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NUR-502

Discussion 2

6-5-2020

J.D is a 37 years old woman who present to her gynecologist complaining of 2 months history of intermenstrual bleeding, menorrhagia, increased urinary, mild incontinence, extreme fatigue, and weakness. Her menstrual period occurs every 28 days and lately there have been 6 days of heavy flow and cramping. She denies abdominal distention, back-ache, and constipation. She has been had her usual energy levels since before her last pregnancy.

The contributing factors on J.D that may put her at risk to develop iron deficiency anemia one is of her history of 2 months of intermenstrual bleeding. Menorrhagia. Menorrhagia, is one of the most frequently encountered symptoms in gynaecology, defined as menstruation periods at regular cycle but excessive flow which may last more than 7 days. Menorrhagia can cause menstrual bleeding or more than 80 ml in each cycle( Vilos et al; 2001).

The reason J.D might be presenting constipation or dehydration is one is because she is taking OTC medication ibuprofen which on e of the side effects is constipation. Mr J.D used to take three tablets each day for about 2 ½ years ago for her knee. She stated that due to slowly progressive increase in pain and a loss of adequate relief with three tablets, she double the daily dose of ibuprofen. According to healthline (2020),Ibuprofen is so wide used that it can be easy to forget this drug can cause side effects. Still , ibuprofen is a drug, and it comes with risks like any other drug. The more common side effects of ibuprofen are:

· Stomach pain

· Heartburn

· Nausea

· Vomiting

· Gas

· Constipation

· Diarrhea

Mrs J.C might be presenting dehydration due to that she been treated with diuretic for her history of hypertension. Diuretics, also called water pill, are medication designed to increase the amount of water and salt expelled from body as urine. Side effects of diuretics the most common are:

· Too little potassium in the blood

· Too much potassium in the blood (or potassium-sparing diuretics}

· Low sodium level

· Headache dizziness

· Thirst

· Increase blood sugar

· Muscle cramps

· Increase cholesterol

· Skin rash

· gout

· dehydration

Another cause of dehydration is blood loss. According to Koury (2014),blood loss is one of the most serious, and sometimes life-threatening, complication of dehydration.

Erythropoiesis is the process in which new erythrocytes are produced. These new erythrocytes replace the oldest erythrocytes (normally about one percent) that are phagocytosed and destroy each day. Folate ,Vitamin B12 ,and iron have crucial roles in erythropoiesis. Erythroblast require folate or Vitamin B12 for proliferation during their differentiation. Deficiency of folate or Vit B12 inhibits purine and thymidylate syntheses, impairs DNA synthesis, and causes erythroblast apoptosis, resulting in anemia from ineffective erythropoiesis .Erythroblast requires large amounts of iron for hemoglobin synthesis. Large amounts of iron are recycled daily with hemoglobin breakdown from destroyed old erythrocytes. Many recently identified proteins are involved in absorption, storage, and cellular export of nonheme iron and in erythroblast uptake and utilization of iron. Erythroblast heme levels regulate uptake of iron and globin synthesis such as iron

deficiency causes anemia by retarded production rates with smaller, less hemoglobinized erythrocytes.

According to Everyday Health (2020),Iron deficiency anemia is the most common type of anemia, and it occurs when your body does not enough of mineral iron. Your body needs iron to make hemoglobin. When there is not enough iron in your blood stream, the rest of your body can not get the amount of oxygen it needs. Signs of iron deficiency are the following:

1. Extreme fatigue and exhaustion Fatigue is one of the most common sign of iron deficiency because it means your body is having trouble carrying the oxygen to cell it is effecting energy levels

2. Frequent infections Iron plays a key role in a healthy immune system, so lower levels of the mineral can make someone more susceptible to infections. Red blood cells help to transport oxygen to the spleen, which is one place where infections can be fought off.

3. Pale skin Hemoglobin gives skin its rosy color, so low levels cause the skin to become lighter.

4. Swollen tongue Changes to your tongue, including soreness or swelling, can be a sign of iron deficiency. Cracks on the outside of the mouth are also common among people with iron deficiency.

5. Restless legs Syndrome Some people who have iron deficiency develop restless legs syndrome, a disorder that causes to have s strong urge to move your legs. The urge often comes and unpleasant, crawling sensation in the legs can make it hard to sleep.

6. Pica People with iron deficiency may develop craving for non-food substances, such as clay, dirt, or chalk, a condition known as pica.

7. Hair loss Iron deficiency, especially when it develops into anemia, can cause hair loss. When hair follicles do not get enough oxygen, they go into a resting stage, and hair falls out and does not growth back until anemia is improve

Management of Iron Deficiency Anemia

There is clear evidence to support prompt treatment for Mrs J.D with iron deficiency because it is known that treatment improves quality of life and physical condition as well alleviates fatigue and cognitive deficits. The treatment is oral iron 100 mg . Oral iron supplementation is effective when intestinal uptake is intact. However, it is use should be limited to patients with mild anemia (Hb, 11.0-11-9). In non-pregnant women because repletion occurs slowly. When faster repletion is desired, intravenous administration is the preferred route. Nevertheless iron is readily available, inexpensive, and convenient, making it a viable treatment option( Jimenez et al.,2015)

In conclusion, Heavy menstrual bleeding and blood loss during childbirth are the most common causes of iron deficiency anemia in women of childbearing age.

