Heart rate is the main variable characterizing the work of the patient’s cardiovascular system. According to Reil et al. (2011), “heart rate is a major determinant of myocardial oxygen demand, coronary blood flow, and myocardial performance” and it “affects nearly all stages of cardiovascular disease” (p. 13). In connection with the above-mentioned, a nursing professional needs to pay one’s constant attention to the patient’s heart rate. At that, the older the patient is, the bigger the risks related to the heart rate abnormalities exist (Reil et al., 2011).
In their research study, Reil et al. (2011) found that the increased heart rate in the older population is the most frequent mortality factor in the United States. In addition, according to Reil et al. (2011), “patients with elevated heart rates (mean 79.2 bpm) bear higher risks for coronary revascularization (38%), admission to hospital for myocardial infarction (46%) or heart failure (53%), and cardiovascular death (34%) compared with those with lower heart rates (64.1 bpm)” (p. 14).
With respect to the information cited above, it is very important to control Mr. Roberts’ heart rate. The heart rate of 160 beats per minute is considerably higher than the normal one for a male person of the age of 76. With the normal resting heart rate of around 60 to 100 beats per minute, the heart rate of 160 is significantly increased and presents a serious threat to Mr. Roberts (McCance et al., 2013). Below, the mechanism of this risk will be explained in detail.
When there is an elevated heart rate, stroke volume becomes decreased (Reil et al., 2011). The decrease of stroke volume takes place because shorter diastolic periods cause incomplete filling of heart chambers (McCance et al., 2013). In its turn, reduced stroke volume results in blood pressure reduction (McCance et al., 2013). The outcomes of these developments are the reduced coronary artery perfusion along with the reduced myocardial oxygen delivery (McCance et al., 2013).
The reduced coronary artery perfusion deprives the adequate blood supply (Volo et al., 2014). This negative factor, in turn, reduces the myocardial oxygen delivery. As a result of the myocardial oxygen delivery reduction, the myocardium suffers because its metabolism largely relies on oxygen (Volo et al., 2014). In case there is the prolonged lack of oxygenation of the heart muscle, necrosis of some of its portions may occur (Reil et al., 2011). This malice development may cause the myocardial infarction, chronic heart failure, and other life-threatening cardiovascular disorders (Reil et al., 2011).
With the heart rate of 160 beats per minute, Mr. Roberts is thus at the high risk of heart attack or other life-threatening conditions. Therefore, his heart rate needs to be corrected in order to eliminate the existing hazards. In addition, to improve life expectancy and eliminate the risks of the heart attack, stroke, and other related conditions, it is very important to control other symptoms such as the chest pain, feeling of pressure in the anterior chest, pain radiating into the neck, jaw or shoulders, strangling sensation, feeling of weakness in arms or hands, and shortage of breath (Reil et al, 2011). If some of the other symptoms become manifest, it is important to have a detailed record of the physical and clinical signs to help Mr. Roberts control his health condition.
- The loss of one-fourth of one’s blood is very dangerous for the organism because an adequate cardiac output vital for the life sustainment directly depends on the blood volume (McCance et al., 2013). Such condition can be classified as the acute hemorrhage. According to Gruen et al. (2012), acute blood loss is the most common preventable cause of premature deaths in patients with trauma. “It causes approximately a third of the almost six million trauma deaths per year. About half occur before the patient reaches the hospital” (Gruen et al., 2012, p. 1099).
Acute hemorrhage affects the body by decreasing the cardiac output and jeopardizing oxygen delivery (Moore, 2014). Physiological response to the acute blood loss depends on the amount of blood loss, compensatory mechanisms, and the general state of an individual’s health (McCance et al., 2013).
Physiological response to the acute hemorrhage involves the following constitutes: (1) neural and humoral regulation of the available blood and its direction to the vital systems and organs; (2) replacement of the lost plasma by the water retention and evolving salt; and (3) gradual replacement of the lost blood cells (McCance et al., 2013). Within the first stage of rehabilitation, the organism responds by the primary reduction of cardiac output, arterial pressure decrease, vasoconstriction, and heart rate increase or tachycardia (Moore, 2014).
