermore, the left ventricular function is reduced and end – systolic wall stress is increased with the administration of cocaine. Hence, myocardial demand is increased by increasing the heart rate, blood pressure, and contractility. McCord (2008) also stated that even at small doses of intranasal cocaine have been linked with coronary artery vasoconstriction. Arkangel (2005) related that sympathetic nervous system stimulation is considered to be the major effect of cocaine. Sympathetic nervous system, which is primarily controlled by adrenaline or epinephrine is known to be responsible for the “fight and flight response,” and consequently results to increased heart rate, narrowing of blood vessel, and increase in blood pressure (Abbas, et al., 2004 and Arkangel, 2005). Arkangel added that other known toxic complications of cocaine are chest pain secondary to decreased myocardial blood supply and heart attack, which is currently considered to be the most common existing problems in Emergency Departments in the urban areas. Main Effects of Chronic Use of Cocaine (Source: Transmetron, 2009) 2. Shortness of Breathing secondary to chronic cocaine use Bozkurt and Mann (2003) stated that various mechanisms such as stress, high levels of activity and environmental conditions such as high altitudes or changes in temperature or medical problems, which are related to different problems in the body causes dyspnea or shortness of breathing. SOB can be caused by several factors, and one of these factors that we will consider in the case of Carissa is due to cocaine abuse. Arkangel (2005), Cohn and Cohn (2992), Keller and Lemberg (2002) stated that smoking cocaine is directly responsible for most complications in the lung and breathing such as shortness of breath and chest pain. Arkangel added that collapsed lung can be caused by deep inhalation technique and holding of breath to maximize inhaled cocaine. 3. Chronic Substance Abuse, Cocaine and Alcoholism As explained previously, cocaine and alcoholism abuse are the main co – morbidity observed in the client that contributed mainly to the pathophysiology of her medical problems. 4. Status Post Mastectomy secondary to Stage II Left Intraductal Breast Carcinoma The pre – existing medical problem and surgical procedure undergone by the patient can be considered to be one of the main factors that contribute to the anxiety of the client. B. Describe the Surgical Procedure has been Performed Surgical Procedure The client was status post mastectomy secondary to stage II left intraductal breast carcinoma, metastatic with 1/14 left axillary lymph nodes. The client was treated with surgery, chemotherapy, and XRT C. Diagnostic Tests since Admission and Discuss the Significance of the Test Results 1. Blood Chemistry Blood chemistry is determined to assess the organ function and condition. Blood test includes electrolyte determination. Electrolytes balances fluid levels in the body keeping the muscles, heart, and other vital organs function appropriately. 2. Cardiac Enzymes Elevation of cardiac enzymes, CK – MB, confirms that the client is experiencing heart attack. However, elevation of CK – MB does not show until after 8 hours following the onset of MI (Ruppert, 1997). 3. Chest X – ray Chest x – ray is important to identify presence of myocardial infarction as evidence in the chest x –ray as pulmonary congestion 4. Electrocardiogram Electrocardiogram is an immediate diagnostic study done among clients with complaints of chest pain and shortness of breathing (Ruppert, 1997). D. Nursing Care Plan Nursing Diagnosis/Problem Statement 1. Alteration in cardiovascular function related to diminished myocardial oxygenation as evidence by chronic chest pain 2. Alterations in blood flow to the heart related to substance abuse (cocaine and alcohol) as evidenced by increase in blood pressure and chest pain 3. Ineffective gas exchange related to substance abuse as evidenced by shortness of breathing 4. Altered family processes related to the client’s chronic condition, hospitalization related to recurring condition, treatment course, and home care requirements for client 5. Ineffective coping related to client’s personal susceptibility as evidenced by expression of inability to cope and substance abuse Nursing Diagnosis/Problem Statement Alteration in cardiovascular function related to diminished myocardial oxygenation as evidenced by chronic chest pain Manifested by: The client is restless and is evident with increased blood pressure EXPECTED OUTCOME NURSING INTERVENTION SCIENTIFIC RATIONALE Pain control as evidenced by demonstrating often client’s ability to properly use analgesics After 4 hours of nursing intervention, the client will verbalise understanding of proper analgesic use After two days of nursing intervention, the client must demonstrate to the nurse the proper dosage of analgesic intake It is the right of the client to expect maximum relief of pain (Kozier, et al, 2004). ( The client must learn to medicate herself to provide optimum pain relief while at home (Kozier, et al, 2004) Decreased pain level as evidenced by mild to absence of pain, and decrease of blood pressure and heart rate to baseline data After two hours of nursing intervention, the client must verbalise absence of pain Teach the client how to eliminate the factors that causes chronic pain To effectively plan treatment, the