References

Everyday Health (2020) Unusual Sings Iron Deficiency. Retrieved from

https://www.everydayhealth.com/news /unusual-signs-iron-deficiency.

Mayo Clinic [2020,July 5]. Dehydration. Retrieved from

htt;//www.mayoclinic.org.Symptoms cause? Syc-20354086

Health Line [2020 ,July 5] Ibuprofen Side Effects. Retrieve from

https://www.heathline.com /health/ Ibuprofen-side-effects

Health Line[2020, July 5]. What to know About Diuretics Retrieve from

https://ww.healthline.com/diuretics

Jimenez K., Kulnigg-Dabsch, S., Gasche C (2015). Management of iron Deficiency Anemia.

Gastroenterology & Hepatology, 11(4),241-250.

Mark .J. Koury Prem Ponka. New Insight into Erythropoisis; The role of folate, Vitamin B12

and Iron. Annual Review of Nutrition 2004. 24:1,105,131

Vilos GA, Lefebvre G, Graves GR. Guidelines for the management of abnormal uterine

bleeding .SOGC clinical practice guidelines. Journal of obstetrics and gynaecology Canada.

2001;106:1-6

Maria, Gonzalez

NUR-502

7-6-2020

Module 2

Cardiovascular

Mr. W.C. is a 53 years-old white man who began to experience chest discomfort while playing tennis with a friend. At first, he attributed his discomfort to the heat and having had large breakfast. Gradually, however, discomfort intensified to a crushing sensation in the sternal area and the pain seemed to spread upward into his neck and lower jaw. The nature of the pain did not seem to change with deep breathing. When Mr. G. complained of the feelings nauseated and began rubbing his chest, hiss tennis partner was concerned that his friend was having a heart attack and called 911 on his cell phone. The patient was transported to the ED of the nearest hospital and arrived 30 minutes of the onset of the chest pain. In the route to the hospital, the patient was place on nasal cannula and an IV D5W was started. Mr. G. received aspirin (325mg po) and 2 mg/IV morphine. He is allergic to meperidine (rash). His pain has eased slightly in the last 15 minutes but still significant; was 9/10 in severity; now 7/10. In the ED, chest pain was not relieved by SL NTG tablet. He denies chills

Predisposing risk factors for myocardial infarction are generally divided in two categories which are Non modifiable and Modifiable predisposing risk factors.

NON- MODIFIABLE PREDISPOSING RISK FACTORS

Increase Age

Older adults are more likely to die of heart disease. About 80% of heart disease death occur in people age 65 or older

Gender

Men tend to have heart attack increases after menopause but does not equal men’s rate. Even so, heart disease is the leading cause of death for the both men and women (Braunwald et al., 2001).

Hereditary/ Family history:

Increased risk if a first disease or stroke before the age of 55 years for male relative and 65 years for female relatives (Braunwald et al., 2001).

Genetic Factor:

Coronary artery disease and myocardial infarction are the most frequent causes of death. Even nowadays, every second myocardial infarction is lethal and hits the patients unexpectedly without previous signs or symptoms. A comprehensive analysis using molecular genetic testing including the cardiovascular risk factors showed that 1. This myocardial infarction locus is unique and does overlap with chromosomal loci -established risk factors. 2. Cardiovascular risk factors, such as LP (a), diabetes mellitus, serum lipids, or arterial hypertension have strong genetic components. These finding do not exclude a role of cardiovascular risk factors or candidate genes in the pathogenesis of myocardial infarction of myocardial infarction, but rather demonstrate that risk factors may act as surrogates of specific underlying disease mechanism. It is thus necessary to perform a comprehensive analysis of complex polygenic diseases, such as myocardial infarction, including both, established cardiovascular risk factors genomic (Hengsberg et al., 2002).

MODIFIABLE PREDISPOSING RISK FACTORS

Smoking

Smoking is considered as strong risk factor for myocardial infarction, premature atherosclerosis and sudden cardiac death. Smoking results in early STEMI especially in otherwise healthier patients. Smoking causes and average of 7 years earlier and more likely twice the chances of infarction than non-smoker (Zhang et al; 2010).

Physical activity

Inactivity people with multiple cardiac risk factors are more likely to develop MI. To get benefit, these individuals should star from modest exercise training. There should be aggressive risk factor modification before performance of vigorous activity (Satyendra et al., 1999).

LDL and triglyceride levels.