John’s case can be related to class two blood loss according to Moore (2014) because he lost around 25 per cent of his blood. In the blood loss of this class, “the traditionally measured parameters may still remain within normal limits or may show mild deviations of normal limits”; at that, “the sympathetic vasoconstriction spreads to the liver, pancreas, kidney, and gastrointestinal tract” (Moore, 2014, p. 629).
Normally, acute blood loss of class two is not characterized by the shock stage because the body may still respond to the developing lack of blood volume through the mechanism of vasoconstriction and heart rate increase. In case there is still the beginning shock state, it can be easily prevented by the urgent blood loss control (Moore, 2014). In appearance, such patients may become pale, and their body temperature may reduce. Additionally, the patients may have slight changes in behavior but no vivid signs of the shocked condition are expected. They may feel thirsty because the organism is trying to compensate the lost blood volume by the water input (Gruen et al., 2012).
The complexity of the given case is that the hemorrhage is arterial and hence, the patient is losing the arterial blood rich in oxygen; thus, the damage to the body becomes more tangible than it is in the event of phleborrhagia (Moore, 2014). To cope with this considerable blood loss, the body will respond by the replacement of the lost blood cells (McCance et al., 2013). However, this process is quite long, and for this reason, the organism will suffer from the lack of oxygen at the first period of rehabilitation. Therefore, it is expected that the prevention therapy will consider the problem of the lack oxygenation and will include medicines stimulating the additional development of erythrocytes and helping tolerate the shortage of oxygen (Gruen et al., 2012).
Simultaneously, the body will strive to increase the blood volume. To achieve this goal, the kidney will release rennin to stimulate the aldosterone development. The aldosterone, in its turn, will retain sodium (Gruen et al., 2012). The posterior pituitary releases antidiuretic hormone, which retains water (McCance et al., 2013). When the blood volume gets bigger, the blood pressure also goes up along with the cardiac output (McCance et al., 2013).
- Analysis of Mr. Black’s complaints suggests a conclusion that there is the high probability of peripheral artery disease (McCance et al., 2013). Peripheral artery disease is the form of arteriosclerosis. The risk factors contributing to the development of this condition are the lack of physical activity, unhealthy diet, smoking, and the age of over forty (McCance et al., 2013). Since the patient has a profession that requires staying unmovable for many hours and being on the road for many hours without a chance to cook and consume the healthy food, it is to reasonable to assume that he is subjected to the risk factors identified above.
Peripheral artery disease is a cause of limb ischemia (McCance et al., 2013). The symptoms of limb ischemia are the pain in the limbs, loss of pulses in limbs, and the change of skin quality and skin color (Tendera et al., 2011). At that, the pain in the limbs is getting stronger when a person is doing activity and relieves at rest. The phenomenon of pain in limbs during activity is called intermittent claudication (McCance et al., 2013). With the reported intermittent claudication, the probability of peripheral artery disease is even higher for this patient. Therefore, Mr. Black will need the following assessment: physical examination, control for skin breakdown or positional color changes, blood pressure control, segmental limb pressure control, blood sugar control, lipid control, cholesterol control, and velocity waveform analysis (McCance et al., 2013). Depending on the results of the initial assessment, he might also need some additional control including Duplex scanning or Advanced imaging techniques (Tendera et al., 2011). The rationale for choosing the above-mentioned assessment techniques is the necessity to identify whether Mr. Black has the high cholesterol, vessel blockage in limbs, and high blood pressure. While performing the assessment, the healthcare professional will need to apply the systematic approach (McCance et al., 2013). This means that each step of testing is important for establishing the diagnosis.