client must describe the pain since pain is experienced subjectively (Kozier et al, 2004) To enhance the overall management of pain, factors that causes the pain must be reduced or eliminated Evaluation of Care Given: Subjective data: The client will verbalize, “I have only mild chest pain, and sometimes, I don’t feel it at all.” Objective data: The client is more relaxed with blood pressure decreased to baseline. Assessment: Nursing intervention successful Plan: The client must continue the current intervention Nursing Diagnosis/Problem Statement Alterations in blood flow to the heart related to substance abuse (cocaine and alcohol) as evidenced by increase in blood pressure and chest pain Manifested by: Blood pressure of 160/108 mmHg, increased in respiration, shortness of breath EXPECTED OUTCOME NURSING INTERVENTION SCIENTIFIC RATIONALE After 8 hours of nursing intervention, the client must verbalise understanding on hypertension and its sequelae The nurse must explain to the client what is hypertension, and its effect to the vital organs such as the brain, kidney, and heart Help the client identify risk factors in hypertension such as alcohol and cocaine abuse Clarifies known misconceptions on high blood pressure and provides understanding on increase in blood pressure and its effect (Kozier, et al, 2004) Alcohol and cocaine abuse are known to be the modifiable risk that contributes to hypertension After 8 hours of nursing intervention, the client must verbalize the importance of preventing high blood pressure Reinforce to the client the importance of proper control of blood pressure Provide information that helps the client make changes in lifestyle The main reason of failure of treatment is lack of cooperation of the patient (Kozier, et al., 2004)M Informative resources helps blood pressure control Evaluation of Care Given: Subjective data: The client does not complain of palpitation and is not nauseated Objective data: Not agitated with vital signs taken as follows: BP of 130/90 mmHg, HR of 85 beats per minute, RR of 18 cycles per minute, O2 Sat of 99% on 2L of oxygen Assessment: Successful nursing intervention Plan: Encourage the client that proper cooperation and coordination with the health care provider helps decrease her current complaints Nursing Diagnosis/Problem Statement Ineffective gas exchange related to substance abuse as evidenced by shortness of breathing Manifested by: Shortness of breathing and increase in respiratory rate EXPECTED OUTCOME NURSING INTERVENTION SCIENTIFIC RATIONALE Both lung fields are clear on auscultation The nurse must assess the respiratory rate of the client every 4 hours The nurse must monitor the breath sounds of the client every 4 hours Symptoms of fluid overload can be detected with constant monitoring (Kozier, et al., 2004) With decreased cardiac output, accumulation of fluid may occur in the lungs (Kozier, et al., 2004) Within 24 hours, the client will have no complaints of shortness of breathing The nurse must monitor the blood pressure every 4 hours The pulse rate must be determined every 4 hours BP is a sign of stress in the body, and to ascertain treatment response, BP must be constantly monitored (Kozier, et al., 2004) Peripheral pulses may be weakened with altered cardiac output (Kozier, et al, 2004) Evaluation of Care Given: Subjective data: The client denies complaints of shortness of breathing Objective data: Both lung fields are clear on auscultation. RR: 16 – 18 cycles per minute, and HR: 85 beats per minute Assessment: The client is now more relaxed Plan: Encourage deep breathing Nursing Diagnosis/Problem Statement Altered family processes related to the client’s chronic condition, hospitalization related to recurring condition, treatment course, and home care requirements for client Manifested by: Uneasiness, anxiety, and apprehension EXPECTED OUTCOME NURSING INTERVENTION SCIENTIFIC RATIONALE The family of the client demonstrates understanding of home care The nurse will encourage the children to participate in the care plan of the client The nurse supports the children to express their concern Proper coaching to family members reduces the anxiety felt by the client (Kozier, et al., 2004) Helps reduce the anxiety felt by the children and subsequently, provides them assurance (Kozier, et al., 2004; Ruppert, 1997) To reduce that anxiety and fear felt by the client The nurse reassures the client and children that she will stay with them during bouts of chest pain and SOB The nurse encourages the children and the client to clarify uncertainties with her This reassures both the client and her children that they are safe (Kozier, et al., 2004; Ruppert, 1997) Supports the client and children away from fear and anxiety (Ruppert, 1997) Evaluation of Care Given: Subjective data: The client verbalizes that “I am now happy with better outlook in life.” Objective data: No observable traces of anxiety and fear in the children and client’s face Assessment: The client shows a good affect to the examiner Plan: Encourage the client to seek a social group of people to correct cocaine and alcohol abuse, such as the “Alcoholic Anonymous.” Nursing Diagnosis/Problem Statement Ineffective coping related to client’s personal vulnerability as evidenced by expression of inability to cope, substance abuse, and S/P mastectomy Manifested by: Outburst of