Elevated triglyceride levels and dense, small LDL particles act as predisposing risk factor for MI. Non fasting triglyceride levels appear to be strong and independent predictor of future risk of MI, particularly when the total cholesterol level is also elevated. The reason

behind it is that decreased HDL-C levels and increased triglyceride levels cause metabolic perturbation thus causing adverse consequences. To identify high risk individual , elevated triglyceride levels may become markers(Meir et al., 1996).

Obesity/ Body mass index(BMI):

Increased BMI is directly related to incidence of MI. Infarction is greatly enhanced by extreme obesity because it is a recognized risk factor for MI. To reduce the population burden of MI in US, strategies are devised to promote optimal body weight (Kenchaiah et al., 2002).

Diabetes mellitus (DM):

Significant differences in parameters measured were noted when all diabetic and non-diabetic patients were compared to the control group. It was found that in men with myocardial infarction there are significant difference between diabetic and non-diabetic patients with respect to certain risk factors such age, hypertension and hypertriglyceridemia in diabetic patients while smoking and family history are predominant factors in non- diabetic patients. However, newly diagnosed diabetic men have similar risk profiles to their known diabetic conterparts (Sewdarsen et al.,1991).

Hypertension

Hypertension is strong and independent risk factor for MI. It is major risk factor of causing atherosclerosis in coronary blood vessels, result in heart attack or MI are closely (Dunn et al., 1983).

According to Suray (2005), Acute coronary event common EKG will show abnormalities including T wave tenting or inversion, ST-segment elevation or depression (including-J point of elevation in multiples leads ) a pathologic Q wave.

Cardiac biomarkers

Troponin I is better cardiac marker than CK-MB for myocardial infarction because it is equally sensitive yet more specific for myocardial injury. Troponin T is relatively poorer cardiac maker than CK-MB because it is less sensitive and less specific for myocardial injury. Both troponin I and Troponin T may be used as independent prognosticator of future cardiac events (Rice et al., 1999).

A slight to moderate ride of temperature is a common clinical finding in the first 24-48 hours after acute myocardial infarction. The rise in temperature is directly proportional to the size of infarct the higher the fever. Fever is generated by indigenous mediators identical to Interleukin. It causes fever by altering the set point for thermostat in hypothalamus. This factor is produced from phagocytes when activated. The same mechanism is involved in myocardial infarction and other non- infectious causes. Normally a rise of temperature of 1 C increases the heart rate by 30 BMR and oxygen consumption by 10-15%. This effect in a diseased myocardium is even greater and could prove deleterious. A raised body temperature also increases the slope of the phase 4 depolarization which may lead to different types of thakyanythmias ( Riso et al.,1986).

Mr. W. experienced pain during his myocardial Infarct is because the usual cause of sudden blockage in a coronary artery is the formation of a blood clot(thrombus). Each coronary artery supplies blood to a specific part of the heart’s muscular wall, so a blocked artery may cause pain and malfunction in the area it supplies.

Conclusion, Approximately 1.5 million cases of myocardial infarction (MI) occur annually in the United States; the yearly incident rate is approximately 600 cases for 1000,000 people.

References

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Lowel H, Peigger G, Schunkert H. : Genetic factors in myocardial infarction-Results from a candidate gene and a genome-wide approach between beta blockers. JAMA 2002 Nov

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Kenchaiah S, Evan JC, Levy D, Wilson PW, Benjamm EJ, Larson MG, Kannel WB, Vasan RS:

Obesity and risk of the heart failure-Journal of Medicine 2002Agu 1;347(5):305-13

Mier J. Stamper, Ronal M.Kraus,Jim Ma,Patricia , J.Blanche, Laura G.Holl, Frank M.Sacks,

Charles H.Hennekens;A prospective study of triglyceride level, low density lipoprotein

particle diameter and risk of myocardial infarction. JAMA 1999;276(11):882-888

Satyendra , Giri, Paul D, Thompson, Francis J.Kiernan, Jonathan Clive, Daniel B, Fram,

Joseph F, Mitchel, Jeffrey A. Hirst, Raymond ,G Mckay, David D. Waters:Clinical and

angiographic characteristics of exertion related acute myocardial infarction . JAMA

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Rice, MS., & MacDonald, D.C. (1999). Appropriate roles of cardiac troponins in evaluation

patients with chest pain. The Journal of the America Board of Family Practice, 12(3), 214-

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Risoe, C and Krikeby, OJ. Reduction of the pyrexial response to acute myocardial infarction

by beta-adrenoceptor blockade. Acta Med. Scand. 1986; 271-274.

Sewdarsen, S. Vythilingum, I Jialal, M.C. Kamdar: Coronary risk factors in newly diagnosed

and previously diagnosed type 2 diabetic men with myocardial infarction. Diabetes

research and clinical practice 1991 mar; 11(3):169-176

Zhan H, Sun S, Tong L., LiR, Cao XH , Zhang BH, Zhan LH. Huang JX, Ma CS. Effects of

Cigarette smoking on clinical outcomes of hospitalized Chinese male smokers with

acute myocardial infarction. JAMA Nov 10, 1999.,282:1731-1736