First of all, physical examination can help a physician to detect important signs of the vascular disease presence. According to Tendera et al. (2011), a physician should perform at least the following physical examination tests to identify the cause of pain in limbs, “measurement of blood pressure in both arms and notation of inter-arm difference”, “auscultation and palpation of the cervical and supraclavicular fossae areas”, “palpation of the pulses at the upper extremities”, “abdominal palpation and auscultation at different levels including the flanks, periumbilical region, and the iliac regions”, “auscultation of the femoral arteries at the groin level”, and “palpation of the femoral, popliteal, dorsalis pedis, and posterior tibial sites” (p. 2858). In addition, Tendera et al. (2011) recommend performing the physical examination of feet for the presence of ulcerations and skin characteristics such as integrity, color, and temperature. Other findings to be made during the physical examination include the examination of the calf for skin changes and hair loss, control of upper and lower extremities for the signs of subclinical vascular disease, and carotid bruit test (Tendera et al., 2011). In their article towards peripheral artery disease detection and treatment, Tendera et al. (2011) provide the following research data proving the importance of carotid bruit test and the related tests,
A meta-analysis published in 2008 emphasized the prognostic value of carotid bruit.23 People with carotid bruits have twice the risk of myocardial infarction and cardiovascular death compared with those without. This predictive value can be extended to other clinical signs, such as femoral bruit, pulse abnormality in the lower extremity, or inter-arm blood pressure asymmetry (p. 2858).
Laboratory assessment with the aim of detecting the major risk factors for vascular disease is crucial for the diagnostics of Mr. Black’s health status (McCance et al., 2013). Tendera et al. (2011) recommend the following criteria to be tested: cholesterol control, blood sugar rate control, lipid control, lipoprotein control, C-reactive protein control, fibrinogen control, and urinary albumin-to-creatinine ratio control.
Other methods for the peripheral artery disease detection are the ultrasound methods and ankle–brachial index. Today, Duplex ultrasound is one of the most commonly used ultrasound methods for vascular lesions diagnostics. According to Tendera et al. (2011), Duplex ultrasound encircles ‘B-mode echography, pulsed-wave Doppler, colour Doppler, and power Doppler in order to detect and localize vascular lesions and quantify their extent and severity’ (p. 3859). Next, the ankle–brachial index is one of the most commonly used variables for vascular disease identification by the physicians all over the world. Tendera et al. (2011) argue that the ankle–brachial index is a “strong marker of CVD and is predictive of cardiovascular events and mortality” (p. 2858). The ankle–brachial index value of less than 0.90 is the sign of atherosclerosis (Tendera et al., 2011).
Finally, a physician may utilize the computed tomography angiography to diagnose the cause of Mr. Black’s limb pain. This assessment method applies when there is a need to confirm a diagnosis promptly. However, the computed tomography angiography has significant limitations. According to Tendera et al. (2011), “the use of computed tomography angiography is not recommended for screening purposes due to the high doses of radiation used, potential contrast nephrotoxicity, and the lack of data demonstrating the effect of screening with CT” (p. 2859). In the recent period, this method is often replaced by the similar testing called magnetic resonance angiography (Tendera et al., 2011). The advantages of magnetic resonance angiography are high performance, low invasive characteristics, and prompt data acquisition (Tendera et al., 2011).
- The neonate is experiencing lesions that are accompanied by the blood shunting from left to right (McCance et al., 2013). Cyanosis may appear because of these shunts as they reverse and develop into Eisenmenger syndrome (pulmonary hypertension) or similar disorders (McCance et al., 2013). Although the harsh, loud, systolic murmur best heard at the left lower sternal border is a serious symptom that may be related to a structural heart disease, it may also occur in the neonatal without it due to the transition from the fetal circulation to the adult circulation (Frank & Jacobe, 2011).
During the initial examination, the lack of cyanosis was observed due to the fact that the neonatal only started to use one’s pulmonary system and thus, some time needs to pass before the symptoms would show (McCance et al., 2013). The full transition from the fetal to adult circulation may take up to the one-month period or even longer in some cases. The differences between the fetal blood circulation and the adult one may explain why babies may develop complicated cardiac disorders after a few hours or days after their birth.