anger, fatigue, physical illness, and substance abuse EXPECTED OUTCOME NURSING INTERVENTION SCIENTIFIC RATIONALE Coping as evidenced by client’s ability to verbalize self control The nurse provides the client an atmosphere of acceptance Encourage the client to verbalise feelings, perceptions, and fears Share of feelings is important to create an atmosphere of warmth and trust (Kozier, et al, 2004) Release and nonthreatening discussions identifies factors that causes and contributes to client’s feelings (Kozier, et al., 2004) Social support as evidenced by eagerness to call others for assistance The nurse determines with the client possible barriers to use support system Discuss with the client’s social group means how they can help the client Support system might be available but the client may not effectively use it (Kozier, et al.,2004) Identify detailed strategies including praise and encouragement during healing to promote acceptance (Kozier, et al., 2004) Evaluation of Care Given: Subjective data: The client verbalizes her feelings to others Objective data: The client allows her children provide emotional support and direct care Assessment: Successful nursing intervention Plan: Continue to offer to the client information on how to verbalize her feelings III. DISCUSSION Kozier, et al., (2004) stated that the American Holistic Nurses Association described that the goal of holistic nursing is to enhance healing of the client and recognize biopsychosocial and spiritual dimensions of the client. In this scenario, it is apparent that the client needs a holistic approach in nursing care including physiological, psychological, socio – cultural, developmental, and spiritual to help the existing problem of the client with substance abuse and chronic alcoholism, manifested clinically as shortness of breathing and chest pain secondary to decreased oxygenation to the heart. Accurate nursing assessment, diagnosis, goal planning, intervention/implementation, rationale, and evaluation criteria are all necessary to provide cost effective approach to achieve holistic nursing management of client’s chest pain and shortness of breathing. Substance and alcohol abuse greatly affects the entire population and includes socioeconomic, cultural, physical, cultural, and religious practices. In the case of the client, it is not apparent enough to declare that the cause of the chest pain and shortness of breathing of the client is mainly due to chronic use of cocaine coupled with chronic alcoholism that leads to decrease oxygenation of the heart or caused by the pre – existing medical condition of the client (Arkangel, 2005). Proper education of the client on the potential medical effects of cocaine abuse and alcoholism to the body achieves and maintains most favorable wellness of the client. IV. CONCLUSION From the findings available in the report, it can be concluded that the client is experiencing chest pain, shortness of breathing, fear, anxiety, and medical problems as a result of the client’s chronic cocaine abuse and chronic alcoholism. To recapitulate, it is evident that the client is engaged in chronic alcoholism and cocaine abuse because of deficient cognitive information related to the effects of chronic alcoholism and cocaine abuse to the body. V. REFERENCES Abbas, A., Fadel, P., and Clark, S. 2004. P – 132: Chronic Cocaine Abuse as a Cause of Left Ventricular Hypertrophy. American Journal of Hypertension, 2004(17): 81A Arkangel, C. 2005. Cocaine Abuse. ­EMedicine Health. Retrieved from http://www.emedicinehealth.com/cocaine_abuse/page12_em.htm Bozkurt, B. and Mann, D. 2003. Shortness of Breath. Journal of the American Heart Association, 108(2): e11-e13 Burnett, L. 2010. Toxicity, Cocaine. Medscape. Retrieved from http://emedicine.medscape.com/article/813959-overview Cohn, J. and Cohn, P. 2002. Chest Pain. Circulation, 2002(106): 106-530. Hobbs, S. 2010. Cocaine and Related Disorders. Encyclopedia of Mental Disorders Kalles, S., Feldman, J., and Pepper, L. (1994). Carboxyhemoglobin Levels in Patients with Cocaine related Chest Pain. Chest Journals, 1994(104): 147 – 150. Keller, K. and Lemberg, L. 2002. The Cocaine – Abused Heart. American Journal of Critical Care, 2003(12): 562-566 Kozier, B., Erb, G., Berman, A., and Snyder, S. (2004). Fundamentals of Nursing, 7th Edition. Connecticut: Pearson Education, Inc. McCord, J., Jneid, H., and Hollander, J. 2008. Management of Cocaine-Associated Chest Pain and Myocardial Infarction. Journal of the American Heart Association, 117(14): 1897-1907 McCord, J., Jneid, H., and Hollander, J. 2008. Management of cocaine-associated chest pain and myocardial infarction. A scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. National Guideline Clearinghouse. Retrieved from http://www.guideline.gov/summary/summary.aspx?doc_id=12951 Ruppert, S. 1997. Chest Pain: A Diagnostic Dilemma. The Internet Journal of Advanced Nursing Practice, 1(1): ISSN 1523 – 6064 The Nemours Foundation (2010). Basic Blood Chemistry. Nemours. Retrieved from http://kidshealth.org/parent/general/sick/labtest5.html Transmetron. 2009. Cocaine Information: Use, Testing, and Treatment. Retrieved from http://www.cocaine-drug.com/ Weber, J., Shofer, F., and Larkin, L. (2003). Validation of a Brief Observation Period for Patients with Cocaine-Associated Chest Pain. The New England Journal of Medicine, 348(6): 510 – 517. Read More