The fetal pulmonary system does not operate as in adults because oxygenation of blood in fetus occurs through the placenta (Frank & Jacobe, 2011). As the lungs do not participate in the process of oxygenation, there is no high blood flow. In addition, the liver does not participate in the fetal blood flow as well, since the functions of liver are performed by the maternal hepatic system (McCance et al., 2013).
These peculiarities of the fetal blood flow explain why blood shunts through the ovale directory from the right atrium to the left one bypassing the lungs (McCance et al., 2013). Since the cardiac system of the fetus and the adult person function differently, the neonate needs to experience transition from the fetal blood flow to the adult circulation. When such transition takes place, the possible cardiac disorders can manifest themselves (Frank & Jacobe, 2011). Of course, not all newborns with murmur and cyanosis have cardiac disorders. According to Frank and Jacobe (2011), in over forty per cent of cases, the neonates with murmurs and cyanosis do not have the structural heart disease. Instead, such children have these symptoms because of the peculiarities of the ovale directory work.
In case of physical impairment, full transition from the fetal circulation to the adult one does not occur. Then, a certain type of congenital heart defect may develop. There are four types of congenital heart defects including lesions increasing pulmonary flow of blood, lesions decreasing pulmonary flow of blood, obstructive lesions prohibiting the blood outflow from the heart and mixed lesions resulting in the mix of oxygenated and deoxygenates blood in the great vessels or the heart (Frank & Jacobe, 2011).
The neonates with heart murmur need prompt assessment because the structural disorders they may have can be potentially life-threatening. At that, there may not be other symptoms rather than the murmur and cyanosis (Frank & Jacobe, 2011). Judging on the above-mentioned facts, every newborn with the heart murmur needs a very thorough clinical examination with the pulse oximetry. Those with the identified problems such as the low oxygen saturation or low-palpable femoral pulse require urgent echocardiographic assessment (Frank & Jacobe, 2011). The neonates having murmur without clinical symptoms of the cardiac disorders still need echocardiographic assessment but it can be the routine echocardiographic assessment.
The incidence of the structural heart disease in infants with the heart murmur is quite high. According to Frank and Jacobe (2011), “the reported sensitivity for detection of a pathologic heart murmur in newborns ranges from 80.5 to 94.9 percent among pediatric cardiologists, with specificity ranging from 25 to 92 percent” (p. 799). This fact only explains the rationale for the prompt echocardiographic assessment of the neonate in the given case. The situation in this case is even more serious due to the fact that the murmur identified in this infant is harsh, loud, and systolic and it is best heard at the left lower sternal border. All these signs commonly refer to the life-threatening cardiac defect (McCance et al., 2013).
Frank, J. E., & Jacobe, K. M. (2011). Evaluation and management of heart murmurs in children. American Family Physician, 84(7), 793-800.
Gruen, R. L., Brohi, K., Schreiber, M., Balogh, Z. J., Pitt, V., Narayan, M., & Maier, R. V. (2012). Haemorrhage control in severely injured patients. The Lancet, 380(9847), 1099-108.
McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2013). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MO: Mosby.
Moore, K. (2014). The physiological response to hemorrhagic shock. Journal of Emergency Nursing, 40(6), 629-31.
Reil, J., Custodis, F., Swedberg, K., Komajda, M., Borer, J. S., Ford, I., & Böhm, M. (2011). Heart rate reduction in cardiovascular disease and therapy. Clinical Research in Cardiology, 100(1), 11-19.
Tendera, M., Aboyans, V., Bartelink, M., Baumgartner, I., Clément, D., Collet, J., & Zeller, T. (2011). ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). European Heart Journal, 32(22), 2851-2906.
Volo, S. C., Kim, J., Gurevich, S., Petashnick, M., Kampaktsis, P., Feher, & Weinsaft, J. W. (2014). Effect of myocardial perfusion pattern on frequency and severity of mitral regurgitation in patients with known or suspected coronary artery disease. The American Journal of Cardiology, 114(3), 355-61.